AC4411(1) DAGEWITAM (hater Man.B) DAG 7 The Urban District Council of Dagenham c. 19 26 Annual Report OF THE medical officer of health FOR THE YEAR 1933 The Urban District Council of Dagenham 1926 Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1933 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 10 Hospital Provision 10 Ambulance 11 Clinics 12 Nursing in the Home 14 Laboratory Facilities 15 Legislation in Force 15 Sanitary Circumstances of the Area 16 Disinfection 19 Sanitary Inspection 23 Housing Statistics 25 Statistics of Inspections 25 Slum Clearance 26 Inspection and Supervision of Food 31 Food Poisoning 35 Nutrition 37 Infectious and Other Diseases 42 Diphtheria 42 Scarlet Fever 49 Tuberculosis 55 Cancer 58 Maternity and Child Welfare 60 Infant Mortality 60 Maternal Mortality 63 Infant Welfare Centres 65 Ante-Natal Services 68 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 1933. The year was a healthy one in this district apart from the prevalence of influenza in the early weeks, and a high incidence of scarlet fever in the last months. The infant mortality and maternal mortality rates were strikingly low. The steady development of the district by erection of new houses necessitated some extension of the clinic facilities provided. Apart from this, the only fresh development has been the issuing of birthday letters referred to in the report, and the abolition of terminal disinfection on the occurrence of notifiable diseases. 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, E. W. CARYL THOMAS. Public Health Offices, Becontree Avenue, Dagenham. 5th May, 1934, 6 OFFICERS of the PUBLIC HEALTH SERVICES. Full-Time Staff. Medical Officer of Health: E. W. CARYL THOMAS, M.D., B.Se., 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: R. J. DAW, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. F. W. S. FOX, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. A. J. JAMES, Certificate of Royal Sanitary Institute. L. E. PRIOR, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. Health Visitors: D. BRACE, General trained: C.M.B., New H.V.'s Cert. V. EVERITT, General trained: C.M.B., New H.V.'s Cert. N. MILBURN, General trained: C.M.B., New H.V.'s Cert. I. RICHARDSON, General trained : C.M.B., H.V.'s Cert. H. SHUTT, General trained: C.M.B., New H.V.'s Cert. M. SMITH, General trained: C.M.B., New H.V.'s Cert. D. WALLER, General trained: C.M.B., New H.V.'s Cert. L. WEALE, General trained: C.M.B., M. & C.W. Cert., New H.V.'s Cert., Sanitary Inspector's Cert. 7 Clerical Staff : Three 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. Two full-time Clerks 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., D.P.H. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Registrar-General's estimate of resident population 1933 95,550 Number of inhabited houses (end of 1933) according to Rate Books 20,754 Rateable value (Dec. 31st, 1933) £451,354 Sum represented by a penny rate (estimated 1933-34) £1,760 Social Conditions of Inhabitants. There is relatively less unemployment in this area than in other working class districts in the country. The percentage is lower and the lengths of spells of unemployment are shorter. Extracts from Vital Statistics for the Year. Live Births:— Total Male. e. Legitimate 1,741 925 816 Birth Rate per 1,000 of the estimated resi- dent population, 18.6 Illegitimate 44 20 24 Stillbirths:— Legitimate 72 44 28 Rate per 1,000 total (live and still) births. Illegitimate 3 3 - Deaths 622 326 296 Death rate per 1,000 of the estimated resident population, 6.5 Deaths from puerperal causes:— Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis 2 1.07 Other puerperal causes 3 1.61 Total 5 2.68 Death Rate of Infants under one year of age:— All infants per 1,000 live births 48.17 Legitimate infants per 1,000 legitimate live births 48.82 Illegitimate infants per 1,000 illegitimate live births 22.73 9 Deaths from Measles (all ages) 1 „ Whooping Cough (all ages) 5 „ Diarrhoea (under 2 years of age) 6 In the early part of the year, the district was attacked by the epidemic of influenza which was generally prevalent and which caused a number of deaths, particularly of the aged, in the first few weeks of the year. Scarlet Fever was more prevalent than in previous years, especially towards the latter part of the year. Population. The mid-year estimate for 1932 was 92,600 and for 1933, 95,550. The increase is partly due to the natural increase of population (i.e., the excess of 1,924 births over the 614 deaths in 1932, the corresponding figures for 1933 being 1,785 and 622), and partly to the occupation of the 802 new houses erected. Births. 1,785 births were registered during the year. The birth rate per 1,000 population was thus 18.6, compared with 14.4 for England and Wales. The rate compares with that of 24.2, 26.5, 30.6, 23.8, 23.6 and 20.4 for the years 1927 to 1932. The illegitimate birth rate is still low, being only 2.4 per cent of total births. The rate of illegitimate stillbirths is higher, being 4.0 per cent of total stillbirths. Death Rate. Total Deaths in district 353 Outward transfers 88 Inward transfers 357 Deaths of residents 622 Of the 88 deaths of non-residents occurring in the district, 66 took place at the West Ham Sanatorium and 10 at the Isolation Hospital. Of the 357 deaths of local residents taking place outside this Mea, most occurred in institutions. Of these, 225 occurred at Oldehureh Hospital, 25 at King George Hospital, Ilford, 6 at Severalls Mental Hospital, 4 at the London Fever Hospital, 33 at various general hospitals in London and 14 at children s hospitals. 622 deaths in a population of 95,550 represents a death rate of 6.5 compared with 12.3 for England and W ales. For the years from 1927 to 1932, the local rates were 7.0, 7.3, 8.3, 6.6, 7.2, and 6.5. 10 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Hospitals provided or subsidised by the Local Authority or by the County Council. a. (1) Fever. Rush Green Isolation Hospital is maintained by the Romford Joint Hospital Board, which consists of representatives of the Urban District Councils of Dagenham, Hornchurch and Romford, and the Rural District Council of Romford. Owing to the prevalence of Scarlet Fever in the latter part of the year the accommodation at the Isolation Hospital proved insufficient to meet the demands. A number of urgent cases were admitted to other hospitals, but many cases had to remain at home. (2) Smallpox. The Joint Hospital Board has an arrangement with Orsett Hospital Authorities for the admission of Smallpox cases to their hospital. b. Tuberculosis. For the table of hospitals and institutions into which local cases might, through the Essex County Council, be admitted, see page 13 of Annual Report, 1931. The following are the numbers of persons admitted from this district during the year:— Pulmonary. Non-Pulmonary Total. Male. Female. Male. Female. Adult 33 26 4 11 74 Children 2 2 25 13 42 Hospitals for General Cases. (1) Hospitals for Medical and Surgical Cases. Oldchurch Hospital, Romford.—See page 13 of 1930 Annual Report. King George Hospital, Ilford.—See page 15 of 1930 and page 14 of 1931 Annual Reports. 11 (2) Hospitals for Maternity Cases. Most of the maternity cases for whom the Council arranges institutional treatment are now admitted to the East End Maternity Hospital. A few patients are still admitted to Oldchurch Hospital and Queen Mary's Hospital, Stratford, whilst a number are admitted under the eare of the Consultant Gynaecologist to Charing Cross Hospital. Cases of puerperal infection are admitted to Oldchurch Hospital or to Rush Green Isolation Hospital. (3) Hospitals for Children. Most cases requiring operative treatment for Tonsils and Adenoids are now treated as in-patients at King George Hospital, though a small number are, at the parents' election, treated as out-patients. Other hospitals with which arrangements are in force for the treatment of this condition include Oldchurch and Queen Mary's Hospital, Stratford. Cases of ophthalmia neonatorum are admitted to St. Margaret's Hospital, Hampstead, and to the Isolation Hospital ; and cases of pemphigus either to Oldchurch Hospital or to the Isolation Hospital. (4) Orthopaedic Hospitals. Orthopaedic cases are admitted to the Royal National Orthopaedic Hospital, Queen's Hospital, Hackney, or Cheyne Hospital. Institutional provision for unmarried mothers, illegitimate infants and homeless children. See page 15, 1931 Annual Report. Ambulance Facilities. (a) For Infectious Cases. A motor ambulance, provided by the Joint Hospital Board, is Rationed at the Isolation Hospital at Rush Green. b) Non-Infectious Cases and Accidents. For details of the working of the two ambulances and of the rules and charges made, see page 15 of 1931 Annual Report. The following are the details of the work done by the ambulances during the year, with the 1932 figures for purposes of comparison:— 1933. 1932. No. of accident cases conveyed 408 351 No. of other cases conveyed 1,370 664 No. of journeys made1,587 1,443 No. of miles run 17,863 16,246 12 The Council has an agreement with the Borough Councils of Barking and Ilford for the reciprocal use of ambulances and for the conveyance of street cases. In the event of the ambulance of one Authority being called to a case just inside the boundary of one of the other districts, the patient is removed by the ambulance summoned. Both ambulances were out together 245 times, while in addition on 27 occasions when both vehicles were in commission, the ambulance of one of the neighbouring Authorites was requisitioned. During the year use was made of the Ilford ambulance on 15 occasions and of the Barking ambulance 12 times. Ilford called on the Dagenham ambulance six times, and Barkis twice. (c) Maternity Cases. See page 17 of 1931 Annual Report. 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 attendances per session:— Infant Welfare Centres. CENTRE. Sessions held. Times Sessions held. Averag Attend ances. Average New Cases. Wesleyan Chapel, High Road, Chadwell Heath. Weekly Monday, p.m. 50 3 Wesleyan Chapel, Marks Gate. Bi-monthly (commenced 24/8/1933) Thursday, a.m. 8 1 Becontree Clinic, Becontree Avenue, Chadwell Heath. Weekly Monday, p.m. 61 4 Weekly Thursday, p.m. 75 4 Weekly Friday, p.m. 39 2 Ford Road Clinic, Ford Road, Dagenham. Weekly Tuesday, p.m. 46 6 Weekly (commenced 25/10/1933) Wednesday, a.m. 26 1 Weekly Wednesday, p.m. 79 6 Weekly Friday, p.m. 51 3 Out-Patient Department, King George Hospital, Five Elms, Dagenham. Weekly Tuesday, 76 5 Weekly p.m. Wednesday, p.m. 62 5 13 Ante-Natal Clinics. CENTRE. Sessions held. Times Sessions held. Average Attendances. Average New Cases. Wesleyan Chapel, High Road, Chadwell Heath. Monthly (1st in month) Thursday, p.m. 7 2 Becontree Clinic, Becontree Avenue, Chadwell Heath. Weekly Monday, a.m. 5 1 Weekly Friday, a.m. 10 2 Ford Road Clinic, Ford Road, Dagenham. Weekly Tuesday, a.m. 12 3 Weekly Thursday a.m. 14 4 Out-Patient Department, King George Hospital, Five Elms, Dagenham. Weekly Wednesday, a.m. 14 3 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 the Becontree 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 the Becontree Clinics. Tuberculosis Clinic. A Tuberculosis Clinic is held every Monday and Thursday morning at the King George Out-Patient Department. Venereal Diseases. I here 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. 14 Orthopaedic Clinics. The Consultant Orthopaedic Surgeon attends about four times a year to see cases referred by the School and by the Maternity and Child Welfare Authorities. Remedial Exercises and Massage Clinic. Two sessions are held weekly at the Ford Road Clinic, namely, on Monday afternoons and Thursday mornings ; and a weekly session held on Wednesday alternately morning and afternoon at the Becontree Clinic. Light Clinic. During the winter months, 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. Professional Nursing in the Home. (a) General. For particulars of the Dagenham District Nursing Association which is the only local service for providing general nursing, see page 20 of the 1931 Annual Report. A total of 604. general nursing cases were treated during the year, involving 5,538 visits to the homes. 