AC4342 HOL 19 The Metropolitan Borough of Holborn. ANNUAL REPORT OF THE Medical Officer of Health, C. W. HUTT, M.A., M.D., D.P.H. For the Year 1922 London: Printed by DIPROSE, BATEMAN & CO., Sheffield Street, Kingsway, W.C. 2. 1923. INDEX. Page. Public Health Committee Housing of the Working Classes Committee 1 Maternity and Child Welfare Committee 2 Staff 2 Statistical Summary 3 Natural and Social Conditions 5 Population and Houses 5 Buildings 6 Tenements 7 Social Conditions and Chief Occupations 8 Foreign Residents 9 Births 9 Deaths 10 Seasonal Mortality 11 Infantile Mortality 11 Poor Law and Hospital Relief 12 Sanitary Circumstances 12 Scavenging. Removal of House Refuse 12 Removal of Manure 13 Sanitary Inspection of District 13 Notices Served 14 By-laws as to Houses let in Lodgings 16 Rat Repression 18 Smoke Abatement 20 Common Lodging Houses 20 Food 21 Milk Supply 21 Milk and Dairies (Amendment) Act, 1922 21 Milk (Special Designations) Order, 1922 22 Pasteurised Milk 22 Dirty Milk 22 Bacteriological Examination of Milk 23 Public Health (Milk and Cream) Regulations, 1912 25 Bakehouses 25 Places where Food is Prepared for Sale 26 Market Streets 26 Fried Fish Shops 27 Ice Cream 27 Meat 27 Unsound Food 28 Sale of Food and Drugs Acts 29 Preservatives in Food 32 Food Poisoning 35 Prevalence of and Control over Infectious Diseases 37 Infectious Diseases Generally 37 Smallpox 37 Vaccination 38 Diphtheria 39 Schick Test and Immunization against Diphtheria 41 Scarlet Fever 43 Puerperal Fever 44 Enteric Fever 44 Typhus Fever 45 Cerebro-Spinal Fever45 Dysentery 45 Malaria 45Encephalitis Lethargica 45 Acute Poliomyelitis 45 Pneumonia 46 Influenza 46 Anthrax 46 Venereal Disease 46 Botulism 47 Bacteriological Work 47 A2 Page. Disinfections 47 Cleansing of Persons Act 47 Shelter during Disinfection 48 Scabies 48 Tuberculosis 48 Notifications 48 Delay in Notification 49 Institutional Treatment 50 Visitation of Home 50 Contacts 50 Prevention of Spitting 51 Deaths from Pulmonary Tuberculosis 51 Tuberculosis Dispensary 52 Interim Tuberculosis Care Committee 54 Dental Clinic 56 Cancer 57 Maternity and Child Welfare 57 Notification of Births 57 Home Visiting 58 Work at Centre 59 Ante-natal Hygiene 60 Maternal and Infant Consultations 61 Still-Births 64 Illegitimate Births 64 Dental Treatment 64 Assistance with Denture64 Supply of Milk and Food for Mothers and Infants 65 Home Help 67 Convalescent Home Treatment 67 Saffron Hill Maternity and Child Welfare Centre 68 Deaths of Infants under One Year 68 Infectious Diseases among Mothers and Children 69 Puerperal Fever 69 Ophthalmia Neonatorum 69 Measles 73 Whooping Cough 74 Epidemic Diarrhœa 74 Poliomyelitis 75 Nursing Arrangements 75 Exchequer Grants for Maternity and Child Welfare Services 75 Health and Baby Week 76 Medical Inspection and Treatment of School Children 78 Death of Children, 5-15 Years 81 Sanitary Administration 82 Mortuary 82 Inquests 82 Revenue Acts 82 Danger from Flies 82 Dirty Tenants 82 Rag Flock Act, 1911 83 Housing 83 APPENDIX. Table I. Vital Statistics, 1922, and ten previous years 86 Table II. Causes of and Ages at Death, 1922 87 Table III. Infectious Diseases Notified during 1922 88 Table IV. Infectious Diseases in Holborn during 1922 and ten previous years 89 Table V. Information required by L.C.C. 90 Table VI. Factories, Workshops, &c. 91 (1) Inspections 91 (2) Defects found 91 (3) Home Work 92 (4) Registered Workshops 93 (5) Other Matters 93 Table VII. Legal Proceedings 94 1 PUBLIC HEALTH COMMITTEE. 1921-22. 1922-23. Chairman— Chairman— Councillor Sir William R. Smith, D.L., J.P., M.D.Councillor Sir William R. Smith, D.L., J.P., M.D. Vice-Chairman— Vice-Chairman— Councillor Francis J. Pullen. Councillor the Rev. Henry Ross. Ex-Officio— Ex-Officio— The Right Worshipful The Mayor, The Right Worshipful The Mayor, Councillor George Harvey, J.P. Councillor George Harvey, J.P. Alderman Henry Jewell. Alderman Henry Jewell. Councillor W. B. Foster Bovill. Councillor John Boraston, C.B. ,, Thomas W. J. Coffin. „ James J. Claydon. ,, Richard Davies. , Rev. Wilfred H. Davies, M.A. „ Rev. Wilfred H. Davies, M.A. „ William H. Edwards. „ William H. Edwards. „ Edward M. Evans. „ Henry W. Ellis. „ George Hands. ,, Miss Norah H. March, B.Sc. ,, Francis J. Pullen. „ Rev. Henry Ross. „ John W. Roberts. „ John H. Worrall. „ Brncewell Smith, B.Sc. HOUSING OF THE WORKING CLASSES COMMITTEE. 1921-22. 1922-23. Chairman— Chairman— Councillor The Rev. Wilfred H. Davies, M.A. Councillor The Rev. Wilfred H. Davies, M.A. Vice-Chairman— Vice-Chairman— Alderman Henry Jewell. Alderman Henry Jewell. Ex-Officio— Ex-Officio— The Right Worshipful The Mayor, The Right Worshipful The Mayor, Councillor George Harvey, J.P. Councillor George Harvey, J.P. Alderman Robert W. Dibdin, J.P. Councillor Miss Emily Dibdin. ,, W. Gipps Kent. ,, Henry W. Ellis. „ Sir George P. Parker, O.B.E. ,, Ernest Hamlin. Councillor Miss Emily Dibdin. „ George Hands. ,, Henry W. Ellis. „ Alfred Humphreys. „ Alfred Humphreys. „ Raymond A. Miles. ,, Miss Norah H. March, B.Sc. ,, Rev. Henry Ross. ,, Raymond A. Miles. ,, Bracewell Smith, B.Sc. ,, William B. Shearn. „ J. St. Lawrence Stallwood. J. St. Lawrence Stallwood. „ George Witherby. B 2 MATERNITY AND CHILD WELFARE COMMITTEE. 1921-22. 1922-23. Chairman— Chairman— Councillor Miss Norah H. March, B.Sc. Alderman Sir George P. Parker, O.B.E. Vice-Chairman— Vice-Chairman— Alderman Sir George P. Parker, O.B.E. Councillor Francis J. Pulleu. Ex-Officio— Ex-Officio— The Right Worshipful The Mayor, The Right Worshipful The Mayor, Councillor George Harvey, J.P. Councillor George Harvey, J.P. Councillor W. B. Foster Bovill. Councillor Richard Davies. „ Thomas W. J. Coffin. „ Miss Emily Dibdin. „ Richard Davies. „ Arthur C. Fox-Davies. „ Miss Emily Dibdin. „ John W. Roberts. ,, Francis J. Pullen. ,, Rev. Henry Ross. „ Rev. Henry Ross. „ Lady Smith. „ Lady Smith. „ Mrs. Ethel M. Wilson. ,, Mrs. Ethel M. Wilson. „ George Witherby. Nurse M. Baylee. Nurse M. Baylee. Miss M. R. Lovelock. Mr. Thomas W. J. Coffin. „ A. F. Filley. Miss M. R. Lovelock. „ Alice Michelmore. ,, Norah H. March, B.Sc. „ Emily R. Thoulesa ,, Alice Michelmore. STAFF. The following was the Staff during 1922. Medical Officer of Health—C. W. HUTT, M.A., M.D., D.P.H. Medical Officer of Maternity Centres—BEATRICE MARY KIDD, M.B.Lond. Medical Officer of Tuberculosis Dispensary—HARRY EVANS. M B., D.P.H. Public Analyst—JAMES HEAR COLWELL, F.I.C. Sanitary Inspectors—ALBERT BENNETT. GEORGE F. CLARK. SAMUEL LARARD, M.R.San.I. Sanitary Inspector and Health Visitor—ETHEL JANE CHARLESWORTH, C.M.B. Health Visitor—ELIZABETH LISTER SHINNIE, C.M.B. Tuberculosis Visitor—ESTHER BAYLEY (To 2nd April). ELIZABETH CAFFYN BALLARD (From 3rd April). Chief Clerk and Committee Clerk—EDWIN KENT. Assistant Clerks—FRANK FITCH. ARTHUR LONG. PHYLLIS BULL. Dental Clinic—(10, John Street). Dentist—CECIL O. GRAY, L.D.S. (British Dentists Hospital). Anesthetist—JAMES MAUGHAN, M.D., M.R.C.S. Attendant—MAUD CATER. Mortuary Keeper and Superintendent of Cleansing Station—CHARLES H. DAY. Superintendent of Women's Cleansing Station—ADELINE DAY. Caretaker of Maternity Centre—ELIZABETH ALDERTON. Home Help—ELIZABETH MOORE. Disinfector—HENRY EMMS. Assistant Disinfector—JAMES ROWAN. 3 STATISTICAL SUMMARY, 1922. Population, estimated to middle of year (as supplied by the Registrar-General) for birth and death-rates 42,85C Population—Census, 1921 43,192 Births 664 Annual Rate of Births per 1,000 population 15.5 Deaths 570 Annual Rate of Deaths per 1,000 population 13.3 Zymotic Death Rate 0.44* Tuberculosis Death Rate per 100,000 119 Excess of Registered Births over Deaths 94 Infantile Mortality per 1,000 Births 72 Area of Borough in Acres 405.1 Rateable Value 1st November, 1922 £1,350,236 A Rate of 1d. in the £ estimated to yield £5,383 *Excluding deaths from Epidemic diarrhœa. Vital Statistics. England and Wales, London and Holborn. Annual Rates per 1,000 living. Deaths under 1 year to 1,000 Births. Births, Deaths. England and Wales 20.6 12.9 77 London 21.0 13.4 74 Holborn 15.5 13.3 72 B2 4 PUBLIC HEALTH DEPARTMENT, COUNCIL OFFICES, 197, HIGH HOLBORN, W.C. 1. March, 1923. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Holborn. Ladies and Gentlemen, Herewith I beg to present a Report upon the Health and Sanitary Conditions of the Borough for the year 1922. Believe me, Ladies and Gentlemen, Yours obediently, C. W. HUTT, Medical Officer of Health. 5 NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Population and Houses. The corrected enumerated population at the Census taken on Sunday, June 19th, 1921, was- 43,192, a reduction of 6,125 on the previous census of 1911 or 12-5 per cent. During the previous decennium 1901-1911 there was a reduction of 10,048 or 16-9 per cent. The following estimate of population as supplied by the Registrar-General has been adopted for the calculation of the death-rate and birth-rate of the Borough for the year 1922—42,850. The figures in the following tables are extracted from the Census lleport, 1921: — Population. Persons. Males. Females. 1001. 1911. 1921. 1901. 191 1921. 1901. 1911. 1921. St. Giles and St. George, Bloomsbury 31,46 25,088 22,830 15,370 12,036 11,218 16,066 13,052 11,612 Lincoln's Inn 61 69 135 41 44 68 20 25 67 St. Giles and Bloomsbury 31,497 25,157 22,965 15,411 12,080 11,286 16,086 13,077 11,679 St. Andrew and St. Georgethe-Martyr 25,103 22,283 19,224 12,441 10,912 9,002 12,622 11,371 10,222 Liberty of Saffron Hill, Hatton Garden Ely Bents, and Ely Place 2,561 1,733 825 1,48S 992 370 1,073 741 456 Grays Iun 232 173 161 140 96 63 92 77 98 Staple Inn 12 11 17 9 9 11 3 2 6 Holborn Sub-Division 27,908 24,200 20,227 14,078 12,009 9,446 13,830 12,191 10,781 Holborn Borough 59,504 49,357 43,192 29,858 24,089 20,732 29,916 25,268 22,460 Wards— Bloomsbury, North 5,204 5,144 5,348 2,411 2,311 2,533 2,793 2,803 2,815 Bloomsburv, South 7,194 5,851 6,528 3,219 2,624 3,263 3,975 3,227 3,265 Lincoln's Inn 5,605 3,430 2,575 2,974 1,921 1,424 2,631 1,509 1,151 Saffron Hill 2,661 1,733 825 1,488 992 370 1,073 741 455 4,518 3,946 3,442 2,142 1,948 1,585 2,376 1,998 1,857 St. Andrew, South-East 10,549 10,038 8,740 5,506 5,006 4,164 5,043 5,032 4,576 St George-the-Martyr 10,280 8,483 7,220 4,942 4,063 3,327 5,338 4,420 3,893 St Giles, Central 9,622 7,657 5,432 5,196 4,173 2,891 4,426 3,484 2,541 St. Giles, North 3,872 3,075 3,082 1,611 1,021 1,175 2,261 2,054 1,907 6 At the Census, 1921, the number of structurally separate dwellings occupied in the Borough by private families was 6,494. A structurally separate dwelling is defined for the Census as "any room or set of rooms intended or used for habitation, having separate access either to the street or to a common landing or staircase;" thus each flat in a block of flats is a separate unit; a private house not structurally sub-divided is similarly a single unit, whether occupied by one or more families, but where a private house has been sub-divided into maisonettes each having its front door opening on to the street or on to a common landing or staircase, then each such portion is treated as a separate unit. It will be seen from the following table that at the date of the Census, 1921. there were 3,473 "buildings" in the Borough containing dwellings; 1,604 "buildings" not containing dwellings (i.e., used for business purposes only) and 12 in course of erection. In the enumeration of buildings a "building" has generally been regarded as a structure wholly detached or separated from another by a vertical party wall. A block of flats would be one building. Buildings. Kind ok Buldiso. Completed Buildings. In Course of Erection. Population. Total Separate Dwellings. Total Booms. Containing Dwellings. Not Containing Dwellings. Private Dwelling Houses, Undivided 1,280 ... ... 12,993 1,280 9,135 Ditto Structurally divided 16 ... ... 135 41 153 Blocks of Flats, Tenements, &c 416 ... ... 11,267 4,120 11,450 (Shops 886 540 1 6,324 886 5,235 Offices, Factories, Warehouses and Workshops 658 940 6 2,142 875 3,581 Hotels 66 1 5,249 Institutions 16 ... ... 1,216 Places of Worship 2 9 ... 3 Places of Amusement ... 4 1 ... Other 133 111 3 3,863 Total 3,473 1,604 12 43,192 7,202 29,554 22.3 per cent, of the private families in the Borough were found to be living in one-room tenements; 32.3 per cent, in two-room tenements; 22.9 per cent, in three-room tenements; 11 per cent, in four-room tenements and 11.5 in tenements of five or more rooms. 26,911 rooms were occupied by private families, the average number of rooms per person being 0.89. Of the total population, 8.4 per cent, resided in one-room tenements; 21.2 in two-room tenements; 19.1 in threeroom tenements and 9.6 in four-room tenements. 7 Number of Tenements. At the Census, 1921, the total number of private families in the Holborn Borough was 9,682 in comparison with 10,584 at the Census, 1911. The following table gives details of the tenements of one, two, three and four rooms:— Overcrowding. Percentage of Population ill such Tenements. Tenements with Number of Tenements. Percentage of all Private Families. Total Occupants. Percentage of Population in each group of Tenements. Average Occupants per room. No. of 1-4 room Tenements with more than two Occupants per Room. Number of Occupants of such Rooms. 1911 1921 1911 1921 1911 1921 1911 1921 1911 1921 1911 1921 1911 1921 1911 1921 One room 2398 2159 22.6 22.3 4945 3630 10.0 8.4 2.06 1.67 611 319 2382 1156 4.83 2.68 Two rooms 3447 3131 32.6 32.3 11412 9142 23.1 21.2 1.65 1.46 755 451 4506 2621 9.13 6.06 Three Rooms 2177 2217 20.6 22.9 8713 8246 17.7 19.1 1.18 1.24 262 221 2110 1719 4.27 3.98 Four Rooms 999 1064 9.4 11.0 4295 4161 8.7 9.6 10.7 0.98 54 41 545 402 1.10 0.93 Total 9021 8571 85.2 88.7 29365 25179 59.5 58.3 1.48 1.30 1682 1032 9543 5898 19.33 13.65 The word " overcrowding" is used in the sense that the tenements were occupied by more than two persons per room, and not in the legal sense, for of the 1,032 "overcrowded " tenements there were probably comparatively few for which the Council could take action to abate overcrowding. 8 The density of the population was 107 persons per acre contrasted with 60 persons per acre for the County of London. The character of population shows wide and striking contrasts, including as it does the occupants of expensive residential llats, the migratory population in the large hotels, the student class in the Bloomsbury boarding houses, residents in large commercial, social and philanthropic hostels, working class population in model dwellings and tenement lodging houses, and a large proportion of very poor people in common lodging houses. Although the number of hotels and boarding houses keeps increasing, the Borough is becoming less and less residential and more and more important as a business centre. The number of factories, workshops, workplaces and offices keeps increasing so that we are adding to our very large and crowded day population of London's workers. Occupations. The following is a summary of the principal occupations of Holborn residents over 12 years of age, viz.:—Males, 17,853; Females, 19,652:— Males. Females. Males. Females. Agriculture 59 5 Brought forward 3,398 1,677 MiniDg and Quarrying 41 1 Painters and Decorators 178 2 Pottery and Glass 49 20 Rubber, Vulcanite, Bone, &c 35 26 Chemical Processes 46 IS Workers in Mixed or Undefined Material 98 62 Metal Workers 816 44 Transport and Communication 1,924 121 Precious lletals and Electroplate 110 43 Commercial, Finance and Insurance (excluding Clerks) 2,164 1,070 Electrical Apparatus 184 10 Public Administration and Defence 682 142 Watches, Clocks and Scientific Instruments 86 14 Leather Work (not Boots) 76 50 Professional (excluding Clerks) 1,277 863 Entertainments and Sports 420 256 Textile Workers 41 25 Personal and Domestic 2,161 4,728 Makers of Textile Goods and Articles of Dress 546 913 Clerks and Draughtsmen 1,158 1,122 Makers of Food, Drinks and Tobacco 236 118 Warehousemen 462 212 Other Occupations 771 52 Wood and Furniture 295 46 lletired or not Gainfully Occupied 3,125 9,319 Paper, Priutersand Bookbinders 557 370 Builders and Bricklayers 256 — Carried forward 3,398 1,677 Total 17,853 19,652 9 The chief occupations of the day population of the Borough are connected with Professions (Law, Architecture, etc.); Public Societies' and Commercial offices; Hotels and Boarding Houses; Printing and Bookbinding; Metal Refining; Precious Stones and general trades and businesses. The population in the 999 L.C.C. tenements in the Borough was estimated at 3,493. The number of deaths was 27 or a death-rate of 7.7 per 1,000; considerably below the average death-rate for the whole of the Borough (13.3). On the other hand the number of deaths of residents of Common Lodging Houses in the Borough, which contain 1,220 beds was 47 which, calculated on the number of beds, was a rate of 38 per 1,000. Foreign Residents in Holborn. At the Census, 1921, there were 4,652 foreign residents or visitors in the Borough. Of these 227 were British subjects by birth and 259 British subjects by naturalisation. The distribution by country of birth was as follows: — Italy 1,296 United States of America 635 France 617 Poland 354 Russia 353 Switzerland 257 Belgium 225 Germany 170 Netherlands 114 Other countries 631 4,652 Registered Births and Birth-Rate. The total number of births registered as occurring in the Borough was 485, (276 males and 209 females). Of the 485, 461 were legitimate and 24 illegitimate. The registered birth rate per 1,000) of the population was 11.3. Corrected Births and Birth-Rate. I received from the "Registrar-General information of the births in outlying institutions in London of 149 legitimate infants and 44 illegitimate infants whose mothers were residents of the Borough. Fourteen of the births occurring in the Borough, viz. 8 legitimate births and 6 illegimate births, were infants of mothers who were non-residents of the Borough. 10 The following table gives the number of corrected births and the corrected birth-rates for the fifteen years 1908-1922: — Year. Total Births. Legitimate Births. Illegitimate Births. No. Rate per 1000. No. Rate per1000 of population. Proportion per 1000 total Registered Births No. Bate per 1000 of population. Proportion per 1000 total Registered Births. 1908 1066 20.41 1020 19.53 956.8 46 0.88 43.2 1909 986 19.26 935 18.27 948.2 51 0.99 51.8 1910 1017 20.27 959 19.11 943.0 58 1.16 57.0 1911 920 18.73 865 17.61 940.2 55 1.12 59.8 1912 901 18.76 835 17.38 926.7 66 1.38 73.3 1913 798 16.99 743 15.82 931.1 55 1.17 68.9 1914 765 16.33 705 15.05 921.6 60 1.28 78.4 1915 670 14.44 616 1328 919.4 54 1.16 80.6 1916 649 15.63 585 14.09 901.4 64 154 98.6 1917 571 14.50 496 12.60 868.7 75 1.90 131.3 1918 497 1206 428 10.38 861.2 69 1.68 138.8 1919 539 1356 477 12.00 885.0 62 1.56 115.0 1920 827 20.84 749 18.87 905.7 78 1.97 94.3 1921 648 14.88 593 13.62 915.1 55 1.26 84.9 1922 664 15.49 602 14.04 906.6 62 1.45 93.4 In London the corrected birth-rate in 1922 was 21.0 per 1000 in comparison with 22.3 for 1921, Mortality. The total number of deaths registered as occurring in the Borough was 746 of which 399 were males and 347 females. Of these deaths the following occurred in Public Institutions, etc., within the urea of the Borough:— Institution. Residents. Non-Residents. St. Giles and Bloomsbury. Holborn. St. Giles and Bloomsbury. Holborn.p French Hospital 1 28 — Children's Hospital — 7 — 257 National Hospital 2 69 London Homoeopathic Hospital 2 8 - 89 Italian Hospital 2 4 — 35 Alexandra Hospital — — — Private — — 23 5 Total 5 21 51 455 11 There were 342 deaths of Civil "Residents" in various Workhouses, Infirmaries, Asylums, Hospitals, etc., outside the Borough, 46 of whom were removed from Common Lodging Houses in the Borough. Corrected Deaths and Death-Rates, 1922, compared with 1921. Year. Total Deaths at all ages registered in District. Deaths in Public Institutions in District. Deaths of of nonresidents of Borough registered in District. Deaths of residents registered beyond the District. Nett Deaths' at all ages. Death Rate for Borough Death Rate. Itegistration London. 1922 1921 740 859 478 630 518 622 342 319 570 556 13.3 12.8 13.4 12.4 For details of causes of and ages at death, see Table II., page 87. Seasonal Mortality. The mortality in the four quarters of the year is shown below: — Death-rate per 1,000. Deaths First Quarter 187 17.5 Second ,, 153 14.3 Third „ 96 9.0 Fourth ,, 134 12.4 570 13.3 Infantile Mortality. The number of deaths of children under one year of age, and the number of deaths of children under one year of age per 1,000 corrected births, were the following:— Year. Deaths under 1 year of age. Deaths under 1 year per 1000 corrected legitimate Births. Deaths under 1 year per 1000 corrected illegitimate Births. Deaths under 1 year per 1000 corrected Births. London. Deaths under 1 year per 1000 Births. 1922 48 68 113 72 74 1921 51 77 91 79 80 Death-rate per 1,000 corrected births in 1922 and in ten preceding years during which details respecting births have been supplied. 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 Av'ge, 1912-21 1922 Holborn Borough Loudon 78 100 88 96 97 107 141 96 66 79 94.8 72 91 105 101 112 89 103 107 85 75 80 94.8 74 See also Table, page 68. 12 tkiring the year attention was called to the high infantile mortality rate in the Borough as given by the Registrar-General in his quarterly report for the second quarter of the year 1922, and attention has again been directed to the subject in connection with the figures published for the first quarter of the current year (1923). It should be clearly understood that the figures given in these quarterly reports necessarily refer to incompletely corrected infantile mortality rates. Corrections for deaths are made (i.e., deaths occurring in institutions of persons who were not residents of the areas where deaths take place, are transferred to the areas of residence), but the corresponding correction for births (i.e., the transference of births occurring in institutions to the residential area of the parents) is not made until after the publication of the quarterly report. Holborn has no maternity institution in the Borough, but has the advantage of a number of large hospitals with maternity wards near the Borough and many Holborn mothers go into such institutions for confinement. As a result of this the birth corrections considerably modify the Holborn infantile death-rate as will be seen from the following figures:— Infantile Death-rate in Holborn per 1000 Births Registrar General's Quarterly Report Corrected 1st Quarter 1922 90 68 2nd ,, 1922 4492 1st „ 1923 117 84 Poor Law and Hospital Relief. The Clerk to the Guardians of the Holborn Union has kindly supplied me with the following information relating to persons from the Holborn Division of the Union who received Poor Law Relief during the vear 1922. Indoor Relief 1,263 persons Outdoor Relief 420 cases Outdoor Medical Relief 183 persons Of the total number of 570 deaths, 368 died 111 hospitals and public institutions either within or without the Borough. SANITARY CIRCUMSTANCES OF THE BOROUGH. Scavenging. The removal of house and trade refuse is carried out by contract. In the main thoroughfares, and in a number of other principal streets, there is a daily collection. In the remainder of the streets the collection is twice weekly. 13 In a very large majority of the houses in the Borough, the old large fixed ashpits have been replaced by movable sanitary ashbins. The number of notices served for the absence of, or defective, nshbin was 79. Removal of Manure. The removal of manure from the various mews in the Borough was satisfactorily carried out during the year. Again no complaint was received. The probability of nuisances arising from the irregular removal of manure is considerably reduced by the substitution of motor for horse traffic. Less manure is produced and the demand for it is correspondingly increased. Sanitary Inspection of the District, including Premises and Occupations which can he controlled by By-Laws and Regulations. In addition to my inspections, the Sanitary Inspectors made 22,983 varied inspections and visits as set out in the following table. Each inspection frequently covers a number of different sanitary matters. Sanitary Inspectors' and Health Visitors' Work, Year 1922. Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Complaints received 21 44 68 3 ... 136 Do. found to be justified 20 42 62 3 ... 127 Inspection of Houses — Dwelling-houses 52 269 70 ... ... 391 Houses let in lodgings 384 3C0 203 47 ... 934 Common lodging-houses 2 5 6 ... ... 