HoL 68 The Metropolitan Borough of holborn. ANNUAL REPORT OF THE Medical 0fficer of health, C. W. HUTT, M.A., M.D., D.P.H., For the Year 1924. London: Printed by DIPROSE, BATEMAN & CO., Sheffield Street, Kingsway, W.C.2. 1925 INDEX. Page Public Health Committee 1 Housing of the Working Classes Committee 1 Maternity and Child Welfare Committee 2 Staff 2 Statistical Summary 3 Natural and Social Conditions 5 Population and Houses 5 Births 5 Deaths 6 Seasonal Mortality7 Infantile Mortality 7 Poor Law and Hospital Relief 8 Sanitary Circumstances 8 Scavenging. Removal of House Refuse 8 Removal of Manure 9 Sanitary Inspection of District 9 Notices served 11 By-law as to Houses let in Lodgings 12 Rats and Mice (Destruction) Act 12 Inspection of Workshops 15 Factories Bill, 1924 16 Smoke Abatement 17 Common Lodging Houses 18 Food 18 Dairies, Cowsheds and Milk Shops 18 Residue from Milk Clarifiers 18 Bacteriological Examination of Milk 18 Dirt in Milk 19 Comparison of London and Copenhagen Milk Supply 21 Milk (Special Designations) Order, 1923 22 Public Health (Milk and Cream) Regulations, 1912-17 23 Cream—Sale in Unsuitable Premises 23 Condensed Milk 24 Dried Milk 25 Margarine 26 Bakehouses 26 Fried Fish Shops 27 Market Streets and Exposure of Food Generally 27 Ice Cream 27 Meat 27 By-laws for Slaughter Houses 28 Places where Food is Prepared for Sale 28 Washing-up Arrangements in Restaurants, etc 28 Unsound Food 29 Sale of Food and Drugs Acts 29 Preservatives in Foods 29 Report of Departmental Committee 30 Adulterated Samples 32 Flour "Improvers" 34 Ginger Wine 35 Need for New Sale of Food and Drugs Act 36 Contamination of Food 35 Protection of Food from Flies, etc. 36 Licensing of Eating Places 37 Food Standards 37 Ditto in Austria 37 Ditto Canada and Australasia 38 Milk—Fat Content 40 Table of Samples Purchased 42 Sophistication of Wines 43 Prevalence of and Control over Infectious Diseases 45 Infectious Diseases Generally 45 Smallpox 46 Vaccination 47 Diphtheria 48 Schick Test and Immunisation against Diphtheria 49 Scarlet Fever 52 Enteric Fever 52 Typhus Fever 53 Cerebro-Spinal Fever 53 Dysentery 53 Malaria 53 Encephalitis Lethargica 53 Page Acute Poliomyelitis 54 Pneumonia 54 Influenza 55 Anthrax 15 Chickenpox 55 Mumps 55 Bacteriological Work 55 Disinfections 56 Cleansing of Persons Act 56 Scabies 56 Shelter during Disinfection 56 Arrivals from Infected Ports 56 Tuberculosis 57 Notifications 58 Sleeping Conditions 59 Classification of Homes 59 Delay in Notification 60 Institutional Treatment 61 Visitation of Home 61 Contacts 61 Prevention of Spitting 62 Deaths from Pulmonary Tuberculosis 62 Tuberculosis Dispensary 62 Tuberculosis Care Committee 65 Employment of Tuberculous Persons 68 Home Nursing 68 Dental Clinic 68 Cancer 69 Maternity and Child Welfare 69 Notification of Births 69 Home Visiting 70 Work at Centre 71 Ante-natal Hygiene 72 Maternal and Infant Consultations 74 Breast Massage 75 DiarrhŒa 75 Still-Births 75 Illegitimate Births 76 Dental Treatment 76 Assistance with Denture 76 Supply of Milk and Food for Mothers and Infants 76 Home Help 77 Convalescent Home Treatment 78 Saffron Hill Maternity and Child Welfare Centre 78 Deaths of Infants under One Tear 79 Deaths of Children, One to Five Years 80 Infectious Diseases among Mothers and Children 80 Puerperal Fever 80 Ophthalmia Neonatorum 80 Whooping Cough 83 Measles 84 German Measles 85 Epidemic DiarrhŒa 85 Nursing Arrangements 86 Pensions for Mothers and Widows 86 Health and Baby Week 86 Medical Inspection and Treatment of School Children 86 Deaths of Children, 5-15 Tears 91 Sanitary Administration 92 Mortuary 92 Inquests 92 Revenue Acts 92 Dirty Tenants 92 Rent and Mortgage Interest Restriction Acts, 1920 and 1923 93 Other Propaganda 93 Housing 93 APPENDIX. Table I. Vital Statistics, 1924, and ten previous years 96 Table II. Causes of and Ages at Death, 1924 97 Table III. Infectious Diseases Notified during 1924 98 Table IV. Infectious Diseases in Holborn during 1924 and ten previous years 99 Table V. Information required by L.C.C. 100 Table VI. Factories, Workshops, &c. 101 (1) Inspections 101 (2) Defects found 101 (3) Home Work 102 (4) Registered Workshops 103 (5) Other Matters 103 Table VII. Legal Proceedings 104 1 PUBLIC HEALTH COMMITTEE. 1923-24. 1924-25. Chairman— Chairman— Councillor the Rev. Henry Ross. Councillor the Rev. Henry Ross. Vice-Chairman— Vice-Chairman— Councillor Francis J. Pullen. Councillor Francis J. Pullen. Ex-Officio— Ex-Officio~ The Right Worshipful The Mayor, The Right Worshipful The Mayor, Alderman George Harvey, J.P., M.P., L.C.C. Councillor Harold Warren Coleman, J.P. Alderman Henry Jewell. Alderman Henry Jewell. Councillor John H. Boraston, C.B. Councillor John H. Boraston, C.B. „ Rev. Wilfred H. Davies, M.A. ,, Rev. Wilfred H. Davies, M.A. „ Henry W. Ellis. „ Henry W. Ellis. ,, Edward M. Evans. „ Edward M. Evans. „ George E. Hutchinson. ,, George E. Hutchinson. „ John Phillips. ,, Harold Jewell. „ John W. Roberts. ,, John W. Roberts. „ Sir William R. Smith, D.L., J.P., M.D. ,, Sir William R. Smith, D.L., J.P., M.D „ Arthur Youngman. ,, Arthur Youngman. HOUSING OF THE WORKING CLASSES COMMITTEE. 1923-24. 1924-25. Chairman— Chairman— Alderman Henry Jewell. Alderman Henry Jewell. Vice-Chairman—- Vice-Chairman— Councillor James J. Claydon. Councillor James J. Claydon. Ex-Officio— Ex-Officio— The Right Worshipful The Mayor, The Right Worshipful The Mayor, Alderman George Harvey, J.P., M.P., L.C.C. Councillor Harold Warren Coleman, J.P. Councillor Charles R. Baddeley. Councillor Charles R. Baddeley. „ Rev. Wilfred H. Davies, M.A. „ The Rev. Wilfred H. Davies, M.A. „ Miss Emily Dibdin. „ Miss Emily Dibdin. „ Henry W. Ellis. „ Henry W. Ellis. „ Ernest Hamlin. ,, Ernest Hamlin. „ Alfred Humphreys. „ Alfred Humphreys. „ Rev. Henry Ross. „ Raymond A. Miles. „ J. St. Lawrence Stallwood. „ J. St. Lawrence Stallwood. ., George Witherby. „ George Witherby. „ Arthur Youngman, ,, Arthur Youngman. A 2 MATERNITY AND CHILD WELFARE COMMITTEE. 1923-24. 1924-25. Chairman— Chairman— Councillor Francis J. Pullen. Councillor Francis J. Pullen Vice-Chairman— Vice-Chairman— Councillor John W. Roberta. Councillor John W. Roberta. Ex-Officio— Ex-Officio— The Right Worshipful The Mayor, The Right Worshipful The Mayor, Alderman George Harvcv, J.P., M P., L.C.C. Councillor Harold Warren Coleman, J.P. Alderman Sir George P. Parker, O.B.E., J.P. Councillor James W. Coade. Councillor Richard Davies. ,, Richard Davies. „ Miss Emily Dibdin. „ Miss Emily Dibdin. ,, Edward M. Evans. ,, George E. Hutchinson. „ George E. Hutchinson. „ Rev. Henry Ross. „ Rev. Henry Ross. ,, Lady Smith. „ Lady Smith. „ Mrs. Ethel M. Wilson. ,, Mrs. Ethel M. Wilson. Nurse M. Baylee. Nurse M. Baylee. Mr. Thomas W. J. Coffin. Mr. Thomas W. J. Coffin. The Mayoress (Mrs. H. Warren Coleman). Miss M. R. Lovelock. Mrs. Wilfred H. Davies. „ Norah H. March, B.Sc. Miss Norah H. March, B.Sc. ,, Alice Michelmore. STAFF. The following was the Staif during 1924. Medical Officer of Health—C. W. Hutt, M.A., M.D., D.P.H. Medical Officer of Maternity Centres—Beatrice Mary Kidd, M.B.Lond. (To 30th November, 1924). Ditto (Temporary) Bichenda Gillett, M.D.Brux. L.S.A. (From 1st December). Medical Officer of Tuberculosis Dispensary—Robert Hilton, M D)., M.R.C.P. (To 30th Sept.). James Arthur Struthers, M.B., B.Ch., M.R.C.P. (From 1st October). Public Analyst—James Kear Colwell, F.I.C. Sanitary Inspectors—Albert Bennett. George F. Clark. Saimiel Larard, M.R.San.I. Sanitary Inspector and Ilealth Visitor—Ethel Jane Charlesworth, C.M.B. Health Visitor—Elirabeth Lister Shinnie, C.M.B. Tuberculosis Visitor—Elizabeth Caffyn Ballard (To 30th June, 1924). Rose Aldis, C.M.B. (From 1st July, 1924). 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 O. Gray, L.D.S. (British Dental Hospital). Anusthctist—G. C. Nelson Younger, M.R.C.S., L.lf.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. 3 STATISTICAL SUMMARY, 1924. Population, estimated to middle of year (as supplied by the Registrar-General) for birth and death rates 43,250 Population—Census, 1921 43,192 Births 578 Annual Rate of Births per 1,000 population 13.36 Deaths 529 Annual Rate of Deaths per 1,000 population 12.2 Zymotic Death Rate 0.51* Tuberculosis Death Rate per 100,000 124 Excess of Registered Births over Deaths 49 Infantile Mortality per 1,000 Births 81 Area of Borough in Acres 405.1 Rateable Value, 1st November, 1924 £1,379,023 A Rate of Id. in the £ estimated to yield £5,490 *Excluding deaths from Epidemic diarrhoea. Vital Statistics, 1924. 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 18.8 12.2 75 London 18 .6 12.2 69 Holborn 13.36 12.2 81 A 2 4 PUBLIC HEALTH DEPARTMENT, COUNCIL OFFICES, 197, HIGH HOLBORN, W.C. 1. March, 1925. 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 1924. Believe me, Ladies and Gentlemen, Yours obediently, C. W. HUTT, Medical Officer of Health 5 NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Population and Houses. The 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 1924—43,250. 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 3,511. The number of deaths was 33, a death-rate of 9.4 per 1,000, considerably below the average death-rate for the whole of the Borough (12.2). On the other hand the number of deaths of residents of Common Lodging Houses in the Borough, which contain 1,220 beds, was 05, which, calculated on the number of beds, was a rate of 53.3 per 1,000. Registered Births and Birth-Rate. The total number of births registered as occurring in the Borough was 394 (211 males and 183 females). Of these, 377 were legitimate and 17 illegitimate. Corrected Births and Birth-Rate I received from the Registrar-General information of the births in outlying institutions in London of 163 legitimate infants and 33 illegitimate infants whose mothers were residents of the Borough. Twelve of the births occurring in the Borough, viz., 8 legitimate births and 4 illegitimate births, were infants of mothers who were non-residents of the Borough. 6 The following table gives the corrected number of births and the corrected birth-rates for the seventeen years 1908-1924: — Year. Total Births. Legitimate Births. Illegitimate Births. No. Rate per 1000 of Population. No. Rate per 1000 of population. Proportion per 1000 total Registered Births. No. Rate per 1000 of population. Proportion per 1000 total Registered Births. 1908 1006 20.41 1020 19.53 956.8 46 0.88 43.2 1909 986 19.26 935 18.27 948.2 51 0.99 51.8 1910 1017 20.27 959 19.11 94.0 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 54 116 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 53.2 12.30 920.4 46 1 .06 79. 6 In London the corrected birth-rate in 1924 was 18 6 per 1000 in comparison with 20.2 for 1923. Mortality. The total number of deaths registered as occurring in the Borough was 670, of which 393 were males and 277 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. Holbon. St. Giles and Bloomsbury. Holbon. French Hospital 6 1 39 - Children's Hospital 4 4 - 241 National Hospital 1 3 - 78 London Homoeopathic Hospital 4 5 - 69 Italian Hospital 1 6 - 26 Alexandra Hospital - - - - Private - - 15 2 Total 16 19 54 416 7 There were 329 deaths of Civil "Residents" in various Workhouses, Infirmaries, Asylums, Hospitals, etc., outside the Borough, 59 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 1924 gives the total deaths for the Borough as 529. Corrected Deaths and Death-Rates, 1924, compared with 1923. 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. Ratee is rat:on London. 1923 718 501 491 299 526 12.1 11.2 1924 670 488 470 329 529 12.2 12.1 For details of causes of and ages at death, see Table II., page 97. Seasonal Mortality. The mortality in the four quarters of the year is shown below: — Deaths. Death-rate per 1,000. London Rate. First Quarter 160 14.8 17.8 Second ,, 130 12.2 10.7 Third ,, 100 9.2 8.6 Fourth ,, 139 12.8 11.1 529 12.2 12.1 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. 1923 47 75 120 79 60 1924 47 71 196 81 69 Infantile Mortality. 8 Death-rate per 1,000 corrected births in 1924 and in ten preceding years during which details respecting births have been supplied. 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 Av'ge, 1914-23 1924 Holborn 88 96 97 107 141 96 66 79 72 79 92.1 81 Borough London 101 112 89 103 107 85 75 80 74 60 88 .6 69 See also Table, page 79. 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: — Infantile Death-rate in Holborn per 1000 Births Year 1924. Registrar General's Quarterly Report Corrected 1st Quarter 149 107 2nd "84 54 3rd „ 120 70 4th „ 142 93 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 1924: — Indoor Relief 1,217 persons Outdoor Relief 378 cases Outdoor Medical Relief 295 persons Of the total number of 529 deaths, 364 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 gradual substitution of motor vehicles in place of horse-drawn wagons 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, ashbin was 58 and for breach of By-laws as to the removal of refuse, 2. 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 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. 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 six cases notices were served in connection with the structure of manure receptacles 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 22,239 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 1924. Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Complaints received 17 40 26 1 ... 84 Do. found to be justified 17 38 24 1 ... 80 Inspection of Houses — Dwelling-houses 53 247 81 1 ... 382 Houses let in Buildings 394 314 203 40 ... 951 Common lodging-houses 1 4 6 ... ... 11 Drains tested by smoke ... 7 1 ... ... 8 „ „ water ... ... ... ... ... ••• „ ,, chemicals 2 2 4 ... ... 8 Re underground rooms 2 ... ... ... ... 2 „ Rent (Restriction) Act. ... 4 1 ... ... 5 „ New Buildings ... ... ... ... ... ... Factories — Bakehouses 19 29 13 ... ... 61 Food preparation (other than above) ... ... 30 ... ... 30 Other 24 95 142 2 ... 263 Laundries ... ... ... ... ... ... Inspections carried forward 495 702 481 43 - 1,721 10  Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Shinnie Total Brought forward 495 702 481 43 - 1,721 Workshops and Workplaces — Food premises: Dairies and Milkshops 31 103 15 ... ... 149 Ice Cream, Manufacture 27 20 113 ... ... 160 Do. Storage or Sale 10 3 6 ... ... 19 Slaughter-houses ... 5 ... ... ... 5 Hotels and Restaurants 54 34 26 ... ... 114 Butchers 334 18 251 ... ... 606 Bakehouses 6 22 13 ... ... 41 Fried Fish shops 192 11 28 ... ... 231 Market Streets 325 77 438 ... ... 840 Other food shops 153 29 72 ... ... 254 Laundries ... ... ... ... ... ... Other workshops 95 225 153 24 1 498 Other workplaces 61 120 60 ... ... 241 Outworkers' Registers 26 42 61 ... ... 129 Stable and Stable yards 45 115 ... ... ... 160 Rag and Bone shops 107 3 ... ... ... 110 Public Houses ... 3 ... ... ... 3 Outworkers' rooms ... ... ... 13 ... 13 Miscellaneous— Black smoke 166 82 262 ... ... 510 Keeping of animals ... 6 ... ... ... 6 Dust, Special Inspections 40 109 31 ... ... 180 Rats and Mice (Destruction) Act 110 82 106 ... ... 298 Public Urinals and Lavatories ... 19 1 2 1 23 Sale of Food and Drugs Act, samples 216 207 185 ... ... 608 Other Inspections 9 8 4 20 ... 41 Periodical Inspections: Includes W.C. and yards, dustbins, especially houses let in lodgings, and other suitable buildings 1,756 2,112 2,696 ... ... 6,864 Re-Inspections— Houses 668 1,157 662 7 ... 2,494 Factories 2 25 2 ... ... 29 Workshops and Workplaces 63 176 76 4 ... 319 Miscellaneous 2 1 ... 86 25 114 Visits re Infectious Diseases 63 111 97 233 146 650 Do. on School Reports ... 1 ... ... ... 1 Tuberculosis—First visits 20 26 26 ... ... 72 Do. Re-visits 168 151 127 ... ... 446 Scabies ... ... 3 1 ... 4 Vermin ... ... •• 6 15 21 Other Visits- Police Courts 4 5 5 ... ... 14 Various 214 565 219 15 ... 1,043 Maternity— Visits: Children under 1 year ... ... ... 341 234 575 Do. 1 to 5 years ... ... ... 6 3 9 Expectant Mothers ... ... ... 63 47 110 Ee-visits ... ... ... 811 1,367 2,178 Do. Expectant Mothers ... ... ... 27 52 79 Other Maternity Visits ... ... ... 71 94 165 Attendances at Maternity Centres ... ... ... 189 203 392 Total 5,462 6 375 6,252 1,962 2,188 22,239 11 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 1,563, viz.: — Public Health (London) Act, 1891— Intimation Notices 647 Statutory Notices 87 By-laws— Houses let in Lodgings 793 Removal of Refuse 2 London County Council (General Powers) Acts— Verminous rooms 30 Food premises 2 Regulations as to Dairies, Cowsheds and Milk Shops — Rats and Mice (Destruction) Act, 1908 2 1,563 The following Table shows the work done to abate nuisances for which information noticecs were served:- Water Supply— Houses. Factories, Workshops and Workplaces. Provided 4 l Cisterns cleansed, repaired, etc. 34 13 Waterclosets— Cleansed 21 11 Water supplied, flushing cistern repaired, etc. 21 19 Bepaired, new pans, etc. 104 20 Ventilation improved 2 6 Separate accommodation for sexes provided - 7 Position improved - - Direct communication with workrooms remedied - 4 Accommodation provided 2 2 Soil Pipes— Bepaired, renewed and ventilated 4 1 Rainwater Pipes— Repaired or renewed 19 1 Drains— Repaired 10 4 Unstopped, cleansed, etc. 27 6 Sinks, etc. Waste pipes repaired, renewed, etc. 31 4 Yards, Areas and Washhouses— Cleansed 25 4 raved and paving repaired 14 3 Houses and Workshops, etc.— Cleansed 109 34 Dilapidations repaired and made good 101 8 Ventilation improved - 7 Dampness— Roofs repaired 132 4 Gutters repaired 26 1 12  Houses. Factories, Workshops and Workplaces. Floor cavities ventilated l - Other works to prevent dampness 25 2 Ashbins— Provided, repaired, etc. 40 18 Urinals— Repaired, cleansed, etc. - 9 Various— Underground Rooms vacated 8 - Smoke—Emission of black smoke abated - 4 Animals—Improper keeping discontinued 3 - Accumulations of Refuse—Removed 28 12 Overcrowding abated 3 2 Manure receptacles repaired - 6 Other nuisances abated 12 5 The following Table shows the nuisances for which the 87 Statutory Notices Houses. Factories, Workshops and Workplaces. were issued under the Public Health (London) Act, 1891. Section 2 (a) Dirty and dilapidated premises, etc. 37 7 ,, (a) Absence of light and ventilation 1 - ,, (b) and Section 37, Ashbins 5 1 ,, (b) Drains and W.C.'s 31 9 ,, (d) Accumulation of rubbish 4 7 ,, (f) and Section 48. Water supply 3 1 ,, (g) Ventilation of Workshop - 1 ,, 21 Business carried on so as to be a nuisance - 1 ,, 24 Black Smoke - 1 ,, 38 W.C.'s communicating with workrooms - - ,, ,, W.O. and urinals, insufficient accommodation 1 ,, ,, W.C. Absence, of separate accommodation for sexes 4 ,, 96 Underground rooms 2 - By-laws as to Houses let in Lodgings. At the end of the year 589 houses were registered under these By-laws. Of these, 297 are in St. Giles and Bloomsbury and 292 in the Holborn District. There were 951 inspections of these premises, excluding a very large number of periodical inspections and re-inspections. 200 notices were served for breaches of the By-laws, exclusive of 587 notices that were served for annual cleansing as required by the By-laws. Rats and Mice Destruction Act, 1919. During the year 213 premises were inspected under the above Act, the total inspections being 298. Two notices for breaches of the Act were served. As a result, in one case the drains were reconstructed and in the other 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 :— 13 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. 12 4 4 2 1 - 1 2 3 free 2 occasional rat 1 numbers reduced 1 B. 17 3 2 2 - - - 1 1 free 1 number reduced 1 rats still seen 1 C. 19 10 4 5 3 3 - — 3 free 6 improved 4 D. 15 5 4 2 — 1 - - 5 free 4 occasional rats 1 E. 8 3 - 2 - - 1 - 3 apparently free 1 great improvement 1 occasional rat 1 F. 19 3 2 3 - - - - 3 free 2 improved 1 G. 60 8 1 8 - 1 1 - 7 free 6 nearly free 1 improved 1 H. 46 34 22 22 2 8 - 2 8 free 27 improved 4 occasional rats 3 I. 17 15 8 3 3 4 - 3 2 free 10 improved 5 213 85 47 49 9 17 3 8 35 free 59 improved but occasional rats 26 85 14 In accordance with the suggestion of the Ministry of Agriculture and Fisheries "rat week" was observed in the Borough during the week ended the 3rd November. With the object of securing concerted effort during this week and drawing attention to the importance of rat repression the following action was taken: — A circular letter was issued io the Occupiers of restaurants, hotels, eating houses and other food premises, factories, workshops, and premises where it was thought rats might exist. A leaflet on "some simple suggestions for rat prevention and destruction was widely distributed in the Borough. A variety of rat traps and poisons were exhibited in the Public Health Department. An anti-rat film was exhibited at a local cinema, and still slides were shown at a local music hall. The baits laid weekly in the Council's sewers were quadrupled during rat week. The enquiries received gave ample indication that in a number of cases the desired action was being taken. The general arrangements made by the Council for the repression of rats during the year were the same as last year. The Rats and Mice (Destruction) Act, 1019, places the obligation to carryout 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. 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. 15 On the recommendation of the Public Health Committee the Council agreed with the suggestion and notified the London County Council accordingly. A suitable clause has now been generally agreed and it is hoped that the provision will be included in the next L.C.C. (General Powers) Bill. Inspection of Workshops, etc. The routine inspection of factories, workshops and workplaces has been carried out during the year. 354 factories were inspected, 589 workshops and 2,905 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 575 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 in 33 such cases the necessary transfer to the factory register was effected. Variations in the staff employed were also frequently reported. Of the 744 workshops on the register at the end of the year 386 employed men only, 106 employed women only, and 252 employed both men and women. The number of employees is often very small and many of the workshops are in tenement houses. It was necessary to serve the following notices tor the abatement ot sanitary nuisances in factories, workshops and workplaces. Intimaton Notices. Statutory Notices. Factories 27 5 Workshops 60 10 Workplaces 66 8 153 23 No less than 125 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 10 1 - 11 Boot makers and repairers 16 - 2 18 Cabinet makers 9 - 1 10 Clock and Watch makers 16 - - 16 Dressmakers and ladies'tailors 1 48 7 56 Diamond mounters 11 - 3 14 Engravers 19 - - 19 Jewellers 40 - 18 58 Jewel case makers - - 11 11 Leather goods makers 4 - 6 10 Metalworkers 11 - - 11 Picture framers 11 - 2 13 Sign writers 8 1 1 10 Tailors 29 9 106 144 Tyre makers and repairers 7 2 1 10 16 These special 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 250 factories had been entered on the register. This number, although small in comparison with the total factories in the Borough, indicates the variety of works carried on and the increasing use of premises in the Holborn area for industrial purposes. The 250 factories include 65 different industries. In 133 cases men only were employed, in 5 women only, and in 112 both sexes. The more important industries were : Bookbinding Engineers Jewellers Metal workers Printers Factories Bill, 1924. This Bill was introduced 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 Hill applied to factories included under the new and old definitions. Sanitary control—as now administered. Under existing Acts the provisions relating to the 6anitary 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 are 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 wor'i of local authorities by unnecessary overlapping. 