DAG 3 The Urban District Council of Dagenham 1926 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR E. W. CARYL THOMAS. M.D., B.Sc., D.P.H. BARRISTER-AT-LAW. ,'T \ 3 MEMBERS OF THE COUNCIL. Councillor H. R. HILL, J.P., Chairman H. C. PARRY, J.P., C.C., Vice-Chairman P. G. ASHTON A. E. BALE C. DELLOW, C.C. H. C. DYER R. A. FISHER W. F. FRANKS W. GRAY R. HEATLEY J. B. HILTON F. J. HUDSON W. H. LANGLOIS W. C. MARKHAM J. MURPHY S. G. PHILLIPS (Mrs.) S. A. PHILLIPS J. A. PRESTON A. ROGERS (Mrs.) M. ROTHWELL, Chairman of Public Health and Maternity and Child Welfare Committees. G. B. SMITH (Mrs.) L. TOWNSEND J. W. H. TYLER 4 To the Chairman and Members of the Urban District Council of Dagenham. Mr. Chairman, Ladies and Gentlemen, 1 beg to submit my report on the health and sanitary conditions of the district for the year 1929. The year saw the last of the phenomenal rate of development and almost the completion of the London County Council Housing Estate of Becontree in the Dagenham area. During the year some 4,000 Estate houses were erected, making a total in this area of 15,033 houses; and leaving to be completed early in 1930 another 232. This cessation of expansion will now permit of arrears being overtaken and case the administration of the local public services. With regard to the health services, conditions arc rapidly improving. During the year, sanction was obtained for the erection of the two Combined Treatment Centres in this area and in December work was begun on the Becontree Clinic. The official opening of the building took place on 12th April. 1930. In January the Dagenham Clinic was started and will shortly be available for use. These clinics are used for the holding of Infant Welfare Centres and Ante-natal Clinics, and are loaned to the Essex County Council for the holding of Minor Ailment Clinics and Tuberculosis Dispensaries. In addition to these clinics, the premises are equipped as dental clinics and for the application of ultra-violet therapy. In the Becontree clinic a small laboratory has been fitted enabling diphtheria swabs now to be reported upon in a shorter time. A local Out-Patients Department is being erected at Five Elms in connection with the extensions of the King George Hospital at llford, while the extensions of the Isolation Hospital at Rush Green are now approaching completion. The Local District Nursing Association is now firmly established, Maintaining a permanent staff of three, with additional temporary staff of a further three. There are prospects of the establishment of a Branch Training Home in the locality in connection with this Association. This should greatly increase the facilities for home general nursing in the district. The Essex Education Committee through the Provision of Meals 5 Sub-Committee instituted the provision of free mid-day meals for necessitous school children. Started as a temporary measure at two centres, this scheme has since continued at three centres. The committee subsequently, as the Dagenham Care Committee extended their activities to include the provision of dental treatment, boots, etc. A local Tuberculosis After-Care Association was also inaugurated during the year. The Registrar General's estimate of the population at midyear is 76,970, being an increase of only 10,000 on that for mid-year 1928. This increase is low, considering that some 4,000 houses were erected during that twelve months. The local estimate was 85,000. The notifications of Scarlet Fever and Diphtheria were again both relatively high, though not when based on the standardised population. Smallpox was notified for the first time in this district in December, during which month a total of three cases occurred Additional clinics were opened to meet the increasing demand, and, during the year, further arrangements were made in connection with the Maternity and Child Welfare Scheme with regard to institutional and home-treatment of patients. I desire to thank the members of the Council and administrative staff for the help they have given me in the past year. I have the honour to be, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, E. W. CARYL THOMAS. Public Health Offices, Becontree Avenue, Chadwell Heath. 20th June, 1930. 6 GENERAL STATISTICS. Area (exclusive of tidal water and foreshore), 6,556 acres. Population Census 1921 9,127 Registrar General's Estimate 1929 (mid-year) 76,970 No. of structurally separate dwellings (Census 1921) li,'871 No. of families (Census 1921) 1,957 Rateable value (mid-year 1929) £379,092 Sum represented by a penny rate £1,482 Occupations of Inhabitants. Owing to the slower pace of housing erection in the district, there was a large reduction in the number of men employed in the building trade. On 17th May, 1929 took place the formal ceremony, marking the beginning of the erection of the local Works for the manufacture of Ford cars. Extracts from Vital Statistics for the Year. Births. Legitimate Illegitimate Total. 2,277 37 Male. 1 157 21 Female. 1,120 16 2,314 1,178 1,136 Deaths. 643 342 Birth rate 30.6 301 Death rate 8.3 Number of women dying in, or in consequence of, childbirth from Sepsis 7 other causes 1 Deaths of infants under one year of age per 1,000 births:— Legitimate 64.5 Illegitimate 270 Total 67.7 Deaths from Measles (all ages) 14 " " Whooping Cough (all ages) 28 " " Diarrhœa (under 2 years of age) 37 7 Population. Of the 643 deaths occurring in the district during the year. 537 were amongst occupants of Estate houses. Of these 418 were persons under 45. This would give an Estate population of 68,000 under the age of 45. Among persons over 45 the deaths numbered only 119, indicating that this age group was only 1/8 represented, comprising a population of 3,500. The total estate population would then be 71,500. The Estate houses at mid-year 1929 numbered 14,530, with an average of occupants per house being 4.92. To this Estate population must be added the residents in the older houses of the district and also of the newly ercctcd buildings. The total population for the district is therefore approximately 85,000 and is divided into the following age groups:— Ages. 0/1 2,350 1/5 9,400 5/14 23,800 15/44 41,150 45 and up 8,550 The under 15 population is 36,550. This age-group in a normally distributed population of 85,000 would comprise some 21,000 persons. Births. 2,314 births were registered during the year, grouped as follows in respect of sex and legitimacy. Males. Females. Total. Legitimate 1,157 1,120 2,277 Illegitimate 21 16 37 1,178 1,136 2,314 The birth rate per 1,000 of population was thus 30.6 compared with 16.3 for England and Wales. The fertility rate for females 25 to 45 is 127 compared with 106 for England and Wales fur 1927 for the same ages. 8 Illegitimate births numbered 37, being a percentage of total births of 1.59 compared with the figures of 2.9 and 2.1 for the two preceding years, and 4 for England and Wales. Even this low figure overstates the true illegitimate rate of the district, as just over half of these infants were born to mothers who had never been resident in the area but had come down to relatives or friends for the birth of the child, subsequently returning to their homes. Marriages. Marriages which actually took place in the Dagenham Urban District 138 Marriages of Dagenham Residents solemnized at the Registry Office, Romford:— Both parties belonging to Dagenham 72 Male only „ „ „ 8 Female only „ „ „ 23 Death Rate. Total Deaths in district 377 Transfers out of district 94 Inward transfers 357 Deaths of residents 640 Of the 94 deaths of non-residents occurring in the district, 65 took place at the West Ham Sanatorium and 19 in Isolation Hospital. Of the 357 deaths of local residents taking place outside this area, most occurred in institutions. Of these 243 occurred at Oldchurch Hospital, 13 at King George Hospital, Ilford, 11 at the London Hospital, 7 each at Queen Mary's Hospital, Stratford, and Great Ormond Street Hospital, and 6 at St. Mar'y s Hospital, Plaistow. 643 deaths in a population of 76,970 represents a death rate of 8.3, as compared with 7.28 of the last year and 13.4 for England and Wales. Of these deaths only 22 per cent. occurred in persons over 45, compared with 30 per cent. for the year 1928, a fall accounted for by the influx of the young adult population. That, in spite of this influx, the death rate has risen suggests that the population figure on which the rate is calculated is too low. TABLE I. CAUSES OF DEATH. Under 1 year Over 1 and under 2 Oyer 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 Male Female Total. RegistrarGeneral's Allocation. Male Female 1. Enteric Fever - - - 1 1 2 2 2 — 2. Smallpox — — — — — — — — — — — — — — — 3. Measles — 5 4 4 - - - - - - 6 7 13 7 7 4. Scarlet Fever — — 1 3 - - - - - - 2 2 4 2 2 5. Whooping Cough 9 12 6 1 - - - - - - 11 17 28 11 17 6. Diphtheria — 3 5 8 — l — — — — 9 8 17 7 8 7. Influenza. 3 1 1 — — l 3 1 — 4 8 6 14 8 6 8. Encephalitis Lethargica — — — — — 1 — — — — 1 — 1 1 — 9. Meningococcal Meningitis — 1 1 — — — — — — — 1 1 2 1 1 10. Tuberculosis—respiratory — — — 1 13 19 21 6 2 — 30 32 62 32 34 11. Other Tuberculous diseases 2 3 2 5 — 1 - — — — 5 8 13 4 8 12. Cancer, malignant disease — — 1 1 2 2 7 11 5 14 20 23 43 22 23 13. Rheumatic Fever - - — 1 — — 1 — - — 1 1 2 1 3 14. Diabetes - — — — — — - — 2 1 1 2 3 1 2 15. Cerebral Hæmorrhage - - - - - 2 3 2 - 7 9 5 14 10 6 16. Heart disease 4 1 1 3 5 5 7 — 10 21 26 31 57 36 30 17. Arterio-sclerosis - — — 1 - — - - 1 2 1 3 4 1 4 18. Bronchitis 6 2 — — - — 2 1 2 13 16 10 26 11 7 19. Pneumonia 31 12 12 4 2 3 15 5 7 8 58 41 99 53 33 20. Other respiratory diseases — 1 1 2 — — 1 1 1 2 5 4 9 5 6 21. Ulcer of Stomach or Duodenum - - - — — 1 2 - 1 — 2 2 4 2 1 22. Diarrhœa (under 2 years) 36 4 - - - - - - - - 19 21 40 18 19 23. Appendicitis - — - 1 2 1 — - — — 2 2 4 3 2 24. Cirrhosis of Liver - - - - — 1 - - — 1 1 1 2 1 2 25. Acute and Chronic Nephritis - - 1 - - 3 2 — 1 1 6 2 8 7 2 26. Puerperal Sepsis - - - — — 5 3 — — — — 8 8 — 7 27. Other accidents and diseases of Pregnancy and Parturition - - - - - 1 - - - - - 1 1 - 1 28. Congenital Debility and Malformation, Premature Birth 49 - - - - - - - - - 30 19 49 39 21 29. Suicide - - - — 1 - 4 1 1 - 4 3 7 4 4 30. Other Violence - l 6 5 4 6 2 4 — - 21 7 28 22 6 31. Other defined diseases 20 3 4 6 - 8 5 3 7 23 47 32 79 31 34 32. Causes ill-defined or unknown — - — - - - - - - - - - 10 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Hospitals provided or subsidised by the Local Authority or by the County Council. a. (1) Fever. Rush Green Isolation Hospital is maintained by the Romford Joint Hospital Board, which consists of representatives from the Urban District Councils of Dagenham, Hornchurch and Romford, and the Rural District Council of Romford. The building of the extensions of the Isolation Hospital was begun in August and it is anticipated that the additional beds will be available before next autumn. The shortage of accommodation was greatly felt, though relieved to some extent in the Summer months by the admission of patients to the hospitals of neighbouring Authorities. About two-thirds of the total Scarlet Fever patients however, remained at home throughout the entire course of the illness. In the last three months of the year only one in five Scarlet Fever patients was admitted. Up to the end of the year however, practically all patients suffering from Diphtheria were removed to the hospital. Of the 383 cases of Diphtheria admitted in the course of the year, 189 were Dagenham patients, and 155 out of the 223 cases of Scarlet Fever. Endeavours were made, without success, to obtain premises in which to house mild or convalescent cases in order to relieve the demand on the hospital beds. (2) Smallpox. The Joint Hospital Board, with other districts, has an arrangement with the West Ham Corporation for the reception of Smallpox cases at Orsett Hospital. Dagenham Hospital, owned by 'the West Ham Corporation, originally intended as the Smallpox Hospital for the area, but now used as a Sanatorium, has not been used for the reception of Smallpox patients. These patients, when Orsett Hospital is full, have been admitted to the M.A.B. (now L.C.C.) Hospitals. 11 b. (1) Tuberculosis. The Essex County Council, as the Tuberculosis Authority, maintain a number of beds for adults and children of both sexes at various institutions. (See 1928 report). (2) Maternity. Maternity cases from this district are admitted, by arrangement with the Council, to Oldchurch Hospital, and Queen Mary's Hospital, Stratford. Puerperal cases are admitted to Oldrhurch Hospital. (3) Children. The following Table shows the hospitals at which the Council has arranged that certain cases shall be treated. Tonsils and Adenoids—Queen Mary's Hospital, Stratford, Out-patients only. Oldchurch Hospital. In-patients only. King George Hospital, Ilford. Outpatients or In-patients. Ophthalmia Neonatorum—St. Margaret's Hospital, 1 lamp- stead. Pemphigus—Oldchurch Hospital. (4) Orthopaedic—Royal National Orthopaedic Hospital. Queen's Hospital, Hackney. Cheyne Hospital. Institutional provision for unmarried mothers, illegitimate infants and homeless children. The only provision of this nature is that made by the Romford Guardians at their Institution. Ambulance Facilities. (a) For Infectious Cases. A motor ambulance provided by the Joint Hospital Board is stationed at the Isolation Hospital at Rush Green. 