13 Drains tested by smoke 3 14 2 ... ... 19 Factories— Bakehouses 5 38 27 ... ... 70 Food preparation (other than above) ... 2 19 ... ... 21 Other 17 35 24 ... ... 76 Worksnors and Workplaces— Food premises: Dairies and Milkshops 43 87 29 ... ... 159 Ice Cream, Manufacture 15 20 157 ... ... 192 Do. Storage or Sale 8 6 1 ... ... 15 Slaughter-houses ... 6 ... ... ... 6 Hotels and Restaurants 5 74 99 ... ... 178 Butchers 343 35 247 ... ... 625 Bakehouses 7 3.5 16 ... ... 58 Fried Fish shops 182 27 145 ... ... 354 Market Streets 327 78 386 ... ... 791 Other food shops 144 63 109 ... ... 316 Laundries ... 2 ... ... ... 2 Other workshops 79 129 75 9 ... 292 Other workplaces 69 114 93 ... ... 276 Outworkers' rooms ... ... ... 27 1 28 Do. Registers 23 38 53 ... ... 114 Stable and Stable yards 50 73 ... ... ... 123 Rag and Bone shops 191 23 16 ... ... 230 Inspections carried forward 1,949 1,473 1,777 83 1 5,283 14  Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Brought forward 1,949 1,473 1,777 83 1 5,283 Miscellaneous— Black smoke 63 40 2S2 ... ... 385 Keeping of animals 1 1 1 ... ... 3 Dust, Special Inspections 4 19 I ... ... 24 Rats and Mice (Destruction Act 73 110 57 1 ... 241 Public Urinals 26 3 ... ... 29 Sale of Food and Drugs Act, samples Other Inspections 206 1 169 1 190 1 ... 3 ... ... 565 6 Periodical Inspections: Includes V.V.C. and yards, dustbins, especially houses let in lodgings, and other suitable buildings 1,732 1,819 3,313 ... ... 6,864 Re-Inspections— Houses 657 1,163 528 2 ... 2,350 Factories ... 6 1 ... ... 7 Workshops and Workplaces 78 161 100 1 ... 340 Miscellaneous 4 22 1 87 54 168 Visits re Infectious Diseases 93 150 161 205 124 733 Do. on School Reports ... 3 ... ... ... 3 Tuberculosis—First visits 20 36 81 ... ... 87 Do. Re-visits 201 72 91 ... ... 364 Scabies ... ••• ... 4 1 5 Vermin ... 2 l 15 18 36 Other Visits— Police Courts 5 5 6 ... ... 16 Various 458 649 789 22 10 1,928 Maternity— Inspections: Children under I year ... ... ... 853 269 622 Do. 1 to 5 years ... ... ... 4 1 5 Expectant Mothers ... ... ... 49 71 120 Re-inspections ... ... ... 961 1,333 2,294 Other Maternity Visits ... ... ... 47 23 70 Attendances at Maternity Centres ... ... ... 199 236 435 Total 5,545 fi.9!7 7,334 2,036 2,141 22,983 The total number of notices served for nuisances found in dwelling houses and factories, workshops and workplaces, and premises that are subject to various By-laws, was 1,710. viz.: — Public Health (London) Act, 1891— Intimation Notices 669 Statutory Notices 105 By-laws as to Houses let in Lodgings 872 London County Council (General Powers) Act, 1904— Vermin 55 London County Council (General Powers) Act, 1908 2 Bats and Mice (Destruction) Act, 1919 7 1,710 15 The following Table shows the work done to abate nuisances for which intimation notices wore served:— Water Supply— Provided 4 Cisterns, cleansed, repaired, covered, etc. 53 Waterclosets— Cleansed 48 Water supplied, flushing cistern repaired, etc. 60 Repaired, new pans, etc. 136 Ventilation improved 12 Separate accommodation for sexes provided 8 Position improved 7 Direct communication with wookrooms remedied 10 Soil Pipes— Repaired, renewed and ventilated 5 Rainwater Pipes— Repaired or renewed 26 Drains— Repaired 23 Unstopped, cleansed, etc. 35 Sinks, etc. Waste pipes, repaired, renewed, etc. 34 Yards, Areas and Wash houses— Cleansed 46 Paved and paving repaired 26 Houses and Workshops, etc.— Cleansed ... 180 Dilapidations repaired and made good 119 Ventilation improved 9 Dampness— Roofs repaired 135 Gutters repaired 10 Floor cavities ventilated 1 Other works to prevent dampness 19 Ashbins— Provided, repaired, etc. 67 Urinals— Repaired, cleansed, etc. 3 Various— Underground Rooms vacated 3 Smoke—Emission of black smoke abated 15 Animals—Improper keeping discontinued 4 Accumulations of Refuse—Removed 48 Overcrowding abated 6 Manure receptacles provided 2 Other nuisances abated 17 16 The following Table shows the nuisances for which the 101 Statutory Notices were issued under the Public Health (London) Act, 1891. Section 2 (a) Dirty and dilapidated premises, etc. 67 ,, (b) and Section 37, Ashbins 12 ,, (b) Drains and W.C.'s 36 ,, (c) Animals improperly kept 1 ,, (d) Accumulation of rubbish 7 ,, (e) Overcrowding 3 ,, (f) and 48. Water supply 5 ,, (g) Ventilation of Workshop 2 ,, 24 Smoke 5 ,, 96 Underground rooms 1 ,, 38 W.C.'s communicating with workrooms 5 , W.C.'s, separate accommodation for sexes 2 By-Laws as to Houses let in Lodgings. At the end of the year 591 houses were registered under these By-laws. Of these, 295 are in St. Giles and Bloomsbury and 296 in the Holborn District; 11 3uch houses were removed from the Register and 1 was added. There were 932 inspections of these premises, excluding a very large number of periodical inspections and re-inspections. One notice was served for an overcrowded room, and 270 notices for other breaches of the By-laws, exclusive of 601 notices that were served for annual cleansing as required by the By-laws. The draft By-laws as to Tenement Houses proposed to be made by the London County Council under the Housing, Town Planning Act, 1909, were again considered. These By-laws require increased air space for sleeping apartments, the separation of sexes, accommodation for washing clothes and for the storage, preparation and cooking of food, and proper light on common staircases. The By-Jaws are awaiting the approval of the Ministry of Health. Special enquiries were made in 102 typical tenements in the Borough to ascertain the effect the new By-laws would be likely to have on tenements. The information obtained is summarised in the Table opposite. The Table discloses the following:— Overcrowding Under the existing By-laws in 20 instances technical overcrowding exists: in the absence of alternative accommodation no action has been taken. Under the proposed By-laws 31 instances would occur. Washing of Clothes. No accommodation is provided in 41 instances. In 9 the accommodation is unsatisfactory, e.g., the water supply is a considerable distance from the copper. Table showing Conditions in Typical Talement-houses respecting Overcrowding, Accommodation for Washing Clothes, Storing and Cooking Food, &c. TYPE OF HOME. Number of Homes Reported On Overcrowded Accommodation for Washing Clothes Storage for Food Accommodation for Cooking Food Lighting of Staircase Existing By-laws Proposed New Bv-law (H.T.P. Act) Percentage Overcrowded under New By-law Provided Not Provided Percentage Not Provided Provided Not Provided Range Gas Cooker Range and Gas Cooker Open Fire Percentage with Open Fire only Natural Percentage NotAdequate Artificial Percentage Not Provided Satisfactory Not Satisfactory Satisfactory Not Satisfactory No. Per rentage. Adequate Not Adequate Provided Not Provided One room 50 4 6 12 23 3 24 48 ... 7 43 88 14 9 11 16 32 48 8 14 7 49 88 Two rooms 29 1 st room 6 8 19 15 2 12 41 2 0 22 6 9 7 10 3 10 2nd room 3 3 Three rooms 18 1 st room 2 3 22 2nd room 4 7 9 4 5 28 4 6 8 55 4 6 7 1 6 3rd room 1 2 Four rooms 5 1st room ... ... 10 2nd room ... 2 5 ... ... ... ... 2 3 60 ... 1 4 ... ... 3rd room ... ... 4th room ... ... Total 102 20 31 17 52 9 41 40 6 20 76 74 27 23 32 20 20 48 8 14 7 49 88 18 Storage of Food. No accommodation was provided in 76 instances; of the remaining 26 it was only satisfactory in 6. In many cases the food cupboard was placed next to the fire and was without external ventilation. Lighting of Staircases. Of 56 staircases inspected only 7 were provided with artificial light. As regards natural light 8 out of the 56 staircases would not comply with the proposed requirements. Cooking of Food. The provision of an open fire only may be deemed unsatisfactory; 20 such instances were found. National Rat Campaign. In accordance with the suggestions of the Ministry of Agriculture and Fisheries a National Bat Week was again observed in 1922, the dates selected being 6th-llth November. In connection with the observation of this special week in the Borough, and in order to assist in giving wide publicity to the importance of concerted efforts for the extermination of rats, arrangements were made for a Conference on the subject on the opening day of Bat Week, Monday, 6th November. The Conference was held in the Couti Boom, at the Council Offices, and was presided over by the Bight Worshipful the Mayor of Holborn, Councillor George Harvey, J.P., L.C.C. The Conference was largely attended, representatives being present from Government Departments, Naval, Military and Air Forces, County Councils, Metropolitan Borough Councils, Corporations, Urban and Bural Authorities in the Home Counties Boards of Guardians, large trading concerns, commercial and industrial organisations concerned with the importation and distribution of food stuffs and other businesses likely to harbour rats, etc. The Conference was addressed by Mr. Ernest C. Beed, Technical Adviser to the Ministry of Agriculture and Fisheries, Sir Frederick Andrewes, O.B.E. of St. Bartholomew's Hospital, Dr. W. M. Willoughby, Medical Officer of Health of the Port of London, Dr. Francis J. Allan, Medical Officer of Health of the City of Westminster, Dr. G. Millson, O.B.E., Medical Officer of Health of Southwark and Mr. E. C. Claremont, B.Sc., late Bat Bepression Besearch Chemist to the Ministry of Agriculture. The crowded attendance at the Conference M'as an evidence of the need for such a gathering and the widespread desire to deal effectively with the difficult problem of rat repression. A small exhibition was held including exhibits from the Bat Bepression Department of the Ministry of Agriculture and Fisheries, and trade exhibits of traps, poisons and various apparatus connected with rat repression. In connection with the more local efforts for the observation of Bat Week in the Borough, preparatory visits were paid by the Sanitary Inspectors to premises where rats were believed to exist and advice and information given with a view to securing general and concerted efforts for the suppression of the vermin. 19 Arrangements were made for increasing the baits to be laid down in the Council's sewers; 4,000 being used during Rat Week in comparison with the usual number, 1,000 baits per week. A number of owners and occupiers responded to the suggestion for concerted effort. A return from one firm shows 150 rats killed at its various branches as a result of Eat Week Campaign. The arrangements made by the Council as a result of the Rat Campaign in 1021, operated during the year as follows: — (1) Systematic baiting in the Council's sewers has been carried out, the baits used being barium carbonate, squill tablets, and " Dalroc." (2) The services of one of the Council's workmen has been available for the purpose of rat proofing, the cost of such service and material used being defrayed by the occupiers of premises were work is carried out. (3) The arrangement made by the Council with two firms of rat catchers for dealing with rat infested premises at the cost of the occupier has proved useful; in a number of cases considerable work in connection with rat repression and rat proofing has been carried out. In one case as many as 73 rats were killed in one night The following firms of rat-catchers carry out work connected with rat repression for owners and occupiers in the Borough at the following rates: — Small Houses 8 rooms. Stables 10 horses. Shops small. Hotels, &e., and large shops. Dalton & Son 10s. per night — £1 10s. per night Howard & Sons £1 5s. per house £1 10s. £2 2s. To be quoted for separately. (4) Suitable rat poisons have been on sale in the Public Health Department at cost price during the year. In the year 1021 the Council adopted resolutions in favour of:— (a) Registration of rat-catchers. (b) Placing on owners or occupiers of property an obligation to notify the local sanitary authority on ceasing to use any drain or similar sanitary fitting and for making it an offence to cease to use any such drain without efficient sealing off. (c) Extending liability under the Rats and Mice Destruction Act, 1919 to the "owner " as well as the occupier to rat infested premises. A considerable number of local authorities expressed agreement with these resolutions and a communication was received from the London County Council, dated 31st July, 1922, stating that after careful consideration that Council had passed the following resolutions:— (a) That legislation be promoted in the session of Parliament, 1923, to place upon owners or occupiers of property an obligation to notify the local sanitary C2 20 authority on ceasing to use any drain or similar sanitary fitting, and to make it an offence to cease to use any such drain or sanitary fitting without efficient sealing off. (b) That legislation be not promoted for (i.) the registration of rat catchers, or (ii.) extending liability under the Rats and Mice (Destruction) Act, 1919, to the owner as well as the occupier of rat-infested premises. Clauses to deal with the proposed legislation were included in the London County Council (Genera) Powers) Rill, 1923, but having regard to certain points of difficulty it was decided to give further consideration to the proposal before proceeding with the promotion of legislation on the subject. Smoke Abatement. The smoke shafts in the Borough were frequently kept under observation and in 385 cases the inspections were recorded. Many of these observations were made in the early morning when smoke pollution is more prevalent. Generally the observations extended over periods not less than one hour. Twelve complaints were received and 20 notices served, including five statutory notices. In several cases the persons concerned have supplied a better quality coal, and taken care not to burn coal dust. Cases have been brought to our notice where stokers have no means of knowing that black smoke is being emitted from the chimney. This difficulty has been overcome by a suitable arrangement of mirrors. Some of the complaints referred to premises where on inspection it was found that oil fuel was being used. I therefore made enquiries and investigations to ascertain the best method of dealing with smoke nuisances arising from the use of this fuel. As a result I ascertained that the chief factor in reducing the amount of smoke created was the minute adjustment of the amount of air entering the chamber where the oil fuel was being burnt. Common Lodging Houses Acts, 1851 and 1853. Seventeen Common Lodging Houses are registered in the Borough for 1.220 lodgers, viz , 1,058 males and 162 females. The Common Lodging House accommodation in Holborn is equal to 28 beds per 1,000 of the population, a higher rate than in any other Metropolitan area except the City of London. The death-rate amongst common lodging house residents is very high; in this Borough it was 39 per 1,000 in 1922. 21 FOOD. Dauit's, Cowsheds and Milk shops. The number of registered dairies and milkshops in the Borough at the end of the year was 154. Eleven dairies and milkshops were newly registered, and eleven removed from ibe register. Tn addition to my inspections the Sanitarv Inspectors made 159 inspections of these premises, and two notices were served for sanitary defects or breaches of regulations. Milk and Dairies (Amendment) Act, 1922. This Act received the Royal Assent on the 4th August, 1922, and came into operation on 1st September, 1922. It empowers local authorities under certain circumstances to refuse to register a retail purveyor of milk or to remove such person from the register. It also provides for the sale, under licence, of milk designated as "Certified," "Grade A," or "Pasteurised." The existing Order prohibiting the addition of colouring matter, etc., to milk is continued and extended The Act also prohibits the sale of milk from a cow suffering from tuberculosis of the udder. Other Sections deal with regulations respecting imported milk, penalties, proceedings, etc. The Act will be administered by the local authorities concerned with the enforcement of the Sale of Food and Drugs Acts. It is a matter for regret that the power to refuse registration or remove from the register is limited to "retail" purveyors and does not include wholesale dealers or producers. In connection with the registration of retail milk sellers compliance is required with the provisions of the Regulations as to Dairies, Cowsheds and Milkshops, and with the following requirements: — 1. The lighting and ventilation should be sufficient. 2. No room which is used as a sleeping room should communicate directly with the room or shop in which the milk is sold or stored. 3. The premises should be so constructed that every part of the interior is capable of being maintained in a satisfactory state of cleanliness. 4. There should be no inlet to any drain in the room or place in which milk is sold or stored. 5. Efficient means of cleansing the milk vessels, either by steam or hot water should be available. 6. A plentiful supply of water should be provided, and where a storage cistern is necessary such cistern should be properly covered and ventilated and so placed as to be readily accessible. 7. No premises should be registered where it is possible that milk may be stored in close proximity to any article capable of contaminating such milk, as for instance, paraffin, fish, coal, vegetables, etc. 8. No premises should be registered if there is a manure pit or other offensive accumulation in close proximity. 9. Efficient means for the storage and removal of house or other refuse should be provided. It is unfortunate that, by a decision of the Appeal Court, restaurants and eating houses are not required to be registered for the sale of milk by retail. However, a considerable number of such establishments in the Borough apply 22 lor registration and, subject to compliance with the conditions governing the registration of retail milk sellers, are so registered. It would be an advantage if all such places were required by law to be registered not only ft.r the sale of milk, but for the preparation and sale of food generally Mill; (Special Designations) Order, 1922. This Order issued by the Minister of Health on December 9th, 1922, prescribes the terms and conditions subject to which licences may be granted for the sale of milk designated as "Certified," "Grade A (Tuberculin Tested)," "Grade A." or "Pasteurised." These milks are to be sold under licences which will expire on the 31st December in each year. Producers, i.e., dealers having control of a herd from which milk is obtained will be licensed by the Ministry of Health, County Councils, or the Councils of County Boroughs. Non-producers who sell "designated" milk will be licensed by sanitary authorities; in London, Metropolitan Borough Councils. The schedules of the Order set out the conditions under which licences may be granted, suspended or revoked, and provide for the fees payable for licences. Up to date of the preparation of this Report licences for the sale of designated " milk in the Borough have been issued as follows:— Certified Milk. 3 Grade A Milk 2 Supplementary (Certified) 1 Pasteurised Milk. In the course of enquiries made of the managers of large milk depots respecting the sale of certified, Grade A and pasteurised milk, they expressed the view that sale of milk designated " pasteurised " is not likely to become popular at present. Many wholesale milk sellers habitually pasteurise the milk which they receive before releasing the same for retail sale and although they will continue to do this it is unlikely they will apply for certificates to "designate" and sell the same as " pasteurised " milk. It is suggested that the public would not be disposed to pay a higher price for pasteurised milk and the sale of such milk without the designation obviates compliance with the regulations. In one case it was pointed out that on the completion of pasteurising, the milk is put through a cooler. On bacteriological examination after coding the first half churn is frequently found to contain bacteria exceeding the numbers allowed by the Order. It is the practice to return this half churn for repasteurising. If the milk were sold under the designation of "pasteurised" milk this practice would be illegal and the milk wasted or sold with unpasteurised milk notwithstanding its high percentage of bacteria. The advantages of clean milk as opposed to pasteurised milk were set forth in a paper read by the writer at the Annual Conference of the Royal Sanitary Institute at Folkestone in 1921. Dirty Milk. During the year 1922 arrangements were initiated for the systematic examination of samples of milk for the presence of dirt. One hundred samples were tested. In 8 cases evidence of the presence of dirt was discovered ranging from faint traces to 7 parts per 100,000 by volume. 23 In four cases communications were sen I to the retail vendors drawing attention to the unsatisfactory condition of the milk. Communications were also addressed to the wholesalers and, where information could be obtained as to the farms from which the milk came, letters were also sent to the Medical Officers of Health of the districts where such farms were situated. In reply to such communications a Medical Officer of Health of a Rural District wrote that although the farm in question was found to be kept exceptionally well both as regards the house, farmyard and buildings, the letter had been of great help to the Sanitary Inspector of the district and any further reports of a similar nature would be welcome. The Medical Officer of Health of a County wrote that the Sanitary Inspector reported that the sheds of the farm concerned were in a clean condition, but an accumulation of mud, etc., existed near the brook where the cows drunk and possibly some of this mud adhered to the udders and if not washed before milking got into the milk. Steps were taken to deal with this condition. In another case a large wholesale company arranged for special sampling in the Holborn District, for sediment and bacteriological count and also for samples to be taken at the railway station of delivery, these steps indicate co-operation, but on the other hand, we are authoritatively informed that there is often difficulty in ascertaining the exact source from which the milk is obtained because a great proportion of milk sold in the Borough is a mixed product from many farms. A number of Medical Officers of Health have kindly supplied me with information as to action taken by them for the detection of dirt in milk. The following summary of their replies will be of interest: — Dirt in Milk, 1922. District. Samples examined for Dirt. Samples in which Dirt reported. Amount of Dirt found. Parts per 100,000. Remarks. Lancashire County 2814 62 Fourteen above 5 Forty-eight above 2 Cow dung only reported as dirt. Under 2 parts per 100,000 not included. Hampshire County 460 129 " Visible " quantities of dirty debris to "considerable " quantities Salford 426 259 0.5 to 15-0 13.1 % had2 too parts per 100,000 4'5 ., 6 to 10 ,, ,, ,, 2 samples 12 ,, ,, ,, 2 „ 15 ,, „ „ Nottingham 146 22 4.3 to 15 Samples with 4 parts or upward only included in the 22. Samples with relatively small quantities not included. Poole 121 11 lo to 35 Southport 97 1 2.8 Chester 45 4 Too small to specify. Newark-on-Trent 30 5 Traces to 4.3 St. Helens 3 1 11-4 Holborn 100 8 Faint traces to 7. 