HOL 25 The Metropolitan Borough of holborn. ANNUAL REPORT OF THE Medical Officer of Health C. W. HUTT, M.A., M.D., M.R.C.P., D.P.H. For the Year 1927. London: Printed by DIPROSE, BATEMAN & CO., Sheffield Street, Kingsway, W.C.2. 1928 2 PUBLIC HEALTH DEPARTMENT, TOWN HALL, 197, HIGH HOLBORN, W.C. 1 March, 1928. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Holborn. Ladies and Gentlemen, Herewith I beg to present a Report upon the Health and Sanitary Conditions of the Borough for the year 1927. Believe me, Ladies and Gentlemen, Yours obediently, C. W. HUTT, Medical Officer of Health INDEX. Page Public Health Committee Housing of the Working Classes Committee 6 Maternity and Child Welfare Committee 7 Staff 7 Statistics and Social Conditions 8 Statistical Summary General Provision for Health Services 9 Population and Houses 11 Births 11 Deaths 13 Seasonal Mortality 14 Infantile Mortality 14 Marasmus 16 Poor Law and Hospital Relief 16 Sanitary Circumstances 16 Scavenging. Removal of House Refuse 16 Removal of Manure 18 Sanitary Inspection of District 18 Notices served 19 By-law as to Houses let in Lodgings 21 Rats and Mice (Destruction) Act 21 Rat Week 22 Rate from Disused Drains 24 Inspection of Workshops 24 Factories 25 Factories Bill, 1927 27 Underground Workshops 28 Sanitary Condition of Offices 28 Smoke Abatement 29 Common Lodging Houses 29 Cecil House 30 Housing 30 Betterton Street Scheme 30 Housing Accommodation on L.C.C. Estates 31 Housing Conditions Statistics, 1927 32 Food 36 Dairies, Cowsheds and Milk Shops 30 Residue from Milk Clarifiers 36 Bacteriological Examination of Milk 36 Milk and Dairies Order, 1920 38 Milk (Special Designations) Order, 1923 38 Public Health (Milk and Cream) Regulations, 1912-17 38 Condensed Milk 39 Dried Milk 39 Margarine 40 Bakehouses 40 Sale of Fish 40 Fish Shops 40 Fish Stalls 41 Fried Fish Shops42 Market Streets and Exposure of Food Generally 42 Street Trading 42 Ice Cream 43 Meat Regulations 44 Places where Food is Prepared for Sale 46 Hygiene of Restaurants, Eating Houses and Public Houses 40 Cleansing of Table Utensils, etc 40 Restaurants, Sanitary Accommodation for Customers 47 Sale of Food Order 47 Unsound Food 48 Sale of Food and Drugs Acts 48 Preservatives in Food Regulations 48 Agar-Agar 48 ' 2 4 Page Cream 49 Grape Juice 49 Jam 49 Kaola and Lemon Squash 49 Minced Meat 50 Milk 50 Tinned Peas 50 Wine 50 Milk—Fat Content 51 Table of Samples Purchased 53 Prevalence of and Control over Infectious Diseases 56 Infectious Diseases Generally 56 Smallpox 57 Vaccination 58 Diphtheria 58 Schick Test and Immunisation against Diphtheria 60 Scarlet Fever 71 Enteric Fever 72 Typhus Fever 73 Cerebro-Spinal Fever 73 Dysentery 73 Malaria 73 Encephalitis Lethargica 73 Acute Poliomyelitis 74 Pneumonia 75 Influenza 75 Anthrax 75 Chickenpox 75 Mumps 75 Infectious Diseases (London) Regulations, 1927 76 Bacteriological Work 76 Disinfections 76 Cleansing of Persons Act 77 Verminous Condition and Scabies 77 Shelter during Disinfection 77 Tuberculosis 78 Notifications 78 Correction of Register 80 Sleeping Conditions 80 Classification of Homes 81 Delay in Notification 82 Institutional Treatment 82 Visits to Home 82 Contacts 83 Prevention of Spitting 83 Deaths from Tuberculosis 83 Tuberculosis Dispensary 84 Tuberculosis Care Committee 88 Home Nursing 91 Dental Clinic 92 Employment of Tuberculous Persons 92 Cancer 93 Prevention of Hernia (Rupture) 93 Maternity and Child Welfare 94 Notification of Births 94 Number of Births 94 Births in Crowded Homes 95 Home Visiting 95 Attendances at Infant Welfare Centres 96 Work at Centres 96 10, John Street 96 Short's Gardens 97 Ante-natal Hygiene 98 Voluntary Notification of Pregnancy 99 Maternal and Infant Consultations 100 Breast Massage 101 5 Page Diarrhoea 101 Still-Births 101 Illegitimate Births 102 Dental Treatment 102 Assistance with Denture 103 Supply of Milk and Food for Mothers and Infants 103 103 Home Help 104 Convalescent Home Treatment 105 Visitors to Centre 105 Saffron Hill Maternity and Child Welfare Centre 105 Deaths of Infants under One Tear 106 Deaths of Children, One to Five Years 107 Infectious Diseases among Mothers and Children 107 Puerperal Fever and Pyrexia 107 Ophthalmia Neonatorum 108 Whooping Cough 111 Measles 112 Measles, Control in Schools 113 German Measles 113 Epidemic Diarrhœa 114 Nursing Arrangements 115 Widows', Orphans', and Old Age Contributory Pension Act, 1925 115 Health and Baby Week 115 Minor Ailments Clinic 117 Medical Inspection and Treatment of School Children 117 Deaths of Children, 5-15 Years 120 Sanitary Administration 121 Mortuary 121 Inquests 121 Revenue Acts 121 Dirty Tenants 121 Removal of Aged Persons 121 Rent and Mortgage Interest Restriction Acts 122 Nuisances—Notified by Relieving Officers 122 Dogs—Nuisance from—By-laws 122 Choked Water Closets 123 Old Buildings—Demolition of 123 Nuisance from Pigeons 124 Brick Crushing—Nuisance from 125 Foundling Hospital Site 125 Town Planning Scheme 126 Children's Country Holiday Fund 127 Lavatory Accommodation at Railway Stations 127 Other Propaganda 127 Manufacture of Wine 128 Juvenile Employment—Finsbury and Holborn Advisory Committee 128 Vita Glass, use of 128 APPENDIX. Table I. Vital Statistics, 1927, and ten previous years 129 Table II. Causes of and Ages at Death, 1927 130 Table III. Infectious Diseases Notified during 1927 131 Table IV. Infectious Diseases in Holborn during 1927 and ten previous years 132 Table V. Information required by L.C.C. 133 Table VI. Factories, Workshops, &c. 134 (1) Inspections 134 (2) Defects found 134 (3) Home Work 135 (4) Registered Workshops 136 (5) Other Matters 136 Table VII. Legal Proceedings 137 Table VIII. Meteorology of London, 1927 138 Table IX. Sunlight (Ultra-Violet Rays), 1927 139 6 PUBLIC HEALTH COMMITTEE. 1927-28. 1926-27. Chairman— Chairman— Councillor John H. Boraston, C.B. Alderman Francis J. Pullen. Vice-Chairman— Vice-Chairman— Councillor The Rev. Wilfred If. Davies, M.A. Councillor John H. Boraston, C.B. Ex-Officio— Ex-Officio— His Worship The Mayor, His Worship The Mayor, Councillor Albert J. Clark, J.F. Alderman Harold Warren Coleman, J.P. Councillor Edmund Balding. Councillor Albert J. Clark. „ Henry W. Ellis. ,, Rev. Wilfred n. Davies, M.A. „ Harold J. Jewell. „ Henry W. Ellis. „ Horace W. Langdon. „ Harold Jewell. „ Miss Marjorie R. Lovelock. „ Horace W. Langdon. „Rev. Henry Ross. „ Miss Marjorie R. Lovclock. „ Charles Shortland. „ Rev. Henry Ross. Sir William R. Smith,D.L.,J.P.,M.D. „ Sir William R. Smith,D.L..J.P.,M.D. „ Mrs. Ethel M. Wilson. „ Mrs. Ethel M. Wilson. „ Arthur Youngman. „ Arthur Youngman. HOUSING OF THE WORKING CLASSES COMMITTEE. 1927-28. 1926-27. Chairman— Chairman— Alderman James W. Coade. Councillor J. C. St. Laurence Stallwood. Vice-Chairman— Vice-Chairman— Councillor Horace W. Langdon. Alderman James W. Coade. Ex-Officio— Ex-Officio— His Worship The Mayor, His Worship The Mayor, Councillor Albert J. Clark, J.P. Alderman Harold Warren Coleman, J.P. Alderman H. Warren Coleman. Alderman Sir Robert W. Dibdin, J.P. ,, Sir Robert W. Dibdin, J.P. Councillor Rev. Wilfred H. Davies, M.A. Councillor Rev. Wilfred H. Davies, M.A. ,, Miss Emily Dibdin. „ Miss Emily Dibdin. ,, Henry W. Ellis. ,, Ernest Hamlin. ,, Ernest Hamlin. „ Roland H. Haxell. „ Roland H. Haxell. ,, Alfred Humphreys. ,, Alfred Humphreys. ,, Raymond A. Miles. ,, Horace W. Langdon. ,, George D. Pooley. „ Raymond A. Miles. ,, J. St. Laurence Stallwood. „ George D. Pooley. 7 MATERNITY AND CHILD WELFARE COMMITTEE. 1927-28. 1926-27. Chairman— Chairman- Councillor Albert A. Mussett. Councillor The Rev. Henry Ross. Vice-Chairman— Vice-Chairman— Councillor George D. Pooley. Councillor Miss Emily Dibdin. Ex-Officio— Ex-Officio— His Worship The Mayor, His Worship The Mayor, Councillor Albert J. Clark, J.P. Alderman Harold Warren Coleman, J.P. Councillor Edmund Balding. Councillor Edmund Balding. ,, Richard Davies. „ Richard Davies. ,, Miss Emily Dibdin. Percy Hill. ,, Percy Hill. ,, Miss Marjorie R. Lovelock. ,,Miss Marjorie R. Lovelock. ., Albert A. Mussett. ,, Lady Smith, J.P. „ Lady Smith, J.P. ,, Mrs. Ethel M. Wilson. „ Mrs. Ethel M. Wilson. ,, George Witherby „ George Witherby. Mrs. Cecil J. Coade. Mr. Thomas W. J. Coffin. Mr. Thomas W. J. Coffin. The Mayoress (Mrs. H. Warren Coleman). Mrs. H. Warren Coleman, Mrs. Wilfred H. Davies. Mrs. Wilfred H. Davies. Miss Norah H. March, B.Sc. Miss M. Wilmshurst. ,, M. Wilmsliurst. STAFF. The following was the Staff during 1927. Medical Officer of Health—C. W. Hutt, M.A., M.D., M.R.C.P., D.P.H. Medical Officers of Maternity Centres— 10, John Street—Richenda Gillett, M.D.Brux., L.S.A. Short's Gardens—James Arthur Struthers, M.B., B.Ch., M.R.C.P., D.P.H. Medical Officer of Tuberculosis Dispensary— James Arthur Struthers, M.B., B.Ch., M.R.C.P., D.P.H. Medical Officer—Diphtheria Immunisation—E. Goodwin Rawlinson, M.D., L.R.C.P., D.P.H. Public Analyst—James Kear Colwell, F.I.C. Sanitary Inspectors—Albert Bennett. George F. Clark. Samuel Larard, M.ll.San.I. Sanitary Inspector and Health Visitor—Ethel Jane Charlesworth, C.M.B. Health Visitor—Muriel G. Stockwell, C.M.B. Tuberculosis Visitor —M. Watson. Chief Clerk and Committee Clerk—Edwin Kent. Assistant Clerks—Frank Fitch. Arthur Long. Phyllis Bull. Doris Brown (to 24th December). Dental Clinic—(10, John Street). Dentist—Sidney Adams, L.D.S. (British Dental Hospital). Anæsthetist—P. Lloyd-Williams, M.R.C.S., L.R.C.P. Nurses—The Metropolitan Nursing Association. Mortuary Keeper and Superintendent of Cleansing Station—Charles H. Day (to 6th Dec.). Superintendent of Women's Cleansing Station—Adeline Day. Caretaker of Maternity Centre—Elizabeth Alderton. Home Help—Margaret Smith. And Panel of Emergency Home Helps. Disinfector—Henry Emms. Assistant Disinfector—E. E. Denny. 8 STATISTICS AND SOCIAL CONDITIONS. Statistical Summary, 1927. Area of Borough in acres 4051 Population—estimated to middle of year (as supplied by the Registrar-General) for birth and death rates 42,209 Population—Census, 1921 43,192 Number of inhabited houses (1921) 6,494 Number of families or separate occupiers (1927) 9,682 Rateable value 1st November £1,626,451 Rate of 1d. in the £ estimated to yield £6,443 Total M. F. Births Legitimate 452 227 225 505 Illegitimate 53 26 27 Annual rate of births per 1,000 population 11.96 Deaths 530 Annual rate of deaths per 1,000 population 12.5 Number of women dying in, or in consequence from sepsis 2 of, childbirth „ other causes — Deaths of infants under one year of age per 1.000 births— Legitimate 40. Illegitimate 19. Total 38 Deaths from measles (all ages) 0 „ „ whooping cough (all ages) 5 ,, „ diarrhœa (under two years of age) 5 Zymotic death rate* 0.14 Tuberculosis death-rate per 100,000 130 Excess of registered births over deaths — Excess of registered deaths over births 25 * Excluding deaths from Epidemic diarrhœa. Vital Statistics, 1927. 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 16.7 12.3 69 London 16.1 11.9 59 Holborn 11.96 12.5 38 9 General Provision of Health Services for the Borough. Hospitals provided or subsidised by the Local Authority or by the London County Council. Fever and Smallpox.—Hospitals for patients suffering from these diseases are provided the Metropolitan Asylums Board—one of the hospitals of the Board (St. Margaret's) is also available for cases of Marasmus. Tuberculosis.—Residential institutional treatment for tuberculosis is provided by the London County Council. The Council's Tuberculosis Dispensary is situated at, and linked up with, the University College Hospital. Maternity.—The Borough Council has arranged for the reservation of beds for maternity cases at the University College Hospital. Other Hospitals—not subsidised by the Borough Council. The following hospitals are situated in the Borough: — French Hospital, Shaftesbury Avenue. Hospital for Sick Children, Great Ormond Street. Italian Hospital, Queen Square. National Hospital, Queen Square. Royal Westminster Ophthalmic Hospital, Broad Street. London Homoeopathic Hospital, Great Ormond Street. St. Paul's Hospital (Genito-urinary and Skin), Endell Street. Institutional Provision for Unmarried Mothers, Illegitimate Infants and Homeless Children. There are no institutions for unmarried mothers, illegitimate children or homeless children in the Borough, but St. Faith's Home, Myddelton Square, receives such mothers from the Holborn area. Ambulance Facilities. For Infectious Cases—Provided by the Metropolitan Asylums Board ('Phone : City 7200). For Non-Infectious Cases—The Ambulances of the Metropolitan Asylums Board. (Minimum fee 10/-.) For Accidents—The London County Council and the St. John Ambulance Association. For Maternity—The London County Council Ambulances ('Phone Hop 5000). Clinics and Treatment Centres. Ante-natal and Post-natal Clinic. (Municipal.) 10, John Street Tuesday at 2 p.m. Maternity and Child Welfare. (Municipal.) Tuesday 10, John Street at p.m. Thursday Friday St. Giles' Buildings Monday Short's Gardens Thursday at p.m Minor Ailments Clinic. (Municipal.) Tuesday at p.m 10, John Street Friday at 2 p.m. Diphtheria Schick Test and Immunisation. (Municipal.) 10, John Street Wednesday at 2.30 p.m. 10 Dental. 10, John Street, for expectant and nursing mothers and children up to 5 years Thursday at 2 p.m. Do. General and Tuberculosis Tuesday at 6.30 p.m. School Clinics—Provided by the London County Council (see page 117). Day Nurseries.—Established and controlled privately. Kings way Creche, Kingsway Hall, Kingsway. Field Lane Institution Creche, Vine Street, Clerkenwell Road. St. Alban's Day Nursery, Greville Street. Tuberculosis Dispensary. At University College Hospital (entrance in Huntley Street) Venereal Diseases.—Treatment clinics are arranged by the London County Council, Those in the Borough are:— St. Paul's, Endell Street, daily 8 a.m. to 10 p.m., Hospital for Sick Children (for children only), Great Ormond Street, 0-10 a.m. daily and 2-4 p.m., except Wednesday and Saturday. Public Health Officers of the Local Authority. See list on page 7. Professional Nursing in the Home. General.—The Metropolitan District Nursing Association of 31, Bedford Place, provides skilled nurses for the sick poor. Infectious Diseases.—By arrangements made by the Borough Council with the Nursing Association, nurses are available for cases of:— Summer Diarrhoea (in children under 2 years of age). Measles with severe complications. Whooping Cough with severe complications. Lobar Pneumonia. Influenzal Pneumonia. Ophthalmia Neonatorum. Puerperal Fever. Puerperal Pyrexia. Tuberculosis. Maternity.—By arrangement with the Metropolitan District Nursing Association, skilled maternity nursing is available for necessitous maternity cases subject to the prior approval of the Maternity and Child Welfare Committee or the Medical Officer of Health, also for complications after confinement, including deficient lactation. Contributions towards the service arc required in connection with maternity nursing and the nursing of puerperal fever and puerperal pyrexia, the amount being assessed according to ability to pay. Midwives.—The Borough Council does not employ or subsidise any midwives. Home Helps.—Home Helps are available for service in homes during confinements—contributions towards the cost are required in accordance with ability to pay. Chemical Work.—Particulars of the work carried out by the Public Analyst are included in pages 48-55. Bacteriological Work.—Bacteriological work is carried out for the Borough Council by the Royal Institute of Public Health, 37, Russell Square. 11 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 1927—42,209. 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 (many of whom are very poor), and a relatively 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 3,490. The number of deaths was 31, a death-rate of 8.8 per 1,000, considerably below the average death-rate for the whole of the Borough (12.5). On the other hand the number of deaths of residents of Common Lodging Houses in the Borough, which contain 967 beds, was 55 which, calculated on the number of beds, was a rate of 56.9 per 1,000. The birth-rates and death-rates given in this report are the crude rates, that is to say no correction has been made for sex and age distribution. The population of the borough, however, is such that probably a truer indication of the birth and death incidence would be indicated by rates corrected for such distribution. As, however, the Registrar-General in his summary tables and statistical review gives crude rates only, it is thought better for comparison purposes to adopt the same principle for this report. The report of the Census, 1921, points out that the City of London and Holborn stand rather apart from the other Boroughs, owing to the general unsuitability of their dwellings for private family occupation. Here the relatively high population of males is similar to that found in the industrial areas; but there are fewer young children and the population is in consequence above the normal as regards age. Registered Births and Birth-Rate. The total number of births registered as occurring in the Borough was 320 (165 males and 155 females). Of these, 302 were legitimate and 18 illegitimate. 12 Corrected Births and Birth-Bate. I received from the Registrar-General information of the births in outlying institutions in London of 162 legitimate infants and 35 illegitimate infants whose mothers were residents of the Borough. Twelve of the births occurring in the Borough, all legitimate, were infants of mothers who were non-residents of the Borough. The following table gives the corrected number of births and the corrected birth-rates for the twenty years 1908-1927:— Year. Total Births. Legitimate Births. Illegitimate Births. No. Rate per 1,000 of Population. No. Rate per 1,000 of population. Proportion per 1,000 total Registered Births No. Rate per 1,000 of population. Proportion per 1,000 total Registered Births. 1908 1,066 20.41 1,020 19.53 956.8 46 0.88 43.2 1909 986 19.26 935 18.27 948.2 51 0.99 51.8 1910 1,017 20.27 959 19.11 943.0 58 1.16 57.0 1911 920 18.73 865 17.61 940.2 55 1.12 59.8 1912 901 18.76 835 17.38 926.7 66 1.38 73.3 1913 798 16.99 743 15.82 931.1 55 1.17 68.9 1914 765 16.33 705 15.05 921.6 60 1.28 78.4 1915 670 14.44 616 13.28 919.4 54 1.16 80.6 1916 649 15.63 585 14.09 901.4 64 1.54 98.6 1917 571 14.50 496 12.60 868.7 75 1.90 131.3 1918 497 12.06 428 10.38 861.2 69 1.68 138.8 1919 539 13.56 477 12.00 885.0 62 1.56 115.0 1920 827 20.84 749 18.87 905.7 78 1.97 94.3 1921 648 14.88 593 13.62 915.1 55 1.26 84.9 1922 664 15.49 602 14.04 906.6 62 1.45 93.4 1923 595 13.71 547 12.61 919.3 48 1.10 80.7 1924 578 13.36 532 12.30 920.4 46 1.06 79.6 1925 527 12.16 490 11.31 929.8 37 0.85 70.2 1926 535 12.38 489 11.32 914.0 46 1.06 86.0 1927 505 11.96 452 10.71 895.0 53 1.25 105.0 In London the corrected birth-rate in 1927 was 16.1 per 1,000 in comparison with 17.1 for 1926. 13 Mortality. The total number of deaths registered as occurring in the Borough was 728, of which 426 were males and 302 females. Of these deaths the following occurred in Public Institutions, etc., within the area of the Borough:— Institution. Residents. Non-Residents. St. Giles and Bloomsbury. Holborn. St. Giles and Bloomsbury. Holborn. French Hospital 11 - 40 - Children's Hospital 2 5 — 249 National Hospital 1 4 — 104 London Homœopathic Hospital 1 7 — 78 Italian Hospital 2 4 — 28 St. Paul's Hospital — — 17 — Private — — 13 2 Total 17 20 70 461 There were 333 deaths of Civil "Residents" in various Workhouses, Infirmaries, Asylums, Hospitals, etc., outside the Borough, 54 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 1927 gives the total deaths for the Borough as 530. Corrected Deaths and Death-Rates, 1927, compared with 1926. Year. Total Deaths at all ages registered in District. Deaths in Public Institutions in District. Deaths of nonresidents of Borough registered in District. Deaths of residents registered beyond the District. Nett Deaths at all ages. Death Rate for Borough Death Rate. Registration London. 1926 629 476 454 347 522* 12.1 11.6 1927 728 553 531 333 530 12.5 11.9 For details of causes of and ages at death, see Table II., page 130. 14 Seasonal Mortality. The mortality in the four quarters of the year as given in the Quarterly Reports of the Registrar-General is shown below:— Deaths. Death-rate per 1,000. London Rate. First Quarter 182 16.9 16.8 Second,, 121 11.2 10.0 Third „ 93 8.7 8.7 Fourth ,, 123 11.4 11.7 519* 12.0* 11.9* Infantile Mortality. The number of deaths of children under one year of age, and the number of deaths of children under one year of age per 1,000 corrected births, were the following:— Year. Deaths under 1 year of age. Deaths under 1 year per 1000 corrected legitimate births. Deaths under 1 year per 1000 corrected illegitimate Births. Deaths under 1 year per 1000 corrected Births. London. Deaths under 1 year per 1000 Births. 126 48 80 196 90 64 1927 19 40 19 38 59 Death-rate per 1,000 corrected births in 1927 and in ten preceding years during which details respecting births have been supplied. 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 Avge, 1917-26 1927 Holborn Borough 107 141 96 66 79 72 79 81 63 90 87.4 38 London 103 107 85 75 80 74 60 69 67 64 80.9 59 See also Table, page 106. 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. *In these figures as published in the Registrar-General's Quarterly Returns for 1927, the complete corrections for deaths are not included. These corrections increase the nett deaths in Holborn to 530 giving a corrected death-rate of 12.5 per 1,000, the corresponding rate in London being 11.9 per 1,000. 15 The corrections considerably modify the Holborn rates as will be seen from the following figures:— Infantile Death-rate in Holborn per 1,000 Births Year 1927. Registrar-General's Quarterly Report Corrected 1st Quarter 58 39 2nd 73 50 3rd 27 24 4 th 69 37 It will be seen from the analysis on page 106 of the ages at which these infantile deaths took place that four occurred under the age of four weeks. Such deaths are not considered to be due to the environment of the baby, but to ill defined alterations to the health of the mother; they are recognised as being especially difficult to prevent. Some difficulty exists in connection with infants whose parents are of foreign birth and upbringing, and who do not readily conform to the accepted standards of infant care and hygiene in this country. Of the 19 deaths in 1927, five occurred in Italian families; two of these children were born in Italy, and brought up there for some time; one of these attended the Council's Infant Welfare Centre soon after coming to this country. There is a tendency for these mothers to hand feed their children either instead of or as well as feeding them on the breast. These mothers are more inclined to be influenced by the advice of Italian godmothers than by that of English women. In order to enlist the support of other workers who come into contact with Italian mothers, visits were paid to the headmistresses of the schools in Holborn which have a large proportion of Italian scholars, and the teachers expressed their willingness to advise mothers to take their babies and young children to an Infant Welfare Centre and to endeavour to engender confidence in English hygiene teaching, whenever opportunity arose. Defective hygiene was also found in connection with two English infant deaths. In both the deaths seemed to be due chiefly to incorrect feeding. The grandfather of one counteracted any advice given, and in the other the mother seemed unable to profit by the instruction given. Three deaths were due to whooping cough (see page 111) contracted from an elder child in the family; one was entirely breast fed and was making good progrest 16 until the onset of whooping cough at the early age of two months. The others were partly breast and partly hand fed; neither had made normal progress and wero not likely to withstand an attack of any serious illness. Marasmic Infants. During 1927 three babies suffering with marasmus were sent to St. Margaret's Hospital (M.A.B.), Kentish Town, for in-patient treatment; the results so far are satisfactory. All three were the children of parents who had lost a baby in the previous year and the prospects of the infant's survival in each case seemed very poor unless specialised care was given. The ages of the infants at the time of admission were respectively three weeks, four months and two months. All three made slow but definite progress during prolonged residence in St. Margaret's, but on return seemed unable to adapt themselves to their environment and to be unusually dependent on the routine of institutional life. After short periods at home after being discharged from St. Margaret's Hospital, all three have been again admitted to hospital; one directly to St. Margaret's Hospital, one has returned there after a few weeks in a general hospital, and one is in a general hospital. 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 1927:— Indoor Relief 1,105 persons Outdoor Relief 347 cases Out-door Medical Relief 225 persons Of the total number of 530 deaths, 370 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. 17 The Council has made arrangements with the contractor for the substitution of motor vehicles in place of horse-drawn waggons for the removal of house and trade refuse. Two horse-drawn vehicles are retained for use in streets where large motor vehicles would be inconvenient and in streets congested with market traffic. The collection of house refuse from the main streets is now completed by 9 a.m., the householders being required to put the bins on the kerb of the footway in front of their premises between the hours of 6 and 8 a.m. This earlier daily collection has worked well. In a very large majority of the houses in the Borough, the old large fixed ashpits have been replaced by movable sanitary ashbins. The number of notices served for the absence of, or defective ashbins was 58 At the request of a number of occupiers in Upper Bedford Place, arrangements were made with the Contractor for the daily removal of house refuse from the houses in that thoroughfare. Notices requiring the refuse to be placed on the kerb in properly covered receptacles between the hours of 6 and 8 a.m. daily were served on the occupiers and the arrangement came into operation on Tuesday, the 17th January, 1928. In October, 1927, a leaflet on the subject of the removal of house refuse was prepared and distributed throughout the Borough. The following is a copy of the leaflet: — THE METROPOLITAN BOROUGII OF HOLBORN. Removal of House Refuse. To the occupiers of premises in Holborn. If you want health, economy and efficiency:— Don't provide more refuse than is absolutely necessary; burn as much as possible. Don't put in your dust bin any liquids whatsoever; pour these down the drain. Don't pack your dust bin tight; a tightly packed bin has to be knocked hard to empty it. Don't keep the dustmen waiting; put the bin in a place easy for the dustmen to get it. Wrap up wet refuse in paper; this is hygienic, prevents rust and makes emptying easier. It is in your interest to make the collection and emptying of the bins as easy and speedy as possible. In all streets where there is a daily morning collection, the refuse must be placed on the kerb, outside the houses, in small properly covered metal ashbins between 6 and 8 o'clock every morning (Sundays, Christmas Day, Good Friday and Bank Holidays excepted). The ashbin must have one or more suitable handles and cover, and not hold more than two cubic feet. C. W. HUTT, m.d., d.p.h., Medical Officer of Health. Town Hall, High Holborn, W.C. 1. October, 1927. B 18 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. Sanitary Inspection of the District, including Premises and Occupations which can be controlled by By-Laws and Regulations. In addition to my inspections, the Sanitary Inspectors made 21,600 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 1927. Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Stockwell Total Complaints received 53 61 67 1 ... 182 Do. found to be justified 53 60 67 1 ... 181 Inspection of Houses — Dwelling-houses 77 143 61 ... ... 281 Houses let in lodgings 308 285 193 19 ... 805 Common lodging-houses 3 4 3 ... ... 10 Schools ... 4 ... ... 4 Drains tested by smoke ... 3 ... ... ... 3 ,, ,, ,, water 1 ... l ... ... 2 ,, ,, ,, chemicals 1 ... ... ••• ... 1 Re underground rooms 2 2 ... ... ... 4 ,, Rent (Restriction) Act ... ... ... ... ... ,, New Buildings ... ... ... ... ... ... Housing (Inspection of District) Regulations ... ... ... ... ... ... Factories — ... Bakehouses 9 20 8 ... ... 37 Food preparation (other than above) ... ... 42 ... ... 42 Other 89 132 257 5 ... 483 Workshops and workplaces — Food premises: Dairies and Milkshops 31 51 16 ... ... 98 Ice Cream, Manufacture 43 15 281 ... ... 339 Do. Storage or Sale 1 ... 1 ... ... 2 Slaughter-houses ... 7 ... ... ... 7 Hotels and Restaurants 70 153 209 ... ... 432 Butchers 279 39 361 ... ... 679 Bakehouses 2 8 6 ... 16 Fried Fish shops 186 15 15 ... ... 216 Market Streets 316 78 409 ... ... 803 Licensed Premises ... 5 ... ... ... 5 Sweet shops 33 46 62 ... ... 141 Other food shops 92 57 79 ... ... 228 Other workshops 203 213 237 82 ... 735 Other workplaces 140 190 33 2 ... 365 Outworkers' Registers 21 34 59 ... 114 Stable and Stable yards 46 72 ... ...... ... 118 Rag and Bone shops 89 9 5 ... ... 103 Outworkers' rooms 10 ... ... ... 10 Offices 86 34 16 ... ... 136 Inspections carried forward 2,128 1,629 2,364 108 — 6,219 19  Mr. Bennett Mr. Clark Mr. Larard Miss Charlesworth Miss Stockwell Total Brought forward 2,129 1,629 2,354 108 - 6,219 Miscellaneous — Black smoke 109 29 103 ... ... 241 Dust, Special Inspections 49 159 26 ... ... 234 Rats and Mice (Destruction) Act 78 155 54 ... ... 287 Public Urinals and Lavatories ... ... 2 ... ... 2 Sale of Food and Drugs Act, sampling 215 191 207 ... ... 613 Other Inspections 1 7 55 4 4 71 Periodical Inspections: Includes W.C. and yards, dustbins. especially houses let in lodgings, and other suitable buildings 1,670 2,433 2,622 ... ... 6,725 Re-Inspections— Houses 692 762 521 44 ... 2,019 Factories 7 45 33 ... ... 85 Workshops and Workplaces 7 120 58 1 ... 186 Offices ... 1 1 ... ... 2 Restaurants 8 43 20 ... ... 71 Licensed premises ... 1 ... ... ... 1 Miscellaneous 21 24 41 25 120 231 Visits re Infectious Diseases 47 105 67 56 95 370 Do. on School Reports ... ... ... ... ... ... Tuberculosis—First visits ... ... ... ... ... ... Do. Re-visits ... ... ... ... ... ... Scabies ... ... 1 ... ... 1 Vermin ... ... ... 30 55 85 Other Visits— Police Courts 13 5 6 ... ... 24 Various 158 312 216 7 8 701 Maternity— Visits: †† Children under 1 year ... ... ... 210 280 490 Do. 1 to 5 years ... ... ... 6 10 16 Expectant Mothers ... ... ... 60 59 119 Re-visits: Children under 1 year ... ... ... 661 627 1,288 Do, 1 to 5 years ... ... ... 375 489 864 Expectant Mothers ... ... ... 15 80 95 Other Maternity Visits ... ... ... 99 68 167 Attendances at Maternity Centres ... ... ... 196 197 393 Total 5,203 6,02 1 6,387 1,897 2,092 21,600 † All outworkers' rooms in houses let in lodgings (these comprise the larger majority), have been inspected but the visits have been counted under inspections of houses let in lodgings. †† See page Notices Served. The total number of notices served for nuisances found in dwelling houses and factories, workshops and workplaces, and premises subject to various By-laws. B 2 20 including notices requiring annual cleansing of houses let in lodgings, was 1,394, viz.: — Public Health (London) Act, 1891— Intimation Notices 515 Statutory Notices 77 By-laws— Houses let in Lodgings 750 London County Council (General Powers) Acts— Verminous rooms 46 Rats and Mice (Destruction) Act, 1908 6 1,394 The following table shows the work done to abate nuisances for which intimation notions were served: — Water Supply— Houses. Factories, Workshops and Workplaces Provided 2 2 Cisterns cleansed, repaired, etc. 30 8 Waterclosets— Cleansed 44 13 Water supplied, flushing cistern repaired, etc. 18 9 Repaired, new pans, etc. 65 19 Ventilation improved — 17 ,, to lobby provided or improved — 7 Separate accommodation for sexes provided — 4 Position or construction improved 1 11 Direct communication with workrooms remedied - 7 Accommodation provided - 2 Soil Pipes— Repaired, renewed and ventilated - - Rainwater Pipes— Repaired or renewed 17 3 Drains— Repaired 39 2 Unstopped, cleansed, etc. 1 — Sinks, etc. Waste pipes repaired, renewed, etc. 13 4 Yards, Areas and Washhouses— Cleansed 16 - Paved and paving repaired 20 3 Houses and Workshops, etc. Cleansed 56 44 Dilapidations repaired and made good 59 5 Ventilation improved - 8 21  Houses. Factories. Workshops and Workplaces. Dampness— Roofs repaired 67 4 Gutters repaired 14 — Other works to prevent dampness 9 1 Ashbins— Provided, repaired, etc. 53 5 Urinals— Repaired, cleansed, etc. - 5 Various— Underground Rooms vacated 9 - Smoke—Emission of black smoke abated - 2 Accumulations of Refuse—Removed 27 2 Overcrowding abated 2 5 Animals—Improper keeping discontinued 1 — Other nuisances abated 6 28 Statutory Notices. The following table shows the nuisances for which the 77 Statutory Notices were issued under the Public Health (London) Act, 1891. Houses. Factories. Workshops and Workplaces. Section 2 (a) Dirty and dilapidated premises, etc. 34 9 ,, (b) and Section 37, Ashbins 5 — ,, (c) Drains and W.C.'s 15 10 ,, (d) Accumulation of rubbish 2 1 ,, (e) (g) (i) Overcrowding 2 — „ (f) and Section 48. Water supply 11 ,, 38 W.C.'s communicating with workrooms — 3 ,, ,, W.C. Absence of separate accommodation for sexes - 4 ,, ,, Insufficient accommodation 1 — ,, 96 Underground rooms 5 — By-laws as to Houses let in Lodgings. At the end of the year 557 houses were registered under these By-laws. Of these, 270 are in St. Giles and Bloomsbury and 287 in the Holborn District. There were 805 inspections of these premises, excluding a very large number of periodical inspections and re-inspections. 193 notices were served for Breaches of the By-laws, exclusive of 557 notices that were served for annual cleansing as required by the By laws. Rats and Mice (Destruction) Act, 1919. During the year 275 premises were inspected under the above Act, the total inspections being 287. Six notices for breaches of the Act were served. As a result, in all six cases the rat runs were pealed up, in two cases old brick ashbins were abolished and sanitary bins substituted, and in two cases the cellars were paved. 