375 midwifery cases and 124 maternity cases were nursed, these patients receiving ? total of 7,783 visits during the year. In addition, these patien s paid a total of 1,554 visits to the ante-natal clonic held . House. Altogether then, the number of persons attended to durinf. the year was 1,103, to whom 14,875 visits were paid. (b) Nursing of Cases of Infectious Diseases. Most of the notifiable infectious cases are removed to the Isolation Hospital. In the case of the non-notifiable iniec ion ^ nursing is provided by special nurses of the District JNur Association. Mid wives. There are no midwives in the district employed by the Local Authority. At the end of the year there were 20 midwives living in the district whose practices were confined almost entirely this area. 15 Laboratory Facilities. Examination of clinical material is undertaken at the Essex County Public Health Laboratory, Queen Victoria Street, London. During the year, 461 swabs were examined for diphtheria bacillus. 312 samples of sputum for tuberculosis bacillus, 1 sample for typhoid organisms and 39 samples of hair for ringworm. The same laboratory also undertakes the bacteriological examination of milk, of which 122 samples were submitted during the year. 288 swabs were examined for diphtheria bacillus at the Public Health Offices. Legislation in Force. See pages 23 and 24 of the Annual Report of 1930, and page 21 of the 1931 Report. Byelaws governing Houses Let in Lodgings (revised) were confirmed 27th April, 1932. Smoke Abatement Ryelaws were confirmed on 21st April, 1933. The following sections of the Essex County Council Act, 1933, Me of interest:— Section 87. Local Authority may make bye-laws for the purpose of securing the cleanliness of any premises in any county district for the purpose of carrying on the business of a hairdresser or barber, and of the instruments, towels and materials used in such premises. Section 54. Establishments for massage or special treatment to be licensed. Bye-laws as to such establishment may be framed. Section 146. Control of refuse dumps. Sections 158 and 159. Ice-Cream Vendors. 158. Registration of vendors of ice-cream and premises used by them, with power to refuse registration or removal from register. 159. Regulating the manufacture and sale of icecream, etc. (1) Notification of infectious disease amongst employees, by manufacturers or vendors. (2) l'ower to seize ice-cream, with payment of compensation where liable to cause infectious diseases. (3) Name of vendor to be inscribed on vehicle or stand. (4) Power of Inspection. 16 SANITARY CIRCUMSTANCES OF THE AREA. Water. See Annual Reports, 1930 and 1932. There was no water shortage in this district during the year and no complaints received on the quality of the water. Drainage and Sewage. See reports of 1927, 1928 and 1932. Sewage Works Extensions. See page 22 of 1931 Annual Report. The first stage of the extension of the sewage works was completed by the end of the year and this portion was in operation. The works have been designed to permit elasticity of operation as circumstances demand. At the moment, domestic sewage and trade waste are being dealt with separately. Domestic Sewage. After passing through mechanical screens of £ in. bar spacing, the sewage passes to a circular settling tank which acts as a detritus tank, a preliminary and a secondary sedimentation tank. l|le tank is fed by pipes at the bottom, and the sewage passes to a central weir over which it flows past deflectors and baffles un 1 it finally flows at a low velocity over a circumferential weir. Heau solids settle to the central cone bottom to which automatic scrape'5 push the primary sludge. This cone, of two day capacity, 15 emptied by hydrostatic pressure. For the time being, and P® "? the construction of the sludge digesting tanks in the next stage the extensions, the sludge is being ploughed into land, period of detention in this tank is 3 hours for a 3 m.g.p.d., or 2 nou for a 4| m.g.p.d. flow. The effluent then passes to the Simplex Aeration plant which consists of 20 units in 4 rows of five. Here the liquor is given four hours aeration by means of mechanical revolving cones. The aerated sewage then passes into 24 cone-bottom setting tanks for detention for a period of 6 hours before the final effuent is discharged. 17 The activated sludge is pumped to the diffused air re-aeration tanks which are on a ridge and furrow principle. After a period of 24 hours re-aeration, the re-activated sludge is returned in controlled volumes to the aeration plant for re-use in treatment. The excess sludge in the tanks above that required to be re-aerated for subsequent use is returned to the pump well and settled out as a mixture with the raw sludge in the circular settling tank. Trade Waste: Most of the trade waste flow is from the Ford Works. For the time being, this is being treated by sedimentation in Dorr Clarifiers, allowing a period of settlement of 3 hours. The effluent from these tanks flows to a pump well which also receives the effluent from the settling tanks. Pumps eject the nixed effluent against any state of the tide into the Thames, while at low tides the effluent can gravitate to the creek. The strength of the domestic sewage in terms of oxygen absorbed in 4 hours averages 13 parts per 100,000. After sedimentation this figure is reduced to 9, whilst after 4 hours aeration, it is reduced to about 2.5 parts per 100,000. Rivers and Streams. See 1930 report. Owing to the fouling of the Seven Kings Stream, colour tests were carried out in the northern part of the district to determine the sources of pollution, following which the owners of property ui that area were requested to disconnect the overflows from their cesspools. The trouble seems to arise from the fact that the Council's cesspool emptier empties free of charge the cesspools only once per month, though there are few cesspools having a Month's capacity. For emptying at more frequent intervals a charge of 15s. Od. per load is niade. The majority of the residents in the area concerned, during the summer months, supply teas at week-ends and holidays to the members of the public who spend their time at Hainault. The use by these persons of the lavatory accommodation of the premises results in the overloading of cesspools. If a public lavatory were conveniently situated, this nuisance would be very much less. A scheme has now been put forward and is in hand for a small sewerage plant to be installed in this area as suggested in the Annual Report for 1927. Closet Accommodation. See 1930 report. 18 Scavenging. Collection and Disposal of House and Trade Refuse. The following figures relate to the cost of this service for the financial year ended 31st March, 1933:— Collection. Disposal Total Net cost £9,653 £3,955 £13,608 Net cost per ton 9s. 0.42d. 3s. 8.42d. 12s. 8.84d. Net cost per 1,000 population £104 £43 £147 Net cost per 1,000 premises £482 £198 £680 Total refuse collected 21,368 tons Weight per 1.000 population per day 12.6 cwts. No. of houses and premises 20,020 All refuse collected by 7 mechanical vehicles. Refuse Separation and Incineration Plant. See Annual Report 1932, page 26, for description of the plant. This plant was opened on August 28th, 1933, since when disposal at the tip previously used has been discontinued. Earth Closets. The night soil from the 48 dry earth closets and privy pits in the district is collected at night in a tumbler cart and deposited on fields. Cesspools. Most of the 52 cesspools of the district are emptied by the Council's gully emptier at intervals of a month. Emptying at more frequent intervals can be carried out at the expense of the occupier of the premises. The contents of the cesspools were deposited down the manholes of the sewers. This led to complaints from the resident of the adjacent property. To eliminate this nuisance, the contents will in future be deposited down a manhole at the Separation Plant. 19 Disinfection. Terminal fumigation was abolished early in the year. In its place, reliance is placed on the disinfection of infected articles by the householders. A leaflet of instructions is given by the Sanitary Inspectors and the procedure elaborated by them. A supply of disinfectant is obtainable at the Public Health Offices and also a disinfectant soap. In the case of home treated patients, stress is laid on the importance of concurrent disinfection by which particular attention is given to those articles likely to be infected. After the freeing of a case, or removal ol the patient to hospital, a further visit is paid by the inspectors to ensure that the necessary steps have been taken in regard to potentially infected articles. The only indication as to the infectivity of premises or articles to be obtained in ordinarv circumstances is that they act as foci of infection and lead to further cases. The guide therefore should be the number of cases of secondary infection. It is admitted even by those who see in fomites an important factor in the spread of infection, that the chief factor is the infectious person, either a patient or a carrier. While therefore an infectious patient is being treated at home, there are no grounds for attributing the source of infection of a secondary ease to fomites. Similarly, if the onset of infection of the secondary case lies well within the incubation period of the disease from the time ot removal of the primary case, the secondary case can be assumed to have been infected from the first patient. Actually the number or percentage of secondary cases can form no guide to the extent of infection by fomites, as, apart from these considerations, the number is associated with the facilities available for the immediate removal to hospital of the primary case, and also with the herd immunity of the population to the particular disease. As however, this is the first year in which terminal fumigation has been abandoned and as in the same year the number of cases of secondary infection of scarlet fever was high, these figures will now be analysed. Of the 89 cases, 37 were infected before the recognition of the disease in the primary case, in some cases the primary case being completely missed and in others the primary case not being recognised until a medical attendant has been called in to the second case. 20 of these were single infections; 8 cases were due to two secondaries following a primary; and 9 cases were groups of three secondaries subsequent to three primary cases. 