HOL 17 The Metropolitan Borough of Holborn. ANNUAL REPORT OF THE Medical Officer of Healtb, C. W. HUTT, M.A., M.D., D.P.H. For the Year 1923 London: Printed by DIPROSE, BATE MAN & CO. Sheffield Street, Kingsway, W.C. 2. 1924. INDEX. page Public Health Committee 1 Housing of the Working Classes Committee 1 Maternity and Child Welfare Committee 2 Staff 2 Statistical Summary 3 Natural and Social Conditions Population and Houses 5 Ages 5 Occupations 6 Births 6 Deaths 7 Seasonal Mortality 8 Infantile Mortality 9 Poor Law and Hospital Relief 9 Sanitary Circumstances Scavenging. Removal of House Refuse 9 Removal of Manure 10 Sanitary Inspection of District 10 Notices served 11 By-law as to Houses let in Lodgings 13 Rats and Mice (Destruction) Act 13 Inspection of Workshops 16 Hygienic Arrangements for Staffs of Hotels, Restaurants and Eating Houses 17 Hygienic Inspection of Licensed Houses 17 Smoke Abatement 18 Common Lodging Houses 18 Food Dairies, Cowsheds and Milk Shops 18 Milk Supply 18 Dirt in Milk 19 Bacteriological Examination of Milk 20 Milk (Special Designations) Order, 1923 21 Public Health (Milk and Cream) Regulations, 1912-17 22 Condensed Milk 22 The Hygiene of Restaurants, Eating Houses and Public Houses 23 Kitchens 23 Storage of Food 24 Washing up Arrangements 25 Public Houses 26 Bakehouses 28 Fried Fish Shops 29 Market Streets and Exposure of Food Generally 29 Ice Cream 29 Meat 30 Places where Food is Prepared for Sale 30 Unsound Food 30 Sale of Food and Drugs Acts 31 Preservatives in Foods 31 Adulterated Samples 31 Cream Cheese 32 Milk—Fat Content 34 Chlorodyne 36 Table of Samples Purchased 37 Prevalence of and Control over Infectious Diseases 39 Infectious Diseases Generally 39 Smallpox 40 Vaccination 14 Diphtheria 42 Schick Test and Immunisation against Diphtheria 44 Scarlet Fever 46 Enteric Fever 46 Typhus Fever 46 Cerebro-Spinal Fever 46 Dysentery 46 Malaria 47 Encephalitis Lethargica 47 Acute Poliomyelitis 47 Pneumonia 47 a Page Influenza 47 Anthrax 48 Chicken pox 48 Mumps 48 Bacteriological Work 48 Disinfections 48 Cleansing of Persons Act 48 Scabies 49 Shelter during Disinfection 49 Tuberculosis 49 Notifications 50 Delay in Notification 51 Institutional Treatment 52 Visitation of Home 52 Contacts 52 Prevention of Spitting 53 Deaths from Pulmonary Tuberculosis 53 Tuberculosis Dispensary 53 Tuberculosis Care Committee 55 Home Nursing 57 Dental Clinic 58 Cancer 58 Maternity and Child Welfare 58 Notification of Births 58 Home Visiting 59 Work at Centre 60 Ante-natal Hygiene 62 Maternal and Infant Consultations 63 Breast Massage 64 Diarrhœa Still-Births 64 Illegitimate Births 65 Dental Treatment 65 Assistance with Denture 65 Supply of Milk and Food for Mothers and Infants 65 Home Help 67 Convalescent Home Treatment 67 Saffron Hill Maternity and Child Welfare Centre 67 Co-operation with Clergy 67 Deaths of Infants under One Year 68 Deaths of Infants, One to Five Tears69 Infectious Diseases among Mothers and Children69 Puerperal Fever 69 Ophthalmia Neonatorum 69 Measles 72 Whooping Cough 72 Epidemic Diarrhœa 73 Poliomyelitis 74 Nursing Arrangements 74 Pensions for Mothers and Widows 75 Health and Baby Week 75 Medical Inspection and Treatment of School Children 75 Deaths of Children, 5-15 Years 77 Sanitary Administration 79 Mortuary 80 Inquests 80 Revenue Acts 80 Danger from Flies 80 Dirty Tenants 80 Poisoning by Coal Gas 81 Rent and Mortgage Interest Restriction Acts, 1920 and 1923 81 Food Poisoning 82 Other Propaganda 82 International Hygiene 82 Housing 84 APPENDIX Table I Vital Statistics, 1923, and ten previous years 88 88 Table II. Causes of and Ages at Death, 1923 89 Table III. Infectious Diseases Notified during 1923 90 Table IV. Infectious Diseases in Holborn during 1923 and ten previous years 91 Table V. Information required by L.C.C. 92 Table VI. Factories, Workshops, &c. 93 (1) Inspections 93 (2) Defects found 93 (3) Home Work 94 (4) Registered Workshops 95 (5) Other Matters 95 Table VII. Legal Proceedings 96 1 PUBLIC HEALTH COMMITTEE. 1922-23. 1923-24. Chairman— Councillor Sir William R. Smith, D.L., J.P., M.D Vice-Chairman— Councillor the Rev. Henry Ross. Ex-Officio— The Right Worshipful The Mayor, Alderman George Harvey, J.P., L.C.C. Alderman Henry Jewell. Councillor John Boraston, C.B. „ James J. Claydon. „ Rev. Wilfred H. Davies, M.A. „ William H. Edwards. „ Edward M. Evans. „ George Hands. „ Francis J. Pullen. „ John W. Roberts. „ Bracewell Smith, B.Sc. Chairman— Councillor the Rev. Henry Ross. Vice-Chairman— Councillor Francis J. Pullen. Ex-Officio— The Right Worshipful The_Mayor, Alderman George Harvey, J.P., L.C.C. Alderman Henry Jewell. Councillor John H. Boraston, C.B. „ Rev. Wilfred H. Davies, M.A. „ Henry W. Ellis. „ Edward M. Evans. ,, George E. Hutchinson. „ John Phillips. „ John W. Roberts. Sir William R. Smith, D.L., J.P., M.D. ,, Arthur Youngman. HOUSING OF THE WORKING CLASSES COMMITTEE. 1922-23. 1923-24. Chairman— Councillor The Rev. Wilfred H. Davies, M.A. Vice-Chairman— Alderman Henry Jewell. Ex-Officio— The Right Worshipful The Mayor, Alderman George Harvey, J.P., L.C.C. Councillor Miss Emily Dibdin. „ Henry W. Ellis. „ Ernest Hamlin. ,, George Hands. „ Alfred Humphreys. „ Raymond A. Miles. „ Rev. Henry Ross. „ Bracewell Smith, B.Sc. „ J. St. Lawrence Stallwood. ,, George Witherby. Chairman— Alderman Henry Jewell. Vice-Chairman— Councillor James J. Claydon. Ex-Officio— The Right Worshipful The Mayor, Alderman George Harvey, J.P., L.C.C. Councillor Charles R. Baddeley. ,, Rev. Wilfred H. Davies, M.A. „ Miss Emily Dibdin. ,, Henry W. Ellis. „ Ernest Hamlin. „ Alfred Humphreys. „ Rev. Henry Ross. „ J. St. Lawrence Stallwood. „ George Witherby. ,, Arthur Youngman. b 2 MATERNITY AND CHILD WELFARE COMMITTEE. 1922-23. 1923-24. Chairman— Alderman Sir George P. Parker, O.B.E. Vice-Chairman— Councillor Francis J. Pullen. Ex-Officio— The Eight Worshipful The Mayor, Alderman George Harvey, J.P., L.C.C. Councillor Richard Davies. „ Miss Emily Dibdin. „ Arthur C. Fox-Davies. ,, John W. Roberts. „ Rev. Henry Ross. „ Lady Smith. „ Mrs. Ethel M. Wilson. „ George Witherby. Nurse M. Baylee. Mr. Thomas W. J. Coffin. Miss M. R. Lovelock. ,, Norah H. March, B.Sc. „ Alice Michelmore. Chairman— Councillor Francis J. Pullen. Vice-Chairman— Councillor John W. Roberts. Ex-Officio— The Right Worshipful The Mayor, Alderman George Harvey, J.P., L.C.C. Alderman Sir George P. Parker, O.B.E., J.P. Councillor Richard Davies. „ Miss Emily Dibdin. ,, Edward M. Evans. ,, George E. Hutchinson. „ Rev. Henry Ross. „ Lady Smith. „ Mrs. Ethel M. Wilson. Nurse M. Baylee. Mr. Thomas W. J. Coffin. Miss M. R. Lovelock. „ Norah H. March, B.Sc. „ Alice Michelmore. STAFF. The following was the Staff during 1923. 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. (To 30th June). Robert Hilton, M.D., M.R.C.P. (From let July). Public Analyst—James Kear 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—Elizabeth Caffyn Ballard. 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). Anaesthetist—James Maughan, M.D., M.R.C.S., (To 15th March, 1923). G. C. Nelson Younger, M.R.C.S., L.R.C.P. (From 12th April). Nurse—Maud Cater (To 25th January). The Metropolitan Nursing Association (From 1st February). 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 (To 10th February, 1924). Annie Axtell (From 11th February, 1924). Disinfector—Henry Emms. Assistant Disinfector—James Rowan. 3 STATISTICAL SUMMARY, 1923. Population, estimated to middle of year (as supplied by the Begistrar-General) for birth and death-rates 43,376 Population—Census, 1921 43,192 Births 595 Annual Rate of Births per 1,000 population 13.71 Deaths 526 Annual Bate of Deaths per 1,000 population 12.1 Zymotic Death Bate 0.34* Tuberculosis Death Bate per 100,000 110 Excess of Begistered Births over Deaths 69 Infantile Mortality per 1,000 Births 79 Area of Borough in Acres 405.1 Rateable Value, 1st November, 1923 £1,372,232 A Bate of 1d. in the £ estimated to yield £5,383 *Excluding deaths from Epidemic diarrhœa. Vital Statistics, 1923. 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 19.7 11.6 69 London 20.2 11.2 60 Holborn 13.71 12.1 79 B 2 4 PUBLIC HEALTH DEPARTMENT, COUNCIL OFFICES, 197, HIGH HOLBORN, W.C. 1. March, 1924. 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 1923. I regret to have to record the death during the year of my predecessor, Dr. W. A. Bond, the first Medical Officer of Health of the Metropolitan Borough. Believe me, Ladies and Gentlemen, Yours obediently, C. W. HUTT, Medical Officer of Health s NATURAL AND SOCIAL CONDITIONS OF THU 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 1923—43,376. The density of the population, according to the Census, 1921, 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 flats, 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 large and crowded day population of London's workers. The following information is from the Report of the Census, 1921, respecting the average ages, etc., of population, and is supplemental to that included in the Annual Report for 1922:— Average Age of Population. Children under 5 years per 1,000 of population. Females per 1,000 Male population M. F. M. F. County of London 30.0 31.4 92 77 1,165 Holborn 34.1 33.8 56 49 1,083 Range of variation in London—Highest 34.7 35.1 111 102 1,594 Lowest 27.2 27.7 44 39 1,015 In commenting on the local age distribution in London the Census Report says:— " The City of London and Holborn stand rather apart from other Boroughs Here the relatively high proportion of males is similar to that found in the industrial areas; but there are relatively few young children, and the population is in consequence above the normal as regards age." 6 Occupations, etc. The total number of males over 12 years of age in the Borough is given in the Census Report as 17,853; of this number 14,728 are stated to be gainfully occupied. The total number of females over 12 is given as 19,652; of this number 10,333 were described as gainfully occupied. The following table gives the population in Holborn over 12 years of age in relation to marriage and occupation:— Males. Females. Single. Married. Widowed or Divorced. Single. Married. Widowed or Divorced. Total 8 708 8,297 947 9,415 7,741 2,496 Number occupied 6,643 7,296 689 7,149 1,830 1,354 Number not occupied 2,065 901 159 2,266 3,911 1,142 The number of married women occupied away from their homes is equal to 23.7 per cent. of the total number of married women in the Borough. This high percentage of wives following an occupation is exceeded in London only in the City of London, where the proportion is 30.6 per cent., and in the Borough of Shoreditch, 24.1 per cent.; Holborn is closely followed by Finsbury with 23.1 per cent.; at the other end of the scale we have Woolwich with 5.3 per cent., Lewisham 6.1 per cent., Wandsworth 7.8 per cent., and Stoke Newington 10.2 per cent. 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 3,525. The number of deaths was 37, a death-rate of 10.1 per 1,000, considerably below the average death-rate for the whole of the Borough (12.1). On the other hand the number of deaths of residents of Common Lodging Houses in the Borough, which contain 1,220 beds was 58 which, calculated on the number of beds, was a rate of 46. 5 per 1,000. Registered Births and Birth-Rate. The total number of births registered as occurring in the Borough was 423, (216 males and 207 females). Of the 423, 400 were legitimate and 23 illegitimate. Corrected Births and Birth-Rate. I received from the Registrar-General information of the births in outlying institutions in London of 158 legitimate infants and 30 illegitimate infants whose mothers were residents of the Borough. Sixteen of the births occurring in the Borough, viz., 11 legitimate births and 5 illegitimate births, were infants of mothers who were non-residents of the Borough. 7 The following table gives the corrected number of births and the corrected birth-rates for the sixteen years 1908-1923:— Year. Total Births. Legitimate Births. Illegitimate Births. No. Rate per 1000 of Population. No. Rate per 1000 of population. Proportion per 1000 total Registered Births No. Rate 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 13.28 919.4 54 1.16 80.6 1916 649 15.63 585 14.09 901.4 64 1.54 98.6 1917 571 14.50 496 12.60 868.7 75 1.90 131.3 1918 497 12.06 428 10.38 861.2 69 1.68 138.8 1919 539 13.56 477 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 1923 595 13.71 547 12.61 919.3 48 1.10 80.7 In London the corrected birth-rate in 1923 was 20.2 per 1000 in comparison with 21.0 for 1922. Mortality. The total number of deaths registered as occurring in the Borough was 718, of which 386 were males and 332 females. Of these deaths the following occurred in Public Institutions, etc., within the area of the Borough:— Institution. Residents. Non-Residents. St. Giles and Bloomsbury. Holborn. St. Giles and Bloomsbury. Holborn. French Hospital 2 2 33 – Children's Hospital – 2 – 269 National Hospital 1 2 – 85 London Homœopathic Hospital 2 15 – 65 Italian Hospital 1 3 – 19 Alexandra Hospital – – – – Private – – 14 6 Total 6 24 47 444 8 There were 299 deaths of Civil "Residents" in various Workhouses, Infirmaries, Asylums, Hospitals, etc., outside the Borough, 55 of whom were removed from Common Lodging Houses in the Borough. The deaths are further corrected by the Registrar-General by the inclusion of all deaths registered in the calendar year as distinct from the registration year of 52 weeks. This correction, together with deaths, transferred from extra Metropolitan Institutions, accounts for the variation in the number of deaths given in the four quarterly reports of the Registrar-General and in his Annual Report. The final correction supplied by the Registrar-General for 1923 gives the total deaths for the Borough as 526. Corrected Deaths and Death-Rates, 1923, compared with 1922. Year. Total Deaths at all ages registered in District. Deaths in Public Institutions in District. Deaths of of nonresidents of Borough registered in District. Deat hs of residents registered beyond the District. Nett Deaths at all ages. Death Rate for Borough Death Rate. Registration London. 1922 746 478 518 342 570 13.3 13.4 1923 718 501 491 299 526 12.1 11.2 For details of causes of and ages at death, see Table II., page 89. Seasonal Mortality. The mortality in the four quarters of the year is shown below:— Deaths. Death-rate per 1,000. First Quarter 157 14.5 Second ,, 115 10.1 Third ,, 86 8.0 Fourth ,, 168 16.5 526 12.1 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 1923 47 75 120 79 60 9 Death-rate per 1,000 corrected births in 1923 and in ten preceding years during which details respecting births have been supplied. Holborn Borough London 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 Av'ge, 1913-22 1923 100 88 96 97 107 141 96 66 79 72 94.2 79 105 101 112 89 103 107 85 75 80 74 93.1 60 See also Table, page 69. Attention was again directed to the figures respecting infantile deaths published in the Quarterly Reports of the Registrar-General. The figures on which the rate given in these reports are based are necessarily only partly corrected; the final correction including the transference of births in institutions to the residential area of the parents is made before the publication of the Registrar-General's Annual Report. The corrections considerably modify the Holborn rates as will be seen from the following figures:— Year 1923. Infantile Death-rate in Holborn per 1000 Births Registrar General's Quarterly Report Corrected 1st Quarter 117 78 2nd „ 81 69 3rd „ 80 68 4th 147 102 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 year 1923:— Indoor Relief 1,136 persons Outdoor Relief 437 cases Outdoor Medical Relief 294 persons Of the total number of 526 deaths, 329 died in 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. During the year arrangements were made with the contractor for the gradual substitution of motor vehicles in place of horse-drawn wagons for the removal of house and trade refuse. 10 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, ashbin was 76, and for breach of by-laws as to the removal of refuse, 5. 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. In one case it was necessary to serve a notice in connection with the structure of a manure receptacle for a breach of By-laws made by the London County Council. Sanitary Inspection of the District, including Premises and Occupations which can be controlled by By-Laws and Regulations. In addition to my inspections, the Sanitary Inspectors made 23,596 various 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 1923. Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Complaints received 30 35 39 ... ... 104 Do. found to be justified 28 32 36 ... ... 96 Inspection of Houses— Dwelling-houses 80 172 55 ... ... 307 Houses let in lodgings 341 284 175 33 17 850 Common lodging-houses ... 4 ... ... ... 4 Drains tested by smoke ... 3 3 ... ... 6 ,, „ ,, water ... ... 1 ... ... 1 ,, „ ,, chemicals 5 2 ... ... ... 7 Re underground rooms 712 613 48 ... ... 1,373 „ Rent (Restriction) Act ... 1 ... ... ... 1 „ New Buildings ... ... 1 ... ... 1 FACTORIES— Bakehouses 9 31 15 ... ... 55 Food preparation (other than above) ... ... 45 ... ... 45 Other 14 23 46 ... ... 83 Laundries ... 1 ... ... ... 1 WORKSHOPS AND WORKPLACES — Food premises: Dairies and Milkshops 31 119 62 24 12 248 Ice Cream, Manufacture 18 27 161 ... ... 209 Do. Storage or Sale 9 20 2 ... ... 31 Slaughter-houses ... 3 ... ... ... 3 Hotels and Restaurants 89 123 107 ... ... 319 Butchers 336 31 279 ... ... 646 Bakehouses 8 23 6 ... ... 37 Fried Fish shops 190 25 111 ... ... 326 Market Streets 342 70 412 ... ... 824 Other food shops 171 15 94 ... ... 280 Laundries 1 ... ... ... ... 1 Other workshops 45 72 67 l ... 185 Other workplaces 28 77 67 ... ... 172 Outworkers' Registers 24 41 57 ... ... 122 Stable and Stable yards 40 71 ... ... ... 111 Rag and Bone shops 145 12 ... ... ... 157 Public Houses 10 25 41 ... ... 76 Inspections carried forward 2,648 1,888 1,858 58 29 6,481 11  Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie | Total Brought forward 2,648 1,888 1,858 58 29 6,481 Miscellaneous— Black smoke 125 65 218 ... ... 411 Keeping of animals 3 12 ... ... ... 15 Dust, Special Inspections 158 208 66 ... ... 432 Rats and Slice (Destruction Act 83 50 66 ... ... 199 Public Urinals ... 29 1 ... ... 30 Sale of Food and Drugs Act, samples 218 200 204 ... ... 622 Other Inspections 20 32 10 40 ... 102 Periodical Inspections: Includes W.G. and yards, dustbins, especially houses let in lodgings, and other suitable buildings 1,655 1,711 3,374 ... ... 6,740 Re-Inspections— Houses 728 1,088 503 1 ... 2,380 Factories ... 4 5 ... ... 9 Workshops and Workplaces 61 118 108 ... ... 290 Miscellaneous 14 5 6 68 40 133 Visits re Infectious Diseases 104 227 110 126 71 638 Do. on School Reports ... 6 ... ... ... 6 Tuberculosis—First visits 27 26 27 ... ... 80 Do. Re-visits 101 59 96 ... ... 256 Scabies ... ... ... 3 ... 3 Vermin ... ... 1 4 24 29 Other Visits— Police Courts 4 11 6 ... ... 21 Various 263 450 276 31 2 1,022 Maternity— Visits: Children under 1 year ... ... ... 338 256 594 Do. 1 to 5 years ... ... ... 13 3 16 Expectant Mothers ... ... ... 46 69 115 Re-visits ... ... ... 917 1,464 2,381 Do. Expectant Mothers ... ... ... 27 36 63 Other Maternity Visits ... ... ... 85 38 123 Attendances at Maternity Centres ... ... ... 191 225 416 Total 6,215 6,193 6,995 1,948 2,257 23,607 The total number of notices served for nuisances found in dwelling houses and factories, workshops and workplaces, and premises subject to various By-laws, was 1,560, viz.:— Public Health (London) Act, 1891— Intimation Notices 663 Statutory Notices 79 By-laws— Houses let in Lodgings 773 Removal of Refuse 5 London County Council (General Powers) Acts— Verminous rooms 24 Food premises 4 Regulations as to Dairies, Cowsheds and Milk Shops 1 Rats and Mice (Destruction) Act, 1908 11 , \ 1,560 12 The following Table shows the work done to abate nuisances for which intimation notices were served:— Water Supply— Houses. Factories, Workshops and Workplaces. Provided – l Cisterns cleansed, repaired, etc. 43 7 Waterclosets— Cleansed 31 8 Water supplied, flushing cistern repaired, etc. 31 11 Repaired, new pans, etc. 130 12 Ventilation improved 2 5 Separate accommodation for sexes provided – 5 Position improved – 8 Direct communication with workrooms remedied – 9 Accommodation provided 2 1 Soil Pipes— Repaired, renewed and ventilated 6 3 Rainwater Pipes— Repaired or renewed 14 8 Drains— Repaired 11 5 Unstopped, cleansed, etc. 21 8 Sinks, etc. Waste pipes repaired, renewed, etc 30 5 Yards, Areas and Washhouses— Cleansed 43 4 Paved and paving repaired 27 3 Houses and Workshops, etc.