22 WARD Number of premises inspected. Number rat infested. Action for Rat Repression. RESULT. The following summary shows the condition found on inspection, the action taken and the results obtained. Traps. Poisons. Rat catchers. Dogs. Cats. Proofing. Council. Other. A. 14 1 1 1 - Rats still caught 1 B. 21 — - — — c. 20 3 1 1 1 1 — — 2 Free 3 D. 48 1 — — — — — — 1 Rat occasionally seen 1 E. 19 7 2 4 — — — — 6 Free 4 Numbers reduced 2 Rats occasionally seen 1 F. 45 10 1 5 — - — - 10 Free 8 Numbers reduced 2 G. 15 9 2 2 — 1 — - 8 Free 5 Numbers reduced 3 Work in progress 1 H. 68 13 6 5 — 4 1 3 1 Free 6 Numbers reduced 2 Rats occasionally seen 5 I. 25 7 7 4 2 — 1 1 3 Free 3 Rats occasionally seen 4 275 51 24 21 3 7 2 4 31 Free 29 Numbers reduced 9 Rats only occasionally seen 11 Rats still seen 1 Work still in progress 1 Rat Week. In accordance with the suggestion of the Ministry of Agriculture and Fisheries, Eat Week " was observed during the first week in November. The importance 23 of this annual attack on the rodent population has long been recognised; it forms a fitting opportunity to remind the public of their duties under the Eats and Mice (Destruction) Act and, by means of suitable propaganda, to urge the necessity for rat destruction. But it would be a mistake to regard "Rat Week" as an end in itself; to concentrate all effort into a single week would at best produce a sporadic response and court comparative failure. The Sanitary Inspector and the occupiers of premises that are, or may be, rat infested, can only be assured of success by systematic routine work all the time. An essential for the success of any rat week is co-operation. The need for concerted action against rats can hardly be overemphasised. This applies particularly in an old built up area such as Holborn where individuals are handicapped in their efforts to destroy rats by the difficulty or impossibility of dealing with conditions beyond their immediate control; the solution of the problem often depends on simultaneous action by all occupiers and owners of premises in infested areas. The failure of one occupier in an infested block will effectually mitigate against the successful extermination of rats in the area concerned. In the observation of "Rat Week" in the Borough we endeavoured to secure, during the six days, intensive action and complete co-operation by occupiers in rat infested blocks, and efforts were made to deal effectively with the various causes at the roots of infestations. As a corollary to this, the importance of continuous systematic routine work for the extermination of rats and the prevention of re-infestation was emphasised. The general arrangements made by the Council for rat repression included: — (1) Systematic baiting in the Council's sowers, the bait used being small cubes of bread soaked in liquid extract of red squills and "Dalroc," which are found to be more effective than barium carbonate. The baits were laid in the sewers weekly during the year, including four times during the first week in Novembe. A quarter of a gallon of the poison, making 1,000 baits, is used each time. The men who work in the sewers report that the baits were taken and dead rats occasionally seen. (2) The services of the Council's workmen were available for rat proofing subject to the cost of such service and the material used being defrayed by the owners or occupiers of the premises where the work was carried out. (3) Arrangements were continued with a firm of rat catchers for dealing with rat infested premises at the cost of the occupiers. This arrangement has proved useful and reports are from time to time received from the rat catchers employed respecting their inspections of the premises and the work ultimately carried out. In all cases where rat catchers are employed under the arrangements made by the Council information is given to the Medical Officer of Health by the firms employed as to the work done and the results, but in many cases other firms of rat catchers are employed and it would be an interesting consideration as to whether the duty should be placed on all rat catchers to notify the Local Authority when they discover the presence of rats or rat runs. 24 Bats from Disused Drains. In the year 1921 the Public Health Committee had under consideration the question of nuisances arising from the presence of rats, where the access of the vermin to the premises concerned was found to result from the presence of unsealed disused drains. On the recommendation of the Committee the Council, at its meeting on the 23rd November, 1921, decided to address a communication to the Minister of Health, the Minister of Agriculture and Fisheries and the London County Council, urging that legislation be introduced to provide for placing on owners or occupiers of property an obligation to notify the Local Sanitary Authority on ceasing to use any drains or similar sanitary fitting and for making it an offenec to cease to use any such drain or other similar sanitary fitting without efficiently sealing off. Copies of this resolution were also sent to the various Metropolitan, City and Borough Councils. A number of the Local Authorities in London agreed with and supported the representations made by the Council and 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 these clauses were subsequently withdrawn The matter was further considered by the London County Council and the various Metropolitan Local Authorities, and clauses dealing with the subject were again included in the London County Council (General Powers) Bill, 1928. The Bill was referred to the Local Legislation Committee of the House of Commons and as your Medical Officer of Health I was asked to give evidence before the Committee in support of the representations originally made by the Holborn Borough Council. Evidence was therefore prepared giving a number of specific cases where rat infestation had occurred from disused unsealed drains. When the part of the Bill dealing with the matter came before the Committee after considerable legal argument and various suggestions for amending the wording of the clause, the Chairman intimated that, the Committee did not want to hear any evidence in support of the proposal because the Committee were satisfied as to the necessity for the clause, a statement which, if I may be permitted to add as an officer of the Holborn Borough Council, caused me much personal satisfaction as a testimonal to the sagacity of the decision of the Public Health Committee and the Council. The clauses were amended by the Committee and remained part of the Bill as approved by the House of Commons. At the time of the preparation of this report the Bill is in course of progress through the House of Lords. Inspection of Workshops, etc. The routine inspection of factories, workshops and workplaces has been carried out during the year. 562 factories were inspected, 751 workshops and 3,682 workplaces. 25 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 151 premises no longer used for the purpose for which they had been registered were removed from the register of workshops. In six cases, owing to the introduction of machinery, former "workshops' had become "factories" and the necessary transfer to the factory register whs effected. Variations in the staff employed were also frequently reported. During the year 80 workshops were added to the register. It was necessary to serve the following notices for the abatement of sanitary nuisances in factories, workshops and workplaces. Intimation Notices. Statutory Notices. Factories 35 5 Workshops 51 7 Workplaces 73 11 159 23 Of the 623 workshops on the register at the end of the year 324 employed men only, 65 employed women only, and 231 employed both men and women. The number of employees is often very small and many of the workshops are in tenement houses (houses let in lodgings). No fewer than 165 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. Boot makers and repairers 19 - - 10 Builders 12 — — 12 Cabinet makers 5 - — 5 Carpenters 12 — 12 Clock and watch makers 15 - 1 16 Dressmakers and ladies' tailors 25 19 44 Diamond mounters 10 - 4 14 Engravers 18 — 1 19 Glass blowers 8 — 3 11 Jewellers 49 — 11 60 Lamp shade makers — 4 2 6 Leather goods makers 3 — 6 9 Metal workers 6 — 1 7 Picture framers 11 — 2 13 Tailors 27 4 77 108 Factories. These visits also afforded an opportunity for extending and revising information relating to "factories'' in the Borough. Steps are being taken for the gradual compilation of a register of such places, and at the end of the year 418 factories had been entered oil the register. Workshops are automatically converted, at a very small cost, into factories by the installation of a small electric motor ; the health conditions then may no longer be inspected by the Borough Council's staff except as regards sanitary accommodation. 26 The 418 factories include 53 different industries. In 208 cases men only were employed, in 7 women only, and in 203 both sexes. The more important industries carried on in these factories are: Bookbinding 17 Engineering 43 Jewellers' work 10 Metal work 9 Printing 82 Among the industries, recorded in our registers, which might be regarded as uncommon for a central London area, may be mentioned brass founders, aluminium founders, gold beaters, plaster statuette making, cloth shrinking, artificial limb-making, printers' type founders and X-ray apparatus makers. The following is a summary in tabular form of the work done by the Inspectors in factories, workshops and workplaces in the year 1927:— Mr. Bennett. Mr. Clark. Mr. Larard. Miss Charlesworth. Total. Factories— Inspections 89 132 299 5 525 Re-inspections 7 45 33 - 85 Workshops— Inspections 203 213 237 82 735 Re-inspections 3 62 52 1 118 Workplaces— Inspections 140 190 33 2 365 Re-inspections 4 58 6 - 68 Offices— Inspections 86 34 16 - 136 Re-inspections — 1 1 — 2 Bakehouses— Inspections 11 28 14 - 53 Re-inspections — — — — Restaurants— Inspections 70 l53 209 - 432 Re-inspections 8 43 20 — 71 Licensed Premises— Inspections - 5 - - 5 Re-inspections — 1 - - 1 Defects Found— Want of cleanliness 2 33 11 1 47 „ ventilation 1 6 1 - 8 Overcrowding — 1 3 1 5 Want of drainage of floors — — — — — ,, lavatory accommodation — - - — — Food improperly stored — 1 — — 1 Storage cistern defective 2 7 — — 9 Accommodation for refuse - 5 — — 5 Accumulation of refuse - 4 1 - 5 Sanitary accommodation Insufficient - 1 1 - 2 Unsuitable 2 23 13 — 38 Defective 5 11 9 1 26 Not separate for sexes — 2 2 — 4 Stopped - 6 1 — 7 Foul — 3 1 — 4 Direct communication with workroom - - 2 - 2 Other nuisances 4 29 9 6 52 Total defects 20 132 54 9 215 27 Action taken, Matters referred to H.M. Inspector:— Nuisances remediable by H.M. Inspector Failure to affix abstract 25 Matters referred by H.M. Inspector:Notified by H.M. Inspector 50 Notices served. Mr. Bennett. Mr. Clark. " Mr. Larard. Miss Charlesworth. Total. Factories- Intimation 3 13 19 - 3.5 Statutory — 2 3 — 5 Workshops— Intimation 6 23 19 3 51 Statutory — 2 3 — 5 Workplaces— Intimation - 35 1 - 36 Statutory - — — - — Offices— Intimation - 3 - 3 Statutory — — — - — Restaurants— Intimation 2 16 8 - 26 Statutory — - — — — Licensed Premises— Intimation - 2 - - 2 Statutory - — — - - Legal Proceedings — - - - - Outworkers. Lists received from Holborn Firms 111 Names and addresses received from other Authorities 372 Names and addresses sent to other Authorities 355 Notices served on Employers — Firms visited 107 Outworkers lists not kept — „ ,, not sent 7 Infectious diseases in outworkers premises Factories Bill, 1927. This Bill was introduced into the House of Commons in February, 1927, to consolidate and amend the enactments relating to factories and workshops. The Bill was on the same general lines as that introduced in the previous year by the Government. In connection with the previous Bill (Factories No. 2, 1926), the Council adopted a resolution directing the attention of the Minister of Health to the proposals contained therein relative to the sanitary control of workshops and factories, and expressed the opinion that the existing powers of control should continue to be the responsibility of sanitary authorities. 28 It is a matter of considerable importance that the local sanitary authority should be responsible for the sanitation of ail places within its jurisdiction. This Hill, if passed into law, would be the first piece of legislation which has removed any promises 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 its area comes under the local sanitary authority. 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 Ministiy of 1 ealth; 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 lccal authorities in relation to retail bakehouses uuder Section 102 of the Act of 1901." The proposals in the Factory Bill go directly against this movement. At the date of the preparation of this report it would appear that progress of the measure is likely to be further postponed. it is essential in the meantime that local authorities should takq every opportunity to express their views in order that there s':ould bo no curtailment of their powers and duties in connection with the sanitary supervision of factories and workplaces. Underground Workshops. Underground rooms are often used lor trade purposes, not only as store places, but as workshops. The construction of many basements often interferes considerably with their lighting and ventilation. As an example of this, reference can be made to a basement found during last year occupied by a "misfit" tailor. The basement room was used as a fitting "room and a vault under the footway was used as a workroom. The W.C. was situated in the covered area between the fitting room and the cellar workroom. The only ventilation provided for this basement was by means of a small opening in the shop front over the W.C. There was no natural light in the fitting room or the cellar workshop. Improved ventilation was effected in this case by shutting off the W.C. from the remainder of the basement and installing a suitable ventilating shaft with electric fan to provide ventilation for the basement room and cellar workshop. No improvement, however, could be effected in the light. The use of such rooms as workshops can only be regarded as extremely unsatisfactory. Sanitary Condition of Offices. The question of the sanitary supervision of offices is one of considerable importance in an area such as Holborn, containing as it does a very large number of professional and commercial offices. During the year 19.27, 136 separate offices were inspected and it is satisfactory to report that in two cases only was it found necessary to serve notices for the abatement of nuisances. The question has been raised as to the powers possessed by Metropolitan Local Authorities for the inspection and supervision of offices and the matter has, from time to time, been considered by the Metropolitan Boroughs Standing Joint Committee. A representation was made by that Committee to the Minister of Health asking for the introduction of legislation definitely granting to Local 29 Authorities power for this inspection and supervision. In reply the Minister drew attention to the powers possessed by Local Authorities in London under the Public Health (London) Act, 1801, for deaJing with insanitary premises, and the Minister considered that in view of the decision in the case of Bennett v. Harding (1900), the expression "workplace" which occurs in Sub-Section 2 of Section 38 of the Act, was wide enough to cover offices. Subsequently, however, a further letter was addressed bv the Minister to the Standing Joint Committee expressing the hope that it would be found possible for some Metropolitan "Borough Council to arrange for a test case. No such test- case however, has yet been taken. Smoke Abatement. The smoke shafts in the Borough were frequently kept under observation and n 241 cases the inspections were tecorded. Some of these observations were nude in the early morning when smoke pollution is more prevalent. Generally the observations extended over periods of not less than one hour. TCight complaints were also received. As the result of the inspections two intimation notices were served. Much of the black smoke nuisance arises from caieless or inefficient stoking. Stoking is usually considered an unskilled employment, and the stoker commonly ireceivesbut 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 There are some grounds for hoping much nuisance from smoke might be avoided by the more general use of smokeless fuel and there are indications that progress in this direction is being made. Such fuel is made by treating small coal; at the same time all the valuable products contained therein are also retained. The producers of this fuel claim that it lights easier than coal, requires less attention, remains bright and radiant, maintains a uniform heat, creates no smoke, deposits no soot, ensures clear flues, radiates twice as much heat as coal and generally makes for comfort, cleanliness and economy. It is urged that its nse is equally suitable for domestic or industrial purposes. Observations are being made in the Public Health "Department, and at the Co"ncil's disinfecting depot w'th a view to ascertaining how far smokeless fuel now on the market meets the claims put forward by the promoters. These experiments are not yet completed but the indication at the date of the preparation of this report is that so far as its heating properties and absence from smoke are concerned the fuel is satisfactory; on the other hand, weight for weisht the smokeless fuel is more bulkv than ordinary coal, and this may to some extent hinder its general use in crowded areas like Central London where storage accommodation is very limited Common Lodging Houses Acts, 1851 and 1853. Thirteen Common Lodging Houses are registered in the Borouph for 967 lodgers, viz., 842 males and 135 females. 30 The Common Lodging House accommodation in Ilolborn is equal to 21 beds per 1,000 of the population. The death-rate amongst common lodging house residents is very high ; in this Borough it was 56.9 per 1,000 in 1927. At the L.C.C. Licensing Session in June, 1927, a licence was issued for the premises No. 35, Devonshire Street, providing accommodation for 45 women and 2 children and increasing the total accommodation in the Borough for women from 78 to 125. This common lodging house for women, know as "Cecil House," in addition to the ordinary sanitary arrangements is provided with baths, lavatory basins, and sinks for washing clothes; there is also a common room on the ground floor. The charge made is Is. per night which includes use of bath and a cup of tea and biscuits before the residents leave in the morning. The accommodation at the house is not available during the day time. As the use of this type of common lodging house develops the promoters may find it worth while to consider whether, as in some other places of a similar kind, a common sitting room should not be available for use throughout the day. HOUSING. During (he year 855 houses occupied by the working classes were inspected; this number consisted of 557 registered lodging houses and 298 non-registered houses occupied by working classes. The total number of buildings in the Borough occupied for dwelling purposes is given bv 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 Scheme, Betterton Street. In the Annual Report for 1926 reference was made to a small housing scheme undertaken by the Council in Betterton Street. Three houses were acquired and the vacant site of a fourth house already demolished. The houses were not suitable for reconstruction as the walls were not in the required positions nor of the required thickness or condition. The Council therefore decided to demolish the three houses and construct on the site a block of self-contained flats. The building was completed in the first half of the year and was formally opened by H.H.H. Princess Arthur of Connaught on the 7th July, 1927. The new block of tenements is of five storeys constructed of red bricks with fire-proof floors and a tiled roof. There is also a basement let for storage purposes. The block comprises 15 flats, 3 on each floor giving accommodation for approximately 75 persons in lieu of about 50 who were displaced from the old houses. With one exception each flat has a living room, 2 bedrooms, a scullery. W.C. and bathroom, and a coal bin. Entrance from Betterton Street is through an archway leading to a court yard at the rear of the block and to a fire-proof staircase. The entrance doors of the three flats on the ground floor open to the 31 court yard; access to the upper flats is from balconies running the whole length of the building on each floor The flats are lighted by electric light and each living room is provided with a dresser and an "Interoven" stove. There is a copper and gas cooker in each scullery; the living and bedroom floors are boarded. The floors of the passages, sculleries and W.C.'a are paved with granolithic paving. The buildings were designed in the Borough Surveyor's office and I he work was carried out by the Canonbury Construction Co., Ltd., under the supervision and direction of Mr. J. E. Parr, A.M.Tnst.C.E., the Borough Surveyor. The illustrations show the site before the demolition of the old buildings and the front elevation of the new building Imown as Betterton House. The Council subsequently decided to extend the scheme and adjoining houses have been obtained. The demolition of these and the extension of the block of tenement dwellings is likely to be proceeded with during the present year (1928). Upwards of 120 applications were received for the 15 flats in Betterton House. Several of these came from families who had been displaced when the old buildings were demolished and preferential consideration was given to such applicants. The Housing of the Working Classes Committee was then faced with the difficult problem of selecting from the remaining applications those whose need for improved housing accommodation appeared to be most urgent. Ample evidence was afforded as to the urgent necessity which exists in the Borough for additional accommodation for families of the working classes. Accomviodcition on L.G.C. Housing Estates. In the year 1024 arrangements were made by the London County Council for a certain number of houses on several of that Council's housing estates to be available for applicants nominated and recommended by the Metropolitan Borough Councils. The arrangement was primarily to secure reduction in overcrowding, that is, to provide housing accommodation for families residing more than 2 per room. It was, however, recognised that other cases of hardship existed and the scheme was extended to include these. Applications for such accommodation are submitted by residents in this Borough to the Public Health "Department where thev are examined and before submission to the London County Council the applicants are in all cases interviewed. From the commencement of the scheme up to the end of 1927, 180 applies Hons have been forwarded through the Public Health "Department. Information lias been received that in 34 of these the applications for various reasons cannot be accepted for houses on London County Council estates; in 69 cases information has been received that accommodation has been offered to and in most cases accepted by, the applicants; the remaining cases are still under consideration. The scheme, has proved of considerable advantage to a number of families who were resident in this Borough and who, through the operation of the scheme, have obtained improved housing accommodation in suburban areas. 32 HOUSING CONDITIONS. Statistics. Year Ended 31st December, 1927. GENERAL. (1) Estimated population 12,209 (2) General death rate 12.5 (3) Death-rate from tuberculosis (all forms) 1.30 (4) Infantile mortality rate 38 *(5) Number of buildings containing dwellings (Census, 1921) 3,473 †(6) Number of separate dwellings (Census, 1921) 7,202 ‡(6a) Number of working-class tenements (Census, 1921) 8,571 (7) Number of new working-class houses erected 1 Block 115 tenements erection completed) The following information is required by the Ministry of Health to be set out in this report:— Number of New Houses erected during the Year: — (a) Total (including numbers given separately under (b)) 1 Block (15 tenements erection completed) (b) With State assistance under the Housing Acts: (i) By the Local Authority nil (ii) By other bodies or persons r —INSPECTION OF DWELLING -HOUSES DURING THE YEAR (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 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-bead) found not to be in all respects reasonably fit. for human habitation 354 *"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 I!A11 the more insanitary houses are always annually inspected. 33 II.—REMEDY OF DEFECTS DURING THE YEAR WITHOUT SERVICE OF FORMAL NOTICES. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers ? III —ACTION UNDER STATUTORY POWERS DURING THE YEAR. A. Proceedings under Section 3 of the Housing Act, 1025: — (1) Number of dwelling-houses in respect of which notices were served requiring repairs nil (2) Number of dwelling-houses which were rendered fit after service of formal notices: — (a) by owners nil (b) by Local Authority in default of owners ni] (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:— fl) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 354 (2) Number of dwelling-houses in which defects were remedied ■after service of formal notices: — (a) by owners 354 (b by Local Authority in default of owners nil C. Proceedings under Sections 11, 14, and 15 of the Housing Act, 1925: — (1) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling-houses in respect of which Closing Orders were made nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit nil (4) Number of dwelling-houses in respect of which Demolition Orders were made nil |'5) Number of dwelling-houses demolished in pursuance of Demolition Orders nil C 34 Houses in Bettrrton Street—IJefoke Housing Scheme. 35 15 Tenements. Ehection Completed, 1927, Betteeton Street Housing Scheme. c 2 36 FOOD. Dairies, Cowsheds and Milkshops. The number of registered dairies and milkshops in the Borough at the end of the year was 129. Seven retail dairies and milkshops were newly registered, and two removed from the register. In eight other cases alterations in the register became of necessary on change to ownership. In addition to my inspections the Sanitary Inspectors made 98 inspections of these premises. No notice had to be served for sanitary defects or breaches of regulations. From time to time itinerant vendors, other than those registered in connection with premises within the Borough area, sell milk in the Borough. In these cases it is our practice to communicate with the Medical Officer of Health of the district from which the itinerant dealer comes in order to ascertain that the milkseller is registered as required by the Milk and Dairies Order. Residue from Milk Clarifiers. As it would seem probable that pigs have been infected with tuberculosis as a result of feeding with infected milk and slime from clarifiers, enquiry was made at the various establishments in the Borough where milk is cleansed by clarifiers to ascertain what is done with the residue after the milk has been passed through the cleansers. It was found in one case that this residue is at once destroyed by burning in a furnace used in connection with a pasteurising plant, in a!] other cases it is at once washed down the drains. Bacteriological Examination of Milk. Twenty-five samples of milk were examined for the presence of tubercle bacilli; five of these were also examined to ascertain the number of organisms per cubic centimetre and the smallest volume containing B. coli. Examinations for tubercle bacilli were carried out by animal inoculation ; four of the samples examined were found to contain tubercle bacilli. The following table refers to the 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. 1927 Aug. 8 Large milkshop... 9,000 0.1 CC. Aug. 8 Milkshop 56,000 0.000l cc. Oct. 24 General shop 13,000 0.1 cc. Oct. 24 Milkshop 300,('00 0.001 cc. Nov. 30 Small milkshop 80,000 0-01 cc. 37 Further information with regard to the milk containing tubercle bacilli follows: — Sample "N."—Slight infection only, a few tubercles were noted on the liver of the guinea pig inoculated. This sample was purchased from a retail dealer occupying a general shop; he obtained the milk from a large wholesale Company; communications were addressed to this Company in order to ascertain the source of supply. After some correspondence a letter was received from the Managing Director stating that as his Company handles thousands of gallons of milk daily it was not easy to trace the source of supply. He suggested, however, that the Company's carman might have taken a churn of milk direct from the station to the premises of the retailer without the milk going through the Company's pasteurising plant, contrary to their rules. This communication can only be regarded as unsatisfactory indicating, as it does, the reliance on pasteurisation to secure the delivery of milk free from infection, rather than on the production and delivery of clean milk free from tubercle bacilli. Moreover, it confirms the experience gained in previous years that owing to the practice of distributing milk from large mixing depots it is frequently inipracticable to trace the actual source of an infected milk supply. Sample "S" was purchased from a fairly large milk shop. On enquiry it was ascertained that the milk was supplied to the retailer in this Borough by a Derbyshire Company. A communication was addressed to the Company who replied that milk is collected by them from about 150 farms and taken to their depot where it is mixed in a receiving vessel and " heat treated "in a flash pasteuriser to a temperature of 167° F. and immediately cooled over a brine cooler down to about 30° F. This Company also pointed out that it was practically impossible for them to detect the farm from which the infected milk came; in this case also it would appear that pasteurisation is relied on rather than the production of clean and non-infected milk. The Holborn Council, however, in this instance had the satisfaction that their efforts to obtain purer milk were not blocked by a mere non possumus. Information respecting this sample was sent to the County Medical Officer of Derby who replied that he had arranged with the Company that their farmers should be notified of the presence of tubercle bacilli in the mixed milk from the 150 farms and that they should be instructed to keep particular watch on their beasts. In addition to this the Company instructed their Factory Managers to look into the farms under their control and endeavour to trace the source of infection sufficiently nearly for the County Medical Officer to take action under the Tuberculosis Order. Sample "V."—This sample was purchased from a milk seller occupying a small general shop. The milk was obtained by the retailer from a dairyman in the Borough. Information was obtained from the wholesale dairyman that the milk from which this retailer was supplied was obtained from Derbyshire and that about the time that the sample was taken, the milk came from a farmer, who since that date had had all his cattle destroyed owing to foot and mouth disease. 38 Sample " R " was purchased from a branch shop of a retail dairyman, who obtained the milk from a provincial wholesale milk Company. Efforts to trace the exact source of supply were not successful, but information was received from the retailer that he had ceased to obtain milk from this provincial Company. Milk and Dairies Order, 1926. Some difficulty is experienced in securing strict compliance with the provisions of the above Order, so far as the cleansing of vessels and appliances is concerned. The Order provides for every vessel, lid and appliance to be thoroughly washed as soon as may be after use and to be cleansed and scalded with boiling water or steam before its use again. The cost of providing proper steam chests is such that the small retail milk seller is not willing to comply with a suggestion that this course should be taken. In shops where there is only a counter trade probably the vendors cannot reasonably be expected to buy a relatively expensive steam chest, but in milk businesses where there is a round entailing the use of cans or bottles it is essential for strict compliance with the Order that proper plant should be installed. ' During the year milk roundsmen were observed removing discs from bottles of milk in order to serve small quantities from the bottles. This action being contrary to the provisions of the Order the attention of the roundsmen and their employers was called to the matter; no repetition of the offence has been reported. The Milk (Special Designations) Order, 1923. During the year 1927 licences available up to the 31st December, 1927, for tho sale of designated milk in the Borough were issued as follows: — Certified Milk 5 Grade A (Tuberculin Tested) 5 Grade A 2 Pasteurised 4 Up to the date of preparation of this report licences for the year 1928 have been issued as follows: — Certified Milk 4 Grade A (Tuberculin Tested) 5 Grade A 1 Pasteurised 3 Public Health (Milk and Cream) Regulations, 1912 and 1917. The Public Health (Milk and Cream) Regulations, 1912-1917, were enforced in the Borough throughout the year. One hundred and sixty-eight samples of milk were examined ; none was found to contain preservative; 12 samples of cream were examined, 2 of which were found to contain preservative, viz., boric acid to the extent of 0.73 and 0'248 per cent, respectively. 