20 17 secondary infections occurred where the primary case remained at home. 7 of these were single infections. In one instance there were two secondary cases, in one three, and in another five cases. In two other cases where the primary infecting case could not be immediately removed, two secondary cases occurred. The total of secondary infections, therefore, where the primary case was at home at the time of onset of the illness of the secondary was 19. In the Memorandum on Closure of and Exclusion from Schools issued jointly by the Ministry of Health and the Board of Education, the incubation period of Scarlet Fever is given as 1 to 8 days, and the interval between the onset of illness and the appearance of the rash 1 to 2 days. Whereas an interval of under 24 hours separating the onset of illness between two cases in the house would lead to the supposition of there being a common source of infection affecting both, when the onset of the secondary is the next day after the onset of the primary the presumption is very strong that the erne infected the other. Of the 31 cases which occurred secondarily to a primary case which was removed to hospital, the number of cases in whom the onset of the disease in the secondary was within 24 hours of the removal of the primary was 14; of those within another 24 hours 4; and a further 7 in the next 24 hours. That is to say, in 25 cases out of the 31, the onset was within 72 hours o1 the removal of the infecting source. Another three fell within the limit of the 8 days of period of incubation, leaving only 3 outside this period, the interval separating the onset of the illness from the removal of the infectious patient being in these cases, 8, 11, and 11 days. Of the 89 secondary infections therefore, in practically every one the primary infecting case was presumably the source, acting by direct infection, without invoking the hypothesis of indirect infection by inanimate articles. Even in the case of those whose onset was outside the incubation period from the time of removal of the infecting source, it is not always necessary to ascribe infection to fomites. At times, the time of eruption of the rash is given as the onset of the illness, whereas, in the case of adults particularly the eruption may not appear for a number of days from the true onset as determined by the development of faucial involvement. Further, an incubation period is not always a definite time in that infection might lie dormant for a period until some constitutional. factor upsets the balance in favour of the invading organisms Before the bacteriological nature of infections was appreciated much stress was laid on aetiological factors as the reason for 21 infections. The tendency later was to attribute an infectious illness as due only to invasion by the peccant organisms. The swing of the pendulum probably went too far, as there is no doubt about the influence of factors in affecting the susceptibility of the host. In the absence of the virulent organisms, the specific disease does not arise; but something more than the mere presence of the organism is required to determine the onset of disease, and constitutional factors can influence for longer or shorter periods of time the degree of susceptibility or immunity of the host. While therefore, it is possible to ascribe within certain limits the ordinary period of incubation of a disease, in certain circumstances there may arise a combination of factors which can result in the interval of time between the reception of the invading organisms by the host and the onset of the illness being outside the ordinary maximum limits of the incubation period. The large number of secondary cases of scarlet fever cannot therefore be taken as an indication that the present steps taken in dealing with infected articles in the home are any less efficient than those previously carried out. Actually it is probable that they are far more effective, in that when terminal fumigation was practised, there would be a tendency on the part of many to consider that the procedure afforded complete protection and so would render the householders lax in carrying out the most necessary steps in regard to the disinfection of those articles more likely to be contaminated; whereas now, in the absence of fumigation, they are made to realise that those steps are essential and this should result in their being much more efficiently carried out. The 10 secondary cases of diphtheria could also be attributed direct personal infection. Two were secondary to a missed nasal case; in another four the onset of the secondary was prior to the removal to hospital of the primary case, and in the case of a further three, the onset of the secondary was within 24 hours after the removal of the primary infecting case. The remaining case was one whose alleged onset was the fourth day after the removal of the primary case. As the incubation period of this disease is given as 2 to 10 days, it can be accepted that this was another direct personal infection. In none of these cases then is it necessary to assume infection by means other than direct from the patient, and they afforded no proof of the infectiousness of inanimate articles. The relation of secondary infection to removal to hospital of the primary case is considered under the heading of scarlet fever; also consideration is there given to the return eases. One of the alleged reasons for these cases is the bringing out on the 22 return home of a patient of articles which were infected before his removal and which had not been used in the meantime. Actually as a percentage rate on the total number of notifications, these figures this year are no higher than they have been in past years and afford no evidence on this suggestion. Return cases, just as cases of secondary infection, are due to direct personal infection. Smoke Abatement. As last year, there was only one important source of smoke nuisance in the district. A total of 49 observations were carried out showing that in 1,390 minutes there were 376¾ minutes of no smoke, 744¾ minutes of moderate smoke and 268½ minutes of black smoke. These figures show a decided improvement over those of last year. A factory refuse destructor has been provided at these premises and all refuse is now burnt and used for steam raising. For the original furnaces, eliminators have been provided with a view to abating nuisance from smoke from the imperfect combustion of sawdust. 35 observations on six other factory premises showed for a total of 841 minutes, the emission of black smoke for 29¼ minutes, moderate 660 minutes, and no smoke 151¾ minutes. Premises and Occupations which can be Controlled by Bye-Laws. Offensive Trades—Fried Fish Shops. There are 15 fried fish shops in the district to which a total of 128 visits were paid during the year. An application was received for the establishment of a fried fish shop and certain works were requested to be carried out. As trading was commenced before the request was complied with, proceedings were taken against the offender. The case was heard at Stratford Police Court on 29th November, 1933, and was adjourned for 5 weeks with a view to the works required being carried out satisfactorily- Application was received in October, 1933, for permission to carry on the business of an itinerant vendor of fried fish from a motor vehicle. Permission was refused, and the business, which had been commenced, was discontinued. Rag and Bone Dealers. Two persons were seen to be exchanging toys for rags, in contravention of Section 73 of the Public Health Act,1925. Warning letters were sent in each case. 23 Mortuary and Disposal of the Dead. See Annual Report for 1930. One exhumation was carried out during the year, for transference of the body of a child from one grave to another. The arrangements and proceedings were carried out satisfactorily. Schools. The sanitary accommodation and water supply of the schools, most of which are modern buildings, are satisfactory. Schools have again played very little part in the dissemination of infection. Their slight influence is referred to under the various infectious diseases. No school has been closed or disinfected during the year on account of infectious disease. Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections of:— Houses 7,818 Bakehouses 34 Slaughterhouses 816 Milkshops and Dairies 65 Cowsheds 36 Foodshops 752 Infectious diseases enquiries 4,705 Rooms disinfected 56 Food poisoning enquiries 66 Visits to foster mothers' premises 44 Smoke observations 84 No. of nuisances investigated 320 Outworkers premises 42 Houses let in lodgings 47 Ice-Cream premises 161 Factories, Workshops, etc. 94 Other visits 38 (b) Notices served. Complied with. Statutory 36 32 Informal 917 703 On the Administration of the Factory and Workshop Act, 1901. In this district there are 38 factories, 40 workshops, and 7 workplaces, to which visits were paid during the year as follows ;— 24 factories 32, workshops 62; workplaces, nil. One written notice was served during the year in respect of factories. The sanitary accommodation was found to be defective at one factory, and a notice under the Public Health Acts was served and complied with. Notices were also served in respect of two other nuisances. These were both complied with. There were 72 premises in which outwork was carried on. At 44 of these, the work done was the making up of wearing apparel, There was no outwork in unwholesome premises. Shops Acts, 1912-1930. 90 shops were registered and 329 re-visited during 1933 A number of infringements of the laws relating to the closing hours were reported, and three offenders cautioned. A whole-time Shops Inspector was appointed at the beginning of the current year, so these Acts are no longer administered by this department. Quarry Fencing Act, 1887. Notice was served under this Act requesting the fencing of a gravel pit "dangerous to the public in open or unenclosed land, within 50 yards of a highway." Rats and Mice (Destruction) Act, 1919. As heretofore, tins of rat biscuits, rat-lime and paste have been handed to persons, on request, for dealing with infestations of rats and mice. A special effort was made in connection with National Rat Week to deal with these pests and 200 circular letters were sent to provision merchants, butchers, bakers, farmaers and occupiers of other premises where rats would be likely to be found, offering them supplies of poison free of charge together with advice and assistance. As a result of these letters, six dozen tins of rat biscuits and other poisons were supplied. Arrangements were also made to disinfest the Council's now derelict refuse tip at Marks Gate with cyanide. Two applications of and one of baiting were carried out and about 40 rats were actually killed in the open. A report has since been received that when workmen were removing a sleeper road from the tip', literally hundreds of rats were found beneath the surface. 25 HOUSING. HOUSING STATISTICS FOR THE YEAR 1933. Number of New Houses erected during the Year:— Total 1,323 (1) By the Local Authority 132 (2) By other Local Authorities 21 (3) By other bodies and persons 1,170 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) 2,654 (b) Number of inspections made for the purpose 7,818 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 2,146 (b) Number of inspections made for the purpose 6,198 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 9 (4) Number of dwelling-houses (excluding those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 549 2. Remedy of Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 314 3. Action under Statutory Powers during the Year:— A. Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930 (1) Number of dwelling-houses in respect of which notices were served requiring repairs 1 26 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 7 (b) By local authority in default of owners Nil B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 380 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners (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 (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 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit The Closing Orders referred to in paragraph D(l) were made in respect of houses attached to shops, where it was not desired to interfere with trade carried on in the shop premises as wou have been the case had a demolition order been made. Slum Clearance. The following is a copy of a report submitted to the Public Health Committee in September. 27 Circular 1331 of the Ministry of Health relating to Part 1 of the Housing Act, 1930, requests that the Local Authority proceed to:- 1. Prepare and adopt a programme the components of which should be (a) A list of the areas in which clearance is necessary, with information of the number of houses to be demolished in each, and the number of their inhabitants. (b) A list of the areas in which improvement, by way of reconditioning and otherwise, is necessary, with information as above. 