12 (b) For Non-infectious Cases and Accidents. The Morris Ambulance maintained by the Council is stationed at the Fire Station, Beacontree Heath. During the course of the year, the number of accident cases conveyed was 197 the number of other cases conveyed was 518 the number of journeys made was 739 the number of miles run was 8,408 calls on other ambulances totalled 24 Clinics and Treatment Centres. The following Infant Welfare Centres were maintained by the Council:— CENTRE. Held Day Average Attendances. Average New Cases. Congregational Church Hall, Mill Lane, Chadwell Heath Weekly Monday, p.m. 44 3 Church Institute, Burnside Road, Chadwell Heath Weekly Friday, p.m. 74 7 St. Mary's Mission Hall, Grafton Road, Chadwell Heath Weekly to 22nd June, then Bi-weekly Tuesday, p.m, Monday a.m. 84 39 10 3 Wesleyan Chapel, Heathway, Dagenham Bi-weekly Wednesday, p.m. Thursday, a.m. Thursday, p.m. 72 46 9 4 Labour Institute, Church Elm Lane, Dagenham Weekly 59 6 The following Ante-Natal Clinics were held:— SI. Mary's Mission Hall, Grafton Road, Chadwell Heath Weekly Tuesday, a.m. 14 6 Wesleyan Chapel, Heathway Dagenham Weekly till 1st May, then Bi-weekly till Nov. 1st, then Thrice Weekly Wednesday, a.m. 16 7 Friday, a.m. 10 3 Monday, a.m. 3 1 13 The School Clinic, maintained by the Essex Education Committee, was held at 25, Alibon Road, Dagenham. It was open on Monday, Tuesday and Wednesday mornings with; Doctor in attendance on Tuesdays. A Tuberculosis Visiting Station, maintained by the Essex County Council, was held at the same address as the School Clinic, being open on Thursday morning and afternoon. 'The Ilford Tuberculosis Dispensary at 38. Oakfield (Road, also maintained by the County Council, was more convenient for persons in the northern part of the district. This was open for adults on Monday 7.30 p.m., Tuesday 3 p.m., Friday 4 p.m., and for children on Wednesday at 10 a.m. There are no Treatment Centres for Venereal Diseases in this area, which is included in that for which provision is made in the London and Home Counties Scheme. Public Health Officers of the Local Authority. Medical Staff. * The Medical Officer of Health: full time since April 1st. 1929; up to that date, part of time taken up as Assistant County Medical Officer for the same area. * Eleanor Henderson, M.B., Ch.B., D.P.H., Assistant Medical Officer (Maternity and Chlild Welfare); full time sincc 1st February, 1929. * Sybil Pratt, M.R.C.S., L.R.C.P. Medical Officer in charge of Maternity and Child Welfare Centres. Resigned 31-1-1929 * H. G. Everard Williams, M.D., M.R.C.P,, Consultant Gynaecologist. *B. Whitchurch Howell, F.R.C.S., Consultant Orthopædic Surgeon. * Proportion of salary contributed under Public Health Acts, or by Exchequer grants. 14 Health Visitors. *M. A. S. Batty, General trained: Cert. C.M.B., H.V.'s Certif. Resigned 9/5/1929. *1. Richardson, General trained: Cert. C.M.B., H.V.'s Cerlil. *A. L. Hinton, Children's training: H.V.'s Certif. C.M.B. *M. Smith, General trained: C.M.B., H.V.'s Cert. *L. Weale, General trained: C.M.B., H.V.'s Cert., M. & CAV. Cert., Sanitary Inspector's Cert., New H.V.'s Cert. Began duties 15th May, 1929. *A. Trueman, Fever trained: General trained: C.M.B. Began duties 1st June, 1929. Up to March 31st, 1929. all Health Visitors continued their work under the arrangement begun in February, 1928, by which each nurse devoted roughly one-third of her time to school work under the Essex Education Committee. Since that time, their duties have been confined to Maternity and Child Welfare work. Sanitary Inspectors. *G. T. Carter, Senior Sanitary Inspector. Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. *J. A. Dawson, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. *L. Butterworth, Certificate of Royal Sanitary Institute; Certificate Meat Inspection (Birmingham College), Clerical Staff. Two full time clerks in the General Office. * Two part time clerks dealing with foodstuffs at the Infant Welfare Centres, remainder of time in General Office. One full time clerk in Sanitary Inspector's Office. *Portion of salary contributed under Public Health Acts, or by Exchequer grants. 15 Professional Nursing in the Home. (a) General. Three nurse-midwives are maintained by the Dagenham District Nursing Association. Grants are paid to the Assoiciation by the Essex County Council in rcspect of Maternity, School work and Tuberculosis nursing. The Local Authority use their services for the home nursing of such cases as Puerperal Fever, Ophthalmia, Pemphigus, etc For this purpose an extra nurse is usually engaged. (b) For Infectious Diseases. The same arrangement continues as to the home visiti of Scarlet Fever cases by the Health Visitors. Home Helps arc provided in cases of domestic difficult arising out of the home treatment of these cases. Midwives. There are no midwives in the district employed by the Local Authority. At the. At end of the year there were 19 midwives living in the district whose practices were confined almost entirely to this area. In addition, three midwives live on the boundaries of the district and have some cases here. Legislation in Force. The following bye-laws were made by the Romford Rural District Council and have been taken over by the Dogenham Urban District Council. Date of Confirmation Cleansing of Footpaths January, 1885 Removal of House Refuse January, 1885 Cleansing of Earth Closets, etc January,1885 Common Lodging Houses December, 1901 Nuisances May, 1902 Houses Let in Lodgings June, 1902 Tents, Vans, Sheds, etc March, 1908 16 Regulation of Certain Offensive Trades. Animal Charcoal Manufacturer; Blood Boiler; Blood Drier; Bone Boiler; Cat Gut Manufacturer; Fat Melter or Fat Extractor; Fish Skin Dresser; Glue Maker; Size Maker; Gut Scraper; Leather Dresser; Manufacture of Manure from fish offal or other putrescible animal matter; Soap Boiler; Tallow lelter; Tanner and Tripe Boiler. Confirming Order July, 1911. Bye-laws confirmed August, 1912. Rag and Bone Dealer; Fish Fryer. Confirming Order 25th March, 1927. Bye-laws confirmed 26th September, 1928. Slaughter Houses (Revised). 26th September, 1928. New Streets and Buildings. July, 1925. Regulations with respect to Dairies, Cowsheds, etc. February, 1908. Adoptive Acts. Public Health Act (Amendment) Act 1890 (Part 111.)— 5/12/27. Infectious Disease (Prevention)'Act 1390.—1/3/23. Private Street Works Act, 1892. Public Health Act (Amendment) Act 1907 (except Sections 19, 61, 78, 82/86 and 92/94). Small Dwellings Acquisitions Acts. Public Health Act, 1925. Local Acts. Dagenham Urban District Council Act, 1928 (3/8/28). Dagenham Urban (Water) Order 1929. 17 SANITARY CIRCUMSTANCES OF THE AREA. Water. Sec the report tor 1927. In certain parts of the district there are erected for habitation, buildings whose only water supply is derived from wells sunk in the land on which is emptied the contents of the cesspools of the houses. The only stipulation with regard to the water supply to be complied with before the occupation of such premises was sanctioned, appeared to be that the source of the water supply should be shown on the plans. To remedy these conditions, the Council made application to be invested with the powers under the Public Health (Water) Act 1878. On 24th September, 1929, a Local Inquiry was held, subsequent to which the Dagenham Urban (Water) Order 1929, came into operation as from 30/10/29. Drainage and Sewerage. See Reports of 1927 and 1928. The extension of the Isolation Hospital at Rush Green prevented the further use of the existing plant for sewage disposal. As a temporary arrangement, the hospital is being drained into the Hornchurch Sewers, the sewage being pumped to the higher levels. Early in 1930 a Local Inquiry was held in connection with the proposal to run a sewer up the Beam Valley for the purpose of draining this portion of the district. As mentioned in the 1928 report, such a scheme, in addition to providing for the drainage of the Hospital, would remedy the unsatisfactory state of affairs existing on the Manor Farm Estate. Further steps have been taken with regard to the extension of the sewage works at Rainham. The proposal is to run the major part on one of the Activated Sludge methods with possibly, in addition, some form of sludge digestion treatment A separate sewer is to be run from the Ford factory to the sewage works. Most of the factory effluents of the district will then be carried in this sewer, to be dealt with at the Works by a process distinct from that for the treatment of domestic sewage 18 Closet Accommodation. Sec Reports 1927 and 1928. During the year an underground Sanitary Convenience situated near the "Chequers" was opened. This structure has six W.C.s and eleven urinals on the male side, and eight W.C.s on the female side. The staff consists of two full time male attendants, and one relief, and' a coresponding female staff. The estimated annual cost of running, including loan charges, is nearly £1,200 per annum. A beginning was made during 'the year on a similar convenience at Beacontree Heath. A small convenience was erected at Valence Park and another one in Goresbrook Park. Scavenging. The following table gives some statistics relating to the collection of refuse. 1. Estimated weight of house and trade refuse collected per week—292 tons. 2. Number of premises visited per week—18,314. 3. Total all-in cost of this service per week—£186 3s. 9cl. 4. Cost of collection per house per week—2.43d. 5. Personnel and equipment— For six days: 1 Fordson Trailer and driver, 1 Harvester with driver and 2 trailers, 1 horse and driver. .For three days: 5 and 6 S.D. Freighters and drivers, with 26 and 28 men collecting refuse. The same arrangements continue in force with regard to the collection of trade refuse. Much annoyance is still caused by traders disposing of their refuse by incineration. 19 The house and trade refuse continues to be disposed of by crude dumping on the tip in the northern part of the district. This dump is now yards above its surroundings and causes a nuisance to the neighbourhood by the smoke and fumes and blown paper. In May, a deputation of the public Health Committee visited Aylesbury to inspect the salvage plant and reported in favour of the adoption of a method disposal on similar lines. Early this year a joint deputation o: the Public Health and Works Committees visited Birmingham to inspect a plant workcid on the same principle but on a larger scale. As a result it is probable that some such method will be utilised for disposing of the local house refuse and lead to the termination of the nuisance created by the present method. Disinfection and Disinfestation. Disinfection of Homes. All houses are disinfected as a routine practice after the occurrence of Scarlet Fever or Diphtheria, being fumigated with a Formigator left for six hours. The rooms of the Estate houses are subsequently distempered by the L.C.C. Authorities. Rooms vacated by tubercular persons are fumigated on Vcquest. Bedding. By arrangement with the Joint Hospital Board, bedding can be removed and stoved at the hospital, at the expense of the owner. In the course of the year the question of the provision of some form of Cleansing Station has been discussed. In a report submitted it was pointed out that, in this area, there were no facilities for dealing with persons suffering from scal or lor dealing wi-esth the garments and bedding of those suffering from scabies or vermin nor for providing tor disinfection infectious materials. Though admittedly fomites play but a small pari in the dissemination of the more ordinary infections and the routine terminal fumigation of premises might well be dispensed with, there arc certain circumstances in which one would prefer to have facilities for ensuring thorough disinfection of goods. Such cases are those of Smallpox in which fomites are credited with being of more importance in the spread than in the more common infections: Typhoid Fever, 20 in which bedding is liable to contamination; while any midwife who has been in contact with a case of infection is required to disinfect herself and her appliances to the satisfaction ot the Local Supervising Authority. To meet these difficulties lit was suggested that a combined Disinfecting and Cleansing Station be erected (cost about £3.000), 'the disinfecting side containing a steam disinfector and the cleansing station containing four baths and cubicles. At 'the end of the year the scheme was still under consideration. Rats and Mice (Destruction) Act, 1919. Rats in this locality are limited to confined areas, namely the refuse tip, farms and premises on made soil. Use is still being made of the rat poison obtainable at the Sanitary Department. Smoke Abatement. No action has been necessary during the year for the abatement of smoke. Offensive Trades. Fried Fish Shops. Consent was granted in four instances for the use of Premises for the purpose of conducting therein the trade of fish-frying. In one case consent was refused owing to the layout of the yard. Later a subsequent owner by being able to brow in part of the adjacent yard, overcame this objection and consent was granted. On 4/12/29, a trader was summoned and a fine inflicted for carrying on the trade of fish-frying without having obtained Previously the sanction of the Council. Consent was subseI fluently granted. I and Bone Dealers. 