HOL 23 The Metropolitan Borough of Holborn. ANNUAL REPORT OF THE Medical Officer of Health, C. W. HUTT, M.A., M.D., D.P.H., For the Year 1925. London: Printed by DIPROSE, BATEMAN & CO., Sheffield Street, Kingsway, W.C.2. 1926 2 PUBLIC HEALTH DEPARTMENT, COUNCIL OFFICES, 197, HIGH HOLBORN, W.C. 1. March, 1926. 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 Condition, of the Borough for the year 1925, embodying a Survey Report for the preceding four years in accordance with instructions of the Ministry of Health. Believe me, Ladies and Gentlemen, Yours obediently, C. W. HUTT, Medical Officer of Health INDEX. Page Public Health Committee 5 Housing of the Working Classes Committee 5 Maternity and Child Welfare Committee 6 Staff 6 Statistical Summary 7 Natural and Social Conditions Population and Houses 8 Births 8 Deaths 9 Seasonal Mortality 10 Infantile Mortality 10 Poor Law and Hospital Relief 11 Sanitary Circumstances Scavenging. Removal of House Refuse 11 Removal of Manure 13 Sanitary Inspection of District 13 Notices served 15 By-law as to Houses let in Lodgings 16 Rats and Mice (Destruction) Act 16 Inspection of Workshops 20 Factories 21 Factories Bill 21 Smoke Abatement 23 Common Lodging Houses 24 Food 24 Dairies, Cowsheds and Milk Shops 24 Sale of Groceries in Dairies 24 Residue from Milk Clarifiers 24 Bacteriological Examination of Milk 25 Dirt in Milk 26 Milk (Special Designations) Order, 1923 28 Public Health (Milk and Cream) Regulations, 1912-17 28 Condensed Milk 29 Dried Milk 29 Margarine 29 Bakehouses 29 Fried Fish Shops 30 Fish Shops and Stalls 30 Market Streets and Exposure of Food Generally 30 Ice Cream 30 Meat Regulations 31 Sale of Fish—Proposed Regulations 33 Places where Food is Prepared for Sale 33 Washing-up Arrangements in Restaurants, etc. 34 Cleanliness and Food 34 Restaurants, Sanitary Accommodation for Customers 35 Registration of Eating Places 35 Unsound Food 36 Sale of Food and Drugs Acts 36 Preservatives in Food Regulations 36 Adulterated Samples 39 Apples—Contamination by Arsenic 41 Cheese 12 Sophistication of Wines 44 Mussels 44 Contamination of Food 46 Food Standards 46 Milk—Fat Content 47 Table of Samples Purchased 49 Prevalence of and Control over Infectious Diseases Infectious Diseases Generally 51 Smallpox 52 Vaccination 53 Diphtheria 54 Schick Test and Immunisation against Diphtheria 55 scarlet Fever 62 Enteric Fever 62 Typhus Fever 62 Cerebro-Spinal Fever 62 Dysentery 63 Malaria 63 Encephalitis Lethargica 63 Acute Poliomyelitis 63 Pneumonia 64 Influenza 66 Anthrax 66 Chickenpox 66 Mumps 66 A2 Page Bacteriological Work 66 Disinfections 66 Cleansing of Persons Act 67 Verminous Condition and Scabies 67 Shelter during Disinfection 68 Tuberculosis 68 Notifications 70 Correction of Register 71 Sleeping Conditions 71 Classification of Homes 72 Delay in Notification 73 Institutional Treatment 73 Visitation of Home 74 Contacts 74 Prevention of Spitting 74 Danger to others from Coughing 74 Deaths from Pulmonary Tuberculosis 74 Tuberculosis Dispensary 75 Tuberculosis Care Committee 77 Employment of Tuberculous Persons 79 Home Nursing 80 Dental Clinic 80 Cancer 81 Maternity and Child Welfare 82 Notification of Births 82 Home Visiting 83 Attendances at Infant Welfare Centres 83 Work at Centre 84 Ante-natal Hygiene 86 Maternal and Infant Consultations 89 Artificial Sunlight 89 Breast Massage 90 Diarrhœa 90 Still-Births 90 Illegitimate Births 92 Dental Treatment 92 Assistance with Denture 92 Supply of Milk and Food for Mothers and Infants 93 Home Help 94 Convalescent Home Treatment 95 Visitors to Centre 96 Saffron Hill Maternity and Child Welfare Centre 96 Deaths of Infants under One Year 97 Deaths of Children, One to Five Years 98 Infectious Diseases among Mothers and Children 98 Puerperal Fever 98 Ophthalmia Neonatorum 98 Whooping Cough 101 Measles 103 German Measles 103 Epidemic Diarrhœa 104 Nursing Arrangements 104 Widows', Orphans', and Old Age Contributory Pension Act, 1925 105 Health and Baby Week 106 Minor Ailments Clinic 108 First International Congress on Child Welfare 108 Child Welfare Work in Alsace Lorraine 109 Medical Inspection and Treatment of School Children 109 Deaths of Children, 5-15 Years 112 Sanitary Administration 113 Mortuary 113 Inquests 113 Revenue Acts 113 Dirty Tenants 113 Rent and Mortgage Interest Restriction Acts 114 Other Propaganda 114 Pigeons 114 Housing 115 Betterton Street Scheme 115 Housing Conditions 116 APPENDIX Table I. Vital Statistics, 1925, and ten previous years 118 Table II. Causes of and Ages at Death, 1925 119 Table III. Infectious Diseases Notified during 1925 20 Table IV. Infectious Diseases in Holborn during 1925 and ten previous years 121 Table V. Information required by L.C.C. 122 Table VI. Factories, Workshops, &c. 123 (1) Inspections 123 (2) Defects found 124 (3) Home Work 125 (4) Registered Workshops 125 (5) Other Matters 125 Table VII. Legal Proceedings 126 5 PUBLIC HEALTH COMMITTEE. 1924-25. Chairman- Councillor the Rev. Henry Ross. Vice-Chairman— Councillor Francis J. Pullen. Ex-Officio— The Right Worshipful The Mayor, Councillor Harold Warren Coleman, J.P. Alderman Henry Jewell. Councillor John H. Boraston, C.B. „ Rev. Wilfred H. Davies, M.A. „ Henry W. Ellis. „ Edward M. Evans. ,, George E. Hutchinson. ,, Harold Jewell. „ John W. Roberts. ,, Sir William R. Smith, D.L., J.P., M.D. , Arthur Youngman. 1925-26. Chairman— Alderman Francis J. Pullen. V ice-Chairman— Councillor John H. Boraston, C.B. Ex-Officio— The Right Worshipful The Mayor, Alderman Harold Warren Coleman, J.P. Councillor Albert J. Clark. „ Rev. Wilfred H. Davies, M.A. „ Henry W. Ellis. „ Harold J. Jewell ,, Horace W. Langdon. „ Miss Marjorie R. Lovelock. „ Samuel W. Price. ,, Rev. Henry Ross. ,, Sir William R. Smith, D.L., J.P., M.D ,, Mrs. Ethel M. Wilson. HOUSING OF THE WORKING CLASSES COMMITTEE. 1924-25. Chairman— Alderman Henry Jewell. Vice-Chairman— Councillor James J. Claydon. Ex-Officio— The Right Worshipful The Mayor, Councillor Harold Warren Coleman, J.P. Councillor Charles R. Baddeley. „ Rev. Wilfred H. Davies, M.A. „ Miss Emily Dibdin. „ Henry W. Ellis. ,, Ernest Hamlin. „ Alfred Humphreys. „ Raymond A. Miles. „ J. St. Laurence Stallwood. „ George Witherby. „ Arthur Youngman. 1925-26. Chairman— Councillor J. C. St. Laurence Stallwood. Vice-Chairman— Alderman James W. Coade. Ex-Officio— The Right Worshipful The Mayor, Alderman Harold Warren Coleman, J.P. Councillor Rev. Wilfred H. Davies, M.A. ,, Miss Emily Dibdin. „ Henry W. Ellis. ,, Ernest Hamlin. „ Alfred Humphreys. ,, Horace W. Langdon. „ Raymond A. Miles. „ Albert A. Mussett. ,, George D. Pooley. „ Arthur Youngman. 6 MATERNITY AND CHILD WELFARE COMMITTEE. 1924-25. Chairman— Councillor Francis J. Pullen. Vice-Chairman— Councillor John W. Roberts. Ex-Officio— The Bight Worshipful The Major, Councillor Harold Warren Coleman, J.P. Councillor James W. Coade. „ Richard Davies. „ Miss Emily Dibdin. „ George E. Hutchinson. „ Rev. Henry Ross. „ Lady Smith. ,, Mrs. Ethel M. Wilson. Nurse M. Baylee. Mr. Thomas W. J. Coffin. The Mayoress (Mrs. H. Warren Coleman). Mrs. Wilfred H. Davies. Miss Norah H. March, B.Sc. 1925-26. Chairman— Councillor The Rev. Henry Ross. Vice-Chairman— Councillor Lady Smith, J.P. Ex-Officio— The Right Worshipful The Mayor, Alderman Harold Warren Coleman, J.P. Alderman Francis J. Pullen. Councillor Richard Davies. „ Miss Emily Dibdin. ,, Percy Hill. „ Miss Marjorie R. Lovelock. „ Albert A. Mussett. „ Mrs. Ethel M. Wilson. „ George Witherby. Mr. Thomas W. J. Coffin. The Mayoress (Mrs. H. Warren Coleman). Mrs. Wilfred H. Davies. Miss Norah H. March, B.Sc. „ H. M. Wilmshurst. STAFF. The following was the Staff during 1925. Medical Officer of Health—C. W. Hutt, M.A., M.D., D.P.H. Medical Officer of Maternity Centres—(Temporary) Richenda Gillett, M.D. Brux. L.S.A. Medical Officer of Tuberculosis Dispensary—James Arthur Struthers, M B., B.Ch., M.R.C.P. Medical Officer—Diphtheria Immunisation—E. Goodwin Rawlinson, M.D., L.R.C.P., D.P.H. 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—Rose Aldis, C.M.B. Chief Clerk and Committee Clerk—Edwin Kent. Assistant Clerks—Frank Fitch. Arthur Long. Phyllis Bull. Doris Brown (temporary). Dental Clinic—(10, John Street). Dentist—Cecil C Gray, L.D.S. (British Dental Hospital). Anœsthetist—G. C. Nelson Younger, M.R.C.S., L.R.C.P. Nurses—The Metropolitan Nursing Association. 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—Annie Axtell And Panel of Emergency Home Helps. Disinfector—Henry Emms. Assistant Disinfector—James Rowan (To 14th October, 1925). E. E. Denny (From 14th October, 1925). 7 STATISTICAL SUMMARY, 1921-2-3-4-5. 1921 1922 1923 1924 1925 Average Population—estimated to middle of year (as supplied by the Registrar-General) for birth and death rates 43,520 42,850 43,376 43,250 43,315 43,262 Population—Census, 1921 43,192 43,192 43,192 43,192 43,192 43,192 Births 648 664 595 578 527 602 Annual rate of births per 1,000 population 14.8 15.5 13.71 13 36 12.16 13 91 Deaths 556 570 526 529 542 545 Annual rate of deaths per 1,000 population 12.8 13.3 12.1 12 2 12.5 12.58 Zymotic death rate* 0.24 0.44 0.34 0.51 0.30 0 36 Tuberculosis death rate per 100,000 110 119 110 124 124 117 Excess of registered births over deaths 92 94 69 49 — Excess of births 289 Excess of registered deaths over births — — — — 15 over deaths 5 years Infantile mortality per 1,000 births 79 72 79 81 63 75 Area of Borough in acres 405.1 — — — — — Rateable value 1st November £ 1,334,908 £ 1,350,236 £ 1,372,232 £ 1,379,023 £ 1,390,818 £ 1,365,443 Rate of Id. in the £ estimated to yield 5,412 5,383 5,383 5,490 5,516 5,437 *Excluding deaths from Epidemic diarrhœa. Vital Statistics, 1925. 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 18.3 12.2 75 London 18.0 11.7 67 Holborn 12.16 12.5 63 8 NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Population and Houses. 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 1925—43,315. 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 population in the 999 L.C.C. tenements in the Borough was estimated at 3,499. The number of deaths was 25, a death-rate of 7.1 per 1,000, considerably below the average death-rate for the whole of the Borough (12.5). On the other hand the number of deaths of residents of Common Lodging Houses in the Borough, which contain 1,220 beds, was 56, which, calculated on the number of beds, was a rate of 45.9 per 1,000. Registered Births and Birth-Rate. The total number of births registered as occurring in the Borough was 364 (175 males and 189 females). Of these, 351 were legitimate and 13 illegitimate. Corrected Births and Birth-Rate. I received from the Registrar-General information of the births in outlying institutions in London of 151 legitimate infants and 27 illegitimate infants whose mothers were residents of the Borough. Fifteen of the births occurring in the Borough, viz., 12 legitimate births and 3 illegitimate births, were infants of mothers who were non-residents of the Borough. 9 The following table gives the corrected number of births and the corrected birth-rates for the eighteen years 1908-1925:— Year. Total Births. Legitimate Births. Illegitimate Births. No. Rate per 1,000 of Population. No. Rate per 1,000 of population. Proportion per 1,000 total Registered Births No. Rate per 1,000 of population. Proportion per 1,000 total Registered Births. 1908 1,066 20.41 1,020 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 1924 578 13.36 532 12.30 920.4 46 1.06 79.6 1925 527 12.16 490 11.31 929.8 37 0.85 70.2 In London the corrected birth rate in 1925 was 18.0 per 1,000 in comparison with 18.6 for 1924. Mortality. The total number of deaths registered as occurring in the Borough was 725, of which 389 were males and 336 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 3 — 37 — Children's Hospital 3 4 — 290 National Hospital 1 1 — 87 London Homœopathic Hospital 4 10 68 Italian Hospital 2 8 15 Private — — 11 5 Total 13 23 48 465 10 There were 330 deaths of Civil "Residents" in various Workhouses, Infirmaries, Asylums. Hospitals, etc., outside the Borough, 53 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 1925 gives the total deaths for the Borough as 542. Corrected Deaths and Death-Rates, 1925, compared with 1924. Year. Total Deaths at all ages registered in District. Deaths in Public Institutions in District. Deaths of nonresidents of Borough registered in District. Deaths of residents registered beyond the District. Nett Deaths at all ages. Death Rate for Borough. Death Rate. Registration London. 1924 670 488 470 329 529 12.2 12.1 1925 725 533 513 330 542 12.5 11.7 For details of causes of and ages at death, see Table II., page 119. Seasonal Mortality. The mortality in the four quarters of the year is shown below:— Deaths. Death-rate per 1,000. London Rate. First Quarter 172 15.8 14.1 Second ,, 123 11.4 10.1 Third ,, 111 10.3 9.1 Fourth ,, 136 12.6 13.6 542 12.5 11.7 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. 1924 47 71 196 81 69 1925 33 57 135 63 67 11 Death-rate per 1,000 corrected births in 1925 and in ten preceding years during which details respecting births have been supplied. 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 Av'ge, 1915-24 1925 Holborn Borough London 96 97 107 141 96 66 79 72 79 81 91.4 63 112 89 103 107 85 75 80 74 60 69 85.4 67 See also Table, page 97. The figures on which the rates given in the Registrar-General's Quarterly 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 1925. Infantile Death-rate in Holborn per 1,0~0 Births Registrar-General's Quarterly Report Corrected 1st Quarter 178 158 2nd „ 52 37 3rd „ 50 26 4th „ 107 62 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 1925:— Indoor Relief 1,241 persons Outdoor Relief 419 cases Outdoor Medical Relief 309 persons Of the total number of 542 deaths, 366 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. The Council has made arrangements with the contractor for the substitution of motor vehicles in place of horse-drawn waggons for the removal of house and trade refuse. 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, ashbins was ???. 12 The increasing congestion of traffic in the main thoroughfares has rendered difficult the daily removal of refuse from these streets. With a view to completing the collection before the busy hours of the day the Council made arrangements with the contractor in 1924 for the daily collection of house refuse from the main thoroughfares shortly after 8 a.m., instead of shortly before 10 a.m. To enable this to be done an Order was issued requiring occupiers of premises in the thoroughfares concerned to place the refuse on the curb in small properly covered metal receptacles between the hours of 6 and 8 a.m. Six motor lorries, 3 trailers and 2 horse waggons are used in the collection and removal of refuse from the Borough. The quantity of refuse requiring removal shows a marked seasonal variation. The average in the half-year, April to September, is about 332 tons per week in contrast with an average of 462 tons per week in the half-year, October to March. This quantity is equal to a daily average during the months, April to September, of 1.27 ton per thousand of the population, and from October to March, 1.78 ton per thousand of the population. When the refuse is removed from the Borough it is taken first to the contractor's depot where it is "forked" over for the extraction of paper, straw and other combustible matter which is at once destroyed by burning in destructors. In the course of the "forking" parts of the refuse are salvaged, e.g., tin cans and other metal articles, bottles, glass, rags, bones, also bread and other food material for sale to pig breeders. The remaining refuse, including cinders directly from the household refuse, is loaded into barges and conveyed, at present, to dumps on brickfields at Sittingbourne, for use in brick-making. The "forking" at the contractor's yard is carried out immediately on the delivery of the refuse and there is regular daily barging so that undue accumulations of Holborn refuse or nuisances arising therefrom are avoided. Occasional visits are paid to the contractor's depot to supervise the arrangements for dealing with the refuse from the Borough. An opportunity was taken during 1925 to visit the brickfields at Sittingbourne to inspect the arrangements made by the contractor for the disposal of the Holborn house refuse. The refuse is conveyed by barge from the contractor's wharf at Vauxhall to fields outside Sittingbourne belonging to a large firm of brick-makers. The refuse is deposited on to the land for subsequent use in connection with the industry carried on there. The site of the brick-making fields is on the banks of the River Thames, a short distance from Sittingbourne, the nearest residences being about one mile away, at the village of Conyer. The site occupied for the tipping and sorting of the refuse and the brick-making industry extends over about four acres. The refuse as brought from the barge, is stacked into large heaps and remains for about three years before it is used. At the end of the storage period the refuse is sifted through a sieve, 3/8" mesh. This sifting separates the fine ash; the "hard core" is picked out leaving the breeze. The fine ash and breeze are used in connection with the brick-making. A sufficient quantity for the effectual burning of the bricks is mixed with the clay and the remainder is used for fuel either in kilns or clamps. The "hard core" is used entirely for road making or the making up of the land of the brickfields which, owing to its marshy nature, shows frequent subsidence. At the time of inspection refuse was seen newly deposited and at varying periods of storage up to the maximum of three years. A heap deposited three years previously, or thereabout, was in course of sifting and sorting into three types, fine ash, breeze and "hard core." No objectionable smell or other nuisance was observed from either the newly deposited refuse or the storage heaps. 13 In reply to questions, the local manager and the foreman of the brickfields stated that rats were rarely found in the refuse: neither rats nor flies had given rise to nuisance: so far as they were aware no complaint had ever been received of any nuisance arising from the deposit or storage of the refuse or the making of bricks on the fields. In reply to questions relative to the use of earth for covering layers of refuse, the London Manager of the brick-making company intimated that the cost of treating the refuse in this way would prohibit the use by the company of London refuse in the industry. He pointed out that the fields and surrounding lands by reason of their nature would not permit of excavation so that it would be necessary to obtain the earth elsewhere and import it to the tips. This cost, added to that incurred for sifting and sorting refuse, would increase the expense so much that the use of coal for brick-making would become more economical than the use of London refuse. The brick-making works were subsequently inspected. Two methods were in use; first, the kiln method for machine-made bricks, dried by hot air and passed through long tunnel kilns for burning; no nuisance from smell was observed from this work; the Manager intimated that this method had been in operation in the brick industry about 25 years only. In the second, the clamp method, hand-made bricks were dried in the open air and fired in clamps, breeze being used for fuel. It was stated that a fair-sized clamp would take about three months to burn; considerable smell is given off during burning, and it would seem that these fumes might become a source of nuisance if carried out near dwellings. As, however, the nearest houses are, as previously stated, nearly a mile away, there seems no reason to suppose that the burning of the clamps on these fields give rise to nuisance. 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 notice was served in connection with the structure of a manure receptacle for 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 21,645 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 1925. Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Complaints received 24 40 35 ... ... 99 Do. found to be justified 24 39 35 ... ... 98 Inspection of Houses — Dwelling-houses 113 192 69 ... ... 374 Houses let in lodgings 380 332 318 14 ... 1,044 Common lodging-houses ... i ... ... ... 1 Drains tested by smoke 1 2 6 ... ... 9 „ „ ,, water ... ... ... ... ... ... ,, ,, ,, chemicals 1 3 1 ... ... 5 Re underground rooms 2 3 ... ... ... 5 ,, Rent (Restriction) Act ... ... ... ... ... ... ,, New Buildings ... ... ... ... ... ... Housing (1nspection of District) Regulations ... ... 7 ... ... 7 Factories — Bakehouses 20 33 18 ... ... 71 Food preparation (other than above) ... ... 13 ... ... 13 Other 15 49 114 ... ... 178 Inspections carried forward 532 615 546 14 — 1,707 14  Mr. Bennett Mr. Clark Mr. Larard Miss Charles, worth Miss Shinnie Total Brought forward 532 615 546 14 — 1,707 workshops and workplaces — Food premises: Dairies and Milkshops 32 73 36 ... ... 141 Ice Cream, Manufacture 16 21 207 ... ... 244 Do. Storage or Sale 12 4 4 ... ... 20 Slaughter-houses ... 2 ... ... ... 2 Hotels and Restaurants 73 137 209 ... ... 419 Butchers 352 59 306 ... ... 717 Bakehouses 7 22 6 ... ... 35 Fried Fish shops 202 18 22 ... ... 242 Market Streets 330 73 378 ... ... 781 Other food shops 167 35 81 ... ... 283 Other workshops 73 147 158 5 ... 383 Other workplaces 161 73 69 ... ... 303 Outworkers' Registers 20 38 62 ... ... 120 Stable and Stable yards 48 103 ... ... ... 151 Rag and Bone shops 128 12 ... ... ... 140 Outworkers' rooms ... ... ... 1 ... †1 Miscellaneous— Black smoke 201 89 314 ... ... 604 Dust, Special Inspections 56 75 35 ... ... 166 Rats and Mice (Destruction) Act 122 77 69 ... ... 268 Public Urinals and Lavatories ... 8 ... ... ... 8 Sale of Food and Drugs Act, sampling 222 200 179 ... ... 601 Other Inspections 36 7 28 11 ... 82 Periodical Inspections: Includes W.C. and yards, dustbins. especially houses let in lodgings, and other suitable buildings 1,803 2,281 2,902 ... ... 6,986 Re-Inspections— Houses 695 1,176 638 3 ... 2,512 Factories 1 ... 2 ... ... 3 Workshops and Workplaces 43 96 89 ... ... 228 Miscellaneous ... ... 3 111 43 157 Visits re Infectious Diseases 59 128 82 146 127 542 Do. on School Reports ... ... ... ... ... ... Tuberculosis—First visits 6 ... 2 ... ... 8 Do. Re-visits 46 46 31 ... ... 123 Scabies ... • •• 2 3 1 6 Vermin ... ... ... 2 18 20 9 Other Visits— Police Courts 3 4 3 ... ... 10 Various 145 357 185 4 ... 691 Maternity— Visits: ††Children under 1 year ... ... ... 279 187 466 Do. 1 to 5 years ... ... ... 3 4 7 Expectant Mothers ... ... ... 48 26 74 Re-visits ... ... ... 713 990 1,703 Do. Expectant Mothers ... ... ... 25 26 51 Other Maternity Visits ... ... ... 113 147 260 Attendances at Maternity Centres ... ... ... 184 196 380 Total 5,591 5,976 6,648 1,665 1,765 21,645 †All outworkers' rooms in houses let in lodgings (these comprise the larger majority), have been inspected but the visits have been counted under inspections of houses let in lodgings. ††see page 83. 15 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 1,481, viz.:— Public Health (London) Act, 1891— Intimation Notices 527 Statutory Notices 94 By-laws— Houses let in Lodgings 807 London County Council (General Powers) Acts— Verminous rooms 49 Food premises 1 Rats and Mice (Destruction) Act, 1908 3 1,481 The following table shows the work done to abate nuisances for which intimation notices wore served:— Water Supply— Houses. Factories, Workshops and Workplaces Provided 3 2 Cisterns cleansed, repaired, etc. 31 6 Waterclosets— Cleansed 23 4 Water supplied, flushing cistern repaired, etc. 19 4 Repaired, new pans, etc. 105 5 Ventilation improved 2 4 Separate accommodation for sexes provided — 7 Position or construction improved — 3 Direct communication with workrooms remedied — 5 Accommodation provided 1 3 Soil Pipes— Repaired, renewed and ventilated 1 3 Rainwater Pipes— Repaired or renewed 17 4 Drains— Repaired 14 1 Unstopped, cleansed, etc. 27 2 Sinks, etc. Waste pipes repaired, renewed, etc. 26 5 Yards, Areas and Washhouses— Cleansed 34 7 Paved and paving repaired 25 — Houses and Workshops, etc.— Cleansed 81 53 Dilapidations repaired and made good 89 4 Ventilation improved 3 2 Dampness— Roofs repaired 62 2 Gutters repaired 5 3 16  Houses. Factories, Workshops and Workplaces. Floor cavities ventilated — — Other works to prevent dampness 27 2 Ashbins— Provided, repaired, etc. 44 16 Urinals— Repaired, cleansed, etc. — 1 Various— Underground Rooms vacated 3 — Smoke—Emission of black smoke abated — 7 Accumulations of Refuse—Removed 25 10 Overcrowding abated 4 2 Manure receptacles repaired or provided — 1 Other nuisances abated 11 5 The following table shows the nuisances for which the 94 Statutory Notices were issued under the Public Health (London) Act, 1891. Houses. Factories, Workshops and Workplaces. Section 2 (a) Dirty and dilapidated premises, etc. 41 5 ,, (b) and Section 37, Ashbins 7 l ,, (b) Drains and W.C.'s 29 2 ,, (d) Accumulation of rubbish 5 — ,, (e) (g) (i.) Overcrowding 2 l ,, (f) and Section 48. Water supply 2 — ,, (g) (ii.) Ventilation of Workshop — 2 ,, 24 Black Smoke — 4 ,, 38 W.C.'s communicating with workrooms — 3 ,, ,, W.C. Absence of separate accommodation for sexes — 4 ,, 96 Underground rooms 3 — By-laws as to Houses let in Lodgings. At the end of the year 577 houses were registered under these By-laws. Of these, 286 are in St. Giles and Bloomsbury and 291 in the Holborn District. There were 1,051 inspections of these premises, excluding a very large number of periodical inspections and re-inspections. 218 notices were served for breaches of the By-laws, exclusive of 589 notices that were served for annual cleansing as required by the By-laws. Rats and Mice Destruction Act, 1919. During the year 220 premises were inspected under the above Act, the total inspections being 268. Three notices for breaches of the Act were served. As a result, in one case the drains were reconstructed and in the others accumulations of refuse in vaults under the pavement were cleared out and rat runs sealed up. The following summary shows the condition found on inspection, the action taken and the results obtained . 17 Rats and Mice (Destruction) Act, 1919. WARD. Number of premises inspected. Number rat infested. Action for Rat Repression. RESULT. Traps. Poisons. Rat catchers. Dogs. Cats. Proofing; Council. Other. A. 17 2 2 — 1 — — 1 2 Numbers reduced 2 B. 26 1 1 — — — — 1 1 Numbers reduced 1 C. 21 4 3 3 1 — — — 3 Free 2 Numbers reduced 1 Rats occasionally seen I D. 28 6 — — — — — — 6 F ree 6 E. 18 9 1 2 — — 1 ' — 7 Free 8 Numbers reduced 1 F. 31 6 1 3 — — 1 — 5 Free 4 Numbers reduced 2 G. 14 4 — 3 — — — — 3 Free 2 Numbers reduced 2 H. 43 20 16 15 3 — 1 3 5 Free 10 Numbers reduced 6 Rats occasionally seen 4 I. 22 10 6 6 4 — — — 1 Free 3 Numbers reduced 3 Rats occasionally seen 4 220 62 30 32 9 — 3 5 33 Free 35 Numbers reduced 18 Rats only occasionally seen 9 18 In, accordance with the suggestion of the Ministry of Agriculture and Fisheries, Eat Week was observed in the Borough during the first week in November. Endeavours were made to secure concerted efforts during the Week and attention was drawn to the importance of rat repression. The following action was taken in connection therewith:— The distribution was continued of a special leaflet issued in 1924 on "Some Simple Suggestions for Eat Proofing and Destruction." Suitable poisons were sold from the Public Health Department in the Town Hall. An anti-rat film was exhibited at a local cinema and still slides were shown at a local music hall. The number of baits laid weekly (1,000) in the Council's sewers were quadrupled during Eat Week. The general arrangements made by the Council for rat repression were continued during the year and included:— (1) Systematic baiting in the Council's sewers, the bait used being small cubes of bread soaked in liquid extract of red squill (found more effective than barium carbonate). (2) The services of the Council's workmen were available for rat proofing, subject to the cost of such services and the material used being defrayed by the owners or occupiers of the premises where the work was carried out. (3) Arrangements were continued with a firm of rat catchers for dealing with rat infested premises at the cost of the occupiers. This arrangement has proved useful and reports are from time to time received from the rat catchers employed respecting their inspections of the premises and the work ultimately carried out. Typical reports from these rat catchers are the following:— (i.) "Acting on instructions received from Dr. C. W. Hutt, Medical Officer of Health of Holborn, I called at your premises to-day and surveyed the same. The premises seem to be in a, fairly bad state of rat infestation by ship rats. I found evidence of rats outside on the roof beside the whole of the inside of the building. I consider that the best method to adopt will be as follows:— To work the premises everywhere possible to do so with dogs and ferrets. To search the premises for means of ingress. To treat the premises with raticides twice per week for a period of three weeks. To rat proof on our advice. We are prepared to undertake to work dogs and ferrets everywhere possible to do so in the building. To search for means of ingress and to advise you as to what we consider the best method of rat proofing. 