2. Make an immediate beginning with a programme by a declaration as to clearance or improvement areas of such areas as can be immediately dealt with, and by making the necessary orders. The programme should, so far as practicable, be drawn up on the basis of clearing all areas that require clearance not later than 1938. At the time of the 1901 census there were some 1,500 houses in the Dagenham district. This number has since been reduced by demolition, including a number pulled down when the L.C.C. were developing their housing estate at Beeontree. The Local Authority has been instrumental in obtaining the demolition of a number which could not be rendered fit for habitation, and the owners of some found it expedient to demolish the properties to enable them undertake more profitable development of their land. Round about the year 1900 there was some development in the Chadwell Heath Ward—apart from this, between the years 1900 and 1919 there could have been very little housing development in this area as the 1921 census disclosed that there were only 1,871 structurally separate dwellings. The property in this district can be divided, roughly, into the older, erected prior to 1900, and the new. For the purpose of this report every house built before 1900 has been under review with the particular object of determining whether the house is likely to require consideration from the point of view demolition, within the next five years. There have been and are at the moment no houses which can advantageously be grouped as clearance or improvement areas. The activities of the Council during the past few years have resulted in the demolition of a certain number of houses, these being dealt with 28 under Section 19 of the Housing Act. In the ordinary way a certain number of houses will be demolished in the next five years. It is impossible to say of any particular property that cannot today be considered as suitable for action under Section 19, that it will need to be dealt with within five years. Apart from other considerations, the standard set by the Court as the result of an appeal under any order under Section 19 might be so raised that conditions that today one might consider would justify a demolition order, might not be sufficiently bad to warrant similar action being taken at a later date. Then again, the desirability of preventing occupation of an unsatisfactory house is bound up, to a large extent, with the capacity of the tenants to pay for alternative accommodation. Where the added rent seriously depletes the family income a disservice might be rendered to that family by obtaining the demolition of their original home. In this way the problem is related to such wide matters as the general economic state of the country and more particularly of local employment conditions. It can be seen that while, in this report, consideration is given to every property which may conceivably require demolition within a period of time, it does not of necessity follow that all these properties will not be standing at the end of this period. On the other hand, it is quite possible that other properties that ordinarily would be the subject of a demolition order might be pulled down by the action of the owners where the cleared site is required for the purposes of development. In 1930 the quinquennial statement to the Ministry of Health gave as the estimated number of houses to be demolished within the next five years:— In clearance areas nil In improvement areas nil Individual houses outside clearance and improvement areas 100 In 1931 fifteen houses were demolished under the Housing Act, and a further nineteen in 1932. In addition a number have been pulled down by the owners. Of the 20,071 houses in the district, 1,371 are over 30 years old, in addition to which there are 98 inhabited shops of the same age. Of this number 54 will probably come down in the next five years. A certain number have already been reported as requiring demolition, but for various reasons a demolition order has not been made. In this group are classed Nos. 1 to 6, Bell Cottages, which are the subject of negotiation between this Council, the Ministry of Transport and the Essex County Council, as their removal is required urgently to effect the widening of a very busy. 29 road. Others falling into this group are shop properties, where in some cases the owner of the shop resides in the house. Some of these houses are at present empty, and an undertaking has been entered into by the owner that the properties will not be relet. The only other properties which, at the moment, could be demolished as being incapable of being rendered fit at a reasonable cost, are mostly situated in the rural parts of the district. There are some half-dozen of these which are inhabited by families which are deemed incapable of paying a higher rent than the very low one they pay at the moment, and where the wage-earner, if any, is locally employed. There is no alternative accommodation to offer these in the neighbourhood of their present homes. Some are occupied only by aged persons, and in such cases an endeavour is made to obtain an agreement from the owner that he will not relet them should they become vacant. The following is a copy of the return made to the Ministry of Health on form "Housing 129" on Slum Clearance under the 1930 Housing Act:— 1. Clearance areas Nil 2. Improvement areas Nil 3. Individual houses to be dealt with under section 19 of the Act:— Number of individual houses proposed to be demolished under section 19 54 Number of persons to be displaced from such houses 200 Number of new houses proposed in Covered by last connection with these displacements section of the Council's housing scheme. Appeal against Demolition Order. In the Report for 1933, a case is referred to where the owner of the property appealed against a Demolition Order made under Section 19 of the 1930 Act. The judgment of the Court was that the owner was to carry out the work deemed necessary by the owner's Surveyor and the Council's Surveyor, or failing agreement between them, by an independent Surveyor. The work having been done to the satisfaction of the Arbitrator, the case was returned to the Court and dismissed without costs. Owing to the extent of the gross sanitary defects still unrectified, it is Proposed that action should be taken under the Public Health Acts, 30 Houses Let in Lodgings. At the end of the year there were 13 registered Houses Let in Lodgings, to which 47 visits were paid. Two applications for registration were abandoned after preliminary inspections owing to the cost of the alterations necessary to comply with the bye-laws, whilst one house was vacated in order that the premises could be completely reconditioned in accordance with the requirements. The standard required for Houses Let in Lodgings in this district is, apart from that specified in the bye-laws, a separate sink, water supply, food cupboard, and gas stove, and where possible, a water closet and washing accommodation for each family. Overcrowding. With the erection of factories in the southern part of the district, overcrowding, as mentioned in last year's Report, has become more prevalent in certain parts of the district. The London County Council and the Dagenham Urban District Council both exercise strict supervision OVER their properties. Overcrowding is therefore confined to those houses built by private enterprise. Owing to the practice adopted in some "factories resulting in the instability of the occupation of the employees, workmen with their families, who have migrated from all parts of the country, are hardly in a position to contemplate house purchase, and are therefore forced to take accommodation in privately owned houses, with consequent overcrowding. The situation, however, is not confined to families but includes the case of single men who upon obtaining work in this district take lodgings in various houses in the locality. Where several are received in the same house, overcrowding frequently occurs. What is the remedy ? In the case of the unmarried man, it would seem that a hostel built and controlled by the local authority would in all probability go a great way to solve the difficulty. In the case of families, however, there seems to be only the one solution, that is, that the local authorities with houses in the district accept as tenants these locally employed men. With a view to abating, as far as possible, the overcrowding of the houses in this district which are privately owned, routine housing inspections are carried out by the Sanitary Inspectors. 31 INSPECTION AND SUPERVISION OF FOOD. (a) Milk Supply. There are 53 retailers of milk in the district, including 9 company distributing centres. The following is a classification of the milks retailed:— Ungraded Milk 36 Grade "A" 5 Pasteurized 3 Sterilized Milk 9 Carton Milk 15 Grade "A," Grade "A" Pasteurized, and Certified Milk 1 each 19 retailers were registered during the year, while 5 discontinued business. 20 dairies were registered and 4 businesses changed hands. There are now only 6 cowkeepers in the district. In December, 1932, it was discovered that some converted garages were being used as a dairy by a firm who had previously carried on a round in this district from premises in another area. A roundsman of this firm had, on previous occasions, been detected bottling in the street. The firm after a while, not only carried on as retailers but acted as wholesalers by supplying a number of individual roundsmen with their supplies, these men using the same premises as their dairies. In May the firm was fined 50s. Od. for using these unregistered premises. An application was made by the secretary of the company for registration as purveyors. June a roundsman of the firm was detected bottling in the street and was later fined 20s. Od. A number of samples of milk dealt with at these premises proving unsatisfactory, in July notice was served under Section 2 of the Milk and Dairies (Amendment) Act, 1922, to show cause why the Council should not refuse to register them as retail purveyors. No representative of the firm was in attendance, and later intimation was sent of the decision of the Council to refuse to register. Before the time for appeal against this decision had lapsed, a communication was received in the name of another company who later applied for registration as retail purveyors and wholesale traders. Again the firm was given notice to appear under Section 2 of the 1922 Act on account of poor samples of milk. In spite of the appearance this time of the representative, the Council refused to register 32 them as retailers, and in October they were fined £5 for being unregistered. Within a few days, fresh applications were received from another firm in respect of these premises. There was a further offence of bottling in the street and towards the end of November, the inspectors detected members of the firm reconstituting milk at the dairy premises. In January of this year they were fined £5 and 5 guineas costs in respect of these offences. In brief the present position is that persons trading as a company can flout the law owing to the delay in following the procedure laid down in the Act, particularly the time permitted for appeal. Individuals can carry on a round in spite of the quality of their milk; after many weeks they are convicted by the Court, but before the penalties are paid, the company has gone out of existence and the same individuals are trading in the name of another company. The premises have been used as a dairy, though unregistered, since the end of 1932, and these individuals have carried on a round though not registered as retail purveyors. Vast sums in total have been inflicted as fines, though very small payments have been made, and the milk supplied to the public has a very poor bacterial count and part is reconstituted. Milk Sampling. During the year 122 samples of milk were analysed; the same system of sampling was continued. The following table shows the results of these analyses, divided into those produced on a small scale and those distributed by large companies Small Dealers