The Urban District Council of Dagenham 1928 Annual Report of the MEDICAL OFFICER OF HELTH FOR THE YEAR 1931 E.W CARYL THOMAS, M.D., B.Sc, D.P.H., BARRISERA-AT-LAW. The Drayton Press, Ley Strest, Ilford. The Urban District Council of Dagenham 1926 Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 19 3 I E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., BARRISTER-AT- LAW. 3 TABLE OF CONTENTS. PAGE. Officers of the Public Health Services 6 General Statistics 8 General Provision of Health Services for the Area 12 Hospital Provision 12 Ambulance 15 Clinics 18 Nursing in the Home 20 Laboratory Facilities 20 Sanitary Circumstances of the Area 22 Sanitary Inspection 26 Housing Statistics 27 Inspection and Supervision of Food 30 Infectious Diseases 34 Diphtheria 34 Scarlet Fever 41 Smallpox 45 Tuberculosis 48 Maternity and Child Welfare 57 Infant Mortality 58 Maternal Mortality 60 Infant Welfare Centres 62 Ante-natal Services 65 5 To the Chairman and Members of the Urban District Council of Dagenham. Ladies and Gentlemen, I beg to submit my report on the health and sanitary circumstances of the district for the year 1931. The year was, on the whole, a healthy one locally. The incidence of diphtheria was low but of scarlet fever was slightly higher than the rate obtaining in the rest of the country. There were a number of cases of smallpox in the early months of the year and an outbreak of whooping cough in the last few weeks exacted its toll amongst infants. The cool summer was reflected in the low prevalence of epidemic diarrhoea. There were no marked developments in the health services during the year, the most important features of advance being the erection of premises of various kinds specially designed for the health services. In January the local Out-Patient Department of King George Hospital was opened. This is a building designed so that one half is used for hospital purposes and one half for services provided by the Urban District Council as Maternity and Child Welfare Authority and the Essex County Council as Education and Tuberculosis Authorities. In February, the accommodation of Rush Green Isolation Hospital was extended, rendering available greater facilities for the isolation and nursing of the infectious sick. In May, York House, the home of the District Nurses, was opened, and in July the extensions at King George Hospital, Ilford, were formally opened. The provision of these additional beds at this institution is a step towards meeting the needs for institutional accommodation of this area. As a result of the last census declaring the population to be over 20,000, certain additional duties devolved on the Local Authority; amongst these are the duties under the Shops Acts, "ending the appointment of a special inspector for the purpose, the work is being undertaken by the sanitary inspectors. 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, Ladies and Gentlemen, Your obedient servant, Public Health Offices, E. W. CARYL THOMAS. Becontree Avenue, Chadwell Heath. * 28th April, 1932. 6 OFFICERS of the PUBLIC HEALTH SERVICES. Full-Time Staff. Medical Officer of Health : E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law. Assistant Medical Officer (Maternity and Child Welfare): ELEANOR HENDERSON, M.B., Ch.B., D.P.H. Senior Sanitary Inspector : G. T. CARTER, Certificate of Royal Sanitary Institute ; Meat Inspector's Certificate. Sanitary Inspectors : L. BUTTERWORTH, Certificate of Royal Sanitary Institute. R. J. DAW, Certificate of Royal Sanitary Institute ; Meat Inspector s Certificate First-Class Certificate Practical Sanitary Science. A. J. JAMES, Certificate of Royal Sanitary Institute. L. E. PRIOR, Certificate of Royal Sanitary Institute ; Meat Inspector's Certificate. (Commenced 28/10/31.) Health Visitors : D. BRACE, General trained : C.M.B., New H.V.'s Cert. (Commenced duties 1/5/31.) V. EVERITT, General trained : C.M.B., H.V.'s Cert N. MILBURN, General trained : C.M.B., H.V.'s Cert. Ex Queen's Nurse. I. RICHARDSON, General trained : C.M.B., H.V.'s Cert. II. SHUTT, Nursery trained : C.M.B. (Commenced duties 7/10/31.) M. SMITH, General trained : C.M.B., H.V.'s Cert. D. WALLER, General trained : C.M.B., H.V.'s Cert. L. WEALE. General trained : C.M.B., H.V.'s Cert., M. & C.W. Cert, New H.V.'s Cert., Sanitary Inspector's Cert. 7 Clerical Staff: Two full-time Clerks in the General Office. Two full-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 Inspectors' 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 Officers, Infant Welfare Centres : M. TURNER, M.R.C.S., L.R.C.P. S. GOODWILL, M.B., B.S. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Registrar-General's estimate of resident population, 1931 90,870 Number of inhabited houses (end of 1931) according to Rate Books 19,457 Rateable value (Sept. 30th, 1931) £394,151 Sum represented by a penny rate £1,550 Social Conditions of Inhabitants. There has been little change in the occupation of inhabitants of the district, most of whom find their employment outside the area. The factories in the southern industrial area have not, apparently, drawn much of their labour from the locality. Imported labour has resulted in a large measure of sub-letting of premises in this and adjoining districts. A number of houses are being erected by private enterprise in separate portions of the district and will, no doubt, meet the demand for these workers. Extracts from Vital Statistics for the Year. Live Births Total. Male. Female. Legitimate Illegitimate 2,099 43 1,052 22 1,047 21 Birth Bate per 1,000 of the estimated resident population, 23.56 Stillbirths 66 33 33 Bate per 1,000 total (live and stillbirths). 2.99 Deaths 653 356 297 Death Rate per I.000 of the estimated resident population, 7.1 Deaths from diseases and accidents of pregnancy and childbirth :— 4 From sepsis other causes Death Bate of Infants under one year of age :— All infants per 1,000 live births 62 09 Legitimate infants per 1,000 legitimate live births 60.9S Illegitimate infants per 1,000 illegitimate live births Deaths from Measles (all ages) 1 „ Whooping Cough (all ages) 10 Diarrhoea (under two years of age) 12 9 Population. The 19.31 Census figure for the local population was 89,365, of whom 44,928 were males and 44,437 females. This figure is an increase of 879 per cent, on the 1921 Census figure. It will be noticed that, rather exceptionally, the number of males slightly exceeds the females. In previous reports, it was pointed out that the usual excess of females probably did not exist here. The distribution of the population has, up to this, been calculated by an indirect method. The increasing population, with larger numbers dying at each age group, now permits of the use of the direct method from the deaths occurring in each age group. The following table shows the distribution of the Estate population for the year 1930. The only material difference for the year 1931 would bean increase in the over-45 age group, as this group has increased each year by additions from a lower group, but is not diminished, as are all the other groups, by deductions of persons passing into the higher age groups :— Age group. Direct method. Indirect method. 0/1 1,900 2,300 1,150 1/4 8,000 8,700 4,550 5/14 23,090 23,000 14,150 15/24 7,420 7,500 13,250 25/44 29,410 30,400 21,960 45+ 5,410 2,900 19,940 75,230 74,800 75,000 The third column shows a population of 75,000 of normal age distribution. The local under-15 years population forms 44 per ®nt. of the total compared with 26 per cent, in a normally distributed population. Births. 2,142 births were registered during the year. The birth rate Per l,000 population was thus 23.56 compared with 15.8 for England and Wales. The rate for the year 1927 was 24.2, and for the three following years 26.5, 30.6 and 23.8. This rate should steadily fall. As to whether it falls below the rate obtaining for the country as a whole spends on the provision to be made for retaining in this district " children of the present tenants. 10 Marriages. Marriages which actually took place in the Dagenham Urban District 15,1 Marriages of Dagenham Residents solemnized at the Registry Office, Romford :— Roth parties belonging to Dagenham 96 Male only „ „ „ 21 Female only „ „ „ 40 Death Rate. Total Deaths in district 402 Outward transfers 83 Inward transfers 334 Deaths of residents 653 Of the 83 deaths of non-residents occurring in the district, 58 took place at the West Ham Sanatorium and 3 in the Isolation Hospital. Of the 334 deaths of local residents taking place outside this area, most occurred in institutions. Of these, 228 occurred at Oldchurch Hospital, 18 at King George Hospital, Ilford. 8 at the London Hospital, 8 at the London Fever Hospital, 5 at Queens Hospital, Hackney, 5 at St. Mary's Hospital, Plaistow, and 1 at Queen Mary's Hospital, Stratford. 653 deaths in a population of 90,870 represents a death rate of 7.19 compared with 12.3 for England and Wales. The figure in 1927 was 7.0, and in the three following years 7.3, 8.3 and 6.6. The low rates for these years are attributable to the abnormal agt distribution of the population, particularly the paucity of older aged persons. Any development in the district, with the importation of a population of young adults will be, compared with the present population, relatively slight, and the chief influence on the death rate from now on will be the ageing of the Estate population. This will result in a steady rise of the local death rate, the height to which it rises depending, in the same manner as the birth rate, on the provision made for the retention of young adults in the district. TABLE 1 CAUSES OF DEATH. Under 1 year Over 1 and under 2 Over 2 and . under 5 Over 5 and under15 Over 15 and under25 Over 25 and under35 j Over 35 and |under45 Over 45 and under55 'over 55 and undert55 Over 65 and under75 Over 75 Male Female Total RegistrarGeneral's Allocations. Male. Female- 1. Typhoid and paratyphoid fevers – – – – – – – — — — — 2. Measles 1 – – – – – – – – – – 1 1 1 — 3. Scirlef fever – – – – – – – – – – – – – – – – 4. Whooping-cough – 3 2 – – – – 6 4 10 6 4 5. Diphtheria – – – 4 1 – – 9 3 12 9 3 6. Influenza – – 1 – – 2 4 2 1 3 4 8 9 17 8 8 7. Encephalitis lecharcica – – – 1 – – — — — 1 — 1 1 — 8. Cerebro-soinal fever – 2 – – – 1 _ — 3 — 3 1 — 9. Tuberculosis of respiratory system 1 – 3 15 35 21 10 2 1 — 48 40 88 49 40 10 Other tuberculous diseases 3 2 5 3 2 1 2 — — — — 6 12 18 6 12 11. Syphilis – – – – — — — — — — — — — — — — 12. General paralysis of the insane, tabes dosease – – – – – 2 — — 2 — 2 2 — 13 Cancer malignant disease – – 1 1 2 6 13 17 10 2 24 28 52 24 28 14. Diabetes – – – – – – 1 2 1 — 2 2 4 2 2 15. Cerebral haemorrhage, etc. – – 1 — 1 3 3 2 4 9 5 14 5 7 1G. Heart disease 1 4 1 5 2 7 7 12 26 32 33 65 39 38 17. Aneurysm – – – – 1 – – – – – 1 – 1 1 – 18 Other circulatory diseases – – – – — 1 — 7 2 6 8 6 4 19. Bronchitis 5 1 2 1 6 2 9 13 19 20 39 16 18 20. Pneumonia fall forms) 37 13 2 1 6 . 9 6 4 4 4 56 37 93 52 30 21. Other respiratory diseases ' 1 \ 9 1 1 2 1 — 1 7 3 10 2 6 22. Peptic ulcer – – – – – 0 1 3 1 7 — 7 7 — 23. Diarrhoea, etc, (under 2 year) 13 – – – – – – – – – – 8 5 13 7 5 24 Appendicitis – – 3 2 2 1 — — — — 4 4 8 4 4 25. Cirrhosis of liver – – — — — — — — — — — — — — 26. Other diseases of liver etc – – — — — 1 — — 1 — 1 1 — 27 Other digestive diseases 1 1 1 – 1 — — — — 2 2 4 3 11 28. Acute and chronic nephritis – – – 2 1 1 1 1 1 2 — 5 4 9 4 4 29. Puerperal sepsis – – – – – 2 2 – – – – – 4 4 — 4 30. Other puerperal causes – – 2 2 1 – – – – – 5 5 — 5 31. Congenital debility, premature birth malformations, etc. 63 – – – – – – – – – – 33 30 63 40 31 32. Senility – – — — — — — 1 — 1 1 — 1 33. Suieide – – – – 3 2 — 1 2 4 6 2 4 34 Other violence – 1 1 7 8 4 6 3 1 2 2 30 5 35 30 5 35. Other defined diseases 4 2 8 9 3 7 9 4 6 1 4 28 29 57 27 23 36. Causes ill-defined or unknown – – 1 – – – – – – – – 1 – 1 1 – 133 25 40 39 36 79 72 64 49 47 69 357 295 652 356 297 12 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 of the Urban District Councils of Dagenham, Hornehurch, and Romford, and the Rural District Council of Romford. The accommodation at the Isolation Hospital was extended by the addition of 100 beds. The formal opening of the extensions took place on 28/2/31. These additional beds did not result in an immediate extension of the available accommodation as the older wards were in need of reconditioning. By the autumn, however, the full complement of 150 beds was in use. The present aceom modation consists of 121 beds in six wards and 29 beds in separate cubicles. The additional beds resulted in far fewer cases of scarlet fever being treated at home than in the last few years. Out of 420 eases notified, 273 were admitted to Rush Green Isolation Hospital, 39 to other hospitals and 108 were treated entirely at home. The added accommodation, particularly the supplementing of the cubicle beds, now permits of cases other than scarlet fever and diphtheria being treated at the hospital. During the year, some cases of erysipelas, pemphigus, puerperal fever and complicated whooping cough and measles were admitted from this area. (2) Smallpox. The Joint Hospital Board has, with other districts, 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. The agreement between the West Ham Corporation and the neighbouring Authorities terminates early in 1932 with a result that all these Authorities have to make alternative arrangements for the isolation of smallpox cases. For the prevailing mild type of disease, there seems no justification for making arrangement different from those for the more common notifiable diseases which are treated at the local Isolation Hospitals. Owing to the mildness of the symptoms, Variola Minor is a disease much more diffcult to 13 check than Variola Major. To provide a separate hospital for its treatment would necessitate the provision of a very laige number of beds to meet the possibility of a formidable spread of the disease. On the other hand, for long periods of time few, or possibly at times none, of these beds would be used. An alternative arrangement would be an agreement between a number of adjacent districts for the admission of all cases occurring in these areas to a ward opened at the hospital of one of these areas. If all Authorities entering into the arrangement undertook to provide this ward in turn, there would be immediately available, on the occurrence of an extensive outbreak, one ward at each of these separate hospitals. In the meantime, in the absence of cases of smallpox, these beds would be available in the ordinary way for the admission of patients suffering from the more common infectious diseases. b. Tuberculosis. The Essex County Council maintain a number of beds for adults and children of both sexes at various institutions. The following is a list of institutions to which patients were admitted from the County of Essex during the year :— Institution. Type of case treated. Black Notley Sanatorium Women and children—pulmonary. Men, women and children— non-pulmonary. Harold Court Sanatorium Men—pulmonary. High Beech Sanatorium Children—non-pulmonary. Chingford Sanatorium Women—pulmonary. Colchester Sanatorium Women—pulmonary. Hford Sanatorium Men—non-pulmonary. I'Ord Mayor Treloar Cripples Hospital Children—non-pulmonary. king George Sanatorium, Bramshott Men—pulmonary and non- pulmonary. Burrow Hill Colony, Frimley Boys—pulmonary. Church Army Sanatorium, Farnham Boys—pulmonary and glands. Hawthori idene Sanatorium, l.ofW. Women—pulmonary. Liverpool Road Hospital Men—pulmonary (advanced). '"''church Hospital. Romford Men and women—pulmonary and non-pulmonary. 14 Institution. Type of case treated. Papworth Hall Colony Men—pulmonary. Preston Hall Colony Men—pulmonary. Royal National Sanatorium, Ventnor Men and women—pulmonary. St. Anthony's Hospital, Cheam Men and women—mixed cases. St. Joseph's Hospice, Hackney Men and women—pulmonary (advanced). Victoria Park Hospital, London Men, women and children— pulmonary. King Edward VII Sanatorium, Midhurst Men—pulmonary. The following are the numbers of persons admitted from this district during the year :— Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Total. Adult ... 49 25 3 1 78 Children 6 3 21 8 38 Hospitals for General Cases. (1) Hospitals for Medical and Surgical Cases. Oldchurch Hospital, Romford.—See page 14 of 1930 Annual Report. King George Hospital, Ilford.—See page 15 of 1930 Annual Report . By the end of the year, there were in use, 132 beds at this hospital. The local Out-Patient Department was opened on 3/1/31. the hospital service provided at the outset being nursing treatment ot minor ailment cases. This service was supplemented by a casualty officer attending at required times. The work in time grew so that this officer now attends one session each day. It is hoped that more use will be made of this building for providing treatment, and so obviate the inconvenience to the local residents of making time-consuming journeys to more distant hospitals. Additional services which could be provided at tin Out-Patient Department are operative treatment of tonsils an adenoids, massage treatment and a consultant service carried out by the visiting physicians and surgeons of the main hospital- 15 (2) Hospitals for Maternity Cases. Maternity cases from this district are admitted, by arrangement with the Council, to Oldchureh Hospital and Queen Mary s Hospital, Stratford. Cases of Puerperal Fever or Pyrexia are admitted to Oldchurch Hospital, or to Rush Green Isolation Hospital. (3) Hospitals for Children. The following is a list of the hospitals at which the Council has arranged that certain cases shall be treated :— Tonsils and Adenoids—Queen Mary's Hospital, Stratford ; Out-patients only. Oldchurch Hospital; In-patients only. King George Hospital, Ilford ; Outpatients or In-patients. Ophthalmia Neonatorum—St. Margaret's Hospital, Hampstead. Pemphigus—Oldchurch Hospital. (4) Orthopaedic Hospitals—Royal National Orthopaedic. 