4 number of Rag and Bone Dealers pay frequent visits to this area, at times exchanging toys for rags. The chief "of ,offer, who employs agents, was himself cautioned, as were subsequently his agents. For a further offence, the dealer and an assistant were, on 4/12/29, summoned and fines inflicted. 21 Tents, Vans, Sheds. Previous mention has been made of the unsatisfactory condition of two neighbouring sites occupied by migratory inhabitants of vans. A notice was served on the owner to abate the nuisance which occurred periodically from overcrowding of the yard, from the offensive refuse pit and from the neglected sanitary convenience. The case was heard at court on 19/6 29 and an order made for the removal of the vans. Schools. The only new school opened in the course of the year was Five Elms School. The total number of children attending the Public Elementary Schools in the Dagenham Urban District at the end of June was 20,135. Infectious Diseases. No schools were closed during the year on account of the prevalence of infectious diseases. In one instance only was school attendance apparently responsible for any number of cases. In this case a diphtheritic convalescent carrier infectcd a number of his classmates. Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections. Houses 1,515 Bakehouses 48 Slaughterhouses 833 Milkshops and Dairies 148 Cowsheds 97 Infectious diseases enquiries 2,728 Houses disinfected 714 No. of Nuisances investigated (b) Notices served. Complied with. Statutory 31 31 Informal 86 78 22 On the Administration of the Factory and Workshop Act, 1901. In this district there are 19 factories, 19 workshops, and 31 workplaces. | 1. Inspection. PREMISES. Number of Inspections. Written Notices. Prosecutions. Factories 57 - - Workshops 57 — — Workplaces 201 — — 2- Defects. Nuisances under the Public Health Acts. Found. Remedied. Defective Sanitary Accommodation 1 1 "Other nuisances" 3 3 3. Outwork in Unwholesome Premises—Section 108. There was no outwork conducted in unwholesome premises. There were 92 premises in which outwork was carried on. The following table shows the various occupations:— Dressing Gowns 2 Leather Cutting 1 Brushes 8 Boxes 2 Blouses 6 Fancy Goods 1 Millinery 4 Ties 2 Boots 15 Outfitting 1 Tailors 6 Trimmings 1 Overalls 4 Art Needlework 1 Neckwear 2 Costumes 1 Wearing Apparel 19 Shirts 2 Underwear 3 Gowns 1 Robes 5 Baby Clothing 1 Christmas Crackers 1 Waterproofs 1 dollars 1 Life Belt Makers 1 Rag Flock Act, 1911 and 1918. There are no premises in the district in which rag flock is manufactured, used, or sold. 23 HOUSING STATISTICS FOR THE YEAR 1929. Number of houses erected during 1929: — (a) Total including (b) 1,681 (b) With State assistance under the Housing Acts : — (1) By the Local Authority (2) By other bodies or persons 1,572 1. Unfit Dwelling Houses. Inspection. (1) Total number of houses inspected for housing defects (under Public Health or Housing Acts) 1,515 (2) Number of houses which were inspected and recorded under Housing (Consolidated) Regulations 1925 280 (3) Number of houses found to be in a state so dangerous or injurious to health as to he unfit for human habitation (4) Number of houses (exclusive of 3) found not to be in all respects reasonably fit for human habitation 278 2. Remedy of defects without service of formal notices. Number of defective houses rendered fit in consequence of informal action by the Local Authority or their office.s 3. Action under Statutory Powers. A. Proceedings under S.3 Housing Act, 1925: — (1) Number of houses in respect of which notices were served requiring repairs 225 24 (2) Number of houses which were rendered fit— (a) By owners 218 (b) By Local Authority in default of owners 0 (3) Number of houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 2 Proceedings under Public Health Act— (1) Number of houses in respect of which notices were served requiring defects to be remedied 183 (2) Number of dwelling houses in which defects were remedied— (a) By owners 175 (b) By Local Authority in default of owners 0 • Proceedings under S.S.ll, 14. and 15 of Housing Act, 1925— (1) Number of representations made with a view to the making of Closing Orders A (2) Number of houses in respect of which Closing Orders were made 3 (3) Number of houses in respect of which Closing Orders were determined, the houses having been rendered fit 0 (4) Number of houses in respect of which Demolition Orders were made 0 (5) Number of houses demolished by owners 2 25 Housing. The Council acquired for the purpose of housing development 3 plots of land, namely, Eastbrook Farm, Rabbit Field and Rail Pond Field, a total of about 40 acres for about £10,000 In August a beginning was made on the work of sewering and making the roads on Rabbit Field and a small part of the Kail Pond Field. There was a large decline in the rate of growth of the L.C.C. Becontree Housing Estate, only some 1.400 houses having been erected in the course of the year in the Dagenham area. Tim made a total of the Becontree Estate in this area of 15.033 houses and left some 232 for full completion. The following is a list of new roads on the Estate: Wren Gardens, Durell Road, Durell Gardens and Daye Gardens, Danette Gardens. 26 INSPECTION AND SUPERVISION OF FOOD (a) Milk Supply. There are 26 retailers of milk in the district, the following being the number of premises from which the various classes of milk are retailed. Ungraded Milk 24 "Grade A'' Milk " Grade A" Pasteurised Milk 7 Certified Milk 7 Pasteurised Milk 8 The number of Company Distributing Centres is 7. Further changes occurred during the year, two businesses changing hands. One trader discontinued as a retailer but continued as a small scale producer. One new dairy was opened, while another dairy was erected to replace one, use of which was discontinued owing to its unsuitability for the purpose. An application for registration as a retailer was refused owing to the unsuitability of the proposed premises; as was an application for permission to use some existing buildings as a cowshed: in this case the buildings and the drainage were not satisfactory . In another case, registration as producer was withheld until 'he rectification of defects of the cowshed. Milk Sampling. During the year 142 samples of milk were analysed; the same system of sampling was continued. The following table shows the results of these analyses, divided into those produced on a small scale and those distributed by large companies. Small Dealers Large Scale. No o[ Bacteria. Local produce. Not local Per c.c. in '"Thousands. Satisfactory NOT Satisfactory NOT Satisfactory NOT Under 30 9 6 1 20 1 30—100 9 1 18 2 6 1 100—200 6 1 16 8 1 1 200-500 - 6 9 1 4 Over 500 24 — - 12 - 2 24 2 46 32 28 9 27 These figures show that the milk of the small producer in 16% of cases had counts below that permitted for Certified Milk and that 8O% were within (the standard prescribed for " Grade A " Milk. Ordinary milk is liable to bactcrial infection including that by the tubercle bacillus. In Certified and in " Grade A" milk, particularly where the herds are tuberculin tested, the risks arc greatly minimised but cannot with certainly he eliminated. Untreated milk must therefore remain a potential source of infection, even though produced under model conditions. Efficiently pasteurised milk can be rendered a safe milk from the point of view of elimination of pathogenic bacteria, and, so. apart from mechanical defects of the plant or the risk of contamination after the heating process of such milk, it should be possible to say,that that milk wlill not cause any of the infectious diseases. Heating however, by improving the keeping qualities of the milk, pcrmits of its production under conditions which result in contamination not economically possible in the case of an untreated milk. To advocatc wholesale pasteurisation of milk at this stage as resulting in a safc milk savours' of a iconfession of failure and would be a step which would tend to prevent the present trend towards improvement in milk production. It seems the rational development with regard to milk for wholesale distribution should be that all should be produced under conditions satisfying the present " Grade A " standard, and it should then be pasteurised—that is, the production of " Grade A " Pasteurised milk should become the rule instead of the exception. Whilst strict pasteurisation has its advocates —namely the process by which milk is heated to a certain temperature for ' definite time with known results on bacteria- it seems difficult to justify the state of affairs which permits milk to be heated and sold with no indication of its having being treated. In the; case of the result of the analysis being unsatisfactory, the retailer is communicated with, and another sample taken shortly after. Should this show no improvement, the retailer is interviewed as to the steps taken to remedy the defect'. He is advised and assisted, to take samples of milk from his separate producers. This usually exonerates all but one or two with whom he then takes up the matter. A report is sem to the County Medical Officer of Health who arranges an examination of the premises of the producer and, if necessery, a veterinary inspection. This usually results in the improve. ment in the condition of the premises or in the procedure 28 milk production or in the rejection of milk of parts of the herds, and is followed by an improvement in the condition of the milk. A number of consecutive samples from a firm which bottles milk were of poor bacterial count and suggested the fault lay in the dirty condition of the bottles. On visiting the premises it was found that the washing apparatus for cleaning the bottles was being worked beyond its capacity. Other conditions existed which offered possible contamination of the milk from the time of bulk heating of the milk to the final sealing of each individual bottle. A number of alterations were effected since when the milk samples have proved satisfactory. Meat. In this district there arc four slaughterhouses, one of which is licensed and three registered and to which a tolal of 833 visits were paid during the year. These premises are mostly of unsuitable construction, arc placed in populous localitiis and the small available area prevents any satisfactory alterations being carried out to improve existing conditions materially. In January the Public Health Committee favourably considered the question. of the erection of a Municipal Abattoir and the local meat traders were approached to determine to what extent they would support the slaughterhouse and cooling room. In June a Sub-Committee met, for discussion, the local butchers and meat retailers, accompanicd by representatives of the London Retail Meat Traders Association. A Sub-Committee visited some of the slaughterhouses in the district. The matter was still under consideration at the end of the year. On 12 2 29 a demonstration was made by one of the inspectors of the R.S.P.C.A. at one of the local slaughterhouses jo which all the slaughterers of the district were invited. The Case "Captive Bolt" humane killer was used on beasts and sheep. The demonstration proved the suitability and the advantages of this method of killing. Bakehouses. There are four bakehouses in the district, two factory and two retail: there being none underground. 48 visits were paid in the course of the year. Sale of Food and Drugs Acts. .These acts are administered by the Essex County Council. addition 42 samples were taken by the Senior Sanitary Inspector and submitted for chemical analysis, 20 of butter and 22 of milk. All proved satisfactory. 