20 The District Registrars of Births and Deaths are :— For N.E. Bethnal Green :— For S. W. Bethnal Green :— H. J. Hardwick, Miss M. Peters, 106, Bishops Road. 347, Bethnal Green Road. Office hours :— Office hours :— Mon.-Fri. 10 a.m.-l p.m. 10.30 a.m.-l p.m. daily. Sat. 10 a.m.-12 noon. Mon. and Fri. 3-5 p.m. VACCINATION. The Public Vaccinators are :— For N.E. Bethnal Green :— For S. W. Bethnal Green :— Dr. J. Duffin, Dr. J. G. L'Etang, 38, Bishops Road. 386, Bethnal Green Road. Each Registrar of Births and Deaths acts as Vaccination Officer in his (or her) district. HEALTH EDUCATION. The usual daily educational work of the Welfare Centre by Doctors and Health Visitors, and also of the Sanitary Inspectors was carried on during the year. Leaflets on a variety of subjects supplemented the spoken word. It was not deemed necessary to arrange any special lectures. 21 VITAL STATISTICS. EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. BIRTHS. Males Females TOTAL Birth Rate Legitimate 727 684 1,460 14.3 Illegitimate 26 23 1'460 14.3 DEATHS. Males Females TOTAL Death Rate 634 573 1,207 11.8 When corrected by the Comparability Factor of the Registrar-General (1.13), the Death Rate becomes 13.3. MATERNAL MORTALITY. Number of women dying in, or in consequence of, childbirth :— Rate por 1,000 total (live & still) births. From Sepsis 1 .6 From other puerperal causes 2 1.3 INFANT MORTALITY. Deaths of infants under one year of age per 1,000 births :— Legitimate 66.6 72.6 Illegitimate 244.9) Deaths from Measles (all ages) 34 Whooping Cough (all ages) 8 Diarrhoea (under two years of age) 32 22 VITAL STATISTICS of Bethnal Green During 1934 and Previous 5 Years. Year Population Estimated to Middle of Each Year Births Total Deaths Registered in the Borough Transferable Deaths Net Deaths of Persons Resident in the Borough Net Of Nonresidents registered in the Borough Of Residents not registered in the Borough At all Ages Under 1 year of Age Uncorrected Number Number Birth Rate Number Death rate Number per 1,000 births or i nfatitile mortality 1929 110,500 1,491 2,064 18•6 1,529 270 251 1,510 13•6 133 64•4 1930 Not available 1,374 1,955 17•7* 1,197 243 267 1,223 11•1* 118 60•3 1931 109,200 1,289 1,836 16•8 1,423 331 275 1,367 12•5 161 87•7 1932 106,300 1,139 1,635 15•4 1,334 335 292 1,291 12•0 113 69•1 1933 104,200 1,037 1,494 14•3 1,353 325 278 1,306 12•5 99 66•3 1934 102,060 993 1,460 14•3 1,272 352 287 1,207 11•8 106 72•6 * Calculated on estimated population in 1929. 23 POPULATION. The Vital Statistics in this report have been calculated on the estimated resident population of the Borough at the middle of the year 1934 of 102,060. MARRIAGES. The number of marriages registered in Bethnal Green during 1934 was 833. This is equal to a rate of 16.3 persons marrying per 1,000 of the population. BIRTHS. The number of births registered in the Borough during 1934 was 995, and in addition 465 occurred outside the Borough to Bethnal Green residents in excess of those occurring in Bethnal Green to residents of other localities, making a total of 1,460 births (753 males, 707 females). The birth-rate for 1934 was, therefore, 14.3 births per 1,000 population, the same as last year, the lowest ever recorded in the Borough. The provisional birth-rate for London is given as 13.2 and for England and Wales as 14.8. ILLEGITIMACY. Of the 1,460 births credited to this Borough, 49 were illegitimate, being 26 males and 23 females, and being 3.3 per cent. of the total number of births. STILLBIRTHS. Forty-five stillbirths were registered as belonging to the Borough, being a proportion of 3 per cent. of all births alive or dead. 24 DEATHS. The number of deaths during the year belonging to the Borough, was 1,207. This figure gives an annual death rate of 11.8 per 1,000 population, which com pares with 11.9 for the County of London and 11.8 for England and Wales as a whole. Measles, Cancer and Gastric Ulcer all show increases, but there is a decrease in the deaths from Influenza, Pneumonia and other respiratory diseases, and also from accidents. Infantile mortality and the mortality from cancer, street accidents and from tuberculosis and other infectious diseases are subjects of comment in other parts of this report. As is well known, the death rate varies according to age. A population which is composed largely of old people will tend to have a higher death rate than a district which is chiefly made up of younger people. This age factor makes it difficult to compare the health conditions of one district with another, as measured by the ordinary death rate, unless allowance is made. Sex also affects the death rate. The Registrar General has accordingly calculated a factor (called the Comparability Factor) for each district. This is, in effect, an adjustment of the age and sex composition of the district to that of England and Wales as a whole, so that all may be compared on the same basis. Consequently when the crude death rate (that is, the rate at which people die per 1,000 of the actual population of the district) is multiplied by this Comparability Factor it has the effect of making the corrected death rate comparable with the 25 death rate of any other district which has been similarly adjusted as though they had similar age and sex compositions. The Comparability Factor for Bethnal Green is 1.13 and the death rate for 1934 when so adjusted becomes 13.3. The causes of death among the population of Bethnal Green as returned by the Registrar General are given in the accompanying table. 26 27 CAUSES OF DEATH at different periods of life in the Metropolitan Borough of Bethnal Green, 1934. Cause of Death. All Ages Number of Deaths of residents at various ages, whether occurring within or without the Borough 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 35 years 35 and under 45 years 45 and under 55 years . 55 and under 65 years 65 and under 75 years 75 SO and upwards All causes M 634 57 21 15 11 24 28 32 73 142 124 107 F 573 49 13 17 16 17 26 26 42 86 129 152 1. Typhoid and Paratyphoid Fevers M 1 ... ... ... ... ... 1 ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 2. Measles M 16 2 12 2 ... ... ... ... ... ... ... ... F 18 2 8 8 ... ... ... ... ... ... ... ... 3. Scarlet Fever M ... ... ... ... ... ... ... ... ... ... ... ... F 1 ... ... ... 1 ... ... ... ... ... ... ... 4. Whooping Cough M 5 3 1 1 ... ... ... ... ... ... ... ... F 3 ... 3 ... ... ... ... ... ... ... ... ... 5. Diphtheria M 8 1 1 4 2 ... ... ... ... ... ... ... F 2 ... 1 1 ... ... ... ... ... ... ... ... 6. Influenza M 3 1 1 ... ... ... ... ... F 6 ... ... ... ... 1 1 ... ... ... ... 1 7. Encephalitis Lethargica M ... ... ... ... ... ... ... ... ... ... 1 3 F 1 ... ... ... ... ... 1 ... ... ... ... ... 8. Cerebro-Spinal Fever M ... ... F ... ... ... ... ... ... ... ... ... ... ... ... 9. Tuberculosis of respiratory system M 50 ... ... ... ... 6 10 12 12 ... ... ... F 24 1 ... ... ... 10 6 3 2 9 1 10. Other Tuberculous Diseases M 2 ... ... ... ... ... 2 ... 2 2 ... ... F 5 ... 1 1 1 1 ... ... ... ... ... 11. Syphilis M 3 ... ... ... ... 1 ... 1 1 1 ... F ... ... ... ... ... ... ... ... ... ... 1 ... 12. General Paralysis of the Insane, tabes dorsalis M 1 ... ... ... ... ... ... ... 1 ... ... ... F 1 ... ... ... ... 1 ... ... ... ... ... ... 13. Cancer, malignant disease M 92 ... ... ... 1 ... ... 4 9 36 27 15 F 89 ... ... ... ... ... 2 7 13 24 20 23 14. Diabetes M 3 ... ... ... ... ... ... ... ... ... 2 1 F 6 ... ... ... ... ... ... ... ... 3 1 2 15. Cerebral Haemorrhage, etc. M 10 ... ... ... ... ... ... ... ... 3 2 5 F 19 ... ... ... ... ... ... ... 1 4 9 5 16. Heart Disease M 170 ... ... ... 2 5 2 1 15 40 47 58 F 167 ... ... ... 5 1 8 3 10 27 49 64 17. Aneurysm M 2 ... ... ... ... ... ... ... ••• 1 1 ... F 2 ... ... ... ... ... ... ... 2 ... ... ... 18. Other Circulatory Diseases M 13 ... ... ... ... ... ... ... 2 1 8 2 F 12 ... ... ... ... ... ... ••• 1 6 5 19. Bronchitis M 29 2 1 ... ... ... 1 1 5 10 6 3 F 15 1 ... ... ... ... ... 1 ... 3 6 4 20. Pneumonia (all forms) M 53 15 3 4 2 1 1 4 3 1 1 6 3 F 48 12 ... 7 1 ... 2 5 5 3 8 5 21. Other respiratory diseases M 10 ... ... ... ... ... ... ... 1 l 2 6 F 40 ... ... ... ... ... ... ... ... 3 15 22 22. Peptic Ulcer M 16 ... ... ... ... ... 2 3 4 5 2 ... F ... ... ... ... ... ... ... ... ... ... ... ... 23. Diarrhoea, etc. M 19 13 2 ... ... 2 ... ... 1 ... 1 ... F 19 17 ... ... ... ... ... ... 1 ... ... 1 •24. Appendicitis M 6 ... ... 1 1 ... 1 ... 1 2 ... ... F 4 ... ... ... 2 ... ... ... ... 1 1 ... 25. Cirrhosis of Liver M 2 ... ... ... ... ... ... ... ... ... ... ... F 1 ... ... ... ... ... ... ... ... ... ... 1 26. Other Diseases of Liver, etc. M 1 ... ... ... ... ... ... ... ... ... 1 ... F 4 ... ... ... ... ... 1 ... ... 1 ... 2 27. Other Digestive Diseases M 14 ... ... ... ... ... 2 1 2 5 3 1 F 6 ... ... ... ... ... ... 2 ... 1 1 2 28. Acute and Chronic Nephritis M 19 ... ... 1 ... 2 1 1 4 3 4 3 F 13 ... ... ... ... ... ... ... 3 2 5 3 29. Puerperal Sepsis 1 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 30 Other Puerperal Causes ... ... ... ... ... ... ... ... ... ... ... ... ... F 2 ... ... ... ... 1 ... 1 ... ... ... ... 31. Congenital Debility, Premature Birth, Malformations, etc. M 20 20 ... ... ... ... ... ... ... ... ... ... F 14 13 ... ... ... ... ... ... ... 1 ... ... 32. Senility M 2 ... ... ... ... ... ... ... ... ... 1 1 F 3 ... ... ... ... ... ... ... ... l ... 2 33. Suicide m 9 ... ... ... ... 1 ... 1 2 4 1 ... F 3 ... ... ... ... ... 2 1 ... ... ... ... 34. Other Violence M 16 1 ... 1 2 3 1 3 2 1 1 l F 10 ... ... ... 1 ... ... ... ... 5 2 2 35. Other Defined Diseases m 39 ... 1 1 1 3 2 1 8 8 7 7 F 34 3 ... ... 5 3 1 3 5 3 5 6 36. Causes ill-defined or unknown M ... ... ... ... ... ... ... ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... ... ... Totals 1207 106 34 32 27 41 54 58 115 228 253 259 28 MATERNAL MORTALITY. Systematic inquiry continues to be made into every maternal death belonging to the Borough. Three cases were investigated (1) Septic Abortion (2) Haemorrhage from Hydatidi form mole of Uterus. (3) Prolonged labour and delivery The maternal death rate was therefore 2.1 per 1,000 live births, or 1.9 per 1,000 total births (live and still). In England and Wales these rates were 4.60 and 4.41 respectively. There were two other cases in which childbirth was complicated by other conditions (intestinal ob struction and yellow atrophy of liver), but these have have not been counted as cases of maternal mortality. Only one of the mothers concerned attended the Council's Maternity Clinic, but with one exception all received some ante-natal care. INFANTILE MORTALITY. One hundred and six deaths of Bethnal Green infants under one year of age are reported by the Registrar-General as having taken place during the year. This is equal to a rate of infantile mortality of 72.6 per 1,000 births. The infant death rate for London was 67 and for England and Wales as a whole 59. Comparison with previous years is as follows :— 1924 78.0 1925 80.6 1926 71.1 1927 57.7 1928 73.9 1929 64.4 1930 60.3 1931 87.7 1932 69.1 1933 66.3 29 The causes of death among infants are show in the following table. Infantile Mortality in Bethnal Green in 1934 Causes of Death Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks 4 weeks & under 3 months 3 months & under 6 months 6 months & under 9 months 9 months & under 12 months Total Deaths under 1 year per 1,000 Births Measles ... ... ... ... ... ... ... 2 2 4 2•7 Whooping Cough ... ... ... ... ... 1 ... 1 1 3 2•1 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... Diphtheria and Croup ... ... ... ... ... ... ... 1 ... 1 0•7 Tuberculosis ... ... ... ... ... ... ... 1 ... 1 0•7 Bronchitis ... ... ... ... ... ... 2 ... 1 3 2•1 Pneumonia (all forms) 2 ... 2 ... 5 5 6 9 ... 27 18•5 Other Respiratory Diseases ... ... ... ... ... ... ... ... ... ... ... Diarrhoea and Enteritis ... ... ... ... ... 9 13 2 ... 30 20•5 Other Digestive Diseases ... ... ;;; ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... Congenital Malformations 1 ... 1 ... 2 1 1 ... ... 4 2•7 Congenital Debility ... ... ... ... ... ... ... ... ... ... ••• Premature Birth 12 ... 1 1 17 3 ... ... ... 20 13•7 Injury at Birth 6 ... ... ... 6 ... ... ... ... 6 4•1 Other early infancy diseases 2 1 ... ... 3 ... ... ... ... 3 2•1 fOther Causes ... 1 ... i 2 1 1 ... ... 4 2•7 Totals 23 5 4 3 35 20 23 16 12 106 72•6 Net Births in (legitimate 1411 Net Deaths in J legitimate infants 94 the year (illegitimate 49 the year Iillegitimate infants 12 † Erysipelas (2), Murder and Haemorrhagic dis. (1 each). 30 CANCER. Cancer was responsible for 181 deaths or 15 per cent. of the total deaths in the Borough. The local distribution of the disease in these deaths was as follows:— M. F. Total. Buccal cavity, pharynx 11 — 11 Digestive organs and peritoneum 50 48 98 (Esophagus (5-4) Stomach (15-15) Intestines (19-18) Rectum (8-7) Others (3-4) Respiratory organs 14 6 20 Uterus — 8 8 Other female genital organs — 2 2 Breast 1 18 19 Male genito - urinary organs 9 — 9 Skin ... — 1 1 Other or unspecified organs 7 6 13 92 89 181 DEATHS FROM MOTOR TRAFFIC. For some years I have drawn attention to the increasing mortality from motor traffic accidents in the streets. 31 This year I am glad to note a substantial decrease. The following cases, all pedestrians, occurred during 1934 : M 34 Run over by motor bus. M 39 Knocked down by motor bus. M 42 Knocked down by motor car. M 44 Knocked down by private car. F 64 Knocked down by lorry. M 66 Knocked down by pedal cycle. F 71 Knocked down by motor lorry. F 74 Knocked down by motor car. While this is less than half the number in preceding years, it is 8 deaths too many and indicates that still further measures require to be taken to make the roads safe, particularly for pedestrians. PUBLIC MORTUARY. (Church Row, Bethnal Green, E.2.) During the year 8 bodies were received at the Mortuary, practically all cases of infectious disease, at the request of relatives. The limited use of the mortuary is due to the fact that the District Coroner now conducts the inquests in Bethnal Green cases at Courts in adjoining boroughs and the bodies in such cases are of course deposited in the mortuaries attached to these Courts. THE CREMATION OF THE DEAD. I desire to draw attention to the desirability of a more enlightened view with regard to the manner of disposal of the dead. Although burial in the earth is the time honoured method adopted in this country, more hygienic methods have been used elsewhere, and there is no reason why tradition should prevent their adoption here. With the large aggregation of population in and around London, it becomes urgently necessary that proper consideration should be given to this matter. Equipment for the efficient and dignified destruction of dead bodies by fire now exists in various parts of the London area, and it is to be hoped that this process will soon become generally accepted. 32 I have no information as to the number of Bethnal Green residents earth-buried or cremated, respectively, this important matter falling outside what are regarded as public health statistics. I am afraid, however, that, in the case of the latter, the number is very small. The reasons for this are many, but they can probably be resolved into three: (1) lack of thought about the subject, (2) the idea that cremation is very expensive, (3) false sentimentality. One cannot argue very effectively about the third of these except to point out that if all the facts of earth burial were realised, most right minded people would feel that it was neither a decent nor a satisfactory manner of treating the dead. Ignorance concerning cremation is, I fear, pretty general, and this is probably responsible for the impression that it is costly. Actually the process of cremation can be effected for less than £5. There are of course other incidental charges, for the burial service and in connection with accommodation for the burial urn containing the ashes, such as correspond to a conventional earth burial, but having regard to the somewhat lavish expenditure on funerals which seems to be the general custom, there is really no adequate ground for objecting to cremation on grounds of cost. 33 MATERNITY & CHILD WELFARE. Although forms of Maternity and Child Welfare activity had been carried on in the Borough for many years previously, the work was not organised on a really comprehensive scale until 1920, when the centres and staff of a voluntary committee were transferred to the Council. In 1922 a new permanent Welfare Centre was provided in Cornwall Road (adjoining the Public Library and Bethnal Green Estate, erected at the same time). The hired centres elsewhere in the Borough were closed, with the exception of one held at a Mission Hall in the West Ward. At that time, the work was largely restricted to the ordinary work of a Welfare Centre: medical consultations for expectant mothers and babies, also convalescent treatment and milk grants. Since 1922, various new branches of work have been undertaken, mostly at or in connection with the Cornwall Road Centre : Commenced Massage Sept, 1924 Special Clinic for Delicate Children June, 1925 Light treatment June, 1925 Dental treatment Sept., 1925 Orthopædic treatment Jan., 1928 Treatment of Enlarged Tonsils Feb., 1928 Home Helps and Maternity Outfits Mar., 1928 Inhalation May, 1930 Mothers' Clinic Oct., 1932 During this period, naturally the ordinary work of the Centres has expanded. The Staff was increased by a Borough Midwife in 1924 and a Health Visitor and Clerk Dispenser in 1925, while in 1931, a full-time Medical Officer was appointed to replace the services of certain of the part-time medical officers at the centres. 34 We have for some time been at the stage when, with the premises at our disposal, no substantial further increase of activity is possible. That such further work is necessary, notwithstanding the fall in the Birth rate, is amply shown by our records with regard to Toddlers and by the fact that despite our relatively favourable experience of maternal mortality much still remains to be done for ante-natal and post-natal care. At the end of the year, the Public Health Committee requested me to report on the position of the Maternity and Child Welfare Services of the Council. The result of this consideration of the matter will doubtless appear in my next report. NOTIFICATION OF BIRTHS ACTS, 1907 AND 1915. During the year, 995 live births were registered in the Borough ; and 975 live births were notified to the Medical Officer of Health. There were also 29 stillbirths notified. Of the 1,004 living and stillbirths notified, 37 were found to relate to other districts and were duly transferred, 755 were notified by midwives, 136 by maternity assistants of the London Hospital, 53 by medical practitioners, and 23 by parents and others. Through the courtesy of neighbouring Medical Officers of Health I also received copies of notifications of births of Bethnal Green babies which took place outside the Borough, information as to 522 live babies and 19 stillbirths being received in this way. The nett total of notified live births belonging to the borough was thus 1,460. WORK OF HEALTH VISITORS. The following table gives some account of the outdoor work of the Health Visitors so far as this can be expressed in statistics :— 35 Visits. Re-visits. Babies (under 1 year) 1,451 11,201 Children (1—2 years) 5 6 4,3501 13,662 „ (2—3 years) - 4,024 „ (3—4 years) 1 3,060 „ (4—5 years) — 2,228 Mothers (Ante-Natal) 1,048 519 ,, (Post-Natal) 169 237 Stillbirths 41 31  Visits. Re-visits. Infant Deaths 49 16 Maternal Deaths — — Puerperal Fever (3) and Pyrexia (24) 9 18 Ophthalmia Neonatorum 12 22 Acute Poliomyelitis 1 1 Other Notifiable Diseases 1 7 Diarrhoea and Enteritis — — Measles (3,027*), and German Measles (21) 1,608 1,440 Whooping Cough 95 177 Other Non-Notifiable Diseases 19 46 Milk Grants 4 6 Convalescent Treatment 11 3 Other matters 100 215 Total Visits 4,624 27,601 Grand Total 32,225 *Most of these visits were made by the Special Measles Health Visitor. In addition, 266 visits and 2,359 re-visits were rendered futile owing to the absence of the mother or the occasion being inconvenient for an interview. The indoor (clinic) work of the Health Visitors is shown in the following figures Sessions attended. Maternity Clinics 309 Children's Clinics 1,109 Dental Clinic 112 Light Clinic 195 Mothers' Clinic 42 Other Clinics 371 Total 2,138 The indoor (clinic) work of the Health Visitors is shown in the following figures:- Sessions attended. Maternity Clinics 309 Children's Clinics 1,109 Dental Clinic 112 Light Clinic 195 Mothers' Clinic 42 Other Clinics 371 Total 2,138 36 The Council's Health Visitors assist the London Hospital Maternity Charity by reporting on the home conditions and preparations of expectant mothers who have booked with that hospital for midwifery services. Liaison also exists with the L.C.C. School Medical Service, our child welfare records being transferred to the Divisional Medical Officer as the children either enter school or attain the age of 5. The number of outdoor visits has again increased but this is mainly due to the work of the special Health Visitor who was engaged during the measles epidemic. It is still unsatisfactory that the staff available does not permit of more than an annual visit to the 3 and 4 year olds, among whom more intensive work is so necessary. MATERNITY AND CHILD WELFARE CENTRES. At the Council's principal Centre in Cornwall Road, there are 2 morning sessions and 3 afternoon sessions for infant consultations, a morning session for toddlers and 2 sessions in connection with the Maternity Clinic each week. Other work carried on at the Centre in connection with the Special Clinic for Delicate Children, massage, milk grants, etc., will be found reported on under these separate headings. The auxiliary Centre at St. Matthew's Institute, Hereford Street, is used for Infant Consultation Sessions on Monday and Thursday afternoons, and an Ante-Natal Clinic on Thursday mornings. The following ratios may be of interest:— Ante-Natal Clinics Children's Clinics Acreage per Centre 380 380 Population per Centre 51,030 51,030 Percentage of new expectant mothers, or babies under 1, attending Centres respectively, to total net births 29•7 69•9 37 MATERNITY CLINIC (CORNWALL ROAD). This is open every Wednesday and Thursday morning. Particulars of attendances : Total. Expectant Mothers—First visits 3301 952 „ „ —Subsequent visits 6221 Mothers recently confined—First visits 197 289 „ „ „ —Subsequent visits 92 Total Attendances 1,241 The number of sessions was 102, and the average attendance per session was 12.2, as compared with 14.5 the previous year. 95 of the mothers who attended for pre-natal care also attended the Maternity Clinic after their confinement, and some of them were sent away to a convalescent home. The 