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 Board of Guardians. Ambulance Facilities. (a) For Infectious Cases. A motor ambulance, provided by the Joint Hospital Board, is stationed at the Isolation Hospital at Rush Green. lb) For Non-Infectious Cases and Accidents. Up to this year, the ambulance work has been carried out by single Morris ambulance possessed by this Council. By agreement with neighbouring Authorities, it was possible to call on another vehicle should a demand come through for an ambulance the local one was commissioned. Owing to the increasing 11 tmand made on the ambulance, a second one was put into 16 mission in October ; this is a 24 h.p. Ford Chassis with body and internal fittings by Messrs. Lomas, Manchester. A special feature of the internal arrangements is the provision of three stretchers, the upper one being arranged to tip up and when not in use is out of the way of the patient on the lower stretcher. A Moselev air bed is fitted to one stretcher. The following is an extract of the rules and charges for the use of the Ambulance :— 1.—The Ambulance shall be stationed at the Fire Station, Beacontree Heath, and shall be available at any time, night or day. For the use of the Ambulance (except in cases of street accidents) a permit must be obtained from one of the following :—a medical practitioner ; the Chairman, or, in his absence, the vice-chairman of the Urban District Council ; a local chemist ; the Surveyor to the Council ; the Chief Officer of the Fire Brigade ; a member of the Police Force ; a qualified member of an Ambulance Brigade. 2.—No hospital cases, other than stretcher cases, shall be carried unless by special permission of a Medical Practitioner, who will grant the necessary permit. 3.—A holder of a permit for the use of the Ambulance shall be allowed to telephone for the Ambulance, on arrival of which, the permit must be handed to Driver or Attendant. 4.—The number of persons allowed to accompany a patient shall be two, who will be expected to return home at their own pleasure and expense. 5.—The Ambulance shall not be used for drunken or infectious cases, nor for the removal of dead bodies. 6.—Maternity cases shall not be removed unless proper permission has been obtained from a local Medical Practitioner, except in cases of extreme emergency, when a certified C.M.B. Nurse maj call the Ambulance. In all maternity cases a qualified nurse must travel with the patient. 7.—The charges for the use of the Ambulance shall as follows :— To Bona-fide Ratepayers and Residents. A.—To or from all Hospitals, Institutions, etc., within a of 8 miles from the Dagenham Fire Station, cases s 11 be conveyed free of charge. 17 B.—To or from all Hospitals, Institutions, etc., beyond a radius of 8 miles and within a radius of 15 miles from the Dagenham Fire Station, the charge shall be 7s. 6d. C.—To or from all Hospitals, Institutions, etc., beyond 15 miles radius from the Dagenham Fire Station, a charge of Is. 3d. per mile over and above the fee of 7s. 6d. shall be made. The charge for the remo\al of a case from one house to another (within or without the District) shall be determined by the Committee in each case. To Persons other than Bona-fide Ratepayers or Residents. D.—The charge shall be at the rate of Is. 3d. per mile, plus the cost of any damage incurred in the use of the Ambulance by the patient and for the washing of blankets, bandages, etc. Mileage in all cases shall be calculated from and to the Fire Station, Beacontrce Heath. The following are the details of the work done by the ambulances during the year, w ith the 1930 figures for purposes ol' comparison :— 1930. 1931. No. of accident cases conveyed 351 363 No. of other cases conveyed 529 885 No. of journeys made 833 1,248 No. of miles run 8190.7 11,981 (c) Maternity Cases. l'liese cases, if requiring the use ot an ambulance, are removed either by the Council's ambulance, or in the case of patients being admitted to Oldchurch Hospital, sometimes by the ambulance attached to that institution. In the latter case, a nurse is always in attendance. When the Council's ambulance is requested lor a maternity case, a doctor's certificate is required before removal, to the effect that the person is fit for conveyance. By arrangement with the District Nursing Association, it is now possible for a certified midwife to accompany all maternity cases. 18 Clinics and Treatment Centres. The following table shows the times at which the various Infant Welfare Centres and Ante-natal Clinics are held in the different buildings throughout the district and also the average attendance per session :— Infant Welfare Centres. CENTRE. Held. Day. Average Attendances. Average New Cases. Wesleyan Chapel, High Road, Chad well Heath. Weekly Monday, p.m. 47 1 Becontree Clinic, Becontree Avenue, Chadwell Thrice weekly Monday, p.m. 59 5 Heath. Thursday, p.m. 59 6 Friday, p.m. 50 3 Ford Road Clinic, Ford Road, Dagenham. Twice weekly to Tuesday, p.m. 69 6 Oct. 23rd, then Wednesday, p.m. 72 6 Thrice weekly. Friday, p.m. 30 4 Out-Patient Department, King George Hospital, Twice weekly Tuesday, p.m. 51 6 Five Elms, Dagenham. Wednesday, p.m. 46 4 Ante-Natal Clinics. PLACE. Sessions held. Times Sessions held. Average attendance. 'Average New Cases. Wesleyan Chapel, High Road, Chadwell Heath. Fortnightly Saturday, a.m. 3 1 Becontree Clinic, Becontree Avenue, Chadwell Heath. Twice weekly Monday, a.m. Friday, a.m. 6 9 2 3 Ford Road Clinic, Ford Road, Dagenham. Twice weekly Tuesday, a.m. Thursday, a.m. 8 9 2 4 Out-Patient Department, King George Hospital, Five Elms, Dagenham. Weekly Wednesday, a.m. 10 3 19 The following is a summary of the various other clinics held in the district:— School Clinics. A Minor Ailment Clinic is held each morning from 9 to 10 a.m. at the Dagenham and at the Bccontree Clinics and at King George Out-Patient Department. In addition, an Inspection Clinic is held on Monday mornings at the Dagenham Clinic, on Wednesdays at the Becontree Clinic and at the Out-Patient Department on Friday mornings. Refraction Clinics and Dental Sessions are held as required at the Dagenham and at the Becontree Clinics. Tuberculosis Clinic. A Tuberculosis Clinic is held every Monday and Thursday morning at the King George Out-Patient Department. Venereal Diseases. There is no local treatment provided for persons suffering from Venereal Diseases. Provision is made under the London and Home Counties Scheme, the nearest treatment centre being the London Hospital. It is hoped that arrangements will be made for establishing a clinic at King George Hospital, Ilford. Orthopaedic Clinics. The Consultant Orthopaedic Surgeon attends about four times a year to see cases referred by the School and by the Maternity and Uiild Welfare Authorities. Remedial Exercises and Massage Clinic. Since January, this work has been carried out at the Ford Road * linic, commencing with two sessions a week. It was found that an additional weeklv session was required. Treatment is now carried out on Monday afternoons, Wednesday and Thursday mornings for children of school age and of under school age. Light Clinic. for two sessions a week, a Light Clinic is held both at the Becontree and at the Dagenham Clinics. Treatment is carried out for children of under school age and of school age referred from the various clinics. 20 Professional Nursing in the Home. (a) General. The staff of the Dagenham District Nursing Association was previously housed in one of the London County Council cottages at 25, Alibon Road. To meet the needs of the district, additional nurses were required and it was decided to build a branch home to accommodate them. This building, York House, was erected in what will be, when this area is fully developed, a central site, and was opened on May 23rd. The staff, to start with, consisted of the Sister-in-Charge, a staff nurse and three nurses. In times of need, temporary nurses are added, on occasion there being as many as twelve residing in the home. Whereas previously the services of the nurses were largely limited to the area surrounding their residence, it is now possible for them to undertake work throughout the entire district, and no applications for nurses in any part of the area have been refused. A standard charge is made per visit for general nursing cases, with a maximum weekly charge, but this is waived in necessitous cases. The Local Authority use the services of the nurses for home treatment of such cases as puerperal fever, ophthalmia, pemphigus, etc. An arrangement has also been entered into by which a nurse is available to accompany any maternity case being removed by the Council's ambulance. Nurses have also, on occasion, attended the Infant Welfare Centres in times of shortage of the Health Visitors staff. (b) For Infectious Diseases. Home Helps are provided in cases of domestic difficulties arising out of the home treatment of cases of scarlet fever. Midwives. There are no midwives in the district employed by the Local Authority. At the end of the year there were 21 midwives living in the district whose practices were confined almost entirely to this area. In addition, 3 midwives living on the boundaries of the district attend some confinements in this area. Laboratory Facilities. Examination of clinical material is undertaken at the Esst* County Public Health Laboratory, Queen Victoria Street, London. During the year, 368 swabs were examined for diphtheria bacillus, 330 samples of sputum for tuberculosis bacillus ; 5 samples tor typhoid organism and 49 samples of hair for ringworm. The same laboratory also undertakes the baeteriologi('al examination of milk, of which 106 samples were submitted during the year. 373 swabs were examined for the diphtheria bacillus at the Public Health Offices. 21 Legislation in Force. See pages 23 and 24 of the Annual Report of 1930. The Dagenham Urban District Council Act, 1931, was passed during the year. A summary of its sanitary provisions was given in the 1930 report. The last Census having disclosed that the local population is over 20,000, the administration of the following Acts is in the hands of the Local Authority :— Shops Acts, 1912 to 1930. Blind Persons Act, 1920. Old Age Pensions Acts, 1908 to 1924. 22 SANITARY CIRCUMSTANCES OF THE AREA. Water. See Annual Report, 1930. Previous reports have referred to the unsatisfactory condition of the Manor Farm Estate, which was without a piped water supply and was not sewered. The South Essex Waterworks Company has now agreed to lay a 4 in. water main, under a guarantee by the Council of 15 per cent, per annum of the cost involved. Credit against the guarantee will be given for revenue derived from the domestic supplies. Water was analysed at a new house owing to the suggestion that the illness of a number of the inmates of a house was due to an impure supply. The analysis proved that the water was satisfactory in all respects. Samples were taken of well water of premises, to support the refusal of a habitat ion certificate under the Dagcnham Urban (Water) Order, 1929. The results of the analysis confirmed the opinion previously held, that the water was not wholesome. Drainage and Sewerage. See reports of 1927 and 1928. The Beam Valley sewer was completed during the year. This is laid along the valley of the Beam River from the New Road to Harveys Lane, Rush Green, and permits of possible development of over 700 acres of land in the district. A branch extension of this, the Eastbrook End sewer, drains the land adjoining Dagenhani Road. The Ford sewer, draining the southern industrial area south of the Ripple Road, was completed during the year. Sewage Works. The following summary of the proposed extensions of the new sewage works has been kindly supplied by T. P. Francis, Esq.. A.M.I.C.E., F.S.I., Engineer and Surveyor to the Dagenham U.D.C. The present works constructed in 1924, were originally intended for a flow of about one million gallons per day. Simple sedimentation alone does not reduce the effluent to the standard required by the Port of London Authority, namely, .3 parts per million c. albuminoid ammonia. The industrial area is localised on the Thames side and a separate trade waste sewer of capacity of 6i m.g.p.d. was constructed to serve this area. This trade waste is to be kept separati from the domestic sewage, but arrangements are made to proviw for intermixture if desired. 23 The old works are to be retained in use, with the new works for trade waste and domestic sewage treatment located on each side. Pumping is necessary throughout, the lifts ranging between 18 to 34 feet. At the old works, screened sewage is received into a sump and lifted. The first stage of treatment is in cone bottom detritus tanks, proceeding into " downward " and " upward flow chambers, and thence into four rectangular sedimentation tanks, 100 ft. long by 30 ft. wide and 71/2 ft. deep. After sedimentation the effluent either runs off or is retained in rectangular tidal tanks until the head allows of discharge against the tide level. Penstocks and flap valves prevent backflow from the river. Sludge from the tanks gravitates to a sludge well, whence two 100 gallon Shone ejectors propel it through pipes for disposal on land by ploughing in. The extensions for treatment of domestic sewage have been designed to deal with an estimated flow of 3 m.g.p.d. and a prospective flow of 41/2 m.g.p.d. After passing through an Airdrie type mechanical screen of 1/2 inch bar spacing, the sewage is lifted and conducted into a circular sedimentation tank of the Pruss type providing 3 hours detention. Following this, the sewage is to be aerated in Simplex tanks providing 4 hours detention plus 71/2 per cent, of activated sludge. The purification being partial, provision is made for the re-aeration of the activated sludge in diffused air ridge and furrow tanks. These provide 14 hours detention and a 25 per cent, concentration of sludge. The activated sludge is settled out in cone bottom tanks which provide 3 hours detention and the effluent run off to a pumping station from where it is discharged. The domestic sewage has a strength on oxygen absorbed of 14 parts per 100,000. After sedimentation the figure is 7, whilst after aeration, it becomes about 2. This shows a purification of nearly 86 per cent, on raw sewage and 71 per cent, on sedimented liquor. It is proposed to treat the sludge in a Dorr Digester with a capacity of 1.33 cubic foot per inhabitant. If the sludge is sufficiently digested, it will be dried in lagoons ; if imperfectly digested, lxtrtions of the lagoons will be converted into secondary digestion tanks where the digestion process may be completed. For treatment of trade waste, the 42 inch trade sewer discharges into the old screen pit and pump well. It is proposed to allow tor sedimentation in Dorr Clarifiers for a volume of 4 m.g.p.d. with a detention of 3 hours. It will possibly later be necessary to 'nstal percolating filters in addition. The effluent will run to a common collecting chamber for pumping to the effluent culvert. The sludge is to be treated on ordinary underdrained sludge beds. 1 he estimated cost of the entire scheme, which will provide for treatment of a flow of 81/2 m.g.p.d. is £268,593. 24 Rivers and Streams. See 1930 report. Closet Accommodation. See 1930 report. Scavenging. The following table gives some statistics relating to the collection of refuse :— 1. Total all-in cost per week £179 2. Estimated weight of house and trade refuse collected per week 380 tons 3. Average number of premises visited per week 18,822 4. Cost of collection per house per week 2.28 pence 5. Personnel and Equipment :— 22 men for 6 days and 4 for 3 days. 6 vehicles for 6 davs and 1 for 3 davs. The same method of disposing of house refuse, namely crude dumping on a tip in the northern part of the district, continues in operation. This tip has now for years been a source of annoyance to the surrounding countryside. Other possibilities of disposal have been under consideration. Disposal in some disused gravel pits in the eastern part of the district was suggested. The method would have been liable to cause a nuisance owing to the contained water in the pits, and housing development is already taking place in the near vicinity. The proposal for disposing of the refuse on waste land in the southern part of the district, adjoining the industrial area, was abandoned owing to the expense neccssary in making up the approach road and the difficulties that would have been met with in crossing a railway line. The present proposal is the erection of a separation plant on a site in the middle of the district. 