— Cleansed 99 34 Dilapidations repaired and made good 89 6 Ventilation improved – 1 Dampness— Roofs repaired 73 2 Gutters repaired 12 2 Floor cavities ventilated 1 1 Other works to prevent dampness 17 2 Ashbins— Provided, repaired, etc. 73 66 Urinals— Repaired, cleansed, etc. 2 9 Various— Underground Rooms vacated 6 – Smoke—Emission of black smoke abated – 6 Animals—Improper keeping discontinued 2 – Accumulations of Refuse—Removed 24 5 Overcrowding abated 3 – Manure receptacles repaired – 1 Other nuisances abated 17 5 13 The following Table shows the nuisances for which the 79 Statutory Notices were issued under the Public Health (London) Act, 1891. Section 2 (a) Dirty and dilapidated premises, etc. 44 „ (b) and Section 37, Ashbins 9 „ (c) Drains and W.C.'s 31 „ (d) Accumulation of rubbish 6 „ (f) and Section 48. Water supply 3 „ (g) Ventilation of Workshop 1 „ 24 Black Smoke 4 „ 96 Underground rooms 2 „ 38 W.C.'s, communicating with workrooms 2 „ W.C., insufficient accommodation 1 By-laws as to Houses let in Lodgings. At the end of the year 587 houses were registered under these By-laws. Of these, 295 are in St. Giles and Bloomsbury and 292 in the Holborn District. Four such houses were removed from the Register. There were 850 inspections of these premises, excluding a very large number of periodical inspections and re-inspections. Six notices was served for nine overcrowded rooms and 197 notices for other breaches of the By-laws, exclusive of 590 notices that were served for annual cleansing as required by the By-laws. Rats and Mice (Destruction) Act. In accordance with the suggestion of the Ministry of Agriculture and Fisheries "Rat Week" was again observed in the Borough during the week commencing Monday, 5th November. Preparatory visits were paid by the Sanitary Inspectors to premises thought to be possibly rat infested and two leaflets, one drawing attention to the requirements of the Rats and Mice (Destruction) Act, 1919, and one on "Rat Proofing," were left with the occupiers of the premises. The occupiers of these premises and of adjoining premises were encouraged to take concerted action during rat week. Arrangements were made for increasing the baits laid down in the Council's Sewers, 4,000 baits of red squill biscuits being used in place of the usual 1,000. The Borough Surveyor estimated that not more than 50 per cent. of the bait was taken; in some places where the bait was repeated after being taken the first time, the second was left untouched. During the year, 199 inspections of premises were made in connection with rats. The arrangements made by the Council for the repression of rats 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," a liquid extract 14 of red squills. Most success appears to have been obtained by exposing bait made by saturating small pieces of stale bread (25 to the pound) with this liquid preparation. In the Report of the Director-General of Public Health, New South Wales, for the year 1922 in Sydney, the subject of rat poisoning is dealt with. Dr. E. W. Ferguson writes:—"The tests with barium carbonate were unsatisfactory, in that it was difficult to make the rat eat the baits, even when other food was withheld. The fiction of red squills was found to be variable, probably depending on the age of the preparation. Some samples were quite inert, but one bottle proved to be efficient, and graduated doses showed that 2¼ c.c. was lethal though 1 c.c. was not." (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 where 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. 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, &c., ard 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. In the Annual Report for 1922 reference was made to resolutions adopted by the Council and a number of other Metropolitan Borough Councils in favour of legislation requiring owners or occupiers of property 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 sufficient sealing off. Clauses to deal with the matter were included in the London County Council General Powers Bill, 1923, but having regard to certain points of difficulty were ultimately withdrawn for further consideration. The difficulties referred to arose in connection with a proposal that owners and occupiers should become liable for the sealing off of drains already disused at the time of the passing of legislation as well as those which might become disused after that time. It appeared that hardship might be caused to owners or occupiers by these requirements, because such owners or occupiers might be in no way responsible for the existence of such disused drains. As a result of further consideration by the London County Council it was suggested that in the case of drains, the use of which had already been abandoned at the time of passing of legislation, the owner or occupier if he had knowledge 15 thereof should be required to notify the sanitary authority, but the authority itself should be responsible at its own cost for any necessary sealing off or removal. On the recommendation of the Public Health Committee the Council agreed with the suggestion and notified the London County Council accordingly. The following is a copy of the Memorandum issued in the Borough on rat proofing:— The two kinds of rats commonly found in Holborn are the brown rat and the black rat, also known as the house or ship rat. The brown rat is found in sewers and drains, and generally enters a building through a defective house drain. But it frequently burrows under the footpaths from a defective sewer or a defective point of connection of a house drain with a sewer and works its way along until it finds a weak spot in the wall of the basement or in the brickwork of a coal shoot which it gnaws through and so obtains entrance to the premises. The black rat is an expert climber and can not only climb up the stack pipes and mount to the higher window ledges and roofs of houses, but can also travel by overhead telegraph and telephone wires. This rat therefore can enter premises by way of chimneys, windows, roof ventilators, and any other similar openings; a very thorough system of rat-proofing is required to prevent its gaining access to buildings. At night rats have been seen running about the streets; these get into buildings through unprotected area gratings, defective basement lights, and windows, and often through doors which have been left open. In some cases where a siOpe has been made up to a door to do away with a step, the door when closed has a wide space underneath through which rats can easily enter. In addition to the use of poisons, traps, dogs, ferrets, etc., to get rid of rats, it is necessary:— (1) To prevent any more rats getting into the premises. To effect this:— (a) All holes in basement walls and floors should be filled up with broken brick and cement or glass and cement. Loosely-filled spaces should similarly be treated, particularly where drains run close to the floor. (b) A good cement floor should be laid down in the basement, if not already in existence. (c) Disused drains which formerly opened into the basement or other parts of the premises should be removed and the openings at the sewer end completely blocked up with cement. (d) Openings into basements such as area windows or the ventilating windows of W.C.s near the ground level, should be fitted with small mesh galvanised iron wire netting—¼ inch mesh is a suitable size. Defective pavement lights should be seen to. (e) Doors should be made to fit closely at the bottom; if necessary the foot should be covered with sheet iron, 16 (f) All openings through walls by which pipes enter buildings such as water, gas, electricity mains, ventilating tubes, holes behind fascia or sign boards, etc., or beneath stall boards, should be carefully blocked up. (g) To prevent the black rat getting into the building by way of the upper floors or the roof, the posts and carriers of telegraph and telephone wires, cornices and window ledges, openings in the roofs such as chimneys, skylights, etc., should be guarded by wire or sheet metal. These measures are especially necessary where restaurants or canteen kitchens are situated on the upper floors of premises. (2) To prevent the rats already on the premises getting food or water:— (a) All food must be kept on unclimbable surfaces such as counters with marble sides or in rat-proof receptacles (metal bins, metal-lined drawers, etc.), or in rat-proof larders or store rooms. (b) Where meals are consumed on premises every particle of food, even the crumbs, should be gathered up each evening and removed. (c) Any refuse which cannot be burnt and which must be stored in kitchens should be kept in metal bins, the covers of which must fit tightly and not be left off. (d) The rats should not be allowed to gain access to water or other suitable drink; any receptacles containing water which cannot be done away with should be kept properly covered. (3) To prevent rats already on the premises nesting and breeding:— In buildings where lath and plaster ceilings are attached to the joists or rafters, the lath and plaster should be removed leaving the joists exposed. In new buildings, floors and ceilings should be of solid construction. Inspection of Workshops, etc. The routine inspection of factories, workshops and workplaces has been carried out during the year. 184 factories were inspected, 223 workshops and 3,402 workplaces. 188 intimation notices were served, namely, factories 29, workshops 43, and workplaces 116. The Sanitary Accommodation Order of the 4th February, 1903, does not apply to London, and it is desirable that some standard for sanitary accommodation in London workshops should be set up. Difficulty is sometimes experienced in dealing with workshops or workplaces where the number of persons of both sex employed fluctuates frequently and largely, and some definite standard as to the number of W.C-.'s that should be provided for places of this character is desirable with a view to securing uniformity of requirements. This number should not be merely the number adequate for the average number employed, and yet, if the fluctuations are very large and frequent, a large number of persons being occupied for a few days consecutively, the requirement of provision of W.C.'s for the largest number employed might be considered to press unduly on the employers, 17 Hygienic Arrangements for Staff of Hotels, Restaurants and Eating Houses. In connection with 221 premises of this nature inspected during the year the following defects were found:— Sanitary Accommodation— Dirty 2 Pan defective or foul 3 Dark 5 Ventilation unsatisfactory 6 Without water for flushing 1 Insufficient accommodation 1 Unsatisfactory separation for sexes 1 Other unsatisfactory conditions 5 Sleeping Accommodation— Damp 1 Dark 1 Inadequate 1 Dressing Rooms— Unsatisfactory 7 In many cases, particularly in small establishments, no staff dressing room is provided. Where possible steps were taken to improve these conditions. Hygienic Inspection of Licensed Houses. During the year the sanitary accommodation provided at 101 houses licensed for the sale of beer, wine and spirits, was inspected, and the following conditions found:— For Customers— W.C. and urinal supplied 53 W.C. only „ 14 Urinal only „ 21 No accommodation for customers 13 In several of the houses where no sanitary accommodation for the use of customers was provided, the necessity for such provision is not imperative having regard to the nearness of Public Sanitary Conveniences. In three instances the attention of the licenses was drawn to the desirability of such provision being made In nine cases attention was drawn to the unsatisfactory conditions of the W.Cs. or urinals provided for the use of customers. For Staff— In a number of instances it was found that no separate sanitary accommodation was provided for the staff. In most cases, however, the number employed was very small, and the sanitary accommodation provided for the licensee and his family was available for the staff. c 18 Smoke Abatement. The smoke shafts in the Borough were frequently kept under observation and in 411 cases the inspections were recorded. Some 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. Ten complaints were also received. As the result of the inspections six intimation notices were served followed by statutory notices in four of the cases. Much of the black smoke nuisance arises from careless or inefficient stoking. Stoking is usually considered an unskilled employment, and the stoker commonly receives but little instructions how to carry out his work. With a view to encouraging careful and efficient stoking, poster cards giving practical instruction as to stoking, and suitable for hanging in boiler rooms, were obtained and a number of employers agreed to exhibit them. 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 46'5 per 1,000 in 1923. FOOD. Dairies, Cowsheds and Milkshops. The number of registered dairies and milkshops in the Borough at the end of the year was 127. Six dairies and milkshops were newly registered, and 33 removed from the register. In addition to my inspections the Sanitary Inspectors made 248 inspections of these premises, and five notices were served for sanitary defects or breaches of regulations. Detailed inspections were made of 61 dairy premises occupied by registered milk sailers, of these 38 were general shops, 10 milk shops where refreshments also are sold, and 13 milk shops with no other business. It will be seen that a large number of registered milk sellers are engaged in the business of chandlers. In many of these shops although offensive substances are not sold, the trade includes the sale of articles likely to attract flies, e.g., open jams, open sugar, cakes, soft fruits, meat, fish, etc. With one exception the premises and milk utensils were found to be kept in a clean condition, and, generally speaking, the persons and clothing of persons engaged in the business were also found to be clean In the case of the registered milk seller 19 where dirty conditions were found, the Public Health Committee removed the name of the retailer from the Register. In 34 of the premises overalls were worn. Enquiries as to what is done with milk left over at the close of the day, elicited such varied replies as "kept in shop," "kept in basement," "home use," "none left," "sold next day," "thrown away," "kept in outbuilding," "returned to wholesaler," "cold store," "pasteurised," "loaded barrow kept under cover in the yard." Comparatively few shops have any suitable storage for such milk. The distribution of milk in bottles in the Borough is unfortunately by no means general. Sixteen registered milk sellers have bottled milk on sale. The advantage of buying milk in bottles is that the milk can be kept in the bottle and used just as if it were in a jug. It is difficult to ensure that the inside of a jug is sufficiently free from germs; the result of using jugs for milk is often avoidable home contamination of the milk. Daring the year as the result of the Council's interest in the hygiene of food, I was sent reports on the subject from the United States of America and Canada From these I learnt that in Birmingham (Alabama) and in several Canadian cities, milk is sold by retail in bottles only. The Chief of the Division of Food and Dairy Inspection of Birmingham (Alabama, U.S.A.), Mr. L. C. Bulmer, writing to me on the subject says:— "Only bottled milk is permitted to be retailed, which in itself is a big health safeguard against contamination during distribution and domestic contamination in the home. The fact cannot be questioned that the old slipshod way of dipping milk in the open street, and on the door step of the customer, is not only a disgraceful custom that should be abolished everywhere, but is also a blot on the intelligence of any community or country that permits the practice to continue. "Milk by its nature and composition is the most valuable single article of diet we possess for infants or adults; its constitutes the main sustenance of all children up to two years of age, while of all foodstuffs milk is the most difficult to protect and keep free from serious contamination. "One would be appalled to see a city water supply slopped about on the wide open streets into basins, jugs and cans of questionable cleanliness, and yet milk is far more valuable, much more easily contaminated and constitutes a great deal better medium for the growth of pathogenic organisms than water. Because milk is opaque, white and innocent in appearance and the dirt, filth and manurial sediment that it often contains cannot be seen, many people are fooled and deceived as to the true significance of the menace." Residue from Milk Clarifiers. As it would seem probable that pigs have been infected with tuberculosis as a result of feeding with infected milk and slime from clarifiers, enquiry was made C2 20 at the various milk mixing and cleansing depots in the Borough to ascertain what is done with the residue after the milk has been passed through the cleansers. It was found in each case that this residue is at once destroyed. Dirt in Milk. During the year 100 samples were examined in the Health Office for dirt; 2 contained dirt, one was grossly contaminated, 17 parts per 100,000 being present, the other contained a faint trace. This very dirty milk was stated by the wholesaler to be a mixed milk derived from a creamery supplied by "many hundreds of dairies;" it was sold by them to one retailer who sold it to another, neither of whom were known to us as retailing dirty milk. This milk reaches Euston Station consigned from the dairy farmers to the wholesale milk sellers. In similar instances samples of the milk from individual churns (which bear the farmer's name) can be taken by the Sanitary Authority in whose area the railway termini are situated and the source of the dirt traced. In six other cases the Borough analyst examined milk purchased from retailers who had been proved by examination in the Health Office of milk sold by them to sell milk which at any rate was occasionally dirty. All these six were found to contain dirt the quantities being in parts per 100,000, 2.2 ; 2'0; 0.9; 0.8; 0.2and a faint trace. The presence of two parts of dirt per 100,000 is sufficiently serious to warrant stringent enquiry and serious warnings ; in one of the cases the wholesalers had, in consequence, the milk delivered to Holborn retailers examined for sediment (dirt) and bacteriological counts made. Bacteriological Examination of Milk. Eighteen samples of milk were examined for the presence of tubercle bacilli, six of these were also examined to ascertain the number of organisms per cubic centimetre and the smallest volume containing b. coli. Examinations for tubercle bacilli were carried out by animal inoculation ; in two cases (11 per cent.) evidence was established of tubercle infection in the milk. The vendor of the first sample, who obtains milk from two sources, stated that the sample in question was from a London wholesaler; on enquiry this milk was found to be part of a consignment of milk originating from many hundreds of farms ; at the mixing depot it is stated to be dumped into receiving vats, put through cleaners and pasteurisers and over coolers. The second supply to this retailer comes from a provincial source and particulars of the examination were sent to the County Medical Officer of Health concerned, who replied that no action could be taken as the depot was one dealing with mixed milk from a large number of farms. In this case a guinea pig was inoculated on the 20th November 1923 and died on the 28th, the post-mortem examination disclosed heavy infection of generalised tuberculosis, tuberculous nodules 21 being present in the spleen, liver, lungs, glands and peritoneum. The infection was therefore very virulent and the inability to trace the source of production illustrates the weakness of the present position. In the case of the second sample the producing farm was disclosed and the information forwarded to the Medical Officer of Health of the London County Council. The Veterinary Inspector of that Council visited the farm and examined 98 cows and reported them to be healthy with one exception, viz. a cow showing evidence of tuberculous disease which had been "put dry" a month before the inspection. The date however would be after the date when the sample was purchased. The following table refers to the six samples examined as mentioned above:— Date sample taken. Nature of Shop where purchased. No. of Organising per cc. grown at 37° C for 24 hours. Minimal volume containing Bacillus Coli. 1923 Not. 20 Small milkshop 11,750 0.01 cc. Nov. 20 Small milkshop 28,000 0.001 cc, Not. 14 Large milkshop 32,000 1 cc. Nov. 14 Small milkshop 55,000 0.001 cc. Nov. 20 Small milkshop 240,000 0.001 cc Nov. 14 Large milkshop 420,000 0. 001 cc. The result of our investigations bring out very clearly the fact that the practice of mixing milk from various farms before sale to the customer has the disadvantage of almost rendering void the efforts of local authorities, remote from the place of production of the milk, to trace the source of contamination of the milk consumed by the inhabitants of their areas; this makes all the more necessary inspection of dairies, milking and herds by the local authorities of the areas in which the milk is produced and examination of the milk not only as it enters these large creameries where it is mixed, but also as it leaves, for from time to time it would seem that certain of the churns of milk supplied by the farmers are by error not emptied in the mixing vats but pass out in their original state, escaping the cleansing process which unfortunately is the chief safeguard to-day to prevent the presence of dirt in milk. This is not the place to labour the point that it is the invisible dirt in milk, i.e., bacteria, that the milk trade should endeavour to prevent. The effort, however, to get rid of the grosser impurities in milk will inevitably bring the effort to prevent bacterial contamination in its train. The Milk (Special Designations) Order, 1923. This Order, which was issued in May, 1923, and came into force on the 1st July, 1923, revoked the Milk (Special Designations) Order, 1922, and the Milk (Special Designations) Amendment Order, 1922, as from that date. The new Order does not alter the general scheme of grading at present in operation but it provides for some relaxation of the conditions under which licences may be 22 granted for the sale of Grade A milk and Pasteurised milk. A number of minor alterations have been made with a view to removing doubts raised as to the proper interpretation of the former Order. During the year 1923, licences available up to the 31st December, 1923, for the sale of "designated" milk in the Borough were issued as follows:— Certified Milk 3 Grade A Milk 2 Supplementary Certified (Supplementary) 1 Grade A (Tuberculin Tested) (Supplementary) 1 Up to the date of the preparation of this Report licences for the year 1924 have been issued as follows:— Certified Milk 3 Grade A (Tuberculin Tested) Milk 1 The value of the Order lies to a considerable extent in its educational effects; the existence of such arrangements shows milk producers that clean milk can be produced on farms (if they like they can learn how to produce clean milk themselves) and that medical opinion has been able to convince the representatives of the public of the importance of keeping milk as free as possible from bacteria and above all from tubercle bacilli. Public Health (Milk and Cream) Regulations, 1912 and 1917. The Public Health (Milk and Cream) Regulations, 1912-1917, were enforced in the Borough throughout the year. Two hundred and eight samples of milk were examined; none was found to contain preservative, 19 samples of cream were examined 3 of which were found to contain preservative, viz., boric acid to the extent of 0.223, 0.272 and 0.272 per cent. by weight respectively. Communications were in each case sent to the vendor, and in one the vendor was interviewed by the Public Health Committee; the explanations submitted were considered to be satisfactory, and no further action was taken. Eighteen samples of preserved cream were examined and found to be in accordance with the Regulations, the statement on the labels as to the amount of preservative being in each case correct. In all the samples of preserved cream the fat exceeded 35 per cent. No contravention of the Regulations, other than those mentioned above, was discovered during the year. Condensed Milk. The Public Health (Condensed Milk) Regulations, 1923, came into operation on the 1st November, 1923. The Regulations provide that condensed milk is to be contained in a tin or receptacle labelled in accordance with the rules detailed in a schedule of the Order. The label is to include a declaration that the contents of the tin are the equivalent of a definite quantity of milk to be stated on the label in pints or fractions of pints. Machine skimmed condensed milk is to be labelled "unfit for babies." 