39 Explanations were submitted by the sellers of the circumstances of the sales of these two samples of cream without the required labels and no action was considered necessary beyond letters of warning to both vendors. Eleven 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 that mentioned above, was discovered during the year. Condensed Milk. The Public Health (Condensed Milk) Regulations, 1923, came into operation on the 1st November, 1923. During the year 1927, 14 samples of condensed milk, viz., five full cream, and nine skimmed sweetened, were examined by the Borough Analyst under the Regulations. All the samples complied with the requirements of the Regulations as to labelling. All the samples were examined for standard of composition and all were found to be equal to or above the standard required. The following table gives the percentages of the milk fat and milk solids found: — Milk fat per cent. Milk solids (including fat) per cent. Full cream sweetened 9.2 31.4 " " 9.2 31.1 " " 9.0 34.0 " " 9.0 33.0 " " 9.0 32.9 Skimmed ,, 3.0 30.0 " " 1.4 29.6 " " 0.8 31.8 " " 0.8 30.1 " " 0.6 30 .6 " " 0.6 29 .6 " " 0.4 29 .0 " " 0 .2 27 .9 " " 0 .2 27 .5 Public Health (Dried Milk) Regulations, 1923. These Regulations came into operation on the 1st day of May, 1924, and are generally similar to the Regulations with regard to condensed milk. Very few brands of dried milk are sold in the Borough. Nine samples, covering those generally used, were obtained during the year, and found to comply with the Regulations. 40 Condensed and Dried Milks.—Amended Regulations. In November, 1927, a communication was received from the Minister ol Health forwarding for the information of the Local Authority, copies of the Public Health (Condensed Milk) Amendment Regulations, 1927, and the Public Health (Dried Milk) Amendment Regulations, 1927. These new regulations amend the Condensed and Dried Milk Regulations, 1923. The amendments are primarily designed to secure that in the labelling of condensed and dried skimmed milks, greater prominence shall be given to the words "unfit for babies" and that those words shall also be printed on the outside of any paper or other wrapper in which tins of such milk may be enclosed. In order to give time for the disposal of existing stock, the operation of the amended regulations was deferred until the 1st September, 1928. Margarine. The registration of wholesale margarine dealers is required by Section 9 of the Margarine Act, 1887, as extended by Section 7 of the Sale of Food and Drugs Act, 1899. Under this Section every wholesale dealer in margarine is required to keep a register showing the quantity and destination of each consignment and the register is open to inspection by any officer of the Board of Agriculture. The Local Authority has no power to refuse registration or to set up any standard of requirements before effecting such registration. There are five registered dealers in the Borough. Bakehouses. At the end of the year 1927 there were 24 bakehouses in the Borough of which 19 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 53 inspections of bakehouses. Sale oj Fish. During the past year special detailed inspections were made of all the fish shops and fish stalls in the Borough. There were 10 fish shops of which five were in the Central Fish Market (a part of the Smithfield Central Markets, Farringdon Road, the fish being sold by retail). Both wet and fried fish were found to be sold at all the shops; at five, shell fish was also sold. In one instance only, a small quantity of fish was smoked on the premises. In four shops the fish was displayed for sale on slabs extending beyond thebuilding line. In three of these the fish was protected by shop blinds and side screens; in the other the projection beyond the shop front was only a few inches. The surfaces of the slabs on which the fish was displayed were of marble or marble and slate in six cases, marble and wood in two, slate in one and wood in one. Newspaper was used on two slabs and white paper on one under dried fish. All the surfaces were found to be properly drained and in a satisfactory condition; no contamination of (he fish by flies or dust was observed. 41 All the 10 shops were provided with ice-tanks or safes for cold-storage; in the case of one shop only was nuisance found from the storage of the boxes in which the fish is received from the wholesalers. In the case of two shops, however, fish boxes (containing fish for sale) were found to be placed near the ground level where they might be contaminated or fouled by dogs, etc. This practice is all the more objectionable because fishmongers like to keep some kinds of fish, such as herrings, in the boxes in which they are packed until the actual sale, because if they are placed in cold storage or exhibited on slabs in the shop front they are apt to deteriorate in appearance and the selling value is lessened, and moreover, the scales become a source of nuisance as they wash off readily and accumulate in the slab wast-e-pipe. In one of the two cases above referred to, the fishmonger was asked to discontinue placing the boxes in a position where the contents might become fouled. Tn the other case the shop was within the precincts of the Central Market where fouling by dogs, etc., would be less likely. Nine of the shops were provided with suitable sinks for the cleansing and cutting up of the fish and all had proper metal receptacles for gut and other fish refuse. From one shop this refuse was removed twice daily and from all the others once daily. Facilities for personal washing and cloakroom accommodation for the staff were found to be provided in seven shops, but in the others the only arrangement for personal washing was at the cutting-up sink. Fish Stalls. In addition to the shops referred to above, there are five stalls in the .Borough for the general sale of fish. At three of these wet, dried and shell fish is sold, at one wet and dried fish is sold but no shell fish, and at the other wet fish only. The fish on two of the stalls is protected by linen covers in hot weather. In one case the stall has a top cover and one has a top cover and side screens. The surfaces of the stalls were wooden, but on one stall the fish was usually placed on enamel dishes and on another the fish was displayed as a rule in the market boxes in which it was delivered to the stall holder. The surfaces on which the fish were placed were in all cases reported to be satisfactory; no contamination of the fish by flies or dust was noticed. As regards the storage of the fish it was reported that in two cases the stock was always sold out daily, in one case the fish left over at the end of the day was stored in an adjacent shop with which the stall was connected; in one case the storage was in ice boxes at a store-place in the Borough, and in the remaining case the storage was in an adjoining Borough. No fish boxes were found stored at the stalls so close to the ground level as to render the contents liable to be fouled by dogs, etc. In three cases the receptacles for gut and other fish refuse were made of wood and in two of metal. The refuse was found to be removed at least daily and in some cases twice daily. There was also one stall for the sale of shell fish only. At this stall cockles, escallops, mussels, oysters, winkles and whelks are all sold in season. The fish is consumed at the stall. All the plates and other utensils used at the stall were found to be in a clean condition. The stall is inside the Central Market building and side screens and top cover were therefore unnecessary. Metal receptacle was provided for waste matter which was. removed daily by the City Corporation. 42 Other Fi$h Shops. In addition to the above there is a shop in the Borough for the sale of shell fish only and two for the sale of stewed eels. These premises were also kept under observation. Fried Fish Shops. There are also 11 fried fish shops. These are regularly inspected to see that they are kept in conformity with the by-laws made by the London County Council. During the past year '21G inspections of these premises were made. At the same time a careful iook-out has been kept on the soundness of the fish and tho wholesomeness of the materials used in frying. During the year three samples of fried fish were submitted to the Borough Analyst for examination and were found to be " genuine." Market Streets. There were 803 inspections of market streets, each of which includes a number of stalls at which meat, fish, fruit and vegetables are sold. These streets are regularly inspected daily and on Saturday evenings and Sunday mornings. The daily inspection of these market streets helps to secure the maintenance by the regular stallholders of good, sound food only, and, in addition, has the effect of keeping away from these markets casual and unsatisfactory hawkers, who generally avoid markets subject to regular and strict supervision. In order to minimise as far as practicable any contamination of the food exposed for sale in market streets from dust arising during street cleansing, the Borough Surveyor has arranged for these streets to be sufficiently watered before the scavenging to prevent dust arising. Street Trading. The London County Council (General Powers) Act, 1927, by Bart VI, conferred powers on Local Authorities in London to issue licences to street traders and made it unlawful for any person to sell or expose, or offer for sale, any article or thing from or upon any barrow, cart, stall, or other receptacle occupying a stationary position at a place in the carriage way or footway of any street in any Metropolitan Borough, without such licence. The Act also provided for the making of by-laws by the Borough Council relative to various matters cognate to such street trading, including the storage of and the sanitary supervision (while at the place of intended sale or exposure or offering for sale) of articles of food intended to be sold or exposed or offered for sale under the authority of the licence. By-laws made by the Holborn Council in pursuance of these powers were approved by the Home Secretary and came into operation in the earlv part of 1928. The enforcement of the by-laws, so far as they deal with the sanitary supervision of (hp articles exposed for sale, is being undertaken by the Public Health Department. 43 Ice Cream. During the year there were 42 premises in the Borough where ice cream was manufactured, and in addition to my inspections 311 inspections of these premises were made, and five notices were served. Ice cream is manufactured in the Italian colony as follows :— Premises on which 20 gallons made daily 1 ,, ,,10 ,, ,, ,, 3 ,, ,, 8 ,, ,, 1 ,, ,, 4 ,, ,, 8 ,, ,, 2 ,, ,, 7 ,, „ less than 2 gallons „ 1 In addition ice cream was also manufactured on the following premises :— Mr. Bennett's District. Mr. Clark's District. Mr. Larard's District. Restaurants 3 1 1 Confectioners — 5 4 Other 1 4 2 During the summer of 1927 ten samples of ice cream were purchased and submitted to bacteriological examination. The result of the bacteriological examination is shown in the following table : — Sum pie and date purchased. Where purchased. Organisms per cc. growing on Agar at 37°C for 24 hours. Streptococci present, in I cc. Minimum volume showing coliform organisms.* Minimum volume showing B enteritidis sporogenes. 1 11/8/27 Barrow 16,000,000 short chained variety 0-01 cc 1 cc. 2 Barrow 19,000,000 ditto 0.0001 cc. 2 cc. 3 Small sweet 7 1,000,000 ditto 0.01 cc. not observed in 2 cc. 4 shop Barrow 43,000,000 ditto 0.001 cc. 2 cc. 5 Barrow 18,00,003 ditto 0.001 cc. 2 cc. 6 16/8/28 Rest;i urant high-class 3,000,000 none observed 0.000001 cc. 0.1 cc. 7 Restaurant high-class 2,000,000 present 0.1 cc. 1 cc. 8 Restaurant middle-class 450,000 present 0.001 cc. 1 cc. 9 Dairy 600,000 none observed 0.1 cc. not observed in 2 cc. 10 Barrow 6O 000,000 present 0. 000001 cc. 2 cc. * Typesof coliforni organism» approximate to B. lactis asrogenes, B. coli and B. acidi lactici group. 44 The bacteriological examinations were carried out at the Eoyal Institute of Public Health. Samples were delivered at the laboratory of the Institute immediately aiter purchase and arrangements were made for the examinations to be commenced forthwith. In four cases the ice cream was made at premises in the Borough all of which are kept under regular supervision. In six cases the ice cream was made outside the Borough. Where ice cream sold in the Borough is made at premises outside Holborn, it is our practice to ask for information as to the conditions of manufacture from the Medical Officer of Health of the area concerned. On the other hand, we receive a number of such enquiries from other districts respecting ice cream made in Holborn, principally in the " Italian Colony," and sold in other districts. From time to time attention has been directed to the need for further legislation for the better control of the manufacture, storage and sale of ice cream. Powers to deal with the matter were conferred on Metropolitan Local Authorities by the London County Council (General Powers) Act, 1902, but in practice these powers have been found insufficient partly because of the absence of any satisfactory definition of ice cream. During the past year the Council forwarded a resolution to the London County Council in favour of legislation requiring the registration with lccal authorities of all premises where ice cream is made, stored or sold and provision for this has been included in the London County Council (General Powers) Bill, 1928. The section requires the registration of premises only, 'he London County Council being of opinion that the existing powers of control under the 1902 Act cover the manufacture, sale and storage. It is to he regretted that the opportunity was not taken to include a legal definition of ice cream and to establish a satisfactory standard, particularly as this commodity is being consumed in increasing quantities. In December, 1927, the Ice Cream Association of Great Britain and Ireland formulated suggestions for a legal definition of the commodity, providing that the product should contain not less than 8 per cent, milk fat and not less than 10 per cent, milk solids not fat. The Association, however, was not then prepared to suggest a bacteriological standard because, although many members of the industry might favour such a standard, the greater bulk of the manufacturers of ice cream had not reached the stage when they would be willing to recommend that a standard should be fixed. In the light, however, of the provisions operating in British Dominions, to which reference was made in my Annual Pie port for 1925, it would seem that steps in this direction to safeguard British consumers should not be long delayed. Public Health (Meat) Regulations, 1924. These Regulations came into operation on the 1st April, 1925; they deal with slaughter-houses, meat marking, the handling of meat in wholesale markets, conditions of transport, the protection of meat in butchers' and other shops and on stalls from contamination by flies, mud and other contaminating substance. 45 The following summary shows the number of butchers' shops and meat stalk in the Borough, and the number of other shops where meat is sold: — Butchers' shops 27 Butchers' stalls 3 Provision dealers 25 Provision dealers' stalls 3 Ofial shops 3 Cooked meats 10 Wholesale (bacon; sausage) 3 74 All the butchers' shops and meat stalls in the Borough are regularly inspected to ensure compliance with the regulations; during the year 679 such inspections were made. It is regretted that in a few cases (seven) the undesirable practice continues of exposing meat for sale outside the shop on stallboards projecting beyond the building line. If all butchers selling from shops were required to discontinue the practice of exposing meat in front of their shops it is difficult to see that any hardship would be caused. It is noteworthy that during the hot weather, in the best shops, very little meat is displayed; it is in the cold storage plant, but no one contends that the sale of meat is thereby prejudiced. Any attempt to convert the benches into imitation stalls is not in accordance with hygienic ideals. The existence of stalls in market streets in the form allowed by the Regulations is countenanced because it is thought their existence enables meat to be sold at competitive prices and so tends to bring down the prices generally at which meat is sold to the public. In all eases in the Borough, where meat is exposed for sale outside shops or on stalls, suitable screens are provided and used for the protection of meat, as far as practicable, from dust, mud and other contaminating substances. The practice of handling meat by customers before purchase has generally ceased in the Borough. In the shops where " pieces " are sold, a notice is exhibited urging customers not to handle meat before purchase, and in most of these shops forks are provided to enable the pieces to be turned over by purchasers without direct handling. As a result of their observations and enquiries the Inspectors report that the forks so provided are generally used. It is satisfactory to record that it has not been necessary in any case to serve notice for breach of the Regulations. In the early part of the year 1927. a conference on the Public Health (Meat) Regulations was held at the Royal Sanitary Institute. Attention was drawn to the lack of uniformity in carrying out the Regulations in different administrative areas, and consequent dissatisfaction in the meat trade. Reference was also made to the different experiences by local authorities in their efforts to obtain glass fronts to butchers' shops; there was, however, evidence that butchers who had studied the question, from the economical standpoint, kept their meat behind closed glass windows and so prevented the meat losing its 46 bloom, thus necessitating sale at a cheaper rate. It was pointed out that in a large provincial town two firms, one with fifty and one with forty branches, had provided fixed glass windows to all their shops with no loss of trade when the practice of hanging up meat outside the shops was discontinued. In connection with the difficulties arising from the sale of meat from street stalls, reference was made to the practice in some continental towns where all meat exposed for sale on meat stalls has to be kept behind glass. Places ivhere 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. The number of such places on the register at the end of the year was as follows: — Hotels, Restaurants and Eating Houses 255 Slaughter-houses 1 Tripe, offal and other meat shops 32 Fried Fish shops 11 Fish shops 14 Tee Cream (Manufacture) 42 Poulterers 3 During the year 3,015 inspections of food premises and market streets wero made and 32 notices served for sanitary defects found. Hijgiene of Restaurants, Eating Houses arid Public Houses. In the Annual Report for 1923 special 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 the issue by the President of the New Health Society, of a Memorandum to Licensing Justices. The Memorandum deals with matters concerned with hygiene in hostels, bars, taverns, inns and other licensed premises and refers to the practice of exposing food such as sandwiches, pastries, cakes, meats, cheeses, biscuits, chocolates, etc., on counters and shelves of public bars where it is liable to ail-borne infection and contamination by dust, flies and vermin. A suggestion is made that Licensing Justices, in so far as it lies within their discretion, should, in considering applications for renewals, extensions, etc., be satisfied that facilities for tho storage and display of foodstuffs are of a hygienic character. The Justices are also requested to express their views regarding practical steps to encourage cleaner drinking vessels in licensed premises. The Memorandum statfs that investigations made show that it is not an uncommon practice for public house customers to be served with drink in glasses or tankards which have received no cleaning except dipping into dirty lukewarm water, sometimes the vessels being wiped with a cloth that has served the same purpose hundreds of times in a few hours. As a practical solution of the problem the Memorandum suggests that brewers and landlords be recommended by the Licensing Justices (a) to advise their tenants when replacing stock to instal plain glasses which are easy to clean, (b) to encourage the installation of modern appliances for proper washing, disinfecting, drying and polishing drinking vessels. Cleansing of Table Utensils. In this connection it may be interesting to refer to a system for the rating of utensil* emanating from the Dayton (Ohio, U.S.A.) Health Department. 47 The problem which the system seeks to faee is, how can the Health Officials know whether actual sterilisation of utensils is accomplished. In an attempt to solve this problem the Dayton Health Department expressed the view that the greatest interest to the health worker is not the condition of floors, walls, ceilings, plumbing, etc., but the extent to which the Public is protected from disease by the sterilisation of the utensils. It was suggested that 95 per oent. of importance should be given to this question of sterilising and 5 per cent, to the value of cleanliness of surroundings. Of course, every Inspector would know: " That if the parlour is filthy and ill-kept, the kitchen will likewise be filthy." " Good housekeeping in food establishments will not be limited to dish washing, but conversely, crystal fronts and tiled floors are not a guarantee that disease protection is practised in the kitchen." AB Dayton articles of table-ware, glasses, spoons, forks, cups, etc., are collected by the Inspectors in a sterile towel and brought to the laboratory, where they are cultured in Petri dishes by immersing the bowl of the spoon or fork, or the brim of the glass in the liquid culture medium. The medium is then agitated and after proper incubation (about 48 hours), actual counts are made, the same as in making milk counts. In arriving at a basis for rating groups practical conditions met with are considered, e.g., while sterilisation means that no cultures should be found upon plating) it is kept in mind that a restaurant cannot be run on the same principle of asepsis in all stages of operation as a surgical room in a hospital. Allowance is made for air contamination and handling. After many testa it was determined that under a count of 10, a rating of " excellent " would be reasonable. Other groups would be good, fair, poor, very bad. It is not suggested that this method of rating establishments has reached a degree of perfection which would commend its adoption generally in areas of large populations and it is admitted that while in every way fair to food and drink dispensers the system needs improvement and simplification. It is, however, certainly interesting as an evidence of progressive development in food control in the United States of America; the principle may perhaps be found suitable for adoption in this country. Sanitary Accommodation for Customers at Bestanranta, etc. The question arises from time to time of the necessity for the provision in restaurants of sanitary accommodation for customers of both sexes. Many of the larger and better equipped restaurants provide suitable accommodation, a much appreciated boon, particularly in Central London, where such restaurants are largely used by strangers to the Metropolis. There is something to be said in favour of such provision being required in all restaurants, or at least in all the larger establishments, although everyone recognises that in crowded areas where space is valuable it is not always easy to spare the superficial area. At times the nearness of public sanitary conveniences renders provision in a restaurant less imperative. Under various local Acts relating to provincial towns sanitary accommodation must be provided for customers. Sale of Food Order. During the year we received a communication from the Ministry of Agriculture and Fisheries that a complaint had been made to the Ministry that imported eggs were exposed for sale at premises in the Borough contrary to the provisions of the Food Control Order, 1921. On visiting the premises the Council's Inspector found a quantity of South African eggs exposed for sale not labelled as imported, as required by the Order. There was evidence, however, that the required label had been attached to the consignment exposed for sale, the words required by the Order having been written in chalk on brown paper; they were, however, obliterated, possibly as the result of handling. A communication was at onca 48 addressed to the vendor of the eggs requiring strict compliance with the Order and the necessary label was thereupon attached to the boxes containing the eggs. No other breach of the Order was brought to knowledge during the year. Unsound Food. The following unsound food waa condemned during the year 192" :— Commodity. Quantity. Condition. Result of Action taken. Fish :— Brill 6 stone Stale and offensive smell Surrendered Fbcit :— Pears 204 bags liotten Do. Pears 25 cwts. Do Do. Black Currants 362 half bushel baskets Do. Do. vegetables : — Onions 30 lbs. Heated and fermenting ... Do. Cabbage 4 tons Do. Do Beetroot 7½ tons Decomposed Do. Meat, etc. : — Bacon 17 lb Decomposed Do. Lamb 11 stone Do. Do. Turkey 10 lbs. Do. Do. Sale of Foods and Drugs Act. The Public Health (Preservatives, etc., in Food) Regulations, 1925. The Public Health (Preservatives, etc., in Food) Amendment Regulations, 1920. The above regulations came into operation on the 1st January, 1927, except that in the case of the following operation of the regulations was postponed to the under-mentioned dates: — (1) Bacon, ham, egg yolk and articles of food containing preservative necessarily introduced by the use in their preparation of preserved margarine 1st July, 1927. (2) Butter, cream and articles of food containing preservative necessarily introduced by the use in their preparation of preserved bacon, preserved ham, preserved egg yolk or preserved cream ... 1st January, 1928. (3) Articles of food containing preservative necessarily introduced by the use in their preparation of preserved butter ... ... ... ... ... 1st July, 1928. In the year 1927 ten articles of food were found on analysis to contain preservative contrary to the provisions of the regulations, namely, Agar-Agar, three samples, all contained boric acid; Cream, two samples contained boric acid; TCaola, one sample contained salicylic acid; Lemon Squash, one sample contained salicylic acid; Minced Beef, one sample contained sulphur dioxide and two samples contained boric acid. The following observations refer to samples purchased and analysed during the year:— Agar-Agar. A firm of retail vendors of this commodity asked for advice as to its sale having regard to the provision of the new preservative regulations. Three samples 49 of different varieties of the article were examined, all being found to contain boric acid. The vendors were advised the the sale of the commodity with the preservative would be contrary to the provision of the Public Health (Preservatives, etc., in Food) Regulations, and that proceedings would follow if such sale continued after reasonable time had been allowed for the existing stock to be cleared. The sale of the article was shortly afterwards discontinued. Cream. Twelve samples of cream were purchased and analysed, of these two were found to contain preservative, namely, boric acid. In reply to communications addressed to the vendors explanations were submitted and the Public Health Committee were satisfied that in each case the sale of the preserved creqm without the required disclosure of the presence of preservative was by inadvertence. No action was taken beyond letters of caution to each vendor. Grape Juice. Two samples of grape juice were purchased and both were found to contain sulphur dioxide. The vendors claimed that as this grape juice was sold without a label required by the second schedule of the Public Health (Preservatives, etc., in Food) Regulations, 1925, its sale was not governed by the fourth paragraph of the first schedule of the Regulations but came within the fifth paragraph of the first schedule which permits sulphur dioxide up to 350 parts per million, and in support of this claim they submitted copy of a communication from the Chambre de Com mcrce Fran (-disc tlr Londres intimating that they had received information that: "The importation in England of unfermented grape juice containing sulphur dioxide is not prohibited if the quantity of sulphur dioxide does not exceeds 350 parts per million, calculated by weight." A communication was addressed to the Ministry of Health on the subject and subsequently a reply was received intimating that unfermented grape juice other than that referred to under Ttem 4 of part 1 of the first schedule of the Regulations of 1925 may contain either sulphur dioxide or benzoic acid in accordance with Ttem 5 and is not required to be labelled. The vendor concerned with the samples in this Borough was therefore informed that the sale of the commodity was not contrary to the Regulations. Raspberrij Jam. One sample of raspberry jam was found to be adulterated by the addition of 10 per cent, of apple matter, no disclosure of the addition thereof being made on the label attached to the container in which the jam was sold. Proceedings were instituted against the vendor, the summons being dismissed on a warranty defence. Proceedings were then instituted against the manufacturers for giving a false warranty. On the hearing of this summons the defendants pleaded guilty and were dealt with under the Probation of Offenders Act, being ordered to pay £10. 10s. Od. costs. Kanla and Lemon Squash. Samples of each of these beverages were examined during the year and found to contain salicylic acid. From information received it appeared that both the Knola and Lemon Squash were supplied to the retailers in this Borough by the same manufacturers; (he attention of Ihe manufacturing company was cnl'od to D 50 the breaches of the Regulations and a communication was received from the company stating that no salicylic acid had been used by them in the manufacture of the commodities since the 1st January, 1927, when Regulations came into operation. They expressed the view that the samples obtained were old stock which had been in the retailer's possession for some time. In order to encourage the early clearance of old stock from retailers' shops, the manufacturing company issued a printed notice to their travellers instructing them to request customers always to sell their old stocks first and, when stocking shops, to place the fresh deliveries behind the old. Minced Meat. A sample of minced beef was found to contain sulphite preservative equal to 0-054 per cent, of sulphur dioxide or 540 parts per million. A communication was received from the vendor admitting the use of the preservative and stating that he understood he was allowed to do so during the summer months. A letter of caution was addressed to this retailer but on subsequent samples being taken they were found to contain boric acid. Proceedings were therefore instituted against the vendor who was convicted and fined £1 18s. Od. with costs £1 3s. Od. Milk. Of the 168 samples of milk purchased and analysed eight were reported as not genuine. In one case where the abstraction of fat was only 2 per cent, no action was taken. In two cases where the abstractions of fat were respectively 3-3 per cent, and 4-6 per cent, letters of warning were addressed to the milk sellers and samples subsequently taken from the same vendors were found to be genuine. In the remaining five cases proceedings were instituted with the following results:— 4-0 per cent, abstracted fat; summons dismissed, Probation of Offenders Act, 21s. costs. 4-0 per cent, abstracted fat; warranty pleaded, summons dismissed. 6-0 per cent, abstracted fat; warranty pleaded, summons dismissed. 9-0 per cent, abstracted fat; defendant convicted, fined 40s. 7-1 per cent, added water; summons dismissed on payment of 21s. costs. Tinned Peas. Twelve samples of tinned peas were examined, one of which was found to contain copper, equal to 1-239 grains per pound of copper sulphate. Evidence was submitted that these tinned vegetables had been purchased by the retailer as free from copper. When the sample was purchased the retailer had remaining in stock 2 tins only and on receiving a communication drawing attention to the presence of the copper he immediately discontinued the sale of this brand. Wine Six samples were taken of sweet white wines; all proved to be genuine. The samples examined were: — Rauternes (Bordeaux) (2). Barsac. Tvoupiac (Yin de Bordeaux). White Port (Australian). Marsala (Italian). 51 In addition to these, two samples, of British wine, one Elderberry and one Raisin, were examined both proving to be genuine. In no case was there any breach of the Public Health (Preservatives, etc., in Food) Regulations. Milk. The following table shows the fat content of the 168 samples of milk :— [###Percentage of Fat. Number of Samples. Shops. Restaurants. Streets. Total. Less than 8 0 4 3 1 8 3.0 6 — 1 7 3.1 13 3 0 18 3 .2 12 3 3 18 3.3 16 3 1 20 8.4 13 1 3 17 3 .5 9 — 3 12 3.6 12 2 3 17 3 .7 11 — 1 12 3 .8 8 1 1 10 3 .9 8 1 1 10 4.0 6 — — 4.1 3 — 1 4 4.2 1 — — I 4.3 I — — I 4 .4 1 — — 1 4 .6 — 1 — 1 4.6 1 — — 1 4.8 1 — — 1 5.0 1 — - 1 5.2 — 1 — 1 6. 