29 INFECTIOUS DISEASES. Cages Notified. Admitted to Isolation Hospital Rush Green Admitted to Otlier Isol. Hosp. Admitted to Other Hospitale. Deaths registered. Scarlet Fever 501 149 42 4 Diphtheria 217 206 10 — 15 Enteric Fever 6 2 3 1 2 Puerperal Fever 8 1 - 6 7 Puerperal Pyrexia 11 — — 5 7 Pneumonia Primary 152 - - - Influenzal 23 - - - 91 includes secoundry Erysipelas 21 * — - 8 — Encephalitis Lethargica 1 — — — 1 Ophthalmia Neonatorum 26 3 — Cerebro Spinal Meningitis 2 — — 2 2 Poliomyelitis — — — — — Polioencephalitis 1 — 1 1 Pemphigus 10 — 6 8 Smallpox 3 - 3 - - * Made notifiable in this district end of May, 1929. Under 1 year. 1 2 3 4 5 10 15 20 25 35 45 55 65 | Total Diphtheria 1 4 11 18 21 128 1 5 1 4 7 4 1 — 217 Scarlet Fever 1 10 21 45 46 288 47 14 8 15 4 — — 1 501 Enteric Fever — — 1 1 ? - - 1 1 — — - 6 - - - - - - - - - 7 1 - 8 Puerperal Pyrexia - - _ - - - - -_ 7 4 — - 11 Pneumonia (Primary 23 19 7 17 10 21 4 4 1 9 16 6 7 8 152 Pneu monia (Influenzal) - 2 1 2 - 1 - 1 - 6 8 2 — - 23 Erysipelas 1 - 1 — 2 1 1 — 6 7 1 — 1 21 Encephalitis Lethargica - - - - - - - - - 1 - - — — 1 C. S. Meningitis - 1 1 — _ — — — — — I Polioencephalitis - - - - - - - - - - - - - — 1 Smallpox - - - - - - - 1 1 1 — - - — - 501 cases of Scarlet Fever is at the rate of 3.05 per 1,000 and the 217 cases of Diphtheria a rate of 1.59 per 1.000- The rate for children under 15 is for Scarlet Fever 13.7, compare with 12.2 for England ar.d Wales, whilst for Diphtheria the corresponding figures were 5.93 and 6 35. The incidence rate for under 15 then was, in the case of Scarlet Fever,/ 1.1. and for Diphtheria 0.9 of that obtaining for the country as a whole The ligurcs of incidcnce of Diphtheria for the last three months of the year were lower than anticipated and accounts for 30 the low total rate of the year. An excessive prevalence for the first two months for 1930, when for eight consecutive weeks double figures were recorded, brings up the total incidence from the beginning of the Autumnal rise to the anticipated figure. That is to say that, had these excess cases occurred at the end of 1929 instead of at the beginning of 1930, the Diphtheria rate for the District would have shown, just as he Scarlet Fever rate showed, a slight excess over that obtaining in the country as a whole. The interesting features of these figures is shown by com-: parison with the preceding years. For Scarlct Fever the factor of incidcnce in Dagenham, compared with the country as a whole for 1927 was 1.6,. for 1928 1.4 and 1929 1.1. The corresponding figures for Diphtheria were 1.7, 1.3 and 0.9. Considering the cases occurring in the Estate houses alone, the expected incidence of Scarlet Fever,(all cases) was 344, compared with an actual incidcnce of primary cases only of 351. For Diphtheria there were 189 primary cases on the Estate compared with an expected number of 178 all cases. The expected rate is calculated from the number of houses and the population per house, allowance being made for the altered age distribution of the population. Plotting these figures on the graphs of actual and expected incidence, it is seem that the lines of the curves vary. For Scarlet Fever the incidence curve remained low until 1925, when it underwent a marked alteration in direction, so that in 1927 it crosscd the curve representing anticipated cases and fame to lie above it. Since that date both curves have converged and arc now running parallel and almost coincident, since the expected and actual figures for 1929 and 1928 were almost equal. In spite of the deceleration in the rate of housing growth, these two curves for Scarlet Fever continue in the same line as for previous years and do not run parallel to the Population curve. . The Diphtheria curves up to this year remained essentially similar to the Scarlet Fever curves, except that the marked change in the direction of the incidence curve took place a year later in this disease in 1927 the incidence crossed the anticipated curve and rose well above it for 1928. In 1929. however the two curves converged again, the actual number of cases being only slightly more than the expected incidence. Fur- ther the curve of actual incidence, instead of continuing in a 31 straight line as did the Scarlet Fever curve, bends over parallel to the population curve This, of course, may be just chance. As already indicated, the incidence rate which is low would have been normal had some of the surplus cases of early 1930 occurred in late 1929. Again, too, accounting for the different lines of the expected curves, whereas for the country the rate of Diphtheria per 1,000 population in 1929 showed an increase of only 2 per cent. over that of 1928, the Scarlet Fever rate increased by 18 per cent. A study of the graphs as they stand, however, shows that up to this year they are essentially similar for live two diseases, though with a longer period of lag in Diphtheria before the excess incidence appeared; but that when it did appear, the surplus was relatively greater than for Scarlet Fever; suggesting that the same factors arc in operation in both rases. If 'this is so, then presumably the alteration in the present year is due to the change occurring in the case of one before the. other, just as the increase occurrcd in Scarlet Fever earlier than Diphtheria. If this be the trend, then shortly, the incidence curve should cross the exported curve again to come to lie below it—that is, the incidence of Diphtheria will be relatively lower than that obtaining in the country as a wholes Similar figures held as shown previously with regard to the time persons had been resident in the area before suffenng from infection. In the case of Diphtheria, out of 187 primary cases 7 occurrcd within the first five months, whereas 77 look place between this period and 18 months, leaving only 103 occurring in persons who had been here over 18 months. Similarly with regard to Scarlet Fever, 113 cases occurred between live and 18 'months of the patient's coming to reside in the area 17 occurred within the five months and 192 over the 18 months. This disproportionate distribution might conceivably be due to two factors. 1, The development of the. district. Only a 'few houses have been up seven years, whereas most, at the time of calculating, would have been up six months. Naturally, therefore, a greater numerical incidence occurs amongst those houses which have been up the shorter time owing to their greater number. 32 2. The age incidence of infection. Scarlet Fever and Diphtheria mostly attack children round five and under five, so that there 'would be fewer cases of infection amongst persons who had been here over five years, not becausc they had been here that length of time, but because their age being further removed from five, they would be less susceptible to infeclion. If this were a point of importance one would expect to see it reflected in the age distribution of disease incidence and to show up regularly and consistently in succeeding years," Below is appended a table showing the age distribution of cases of Scarlet Fever and Diphtheria occurring in the Estate hou..es for the three years 1927-29 and in comparison the age distribution. of cases admitted to the Eastern Hospital, taken from the Medical Research Council, Special Report Series No. 137. Age Distribution of Infectious Diseases. (All ages). DIPHTHERIA. SCARLET FEVKR. 1927 1928 1929 Eastern Hospital 1927 1928 1929 Extern Hospital Uuder 1 1.2 0.5 0.9 1.5 — - — 0 6 1/2 3 8 5.6 1.8 6 5 5.5 3.0 2.3 3 2 2/3 5 7 10.3 5.3 10.3 6 2 7.2 4.0 7 2 3/4 10.8 10.8 7.1 12.9 8 2 10.2 7.8 98 4/5 8.9 13.1 10.2 13.6 10 3 8.0 8.9 11.4 5/6 7.0 11.7 12.5 11.9 13.7 17 4 17.6 11.5 6/7 10.2 10.3 18.7 8.9 17.7 13.3 10.7 10.0 7/8 8.3. 10.3 11.1 6.6 11 6 11.3 12.4 8.0 8/9 8.9 5.6 8.0 4.8 6.2 9.9 10.4 6.9 9/10 3.8 3.8 9.3 3.5 6.2 3.4 7.2 5.5 10/15 16.6 8.4 6.7 11.1 8.9 9.5 11.8 16.9 Over 15 14 6 9.4 8.9 8 4 5.4 6.3 6.5 9.0 Under 5 30 4 40.3 25.3 44.8 30.2 30.4 23 0 32.2 5/10 38.2 41.7 59.6 35.7 54.4 55.3 58.3 41.9 In the case of Diphtheria, if one assumed this greater incidence within two years of residence were due to the fact that, during this period, there were more children of susceptible ages, one would expect to see a heavier incidence amongst children under five than over five. Actually the Eastern Hospital figures are 44.8 per cent, under five to 35.7 per cent, five to;ten,whereas in none of the three years did the under fives show this excess. on the other hand, if for any reason one particular year of ago were especially markedly represented in the population, one would cxpcct this age group to show a relative excess due to 33 increased numbers. This exccss in the next year should appear in the next succeeding age group, Now when this year of age reaches the year of maximum incidence of Diphtheria the combination of excess population for that age group and relative excess incidcnce of that particular age should be reflected in a much greater incidence for any particular year. Considering the year 1927, the years 3 and' 4 are high and 6 also high. Assuming that the age 6 incidence was due to the disease favouring ago 6 and the increase at 3 and 4 the increased population at these ages, this would be in accord with the figures for 1928 which again show a high figure at age 6. due to age predilection), and' a high figure at 4 and 5 due to that increased population which in the previous year accounted for the increase at ages 3 to 4. 1929 would be the year of conjunction of the exccss population occurring at the age group most favoured by the disease. This would account for the particularly high incidence of infection in 1929 of age 6. 1 he figures for Scarlet Fever do not bear this out as, although for the years 1927 and 1928 it would fit in, 1929 is aiuomaious Considering the graphs 2 and' 3 on pages 41 and 43 of the 1928 report, it was found that taking all the years together, the maximum incidcnce occurrcd during the period 6 to 18 months after the persons became resident on the Estate: and after that period of time that the incidence fell to below' normal; further, that the curves were essentially similar for the two diseases, Scarlet Fever and Diphtheria. Plotting out the graphs for each year separately for each disease shows that the type of curve each year differs,, but that it is essentially similar in each disease. Up to 1927 the figures were low and on charting give an erratic curve. For 1927 the curves are both flat, with a low maximum at the period 12 to 18 months, after which it fell gradually. In 1928 in both diseases the curve shows a peak maximum after 6 months, falling rapidly after 12 months and more gradually after 18 months. The 1929 curve is much flatter. The maximum in Diphtheria is represented by a plateau for the period of 12 to 18 months. In the Scarlet Fever curve this is replaced by two maxima at 12 and 24 months, with a drop at 18 months, Apart from this difference, the curves resemble each other, there being a rapid fall in the third year, but after that a gradual decline. 34 The most important feature perhaps, is not so much the actual form of the various curves, but that there is a marked semblance in those for each disease. The following facts relating to the incidcnce of infectious disease for this Estate need correlating. 1. That there is a large, recently imported, population resident here of a peculiar age distribution, being particularly deficient in representation of the age groups above 45 or 50. 2. That the population has come largely from congested Metropolitan areas to a newly erected Estate in which each house has its garden and the whole area provided with wide streets and open spaces. 3. That for a period of over 2 years the incidence of the two diseases Scarlet Fever and Diphtheria, a rate based on the standardised population, has been much above normal. 4. That this excess incidcnce is most marked amongst the population after a period of residence of some 6 months to 2 years. 5. That this exccss incidence did not appear until about the 5th year of the development of the Estate. Up to that time the incidence of the diseases was below what might have been anticipated. About the 5th year, however, the prevalence of both diseases became apparent and has remained above normal ever since. The excess, however, is becoming less -marked, the incidence of both infections becoming more closely normal. As an explanation of these facts the following hypothesis is suggested: — The principle of active immunisation of the population by repeated sub-linimal doses of infection is accepted and that these immunisation doses are given off largely by the immune members of the population. 2- That the population in this locality, lacking as it doe.; its due proportion of adults over 45, who form such a great proportion of the immunes in an ordinary population, is thereby deprived to a large extent of its sublethal immunising doses 35 3. The child population resident in congested areas in London is in a partially immunised condition the extent of immunity increasing with advancing age. On coming to reside here and being deprived of further sub-lethal doses of infection, their immunity is lost. After this they are in a position to succumb to infection. 4. In the early years of the development of the Estate, the rate of growth was, compared with later years, slow Further, building was started at different points Separated from each other. In these circumstanees there would not be any one large section of population becoming susceptible at once. As, after a period of months, a certain proportion lost their immunity, they would be merged in with the new-comers who at that time would still be relatively immune. More recent development however has taken place at a greater rate and in sections contiguous to already developed areas. The circumstances would now be altered in that larger sections of the population would become susceptible at the same time, without the balancing effect of an imported population. Such sections will, after a period during which loss of immunity occurs show a relative excessive incidence of infection. 