12 28 13 1 1 41 17 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 local 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. 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 various 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 510 eases 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. Four complaints were also received. As the result of the inspections four intimation notices were served followed by statutory notices in one case. B 18 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. 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 53.3 per 1,000 in 1924. FOOD. Dairies, Cowsheds and Milkshops. The number of registered dairies and milkshops in the Borough at the end of the year was 127. Seven dairies and milkshops were newly registered, and seven removed from the register. In addition to my inspections the Sanitary Inspectors made 1-19 inspections of these premises) and one notice was served for sanitary defects or breaches of regulations. 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 milk mixing and cleansing depots in the Borough to ascertain what is done with the residue after the milk has been passed through the cleansers. It was found in each case that this residue is at once washed down the drains. Bacteriological Examination of Milk. Eighteen samples of milk were examined for the presence of tuberele bacilli; six of those were also examined to ascertain the number of organisms per cubic centimetre and the smallest volume containing B. coli. Examinations for tubercle bacilli were carried out by animal inoculation ; in two cases (11 per cent.) evidence was established of tubercle infection in the milk. The vendor of the first of these two samples obtained milk, through a Wholesale Company, from three farms and, although in this case the milk was delivered to the retailer without passing through and being mixed at the Wholesale Company's depot, it was still found impracticable to obtain reliable information as to exactly which farm the infected milk came from. Information respecting 10 the matter was sent to the London County Council with a view to each of the three farms being inspected. No evidence of disease could be detected at two, but at the third it was found that one cow, out of thirty examined, showed signs of tuberculosis. Arrangements were accordingly made for this animal to be "put dry" and prepared for slaughter and for the milk to be no longer used in the meantime. The vendor of the second sample of milk giving evidence of tuberculous infection obtained his supply from a Wholesale Company; this milk was mixed with consignments from many farms and was stated to have been pasteurised. Communications were addressed to the company respecting the matter. A reply was received from a representative of the company that it would be an almost impossible task to identify the milk in question to any particular farmer. The company arranged for tests to be made to ascertain the efficiency of the pasteurising process and for a close watch to be kept to see if there was any possibility of a man getting away with some raw milk when he should only take pasteurised. 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. 1921 Nov. 20 Large milkshop 33,100 0.0l CC N.ov. 20 Large milk depot 37,250 1 .CC. Nov. 14 Small milkshop 67,650 0.001 cc. Nov. 14 Small milkshop 57,650 0.001 cc. Nov. 20 Small milkshop 328,400 0.01 cc Nov. 14 Large milkshop 423,000 0 .0001 cc. Dirt in Milk. During the year 55 samples were examined in the Health Office for dirt; 2 contained dirt, 5 and 2 parts per 100,000 being present. Those samples of dirty milk were stated by the wholesaler to be from mixed milks derived from many dairies. This milk reaches Euston Station consigred from the dairy farmers to the wholesale milk sellers. In similar instances samples of the milk from individual churns (which bear the farmer's name) can be taken by the Sanitary Authority in whose area the railway termini are situated and the source of the dirt traced. In eleven other cases the Borough analyst examined milk purchased from retailers who had been proved by examination in the Health Office of milk sold by them to sell milk which at any rate was occasionally dirty. Ten of these were found to contain dirt the quantities being in parts per 100,000, 1.5; 1.5; 1.4 ; 1.2; 1.2; 1.0; 0.9; 0'75 and a faint trace in 2. The presence of two parts of dirt per 100,000 is sufficiently serious to warrant stringent enquiry and serious warnings. B 2 20 The retail shops from which samples of milk containing dirt were purchased were found on inspection to be generally satisfactory. As a result of enquiries it was found that the milks were obtained from various wholesale dealers and communications were addressed to the dealers concerned. Where the depots of the dealers were outside the Borough information was also sent to the Medical Officers of Health of the districts concerned. In one case a wholesaler replied that all milk supplied from the Company's depot "is strained as it comes from the farms, cleaned through a Titan Cleaner and afterwards pasteurised by the positive holding process of pasteurisation." In dealing with dirty milk and with milk with bacterial infection local authorities are seriously handicapped by reason of their inability to trace the milk to its source. The modern practice of collecting milk from many farms to large creameries and milk depots, where it is mixed and pasteurised, prevents the possibility of tracing either dirty or infected milk to the source of production. We also obtained evidence of the presence of dirt in milk from the bacteriological examinations mentioned above. In the cases of two of the samples where examination was made by animal inoculation the animals died a few days after inoculation. The organisms isolated in one case were B. coli, streptococci, B. enteritidis sporogenes, and in the other streptococci, B. enteritidis sporogenes, but no evidence of tubercle infection was found in either case. In the first of these the address of the farm from which the milk came was obtained and a communication was sent to the County Medical Officer of Health concerned, who in his reply said: — I am not at all surprised that an average milk, produced under present conditions, after it has gone to London, and the coli and other organisms multiplied in transit, killing a guinea pig." He arranged for the dairy to be inspected and subsequently the following report of the inspection was received: — "The dairy is clean and airy, the cowsheds are good, but were not as clean as I should like them to be. I advised more care with regard to the milkers' hands, the wearing of clean smocks, the cleansing of the udders and the use of covered milk pails." In the case of the second sample the supply, a mixed milk from a Wholesale Company, was delivered to a central branch of the Holbon retailer and conveyed by him to his retail shop in this Borough. Another sample of milk in which dirt was disclosed also came from the same retailer. As the result of communications with this trader he agreed to take further precautions by conveying the milk from his central depot to his retail shop in this Borough in a dust-proof churn. 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. 21 A bacteriological standard of purity of milk will doubtless eventually be demanded by the public. Comparison of London and Copenhagen Milk Supply. (Population 670,000—1922). It is interesting to compare the condition of the milk supply of London with that cf Copenhagen, where I paid a visit in the course of the year, and saw what was being done. In Copenhagen objection is taken to the presence of any dirt—milk which after standing two hours gives a noticeable deposit shall be considered as polluted to an inadmissible degree. If the dirt is found in the milk obtained from a producer after the first offence, the producer runs the risk of not being allowed to sell his milk in Copenhagen. In 1923, 11,000 samples were examined for dirt, in five only was it found. During recent years the supply of milk has been stopped by the authorities on account of unsatisfactory conditions of the cowsheds, uncleanliness of the cows, milk pails and other utensils, and unsatisfactory water supply. In order to secure the carrying out of the regulations of the Copenhagen Health Committee they are empowered to demand from a milk dealer a fortnightly certificate, signed by a veterinary surgeon, that the condition of health, feeding, care and milking of the cattle is in accordance with the regulations. These were drawn up by the Danish Veterinary Surgeons' Association. In every case the owners of live stock from which whole milk is supplied to Copenhagen must have the cattle inspected once a month by a veterinary surgeon, and the necessary certificate forwarded to the Health Committee. The milk of cows suffering from tuberculosis or other specified diseases must not be sold. Regulations are laid down as regards milking, supply of clean water, the presence of adequate lighting of the stable, so that the cleanliness of the cow's udder and flanks can be observed, straining of the milk, and the clean handling and cleanliness of all utensils used. In 1921, the milk of 6,279 (and in 1922, 8,416) sick cows was excluded temporarily or permanently from the Copenhagen milk supply. All cows whose udders are found to be tuberculous are slaughtered, the Government paying compensation. The average daily consumption of milk per head in Copenhagen is "85 pint. The figure given for London in January, 1918, was .33 pint.* About 22,750 pints of certified children's milk, very similar to our Grade A. tuberculin tested milk, is sold daily in Copenhagen, and about 6,650 pints of Jersey milk (fat standard 4 75 per cent.). It should be remarked that the fat standard of ordinary milk is 3 25 per cent. The price of Copenhagen cream milk compares very favourably with that in London, The respective prices on October 12th last were: — Copenhagen. London, (add cost of delivery). Per <iuart Cream 3s. 9d 32% fat 7/Grade A 6 2d. (tuberculin tested (Children's milk) 9d. milk) Pasteurised milk 7, Ordinary milk j About d. is charged for delivery of each bottle of one litre or lesser size. *From information obtained through Local Food Control Committees it was shown that the consumption of ordinary cows' milk per head per day in Great Britain varied in January, 1918, from one-tenth of a pint in Inverness to one-third of a pint in London ; the average for the country was one-quarter of a pint per head per day. Working class consumption has been put by the Board of Trade at 1.8 pints per head per week,* which also works out to one-quarter of a pint per head per day. This is less than half the normal average consumption of the City of New York. Consumption in Great Britain is uneven and varies, according to the available returns in the large towns, from .63 pints per head per day in Hornsey to .08 pints per head per day in Dudley, and in the smaller towns from -67 pints per head per day in Winchester to -06 pints per head per day in Llanelly. Though there must be some uncertainty attached to the returns of retail sales on which these figures, particularly those relating to rural and small urban areas are based, it is clear that the average daily consumption of milk throughout Great Britain is much lower than is desirable.—(Final Report, Committee on the Production and Distribution of Milk, page 8.) 22 A large proportion of tlie milk soul is sold in bottles, Two large linns I visited sold nothing else; they disposed of 70,000 and 50,000 bottles respectively a day. One of these firms, the Trifolium, pasteurised very little of their milk; their view was that customers when supplied with raw milk know the actual condition of the milk by its taste and smell, whereas pasteurised milk may be any fluid derived from the cow's udder, no matter how stale. Milk which has been pasteurised may only be sold in Copenhagen if it is described as such; the customer must be in a position to know that it has been pasteurised; unfortunately no such declaration is required in this country. Efforts are being made to eradicate tuberculosis from milch cows, the procedure advocated by Professor B. Bang (Senior) being carried out. The animals are tested by tuberculin, and any which react are either slaughtered or isolated from the healthy stock and their milk discarded for human consumption. When this isolation is carried out satisfactorily the Slate assist the stockowner by making a payment for carrying out the tuberculin test. Of late years a large number of Co-operative Dairies have of their own initiative made attempts to free their herds from tuberculosis; the cost is borne by the Daries and is collected from their members, who are charged according to the number of their cows. 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 0.1 c.c. 23 (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 1924 licences available up to the 31st December, 1924, for the sale of designated milk in the Borough were issued as follows: — Certified Milk 4 Grade A (Tuberculin Tested) 1 Up to the date of preparation of this report licences for the year 1925 have been issued as follows: — Certified Milk 4 Grade A (Tuberculin Tested) 3 Grade A 1 Pasteurised 1 The value of the Order lies to a considerable extent in its educational effects; the existence of such arrangements shows milk producers that clean milk can be produced on farms (if they like they can learn how to produce clean milk themselves) and that medical opinion has been able to convince the representatives of the public of the importance of keeping milk as free as possible from bacteria, and above all from tubercle bacilli. Public Health (Milk and Cream) Regulations, 1912 and 1917. The Public Health Milk and Cream) Regulations, 1912-1917, were enforced in the Borough throughout the year. Two hundred and twenty-six samples of milk were examined; none was found to contain preservative; 15 samples of cream were examined 3 of which were found to contain preservative, viz., boric acid to the extent of 0'062, 0.236 and 0'336 per cent. by weight respectively. Communications were in each case sent to the vendor, and in two the vendors were interviewed by the Public Health Committee ; the explanations submitted were considered to be satisfactory, and no further action was taken. Twenty five s 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. Cream—Sale in Unsuitable Premises. During the year attention was directed to certain premises used as a depot for the storage and sale of cream. On inspection it was found that the premises, formerly a stable, were situated in a mews and that the manure heap of an adjoining stable was immediately adjacent to the entrance to the cream store, and that this manure was trampled into the ex-stable, so that it could be found near the open chum; cream was delivered to the depot in ordinary milk churns and was sent out from the depot in small lever lid tins. 24 The Council was advised that the business came within the definition of "dairyman" under the Dairies, Cowsheds and Milkshops Orders, and that the vendor was, therefore, required to be registered. Subsequently, application for registration was received from the proprietor. The Public Health Committee were satisfied that the premises were unsuitable for the storage or sale of cream, and refused the application. Shortly afterwards the use of the premises as a creamery was discontinued. Condensed Milk. The Public Health (Condensed Milk) Regulations, 1023, came into operation on the 1st November, 1923. During the year 1924 nine samples of condensed milk, viz., six full cream (five sweetened and one unsweetened), and three skimmed sweetened, were examined by the Borough Analyst under the Regulations. All the nine samples complied with the requirements of the Regulations as to labelling. Five of the samples were examined for standard of composition and all were found to be above the standard required. Four were examined for the accuracy of the statement as to the equivalent quantity of milk in the tin and all complied with the Regulations. The following table gives particulars of the milk fat and milk solids found in the nine samples:— Milk fat. Milk solids (including fat). Examined, for standard of composition— Full cream sweetened 9.80 32.6 „ „ 9.20 34.4 „ „ 9.11 31.7 Skimmed ,, 1.40 29.6 „ „ 0.80 30.5 Examined for accuracy of statement as to equivalent quantity— Full cream sweetened 3.80 12.77 „ „ 3.60 12.47 ,, unsweetened 3.79 13.28 Skimmed sweetened 0.50 9.52 In the earlier part of the year information was received from the Ministry of Health respecting an infringement of the Regulations in connection with 200 cases of imported "full cream" condensed milk consigned to a trading company in this Borough. The labels on the tins in this consignment contained directions for feeding infants on this brand of milk and contravened the Regulations because the instructions did not specify that the fluid so produced would not be of equivalent composition to milk under the Regulations, and the type, both large and small, was below the minimum size. Communications were at once opened up with the Company to stop the sale of the milk pending the amendment of the label. 25 Subsequently I received from the Ministry of Health a copy of a report from the Government Chemist on the composition of the milk, from which it appeared that it contained less than the minimum quantity of milk fat (8.15 instead of 9 0), and the fluid produced in accordance with the instructions on the label would contain less milk fat and milk solids than defined by Rule 2 of the Regulations. The importing Company was, therefore, informed that the milk could not be sold for human food. 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. The varieties of dried milk recognised are as follows :— Full cream—containing not less than 26 per cent, of milk fat. Partly skimmed Three-quarter-cream „ „ 20 ,, ,, ,, Half-cream ,, 14 ,, „ ,, Quarter-cream „ ,, 8 „ „ ,, Skimmed—containing less than 8 „ ,, ,, The declaration on the label must include a description of the milk under one of the three main varieties and in the case of partly skimmed milk the material has to be further classified into three quarter, half or quarter cream milk. The labels must also contain a statement as to the number of pints of ordinary liquid milk of each class to which the contents of the container are equivalent. For the purposes of the Regulations the terms "milk," "three-quarter cream milk," etc., mean milk containing not less than the following percentages of milk fat and milk solids:— Milk fat. Milk solids (including fat). Milk 3.6 12.4 Three-quarter cream milk 2.7 11.6 Half cream milk 1.8 10.8 Quarter cream milk 0.9 9.9 Skimmed milk means milk which contains not less than 9 0 per cent, of milk solids other than milk fat. The labels on the containers of "partly skimmed dried milk" must contain the words "should not be used for babies except under medical advice," and those on the container of the " skimmed " variety the words " unfit for babies." The Regulations apply to dried milk to which no other substance has been added and to dried milk contained in any powder or solid of which not less than 70 per cent, consists of dried milk. 26 Provision is also made for the sale, with adequate declaration, of sweetened, modified or compounded dried milk. Five samples of various brands of dried milk were obtained, at the latter part of the year, four were examined and found to comply with the Regulations. One, a tin of half-cream dried milk, was found to be labelled contrary to the provisions of the Regulations. On communicating with the retailer and the makers it was shown that this tin had inadvertently been overlooked when the general stock was returned to the makers for adjustment of labels on the Regulations coming into operation. The sale was obviously an error and no further action was considered necessary. Margarine. Applications were received during the year for registration of two wholesale margarine dealers. The premises were inspected and the registrations effected. Notifications of the registrations were forwarded to the Board of Agriculture and Fisheries. 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. During the year an enquiry was received from the director of a residential institution respecting the merits of margarine as a food in place of butter. The food value of margarine turns on the presence of vitamines. Margarine made from vegetable oils contains practically no vitamines, whereas oleo margarine does contain vitamines, but in less quantity than butter. It is found that many purchasers of this article do not know whether they are getting vegetable or oleo margarine, or that there is any difference in the food value; moreover, the shop assistants are also found to be ignorant of whether they are selling vegetable or oleo margarine. It should be remarked that the common practice of mixing butter with margarine before sale has the effect of supplying a certain amount of vitamines. Bakehouses. At the end of the year, 1924, 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 arc now classified as "factories" owing to the installation of machinery. During the year, in addition to my inspections, there were 102 inspections of bike houses. Four notices were served for sanitary defects. 21 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 thirty one inspections of such premises were made last year. At the same time a careful look-out is kept on the soundness of the fish and the wholesomeness of the materials used in frying. Market Streets. There were 840 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 011 Saturday evenings arrd 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 83 premises in the Borough where ice cream was manufactured, and in addition to my inspections 179 inspections of these premises were made, and one notice was served. Ice cream is in manufactured in the Italian Colony as follows:— Premises on which 10 gallons made daily 3 „ „ 8 „ „ 1 „ „ 6 „ „ „ 1 „ „ 4 „ „ „ 7 „ „ 2 „ „ „ 10 ,, less than 2 „ ,, ,, 3 In addition ice cream was also manufactured on the following premises:— Mr. Bennett's Mr. Clark's Mr.. Larard's District. District. District. Restaurants 10 3 7 Confectioners 5 13 12 Other l 5 2 Meat. All the butchers' shops were frequently inspected. The meat was found to be dealt with under cleanly conditions. There is only one slaughter house in the Borough. This was inspected on five qcc .3:0113 during the year. Sheep only are slaughtered. 28 By-laws for Slaughter-houses. Under Section 19 (4) of the Public Health London Act, 1891, the London County Council made By-laws for regulating the conduct of the business of a slaughterer of cattle in the County of London. The object of the By-law is to secure more humane slaughtering, and it prohibits the slaughter of an animal until it shall have been effectually stunned with a mechanically operated instrument. The By-law does not apply to a member of the Jewish faith licensed by the Chief Rabbi as a slaughterer when engaged in the slaughtering of cattle intended for the food of Jews according to the Jewish method of slaughtering, if no unnecessary suffering is inflicted. An amendment of the By-law is now under consideration (March, 1925), to extend the exception to any person professing the Mohammedan religion when engaged in the slaughtering of any animal intended for the food of Mohammedans, in accordance with the procedure prescribed by Moslem law and custom, if no unnecessary suffering is inflicted upon such animal. Places where Food is prepared for Sale. Under this head are included kitchens of hotels, restaurants and eating-houses of all sorts, slaughter-houses, tripe, offal and other meat shops, fried fish, eel and other fish shops, premises where ice cream is made, and other places where food is prepared for sale, excluding bakehouses which are given above. The number of such places on the register at the end of the year was as follows:— Hotels, Restaurants and Eating Houses 228 Slaughter-houses 1 Tripe, offal and other meat shops 35 Fried Fish shops 11 Fish shops 14 Tee Cream (Manufacture) 83 Poulterers 3 During the year 2,419 inspections of food premises and market streets were made and 21 notices served for sanitary defects found. Washing up Arrangements in Restaurants, Eating Houses and Public Houses. In last year's Annual Report 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. 