330 women who attended for the first time may be grouped as follows:— Gravid:—Primiparæ 52 —Multiparæ 257 309 Not pregnant 21 330 In the case of the 309 gravid women, the following were the periods of gestation nil were in the 1st month 24 „ „ „ 2nd „ 25 „ „ „ 3rd „ 30 „ „ „ 4th „ 54 „ „ „ 5th „ 71 „ ,, „ 6th „ 73 ,, ,, ,, 7th ,, 31 „ „ „ 8th „ 1 ,, ,, ,, 9th ,, 38 An analysis of these cases shows :— Full-term confinements 202 Premature births 51 Miscarriages (6) ; Stillbirths (8) 14 Not yet confined 74 Left Borough (results unknown) 14 The known confinements took place :— 167 at home, and 54 in institutions. The results of the 96 cases brought forward from 1933 were as follows :— Full-time confinements 89 Premature births — Miscarriages (-); Stillbirths (1) 1 Found to be not pregnant 3 Left district (result unknown) 3 Dr. R. C. Townshend reports on the work of the Maternity Clinic, as follows :— Report to the Medical Officer of Health on the Cornwall Road Maternity Clinic for the year 1934. I am glad to be able to give a satisfactory report of the result of the work at the Clinic during the year, although there has been a decrease in the attendances, due I believe to an increased desire on the part of the mothers to be confined in hospital or an institution, and their consequent attendance at the ante-natal clinics in connection with these institutions. This fact also leads to the transfer of a considerable number of mothers at the 7th month of pregnancy to the clinic attached to the hospital at which they are going to be confined. A considerable number of mothers have been recommended for dental treatment, but it is very difficult to persuade expectant mothers to avail themselves of this. There were no deaths amongst the mothers attending the Clinic. There was one Caesarean birth in a mother who had already undergone two previous operations for Caesarean section. With regard to the miscarriages, in one case the patient was a primipara who attended the Clinic for "the first time on account of a threatened miscarriage and her symptoms were so urgent that she was immediately recommended to hospital for treatment. The remaining cases occurred in multiparae, and in one case the patient attended for the first time with 39 urgent symptoms and was immediately referred to hospital. In two cases the patients attended the Clinic on the first occasion on account of threatened miscarriages and were referred to their own doctors, and in one case the miscarriage was apparently the result of a fall in the street. In every case the patient was attended either in an institution or by her own doctor and made a successful recovery. With regard to the still-births, two cases occurred in primipara ; in the first case the patient was suffering from severe kidney disease and was recommended for admission to hospital, and in the other case the patient was an elderly primipara suffering from extreme muscular rigidity and recommended for admission to hospital in order to minimise the risks of a difficult labour, but she removed from the district before her confinement and no information was obtainable. The remaining cases occurred in multiparae in one case the patient was an elderly multipara (9) with a tuberculous hip who had been receiving treatment for anaemia. In two cases the patients were 6 multiparas with a history of antepartum haemorrhage resulting in 8 month premature confinements and were treated in hospital. In one case the patient was a multipara (5) with a history of ante-partum haemorrhage and had a 26 weeks premature confinement of twins, one of which was still-born. In one case the patient was an elderly multipara with severe dental sepsis who was recommended to have dental treatment, but was unwilling to have this carried out, and transferred to a hospital. In one case, the patient had a fall in the street followed five days later by a premature 7 A months still-birth. With regard to the premature confinements, in two cases the patients were primiparae—in one case the patient was an elderly primipara with a contracted pelvis who had an 8 months premature infant, and the other case was a young primipara who had a 7 months premature confinement, and the child weighed 2½ lbs. and died 6 hours after birth—the mother giving a history of kidney trouble during the early months of pregnancy. In both cases the patients were attended by doctors at the confinement. The remaining cases occurred in multipara, in one case the patient was recommended to hospital on account of a contracted pelvis, and one case was a 7½ months premature confinement due to premature rupture of the membranes. The remaining case was a 26 weeks premature confinement due to ante-partum haemorrhage. The Borough Midwife continues to attend the Clinic and report upon her cases, and the local midwives attend occasionally with their patients, and in addition a number of patients have been referred to the Clinic by the local doctors. 40 Finally, I would like to acknowledge the work of the Health Visitors in attendance at the Clinic, especially in regard to the very efficient method of taking the history of the patients and filing the records so that they are immediately available for future reference. February 21th, 1935. Ruth C. Townshend. MATERNITY CLINIC, HEREFORD STREET. Dr. K. M. Horton reports with regard to the Maternity Clinic at the Hereford Street Centre, as follows :— Steady work has continued throughout the year. While the average attendance is slightly less than last year the number of expectant mothers attending shows a small increase and subsequent attendances have been good. The importance of post-natal care is learnt slowly by our mothers and while many attend once after confinement subsequent attendances are disappointing. In many cases any discomfort or inconvenience following delivery is such a familiar and apparently inevitable occurrence that the mother never thinks of seeking help, and in others the responsibilities of home and family with the additional new member requires all available time and energy, leaving none in which to take care of herself. It is hoped that continued teaching and improved conditions of living in the future will enable many mothers to make use of the facilities available. The mother of the one premature baby was a multipara and her physical condition poor. In both cases of stillborn children there was a history of threatened miscarriage, one before attendance at the clinic, delivery occurring at 7½ months, and the other was referred to hospital from the clinic but in spite of rest and treatment she also delivered herself at 7½ months. Two miscarriages occurred among the mothers attending the clinic, one at about 3 months pregnancy and she was admitted to Bethnal Green Hospital; the other occurred in a case of pregnancy with an ovarian cyst. She was referred to Miss Basden, F.R.C.S., at the Mildmay Hospital for consultant's opinion and was admitted for operation. Subsequently she attended the clinic and did well. One case of Bartholin's cyst occurred during the year. She was also admitted under the care of Miss Basden at the Mildmay Hospital and made a good recovery. One mother was found to be suffering from carcinoma of the breast when 41 she was then about 7 months pregnant. She was admitted to hospital for induction of labour and subsequent operation. Pleasant co-operation between hospital and doctors in practice in the district is continued. The Borough Midwife visits the clinic as her time permits, giving the mothers who engage her for their confinements an opportunity of seeing her if they wish. Records :— Expectant Mothers First attendances 120 Subsequent attendances 367 Mothers recently confined First attendances 84 Subsequent attendances 64 Total Attendances 635 Number of sessions held 51 Average attendance per session 12.5 Mothers attending both before and after confinement 28 Primiparse 7 Multiparae 99 Not pregnant 15 121 Periods of gestation :— In the 1st month Nil 2nd 8 3rd 10 4th 24 5th 17 6th 22 7th 16 8th 7 9th 2 Full-term confinements 49 Not yet confined 42 Removed from district 11 Premature child 1 Miscarriages 2 Stillbirths 2 Known confinements at home. 39 in institutions 14 Cases brought forward from 1933 :— Full-term confinements 31 Removed from district 1 Not pregnant 1 Induction for carcinoma of breast 1 42 BIRTH CONTROL. During the year, the Ministry of Health issued a further circular with regard to Birth Control, slightly extending the grounds on which women suffering from definite ill-health may be afforded contraceptive advice at clinics established by local authorities. The Council were, however, of opinion that this still leaves unprovided for a large number of women whose health is impaired not by any particular disease but by poverty, often accentuated by unduly frequent pregnancies. Where a woman has already borne 3 or 4 children and the family income is insufficient to provide adequately for them, it seems contrary both to public policy and to the interests of the mother and children that further children should be born. The Council were of opinion that contraceptive advice should be available for such mothers at municipal birth control clinics if they wish to avail themselves of it—an opinion in which I concur—and the Minister of Health was accordingly requested to allow municipal birth control clinics to deal with such cases. As will be seen from the following report, the Council's Clinic is fulfilling an increasingly useful service, even within the present restrictions. MOTHERS' CLINIC. Dr. Horton reports : Two factors have increased the scope of the work of this clinic in 1934. The first was the decision of the Public Health Committee that the session might be held every month instead of every two months, and the second was the issue of Circular 1408 by the Ministry of Health on May 31st. It has been possible in consequence to give the mothers more opportunity of seeking advice and to offer treatment to many who had previously been referred to other clinics where the work is not confined within the terms of the Memorandum of the Ministry of Health. The equipment of the clinic has been improved and there are 4 cubicles for examination and treatment. The average attendance per session is nearly as high as last year. Three-quarters of the new mothers had attempted 43 some kind of birth control, with unsatisfactory results, before attending our clinic. Over half of this number had used Coitus Interruptus and had found it unreliable. It is of interest to note that all cases included under the heading Neurasthenia belonged to this group. There was a history of previous miscarriages in 29% and of stillbirths in 22% of the total new cases. It is satisfactory to note the steady improvement in health as shown by the appearance and vitality among the mothers making subsequent attendances. The incidence of pregnancy has been low, 5 in all. Three of these were due to failure of technique, which was freely admitted by the mothers concerned. This may be regarded as a satisfactory comment on the efficiency of method used and a tribute to the care and good faith with which the mothers follow advice given. It is pleasant to record the good tone and friendly atmosphere of this clinic. Attendances have been as follows :— January 21 February 17 March 13 April 16 May 17 June 26 July 21 August 26 September 4 October 26 November 30 December 24 Total 241 Average Attendance 20.08 Mothers have been referred by :— Medical Officers of Welfare Centres 42 Health Visitors 22 Public Assistance Committee 1 Mother attending Clinic 1 Analysis of cases attending :— First Attendances : Contraceptive advice given 53 Referred to Burdett Road Clinic 13 Total 66 Subsequent Attendances 175 Total Attendances 241 44 Clinical Analysis of Cases given Contraceptive Advice :— Anaemia and Malnutrition 6 Carcinoma of Breast 1 Contracted Pelvis 2 Diabetes Mellitus 3 Endocarditis 8 Epilepsy 3 Hyperthyroidism 3 Myocarditis 7 Nephritis 2 Neurasthenia 11 Recurrent adherent Placenta 1 ,, Toxaemia of Pregnancy 1 Tuberculosis 5 Total 53 Clinical Analysis of Cases referred to Burdett Road Clinic :— Anaemia and Debility 4 Arthritis 1 Neurasthenia 2 No physical signs 6 Total 13 Incidence of Pregnancy :— Failure of technique 3 By own wish and at own risk 2 Total 5 BOROUGH MIDWIFERY SERVICE. The Borough Midwife had 22 bookings carried forward from 1933. During 1934, 106 bookings were received, and 24 cases remained on the books at the end of the year. The following figures show the work of the Borough Midwife during the year : Bookings carried forward 22 „ received in 1934 106 128 45 Cases delivered by— Borough Midwife 77 Deputy 19 96 (of these 8 were primiparse, and 88 multiparae). Cases removed in labour to hospital by Borough Midwife 4 Cases entering hospital on own account 3 Removed from Borough 1 Cases on books at end of year 24 128 The Borough Midwife and her deputy paid 1,115 visits in connection with her practice. She also conducts a regular weekly session for ante-natal care of her patients. It is gratifying to record that 31 of the mothers delivered by the Borough Midwife during the year had been previously attended by her, 18 on one previous occasion, 5 of them on two previous occasions, 5 on three occasions, and 3 on four occasions. OBSTETRICAL CONSULTANTS. The Council has a panel of five Obstetric Consultants, who may be called in by any general practitioner in any midwifery case which presents difficulty or abnormality. No consultation took place during the year. HOME HELPS. At the end of the year, there were 12 Home Helps on the panel, with 2 other women acting occasionally as relief helps. During the year, there were 147 applications for Home Helps, as compared with 206 in 1933, 250 in 1932, 275 in 1931, 165 in 1930, and 65 in 1929. In 68 cases the mother paid a contribution for the services rendered. 46 MATERNITY OUTFITS. Outfits were issued as follows:—Free, 153; Sold, 90. Total, 243. BREAST FEEDING CLINIC. (CORNWALL ROAD CENTRE). Dr. Horton reports: This clinic has been held on Tuesday mornings every week. All mothers attending have been found by the doctors at infant consultations to be in serious difficulties with breast feeding. They attend in small numbers and in surroundings that are as quiet and comfortable as possible. They feed their babies under skilled supervision. Test feeds are given and Complementary feeds ordered as required and the technique of individual management quietly explained. When necessary they are seen by the doctor. The average attendance is lower than last year, 13.2 per session as against 16.2 last year, but this year's better results indicate the value of more time for the patients and personal observation essential at such a clinic. A certain number of test feeds have been arranged in the afternoon and those results have justified the effort made. Results for the year are satisfactory. On discharge from the clinic 48% of the infants were entirely breast fed and 36% breast fed with small Complementary feeds, i.e., breast feeding was maintained in 84% of the total. Definite failure occurred in 3%, while in the remaining 13% the results are not known as they have either removed from the borough or are carried forward to 1935. We continue to estimate the value of the work by a visit of six months. It was found that 66.7% of the infants were entirely breast fed or breast fed with a Complementary feed and 26.7% were not. The probability is that all these infants would have been bottle fed if they had not attended the clinic. It is satisfactory to report that the number of mothers who refused to breast feed is less than half as compared with last year. Care was taken to discover any reason for this refusal but no definite conclusion could be reached. It is possible that advice or influence outside of the clinic is responsible for some cases. In others it seemed as if there were little maternal instinct in the individual mother. Breast milk failed in 13 cases and on analysis bad management and worry seemed to be the factor mainly responsible, while 10 mothers weaned their babies although there was no failure of the breast milk because of worry about themselves, 47 their families or their circumstances. It is remarkable how often a growing toddler, an ex-baby, will prevent the successful breast feeding of its successor in the family and how frequently the vicious circle set up by the worried mother who has therefore badly managed children, reacts on the well-being of the new baby. Records:— New cases 221 Brought forward from 1933 15 Subsequent attendances 437 Total attendances 673 Doctors' consultations 164 Number of sessions 51 Average attendance per session 13.2 Results on discharge from the clinic :— Breast fed 113 ,, „ with Complementary feed 84 Weaned 7 Removed 17 Total 221 Results shown by visiting homes at 6 months old:— Breast fed 85 ,, ,, with Complementary feed 59 Weaned 59 Removed 17 Died (Septicemia) 1 Total 221 Carried forward to 1935 15 Reasons for weaning in 59 cases :— Breast milk failed 13 Mother worried 10 ,, refused to breast feed 14 „ at work 3 Illness of mother 15 „ ,, infant 4 Failure of breast milk in 13 cases was due to:- Badly managed infant 6 Mother worried 5 Home conditions 1 Debility of mother 1 Infants died (Septicemia—Otitis Media) 1 48 HEALTH TALKS. Talks on subjects of interest to the mothers attending the Centres have been given at intervals throughout the year. In many cases they have been given with practical demonstrations and great interest has been taken in them, questions being asked and discussion often following. Our thanks are due to the senior student Health Visitors who attend here for their practical work for their able assistance with these talks. The three main groups of subjects that have been taken as the basis for individual talks are the Mother, the Infant and the Toddler. A classification of the talks is given below. Classification :— I.—The Management of the Mother. Care of the Expectant Mother. A Day in the Expectant Mother's Life. Preparation for Confinement. Care of the Mother after Delivery. II.—The Management of the Infant. Establishment of Breast Feeding. Difficulties of Breast Feeding. Feeding Methods. Importance of Food Values. Baby's Cot and Bath. Formation of Good Habits. Development of the Teeth. III.—The Management of the Toddler. Safety First at Home. Treatment of Minor Injuries. How to Bathe an Eye. Measles. Food Values and Diets. Refusal to Eat. Bed Wetting. Care of the Teeth. Thrift Clothing. 49 CHILD WELFARE CLINICS. Cornwall Road Hereford Street Sessions per week 6 2 Doctors' attendances per week 9 3 The statistics of attendances at the Centres during 1934, and in previous years are as follows :— 1934 Cornwall Road Hereford Street Total Babies (0—1) : First attendances 702 319 1,021 Subsequent „ 6,112 2,391 8,503 Children (1—5) : First „ 91 48 139 Subsequent ,, 4,203 1,961 6,164 Toddlers Clinic attendances 368 — 368 Total ,, 11,476 4,719 16,195 The numbers of children seen by the doctors were as follows :— Cornwall Road Hereford Street Total Babies (0—1) 3,584 1,523 5,107 Children (1—5) 2,696 1,222 3,918 Total 6,280 2,745 9,025 1933*. 1932*. 1931. 1930. 1929. 1928. Total Attendances 17,632 18,668 19,100 19,843 18,481 19,373 New Cases 1,466 1,510 1,400 1,497 1,452 1,536 Medical Consultations 9,969 10,462 12,062 11,982 11,800 12,552 *Including Toddlers Inspections. Statistics with regard to the attendances at the Maternity Clinic are given in detail later. INFANT CONSULTATIONS. Dr. K. M. Horton reports : (CORNWALL ROAD CENTRE). Two morning sessions and three in the afternoon have continued to be held each week. The attendance at the Friday morning clinic has increased and continues to do so, but on Tuesday the morning session is still poorly attended. It would seem that morning sessions in the early part of the 50 week are not convenient for mothers in Bethnal Green, when the week's washing and the rent and insurance collectors claim their time. We have continued an effort to keep the waiting time in the Centre for the mothers and infants as short as possible, realising the many other calls that are made on the mothers. Model clothing and wool for making garments have been on view at the stall, at which the Borough Midwife has given useful instruction when her time permits. A series of health talks has been given from time to time throughout the year by student Health Visitors from the College of Nursing. It is difficult to fit in systematic talks and at the same time to help the mothers to get home as quickly as possible. Tea and biscuits are available for any mothers who wish for them. The results of past years of health teaching is shown in the small number of children who attend the Centre who are really ill. Most mothers have evidently learnt to go to their own doctors or to hospital as soon as they notice anything wrong but the art of mothercraft is still far from being generally understood. Child management in all its stages and aspects is the main problem that presents itself. In the busy life that our mothers have to lead many expedients have to be used that are far from being the best, although they enable the mother to get through her day. The " dummy " and the feeding between meals, overfeeding, stuffy rooms and insufficient sun and fresh air, insufficient sleep, the screaming infant and the selfwilled child, all these and many other well-known signs of bad management are with us in numbers. While knowing that in many cases there is good excuse for them, we know that they can be avoided and we cannot be content with our work in the clinics until these children are as uncommon as the really ill child has apparently become. Mention should be made of the minority of splendid mothers who under similar circumstances manage their children well. Good use has been made of the special treatment clinics available at the Centre, the sunlight, dental, massage, etc., and satisfactory results obtained. The efficient method of giving milk grants to all necessitous children probably accounts for satisfactory standard of nutrition. Student Health Visitors and final-year medical students from the London Hospital have attended the Centre throughout the year as part of their examination course. (HEREFORD STREET CENTRE.) The majority of the mothers who have attended the Maternity Clinic at this Centre bring their babies to the infant 51 consultations soon after delivery so that the habit of regarding the Centre as the place for help and advice for the family is being formed. The attendances at the two afternoon sessions held weekly at this branch Centre have remained steady. A considerable number of children have been transferred to the main Centre at Cornwall Road for attendance at the breast feeding, sunlight and other special clinics as occasion arises. It is satisfactory to report that attendances at these clinics by families living in the area supplied by the Hereford Street Centre have been good in spite of the journey involved. An increasing proportion of mothers (most of those who are delivered in institutions) do not attend, however, until after the child is two months old and possibly, if this critical stage of infancy is safely passed, not at all. Hospitals in the neighbourhood seem in most cases to have their own infant welfare clinics to which the mothers are invited on their discharge after delivery. Taking these facts into account and adding to them over 100 families that records show to have removed from the borough this year, the year's work at this Centre may be regarded as satisfactory. TODDLERS' CLINIC. During the year, there were 44 sessions for the medical inspection of toddlers. 