3 1 1 2 127 20 21 168 Average 8.53 3.60 3.43 3.58 D 1 52 Eleven per cent, of the samples contained 4 per cent, or more fat. Milk with this fat content does not appear to be uncommon. In 16 cases where the fat content subsequently proved to be four per cent., from observations made at the time of purchasing, the samples showed that in 10 instances the milk was stirred with a hand measure before serv ing. In one case a plunger was used and in two other cases where the milk was served at tables in restaurants plungers are provided and it is probable they were used. In three cases the milk was served from the hand cans of roundsmen and was probably well mixed. Tt is probable that even distribution of milk fat is not secured by casual mixing with hand measures. The use of efficient plungers would secure this end. On the other hand, where there is reason to believe milk is properly plunged, an analysis has shown the presence of over four per cent, of fat. Of the 16 samples referred to above nine were purchased at dairies or milk shops, two in restaurants and three from street vendors. The following table shows the average composition of milk samples purchased during each month of 1927. Number of Samples examined. Total Solids. P er cent, average. Solids Non-fat. Per cent, average. Fat. Per cent, average. January 17 12.28 8.76 3 .5 February 15 12.41 8.82 3.6 March 9 12.47 8.91 3.5 April 15 12.15 6.81 3.3 May 20 12.00 8.7£ 3.2 June 16 12.16 8.85 3.3 July 13 12.23 8.89 3.3 August 10 12.13 8.88 3.2 September ., 12 12.69 8.99 3.7 October 20 12.54 8.81 3.7 Novembe 14 12.88 8.97 3.9 December 7 13.05 8.96 4.1 Whole year 168 12.41 8.88 3.53 Legal Minimum 11.50 8.50 3.00 53 Articles Analysed. Formal Samples. article. Number Purchased Result of Analysis Proceedings taken. Convictions. Fines and Costs. Genuine. Adulterated. Almonds, gr.und 2 2 ... ... ... ... Apples, drif d 2 2 ... ... ... ... Apricots, dried 2 2 ... ... ... ... AsparRgua, tinned 3 3 ... ... ... ... Aspirin tablets 2 2 ... ... ... ... Bacon 5 5 ... ... ... ... Beans, tinned 4 4 ... ... ... ... Bicarbonate of soda 2 2 ... ... ... ... Borax 4 4 ... ... ... ... Boric ointment; 2 2 ... ... ... ... Brandy 2 2 ... ... ... ... Brawn 4 4 ... ... ... ... Bread and butter 4 4 ... ... ... ... Bu'ter 48 48 ... ... ... ... Cake 5 5 ... ... ... ... Calomel ointment 4 4 ... ... ... ... Cayenne pepper 3 3 ... ... ... ... Camphorated oil 3 3 ... ... ... ... Cheese 2 2 ... ... ... ... Christmas pudding 2 2 ... ... ... ... Cinnamon, ground 2 2 ... ... ... ... Coffee and chicory 4 4 ... ... ... ... Coffee extract 4 4 ... ... ... ... Cream 12 10 ... ... ... ... Cream, preserved 11 11 ... ... ... ... Cyder 5 3 ... ... ... ... Cyderade 1 1 ... ... ... ... Dripping 3 3 ... ... ... ... Egg substitute 2 2 ... ... ... ... Elderberry wine 1 1 ... ... ... ... Fish 6 6 ... ... ... ... Fish, fried 3 3 ... ... ... ... Fish paste 5 5 ... ... ... ... Fish, smoked 6 6 ... ... ... ... Fruit, crystallised 6 5 ... ... ... ... Fruit; dried 2 2 ... ... ... ... Gin 2 2 ... ... ... ... Gingerbread 1 1 ....... ... ... ... Ginger beer 2 2 ... ... ... ... Grape juice 8 6 2 ... ... ... Ice cream 6 6 ... ... ... ... Jam 2 1 1 ... dismissed on warranty Costs. £ 10. 10s Do (givin ir false war ranty) ... Ketchup 1 1 ... ... ... ... Kaol 1 0 1 ... ... ... Lard. 2 2 ... ... ... ... Lemonade 3 3 ... ... ... ... Lemonade powder 2 2 ... ... ... ... Lemon squash 1 0 1 ... ... ... Lime juice cordial 4 4 ... ... ... ... Liniment of turpentine 9 9 ... ... ... ... Liqnorice powder 2 2 ... ... ... ... 54 ARTICLE. Number Purchased. Result of Analysis. Proceedings taken. Convictions. Fines and Costs. Genuine. 1 Adulterated. Macaroni 3 3 ... ... ... ... Margarine 13 13 ... ... ... ... Marmalade 3 3 ... ... ... ... Meat paste 3 3 ... ... ... ... Meat patty 2 3 ... ... ... ... Meat pie 1 1 ... ... ... ... Meat, minced 7 4 3 1 1 Fine, 4vJs. Costs. 218. Milk 168 160 8 5 1 Fine, 40s. ... ... ... Costs, 42s. Milk, condensed 14 14 ... ... ... ... Milk, dried 10 10 ... ... ... ... Mincemeat 2 2 ... ... ... ... Olive oil 4 4 ... ... ... ... Paregoric 2 2 ... ... ... ... Pears, dried 2 2 ... ... ... ... Peas, tinned 12 11 ... ... ... • • Peaches, dried 2 2 ... ... ... ... Peel, candied 5 5 ... ... ... ... Pickles 4 4 ... ... ... ... Porter 1 1 ... ... ... ... Prescriptions 4 4 ... ... ... ... Haisins o 2 ... ... ... ... Raisin wine i I ... ... ... ... Hum 2 2 ... ... ... ... Rum and coffee extract 1 1 ... ... ... ... Sauce 3 3 ... ... ... ... Sausages 10 10 ... ... ... ... Sausage roll 1 1 ... ... ... ... Shrimps 1 1 ... ... ... ... Spongecake 9 9 ... ... ...... ... Stout 1 I ... ... ... ... Suet, shredded 7 7 ... ... ... ... Sugar 3 3 ... ... ... ... Sultanas 4 4 ... ... ... ... Sweets 5 5 ... ... ... ... Swiss roll 1 1 ... ... ... ... Tea dust 3 8 ... ... ... ... Tincture of iodine 2 2 ... ... ... ... Tomato puree 1 1 ... ... ... ... Treacle 2 2 ... ... ... ... Vinegar 3 3 ... ... ... ... Whisky 2 2 ... ...... ... ... White precipitate ointment 3 3 ... ... ... ... Wine 6 6 ... ... ... ... Zinc ointment 3 3 ... ... ... ... Total 560 541 19 8 2 Fines. £1 Costs, £13 13s. 55 In addition to the proceedings recorded above, three summonses were issued in connection with samples purchased in the year 1926, viz., two connected with jam (one for the sale of jam with 10 per cent, apple matter and one for giving false warranty) and one for milk 32-0 per cent, deficient in fat, details of legal proceedings are given in Table, page 137. Informal Samples. article. Number Purchased. Result of Analysis. Proceedings taken. Fines and Convictions. Genuine. | Adulterated. A gar-Agar 3 0 3 ... ... Apples, dried 1 1 ... ... ... Apricots, dried 1 1 ... ... ... Bicarbonate of soda 1 1 ... .... ... Borax 1 1 ... ... ... Butter 2 2 ... ... ... Cheese 1 1 ... ... ... Coffee 1 1 ... ... ... Coffee extract 1 1 ... ... ... Crab, dressed 1 1 ... ... ... Cream cheese 1 1 ... ... ... Custard powder 1 1 ... ... ... Fish paste 1 1 ... ... ... Fried fish batter 3 1 ... ... ... Jam 7 1 ... ... ... Juvis 1 1 ... ... ... Jelly powder 1 1 ... ... ... Lemon curd 1 1 ... ... ... Marmite 1 1 ... ... ... Nectarines 1 1 ... ... ... N utmarto 1 1 ... ... ... Pears, dried 1 1 ... ... ... Peas, tinned 1 1 ... ... ... Plums, dried 1 1 ... ... ... Sauce 1 1 ... ... ... Soup 1 1 ... ... ... Sponge mixture 1 1 ... ... ... Swiss roll 1 1 ... ... ... Total 39 35 4 — — Total all Samples 599 576 23 — — 56 PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. The relative importance of the commoner infectious diseases as regards number! of deaths caused is shown by the following table :— ENGLAND AND WALES. Common Infectious Diseases. Deaths at all Ages. 1917. 1918. 1919. 1820. 1921. 1922. 1923. 1924. 1925. 1926. Yearly average 1917-1926. Pneumonia (all forms) 39,832 59,666 38,949 37,149 34,708 40,930 33,413 38,970 36,990 32,339 39,294 Pulmonary Tuberculosis 42,335 45,338 35,984 32,791 33,505 33,919 32,097 32,690 32,382 30,108 35,115 Measles 10,538 9,787 3,534 7,190 2,241 5,694 5,316 4,834 5,337 3,483 5,795 Whooping Cough 4,509 9,898 2,605 4,401 4,576 6,370 4,162 3,983 6,058 4,118 5,068 Diphtheria 4,477 4,803 4,888 5,648 4,772 4,075 2 722 2,501 2,774 2,994 3,965 Scarlet Fever 768 1,020 1,221 1,430 1,305 1,382 993 888 988 677 1,067 Enteric Fever 977 950 577 537 613 465 450 496 388 367 582 57 The total number of notifications relating to Holborn residents received during the year was 400 in comparison with 416 in the year 1926. Attention has had again especially to be called to the non-notification of whooping cough, primary pneumonia and ophthalmia neonatorum. A special reference card with complete list of notifiable diseases is supplied to all doctors practising in the Borough. In addition to the above there were received 218 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 218 notifications so received were as follows:— Diphtheria 89 Scarlet Fever 25 Whooping Cough 3 Pneumonia 3 Erysipelas 2 Cerebro-spinal Meningitis 7 Infantile Paralysis 1 Tuberculosis 84 Enteric Fever 4 218 Smallpox. No case of smallpox was notified in the Borough during the year; five cases of the disease were notified in London. Information of 12 passengers or staff arriving on vessels on which smallpox had occurred during the voyage or which came from infected ports was received and, where practicable, the necessary visits for keeping such contacts under observation were made. In three of the cases the addresses given in this Borough were at hotels or boarding houses. In two cases the addresses or the names given could not be traced. In the remaining cases the travellers were seen and found to be in good health. In six cases re-vaccination had been carried out on board the ships and in two other cases the passengers had been re-vaccinated within the previous two years In April, 1927, several cases of smallpox occurred in a London suburb. Information was received that contacts of these cases visited two large drapery establishments in a Metropolitan Borough. One at least of such contacts subsequently developed smallpox and it was stated, was unwell at the time of the 58 visit to the drapery establishments. Shortly after it was reported to me that a member of the staff in each of the two establishments, engaged in the departments visited by the patient and the contacts, was away ill, the home addresses of both being in this Borough. On enquiry at the home address in the first case it was ascertained that this contact had removed temporarily to Reading; communication by telephone was at once made with the Medical Officer of Health of Reading so thai the contact could be visited. In the second case also it was ascertained that the contact had left London for a day or two leaving no address. Both contacts returned to their addresses in this Borough and were kept under observation for the necessary period, after which they returned to work. In May information was received respecting a case of smallpox which occurred in London where the patient was stated to have taken part in a theatrical performance. It was ascertained that two seats had been reserved for a resident in this Borough and it was stated that this Holborn resident had probably been on the stage during the performance. On enquiry, however, it was ascertained that although tickets for the seats had been obtained by the Holborn resident they had in fact not been used. Vaccination. The following table kindly supplied by the Vaccination Officer of the Holborn Union on the 19th March, 1928, 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, 1927 198 83 19 31 0 21 25 19 St. Giles and Bloomsbury Sub-District: 12 months ended 30th June, 1927 121 55 13 13 0 13 15 12 319 138 43% 32 44 0 34 40 31 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. Diphtheria. Notifications relating to 54 cases of diphtheria occurring in residents in the Borough were received. All but one were removed to hospital. Nine were found not to be suffering from diphtheria, and one case, notified from a hospital staff, was notified as a "carrier" only. 59 Of the 44 cases of diphtheria:— 1 was under 1 year. 13 were 1 to 5 years. 15 „ 5 „ 15 „ 12 „ 15 „ 25 „ 1 was 25 „ 45 „ 2 were, 45 „ 65 „ One death occurred. Thirteen "secondary" cases were notified. A "secondary" case is one occurring in the same household as the primary case. Eleven of the 13 "secondary" cases were nurses at hospitals in the Borough; from the same hospitals 50 in-patients were notified as suffering from diphtheria, none of these was resident in the Borough. Two of these were notified as carriers only, and eight as " nasal " diphtheria. One "return" case was notified 11 days after the return home of the primary case from hospital. Six days after the return home of the primary case the mother of the primary patient, with a baby aged three months, was admitted to a hospital suffering with tonsilitis. Five days afterwards the baby was notified as suffering with diphtheria and was removed to a hospital of the Metropolitan Asylums Board. The mother and baby both died, the cause of death in the case of the mother being given as "septic tonsilitis and septic pneumonia," and of the baby as "diphtheria." In London 12,183 cases were notified giving rise to 387 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 diphtheria or scarlet fever. Diphtheria in Hospitals. During the year notifications were received from two hospitals in the Borough of 61 cases of diphtheria. Of the 61 cases, six were reported as "nasal" cases and three as harbouring diphtheria bacilli. Fifty of the cases were in-patients, all being non-residents of Holborn. The remaining 11 were nurses on the staffs of the hospitals; of these ten were clinical diphtheria, and one harboured diphtheria bacilli. The number of cases of diphtheria occurring from year to year amongst the nursing staff of hospitals suggests the need for the immunisation of hospital nurses. It would seem to be obvious that fever hospital nurses should be protected against diphtheria and it is difficult to avoid the conclusion that all hospital nurses, nursing in children's wards, should be immunised. It must be within the experience of many that nurses in children's hospitals and subsequently the children themselves are often attacked. The possible objection that a nurse would have to be immunised against diphtheria, scarlet fever and typhoid and paratyphoid fevers does not carry much weight. Many during the war were immunised against more diseases than these 60 —those going Bast were protected against smallpox, typhoid and the paratyphoid fevers, cholera, dysentery and plague. Who can show that they suffered any harm by taking advantage of the progress of science? The Schick test and immunisation against diphtheria is already being successfully applied to the nursing and domestic staffs in certain hospitals, including those of the Metropolitan Asylums Board. Moreover it is becoming more and more the rule for nurses on the staffs of infectious diseases hospitals to be immunised against the diseases they might contract as the result of their being in contact with infectious patients. Diphtheria Contacts. Bacteriological Examination of Nose and Throat Swabs. Total Contacts swabbed 32 Negative 6 Positive 26 (12.5 per cent.) Contacts swabbed. Positive Results. Nose and Throat. Nose only. Throat only. Contacts positive. First Examination 32 — 6 — 6 Second ,, 6 1 2 — 3 Third „ 3 — 3 — 3* Fourth ,, — — — — — The swabs from these contacts were tested for virulence and found nonvirulent. The parents or others in charge of children harbouring diphtheria bacilli were given written directions as to the precautions necessary. The results of the examinations of child contacts were communicated to the School Medical Department of the London County Council so that children harbouring diphtheria bacilli could be kept from school providing there was no evidence that the organisms were avirulent. Three virulence tests were made in 1027, all being found avirulent. Diphtheria antitoxin was available free of charge on application by medical practitioners. 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. Inquiries 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. 61 Information as to the work carried out for six years, ending December, 1927, follows:— TABLE I. HOLBORN MUNICIPAL INFANT WELFARE CENTRE, 1922, 1923, 1924, 1925, 1926, 1927. Ages of Persons Schick-Tested with Result of Test. Ages. 0 to 12 months 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 years 7 to 8 years 8 to 9 years 9 to 10 years 10 to 11 years 11 to 12 years 12 to 13 years 13 to 14 years 14 to 15 years 15 and above years Total for 6 years, 1922-27. 80 226 153 123 94 73 61 51 42 55 43 29 24 28 4 75 = 1161 Result or Schick Test Pos. Neg. Pos. Neg. Notread Pos. Neg. Pos. Neg. Notread Pos. Neg. Notread Pos. Neg. Notread Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Notread Total for 6 years. 74 6 215 8 3 146 7 105 17 1 67 25 2 47 24 2 44 17 38 13 26 16 24 31 22 21 15 14 11 13 9 19 2 2 29 42 4 874 Pos. 275 Neg. 12 Not read. TABLE II. Ages of Persons Immunised. Age. 0 to 12 months 1 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years 5 to 6 years 6 to 7 ears 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 6 years 64 181 119 86 54 37 46 35 20 21 17 13 8 5 2 12 = 720 62 TABLE III. HOLBORN MUNICIPAL INFANT WELFARE CENTRE. Schick Test and Diphtheria Immunisation. Six years, 1922-23-24-25-26-27. Total Tested. Rresult of Test. A B Immunisation of Positives. C D E F G Negative. Positive. Not read. Found NEGATIVE to Re Schick Test after Found NEGATIVE to Re Schick Test after First immunised with T A. F. and found NEGATIVE to Re Schick after Found POSITIVE to Re Schick Test after 3 ccm T. A.T. or T.A.F. Total Re Schick Tested Given 3 ccm T.A.T or T.A.F. Not Retested. Failed to complete 3 inoculatns. Inoculatns. not begun. Inoculatns. still in progress. Given 1 ccm not yet Re-tested. 1 ccm T.A.T 2 ccm T.A.T 3 ccm T.A.T or T.A.F. 4 ccm T.A.T. 6 ccm T.A.T 6 ccm T.A.T 8 ccm T.A.T Further doses of T.A.F. 3 ccm T.A.T. Given further inoculation but not yet Retested. No further inoculation given. C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A C A c A 1087 74 231 44 847 27 9 3 16 0 16 1 439 5 19 0 8 1 8 0 1 0 3 0 2 0 23 1 10 2 544 11 152 0 72 5 63 10 3 1 13 0 1,161 †††† 275 874 ††† 12 16 17 444 19 9 8 1 3 2 24 12 555 †† 152† 77 73 $ 4 13 * These columns refer to 78 cases—88 were Schick positive on Retesting after S ccm T.A.T. 10 were Schick positive on retesting after T.A.F. † 42 of these removed from the Borough. $ 9 of these have removed from the Borough, †† These retests include those made up to 21st March, 1S28. ††† 21 of these positives in 1927 were given T.A.F. instead of T. A.T. (see page 67). †††† Includes 13 children under two years who were considered positive without being tested. Note.—Columns BC 1>E give details of the total 555 given in Column F. Columns F G give details of the total 874 positives given in Column A. 63 [n view of the satisfactory results obtained by R. A. O'Brien in the Holborn (Poor-law) schools, arrangements were made in 1922 to render the measure available for the general child population of Holborn. The results obtained are summarised in Tables I., II., and III. The results of the Schick testing were very much the same as those found in all other urban areas; we have, however, analysed them in connection with the immunity to diphtheria of various members of the families dealt with. The last column in Table IV shows the number of exceptions (9.2 per cent.) to the expectation that positive reactions will be manifested only in the younger members. TABLE IV. No. of children in family. No of families. Of which the members are— All Schick positive. All Schick negative. One or more elders negative, younger positive. One or more elders positive, younger negative. 2 146 112 10 17 7 3 60 35 5 14 6 4 19 8 — 6 5 5 10 2 — 5 3 6 3 1 — 2 - 7 2 — — 1 1 — 240 158 15 45 22 In one family of five children, twins (F.) of 2-3 years of age were both positive; of twins of 7-8 years, one (M.) was positive, the other (F.) was negative. In one family of three children one twin (M.) was negative, the other (F.) waa positive; the latter had already been in hospital with diphtheria. In another family, twins, one male aged 2 years when tested and one female aged 6 years when tested were both Schick positive. In one family of five, all Schick positive to the first test, two members were found to be Schick positive to the second test. The first of these (F. 4) was immunised some months 64 previously to the second one (M. 1), and both were further inoculated, and were negative to the second test. In another family of six (Fs.), all Schick positive to the first test, the eldest only was Schick positive to the retest; this child was still Schick positive after a second course of 3 c.cin.; she became Schick negative after a total of 8 c.cm. had been given. Routine Procedure. The routine of the procedure carried out is as follows. The child is Schick tested at the Council's Maternity and Child Welfare Centre, and if susceptible, to diphtheria is brought up by the parent at weekly intervals for the next three weeks for immunisation, and then at the end of another three months (formerly we tried for the period six to eight weeks) for re-Schick testing, when, if it is still positive, it receives further inoculation. A modification of the routine occurs if from the Schick test it is seen that the child is particularly susceptible to protein reactions; in this case the 3 c.cm. of toxoid antitoxin mixture are given in four or five dopes at weekly intervals; again if in older children the Schick reaction is very faint, it is sometimes considered that 1 c.cm. will be sufficient; the retest as a rule confirms this. Some difficulty has been experienced in securing the necessary number of immunising injections owing to families removing from the district; some of these, however, attend to finish the course. A few adolescents at times fail to complete the course by reason of being employed and it no longer being convenient for them to attend. Although Park and Zingher recommended some time ago that Schick testing should be applied only to children over five years, it seemed inadvisable for some time to dispense with the test as a routine in Holborn. It was a great satisfaction to nervous parents to think that there would be no inoculation unless susceptibility was proved. Now that immunisation is being given at other welfare centres in London, it is easier to dispense with Schick testing of very young children and at the end of 1927, thirteen children under five were immunised without a preliminary test, and now nearly all the children under five attending are being immunised without a preliminary test. The following table gives particulars of 555 cases retested, of whom 78 were found to be still Schick positive after three inoculations:— 65 TABLE V. Re-Schick tested after an interval of years or fraction of years. Number re tested after this interval. No. found positive. Age in years and sex of positives when first tested. Negative to 2nd re-Schick test and lotal of T A.T. or T. A. F. given in all. Total 556 (250 305) 78 M. 32 F. 46 37 T.A.T. + 5 T.A.T. M F 5/52 10 ( 6 4) 1 13, F. Neg.; 4 c.cm. 6/52 3(1 2) - — — 7/52 6(4 2) - — — 2/12 26 (13 18) 4 (a) 9, M. Neg. ; 6 c cm (b) 5, M. (T.A.F.) — (c) 1, F. Neg. ; 1.1 T.A.F. (d) 1, F. Neg. ; 1.1 T.A.F. 2½/12 16 ( 5 11) 1 — — (a) 6, F. Neg. ; 3 T.A.T. + 0.5 T.A.F. 3/12 117 (53 64) 14 (a) 8, F. Neg. ; 4 c.cm. (b) Ad., F. — (c) 3, M. — (d) 9, M. Neg. ; 4 c.cm. (e) 6, M. Neg. ; 6 c.cm. (f) 11/12,M. Neg. ; 4 c.cm. (g) 5, M. - (h.) 2, M. - (i) 5, F. Neg. ; 6 c.cm. (j) 7, F. — (k) 6, F. — (l) 6, M. — (m) 7, F. - (n) 4, F. — 3½/12 21 ( 9 12) 2 (a) 4, F. Neg. ; 5 c cm. (b) 1, F. Neg. ; 5 c.cm. 4/12 66 (31 35) 11 (a) 4, F. *Neg. ; 4 c.cm. (b) 6, F. Neg. ; 8 c.cm. (C) 10/12,M. Neg. ; 4 c.cm. (d) 2, F. Neg. ; 5 c.cm. (e) 1, F. Neg. ; 5 c.cm. (f) 6, F. — (g) 4, F. Neg. ; 5 c.cm. (h) 1, M. Neg. ; 1 c.c. T.A.F. (i) 1, F. Neg. ; 5 c.c. T.A.F. + 3 c.c. T.A.T. (j) 6, M. Neg. ; 4 c.c. T. A.T. (k) 7F. — 4½/12 4(0 4) 2 (a) 5, F. Neg. ; 6 c.cin. (b) 2, F. Neg. ; 4 c.cm. 5/12 36 (14 22) 5 (a) 2, F. Neg. ; 6 c.cm. (b) 2, M. Neg. ; 4 c.cm. (c) Ad.. F. - (d) 3 M. - (e) 1 F. - 6/12 38 (18 20) 8 (a) 1, M. - (b) 2, M. Neg. ; 5 c cm. (c) 3, M. — (d) 4, F. Neg. ; 5 c.cm. (e) 2, M. - (f) 6, M. Neg. ; 4 c.cm. (g) 3, M. Neg, ; 6 c.cm. (h) 3, M. — 7/12 20 ( 8 12) 1 9, F. Neg. ; 6 c.cm. 8/12 11 1 4 7) 2 (a) 11, F. — (b) 1, F. — 9/12 12 ( 8 4) 3 (a) 1, M. — (b) 8, M. — (a) A.M. E 66 TABLE V—continued. Re-Schick tested after an interval of years or fraction of years. Number retested after this interval. No. found positive. Age in years and sex of positives when first tested. Negative to 2nd re-Schick test and total of T.A.T. or T.A.F. given in all. 10/12 13 ( 5 8) 1 4. F. †Neg. ; 5 c.cm 11/12 5(3 2) 1 1, M. Neg ; 4 c.cm. 1 7(1 6) 1 9/12 F. Neg. ; 4 c.cm. 1.2 84 (41 43) 15 (a) 1, F. Neg. ; 4 c.cm. (b) 2, M. Neg. ; 4 c.cm. (c) 2, M. — (d) 2, M. Neg. ; 4 c.cm (e) 2, F. Neg. ; 4 c cm. (j) 6, M. Neg. ; 4 c.cm. (g) 7, F. Neg. ; 4 c.cm. (h) 8, F. — (i) 9, M. - (j) 9, F. — (k) 11, F. — (l) 12, M. — (m) 12, F. — (n) Ad., F. Neg. ; 5 c.cm. (o) 1, F. Neg ; 4 c.cm. 2.3 60 (26 34) 6 (a) 2, F. Neg. ; 6 c.cm. (b) 5, F. Neg. ; 4 c.cm. (c) 12, F. — (d) 2, F. — (e) 1, M. — (f) 2, F. — Total 555 (250 305) 78 M. 32 F. 46 37 T.A.T. + 5 T.A.T. * Another child in same family (F.), aged 4 years, was negative. † Three children in this group were members of one family: 2 negatives (M.), aged 2 years, (F.), aged B years; 1 posiiive (F.). aged 4 years. In addition, one child re-Scliiek tested 15 months after 1 c.cm. T.A.T., was found positive and two children retested after 3 c.cm. were on the information given by the mother considered to be slightly positive. Sixty-six of those positive on re-Schicking have been further inoculated, and 42 of them further tested and found negative. Efforts are being made to continue the inoculation of the remainder. As seen in the footnote to Table V one child (F., aged 4 years) was positive to the second re-Schick after 6 c.cm., but was negative after 8 c.cm.; this child was the eldest of four girls; the three younger ones were negative after the routine 3 c cm.; two of these receiving their routine injections on the same day and from the same batch of antitoxin as the eldest. Of the 555 persons retested, 250 were males and 305 were females. Among the positive were 32 males and 46 females. Neither age nor interval seems to have any influence on the phenomenon. It would seem conceivable that some batches of toxin antitoxin might prove to be less efficacious than others. An analysis of the results obtained in Holborn would seem to indicate clearly that this is so; also that the toxoid antitoxin used was as efficacious as the toxin antitoxin. The toxin antitoxin mixtures used were all 3 L + per c.cm. mixtures, tho toxoid antitoxin contained toxoid diluted 1-10 with added antitoxin. (Table VI.) Use has also been made of T.A.F. (flocculated toxin-antitoxin) in the case of 23 persons found Schick positive. Of these 23 persons, 21 have been retested; be noted that in five of these children the reaction to the first test was so slight that they were recorded as suitable for immunisation with only one dose if T.A.T. 11 of these (nine children and two adults) were negative to the retest. Tt should had been used. Ten (nine children and one adult) were po itive to the re-Schick test; of these, six were further inoculated with T.A.F. (three of these were negative to the second re-Schick), four were further inoculated with toxin-antitoxin (two of these were negative to the retest). The use of T.A.F. has been discontinued for the time being. 67 TABLE VI. Batches of Toxin Antitoxin and Toxoid Antitoxin and the Flocculatea Antitoxin Coin pared. Designation of batch of immunising mixture. No. of persons inoculated and retested. No. of these persons found positive on retesting. Toxin antitoxin mixture B. 346 59 2 B. 475 28 3 B. 654 28 1 B. 671 74 18 B. 671A 2 1 B. 672A 30 2 B. 617 35 2 B. 675 1 - B. 672 1 — T oxoid antitoxin mixture B. 1017 33 4 B. 1090 16 1 B. 1038 13 — B. 1018 43 10 B. 1129 18 3 B. 995 10 - B. 1148 8 2 B. 1197 22 9 B. 1198 15 3 B. 1205 17 3 B. 2060 3 - B. 2079 31 — B. 2081 15 — B. 2230 1 — B. 2309 4 1 B. 2320 17 2 B. 2525 11 — B. 3377 7 - B. 3378 2 1 Flocculated antitoxin mixture T.A.F. 21 10 Total 555 78 Retesting. Betesting is unpopular with parents, and the need for it does not help to increase their confidence in immunisation. Of 555 that have been retested 68 were found to be still Schick positive after three inoculations and ten after T.A.F. The facts relating to these are given in Table V. That considerable importance attaches to the retesting is shown by the fact that our six cases of diphtheria among those treated occurred in children who were given the routine three injections, but had not been retested. Diphtheria in Children Treated with Immunising Injections. Up to the end of the year 1927 six cases of diphtheria occurred in children who had been found positive on Schick test and treated with three immunising injections. Diphtheria was also notified as having occurred in three other children who had completed their course of inoculation, but the diagnosis in these cases was eventually not confirmed. Two of these (brother and sister) were removed to M.A.B. hospitals as suffering from diphtheria, but they were diagnosed as suffering from rubella and "carrying" diphtheria bacilli but not as suffering from diphtheria. Both these children had been found negative to the re-Schick test some time pieviouslv. The third was removed to M.A.B. hospital as suffering from E 2 68 diphtheria, but was shortly afterwards discharged as not a case; he had not been re-Schicked since being inoculated, but after his return from hospital gave a negative reaction to the re-Schick test. The following table gives particulars of the six cases of diphtheria:— DIPHTHERIA IN CHILDREN SCHICK TESTED and Treated with Immunising Injections. Initials Age in yearsut date of Schick Test Sex Type of Home Date of Schick Test First In jection Final Injection Retest Result of Retest Date of onset of Diphtheria Interval between last injection and date of onset of disease Confirmation of diagnosis by Character of Attack 1. A.C. 4 4/12 M. Artizan— moderately satisfactory; house let in lodgings 30/1/24 7/2/24 20/2/24 Third, none — 18/3/25 13 months Metropolitan Asylums Board (N.E. Hospital) Very severe 2. G.L. 6 5/12 M. Higher Artizan— model dwellings 4/4/23 11/4/23 25/4/23 (Third) none — 29/5/25 13 months Metropolitan Asylums Board (N.E. Hospital) Very mild 3. M.T. 3 3/12 F. Higher Artizan— model dwellings 24/9/24 1/10/24 15/10/24 (Third) none — 5/4/26 18 months Metropolitan Asylums Board (N.E. Hospital) Mild 4. L.P. 6 8/12 F. Higher Artizan— part of private house 11/11/26 17/11/26 1/12/26 (Third) none — 23/12/26 22 days* Metropolitan Asylums Board (N. W. Hospital) Severe 5. R.H. 7 M. Residential, separate private house 28/9/27 5/10/27 19/10/27 (Third) none — 21/10/27 2 days* Cuddington Isolation Hospital Mild 6. P.P. l 8/12 F. Artizan— model dwellings 5/9/23 12/9/23 26/9/23 (Third) none — 26/10/27 4 years Metropolitan Asylums Board (N.E. Hospital) Mild *These two cases occurred before the elapse of 9 months, the period laid down at Edinburgh as required to secure this artificial immunisation. The above table shows that none of the children was retested after the last injection and emphasises the importance attached to retesting. It cannot be assumed tbat immunity invariably follows the administration of three immunising injections. 69 Reactions. Our experience is that the reaction after the injection of the toxin antitoxin and toxoid antitoxin is in practically every case negligible. All we have to record is that on one child considerable swelling of the whole of the arm occurred, but the next day when at the centre, she was running about and helping the other children eat their cakes ; the swelling went down without any further result. Another, a boy of 10 yenrs of age, his mother informed me, suffered with vomiting after each of his three inoculations and spent the next day in bed, but he and his mother stuck to it, and be was subsequently proved to have been satisfactorily immunised. In another child, a small, hard, sliphtly tender nodule developed above the external condyle, but the tenderness only remained for a few days. The use of toxoid antitoxin does away with the risk of fatality incurred by using improperly made toxin antitoxin. What of the Future ? Most of the attendances are the result of repeated efforts of peisuasion and encouragement. Prejudice against inoculation is widespread; some of the most stubborn opponents of inoculation admit that if T.A.T. could be given in tabloid form or in spoonfuls they would agree to it. They object, in fact, to the introduction of animal products by means of a hypodeimic syringe into the human body, but continued propaganda is sure to produce its results. The aim of every ;ne who takes up the work must be to get all the children living in the area immunised as soon after they reach the age of 6 months as possible. In Holborn we have not reached tiiis stage yet; the history of vaccination against small pox suggest® we never shall. But a local health authority is justified in considering that it has done all in its power to prevent loss of life and illness from diphtheria if it offers immunisation, supported by necessary advice and information to parents. It might be expected that if the immunisation were carried out among the school population in a large town the parents would come to regard the procedure as more ordinary, and be prepared to allow the younger children to be immunised at infant welfare centres. Apparently it cannot be too often repeated that it is immunisation at a very early age that we want carried out; if it is delayed till school age half the deaths will have occurred. In London during five years 1921-25, of the total deaths from diphtheria, 57 per cent, occurred under five years of age. Certainly if the immunisation could be completed at one visit the energy spent iii looking up those failing to attend could be used in getting new recruits, and tJifi parents would be spared much trouble. The decision of the London County Council not yet to take up the matter of diphtheria immunisation in the schools though willing to help the work started in the various boroughs, by affording facility in the schools for the circularisation of information to parents, was somewhat of a disappointment to several Medical Officers of Health of Metropolitan Boroughs. Where a Borough Council has definitely decided in favour of diphtheria immunisation and offers it to children 70 under live years of age, each )oung child is brought to the 1 minimisation Centre as a result of individual effort, but the organisation of a public elementary school lends itself so easily to the mass immunisation of a large body of children that it seems very unfortunate that the Borough who has approved the principle should lose this advantage. It should be pointed out that the results obtained in Holborn from antidiphtheria immunisation are not necessarily those which would be obtained from the widespread practice of the procedure throughout the whole of the country. It is a commonplace in the public health world that satisfactory statistics cannot be compiled from a relatively small number of cases. If we are to reduce the incidence of diphtheria further we are to all intents and pin-poses forced to employ a method of this nature and for this reason. Diphtheria is a very difficult disease to control; it is spread mainly by healthy ' carriers," that is to say, by healthy persons who harbour virulent diphtheria bacteria chiefly in their throats or noses or both, these bacilli are often passed on during the act of coughing or even loud speaking, or perhaps for a very short distance by ordinary breathing, especially in the case of overcrowded vehicles or passenger lifts, or by means of incompletely cleansed drinking vessels or eating utensils placed in the mouth such as spoons, forks, etc. Anti-diphtheria immunisation is worthy of an extensive triai. The procedure has already gained wide acceptance in the United States of America; other countries nearer home, such as Germany, France and Belgium are immunising their children in this way. In these islands it has proved its worth as a means of preventing diphtheria in hospital nurses and in stamping out diphtheria in institutions where the disease has been present for a considerable time and has given rise to case after case. The Edinburgh statistics relating to school children are, to say the least, verv encouraging. The control of smallpox obtained by vaccination is so complete that progressive members of the medical profession have been stimulated to obtain a similar control of other infectious diseases including not only diphtheria, but also scarlet fever and measles, and the measure of success already obtained in controlling diphtheria warrants further effort. We used to be asked: If it is such a good thing why are not other people doing it as well as Holborn?" We now fortunately are able to say that Battersea, Beckenham, Camberwell, Finsburv, Deptford, Lambeth, St. Marylebone, Stoke Xewington and Westminster are also doing it and others are considering it. In Manchester the Public Health Committee has reaffirmed it- approval of a report by the Medical Officer of Health of Manchester respecting immunisation against diphtheria. The Medical Officer of Health recommended that a scheme for the free inoculation of children be put in operation by the Public Health Committee acting with the Education Committee at the School Clinics, the Welfare Centies, and the civic buildings, only children being treated whose parents permitted. The following table shows the diphtheria notification rates in England and Wales, London, and Holborn during the five years 1922-26. As the Schick test 71 and immunisation against diphtheria were started in Holborn in the early part of 1022 the figures are of interest: — Diphtheria—Notification rate per 1,000 population. England and Wales London Holborn 1922 1.37 3.37 2.52 1923 1.05 2.27 2.25 1924 1.07 2.31 1.58 1925 1.23 2.73 1.75 1926 1.31 2.96 1.69 The figures for England and Wales and London are taken from the RegistrarGeneral 's Statistical Reviews for the years 1922-26. Diphtheria in London Elementary Schools. A summary of the prevalence of infectious diseases in the London Elementary Schools during a period of 22 weeks ended 24th December, 1927, has b:en prepared by the London County Council. The following information, extracted from the summary, shows the very low diphtheria rate in the Holborn schools in comparison with the rest of London. Diphtheria School Rate per 1,000 children. London County 4.2 Highest Borough rate 8.7 Lowest Borough rate (Holborn) 0.7 Scarlet Fever. There were 59 notifications of scarlet fever. All but 2 were removed to hospital. Seven notifications of "secondary" cases was received, all being nurses at hospitals in the Borough; from the same hospitals 17 in-patients were notified as so suffering. None was resident in Holborn. No "return " cases were notified. There was no death from this disease. 