29 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 its due consideration. Unsound Food. The following unsound food was condemned during the year 1924:— Commodity. Quantity. Condition. Result of Action taken. Cereal:— Macaroni 8 cases (16cwt.) Mouldy and maggoty Surrendered Fish:— Herring roes 64 lbs Decomposed Do. Brussels 1 bag (50 lbs.) Do. Do. Whiting 1 trunck (6 stone) Do. Do. Fruit:— Apples 102 boxes (1H cwt. 3 qrs.) Decomposed Do. Cocoanuts 5 bags (5 cwt.) Do. Do. Grape fruit 1'28 cases(5 tons 3 cwt.) Do. Do. Greengages 187 crates (2 tons 1 cwt.) Do. Do. Lemons 110 half eases (2 tons 9 cwt.) Do. Do. Melons 36 cases Do Do. Meat:— Fresh 26 stones Decomposed Do. Cured (Bacon) ½ cwt. Abscess Do. Poultry:— Rabbits 45 lbs. Decomposed Do. Vegetables:— Carrots 2 tons Decomposed Do. Celery 4 baskets (50 lbs.) Do. Do. Onions 1 tons, 14 cwt. 1 qr. Do. Do. Potatoes 7 5 bags (3 tons 15 cwt.) Do. Do. Tomatoes 14 bundles (14 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. 30 A communication on these lines was forwarded by the Holborn Council to the Minister of Health, and a copy of my report on the subject was sent to the Medical Officers of Health of the large towns of England and Wales; a number of municipal authorities in such towns, as well as several metropolitan authorities, male similar representations to the Ministry. As mentioned in the last Annual Report a Departmental Committee was subsequently appointed to consider the question of preservatives and colouring matters in food. The following is the summary of conclusions and recommendations issued by this Committee: — 1. Preservatives should be prohibited in all articles of food and drink offered or exposed for sale whether manufactured in this country or imported, except that (A) Sulphur dioxide only should be permitted (i.) in sausages in amounts not exceeding 3 grains per pound; (ii.) in jam in amounts not exceeding 0.3 grain per pound; (iii.) in dried fruit in amounts not exceeding 7 grains per pound; (iv.) in preserved (but not dried) whole fruit or fruit pulp in amounts not exceeding 5 grains per pound; (v.) in beer and cider, whether in bottle or in cask, in amounts not exceeding 5 grains per gallon; (vi.) in alcoholic wines, non-alcoholic wines and cordials, and fruit juices, sweetened and unsweetened, in amounts not exceeding 3 grains per pint. (B) Benzoic acid only should be permitted (i.) in coffee extract in amounts not exceeding 3 grains per pound; (ii.) in non-alcoholic wines and cordials, and sweetened and unsweetened fruit juices (as an alternative to sulphur dioxide) in amounts not exceeding 5 grains per pint; (iii.) in sweetened mineral waters and in brewed ginger beer in amounts not exceeding 1 grain per pint. The method of estimating the foregoing preservatives should be prescribed by the Minister of Health. 2. The sale of any preparation as a food preservative or for use in such circumstances that it may be introduced into food should be declared illegal unless such preparation (a) bears a description clearly indicating its composition and strength; (b) is free from impurities and in particular contains not more than 1/100th part of 1 grain of arsenic per pound or more than 1/7th part of 1 grain of lead per pound. 3. The use of preservatives so far as they are permitted should be upon the condition that the nature and quantity of the preservative present in the article of food should be declared in a manner prescribed by the Minister of Health. In cases in which the declaration of the preservative might be difficult to enforce or might result in undue harm to the industry without compensating advantage to the consumer, exception to this requirement might be made, but the exception should in no circumstances apply to sausages. 4. The employment of a copper salt to colour or preserve the colour of peas and other vegetables should be prohibited. 5. A schedule should be issued by the Minister of Health after such enquiry as is necessary of colouring matters, the use of which may be considered non-injurious to health, such schedule to be subject to amendment or extension from time to time as 31 occasion may require. Within a suitable period after the publication of this list the use of any other colouring matter should be prohibited unless and until it shall have been approved by the Minister. 6. Before prohibition of preservatives or of colouring matters in food (including the use of copper salts for the so-called greening of vegetables) is enforced, a period of grace should be allowed sufficient to enable manufacturers and importers to adjust their methods and processes and to allow stocks to be cleared. 7. Improved methods in the storage and transport of food by rail, road and water, especially as regards the use of refrigeration and cool air storage, are urgently required. 8. It should be provided by law that any Regulations or Statute prohibiting or limiting the use of preservatives and colouring matters should bind the courts in proceedings taken under the Sale of Food and Drugs Acts in respect of their use. 9. An amendment of the law is required to render more expeditious the prosecution of a person actually responsible for offences under these Acts, where a warranty defence is pleaded. 10. Further powers of control by registration, licensing cr inspection should be given to Local Authorities in relation to all places concerned in the production, sale, or storage and distribution of food. Draft regulations have now been framed to give statutory force to most of these recommendations. In the year 1924, thirty-three 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 repeats the experiences of previous years and again emphasises the difficulties which face local authorities in their efforts to obtain pure food free from preservatives and colouring matter. Bloater paste Boric acid 1 Beans (tinned) Copper sulphate 1 Cake (pound) Boric acid 1 Cream Boric acid 3 Fruit cordials Salicylic acid 6 German sausage Boric acid 2 Ham and beef pie Boric acid 1 Ham and beef rissole Boric acid 1 Lemon squash Salicylic acid 1 Meat pies Boric acid 2 Meat paste Boric acid 1 Peas (tinned) Copper sulphate 1 Pork pies Boric acid 4 Sausages Boric acid 1 Veal and ham pies Boric acid 2 Sponge roll Boric acid 3 Wine (Ginger and liaisin) Boric acid and Benzoic acid 2 33 32 Legal proceedings were not taken in any of these cases, as under the existing law it is unlikely that conviction would have been obtained. In a number, e.g., bloater paste, meat paste, and pies, sausages,- etc., the amount of preservative found was comparatively small, and in a number of other samples the presence of the preservative was disclosed on the bottle or package. In ten cases where no disclosure was made and the amount of the preservative justified the action, communications were sent to vendors, wholesale dealers and manufacturers suggesting the desirability of the use of the preservative being discontinued, or its presence disclosed to the purchaser. In one case of fruit cordial, the manufacturers replied that they were experimenting with the preservative recommended by the Departmental Committee. In a sample of preserved meat paste the makers replied that the Committee's recommendations are not "law," and in the case of a preserved wine the makers stated they were not aware that the Sale of Food and Drugs Acts specified that the presence of a preservative should be declared on the label. The following observations refer to samples purchased and analysed during the year:— Bloater Paste. The amount of boric acid present in this fish paste was too small to call for proceedings. Beans, Tinned. A sample of tinned beans was found to contain colouring matter, namely copper sulphate, but as the quantity was less than two grains per pound and its presence was disclosed on the label, no proceedings were taken. Cake. A sample of pound cake was found to contain a small percentage of boric acid. Communications were addressed to the vendor and the makers of the cake expressing the hope that the use of this preservative in cake would be discontinued. Fruit Cordials and Syrups. Six out of fourteen samples of fruit cordials and syrups were found to be preserved with salicylic acid. The amounts were small and no action was considered necessary except in one case where a communication was addressed to the manufacturers expressing the hope that the use of the preservative would be discontinued or its presence disclosed on the label. The manufacturers replied that they were experimenting with the preservative recommended by the Departmental Committee. German Sausages. Two out of four samples of German sausage contained boric acid, but as the amounts were less than in cases where convictions had been obtained no action was taken 33 Meat Pie and Rissoles. Some samples were found to be preserved with boric acid, but legal proceedings would probably have been unsuccessful. Lemon Squash. A sample of this beverage was found to contain salicylic acid. The quantity was small and its presence disclosed on the label. No action was therefore taken. Meat Paste. One out of six samples of meat paste was found to contain boric acid. A communication was addressed to the manufacturers, who replied that the recommendations of the Departmental Committee had not been made law. Milk. In all 226 samples of milk were examined during the year. The milk was obtained from milk shops, restaurants, and street vendors. A proportion of the samples was purchased on Sundays. Legal proceedings were instituted against the vendors of five adulterated samples. In three cases convictions were obtained with fines and costs amounting to £7. 2s. Od. One summons was dismissed on a warranty defence, and in one case the summons was withdrawn on the defendants paying a guinea costs. In eight samples the adulteration refers to the presence of dirt. See page 19Peas, Tinned. One sample was found to contain colouring matter. The amount of copper sulphate was two grains per pound, and its presence was disclosed on the label; no proceedings were therefore considered necessary. Sausages. One out of four samples of sausages was found to contain boric acid. The amount of the preservative was too small to call for proceedings. Sponge Roll. Three put of four samples of sponge roll were found to contain boric acid. The preservative is introduced by the use of liquid eggs preserved with boric acid. The arrangement made by the Ministry of Health with the Bakery Allied Traders' Association respecting the exclusion of boric acid from liquid eggs used in the C 34 manufacture of sponge cakes, sponge fingers, and sponge biscuits, does not extend to such articles as sponge roll, Swiss roll, and other confectionery made with a sponge mixture. Letters were sent to the vendors and makers of the preserved sponge roll, followed by interviews with the importers of the liquid eggs and the makers of the sponge roll. From these interviews it would appear that the limitation of the prohibition in the arrangement made by the Ministry of Health is generally assumed to confer a right to use preserved liquid eggs in all sponge cakes other than those expressly defined in the Ministry's circular, subject to the amount of the preservative in the liquid eggs not exceeding 1.5 per cent. of boric acid. At an interview a maker of sponge roll agreed to reduce the amount of liquid egg used in the manufacture so as to decrease the amount of boric acid present. On subsequent samples being examined, however, exactly the same proportion of preservative was discovered. The maker's attention was drawn to this continued use of the same amount of preservative and he replied that he was advised by the Bakers' Allied Traders Association that the goods he manufactured were allowed and that he need have no hesitation in continuing to use liquid eggs if supplied through the members of the Association. Tt would seem that in the absence of definite legal prohibition of preservatives, or restrictions of the amount allowed, efforts of local authorities to secure the discontinuance of the use of boric acid even in foods which are largely used for children and invalids, will be of no avail. Flour "Improvers." Samples of flour, including special flour, e.g., cake and sponge mixture, were submitted for examination, particularly for the presence of"improvers. " In reporting on the special flours, the Borough Analyst states that all contain bicarbonate of soda, but the acid ingredient in seven of the eleven samples examined was tartaric acid or acid tartrate, and in four superphosphate. Four of these samples were sweetened with sugar, the amounts varying from three to four per cent.; in all cases the acid reagent was tartrate. Nine self-raising flours were examined, seven containing superphosphate and two tartaric acid or acid tartrate. All these samples were examined for arsenic with entirely negative results, nor were"improvers " found in any sample of these special flours. Four of the five samples of ordinary flour and a sample of bread were found to contain " improvers, " apparently persulphate; owing to the small quantity of " improver " found it was practically impossible to identify it definitely in all cases, but there was no doubt that an extremely powerful oxidising agent had been employed. 35 It may be of interest to point out, from experiments made, that the quantity of "improver" necessary to produce results seems to be most minute; certainly as little as 01 grain of improver per lb. of flour acted most effectively. Wine. A sample of ginger wine was found to be preserved with salicylic acid and a sample of raisin wine with benzoic acid. In one case where the preservative was not disclosed on the label a communication was sent to the vendors and makers expressing the hope that the use of the preservative would be discontinued, or its use disclosed on the label. The makers replied that they were not aware that the requirements of the Sale of Food and Drugs Acts specified that the use of the preservative should be mentioned on the label. The position about ginger wine is unsatisfactory. This is one of the wines which, although generally sold in perfectly good faith as to their character, there is reason to believe are often bought in the belief that they are temperance drinks. Analyses of ginger wine, a wine often given to children at children's parties, and frequently given with cod liver oil to cover the flavour of the oil, have shown that such wine may contain as much alcohol as port, the most alcoholic of all wines, containing 20 per cent, of alcohol by volume. Obviously it is undesirable that children if they be given wine at all should be given so strong a wine; it must often be one of the reasons why children are ill after parties. Many of the parents who purchase this wine are unaware of its strength and do not know what their children are being given. There is both alcoholic and non-alcoholic ginger wine; this must account for much of the confusion. Non-alcoholic ginger wine can be bought at the grocers; it costs from Is. 8s. to 2s. 2d. per bottle. Alcoholic ginger wine can only be purchased at licensed premises, during licensed hours, grocers' shops having an " off licence " being the usual source of supply. It costs about 2s. 6d. per bottle. The vendor does not usually stock both the alcoholic and the non-alcoholic wines; as a rule grocers with a licence only stock the alcoholic wine, and the shop assistant therefore is not likely to ask the customer if he wants alcoholic or non-alcoholic wine. Firms whose names are associated in the public mind with aerated waters make alcoholic ginger wine. Again the expression green ginger wine is used for non-alcoholic and alcoholic ginger wine, C2 36 The Need of a New and Consolidated Sale of Food and Drugs Act. During the last two or three years especially, considerable dissatisfaction has been expressed on the absence of adequate legislation to prevent contamination of food and to ensure its purity and quality; this has now in some measure been met by the issue of the "Public Health (Meat) Regulations and the Public Health (Preservatives, etc., in Food) Regulations, which are useful steps in the right direction. But there is need for a consolidation Act as well; the food-trader also cannot reasonably be expected to bear in mind all his duties nor can he purchase anywhere a publication which will easily show the whole of these duties. We want a new Sale of Food and Drugs Act which would not only codify the whole of the laws relating to the preparation, sale and storage of food, but also include such definitions of various articles of food as would more or less settle finally, as far as local authorities were concerned, the many questions outstanding at the present time. Contamination of Food. We have not sufficiently stringent and definite legislation dealing with the contamination of food. The Regulations made under the South Australian Foods and Drugs Act, 1908, have a section containing 17 general regulations dealing with the protection of food from contamination. They include provisions dealing with the cleanliness of the clothing and body of all persons handling food for sale. They require that no persons suffering from any contagious, infectious or loathsome disease shall handle such food; the comparable New Zealand regulation is worded:— "No person who is suffering from any communicable disease, or who is a "carrier"of any infectious disease, or who is suffering from any condition causing a discharge of pus or serum from any part of the head, neck, hands, or arms shall engage in the manufacture, preparation, storage, packing, carriage, or delivery for sale of any food or of any article used or likely to be used as a food, and no person who is in contact with any infectious disease shall so engage if forbidden to do so by the Medical Officer of Health." Another regulation of general application found in the South Australian code requires that the premises are to be clean, properly constructed, kept in good repair and constructed of such material as may be approved by the Central Board of Health. Protection from Flies. The South Australian code states food for sale must be protected from rats, mice, cockroaches, flies, spiders, bugs, moths and all other vermin, and from any unwholesome substance, odour or smell. A regulation made under the New Zealand Health Act of 1920 requires that every person who sells any food which is ordinarily consumed in the state or condition in which it is sold shall, while it is in his possession or under his control, protect such food from dust and flies and any unwholesome matter by storage in covered receptacles or by covering with gauze, or by other effectual means. Fruit and vegetables commonly eaten in an uncooked state shall be protected from flies, dust and unwholesome matter in such manner as the local authority may by by-law direct, or, in the absence of such by-law, then to the satisfaction of an Inspector of Health. 37 Washing up in Eating Places. Licensing of all Ealing Places advocated. The New Zealand code contains the following: — "In every bar, restaurant, dining-room, tea-room, refreshment stall or booth, and in "every place where food or drink is sold, all drinking vessels and other table appliances "shall be thoroughly washed after use, and shall be kept clean; and no such vessel or "appliance shall be deemed to be thoroughly washed unless all traces of food or foreign "matter have been removed from it, and it has then been rinsed in clean hot water, or "washed in some other approved manner. In this clause 'hot water' means water of such "temperature that all grease and fat is at once liquefied and removed from the surface of "articles which arc plunged therein." It is difficult to avoid the conclusion that all restaurants (including those in hotels) and eating houses should be licensed by local sanitary authorities. With some of the restaurants, especially the high class restaurants, the inspection showed that very little fault, if any, could be found. It is just these places that are willing to accept voluntary registration which ill their case is little more than a formality; such a system of registration is therefore of very little value, except that it brings the sanitary staff in contact with the work of the leaders of this occupation and assists the sanitary staff to form a standard of efficiency. Such legislation is in force in America and Canada. For instance, in Minneapolis an Ordinance was published on the 17th July, 1922, dealing with the inspection of hotels, restaurants, cafes, boarding-houses, inns, taverns, meat-markets, mercantile establishments, and all places offering for sale or selling any food or drink. The Ordinance provides for licensing of all such traders. Regulations under the Ordinance deal with the care of stores and equipment, plumbing, refrigeration, and care of utensils, care of persons, and the storage and care of foodstuffs. Again, in Winnipeg regulations require in places where food is sold for consumption on the premises that cups, saucers, plates, glasses, knives, spoons and forks, and other utensils shall be cleansed in boiling water after use, and the use of cold or dirty water for washing such utensils is prohibited; moreover, a building may not be used for the preparation of food until certified as suitable by the Health Officer. Food Standards—The position in England and Wales. In 1913 the Government in this country introduced a Sale of Food and Drugs Bill to set up standards of quality and purity of food, but it was far from an agreed measure and failed to pass. In 1914 the President of the Local Government Board on being asked when he proposed to reintroduce the Bill replied: "when one lias an opportunity." The essential items in the Bill read as follows :— The Local Government Board may, after such inquiry as they think necessary, make regulations defining an article of food in any matter affecting its nature, substance or quality. Any article sold which does not comply with such regulations shall be deemed not to be of the nature, substance and quality of the article demanded and to be sold to the purchaser to his prejudice. The same is to apply to imported articles referred to in Section 1 of the Sale of Food and Drugs Act, 1899, i.e., margarine, margarine cheese, adulterated or impoverished milk or cream, any adulterated or impoverished article of food to which His Majesty may by Order in Council direct that this section shall be applied unless the same be imported in packages or receptacles conspicuously marked with a name or inscription that the article has been so treated. The sale of articles manufactured, prepared or treated in any manner prohibited by the Regulations is to be an offence. Austria. In framing these standards the experience of Austria and the States of the Commonwealth of Australia will have to be taken into account. 