368 children were inspected, of whom 286 were found to require treatment of some kind. Dr. Horton reports This clinic is slowly establishing itself in spite of the difficulty that many mothers find in coming to the Centre on Monday mornings. The average attendance is greater than last year, 45 mothers who had never attended the Centre before bringing their children for examination. In many cases the interval between the last attendance at the Centre and the attendance at the Toddlers' Clinic was a long one, due to the advent of yet another new baby in that time. The weighing, measuring and examination of these children is no easy matter and the greatest care is taken to ensure not only that the mother is satisfied with the result of her effort in attending, but that the reaction of the children themselves shall be a happy one. In consequence only a small number of children can be dealt with at one session. Records show that more girls attended than boys and their average weights and heights compared with a standard in age groups show that up to 3 years the boys' weights compare favourably with the standard but in the 4-year age group 52 there is a big fall below it. The girls in both the 3 and 4 year old age groups are below standard. The heights of all groups is higher than standard and this fact may be accountable for the lower weight in the 4 year old age group. Standard Average Average Average Age Weight Weight Boys Weight Girls Weight 2 yrs. 28—29 lbs. 28 lbs. 1 oz. 29 lbs. 1 oz. 27 lbs. 0 oz. 3 „ 33—34 „ 32 „ 8 „ 33 „ 0 „ 31 „ 9 „ 4 „ 37—38 „ 34 „ 8 „ 33 „ 11 „ 35 „ 8 „ Standard Average Average Average Age Height Height Boys Height Girls Height 2 vrs. 2 ft. 7-9 in. 2 ft. 11 in. 2 ft. 11 in. 2 ft. 11 in. 3 „ 2 „ 10-11 „ 3 „ 1 „ 3 „ 1 „ 3 „ 1 „ 4 „ 3 „ 1-3 „ 3 „ 5 „ 3 „ 7 „ 3 „ 3 „ Analysis of conditions found on examination shows that defects of Nutrition formed our biggest group and in this Dental Caries and Rickets are most numerous. Nearly 50% of the dental caries occurred in the 4-year old group, while it was lowest in the 2-year old group. Severe rickets was seen infrequently but early signs were noted in 73 cases. Very few children were markedly below weight. Defects of management was the next biggest group, the children showing behaviour symptoms. A large number of big tonsils was noted and as the majority of these children showed no sign of discomfort the enlargement has been recorded as physiological and classified accordingly. Our thanks are due to the nursing staff in charge of this clinic for their willing and efficient co-operation in the work. Conditions found on examination :— Defects of Development ... Late teething 1 „ walking 14 ,, talking 16 Chest deformities 4 Kyphosis 2 Toe deformities 2 Congenital Inguinal Hernia 1 Umbilical Hernia 1 Tonsils enlarged 73 Adenoids 36 Internal Strabismus 1 Defects of Nutrition ... Markedly below weight 6 Muscular tone poor 13 „ „ only fair 46 Rickets (early) 26 Genu Valgum 35 ,, Varum 7 Dental Caries 45 53 Defects in Management ... Nervous Tension 50 Night Terrors 58 Enuresis 28 Anorexia 1 Results of Infection ... Adenitis, Cervical 74 Ear—N ose—Throat Otorrhcea 11 Nasal Catarrh 2 Tonsillitis 2 Stomatitis, Ulcerative 1 Eyes Blepharitis 1 Conjunctivitis 2 Corneal Ulcer 1 Recurrent Styes 1 Skin Urticaria 16 Impetigo 2 Chest Cardiac Murmurs3 Fibroid Lung1 Bronchitis 2 Rheumatism 1 Threadworms 2 SPECIAL CLINIC FOR DELICATE CHILDREN. Since 1925, a Special Consultation Clinic for Delicate Children has been in operation at the Centre, conducted by Dr. Helen M. M. Mackay, M.D., F.R.C.P. Medical Officers at the Infant Consultations observing children whose conditions require special investigation, or on whom they desire a second opinion, refer such children to the Special Clinic. Dr. Mackay reports on the work of the year as follows :— There is little to report about this clinic during the past year. The number of children referred to the clinic has been small, the types of cases similar to past years. A number of children and their mothers have been recommended for dinner at the Invalid Kitchen, which now supplies meals in a building within a few minutes' walk of the Welfare Centre, and I regard the help there obtained as most valuable. 54 The mothers' standards in the care of their children is I think fairly steadily rising; one wishes more could be done for the general health of the women themselves. H. M. M. Mackay, M.D., F.R.C.P. DENTAL CLINIC. Two sessions per week are held in connection with the Dental Clinic, one conducted by Miss J. H. M. Sutherland, L.D.S.(R.C.S.) and the other by Mr. F. Reginald Bate, L.D.S.(R.C.S.). Miss Sutherland reports on her work during the year as follows :— Sessions held Total. 44 of which 10 were Gas Sessions. Children. rs. New cases 99 45 54 Subsequent attendances, including cases brought forward from 1933 327 51 286 Total 426 96 340 Total. Children. Mothers. Average attendance 10 Gas administrations 58 10 48 Local anaesthetic 14 11 3 39 Temp, teeth. Extractions 227 ... ... ... 21 51 188 Perm, teeth. Fillings 43 16 Temp, teeth. 13 15 ... ... ... 27 Perm, teeth. Gum treatment 28 5 23 Dressings 7 - 7 Silver Nitrate 9 9 — Scaling and polishing 15 3 12 Dentures 40 4 One plate 18 Two plates — 22 Expectant mothers treated — 28 Cases referred to London Hospital — 15 Patients recommended by Centre Doctors 14 21 „ „ „ H.V 22 29 Forty-four sessions were held during the year 1934. Fewer new cases attended but the subsequent visits have increased so that the average attendance is only slightly lower than last year. As the denture work increases steadily each year and more difficult and complicated cases are now being undertaken, much of the time each week is given to these mothers. A good deal of educational and prophylactic work on behalf of the very young children of these patients is carried on at the same time, and every effort is being made to prevent, 55 as far as possible, the onset of dental caries in these children. The older children are very adequately dealt with in the afternoon sessions, and as it has been found that the mothers' dentures steadily need more time and attention, the routine inspection of toddlers in the mornings has been temporarily suspended. Janet H. M. Sutherland, Dental Surgeon. Mr. Bate furnishes me with the following statistics :— Sessions held, 47, of which 14 were Gas Sessions. Children attending routine inspections, 163, of whom 85 were found to require treatment. 60 of these children were treated, the remaining 25 failing to re-attend for treatment. Children referred by Medical Officers and Health Visitors. 60 all requiring treatment and making 181 subsequent attendances. Teeth extracted Children or stopped Treatment under gas ... ... 100 339 Treatment under ethyl chloride spray ... ... ... ... 20 22 Stoppings 27 66 Removal of stain by polishing ... 16 — Silver nitrate ... ... ... 23 teeth — Cases referred to City of London Hospital for urgent treatment 1 — F. Reginald Bate, L.D.S., R.C.S. (Eng.), Dental Surgeon. Dr. D. I. Mart acts as anaesthetist for both Miss Sutherland and Mr. Bate. ENLARGED TONSILS, ADENOIDS AND MASTOID DISEASE. In accordance with the arrangements with the Queen's Hospital, 18 young children had operations for enlarged tonsils as in-patients upon the recommendation of the Medical Officers of the Welfare Centres. ARTIFICIAL SUNLIGHT CLINIC. I append the report of Dr. Horton, who conducts the Light Clinic 56 This clinic has made full use of the 3 mercury vapour lamps installed at the Centre. Over 600 more treatments were given this year than last and results have been satisfactory. It is difficult to persuade mothers who are debilitated after confinement to attend for treatment for themselves, but as our numbers show mothers are very willing to make a continued effort to attend for a course of treatment for their children. The proportion of lapsed cases is less this year than last and on analysis two-thirds of these cases have failed to complete the course of treatment for good and sufficient reasons. It is good to report that many mothers ask for further treatment as they are so satisfied with the beneficial result of a previous course Records are classified in groups and sub-groups to include conditions subsidiary to the main one. Rickets in its early stages continues to form our biggest group, the more severe cases being simultaneously under the care of the Orthopaedic Department at the Queen's Hospital. In the malnutrition group those children who attended regularly showed definite gain in weight and the colour and energy of the children grouped under Anaemia showed marked improvement at the end of the course. Nineteen children attending this clinic also had Massage and all those showing any catarrhal symptoms received Inhalation treatment at the same time. Records :— No. of sessions 148 Average attendance 50.6 Treatments— Children First attendances 487 Subsequent attendances 6,965 Mothers First attendances 1 Subsequent attendances 31 Total treatments 7,484 Cases carried forward from 1933 65 Cases carried forward to 1935 65 Analysis of Cases :— Mothers No. of cases Marked Improvement Improved Lapsed Moved No change Anæmia 1 1 — — — — Bronchitis 1 — 1 — — — Children Malnutrition 61 10 19 27 3 2 Anæmia 12 3 4 4 — 1 Nervous Tension 3 — — 2 — 1 Recurrent Colds 2 — 1 — — 1 Delayed Development 1 — — 1 — — 57  No. of cases Marked Improvement Improved Lapsed Moved No change Anæmia. 49 12 12 23 1 1 Malnutrition 28 5 12 10 1 — Rickets 4 3 — 1 — — Recurrent Colds 5 1 1 3 — — Cervical Adenitis 3 — 2 1 — — Nervous Tension 3 1 — 2 — — Delayed Development 3 — 3 — — — Rickets 118 24 43 49 1 1 Persistent Loss of Weight 1 — 1 — — — Recurrent Colds 7 1 2 4 — — Delayed Development 63 12 26 21 4 — Mongol 2 — 2 — — — Nervous Tension 17 6 4 7 — — Skins Recurrent Styes 6 1 2 3 - _ Chilblains 3 2 — 1 — — Urticaria 9 3 2 4 — — Debility after Measles 46 3 19 23 1 - Whooping Cough 8 1 3 3 — 1 Scarlet Fever 1 — — 1 — — Diphtheria 3 1 1 1 — — Influenza 3 2 1 — — — Pneumonia 12 4 5 3 — — Bronchitis 8 1 3 3 1 — Mastoidectomy 1 — 1 — — — Removal of Tonsils 1 — 1 — — — Adenitis 3 — 2 1 — — INHALATION CLINIC. This clinic was established in 1930 for the relief of catarrhal conditions of the upper respiratory tract by means of the Spiess-Drager Inhaler in which volatile oils are vaporised on the passage of oxygen and inhaled by the patient. Dr. Horton reports : As the result of experience in previous years it has been found that a mixture of Pine Oil with Cajuput Oil in equal parts gives us the most satisfactory results and it is this combination of oils that has been used in the clinic throughout the year. This beneficial effect is shown in our results recorded below for while in 1933, 70 cases showed improvement after treatment, in 1934,103 patients were relieved of their symptoms 58 and this in spite of the fact that the average attendance per session is rather less than last year. Our total number of treatments is less than it has been but the long sunny summer of 1934 lessened the occurrence of many conditions for which this clinic is useful. Reattendances on the whole have been good and of the 42 lapsed cases over half were due to illness in the family preventing further attendance. It is of interest that relief seems to be obtained within a few days of beginning treatment and that complete relief occurs in many cases within a month. It is satisfactory to record that many mothers ask for a second course of inhalation for their children as they need it, having already experienced its efficiency. Records :— Cases carried forward from 1933 34 New cases in 1934— Children 138 Subsequent treatments 1,289 New cases in 1934— Mothers 7 Subsequent treatments 97 Total treatments—1934 1,565 Cases carried forward to 1935 23 No. of sessions held in 1934 148 Average attendance per session 10.6 Analysis of Cases :— Cases Cured Improved *Lapsed No change Bronchitis 40 16 13 8 3 Tracheitis 2 1 — — 1 Fibroid Lung 1 — 1 — — Catarrh after Whooping Cough 11 3 3 4 1 „ „ Measles 6 2 1 3 — „ „ Pneumonia 9 1 6 2 — ,, with Teething 8 4 2 2 — ,, „ Enlarged Tonsils and Adenoids 3 1 2 — — „ „ Rickets 2 1 — 1 — Recurrent Colds 86 25 22 36 3 *Under this heading insufficient attendances have been made to obtain any result. 59 ORTHOPÆDIC TREATMENT. Children who on attendance at any infant consultation or at the Toddlers' Clinic show evidence of any need for Orthopaedic treatment are referred to the Queen's Hospital for Children with a card from the doctor. By arrangement of the Borough Council they are seen by an Orthopaedic Surgeon and suitable treatment is prescribed. Massage and Artificial Sunlight are given at the Welfare Centre but the children report to the surgeon at intervals as required. Children may be admitted to hospital if surgical treatment should be necessary. A " follow up " scheme to ensure regular attendances at the hospital is working well and our thanks are due to the Almoner at the Queen's Hospital for her interested co-operation. More children attended than in 1933 and in spite of the fact that a number of parents still refuse to allow their children to receive treatment the importance and great value of this scheme is being realised steadily. Completion of treatment and cure of these conditions is necessarily slow, so that the small number recorded below as cured is no index to the work done. All the children attending are making steady progress and it is only a question of time before most of these will be included under this heading. Records :— Carried forward from 1933 33 New cases attended in 1934 55 Total No. referred to hospital 88 Two children were admitted to hospital for in-patient treatment, while appliances were supplied in 47 cases. Results :— Discharged cured 4 Genu Valgum with Flat Foot 3 ,, Varum 1 Treatment completed but children still under observation 2 Congenital Dislocation of Hip 1 Wry Neck 1 60 Transferred to other hospitals 6 At school under L.C.C. 8 Removed from district 8 Parents refused treatment 15 Under treatment and carried forward to 1935 45 88 Analysis of Cases :— Genu Valgum 33 „ Varum 19 „ Valgum with Flat Foot 25 „ Varum 5 Congenital Dislocation of Hip 2 Rickets with Flat Foot 1 Trigger Thumb 2 Wry Neck 1 Grants were made to the Royal National Orthopaedic Hospital in respect of the treatment of two Bethnal Green children in that hospital. MASSAGE. Full use of the facilities for Massage (6 sessions per week) has been made at the Welfare Centre this year. Massage has been given to children attending the Queen's Hospital for Children under the Council's Orthopaedic scheme as well as to those children who are recommended by the Medical Officers at the infant consultations. A large number of children have been taught remedial exercises which they practise at home and it is interesting to see how well the children do them and the good that results. The analysis of cases indicates the range of the work done, the groups due to defects in nutrition being considerably bigger than those due to pathological conditions and these are the children that respond best to treatment. Thanks are due to the Masseuse for the efficiency and popularity of this clinic. The supply of work for it is limited only by the time available for it. 61 Records :— Cases carried forward from 1933 23 New cases treated in 1934 118 Subsequent attendances 1,639 Total treatments 1,780 Discharged 124 Carried forward to 1935 17 Analysis of Cases :— Children Rickets 23 Genu Valgum 8 „ Varum 4 Curved Tibia 33 Flat Foot 6 Poor Muscular Development 21 „ Chest „ 8 Faults in Walking 6 Talipes 2 Hammer Toe 1 Congenital Dislocation of Hip 1 Sprained Ankle 1 Trigger Thumb 1 Torticollis 15 Amyotonia Congenita 1 Anterior Poliomyelitis 1 Erb's Paralysis 1 Constipation 5 Mothers Failing Breast Milk 3 CONVALESCENT TREATMENT. During the year 10 mothers were sent to the London Mothers' Convalescent Home, Sunningdale, Berkshire, and 9 mothers to the " George Whitlaw " Convalescent Cottage, Amerden, near Taplow. With regard to children, the arrangement made with the Hertfordshire County Council in 1922 was continued, and 54 children were sent to that Council's Home at St. Leonard's-on-Sea, Sussex, for periods varying from 1 to 7 weeks. In addition, 4 children were sent to the Noel Home, Letchworth, for periods of 3 to 9 weeks, and 4 children to the John Madock's Home, Basing, for periods of 4 to 7 weeks. 62 Owing to the increasing demand for this service and the long waiting lists created thereby, it has been necessary during the year to find further accommodation, and arrangements have accordingly been made with the Association of Maternity and Child Welfare Centres for the reservation of 3 cots throughout the year to be used interchangeably at the John Madock's Babies Home, Basing, and the Noel Home, Letchworth. This arrangement came into operation on the 1st October. Notwithstanding this extra accommodation, owing to the outbreak of infection at the St. Leonard's Home, there was some delay in getting children away. It is to be hoped that the proposed Zachary Merton Trust Home may be established in the early future to relieve the undoubted need for further convalescent home accommodation. Dr. Horton reports : An increased number of children were recommended for Convalescent Homes this year and more were admitted than last year. Records show that the number of lapsed cases has increased and on analysis of these cases in three-quarters of them the parents either did not proceed with their applications or declined an offered vacancy. This is unfortunate and indicates the need for continued teaching as to the great value of a seaside or country holiday for children recovering from an illness. The many children who have returned fit and happy after their convalescence and the satisfaction expressed by their parents on their return home encourage us for the future. The number of mothers sent to Convalescent Homes is less than last year, the difficulty of leaving husbands and families for any longer than the bare minimum time for recovery from confinement being too great for many to solve. This is a definite handicap to them and to this branch of the work and it is difficult to see how to deal with it. As with the children, we hope that the excellent accounts given by those mothers who do go away of the Homes they go to and their own marked improvement physically and mentally will slowly persuade others to avail themselves of this valuable service. 63 Records :— Children recommended 82 ,, sent to Convalescent Homes 62 Lapsed cases 20 Analysis of Lapsed Cases :— Did not proceed with application 7 Declined vacancy 8 Removed from borough 1 Unable to go when vacancy offered 3 Mothers recommended 33 ,, sent to Convalescent Homes 20 Lapsed cases 13 Analysis of Lapsed Cases :— ' Did not proceed with application 2 Declined vacancy 2 Went elsewhere 4 Difficulty of domestic arrangements ... 5 Analysis of Cases :— Children- General Debility 8 Anaemia 8 Malnutrition 13 Under weight 6 Anorexia 1 Debility after Measles 27 „ „ Whooping Cough 3 ,, ,, Chicken Pox 1 „ „ Diphtheria 1 ,, ,, frequent infections 1 ,, ,, Mastoidectomy 2 ,, ,, removal of Tonsils and Adenoids 4 ,, ,, Arthrectomy (following Scarlet Fever) 1 „ ,, Pneumonia 3 ,, ,, Bronchitis 3 Mothers— Debility after confinement 33 My thanks are due to the staff for their valuable assistance in maintaining the standard of work and the friendly atmosphere that obtains at the various clinics. 64 HOSPITAL TREATMENT FOR MALNUTRITION. We have no formal arrangement for prolonged observation and in-patient treatment for children suffering from dietetic mismanagement and malnutrition. Such cases as cannot be dealt with through the Council's Special Clinic for Delicate Children are referred to the Queen's Hospital or one of the General Hospitals. SCALES OF CONTRIBUTIONS FOR MATERNITY AND CHILD WELFARE SERVICES. These scales were revised during the year to bring them more into conformity with prevailing economic circumstances. PROVISION OF MILK FOR NECESSITOUS MOTHERS AND CHILDREN. The prevalence of unemployment and low wages among the residents in the Borough, to which reference has been made elsewhere, has led to increased privation among the mothers and children. So far as necessitous expectant and nursing mothers and young children under 5 are concerned, the Council is able to render some slight assistance by way of grants of milk. Grants of this kind were made to 7,023 families (compared with 7,990 in 1933), the grants being in respect of 8,575 individuals. There were 2 sessions a week, and 22,340 attendances at the Welfare Centre in connection with Milk Grants. During the year the following quantities of milk were issued to necessitous mothers:— Grade A (Tuberculin Tested) Milk 4,837 galls. Dried Milk 31,861 pkts. together with medicines, etc. The approximate cost of milk given in this way was £2,8S5. 65 In the second half of the year there was put into operation a scheme of co-ordination between the London County Council Public Assistance service and the Borough Council's Milk Grants for expectant and nursing mothers and young children. Under the new arrangements, the Borough Council's expenditure on milk supplied to families who are on public assistance is refunded by the L.C.C. This amounted to £367 at the end of the year. The scheme involves the provision to the L.C.C. of a monthly medical certificate in respect of each case and a fairly elaborate accounting system. It is understood that the milk provided is an addition to the relief which is granted by the L.C.C. As a reciprocal arrangement, expectant mothers who are attending the L.C.C. Ante-Natal Clinics and who are in poor circumstances but not on public assistance are wherever necessary referred to the Borough Council's Welfare Centres for milk grants under the Maternity and Child Welfare scheme. The new arrangments are working fairly well but I am bound to observe that the volume of clerical work involved by the present system of accounting seems to me to be wholly out of proportion with the amount of money concerned in the transfer. SUPPLY OF DRIED MILKS, Etc. Apart from the milk issued free or at half-price, dried milk of various brands, labelled specially to the Council's directions to avoid the use of trade names, is sold to the mothers a little above cost price. The amount sold during the year was as follows :— Dried Milk. 6,017 pkts. NURSING ASSISTANCE. A scheme of home nursing has been in operation for some years by arrangement with a voluntary organisation, the Shoreditch and Bethnal Green Nursing Association. 