19 To treat the premises with raticides twice per week for a period of three weeks." (ii.) "As per arrangements, we called at the above and worked all night, 25 rats all told were killed on the surface and several more killed by ferrets. We searched the premises as per contract for the means of ingress, and are of the opinion that the chief source is in the badly fitting windows to male W.Cs. There is also a weakness to the walls where the iron girders are cut into the same, also the old fire flues that run up through the building. We advise that the window frames be made to fit and the windows be proofed with wire mesh, fitted close up to the brickwork all round. Twin girders to be properly sealed with cement all round, and in the space in the centre where girders enter the walls. Old fire flues to be bricked up. May we suggest that one or two metal refuse bins with lids be used for the workpeople to put uneaten food and greasy paper in? This will prove a great help to you, and will not only stop encouragement to rats, but also to mice." The poisons mainly used by occupiers of rat infested premises were barium carbonate and liquid extract of red squill and in a few premises (although we advise against it) Liverpool virus was employed. Wo know of at least one large firm with a number of premises in the Borough which continues to keep a weekly record of action taken in connection with rat repression and pays a small gratuity for every rat caught. The Eats and Mice (Destruction) Act, 1919, places the obligation to carry out work for rat repression on the "occupier" of infested premises. This sometimes leads to difficulty in cases where structural work is required and the "occupier" has only a short holding. It is desirable that in any amendment of the Act the liability should be extended to the owner also. 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. B 2 20 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 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 Council County accordingly. A suitable clause was subsequently generally agreed and included in the London County Council (General Powers) Bill, 1926, as Part IV. of the Bill (Disused Drains). At the date of the preparation of this report information has been received that the Metropolitan Boroughs Standing Joint Committee on the 1st March. 1926, agreed to this part of the Bill being withdrawn, with a view to further evidence being obtained of the need for the provision and to new clauses being drawn for insertion in a later Bill. Evidence of the character required has been duly furnished. Inspection of Workshops, etc. The routine inspection of factories, workshops and workplaces has been carried out during the year. 262 factories were inspected, 418 workshops and 3,444 workplaces. It is found that changes frequently occur in the occupation of workshops. To obtain information of such changes and further details of industrial conditions in the Borough a large number of visits and inspections were made in addition to the routine inspections mentioned above. As the result of these visits 258 premises no longer used for the purpose for which they had been registered were removed from the register of workshops. In some cases, owing to the introduction of machinery, former "workshops" had become "factories' and the necessary transfer to the factoryregister was effected. Variations in the staff employed were also frequently reported. During the year 158 workshops were added to the register. It was necessary to serve the following notices for the abatement of sanitary nuisances in factories, workshops and workplaces. Intimation Notices. Statutory Notices. Factories 16 5 Workshops 58 13 Workplaces 64 5 138 23 Of the 644 workshops on the register at the end of the year 364 employed men only, 71 employed women only, and 209 employed both men and women. The number of employees is often very small and many of the workshops are in tenement houses (houses let in lodgings). 21 No less than 175 different industries are carried on in these workshops, among the principal being the following:— No. of Workshops Employing Men only. Women only. Both Sexes. Total. Barometer and thermometer makers 6 1 — 7 Boot makers and repairers 21 — 2 23 Cabinetmakers 8 — — 8 Clock and watch makers 14 — — 14 Dressmakers and ladies' tailors — 29 2 31 Diamond mounters 4 — 3 7 Engravers 19 — — 19 Jewellers 46 4 15 65 Jewel case makers 5 — — 5 Leather goods makers 7 — 5 12 Metal workers 8 — 1 9 Picture framers 11 — 2 13 Sign writers 5 1 — 6 Tailors 39 6 98 143 Tyre makers and repairers 4 1 1 6 Factories. These visits also afforded an opportunity for extending and revising information relating to "factories" in the Borough. Steps are being taken for the gradual compilation of a register of such places, and at the end of the year 301 factories had been entered on the register. Workshops are automatically converted, at a very small cost, into factories by the installation of a small electric motor; the health conditions then may no longer be inspected by the Borough Council's staff except as regards sanitary accommodation. The 301 factories include 79 different industries. In 163 cases men only were employed, in 5 women only, and in 131 both sexes. The more important industries carried on in these factories are:— Bookbinding 12 Engineering 36 Jewellers' work 12 Metal work 15 Printing 53 Factories Bill. A Bill has been introduced and will probably shortly be reintroduced into Parliament to consolidate, and amend, the law relating to factories and workshops. In connection therewith I submitted the following report to the Public Health Committee:— Distinction between "Factory" and "Workshop" to be abolished. This Bill abolished the distinction which exists under the present law between factories and workshops, and employed only one term "Factory," and the provisions of the Bill applied to factories included under the new and old definitions. 22 Sanitary control—as now administered. Under existing Acts the provisions relating to the sanitary conditions of workshops, cleanliness, overcrowding, ventilation, and the drainage of floors, are enforced in the first instance by the Local Sanitary Authority, and not by the Factory Inspectors. In the case of factories, the Factory Inspectors are responsible. The provisions as to sanitary conveniences in factories and workshops axe also enforced by the sanitary authorities. Sanitary Authority's control to be transferred to Factory Inspector. Under the Bill of 1924 all these provisions were to be made enforceable by the Factory Inspectors, except in any factory in which mechanical power was not used and which formed part of a dwelling or shop, or which was adjacent to a dwelling house or shop, in the same occupation. In these instances, which are few in number and of comparatively slight importance, the local sanitary authority would still have been the responsible administrative body. In other instances, it was proposed that the Secretary of State might arrange for the enforcement of the provisions of the Act in any factory in which mechanical power was not used, by the sanitary authority instead of by the Factory Inspector. Workshops (factories) in dwelling houses. Dual inspection. Many workshops, which would be factories under the definition of the 1924 Bill are situate in or adjacent to tenement houses, although these workshops are not "in the same occupation" as the part of the house used for dwelling purposes. The enactment of a measure on the lines of the 1924 Bill would result in inspection and supervision of part of such houses by the Factory Inspectors, and part by the Local Sanitary Authority. Supervision of Drainage work—apart from Factory Law. Under the existing law all drainage work and the construction or reconstruction of all sanitary conveniences have to be carried out under the supervision and to the satisfaction of the local authority. The suggested transfer to the Factory Inspector of control respecting the sanitary condition of factories would not remove this responsibility but might complicate this important branch of the work of local authorities by unnecessary overlapping. Food Factories. It may also be mentioned that the work carried on in a large number of factories and workshops is connected with the preparation, manufacture, or packing of various foods. The supervision of such places so far as the food is concerned is a responsible duty of the loca authority; it would seem desirable that the sanitary conditions under which the work is done should remain under the control of the authority responsible for securing the purity of the food. Bill creates startling precedents. It appears to be a matter of very considerable importance that the Sanitary Authority should be responsible for the sanitation of all places within its jurisdiction. This is the first piece of legislation which has removed any premises from the sanitary control of a local authority. With the exception of buildings occupied by H.M. Government in all branches, the hygienic arrangements of every building in an area come??? under the Local Council. When the Act establishing the Ministry of Health was passed it was contemplated that all future steps would be in the direction of unifying and concentrating the duties and powers concerning Public Health under the Public Health Authority. In 1921 certain duties relating to health enacted under the Factory and Workshops Act, 1901, were transferred from the Home Office to the Ministry of Health; at this time an official circular stated that "it seems to the Minister that the enforcement of the provisions relating to bakehouses can better be undertaken locally than centrally, especially as the work is of the same character as that at present performed by the sanitary staff of local authorities in relation to retail bakehouses under Section 102 of the Act of 1901." The proposals in the Factory Bill of 1924 go directly against this movement. 23 No saving effected by new proposals. It has been stated that the handing over of the duties hitherto carried out by Sanitary Inspectors to Factory Inspectors is designed to prevent duplication of inspection work which is stated to cause needless expense and trouble. It is difficult to conceive that such statements can be justified; the work is carried out by an existing sanitary staff; no new duties are imposed by the Factory Bill on the existing staff as far as is known; no new sanitary staff is wanted. We have worked out that only 13 per cent. of the inspections made by the Sanitary Inspectors in this Borough would be affected; there is no question of lessening the cost of sanitary inspections in this Borough. At present the only expense involved is the cost of very infrequent letters from the Factory Inspector stating that they have found an infringement of a sanitary regulation and calling the attention of the Public Health Department to the matter. Efficiency of service by Sanitary Inspectors. No complaints generally have been raised as to the visits of Sanitary Inspectors, who from their long experience of the work have been able to form practical judgments of the variouB requirements under the Acts so that the work can be carried on in the spirit rather than in the letter of the law. On the contrary there is reason to believe that employers in the district as regards such matters as sanitation would prefer that the Local Authority supervised them rather than a Central Body. Smoke Abatement. The smoke shafts in the Borough were frequently kept under observation and in 604 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. Seven complaints were also received. As the result of the inspections four intimation notices were served followed by statutory notices in three 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. We have had numerous enquiries from all over the United Kingdom in reference to these cards. In a central London area atmospheric pollution is a matter of importance and it is of interest to observe in a Beport to the Air Ministry (from stations in the British Isles at which deposit from the atmosphere is measured) that the year 1924-25 shows a slight improvement on the previous five years. The annual solids falling on a London area is given as equal to 461 tons per square mile Experiments have shown that the development of London fogs is due to the replacement of water particles by smoke rather than the dirtying of the particles themselves. In the suburbs a dense fog contains much water and little smoke but in Central London the number of water droplets is reduced and replaced by soot. The air over the City is warmer than elsewhere and the fog-causing water particles tend to evaporate so that if there were no soot to take the place of the water there should be even less natural fog in London than in the surrounding country. 24 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 45.9 per 1,000 in 1925. FOOD. Dairies, Cowsheds and Milkshops. The number of registered dairies and milkshops in the Borough at the end of the year was 129. Ten retail dairies and milkshops were newly registered, and eight removed from the register. One wholesale dairy company was also registered. In addition to my inspections the Sanitary Inspectors made 141 inspections of these premises. It was not necessary for any notice to be served for sanitary defects or breaches of regulations. Sale of Groceries in Dairies. There is a growing tendency among dairymen to stock goods ordinarily sold by grocers. Practically all dairies (as distinct from general shops) sell bread, tea, flour and mineral waters, but an increasing number of them now sell such things as jam, tinned fruit and fish, potted meat, cheese, salt, suet, puff pastry, coffee extract, etc. These goods, except the cheese, are kept in packets. Some dairies also sell cooked meats in small quantities and meat sandwiches. The importance of this matter is that this tendency reacts on the general shops, which, as a rule are not eminently suitable for the sale of milk. A number of these general shop keepers say they would prefer not to sell milk, but do so in order to attract customers who also purchase goods such as those mentioned above. 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 at the various establishments in the Borough where milk is cleansed by clarifiers 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 washed down the drains. Bacteriological Examination of Milk. Twenty-four 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. 25 Examinations for tubercle bacilli were carried out by animal inoculation ; none of the samples examined was found to contain tubercle bacilli. The following table refers to the six samples examined as mentioned above:— Date sample taken. Nature of Shop where purchased. No. of Organisms per cc. grown at 37° C for 24 hours. Minimal volume containing Bacillus Coli. 1925 Not. 10 Small milk shop 21,700 0.01 cc. Nov. 5 Large milk depot 44,000 0.0001 cc. Nov. 5 Large milkshop 51,000 0.001 cc. Nov. 10 Large milkshop 52,400 1 cc. Nov. 20 Large milkshop 96,000 0 0001 cc Nov. 14 Large milkshop 11,250,000 1 cc. Dirt in Milk. During the year 100 samples were examined in the Health Office for dirt; in one only a trace of dirt was found. This examination has the advantage of being easily carried out, but cannot be compared for efficiency with bacteriological examination. It cannot be emphasised too much 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. A bacteriological standard of purity of milk will doubtless eventually be demanded by the public. It is generally recognised that the number of bacteria in milk is the only safe indication of its cleanliness and keeping qualities. The introduction of skilled milkers and the proper cleansing of cows before milking and of utensils are essential for securing a high standard of cleanliness. Information was furnished to one of the Council's Inspectors attending a course of lectures on clean milk production that the adoption of these methods, without altering the structure of buildings, has been shown in a number of instances to reduce the bacteriological count from an uncountable number to well below 1,000 per cubic centimetre. More depends on the intelligence and training of the personnel than on the structure of the buildings. The success resulting from strict observation of the precautions necessary is shown by the fact that it is not uncommon to get a bacterial count of about 100 per c.c. in Grade A milk while the bacteria in ordinary milk, a few hours old, may as shown in the table above run into millions. 26 The Milk (Special Designations) Order, 1923. Under the provisions of the Milk and Dairies Act, 1922, the principle of grading milk is established as a recognised part of the system of milk control. In accordance with this Act and the Order made under it a person who wishes to sell milk under a prescribed designation has first to obtain a licence issued by the Ministry of Health or a local authority. Provision is made for five grades of milk described as "Certified," "Grade A (Tuberculin Tested)," "Grade A," "Grade A (Pasteurised)," and "Pasteurised." The conditions which have to be satisfied by milk sold under these designations are laid down at length in the Milk (Special Designations) Order, 1923. Dr. A. W. J. MacFadden, C.B., Senior Medical Officer, Ministry of Health, summarises the general effect of these conditions as follows:— (1) Certified Milk must be produced from cows which have passed a prescribed tuberculin test and veterinary examination. The whole herd must be submitted to the test and examination at intervals of six months and every animal added to the herd must be tested immediately before admission. The milk must be bottled on the farm and must not at any time contain more than 30,000 bacteria per c.c., or any coliform bacillus in 0.1 c.c. (2) Grade A (Tuberculin Tested) Milk is subject to the same conditions as certified milk as regards the testing and examination of cattle. The milk must be bottled before distribution and must not at any time contain more than 200,000 bacteria per c.c., or any coliform bacillus in 0.01 c.c. (3) Grade A Milk must satisfy the same conditions as Grade A (Tuberculin Tested) milk, with the exception that the tuberculin test is not required and that veterinary examinations of the cows in the herd are made at intervals of three months instead of six. (4) Grade A Milk (Pasteurised) is Grade A Milk which has been pasteurised by the holder process as defined in the Order—that is to say, it must be held at a temperature of 145° to 150° Fahrenheit (63°—66° C.) for at least half an hour and then cooled to 55° Fahrenheit (13° C.); and it must not be heated more than once. It must not at any time contain more than 30,000 bacteria per c.c., or any coliform bacillus in O.l c.c. (5) Pasteurised Milk is any milk which has been pasteurised by the same process as is required for Grade A (Pasteurised). The bacteriological condition for this grade of milk is that it must not contain more than 100,000 bacteria per c.c. There is no test for coliform bacillus and the milk need not be sold in bottles. During the year 1925 licences available up to the 31st December, 1925, for the sale of designated milk in the Borough were issued as follows:— Certified Milk 4 Grade A (Tuberculin Tested) 3 Grade A 1 Pasteurised 2 27 Up to the date of preparation of this report licences for the year 1926 have been issued as follows:— Certified Milk 5 Grade A (Tuberculin Tested) 6 Grade A 2 Pasteurised 3 Since the Order came into operation in 1923 licences for the sale of designated milk have been issued in the Borough as shown in the following table:— Designation. Number of licences issued. 1923 1924 1925 Certified 3 4 4 Grade A (Tuberculin Tested) — 1 3 Grade A 2 — 1 Pasteurised — — 3 Supplemental (Primary licence in another Borough), Certified 1 — — Grade A (Tuberculin Tested) 1 — — It will be seen that the number of milk dealers selling designated milk, although still very small, shows a tendency to increase, but 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. The extra cost of producing Grade A Tuberculin Tested milk is creditably stated to be 2.86d. per gallon. The extra price obtained by the farmer is only 3d. a gallon. Thus for all his trouble the farmer only receives 0.14d. per gallon Small though this profit be, once farmers are licensed for the production of designated milk they do not revert to the old methods of production. The expense is chiefly involved in the collection of a herd of suitable cattle. Owing to the elimination of tuberculosis and the supervision by veterinary surgeons (a requirement for the granting of a licence for the production of designated milk) the general health of the cows is improved with the result that the quantity of milk is maintained at a high level and there are very few, if any, "wasters" and no loss when the milch cows are sold for meat. The consumer 28 obtains milk from healthy cows which is free from tubercle bacilli, contains a minimum of other bacteria, is clean and will keep fresh for a reasonable period. an advantage of considerable importance to the town dweller who cannot get milk fresh from the cow. 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. One hundred and ninety-three samples of milk were examined; none was found to contain preservative; 21 samples of cream were examined, 3 of which were found to contain preservative, viz., boric acid to the extent of 0.23, 0.24 and 0.34 per cent. by weight respectively. Communications were in each case sent to the vendor; the explanations submitted were considered to be satisfactory, and no further action was taken. Thirty-one 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. During the year 1925 ten samples of condensed milk, viz., four full cream, and six skimmed sweetened, were examined by the Borough Analyst under the Regulations. All the ten samples complied with the requirements of the Regulations as to labelling. All the samples were examined for standard of composition and all were found to be above the standard required. The following table gives particulars of the milk fat and milk solids found in the ten samples:— Milk fat per cent. Milk solids (including fat) per cent. Examined for standard of composition— Full cream unsweetened 9.0 40.2 Full cream sweetened 11.00 31.7 ,, ,, 10.40 32.8 ,, ,, 9.00 32.8 Skimmed ,, 1.2 30.18 ,, ,, 0.9 33.49 ,, ,, 0.8 29.0 ,, ,, 0.8 33.6 ,, ,, 0.6 35.49 ,, ,, 0.4 31.4 29 Public Health (Dried Milk) Regulations, 1923. These Regulations came into operation on the 1st day of May, 1924, and are generally similar to the Regulations with regard to condensed milk. Very few brands of dried milk are sold in the Borough. Three samples, covering those generally used, were obtained during the year, and found to comply with the Regulations. Margarine. The registration of wholesale margarine dealers is required by Section 9 of the Margarine Act, 1887, as extended by Section 7 of the Sale of Food and Drugs Act, 1899. Under this Section every wholesale dealer in margarine is required to keep a register showing the quantity and destination of each consignment and the register is open to inspection by any officer of the Board of Agriculture. The Local Authority has no power to refuse registration or to set up any standard of requirements before effecting such registration. There are five registered dealers in the Borough. Bakehouses. At the end of the year 1925 there were 29 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. During the year, in addition to my inspections, there were 106 inspections of bakehouse". In view of the hypothesis that "bakers itch," affections of the skin due to the handling of dough, is due to insanitary conditions in bakehouses, specially detailed inspections were made of Holborn bakehouses paying particular attention to ventilation and arrangements for washing the hands and arms. Evidence or history of skin disease was found at only one bakehouse, where two cases had occurred within the previous few weeks, one being a bread baker and the other a cake maker; both cases had been notified to the Certifying Factory Surgeon for the district and both men had been examined by him. At this particular bakehouse the washing arrangements were entirely satisfactory. Adequate sanitary accommodation was found at all the bakehouses; satisfactory ventilation and facilities for washing were also found in all cases. A tabulated and detailed statement of the conditions at each bakehouse was sent to the local Factory Inspector for transmittal to the Home Office. 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 by the London County Council. Two hundred and forty-two 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. 30 Fish Shops and Stalls. Exclusive of fried fish shops, stewed eel shops and fish stalls, there are only five fishmongers' shops in the Borough; at each of these both fresh and dried fish is sold. When detailed inspection of these shops was made during the past year it was found in four cases that fish was exposed for sale on stallboards beyond the front line of the shop, but in all such cases the fish was protected by shop sun blinds and side screens. Flies were reported to be present in fair numbers in two out of the five shops, but in no case was there any evidence of contamination of the fish by flies, dust, soot, etc. In addition to the above shops there were during last year eight stalls in the Borough for the regular sale of fish. Three of these are in the Central Markets and are almost of the nature of shops. At seven of the stalls both fresh and dried fish was sold and at one fresh fish only. Fish on four stalls was protected by tarpaulins or canvas covers or screens over the top and at the sides and back of the stalls, but in four stalls no protection was provided. Flies were not found to be present in any considerable numbers at either of the eight stalls and in no case was there any evidence of contamination of the fish by flies, dust or soot when the stalls were inspected in July, 1925. In three stalls in the Central Markets water supply is laid on to the slabs on which the fish is exposed for sale. Market Streets. There were 781 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 daily and on Saturday evenings and Sunday mornings. The daily inspection of these market streets helps to secure the maintenance by the regular stallholders of good sound food only, and, in addition, has the effect of keeping away from these markets casual and unsatisfactory hawkers, who generally avoid markets subject to regular and strict supervision. Ice Cream. During the year there were 81 premises in the Borough where ice cream was manufactured, and in addition to my inspections 264 inspections of these premises wore made, and one notice was served. Ice cream is manufactured in the Italian colony as follows:— Premises on which 10 gallons made daily 3 ,, ,, 8,, ,, ,, 4 ,, ,, 6,, ,, ,, 4 ,, ,, 4,, ,, ,, 10 ,, ,, 2,, ,, ,, 12 31 In addition ice cream was also manufactured on the following premises:— Mr. Bennett's District. Mr. Clark's District. Mr. Larard's District. Restaurants 11 2 1 Confectioners 6 10 9 Other 3 5 3 The Public Health (Meat) Regulations, 1924. These Regulations, which came into operation on the 1st April, 1925, were issued in consequence of the wishes of a large part of the public; the handling of meat in wholesale markets, the conditions of its transport, the absence of protection in shops and on stalls from dust and flies had been the subject of widespread comment for a considerable time before the issue of the Regulations. There is no doubt that the requirement of extreme cleanliness in connection with food generally is very wise. Obviously it is difficult to persuade cooks, domestic servants and wives of the labouring class to carry out the extreme degree of cleanliness required in the home if they are able to point out that before the food reaches them it has already undergone contamination. Yet to increasing cleanliness as regards food in the home must we ascribe the striking decrease in typhoid fever and infantile diarrhœa. The Holborn Council have always supported any measures tending towards increased cleanliness in connection with food. Recently their support was given to the protection of bread from contamination, an article of food which should be protected, but is not so dangerous when contaminated as meat, the surface of which provides abundant food for the nutrition of germs and consequently favours their multiplication. It has been urged that no harm results from the contamination of meat because it is always washed and then cooked before consumption. But it is rash to state that meat is always washed before cooking. Even if it were, the washing is not of the order of washing the hands and obviously could not be depended upon for a moment to remove bacterial contamination. The protection often considered to be afforded by cooking is being proved by research to be fallacious. Recent research on food poisoning has shown that some of the toxins or poisons produced by the germs are not destroyed even when the germs are killed; in fact their power of doing harm is actually increased by heating to high temperature. The present form of a large number of butchers' shops is one which is far from suitable for the hygienic sale of meat. One of the difficulties in connection with the Regulations is the matter of glass shop fronts. Obviously the installation of glazed sashed windows will tend to prevent contamination of the meat by dust or flies and their use is to be advised coincident with suitable arrangements for ventilation. Difficulty in persuading butchers to instal them will be met when the butcher's business is not sufficiently prosperous, also when the term of the lease is too short to compensate for the outlay. 