24 6 of tlie above samples. The ascertainment, of tlie amount of dirt deposited by a certain volume of milk is useful in that it is a handy measurement; the examination can be readily carried out in the absence of a bacteriological laboratory. In the cases where dirt was found in any considerable quantity a further sample has been examined later by the Borough Analyst so that an analyst's certificate could be available if required for the purposes of prosecution these examinations (6) have been carried out in 1923, dirt being discovered in five samples in quantities ranging from 0.2 parts per 100,000 to 2.2 parts per 100,000 Arrangements were made for the bacteriological examination of milk for:— (1) Tubercle Bacilli, 18 samples. (2) Organisms per cc. at 37° C. (3) Minimal volume containing B. Coli The examinations for tubercle bacilli were carried out by animal inoculation. In three cases, i.e., 16.6 per cent, evidence was established of tuberculous infection of the milk. In connection with these samples, in addition to communicating with the retailers and wholesalers, information was sent to the Medical Officer of Health of the London County Council, with a view to the farms in question being inspected. On enquiry by me it was found that the first sample was part of a consignment by "bulk." the milk originating from hundreds of separate farms so that the actual source of supply could not be traced. The seriousness of the situation was pointed out to the Secretary of the wholesale company who undertook to communicate with every one of the farmers from whom the company's supply is derived, impressing upon them the importance of having all their cows examined immediately and stopping the supply of milk from any cows suspected of being tuberculous. In the second sample two farms were inspected by the L.C.C. Inspector and 128 cows examined, but no evidence of disease detected. It was, however, ascertained that some weeks prior to the inspection two cows suspected to be suffering from tuberculosis were removed from one of the farms and slaughtered. It is possible that the sample in this case orginated from one of these cows. In the third case the farm was visited and the herd consisting of 50 cows inspected and found to be extremely healthy. No evidence of disease could be detected. In the case or the six samples examined tor organism as set out in (2) and (6) above, the results wore as follows: — No. No. of Organisms per cc grown at 37° C. Minimal volume containing Bacillus Coli. 1 9,760 0.1 cc (acid and gas formed) Organisms isolated were B. Fajcalis Alkaligenes. 2 12,600 0.1 cc (acid and gas formed) Organisms isolated were coliform and not typically B. Coli. 3 14,940 ..1 cc (acid and gas formed) Organisms isolated B. Acidi Lactiei. 4 279,000 .001 cc B. Coli isolated. 5 352,000 .00001 co B. Coli isolated. 6 86,000 .001 cc. B. Coli isolated. 25 In connection with the sample containing B. Fiecalis Alkaligenes,* a communication was sent to tlie Medical Officer of Health of the district in which the farm is situated. As a result of his inspection it was found that the milkers had an exceptionally clean bill of health and the dairy was undoubtedly above the average. The cows were examined periodically by a veterinary surgeon and any in a doubtful state of health promptly withdrawn from the milking herd. The water used was obtained from a spring which does not appear liable to contamination The milkers were said to wash their hands before milking and they wear overalls. Their milking caps, however, were, as is often the case, found filthy. Tlie farmer undertook to obtain washable caps and to take certain additional precautions. The number of milks, in the few samples submitted, found to contain dangerous organisms demonstrates the extreme necessity of constant supervision of the milk supply in London. The difficulty which arises owing to the mixing of milk from very large numbers of farms, by the great wholesale companies is of serious importance as the tracing of infected milk becomes almost impossible. Moreover, it is occasionally found that in some cases wholesalers who deal with mixed milks are reluctant to supply information as to the farms from which the milks come. It would seem desirable that wholesale milk dealers should be required to disclose to local authorities the exact source of supply in all such cases. Public Health (Milk and Cream) Regulations, 1912 and 1917. The Public Health (Milk and Cream) Regulations, 1912 and 1917, were enforced in the Borough during the year. Two hundred and thirty-one samples of milk and eight samples of cream were examined; no sample was found to contain preservative. Eleven samples of preserved cream were examined and found to be in accordance with the Regulations, the statement on the label as to the amount of preservative being in each case correct. No contravention of the Regulations was discovered during the year. Bakehouses. At the end of the year, 1922, there were 29 bakehouses in the Borough of which 18 were factory bakehouses. Although these are described as "factories" they are not large and only supply local needs; a number were formerly workshops and are now classified as " factories " owing to the installation of machinery. Two new bakehouses were opened, viz., 16, Store Street and 21, Hand Court, both are " factory " bakehouses. During the year, in addition to my inspections, there were 128 inspections of bakehouses. Seven notices were served for sanitary defects. *The pathogenity of this organism, although well established, has perhaps not received due recognition. At the end of a convincing article written by Drs. A. Rochaix and H. Blanchard in the " Annales de Medecine," Sept., 1920, p. 173, they state " it has been demontrated that this bacillus has been the cause of general infections which resemble typhoid fever, benign and without complications. A case of pyelo-nephritis has occurred in a pregnant woman due to this organism which also seems to play a certain part in intestinal infections." 26 Places where Food is prepared for Sale. Under this head are included kitchens of hotels, restaurants and eating-houses of all sorts, slaughter-houses, tripe, offal and other meat shops, fried fish, eel and other fish shops premises where ice cream is made, and other places where food is prepared for sale, excluding bakehouses which are given above. The number of such places on the register at the end of the year was as follows:— Hotels, Restaurants and Eating Houses ... 177 Slaughter-houses 1 Tripe, offal and other meat shops ... 34 Fried Fish shops 6 Fish shops 18 Tee Cream (Manufacture) 85 Poulterers 3 During the year 2,785 inspections of food premises and market streets were made and 34 notices served for sanitary defects found. The supervision of the many places in the Borough where food is sold, stored, or prepared for sale is of considerable importance; much attention has to be devoted to this work to ensure the cleanliness both of premises and utensils, and sound condition of the food. Market Streets. There were 791 inspections of market streets, each of which includes a number of stalls at which meat, fish, fruit and vegetables are sold. These streets are also regularly inspected on Saturday evenings and Sunday mornings. In these markets the food exposed for sale is subject to contamination from dust, flies and other sources of impurity. Moreover if the food is exposed for sale or stored near the roadway it may become contaminated with the excreta of animals. To a lesser extent the danger of contamination is prevalent in connection with " open " shops. In some parts of the Borough goods exposed for sale in butchers, nrovision dealers, greengrocers, and other shops, are protected by closed fronts. Tn other districts, the shops concerned are " open and the . difficulty of protecting the food from contamination is increased. It is desirable that further powers should be conferred on Local Authorities to control the sale of food and other commodities from open shops and in street markets. These powers should be sufficient to prevent contamination by street dust, animals, etc., particularly of such articles as butter, margarine, cheese, etc., which are not cooked or washed before consumption. A supply of clean water would be of especial value, particularly to the vendors of fish, vegetables, ice cream and refreshments, including coffee stalls. Such powers might also extend to the control of street vendors of food generally. 27 Fried Fish Shops. The fried fish shops in the Borough are regularly inspected to see that they are kept in conformity with the by-laws made in the London County Council. Three hundred and fifty-four inspections of such premises were made last year. At the same time a careful look-out is kept on the soundness of the fish and the wholesomeness of the materials used in frying. One new fried fish shop was opened. It was found not to comply in all respects with the hv-laws, but the owner at once carried out all the necessary work to bring the premises into conformity therewith. These works included a modification of the means provided for carrying off the fumes from frying, the exhaust pipe or flue, being carried to the top of the building. Ice Cream. During the year there were 85 premises in the Borough where ice cream was manufactured, and in addition to my inspections 207 inspections of these premises were made. The existing po.vers of Local Authorities in London for dealing with the manufacture, storage and sale of ice cream are not entirely adequate for the purpose. The manufacture and sale of this commodity is essentially an industry that should be subject to registration. The registration should extend to itinerant vendors so that the premises where ice cream containers, and other utensils used in connection with the trade are stored, could be kept under proper supervision. Further powers for enforcing cleanliness in the conduct of the business by street vendors are also desirable. Ice cream is manufactured in the Italian Colony as follows: — Premises on which 22 gallons made daily 1 ,, ,, 10 ,, ,, ,, 3 ,, ,, 8 ,, ,, ,, 2 ,, ,, ,, 4 ,, ,, ,, 10 ,, ,, ,, 2 ,, ,, ,, 12 In addition ice cream is also manufactured on the following premises:— Mr. Bennett's District. Mr. Clark's District. Mr. Larard's District. Restaurants 1 1 3 Tea Shops — 1 2 Confectioners 4 10 12 Other — 2 2 Meat. All the butchers shops were frequently inspected. The meat was found to be dealt with under cleanly conditions and no diseased meat was discovered. There is only one slaughter-house in the Borough. This was inspected on six occasions during the year. Sheep only are slaughtered. 28 Unsound Food. The following is a list of unsound food condemned during the year 1922:— Commodity. Quantity. Condition. Result of Action taken. Meat:— Fresh Cured (Bacon) 2 cwts. Contaminated by chemicals in transit Surrendered Fish:— Cod 5 stone Decomposed Do. Plaice ½ cwt. Decomposed Do. Soles 8 stone Decomposed Do. Whiting 8 stone Decomposed Do. Roe 1 stone Decomposed Do. Poultry:— Ducks 21 Decomposed Do. Vegetables:— Tomatoes 9 cwt. (18 bundles) Decomposed Do. Fruit:— Oranges 84 cases Decomposed Do. An undue amount of work is thrown on the Health Departments of Loeal Authorities in connection with the sale of fruit by retail, particularly when such sale is by street vendors, owing to the wholesalers being allowed to sell packages containing a considerable proportion of unsound fruit without previous sorting. At a Conference on the subject convened by the Islington Council, resolutions were adopted directing the attention of the Minister of Health to the necessity for the law relating to the sale of unsound food being amended so as to require the sorting of fresh fruit and vegetables and tinned food by wholesalers. Enquiries were made as to the possibility of efficiently carrying out such sorting and conclusive evidence was forthcoming that the present arrangements of the trade do not allow of this being done. Sorting is therefore left in the hands of the person to whom the goods are sold. No special place is arranged where these goods can be sorted under the supervision of a sanitary authority. The solution which finds most favour with the trader is that attached to every market there should be a sorting shed, where sorting could be carried out under the supervision of officers of local authorities. The difficulty of providing such sheds, however, in existing markets, hinders the ready adoption of the suggestion. There is no doubt that any new market established, however, should include such accommodation and every effort should be made to provide the accommodation in existing markets. The difficulties with regard to the sorting of tinned food are minimal in comparison with those conducted with sorting fresh fruit, etc. To a limited extent the sorting can be and is, carried out at the docks and wharves. If not sorted here it can and usually is carried out in the inland warehouses of manufacturers or middlemen. 29 The Holborn Council expressed agreement with the Islington Conference so far as it applies to tinned foods. With regard to fresh articles such as fruit, vegetables, etc., it considered that the difficulties of the trader at present prevent application for the proposed emendation of the law with regard to these goods. Sale of Food and Drugs Acts. The following is & list of articles purchased during 1922:— ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Apple Juice 1 1 ... ... ... ... Apricots, tinned 4 4 ... ... ... Baking Powder 5 5 ... ... ... ... Beans, canned 5 0 5 3 ... ... Bloater Paste 2 2 ... ... ... ... biscuits 1 1 ... ... ... ... Boracic Ointment 5 5 ... ... ... ... Borax, refined 6 0 ... ... ...... ... Brandy 2 2 ... ... ... ... Bread and Butter 5 5 ... ... ... ... Butter 79 77 2 1 1 Fine, £5. Calomel Ointment 3 3 ... ... ... ... Camphorated Oil 2 2 ... ... ... ... Cheese 7 7 ... ... ... ... Chicken and Tongue Paste 1 1 ... ... ... ... Chicken and Ham Paste 3 3 ... ... ... ... Cocoa 12 12 ... ... ... ... Coffee 3 3 ... ... ... ... Coffee Extract 2 1 1 ... ... ... Coffee and Chicory Extract 10 8 2 ... ... ... Cream 8 8 ... ... ... ... Cream, Preserved 11 11 ... ... ... ... Cream of Tartar 5 5 ... ... ... ... Custard Powder 2 2 ... ... ... ... Dripping 3 2 1 ... ...... ... Eggs, dried 3 3 ... ... ... ... Egg Powder 3 3 ... ... ... ... Fish Paste 3 3 ... ... ... ... Fruit Syrup 5 5 ... ... ... ... Gin 2 2 ... ... ... ... Glauber's Salts 1 1 ... ... ... ... Glucose 1 1 ... ... ... ... Golden Syrup 3 3 ... ... ... ... Gregory's Powder 8 8 ... ... ... ... Ham Loaf 1 1 ... ... ... ... Honey 1 1 ... ... ... ... Jam 6 4 2 1 Nil. Costs, £2 2s. Lemonade Powder 3 3 ... ... ... ... Lsmon J uice 1 1 ... ... ... ... Lemon Squash 7 5 2 ... ... ... Lime Juice 2 2 ... ... ... ... Lime Juice Cordial 2 0 2 ... ... ... Lobster, potted 2 2 ... ... ... ... Lozenges:— Brompton 1 1 ... ... ... ... Chlorodyne 1 1 ... ... ... ... Cough 1 1 ... ... ... ... Linseed, &c 4 4 ... ... ... ... Paregoric 5 5 ... ... ... ... 30 ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Macaroni 4 4 ... ... ... ... Maraschino Syrup 2 1 1 ... ... ... Margarine 26 26 ... ... ... ... Milk 231 224 7 2 1 Fine, £1 ; Costs, £2 6s. 6d. Milk, Condensed 10 10 ... ... ... ... Olive Oil 7 7 ... ... ... ... Orange Syrup 1 1 ... ... ... ... Paregoric Elixir 2 2 ... ... ... ... Peaches, tinned 1 1 ... ... ... ... Peas, tinned 16 3 13 6 3 Fines, £2 1s.; Costs, £3 2s. Prescriptions 5 5 ... ... ... ... Pine Apple, tinned 1 1 ...... ... ... ... Rum 2 2 ...... ... ... ... Sausages 9 5 4 ... ... ... Savoy Fingers 1 1 ... ... ... ... Salmon, tinned 2 2 ... ... ... ... Salmon and Anchovy Paste 2 2 ... ... ... ... Salmon and Shrimp Paste... 1 1 ... ... ... ... Spinnch. tinned 1 1 ... ... ... ... Sponge Biscuit 1 1 ... ... ... ... Sponge Cake 3 3 ... ... ... ... Suet, Shredded 2 2 ... ... ... ... Sweet Spirits of Nitre 2 2 ... ... ... ... Tincture of Iodine 3 3 ... ... ... ... Vinegar 3 3 ... ... ...... ... Whisky 5 5 ... ... ... Costs, £5 5s. Informal:— Flour 2 2 ... ... ... ... Frying Oil 2 2 ... ... ... ... 600 558 42 ... ... ... Summary:—231 Milk 7 not genuine = 2.0 per cent. 79 Butter 2 „ „ = 25 42 Drugs 0 „ ,, = 0.0 „ 227 Various foods 15 ,, ,, = 6.6 „ 21 Tinned Vegetables 18 „ ,, = 86.0 ,, Total 600 42 = 7.0 „ During the year we have endeavoured not only to supervise the condition as regards adulteration and possible harmfulness of food articdes generally, but also to concentrate our attention on groups of articles, e.g.. tinned vegetables coloured with copper sulphate and fruit syrups, etc. preserved with salicylic acid, which we have especial reason to believe may contain some substance prejudicial to health. This alteration of procedure accounts for the apparent increased percentage of adulteration found this year, 7 per cent as opposed to 5 per cent, in 1921. The following observations refer to samples reported to be not genuine where no legal proceedings were taken. 31 Beans—Tinned. Five samples of tinned beans were examined and were found to contair. colouring matter, namely, copper. In one case no proceedings were taken because the label disclosed the presence of the colouring matter, and in another case because proceedings for a similar offence were being taken against the same vendor. Butter. One sample contained only a very small excess of water. A cautionary letter was sent to the vendor. Coffee Extract and Coffee and Chicory Extract. Three of the twelve samples examined were found to contain salicylic acid. Cautionary letters were sent to the retailers and the manufacturers, and the sale of the extract containing the preservative was discontinued. Dripping. One sample contained a small proportion of water slightly in excess of the standard laid down in the Sale of Food Order, 1921. As, however, Part 5 of this Order applying to dripping was revoked by an amending Order dated 14th December, 1921, no proceedings were taken. Jam. One sample contained a very small addition of salicylic acid; the quantity being sufficiently small to warrant the case being met by a cautionary letter. Lemon Squash, Lime Juice Cordial, Maraschino Syrup. The quantities of salicylic acid found in five samples of these articles were too small to warrant legal proceedings without previous warning. Retailers and manufacturers were written to with a view to insuring that the sale of the commodity with salicylic acid should not continue without full disclosure on the label. Replies were received from the manufacturers pointing out that the law does not require the presence of this preservative to be disclosed. Milk. Two samples of milk were found to contain colouring matter contrary to the provisions of the Mi'k (England and Wales) Order, 1921. These were the first offences against the Ord<ir discovered in the Borough. Letters of warning were sent to the vendors. In three cases the abstraction of fat was too small to warrant legal proceedings without warning letters. A communication was sent to the vendor in each case. Peas—Tinned. Sixteen samples were examined—in 13 colouring matter, namely, copper sulphate was found ; in.seven of these no legal proceedings were instituted because the amount of copper was very small or its presence was adequately disclosed on the label. 32 Sausages. Four samples were found to contain boracic acid, but the quantity was too small to warrant proceedings. From the list of articles included in the above table it will be observed that considerable attention has been given to the administration of the Sale of Food and Drugs Acts, in the Borough. The sophistication of foods opens up problems of considerable complexity and difficulty The matter is one of special importance in a Central London Borough with its crowded day population which takes two at least of its daily meals during the working day in the Borough. Preservatives in Food. At its meeting on the 24th May the Council supported a representation made by the Kensington Borough Council to the Minister of Health, urging that in the interests alike of the public, the local authorities and the traders, the enquiry promised by the President of the Local Government Board in 1917 respecting the addition of boric, acid to cream, should be instituted forthwith and definite instructions laid down for the guidance of local authorities and traders. A reply was received from the Ministry of Health, dated 3rd August, 1922, intimating that the Minister does not feel that any useful purpose would be served by the appointment of a Committee to investigate the question of preservative iti .-ream. The communication further stated that if an investigation were made the first question for consideration would be, " In what quantities and under what conditions is boric acid dangerous to health?" In this connection the Minister was advised that no appreciable evidence has accrued since 1917, and he was of opinion that if this question were to be specially investigated the enquiry would have to relate to all foods and should not be limited to cream. The necessity to extend any investigation to articles of food other than cream has become evident. During the years 1919-20-21-22 samples purchased in che Borough have been found to contain preservatives as shown in the following table:— Preservative. Foodstuff. No. of Occasions. Quantities. Maximum. Minimum. Boric Acid Butter 62 0.4 per cent. 0.1 per cent. Do. Cream* 4 0.273 do 0.05 do. Do. Fish paste 1 9.52 grains per lb. Do. Margarine 6 0.3 per cent. 0.1 percent. Do. Sausages 7 20.04 grains per lb. 8.68 grains per lb. Copper Sulphate Peas (canned) 14 3.45 do. 0.84 do. Do. Beans do. 5 2.04 do. 1.07 do. Salicylic Acid Jam 1 0.61 do. Do. Lemon squash 2 6.3 grains per pint 0.96 grains per pint Do. Lime juice cordial 2 2.19 do. 0.87 do. Do. Maraschino syrup 1 3.9 do. *Exclusive of Cream sold as " Preserved" Cream. 33 There are many other articles of food found from time to time to contain preservative, e.g., milk, potted meat, fruit syrups, wine, etc. Dr. W. J. Howarth, Medical Officer of Health of the City of London, recently reported on the presence of boric acid in egg albumen or preserved eggs used for making sponge fingers and savoy cakes. He also reported respecting preservatives found in coffee extract. I was recently consulted by the Incorporated Institute of Hygiene in connection with some lemon juice, which it was proposed to put on the market for sale. The lemon juice contained a small amount of preservative, sulphite, which the manufacturers state is a harmless preservative. This statement is incorrect: sodium sulphite, even in minute amounts, interferes with the ferments and thus influences the digestion. When injected under the skin death is caused by paralysis of respiration. The substance, on account of its dangerous properties, was forbidden in Germany as long ago as 1898; its use is also forbidden in the United States of America from 1916 onwards. The manufacturers haveput their product on the market to some extent and hope to make efforts to extend their business shortly. In their trade literature they acknowledge the presence of the preservative, a state of affairs which is deplorable, in view of the foregoing. It might be contended that the absence of any legislation on the matter in England reveals a state of affairs by no means flattering to our scientific record. It would therefore seem desirable that such inquiry should be at once undertaken and should extend not only to boric acid but to the use of numerous other preservatives found in common articles of food. The commonest complaints from which people suffer are indigestion and headache arising from indigestion. These seriously interfere with efficiency and comfort. In many cases they arise from the use of chemical preservatives found in a variety of foods, taken day in and day out. A considerable amount of drugs are thus consumed without medical supervision or advice. Tt might be thought that the consumer has a right to know how much drug is being taken with his food, so that if he so desires he can for his guidance obtain an unbiassed and skilled technical opinion on the matter. It might reasonably be held that manufacturers should be required to disclose the nature and amount of chemical preservative in any article made or prepared by them for sale for the food of man. At present disclosure is required only in connection with the sale of preserved cream. Some manufacturers are alive to the importance and reasonableness of adequate disclosure, e.g., during the current year some samples of non-alcoholic beverages purchased in this Borough have been labelled to contain salicylic acid and samples of tinned peas, labelled to contain copper. In other cases, where only small amounts of preservative have been found and no disclosure thereof made, correspondence has ensued with the vendor and the wholesaler or manufacturer suggesting the advisability of disclosure by label. The following are extracts from replies recently received from manufacturers;— D 34 (i.) "So far as we are aware, there is no Section in the Food and Drugs Acts 01 subsequent Regulations which make it obligatory on the part of a manufacturer to state on the label that a preservative has been used and the amount, and we shall esteem it a favour if you will kindly refer us to any Section or Regulations bearing on the subject.'' (ii.) "In reply to your letter we beg to say that we have always understood that for the small amount of salicylic acid used in our cordials it was unnecessary to make any statement on the labels. If you will be good enough to inform us of the state of the law on the question we shall take care to keep within its provisions." The general standard guiding local authorities in the institution of proceedings is that suggested by the recommendations of the Departmental Committee in a Report dated 1901. These recommendations have not been given effect to by law; the standard has been found unsatisfactory moreover in connection with the greening of preserved vegetables; although three (of four) members of the Departmental Committee recommended that the use of copper salts should be prohibited, one member, in a minority report, recommended that its use should be allowed, subject to declaration and limitation to two grains of crystallised copper sulphate per pound. This minority recommendation leads to manufacturers assuming that a small quantity of sulphate of copper is allowed by the Sale of Food and Drugs Acts for the purpose of keeping the colour of peas. This assumption is wrong, but these two recommendations, neither having legal force, increase the difficulties of local authorities administering the Sale of Food and Drugs Acts. It is frequently urged by traders and their legal and technical advisers that the effect of the recommendations of the Departmental Committee is to establish a right to use chemical preservatives, although the correlative recommendation that its presence should in all cases be declared is not so generally accepted, and that its presence should in all cases be declared is not so generally accepted Local authorities are constantly called on to incur the expense of expert evidence in support of prosecutions for preservatives in food, and appeals from one Court to a higher and more expensive Court. Further difficulty is experienced by reason of the conflicting views on the use of preservatives. It will be remembered that although the Departmental Committee recommended the limitation of boric acid in cream to 0.25 per cent., the Milk and Cream Regulations fix the limit at 0.4 per cent. I have already mentioned that the Departmental Committee recommended that the use of copper salts for greening preserved vegetables should be prohibited, but one member of the Committee favoured its use, the quantity not to exceed two grains per pound crystallised copper sulphate. Yet there is considerable evidence that a quantity not exceeding one grain per pound is ample for all trade purposes. And again the Departmental Committee recommended the limitation of salicylic acid in liquid food to one grain per pint, but a case recently taken before a Metropolitan Police Magistrate where the amount exceeded two grains per pint, was dismissed with costs against the Borough Council. 