66 During the year 246 children under the age of 5 were nursed, a total of 2,733 visits being made. 33 mothers received 337 visits for nursing in connection with conditions incidental to child-bearing. Nursing Assistance, 1934. Disease Children UNDER FIVE years Mothers Others Total Visits Cases Visits Cases Visits Cases Visits Ophthalmia Neonatorum 4 26 ... ... ... ... 26 Discharging Eyes 37 498 ... ... ... ... 498 Measles 23 360 ... ... 3 34 394 Whooping Cough 1 6 ... ... ... ... 6 Diarrhæa 1 2 ... ... ... ... 2 Puerperal Fever and Pyrexia ... ... 1 24 ... ... 24 Other pre-natal and postnatal conditions ... ... 32 313 ... ... 313 Otorrhœa, other Ear dis. 22 428 ... ... ... ... 428 Tonsils and Adenoids 44 162 ... ... ... ... 162 Influenza 2 14 ... ... 7 85 99 Bronchitis 3 21 ... ... ... ... 21 Pneumonia 17 219 ... ... 19 279 498 Tuberculosis ... ... ... ... ... ... ... Intestinal Conditions ... ... ... ... ... ... ... Threadworms 45 522 ... ... ... ... 522 Discharging Umbilicus 32 331 ... ... ... ... 331 Impetigo and Eczema 2 10 ... ... ... ... 10 Circumcision 1 12 ... ... ... ... 12 Septic arm, leg. etc. 2 20 ... ... ... ... 20 Miscellaneous 10 102 ... ... 2 50 152 Totals 246 2733 33 337 31 448 3518 6 cases were in hand at the beginning of the year. 5 cases were in hand at the end of the year. PUERPERAL FEVER AND PUERPERAL PYREXIA. One case of Puerperal Fever was reported during the year. The patient was treated in the North Western Hospital, but died from the disease. 67 Twelve cases were notified as Puerperal Pyrexia. Two patients were treated at home. The other patients were treated at the following Hospitals :— Bethnal Green (1), Mothers' (4), East End Maternity Hospital (1), Jewish Maternity (3), St. Peter's (1). OPTHALMIA NEONATORUM, &c. Thirteen notifications of Ophthalmia Neonatorum were received during the year. All the patients were treated at home except 2 who received hospital treatment at St. Margaret's. The Health Visitors paid 44 visits to cases. All the cases cleared up without any impairment of vision being reported. Thirty reports were also received from Medical Officers of the London County Council concerning new born babies suffering from inflammation of the eyes, 1 of these cases being subsequently notified as Ophthalmia Neonatorum. These cases were also visited by the Health Visitors. The district nurses treated 37 cases of discharging eyes in young infants, paying 498 visits for the purpose. CHILDREN ACT, 1908 (Part I). CHILDREN & YOUNG PERSONS ACT, 1932 (Part V) Under the Transfer of Powers (London) Order, 1933, the duties of the London County Council under the above-mentioned Acts were transferred to the Metropolitan Borough Councils. At the end of the year, there were 15 foster mothers and 18 foster children on the register in the Borough. The children are visited regularly by the Health Visitors. MEDICAL INSPECTION OF SCHOOL CHILDREN. The County School Medical Officer has kindly furnished me with the following statistics with regard to the medical inspection of the school children in the Borough: 89 Routine Medical Inspection of Elementary School Children in Bethnal Green in 1934. Age Groups Number Examined clothing and boots nutrition cleanliness of head CLEANLINESS OF BODY teeth vision Good Fair Poor Good Average Below normal Bad Clean Nits Pediculi Clean Dirty Pediculi All sound Less than 4 decayed 4 or more decayed 6,6 in both eyes 6/9 in either or both eyes 6/12 or worse in ' either or both eyes entrants Boys 893 75 816 2 83 765 45 — 891 2 — 882 10 1 482 323 88 — — — Girls 934 113 820 1 102 783 48 1 917 17 — 928 5 1 498 341 95 — — — Age 7— 65 Boys 419 58 360 1 18 377 24 — 409 10 — 416 2 1 274 122 23 179 173 Girls 431 42 387 2 23 390 18 — 416 15 — 425 6 — 293 120 18 189 173 65 Age 11- Boys 816 111 703 2 40 732 44 — 809 7 — 814 2 — 594 210 12 446 205 161 Girls 827 106 720 1 77 707 43 — 819 7 1 825 2 — 632 185 10 456 216 154 Age 14— Boys 889 115 772 2 127 729 33 — 888 1 — 887 — 2 666 211 12 491 212 183 Girls 1138 158 979 1 149 970 19 — 1131 6 1 1136 2 — 845 280 13 612 288 235 Total 6347 778 5557 12 619 5453 274 1 6280 65 2 6313 29 5 4284 1792 271 2373 1267 863 Percentage 12·3 87·5 0·2 9·8 85·9 4·3 — 99·0 1·0 — 99·5 0·5 0·0 67·5 28·2 4·3 52·7 28·1 19·2 London 53·9 45·5 0·6 20·5 75·3 4·2 — 96·9 2·8 0·3 98·9 1·1 0·0 68·8 26·5 4·7 65·3 19·2 15·5 69 Examination of Elementary School Children in Bethnal Green, 1934. Number examined BOYS GIRLS Entrants Age 7 Age 11 Age 14 Entrants Age 7 Age 11 Age 14 893 419 816 889 934 431 827 1138 Cases * Cases * Cases * Cases * Cases * Cases * Cases * Cases * Malnutrition 16 14 13 6 9 9 10 10 16 14 2 1 15 10 9 8 Skin disease 15 7 9 5 10 8 8 7 15 11 3 1 3 — 12 12 Defective teeth — 356 — 121 — 198 — 222 — 376 — 100 — 185 — 290 Enlarged tonsils 151 52 43 22 32 6 16 5 123 42 35 14 42 13 22 10 Adenoids 9 8 2 2 — — — — 6 2 4 3 2 1 1 1 Enlarged tonsils and adenoids 17 16 3 2 — — — — 14 11 — — 3 3 2 1 Other nose and throat defects 13 9 8 3 9 1 6 3 17 9 4 1 7 5 4 2 Enlarged glands 22 7 3 — 5 2 1 — 13 2 6 - 5 2 6 1 Eye disease 35 23 12 3 5 3 1 — 39 25 8 4 10 8 13 8 Vision defect — — — 39 — 114 — 120 — — - 41 - 95 - 149 Otorrhoea 8 6 2 2 5 3 1 1 10 8 4 2 5 3 6 4 Other ear disease 3 1 3 2 - — 3 1 7 4 3 2 3 3 1 1 Defective hearing 1 1 1 — 1 — 4 3 1 — 2 — 5 — 4 4 Speech defects 5 — 5 1 1 — 4 2 3 1 2 — 1 — - - Heart defects 13 — 8 — 12 — 5 1 20 2 7 1 15 — 16 - Anaemia 10 5 4 2 2 1 1 1 1 — 2 1 6 1 3 1 Lung defects 63 10 13 2 10 2 7 — 55 15 8 2 10 3 9 5 Nervous defects 3 2 5 — 3 — 1 — — — 1 1 5 2 — — Phthisis 1 — — — - — 1 ] — — — — — 1 — Other t.b. disease — — — — — — — — — — — — — — —- — Rickets 3 1 — — 1 — 2 — 1 — 1 — 1 - — Spinal deformities — — 1 — 5 — 2 1 — — 3 — 6 2 5 3 Other deformities 10 1 2 1 12 3 14 9 6 — 3 1 20 9 18 11 Other defects 36 27 6 1 20 10 11 4 33 21 6 4 25 13 25 13 Number of children noted for treatment 437 184 307 339 447 152 296 448 * Defects however slight are included under "cases"; those severe enough to require treatment are shown under * 70 These figures are particularly instructive as they represent the only systematic health stocktaking which is carried out in the borough for a complete section of the population. A large number of babies are seen at the Welfare Centres but there is no law to require all of them to be taken there and the inspection of " toddlers " has not reached a sufficiently large proportion of them to enable us to claim that our data is fully representative. Over school age there is no regular medical inspection and such data even as is available from the medical examination of sick persons under the health insurance scheme is not available to me. The facts elicited at the medical inspection of school children are therefore of great value in estimating the physical condition and tendencies of at any rate one substantial section of the population. Last year's inspections reveal further deterioration in nutrition, the percentage marked "good " falling from 10.3 to 9.8, compared with the average for London of 20.5. With regard to soundness of teeth and vision, Bethnal Green children are below the London average. Once again I draw attention to the ironic fact that in Bethnal Green where a considerable amount of clothing is made and which is one of the centres of the boot and shoe trade, only 12.3% of the children are well clothed and shod compared with 53.9% in London as a whole. This is a deterioration since last year when the Bethnal Green percentage was 19.9. On the other hand, I am glad once more to pay tribute to the housewives of Bethnal Green with regard to their care for the cleanliness of their children. Having regard to the housing accommodation, lack of bath rooms or hot water supply and privacy, it is remarkable that Bethnal Green children should have the high distinction of 99% clean in the head and 99.5% clean in the body, particularly as these figures are actually higher than the averages for London of 96.9% and 98.9% respectively. Such facts should help to refute the reference, still occasionally heard, to the alleged " dirty habits of the poor," and indicate 71 that, considering their adverse circumstances, working people actually expend more energy upon cleanliness than many people imagine. The second table showing the various kinds of physical defects found in the children shows that nearly half of them require urgent medical attention. The entrant's group seems to be rather worse than last year, 48.8% of the boys and 47.8 of the girls requiring attention compared with 45.7% and 45.1% respectively last year. Most of these defects ought to be prevented by more adequate medical and dental supervision before entry to school. It is satisfactory to record, as this report is being drafted, that the Council has decided to establish additional welfare centres and to increase the health visiting staff' with a view, among other things, of devoting more care to the toddlers. 72 THE CONTROL OF DISEASE. During the year, the number of cases of practically every infectious disease showed a substantial decrease, except Pulmonary Tuberculosis and Ophthalmia Neonatorum. Scarlet Fever dropped from 786 to 435 and Diphtheria from 488 to 370. The total number of cases of all diseases (including Tuberculosis) fell from 1,813 to 1,236. The reasons for this welcome reduction of infectious disease are as mysterious as those for the substantial increase I had to record in the previous year. Malnutrition has been cited as a probable explanation, but while this is a factor which cannot be ignored it does not seem very reasonable to suppose that the standard of nutrition in the borough suddenly fell in 1933 sufficiently to explain the heavy incidence of infectious disease and its virulent character in that year or that it rose again in 1934 to such an extent as to cause a 50% fall in the amount of such disease. It is rather more scientific to attribute a good many of these fluctuations to the periodic character of the diseases in question, which may of course be complicated by variations in the physical condition of the population, virulence of the infection, housing, etc. In any case it is difficult to draw precise conclusions from the statistics of infectious disease for a single London borough or even for the County as a whole because of the inter-communication which takes place between home and workplace, restaurants, places of amusement, buses, trams, trains, etc. over a large area in London and Greater London. Nevertheless, as there is a reason for everything if it can only be found, it is desirable that research should be conducted into the causes for these variations, with a view if possible to determining the relative influence of such factors as malnutrition, housing, smoke, sunlight, as well as the special characteristics of the diseases concerned. The accompanying table shows the number of cases of each disease, the age composition of the patients and the numbers removed to hospital. Cases of Notifiable Diseases Notified during 1934. Disease Number of Cases Notified Removed to Hospital Reported .by RegistrarGeneral. Total Under 1 year 1 and under 2 years 2 and under 3 years 3 and under 4 years 4 and under 5 years 5 and under 10 years 10 and under 15 years 15 and under 20 years 20 and under 25 years 25 and under 45 years 45 and under 65 years 65 and upwards Smallpox 1 2 ... ... ... ... ... 1 1 ... ... ... ... ... 2 Enteric Fever 3 3 ... ... ... ... ... 1 ... ... ... 1 1 ... 3 Diphtheria (inc. Memb. Croup) 371 370 7 22 36 43 46 132 49 13 6 12 4 ... 368 Scarlet Fever 443 436 4 23 36 44 40 159 72 18 22 16 2 ... 422 Puerperal Fever 1 1 ... ... ... ... ... ... ... ... ... 1 ... ... 1 Puerperal Pyrexia 12 12 ... ... ... ... ... ... ... ... 2 10 ... ... 10 Ophthalmia Neonatorum ... 13 13 ... ... ... ... ... ... ... ... ... ... ... 2 Erysipelas 80 80 2 ... 2 2 ... 5 2 ... 10 22 29 6 45 Cerebro-spinal Fever ... 3 ... ... ... 1 ... 1 1 ... ... ... ... ... 3 Acute Poliomyelitis ... 3 ... 1 ... ... ... 1 ... ... ... ... ... ... 2 Acute Encephalitis Lethargica ... 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... Acute Polio-encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Acute Primary Pneumonia 154 135 11 7 7 9 7 24 8 9 9 19 17 8 96 Acute Influenzal Pneumonia 19 ... ... ... ... ... ... 1 2 3 2 7 4 4 Dysentery ... 1 ... ... ... ... 1 ... ... ... ... ... ... ... 1 Malaria ... 2 ... ... ... ... ... ... ... ... ... 1 1 ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Typhus Fever, Cholera, Plague, Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anthrax, Hydrophobia, Glanders ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Tuberculosis ... 127 ... 1 ... 1 1 3 1 10 30 51 . 25 4 * Other forms of Tuberculosis ... 28 1 ... ... ... 3 4 1 6 2 6 3 2 * Total 1236 38 54 81 101 98 331 137 58 84 141 89 24 959 ' See particulars as to Sanatorium Treatment in Tuberculosis section. t The Registrar-General's figures are for notifications received during the 52 weeks ended 29th December, 1934, and include several non-residents and duplicate cas>es. The Council's figures are for cases notified during the calendar year, and exclude non-residents. 73 74 DIPHTHERIA IMMUNISATION. There has been a great deal of discussion in recent years concerning the advantages of obtaining artificial immunity from Diphtheria by injections of toxin-anti-toxin and other preparations. The main grounds for this propaganda are the dangers and prevalence of Diphtheria. As a preliminary therefore to any serious consideration of a scheme of immunisation, one requires a fairly complete knowledge of the local incidence of and mortality from this disease. With this object, Mr. Lloyd has carried out a very exhaustive analysis of our statistics on these subjects relative to the past 34 years. The full result of this enquiry would be too detailed and lengthy for submission in this report, but the following summary will show the main conclusions to which it tends : Case Rate per 1,000 popn Death Rate per 1,000 popn. Case Mortality Rate per 100 cases 1901-1905 2.6 0.3111.5 1906-1910 1.8 0.16 9.3 1911-1915 2.5 0.18 7.7 1916-1920 4.0 0.30 7.3 1921-1925 4.5 0.23 5.1 1926-1930 4.0 0.11 2.7 1931-1934 3.5 0.10 2.9 It will be seen that while the mortality has very substantially declined, the case rate shows some increase. With regard to the latter, however, it should be borne in mind that this is calculated on the number of " notified " cases and is not altogether a reliable statement of the number of cases of clinical Diphtheria which occurred in the year. In 1933, for instance, I received notice from the fever hospitals that in 82 cases or 16.8% of the total, the diagnosis of Diphtheria was found to be incorrect. In 1934 this happened in 14.9% of the cases. In 1901 and 1902, a similar correction was made in 7.8% and 8.1% of the cases. I have no means of knowing whether these corrections are complete or not, but it seems obvious 75 that there is a large margin of probable error in notification figures and that the apparent increase cannot be accepted as a certain actual increase. Further interesting statistics have been compiled with regard to three age periods among children for the same quinquennia : Case Rate per 1,000 children at ages cited Death Rate per 1,000 children at ages cited Case Mortality per 100 cases at ages cited 0-1 1-5 5-15 0-1 1-5 5-15 0-1 1-5 5-15 1901-1905 2.4 11.3 4.5 0.8 1.9 0.4 36.1 16.3 7.6 1906-1910 3.0 8.9 2.9 0.7 1.1 0.4 23.5 12.4 5.4 1911-1915 4.6 11.3 4.7 1.1 1.2 0.2 22.9 10.7 3.3 1916-1920 5.4 16.5 8.3 0.8 2.1 0.3 16.3 12.6 3.7 1921-1925 6.8 24.7 8.8 0.7 2.1 0.2 10.8 8.6 2.6 1926-1930 6.0 21.8 10.2 0.6 0.8 0.2 10.1 3.6 1.9 1931-1934 4.4 19.5 10.4 0.3 0.9 0.2 8.6 5.2 1.5 These figures illustrate the high incidence of the disease at the age periods 1-5 and 5-15 and while they are subject to the corrections previously mentioned they appear to lend more support to the view that there may be an actual increase than do the figures for the population as a whole. It will, however, be noticed that since the peak period 1921-25 there appears to be a declining tendency. The substantial decline in mortality, whether measured on the child population as a whole or on the notified cases, is a marked feature in each age group but especially in the 5-15 and in the case mortality among infants. Again it will be observed that the war and immediate post-war periods were characterised by a specially high incidence. It is not possible to draw conclusions of general application from these figures, but they certainly indicate that reduction in Diphtheria incidence sometimes occurs irrespective of immunisation schemes and 76 that this is markedly true of the great improvement in Diphtheria mortality which has occurred during the past 34 years. Whether such improvements would be enhanced by immunisation is arguable. The difficulty is that if there is some long term biological cycle which influences these statistics, in addition to such factors as current economic circumstances and their effect upon the resistance to disease, one cannot very well distinguish between what has been the result of the natural curve, the environmental factor or the active immunisation measures. In the absence of substantial proof of this kind, is it the proper line of action to launch a vigorous immunisation campaign (anything less would appear to be of little value) or to appropriate the money and labour involved towards other more tangible public health activities ? In considering a possible national drive for Diphtheria immunisation, if this be the proper course, it is well to bear in mind that unless 60 to 70 per cent, of the child population is immunised the aim of a protected community cannot be realised. At present, we know that a large number of children are so-called Diphtheria carriers (I say " so-called " because they are usually not carrying virulent Diphtheria bacilli) and consequently as children enter school they probably receive infinitesimal doses of infection, thereby obtaining a certain degree of herd immunity. This is indicated by work that has been done in the East End in testing children as to their susceptibility to Diphtheria, from which it would seem that 60 to 70 per cent, are insusceptible, thus leaving us with about 30-40% susceptibles. When one adds to this analysis the difficulties experienced relative to vaccination, it is questionable whether the response to voluntary immunisation would be sufficient to produce any more appreciable effect in a district like Bethnal Green. In all the circumstances, the weight of evidence seems to me to be decidedly in favour of the second of the two courses indicated above. 77 Diphtheria. There were 370 cases of diphtheria notified during the year. The age grouping of the cases is given in the accompanying table. All but 2 of the cases were removed to an isolation hospital. 10 deaths from this disease occurred during the year, equivalent to a case mortality of 2.7 per cent., or general death rate of 0.1 per 1,000 of the population. From information received from the hospitals it would appear that in 55 cases (or 14.9 per cent, of the total) the diagnosis of Diphtheria was not confirmed. Eighteen cases seem to have been developed in hospital, while there were 15 " second cases " in families in which a case had recently occurred. Anti-diphtheritic serum is stocked at the Town Hall and supplied free on the order of a doctor; 52,000 units were supplied during the year. Scarlet Fever. There were 436 cases of scarlet fever notified during the year, 422 of the patients being removed to an isolation hospital. One death was certified as due to scarlet fever during the year, equal to a case mortality of 0.2 per cent., and a death rate of 0.01 per 1,000 population. From information received from the hospitals, it would appear that in 36 cases (or 8.2 per cent, of the total) the diagnosis was not confirmed. Eight cases seem to have been developed in hospital, while there were 20 " second cases." Mild Smallpox. Two cases of mild Smallpox were notified but the diagnosis was not confirmed at the hospital. 78 Enteric Fever. Three cases were notified and removed to hospital, in one case the diagnosis proving incorrect. There was one death from the disease. Other Notifiable Diseases. Particulars of the number of notifications of various diseases and the age grouping of the patients will be found in the accompanying table. In addition to the usual routine enquiries and protective measures, special enquiries have been made in a number of cases of Cerebro Spinal Fever, etc., on behalf of the London County Council. Consultations with Medical Practitioners. I was called in consultation by medical practitioners with a view to discussing the diagnosis in a number of doubtful cases. Statistics and notes with regard to Puerperal Fever, Ophthalmia Neonatorum, and Home Nursing will be found in the section relating to Maternity and Child W elf are. VACCINATION. The following is the latest available return prepared by the Vaccination Officers for the Borough, respecting the Vaccination of Children whose Births were registered from 1st January to 31st December, 1933, inclusive. Registration SubDistricts comprised in each Vaccination Officer's District. No. of Births from 1st Jan. to 31st Dec., 1933. Number of these Births duly entered by 31st Jan., 1935. No. of Births which on 31st Jan.. 1935, remained unentered in the Vaccination Register on account of— No. of these births remaining on 31st Jan., 1935, not accounted for Total No. of Certificates of successful Primary Vaccination of children under 14 received during Calendar Year 1934 No. of Dec larations of Conscienous Objection actually received by Vaccination Officer during the Calendar Year 1934. Successfully Vaccinated. Insusceptible of Vaccination. Had Smallpox. Declaration of conscientious objection received. Died, Unvaccinated. Postponement by Medical Certificate Removal to Districts, V.O. of which apprised. Removal to places unknown and cases not found. North East 722 104 1 — 442 24 10 34 107 175 476 South West 313 38 — — 199 17* — _ 4 55 204 199 TOTAL ... 1,035 142 1 — 641 41* — 10 38 162 379 675 Children vaccinated after declaration of conscientious objection: N.E., nil; S.W., nil. Vaccination certificates for 1934 sent to other Vaccination Officers : N.E., 48 ; S.W., 46. *plus 6 cases in which statutory declarations were made and children subsequently died unvaccinated. 79 80 TUBERCULOSIS. Tuberculosis of all kinds is notifiable, and particulars of the notification certificates received during the year are set out in the tables appended hereto, from which it will be seen that 154 new cases of Tuberculosis were notified under the Public Health (Tuberculosis) Regulations. In addition 1 posthumous notification was received making a total of 155 certificates. Information was also received from the Register-General or from the Local Registrars of the deaths of 9 persons who had died from Tuberculosis but who had not been notified under the Regulations. During the year 18 persons who had been notified in other Boroughs to be suffering from Tuberculosis took up their residence in this Borough. The number of patients remaining on the Tuberculosis Register at the 31st December, 1934, was 1,309. The details are given in the table on pages 81 and 82. During the year there were registered 74 deaths from Pulmonary Tuberculosis, and 7 deaths from other tuberculous diseases. The number of deaths from Tuberculosis of all kinds during the past few years is as follows :— Pulmonary Non-Pulmonary Total 1923 164 19 183 1924 134 18 152 1925 121 21 142 1926 121 20 141 1927 115 17 132 1928 105 18 123 1929 109 10 119 1930 96 12 108 1931 119 13 132 1932 99 11 110 1933 74 14 88 Public Health (Tuberculosis) Regulations, 1930. PART I.—SUMMARY OF NOTIFICATIONS during the period from the 1st January, 1934, to the 29th December, 1934, in the area of the Metropolitan Borough of Bethnal Green. AGE PERIODS Formal Notifications Number of Primary Notifications of new cases of tuberculosis Total Notifications 0— 1— 5— 10— 15— 20— 25- 35- 45— 55— 65— total fall ages) Pulmonary Males ... 1 1 1 5 16 16 16 9 10 4 79 101 Females ... 2 2 ... 5 14 13 6 2 3 ... 47 57 Non-Pulmonary Males ... 3 2 1 3 1 ... 1 2 ... 2 15 21 „ „ Females 1 ... 2 ... 3 1 4 1 ... 1 ... 13 16 PART II.—SUPPLEMENTAL RETURN.—New Cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the above mentioned period, otherwise than by formal notification. AGE PERIODS 0- 1— 5— 10- 15— 20— 25— 36— 45- 55— 65— Total Pulmonary Males ... ... ... ... 1 2 4 4 4 2 ... 17 ,, Females ... ... ... ... ... 1 5 ... ... 1 ... 7 Non-Pulmonary Males ... ... ... ... ... 1 ... ... ... ... ... 1 ,, „ Females ... 3 ... ... ... ... ... ... ... ... ... 3 The source or sources from which information as to the above-mentioned cases was obtained, is stated below: Source of Information No. of cases Pulmonary NonPulmonary Death Returns from local Registrars 4 1 transferable deaths from Registrar General 3 1 Posthumous notifications 1 "Transfers" from other areas (other than transferable deaths) 16 2 Other Sources if any (specify) ... ... PART III.—NOTIFICATION REGISTER. Number of cases of Tuberculosis remaining at the 31st December, 1934, on the Register of Notifications kept by the Medical Officer of Health of the Metropolitan Borough Pulmonary Non-Pulmonary Total cases Mates Females Total Males Females Total 484 382 866 252 191 443 1309 Number of cases removed from the Register(s) during the year by reason of:— 1 Withdrawal of notification ... ... ... ... ... ... ... 2 Recovery from the disease ... 1 1 1 1 2 3 3 Death 62 25 87 3 4 7 94 4 Patients removed from Borough 34 28 62 13 22 35 97 5 Lost trace 8 1 9 2 2 4 13 Total 104 55 159 19 20 48 207 81 82 Tuberculosis Register. Pulmonary Non -Pulmonary Total Males Females Males Females Number of cases on the Tuberculosis Register 31/12/33 4S7 382 256 205 1330 Number of new cases notified under the Public Health (Tuberculosis) Regulations, 1930, during the year 80 47 15 13 155 Transferred from non-pulmonary 1 1 ... ... 2 Other cases added to the Tuberculosis Register during year 20 7 1 3 31 Number of cases removed from Tuberculosis Register during year. (For details see separate statement) 588 437 272 221 1518 104 55 19 29 207 Transferred to pulmonary ... ... 1 1 2 Cases remaining on Tuberculosis Register 31/12/34 484 382 252 191 1309 Notification is fairly satisfactory on the whole but delay is sometimes experienced in the receipt of notifications of admissions to and discharges from sanatoria. There were 9 deaths certified from Tuberculosis in which the deceased person had not previously been notified. This represents 11 per cent, of the- deaths from Tuberculosis during the year. Enquiry of the certifying practitioner in each case elicited the following explanations :— Assumed previously notified 3 Diagnosis only reached at or immediately before death 3 Certified by Coroner 1 No reply 2 83 Late notification, probably due to delay in seeking medical treatment, is shown by the following figures:— Notified practically at time of death 2 „ within 1 month „ „ 8 ,, „ 3 months ,, ,, 8 ,, ,, 6 months „ „ 5 The foregoing figures are tragic. It is impossible to say that everyone of these 32 patients would have been saved from a premature death from Tuberculosis even if he had been seen by a doctor earlier in the course of the disease but it is certain that many of them would have had their resistance to the disease strengthened and many more years of useful life if they had promptly sought medical advice and treatment when the first symptoms appeared. I am afraid, however, that until the community has the foresight to provide for the maintenance of the family of the tuberculous worker during his necessary treatment and for his industrial protection afterwards, it is futile to expect his early recourse to the doctor. For the average worker, a diagnosis of tuberculosis is tantamount to a sentence of increasing poverty for his family. If he accepts treatment in a sanatorium they are deprived of their breadwinner. If he delays treatment, his condition gets progressively worse and he finds increasing difficulty in earning a living. I refer to this subject again in commenting on Dr. Howell's report on the Dispensary. TUBERCULOSIS DISPENSARY. The Tuberculosis Dispensary for the borough is provided under agreement by the City of London Hospital for Diseases of the Heart and Lungs and is shared with the Hackney Borough Council. A full report on the work of the Dispensary, by Dr. H. T. Howell, the Clinical Tuberculosis Officer, appears in the appendix to this report on page 128. This position, adopted for convenience, by no means indicates the relative importance of Dr. Howell's report, and I 84 strongly recommend its perusal as a valuable contribution to our better understanding of the problems of Tuberculosis. I wish to draw special attention to Dr. Howell's description of the facilities at the Dispensary for the efficient diagnosis of Tuberculosis and the arrangements made there for the comfort and convenience of patients, also to his remarks about the problem of the ex-sanatorium patient. TUBERCULOSIS AND EMPLOYMENT. There is no doubt that here Dr. Howell touches upon one of the most vital aspects of Tuberculosis, the economic and family aspect. Giving a patient one or more periods of sanatorium treatment is of little avail if the patient eventually has to return to an overcrowded tenement in a congested area and to work under the arduous conditions of modern industry where speeding up and severe competition for employment soon drive the weak to the wall, and their families with them. At present large sums are being expended on sanatorium treatment, which is as good as wasted because the work begun is not carried to a satisfactory conclusion. Large sums are also being spent in Unemployment Benefit, on Public Assistance and in charity to support the ex-sanatorium patient and his family, when he has been compelled to give up the struggle. This latter expenditure does not figure in the Tuberculosis Accounts and so we do not realise it, but it should be remembered if we want to calculate the actual present cost of this disease. It would appear to be a truer economy to spend this money on establishing the patient in conditions where he could live healthily and earn a living under friendly medical supervision without overtaxing his impaired strength or losing heart. The Pap worth and Preston Hall settlement schemes are the best means so far devised for securing this. It must be candidly confessed that well intentioned local schemes for " finding employment " for the tuberculous are utterly inadequate to 85 deal with the problem and merely lead to wasted effort and disappointment. The problem is too big for the limited resources of a local authority and requires to be tackled by some body like the London County Council or, better still, by the State as a national question. WORK OF TUBERCULOSIS VISITORS. The two Tuberculosis Visitors paid 4,125 visits of enquiry and advice with regard to the welfare of tuberculous patients in the Borough. The reduced number of visits was owing to the illness of one of the visitors. In addition they made 347 futile calls owing to patients being out. In the course of their work they endeavour to persuade patients to adopt such hygienic manner of life as is practicable by separate sleeping accommodation, safe collection and disposal of sputum, etc. They also make economic enquiries on behalf of the L.C.O. in connection with sanatorium treatment, etc. TUBERCULOSIS CARE COMMITTEE. The Sub-Committee of the Public Health Committee has functioned during the year as the local Tuberculosis Care Committee, dealing with such matters as grants of extra nourishment, assessments for sanatorium treatment on behalf of the London County Council, provision of special treatment, etc. SUPPLY OE SPUTUM OUTFITS. During the year 17 sputum flasks were distributed to patients. Six sputum tins, with 497 cardboard refills were distributed to patients for use indoors. 86 OPEN-AIR SLEEPING SHELTER. The Council's Open-Air Sleeping Shelter was in use during part of the year. Unfortunately, owing to the limited space available in the yards and gardens attached to the houses in the Borough, very little extension of use can be made of this valuable adjunct to treatment. PROVISION OF BEDSTEADS AND BEDDING, AND CLOTHING. The bedsteads and bedding which are available for loan to necessitous patients to enable them to sleep alone were frequently used during the year. Some assistance has also been rendered to patients in getting necessary clothing for use while in sanatoria. SANATORIUM TREATMENT. During the year 130 patients were recommended for Sanatorium or Hospital treatment and 120 of them were sent away to institutions. In addition, 68 patients received treatment for Tuberculosis in the general hospitals of the L.C.C. Twelve children were recommended for admission to an open-air school, all being accepted. A reform of great value has been the decision of the L.C.C. to cease charging contributions in respect of residential treatment for tuberculosis or the boarding out of child contacts of cases of tuberculosis. There can be no doubt that the practice of charging contributions, no matter the amount or how carefully assessed, has been a deterrent to some patients obtaining or continuing treatment. It has also been a somewhat distasteful task for the staff and committees concerned with the assessment, distracting attention to some extent from the essential work of advising and assisting the patients and their families in dealing with the disease and the problems in its train. 87 GRANTS OF EXTRA NOURISHMENT. During the year 218 grants of Grade A (Tuberculin Tested) milk and new laid eggs were made to 93 necessitous tuberculous patients at an estimated cost of £125. DENTAL TREATMENT FOR TUBERCULOUS PATIENTS. During 1934, 5 dispensary patients received dental treatment at the City of London Hospital for Diseases of the Heart and Lungs, each making one attendance therefor. Five patients were also assisted in the provision of artificial dentures. FINSEN AND ARC LIGHT TREATMENT. PNEUMOTHORAX REFILLS. Since 1921, the Council has paid for the Finsen Light treatment of cases of Lupus at the London Hospital. During the year 6 patients were so treated, making 633 attendances for treatment. Two patients also made 395 attendances for arc light treatment of Lupus at the same hospital. In addition, one patient suffering from Glandular Tuberculosis was recommended by the Tuberculosis Officer for Arc Light treatment at the London Hospital and made 115 attendances. Under the Council's arrangements for the provision of pneumothorax refills, 1 patient had 6 refills at the Brompton Hospital, 19 patients received this form of treatment at the City of London Hospital, having 175 refills between them, 2 patients had 25 refills at Colindale Hospital, and 1 patient at Grove Park had 6 refills. PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS) REGULATIONS, 1925. No action was taken under these regulations during the year. 88 NON-NOTIFIABLE DISEASES. Measles. During the year 1,879 cases of Measles came to my knowledge from the following sources:— Schools 1,129 L.C.C. Ambulance Service 459 Other Hospitals 10 Medical Practitioners 63 Health Visitors 150 Sanitary Inspectors 62 Other 6 All cases were visited, either by a Health Visitor or the District Sanitary Inspector, according to the age of the patient. A special Measles Health Visitor was engaged for the period 22nd January to 31st March. 529 patients were removed to L.C.C. Special Hospitals, and in 26 cases nursing assistance was provided by the Council, 394 nursing visits being paid to them. After various corrections of diagnosis and sifting of " suspected " cases, there would appear to have been a nett total of at least 1,771 actual cases. Information as to cases not already known to them is passed on to the L.C.C., to enable that authority to check the spread of infection in the schools and similar information is sent to Sunday Schools. There were 34 deaths from measles during the year. The scheme of co-operative action by the L.C.C. and the Borough Council seems to have been of considerable value in obtaining greater control over the spread of the disease and in securing its prompter and more effective treatment. The need for such measures is shown by the high mortality of this serious disease among young children. 89 German Measles. 69 cases of German Measles were also reported, 13 of them being removed to hospital. Correction of diagnosis and sifting of " suspected " cases, makes the nett total of actual cases about 67. Whooping Cough. 120 cases of Whooping Cough came to my know2 ledge ; through reports from the L.C.C. (37), Health Visitors (19), Sanitary Inspectors (5), Schools (55), and doctors (4), and these children were visited by the Health Visitors and the Sanitary Inspectors. 43 children were removed to an Isolation Hospital. 8 deaths from this disease were recorded during the year. Miscellaneous Investigations. 331 cases of Chickenpox were reported and visited by the Sanitary Inspectors. A number of other children were also visited by the Inspectors for illnesses reported by the Head Teachers, and suggestive of one of the notifiable diseases. Diabetes. Arising out of an application from the University College Hospital on behalf of a poor Bethnal Green patient, the Council sought and obtained the sanction of the Ministry of Health to pay for the provision of insulin for such patient. This was continued throughout the year and the patient has shown some improvement under treatment. BACTERIOLOGICAL EXAMINATIONS. The Council's bacteriological work is carried out by the Clinical Research Association. The following specimens were examined during the year:— 90 Throat and Nasal Swabs—submitted for examination 1190 Diphtheria bacilli present in 134 Sputum—specimens submitted for examination 106 Tubercle bacilli present in 9 Blood-serum—specimen examined for Widal reaction (negative) 1 „ „ specimen submitted for Wassermann reaction (negative) 1 Faeces—specimen submitted for Dysentery (negative) 1 Other bacteriological examinations in connection with food are reported on elsewhere. SHELTER FOR CONTACTS. (3, St. James Road). These premises, consisting of a nine-room house, are occupied by a caretaker and are available, as required by statute, for the accommodation of contacts of infectious disease during the disinfection of premises. The shelter was used during the year. DISTRIBUTION OF DISINFECTANTS. During the year 5,394 pints of partially diluted disinfecting fluid were distributed to applicants at the Town Hall. DISINFECTION SERVICE. During the year, 1,449 rooms and 32,184 articles were disinfected for various reasons, liquid Formalin in the form of a spray being used for the purpose of disinfecting rooms. Two Morris motor vans are used for conveying articles for disinfection. 91 The table appended gives details of the rooms, bedding and clothing disinfected. No. of Rooms Articles of Clothing, etc., Disinfected by Disinfected Steam Formalin Infectious disease 965 8,272 1,486 Scabies 44 2,171 — Verminous condition 432 5,411 1,275 Other conditions 8 111 — Hospital bedding — 12,322 1,136 1,449 28,287 3,897 No. of articles destroyed by request, 1,053. Arrangements are now in operation for any necessary disinfection to be carried out during the week-end, one disinfector standing by for duty on Saturday afternoon and Sunday morning. Spraying Machines. A small stock of spraying machines is kept for issue on loan, with a quantity of insecticide, to residents desirous of following up and completing the disinfection of their rooms. The sprayers were lent on 475 occasions during the year, as compared with 467 in 1933. Verminous Conditions. Thirty-two children (in 27 families) were reported from the L.C.C. Cleansing Station as being infested with vermin, 17 of the families being cases of head lice only. In every case advice as to the treatment of the clothing and bedding was given and disinfestation by steam was offered. In 11 cases disinfection of some kind was accepted. These reports continue to show steady improvement. Considering the conditions under which a large proportion of the children live, it 92 is remarkable that such few cases of vermin are reported, and speaks well for the care taken by mothers to keep their children clean despite adverse circumstances. Rooms were disinfested of vermin in 432 cases. Scabies or Itch. Sixty-five children suffering from this disease were excluded from the Elementary Schools. In addition, 23 cases of Scabies were reported by the London Hospital, one by the Mile End Hospital, one by the Queen's Hospital, and one by the London Jewish Hospital. In all of these cases the bedding and clothing was disinfected. 44 rooms were also fumigated after Scabies. Personal Cleansing Station. The Personal Cleansing Station is becoming better known to the public as part of the Council's considered scheme for the destruction of insect pests, although it has been little used by women. The baths are available for women on Wednesdays, when a woman attendant is engaged, the other days being allocated to men. During the year 211 men, 15 women and 8 children had 235 baths and their clothing was disinfected for vermin, and 42 men, 39 women and 6 young children had treatment with sulphur ointment, in addition to baths and disinfection, on a total of 186 occasions, for Scabies. By arrangement with the Shoreditch and Stepney Borough Councils, residents in those boroughs have been dealt with at the Personal Cleansing Station during the year as follows:— Persons Baths Scabies 24 65 Vermin nil nil These figures are included in the foregoing figures of total work done at the Station. 93 VERMIN IN RELATION TO HOUSING. Arising out of my report to the Housing Committee last year, systematic efforts are now being made to reduce the risk that families moving into municipal houses may be carrying vermin into the new tenement. Notwithstanding the efforts of clean tenants to get rid of them, bugs are found in the furniture as well as in the walls of most old houses in such congested districts as Bethnal Green. This arises from the fact that in this property the defective plaster and woodwork and the recesses of the furniture provide excellent breeding and hiding grounds. Ordinary methods of disinfection by spraying or fumigation are only partially and temporarily successful. Houses are closely built in terraces and vermin find it comparatively easy to travel from house to house, while a further complication is that in many cases poor tenants are compelled to buy second-hand furniture in which the presence of vermin is difficult to detect and even more difficult to eradicate by the means mentioned. While therefore some good is being done by our present methods of disinfecting the furniture of prospective Council tenants, it cannot be pretended that they afford any guarantee of destruction of the vermin therein and certainly they give no guarantee of the disinfestation of the old tenement. In these circumstances, serious consideration has been given during the year to more effective measures for vermin destruction of which the hydrocyanic gas process has been the most favoured. The gas is introduced into a specially constructed removal furniture van in which the furniture has been placed and the method appears to give a guarantee of the complete destruction of all vermin without damage to the furniture. The gas is of course highly dangerous and the process has to be carried out by specially trained men under conditions of safety. The containers, motor chassis for conveying them, and the electrical plant for carrying out the process involve substantial capital expenditure while the cost of running the plant is also 94 fairly considerable. The alternative of having the work done by private contractors is also expensive. It would therefore appear that some joint arrangement between the Metropolitan Boroughs and the London County Council may be desirable in order that the undoubted advantages of this more effective means of vermin destruction can be obtained without unnecessary expenditure. The problem of the vermin infested old terrace house would still remain. The hydrocyanic gas process is too dangerous to adopt in a single house, because of the risk of the percolation of the gas into adjoining houses, although it might be possible to apply it in a small terrace of houses if they could all be vacated at the same time. It may be pointed out, however, that the verminous house is quite frequently bad in other respects and it is to be hoped that clearance schemes may help towards its gradual elimination. LONDON COUNTY COUNCIL (GENERAL POWERS) ACT, 1928, SECTION 28. Care of Aged and Infirm Persons. During the year, it was not found necessary to apply for a magistrate's order for the removal to hospital of any aged and infirm person found to be living under insanitary conditions and not receiving proper care and attention. FOOD POISONING. Food Poisoning has been notifiable throughout London since 1932. During the past year, 25 cases were notified. Of these cases, 13 were attributed to eating fish (including tinned fish) and 12 to meat (including tinned meat). One patient was notified to be suffering from Ptomaine Poisoning and admitted to hospital, but the diagnosis was not confirmed. 