32 Another difficulty is the display of meat on benches outside the shop and the hanging of carcases on the outside of the shop adjoining the door. No matter the direction of the wind the effect of the presence of buildings on both sides of a street is to cause the wind to blow in one direction either up or down the street along the line of frontage; any meat in front of the shop which is inadequately protected from the wind must necessarily receive a deposit of dust. The actual inspection of meat which has been so exposed invariably shows the presence of dust. If carcases hang too low they are liable to be contaminated by animals. Although during rush hours the sale of meat from the pavement is a convenience to butchers it is at the sacrifice of hygiene. If all butchers selling from shops were required to discontinue the practice of exposing meat in front of their shops it is difficult to see that any hardship would be caused. It is noteworthy that during the hot weather, in the best shops, very little meat is displayed; it is in the cold storage plant. No one contends that the sale of meat is thereby prejudiced. Any attempt to convert the benches into an imitation stall is not in accordance with hygienic ideals. The existence of stalls in market streets in the form allowed by the Regulations is only countenanced because it is thought that their existence enables meat to be sold at a competitive price and so tends to bring down the prices generally at which meat is sold to the public. If canvas is to be used for the sides and top of stalls in market streets obviously when it is not in use it should be stored in a cleanly fashion. It is very desirable that close attention should be paid to the use of water carts in such streets before street scavenging so as to lessen the dust raised. The following summary shows the number of butchers' shops and meat stalls in the Borough, and the number of other shops where meat is sold:— Butchers' shops 27 Butchers' stalls 3 Provision dealers 25 Provision dealers' stalls 3 Offal shops 3 Cooked meats 10 Wholesale (bacon; sausage) 3 74 Copies of the Regulations were sent to all the butchers in the Borough and the necessary inspections made to ascertain to what extent, if any, the Regulations were not being complied with. It was found to be the practice in some shops (seven) to expose meat for sale, outside the shop, on stallboards projecting beyond the building line. Communications were addressed to the proprietors of such shops suggesting that in order to guard against the contamination of the meat by mud, filth, etc., the exposure of the meat beyond the building line of the shop should be discontinued. In two cases this suggestion was at once adopted. In the other cases the practice is continued, some protection is afforded by side and top screens and in a few of them gauze coverings are also used. 33 In a circular letter dealing with the Regulations the Ministry of Health referred to some practices which do not lend themselves to control by regulation and in regard to which improvement can only be effected by force of public opinion and the refusal of the public to buy their meat where such conditions obtain. An instance of this is the common practice of touching the meat before buying it. To deal with this the co-operation of the meat trade in the Borough was invited and suggestions were made to vendors that notices should be exhibited in their shops urging customers not to handle meat before purchase. The butchers readily responded to this suggestion and in 22 shops the notices are exhibited; in other cases the butcher states that handling by customers is discontinued; in some very few, if any, "pieces" are sold. In most of the shops forks are provided to enable "pieces" to be moved or turned over by customers without direct handling. In two shops where customers do not handle meat before buying it the notices are not required and in one case the proprietor has now promised to exhibit the notice and provide forks. Proposed Regulations for the Sale of Fish. During the year letters were received from the Town Clerk of Bermondsey and the Honorary Clerk of the Metropolitan Boroughs Standing Joint Committee respecting proposed Regulations for controlling the sale of fish and other articles of food on the lines of the Public Health (Meat) Regulations, 1924. Except that no complaints have been made as regards uncleanliness during transport of fish the need of protection of fish is very much the same as in the case of meat. While making inspections of butchers' shops in connection with the new Meat Regulations a certain amount of dissatisfaction was expressed by butchers on the fact that they among food purveyors were singled out for restrictive legislation. It must be admitted in many fish shops a high standard of care is mantained; the fish are displayed on impervious slabs and frequently cleansed by a current of water directed by a hose; on the other hand in some fish shops this high standard is not maintained. The latest Circular on the Meat Regulations states that the same general standard of freedom from contamination should be aimed at both for shops and stalls selling meat; it is an obvious corollary that shops and stalls selling fish should be treated in the same manner. At the same time as a matter of actual practice it would be an advantage to obtain experience in the working of the Public Health (Meat) Regulations before urging the issue of Regulations to govern other articles of food; the Holborn Public Health Committee were of this opinion and, therefore, took no action in the matter. 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 C 34 and other fish shops, premises where ice cream is made, and other places where food is prepared for sale, excluding bakehouses which are reported on above. The number of such places on the register at the end of the year was as follows:— Hotels, Restaurants and Eating Houses 224 Slaughter-houses 1 Tripe, offal and other meat shops 33 Fried Fish shops 11 Fish shops 14 Ice Cream (Manufacture) 81 Poulterers 3 During the year 2,884 inspections of food premises and market streets went made and 31 notices served for sanitary defects found. Washing up Arrangements. The Hygiene of Restaurants, Eating Houses and Public Houses. In the Annual Report for 1923 especial attention was called to the need for efficient washing up arrangements in connection with the large number of places in the Borough where meals were consumed by the public. An interesting comment on the importance of this subject is a report by a wellknown American bacteriologist who confirms, what we have known for a long time, that table utensils which have been used by tuberculous people do carry bacilli, and that the remains of food found on their unwashed spoons and forks give tuberculosis to about 10 per cent. of the guinea pigs into which they are injected. But it must be noted that these results were obtained before any washing has taken place. After carefully cleansing the crockery and plate in a mechanical apparatus in which they are stirred about in boiling water and then dried with hot air, no animal used for experimentation has ever contracted tuberculosis. In many restaurants fortunately hot soda water is most frequently used for the crockery, as it is the easiest way of cleaning greasy plates. It happens to be, at the same time, an excellent way of disinfecting. The problem is more complicated, however, for glasses, as hot water cracks common glasses; it is to be hoped that in the conflict between respect for hygienic measures and the fear of breakage, the public health will receive due consideration. Cleanliness and Food. Not less important than the cleansing of crockery and utensils is the cleanliness of all persons engaged in the preparation and handling of food. The hands of all such persons should be kept clean and the washing of hands after using the water closet should be secured; facilities for such washing should be provided adjacent or near to the sanitary accommodation in all premises where food is prepared and clean towels should be readily available. 35 Another feature connected with the sale of food in restaurants is the practice of displaying food in the shop window. In many of the modern refreshment rooms, common in the main London streets, it is a general practice to display samples of the actual food provided, particularly cakes, pastries and sweets. Close examination of some of the goods so displayed gives evidence of the settlement of dirt on their surfaces. This food is subsequently served to customers. Sanitary Accommodation for Customers. The question arises from time to time of the necessity for the provision in restaurants of sanitary accommodation for customers of both sexes. Many of the larger and better equipped restaurants provide suitable accommodation, a much appreciated boon, particularly in Central London, where such restaurants are largely used by strangers to the Metropolis. There is something to be said in favour of such provision being required in all restaurants, or at least in all the larger establishments, although everyone recognises that in crowded areas where space is valuable it is not always easy to spare the superficial area. At times the nearness of public sanitary conveniences renders provision in a restaurant less imperative. Under various local Acts relating to provincial towns sanitary accommodation must be provided for customers. Registration of Eating Places. The whole subject of the control of restaurants and eating-houses is of much importance. Local Authorities in Central London have thrown upon them the responsibility for safeguarding the health of the non-resident population who come daily into their area, especially with regard to the hygienic preparation and serving of meals and liquid refreshment. This applies equally to a considerable number of visitors to London. The problems facing an authority endeavouring to secure a high standard in such matters include the position and size of kitchens, the presence of vermin, e.g., rats, cockroaches, etc., the disposal of kitchen refuse, provision for the storage of food, washing-up arrangements, sanitary conveniences, as well as the purity of the food supplied, its handling during preparation and service and the cleanliness of the personnel. It is difficult to avoid the conclusion that all restaurants (including those in hotels) and eating-houses should be registered by Local Authorities. Our experience is that some of the restaurants, especially the high-class type, show very little fault, if any, can be found, but it is just these places that are willing to accept voluntary registration, which in their case would be little more than a formality. It is a system of compulsory registration that is required, such as that applied to milkshops, so as to bring the less satisfactory restaurants up to a recognised standard of efficiency. c 2 36 Unsound Food. The following unsound food was condemned during the year 1925:— Commodity. Quantity. Condition. Result of Action taken. Fish:— Plaice 9½ stone Decomposed Surrendered Skate 35 lbs. Do. Do. Hake 6 stone Do. Do. Fruit:— Apples 54 boxes (1 ton, 7 cwt.) Do. Do. Cherries 1 ton, 12 cwt. Do. Do. Pears 395 trays (2 tons, 9 cwt.) Do. Do. Vegetables:— Potatoes 60 bags (4 tons) Do. Do. Tomatoes 86 bundles (4 tons, 6 cwt.) Do. Do. Sale of Food and Drugs Acts. In the Annual Report for the year 1922 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 largo 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. Public Health (Preservatives in Food) Regulations, 1925. In the Annual Report for the year 1924 a summary was given of the conclusions and recommendations issued by the Departmental Committee on the use of preservatives and colouring matter in food. In August, 1925, the Ministry of Health made Regulations for dealing with the use of preservatives, etc., in food. The Regulations are based on, and generally give effect to, the recommendations of the Departmental Committee. They prohibit the importation, manufacture or sale of most articles of food containing added preservatives or certain colouring matters. Sausages, fruit, fruit pulp, dried fruit, wines, jam, sugar, beer, mineral waters, and a few other specified articles, may contain one of two preservatives, namely. sulphur dioxide or benzoic 37 acid. The quantity permitted in each article of food is definitely specified. When preserved articles are sold they are to be labelled as such. The provisions as to importation are to be enforcd by the officers of customs and excise, port and other sanitary authorities, responsible for the administration of the Public Health (Imported Food) Regulations, 1925. The provisions relating to the manufacture and sale of articles of food containing preservative are to be enforced by the sanitary authorities in London the Metropolitan Borough Councils. Generally the Regulations are to come into operation on the 1st January, 1927; so far however as they relate to butter and cream, the operation is postponed to the 1st January, 1928. So far as they relate to an article of food containing preservative necessarily introduced by the use in its preparation of preserved bacon, ham, margarine or butter the operation is postponed to the 1st July, 1927 (bacon, ham, margarine), and to the 1st July, 1928, in the case of butter. One of the recommendations of the Departmental Committee was that any prohibition or limitation imposed by the Regulations should bind the Courts in proceedings taken under the Sale of Food and Drugs Acts. The Committee went on to say:— "If this were done, traders and the public generally would know what was permissible and what was not, and there would be no conflict of expert evidence on the question whether the amount of preservative or colouring matter was or was not injurious to health. The only point at issue would normally be whether the preservative or colouring matter found in the food, or the amount of it, was in contravention of the Regulations. A change in the law in this direction would, we feel sure, be appreciated both by Local Authorities and by traders." In a circular letter issued to Local Authorities from the Ministry of Health in August, 1925, the Minister expressed agreement with the view of the Committee, but intimated that it had not then been practicable to introduce legislation to give effect to the recommendation. The Minister commended the matter to the consideration of Local Authorities and suggested that proceedings should not be taken under the Sale of Food and Drugs Acts in respect of the addition of preservatives in food except where such additions would be contrary to the provisions of the Regulations. It is to be hoped that the necessary legislation to give effect to the recommendation of the Committee in this direction will become practicable in the near future. In the year 1925, 29 articles of food, purchased in the Borough, were found to contain preservative. The number of preserved samples and the variety of the articles as shown in the list below repeat the experiences of previous years 38 and again emphasises the difficulties which face Local Authorities in their efforts to obtain pure food free from preservatives and colouring matter. Bacon Cake Cream Egg-liquid Fruit cordials Ice Cream Lemon curd Meat pies Sausages Sausage roll Sponge roll Boric acid 3 Boric acid 9 Boric acid 3 Boric acid 2 Salicylic acid 1 Boric acid 2 Boric acid 1 Boric acid 2 Boric acid 3 Boric acid 2 Boric acid 1 29 In addition most of the samples of butter and margarine analysed during the year were found to contain preservatives, but in all cases the quantity was less than 0.5 per cent. In the final report of the Departmental Committee on the Use of Preservatives in Food, 1924, it is stated that a large proportion of the butter made at farms or creameries in this country, most of which is sold direct to the consumer, is free from preservatives and representatives of the British Dairy Farmers' Association informed the Committee that preservatives were not necessary in butter made in this country. In addition to the butter produced in this country large quantities are imported; that which comes from Denmark, Norway, Sweden, Finland and Russia is free from preservative and a large proportion from Holland and a small proportion from France also contain no preservative; hence it would appear that no difficulty should arise in respect of imports from European countries when preservatives in butter are prohibited. In the case of margarine the report of the Committee states that very little attention appears to have been directed by many manufacturers to the preparation of margarine without preservatives. The limit of 0.5 per cent. boric acid per pound suggested by the Departmental Committee of 1899 has been tacitly accepted by manufacturers and generally regarded by them as necessary for preservative purposes. One witness, however, representing a very large firm. gave evidence that his firm had found that margarine containing no preservative could be kept easily for four weeks. There would seem to be no reasonable claim to regard the supplies of margarine as of a more perishable nature than butter. All samples of milk were examined as a routine for preservative, but in no case was any preservative found to be present. 39 The following observations refer to samples purchased and analysed during the year:— Apples. Samples of imported apples were examined for the presence of arsenic; reference to these examinations will be found on p. 42. Bacon. Samples of bacon were examined for the presence of preservative. It is the practice of some producers and exporters to preserve bacon by dusting the same with boric acid, and in three of the ten samples purchased in the Borough evidence of the use of this preservative was found; the quantity of the preservative, however, was not sufficiently large to call for legal proceedings. In one case where the amount of boric acid warranted it communications were addressed to the retailers, the wholesale dealer and the producers, drawing attention to the matter and expressing the hope that the use of the preservative would be discontinued; ultimately the producers replied agreeing to stop dusting boric acid on bacon exported by them. Cake. Nine samples of cake were examined, all of which disclosed the presence of boric acid in quantities ranging from 1.75 to 17.50 grains per pound. The preservative is introduced by the use of liquid egg. The arrangements agreed to by the Bakery Allied Traders' Association relative to the use of liquid egg provided for its exclusion from sponge fingers, sponge biscuits and 1d., l½d., and 2d. sponge cakes; unfortunately the restriction did not apply to such articles as sponge roll, Swiss roll, the larger sponge cakes or Madeira, fruit or other cakes. The limitation of the prohibition to the particular types of sponge cakes referred to has resulted in a general assumption by bakers that liquid egg preserved with boric acid can be used in the making of any cake other than small sponge cakes, subject to the liquid egg not containing more than 1 per cent. of boric acid. Any action by Local Authorities with a view to securing the elimination of this preservative in cakes is therefore rendered difficult and will continue to be of little avail until the Regulations respecting preservatives in food become operative. Letters drawing attention to the desirability of discontinuing the use of the preservative were sent to the vendor of the samples in which the larger amounts of preservative were found, and after some correspondence he intimated that the use of liquid egg preserved with boric acid would be discontinued. Calomel Ointment. One sample of eight examined was found to be deficient in calomel to the extent of 42.5 per cent. Proceedings were instituted against the vendor who was convicted and fined £7. 40 Fruit Syrup. A sample of fruit syrup was found to contain some salicylic acid. In this case there was no disclosure on the label, and communications were therefore addressed to the vendors; from the reply received it appeared that the absence of a declaration that the syrup was preserved with salicylic acid was due to error. Lemon Curd. A sample of lemon curd used in the preparation of lemon cheese cakes was found to contain a small quantity of boric acid. Enquiry of the vendors elicited the information that in the preparation of the lemon curd liquid egg was not used; the only ingredient which appeared likely to contain preservative was margarine and a suggestion was therefore made to the vendors that butter or margarine without preservative should be used in future. Milk. One hundred and ninety-three samples of milk were examined of which five were reported as not genuine. In one case the sample was deficient in fat to the extent of only 2 per cent., and no action was taken; in four cases proceedings were instituted with the following results:— (a) Defendant discharged on payment of 12s. 6d. costs. (b) Warranty pleaded, summons dismissed on payment of 12s. 6d. costs. (c) Summons withdrawn on payment of 21s. costs. (d) Defendant ordered to pay 21s. costs. Sausages. Three out of six samples of sausages examined were found to contain boric acid; in one case the quantity of preservative was equal to 18.2 grains per pound. Sausage Rolls. The two samples of sausage roll examined contained preservative, but the amount was too small to justify any proceedings pending the Regulations as to preservatives becoming operative. Swiss Roll. One of the two samples of Swiss roll purchased was found to contain preservative, but having regard to the arrangements made by the Ministry of Health with the Bakers Allied Traders' Association, it was considered inadvisable to institute legal proceedings. Letters were, however, sent to the retailers and the makers of the roll drawing attention to the recognised objection to this preservative especially in the case of sponge calces and expressing the hope that its use in articles of food made with sponge mixture would be discontinued; subsequently a communication was received from the vendor in the following terms:— 41 "We are advised by the Bakers Allied Traders' Association that the goods we manufacture are allowed and that we need have no hesitation in continuing to do so and to use liquid eggs if supplied through the members of the Bakery Allied Traders' Association.'' Experience gained through the year in connection with articles of food liable to be preserved continues to emphasise the urgent necessity for the Regulations respecting preservatives in food to become operative as soon as possible. Vinegar. One sample of vinegar out of 20 examined was found to be deficient in acetic acid; on a further sample of vinegar being taken from the same vendor shortly afterwards it was found to be genuine. Contamination of Apples by Arsenic. In December, 1925, a circular letter was received from the Ministry of Health drawing attention to the presence of considerable quantities of arsenic on the surface of certain imported apples. The communication stated that two cases of arsenical poisoning had been traced to the consumption of imported Jonathan apples and a number of samples of those apples had shown various amounts of arsenic ranging up to ??? of a grain per pound. The Minister urged on Local Authorities the necessity of making full use of their powers under the Sale of Food and Drugs Acts, the Public Health Acts and the Public Health (Imported Food) Regulations to protect the public by the examination of samples of apples likely to be affected and by arranging for the withdrawal from sale of those found to be dangerously contaminated. Arsenic is used, generally in the form of arsenate of lead, to kill the larvae of the Codlin moth, the worms or maggots frequently found in apples. The moth emerges from its cocoon about the time apple trees are in bloom; it lays its eggs on the branches, leaves or the future fruit; the larvae, which develop later, attack the fruit, generally by way of the calyx. In some of the Western States of America there are as many as four broods of the moth each summer; in Great Britain rarely does a second brood develop to any extent. The arsenic spray is universally used immediately the fruit is set so as to get a deposit of poison into the calyx. In England one spraying is usually sufficient, but in the dry climate of the Western States (Oregon for example. where a considerable amount of imported apples are grown) spraying is performed six times at intervals of a fortnight. The fruit is well developed when the last spraying is performed and is hanging down; the arsenic solution consequently runs into the depression around the stalk; the liquid evaporates leaving the dry arsenic behind. Several 42 varieties of dessert apples grown in California and Oregon, including the "Jonathan" apple, have a very deep depression around the stalk and consequently are peculiarly liable to retain the arsenic, especially as there is practically no rain during the ripening season to wash it away. Apples grown in England and other cooler climates with a similar rainfall are almost invariably free from arsenic as the single spraying is done when the fruit is only just set and the small amount of arsenic present is washed away by rain. In conformity with the suggestion of the Minister samples of imported apples on sale in the Borough were obtained for examination. Fourteen such samples were submitted to the Borough Analyst. The following table shows the variety and the results of the examinations. Variety. Amount of Arsenic found (if any). Jonathan nil Jonathan nil Jonathan 1/500 grain Per pound Jonathan 1/900 do. York Imperial 1/250 do. York Imperial 1/900 do. Spitzberger 1/1430 do. Newtown Oregon nil Newtown Oregon 1/475 grain per pound Newtown Oregon 1/475 do. Newtown Oregon 1/700 do. Newtown Oregon 1/800 do. Newtown Oregon 1/840 do. South African nil It will be seen that on ten out of the 14 samples, traces of arsenic were found. It is, however, laid down that no action is necessary where the quantity is less than 1/100 grain per pound, and in all the above samples the quantity of arsenic found was considerably less than this. The matter is receiving the serious attention of the apple trade but at the time of writing samples continue to show the presence of arsenic. Cheese. The importance of cheese as an article of food, particularly in the dietary of the poorer part of the community, is such that the necessity of securing a high nutritive standard is obvious. Unfortunately legislation has not yet been enacted in this country to standardise this and other essential articles of food, although a Bill for the purpose was introduced as long ago as 1913. 