23 For the purpose of the rules milk is defined to mean milk which contains not less than 12.4 per cent. of milk solids (including not less than 3.6 per cent. of milk fat) and skimmed milk means milk which contains not less than 9 per cent, of milk solids other than milk fat. It is to be noted that the standard of 3'6 per cent. for content of milk fat is taken and not the standard of 3 per cent. laid down by the Sale of Milk Regulations 1901. The second schedule of the Order gives the appropriate percentage of milk fat and milk solids as under:— Description of Condensed Milk. Percentage of milk fat. Percentage of all milk solids including fat. 1. Full cream unsweetened. 9.0 31.0 2. „ sweetened 9.0 31.0 3. Skimmed unsweetened — 20.0 4. ,, sweetened — 26.0 Before the Order came into force a communication drawing attention to its provisions was addressed to grocers and other traders selling the commodity in the Borough. Up to the present no breach of the Regulations has been detected locally. The Hygiene of Restaurants, Eating Houses and Public Houses. Central authorities in London have thrown upon them the responsibility for safeguarding the health of the non-resident population who come daily to their area, especially with regard to the hygienic preparation and serving of their meals, and the hygienic serving of liquid refreshment. A high standard in these matters has been set by the City of London; in Holborn we have worked on parallel lines particularly with regard to inspection of eating places. The conditions ascertained as the result of our inspections of the kitchens, cooking and washing arrangements, dining rooms, etc., of 221 hotels, restaurants and eating houses follows A convenient classification of these establishments can be made as under:— (i.) Hotels and high-class restaurants 32 (ii) Restaurants catering for the average business employee 104 (iii.) Working-class restaurants £5 221 Kitchens—position, size, etc. In 114 restaurants (50 per cent.) the kitchens were found to be in the basement As long ago as 1901 legislation dealt with underground bakehouses; a development of this legislation, to deal with all underground places where food is prepared and cooked, would seem a natural corollary, particularly as many kinds of prepared food are certainly not less important than bread as far as bacterial contamination is concerned. 24 It may be said that work in underground bakehouses is carried on at night; it is equally true that in many basement kitchens especially where evening meals are prepared, such work is done with artificial light. In the day time often artificial light has to be used and all the hygienic advantages of natural lighting are lost; also, unless care is taken to provide adequate lighting of all parts of the room, the corners and recesses will be poorly illuminated and in consequence poorly cleansed. Ventilation is at the street level and, unless cleared away regularly, dust is apt to accumulate at the necessary openings. This is not to say that the use of basement kitchens should be entirely condemned, but their use calls for certain precautions, and from the hygienic point of view in new establishments if practicable (but often it is not), the kitchen should be elsewhere. For the purpose of convenience we are told that the kitchen should either be on the same floor as the dining-room and in immediate proximity to it or on the floor immediately underneath. Objection has been raised to the use of the top floor for this purpose because it is too far from the dining-room. From the point of view of hygiene the placing of the kitchen on the top floor has much to recommend it, chiefly on the grounds of ease of obtaining natural lighting and adequate ventilation. Nothing is more unpleasant than the smell of cooking which sometimes penetrates the whole of the rooms above the kitchen. Every kitchen should be properly ventilated to get rid of smells and heat, but not to such an extent as to check the draught of ranges. In 13 instances the kitchens fortunately were on the top floor. The cleanly conduct of the business must be prejudiced if the space provided is inadequate. In 10 cases the kitchens were too small for efficiency; in 26 cases the limited cooking required was carried on in the shop used also as the dining room. Vermin.—Comparatively few restaurant-kitchens were found to be vermin infested. In 7 there was evidence of the presence of rats, and in 9 of cockroaches, and in 1 there was evidence of both rats and cockroaches. Other defects found were— Dirty 15 Untidy 4 Ventilation unsatisfactory (in one no ventilation provided) 12 Light unsatisfactory 1 Sink not provided 1 Sink unsatisfactory 1 Open gully 2 Dampness from water leakage 1 Paving defective 1 Dilapidated 2 Coal stored loose 4 Kitchen Refuse— Bin unsatisfactory 3 No proper bin 1 Position of bin unsatisfactory 1 25 Storage of Food. The provision for storage of food both before and after cooking is shown in the following table:— Provision for Storage of Food. Type of Restaurants, etc. Hotels and high-class restaurants. Restaurants for average business employee. Restaurants, working class. Pantries and larders 21 12 1 Ice safes, refrigerators or meat safes 4 57 22 Special storage rooms or cupboard 7 20 32 Shelves in kitchen — 5 3 No Bpecial provision other than counter or shelves in shop — 10 27 32 104 85 In those cases where ice-safes and refrigerators are used for perishable articles such as meat and fish, cupboards are usually also provided for the storage of dry goods. In the majority of eating places the accommodation provided for storage both before and after cooking was found to be adequate, the larders, pantries, safes, cupboards and special store rooms being generally clean and adequately ventilated and the food reasonably protected from contamination, but in 37 cases no special provision was made and the food was necessarily stored on counters or shelves in the shop or kitchen. The usual statement in such cases was to the effect that perishable goods were purchased every day; apart however, from the question of such goods as may be left over proper provision for the storage of other articles, particularly such as are likely to attract flies, is important and should be made in connection with all restaurants and eating houses. Washing-up Arrangements. Special attention was directed towards the arrangements for washing up. It will be remembered that within recent years attention was widely directed towards the possibility of the spread of influenza by the use of an imperfectly washed drinking vessel after it had been used by a sufferer with influenza ; it is held to be possible that several other infectious diseases in which the virus is present in the secretions of the mouth, e.g., diphtheria and venereal disease, may be similarly spread Obviously the risk is much the same whether the imperfectly washed vessel is used in restaurant, public house or the home, but it might be argued that the degree of responsibility of public 26 health authorities was considerably greater in the case of restaurants and public houses than in the home. Enquiries were, in consequence, made both in restaurants and public houses as to the appliances and methods used for washing up. The inspection of hotels, restaurants and eating houses (221) showed the following defects in the washing up arrangements:— No sink 4 Articles not rinsed 36 Dish-cloths unsatisfactory 3 Other unsatisfactory conditions 4 At three restaurants in the Borough sterilising and washing-up machines have been installed and are in use. One machine is capable of washing, rinsing and sterilising 5,000 articles per hour and is reported to be quite satisfactory. In the second case a large hotel, the machine is capable of washing 1,000 articles per hour with practically no breakages and is reported to save the labour of five men. The third restaurant using mechanical cleansing apparatus has a machine dealing with 800 articles per hour with practically no breakages and a labour saving equal to one person. This machine is somewhat complicated, and although the proprietors of the restaurant would not fix another of this type they arc satisfied with the usefulness and economy of mechanical washing up. On the other hand, the use of washing machines installed in two hotels has been discontinued, one because the cleansing was not effective and one because of the extent of breakage of plates, &c. But on the whole the evidence available in connection with the Borough goes to show these appliances are valuable. During the preparation of this report the proprietors of a restaurant referred to above have opened new premises in the Borough. After experience with mechanical cleansing machines at other restaurants in and outside the Borough of Holborn they have repeated the establishment of washing, rinsing and sterilising machines in their new premises, which seems reasonable evidence of the efficiency and satisfactory working of such machines. Most of the kitchens have an ample, supply of hot water. In the larger places independent boilers are fitted, others have boilers attached to the cooking range, whilst a few of the smaller places depend on kettles for hot water. Soda is generally used in the washing water. In most cases (36 exceptions) utensils are rinsed after washing and in a majority of cases twin sinks are provided, one for washing and one for rinsing. The water for washing-up is generally used as hot as practicable for hand washing and this, in conjunction with soda in the water, keeps the swabs reasonably clean. Apart from sterilising machines, the most satisfactory method is to wash in hot water, rinse in separate hot water and dry by draining in suitable rack and polish when dry. 27 Public Houses. In the 101 public houses inspected the conditions found were as follows:— Bars and Washing-up Sinks. No. of Houses. Number of Sinks. Nil. 1 2 3 4 5 6 One bar Houses 5 ... 3 2 ... ... ... ... Two „ „ 21 1 4 12 4 ... ... ... Three „ ,, 30 ... ... 23 5 1 ... 1 Four „ „ 31 ... ... 16 9 4 2 ... Five „ ,, 13 ... ... 7 2 1 2 1 Six ,, ,, 1 ... ... ... ... 1 ... ... Water laid on to Sinks in Bars. Hot and cold 23 Cold only 77 Nil 1 After EACH use Glasses Rinsed or Washed with:— Hot water only 24 This "washing" is usually rinsing only. Hot water and soap, soda, etc. 10 Cold water 67 Method of Drying. Drying cloth 42 Draining 9 Drying cloths and draining 50 Glasses washed in Hot Water with Soap, Soda, etc. After each use 10 (included above.) Three times daily 3 Twice daily 21 Daily 65 Three times weekly 1 Twice weekly 1 (licensee at our request arranged for glasses to be washed twice daily with soap and soda.) 28 It will be observed that the chief method of dealing with glasses in public houses in the Borough after each use is for washing or rinsing more often than not in cold water only. This method cannot be regarded as satisfactory. Arrangements for sterilising the glasses after each use are obviously more satisfactory from the hygienic point of view. There are at least three appliances on the market by means of which glasses can be not only washed but efficiently sterilised; the prices of such appliances range from £6 10s. upwards, and are therefore not prohibitive. Licensing of all Eating Houses Advocated. It is difficult to avoid the conclusion that all restaurants (including those in hotels) and eating houses should be licensed by local sanitary authorities. With some of the restaurants, especially the high class restaurants, the inspection showed that very little fault, if any, could be found. It is just these places that are willing to accept voluntary registration which in their case is little more than a formality; such a system of registration is therefore of very little value, except that it brings the sanitary staff in contact with the work of the leaders of this occupation and assists the sanitary staff to form a standard of efficiency. Such legislation is in force in America and Canada. For instance, in Minneapolis an Ordinance was published on the 17th July, 1922, dealing with the inspection of hotels, restaurants, cafes, boarding houses, inns, taverns, meat markets, mercantile establishments, and all places offering for sale or selling any food or drink. The Ordinance provides for licensing of all such traders. Regulations under the Ordinance deals with the care of stores and equipment, plumbing, refrigeration, and care of utensils, care of persons, and the storage and care of food-stuffs. Again in Winnipeg, regulations require in places where food is sold for consumption on the premises, that cups, saucers, plates, glasses, knives, spoons and forks and other utensils shall be cleansed in boiling water after each use, and the use of cold or dirty water for washing such utensils is prohibited; moreover, a building may not be used for the preparation of food until certified as suitable by the Health Officer. Bakehouses. At the end of the year, 1923, there were 28 bakehouses in the Borough of which 21 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. One bakehouse was closed during the year. During the year, in addition to my inspections, there were 92 inspections of bakehouses. Four notices were served for sanitary defects. 29 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 twenty-six 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. Market Streets and Exposure of Food generally. There were 824 inspections of market streets, each of which includes a number of stalls at which meat, fish, fruit and vegetables are sold. These streets are regularly inspected on Saturday evenings and Sunday mornings. Attention was called in last year's report to the need of powers to prevent contamination by street dust, animals, etc., of such articles as butter, margarine, cheese, which are not cooked or washed before being eaten ; also to the value of a supply of clean water to vendors of fish, vegetables, ice cream and refreshments, including coffee stalls. In this connection should be mentioned the desirability of closed fronts to shops and where food is sold, the need for protection of sweets, sundaes, pastry, etc., from dust and flies. The practice of proprietors of restaurants and eating houses of dressing their windows with articles of food—both cooked and uncooked-—which almost certainly are to be consumed by the customers later, has nothing to recommend it from the hygienic point of view. In some of these shops however the display is arranged in a dust and fly proof window case. Ice Cream. During the year there were 81 premises in the Borough where ice cream was manufactured, and in addition to my inspections 240 inspections of these premises were made, and five notices were served. Ice cream is manufactured in the Italian Colony as follows:— Premises on which 10 gallons made daily 3 „ „ 8 „ „ „ 1 „ „ 6 „ „ „ 1 „ „ 4 „ „ „ 7 „ „ 2 „ „ „ 10 „ less than 2 „ „ ,, 3 In addition ice cream was also manufactured on the following premises:— Mr. Bennett's District. Mr. Clark's District. Mr. Larard's District. Restaurants 12 3 6 Confectioners 5 13 12 Other — 3 2 30 Meat. All the butchers shops were frequently inspected. The meat was found to be dealt with under cleanly conditions. There is only one slaughter-house in the Borough. This was inspected on three occasions during the year. Sheep only are slaughtered. 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 225 Slaughter-houses 1 Tripe, offal and other meat shops 38 Fried Fish shops 10 Fish shops 10 Ice Cream (Manufacture) 81 Poulterers 3 Daring the year 2,652 inspections of food premises and market streets were mnde and 42 notices served for sanitary defects found. Unsound Food. The following unsound food was condemned during the year 1923:— Commodity. Quantity. Condition. Result of Action taken. Dairy Produce: — Eggs 1200 (75 lbs.) Decomposed Surrendered Condensed Milk 11 tins (9 lbs.) Decomposed; badly blown tins Do. Meat:— Fresh 20 lbs Badly bruised Do. Cured (Bacon) 31 lbs Decomposed Do. Fish :— Herrings 6 stone Decomposed Do. Plaice ½ cwt. Decomposed Do. Soles 9 stone Decomposed Do. Poultry: — Ducks 21 Decomposed Do. Vegetables: — Tomatoes 2 cwt. (12 bundles) Decomposed; became wet in transit Do. Fruit:— Oranges 200 cases (11½ tons) Much decomposed. Do. Bananas 34 cwts. Decomposed Do. Fruit Pulp casks (50 gals, each) Decomposed Do. Tinned Cherries 80 tins (56 lbs.) Tins blown Do 31 Sale of Food and Drugs Acts. In the Annual Report for last year a reference was made to the desirability of a communication being addressed to the Ministry of Health urging, in the interests alike of manufacturers, retailers, consumers and local authorities, that steps should be taken without delay to appoint a Departmental Committee to enquire into the use of preservatives and colouring matter in food, and that recommendations of such Committee should be given effect to by law. A communication on these lines was forwarded by the Holborn Council to the Minister of Health, and a copy of my report on the subject was sent to the Medical Officers of Health of the large towns of England and Wales; a number of municipal authorities in such towns, as well as several metropolitan authorities, made similar representations to the Ministry. The subsequent appointment of a Departmental Committee to consider the question of preservatives aud colouring matters in food, was noted with general satisfaction. The report of this Committee is anticipated with interest; in the meantime it will be seen that steps continue to be taken to deal with the matter as adequately as existing legislation allows. Experience of the last year continued to sh >w the difficulties which face local authorities in their efforts to secure pure food free from preservatives and colouring matter; when ca-es arc taken to court in the absence of any definite ruling in the matter, some magistrates are loath to convict even when they express an opinion that the presence of such colouring matter is undesirable. The table on page 37 shows that the analyses under the Sale of Food and Drugs Acts during the year covered a wide range of articles. Of the 601 samples examined 52, or 8'6 per cent. were reported to be "not genuine," in comparison with 7.0 per cent. in the preceding year. The following observations refer to those samples reported to be "not genuine" Beans, tinned. Of six samples examined five were found to contain colouring matter, namely copper sulphate ; in four of these disclosure of the presence of colouring matter, and its amount (which was small) was made on the label; in the fifth the vendor was communicated with, and gave an undertaking to disclose the presence of copper in future sales. The prosecutions recorded on page 96 refer to purchases made in 1922. Butter. Four samples of butter were found to contain an excess of water. In two cases where proceedings were instituted warranties were submitted and the summonses withdrawn; one of these samples was an imported butter and information was sent to the Medical Officer of Health of the port of entry. In the other two cases warning letters were sent to the vendors. 32 Coffee Extract, coffee and chicory extract. One of the six samples examined was found to contain salicylic acid; communications were sent to the vendor and the wholesalers, and, as a result, the remaining stock was withdrawn from sale. Cream. Three samples of cream sold as fresh cream were found to contain preservative and were dealt with under the Public Health (Milk and Cream) Regulations. Cream cheese. The need for a definite standard especially of fat content of cream cheese was expressed by the Council, the result of an analysis of four cream cheeses by the Borough Analyst having shown a deficiency of fat. The Council made a representation to the Minister of Agriculture and Fisheries drawing attention to the absence of any standard as to the quantity of fat cream cheese should contain and asking for steps to be taken for the establishment of a standard or limit as in the case of milk. In submitting his report the Borough Analyst wrote as follows:— "Notwithstanding the fact that there is no standard for the quantity of fat which cream cheese—or even ordinary hard cheese—should contain, I have certified three of the samples as being deficient in fat, and have based my opinion upon the differences between the amount of fat found in each sample respectively, and that which should have been present—as calculated from the percentage of protein in each case—had the samples been made from genuine whole milk of the poorest quality, as defined by the Board of Agriculture limits (i.e. 3 per cent. of fat)." The particulars of samples reported to be deficient in fat were as follows :— Fat. Water. Protein. Deficiency of Fat. 4.38 73.95 21.67 66 per cent. 3.09 76.25 20.66 78 per cent. 1.32 76.65 23.03 93 per cent. 11.60 65.10 23.50 42 per cent. The amount of fat in the samples was far below the percentage present in ordinary (hard) cheese which contains about from 20 per cent. to 30 per cent. ; the word "cream " might be considered by many people to indicate that more fat was present than in ordinary cheese. Proceedings were instituted against the vendor of one of the samples. After hearing the evidence the Magistrate gave a considered judgment in favour of the Council, imposing a penalty of £5. 