13,178 cases of scarlet fpvpr were notified in London with 63 deaths. 72 Enteric Fever. 1'our cases of enteric fever were notified during the year; none died. the facts relating1 to the cases are as follows: — Case No. 1. The patient was a professional man, aged 63 years, residing in a good class flat. He first became ill about the middle of April and was notified as suffering from Enteric Fever on the 7tli May. The Widal test gave a negative result. No definite source of infection could be ascertained but it was stated that the patient caught cold whilst playing golf a few days before the first symptoms of the illness and subsequently he developed symptoms resembling those of influenza, and these were followed by gastric trouble. Case No. 2. This patient was a male, aged 22, residing in a good class residential house. The Widal test gave a positive result. The patient became ill about the third week in November. He was reported to have had a high temperature for two or three days, a month prior to his illness, again two weeks later, and again two days before the definite symptoms of Enteric Fever developed. This patient had partaken of shell-fish, oysters in the early part of November but other members of the family also partook of oysters from the same batch at the same time and suffered no illness. Communications, however, were sent to the large Stores from which the oysters were obtained and after enquiries the Secretary of the Company intimated that they had sold a very large number of oysters since the beginning of the season but no complaint of any description had been received in connection therewith. It would, therefore, seem difficult to associate this case of Enteric Fever with the consumption of these shell-fisli. Cases Nos. 3 and 4. These patients were nurses, aged 29 and 20 years respectively, working in a hospital in the Borough and were notified, one on the 7th and the other on the 14th of December. Both gave a Positive reaction to the Widal test. On enquiry iT. was ascertained that both patients had worked in the same ward during the month prior to their illness. An examination was therefore made of all the patients in the ward concerned and it was found that one patient, a child of 5½ years, gave a positive reaction to the Widal test. Her serum agglutinated the Oxford Standard B. typhosus in dilutions 1-25, 1-50, 1-125 and 1-250—the reaction to Oxford Para B. and Para C. were completely negative. On five consecutive examinations of her stools no B. typhosus were found, her urine remained negative also, and there were no clinical symptoms of Enteric Fever. This patient had been admitted to hospital on the 11th November with acute appendicitis and the Resident Medical Officer of the hospital stated that there were no symptoms of typhoid while she was a patient in the hospital, the reaction being tested only because of the other cases which had occurred in the ward. Further, this child did not appear to have shown any signs of ill-health until November, when the symptoms of acute appendicitis began. The home address of this patient was outside the County of London and information '.especting the matter was sent to the Medical Officer of Health of the district in which the child resided. Tn reply, information was received that a brother of this child had been admitted to an isolation hospital in October suffering from Enteric Fever. This boy was discharged from hospital on November 28th. Prior to his discharge examination of his excreta for the presence of typhoid and paratyphoid organisms gave a negative result. A further case a-sociated with this small outbreak was notified on January 20th, 1928, the patient being a nurse wha had been working in the same ward from the early part of December until she was taken ill about the 1st January. Enteric Fever, however, was not definitely diagnosed until two weeks later. In addition to the foregoing, two other cases occurred among in-patients in hospitals in the Borough, the home address of one patient being in another London Borough and that of the other outside the County of London. In both these instances the onset of the illness commenced before admission to hospital so that the disease was in both instances contracted before the patients came into this Borough. 322 cases were notified in London with 27 deaths. 73 Typhus Fever. No case of typhus fever was notified during the year, either in the Borough or in London. Cerebrospinal Fever. No.case of cerebro-spinal fever was notified. 93 cases were notified in London. Dysentery. No case of dysentery was notified. Reference to the Infectious Diseases (London) Regulations, 1927, dealing with dysentery will be found on page 76. 24 cases were notified in London. Malaria. No case of malaria was notified (see also page 76). 65 cases were notified in London. Encephalitis Lethargica. No case of encephalitis lethargica was notified in the Borough during the year. 142 cases were notified in London. The following table gives information up to the end of 1927 respecting the 11 real cases of encephalitis lethargica notified in the Borough since the Public Health (Encephalitis Lethargica) Regulations came into force on the 1st January, 1919: — Date of Notification. 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 Gone to Australia. Complete recovery reported 9/7/24 F.H. 7 years Complete recovery 26/9/24 B.V. 53 years Died 21/9/24 4/5/25 C.S. 28 years Right leg partially paralysed, but walking improving; right arm tremulous; now quite cheerful 29/5/26 H.P. 33 years Died 30/5/26 The table excludes one case notified 15/11/24 who was subsequently found not to be suffering from this disease. In the early part of the present year, February, 1928, a communication was received from the Medical Officer of Health of the London County Council respecting non-notified cases of encephalitis lethargica. Information of such cases in the Borough was forwarded in order that where the patients were not of school nge 74 I hey could be kept under observation in the same way as notified cases. Two such cases reside in the Borough, both of whom were visited. In the first case (P.L.) the illness commenced in 1920 and was reported to have started with " sleepy sickness," and at the end of 1927 the following report was made by the visitor:—" The left arm appears paralysed, but patient's sister states that the patient uses it when angry. He is very dull when spoken to, but after a time answers intelligently. No special treatment is being given." The second case (W.P.) also commenced in 1920. The visitor reports that: " This patient can do nothing for himself. Eight arm paralysed; does not walk; mouth open, but tongue not out. The patient attends hospital monthly." Information respecting two other non-notified cases was also furnished by the Medical Officer of Health of the London County Council, but these patients are still of school age, and according to the arrangements in force are supervised by the L.C.C. Acute Poliomyelitis. No case of acute poliomyelitis or polioencephalitis was notified. 79 cases were notified in London. From the coming into operation of the Poliomyelitis Order, 1912, to the end The following table gives particulars of these cases with (he condition at the end of 1927: — Date of Notification. Patient. Age at date of Notification. 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. Health satisfactory. 26/1/16 A.C. 4 „ „ Died 26/1/16. 27/1/16 T.B. 4 „ „ Now working—dragging of leg hardly noticeable Health satisfactory. 5/9/16 F.B. 2 months „ Died. 6/6/20 I. P. 3½ years „ Recovered—no crippling. 23/7/20 E.W. 15 „ „ No use of lower limbs. 17/9/20 E.H. 1 8/12 „ „ Recovered—no crippling, "thinness" of leg only. 4/9/22 Y.R. 1 10/12 „ Home Died in Paris. 5/2/23 J.N. 3½ „ Hospital Recovered—no crippling. 2/5/23 M.H. 11 mths. „ Again an out patient at Orthopædic Hospital, wears surgical boot— goes to school. 14/8/25 B.T. 26 years „ Hotel guest; could not be traced. 30/10/25 V.H. 5 „ „ Removed from Borough —lost sight of. The table excludes one case notified 4/12/18 who was subsequently found not to be suffering from this disease. 75 Pneumonia. Forty-eight cases of pneumonia were notified during the year. Eight of these were influenzal pneumonia. Thirty-six deaths were recorded from all forms of pneumonia. Four of these were from influenzal pneumonia. The 40 cases of primary pneumonia were notified at the following ages: — Under 1 year, 0; from 1 to 5 years, 7; from 5 to 15 years, 6; from 15 to 25 years. 4; from 25 to 45 years, 7; from 45 to 65 years, 14; and 65 years and upwards, 2. Sixteen were treated at home; 10 were removed to voluntary hospitals; and 14 to Poor Law Infirmaries. Six of the patients were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. Of the 40 cases of primary pneumonia, 16 resided in tenement lodging houses, 15 in separate private dwelling houses or model dwellings, 2 in hotels, and 7 in common lodging houses. The cleanliness of the houses was reported to be satisfactory in 18 cases, but only fairly so in 4, and in one case as unsatisfactory. The economic conditions of the families concerned was found to be good in 12 cases, fair in 16, poor in 8, and very poor in 4; 11 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 bronchitis 6 Following cold 6 Following pleurisy 2 Following asthma 1 Following measles 1 Following exposure (wandering during mental breakdown) 1 Insufficient food 1 Influenza. There were 20 deaths from influenza in comparison with 8 in 1926, 9 in 1925 11 in 1924, and 1 in 1923. Anthrax. No case of anthrax was notified in the Borough during the year. Five cases were notified in London. Chicken-pox. During the year information of 65 cases was received from school teachers and others. Gases of chicken-pox are visited when small-pox is present. In the past year it was necessary to visit five such cases only. Mumps. Information was received from school teachers and others of 94 cases of mumps. 76 The Infectious Diseases (London) Regulations, 1927. These .Regulations were made by the Ministry of Health in December, 1927; they supersede the Public Health (Pneumonia, Malaria, Dysentery, etc.} Regulations, 1919, as from the 1st January, 1928. The new Regulations generally continue the requirements of the 1919 Regulations with the following important modifications: — (1) Trench Fever is no longer notifiable. (2) Malaria. Every ease in which the Medical Practitioner becomes aware that a person on whom he is in professional attendance is suffering from malaria, is notifiable except cases of malaria occurring in an institution in which the disease has been induced for therapeutic purposes. The exemption from notification of a case which has already been notified within six months of the date on which the Medical Practitioner first becomes aware of the disease is not continued. Cases of malaria in institutions where the disease has been induced for therapeutic purposes are not notifiable in the first instance but if the Medical Practitioner under whose charge the patient has been, is of opinion that the patient may be regarded as liable to relapses of malaria, he is required at least four days before the discharge of the patient from the institution to notify the case on a special form prescribed by the Regulations to the Medical Officer of Health of the district in which the patient proposes to reside. (3) Dysentery. This disease is defined by the Regulations to include amoebic and bacillary dysentery. As required by the Regulations information of the duties imposed on Medical Practitioners were sent to all doctors practising in the Borough. Bacteriological Work. The following table gives details of the examinations made during the year: — Diphtheria Pulmonary Tuberculosis Enteric Fever Other Number Submitted Result of Examination Number Submitted Result of Examination Number Submitted Result of Examination Number Submitted Result of Examination 241 Bacilli not found 219 89 Bacilli not found 72 3 Negative 3 1 Negitive 1 Bacilli found 22 Bacilli found 17 Positive 0 Positive 0 Disinfections. During the year 484 rooms and 4,291 articles of bedding, clothing, etc., were disinfected after various infectious diseases, inclusive of tuberculosis. Sixty rooms and o35 articles of bedding, clothing, etc., were disinfected after tuberculosis. Special attention is devoted to toys and more particularly to any toy put in the mouth. Twenty two books and 29 toys were disinfected; also three L.C.C. ambulances after their use for the conveyance of infected persons. 77 Cleansing of Persons Act. Daring the year 93 persons (88 men and 5 women) infested with vermin had their bodies and 1,690 articles of clothing disinfected, free of charge, at our cleansing station (Goldsmith Street). One hundred and twenty-six verminous rooms were disinfected. In connection with the fumigation of verminous rooms, it is now our practice to repeat the fumigation at the end of a week, by which time it is expected that any eggs will have hatched out; a single fumigation of any badly infested room cannot be regarded as satisfactory. In 61 cases last year this course was adopted. 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 elementary schools and residing in the Borough, found to be verminous or suffering from scabies. During the year information was received under this arrangement respecting 108 children reported to be verminous. In one case the same child was reported as verminous on three different occasions in the year and in two cases the children were reported a second time. All the cases were visited as soon as practicable after receipt of each report. In nearly all the cases, the rooms occupied by the family and the beds and bedding were found to be clean, although in seven cases the homes and beds were reported as only "fairly" clean. In two cases where the bedding and rooms were found to be verminous, arrangements were made for the fumigation of the rooms and the bedding was removed to the Council's disinfecting station for disinfection. In nine cases the Health Visitors reported that nits were still observable in the hair of the children concerned. In these cases, that nits were still observable in the hair of the children concerned. In these and a considerable number of other cases, card instructing mothers on methods of cleaning the heads of children were left with the parents or guardians, a number of whom expressed their appreciation of these cards and promised to cam' out the instructions given. In two cases where nits persisted, a shorter clipping of the hair was recommended. Six children could not be traced, incorrect addresses having been given or the families hnd moved. In no less than ten cases it was found that the mothers were out at work daily, in four the mothers were in poor health, and in four the mothers appeared to have defective sight. Two children in the same family were reported to be suffering with scabies. Disinfection of the home and bedding was carried out; both children recovered and so far there has been no recurrence of the disease. 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, 78 Tuberculosis. Summary of Notifications and Deaths. The following table gives the number of new cases of tuberculosis and deaths from the disease in the Borough during 1927 in the form required by the Ministry of Health:— Age periods. New Cages. Deaths Pulmonary. Non-pulmonary. Pulmonary. Non-pulmonary. M F M F M F M F 0 - - 1 - - - - - 1 — 1 2 3 — - 1 1 5 — — 1 1 — — — — 10 - — 2 — — — — — 15 4 2 3 1 1 2 1 — 20 3 3 3 — 1 2 — — 25 10 9 — 1 6 2 - - 35 18 7 — 1 6 1 — — 45 14 4 — — 10 6 — — 55 8 3 — — 7 4 — — 65 2 3 — 1 2 1 — 1 59 32 12 8 33 18 2 2 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 continue to prove beneficial; the knowledge of the local Public Health Staff of the patients is increased in a natural and easy way and the interest in the work encouraged. Total number of cases on the Register of Tuberculosis in the Borough on the 31st December, 1927 202 Number of these patients residing in common lodging houses (about) 20 The average number of cases notified annually during the past ten years 104 The number notified in the year 1927 111 Of the 111 cases notified in 1927. the number who attended the Dispensary 38 Total number of new cases examined at the Dispensary for the first time in 1927. including the above 38, and all contacts 142 Total attendances at the Dispensary in 1927 874 79 Supervision of home conditions; visits paid by— Tuberculosis Officer 65 Dispensary Nurse 1,165 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 2nd January, 1927, to the 31st December, 1927, 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 Form B. Poor Law Institutions. Sanatoria. 0 to 1. 1 to 5. 5 to 10. 1 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. (55 and upwards. Total Primary Notifications. Total Notifications on Form A. Under 5. 5 to 10. 10 to 15. Total Primary Notifications. Pulmonary Males ... ... ... ... 4 2 9 16 13 8 2 54 66 ... ... ... ... ... 35 29 ,, Females ... 1 ... ... 2 3 8 6 4 2 1 27 38 ... ... ... ... ... 8 16 Non-pulmonary Males 1 1 1 2 2 3 ... ... ... ... ... 10 11 ... ... ... ... ... ... 7 ,, Females ... 3 1 ... 1 ... 1 1 ... ... ... 7 8 ... ... ... ... ... ... 1 Supplemental Return. New cases of Tuberculosis coming to the knowledge of the Medical Officer cf Health during the period from the 2nd January, 1927, to the 31st December, 1927, otherwise than by notification on Form A or Form B under the Public Health (Tuberculosis) Regulations, 1912. Age-periods. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards. Total Cases. Pulmonary Males ... ... ... ... ... 1 1 2 1 ... ... 5 „ Females ... ... ... ... ... ... 1 1 ... 1 2 5 Non-pulmonary Males ... 1 ... ... 1 ... ... ... ... ... ... 2 „ Females ... ... ... ... ... ... ... ... ... ... 1 1 Seven of the 13 were ascertained from the death returns and six were transfers from other areas. 80 Tuberculosis Notifications. Excluding duplicates the total number of notifications received on Forms A or B during the year 1927 was 98; 13 other cases were brought to my knowledge, (making 111 new cases in the year). These were:—Private cases 32, hospital cases 46, Poor Law cases 20. from death returns 7, transfers from other districts 6. Correction of Tuberculosis Register during the year 1927. Number of cases on Register, 31st December, 1926 295 New cases registered, 1st January to 31st December, 1927 111 406 Removed from the Register during the same period for following reasons: — Removed from Borough 47 Recovered 12 Died 4 Not suffering from tuberculosis 1 (Notification withdrawn.) — 114 Number on Register, 31st December, 1927 292 Of the 111 cases entered on the Register in 1927, 91 were pulmonary tuberculosis and 20 non-pulmonary tuberculosis. Sixty-nine of the cases were removed for treatment to hospital, infirmary or sanatorium. Sleeping Conditions. In 90 of the 111 new cases of tuberculosis in 1927 it was possible to obtain information as to the sleeping conditions at the date of notification. Thirteen of the remaining cases were residents in common lodging houses; in five cases incorrect addresses were given, or the patients no longer resided in the Borough, and in three cases no information was obtainable. The following is a summary of the information in the 90 cases above referred to; — Patient slept in— Separate bed room 30 Separate bed in living room 18 Separate bed in room shared with— 1 person 3 2 persons 5 5 persons 1 81 Shared bed with— No others in room. 1 adult (H. or W.) 18 1 adult (not H. or W.) 1 1 child 1 1 adult and 1 child 1 Shared bed with— 1 adult and 1 child 1 adult 1 adult 1 adult 1 child 1 child Other persons in bedroom 1 adult and 2 children 1 1 adult and 1 child 5 2 adults 1 1 adult, 2 children 2 1 adult, 1 child 2 t 2 adults, 1 child 1 90 Classification of Homes. The classification of homes as suggested by the London County Council haa 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 28 " B."—Fair. Separate bed, but not separate bedroom 51 " C."—Bad. Dirty environment, dirty ill-kept home, no separate bed, bad management as to food and clothing n 90 The following summary gives the position at the end of 1927 of the 111 new cases respecting which information was received during the year: — Dead 34 Cases removed to Hospital or Infirmary and still inpatients at the end of year 14 Out-patients at Hospitals 7 In-patients in Sanatoria at end of year 8 Not traced—Incorrect addresses 6 Removed from Borough 20 Dispensary, Treatment or supervision 7 Home Treatment—Private or Panel Doctor 11 Nursing Home 1 Waiting admission to Institution l Training Colony 1 Diagnosed not tuberculous 1 11 F 82 Thirty-eight of the 111 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 22 Out-patients at other Hospitals or Dispensaries 6 Dead before notification or died before attendance at Dispensary 19 Treatment at. home by private doctor 5 Not traced 6 Removed from Borough 15 73 , 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 twelve cases were notified only at death, seven within one month of death, three within three months and three within six months of death. Eight of the cases notified at death died in hospital. It is unfortunate that by a proviso in the Regulations of 1912, a medical practitioner is not required to notify a case of tuberculosis if he has reasonable grounds for believing that the case has already been notified. It would seem that any disadvantage accruing from duplication would be easily outweighed by the advantage of the additional encouragement to promote early notification which would ensue from the withdrawal of this proviso from the Regulations. The Regulations also require notification of the admission and discharge of patients to poor law institutions and sanatoria. Institutional Treatment. During the year notifications were received of 101 admissions to institutions. These admissions represent 76 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 101 admissions were to the following institutions:— Poor Law Institutions 47 Institutions of the Metropolitan Asylums Board 31 Other Institutions 23 Twenty-five of these admissions were transfers from one institution to another or re-admissions. Visits to Homes, etc. During 1927 the Tuberculosis Officer made 65 visits to the homes of patients, The general visitation of the patients and supervision of home conditions is carried out by the Tuberculosis Nurses who made 1.165 visits, 83 Contacts. All contacts are invited to attend for examination at the Tuberculosis Dispensary. Sixty-one contacts, viz., 34 adults and 27 children under fifteen years of age, responded to this invitation and were examined for the first time during the year 1927. Of these, two adults and two children were found to be definitely suffering from tuberculosis, four adults and one child were doubtfully so suffering. Fifty-four were definitely diagnosed as not suffering from the disease. The routine examination of contacts is desirable as a means of discovering not only cases of tuberculosis in early stages of infection, but also advanced and infective cases which may be disseminating infection although remaining undiscovered and untreated. Arrangements were continued during the year for fuller co-operation with the school medical service so as to ensure that no contacts of school age will remain unexamined; if such examination cannot be carried out at the Dispensary the School Medical Officers are notified so that the examination may be carried out at the school. Information as to the results of such examinations, whether at the Dispensary or the schools, is interchanged as necessary. Prevention of Spitting. The necessity for the prevention of spitting, with a view to minimising the spread of tuberculosis, has been emphasised by the issue of warning cards on the subject. These have been exhibited in the various buildings in the control of the Council, also in common lodging houses, and in the workrooms of a number of large firms in the Borough. In addition specially designed opal plates have been placed on the Council buildings. They ask people not to spit and so prevent not only tuberculosis, but pneumonia and other diseases the germs of which are carried in the mouth and nose. It is very conceivable that such a disease as encephalitis lethargica is spread in this way in towns. Deaths from Tuberculosis. The number of deaths from pulmonary tuberculosis during the year was 51, a death rate of 1-21 per thousand in comparison with 0-60 for 192G. There were also four deaths from other forms of tuberculosis, a rate of 0-09 per thousand, their aims. The following table shows where the patients died in their own homes or institutions: — Showing the number of Patients who died in their oivn homes and the number who died away from home in Hospitals or other Institutions. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- All Ages. Males. Females. Total. Number of patients who died at home ... ... ... ... 1 ... 2 1 5 3 1 6 7 13 Number of patients who died in hospitals, etc. ... 2 ... ... 3 3 6 6 10 9 3 20 13 42 ... 2 ... ... 4 3 8 7 15 12 4 35 20 55 F 2 84 Tuberculosis Dispensary. The following is the Report of the Tuberculosis Officer, J. A. Struthers, M.B., B.Ch., M.R.C.P., D.P.H., for the year 1927 : — (Memo. 37/T.: Table I.) Return showing the Work of the Dispensary during the year 1927. Diagnosis. Pulmonary. Non-Pulmonary. Total. Adults. Children. Adults. Children. Adults. Children. M. F. M. F. M. F. M. F. M. F. M. F. A.—New Casks examined during the year (excluding contacts):— (a) Definitely tuberculous 32 8 2 0 2 1 5 0 34 9 7 0 (b) Doubtfully tuberculous — — - - - - — — 11 4 2 0 (c) Non-tuberculous - - - - - - - — 6 7 0 1 B.—Contacts examined during the year:— (a) Definitely tuberculous 1 1 0 0 - - — — 1 1 — — (b) Doubtfully tuberculous - - - — — - - - 1 3 - 1 (c) Non-tuberculous — — — - - - — — 8 20 12 14 C.—Cases written off the Dispensary Register as (a) Cured 4 3 - - 1 1 3 - 5 4 3 - (b) Diagnosis not confirmed or non-tuberculous (including cancellation of cases notified in error) - - - - - - - - 22 34 14 16 D.—Number of Persons on Dispensary Register on December 31st — (a) Diagnosis completed 74 62 6 1 8 12 9 6 82 74 15 7 (b) Diagnosis not completed - - - - - - - - 2 - - - 85 1. Number of persons on Dispensary Register on January 1st, 1927 195 2. Number of patients transferred from other areas and of " lost sight of" cases returned 8 3. Number of patients transferred to other areas and cases "lost sight of" 45 4. Died during the year 22 5. Number of observation cases under A (b) and B (b) above in which period of observation exceeded 2 months 0 6. Number of attendances at the Dispensary (including contacts) 874 7. Number of attendances of non-pulmonary cases at Orthopædic Out-stations for treatment or supervision - 8. Number of attendances, at General Hospitals or other Institutions approved for the purpose, of patients for (a) " Light" treatment - (b) Other special forms of treatment 118 9. Number of patients to whom Dental ment was given, at or in connection with the Dispensary 11 10. Number of consultations with medical tioners :— (а) At Homes of Applicants 9 (b) Otherwise 58 11. Number of other visits by Tuberculosis Officers to Homes 65 12. Number of visits by Nurses or Health Visitors to Homes for Dispensary purposes 1165 13. Number of (а) Specimens of sputum, &c., examined 201 (b) X-ray examinations made 38 in connection with Dispensary work 14. Number of Insured Persons on Dispensary Register on the 31st December 96 15. Number of Insured Persons under Domiciliary Treatment on the 31st December 52 16. Number of reports received during the year in respect of Insured Persons :— (a) Form G.P. 17 45 (b) Form G.P. 36 3 86 Condition at the time of the last record made during the year to which the Return relates. Previous to 1926. 1926. 1927. (a) Pulmonary Tuberculosis. Class T.B. minus. Class T.B. plus. Class T.B. minus. Class T.B. plus. Class T.B. minus. Class T.B. plus. Group 1. Group 2. Group 3. Total (Class T.B. plus). Group 1. Group 2. Group 3. Total (Class T.B. plus). Group 1. Group 2. Group 3. Total (Class T.B. plus). Alive. Discharged as cured. Adults M. 2 2 — — 2 F. 2 1 — — 1 Children M. 1 — — — — F. — — — — — Disease arrested. Adults M. 9 4 1 — 5 F. 9 4 — — 4 Children M. 2 — — — — F. — — — — — Disease not arrested. Adults M. 9 8 8 1 17 4 3 2 — 5 10 11 4 — 15 F. 7 16 8 2 26 4 1 1 1 3 7 1 1 — 2 Children M. 1 — — — — — 1 — — 1 2 — — — — F. — 1 — — 1 — — — — — — — — — — Condition not ascertained during the Year. Lost Sight of or otherwise removed from Dispensary Register. 27 25 17 5 47 3 2 3 1 6 1 — 1 — 1 Dead. Adults M. 1 1 1 7 9 — 1 3 — 4 — — — 6 6 F. 1 — 2 2 4 — — 4 — 4 — — — — — Children m. — — — — — — — — — — — — — — — F. — — — — — — — — — — — — — — — Totals 71 62 37 17 116 11 8 13 2 23 20 12 6 6 24 Annual Return showing in summary form the condition of all Patients whose case records are in the possession of the Dispensary at the end of 1927, arranged according to the years in which the patients first came under Public Medical Treatment for pulmonary tuberculosis, and their classification as shown on Form A. 87 Condition at the time of the last record made during the year to which the Return relates. Previous to 1926. 1926. 1927. (b) Non-Pulmonary Tuberculosis. Bones and Joints. Abdominal. Other Organs. Peripheral Glands. Total. Bones and Joints. Abdominal. Other Organs. Peripheral Glands. Total. Bones and Joints. Abdominal. Other Organs. Peripheral Glands. Total. Alive. Discharged as cured. Adults M. 1 — — — 1 F. — 1 — — 1 Children M. — 1 1 1 3 F. — — — — — Disease arrested. Adults M. 1 — — — 1 F. — — — — — Children M. 1 — — — 1 F. — — — 2 2 Disease not arrested. Adults M. 3 — 1 — 4 1 1 1 1 — — 2 F. 3 2 2 1 8 2 1 — — 3 1 1 Children M. — — — — — 3 3 1 1 3 5 F. 1 1 — — 2 1 — — 1 2 — — — — — Transferred to Pulmonary Condition not ascertained during the Year Lost Sight of or otherwise removed from Dispensary Register 7 4 4 8 23 1 — 1 2 Dead. Adults M. — — — — — F. — — — — — Children M. — — — — — F. — — — — — Totals 17 9 8 12 46 3 2 — 6 11 1 2 1 4 8 88 The number of new cases examined in 1927 shows an increase; but at the same time, owing to the fact that a quarter of the number of the cases notified in the last four months of the year had no contacts, the number of contacts examined shows a diminution. Every opportunity has been taken to make use of the arrangements now available for the provision of convalescent treatment for weakly children among the contacts of tuberculous patients. The number of sputum and X-ray examinations, as also of attendances for special forms of treatment," has increased. Once again the value of the close touch maintained with other departments of the University College Hospital has been emphasised by the readiness with which such " special forms of treatment " are made available. Close co-operation is also maintained with the local practitioners, who continue to make frequent use of the Dispensary, and the number of consultations with whom has materially increased. The question of the employment of tuberculous persons continues to be a difficult one; and it is a pleasure to record the help given in this respect by the Tuberculosis Care Committee. On the administrative side there is an innovation to record in the appearance, for the first time, of Form IV, which gives a summary of the condition at the end of each year, arranged according to the years in which they first came under public medical treatment. It will be of service in connection with " following up." Tuberculosis Care Committee. The Holborn Tuberculosis Care Committee constituted by the scheme prepared in the year 1922 took over the work of the Interim Care Committee on the 1st April, 1923. The Committee includes the following representation:— Holborn Borough Council Councillor Miss M. R. Lovelock. Medical Officer of Health (Dr. C. W. Hutt). Tuberculosis Dispensary Councillor Sir William Smith, D.L., J.P. Tuberculosis Officer (Dr. J. A. Struthers). London County Council Dr. F. C. Lewis. Miss H. Bell. Guardians of the Holborn Union Councillor Alfred Humphreys. Charity Organisation Society Miss E. F. Bolton. Local Association of Children's School Miss A. E. Dove. Care Committees. Invalid Children's Aid Association ... Miss Butler. Metropolitan District Nursing Association Miss M. Wilmshurst. Almoners of hospitals Miss J. G. Salmon. Miss A. M. Smith. Insurance Committee for the County of Miss S. Double. London. Northern London War Pensions Committee Councillor Richard Davics (from Feb., 1926) British Red Cross Emergency Help Fund Mrs. Paige. Other social workers (co-opted) Mrs. E. C. Bedford. Miss H. M. Matbieson. Miss O. Lazarus. Cav. R. Terroni. 