95 CARE OF THE FEET. A branch of work which has received a good deal of attention during recent years is Chiropody. The clinics which have been established at the Chelsea Polytechnic and by the Bermondsey and Walthamstow Borough Councils have revealed the existence of a large amount of acute physical discomfort, readily amenable to treatment to the great advantage of numbers of working people whose working efficiency has been impaired by foot troubles. The clinics have also brought to light orthopaedic defects which might otherwise have been neglected and by the reference of such cases to orthopaedic surgeons early appropriate treatment has been obtained for the correction of such defects. The teaching of foot hygiene is another useful adjunct. At the request of the Public Health Committee, I reported on this subject last year and furnished particulars of the equipment and staff which would be necessary if the Council decided to establish a Foot Clinic. For financial reasons, the scheme was not proceeded with. A privately run clinic has since been established in the borough, and another clinic exists just over the borough boundary in Mare Street, Hackney, both, I understand, well attended. 96 PROTECTION OF FOOD SUPPLY. The work of the Local Health Authority with a view to the protection of the food supply takes three forms: (i) Supervision of premises where food is prepared or sold, to ensure cleanliness; (ii) Examining food as to its soundness; and (iii) Sampling food to ascertain its composition and quality. The whole sanitary inspecting staff co-operate in exercising general supervision over the cleanly conduct of the food trades. The conditions under which food is sold in the street or from shops with open fronts still gives room for much dissatisfaction. Unsound food is much less frequently found than in former years and in this as in the matter of cleanliness, food traders and the public are rightly recognising the need for higher standards. The figures which follow illustrate the problems which arise in testing the quality and nature of the great variety of foodstuffs now in common use. CLEANLINESS IN THE FOOD TRADES. Draft byelaws were prepared in February, 1934 by the London County Council under Section 6 of the London County Council (General Powers) Act, 1932, to promote sanitary and cleanly conditions in the manufacture, etc. of any article intended for the food of man. These proposals, while containing many much needed provisions for the protection of the public, appear to be rather inadequate as regards personal precautions. Particular attention should be given to the need for every person concerned in food preparation to keep his clothing, hands, finger nails and body thoroughly clean, for which purpose food traders should be required to provide their employees with clean washable overalls and the means of personal 97 cleanliness in the form of an adequate supply of washing basins, hot and cold water, soap, nail brushes and towels. The draft byelaws are still under consideration but it is to be hoped they will be issued in their substantive form as soon as possible. The Borough Council has been concerned, so far as its powers permit, to improve the hygienic conditions under which food is sold from street stalls, following upon a report I submitted to the Public Health Committee in 1933 concerning the sale of unwashable food by street traders in the borough. In addition to the general requirement that such traders must guard against contamination of the food they offer for sale, the Street Trading Committee intimated to licensees during 1934 that certain foods must not remain exposed for sale uncovered unless the stalls concerned were covered on top and enclosed at the back and sides. The foods in question were sweets, toffee apples, cakes and biscuits, sugar, meat pies, fruit from tins and jellied eels. There are of course some itinerant vendors to whom the street trading byelaws do not apply and these are particularly difficult to control. Anomalies also exist in the conditions applying respectively to shops, especially those with open fronts or projecting stalls, and street stalls. Hence the need for general regulations concerning the manufacture and sale of food, irrespective of the particular form of manufacture or place of trading. FOOD AND DRUGS ACTS. Seven hundred and thirty-five samples were taken; 690 of these proved to be "genuine" and 45 or 6.2 per cent. adulterated. 98 The details are given in the following table:— SUMMARY OF ANALYST'S REPORTS. Article Samples taken formally Samples taken informally Total number of samples taken No. taken Genuine Adulterated No. taken Genuine Adulterated Milk 404 381 23 3 3 ... 407 Butter 100 100 ... 12 12 ... 112 Margarine 7 7 ... ... ... ... 7 Dried Milk 5 5 ... ... ... ... 5 Condensed Milk 1 1 ... 3 3 ... 4 Evaporated Milk 1 1 ... ... 1 ... 2 Cream 11 11 ... ... ... ... 11 Dripping 3 3 ... ... ... ... 3 Ale and Beer 2 2 ... 8 7 1 10 Wine ... ... ... ... 1 ... 1 Whisky 5 4 1 ... ... ... 5 Gin 3 3 ... ... ... ... 3 Parrish's Food ... ... ... 2 2 ... 2 Camphorated Oil 1 1 ... ... ... ... 1 Comp. Liquorice Powder ... ... ... 5 5 ... 5 Mercury Nitrates ... ... ... 1 1 ... 1 Aspirin Tablets 2 1 1 2 ... 2 4 Sugar ... ... ... 2 2 ... 2 Table Jelly 5 4 1 2 1 1 7 Custard Powder ... ... ... 2 2 ... 2 Pepper 2 1 1 5 5 ... 7 Lemon Curds 1 1 ... ... ... ... 1 Ground Ginger 2 2 ... 4 4 ... 6 Tea ... ... ••• 1 1 ... 1 Biscuits ... ... ... 1 1 ... 1 Mincemeat ... ... ... 2 2 ... 2 Sweets 9 9 ... 4 4 ... 13 Bread ... ... ... 1 1 ... 1 Self-raising Flour ... ... ... 2 2 ... 2 Flour ... ... ... 4 4 ... 4 Jam 24 21 3 3 3 ... 27 Honey 1 1 ... 1 1 ... 2 Vinegar 29 24 5 5 3 2 34 Malt Vinegar 5 5 ... 1 1 ... 6 Sauce 1 1 ... ... ... ... 1 Minced Meat 1 1 ... 12 8 4 13 Sausages 1 1 ... 3 3 ... 4 Suet, Shredded 1 1 ... ... ... ... 1 Dried Fruits ... ... ... 10 10 ... 10 Chopped Peel ... ... ... 5 5 ... 5 Totals 627 592 35 108 98 10 735 99 The Public Analyst has furnished me with the following report on his work during the year:— Annual Report of the Public Analyst. During the year 1934, 735 samples were examined under the Food and Drugs (Adulteration) Act. Twenty-four of these samples were submitted by neighbouring Authorities, the remainder by the Inspectors. No sample under the Act was submitted by the Public. One hundred and eight of the Inspectors' samples were purchased informally. Forty-five samples were found to be adulterated, thirtyfive formal and ten informal. In addition, sixty other samples were reported as of doubtful purity or inferior quality. The adulteration was at the rate of 6.1 per cent. as compared with 2.68 per cent. for the whole of London and 5.5 per cent. for the whole of England and Wales in 1933. The adulteration in the Borough for the past ten years was as follows:— Year No. of samples examined Percentage of adulteration 1934 735 6.1 1933 738 7.7 1932 718 7.9 1931 749 7.1 1930 737 6.5 1929 750 8.0 1928 731 9.3 1927 728 9.2 1926 721 3.3 1925 745 3.9 Average 735 6.9 The rate of adulteration is lower than it has been for the past eight years, but still remains higher than the figures for other Boroughs of similar character. The number of samples examined was at the rate of 7.7 per 1,000 of the population, as compared with 9.7 per 1,000 for the whole of London and 3.46 per 1,000 for the whole of England and Wales in 1933. Four hundred and seven samples of milk were examined during the year of which twenty-three samples, or 5.65 per cent. were found to be adulterated, and fifty-seven samples were reported as of inferior quality or doubtful purity. 100 The milk adulteration for the past ten years was as follows:— Year No. of samples examined Percentage of adulteration 1934 407 5.7 1933 355 5.6 1932 332 6.4 1931 303 3.0 1930 296 6.8 1929 287 5.2 1928 306 8.2 1927 275 5.4 1926 340 2.9 1925 355 4.8 Average 326 5.4 Condensed Milks. Four samples of condensed milk were examined, all of which were satisfactory. Preservatives. There were nine contraventions of the Preservatives Regulations. Other samples examined during the year were:— 23 Rag Flocks, four of which were unsatisfactory. 1 Plating Solution, " Lusilvia." all for the Public Health Department. Albert E. Parkes, F.I.C. FOOD AND DRUGS. Legal Proceedings, 1934. Particulars of the legal proceedings taken during the year in respect of foods and drugs, will be found in the appendix, p. 125. SAMPLES TAKEN INFORMALLY. One hundred and eight samples were taken informally during the year, 10 of which were found to be adulterated as follows:— 101 Article No. of Sample Offence Aspirin Tablets 133 5% deficient in aspirin. Ale 207 76 parts per million Sulphur Dioxide Minced Beef 251 198 „ ,, ,, ,, ,, do. 253 55 „ ,, ,, ,, ,, Table Jelly 274 261 „ ,, ,, ,, ,, Minced Meat 441 150 „ ,, ,, ,, ,, Aspirin Tablets 551 5.8% Talc Table Vinegar 605 32.5% deficient in Acetic Acid do. 623 32% „ „ „ „ Meat 613 264 parts per million Sulphur Dioxide The genuine samples are indicated in the table on page 98. PUBLIC HEALTH (PRESERVATIVES, &c., IN FOOD) REGULATIONS, 1925 to 1927. Three formal and 6 informal samples taken under these Regulations were found to contain preservatives, to wit, sulphur dioxide, in parts per million, as follow: Minced Meat 55 Jam 50 „ 150 „ 45 „ 198 Ale 76 „ 264 Table Jelly 261 „ „ 275 PUBLIC HEALTH (CONDENSED MILK) REGULATIONS, 1923. Two formal and four informal samples of condensed milk were taken, and were found to comply with the Regulations. PUBLIC HEALTH (DRIED MILK) REGULATIONS, 1923. Five samples of dried milk were taken during the year, and were found to comply with the Regulations. 102 BACTERIOLOGICAL EXAMINATIONS OF FOOD. During the year 15 bacteriological examinations of milk, and 2 of other food were made as follows:— Ordinary Milk, 1; Grade A (Tuberculin Tested) Milk, 3; Grade A Milk, 1; Pasteurised Milk, 10; Soft Cheese, 2. B. Coli were found in 4 samples of Pasteurised Milk, and 1 of Grade A (T.T.). FOOD PREMISES. Milkshops and Dairies. 65* applications for registration were considered during 1934, 9 of them referring to a round only. The figures in regard to registration of Milkshops are set out below:— Number of purveyors of milk on register at end of 1933 316 Deduct number of purveyors removed from register during the year 24 Add number of new purveyors added to register by resolution of the Public Health Committee during the year 8 Number of purveyors of milk on register at end of 1934 300 During the year 758 inspections of milkshops were made by the Inspectors, and 92 notices were served under the Public Health (London) Act, 1891. Legal proceedings were not found to be necessary in respect of milk premises. *This includes changes of occupier in premises previously on the register. 103 Some careless or unscrupulous milk traders are occasionally found filling bottles in the street and perhaps sealing them with discs taken from their pocket —a practice both contrary to the Milk and Dairies Order and to the principles of hygiene. One milk vendor was summoned for the offence, being ordered by the magistrate to pay 2s. Od. in costs. One person was fined £2 with £2 2s. Od. costs for not having his milk receptacles properly inscribed with his name and address and another was ordered to pay £1 1s. Od. costs. In a third case of this nature, the summons was dismissed, the Council being unable to prove ownership by the defendant. Milk (Special Designations) Order, 1923. 12 dairymen were licensed to sell "Grade A (Tuberculin Tested)" Milk, 1 for the sale of "Certified" Milk, 1 for the sale of "Grade A" Milk and 7 for the sale of "Pasteurised" Milk, while supplementary licences to sell "Certified" Milk in the Borough from premises in Stepney and Hackney and others to sell " Grade A (Tuberculin Tested)," " Grade A " and " Pasteurised " Milk in the Borough from premises in Poplar, Shoreditch, Hackney, Stepney, Finsbury and Rugby were also granted during the year. School Milk Scheme. It is common knowledge that in the latter part of the year an important scheme came into operation for the provision to school children at a reduced price of one-third of a pint of milk each school day. Pasteurised milk is being supplied to the schools in the borough and arrangements have been made for the supply to be tested from time to time as to its composition and bacterial standard. Cowhouses. There were at the end of 1934 8 licensed cowhouses in the Borough. 47 inspections were made during the year. No notices were served. 104 In 1933, by the operation of the Transfer of Powers (London) Order, the licensing of Cowsheds was transferred to the Borough Council. The following premises are duly licensed:— 63, Bishop's Road—Shed No. 1—(8 cows). Shed No. 2—(6 cows). 23, Ezra Street—(6 cows). 38, Fellbrigg Street—Shed No. 1—(8 cows). Shed No. 2—(8 cows). 104, Gibraltar Walk—(18 cows). 55, Kerbela Street—Shed No. 1—(18 cows). Shed No. 2—(2 cows). 2, Lisbon Street—(19 cows). 64, Squirries Street—(14 cows). 38, Three Colts Lane—(23 cows). Ice Cream Premises. There were 172 ice cream premises registered at the end of the year, and 343 visits were paid to them by the district inspectors: 20 notices were served. Fried Fish and Fish-Curing Premises. At the end of 1934 there were 40 fried fish vendors' premises in the Borough, at 2 of which curing was also carried on. There were 21 fish curers' premises, including these two. Two hundred and sixty-five visits were made by the Food Inspectors to these premises, and 42 notices were served for insanitary conditions. Workshop Bakehouses. There are, in Bethnal Green, 36 workshop bakehouses, 10 of which are underground: 126 visits were made to them during the year, resulting in the serving of 16 sanitary notices. 105 Factory Bakehouses. There are also 29 factory bakehouses, 9 of which are underground. In nearly every case the mechanism used, which causes the bakehouse to be a factory, is a dough mixer. Generally speaking, the factory bakehouses are kept clean and in a sanitary condition. One hundred and nine inspections were made during the year, and 15 notices were served. Other Premises used for the Preparation or Sale of Food. There were 218 such premises on the register, the majority being restaurant-kitchens or butchers' shops. 846 inspections were made during the year, and arising out of such inspections 109 notices to remedy faults or insanitary conditions were issued. Slaughterhouses. There are two licensed slaughterhouses in the Borough, situated at:— 294, Bethnal Green Road. 354, Bethnal Green Road. The licensing is now in the hands of the Borough Council. 20 visits were made to slaughterhouses by the Food Inspector. Public Health (Meat) Regulations, 1924. The number of animals killed at the slaughterhouses was as follows:— Lambs 52 Sheep 1 Total 53 106 No carcases or offal were condemned. It will be seen that the number of animals slaughtered shows a progressive decline compared with former years, and it is to be hoped that the use of these small private slaughterhouses will be discontinued altogether shortly. Slaughter of Animals Act, 1933. This Act which came into operation on the 1st January, 1934 provides for the humane and scientific slaughter of animals in slaughterhouses, and for the licensing of slaughtermen. The Council has appointed the Medical Officer of Health and the Sanitary Inspectors from time to time in the employ of the Council as officers to execute the Act and has decided that slaughtermen's licenses shall be for a period of one year. Three slaughtermen have been so licensed. The Council has exercised its option to include sheep, ewes, wethers, rams and lambs within the protection of the Act. Slaughterers op Poultry. There are 9 slaughterhouses for poultry in use, all of them situated in the West ward of the Borough: 144 visits were paid to them during the year. Sanction was given to the establishment of this business at a new slaughterhouse during 1934. UNSOUND FOOD. In addition to the special inspections of slaughterhouses and other premises where food is prepared or sold, the Food Inspectors keep stalls and market places under regular supervision, particularly during the week-end. The District Sanitary Inspectors also keep general observation in the course of their duties. No seizures took place. On 7 occasions during the year, unsound food, comprising the following articles was surrendered by the owners and destroyed as trade refuse:— 107 Description of Article. Weight. Tons. Cwt. ##] Fish — 1 42 Meat — - 19½ Tinned Meats 2 3 82 Hams — — 76 Potatoes 20 — — Fruit — 4 — Sugar — 14 14 Chocolate — — 0¼ also 36 dozen Lettuces, 1 case Lobsters, and 9 boxes Kippers. FOOD POISONING. During the year 25 cases of suspected food poisoning were investigated. The subject is dealt with more fully in the preceding section dealing with the Control of Disease. PHARMACY AND POISONS ACT, 1933. This Act contains numerous provisions with regard to the sale of poisons, membership of the Pharmaceutical Society and the conditions to be fulfilled by pharmacists in order to become authorised sellers of poisons. Poisons are to be divided into two groups according to recommendations by an Advisory Committee to be set up by the Home Office. Those in the first group will only be sold by registered pharmacists while those in the second group may be sold by registered pharmacists and certain other persons registered by the local authority (in London, the Borough Council). The inspection of the premises of registered pharmacists will be in the hands of the Pharmaceutical Society, but the inspection of the premises of the other persons will be the responsibility of the local authority. The Medical Officer of Health and the Sanitary Inspectors from time to time in the employ of the Council have been appointed as officers to execute the Act. So far, the lists of poisons and regulations for procedure under the Act have not been issued by the Home Office. 108 SANITATION AND HOUSING. During the past 25 or 30 years, the duties of the Public Health Department have so increased by newer branches such as Tuberculosis and Maternity and Child Welfare that the original basis of the service—house sanitation—is sometimes in danger of being overlooked. No one can gainsay the necessity and importance of the work that is now carried on for the welfare of the young or of the complex organisation we now possess for the control of Tuberculosis and other dangerous diseases, but during all this development, the sanitary supervision of the home, school and workplace has still retained its vital place in our defence against insanitary conditions and the ill health that results therefrom. This branch of the work is even more important than formerly in a district like Bethnal Green, where the housing is so ill planned, old and congested, and where poverty always tends to overcrowding. Advice at the Welfare Centre and the Tuberculosis Dispensary about the advantages of fresh air, sunlight, cleanliness, the hygienic storage of food and proper sleep is rendered somewhat futile if these conditions are in fact unobtainable owing to the housing in which families are compelled to live in the Borough. Strenuous efforts to secure a decent environment have been made by the local authority and a succession of devoted sanitary inspectors, and undoubtedly great improvements have been effected. To understand the true situation, however, one must remember the character of the bulk of the houses with which the sanitary inspectors have still to deal. Town planning, which is now taken for granted as a necessity when districts are being "developed" not only did not exist while Bethnal Green was being built over, but the most elementary principle of spacing houses so as to allow free light and air was completely ignored. Modern building byelaws and 109 practice, providing some reasonable kind of standard of hygiene and domestic comfort and amenity, did not operate and consequently we find dismal rooms whose ugliness is only equalled by their discomfort and lack of provision for healthy life within them. Obviously a large part of Bethnal Green housing ought to be demolished and replaced by modern houses. This would involve great expenditure of money and disturbance of population and seems, urgently desirable as it may be, rather utopian a prospect at the moment. Nevertheless it is well to remember that a great deal of the work of the sanitary inspectors is created by these old bad houses which we can neither demolish nor put right. All we can do is to remedy sanitary "nuisances," i.e., defective roofs, dirty walls and ceilings, defective w.c.'s., etc. The equally real defects of insufficient light and air, of absence of convenient hot water, bathrooms and lavatory basins, of no properly ventilated larder, lack of privacy, still remain. The present patching and repairing of these old houses is carried on in an atmosphere of uncertainty whether they may or may not be included in a clearance area this year or next. In any case it is futile, except as a temporary postponement of the decay of the property and the rendering a little more tolerable the life of the unfortunate residents. Sanitary work under these conditions requires great courage and cheerfulness. The Council is to be congratulated on a sanitary staff which quietly and persistently carries on its duties in spite of discouragements. While these remarks mainly apply to dwelling houses, it must be confessed that some of the older schools and workplaces in the borough are sadly behind modern ideas with regard to lighting and air space. So far as the schools are concerned, although they are open to the sanitary inspection of the local sanitary authority their sanitary supervision is in practice left to the education authority—the L.C.C. No doubt that body has in mind the desirability of reconstructing some of these dismal, prison-like 110 ings and giving them more of the cheerful aspect of a place of light and learning. With regard to workshops, the local authority has no power to require alterations merely on account of age and higher modern standards. So long as the premises are adequate for the purpose and the workers are tolerably treated with regard to lighting, temperature, cleanliness and sanitary accommodation we must be content. There is, however, an unfortunate multiplicity of small workshops conducted by employers of limited resources and this tends to lead to a low standard of workshop hygiene, which is especially the case when the workshops are old or frequently changing hands. SANITARY SUPERVISION OF THE BOROUGH. A Summary of Inspections and Visits, with Matters Outstanding, for the 52 WEEKS ended 29th DECEMBER, 1934. Nature of Visit Totals Infectious Diseases (notifiable) 1087 Infectious Diseases (non-notifiable) 1568 Food Poisoning — Complaints 4818 House to House Inspections 856 Milkshops (570) and Cowsheds (37) Inspections 607 Other Food Premises Inspections (Slaughterhouses 25, Poultry 114, Others 1347) 1486 Factory (776) and Workshop (1700) Inspections 2476 Outworkers' Homes Inspections 762 Common Lodging House Inspections 13 Tenement House Inspections 588 Drainage Inspections 3833 Smoke Nuisances—Premises under observation 41 Other Inspections or Special Work 5354 Re-Inspections 18541 Total Visits for the Year 42030 Unsound Food Seizures (0) or Surrenders (16) 16 Samples of Food, etc., taken 708 Samples of Rag Flock taken 23 Police Court Attendances 80 Premises where Nuisances abated 5535 Premises where Matters Outstanding 840 111 The following sanitary defects were discovered during the year:— Dirty rooms 5,884 Defective drains and choked w.c.'s 802 Defective and dirty w.c.'s 2,284 Defective water supply 425 Defective paving 636 Defective gutters and rainwater pipes 708 Defective roofs 1,367 Dampness 718 Defective dustbins 1,332 Smoke nuisances 6 Overcrowding 28 Other defects 9,282 Total 23,472 The work of the outdoor staff is reflected in the volume of clerical work associated with sanitaryadministration. During the year 5,151 Preliminary Notices were served requiring the remedying of Nuisances. 2,286 Statutory Notices were served. The legal proceedings which were necessary to enforce the Notices served are reported on in the appendix to this report. At the beginning of the year there were 766 premises with nuisances outstanding. During the year, nuisances at 5,422 premises were abated and 840 premises with nuisances outstanding were carried forward to 1935. COMMON LODGING HOUSES. During the year one of the common lodging houses was discontinued. There are now 4 such premises in the Borough, and the inspectors paid 47 visits to them. Three sanitary notices were served. 112 TENEMENT HOUSES. The number of houses on the register as being let in lodgings or occupied by members of more than one family was 287; 864 visits of inspection were made to these houses, and arising out of such visits 270 notices were served. Comprehensive by-laws with regard to tenement houses were made in 1925, although many important clauses do not fully operate until six months after the Rent Restrictions Acts have ceased to be in force. During 1931, the L.C.C. made amending by-laws, whereby certain of these clauses come into operation upon any tenement houses becoming decontrolled. Steps are now being taken to bring on to the register the numerous premises in the Borough which come under the by-laws. A commencement has been made with those houses where a non-resident owner has let the whole of the tenement separately. RENT AND MORTGAGE INTEREST RESTRICTIONS (AMENDMENT) ACT, 1933. During the year no application for a certificate as to the state of repair of a house was received. WATER SUPPLY TO NEW HOUSES. During the year 85 new houses were certified as having a proper and sufficient water supply. SMOKE NUISANCE. During the year, 41 formal observations of smoke shafts were made and 2 intimations and 1 statutory notice were served. NOISE. I again draw attention to the urgent need for legislation to deal with the growing evil of noise. In the streets, we have more and more mechanical vehicles of greater size and power and carrying heavier 113 loads, to say nothing of street repairing machines and building operations. There are factories containing powerful machinery often worked until late in the evening. The housing shortage frequently compels families to live in close proximity to industrial buildings; and where loud processes are carried on at all hours of the night as well as during the day, life almost becomes intolerable. It is useless for the doctors and health visitors at the welfare centres to advise good habits of sleep, when the means of practising such habits is denied the parents. This barrage on our complex nervous system is not conducive to good health and temper and ought to be brought under stringent public restriction. The people who have become accustomed to turn to the Public Health Department for assistance in dealing with their health problems cannot understand our helplessness in the face of an obvious menace to health, and it is to be hoped that some definite action will be taken very soon to deal with the matter. RATS AND MICE (DESTRUCTION) ACT, 1919. No formal notices were served under the Act during the year. A number of complaints as to rat infestation have been investigated and dealt with and occupiers of premises have been advised in the matter. Poor occupiers have been assisted by the supply of rat poison, 141 tins of treated biscuits and 2 bottles of Squill being issued in this way, while 455 tins of biscuits were used as baits in the sewers in the quarterly campaigns described later. The planned measures for rat destruction for one week every three months in co-operation with the Medical Officers of Health and Borough Engineers of Hackney, Poplar, Shoreditch and Stepney, have been continued during the year. So far as it is possible to estimate the result in figures, the following statistics concerning Bethnal Green illustrate it : Baits laid (in 303 manholes) 17,502 Baits taken 15,971 Percentage of baits taken 91 114 OFFENSIVE MATTER. During the summer months, the inspectors keep special observation to see that offensive matter is not conveyed through the streets during hours prohibited by the by-laws. Legal proceedings were necessary in one instance during the year, the defendant being fined £2 and costs £1 1s. Od. on each of two summonses. OFFENSIVE TRADES. During the year, one offensive trade, that of a Fur-skin Dresser, was carried on at 74, Florida Street. 16 inspections were made at these premises. Poultry slaughtering, an offensive trade also, is dealt with elsewhere in this report. RAG-FLOCK ACT, 1911. 23 formal samples of rag-flock were taken during the year, and in 5 cases the amount of chlorine present was found to be slightly in excess of the limit fixed by the Regulations. Proceedings were taken in 4 instances (including the wholesaler for two of the other defendants), costs amounting to £17 17s. Od. being awarded against the defendants. RAG AND BONE DEALERS. Twelve persons or firms are known to be carrying on this business in the Borough. During the year 13 visits of inspection were made, but no sanitary notices were needed. HAIRDRESSERS. 98 hairdressers' premises were on the register, 191 visits were made to them, and 29 Notices were served. 115 COMBINED DRAINAGE SYSTEMS. The reconstruction and maintenance of such combinations of drains of houses and premises as are found to be sewers by law defined and are not under highways is carried out by the Public Health Department. The staff engaged on this work consists of a drainlayer and four labourers, with additional help as required. During the year 4 systems were reconstructed, taking 19 houses. At the end of the year there were 633 such combined drainage systems, taking 3,210 houses. DRAINAGE WORK. No legal proceedings were taken during the year in respect of offences in connection with drainage work. 116 HOUSING. GENERAL. In the earlier part of this section of my report I have commented generally on the character of the housing in the Borough. The full picture can only be seen when the figures from the last census are brought into it. These revealed the fact that Bethnal Green was the third worst borough in London with regard to congestion of population, having 142 persons per acre and an average of 1.35 persons per room. The latter average masks the true extent of the evil of overcrowding, which is represented in one way as the proportion of the population living more than 2 per room, namely 23.6 per cent., but might be more justifiably calculated on the basis proposed in the new Housing Bill when the percentage would be found to be 33% or more. Overcrowding to this gross extent in well-built, light, airy, modern houses, with every domestic convenience would be thoroughly bad, but overcrowding in Bethnal Green frequently takes place in old, gloomy, airless, inconvenient houses and tenement buildings, themselves crowded together, so that one evil is added to another. One may therefore be excused some measure of impatience with the difficulties and delays which seem to stand in the way of improving this deplorable situation. INSANITARY AREAS: Slum Clearance and Improvement Schemes. Some progress has been made during 1934 by the plan of co-operation with the L.C.C. with regard to Clearance Areas. It is to be hoped that this cooperation will develop into a definite joint long-term programme with a view to an expeditious and systematic clearance and re-building of all the insanitary areas in the borough, many of which have been represented as long ago as 1920. The complicated procedure of the Housing Acts involves great delay from the time action 117 is initiated by the Medical Officer of Health until it materialises in actual demolition and re-building. Hence it is very necessary to maintain steady pressure in order to secure the completion of any programme within a reasonable space of time. During the year, the following areas were represented by me to the Borough Council, and upon being reported to the L.C.C., that authority came to the decisions mentioned in each case: Area Houses Population Decision of L.c.c. Martha Court 13 58 Left to Borough Council. Delta Street 12 51 L.C.C. to clear area and hand over site to Borough Council. Usk St. and Warley St. 42 297 L.C.C. will probably deal with this as part of larger area including Moss Street. Charlotte Street III 607 L.C.C. recommend postponement, and will probably deal with this as part of larger area. The problem of accommodating persons displaced from clearance areas who cannot be re-housed on the site may be partially solved by the undertaking of the L.C.C. to provide alternative accommodation for such persons subject to due notice being given. The L.C.C. have intimated their intention of proceeding with the clearance and improvement of the following areas: Area Houses Population Pott Street 146 720 Hollybush Gardens 19 119 There still remain two small portions of the notorious Brady Street area (originally represented in 1904 and re-represented in 1912) which have not been dealt with. The Teale Street area, which the L.C.C. 118 decided to deal with in 1928 still awaits completion. The Digby Street areas, represented to the Borough Council in 1929, were not proceeded with owing to adverse legal decisions elsewhere. They were again represented to the Borough Council in 1933 and are now in process of development. RENT AND TRANSPORT. The Housing problem is so intimately bound up with the economic position of the residents in the borough that no consideration of housing reform can ignore the prime importance of rent. At present the most extraordinary anomalies exist. An unemployed worker with a large family may live in one or two rooms, the rent of which may be anything from 4/or 7/- to 6/6 or 10/- according to whether the house is decontrolled or not. In either event, the hope of improved housing for the family is remote because of the man's inability to fulfil the required rent standards of the Borough Council or L.C.C., and because no private landlord will take him. At the other extreme there are a few cases where a family with grown up children is still living at a comparatively low rental in the one or two roomed tenement in which they were born, with a collective income sufficient to rent adequate accommodation but unwilling to move. In between are the more typical cases of families with breadwinners earning low wages, a disproportionate part of which is already going in rent, and whose prospects of securing better housing are very small because either the rent for adequate accommodation near the workplace is too high or the fares to a house of lower rental are too great to enable them to take advantage of such accommodation. The heavy cost of transit from home to workplace is another factor to which insufficient attention has been paid. Where the income is limited, any undue expenditure on rent or travelling must come out of the food supply. This direct relation between housing, transport and lack of proper food is a matter to which special consideration needs to be given. 119 OTHER HOUSING SCHEMES. HOUSING STATISTICS FOR 1934. Number of Houses erected during the year—85 tenements. 1. Inspection of Dwelling Houses during the Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 9,679 (b) Number of Inspections made for the purpose 18,949 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 856 (b) Number of Inspections made for the purpose of the regulations 856 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subhead) found not to be in all respects reasonably fit for human habitation Nil 2. 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 Nil 3. Action under Statutory Powers during the Year :— (A) Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930 :— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were ren- dered fit after service of formal notices :— (a) By owners Nil (b) By Local Authority in default of owners Nil (B) Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring fects to be remedied Notices served: Intimations 5,151 Statutory Notices 2,286 120 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 5,535 (b) By Local Authority in default of owners Nil (C) Proceedings under Sections 19 and 21 of the Housing Act, 1930 :— (1) Number of dwelling-houses in respect of which Demolition Orders were made Nil (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil (D) Proceedings under Section 20 of the Housing Act, 1930 (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil (E) Proceedings under Section 3 of the Housing Act, 1925 :— (1) Number of dwelling-houses in respect of which notices became operative 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 Nil (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declaration by owners of intention to close Nil (F) Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which Closing Orders became operative Nil (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil (3) Number of dwelling-houses in respect of which Demolition Orders became operative Nil (4) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil 121 FACTORIES, WORKSHOPS, OUTWORKERS, &c. Inspection of Factories, Workshops and Workplaces. Premises Number of Inspections Written Notices Prosecutions Factories (Including Factory Laundries) 1706 295 ... Workshops (Including Workshop Laundries) 2404 405 1 Workplaces (Other than Outworkers' Premises) 135 28 ... Total 4245 728 1 Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects Number of Prosecutions Found Remedied Referred to H.M. Inspector Nuisdnces under the Public Health Acts:— Want of cleanliness 165 183 3 ... Want of ventilation 3 3 2 ... Overcrowding 2 2 ... ... Want of drainage of floors 1 1 ... ... Other Nuisances 437 432 2 ... Sanitary accommodation— insufficient 7 7 ... ... unsuitable or defective 605 616 ... 1 not separate for sexes 8 8 ... ... Offences under the Factory and Workshop Acts :— Illegal occupation of underground bakehouse (s. 101) ... ... ... ... Other offences (Excluding offences relating to out work). ... ... ... ... Total 1228 1252 7 1 122 Registered Workshops. Workshops on the Register (s. 131) at the end of the year. Number Workshops 1117 Workshop Bakehouses 36 Total Number of Workshops on Register 1153 Other Matters. Class Number Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Acts (s. 133, 1901) 33 Action taken in matters referred by H.M. Inspector as remedi able under the Public Health Acts, but not under the Factory and Workshop Acts (s. 5, 1901). Notified by H.M. Inspector 24 Reports (of action taken) sent to H. M. Inspector. 24 Underground Bakehouses (s. 101) in use at the end of the year (including factories) 19 Home Workers. Of the 2,237 workmen and contractors whose names appeared on the lists received, 1,660 resided within the Borough. The latter figure is approximately double the number of individual workers, as in the majority of cases the same people are notified in February and in August. 123 The number of visits paid to Home Workers' dwellings was 1,103. The number of premises found to be in an insanitary condition was 173, or 38.8 per cent, of the 446 premises inspected. Notices were served in 161 cases, while 28 other premises were under notice arising from other visits, and a verbal intimation was given in 21 further cases. Difficulty is still experienced in getting some employers promptly and accurately to send in copies of their list of outworkers, but no legal proceedings were taken in the matter during the year. It may be of interest to mention that some of the homeworkers resident in Bethnal Green are employed by firms whose place of business is as far away as Epsom, Enfield and Kingston-upon-Thames, and local firms have sent in lists containing outworkers resident in Billericay, Dagenham, Enfield, Folkestone, Hemel Hempstead, Ilford, Northampton, Romford and Southend-on-Sea. HOME WORK. OUTWORKERS' LISTS, SECTION 107 * Outworkers in unwholesome premises,Section 108 Outwork in infected premises, Sections 109,110 Nature of Work Lists received from Employers Addresses of Outworkers Notices served on Occupiers as to keeping or sending lists Prosecutions Instances Notices served Prosecutions Instances Orders made (s. 110) Prosecutions (s. 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 Received from other Councils Forwarded to other Councils Contractors Workmen Contractors Workmen Wearing Apparel— Making, etc. 60 129 191 4 3 9 925 195 53 ... ... 55 53 ... ... ... ... Boots and Shoes 20 9 191 1 ... 8 99 144 16 ... ... 38 32 ... 3 ... ... Curtains, Furniture hangings and Trimmings 4 40 4 ... ... ... 14 13 4 ... ... 9 8 ... ... ... ... Fur-pulling and feathers ... ... ... ... ... ... 11 ... ... ... ... ... ... ... ... ... ... Umbrellas, etc. 2 ... 4 1 ... 3 19 1 4 ... ... 4 6 ... ... ... ... Artificial Flowers ... ... ... ... ... ... 6 ... ... ... ... 3 2 ... ... ... ... Paper, etc., Boxes, Paper Bags 16 ... 146 1 ... 1 113 36 15 ... ... 40 37 1 2 ... ... Brush-making 8 ... 146 ... ... ... 20 114 2 ... ... 7 7 ... ... ... ... Draught Board Making 2 ... 2 ... ... ... ... ... 2 ... ... ... ... ... ... ... ... Cosaques, Christmas Crackers, Christmas Stockings, etc. 2 ... 13 ... ... ... 10 10 2 ... ... 9 9 ... ... ... ... Textile Weaving 2 ... 16 ... ... ... ... ... 2 ... ... ... ... ... ... ... ... Toys 2 ... 98 ... ... 7 64 2 ... ... 8 7 1 ... ... ... Total 118 178 811 7 3 21 1224 577 102 ... ... 173 161 2 5 ... ... * The figures in these columns relate to outworkers' premises at which nuisances were found and dealt with under Public Health (London) Act. 124 125 APPENDIX I. LEGAL PROCEEDINGS. During the year, 35 summonses were heard in respect of nuisances, with the following results :— Withdrawn on payment of costs amounting to :— £1 1 0 24 Nuisance Orders obtained with costs amounting to :— £2 2 0 10 In one instance a closing order was made. It was also found necessary in one case to obtain a Distress Warrant for the recovery of costs. Other legal proceedings are summarised in the following list:— Legal Proceedings, 1934. No. of Sample in F. and d. a. cases Date Offence Result 1 21.2.34 Food and Drugs (Adulteration) Act. Selling Vinegar 5% deficient in acetic acid No fine Costs £2 2s. Od. 66 26.3.34 Selling Milk 3.3% deficient in fat No fine Costs £3 3s. Od. 26.3.34 Milk and Dairies (Consolidation) Act. Selling Milk from receptacle not conspicuously inscribed No fine Costs £1 Is. Od. 65 28.3.34 Food and Drugs (Adulteration) Act. Selling Milk containing 2.3% added water Dismissed (warranty defence) No costs 86 28.3.34 Deliver in pursuance of contract, Milk 20% deficient in fat Dismissed (warranty defence) No costs 76 4.4.34 Selling Milk containing 8.2% added water No fine Costs £2 2s. Od. 126 Legal Proceedings—contd. No. of Sample in F. and D. A. cases Date Offence Result 88 28.3.34 Deliver in pursuance of contract, Milk 6.6% deficient in fat No fine Costs £5 5s. Od. 93 28.3.34 Deliver in pursuance of contract, Milk 10.0% deficient in fat No fine Costs £5 5s. Od. 118 28.3.34 Selling Vinegar 12.5% deficient in acetic acid Fine £1 Costs £3 3s. Od. — 9.5.34 Milk and Dairies Order, 1926. Filling bottle with milk otherwise than on registered premises No fine Costs 2/- 143 9.5.34 Food and Drugs (Adulteration) Act. Selling Aspirin Tablets 5% deficient in aspirin Public Health (London) Act. Fine £1 Costs £10 10s. Od. (paid by wholesalers) — 3.5.34 Conveying offensive matter in unsuitable uncovered carriage, so as to permit a nuisance to arise Fine £2 Costs £1 Is. Od. Failing to prevent offensive matter escaping from oarriage in which it was conveyed Fine £2 Costs £1 Is. Od. — 31.5.34 Rag Flock Act. Have in possession Rag Flock containing 9 parts excess of chlorine Summons withdrawn, warranty admitted (Proceedings taken against wholesaler) — 31.5.34 Have in possession Rag Flock containing 11 parts excess of chlorine No fine Costs £3 3s. Od. 195 30.5.34 Food and Drugs (Adulteration) Act Selling Raspberry Jam containing 50% Gooseberry Jam No fine Costs £1 3s. Od. 232 6.6.34 Selling Milk containing 17.6% added water Warranty accepted, Summons withdrawn on payment of £2 2s. Od. Costs 232 6.6.34 Selling Milk containing 17.6% added water Fine £2 Costs £3 127 Legal Proceedings—contd. No. of Sample in F. and D. A. cases Date Offence Result — 31.5.34 Rag Flock Act Have in possession Rag Flock containing 10 parts excess of chlorine Summons withdrawn, warranty admitted (Proceedings taken against wholesaler) — 31.5.34 Supplying Rag Flock on warranties given containing excess of chlorine Ordered to pay £7 7s. Od. Costs on each of two summonses Public Health (Preservatives in Food) Regulations 240 4.7.34 Selling Table Jelly containing 76 parts per million excess of sulphur dioxide Summons withdrawn (Proceedings taken against wholesaler) 240 4.7.34 Selling Table Jelly containing 76 parts per million excess of sulphur dioxide No fine Costs £10 10s. Od. Food and Drugs (Adulteration) Act 355 1.8.34 Selling Vinegar 52% deficient in acetic acid Fine 5/- Costs 10/- Milk and Dairies (Consolidation) Act — 1.8.34 Selling Milk from vehicle and receptacle not properly inscribed Fine £2 Costs £2 2s. Od. Food and Drugs (Adulteration) Act 387 8.8.34 Selling Milk 10% deficient in fat No fine Costs £4 4s. Od. 407 5.9.34 Selling Milk 16.6% deficient in fat No fine Costs £4 4s. Od. 395 3.9.34 Selling Vinegar 12.5% deficient in acetic acid Fine £2 Costs £2 2s. Od. 416 12.9.34 Selling Milk 26.6% deficient in fat No fine Costs £3 3s. Od. 429 19.9.34 Selling Milk containing 12.9% added water Fine £2 Costs £3 3s. Od. 502 7.11.34 Selling Milk 13.3% deficient