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 tin fields. Cesspools. Most of the cesspools of the district are emptied by the Council gulley and cesspool emptier, the contents being pumped into tin' sewer. Complaints are sometimes received from occupants o 25 houses near the manhole in which the contents are deposited. Difficulties have arisen over the question as to the frequency with which cesspools should be emptied; in some cases this is due to the occupants of the houses using water in a manner which in the circumstances is unreasonable. It is proposed, for the future, that cesspools shall be emptied free of cost at intervals of a month and a charge is to be made for any service provided over this. Disinfection and Disinfestation. See 1930 report. Smoke Abatement. In the latter part of the year, considerable nuisance was caused by smoke from one of the new factories in the southern industrial area. Wood dust from waste was used for power purposes and some imbalance between feed and consumption occurred which resulted in a deficient consumption of the material. The matter was still under investigation at the end of the year. Premises and Occupations which can be controlled by Bye-Laws. Offensive Trades—Fried-Fish Shops. Consent was given during the year to the establishment of two new fried-fish shops in the district. Business ceased at one shop and three businesses changed hands. One fried-fish shop opened without consent, but was closed until the work had been done w'hich was necessary to render the premises suitable for this trade. There are no underground sleeping rooms in the district. Rag Flock Acts, 1911 and 1928. There are no premises in the district in which rag llock is manufactured, used or sold. Mortuary and Disposal of the Dead. See 1930 report. Schools. 1 he sanitary accommodation and water supply of the schools, most of which are modern buildings, are satisfactory. Schools nave again played very little part in the dissemination of infection, iheir slight influence is referred to under the various infectious diseasts. No school has been closed or disinfected during the year on account of infectious disease. 26 Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections :— Houses 3,227 Bakehouses 40 Slaughterhouses 620 Milkshops and Dairies 109 Cowsheds 40 Foodshops 525 Infectious diseases enquiries 7,325 Rooms disinfected 687 Food poisoning enquiries 24 Visits to foster mothers' premises 56 Smoke observations 6 No. of Nuisances investigated 186 (b) Notices served. Complied with. Statutory 364 . 304 Informal 144 144 On the Administration of the Factory and Workshop Act, 1901. In this district there are 35 factories, 34 workshops and 4a workplaces. 1. Inspection. PREMISES. Inspections. Number of Written Notices. Prosecutions. Factories 95 3 Workshops 126 — — Workplaces 160 — — 2. Defects. Nuisances under the Public Health Acts :— Found. Remedied. Defective Sanitary Accommodation 3 "Other Nuisances " 3. Outwork in Unwholesome Premises—Section 108. There was no outwork conducted in unwholesome premises There were 34 premises in which outwork was carried on. At 27 the work done was the making up of wearing apparel. 27 HOUSING STATISTICS FOR THE YEAR 1931. Number of New Houses erected during the Year :— Total 457 (1) By the Local Authority 98 (2) By other Local Authorities Nil (3) By other bodies and persons 359 1 Inspection of Dwelling-Houses during the year :— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts 1,191 (b) Number of inspections made for the purpose 3,227 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 769 (b) Number of inspections made for the purpose 2,281 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 27 (1) 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 481 2 Remedy of Defects during the Year without Service ot formal Notices :— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 75 5 Action under Statutory Powers during the Year ;— A. Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930 :— (1) Number of dwelling-houses in respect of which notices were served requiring repairs ... 364 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners 304 (b) By local authority in default of owners Nil 28 B. Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 83 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 69 (b) By local authority in default of owners Nil C. Proceedings under Sections 19 and 21 of the Housing Act, 1930 :— (1) Number of dwelling-houses in respect of which Demolition Orders were made 26 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders D. Proceedings under Section 20 of the Housing Act, 1930 :— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit E. Proceedings under Section 3 of the Housing Act, 1925 :— (1) Number of dwelling-houses in respect of which notices were served requiring repairs (2) Number of dwelling-houses which were dered fit after service of formal notices :— (a) By owners (b) By local authority in default of owners (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 29 F. Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925 :— (]) Number of dwelling-houses in respect of which Closing Orders were made . Nil (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil (3) Number of dwelling-houses in respect of which Demolition Orders were made ... Nil (4) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil 30 INSPECTION AND SUPERVISION OF FOOD. (a) Milk Supply. There are 29 retailers of milk in the district, the folio win? being the number of premises from which the various classes of milk are retailed :— Ungraded Milk 26 " Grade A " Milk 1 " Grade A " Pasteurised Milk 3 "Grade A "T.T. Milk 2 Certified Milk 3 Pasteurised Milk 9 Sterilised Milk 5 The number of Company Distributing Centres is 10. During the year, five retailers were registered for the first time, registration was refused in one case and two businesses chansei hands through the buying out of smaller concerns by one of the larger. Milk Sampling. Small Dealers Large Scaie No. of Bacteria Local producer. Not local. perc.c. in thousands. Satisfactory. not Satisfactory. not Satisfactory not Under 30 6 2 12 — 19 — 30—100 11 1 12 2 16 — 100—200 3 1 5 3 5 1 200—500 — — 1 1 1 3 Over 500 — — — 1 — — 20 4 30 7 41 4 These analyses show a steady improvement in the quality of the milk sold, though, of course, the low summer temperature favoured low counts. Of the milk of the small producers, 20 out of 21 samples of the local producers and 30 out of 37 of the outside producers were satisfactory. These figures compare with 17 out of 19 and 46 out of 62 for last year. 30 per cent, of the milk of the small producers complied with the bacterial standard of certified milk and 75 per cent, with the standard of "Grade A" milk. The 31 corresponding figures for 1930 were 16 and 50. The milk dealt with on a large scale shows a similar improvement, 41 out of 45 samples proving satisfactory compared with 32 out of 44 in 1930. Out of the seven samples of milk with a total bacterial count of over 200,000 bacteria per c.c., four were of samples which had been treated by heat. A defect in the technique which permits of this number of organisms in the milk cannot result in the absolute confidence in the safety of pasteurised milk which its advocates claim. Pasteurisation has for long been advocated as an essential treatment. It is possible the powers applied for by Manchester will become generalised throughout the country. Whilst a desirable measure for large scale distributing firms, it does not seem that its use can justly be made applicable throughout the country. The efficient small scale producers can produce a milk clean, safe and fresh. Such milk will probably always find a market. The distribution has commenced during the year, from a number of premises, of milk in waxed paper containers. The use of these non-returnable containers in place of the bottle will do much to remove certain of the disadvantages in the present system of distribution of treated milk. (b) Meat and Other Foods. Meat Inspection. There are four slaughter houses in the district, one licensed and three registered. To these, a total of 620 visits were paid 'luring the year. The carcases inspected numbered 2,382, and 5,722 Its of meat were condemned and surrendered. Bakehouses. There are two factory and two retail bakehouses in the district; to these, 40 visits were paid in the course of the year. In August, a piece of bread sold by a large distributing firm, when broken was found to contain a maggot. A report from the National History Museum states that this was the " larva of a beetle known by the name of Trogosita mauritanica, Linn. This is the species which the French christened the Cadelle. The Cadelle is a well-known denizen in flour and grain. It may be either predacious or vegetarian." The point of interest is the mode of entry of this larva into the bread, which was made in a newly created plant specially designed to exclude exposure of the food, or contact by hand. The flour is first passed through a sieve of a very fine mesh in all subsequent processes the bread is scarcely even seen. The only method of entry which seemed possible, is that a sackful of French flour, which, it was admitted, was added to the test, was added after and not before the sifting process. 32 Ice Cream. Section 91 of the Dagenham Act, 1931, calls for the registration of ice cream manufacturers and premises. During the year there were two premises registered. Before the operation of this Act, a notice under Section 72 of the Public Health Act, 1925, was served to discontinue the manufacture of ice cream in unsuitable premises. Shops. 525 visits were paid to shops at which foodstuffs were sold. Food Poisoning. Section 105 (1) of the Dagenham Urban District Council Act, 1931, reads : " Every medical practitioner attending on a person who is or is suspected to be suffering from food poisoning, shall forthwith, on becoming aware that such person is or is suspected to be so suffering, send to the Medical Officer a notification of tin case, stating the name of such person and the place at which such person is." Notice was given of the effect of the Act in July, 1931, since when 27 notifications have been received. In few cases did a diagnosis of food poisoning seem justifiable, many of the patients suffering from alimentary disorders which were apparently due to some pathological condition. In those cases where some food partaken seemed to be the cause of the disturbance, effective action could rarely be taken as in most instances the food had been purchased outside the district. While notification ot this condition is justifiably called for, it appears, at least in a distric of this nature where little food is prepared or manufactured, that little good will accrue in most cases until notification is called to in all areas; in such case a number of complaints would then possibly be traced to the source. As an instance may be given an attack of food poisoning apparently attributable to oysters which were purchased and consumed in another area. The medical Officer of Health of that area was communicated with, but in default of information being received in respect of persons ot areas suffering, it could not be definitely proved that the oysters consumed were the cause. Two persons of separate households consumed a pork Pie and suffered from an apparently true attack ; sausages were apparently responsible for an attack of four members of a family, and or another occasion, two members of a family. Han and crab each seemed to be the cause of two members of a family suffering in each case ; a meat pie and cheese were supposed to be the cause case each. 33 Prior to food poisoning being notifiable, information was received of the illness of a boy, caused by a bad sausage roll. On investigation at the shop where this was purchased, it was found that a number of other rolls were mouldy. The Medical Officer of Health of the district where the rolls were manufactured was satisfied with the conditions under which they were made. It appears that the manufacturers, on sending out these rolls, specify that they shall not be sold after two days. In this instance it appears that part of a consignment had not been sold before the fourth day after delivery. The medical practitioners were all circularised but no other cases were brought to notice. A family outbreak of a dysenteric infection was brought to the notice of the department indirectly some time after the original infection. A number of the family, including the mother, fell ill successively with severe diarrhoea and were admitted to hospital, one case proving fatal. Enquiries failed to lead to the detection of the source of infection. (c) Adulteration, etc. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year 276 samples were analysed, of which 34 were milk and 83 butter. (d) Chemical and Bacteriological Examination of Food. Bacteriological examination of milk, etc., is carried out at he Essex County Public Health Laboratories, 91, Queen Victoria Street, London E.C.4. Chemical analyses are performed by Dr. Bernard Dyer at 17, Great Tower Street, E.C.3. 34 INFECTIOUS DISEASES. Admitted Cases to Isolation Notified. Hospital, Rush Green Admitted to other Isol. Hosp. Admitted to other Hospitals. Deaths Registered. Diphtheria 210 203 4 — 12 Scarlet Fever... 423 277 37 — — Enteric Fever... — — — — Puerperal Fever 4 — 4 9 Puerperal Pyrexia 8 — 3 Pneumonia (Primary) 103 — 7 82 (Influenzal) 22 — 1 Erysipelas 18 1 — 8 — Encephalitis Lethargica 1 — 1 1 Ophthalmia Neonatorum 11 — — — Poliomyelitis ... 1 — 1 — Smallpox 69 69 — — Pemphigus 8 — 4 — — Food Poisoning 27 — — — Diphtheria. The light incidence of diphtheria in the country as a whole during 1931 was reflected in the small number of local notification received, there being only 207 compared with 383 in 1930. Per thousand population this is an incidence rate of 2.28 compared with 1.92 in the previous year, or a rate per thousand under 15 of 5.18. The rate per thousand population in England and Wales was l.27 or per thousand under 15, 4.88. The incidence of diphtheriain this district, compared with that of the country as a whole was. for all ages, 1.79, but for the population under 15 years of age, 10.4 1 2 3 4 5 10 15 20 25 35 45 55 65 l Total.' Diphtheria 4 5 18 17 20 102 27 5 4 6 2 — — 210 Scarlet Fever 4 14 27 33 51 196 56 14 8 11 6 3 — — 423 Puerperal Fever — — — — — — — — 4 — — —■ — 4 Puerperal Pyrexia — — — — — — 4 3 1 — — 8 Pneumonia (Primary) 15 5 7 9 6 15 7 6 2 11 11 5 3 1 103 ,, (Influenzal) — — 1 1 1 — 1 3 — 5 6 1 — Erysipelas 2 2 2 — — 2 3 2 4 — 1 15 Enceph. Lethargica — — — — — — — 1 — — — — — — 1 Poliomyel1itis — 1 — — — — _ — — — — — — 1 Smallpox ... 3 1 3 1 4 9 17 12 8 7 4 — — — — Typhoid Fever — — — — — — — — 7 of Food Poisoning — — — — 1 3 — 2 2 — 6 3 l 27 35 Out of the 211 cases, 196 were primary, 13 secondary and 2 were return cases. Each of the secondaries arose from a separate primary case. In only one case did the onset of the secondary occur within the 5th day from the onset of the primary. In 3 of the secondary cases the onset was on the 11th, 12th and 16th day after the removal to hospital of the infecting case. No other cases were found in the house to suggest a connecting link between the primary and the secondary case. In cases with such a long incubation period, the presumption is that the organisms are not sufficient in the earlier stages to overcome the resistance of the individual, but probably through some local or general lowering of resistance they gain the upper hand, the reaction being then demonstrated by the occurrence of a clinical case of the disease. Of the return eases, the onset of one was within one week and the other, in the third week after the discharge from hospital of the infecting case. No difficulty was experienced during the year in removing cases to hospital. Four cases remained at home during the entire course of the illness, at the election of the parent. A few cases were admitted to the London Countv Council hospitals, these being children who had attended as Out-Patients at the various London General Hospitals. Of the cases, 6 were laryngeal and 10 were nasal without faueial involvement. There were two cases of double infection, the concurrent illness in one being smallpox and the other scarlet fever. Death Rate. 12 deaths (9 male and 3 female) occurred from diphtheria in the course of the year, being a case mortality of 5.8 per cent. One of these was a case of laryngeal diphtheria. Two of the fatal eases were admitted on the third day from the alleged onset, all the others being the fourth day or after. Bacteriological Examination. 