35 The quantity of salicylic acid alleged by manufacturers to be necessary to preserve non-alcoholic drinks from fermentation varies according to the amount and kind of sweetening agent, but it is held by some medical experts that salicylic acid even in quite small quantities has injurious effects on digestion. Another point of difficulty which has weight with Magistrates before whom cases are heard, is that the local authorities institute proceedings against the vendor, i.e., the retailer, although in the majority of cases it is not the retailer who adds the preservative. There does not appear to be any procedure by which the local authority can take action under the Sale of Food and Drugs Acts against manufacturers. This difficulty could be overcome if the addition of preservatives was prohibited altogether or it made an offence to sell by wholesale or retail, food containing preservative, without proper disclosure of the nature and amount, of preservative used With such a mass of conflicting opinion and evidence it is not surprising that legal decisions in prosecutions for preservatives in food show little consistency, and it would seem very necessary that some definite ruling on the whole subject should be established. The Departmental Committee on the use of preservatives and colouring matters in food, was appointed in July, 1890, and the report and recommendations of the Committee were issued in 1901; 23 years have passed since the appointment of the Committee and 21 since its recommendations were issued. During this time considerable scientific progress has been made and it is reasonably certain that if an enquiry were held to-day the recommendations, if they did not prohibit the addition of preservatives, would not only suggest compulsory declaration of presence, but also disclosure of the amount and that the maximum should be limited by law. I therefore recommended:— That a communication be addressed to the Ministry of Health urging that in the interests alike of manufacturers, retailers, consumers and local authorities, steps should be taken without delay, to appoint a Committee to enquire into the use of preservatives and colouring matters in foods and that the recommendations of such Committee should be given effcct by law. The Council adopted this recommendation and a communication was sent to the Ministry of Health accordingly. Food Poisoning. At an inquest he'd during the year on the death of a resident in the Borough, the death was found to be due to syncope while the deceased was suffering from an acute attack of gastro-enteritis consequent on food poisoning. A bacillus of the Gaertner type was recovered from the spleen and bile of the gall bladder. On enquiry it was ascertained that the patient who was suffering with diarrhoea and vomiting was admitted to a nursing home in a prostrate condition. D 2 36 The patient was a resident in a private hotel where about forty visitors and ten members of the staff also resided. Five visitors and one of the staff also became ill suffering from diarrhoea and vomiting; another complained of severe abdominal pain. Those who recovered were all able to resume ordinary food within a day or so. It could not be ascertained that any article of food, except potatoes and green vegetables had been consumed by all the sufferers at the evening meal preceding the development of the illness. The potatoes were not green or sprouting. All the sufferers except the member of the staff partook of luncheon away from the hotel. It was found that the cook suffered from " bilious attacks and a bad stomach." She stated that she had an attack of diarrhoea a month previously. The attack was evident several days before the others were infected and was over well before the development of the first case. The cooking utensils were of iron and enamel. In accordance with Memorandum 30 (Foods) of the Ministry of Health specimens of blood were submitted for examination. The blood of one of the sufferers gave indubitable evidence of "Aertrycke" infection. The cook's blood gave a positive though lesser result similar to that of the sufferer before mentioned. It would therefore seem clear that the outbreak was caused by the cook infecting the food consumed at dinner (April 15th) prior to outbreak of the illness. There was no evidence as to how the cook became infected. Arrangements were made for the cook not to resume her work. Later in the year an enquiry in connection with another outbreak was made, but with a negative result. In October a communication was received from the Medical Officer of Health, Tnner and Middle Temple, respecting cases of illness, nausea, vomiting, rigors and diarrhoea, after consuming milk. The milk in question was supplied from a dairy in the Borough. I ascertained from the dairyman the names and addresses of all the customers who had been supplied from the same consignment, forwarding those which were not in this Borough to the Medical Officers of Health concerned. All were visited but no other case of illness was found amongst any of them. It is very important that a Medical Officer of Health should receive early information as to all cases of food poisoning in his district. He should not be dependent for the first information of such illnesses on casual sources such as newspaper reports, etc. It is true that neither medical practitioners nor the general public are under statutory obligation to report cases of food poisoning to the Medical Officer of Health, but in a memorandum on the subject recently issued by the Ministry of Health the belief is expressed that if it is generally undei stoo l that the local authority, with a view to safeguarding public health, is prepared to authorise any necessary enquiries and investigations, the arrangements made will receive general approval and secure the co-operation of all concerned, 37 PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. Excluding chicken pox the total number of notifications received during the year was 543 in comparison with 685 in the year 19'21. Attention has h!«d again especially to be called to the non-notification of whooping cough, primary pneumonia and ophthalmia neonatorum. A list of the notifiable diseases was in 1920 supplied to all doctors practising in the Borough. Smallpox. One notification was received of a case of smallpox a female aged 34. The patient attended a general hospital for treatment and was provisionally diagnosed as suffering from smallpox. The Hospital Authorities arranged for removal to the receiving wards of the Metropolitan Asylums Board. The patient was returned home the following day certified not to be suffering from smallpox. In the meantime the residence of the patient, bedding, etc., were disinfected and all contacts vaccinated or re-vaccinated. In consequence of the outbreak of smallpox in London special steps were taken to deal with any case arising in the Borough. Posters and leaflets respecting the advantages of vaccination were issued. Arrangements were made with the Public Vaccinators and Vaccination Officer to secure the prompt vaccination and re-vaccination of all contacts. The Medical Officer of Health also obtained a supply of lymph and in accordance with the powers conferred on him personally carried out a number of vaccinations. With a view to assisting in the detection of any suspected case in the Borough the Council, pursuant to powers under the Public Health (London) Act, 1891, made an Order requiring the notification of chicken pox for a period of six months. The Order was approved by the Ministry of Health and came into operation on the 4th day of December, 1922. Up to the end of the year, 21 notifications of chicken pox were received. All these were visited and information was sent to the Vaccination Officer respecting a number of children found to be unvaccinated. Information respecting a number of suspected cases of smallpox was furnished to the Medical Officer of Health by various medical practitioners. All these cases were at once seen by the Medical Officer of Health or one of the smallpox experts of the London County Council. Fortunately no case of genuine smallpox occurred in the Borough during the year. Sixty-two cases of smallpox were notified in London, with 20 deaths. This comparatively heavy mortality rate is an indication that we cannot legitimately 38 conclude from the relatively mildness of some recent outbreaks of the disease that the infection has definitely assumed a mild character. Tlie following Table shows the incidence of smallpox in England and Wales, London and the Borough of Holborn during the twenty years 1902-21. Smallpox, 1902-21. YEAR. England and Wales. London. Holborn. Cases. Deaths. Death Hate per 100,000 Cases. Deaths. Death Hate per 100,000. Cases. Deaths. Death Hate |Per 100,000. 1921 316 5 0.0 2 0 0 .0 1 0 0.0 1920 263 30 0.1 19 2 0.0 0 0 0.0 1919 297 28 0.1 26 6 0.1 0 0 0.0 1918 64 2 0.0 34 0 0.0 1 0 0.0 1917 7 3 0.0 0 0 0.0 0 0 0.0 1916 151 18 0.0 2 0 0.0 0 0 0.0 19!5 92 13 0.0 13 3 0.1 0 0 0.0 1914 66 4 0.0 3 0 0.0 0 0 0.0 1913 116 10 0.0 4 0 0.0 0 0 0.0 1912 124 9 0.0 6 1 0.0 0 0 0.0 1911 293 23 0.0 72 9 0.2 0 0 0.0 1910 135 19 0.0 7 0 0.0 0 0 0.0 1909 ... 21 0.0 21 2 0.0 1 0 0.0 1908 ... 12 0.0 4 0 0.0 0 0 0.0 1907 ... 10 0.0 8 0 0.0 0 0 0.0 1906 ... 2! 0.1 31 0 0.0 0 0 0.0 1905 ... 116 0.4 74 10 0.2 1 0 0.0 1904 ... 507 1.5 489 25 0.6 6 2 0.00 1903 ... 760 2.3 417 13 0.3 2 0 0.0 1902 ... 2,464 7.5 7,798 1,314 28.5 217 46 78.5 Vaccination. Whilst it is true that the extensive vaccination of large numbers of men during the war years has conferred n degree of immunity, it is equally true that the resumption of intercourse with all parts of the world, on the cessation of hostilities, has increased the danger of the spread of infectious illness. Moreover, the increasingly large number of children who are unvaccinated produces a further accumulating danger and signs are not wanting that serious outbreaks of smallpox in England are threatened. The neglect of vaccination can only be fraught with most grave risks. 39 Not only is vaccination easy to evade, but the law, as at present operating, does not compel vaci-ination or re-vaccination of actual contacts. The following Table, kindly supplied by the Vaccination Officer of the Holborn Union gives information respecting vaccination in the Borough of Holborn:— Total Number of Births Vaccinated Died before Vaccination Cons. Objectors Insusceptible Postponed by Medical Certificate Removed Temporarily Unaccounted for IIOLBOKN SUK-UISTltlCT: July to December, 1921 146 51 13 23 1 18 21 19 and January to June, 1922 159 61 14 24 0 17 23 20 303 112 27 47 1 35 41 39 St. Giles and Uloomsbuhy Sub-District: July to December, 1921. and 89 39 6 12 0 11 9 12 January to June, 1922 101 41 6 27 0 9 10 8 100 80 12 39 0 20 19 20 Diphtheria. One hundred and eight notifications of diphtheria were received during the \ear at the following ages: — Under 1 year 1 1 to 5 years 30 5 ,, 15 ,, 49 15 ,, 25 10 25 „ 45 10 45 ,, 65 2 Of these 107 were removed to hospital. Eighteen cases were returned from the hospitals of the Metropolitan Asylums Board certified as not suffering from diphtheria. Four of these were apparently "carriers" as diphtheria bacilli were found in the swabs taken before removal of the patients. Four deaths occurred. Ten " secondary " cases were notified, but as two of these were found not to be diphtheria the number of genuine " secondary " cases was only eight. A secondary " case is one occurring in the same household as the primary case. There was one " return " case notified twelve days after the return of the original case Swabs were taken from the throat and nose of the original case after her return from hospital when she was found still to be harbouring diphtheria bacilli. 40 One case of diphtheria was re-notified a week after the return home from hospital as bacteriological examination gave a positive result. This patient was, in consequence, isolated at home; a second bacteriological examination a fortnight later gave a negative result. In London 15.272 cases were notified giving rise to 1,137 deaths. We endeavour to co-operate with the Medical Superintendents of the Metropolitan Asylums Board Fever Hospitals; information is now sent to them as to any bacteriological examinations before admission or after discharge of the patients, and also with regard to return cases of scarlet fever. The practice of taking swabs from the throats and noses of child contacts was continued during the year and 79 children were so swabbed. In four families swabs were also taken from mothers, making a total of 83 contacts dealt with. Of these 31 were negative and in 53 (64-6 per cent.) positive results were obtained. In three cases where clinical symptoms also indicated diphtheria, the contacts were notified as suffering from diphtheria and were removed to hospital. The remaining positive cases were re-swabbed at intervals of a fortnight until found negative the results of the examinations being shown in the following Table:— Diphtheria Contacts. Bacteriological Examination of Nose and Throat Swabs. Total Contacts swabbed 83 Negative 31 Positive 52 Contacts swabbed. Positive Results. Contacts positive. Nose and Throat. Nose only. Throat only. First Examination 83 9 37 6 52 Second ,, 52 6 17 2 25 Third „ 25 3 11 1 15 Fourth ,, 15 ... 8 1 9 Fifth ,, 9 2 4 ... 6 Sixth ,, G ... 4 ... 4 Seventh „ 4 ... 2 ... 2 Eighth ,, 2 ... 1 ... 1 Ninth ,, 1 ... 1 ... 1 Tenth ,, 1 ... ... ... ... The parents of persistent carriers were advised to obtain treatment for the children concerned and were recommended to take such contacts to St. Mary's Hospital for treatment and by inoculation with vaccine made from the patient's own germs. 41 In four cases the advice given was taken and the treatment continued until the children were found to be free from diphtheria bacilli. In five cases of persistent carriers tests for virulence were made; all these cases were found to be avirulent. The parents or others in charge of children harbouring diphtheria bacilli were given written directions as to the precautions necessary; these are detailed below:— 1. Until the Holborn Health Department or the London County Council notifies the parent or guardian to the contrary, attendance of the "carrier" at day school, Sunday school, cinemas, theatres, music halls, teas or treats or any gatherings is forbidden. The child must be kept away from all other children and no other child be allowed to visit the house. 2. The child must sleep by himself or herself. 3. Special cups saucers, plates, spoons, knives and forks should be reserved for the use of the carrier and washed up separately after the others have been washed up. 4. The child should use pieces of rag instead of handkerchiefs. These rags should be burnt as soon as possible. 5. No books belonging to a public library should be read by the " carrier," or any book which the parents or guardian are not prepared to destroy or have disinfected by the Public Health Department. The results of the examinations of child contacts were communicated to the School Medical Department of the London County Council so that children harbouring diphtheria bacilli could be kept from school providing there were no evidence that the organisms were avirulent. Diphtheria anti toxin was supplied free of charge on application by medical practitioners. During the year it was supplied in 15 cases. The Schick Test and Immunisation against Diphtheria. The Schick test is made by injecting a minute amount of diluted diphtheria toxin into the skin, the skin of the forearm being usuallvselected. If the person is immune to diphtheria, that is to say, if his blood contains substances that neutralise the toxin that is injected no change occurs, but if his blood does not contain this anti-toxin a small rose coloured spot appears at the point of injection and persists for a few days; little or no discomfort is caused. We know that all persons are not susceptible to diphtheria. The value of the Schick test lies in its selecting those who are susceptible to the disease so that they may be immunised by a mixture of toxin and anti-toxin. At, and for a short time after birth very few children (probably less than 10 per cent.) are susceptible to diphtheria infection on account of the anti-toxin which they have absorbed from their mothers. This natural immunity rapidly diminishes until, at the end of a year, positive Schick reactions show that threequarters of all children are susceptible. As the result of repeated small doses of 42 diphtheria protein in the succeeding ten or fifteen years of life, many of these previously susceptible children develop some degree of immunity, although about one-third of the young adult population is still capable of being infected with diphtheria. The ideal precaution, if parents only knew of it and would use the safeguard, would be to immunise all children at the age of six months. If this were done many lives would undoubtedly be saved; in London during 1922, 1,137 nersons, mostly children, died from diphtheria; another 1.1,135 persons suffered from an attack. Most, if not all, these deaths and illnesses could have been prevented. Three injections each of 1 c.c. of a suitable anti-toxin mixture will cause about 85 per cent, of susceptible children or older persons to develop sufficient anti-toxin to produce marked, if not absolute, protection against diphtheria. The remaining 15 per cent, can be immunised by a further course of injection, repeated if necessary yet once again. The development of immunity is a natural proccss and is therefore not rapid; from one to six months must pass before the previously susceptible persons becomes immune; although immunity can be produced by the injection of anti-toxin such artificial immunity lasts only for n short time, for a fortnight to a month, but the natural immunity caused by the toxin-anti-toxin injection persists; in at least 90 per cent, it lasts for a certainty for six years and in all probability for the remainder of life. A very large number of parents of children residing in Holborn were informed by the Health Visitors and Sanitary Inspectors of the possibility of preventing their chi'dren from catching diphtheria. They were told verbally and given a leaflet written in simple language. As the result of the persuasions of the staff, chiefly of the Health Visitors, a considerable number of persons (133) were tested; of these a very fair proportion —98 out of 13.3 (G6 per cent.)—completed the course of immunisation. This work has been carried out by Drs. O'Brien, Okell and Eagleton; we are indebted to Mr. Henry Wellcome for providing the facilities. Tlie following T.ihle gives details of the tests carried out:— Schlick Testing and Anti-Diphtheria Immunisation at the Holborn Borough Council's Maternity and Child Welfare Centre, No. 10, John Street, Theobald's Hoad, from April 24th, 7922, to December 31st, 1922, inclusive. Totol tested. Result of Test. Immunisation of Positives. Tested after third inoculation and found Tested after fourth inoculation and found negative. Negative. Positive. No read. Three inoculations. Failed to complete three inoculations. Did not begin inoculatious. Inoculation postponed. Negative. Positive. Children 183 49 129 6 96 18 13 1 40 1 1 Adults 21 17 4 2 2 1 1 1 0 1* ... Total 207 66 133 8 98 19 14 2 40 2 1 *Did not continue inoculations. Total attendances during the year 711 43 That immunisation should not be delayed and should be carried out in connection with Infant Welfare Centres rather than institutions which deal with children of later age is well borne out by the facts as regards the age of attack and mortality given below. The number of deaths shown in the following Table do not bear an exact relationship to the number of cases notified because some of the deaths included as occurring in 1919 may have been cases notified during the latter part of 1918, and some deaths of eases notified in the latter part of 1921 may not have occurred until 1922. The figures, however, give a useful indication that diphtheria attacks a considerable number in the early years of life with a high mortality rate. It will be seen that 26.9 per cent. of the total cases were children under five years of age and these notifications accounted for not less than 52.6 per cent. of the total deaths. AGES 1919 Notifications Deaths 1920 Notifications Deaths 1921 Notifications Deaths Three Years, 1919-21 Notifications Total Received % of Total all Ages Total Deaths %of Attacks % of Total all Ages Under 1 year llto 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 10 years 10 to 15 years 0-15 years All ages 169 354 531 788 826 3804 1461 7933 0181 37 66 305 345 753 775 281 539 689 957 1138 5522 2357 11483 13734 62 98 379 446 985 1023 353 957 883 994 1207 6082 2996 13472 16281 66 165 374 503 1108 1150 803 1850 2103 2739 3171 15408 6814 32888 39496 2.0 4.7 5.3 6.9 8.0 39.0 17.3 83.2 100.0 165 329 1058 1294 2846 2948 20.5 I7.6 13 .2 5.8 8.6 7.4 5.6 11.l 35.9 43.9 96.5 100.0 Scarlet Fever. All the 147 cases of scarlet fever were removed to hospital with the exception of three which were satisfactorily isolated at home. Two cases were returned from hospital "not scarlet fever." In connection with 13 of the cases during the year there were 37 secondary cases. Thirty-five of these were notified either at the same time or within a few days of the primary case. Of these secondary cases 14 were among the staff of two hospitals and 10 lived at a large residential establishment. There was one "return" case, i.e., a case of scarlet fever occurring within 28 days of the return from hospital to the same house of a previous case of scarlet fever. The "return" case was notified eight days after the return home of the 44 primary case The primary case was reported to have a discharge from the nose and on examination was diagnosed by me as still suffering from scarlet fever; swabs taken from the patient's nose and throat gave evidence that he was also a diphtheria "carrier." I notified the case and the boy was again removed to hospital. Return cases occur when patients are treated at home and in much the same proportion There were two deaths from scarlet fever. 