38 In Austria the chemical analysis of samples of food, taken by the officials of local authorities, under the Austrian Food Act, are examined by chemists of the local state chemical laboratory. Shortly after the passing of the Act the opinions given by the analysis in cases heard in the courts were so often contradictory that discord was thrown on the whole procedure. In 1891 an attempt was made to formulate a common mode of examination of samples and general standards by which an opinion on the condition of the article would be given which would be accepted by the majority of experts. But as this effort originated from professional men only and had received no official recognition the conclusions reached carried but little weight in the law courts. The need for Government intervention became obvious, and in 1907 an official commission was appointed consisting of representatives of the Ministers concerned, the chief health officials, professional men, and one member of the Chamber of Commerce of Vienna. From these a small editorial subcommittee was appointed by professional men, health officials, a representative of the Viennese Chamber of Commerce and a small number of experts chosen from manufacturers and traders, these latter varied according to the article of food under consideration. Before the final report was issued a draft of the findings was submitted far their observations to members of the larger committee and to all the Chambers of Commerce in Austria. The Codex alimentarius thus formulated did not, however, obtain the status of a legal document; it was not given the force of law. The analysts were required to use the methods of examination laid down, and in forming their conclusions to pay regard to the standards given in the Codex. But the court of justice were not required to base their verdicts on the Codex; to the magistrates it is only an official collection of the opinion of experts which serves as a guide; they are at liberty to use their own judgment when considering their verdict. The institution of the Codex has had the effect of diminishing almost to vanishing point complaints of unfairness of legal verdicts, and although some of the requirements are stringent the Austrian trading world have come to see that they make for fair dealing between vendor and consumer. Canada and Australasia. ' The formulation of the Austrian Codex has had an effect, directly and indirectly, on the food legislation of many other countries. Although they do not follow the Codex closely, the Sale of Food and Drugs Acts and the regulations made under them by Canada, New Zealand and the several Australian States, New South Wales, Victoria, Queensland, South Australia, Western Australia and Tasmania all include standards. These States have gone farther than Austria in that these standards are legal standards. The requirements of each of these States, although in the main similar, are by no means identical. As a rule the regulations do not enact that certain tests shall be followed in the analysis a marked feature of the Austrian Codex consequent largely on the history of its origin. However, the Regulations for South Australia do enact in the case of the determination of fat in milk, the mode of sampling to be followed under varying conditions and lay down the method of carrying out the test. In this country controversies on the correct terminology of the various kinds of flour and bread have been going on for many years. When we ask for brown bread we do not know nor have we any real guarantee of what we are getting. Obviously in the case of bread, a foodstuff which constitutes so large a part of the daily food of millions, the public should be in a position to know exactly what they are eating. Any manipulation of flour such as bleaching which might permit an inferior quality to be sold as a superior article is undesirable. The Regulations under the New Zealand Sale of Food and Drugs Act, 1908, for example, make the position quite clear; in them flour is distinguished as whole-meal flour, part wholemeal flour, flour and self-raising flour, they require that whole-meal flour shall be the clean sound product obtained by grinding end well-cleaned sound milling wheat, and shall contain 39 all the constituents of such wheat (including the germ); it shall contain not more than fourteen parts per centum of moisture. Mixtures of flour and bran shall not be sold as whole-meal flour. Flour shall not be artificially bleached nor shall it be sprayed at any stage of its production. Various problems which in England are only in the state of expressions of opinion in reports by officials of the Local Government Board are boldly and clearly legislated in New Zealand. For instance the regulations require that flour shall not contain any added substance, in other words no " improvers " such as calcium phosphate and sodium persulphate shall be added to flour so as to enable the baker to bake a loaf containing a higher proportion of water and thus to make more loaves from a sack of flour. Much fraud goes on in connection with sausages in this country; in the absence of a definition a large quantity of a less expensive food such as bread can be added to a small quantity of meat and the mixture sold at a price approximating to that of meat of fair quality. The New Zealand Regulations require that minced meat, sausage-meat and saveloy sausage-meat shall be chopped or comminuted meat, with or without salt, sugar, spices, herbs, saltpetre (potassium or sodium nitrate) and wholesome farinaceous substances. It shall contain not less than seventy-five parts per centum of meat of the kind or kinds designated in the label attached to the outside of the package in which it is contained not more than fourteen grains of saltpetre (potassium or sodium nitrate, calculated as potassium nitrate) to the pound; provided that if minced meat, sausage-meat and saveloy sausage-meat be sold enclosed in a skin of animal origin, the said skin shall be deemed to be an integral portion of the said meat. England and Wales. The only substances with regard to which power to make standards exists in this country are milk, cream and cheese, also butter and milk-blended butter in so far as the proportion of any milk solid, other than milk fat is concerned. In other words the amount of water permissible may be limited. The Board of Agriculture has issued standards for milk and butter; very indirectly a standard for cream is given in the Public Health (Milk and Cream) Regulations, 1912. The Board of Agriculture have not found themselves to be in a position to use their powers to make standards with regard to cheese, yet standards with regard to hard cheese and cream cheese are badly wanted. We are in the same weak position as Austria before the issue of the Codex; it is left to an enterprising local authority administering the Sale of Food and Drugs Acts to undertake expensive prosecutions with every prospect, in event of success, of a more expensive appeal to a higher court. The Ministry of Health can only report that " fines were also imposed in respect of the sale as Cheshire cheese of two samples containing respectively 31 per cent, and 33'3 per cent, only of fat calculated in the moisture-free content, whereas it is generally considered that Cheshire cheese and cheese of similar character should contain at least 45 per cent, of fat calculated on this basis," and again "although the conviction in this case (brought by the Metropolitan Borough of Holborn) was squashed on appeal on a technical point, the conclusion on which the conviction was based, viz., that cheese made from separated or partly separated milk should not be described as cream cheese does not appear to have been disputed." Contrast the definite position established by the issue of standards. The New Zealand Regulations state that" cheese is to contain in the water-free substance not less than fifty parts per centum of fat wholly derived from milk and it shall not contain any foreign fat. Skiinmilk cheese is to contain not less than ten parts per centum of fat wholly derived from milk. Cream cheese shall be cheese made from milk and cream or from milk containing not less than six parts per centum of milk fat. It shall contain in the water-free substance not less than sixty parts per centum of fat wholly derived from milk." Similar instances could readily be given of the value of standards in respect of articles of food, notably cocca and allied substances, pure fruit cordials and syrups, baking powder, self-raising flour, custard powders, infants' foods, vinegar, honey and jam. 40 Milk. The following table shows the fat content of the 217 samples of milk :— . Percentage of Fat. Number of Samples. Shops. Restaurants. Streets. Total Less than 3.0 3 1 1 5 3.1 4 1 3 8 3.2 11 1 6 18 3.3 12 2 3 17 3.4 20 3 4 27 3.5 21 5 6 32 3.6 17 5 6 28 3.7 18 3 8 29 3.8 9 — 5 14 3.9 5 — 2 7 4.0 5 1 — 6 4.1 7 1 — 8 4.2 1 1 1 3 4.3 3 — — 3 4.4 — — 1 1 4.5 2 — 1 3 4.8 2 — — 2 5.1 — 1 — 1 5.2 — — 1 1 5.3 1 — — 1 6.0 1 — — 1 6.1 1 1 — 2 143 26 48 217 Average 3.61 3.79 3.58 3.64 Fifteen per cent, 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, 42 out of 244 samples (17 per cent.) of milk examined in 1924 contained 4 per cent, of fat and over. 41 From records kept in twenty of the purchases where the fat exceeded 4 per cent, it was found that generally the milk was stirred with a hand measure before serving. It is possible that even distribution of the milk fat is not secured in (his way and that the use of efficient plungers would secure this end. On the other hand, when there is reason to believe that milk is properly plunged an analysis has shown the presence of over 4 per cent, of fat. 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 1924: Number of Samples examined. Total Solids, per cent, average. Solids Non-fat. Per cent, average. Fat. Per cent, average. January 20 12.68 9.04 3.64 February 20 12.64 8.93 3.71 March 20 12.46 8.84 3.62 April 20 12.33 8.8l 3.52 May 24 12.42 8.86 3.56 June 20 12.43 8.93 3.50 July 18 12.37 9.01 3.36 August 20 12.24 8.77 3.17 September 20 12.55 8.85 3.70 October 20 12.80 8.92 3.88 November 5 13.18 8.98 4.20 December 10 12.88 8.90 3.98 Whole year 217 12.58 8.90 3.68 Legal Minimum 11.50 8.50 3.00 It will be seen that the seasonal variations are not very marked; the highest percentage of fat was in November and the lowest in July. 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. 42 The following is a list of articles purchased in 1924:— ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costs. Almonds, ground 2 2 0 ... ... ... Ammoniated Tincture of Quinine 3 3 0 ... ... ... Asparagus 2 2 0 ... ... Beans 2 1 1 0 ... ... Bramble Jelly 2 2 0 ... ... ... Brandy 2 2 0 ... ... ... Bloater Paste 1 0 1 0 ... ... Butter 67 67 0 ... ... ... Cake 4 3 1 0 ... ... Cake Mixture 2 2 0 ... ... ... Chicken and Ham Paste 1 1 0 ... ... ... Chlorodyne 3 3 0 ... ... ... Chocolate 3 3 0 ... ... ... Cocoa 2 2 0 ... ... ... Cream of Tartar 2 2 0 ... ... ... Cream 15 12 3 ... ... ... Cream, Preserved 25 25 0 ... ... ... Egg Substitute 3 3 0 ... ... ... Fish Paste 2 2 0 ... ... ... Fruit Cordials and Syrups 14 8 6 0 ... ... Frying Oil 6 6 0 ... ... ... Golden Syrup 2 2 0 ... ... ... German Sausage 4 2 2 0 ... ... Ham and Beef Pie 1 0 1 0 ... ... Ham and Beef Rissole 1 0 1 0 ... ... Honey 3 3 0 ... ... ... Jam Sandwich 2 2 0 ... ... ... Jam 1 1 0 ... ... ... Lemonade and Sherbet 2 2 0 ... ... ... Lemon Squash 1 0 1 0 ... ... Lime Juice Cordial 1 1 0 ... ... ... Margarine 3 3 0 ... ... ... Meat Paste 6 5 1 ... ... ... Meat Pie 4 2 2 ... ... ... Milk 226 213 13 5 3 £5 & £2 2s. costs Milk Condensed 12 12 0 ... ... ... Milk, Dried 4 4 0 ... ... ... Mincemeat 7 7 0 ... ... ... Mustard 3 3 0 ... ... ... Olive Oil 11 11 0 ... ... ... Peas tinned 2 1 1 ... ... ... Pork Pie 12 8 4 ... ... ... Prescriptions 6 6 0 ... ... ... Pudding, Christmas 2 2 0 ... ... ... Rice 4 4 0 ... ... ... Rum 2 2 0 ... ... ... Salmon, tinned 6 6 0 ... ... ... Salmon and Shrimp Paste 1 1 0 ... ... ... Salad Oil 3 3 0 ... ... ... Savoy Cakes 2 2 0 ... ... ... Sausages 4 3 1 ... ... ... Senna, Confection of 3 3 0 ... ... ... Soups 4 4 0 ... ... ... Spinach 2 2 0 ... ... ... Sponge Cakes 4 4 0 ... ... ... Sponge Fingers 6 6 0 ... ... ... Sponge Roll 4 1 3 ... ... ... Suet, Flaked or Shredded 7 7 0 ... ... ... Sweets 9 9 0 ... ... ... Treacle 4 4 0 ... ... ... Veal and Ham Pie 2 0 2 ... ... ... Vinegar 9 9 0 ... ... ... Whiskey 2 2 0 ... ... ... Wine (Ginger and Raisin) 5 3 2 ... ... ... Total 562 516 46 5 3 £7 2s. 0d. 43 ARTICLE. Purchased. Genuine. Adulterated. Proceedings taken. Convictions. Fines and Costa. Informal:— Bread 1 1 0 ... ... ... Flour 5 5 0 ... ... ... „ Bun 1 7 0 ... ... ... ,, Cake 3 3 0 ... ... ... ,, Self-raising 11 11 0 ... ... ... Sponge 2 2 0 ... ... ... Lemonade 4 4 0 ... ... ... Milk 1 1 0 ... ... ... Sponge 11 Mixture 1 I 0 ... ... ... Total 35 35 0 ... ... ... Total Samples 597 551 46 5 3 £7 2s. 0d. Sophistication of Wine. During the year at the request of the Public Health Committee I prepared a report on the sophistication of wine, from which the following is abstracted: — About 16¼ million gallons of wine are imported into this country every year; 9 millions, chiefly port, coming from Portugal, 3¼ millions from France, and 3 millions from Spain. Port and Madeira are defined by the Anglo-Portuguese Commercial Treaty Act of 1914 and the. Amending Act of 1916. The red Spanish wine imported resembles port. Interest centres chiefly in French wines, which are produced in provinces much more familiar to us than Spain. There is abundant French legislation designed to protect the consumer. Various measures have been passed indicating those vineyards which may use a certain name such as Champagne and Bordeaux. As regards the sale of French wines in this country it should be stated that the French law, which strictly limits the use of designations on the label to their correct places of origin, does not apply to French wine sold in England. In 1907 the law declared as fraudulent all practices and manipulations which had had as an object the alteration of the wine in its natural state in order to deceive the purchaser as to its real quality or place of origin or to cure any disease present. To grapes or to the must which is being made into wine, producers are allowed to add calcium sulphate to the extent of not more than an amount equal to 2 grammes per litre of potassium sulphate; calcium or ammonium phosphate may be added instead of plaster, alkaline bisulphites may be added up to the amount of 20 grammes per hectolitre. To wine itself might be added instead of alkaline bisulphites sulphurous acid not exceeding more than 350 milligrammes per litre, of which 150 may be in the free condition. The manufacture, display and sale of substances of unknown composition, whether to improve or give a bouquet to the must or to wines, or to cure diseases or to make artificial wines, is forbidden. Wines affected by disease were declared to be unfit for consumption if they had an abnormal taste and contained more than a certain amount of volatile acid. The commonest sophistication in France is the addition of water; it may often be masked by the addition of other substances such as alcohol, organic acid or glycerine; instead of water, substitutes for wine such as piquettes or vins de sucre or wine made from raisins are often added. Colouring substances, in some cases derived from dangerous coal tar products, have been used to colour diluted wine. Another fraud is the decolouration of red wine to make it into a more expensive white wine. No glucose may be added to wines; the only method of sweetening wine permitted is the addition of wines with must preserved by sulphurous acid. Sugar may, however, be added to the grapes not beyond a certain stated amount provided that its use is declared. Saccharine or any other substances such as dulcine and sucramine are not to be used. The 44 use of colouring matters is forbidden, also the use of any preservative other than sulphurous acid. From the French literature it is evident that at times there has been introduced into wine poisonous metals, either derived from the vessel in which the wine is contained or by the too liberal use of some solution containing copper, arsenic or lead employed to protect the grape vine from fungoid diseases or attacks of insects. The legislation of the United Kingdom concerning wine is as follows:— In the Revenue Act, 1906, clauses were inserted requiring a licence to be taken out annually by manufacturers for the sale of British wines or sweets or made wines, authorising manufacture, the licence costing £1. This was in consequence of the use of foreign grape must in the manufacture of British wines; it was alleged that British wines so manufactured were frequently used as the basis of wines which were passed off as foreign wines. The object of these clauses was to put a manufacturer of British wines under observation. In 1908 attention was called to the manufacture of red and white wines, said to contain 26 per cent, and 27 per cent, of spirit respectively, the prices being 1s. 6d. and 1s. 9d. per gallon for the red wine and 1s. 6d. for the white wine, made presumably at Kingston-onThames from pure grape juice; these were sold for the purpose of blending with any wine. The Statutory Rules and Orders, 1906, No. 573 Regulations, dated August 8th, 1906, made by the Commissioners of the Revenue under the Section 7 (2) of the Revenue Act, 1906, as to licences to be taken out by manufacturers for sale and also as to the manufacture for sale of British wines or sweets or made wines, require that no person must manufacture for sale British wines or sweets or made wines without having an excise licence, and for manufacturers of British wines or sweets or made wines to keep a book in which to enter full particulars of quantity and description of all materials used for their manufacture, and to keep an account of quantity and description of British wines or sweets or made wines manufactured by him. By Section 10 regulations were issued, coming into force April 1st, 1912, which restricted within certain specified limits the mixing of British with foreign wines, and prohibited the sales of wine so mixed unless they were mixed under the conditions prescribed in the regulations; 15 gallons of foreign wine might be mixed with 100 gallons of British wine, and such blended wine must be sold under the designation of " British wine." In 1913 in consequence of the decision in the case of the Wine and Spirit Traders Association, and Messrs. Piper, Ltd., the Chancellor of the Exchequer was asked to consider the whole question of basis wine, both as regards their manufacture, competition of the genuine wines, and the loss to the lievenue caused by the sale of duty free so-called British wiue. This was not gone on with because application had been made to the magistrates to state a case for a High Court with a view to an appeal from his decision, and until the result of the application was known Mr. Lloyd George did not think that he could usefully take any steps in the matter. Since then no further action has been taken. The average quantity of British fermented wine manufactured yearly is about 2,000,000 gallons. It should be noted that the legislation of South Australia constitutes a very clear and definite food standard as regards wine. It mentions those substances which may be added to wine in different stages of its production and those substances the addition of which is prohibited. I have endeavoured to obtain information as to the extent to which the foreign wine sold in this country is adulterated. On the one hand it would seem that the various practices which have to be held in check by legislation in foreign countries and the supervision carried out by the officials appointed for the purposes would almost equally have to be checked in this country. It might be argued that it would not pay wine importers to pay the transport charges on wine of an inferior quality; the United States legislation might be thought to be an indication that wine of an inferior quality is transported even longer distances than from the Continent to England. One conclusion can, however, safely be drawn from the consideration of the subject; it is freely acknowledged that white wines containing sugar are maintained as such by the use of sulphurous acid. The new regulations as to the use of preservatives will in all probability contain a restriction on the use of sulphurous acid; when they come iuto force bottles of such wine should be examined to ascertain that the legal limit is not exceeded. 45 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. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1821. 1922. 1923. Yearly average 1914-1923. Pneumonia (all forms) 40,070 48,874 37,916 39,832 59,666 38,949 37,149 34,708 40,930 33,413 41,150 Pulmonary Tuberculosis 37,838 40,803 40,769 42,335 45,338 35,984 32,791 33,505 33,919 32,097 37,537 Measles 9,144 16,445 5,413 10,538 9,787 3,534 7,190 2,241 5,694 5,316 7,530 Whooping Cough 8,040 8,143 6,075 4,509 9,898 2,605 4,401 4,576 6,370 4,162 5,877 Diphtheria 5,863 5,865 5,366 4,477 4,803 4,888 5,648 4,772 4,075 2,722 4,847 Scarlet Fever 2,843 2,406 1,381 768 1,020 1,221 1,430 1,305 1,382 993 1,474 Enteric Fever 1,705 1,388 1,122 977 950 577 537 613 465 450 878 46 The total number of notifications relating to Holborn residents received during the year was 446 in comparison with 430 in the year 1923. 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 226 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 226 notifications so received were as follows:— Diphtheria 24 Scarlet Fever 28 Whooping Cough 1 Typhoid Fever 2 Paratyphoid Fever 1 Cerebro-spinal Meningitis 4 Encephalitis Lethargica 8 Acute Poliomyelitis 31 Pneumonia 2 Ophthalmia Neonatorum 9 Measles 2 Tuberculosis 114 226 Smallpox. No notification was received. Five cases of smallpox were notified in London. Information of 15 passengers arriving on vessels on which smallpox had occurred during the voyage, or which came from infected po:ts, was received, and the necessary visits for keeping such contacts under observation were made. In all except one case the addresses given in this Borough were hotels. It was possible to see 12 of the 15 travellers. In one case the name given was not known, and in another, although the passenger had visited the hotel he had gone away leaving no address, before he could be visited after receipt of notice from the Port Sanitary Authority. In a third case the passenger had also left the hotel, but we were able to obtain his new address and forward the information to the Medical Officer of Health of the district concerned. 47 The following Table, kindly supplied by the Vaccination Officer of the Holborn Union gives information respecting vaccination in the Borough of Holborn:— Total Number of Births Vaccinated Died before Vaccination Cons. Objectors Insusceptible Postponed by Medical Certificate Removed. No information as to Vaccination Temporarily unaccounted for Holborn Sub-District: 12 months ended 30th June, 1924 243 122 30 28 1 24 23 15 St. Giles and Bloomsbury Sub-District: 12 months ended 30th June, 1921 168 86 15 21 0 19 16 11 411 208 45 49 1 43 39 26 As in previous years a leaflet respecting the advantages of vaccination was sent to the parents of all infants born in, or belonging to, the Borough. As mentioned in the last Annual Report by arrangement with one of the Medical Officers of the Ministry of Health, a special leaflet prepared by him was used in the Bjrough during the latter part of the year 1923 and the early part of 1924 simultaneously with the Holborn Vaccination leaflet. An attempt being made to ascertain to what extent the respective leaflets were effective, the system adopted was to issue alternately the Holborn leaflet "H" and the leaflet prepared by the Medical Officer of the Ministry of Health "W." A hundred of each of these leaflets were issued, a post card for reply being sent at the same time. Careful note was kept as to the homes to which the respective leaflets were issued, and at the end of 1924 it was possible, with the co-operation of the Vaccination Officer, to compile the following table showing the results obtained. Return respecting vaccination of children whose births were notified in 1923 and to whose parents leaflets were sent as arranged with a Medical Officer of the Ministry of Health:— Leaflets. No. issued. No. of Children Vaccinated. Obtained exemption. Dead Unvaccinated. Postponed to be done later. Removed no trace. Refused Vaccination. "W" 100 50 9 5 19 15 2 "H" 100 50 13 1 22 8 6 200 100 22 6 41 23 8 The advantage is only slightly, if at all, in favour of Leaflet \V. A comment was made that in Holborn an exceptionally high rate of vaccination was secured, and that this made it a less satisfactory district for the experiment. 48 Diphtheria. Sixty-eight notifications of diphtheria relating to residents in the Borough were received dining the year at the following ages:— Under 1 year 1 1 to 5 years 28 5 „ 15 „ 19 15 „ 25 ,, 13 (includes 5 hospital 25 „ 45 „ 6 nurses) 45 „ 65 „ 1 Of these 67 were removed to hospital. Fifteen cases were returned from the hospitals of the Metropolitan Asylums Board certified as not suffering from diphtheria. Four deaths occurred. Four 'secondary" cases were notified, but as 2 of these were found not to be diphtheria the number of genuine "secondary" cases was only 2. A "secondary" case is one occurring in the same household as the primary case. The 2 secondary cases include a nurse in a hospital in the Borough. From the same hospital 24 in-patients were notified as suffering from diphtheria; none of the in-patients were residents of the Borough. There was no "return" case notified. In London 10,684 cases were notified giving rise to 571 deaths. We endeavour to co-operate with the Medical Superintendents of the Metropolitan Asylums Board Fever Hospitals; information is now sent to them as to any bacteriological examinations before admission or after discharge of the patients, and also with regard to return cases of scarlet fever. The practice of taking swabs from the throats and noses of child contacts was continued during the year and 73 children were so swabbed. Of these 61 were negative and in 12 (16 per cent.) positive results were obtained. Diphtheria Contacts. Bacteriological Examination of Nose, and Throat Swabs. Total Contacts swabbed 73 Negative 61 Positive 12 Contacts swabbed. Positive Results. Contacts positive. Nose and Throat. Nose only. Throat only. First Examination 73 1 10 1 12 Second ,, 13* 1 5 ... 6 Third ,, 6 ... 3 ... 3† Fourth „ 1 ... 1 ... 1‡ * One negative was reswabbed. †Two tested for virulence, one positive—Reswabbed 1925, one negative, ‡Referred to St. Mary's Hospital. 49 The parents of persistent carriers are advised to obtain treatment for the children concerned and are recommended to take such contacts to St. Mary's Hospital for treatment by inoculation with vaccine made at times from the patient's own germs; one case was so treated last year. The parents or others in charge of children harbouring diphtheria bacilli were given written directions as to the precautions necessary. The results of the examinations of child contacts were communicated to the School Medical Department of the London County Council so that children harbouring diphtheria bacilli could be kept from school providing there were no evidence that the organisms were avirulent. Diphtheria antitoxin was supplied free of charge on application by medical practitioners. During the year it was supplied in 4 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 possible source of delay in administering antitoxin is if the doctor sees a patient and after examination he suspects that he is dealing with a case of diphtheria he merely takes a swab for bacteriological examination and does not inject antitoxin at once, but delays till he hears the result of the bacteriological examination some 24 hours or so later. This source of delay is so important that it has been suggested that Public Health 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 three years, ending December, 1924, is given in the following tables — D 50 HOLBORN MUNICIPAL INFANT WELFARE CENTRE. Schick Test and Diphtheria Immunisation. Three years, 1922-23-24. Total Tested. Result of 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 Re-tested. Failed to complete 3 inoculatns. Inoculatns. not begun. Inoculatns. still in progress. 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 Re-tested. 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 593 49 146 26 440 20 7 3 8 0 7 1 159 3 3 0 1 0 2 0 9 1 1 1 2 0 192 6 170 0 43 5 35 9 642 172 460 10 8 8 162 3 1 2 10 2 2 198 170 48 44 * These columns refer to 20 cases that were Schick positive on re-testing after 3 ccm T.A.T. 51 HOLBORN MUNICIPAL INFANT WELFARE CENTRE, 1922, 1923, 1924. Ages of Persons Schick-Tested with Result of Test. Ages. 6 to 12 months 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to 11 years 11 to 12 years 12 to 13 years 13 to 14 3_ears 14 to 15 years 15 and above years Total for 3 years, 1922-24. 40 101 87 84 57 33 30 21 29 40 24 15 12 19 1 49 - 642 Result of Schick Test. Pos. Neg. Pos. Neg. Not read Pos. Neg. Pos. Neg. Not read Pos. Neg. Not read Pos. Neg. Not read Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Not read Total for 3 years. 35 5 94 5 2 84 3 69 14 1 41 14 2 18 13 2 19 11 12 9 18 11 17 23 14 10 6 9 6 6 6 13 1 0 20 26 3 460 Pos. 172 Xeg. 10 Not read. 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 3 years 30 77 70 53 34 16 18 11 13 14 11 6 4 4 1 6 = 368 D2 52 In addition to the above 12 others Schick tested in 1924 were still undergoing immunisation at the end of the year. Eighteen others Schick tested in 1923 completed immunisation in 1924. Those found to be Schick positive are given three inoculations of 1 ccm. of toxin-anti-toxin (T.A.T.) on three consecutive Wednesdays; after some weeks have elapsed all those who have completed the routine attendances should attend again for re-testing. As a rule, those found positive to Schick testing who do not begin inoculations, are children whose fathers will not give their consent to immunisation. During 1924, 217 persons (208 children and 9 adults) were tested; 166 were positive, 50 negative, and one was not able to re-attend for reading, or to be seen at home; 41 failed to complete, or did not begin, the attendances for immunisation. Experience leads us to believe that many of these will complete their attendance in 1925. Eleven children were given 3 ccms. T.A.T. in smaller doses to avoid possible reaction, the occurrence of a very marked positive Schick reaction being taken as an indication of probable sensitiveness to protein. When the matter of immunisation against diphtheria is discussed attention is concentrated on the immunisation of school children. This is unfortunate. In the report for 1922 it was shown that in London 52'6 per cent, of the deaths from diphtheria in the three years 1919-1921 occurred in children under five years; immunisation should not be delayed until the child is of school age. Scarlet Fever. All the 88 cases of scarlet fever were removed to hospital. Five cases were returned from hospital "not scarlet fever." In connection with 6 of the cases during the year there were 8 secondary cases. All 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 tne same hospital 28 in-patients were notified as suffering with the disease; none of these in-patients were residents of Holborn. There was no "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. 11,610 cases of scarlet fever were notified in London with 129 deaths. Enteric Fever. Two cases were notified during the year. In one case the illness was contracted whilst the patient was travelling from Australia to England via Canada. This patient died in hospital outside the Borough. As the patient's home address was in Australia the death was not transferred to Holborn. In the second case the patient was an Italian taking all meals, except supper, at various eating houses. 410 cases were notified in London, with 52 deaths. 53 Typhus Fever. No case of typhus fever was notified during the year, either in the Borough or in London. Cerebro-Spinal Fever. No case of cerebro spinal fever was notified. 97 cases were notified in London, with 69 deaths. Dysentery. One case of dysentery was notified. 17 cases were notified in London. Malaria. One case of malaria was notified. The disease was contracted whilst the patient was travelling from South Africa to England, the first symptoms appearing as he was passing through the Red Sea. 81 cases were notified in London. Encephalitis Lethargica. Six cases of encephalitis lethargica were notified in the Borough during the year. One case was returned home not suffering from the disease. There were two deaths. Two of the six are reported to have completely recovered. The remaining patient, an Italian, has left the Borough and returned to Italy. 605 cases were notified in London, with 122 deaths. The following table gives information up to the end of 1924 respecting the ten 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. Patient. Age when notified. Subsequent History. 6/2/20 p.p. 8 years Died 28/2/20 7/2/20 w.w 47 yeais 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 15/11/24 a.g. 27 years Returned from m.a.b. Hospital not encephalitis ethargica 54 Acute Poliomyelitis. No case of acute poliomyelitis or polioencephalitis was notified. 116 cases were notified in London, with 14 deaths. From the coming into operation of the Poliomyelitis Order, 1012, to the end of 1924, a total of 12 cases of this disease was notified as occurring in the Borough. The following table gives particulars of these cases with the condition at the end of 1924:— Date of Notification. Patient. Ape at date of Votification. Where Treated. Subsequent History. 17/7/13 F.D. 1 8/12 years Hospital Died from diphtheria 23/10/13 F.H. 2½ „ ,, Wears surgical boot and still O.P. at Hospital 26/1/10 A.C. 4 „ ,, Died 26/1/16 27/1/16 T.B. 4 ,, ,, Recovered—no crippling 5/9/16 F. B. 2 months ,, Died 4/12/18 G.B. 7 years ,, Returned from Hospital, not poliomyelitis 6/6/20 i. P. 3½ „ ,, Recovered—no crippling 23/7/20 E.W. 15 „ ,, No use of lower limbs 17/9/20 E H. 1 8/12 .. ,, Recovered—no crippling 4/9/22 Y.R. 1 10/12 ,, Home ,, ,, 5/2/23 J N 3½ „ Hospital ,, ,, 2/5/23 m.h 11 mths ,, Still an O.P. at Hospital Pneumonia. Sixty-three cases of pneumonia were notified during the year. Ten of these were influenzal pneumonia. Forty-five deaths were recorded from all forms of pneumonia. The 53 cases of primary pneumonia were notified at the following ages:— Under 1 year, 3; from 1 to 5 years, 13; from 5 to 15 years, 2; from 15 to 25 years, 1; from 25 to 45 years, 13; from 45 to 65 years, 16; and 65 years and upwards, 5. Twenty of the 53 died. Twenty-five were treated at home; 18 were removed to voluntary hospitals; 9 to Poor Law Infirmaries; and one to a children's nursing home. Fourteen of the patients were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. It was possible to obtain some further information in 41 cases; of these 24 resided in tenement lodging houses, 6 in model dwellings, 5 in separate private dwellinghouses, 1 in a boarding house and 4 in hotels. 55 The cleanliness of the homes was reported to be satisfactory in 22 cases, but only fairly so in 18, and in one case was unsatisfactory. The economic conditions of the families concerned was found to be good in 9 cases, fair in 12, poor in 15, and very poor in 4; only 4 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 18 instances:— Following chronic bronchitis 4 Following cold 9 Following measles 3 Exposure to bad weather (commercial motor driver) 1 After pleurisy 1 Influenza. There were 11 deaths from influenza in comparison with 1 in 1923, 21 in 1922, 8 in 1921, 11 in 1920, 46 in 1919, and 138 in 1918. Anthrax. No case of anthrax was notified in the Borough during the year. Six cases were notified in London. In August information was received of a fatal case of anthrax, caused by the use of an infected shaving brush; the patient resided in an adjoining area. On enquiry it was found that he purchased a shaving brush (one of a large consignment) in the Borough of Holborn. He cut himself whilst shaving and the evidence given at the Coroner's inquest pointed to infection from the shaving brush. It was ascertained that the brush was from a consignment of twelve to thirteen thousand brushes of mixed types supplied to a dealer in this Borough who sold by wholesale and retail. Efforts were made to trace the source of the brushes and also the destination of those which had been sold. It was impracticable to secure reliable evidence as to the exact source of production of this mixed consignment, but most of the brushes were made up in the United States of America. A very large proportion of the brushes was recovered from various retailers both in London and the Provinces and, with a view to preventing the possible spread of the disease, the Council wisely decided to destroy the 6,279 brushes which were recovered. Chicken-pox. During the year information of 6 cases was received from school teachers and others. Mumps. Information was received from school teachers of 46 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 281 Bacilli not found 246 2 79 Bacilli not found 6: Nil Bacilli found 35 Negative 2 Bacilli found 13 56 Disinfections. During the year 342 rooms and 3,342 articles of bedding, clothing, etc., were disinfected after various infectious diseases. Sixty-seven rooms 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-five toys were disinfected. Arrangements were also made at the request of a trading firm for the disinfection at the cost of such firm, of a quantity of second-hand clothing, prior to exportation to South Africa; 9,216 hats and 200 articles of clothing were so disinfected and certificates given. Forty-six books belonging to the Holborn Public Library were disinfected. An ambulance belonging to the London County Council in which an infectious patient had been conveyed and a car belonging to a traveller were also disinfected. Cleansing of Persons Act. During the year 124 persons (117 men and 7 women) infested with vermin had their bodies and 1,441 articles of clothing disinfected, free of charge, at our cleansing station Goldsmith Street. Fifty-three verminous rooms were disinfected. 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 18 children reported to be verminous. In four instances the same children were reported as verminous on three different occasions in the year and in one case the child was reported a second time. All 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. Seven children were reported as suffering from scabies; 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. Notice of Arrivals from Infected Ports. In accordance with arrangements for notifying arrivals of passengers from infected ports information was received during the year from medical officers of health of various port sanitary authorities respecting 20 persons from foreign ports infected with cholera and plague and 15 persons from foreign ports infected with smallpox. In all, except two, the addresses given in this Borough were hotels. 57 In the cases of travellers from ports infected with smallpox it was possible to see 12 of the 15. In one case the passenger was "not known," and in another although the passenger had visited the hotel he had left giving no address of subsequent destination before the notice was received by me. In the remaining case the passenger had also left the hotel in this Borough, but it was possible to obtain his new address and forward information to the medical officer of health concerned. In the case of the 20 persons arriving from cholera and plague infected ports suitable letters were sent. In two cases the names were "not known," and in one case the letter was subsequently returned marked " not claimed." From time to time it is found that incorrect addresses are given, or, before a visit can be made, the traveller has departed leaving no information respecting his subsequent destination. It would seem desirable that regulations respecting fhe movements of travellers from infected ports should be strengthened so as to ensure the possibility of their being traced until all danger of development of disease is past. When there is a question of smallpox more information should be given, especially the date of occurrrence of the case, the degree of contact of the individual concerned with the patient and the condition as regards vaccination of the contact. Tuberculosis. The initiation of the Tuberculosis Care Committee as a local institution and the administrative change whereby all correspondence concerning tuberculous patients is sent to the Borough Medical Officer of Health have at once proved beneficial; the knowledge of the local Public Health Staff of the patients is increased in a natural and easy way and the interest in the work encouraged. Total number of cases on the Register of Tuberculosis in the Borough on the 31st March, 1925 268 Number of these patients residing in common lodging houses (about) 19 The number classified as Dispensary patients, i.e., patients who have attended the Dispensary at the University College Hospital or have returned home from institutional treatment 189 The average number of cases notified annually during the past ten years 133 The number notified in the year 1924 87 Of the 87 cases notified in 1924, the number who attended the Dispensary 30 Total number of new cases examined at the Dispensary for the first time in 1924, including the above 30, and all contacts 108 Total attendances and examinations at the Dispensary in 1924, attendances 654 examinations 605 Supervision of home conditions; visits paid by— Tuberculosis Officer 11 Dispensary Nurse 998 Sanitary Inspectors . 518 58 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 30th December, 1923, to the 3rd January, 1925, in the Metropolitan Borough of Holborn. Age-periods. Notifications on Form A. Notifications on Form B. Number of Notifications on Form C. Number of Primary Notifications. Number of Primary Notifications. Total Notifications on Fonn 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. Total Notifications on Form A. Under 5. 5 to 10. 10 to 15. Total Primary Notifications. Pulmonary Males 1 1 5 7 12 9 4 3 43 65 25 28 ,, Females 1 1 2 3 5 10 5 4 1 1 33 55 17 16 Non-pulmoiiary Males 3 1 1 2 2 9 10 7 ,, Females 1 1 1 3 3 1 Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 30th December, 1923, to the 3rd January, 1925, otherwise than by notification on Form A or Form B under the Public Health (Tuberculosis) Eegulations, 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 1 3 ,, Females 1 1 2 Non-pulmonary Males ,, Females Tuberculosis Notifications. Excluding duplicates the total number of notifications received on Forms A or B during the year 1924, was 87; 5 other cases were brought to my knowledge making 92 new cases in the year. These were, private cases 29, hospital cases 42, poor law cases 21. 59 Of the 92 cases, 80 were pulmonary tuberculosis and 12 non-pulmonary tuberculosis. Fifty-nine of the cases were removed for treatment to hospital, infirmary or sanatorium. Sleeping Conditions. In 67 of the 92 new cases of tuberculosis in 1924 it was possible to obtain information as to the sleeping conditions at the date of notification. Ten of the remaining cases were residents in common lodging houses; in 15 cases there had been residence in institutions prior to notification, or incorrect addresses were given. The following is a summary of the information in the 67 cases above referred to:— Patient slept in— Separate bed room 13 Separate bed in living room 1 Separate bed in room shared with— 1 person 7 2 persons 6 3 persons 2 4 persons 1 Shared bed with— 1 adult (H or W.) 14 No others 1 adult (not H. or W.) 8 in room. 1 adult and 2 children 1 1 child 1 Shared bed with— 1 adult Other person in bedroom 1 child 6 1 adult 2 children 3 1 child 3 children 2 1 adult 2 adults 1 1 adult and 1 child 3 children 1 67 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 22 "B."—Fair. Separate bed, but not separate bedroom 38 "C."—Bad. Dirty environment, dirty ill-kept home, no separate bed, bad management as to food and clothing 7 67 60 The following summary gives the position at the end of 1924 of the 92 new cases respecting which information was received during the year:— Dead 23 Cases removed to Hospital and still in-patients at the end of year 10 Out-patients at Hospitals 2 In-patients in Sanatoria at end of year 12 In-patients in Infirmary 9 Not traced—Incorrect addresses 4 Removed from Borough 15 Dispensary Treatment 2 Home Treatment 11 Away with relatives in country 1 Improved- (No medical attendance now) 2 Treatment and Training Colony 1 92 Thirty-two of the 92 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 35 Out-patients at other Hospitals or Dispensaries 3 Dead before notification 7 Treatment at home by private doctor 4 Not traced 4 Removed from Borough 7 60 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 seven cases were notified only at death, five within one month of death, six within three months and one within six months of death. Of the seven cases notified a death four died in Poor Law Institutions, one in hospital, and two at home. 61 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. It has been found necessary during the year to communicate with both classes of institution drawing attention to the Regulations and urging strict compliance therewith. Institutional Treatment. During the year notifications were received of 96 admissions to institutions. These admissions represent 74 patients, some of whom are transferred from one institution to another, and others are discharged, or take their own discharge, and subsequently are re-admitted. The 96 admissions were to the following institutions: — Poor Law Institutions 46 Institutions of the Metropolitan Asylums Board 27 Other Institutions 23 Twenty-two of these admissions were transfers from one institution to another or re-admissions. Visitation of Homes, etc. During 1924 the patients were visited by the Sanitary Inspectors or by the Tuberculosis Nurse; arrangements have been made whereby after March 31st, 1925, all such visits are paid by the Tuberculosis Nurse. Contacts. All contacts are invited to attend for examination at the Tuberculosis Dispensary. Forty-eight contacts, viz., 22 adults and 26 children under fifteen years of age, responded to this invitation and were examined for the first time during the year 1924. Of these, two adults were found to be suffering from pulmonary tuberculosis and one child from non-pulmonary tuberculosis. Forty-five 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 services so as to ensure that no contacts of school age will remain unexamined; if such examination cannot be carried out at the Dispensary the 62 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. Deaths from Pulmonary Tuberculosis. The number of deaths from pulmonary tuberculosis during the year was forty-seven, a death rate of 108 per thousand in comparison with 1'03 for 1923. The following Table shows where the patients died in their own homes or institutions: — Showing the number of Patients who died in their own homes and the number who died away from home in Hospitals or other Institutions. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- All Age. Males. Females. Total. Number of palients who died at home 1 5 4 3 3 1 1 7 11 18 Number of patier.ts who died in hospitals, etc. 4 7 5 11 2 18 11 29 — — 1 — — 9 11 8 14 3 1 25 22 47 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 1924: — Number of Cases examined for the first time in 1924:— Insured. Non-Insured. Children under 15. Males. Females. Males. Females, Males. Females. Total. 