43 The various cheeses on sale in the Borough include the following; the order approximates to the frequency with which they are seen exposed for sale:— Cheddar, Colonial hard Do. English hard Gorgonzola hard Gruyère hard St. Ivel and similar lactic cheeses soft Kraft (a Canadian hard cheese similar in flavour to Cheddar) Dutch hard Cheshire hard Camembert soft Italian hard Stilton hard Chedlet (an English cheese similar to Kraft) hard The restaurants generally supply two or three varieties, one of which is Cheddar; the more expensive restaurants sell English, the less expensive, Colonial Cheddar; the other cheeses sold are commonly Gorgonzola, Gruyère or St. Ivel. The cheap Dutch cheeses made from skimmed milk are not being sold so much at present possibly because cheese made from full milk imported from the Dominions has taken their place. In the dining-rooms for the working classes very little cheese is sold; the labouring classes evidently prefer to buy cheese at the provision dealers, bread at the bakers, and eat such portable food in the workplace or public house; in the latter, tables, or in some instances upturned barrels, are provided; also bread and cheese can be purchased more cheaply at public houses than in the eating-house. The following table gives particulars of a number of samples of cheese recently purchased in the Borough and examined by Mr. J. Kear Colwell, F.I.C., the Public Analyst. Kind of Cheese. Weight of Sample. Price paid for Sample. Description of shop where Sample purchased. Content of Sample. Water. Fat. Protein. Cheshire ¼lb. 9d. Dairy 39.40 28.95 24.47 Cheddar ¼lb. 9d. Dairy 39.10 28.10 23.76 Stilton ¼lb. 7½d. Provision dealer 25.90 40.40 22.51 Colonial Cheddar ¼lb. 3½d. General shop 32.0 30.8 23.6 Colonial Cheddar ¼lb. 3½d. General shop 31.4 29.8 29.7 Colonial Cheddar ¼lb. 3½d. Dairy 30.8 31.5 28.7 Cheddar ¼lb. 3½d. Dairy 28.1 38.8 29.4 44 It will be observed that the most highly priced cheeses showed the lowest fat values; three of seven samples contained less than 30 per cent. fat, the standard adopted in some British Colonies. In Canada, however, the standard is 45 per cent. milk fat calculated in the moisture free content and it is generally considered that Cheshire cheese and cheese of similar character should contain at least this quantity of fat calculated on this basis. In New Zealand the regulations state that ''Cheese is to contain in the water-free substance not less than 50 parts per centum of fat wholly derived from milk and it shall not contain any foreign fat." Sophistication of Wine. In view of the use of sulphurous acid for the preservation of white wines containing sugar, when the Public Health (Preservatives, etc., in Food) Regulations, 1925, come into force the use of preservative in alcoholic wines will be limited to sulphur dioxide not exceeding 450 parts per million. Bottles of such wine should be examined to see that the legal limit is not exceeded. Mussels. Seeing the important part played by shell fish in the spread of disease, notably enteric fever, it was thought useful to examine a sample of mussels bacteriologically. The advance of present day knowledge suggests that routine bacteriological as well as chemical examination should be made of food if we are to prevent disease. An attempt to purchase English mussels having failed we bought some South Dutch mussels which we were assured by several traders had a much better name than English mussels. Detailed and thorough bacteriological examinations of each of ten mussels were made, the result of which put very briefly showed that nine out of the ten mussels examined were unclean; they contained B. Coli; the mussels of which the sample formed part were not fit for human consumption. The Fishmongers' Company were promptly informed; they had other consignments examined bacteriologically and the result of our bacteriological examinations were confirmed. In a telephone message, the Secretary of the Fishmongers' Company, thanked the Public Health Committee for undertaking the examinations and said that they had resulted in a thorough reinvestigation of the situation not only as regards South Dutch mussels, but also as regards North Dutch mussels; the beds of both localities were to be the subject of a searching enquiry. Subsequently a communication was received from the Fishmongers' Company giving the results of the enquiry and investigations into the deterioration in the quality of the mussels. Samples direct from the beds concerned were examined with satisfactory results by Dr. Folpmers, Fisheries Laboratory, Bergen up Zoom. Dr. Folpmers pointed out that topographically contamination by sewage was excluded. The Fishmongers' Company agreed with this contention as the sewage 45 disposal arrangements were entirely altered some years ago after representations by the Company to the Dutch Authorities and no sewage is now discharged where it can gain access to the mussel beds. A suggestion was made with which the bacteriologist acting for the Fishmongers' Company agreed, that sufficient care had not been exercised by the fishermen as to the cleanliness of the bags in which the mussels were packed; this was to be remedied. Further examinations by the Fishmongers' Company of consignments going to the London market gave satisfactory results and there appeared to be no further cause for anxiety. The following is the report of the bacteriological examination of the samples submitted from this Borough:— Technique. Short Method. Eyre. No. of Mussels. MacConkey's Bile Salt Broth for presumptive B. Coli. Litmus Milk for presumptive B. Welchii. Glucose Formation Broth for Streptococci. From .2 c.c. of liquor From 1 c.c. of liquor From .2 c.c. of liquor 1 Acid Raft clotting Streptococci present 2 Acid and Gas — — 3 Acid and Gas — — 4 Acid and Gas — Streptococci present 5 Acid and Gas — — 6 Acid and Gas — — 7 Acid and Gas — — 8 Acid and Gas Raft clotting Streptococci present 9 Acid and Gas Raft clotting -- 10 Acid and Gas — — RESULTS: 9 mussels containing B. Coli. 90 per cent. are therefore unclean. 3 out of 3 mussels contain B. Welchii. 3 „ 3 „ „ Streptococci. Determination of B. Coli Index. Identification of Coliform Organism. 5.6c.c. of the mussel liquor having already been used the following results obtained should necessarily be slightly greater. The liquor and mussels divided up were then made up to 100c.c. with sterile water; therefore one mussel equals 10c.c. of fluid. .05c.c. to plated agar incubated at 37°C. for 24 hours=66 colonies=132,000 colonies per mussel. .05c.c. to plated Gelatine incubated at 20°C. for 48 hours=2,000 colonies=400,000 colonies per mussel. Of these a large percentage were liquefiers, i.e., organisms causing decomposition of proteins. 46 lc.c. of the liquor—1/10 of a mussel was then diluted as follows in fractions of a mussel and lc.c. of each dilution added to McConkey Bile Salt Lactose Broth and incubated for 24 hours at 37°C. 1. 1/100 Acid and Gas present. 2. 1/1,000 Acid and Gas present. 3. 1/10,000 Acid and Gas present. 4. 1/100,000 No change. 5. 1/1,000,000 No change. 6. 1/10,000,000 No change. 7. 1/100,000,000 No change. 8. 1/1,000,000,000 No change. Therefore the organisms finally isolated must have been present to the extent of at least 10,000 per mussel. The coliform organism isolated gave the reactions approximately of an atypical B. Coli; it fermented Lactose, Glucose, Mannite, but produced no Indol; the organism therefore, if not identical with the organism derived from the human intestine, approximates closely to it and is to all intents and purposes an indication of fæcal contamination, probably human. lc.c. of the same dilutions after heating at 80°C. for ten minutes was inoculated under anaerobic conditions for 48 hours at 37°C. "Stormy" coagulation ("raft" clotting) occurred in the 1/100 dilution, indicating the presumptive presence of B. Welchii (B. enteritides sporogenes). Prom the above data it would appear that the 10 mussels submitted to examination were not fit for human consumption. (Sd.) E. GOODWIN RAWLINSON, M.D., D.P.H. Contamination of Food. In my report for 1924 I drew attention to the need for definite and more stringent legislation for dealing with the contamination of food and commented on the Food Regulations operating in British Colonies. In South Australia, for instance, such Regulations include provisions dealing with the cleanliness of the clothing and body of persons handling food, freedom from contagious, infectious or loathsome disease, the protection of food from rats, mice, cockroaches, flies, spiders, bugs, moths, and other vermin, as well as the cleanliness and construction of food premises. The New Zealand Code contains provision for the thorough washing and rinsing of drinking vessels and table appliances after use. Similar legislation is in force in Canada, where, in some parts, licensing of all restaurants, cafes, etc., is required. Food Standards. In the same report (1924) I also commented on the need for standards of quality and purity of food, and referred to the Bill introduced by the Government in 1913 to set up such standards. I also suggested that in framing such standards the experience of Austria and the States of the Commonwealth of Australia would have to be taken into account. 47 Milk. The following table shows the fat content of the 199 samples of milk:— Percentage of Fat. Number of Samples. Shops. Restaurants. Streets. Total. Less than 3.0 4 — 2 6 3.0 4 — — 4 3.1 8 — 2 10 3.2 10 1 3 14 3.3 17 3 8 28 3.4 17 3 7 27 3.5 17 4 6 27 3.6 12 3 3 18 3.7 16 6 3 25 3.8 7 2 3 12 3.9 6 — — 6 4.0 7 — 1 8 4.1 1 1 — 2 4.2 3 — — 3 4.3 3 — — 3 4.4 1 — 1 2 4.5 2 — — 2 4.9 — 1 — 1 7.6 1 — — 1 136 24 39 199 Average 3.41 3.62 3.48 3.53 Eleven per ccnt. of the samples contained 4 per cent. or more fat. Milk with this fat content docs not appear to be uncommon. In the City of London, 46 out of 295 samples (15.6 per cent.) of milk examined in 1925 contained 4 per cent. of fat and over. In 22 cases where the fat content subsequently proved to be four per cent. or over observations made at the time of purchasing the sample showed that in 19 instances the milk was stirred with a hand measure before serving. In one case only a plunger was used, whilst in two cases the agent reported that the milk was not stirred at all prior to sale. In one of these the milk was delivered 48 by the wholesaler to the retailer just before the purchase and presumably served from the can without stirring. It is probable that even distribution of the milk fat is not secured by casual mixing with a hand measure, the use of efficient plungers would secure this end; on the other hand where there is reason to believe milk is properly plunged an analysis has shown the presence of over four per cent. of fat. Of the 22 samples referred to above 12 were purchased at dairies or milk shops, eight at general shops and two from street vendors. But to my knowledge analyses of the contents of individual churns show that the percentage of fat in very many is considerably above 3 per cent. In some the fat contents of the milk were over 4 per cent. The following table shows the average composition of milk samples purchased during each month of 1925. Number of Samples examined. Total Solids, per cent. average. Solids Non-fat. Per cent. average. Fat. Per cent. average. January 19 12.18 8.85 3.33 February 22 12.22 8.83 3.39 March 18 12.41 8.92 3.49 April 20 12.57 8.90 3.67 May 20 12.45 8 .95 3.50 June 28 12.44 8 .99 3.45 July 10 12.29 8.91 3.38 August 10 12.50 8.97 3.53 September 10 12.55 9.02 3.53 October 14 12.97 9.08 3.89 November 19 12.47 8.81 3.66 December 9 13.11 9.03 4.08 Whole year 199 12.48 8.93 3.55 Legal Minimum 11.50 8.50 3.00 It will bo seen that the seasonal variations are not very marked; the highest percentage of fat was in December and the lowest in January. 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, 49 With a view of testing the difference in the fat content of "top" and "bottom" milk in churns as used on street hand-barrows in the Borough, twelve samples were taken from six street vendors; two samples were taken from the same churn at the same time, one by the use of a hand measure from the top of the milk in the churn, "top milk," and one from the draw-off tap at the lower part of the churn, "bottom milk." Two of the churns were fitted with plungers. The following table shows the result of the examination of the six pairs of samples and it will be seen that no marked difference was discovered even where no plungers were fitted. Top Milk. Bottom Milk. Fat. Non-Fatty Solids. Fat. Non-Fatty Solids. Samples 1 and 2 4.0 9.20 3.8 9.03 ,, 3 „ 4 3.9 8.92 3.8 9.03 ,, 5 „ 6 4.0 9.08 4.0 9.08 ,, 7 „ 8* 3.7 9.14 3 .7 9.14 ,, 9 „ 10* 3.1 9 .02 3.1 9. 28 ,, 11 „ 12 3.4 8 .95 3.3 9.07 *Fitted with plungers. Articles Analysed. Formal Samples. ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Apples 6 2 4 ... ... ... Bacon 10 7 3 ... ... ... Barley, pearl 4 4 ... ... ... ... Brandy 1 1 ... ... ... ... Bread 5 5 ... ... ... ... Butter 59 59 ... ... ... ... Cake 9 0 9 ... ... ... Calomel ointment 8 7 1 1 1 Fine, £7 0s. 0d. Chocolate cream 3 3 ... ... ... ... Christmas pudding 2 2 ... ... ... ... Cinnamon, ground 2 2 ... ... ... ... Cream 21 18 3 ... ... ... Cream, preserved 31 31 ... ... ... ... Currants 2 2 ... ... ... ... Custard Powder 5 5 ... ... ... ... Egg powder 2 2 ... ... ... ... Fish paste 8 8 • •• ... ... ... Fruit syrup 9 8 1 ... ... ... Galantine 1 1 ... ... ... ... Gin 1 1 ... ... ... ... Herrings in tomato 3 3 ... ... ... ... Iodine, liniment of 1 1 ... ... ... ... D 50 ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Jam 6 6 ... ... ... ... Lemon curd 2 1 1 ... ... ... Lemon squash 2 2 • •• ... ... ... Margarine 15 15 ... ... ... ... Meat extract 3 . 3 ... ... ... ... Meat pa???te 11 11 ... ... ... ... Meat pie 12 10 2 ... ... ... Mincemeat 2 2 ... ... ... ... Milk 193 188 5 4 0 Costs, £2 8s. 6d. Milk, dried 6 6 ... ... ... ... Milk, condensed 9 9 ... ... ... ... Oil, cotton seed 1 1 ... ... ... ... Oil, frying 7 7 ... ... ... ... Oil, olive 5 5 ... ... ... ... Oil, salad 5 5 ... ... ... ... Pineapple, tinned 6 6 ... ... ... ... Pork pie 3 3 ... ... ... ... Pork and beans 1 1 ... ... ... ... Prescription 2 2 ... ... ... ... Raisins 2 2 ... ... ... ... Rice, polished 3 3 ... ... ... ... Riss???le 1 1 ... ... ... ... Rum 1 1 ... ... ... ... Sausages 6 3 3 ... ... ... Sausage roll 2 0 2 ... ... ... Shrimp paste 3 3 ... ... ... ... Soup 2 2 ... ... ... ... Sponge cake 15 15 ... ... ... ... Swiss roll 2 1 1 ... ... ... Sultanas 2 2 ... ... ... ... Sweet spirit of nitre 2 2 ... ... ... ... Tomatoes, tinned 3 3 ... ... ... ... Tomato purée 1 1 ... ... ... ... Treacle 3 3 ... ... ... ... Vinegar 20 19 1 ... ... ... Wine, raisin 3 3 ... ... ... ... Whiskey 1 1 ... ... ... ... Total 556 520 36 5 1 Fine. £7 0s. 0d. Costs, £2 8s 6d. Informal Samples. ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Bacon 1 1 ... ... ... ... Bread 1 1 ... ... ... ... Cheese 12 12 ... ... ... ... Ice cream 21 19 2 ... ... ... Liquid egg 2 0 2 ... ... ... Lung syrup 1 1 ... ... ... ... Milk 6 6 ... ... ... ... Total 44 40 4 ... ... ... Total Samples 600 5 6O 40 5 1 Fine, £7 6s. 0d. Costs, £2 8s. 6d. 51 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. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. Yearly average 1915-1924. Pneumonia (all forms) 48,874 37,916 39,832 59,666 38,949 37,149 34,708 40,930 33,413 38,970 40,040 Pulmonary Tuberculosis 40,803 40,769 42,335 45,338 35,984 32,791 33,505 33,919 32,097 32,690 37,023 Measles 16,445 5,413 10,538 9,787 3,534 7,190 2,241 5,694 5,316 4,834 7,099 Whooping Cough 8,143 6,075 4,509 9,898 2,605 4,401 4,576 6,370 4,162 3,983 5,472 Diphtheria 5,865 5,366 4,477 4,803 4,888 5,648 4,772 4,075 2,722 2,501 4,517 Scarlet Fever 2,406 1,381 768 1,020 1,221 1,430 1,305 1,382 993 888 1,279 Enteric Fever 1,388 1,122 977 950 577 537 613 465 450 496 750 52 The total number of notifications relating to Holborn residents received during the year was 415 in comparison with 446 in the year 1924. 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. In addition to the above there were received 243 notifications respecting patients not residing in Holborn, many being in-patients of hospitals in the Borough. All these were forwarded to the Medical Officers of Health of the districts concerned. The 243 notifications so received were as follows:— Diphtheria 73 Scarlet Fever 52 Whooping Cough 4 Typhoid Fever 1 Paratyphoid Fever 4 Cerebro-spinal Meningitis 1 Encephalitis Lethargica 4 Acute Poliomyelitis 4 Erysipelas 5 Tuberculosis 95 243 Smallpox. No case of smallpox was notified in the Borough during the year; 13 cases of the disease were notified in London. Information of 28 passengers or staff arriving on vessels on which smallpox had occurred during the voyage or which came from infected ports was received and, where practicable, the necessary visits for keeping such contacts under observation were made. In 22 of the cases the addresses given in this Borough were at hotels or boarding houses. In five cases the addresses or the names given could not be traced. In five cases although the travellers had visited the hotel mentioned, they had gone, leaving no address, prior to the Inspector's visit. In one case the passenger contact had been removed to hospital and died, death being due to heart disease. There was no evidence or suggestion that this patient had suffered from smallpox, the body was seen and contained no indication of any rash. In addition to contacts notified by the Port Medical Officers of Health, I received information from the London County Council and two Medical Officers of Health in London respecting eight residents in Holborn who were contacts of cases of smallpox occurring in other Metropolitan areas. All these contacts were seen and kept under observation during the incubation period, and re-vaccinated where this had not been performed within the last five years. None of the contacts developed the disease. 53 The following table kindly supplied by the Vaccination Officer of the Holborn Union on 12th April, 1926, 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 Temporarily unaccounted for Holborn Sub-District : 12 months ended 30th June, 1925 253 104 29 36 0 27 29 28 St. Giles and Bloomsbury Sub-District: 12 months ended 30th June, 1925 129 51 19 23 0 14 12 10 3S2 155 41% 18 59 0 41 41 38 As in previous years a leaflet respecting the advantages of vaccinal ion was sent to the parents of all infants born in, or belonging to, the Borough. The following table respecting vaccination in the Borough since 1913 has been compiled from information furnished by the Vaccination Officer. Prior to 1913 the Borough was divided into two for poor law purposes, viz., St. Giles and Bloomsbury Union and part of the Holborn Union. In 1913 the St. Giles and Bloomsbury Union was amalgamated with the Holborn Union. Year. *Birth8. Vaccinated. Exemptions. Others. 1913 868 486 113 269 1914 735 387 116 282 1915 614 321 90 203 1916 578 283 71 224 1917 477 226 58 193 1918 350 149 39 162 1919 402 118 57 227 1920 638 192 101 315 1921 495 178 84 233 1922 498 174 101 223 1923 428 165 69 204 * These figures refer to births occurring and registered in the Borough. It will be seen that a large number of infants are not vaccinated, although there is no reason to think that Holborn is worse than any other area in this respect; in fact, there is reason to believe that it is better than many others. 54 Diphtheria. Seventy-six notifications of diphtheria relating to residents in the Borough were received during the year at the following ages:— Under 1 year — 1 to 5 years 26 5 „ 15 „ 26 15 25 16 (includes 12 hospital 25 „ 45 8 staff) 45 „ 65 „ — Of those 74 were removed to hospital. Sixteen cases were returned from the hospitals of the Metropolitan Asylums Board certified as not suffering from diphtheria. Two deaths occurred. Seventeen "secondary" cases were notified. A "secondary" case is one occurring in the same household as the primary case. Thirteen of the secondary cases were nurses or staff at hospitals in the Borough. (From the same hospitals 40 in-patients were notified as suffering from diphtheria; none of the in-patients were residents of the Borough.) There were two "return" cases notified 16 and 18 days respectively after the return of the primary cases from hospital. In London 12,472 cases were notified giving rise to 481 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. Diphtheria in Hospitals. During the year notifications were received from two hospitals in the Borough of 64 cases of diphtheria, 47 and 17 respectively. Of the 47 cases occurring in the first hospital 34 were reported as clinical diphtheria, 12 as carriers only, and in one the diagnosis was not confirmed. Seven of the clinical cases were nurses on the hospital staff and two were ward-maids; the remaining cases were in-patients of the hospital, all the latter being nonresidents of the Holborn Borough. Of the 17 cases at the second hospital seven were clinical and ten carriers. Two of the clinical cases were nurses on the hospital staff, and one carrier was a member of the resident medical staff. The number of cases of diphtheria occurring from year to year amongst the nursing staff of hospitals suggests the need for the immunisation of hospital nurses. It would seem to be obvious that fever hospital nurses should be protected against diphtheria and it is difficult to avoid the conclusion that all hospital nurses, nursing in children's wards, should be immunised. It must be within the experience of many that nurses in children's hospitals and subsequently the children themselves are often attacked. The possible objection that a nurse would have to be immunised against diphtheria, scarlet fever and typhoid and paratyphoid fevers does not carry much weight. Many during the war were immunised against more diseases than these —those going East were protected against smallpox, typhoid and the paratyphoid fevers, cholera, dysentery and plague. Who can show that they suffered any harm by taking advantage of the progress of science? The Schick test and immunisation against diphtheria is already being successfully applied to the nursing and domestic staffs in a few hospitals, including those of the Metropolitan Asylums Board. 55 Diphtheria Contacts. Bacteriological Examination of Nose and Tiikoat Swabs. Total Contacts swabbed 52 Negative 45 Positive 7 (13 per cent.) Contacts swabbed. Positive Results. Contacts positive. Nose and Throat. Nose only. Throat only. First Examination 52 _ 6 1 7* Second ,, 4 — — — — * Two of these were notified as diphtheria and removed to hospital. One was a resident in an adjoining Borough and information was forwarded to the Medical Officer of Health concerned. 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 was no evidence that the organisms were avirulent. No virulence tests were necessary in 1925. Diphtheria antitoxin was supplied free of charge on application by medical practitioners. During the year it was supplied in nine 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 prophylactic 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 possibla 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 Departments 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 Schick 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. 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 for four years, ending December, 19.2"', follows:— 56 TABLE I. HOLBORN MUNICIPAL INFANT WELFARE CENTRE, 1922, 1923, 1924, 1925. Ages of Persons Schick-Tested with Result of Test. Ages. 0 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 14 to 15 years 15 and above years Total for 4 years, 1922-25. 52 144 111 100 72 49 38 24 37 46 32 22 16 24 3 60 = 830 Result of Schick Test. Pos. Neg. Pos. Neg. Not read Pos. Neg. Pos. Neg. Not read Pos. Neg. Not read Pos. Keg. Not read P08. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. | Neg. Pos. Neg. Pos. Neg. Pos. Neg. | Not read Total for 4 years. 47 5 135 6 3 104 7 84 15 1 50 20 2 29 18 2 24 14 14 10 23 14 20 26 10 16 10 12 9 7 7 17 1 2 22 34 4 595 Pos. 223 Neg. 12 Not read. TABLE II. Ages of Persons Immunised. Age. 6 to 12 months 1 to 2 years 2 to 3 years 3 to 4 years 4 to 6 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 14 to 15 years 15 and above years[ Total for 4 years 40 109 85 66 39 23 28 12 16 16 11 9 7 4 1 6 = 472 57 table iii. HOLBORN MUNICIPAL INFANT WELFARE CENTRE. Schick Test and Diphtheria Immunisation. Four years, 1922-23-24-25. Total Tested. Result op Test. Immunisation of Positives. Negative. Positive. Not read. Found NEGATIVE to Re Schick Test after Found NEGATIVE to Re Schick Test after Found POSITIVE to Re Schick Test after 3 ccm T.A.T. Not yet read after Re Schicking. Total Re Schick Tested Given 3 ccm T.A.T. Not Retested. Failed to complete 3 inoculatns. Inoculatns. not begun. Inoculatns. still in progress. Given 1 ccm not yet Re-tested. 1 ccm T.A.T. 2 ccm T.A.T. 3 ccm T.A.T. 4 ccm T.A.T. 5 ccm T.A.T. 6 ccm T.A.T. Given further inoculation but not yet Retested. No further inoculation given. C A C A C a C A C A C A C A C A C A C A c A C A C A C A C A C A c A C A c A 771 59 187 36 575 20 9 3 9 0 14 1 280 3 6 0 2 1 3 1 15 0 6 1 0 0 335 7 132 0 43 4 53 7 3 0 11 0 830 223 595 12 9 15 283 6 3 4 15 7 0 342 132 † 47 60 3 11 * These columns refer to 35 cases that were Schick positive on Retesting after 3 ccm T.A.T. † 29 of these are dead or removed from the Borough. 58 In view of the satisfactory results obtained by R. A. O'Brien in the Holborn (Poor-law) schools, arrangements were made in 1922 to render the measure available for the general child population of Holborn. The results obtained are summarised in Tables I., II., and III. The results of the Schick testing were very much the same as those found in all other urban areas; we have, however, analysed them in connection with the immunity to diphtheria of various members of the families dealt with. The last column in Table IV. shows the number of exceptions (11.5 per cent.) to the expectation that positive reactions will be manifested only in the younger members. TABLE IV. No. of children in family. No of families. Of which the members are- All Schick positive. All Schick negative. One or more elders negative, younger positive. One or more elders positive, younger negative. 2 103 74 7 13 7 3 45 21 4 14 6 4 15 6 — 4 5 5 8 2 — 4 2 6 2 — — 2 — 7 2 — — 1 1 — 175 105 11 38 21 In one family of five children, twins (F.) of 2-3 years of age were both positive; of twins of 7-8 years, one (M.) was positive, the other (F.) was negative. In one family of three children one twin (M.) was negative, the other (F.) was positive; the latter had already been in hospital with diphtheria. In one family of four, all Schick positive to the first test, two members were found to be Schick positive to the second test. The first of these (F. 4) was immunised some months previously to the second one (M.1), and was further inoculated, being negative to the second test; the second child is not yet retested. In another family, twins, one male aged 2 years when tested and one female aged 5 years when tested were both Schick positive. Routine Procedure. The routine of the procedure carried out is as follows. The child is Schick tested at the Council's Maternity and Child "Welfare Centre, and if susceptible to diphtheria is brought up by the parent at weekly intervals for the next three weeks for immunisation, and then at the end of another three months (formerly we tried for the period six to eight weeks) for re-Schick testing, when, if it happens to be still positive, it receives further inoculation. A modification of the routine occurs if from the Schick test it is seen that the child is particularly susceptible to protein reactions; in this case the 3 c.cm. of toxin antitoxin mixture are given in four or five doses at weekly intervals Some difficulty has been experienced in securing the necessary number of immunising injections owing to the children belonging to families who remove from the district; some of these however attend to finish the course. A few adolescents at times fail to complete the course by reason of being employed and it no longer being convenient for them to attend. 59 Although Park and Zingher recommend that Schick testing should only be applied to children over 5 years, it would seem inadvisable to dispense with the test as a routine at the present time in Holborn. It is a great satisfaction to nervous parents to think that there will be no inoculation unless susceptibility is proved. Retesting is unpopular with parents, and the need for it does not help to increase their confidence in immunisation. Of 342 that have been retested 38 were found to be still Schick positive after three inoculations. The facts relating to these are given in Table V. TABLE V. Results of 342 re-Schick Tests up to 31s/ December, 1925. Re-Schick tested after an interval of years or fraction of years. Number retested after this interval. No. found positive. Age in years and sex of positives when first tested. Negative to 2nd re Schick test and total of T A.T. given in all. 1 F 5/52 10 6 4 1 13, F. Neg. ; 4 c.cm. 6/52 3 1 2 — — — 7/52 6 4 2 — — — 2/12 19 9 10 1 9, M. Neg. ; 6 c cm 24/12 11 4 7 — — — 8/12 39 18 21 4 (a) 8, F. Neg. ; 4 c.cm (b) Ad., F. — (c) 3, M. (d) 9, M. — 34/12 14 5 9 1 4, F. Neg. ; 5 c.cm 4/12 21 11 10 1 4, F. Neg. ; 4 c.cm. 4½/12 4 0 4 2 (a) 5, F. Neg. ; 6 c.cin. (b) 2, F. — 5/12 12 3 9 1 2, F. Neg, ; 6 c.cm 6/12 23 11 12 4 (a) 1, M. — (b) 2, M. Neg. ; 5 c cm. (c) 3, M. — (d) 4, F. — 7/12 15 7 8 1 9, F. Neg. ; 6 c.cm. 8/12 8 3 6 — — — 9/12 7 3 4 — — — 10/12 9 3 6 1 4, F. †Neg. ; 5 c.cm. 11/12 3 1 2 — — — 1 5 1 4 1 9/12, F. Neg. ; 4 c.cui. 1-2 80 38 42 15 (a) 1. F. Neg ; 4 c.cm. (b) 2, M. — (c) 2, M. — (d)2, M. — (e) 2, F. Neg.; 4 c.cm. (f) 6.M. Neg. ; 4 c.cm. (g) 7, F. Neg. ; 4 c.cm. (h) 8, F. — (i) 9, M. — (j) 9, F. — (k) 11, F. — (/) 12, M. — (m) 12, F. Ad., F. Neg. ; 5 c.cm. (n) 1. F. Neg ; 4 c.cm. 2 3 53 21 29 5 (a) F. — (b) 5, F. Neg. ; 4 c.cm. (c) 12, F. — (d) 2, F. — (e) 4, M. — Total 312 152 190 38 * Another child in same family (F.), aged 4 years, was negative. † Throe children in this group -were members of one family: 2 negatives (M.), aged 2 years (F.), aged 6 yours; 1 positive (F.), aged 4 years. 60 In addition, one child re-Schick tested 15 months after 1 c.cm. T.A.T., was found positive, and two children retested after 3 c.cm. were on the information given by the mother considered to be slightly positive. Twenty of those positive on re-Schicking have been further inoculated, and ten of them further tested and found negative. Efforts are being made to continue the inoculation of the remaining ten. Of the 295 persons retested, 137 were males and 158 were females. Among the positive were ten males and 20 females. Neither age nor interval seems to have any influence on the phenomenon. It would seem conceivable that some batches of toxin antitoxin or toxoid antitoxin might prove to be less efficacious than others. An analysis of the results obtained in Holborn would seem to indicate clearly that one batch of toxin antitoxin was less successful than the others; also that the toxoid antitoxin used was as efficacious as the toxin antitoxin. The toxin antitoxin used were all 3 L+ per c.cm. mixtures, the toxoid antitoxin contained toxoid diluted 1-10 with added antitoxin. (Table VI.) That considerable importance attaches to the retesting is shown by the fact that our one case of diphtheria among those treated occurred in a child who was given the routine three injections. The boy suffered from a severe attack of the disease, but recovered without any complications or sequelae; his recovery was ascribed certainly by his mother to the inoculations of T.A.T. given after Schick testing. A second case is said to have occurred in a boy (aged 8) also given the routine three injections. Two years later he was diagnosed (for the third time in his life) as suffering from diphtheria ; no swab was taken. On admission to the M. A.B. Hospital he was first found to be swab negative, later swab positive, but was diagnosed as a case of diphtheria. The mother fortunately is still convinced that the boy did not suffer from diphtheria. TABLE VI. Batches of Toxin Antitoxin and Toxoid Antitoxin Compared. Designation of batch of toxin antitoxin mixture or toxoid antitoxin mixture. No. of persons inoculated and retested. No. of these persons found positive on retesting. Toxin antitoxin mixture B. 346 59 2 B. 475 26 3 B. 654 26 1 B. 671 70 17 B. 671a 2 1 B. 672a 30 2 B. 617 35 2 B. 675 1 — B. 672 1 — Toxoid antitoxin mixture B. 1017 32 4 B. 1090 15 1 I!. 1038 10 B. 1018 31 4 15.1129 1 1 B 995 3 — Total 342 38 61 Reactions. Our experience is that the reaction after the injection of the toxin antitoxin and toxoid antitoxin is in practically every case negligible. All we have to record is that in one child considerable swelling of the whole of the arm occurred, but the next day, when at the centre, she was running about and helping the other children eat their cakes; the swelling went down without any further result. Another, a boy of 10 years of age, his mother informed me, suffered with vomiting after each of his three inoculations and spent the next day in bed, but he and his mother stuck to it, and he was subsequently proved to have been satisfactorily immunised. In another child, a small, hard, slightly tender nodule developed above the external condyle, but the tenderness only remained for a few days. The use of toxoid antitoxin does away ivith the risk of fatality incurred by using improperly made toxin antitoxin. What of the Future? Most of the attendances are the result of repeated efforts of persuasion and encouragement. Prejudice against inoculation is widespread; some of the most stubborn opponents of inoculation admit that if T.A.T. could be given in tabloid form or in spoonfuls they would agree to it. They object, in fact, to the introduction of animal products by means of a hypodermic syringe into the human body, but continued propaganda is sure to produce its results. The aim of everyone who takes up the work must be to get all the children living in the area immunised as soon after they reach the age of 6 months as possible. In Holborn we have not reached this stage yet; the history of vaccination against smallpox suggests we never shall. But a local health authority is justified in considering that it has done all in its power to prevent loss of life and illness from diphtheria if it offers immunisation. It might be expected that if the immunisation were carried out among the school population in a large town the parents would come to regard the procedure as more ordinary, and be prepared to allow the younger children to be immunised at infant welfare centres. Apparently it cannot be too often repeated that it is immunisation at a very early age that we want carried out; if it is delayed till school age half the deaths will have occurred. In London during five years 1921-25, of the total deaths from diphtheria, 57 per cent. occurred under five years of age. Certainly if the immunisation could be completed at one visit the energy spent in looking up those failing to attend could be used in getting new recruits, and the parents would be spared much trouble. At the present time efforts are being made to produce a substance which can be used to ascertain the susceptibility of the individual and at the same time to give some degree of immunity. Obviously experiments on these lines would seem to be concerned with the use of toxoid as opposed to a toxoid antitoxin mixture, but the methods used up to the present do not produce a toxoid of sufficiently uniform strength to enable it to be used for routine immunisation. There is, however, much probability that this problem will shortly be solved. 62 Scarlet Fever. All the 86 cases of scarlet fever were removed to hospital. Seven cases were returned from hospital "not scarlet fever." In connection with five of the cases during the year there were six secondary cases. All but one of these were notified either at the same time or within a few days of the primary case. These secondary cases are exclusive of two nurses at a hospital in the Borough who were notified as suffering with scarlet fever; from the same hospital 45 in-patients were notified as suffering with the disease; none was resident in 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. There was one death from scarlet fever. 12,215 cases of scarlet fever were notified in London with 100 deaths. Enteric Fever. Six cases were notified during the year; in one the diagnosis was subsequently not confirmed. One of the patients died. The facts relating to the cases are as follows:— (i.) An assistant in a draper's establishment who had meals in common with the other employees. The source of infection could not be traced; no other case occurred amongst the staff. (ii.) A child of school age who died; the father of this child was a restaurant cook and it was stated that two cases of enteric fever had occurred amongst the restaurant kitchen staff six months previously; there was, however, no apparent connection between these cases and the child notified in this Borough. (iii.) A nurse at a hospital in the Borough who contracted the disease from a patient in the hospital, suffering from paratyphoid B. (iv.) This patient had recently spent a day at a seaside town where she partook of cockles purchased from a stall. On enquiry of the M.O.H. it was ascertained that several other cases of enteric fever had occurred in the seaside town, but these were not traced to the consumption of cockles. (v.) A child who was staying temporarily at a hotel in the Borough and had recently arrived from the Continent. The illness was contracted abroad; it began in France three weeks prior to the notification. 395 cases were notified in London with 48 deaths. Typhus Fever. No case of typhus fever was notified during the year, either in the Borough or in London. Cerebrospinal Fever. One case of cerebro-spinal fever was notified. The patient was removed to the North-Western Hospital where she was found to be suffering from acute pneumonia and not cerebro-spinal fever. 93 cases were notified in London, with 80 deaths. 63 Dysentery. No case of dysentery was notified. 14 cases were notified in London. Malaria. No case of malaria was notified. 55 cases were notified in London. Encephalitis Lethargica. One case of encephalitis lethargica was notified in the Borough during the year. 293 cases were notified in London, with 117 deaths. The following table gives information up to the end of 1925 respecting the ten real cases of encephalitis lethargica notified in the Borough since the Public Health (Encephalitis Lethargica) Regulations came into force on the 1st January, 1919:— Date of Notification. Pa'ient. A^e when notified. Subsequent History. 6/2/20 P.P. 8 years Died 28/2/20 7/2/20 WW. 47 years Died 7/2/20 13/1/20 B.R. 32 years Died 13/1/20 26/4/22 W.H. 14 years Died 19/4/22 4/4/24 A. K. 28 years Died 28/3/24 16/5/24 G.C. 36 years Returned to Italy 20/6/24 R.V.M. 40 years Complete recovery 9/7/24 F.H. 7 years Complete recovery 26/9/24 B.V. 53 years Died 21/9/24 4/5/25 CS 28 years Right leg partially paralysed ; right arm tremulous ; extreme depression The table excludes one case notified 15/11/24 who was subsequently found not to be suffering from this disease. Acute Poliomyelitis. Two cases of acute poliomyelitis or polioencephalitis were notified. 49 cases were notified in London, with 14 deaths. From the coming into operation of the Poliomyelitis Order, 1912, to the end of 1925, a total of 14 casks of this disease was notified as occurring in the Borough. 64 The following table gives particulars of these cases with the condition at the end of 1925:— Date of Notification. Patient. Age at date of Notification. Where Treated. Subsequent History. 17/7/13 F.D. l8/12 years Hospital Died from diphtheria 23/10/13 F.H. 2½ „ „ Wears surgical boot and still O.P- at Hospital 26/1/16 A.C. 4 „ „ Died 26/1/16 27/1/16 T.B. 4 „ „ Recovered—no crippling 5/9/16 F.B. 2 months „ Died 6/6/20 I. P. 3½ years „ Recovered—no crippling 23/7/20 E.W. 15 „ „ No use of lower limbs 17/9/20 E.H. 18/12 „ „ Recovered—no crippling 4/9/22 Y.R. 116/12 „ Home „ „ 5/2/23 J N. 3½ „ Hospital „ „ 2/5/23 M.H. 11 mths „ Still an O.P. at Hospital 14/8/25 B.T. 26 years „ Hotel guest; could not be traced 30/10/25 V.H. 5 „ „ Splint on right leg. O.P. at St. Thomas's Hospital The table excludes one ease notified 4/12/18 who was subsequently found not to be suffering from this disease. Pneumonia. Fifty-five cases of pneumonia were notified during the year. Ten of these were influenzal pneumonia. Forty-one deaths were recorded from all forms of pneumonia. Three of these were from influenzal pneumonia. The 45 cases of primary pneumonia were notified at the following ages:— Under 1 year, 0; from 1 to 5 years, 1; from 5 to 15 years, 5; from 15 to 25 years, 10; from 25 to 45 years, 8; from 45 to 65 year, 13; and 65 years and upwards, 8. Nineteen were treated at home; 9 were removed to voluntary hospitals; 16 to Poor Law Infirmaries; and one to a nursing home. Ten of the patients were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. Of the 45 cases of primary pneumonia, 22 resided in tenement lodging houses, 9 in separate private dwellinghouses or model dwellings, 3 in boarding houses, 4 in hotels, 5 in common lodging houses, 1 at an institution and 1 was notified from a casual ward. 65 The cleanliness of the homes was reported to be satisfactory in 31 cases, but only fairly so in 10, and in four cases as unsatisfactory. 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 8; only 9 cases were nursed in a separate room. In the majority of cases the disease was not ascribed to any special cause, but the following was given in 11 instances:— Following chronic bronchitis 2 Following cold 8 Following influenza 1 Pneumonia—5 years, 1921-5. During the five years, 225 cases of primary pneumonia were notified as occurring in the Borough at the following ages:— Under 1 year 13 1 and under 5 years 33 5 „ „ 15 18 15 „ „ 25 23 25 „ „ 45 47 45 „ „ 65 64 65 years and upwards 27 225 Of the above, 122 were removed to hospital or other institution for treatment, viz:— Voluntary hospitals 65 Poor Law hospitals 52 M.A.B. hospital 1 Nursing homes 4 Thirty-eight of the patients remaining at home were nursed by nurses of the Metropolitan Nurses' Association under arrangements made by the Council. The following further particulars were ascertained as a result of enquiries in the above cases:— Nursed in separate bedroom 22 Cleanliness of home only fairly satisfactory 42 Cleanliness of home unsatisfactory 8 Economic circumstances of families:— Good 25 Fair 42 Poor 41 Very poor 16 E 66 In most cases the onset of the disease was not ascribed to any special cause but the following were given in 44 cases:— Following chronic bronchitis 11 Following cold 18 Following measles 6 Following pleurisy 3 Chill after sleeping on roof in hot weather 1 After immersion in sea 1 Getting very wet during work 2 Exposure to bad weather (commercial motor drivers) 2 Influenza. There were 9 deaths from influenza in comparison with 11 in 1924, 1 in 1923, 21 in 1922, and 8 in 1921. Anthrax. No case of anthrax was notified in the Borough during the year. Six cases were notified in London. Chicken-pox. During the year information of 58 cases was received from school teachers and others. . Mumps. Information was received from school teachers of 57 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 274 Bacilli not found 262 3 Positive 1 71 Bacilli not found 59 1 Negative I Bacilli found 22 Negative 2 Bacilli found 12 Disinfections. During the year 502 rooms and 3,507 articles of bedding, clothing, etc., were disinfected after various infectious diseases. Fifty-nine rooms and 504 articles of bedding, clothing, etc., were disinfected 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. Twenty-two toys were disinfected, 67 Arrangements were also made at the request of the keeper of a common lodging house for the disinfection of 688 blankets. Forty-four books belonging to the Holborn Public Library were disinfected. Two ambulance cars belonging to the London County Council in which infectious patients had been conveyed were also disinfected. During the year two small motor vehicles were provided for the conveyance of infected bedding and articles of clothing to and from the disinfecting station. These vehicles were substituted for the hand trucks which were formerly used. The conveyance of infected articles by hand trucks was considered to be not only slow but obsolete and unsnited for a Central London Borough. The following table summarises the disinfections carried out in the last five years—1921-2-3-4-5:— Year. Routine disinfection after infectious disease in Ho: born. Articles disinfected after infectious disease in Finsbury. * Articles disinfected at request of traders and others. Disinfections Rooms after Tuberculosis. Articles Disinfected for Vermin (Cleansing of Persons Act.) Rooms. Artieles. 1921 389 6,785 2,79S 124,000 (second hand clothing) ? 2,370 1922 389 3,991 3,513 307,211 (second hand clothing) 29 1 232 1923 354 3,342 82 450 (sccond hand clothing) 36 1,146 1924 342 3,342 - 9,4 16 (hats, &c.) 67 1,411 1925 502 3,507 - 688 (blankets) 59 (& 504 articles) 1,751 Five years 1,976 20,907 6,393 441,768 191 8,240 * During repair of the Finsbury disinfecting apparatus. In addition to above, the disinfections during the five years included those of toys, books, ambulances and motor cars. Cleansing of Persons Act. During the year 124 persons (120 men and 4 women) infested with vermin had their bodies and 1,751 articles of clothing disinfected, free of charge, at our cleansing station (Goldsmith Street). One hundred and forty-three verminous rooms were disinfected. In connection with the fumigation of verminous rooms, it is now our practice to repeat the fumigation at the end of a week, by which time it is expected that any eggs will have hatched out; a single fumigation of any badly infested room cannot be regarded as satisfactory. In 67 cases last year this course was adopted. During the five years, 1921-25, 658 persons (608 men and 50 women) infested with vermin had their bodies and 8,240 articles of clothing disinfected, free of charge, at our cleansing station E 2 68 Verminous Conditions and 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 information was received under the above arrangement respecting 20 children reported to be verminous. In one instance the same child was reported as verminous on four different occasions in the year, in two cases the children were reported a third time, and in five cases a second time. Ali the cases were visited after receipt of each report, but it was not found necessary for any action to be taken in connection with the bedding or homes. Four children were reported as suffering from scabies; one child being so reported on two occasions; arrangements were made for the disinfection of bedding and rooms. 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. Summary of Notifications and Deaths. Five years, 1921-25. Year. Notifications. Deaths. Pulmonary. Nonpulmonary. Total. Pulmonary. Death-rate per 1,000. 1921 96 21 117 42 0.96 1922 68 11 82 43 1.00 1923 50 10 60 45 1.03 1924 75 12 87 47 1.08 1925 63 11 74 45 1.04 Average 5 years 70 14 84 44 1.02 The following table gives the number of new cases of tuberculosis and deaths from the disease in the Borough during 1925 in the form required by the Ministry of Health:— 69 Age periods. New Cases. Deaths. Pulmonary. N on-pulmonary. Pulmonary. Non-pulmonary. M F M F M F M F 0 — — — 1 — — — l 1 — 1 1 2 — — — 2 0 — — 1 — — 1 — 1 10 1 — — 1 — — — — 15 1 3 — 6 1 2 1 20 4 6 1 — 1 1 1 — 26 13 9 — — 3 6 — — 35 8 9 — — 7 1 I — 45 9 3 — — 9 — — 1 55 5 2 — — 9 3 — — 65 2 - — — 1 — 1 — 43 33 3 10 31 14 n G 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 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 December, 1925 270 Number of these patients residing in common lodging bouses (about) 20 The average number of cases notified annually during the past ten years 129 The number notified in the year 1925 89 Of the 89 cases notified in 1925, the number who attended the Dispensary 36 Total number of new cases examined at the Dispensary for the first time in 1925, including the above 36, and all contacts 197 Total attendances and examinations at the Dispensary in 1925, attendances 746 examinations 517 Supervision of home conditions; visits paid by— Tuberculosis Officer 55 Dispensary Nurse 987 Sanitary Inspectors 131 70 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. The Dispensary covers the whole of the Borough of Holborn. The Tuberculosis Officer attends three sessions each week, namely, Monday and Wednesday afternoons and Thursday evenings. The Dispensary Nurse assists at the Dispensary and visits cases in their homes. Public Health (Tuberculosis) Regulations, 1912. Summary of Notifications during the period from the 4th January, 1925, to the 2nd January, 1926, in the Metropolitan Borough of Holborn. Age-periods. Notifications on Form A. Notifications oil Form B, N umber of Notifications on Form C. Number of Primary Notifications. Total Notifications on Form A. Number of Primary Notifications. Total Notifications on Form B. Poor Law Institutions Sanatoria. 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and upwards. Total Primary Notifications. Under 5. 5 to 10. 10 to 15. Total Primary Notifications. Pulmonary Males ... ... ... 1 1 2 10 7 7 3 2 33 44 ... ... ... ... ... 23 18 ,, Females ... ... ... ... 3 6 8 8 3 2 ... 30 38 ... ... ... ... ... 11 13 Non-pulmonary Males ... 1 1 ... ... 1 ... ... ... ... ... 3 3 ... ... ... ... ... ... 3 ,, Females ... 1 ... 1 6 ... ... ... ... ... ... 8 9 ... ... ... ... ... ... 5 Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 4th January, 1925, to the 2nd January, 1926, 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 55 to 65 65 and upwards. Total Cases. Pulmonary Males ... ... ... ... ... 2 3 1 2 2 ... 10 ,, Females ... 1 ... ... ... ... 1 1 ... 3 Non-pulmonary Males ... ... ... ... ... ... ... ... ... ... ... ... ,, Females 1 1 ... ... ... ... ... ... ... ... ... 2 71 Tuberculosis Notifications. Excluding duplicates the total number of notifications received on Forms A or B during the year 1925 was 74; 15 other cases were brought to my knowledge, (making 89 new cases in the year). These were:—Private cases 13, hospital cases 42, Poor Law cases 19, death returns 5, transfers from other districts 7, notified after death 3. Correction of Tuberculosis Register during the year 1925. Number of cases on Register, 1st January, 1925 267 New cases registered, 1st January to 31st December, 1925 89 356 Removed from the Register during the same period for following reasons:— Removed from Borough 33 Recovered 11 Died 42 86 Number on Register 31st December, 1925 270 Of the 89 cases entered on the Register in 1925, 76 were pulmonary tuberculosis and 13 non-pulmonary tuberculosis. Forty-seven of the cases were removed for treatment to hospital, infirmary or sanatorium. Sleeping Conditions. In 64 of the 89 new cases of tuberculosis in 1925 it was possible to obtain information as to the sleeping conditions at the date of notification. Seven of the remaining cases were residents in common lodging houses; in 18 cases there had been residence in institutions prior to notification, incorrect addresses were given, or the patients no longer resided in the Borough. The following is a summary of the information in the 64 cases above referred to:— Patient slept in— Separate bed room 14 Separate bed in living room 1 Separate bed in room shared with— 1 person 7 2 persons 8 3 persons 3 4 persons 2 72 Shared bed with— No others in room. 1 adult (H. or W.) 7 1 adult (not H. or W.) 4 1 adult and 1 child 2 . 2 adults 2 Shared bed with— 1 adult Other persons in bedroom 1 child 6 1 adult 2 children 2 1 adult 3 children 1 1 child 3 children 1 1 adult 1 adult 2 1 adult 4 children 1 2 adults 1 child 1 64 Classification of Homes. The classification of homes as suggested by the London County Council has been reported on as far as practicable with the following results:— "A."—Good environment, clean, well-kept, separate bedroom (or in the case of husband and wife, no other occupant of bedroom), good food and clothing 15 "B."—Fair. Separate bed, but not separate bedroom 39 C."—Bad. Dirty environment, dirty ill-kept home, no separate bed, bad management as to food and clothing 10 64 The following summary gives the position at the end of 1925 of the 89 new cases respecting which information was received during the year:— Dead 23 Cases removed to Hospital or Infirmary and still inpatients at the end of year 15 Out-patients at Hospitals 4 In-patients in Sanatoria at end of year 15 Not traced—Incorrect addresses 5 Eemoved from Borough 13 Dispensary Treatment 1 Home Treatment 4 Improved—(No medical attendance now) 5 No information 4 89 73 Thirty-six of the 89 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 14 Out-patients at other Hospitals or Dispensaries 6 Dead before notification or died before attendance at Dispensary 14 Treatment at home by private doctor 3 Not traced 4 Removed from Borough 12 53 Delayed Notification. The Public Health (Tuberculosis) Regulations, 1912, require notification within 48 hours of the medical practitioner first becoming aware that the person is suffering from tuberculosis. It is still found that medical practitioners do not notify cases of this disease until tubercle bacilli have been found in the sputum and in a number of cases notifications are not received until the death of the patient or shortly before death takes place. In the past year eight cases were notified only at death, seven within one month of death, seven within three months and three within six months of death. Of the eight cases notified at death five died in hospitals, and three at home. 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 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. Institutional Treatment. During the year notifications were received of 82 admissions to institutions. These admissions represent 68 patients, some of whom are transferred from one institution to another, and others are discharged, or take their own discharge, and subseouentlv are re-admitted The 82 admissions were to the following institutions:— Poor Law Institutions 33 Institutions of the Metropolitan Asylums Board 24 Other Institutions 25 Fourteen of these admissions were transfers from one institution to another or re-admissions. 74 Visitation of Homes, etc. During 1925 the patients were visited by the Sanitary Inspectors or by the Tuberculosis Nurse; the arrangements made whereby after March 31st, 1925. all such visits are paid by the Tuberculosis Nurse, came into operation and continues. Contacts. All contacts are invited to attend for examination at the Tuberculosis Dispensary. Eighty-eight contacts, viz., 35 adults and 53 children under fifteen years of age, responded to this invitation and were examined for the first time during the year 1925. Of these, one adult was found to be suffering from pulmonary tuberculosis; one was doubtfully so suffering. Eighty-six were definitely diagnosed as not suffering from the disease. The routine examination of contacts is desirable as a means of discovering not only cases of tuberculosis in early stages of infection, but also advanced and infective cases which may be disseminating infection although remaining undiscovered and untreated. Arrangements were continued during the year for fuller co-operation with the school medical service 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. In addition specially designed opal plates have been placed on the Council buildings. They ask people not to spit and so prevent not only tuberculosis, but pneumonia and other diseases the germs of which are carried in the mouth and nose. It is very conceivable that such a disease as encephalitis lethargica is spread in this way in towns. Dangers to others from Coughing. Posters were displayed and small illustrated handbills given away dealing with the dangers resulting to others from patients coughing without guarding the mouth. Recently the leaflet given to patients suffering from tuberculosis has been revised and brought up-to-date. Deaths from Pulmonary Tuberculosis. The number of deaths from pulmonary tuberculosis during the year was forty-five, a death rate of 104 per thousand in comparison with 1.08 for 1924. The following table shows where the patients died in their own homes or institutions:— 75 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- 60- All Ages. Males. Females. Total. N umber of patients who died at home ... ... ... ... ... ... ... 1 3 4 ... 6 2 8 Number of patients who died in hospitals, etc. ... ... 1 ... 3 4 8 7 6 7 1 24 13 37 — — 1 — 3 4 8 8 9 11 1 30 15 45 Tuberculosis Dispensary. The following is the Report of the Tuberculosis Officer, J. A. Struthers, M.B., B.Ch., M.R.C.P., for the year 1925:— Number of Patients examined for the first time in 1925:— Insured. Non-Insured. Children under 15. Males. Females. Males. Females, Males. Females. Total 42 25 24 44 32 30 197 Analysis of 197 New Patients in 1925. Patients examined. Found to be suffering from Tuberculosis. Not suffering from Tuberculosis Ceased attendance before completion of diagnosis. Under observation at Dispensary 31st Dec. pending diagnosis. Pulmonary. NonPulmonary A. All persons including"Contacts." Adults M. 6G 39 2 24 1 — „ F. 69 36 2 29 1 1 Children M. 32 — 1 31 — — Sunder 15 F. 30 — 3 27 — — Total 197 75 8 111 2 1 B. "Contacts" included in A. Adults M. 8 8 — — J2 F. 27 1 b 25 — 1 Children M. 28 — — 28 — — under 15 F. 25 — — 25 — — C. Insured persons included in A. M. 42 25 2 15 F. 25 12 1 10 1 1 76 Attendances and Examinations at the Dispensary in 1925:- Insured. Non-Insured. Total Attendances 355 391 746 Examinations 231 283 517 Number referred to Hospital Departments 15 23 38 Specimens of Sputa examined 69 4.7 116 Supervision of Home Conditions:— Nurses Visits 448 539 987 M.O.'s Visits 38 17 55 Reports and Communications:— To Public Authorities 179 140 319 To Practitioners 87 43 130 Summary of 144 Cases disposed of in 1925:— Left the Borough 11 Definitely non-tuberculous 111 Died 22 144 Number of Patients under treatment or supervision at the Dispensary 31st December, 1925 292* * This figure includes a number diagnosed as non-tuberculous whose condition or environment is such that further examinations are desirable. The chief alteration made during the year in the running of the Dispensary was the severance of connection with South St. Pancras after March 31st, as the result of re-arrangements in the Dispensary facilities in that Borough. At the same time, re-arrangements in the Borough of Holborn have resulted in increased work for that Borough in the matter of visits and other work The visiting of all cases notified—a total of 89 last year, and not only of patients attending the Dispensary—is now carried out by the Tuberculosis Officer and subsequently by the Tuberculosis Nurse. Close co-operation is maintained with the Public Health Department by a daily visit of the Tuberculosis Nurse and a weekly visit of the Tuberculosis Officer; also one of the clerks of the Public Health Department visits the Dispensary weekly. Close touch has also been maintained with the Invalid Children's Aid Association, with the School Medical Service, and with the Maternity and Child Welfare Centre, Help has been obtained from the I.C.A.A. in sending away for convalescence children who, while not affected by tuberculosis, were of a type likely to contract that disease; and advantage has also been taken, when occasion offered, of the arrangements made between the L.C.C. and the I.C.A.A. for sending to the country children who were contacts of tuberculous patients and thus liable to infection. Help has also been obtained from the School Medical Service in examination of child contacts whose attendance at the Dispensary could not be secured; while on the other hand children suspected 77 of being tuberculous have been referred to the Dispensary by the School Medical Service and Maternity and Child Welfare Centre. From the Centre have also come mothers suspected of suffering from tuberculosis. As in previous years, contact has been maintained with the local practitioners and also with University College Hospital, and the other hospitals situated in or near the Borough, between which hospitals and the Dispensary there is a considerable interchange of patients. Full advantage has also been taken of the valuable help given by University College Hospital in the diagnosis of obscure cases, particularly in the matter of X-ray work, laryngoscopy and pathological investigations. To the Hospital have been referred cases of nontuberculous disease, from which tuberculous patients, like others, are liable to suffer. On the other hand, the Dispensary is used by the Hospital as a channel for furnishing the various reports sent to the County Councils concerning In-Patients who come under the schemes for institutional treatment of tuberculosis, while those referred from the Out-Patient Department are put in touch with the Tuberculosis Officer of the area in which they reside and their removal to sanatoria, etc., facilitated. Tuberculosis Care Covimittee. 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 Rev. Henry Ross (to Nov., 1925). Councillor Miss M. R. Lovelock (from Nov., 1925). Medical Officer of Health (Dr. C. W. Hutt). Tuberculosis Dispensary Councillor Sir William Smith, D.L., J.P. Tuberculosis Officer (Dr. J. A. Struthers). London County Council Dr. F. C. Lewis, Miss H. Bell. Guardians of the Holborn Union Conncillor Alfred Humphreys (from July, 1925). Charity Organisation Society Miss E. F. Bolton. Local Association of Children's School Care Committees. Mrs. Allan Parsons (from Oct., 1925). Invalid Children's Aid Association Miss E. Fildes. Metropolitan District Nursing Association Miss M. Wilmshurst. Almoners of hospitals Miss J. G. Salmon. Miss A. M Smith. Insurance Committee for the County of London. Miss S. Double. Northern London War Pensions Committee Mr. S. Tozer (died Oct,, 1925). Councillor R'chard Davies (from Feb. 1926). British Red Cross Emergency Help Fund Other social workers (co-opted) Mrs. Paige. Mrs. E. C. Bedford. Miss H. M. Mathieson. Rev. Wilfred H. Davies, M.A. 78 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 Tuberculosis 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 arrangement made by the Council for dental treatment. The Annual Report of the Committee is as follows:— The Committee has met 11 times during the year. Sixty-one cases have been considered—37 new and 24 old cases. Thirty-nine cases—35 adults and 4 children—were referred by the L.C.C. for assessment. Of these, 14 were granted free treatment, and 25 were assessed to pay contributions, varying from 2s. 6d. to 15s. per week, towards the cost of treatment and maintenance. Contributions towards the cost of treatment and maintennnce, amounting to £81 1s. 6d., were collected on behalf of the L.C.C. in 21 cases—15 adults and 6 children. Eight of these were still under treatment at the close of the year. Fifteen Quarterly Progress Reports on 7 children were received from the L.C.C., and the information contained therein was conveyed to the parents. One case was transferred to another Borough. On May 8th a Conference was held at County Hall, between the Public Health Committee of the L.C.C. and Representatives of the Metropolitan Borough Tuberculosis Care Committees. Holborn was represented by the Medical Officer of Health, the Tuberculosis Officer, and the Chairman and the Hon. Secretary of the Care Committee. A full report of the Conference was published by the L.C.C., and copies of it were sent to each Borough Council and Care Committee. On October 7th a meeting was held at the Town Hall to consider the urgent need for the provision of adequate subsidised workshops for tuberculous men and women. As an outcome of this meeting the following Resolutions were passed at the next meeting of the Care Committee:— (1) That the Ministry of Health and the London County Council be informed that the Holborn Tuberculosis Care Committee desires to support the institution of workshops for tuberculous men and women, carried on under a Committee of Management on which the Local Public Health and Tuberculosis Care Committees are represented. 79 (2) That a copy of the foregoing Resolution be sent to Metropolitan Borough Councils and Tuberculosis Care Committees, and that they be asked to adopt a similar Resolution. Replies were received from 19 Borough Councils and 14 Care Committees. Nearly all of these expressed sympathy with the Resolution, and 15 definitely stated that they were forwarding a similar Resolution. As an experiment, the L.C.C. decided to put into operation, for a period of twelve months from 1st April, 1925, a scheme, in co.operation with the Invalid Children's Aid Association, for providing facilities for:— (1) The removal of children from heavily infected and overcrowded homes, during the terminal stage of a dying case of pulmonary tuberculosis in the home. (2) The boarding.out of children who are being discharged from sanatorium treatment, and whose homes are inimical to the maintenance of health. The period of boarding.out was to be limited to three months. Later, the scheme was extended to include weakly children, in suitable instances, whose parents were under treatment for tuberculosis, the children, in all categories, to be kept away as long as the conditions in the home were unfavourable to their return. Six children were sent away from Holborn under this scheme. H. M. MATHIESON J. G. SALMON (Hon. Secretary) (Chairman) Employment of Tuberculous Persons. A problem of much difficulty in connection with tuberculosis is the employment of tuberculous men. For the past three years the Central Fund for the Industrial Welfare of Tuberculous Persons has been engaged in an experimental enquiry into the conditions under which tuberculous men living in their own homes can with advantage be employed in hygienic workshops. Their first workshop, for the production of high class fancy leather goods, was opened in the Borough in Cross Street, Hatton Garden. A memorandum issued by the Fund states that the purpose in view was not to show that tuberculous men could be employed in a health resort, but in some central place not far from their homes and not differing materially from their usual surroundings. The workers selected had already undergone a course of treatment and training in a sanatorium and some, but not all, had obtained either arrest or quiescence of the disease. They were drawn from the industrial class and preference was (and is) given to ex.Service men. The workshop now has its full complement, 20 workers. The hours of work are 8.30 a.m. to 10.30 a.m. then a rest (10 minutes); 10.45 a.m. to 12.30 p.m. then dinner interval (one hour); work ceases at 5.30 p.m. Wages are based on hours actually worked and the value of the output. The Annual Report of the Fund for the year 1924 says " the experience gained in the working of the first hygienic workshop during the last two years is convincing testimony that the scheme of 80 providing industrial employment for the tuberculous in hygienic workshops is worth a more extended trial," and the report adds that the co.operation of the Borough Tuberculosis Officer together with the Care Committee of the district in which the workers live is essential if the organisation of the scheme is to prove successful. In connection with the observation of Health Week in the Borough a meeting on the subject of the provision of subsidised workshops for tuberculous men and women was held at the Town Hall under the Chairmanship of the Eight Worshipful The Mayor (Alderman H. Warren Coleman. J.P.) and the Chairman of the Public Health Committee (Councillor the Eeverend Henry Boss). The meeting was well attended by members of the Metropolitan Public Health and Poor Law Authorities. representatives of labour exchanges and employment bureaux, insurance companies, approved societies and various voluntary organisations interested in the welfare of tuberculous persons and public health generally. Subsequently the Public Health Committee adopted a resolution supporting the institutions of subsidised workshops for skilled and unskilled tuberculous men and women, carried on under a Committee of Management on which the local Public Health and Tuberculosis Care Committees should be represented. Copies of this resolution were forwarded to the Ministry of Health and the London County Council. Home Nursing for Tuberculous Patients. With the sanction of the Minister of Health arrangements were made for nursing of tuberculous patients by the Metropolitan Nursing Association. The nursing is 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 will not be allowed to stand in the way of admission to institution. During the year four such cases were nursed, a total of 115 visits being paid to these patients. Dental Clinic for Tuberculous Persons. Arrangements were continued 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 Dental Hospital, No. 10, John Street, W.C. In the year 1925, 12 new patients were treated. Scaling and gum treatment was given in one case. Extractions with general anaesthetic in one case and with local anaesthetic in two cases. The Clinic is held by the British Dental Hospital at the Council's Maternity Centre, 10, John Street, on Tuesday evenings. Before the tuberculous patients we admitted the Clinic is open for the inhabitants of the neighbourhood. 81 The Secretary of the Hospital has kindly supplied the following information of the work at the Clinic during the year 1925:— Summary of Work carried out at Dental Clinic, 10, John Street, Holborn, on Tuesday Evenings, during 1925. Number of sessions held 46 Number of patients' attendances 327 Number of fillings 43 Number of scalings 16 Number of extraction cases Without anaesthetic 10 With local anæsthetic 42 With gas 31 Number of teeth extracted 165 Number of dentures (including repairs) 25 Number of dressings 49 Number for advice 40 Number of denture visits 64 Number of new patients 81 Cancer. Deaths and Death Bates. Five years, 1921.25:— Year. Number of Deaths. Death.rate per 1,000. 1921 56 1.28 1922 58 1.30 1923 59 1.36 1924 70 1.61 1925 66 1.52 Average — 5 years 62 1.41 During the year 1925, 66 deaths were recorded as due to cancer, equal to a rate of 1.52 per thousand. In the year 1905 the death rate from cancer in the Borough was 0.92; in 1914, 1.61; the decennial average rate was 1.08 for the 10 years 1905.1914, and 1.37 for the 10 years 1915.1924. It will thus be seen that there is apparently an increase in the cancer death rate, and although some part of this increase, if not all, 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 the distribution was continued of a special leaflet giving early signs and symptoms of cancer. Arrangements were also continued 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. F 82 MATERNITY AND CHILD WELFARE. During the year 364 births were registered as occurring in the Borough. During the same period 336 notifications of births occurring in the Borough were received. Of these 295 were from doctors and midwives, 41 from parents, 36 being after letters drawing attention to non.notification. From the 295 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 73 Private Midwives 56 Out-patient Midwifery Departments of General Hospitals and Institutions:— Externs and others 30 Midwives.—Charing Cross Hospital 10 University College Hospital 34 Middlesex Hospital 27 Royal Free Hospital 2 Other Institutions 20 Training Institution for Midwives, Myddelton Square 43 295 Eight notifications related to stillbirths, and two 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 15 The number of net births belonging to the Borough was 527 There are no Maternity Hospitals or Public Lying.in Institutions in the Borough but maternity cases arc admitted to certain nursing homes in the area. 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 of Total Births. No. Percentage of Total Births. One roomed homes 78 15 53 10 Two „ „ 154 29 60 11 Three „ „ 41 8 18 3 Four „ „ 12 2 5 1 These figures show that many of the women are confined under very uncomfortable and unfavourable circumstances, 83 Home Visiting. The visits paid to the homes by the Health Visitors during the year were as follows:— First Visits. Revisits. Total. Expectant Mothers 74 52 126 Children under 1 year of age 465 751 1,216 Children 1 to 2 years of age 1 358 359 Children over 2 years of age 7 594 601 Enquiries re stillbirths 17 „ re ophthalmia neonatorum 11 Other Visits 261 In addition 827 visits were made by student Health Visitors. As shown in the table above, 465 first visits to infants under one year were paid in 1925 subsequent to the receipt of a notification of birth. Some of these notifications related to stillborn children, others to those who died shortly after birth, others to those who were temporarily living at the address given. In a few instances an incorrect address had been given and the mother could not be traced. When visiting homes in connection with children under 1 year, the Health Visitors also deal with children from 1 to 5 years, but these are not counted as separate visits. First visits or further visits were not paid where the home conditions were above the standard adopted for home visiting. Four hundred and twenty-three 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. 145 attended the Council's M. & C. W. Centre at 10, John Street. 19 ,, ,, ,, Mary Ward Settlement, Tavistock Place. 8 attended the Centre at the Onslow Street School, Saffron Hill. 3 ,, ,, Charing Cross Hospital. 3 ,, ,, Myddelton Square. 9 ,, ,, Middlesex Hospital. 3 ,, ,, University College Hospital. 4 ,, ,, Royal Free Hospital. 5 ,, ,, Other Centres. 199 attended an Infant Welfare Centre. Thus rather less than one.half of those visited attended an Infant Welfare Centre, and of these about four.fifths attended the Council's Centre. F 2 84 The following table shows the numbers of infants whose births were notified in the years, 1922, 1923, 1924 and 1925, who, on being visited, were found to be attending Infant Welfare Centres:— 1922 1923 1924 1925 Holborn Council Centre, 10, John Street 193 165 170 148 Mary Ward Settlement, Tavistock Place (subsidy paid by Holborn) 16 16 15 19 Onslow Street School, Saffron Hill 17 13 8 5 Charing Cross Hospital 8 2 1 3 Greek Street 2 2 — — Myddelton Square 1 2 2 3 Middlesex Hospital — 4 12 9 Oakley Square 2 — — — University College Hospital 5 2 2 3 Royal Free Hospital 6 5 5 4 Other centres 6 4 3 5 256 215 218 199 Percentage of cases visited found to be attending Infant Welfare Centres 47 44 44 47 Of the total found attending Infant Welfare Centres during the four years. 76 per cent. attended the Council's Municipal Centre. 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. This has now been discontinued owing to the need for the money for the purposes of a new Municipal Centre. 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—1 p.m. Medical Consultation 2—5.30 p.m. No. of Sessions 26 26 26 52 43 49 49 Total attendances — Children 559 468 1409 11 145 1105 Mothers 113 130 84 188 422 362 181 Average weekly attendances— Children 22 18 27 3 23 Mothers 4 5 3 4 10 7 4 85 Attendances at Municipal Centre, 10, John Street, four years, 1922.3.4.5:— Tuesday. Wednesday. Thursday. Friday. Medical consultations (alternate weeks ) Ante-natal and Post-natal (alternate weeks.) Children & Mothers seen at Ante-natal Clinic. Medical consultations. Class. Dentist. Medical consultations. No. of Sessions—4 yrs. 103 105 79 (3 yrs.) 20S 189 202 202 Total attendances: Children 1,847 - 645 5,344 131 381 4,479 Mothers 595 462 144 956 1,921 1,249 825 Average attendance per session: Children 18 - 8 26 1 22 Mothers 5 4 2 5 10 6 4 The total number of attendances made by the Health Visitors at the Centres in 1925 was 381. At the Municipal Centre, 5,160 attendances were made by a number of mothers, including 46 expectant mothers, and 501 children, of whom 284 were under one year, 65 between one and two years old, and 152 aged 2.5 years on the date of their first attendance. At the Mary Ward Centre 1,004 attendances of Holborn mothers and children were made by expectant mothers and 72 children, of whom 37 were under one year, 5 from one to two years, and 30 between two and five years. The attention of mothers of bottle fed infants is drawn to the necessity of supplying Vitamin.C in the diet by the giving of fruit juice daily in suitable quantities; orange juice is used, as a rule. During the shipping strike in the early autumn when oranges were dear and of inferior quality, while English tomatoes were comparatively cheap, plentiful, and at their best, the use of tomato juice was advised, and a special poster made to replace the usual one advocating orange juice. Mothers however preferred to pay the higher price for the oranges even when they could not easily do so, rather than try the new suggestion; they are equally conservative when advised to try the juice of raw swede turnips, which are at their best and most plentiful when the oranges are dearest. In addition to the Thursday afternoon classes for mothers there have been lectures and demonstrations on Cookery. In November, the National Clean Milk Society provided a course of four lectures on Milk and its Food Value, and a demonstration on the cooking of dishes in which milk is an important ingredient. In December, arrangements were made for two demonstrations by Miss Petty, of the Food Reform League, in methods of conservative cooking of vegetables and the preparation of wholesome and inexpensive dishes. 86 All these lectures were well attended and very popular; and copies of the recipes used by the demonstrators were prepared for distribution and were much appreciated. During the year there was also a ready sale for the " Mothers' Cookery Book," newly published by the National League for Maternity and Child Welfare. This was purchased on terms which enabled it to be sold at a cost of 2d. per copy. We have endeavoured to use pictures and mottoes dealing with health as much as possible. The Health Visitors are to be congratulated on the interesting and useful home.made posters they have designed. A set was shown in the Hygiene Exhibition at Wembley during the year 1924. 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. Three hundred and eighty.nine hanks of wool of a superior quality obtained from Wales were sold at cost price to the value of £20 5s. 2½d. The maternity bags have been used during the year by seven mothers. An outing was arranged for about 50 mothers. most of whom carried infants in arms, and 37 older children below school age, during the summer to Bricket Wood. The costs of the fares of some of the mothers were defrayed in part from money collected by private subscriptions. Ante.natal Hygiene. During the last four years, enquiries were made of mothers as to their attendance at an ante.natal centre immediately previous to the birth of the child visited. Of 1.943 cases, about whom information was obtained, 712 (37 per cent.) were found to have attended Ante.natal Centres or received ante.natal care as under:— 1022. 1923. 1924. 1925. 4 years, 1922 25. Number of enquiries made 54 1 481 495 423 1,943 Centre Attended— Municipal Centre, 10, John Street 33 33 31 17 114 Royal Free Hospital 23 19 34 34 110 Middlesex Hospital 29 29 41 33 32 Charing Cross Hospital 10 18 34 30 97 University College Hospital 12 5 18 16 51 Myddelton Square Institution 11 5 12 20 48 St. Bartholomew's Hospital 8 8 18 21 57 City of London Hospital 3 3 10 10 26 Queen Charlotte's Hospital 3 2 6 8 19 Other Centrea 12 8 12 6 38 Ante.natal care from private doctor 1 4 3 12 20 145 134 219 214 712 87 At the Council's Ante.natal Clinic 54 women attended during the year; of these 46 attended as ante.natal and made 104 attendances; 8 others attended after confinement making 21 attendances. One hundred and twenty.five attend. ances were made at the Clinic. Five of the ante.natal cases were expectant mothers for the first time; a number of the expectant mothers were found to have defects either due to or especially of concern in view of their pregnancy, the number and kind of defect present being as follows:— Placenta prævia 1 Contracted pelvis 2 Threatened miscarriage 1 Varicose veins 14 Albuminuria 1 Venereal disease 1 Marked vaginal discharge 2 Other diseases present were respiratory diseases 1; heart disease 7; anaemia 7; dyspepsia 9; constipation 10; dental caries 14; pyorrhoea 6; enlarged thyroid 2; umbilical hernia 1. Forty-one tests of urine were made for albuminuria; the urine of one woman showed a cloud of albumin. Dietetic advice was afforded and arrangements made for her confinement to take place in an institution. In 2 other cases there was a faint haze only. Twelve expectant mothers were referred to Maternity Hospitals for confinement (3 normal; 9 abnormal); and 18 to the Dental Clinic for treatment. In connection with the 8 post.natal cases attending the Ante.natal Clinic, the defects noted were:—Generative organs 2; heart disease 1; vision 1; enlarge! glands 1; venereal disease 1; and rheumatism 2. The following is a summary of the numbers of expectant mothers found to have defects either due to or especially of concern in view of their pregnancy, during the past five years:— 88 Ante-natal Hygiene. 1921 1922 1923 1924 1925 Total 1921.25 No. of Women attending Ante . natal Clinic 52 58 61 74 54 299 No. of Ante-natal cases 47 44 42 48 46 227 Attending after confinement 5 14 19 2ti 8 72 Expectant Mothers for first time 13 5 6 9 5 38 Defects, especially connected with pregnancy— Venereal disease — — — 1 1 2 Deformed pelvis 6 2 4 1 2 15 Threatened abortion 1 — o 2 — 5 Threatened miscarriage — — — — 1 1 Excessive vomiting 1 1 8 — — 10 Edema 6 — — — — 6 Varicose veins 9 12 8 2 14 45 Excessive vaginal discharge 5 — — 1 2 8 Albuminuria (slight) 8 1 4 1 1 15 Ante partum hæmorrhage — 1 — — — 1 Vaginal prolapse — 4 — — — 4 Pendulous abdomen — 1 6 2 — 9 Retroverted gravid uterus — — 1 — — 1 Toxaemia of pregnancy — — 1 — — 1 Extra uterine pregnancy — — — 1 — 1 Placenta previa — — — — 1 1 Other defects A — — . — — 6 Other defects— Pulmonary tuberculosis 1 1 1 1 — 4 Heart disease 2 3 1 3 7 16 Anaemia 8 6 9 5 7 35 Respiratory diseases 2 — 3 2 1 8 Constipation 8 18 20 5 10 61 Dental caries 22 27 27 20 It 110 Sleeplessness — 1 — — — 1 Dyspepsia — 1 9 9 9 28 Umbilical hernia — — — — 1 1 Sciatica — — — 1 — 1 Pyorrhœa — — — — 6 6 Enlarged thyroid — — — — 2 2 Other defects 3 1 6 6 — 16 No. referred to Maternity Hospitals 11 11 12 13 12 59 Normal 5 0 4 10 3 28 Abnormal 6 5 8 3 9 31 No. referred to other Hospitals 3 4 1 1 — 9 „ „ „ Tuberculosis Dispensary — 1 2 2 — 5 „ „ „ Dental Clinic 20 21 22 20 18 101 No. of urine tests made — 41 71 6S 41 221 No. of Wassermann tests made — 4 4 17 — 25 Ante-natal — 4 1 4 — 9 Post-natal — — 3 13 — 16 89 Maternal and Infant Consultations. The following summary refers to maternal and infant consultations at 10, John Street and the Mary Ward Centres during the five years 1921.25 inclusive:— Reasons for Attendance. John Street. Mary Ward. 1921 1922 1923 1924 19 5 1921 1922 1923 1924 1925 Mothers— Healthy — — — 12 34 Difficulty with breast feeding 70 92 49 37 27 1 2 1 Generative organs 19 — — Dental caries 98 111 73 60 5 2 — Heart disease 2 2 2 — — — — Debility 24 28 10 17 3 16 1 2 Anæmia 63 57 29 19 0 6 1 — Venereal disease 5 1 6 5 — — — — Respiratory disease 9 1 3 9 — 2 — — Digestive disorders 10 29 7 5 1 1 1 — Other disorders 25 16 13 19 6 3 2 Children— Healthy — — 171 214 — — 18 — Congenital syphilis 3 1 1 4 2 Alimentary disorders 154 269 243 101 46 30 5 15 6 Rokets 36 50 49 39 32 4 2 2 6 Respiratory diseases 83 175 74 43 24 15 12 8 3 Hernia, umbilical 23 30 25 13 14 3 2 — 1 do. inguinal 3 — — — — — — Phimosis 19 41 51 8 32 — 1 — — Rash 7 126 76 17 15 3 8 7 2 Disease of eye 6 18 21 4 16 1 1 1 6 Disease of ear 12 28 11 4 10 5 5 1 — Disease of nose and throat 16 56 57 41 26 5 3 1 Other diseases 25 47 34 53 7 2 2 4 In this table the more important ailment only has been recorded in each case. Artificial Sunlight. Twelve babies or children with signs of rickets were referred for artificial sunlight treatment. Five of these cases had courses varying from 2½ to 4 months with very marked improvement. Three attended for 3 or 4 weeks with not much improvement. In three cases the children began attendance at the Tufton Street Clinic, but for various reasons, chiefly illness, did not continue. and one who was referred did not attend at all. Mothers and children attending Municipal Centres referred to other departments for assistance during five years 1921.5. 90 Referred to Mothers. Children. Total. 