89 The duties of the Committee were defined to include enquiries as to the economic position of the family of a patient suffering from tuberculosis as soon as the patient comes within the purview of the Tuberculosis Dispensary Scheme with a view to rendering such advice and assistance as the circumstances of the case dictate; assistance in the provision, where necessary, of clothing as required by the institution to which the patient is sent, and any arrangements for the family to be properly looked after during the absence of father or mother; the securing of auxiliaries for domiciliary treatment which cannot be provided without charitable assistance; recommendations to the London County Council as to the amount of payment, if any, to be made towards institutional treatment and the collection of agreed amounts; advising the Borough Council whether the patients recommended for extra nourishment are in a position to pay for the same and, if not, the extent to which assistance should be given; advising the Borough Council as to the contributions, if any, to be made by patients in respect to the provision of dentures under any arrangement made by the Council for dental treatment. The Annual Report of the Committee is as follows:— The Committee has met 11 times during the year. The average attendance of members at each meeting has been 8.45. Fifty-two cases have been considered—27 new, and 25 old cases. Thirty-six cases—29 adults, and 7 children—were referred by the London County Council for assessment. Of these, 10 were granted free treatment, and 23 were assessed to pay contributions, varying from Is. to 15s. per week towards the cost of treatment and maintenance; two refused treatment before an assessment was considered, and one made his own arrangements for treatment. Contributions towards the cost of treatment and maintenance amounting to £114. 0s. 6d. were collected on behalf of the London County Council in 26 cases— 16 adults and 10 children. Nine of these were still under treatment at the close of the year. Two cases had to be referred back to the London County Council for refusal to pay any contributions—one being that of a man in regular employment with no dependent children whose wife was sent away for treatment. Six quarterly reports on five children were received from the London County Council and the information contained therein conveyed to the parents. One case was transferred to the Care Committee of another Borough. Three children were sent away through the Contact Scheme of the London County Council. Two others were recommended but their parents failed to let them go. One child was sent away for convalescence through the Invalid Children's Aid Association. One ex-Service man had convalescence at the United Services Fund's Home at Bournemouth and the United Services Fund gave assistance towards convalescence in the case of an ex-Service man's wife and baby. Convalescence through Stafford's Charity was arranged for a mother while her child was away for treatment but she removed the child from treatment and failed to take advantage of convalescence for herself. A " Free Bed " was obtained at St. Michael's Home, Axbridge, for three months for one patient. A letter for a Convalescent Home was obtained in another case. 90 One patient was referred to the Borough Council for dentures and on the recommendation of the Committee the Council agreed to undertake the full cost. Clothes for patients entering sanatoria have been obtained from various sources —from the Charity Organisation Society in four cases and from the United Services Fund, the Royal Scottish Corporation and the Swiss Benevolent Society in one case each. The Charity Organisation Society has also co-operated in other ways—in arrangements for Homes in two cases, in the cost of removal in two cases, in the cost of spectacles and in the payment of a National Health Insurance arrears penalty. The United Services Fund gave temporary financial assistance in one case. One Italian widow was referred to the Italian Benevolent Society for advice regarding the disposal of her late husband's business. Our thanks are due to the representative of the British Bed Cross Society's Emergency Help Fund for advice in the cases of several ex-Service men. Several families have been advised regarding National Health Insurance difficulties. Help has been given in the filling up of National Health Insurance, Widows', and Old Age Pension Forms, and in many other trivial ways, impossible to enumerate. Three Holborn families have removed from London during the year—one to Devonshire and two to the Watling Estate, Hendon, but our great difficulty is the lack of proper housing accommodation for the families who for various reasons cannot leave Central London. Failure seems to pursue the efforts of a Tuberculosis Care Committee—failure to find employment for the ex-sanatorium patient—failure to improve the housing conditions of the incipient case and the ex-sanatorium case—failure to achieve their aims. In this last connection a typical case may be cited: — Father died of pulmonary tuberculosis in 1924; mother in a chronic, somewhat advanced stage of pulmonary tuberculosis, unable to work, living at home, under unsatisfactory conditions, with five children—at least four of whom were delicate Two of the children are earning. The third, who was due to leave school, showed a tendency to tuberculosis, but it was thought the disease might be averted if she were placed in the country for some time. She had expressed a desire to become a children's nurse, so, with her own and her mother's consent—and with the co-operation of the Charity Organisation Society—arrangements were made for her to enter a Training Home for Domestic Service at St. Albans. She seemed to settle down quite happily in the Home, but, after a short time, she developed what was thought to be tuberculous dactylitis. She agreed to go to Hospital for treatment, on condition that she might return to the Home afterwards. Treatment was completed, and arrangements made for her return to the Home. For some inexplicable reason, she flatly refused to return to the Home, or to enter any branch of domestic service. She is now back in the old home, under the old conditions from which it was hoped to rescue her. Efforts to obtain better housing accommodation have also failed. The Standing Conference of City and Metropolitan Borough Tuberculosis Care Committees met in May and November. Representatives of the Holborn Tuberculosis Care Committee were present on both occasions. At the meeting in November the Holborn Committee submitted the two following resolutions : — 91 (a) That there should be an Honorary Librarian at every Institution of the Metropolitan Asylums Board at which tuberculous patients are received, and that a resolution to this effect be sent to the London County Council, with the request that they will approach the Metropolitan Asylums Board on the subject. (b) That the attention of the Omnibus and Tramway Companies be drawn to the fact that rides on the upper decks of their vehicles are the only means that many people have of obtaining fresh air drives, and that, in the interests of the prevention and cure of tuberculosis, the Companies be asked to provide a larger proportion of open topped vehicles. Both resolutions were carried. In June, the following resolution was submitted to the Holborn Board of Guardians: — That the Holborn Board of Guardians be requested to allow two visiting days per week at the Holborn and Finsbury Hospital, instead of one as at present. Several Boards of Guardians admit visitors on two days in the week, and it was felt that patients might be more inclined to remain longer in the institutions if their friends were allowed more facilities for visiting them and giving them news of home affairs. The Board of Guardians, however, did not see its way to granting the Committee's request. Handicraft classes have been started in several Boroughs with the object of providing some useful and interesting occupation for tuberculous persons who are unable to follow any regular employment. Holborn not having enough patients to run a class on its own, the Finsbury Tuberculosis Care Committee was approached with a view to ascertaining whether a joint class could be formed. No reply was received. It was a great relief to learn that, owing to the strenuous opposition, the Covent Garden Market Bill was withdrawn but it is very disappointing that no plan for the preservation of the Foundling Hospital site as an open space has yet matured. Owing to the congested state of the district and the absence of any playground facilities for children it is most desirable that the grounds of the Foundling Hospital and the adjacent squares should remain unbuilt upon, and that as much as possible of them should be accessible to the public—and especially to the children of the district—for recreation. At the end of the year, Miss O. Lazarus, of the West Central Jewish Girls' Club, and Cavaliere R. Terroni, of the Italian Benevolent Society, were invited to join the Holborn Tuberculosis Care Committee. It is gratifying to report that both accepted the invitation. H. M. MATHIESON, Hon. Secretary. 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. 92 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 six such cases were nursed, a total of 202 visits being paid to these patients. Dental Clinic for Tuberculous Persons. Arrangements were continued for tuberculous persons referred from the Tuberculosis Dispensary to receive dental treatment as part of the Council's Tuberculosis Dispensary Scheme, at the Clinic of the British Dental Hospital, No. 10, John Street, W.C. In the year 1927, six new patients were treated. Filling was carried out in one case and scaling and gum treatment was given in two. Extractions with general anesthetic in six cases, and local anaesthetic in two cases. Two dentures were provided. 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 inhabitants and workers of the neighbourhood. The Secretary of the Hospital has kindly supplied the following information of the work at the Clinic during the year 1927:— Summary of Work carried out at Dental Clinic, 10, John Street, Holborn, on Tuesday Eveninqs, during 1927. Number of sessions held 46 Number of patients' attendances 287 Number of fillings 21 Number of scalings 6 Number of extraction cases Without anaesthetic 1 With local anaesthetic 28 With gas 62 Number of teeth extracted 214 Number of dentures (including repairs) 21 Number of dressings 10 Number for advice 49 Number of denture visits 71 Number of new patients 74 Employment of Tuberculous Persons. In the Annual Report for 1925, reference was made to the difficult problem connected with the employment of tuberculous persons. This problem is one of the major difficulties associated with the after care of tuberculous patients. Many of these patients make a conditional recovery under sanatorium treatment. Money is freely spent in providing this treatment but no corresponding effort is made to provide conditions necessary to the after care of the patient. These would include home conditions modified on sanatorium lines and remunerative employment. Patients who can return to suitable home conditions and means of livelihood may 93 live for years in the enjoyment of good health. Unfortunately these form a small minority of patients passing from sanatoria. The convalescent frequently breaks down in health often through lack of good nourishment, owing to the difficulty of obtaining suitable employment. In the Annual Report previously referred to, reference was made to the experimental workshop promoted by the Central Fund for the Industrial Welfare of Tuberculous Persons, opened in the Borough in Cross Street, Hatton Garden. There is urgent need for much development on the lines of such workshops so that patients on their discharge from sanatoria can have a chance of re-establishing themselves in useful occupations. Cancer. During the year 1927, 50 deaths were recorded as due to Cancer in comparison with 63 in the previous year. The deaths in 1927 were equal to a rate of 1.18 per thousand, the corresponding rate in 1926 being 1.46 per thousand. In the year 1907 the death rate from Cancer in the Borough was only 0.82, the decennial average rate was 1.12 for the ten years, 1907-1916, and 1.41 for the ten years, 1917-1926. It will be seen' that the death rate from Cancer in the Borough in 1927 was, fortunately, lower than in the previous year, being only 1.18 per thousand in comparison with 1.46 per thousand. The rate, however, for one year in districts of comparatively small populations does not furnish a reliable indication of the prevalence of a particular disease. The decennial rates which afford much more reliable indication of the seriousness of Cancer show that in the past 20 years there has apparently been a marked increase in the death rate from this disease, for while the decennial average for the ten years, 1907-1916, was 1.12, the corresponding rate for the ten years, 1917-1926, was 1.41. Some part of this increase may reasonably be attributed to improved facilities for diagnosis. The figures indicate the high mortality from malignant diseases. Prevention of Hernia (" Rupture "). In view of the serious inconvenience and at times death arising from " rupture " preventive measures should be taken. I have asked Mr. McAdam Eccles, M.S., F.B.C.S., kindly to lend his authority to a statement on the matter. He writes:— j 1 " Hernia, which is commonly called ' rapture,' is far more common than is usually recognised, and it is certain that some information upon its prevention is not out of place. It must be understood that the term ' rupture ' has led to an entirely erroneous idea as to the causation of the condition. There is never a tearing or breaking of parts in its oncoming. A hernia consists of a pouch of the lining membrane of the " stomach " (abdominal) wall, and this pouch is very usually born with the person, and a large number of persons of both sexes have this pouch on one or both sides and are quite unaware that it exists But in 94 addition for a hernia to be actually present, this pouch must receive some of the contents of the ' stomach ' (abdominal organs), such as bowel coming down into it. This descent is due to a large number of causes, some of which are preventible. Among these coughing, sneezing, and straining at stool, acts frequently repeated, are common reasons for descent of bowel or omentum. Repeated strains at work may produce similar results, but a single strain cannot produce a pouch or the descent of intestine into a hernial pouch, unless the pouch (' sac ') was present at birth. In connection with the prevention of hernia, constipation, and its associated straining at the closet, is of great importance. The ordinary closet, particular that encased in wood, is often so high that the person using it sits with the abdominal apertures entirely unsupported by the thighs, and hence there is a great tendency for any straining in this position to lead to the gradual formation of a hernia. A lower seat to the closet, or a fixing of a step in front of the seat on which the feet can rest and the knees be raised, is definitely of considerable value in the prevention of hernia from this cause." MATERNITY AND CHILD WELFARE. Notification of Births. During the year 320 births were registered as occurring in the Borough. During the same period 294 notifications of births occurring in the Borough were received. Of these, 267 were from doctors and' midwives, 27 from parents. From the 267 notifications of birth forms from doctors or midwives, we are able to give the following information as to by whom the mothers were attended at the confinement, etc.:— Private Doctors 62 Private Midwives 36 Out-patient Midwifery Departments of General Hospitals and Institutions: — Externs and others 21 Midwives.—University College Hospital 34 Middlesex Hospital 19 Royal Free Hospital 28 Other Institutions 32 Training Institution for Midwives, Myddelton Square 35 267 Seven notifications related to stillbirths, and one notified the birth of twins. 95 Number of Births. The number of births transferred to the Borough from outlying institutions was 197 The number of births transferred from the Borough to other districts was 12 The number of net births belonging to the Borough was 505 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. Births in Crowded Homes. An analysis has been made of the birth cards in 386 cases where visits were made in connection with the births, to ascertain where the mothers living in crowded houses wore confined. The information obtained is given below Living in Confined at Home. In Hospital. No. Percentage of No. Percentage of Total Births. Total Birth One roomed homes 60 16 61 16 Two „ „ 131 34 68 17 Three „ „ 39 10 14 4 Four „ „ 8 2 5 1 These figures show that many of the women are confined under very uncomfortable and unfavourable circumstances. In 51 cases visits were not made for the following reasons: — Infants died before visit due or before information of birth received 6 Above the standard for visitation 45 51 Home Visiting. The visits paid to the homes by the Health Visitors during the year were as follows :— First Visits. Revisits. Total. Expectant Mothers 119 98 217 Children under 1 year of age 491 1,289 1,780 Children 1 to 2 years of age 6 475 581 Children over 2 years of age 12 387 399 Enquiries re stillbirths 19 „ re ophthalmia neonatorum 10 Other visits 166 96 Four hundred and fifty-four visits related to infants who came under further observation in their own homes or at Infant Welfare Centres; of these, 29 removed from the Borough before the age of one month or did not return to the Borough after the birth of the child, and 19 were not known at the address given, leaving 406 infants as possible attendants at a Maternity and Child Welfare Centre; of this number 242 were recorded as attending a Centre, i.e., 53 per cent. The Centres attended were the following:— 164 attended the Council's M. & C. W. Centre at 10, John Street. 39 „ „ Short's Gardens. 4 attended the Centre at Onslow Street School, Saffron Hill. ,, ,, Charing Cross Hospital. 4 ,, ,, Myddelton Square. 7 ,, ,, Middlesex Hospital. 2 „ „ University College Hospital. 10 „ „ Royal Free Hospital. 7 „ „ Other Centres. 3 „ ,, St. Bartholomew's Hospital. 242 attended an Infant Welfare Centre. Thus more than one-half of those visited attended an Infant Welfare Centre and of these well over four-fifths attended the Council's Centres. Work at Centres. Holborn Centre, 10, John Street. The following is an analysis of the attendance at this Municipal Centre: Tuesday. Wednesday. Thursday. Friday. Medical Consultation (alternate weeks) 2-5.30 p.m. Ante-natal and Postnatal cases only (alternate weeks) 2-5.30 p.m. Children and Mothers seen at Antenatal Consultation Medical Consultation 2-5.30 p.m. Class 3-5.30 p.m. Dentist. 2-4 p.m. Medical Consulation 2-5.50 p.m. No. of Sessions 26 25 25 52 31 52 51 Total attendance — Children 506 ... 409 1296 ... 87 1184 Mothers 137 127 70 195 426 324 227 Average weekly attendances— Children 19 ... 16 26 ... 1 23 Mothers 5 5 3 4 12 6 4 97 St. Giles' Centre, Short's Gardens. The attendances at this Branch Centre during the year 1927, were as follows:— Monday 2-5.30 p.m Thursday Medical Consultation 2-5.30 p.m. Class. Children weighed. No. of Sessions 47 47 52 Total attendances— Children — 99 526 Mothers 167 — 47 Average weekly attendances— Children — 2 10 Mothers 4 — 1 The total number of attendances made by the Health Visitors at the Centres in 1927 was 403. At the Holborn Centre, No. 10, John Street, 4,988 attendances were made by a number of mothers, including 50 expectant mothers, and 497 children, of whom 279 were under one year, 69 between one and two years old, and 149 aged 2-5 years on the date of their first attendance. At the St. Giles' Centre, Short's Gardens, 839 attendances were made by 34 mothers and 112 children, of whom 54 were under one year, 21 from one to two years and 37 between two and five years. The attention of mothers of bottle fed infants is drawn to the necessity of supplying vitamin C in the diet by the giving of fruit juice daily in suitable quantities; orange or tomato juice is advised as a rule. For some years, both in the home and at the Centres, we have made use of simple leaflets dealing with the hygiene of infancy and maternity, and have hung the walls of the Centres with pictures and mottoes to give point to our teaching and to draw attention to the series of leaflets. At one time leaflets were received with indifference, but in the past year the demand for these has grown remarkably and there are signs that they are much appreciated and have been of real service to those using them. 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. The model garments used for demonstration were overhauled during the year, obsolete types being withdrawn and replaced by modern ones. Three hundred and sixty-nine hanks of wool of a special quality obtained from Wales were sold at cost price to the value of £19. 18s. 10½d. The maternity bags have been used during the year by two mothers. A by no means inconsiderable area of the Borough is occupied by a settlement of Italian people known as the Italian Colony. Many of these cannot speak or G 98 write English and in order to assist, as far as possible, expectant and nursing mothers in this area we have succeeded after considerable trouble in obtaining through the British Consul at Milan, to whom we owe our thanks, a supply of Maternity and Child Welfare propaganda literature in Italian. It is hoped that this will prove of considerable service to the Italian mothers. A summer outing was arranged to Burnham Beeches for about 70 mothers, many of whom carried infants in arms, and 63 other children mostly below school age. The cost of the fares of some mothers was defrayed in part from money collected by private subscriptions. Ante-natal Hygiene. During the year, enquiries were made of mothers as to their attendance at an Ante-natal Centre immediately previous to the birth of the child visited. Of 451 mothers, about whom information was obtained, 302 (66 per cent.) were found to havn attended Ante-natal Centres or received ante-natal care as under: — Number of enquiries made 454 Centre Attended— Holborn Centre, 10, John Street 42 Royal Free Hospital 43 Middlesex Hospital 42 Charing Cross Hospital 35 University College Hospital 47 Myddelton Square Institution 21 St. Bartholomew's Hospital 28 City of London Hospital 9 Queen Charlotte's Hospital 6 Other Centres 23 Ante-natal care from private doctor 6 302 The following is a summary of the numbers of expectant mothers attending the ante-natal clinic, 10, John Street, found to have defects either due to or especially of concern in view of their pregnancy, during the year 1927: — No. of Women attending Ante-natal Clinic 55 No. of Ante-natal cases 50 No. of attendances made by ante-natal cases 111 Attending after confinement 1 No. of attendances made by post-natal cases 5 Expectant Mothers for first time 5 Defects, especially connected with pregnancy— Venereal disease 1 Deformed pelvis 5 Threatened miscarriage 1 Breech presentation 2 99 Placenta prævia 1 Excessive vomiting 6 Œdema 3 Varicose veins 13 Excessive vaginal discharge 1 Albuminuria (slight) 1 Pendulous abdomen 4 Retroverted gravid uterus 1 Other defects 1 Other defects— Heart disease 5 Anæmia 5 Respiratory diseases 1 Constipation 21 Dental caries 16 Sleeplessness. 4 Dyspepsia 6 Pyorrhœa 4 Enlarged thyroid 2 Eczema 2 Other defects 2 No. referred to Maternity Hospitals 9 Normal l Abnormal 8 No. referred to Dental Clinic 13 No. of urine tests made 64 The urine of one woman showed a cloud of albumin. Dietetic advice was afforded and arrangements made for her confinement to take place in a hospital. In one other case there was a faint trace only. In connection with the 5 post-natal cases attending the Ante-natal Clinic, the defects noted were: fibroids 1; debility 1; dyspepsia 1; mastitis 1; 1 mother attended for examination for suspected pregnancy. Voluntary Notification of Pregnancy. An important development of the Maternity and Child Welfare work in the Borough during the year 1927, was the adoption by the Council of a scheme for the voluntary notification of pregnancy. The Maternity and Child Welfare Committee had under consideration during the year the high rate of infant mortality in the Borough during the preceding year, 1926, when the mortality during the first month of life (neo-natal) was higher than in the preceding years. Death at this stage of life is due more to the health of the mother during pregnancy than to anything else and it appeared to the Committee that the only way in which the Council could more or less influence the health of the mother during this period was to take any action possible after obtaining knowledge of the existence of pregnancy. For this purpose the Council established, some years ago, an G 2 100 natal clinic. This clinic has proved of much service to expectant mothers in the Borough, but it was felt that its usefulness might be increased if earlier knowledge of pregnancy was furnished to the Medical Officer of Health. The Health Visitors could then endeavour to persuade the expectant mother to attend the ante-natal clinic; offer her advice as to a healthy mode of life during pregnancy, this advice being set out in a leaflet which had already proved acceptable; keep in touch with the mother and persuade her to obtain medical advice if her health in any way was not satisfactory. It was proposed that a scheme for the voluntary notification by medical practitioners and midwives should be instituted, fees to be paid at the rate of 2s. 6d. each notification in private practice and 1s. for each notification in public practice as Medical Officers or midwives acting for public institutions, the notifications to be made only with the approval of the expectant mothers. The Council agreed, subject to the approval of the Minister of Health, to put the scheme into operation. The sanction of the Minister was obtained and the scheme came into operation at the beginning of 1928. Maternal and Infant Consultations. The following summary refers to maternal and infant consultations at 10, John Street and the Short's Gardens Centres during the year 1927 :— Reasons for Attendance. John Street Short's Gardens. Mothers— Healthy 24 6 Difficulty with breast feeding 28 7 Generative organs 9 5 Dental caries 45 7 Heart disease 3 — Debility 11 5 Anæmia 16 — Venereal disease 3 — Respiratory disease 5 1 Digestive disorders 6 — Other disorders 27 3 Children— Healthy 157 52 Congenital syphilis 2 — Alimentary disorders 76 9 Rickets 26 13 Debility 14 10 Respiratory diseases 64 9 Hernia, umbilical 15 - do. inguinal 3 — Phimosis 21 1 Diseases of skin 34 2 Disease of eye 20 1 101 Disease of ear 13 3 Disease of nose and throat 21 6 Digestive diseases 31 4 Other diseases — 2 In this table the more important ailment only has been recorded in each case. Mothers and children attending the Municipal Centres were referred to other departments for assistance during the year 1927 as follows: — Referred to. Mothers. Children. Dental Clinic 65 14 Hospitals 13 32 Metropolitan Nursing Association 16 1 Assisted Milk 33 29 Convalescent Homes 4 6 Ante-natal Clinic 1 — Massage Clinic — 1 Private doctor 1 — Tuberculosis Dispensary — 1 Relieving Officer — 1 Minor Ailments Clinic 19 121 Light Treatment — 5 152 210 Breast Massage. The following summary gives particulars of mothers referred for breast massage in 1927 : — Number referred to Metropolitan Nursing Association 20 Results— Lactation completely restored 11 Breast secretion re-established, but small bottle feeds required in addition to breast feeding 2 Massage unsuccessful 7 Diarrhœa. During the year the cases of diarrhoea occurring in children attending the Council's Centres were as follows:— 10, John Street. Short's Gardens. 1. Simple diarrhoea 17 cases 1 case. 2. Ordinary summer diarrhoea none none. Stillbirths. During 1927 there were 19 stillbirths in the district. Difficult labour was responsible for seven of these; of these two were due to an abnormal foetus, one being hydrocephalic; one was due to contracted pelvis, one to foot and one to breech presentation; one to a tumour, and in one instance enquiry did not elicit the determining factor. 102 Of the other 12, Brights disease was the most likely cause of one; prematurity of four; albuminuria of one; ante-partum hæmorrhage of varicose veins one; in one case the stillborn child was reported to be one of triplets; in two cases the parent was unable to give any information which could be used in assigning a probable cause; in the remaining two no information of any kind could be obtained. Two of the 19 stillbirths occurred in the private practice of a doctor; eight in the extern practice of an institution and nine in an institution. Of the mothers of these 19 stillborn children, 13 were known to have had ante-natal care; of these 13, one was under the supervision of a doctor in private practice, and 12 attended an ante-natal clinic. One mother (stillbirth was due to albuminuria) had been advised at the ante-natal clinic to enter hospital for her confinement, but had refused. One mother (stillbirth due to breech presentation) stated that as it was her eighth child she thought it was not necessary to go to an ante-natal clinic. Illegitimate Births. The following table gives a summary of the information obtained as a result of enquiries respecting the circumstances of illegitimate babies in the year 1927: Number of illegitimate births registered 53 Number respecting which enquiries were made for further information 49* Lived with mothers who remained in parents' home 7 Lived with mothers who went out to work 2 Boarded out with foster mothers 4 Lived in Institution 4 Lived with both parents who lived together permanently 9 Died in early infancy 1 Stillborn 0 No information (gone away, etc.) 22 *Four were above standard for enquiry. 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 64, viz., 35 women and 29 children; the number of attendances 393 (women 314, children 79). 103 Assistance with Dentures, etc. Ordinary extractions were made in 8 cases (1 woman, 7 children); extractions with local anaesthetic were made in 9 cases (all women), and with general anæsthetic in 69 cases, including 26 children. Scalings were carried out in 14 cases (13 women). Small fillings were provided in 34 cases, including 12 children. Dentures were provided for 24 patients, 11 were required to pay the whole cost, 11 contributed towards the cost, and in the remaining 2 cases where the patients were very poor the dentures were provided free. In 11 cases dentures were repaired and dressings were given in 8 cases. In the provision of dentures the cost is based on the charge approved for the time being for dentists on the Ministry of Pensions Panel. Supply of Milk and Food for Expectant and Nursing Mothers and for Infants. The supply of milk and food at less than cost price was continued during the year under the Maternity and Child Welfare Act, 1918, for: — (a) Nursing Mothers; (b) Expectant mothers in the last three months of pregnancy; (c) Children up to three years of age and, exceptionally, to children between three and five years of age. Scale of Necessity. The approved scale of necessity adopted by the Council on the 14th October, 1921, continued in force during the year 1927. 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 ana 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 277 applicants received free or assisted milk under the Scheme. This number included 120 who were receiving such assistance at the end of the year 1926. Grants were made in 157 new cases At the end of the year 1927, 140 cases were receiving assistance, viz.: — 104 Mothers. Children. Total. Free milk 45 77 122 Half price milk 4 11 15 Prepared milk — 3 3 49 91 140 The following table shows new cases assisted in 1927: — Milk. Prepared Milk. Free. Part Cost. Free. Part Cost. Expectant Mothers 21 1 — — Nursing Mothers 35 6 — — Children 66 9 12 7 Early in the year 1928, a communication was received from the Ministry of Health suggesting that with a view to reducing the expenditure on the supply of milk during the year 1928-1929, the Council should reconsider the procedure adopted in dealing with applications for milk at less than cost price, so as to secure strict observance of the following conditions:— (1) Milk to be supplied by the Council solely on medical grounds and not to be supplied to applicants who are already in receipt of Poor Law Relief; applicants whose circumstances are such that they can only be dealt with adequately through the machinery of the Poor Law to be referred to the Guardians. (2) Every applicant for milk to be seen in the first instance by the Medical Officer of Health or the Medical Officer of the Maternity and Child Welfare Centre and no applicant to be considered unless the Medical Officer furnishes the certificate that a supply is essential on grounds of health. / (3) The scale of income to be revised to bring it into accord with the fall in the index figure of the cost of living since the existing scale was framed. (4) The Council to be satisfied that they are obtaining supplies of milk at prices which bear adequate relation to the quantities of milk distributed by them. At the date of the preparation of this report steps are being taken by the Maternity and Child Welfare Committee to give effect to the suggestions of the Minister of Health as set out above. Home Help. The Council's Home Help attended 21 cases during the year in comparison with 25 in the year 1926. In 10 of these the whole-time officer attended entirely and in 9 she attended during the earlier part of the lying-in period, being replaced later by one of the Home Helps from the emergency panel in order to take over new cases. In 2 cases emergency Home Helps only were employed. The latter were engaged when more than one case occurred at the same tin e and during the summer vacation and sick leave. 