368 diphtheria swabs were examined during the year at the Essex County Public Health Laboratories and 373 at the Public Health Offices. Schools and Diphtheria. Schools again appeared to play no part in the dissemination of this infection. Out of the 196 primary infections, 90 occurred amongst children attending schools. On two occasions only did the cases Soccur in the same week in children attending the same 'pavtment, and on three occasions a case occurred in the same department in two successive weeks. Apart from these instances, all eases in any one department were separated bv intervals of at ■east one week. . No schools were closed during the year on account of this information, and no schools or schoolrooms were fumigated. 36 Schick Testing and Immunization. Diphtheria prevention was started in the latter part of the year 1930. Apart from a number of cases of school children who desired treatment following the occurrence of a few cases of diphtheria in the school, most of the earlier cases treated were drawn from those attending the Infant Welfare Centres. Early in the year all children attending the infants' departments in all schools were handed a leaflet containing some notes on Schick testing and inoculation, and also a consent form which the parents were asked to complete and return to the school in respect of any child, not necessarily children attending the school, for whom treatment was required. The response varied between 5 to 15 per cent, of the forms distributed. Later the same method was applied in the case of the older school children. This led to some of the younger children being dealt with for whom treatment was not requested in the first instance. Other persons were recruited by these leaflets being delivered at homes on the occurrence of a case of diphtheria. 51 sessions were held during the year, clinics being held in three different buildings. The average attendance per session was 99. Schick reactions were read a week after the test and injections were carried out at, roughly, weekly intervals. 491 children under six years of age were immunized without previous testing. of 1,013 children tested. 330 were negative ; the 683 positives received three injections. There were 23 children tested whose reactions were not read, and 87 who failed to complete the course. children were Schick-tested in 1931 subsequent to receiving inoculations, but a number have already been dealt w ith in the early part of this year. Owing to the high proportion found still to be Schickpositive after three doses, inoculations are now spaced at fortnightly, instead of weekly, intervals. The total cost including salaries, etc., was 5s. 2d. per child immunized, or 3s. lid. Pre child inoculated or proving immune. No children who were declared Schick-negative or who had received a full course of immunizing doses, have yet been attacked by diphtheria. The following cases of illness have occurred amongst the children treated :— (1) A child of 6, not Schick-tested, received a dose of 1 c.c. on 20/10/30 and on 1 /II /30; and fell ill with diphtheria on 19/11/30. (2) On 4/1 /82, a boy of 2 who had received one dose on 18/9/3'0 contracted diphtheria. .37 (3) On 10/1/32, a girl of 6 was notified as suffering from theria. She was Sehick-positive when tested on 25/9/31 and received 1 c.c. Toxoid Anti-toxin on October 1st, 8th and 15th, but was not subsequently Schick-tested. The illness from which she was suffering however, was scarlet fever. (4) A child of 3 received 1 c.c. doses on 1st, 8th and 15th October, 1931. He was admitted to hospital on 4/2/32 suffering from what appeared to be diphtheria. The diagnosis was, however, changed to tonsillitis, both on account of the clinical condition and as result of swab examinations proving negative to the diphtheria organism. m The following table shows the proportion of children of various ages who reacted Schick positively :— Age. Total. No. of Positives. Percentage of positives. Under 6 13 8 61.5 7 225 170 76.0 8 242 171 70.6 9 224 149 66.5 „ 10 206 133 64.5 11 158 100 63.9 „ 12 148 86 58.1 ,, 13 71 36 50.7 >. 14 42 14 33.3 ,, 15 7 4 57.0 Over 15 15 8 53.3 This table shows that of those children under 7 years of age, 74.7 per cent, are positive ; of children 7 to under 12, 65.3 per cent., and of children over 12, 45.9 per cent, are susceptible. Of children under 7 years tested in Holborn, 85 per cent., and in Camberwell, 79 per cent, are Sehick-positive. These figures are probably not strictly comparable as whereas the under-7 group in this district were almost entirely children of age 6, in the other two districts they would be comprised largely of children of younger ages. Of children of 7 to under 12 years, the local percentage of positive reactors, namely, 65.3 per cent., compares with figures of 54.77 in Holborn and 59.0 in Camberwell. The percentage of positive reactors in those of age 12 and over was 45.9 in Dagenham, 41.77 in Holborn and 50.0 in Camberwell. Of children of ages 5 to 10, the proportion of positive reactors in this district agrees closely with that found in Lambeth, namely, 69.3 per cent, and 69.8 per cent. In age-group 10 to 15 the local figures were 56.2 per cent., and Lambeth 66.6 per cent. 38 Herd Immunity. On page 104 of 1930 Annual Report, appears the following paragraph :— "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 carriers compared with the number of susceptibles, the children do not receive these small doses to the same extent as formerly, and so far from acquiring, by repeated small infections, their immunity—in certain cases they might even lose that amount of resistance they had previously acquired. This loss of resistance would render them in a position to succumb to infection at some period after their original date of taking up residence here." To determine the accuracy of this suggestion, three lines of enquiry have been followed :— (1) The relation of the number of immunes in the household to the Schick reactions of the children of the various ages. The following table shows this :— No. of Immunes in family. Under 7. 7 and 8. 9 and 10. 11 and over. 6 66 (6) 62 (8) .50 (13) 33 (15) 5 62.5 (8) 52 (21) 38 (22) 20 (15) 4 41 (19) 40 (45) 31 (45) 25 (36) 3 58 (41) 54 (104) 48 (85) 48 (60) 2 81 (141) 80 (250) 80 (179) 60 (108) The columns show the percentage of Schick-positive reactors of children of the various ages according as to whether there are 3, 4, 5, 6 or over immunes in the house. An immune, for these purposes, is accepted as a person of over 15 years of age, a person who has had diphtheria (unless a Schiek-reaction shows that he is still positive) and those who are proved to be Schiek-negativeThis is admittedly, inaccurate, as it ignores the fact that many of over 15 years of age and also some who have had diphtheria not be immune, and that many of under 15 will be insusceptiable This latter objection is less weighty than might be supposed usually all children of a family will come together for testing. The figures in brackets show the total number of persons considered. 39 in that group. At the higher ages and particularly in the groups dealing with the larger number of immunes per family, these figures are admittedly small. Taken on the whole, and discounting those groups where only small numbers are dealt with, the table shows that the percentage of susceptibles rises as the number of immunes in the family diminishes. (2) Another line of enquiry was to determine the effect of the occurrence of a case of diphtheria in the home on the Schickreactions of the remainder of the children. The following table shows for three age groupings the percentage of positive reactors in the groups, and also the percentage of susceptibles amongst the total population, including those from homes in which a case of diphtheria has occurred. The effect of a case on any particular child is counted only if that infection occurred subsequent to the birth of that particular child. Positive. Negative. Total. Percentage Positives. Percentage Positives in general local Population. Under 8 30 22 52 57.7 72.7 8 to 12 47 36 83 56.6 63.6 12 and over 7 8 15 46.6 45.9 From the few figures dealt with, it appears that a case of diphtheria occurring in the house has a slight but definite effect in immunizing the remaining occupants of the house. (3) The third line of enquiry was to analyse the Schick-reactions of children tested, according to their period of residence here. The following table shows this :— Period of Residence. Under 8 Percentage Positive. 8 to 12 Percentage Positive. 12 and over Percentage Positive. Total Percentage Positive. Under 6 months . 75(8) 75(12) 80(5) 72 (25) 6 to 12 months 100 (4) 75(12) 100(1) 76(17) 1 year 90(10) 68(19) 50(6) 71 (35) 2 years 82 (34) 70 (67) 45(11) 72(112) 3 „ 73 (74) 65(129) 62(21) 67(224) 4 „ 77(49) 57 (92) 41(17) 62 (158) 5 „ 62(16) 48 (36) 29 (7) 49(59) 6 „ 80(10) 88(17) 50(4) 80(31) 7 „ 86(15) 66(3) 83(18) 8 „ 80(10) — (2) 66(12) 9 and over 87 (23) 33(3) 80 (26) 40 The figures in brackets are the numbers dealt with in any group. As can be seen from the table, the figures are too small when split up in this large number of groups to give satisfactory results; and to ignore the ages of the children and to total the ligures gives erroneous results owing to the extreme difference in the percentage of reactors at different ages. Furthermore, these tests were performed in 1931 ; the results would have been more valuable if they had been known for the years in which the general susceptibility of the population was assumed to be high. The excessive number of cases occurring for a period would have altered the immunity of the population both by reason of the immunity produced in those who had suffered an attack and also by reason of the effect of these patients in immunizing their contacts. An alteration in the percentage of susceptibles brought about in this way, might be sufficient to reduce the proportion of immunes to below that figure which favours an outbreak, even while leaving the population as a whole more susceptible than the average population. Should this be the case, the population might still be considered to be vulnerable and liable to an epidemic, and, whilst the extent of immunizing carried out might show no marked effcct in reducing the number of cases each year -though having a definite effect on the individual children immunized—it should at least help towards keeping the immunity index of the population sufficiently high to prevent the occurrence of a violent outbreak. A number of Schick-tests have this year been carried out on those children who received their three inoculations last year. The following table shows these results :— Negative. Positive. Total. Per Cent. Positive. Under 2 7 1 8 12 Under 3 9 3 12 25 „ 4 5 5 10 .50 „ 5 8 5 13 40 „ 6 16 10 26 40 „ 7 18 15 33 45 „ 8 36 13 49 26 „ 9 20 6 26 23 „ 10 10 5 15 33 „ 11 8 3 11 27 „ 12 6 3 9 33 12 and over 3 3 6 50 The percentage of those susceptible after receiving three doses is higher than the average. It is seen that very young children react negatively to the test, as do also the older children. A large proportion however of those of ages of 41 three to six are shown to be still susecptible. These results can be explained by consideration of the individual immunity of the children of the different ages before receiving their protective doses. Three doses apparently protect children only who have some anti-toxin in their system. The older children would be in this state by reason of having been previously exposed to subliminal doses of infection and so are immunized by their reaction to the additional toxin added to their system. Very young children already possess some immunity ; presumably at the time of inoculation some anti-toxin still remains in their system and the combined effect of this and the inoculation is sufficient to render them Schick-negative. Children of 3 to 6, however, have, at the time of receiving their inoculations, lost their natural immunity of babyhood and have not been sufficiently exposed to sub-lethal doses of infection to develop their further immunity ; three inoculations in them will not be sufficient to awaken a response of that degree that will render them Schick-negative. If this is the explanation of these differences at the different ages, then it seems very probable that these younger children who are Schick-negative will, after a period of years, become again susceptible to infection. Whilst the conclusion might be arrived at that a case of diphtheria occurring in a house does have some effect on the Schickreaetion of the remaining occupants, this influence seems slight compared with the definite effect produced by the immune contacts as shown by the decreasing percentage of Schick-positives at any age occurring with an increase in the number of immunes in the family. This effect of the immunes, who presumably act as healthy carriers, probably only intermittently, supports the suggestion previously made, that the outbreak which occurred in this district in the years 1927-28, was due to the fact that the children, on coming to reside here, lost what immunity they had acquired previous to transerring to this district. Scarlet Fever. 424 eases of scarlet fever were notified during the year. This |s an incidence rate of 4.66 per thousand population or 10.34 per thousand population under 15 years of age. The corresponding 'jxures for England and Wales were 2.05 and 8.09. The compara- mc'f'euee rates in the two groups were, therefore, 2.27 and The distribution was fairly even throughout the year, there Hl"f! no periods of very heavy incidence. In the early months of the year, the shortage of hospital accommodation was again felt, though the difficulties were much relieved by the admission of cases to other Isolation Hospitals. The diffulties were not comparable to those in previous years as all 42 cases in which removal was specially desired were accommodated. The opening of the new wards at the Isolation Hospital in February did not immediately render available additional accommodation as some of the older wards were temporarily closed for structural alterations. These beds were, however, available by the autumn. During the first four months of the year 42 cases were treated entirely at home, 65 cases removed to Rush Green and 34 cases to other hospitals. In addition, there were 5 cases who commenced home treatment but who were subsequently admitted. Of these. 4 would have been removed earlier had beds been available. In the second four months of the year, 37 cases were treated at home, 77 admitted to Rush Green Hospital, and 2 to other hospitals. In the last four months, the corresponding figures were 29, 124 and 2. In addition, 2 cases commenced home treatment but were subsequently admitted. During the year then, out of 420 cases, 108 were treated entirely at home, 266 were admitted to Rush Green Hospital, 39 to other hospitals and, in addition, 7 cases who commenced home treatment were subsequently removed. Home Treated Cases. Of those treated at home, few suffered from complications. Three had cervical adenitis in the third week which cleared in seven to ten days. Otorrhoea occurred in the second week, in three cases, albuminuria in the fifth week in one, and scarlatinal rheumatism in the third week in one case. Of the seven who commenced home treatment but were subsequently admitted, two were removed on account of the severity of the attack and one owing to the patient developing concurrent diphtheria. Secondary Infection. Of the 57 cases of secondary infection, 13 occurred where the primary case was treated at home, 5 were subsequent to a missed primary case, and in 12 the onset of the second was before the notification and removal of the primary case. In these cases, the onset of the secondary occurred on the second day from the onse of the primary in 6 cases, and on the third day in 7 cases, In a total of 21 the onset was within one week of the onset of the primary. In 5 cases, the onset was in the second week ana in 6 in the third week. Of the secondary eases occurring after the removal of the primary case to hospital, 14 occurred within the first three days after removal, only 2 occurring in the remainder of the first weej and 3 in the second week. In 5 cases the onset was reported to be in the third week after the removal of the primary case. 43 none of these was it found that any of the remaining members of the household had the infection and acted as a link between the two cases. Of the secondary cases occurring when the primary case was treated at home, the onset of the secondary was within one week of the onset of the primary in 9 instances, within two weeks in 2, and within three weeks in 5 cases. These cases occurring in the second and third weeks would ordinarily be assumed to have been preventable by early removal of the primary case. When, however, the primary case was removed early—and ignoring those cases where the onset of the symptoms of the secondary case occurred before removal of the primary infecting source, 16 cases of secondary infection occurred in whom the onset was within one week of the removal of the primary, 3 in the second week and 5 in the third. These figures then show that later infections occurring as secondaries to a home treated case would not necessarily have been prevented by hospitalization of the primary case. In most cases there was only one secondary case in the house, there being two instances of