5. The introduction of infection might well be through the medium of Visitors to London. The.iC persons become recognised or unrecognised cases or temporary or chronic carriers and bring infection to the susceptible population who then succumb. In support of the various items of this hypothesis:— 1. Whilst it is admitted that active acquired immunity developed as a result of exposure to sub-lethal doses infection, it is unknown what this source of infection is Active cases of illness, when recognised, arc segregate so that although posibly active in the producation of immunity amongst immediate contacts, just as they are liable to cause infection amongst these persons they cannot have much effect on the general population That the. proportion of immunes rises in a semi-isolated community after the occurrence of cases does not of necessity require that the active cases of disease should have been instrumental in causing this immunity cases might have given rise to temporary healthy carries who thereupon pass on immunising doses to " other Chronic carriers, particularly nasal, are a source of infection to a wide circle. They can, presumably,be 36 equally activc as immunisers. The ordinary healthy carrier—namely, the immune person who has just been exposed to infection and temporarily retains the infecting organisms—will probably, as compared with the chronic convalescent carrier, play amuch smaller part in causing actual cases of illness but is equally effective in handing out immunising doses. 2. The age distribution of the population on the Estate was discussed in detail in the Annual Report tor the .. year 1927. 3 and 4. Graphs 2 andi 3 in the 1928 Report showed that the greatest incidence of infection occurred 'in the period averaging 6 to 18 months residence on the Estate; Further, table '5, which gave the incidence of infection for both diseases on each section of the Estate, showed that there was a lag period of months in almost all instances before any particular section succumbed to infection, and that, in general, infection when it occurred, has been heavier in those sections which developed rapidly. Also the varying nature of the three pairs of graphs showing the periods of incidence before infection for each of the three years supports this suggestion. Up to 1926 development was relatively slow and no effect was apparent. By 1927 the period had just been reached when the effect of the more rapid development of 1925 made itself felt. This was much more marked for the year 1928, This year was the peak year of expansion and is reflected by the marked peak showing incidence amongst residents of about 6 months' duration. The slower development of 1929 gave a flatter curve with a maximum incidence after 12 to 18 months' residence. With regard to the importation of infection from London, it was shown in the report for 1923 that there was a heavy incidence of infection within the first few weeks residence here and that in a number of cases, definite association with a London case was shown. Apart from the possible risk of infection to susceptible both at the places visited and in congested carnages in transit to and fro, must be added the possibility of infertion being brought down to the district by visitors from the congested Metropolitan areas. 37 Diphtheria. 217 cases of Diphtheria in a population of 76,970 Is ar the rate of 282 per 1,000 living, compared with 1.59 for the country as a whole./ The incidence per 1,000 under 15 is 5.93, compared with 6.36 for the same ages in England and Wales. All cases but one were admitted to the Isolation Hospital. This was a case with concurrent measles, whom it was impossible to isolate separately in the hospital. The incidence rate was steadily low for the first seven months with a total of 80 cases, August was the month with the greatest number of cases, namely 40. In September the rate fell to 'the a'verage, and in each of the last three months the incidence was slightly heavier, though there was no very marked autumnal rise. The low incidence is in marked contrast to the number of cases occurring in the earlier part of 1930, when, for eight consecutive weeks, double figures were recorded, giving a total of 125 cases for the first nine weeks of the year. Of the primary cases 190 were on the Estate (out of a population of .32,000 children) and 18 cases in other houses in a population of 4,000 children.. This latter figure, however includes five cases occurring in a school, secondary to two convalescent carriers. Secondary Cases. In the 14 houses in which secondary cases occurrcd, there and in one instance four followed on a primary infection, making a total of 18 cases secondary to 15 primary cases. All these secondary infections occurrcd in Estate houses In three of them the second patient was infected before a doctor was called in to the first, and in one instance the occurrence of the secondary case led to the recognition of the primary case. Of the remaining 11 infections the primary case was not removed to the hospital before the 4th day in 6 cases. in three instances the mother of the patient succumbed to the disease. In the 14 houses in which secondary cases occurred, there was a room average of 0.6 adults and 0.8 children and a bedroom average of 0.8 adults and 1.2 children. The corresponding figures for the 184 houses in which no secondary infection occurred were room average 0.5 adults with 0.7 children and bedroom average 0.8 adults and 1.1 children. 38 Return Cases. There was a remarkable freedom from return cases of liphtheria in the course of a year, the only case occurring being one in one of the older houses of the district. The, infecting patient was removed to hospital on the 5th day, being detained 38 days or 43 from the onset. The onset of the Return casc was 26 days from the discharge of the presumed infecting case, who however had appeared healthy. with normal mucosa and giving a negative swab. Death Rate. 15 deaths, 7 male and 8 female, occurred from Diphtheria in the course of the year. Of these 3 were laryngeal cases. Two other children died, having had croup following measles. The case mortality is under 7%. 8 of the cases were admitted to hospital on or after the 4th day from the alleged onset. 8 died within a short period after admission. Schick Testing and Immunisation. No children have been Schick tested or immunised. Bacteriological Examination. 497 swabs were examined during the year at the Essex County Public Health Laboratories. Schools and Diphtheria. On only one occasion did school attendance appear to have any effect on the dissemination of infection. This was an Infants School of the old type of building from which 4 scholars were notified in the course of a few days. the school was run as two separate classes, though mixed for some pur poses. J'"' seating accommodation was of benches in front of long desk All four cases were from one class, from the register was found that one boy had been absent recently with a septic throat " and another with a " poisoned stomach. these two on examination were found to have typical blood stained nasal discharge with excoriation. Examination of the children showed another boy with a patch on his tonsils. These three children were excluded. The nasal cases both subsequently gave positive swabs. No other children were swabbed, nor were the premises disinfected. One case occurred subsequent to the removal of these two nasal carriers, but proved to be a home contact of one of them. 39 Scarlet Fever. 501 cases of Scarlet Fever in a population of 76,970 is at the rate of 6.24 per 1,000 living, compared with the figure of 3.05 for England and Wales. The figures of incidence per 1,000 children under 15 is 13.7 compared with 12.2 for the country as a whole which is only about 1.1 times as much. Of the primary cases, 351 occurred in Estate houses and 63 in other houses, the comparative incidence in these latter being therefore somewhat heavier. Owing to lack of accommodation, about two thirds of the total number of Scar let Fever patients bad to remain at home during the entire course of the illness The following table shows the numbers of home and hospital treated in each month. Treated at home. Removed to Hospital. Started at home Admitted later. January 28 5 — February 10 11 1 March 22 5 4 April 9 12 5 May 24 14 1 June 14 19 - July 11 11 — August 11 21 - September 27 19 2 October 56 17 3 November 64 7 4 December 41 9 — 317 150 20 Beds were more or less free in February, though not all cases desiring admission were removed. In April beds were free, more particularly as patients were admitted to the hospitals of other Authorities. This state continued until September. By October, however, cases were being admitted only exceptionally and primarily on clinical grounds. In addition 7 cases diagnosed as Out-Patients at the London hospitals were removed to the M,A.B. Isolation Hospitals. It will be noticed that at [the time beds were free approximately half of the patients were admitted; but in the last three months, approximately only one in six was remove 40 The causcs of admission were:— 1. Clinical grounds. Severity of attack 3 1 Severe throat involvement 5 1 Other complications 7 6 Other concuirent illness necessitating hospital treatment 7 1 22 9 2. Difficulty in nursing. Adult patients 10 2 Absolute poverty in the home 11 1 Illness, etc., of mother, including pending confinement 22 4 43 7 3. Wage earner would be excluded 22 3 4. Crowded homes with much risk of spread of infection 57 1 5. No reason 11 — 155 20 The column on the right is the apportionment of those who commenced home treatment but were subsequently admitted In a few cases more than one cause being present fluencecl admission. The casus who began treatment at home and were later admitted were almost always eases for whom admission was desirable at the out set but beds were available. In five cases only were these admissions of patients who developed compliations under home treatment. To alleviate the hardships arising from the retention of Scarlet Fever patients at home, an attempt was 'made to obtain temporary accommodation in local buildings, either for the direct admission of mild cases or for the transference of convalescent patients from the Isolation Hospital. Nothing, however could be achieved in this direction. 41 Home treated cases. The same practice was continued of supervising these cases by the Health Visitors up to the '6th week. Disinfection was carried out shortly after 23th day in most cases. In the latter part of the year a scheme of assistance by Home Helps was brought into operation, working under section 67 of the Public Health Act Amendment Act, 1907. These were women from homes in which there were no susceptible children, and were made use of particularly in those cases where the mother herself succumbed to infection. The following table gives a list of the complications occurring amongst those cases who were 'treated at home throughout the course of their illness. Certified Adenitis 7 per cent. Commonest late in the second or early in third week, with an average duration of 10-14 days. Rheumatic Pains, 4 per cent. Commonest in the second week, mostly of only a few days duration; Otorrhoea, 2.2 per cent. Commonest in the first week. Rhinorrhoea, 1.6 per cent. Three cases of tonsillitis occurrcd about the 21st day from the onset. Temporary cardiac and renal involvement was reported in five eases. All these .cases, however, apparently made a complete recovery. In addition to these cases were the five who were admitted owing to complications. 1. Developed signs of mastoid. Removed on 10th day 2. Nephritis and otorrhoea. These complications were present at the time the patient was first diagnosed, in his third week of illness. 3. Admitted in fourth week on account of severe tism. 4. Admitted in fourth week with tonsillitis. 5.. Admitted in third week owing to cervical adenitis and ? nephritis. Secondary Infection. Out of the 317 primary cases treated entirely at home. 38 gave rise to 52 secondary cases, 2|8 giving rise to one, 9 to 2 and 2 to 3. Ample accommodation, permitting of the removal of the primary case, would have prevented the onset 42 lot 17 of the secondary cases, but w|ould not have saved 25. Of Ithese latter the secondary case was infected before the primary |v.is diagnosed in 16 instances. In 7, the primary ease was Imissed and there were two eases of apparently simultaneous lonset. I In a number of cases it is doubtful whether removal ot ■tie primai y would have been effective in preventing the onset ■of the secondary, these being particularly cases in which the PW of the secondary occurred some 3 to 8 days after tha I'M of the primary, but only som,ri 2 to 4 days after the date V recognition of the primary as a case. I Of the 17 preventable eases 5 were of adults nursing the Children. The onset of the secondary infection occurred any time up ■° the 28th day. There appeared to be no particular time ■rom the onset of the first to,'the time the secondary succumbed ■wee weeks being slightly the commonest interval. ■^Luru Cases. I. E«ht cases occurred within 10 days after the disinfection 'he premises and the patient allowed his liberty. Another ■furred on the 49th day from the onset of the primary case ■ °> at that time, was suffering from otorrhoea. I Taking these and the secondary cases together, it is noB'c that the cases occurred at the following times from the |;dsc! °' the primary infecting case—within 1 Vreek 4; 2 weeks 3; B 3. 4th 2; 5th 2; 7th 4. Realising that the isolation in many Erf °' t'1° most perfunctory nature, particularly after the ■ ew days, these figures suggest that it is only in a few » es that patients suffering from Scarlet Fever are infectious ■cof"? °' time -but that in these few, infectivity may •at ^ration. ,In the case of the others, it seems probable ■J! ^ctivity is limited Wol a very short period and that Segre|s°" w l'lc short time of the acu'te attack would probably ■j . ;,ent ® the average case. The assumption of absence of Kj Ult- after the first few days would explain why there is BveraB-Case C'lc Parentage of return cases on shortening the ■Srha ^orioc' °f stay, the absence of return cases in caScs ■'un/ i ear|y ^rorn hospital after treatment with specific fcent t'1e a^se|tcc of return cases following the freeing of Kc J ^eated by such methods as the Milne treatment, UOus relative commonness of return cases would 43 no doubl be due to the failure to recognise the importance of rhinorrhoca as a |factor in the spread of disease and treatment under conditions of less satisfactory ventilation would cause a greater number of such cases. In six cases where a patient was treated at home, apart from the secondary cases of the disease, the mother, within the first few days of the onset, suffered from a sore throat or tonsillitis. but apparently with no rash or subsequent peeling. These would presumably be cases of anti-toxic immunity without bactericidal resistance. One patient suffered from two attacks within a short space of time: On April 3rd this boy, aged 3, suffered from a typical attack. On the 16th October his sister, the only other child in the house, suffered from Scarlet Fever and secondarily infected him on the 19th, This attack was typical in its acute stage and subsequent desquamation.^ For the first three weeks of illness the patient suffered from marked rhinorrhoea. Hospital Treated Cases. Of the cases admitted to hospital, 10, on returning home, gave rise to 12 return cases. A large number of the infecting patients were found to have rhinorrhoca, with a history of a normal nose on discharge from hospital, but the patient subsequently developed a head cold. The onset of the Return Case from the time of discharge of the infecting patient was unddr 5 days in 5 cases, under 9 days in 9; the remaining intervals were 13. 17 and 27 days. In two' instances the Return Case was the mother of. the child. The infecting patient was discharged from hospital after a stay of 28 days in two cases, 3 were discharged in the 5th week, 2 in the 7th, and 2 in the 8th week, whilst one had been in 13 weeks. In none of these cases had the infecting patient given rise to a secondary case of infection before removal to hospital, although, in only 3 oases, was the patient removed as early even as the 2nd day after the onset; Further, from the length of time of retention in hospital, it is obvious that some complication was present in most of the patienit's, leading to their detention. 44 Blic report of the Medical Superintendent of the Isolation, iosltal gives the following figures relating to the Scarlet Fever patients:— ^fcdmissions—233, of which 155 were Dagenham patients, ^ftverage stay in hospital—47 days. ^Complications—Rhinitis 23<y0. Otitis Media 7ft<>. Mastoid disease 5®/o. > ^■hese figures indicate the extraordinary difficulty under the hospital has been running for the past year. Owing clinical condition of the patient, or home circumstances, Hhjn' been admitted to hospital in excess of the normaj ^Hmodation. This overcrowding has led to an increased ^Hcn<< of rhinitis, etc,, which in its turn prevented the hi the patient within the usual period of Itime and ^Hs<'d the turnover of each bed. A number of these ^H's no doubt, while free from any rhinorrhoca on disH developed it again at home and caused the Return Mrven out of the 10 infecting patients were discharged f the three months October to December—that is. just at ^wriod of time that the accommodation would be most CVfr|y strained. ^■hat this high complication rate is due to overcrowding ISfgcsted when a comparison is made with those ca.s,esi Hd at home—when it is realised that a total of only 31 out 175 were admitted on clinical grounds, the remainder ^Bsent in on account of home circumstances, and so would ^■nparable clinically. 26,7 ,i child succumbed to Scarlet Fever and was ^^fed on 29 7, He was discharged on 23/8 but was iv.- [ Ie(l the same day suffering from a relapse and was sub'- rHitly discharged on 28/9. Nfriison of Home and Hospital Treatment. assessing the advantage of removal of patients to fj" 'n preventing spread of infection, it is nccessary ^V,se that even with ample accommodation at the hospital number of secondary cases will occur owing to infodMccurring before the primary case is recognised. These l!"11 also occur when the patient is to be treat,ed ht ^Ba'id consequently these figures must be deducted from ^Per se;ondary cases which have occurred later and which 8nl detmitcly be assumed to have been preventable. 45 The following comparison of hospital and home treatment is made therefore by considering, on the one hand, only return cases to hospital treated eases, and on the other those cases which occurred within a month of the freeing of the primary patient and those secondary cases which might have been prevented had the primary case been removed. Ten hospital treated infecting patients on their discharge gave rise to 12 return cases. This was in a (total of 145 infected houses, in which, apart from the patients, there were 330 adults and 325 children under 15. In the case of the home-treated primary cases, there were 16 preventable secondary cases and 9 cases infected after the freeing 'of the primary case. This occurred in a total of 246 houses, in which there were 562 adults and 394 children under 15. Deaths. Four deaths were ascribed to Scarlet Fever. In two of them pneumonia was given as the primary cause of death. In another, following car trouble which developed four months after the attack, tonsillectomy was performed four months later and was followed by a mastoid., In the other case the patient died from mastoid complications. Dick Test. No children were submitted to the Dick Test. Schools. No Public Elementary Schools were closed during the year for Scarlet Fever. Enteric Fever. There were 6 notifications for Enteric Fever received in the course of the year, 2 cases proving fatal. Three cases were para-typhoid Fever occurring in the same family. A girl of 9, suffering from Scarlet Fever, was admitted to hospital on the 6th day, together with her sister, aged 3, who had been Secondarily infected. When- the temperature had fallen and the cases apparently doing well, diarrhoea started, the temperature rose again and spots subsequent!) appeared. The Widal reaction was positive. On enquiry at the home, a brother, aged 11, was found suffering from diarrhoea and spots; the remaining 5 members of the family were apparently well. 46 Erysipelas. 21 cases of Erysipelas were notified, 15 male and 6 female, of whom 8 were admitted to hospital 40 per cent of the cases occurred in persons aged over 40. The face was affectcd in 70 per centy of the cases. 60 per cent occurred in the last three months of the year. Cerebro-Spinal Meningitis. Two cases of Cerebro-Spinal Meningitis were notified. There were two deaths, one of a girl aged four, in April, aud one of a (boy of 18 months, in March.; Poliomyelitis. No notifications of Poliomyelitis were received, but one of Polioencephalitis. This was a boy aged four and proved fatal after an illness of 10 days' duration. Encephalitis Lethargica. One notification was received of a man aged 31, who, after an acute illness commencing with a period of unconsciousness of 20 hours, subsequently made an apparently complete recovery .One death from this cause was registered of a man whose onset was in 1919 and who for years had been receiving nstitutional treatment. Smallpox. No cases of Small Pox were notified in this district until the last month of the year, when three notifications were received. The first case was an unvaccinatcd adult, aged 19, who was one of a number of cases who contracted the di- sease at his workplace in one of the Metropolitan Boroughs. The patient was at home four days before removal, spending the days in the living room with four members of the family!, and the nights in a bedroom with four others. Although only one out of the remaining 9 members had been vaccinated, only one secondary case occurred—namely, a brother with whom he slept the lack of infectivity was in marked contrast to that exhibited at the works, where some 15 succumbeds the third case was an unvaccinatcd adult woman, in the case of whome the source of infection could not be traced. All three cases were mild and made an uninterrupted recoveryin hospital. .A total of 1,033 visits were paid to the homes of Smallpox contacts by the Sanitary Inspectors. Visiting is continued 19th day from last exposure to infection. Chickenpox was for three months in 1928 added to the list of hotifiablei 47 diseases. This procedure has not been repeated as little advantage accrues unless there is a sufficient skilled stall' for all cases to be visited. Very few notifications were received from parents in cases where a doctor was not in attendance, and information is ordinarily received from the schoo's without notification. The following table shows the position of vaccination for last year. 1. Successfully vaccinated 353 2. Insusceptible 2 3. Conscientious Objectors 930 4. Died after Vaccination Nil 5. Postponed by Medical Certificate 36 6. Removed 171 7. Unaccounted for at present 641 The following two cases were suspected of being cases of Post-vaccinal Encephalitis. 1. Female aged 15; on 22/4 vaccinated but did not take; 26/4 vaccinated successfully; 29/4 suffering from headache, attended work to 1/5; 2/5 periods of blankness, progressive sleepiness, not taking food, falls to sleep while feeding; 6/5 very sleepy, wakes if roused; 7/5 irritable, restive, sleepy, pulse 52. No history of sore throat, coryza, etc., scab on site of vaccination, bowels open with medicine, no incontinence, taking little, urine output small, fauces normal. Eyes ? divergeat squint, knee-jerks brisk, plantar reflex. Removed to hospital. 8/5, improving; on 10/5 threatened to jump out of window." The patient was in bed for three day then allowed up and subsequently returned home at parents request. Later it appeared she remembered nothing' except being brought back in the ambulance.The diagnosis of dementia prascox was made at the hospital. 2. Male aged 53; vaccinated in infancy; on 13/5 revaccinal ed, normal take; 26/5 he suddenly dropped a panel from the right hand; 29/5 suffering from mental confusion, mind clear about some things but amnesia for other temperature 102, pulse 120, abdominal reflexes absent, right knee-jerk increased, plantar rellexes right extensor, left flexor; sensation normal, eyes react nor mally, tongue and face normal; suffering from headache but no vomiting; 30/5 mentally more blurred confusion most marked for period subsequent to vaccination; 1/6 right side monoplegic: conscious: aphasic: incontinence of faeces. Admitted to hospital. 15/6, died following two days of seizures. Post-mortem examination. cerebral haemorrhage following cercbral thrombosis. Anthrax and Plague. There were no cases ot Anthrax and Plague in this district. Tuberculosis. New Cases. (Forms A & B). Transfers into District. Deaths. Pulmonary. Nonpulinonary. Pulmonary. Nonpulmonary. Pulmonary. Nonpulmonary. M F M F M F M F M F M F - 1 1 - - - _ - _ 1 2 l — - 7 9. - 2 2 1 1 — 2 4 5 2 2 7 5 2 9 5 1 - 1 2 2 10 — 92 9. 3 - 7 2 9. 1 _ 1 15 4 8 2 1 1 9 1 5 - - - 20 5 6 - 8 9 - 2 5 6 - - 25 8 15 1 9 15 2 1 8 13 1 1 35 14 10 1 - 4 6 — 1 15 11 - - 45 8 - - 4 1 — - 5 2 - - 55 — 1 - - 1 - - 1 - - 65& UPWARDS 1 - 1 - - 1 - - - - - - 42 44 19 13 29 45 11 9 38 35 6 10 48 49 The number of primary notifications of Pulmonary Tuberculosis were 42 males and 44 females, as compared with 21 and 33 for last year, This increase is roughly in proportion to the increase in population. There was a marked diminution in the number of nonpulmonary cases which were only 32 compared with 51 for 1928. As mentioned before, this previously existing large number was in excess of the rate obtaining in the countrv and was probably due to transference of large numbers of children who, while not notifiable before transference, exhibited definite signs of tuberculosis after a period of residence here. The number of cases transferring into the district suffering from Pulmonary diseases was 74 compared with 76 for 1928; and from Non-pulmonary 20 as compared with 15. Deaths. The 61 Pulmonary deaths are divisible into those occurring amongst: — (a) Old residents of Dagenham 11 (b) Those who transferred here free from disease 15 Of these the onset of one was within 6 months of residence herej, 6 had been here 1 to 2 years and 5, 2-3 years; while three had lived here over 3 years before becoming ill. Six died within 6 months of onset, 4 in the second 6 months and a total of 14 before the end of the second year (c) Those who transferred here suffering from the disease 25 10 died within a year of transferring here, 7 of these occurring within 6 months, 8 died in their second year of residence and 5 in the third. Notifications of the fatal Pulmonary Cases. Number not on register at death 5 Number been on register over 12 months 28 Number on register within 12 months (of which 19 were under 3 months, and 11 under 4 weeks) 28 Of the non-pulmonary cases, tubercular meningitis was the responsible cause for 9 deaths, 7 being of children under 6. Miliary tuberculosis caused one death and an operation for removal of cervical glands another. No deaths were registered as due to tuberculosis peritonitis. Sputum Analysis. 