105 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 15s. 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. Four applications for convalescent home treatment for mothers and their babies were granted in comparison with 2 in the previous year. The smallness of the number was due to the difficulty in obtaining suitable accommodation for mothers and babies. Two applications were subsequently withdrawn as the applicants were able to go away into the country to stay with relatives. In the 2 cases sent away small contributions towards the cost were required. Nine applications were granted for convalescent home treatment for children. In 2 cases the applications were subsequently withdrawn because the parents could not pay towards the cost. In one case a child was found not well enough for convalescent home treatment. Six children were sent away in comparison with 12 in 1920. All of these were sent to the Hopedene Convalescent Home at Bamet, by the kind co-operation of Sister Hope of the West London Mission, Kingsway. In 3 cases the children were sent away free, and in 3 contributions were required towards the cost. Visitors to Centre. Being centrally situated in London, during last year, as in previous years, we have been able to welcome a considerable number of visitors, both from the country and abroad, at the Municipal Centre, No. 10, John Street. Saffron Hill Maternity and Child Welfare Centre. Consultations in connection with this Voluntary Centre are held at the St. Winifred Club, St. Feter's School, Onslow Street, Saffron Hill. During the year ended 31st March, 1927, 413 infants and children under 5 attended the consultations, 121 of the total number coming from the Holborn liorough Extra food and nourishment was provided, also convalescent treatment at country and seaside 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. 106 Deaths of Infants under One Year of Age, 1927. 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 Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 1 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... 1 1 ... 1 ... ... ... 2 1 3 Pneumonia (all forms) 1 ... ... ... ... ... ... ... 1 ... 1 1 ... ... ... ... ... 1 ... 3 ... 3 Diarrhœa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteritis ... 1 ... ... ... ... 1 ... 1 1 2 ... ... ... ... 1 ... ... 1 2 2 4 Nephritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... 1 Congenital Malformations ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Premature Births 1 ... ... ... ... ... ... ... 1 ... 1 ... ... 1 ... ... 1 ... ... 2 1 3 Atrophy, Debility, Marasmus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other causes ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... ... 2 ... 4 ... 4 Totals 2 1 0 0 0 0 1 0 3 1 4 2 1 3 1 3 1 3 1 14 5 19 Total both sexes 3 0 0 1 4 3 4 4 4 19 Net births registered during the calendar year. Net deaths registered during the calendar year. Males Females Both sexes Males Females Both sexes Legitimate Infants 227 225 452 Legitimate Infants 13 5 18 Illegitimate Infants 26 27 *53 Illegitimate Infants 1 0 1 107 Dealth of Children 1 to 5 Years, 1927. Twelve children between the ages 1 to 5 years died from the following causes:— Cause of Death. Ages. Total. 1-5 1-2 2-3 3-4 4-5 M. F. M. F. M. F. M. F. M. F Both Sexes Whooping Cough ... 1 ... ... ... ... ... 1 ... 2 2 Tuberculosis (non-pulmonary) 1 ... ... ... ... 1 ... ... 1 1 2 Pneumonia ... 2 ... 1 ... ... 1 ... 1 3 4 Bronchitis ... 1 ... ... ... ... ... ... ... 1 1 Diarrhœa ... 1 ] ... ... ... ... ... 1 I 2 Other Causes ... ... ... ... ... ... ... 1 ... 1 1 Totals 1 5 1 1 0 1 1 2 3 9 12 Totals—Both Sexes 6 2 1 3 12 Infectious Diseases among Mothers and Children. Puerperal Fever and Puerperal Pyrexia. Four cases of puerperal fever occurred in 1927; 3 of these were notified and information of 1 was obtained from the death returns; 2 patients died. Notification was also received of 8 cases of puerperal pyrexia. The details of the cases of puerperal fever are as follows:— Case No. 1 (notified March 12th). The disease followed the birth at home of a full-time child; there had been six previous pregnancies, terminating in two full-time live births, one stillbirth and three miscarriages; the mother has attended the ante-natal clinic at the Council's Centre. The case occurred in the extern practice of a midwifery institution, a doctor being called in when a rise of temperature occurred on the 7th day. It was stated that a considerable amount of pelvic cellulitis and cystitis existed. The history of the case suggested that there was old standing pelvic inflammation and that the condition was not entirely due to the present confinement. Case No. 2 (notified May 11th). The disease followed the birth of a full-time child; there had been six previous pregnancies, terminating in five full-time live births and one abortion. The birth occurred in the extern practice of the midwifery department of a hospital; partial retention of membrane seemed to have been the cause of the onset of illness. The patient had attended the Council's ante-natal Centre, and that of a hospital; she was removed to this hospital on the fourth day of the puerperium and made a good recovery. Case No. 3 (information from death returns, November 9th). The disease followed an abortion about the end of the third month of pregnancy. There had been one previous pregnancy terminating in a two months' abortion . When the patient complained at home of illness 108 she was taken directly to a hospital and. died there one hour after admission; the result of the inquest held on this patient was a verdict of death from syncope, septicaemia, abortion and septic infection of the uterus. Case No. 4 (notified November 14th) terminated fatally. The disease followed an abortion at the end of one month of pregnancy; at the onset of illness a doctor was called in who ordered immediate removal to a hospital; the patient died there eight days later. The case was notified as one of septicaemia following abortion. Puerperal Pyrexia. In a case (notified 6th January) the patient was confined in the hospital which she had attended ante-natally. The patient was known to have been suspected) of tuberculosis prior to her pregnancy, and soon after pyrexia had been notified she was also notified as having tuberculosis. She remained some time in the hospital and subsequently attended the Council's Tuberculosis Dispensary. In cases notified February 14th, June 4th and November 14th, the condition was ascribed to mastitis; in two of these the births occurred in hospital, the third in the patient's home. The two former had both attended an ante-natal clinic. In the case notified March 1st, the patient was removed to a M.A.B. hospital on account ol puerperal pyrexia and soon after arrival there was diagnosed as suffering from scarlet fever. In the case notified April 26th, enquiry did not elicit any definite cause. The patient has attended regularly at the Council's ante-natal Centre; the home conditions seemed entirely satisfactory. The patient had a prolonged illness but refused removal to hospital. Advantage was taken of the Council's arrangements to supply trained nurses in' such cases; the nurses attended the patient for several weeks, part of the cost being recovered from the patient. In the case notified August 11th, the patient was delivered of twins in a nursing home, the doctor in attendance desired to have a second opinion on the case and advantage was taken of the Council's facilities for supplying a consultant in such cases, half of the cost of this consultation was borne by the patient. Parametritis was found. In the ease notified June 26th, the patient was confined at home and removed to a hospital of the M.A.B.; it was stated that prolonged and difficult labour and some degree of mental derangement were responsible for the pyrexia. Ophthalmia Neonatorum. During the year 10 cases of ophthalmia neonatorum were brought to our notice, 9 of which were notified in pursuance of the Public Health (Ophthalmia Neonatorum) Regulations, 1914; 1 of the notifications was from a doctor in private practice and 8 from the Medical Officers of institutions. Three of these notifications were received as the result of correspondence, after the existence of the cases had been brought to our notice. In 1 case notification in accordance with the Regulations was not received; information respecting this one came from 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 109 In the following tables particulars are given as to each case:— Nine Cases Notified in Accordance with the Public Health (Ophthalmia Neonatorum) Regulations, 1914. Case Number. Age when Notified. Age at Onset. By whom Notified. Type of Disease on Health Visitor's first visit. Where Treated. Medical Attendance and Nursing. Result. Birth Notified by. REMARKS. 2 16 days 3 days Doctor (Hospital) after correspondence Slight Home Doctor, Royal Free Hospital Midwife, Royal Free Hospital Cured Extern Department, Hospital 3 22 days 7 days Doctor (Hospital) after correspondence Slight Maternity Hospital. Later at home Maternity Hospital and Out-patient Department, Charing Cross Hospital Cured Intern Midwifery Department, Hospital 4 7 days 11 days Doctor (Hospital) Not seen Maternity Hospital In-patient, University College Hospital Not seen Extern Department, Hospital Did not return to previous address from the hospital 5 18 days 17 days Doctor (Private Practice) Slight Home Doctor in charge of case, District Nurses Cured Doctor 6 6 days 6 days Doctor (Hospital) Not seen Holborn and Finsbury Hospital, then St. Margaret's Hospital. In-patient, Hospital treatment Cured Extern Department, Hospital Mother removed to hospital with puerperal fever on same day as child was admitted to Holborn and Finsbury Hospital. 110 7 18 days 15 days Doctor (Hospital) Slight Home Doctor, Charing Cross Hospital, and later Out-patient, Charing Cross Hospital, and Nurse, Charing Cross Hospital Cured Intern Midwifery Department 8 11 days 8 days Doctor (Hospital) Moderate, both eyes Hospital, and later at home In Maternity Hospital Cured Intern Midwifery Department 9 10 days 6 days Doctor (Hospital) Moderate, both eyes Home Doctor, Middlesex Hospital, and later as Outpatient, Middlesex Hospital, and District Nurse Cured Extern MidwiferyDepartment 10 19 days 1 st day Doctor (Hospital) after correspondence Slight Home Midwife, University College Hospital, and Outpatient, and University College Hospital Not seen Extern Department, Maternity Hospital One Case 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. Birth notified by. Remarks. 1 16 days 3 days London County Council Not seen Home Doctor and Midwife - Midwife Patient left her address on the 12th day of confinement between morning and evening visits of doctor and midwife and did not return to this address did not leave any address and could not be traced 111 Ophthalmia neonatorum is one of the most important causes of blindness. Fortunately, however, as far as we have been able to ascertain, no case coming to our knowledge last year in the Borough suffered permanent injury in this way. In two cases reliable information could not be obtained because the mother of the infant did not return to this Borough, but in the remaining eight cases there was definite evidence that the patients were cured. This result was secured by the expenditure of much time and energy, and incidentally money, by all concerned; the occurrence of most, if not all, of the cases could have been prevented by a simple procedure. Two or three years ago the Scottish Board of Health issued a circular to medical practitioners strongly recommending the installation of silver nitrate solution into the eyes of newly-born children, and intimating that they will in future require a report with particulars of treatment from Medical Officers of Health in all cases in which there occurs loss of vision. In this country the installation has been recommended with fortunate results by at least several Medical Officers of Health to those attending childbirths in their areas, but legislation in some form advocating or requiring its adoption generally is required so that the whole country may benefit. Whooping Cough. Visits were paid to 103 persons suffering from whooping cough. Of these, 82 were notified by doctors; in 12 others the information was derived from the schools; 3 from parents; 5 from M.A.B., and 1 from a hospital. Five died, 3 under 1 year and 2 between 1 year and 5 years. Age. Thirteen were children under 1 year, sixty were aged 1 to 5 years, and thirty 5 to 16 years. Contacts. (103 enquiries.) Thirty-seven had no contacts; 66 had contacts. The number of contacts was 196, of whom 120 were susceptible, 76 already having suffered from an attack. No. of cases and 17 11 9 8 6 2 1 0 2 1 No. of contacts 1 2 3 4 5 6 7 8 9 15 No. of cases and 22 13 6 5 0 1 0 1 2 No. of susceptible contacts 1 2 3 4 5 6 7 8 10 Spread of Infection in Family. The 103 cases occurred in 77 families. In 56 families 1 case occurred; in 17 families 2 cases occurred, and in 3 families 3 cases occurred; and in 1 family there were 4 cases. 112 The continued advice to parents to look upon a child suffering from whooping cough as a serious menace to others has drawn their attention to the fact that this disease is one which should he viewed with more concern than it is at present. Parents frequently express the view that there is need to educate public opinion as to the dangers of leaving children exposed to the risk of infection from whooping cough as is so often the case at present. Measles. The notification of measles was discontinued at the end of 1919 but during 1927 I received information of 22 cases of measles. Of these, 4 were notified by school teachers, and 7 by medical practitioners; information of 3 was given by the Metropolitan Asylums Board, 4 by the Health Visitors, and 4 by parents. Ages. 2 were under 1 year. 9 were between 1 and 5 years. 9 were between 5 and 16 years. 2 were over 16. Contacts. Eleven had no contacts, the L.C.C. definition of a contact being used. Eleven had contacts. The number of contacts was 38 of whom 15 were susceptible, 23 having already suffered from an attack. No. of cases 4 3 1 1 0 1 1 and No. of contacts 1 2 3 4 5 6 15 No. of cases 2 5 1 and No. of susceptible 1 2 3 contacts Spread, in Family. The 22 cases occurred in 20 families. In 16 families 1 case occurred, in 2 families 3 cases occurred. Removals. Four patients were removed to a M.A.B. Hospital. Home Nursing. Two cases of measles were nursed by the Metropolitan Nursing Association under the arrangements made by the Council. 113 Spread of Infection. There is much difficulty in getting parents to realise that the child of preschool age must be sheltered from the risk of infection as much as the child attending school. Parents realise that the school child is a potential focus of infection for many other children, and should be guarded from infection; they fail to realise that the pre-school child, although less likely to spread the disease, is less able to resist the dangers of an attack; many parents state candidly that they send children with whooping cough into the squares and streets during school hours, when "there are no other children about." Measles Control in Schools. In view of the biennial epidemic of measles which was expected at the end of the year 1927, arrangements were made by the London County Council to speed up the machinery for securing through the School Organisation, earlier information of cases of measles. The need for improving the procedure was given impetus by the decision of the Metropolitan Asylums Board to allocate in their infectious diseases hospitals a greater proportion of beds for measles than for scarlet fever. The primary object of any scheme of notification of measles, whether compulsory or voluntary, is to obtain the co-operation of parents. In this connection advice leaflets to parents were prepared for distribution through the School Organisation and arrangements were made for the head teachers to facilitate this distribution so that the leaflets should reach every family represented in a school where measles was reported to have occurred in the family of any of the pupils. Arrangements were made for Health Visitors to follow up cases of measles notified from the schools; provision was continued for nursing assistance in the homes where necessary and efforts were made to secure removal of patients to hospitals of the Metropolitan Asylums Board. The arrangement also included provision for the notification by the Medical Officer of Health to the head teachers of the various schools of cases of measles occurring in houses occupied bv children attending the schools which were discovered by the Health Visitors, apart from the' notifications received from the School Organisation. Tn the latter part of 1927 and the early part of 1928 the scheme was applied to nine schools in the Borough. German Measles. During the year information was received relating to 4 cases; information of 1 case was received from the M.A.B., the other 3 cases occurred in the same family and information was given by the mother. Ages. 2 were between 1 and 5 years. 1 was between 5 and 16 years. 1 was an adult. Contacts. The number of contacts was 5 of whom 3 were susceptible, 2 already having suffered from an attack; 1 had nc contacts. h 114 Spread in Family. The 4 cases occurred in 2 families. Tn 1 family 1 case occurred, in 1 family 3 cases occurred. Removals. 1 case was removed to the London Fever Hospital. Epidemic Diarrhcba. 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 5, of whom 4 were under 1 year. The deaths were equal to a rate of 9.9 per 1,000 births in comparison with 7.5 for all London The methods used to deal with the disease have been detailed in a previous report; the most important perhaps is that during the third quarter of the year extra visits are paid to those homes in which epidemic diarrhoea is more likely to occur. Nursing of Pemphigus Neonatorum. From time to time outbreaks of pemphigus, a contagious skin disease, fatal at times, occurs among young babies and it is considered possible that the disease may be spread by midwives. During the year 1927 the Maternity and Child Welfare Committee were informed that the London County Council desired arrangements to be made by which midwives should be relieved of such cases immediately they occurred. Any arrangement, therefore, for the nursing of pemphigus would necessarily include the nursing of the mother until the end of puerperium. With a view to meeting the position and so avoiding risk of infection being carried by midwives, the Council made arrangements with the Metropolitan District Nursing Association for the nursing of such cases by their nurses, payment to be at the same rate as for other nursing undertaken by the Association for the Council. In a communication dated 17th November, 1927, the sanction of the Minister of Health to the arrangement was conveyed subject, however, to the condition that although the maternity nursing of the mother would up to the end of the lying-in period rank for grant under the Maternity and Child Welfare Regulations, the grant would not be available in respect of the cost of nursing the baby suffering from pemphigus. The communication, however, intimated that the matter would be reconsidered in connection with any revision of the Regulations. 115 Nursing Arrangements. Nursing arrangements have been made with the Metropolitan Nursing Association of 31, Bedford Place, W.G.1, for the nursing, when required, of necessitous cases of measles, whooping cough, ophthalmia, neonatorum, pemphigus neonatorum, epidemic diarrhoea, pneumonia, encephalitis lethargica, tuberculosis, maternity (including complications after confinements), puerperal fever and puerperal pyrexia. In cases of tuberculosis nursing is restricted to patients recommended for such services by the Tuberculosis Officer. Nursing in necessitous maternity cases is subject to the approval of the Maternity and Child Welfare Assistance Sub-Committee. In these cases and those relating to puerperal fever and puerperal pyrexia, it is expected that the patients or their relatives will contribute towards the cost in accordance with their means. The services of the nurses were used as follows in 1926:— Deficient Lactation 25 Cases 308 Visits. Complications after Pregnancy 2 „ 55 „ Measles 2 „ 20 „ Whooping Cough 1 Case 51 „ Ophthalmia Neonatorum 2 Cases 30 „ Pneumonia 6 „ 103 „ Influenza 1 Case 8 „ Tuberculosis 6 Cases 202 „ Total 45 Cases 777 Visits. Widows', Orphans' and Old And Contributory Pensions Act, 1925. No case was referred to the Council for enquiry under the above Act during the past year. Health and Baby Week, 1927. The observation of Health and Baby Week during the first week in October in 1927 was limited to co-operation with the School Organisation and a special session for mothers attending the Maternity and Child Welfare Centres. Co-operation with Schools.—The School Organisation in the Borough co-operated as in previous years by arranging for health lessons to be given and for a series of health questions to be submitted to the children during health week. The questions were prepared in the Public Health Department. The best three 6ets of answers in each school department were selected by the head teacher for H 2 116 examination in the Public Health office, two prizes being awarded to each school, one for boys and one for girls. The Mayor and Mayoress kindly entertained to tea the prize winners and the children whose essays were selected from the various schools. Tn addition, the Mayor kindly provided six additional prizes, two of these taking the form of special prizes for the boy and girl whose answers to the questions were considered the best in the Borough. The four other Mayor's prizes took the form of consolation prizes and were given to the four children, two boys and two girls, whose papers were considered to be next in order of merit to the ordinary prize winners. It is satisfactory to record that all the Elementary schools in the Borough took part in this movement, which has now become a useful and well established annual custom in Holborn. The following- is a copy of tlie questions submitted to the children in the schools: — Section A. (All four questions to be answered.) 1. Why do children need more sleep than healthy adults? Describe a bedroom as it would be kept in a home where health is fully considered, giving reasons for what you say. 2. What would you do to keep a pantry clean ? How could fresh air be admitted, and, at the same time, dust, dirt and flies be kept out? 3. Mention some of the best ways of exercising your body. When and where should this be done? 4. What is the best way of cleansing your body ? Why is it so necessary to be perfectly clean ? Section B. (Any two of the following questions to be answered.) 5. Why should children not eab heavy suppers? What food should they ha\e, and how long before going to bed ? 6. Mention the best means of keeping teeth and gums in a healthy condition. 7. Why should children not be allowed to play in the streets and roads? Where are the best places for them to carry on their games, and why ? 8. Why does every child need a pocket-handkerchief? At what times should it be used? Meeting for Mothers.—On Thursday, October 4th, a special meeting for mothers attending the Maternity Centres was held at the Centre, No. 10, John Street. An address on " Common Sense and Health " was given by Mrs. T. Eve (nee Miss Enid Orange) formerly Health Visitor in the Borough. The large number of mothers present greatly enjoyed the return visit from Mrs. Eve who, in the early days of the Centre, did much to establish its usefulness and increase its popularity. Mrs. Eve's practical address was much appreciated and subsequently was duplicated and a copy furnished to every mother attending the Centre. 117 Minor Ailments Clinic. Arrangements were continued at the Municipal Child Welfare Centre, 10, John Street, for the treatment of minor ailments in children up to 5 years of age. The Clinic opened on the 12th April, 1925; it is held every Tuesday and Friday afternoon to deal with such minor ailments as ringworm, impetigo, scabies, intertrigo, sores, cuts, grazes, burns, blepharitis, conjunctivitis, ear discharge, etc. The Clinic is under the supervision of the Medical Officer of the Maternity and Child Welfare Centre and a qualified nurse is in attendance. 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 tlie L.C.C. Schemes:— (1) Finsbury Centre, Spencer Street, Goswell Road. (2) Moorlields Ophthalmic Hospital, City Road. (3) Solio 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 tile following Hospitals and Dispensaries:— (1) St. Bartholomew's Hospital. (2) Bloomsbury Dispensary. (3) Central Londou Ophthalmic Hospital. (4) Central London Throat and Ear Hospital. (5) Dental Hospital. (6) Homoeopathic Hospital. (7) Hospital for Sick Children. (8) Italian Hospital. (9) Metropolitan Ear, Nose and Tnroat 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. A suggestion has been made that possibly this co-operation might be extended by facilities being given for the establishment at the Council's Maternity and Child Welfare Centre, No. 10, John Street, of a Medical Inspection and Treatment Centre for children attending elementary schools in the Borough. For some years a Minor Ailments Clinic has been established at this Centre and this Clinic could conveniently be made available for use by children of school age. The Maternity and Child Welfare Committee have approved the suggestion and it is probable that the matter will shortly be brought before the appropriate Committee of the Educational Authority, the London County Council. 118 Medical Examination of School Children-Routine Inspections—Elementary Schools in Holborn, 1927. Age Group. Number examined. Clothing and Boots. Nutrition. Cleanliness of Head. Cleanliness of Body. Condition of Teeth. Vision. Good. Fair. Poor. Good. Average. Below normal. Clean. Nits. Pediculi. Clean. Dirty. Pediculi. All sound. Less than four decayed. Four or more decayed. 6/6 in both eyes. 6/9 in either eye. 6/12 or wor»e in either eye. Entrants— Boys 152 87 63 2 17 129 6 137 15 ... 149 3 ... 82 54 16 ... ... ... Girls 237 148 88 1 34 183 20 228 8 1 236 1 ... 126 79 32 ... ... ... Age 8— Boys 210 64 129 17 33 158 19 188 21 1 208 2 ... 116 66 28 152 15 39 Girls 154 66 82 6 27 113 14 122 25 7 152 2 ... 84 59 11 112 10 30 Age 12- Boys 189 49 132 8 27 146 16 173 15 1 185 4 ... 130 55 4 141 11 37 Girls 195 46 142 7 46 139 10 143 47 5 193 2 ... 137 53 5 136 12 47 Age 14— Boys 227 45 167 15 50 160 17 208 18 1 227 ... 164 59 4 164 13 49 Girls 19 51 142 3 46 136 14 161 34 1 195 1 ... 147 48 1 137 10 49 Total 1,560 556 945 59 280 1,164 116 1,360 133 17 1,545 15 ... 986 473 101 842 71 251 1164 Holborn % ... 35.6 60.6 3.8 18.0 74.6 7.4 87.2 11.7 1.1 99.0 1.0 ... 63.2 30.3 6.5 72.3 6.1 21.1 London % ... 58.7 40.2 1.1 20.2 74.8 5.0 93.5 5.9 0.6 96.6 3.3 0.1 63.0 29.4 7.6 54.2 25.9 19.9 119 Defects Found At Medical Inspection, Holborn Elementary Schools, 1927. Defect. Boys. Girls. Entrants Age 8 Age 12 Age 14 Entrants Age 8 Age 12 Age 14 Number Examined 152 210 189 227 237 154 195 196 Cases + Cases + Cases + Cases + Cases + Cases + Cases + Cases + Malnutrition - - - - - - - - - - - - - - - - Skin Disease — — 2 1 1 1 - — 5 5 1 1 — - 1 1 Enlarged Tonsils 15 5 9 6 2 2 2 2 9 1 6 2 6 5 3 2 Adenoids 3 2 5 5 2 2 1 1 4 3 6 4 4 4 3 3 Tonsils and Adenoids 26 20 12 10 2 2 7 7 22 22 8 6 5 5 5 4 Other Nose and Throat 1 1 1 — — — 2 2 1 1 3 2 1 1 1 1 Enlarged Glands — — — - — — — — 1 1 1 - — - - — External Eye Disease 11 10 7 2 4 1 2 1 9 9 4 2 6 5 3 1 Vision for treatment — — — 30 — 29 — 24 — — — 9 - 38 - 24 Otorrhœa 3 2 1 1 1 1 4 1 4 4 — — 1 - - 3 Other Ear Disease - - - - - - - - - - - - - - - - Hearing 1 1 1 1 1 1 1 1 — — 2 1 1 1 1 1 Speech defects - - 1 1 - - - - - - - - 1 - - - Heart — — 1 — 1 — — — - - 2 1 3 — 3 — Anæmia — - 1 1 2 1 — — 1 1 — — 1 - — — Lung Disease (excl. TB.) 3 - 2 1 - - 1 1 3 1 1 - - - — - Nervous Disorders — - — — - - 1 1 — — — — 1 - 1 — Phthisis - - - — - - 1 - - - 1 - - - - - Other Tblr. Disease 1 1 1 1 — - — — 1 1 — — — — — — Rickets 1 - - - - - - - - - - - - - - - Spinal Deformities - - 1 - 1 - - - - - - - 1 - - - Other Deformities — — — — — — — — 1 — 1 — - — 1 1 Teeth (treatment cases) — 46 — 76 — 49 — 61 - 86 — 60 — 43 — 41 Other Defects - - - - - - - - - - - - - - - - Number of Children noted for treatment 72 109 73 89 111 83 86 65 + = Cases referred for treatment. 120 Deaths of Children 5-15 years, 1927. 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 Pneumonia ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Violence ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 Heart Disease ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... ... 2 2 Other Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... ... 1 1 2 Total ... ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... ... 1 2 1 ... 3 3 6 Total both sexes ... ... ... 1 ... ... 1 ... 3 1 6 121 SANITARY ADMINISTRATION. Public Mortuary. The Public Mortuary provided by the Council is situated in Goldsmith Street During the year 55 bodies were deposited. There were 38 post mortem examinations made, and 28 inquests held. The inquests are held in the Court Room at the Town Hall. On 10 occasions bodies awaiting burial were removed to the mortuary on account of inadequate accommodation in the homes; 44 bodies were brought in by order of the Coroner, and 1 by the Police. Inquests. During the year 37 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, 16; Accidents, 9; Suicide, 11; Misadventure, 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. The Removal of Aged, Infirm and Diseased Persons. Difficulty from time to time arises in connection with aged, infirm or physically incapacitated persons living alone, usually in single rooms. Many of these have nobody to look after them and gradually become feebler, eventually being unable to look after themselves or their homes properly and yet they are most unwilling to enter a Poor Law Institution. 122 At present persuasion is used, but the condition persists for a considerable time. It is difficult to suggest any solution of the problem other than the granting to local authorities of powers to compel removal to suitable institutions. The principle of such compulsory power has been established by the Bradford Corporation Act, 1925. Under this Act a Court of Summary Jurisdiction may, on the application of the Medical Officer of Health, issue an order for the removal of any aged, infirm or physically incapacitated person where it is shown that, in the public interest or in the interest of the person concerned, such removal is necessary. During the year 1926 the views of the Council were asked as to the desirability of similar provisions being incorporated in a London County Council (General Powers) Bill and on the recommendation of the Public Health Committee the Council adopted a resolution approving in principle that Metropolitan, Borough and City Councils should be granted powers to obtain the removal of infirm and diseased persons in certain cases, and approving a request to the London County Council to insert provision accordingly in their next General Powers Bill. In the London County Council (General Powers) Bill introduced into the House of Commons in the session 1928, a section is included to give power to a petty sessional court to make an order for the removal to a suitable hospital or other institution, of aged, infirm or physically incapacitated persons, subject to conditions specified and a certificate from a Medical Officer of Health that such person is unable to attend to himself or to receive from persons with whom he resides proper care and attention. Rent and Mortgage Interest (Restriction) Acts, 1920-1923. No application was received during the year for a certificate under the above Acts that a house was not in all respects reasonably fit for human habitation or otherwise not in a reasonable state of repair. One application was received from the landlord of a house for a certificate that the repairs required to put a dwelling house into a reasonable state of repair had been executed to the satisfaction of the Sanitary Authority. The work necessary having been efficiently carried out, this certificate was granted. Nuisances—Complaints from Relieving Officers. Under Section III of the Public Health (London) Act, 1891, it is the duty of every Relieving Officer in accordance with the regulations of the Authority having control over him, to give information to a Sanitary Authority of any nuisance liable to be dealt with summarily under the Act. In accordance with this requirement four informations of nuisances were received from the Believing Officers during the year, dealing with the dirty condition of rooms, overcrowding and offensive smells arising from the improper keeping of cats and dogs. Steps were at once taken to secure the abatement of the nuisances referred to. This co-operation with the Officers of the Board of Guardians is found to be most useful. Nuisances Caused by Dogs. With a view to the prevention of nuisances from the fouling of footways by dogs the Council, in the year 1926, made the following by-law:— 123 " No person being in charge of a dog in any street or public place and " having the dog on a lead shall allow or permit such dog to deposit its " excrement upon the public footway." The by-law is to remain in force until the 1st June, 1928. Choked Water Closets. Nuisances frequently arise, particularly in tenement houses, due to the misuse of water closets resulting in repeated choking. It is found that tenants get into the habit of using one pail as a receptacle for refuse of all kinds, e.g., bedroom slops and waste water, tea leaves, vegetable parings, etc., the contents being ultimately thrown down the water closet. This practice inevitably leads to the water closet being stopped up; on the other hand it would be objectionable if the whole contents of these pails, often largely of a liquid nature, were placed in the dust bins. The use of a " scullery receptacle " would enable this difficulty to be met. This receptacle consists of an ordinary sized domestic pail with a movable drainer. The use of this article in the place of an ordinary pail enables solid matter, such as potato parings, to be separated from the liquid matter. The latter can be readily disposed of by emptying down the water closet or suitable gulley, the former can be burnt or placed in the dust bin. Demolition of Old Buildings. From time to time nuisances occur from dust arising from the demolition of old buildings. In the year 1926 the Council adopted a resolution in favour of the inclusion in a London County Council (General Powers) Bill of powers to control the demolition of old buildings, the powers to be administered by and at the discretion of the Borough Councils, with a view to the prevention of nuisances from dust. The London County Council (General Powers) Act, 1927, gives power to the London County Council to make by-laws in relation to the demolition of old buildings within the County, exclusive of the City of London and the places known as the Inner and Middle Temple. Pending the making of the by-laws a series of suggestions for the prevention of such nuisances was prepared for use in Holbom. Information respecting proposed demolitions is furnished by the Borough Surveyor and a copy of the suggestions is then forwarded to Contractors proposing to commence demolitions in the Borough. In the year 1927 the suggestions were forwarded to nine Contractors, a number of whom acknowledged the communications and agreed to comply with the suggestions made. The following is a copy of the suggestions referred to:— 1. Provide and fix proper fans at first floor level and other floors if necessary. 