two secondary infections and one of three. In addition, at the time of the illness of a home treated case, the mother suffered from tonsillitis in four cases and from quinsy in one. Return Cases. There were 13 return cases in the course of the year, of which more than one-half occurred in the first two months of the year. No rases have occurred since July. The distribution of the cases in point of time confirms the statements made when discussing return cases in previous years, that the number then occurring was due to the overcrowded condition under which the hospital had to be run pending the extension of accommodation. Eight of the return cases occurred within one week of the return home of the primary case, two in the second and third and one in the fourth week. One recovery case occurred in the third week after the freeing of a primary case. Some of the infecting cases showed abnormal mucosa developing a short time after discharge from hospital. Most of the Primary eases had apparently suffered from an uncomplicated attack as they were discharged on or about the 28th day. Some were discharged in their sixth week after admission and one in the eighth. All had at the onset been at home some days before removal to hospital, the shortest period being four days from the onset and most had been removed on the sixth day. Two had been treaated at home for 10 days before removal and one for 25 days, ""sidering the probable absence of any effective measures of 44 tion of these patients before removal to hospital, the fact that they subsequently gave rise to infections in the house can only suggest their having picked up, during their stay in hospital, a more infectious type of organism. Deaths. No deaths were certified during the year as being due to scarlet fever. Dick test. No children were submitted to the Dick test. Schools. School attendance again appeared to play no part in the spread of scarlet fever in this district. Out of 420 cases, only 173 primary infections occurred amongst children attending the public elementary schools just prior to succumbing to the illness. There were very few instances of even two cases occurring in the same department of any schools in the same week, and in most cases the interval separating one case from another in the same department was more than one week. The distribution of cases by weeks would at first glance lend support to the suggestion of the effect of schools in spreading this infection, if the occurrence of a large number of cases occurring within a short period after the opening of schools after holidays is taken as evidence of this influence. This was especially marked in the case of the Easter holidays. The notification figures for consecutive weeks in late March and early April were, 9, 5, 7, 1.19> 16, 9. The 19 cases were notified up to the end of the week during which the schools reopened after the holidays. Of these cases, however, 3 were secondary to preceding infections and one was a return case. Of the 15 primary cases, 5 were of children under school age and 2 were of persons over school age ; of the remaining 8, only one attended school during that week, none of the others having attended since the end of the previous term. Similarly of the 16 infections in the following week, 10 were of children of school age but of these 4 had not attended school since the holidays. This analysis then, discounts the suggestion of school influence in spreading infection. Two cases were notified as puerperal scarlet fever. In oneoi these the onset was the fourth day after the confinement and appeared a typical case. The other, however, was more probably a case of a rash occurring through septic infection of the uterus. Enteric Fever. No notifications were received during the year of cases of enteric fever. 45 Dysentery. In May, a notification was received of a boy of 12 suffering from the Sonne type of bacillary. dysentery. He had been admitted to a hospital some ten weeks previously for some other condition. Erysipelas. 18 cases of erysipelas were notified, 7 male and 11 female, of whom 9 were admitted to hospital, 8 being to Oldchurch Hospital. In a child of two years of age the illness proved fatal. Most of the infections occurred in the autumn, lhe leg was affected in 6 cases, the face in 8 and the head in 4. Cerebro-Spinal Meningitis. In September a notification was received that a boy of 15 months was suffering from cerebro-spinal meningitis. The illness proved fatal. Acute Anterior Poliomyelitis. One case, a boy of two years of age, was notified in January as suffering from poliomyelitis. After a period of in-patient treatment he made a good recovery. Encephalitis Lethargica. In September a girl of seven was notified as suffering from acute encephalitis lethargica and was admitted to hospital. A fatal case occurred in May in a man of 32 who had been suffering for the previous two months. Smallpox. 66 cases of smallpox were notified during the year, being practically limited to the first three months of the year. Many °f the infections were attributable to three main sources. In the 1930 report an account was given of a number of cases occurring in the latter part of November and through December, through a school infection, due primarily to a case being mistaken for one of chickenpox. A few cases occurred early in 1931 as home infections secondary to some of the patients in 1930. A child, whose onset was 6 /1 /31, was probably associated with these cases. She was detected by a case occurring at the end of January, this child infecting another, who then passed the disease on to his mother. 14 cases occurred as the result of an attack in a child being d'agnosed as chickenpox. On 16/1/31 a boy D.V. was notified as suffering from smallpox. One brother and one sister were found also suffering and all were removed. A sister had suffered from a 46 slight illness during the Christmas holiday and was diagnosed as a case of chickenpox. The distribution of the healed lesions however, left no doubt that her illness had been smallpox. Three days after the removal of these patients a married sister, Mrs. R., another brother living at home, and his fiancee, R.A., were removed. The following day two more sisters at home had an eruption and were removed. Early in February further secondary infections occurred, three in the home of Mrs. R., and one in the home of R.A. This latter was followed at the end of the month by another case residing in the house, and also a case occurring in a visitor. On 20/1/31, smallpox was diagnosed in two sisters. This led to the recognition of a missed case L.M., aged eight, who had the rash about 25/12/30. On 3/2/31 a case was recognised in whom the onset of the illness had been on 14/1/31, and the rash had been out since 18/1 /81. In the same house was found a girl with a rash which came out 18/1/31, and another girl P.M., aged eight, whose rash came out 27/12/30. These two girls P.M. and L.M. both attended the same school. Investigations led to finding that a child K.B. had suffered from an unrecognised attack of smallpox, the onset being 11/12/30. This child had apparently infected: (1) her brother and sister at home—in both eases the disease had been unrecognised ; (2) P.M., in whom the disease was unrecognised —she infected her sister and her brother, and it was not until her brother had had the rash 16 days that the illness was diagnosed; (3) L.M., another unrecognised case who infected her two sisters; (4) W.L., who infected his mother and brother, and in whose cases no medical attendant had been called in. 11 cases then were apparently due to this unrecognised smallpox occurring early in December. There is every reason to believe that the other child referred to above who suffered during the Christmas holidays and led to 14 cases, was infected from the same sourcc, as she lived in the same area and her onset was about the same date as these other secondary infections. No direct connection could, however, be found. Another missed case with an onset early in February gave rise to two secondary cases in the home at the end of the month. Another person who was a frequent visitor to the house fell ill about the same time and gave rise to a further four cases in her own home. Two cases in the same house with a simultaneous onset led to the detection of another missed case. A number of other cases gave rise to secondaries in the home, one to four, one to three, and for to one, and another gave rise to four in the home and to one visitor. ^Three cases were secondary to one occurring in 1930 and one to another; and one infection was secondary to a missed case occurring in December, 1930. 4.7 In a few cases the origin of the primary infection could be traced, three separate cases being attributed to the patients having visited cases in London. One patient worked in the receiving room of a laundry at the time that the disease was prevalent in the district. There were, however, many cases in whom the infecting source could not be found, some occurring amongst children who had not been out of the district. It is highly probable that there were, during the last few months of 1930, and in the early part of 1931, a great number of missed cases going about while infectious. Out of the 66 eases notified, 17 were primary. In 3 of these a source of infection was known, namely, a case in London. In the remaining cases there was no known contact. There were 49 secondary cases. Of these, 5 were home contacts of a 1930 case, and 39 of a 1931 case. In 5 instances the case was attributed to a school infection. In addition, it was discovered that there had been 14 cases whose onset occurred in 1931 in whom the diagnosis was not made while the patient was in an infectious state, and a further 4 eases who had been attacked in the latter part of 1930. A large number of the missed cases were assumed to be chickenpox and no medical attendant called in. Chickenpox is not now a notifiable disease in this area. Had it been so, it is possible that some few of these cases would have been detected. During a period of three months, however, when it was notifiable, only one notification was received from a parent. The other two sources of information of the prevalence of the disease are the head teachers of the schools and the medical practitioners. The information is received from the school whether or not the disease is notifiable. The only advantage therefore accruing from the notification of ehickenpox is obtained if there is a sufficient medical staff to enable all cases to be visited. This, however, would not eliminate entirely the risk of missed cases as many other diagnoses are made of the eruption, the commonest being food poisoning and weakness following influenza. Of all the cases attacked, only four had been previously ^aceinated, excluding those vaccinated some days after exposure. These cases were all secondary to a home infection with opportunities [or massive doses of infection. All had been vaccinated in infancy. Their ages were 28, 29, 34 and 37. The commonest day of eruption from the onset of the illness was the sixth, accounting for one-third. In one-sixth of the cases it was the fourth and a similar number on the seventh. In four cases no history of a preceding illness could be obtained. The commonest interval between the onset of the primary and onset of the secondary case was 20 days, the shortest period being and the longest 28 days. From the occurrence of the rash of 48 the primary to the onset of the secondary, the intervals were most frequently 14, 17 and 18 days, the shortest being 10 and the longest 28. The corresponding times between the onset of the primary and the rash of the secondary were 26, 20 and 29 days, and between the rash of the primary and the rash of the secondary 22, 14 and 25 days. The longest interval between removal of the primary and onset of the secondary case was 18 days, and between removal and rash of the secondary 22 days. A total of 5,517 visits were paid to the homes of smallpox contacts by the Sanitary Inspectors. Visiting is continued to the 19th day from last exposure to infection. The followirg table shows the position of vaccination for the last year :— 1. Successfully vaccinated 587 2. Insusceptible 3 3. Conscientious Objectors 858 4. Died before Vaccination 62 5. Postponed by Medical Certificate 50 6. Removed 87 7. Unaccounted for at present 206 No vaccinations were performed during the year by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. Tuberculosis. New Cases. Deatltf. Primary Notification. Brought to notice other than by Form A. Pulmonary NonPulmonary Non- Pulmonary N'onPulmonaryp Pulmonary Pulmonary M F M F M F M F M F M F — — — 1 7 — — — — — — 2 1 l 2 3 5 — — 1 — 1 — 2 1 5 2 2 6 2 2 — — 3 — — — 1 10 1 2 5 2 1 2 4 — 2 1 1 1 15 4 7 4 — 4 1 — 1 2 5 — — 20 10 4 2 — 4 2 — — 5 3 1 1 25 2!1 19 1 2 3 4 1 l6 10 — 2 85 18 9 0 3 7 1 — 12 9 — — 45 8 4 2 1 — 9 1 — — 55 1 2 1 1 1 — •1 — — 65 & upwards — — — — — — — — — — — 69 49 25 18 19 18 7 5 48 49 6 12 49 Register. Pulmonary Non-Pulmonary Male. Female. Male. Female. No.on register 1st Jan., 1931 374 328 170 143 During the year :— New notifications 69 49 25 18 Deaths 41 33 4 6 Transfers into area 19 18 7 5 Transfers out of area 22 10 6 1 No. on register Dec. 31st, 1931 399 352 192 159 During the year there were notified 118 cases of Pulmonary Tuberculosis and 43 cases of Non-Pulmonary Tuberculosis. Although these cases are added to the register in the one year, it does not mean that this number of cases has been notified for the first time in this year. Many were cases in whom the disease had occurred some time previously while the patient resided in another area and information of these had already been received. Actually, about one-quarter of the pulmonary cases and one-sixth of the non-pulmonary cases transferred to the district while suffering from tuberculosis. Other cases were added to the Register, having come to notice otherwise than by notification by a medical practitioner. This number in previous years was very large during the development of the Estate, but the numbers should now steadily diminish. These figures represent the extent of disease occurring in persons who transfer here to occupy vacated Estate houses and also to reside in the comparatively few newly erected dwellings. 1 he numbers of these patients brought to notice during the year and who have not been notified to this office since residing at their new address are 37 Pulmonary and 12 Non-pulmonary. 118 notifications is a rate of 1.3 per thousand population, compared with the rate of 1.4 for England and Wales. Excluding those who transferred here with the disease, the notification rate those pulmonary cases is 1.0 per thousand. The 44 non-pulmonary cases is a rate of 0.5 per thousand population compared with 0.46 England and Wales. Excluding those who contracted the disease before transfer, the rate is only 0.41 per thousand populaton. The turnover of occupation of Estate houses is now about per cent, per annum or roughlv 7,000 persons. The number 50 of transferred eases in this population, assuming the incidence rate to equal that occurring in the Metropolitan population, would be 62 pulmonary and 25 non-pulmonary cases. Actually the number of transfers is much less than this. Of the primary pulmonary notifications, 74 per cent, were original cases, and 26 per cent were transfers. Of the percentage of original cases, 64 were of persons resident in the Estate houses, J occupied houses erected since ] 921 and 6 were occupants of the older houses. Of the percentage of transfers, 23 were occupants of Estate houses. Of those in whom the disease was first diagnosed while the persons were residing here, in not all cases could it be assumed that the onset had occurred within that period. Six cases were notified as suffering from pulmonary tuberculosis within six months of transferring here and a total of 12 within 1? months. These persons, in most cases, gave their history of onset of illness oidy shortly before being notified, but considering the usual delay in seeking medical advice, it is very probable that most, if not all, of these patient s had contracted their illness before coming to reside in this area. Of the non-pulmonary eases notified, 16 per cent, were transfers, all of these being residents of Estate houses. Of the other cases, in 4 the onset was within six months of their residing here, the disease probably having been contracted before removal of the patient from his previous residence. 5 per cent, of the nonpulmonary cases occurred amongst occupants of the older property of the district. Of the persons suffering from pulmonary tuberculosis who were first notified in this area, the onset of illness occurred within six months of residence here in 6 cases, in the second six months 7 cases ; in the second year 9 cases; in the third 18 ; in the fourth, fifth and sixth years 13, 7 and 6 respectively ; and 10 cases occurred amongst persons who had lived here six years and over. Of the non-pulmonary cases, the onset of 4 was within six months of residence and 6 within twelve months. In 5 cases the onset was in the second year and 10, 3, 1 and 4 in the third to sixth years, and one in a person who had lived here over 6 years. Of the non-pulmonary cases who were first notified here, 10 were persons of over school age. Of these, glands were affected in 4 instances, the spine in 2, the intestines in 2, the tongue in one and one person died of meningitis. Seven children of school age were notified as suffering from tuberculous glands and 4 children of under school age. Meningitis was notified 3 times in children of 5 and under; tuberculosis of the spine in 4 and of the hip in 1- Three children of school age suffered from a tubercular spine, and 2 from tubercular peritonitis. Of children of under school age, a family 51 history was obtained in 2 out of 10 cases. Of children of school age, the history was obtained in 8 out of 20 cases. Ill all cases the milk supplied to the home had been treated by heat. The difference in the proportions of cases in which a family history was obtained suggests that the home infection was there, causing the disease in the ease of children under school age, but that it is not until it is sufficiently advanced in the infecting source that it is recognised, and by that time the children have reached school age. Amongst the males over school age, a family history was obtained in one-third of the cases. One-third of the males were engaged in some outdoor occupation, such as motor driving, labouring, etc., 3 patients worked in the printing trade and another 6 were engaged in a dusty occupation. Of the females, most were engaged in housework. A family history of disease was obtained in nearly one-half of these latter cases. The fact that the notification rate is lower than that obtaining in the country as a whole is probably accounted for to a certain extent by the age distribution of the population. Amongst persons of over 45, only 15 notifications were received, which is a lower percentage than ordinarily obtains, and is due to the shortage of persons of these ages. This would however, account for only part of the reduction, and one would assume that the better housing conditions here have had a beneficial effect. Tuberculosis, however, is essentially a disease in which nutrition plays a large part, and the relative poverty of the inhabitants must adversely affect any benefits obtained by better housing. Rents are high and in many cases the family income is depleted by the cost of travelling expenses. I he resulting net income is low and it is a question whether the advantages of satisfactory housing in an area such as this are sufficient to outweigh the effects of shortage of wholesome food which occurs in many households. Housing and Tuberculosis. The relationship of housing to tuberculosis is one difficult to assess. Although there is frequently found a close connection Between poor housing conditions and a high incidence of tuberculosis, so many factors arc involved that the association cannot be said to be one of cause and effect—so often poverty following disease in the wage earner results in the family being forced into unsatisfactory dwellings. It seems that some tend to overstress the beneficial effects of suitable housing in its relations to tuberculosis. The consideration of suitability too must not be limited to the fact that persons are placed in houses which are from a sanitary point of view, sound—so much depends upon the Use made of the premises. A house might be ideal for a 52 tuberculous person in that efficient ventilation can be maintained and use rtiade of a garden—but no advantage may be taken of these benefits because of the mode of life of the occupants. These houses might be of no more benefit than crowded slums if the consumptive is careless in disposal of his sputum, if windows are shut, or if the premises are overcrowded. W hat are the advantages to the tuberculous person and his family of living in satisfactory housing conditions compared with living in unhygienic premises ? To the case infected but not clinically recognised, the difference might not result in his overcoming the infection ; similarly, satisfactory housing conditions might result in the contacts of a patient successfully resisting infection to which in other surroundings they might succumb. In very rare cases the patient might overcome his infection ; in any event he should be less likely to suffer a relapse should his infection be arrested as the result of treatment or otherwise ; in progressive cases, death may be postponed. For the home contacts of an infectious patient there should be less exposure to massive doses of infection, and, living in healthy surroundings, they should be better able to resist infection. These beneficial effects should be demonstrated in the postponement of the age of death of the tuberculous, and in the occurrence of a smaller number of cases of tuberculosis, especially in those of younger ages. To obtain full benefit of the improved housing full co-operation of the patient is necessary ; this applies especially to the benefits to be obtained by contacts. Apart from the personal conduct of the patient, the factor of most importance probably is nourishment. The advantages of satisfactory housing are chiefly to be found in aiding in building up the resistance of those exposed ; shortage of suitable food would outweigh any such advantages. It is very difficult to compare local statistics with others to determine the extent of tuberculosis. Notification figures are of little use—apart from the fact that in different districts the extent to which notification is carried out varies so widely. In this district, with its population growing by importation, notifications are received each year of those cases already occurring in the transferred population. Although they might individually have been notified in the other districts over a number of years they are all added to the local register in one year. Further, there is sometimes an interval of two or more years between a tuberculous patient transferring here and a notification being received. To remedy these defects the use of the register for comparative purposes was considered. The deficiencies of notification are. 53 however, reflected in the register. The figures on the register per 100.000 population for each of the five years 1927 to 1931 were, for pulmonary cases, 853, 775, 768, 784, 827, and for non-pulmonary cases, 289, 297. 310, 349 and 386. The corresponding figures for the country as a whole in 1929 were 629 and 241, from which it can be seen that the local rate is higher. It was, however, considered that more reliable figures for purposes of comparison could be obtained from the deaths registered. One disadvantage, of course, is that persons dying of tuberculosis do not die in the homes in which they contracted the disease. Any effect in this way should be to make the local figures lower than the true ones, as persons would possibly return to their old quarters in London before dying. Another disadvantage when using these figures to judge the effect of housing is that, to some extent, the population is a selected one in that some people have come to live here either because they are suffering from or are contacts of cases of tuberculosis. In recent years, however, the number of transfers has been less than the number of cases which would normally occur in the transferred population. The following table shows the mortality from pulmonary tuberculosis per million of population of the whole district compared with the rates for England and Wales ; in the one column comparison is made with the standardised population, the other column giving the crude rate:— Local. Per Million Living. Kngland and Wales Standardised. England and Wales Crude. 1927 545 744 791 1928 692 709 755 1929 741 738 793 1930 692 685 739 1931 968 – – The diminishing difference is partly to be accounted for by the altering ratio the original rural population bears to the total. The figures, however, are not comparable owing to the different age constitutions of the populations compared. The following table rectifies this as it shows the comparison of ocal (Estate population) and general deaths per 100,000 population at various age-groups. For this purpose, the figures of deaths and of Imputation for the five years, 1927 to 1931, have been taken:— 51. Age-Group. Death Rate per 100,000. Local. England and Wales, 1929. Male. Female. Male. Female. 10/14 22 28 11 23 15/10 122 122 63 100 20/24 114 142 107 134 25/34 102 160 119 109 35/44 172 100 149 77 45/54 280 66 173 60 55 /64 – – 136 48 65/75 – – 89 40 75 and Over – – 33 20 It is seen that except for the one group (males of age 25 to 31) the local figures exceed those of England and Wales. These figures of course are based on population figures which are only hypothetical, and the same applies to the age-grouping. There is no reason however to suppose that the population figure widely diverges from the true for each year as in the census year there is a difference of only 1,000; similarly the check of age constitution obtained bv the direct method is sufficiently near to that obtained by the indirect method to lead one to suppose the figures are correct. In the following table, however, actual figures only have been used. The table shows the percentage of deaths caused by tuber culosis (all forms) at various age-groups in the Estate population compared with a similar percentage obtained for the population of the country:— Age-Group. Percentage Deaths. Estate Population, 1927-1931 England and Wales. Male. Female. Male. Female. 0/4 3.1 2.7 3.6 3.5 5/14 9.4 15.0 13.1 16.5 15/24 43.9 51.1 33.4 46.7 25/34 28.7 44.6 33.2 33.8 35/44 30.4 21.5 23.5 17.2 45/54 29.2 8.8 14.1 7.5 55/64 5.2 .0 5.6 2.9 65 and Over .0 1.0 0.9 0.5 55 It will be noted that the proportion of deaths caused by tuberculosis is higher at each age-group, except those under 15 and males of ages 25 to 34, in this district than in the country as a whole, and the differences are more marked than might be accounted for by assuming the local death rate in each group is lower than that for England and Wales. It seems then that in this district any advantages accruing from the better housing of the occupants are outweighed by other factors. Deaths. There were, during the year, 88 deaths from pulmonary tuberculosis. 10 of these were of patients residing in the older property of the district, in 9 of whom the disease was contracted here. 7 cases occurred amongst the residents of the newer property, of whom 2 transferred here with the disease. Of the remainder, approximately one-half contracted the disease since living here, the others having transferred here while suffering from tuberculosis. Of those who presumably contracted the disease while living here, 17 out of 38 died within six months of the alleged onset and a total of 25 within twelve months. In 8 cases the death occurred in the second year. No patient apparently survived 5 years. Of the 31 persons who transferred here with the disease, 7 died within six months of transfer and a total of 10 within twelve months ; 7 died in the second year, 4 in the third and 2 in the fourth, two patients survived 5 years. The period from the onset of the illness in these patients to their deaths was under 6 Months in 2 eases, 1 to 2 years in 8 cases, and in 9 cases, the duration of illness was 5 years or over. In 11 instances pulmonary tuberculosis appeared on the death certificate of persons whose names had not appeared on the Tuberculosis Register. In some of these cases particulars were not obtainable owing to the family having removed out of the district on the death of the patient. To remove the misconception on the part of some Petitioners as to their duties in regard to their patients who had been notified while living in other areas, all practitioners have been cirularised and informed of the position with regard to of the 18 deaths from non-pulmonary tuberculosis, meningitis accounted for 14. In 11 Instnces the age at death was 5 or under.In 2 cases only was family history obtainable. Most of the childern had been born here and the milk supply to the homes was almost invariable a heated milk. The other cases notified were 2 of peritonitis,one on spinal disease and one of general miliary tuberculosis. 56 Sputum Analysis. 330 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. 57 MATERNITY AND CHILD WELFARE. Notification of Births. 1,742 notifications of live births were received during the year (male 890, female 852). 334. notifications (including stillbirths) were received from medical practitioners and parents, and 1,455 from midwives. In addition, information was received of 209 births outside this area. The following list shows where most of these births occurred:— Oldchurch Hospital 114 Queen Mary's Hospital, Stratford 10 East End Maternity Hospital 28 Plaistow Maternity Hospital 21 Upnev Hospital, Barking 5 London Hospital 4 Other Institutions 27 Stillbirths. 47 stillbirths were notified (22 male, 25 female), the corresponding figures for registration being 33 and 33. The rate per 1,000 of total population registered was 0.72, the rate for England and Wales being 0.67. In 16 cases the infant was dead before the onset of labour. In most of these, the cause was apparently maternal. Antepartum haemorrhage accounted for 5, and toxaemias of pregnancy another 5. 3 were apparently due to the mother having suffered from an attack of influenza. There were 11 cases in which labour was premature and the child presumably alive shortly before labour; shock was the presumed cause in 2 cases, a fall in another 2. Hyperemesis was the cause in one and was the reason for induction of labour in another. One infant was one of twins delivered at seven months. In the other cases no cause could be found for the onset of labour. In the remaining 20 cases, the child was apparently lost during course of labour. In 2 cases in which labour occurred and the infant was born before the arrival of the attendant, one child was lost because of the cord round the neck, and another was born with the membranes over the face. A difficult labour necessitating the application of forceps accounted for 5 eases. The remaining cases were all attended by midwives, and the labour was apparently normal. 58 Infant Mortality. Neo-natal deaths: there were 57 deaths of infants under one month of age, giving a neo-natal mortality rate of 26.6 and constituting 42.8 per cent, of the total infant mortality rate. Of these deaths, 19 occurred within 24 hours of birth. In 9'of these the birth was premature, in 3 the infant was small and feeble, even though full time ; in 3 cases death was due to congenital abnormalities and 4 deaths were due to cerebral haemorrhage or other injuries received during a difficult labour. Of the other 25 children who died within the week, 16 were premature infants, 2 were feeble, 3 suffered from congenital abnormalities and 3 suffered from birth injuries. Of the remaining 13 who lived over one week but under one month, 6 were premature and 3 suffered from debility. Of these premature infants dying within one week, 6 were due to twin deliveries, in which labour set in at six months in the case of two and at seven months in the case of the other. 2 more were due to twin birth in which the other infant was stillborn. In most cases the reason for the premature onset of labour could not be determined. Of those dying in the early days from debility, the infants were full time, but in a number of cases were of very poor development. In two of these cases, the cause of death should more properly be ascribed to difficult labour. Those who died from injury incurred in labour were all full time, and operative measures had been necessary. In one instance the mother suffered from ante-partum haemorrhage, but in the others it seems that ante-natal supervision of the mother might have saved the infant. In the second and third months, environmental conditions played more part. Of the 19 lost at these ages, 9 died from some chest condition, 4 from marasmus and 3 from enteritis. In many of these infants the chances of survival had all along been small, and the ascribed cause of death was more a mode of death than the actual cause. In the third to sixth months, 19 infants died. Developmental abnormalities accounted for 2 and debility for 3. Chest conditions accounted for 8, gastro-enteritis 3 and whooping cough 2. Of children dying in the second six months of life, the cause in most cases was bronchitis or pneumonia, these chest conditions accounting for 17 out of the 30 deaths. In a large number of instances, a history of preceding influenza in a member of the faniu) was obtained, especially in the latter weeks of the year. In some cases the onset in the child appeared as a "cold" or "teething bronchitis." In very few and even then only in those nearly 12 months old, did the chest condition appear to be primary. Pneumonia is essentially a disease where skilled nursing is required an hospital accommodation sufficient to admit all these cases withou 59 any overcrowding would doubtless result in the saving of many lives. On the parents' part, a truer appreciation of the infectivity of the common cold and of its deleterious effects on the young, and of the importance of extreme care of infants whose chests are in any degree affected, would do much to prevent the loss of these lives. Gastro-enteritis was an unimportant factor as a cause of infant mortality. This was expected in view of the low mean summer temperature. Until the latter part of the year, the district was comparatively free from measles and whooping cough, with a result that measles appeared on the death certificate only once in the case of a child under one year of age and not at all in those of ages of one to 5. Whooping cough accounted for a total of 8 deaths in those under one year of age. Deaths of Older Children. Of children in the second year of life, slightly fewer died this year than last. Chest conditions again were the chief cause, accounting for 15 out of the 27 deaths. Whooping cough and tuberculosis accounted for 3 deaths each. Ot the 13 deaths of those in the third year, diphtheria accounted lor 2 and whooping cough one. Chest conditions accounted for only 3, and for a similar low figure in each of the next years of life. Ihe deaths amongst those of 3 and 4 years of age were higher than last year, but due to no one particular cause, the largest group of 5 being that of diphtheria in the fourth year. Ophthalmia Neonatorum. Notified. Treated at Home. Treated in Hospital. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. 11 11 – 11 – – 1 11 eases of Ophthalmia Neonatorum were notified in the course of the year. In addition, in another 49 cases, a copy was received of the medical aid notice sent to the County Medical Olficer by the midwife. No cases, apparently, occurred where a doctor was in attendance at birth. All cases are investigated by the Health Visitors on receipt ol information and are visited reguiarly until the eyes arc clear. 60 Most cases were very mild, definite pus being present in very few cases, many of the others suffering only from a slight watery discharge. A weakly premature infant in whom ophthalmia was notified, died after a few days, the cause of death being "debility." No cases were removed to hospital for treatment. Two cases were treated at home by the District Nurses at a cost of £8 12s. 6d. Pemphigus. 8 cases of Pemphigus were notified during the year, all of which were midwives' cases to which the doctor had been called in by a medical aid notice. 4 of these were mild cases which were treated at home. 3 were admitted to Rush Green Isolation Hospital and one to Oldchurch Hospital. This child was in 31 davs at a cost of £12 3s. 0d. All cases recovered. The onset of the eruption was in most cases before the tenth day, the seventh and eighth days being the commonest. The earliest eruption occurred on the third day and the latest on the twelfth. 5 of the cases occurred in the first two months of the year and 2 in December. They occurred in the practice of different midwives, none of whom had, during the year, more than one case. Maternal Mortality. There were 9 deaths due to pregnancy, of which 4 were due to sepsis, giving a maternal mortality rate for sepsis of 1.86 and tor other accidents and diseases of pregnancy and parturition a rate of 2.33, being a total rate of 4.20. Of the fatal cases of septicaemia, one followed a self-induced abortion, another was apparently due to an extension upwards ol a septic infection of a tear caused by instrumental delivery of a case which had no ante-natal supervision. The third case was a woman who was immediately admitted to hospital on the occurrence of an ante-partum haemorrhage due to central placenta praevia. The haemorrhage was slight and the condition of the woman good, the urgency of admission being on account of the child. A living child was delivered and things went well till the fourth day, when the lochia became offensive. This condition was improving when the patient suddenly died from pulmonary embolism. T he other case was also one who suffered from an ante-partum haemorrhage due to a lateral placenta praevia. She was immediately admitte to hospital. Of the other deaths associated with pregnancy, few seem to have been preventable. One case was a death from puhnonar) tuberculosis accelerated by pregnancy and parturition.In one 61 case a pregnant woman died from haemorrhage, following traumatic rupture of the spleen. Labour having just commenced rendered a diagnosis of internal haemorrhage exceedingly difficult and possibly resulted in a delay in operative measures being carried out. Two deaths occurred in persons admitted to hospital for caesarean section where the size of the pelvis precluded the possibility of the passage of a viable child. The condition of both before operation was good and everything at the end of the operation in each case appeared satisfactory. One of the cases some two hours later commenced a severe uterine haemorrhage which proved fatal. In the other case, a few days after the operation a peritoneal abscess developed. On post-mortem examination this abscess appeared to have no connection with the uterus which seemed healthy. One patient was admitted to hospital for concealed ante-partum haemorrhage, but died of post-natal shock following delivery. It is a question in cases of this nature, whether the transferring of a patient from her home to a hospital does not cause too much harm, and whether treatment carried out in the home would not save some of these patients. If an emergency outfit, including the services of a nurse, were available at short notice, the patient would possibly stand more chance of survival by treatment in the home than she would following removal. The remaining fatal case was a woman who, on the tenth day following a normal delivery, developed pleurisy. She was admitted to hospital and was apparently doing very well, when on the nineteenth day from confinement, she died suddenly from pulmonary embolism. The cause of the earlier pleurisy was presumably embolism. Investigations into maternal mortality due to pregnancy and childbirth, as suggested bv the Maternal Mortality Committee of the Ministry of Health, arc carried out bv the Medical Officer ot Health. Puerperal Fever and Pyrexia. 12 notifications were received, 8 being of Puerperal Pyrexia and 4 of Puerperal Fever. Per 1,000 total births the rates for these conditions are 6.21 and 3.10, the corresponding figures for the country as a whole being 8.71 and 3.55. of the cases of Puerperal Pyrexia, 5 made an uninterrupted recovery at home. One case was admitted to the Isolation Hospital as a case of Puerperal Scarlet Fever and the two others to Oldchurch hospital .All these cases recovered. Two of the casts followed an instrumental delivery, 5 a normal labour and in one the baby was born before the arrival of the attendant. All the eases of Puerperal Fever were admitted to hospital, 3 going to Oldchurch Hospital. 2 cases followed a forceps delivery. 62 In one the patient had a central placenta praevia and in theothera miscarriage which had been brought about by a douche. Puerjwrai Septicaemia was certified as the cause of death of 4 women. Work of the Health Visitors. Routine visits are paid to infants as soon as possible after the tenth day and special visits arc paid to cases of Ophthalmia Neonatorum, Puerperal Fever, Stillbirths, Infant Deaths, etc. and subsequent to operative treatment of Tonsils and Adenoids. Each Health Visitor was appointed Infant Protection Visitor for her own area. The Health Visitors also attend the various clinics. In the case of Infant Welfare Centres and Ante-natal Clinics, the Health Visitor is, as far as possible, in charge of the session at which the mothers from her district attend. The following table shows the number of visits paid by Health Visitors during the year:– (a) To expectant mothers First visits 278 Total visits 576 (b) To children under 1 year of age First visits 2,714 Total visits 7,721 (c) To children between the ages of 1 and 5 years Total visits 6,712 Infant Welfare Centres. The number of weekly Infant Welfare Centres at the end of the year was 9, compared with 8 at the beginning of the year. AH the Centres are maintained by the Local Aut hority, 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 of the Centres a number of voluntary workers have kindly assisted. 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 14,845 (2) By children between the ages of 1 and 5 9,062 Average attendance of children per session at all Centres during the year 56 Total number of children who attended at the Centres for the first time during the year:– (1) Children under 1 year of age 1,427 (2) Children between the ages of 1 and 5 years 713 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 73.7 63 Treatment. Tonsils and Adenoids. The same arrangements continue in operation for the treatment of this condition. Most cases, however, were treated at King George Hospital, Ilford, being detained overnight. During the year, 42 cases were assisted at a cost of £43 2s. 0d. Orthopaedic Treatment. (a) Ascertainment Clinic. The Consultant Orthopaedic Surgeon paid four visits to the district during the year, when 78 ehildren made 110 attendances at a cost to the Local Authority of £13. Most cases attended the Clinic once only, 21 attending twice, and 5 three times. The commonest disability for which children were referred was flat foot, either alone or with some bowing of the tibiae, or genu valgum. Of the 18 cases referred, 15 were ordered wedges to their shoes. Of 13 cases of bowed tibiae, splints were ordered in 6, wedges in 4, and in 2 operative measures were required. Of 7 cases of genu valgum, 5 were ordered wedges and one a brace and wedges. Three cases of torticollis due to a ruptured sterno-mastoid were referred to the massage clinic for treatment. Seven cases of congenital talipes were seen, for 3 of whom wedges were advised, and splints in 4 cases. One of these eases was subsequently admitted to hospital for osteoclasis. Two eases of Erbs palsy were seen and 4 children suffering from scoliosis were recommended to wear a back board. (b) Massage Clinic. The massage and remedial exercises clinic held at Ford Road is staffed by the Essex County Council, during the year 42 children under school age received treatment at a cost of £6 6s. 0d. 30 of these cases were treated for flat foot, knock knee or bowed legs. There were under treatment 4 cases of congenital equinovarus. Three children suffering from naematoma of the sterno mastoid received massage and were discharged before the end of the year. (c) Provision of Appliances. A member of the staff of a firm of instrument makers attends, usually at the same time as the Orthopaedic Surgeon, to take measurements of those children requiring surgical appliances. The Local Authority assists in payment of these according to the financial circumstances of the family. During the year such assistance was given in 9 cases at a total cost of £6 1s. 0d. (d) Hospital Treatment. One child was admitted to hospital, being in 5 weeks at a cost of £8 10s. 0d. 64 Ultra Violet Therapy. Light treatment is carried out at the Becontree and at the Dagenham Clinics, two sessions being held weekly. The cases treated are referred from the Infant Welfare Centres and all children are seen by the Medical Officer everv fortnight. A few children of school age are referred by the School Medical Officer, a charge being made to the Essex Education Committee for each treatment. A course of treatment commences with a two minutes exposuir back and front working up to a 6 minutes double exposure, being 12 exposures in all. Many cases are put down for another course of treatment after an interval of four to six weeks. The Clinics closed down from May to September. 175 children commenced treatment, of whom 90 completed the course. The total number of individual exposures was 1,736. Of those who commenced but did not complete the course of treatment, a large number were removed from the list on account of laxity in attendance. Such a step was necessary to prevent a long waiting list. After two failures to attend, the parent is visited and if the absence was apparently not justifiable, no further appointment is given. In a number of cases the partial treatment was due to a postponement on account of illness. Two-thirds of the cases referred for treatment were on account of rickets, most of these children being in their second year. It is exceptional, in this condition, that an improvement is not recorded, less than 10 per cent, failing to show any. This improvement is not necessarily associated with any gain in weight, but is shown by the increased muscle tone and in the generally improved condition, mental and physical, frequently remarked upon by the mothers. In practically all these cases which received treatment, the children were also on Cod Liver Oil in one form or another. They would, however, have been in the habit of taking this before being referred for treatment, so that any improvement noted after a course of exposures would presumably be attributable to the light treatment. One-quarter of the cases treated were on account of malnutri tion. These children too would be having Cod Liver Oil or some other preparation. The proportion of failures to show an improve ment was much greater in this type of case, amounting to over onethird. This was more marked in the case of children over two. In those below this age, an improvement was recorded in most. A few cases were treated as being subjects of recurrent attacks of bronchitis. No improvement was noted in any of these cases To be of any avail in this type, it woidd presumably be necessary to carry out treatment over a prolonged period. A number children convalescent from whooping cough were also treated. 65 Dental Treatment. 12 extraction sessions were held, at which 53 children were treated and 136 mothers, making a total of 196 attendances. The cost was approximately £30. The extractions are free to those whose incomes are below a set scale. A fee of Is. per attendance is charged where the income is slightly higher than this, and a fee of 2s. where the family income is between this scale and a maximum limit. For those with incomes above this limit, no treatment is provided at the clinics. Financial assistance is granted to mothers in obtaining dentures which vary in cost from £3 to £4 10s. Od., the amount of help being granted depending on the family income. Dentures were provided to all cases requiring them irrespective as to when they commenced treatment. It was however found in a number of cases that owing to the interval separating extractions and also the interval between the final extractions and the fitting, dentures would be be provided to mothers who had finished nursing their infants. To avoid this, dentures are now provided, as a rule, only to those women who commenced dental treatment before the baby was born. The financial assistance granted by the Council during the year towards the obtaining of dentures was £185. Convalescent Home. A mother and her child were sent to a convalescent home for a period of two weeks at a cost of £3 8s. 0d; another child for a period of 10 weeks at a cost of £10 10s. 0d. Ante-natal Clinic. During the year two weekly ante-natal sessions were held at the Becontree Clinic, two at the Dagenham Clinic and one at the Five Elms Out-Patient Department. In addition, a fortnightly session was held in the Chadwell Heath ward. This session was held on Saturday mornings; as the reason for the low attendances was assumed to be the inconvenient time the session was held, it was transferred to Thursday afternoon, with little improvement in the average attendance. At the Five Elms Out-Patients Department the Consultant gynaecologist paid fortnightly visits throughout the year, seeing a total of 118 women who made 162 attendances. Most cases requiring institutional treatment were admitted to olchurch Hospital though a few went to Queen Mary's Hospital, ,,stardford. In addition, a number were referred to one of the London Hospitals under the care of the Consultant Gynaecologist. For The 43 women who were admitted under the Council's scheme, the local Authority paid £320. 66 Amongst the women attending the clinic were 46 who attended for post-natal examination, of whom about one-half were referred to hospital or to their own doctors for treatment. In addition, 37 on attending were found not to be pregnant. 37 per cent, of the cases attended of their own accord, 35 per cent, were referred by the midwives, 15 per cent, on the recommendation of a neighbour and 10 per cent, on the advice of a Health Visitor. 3 per cent, of the cases were referred by local practitioners. The practice of the midwives varies largely, some referring up to one-third of their cases, others, on the other hand, referring only one or two in the course of the year. 176 patients paid only one visit, 101 two visits, 96, 84 and 47 paid three, four and five visits respectively, and 82 paid six or over. These figures are exclusive of those patients who had a miscarriage or who removed from the district before the confinement. 12 patients attended before they were two months pregnant, 59 attended for the first time in the third month of pregnancy; the numbers attending for the first time in the next months were 67, 90, 107, 113, 89 and 48. The number who attended once only is far too great, particularly when it is realised that this single attendance was paid, in many cases, early in pregnancy. Out of these single attendances, 2 came before the third month of pregnancy. The number who attended in the third month was 13, and in the following months 26, 32, 38, 31 and 22. These single attendances, particularly when paid in the early months, represent much waste of work. 82 patients paid 6 visits or over. Many of these, of course, paid their first visit in the early stages of pregnancy and continued regular attendances. Too frequent attendances by normal patients tends to cumber the work of the clinic and to prevent proper attention being given to the routine cases and also renders too easy the losing sight of cases which should be followed up. In an attempt to obviate these disadvantages, an appointment register is now kept and the patient given a date on which to attend. Should she fail to put in an appearance, she is visited and unless she has made other arrangements is encouraged to attend the clinic. To the women who attended the Ante-natal Clinics a miscarriage occurred or the infant was stillborn in 16 instances. In addition, a difficult confinement occurred in 26 cases, in 22 of Which forceps were applied. The other confinements occurring at home were apparently uncomplicated. 67 The following table shows the work done at the clinics:— (1) Total number of attendances by expectant mothers at all clinics during the year 2,293 (2) Average attendance of expectant mothers per session at all clinics during the year 8 (3) Total number of expectant mothers who attended at the clinics during the year 733 (4) Percentage of total notified births represented by the total number of expectant mothers who attended the centre during the year 40.9% Hospital Gases. Of the 42 cases admitted to Oldchurch Hospital, 8 were admitted on account of anticipated difficulty in labour due to a bad obstetric history or finding a small pelvis, etc.: 6 were admitted on account of albuminuria or toxaemia of pregnancy and 6 because of debility, anaemia, etc.; 15 were referred to hospital on account of economic conditions and 10 owing to difficulty of nursing conditions in the home, in 5 of which cases the family was living in one room. In four other instances the mother was unmarried. 11 women were leferred to hospital for confinement as it was their first pregnancy. In several instances, of course, more than one of these factors operated in determining advisability of admission to an institution. 14 patients were admitted to Charing Cross Hospital under the care of the Consultant Gynaecologist. Of these, 5 were referred on account of contracted pelvis; induction was carried out in 4 cases. 3 were admitted on account of heart involvement of whom one was induced before term. The other conditions for which patients *ere admitted included haemorrhage, overdue labour, malpresentation and tubal pregnancy. Three infants out of this number ot pregnancies were stillborn. Consultant Ante-natal Clinic. Of the 118 women seen by the Consultant. 40 were referred on account of small or a fiat pelvis. Of this number, 12 were advised admission to hospital for induction and another 8 to have their confinements in hospital. 3 cases required eaesarean section. 9 cases were referred on account of their cardiac condition, of whom 7 were recommended to have their confinement in hospital. 7 out of 9 cases of breech presentation were referred to hospital lor Induction; other cases similarly referred included cases of ante- 68 partum haemorrhage, disproportion and post maturity. 9 eases of vaginal discharge were seen, 3 of these being due to a fungus and others to cervicitis. 3 cases of mole were referred to hospital for emptying of the uterus. The following is a copy of a report on Ante-natal services submitted in October to the Maternity and Child Welfare Committee:— Ante-natal supervision of women is of comparatively recent date. Its importance at one time was not realised, little attention being paid to it in the training of doctors and midwives. This resulted in an almost complete neglect by the previous generation of practitioners of this class of work. The need being felt, Local Authorities provided the service which, with the education of the women as to its importance, is steadily increasing. The presentday student as compared with his predecessor is impressed in his teaching with this side of the work, and most practitioners are now fully competent and willing to carry it out. It is accepted as a cardinal principle that the ante-natal supervision should be undertaken by the doctor who is to attend the confinement. In districts possessing their own maternity homes, where the resident Medical Officer of the Home conducts the antenatal clinics, this requirement is satisfied in those cases who arc admitted. Provided there is sufficient accommodation to take in all cases which are likely to need the attendance of a doctor, such an arrangement is satisfactory, and it is anticipated by some that the future development of the maternity services will be on these lines, straightforward cases being attended by midwives, possibly municipal, in their own homes and cases of anticipated complication being attended in the institution. Such development would, of course, necessitate a large increase in the number of beds available for maternity cases. In a district such as this, without its maternity home, the ante-natal services suffer from the obvious disadvantage of the patients being attended at confinement by doctor who did not carry out the ante-natal supervision. As a detached unit run on these lines, the ante-natal clinic can never effect those improvements in the conditions of labour that were hoped would materialise from efficient pre-natal care. It is premature to decry the utility of the clinic as there arc some services that in any event it can supply. The ante-natal service can claim that it" has been responsible for the education of the women as to the need of supervision at this time, necessity is probably not even yet appreciated by the bulk of the women, and Health Visitors are likely to be more successful in inducing women to attend a clinic at which they would be presen than in getting them to attend a doctor's surgery. There is, too. 69 a large number of women who will have normal confinements in whose cases the examination by the Clinic Medical Officer would be supplementary to that provided by the midwife who will conduct the confinement. Again, there is the reed of post-natal examination which should be carried out in all cases. The clinic would be available in this case for all mothers who are attended in their confinements by midwives. It has been suggested that all these services can be provided by the general medical practitioners. Many women, however, are not covered by the panel and without actually requiring relief as provided by the Public Assistance Committee, are in receipt of incomes so low that the sum charged per attendance would seem large, particularly for a service of the value of which they were not absolutely convinced. The alternative is the provision of a service free to certain applicants, provided by the general medical practitioner, who would be paid by the Local Authority. This is a line of development which is in the experimental stage in some areas and is considered by some as the probable solution. Page 26 in "The State of Public Health, 1930" reads :— "It is possible that eventually the ante-natal clinic, as we know it to-day, especially in the larger towns, may to some extent disappear, thus leaving the ante-natal supervision of maternity patients to be carried out by private practitioners with the assistance °f a relatively small number of consultative ante-natal clinics staffed by specialists. Whatever the ultimate destiny, however, it is elear that there will remain a need for ante-natal clinics, particularly in industrial and urban areas, for some time to come; the tull development of pre-natal supervision will depend very greatly upon the efficiency of these clinics." lo obtain the maximum benefit from the ante-natal services run on its present lines, it is necessary to have clearly in mind the purposes of the service and its limitations. It is first necessary to Classify the case as regards normality. This will determine the Category of the attendant required for the confinement. For normal cases booked by midwives the ante-natal clinic can provide the necessary medical care. Abnormal cases should at once be referred to the medical attendant who is to conduct the confinement. In this district the abnormal confinement will take place either at home with a medical practitioner in attendance, at Oldchurch Hospital, or at once of the london Hospitals to which the patient is admitted under the care of the Consultant Gynaecologist. Abnormal cases then.when diagnosed,are taken off the books of the ante-natal clinic.Normal cases should attend at specified times and it should be the duty of each attendant midwife to see that each of her patient dose obatin the necessary medical examination at the required times. The home supervision of all cases then, will be 70 continued, until the Health Visitor is satisfied that the patient has definitely passed into the hands of the attendant, either midwife or doctor, with further occasional visits to determine that the patients are continuing under such supervision. The co-ordination between the ante-natal service as provided by the Council and the existing medical and nursing services will vary according to the needs of the patient which will determine the attendant. (1) Normal Cases: to be ordinarily attended by midwives. (A certain number of normal cases will be attended by the medical practitioners. Any of these cases attending the clinic will do so only because they have not disclosed that they intend having a doctor at their confinement.) The following steps are taken to ensure close co-operation between the midwives and the clinic :— (a) A written clinic report is sent on each case to the midwife by the Medical Officer of the Clinic. (b) Midwives are encouraged to attend the clinics with their patients. "(c) Each midwife has been supplied with a book of forms which she completes and sends to the clinic with any of the patients she refers. She is also invited to make use of another form giving particulars of the confinement of any of her cases which have attended the clinic. (d) To prevent any loss of income to the midwife by anyofher cases being referred to hospital, compensation is paid to the midwife for each case lost to her in this manner. (2) Abnormal Cases. (a) Some cases attending the ordinary ante-natal clinics are referred for examination by the Consultant Gynaecologist. A certain number of them he decides to admit to his own beds atone of the London hospitals. These eases will continue under his supervision at his ante-natal clinic until the time for admission to hospital. (b) Some eases of abnormality desire to be confined in hospital Arrangements, where so desired, will be made for their admission to Oldchurch Hospital. These cases are transferred from the ante natal clinic to the ante-natal clinic at Oldchurch Hospital which is conducted by the medical superintendent. In case of non- | attendance, on being informed, the Health Visitor visits the case to encourage further attendance. 71 (Other cases are admitted to Oldchurch Hospital not on medical "rounds but on social or economic grounds. These cases would ordinarily, so long as they appear normal, continue under supervision at"the ante-natal clinic until a few weeks before the confinement. The Medical Superintendent of the Hospital is notified in time to call up each of those cases to his own ante-natal clinic some time before the confinement ) In these cases, the ante-natal records are transferred from the clinics to the hospital clinic until the confinement, when, after particulars of the ante-natal visits and of the confinement have been entered, they are returned. (c) Other cases are referred to their own medical attendants into whose hands they then pass. He can, if he desires, request that arrangements be made for institutional treatment or for examination by the Consultant Gynaecologist. Ordinarily, however. he attends the case. In a report to the Public Health Committee, it was suggested in these cases where the family income was below a certain limit, that the Local Authority should bear the cost of this ante-natal supervision by the medical attendant. The recommendation was not acccpted on the grounds that the patient could place herself in the hands of a doctor free of charge to the patient by first passing into the care of the midwife who would then call in the doctor on the medical aid notice, the doctors fees in that case being paid by the County Council. Apart from the fact that it is laid down that it is the duty of the Maternity and Child Welfare Authority and not of the Local Supervising Authority of the midwives to provide the ante-natal services, an impossible situation would arise if the Clinic Medical Officer were to refer a definitely abnormal case to the midwife with the advice that she should refer the case to a doctor, ihese abnormal cases who are to be confined at home, and also cases of abnormality of pregnancy, should pass out of the care of the ante-natal clinic into the hands of the general practitioner immediately; and in necessitous cases, the doctors' fees should be paid by the Local Authority as part of the expenditure of their ante-natal services. Under this arrangement, almost all abnormal cases pass out of the hands of the clinic staff to the care of those who will be conducting the confinement. The Health Visitors will continue to pay home visits as necessary to satisfy themselves not only that the patients have passed into the care of the attendants but that they are continuing under that care. For the case continuing under the care of the ante-natal clinic, particularly until such time as it is established that the patient has passed into the hands of an attendant,it is essential that responsibility is accepted. This necesssitates the patients being kept under observation. For this 72 purpose an appointment register is kept and the date of the next visit noted. Should the patient fail to attend the clinic, a home visit is paid to ensure that the patient will receive care either at the clinic or elsewhere. Foster Children. The same arrangements continued for the supervision of foster children, the only change made during the year being that in assessing the sleeping accommodation, that whereas previously those over 10 years of age were counted as adults, the age is no# lowered to 5 years. The following tables show the number of foster children and foster mothers in the district and the changes that occurred during the year :— Foster Children. Number on register, December 31st, 1930 62 Number added to register 58 Number deducted owing to refusal, removal, death, or reaching age of seven 69 Numberon register, December 31st, 1931 51 Foster Mothers. (1) Numberon register, 31st December, 1930 56 (2) Number of additions during year 15 (3) Number taken off during year 62 (4) Number on register, 31st December, 1931 39 The taking of foster children from outside the area is not encouraged. Some of the foster mothers take in children because they like the presence of a young child in the home. Most, however, do it definitely for the sake of the money to be made. The average sum received per child is 10s. to 12s. 6d. a week. When the family is in straitened circumstances, there is too much inducement for the infant to be deprived of its necessities. A number of children were removed oil request without the necessity of obtaining an order from the Justices or from the Authority. In one case the children were removed when the foster mother learned that an application to the Local Authority for an order was being made. In another case, application for an order was made to the Justices and was received. The law as it stands, is most unsatisfactory. The childeren Acts were passed with the object of controlling the iniquitous conditions which had previously existed and to prevent any form 73 of baby farming. The standard of child care since the inception and development of the Maternity and Child Welfare services has been raised far above this level. Under the 1908 Act, application can be made for removal of a child kept by any person who, by reason of negligence, ignorance, inebriety, immorality, etc., is unfit to have care of it. There are foster mothers who are unsatisfactory for reasons which might not be included under such a degree of negligence as would be required to be proved to the Court. Maternity Homes. There are no Nursing or Maternity Homes in the district. Assisted Milk Scheme. The expenditure incurred by the Council under the assisted milk scheme for the year was £1,276. £ (a) For ordinary milk 1,025 (b) For dried milk 251 Education. 2,000 copies of "Better Health" are 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.