1921 1922 1923 1924 1925 1921 1922 1923 1924 1925 Mothers. Children. Dental Clinic 49 102 93 129 67 5 17 17 30 11 440 80 Hospitals 11 16 15 24 15 42 84 89 85 41 81 341 Metropolitan Nursing Association 9 9 28 20 15 17 28 34 21 9 81 109 Assisted Milk 14 35 40 43 19 37 53 32 73 21 151 216 Convalescent Homes 29 17 11 20 18 7 17 20 37 18 95 99 Ante-natal Clinic — 27 16 19 3 — — — — — 65 — Private doctor — — — — — — — — 6 — — 6 Tuberculosis Dispensary — — — 1 2 — — — 6 — 3 6 Reilieving Officer — — — — — — — — 2 — — 2 Minor Ailments Clinic. — — — 7 — — — — 89 7 89 Massage Clinic — — — — — — 2 — 2 Light Treatment — — — — — — — — — 12 — 12 112 206 203 256 146 108 199 192 260 202 923 962 The following summary gives particulars of mothers referred for breast massage since 1923 when the arrangement came into operation:— 1923 1924 1925 Total 3 Years. Number referred to Metropolitan Nursing 24 14 9 47 Association Results— Lactation completely restored 5 3 2 10 Breast secretion re-established, but small bottle feeds required in addition to breast feeding 6 3 4 13 Lactation re-established for short time only to be lost again 5 3 — 8 Massage quite unsuccessful 7 4 3 14 No further information obtainable 1 1 — 2 Diarrhoea. During the year the cases of diarrhoea occurring in children attending 10. John Street, were as follows:— 1. Simple diarrhoea 23 cases. 2. Ordinary summer diarrhoea 3 cases Stillbirths. During 1925 there were 17 stillbirths in the district. Difficult labour was responsible for 7; of these 2 were due to contracted pelvis and 2 to abnormal presentation, one was a twin; in the remaining 3 enquiry did not elicit the determining factor. Of the other 10 prematurity was the most likely cause of 1; knotted cord 2; prolapse of cord 1; placenta prævia 1; mother's attack of influenza immediately before confinement 1; in 1 case the parent was unable to give any information which could be used in assigning a probable cause; in the remaining 3 no information could be obtained. 91 Four of the 17 stillbirths occurred in the private practice of a. doctor; 4 in the extern practice of an institution; 8 in an institution, and 1 in the practice of a midwife. Stillbirths, 1921-1925 Reason. 1921 1922 1923 1924 1925 Total. Occurrence of Birth. 1921 1922 1923 1924 1925 Total 4 years Difficult labour 7 4 13 7 7 38 Practice of private doctors — 4 8 4 4 20 Antepartum bæmorrhage 2 — — — — 2 Practice of midwives — 3 1 — 1 5 Plancenta prævia — 2 1 1 1 5 Extern practice of — 4 9 3 4 20 Accidentsduring labour 2 — — — — 2 hospital Knotted cord — — — — 2 2 Nursing home — 1 — — — 1 Prolapse of cord — — — — 1 1 Institution — — 5 11 8 24 Malformation of foetus — 1 — — — 1 Prematurity — — 2 2 1 5 Maceration — — — 1 — 1 Other causes 1 — 3 1 1 6 No definite information 2 4 4 4 1 15 Cause unknown — 1 — 2 3 6 No enquiries made 5 — — — — 5 19 12 23 18 17 89 — 12 23 18 17 70 92 Illegitimate Births. The following table gives a summary of the information obtained as a result of enquiries respecting the circumstances of illegitimate babies in the five years 1921-25: 1921 1922 1923 1924 1925 Total. Number of births registered 56 62 48 46 37 249 Number respecting which enquiries were made for further information 56 62 48 41 37 247 Lived with mothers who remained in parents' home 4 10 10 4 5 33 Lived with mothers who went out to work 6 4 3 8 — 21 Lived with other relatives — — — — 2 2 Boarded out with foster mothers 3 11 5 5 4 28 Lived in Institution — 1 5 2 1 9 Lived with both parents who lived together permanently 11 18 7 7 10 53 Died in early infancy 5 — 4 6 2 17 No information (gone away, etc.) 27 18 14 12 13 84 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 81, viz.. 49 women and 32 children; the number of attendances 443 (women 328, children 115). Assistance with Dentures, etc. Extractions with no anaesthetic were made in 3 cases (1 woman and 2 children;; with local anaesthetic in 27 cases (25 women and 2 children), and with general anaesthetic in 65 cases, including 27 children. Scalings were carried out in 48 cases (all women). Small fillings were provided in 154 cases, including 57 children, and root fillings in 10 cases (mothers). Dentures were provided for 16 patients, all of whom contributed towards the cost. In 2 cases dentures were remodelled; 1 was repaired and dressings were given in 52 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. 93 The following is a summary of attendances, etc., at the dental clinic during the five years, 1921.25:— Year. Total. 1921 1922 1923 1921 1925 m. C. m. C. m. C. m. C. m. C. m. C. New patients 44 25 66 23 50 23 45 45 49 32 254 148 Attendances 351 302 310 451 443 1,857 Extractions— No anæsthetic — — — — 1 2 1 2 Local anaesthetic 33 0 27 6 34 1 18 1 25 2 137 10 General anesthetic 33 17 34 10 44 16 41 29 38 27 190 99 Fillings 24 15 33 22 48 12 78 31 107 57 290 137 Dentures provided 28 21 15 17 16 97 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:— (a) Nursing Mothers; (b) Expectant mothers in the last three months of pregnancy; (c) Children up to three years of age and, exceptionally, to children between three and five years of age. Scale of Necessity. The approved scale of necessity adopted by the Council on the 14th October, 1921, continued in force during the year 1925. Applications received for milk free or at less than cost price are carefully investigated. Enquivies 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 94 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 229 applicants received free or assisted milk under the Scheme. This number included 111 who were receiving such assistance at the end of the year 1924. Grants were made in 118 new cases. At the end of the year 1925, 121 cases were receiving assistance, viz., free milk 86, milk at half. price 20, prepared milk free 14, half-price 1. The following table shows new cases assisted in 1925:— Milk. Prepared Milk. Free. Part Cost. Free. Part Cost. Expectant Mothers 14 1 — — Nursing Mothers 84 3 — — Children 35 2 26 3 The following table shows the cases assisted in the five years 1021-25:— Year. Milk. Other Food. Prepared Milk. Free. Part Cost. Free. Part Cost. Free. Part Cost. Expectant Mothers. Nursing Mothers. Children. Expectant Mothers. Nursing Mothers. Children. Expectant Mothers. Nursing Mothers. Children.; Expectant Mothers. Nursing Mothers. Children. Children. Children. 1921 23 62 80 3 30 36 2 8 4 0 1 4 29 16 1922 21 61 47 0 13 6 3 3 0 0 0 0 12 4 1923 14 42 41 3 12 6 1 0 0 0 0 0 12 5 1924 27 35 52 4 6 11 — — — — — — 11 11 1925 14 34 35 1 3 2 — — — — — — 26 3 Total years 99 234 255 11 64 61 6 11 4 0 1 4 90 39 Home Help. The Council's Home Help attended 29 cases during the year in comparison with 29 in the year 1924. In 12 of these the whole-time officer attended entirely and in 14 she attended during the earlier part of the lying-in period, being replaced 95 later by one of the Home Helps from the emergency panel in order to take over new cases. In 3 cases emergency Home Helps only 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 3 cases 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 22s. 6d. to 5s. Od. per week. The services of the Home Help have been much appreciated; it has been found that the Council's provision meets a much felt want in the Borough. In the five years 1921.25, 112 mothers have received assistance iron the Council's Home Help service. In 57 of these the whole.time officer attended entirely, but in 55 cases it was necessary to employ Home Helps from the emergency panel. In the majority of these cases, however, the whole.time officer was able to go into the homes during the earlier part of the lying.in period, being replaced from the emergency panel when other confinements overlapped. In 17 of the 112 cases where there was extreme necessity, the services of the Home Help were granted free of charge. In all other cases the applicants were assessed to contribute sums varying from 2s. 6d. to 25s. per week towards the cost. Convalescent Homes. Seven applications for convalescent home treatment for mothers and their babies were granted in comparison with 16 in the previous year. One baby was subsequently found to be unfit for residence in a convalescent home and 2 others for various reasons withdrew. Four mothers with their babies, and in one case an elder child also, were sent away in comparison with 9 in 1924. All the 4 mothers were admitted to the Church Army Convalescent Home at St. Leonards. on.Sea. In 1 case the arrangements were made possible by the willingness of the Church Army to admit a second child with the mother and baby. The facilities afforded by this, organisation for convalescent treatment for mothers and babies have proved most valuable. In 2 cases of extreme necessity the mothers and infants were sent away free; in the remaining, contributions towards the cost were required. Twenty applications were granted for convalescent home treatment for children. In 5 cases the applications were subsequently withdrawn. Fifteen children were sent away in comparison with 16 in 1924. Six of these were sent 96 to the Marjorie Lumley Convalescent Home, where the Council reserved a bed, and 9 were admitted to the Hopedene Convalescent Home at Barnet, by the kind co.operation of Sister Hope of the West London Mission, Kingsway. In 3 cases the children were sent away free, and in 12 contributions were required towards the cost. In the five years 1921.25, 33 mothers and infants have been sent away to suitable convalescent homes. In 9 cases of extreme necessity the treatment has been provided free of charge; in the remaining cases, after careful consideration of the economic circumstances of the families, the applicants have been assessed to make contributions towards the cost ranging from 2s. to 21s. per week. During the same period, 59 children below 5 years of age were also sent away for convalescent home treatment, mostly to the Marjorie Lumley Home at Maidenhead or to Hopedene Convalescent Home at Barnet. In 16 cases the arrangement was without cost to the parents. In the remaining cases, where it was considered the parents could afford it, contributions were required ranging from 3s. 6d. to 12s. fid. per week. Visitors to Centre. Being centrally situated in London, during last year, as in previous years, we have been able to welcome a considerable number of visitors, both from the country and abroad, at the Municipal Centre. No. 10, John Street. The Centre was used for the purposes of instruction in infant care of the oldest girls attending Christ Church Public Elementary School. Eighteen girls attended, in 3 parties of 6 each. 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, 1925, 412 infants and children under 5 attended the consultations, 108 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, 97 Deaths of Infants under One Year of Age, 1025. The homes were visited in a large proportion of the infant deaths, and any requisite information obtained, and when required, suitably 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.G Months G.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 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 2 ... ... 2 2 4 Tuberculous Disease (non-pulmonary) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 1 Bronchitis ... 1 ... ... ... ... ... ... ... 1 1 ... ... ... ... ... 1 ... ... ... 3 3 Pneumonia (all forms) ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 1 ... 1 2 2 4 Diarrhoea ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteritis ... ... 1 ... ... ... ... ... 1 ... 1 ... ... 1 3 ... ... ... ... 3 3 6 Congenital Malformations ... 1 ... ... ... ... ... ... ... 1 1 1 ... ... ... ... ... ... ... 1 1 2 Premature Births 1 3 ... ... ... 1 ... ... l 4 5 ... 1 ... ... ... ... ... ... 1 5 6 Atrophy, Debility, Marasmus ... ... ... ... ... ... ... ... ... ... ... 1 1 2 1 ... ... ... ... 3 2 5 Other causes 1 1 ... ... ... ... ... ... 1 1 2 ... ... ... 1 ... ... ... ... 1 1 2 Totals 2 6 1 0 0 1 0 0 3 1 10 2 3 6 4 1 4 1 2 13 20 33 Total both sexes 8 1 1 0 10 5 10 5 3 33 Net births registered during the calendar year. Net deaths registered during the calendar year. Males Females Both sexes Males Females Both sexes Legitimate Infants 232 258 490 Legitimate Infants 11 17 28 Illegitimate Infants 22 15 37 Illegitimate Infants 2 3 5 98 Deaths of Children 1 to 5 Years, 1925. Eighteen 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. Whooping Cough 2 1 ... 2 ... ... ... ... 2 3 5 Pulmonary Tuberculosis ... ... ... 1 ... ... ... ... ... 1 1 Other Tuberculous Diseases ... 2 ... ... ... ... ... ... ... 2 2 Pneumonia ... 2 1 ... ... ... ... ... 1 2 3 Nephritis ... ... ... ... 1 ... ... ... 1 ... 1 Violence ... ... ... ... ... ... 1 ... 1 ... 1 Other Causes 1 ... 1 ... 1 ... ... ... ... ... 3 Rheumatic Fever ... ... ... ... ... ... l ... 1 ... 1 Cirrhosis of Liver 1 ... ... ... ... ... ... ... 1 ... 1 Totals 4 0 2 3 2 ... 2 ... 10 8 18 Totals—Both Sexes 9 5 2 2 18 Infectious Diseases among Mothers and Children. Puerperal Fever. Two cases of puerperal fever were notified in 1925. One patient died. In the first case the disease followed the birth of a first child. The mother was attended at the confinement by a doctor, and the district nurses were in attendance. This patient recovered. The second case, which terminated fatally, was notified as puerperal fever on October 24th. The patient was a married woman. She had a healthy child at a confinement normal as far as can be ascertained. This confinement took place at the normal time at home in exceptionally clean surroundings; she was attended by the external midwifery service of a hospital and by a nurse of the midwifery service of a nursing association. Labour occurred on October 21st and was normal; on October 23rd the patient was removed to the Poor Law Infirmary, and from thence, on October 24th, to a hospital of the Metropolitan Asylums Board as it was found that she was suffering from scarlet fever in addition to puerperal fever. Death took place on October 27th. As far as could be discovered there had been no contact with scarlet fever either on the part of the student attending from the hospital or the nurse, nor had either of them been in attendance on a septic case. On the appearance of the fever a swab was taken from the vagina for bacteriological examination, and from it were grown streptococci and diphtheroid organisms from which it was thought that the genital tract was the source of the generalised infection from which the patient died. Ophthalmia Neonatorum. During the year 11 cases of ophthalmia neonatorum occurring in babies belonging to the Borough were brought to our notice. Nine out of the 11 cases were notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914, all these notifications being from institutions. One of these cases was only notified after communication with the medical attendant. 99 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:— Nine Cases Notified in Accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914. Case Number. Age when Notified. Age at Onset. By whom Notified. Type of Disease on Health Visitor's first visit. Where Treated. Medical Attendance and Nursing. Result. Birth Notified by remarks. 2 1 day 1 day 1. M. A. B. 2. Uoctor (Hospital) Middlesex Hospital and St. Margaret's Hospital Middlesex Hospital and St. Margaret's Hospital Died Extern Department Hospital Died in St Margaret's Hospital set. 14 days 8 14 days 9 days Doctor [(Hospital) Slight Middlesex Hospital (in-patient) and Home In-patient, Maternity Wards. Middlesex Hospital. District Nurse Cured Intern Department Hospital 4 12 days 8 days Doctor (Hospital) Slight University College Hospital (out-patient) and Home Midwife and out-patient University College Hospital Cured Extern Department Hospital 6 14 days 8 days 1. M. A. B. 2. Doctor (Hospital) St. Pancras House and St. Margaret's Hospital St. Pancras House and St. Margaret's Hospital Not ascertainable Hospital Doctor Did not return to this Borough 6 8 days 6 days Doctor (Hospital) Moderate Home Doctor (Middlesex Hospital), and District Nurse Cured Extern Department Hospital 7 2L days 7 days Doctor (Hospital) out-patient department Hospital for Sick Children Gt. Ormond Street out-patient department Hospital for Sick Children, and St. Margaret's Hospital (in.patient and out-patient) Cured Midwife 8 10 days 3 days Doctor (Hospital) Maternity Ward Middlesex Hospital In.patient and outpatient Middlesex Hospital Cured Intern Department Hospital 9 13 days 1 day Doctor (Hospital) after correspondence Moderate Home Doctor (Royal Free Hospital) and Midwife Cured Extern Department Hospital 10 10 days 6 days Doctor (Hospital) Moderate Maternity Hospital (City of London). Out-patient Royal Ophthalmic Hospital City Rd. and Home City of London Maternity Hospital (in-patient), Royal London Ophthalmic Hospital. City Road (out-patient) and District Nurse Cured Intern Department Maternity Hospital G 2 100 Two Cases not Notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914. Case Number. Age when Information received. Age at Onset. Information. Type of Disease on Health Visitor's first visit. Where treated. Medical Attendance and Nursing. Result. Confinement attended by. Remarks. 1 11 days 3 days Health Visitor Slight Home and out-patient Department, Central London Ophthalmic Hospital Midwife, University College Hospital Cured Midwife, University College Hospital 11 12 days 8 days Doctor after correspondence Slight Home and out-patient Department, Royal Ophthalmic Hospital out-patient Royal Ophthalmic Hospital and Doctor-in-charge of case and District Nurse Cured Doctor Removed at 21 days 101 Ophthalmia neonatorum is one of the most important causes of blindness. Fortunately, however, as far as we have been able to ascertain, no case coming to our knowledge last year in the Borough suffered permanent injury in this way. One child died in hospital when 14 days old. In 2 cases reliable information could not be obtained because the mothers of the infants did not return to this Borough, but in the remaining eight cases there was definite evidence that the patients were cured. This result was secured by the expenditure of much time and energy, and incidentally 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 newly.born 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 five years 1921.25, information of cases of ophthalmia neona torum was received as follows:— Year. Notified in accordance with Regulations. Not notified. Total. 1921 6 4 10 1922 9 2 11 1923 6 8 14 1924 9 4 13 1925 9 2 11 39 20 59 Whooping Cough. Visits were paid to 152 persons suffering from whooping cough. Of these 113 were notified by doctors; in 17 others the information was derived from the schools; 10 from the Health Visitors; 5 from parents, 4 from hospitals, and 1 from death returns. Nine died, 4 were under 1 year, and 5 between 1 and 5 years. Age. Nineteen were children under 1 year, eighty-eight were aged 1 to 5 years, and forty-five 5 to 16 years. 102 Contacts. (152 enquiries.) Fifty-nine had no contacts; 93 had contacts. The number of contacts was 280, of whom 134 were susceptible, 146 already having suffered from an attack. No. of cases and 31 23 11 7 8 3 5 2 3 No. of contacts 1 2 3 4 5 6 7 8 10 No. of cases and 32 13 12 3 2 3 No. of susceptible contacts 1 2 3 4 5 6 Spread of Infection in Family. The 152 cases occurred in 117 families. In 88 families 1 ease occurred; in 23 families 2 cases occurred, and in 6 families 3 cases occurred. Removal. Fifty.one children were removed to hospital, approximately 33'0 per cent. as opposed to 46 per cent. last year. These were all admitted to hospitals of the M.A.B. Spread of Infection. There is much difficulty in getting parents to realise that the child of preschool age must be sheltered from the risk of infection as much as the child attending school. Parents realise that the school child is a potential focus of infection for many other children, and should be guarded from infection; they fail to realise that the pre.school child, although less likely to spread the disease, is less able to resist the dangers of an attack; many parents state candidly that they send children with whooping cough into the squares and streets during school hours, when " there are no other children about." Disinfection of premises is carried out in connection with whooping cough. The following table relates to whooping cough in the Borough in the five years 1921.25. Year Number of persons known to be suffering Number of families affectcd Number cf patients under 5 years of age Number removed to hospital 1921 173 123 107 24 1922 132 90 96 25 1923 138 95 106 42 1924 136 109 111 63 1925 152 117 107 51 Five years 731 534 527 205 103 Measles. The notification of measles was discontinued at the end of 1919, but during 1925. I received information of 45 cases of measles. Of these 17 were notified by school teachers, 17 by medical practitioners, information of 6 was given by the Metropolitan Asylums Board, of 1 by the Health Visitors, 3 by parents, and 1 by a divisional surgeon of police. Ages. 2 were under 1 year. 8 were between 1 and 5 years. 31 were between 5 and 16 years. 4 were over 16. Contacts. Nineteen had no contacts, the L.C.C. definition of a contact being used. Twenty-six had contacts. The number of contacts was 84, of whom 56 were susceptible, 28 having already suffered from an attack. No. of eases and 6 9 2 1 3 2 1 2 No. of contacts 1 2 3 4 5 6 7 8 No. of cases and 10 3 1 3 1 0 0 0 No. of susceptible contacts 1 2 3 4 5 6 7 8 Spread in Family. The 45 cases occurred in 41 families. In 38 families 1 case occurred, in 2 families 2 cases occurred, and in 1 family 3 cases occurred. Removals. In all about 25 per cent. of the patients were removed to institutions. 6 were removed to a M.A.B. Hospital. 4 ,, ,, ,, the Holbom Poor Law Infirmary. 2 ,, ,, ,, the London Fever Hospital. Home Nursing. No case of measles was referred to the Metropolitan Nursing Association for home nursing under the Council's arrangements. During the five years 1921.25, information was received of 633 cases of measles. Of these 308 were under 5 years of age. About 24 per cent. were removed to hospital for treatment. German Measles. During the year information was received relating to 99 cases; 6 were notified by doctors and information of 70 cases was received from schools, 11 from the M.A.B., 2 from the Health Visitors, 8 from parents, and 2 from a divisional surgeon of police. 104 Ages. 13 were between 1 and 5 years. 75 were between 5 and 16 years. 11 were adults. Contacts. The number of contacts was 183 of whom 109 were susceptible, 74 having already suffered from an attack; 35 had no contacts. No. of cases and 19 13 15 5 5 4 2 0 0 1 No. of contacts 1 2 3 4 5 6 7 8 9 10 No. of cases and 22 13 12 3 0 1 1 0 No. of susceptible contacts 1 9 3 4 5 6 7 8 Spread in Family. The 99 cases occurred in 86 families. In 77 families 1 case occurred, in 6 families 2 cases occurred, in 2 families 3 cases, and in 1 family .1 cases. Removals. About 13 per cent. of the cases were removed to institutions— 11 to the London Fever Hospital. 1 to a Nursing Home. 1 to the Holborn and Finsbury Hospital. Epidemic Diarrhcea. 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 6, all under 1 year. The deaths were equal to a rate of 11.4 per 1,000 births in comparison with 10.6 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 diarrhoea is more likely to occur. During the five years 1921.25, 31 deaths of Holborn children under 2 years of age were recorded from this disease, equal to 10.2 per ,000 births in comparison with a rate of 11.5 per 1,000 in all London. Nursing Arrangements. Nursing arrangements have been made with the Metropolitan Nursing Association, No. 23, Bloomsbury Square, now 31, Bedford Place, for the nursing, when required, of necessitous cases of measles, whooping cough, ophthalmia neonatorum, epidemic diarrhoea, pneumonia, encephalitis lethargica and tuberculosis. 105 Their services were used as follows:— Deficient Lactation 15 Cases 178 Visits. Whooping Cough 1 Case 7 „ Measles 0 „ 0 „ Ophthalmia Neonatorum 3 Cases 117 „ Pneumonia 10 „ 240 Influenza 1 Case 5 „ Tuberculosis 4 Cases 204 ,, Total 34 Cases 751 Visits. During the five years, 1921-25, the facilities for nursing provided by the Council have been used as follows:— Year. Whooping Cough. Measles. Ophthalmia Neonatorum, Influenza. Pneumonia Deficient Lactation, Tuberculosis. Cases. Visits. Cases. Visits. Cases. Visits. Cases Visits. Cases. Visits. Cases. Visits. Cases. Visits. 1921 1 4 — — 7 133 — — 11 177 — — — — 1922 2 19 6 80 3 104 — — 12 183 — — — — 1923 1 24 4 38 3 82 6 170 4 116 — — — — 1924 1 45 10 93 2 40 8 109 14 219 14 191 4 123 1925 1 7 — — 3 117 1 5 10 240 15 178 4 204 6 99 20 211 18 476 15 284 51 935 29 369 8 327 Widows', Orphans' and Old Age Contributory Pensions Act, 1925. This Act, passed in 1925, imposed certain limited duties on Local Authorities respecting cases where, in the interests of a child, a pension payable under the Act should be administered other than through the mother. The Local Authority in London for this purpose was the London County Council, but authority was conferred on that Council to delegate the powers and duties to the Metropolitan Borough Councils, and shortly after the Act came into operation, the London County Council delegated the whole of the powers and duties conferred on it by Section 6 of the Act to the Borough Council. It is not anticipated that there will be many such cases in the Borough. The duty will include enquiry to ascertain the facts of any cases which may have to be dealt with, and ordinarily the widow or other person affected will be given an opportunity of presenting her case to the Local Authority before the particulars are submitted to the Minister of Health. It is expected that information respecting such cases will come to the notice of the Council through its 106 Maternity and Child Welfare service, the Local Education Authority, Poor Law Officers, the Society for the Prevention of Cruelty to Children and Social Service Workers. Health Week and Baby Week. Following the precedents of recent years the celebration of these weeks was combined, and observed from the 4th to 10th October, 1925. The efforts made during the week included the following:— 1. A meeting was held in the Court Room on the subject of the provision of subsidised workshops for tuberculous men and women. The Right Worshipful The Mayor presided at the opening and the first part of the meeting, the Chair being subsequently taken by Councillor The Rev. Henrv Ross, Chairman of the Public Health Committee. The speakers, in addition to the Mayor and Councillor Ross, included Mr. G. H. Walmisley, M.C., L.C.C. Dr. Haden Guest, M.C., M.P. Dr. Otto May (The Prudential Assurance Company). Dr. Harry Campbell. Dr. Noel D. Bardswell, M.V.O. (representing the Central Fund for the Industrial Welfare of Tuberculous Persons). The Rev. J. C. Pringle (General Secretary, Charity Organisation Society). Dr. G. Quin Lennane (Medical Officer of Health of Battersea). Councillor J. Berliner (Finsbury). Mr. W. Westcott, J.P. (Southwark). The meeting was well attended by members of Metropolitan Public Health and Poor Law Authorities. Labour Exchanges and Employment Bureaux, Insurance Companies and Approved Societies and various Voluntary Organisations interested in the welfare of tuberculous persons. 2. With the co-operation of the teachers in elementary schools a series of questions, prepared in the Public Health Department, on health topics, were submitted to the elder children in schools in the Borough. Prizes were awarded for the best answers received from each school and three boys and three girls from each school taking part, whose replies were selected by the Head Teacher as best, were entertained to tea by the Mayor and Mayoress on the occasion of the distribution of prizes. Every school in the Borough, with the exception of one where only junior children are admitted, took part. 107 The observation of Health Week in the schools is becoming increasingly popular and the year was probably the most successful we have had. The questions submitted to the children in the schools were as follows:— Section A. (All four questions to be answered). (Put the number of each question before the answer). 1. Why do we need food? Say what uses are served by it. 2. Mention diseases or illnesses that may be caused by decaying and neglected teeth. Describe how you would keep your teeth clean. 3. Why are parks and open spaces often called the lungs of London? Say why we value these spaces so much. 4. What games or sports do you think are the best to help a girl or boy grow strong and healthy ? Say why you think so. Section B. (Any two of the following questions to be answered). (Put the number of each question answered before the answer). 5. What is the use of the skin? Why should the skin of the body be kept clean and how would you keep it so? 6. Several dangers may arise from dirty nails, name some of these, and say how you would keep your nails clean. 7. Why is it especially necessary to wash and change one's underclothing very frequently ? 