362 samples of sputa were submitted for analysis during the year at the Essex County Public Health Laboratories. Public Health Act, 1925, S. 62. i No action was taken during the year for compulsory removal to hospital of any infectious Tuberculous person. Tuberculosis After-Care Association. On 23/2/29, a meeting was held regarding the formation of a local Tuberculosis After-Care Association. This association held its first meeting on 14/6/29 and has met monthly since. Much work has been done: grants given to necessitous cases, and assistance given in obtaining suitable employment, etc. 50 51 MATERNITY AND CHILD WELFARE. Notification of Births. 2,049 notifications of live births were received during the year (male 1,044, females 1,005). 409 notifications (including still births) were received from medical practitioners and parents, and 1695 front midwives. In addition, information was received of 166 births outside this area. The following list shows where most of these births occurred: — Oldchurch Hospital 58 Queen Mary's Hospital, Stratford 11 East End Maternity Hospital 7 Ilarford Maternity Home 2 Barking Maternity Home 9 Plaistow Maternity Hospital 17 City of London Maternity Home 15 Royal Free Hospital 4 St. Thomas's Hospital 4 St. Bartholomew's Hospital 4 Charing Cross Hospital 2 Still Births. 55 still births were notified (34 male, 21 female), the corresponding figures for registration being 76, 49 and 27 The rate per 1,000 of total population was 0.68. 1 he following tablec analyses the causes of these: — 1. Maternal Causes.—17. Placenta Pra-via, 2; Heart, 2; Shock. 2; Syphilis. 1; Hyperemesis. 1: Albuminuria, 4; Falls. 3; Influenza. 2. 52 2. Difficulties in Labour.—17. Abnormal Presentation,1; Breech Delivery, 4; Complications of Labour, 12. 3. Foetal Causes.—8. Anencephaly, 3; Dead Foetus, 5. 4. Other Causes, 7. Infant Mortality. 157 deaths (95 male, 62 female) of infants under one year of age occurred, being an infant mortality rate of 67.7 compared 74 for the country as a whole and 73.1 for last year. The rate amongst legitimate children is 64.5 and illegitimate 270. The following table analyses the causes of death occurring in the first three months: — Disease. Under 1 day. 1-7 days. 1 week1 month. 1-3 months. M M F M F M F Prematurity 8 3 3 4 2 4 1 — Deficient Inherent Vitality 3 0 1 2 0 1 — — Atelectasis — — — — — — — — Debility — — — — — — — — Congenital Heart 4 1 1 1 2 0 1 0 Congenital -Defects 0 0 0 2 0 1 1 0 Asphyxia 2 — — — — — — Cerebral Haemorrhage 1 — 1 — 1 — — — Pneumonia and Bronchitis — — — — 3 1 5 2 Pemphigus — — — — 8 — — — Pyloric-stenosis — — — — — 1 2 — Enteritis — — — — — — 4 1 Infections — — — — — — — 2 Convulsions — — — 1 — — — — 18 4 6 10 16 8 14 5 . The Neo-natal deaths, that is, those occuring within the first month, make a total of 62 (males 40, females 22) providing 7 themselves an infant mortality rate of 25 or 40% of the total Want mortality rate. 25 deaths (14 male, 11 females), occurring in the tirst three months were ascribed to prematurity, of which 18 occurred within the first few days after birth. Of these a number were definitely due to the immature condition of the infant at the time of birth not permitting of its adaptation to its new 53 environment. In most cases there was apparently no reason for the premature onset of labour. In two cases the birth was. intentionally brought on prematurely on account of the small pelvic measurements of the mother. In 5 instances the infant was one of twins. In one case the onset was apparently clue to shock and in another to some maternal uterine abnormality Until more is known of the causation of the on set of normal labour after a certain period of gestation, the cause of most premature labours will remain unrecognised. Until that time most of these deaths cannot be classified as preventable. Seven deaths were classified as deficient inherent vitality, atelectasis or debility. In three cases (one a twin) the infant although full time, was much under weight. These cases, too, represent a failure of adaptation to new surroundings. Congenital heart was the cause of death in 10 instances (8 male and 2 female) and other congenital abnormalities in four (1 male, 3 female). Doubtless some of these occurring shortly after birth and asc ribed to congenital heart should be classified in the previous group. As a cause of death, its effect remains apparent for the rest of the year as, amongst infants dying from 3-12 months of age, there were two deaths from this cause. This group must remain amongst those causes of death which are not preventable. Birth injuries, in which are included those deaths from asphyxia and from cerebral hæmorrhage. caused 5 deaths all of male infants. In two instances the baby was born before the arrival of the attendant. In the other three cases, labour was difficult, necessitating the application of forceps for delivery This type of case is largely preventable by ante-natal supervision of the mother. Bronchitis and Pneumonia caused, within one month of bith 4 deaths, and within three months, a total of 11 (8 males, 3 females). Of the earlier ones 2 were of children who had never been well and represent probably a mode of dying of a feeble infant. The others, however, appeared to be definite infections, in some cases there being an acute onset, in others a progression of disease from an original nasopharyngeal infection. There is still a lamentable lack of appreciation of the infectiousness of the common cold and of its possible serious consequences where occurring in an infant. None of the deaths within one month of age were ascribed to enteritis or the infections, which, however, both begin show their effect in the next month. The remaining important group is pemphigus which the death of 8 male infants of ages between one week and one month. 54 Deaths of older children: — Disease. 3-6 months. 6-12 months. 1-2 years. 2-3 years. 3-4 years. 4-5 years. M F M F M F M M M r M F Developmnetal Congenital Heart 1 — 1 — — 1 — — — — — — Congenital cephalus 1 — 1 — 1 — — — — — — — Infections. hooping Cough ... 1 1 3 4 7 4 — 3 — 2 1 — Measles — — — — 3 9 2 1 — — — — Diphtheria — — — — 1 1 — — 2 — 2 1 Chest Conditions . 5 1 9 8 8 6 5 5 1 2 2 1 1 Tberculosis... — 1 — 1 2 — 1 — — 1 — — Meningococcal Meningitis — — — — 1 — — — — — — 1 Gastro-enteritis 5 6 9 10 1 2 — — — — — — Accidents — — — — — — 1 2 — 1 — 3 — Various 1 — 3 2 — — 2 — 3 1 1 — 14 9 27 25 24 18 12 9 9 6 8 3 This table shows the diminishing importance of developmental conditions in the causation of deaths of infants with advancing age, and the relatively greater damage done by the infections. Gastro-enteritis, which did not figure as a cause of death under one month, appeared within the next two months and is very marked up to the age of 12 months. After this, it had little effect and caused no deaths amongst those over the age of 2. Of the total number of deaths from this cause 50 per cent. occurred in the two months September and Octoher The onset of these would be associated with the hot weather occurring during September, in which month diarrhœa amongs infants was very common. This hot period was ac- companied by an excessive prevalence of flics. The change to the older weather early in October led to the cessation of the enteritis and of the prevalence of flies. Practically all these fatal cases were of children who, although mostly under nine months old, were artificially fed. Of the 5 cases occurring on the last two months of the year, 5 were attributable to measles from which the children had suffered in November. Pulmonary Diseases caused a large number of deaths (23) in the last 9 months of the first year, 14 in the second 55 year, 10 in the third and 4 in the fourth. Of these, 65 per cent. occurred in the two months February and March. Whooping Cough prevailed in the district in the first three months of the year, 70 per cent, of the deaths occurring in the four months February to May. Measles accounted for 8 deaths in the year, 5 of children of one year and 3 of two: All the deaths occurred in the two months November and December. The disease was first markedly apparent in the first week in November in the southern part of the district. It then spread northwards, reaching the northern part of ;the Estate in the second week in December. After this, its course apparently was retraced so that in the middle of January of this year it had returned to the central portion of the Estate. Non-Pulmonary Tuberculosis accounted for two deaths under one year of age, and another four under four years. Four cases were of meningitis, one of miliary tuberculosis, and one death followed operative removal of cervical glands. Ophthalmia Neonatorum. Notified. Treated at Home. Treated in Hospital. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. 26 24 2 26 — — — Twenty-six cases of Ophthalmia were notified in the course of the year. In addition, in another 97 cases, a copy of the medical aid notice sent by a midwife on account of abnormalities of the eyes of an infant was received from the County Medical Officer of Health. These cases are all visited by the Health Visitors and a copy of the report sent to the County Medical Officer of Health. For home treatment of these eye cases, the Council has an arrangement with the local District Nursing Association for a nurse to attend, the Council paying the fees where the income is below scale. Severe cases are admitted to St. Margaret's Hospital . Hampstead, at a cost of 10/- per head per day. An endeavour is always made to induce the mother to enter the hospital with the infant. The cost of this inpatient treatment and the ambulance charges arc borne by the Local Authority. 56 The great majority of these cases were very slight infecions, resulting in some stickiness of the lids. One quarter were cleared within the first week and three quarters within two veeks. All cases recovered with no impairment of vision. Three cases, with their mothers, were admitted to St. Margaret's Hospital, being there a total of 86 days at a cost of £43. Pemphigus. Towards the end of 1928 a number of cases of Pemphigus Neonatorum occurred, scattered round the district. These foreshadowed the outbreak which appeared in the first 4 months of this year, when 36 eases occurred with 7 deaths. After a period of three months' absence it again appeared, 28 cases occurring in the remaining 5 months of the year, one proving fatal. From 13/5/29 the disease was 'made notifiable for a period of three months. At the expiration of this period it was continued for another three months, since when Pemphigus has been added to the permanent list of Notifiable Diseases. For home treatment, the Council has arranged for a special nurse from the local branch of the District- Nursing Association to undertake the dressings. Severe tases are admitted, with the mother if possible, under the Council's scheme,' to Oldchurch Hospital. Under these combined arrangements three patients were treated during the year at a total cost of £6 3s. 6d. The onset in 70 per cent. of the cases occurred between the 4th and 12th days. The cord was apparently normal in one-half of the cases. In about one-third of the cases the lesion first; started on the abdomen, frequently near the umbilicus. In almost another one-third the lesion first appeared on the inner Part ot the thighs, the groins or genitals. In two of the cases with a delayed onset, there was a granuloma at the umbilicus, which, however, appeared normal in the remaining four eases. In four instances there was impetigo present in the house, and two other patients had been' circumcised. One case started on ithe face near the site of an. injury due to forceps application. Apart from these cases there was no apparent causative condition. 