Large Scale No. of Bacteria per c.c. in thousands. Local producer Not local. Satisfactory not Satisfactory not Satisfactory not Satisfactory not Under 30 7 — 32 6 11 — 50 6 30—100 5 — 28 2 7 1 40 3 100—200 — 1 2 6 1 3 3 10 200—500 — 1 — 7 — 2 — 10 Over 500 — 12 2 62 21 19 6 122 Those milks which are classed as being not satisfactory in spite of possessing a relatively low bacterial count may possess cells or sediment, or have a high B.Coli count. Seven samples of milk were submitted to biological examination. One proving positive resulted in the detection of the cows suffering from tubercular udders. These cows slaughtered early in this year. 33 (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 816 visits was paid during the year. The carcases inspected numbered 2,817. The following are the details of the extent of unsoundness existing in these animals, all of which were surrendered, with the exception of those mentioned under "Legal Proceedings," which were seized. Beasts : No. slaughtered, 655. No. unsound in some respect, 161. Cause Head Tongue Lung Heart Liver Stomach Spleen Kidney Fat Abscesses — — 4 — 13 1 — — — Actinomycosis 5 1 1 — 1 — — — — Cirrhosis — — — — 4 — — — — Parasitic diseases — — 7 — 33 — — 1 4 Pleurisy — — 4 — — — — — — Tuberculosis 28 28 72 — 18 3 2 4 36 Other causes — — — 2 2 1 1 2 — In addition to the above, 2,072 lbs. of beef were condemned for various reasons, the chief of which were tuberculosis (1,426 lbs.), unsoundness (370 lbs.), and emaciation (250 lbs.). In addition, 6 lbs. of pig skin was condemned for urticaria, and 6 lbs. of pork for unsoundness. Sheep: No. slaughtered, 1,449, No. unsound in some respect, 32, Pigs : No. slaughtered, 713. No. unsound in some respect, 73. Cause Head T ongue Lung Heart Liver Stomach Spleen Kidney Fat Cirrhosis — — — — 18 — — — — Parasitic diseases — — 2 — — — — 2 — Pericarditis 4 — Pleurisy — — 4 — — — — — — Pneumonia — — 11 — — — — — — Tuberculosis 23 23 11 — 2 — — — 19 Other causes — — 2 — — — 1 — — 34 The causes of condemnation of organs amongst sheep were as follows:—Livers of 8 sheep—as the result of being affected by parasitic disease in 6, cirrhosis and abscesses in one each; Lungs of 29 sheep—parasitic disease in 20, pleurisy in 6, and pneumonia in 3. In addition there were two sheep's carcases and offal condemned, one for emaciation and one asphyxia, the total weight being 80 lbs. ; and 22 lbs. of mutton for unsoundness. Legal Proceedings. Condemned meat is collected by lorry and conveyed to the Separation Plant to be burned. In one case it was ascertained that a butcher had surrendered a condemned head, but had failed to surrender the tongue. After inquiries two tongues were seized on the premises. Legal proceedings were instituted, but the case was dismissed owing to conflicting evidence. Proceedings were taken against a butcher for removing a detained beast's liver which was diseased. The butcher was fined £20. A man was observed selling meat from a motor van which did not bear his name and address. Proceedings were taken and the defendant was convicted and fined 20s. Od. Bakehouses. There are four factory and three retail bakehouses in the district; to these, 34 visits were paid in the course of the year. Food Shops. 430 visits were paid to butchers shops, 153 to fish shops, 78 to provision shops, 65 to dairies and milkshops and 26 to greengrocers shops. The following amounts of foodstuffs were condemned:5 cwt. of tinned food—" blown." These tins were found to be damaged following a fire which had broken out at the shops previously. Fish—24 stone. Apparently the practice in this area is for the fishmongers to buy their stock from samples seen at Billingsgate. If any of the fish is unsound it is brought to the Sanitary Inspector in order to procure a condemnation note with the hope of getting a rebate from the fish salesman. 35 Ice-Cream. Section 99 of the Dagenham Urban District Council Act, 1931, calls for the registration of (a) any person being the manufacturer of or merchant or dealer in ice-cream or other similar commodity within the district, and (b) any premises within the district used or proposed to be used for the manufacture or sale of ice-cream or other similar commodity. The additional powers granted under the Essex County Council Act, 1933, to refuse registration or remove from the register should prove useful. During the year 161 visits were paid to premises used for the sale or manufacture of ice-cream. 13 samples were purchased and submitted for bacterial analysis, of which 8 were satisfactory, and 5 not. The applications for registration ot those manufacturers or vendors whose samples were unsatisfactory were deferred for one month, by which time the ice-cream trade had diminished and practically ceased for the year. The number of manufacturers or vendors registered during the year was 77. The standard required before applicants for registration are deemed satisfactory, in the case of vendors, is:—glass covers for wafer biscuits, cones, etc., when exposed on shop forecourts; tin lids of biscuit boxes carried on tricycles of itinerant vendors to be kept closed; systematic changing of water in which instruments for making wafers, etc., are kept. So far as the manufacturer is concerned, most of the ice-cream consumed in this district is made outside, usually by well-known companies. In these cases, when application is made for registration, the district in which the manufacturer is situated is written to regarding the satisfactoriness or otherwise of the manufacturer. Ice-cream manufactured in the district is found in the main to be made in the domestic quarters of shop premises. Upon visiting the premises the Inspectors satisfy themselves as to the cleanliness and suitability of the room in which the ice-cream is made, including the arrangements for storage ; the personal cleanliness of the manufacturer ; the Provisions for the cleansing of utensils, including efficient means scalding, etc.; the milk supply. Food Poisoning. Under Section 105 (1) of the Dagenham Urban District Council Act, 1931, 57 notifications of food poisoning were received. There were only three instances in which two members of the same family suffered from symptoms of food poisoning. In order to assist the enquiries in the source of poisoning, the medical 36 practitioner is now required, when notifying a case, to include particulars of the food he suspects. All except three of the cases occurred in the months July to early October. Vomiting and diarrhoea occurred in more than one-half the cases, some of these patients in addition suffering from abdominal pains, and/or rash, and/or fever. Of the instances where more than one case appeared in the same family, fried fish was apparently the cause in two. and ice-cream in one. None of the cases was seriously ill, and all made an uninterrupted recovery. The question has been raised as to what should be included in "food poisoning," for purposes of notification. Sanitary Authorities are concerned not so much with the individuals affected as with the possibility of numbers of the community suffering in a similar manner. One criterion, therefore, might be that the food causing the poisoning should be one which, had it been consumed by others, would have caused similar results in them, not necessarily of course that it should affect all, but that there is the probability that it would have caused symptoms amongst a proportion of them. Such a test would rule out those reactions of the individual which are due to sensitiveness of the person to the article of diet, not because of any fault in the food, but on account of some property peculiar to the individual. It would therefore exclude the gastro-intestinal disturbances brought about by the ingestion of an article of diet by those suffering from say gastric ulcer, and also exclude those which are manifestations of sensitiveness of a person to some particular article shown by their reacting to it either by the production of a rash or in some other manner. The bacterial food poisonings are the ones which most commonly would be brought within the net, but in the interest of the public there is advantage in not confining the definition within such limitations. Symptoms of belladonna or mushroom poisoning occurring simultaneously in a group of persons, would, on notification, lead to the necessary precautionary measures being taken; in default of notification it would fall to the lot of no-one to take such action. Such occurrences as those of antimony poisoning due to drinking lemonade from enamelware, or ingestion of sweets treated by arsenious oxide call for immediate action. Attention would be far more quickly drawn to such occurrences and notice would be taken on the occurrence of fewer cases, were food poisoning notifiable. To obtain full benefit however from sueh notification, it should be made general. In these days, consumption of food takes place a long way from its manufacture and correlation can only be obtained by notification being made compulsory in all areas, so that the occurrence of small numbers of cases in different districts would point to the original source of the trouble. 37 The symptoms on which a diagnosis is made are usually two or more following:—vomiting, diarrhoea, abdominal pain, fever and a rash. Where only one member of a household is suffering from some of these symptoms, particularly when all ingested the same foodstuffs, it rather suggests that it is more some idiosyncrasy or pathological state of the patient that causes the symptoms, than that the case is one of food poisoning. (c) Adulteration, etc. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year 240 samples were analysed. Proceedings were taken in one instance, the defendant paying 10s. Od. costs. (d) Chemical and Bacteriological Examination of Food. Bacteriological examination of milk, etc., is carried out at the 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. (e) Nutrition. The following is a copy of a report submitted to the Public Health Committee:— In May, 1932, two reports were issued by the Minister of Health's Advisory Committee on Nutrition, the first being a Report on Diets in Poor Law Children's Homes and the second a Memorandum on the Criticism and Improvement of Diets. According to Circular 1370, the Committee, in fixing the various Prices, had not specifically in view the case of unemployed persons and their families, but contemplated generally persons not engaged in more than moderate physical labour. The Committee adopted 3,000 calories and 37 grammes of first-class protein as adequate values for the calculation of sufficient diets. In the Supplement to the B.M.J, of 25/11/33 was published the report of a Committee of the B.M.A. appointed with the following terms of reference—"To determine the minimum weekly expenditure on foodstuffs which must be incurred by families of varying size, if health and working capacity are to be maintained, and to construct specimen diets." This Committee were of the opinion that the minimum requirements were 3,400 calories and 50 grammes of first-class protein daily. 38 The B.M.A. Committee deliberately adopted figures which were higher than those of the Advisory Committee of the Minister on the grounds that in assessing the 3,000 calories sufficient allowance had not been made for wastage, and accepted the 50 grammes of first-class protein as being the mean of the 62 grammes which is allowed in the standard ration of the Army troops in peace time and the 37 grammes more generally accepted. The divergence of opinion on the minimum of the daily calorie requirement is not a matter of great importance as calories as such can be easily provided—for instance, 1 lb. bread possesses a calorie value of 1,000, 1 lb. sugar a value of 1,800 and 1 lb. margarine a value of 3,500. A 25 per cent, increase in the daily allowance of first-class protein is of more importance as the foods providing these requirements are ordinarily more expensive. There are, however, suitable low-priced sources such as cheese (with 110 grammes protein per lb.) and herrings, articles of diet of which little use appears to be made in this district. The first part of this report is to determine the minimum weekly expenditure on foodstuffs in the Dagenham Urban District necessary to maintain the health and working capacity of families of varying sizes on (1) the basis of the standard recommended in the report of the B.M.A. Committee and (2) the basis of the standard recommended in the report of the Minister's Advisory Committee on Nutrition. It will be noted the wording follows the terms of reference of the B.M.A. Committee, but that that of the Minister's Committee is not similar, and in the latter report, no actual diets are given. It is proposed then, to study the cost of the diets submitted in the B.M.A. report. The following diet is an example of that suggested by the B.M.A. Committee for a family of man, wife and one child aged 1 to 2 years beef 1½ lb., minced meat 1 lb., bacon 1 lb., corned beef 1 lb., liver ½ 1b., eggs Jib., cheese ljlb., milk 10½ pints, fish (cod) ½ lb., butter ½ lb., suet ½ lb., lard ½ lb., bread 20¾ lb., sugar l½ 1b)., jam 1 lb)., potatoes 7 lb., peas ½ lb., tea ½ lb., oatmeal ½ lb rice ½ lb., treacle ½ lb., butter beans ½ lb., and fresh fruit and green vegetables. The man value of this diet is 2.13. Its cost locally is 13s. 10d. compared with a figure of 13s. 6d. as mean of the B.M.A. investigations, and 11s. 3½d. of the Stockton figures. As another example, the following is the diet suggested for a family consisting of a man, wife and three children, aged years, 10-12 years and 12-14 years:—beef 3 lb., mutton 2 lb., minced meat 1 lb., bacon 1 lb., corned beef 2 lb., cheese 3 lb., 39 milk 14 pints, kippers 1¼ 11)., butter ½ lb., suet ¼ lb., lard (dripping) ½ lb., margarine ½ lb., bread 39½ lb., sugar 6½ lb., jam 1 lb., potatoes 10½ lb., peas (split) 1 lb., tea ½ lb., oatmeal ½ lb., rice 1 lb., treacle ¾ lb., butter beans ½ lb., barley 1 lb., fresh fruit and green vegetables. The man value of this diet is 4.13. The local cost is 23s. 5d. per week compared with the B.M.A. average figure of 22s. 6½d. For purposes of comparison, the following are the local costs, the cost of the B.M.A. average and the mean of the prices of the Stockton for families of varying sizes:— Local. Mean B.M.A. Stockton. s. d. s. d. s. d. 13 10 13 3½ 10 11½ 14 3 13 8 11 3 14 2 13 8¼ 11 3½ 14 8 14 0¾ 11 7 20 7½ 19 3½ 16 5 20 9 20 0¼ 16 5¼ 23 5 22 6½ 18 5¼ The sum entered for fruit and vegetables is that included in the B.M.A. dietary as no details are given, but actually fruit is cheap here and the cost of the particular goods would probably be less here than the sum allotted. The Stockton figures are lower than the average for the country, partly because bread is largely baked at home there (this accounts for about 3d. per man value per week). The general B.M.A. costs were calculated on summer prices, whereas these local costs are for winter prices which are generally higher—for instance, one diet referred to includes 24 pints of milk; the difference between winter and summer prices on this item alone would be is. 0d. The prices of the goods are not necessarily the lowest that can be obtained in any part of the district, but are calculated as the mean of the prices paid by good shoppers who are concerned with the value of the goods received, as well as with the actual cost. The second part of this report is to determine the relation such minimum weekly expenditure bears to (1) unemployment benefit, (2) transitional benefit, (3) poor law relief, after provision is made for the payment of rent and rates appropriate to the size of the families, but without providing for insurances, clothes, heat, light, cleaning materials and other requirements. The approximate weekly rent, including rates and water charges, for the different types of accommodation on the Estate are:—2 roomed flat 9s. 6d., 3 roomed 11s. 6d., 3 roomed cottage 12s. 6d., 4 roomed cottage, non-parlour 14s. 0d., or parlour type 40 15s. 6d. 5 roomed cottage 17s. 6d., and 6 roomed 22s. 6d. These are the average figures ; in practice, some pay up to 4s. Od. over these sums for their accommodation. Under the 1930 Housing Act, the following standard of accommodation is adopted as the normal for certain types of houses 2 bedroomed house, 4 persons, 3 bedroomed, 5 persons, and 4 bedroomed house 7 persons, Actually houses could be obtained at lower rents than these without causing undue overcrowding. In the case of those chronically unemployed, such a change would be desirable as the slight loss in housing facilities would be more than counterbalanced by the increased purchasing power of the family income. In the ease of those temporarily unemployed, however, such a recommendation would not be made. This standard has been adopted in the following table which gives, for various types of families, the cost in this district of providing for the family the diets set out in the B.M.A. dietaries, the rent of the appropriate accommodation, the public assistance allowance for the family and the unemployment benefit. Unempl. Benefit. Public Assist. Family. Food. Rent. s. d. s. d. s. d. s. d. M.W. Ch. 1-2 13 10 9 6 25 3 25 8 M.W. Ch. 2-3 13 10 9 6 25 3 25 8 M.W. Ch. 3-6 14 3 12 0 25 3 27 2 M.W. Ch. 6-8 14 2 12 6 25 3 27 6 M.W. Ch. 8-10 14 8 12 6 25 3 27 6 M.W. Ch. 1-2 : 2-3 : 3-6 20 7½ 15 6 29 3 34 3 M.W. Ch. 1-2 : 6-8 : 8-10 20 9 15 6 29 3 34 3 M.W. Ch. 6-8 : 10-12 : 12-14 23 5 17 6 29 3 35 6 It will be noted that although the allowance for children does not cover the extra cost of food alone for the larger families, that the larger families are additionally handicapped by a substantial increase in the rent if they are to be sutably housed. The 1931 Census disclosed that the average size of family here was. 4.7, which means that a larger than average number of families would require the greater accommodation. The district, however, is relatively fortunate in the extent of its unemployment. Compared with other working class districts the percentage of unemployment is small and the length of spells of unemployment short, partly owing to the comparative youthfulness of the population. The problem is not so much the ease of the unemployed, as of the low wage earners who might be worse off in effective income than the other groups. The following 41 are two typical instances, in each case the mother a good manager— Family consists of husband, wife and children 4½ and 1 year old; wages £2 7s. 0d. Expenditure—fares 4s. 6d., insurance 3s. 6d.. rent 13s. 3d., coal 2s. 6d., gas 3s. 0d. ; leaving 19s. 6d. for food; of this the major items are meat 3s. 6d., bread 2s. 9d., butter 2s. 0d., eggs Is. 0d., tea Is. 0d., greens Is. 0d., cereals Is. 0d., cows' milk Is. 2d. The next family consists of husband, wife and 4 children aged 7, 6, 3½ and 11 months. Out of the wages of £2 lis. 0d., 4s. 8d. is taken up in fares, 3s. 11d. in insurances, 12s. 8d. in rent, 2s. 6d. in coal and gas Is. 9d., leaving 25s. 8d. for food, etc., of which 6s. 2d. goes in groceries, 2s. 0d. in a joint of meat, 3s. 6d. in bread and 2s. 0d. in milk. One of the striking features is the misappliance of money by many and the failure of appreciation of the value of some articles of food. Cheese is an item which rarely appears in the family dietary, while eggs and milk are considered luxuries. As filling meals, more reliance is placed on bread and potatoes than on suet puddings. Many purchase some of the cheaper brands of tinned foods, while fish and chips bought at the nearest fish frying shop forms an expensive meal. In many households, tinned Milk is largely used, partly because it can be purchased at the grocery store and partly as it is considered to be a cheap article, though the manner in which it is used converts it into an expensive item. There can be no question as to the necessity for widespread education of the housewife on the matter of wise purchasing, having regard to the true nutritional value of the article, and on the simple cooking of wholesome dishes which could be made available at prices no higher than the amount ordinarily expended. 42 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. NOTIFIABLE DISEASES (other than Tuberculosis) Under 1 year 1/5 5/10 10/15 15/20 20/25 25/35 35/45 45/55 55/65 65 & over Total. Cerebro-Spinal Fever 2 — — — — — — — — — — 2 Diphtheria 1 32 41 16 6 2 6 4 — — — 108 Encephalitis Lethargica — — — .— — — — — — — — — Enteric Fever — — — 1 — — — 1 — — — 2 Erysipelas 1 — 4 1 — 2 6 13 3 4 2 36 12 Ophthalmia Neonatorum 12 — — — — — — — — — — Pneumonia Acute Primary 5 16 6 7 3 5 4 15 1 — — 62 74 ,, Influenzal — 7 5 1 6 7 14 26 6 1 1 Poliomyelitis Acute — — 1 — — — — — — — — 1 2 Puerperal Sepsis — — — — — 1 1 — — — — ,, Pyrexia — — — — — 3 5 2 — — — 10 Scarlet Fever 4 141 270 109 18 6 17 9 — — — 574 Smallpox — 1 — 1 1 1 2 — — — — 6 Food Poisoning — 2 5 4 7 5 13 14 3 — — 53 Pemphigus 9 9 — — — — — — — — — 9 Cases Notified. Admitted to Isolation Hospital, Rush Green Admitted to other Isol. Hosp. Admitted to other Hospitals. Deaths Registered. Diphtheria 108 108 — 11 Scarlet Fever 574 353 19 2 2 Puerperal Fever 2 1 — — 2 Puerperal Pyrexia 10 1 — 1 — Pneumonia (Primary) 62 1 — — 45 „ (Influenzal) 74 26 — — 4 Erysipelas 36 8 — 11 — Smallpox 6 — 6 — — Typhoid Fever 2 2 — — — Food Poisoning 53 — — — — Encephalitis Lethargica — — — — — Poliomyelitis 1 — — 1 — Pemphigus 9 — — — — Ophthalmia Neonatorum 12 1 — — 1 Cerebro-Spinal Fever 2 — — 2 Diphtheria. The incidence of diphtheria during 1933 was very low, the number of notifications received being only 108. Per 1,000 population, this is a rate of 1.13 or a rate per 1,000 under 15 of 43 2.75. The corresponding rates for the country as a whole were 1.18 and 4.54, giving a proportionate local incidence in the two groups of 0.96 and 0.60. There were no return cases, but 10 cases of secondary infection. Two of these were secondary to a missed nasal case ; in another the onset was before the removal to hospital of the primary case ; and in the case of a further three the onset of the secondary was within 24 hours of the removal of the primary infecting case. The remaining case was one whose alleged onset was on the 4th day after the removal to hospital of the primary patient. There was no difficulty about removal of patients to hospital until the latter part of the year, when there was delay in one case. Six cases were of purely laryngeal involvement. Localised Outbreak. The following is a copy of a report submitted on the occurrence of a localised outbreak:— In the week ending December 9th, 13 cases of diphtheria were notified. Apart from this week, throughout the year the weekly incidence of diphtheria has been low, the only times when more than four cases have been notified being the weeks ending September 16th and 30th, when there were five and six cases. The numbers in the subsequent weeks of the year were two, two. and one. Of these 13 eases in this week, 8 died. 5 (of which one was fatal) were scattered in various parts of the district. The remaining 8 were localised in their distribution, and another case was notified from the same district in the following week. Of these 9, 2 were children not attending school. The remaining 7 attended the same school but not all the same department. The school is a large one with three separate and entirely unassociated departments. Four attended the infants' department but apparently only two were members of the same class. Three the fatal cases were members of one family (incidentally, the two remaining children of this family were found, on testing, to be Schick negative). There was, apparently, no association of the children in other places such as Sunday schools. The factor of greatest importance in the fatality of diphtheria is the time which elapses before the patient is under treatment. 44 In ordinary cases, provided treatment is begun early, the case fatality is low, hut rises with each day of delay that elapses before specific treatment is started. There are, however, instances in which from the first the advantage lies with the organism. Sometimes this seems to be due to some inherent susceptibility of the patient. It is well known that it is practically impossible to render some persons immune to diphtheria, and there are instances of familial susceptibility which suggest the reason for the ascendance of the invading organism lies rather in the lack of resistance of the patient than in the virulence of the organism. In other cases, on the other hand, the cause of the severity of the attack seems to be inherent in the organism, some outbreaks containing a heavy incidence of " bull neck " cases, or of haemorrhagic cases. The reason for the high fatality of this localised outbreak seems, in some case, to be due to the delay in obtaining treatment, but in others to the virulence of the organism. There were 4 cases probably infected with the same organism, viz.:—3 children of one family and a school contact. Treatment in these cases was commenced on the 3rd, 1st., 1st., and 4th days of illness, the patients dying on the 4th, 5th, 7th and 14th day of illness. One of the other cases apparently not associated with these, was a bull neck case for whom treatment was begun on the 4th day of illness, and a fatal ending occurred on the 5th. In one case treatment was commenced on the 4th day, death occurring on the 8th, and in the other no treatment was started until the 10th day, this case proving fatal on 13th day. Since diphtheria immunization was started in this district this is the first instance of a localised outbreak of this nature. This was reflected in the returns of the consent forms which were distributed to all the children in the schools, together with a leaflet outlining the procedure of Schick-testing and immunization. Ordinarily only about 5 per cent, of consents are obtained from the forms sent out from the schools; but on this occasion 160 consents have followed the issuing of 900 forms. Included amongst the children to whom the forms were given there would, of course, be many who had previously been proved to be Schick-negative. Death Rate. There were 11 deaths (2 male and 9 female) recorded during the year, giving a case mortality rate of 10.2 per cent. Most these deaths occurred amongst those cases referred to in the account of the localised outbreak. 45 Bacteriological Examination. 461 diphtheria swabs were examined during the year at the Essex County Public Health Laboratories, and 288 at the Public Health Offices. Schools and Diphtheria. Schools again appeared to play no part in the dissemination of this disease. Out of the number of cases notified, only 36 were in attendance at school. In only two instances did two cases of diphtheria occur in the same department of any school within a period of 10 days. No schools were closed during the year on account of diphtheria and no schools or school rooms fumigated. Schick Testing and Immunization. Sessions were held during the year at four different centres in the district. Most of the new cases were obtained by circularising the parents by issuing leaflets from the schools for the children to take home. Immediately following the small outbreak previously referred to, this school was again circularised with a gratifying response; the results of most of these children dealt with however will appear in the 1934 and not the 1933 returns. The success of issue of forms in this way, in the absence of any local prevalence of the disease, seems to depend entirely on the enthusiasm of the head teacher for this line of treatment. Advantage is being taken when sending the birthday cards to children at each age, to include informatory leaflets and consent forms for diphtheria immunization. This is undoubtedly resulting in a certain number of applications. It is hoped that the cumulative effect of repeatedly drawing the attention of the parents to the advantage of the treatment will result in a satisfactory response. A greater proportion of children now attend for their testing after receiving the three doses. This is ascribed to the fact that the present practice is that at the time of the giving of the final dose, a leaflet is given to the child pointing out the advisability having this test performed after the lapse of some months. Immunizing doses are now being spaced at three-weekly intervals. This procedure is more difficult from an administrative Point of view, but is apparently justified by the small proportion 46 of those who are Schick-positive after receiving three doses. It does not appear either that it has resulted in any greater proportion failing to complete the full course of injections. The following table shows the difference in the percentage of those who are Schick-negative after three doses under the new arrangement compared with the numbers found Schick-negative after three doses at shorter intervals. In spite of the small numbers yet available for purposes of comparison, it is felt that it is better to divide them into the various age-groups to avoid any question of the effect of dealing with children of different ages. Age Weekly doses 1 week between first 2 doses; longer between 2nd and 3rd. 1 week between 2nd and 3rd; longer between 1st and 2nd Doses at two or three weekly intervals. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Under 2 12 2 5 1 4 1 6 — „ 3 35 13 11 3 5 — 21 — „ 4 23 9 10 — 5 3 18 1 ,, 5 38 12 8 1 8 1 14 — 6 29 14 16 4 5 4 16 2 ,, 7 52 26 23 2 7 1 41 2 „ 8 62 19 11 4 21 10 53 3 „ 9 40 18 9 1 22 1 37 3 „ 10 42 19 9 1 8 2 13 — „ 11 45 14 10 2 8 3 12 2 „ 12 14 16 3 1 8 1 9 3 1 „ 13 20 6 5 .—. 4 1 13 „ 14 2 5 5 — 2 — 5 — Over 14 — — — — 1 — — — The following is a summary of the work carried out during the year :— No. immunized without preliminary testing ••• * No. Schick Tested Of these 126 were Negative. Of the Schick-positives, number who received three doses No. of Re-Schick tests Of these 196 were Negative. Of the Schick-positives, number who received three doses 47 No. of Re-Schick positives subjected to further Schick test 59 All of the 59 were negative. The following notes relate to the only case this year in which diphtheria occurred in a child who had received three doses of toxoid anti-toxin. In December a girl aged 4 contracted diphtheria. She had received three doses of toxoid anti-toxin on 1/10/31, 8/10/31 and 15/10/31. She had not been re-Schick tested. The following table shows the proportion of children of various ages who reacted Schick-positively:— Age Total. No. of Positives. Percentage Positive. Under 6 14 9 64 .3 7 389 292 75 .0 8 343 240 69 .9 ,, 9 295 191 64.7 ,, 10 278 175 63.0 ,, 11 212 130 61.3 ,, 12 200 120 60.0 ,, 13 108 61 56.5 ,, 14 58 21 36.2 ,, 15 10 3 30.0 Over 15 15 8 53.3 The following figures are those of children dealt with from the time immunization was first started in September, 1930, to December 31st., 1933. No. subjected to Schick Test (Primary) Positive 1,302 Negative 689 No. subjected to Re-Schick Test (after having undergone one course ofinjections). Positive 174 Negative 698 No. subjected to Re-re-Schick Test (after having undergone two courses of injections). Positive Nil. Negative 59 Number of children immunized without having been Schick-tested (under 6 years) 917 48 The following table shows the relation of the number of immunes in the household to the Schick-reactions of the children of various ages:— No. of immunes in family Under 7 7 and 8 9 and 10 11 and over. 6 66.6 (12) 61.5 (13) 50.0 (20) 33.3 (21) 5 61.5 (13) 50.0 (26) 33.3 (27) 16.6 (18) 4 40.0 (30) 44.4 (63) 32.8 (61) 28.3 (53) 3 57.6 (59) 50.0 (132) 46.9 (113) 44.6 (92) 2 78.1 (229) 78.6 (327) 82.7 (232) 68.8 (144) (The numbers in brackets are the total number of children dealt with in the group.) The following table shows the influence of a case of diphtheria occurring in the home on the Schick-reactions of the remaining occupants:— Age. Positive. Negative. Total. Percentage Positive. Percentage Positive in general local population. Under 8 38 25 63 60.3 72.5 8 to 12 54 50 104 51.9 62.5 12 and over 8 11 19 42.1 54.4 The following table shows the analysis of the Schick-reactions of the children tested, according to their period of residence here Period of Residence. Under 8 Percentage Positive. 8 to 12 Percentage Positive. 12 and over Percentage Positive. Total Percentage Positive. Under 6 months 75.0 (24) 59.1 (22) 50.0 (8) 64.8 (54) 6 to 12 months 78.6 (14) 61.9 (21) 100.0 (2) 70.3 (37) 1 year 80.9 (21) 62.1 (29) 55.5 (9) 67.8 (59) 2 years 87.5 (56) 67.1 (82) 50.0 (14) 73.0 (152) 3 „ 74.7 (87) 66.6 (141) 45.8 (24) 67.8 (252 4 „ 75.6 (86) 88.2 (76) 36.3 (22) 76.1 (184) 5 „ 70.5 (44) 50.9 (57) 30.0 (10) 56.8 (111) 6 „ 72.2 (36) 63.8 (58) 50.0 (14) 64.8 (108) 7 „ 46.6 (15) 75.5 (45) 66.6 (6) 68.1 (66) 8 „ 60.0 (5) 66.6 (24) 33.3 (9) 57.9 (38) 9 and over 74.4 (39) 57.1 (7) 71.7 (46) These four tables refer to all children dealt with in this district from the time immunizing was started here. 49 Scarlet Fever. 574 cases of scarlet fever were notified during the year. This is an incidence rate of 6.00 per thousand population, or 14.65 per thousand population under 15 years of age. The corresponding figures for England and Wales were 3.21 and 12.34. The comparative incidence rates of the two groups were therefore 1.87 and 1.09. The incidence rate was low for the first half of the year, only in two weeks were double figures recorded. A slight increase was once more noticed at the end of July and early August. Following this, the figures fell, to start rising in the second half of September, reaching a high figure towards the end of October and maintaining this for the rest of the year, the weekly average for the last 10 weeks being 25. Reason for Removal to Hospital. From the middle of October, the accommodation at the Isolation Hospital was insufficient to meet the demands, and cases had to be selected for admission. Out of the 292 cases which occurred in these last weeks of the year, 100 were admitted to hospital. The reasons for admission were:—clinical condition 30; difficulty in nursing 36 (these reasons included the following groups: adult patient, mother expectant, no facilities for isolation, poverty); exclusion of wage earner 22; risk of infection owing to large number of children at home 9. One obtains an impression that the type of scarlet fever is getting more severe. This impression is to a certain extent supported by the above figures. In 1930, out of 513 cases, 213 were admitted to hospital, out of which 40 cases were admitted on account of the clinical condition of the patient. Actually in these last weeks of the year, 30 out of 292 not ified cases were admitted on clinical grounds. In one-third of these the reason for admission was the severity of the illness; 5 cases went in later with nephritis, and 5 suffering from ear complications. Of the 574 cases notified 466 were cases of primary infection, secondary and one recovery case. There were 17 return cases and three others in which the case might have been either return or secondary, in that a third case occurring in the house after the return home of the infecting ease might be either a second return case or might be a secondary to the return case. 50 Secondary Infection. Relation to Disinfection. Considered under Disinfection. Relation to Removal of Primary Infecting Case. In previous reports, particularly those for the years of heavy scarlet fever incidence when many cases were treated at home, it was shown that removal to hospital of the infectious case does not play a great part in limiting infection; or conversely, that retention at home of an infectious case does not result in a high incidence of disease. The following table which gives the percentage of secondary cases, return cases and home-treated cases as a factor of the total number of cases notified in the year shows that there is no constant relation between the proportion of cases treated at home and the extent of secondary infection. Home- Percentage of Treated Secondary Cases Return Cases Cases. 1927 12.6 0.4 18 1928 10.0 3.0 63 1929 17.4 4.0 62 1930 12.0 3.8 58 1931 13.5 3.1 25 1932 13.0 3.3 16 1933 15.3 4.1 38 In considering the effect of hospitalization in preventing secondary infection, one must take account not of the date of removal of the primary case, but the date of notification which can be accepted as being that of the date of diagnosis. It is apparent that if there is delay in removing the primary case owing to limited accommodation, some secondary infections might occur which would have been prevented had immediate removal been possible. On the other hand, the occurrence of those secondary infections through failure for any reason to diagnose the infecting case would not be lessened by the most ample hospital provision. 37 secondary cases occurred before the primary cases were diagnosed and therefore were not attributable to shortage of hospital accommodation. A further 27 secondary cases occurred in spite of immediate removal to hospital of the primary case. Of the remainder, in only 4 cases did the onset of the illness of the secondary case occur later than the 8th day from the onset of the illness of the primary case. 51 Out of the 25 secondaries where the primary ease was removed immediately, the onset of the illness of the secondary from the time of the onset of illness of the primary was not later than the 4th day in 8 cases; not later than the 8th day in a further 12; and occurred after the 8th day in 5. The corresponding figures in the case of the 27 secondaries where the primary case was immediately removed were 14, 5 and 8. If one accepts those cases occurring within 4 days as not preventable but those over this time as possibly preventable, it would appear, owing to the greater number of cases in which the onset was 5 to 8 days in the series of the home-treated primaries, that the retention at home of the primary case resulted to some extent in the occurrence of secondaries. An analysis of the 12 cases however shows that in at least half of them the primary case was not diagnosed before the third day of illness, and that therefore many of these secondaries would not have been prevented by immediate removal of the primary infecting case. It is not unnaturally acccpted that those secondary infections occurring late after the onset of a home-treated primary case would have been prevented by the early removal of the infectious patient, so that it is of interest to note the occurrence of a number of late cases subsequent to the early removal to hospital of the primary case. This analysis only confirms the findings of previous years, that sufficient hospital accommodation to permit of the removal of cases of scarlet fever to hospital immediately on diagnosis does not materially affect the number of cases of secondary infection. Return Cases. There were 17 return cases, in addition to which there were single cases occurring in three separate households which were either return cases or secondary to a return case. There was also one case in which the onset was 30 days from the date of return home of the primary ease who had developed a nasal discharge. One recovery ease occurred in which the onset ol illness was 6 days after the freeing of the primary patient who had been isolated for 28 days from the onset of illness. 52 Most of the infecting patients gave a history of being apparently well on their return home, but after a few days developing a nasal discharge. In three instances, two return cases occurred in the same household, the onset of illness of each of the pair being the same date. The period from the time of return home to the onset of illness was unusually long in most cases. In two instances it was on the 5th day after return home, and in five it was the 7th day. The onset was in the second week in 4 instances, and in the 3rd week 6, of which 5 were on the 20th day. Although in most cases the primary patient was removed early to hospital, in two instances removal was not effected until the 4th day, and in one each the 5th, 10th and 15th days. This last patient, after a period in hospital of 28 days, on the 7th day after his return home, infected two cases. This year too, the average period of detention in hospital was longer, presumably on account of complications. Although a few were discharged after less than 28 days in hospital, no patient was discharged within 28 days from the onset of the illness. Actually in five instances the infecting case was discharged from hospital in the 5th week from the onset of illness; in one instance the 6th; in four the 7th; and in one each the 8th, 10th, 11th and 12th weeks. Infectivity of Scarlet Fever. In the case of 27 secondary infections where the primary case was removed to hospital, the time from the onset of illness of the primary to the onset of illness of the secondary was under 7 days in 18 instances; was between 8 and 15 days in 8 instances; and in only one case was the period longer than 15 days. These figures do not represent the actual periods of incubation of the disease, as included in this list of cases are some in respect of whom the primary infecting case, while removed to hospital immediately on notification, owing to slight delay in diagnosis was not sent in on the date of onset—in fact, removal of the primary ease on the actual day of onset of the disease was comparatively rare. Ihe primary case would therefore in most instances have been at home one or more days before removal. In these circumstances, the actual time of infection would range over this period. Where, however, cases had to be detained at home for many days, even though eventually removed, they have been included in the other list. 53 Of the 61 secondary infections following on a primary case treated at home (and for this purpose the case is considered to be home treated if, owing to delay in diagnosis or to delay in removal owing to lack of accommodation, detention at home occurred for sufficiently long a period for the case before removal to have given rise to a secondary case, even though the patient was later removed to hospital), the time from onset of the primary to the onset of the secondary was 7 days or under in 47 instances, in the second week in 10, in the 3rd week in two and in the 4th week in two. The greatest period of infectivity therefore was the first few days, most of the damage having been done before the recognition of the nature of the disease in the primary infecting patient. When the extent of secondary infection occurring in the second week after the removal of the infectious patient to hospital is taken into account, it can be appreciated the very limited amount of secondary infection occurring after the first week when the primary case is treated at home. Either this is a tribute to the efficiency of the methods of isolation practised in these homes, or it is a further demonstration of the suggestion made following an analysis of home treatment of scarlet fever cases in previous years, namely, that this disease, in the case of the vast majority of sufferers, is infectious for a very limited period of time only, possibly only a few days, but that some patients, a small proport ion, are infectious for weeks. The probable state of affairs is a very high percentage of infectiousness for the first few days; by the end of the week a sudden drop to a low level, and then possibly a gradual decline in the proportion for succeeding weeks. This suggestion is not at variance with the demonstration of the presence of the haemolytic streptococci in the throats of convalescents up to the '21st day. the high proportion of return cases compared with recovery cases suggests infection of the patient in the wards, and presumably continued re-infeetion, a re-infection to which the patients would not be exposed when treated at home. Deaths. Two deaths were certified during the year as being due to scarlet fever, one a boy of 5 dying from meningitis following mastoditis, and the other a girl of one who died of pyaemia. Dick Test. No children were Dick-tested during the year. 54 Schools. Out of the cases notified, only 258 were of children who at the time they fell ill, were attending school. There was again comparatively little association of cases through school attendance. Two cases occurred in the same department of a school within one week 11 times; three cases in the week 3 times; and four eases once. On one occasion three cases occurred over two weeks, and on another occasion four cases in the two weeks. The most striking apparent association of the disease with school attendance that has occurred in this district in the new school buildings was at an infants' department from October 13th to December 31st, when 19 children attending the department succumbed to this disease. The cases occurred irregularly throughout this time, but with usually less than one week's interval separating their times of onset. As however it was just at this period that the weekly incidence was about 25, and as the children were scattered through different classes in the department, it is improbable that much of the infection was actually contracted by school attendance. No schools were closed on account of the disease, and no schools or rooms fumigated. Enteric Fever. Two notifications of enteric fever were received. One case however, turned out to be pneumonia. The other was a ease of para-typhoid fever who contracted the disease whilst staying in a district in which this infection was temporarily prevalent. Erysipelas. 36 cases of erysipelas were notified, 19 male and 17 female, of whom 18 were admitted to hospital—7 to the Isolation Hospital and 11 to Oldchurch Hospital. Four cases proved fatal, 3 being of males of ages 46, 16 and 81, and one female of 57. The face was the region most commonly affected, the ear being the site in two instances and the leg in one. Nearly one-half of the cases occurred in the last three months of the year; this coincided with the time of greatest prevalence of scarlet fever. Cerebro-Spinal Meningitis. Two cases of this disease were notified during the year. March a boy of 9 suffered from an attack which proved fatal, an in October a boy of 10 months recovered from the illness. Acute Anterior Poliomyelitis. In May a boy of 5 suffered from a fatal attack of poliomyelitis. 55 Smallpox. Only six cases of smallpox were notified this year, two families being attacked. On 16th January a girl of 15 fell ill, giving a history of being a contact at Christmas time of a case in London. Her illness was followed by the appearance of the disease in her brother and her sister. About the date that these two succumbed, a woman of 33 fell ill. She had apparently been infected by a missed ease occurring in the same neighbourhood as the other infecting case in London. On the 16th day from the appearance of eruption, her husband first had symptoms. The following table shows the position of vaccination for the last year:— 1. Successfully vaccinated 388 2. Insusceptible 5 3. Conscientious Objectors 738 4. Died before Vaccination 36 5. Postponed by Medical Certificate 33 6. Removed 73 7. Unaccounted for at present 159 Tuberculosis. New Cases. Deaths. Primary Notification. Brought to notice other than by Form A. Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F i\l F M F Under l - - 1 - - - - - - - 1 1 1— — — 1 1 — — 1 1 — — — 4 5— 3 3 11 2 1 — 2 1 — — — 1 10— 2 3 9 10 1 2 2 — — — 1 — 15— 8 3 1 4 3 1 — 1 1 6 — — 20— 2 11 1 3 1 4 2 — 2 3 1 — 25— 13 14 1 5 5 3 — — 3 8 — — 35- 33 13 3 — 1 2 — — 8 5 3 1 45- 6 4 1 — 1 1 — — 2 2 — — 55— 2 1 — — 1 — — — 4 — — — 65 & upwards 1 1 — — — — — — 2 1 — 1 70 53 29 25 14 13 7 3 22 25 6 8 No vaccinations were performed during the year by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. 56 Register. Pulmonary Non-Pulmonary Male. Female. Male. