DAG 4 The Urban District Council of Dagenham 1926 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1930 E. W. CARYL THOMAS, M.D., B.Sc., D.P.H, HARRISTER-AT-l.AW. 914.2671 48880 AP 32 Cantrol 3 MEMBERS OF THE COUNCIL. Councillor H. C. PARRY, J.P., Chairman. (Mrs.) M. ROTH WELL, Vice-Chairman. P. G. ASIITON A. E. BALE A. F. CIIORLEY C. DELLOW, C.C. H. C. DYER W. F. FRANKS W. GRAY II. R. HILL J. B. HILTON F. J. HUDSON W. H. LANGLOIS W. C. MARKIIAM W. II. MELTON A. II. OLIVE S. G. PHILLIPS (Mrs.) S. A. PHILLIPS J. A. PRESTON A. ROGERS G. B. SMITH (Mrs.) L. TOWNSEN1) Chairman of I'ublic Health anil and Child Welfare Committees. J. W. II. TYLER 5 OFFICERS of the PUBLIC HEALTH SERVICES. Medical Staff. Mcdical OJJiccr of Health : *E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barristcr-at-Law, Assistant Medical Officer (Maternity and Child Welfare) : *ELEANOR HENDERSON, M.B., Ch.B., D.P.II. Senior Sanitary Inspector: *G. T. CARTER, Certificate of i toy a I Sanitary Institute; Meat Inspector's Certificate. Sanitary Inspectors : *J. A. DAWSON, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. (Resigned 10/2/30.) *L. BUTTERWORTH, Certificate of Royal Sanitary Institute. *A. J. JAMES, Certificate of Royal Sanitary Institute. (Commenced duties 3/3/30.) *R. J. DAW, Certificate of Royal Sanitary Institute ; Meat Inspector's Certifieate; First Class Certificate Practical Sanitary Science. (Commenced 1/4/30.) Health Visitors : *I. RICHARDSON, General trained : Cert. C.M.B., II.V.'s Cert. *A. L. IIINTON, Children's training : II.V.'s Cert. C.M.B. (Resigned 31/3/30.) *M. SMITH, General trained : C.M.B., II.V.'s Cert. *L. WEALE, General trained : C.M.B., II.V.'s Cert., M. & C.W. Cert., Sanitary Inspector's Cert., New II.V.'s Cert. *A. TRUEMAN, Fever trained : General trained : C.M.H. (Kesigned 31/12/30.) *V. EVEllITT, General trained : C.M.B., Health Visitor's Cert. (Began duties 13/1/30.) *D. WALLER, General trained : C.M.B., Health Visitor's Cert. (Began duties 2/2/30.) *N. MILBURN, General trained : Ex Queen's Nurse. C.M.B., Health Visitor's Cert., (Began duties 19/5/30 ) 6 Clerical Staff. Two full-time Clerks in the General Office. 'Two part-time Clerks—part of time dealing with foodstuffs at the Infant Welfare Centres, remainder of time in General Office. One full-time Clerk in Sanitary Inspector's Office. Part Time Staff. Consultant Gynaecologist: H. G. EVERARD WILLIAMS, M.D., M.R.C.P. Consultant Orthopaedic Surgeon : B. WHITCHURCH HOWELL, F.R.C.S. Dentist : F. C. RITCHIE, L.D.S., R.C.S. (Edinburgh). Medical Officer Infant Welfare Centres: M. TURNER, M.R.C.S., L.R.C.P. 'Proportion of salary contributed under Public Health Acts or by Exchequer Grants. 7 To the Chairman and Members of the Urban Distric Council of Dagenham. Mr. Chairman, Ladies and Gentlemen, I beg to submit my report on the health and sanitary circumstances of the district for the year 19.30. Early in the year the last of the houses of the Dagenham portion of the Bccontrec Housing Estate was completed, the total number of houses on the estate in this district being 1 The year was one in which there was considerable development of the health services. On April 12th, the Hecontrcc Clinic « opened, providing for Maternity and Child Welfare and School Medical Services. In October, the Dagenham Clinic, providing lor similar services, was completed, and opened on Novenilxr 1st. At Five Elms, an Out-Patient Department of the King Gconjc Hospital, Uford, was erected, and opened on 3/1/31. One portion of this building is reserved for the services provided by Kin; George Hospital, the other is used for the Maternity and Child Welfare services of the Local Authority and by the Essex County Council for School Clinics and Tuberculosis Services. The Isolation Hospital extensions were sulliciently advanced for the formal opening to take place on 28/2/31. Additional clinics have been opened to keep pace with the demands made by the increasing population. Services established for the first time during the year include bacteriological examination of throat swabs at the Laboratory at the Public Health Offices, and Schick testing and immunisation against diphtheria. On the Maternity and Child Welfare side, the most important extensions have been the opening of an Artificial Sunlight Clinic, the establishment of Dental Clinics and of a Massage and Remedial Exercises Clinic. Little additional work accrued to this department as a result of the Local Government Act, 1929, the only section affecting it being section 2(a) which transferred to the Maternity and Child Welfare Authority, the functions under Part I of the Children 8 Act, 1908, previously discharged by the Poor Law Authorities. Application was made, unsuccessfully, under section 62, for the transfer, from the County Council to the District Council, of the functions of the Local Supervising Authority of the Midwives. There was no outstanding incidence of infection during the year, the standardised rates for scarlet fever and diphtheria being very slightly higher than the rate for the country as a whole. Smallpox, which had appeared for the first time in December of the previous year, occurred throughout the year. During the year a Hill was promoted, the purposes being to "make provision in regard to the utilisation of certain waste lands known as Bcacontrce Heath in the Dagenham Urban District; and to make further provision in regard to the improvement, health, local government and finance of the district; and for other purposes." This Hill was promoted on 21/11/30. The Electors meeting was held in December and the Hill received its first reading on 27/1/31, and the second on 3/2/31. The Hill as presented contained 175 clauses, Part V dealing with Infectious Diseases and Sanitary Provision, containing 44 clauses. Part IV dealing with Streets, Buildings, Sewers and Drains, contained a number of clauses directly concerning the sanitation of buildings. As the Registrar-General is not submitting a mid-year estimate, tlie local estimate of 90,500 has been used in the compilation of statistics. 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 May, 1931. 9 GENERAL STATISTICS. Area (exclusive of tidal water and foreshore), 6,556 acrcs. Population Census 1921 9,127 Registrar-General's Estimate 1929 (mid-year) 79,970 Local Estimate 1930 (mid-year) 90,500 No. of structurally separate dwellings (Census 1921) 1,871 No. of families (Census 1921) 1.957 Rateable value (mid-year 1930) . £368,918 Sum represented by a penny rate £1,490 Occupations of Inhabitants. Little progress has been made in the past year towards the creation of employment in the district. Most adult males find their employment'outside the area, largely in London ; though a large proportion are engaged on the transport services. Actual unemployment is not as serious a feature as in some other districts, the chief disability from which the area suffers being the relatively low level of available income. The average resident lias a low gross income. This is depleted by the high rent and, in many) eases, by the cost of transport to and from the place of occupation. Until local employment is available, the question of this transport must remain a serious factor weighing against the advantages of the creation of an Estate such as this. Apart from the actual loss to family income by transport charges, the time spent daily, under conditions not conductive to health, is a marked disadvantage. Extracts from Vital Statistics for the Year. Births. Total. Male. Female. Legitimate 2,111 1,077 1,034 Illegitimate 41 23 18 2,152 1,100 1,052 Deaths. Birth rate 23.S 505 334 201 Death rate 4.4 Number of women dying in, or in consequence of, childbirth from sepsis 5 other causes 9 10 Deaths of infants under one year of age per 1,000 births :— Legitimate 63.9. Illegitimate 293. Total 68.3. Deaths from Measles (all ages) 18 „ „ Whooping Cough (allages) 4 „ „ Diarrhoea (under 2 years of age) 14 Population. Early 1930 saw the completion of the development of the Beeontrce Estate in Dagenham, and the cessation of the rapid increase in population which occurred in the preceding years. At mid-year, the number of inhabited houses was 19,300, made up of some 15,000 Estate houses, 1,800 houses built before 1921, and 2,500 houses erected since that year. The average population per Estate house for the three preceding years was 4.9. Taking the age group 25 to 44 as unity, the factors for the other age groups in the Estate population would he, age group 0 to 14, 1.3, group 45 to 49, 0.4, and group over 50,0.1. The total population of 74,800 occurring in the 15,265 Estate houses would be :— Ages. 0/1 2,300 1/4 8,700 5/14 23,000 15/24 7,500 25/44 30,400 Over 45 2,900 85 deaths occurred amongst the tenants of houses built before 1021. Of these, some 70% were of persons over 45 and the general distribution amongst the age-groups indicates the existence of a population of some 9,000 of normal a»e distribution. Only 34 deaths occurred amongst the residents of houses erected since 1921. The age-group distribution of these shows that. this population is abnormally constituted, being in the same wanner as the Estate population deficient in old age population hut not to the same extent, as persons over 45 arc about one-third represented. Calculated on the death rate occurring in the Population of younger ages, the total resident population in these houses would be some 6,500. 11 The following table then shows the distribution of the population in the three types of houses in the district :— Age Group. Estate Houses. Houses creeted before 1921. Houses erectcd since 1921. Total. 0/1 2,300 150 100 2,550 1/4 8,700 650 500 10,050 5/14 23,000 1,500 1,300 25,800 15/24 7,500 1,000 1,400 10,500 25/44 30,400 2,800 2,500 35,700 Over 45 2,900 2,300 700 5,900 Total 74,800 9,000 6,500 90,500 Births. 2,152 births were registered during the yc;ir. The birth rate per 1,000 of population was thus 23.8 compared with 30.6 for 1929 and 16.3 for England and Wales. Marriages. Marriages which actually took place in the Dagenham Urban District 166 Marriages of Dagenham Residents solemnized at the Registry Office, Romford :— Both parties belonging to Dagenham 84 Male only „ „ „ 15 Female only „ „ „ 35 Death Rate. Total Deaths in district 336 Outward transfers 87 Inward transfers 346 Deaths of residents 505 Of the 87 deaths of non-residents occurring in the distriet. 58 took place at the West Ham Sanatorium and 16 in the Isolation Hospital. Of the 346 deaths of local residents taking place outside this area, most occurred in institutions. Of these, 237 occurred at Oldchurch Hospital, 9 at the London Fever Hospital, 8 at the 12 London Hospital, and 8 .at King George Hospital, 7 at Great Onnond Street, 6 at Queen Mary's Hospital, Stratford, 4 at St. Mary's Hospital, Plaistow, and 4 at Sevcralls Mental Hospital. 505 deaths in a population of 00,500 represents a death rate of 1.4 compared with 8.3 for last year and 11.4 for England and Wales. Of these deaths 30% occurred in persons over 45, compared with '22% for the previous year. Now that the Estate has reached its full development in this area, any further increase in population will, compared with the increase that has occurred, he relatively small. The death rate of the district has been low, owing to the age distribution of the Estate population. This effect has also been shown by the small proportion the deaths of persons over 15 bears to the total deaths. Each year sees a number passing to the higher age-groups, with their greater mortality rate, and so the death rate of any particular section will rise steadily year by year ; as will also the proportion of deat hs amongst those over 45. While the Estate has been growing, this rise in death rate amongst, the earlier residents lias been masked by the influx of the young adult population into other sections of the Estate with a result that, for the whole dist rict, the death rate has not markedly altered year by year, From now onwards, however, this masking effect will be eliminated, the effect being that the death rate for the whole district will steadily rise and the proportion of deaths occurring amongst persons over 15 will rise towards the normal percentage of 70. Nic outlook at some future date will be determined by the provision made for the present child population to remain in the distriet. If there is no accommodation for them in this area, they will move away, with a result, that, the death rate for the district will tend to rise above that obtaining for the country as a whole, when the present middle age population has passed into the age groups ol higher mortality. This exodus might be limited to the older children of the family. When the younger reach marriageable age the house will be relatively less crowded. This generation, marrying and carrying on the house will help to retain the normal age distribution of the population. Hi TABLE I CAUSES OF DEATH. Under 1 year Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under25 Over 25 and under 35 Over 35 and under 45 Over 45] and under 55 Over 55 and under 05 Over G5 Male Female Total RegistrarGeneral's Allocation Male Female 1. Enteric. Fever — — — — — — — — — — — — — —_ — 2. Smallpox — — — 1 — — — — — — 1 — 1 1 — 3. Measles 7 4 4 4 — — — — — — 6 13 19 12 12 4. Scarlet Fever — — 2 3 — — — — — — 4 1 5 3 2 5. Whooping Cougli 2 2 — — — — — — — — 3 1 4 3 1 6. Diphtheria 3 3 8 14 — — — — — — 12 10 28 12 17 7. Inlluenza — 1 — — — 2 — 3 — 3 6 3 9 6 3 8. Encephalitis Lcthargica — — — — — — — — — — — — — — — 9. Meningococcal Meningitis — — — — 1 — — — — — 1 — 1 1 — 10. Tuberculosis—respiratory — — 2 2 9 23 18 9 2 2 40 27 67 40 27 11. Other Tuberculous diseases 4 — — 8 3 1 5 6 11 G 5 12. Cancer, malignant disease — — — 1 — 2 13 8 7 8 11 28 39 12 25 13. Rheumatic Fever — — — 1 — — — — — — — 1 1 — 1 14. Diabetes — — — — — — — — 1 1 — 1 1 — 15. Cerebral Haemorrhage — — — — — — 1 3 1 7 8 4 12 7 5 16. Heart disease 3 — 4 3 8 6 6 12 26 36 32 68 35 33 17. Arterio-sclerosis — — — — — — 1 4 2 3 5 1 4 18. Bronchitis 5 — 1 — — — 3 — 3 8 12 8 20 12 8 19. Pneumonia 31 12 8 4 2 3 8 4 3 8 48 35 83 46 29 20. Other respiratory diseases — — 1 1 — 1 — — — 2 3 2 5 2 1 21. Ulcer of Stomach or Duodenum 1 — — — — 1 o 1 — — 5 — 5 7 — 22. Diarrhoea (under 2 years) 13 — — — — — — — — — 8 5 13 8 6 23. Appendicitis — — — 2 2 — 1 1 — — 3 3 6 3 3 24. Cirrhosis of Liver — — — — — — — — — 2 2 — 2 2 — 25. Acute and Chronic Nephritis — — — — — 1 4 1 — — 5 1 6 6 1 26. Puerperal Sepsis — — — — 5 — — — — — 5 5 — 5 2T. Other accidents and diseases of Pregnancy and Parturition — — — — — 2 7 — — — — 9 9 — 9 28. Congenital Debility and formation, Premature 1 i i r tli 29. Suicide 60 — — — — — — — — — 35 25 60 38 25 30. Other Violence — — — — — — 1 — — 1 — 2 2 — 2 31- Other defined diseases 2 4 2 5 1 5 2 3 1 — 17 8 25 22 9 32. Causes iW-dcfincd or vu^kuown 15 5 3 10 -4 4 I 9 7 3 23 59 24 83 54 28 14 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. Ilornchurch, and Bomford, and the Rural District Council of Romford. The extensions had not advanced during the year sufficiently to render available any additional beds, with a result that large numbers of Scarlet Fever patients had again to be nursed in their homes. The difficulties arising through this were less acute this year, as many patients were admitted through the Hospital Savings Association to the London Fever Hospital, Islington. Of the Scarlet Fever eases, about 55% were treated at home during the entire course of their illness. Practically all cases of Diphtheria were removed to hospital, those few cases remaining at home being of a mild nature and with suitable home circumstances. Cases of other infections such as Typhoid Fever and Erysipelas were treated in Oldchurch Hospital. (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. When there is no available accommodation at this hospital, cases are admitted, by arrangement with the London County Council, to Joyce Green Smallpox Hospital. 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 Annual Report for the year 1928.) General Medical and Surgical Cases. Oldchurch Hospital, Romford.—This hospital was the Poor Law Hospital of the Romford Union. It consists of about 600 beds allocated as:- 15 Children's Hospital 100 Mental Ward 24 Wards for Chronic Cases 188 Wards for Acute Cases (including Maternity Cases) 181 Isolation Beds 14 Tuberculosis Pavilion 68 Bungalow for Chronic Cases 21 The hospital is largely used as the general hospital for the area, admitting the vast majority of local emergency cases and accidents. The demand on the beds necessitates the admission of more patients to every ward than the allotted number. The Local Authority arrange for the admission to this hospital of maternity eases, eases of puerperal fever and pyrexia, and eases of pemphigus. King George Hospital, Ilford.—A new General Hospital was required to meet the needs of the large population which lias grown, and is still expanding this side of London. It was decided that this could best be effected by using the existing Ilford Emergency Hospital of 70 beds as a nucleus and extending and converting this into a large general hospital. The Charter, incorporating the King George Hospital, was dated 14/1/1930. The extensions were begun and it is hoped, by the end of the year, the hospital will have 180 available beds. A consultant Out-Patient Department is run at the hospital to which cases are referred by appointment by their medical attendants. General medical and surgical eases arc seen and' gynecological, ophthalmic, and car, nose and throat surgeons are in attendance. There is an X-ray and a massage department. To meet the needs of the persons residing in this area, a local Out-Patient building has been erected, run by the Hospital. this building was designed so that a portion of it provided accommodation for the holding of clinics, namely, infant welfare and ante-natal clinics by the Urban District Council, and school clinics and tuberculosis sessions provided by the Essex County Council. The service to be provided by the Hospital Authorities to begin with is of a two-fold nature: (1) Consultant scrvicc, carried out by the visiting physicians and surgeons of the main 16 hospital in the same manner as the service provided in the Ilford Hospital Out-Patient Department. (2) Nursing treatment of minor ailments. It is hoped that further provision will be made to meet local needs. It is not suggested that there should be provided the old type of out-patient department with open doors to all comers, resulting in congestion by persons attending for a bottle of medicine. Much of this work should naturally be retained bv the medical attendants of the patients, more particularly the panel patients. There is much however that can be done locally for the benefit of the residents. Daily, persons are attending the out-patient departments of one or more of the London hospitals. This is timeconsuming and the transport fares deplete the family income. This area suffers particularly for another reason, in that the residents here arc still largely strangers to each other. For a mother to attend a hospital with one child frequently necessitates taking the remaining children of the family with her, as she knows no one with whom she can place them for the day. It is hoped that the services provided at the out-patient department will be extended to provide locally those advantages which at present are obtainable only by journeying. This work need not encroach on that already provided by the local medical practitioners, its scope including such matters as operative removal of tonsils and adenoids, massage clinics, dressings or massage of post-operative cases, etc. (2) Maternity. Maternity cases from this district are admitted, by arrangement with the Council, to Oldchurch Hospital and Queen Mary's Hospital, Stratford. Cases of Puerperal Fever or Pyrexia are admitted to Oldchurch 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. 17 Ophthalmia Neonatorum—St. Margaret's Hospital, Hamp' stead. Pemphigus—Oldchurch Hospital. (4) Orthopaedic—Royal National Orthopedic 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 at the Institution. Romford, previously under the control of the Romford Hoard of Guardians. Ambulance Facilities, (a) For Infectious Cases. A motor ambulance, provided by the Joint Hospital Hoard, is stationed at the Isolation Hospital at Rush Green. (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 vear, 1930. 1929. the number of accident eases conveycd was 351 197 the number of other cases conveyed was 529 518 the number of journeys made was 833 739 the number of miles run was 8190.7 8,408 calls on other ambulances totalled :— Barking 20 21 Ilford 4 _ Clinics and Treatment Centres. All Infant Welfare Centres and Ante-natal clinics were,up to early 1930, held in various church halls in the district. the school Clinic and Tuberculosis Visiting Station were held at 25, Alibon Road, one of the Estate cottagcs which is the home of the Local District Nursing Association. 18 In 1920 sanction was received by the Council for the erection of two Combined Treatment Centres, one to be erected in the grounds of Valence House, the other in Old Dagenham Park. Work was begun on the Recontrcc Clinic in December, 1929, and the building was officially opened on April 12th, 1930. Tins is a two-storey building, the first, floor being used as the Public Health Offices. The ground lloor is used only for clinic purposes. It consists of a large central waiting hall (33 by 24 feet), on one side Hanked by the weighing room which communicates with the doctor's room by a passage off which lead the dressing boxes. The other wall is flanked by the toddlers' room, food store and dentist's surgery, in communication with which is the Recovery Room.This floor is used for the holding of Ante-natal clinics and Infant Welfare Centres. It is also utilised by the Essex County Council for holding School dirties and as the Tuberculosis visiting station. The dental rooms are used by the Maternity and Child Welfare, and by the School Authorities. In the toddlers' room a mercury vapour lamp is installed for ultra violet ray therapy. The building cost £1,000. The running costs for the whole building, including loan charges, are £400 per annum, of which approximately half is allocated to the account of the clinic services and half to Public Offices. The Essex County Council contribute about, half of the clinic cost. Work was begun on the Dagenham Clinic in January, and the official opening took place on November 1st. This is a single storey building of similar design to the ground floor of the Recontree Clinic. The toddlers' room has been fitted with wall bars, etc., for remedial exercises. The cost of the building was £2,200, and the annual running costs, including loan charges £340. To this the Essex County Council contributes half. On the opening of these clinic buildings, the nearest Antcnatal clinics and Infant Welfare Centres were transferred from the church halls. Also the school clinic sessions and Tuberculosis session were removed here from 25, Alibon Road. The King George Hospital Out-Patient Department at Five Elms was designed to enable one portion to be used for clinic poses apart from the hospital service. This building was completed In the latter part of the year and has, since 5/1/31, been used by the Maternity and Child Welfare Authority and the Tuberculosis Authority. 19 The following Infant Welfare Centres were maintained by the Council:— CENTRE. Held Day Average Attend ances Average New Cases Wcsleyan Chapel, High Road, Chadwcll Heath. Weekly Monday, p.in. 47 3 Church Institute, Burnsidc Xtoad, Chadwell Heath, to March 31st. Weekly Friday, p.m. 45 3 St. Mary's Mission Hall, Grafton Road, Chadwcll Heath, Thrice Weekly Monday, p.in. 32 3 to March 31st. Tuesday, p.m. G5 8 Thursday, p.m. 45 3 Recontrcc Clinic, Becontrcc Avenue, Chadwcll Heath, from April 1st. Bi-weekly till Nov. 17th, then Thricc Weekly Monday, p.m. 70 8 Thursday, p.m. 90 9 Friday, p.m. 34 1 Wcsleyan Chapel, Hcathway, Dagenham, till July 19th. Bi-wcckly Wednesday, 47 5 p.m. Thursday, a.m. 50 3 Ford Road Clinic, Ford Road, Dagenham, July 21st onwards. Bi-weekly Tuesday, p.m. 65 5 Wednesday, p.m. 60 5 Labour Institute, Church Elm Lane, Dagenham, to March 31st. Weekly Thursday, p.m. 43 5 St. George's Church, Rogers Road, Dagenham, April 1st onwards. Bi-wcckly Wednesday, p.in. 75 7 r. Friday, p.m. 65 6 20 The following Ante-Natal Clinics were held :— Wcsleyan Chapel, High Road, Chadwcll Heath. Fortnightly Saturday, a.m. 4 1 Bceontrce Clinic, Recontrcc Avenue, Chadwcll Heath, from April 1st. Bi-weekly Monday, a.m. 11 6 Friday, a.m. 9 3 St. Mary's Mission Ilall, Grafton Road, Chadwell Heath, to March 31st. Bi-weekly Tuesday, a.m. 17 6 Thursday, a.m. 9 2 Wesleyan Chapel, Hcathway, Dagenham, to July 10th. Bi-weekly, Jan. 1st— 31st, and April 1st onwards Monday, a.m. 6 2 Wednesday, a.m. 8 3 (Thursday in place of Wednesday) TliriceWeekly February and March Friday, a.m. 6 3 Ford Road Clinic, Ford Road, Dagenham, July 21st onwards. Bi-weekly Tuesday, a.m. 8 3 Thursday, a.m. 9 3 St. George's Church, Rogers Road, Dagenham. Weekly Wednesday, a.m. 15 4 School Clinics and Tuberculosis Sessions. All these were held at 25, Alibon Road up to April, the Minor Ailment Clinic on Monday, Tuesday and Wednesday mornings, the Inspection Clinic on Tuesday mornings, and the Tuberculosis Sessions Thursday a.m. and. p.m. Since April the following sessions have been held :— Becontree Clinic. Minor Ailment Clinic, daily 9 to 10, except Thursday and Saturday. Inspection Clinic, Wednesday a.m. Tuberculosis Session, Thursday a.m. 21 Dagenham Clinic. Minor Ailment Clinic, daily 9 to 10, except Monday and Saturday. Inspection Clinic, Friday a.m. Tuberculosis Session, Monday a.m. The residents of the Northern part of the area find it more convenient to attend the Ilford Tuberculosis Dispensary. This was, up to April, held at 38, Oaklield Road, and since that date at the new dispensary at 130 to 132, Cranbrook Road. The sessions arc held on Mondays 7.30 to 8.30 p.m., Tuesday and Friday 3 to 5 p.m., with a children's session on Wednesday at 10 a.m. to l'inoon. Venereal Diseases. There arc 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. Orthopaedic Clinics. The Consultant Orthopedic Surgeon attends about four times a year to see cases referred bv the School and by the Maternity and Child Welfare Authorities. Remedial Exercises and Massage Clinic. Up to the present, both school and prc-school children requiring treatment have attended the sessions held at the School Clinic. Eastern Road, Romford. From carlv 1031 such eases have attended the Dagenham Clinic at which sessions are held on Monday and Thursday afternoons. Light Clinic. In the latter part of the year a Light Clinic was opened in the Recontrcc Clinic. This is licid on Tuesday afternoons and Friday mornings, for treatment of cases referred from the Infant Welfare Centres. Professional Nursing in the Home. (a) General. The Dagenham District Nursing Association, alliliated to the Essex County Nursing Association, maintain three nurses at their Home in 25, Alibon Road. Of these, in ordinary circumstanees, one devotes her time to general work, the other two acting as midwives. A grant is received from the Essex County Council in respect of the maternity work. 22 The Local Authority use the services of the nurses for the home treatment of such cases as puerperal fever, ophthalmia, pemphigus, etc. In the present building, only these few nurses can be housed. The result of the meagre staffing is that only the nearby portion of the district can be served. To remedy this state, the County Nursing Association has decided on the erection of a Branch Home on a site in a central portion of the district. Work has already commenced 011 this home. This building will be for the purpose of: (a) establishing a branch home for the training of midwifery pupils and (b) for carrying on the work previously done by the Dagenham District Nursing Association for midwifery and general nursing services. The building will be owned and maintained by the County Nursing Association, who will also have control of matters relating to the training of midwives. Other matters will still be dealt with by the local District Nursing Association Committee. (b) For Infectious Diseases. The same arrangement continues as to the home visiting of Scarlet Fever cases by the Health Visitors. Home Helps arc provided in eases of domestic difficulties arising out of the home treatment of these eases. Midwives. There are no midwives in the district employed by the Local Authority. At the end of the year there were 18 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. Laboratory Facilities. The examination of clinical material is undertaken at the psex County Public Health Laboratory, Queen Victoria Street, London. During the year :— 663 swabs were examined for Diphtheria bacillus. 205 samples of sputum for Tuberculosis. 17 samples of hair for ringworm. 23 The same laboratory also undertakes tlic bacteriological examination of milk, of which 125 .samples were submitted during the year. In addition three samples of milk were examined biologically by guinea pig inoculation. The chemical analysis of food is carried out a t the Laboratories. Arrangements have been made for the examination of diphtheria swabs left at the Public Health Offices. This usually results in a report being to hand some 12 hours earlier than if sent to the County Laboratories, as they are delivered by hand instead of being posted. During the seven months of the year that this servkc has been available, 324 swabs were submitted for examination. Legislation in Force. The following bye-laws were made by the Romford Rural District Council and have been taken over by the Dagenham 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 Regulation of Certain Offensive Trades. Animal Charcoal Manufacturer ; Blood Boiler ; Blood Drier; Bone Boiler ; Cat Gut Manufacturer ; Fat Mclter 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 Mclter ; 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 20th September, 1928. Slaughter Houses (Revised). 20th September, 1928. 24 New Streets and Buildings. July, 1925. Regulations with respect to Dairies, Cowsheds, etc. February, 1908. Adoptive Acts. Public Health Act (Amendment) Act, 1890 (Part III)— 5/12/27. Infectious Disease (Prevention) Act, 1890—1/3/23. Private Street Works Act, 1892. Public Health Act (Amendment) Act, 1907 (except Sections 19, 01, 78, 82/80 and 92/94). Small Dwellings Acquisition Acts. Public Health Act, 1925. Local Acts. Dagenham Urban District Council Act, 1928 (3/8/28). Dagenham Urban (Water) Order, 1929. 25 SANITARY CIRCUMSTANCES OF THE AREA. Water Most of the district is supplied with water by the South Essex Waterworks Company. The area north-west of Hog Hill is supplied by the Metropolitan Water Board and in sonic parts of the district shallow wells are still in existence. Complaints arc occasionally received with regard to discolouration of the water, a defect apparently mostly noticed after the water has been standing for a while. This colour is attributed to iron which enters at the time new connections arc being made in the mains. The present supply apparently is not sufficient in the summer months for the area supplied. It is understood that to meet this, the works are being extended. The Dagenham Urban (Water) Order, 1029, invested the Council with certain powers, under the Public (Health) Water Act. A habitation certificate can now be refused for a house without " a sufficient supply of wholesome water within a reasonable distance." Drainage and Sewerage. See Reports of 1927 and 1928. Work was begun during the year on two additional main sewers :— (1) Dagenham Dock Outfall Sewer. This extends from the sewage works at Rainham, across the Hornchurch Marshes and the Beam River to the Ford Motor Company's factory. It is designed to take up the whole of the Trade Wastes for the Industrial Area in the district lying south of the ltipple Boail. provision being made for further extensions as far as Chequers Lane. The maximum discharge is approximately 8,000,000 gallons per day. It is anticipated that the work will be completed by the middle of April at a cost of some £10,000. (2) Beam Sewer.—The Local Inquiry was held on April 1st, 1930, and sanction received on July -1-th for the execution of this work. The sewer commences at the existing outfall sewer near the junction of Ripple Road and the Beam River, and will northwards along the Beam Valley to Harvcys Lane. the maximum discharge will be 2,000,000 gallons per clay. R is estimated that it will cost about £21,000. 26 Rivers and Streams. The upper portion of the district is drained by a number of channels which run in a westerly direction, ultimately finding their way out of the area into the River Roding, whieh discharges into the Thames. The portion so drained includes the area north of Hog Hill, Marks Gate, Chadwell Heath ward and part of the Bccontrec Ward. The eastern side of the district is drained by the Wantz Stream running due south. The largest ditch runs into this near Dewey Road. Another channel runs into it from the Old Dagenham Park. The Wantz Stream then takes an easterly course to connect to the Ream River, by which it empties into the Thames. The third main surfacc drainage is the Gores Rrook. This runs due south in the western portion of the Dagenham Ward and discharges into the Dagenham Rreech. Closet Accommodation. The houses are, in the main, connected with sewers, though in some of the outlying parts, cesspools arc in existence. Some new houses erected on portions of the district not sewered, arc granted habitation certificates subject to the occupier undertaking to connect to the sowers when laid and, in the meantime, making his own arrangements for the emptying of the cesspool. This practice is one to be condemned, more particularly in those portions of the district where there is no piped water supply. One part is divided into building plots, unsewered and without, water supply. Any cesspool constructed can only be emptied within the confines of these plots with, in time, every likelihood of a nuisance from odours and a perpetual risk of infection of the water drawn from the surface well in the same plot. Scavenging. The following table gives some statistics relating to the collection of refuse:— 1. Total all-in cost £161 lis. 1-½d. per week. 2. Estimated weight of house and trade refuse collected per week—370 tons. 3. Number of premises visited per week—19,064. 4. Cost of collection per house per week—2.03 pence. 27 5. Personnel and Equipment:— 25 men 2 days per week. 22 „ 3½ „ „ 6 Freighters 5½ „ „ 1 Tractor and Trailer 2 „ „ House and Trade Refuse is still disposed of by crude dumping on the tip in the northern part of the district. This tip, which began as the dumping of refuse to fill in a gravel pit, is now many yards above the surroundings and stands as an eyesore, being a perpetual nuisance. Although it has long been agreed that some other method of disposal should be adopted, this dump at the present moment continues to be added to. From a sanitary point of view, there seems to be only two possibilities of disposing of this quantity of refuse now amounting to nearly 400 tons per week. One is by crude dumping on the industrial area in the southern portion of the district ; the other by the crection of a separation plant more centrally placed in the district, using the screenings for land reclamation. Earth Closets. The night soil from the earth closets in the northern part of the district is collected in a tumbler cart, and deposited on the fields. Cesspools. Most of the cesspools in the district arc emptied by the Council s gullcy and cesspool emptier, the contents then being pumped into sewers. In some cases the occupants, living in houses with a piped water supply but fitted with cesspools continue to be as lavish in their use of water as when they lived in houses with water carriage removal. Complaints are received from some of these people of the inadequacy of a service which will not always permit of the cesspool being emptied as soon as it is filled. Disinfection and Disinfestation. Disinfection of Homes. All houses are disinfected as a routine practice aftci the occurrence of Scarlct Fever or Diphtheria, being fumigated with a Formigator left lor six hours. The rooms of the Estate houses are subsequently distempered by the London County Council Authorities. Rooms vacated by tubercular persons arc fumigated or request. Those who wish to dispense with the fumigation are encourged to do so, advicc at the same time being given as to the necessary treatment of bed linen, personal linen, etc. 28 Bedding. By arrangement with the Joint Hospital Board, bedding can be removed and stoved at the hospital at the expense of the owner. The question of the provision of a Cleansing Station, which would provide steam disinfection and for disinfestation, had been considered but on financial grounds the proposal was rejected. An airtight cabinet has been fitted with shelves and hangers for the reception of books and clothing. Infected articles are placed inside and sprayed with formalin, the cabinct then being shut and left for 12 hours. . Rats and Mice (Destruction) Act, 1919. Many complaints have been received with respect to rats, chiefly from new houses and shops bordering undeveloped areas or open spaccs. In one instance—at High Road, Chadwell Heath— this nuisance has been aggravated by the demolition of very old farm buildings including many pig-sties, and the consequent displacement of the rats. With the co-operation of the occupiers of the various premises the poisons, etc., supplied by the Council have proved to be effective. Smoke Abatement. No action has been necessary during the year for the abatement of smoke. Offensive Trades. Fried Fish Shops. Consent was granted to the establishing of five new fried fish shops in the district. All consents to the opening of fried fish shops are now, under Section 44, Public Health Act, 1025, limited to a period of one year. Rag Flock Acts, 1911 and 1928. There are no premises in the district in which Rag Flock is manufactured, used or sold. There arc no underground sleeping rooms in this district. Mortuary. The Council's Mortuary, situated in Church Street, Dagenham, is a one-roomed building, fitted with one table. The attendant lives at No. 4, Church Street, in close proximity to the premises. during the year 40 eases were admitted and post-mortem laminations carried out on 31 of them. 29 Disposal of the Dead. The following are the cemeteries in the district at present used: (1) Dagenham Parish Church Yard ; size approximately 2 acres. (2) New Bccontrec Cemetery; owned by the United Cemeteries, Ltd., approximately 21 acres. The Local Authority scheduled, under the Dagenham Act, two portions of land for this purpose, the first a site of approximately 26 acres at Rose Lane, Chadwcll Heath, and the other a site of approximately 30 acrcs at East brook End. Schools. There are 23 schools in this district., run as 51 separate departments. Of these, 15 have been crcctcd sincc the development of the Bccontrec Estate. They were crcctcd on the assumption that the requirements would bo 1.5 school places per house. This number was found insufficient and it is proposed that eight of these schools should be extended; three, namely, Five Elms, Halbutt Street and South Wood Lane, to give additional accommodation for 450 children and five others, additional accommodation for 300 each, these being Arnold Road, Bccontrec Avenue, Finnymore Road, Charlecote and Alibon Road. The newer schools arc well designed, well ventilated and fitted with sufficient water supply and suitable sanitary conveniences. The condition of some of the older schools is not so satisfactory. Some are overcrowded and because of the older type of structure and deficient heating arc not well ventilated. Schools have played a very small part in the disseminationnl Infectious Diseases. No school has been closcd on this account, nor have any been disinfected. In the newer type of school, efficient ventilation and sufficient Moor space per child, the notifiable diseases do not appear to spread to any extent. During the year, the only definite instances of school infect ion in the new buildings were some cases of Smallpox, where the school appeared possibly the place of infection. In the ease of the older schoolc buildings, conditions arc not the same. Attendance at t schools definitely was the source of infection in a number of case instances appearing during the year of infection by this source cases of Smallpox and Diphtheria. 30 Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections:— Houses 682 Bakehouses 48 Slaughterhouses 536 Meat condemned and surrendered 2,812 lbs. Carcases inspected 2,042 Milkshops and Dairies 95 Cowsheds 36 Foodshops inspections 722 Infectious diseases enquiries 6,421 Houses disinfected 1,063 No. of Nuisances investigated 149 (b) Notices served. Complied with. Statutory 88 88 Informal 149 149 On the Administration of the Factory and Workshop Act, 1901. In this district there are 29 factories, 34 workshops, and 43 workplaces. 1. Inspection. PREMISES. Number of Inspections. Written Notices. Prosecutions. Factories 67 2 — Workshops 102 1 — Workplaces 112 6 — 2. Defects. Nuisances under the Public Health Acts:— Found. Remedied. Defective Sanitary Accommodation — — "Other Nuisances " 9 9 31 3. Outwork in Unwholesome Premises—Scction 108. There was no outwork conductcd in unwholesome premises. There were 05 premises in whieh outwork was carricd on. The following table shows the various occupations:— Robes 6 Millinery 3 Boots and Shoes 10 Cardboard Boxes 4 Tailors 9 Neckwear 5 Shirts 2 Baby Clothing 2 Overalls 4 Belts 1 Waterproofs 0 Umbrellas 1 Lifebelts 1 Brushes 4 Outfitting 2 Christmas Crackers 2 Blouses 3 Wearing Apparel 21 Underwear 4 Artificial Flowers 1 Embroidery 3 Feather Cutting 1 32 HOUSING STATISTICS FOR THE YEAR 1930. Number of New Houses erected during the Year:— (a) Total (including numbers given separately under (b) 365 (1) By the Local Authority 12 (2) By other Local Authorities 170 (3) By other bodies and persons 183 (b) With State assistance under the Housing Acts:— (1) By the Local Authority— (a) For the purpose of Part II of the Act of 1925 Nil (b) For the purpose of Part III of the Act of 1925 Nil (c) For other purposes 12 (2) By other bodies or persons 170 1. Inspection of Dwelling-Houses during the year:— (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing 682 Acts) and the number of inspections made 1,470 (2) Number of dwelling-houses (included under subhead (1) above) which were inspected and recorded under the Housing Consolidated Regu- 445 lations, 1925, and the number of inspections made 894 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 52 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 250 2- Remedy of Defects during the Year without Service of formal Notices Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 46 33 3. Action under Statutory Powers during the Year A. Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which notices were served, requiring repairs 204 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 200 (b) By Local Authority in default of owners Nil (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which noticcs were served requiring defects to be remedied 237 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 237 (b) By Local Authority in default of owners Nil C. Proceedings under Sections 11, 14, and 15 of the Housing Act, 1925:— (1) Number of representations made with a view to the making of Closing Orders 2 (2) Number of dwelling-houses in respcet of which Closing Orders were made 2 (3) Number of dwelling-houses in respect of whieh Closing Orders were determined, the dwelling-houses having been rendered fit 2 (4) Number of dwelling-houses in respect of which Demolition Orders were made Nil (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 1 34 4. Number of Houses owned by the Local Authority, distinguishing those built in the last two jyears and held under:— (1) Part III of the Housing Act, 1925 Nil (2) Part II of the Housing Act, 1925 Nil (3) Other powers ... 12 Built by Romford Rural District Council and administered by Dagenham Urban District Council 358 Housing Conditions. 1. General Observations as to Housing Conditions. Dagenham Parish, in the Romford Rural District, contained in 1921, 1,871 houses with a population of 9,127. In 1922, 196 houses were crcctcd by the Local Authority in what is now the Dagenham Ward, and 162 houses in the Chadwell Heath Ward. In 1920 the London County Council obtained powers to buy some 2,768 acrcs of land, most lying in Dagenham, for housing development. The first houses in this area were completed in 1921 from Mich time, up to and including 1930, houses were being completed, until to-day, out of some 19,000 houses in the district, about 15,000 are included in the London County Council Bccontrec Estate. Private enterprise has resulted in considerable expansion, Inluding habitations crcctcd over shop property, the total number of houses built since 1901 is some 2,000. The Estate houses are well looked after, the scheme providing for internal decoration every two years and outside decoration every three years. Much of the older property has had its life. Many of 1 the houes need extensive repairs and, for several, this is not economieally feasible. With the provision of alternative accommodation for the tenants, large numbers of these houses should be demolished, For much of the old property, it seems rarely justifiable to incur heavy expenditure for repairs. A house that has reached a stage Necessitating reconditioning, can rarely be returned to a condition free from defects. Some of the new property has been found suffering from serious defects within a few months of habitation, numbers having rooms uninhabitable owing to dampness. 35 2. Sufficiency of Supply of Houses. Applications for houses are received from persons :— (a) Residents in the older property—either on account o defects in their houses or on account of crowding, resulting from the family growing up. Some of these applicants arc able and willing to pay the increased rent of a new house; others arc able but not willing to pay the added rent, while others again, are unable to pay it. In the old property too, are persons of small families, for whom a small house is required. (b) Persons working locally who have obtained lodgings or are sub-tenants in one of the other houses of the district. In many cases, these families have been taken in to enable tenants to pay the rent, and in not a few cases severe overcrowding is caused in this manner. (c) Other persons who have obtained work locally, but do not reside here owing to difficulty of obtaining accommodation. Comparatively few of the hundreds of teachers employed in the new schools on the Estate have been able to rent houses locally. (d) The children of the Estate who have grown up and wish to be or are married. To meet these needs, it was suggested in that that some 500 houses would be required. The Council, under the Dagenham Act, scheduled and subsequently purchased three portions of land for housing purposes, namely, Eastbrook Farm, Rabbit Field and Rail Pond Field, a total of about 40 acres. Proposals were submitted for the erection of 313 houses. Sanction was obtained for the first 107. The work was begun on September 1st, 1030, and by the end of the year 12 houses had been erected. There are, in this district, no sites which could be dealt with under the 1930 Housing Act as "Clearance Areas "or" Improvement Areas." The following tabic is the quinquennial statement submitted under the Housing Act, 1930, Section 25 (2) Number of inhabited houses (according to rate books) 19,106 A. Estimated production of houses by the Local Authority during the next live years 475 B. Estimated production of new houses of working class type by private enterprise during the next five years:— 36 1. With subsidy under the Act of 1924 Nil 2. Under arrangements made under Section 29 of the Act of 1930 Nil 3. Otherwise (other than London County Council) 1,175 Total 1,650 c. Estimated number of new houses to be allocated by the Local Authority during the next five years to the purposes of the Housing Act, 1930 100 D. Estimated number of new houses to be allocated by the Local Authority during the next five years to the purposes of the Act of 1924 375 Total 475 E. Estimated number of houses to be demolished during the next five years :— (i) In clearance areas Nil (ii) In improvement areas Nil (iii) Individual houses outside clearance and improvement areas 100 Total 100 F. Estimated number of persons to be displaced during the next five years:— (i) By any of the processes mentioned in E 500 (ii) To abate overcrowding in improvement areas Nil Total 500 G. Estimated number of houses to be repaired under Part 11 of the Housing Act, 1930, during the next five years 2,000 These houses should be sufficient in numbers to meet the requirements in connection with the old property and to abate the overcrowding. The chief difliculty will be the capacity or willingness of the persons to pay the increased rent. The housing site 37 is on the edge of the district as at present developed, and is distant from places of occupation and railway stations. Tenants will probably be loath to remove from their present houses which are more conveniently situated. In building a housing estate, it is essential that a sufficient number of larger type houses should be built to allow for the increaing size of the family. On the other hand, there is a difficulty a times in letting the larger houses to the larger families as these ordinarily, are not in the same position to pay the extra rents compared with those of smaller families. One method of over coming this difficulty is to allocate these houses to a small family and to sanction the taking in of a single lodger. When the size of the family warrants it, the tenants can be requested to get rid of the lodger. In addition to making provision for the future larger family and also assisting the tenant in the payment of his rent, such a procedure would be of advantage to many people who world in the district but arc at present unable to live here as they cannot obtain a house or lodgings. Such a practice should definitely be restricted to lettings to single lodgers. Any extension to include married couples would only result in further difficulties through overcrowding by the two families in the house. The greatest difficulty anticipated in this district, however, is expected to arise in the Bccontrec Estate. There arc over 15,000 houses with a high population per house and deficient in old age persons. The result is that the increase per house from births will not, for a considerable period of time, be balanced by the deaths. A serious condition of affairs must arise when the children reach adolescenec. While young, the children can be placed in bedrooms irrespective of sex, but at adolescence, separation will be required. A further difficulty will arise when these children reach a marriageable age. Either they will have to live in the homes with their parents, as so many are already doing, will resultant overcrowding, or they will leave to find accommodation outside the district. No doubt this will be determined by the place of occupation of the wage earner. Should this exodus of young adults occur to any great extent, this district will again show a peculiar age distribution, in that it will then contain an excess of old age persons without the compensating young adults. Ina few years, there will be an annual increase of persons over 20 of about 2,500 by persons under 20 reaching that age. To retain them in the district in suitable circumstances, provision will to be made. Smaller estates built on t he adjoining stable have not experienced this difficulty to any extent. There the overflow is absorbed into the neighbouring stable areas. Here, however, there is no such district in a position to absorb them 38 The year 1930 saw the completion of the erection of the Bccontrec Housing Estate in the Dagenham area and the cessation of the rapid expansion of the district. Flanking the Estate on the eastern side is a large area of hitherto undeveloped land, of which it seems, much is shortly to be built on. On the eastern boundary of this portion runs the Beam Valley, which is now being sewered, so aiding building developments on that side. At the northern end of this, development has already taken place. The Ford Motor Company's factory in the southern portion of the district will shortly be demanding thousands of hands—to say nothing of the auxiliary factories which this will naturally attract. Whether or not any large proportion of employees is recruited from the local residents, it seems that there must be much importation of persons needing to be housed. Private enterprise, either in or outside the district, will probably be prepared to meet this demand, and it seems certain that much of the at present undeveloped land will, in the comparatively near future, be used as housing sites. 3. Overcrowding. There is comparatively little serious overcrowding in this area. Amongst the old property a certain amount has been caused by the growing up of the families. More, however, takes place in the newer private property. In assessing overcrowding, notice is taken of the cubic capacity per head and of facilities for separation of the sexes at night. Part of the overcrowding arises from the difficulty of obtaining houses to rent: but in some of the new houses particularly, sub-letting occurs to enable the tenants to pay the rent. Overcrowding in the Council houses or in the Estate houses has been dealt with by referring to the Authority concerned, who can take action under the tenancy agreement. Action in the case of old standing overcrowding has largely been deferred, pending the erection, by the Local Authority, of new houses. With respect to the occupation of the Estate houses, there are objections to the standards adopted by the London County Council, namely, that in calculations, children under 5 are ignored, those between 5 and 10 counted as half adult and those over 10 as adults. Children under 5 remain at home all day, whereas those over 5 are at school; and at night time the requirements of children under 5 are little less than of those over that age. To assess a child of 9 39 as half an adult is not physiologically corrcct. It may be near enough to the mark if all under 10 as an average are assessed in this way ; but when the under fives are ignored and merely those of 5 to 10 considered, a child should be reckoned as nearer an adult. 4. Fitness of Houses. No special difficulties have been found under the Public Health Acts or Section 3 of the Housing Act, 1925. There arc few houses which arc not provided with an adequate internal water supply. There arc about 10 houses fitted with a private supply placed externally to the house,' and two separate lots of about 8 houses each, fitted with a common tap. About 10 houses arc supplied each by its own well. There is in the district no sanitary accommodation common to more than one house. There are about 25 houses fitted with earth closets emptied by the Council, and a further dozen in which the occupants dispose of the contents. 5. Unhealthy Areas. There are no groups of houses in the district which can be classified as unhealthy areas. 6. Eye-laws. (1) Relating to houses let in lodgings. There is only one house in the district which could be classified as a house let-inlodgings. Owing to the rent limit in the bye-laws, the issue was evaded by raising the rents of the tenants to above the minimum figure. (2) Relating to Tents, Vans and Sheds. The chief difficulty in dealing with tents, vans and sheds, is due to the fact that the occupants arc itinerant and have moved on before any action can be taken. The position will not be satisfactory until all districts possess bye-laws in which each tent or van is counted as a house, needing its individual water supply and sanitary accommodation. The police arc rendering assistance with respect to van dwellers whenever they arc able to do so. 40 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 23 "Grade A " Milk 1 "Grade A " Pasteurised Milk 3 Certified Milk 3 Pasteurised Milk 8 Sterilised Milk 5 The number of Company Distributing Centres is 9. During the year three businesses changed hands through the buying out of smaller concerns by one of the larger. In addition four retailers were registered for the first time. Milk Sampling. During the year, 125 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:— No. of Bacteria perc.c. in thousands. Small Dealers Larce Scale Local producc. Not local. Satisfactory NOT Satisfactory. NOT Satisfactory. not Under 30 5 — 8 — 17 — 30-100 6 1 24 1 12 1 100—200 4 — 12 3 3 3 200—500 2 1 2 5 — 4 Over 500 — — 7 — 4 17 2 46 16 32 12 These figures again show that, of the milk ol the small producer, a percentage, namely, 10% of milks comply with the stand aid Of Certified Milk and 50% had counts below that permitted for Grade "A" Milk. There are many advocates of wholesale pasteurisation of milk, chiefly with the object of reducing tuberculous infection of early childhood. Localised outbreaks of typhoid fever or septic sore throat and cases of abortus fever all increase the list of converts. 41 Many of these seem prepared to accept pasteurising as the entire remedy, irrespective of the original condition of the milk before treatment. Given the advantages of the process, it is cssenti; that it should be realised that it should be only one step in the attempt to produce a safe milk. Production of milk should be compared with large scale furnishing of water. In that, the water shed is inspected and kept, as clean as possible and then the wate is filtered or purified before being passed on to the consumer This double process of prevention of contamination and of subsequent purification should be applied to milk. Milk should be produced from healthy cattle kept under cleanly conditions maintained so by systematic inspection so that the milk before entering the pasteurising plant has the minimum of bacteria and organic pollution. The issue then is not pasteurisation as opposed to or as a substitute for the production of milk under cleanly conditions, but that pasteurisation is fitted in as one step in the process which results in the sale of a safe product. Pasteurising docs not result in sterilisation. It effects only a percentage reduction of bacteria and is much less effective when the milk contains organic matter. Pasteurisation has probably already been a factor militating against the production of clean milk. In the absence of pasteurisation and since the prohibition of the addition of preservatives to milk, long distance transport could have been effected only of milk with the minimum of contamination. Even pasteurised milk is not absolutely without its dangers. The Montreal outbreak of Tvphoid Fever in 1927 showed the risks of dealing with milk on a large scale. Infection of milk by the small producer results in a localised outbreak. Infection of the issued article from a plant supplying a large area can give rise to a very extensive outbreak. Two samples of "Pasteurised milk" submitted for analysis showed units of 122,000 and 1,850,000 organisms per c.c. Distribution in bottles, which is an essential feature of the pasteurised milk, has certain disadvantages, particularly the risk of infection of the bottles. Overworked cleansing plants do no always result in an absolutely clean bottle and multiplication" any pathogenic organisms in milk as a culture medium might easily reach a dangerous dose. This disadvantage can be remove by distributing the milk in non-returnable containers. One retailer had, during the year, a number of doubtful samples, some of which suggested udder trouble in some cows the herd. The supply was from a number of producers. For the worst of them the contract was not renewed. In July a count was 42 doubtful and a later one was positive to guinea pig inoculation test. Separate samples of all the producers were then taken for bacteriological examination. One of these showed blood and cells present and another suggested the presence of mastitis. Three of the suspicious milks were then examined biologically and two were found to be positive. Two cows of the herd were slaughtered, both of which showed signs of tuberculosis post mortem. A veterinary inspection of the other herd giving a positive milk, showed one cow with indurated udder but negative tuberculin reaction. Subsequent examination of samples of milk from this producer gave no further indication of disease amongst any animals. Meat. There are four slaughter houses in the district, one licensed and three registered. To these, a total of 530 visits were paid during the year. The question of the provision of a Municipal Abattoir has been deferred. Bakehouses. There are two factory and two retail bakehouses in the district; to these 48 visits were paid in the course of the year. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year 255 samples were analysed of which 53 were milk and 77 butter. Proceedings were taken on two occasions, one in respect of milk and the other butter, and fines inflicted in each case. 43 INFECTIOUS DISEASES. Cases Notified. Admitted to Isolation Hospital, Rush Green Admitted to Other Isol. Hosp. Admitted to Other Hospitals. Deaths Registered Diphtheria 383 332 8 — 28 Scarlet Fever 513 161 52 — 5 Enteric Fever 4 — — 4 — Puerperal Fever 7 — — 6 5 Puerperal Pyrexia 9 — — 3 Pneumonia (Primary) 112 — — 7 83 „ (Influenzal) 6 — — — Erysipelas 33 — — 8 1 Encephalitis Lethargica 1 — — 1 — Ophthalmia Neonatorum 31 — — — — Poliomyelitis ] — — 1 1 Smallpox 60 — 60 — 1 *Pemphigus 8 — — 1 — * 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 4 9 30 29 37 198 44 12 3 9 5 3 — 383 Scarlet Fever 3 13 31 54 52 242 79 13 7 13 6 — — 513 Puerperal Fever — — — — — — — — 1 5 1 — 7 Puerperal Pyrexia — — — — — — — — 3 it — 1 — 9 Pneumonia (Primary) 11 12 8 8 9 18 5 3 3 J 1 18 J 2 112 „ (Influenzal) — — 1 — — — — 1 — — 2 1 1 6 Erysipelas 2 — — 1 1 2 — — 1 3 J2 0 — 33 Enceph. Lcthargica — — — — 1 — — — — — — — — 1 Poliomyelitis — — — — — — — — — — — — — 1 Smallpox — 1 — — 3 15 10 10 9 0 4 — 60 Typhoid Fever — — — — — 1 1 — 2 — — — — — 4 Diphtheria. 383 cases is a rate of 4.23 per thousand population or of 9.45 per thousand under 15. This latter compares with the figure 7.68 for the corresponding population in England and Wales, giving a comparative incidence rate of 1.23. In the Estate population of these ages, the comparative incidence of infection was The incidence of infection was particularly heavy in the early weeks of the year, when 125 cases occurred in the first nine weeks. The rest of the year the rate was steady, being an average of seven to eight a week from March to May, failing in the summer months, to rise again to a weekly average of eight to nine in October and November. 44 Of these cases, 294 were primary. 46 were eases of secondary infection, resulting from 39 primary cases. In 18 instances, the primary gave rise to one case ; eight primaries gave rise to two secondaries each and one each to three, four and five eases. In one instance the primary case was one of nasal diphtheria and in three the primary case was undiagnosed. In the others there was much delay before the infecting ease was removed to hospital. In less than a quarter of the eases was the primary case removed before the fourth day from the alleged onset of the illness. There were 10 return cases, one each from 10 infecting cases. Only three of these primary cases were removed to hospital before the third day from the alleged onset, the remainder having been at home from varying periods over four days before removal. Two were discharged before four weeks in hospital, two in the fifth and two in the sixth weeks ; the remainder were in for longer periods. In five of the return eases, the onset was within one week of the return home of the infecting patients, one in the second and two in the third. None of the infecting cases showed any abnormality of the mucosa and in no case was a positive swab obtained. Death Rate. 29 deaths (12 male, 17 female) occurred from diphtheria in the course of the year, being a ease mortality rate of 7.5 % 01 these fatal eases two suffered from laryngeal involvement, one following whooping cough. The other was a case of croup and quinsy, which died at home. In five cases the child was removed to hospital on the second day, and in four cases on the third day from the onset of the illness. Considering the insidiousncss of the onset of this infection, particularly in small children, it is extremely unlikely that the history obtained gave the true time of onset of infection, the probability being that most of these cases had been absorbing toxin for a period considerably longer than that given by the history. Schick Testing and Immunisation. fowards the end of the year, a number of children were Schick and immunised. The advantages of the process are brought to the notice of the mothers at the Infant Welfare Centres. Also, on theoccurrence of a case of diphtheria, the Sanitary Inspector, on his visit to the home, leaves an instructional leaflet and a form which the parents can signify their desire to have the treatment carried out. In one of the small infant schools, a few cases of diptheria occurred from a primary nasal infection. Opportunity as taken of this to inform the parents of the scholars of the procedure with the result that some 30% consents were obtained. 45 Children over six were Schick tested before immunisation. Owing to the very high percentage of positives at age six, only those over seven are now tested. Out of 16 children aged six, only one was negative. Of children of seven, one was negative out of eight. Six out of 17 of those of ages eight and nine were negative and 10 out of 26 of those of 10 and over. 105 children completed the course of three injections at roughly weekly intervals. None have as yet been re-tested. A few of the children of eight and over suffered from slight local reactions but none below that age. One Schick positive child had received one injection when she developed an attack of diphtheria. Bacteriological Examination. 663 diphtheria swabs were examined during the year at the Essex County Public Health Laboratories and 321 at the Public Health Offices. Schools and Diphtheria. The only instance where a definite school infection could he traced was in a small infants' school which suffered in a similar manner in 1929. The school, of an old type of building, contains two classes in one of which three cases of diphtheria appeared, one in one week and two in the following week. In this class was a child with rhinorrhœa which contained the diphtheria bacillus. On excluding him, no further eases appeared in that school. Of the 383 eases of diphtheria occurring through the year, 123 were primary cases in children who attended school. Of the number, however, in 70 instances the case was the only one in that department at that time, and was separated by more than one week from another case of diphtheria in that department. Presumably then, in these cases, infection of the patient was not caused in the school. In 17 eases a child in the same department suffered in the preceding week. This, however, does not. necessarily mean the same class as many departments are run in as many as eight or nine classes, completely separated, cach in its own room. In 15 instances there was more than one case in a department in the same week, making a total of 36 children. 22 of these, however, occurred two each in one department in the week. Three infections in one week occurred in separate departments on three occasions, and in one instance five children from a department fell ill in one week. 46 In the school previously referred to, the grouping of cases was 1, 1, in consecutive weeks. An infants' department had the following eases, 1, 0, 5, which were probably associated, and some months later 2, 1, 3. Apart from one other instance of three cases in one department in one week, there were no groupings to suggest that there was an infccting case in the school. Actually it seems that the schools play a very small part in the spread of diphtheria. Scarlet Fever. 513 cases is at the rate of 5.67 per thousand population or 12.00 per thousand of population under 15. This latter compares with a rate of 11.52 for the corresponding age group population of England and Wales, being a comparative incidencc rate of 1.09. In the Estate population of these ages, the comparative incidcnce of infection was 1.11. Infection was heaviest in the first three months of the year with a weekly average of 13. This fell to two in June but rose sharply in July to 12 with a total of 45 cases in that month. Falling in August to 33 cases for five weeks and September 26 cases in four weeks, the incidencc rose to a weekly average of 12 in October, falling for the rest of the year to 11. Other districts showed this heavier incidence in July but not to the same extent. Shortage of accommodation at the Isolation Hospital was again felt. hi the first three months, 113 cases were treated entirely at home, 20 admitted to hospital and a further 11, who commenced home treatment, were subsequently admitted. Out of the 72 cases in the next three months, 45 commenced home treatment of whom three were later admitted and 18 others were removed immediately. In July eight out of 32 who began home treatment were subsequently admitted and 11 others removed. From August to the end of the year more cases were admitted each month than were treated at home, namely, 106 admitted, 79 home treated and a further two admitted after a period of home treatment. During the year the total number of eases treated at home were 221, treated at Rush Green Isolation Hospital 114, and at other Fever Hospitals 50. Those cases removed to Rush Green Isolation Hospital were admitted on the following grounds:— 47 (1) Crowding in the home 27 (2) Difficulty of nursing at home 11 (3) Clinical condition 41 (4) Admitted when beds free 22 (5) On account of contact's work 17 (6) Poverty 4 Of the cases admitted on account of the clinical condition, 15 suffered from an acute illness, severe throat involvements eight, otorrhoea two, mastoid involvement two, rheumatism two, abscess of neck and albuminuria one each ; concurrent other illness eight, Home Treated Cases. Of the 221 cases treated at home, a larger number suffered from some complication that had happened in previous years. Cervical adenitis occurred in 10% of eases, most, commonly in the second and third weeks. Most clcared up within the fortnight though a number lasted three weeks. One child was removed to hospital for the opening of an abscess in a suppurating gland. Rheumatism seemed less common, namely, 2% though more severe and two cases were admitted for treatment of this condition. Otorrhoea occurred in 3% of cases, the first week again being the commonest period of onset. Some cleared in the second, hut others were not clear until the fifth week. One child became very (leaf in the fourth week but suffered from no discharge, whilst another child was admitted on the tenth day on accoutnt of mastoid complications. Rhinorrhœa occurred in 2% of eases, chiefly in the second week and mostly persisted for two weeks. Of the other children admitted later on account of complications, one was sent in in the second week suffering from stomatitis, another admitted the same date with albuminuria and one child was admitted in the fifth week owing to cardiac complications. Secondary Infection. Of the 02 secondary infections, 14 were subsequent to a primary case which was removed to hospital on receipt of notification. The remaining 4S followed a primary case which was home treated (including for this purpose, those eases which began home treatment but were subsequently removed to hospital). Of these latter, a large number of cases would have occurred even had then been ample accommodation. In 14 of them, infection had occurred before a medical attendant had been called in to the primary case, in many instances both cases being notified together. Five other cases followed on three missed eases in which the illness of 48 secondary lead to the diagnosis of the first ease. These 19 cases of secondary infection then, out of the 48 subsequent to a home treated primary, would have occurred even had the primary been removed at the time of notification. It is questionable if all the others would have been prevented ; as instance, on two occasions three children were infected within six days of the onset of the primary case ; in another the onset was two days after the onset of the primary. In the other cases the intervals separating the onset of the second from the onset of the primary, were 4 days, one case ; 5 days, three ; 6 days, four ; 7, 9 and 10 days, one case; 16 days, two; 19, one; 20, two; 21, one; and 23, two. In one case where the primary patient suffered from otorrhoea, the second ease sickened on the thirty-first day from the onset of the primary. Return Cases. There were 17 return cases in the course of the year, in five of which the infectious case was discharged from one of the London Fever Hospitals. In addition, there were four other cases which might have been return cases or secondary to the first of the return cases in the home. In two instances, the return case was the mother of the infecting case. In one instance the primary case was at home 17 days prior to removal to hospital as an unrecognised case of Scarlet Fever. He was then admitted on a wrong diagnosis of diphtheria and detained in hospital 18 days. On the seventh day from his return, his brother developed Scarlet Fever of a septic type from which he died. In a number of other instances, the primary case was at home some days after the onset, few being removed before the third day. Most were apparently uncomplicated cases and were discharged about the 28th or 30th day. In eight instances the onset of the return case was within the first week after the return of the infecting case; in five instances in the second week and three in the fourth. A number of infecting cases, though apparently normal on dischargc, developed a presumably infectious rhinorrhœa within a few days. Recovery Cases. These are cases developing within the same period as a return case but subsequent to the freeing of a home treated primary case. Out of the seven of these cases, in two instances in whieh the primary had not been cleared, the intervals separating the onset of 49 the two cases were 35 and 30 days. Of the others, the onset of the second ca.se was within five days of clcarancc in three eases, whilst in the other two the intervals were 12 and 23 days. Of the cases treated at home, very few probably arc genuinely isolated for the whole period and most arc probably as serious a source of infection before as after the disinfection of the premises. In many, the first ease was not diagnosed for a number of days after onset. In two out of the number which gave rise to recovery cases, the diagnosis was not made in the ease of the primary for 11 and 16 days. Probably for this period they mixed with the others, except possibly for the few days at the time of the acute illness of onset. Considering, in relation to home treated cases, those cases where another infection occurred subsequent to the diagnosis of the first case, the following numbers of cases occurred in succeeding weeks from the onset ; within 7 days of onset 8, and in the succeeding weeks 4, 5, 3, 2, 2, 2. These figures again suggest that the most infectious period of Scarlet Fever infection is for a number of days in the neighbourhood of the onset; and that after that, infcctivity in most cases is very slight but a few cases remain infectious for a period up to 7 weeks. Comparison of Home and Hospital Treatment. As many secondary infections occur before the recognition of the primary case and therefore would occur whether or not the primary case were removed to hospital, the comparison is made only between the return eases following on hospital treatment, nd, in relation to the home treated patients, those secondary cases which would probably have been prevented by early removal of the primary and also the recovery cases. There were 17 return cases occurring in 100 houses in which there were, apart from the infccting cases, 373 children under 15 and 366 adults: Subsequent to 219 primary cases treated at home, there were 29 preventable secondary cases and seven recovery cases in a child population of 250, and an adult population of 523. These figures this year, show an advantage in the removal to hospital of the first case. This is less marked, however, if to the cases infected by hospital treated primary eases are added that number (14) of secondary infections which occurred despite hospital removal of the primary case. 50 In the 3 years, 1928-30, following 615 eases treated at home, in a total susceptible home population of 1,026, there were 13-1 secondary and 16 recovery cases. Of the secondary, at least 49 would not have been avoided had there been ample hospital accommodation, owing to infection of the secondary having occurred before recognition of the primary case. Included in the remaining 85 secondaries arc a large number of cases which were probably so infectcd, but have actually been classified as preventable by removal of the primary source. In the same period of time, 419 hospital treated cases in a total susceptible population of 1,037 gave rise to 45 secondaries and 39 return cases. Where a patient commenced home treatment but was later admitted to hospital, for these purposes he is classified as a hospital treated case if he caused no secondary infection. If however, he infected a secondary case and was removed, he is counted as both a home and hospital treated ease. In approximately the same number of susceptible population, 84 eases occurred subsequent to the hospital treated primary case and 101, namely, 16 recovery and 85 preventable cases, secondary to the home-treated cases. In this area then, for this period, removal to the Isolation Hospital has played little part in the prevention of the spread of the disease. The advantage should be more marked in the future, as the number of return cases that occurred, undoubtedly, was due to the difficult conditions under which the hospital has been run for the past few years. Possibly too, the difference between the effect of the two conditions of treatment are less marked in this district because of the poverty of the inhabitants leading the delay in calling ui the medical attendant, with resulting delay in the isolation of the patient from the rest of the family. The mild nature of the illness acts in a similar manner, leading to the delay in recognition and subsequent isolation. Deaths. Five deaths from Scarlet Fever occurred in the course of the year being a ease mortality rate of 0.97%. One of these, a return case, has previously been referred to. Two other cases were the third cases of infection occurring in a house, in each instance the previous cases being clinically mild. One of these died about the fourth day from toxaemia and the other, in the third week, from Pneumonia. One case ascribed to Scarlet Fever was a child with an apparently mild infection who was treated at home. She sickened 19th September and was freed on 10th November. She was later admitted to hospital and on the 4th December died, the death certificate reading " Endocarditis, following Scarlet Fever." 51 Dick Test. No children were submitted to the Dick Test. Schools. Schools apparently played a very small part in the spread of infection. Of the 252 primary eases occurring amongst school children, in 176 instances the ease was separated from any other ease in the same department by more than one week, while in 33 instances there was a case in the preceding week. On 20 occasions, more than one ease occurred in the same department, providing a total of 43 cases. In one instance, school infection occurred. This was a small school of 4 classes in an old type of building. 2 classes were held in the main hall and 1 class in each of the other two rooms. A ease was notified week ending February 2nd. On week ending February 22nd, .3 children were notified and 2 more the following week. All these children were found to be scholars in the two classes in the main hall. 3 suspicious cases, two of whom *w desquamating, were found and excluded. The other child, suffering from otorrha-a, had recently returned after an abscncc following an illness supposed to be measles. After exclusion of these children, no further cases occurred. On two other occasions only, did as many as three cases occur in any one department in one week. Twice a single ease occurred in 3 consecutive weeks. The following figures show the only other suspicious groupings in any department of a school throughout the year 1, 2, 0, 3 ; 1, 2, 6, 1 ; 2, 0, 1, 0, 1, 1 ; 2, 1; 2,1,1. 0, 1, 0, 1, 0, 1. No schools were closed or disinfected during the year on account of this infection. One adult woman suffered from two typical attacks of Scarlet Fever within a period of three months. One woman, confined 10 days previously, suffered from Scarlet Fever and gave rise to a secondary case in the person of one of her children. Another case occurred 4 days after delivery, the patient suffering from sore throat, nausea and malaise and subsequent peeled typically. Enteric Fever. There were 4 notifications of Entcric Fever (one for paratyphoid B) received during the year. All eases were treated in Oldchurch Hospital and recovered. The source of infection could not be traced in any of the cases, none of which apparently was associated in any way with any other case. 52 Erysipelas. 33 cases of Erysipelas were notified, '20 male and 13 female, of whom 9 were admitted to hospital, 8 being to Oldchurch Hospital. 40% of the cases were of persons over 40. Two proved fatal, one a female aged 72 and one a male aged 7 weeks. The face was affectcd in 70% of the cases. Nearly CO % of infections occurred in the first 4 months of the year. Cerebro-Spinal Meningitis. No eases of Cerebro-spinal Meningitis were notified during the year. Poliomyelitis. A girl aged 8 suffered from poliomyelitis which proved fatal after an illness of 10 days. Encephalitis Lethargica. One notification was received of this infection. This was a girl aged 5 who suffered from measles on January 18th and was notified as Encephalitis on the 3lst. She survived the acute stage but now suffers from mental trouble. Smallpox. 60 notifications were received of eases of Smallpox during the year. Of these patients, all but three were unvaccinated or were vaccinated only some days after exposure to infection. Of the 3 who had previously been vaccinated, all were secondary to cases occurring in the home. Two of these persons, aged 40 and 52, had been vaccinated in infancy and one aged 50 had been vaccinated in 1916. 24 cases were infected outside their homes and gave rise to 32 cases amongst their home contacts. In a large number of cases, , diagnosis of the secondary case lead to the detection of the original source, which had frequently been diagnosed as a case of chicken pox, food poisoning or influenza. A number of contacts of the primary eases were vaccinated but too late after exposure to infection to be effective in warding off the disease. In a few instances, the source of infection of the primary case could be traced. Mostly, this was contact with a patient in London. In a number of eases, however, it was impossible to trace the source. This is understandable when one realises that so many of the people 53 travel in congested railway carriages each day and knows too of the number of patients actually suffering from the disease who, through it being unrecognised, travelled up daily to work. Most of the cases occurred in the latter part of the year. In January there were two primary cases, one of which gave rise to 5 secondaries. In February 1 primary, and in March 3 primaries, giving rise to 7 secondaries. 2 eases in April infected 4 others in May. There were 3 primary cases in May and 1 in June gave rise to a secondary. One patient in August infected 2 home contacts and another in October gave rise to 3 eases. In November there were a number of school cases. In addition there were 2 separate primary cases, each of which gave rise to 3 secondaries. The school infection occurred in one of the old type buildings which is rather crowded. On 17/11 a notification was received of I a girl scholar of 6, No. 31, in whom the onset was 13/11, the last day she attended school. On 20/11, No. 32, a girl of 6 of the same class was diagnosed. Her onset was 12/11. The school was visited and all the children examined with a view to discovering the source of infection. A child G. C., with scars of a typical distribution, who had been ill, on 12/11 was excluded. Visiting the absentees led to a family 1)., in whom sonic nicn>bcrs were suffering and some recovering from smallpox. I'-lf had suffered and was at school to 22/10. lie had iufcctcd his brother and his mother. This family was apparently infected by their next-door neighbours, family I}., who came to this district about 10/10 from a part of London in which smallpox had appeared Some members had suffered while in Iiondon and in others the onset was shortly subscquent-to their coming here. None of the members of this family at the time of the visit appeared to be infectious. On 30/11, No. 40, I. G., a girl of 6 attending the same school, was attacked. Early in 1931, another case of smallpox occurring led to the recognition of the fact, that two brothel's F. C. and I. C. attending this school, had suffered from the illness about 30/11. Most cases gave rise to at least one secondary case at home. The history of the outbreak then, seems to have been : (1) Family B. contracted the disease in London and transferred here infectious. No cases were diagnosed in the infectious stage. (2) Family B. infected their next-door neighbours, family D- (3) The school child of family D. infected at school Nos. 31, and G. C. (G. C. was not recognised while infectious). (4) Nos. 31 and 32 gave rise to home infections, as did also G.C. In addition one more of these was responsible for infecting at school (a) F. C. and G. C. who gave rise to one secondary case at home, (b) I. G. who 54 infected two cases at home. No other eases occurred in 1931 connected with this school outbreak. A number of cases, however, occurring in the early part of 1931 when traced back showed that at least three cases of Smallpox, occurring amongst children in November and December, were unrecognised and gave rise to many cases in the early part of this year. All cases were of the mild type, though some suffered from extensive rashes, even though the infecting cases suffered only to a very slight degree. When beds were available, patients were removed to Orsett Hospital; otherwise they were admitted to the London County Council Hospital at Joyce Green. Smallpox appeared on one death certificate as a contributing cause. Actually, the disease had apparently nothing to do with the fatal termination. The case was a boy aged 5 of family D. who was unrecognised as suffering from smallpox until found in the home when visiting school contacts. At the time of the visit, his skin lesions were almost healed, but he was found to be suffering from diphtheria to which he succumbed. Out of 32 cases, the rash appeared on the third day of illness, ill 8 instances ; 9 on the fourth, 4 on the fifth, 7 on the sixth and 6 on the seventh day. The commonest interval between the onset of the primary and of the secondary cases was 17 days and between the first day of the eruption of the primary and of the onset of the secondary, 14 days. The shortest periods for these intervals were 6 days and 13 days respectively. The longest interval between the secondary, and the primary cases were, from onset to onset 20 days, rash to onset 24 days, and rash to rash 28 days. In these instances the primary case was not removed for several days after the onset. lc longest period between the removal of the primary and the onset of the secondary was 17 days, and from removal to the rash of the secondary 19 days. A total of 4,175 visits were paid to the homes of Smallpox contacts by the Sanitary Inspector's. Visiting is continued to the 19th day from last exposure to infection. the following table shows the position of vaccination for last year:— 1. Successfully vaccinated 375 2 Insusceptible 2 3. Conscientious Objectors 906 4. Died before Vaccination 32 5. 6. Postponed by Medical Certificate 50 Removed 41 7. Unaccounted for at present 525 55 No vaccinations were performed during the year by the Medical Officer of Health under the P.H. (Smallpox Prevention) Regulations, 1917. Anthrax and Plague. No eases of Anthrax or Plague occurred in this district, during the year. Tuberculosis. New Cases (Forms A & B). Transfers into District. Deaths. Puimoniry- Nonpulmonary. Pulmonary. Nonpulmonary. Pulmonary. Nonpulmonary. M F M F M F M F M F M F — 1 — 1 1 — — — — — — 1 1 1 1 — 8 3 — — 1 — 1 — — — 5 2 1 11 7 — 1 2 2 — — — — 10 — — 9 2 4 — 1 1 — — 1 — 15 6 2 1 3 — — — 1 1 3 — — 20 5 3 — 1 3 1 1 1 2 2 1 — 25 14 17 — 2 8 6 — 1 10 14 — — 35 16 11 — — 3 1 — — 8 12 1 — 45 6 2 1 — ] — — — 6 2 — — 55 — 1 — — — — — — 1 — — — 65 & upwards — — — — — — — — — — — — 51 37 31 19 19 9 5 6 29 33 4 1 Register. Pulmonary Non-pulmonary Male. Female. Male. Females. No. on register 1st Jan, 1930 312 321 112 122 During the year:— New notifications 51 37 31 19 Deaths 30 32 4 1 Transfers into area 19 9 6 Transfers out of area 8 7 4 3 No. or. register Dec. 81st, 1930 374 328 170 143 During the year there were notified 90 cases of Pulmonary Tuberculosis and 50 cases of Non-pulmonary Tuberculosis, 56 Primary notifications, during the time that any large numbers of population transfer here, are high, as, according to the requirements of the Ministry of Health, for each transferred person suffering from tuberculosis, it is necessary to have a Form A and to reckon that as a primary notification. This procedure seems unnecessary and creates an erroneous picture. It should be sufficient that these names be added to the register, as having been learned of by a method other than Form A. Assuming 1,000 transfers in any one year, in whom there are 8 cases of Pulmonary Tuberculosis ; according to this ruling, 8 Forms A are necessary in respect of these 1,000 persons, whereas actually these 8 cases were notified in the other districts over a number of years and not in any one vear. When these persons transfer here, there should be added to the register 8 names in respect of those persons, but it should not be necessary to have to include 8 primary notifications for them as received during that one year. Of the Pulmonary cases, 85 were of persons residing on the Estate. 20 were of persons who transferred into the district suffering from tuberculosis, whilst 57 apparently contracted the disease here. Of the 55 non-pulmonary cases, 45 were of Estate residents. Of these, 5 were transfers and 39 new cases. The notification in 23 cases was of ccrvical adenitis, hip and spine 3 cases each, knee 2, generalised tuberculosis 2 and meningitis 4. 230 Estate houses were built in 1030 giving a new population of 1,100. Assuming the annual transfer rate amongst the 15,000 Estate houses to be 4% the changed population numbers 3,000, giving a total transferred population of 4,000. If the incidence of tuberculosis amongst this body of persons is at the same rate as that occurring in the Metropolitan population, the number of anticipated transferred tuberculous cases would be pulmonary 34, and non-pulmonary 14. Actually the number of transfer notifications received were pulmonary 20 and non-pulmonary 5. The numbers are not strictly comparable as information would be received in 1030 of persons who transferred here before that date ; similarly, some tuberculous patients who transferred in 1930 will not be on the register before 1931. This correction, however, would only lower the figures of actual cases transferred, as a larger number of persons transferred in 1929 than did in 1930, so that morc notifications would be received in 1930 in respect of 1929 Patients than would be received in 1931 in respcct of 1930 transfers. No account is taken of the altered age distribution. Whilst allowance made for this would diminish the anticipated number of Pulmonary eases, the fact that there is the 60% increase of children under 15 would increase, by this ratio, the number of anticipated cases of non-pulmonary tuberculosis. 57 Amongst the tenants then, who transferred in 1930, there was a lower than average incidence of tuberculosis, this being particularly marked in the case of non-pulmonary disease. Including the transfers us primary notifications for the year, the number of notifications of pulmonary cases, 90, is less than the anticipated number, 100, assuming the same rate to obtain as for the country as a whole. The non-pulmonary cases, 55, arc higher than the average rate, but not when allowance is made for the altered age distribution of the population. No doubt part of this relative excess of non-pulmonary cases is attributable to the fact that some children were already heavily infected before transfer and showed recognisable signs of the disease only later. The mortality rate per head of population is lower for both classcs of disease than the rate obtaining for the country as a whole, namely pulmonary 59 per 100,000, compared with 75 anil nonpulmonary 11 compared with 17. The actual number of cases on the Register at the end of the year were, Pulmonary 702 and Non-pulmonary 313. For a corresponding population in England and Wales the figures would be GOO and 240. As, during the past few years, the number of notifications and the number of transferred cases have been low. these higher figures on the register arc attributable to the fact that in the early years of development of the Estate, the incidence of tuberculosis amongst the transferred population much exceeded the rate occurring in an ordinary population. Deaths. Of the 66 deaths from Pulmonary Tuberculosis there occurred amongst:— (a) the old residents of Dagenham 4 (I)) those who transferred here free from disease 32 Amongst these, the onset of 2 was within 12 months of residence Here ; 8 had lived here 1 to 2 years, six 2 to whilst 11 had lived here over 3 years before becoming ill. Nine died within 0 months of the reputed onset; another 9 in periods between 6 to 12 months from the onset. A total of 28 died within 3 years, only 2 surviving this period. (c) Those who transferred here suffering from the disease 26 58 Four died within 6 months of transferring here, another 3 died within the 12 months, 3 died in the second year, 7 in the third ; whilst another 7 had resided here a period of 3 years or over. There were 8 fatal pulmonary cases not notified. Two of these were of persons on an extended visit to the district. 13 persons had been notified only within 3 months of death and a total of 30 within twelve months of death. 28 were of persons who had been on the register over 12 months. Of the 11 non-pulmonary cases, meningitis accounted for 7, generalised tuberculosis for 2, and peritonitis and nephritis for one each. In only one case was a definite family history of tuberculosis obtainable, and, in most, the milk supply was treated milk supplied in bottles. Sputum Analysis. 205 samples of sputa were submitted for analysis during the year at the Essex County Public Health Laboratories. Public Health Act, 1925, S. 62. No action was taken during the year for compulsory removal to hospital of any infectious tuberculous person. Tuberculosis After-Care Association. This Association has held many meetings throughout the year, giving grants to necessitous cases and assisting in obtaining employment. 59 MATERNITY AND CHILD WELFARE. Notification of Births. 1,924 notifications of live births were received during the year (male 963, females 961). 442 notifications (including still births) were received from medical practitioners and parents, and 1,521 from midwives. In addition, information was received of 183 births outside this area. The following list shows where most of these births occurred Oldchurch Hospital 87 Queen Mary's Hospital, Stratford 19 East End Maternity Hospital 15 Plaistow Maternity Hospital 13 Upney Hospital, Barking 7 London Hospital 5 Stillbirths. 39 stillbirths were notified (23 male, 16 female), the corresponding figures for registration being 33 and 30. The rate per 1,000 of total population registered 0.69, the same figure as for England and Wales. The causes of the stillbirths were:— (a) Maternal Causes—13. Albuminuria, 5 ; anaemia and debility, 2 ; hypecmesis, 1 ; antepartum haemorrhage, 4 ; fright 1. (b) Prematurity—5. Falls, 4 ; Influenza, 1. (c) Death of fœus during labour—24. Abnormal presentation, 3 ; complications of delivery, 3 ; disproportion of head to pelvis, 5 ; cord round ncck, 1 ; other difficulties in labour, usually necessitating application of forceps, 8; unknown causes, 4. 60 Infant Mortality. 145 deaths (89 male, 56 female) of infants under one year of age occurred, being an infant mortality rate of 67.4 compared with 60 for the country as a whole, and 67.7 for last year. The rate amongst legitimate children is 68.0, and illegitimate 288. The following table analyses the causcs of death occurring in the first months :— Disease. Under I day. 1-7 days. 1 weck1 month. 1-3 months. M F M F M F M F Prematurity 8 7 2 2 — — — — Debility, etc. 2 1 6 1 4 2 — — Abnormalities — 2 2 2 2 1 2 3 Cerebral Hasm. 1 — — — — 1 — — Chest conditions — — — — 5 2 6 5 Enteritis — — — — 1 1 4 2 Marasmus — — — 1 2 1 3 — Total 11 11 11 6 17 9 19 11 Nco-natal deaths, that is, those occurring within the first month after birth, accounted for 65 deaths (male 39, female 20), providing by themselves an infant mortality rate of 30.2 or 44 Percent. of the total infant mortality rate. The vast majority of these arc due to failure of adaptation to new surroundings, in many eases due to premature birth. Deaths warning shortly after birth arc apparently described indiscrininately as "deficient inherent vitality," "atelectasis," "congenital debility " or frequently " prematurity." Of the 18 deaths occurring within a few hours' of birth, in nearly all, labour was premature, though in most eases with no obvious cause for the early onset of labour. In two cases the onset was attributable to shock, and in one patient it was induced. Two deaths were due to antepartum haemorrhage, and in one case the child was one of twins of the other child was stillborn. Of the deaths occurring in the first seven days after birth, 9 similarly classified. In 6 of these, labour was premature, one following an antepartum hæmorrhage. Two sets of twins died in this Period. Five survived varying periods up to three weeks, but finally died, death in these cases being ascribed to " debility." In 61 addition to those classified under this heading should he added another 8 who were feeble from birth, 3 of whom died from gastroenteritis, 3 from marasmus and 2 from pneumonia.. Two deaths occurring within the month were due to ccrcbral haemorrhage as the result of difficult labour. Developmental abnormalities accounted for 7 deaths within one month (5 male and 2 female) and a further two in the next two months. Five were due to congenital heart disease, two to spinal bifida, and one each to hydrocephalus and obliterated bile duet. Chest conditions caused, within the first month, 7 deaths and within the first three months a total of 18 deaths (11 male and 7 female). 10 of these occurring in the three months, January, February and December, were primary or secondary to a head cold. Three apparently were complications of measles, whooping cough and influenza. Amongst the remaining deaths under three months, were 2 cases of pyloric stemosis, 2 of gastro-entcritis and 1 of marasmus subsequent on pemphigus. Deaths of older children:— Disease. 3-0 months. 0-12 months. 1-2 years. 2-3 years. 3-4 years. 4-5 years. M F M F M F M F M F M F Devki.opmf.ntal. Congenital Heart 2 1 — — — — — — — — — — Infections. Whooping Cough — — — — 2 — — — — — — — Measles — — 3 4 3 4 1 1 1 — — — Diphtheria — — 2 1 2 1 2 2 — 2 1 2 Tuberculosis 1 — 2 1 — — — — 1 — 1 — Scarlet Fever — — — — — — 1 1 — — — — Chest conditions 3 3 4 3 4 6 2 1 2 — 1 1 Gastro-enteritis 2 2 2 2 1 — — — — — — — Accidents — — — 2 2 3 — 1 1 — — — Other Causes 1 2 4 — 3 1 2 — — — — — 9 8 17 13 17 15 8 6 5 2 3 3 62 Ophthalmia Neonatorum. Notified. Treated at Home. Treated in Hospital. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. 31 31 — — — — — 31 cases of Ophthalmia Neonatorum were notified in the course of the year. In addition, in another 98 cases, a copy was received of the medical aid notice sent to the County Medical Officer of Health by the midwife. No cases, apparently, occurred where the Doctor was in attendance at birth. All cases are investigated by the Health Visitors on rcccipt of information and visited regularly until the eyes arc clear. Out of the total number, 70 were very slight cases of sticky eyes, or eyes with a watery discharge. Most of these were clear within a week. There were none that became very serious, though 10 suffered from definite pus. In the remaining 45, the lids were affected, l>cing puffy or inflamed or the congcntiva was affected. For treatment, the same arrangements made by the Local Authority continued in operation, namely, home treatment carried out by the local District Nurses and hospital treatment provided at St. Margaret's Hospital, Hampstead. During the year only one case required treatment under this schcme, costing £l 2s. 6d. Pemphigus. Pemphigus remained on the list of notifiable Infectious wises. During the year, five cases were notified by medical Petitioners, four of them having been called in on medical aid notices. In four cases, the patients were found at the routine the Health Visitors, two being midwives* cases at which the 'j'Ht apparently was subsequent to the time the midwife ceased 1 (,|jdance ; the other two being cases of infants born in one of the ^iidon General Hospitals. Two cases were first noticed on the 0 'ers bringing the patient to the Infant Welfare Centre. the cases were distributed throughout the year and followed the practice of no particular midwife. They occurred amongst 7 differnt midwives, none of whom had, during the year, more than two cases. All cases were, clinically, of the mild type and recovered. One child was removed to hospital for treatment. Maternal Mortality. There were 11 deaths due to pregnancy, of which 5 were due to sepsis, giving a maternal mortality rate for sepsis of 2.50, and for other accidents and diseases of pregnancy and parturition 9, with a total rate of 7.22. Two of the scptic cases followed abortions following which there was a long delay in obtaining treatment. Two cases followed operative interference for obstruction during the confinement. In one instance, the child was large and induction would probably have prevented a fatal issue. In the other, efficient ante-natal supervision would probably have detected the cause of obstruction and averted the trouble. The other case of sepsis followed an apparently normal delivery. Three eases of eclampsia proved fatal. In not one of them was ante-natal supervision satisfactory in spite of a previous history of kidney trouble. In two of the cases, the urine was not systematically examined. Hæmorrhage through obstructed labour accounted for two deaths. Both of these seem to have been avoidable by ante-natal supervision and treatment. Two eases died in spite of early admission to hospital, one suffering from hæmorrhage from placenta previa and the other suffering from hyperemesis. Of the remaining two fatalities, one was a case of pulmonary embolism following an apparently normal uncomplicated confinement. The other died of pneumonia subsequent to a cæsarian section performed owing to disproportion of head and pelvis. For purposes of comparison of maternal mortality rates, the present system of certification leaves much to be desired. ln sonic cases, " pregnancy " appears on a death certificate of a case in which this had actually no association with the fatal issue. More serious is the fact that in many cases there is no mention of pregnancy in eases in which it or the labour was definitely associated with the death. In other instances an antecedent abortion or miscarriage leads to a condition which terminates fatally, but in which the death certificate records only pneumonia or sonic other illness. Investigations into maternal mortality due to pregnancy and child birth as suggested by the Maternal Mortality Committee of the Ministry of Health are carried out by the Medical Olliccr of Health. 64 Puerperal Fever and Pyrexia. 15 notifications were received, 9 being of Puerperal Pyrexia and C of Puerperal Fever or Sepsis. Of the eases of Puerperal Pyrexia, 4 were treated at home, one terminating fatally. Four were confined at home and were subsequently removed to hospital. Of these one died. One case was in hospital for induction. In one instance infection followed an apparently normal confinement. Another was apparently due to infection of a perineal tear caused by large head. A third case was febrile before confinement. The other five cases followed sonic operative interference, two being for manual removal of the placenta and three cases of forceps delivery, one necessitating subsequent perineal suture. All the cases of Puerperal Fever were treated in hospital. Of the three which terminated fatally, two were subsequent to abortions following which there was much delay in obtaining medical advice. The others followed forceps delivery. Work of the Health Visitors. Routine visits arc paid to infants as soon as possible after the tenth clay and special visits arc paid respecting cases of Ophthalmia Neonatorum, Puerperal Fever, following up operations of Tonsils and Adenoids, etc. The following table shows the number of visits paid during the year by Health Visitors:— (a) To expectant mothers First visits 261 Total visits 493 (b) To children under 1 year of age First visits 2,660 Total visits 6,913 (c) To children between the ages of 1 and 5 years Total visits 4,731 Infant Welfare Centres. The number of weekly Infant Welfare Centres at the end of the year was 8, compared with 7 at the beginning. All the centres are maintained by the Local Authority, there being at each, in addition to the Medical Officer and the two Health Visitors, a clerk for dealing with the distribution of foodstuffs. At some centres assitance has been obtained of ladies from the local detachment of the St. John Ambulance Brigade and lately this help has been supplemented by that of a number of voluntary workers. 65 The following table shows the work done at the Infant Welfare Centres during the year:— Total attendances at all Centres during the year:— (1) By children under 1 year of age 13,655 (2) By children between the ages of 1 and 5 7,697 Average attendance of children per session at all Centres during the year 59 Total number of children who attended at the Centres for the first time during the year:— (1) Children under 1 year of age 1,254 (2) Children between the ages of 1 and 5 years 701 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 65.2% Treatment. Tonsils and Adenoids. The same arrangements continued in operation with regard to the treatment of Tonsils and Adenoids, namely, at Oldchurch Hospital, Queen Mary's Hospital, Stratford, and King George Hospital, Ilford. The Local Authority pays the entire eost where the family income is within a prescribed scale. Where the income is outside the scale, the cases are recommended for treatment and the parents make their own arrangements for payment. During the year 22 cases were treated under the scheme at a cost of £12 8s. 6d. Orthopaedic Treatment. (a) Ascertainment Clinic. The Consultant Orthopædie Surgeon paid four visits to the district during the year when children made 37 attendances at a cost of £1 5s. 0d. Of 9 cases of bowed tibiic, 2 were admitted to hospital and 5 fitted with appliances. One of 6 cases of genu valgum was operated on hospital and 5 fitted with appliances. A case of torticollis was successfully treated by massage. One severe case of tallipes admitted to hospital and another ease fitted with splints. One case of polyarthritis and 2 cases of lesions from old poliomyelitis were treated at hospital. 3 children suffered from pes planus and one from kyphoscoliosis were fitted with appliances. Of the cases, 6 were discharged as cured during the year, and 21 were under treatment at the end of the year. 66 (b) Massage Clinic. This is carried out at the Romford After-care Centre by arrangement with the Essex County Council. Four children received 23 treatments at a cost of £2 6s. 0d. (c) Provision of appliances. The Local Authority assists in payment of appliances where the family income is within the prescribed scale. Three children obtained appliances during the year at a cost of £5 0s. 6d. (d) Hospital Treatment. Two cases were sent to the hospital under the Local Authority's scheme, being there a total of 20 weeks at a cost of £1S 10s. 0d. Ultra Violet Therapy. An Artificial Sunlight Clinic was opened at the Becontree Clinic in the latter part of the year. About 20 children attend each session, which are held twice a week. Cases are referred from the various Infant Welfare Centres in the district. Each child is examined by the Medical Officer before treatment is advised and is then seen once fortnightly. The usual course consists of 12 exposures, starting with two minutes back and front and working up to six minutes double exposure. The eases referred arc mostly of children in whom rickets is anticipated, though a few are referred for such conditions as malnutrition. No pregnant women have been treated up to the end of the year. Dental Treatment. The first session of the dental clinic was held in September. Treatment is provided for expectant and nursing mothers and for children up to school age. The service is provided free to those whose income is within the prescribed scale. Those outside this scale make their own arrangements for treatment. Dentures are provided for the mothers. Eight clinics were held at which 146 persons made 166 attendances. Ante-natal Clinic. At the end of the year there were two weekly ante-natal sessions held at the Becontree Clinic, two at the Dagenham Clinic and one at St. George's Church. In addition, a fortnightly clinic is held in the Chadwcll Heath Ward. The Consultant Gynæcologist paid fortnightly visits throughout the year, 88 women making 124 attendances. 67 The same arrangements continued in operation with regard to institutional treatment; namely, admission to Oldchurch Hospital or Queen Mary's Hospital, Stratford. Five patients were admitted during the year at a cost of £34 7s. 6d. Amongst the persons attending the clinic, were 40 attending for post-natal examination and another 45 who were found not to be pregnant. 50% of the eases attended of their own accord or were recommended by Health Visitors ; 25% were referred by the nurses of the County Nursing Association and 10% by the Salvation Army Nurses. 82 eases were referred by 12 independent midwives and 12 by local practitioners. 251 patients paid only one visit, 113 two visits, 61 three and 65 four. The following table shows the work done at the clinics:— (1) Total number of attendances by cxpcctant mothers at all Clinics during the year 2,100 (2) Average attendance of expectant mothers per session at all Clinics during the year 9 (3) Total number of expectant mothers who attended at the Clinics during the year 706 (4) Percentage of total notified births represented by the total number of expectant mothers who attended the centre during the year 30.6% Ante-natal Services. In December, 1930, Memo 156, M.C.W., dealing with Antenatal services was issued by the Ministry of Health. The following report follows the lines of this Memorandum. Section I.—The functions of the Ante-natal clinic. (a) Medical and Nursing. " Including examination and routine supervision of such women as ask for it ; assistance in supervision of patients of doctors and midwives referred by them for this purpose ; examination of patients referred by doctor advice of an obstetric specialist." 706 women paid 2,100 ante-natal visits, 356 attending of their own accord were previous attenders or came on the advicc of Health Visitor and 291 were referred by midwives. 68 On analysis, it was found that some midwives referred the majority of their cases to the clinics whilst others refer few and some only exceptionally. As all midwives in the district are dealing with the same class of patient, the differences in the proportions referred can he attributed only to the attitude of the individual midwives. Too many women attend once only and often that attendance rather late. The Departmental Committee on Maternal Mortality and Morbidity recommends a general physical examination at the 16th week and the midwives' subsequent supervision to be supplemented by a doctor's examination at the 32nd and 36th weeks, particular attention being paid to presentation or any disproportion of the foetus to pelvis. Too large a number of midwives appear to be satisfied with a report of no abnormality occurring at the time of the single attendance. Co-operation between the midwives referring the cases and the Clinic is obtained by the Medical Officer sending a detailed report of the clinical findings to the patient's attendant. A clinic is held every fortnight in a central position of the district by the Council's consultant. Arrangements are made for the examination of the patients of general medical practitioners at these clinics without previous attendance at the Ante-natal clinics. The medical attendant has sometimes availed himself of the opportunity to accompany his patient. (b) Educational and Social. Apart from the attendance at the Ante-natal clinics, many pregnant women are visited in their homes by tbc Health Visitor. During the year 754 such visits were made. The premises at which the ante-natal clinics are held are spaced so that there are few parts of the district from which the inhabitants are more than half a mile from the centres. There is therefore, for those persons who cannot afford the cost of the antenatal supervision by their own doctors, no excuse on the grounds of inaccessibility for failure to obtain the requisite supervision. Many women cannot afford the cost of a doctor and a midwife at confinement. For such cases the medical supervision by the clinic, supplementing the midwife's attendance, is sufficient for normal eases. The difficulty arises in those cases of complications of pregnancy or anticipated complications of labour, for which the attendance of a doctor is necessary. The doctor who is to attend the complicated case of lalour should undertake complete control 60 of the case as early as possible—but the patient cannot afford this attention. It seems the solution to this difficulty must, be the formulation of a scheme by whieh eases of this nature—of persons of limited financial means—referred from the clinics to their own attendants for supervision, should be financially assisted by the Local Authority paying the doctors' fees. An extension of such a seheme is possible by which the patient's own medical attendant undertakes adequate ante-natal supervision even of normal cases, instead of their attending the clinics. The objections to the proposal would mainly arise through the medical practitioners' difficulty in finding the time necessary to undertake the routine ante-natal supervision of a large number of cases. (2) Supply of Midwives. There arc 18 midwives resident in the area whose practice is almost entirely confined to this district, In addition there arc three midwives resident, on the boundaries whose work is largely carried on here. The number of births notified in the year by these midwives was 1,521. There is no shortage of midwives in this district. In the near future a Training Home for pupil midwives will be opened in connection with the working of the Dagenham branch of the Essex County Nursing Association. The midwives being well distributed through the area and each carrying on a fair practice, there is no need to subsidise any of the present midwives nor is there any justification for the provision of a municipal midwife. Pregnant women who find difficulty in finding the midwives' fees are provided for by the District Nursing Association. The Committee of this Association, after consideration of the financial circumstances waive the fee in necessitiois cases. The objection to this instead of making a financial grant to individual midwives for any necessitous cases they attend is that the patient has not an absolute choice in se lecting her attendant. The displacement of handywomen in a doctor's ease by a midwife is a matter of difficulty. Many patients cannot afford the fee of both Doctor and Midwife. Even though sonic from of grant were made towards payment of a midwife's fee on condition that one were engaged in addition to the doctor, the fact that the persons were in a position to book a doctor would usually mean their income would put them outside the scale in which assistance is granted for other schemes under the Act. 70 (3) Consultants. It is recommended that a consultant should he available for any doctor who needs assistance in difficulties or complications arising during pregnancy or at or after confinement. The Consultant attends every fortnight at a building in the middle of the district, and doctors arc invited to refer to him any cases of difficulty arising during prcgnancy or any post-natal cases. The Local Authority in its scheme, has not yet been advised to include arrangements for the provision of a consultant in difficulties (luring labour. The reason for this is that in most cases the Consultant's services would not be available in time. A further reason is that, were he called, mostly it would be in a case necessitating some operative procedure. It seems that in general, the patient would best profit by immediate removal to hospital, there to have done under suitable surroundings, any operation necessary, rather than for the Consultant to attempt anything, mostly after a period of long delay, in the unsuitable surroundings of the home. There are comparatively few in this district who could well be dealt with in their own homes, and these would usually be in a position to make their own arrangements. The vast majority of residents acquiesce freely in the suggestion of removal to hospital. In a district such as this, the provision of facilities for a second when desired by a doctor, early in labour, could best be met the selection of the doctors amongst themselves. Usually amongst a number of doctors some are found with more than average skill in certain departments, including midwifery. Such skill comes through a number of circumstances, as liking for the speciality, and results in a special study with increased knowledge, The increased skill is recognised and attracts more of that class of work with resultant gam in experience. In this way the doctor becomes recognised and accepted amongst his fellow practitioners as semi-specialist whose opinion they value. One or more in a district will usually be found to accept this position. Living the course of labour. would immediately be available, even during the course of labour. Were such a person elected, the Local Authority could guarantee the payment of his fee when called in by his fellow practitioner to a case of complicated labour. With regard to the provision of the services of Consultant in cases of Puerperal Fever, the same conditions obtain. Whatever the circumstances may be that warrant a second opinion, the question of diagnosis usually necessitates skilled treatment and nursing. For most of the inhabitants of this district, this can best be met by removal to hospital where complete diagnosis and efficient treatment can be insured. 71 (4) Hospital Beds. Hospital accommodation is rccommended:— (1) for eases needing institutional treatment, including not only complications of labour and the puerperium, but also patients suffering from abnormal ante-natal conditions and intercurrent diseases, and (2) for patients whose home conditions are unsuitable for confinement. On financial grounds the Council has had to defer, for the time being, the question of the erection of a Maternity Home. Instead, arrangements have been made for the admission of patients to Oldchurch and Queen Mary's Hospital, Stratford. Most cases admitted have been in anticipation of difficulties of labour, though some few for abnormalities of pregnancy. In addition the Consultant has arranged for the admission of a large number of patient seen by him to his own beds at one of the London Hospitals. Few removals are necessary on account of unsuitable home conditions. Where the difficulties are domestic ones, such as lack of supervision of the other children, etc., the case is best met by the provision of home helps. (5) Provision of Ancillaries. (1) Sterilized maternity outfits arc stored at the various clinic* and are available for clinic mothers at cost price. In certain circumstances, a reduced fee is chargcd and in some eases of hardship the outfits arc provided free. These outfits can also be obtained by non-clinic mothers on the recommendation of their medical attendant. Although doctors, midwives and patients are reminded of these outfits, surprisingly little demand is made on them, even by those who would receive them free. (2) Home Helps arc provided for domestic assistance, usual!) for two weeks after labour, the time being extended when necessary These are available also for complications of pregnancy, in eases where the patient requires removal to hospital. The) are also provided in those eases of mothers who arc receiving natal supervision from their own doctors or from a hospital. (3) In necessitous cases, milk is supplied to mothers during the last three months of pregnancy and also to nursing mothers. (4) Laboratory facilities. Examination of clinical material is undertaken by the Essex County Laboratories. 72 The commonest months of gestation for the first visit were the sixth and seventh, when 121 and 131 first attended. Five attended in the first month and five post-mature cases in the ninth. About 60 cases attended eaeh in the second, third, fourth and eighth months and 88 in the fifth month. A total of 123 had sonic complication of pregnancy or of labour. The commonest serious abnormality found was contractcd pelvis. Out of 25 cases, five had normal confinements and one had a miscarriage. The remainder were referred to hospital. Of them, four had Cesarean Section, seven were induced and one had version performed. 15 patients had some cardiac condition. Of eight who were admitted to hospital, four were induced. Of the six post-mature cases, two of the three admitted to hospital were induced and two of the others delivered at their homes by forceps. Albuminuria cleared up completely in 11 cases, three eases were admitted to hospital, one of whom developed eclampsia. 19 other eases had forceps delivery, two being for persistive occipitoposterior presentation and two for uterine inertia. 13 were delivered of stillborn children. In three cases this seemed to be associated with albuminuria, but in most there was no obvious cause. The condition of the teeth was found to be much the same as in 1929, namely, that in rather more than one-third, the teeth were good, but in an equal number of cases, the bad condition of the teeth impaired health. The remainder were in need of slight treatment. 16 cases attending on the recommendation of a midwife were referred to hospital and so lost to the attendant. Although these cases would undoubtedly have been a source of worry to the midwife, some provision should be made by which midwives do not lose financially by a case passing out of their hands in this way. Of the 16 post-natal cases, 32 were referred to hospital lor treatment and 11 to their own medical attendants. Six cases were of sub-involution, while nine were of prolapse or cystocele. Salpingitis or pelvic inflammation was diagnosed in seven eases, and four were examined on account of a history of stillbirth or miscarriage. The Consultant Gynaecologist held 21 sessions at which 88 Patients paid 121 visits." Most of these patients were referred from the ordinary Ante-natal clinics, though a small number were referred direct by medical practitioners. 73 Foster Children. By the Local Government Act, 1929, Section 2(a), the functions of the Poor Law Authorities in respect of infant life protection were transferred on April 1st to the Local Authority as the Maternity and Child Welfare Authority. At the time of taking over, there were 64 names on the register. Each Health Visitor was appointed Infant Protection Visitor for her district to undertake this work. The younger children are seen at their homes or at the clinic every month, and those over three years, every three months. The home is visited at least every six months. In exceptional circumstances only is the foster child not brought regularly to the clinic. As the Maternity and Child Welfare Authority is not the Local Education Authority, there is dual inspection of children from five to seven. On receipt of an application for registration, the house is inspected by a Sanitary Inspector as to the suitability of sanitation and sufficiency of accommodation. In assessing accommodation, floor space of bedroom only is taken into account with minimum requirements for adults of 10 square feet per head and of children under 10 of 30 square feet. Where the premises prove satisfactory, a report is received from the Health Visitor as to the suitability or otherwise of the foster parent. Foster Children. Number on register, April 1st til Number added to register 65 Number deducted owing to refusal, removal, death, or reaching age of seven 67 Number on register, December 31st 62 Foster Mothers. (1) Number on the records on April 1st 51 (2) Number of persons who became foster mothers during 1930 51 (3) Number of foster mothers whose names were ta ken off the records during 1930 16 (4) Number on the records on 31st December 56 Maternity Homes. There are no Nursing or Maternity Homes in the distric. 74 Assisted Milk Scheme. The expenditure incurred by the Council under the assisted milk scheme for the year was £878. £ (a) For ordinary milk 739 (b) For dried milk 139 Education. 2,000 copies of " Better Health " arc distributed monthly from the various Infant Welfare Centres, School Clinics and Libraries. In addition, a number of educational pamphlets are handed out individually from the Infant Welfare Centres. The Medical Officer of Health has given a number of lectures and talks during the year to various guilds and leagues. 75 DAGENHAM BILL. The following are the clauscs in the Hill chiefly concerning this department. The numbering is that of the Bill as deposited. Part IV. Streets, Buildings, Sewers and Drains. 51. Food storage accommodation to be provided. 55. Sanitary conveniences for workmen engaged on buildings. 50. Sanitary conveniences used in common ; allocation amongst users. 57. Closet accommodation in houses occupied by more than one family. 58. Combined drains authorised. 59. As to houses connected with single private drain ; ment of costs for works executed. 60. Improper construction or repair of water-closet or drain; penalty. 61. Wilful damage to drains, water-closets, etc. ; penalty. 62. As to defective drains, etc. ; Council to carry out work if owner delays 21 hours. 63. Amendment of section 62 of Public Health Act, 1875, to include " Medical Officer." Part V. Infectious Disease and Sanitary Provisions. 67. Parents to notify infectious disease. 68. Power to close Sunday schools and exclude children fro111 entertainments. 69. Restrictions on attendance of children at Sunday schools and places of assembly when infectious disease prevails. 70. Extended meaning of " infectious disease " for certain purposes. 71. Supply of antidotes against infectious disease. 72. Persons to furnish names of laundrymen to whom clothes, etc., from infected houses are sent. 73. Penalty on withholding information from medical officer. 74. As to filthy premises ; owner to recover possession of house habitually kept in filthy condition. 75. Cleansing of dwelling-houses in certain cases. 76. Removal of body of person who has died of infectious disease. 76 77. Entry into premises in case of dangerous infectious disease. 78. Prohibition on infected person carrying on business. 79. Removal of infirm and diseased persons in certain cases. 80. Disinfection in case of tuberculosis. 81. Power to compensate persons for ceasing employment to prevent spread of disease. 82. Cleansing or destruction of filthy, etc., articles. 83. Conversion of existing accommodation into water-closets. 84. Bye-laws as to tipping refuse. 85. Bye-laws as to refuse ; extend to include refuse not fetid or offensive or noxious. 86. Regulation dustbins. Council may require owner to provide. 87. Bye-laws as to stables. 88. As to infected stables and other places ; demolition of unsuitable premises. 89. Discontinuance of offensive trade on six months' notice. 90. Power to order alteration of chimneys, where smoke, gas or vapour is nuisance. 91. Provisions as to tents, vans, etc. 92. Prohibition of tents, vans, etc., on lands without previous approval of Council. 93. Bye-laws as to inspection of meat. 91. Bye-laws as to food ; sanitary and cleanly conditions of transport or exposure for sale in open air. 95. Extension of powers of section 72 of Public Health Act, 1025 ; to apply to yard. 96. Power to prohibit persons suffering from tuberculosis from handling, etc., food. 97. Registration of premises used for preparation of potted and preserved-foods. 98. Registration of ice-cream manufacturers and premises. 99. For regulating manufacture and sale of ice-cream, etc. 100. As to inspection of premises used for storage of food. 101. As to street vendors of food ; name and address on vehicle. 102. Penalty on original vendor of unsound meat. 103. Further powers in relation to unsound food ; examination of vehicles or parcels. 104. Medical practitioners to notify cases of food poisoning, l05. Water supply for dwelling-houses to he provided ; penalty. 106.Bye-laws as to lodging-houses ; exhibition of placard with permitted number of occupants. Separate approach to each room. 107. Power to close slaughter-houses if injurious to public; health. 77 108. Provisions of public slaughter-houses and prohibition of private slaughter-houses thereafter. 109. Extension of section 169 of Public Health Act, 1875 ; sories to slaughter houses. 110. Penalty for throwing rubbish into streams. Part IX. Miscellaneous. 152. As to holding of pleasure fairs ; previous consent of Council to be obtained. INCIDENCE of SCARLET FEVER and DIPHTHERIA on the BECONTREE ESTATE Development of the Becontree Estate. In 1920 the London County Council obtained compulsory powers for the acquisition of some 2,770 acres of land lying in southeast Essex for the crection of a Housing Estate. Of this 270 acres were in Ilford, 1,040 in Barking, and 1,460 in the Romford Rural District. Dagenham Urban District, the area being that of the Dagenham Parish, was separated from the Romford Rural District by an Order which came into operation on April 1st, 1926. The entire portion of the land for the Becontree Estate which previously lay in the Romford District was included in this area. Dagenham Urban District is an irregularly shaped area running from the north at Chigwell, south to the River Thames, a distance of some 7½ miles. The northern part, in the shape of an inverted triangle, is about 3 miles north to south, the apex of the triangle being about 1/3 mile long and is represented by the arterial road crossing the district. This northerly portion consists largely of Crown lands and is essentially rural in character, containing a very small population. The southern portion is roughly the shape of an inverted truncated cone. The southermost part, separated from the remainder hy an arterial road which runs roughly parallel to the river at a distance of 6nc mile from it, is scheduled as an industrial area. In the remaining area were two small villages, Chadwcll Heath, in the north, and Dagenham lying towards the south-east. Lying between these is the smaller aggregation of houses at Bcacontree with. Until the development of the Estate, the rest of the area was agricultural. It is in the western half of this area that the Becontree Estate is erected, and, now that it is fully developed, is just fringed by these small villages. As in the early development no new schools were provided at the pace of the new houses, overcrowding occurred at the schools which previously met the needs only of the small villages. Chadwell Heath village is separated from the Estate by a railway line, and for years there was little association between the district cxcept that occurring through the Estate children going 79 to the village school. To a large extent this still holds, though building having extended up to the railway line now makes for closer contact. Dagenham Village has been in closer touch with the new Estate, owing to the use of the same shopping centre— and even to-day the two old schools in the village arc largely fed by the Estate. In the early days of development, those houses in Dagenham adjacent to the Ilford section practically formed part of Ilford, in so far as concerned contact and communication with the outside. This applies, however, only to the earliest portion ; after which the Estate was distinct and dissociated. The recent development at Harking has not, up to the present, occurred immediately adjacent, to the older developed portion in Dagenham, execpt in one small area in which four roads of a district completed not less than two years ago run into the new portion. For the time being then Dagenham can be taken as a separate unit, not much affected by adjacent development. The erection of the Bccontrce Estate was begun in Ilford, with a small portion in the adjacent Romford (now Dagcnham) area which contained the only houses erected in 1921 and 1922. On this section a total of 1,300 houses were erected in a period of about 3 years. In 1923 a new section, No. 2 Dagcnham, was started in the southern part of the Dagenham ward, about 1,000 houses being put up in two years. This area was quite distinct, from the other and was not brought into communication in any way. Each area used separate lines for transport to Town, had distinct shopping areas and separate schools, and were separated from one another by an intervening strip of agricultural property. Each area developed laterally by the erection of further sections. In the north, Valence No. 4 section of 1,000 houses, was put. up in 12 months between mid-year 1925 and 1926, and the adjacent Valence No. 7 of another 1,000 between early 1926 and 1927. In the south, Dagcnham No. 3 section of 1,000 houses was erected in 12 months, September, 1924, to August, 1925; Dagenham No. 6 of 1,000 between December, 1925, and March,1927. In 1927 and 192S, which were the peak years of development, the intervening land between these two areas was dcveloped. Dagcnham No. 8 section of 2,250 houses was put up in 18 months between April, 1927, and October, 1928. Dagcnham No. 9 of 1,700 houses was started early in 1928, and completed within two years. The northern portion was added to by the erection of Becontree No. 10 section of 2,100 houses between March, 1927, and December, 80 1928, and the southern portion completed by the addition of 600 houses in No. 6a section over a period of two years. In the latter half of 1928 the last section Dagenham No. 11 was started and was completed early in 1930. The following table summarises the rate of development of the various sections :— TABLE I. Erection. Number of Houses. Time taken over Erection, Started. Completed. Years. Months. HfordNo.l 11 /1921 1 /25 1,321 3 2 Valence No. 4 6/25 0/26 1,055 1 0 ValcnceNo.7 3/26 3/27 1,005 1 0 Beeontree No.10 3/27 1/29 2,089 1 9 Dagcnham No. 2 9/23 7/25 990 1 10 Dagenham No.3 9/24 8 /25 996 1 0 Dagenham No. 6 12/25 3/27 994 1 3 Dagenham No. 6a 8/26 11/28 590 2 3 Dagcnham No. 8 4/27 10/28 2,236 1 6 Dagenham No.9 2/28 10/29 1,823 1 8 Dagenham No. 11 7/28 3/30 1,800 1 9 The actual growth of the Dagenham portion of the Bccontree Estate is shown by the following table :— TABLE II. Year. Number of Houses built, during the Year. Total Number of Houses. 