5s. Od. with £15. 15s. 9d. costs. In the course of his judgment the Magistrate said:— ******** " I do not think that it is within my province to lay down any fixed standard of fat for cream cheeses. I hope that as a result of 'Lord Linlithgow's Committee' the proper Authority to make regulations under Section 4 of the Act of 1899, may possibly take action in the 33 matter. Everyone concerned in this case seems to be agreed that it would be desirable in the interests both of the Trade and the Public that some standard should be fixed for cheese of all kinds. "It is sufficient for my purpose to say that a soft cheese which contains only 11 per cent. to 12 per cent. fat can not properly be said to be of the nature, substance and quality of cream cheese. " I am also of opinion that if a person pays the same price for a soft cheese which contains 11 per cent. to 12 per cent. as he pays for a cheese which contains 27 per cent. of fat, or if he gets a cheese which contains very much less fat than he has a right to expect in a cheese which is described as cream cheese, that is a sale to the prejudice of the purchaser. ******** An appeal was entered against this conviction and the Appeal Court not being satisfied that " cream cheese " was asked for at the time of the purchase quashed the conviction on that ground. Lemon squash, lime juice, orange squash, Kola, and sparkling Valenta. Seven samples of these various beverages were found to contain salicylic acid. In two eases no action was taken because the presence of the preservative was disclosed on the label. In the five others letters were addressed to the vendors and makers pointing out the desirability of the presence of salicylic acid being disclosed on the labels It is regretted that the makers were unable to see their way to fall in with the suggestion made; they took the ground that such declaration is not required by the provision of the Sale of Food and Drugs Acts It is to be hoped that as a result of the Departmental Committee recently appointed, if preservatives are not entirely prohibited a declaration on the label of their presence and approximate amount will be compulsory. Madeira Cake. A sample of Madeira cake was found to contain boric acid. Having regard to the circular issued by the Ministry of Health respecting boric acid in sponge cakes, giving details of an arrangement made by the Ministry with the Bakery Allied Traders Association, respecting the exclusion of boric acid from liquid eggs to be used in the manufacture of sponge cakes, sponge fingers, and sponge biscuits, no legal proceedings were instituted. A communication was addressed to the Bakery Allied Traders Association suggesting the extension of the probibition of preservative to eggs to be used for Madeira and other cakes which are used for children and invalids as much as sponge cakes. The Association replied that it would be futile to make new arrangements until the report of the Committee respecting preservatives in food is published. Milk. In two cases, where fat had been abstracted, the cases were met by letters of caution. In a third case of deficieney of fat the vendor produced a warranty and proceedings were not continued. In all 208 samples of milk were examined during the year. The milk was obtained from shops, restaurants and street vendors. D 34 The following table shows the fat content of the 208 samples:— Percentage of Fat. Number of Samples. Shops. Restaurants. Streets. Total Less than 3 0 3 0 1 4 3.0 3 0 1 4 8.1 2 3 5 3.2 5 5 2 12 3.3 14 6 3 23 3.4 14 5 6 25 3.5 19 4 8 26 8.0 14 1 2 17 3.7 18 2 2 22 3.8 19 3 1 23 3.9 3 2 o 7 4.0 4 2 2 8 4.1 9 1 I 11 4.2 4 1 0 5 4.3 1 0 0 1 4.5 1 1 1 3 4.6 3 0 0 3 4.9 1 0 0 1 5,.0 2 1 0 3 0.1 1 0 0 1 5.5 1 0 0 I 7.7 1 0 0 1 8.2 0 1 0 1 8.5 0 1 0 1 142 39 27 208 Average 3.7 3.8 3.5 3.7 Nineteen per cent. of the samples contained 4 per cent. or more fat. Milk with this fat content does not appear to be uncommon. In the City of London. 41 out of 252 samples (16 per cent.) of milk examined in 1923 contained 4 per cent. of fat and over. The Borough Analyst informs me that in certain areas respecting which he has been able to obtain information in the year 1923, milk samples showed a fat content of 35 4 per cent. or over as follows:—A southern borough, 7.9 per cent.; a northern borough, 12.1 per cent.; a western borough, 13'2 per cent.; a central borough. 13.6 per cent. and three country districts, 22.4, 29'5 and 29.5 per cent respectively. The analyst of a large County Borough in the west of England writes:— "There is nothing extraordinary about any sample up to 4.5 per cent. samples with as much as 4.5 per cent. are frequently obtained in the autumn and occasionally at other times of the year. Samples exceeding 4.5 per cent. may be regarded as abnormal." It will be observed that 12 samples in Holborn last year had fat, content ranging from 4'6 per cent. to 8.5 per cent. This high fat content is possibly due in some instances to failure to mix the milk before sale, so that when taken from a fairly full counterpan, "top milk" is supplied with an abnormal amount of fat, there being a corresponding deficiency at the bottom of the pan. It is doubtful whether satisfactory mixing is usually effected by trying to plunge with ordinary measures used for serving; probably all counterparts should be supplied with efficient plungers as are many street churns used by milk carriers. The following table shows the average composition of milk samples purchased during each month of 1923. For the purpose of comparison, I have included corresponding figures for the Borough of Stepney, for which I am indebted to Dr. D. L. Thomas, Medical Officer of Health of that Borough. Number of Samples examined. Total Solids, per cent. average. Solids Non-fat. Per cent. average. Fat. Per cent. average. Holborn. Stepney. Holborn. Stepney. Holborn. Stepney. Holborn. Stepney. January 14 89 12.58 12.69 8.88 8.81 3.70 3.88 February 19 67 12.46 12.48 8.80 8.77 3.66 3.71 March 14 82 12.73 12.49 8.92 8.68 3.81 3.81 April 20 GG 12.66 12.44 8.88 8.70 3.78 3.74 May 20 66 12.54 12.45 8.96 8.79 3.58 3.66 June 20 73 12.29 12.29 8.89 8.73 3.40 3.56 July 20 8S 12.78 12.25 8.84 8.68 3.94 3.57 August 32 12.45 ... 8.85 ... 3.60 ... September 8 76 12.74 12.36 8.86 8.65 3 .88 3.71 October 6 89 12.53 12.72 8.85 8.72 3.68 4.00 November 15 73 12.01 12.50 9.03 8.78 3.98 3.71 December 20 70 12.61 12.72 8.90 8.83 3.74 3.89 Whole year 208 837 12.62 12.49 8.89 8.74 3.73 3.75 Legal Minimum 11.50 11.50 8.50 8.50 3.00 3.00 n 2 36 It will be seen that the seasonal variations is not very marked, and in both boroughs the higher percentage of fat was in November and the lowest in May (Stepney) and June (Holborn). Reports of samples taken all over the country show an average fat content exceeding 3.5 per cent. From this, as well as the figures given above, it would seem that the legal minimum for fat in milk is too low. The regulations issued in 1923 respecting condensed milk and dried milk prescribe that the equivalent of fat must be calculated on a 3.6 per cent. basis, and it seems reasonable to suggest that the legal minimum for ordinary milk should be raised. Peas (tinned). Eleven samples were found to contain colouring matter, namely copper. In 7 of these no actions was taken because the amount of copper was small and its presence was disclosed on the label. In 2 cases disclosure was not made on the labels, but the amount of copper was so small that warning letters to the vendor were considered sufficient. In 2 cases legal proceedings were instituted the result in one being a conviction with a fine of £21 and £10. 10s. costs. The second case was dismissed on the defendant agreeing to pay costs. Prescription. One prescription was found to be deficient in Bismuth carbonate to the extent of ll.l per cent. It was considered that in this instance a warning would be sufficient. Tomato Sauce. A sample of tomato sauce was found to contain tin to the extent of 4.34 grains per pound. This sample was obtained from a wholesale dealer who agreed to the destruction of the whole consignment. Sausages. T »vo samples were found to contain boric acid, but the quantity was too small to call for legal proceedings, Chlorodyne. All the so-called chlorodyne lozenges examined, fortunately were free from morphia, their description being misleading. During the year two samples of chlorodyne were purchased from retail chemists. The first a one-ounce sample was found to contain morphine equivalent to about 0'67 grains per ounce of anhydrous morphine, in the second case a two-ounce sample the amount of morphine present was equivalent to 1.32 grains of anhydrous morphine. 37 A poisonous dose of chlorodyne can evidently be easily obtained ; several deaths have been reported from Coroners' Courts. At the same time attention might be called to the dangers of lysol which owing to the presence of the highest tar acids is also poisonous and equally of concern to Coroners. Flour. The 12 samples of flour examined were genuine and not bleached by means of nitrogen peroxide. The following is a list of articles purchased during 1923:— ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Almond Cake 3 3 ... ... ... ... Almonds, ground 3 3 ... ... ... ... Apricots, tinned 3 3 ... ... ... ... Asparagus, tinned 2 2 ... ... ... ... Baking Powder 2 2 ... ... ... ... Beans, canned 6 1 5 3 - - Bloater Paste 3 3 ... ... ... ... Borax, refined 5 5 ... ... ... ... Butter 82 78 4 2 ... Costs, 12s. 6d. Cheese 3 3 ... ... ... ... Chicken and Ham Paste 4 4 ... ... ... ... Cocoa 4 4 ... ... ... ... Chocolate 2 2 ... ... ... ... Coffee and Chicory Extract 6 5 1 ... ... ... Cream 19 16 3 ... ... ... Cream, Preserved 18 18 ... 1 - ... Cream Cheese 13 9 4 ... ... Cyder 1 1 ... ... ... ... Dripping 1 1 ... ... ... ... Egg Powder 4 4 ... ... ... ... Fish Paste 13 13 ... ... ... ... Gelatine 1 1 ... ... ... ... Ginger, ground 2 2 ... ... ... ... Ginger Wine 2 2 ... ... ... ... Golden Syrup 3 3 ... ... ... ... Honey 3 3 ... ... ... ... Jam 8 8 ... ... ... ... Jelly 6 5 ... ... ... ... Lard 3 3 ... ... ... ... Lemon Curd 7 7 ... ... ... ... Lemon Squash 6 4 2 ... ... ... Lime Juice 6 1 4 ... ... ... 38 ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Madeira Cake 3 2 1 ... ... ... Meat Paste 2 2 ... ... ... ... Margarine 9 9 ... ... ... ... Milk 208 199 9 1 ... Costs, 14s. 6d. Milk, Condensed 6 6 ... ... ... ... Mincemeat 2 2 ... ... ... ... Mustard 2 2 ... ... ... ... Orange Squash 2 1 1 ... ... ... Peas, tinned 20 9 11 5 1 Fine, £21 Costs, 3 cases, £15 15s. Pepper 2 2 ... ... ... ... Prescriptions 8 7 ... ... ... ... Pears, tinned 3 3 ... ... ... ... Prawns, tinned 1 1 ... ... ... ... Raspberry Syrup 2 2 ... ... ... ... Rice 5 5 ... ... ... ... Sauce 4 3 1 ... ... ... Sausages 15 13 2 ... ... ... Salad Oil 3 3 ... ... ... ... Salmon, tinned 3 3 ... ... ... ... Spinach, tinned 2 2 ... ... ... ... Spice 2 2 ... ... ... ... Sponge Cake and Fingers 6 ... 1 ... ... ... Suet, Shredded 3 3 ... ... ... ... Scotch Haddock 3 3 ... ... ... ... Vinegar 2 2 ... ... ... ... Total 560 510 50 ... ... ... Informal: — Bondon Cheese 3 3 ... ... ... ... Cream Cheese 3 3 ... ... ... ... Cheese 1 1 ... ... ... ... Chlorodyne 2 2 ... ... ... ... Flour 12 12 ... ... ... ... Lemon Squash 1 1 ... ... ... ... Lemonade 1 1 ... ... ... ... Peas, dried 6 6 ... ... ... ... Lozenges 6 6 ... ... ... ... Kola 1 0 1 ... ... ... Soda Water 2 2 ... ... ... ... Sweets 2 2 ... ... ... ... Yalenta 1 0 1 ... ... ... 41 39 2 ... ... ... Total Samples 601 519 52 12 1 Fine £21 0s.0d. Costs £17 2s. 0d. Summary :—20S Milk 9 not genuine = 4.3 per cent. 82 Butter 4 „ „ =4.9 ,, 21 Drugs 1 ,, ,, = 4.7 ,, 30 Tinned Vegetables 16 „ „ = 53.3 ,, 260 Various foods 22 „ ,, = 8.5 „ Total 601 52 = 8.6 ,, 39 PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. The relative importance of the commoner infectious diseases as regards numbers of deaths caused is shown by the following table:— ENGLAND AND WALES. Common Infectious Diseases. Deaths at all Ages. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. Yearly average 1913-1922. Pneumonia (all forms) 37,530 40,070 48,874 37,916 39,832 59,666 38,949 37,149 34,708 40,930 41,562 Pulmonary Tuberculosis 36,203 37,838 40,803 40,769 42,335 45,338 35,984 32,791 33,505 33,919 37,948 Measles 10,644 9,144 16,445 5,413 10,538 9,787 3,534 7,190 2,241 5,694 8,063 Whooping Cough 5,458 8,040 8,143 6,075 4,509 9,898 2,605 4,401 4,576 6,370 6,075 Diphtheria 4,457 5,863 5,865 5,366 4,477 4,803 4,888 5,648 4,772 4,075 5,021 Scarlet Fever 2,100 2,843 2,406 1,381 768 1,020 1,221 1,430 1,305 1,382 1,585 Enteric Fever 1,505 1,705 1,388 1,122 977 950 577 537 613 465 983 40 Excluding chicken pox the total number of notifications received during the year was 430 in comparison with 543 in the year 1922. Attention has had again especially to be called to the non-notification of whooping cough, primary pneumonia and ophthalmia neonatorum. A list of the notifiable diseases is from time to time supplied to all doctors practising in the Borough. Smallpox. No notification was received. Fifteen cases of smallpox were notified in London. During the year information was received respecting a resident in this Borough who had been in contact with a case of smallpox at a hotel in one of the Metropolitan areas. The contact, a waitress at the hotel in question, was at once visited, and was found to have been revaccinated, The contact resided with her four children, three of whom had been recently vaccinated and the fourth revaccinated. The contact was kept under observation until the danger of infection was past. Information of 30 other contacts of cases occurring outside London or of passengers arriving on vessels on which smallpox had occurred during the voyage, was received, and the necessary visits for keeping such contacts under observation were made. Chicken pox was made compulsorily notifiable in the Borough for six months including and following on December 4th, 1922. During 1923 the number of cases notified was 57. My services were frequently called upon to examine patients whom it was feared might be suffering from smallpox ; the experience brought home to me the severity of the eruption which might occur in chicken pox and in such cases it was only by the careful application of several diagnostic rules that the diagnosis of chicken pox could be made. The subject of vaccination has been prominently before the public during the year. There has been no alteration in general medical opinion as to the advisability of the practice; although the arrangements to prevent spread in London have proved efficient, when tested in 1922, those carrying out the arrangements are insistent on the need of general vaccination; the human element involved in the prevention of spread of smallpox by the prompt detection and isolation of actual cases and the supervision of contacts is fallible; the possibility of confusion of smallpox with chicken pox has been increased recently owing to the occurrence of a milder form of smallpox. 41 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. No information as to Vaccination Removed. Reported Vaccinated Temporarily unaccounted for Holborn Sub-District: 12 months ended 30th June, 1923 286 123 23 54 1 21 31 3 30 St. Giles and Bloomsbcry Sub-District: 12 months ended 30th June, 1923 172 65 11 34 0 15 21 1 25 458 188 34 88 1 3(5 52 4 55 As in previous years a leaflet respecting the advantages of vaccination was sent to the parents of all infants born in, or belonging to the Borough. By arrangement with one of the Medical Officers of the Ministry of Health, a special leaflet prepared by him was used in the Borough during the latter part of the year simultaneously with the Holborn Vaccination leaflet. An attempt being made to ascertain to what extent the respective leaflets were effective; the system adopted was to issue alternately the Holborn leaflet "H" and the leaflet prepared by the Medical Officer of the Ministry of Health "W." A hundred of each of these leaflets were issued, a post card for reply being sent at the same time. Careful note was kept as to the homes to which the respective leaflets were issued and the replies received. Thirty-two reply post-cards were received, namely, leaflet "W" eighteen, leaflet "H" fourteen. The replies were to the following effect:— Leaflet Leaflet "H" "W" Already vaccinated 2 4 To be vaccinated by private doctor 6 8 Asking for public vaccinator 6 6 The information contained in the replies was forwarded to the Vaccination Officer and in due course enquiries will be made to ascertain whether the vaccinations hav e actually been carried out. 42 Diphtheria. Ninety-eight notifications of diphtheria relating to residents in the Borough were received during the year at the following ages:— Under 1 year 4 1 to 5 years 26 5 ,, 15 „ 22 15 „ 25 „ 31 (includes 14 hospital nurses) 25 „ 45 „ 12 45 „ 65 „ 3 Of these 97 were removed to hospital. Eight cases were returned from the hospitals of the Metropolitan Asylums Board certified as not suffering from diphtheria. Two of these were apparently "carriers," as diphtheria bacilli were found in the swabs taken before removal of the patients. Five deaths occurred. Ten ''secondary" cases were notified, but as one of these was found not to be diphtheria the number of genuine "secondary" cases was only nine. A "secondary" case is one occurring in the same household as the primary case. The 10 secondary cases are exclusive of 14 cases of diphtheria occurring amongst nurses in two hospitals in the Borough (10 and 4 respectively). From the same hospitals 48 in-patients (25 and 23 respectively) were notified as suffering from diphtheria; none of the in-patients were residents of the Borough. There were two ''return'' cases notified eleven days after the return of one original case, swabs were taken from the throat and nose of the original case on her return home from hospital, but she was not found to be harbouring diphtheria bacilli. In London 10,353 cases were notified giving rise to 602 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 61 children were so swabbed. Of these 37 were negative and in 24 (39 per cent.) positive results were obtained. In two case where clinical symptoms also indicated diphtheria the contacts were notified as suffering from the disease and removed to hospital. Two positive contacts removed from the Borough after the first swabbing and information respecting these was sent to the Medical Officer of Health of the district concerned. One contact who was still positive at the second swabbing was removed to hospital suffering with scarlet fever. In one case the third swabbing was carried out by the school medical authorities with negative result. 43 Diphtheria Contacts. Bacteriological Examination of Nose and Throat Swabs. Total Contacts swabbed 61 Negative 37 Positive 24 Contacts swabbed. Positive Results. Contacts positive. Nose and Throat. Nose only. Throat only. First Examination 61 10 12 2 24 Second ,, 21 1 8 2 11 Third ,, 8 ... 1 ... 1 Fourth „ 1 ... ... ... ... The parents of persistent carriers are advised to obtain treatment for the children concerned and are recommended to take such contacts to St. Mary's Hospital for treatment by inoculation with vaccine made from the patient's own germs; one case was so treated last year. In the case of five other persistent carriers tests for virulence were made; all these 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. 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 antitoxin was supplied free of charge on application by medical practitioners. During the year it was supplied in 16 cases. In accordance with present views as to the dose required the antitoxin is stocked in phials containing 8,000 units, the minimum quantity usually required for a patient, and 500 units, for use, as phophylactic doses of temporary value for contacts. The usual dose for this purpose being 500 to 1,000 units. It has been so clearly shown that the earlier antitoxin is given in the disease the better is the chance of recovery that every advantage should be taken of this fact; a possible source of; delay in administering antitoxin is if the doctor sees a patient and after examination he suspects that he is dealing with a case of diphtheria he merely takes a swab for bacteriological examination and does not inject antitoxin at once, but delays till he hears the result of the bacteriological examination some 24 hours or so later. This source of delay is so important that it has been suggested that Public Health 44 ments should refuse to arrange for bacteriological examinations of swabs taken for diagnosis of diphtheria ; while such a proposal is extreme the fact that it has been made by Medical Officers of Health of long experience emphasises the importance of making the diagnosis on what is seen in the throat and of injecting antitoxin straight away in any case in which diphtheria is suspected, a proceeding harmless (except the patient be a sufferer from spasmodic asthma) if it turns out from a bacteriological examination that the patient is not suffering from diphtheria. The Shick Test and Immunisation against Diphtheria. This work is carried on at the Council's Maternity and Child Welfare Centre, 10, John Street, on Wednesday afternoons. During the first half of the year we were again indebted to Mr. Henry Wellcome who gave permission for his research staff of bacteriologists to continue to carry on the work; when the work had been firmly established and they were unable to attend on account of other research work, the Health Committee arranged for the work to be carried on by a well-known bacteriologist, Dr. Goodwin Eawlinson, who commenced on July 18th. Enquiries as to the effect of the testing and inoculation on the individual were made as a routine; we are able to record that any disturbance caused was negligible. Information as to the work carried out is given in the following Tables: — Schick Testing and Anti-Diphtheria Immunisation. Total tested. Result of Test. Immunisation of Positives. Tested af ter third inoculation and found Negative. Positive. Not read. Three inoculations. Failed to complete three inoculations Did not begin inoculations. Negative. Positive. Children 191 46 144 1 127 11 6 11 1 Adults 13 6 7 0 2 2 3 1 0 Total 204 52 151 1 129 13 9 12 l The child positive after the third inoculation has been re-inoculated and found to be negative. Eighteen others were Schick tested in 1923 and were still undergoing immunisation at the end of the year. Six others Schick tested in 1922 received three inoculations each in 1923. 45 Ages of Persons Schick-Tested with Result of Test. Age. 6 to 12 months 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to 11 years 11 to 12 years 12 to 13 years 13 to 14 years 15 and above years No. 8 37 31 28 12 9 15 9 13 14 12 4 4 13 13 - 222 Result or Test. Pos. Neg. Pos. Neg. Not read Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. P08. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. neg. Pos. Neg. No. 7 1 36 0 1 31 0 23 5 10 2 .3 4 11 4 8 1 8 5 8 6 7 5 2 2 2 2 4 9 7 6 169 Positives. = 52 Negatives. Not read. Ages of Persons Immunised. Age. a to 12 months 1 to 2 years 2 to 3 years 3 to 4 3 years 4 to 5 years 6 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to 11 years 11 to 12 years 12 to 13 3 years 13 to 14 years 15 and above years Total. 29 5 26 21 6 2 9 7 6 7 3 2 1 3 2 129 46 When the matter of immunisation against diphtheria is discussed attention is concentrated on the immunisation of school children abroad. This is unfortunate. In last year's report it was shown that in London 52'6 per cent, of the deaths from diphtheria in the three years 1919-1921 occurred in children under five years; immunisation should not be delayed until the child is of school age. Scarlet Fever. All the 102 cases of scarlet fever were removed to hospital. Fourteen cases were returned from hospital "not scarlet fever." In connection with 4 of the cases during the year there were 5 secondary cases. Three of these were notified either at the same time or within a few days of the primary case. These secondary cases are exclusive of five nurses at a hospital in the Borough who were notified as suffering with scarlet fever; from the same hospital 23 in-patients were notified as suffering with the disease; none of these in-patients were residents of Holborn. 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 11 days after the return home of the primary case. Return cases occur when patients are treated at home and in much the same proportion. There were three deaths from scarlet fever. 10,082 cases of scarlet fever were notified in London with 112 deaths. Enteric Fever. Two cases were notified during the year. Both cases arose outside the Borough; the first was a visitor from a provincial town and the second was a child passing through London travelling with her parents from Poland to America. 335 cases were notified in London, with 39 deaths. Typhus Fever. No case of typhus fever was notified during the year, either in the Borough or in London. Cerebro-Spinal Fever. One notification of a case of cerebro-spinal fever was notified. The child was an in-patient in a general hospital and died shortly after notification. 63 cases were notified in London, with 57 deaths. Dysentery. No case of dysentery was notified. 22 cases were notified in London, 47 Malaria. No case of malaria was notified. 84 cases were notified in London. Encephalitis Lethargica. No case of encephalitis lethargica was notified in the Borough during the year. 105 cases were notified in London, with 49 deaths. Acute Poliomyelitis. Two cases of acute poliomyelitis were notified; one patient had completely recovered by the end of the year. The other, who was notified in May, still has some residual paralysis and is attending hospital as an out-patient. 91 cases were notified in London, with 13 deaths. (See also page 74.) Pneumonia. Forty-eight cases of pneumonia were notified during the year. Five of these were influenzal pneumonia. The 43 cases of primary pneumonia were notified at the following ages:— Under 1 year, 6; from 1 to 5 years, 4; from 5 to 15 years, 1; from 15 to 25 years, 3; from 25 to 45 years, 8; from 45 to 65 years, 15; and 65 years and upwards, 6. Twenty-one of the 43 died. Thirteen were treated at home; seventeen were removed to voluntary hospitals; twelve to Poor Law Infirmaries; and one to a private nursing home. Two of the patients were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. 4,764 cases were notified in London. It was possible to obtain some further information in 41 cases; of these 4 resided in common lodging houses, 21 in tenement lodging houses, 5 in model dwellings, 4 in caretakers' residences in offices, 3 in separate private dwellinghouses, 1 in a boarding house and 3 in hotels. The cleanliness of the homes was reported to be satisfactory in 27 cases, but only fairly so in 14. The economic conditions of the families concerned was found to be good in 8 cases, fair in 18, poor in 11, and very poor in 4; 9 cases were nursed in a separate room. In the majority of cases the disease was not ascribed to any cause, but the following was given in 14 instances: — Following chronic bronchitis 5 Neglected cold 1 Following chill caught on a motor trip 1 Chill after sleeping on roof during hot weather 1 After getting very wet 1 Exposure to bad weather (night watchman) 1 After pleurisy 2 Excessive drinking 2 Influenza. There was only 1 death from influenza in comparison with 21 in 1922 8 in 1921, 11 in 1920, 46 in 1919, and 138 in 1918. 48 Anthrax. No case of anthrax was notified during the year. Chicken-pox. Chicken-pox was notifiable in the Borough up to June, and during this period 57 cases were notified by medical practitioners and were visited as a routine by the Medical Officer of Health and Sanitary Inspectors. During the year information of 97 cases was also received from school teachers and others, making a total of 154 cases brought to our knowledge. Some of the cases notified by school teachers were also visited. Mumps. Information was received from school teachers of 56 cases of mumps. 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 366 Bacilli not found 282 Nil ... 82 Bacilli not fouud 71 Nil ... Bacilli found 84 ... Bacilli found 11 ... Disinfections. During the year 354 rooms and 3,869 articles of bedding, clothing, etc., were disinfected after various infectious diseases. Thirty-six 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. 195 toys were disinfected. In addition to the above, 82 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 a trading firm for the disinfection at the cost of such firm, of a quantity of second-hand clothing, prior to exportation to South Africa; 450 articles were so disinfected and certificates given. 83 books belonging to the Holborn Public Library were disinfected. An ambulance belonging to the London County Council in which an infectious patient had been conveyed was disinfected. Cleansing of Persons Act. During the year 125 persons (116 men and 9 women) infested with vermin had their bodies and 1,446 articles of clothing disinfected, free of charge, at our cleansing station Goldsmith Street. Forty-one verminous rooms were disinfected. 49 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 27 cases have been visited for vermin and three 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. Tuberculosis. The initiation of the Tuberculosis Care Committee as a local institution and the administrative change whereby all correspondence concerning tuberculous patients is sent to the Borough Medical Officer of Health have at once proved beneficial; the knowledge of the local Public Health Staff of the patients is increased in a natural and easy way and the interest in the work encouraged. Total number of cases on the Register of Tuberculosis in the Borough on the 31st March, 1924 398 Number of these patients residing in common lodging houses (about) 50 The number classified as Dispensary patients, i.e. patients who have attended the Dispensary at the University College Hospital or have returned home from institutional treatment 209 The average number of cases notified annually during the past ten years 148 The number notified in the year 1923 85 Of the 85 cases notified in 1923, the number who attended the Dispensary 23 Total number of new cases examined at the Dispensary for the first time in 1923, including the above 23, and all contacts 158 Total attendances and examinations at the Dispensary in 1923, attendances 960 examinations 800 Supervision of home conditions; visits paid by— Tuberculosis Officer 13 Dispensary Nurse 1,529 Sanitary Inspectors 336 The present arrangements for the Tuberculosis Dispensary are as follows: — The Dispensary is at the University College Hospital, Gower Street, in the Borough of St. Pancras, E 50 The Dispensary is shared with St. Pancras and covers the area, South St. PaDcras and the whole of the Borough of Holborn. The Tuberculosis Officer attends three sessions each week, namely, Tuesday and Friday afternoons and Thursday evenings. The Dispensary Nurse assists at the Dispensary and visits cases in their homes, working approximately half-time St. Pancras and half-time Holborn. Public Health (Tuberculosis) Regulations, 1912. Summary of Notifications during the period from the 31st December, 1922, to the 29th December, 1923, 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. Number of Primary Notifications. 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. Total Notifications on Form A. Under 5. 5 to 10. 10 to 15. Total Primary Notifications. Total Notifications on Form B. Poor Law Institutions Sanatoria. Pulmonary Males ... ... ... 1 1 3 6 3 9 2 1 26 41 ... ... ... ... ... 60 34 ,, Females ... ... ... ... 4 1 6 7 2 3 ... 23 30 ... 1 ... 1 1 16 13 Non-pulmonary Males ... ... ... 1 1 2 ... ... ... ... 1 5 6 ... ... ... ... ... 2 4 ,, Females ... 1 1 1 ... 1 1 ... ... ... ... 5 6 ... ... ... ... ... ... 2 Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 31st December, 1922, to the 29th December, 1923, otherwise than by notification on Form A or Form B under the Public Health (Tuberculosis) Regulations, 1912. Age-periods. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 56 to 65 65 and upwards. Total Cases Pulmonary Males ... ... ... ... ... 2 ... 5 6 2 4 19 ,, Females ... ... ... ... ... ... 2 ... 1 ... ... 3 Non-pulmonary Males ... ... ... ... ... ... ... ... 2 ... ... 2 ,, Females ... ... ... 1 ... ... ... ... ... ... ... 1 Tuberculosis Notifications. Excluding duplicates the total number of notifications received on Forms A or B during the year, 1923, was 60; 25 other cases were brought to my knowledge mainly by notifications on Forms C and D making 85 new cases in the year. These were, private cases 27, hospital cases 38, poor law cases. 19, school case 1. Of the 85 cases, 72 were pulmonary tuberculosis and 13 non-pulmonary tuberculosis. Forty-three of the cases were removed for treatment to hospital, infirmary or sanatorium. 51 The following summary gives the position at the end of 1923, of the 85 new cases respecting which information was received during the year: — Dead 24 Cases removed to Hospital and still in-patients at the end of year 8 Out-patients at Hospitals 3 In-patients in Sanatoria at end of year 8 In-patients in Infirmary 12 Not traced—Incorrect addresses 4 Removed from Borough 8 Dispensary Treatment 3 Home Treatment 8 Away with relatives in country 3 Improved—(No medical attendance now) 2 Waiting admission to Sanatorium 1 Under observation 1 85 23 of the 85 notified cases 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 38 Out-patients at other Hospitals or Dispensaries 6 Dead before notification 5 Treatment at home by private doctor 7 Not traced 4 Removed from Borough 2 62 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 six cases were notified only at death, eight within one month of death, seven within three months and three within six months of death. It is unfortunate that by a proviso in the Regulations 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 E2 52 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 Regulations 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 Regulations and urging strict compliance therewith. Institutional Treatment. During the year notifications were received of 131 admissions to institutions. These admissions represent 103 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 131 admissions were to the following institutions: — Poor Law Institutions 78 Institutions of the Metropolitan Asylums Board 32 Other Institutions 21 Twenty-eight 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 a Tuberculosis Dispensary or Hospital 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 tuberculous 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. All contacts are invited to attend for examination at the Tuberculosis Dispensary. Seventy-nine, 33 adults and 46 children under fifteen years of age, responded to this invitation and were examined for the first time during the year 1923. Of these, five, namely three adults and two children, were found to be suffering from pulmonary tuberculosis; two, both children, from non-pulmonary tuberculosis. Seventy-one were definitely diagnosed as not suffering from the disease and one remained doubtful at the end of the year. The routine examination of contacts 53 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 continued 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, and in the workrooms of a number of large firms in the Borough. Deaths from Pulmonary Tuberculosis. The number of deaths from pulmonary tuberculosis during the year was forty-five, a death rate of 1.03 per thousand in comparison with 100 for 1922. The following Table shows where the patients died in their own homes or institutions:— Showing 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- 5- 10- 15- 20- 25- 35- 45- 55- 65- All Ages. Males. Females. Total. Number of patients who died at home ... ... ... ... ... 2 2 3 1 2 ... 7 3 10 Number of patients who died in hospitals, ete. ... ... ... ... 3 1 3 6 13 2 7 25 10 35 — — - - 3 3 5 9 14 4 7 32 13 45 The following is the Report of the Tuberculosis Officer, R. Hilton, M.A., M.B., M.R.C.P., for the year 1923: — Number of Cases examined for the first time in 1923 :— Insured. Non-Insured. Children under 15. Males. Females. Males. Females, M. F. Total. 31 21 15 32 28 31 158 54 Analysis of 158 New Cases in 1923 :— A. All persons including " Contacts." Examined for first time during year. Found to be suffering from Tuberculosis. Not suffering from Tuberculosis Doubtful Cases. Pulmonary. NonPulmonary. Adults M. 46 22 24 ,, F. 53 14 2 36 1 Children M. 28 3 25 under 15 F. 31 6 25 Total 158 36 11 110 1 B. "Contacts" included in A. Adults M. 8 1 7 ,, F. 25 2 23 Children M. 23 2 21 under 15 F. 23 2 20 1 C. Insured persons M. 31 18 13 included in (A) F. 21 9 1 11 Attendances and Examinations at the Dispensary in 1923 :— Insured. Non-Insured. Total. Attendances 534 426 960 Examinations 444 356 800 Number referred to Hospital Departments 41 32 73 Specimens of Sputa examined 78 28 106 Supervision of Home Conditions :— Nurses' Visits ... ... 1,529 M.O.'s Visits ... ... 13 Reports and Communications :— Insured. Non-Insured. Total. To Public Authorities 279 86 365 To Practitioners 9 9 18 Summary of 194 Cases disposed of in 1923 :— Left the Borough ... ... 27 Definitely non-tuberculous ... ... 150 Died ... ... 17 Number of Patients under treatment or supervision at the Dispensary 31st December, 1923 194 396 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. 55 The close co-operation with local authorities has been maintained as formerly. The Medical Officers of the School Clinics and the Child Welfare Centre regularly refer to the Dispensary any patient upon whose conditions they desire an opinion. Other co-operation with medical practitioners is improving and more of the new cases are sent on the advice of the practitioners, but it is thought that more use might be made of the Dispensary by the local practitioners. Particular attention has been devoted to securing the examination of contacts. Every advantage is taken of the opportunity of referring patients to the main Hospital especially in Ear, Nose and Throat disease, also to ensure as early a diagnosis of tubercle as possible by the full aid of all modern methods. Tuberculous patients are carefully instructed in the mode of life, and the importance of prevention of infection, especially of small children, is emphasised. Where possible infants are separated from tuberculous mothers, but this branch of the work has many difficulties in the way. R. HILTON, Tuberculosis Officer. Tuberculosis Care Committee. The Holborn Tuberculosis Care Committee constituted by the scheme prepared in the year 1922 took over the work of the Interim Care Committee on the 1st April, 1923. The Committee includes the following representation: — Holborn Borough Council Councillor Revd. Wilfred H. Davies, M.A. Medical Officer of Health (Dr. C. W. Hutt). The Tuberculosis Dispensary Councillor Sir William Smith, D.L.. J P. Tuberculosis Officer (Dr. R. Hilton). The London County Council Dr. F. C. Lewis. Miss H. Bell. The Guardians of the Holborn Union Miss Mary Canney. The Charity Organisation Society Miss C. M. Thornton (to October. 1923). Miss E. J. Bolton (from October. 1923). Children's School Care Committee Miss E. Semple. Invalid Children's Aid Association Miss E. Fildes. The Metropolitan Nursing Association Miss M. Wilmshurst. Almoners of hospitals Miss J. Salmon. Miss A. M. Smith. Insurance Committee for the County of Miss S. Double. London. The Finsbury, Holborn and City War Mr. H. A. Emms. Pensions Committee. The Holborn Social Ex-Service Benevolent Committee of the United Services Fund. Other social workers (co-opted) Mrs. E. C. Bedford. Miss H. M. Mathieson. 56 The duties of the Committee were defined to include enquiries as to the economic position of the family of a patient suffering from tuberculosis as soon as the patient comes within the purview of the Turberculosis Dispensary Scheme with a view to rendering such advice and assistance as the circumstances of the case dictate; assistance in the provision, where necessary, of clothing as required by the institution to which the patient is sent, and any arrangements for the family to be properly looked after during the absence of father or mother; the securing of auxiliaries for domiciliary treatment which cannot be provided without charitable assistance; recommendations to the London County Council as to the amount of payment, if any, to be made towards institutional treatment and the collection of agreed amounts; advising the Borough Council whether the patients recommended for extra nourishment are in a position to pay for the same and, if not, the extent to which assistance should be given; advising the Borough Council as to the contributions, if any, to be made by patients in respect to the provision of dentures under any arrangements made by the Council for dental treatment. During the year the Public Health Committee considered the desirability of some revision in the constitution of the Tuberculosis Care Committees, and agreed with the view expressed by a Conference on Tuberculosis and a number of other Metropolitan Borough Councils, in favour of the formation of a Sub-Committee of the Public Health Committee in each Borough, to deal with all matters in relation to tuberculosis generally, including matters now dealt with by the Tuberculosis Care Committee. It was suggested that on such Sub-Committee various persons might be co-opted, this proposal would tend to co-ordinate and simplify much of the work connected with tuberculosis and would avoid the possibility of duplicate visits and enquiries. It is regretted that the Minister of Health was unable to take the necessary steps to authorise and empower the formation of such Committees. At the first meeting of the new Holborn Tuberculosis Care Committee Miss H. M. Mathieson, who for a number of years had acted as Honorary Secretary of the Interim Committee, was appointed Honoraiy Secretary of the Committee. Her report for the year follows:— The Interim Tuberculosis Care Committee met four times and the Tuberculosis Care Committee six times. Fifty-four cases have been considered—27 new, and 27 old. Twenty-one cases were referred by the London County Council for assessment. Of these, seven cases were recommended for free treatment, and 14 cases were assessed to pay contributions, varying between 2s. and 30s. towards the cost of their maintenance while under treatment. Contributions towards cost of maintenance, amounting to £143 13s. 0d., were collected on 21 cases, on behalf of the L.C.C.; five of these cases were still under treatment at the close of the year. Twenty-four quarterly progress reports, on nine children, were received from the L.C.C. and the information contained therein conveyed to the parents. 57 The Committee gratefully acknowledges the co-operation and practical help given by various voluntary organisations. Eight cases referred for convalescence by the Tuberculosis Officer were dealt with as follows :— 3 cases were arranged for through the Invalid Children's Aid Association. 2 ,, ,, ,, Guardians. 1 case was ,, ,, ,, Jewish Board of Guardians. 1 ,, ,, ,, by a Member of the Committee, the father's ments being supplemented by a grant from the United Services Fund. 1 case could not be dealt with as the parents refused to allow the child to be vaccinated. The Charity Organisation Society has— Provided beds in two instances—thereby enabling the patients to sleep alone and so reduce the risk of infection to others. Arranged convalescence for one child—thereby making it easier for the mother to enter hospital. Organised a maintenance allowance to one household—thereby enabling the principal bread-winner to accept treatment. The cases of four ex-service men who were undergoing treatment, were referred to the Pensions Department of the Headquarters of the British Legion. The British Legion represented these men at the Pensions Appeal Tribunal, and in each case a 100 per cent, award was granted. Two of the men died soon after their cases were heard. The British Red Cross Society Emergency Help Fund assisted two of these men and their families; pending their appeals. This Fund also helped one exservice pensioner and his family to remove to a cottage in the country. Two hospital letters—one for Brompton Hospital and one for Victoria Park Hospital—were obtained for patients for whom the L.C.C. could not provide suitable vacancies. Promises of admission to Homes for the Dying were obtained for two patients, but in both cases the patients died at home. At present the L.C.C. is unable to provide accommodat'on for advanced hopeless cases, and the waiting lists for admission to the few existing Voluntary Institutions which admit this type of case are very long. There is a great need for more accommodation for this plass of patient, if possible, within easy reach of the patient's home, so that relatives can visit. In many cases it is quite impossible to overcome the prejudice to entering a Poor Law Infirmary, which is the only alternative, at present, to the patient remaining at home and infecting the household. H. M. MATHIESON, Hon. Sec. (pro tern.). Home Nursing for Tuberculous Patients. During the year the Public Health Committee again had under consideration the desirability of provision being made for nursing tuberculous patients in the Borough, and the Council, on the recommendation of the Public Health' 58 Committee, applied to the Minister of Health for sanction to the necessary expenditure for such provision which has now been received. The nursing will be carried out by the Metropolitan Nursing Association, and will be under the strict control of the Medical Officer of Health and the Tuberculosis Officer and limited to cases in which there is urgent need of skilled nursing. The service will 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; it must not be allowed to stand in the way of admission to institution. 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 Tuberculosis Dispensary Scheme, at the Clinic of the British Dentists Hospital, No. 10, John Street, W.C In the year 1923, 6 new patients were treated. These patients made 11 attendances. Scaling and gum treatment was given in one case. Extractions with local anaesthetic were made in one case, and with general anaesthetic in five cases. In six cases filling was provided. Cancer. During the year 59 deaths were recorded as due to cancer, equal to a rate of 1.36 per thousand. In the year 1903 the death rate from cancer in the Borough was l.O; in 1913, 1.04; the decennial average rate was 1.03 for the 10 years 1903-1912, and 1.31 for the 10 years 1913-1922. 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 distributed. 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 423 births were registered as occurring in the Borough. During the same period 441 notifications of births occurring in the Borough were received. Of these 395 were from doctors and midwives, 46 from parents after letters drawing attention to non-notification. 59 From the 395 notifications of birth forms from doctors or midwives, we are able to give the following information as to by whom the mothers were attended at the confinement, etc.:— Private Doctors 102 Private Midwives 69 Outpatient Midwifery Departments of General Hospitals and Institutions: — Externs and others 65 Midwives.—Charing Cross Hospital 50 University College Hospital 39 Middlesex Hospital 21 Elizabeth Garrett Anderson Hospital 4 Other Institutions 8 Training Institution for Midwives, Myddleton Square 37 395 Sixteen notifications related to still births, and four notified the births of twins. The number of births transferred to the Borough from outlying institutions was 186 The number of births transferred from the Borough to other districts was 16 The number of net births belonging to the Borough was 593 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 100 25 53 42 Two „ ,, 212 53 66 52 Three „ ,, 67 17 12 9 Four „ „ 17 4 3 2 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 86 90 176 Children under 1 year of age 568 1,306 1,874 Children to 12 years of age 8 626 634 Children over 2 years of age 11 468 479 Enquiries re stillbirths 23 „ re ophthalmia neonatorum 14 Other Visits 126 In addition 681 visits were made by student Health Visitors. As shown in the above Table, 568 first visits to infants under one year were paid in 1923, subsequent to the receipt of a notification of birth. Some of these 60 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. First visits or further visits were not paid where the home conditions were above the standard adopted for home visiting. Four hundred and eighty-six of the visits related to infants who came under further observation, in their own home, or at a Centre. Of these. Attendances at Infant Welfare Centres. 165 attended the Council's M. & C. W. Centre at 10, John Street. 16 ,, ,, ,, Mary Ward Settlement, Tavistock Place. 13 attended the Centre at the Onslow Street School, Saffron Hill. 2 ,, ,, Charing Cross Hospital. 2 ,, ,, Greek Street. 2 ,, ,, Myddleton Square. 4,, Middlesex Hospital. 2 ,, ,, University College Hospital. 5 ,, ,, Royal Free Hospital. 4 ,, ,, Other Centres. 215 attended an Infant Welfare Centre. Thus rather less than 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 and PostNatal cases only (alternate weeks) 2—5.30 p.m. Children and Mothers seen at AnteNatal Consultation Medical Consultation 2—5.30 p.m. Class 3—5-30 p.m. Dentist. 2—4 p.m. Medical Consultation 2—5.30p.m. So. of Sessions 25 26 26 51 51 51 51 Total attendances— Children 389 ... 68 1250 15 74 1091 Mothers 125 106 29 280 614 338 221 Average weekly attendances— Children 15 ... 3 24 ... 1 21 Mothers 5 4 1 5 12 7 4 61 The total number of attendances made by the Health Visitors at the Centres was 418. At the Municipal Centres, 4,600 attendances were made by a number of mothers including 42 expectant mothers and 438 children, of whom 261 were under one year, 61 between one and two years old, and 116 aged 2-5 years on the date of their first attendance. At the Mary Ward Centre 578 attendances of Holborn mothers and children were made by 2 expectant mothers and 46 children, of whom 25 were under one year, 12 from one to two years, and 9 between two and 5 years. In addition to the Thursday afternoon classes for mothers, special talks were arranged during the year as follows : — " Vaccination and Smallpox," by Dr. Wanklyn. " Teeth and their Care," by Mr. C. O. Gray. Infant Welfare in Canada, by Mr. P. B. Tustin. " The Care of Milk " A visit was also paid to premises where the mothers were shown the various proceedings in connection with the bottling of milk. During Health and Baby Week, as mentioned elsewhere, short talks were given by Lady Nott Bower and Dr. King Brown on matters connected with Infant Welfare. 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. In addition to the health talk, assistance is given in the cutting out of garments; patterns of the most suitable woven garments are given away, also directions for making knitted garments and advice as to the choice of suitable materials. Two hundred hanks of wool of a superior quality obtained from Wales were sold at cost price to the value of £8. 15s. Three maternity bags for the use of mothers during confinement were given late in the year to the Centre, 10, John Street, one by Lady Smith, and two by Mr. T. W. Coffin. These gifts have proved very useful, four mothers having been lent the bags in the year 1923. " Welfare " accouchment outfits costing 6s. 2d. each were purchased and sold at the Centre. An outing was arranged for 59 mothers, most of them carried infants in arms, and 30 older children below school age, during the summer to Virginia Water; the costs of the fares of some of the mothers being defrayed in part from money collected by private subscriptions. The report of the working of the Maternity and Infant Welfare Centre at 10, John Street is largely the work of Dr. Mary Kidd, the Medical Officer of the Centre. 62 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. Of the 481 about whom information was obtained— 33 attended the Ante-natal Clinic at the Council's Centre. 19 ,, ,, ,, Royal Free Hospital. 29 ,, ,, ,, Middlesex Hospital. 18 ,, ,, ,, Charing Cross Hospital. 5 ,, ,, ,, Myddelton Square Institution. 5 ,, ,, ,, University College Hospital. 8 ,, ,, ,, St. Bartholomew's Hospital. 3 ,, ,, ,, City of London Hospital. 2 ,, ,, ,, Queen Charlotte's Hospital. 8 ,, ,, ,, other Centres. 4 received ante-natal care from the doctor engaged to attend the confinement. So that 134 received recognised ante-natal care, approximately one-third of the whole number. At the Council's Ante-natal Clinic 61 women attended during the year; of these 42 were ante-natal cases,* and made 106 attendances; 19 others attended after confinement making 28 attendances; 134 attendances were made. Six 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 4 Threatened abortion 2 Retroverted gravid uterus 1 Pendulous abdomen 6 Excessive vomiting 8 Varicose veins 8 Toxaemia of pregnancy 1 Albuminuria 4 Other defects present were pulmonary tuberculosis 1; other respiratory diseases 3; heart disease 1; anaemia 9; dyspepsia 9; constipation 20; dental caries 27; other defects 6. Seventy-one tests of urine were made for albuminuria; the urine of two of the women showed a cloud of albumin. Dietetic advice was afforded and arrangements made for their confinement to take place in institutions. Three presented a faint trace of albumin, one due to back pressure from a somewhat weakly acting heart, the other two women were near their confinement and the albumin was due to pressure. In six other cases the presence of albumin (a faint haze only) was ascribed to leucorrhea. *One woman was pregnant twice in the year; 43 pregnancies were thus dealt with, 63 The blood of four patients (one ante-natal and three post-natal) was submitted for the Wasserman test, one of these was found to be strongly positive, and the other three negative. Twelve expectant mothers were referred to Maternity Hospitals for confinement (four normal, eight abnormal); twenty-two to the Dental Clinic for treatment; two to the Tuberculosis Dispensary, and one to the Heart Hospital. In connection with the 19 post-natal cases attending the ante-natal clinic, the defects noted were:—Generative organs 3; lax abdominal wall 1; respiratory diseases 2; heart disease 1; anaemia 3; debility 4; digestive disorders 6; dental caries 3; pyorrhea 1; difficulty with breast feeding 4. Three of these patients were referred to the Dental Clinic and two to the Tuberculosis Dispensary. 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 year are as follows: — Reason for Attendance. Number attending. Mothers— John St. Mary Ward. Difficulty with breast feeding 49 2 Dental caries 111 5 Heart disease 2 — Debility 28 16 Anaemia 57 6 Venereal disease 1 — Respiratory disease 1 2 Digestive disorders 29 1 Other disorders 16 6 Children— Congenital syphilis 1 — Alimentary disorders 243 55 Rickets 49 2 Respiratory diseases 74 12 Hernia, umbilical 25 2 Phimosis 51 1 Rash 76 8 Disease of eye 21 1 ,, ear 11 5 ,, nose and throat 57 5 Other diseases 47 2 Mothers. Children. Total. Number referred to Clinic Dentist 93 17 110 ,, ,, ,, Hospitals 15 89 104 ,, ,, ,, Metropolitan Nursing Associatioin 28 34 62 Assisted Milk Supply—Recommended for 40 32 73 Advised Convalescent Home Treatment 11 20 31 Number referred to Ante-natal Clinic Expectant Mother 16 16 64 Breast Massage. Twenty-four nursing mothers were referred to the nurses of the Metropolitan Nursing Association for breast massage in order to stimulate the secretion of breast milk. In five case, lactation was completely restored and only in one of these, did one bottle feed each day have to be substituted for a breast feed. In six cases breast secretion was re-established, but small bottle feeds had to be given to the baby in addition to the breast. In five cases the function was re-established for a short time only to be lost again. In seven cases the massage was quite unsuccessful. In one case no further information could be obtained. Diarrhoea. During the year an effort was made to classify the cases of diarrhoea occurring in children attending at 10, John Street. The classification used was as follows:— (i.) Simple diarrhoea. (ii.) Summer diarrhoea. (a) Ordinary summer diarrhoea; some disturbance of the heat regulating mechanism together with digestive disturbance of greater or less severity. (b) Ileocolitis with blood and mucus in the stools (Dr. H. Charles Cameron's Group B comprising cases of acute catarrhal follicular or ulcerative colitis). (iii.) Heatstroke in which cerebro-spinal symptoms are the most prominent. The attacks of children suffering from diarrhoea were so analysed; 33 suffered from simple diarrhoea, 6 from ordinary summer diarrhoea, 4 children had more than one attack, viz:— P.M May Simple d. August Simple d November Simple d M.P May Simple d. September Simple d. D.W August Simple d. September Summer d. V.S July Simple d. September Simple d. Stillbirths. During 1923 there were 23 stillbirths in the district. Difficult labour was responsible for thirteen; of these three were due to contracted pelvis and four to abnormal presentation; in the remaining six the enquiry did not elicit the determining factor. Prematurity was the most likely cause of two, placenta praevia, excessive vomiting, venereal disease and kidney disease each of one; in the remaining four no information was available. Eight of the 23 stillbirths occurred in the practice of private doctors, one in that of midwives and nine in the extern practice of a hospital; five were born in an institution. 65 Illegitimate Births. An enquiry was made into the circumstances of all the illegitimate babies (48) whose birth was registered in 1923. 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. Three lived with their mothers who went out to work, the baby being in a creche in the daytime. Five were boarded out with foster-mothers. Five were in Institutions. Seven were living with both parents, who lived together permanently. In 14 instances no information could be obtained; the majority of these mothers had entered a hospital or infirmary for the confinement and had not returned to their previous address. The remaining four died in the institution in which they were born. Only three of these unmarried mothers came to the notice of the Health Visitors before the birth of the child; in these no special arrangements were required, as the mother lived permanently with the father of the 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 73, viz., 50 women and 23 children; the number of attendances 310. Assistance with Dentures, etc. Extractions with local anaesthetic were made in 35 cases (34 women and 1 child) and with general anaesthetic in 60 cases, including 16 children. Scalings were carried out in 36 cases (women 29, children 7). Fillings were provided in 60 cases, including 12 children. Dentures were provided for 15 patients, 13 of whom contributed towards the cost. In nine cases dentures were remodelled; 24 were repaired and dressings were given in 60 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. The supply of milk and food at less than cost price was continued during the year under the Maternity and Child Welfare Act, 1918, for:— (а) 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. F 66 Scale of Necessity. The approved scale of necessity adopted by the Council on the 14th October, 1921, continued in force during during the year 1923 as follows:— Person 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 16 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 235 applicants received free or assisted milk or food under the Scheme. This number included 100 who were receiving such assistance at the end of the year 1922. Grants were made in 135 new cases. At the end of the year 1923, 118 cases were receiving assistance, viz., free milk 83, milk at half price 21, prepared milk free 12, half price 2. The following Table shows new cases assisted in 1923:— Milk. Prepared Milk. Free. Part Cost. Free. Part Cost. Expectant Mothers 14 3 — — Nursing Mothers 42 12 — — Children 41 6 12 5 67 Home Help. The Council's Home Help attended 19 cases during the year. In ten of these the Whole-time Officer attended and in nine Emergency Home Helps were employed. The latter were engaged when more than one case occurred at the same time 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 4s. 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. Six applications for convalescent home treatment for mothers and babies were granted. Two were subsequently withdrawn and four mothers with their babies were sent away for such treatment. In two cases of extreme necessity the treatment was provided free; in two cases patients contributed 21s. and 10s. per week respectively towards the cost. All four mothers were sent to St. Mary's Convalescent Home, Birchington-on-Sea. In connection with the convalescent home treatment for children under five, the Council reserved a bed at the Marjorie Lumley Convalescent Home, Maidenhead. Five children were sent to this home and five to the Hopedene Convalescent Home, Barnet, which is associated with the West London Mission, Kingsway Hall. In two cases the children were sent away free; in the remaining cases contributions were paid ranging from 12s. 6d. to 3s. 6d. per week. 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, 1924, 458 infants and children under five attended the consultations, 150 of the total number coming from the Holborn Borough. Extra food and nourishment was provided, also convalescent treatment at Homes; 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. Co-operation with Clergy. In order to secure co-operation with any health activities carried on under the auspices of the religious bodies in the Borough, the Health Visitors interviewed the clergy of all denominations. F 2 68 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, and when required, suitable advice given. 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 under 1 Year M F M F M F M F M F Both sexes M F M F M F M F M F Both sexes Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 1 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 1 2 3 Meningitis (non-tubercular) ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... ... ... 1 1 1 1 2 Convulsions ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... ... ... 1 1 2 Bronchitis ... ... 1 ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... ... ... ... ... ... ... ... ... ... 11 ... 1 ... 1 1 1 ... 4 1 5 Diarrhœa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 1 Enteritis ... ... ... ... ... ... ... 1 ... 1 1 4 1 ... ... 1 ... ... ... 5 2 7 Syphilis ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 1 Suffocation ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... 1 1 2 Atelectasis ... 1 ... ... ... ... ... ... ... 1 1 ... ... ... ... ... ... ... ... ... 1 1 Congenital Malformations 2 ... ... ... ... 1 ... ... 2 1 3 ... ... ... ... ... ... ... ... 2 1 3 Premature Births 2 2 ... 1 ... 1 ... ... 2 4 6 ... ... ... ... ... ... ... ... 2 4 6 Atrophy, Debility, Marasmus ... 1 ... ... ... ... ... ... ... 1 1 1 l ... ... ... 1 1 ... 2 3 5 Other causes 1 ... 1 ... ... 2 ... ... 2 2 4 ... l ... 1 ... 1 ... ... 2 5 7 Totals 5 4 2 1 ... 4 ... 1 7 10 17 7 3 3 2 2 5 4 4 23 24 47 Total both sexes 9 3 4 1 17 10 5 7 8 47 Net births registered during the calendar year. Net deaths registered during the calendar year. Males Females Both sexes Males Females Both sexes Legitimate Infants 271 276 547 Legitimate Infants 17 24 41 Illegitimate Infants 24 24 48 Illegitimate Infants 6 ... 6 69 Deaths of Children 1 to 5 Years. Fourteen children between the ages 1 to 5 years died from the following causes:— Cause of Death. Ages. Total. 1—5 1-2 2-3 3-4 4-5 M. F. M. F. M. F. M. F. M. F. Both Sexes. Scarlet Fever ... ... ... 1 1 ... ... ... 1 1 2 Diphtheria ... ... ... ... 1 1 ... ... 1 1 2 Whooping Cough 1 ... ... 1 ... ... ... ... 1 1 2 Measles 2 ... ... ... ... ... ... ... 2 ... 2 Pneumonia ... ... ... ... 1 ... ... ... 1 ... 1 Convulsions ... ... 1 ... ... ... ... ... 1 ... 1 Violence (Accident) ... 1 ... 1 ... ... ... ... ... 2 2 Other Causes ... ... ... 1 1 ... ... ... 1 1 2 Totals 3 1 1 4 4 1 ... ... 8 6 14 Totals—Both Sexes 4 5 5 ... 