57 Clinically there appeared to be two types—the mild, in which the vesicles, though multiple, definitely tended lo heal after reaching a certain size and terminating in the recovery of the patient. The severe type was either *one in which the vesicles grew to large bullæ, which, or rupturing, denuded large areas of surface; or an exfoliative condition in which the course seemed too rapid to allow time for the formation of vesicles. The infection seemed to spread beneath the skin, leading to exfoliation of extensive areas. Nothing in the severe type appeared to bd of any avail in' preventing a fatal termination. In the course of the year, pemphigus appeared in the practice of 17 midwives, though only once in the course of 10 of them and twice in another four. One case occurred in the practice of three separate doctors. One midwife had a tota of 14 cases, one 10 and a third 8. A frequent occurrence was the association of two cases in the practice of a midwife, one case appearing and followed after an interval of a few days by another case. The frequence of this occurrence, seemed to preclude its having been due to mere chance and suggests that the second baby was already infected before the appearance of the eruption in the first. This would suggest that the first child was infectious before the onset (of the eruption, with the possibility of a period of incubation in the second case. This would bring the disease into line with the systemic infections. The facts known with regard to pemphigus are—in its spread a definite association with the prartice on one person; its frequent association with a dirty umbilicus or some other injury; and also with cases of impetigo. Organisms found in the vesicles are not necessarily the causative agents, being in some cases possibly secondary invaders. Although there the association with a person, the means of communication of the disease are unknown, The fact that ordinary means, which are effective in preventing the spread of other infections, are ineffective in this suggests the possibility of infection by carrier The facts can be explained on the assumption that pemphigus is a systemic infection occurring in infants by droplet or air born infection. Its association with impetigo would be that the organism causing this is, either always or frequently one capable of causing infection. Its association with a dirty umbilicus would be either that this lesion forms the source of supply of infecting organisms, or at other limes the unhealthy umbilicus leads to a local lack of tissue resistance. The eruption then starts at this place or at some other with weakened resistance—for instance, through mechanical injury 58 Maternal Mortality. The number of deaths registered as due to puerperal sepsis was 7 and due to other accidents and diseases of pregnancy and parturition one; giving a maternal mortality rate of 3.45. All the fatal cases of puerperal sepsis were admitted to an institution for treatment. Two of them were cases of septicaemia following an abortion. Two other eases followed apparently normal deliveries. In the case of another patient delivery of the child was normal, but manual removal of an adherent placenta as necessitated. The sixth septic case was a patient delivered, eforc the arrival of the attendant and suffered from postpartum haemorrhage. The remaining case required operative interference for the delivery'of a breech with extended legs. Two maternal deaths occurred in the course of the year forn causcs other than sepsis. One died of shock while under anæthetic administered for a forceps delivery; 'the other was due to shock and haemorrhage due to an adherent placenta. Investigations into maternal mortality due ,to pregnancy and child birth, as suggested by the Maternal Mortality Committee the Ministry of Health, are carried out by the Medical Officer of Health. Puerperal Fever and Pyrexia. Of the 8 notified cases of puerperal fever, two proved fatal. One was treated entirely at home, one was a patient delivered in hospital and a third was removed to the Isolation Hospital suffering from Puerperal Scarlet Fever. The remainder were admitted to Institutions for treatment. Two cases followed a miscarriage of two to three months; two instances were subsequent to operative interference, namely manual removal of the placenta, transverse lie and twins. Two cases followed apparently normal labours. In the case of puerperal Scarlet Fever, the first sign was a rash appearing on the lower part of abdomen on the 4th day. This apparently disappeared but was followed two days later by an crythema on the lower part of the chest. There was no sore throat and the tongue was only slightly furred. Desquamation subsquently occurred. 59 Of the 11 cases of puerperal fever, 6 were treated at home and 5 admitted to institutions; two proved fatal. In one case the labour was normal; another was apparently due to infection of a perineal tear, caused by precipitate labour. In 7 cases forceps were applied and in one an adherent placenta removed. The arrangements for the treatment of puerperal cases consists of removal to Oldchurch Hospital for severe casei Mild cases are treated at home by an arrangement with the District Nursing Association. Work of the Health Visitors. Routine visits arc paid to infants as soon as possible after the tenth day, and special visits arc paid respecting cases of Ophthalmia Neonatorum, Puerperal Fever, following up operations for Tonsils and Adenoids, etc. During the year the Health Visitors paid the following visits:— First visit to children under one year 3,373 Subsequent visits to these children 1,645 First visits to children 1 to 5 514 Subsequent visits to children 1 to 5 922 Visits to expectant mothers 514 Work at the Clinics. Infant Welfare Centres:— Total number of sessions held 326 Total attendances of children over 1 year 6,685 Total attendances of children under 1 year 13,265 Average attendance of children per session 61 Number of individual children 2,002 Ante-natal Clinics:— Total number of sessions held 130 Total attendances of mothers 1,510 Average attendance per session 12 Number of first attendances 596 60 Infant Welfare Centres. The number of weekly Infant Welfare Centres at the end of the year was 7 compared With 6 at the beginning. All the cntres are maintained by the Local Authority, there being at ach, in addition to the Medical Officer and two Health Visitors, clerk dealing with distribution of food stuffs. At a number of centres the assistance has been obtained of ladies from the local detachment of the St. John's Ambulance Brigade. I hese helpers arc of great assistance towards the efficient running of the clinic. More help, however, is required, particularly as in the new clinic buildings a separate room has been! provided for toddlers Treatment. Tonsils and Adenoids. The following hospitals have agreed to treat cases of tonsils and adenoids referred to them. Queen Mary's Hospital, Out-patients only, 11s. per head. Oldchurch Hospital, In-patient only, 22s. for 4 days. King George Hospital, Out-patient, 11s. per head. King George Hospital, In-patient, 21s. per head. In respect of patients who are included in the Hospital Savings Association scheme, a contribution of 3s. 6d. per head is received. During the year 13 cases were treated under these arrangements is at a total cost of £6 12s. 6d. Orthopædic Treatment- The Essex Education Committee have arranged for an) orthopædic school children to be interviewed by the consultant orthopædic surgeon, Mr. Whitchurch Howell, who for this purpose visits this district about four times a year. Since October children of under school age have been referred to these clinics. The cost to the Council is the proportionate cost of these pre-school to the total attendances. Under this arrangement 9 children made a (total of 14 visits at a cost of £116s lOd. 61 The cases in detail are:— Condition. Treatment Advised. Result. R.C. Talipes Wedges Still under treatment at end of year J.B. Bowed Tibia; Splints „ „ „ M.J. Hemiplegia Wedges and after care „ „ „ J.N. Poliomyelitis Alteration of Calliper „ „ „ E.B. Bowed Tibiæ Osteoclasis „ „ „ M.M. Cartilage Wedges „ „ „ A.L. Bowed Tibiæ Osteoclasis „ „ „ A.B, Genu Valgum Wedges „ „ „ AC. Achondroplasia No treatment required „ „ „ Arrangements have also been made with the Esses Education Committee by which children under school age requiring massage and remedial exercises can be dealt with at the Romford After-Care Centre. The cost is 2s per head per treatment. One child received 16 treatments at a cost of£1 12s. One child was supplied with a>splint -at a cost of 10s. 6d, Institutional treatment of orthopaedic cases is now obtained at the Royal National Orthopaedic Hospital at a cost of £2 per week or at Cheyne Hospital for 35s. per week. Two children were admitted to Stanmore for a total of 34 weeks at a cost of £70 11s. These children were still in hospital at the end of the year. Ante-natal Clinic. At the end of last year there was one weekly ante-natal clinic held in the Dagenham and in the Becontree wards. additional Ante-natal Clinics were opened in the Dngenham ward in the course of the year. In July the Consultant Gynaecologist, Dr. H. G. Everard Williams, commenced his attendances—monthly to start with but in October fortnightly. The same arrangement continued in operation with regard to the institutional treatment, namely admission to Oldchurch Hospital or Queen Mary's Hospital, Stratford. Two patients were admitted, at a cost of £13 3s. 6d. 62 Fifty-five per cent. of the cases were referred to the clinic by the local midwives, two-thirds of these being sent by the nurses of the District Nursing Association or the Salvation Army Curses. The practice of individual midwives varies greatly in the use they make of the clinic, some referring very lew cases'. Twenty per cent. of the cases attend on the recommendation of a previous patient. Another 20 per cent. attended on the commendation of a Health Visitor or through having seen an advertisement or having themselves attended previously. The total number of new leases attending the clinic was 596, being 25 per cent. of the total number of births registered in the district. Of these cases, 471 had normal confinements with living children, compared with 57 with some abnormality. These, include some 20 pregnant women referred to hospital. Seven cases were admitted to hospital for induction, mostly on account of small or flat pelvis, and two for cæsarian section. Two had lysterectomy performed and two other cardiac cases had normal habours after a period of stay in hospital; as had one case each of raised blood pressure and hydramnios. Three other cases were admitted for conditions associated with pregnancy. Amongst those who attended the ante-natal clinic 6 gave rise to premature births, of which 3 died; another 14 were delivered of stillbirths. Malpresentation occurrcd in three eases while forceps were applied in another 12. In two instances manual removal of an adherent placenta was necessitated. Full benefits of ante-natal attendances cannot be obtained until the patients have realised its importance. 207 cases paid only one visit. No doubt a large number of these are cases referred by the midwives or who came for the comfort of knowing no abnormality is present at the time—but this condition of affairs is not satisfactory when it is realised that fully one-half of these single attendances are made before the completion of the 6th month of pregnancy. Another onequarter paid only two visits. The commonest date of the first attendance was the 6th month when, some 20 per cent. first attended—closely followed by the 7th month. About 15 per cent, paid their first visit in the 5th month and the same in the 8th. 41 persons attended in whoom the diagnosis of pregnancy was not made. 23 attended for post-natal examination, of whom 10 were referred either to their own doctor or to hospital for treatment. In almost one-third of the cases teeth were good; rather less were in need of slight treatment, while tin more than onethird the dental condition was sufficient to cause impairment of health 03 Consultant Clinic. Thirty-four patients paid 38 visits. Most of these were patients attending the ordinary ante-natal clinics though a small number were referred direct by the medical practitioner. There cardiac cases were admitted for induction and tliree were under observation at the end of the year, two having been referred to hospital for X-ray. Seven cases of contracted or flat pelvis were referred to hospital for confinement, one at home and four were still under observation. One case was admitted to hospital for hyper-emesis, and one for raised blood pressure. Twelve eases were referred to hospital for confinement, and1 another live for further examination or for treatment. Foster Children. There were 94 additions to the register of Foster children and 53 erasures due to children reaching the age of 7, dying or removing from the district. Maternity Homes. There arc no Nursing or Maternity Homes in the district, Assisted Milk Schemes. The expenditure incurred by the Council under the Assisted Milk Scheme during the. year was For ordinary milk £577 10 0 For dried milk £140 17 5 Education. 2,000 copies of Better Health," are distributed monthly from the various clinics. In addition a number of educational pamphlets have been prepared and are handed out individuallyThe Medical Officer of Health has given a number of lectures and talks during the year to various guilds and leagues. It has not been possible to have educational talks at the owing to the large attendances and the unsuitability of the premises for this purpose. With the help of voluntary workersfull use can be made; of the toddlers rooms at the new clinics which should result in conditions far more favourable to lecturing.