in fat No fine Costs £2 2s. Od. 528 7.11.34 Selling Milk containing 10.5% added water Fine £2 Costs £7 7s. Od. 525 5.3.35 Selling Milk 33% deficient in fat Summons dismissed (warranty proved) 555 21.11.34 Selling Milk 50% deficient in fat No fine Costs £3 3s. Od. 608 12.12.34 Selling Vinegar 75% deficient in acetic acid No fine Costs £3 3s. Od. 656 9.1.35 Selling Milk 16.6% deficient in fat No fine Costs £4 4s. Od. 128 APPENDIX II. TUBERCULOSIS DISPENSARY. REPORT FOR THE YEAR 1934. By H. Tylford Howell, M.R.C.S., Eng., L.R.C.P., Lond., Clinical Tuberculosis Officer. Before presenting a detailed statement of the work of the Dispensary for the year, I have to record the appointment of Dr. F. Temple Clive as Assistant Tuberculosis Officer in succession to the late Dr. W. J. Dowling. Dr. Clive, whose previous experience of diseases of the chest as House Physician and Resident Medical Officer at Victoria Park Hospital well qualifies him for his present appointment, took up his duties in June. There has been no noteworthy change in the routine work of the department. The sessions, which have remained unaltered, are as follows :—Monday, Wednesday, Thursday, Friday and Saturday mornings from 10 to 12 o'clock ; Wednesday evenings from 5.30 to 7 ; Thursday evenings from 7.30 to 9 o'clock. Saturday mornings are reserved as far as possible for school children, and the evening sessions for those patients who are at work during the day. Except that children may not attend the late Thursday evening sessions, these reservations are not strictly enforced if it is found to be inconvenient for any particular patient to attend during the morning. As a result, I presume, of further recent criticisms with reference to the lengthy periods of waiting in the out-patient departments of some hospitals, I am frequently being asked for information on the subject as it affects Dispensary patients, and on our practice in regard to dressing arrangements. I would like to point out that to avoid unnecessary delays, patients may attend during any part of a session, and are seen strictly in order of their arrival at the hospital, irrespective of whether they are new or old cases. This arrangement reduces the period of waiting to a minimum. The majority of the patients are seen within a quarter of an hour of their arrival, and seldom are they called upon to wait more than half an hour. With regard to dressing facilities, we are fortunate in having two dressingrooms attached to each consulting-room. This arrangement greatly facilitates our work, and renders unnecessary separate sessions for the sexes. Moreover, it ensures privacy for the patients, and even on busy days it is not the practice for more than one patient to occupy a dressing-room at one time, except in the case of members of the same family. The two Medical Officers continue to consult one another on most new cases, and afterwards discuss any point of special difficulty and decide on appropriate treatment. Opportunity for further consultations is available to us, as our close working arrangement with the hospital offers unique facilities for specialist opinions in its various departments. The advice of Physician, Surgeon, Laryngologist, Radiologist, Pathologist or Dentist is always available, and a personal consultation with a member of the Staff readily obtainable. The advantages of such an arrangement are obvious, and we are particularly grateful to the Laryngologist and Radiologist for their ready response to our increasing calls on their time. The number of patients X-rayed (380 Hackney cases and 290 Bethnal Green) shows an increase of 34% over the figures of last year. As was 129 pointed out in my last report, such increase must be expected, as the value of X-rays increases proportionately with improvements in technique and experience in the interpretation of films. It must be borne in mind that their use is not limited to diagnosis—they show also the extent of the disease, and often enable us to form an opinion on its activity ; such information is of the greatest value in deciding appropriate treatment. The films also help us to judge accurately the progress of a case, and are an indispensable guide in treatment by artificial pneumothorax. It is still, however, in the diagnosis of early tuberculosis that X-rays are so invaluable. An X-ray film will often show early infiltration of the lung before the appearance of symptoms and physical signs, and with its aid we are able on occasion to diagnose early tuberculosis in a contact where otherwise it might be missed. Such a patient stands a very good chance of complete cure, and in my opinion any extra expense involved is justified. Personally, I would like to have every contact between the age of 16 and 25—the most susceptible age period—X-rayed as a matter of routine. The age period mentioned above is neglected by the State. The infant welfare service and the school medical service between them undertake the care of children to the age of 14. At the most critical period, as far as tuberculosis is concerned, young boys and girls go out into the world, often into unhealthy and unsuitable occupations, with no supervision of any kind. Should they develop tuberculosis, the natural independence of youth often deters them from seeking advice until the disease is well established. While it may be argued that prolonged control of youth by the State is not desirable, a greater measure of supervision must of necessity be our aim if tuberculosis is to be wiped out. The local charitable organisations continue to help us in many ways. The Hackney and Bethnal Green branches of the Invalid Children's Aid Association have arranged convalescent treatment for increasing numbers of our debilitated children at the seaside or in the country. The Charity Organisation Society and the United Services Fund have assisted in the provision of surgical instruments, dentures, clothing, etc., and have given financial assistance in certain cases. The children attending Stormont House open-air school have made good progress. As reported last year, the London County Council now admit " suspect " cases of tuberculosis to this class of school in addition to notified cases. It was thought that parents of suspect cases might object to their children working in such close contact with definite cases of tuberculosis. There has, however, been no difficulty in this direction, as I have been able to assure the parents that no actively infectious case is allowed to remain at the school. The school accommodates 90 children and is always full. As preference is given to notified cases, any increase in the waiting list does not materially delay the entry of a tubercular child. With few exceptions all the children come from the neighbouring boroughs of Bethnal Green, Hackney and Stoke Newington. Both pulmonary and non-pulmonary cases of either sex are eligible for admission, and the ages range from 6 to 16. The children are kept under strict medical supervision, records of temperature and weight being kept by the nurse, who visits the school daily, while the medical officer makes frequent examinations of the children and supervises the exercise and rest of each child. Hot milk, during the morning and afternoon, and midday meals are provided. The classes are held in open-air shelters, but ample indoor accommodation is available in case of inclement weather. We find it is rarely necessary to bring the children indoors, and it is really astonishing how quickly they become acclimatised to the new conditions, and, what is perhaps more surprising, how soon they learn to prefer open air conditions even in mid-winter. 130 During the year 14 children were discharged as fit for work, and employment was found for them by the school care committee. A strict supervision of their health is maintained for some years, so that any tendency to relapse may be quickly recognised. In addition to the discharges, six cases were transferred to elementary school, further stay in an open-air school being considered no longer necessary. In accordance with the London County Council instructions that all children attending open-air schools should receive an annual holiday, 43 boys and 22 girls were sent to Broadstairs for a period of two weeks during the Summer. These holidays are greatly appreciated by the children and are keenly looked forward to and discussed by them many months in advance. There is little doubt that they have a beneficial influence on their health. I have to report the resignation of Miss Carson, the Head Mistress, during the year. She was an ideal Head for such a school, where individual interest in the welfare of each child is of prime importance. Her educational success at Stormont House met with the full recognition of the authorities, but it is for her ready co-operation in the medical work of the school that I am particularly grateful. One hundred and forty cases were admitted to sanatorium or to hospitals other than the London County Council hospitals, during the year. With adequate accommodation at their disposal, the London County Council now never refuse sanatorium treatment for any case offering a prospect of cure or a reasonable hope of such improvement in health as will enable the patient to resume work. Patients with advanced disease are much more readily inclined than formerly to enter the local general hospital where they know they will continue to be under the supervision of their tuberculosis officer, but if preference is expressed for a hospital more remote from their homes, this is invariably complied with. Formerly, if a patient refused to enter the local hospital he was left with no alternative but to remain at home. The present policy of the London County Council of allowing a certain amount of latitude in the choice of hospitals has removed this difficulty, and has gone a long way to solve the old time problem of the advanced case. The steady decline in the mortality from tuberculosis continues. Since the inauguration of the National Campaign against Tuberculosis some 20 years ago, the figures have fallen by over 40%—a very satisfactory record. A higher standard of living and the less virulent nature of the disease have no doubt contributed to this success, but earlier diagnosis with the help of X-rays, and recent advances in treatment such as the use of Artificial Pneumothorax and Phrenectomy, have played a very important part. But successful diagnosis and treatment are not by any means the whole picture. Of equal importance is the question of after-care. The rapid progress seen in diagnosis and treatment is here lacking. After-care Committees, hampered by lack of funds, can do very little. With distressing frequency we see the most hopeful case, with disease quiescent on leaving sanatorium, relapse later from purely economic reasons although a constant lookout is kept for any reactivity of the disease, and when necessary, further sanatorium treatment recommended. With the help of the after-care committee an attempt is made to ameliorate the lot of the ex-sanatorium patient. A new house or flat is frequently obtained, either through the Borough Council or the London County Council, under the scheme of preferential treatment for tuberculous cases. Beds and bedding are supplied in necessitous cases. A grant of extra diet in the form of milk and eggs is given by both Boroughs on the recommendation of the 131 Tuberculosis Officer. The children of infectious cases are boarded out in suitable homes by the London County Council. The Tuberculosis Care Committee endeavours, with occasional success, to obtain work for those who have lost their employment. The Hackney and Stoke Newington Care Committee also run a Handicrafts class, where patients are taught, among other things, basket making, glove making, artificial flower making, and bead, leather, and pewter work. These classes do not attempt to enable patients to earn a living, but they provide a little pocket money, and what is more important, they give patients an interest to occupy their minds and keep them from brooding over their condition. It will be seen that all these efforts merely lighten the burden of the tuberculous but do not in any way get at the root of the matter—the provision of suitable employment to enable a patient to provide adequate nourishment for himself and family. In my opinion a plentiful supply of good food is the first essential in a patient's fight against tuberculosis. No one will deny that fresh air is desirable and improved accommodation often necessary, but removal of the family to a larger house or flat, if it entails increased demands in the form of rent upon an already restricted income, is a short-sighted policy and often does more harm than good, as less money is then available for food. The majority of patients on leaving sanatorium are capable of work under suitable conditions, but they are not able to compete in the open market with able-bodied men. Their working capacity has been damaged, and their earnings may have to be subsidised for some years. The problem of supplying work for these is one of such magnitude that it can only be satisfactorily solved by the State. It has hitherto been shelved on the grounds of expense, but I doubt if a well-thought-out scheme would be as costly as would at first sight appear to be the case. It would surely be less expensive to utilise a man's earning powers than to keep him and his family in complete unemployment. We have been shown the lines such a scheme should take by several noteworthy experiments in the past. In the village settlements of Papworth and Preston Hall patients live with their families under strict medical supervision and in ideal hygienic conditions until their disease has been arrested for a period of five years, when they may be regarded as cured, and are free once more to live normal lives. Patients are paid a living wage for their labour, the two colonies between them paying £50,000 yearly in wages, and selling goods to the annual value of £200,000. The scheme of municipal workshops might also be given an extended trial, under which also patients would work under strict medical supervision, but would continue to live at home. The class of work and hours should in each case be governed by the patient's physical capacity. A minimum living wage, irrespective of the man's earning powers, should be provided with additional pay to those working full time. One disadvantage of the scheme is that the home conditions of patients do not receive special supervision. It should not be impossible, however, to devise some means of overcoming this. Other experiments have been tried, but on account of expense or for some other reason, have not been a success. Burrow Hill Colony, while not attempting like Papworth and Preston Hall to solve the problem of unemployment, is doing very useful work in another direction. Youths from 13 to 19 years of age continue their treatment at the Colony, and at the same time are trained in horticulture or clerical work according to individual capacity or inclination. A reasonable educational standard is first ensured by attendance at the Colony school. The training in horticulture includes a theoretical course in addition to the practical. By an arrangement with the London County Council a certain number of boys trained at this Colony are, on their discharge, found employment in their Parks department. On the clerical side the technical training includes shorthand, typewriting, book-keeping and commerce, and employment is found for the trainees on completion of the course. 132 The scheme for the closer co-operation between the school medical officers and tuberculosis officers in the supervision of contacts, continues to work smoothly. It provides that contacts of school age who attend the Dispensary and are probably not suffering from tuberculosis, and other children suffering from ill-health not due to tuberculosis, shall be transferred to the school medical service. Should suspicious symptoms develop later in any particular case it may be referred back to the Dispensary for a further opinion. In addition to ordinary dispensary treatment the Boroughs make provision for special forms of treatment, such as Finsen Light in Lupus cases, and refills in Artificial Pneumothorax. The number receiving this latter treatment shows a steady yearly increase. Treatment by Sanocrysin (or " Gold ") has been tried in a few of our cases, but it is too early to say what benefits, if any, have resulted therefrom. These special forms of treatment, like Dispensary treatment, are of course all free to the patient—in fact, since the introduction by the London County Council of the revised scheme for the treatment of tuberculosis in London, all treatment, both residential and Dispensary, has been made free. Thus tuberculosis is brought into line with other infectious diseases. As in the case of Diphtheria or Scarlet Fever, apart from any consideration for the patient, it is to the public advantage that patients suffering from tuberculosis should be cured, or, if this is not possible, at least isolated for a time, and it seems therefore not unreasonable that the public should pay for this measure of protection to themselves. I submit at the end of this report a statistical summary of the work of the department for the year; the tables presented show no striking variation as compared with those of recent years. In conclusion I would like to thank the Medical Officers of Health, the Hospital Physicians and Surgeons, the Resident Medical Officer, and the Hospital Secretary, for their valuable help and advice, and the Dispensary Staff for their efficient work and loyal support. H. TYLFORD HOWELL. 15th March, 1935. 133 STATISTICAL TABLES. BOROUGH OF BETHNAL GREEN. 1. The Totals of New Cases. Males 324 Females 355 679 2. The Sources of the New Cases. Total. Tuberculous. Medical Officer of Health 196 21 I.ocal Practitioners 169 39 Contact cases (per M.O.H.) 217 8 London County Council 6 2 Victoria Park Hospital 11 11 Other sources 63 44 Transferred from other Areas 17 17 3. The Diagnosis of the New Cases. Diagnosis. Adults. Children under 15. Males. Females. Males. Females. Total. Pulmonary Tuberculosis 69 44 2 4 119 Non-pulmonary Tuberculosis 5 7 5 6 23 Non-tuberculous 125 163 113 114 515 Doubtful 5 14 — 3 22 Total 204 228 120 127 679 134 4. The Diagnosis of Contact Cases, Pulmonary Tuberculosis 4 Non-pulmonary Tuberculosis 4 Non-tuberculous 205 Doubtful 4 Total 217 5. Sputum Examinations. Tubercle Bacilli present 85 Tubercle Bacilli absent 365 Total 450 6. Other Figures. Total number of attendances 3,602 Systematic examinations at the Dispensary 1,920 Number of patients sent to hospital or sanatorium by the L.C.C. 55 Number of letters written 1,304 Number of visits to patients at their homes 135 Number of attendances at:— X-Ray Department 290 Dental Department 5 Other Departments 40 135 INDEX. page Aged and Infirm Persons 94 Ambulances 17 Bacteriological Examinations (medical) 89 do. do. (food) 102 Bakehouses 104 Bedsteads, Bedding and Clothing (Tuberculosis) 86 Birth Control 42 Births 21, 23 Breast Feeding Clinic 46 Cancer 30 Chicken Pox 89 Cleansing Stations: Personal 19,92 Clinics 13, 36, 49 Combined Drainage Systems 115 Common Lodging Houses Ill Condensed Milk Regulations 101 Contribution Scales for M.C.W. Services 64 Convalescent Treatment 61 Cowhouses 103 Cremation of Dead 31 Day Nurseries 14 Deaths 21, 24 Delicate Children: Clinic for 53 Dental Clinic (M. & C.W.) 54 Dental Treatment of Tuberculosis Patients 87 Diabetes 89 Diphtheria 77 Diphtheria Immunisation 74 DISEASE, CONTROL OF 72 Disinfectants: Distribution of 90 Disinfection 90 Dispensaries 13, 19, 83 Drainage Work 115 Dried Milk, &c. 65 Dried Milk Regulations 101 Enlarged Tonsils, Adenoids and Mastoid Disease 55 Enteric Fever 78 Expenditure on Public Health Work 10 Extra Nourishment (M.C.W.) 65 do. (Tuberculosis) 87 Factories and Workshops 121 Feet, Care of 95 Finsen Light Treatment 87 Fish Curing and Fried Fish 104 FOOD 96 Food Premises 102, 105 ,, Poisoning 94, 107 Food and Drugs Acts 97 Foot Clinic 95 Foster Children 67 Fried Fish and Fish Curing 104 136 page General Description of District 7 GENERAL SANITARY ADMINISTRATION 108 German Measles 89 Hairdressers 114 Health Education 20, 48 HEALTH SERVICES 10 Health Visitors 34 do. do. Tuberculosis 85 Home Helps 45 Home Workers 122 Hospitals 11 HOUSING 108, 116 „ Schemes 116 Humane Slaughtering 106 Ice Cream 104 Illegitimacy 23 Infant Consultations 49 Infantile Mortality 21, 28 INFECTIOUS DISEASE 72 Inhalation Therapy 57 Insanitary Areas 116 Insurance Acts, National Health 16 INTRODUCTION 6 Invalid Children's Aid Association 14 Joint Dispensary Committee (Tuborculosis) 83 LEGAL PROCEEDINGS 125 Light Treatment (M.C.W.) 55 do. (Tuberculosis) 87 Malnutrition 64, 70 Marriages 23 Massage 60 Maternal Mortality 21,28 MATERNITY AND CHILD WELFARE 33 Maternity Clinics 37 Maternity Institutions 16 Maternity Outfits 46 Measles 88 Meat Regulations 105 Medical Inspection (school children) 67 Medical Practitioners 11 „ „ Consultations with 78 Midwifery: Borough Midwifery Service 44 Other Midwives 16 Milk 99 Milk for necessitous mothers and children 64 Milk in Schools 103 Milkshops and Dairies 102 Milk (Special Designations) Order 103 Mortuary 31 Mothers' Clinic 42 Motor Traffic Accidents 30 Noise 112 Notification of Births 34 Nurseries, Day 14 Nurses and Nursing Assistance 11,65 Nutrition, Rent and 118 Obstetrical Consultants 45 Offensive Matter 114 do. Trades 114 137 page Open-Air Sleeping Shelter 86 Ophthalmia Neonatorum 67 Orphans 15 Orthopaedic Treatment 59 Outworkers 122 Overcrowding 116 Personal Cleansing Stations 19, 92 Pharmacy and Poisons Act 107 Pneumo-thorax Refills 87 Poisons, Sale of 107 Population 23 Poultry Slaughterers 106 Public Assistance 8 PUBLIC HEALTH COMMITTEE 3 Public Health Expenditure 10 Puerperal Fever and Puerperal Pyrexia 66 Rag and Bone Dealers 114 Rag Flock Act 114 Rats and Mice 113 Registration of Births, Deaths and Marriages 19 Rent Restrictions Acts 112 Sanatorium Treatment 86 Sanitary Inspectors, work of 110 Scabies (Itch) 92 Scarlet Fever 77 School Children : Medical Inspection and Treatment 13,67 School Meals 10 School Milk Scheme 103 Shelter for Contacts 90 do. Open-Air Sleeping 86 Slaughterhouses 105 Smallpox 77 Smoke Nuisance 112 Social Welfare 7 Special Clinic for Delicate Children 53 Sputum Outfits . 85 STAFF 4 Stillbirths 23 Street Accidents 30 Talks to Mothers 48 Tenement Houses 112 Toddlers' Clinic 51 Tonsils, Adenoids and Mastoid Disease 55 Transport and Rent 118 TUBERCULOSIS 80 Tuberculosis Dispensary 83 ,, and Employment 84 „ Officer, Report of 128 „ Visitors 85 Unsound Food 106 Vaccination 20 Vaccination Returns 79 Venereal Disease 19 Verminous Conditions 70,91,93 VITAL STATISTICS 21 Water Supply 112 Welfare Centres 36 Whooping Cough 89 Workshops and Factories 121