18 17 12 23 15 23 108 63 Analysis of 108 New Cases in 1924 and 3 Casos under observation on the 31st December, 1923, pending diagnosis:— Cases examined. Found to be suffering from Tuberculosis. Not suffering from Tuberculosis Ceased attendance before completion of diagnosis. Pulmonary. NonPulmonary A. All persons i n c 1 u d i n g "Contacts." Adults M. 30 15 2 7 6 ,, F. 43 14 2 27 — Children under 15 M. 15 1 14 — F. 23 — — 23 — Total ,, 111 29 5 71 6 B. "Contacts" included in A. Adults M. 7 1 — 6 — ,, F. 15 1 — 14 — Children Under 15 M. 8 - 1 7 F. 18 — — 18 - C. Insured persons included in (A) M. 18 10 1 5 - F. 19 9 — 10 2 Attendances and Examinations at the Dispensary in 1924:— Insured. Non-Insured. Total. Attendances 428 226 654 Examinations 339 266 605 Number referred to Hospital Departments 19 27 46 Specimens of Sputa examined 55 48 103 Supervision of Home Conditions:— Nurses' Visits . 998 M.O.'s Visits 11 Reports and Communications:— Insured. Non-Insured. Total. To Public Authorities 136 97 233 To Practitioners 12 14 26 Summary of 265 Cases disposed of in 1924:— Left the Borough „ 16 Definitely non-tuberculous 217 Died 27 Removed to Infirmaries or Mental Hospitals 5 265 Number of Patients under treatment or supervision at the Dispensary 31st December, 1924 239 64 Close co-operation lias been maintained with the local authorities. Frequent consultations take place between the Tuberculosis Officer and the Medical Officer of Health for the Borough, and at the end of the month, the latter is furnished by the former with reports of the work done in the Dispensary. Numerous reports and returns have also been prepared for the London County Council and other authorities. Many of the children seen at the Dispensary have been sent by the Medical Officers of School Clinics and Child Welfare Centres for further opinion. On the other hand use has been made of the arrangements whereby the School Medical Service keep under observation children referred to them either as unexamined contacts (vide infra) or as being in an unsatisfactory state of health. Close co-operation has also been maintained both with the local medical practitioners and with the Hospital; and it is from these sources that the majority of patients have come. Full advantage has been taken of the valuable facilities offered by the Hospital for the diagnosis of obscure cases, particularly in the matter of X-Ray work, Laryngoscopy, and Pathological investigations. It is also a great help to have at hand an Institution to which tuberculous patients can be referred for treatment of non-tuberculous ailments to which they may be subject, the treatment of which adds so much to their welfare. The Dispensary is also used by the Hospital as a channel for furnishing the various reports sent to the County Councils concerning In-patients who come under their Schemes for the Institutional Treatment of Tuberculosis. Patients referred to the Dispensary from the Out-Patient Department of the Hospital are put in touch with the Tuberculosis Officer of their District and arrangements for their removal to Sanatoria, etc., thus facilitated. Special mention must be made of the help given by the Tuberculosis Care Committee, and the organisation which it represents, in the amelioration of home conditions and in assisting the families of those who have gone to Sanatoria, and in other matters, which, though not strictly medical, are of the greatest importance in treatment. All patients attending the Dispensary are visited periodically by the Dispensary Nurse and reports made. Every effort has been made, through the agency of the Dispensary Nurse and otherwise, to get into touch with contacts; but in this matter considerable difficulty has been experienced, not only in securing primary examination, but in following the subsequent history of the individuals concerned. The arrangements under the heading of General Supervision include:— 1. Periodic examination at the Dispensary, when advice is given as to mode of life and prevention of infection. 2. The supply of medicine to non-insured patients. 3. The supervision of home conditions by the Dispensary Nurse. 65 Tuberculosis Care Committee. The Holborn Tuberculosis Care Committee constituted by the scheme prepared in the year 1922 took over the work of the Interim Care Committee on the 1st April, 1923. The Committee includes the following representation:— Holborn Bjrough Council Councillor Revd. Wilfred II. Daviee, M.A. (to Nov., 1924). liev. Henry Ross (from Nov., 1924). Medical Officer of Health (Dr. C. W. Hutt). The Tuberculosis Dispensary Councillor Sir William Smith, D.L., J.P. Tuberculosis Officer (Dr. R. Ililton) (to Sept., 1924). Dr. J. A. Struthers (from Oct., 1924). The London County Council Dr. F. C. Lewis. Miss H. Bell. The Guardians of the Holborn Union Miss Mary Canney (resigned Nov., 1923). (No successor appointed). The Charity Organisation Society Miss E. F. Bolton. Local Association of Children's School Miss E. Semple (died 6th Feb., 1925). Care Committees. Invalid Children's Aid Association Miss E. Fildes. The Metropolitan Nursing Association Mis? M. Wi'mshurst. Almoners of hospitals Miss J. Salmon. Miss A. M Smith. Insurance Committee for the County of Miss S. Double. London. The Finsbury, Holborn and City War Mr. H. A. Emms (to Jan , 1925). Pensions Committee. Mr. S. Tozcr (from Feb., 1925). British Red Cross Emergency Help Fund Mrs. Paige. Other social workers (co-opted) Mrs. E. C. Bedford. Miss H. M. Matbieson. Rev. Wilfred H. Davies M.A. (from Dec , 1924). 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 arrangements made by the Council for dental treatment, E 66 At the first meeting of the new Holborn Tuberculosis Care Committee Miss H. M. Mathieson, who for a number of years had acted as Honorary Secretary of the Interim Committee, was appointed Honorary Secretary of the Committee. Her report for the year is as follows: — Holborn Tuberculosis Care Covimittee. During the year the Committee has met 11 times. 52 cases have been considered—29 new and 23 old. 34 cases (30 adults and 4 children) were referred by the L.C.C. for assessment. Of these, 19 cases were recommended for free treatment, and 15 cases were assessed to pay contributions, varying from 2s. Od. to 30s. per week, towards the cost of their treatment and maintenance. In 3 of the assessed cases the contributions paid were subsequently refunded, as the Ministry of Pensions acknowledged responsibility for treatment. Contributions towards the cost of treatment and maintenance, amounting to £130. 14s., were collected on behalf of the L.C.C. in 18 cases—13 adults and 5 children. Five of these cases were still under treatment at the close of the year. 13 Quarterly Progress Reports on G children were received from the L.C.C., and the information contained therein was conveyed to the parents. During the year 2 cases were transferred to other T.C.Cs. G patients accepted by the L.C.C. for treatment were advised to appeal to the Ministry of Tensions; 5 were successful in their claims under Article 9 of the Royal Warrant. The sixth is now appealing to the Pensions Appeal Tribunal; his ease lias been referred to the Pensions Department of the British Legion, and he will be represented by their Expert at the Court. One man was referred to, and assisted by the B.R.C.S. Emergency Help Fund, pending his appeal. In another case the Committee's recommendation to the Red Cross was forestalled by Brompton Hospital. He was assisted by the Emergency Help Fund until his case could be transferred to the United Services Fund. Owing to unemployment this man was ineligible for any National Health Insurance Benefit during 1924; he was considerably in arrears for 1925, and his income was nil. The Royal Engineers' Charitable Fund was approached, and was asked to pay his N.H.I. Arrears Penalty and so enable him to go on full benefit in 1925. The Fund sent a grant of £2, and asked the Committee to expend the balance in whatever way would most benefit the man. The other patients did not require assistance pending their appeals. One widow, whose husband was successful in his appeal to the Ministry of Pensions last year, was helped to establish her claim. She was successful in obtaining an Alternative Pension, and an extended maintenance allowance for her physically defective only child. The case of one widow—whose husband, it was felt, should have been awarded a pension —was referred to an expert in appeals, but she was not successful in establishing her claim. One widow was helped to recover a sum which had been over-deducted by the Pension Issue Office in respect of her child. Two widows were advised to apply for a Parochial Widow's Charity; both were successful in obtaining pensions. The Charity Organisation Society provided clothing for one patient entering Sanatorium, arranged convalescence in another case, and lent sheets and blankets in a third case. In one case the Rector of the parish, and in another case the Guardians, provided boots for patients undergoing Institutional treatment. Seven children were referred to the Invalid Children's Aid Association for convalescence. Convalescence was arranged in 5 cases, 1 case was withdrawn by the parents when arrangements were nearly completed, and in one case the family removed. 67 In one case the Guardians arranged convalescence for a family of four delicate children, and so enabled the mother to go away for treatment. It is found that about 1 per cent, (or less) of insured persons read the instructions printed on their cards, or the declarations they sign. The inevitable result is that muddles and misunderstandings arise from time to time, and it frequently has to be pointed out that the fault does not lie with either "Lord George" or "the Government." Occasionally, too, Insurance agents are slack, and there are delays in payments by Insurance Companies. Various cases of this description have been dealt with. Naturally, in Care Committee work, there are many disappointments and discouragements, and there are many instances of failure to achieve the object aimed at. It is unnecessary to refer to such cases, except perhaps to remark, in passing, that a failure frequently occupies more time in the doing than a success. The Committee would like to offer their thanks to all individuals and organisations who hare assisted and co-operated during the year. The three following cases, which have occurred during the year under review, may be of interest: — 1. A woman, suffering from tuberculosis, was found to be sleeping on an uncomfortable couch with broken springs; she also required dentures. The Vicar of the rarisli provided the money for a good second-hand bedstead and mattress. The question of the need of dentures was placed before the Borough Council, who contributed 23 per cent, of the cost; the Vicar obtained a Hospital Sunday Fund grant, and the husband paid the balance. Both bed and dentures were much appreciated. 2. A young widow, owing to ill-health, was found to be practically homeless and penniless. She had no N.H.I, benefit, because a former employer had refused to stamp her contribution card. The matter of the insurance was referred to the Divisional Inspectors of the Ministry of Health, who dealt with it successfully. Meanwhile, convalescence was arranged for her through the Stafford Charity. Subsequently, when she was fit for work, a new situation in domestic service was found for her. She has now married again, and has a home of her own. 3. With the co-operation of the C.O.S. and the I.C.A.A. another family lias been enabled to "carry on" during the prolonged illness of the bread winners. The father, a timeexpired soldier, with an exemplary character—but no pension—became ill and was obliged to give up work, much against his will. He was admitted to hospital, and two children (one of whom was recovering from rheumatic fever) were sent away for convalescence. The home, and two other dependent children, were kept going with the father's Sickness Benefit, and the earnings of the mother and eldest daughter—with a little assistance, for a short time, from the British Legion. The father had been employed at Buckingham Palace, under a contractor to H.M. Office of Works, for about 14 years; a few odd debts which had accumulated, and which were weighing heavily on the man's mind, were wiped off by a grant of £5 from the King's Privy Purse. The father died. A grant of £10 was sent by Sir Lionel Earle from a Fund at H.M. Office of Works. The widow obtained a pension of £10 per annum from the Palmer's Charity for Widows. In a few months time the mother broke down, and was also found to be suffering from tuberculosis; she was sent to a Sanatorium. Arrangements had to be made for the home and family in her absence. By this time two daughters were earning. The two youngest children were boarded with a relative, who took charge of them for a nominal sum; one child was boarded out by the I.C.A.A.; arrangements were made for the paying of the rent and insurance. Incidentally, the landlord was induced to erase from the rent book some arrears of rent he was claiming, but to which he was not entitled. The mother is now home again, and, until she is fit to return to her work of office cleaning, she is receiving a supplementary allowance for nourishment through the C.O.S. There is, however, no hope of this family keeping in good health until better housing accommodation can be secured. H M M YTHIESON Hon. Sec. (pro fern.). E 2 68 Employment of Tuberculous Persons. A problem of much difficulty in connection with tuberculosis is the employment of tuberculous men. For the past two years the Central Fund for the Industrial Welfare of Tuberculosis 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; 10.40 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 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. 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 123 visits being paid to these patients. Dental Clinic for Tuberculous Persons. Arrangements have been made for tuberculous persons referred from the Tuberculosis Dispensary to receive dental treatment as part of the Council's Tuberculosis Dispensary Scheme, at the Clinic of the British Dental Hospital, No. 10, John Street, W.C In the year 1924 8 new patients were treated. These patients made 29 attendances. Scaling and gum treatment was given in two cases. Extractions with general dnaesthet.ic in six cases. In one case filling was provided. In two cases dentures were provided. 69 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 are admitted the Clinic is open for the inhabitants of the neighbourhood. The Secretary of the Hospital has kindly supplied the following information of the work at the Clinic during the year 1924: — Summary of Work carried out at Dental Clinic, 10, John Street, Holborn, on Tuesday Evenings, during 1924. Number of sessions held 49 Number of patients' attendances 312 Number of fillings 44 Number of scalings 9 Without anaesthetic 2 With local anaesthetic 55 Extraction Cases. With gas 30 Number of teeth extracted 285 Number of dentures (including repairs) 34 Number of dressings 4 Number for advice 42 Denture visits 91 Number of new patients 80 Cancer. During the year 70 deaths were recorded as due to cancer, equal to a rate of 161 per thousand. In the year 1903 the death rate from cancer in the Borough was l'O; in 1913, 104; the decennial average rate was 103 for the 10 years 1903-1912, and 135 for the 10 years 1914-1923. It will thus be seen that there is a further increase in the cancer death rate, and although some part of this increase may reasonably be attributed to improved facilities for diagnosis, the figures, nevertheless, indicate the seriousness cf 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 symptons 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. MATERNITY AND CHILD WELFARE. During the year 394 births were registered as occurring in the Borough. During the same period 389 notifications of births occurring in the Borough were received. Of these 358 were from doctors and midwives, 31 from parents, 24 being after letters drawing attention to non-notification. 70 From the 358 notifications of birth forms from doctors or midwives, we are able tc give the following information as to by whom the mothers were attended at the confinement, etc. :— Private Doctors 75 Private Midwives 63 Out-patient Midwifery Departments of General Hospitals and Institutions:— Externs and others 47 Midwives.—Charing Cross Hospital 34 University College Hospital 45 Middlesex Hospital 29 Elizabeth Garrett Anderson Hospital 3 Other Institutions 17 Training Institution for Midwives, Myddelton Square 45 358 Eight notifications related to still births, and four notified the births of twins. The number of births transferred to the Borough from outlying institutions was 196 The number of births transferred from the Borough to other districts was 12 The number of net births belonging to the Borough was 578 There are no Maternity Hospitals or Public Lying-in Institutions in the Borough but maternity cases are admitted to certain nursing homes in the area. An an ilysis 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 No. Percentage of Total Births. Total Births. One roomed homes 80 14 71 12 Two „ „ 182 30 74 12 Three ,, „ 37 6 13 2 Four ,, „ 38 6 21 4 These figures show that many of the women are confined under very uncomfortable and unfavourable circumstances. Home Visiting. The visits paid to the homes by the Health Visitors during the year were as follows:— First Visits Revisits. Total. Expectant Mothers 108 81 189 Children under 1 year of age 575 1,128 1,703 Children 1 to 2 years of age 5 424 429 Children over 2 years of age 4 626 630 Enquiries re stillbirths 18 ,, re ophthalmia neonatorum 13 Other Visits 165 In addition 505 visits were made by student Health Visitors. 71 As shown in the previous Table, 575 first visits to infants under one year were paid in 1924 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. First visits or further visits were not paid where the home conditions were above the standard adopted for home visiting. Four hundred and ninety-five 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. 170 attended the Council's M. & C. W. Centre at 10, John Street. 15 ,, ,, ,, Mary Ward Settlement, Tavistock Place. 8 attended the Centre at the Onslow Street School, Saffron Hill. 1 ,, ,, Charing Cross Hospital. 2 ,, ,, Myddelton Square. 12 ,, ,, Middlesex Hospital. 2 ,, ,, University College Hospital. 5 ,, ,, Royal Free Hospital. 3 ,, ,, Other Centres. 218 attended an Infant Welfare Centre. Thus rather less than one-half of those visited attended an Infant Welfare Centre, and of these four-fifths attended the Council's 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. The following is an analysis of the attendance at the Municipal Centre, 10, John Street. Tuesday. Wednesday. Thusday. Friday. Medical Consultation (alternate weeks) 2—5.30 p.m. Ante-Natal and PostNatal cases only (alternate weeks) 2—5.30 p.m. Children and Mothers seen at AnteNatal Consultation Medical Consultation 2—5.30 p.m. Class 3-5-30 p,m. Dentist. 2—4 p.m. Medical Co. sultation 2—5.30 p.m. No. of Sessions 26 27 27 53 52 51 51 Total attendances- Children 371 ... 100 1,551 16 104 1, 233 Mothers 111 140 31 269 148 347 200 Average weekly attendances— Children 14 ... 4 29 ... 2 21 Mother 4 5 1 5 9 7 4 72 The total number of attendances made by the Health Visitors at the Centres was 392. At the Municipal Centre, 4,830 attendances were made by a number of mothers, including 48 expectant mothers, and 479 children, of whom, 265 were under one year, 73 between one and two years old, and 141 aged 2-5 years on the date of their first attendance. At the Mary Ward Centre 524 attendances of Holborn mothers and children were made by 1 expectant mother and 57 children, of whom 23 were under one year, 13 from one to two years, and 21 between two and 5 years. In addition to the Thursday afternoon classes for mothers during the combined Health and National Baby Week a special address was arranged on Venereal Diseases by Dr. Ruth Verney. 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 is being shown in the Hygiene Exhibition at Wembley this year. In addition to the health talk, assistance is given in the cutting out of garments; patterns of the most suitable woven garments are given away, also directions for making knitted garments and advice as to the choice of suitable materials. Two hundred and eight hanks of wool of a superior quality obtained from Wales were sold at cost price to the value of £10 19s. lid. The maternity bags have been used during the year by five mothers. An outing was arranged for 48 mothers, most of whom carried infants in arms, and 28 older children below school age, during the summer to Boxmoor. The costs of the fares of some of the mothers were defrayed in part from money collected by private subscriptions. Ante-natal Hygiene. Enquiries were made of every mother as to her attendance at an Ante-natal Centre immediately previous to the birth of the child visited. Of the 495 about whom information was obtained— 31 attended the Ante-natal Clinic at the Council's Centre. 34 ,, ,, ,, Royal Free Hospital. 41 ,, ,, ,, Middlesex Hospital. 34 ,, ,, ,, Charing Cross Hospital. 12 ,, ,, ,, Myddelton Square Institution. 18 ,, ,, ,, University College Hospital. 18 ,, ,, ,, St. Bartholomew's Hospital. 10 ,, ,, ,, City of London Hospital. 6 ,, ,, ,, Queen Charlotte's Hospital. 12 ,, ,, ,, other Centres. 3 received ante-natal care from the doctor engaged to attend the confinement. So that 219 out of this number received recognised ante-natal care. 73 At the Council's Ante-Natal Clinic 74 women attended during the year; of these 48 attended as ante-natal and made 101 attendances; 43 were real ante-natal cases, 4 were not pregnant, and 1 attended to ask advice re sterility; 26 others attended after confinement making 28 attendances; 6 expectant mothers continued attendance (11 attendances) after their confinement, making a total of 32 individuals attending after confinement. One hundred and forty attendances were made at the Clinic. Nine of the ante-natal cases were expectant mothers for the first time; a number of the expectant mothers were found to have defects either due to or especially of concern in view of their pregnancy, the number and kind of defect present being as follows: — Contracted pelvis ... 1 Extra-uterine pregnancy 1 Threatened abortion and premature labour 2 Pendulous abdomen 2 Varicose veins 2 Albuminuria 1 Venereal disease 1 Marked vaginal discharge 1 Other diseases present were pulmonary tuberculosis 1; other respiratory diseases 2; heart disease 3; anaemia 5; dyspepsia 9; constipation 5; dental caries 20; sciatica 1; other defects 6. Sixty-eight tests of urine were made for albuminuria; the urine of two of the women showed a cloud of albumin. Dietetic advice was afforded and arrangements made for their confinement to take place in institutions. In 12 other cases the presence of albumin (a faint haze only) was ascribed to leucorrhoea. The blood of 17 women (4 ante-natal and 13 post-natal) and 1 child was submitted for the Wasserman test; 3 of these, including the child, were positive, the remainder negative. Thirteen expectant mothers were referred to Maternity Hospitals for confinement (10 normal, 3 abnormal); 20 to the Dental Clinic for treatment; 2 to the Tuberculosis Dispensary, and 1 to the Heart Hospital. In connection with the 32 post-natal cases attending the Ante-natal Clinic, the defects noted were:—Generative organs 5; respiratory diseases 3; heart disease 2; anaemia 5; debility 3; digestive disorders 1; dental caries 8; pyorrhea 1; difficulty with breast feeding 2; mastitis 1. Eight of these patients were referred to the Dental Cl'nic, 3 to the Tuberculosis Dispensary, and 5 for convalescent treatment. 74 Maternal and Infant Consultations. Details as regards the work at the Maternal and Infant Consultations at 10, John Street and the Mary Ward Centres during the year are as follows:— Reason for Attendance. Number attending* Mothers— John St. Mary Ward. Healthy 12 — Difficulty with breast feeding 37 — Dental caries 73 2 Heart disease 2 Debility 10 1 Anæmia 29 1 Venereal disease 6 — Respiratory disease 3 — Digestive disorders 7 1 Other disorders 13 3 Children— Healthy 171 18 Congenital syphilis 4 - Alimentary disorders 101 15 Rickets 39 2 Respiratory diseases 43 8 Hernia, umbilical 13 — Phimosis 8 — Rash 17 7 Disease of eye 4 1 ,, ear 4 1 ,, nose and throat 41 3 Other diseases 34 2 Mothers. Children. Total. Number referred to Private doctor — 6 6 ,, ,, ,, Tuberculosis Dispensary 1 6 7 ,, ,, ,, Relieving Officer — 2 2 ,, ,, ,, Clinic Dentist 129 30 159 ,, ,, ,, Hospitals 24 85 109 ,, ,, ,, Metropolitan Nursing Association 20 21 41 Assisted Milk Supply—Recommended for 43 73 116 Advised Convalescent Home Treatment 20 37 57 Number referred to Ante-natal Clinic— Expectant Mother 19 — 19 * These figures are the number of mothers or children attending; they are classified under the chief defect from which the mother or child suffered. 75 Breast Massage. Fourteen nursing mothers were referred to the nurses of the Metropolitan Nursing Association for breast massage in order to stimulate the secretion of breast milk. In 3 cases, lactation was completely restored. In 3 cases breast secretion was re-established, but small bottle feeds had to be given to the baby in addition to the breast; one of these cases was the mother of twins. In 3 cases the function was re-established for a short time only to be lost again. In 4 cases the massage *was quite unsuccessful. In one case no further information could be obtained. diarrhoea. During the year an effort was made to classify the cases of diarrhoea occurring in children attending at 10, John Street. The classification used was as follows:— (i.) Simple diarrhoea. (ii.) Summer diarrhoea. (a) Ordinary summer diarrhoea; some disturbance of the heat regulating mechanism together with digestive disturbance of greater or less severity. (b) Ileocolitis with blood and mucus in the stools (Dr. H. Charles Cameron's Group B comprising cases of acute catarrhal follicular or ulcerative colitis). (iii.) Heatstroke in which cerebro-spinal symptoms are the most prominent. The attacks of children suffering from diarrhœa were so analysed; 31 suffered from simple diarrhoea, 8 from ordinary summer diarrhoea. Two children had more than one attack, viz:— A.G. July 9th Simple d. July 23rd Simple d. E.F. September Simple d. October Summer d. Stillbirths. During 1924 there were 18 stillbirths in the district. Difficult labour was responsible for 7; of these 1 was due to contracted pelvis and 2 to abnormal presentation; in the remaining 4 enquiry did not elicit the determining factor. Of the other 11 prematurity was the most likely cause of 2 (twins); maceration of 1, and placenta praevia of 1. Less definite information could be obtained in regard to the other stillbirths; in 1 case the child was reported to have been dead for a week; in 4 others the parent was unable to give any information which could be used in assigning a probable cause; in the remaining 2, no information could be obtained. 76 Four of the 18 stillbirths occurred in the private practice of a doctor; 3 in the extern practice of a hospital; 11 in an institution. Illegitimate Births. An enquiry was made into the circumstances of 44 of the illegitimate babies (46) whose birth was registered in 1924. Four lived with their mothers who remained in their parent's home; if in these circumstances I he mother has to go out to work the grandmother minds the baby. Eight lived with their mothers who went out to work, in one case the baby being in a creche in the daytime. Five were boarded out with foster-mothers. Two were in Institutions. Seven were living with both parents, who lived together permanently. In, 12 instances no information could be obtained; the majority of these mothers had entered a hospital or infirmary for the confinement and had not returned to their previous address. Six died; 3 in the institution in which they were born, 2 were admitted to hospital after birth, and died at the age of 8 and 21 days respectively. As the result of an inquest 1 was found to have died at home from want of attention at birth. Only 1 of these unmarried mothers came to the notice of the Health Visitors before the birth of the child; in this case no special arrangements were required, as the mother lived permanently with the father of the child. Dental Treatment. A number of nursing and expectant mothers and young children were treated at the Council's Dental Clinic held at 10, John Street. The number of new patients during the year was 90, viz., 45 women and 45 children; the number of attendances 451 (women 347, children 104). Assistance with Dentures, etc. Extractions with local anaesthetic were made in 19 cases (18 women and 1 child) and with general anaesthetic in 70 cases, including 29 children. Scalings were carried out in 26 cases (all women). Small fillings were provided in 98 cases, including 31 children, and root fillings in 11 cases (mothers). Dentures were provided for 17 patients, 16 of whom contributed towards the cost. In 3 cases dentures were remodelled; 8 were repaired and dressings were given in 60 cases. In the provision of dentures the cost is based on the charge approved for the time being for dentists on the Ministry of Pensions Panel. 77 Supply of Milk and Food for Expectant and Nursing Mothers and for Infants. The supply of milk and food at less than cor-t price was continued during the year under the Maternity and Child Welfare Act, 1918, for:— (а) Nursing Mothers; (б) 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 1924. Applications received for milk free or at less than cost price are carefully investigated. Enquiries are made to verify statements of wages and other income; information is obtained from the Guardians of the Poor as to relief given for unemployment or other necessitous conditions. Other possible sources of assistance are investigated, and all practicable steps taken to prevent overlapping. The applications are considered by an Assistance Sub-Committee of the Maternity and Child Welfare Committee meeting fortnightly for the purpose. Where grants are made the cases are reviewed by the Sub-Committee at intervals not exceeding one month. During the year 281 applicants received free or assisted milk under the Scheme. This number included 118 who were receiving such assistance at the end of the year 1923. Grants were made in 163 new cases. At the end of the year 1924, 111 cases were receiving assistance, viz., free milk 79, milk at halfprice 19, prepared milk free 10, half price 3. The following Table shows new casesassisted in 1924:— Milk. Prepared Milk. Free. Part Cost. Free. Part Cost. Expectant Motheis 27 4 Nursing Mothers 35 6 — — Children 52 11 11 11 Thirteen samples of milk supplied under the scheme were examined to check the measure. The samples were obtained from 9 retail milksellers in the ordinary course of delivery at the homes. In 2 cases the quantity was found below the standard measure and communications were addressed to the proprietors of the dairies concerned. Home Help. The Council's Home Help attended 29 cases during the year in comparison with 19 in the year 1923. Tn 13 of these the Whole-time Officer attended entirely and in 8 she attended during the earlier part of the lying-in period, being replaced 78 later by one of the Home Helps from the emergency panel in order to take over new cases. In 8 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 4 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 17s. 6d. to 2s. 6d. 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. Convalescent Homes. Sixteen applications for convalescent home treatment for mothers and their babies were granted in comparison with 6 in the previous year. One mother was subsequently found to be unfit for residence in a convalescent home and 6 others for various reasons withdrew. Nine mothers with their babies were sent away in comparison with 4 in 1923. Eight of the 9 mothers were admitted to the Church Army Convalescent Home at St. Leonards-on-Sea. In 4 cases 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 has proved most valuable. In 4 cases of extreme necessity the mothers and infants were sent away free; in the remaining 5 contributions towards the cost were required ranging from 5s. to 20s. per week. Twenty-two applications were granted for convalescent home treatment for children. In 6 cases the applications were subsequently withdrawn. Sixteen children were sent away in comparison with 10 in jl923. Five of these were sent 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 8 cases the children were sent away free, and in 8 contributions were required towards the cost. 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, 409 infants and children under 5 attended the consultations, 117 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. 79 -Deaths of Infants under One Year of Age, 1924. The homes were visited in a large proportion of the infant deaths, and any requisite information obtained, and when required, suitable advice given. The cause and age of death are given In the following Table:— Cause of Death Under 1 Week 1-2 Weeks 2-3 Weeks 3-4 Weeks Total under 4 Weeks 4 Weeks and under 3 Months 3-6 Months 6-9 Months 9-12 Months Total under 1 Year M F M F M F M F M F Both sexes M F M F M F M F M F Both sexes Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 1 1 2 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... 2 Meningitis (non-tubercular ... ... ... ... ... ... ... ... ... ... ... ... ......... ... ... ... ... ... ... ... ... ... Other Tubercular ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 Bronchitis ... ... ... ... ... ... ... ... ... ... — 1 ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... 1 ... 1 ... ... ... 2 ... 2 4 1 2 ... 1 1 ... ... 9 2 11 Diarrhœa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... 1 ... ... ... 3 3 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 1 Injury at Birth 2 ... ... ... ... ... ... ... 2 ... 2 ... ... ... ... ... ... ... ... ... ... 2 Atelectasis ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 Congenital Malformations 2 1 ... ... ... ... ... ... 2 1 3 ... ... ... ... ... ... ... ... 2 1 3 Premature Birth 4 3 1 1 ... ... 1 ... 6 4 10 1 1 ... ... ... ... ... ... 7 5 12 Atrophy, Debility, Marasmus ... 1 1 ... ... ... ... 1 1 2 3 1 1 ... ... 1 ... ... ... 3 3 6 Other causes ... 1 ... ... ... ... ... 1 ... 2 2 ... ... ... ... ... ... ... ... ... 2 2 Totals 8 6 3 1 1 0 1 2 13 9 22 7 4 2 3 5 2 1 1 28 19 47 Total both sexes 14 4 1 8 22 11 5 7 2 47 Net births registered during the calendar year. Net deaths registered during the calendar year. Males Females Both sexes Males Females Both sexes Legitimate Infants 280 252 532 Legitimate Infants 21 17 38 Illegitimate Infants 28 18 46 Illegitimate Infants 6 3 9 80 Deaths of Children 1 to 5 Years, 1924. Twenty-five children between the ages 1 to 5 years died from the following causes:— Cause of Death. Ages. Total. 1—5 1—2 2-3 3-4 4-5 m. F. m. F. m. F. m. F. M. F. Both Sexes. Scarlet Fever ... ... 1 ... ... ... ... ... 1 ... 1 Diphtheria 1 ... ... ... 1 ... ... ... 2 ... 2 Whooping Cough 3 1 ... ... ... ... ... ... 3 1 4 Measles 1 2 ... 2 ... ... 1 ... 2 4 6 Pulmonary Tuberculosis ... ... ... ... ... ... ... ... ... ... ... Other Tuberculois Diseases 1 ... ... ... ... ... ... ... 1 ... 1 Pneumonia 5 2 ... 1 ... ... ... ... 5 3 8 Clett Palate—Marasmus ... 1 ... ... ... ... ... ... ... 1 1 Violence ... ... 1 ... ... ... ... ... 1 ... 1 Other Causes 1 ... ... ... ... ... ... ... 1 ... 1 Totals 12 6 2 3 1 ... 1 ... 16 9 25 Totals—Both Sexes 18 5 1 l 25 Infectious Disease among Mothers and Children. Puerperal Fever. Two cases of puerperal fever were notified in 1924. Both patients died; both were married women. One entered a nursing home previous for the birth of her first child, which was born dead (post-mature); she was thence removed to hospital; death occurred two days after the onset of labour. The other was admitted to hospital for operation following miscarriage; death occurred two months after the miscarriage. In addition to the two cases mentioned above a third death is classified by the Registrar-General under the heading puerperal sepsis (see Table II., page 95). The death refers to a female aged 23 years who died in a hospital in the Borough. As the result of an inquest the death was certified to be due to septicæmia, general peritonitis, septic uterus and miscarriage. Ophthalmia Neonatorum. During the year 13 cases of ophthalmia neonatorum occurring in babies born in the Borough were brought to our notice. Nine out of the 13 cases were notified in accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914, 7 of the notifications being from institutions and 2 from private medical practitioners. One of these cases was only notified after communication with the medical attendant. One case was notified by the Medical Inspector of Midwives of the London County Council. 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:— 81 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 j REMARKS. 2 14 days 9 days Doctor (Hospital) as result of correspondence Moderate Middlesex Hospital (out-patient) Midwife (Middlesex Hospital), Doctor and District Nurse Cured Midwife 3 10 days 1 day Doctor (Hospital) Well Maternity Hospital In-patient, Maternity Hospital Cured Born in Hospital Child not seen until its return from Maternity Hospital 5 26 days First day Doctor (Hospital) Both eyes (Slight). University College Hospital (out-patient Midwife, University College Hospital Cured Midwife 7 9 days First day 1. M. A. B. 2. Doctor (Hospital) Slight department) Home and out-patient Midwife and out-patient University College Hospital Cured Born at home 9 6 days 6 days Maternity Home Not seen Maternity Hospital and St. Margaret's Hospital Maternity Hospital St. Margaret's Hospital Cured Born in Maternity Home 10 10 days Third day Doctor (Hospital) Moderate. Both eyes Home and out-patient University College Hospital Midwife (University College Hospital), District Nurse, and out-patient University College Hospital Cured Midwife 11 4 days 3 days Doctor (Private) Slight Home Midwife, Doctor (Private) Cured Doctor 12 11 days 7 days Doctor (Hospital) Moderate Home Doctor (Hospital) and Midwife Cured Extern Department Hospital 13 5 days First day Doctor (Hospital) Moderate. Both eyes Home and out-patient Charing Cross Hospital Midwife and out-patieut Charing Cross Hospital Cured Midwife 82 Four 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 7 weeks 8 days Superintendent, Bloomsbury Nursing Association Slight St. Bartholomew's Hospital (out-patient) District Nurse and out-patient St. Bartholomew's Hospital Cured Extern Department Hospital 4 9 days 9 days Midwife Moderate Charing Cross Hospital (out-patient) District Nurse, Charing Cross Hospital Cured Midwife (Hospital) 6 9 days 8 days Medical Inspector, London County Council Slight Home Doctor (Private) and Midwife Cured Midwife 8 16 days First day Discharge Notice. M. A. B. Not seen St. Margaret's Hospital St. Margaret's Hospital Cured Born in Hospital Birth not notified; not seen until return from M. A. B. Hospital. 83 Ophthalmia neonatorum is one of the most important causes of blindness. Although fortunately all the cases in the Borough coining to our notice last year were cured, this result was the consequence of the expenditure of much time and energy and indirectly money by all concerned; the occurrence of most, if not all, of the cases could have been prevented by a simple procedure. A year or so ago the Scottish Board of Health issued a circular to medical practitioners "strongly recommending the installation of silver nitrate solution into the eyes of newlyborn children and intimating that they will in future require a report with particulars of treatment from Medical Officers of Health in all cases in which there occurs loss of vision. In this country the installation has been recommended with fortunate results by at least several Medical Officers of Health to those attending childbirths in their areas, but legislation in some form advocating or requiring its adoption generally is required so that the whole country may benefit. Whooping Cough. Visits were paid to 136 persons suffering from whooping cough. Of these 95 were notified by doctors; in 8 others the information was derived from the schools; 16 from the Health Visitors; and 7 from parents. Six died (2 in 1925); 2 were under 1 year, 4 were between 1 and 5 years. Age. Twenty-two were children under 1 year, 89 were aged 1 to 5 years, and 24 5 to 16 years, and 1 was an adult. Contacts. (136 enquiries.) Thirty-eight had no contacts; 98 had contacts. The number of contacts was 333 of whom 170 were susceptible, 163 already having suffered from an attack. No. of cases 24 and 15 21 12 11 6 5 3 2 No. of contacts 1 2 3 4 5 6 7 8 9 No. of cases 35 and 14 15 8 6 No. of susceptible contacts 1 2 3 4 5 Spread of Infection in Family. The 136 cases occurred in 109 families. In 115 families 1 case occurred; 17 families had 2 cases, 2 had 3, and in 2 families 4 suffered. Removal. Sixty-three children were removed to hospital, approximately 46.0 per cent. as opposed to 30 per cent. last year. Of these 61 were admitted to hospitals of the M.A.B. Two were admitted with pneumonia to voluntary hospitals and afterwards notified as suffering from whooping cough. Progress is being made as F2 84 regards the proportion of children removed to hospital. The number of requests from parents for their children to be so removed exceeded the number received in previous years. Obviously children of the poorer inhabitants can receive far better attention in a hospital, and when well enough to get out into the air they can do so without spreading the infection to others. In the case of those who are not removed, very little progress has been made in the parents' willingness to isolate their children. They are sent out into the streets to play, especially when the elder children are in school, and are taken out by theri mothers when shopping. The difficulty of educating parents on this point is increased by the fact that, according to their statements, they have been advised by their doctor to take the child out as much as possible; the interest of the community is overlooked in that of the individual. Measles. The notification of measles was discontinued at the end of 1919, but during 1924, I received information of 267 cases of measles. Of these 108 were notified by school teachers, 43 by medical practitioners, information of 47 was given by the Metropolitan Asylums Board, of 4 by the London Fever Hospital, of 39 by the Health Visitors, 18 by parents, 4 by creches, 2 by the death returns, and 2 by nursing homes. An outbreak of measles commenced in the Borough about November 7th, 1923, and continued throughout the early months of 1924. Ages. 9 were under 1 year. 134 were between 1 and 5 years. 103 were between 5 and 16 years. 21 were over 16. Contacts. 87 had no contacts, the L.C.C. definition of a contact being used. 180 had contacts, the number of contacts was 720, of whom 230 were susceptible, 490 having already suffered from an attack. No. of cases and 52 43 26 17 12 7 4 2 5 3 1 1 2 2 1 1 No. of contacts 1 2 3 4 5 6 7 8 9 10 11 14 15 16 17 24 No. of cases and 60 26 13 8 2 1 2 1 1 No. of susceptible contacts 1 2 3 4 5 6 7 8 9 Spread in Family. The 267 cases occurred in 162 families. In 117 families 1 case occurred, in 32 families 2 cases occurred, in 11 families 3 cases occurred and in 2 families 4 cases. 85 Removal. In all about 32 per cent. of the patients were removed to institutions. 66 were removed to a M.A.B. Hospital. 4 ,, ,, ,, the Holborn Poor Law Infirmary. 15 ,, ,, ,, the London Fever Hospital. Home Nursing. Ten cases of measles, by reason of broncho-pneumonia, were referred to the Metropolitan Nursing Association for home nursing under the Council's arrangements; 93 visits were made in these cases. German Measles. During the year information was received relating to 9 cases; 2 were notified by doctors and information of 2 cases was received from schools, 2 from the M.A.B., 2 from the London Fever Hospital, and 1 from a Health Visitor. Ages. 2 were between 1 and 5 years. 4 were between 5 and 16 years. 3 were adults. Contacts. (5 enquiries.) The number of contacts was 13 of whom 12 were susceptible, 1 having already suffered from an attack; 4 had no contacts. No. of cases and 2 1 1 1 No. of contacts 1 2 3 6 No. of cases and 2 1 1 1 No. of susceptible contacts 1 2 2 6 Spread in Family. There was spread of infection in 1 family, 2 cases occurring in 1 family. Removals. 2 to the London Fever Hospital. 2 to Nursing Homes (removal notified by M.A.B.). Epidemic Diarrhœa. This disease is notifiable in only a few districts in London, and is not notifiable in Holborn. The number of deaths of young children under two years of age classified under the head, Diarrhoea and Enteritis, was 3, all under 1 year. The deaths were equal to a rate of 5.2 per 1,000 births in comparison with 8.4 for all London. 86 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. Nursing Arrangements. Nursing arrangements have been made with the Metropolitan Nursing Association, No. 23. Bloomsbury Square, for the nursing, when required, of necessitous cases of measles, whooping cough, ophthalmia neonatorum, epidemic diarrhoea, pneumonia, encephalitis lethargica and tuberculosis. Their services were used as follows: — Deficient Lactation 14 Cases 191 Visits. Whooping Cough 1 Case 45 ,, Measles 10 Cases 93 ,, Ophthalmia Neonatorum 2 ,, 40 ,, Pneumonia 14 „ 219 ,, Influenza 8 ,, 109 ,, Tuberculosis 4 ,, 123 ,, Total 53 Cases 820 Visits. Pensions for Mothers and Widows. This subject has come to the fore again in this Country of late; it might be thought desirable that local authorities should begin to consider how best the work when it is initiated could be administered. It is difficult to avoid thinking that the administration would be best carried out by local Maternity and Child Welfare Committees. Sympathetic, efficient and experienced administration is essential for obtaining the maximum result, and this can only be effected if the administration is carried out by those who have an intimate knowledge of the home conditions of mothers and widows and have been brought into touch with them in a manner which naturally leads to mutual sympathy and confidence. The organisation necessary for such efficient administration already exists in ihe form of the Maternity and Child Welfare Committees of local authorities and the natural relationship of the new work for mothers and widows to that which they are already carrying out postulates that the administration of the new work should be added to their present duties. Moreover, if the State pays Mothers' Pensions it would have a right to see that the mothering were good. This could readily be done by Health Visitors without prying or inquisitorial methods, in the course of their ordinary duties. In the main also it would be more economical for the work to be carried out by existing organisations. There is everything to be said in favour of local as opposed to central administration in view of local authorities' more intimate knowledge of local and personal conditions and greater facilities for supervision. Health Week and Baby Week. Following the precedents of recent years the celebration of these weeks was, in the main, combined and observed from the 5th to the 11th of October, 1924. The efforts made during the week were as follows: — 87 (1) Elementary schools were invited to co-operate as in previous years. Twenty-one school departments out of 25 suitable took part, and essays were afterwards written by about 2,000 children. The subject of the essay was "How I Can Keep Myself Healthy." Prizes were awarded to the boy and girl writers of the best essays in each school. The Mayor and Mayoress entertained GO of the writers of selected essays at tea, and the Mayoress distributed the prizes. (2) Distribution of literature.