17,225 cases of scarlet fever were notified in London with 299 deaths. One patient notified in 1921 who returned home in December, 1921, and gave rise to a "return" ease that year was kept under observation, owing to nasal discharge. The chid was not fit for readmission to school until the middle of June, 1922. Puerperal Fever. No case of puerperal fever was notified; but in the causes of deaths as classified by the Registrar-General, one death is included as caused by puerperal sepsis. This classification was made as a consequence of a further enquiry to the certifying medical practitioner, who stated that when he attended the patient she had just returned in a hopeless condition from hospital, where she had been under treatment for five months. She was suffering from septic endometritis and chronic heart disease and died in three weeks. The medical practitioner was informed that endometritis was due to an incomplete abortion which had occurred some time previous to her admission to hospital. 311 cases were notified in London, and gave rise to 122 deaths. Enteric Fever. Four cases were notified during the year. 265 cases were notified in London, with 44 deaths. The first of the four notified cases was that of a female, ago 17, a visitor at one of the hotels in the Borough, who was removed to a nursing home for treatment. The diagnosis was confirmed by bacteriological examination of blood and urine. The patient and her parents were visiting London from their home in Caermarthenshire. It was ascertained that three or four weeks prior to the onset of the illness the patient had partaken of cockles in connection with a village fete. As a result of enquiries made by the Medical Officer of Health of the County it was ascertained that two other members of the party were found to he ill with abdominal symptoms but apparently neither of these were notified as cases of typhoid fever although the County Medical Officer of Health expressed the view that the history suggested that both patients suffered from paratyphoid fever of one type or another. The second case notified, eventually was found not to be a case of enteric fever. He was a schoolboy aged 12 years. On post mortem examination the disease was ascertained to be cerebro-spinal meningitis. 45 The third cast: notified was contracted abroad, the illness beginning when the patient was at sea two days off Bombay on the homeward journey. The fourth case was a male age three years, admitted for treatment to the London Homeopathic Hospital. No bacilli were isolated on bacteriological examination at the date of his admission, but subsequently on further examination of urine the bacillus of paratyphosus A was isolated; this was confirmed by an examination of a further specimen of urine; the blood agglutination test was positive. The family of the patient eat much fish and the mother thought it very probable that the child had recently partaken of such food. The child, however, had drunk water from puddles in the street gutters. Typhus Fever. No case of typhus fever was notified during the year. Information was, however, received from the Medical Officer of Health of St. Marylebone, respecting a contact of a case of the disease notified in that Borough. A contact of the patient was found to be employed in Holborn. Investigations wore made and it was ascertained that the contact had been excluded from work until the possibility of infection had terminated. Two cases were notified in London. Cercbro-Spinal Fever. One notification of a case of cerebro-spinal fever was received after death; the case was first notified as enteric fever, the diagnosis cerebro-spinal fever not being mad until post mortem examination. 84 cases were notified in London. Dysentery. No case of dysentery was notified. 27 cases were notified in London. Malaria. No case of malaria was notified. Encephalitis Lcthargica. One case of encephalitis lethargica was notified in the Borough during the year. The patient, a male aged 14, was admitted to the Charing Cross Hospital where he died. 68 cases were notified in London. Acute Poliomyelitis. One case of acute poliomyelitis was notified, 38 cases were notified in London. 46 Pneumonia. Sixty-four cases of pneumonia were notified during the year. Twenty-two of these were influenzal pneumonia. The 42 cases of primary pneumonia were notified at the following ages:— Under 1 year, 3; from 1 to 5 years, 10; from 5 to 15 years, 2; from 15 to 25 years, 2; from 25 to 45 years, 11; from 45 to 65 years, 10; and 65 years and upwards, 4. Seventeen of the 12 died. Nineteen were treated at home; twelve were removed to voluntary hospitals; nine to Poor Law Infirmaries; one to a hospital of the Metropolitan Asylums Board, and one to a private nursing home. Six of the patients were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. 7,066 cases were notified in London. Influenza. There were 21 deaths from influenza in comparison with 8 in 1921, 11 in 1920, 46 in 1919, and 138 in 1918. A minor wave of influenza passed over the country during the latter part 1921 and the early part of the present year. The disease is not notifiable and the extent of its prevalence has therefore to be estimated on the number of deaths recorded. This number showed signs of increase in the early part of December, 1921, and continued to increase until the middle of January, 1922, from which date the outbreak subsided. Having regard to the population of Holborn in comparison with the whole of London the deaths recorded in the Borough are less than our numerical proportion, the rate in London being 0.57 per 1,000 and in Holborn 0.49 per 1,000. Moreover as we have a large amount of common lodging house accommodation and our population probably includes more than the norma! proportion of old people, it would appear that the incidence of the disease in the Borough was somewhat less severe than in London as whole. Steps taken to deal with the outbreak included a supply of anti-influenza vaccine; the exhibition of warning posters; the distribution of special leaflets; the maintenance of efficient and uninterrupted ventilation in theatres and cinemas churches and other places of assembly; and a communication to proprietors of restaurants respecting the necessity for thoroughly cleansing all glasses, drinking utensils. etc. Anthrax. No case of anthrax was notified during the year. Venereal Disease. During the year the Council were requested to support a resolution adopted by the Wandsworth Borough Council asking the Government to promote legislation providing for the compulsory treatment of cases of venereal disease, subject to adequate safeguards being taken to prevent publicity. 47 In connection with this subject I submitted a report to the Public Health Committee on the securing of effective medical treatment of venereal diseases, especially directed towards the advisability of initiating legislation requiring those who commenced their treatment in V.D. Clinics to complete the same. Botulism. No case of botulism in the Borough of Holborn was brought to my notice. Cases, however, occurred in the country. In consequence of these and with a view to meeting any possible outbreak the Ministry of Health arranged for a supply of an anti-toxin serum. I forwarded the information to all medical practitioners in the district, giving details respecting the symptoms of the disease, the administration of anti toxin and the necessity for the early application thereof in any suspected case. Bacteriological Work. The following Table gives details of the examinations made during the year: — Diphtheria Enteric Fever Consumption Other Diseases Number Submitted Result of Examination Number Submitted Result of Examination Number Submitted Result of Examination Number Submitted Result of Examination 572 377 bacilli not found Negative 81 71 bacilli not found 3 3 Negative 175 bacilli found Positive 10 bacilli found 0 Positive Disinfections. During the year 389 rooms and 3,991 articles of bedding, clothing, etc., were disinfected after various infectious diseases. Twenty nine disinfections were carried out after tuberculosis. Special attention is devoted to toys and more particularly to any toy put in the mouth These latter are as a rule destroyed. In addition to the above, 3,513 articles of bedding, clothing, etc., were disinfected at the request of the Medical Officer of Health of Finsbury, during repairs to the disinfecting apparatus in that Borough. Arrangements were also made at the request of two firms for the disinfection at the cost of such firms, of a large quantity of second-hand clothing, prior to exportation to South Africa; 307,214 articles were so disinfected and certificates given. Payment for this work was made amounting to £199. Cleansing of Persons Act. During the year 120 persons (113 men and 7 women) infested with vermin had their bodies and 1,232 articles of clothing disinfected. free of charge, at our cleansing station Goldsmith Street. 48 Scabies. In connection with our co-operation with the London County Council School Medical Service, information is received from the Medical Officer of Health of the London County Council respecting children attending schools in the Borough, found to be verminous or suffering with scabies. During the year 36 cases have been visited for vermin and five for scabies. Tn all cases where, on such visitation, the homes or bedding are found to be in a verminous condition the necessary steps for remedying such conditions are taken. Shelter during Disinfection. For some years past the arrangement has been in operation with the Council of the Metropolitan Borough of Finsbury for accommodation to be provided at their Reception House, Northampton Road, for residents of this Borough during the disinfection of their homes after infectious disease. During the year the arrangements were revised the payment to the Finsbury Council for facilities offered being increased to £37 10s. 0d. per annum. Public Health (Tuberculosis) Regulations, 1912. Summary of Notifications during the period from 1st January, 1022, to the 30th December, 1022, in the Metropolitan Borough of Holborn. Age-periods. Notifications on Form A. Notifications on Form B. Number of Notifications on Form C. Number of Primary Notifications. Total Notifications on Form A. Number of Primary Notifications. Total Notifications on Form B. Poor Law Institutions. Sanatoria. 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and upwards. Total Primary Notifications. Under 5. 5 to 10. 10 to 15. Total Primary Notifications. Pulmonary Males ... ... 1 ... 2 2 9 9 13 3 1 40 49 ... 1 ... 1 1 40 25 ,, Females ... 1 2 4 3 7 5 5 1 ... 28 34 ... ... ... ... ... 13 27 Non-pulmonary Males ... 3 2 2 1 1 ... ... ... ... ... 9 14 ... ... ... ... ... ... 2 ,, Females ... 1 ... ... ... 1 2 ... ... ... ... 4 4 ... ... ... ... ... ... 4 Tuberculosis Notifications. Excluding duplicates the total number of notifications received during the year, 1922, was 82, namely private cases 23, hospital cases 46, poor law cases 12 (Holborn Infirmary 11, City of Westminster 1), school case 1. Of the total notifications 68 were pulmonary tuberculosis and 14 nonpulmonary tuberculosis. Forty-one of the cases were removed for treatment to hospital, infirmary or sanatorium, 49 The following summary gives the position at the end of 1922, of the 82 cases notified during the year: — Dead 22 Cases removed to Hospital and still in-patients at the end of year 11 Out patients at Hospitals 2 In-patients in Sanatoria at end of year 13 In-patients in Infirmary 2 Not traced—Incorrect addresses 4 Removed from Borough 15 Dispensary Treatment 5 Home Treatment 8 82 Only 27 of the 82 notified eases attended the Holborn Tuberculosis Dispensary. The following indicates the reasons for non-attendance in the remaining cases:— Removed to Hospitals, etc. for treatment without prior attendance at Dispensary 30 Out patients at other Hospitals or Dispensaries 1 Dead before notification 8 Private home treatment 4 Not traced 4 Removed from Borough 8 55 Delayed Notification. The Public Health (Tuberculosis) Regulations, 1912, require notification within 48 hours of the medical practitioner first becoming aware that the person is suffering from tuberculosis. It is still found that medical practitioners do not notify cases of this disease until tubercle bacilli have been found in the sputum and in a number of cases notifications are not received until the death of the patient or shortly before death takes place. In the past year eight cases were notified only at death, four within one month of death, four within three months and four within six months of death. In this connection I wrote to the London Insurance Panel Medical Committee and the Local Branch of the British Medical Association, drawing attention to the desirability of early notification. Communications were also addressed to a number of medical practitioners, hospitals and other institutions, respecting delay or non-notification. In some cases where the first information was received after death it was reported that the true nature of the disease was diagnosed for the E 50 first time only at post mortem examination. Other reasons given for nonnotification include difficulty of diagnosis and the belief by the medical practitioner concerned that the case had already been notified by a doctor previously attending the patient. It is unfortunate that by a proviso in the Eegulations of 1912, a medical practitioner is not required to notify a case of tuberculosis if he has reasonable grounds for believing that the case has already been notified. It would seem that any disadvantage accruing from duplication would be easily outweighed by the advantage of the additional encouragement to promote early notification which would ensue from the withdrawal of this proviso from the Regulations. The Eegulations also require notification of the admission and discharge of patients to poor law institutions and sanatoria. It has been found necessary during the year to communicate with both classes of institution drawing attention to the Eegulations and urging strict compliance therewith. Institutional Treatment. During the year notifications were received of 111 admissions to institutions. These admissions represent 77 patients, some of whom are transferred from one institution to another, and others are discharged, or take their own discharge, and subsequently are re-admitted. The 111 admissions were to the following institutions: — Poor Law Institutions 59 Institutions of the Metropolitan Asylums Board 32 Other Institutions 30 111 Thirty-four of these admissions were transfers from one institution to another or re-admissions. Visitation of Homes, etc. Arrangements have been made for the home visitation of all non-Dispensary cases by the Sanitary Inspectors. Any patients attending the Tuberculosis Dispensary come under the care of the Tuberculosis Nurse; all others are re-visited at least once a quarter by the Sanitary Inspectors in order to secure the proper disposal of the sputum and the best use possible of the sleeping accommodation. The visitation of tuberculosis patients is frequently rendered difficult because the patients are away from home; in the early stages of the disease patients are not necessarily kept from work and the proper visitation of such patients frequently entails two or three calls by the Inspector or Visitor. Owing to the migratory character of a fair proportion of the notified cases it is somewhat difficult to keep the Tuberculosis Register of a district such as Holborn correctly revised: a considerable number of visits by the staff must be made for this purpose. Contacts. Contacts are invited to attend for examination at the Tuberculosis Dispensary. 51 Fifty-one, 21 adults and 30 children under fifteen years of age, responded to this invitation and were examined for the first time during the year 1922. Of these, five, namely three adults and two children. were found to be suffering from pulmonary tuberculosis; two, both children, from non-pulmonary tuberculosis. Forty-three were definitely diagnosed as not suffering from the disease and one remained doubtful at the end of the year. The routine examination of contacts is desirable as a means of discovering not only cases of tuberculosis in early stages of infection, but also advanced and infective cases which may be disseminating infection although remaining undiscovered and untreated. Arrangements were made during the year for fuller co-operation with the school medical services so as to ensure that no contacts of school age will remain unexamined; if such examination cannot be carried out at the Dispensary the School Medical Officers are notified so that the examination may be carried out at the school. Information as to the results of such examinations, whether at the Dispensary or the schools is interchanged as necessary. Prevention of Spitting. The necessity for the prevention of spitting, with a view to minimising the spread of tuberculosis has been emphasised by the issue of warning cards on the subject. These have been exhibited in the various buildings in the control of the Council also in common lodging houses. In order to secure wider publicity for this card a number of large firms in the Borough were invited to exhibit them. Fifty-eight firms agreed to do so and the necessary supply of cards were furnished to them for the purpose. Deaths from Pulmonary Tuberculosis. The number of deaths from pulmonary tuberculosis during the year was forty-three, a death rate of 1.00 per thousand in comparison with 0.96 for 1921. The following Table shows where the patients died in their own homes or institutions: — Shoiving the number of Patients who died in their own homes and the number who died away from home in Hospitals or other Institutions. 0- 1- 6- 10- 1.-- 20- 25- 35- 45- 55- 65- All Ages. Males. Females. Total. Number of patients who died at home ... ... ... ... 2 1 2 1 3 2 6 5 11 Number of patients who died in hospitals, ete. ... ... 1 1 2 3 4 13 5 3 22 10 32 — — — 1 3 3 5 5 16 5 5 28 15 43 E 2 52 Tuberculosis Dispensary. Since February, 1915, the Council has made arrangements with the University College Hospital, conjointly with the Borough of St. Pancras for dealing with cases of tuberculosis, including contacts, both insured and uninsured. These are examined by the Tuberculosis Officer on Tuesday and Friday afternoons and Thursday evenings and the reports sent me and arrangements made for their removal to hospitals or sanatoria when required. They are visited at their homes by the Tuberculosis Nurse. who reports to and consults with me weekly, and at other times in emergency. The following is the Report of the Tuberculosis Officer, Harry Evans, M.D., D.P.H., for the year 1922. Number of Cases examined for the first time in 1922:— Insured. Non-Insured. Children under 15. Males. Females. Males. Females, M. F. Total. 24 10 7 24 27 24 116 Analysis of 116 New Cases in 1922:— Examined for first time during year. Found to be suffering from Tuberculosis. Not suffering from Tuberculosis. Doubtful Cases. Pulmonary. NonPulmonary A. All persons including "Contacts." Adults M 31 18 1 11 1 F. 34 11 2 16 5 Children M 27 2 1 20 4 under 15 F. 24 2 3 17 2 Total 116 33 7 64 12 B. "Contacts'" included in A. Adults M. 6 1 5 ,, F. 15 2 12 1 Children M 18 2 16 under 15 F. 12 2 10 C. Insured persons M 24 15 1 7 1 included in (A) F. 10 5 4 1 Attendances and Examinations at the Dispensary in 1922:— Insured. Non-Insured. Total Attendances 452 372 824 Examinations 361 282 643 Number referred to Hospital Departments 5 4 9 Specimens of Sputa examined 89 57 146 Supervision of Home Conditions:— Nurses' Visits ... ... 1,709 M.O.'s Visits ... ... 15 5.3 Reports and Communications:— Insured. Non-Insured. Total. To Public Authorities 293 67 360 To Practitioners 16 18 34 Summary of 84 Cases disposed of in 1922 Left the Borough 49 Definitely Non-Tuberculous 17 Died 18 84 Number of Patients under treatment or supervision at the Dispensary 31st December, 1922 432 The following report on the work in the Borough for the year is made under the headings given in Para. 13, Memo. 37/T of the Ministry of Health. The close co-operation with the Local Authorities in matters connected with the Dispensary work has been maintained. All the notifications received by the M.O.H. of the Borough are forwarded to the Tuberculosis Officer. The statutory visit to the homes is made by the Sanitary Inspector and if the patient has not already attended the Dispensary he is advised to do so without delay, unless he is already attending some other Dispensary in the neighbourhood. Periodic consultations between the T.O. and the M.O.H. of the Borough are held and the T.O. submits a return of the work done in the Dispensary to the M.O.H. at the end of each month. The lists of cases in the two Departments are frequently compared and corrected. The Medical Officers of the School Clinics and the Child Welfare Centres regularly refer to the Dispensary any patient upon whose condition they desire an opinion. Co-operation with the medical practitioners and the Dispensary is improving and a fair proportion of the new cases seen are sent on the advice of the practitioner. Every effort is made to secure the attendance for examination of all contacts of notified cases; it is found that fit members of a family are sometimes reluctant to come. In such cases selected contacts from the family are examined, i.e., the nurse enquires carefully after the health of each member of the household, and if there is any doubt as to the complete fitness of any individual, an appointment for examination in the Dispensary is arranged. All the homes of notified cases are periodically visited by the Dispensary Nurse (if Dispensary cases) or the Sanitary Inspector and reported on; these visits are made at three monthly intervals and more often if necessary. 54 The arrangements under the heading,of General Supervision includes: — (1) Periodic examination in the Dispensary when advice is given rc mode of life and prevention of infection. (2) The supply of medicines to non-insured patients. (3) The supervision of the home conditions by the Dispensary Nurse. There is an evening Dental Clinic at 10, John Street, Theobald's Road for patients residing in the Borough. Fourteen patients were referred for dantal treatment in 1922 Cases of Surgical Tuberculosis are dealt with at the Dispensary. They may be sent to Sanatoria or referred to the Out-Patient Department of the Hospital for treatment. Care and After-Care. A report on the work of the Interim Tuberculosis Care Committee follows. No shelters have been provided as the homes in the Borough are unsuitable for such erections Every endeavour by the use of sputum flasks and instruction in mode of life is made to prevent direct massive infection, but further hospital accommodation for the segregation of advanced cases is needed. HARRY EVANS, Tuberculosis Officer. Interim Tuberculosis Care Committee. This Committee met monthly at the Council Offices. Miss H. M. Mathieson, the Honorary Secretary, has kindly supplied me with the following summary of the valuable work done during the year. 1921. 1922. Number of Cases on Register 301 354 ,, ,, Visited 225 158 ,, ,, Visits paid 713 908 ,, ,, Cases collected from 14 20 Amount collected for L.C.C. £43 17 0 £172 6 10 Postage Account (Refunded by L.C.C.) £3 12 5 £3 12 1 Of the 354 cases on the register of the Committee, 51 have died, and 57 have left the Borough; of the latter, 22 have been transferred to other Committees. The Committee has met nine times during the year. Twenty-one cases were referred for assessment by the L.C.C. Free treatment was recommended in three cases; one case refused treatment; in the remaining 65 cases contributions, varying from 2s. to 20s. per week, towards cost of maintenance while under treatment were recommended. Weekly contributions, towards cost of maintenance of patients in residential institutions, have been collected on behalf of the L.C.C. in 26 cases. Ten of these were still under treatment at the close of the year. Eighteen Quarterly Progress Reports—on seven children—have been received from the L.C.C. and the information contained in them conveyed to the parents. addition to this, several interim reports have been obtained at the request of parents At the request of the Committee the L.C.C. re-admitted one patient to an institution transferred one patient from one institution to another, and investigated two cases of complaint of treatment at residential institutions. Spectacles and a surgical boot were obtained for one patient through the Royal Surgical Aid Society Of 11 children referred to the Committee for convalescence: — Two were arranged for by the parents. Four were arranged for through the Invalid Children's Aid Association (though two of these were not actually away by December 31st). Three were sent away through the Guardians. Three were withdrawn by the parents while arrangements were being made. Efforts are still being made to get these children away for convalescence In two cases in which excision of tonsils was advised by the Tuberculosis Officer, arrangements were made for the operations through the School Treatment Centres. One child was taken to a School Treatment Centre for excision of tonsils, five children were taken to the Tuberculosis Dispensary for examination, and three children were taken to hospitals, as the parents were unable to go themselves with the children. An attempt was made to find a boarding school in the country for a delicate child whose parents were above Poor Law standard. Unfortunately, though the Charity Organisation Society took a good deal of trouble, and made various enquiries, a suitable one could not be found within the means of the parents. The greatest difficulties the Committee have to face are still problems of: — (1) Finding employment, both for discharged patients, and for members of their families on whom they may be dependent. (2) Finding more suitable accommodation for overcrowded families. Four families have, during the year, moved to better accommodation; though the Committee cannot claim the credit of having effected this improvement, it nevertheless assisted by urging it. 56 Arrangements are almost completed for emigrating to Australia the relatives of one young patient who died in October. This family has met with many misfortunes since the death of the father a few years ago, and it is hoped to give them a fresh start under happier conditions. It was expected that the brother (aged 16) who is being sent, through the Scottish Corporation, to a Government farm, would have left before Christmas, but the date of sailing is not yet fixed. The mother and sister, who are being sent out through the Salvation Army, expect to sail in March; they will be met on arrival and suitable positions found for them. The I.T.C.C. has no funds of its own, but it tries—in various small ways— to smooth out difficulties that arise, and, in cases where necessity is found, it strives to bring the patient, or the patient's family, in touch with agencies that can assist. By "doing the odd jobs" it endeavours to assist in the great struggle to drive this preventable scourge of Tuberculosis from our land. H. M. MATHIESON. Hon. Secretary. Holborn Tuberculosis Care Committee. During the year a scheme was prepared for the establishment of a permanent Tuberculosis Care Committee for the Borough. The scheme as approved by the Council, the Ministry of Health and the London County Council, includes representatives of the Borough Council, the Tuberculosis Dispensary, the London County Council, the London Insurance Committee, che Holborn Board of Guardians, the Charity Organisation Society, the Invalid Children's Aid Association, the Children's School Care Committee, Almoners of Hospitals, Metropolitan Nursing Association, Holborn War Pensions Committee, and other social workers The scheme provided for the Committee to take over the work of the Interim Committee from 1st April, 1923. Home Nursing for Tuberculosis Patients. It is unfortunate that owing to the difficult economic conditions that this useful addition to the Tuberculosis Dispensary Service in the Borough cannot be approved by the Ministry of Health. The Council have on two occasions, included a moderate provision for such nursing in the annual estimates, but the Ministry of Health have not yet been able to accede to the Council's request, to incur expenditure for this purpose. The service would be most useful both for diagnostic purposes and for nursing patients whose removal to hospital is not practicable or where removal for some reason is necessarily delayed. Dental Clinic for Tuberculous Persons. Arrangements have been made for tuberculous persons referred from the Tuberculosis Dispensary to receive dental treatment as part of the Council's 57 Tuberculosis Dispensary Scheme, at the Clinic of the British Dental Hospital, No. 10, John Street, W.C In the year 1922, 14 new patients were treated, males 8, females 5, children 1. These patients made 37 attendances, namely, males 18, females 17, children 2. Scaling and gum treatment was given in one case. Extractions with local anæsthetic were made in one case, and with general anaesthetic in six cases. In one case filling was provided. In two cases upper dentures were provided the cost being borne by the patients. Cancer. During the year 58 deaths were recorded as due to cancer, equal to a rate of 1.30 per thousand. In the year 1902 the death rate from cancer in the Borough was 0.94; in 1912, 1.22; the decennial average rate was 0.97 for the 10 years 1901-1911, and 1.28 for the 10 years 1912-1921. It will thus be seen that there is a marked increase in the cancer death rate and although some part of this increase may reasonably be attributed to improved facilities for diagnosis, the figures, nevertheless, indicate the seriousness of and high mortality from malignant diseases. No certain cure has yet been found and the best hope at present is in the direction of early diagnosis and surgical treatment. During the year a special leaflet giving early signs and symptoms of cancer was issued for distribution. Arrangements were also made for this leaflet to be placed in "Please Take One" boxes in the Public Libraries, the Public Health Office, and the underground conveniences for both men and women. A large number of the leaflets were so distributed and it is hoped that in this way a large part of the day population was reached. MATERNITY AND CHILD WELFARE. During the year 485 births were registered as occurring in the Borough. From the notification of birth forms we are able to give the following information as to by whom the mothers were attended at the confinement, etc:— Private Doctors 97 Private Midwives 66 Outpatient Midwifery Departments of General Hospitals:— Externs and others 70 Midwives.—Charing Cross Hospital 54 University College Hospital 55 Middlesex Hospital 34 58 Training Institutions for Mid wives:— Myddelton Square 44 Notified by parents only 31 Not notified 34 The number of births transferred to the Borough from outlying institutions was 193 The number of births transferred from the Borough to other districts was 14 The number of net births belonging to the Borough was 664 There are no Maternity Hospitals or Lying-in Institutions in the Borough. An analysis has been made of the birth cards to ascertain where the mothers living in crowded houses were confined. The information obtained is given below:— Living in Confined at Home. In Hospital. No. Percentage. No. Percentage. One roomed homes 114 66 60 34 Two „ „ 185 70 81 30 Three „ ,, 53 64 30 36 Four „ „ 32 49 34 51 These figures show that many of the women are confined under very uncomfortable and unfavourable circumstances. HOME VISITING. The visits paid to the homes by the Health Visitors during the year were as follows:— First Visits. Revisits. Total. Expectant Mothers 56 64 120 Children under 1 year of age 622 1,216 1,838 Children over 1 year of age 5 1,036 1,041 Enquiries re stillbirths 12 12 „ re ophthalmia neonatorum 12 Other Visits 70 In addition 654 visits were made by student Health Visitors. As shown in the above Table, 622 visits to infants under one year were paid in 1922, subsequent to the receipt of a notification of birth. Some of these notifications related to stillborn children, others to those who died shortly after birth, others to those who were temporarily living at the address given. In a few instances an incorrect address had been given and the mother could not be traced. Five hundred and forty-four of the visits related to infants who came under further observation, in their own home, or at a Centre. 59 Of these: — Attendances at Infant Welfare Centres. 193 attended the Council's M. & C. W. Centre at 10, John Street. 16 ,, ,, ,, Mary Ward Settlement, Tavistock Place. 17 attended the Centre at the Onslow Street School, Saffron Hill. 8 ,. ,, Charing Cross Hospital. 2 ,, ,, Greek Street. 1 ,, ,, Myddelton Square. 10 ,, ,, Middlesex Hospital. 2 , ,, Oakley Square. 5 ,, ,, University College Hospital. 6 ,, ,, Royal Free Hospital. 6 ,, ,, Other Centres. 256 attended an Infant Welfare Centre. Thus nearly one half of those visited attended an Infant Welfare Centre, and of these four-fifths attended at the Council's Centres. Work at Centres. In addition to the maintenance of the Council's Maternity and Child Welfare Centre at 10, John Street, the grant towards the Mary Ward Voluntary Centre formerly called the Passmore Edwards Settlement School for Mothers (used jointly with South St. Pancras) was continued during the year. The following is an analysis of the attendance at the Municipal Centre, 10, John Street. Tuesday, Wednesday. Thursday. Friday. Medical Consultation (alternate weeks) 2—5.30 p.m. Ante-Natal, (alternate weeks) 2—5,30 p.m. Medical Consultation 2—5.30 p.m. Class. 3—5-30 p,m. Dentist. 2—4 p.m. Medical Consultation 2—5,30 p.m. No. of Sessions 26 26 52 43 51 51 Total attendances— Children 628 1134 89 58 1050 Mothers 216 86 219 437 202 220 Average weekly attendances— Children 20 ... 22 ... 1 21 Mothers 10 3 4 10 4 4 The total number of attendances made by the Health Visitors at the Centres was 435. At the Municipal Centre, 4,269 attendances were made by 44 expectant 60 mothers and 369 children of whom 258 were under one year and 111 over one year old. At the Mary Ward Centre, 447 attendances of Holborn children were made by 44 children of whom 27 were under one year and 17 over one year. In addition to the Thursday afternoon classes for mothers, special lectures were arranged during the year as follows: — "The Value of Attendance at an Ante-natal Clinic during Pregnancy," by Dr. Mary Kidd. "Prevention of Diphtheria by Immunisation," by Dr. C. W. Hutt. "Travels in South Africa," by Mrs. F. C. Gladwell, B.A. Infant Welfare," by Dr. Charles Porter. The last of these lectures was given during Health Week, when Lady Mond also attended and gave an address to the mothers. The attendances were very good; these special occasions were evidently much appreciated. We have endeavoured to use pictures and mottoes dealing with health as much as possible, care has been taken to select only those pictures which are clear in their teaching; both pictures and mottoes are changed when their novelty is exhausted. In this country there is a great scarcity of suitable pictures designed to teach a health lesson; we have to send to America, France and Austria for the best of our pictures, and even then have to make a careful selection of what we are offered. Leaflets on the following subjects were issued to supplement verbal teaching: — "Save Your Children from Diphtheria." "Bad Teeth Mean Bad Health." "Care of the Teeth" "Clothing for Very Young Children." "Your Baby's Daily Dinner." The Report of the working of the Maternity and Infant Welfare Centre is largely the work of Dr. Mary Kidd, the Medical Officer of the Centre. Ante-natal Hygiene. Enquiries were made of every mother as to her attendance at an Ante-natal Centre immediately previous to the birth of the child visited. 61 Of the 544 about whom information was obtained— 33 attended the Ante-natal Clinic at the Council's Centre. 23 ,, ,, ,, Royal Free Hospital. 29 ,, ,, ,, Middlesex Hospital. 10 ,, ,, ,, Charing Cross Hospital. 11 ,, ,, ,, Myddelton Square Institution 12 ,, ,, ,, University College Hospital. 8 ,, ,, ,, St. Bartholomew's Hospital. 3 ,, ,, ,, City of London Hospital. 3 ,, ,, ,, Queen Charlotte's Hospital. 12 ,, ,, ,, other Centres. 1 received ante-natal care from the doctor engaged to attend the confinement. So that 145 received recognised ante-natal care, approximately one-third of the whole number. At the Council's Ante-natal Clinic 58 women attended during the year; of these 44 were ante natal cases, and made 66 attendances; 14 others attended after confinement making 20 attendances; 86 attendances were made. Five of the ante-natal cases were expectant mothers for the first time; a number of the expectant mothers were found to have defects either due to or especially of concern in view of their pregnancy, the number and kind of defect present being as follows: — Contracted pelvis 2 Ante-partum hæmorrhage 1 Vaginal prolapse 4 Pendulous abdomen 1 Excessive vomiting 1 Varicose veins 12 Albuminuria (slight) 1 Other defects present were pulmonary tuberculosis 1; heart disease 3; marked anaemia 6; marked sleeplessness 1; dyspepsia 1; constipation 18; dental caries 27; other defects 1. Forty-one urine tests were made; the blood of four patients was submitted for the Wasserman test. Eleven expectant mothers were referred to Maternity Hospitals for confinement (six normal, five abnormal); twenty-one to the Dental Clinic for treatment; one to the Tuberculosis Dispensary, and four with other complaints to other hospitals. Maternal and Infant Consultations. Details as regards the work at the Maternal and Infant Consultations at 10, John Street and the Mary Ward Centres during the second half of the year are as follows:—- 62 Reason for Attendance. Number attending. Mothers— John St. Mary Ward. Difficulty with breast feeding 92 1 Generative organs. 19 — Dental Caries 98 - Heart 2 Debility 24 3 Anæmia 63 6 Venereal Disease. 5 — Respiratory Disease 9 — Digestive Disorders 10 1 Kidney Disorders 1 — Other Disorders 24 — Children— Congenital syphilis 1 — Alimentary disorders 269 30 Rickets 50 4 Respiratory diseases 175 15 Hernia, umbilical 30 3 Phimosis 41 — Rash 126 3 Disease of eye 18 1 ,, ear 28 5 ,, nose and throat 56 — Other Diseases 25 7 Mothers. Children. Total Number referred to Clinic Dentist 102 17 119 ,, ,, ,, Hospitals 16 84 100 ,, ,, ,, Metropolitan Nursing Association 9 28 37 Assisted Milk Supply—Recommended for 35 53 88 Advised Convalescent Home Treatment 17 17 34 Ante-natal Clinic— Expectant Mother 18 — 18 Post-natal 9 — 9 Breast Feeding. The following Table gives information relating to the duration of total or partial breast feeding in the case of 351 children born in 1922. The remainder of the children born in that year either removed from the Borough or died before the end of the normal breast feeding period (40 weeks), or were born in the latter months of the year and at the date of preparation of the Table had not reached the age when normal breast feeding should cease. It will be seen from the Table that at the end of three months 252 or 72 per cent were still being entirely breast fed; 41 or 12 per cent. were receiving partial breast feeding and 58 or 16 per cent. were then entirely bottle fed. At the end of 26 weeks 202 or 58 per cent. were entirely breast fed; 60 or 17 per cent. were partially breast fed and 89 or 25 per cent. were entirely bottle fed. At the end of 40 weeks 71 or 20.3 per cent. were still entirely breast fed; 156 or 44.4 per cent. were partially breast fed and 124 or 35.3 per cent. were entirely bottle fed. 63 Total or Partial Breast Feeding. WEEKS. Number of Children entirely Breast-fed up to end of this period.* Number discontinued entire Breastfeeding before end of succeeding Week. Partial Breast-feeding continued for WEEKS. Number of Children entirely Breast-fed up to end of this period. * Number discontinued entire Breastfeeding before end of succeeding Week. Partial Breast-feeding continued for Less than Three Months. Three Months but less than Six Months. Six Months but less than Normal Lactation. Normal Lactation and beyond. Less than Three Months. Three Months but less than Six Months. Six Months but less than Normal Lactation. Normal Lactation and beyond. 1 351 7 4 0 2 1 21 217 2 0 2 0 0 2 315 13 6 6 0 1 22 215 6 0 1 2 3 8 331 10 6 0 4 0 23 209 1 0 0 0 1 4 321 9 5 2 1 1 21 208 5 0 1 0 4 5 312 6 3 0 1 2 25 203 1 0 0 0 I 6 306 10 7 0 1 2 26 202 10 0 0 7 3 7 296 7 0 0 0 2 27 192 1 0 0 0 1 8 289 6 5 0 0 1 28 191 5 0 0 2 3 9 283 9 6 0 0 3 29 186 1 0 0 1 0 10 274 11 0 4 1 1 30 185 23 0 0 8 15 31 263 3 1 0 0 o 31 162 0 0 0 0 0 12 260 8 2 1 1 1 32 162 14 0 0 0 14 13 251 6 0 2 2 2 33 148 0 0 0 0 0 14 246 4 0 1 1 2 34 148 16 0 0 0 16 15 242 1 0 1 0 0 35 132 0 0 0 0 0 l6 241 3 0 2 0 1 36 132 42 0 0 0 42 17 238 1 0 1 0 0 37 90 0 0 0 0 0 18 237 14 0 5 1 8 38 90 17 0 0 0 17 19 223 1 0 1 0 0 39 73 2 0 0 0 2 20 222 5 0 1 0 4 40 71 — 0 0 0 0 71 58 31 35 156 124 * Fourteen babies were entirely bottle-fed before the end of the first week of life. 64 Stillbirths. During 1922 there were 12 stillbirths. Of these four were clue to difficult labour; two were due to placenta prævia; one was due to malformation of foetus; one case the cause was unknown; and four cases no information was available. Of the four stillbirths due to difficult labour, in one there was breech presentation, in another vertex presentation with strangulating cord, and two were vertex presentation. Four of the 12 stillbirths occurred in the practice of private doctors, three in that of midwives, and four occured in the extern practice of a hospital; one child was born in a nursing home. Illegitimate Births. An enquiry was made into the present circumstances of all the illegitimate babies (62) whose birth was registered in 1922. Ten lived with their mothers who remained in their parent's home; if in these circumstances the mother has to go out to work the grandmother minds the baby. Four lived with their mothers who went out to work, the baby being in a creche in the daytime. Eleven were boarded out with foster-mothers. One was in St. Faith's Home; the mother subsequently married. Eighteen were living with both parents, who lived together permanently. Three were known not to have returned from the hospital to the home address given. In 15 instances no information could be obtained; the majority of these mothers who had entered a hospital or infirmary for the confinement and had not returned to their previous address. Of the above illegitimate children seven died. Of these three were living with both parents, one lived with the mother who went to work, and in three instances no information was obtainable. In view of the high death rate among illegitimate babies it is regrettable that so large a proportion of the babies born of Holborn unmarried mothers cannot be visited so as to offer them the benefit of Child Welfare Schemes. Suitable cases are referred with the consent of the client to St. Faith's Home, or to the National Council for the Unmarried Mother and Her Child. Dental Treatment. A number of nursing and expectant mothers and young children were treated at the Council's Dental Clinic held at 10, John Street. The number of new patients during the year was 89, viz., 66 women and 23 children; the number of attendances 302. Assistance with Dentures, etc. Extractions with local anæsthetic were made in 33 cases (27 women and 6 children) and with general anæsthetic in 44 cases, including 10 children. Fillings 65 were provided in 55 cases, including 22 children. Dentures, 11 upper and 10 lower, were provided for 11 patients, 10 of whom contributed towards the cost In five cases dentures were remodelled; eight were repaired and dressings were given in 33 cases. In the provision of dentures the cost is based on the charge approved for the time being for dentists on the Ministry of Pensions Panel. Supply of Milk and Food for Expectant and Nursing Mothers and for Infants. In March, 1921, an Order was issued by the Ministry of Health revoking the Local Authorities Milk (Mothers and Children Order), 1919. At the same time a circular was issued by the Ministry setting out the revised conditions on which sanction would be given to schemes under the Maternity and Child Welfare Act, 1918, for the supply of milk, to expectant and nursing mothers and children under five years of age. These conditions limited the supply of milk at less than cost price to— (a) Nursing Mothers; (b) Expectant mothers in the last three months of pregnancy; (c) Children up to three years of age and, exceptionally, to children between three and five years of age. In sanctioning expenditure for the supply of such milk, the Minister of Health suggested the substitution in desirable cases of meals instead of milk for mothers. Arrangements were therefore made for the supply of such meals at the Maternity Centre in casts where the Medical Officer of the Centre reported this form of assistance would be preferable to the supply of milk. It was not, however, necessary to effect the substitution in any case during the year. In August, 1922. the Ministry of Health addressed a communication to the Council suggesting a revision in the scale of income for regulating the supply of milk and food to expectant and nursing mothers and infants. The Minister of Health expressed the opinion that many scales in force in London, including that adopted by the Council, were too high, having regard to the general fall in the cost of living as represented by the official index figure. He also suggested that the Council should endeavour to obtain milk for this service on specially reduced terms. The scale of necessity then in operation in the Borough was that adopted by the Council in October, 1921, when having regard to the actual and contemplated fall in the cost of living considerable reductions were made. The Maternity and Child Welfare Committee were satisfied from experience in considering numerous applications made to them for milk at less than cost price and from their knowledge of economic conditions in Central London, that no further reductions could be made in the scale at present, without risk of considerable hardship. Representations to this effect were submitted to the Ministry of Health and ultimately the continuance of the scale then in operation, was sanctioned without modification. This scale is as follows: — F 66 Scale of Necessity. Adopted 14th October, 1921. Persons in Family. Free Milk. Half cost Milk. £ s. d. £ s. d. 2 1 5 0 1 7 0 3 1 10 0 1 13 0 4 1 14 0 1 18 0 5 1 17 6 2 2 6 6 2 2 0 2 8 0 7 2 9 0 2 10 0 8 2 16 0 3 4 0 9 3 3 0 3 12 0 10 3 10 0 4 0 0 11 3 17 0 4 8 0 12 4 4 0 4 16 0 Applications received for milk free or at less than cost price are carefully investigated. Enquiries are made to verify statements of wages and other income; information is obtained from the Guardians of the Poor as to relief given for unemployment or other necessitous conditions. Other possible sources of assistance are investigated. and all practicable steps taken to prevent overlapping. The applications are considered by an Assistance Sub-Committee of the Maternity and Child Welfare Committee meeting fortnightly for the purpose Where grants are made the cases are reviewed by the Sub-Committee at intervals not exceeding one month. During the year 243 applicants received free or assisted milk or food under the Scheme. This number included 72 who were receiving such assistance at the end of the year 1921. Grants were made in 171 new cases. At the end of the year 1922, 100 cases were receiving assistance, viz., free milk 84, milk at half price 7, prepared milk free 9. The following Table shows new cases assisted in 1922. Milk. Food. Prepared Milk Free. Part Cost. Free. Part Cost. Free. Part. Cost. Expectant Mothers 21 — 3 — — — Nursing Mothers 61 13 3 — — — Children 47 6 1 — 12 4 67 Home Help. The Council's Home Help attended 16 cases during the year. In nine of these the Whole-time Officer attended and in seven the Emergency Home Helps were employed. The latter were engaged when more than one ease occurred at the same time and during the absence of the Whole-time Home Help on special sick leave due to an accident and during the summer vacation leave. All applications for the services of the Home Help are considered by the Assistance Sub-Committee of the Maternity and Child Welfare Committee In one case of extreme necessity the services of the Home Help were granted free. In all other cases the applicants were required to contribute towards the cost, contributions ranging from 25s. to 2s. 6d. per week. The services of the Home Help have been much appreciated, and it has been found that the Council's provision meets a much felt want in the Borough. » Convalescent Homes. Provision was continued for convalescent home treatment for nursing mothers with their babies and other children up to the age of five years. The reservation of a bed at the Shooters Hill Convalescent Home of the National League for Health, Maternity and Child Welfare, was discontinued owing to the arrangements for the reception of mothers after confinement into that home being modified so that the institution became a home of rest rather than a convalescnt home. Arrangements were then made for the admission of mothers and babies to the Catherine Gladstone Convalescent Home at Mitcham. The closing of this Home is much regretted as it proved very satisfactory. In all 14 applications for convalescent home treatment for mothers and babies were received One was found to be not suitable, five were subsequently withdrawn and eight mothers with their babies were sent away for such treatment. In one case of extreme necessity the treatment was provided free; in seven cases patients contributed towards the cost at rates ranging from 15s. to 2s. per week. In connection with the convalescent home treatment for children under five. the Council reserved a bed at the Marjorie Lumley Convalescent Home, Maidenhead. Six children were sent to this home and six to the Hope Dene Convalescent Home. Barnet, which is associated with the West London Mission, Kingsway Hall. In three cases the children were sent away free; in the remaining cases contributions were paid ranging from 10s. 6d. to 5s. per week. F 2 68 Saffron Hill Maternity and Child Welfare Centre. Consultations in connection with this Voluntary Centre are held at the St. Winifred Club, St. Peter's School, Onslow Street, Saffron Hill. During the year ended 31st March, 1923, 401 infants and children under five attended the consultations, 100 of the total number coming from the Holborn Borough. Extra food and nourishment was provided during the year for 98 mothers and 130 infants and small children, and classes and lectures on Health, Care of the Home, Food Economy and kindred subjects were held. The Chairman and Honorary Secretary is Miss Mary Canney, 75, Lamb's Conduit Street, Deaths of Infants under One Year of Age. The homes were visited in a large proportion of the infant deaths, and any requisite information obtained. The cause and age of death are given in the following Table: — Cause of Death. Under 1 Week 1-2 Weeks 2-3 Weeks 3-4 Weeks Total under 4 Weeks 4 Weeks and under 3 Months 3-6 Months 6-9 Months 9-12 Months Total Deaths under One Year All Causes Certified 16 1 1 1 19 5 8 8 9 48 Uncertified ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... 1 1 2 4 Whooping Cough ... ... ... ... ... ... ... ... 1 1 Convulsions 2 ... ... 2 ... ... ... ... 2 Pneumonia (all forms) 1 ... ... ... 1 1 2 4 3 11 Diarrhœa ... ... ... ... ... 1 1 ... ... 2 Enteritis ... ... ... ... ... ... 1 1 2 4 Rickets ... ... ... ... ... ... ... ... 1 1 Injury at birth 3 ... ... ... 3 ... ... ... ... 3 Atelectasis 1 ... ... ... 1 ... ... ... ... 1 Congenital Malformations 3 ... ... ... 3 ... ... ... ... 3 Premature Birth 4 1 ... 1 6 2 ... ... ... 8 Atrophy, Debility, Marasmus ... ... ... ... ... 1 2 1 ... 4 Other causes 2 ... 1 ... 3 ... 1 ... ... 4 16 1 1 1 19 5 8 7 9 48 Nett Births registered during the calendar year legitimate 602 illegitimate 62 Nett Deaths registered during: the calendar year of legitimate infants 41 illegitimate 7 69 Deaths of Children 1 to 5 Years. Thirty children died between the ages 1 to 5 years from the following causes:— Cause of Death. Ages. Total. 1—5 1—2 2-3 3-4 4—5 Scarlet Fever ... 1 ... ... 1 Diphtheria 2 1 ... 1 4 Whooping Cough 3 2 ... ... 5 Tuberculosis 1 ... 1 ... 2 Measles 3 ... ... ... 3 Influenza 1 ... ... ... 1 Bronchitis ... 1 ... ... 1 Pneumonia 5 1 1 ... 7 Congenital Syphilis 1 ... ... ... 1 Convulsions 1 ... 1 ... 2 Amæmia ... ... ... 1 1 Cancer ... 1 ... ... 1 Shock (Burns) ... 1 ... ... 1 17 8 3 2 30 INFECTIOUS DISEASE AMONG MOTHERS AND CHILDREN. No case of puerperal fever was notified. Ophthalmia Neonatorum. During the year 11 eases of ophthalmia neonatorum occurring in babies born in the Borough were brought to our notice. Nine of the 11 cases were notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914, four of the notifications being from hospitals four from private medical practitioners, and one from the Medical Officer of the Maternity Centre. One case was only notified after communication with the doctor and one case was not notified by either doctor or midwife in attendance. Unless each case is notified to the Local Medical Officer of Health the public will be ignorant of the real extent of the disease: the whole of the cases cannot be followed up to ascertain the amount of permanent damage done to the eyesight. In the following Tables particulars are given as to each case: — 70 Nine Cases Notified in Accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914. Case Number. Age when Notified. Age at Onset. By whom Notified. Type of Disease on Health Visitor's first visit. Where Treated. Medical Attendance and Nursing. Result. Birth Notified by REMARKS. 1 14 days 3 days Doctor (Hospital) Severe Home Midwife Hospital), then attended Hospital, and District Nurse Cured Midwife (Hospital) -2 9 days 6 days Doctor (Hospital) Slight Maternity Hospital, then home Doctor (Hospital), then District Nurse Cured Born in Hospital 3 2 days 2 days Doctor (Private) Severe Home, then St. Margaret's Hospital, admitted when 4 days old Doctor and District Nurse, then Hospital Did not return to address from which entered Hospital Doctor 4 6 days 6 days Doctor (Private) Moderate Home Doctor. Midwife Cured Midwife (Private) 6 18 days 18 days Doctor (M. & C. W. Centre) Slight Home Doctor, District Nurse Cured Born in Hospital 10 10 days 9 days Doctor Born in Hospital, child not seen at any time Maternity Hospital and then St. Margaret's Hospital In-patient. St. Margaret's Hospital Died in St. Margaret's Hospital at 5 weeks of age of prematurity Born in Hospital 11 13 days 12 days Doctor (Hospital) Moderate Home Midwife Cured Midwife (Hospital) 12 3 days 3 days Doctor (Hospital) Moderate Home, then St. Margaret's Hospital Doctor (Hospital) and District Nurse. then St. Margaret's Hospital Cured Midwife (Hospital) 13 3 days 1 day Doctor (Private) Moderate Home, then St. Margaret's Hospital District Nurse, then Hospital Cured Doctor 71 Two Cases not Notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914. Case Number Age when Information received Age at Onset Information Type of Disease on Health Visitor's first visit Where treated Medical Attendance and Nursing Result Attended by Remarks 5 16 days 11 days Found by Health Visitor Moderate Ophthalmic Hospital, Judd Street (out patient) Ophthalmic Hospital, Judd Street (out patient) Cured Doctor. This case was subsequently notified by private doctor. 8 13 days Birth Found by Health Visitor and l.c.c. Inspector Moderate University College Hospital (out patient) Nurses from U.C.H. Then out patient U.C.H. Cured Midwife (Hospital) 72 One other case of ophthalmia neonatorum brought to our notice was that of a patient born in the Borough of St. Pancras, whose mother afterwards moved into this Borough. This case was notified to the Medical Officer of Health of St. Pancras, the disease was severe, hut no injury to the sight resulted. Four patients were admitted to St. Margaret's Hospital, Kentish Town, an Institution of the Metropolitan Asylums Board set apart for the in-patient treatment of this disease. Any infant requiring such treatment can be admitted with its mother on the application to the Metropolitan Asylums Board of a medical practitioner or of a midwife. The baby should be sent in as early as possible and especially before any haziness of the cornea sets in. In this connection earlier notification of the disease would be of service. Six babies were attended in their own homes by the District Nurse, three being under the arrangements made by the Council for such nursing. A footnote in the book of rules of the Central Midwives Board is sometimes regarded by Certified Midwives as relieving them from the duty of notifying cases of ophthalmia neonatorum, except when medical help has not been obtained. It would avoid a possible cause of delay in notification if it could be made clear that the notification should be sent to the Medical Officer of Health by the midwife, whether medical help is obtained or not. As regards prevention the routine application of a suitable preparation of silver to the eyes of a child at birth would undoubtedly very much lessen the disease. This has been the experience in the United States of America. In practically every Federal State the midwife is required by law to treat the eyes of every newly-born infant with a solution of nitrate of silver; the Government supply small doses in sterilised containers free of charge. Recently a circular has been issued by the Scottish Board of Health to medical practitioners "strongly recommending the installation of silver nitrate solution into the eyes of newly-born children and intimating that they will in future require a report with particulars of treatment from Medical Officers of Health on all cases in which there occurs loss of vision." The procedure recommended is a practical means of prevention, ready to-day, and proved to be efficacious. The numbers of cases of the disease notified in England and Wales in the three years 1918-1920 was 25,484; the number of cases notified in New York during the same period was 72. If the attack rate in England and Wales had been no greater than the attack rate in England and Wales had been no greater than the attack rate in New York during the three years, the number of cases would have been only 1,381. The Council addressed a communication to the Ministry of Health suggesting that the Ministry "should take steps to bring to the notice of medical practitioners and midwives the advisability of the routine application of a suitable silver preparation to the eyes of all newly-born children." 73 Measles. The notification of measles was discontinued at the end of 1919, but during the last year I recehed information, of 234 cases. Of these 155 were notified by school teachers; 22 by medical practitioners; 14 by hospitals; and 11 by private persons; the remainder were found by the Health Visitors. 103 patients were children under 5 years. 126 patients were children of 5-14 years. 5 patients were adults. 99 lived in flats or buildings. 126 ,, large houses occupied by more than one tenant. 9 ,, small houses. 88 patients had no contacts. 43 ,, 1 contact. 41 ,, 2 contacts. 43 ,, 3 ,, 11 „ 4 „ 16 „ 5 „ 5 „ 6 „ 7 ,, 8 „ 2 ,, 9 „ 3 ,, 10 or more contacts. 14 cases were removed to M.A.B. Hospital. 2 ,, ,, ,, Holborn Poor Law Infirmary. 5 ,, ,. ,, private hospitals. 3 cases were referred to Metropolitan Nursing Association for home nursing. When visiting eases of measles, special emphasis is laid on the need for adequate care; there is a wide-spread tendency to regard measles as a minor illness which all children must catch, and to think that no harm will result from the attack. The admission of patients suffering with this disease to the hospitals of the Metropolitan Asylums Board is in accordance with the Metropolitan Asylums (Measles) Order, 1911. This Order prescribes regulations subject to which Metropolitan Asylums Board Managers may admit to any of their hospitals a person who is not a pauper and is reasonably believed to be suffering from measles. The Regulations provide that a person to whom the Order applies shall not be admitted unless in the opinion of the Managers there is more accommodation available than is required for the reception of pauper patients suffering from measles. The admissions are to be on the recommendation of the Medical Officer of Health of the District in which the person is residing at the time when the question of removal to hospital arises, provided that the Clerk of the Metropolitan Asylums Board may authorise that a person to whom the Order applies shall be admitted otherwise than on the foregoing recommendation if such admission is desirable on the ground of urgent necessity or for some other or exceptional reason. 74 Whooping Cough. Visits were paid to 132 persons suffering from whooping cough; two of these were not resident in the Borough. The 130 cases occurred in 90 families. In 62 families one case occurred; 19 families had two cases, seven had three, and in two familiies four suffered One hundred and ten cases were notified by doctors, some of which were previously discovered by information received from schools and by observation of the Health Visitors; 19 others were discovered in this way, and one parent voluntarily notified a second case in the family. Ninety-six were children under five, 32 were over five, and two were adults. Contacts. 32 children had no contacts. 23 ,, ,, 1 contact. 14 ,, ,,2 contacts. 16 ,, ,, 3 ,, 11 „ „ 4 „ 8 „ „ 5 10 „ „ 6 2 ,, ,, 7 ,, 4 ,, „ 8 ,, 2 „ ,, 9 ,, 1 „ „ 11 ,, 1 „ „ 13 ,, 3 ,, ,, 14 ,, 1 „ „ 15 ,, 2 „ „ 17 ,, 38 cases occurred in flats in blocks 86 ,. ,, large tenement houses. 6 ,. ,, small houses. Twenty-five children were removed to hospital (18 to M.A.B. Hospital, and seven to Holborn Poor Law Infirmary). One adult was removed to a private nursing home. The admission to M A.B. Hospitals of patients suffering with this disease is in accordance with the Metropolitan Asylums (Whooping Cough) Order, 1911. This Order is similar to that providing for the admission of cases of measles. Epidemic Diarrhœa. This disease is notifiable in only a few districts in London, and is not notifiable in Holborn. 75 The number of deaths of young children under two years of age classified under the head, Diarrhœa and Enteritis, was six, all under one year. Some of these, however, were not real cases of epidemic diarrhoea, although classified under this head. The deaths were equal to a rate of 9.0 per 1,000 births in comparison with 71 for all London. The methods used to deal with the disease were detailed last year; the most important perhaps is that during the third quarter of the year, extra visits are paid to those homes in which epidemic diarrhoea is more likely to occur. Poliomyelitis. One case of poliomyelitis (infantile paralysis) was notified. The child was treated at home and recovered. Nursing Arrangements. Nursing arrangements have been made with the Metropolitan Nursing Association, No. 23 Bloomsbury Square, for the nursing, when required, of necessitous cases of measles, whooping cough, ophthalmia neonatorum, diarrhoea and pneumonia. Their services were used as follows: — Whooping Cough 2 Cases 19 Visits. Measles 6 ,, 80 „ Ophthalmia Neonatorum 3 ,, 104 „ Pneumonia 12 „ 183 „ Total 23 Cases 386 Visits. Exchequer Grants for Maternity and Child Welfare Services. During the year the Maternity and Child Welfare Committee considered the recommendation of the Geddes Committee on National Expenditure recommending that the State contribution towards Tuberculosis and Maternity and Child Welfare work should be on a lump sum basis and not (as now) on a percentage basis, and suggesting that failing a more satisfactory unit basis for measuring the grant, the basis of previous expenditure should be adopted while the present financial stringency continues. The present method is a percentage grant not exceeding 50 per cent. on approved expenditure. It is held that under this system the State cannot forecast its liabilities; that the system leads to extravagance; that it is not a sound principle; that the more a local authority spends, the more it would get from the State. To obtain a grant a detailed estimate of expenditure under the various services has to be submitted for approval to the Ministry of Herlth, the grant being payable only on approved services within the limits sanctioned. 76 Control of expenditure can therefore be exercised at the Government Department concerned, although local responsibility and the stimulus for maintaining economy with efficiency is not removed from local authorities. The advocates of a block grant consider that when an allocation is made only general supervision would be exercised by a Government Department, and local authorities would not be subject to hampering control of detail. If this is so it might result in the grant being used for the expansion of one form of service to the neglect of another. It might be urged with a show of reason that the objections to a block grant include The danger of reducing the national share of the burden of national services without the possibility of corresponding reductions in local expenditure consistently with a due standard of efficiency. The difficulty of equitably assessing grants in proportion to the needs of a district and the tendency to stereotype grants at a uniform level without sufficient regard to local circumstances. The danger that block grants would not keep pace with growing demands, whether due to increase of population or legislation. The Council expressed the view that no alteration should be made in the present percentage basis of grants, but if ultimately it is decided that block grants should be substituted, that the position of local authorities should be safeguarded in the following respects: — (a) The grant for approved service should not be less in proportion to the expense of the service than the grants under the existing system. (b) Due consideration should be given to the services maintained and deemed essential by the local authority in view of the circumstances of its area. (c) A local authority after approval of its estimate should not be required by legislation or the action of a Government Department to undertake services not provided for in their estimate unless the grant is also increased. Health Week and Baby Week. Following the precedent of 1921 the celebration of these weeks was in the main combined and observed from the 8th-14th October, 1922. Among the steps taken to secure the success of these special weeks were the following: — 1. The Clergy. Sunday School Teachers, and promoters of meetings for men and women were asked to co-operate, by arranging for special sermons, lessons, addresses, etc. 2. Two prizes for each school in the Borough, one for boys and one for girls, were offered for the writers of the best essays on "How I Can Keep Myself Healthy." It was arranged that the essays should be based, at the discretion of the Head Teachers. either on special lessons or on the routine lessons on hygiene given during the year. 77 Nineteen school departments took part; upwards of 1,000 children wrote essays which in the main reached a high standard. Subsequently the Mayor and Mayoress kindly entertained 60 of the writers of the best essays to tea and the prizes to the winning writers were distributed by the Mayoress. 3. It was arranged that a party of girls and a party of boys from the two school departments submitting the best essays should be invited to visit the Municipal Institutions. 4. Arrangements were made for the exhibition of a film "Our Children" at the Holborn Cinema. 5. A considerable quantity of literature was distributed through the co-operation of the Clergy, a number of large employers of labour and others. The literature included copies of the two issues of "National Health;" leaflets issued by the Baby Week Council, and leaflets specially prepared for use in the Borough on— (a) "London's Health; Ten Ways to Help It." (b) "Self Help in Health; Hints to Women." (c) "Food Points for Shoppers." (d) "Danger from Flies." 6. Efforts were made to bring the importance of health to the notice of Holborn workers. A number of the larger employers of labour were asked to give facilities for addresses to their staffs. In 11 cases permission was given; in six of these the addresses were given by the Medical Officer of Health, and in five by one of the Health Visitors. 7. A special meeting for mothers was arranged at the Maternity and Child Welfare Centre. The meeting was largely attended. After a short musicai programme the mothers were addressed by Lady Mond and Dr. Charles Porter, Medical Officer of Health of St. Marylebone. Subsequently tea was provided for the mothers, the cost being defrayed by contributions received from Councillors Miss March, Lady Smith, Thomas W. Coffin and J. J. Claydon. In addition to the observation of the combined Week, a Baby Show was held on July 7th, during National Baby Week. There were 127 entries, 108 attended for the preliminary judging, into the following classes. Class l.A 3-6 months 7 entries „ l.B 6-9 14 „ ,, 1.C 9-12 20 „ ,, 2. 1-2 years 23 „ „ 3. 3-5 „ 32 „ „ 4. Delicate and Premature Babies 4 „ „ 5. Twins 4 pairs The preliminary examination was carried out by me during the two weeks immediately preceding the show and the final judging was kindly undertaken by 78 Dr. W. J. Howarth, Medical Officer of Health of the City of London. As a result of the examination it was found possible to award 16 prizes, namely, eight 1st, seven 2nd, and one 3rd. In addition to the prize winners, certificates were awarded in 24 cases, namely, 14 certificates of merit for babies, four certificates for mothercraft, and six certificates for overcoming special difficulties of mothercraft. One hundred babies were brought to the Show on Friday the 7th July, when the Chairman of the Maternity and Child Welfare Committee, Miss Norah March, B.Sc., very kindly entertained the mothers to tea and also distributed the prizes. An analysis of the weights in relation to the ages of the babies entering for the competition showed that approximately half were above and half below the average weights for all babies of the same age in England and Wales; although the numbers dealt with were not large, the rough conclusion can be drawn that TTolborn babies are of equal nutrition to the average baby. Medical Inspection and Treatment of School Children. The medical inspection and treatment of children attending Public Elementary Schools in Holborn is carried out by the London County Council. The following treatment Centres are provided under the L.C.C. Schemes: — (1) Finsbury Centre, Spencer Street, Goswell Road. (2) Moorfields Ophthalmic Hospital, City Road. (3) Soho Centre, Gerrard Street. (4) Lancing Street Centre, Lancing Street, N.W. 1. (5) Cleansing Station (Scabies) Children's Baths, Central Street, E.C. 1. Centres are also provided at the following Hospitals and Dispensaries: — (1) St. "Bartholomew's Hospital. (2) Bloomsbury Dispensary. (3) Central London Ophthalmic Hospital. (4) Central London Throat and Ear Hospital. (5) Dental Hospital. (6) Homeopathic Hospital. (7) Hospital for Sick Children. (8) Italian Hospital. (9) Metropolitan Ear, Nose and Throat Hospital. (10) Middlesex Hospital. (11) Royal Free Hospital. (12) Tuberculosis Dispensary, University College Hospital. (13) University College Hospital. We endeavoured to co-operate with the Education Authority by giving information respecting children suffering from infectious disease and child contacts attending public elementary schools. The County Medical Officer of Health has kindly furnished me with particulars of medical inspections of school children in Holborn in 1921. They are classified in the following Tables:— 79 Medical Examination in Public Elementary Schools. I. Age, Group and number examined. Condition of Clothing. Nutrition. Cleanliness—Head. Cleanliness—Body Condition of Teeth. Vision. Mental Condition. Good. Fair. Poor. Good. Average. Poor. Bad. Clean. Nits present. Pedicum. Clean. Dirty. Pedicum. All sound. Not more than 3 decayed. 4 or more decayed. 6/6 in both eyes. 6/9 in either or both eyes. 6/12 or worse in either eye. Average. Poor. Mentally deficient. Entrants—183 Boys 45 127 1 32 125 24 2 180 2 1 107 13 3 99 46 38 Not Tested 179 Girls 48 122 9 33 124 22 ... 130 39 4 166 12 1 85 02 32 ,, ,, Age 8—263 Boys 68 103 32 54 107 41 1 254 8 1 235 25 3 126 77 60 118 79 64 249 14 ... „ 244 Girls 63 167 14 49 159 30 ... 175 07 2 230 14 ... 127 77 40 136 48 59 233 11 ... Age 12—248 Boys 47 153 48 51 109 28 ... 244 4 ... 233 13 2 162 73 13 161 36 49 234 14 ... ,, 244 Girls 51 107 23 47 179 17 1 158 84 2 133 9 2 170 66 8 129 48 67 241 3 ... Age 13½—119 Boys . 30 01 25 30 71 12 ... 113 0 ... 108 11 ... 72 40 7 69 17 33 114 5 ... „ 114 Girls 27 80 7 20 81 7 ... 90 24 ... 108 6 ... 68 40 6 69 20 25 110 4 ... Total 1594 382 1043 169 328 1075 187 4 1350 234 10 1480 103 11 969 481 204 682 248 297 1181 51 ... Percentage of Examined 24.0 05.4 10.6 20.6 67.4 11.7 0.3 84.7 14.7 0.6 92.8 6.5 0.7 57.0 30.2 12.8 55.6 20.2 24.2 95.9 4.1 ... 