8. Why does a child need sleep? How many hours sleep do children 12-14 years of age require? 9. Describe the bedroom in which you would like to sleep, and state how you would ventilate it. 10. Why do we want to get rid of flies, and how can we do this? 3. The Clergy of all denominations were invited to observe Sunday, the 4th of October, as Health Sunday and in addition to making references to the matter in their services, a number kindly co-operated in the distribution of suitable literature. Councillor the Rev. Wilfred H. Davies, M.A., helped us very much in this connection. 4. Arrangements were made for a competition and exhibition of work done by mothers and fathers of children attending the Council s Maternity and Child Welfare Centre, No. 10, John Street. The exhibition was well attended not only by competitors and exhibitors but by other mothers in the Borough. The exhibition included garments made from new material, renovated garments, knitted garments and cakes made by the mothers, and various useful household articles made by fathers. The exhibits were iudged by Miss M. S. Yeaxlee, Head Mistress. Girls' "Department, Christchurch School. Prizes and certificates were offered and these were distributed by Councillor Miss Emily Dibdin. 108 Dr. E. G. Annis, Medical Officer of Health of Greenwich, spoke to the mothers on "Domestic Public Health," and Mrs. W. Sampson Handley dealt with "Character Training of Children." A copy of her address was subsequently given to all the mothers who attended. 5. Distribution of literature.—As in some previous years arrangements were made with various traders in the Borough to co-operate in the distribution of leaflets from their counters during Health Week. Traders willingly responded to the suggestion and a large number of leaflets were distributed in this way to the shopping public in the Borough. A special poster was prepared and issued for distribution throughout the Borough. The special leaflets used were:— "Our Daily Bread." "From a Father to Fathers" (by kind permission of the National Baby Week Council). "Save your Children from Diphtheria" (illustrated). "Spread of Infection by Coughing" (illustrated). 6. By the kind permission of Messrs. George Kent, Ltd., an attractoscope, showing pictures on health topics was exhibited in a window of their premises in High Holborn and attracted much attention from a large number of passers-by. Much valuable help and sympathetic co-operation was given by the Mayor and Mayoress and the Chairmen of the Public Health and Maternity and Child Welfare Committees (Alderman F. J. Pullen and Councillor The Rev. Henry Ross). Minor Ailments Clinic. Arrangements were made at the Municipal Child Welfare Centre, 10, John Street, for the treatment of minor ailments in children 2 to 5 years of age. The Clinic opened on the 12th April; it has been held every Tuesday and Friday afternoon to deal with such minor ailments as ringworm, impetigo, scabies, intertrigo, sores, cuts, grazes, burns, blepharitis, conjunctivitis, ear discharge, tonsils, adenoids, phimosis, nævi, rickets, hernia, etc. The Clinic is under the supervision of the Medical Officer of the Maternity and Child Welfare Centre and a qualified nurse is in attendance. First International Congress on Child Welfare. As a delegate appointed by the Council I had the privilege of attending the above Congress at Geneva and presented a report subsequently. The Congress was eminently successful. The most striking of many interesting Public Health Institutions seen was one at Zurich for unmarried mothers. The extent to which breast milk was made available for other ailing babies in the town was astonishing. It is evident that much more could be done in this country on these lines. 109 Child Welfare work in Alsace Lorraine. Subsequently I had the opportunity of seeing something of child welfare work in Alsace Lorraine and especially in Strasbourg, where this work is undoubtedly of a high order. The co-ordination of the official work is better than in these islands; much of the work carried out by the British Poor Law is in Strasbourg carried out by a division of the Mairie quite distinct from the Assistance Publique. Not only this but the work done by the Women Visitors of the Protection de la Jeunesse in connection with abandoned, deserted and orphan children of all ages including those put on probation by the Police Magistrates was also co-ordinated with that of the health visitors. The connection of the Protection de la Jeunesse with the City Orphanage was close; on the premises was a depot of the Protection de la Jeunesse in which the children of mothers in difficulty could be placed temporarily. I was also taken to see a foyer where children living under crowded conditions at home and whose mothers went to work were looked after during the day time, the school holidays, and before and after school in term time; they always slept at home. Tounger children are taken charge of in a kindergarten. The Protection de la Jeunesse also possessed a residential institution for delicate children. But the work perhaps on which they pride themselves most is the guardianship of illegitimate children; where necessary the chief official of the Protection de la Jeunesse assumes the position of guardian to all these children and looks after their welfare in much the same way as a foster-father. 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 Eoad. (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) Homœpathic 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. 110 Medical Routine Examination of Elementary School Children in Holborn in 1925. The County Medical Officer of Health has kindly furnished me with particulars of medical inspections of school children in Holborn in 1925. They are classified in the following tables:— Age, Group. Number examined. Clothing and Boots. Nutrition. Cleanliness of Head. Cleanliness of Body. Teeth. Vision. Good. Fair. Poor. Good. Average. Below normal. Bad. Clean. Nits. Pediculi. Clean. Dirty. Pediculi. All sound. Less than four decayed. Four or more decayed. 6/6 in both eyes. 6 9 in either or both eyes. 6/12 or worse in either eye. Entrants— Boys 391 170 204 17 36 330 25 ... 358 31 2 385 5 1 218 117 56 ... ... ... Girls 363 189 162 14 32 293 40 ... 302 52 11 361 4 ... 218 103 44 ... ... ... Age 8— Boys 199 37 148 14 29 151 19 ... 172 25 2 195 4 ... 123 68 8 130 22 42 Girls 178 46 122 10 25 141 12 ... 127 43 8 178 ... ... 177 60 11 119 23 30 Age 12— Boys 226 47 155 24 39 178 9 ... 193 32 1 221 5 162 61 3 147 17 61 Girls 228 52 159 17 46 168 14 ... 155 60 13 226 2 163 62 3 152 17 59 Age 14— Boys 222 51 158 13 65 142 15 ... 199 23 ... 221 ... 1 158 61 3 157 16 49 Girls 181 49 125 7 67 107 7 ... 141 31 9 181 ... ... 124 54 3 122 18 40 Total 1,990 641 1,233 116 339 1,510 141 ... 1,647 297 46 1.968 20 2 1,273 536 131 827 113 281 % Holborn ... 32 .2 62.0 5.8 17.0 75.9 7.1 ... 82.8 14.9 2.3 98.9 1.0 0.1 64.0 19.4 67.7 9.3 23.0 % London ... 60.1 38.6 1.3 21.1 72.9 6.0 ... 91.0 8.3 0.7 95.3 4.6 0.1 61.8 30.2 8.0 53.9 26.3 198 111 Defects Found At Medical Routine Examination of Elementary School Children in Holborn in 1925. Defect. Boys. Girls. Entrants Age 8 Age 12 Age 14 Entrants Age 8 Age 12 Age 14 Number Examined 391 199 226 222 365 178 228 181 Cases + Cases + Cases + Cases + Cases 4- Cases + Cases + Cases + Malnutrition 2 1 1 1 Skin Disease 2 2 2 3 1 6 5 1 1 1 1 Enlarged Tonsils 33 8 8 4 3 1 1 1 31 11 10 4 4 1 6 4 Adenoids 3 2 1 1 7 4 1 1 2 1 Tonsils and Adenoids. 13 8 6 4 1 1 16 13 3 3 4 4 Other Nose and Threat 3 1 1 1 1 3 1 2 2 Enlarged Glands 2 2 2 2 1 External Eye Disease 19 10 13 6 4 4 2 2 24 15 6 4 3 2 2 2 Vision 24 46 33 17 42 23 Otorrhœa 7 2 2 1 3 1 2 1 7 6 1 1 2 1 Other Ear Disease 1 1 1 1 Hearing 1 1 4 4 I 1 1 1 Stani merin g and Speech 1 1 1 Heart ... 3 7 1 1 4 6 5 Ai aemia 5 3 7 2 8 5 6 4 2 2 2 1 3 Lungs ... c 1 5 1 7 3 4 1 1 Nervous Disorders 1 1 1 1 Phthisis 1 2 Other Tblr. Disease 1 Rickets 1 1 Spinal Defects 3 5 4 3 2 7 4 1 4 3 6 3 1 1 Other Deformities Other Defects 2 1 1 1 1 1 3 3 1 1 Teeth 114 51 43 51 104 43 54 48 Number of Children for treatment 141 77 89 82 141 68 92 77 * + = number of defects. 112 Deaths of Children 5.15 years, 1925. Ages. Total. 5 6 7 8 9 10 11 12 13 14 M F Both Sexes. M F M F M F M F M F M F M F M F M F M F Enteric Fever ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Diphtheria ... ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 2 2 Pneumonia ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Violence ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Other Diseases ... ... ... ... ... ... 1 1 ... 1 ... ... ... ... ... ... ... ... 1 ... 2 2 4 Total ... 1 ... ... 1 ... 1 2 ... 2 ... ... ... ... ... ... ... ... 1 ... 3 6 9 Total both 6exes 1 1 1 3 2 ... ... ... ... 1 9 113 SANITARY ADMINISTRATION. Public Mortuary. The Public Mortuary provided by the Council is situated in Goldsmith Street. During the year 37 bodies were deposited. There were 29 post mortem examinations made, and 28 inquests held. The inquests are held in the Court Room at the Town Hall. On 8 occasions bodies awaiting burial were removed to the mortuary on account of inadequate accommodation in the homes; 28 bodies were brought in by order of the Coroner, and 1 by the Police. Inquests. During the year 56 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, 31; Accidents, 13; Suicide, 8; Misadventure, 4. Revenue Acts. No application was received under these Acts. 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 we endeavour, as much as possible, 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. 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. H 114 The principle of such compulsory power has been established by a local Act in Bradford. Under this Act a Court of Summary Jurisdiction may, on the application of the Medical Officer of Health, issue an order for the removal to an institution of any aged, infirm, or physically incapacitated person, where it is shown that in the public interest or the interest of the person concerned such removal is necessary. Some, if not most, of these aged people rely almost entirely on the Old Age Pension for sustenance, and although they endeavour to retain their independence they are sometimes found unable to keep either themselves or their rooms in a decent condition. There would seem to be ample reason for suggesting that some authority should be charged with the responsibility of looking after the welfare of these pensioners. It would not require any elaborate machinery to effect this, and but little expense, if the duty was placed on local authorities, and the work of visiting carried out by Sanitary Inspectors or Health Visitors already attached to Public Health Departments. Rent and Mortgage Interest Restrictions Acts. On the application of a tenant one certificate was issued under the above Acts that the house complained of was not in all respects reasonably fit for human habitation or was otherwise not in a reasonable state of repair. One application was refused. Other Propaganda Leaflets, etc. Arrangements were continued 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 leaflet giving advice to women on constipation was also issued during the year and a very large number were distributed by means of "Please Take One" boxes in the public conveniences for women. Pigeons. Complaints are very occasionally received by various bodies in the Borough of nuisance caused by pigeons; about two years ago it was necessary to serve a notice for the abatement of a nuisance arising from an accumulation of excreta deposited on a window sill by pigeons. These birds are found in considerable numbers in the Borough, particularly in Gray's Inn, at the British Museum, and in the vicinity of some of the church buildings. At the British Museum, pigeons have given considerable trouble for some years past and involved the authorities in considerable cost in clearing away the filth caused by their presence. The birds cause very extensive fouling of the floor of the colonnade, entrance, portico, and outer steps, in addition to splashing the stone plinth course and the ashlar. It is necessary to clean the entrance portico and steps every morning and wash down the colonnade once a week to 115 avoid offensive smell from the accumulation of droppings. In Gray's Inn, where there are two flocks of the birds, less nuisance is noticed but occasional complaints are made relating to pigeon dung on the window sills. The number of pigeons in the Borough has increased in the past five years, and although there is a sentimental interest in the birds which would preclude their complete extermination, it might be desirable to take some step to prevent further increase in the numbers, or even to lessen the number. The matter has been brought to the notice of the Ministry of Health, the London County Council, and the Metropolitan Borough Standing Joint Committee, and the question of legislation to deal with it is under consideration. 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 has provided this housing accommodation on a site purchased from the Council, where a block of dwellings with 37 tenements has been erected. 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 880 houses occupied by the working classes were inspected; this number consisted of 577 registered lodging houses and 303 non-registered houses occupied by working classes. 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. Betterton Strcei Small Housing Scheme. The Housing of the Working Classes Committee have from time to time considered a number of schemes for the construction of houses for the working classes, but owing to the high cost of land in the Borough most of these have been found impracticable. The Committee were of opinion that useful improvements might be effected by the acquisition of unsatisfactory, old and worn houses, and their reconstruction pr demolition and rebuilding. H 2 116 An opportunity occurred for a small scheme on these lines by the acquisition of three adjoining tenement houses in Betterton Street, together with the site of the fourth house which had already been demolished. The houses were not suitable for reconstruction as the existing walls were not in the required positions nor of the required thickness or condition. The Council decided to acquire the vacant site and the three houses for demolition and the construction of selfccntained flats. The scheme entails the displacement of about fifty persons occupying the three houses but the fifteen self-contained flats to be provided will probably provide accommodation for seventy persons, so that, in addition to securing much improved housing accommodation, a larger number of residents will be provided for. HOUSING CONDITIONS. Statistics. Year Ended 31st December, 1925. 1.—GENERAL. (1) Estimated population ... ... ... 43,315 (2) General death rate ... ... ... 12.51 (3) Death-rate from tuberculosis (all forms) ... ... ... 1.24 (4) Infantile mortality rate ... ... ... 63 *(5) Number of buildings containing dwellings (Census, 1921) 3,473 †(6) Number of separate dwellings (Census, 1921) 7,202 ‡(6a) Number of working-class tenements (Census, 1921) 8,571 (7) Number of new working-class houses erected 1 Block (37 tenements) 2.—UNFIT DWELLING-HOUSES. I.—INSPECTION. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 880§ (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 7|| (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 606 II.—REMEDY OF DEFECTS WITHOUT SERVICE OF FORMAL NOTICES. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers *"Buildings."—A structure wholly detached or separated from another by a party wall, e.g., a block of flats is one building. †" Separate dwelling," i.e., having separate access to street or common landing or staircase, e.g., each flat in a block is a separate dwelling, but a private house not structurally divided is a single unit whether occupied by one or more families. ‡" Working-class tenements," i.e., separate occupations of one, two, three or four rooms only. § Practically all these houses were tenement houses containing a number of tenements. ||A11 the more insanitary houses are always annually inspected, although only 7 last year were formally recorded under the above Regulations. 117 III.—ACTION UNDER STATUTORY TOWERS. 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 606 (2) Number of dwelling-houses in which defects were remedied:— (a) by owners 600 (b) by Local Authority in default of owners nil C. Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1919:— (!) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling-houses in respect of which Closing Orders were made nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit 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 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 118 APPENDIX. TABLE I. Vital Statistics of Whole District during 1925 and Ten Previous Years. Year Population estimated to Middle of each Year. Uncorrected Number Births. Total Deaths Registered in the District Transferable Deaths Net Deaths belonging to the District. Under 1 Year of Age At all Ages Net Number Rate of Non residents registered in the District of Residents not registered in the District Number Rate per 1,000 Births Number Rate Number Rate 1916 40,405 594 670 14.4 876 21.8 559 385 64 96 702 17.4 191 6 38,161 564 619 15.7 768 20.2 498 395 63 97 665 17.6 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 13.0 920 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 79 656 12.8 1922 42,850 485 664 15.5 746 17.4 518 312 48 72 670 13.5 1923 43.376 423 593 13.7 718 16.6 491 300 47 79 526 12.1 1924 43,250 394 578 13.36 670 15.5 470 329 47 81 529 12.2 1926 43,315 364 527 12.16 725 16.7 513 330 33 63 542 12.5 In the above table the population, birth rate and death rate are as estimated by the Registrar-General, founded upon his estimates of the civilian population, 119 TABLE II. Causes of, and Ages at, Death, 1925. Causes or 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 342 33 9 9 9 21 49 184 119 109 Uncertified ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever 1 ... ... ... 1 ... ... ... ... ... 2 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... 3. Measles ... ... ... ... ... ... ... ... ... ... ... 4. Scarlet Fever 1 ... ... ... ... 1 ... ... ... ... 5. Whooping Cough 9 4 3 2 ... ... ... ... ... ... 3 6. Diphtheria and Croup 2 ... ... ... 2 ... ... ... ... ... 2 7. Influenza 9 ... ... ... ... 2 ... 3 3 1 1 8. Encephalitis Lethargica 1 ... ... ... ... ... 1 ... ... ... 1 9. Meningo-coccal Meningitis ... ... ... ... ... ... ... ... ... ... 2 10. Tuberculosis of Respiratory System 45 ... ... ... ... 6 17 21 1 ... 22 11. Other Tuberculous Diseases 9 1 ... 1 ... 2 1 1 l ... 42 12. Cancer, malignant disease 66 ... ... ... ... ... 4 28 24 10 51 13. Rheumatic Fever 2 ... ... 1 ... ... ... 1 ... ... 4 14. Diabetes 3 ... ... ... ... ... ... 1 2 ... 1 15. Cerebral Hæmorrhage 69 ... ... ... ... 1 ... 10 11 18 11 16. Heart Disease 40 ... ... ... ... 2 6 27 21 13 13 17. Arterio-sclerosis 44 ... ... ... ... ... 1 11 12 20 4 18. Bronchitis 55 3 ... ... ... ... ... 14 14 24 5 19. Pneumonia (all forms) 41 4 ... 1 1 ... 4 19 6 3 43 20. Other Respiratory Diseases 4 ... ... ... ... ... 1 ... 3 ... 9 21. Ulcer of Stomach or Duodenum 6 ... ... ... .... ... ... 5 1 ... ... 22. Diarrhoea, etc. 12 6 ... ... 1 ... 1 ... 1 2 67 23. Appendicitis and Typhlitis 1 ... ... ... 1 ... ... ... ... ... 4 24. Cirrhosis of Liver 7 ... ... ... ... ... 1 4 1 ... 2 25. Acute Chronic Nephritis 11 ... ... 1 ... ... 1 4 2 3 22 26. Puerperal Sepsis 1 ... ... ... ... ... 1 ... ... ... ... 27. Other accidents and diseases of Tregnancy and Parturition 1 ... ... ... ... ... 1 ... ... ... ... 28. Congenital Debility and Malformation, Premature Birth 13 13 ... ... ... ... ... ... ... ... 70 29. Suicide 10 ... ... ... ... ... 2 5 3 ... ... 30. Other Deaths from Violence . 17 ... ... 1 1 ... 2 6 3 4 6 31. Other Defined Diseases 62 2 1 2 2 ... 5 24 10 11 146 32. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... 342 33 9 9 9 21 49 184 119 109 533 120 TABLE III. Cases of Infectious Disease notified during the year 1925. Notifiable Disease. Number of Cases Notified • Total Cases Notified in each Locality (e.g, Parish or Ward) of the District. Total Cases Removed to Hospitals. At all Ages. At Ages—Years. St. Giles and Bloomsbury. Holborn. Under 1 1 to 6 5 to 15 16 to 25 25 to 45 45 to 65 65 and upwards. Small-pox ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) ... 76 ... 26 26 16 8 ... ... 21 55 74 Erysipelas . 13 ... 1 ... 2 2 4 4 7 6 6 Scarlet Fever 86 ... 22 41 18 5 ... ... 16 70 86 Enteric Fever 6 ... ... 2 1 3 ... ... 3 3 6 Puerperal Fever 2 ... ... ... ... 2 ... ... 2 ... 1 Cerebro-spinal Fever 1 ... ... 1 ... ... ... ... ... 1 1 Ophthalmia Neonatorum 9 9 ... ... ... ... ... ... 4 5 4 Dysentery ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... Pneumonia—Primary 45 ... 1 5 10 8 13 8 26 19 26 do. Influenzal 10 ... 1 1 1 3 1 3 3 7 4 Tuberculosis—Pulmonary 63 ... ... 1 12 33 15 2 32 31 38 do. Non-Pulmonary 11 ... 2 2 7 ... ... ... 6 5 9 \\ hooping Cough 113 16 70 27 ... ... ... ... 37 76 40 Acute Poliomyelitis 2 ... ... 1 ... 1 ... ... 1 1 2 Encephalitis Lethargica 1 ... ... ... ... 1 ... ... ... 1 ... 438 25 123 107 67 66 33 17 168 280 297 121 TABLE IV. Infectious Diseases in Holborn for the last Eleven Years. NOTIFICATIONS DEATHS Decennial Average, 1915-1924 Year 1925 Decennial Average, 1915-1924 Year 1925 Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Number Rate per 1,000 London Rate Small-pox 0.3 0.01 0.00 0 0.00 0.00 0 0.00 0.00 0 0.00 0.00 Diphtheria 9.9 2.45 2.50 76 1.75 2.72 5 0.13 0.18 2 0.05 0.11 Erysipelas 1.9 0.47 0.63 13 0.30 0.42 ... ... ... ... ... ... Scarlet Fever 9.8 2.37 3.30 86 1.98 2.66 ... 0.02 0.04 1 0.02 0. 02 Enteric Fever 4 0.10 0.09 6 0.13 0.09 0.5 0.01 0 .02 1 0.02 0.01 Cerebro-spinal Fever 2.5 0.06 0.07 ... 0.00 0.02 ... ... ... 0 0.00 ... Acute Poliomyelitis 1 0.02 ... 2 0.05 0.01 ... ... ... 0 0.00 ... Whooping Cough† 6.0 2.26 ... 113 2.61 ... 5 0.13 0.18 9 0.21 0.19 Measles ... ... ... ... ... ... 9 0.24 0.22 0 0.00 0.08 Tuberculosis—Pulmonary 111 2.83 ... 63 1.45 1.65 61 1.56 1.30 45 1.04 0.91 Ditto Non-Pulmonary 18 0.49 ... 11 0.25 0.46 8 0.20 ... 9 0.21 0.16 Puerperal Fever* 1.1 2.52 3.16 2 3.79 3.83 1 1.53 ... 1 1.89 1.29 Ophthalmia Neonatorum* 8 13.70 ... 9 17,08 8.58 ... ... ... ... ... ... Diarrhoea (under 2 years)"‡ ... ... ... ... ... ... 8 12.9 15.0 6 11.38 10.6 * Rates per 1,000 births. † Notifiable in Holborn (not in London) since 1914. ‡ Not Notifiable. 122 TABLE V. INFORMATION REQUIRED BY THE LONDON COUNTY COUNCIL. PREMISES. Number on Register at end of 1925. Number of Inspections. Number of Prosecutions. Cowsheds ... ... ... Milkshops 129 141 ... Houses let in lodgings 577 1,050 6 Ice cream premises 81 264 ... Slaughter-houses 1 2 ... Offensive Trades ... ... ... Smoke Nuisances— Number of observations 604 Number of notices 7 Number of nuisances and complaints 7 complaints Number of summonses 0 Housing of the Working Classe:— Number of houses inspected 880 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 o Number of houses included in such Closing Orders 0 Number of Closing Orders determined 0 Number of houses remedied without Closing Orders 0 (A number of houses were remedied without the necessity for representation) Number of demolition orders 0 Number of houses demolished; (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 3 of the Housing Act, 1925 0 Number of houses repaired by local authorities 0 Number of houses closed on notice by owner that they could not be made fit 0 Total number of houses in the borough 3473 (Census, 1921) Number of houses occupied by the working classes 8571 tenements (Census, 1921) Number of houses for working classes— (a) erected during year; 1 block, 37 tenements. (b) in course of erection Underground Rooms— Number illegally occupied for which notices were served 3 Number closed or illegal occupation discontinued 3 Overcrowding— Number of rooms overcrowded for which notices were served 4 Number remedied 4 Prosecutions 2 Cleansing— Number of adults cleansed (for vermin) (Males 120; Females 4) 124 Number of children cleansed 0 Number of rooms or premises cleansed (for vermin) 94 Prosecutions (vermin) 0 Water Supply to Tenement Houses— Premises supplied 5 Prosecutions 0 Sale of Food— Number of premises used other than ice cream premises, milk shops and cowsheds 384 Number of Inspections 2,884 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 1 123 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 262 16 5 ... Workshops 418 68 13 ... Workplace 3,444 65 5 ... Total 4,124 139 23 ... 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 60 60 ... ... Want of ventilation 4 4 ... ... Overcrowding 2 2 ... ... Want of drainage of floors ... ... ... ... Other nuisances 71 71 ... ... Sanitary accommodation insufficient 3 3 ... ... unsuitable or defective 26 26 ... ... not separate for sexes 7 7 ... ... Offences under the Factory and Workshops Act: Illegal occupation of underground bakehouse (S. 101) ... ... ... ... Breach of special sanitary requirements for bake houses (SS. 97 to 100) ... ... ... ... Other offences (excluding offences relating to outwork which are included in Part 3 of this Report) ... ... ... ... Total 173 173 ... ... * Including those specified in Sections 2, 3, 7 and 8 of the Factory and Workshop Act as remediable under the Public Health Acts. 124 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. Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Instances. Notices served Prosecutions. Instances. Orders made (S. 110). Prosecutions (Sections 109, 110) Lists. Outworkers. Lists. Outworkers. Contractors. Workmen. Contractors. Workmen. | Wearing Apparel— (1) Making, &c. 104 315 304 4 9 8 112 ... ... ... ... ... ... ... ... (2) Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquet and Tennis Balls 2 ... 57 ... ... ... 2 ... ... ... ... ... ... ... ... Tent Making ... ... ... 1 ... 1 ... ... ... ... ... ... ... ... ... Paper Bags and Boxes 2 ... 14 ... ... ... 2 ... ... ... ... ... ... ... ... Total 108 315 375 5 9 9 116 ... ... ... ... ... ... ... ... 125 TABLE VI.—continued. 4.—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. (1) Number. (2) Bakehouses (including 16 factory bakehouses) 29 Other Workshops 644 Total number of workshops on Register 673 5.—OTHER MATTERS. Class. (1) Number. (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act (S. 133) 11 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 24 Report (action being taken) sent to H.M. Inspector 24 Other — Underground Bakehouses (S. 101):— Certificates granted during the year - In use at the end of the year 19 126 LEGAL PROCEEDINGS. SALE OF FOOD AND DRUGS ACTS, 1875-1907. Date. Name. Address. Offence. Result. 1925 Mar. 24 & Apr. 20 William G. Mead 2, Portpool Lane Selling milk 8% deficient in fat Discharged on payment of 12s.6d. costs Apr. 20 E. Theodore Thomas 1, Howland Street, St Pancras Selling milk 7% deficient in fat Warranty. Notice not given in time; discharged on payment of 12s. 6d costs Oct. 26 Curtis & Co. 315, High Holborn Selling Calomel Ointment deficient in mercurouschloride to the extent of 42.5% Defendant convicted and fined £7 Oct. 29 E. Jones 49, Devonshire Street Selling milk 4.6% deficient in fat Summons withdrawn on payment of 21 costs Dec. 30 W. E. Childs 37, Short's Gardens Selling milk 4.6% deficient in fat Dismissed on payment of 21s. costs PUBLIC HEALTH (LONDON) ACT, 1891. Date. Name. Address. Offence. Result. 1925 June 26 Annie Edwards 8, East Street Overcrowding third floor rooms Order to abate nuisance within 21 days. do. Nathan Gookwitch 43, Gray's Inn Road Insufficient external light and ventilation to watercloset Order to abate within 7 days and to pay 42s. costs. Nov. 30 & Dec. 7 & Jan. 11 J. Trott 5, New North Street Overcrowding in basement Order to abate in 21 days. 1926 Nov. 30 & Dec. 7 A. H. Dixon 9, Old Gloucester Street Existing nuisance Order to abate within 14 days. do. do. 52, Old Gloucester St. Breach of Bye-Laws Ordered to complete work within 14 days do. do. 18, Devonshire Street do. Work being done by freeholders. Summons withdrawn. Dec. 30 Mrs. N. Keily 38, Emerald Street do. Adjourned to 22nd January, 1926, to enable work to be completed. do. do. 36, Emerald Street do. do. do. do. 9, Chapel Street do. do. do. do. 11, Chapel Street do. do. do. do. 9, Chapel Street Existing nuisance do. do. do. 11, Chapel Street do. do. do. do. 36, Emerald Street do. do do. do. 38, Emerald Street do. do.