—The clergy of all denominations were invited to distribute to the members of their congregations a special leaflet, "Help for families of necessitous sufferers from Tuberculosis." The majority of the clergy in the Borough were so good as to accept the invitation. A special leaflet on "Indigestion—Its Prevention and Cure" was issued and distributed by means of "Please Take One" boxes. (3) A special meeting for mothers was arranged and took place at the Centre, No. 10, John Street, on Thursday, 9th October, when Dr. Ruth E. Verney gave an interesting address to a crowded meeting on "The Child's Inheritance of Health." Subsequently the mothers were entertained to tea. (4) Arrangements were made for dinner hour displays of cinema films, dealing with a variety of health subjects, in the Holy Trinity Parish Hall, Kingsway; two short exhibitions about 30 minutes each were given daily from Monday, 6th October, to Friday, 10th inclusive. Circulars were issued to a large number of employers inviting them to give facilities to their staff to witness the displays. One of the objects in arranging the programme was to endeavour that no one health topic was given undue prominence entirely out of proportion to its relative importance. We cannot go far wrong if the death rate from various diseases is borne in mind. The following films were exhibited:— Monday, Oct. 6th— "The End of the Road" 12.50 to 1.20 p.m. Parts 1 and 2 "The White Bottle" "Public Health Twins" 1.20 to 1.50 p.m. Tuesday, Oct. 7th— "The End of the Road" 12.50 to 1.20 p.m. Parts 3 and 4 "The Fly Peril" "Memories" 1.20 to 1.50 p.m. Wednesday, Oct. 8th— "Perfect Children "The Flaw" 12.50 to 1.20 p.m "The End of the Road " 1.20 to 1.50 p.m. Parts 1 and 2 Thursday, Oct. 9th— "Waste" "Crachez pas par terre" 12.50 to 1.20 p.m. (Tuberculosis) "The End of the Road" 1.20 to 1.50 p.m. Parts 3 and 4 Friday, Oct. 10th— "Whatsoever a man soweth" (Men only) 12.50 to 1.20 p.m. 1.20 to 1.50 p.m. 88 (5) With the co-operation of the Authorities of the Y.M.C.A. arrangements were made for mid-day addresses at the Central Y.M.C.A., Tottenham Court Road, on Tuesday, Wednesday, and Thursday, October 7th, 8th, and 9th. The addresses were given by Arthur J. Martin, Esq., one of the Founders of Health Week ("The Meaning of Health Week"), Professor Henry Kenwood, C.M.G. ("The Choice of Food") and the Medical Officer of Health ("The Health of Office Workers "). (6) By the kind permission of Messrs. George Kent, Limited, an attractascope showing pictures on health topics was exhibited in one of the windows of their premises in High Holborn. Medical Inspection and Treatment of School Children. The medical inspection and treatment of children attending Public Elementary Schools in Holborn is carried out by the London County Council. The following treatment Centres are provided under the L.C.C. Schemes:— (1) Finsbury Centre, Spencer Street, Goswell Road. (2) Moorfields Ophthalmic Hospital, City Road. (3) Soho Centre, Gerrard Street. (4) Lancing Street Centre, Lancing Street, N.W. 1. (5) Cleansing Station (Scabies) Children's Baths, Central Street, E.C. 1. Centres are also provided at the following Hospitals and Dispensaries:— (1) St. Bartholomew's Hospital. (2) Bloomsbury Dispensary. (3) Central London Ophthalmic Hospital. (4) Central London Throat and Ear Hospital. (5) Dental Hospital. (6) Homeopathic Hospital. (7) Hospital for Sick Children. (8) Italian Hospital. (9) Metropolitan Ear, Nose and Throat Hospital. (10) Middlesex Hospital. (11) Royal Free Hospital. (12) Tuberculosis Dispensary, University College Hospital. (13) University College Hospital. We endeavoured to co-operate with the Education Authority by giving information respecting children suffering from infectious disease and child contacts attending public elementary schools. The County Medical Officer of Health has kindly furnished me with particulars of medical inspections of school children in Holborn in 1924. They are classified in the following Tables:— 89 Medical Inspection in Public Elementary Schools in Holborn, 1924. Age, Group and number examined. Condition of Clothing. Nutrition. Cleanliness—Head. Cleanliness—Body. Condition of Teeth. Vision. Mental Condition. Good. Fair. Bad. Good. Average. Poor. Bad. Clean. Nits present. Pediculi. Clean. Dirty. Pediculi. All sound. Not more than 3 decayed. 4 or more decayed. 6/6 in both eyes. 6/9 in either or both eyes. 6/12 or worse in either eye. Average. Poor. Mentally deficient. Entrants—303 Boys 124 162 17 78 205 20 ... 284 19 ... 282 19 2 189 97 17 Not Tested 287 Girls 106 174 7 90 186 11 ... 228 54 5 265 21 1 195 74 18 „ „ Age 8— 243 Boys 64 154 25 29 179 34 1 229 14 ... 215 25 3 154 69 20 150 43 46 242 1 ... ,, 250 Girls 61 174 15 54 170 25 1 175 67 8 231 18 1 156 84 10 155 42 49 250 ... ... Age 12— 248 Boys 50 170 28 74 150 24 ... 230 18 ... 213 31 4 192 51 5 171 18 59 247 1 ... „ 230 Girls 66 153 11 92 125 13 ... 177 48 5 210 17 3 186 42 2 157 18 55 228 2 ... Total 1,561 471 987 103 417 1,015 127 2 1,323 220 18 1,416 131 14 1,072 417 72 633 121 209 967 4 ... Percentage of Examined 30.2 63.2 6.6 26.7 65.0 8.3 84.7 14.1 1.2 90.7 8.4 0.9 68.7 26.7 4.6 65.7 12.6 21.7 99.6 0.4 ... 90 Defects Found. At Medical Inspections in Public Elementary Schools in Holborn, 1924. Entrants. Age 8. Age 12. Boys. Girls. Boys. Girls. Boys. Girls. Number Examined 303 287 243 250 248 230 Defects:— Skin Disease 2 [2] 7 [4] 3 [2] .. 1 [1] 1 [1] Enlarged Tonsils 18 [8] 17 [8] 15 [9] 13 [6] 11 [5] 10 [6] Adenoids 6 [5] 7 [3] 2 [-] 4 [4] ... 1 [1] Tonsils and Adenoids 6 [6] 4 [4] 5 [5] 5 [4] ... 2 [2] Other Nose and Threat 3 [2] 1 [1] ... 1 [1] 2 [2] 2 [-] Enlarged Glands of Neck 3 [2] 1 [-] ... ... 3 [1] 1 [-] External Eye Disease 2 [11] 8 [6] 6 [4] 5 [2] 2 [1] 5 [2] Vision for Treatment Not Examined [15] [20] [29] [24] Otorrhœa and Otitis 3 [3] 1 [1] [1] 2 [2] ... 2 [1] Other Ear Disease 2 [1] 1 [1] ... 1 [1] ... ... Hearing Defect ... 2 [2] ... 1 [1] ... 1 [1] Stammering ... ... 1 [1] ... ... .. Other Speech ... ... ... 1 [-] 1 [-] ... Heart Defects 3 [-] 3 [-] 2 [-] 4 [3] 5 [1] 10 [4] Anæmia 2 [2] 2 [1] 4 [3] 5 [4] 1 [1] 1 [-] Bronchitis and other Lung Disease 8 [4] 13 [4] 1 [-] 4 [-] 3 [-] 2 [-] Nervous Disease ... ... ... 3 [1] ... ... Phthisis ... ... 1 [1] 1 [-] ... ... Other Tubercular Disease 1 [-] ... .. ... .. ... Rickets ... ... 1 [-] 1 [-] ... ... Spinal Defects ... ... .. 5 [3] 2 [2] 2 [-] Other Deformities ... ... ... ... 1 [1] 1 [-] Infectious Disease ... ... ... ... ... ... Other Defects 5 [3] 3 [-] 2 [1] 6 [2] 10 [10] 5 [3] Cases for Dental Treatment [47] [36] [41] [49] [25] [21] The figures in brackets indicate the numbers referred for treatment. 91 Deaths of Children 5-15 years, 1924. Ages. Total. 5 6 7 8 9 10 11 12 13 14 Both Sexes. M F M F M F M F M F M F M F M F M F M F M F Diphtheria 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 2 Measles ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Pulmonary Tuberculosis ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Other Tuberculosis Diseases ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... ... 1 ... ... ... 3 ... 3 Other Diseases ... 1 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 2 3 Total 1 2 1 ... ... 1 ... 1 1 1 ... ... 1 ... ... ... 1 ... ... ... 5 5 10 Total both sexes 3 1 1 1 2 ... 1 1 10 92 SANITARY ADMINISTRATION. Public Mortuary. The Public Mortuary provided by the Council is situated in Goldsmith Street. During the year 40 bodies were deposited. There were 34 post mortem examinations made, and 34 inquests held. The inquests are held in the Court Room at the Council Offices. On 5 occasions bodies awaiting burial were removed to the mortuary on account of inadequate accommodation in the homes; 31 bodies were brought in by order of the Coroner, and 4 by the Police. Inquests. During the year 67 inquests were held on the bodies of Holborn parishioners. Many of these died outside the Borough and the inquests were held in the district where death took place, the deaths being subsequently transferred to Holborn. The causes of death certified as a result of such inquests were:—Natural causes, 29; Accidents, 17; Suicide, 10; Misadventure, 10; Murder, 1. 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. 93 Some if not most of these aged people rely almost entirely on the Old Age Pension for sustenance. 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, 1920 and 1923. On the application of tenants three certificates were issued under the above Acts that the houses complained of were not in all respects reasonably fit for human habitation or were otherwise not in a reasonable state of repair, and on the application of the landlord one certificate was issued that the repairs required to put the dwelling house in a reasonable state of repair had been executed to the satisfaction of the Council. 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. 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 is providing this housing accommodation on a site purchased from the Council. Owing to the extreme difficulty of finding alternative accommodation it has not been found possible to deal with more than a few cases of overcrowding during the year. One of the most unsatisfactory features with regard to housing in the district is the presence of so many houses let in lodgings. These houses were not built for the purpose to which they are now put: the using of the staircases, water supply, washhouses, yards, waterclosets, ashbins, etc., in common leads to misuse and neglect; the tenants suffer much inconvenience in carrying out their ordinary housework In most of the houses there is no suitable provision for the storage of food and cooking. The structure of these houses is in many cases satisfactory; the conversion into self-contained tenements would much improve the accommodation. 94 During the year 907 houses occupied by the working classes were inspected, this number consisted of 589 registered lodging houses and 318 non-registered houses occupied by working classes. Of the 318 non-registered houses, 58 were block dwellings, one block being counted as one house. The 58 blocks included 380 tenements The total number of buildings in the Borough occupied for dwelling purposes is given by the Census, 1921, as 3,473. The number of tenements occupied by working classes as returned to the London County Council is 8,571. This figure represents the total tenements in the Borough consisting of one, two, three or four rooms. HOUSING CONDITIONS. Statistics. Year Ended 31st December, 1924. 1.—GENERAL. (1) Estimated population 43,250 (2) General death rate 12.2 (3) Death-rate from tuberculosis (all forms) 1.24 (4) Infantile mortality rate 81 *(5) Number of buildings containing dwellings (Census, 1921) 3,473 †(6) Number of separate dwellings (Census, 19211) 7,202 ‡(6a) Number of working-class tenements (Census, 1921) 8,571 (7) Number of new working-class houses erected nil 2.—UNFIT DWELLING-HOUSES. I.—INSPECTION. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 907§ (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 nil|| (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation nil (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 700 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. ||All the more insanitary houses are always annually inspected, although none last year was formally recorded under the above Regulations. 95 III.—ACTION UNDER STATUTORY POWERS. A. Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs nil (2) Number of dwelling-houses which were rendered fit— (a) by owners nil (b) by Local Authority in default of owners nil (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 700 (2) Number of dwelling-houses in which defects were remedied:— (a) by owners 700 (b) by Local Authority in default of owners nil C. Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1919:— (1) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling-houses in respect of which Closing Orders were made nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit nil (4) Number of dwelling-houses in respect of which Demolition Orders were made nil (5) Number of dwelling-houses demolished in pursuance of Demolilion Orders nil 3.—UNHEALTHY AREAS. Areas represented to the Local Authority with a view to Improvement Schemes under (a) Part I., or (b) Part II., of the Act of 1890:— (1) Name of area nil (2) Acreage nil (3) Number of working-class houses in area nil (4) Number of working-class persons to be displaced nil 4. Number of houses not complying with the building By-laws erected with consent of Local Authority under Section 25 of the Housing, Town planning, etc, Act, 1919 nil 96 APPENDIX. TABLE I. Vital Statistics of Whole District during 1924 and Ten Previous Years. Year Population estimated to Middle of each Year. Births. Total Deaths Registered in the District Transferable Deaths Net Deaths belonging to the District. Under 1 Year of Age At all Ages Uncorrected N umber Net Number Rate of Non residents registered in the District of Residents not registered in the District Number Rate per 1,000 Birth N umber Rate Number Rate 1914 46,832 703 765 16.4 888 19.0 458 418 67 88 738 158 1915 40,405 594 670 14.4 876 21.8 559 385 64 96 702 17.1 1916 38,161 564 649 15.7 768 20.2 498 395 63 97 665 17.5 1917 35,303 474 571 14.5 865 24.5 567 390 62 107 688 19.5 1918 36,769 340 497 12.1 862 23.4 532 490 70 141 820 22.3 1919 38,156 397 539 13.6 920 24.1 618 322 52 96 624 16.4 1920 39,676 619 827 20.6 827 20.6 568 339 55 66 693 15.2 1921 43,520 483 648 14.8 859 19.7 622 319 51 79 556 12.3 1922 42,850 485 664 15.5 746 17.4 518 312 48 72 570 13.3 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 In the above Table the population, birth-rate and death-rate for the year 1914 has been estimated from the Census Populations of 1901 and 1911. For the years 1915 to 1924 inclusive, the populations, births and birth-rates, deaths and death-rates, are as estimated by the Registrar-General, founded upon his estimates of the Civilian population. 97 TABLE II. Causes of, and Ages at, Death, 1924. Causes of Death. NET DEATHS AT THE SUBJOINED AGES OF "RESIDENTS," whether occurring within or without the District. Total Deaths whether of "Residents" or "NonResidents" in Institutions in the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and under 75 years. 75 and upwards. All causes Certified 329 47 18 7 10 15 65 161 124 82 Uncertified ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... 1 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... 3. Measles 11 3 3 3 1 ... 1 ... ... ... ... 4. Scarlet Fever 1 ... ... 1 ... ... ... ... ... ... ... 5. Whooping Cough 6 2 4 ... ... ... ... ... ... ... 2 6. Diphtheria and Croup 4 ... 1 1 2 ... ... ... ... ... 2 7. Influenza 11 ... ... ... ... ... 3 3 3 2 1 8. Encephalitis Lethargica 2 ... ... ... ... ... 1 1 ... ... 1 9. Meningo-coccal Meningitis ... ... ... ... ... ... ......... ... ... ... 4 10. Tuberculosis of Respiratory System 47 ... ... ... 1 9 l9 17 1 ... 11 11. Other Tuberculous Diseases 7 1 1 ... 3 ... 1 1 ... ... 56 12. Cancer, malignant disease 70 ... ... ... ... 1 6 33 20 8 46 13. Rheumatic Fever 1 ... ... ... ... 1 ... ... ... ... 7 14. Diabetes 2 ... ... ... ... ... 1 ... 1 ... 4 15. Cerebral Hæmorrhage 31 ... ... ... ... ... 2 8 12 9 6 16. Heart Disease 54 ... ... ... ... ... 4 21 22 7 19 17. Arterio-sclerosis 33 ... ... ... ... ... 1 5 12 15 2 18. Bronchitis 53 ... ... ... ... ... ] 14 22 16 7 19. Pneumonia (all forms) 45 11 7 1 ... ... 4 13 5 4 64 20. Other Respiratory Diseases 4 ... ... ... ... ... ... 2 1 1 7 21. Ulcer of Stomach or Duodenum 5 ... ... ... ... ... 2 3 ... ... ... 22. Diarrhœa, etc. (under 2 years) 3 3 ... ... ... ... ... ... ... ... 36 23. Appendicitis and Typhlitis 1 ... ... ... ... ... ... 1 ... ... 8 24. Cirrhosis of Liver 2 ... ... ... ... ... ... 2 ... ... 3 25. Acute Chronic Nephritis 10 ... ... ... ... ... 1 4 3 2 18 26. Puerperal Sepsis 3 ... ... ... ... 1 2 ... ... 1 27. Other accidents and diseases of Pregnancy and Parturition ... ... ... ... ... ... ... ... ... ... ... 28. Congenital Debility and Malformation, Premature Birth 22 21 1 ... ... ... ... ... ... ... 43 29. Suicide 9 ... ... ... ... 1 4 3 1 ... 1 30. Other Deaths from Violence 22 ... ... 1 ... 1 6 8 4 2 1 31. Other Defined Diseases 70 6 1 ... 3 1 6 20 17 16 138 32. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... 529 47 18 7 10 15 65 161 124 82 488 G 98 TABLE III. Cases of Infectious Disease notified during the year 1924. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Locality (e.g. Parish or Ward) of the District. At Ages—Years. Total Cases Removed to Hospitals. At all Ages. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 46 to 65 65 and wards. St. Giles and Bloomsbury. Holborn. Small-pox ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) 68 1 28 19 13 6 1 ... 19 49 67 Erysipelas 22 ... 1 2 2 6 6 5 8 14 12 Scarlet Fever 88 ... 26 52 10 ... ... ... 28 60 88 Enteric Fever 2 ... ... ... ... 1 1 ... 1 1 2 Puerperal Fever 2 ... ... ... ... 2 ... ... 1 1 2 Cerebro-Spinal Fever ... ... ... ... ... ... ... ... ... ... ... Ophthalmia Neonatorum 10 10 ... ... ... ... ... ... 5 5 2 Dysentery 1 ... ... ... ... 1 ... ... 1 ... 1 Malaria 1 ... ... ... ... ... ... 1 ... 1 ... Pneumonia—Primary 53 3 13 2 1 13 16 5 24 29 28 do. Influenzal 10 ... 2 1 ... 4 1 2 4 6 4 Tuberculosis—Pulmonary 75 1 ... 4 14 34 18 4 39 36 51 do. Non-Pulmonary 12 ... 4 2 1 2 3 ... 2 10 8 Whooping Cough 95 17 64 14 ... ... ... ... 10 85 45 Acute Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica 6 ... ... 1 ... 4 1 ... 4 2 4 445 32 138 97 41 73 47 ! 7 146 299 314 99 TABLE IV. Infectious Diseases in Holborn for the last Eleven Years. NOTIFICATIONS DEATHS Decennial Average, 1914-1923 Year 1924 Decennial Average, 1914-1923 Year 1924 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 98 2.43 2.47 68 1.5S 2.30 5 0.13 0.18 4 0.09 0.12 Erysipelas 19 0.47 0.63 22 0.51 0.41 ... ... ... ... ... 0.02 Scarlet Fever 106 2.54 3.60 88 2.03 2.50 2 0.03 0.05 1 0.02 0.03 Enteric Fever 5 0.13 0.09 2 0.04 0.09 1 0.02 0.02 0 0.00 0.01 Cerebro-Spinal Fever 2.5 0.06 0.06 ... 0.00 0.2 ... ... ... 0 0.00 0.01 Acute Poliomyelitis 1 0.02 ... ... 0.00 0.00 ... ... ... 0 0.00 0.03 Whooping Cough† 58 1.39 ... 95 2.2 ... 6 0.13 0.19 6 0.13 0.11 Measles‡ ... ... ... ... ... ... 9 0.24 0.22 11 0.25 0.29 Tuberculosis—Pulmonary 115 2.85 ... 75 1.73 0.91 66 1.65 1.34 47 1.08 0.98 Ditto Non-Pulmonary 18 0.46 ... 12 0.28 0.21 9 0.21 ... 7 0.16 0.17 Puerperal Fever* 1.3 1.41 3.19 2 3.46 3.43 1 1.41 ... 3 5.20 1.16 Ophthalmia Neonatorum* 8 11.28 ... 10 17.30 8.57 ... ... ... ... ... ... Diarrhoea (under 2 years)*‡ ... ... ... ... ... ... 9 13.9 16.9 3 5.20 8.7 g 2 * Kates per 1,000 births. † Notifiable in Holborn (not in London) since 1914. ‡ Not Notifiable. 100 TABLE V. INFORMATION REQUIRED BY THE LONDON COUNTY COUNCIL. PREMISES. Number on Register at end of 1924. Number of Inspections. Number of Prosecutions. Cowsheds ... ... ... Milkshops 127 149 ... Houses let in lodgings 589 951 2 Ice cream premises 83 179 ... Slaughter-houses 1 5 ... Offensive Trades ... ... ... Smoke Nuisances— Number of observations 510 Number of notices 4 Number of nuisances and complaints 4 complaints Number of summonses 0 Housing of the Working Classes— Number of houses inspected 007 Number of houses dealt with under Section 15 of the Housing, Town Planning, etc., Act, 1909 0 Number of representations by householders 0 Number of representations by Medical Officer 0 Number of houses included in such representations 0 Number of Closing Orders 0 Number of houses included in such Closing Orders 0 Number of Closing Orders determined 0 Number of houses remedied without Closing Orders 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 28 of the Housing Act, 1919 0 Number of houses repaired by local authorities 0 Number of houses closed on notice by owner that they could not be made fit 0 Total number of houses in the borough 3473 (Census, 1921) Number of houses occupied by the working classes 8571 tenements (Census, 1921) Number of houses for working classes— (a) erected during year 0 (b) in course of erection 1 block Underground Rooms— Number illegally occupied for which notices were served 8 Number closed or illegal occupation discontinued 8 Overcrowding— Number of rooms overcrowded for which notices were served 3 Number remedied 3 Prosecutions 0 Cleansing— Number of adults cleansed (for vermin) 124 Number of children cleansed 0 Number of rooms or premises cleansed (for vermin) 53 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 380 Number of Inspections 2,419 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 1 101 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 354 27 5 ... Workshops 539 60 10 ... Workplaces 2,905 66 8 ... Total 3,798 153 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 46 46 ... ... Want of ventilation 7 7 ... ... Overcrowding 2 2 ... ... Want of drainage of floors ... ... ... ... Other nuisances 85 85 ... ... Sanitary accommodation insufficient 2 2 ... ... unsuitable or defective 69 69 ... ... 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 218 218 ... ... * Including those specified in Sections 2, 3, 7 and 8 of the Factory and Workshop Act as remediable under the Public Health Acts. 102 TABLE VI.—continued. 3.—HOME WORK. NATURE OF WORK. Outworkers' Lists, Section 107. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sections 109, 110. Lists received from Employers. Notices served on occupiers as to keeping or sending lists. Prosecutions. Instances. Notices served Prosecutions. Instances. Orders made (S. 110). Prosecutions (Sections 109, 110) Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Lists. Outworkers. Lists. Outworkers. Contractors. Workmen. Contractors. Workmen. Wearing Apparel— (1) Making, &c. 110 293 307 3 ... 8 124 ... ... ... ... ... ... ... ... (2) Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquet and Tennis Balls 2 ... 6 ... ... ... 3 ... ... ... ... ... ... ... ... Paper Bags and Boxes 2 ... 16 ... ... ... 2 ... ... ... ... ... ... ... ... Total 114 293 329 3 ... 8 129 ... ... ... ... ... ... ... ... 103 TABLE VI.—continued. 4.—REGISTERED WORKSHOPS. Workshops on the Register (S. 131) at the end of the year. Number. (1) (2) Bakehouses (including 16 factory bakehouses) 29 Other Workshops 744 Total number of workshops on Register 773 5.—OTHER MATTERS. Class. Number. (1) (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act (S. 133) 22 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 19 Report (action being taken) sent to H.M. Inspector 19 Other — Underground Bakehouses (S. 101): — Certificates granted during the year — In use at the end of the year 19 104 LEGAL PROCEEDINGS. SALE OF FOOD AND DRUGS ACTS, 1875-1907. Date. Name. Address. Offence. Result. 1924 Jan. 31 Joseph Scholles 63, High Street Selling sponge cake containing 0.154% of boric acid Fined 40s. May 29 P. Trombetta 9, Cursitor Street Selling milk 8.6% deficient in fat Fined 40s. May 29 & June 19 Emilio Scaramuzza 10, Theobalds Road Selling milk 7.6% deficient in fat Fined 40s. June 19 Rupert H. French 1, Guilford Street Selling milk 8.3% deficient in fat Warranty proved. Summons withdrawn. June 2 & Aug. 11 Francis Collier 15, Baldwins Gardens Selling milk 4.6% deficient in fat Fined 20s. and 21s. costs. July 31 Mobile Catering Co. 112, Theobalds Road Selling milk 23.7% added water Summons withdrawn on payment of 21s. costs. PUBLIC HEALTH (LONDON) ACT, 1891. Date. Name. Address. Offence. Result. 1924 Feb. 11 Sir E. J. Fawke 27, Devonshire Street Existing nuisance Summons withdrawn. 21s. costs. Do. Do. Do. Breach of Lodging Housing By-laws Do. Do. Do. 26, Do. Do. Do. Oct. 20 & Nov. 3 Battley, Son & Holness 42, Millman Street Existing nuisance Nuisance abated. Summons withdrawn.