80 Defects Found. II. Entrants. Age 8. age 12. age 13. Boys. * Girls. Boys. Girls. Boys. Girls. Boys. Girls. Number Examined 183 [80] 179 [92] 203 [142] 244 [114] 248 [113] 244 [98] 119 [62] 114 [56] Defects: — Skin Disease 1 [1] 4 [4] 7 [7] 4 [1] 4 [3] 2 [1] ... 1 [1] Enlarged Tonsils 26 [11] 22 [5] 29 [12] 31 [10] 29 [10] 25 [5] 14 [7] 17 |6] Adenoids 2 [1] 2 [—] 1 [1] ... ... ... ... ... Tonsils and Adenoids 3 [3] 5 [3] 6 [6] 6 [6] 2 [1] 1 [1] ... 2 [—] Other Nose and Threat 12 [4] 6 [4] 13 [7] 6 [4] 10 [6] 9 [4] 4 [3] 1 [-] Enlarged Glands of Neck 3 [-] 1 [-] 3 [-] 6 [1] 5 [-] 11 [1] 2 [—] 5[—] External Eye Disease 2 [2] 2 [2] 12 [7] 3 [3] 4 [2] 6 [3] 3 [—] ... Vision for Treatment Not Examined [17] [15] [31] [48] [18] [10] Otorrhœa and Otitis 2 [-] 3 [3] 1 [-] 1 [1] 2 [2] 1 [1] ... 2 [1] Other Ear Disease 2 [-] ... 2 [2] ... 1 ['] 2 [2] 1 [—] ... Hearing Defect ... ... 1 [1] 2 [1] 1 [1] ... ... ... Stammering ... ... 1 [-] ... ... 1 [-] 1[-] ... Other Speech ... ... ... 1 [—] ... 1 [1] ... ... Heart Defects 4 [1] 2 6 [-] 16 [—] 5 [-] 13 [-] 3 [—] 3 [-] Anµmia 9 [1] 7 [2] 12 |1] 11 [2] 7 [1] 0 [1] 2 [—] 6 [2] Bronchitis and other Lung Disease 10 [-] 17 [4] 16 [4] 9 [-] 11 [-] 6 [—] 4 [—] 3[-] Nervous Disease ... ... 1 [-] ... ... ... ... ... Phthisis ... ... ... ... ... ... ... ... Other Tubercular Disease 1 [-] ... 2 [1] 1 [-] 1 [1] ... ... 1 [-] Rickets 5 [2] 2 [1] 1 [-] 3 [-] 2 [—] ... ... ... Spinal Defects 1 [1] ... 3 [-] 1 [-] 6 [3] 9 [2] 3 [—] 8 [—] Other Deformities ... ... ... 1 [1] 1 [1] ... ... ... Infectious Disease ... ... ... ... ... ... ... ... Other Defects 9 [4] 9 [3] 7 [2] 12 [6] 5 [-] 5 [2] 1 [1] 2 [—] †Cases for Dental Treatment [57] [75] [108] [86] [68] [60] [42] [43] * The figures in brackets are the numbers referred for treatment, and these are included in the total figure, e.g., 183 boys examined, 83 of them noted for treatment. † Defects of Vision and Dental defec ts arc shown in Table I 81 Deaths of Children 5-15 years. Cause of Death. Ages. Total. 5 6 7 8 9 10 11 12 13 14 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... 1 1 Cerebro-spinal Meningitis ... ... ... ... ... ... ... 1 ... ... 1 Tuberculosis— Respiratory ... ... ... ... ... ... ... 1 ... ... 1 Other forms ... ... ... 1 ... ... ... ... ... 1 2 Rheumatic Fever ... ... ... ... ... ... ... 1 ... ... 1 Appendicitis ... ... ... ... ... ... 1 ... ... ... 1 Nephritis ... ... ... 1 ... ... ... ... ... ... 1 Septic Tonsillitis ... ... ... ... 1 ... ... ... ... ... 1 Purpura Hæmorrhagica 1 ... ... ... ... ... ... ... ... ... 1 General Septicœmia 1 ... ... ... ... ... ... ... ... ... 1 Accident 1 ... ... ... ... ... ... ... ... ... 1 3 ... ... 2 1 ... 1 3 1 11 G 82 SANITARY ADMINISTRATION. Public Mortuary. The Public. Mortuary provided by the Council is situated in Goldsmith Street. During the year 42 bodies were deposited. There were 29 post mortem examinations made. and 31 inquests held. The inquests are held in the Court Room at the Council Offices. On 10 occasions bodies awaiting burial were removed to the mortuary on account of inadequate accommodation in the homes; 30 bodies were brought in by order of the Coroner, and two by the Police. Inquests. During the year 67 inquests were held on the bodies of Holborn parishioners. Many of these died outside the Borough and the inquests were held in the district where death took place, the deaths being subsequently transferred to Holborn. The causes of death certified as a result of such inquests were:— Natural causes, 21; Accidents, 10; Suicide, 10; Misadventure, 8: Wilful Murder,1; Execution, 1; Want of attention at birth, 1. Revenue Acts. No application was received under these Acts. Dangers from Flies. With a-view to bringing to the notice of residents in the Borough the dangers arising from flies and emphasising the importance of taking all possible steps to prevent or minimise such dangers a special illustrated leaflet was printed for general distribution. A large number of such leaflets were distributed through the elementary schools. Permission for the use of the school organisation was given by the Education Committee of the London County Council and the teachers of the schools kindly co-operated in the matter. Dirty Tenants. From time to time complaints are received from owners respecting the difficulties experienced by them in keeping their property up to the standard required by local authorities owing to the dirty and destructive habits of tenants It is repeatedly alleged that through carelessness or wilful damage by tenants repairs and cleansing become necessary with unreasonable frequency and that it is impossible to maintain even the minimum requirements of the local authorities without financial loss. These statements have sometimes been found to be well-founded, particularly in the poorer class tenement lodging houses where no responsible keeper or landlord is resident. 83 In order to prevent or minimise difficulties of the owner as much as possible we endeavour to keep in view the considerable powers which the Council has of holding the tenant responsible for defects caused by his neglect or default. During the year the Inspectors have reported a number of cases where dirty conditions of tenements were clearly the fault of the tenants. In these cases the necessary action has been taken to secure the abatement of the nuisance by the tenants. In two cases where the conditions arose to a large extent from the physical inability of the tenants to properly look after themselves, we were able to secure their removal to the Poor Law Institution. Rag Flock Act, 1911. Two samples of rag flock were obtained and examined under the above Act; both samples were found to comply with the Regulations made under the Act. HOUSING. In 1919 the housing survey established the need for sufficient dwellings to rehouse about 200 persons who were about to be displaced by the clearance of the Wild Street area by the Incorporated Society for Improving the Condition of the Labouring Classes. This clearance is in course of progress: the Society intend to provide housing accommodation on a site purchased from the Council. The vacant site in Short's Gardens was acquired by the Council for housing purposes in 1914; the work was deferred till after the War, when, owing to the altered conditions, the Ministry of Health considered the site not suitable for housing purposes. The site has now been sold to the Incorporated Society for Improving the Condition of the Labouring Classes, who will erect dwellings for the working classes thereon. Owing to the extreme difficulty of finding alternative accommodation it has not been found possible to deal with more than a few cases of overcrowding during the year. One of the most unsatisfactory features with regard to housing in the district is the presence of so many houses let in lodgings. These houses were not built for the purpose to which they are now put: the using of the staircases, water supply, washhouses, yards, waterclosets, ashbins, etc., in common leads to misuse and neglect; the tenants suffer much inconvenience in carrying out their ordinary housework In most of the houses there is no suitable provision for the storage of food and cooking. The structure of these houses is in many cases satisfactory, the conversion into self-contained tenements would much improve the accommodation. During the year 665 houses occupied by the working classes were inspected, this number consisted of 591 registered lodging houses and 74 non-registered houses G 2 84 occupied by working classes. Of the 74 non-registered houses, 28 were block dwellings. one block being counted as one house. The 28 blocks included 587 tenements. The total number of buildings in the Borough occupied for dwelling purposes is given by the Census, 1921, as 3,473. The number of tenements occupied by working classes as returned to the London County Council is 8,571. This figure represents the total tenements in the Borough consisting of one, two, three or four rooms. HOUSING CONDITIONS. Statistics. Year Ended 31st December, 1921. 1.—GENERAL. (1) Estimated population 42,850 (2) General death rate 13-3 (3) Death-rate from tuberculosis (all forms) 1-19 (4) Infantile mortality rate 72 *(5) Number of buildings containing dwellings (Census, 1921) 3,473 †(6) Number of separate dwellings (Census, 1921) 7,202 ‡ (6a) Number of working-class tenements 8.571 (7) Number of new working-class houses erected nil 2.—UNFIT DWELLING-HOUSES. I.— INSPECTION. (1) Total number of dwelling-houses inspected for housing defects (under Public or Housing Acts) 991 § (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 nil|| (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation nil (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 789 II.—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 ? *" Buildings."—A structure wholly detached or separated from another by a party wall, e.g., a block of flats is one building. +" Separate dwelling," i.e., having separate access to street or common landing or staircase, e.g., each flat in a block is a separate dwelling, but a private house not structurally divided is a single unit whether occupied by one or more families. ‡" Working-class tenements," i.e., separate occupations of one, two, three or four rooms only. § Practically all these houses were tenement houses containing a number of tenements. II All the more insanitary houses are always annually .inspected, although none last year were formally recorded under the above Regulations. 85 III.—ACTION UNDER STATUTORY POWERS. A. Proceedings under Section 28 of the Housing, Town Planning, etc. Act,1919: — (1) Number of dwelling-houses in respect of which notices were served requiring repairs nil (2) Number of dwelling-houses which were rendered fit— (a) by owners nil (b) by Local Authority in default of owners nil (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 789 (2) Number of dwelling-houses in which defects were remedied: — (a) by owners 789 (bN> by Local Authority in default of owners nil C. Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc. Act, 1919: — (!) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling-houses in respect of which Closing Orders were made nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit 1 (4) Number of dwelling-houses in respect of which Demolition Orders were made nil (5) Number of dwelling-houses demolished in pursuance of Demolilion Orders nil 3.—UNHEALTHY AREAS. Areas represented to the Local Authority with a view to Improvement Schemes under (a) Part I., or (b) Part II., of the Act of 1890: — (1) Name of area nil (2) Acreage nil (3) Number of working-class houses in area nil (4) Number of working-class persons to be displaced nil 4. Number of houses not complying with the building By-laws erected with consent of Local Authority under Section 25 of the Housing, Town Planning, etc . Act, 1919 nil 86 APPENDIX. TABLE I. Vital Statistics of Whole District during 1922 and Ten Previous Years. Year Population estimated to J Middle of each Year. Births. Total Deaths Registered in the District Transferable Deaths Nett Deaths belonging to the District. Under 1 Year of Age At all Ages Uncorrected Number Nett Number Rate of Non residents registered in the District of Residents not registered in the District Number Rate per 1,000 Birth Number Rate Number Rate 1912 48,020 1,250 901 18.8 907 18 9 549 i 357 70 78 715 149 19 3 46,919 868 798 16 9 910 19.9 583 358 80 100 685 141 19:4 46,832 703 765 16 4 888 19 0 658 408 67 88 738 158 1915 40,4 5 591 670 14 4 876 21 8 559 385 64 96 702 174 1916 38,161 564 619 15.7 768 20 2 498 395 63 97 665 17.5 1917 35.303 474 571 14 5 865 24.5 567 390 62 107 688 19.5 19:8 30.769 310 497 12.1 862 23.4 532 490 70 141 820 22.8 1919 38,56 397 539 13.6 920 24:1 6:8 322 52 96 624 164 1920 39,676 619 827 20.6 827 20 6 568 339 55 66 603 15.2 1931 41,520 483 648 14.8 859 19.7 622 319 51 79 556 12.8 1922 42,850 485 661 15.5 746 17 4 518 312 43 72 570 13.3 in the above Table the populations, birth-rates and death-rates for the years 1912-1914 inclusive have been estimated from the Census Populations of 1901 and 1911. For the years 1915 to 1921 inclusive, the populations, births and birth-rates, deaths and deathrates, are as estimated by the Registrar-General, founded upon his estimates of the Civilian population. 87 TABLE II. Causes of, and Ages at, Death, 1922. Causes of Death. NET DEATHS AT THE SUBJOINED AGES OF "RESIDENTS," whether occurring within or without the District. Total Deaths whether of " Residents " or " NonResidents" in Institutions in the District. ' ' All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and under 75 years. 75 and upwards. All causes Certified 570 48 17 13 12 22 75 182 120 82 Uncertified ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... 1 2. Small Pox ... ... ... ... ... ... ... ... ... ... ... 3. Measles 7 4 3 ... ... ... ... ... ... ... 1 4. Scarlet Fever 2 ... ... 1 ... ... 1 ... ... ... ... 5. Whooping Cough 6 1 3 2 ... ... ... ... ... ... 10 6. Diphtheria and Croup 4 ... 2 2 ... ... ... ... ... ... 2 7. Influenza 21 ... 1 ... ... ... 3 11 5 1 4 8. Encephalitis Lethargica 1 ... ... ... 1 ... ... ... ... ... ... 9. Meningo-coccal Meningitis 1 ... ... ... 1 ... ... ... ... ... 8 10. Tubeiculosis of Inspiratory System 43 ... ... ... 1 6 10 21 5 ... 8 U. Other Tuberculous Diseases 8 ... 1 1 2 2 ... 1 1 ... 53 12. Cancer, malignant disease 58 1 ... 1 ... 1 4 29 14 8 42 13. Rheumatic Fever 2 ... ... ... 1 ... ... ... 1 ... 5 14. Diabetes 1 ... ... ... ... 1 ... 1 1 ... ] 15. Cerebral Hcemorrhage 23 ... ... ... ... ... 2 10 8 3 ... 16. Heart Disease 70 ... ... ... ... 2 9 27 21 11 18 17. Arterio-sclerosis 24. ... ... ... ... ... 1 4 9 10 ... 18. Bronchitis 62 ... ... 1 ... ... 1 15 21 24 15 19. Pneumonia (all forms) 45 11 5 2 ... 2 6 12 5 2 46 20. Other Respiratory Diseases 9 ... ... ... ... ... ... 7 2 - 8 21. Ulcer of Stomach or Duodenum 5 ... ... ... ... ... 1 1 3 - 1 22. Diarrhoea, etc., (under 2 years) 10 6 ... ... ... ... ... ... 2 2 34 23. Appendicitis and Typhlitis 2 ... ... ... 1 ... ... ... ... 1 6 24. Cirrhosis of Liver 6 ... ... ... ... ... 2 2 1 1 4 25. Acute Chronic Nephritis 20 ... ... ... 1 ... 3 8 7 1 8 26. Puerperal Sepsis 1 ... ... ... ... ... 1 ... ... ... 2 27. Other accidents and diseases of Pregnancy and Parturition ... ... ... ... ... ... ... ... ... ... ... 28. Congenital Debility and Malformation, Premature Birth 15 15 ... ... ... ... ... ... ... ... 3; 29. Suicide 14 ... ... ... ... 2 7 3 2 ... 2 30. Other Deaths from Violence 26 ... ... 1 1 3 6 12 ... 3 3 31. Other Defined Diseases 84 10 2 2 3 3 18 19 13 14 158 32. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... 570 48 17 13 12 22 75 182 120 81 478 88 TABLE III. Cases ok Infectious Disease notified during the yeah 1022. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Locality (e.g. Parish or Ward) of the District. Total Cases Removed to Hospitals. At all Ages. At Ages—Years. St. Giles and Bloomsbury. Holborn. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and .5, Sinall-pox 1 ... ... ... 1 1 ... ... 1 ... 1 Diphtheria (including Membranous Croup) 108 1 30 49 16 10 2 ... 2g 82 107 Erysipelas 14 1 ... 1 ... 4 7 1 3 11 3 Scarlet Fever 147 ... 33 65 36 11 2 ... 66 81 141 Enteric Fever 4 ... 1 1 2 ... ... ... 1 3 4 Puerperal Fever ... ... ... ... ... ... ... ... ... ... ... Cerebro-Spinal Fever 1 ... ... 1 ... ... ... ... ... 1 1 Ophthalmia Neonatorum 10 10 ... ... ... ... ... ... 7 3 5 Dysentery ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... Pneumonia—Primary 42 3 10 2 2 11 10 4 19 23 23 do. Influenzal 22 1 5 ... 2 4 8 2 10 12 10 Tuberculosis—Pulmonary 68 ... ... 4 11 30 22 1 33 35 31 do. Non-Pulmonary 14 ... 4 5 3 2 ... ... 7 7 10 Whooping Cough 110 16 6'J 23 1 ... 1 ... 15 95 20 Chicken Pox 21 3 8 9 1 ... ... ... 8 13 1 Acute Poliomyelitis 1 ... 1 ... ... ... ... ... ... 1 Encephalitis Lethargica 1 ... ... 1 ... ... ... ... 1 ... 1 564 35 161 16) 74 73 52 8 197 367 361 * Two of these were notified from the Public Health Department on discovery of notified cases. 89 TABLE IV. Infectious Diseases in Holborn for the last Eleven Years. NOTIFICATIONS DEATHS Decennial Average, 1912-1921 Year 1922 Decennial Average, 1911-1921 Year 1922 Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Small-pox 0.1 0.00 0.00 1 0.02 0.00 0 0.00 0.00 0 0.00 0.00 Diphtheria 92 2.26 2.24 108 2.52 3.38 6 0.13 0.16 4 0.09 0.25 Erysipelas 24 0.57 0.73 14 0.32 ... 1 0.02 ... 1 0.02 ... Scarlet Fever 166 2.47 3.63 147 3.43 3.81 1 0.02 0.04 2 0.05 0 47 Enteric Fever 7 0.16 0.12 4 0.09 0.05 1 0.02 0 02 0 0.02 0.01 Cerebro-Spinal Fever 2 0.06 0.07 1 0-02 .. ... ... ... 1 0.02 0.01 Acute Poliomyelitis 1 0.02 ... 1 0.02 ... ... ... ... 0 0.00 0.00 "YVhooping Coughf 38 0.93 ... 110 2.56 ... 6 0.14 0.19 6 0.14 0.25 Measles ‡ ... ... ... ... ... ... 11 0.28 0 25 7 0.15 0.35 Tuberculosis—-Pulmonary 141 3.42 ... 68 1.58 ... 76 1.84 1.40 43 1.00 1.06 Ditto Non-Pulmonary 22 0.48 ... 14 0.32 ... 9 0.22 ... 8 0 18 0.23 Puerperal Fever* 1 1.45 3.13 0 0.00 3.28 1 1.45 ... 1 1.50 1.28 Ophthalmia Neonatorum* 7 10.20 ... 10 15.06 9.18 ... ... ... ... ... ... Diarrhoea (under 2 years)* ... ... ... ... ... ... 9 14.1 1.91 6 9.00 7.1 * Rates per 1,000 births. t Notifiable in Holborn (not in London) aince 1914. Average given for 7 years. † Not Notifiable. TABLE V. Information required by the London county council. PREMISES. Number on Register at end of 1922. Number of Inspections. Number of Prosecutions. Cowsheds ... ... ... MiLkshops 15.4 159 ... Houses let in lodgings 591 932 4 Ice cream premises 85 207 ... Slaughter houses 1 6 Offensive Trades ... ... ... ... Smoke Nuisances— Number of observations 385 Number of notices 20 Number of nuisances and complaints 12 complaints Number of summonses 0 Housing of the Working Classes— Number of houses inspected 665 Number of houses dealt with under Section 15 of the Housing, Town Planning, etc., Act, 1909 0 Number of representations by householders 0 Number of representations by Medical Officer 0 Number of houses included in such representations 0 Number of Closing Orders 0 Number of houses included in such Closing Orders 0 Number of Closing Orders determined 1 Number of houses remedied without Closing Orders 0 (A number of houses were remedied without the necessity for representation) Number of demolition orders 0 Number of houses demolished; (u) in pursuance of Orders 0 (b) voluntarily 0 Obstructive Buildings— Number of representations under Section 38 of the Housing Act, 1890 0 Number of buildings demolished 0 Number of representations still under consideration 0 Number of Orders for repairs issued under Section 28 of the Housing Act, 1919 0 Number of houses repaired by local authorities 0 Number of houses closed on notice by owner that they could not be made fit 0 Total number of houses in the borough 3473 (Census, 1921) Number of houses occupied by the working classes 8571 tenements (Census, 1921) Number of houses for working classes— (a) erected during year 0 (b) in course of erection 0 Underground Rooms— Number illegally occupied 3 Number closed or illegal occupation discontinued 3 Overcrowding— Number of rooms overcrowded 6 Number remedied 6 Prosecutions 1 Cleansing— Number of adults cleansed 120 Number of children cleansed 0 Number of rooms or premises cleansed 55 (vermin) Prosecutions (vermin) 0 Water Supply to Tenement Houses— Premises supplied 4 Prosecutions 0 Sale of Food— Number of premises used other than ice cream premises, milk shops and cowsheds 238 Number of Inspections 2419 Disinfection Shelter— Persons accommodated 0 Ophthalmia Neonatorum Regulations— Number of notifications received during the year from-certified midwives 0 Sanitary Officers— . Number of Sanitary Inspectors (whole-time) Male 3 Female 0 Number of Sanitary Inspectors (part-time) Male 0 Female 1 Number of Health Visitors whole-time 1 part-time 1 91 TABLE VI. Factories, Workshops, Laundries, Workplaces and Homework 1.—INSPECTION. Including Inspections made by Sanitary Inspectors. PREMISES. Number of Inspections. Written Notices. Prosecutions. Intimations. Statutory. Factories 157 22 5 ... Workshops 852 51 14 ... Workplaces 3,292 77 11 ... Total 3,801 150 80 ... 2.—DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to h.M. Inspector. *Nuisances under the Public Health Acts: Want of cleanliness 51 54 ... ... Want of ventilati on ... ... ... ... Overcrowdiug 1 1 ... ... Want of drainage of floors ... ... ... ... Other nuisances 114 114 ... ... Sanitary accommodation insufficient 1 1 ... ... unsuitable or defective 52 52 ... ... not separate for sexes... 8 8 ... ... Offences under the Factory and Workshops Act: ... ... ... ... Illegal occupation of underground bakehouse (S. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses SS. 97 to 100) ... ... ... ... Other offences (excluding offences relating to outwork wliich are included in Part, 3 of this Report) ... ... ... ... Total 230 230 ... ... * Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act as remediable under the Public Health Acts. 92 TABLE VI.—continued. 3.—HOME WORK NATURE OF WORK. Outworkers' Lists, Section 107. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sections 109, 110. Lists received from Employers. Notices served on occupiers as to keeping or sending lists. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made (S. 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 Lists. Outworkers. Lists. Outworkers. Contractors. Workmen. Contractors. Workmen. Wearing Apparel— (1) Making, &c. 115 28S 283 1 4 116 ... ... ... ... ... ... ... ... (2) Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquet and Tennia Balls 2 54 ... ... ... 2 ... ... ... ... ... ... ... ... Paper Bags and Boxes 2 ... lit ... ... ... 2 ... ... ... ... ... ... ... ... Total 119 288 356 1 4 ... 120 ... ... ... ... ... ... ... ... 93 TABLE VI.—continued. 4.--REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. Number. (1) (2) Bakehouses (including 16 factory bakehouses) 29 Other Workshops 1,126 Total number of workshops on Register 1,155 5.—OTHER MATTERS. Class. Number. (1) (2) Matters notified to H.M. Inspector of Factories :— Failure to affix Abstract of the Factory and Workshop Act (s. 133) 5 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Acts (s. 5) Notified by H M. Inspector 52 Report (action being taken) sent to H.M. Inspector... 52 Other — Underground Bakehouses (s. 101): — Certificates granted during the year — In use at the end of the year 18 94 LEGAL PROCEEDINGS. sale of food and drugs acts. Date. Name and Address. Offence. Result. 1922 Jan. 23 & Feb. 13 Ernest Pickard. Caterers, Limited Mrs. Wilson and Herbert Wilson, The Spread Eagle, P.H., 69, Theobalds Road Selling wliiskty 40-10 degrees under proof Withdrawn on payment of £5 5s. costs. Feb. 28 Antonio Simonelli 40, Wurner Street Selling milk 8-3 per cent, deficient in fat Fined £1. Costs £1 5s. Cd. including 10s. Cd. for Interpreter. Mar. 27 Soloman Boris 43, Theobalds Road Selling preserved peas containing 0-C053 per cent, of copper Defendant convicted and fined 40s. and 21s costs. Apr. 24 Evan Edwards 16. Little Earl Street Selling butter containing 12 per cent of foreign fat Defendant convicted and fined £5. May 25 F. Collier 15, Baldwins Gardens Selling milk 78 per cent, added water Summons dismissed on payment of £1 Is. costs. Aug. 9 W. H. Ccllen 1, Broad Street Selling strawberry jam containing 7 5 per cent, apple pulp Withdrawn on payment of £2 2s. costs. Nov. 10 Mrs. Annie Ellman 49. Lamb's Conduit St Selling peas containing 0-0125 per ctnt. of copper, equal to 3 458 grains per pound of crystallised copper sulphate Defendant convicted and tilled 21s. costs. Pec. 12 A. Simonelli 40, Warner Sireet Selling tinned peas containing copper equal to 3 29 grains per pound of crystallised copper sulphate Defendant convicted and fined Is. and 20s. costs. public health (london) act. Date. Nome and Address. Offence. Result. 1922 Aug. 9 Mrs. Edwards 20, Old Gloucester St. Overcrowding Ordei-ed to pay 2s. cost s. Aug. 25 Leiohton & Lonsdale, 263, High Holborn Insufficient water-closet accommodation Order to complete work in 7 days £3 3s costs. Dec. 11 W. J. Nicholls 50, Devonshire Street Nuisance and Breach of Lodging House By-laws Adjourned, sine die. Ditto W. J. Nicholls 51, Devonshire Street Ditto Ditto. Ditto W. J. Nicholls 52, Devonshire Street Ditto Ditto. Ditto W. J. Nicholls 53, Devonshire Street Ditto Ditto. Ditto W. J. Nicholls 51, Devonshire Street Nuisance under Public Health (London) Act, 1891 Order to abate within 21 days. 21s. costs. Ditto W. J. Nicholls 52, Devonshire Street Ditto Ditto.