2. Board up window openings from which sashes and glass have been removed. 3. Pull down internal partitions storey by storey before taking down external walls of the respective storeys. 4. Provide canvas or other suitable screens where necessary to prevent nuisance from dust. 5. Before and during the process of demolition and during subsequent removal all dust and material should be freely sprayed with a hose and rose jet. 124 6. So far as practicable any process connected with the demolition likely to cause nuisance from dust should not be carried out during ordinary business hours, particularly if the building to be demolished is in a main thoroughfare. 7. On completion of demolition all necessary steps should be taken effectually to seal off all drains so as to prevent any nuisance from rats. In connection with the power now conferred on the London County Council to make these by-laws, it may be of interest to recall that as long ago as the year 1915 the Holborn Council asked the Local Government Board to sanction the making of a by-law to control the demolition of old buildings with a view to the prevention of nuisances from dust. The Board was unable to assent to the proposal and suggested that proceedings should be taken for the abatement of any such nuisance under Section 2 of the Public Health (London) Act 1891. Subsequently proceedings were so taken, the summons being dismissed by the Magistrate at the Police Court on the ground that the nuisance did not arise within Section 2 of the before-mentioned Act. Nuisance from Pigeons. The London County Council (General Powers) Act, 1927, gave power to Local Authorities in London to take steps for the purpose of abating or mitigating or preventing or minimising any nuisance, annoyance or damage caused, or which might be caused, by the congregation at any place in the County of London of house doves or pigeons having, or believed by the Local Authority to have, no owner. The Act gave power to Local Authorities to seize, destroy and sell or otherwise dispose of such doves or pigeons in excess of such number as the Authority might consider reasonable. Attention having been drawn by a Local Authority in London to nuisances arising from pigeons, a conference of Medical Officers of Health of areas concerned was convened and held at the County Hall with a view to considering the best steps to be taken for putting into operation the powers above referred to. In Holborn, ownerless pigeons have, from time to time, given rise to nuisance. It was found that a large number of such pigeons lived on and around the British Museum buildings, and H.M. Office of Works expressed willingness to co-operate with the Council in dealing with the matter. Nuisances from similar sources were also found to exist on certain churches and in connection with some other buildings in the Holborn area. A suggestion was made at the Conference above referred to, that concerted action should be taken by the Local Authorities of the districts particularly affected and it was agreed that action was desirable for the purpose of (1) reducing the number of pigeons by one-third to half of the present number and (2") preventing the access to and the breeding of pigeons in churches and other buildings where complaint is made of nuisance. It was proposed that a " trapper " should be employed for trapping in the early morning and the removal alive of the pigeons in suitable baskets to a fixed centre where ringed birds would be separated from the others for handing over to the Homing Union, the ownerless birds being lolled. Communications were opened up with a number of firms dealing with the catching and killing of vermin and quotations were obtained from these firms for undertaking work connected with the killing of pigeons. Difficulties, however, supervened and negotiations between the London County Council, the Local Authorities concerned and the firms who were invited to undertake the work of trapping and killing the pigeons in the London area were continued for some time. Ultimately, in the early part of May, 1928. a Conference of Medical Officers of Health, held at the County Hall, recommended the employment under contract 125 of Mr. Tom Anthony for the trapping and disposing of pigeons in the various Metropolitan Boroughs. An agreement with Mr. Anthony for carrying out the work in Holborn was at once entered into accordingly. Nuisances Connected with Brick Crushing Works. For some years a brick crushing industry has existed in the Borough. Brick rubbish derived from demolished buildings is brought to this yard and crushed. The broken brick f to 1 inch in diameter is used for concrete and the fine dust-like material for the making of mortar and tennis courts. The crushing plant lies well back from the public way and is enclosed on three sides and roofed with corrugated iron. One side is open to allow of the removal of the broken brick. In the ordinary way bricks whole or broken are brought by lorry and unloaded behind the crusher; a hose is turned on the bricks so deposited to damp them down. The material is put into the first crusher and afterwards lifted by an enclosed chain elevator to a riddle and the coarser part passed through a second crusher; the dust amounting to about one-tenth of the whole drops into a barrow and is wheeled away. The crushed brick falls to the floor to be thrown by shovels on to adjacent heaps. Practically no dust escapes during the process and no nuisance appears to arise from the actual work of brick crushing. Nuisance, however, does at times arise from the handling of the material previous to crushing. Although the works have been operating in the Borough for five or six years no complaint was received until the early part of the year 1927. On enquiry it was ascertained that brick rubbish containing an unusually large proportion of dust was being delivered in greater quantity than could be readily dealt with by the crusher. A large heap of the refuse was piled near the front entrance. During unloading, when the rubbish was thrown up several feet to the top of the heap, the finer particle's were caught by the wind and blown in the form of a cloud of dust over the top of the hoarding into the roadway. Representations were made, to the proprietors of the industry who at once arranged for the enclosing hoarding to be raised to a height of from 14 to 15 feet from the ground level. Foundling Hospital Site. An event of the year closely affecting the amenities of the Borough, was the removal of the Foundling Hospital from its historic site in Guilford Street to the country. The Hospital and the grounds in which it stood although not- actually within the Borough was immediately adjacent to the Borough boundary, and the grounds attached to the Hospital afforded a valuable open space in a crowded neighbourhood. Proposals were made for the acquisition of the site for commercial purposes and a Bill was promoted in Parliament to enable Covent Garden Market to be transferred from its present venue to the Foundling Hospital site. Strenuous cpposition was offered to the proposal and the Bill was withdrawn. Efforts were also made to secure the site and utilise the buildings as an Imperial and International Students' Centre for London. Proposals have also been put forward, and found considerable favour, for securing the site for the purpose of building a new Hospital for Sick Children in place of the Hospital now in Great Ormond Street and for the preservation as an open space of the land which would not be 126 used for the purpose of the Hospital. There is reason to believe that proposals are also on foot for utilising the site for the erection of residential flats. Everyone concerned with child life and public health interests in the neighbourhood generally, must be anxious that to whatever use the site is ultimately put, the part of it which has hitherto been open space should be preserved as such and, as far as possible, devoted to the use of children for playground or open air school purposes. Town Planning Scheme. In the year 1926 plans were deposited by the London County Council of a Town Planning Scheme, dealing in part with land within the area of the Borough and known as the Administrative County of London Town Planning Scheme No. 5. The area involved in the first part of the scheme, 133 acres in extent, comprised a portion of the Foundling Hospital Estate (43 acres) and certain adjoining districts, including a number of squares, some being wholly or partly in the Borough. The preservation of these squares (7.13 acres) was considered to be a matter of public importance. The land included in the scheme was in the hands of several owners and it was hoped that by the exercise of town planning powers the County Council would be able to assist in promoting a scheme of re-development of the whole area which would be advantageous to the owners as well as desirable from a public point of view. The second part of the scheme dealt with an adjacent area, about 75 acres, between Euston Road, Great Russell Street, Gower Street, and Woburn Place. The area, it was stated, was ripe for re-development and contained many amenities which it was desirable to preserve aa far as possible. The area covered a number of garden squares, including Russell Square, Tavistock Square, Gordon Square, Torrington Square, and Woburn Square, and, in addition, included about 11½ acres on both sides of Torrington Square which had been offered by the Government as a site for the University of London. Early in the year 1928 a public inquiry into the application for approval of the scheme was held by direction of the Minister of Health. Subsequently the Council received a copy of a communication addressed by the Ministry of Health to the London County Council intimating his findings on the subject of the scheme. The Minister stated that the matter was an important one for the development of London and he appreciated the reasons of the London County Council for putting forward the proposals but on consideration of the evidence and arguments placed before the Inspector who held the enquiry, the Minister found it necessary to distinguish between (a) the site of Ihe Foundling Hospital and the two adjoining squares (Mecklenburgh and Brunswick), (b) the site acquired by the London University north of the British Museum, together with Torrington Square, and (c) the remainder of the land included in the proposed scheme. With regard to the last-mentioned land (c), the Minister was not satisfied that this area, the pre at bulk of which was still closely covered with buildings, could properly be regarded as " land likely to be used for building purposes " within the meaning of Section 1 (1) of the Town Planning Act, 1925, and he, therefore, formed the conclusion that the proposals put forward hy the County Council as regards this land were beyond their powers under Section 1 (1) of the Act. except to the limited extent that land already built upon might be included in a scheme under the proviso to that sub-section. As regards (b) the Minister stated that the London County Council presumably would not consider there would be an advantage in preparing a scheme for the land included in the area, having regard to the prospective use of the land. As regards (a) (Founding Site) it seemed inadvisable to town plan a relatively small area in the midst of already developed areas which could not under present powers be made subject to appropriate restrictions, unless in any particular case there were special conditions which justified an exception. The Minister appreciated that there might be such conditions ir. this case and intimated that hfl would be prepared, if the County Council so desired, to consider proposals for this area and, vnder the proviso to Section 1 (1) of the Act of 1925, for a. fringe of developed land. He suggested, however, that before action was taken on those lines it would be an advantage if the County Council communicated with the owners to s~> whether arrangements as satisfactory as could be expected under the present conditions could not be made without a formal scheme. 127 The Minister also suggested that the County Council might think it well to consider whether to call a conference of the owners of the land included in the original scheme with a view to seeing whether it was practicable to arrive at a voluntary arrangement for the development of the area on systematic lines when any rebuilding operations were undertaken. It appeared to him that such an arrangement might well be to the advantage not only of London as a whole but of the individual owners. In communicatiug his decision to the latter, the Minister urged their favourable consideration of the matter should they be invited to a conference by the London County Council. Children's Country Holidays. In connection with the arrangements made by the Children's Country Holiday Fund, and the Fresh Air Fund, for sending children away for country holidays, we receive and answer many enquiries during the summer months relative to the existence of infectious diseases in the houses from which the children are drawn. This routine co-operation between the local authority and the organisations concerned helps to ensure that children who have been directly exposed to infection shall not be sent away until danger of the development of disease in the contact child is past. Lavatory Accommodation on Railway Stations. During the year attention was directed to the question of lavatory accommodation for men at one of the stations of the Underground Railway in the Borough and some consideration was given to the question whether the public health law requires a railway company to provide sanitary accommodation for travellers using the railway. The underground railways in London are, of course, in a special position; their space below ground is limited, it may even be below sewer level, and their journeys are short. Nevertheless, there seemed no reason why the ever increasing crowd of passengers should be denied facilities at any single station or be left in doubt as to which station contained what they required. The big London shops and stores have long realised that the provision of lavatory accommodation is an attraction to customers, if not a positive duty. If the railway companies, whatever their freedom from statutory obligation, will take the same view the public will be grateful. The Holborn Council on considering the matter decided to communicate with the railway company asking that in the interests of the public, the company would re-open the conveniences at the particular station in question. Propaganda. Arrangements were continued with the co-operation of the Library Committee for distribution of two bookmarks, one for adults and one for children. On the front information was given as to health and education facilities afforded by the Council, on the back of the bookmark for adults information was contained respecting the arrangements for the prevention of diphtheria by immunisation; the back of the children's bookmark contained hints to boys' and girls as to how to keep healthy. In the early part of 1928 during the preparation of this report, arrangements were made with the approval of the Education Authority and the Head Teachers, for a copy of the children's bookmark to be distributed to children attending elementary schools in the Borough. 128 Leaflets on health subjects were issued, as in previous years, for distribution by means of "Please take one " boxes in the public conveniences for men and women. The London County Council (General Powers) Act, 1926, gave power to Metropolitan Local Authorities to arrange for the publication of information of questions relating to health or disease and for the delivery of lectures and the display of pictures in which such questions are dealt with. This new power should be of much use in the dissemination of knowledge of health subjects. In the Borough of Holborn we have, from time to time, made use of pictorial propaganda to the limited extent permissible before passing of the Act of 1926. It is all to the good that essential health requirements should be presented in pictorial form in order that such teaching may be absorbed and made part of the belief and life, not only of children but of young and even adults. Manufacture, of Wine. A number of residents in the Italian Colony make wine. In 2 cases wine is made under excise licences but in other cases it is for home consumption only. The method adopted in the Colony for making the wine, is as follows: — Grapes are imported from Italy in boxes containing about SO lbs. of small black grapes. The grapes having been washed and freed from stalks, are placed in a press where the juice is pressed out into vats. The pulp is also placed in the vats with the juice. To start fermentation, and give the wine its characteristic flavour, grapes with their stalks are boiled and the liquor resulting therefrom is poured into a vat containing the juice from the pressed grapes in the proportion of the liquor from 20 lbs. grapes to 40 gallons juice. The mixture is then allowed to ferment for 8 or 10 days, being stirred twice daily. The liquor is then drawn off and placed in barrels with the open bungholes at the top. Fermentation is continued, the barrel being kept full and the froth or scum allowed to escape. When fermentation ceases the bung is sealed up. After standing about three months the wine is drawn off and bottled. It is stated that from 2½ to 4 gallons of wine is obtained from 80 lbs. of grapes. Finsbury and Holborn Advisory Committee for Juvenile Employment. In June, 1927, the above Committee was re-appointed by the Ministry of Labour. The Committee includes representatnes nominated by the London County Council and the London Teacher's Association. The Secretary of the Committee is Miss A. B. Gaite, King's Cross Employment Exchange, 207a, Pentonville Road. The Annual Report of the Committee for the year 1927 gives a record of the work done in connection with placing boys and girls in employment, industrial supervision of boys and girls, apprenticeships, overseas settlement, and other activities cognate to the welfare of boys and girls leaving school. The Use of Vita Glass. Opportunity has again been taken during the year to call attention to the desirability of the use of Vita glass. This grlass lets actinic rays through and its use in place of ordinary window glass is much to be desired where possible Vita glass is made in three different types, namely. Clear Sheet Vita glass similar to ordinary transparent window glass, which can be used in ordinary sash sizes, the standard price being 2s. per sq. ft... Polished Plate Vita glass about 5/32 in. thick, costing from 4s. per sq. ft. upwards according to size, and Cathedral Yita Glass with a semi-transparent surface about 5 in. in thickness at l'Pd. per so. ft. In the list of prices current for materials as published in The Builder (".Time. 1928V 2fi 07.. English sheet glass (thirds) is quoted at G^d. per sq. ft-, and English rolled plate, 5}d. 129 APPENDIX. TABLE I. Vital Statistics of Whole District during 1927 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 Number Net Number Rate of Nonresidents registered in the District of Residents not registered in the District Number Rate per 1,000 Births Number Rate Number Rate 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 23.1 532 490 70 141 820 22.3 1919 38,156 397 539 13.6 920 24.1 618 322 52 96 624 16.4 1920 39,676 619 827 20.6 827 20.6 568 339 55 66 603 15.2 1921 43,520 483 648 14.8 859 19.7 622 319 51 79 556 12.8 1922 42,850 485 664 15.5 746 17.4 518 342 48 72 570 13.3 1923 43,376 423 593 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 1925 43,315 364 527 12.16 725 16.7 513 330 33 63 542 12.5 1926 43,200 330 535 12.38 629 14.6 454 347 48 90 522 12.1 1927 42,209 320 505 11,96 728 17.2 531 333 19 38 530 12.5 In the above table the population, birth rate and death rate are as estimated by the Registrar-General, founded upon his estimates of the civilian population, I 130 TABLE II. Causes of, and Ages at, Death, 1927. 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 530 19 6 6 6 15 70 191 120 97 Uncertified ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... ... 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... 3 Measles ... ... ... ... ... ... ... ... ... ... ... 4 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... 5. Whooping Cough 5 3 1 1 ... ... ... ... ... ... ... 6. Diphtheria and Croup 1 1 ... ... ... ... ... ... ... ... ... 7. Influenza 20 ... ... ... ... 1 6 11 1 2 2 8. Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 9. Meningo-coccal Meningitis ... ... ... ... ... ... ... ... ... ... 10 10. Tuberculosis of Inspiratory System 51 ... ... ... ... 6 15 27 2 1 21 11. Other Tuberculous Diseases 4 ... 1 1 ... 1 ... ... l ... 42 12 Cancer, malignant disease 50 ... ... ... ... ... 2 21 20 7 52 13. Rheumatic Fever 2 ... ... ... ... ... 2 ... ... ... 4 14. Diabetes 5 ... ... ... ... ... 1 2 1 1 4 15. Cerebral Hæmorrhage 13 ... ... ... ... ... ... 6 4 3 16 16. Heart Disease 81 ... ... ... 2 1 6 34 20 18 24 17. Arterio-sclerosis 45 ... ... ... ... ... 1 8 19 17 2 18. Bronchitis 67 ... 1 ... ... ... 5 20 21 20 18 19. Pneumonia (all forms) 36 3 2 2 1 ... 5 12 7 4 72 20. Other Respiratory Diceases 9 ... ... ... ... ... ... 6 3 ... 13 31. Ulcer of Stomach or Duodenum 4 ... ... ... ... ... 2 2 ... ... 1 22. Diarrhœa, etc. 6 4 1 1 ... ... ... ... ... ... 41 23. Appendicitis and Typhlitis 3 ... ... ... ... 1 1 1 ... ... 2 24. Cirrhosis of Liver 7 ... ... ... ... 1 2 3 ... 1 5 25. Acute Chronic Nephritis 21 1 ... ... ... ... 3 9 6 2 11 26. Puerperal Sepsis 2 ... ... ... ... ... 2 ... ... ... ... 27. Other accidents and diseases of Pregnancy and Parturition ... ... ... ... ... ... ... ... ... ... ... 28. Congenital Debility and Malformation, Premature Birth 3 3 ... ... ... ... ... ... ... ... 46 29. Suicide 11 ... ... ... ... ... 1 10 ... ... ... 30. Other Deaths from Violence 11 ... ... ... 1 1 2 3 3 1 3 31. Other Defined Diseases 73 4 ... 1 2 3 15 16 12 20 159 32. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... 530 19 6 6 6 15 70 191 120 97 548 131 TABLE III. Cases of Infectious Disease notified during the year 1927. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Locality (e.g. Parish or Ward) of the District. Total Cases Removed to Hospitals. At all Ages. At Ages—Years. St. Giles and Bloomsbury. Holborn. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and upwards. Small-pox ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) 54 1 17 18 13 3 2 ... 12 42 53 Erysipelas 21 ... 2 ... 1 5 7 6 6 15 10 Scarlet Fever 59 ... 9 25 16 8 1 ... 21 38 57 Enteric Fever 4 ... ... ... 2 1 1 ... 2 2 2 Puerperal Fever 3 ... ... ... ... 3 ... ... ... 3 3 do. Pyrexia 8 ... ... ... 3 5 ... ... 3 5 7 Cerebro-spinal Fever ... ... ... ... ... ... ... ... ... ... ... Ophthalmia Neonatorum 9 9 ... ... ... ... ... ... 4 5 3 Dysentery ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... 1 ... ... ... 1 1 Pneumonia—Primary 40 ... 7 6 4 7 14 2 17 23 25 do. Influenzal 8 ... ... ... 2 4 1 1 3 5 3 *Tuberculosis—Pulmonary 91 ... 1 ... 12 44 29 5 59 32 56 do. Non-Pulmonary 20 1 5 4 7 2 ... 1 7 13 13 Whooping Cough 82 12 48 22 ... ... ... ... 38 44 37 Acute Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 400 23 89 75 60 83 55 15 172 228 270 *Less 1 withdrawn. I 2 132 TABLE IV. Infectious Diseases in Holborn for the last Eleven Years. NOTIFICATIONS DEATHS Decennial Average, 1917-1926 Year 1927 Decennial Average, 1917-1926 Year 1927 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 Rat. Small-pox 0.3 0.01 0.00 0 0.00 0.00 0 0.00 0.00 0 0.00 0.00 Diphtheria 97 2.37 2.65 54 1.28 2.69 4 0.00 0.17 1 0.02 0.09 Erysipelas 17 0.41 0.18 21 0.50 0.43 ... ... ... ... ... ... Scarlet Fever 93 2.21 3.23 59 1.39 2.91 1 0.03 0.03 ... 0.00 0.01 Enteric Fever 4 0.09 0.08 4 0.09 0.07 0.5 0.01 0.01 0 0.00 0.01 Cerebro-spinal Fever 1.4 0.03 0.05 ... 0.00 0.02 ... ... ... 0 0.00 ... Acute Poliomyelitis 1 0.02 ... 0 0.00 0.02 ... ... ... 0 0.00 ... Whooping Cough† 70 2.45 ... 82 1.94 ... 5 0.11 0.16 5 0.12 0.12 Measles‡ ... .... ... ... ... ... 8 0.20 0.22 0 0.00 0.04 Tuberculosis—Pulmonary 89 2.24 ... 91 2.15 1.59 54 1.36 ... 51 1.21 ... Ditto Non-Pulmonary 15 0.35 ... 20 0.47 0.42 8 0.19 ... 4 0.09 ... Puerperal Fever* 1 3.24 3.23 3 21.78 3.57 1 2.10 ... 2 3.96 ... Ditto Pyrexia 8 Ophthalmia Neonatorum* 8 13.85 9.06 9 17.82 11.11 ... ... ... ... ... ... Diarrhoea (under 2 years)*‡ ... ... ... ... ... ... 8 13.20 13.13 5 9.90 7.5 * Rates per 1,000 births. † Notifiable in Holborn (not in London) since 1914. ‡ Not Notifiable. 133 TABLE V. INFORMATION REQUIRED BY THE LONDON COUNTY COUNCIL. PREMISES. Number in Borough at end of 1927. Number of Inspections. Number of Prosecutions. Cowsheds ... ... ... Milkshops 129 98 ... Registered houses let in lodgings 557 805 ... Ice cream premises 42 311 ... Slaughter-houses 1 7 ... Offensive Trades ... ... ... Restaurants and Eating Houses 255 437 ... Housing of the Working Classes— Number of houses inspected :— (a) On account of complaints or illness (Public Health Act) 553 (b) House to house (Housing Consolidated Regulations, 1925) Number of notices served (a) Under Public Health Act: — (i.) Intimation 515 (ii.) Statutory 77 (b) Under Housing Act 0 Number of houses repaired or nuisances remedied under Public Health Act 515 Number of houses repaired under Section 3 of Housing Act: — (a) By owners 0 (b) By local authority in default of owners 0 Number of houses closed on notice by owner that they could not be made fit 0 Number of houses for the working classes:— (o) Erected during year 1 block (15 tene ments) (b) In course of erection 0 Number of representations by Medical Officer or other person 0 Number of houses included in such representations 0 Number of Closing Orders made 0 Number of Closing Orders determined (i.e., houses made fit) 0 Number of Demolition Orders 0 Number of houses demolished :— (a) In pursuance of Orders 0 (b) Voluntarily 0 Total number of houses in the borough 3473 (Census, 1921) Number of houses occupied by the working classes 8571 tenement* (Census, 1921) Underground Rooms— Number illegally occupied, notices served 9 Number closed or illegal occupation discontinued 9 0 vercrowding— Number of cases of overcrowding found; notices served 2 Number of prosecutions 1 Number remedied 2 Smoke Nuisances— Number of observations 241 Number of notices Number of complaints 8 Number of summonses 0 Cleansing and Disinfection— Number of adults cleansed 93 Number of children cleansed 0 Number of premises disinfected :— (a) After infectious diseases 484 (b) For vermin 46 Water Supply to Tenement Houses— Number of premises supplied 2 Nunber of prosecutions 0 Sanitab r Officers— Nuviber 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 1 134 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 562 35 5 ... Workshops 751 51 7 ... Workplaces 3,672 73 11 ... Total 4,995 159 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 47 47 ... ... Want of ventilation 8 8 ... ... Overcrowding 5 5 ... ... Want of drainage of floors ... ... ... ... Other nuisances 72 72 ... ... Sanitary accommodation insufficient 2 2 ... ... unsuitable or defective 77 77 ... ... not separate for sexes 4 4 ... ... Offences under the Factory and Workshop Act : ... ... Illegal occupation of underground bakehouse (S. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (SS. 97 to 100) ... ... ... ... Other offences (excluding offences relating to outwork which are included in Part 3 of this Report) ... ... ... ... Total 215 215 ... ... *Including those specified in Sections 2, 3, 7 and 8 of the Factory and Workshop Act as remediable under the Public Health Acts. 135 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. 104 274 242 6 14 14 110 ... ... ... ... ... ... ... ... (2) Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquet and Tennis Balls 2 ... 2 ... ... ... 2 ... ... ... ... ... ... ... ... Coathangers ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Paper Bags and Boxes 2 ... 13 ... ... ... 2 ... ... ... ... ... ... ... ... Total 108 274 257 6 14 14 114 ... ... ... ... ... ... ... ... 136 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) 24 Other Workshops 623 Total number of workshops on Register 647 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) 25 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (S. 5) Notified by H.M. Inspector 50 Report (action being taken) sent to H.M. Inspector 50 Other — Underground Bakehouses (S. 101):— Certificates granted during the year — In use at the end of the year 14 137 LEGAL PROCEEDINGS. SALE OF FOOD AND DRUGS ACTS, 1875-1907. Date. Name. Address. Offence. Result. 1927 Jan. 10 & 31st Pearks' Dairies, Ltd. 78, Theobald's Road Selling raspberry jam containing 10% of apple matter Warranty proved— summons dismissed Jan. 27 Imperial (London) Hotels, Ltd. Russell Square Selling milk 32.0% deficient in fat Fined 40/- Costs 21 /- Mar. 14 Apr. 11 May 9 & 23 June 13 & 20 July 15 T. G. Tickler, Ltd. - Giving a false warranty in respect of raspberry jam Fined £20 & £15 15s. costs. Notice of appeal given, but abandoned Apr. 28 May 26 A. C. Taylor. Ltd. 45, Leather Lane Sale of raspberry jam containing 10% of apple matter Warranty proved— summons dismissed June 15 D. Davis 11, Duke's Road Selling milk 4.0% deficient in fat Summons dismissed on payment of 21s. costs July 4 David Jones 13, Chapel Street Selling milk 4.0% deficient in fat Warranty proved— Srmmons dismissed July 25 William Bates 66, Broad Street Selling milk 6.0% deficient in fat do. July 25 William Westell 51, Eagle Street Selling milk 9.0% deficient in fat Defendant convicted, fined 40s. Sept. 5 Mrs. C. Barrett 9, Beauchamp St. Selling milk containing 7.1% added water Summons dismissed on payment of 21s. costs Oct. 6 Wm. Poupart, Ltd - Giving a false warranty in respect of raspberry jam P. O. A. ordered to pay £10 10s. costs Nov. 17 W. H. Everitt 85, Leather Lane Selling minced meat containing 1.75 grains per pound boric acid Fined 40s., costs 21s. PUBLIC HEALTH (LONDON) ACT, 1891. Date. Name. Address. Offence. Result. 1927 Jan. 17 & 24 Mrs. E. Mayhew 3, Ormond Yard Breach of Lodging House By-laws Work done. Summons withdrawn on payment of 10s. 6d. costs Aug. 16 & 30 Sept 27 C. E. Tiffin 151, Shaftesbury Avenue Existing nuisance Nuisance abated Work done Oct. 25 do 153, Shaftesbury Avenue do. do. Dec. 20 Thomas Wareham 201, Shaftesbury Avenue Occupying as a dwelling an underground room Order to vacate in 14 days. Fined 40s. Dec. 20 do. do. Overcrowded Order for abatement Dec. 20 W. H. Mills do. Allowing an underground room to be used as a dwelling Fined £ 10 and ordered to abate nuisance K 138 TABLE VIII. METEOROLOGY OF LONDON 1927. (Deduced from observations at Greenwich under the superintendence of the Astronomer Royal) 1927. Air Temperature. Bright Sunshine. Rain and other forms of Precipitation. Mean of— Mean of A. & B. Difference from Average.* Daily Mean. Difference from Average.* Per cent. of possible. Total Fall. Difference from Average.* A. B. Maximum. Minimum. °F °F °F °F hrs. hrs. % m.m. m.m. January 46.4 35.7 41.1 +2.6 1.27 +0.03 15 39 -4 February 46.1 34.7 40.4 +0.6 1.26 -0.78 13 86 +46 March 54.2 39.4 46.8 +4.3 3.68 +0.28 31 56 +11 April 57.7 39.6 48.7 +1.1 4.59 -0.43 33 44 +7 May 65.9 43.4 54.7 +0.7 6.54 +0.07 42 31 -13 June 67.8 48.3 58.1 -1.8 4.71 -1.99 29 66 +15 July 70.8 53.9 62.3 -1.2 4,27 -2.23 27 57 0 August 71.7 53.7 62.7 -0.1 6.08 -0.12 42 90 +34 September 64.4 49.0 56.7 -1.3 3.32 -1.63 26 103 +58 October 59.3 43.8 51.5 +1.3 2.14 -0.98 20 32 -32 November 48.6 38.6 43.6 -0.4 0.96 -0.76 11 57 -1 December 39.5 32.1 35.8 -4.4 1.23 +0.17 16 86 +29 Year 57.7 42.7 50.2 +0.1 3.35 -0.70 25 746 or 29.37 ins. +150 or + 5.90in. The averages used are obtained from observations extending over 35 years (1881-1915). 139 TABLE IX. Sunlight (Ultra-Violet Rays), 1927—Daily Average. Kindly supplied by Professor Leonard Hill, M.B., F.R.S. Jan. Feb. March April May June July August Sept. Oct. Nov. Dec. London— Hampstead 0.39 0.55 1.34 2.55 3.9 3.22 3.15 4.15 2.66 1.42 0.50 0.32 Kingsway 0.21 0.21 0.74 1.50 3.45 2.57 2.83 3.03 2.53 1.38 0.45 0.26 Lowestoft 1.50 1.39 3.16 2.96 3.48 3.66 4.27 4.67 3.06 3.22 0.88 0.71 Ventnor 2.77 2.48 3.29 3.86 5.19 5.42 4.53 5.08 3.50 2.33 0.96 0.42 Hull 0.18 0.23 0.55 0.86 1.43 2.13 2.79 2.61 1.47 1.42 0.75 0.34 This table represents biologically active ultra.violet rays measured by the acetone blue fading method. One degree on the scale equals 2.4 times the amount of ultra-violet required to produce a very moderate erythema of the white arm—arms differing in sensitiveness.