1921 36 36 1922 946 982 1923 406 1,388 1924 1,279 2,667 1925 1,418 4,085 1926 2,114 6,1 99 1927 3,402 9,601 1928 4,048 13,649 1929 1,400 1 5,033 1930 232 15,265 In the first few years, development was comparatively slow. Moreover the sections were widely separated from each other and individually sparsely populated. With progress of development, new sections were added adjacent to the older comparatively scattered population. This was most marked in 1927 by which time the general filling up of the Estate had begun. Along with 81 this was the accelerated rate of growth resulting in a totally different set of surroundings. In the early years development was slow with the population widely separated. In 1927 and 1928 there was very rapid development with importation of a large volume of new population placed in surroundings, which, compared to the other, were much more congested. Age Distribution of the Estate Population. It was early realised that the Estate Population had an abnormal age distribution, being deficient in the older age-groups. An attempt was made to calculate, from the death rates, the proportions of each of the separate age-groups. The age group 25 to 44 was taken as unity as it is known that the old age population and probably the young adult population are thinly represented; whilst, concerning the child population, there are two unknowns, namely, the number per family and whether there are any local influences which, while not reflceted in the adult statistics, may be acting in the case of the children. The following table shows these results :— Column 1—Age-groups. Column 2—Percentage distribution of deaths in cach agegroup for the country as a whole. Column 3—Actual distribution of deaths in each age-group in Dagenbam. Column 4—Figures of Column 3 in same proportion but based on age-group 25/44 being the same as figure in column 2. Column 5 shows the percentage of actual deaths compared with the number of deaths which would occur in the standardised population. The figures express, for each age-group, the percentage relation of the figures in columns 4 and 2. Column 1. Column 2. Column 3. Column 4. Column 5. Age-Group. Whole Country % Dagenham actual. Percentage. actual death. 110 0/1 9.5 64 10.52 1/4 5. 0 34 5.59 111 5/9 1.6 15 2.46 153 10/14 1.1 5 0.82 74 15/19 1.8 5 0 .82 35 20 /24 2.2 3 0.49 22 25/34 4 .4 10.7 27 65 10. 7 100 35/44 6.3 38 45/49 4.5 13 2.14 47 Over 50 63.6 41 6.74 10 82 The final column shows for the age-groups 0/1 and 1/4 a slight excess. A larger excess occurs in group 5/9. This, however, is based on a very small total, and, actually, this exccss is accounted for by a number of deaths from diphtheria occurring at those ages. Group 10/14 shows a slight deficiency. Groups 15/19 and 20/24 show a very marked deficiency, the total proportion being only 33% of the theoretical number. Group 45/49 shows a 50% deficiency, while the group over 50 is only one-tenth that of the standardised population. A marked deviation might be due to one of two factors :— 1.—Local conditions particularly affecting the death-rates in special age-groups. 2.—The population at risk in any age-group differing widely from the normal proportion. To rule out the first suggestion, the death-rates occurring amongst the residents of the original habitations in the district are considered. The following table shows the number of deaths occurring in this population in each age-group for the two years 1927 and 1928:— Agegroup. 1027. 1928. Number dying at each age-group. England & Wales, Percentage. Number dying at each age-group. England & Wales, Percentage. 0/1 10 9.5 10 9.3 1/4 5 5.0 4 4.3 5/9 2 1.6 1 1.8 10/14 1 1.1 1 1. 1 15/19 - 1.8 2 1.9 20/24 2 2 .2 3 2.3 25/84 3 4 .4 3 4.6 35/44 4 6.3 3 6.1 43/49 4 4 .5 7 4.4 Over 50 60 63.6 65 64. 1 Total 91 — 99 — In 1927, when the death rate for the country was 12.3, 91 deaths would have occurred in a population of 7,400. In 1928 with a death rate of 11 .7, the 99 deaths would have occurred in a population of 8,400. These figures agree sufficiently with the fart that at the last census in 1921 the population was 9,127. Since that date, it will steadily have declined. 83 The percentage deaths in each age-group agree sufficiently closely to permit of the assumption that there was no local influence which caused any serious deviation from the normal of the deathrates, either of the separate age-groups or of the entire population. From this then, particularly in view of the fact that this older population is resident on the fringes of the Estate, one can assume that the same applies to the Estate population. It being accepted then that there arc no local influences which arc instrumental in causing marked deviations in the death-rate for any particular age-group, the only remaining explanation of the deficiency in deaths in particular groups is that the deviations are due to alterations in the population at risk in each group. If this be the case, then the following would be the distribution of the population based on the 1927 figures, the age-group 25/44 being taken as unity :— Age-group 0/14 normal; group 15/24 one-third represented; group 45/49 one-half represented; and population over 50, only 10% represented. This is in accord with what is known of the population of the Housing Estate. The tenants are mostly those with young children—and are, therefore, a young adult population. In the case of persons over 50, their families would mostly have reached adolescence—neither the adults nor the children would in that ease have conic here. This would account for the paucity of adults over 50 and also for the relative deficiency in age-group 15/24. Even in the ease of those families with adolescent children at the time of transfer here, the children having obtained work in Town would frequently remain with relatives there and not come to reside here with their parents. Although not originally included as the original tenants at the time of allocation of a house, in many cases an elderly relative to one of the parents has since come to reside in the house. This practice, together with the fact that each year sees a number passing the 50 age, will gradually increase the proportion of those over 50 as compared with those under 50. To obtain a more accurate representation of the distribution of the population, the following table has been compiled in which the figures for the three consecutive years, 1927 to 1929, have been used :— 84 Column 1. Column 2. Column 3. Column 4. Column 5. 0/1 314 9.3 12.3 132 1/4 175 259 4.31 7.2 6.8 10.0 138 5/9 68 1.8 2.6 10/14 16 1.1 0.6 15/19 21 47 1.9 4.2 0.8 1.8 43 20/24 20 2 .3 1.0 25/34 120 272 4.0 10.7 10.7 — 35/44 152 6.1 45/49 48 4.4 1.8 41 Over 50 190 64. 1 7 .4 - Column 2 is the sum total of deaths in the district occurring in the three years in each age-group. Column 8 is the average percentage of deaths occurring in each group for the country. Column 4 is Column 2 expressed as a percentage. Column 5 shows the percentage ratio of Column 4 to Column 3. The factors for the separate, age-groups are then : group 0/1, 1.3; group 1/14, 1.3; group 15/24, 0.4; group 15/44, unity; group 45/49, 0.4, and group over 50, 0.1. To assess the accuracy of these deductions, the population of 1927 is below constructed, using these factors for the separate agegroups. In that year 10.7% of deaths in England and Wales occurred in the age-group 25/44. In Dagenham, in this age-group, there were 63 deaths. The total deaths occurring in this district then, were the distribution of the population the same as that occurring in the country as a whole, would be 588. The death-rate in England and Wales in 1927 was 12.3 per 1,000 population. deaths at this rate would occur in a population of 47,800. In the following table, a total population of 47,990 is shown in Column 2 distributed in the same proportion in age-groups as holds for the entire population of the country. Column 3 is the previously obtained factor which is to be applied to the appropriate age-group. Column 4 is obtained by the multiplication of these previous two figures :— Column 1. Column 2. Column 3. Column 4. 0/1 800 1.3 1,060 15/24 11,600 1.3 15,400 25/44 7,430 0.4 2,970 45/49 14,110 1.0 14,110 45/49 3,720 0.4 1,490 Over 50 10,330 0.1 1,030 36,060 85 This gives an Estate population of 30,060, of which population there were, under one year of age 1,060 ; under 15 years 16,460. and 5 to 14, 11,060. These figures can now he compared with those obtained from other sources :— (a) From birth rates, actual population under one year of age, 1,030 ; hypothetical figure, 1,000. (b) School population. Number of children actually on register 10,000, of which 1,700 were children not from the Estate, leaving 8,300 Estate children. At this time, however, it was known that there were many hundreds of children for whom there were no vacancies at school. Hypothetical school population 11,000. (c) London County Council census. The last local census showed that there were 18,900 children under 15 years of age in a total population of 40,000, i.e., children under 15 formed 47% of the population. In this calculated population there arc 16,460 children under 15 in a population of 36,060, being 45% of the total. The normal distribution is only 25%. (d) Population per house. The population of 36,060 divided by the mid-year number of houses, viz., 7,300, gives a population per house of 4.94, a figure agreeing fairly with that obtained from other sources. A similar calculation for the year 1928 gives comparable results. The 81 local deaths occurring in age-group 25/44 should occur in a population with a normal age distribution with the deathrate for that year of 11.5 of 65,000. Applying the same factors to the separate age-groups would give the following as the distribution of the Estate population for 1928 :— Under 1 year, 1,400; 1/14, 20,150; 15/24, 4,750; 25/44, 19,430 ; 45/49, 1,340 ; over 50, 1,450. In this total population of 48,520 those of ages 5 to 14 numberd 14,500. Applying the same checks as previously ;— (a) Birth rate, actual 1,500; estimated number 1,400. 86 (b) School population: Total on books 16,500; deducting 1,700 for new Estate children, leaving Estate children 14,800. Estimated number 14,500. (c) Proportion of under 15 to total number: number under 15, 21,550 ; in total of 48,520 gives a proportion of under 15 to total of 44%. (d) Population per house : Number of houses in mid-year, 10,900 gives a population per house 4.45. This distribution then is assumed to hold and from it one obtains the proportion of children under 15 to the total population, namely 45%. Population per House. At the time of home visiting of children under the Notification of Births Acts, the number of occupants of the house are recorded. Excluding the records of houses in which a later birth has occurred, that is, counting the occupants of any single house at the time only at the last visit, a total of 5,141 houses gives an average population of 5.57. This is the maximum average as it includes the child last born, which was the reason for the visit and the record. The minimum average will be not less than this figure minus one for the deduction of the last birth, i.e., 4.47 per house. Assuming this is the average content of the remaining 10,000 houses on the Estate the average per house for the entire Estate will be 1/3 of 5.67 (for the 5.000 houses) + 2/3 of 4.57 (for the remaining 10,000) =4.90. This figure is higher than that found to obtain at the last local census conducted by the London County Council a few years ago.From the nature of the population, one would expect a steady increase for a while. The population of the country increases slightly by the excess of the births over deaths. This district has a young adult population with a relatively high birth rate . Further, being deficient in the older-aged population, the death rate is low. Both these factors tend to increase the natural growth of the population at a rate exceeding that obtaining in the country as a whole. That this actually occurs is shown by the figures of the population per house in different sections of the Estate. The highest average, namely figures of 5.99, 5.94 and 5.72,were found to occur in those sections completed by 1925, or 87 early 1926, whereas the lowest average figures, namely, 5.13, 5.16 and 5.40, were found in those sections completed in 1929, 1930 and later 1928. The average per house of those 1,116 houses in which cases of notifiable infectious disease occurred in the last three years was 5.05, while of a few hundred houses whose population was obtained from other sources the average was 5.04 4.9 then is taken as the average population per Estate house. Growth of the Estate. The following table shows the rate of growth of the Estate and gives the calculated mid-year population. This is based on the figure of a population per house of 4.9. The calculation of the population under 15 is obtained by assuming the number of persons under 15 to be 45% of the total population :— TABLE III Population in Dagunham. Year. Ilouses (mid-year). Population. Population under 15. 1921 18 88 40 1922 509 2,495 1,122 1923 1,185 4,591 2 223 1924 2,027 9,932 4,470 1925 3,376 16,543 7,444 1926 5,142 25,196 11,338 1927 7,900 38,710 17,420 1928 11,625 58,009 26,104 1929 14,341 71,562 32,203 1930 1 5,265 70,172 34,278 Tables IV and V show for diphtheria and scarlet fever for each year:— (a) The total number of cases of these diseases which have occurrcd in the Estate houses. The figures do not. include those infections which occurred in houses other than the Estate. (b) The rate per 1,000 population and the rate per 1,000 of susceptible population on the Estate. (c) The rate per 1,000 population and the rate per 1,000 of susceptible population in England and Wales. The proportion of persons under 15 to the whole population is calculated on the assumption that the rate of decrease occurring in the past few years still holds. 88 TABLE IV. Incidence of Infection of Diphtheria. Year. Dagcnham England and Wales. No. of Cases. Rate per 1,000. Rate per 1,000 under 15. Rate per 1,000. Rate per 1,000 under 15. 1921 0 1.75 0 .61 1922 27 10.82 24.00 1.36 4 .83 1923 6 1 .21 2 .70 1 .04 3.85 1921 11 1.10 2.40 1.08 4.07 1925 10 0.50 1.34 1 .22 4.69 1920 42 1.63 3 .70 1.30 5.07 1927 132 3.41 7.58 1.32 5.10 1928 211 3.63 8.83 1 .55 6.19 1929 210 2.93 6.52 1.58 6.45 1930 334 4.38 9 .74 1.84 7 .68 [The high local incidencc of early 1930 followed a low incidence in late 1929. The notifications in last two months, 1929, were 54, and for first three of 1930, 114. The corresponding figures for previous year were 58 and 27.] TABLE V. Incidence of Scarlet Fever. Year. No. of Cases. Dagenham. England and Wales. Rate per 1,000. Rale per 1,000 under 15. Rate per 1,000. Rate per 1,000 under 15. 1921 0 - - 3.15 11.38 1922 3 1.20 2 .69 3.59 12.74 1923 3 0.60 1 .35 2.82 10 .42 1925 10 1 .00 2 .23 3 .21 8 .32 l926 16 0.96 2. 15 2.35 8.98 1927 96 3.81 8.47 2.09 8.11 1928 199 5.14 11.42 2.16 8 .64 1929 301 5.18 11.53 2.59 10.26 1930 423 5. 91 13.13 8.01 12.36 449 587 12.81 2.76 11.52 The following table shows the relative incidence of infection for both diseases as affecting Dagenham compared with the country as a whole, comparing in the one ease actual total populations, and in the other the population at risk, which is taken as the Population under 15 :— 89 TABLE VI. Ratio of Infection in Dagenham compared with England and and Wales Year. Diphtheria. Scarlet Fever. Per 1,000 Population. Per 1,000 under 15. Per 1,000 Population. Per 1,000 under 15. 1922 7.9 4.0 0.33 0.21 1923 1.16 0.70 0.21 0 .13 1924 1. 02 0.60 0.45 0.26 1925 0.5 0.28 0.41 0.24 1926 1.26 0.73 1.82 1. 04 1927 2.57 1.49 2.38 1.32 1928 2.35 1.42 2. 00 1.12 1929 1.85 1.01 1.96 1.06 1930 2.38 1.26 2.12 1.11 This table shows that, per 1,000 population, in the case of diphtheria, there has been for practically every year some cxcess of incidence rising by 1027 to 2½ times the normal rate of infection. When calculated, however, not per 1,000 population, but per 1,000 susceptible population, it will be seen that in the case of both diseases the relative incidence is not nearly so high. The accompanying graph 1 shows more clearly the trend of relative incidence for both diseases. Excluding the year 1922, in which there were relatively a large number of cases due to infection in an overcrowded school, for the early years of the development of the Estate, infection was very slight. A rise in the relative incidence appeared in 1926 which was continued to 1927, when the diseases were 50% and 30% in excess of the normal rate. The following year saw a dccline in the rate which, however, was still above normal. By 1929 the rate of infection for both diseases was, calculated on the susceptible population, the same as that obtaining in the country as a whole. In 1930 the relative incidence of both infections rose slightly. The incidence of infection amongst the susceptible population: exhibited locally, shows the same trend when compared with the London figures ; though, the incidence in London being higher than the average for the country, the actual figures are lower. From 1922 to 1930 the relative incidence amongst the under 15 population was, for scarlet fever, 0.22, 0.18, 0.26 0.23, 0.89,1.11, 0.95, 1.05 and 0.95, and for diphtheria, 2.29, 0.38, 0.33, 0.15, 0.37, 0.83, 0.94, 0.69 and 0.91. 90 The value of this graph representing, for each year, the local incidence compared with that obtaining in the country as a whole, depends on the accuracy of the previous calculations; namely, those in which one arrives at that unknown quantity, the number of children under 15. The type of graph, however, is of much more importance than its actual level and the type will not be invalidated by any inaccuracies which arc the same in each succcssive year. For instance, should the population per house be 5.0 instead of 4.9; this would increase the total susceptible population by 5% and so would lower the incidence per unit of susceptible population by the same amount, and cause the graph of comparison of local to general incidence to lie nearer the base line. There is, of course, the possibility, and indeed likelihood, of two changes having occurred which would affect the figures recorded. The first is that the average per house in the earlier days was slightly less than at the present time, the existing figure being an average of houses of which some have only recently been erected, others built and inhabited a number of years. These older houses will, on an average, possess a larger population, owing to the families being increased by births, but not correspondingly diminished by deaths. Moreover, the tendency seems to be increasing of bringing down the relatives of one of the parents of the family. This effect, in general, would be slight, and, at most, would result in a slight elevation of the curve for the first few years. The other factor is that concerning the age distribution of the population. It has been assumed that, for each of the years, the percentage population under 15 is 45 of the total. Ordinarily, this figure would, with the passing of years, tend to diminish, as each year would see a number of children passing from the under 15 to the over 15 group. Moreover, the other factor previously Mentioned, viz., the importation of elderly adults, would act in the same direction. These influences would, however, be balanced to a great extent by the new births in the area; a number greater than the number of children passing from 14 to 15. The balance these effects probably results in that assumption being tolerably accurate for each year. 92 The important features of these graphs are :— (1) That the curve is essentially similar for both diseases, scarlet fever and diphtheria. (2) That for a number of years during the early development of the Estate, the incidence of infection was below the average. (3) That this period was followed by one of about three years during which relative incidence was high. (4) That this period was followed by a gradual return to average incidence. The following are possible suggestions in explanation of this :— (1) Pure chance—The very definite line taken by the curves and the closc resemblance of the form of the curves in both diseases precludes this. (2) Effect of schools. (3) Absence of Isolation Hospital accommodation resulting in an excessive number of secondary and return eases. As practically all eases of diphtheria have been removed to hospital this effect should be apparent, to any extent, only in the case of scarlet fever. (4) Owing to the conjunction of an exceptionally large population at any year of age occurring with a general high epidemic rate throughout the country. (5) Some alteration in the herd immunity of the population. These possibilities will now be considered in detail :— (2) Eftect of schools—At first sight, this is a plausible hypothesis, particularly when one realises that for the earlier years of development—when, it is remembered, the incidence of both diseases was low—there were no schools for the children, except for those few who could attend the old village school. The subject will be examined then from this aspect and from two points of view: (a) Whether schools in general have played any great part in infection. If they were responsible, their effect should be operative most in the years of highest incidence and, with growth of school population, the incidence of infection in the district should be higher. (b) There should be a bias in favour of school population if school infection caused any great proportion of the excess. 93 The following figures shows the proportion of children of school age infected in the four years, 1927-1930 :— 1927. 1928. 1929. 1930. Eastren Hospital. Diphtheria 54.8 50.1 66.3 63.8 46.8 Scarlet Fever 63.3 64.8 70.1 62.6 58.8 The year 1927 showed the greatest relative incidence both in scarlet fever and diphtheria, the succeeding years being less heavy. If the extra incidence exhibited were due to the greater relative infection amongst school children, one would have expected the greatest percentage in the 5/14 group to appear in the year 1927; whereas actually there was an increase in the years 1928 and 1929. In general the small effect of schools on infection is shown by the absence of any marked alteration in the curve of incidence of infection at each year of age at the time of entry to school. Taking the incidence for each year from under one year of age to nine years of age for the four years 1927 to 1930, the figures for diphtheria are 8, 31, 74, 87, 102, 166, 143, 98, 78 and53, and for scarlet fever 5, 47, 92, 152, 151, 203, 207, 144. 121. and 79. Represented graphically, these show a slightly asymmetrical curve, with a gradual rise up to a maximum at age six for diphtheria and ages live and six for scarlet fever, with a gradual fall beyond these ages. Were school infection a factor of great importance, there would be a peak shown in the curves at the age five, when children enter the schools. Also, the particular age predilection was shown before the enforcement of attendance at schools. Another fact which shows the same point is the slight effect school holidays have on the incidence of infections. Although, for instance, the summer holiday has, as a rule, the lowest rate of infection, the graph of incidence shows that this period lies at the lowest point of a continuous curve, the decline having commenced much earlier and being well marked before the holidays. Schools apparently have played a very small part locally in the dissemination of the infections, searlet fever and diphtheria. The scarlet fever figures for the last 18 months show that 44.8 out of 852 eases were definitely not due to this cause ; either because the child did not attend school, or the infection was contracted during 94 holidays, or the infection was traceable to another known cause, such as a primary home infection. Of the remaining 404; in 271 cases there was no infection in that department of the school for at least one week previously. In 59 instances, there was another case in the same department in the previous week, and in 35 instances, there was another single case in the same department in the same week (in five instances three cases occurring in the same week). These cases, however, occurred in the same department, not necessarily the same class—and departments number up to 400 children, in nine or ten classes. Actually there was very little grouping of cases sufficient to suggest a local focus of infection. In no one week did more than three eases occur in any department, and in two of these eases, there were other infections in the preceding or succeeding weeks. Only one instance occurred where there appeared to be a definite school infection. This occurred in an infants' school of the old type of building, and the infections in consecutive weeks were 1,1, 0, 3, 2. These followed a missed case who attended school suffering from otorrhæa. School infection played a slightly more prominent part in the spread of diphtheria; though still only a very small one. 296 eases were of persons whose infection was apparently not through school: whilst in the cases of 152 of the other 229 infections, the school was free from infection for at least one week before. In 26 cases, there had been an infection in the preceding week, while in 22 weeks there was more than one child succumbed in one department. In some of these, a definite source of infection was found. Twice within the 18 months the same school—an infants' department of the old type building, having the old bench seating accommodation, was infccted through a carrier, the number of infections in succeeding weeks being 1, 0, 2, 1 and 1, 3. 1. In both instances, no more cases appeared subsequent to the removal of the earner. Although five eases occurred in one week in one department, 3 in another and 2, 1, 3 cases in one department in consecutive weeks in another school, the only definite school infections found were those in the old school. These instances are the only ones in which more than 2 cases of diphtheria occurred in any department in any one week, and in only 4 cases did the disease appear in any department for more than two consecutive weeks. School infection then contributed little to the incidence of diseases and so accounted little for the excess. (3) Shortage of Isolation Hospital accommodation acts in more than one way. Firstly, it means a certain proportion of cases being treated at home, with consequent risk of infection to the remaining occupants. Secondly, owing to cases for admission having to be selected, there is delay in the removal of those which 95 it is decided arc to be admitted. Admission being decided primarily on clinical grounds, some cases remain at home in overcrowded circumstances, with risk of spread of disease. A further factor occurs in the internal administration of the hospital: shortage results in overcrowding, with its frequent high complication rate. These patients, on discharge, develop infections discharges and give rise to return eases. So far as concerns the district for the last two years, all these factors have operated in the case of scarlet fever, though hardly at all in the eases of diphtheria, for which disease there has all along been nearly always sufficient accommodation. The following table shows the distribution of the two infections in each year. It shows that during 1927, which was the peak year of relative incidence, although there were numbers of secondary cases, thev were not attributable to shortage of isolation hospital accommodation, because during that year there was little home treatment for the greater part of the year. In 192S, when over 60% of scarlet fever cases were at home, there was actually a slight reduction in the percentage of infection occurring as secondary or return cases. In 1929, when the same proportion of cases were detained at home, there was a slight increase in the percentage of these infections. These figures then, while not disclaiming that the totals were increased by secondary and return eases, show that they do not explain the excessive incidence for the years it, occurred: — Secondary and Return Cases. Diphtheria. Scarlet Fever. Primary. Secondary. Return. Primary. Secondary. Return and Recovery. 1927 113 21 4 154 29 9 1928 170 17 7 267 36 11 1929 195 19 - 341 64 15 1930 283 40 9 380 53 20 (4) A large population at the susceptible ages, coinciding with a generally high prevalence throughout the country. If for any reason, one particular year of age were especially represented in the population, one would expect this age-group to show a relative excessive incidence of infection. This excess should, in the following year, appear in the next age-group. When the year of age coincides with the year which the infection especially favours, the combination should result in a much greater incidence for that particular year. 96 The following table shows the actual number of notifications received in the four years, 1927-1930 :— TABLE VII. Age. Diphtheria. Scarlet Fever. 1927. 1928. 1929. 1930. 1927. 1928. 1929. 1930. 0-1 2 1 1 4 1 1 3 1-2 8 10 4 9 10 14 10 13 2-3 8 25 11 30 17 22 22 31 3-4 19 21 18 29 23 31 45 53 4-5 17 27 21 37 23 32 40 51 5-6 11 25 27 53 36 59 60 48 6-7 19 22 41 61 46 44 45 72 7-8 15 22 24 37 30 38 83 43 8-9 16 12 17 33 17 34 24 40 9-10 7 8 20 18 17 12 18 32 It can be seen that, at no year of age, is there any outstanding incidence sufficient to justify the assumption of any particular agegroup being relatively heavily represented. (5) The remaining suggestion as an explanation of this excess of infection occurring for these years is that the population, on coming to reside here, loses its immunity and succumbs to infection. The following table shows, for the years up to 1929, the incidence of infection in relation to the period of residence of the patients before they snccumb. The intervals of time taken are the first month, the next three months, four periods of six months each, and after that, periods of 12 months. Each year includes the preceding three months and the following nine months. This eliminates to a certain extent the errors of the returns which are naturally grouped, in the case of the longer intervals, round integer years, rather than in exact years and months :— 1 mth. 2—4 mths. 0 mths. 1 year. 18 mths. 2 years 3 years. 4 years. 5 years. 6 years. Diphtheria 13 26 70 53 37 54 54 30 18 3 Net Fever 7 41 103 65 55 86 82 59 58 - 97 The next table shows these results corrected for the varying intervals of time taken. The year is taken as the unit of time so the figures for the first month are multiplied by 12. The second to the fourth months figures are multiplied by four. The next four intervals of six months each have a factor of two :— 1 mth. 2—4 mths. 6 mths. 1 year. 18 mths. 2 years. 3 years. 4 years. 5 years. 6 years Factor 12 4 2 2 2 2 1 1 1 1 Diphtheria 150 104 140 100 74 108 54 30 18 3 Scarlet Fever 84 164 206 130 110 172 82 50 58 - These results are shown graphically on graph II. 99 The graph shows that the majority of cases of infection appear after a period of residence on the Estate of some six months to two years. This is particularly marked in the case of scarlet fever, but appear similarly in the case of diphtheria. After a period of two years, the cases of infection in relation to the period of residence, appear roughly in proportion to the susceptible population. This grouping suggests that there is some cause which operates after a period of residence here which renders the person more susceptible ; that is, that after a period of residence in this district, the population loses its existing immunity. This suggestion is supported by a consideration of the incidence of infection on the various sections of the Estate in relation to their period of development. Table X shows for each section the time occupied in the erection of the section and the number of cases occurring in succeeding years. Table XI shows the incidence by quarters of the year in each section. It will be noticed that there is a preliminary period of lag of some months in most cases before any infection appears. After this, in the more slowly built sections, there is a slight incidence for a number of years, replaced later by a heavier incidence. In the sections more rapidly erected, however, although there is a period of lag demonstrated, a heavy infection makes its appearance much earlier on, in some cases appearing in the second year of development. That there is a relatively increased susceptibility in this population is demonstrated by the, admittedly few, Schick Tests carried out. Of children of seven years of age and under, two were negative out of 20 ; of those of ages eight and nine there were six immune out of 17 and 10 out of 26 of those over 10 yearsof age. 100 TABLE X. 1922. 1923. 1924. 1925. 1926. 1927. 1928. 1929. 1930. Houses on Section. Months over Erection 1 Sc.F. 3 3 5 2 22 38 23 37 16 1321 38 D. 19 6 5 6 6 9 24 8 19 2 Sc.F. 5 6 17 24 27 52 35 990 22 D. 1 2 8 22 10 15 32 3 Sc.F. 7 14 21 33 44 42 996 12 D. 6 9 14 13 38 4 Sc.F. 13 24 18 20 46 1055 12 D. 5 12 10 22 27 5 Sc.F. 2 24 18 20 46 994 15 D. 3 16 15 10 18 6A Sc.F. 4 12 16 15 596 27 D- 8 4 5 12 7 Sc.F. 6 18 19 22 29 1005 12 D. 1 6 19 14 41 8 Sc.F. 7 46 82 97 2236 18 D. 6 43 42 45 9 Sc.F. 13 43 58 1823 20 D. 3 39 71 10 Sc.F 4 29 52 35 2089 21 D. 4 17 21 18 11 Sc.F 2 23 49 1800 21 D. 5 9 25 101 1 2 3 4 5 C 7 8 Number of 1 Houses 1 Sc. F. 2 1 2 1 1321 D. 3 11 5 3 1 2 2 Sc. F. 1 2 2 3 2 1 990 D. 1 1 1 3 Sc. F. 3 2 2 1 4 3 990 D. 2 1 4 Sc. F. 1 4 4 6 2 8 1055 D. 3 2 4 1 6 Sc. F. 1 1 2 1 2 5 994 D. 2 2 8 5 3 5 6A Sc. F. 1 3 1 590 D. i 2 1 4 1 1 7 Sc. F. 1 1 4 2 10 5 1 3 1005 D. 1 1 1 3 1 3 8 Sc. F. 7 1 5 6 12 23 10 2230 D. 1 1 4 11 7 8 17 1 0 Sc. F. 4 9 4 10 12 1630 D. | 3 7 2 9 10 Sc. F. 1 1 3 — 4 11 4 10 3 2089 D 4 2 4 3 8 3 11 Sc. F. 2 1 5 6 11 1800 D. | 1 4 4 — 3 1 2 As an explanation of the excessive number of eases of infectious diseases in this district, the first suggestion is the large Number of children; giving a large population of susceptibles who, on tie introduction of infection, immediately succumb. Each case, being in contact with a larger number of susceptibles than is usual, rcsult in an extensive outbreak. Further consideration, however, rules 102 this out as an explanation. The large number of children, as such, will not result in any increase, any more than should the same number of children in another district. This area in 1927 had an undev-15 population of 18,750 out of the total population of 48,850. A population with normal age distribution would have that number of susceptibles in a total population of 75,000. The 18,000 susccptibles should contain no more cases in the one than in the other district, if the sole factor in dissemination were the actual susceptible population. Considering the balance of the population, however, it is seen that in this area, the number over 15, that is the presumably immune, are only 1times the number of susceptibles; whereas in a population of ordinary age distribution, the immunised are roughly three times as common as the susceptibles. This low immunity index of the population, by which is taken to mean the proportion of immunes to susceptibles, is probably the determining factor in introducing this increased rate of infection. The question is, in what manner does it produce its effect ? A suggested explanation is the increased contagiousness of the organism as a result of its rapid passage through a susceptible population. There is no evidence to support this. Another suggestion is that there is a general increase in the susceptibility of the population, or to put it the other way round, a loss of what immunity had previously been acquired. It is acceptcd, in general, that lack of susceptibility to infectious diseases shown at increasing age, is not due to the effect of age per se, but that it is the result of tissue reaction to repeated subliminal doses of infection. The result of Schick tests show that, in diphtheria, there is a period of a few months during which most children arc immune, rom six months, at which practically all are susceptible, to the age of 10 or 12, there is a steady fall in the percentage of susceptibles. In congested districts the figure at this age may reach 50%, falling to about 30% for adults. In more rural communities the decline is present but does not reach so low a level. There is, however, no marked deviation in the rate of percentage diminution of susceptibles at or about the age of admission to school. The question is, where does the child receive the subliminal doses that result in the protection. Schools are blamed to a greater or lesser extent for the production or spread of cases of infection action. In the case of the modern elementary school, it not run under conditions of overcrowding, there seems little justification 103 for attributing the spread of scarlct fever or diphtheria to this cause to any extent. Definite eases of school infection do occur, but not to an extent sufficient to justify the popular opinion that, if a school child has contracted either of these diseases, he must have caught it at school—and if a child under school age suffers, he must have contracted it from his brother or sister who attends school. It is conceivable that, although school attendance does not cause actual infection to any extent, it might still result in the production of immunisation amongst the scholars. There is every possibility that a child suffering from diphtheria in the early stage and attending school, even though not infecting any individual child, might give off small doses which will act as part of the series of sub-infective doses which will immunise the contacts. There is this difference, however, that whereas a ease directly infected required only one, probably relatively massive and rapid, infection to succumb, the proccss of immunisation is the result of a long series of small doses. School attendance might result in these doses being obtained at shorter intervals and so the resulting immunity appears at an earlier age. By itself though, school attendance has probably little to do with the production of Schick negative reactors. This suggestion is supported by the following observations :— Dudley in the No. Ill of Special Report Series of Medical Research Council, "Spread of Droplet Infection in semiisolated communities," records how, when dealing with the infections in the Royal Naval School at Greenwich, at which there are residents and day boys, if diphtheria occurred in the community, the carrier rate rose with a rise in the immunity index. This rise, however, occurred much more markedly in the residents than amongst the day boys, the explanation being that there was more time afforded in the dormitories than in the classrooms, to inhale the necessary amount of diphtherial material to effect these reactions. "On the Schick and Dick Tests in Diphtheria and Scarlet Fever" from the Eighth Annual Report of the Scottish Board of Health, 1920, page .5, par. t (b), reacts :— " In Aberdeen, 708 children from west-end schools, children from middle class schools and KM children from cast-end schools were tested. It was found that, of the west-end school children 55G or 78-5% were Schick-positive : of the middle class school children 235 or 62-5% were Schick-positive; while of the east-end school children 126 or 31 -2 were Schick-positive. A possible and probable explanation of the lessened susceptibility of the poorer classes is that, the more crowded the conditions under which they live, the more likely they are the obtain minimum doses of diphtheritic infection, and to develop sufficient antitoxin to prevent them from actually contracting the disease." 104 Were school attendance a potent factor in the production of the Schick negative state, there would not be this difference exhibited amongst the two sets of school children. Moreover, in the results of Schick tests at various ages, as already pointed out, there is no marked change in the curve showing the increase in the percentage of immunes at increasing age, at the age of entry into school. Some factor operates in turning susceptibles into immunes from the youngest ages onwards, and this factor appeal's to be no more, or no less potent, at school age than up to the time of admission into school. The ordinary child is exposed to infection from many sources, some more dangerous than others. Playing with companions in the streets or pleasure grounds, even though contact is very close, for short periods only, should not result in much risk. Considering all the factors involved in the " velocity of infection," including the massiveness of the dose and the time for which it is delivered, a well diluted infection in the open air will not be a very potent factor. The matter is rather different, of course, where " out-ofdoors " consists of a cooped-in back alley. Such places can be as poorly ventilated and as heavily infected as a stuffy room. Exposure to contact with cases in cinemas, shops, buses and trams, owing to the close contact with massive infection over a period of time, is more likely to result in an actual case of illness. It seems that the place where, ordinarily, a child is brought into surroundings in which the circumstances are most in favour of the conveyance to him of organisms of infection, cither in lethal or sub-infective doses, is his own home. Here the influences are operative towards infection, more than in any other place. The infecting person, cither relative or neighbour, is in close contact for a period of time, often in a place suffering from lack of ventilation. Contact in the room results possibly in infection, more often in a subliminal dose. Contact in the bedroom results more frequently in infection. It is suggested that, in general, the gradual increase in relative immunity to the ordinary infectious diseases acquired with increasing age, is due to subliminal infections which are mostly received by the children, in their homes, from healthy carriers. In this district, owing to the relatively smaller proportion of farriers compared with the number of susccptibles, the children c.o not receive these small doses to the same extent as formerly, and so far from acquiring, by repeated small infections, their nnmunity—in certain cases they might even lose that amount of resistance they had previously acquired. This loss of resistance 105 would render them in a position to succumb to infection at some period after their original date of taking up residence here. The absence of heavy infection in the early years would be attributed to relative lack of facilities for conveyance of infection to the population. With the extended development and greater congestion, with more communication of residents amongst themselves, there would be increased exposure of the susceptible to infection. Those sections erected at the more rapid rates would, no doubt, suffer more, as larger volumes of population would be rendered susceptible at the one time. Also the greater crowding of the section in itself, and its proximity to other sections, would permit of greater possibilities of transmission of infection. The relative excess of infection occurring over a period of time will result in an alteration in the herd of immunity. Not only will the susceptibles be reduced by a number equal practically to the number who succumbed to infection, but there will be the effect of each patient contributing, to a greater or less extent, his quota of infectious material to others, resulting in some cases in another infection, but in others in some degree of immunity. By these means, the herd immunity index will gradually be restored to normal, with resulting average incidcncc of infection. It appears that the cxcess infection which has occurred in some years, is determined by a number of factors, some at least of which arc under control. The prevailing type of scarlet fever is mild, and little harm appears to have resulted from the infection of these children. Should the type of scarlet fever illness revert, as it probably will in a number of years, to that which prevailed in this country over a generation ago, the acquisition of some degree of immunity as result of this mild infection, might even result in benefit, by saving the individual from a serious illness in the future. Diphtheria, however, even to-day, is a serious disease and the average fatality rate occurring over the greater number of persons resulted in additional deaths. Ilad the prevailing type of scarlet fever been that occurring at present in South-East Europe, the occurrence of such a large number of cases would have been a matter of grave concern. Since the increased susceptibility appears to be the result of the loss of immunity occurring through the deficiency of healthy carriers, appearing most markedly in districts in which the entire population is in the same state of susceptibility, some preventive measures are possible. 106 (1) In the erection of housing estates of any size, development should be by small sections, spaced out. The first of these small sections should preferably adjoin settled stable communities. Communication with this district will then prevent that loss of herd immunity. When each of these small sections has become absorbed in the neighbouring area and become stabilised, it can be linked up and extended by the addition of other small sections which, in turn, become stabilised by the original new portion of the estate. It would be necessary for each new section to be small, to enable it all to be in touch with a stable district. A large section might result in the creation of an island of susccptibles. (2) Maintenance of the previous level of the immunity index in this scction can be preserved by :— (a) Bringing into the district a population cf normal age distribution, with its further quota of immunes; that is, by bringing the older adults, as well as the younger members of the family. (b) Immunising a large population of the suseeptibles before transfer.