14 Infectious Disease among Mothers and Children. Puerperal Fever. Three cases of puerperal fever were notified in 1923. One was a fatal case, the mother a married woman, entered a maternity hospital in the ordinary way previous to the birth of her second child; she died in hospital when her child was ten weeks old. The second case was an unmarried mother, a primipara, who entered a hospital in the ordinary way, the child lived only three hours dying of asphyxia livida; the mother recovered. The third case was a married woman, a primipara, who had been confined at home at full term, a doctor and midwife being in attendance; the child was bom before the arrival of the doctor, the midwife only being present at the birth. The mother was removed on the recommendation of her doctor to a M.A.B. Hospital; she returned recovered in three weeks time. Ophthalmia Neonatorum. During the year 14 cases of ophthalmia neonatorum occurring in babies born in the Borough were brought to our notice. Six out of the 14 cases were notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914, four of the notifications being from hospitals and two from private medical practitioners. Four of these cases were only notified after communication with the medical attendant. 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 Six 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. 3 18 days 3 days Doctor (Dispensary) as result of correspondence Moderate Home Midwife (Dispensary) Doctor (Dispensary) and District Nurse Cured Midwife 4 8 days Not known 1. M. A. B. 2. Doctor (Hospital) Not seen Maternity Hospital, then St. Margaret's Hospital In-patient, St. Margaret's Hospital Cured Born in Hospital Child not seen until its return from St. Margaret's Hospital) 7 21 days 7 days Doctor (Hospital) as result of correspondence Slight Maternity Hospital. and later at home In Maternity Hospital and then out-patient Royal Ophthalmic Hospital Cured Born in Hospital 8 6 days 3 days Doctor (Private) as result of correspondence Severe. Both eyes Home, and then St. Margaret's Hospital In-patient St. Margaret's Hospital Cured Doctor 12 4 days 3 days 1. M. A. B. 2. Doctor (Hospital) Not seen Maternity Hospital, and then St. Margaret's Hospital In-patient St. Margaret's Hospital Cured Born in Hospital Child not seen until its return from St. Margaret's Hospital 14 2 days 1 day Doctor (Private) as result of communication Slight Home Midwife Doctor (Private) Cured Midwife 71 Eight 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 1 29 days 3 days Found by Health Visitor Moderate Central Ophthalmic Hospita1 (out patient) Doctor and Monthly Nurse. Out-patient Central London Ophthalmic Hospital, Cured Doctor. 2 11 days 8 days Found by Health Visitor Slight Middlesex Hospital (out-patient) District Nurse and out-patient Middlesex Hospital Cured Midwife 5 11days First day Found by Health Visitor Slight Middlesex Hospital (out-patient) District Nurse and out-patient Middlesex Hospital Cured Midwife 6 13 days 3 days Found by Health Visitor Slight. Both eyes Charing Cross Hospital (out-patient) Midwife and out-patient Charing Cross Hospital Cured Midwife 9 11 days 9 days Found by Health Visitor Slight Home Mother Cured Extern Department Hospital 10 12 days 3 days Found by Health Visitor Slight Maternity Hospital and Central London Ophthalmic Hospital (out-patient) Out patient Central London Ophthalmic Hospital Cured Born in Hospital 11 12 days 3 days Found by Health Visitor Slight University College Hospital (out-patient) Midwife and out-patient University College Hospital Cured Midwife 13 18 days 2 days Found by Health Visitor Moderate Maternity Hospital then Central London Ophthalmic Hospital, (out patient) Out-patient Central London Ophthalmic Hospital Removed to another District Born in Hospital 72 Ophthalmia neonatorum is one of the most important causes of blindness. Although fortunately all the cases in the Borough coming to our notice last year were cured, this result was the consequence of the expenditure of much time and energy and indirectly money by all concerned; the occurrence of most, if not all of the cases could have been prevented by a simple procedure. A year or so ago the Scottish Board of Health issued a circular to medical practitioners "strongly recommending the installation of silver nitrate solution into the eyes of newlyborn children and intimating that they will in future require a report with particulars of treatment from Medical Officers of Health in all cases in which there occurs loss of vision. In this country the installation has been recommended with fortunate results by at least several Medical Officers of Health to those attending childbirths in their areas, but legislation in some form advocating or requiring its adoption generally is required so that the whole country may benefit. During the year the advantages of sending suitable cases of ophthalmia neonatorum to St. Margaret's Hospital for in-patient treatment was brought to the notice of those concerned by means of a circular letter. Measles. The notification of measles was discontinued at the end of 1919, but during the last year I received information of 75 cases of measles. Of these 40 were notified by school teachers, 18 by medical practitioners, 16 by the M.A.B. after admission to hospital and one was found by the Health Visitor. Three other children died and we learnt of the cases through the Registrar, all were certified as dying from measles; two of them suffered from both measles and diphtheria. An outbreak of measles commenced in the Borough about November 7th. Age. 7 were under 1 year. 45 were between 1 and 5 years. 21 were between 5 and 16 years. 2 were over 16. Contacts. (72 enquiries). 17 had no contacts, the L.C.C. definition of a contact being used. 55 had contacts, the number of contacts were 242, of whom 101 were susceptible, 141 having already suffered from an attack. No. of cases and 12 10 4 5 3 7 6 3 2 1 2 No. of contacts 1 2 3 4 5 6 7 8 10 11 12 No. of cases and 21 12 4 3 1 2 1 1 No. of susceptible contacts 1 2 3 4 5 6 7 8 Spread in Family. The 75 cases occurred in 62 families. In 53 families 1 case occurred, in 6 families 2 cases occurred, in 2 families 3 cases occurred and in 1 family 4 cases. 73 Removal. In all about 45 per cent. of the patients were removed to institutions. 23 were removed to a M.A.B. Hospital. 3 ,, ,, ,, the Holborn Poor Law Infirmary. 7 ,, ,, ,, the London Fever Hospital. 1 was ,, ,, a nursing home. It would seem that the teaching of the Health Visitors that measles is a serious disease is beginning to bear fruit; the parents are more willing for their children to be removed to institutions. Home Nursing. Three cases of measles, by reason of broncho-pneumonia, and one of German measles were referred to the Metropolitan Nursing Association for home nursing under the Council's arrangements, no others were referred. German Measles. During the year information was received relating to 6 cases, 2 notified by doctors and information of 4 cases was received from schools. Age. 4 were between 1 and 5 years. 1 was between 5 and 16 years. 1 was an adult. Contacts. (5 enquiries.) The number of contacts was 20 of whom 7 were susceptible, 13 having already suffered from an attack. No. of cases and 1 1 1 1 1 No. of contacts 1 3 7 9 0 No. of cases and 1 1 1 No. of susceptible contacts 1 2 4 Spread in Family. There was no spread of infection in the family. Removals. 1 to the London Fever Hospital. 1 to the Poor Law Hospital. 1 to M.A.B. Hospital. Whooping Cough. Visits were paid to 138 persons suffering from whooping cough. Of these 93 were notified by doctors; in 30 others the information was derived from the schools; 14 from the Health Visitors; and one from a parent. Seven died (two in 1924); four were under one year, two were between one and two years, one was over five years. Age. Twenty-three were children under one year, 83 were aged one to five years, and 32 five to sixteen years. 74 Contacts. (138 enquiries.) Forty-nine had no contacts; 89 had contacts. The number of contacts were 348 of whom 192 were susceptible, 156 already having suffered from an attack No. of cases and 19 17 11 8 10 10 4 5 2 2 1 No. of contacts 1 2 3 4 5 6 7 8 9 10 14 No. of cases and 9 17 12 7 6 2 1 1 2 1 No. of susceptible contacts 1 2 3 4 5 6 7 8 9 10 Spread of Infection in Family. The 138 cases occurred in 95 families. In 65 families one case occurred; 19 families had two cases, nine had three, and in two families four suffered. Removal. Forty-two children were removed to hospital, approximately 30 per cent. as opposed to 20 per cent. last year. Of these 40 were admitted to a M.A.B. Hospital and two to the Holborn Poor Law Infirmary; parents are now more willing to allow their children to be removed. Home Nursing. One case was referred to the Metropolitan Nursing Association under the Council's arrangements; no other cases were so referred. Epidemic Diarrhœa. This disease is notifiable in only a few districts in London, and is not notifiable in Holborn. The number of deaths of young children under two years of age classified under the head, Diarrhoea and Enteritis, was eight, all under one year. The deaths were equal to a rate of 13.0 per 1,000 births in comparison with 10'2 for all London. The methods used to deal with the disease have been detailed in a previous report; the most important perhaps is that during the third quarter of the year, extra visits are paid to those homes in which epidemic diarrhœa is more likely to occur. Poliomyelitis. Two cases of poliomyelitis (infantile paralysis) was notified. One child treated at home and one in hospital. One recovered; one still attending hospital. From the coming into operation of the Poliomyelitis Order, 1912, to the end of 1923 a total of twelve cases of this disease were notified as occurring in the Borough. In one case the patient was found to have suffered from influenza and not poliomyelitis. The present condition of the remaining patients is as follows. Four of the eleven cases are quite recovered and no crippling, but in one of these one leg is a little thinner than the other. Less satisfactory results are : One case, notified in 1923, is still an out-patient at the Royal Orthopaedic Hospital. One case, notified nine years ago, still wears a leg-iron although it is hoped, as the result of a recent operation, that the use of this will soon become unnecessary. One child, notified 8 years ago still drags his left leg slightly although he is able to play games. One case, notified 4 years ago, at the age of 15, is now wheeled about in a bath chair having no use of the lower limbs. The remaining three cases died. 75 Nursing Arrangements. Nursing arrangements have been made with the Metropolitan Nursing Association, No. 23 Dloomsbury Square, for the nursing, when required, of necessitous cases of measles, whooping cough, ophthalmia neonatorum, epidemic diarrhoea, pneumonia, and encephalitis lethargica. Their services were used as follows: — Whooping Cough 1 Case 24 Visits. Measles 4 Cases 38 „ Ophthalmia Neonatorum 3 „ 82 ,, Pneumonia 4 „ 116 „ Influenza 6 „ 170 „ Total 18 Cases 430 Visits. Pensions for Mothers and Widows. This subject has come to the fore again in this Country of late; it might be thought desirable that local authorities should begin to consider how best the work when it is initiated could be administered. It is difficult to avoid thinking that the administration would be best carried out by local Maternity and Child Welfare Committees. Sympathetic, efficient and experienced administration is essential for obtaining the maximum result, and this can only be effected if the administration is carried out by those who have an intimate knowledge of the home conditions of mothers and widows and have been brought into touch with them in a manner which naturally leads to mutual sympathy and confidence. The organisation necessary for such efficient administration already exists in the form of the Maternity and Child Welfare Committees of Local Authorities and the natural relationship of the new work for mothers and widows to that which they are already carrying out postulates that the administration of the new work should be added to their present duties. Moreover, if the State pays Mother's Pensions it would have a right to see that the mothering were good. This could readily be done by Health Visitors without prying or inquisitorial methods, in the course of their ordinary duties. In the main also it would be more economical for the work to be carried out by existing organisations. There is everything to be said in favour of local as opposed to central administration in view of local authorities' more intimate knowledge of local and personal conditions and greater facilities for supervision. Health Week and Baby Week. Following the precedents of 1921 and 1922 the celebration of these weeks was. in the main, combined and observed from the 7th to the 13th of October, 1923. The efforts made during the week were as follows: — (1) Elementary schools were invited to co-operate as in previous years. Twenty school departments out of 24 suitable took part, and essays were afterwards written by a large number of children. The subjects of the essays were "Danger from Flies " and " Self Help in Health." A leaflet written on flies in relation to public health had been previously written by me and distributed to the school children in time for them to assist in the destruction of flies during the winter months. 76 Prizes were awarded to the boy and girl writers of the best essays in each school, the Mayor and Mayoress entertained 60 of the writers of successful essays at tea, and the Mayoress distributed the prizes. (2) Distribution of literature.—The clergy of all denominations were invited to distribute to the members of their congregations a special leaflet, " London Health, 10 ways to help it." The majority of the clergy in the Borough were so good as to accept the invitation. A number of the retail traders distributed special leaflets from their counters during Health Week. In food shops, e.g., grocers, provision dealers, bakers, etc., the leaflet used was "Ten Points for Shoppers," and in drapers' shops "Self Help in Health: A Few Words to Young Women." The response from the traders was so satisfactory that more leaflets were applied for than the number arranged to be issued. Upwards from 15,000 leaflets were distributed in this way. (3) A special meeting for mothers was arranged and took place at the Centre, No. 10, John Street, on Thursday, 11th October, when Lady Nott-Bower and Dr. King Brown gave interesting addresses to a crowded meeting. A short musical programme was arranged and subsequently the mothers were entertained to tea. 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 1923. They are classified in the following Tables: — 77 Medical Inspection in Public Elementary Schools in Holborn. I. Age, Group and number examined. Condition of Clothing. Nutrition. Cleanliness—Head. Cleanliness—Body. Condition of Teeth. Vision. Mental Condition. Good. Fair. Bad. Good. Average. Poor. Bad. Clean. Nits present. Pediculi. Clean. Dirty. Pediculi. All sound. Not more than 3 decayed. 4 or more decayed. 6 /6 in both eyes. 6 /6 in either or both eyes. 6/12 or worse in either eye. Average. Poor. Mentally deficient. Entrants—173 Boys 39 120 14 71 93 9 ... 168 5 ... 147 23 3 92 61 20 Not Tested ... ,, 183 Girls 62 110 11 86 80 17 ... 153 29 1 153 30 ... 114 56 13 " " ... Age 8—151 Boys 35 98 18 59 68 24 ... 144 6 1 126 22 3 76 68 7 71 53 26 146 5 ... ,, 178 Girls 18 117 13 72 88 18 ... 129 48 1 158 19 1 122 45 11 97 53 28 172 6 ... Age 12—37 Boys 25 95 17 66 65 6 ... 131 6 ... 124 12 1 97 38 2 86 24 27 134 3 ... ,, 191 Girls 55 120 16 100 72 19 ... 136 54 1 182 8 1 144 43 4 117 39 35 188 3 ... Total 1013 264 660 89 454 466 93 ... 861 148 4 890 114 9 645 311 57 371 169 116 640 17 ... Percentage of Examined 26.0 65.2 8.8 44.8 46.0 9.2 ... 85.0 14.6 0.4 87.9 11.2 0.9 63.7 30.7 5.6 56.6 25.8 17.6 97.4 2.6 ... 78 Defects Found. At Mcdical Inspections in Public Elementary Schools in Holborn. Entrants. Age 8. Age 12. Boys. Girls. Boys. Girls. Boys. Girls. Number Examined 173 183 151 178 137 191 Defects :— Skin Disease ... ... 3 [3] 1 [1] 1 [1] ... Enlarged Tonsils 6 [5] 7 [4] 8 [3] 9 [7] 3 [2] 2 [2] Adenoids 2 [2] 3 [2] ... 3 [3] 1 [1] ... Tonsils and Adenoids 3 [3] 3 [3] ... ... 1 [1] ... Other Nose and Threat 1 [1] 2 [2] 1 [-] 2 [1] ... ... Enlarged Glands of Neck ... ... 1 [-] 1 [1] 1 [-] 1 [1] External Eye Disease 11 [9] 3 [2] 5 [4] 3 [3] 1 [-] ... Vision for Treatment Not Examined [5] [5] [7] [13] Otorrhœa and Otitis 2 [1] 4 [3] 1 [1] 2 [2] 2 [2] 2 [1] Other Ear Disease ... 1 [1] ... 1 [1] ... Hearing Defect ... ... 1 [1] ... ... ... Stammering ... ... ... ... ... ... Other Speech ... ... ... ... ... ... Heart Defects 2 [-] 6 [1] 7 [-] 5 [2] 4 [-] 3 [-] Anaemia ... ... 1 [-] 2 [1] ... 1 [-] Bronchitis and other Lung Disease 12 [6] 9 [5] 5 [2] 6 [1] 1 [-] 2 [1] Nervous Disease 1 [-] 1 [-] 1[-] 2 [-] 2 [-] Phthisis ... ... ... ... ... ... Other Tubercular Disease ... ... ... ... ... ... Rickets 1 [-] ... ... ... 1 [-] ... Spinal Defects 1 [-] ... 1 [-] 1 [-] 2 [2] ... Other Deformities 3 [3] ... ... ... 1 [-] 2 [2] Infectious Disease ... 2 [2] ... ... ... ... Other Defects 1 [1] 2 [1] 3 [2] 4 [3] 1 [-] 5 [2] †Cases for Dental Treatment [28] [24] [22] [30] [4] [10] 79 Deaths of Children 5-15 years. Ages. Total. 5 6 7 8 9 10 11 12 13 14 Both Sexes. M F M F M F M F M F M F M F M F M F M F M F Diphtheria ••• 1 ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ... 2 2 Scarlet Fever ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• 1 1 Heart Disease ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• 1 ••• ••• ••• ••• ••• ••• ••• 1 1 Rheumatic Fever ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• 1 ••• ••• ••• ••• ••• 1 1 Appendicitis ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• 1 ••• ••• ••• 1 ••• 1 Nephritis ••• ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• l ••• 1 Meningitis ••• ••• ••• ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ... ••• ••• ••• ••• I ... 1 Accident ••• ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ... ••• ••• ••• 1 ••• 1 Other Diseases ••• ••• ••• 1 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ... ••• ••• ••• 2 ••• 3 3 Total ••• 2 2 2 1 ••• ••• ••• ••• ••• ••• ••• ••• 1 ••• 1 1 ••• ••• 2 4 8 12 Total both sexes 2 4 1 ••• ••• ••• 1 1 1 2 12 80 SANITARY ADMINISTRATION. Public Mortuary. The Public Mortuary provided by the Council is situated in Goldsmith Street. During the year 45 bodies were deposited. There were 30 post mortem examinations made, and 36 inquests held. The inquests are held in the Court Room at the Council Offices. On nine occasions bodies awaiting burial were removed to the mortuary on account of inadequate accommodation in the homes; 34 bodies were brought in by order of the Coroner, and two by the Police. Inquests. During the year 58 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, 28; Accidents, 18; Suicide, 11; Misadventure, 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. 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. 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. 81 A difficult problem is caused by a number of old people chiefly women living alone usually in a single room. Many of these old people have no one to look after them; gradually becoming feebler they are eventually unable to look after themselves or their homes properly and yet they are most unwilling to enter the Poor Law Institutions. At present persuasion is used, but the condition often persists for a considerable time; it is difficult to suggest any solution of the problem other than the granting of compulsory powers of removal to a suitable institution. Poisoning by Coal Gas. During the year information was received respecting deaths due to poisoning by carbon monoxide present in gas supplied for domestic purposes. In one case two deaths occurred, a man aged 89 and a woman aged 62. The deceased persons slept in adjoining rooms; there was an escape of gas from the upper part of the stem of a 3-light pendant hanging from the ceiling of the room occupied by one of the deceased persons. There were folding doors between this room and the adjoining room under which the gas penetrated to the second room with fatal results to the occupant. The defective pendant was probably about ten or twelve years old and the defect extended over eighteen inches in, the brazed seam of the stem. The amount of carbon monoxide present in the gas at the time of the accident was stated by the Gas, Light & Coke Company to be 15.87 per cent. During the year a communication was received from the Bethnal Green Borough Council asking the Holborn Council to support a resolution, requesting the Prime Minister to appoint a Committee to investigate the composition of gas supplied by gas undertakers, and report as to whether it is practicable to substantially reduce the amount of carbon monoxide therein, and to report as to tests, which should be made by gas undertakings from time to time, to ascertain the conditions of gas mains, consumers' fittings and other gas apparatus. In connection with this communication I reported to the Public Health Committee that, in view of the recent cases of gas poisoning and increasing casualties from the use of geyser water-heaters, I had been in communication with the Metropolitan gas companies and various commercial firms who make and fix gas heaters, cooking stoves and geysers in the Borough, to ascertain the precautions taken, and required, in connection with the fixing of such appliances, also the requirements as to the size of outlets to the external air. I suggested that the attention of the Central Government should be directed to the need for the adoption of scientific principles when fixing gas-heating and cooking appliances especially in connection with the ventilation of rooms and the adequate removal of the products of combustion by suitable large outlets to the external air or otherwise. Representations were accordingly sent to the Prime Minister, Minister of Health and the President of the Board of Trade. Rent and Mortgage Interest Restrictions Acts, 1920 and 1923. On the application of tenants two certificates were issued under the above Acts that the houses complained of were not in all respects reasonably fit for human habitation or were otherwise not in a reasonable state of repair. G 82 Food Poisoning. In July enquiries were made in consequence of the somewhat sudden death of a man aged 57 at a hotel in the area. He suffered from symptoms identical to those of food poisoning, and eventually the enquiries threw a suspicion on some trout which he had consumed at a meal at another hotel in another district the previous evening, twelve to fourteen hours previous to his death. A "charred wood odour "was complained of, but this was possibly due to the trout having been grilled. The trout were received in a live condition daily and were put into a large tank before they were required for cooking. Some had died in the tank during the day but they were not used, and even these when taken out and examined were found to be quite fresh and in good condition; probably the change of temperature of the water, or want of air in the water during transport to the hotel was the cause of their death. No preservative was used in connection with the fish. The deceased partook of hors d'œuvres which probably consisted of sardines, potato salad, tinned vegetables, including peas and beans, which were apparently coppered but were exonerated. The kitchens, larders, etc., of the hotel were all clean and well conducted. I am indebted to Dr. F. J. Allan, Medical Officer of Health of Westminster, for information with regard to the circumstances under which the food was partaken. The verdict returned at the inquest was to the effect that the deceased died of heart failure, fatty degeneration of heart muscle and acute enteritis consequent on some unknown bacterial invasion of the body. Other Propaganda Leaflets, etc. Arrangements were made with the co-operation of the Library Committee for the publication of two bookmarks, one for adults and one for children. On the front information was given as to health and educational facilities afforded by the Council. On the back of the bookmark for adults information was contained respecting diphtheria antitoxin and the arrangements for the prevention of diphtheria by immunisation. The back of the children's bookmark contained hints to boys and girls on how to keep healthy. A revised leaflet on the care of teeth was issued especially for expectant and nursing mothers. International Hygiene. During the earlier part of the year the Council allowed me to accept the invitation of the League of Nations Health Section to study health institutions in Paris, Austria and Geneva over a period of six weeks in company with four English and some twenty-five foreign colleagues. We spent the time profitably; and from intercourse with our foreign colleagues were able to form impressions of the degree to which Public Health had progressed in their various countries, supplementing knowledge already obtained through previous visits abroad, both private and to Conferences and association with international students in our own office and at Bedford College, Regent's Park. In Austria the general outline of Public Health work appeared to be as advanced as ours, a striking number of 83 new Sanatoria for consumptives having been built both during the war and after. One marked feature was the extent to which artificial light was used for the treatment of tuberculosis of the glands, bones, joints, etc. We were shown over a hospital in Vienna entirely devoted to light treatment of skin and other diseases. An important measure used for the prevention of venereal disease was the compulsory detention of diseased women found on police raids of hotels, etc. We had the pleasure of meeting among others Dr. Von Pirquet, the well-known children's specialist, and Dr. Schick with whose procedure with regard to the prevention of diphtheria we are endeavouring to take our share in familiarising the parents of English children. A noteworthy institution visited was an Infants' Hospital in a suburb of Vienna, where the training of Health Visitors was carried out; while it was probably not better than any of ours it was certainly very complete, and the more attractive arrangements probably facilitated teaching. The same is true of the newer hospitals we saw in Vienna and Graz. No serious adverse criticism could be made on the general sanitation of Vienna; the condition of the streets, the disposal of excreta, the water supply were all satisfactory; the results of a laboratory investigation which a friend happened to see indicated that the quality of the water was possibly not so good as the majority of the Viennese think. In Graz we saw a hospital chiefly for the treatment of industrial surgical injuries to which Accident Insurance Companies made considerable contributions. Professor W. Prausnitz, one of the authors of a text book of hygiene well-known on the Continent, demonstated the water-works which were of a remarkably simple character, the underground water streaming down from the adjoining mountain, the Schachtel, being tapped by shallow bore wells on its way to the river Mur which flowed past the water-works. A regulated overflow from the river was also admitted at times after natural filtration through the subsoil. A criticism might be made of the absence of legislative protection from faecal pollution, etc. of the surface in the neighbourhood of these wells. On a later occasion Professor Prausnitz was so good as to show me the Tonnen Fassen conservancy system for the disposal of excreta, a system which possibly shares with the lack of water laid on to some of the poorer houses the obloquy of the relatively large amount of typhoid fever in Graz. Visits were paid to various Baths, including Baden, Ischl, and Bad Gastein. In Baden near Vienna the State utilise the baths for treatment of rheumatism and deformities due to rheumatism, much use being made of a certain topical mud for local applications to joints, etc. Here was a spring in which soldiers disabled in the Napoleonic Wars bathed. In Salzburg I saw a School Hygiene Institute where Dr. Richard Heller was examining school children; routine medical inspection of school children is evidently in its infancy in Austria although studies in school hygiene of exceptional value have been published in that country over a long period of years. Earlier we had encountered on the border of the Traunsee a large party of school girls from Linz, some 40 miles or so away, who were on a school journey accompanied by their teachers and a priest. G 2 84 We had every reason to be grateful for the opportunity of seeing the excellent health institutions, the courtesy with which we were received and the trouble taken in explaining were beyond all praise. The arrangements made did not fail on one single occasion; for this our gratitude is especially due to Dr. Kaiser of the Austrian Ministry of Health and to Dr. Lebzelter, its well-known Librarian. We had the honour of being invited to tea at the Ball Platz by Dr. Michael Hainisch, the President of the Republic; many of the members of the delegation were introduced to him; in the course of conversation he showed himself extremely well-informed of conditions in England, notably those relating to agriculture. From Austria the delegates proceeded to Geneva where the workings of the Lengue of Nations, its Health Section, the International Labour Organisation, and its political work were all demonstrated. The part played by the Health Section in combating epidemics, some of which might spread to this country, were set forth. Conferences were held at which the delegates compared the health institutions of Austria and England, and incidently of their own countries. Of chief interest was a discussion on venereal disease, the Russians wanted to educate illiterate people, the Swedes to compel such people to accept treatment. At the International Labour Bureau Mr. Butler and Mr. Albert Thomas explained how their section was endeavouring to improve the health conditions of the industrial workers in various countries. On the way home I stopped at Dijon to confer with the Medical Officer of Health. He was especially interested in the routine medical inspection of school children which he hoped to institute shortly and accepted with pleasure a set of the cards and forms used for this purpose in London. HOUSING. In 1919 the housing survey established the need in the Borough 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. The Society intend to provide this housing accommodation on a site purchased from the Council. 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 792 houses occupied by the working classes were inspected, this number consisted of 587 registered lodging houses and 205 non-registered houses 85 occupied by working classes. Of the 205 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. Occupation of Basement Rooms. Generally throughout the Borough buildings are constructed with basements. Efforts were made to ascertain the number of such basements used for dwelling purposes with the following results: — (a) Number of basements in the Borough used for dwelling purposes 1,262 (b) Number of basement dwellings in the Borough with ceilings at or below street level 471 (c) Number of basement dwellings in which the width o f area in street does not exceed 3 feet 421 (d) Number of basement dwellings in which the width of the area in street does not exceed 4 feet 107 The figures cannot be considered to be any more than approximate; they were obtained by external inspection from the streets and relate only to front basements in accordance with a request made in order to obtain a rough census of the basement dwellings throughout London. It was observed that a number of areas into which basement rooms opened were painted or distempered in dark colours; with a view to secure, as far as possible, use of white or light coloured paint or distemper for such purposes a communication was sent to a number of builders in the Borough asking them to encourage their customers to have areas so painted or distempered. HOUSING CONDITIONS. Statistics. Year Ended 31st December, 1921. 1.—GENERAL. (1) Estimated population 43,376 (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 ‡(6) Number of working-class tenements 8,571 (7) Number of new working-class houses erected nil *" 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. 86 2.—UNFIT DWELLING-HOUSES. I.—INSPECTION. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 900§ (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 685 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 V 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 685 (2) Number of dwelling-houses in which defects were remedied: — (a) by owners 685 (b) by Local Authority in default of owners nil C. Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc. Act, 1919: — (1) 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 nil (4) Number of dwelling-houses in respect of which Demolition Orders were made nil (5) Number of dwelling-houses demolished in pursuance of Demolition Orders nil § Practically all these houses were tenement houses containing a number of tenements. A11 the more insanitary houses are always annually inspected, although none last year were formally recorded under the above Regulations. 87 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 88 APPENDIX. TABLE I. Vital Statistics of Whole District during 1923 and Ten Previous Years. Year Population estimated to 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 Gate 1913 46,919 868 798 16.9 910 19.9 583 358 80 100 685 14.4 1914 46,832 703 765 16.4 888 19.0 558 408 67 88 738 15.8 1915 40,405 591 670 14.4 876 21.8 559 335 64 96 702 17.4 1916 38,161 564 649 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 1918 36,769 340 497 12.1 862 23.4 532 490 70 141 820 22.3 1919 38,156 397 539 13.6 920 24.1 618 322 52 96 624 16.4 1920 39,676 619 827 20.6 827 20.6 568 339 55 66 603 15.2 1921 43,520 483 648 14.8 859 19.7 622 319 51 79 556 12.8 1922 42,850 485 664 15.5 746 17.4 518 342 48 72 570 13.3 1923 43,370 423 593 13.7 718 16.6 491 300 47 79 526 121 In the above Table the populations, birth-rates and death-rates for the years 1913-1914 inclusive have been estimated from the Census Populations of 1901 and 1911. For the years 1915 to 1920 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. 89 TABLE II. Causes of, and Ages at, Death, 1923. 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 526 47 4 10 12 14 72 175 101 91 Uncertified ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... ... 2. Small Pox ... ... ... ... ... ... ... ... ... ... ... 3. Measles 3 1 2 ... ... ... ... ... ... ... ... 4. Scarlet Fever 3 ... ... 2 1 ... ... ... ... ... ... 5. Whooping Cough 5 3 1 1 ... ... ... ... ... ... 9 6. Diphtheria and Croup 4 ... ... 2 2 ... ... ... ... ... 2 7. Influenza 1 ... ... ... ... ... ... ... ... 1 1 8. Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... 1 9. Meningo-coccal Meningitis 2 2 ... ... ... ... ... ... ... ... 6 10. Tuberculosis of Respiratory System 15 ... ... ... ... 6 14 18 6 1 10 11. Other Tuberculous Diseases 3 ... ... ... ... 2 1 ... ... ... 52 12. Cancer, malignant disease 59 ... ... ... ... ... 7 29 13 10 49 13 Rheumatic Fever 2 ... ... ... 1 ... 1 ... ... ... 5 14. Diabetes 5 ... ... ... ... ... ... 3 1 1 ... 15. Cerebral Hæmorrhage 26 ... ... ... ... ... 2 10 7 7 8 16. Heart Disease 70 1 ... ... l 1 7 30 14 16 22 17. Arterio-sclerosis 26 ... ... ... ... ... ... 6 8 12 5 18. Bronchitis 51 ... ... ... ... ... 1 13 19 18 12 19. Pneumonia (all forms) 40 5 ... 1 ... ... 8 16 5 5 46 20. Other Respiratory Diseases 5 1 ... ... ... ... ... 4 ... ... 2 21. Ulcer of Stomach or Duodenum 2 ... ... ... ... ... ... 2 ... ... 2 22. Diarrhœa, etc., (under 2 years) 10 8 ... ... ... ... ... 2 ... ... 44 23. Appendicitis and Typhlitis 5 ... ... ... 1 1 3 ... ... ... 10 24. Cirrhosis of Liver 8 ... ... ... ... ... 2 4 2 ... 3 25. Acute Chronic Nephritis 26 ... ... 1 1 2 2 11 7 2 12 26. Puerperal Sepsis 1 ... ... ... ... 1 ... ... ... ... ... 27. Other accidents and diseases of Pregnancy and Parturition 1 ... ... ... ... ... 1 ... ... ... 1 28. Congenital Debility and Malformation, Premature Birth 14 14 ... ... ... ... ... ... ... ... 52 29. Suicide 11 ... ... ... ... ... 6 4 ... 1 1 30. Other Deaths from Violence 16 2 1 ... 1 ... 4 3 3 2 7 31. Other Defined Diseases 82 10 ... ... 4 1 13 20 16 15 139 32. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... 26 17 4 10 12 14 72 175 101 91 501 90 TABLE III. Cases of Infectious Disease notified during the year 1923. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Locality (e.g. Parish or Ward) of the District. At all Ages. At Ages—Years. St. Giles and Bloomsbury. Holborn. Total Cases Removed to Hospitals. Under 1 1 to 5 5 to 16 16 to 25 25 to 45 45 to 65 65 and wards. Small-pox ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) 98 4 26 22 31 12 3 ... 25 73 97 Erysipelas 14 ... ... 2 1 3 4 4 6 8 9 Scarlet Fever 102 3 38 46 9 6 ... ... 18 84 102 Enteric Fever 2 ... ... 1 1 ... ... ... 1 1 2 Puerperal Fever 3 ... ... ... 3 ... ... ... 1 2 3 Cerebro-Spinal Fever 1 1 ... ... ... ... ... ... 1 ... 1 Ophthalmia Neonatorum 6 6 ... ... ... ... ... ... 1 6 4 Dysentery ... ... ... ... ... ... ... ... ... ... Malaria 1 ... ... ... 1 ... ... ... ... 1 ... Pneumonia—Primary 43 6 4 1 3 8 15 6 12 31 26 do. Influenzal 5 ... ... 1 ... 2 1 1 ... 5 5 Tuberculosis—Pulmonary 50 ... ... 2 9 22 16 1 26 24 20 do. Non-Pulmonary 10 ... 1 3 4 1 ... 1 4 6 5 Whooping Cough 93 13 56 24 ... ... ... ... 43 50 22 Chicken Pox 57 6 25 26 1 ... ... ... 10 47 ... Acute Poliomyelitis 2 1 1 ... ... ... ... ... ... 2 1 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 487 39 151 128 63 54 39 13 148 339 297 91 TABLE IV. Infectious Diseases in Holborn for the last Eleven Years. NOTIFICATIONS DEATHS Decennial Average, 1913-1922 Year 1923 Decennial Average, 1913-1922 Year 1923 Number Rate per 1,000 London Hate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Small-pox 0.3 0.01 0.00 0 0.00 0.00 0 0.00 0.00 0 0.00 0.00 Diphtheria 94 2.32 2.42 98 2.25 2.28 5 0.13 0.18 4 0.09 0.13 Erysipelas 21 0.49 0.69 14 0.32 ... ... ... ... ... ... 0.01 Scarlet Fever 109 2.58 3.76 102 2.35 2.22 1 0.02 0.05 3 0.07 0.02 Enteric Fever 6 0.14 0.13 2 0.04 0.07 1 0.02 0.02 0 0.00 0.00 Cerebro-Spinal Fever 2 0.06 0.06 1 0.02 ... ... ... ... 1 0.02 0.01 Acute Poliomyelitis 1 0.02 ... 2 0.04 ... ... ... ... 0 0.00 0.00 Whooping Cough† 54 1.40 ... 93 2.14 ... 2 0.05 0.20 5 0.11 0.09 Measiest ... ... ... ... ... 9 0.25 0.25 3 0.07 0.08 Tuberculosis—Pulmonary 127 3.15 ... 50 1.15 ... 70 1.74 1.31 45 1.03 0.93 Ditto Non-Pulmonary 21 0.51 ... 10 0.28 ... 9 0.22 ... 3 0.07 0.17 Puerperal Fever* 1 1.66 3.11 3 5.08 3.89 1 1.66 ... 1 1.68 1.32 Ophthalmia Neonatorum* 8 11.61 ... 6 10.12 8.32 ... ... ... ... ... ... Diarrhoea (under 2 years)* ... ... ... ... ... ... 9 14.1 1.86 8 13.49 10.2 * Rates per 1,000 births. † Notifiable in Holborn (not in London) since 1914. Average given for 9 years. ‡ Not Notifiable. 92 TABLE V. INFORMATION REQUIRED BY THE LONDON COUNTY COUNCIL. PREMISES. Number on Register at end of 1923. Number of Inspections. Number of Prosecutions. Cowsheds ... ... ... Milkshops 127 248 ... Houses let in lodgings 587 850 4 Ice cream premises 81 240 ... Slaughter houses 1 3 ... Offensive Trades ... ... ... Smoke Nuisances— Number of observations 411 Number of notices 10 Number of nuisances and complaints 10 complaints Number of summonses 0 Housing of the Working Classes— Number of houses inspected 900 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 0 Number of houses remedied without Closing Orders (A number of houses were remedied without the necessity for representation) 0 Number of demolition orders 0 Number of houses demolished; (a) 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 Number of houses occupied by the working classes (Census, 1921) 8571 tenements Number of houses for working classes— (Census, 1921) (a) erected during year 0 (b) in course of erection 0 Underground Booms— Number illegally occupied 6 Number closed or illegal occupation discontinued 6 Overcrowding— Number of rooms overcrowded 3 Number remedied 3 Prosecutions 0 Cleansing— Number of adults cleansed 125 Number of children cleansed 0 Number of rooms or premises cleansed 41 (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 375 Number of Inspections 2652 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 93 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 184 29 5 ... Workshops 223 43 5 ... Workplaces 3,402 116 5 ... Total 3,809 188 15 ... 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 40 40 ... ... Want of ventilation 1 1 ... ... Overcrowdiug ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances Sanitary accommodation insufficient 133 1 133 1 ... ... unsuitable or defective 62 62 ... ... not separate for sexes 5 5 ... ... 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 which are included in Part 3 of this Report) ... ... ... ... Total 242 242 ... ... * Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act as remediable under the Public Health Acts. 94 « 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. 107 274 333 2 1 2 109 ... ... ... ... ... ... ... ... (2) Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquet and Tennis Balls 2 ... 52 ... ... ... 2 ... ... ... ... ... ... ... ... Paper Bags and Boxes 2 ... 15 ... ... ... 2 ... ... ... ... ... ... ... ... Total 111 274 400 2 1 2 113 ... ... ... ... ... ... ... ... 95 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) 28 Other Workshops 1,145 Total number of workshops on Register 1,173 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) 8 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 Report (action being taken) sent to H.M. Inspector 25 25 Other — Underground Bakehouses (s. 101): — Certificates granted during the year — In use at the end of the year 18 96 LEGAL PROCEEDINGS. SALE OF FOOD AND DRUGS ACTS, 1875-1907. Date. Name and Address. Offence. Result. 1923 Feb. 13 W. W. J. Barley 73, Marchmont Street Selling tinned peas containing copper equal to 1.099 grains per pound copper sulphate Dismissed. Do. R. Tekroni, 138, Clerk - enwell Road P. Servini, 57, Mount Pleasant R L. Plgnataro, 67, Leather Lane Selling tinned beans containing copper equal to 1.375, 2.014 and 1.512 grains per pound crystalised copper sulphate respectively A djourned, sine die. Feb. 12 J. Elgar & A. S. Gilbert 78, Southampton Row Selling tinned peas containing copper equal to 1.40 grains per pound crystalised copper sulphate Withdrawn owing to a defendant's death on payment of £2 2s costs Mar. 19 A. Misirottie 19a, Charles Street Selling milk containing 5.5 per cent. added water Dismissed with a cautiou on payment of 14s. 6d. costs. „ 20 W. B. Shearn 231, Tottenham Court Road Selling tinned peas containing foreign ingredients (copper sulphate) Fine twenty guineas. Costs ten guineas. Apr. 23 & 30 May 2 & 22 June 5 Welford & Sons, Ltd. 13, Cosmo Place Selling cream cheese not of nature, substance and quality demanded The Order of the Police Court to pay £5 5s. fine and £15 15s. costs was quashed on appeal at Quarter Sessions on the ground of unsatisfactory purchase. Sept. 22 F. Collier 15, Baldwins Gardens Selling butter containing 1.95 per cent excess of water Summons withdrawn on payment of 12s 6d. costs. Oct. 10 J. Sainsbury, Ltd. 173, Drury Lane Selling butter containing 2.3 percent. excess of water Warranty proved. Summons dismissed. Dec. 19 W. S. Chapman&Co.Ltd. 70. Lamb's Conduit St. Selling tinned peas containing 0.015 grains per pound crystalised copper sulphate Summons dismissed on payment of £3 3s costs. PUBLIC HEALTH (LONDON) ACT, 1891. Date. Name. Premises. Offence. Result. 1923 Oct. 8 and 17 W. J. Nlcholls 50, Devonshire Street Nuisance under Public Health (London) Act, l89l Order made to abate same within 14 days. 10s. 6d costs. Do. Do 51 Do. Do. Do. Do. Do. 52 Do. Do. Do. Do. Do. 53 Do. Do. Do. Oct. 8 Do. 50 Do Preach of Lodging House By-laws Fined 40s. Do. Do. 51 Do. Do. Do. Do. Do. 52 Do Do. Do. Do. Do. 53 Do. Do. Do. Nov. 21 The Owner 21, Old Gloucester St. Drain choked. Front area dirty Order to abate within two days. Do. J. W. Tyoard Do. Do. Do.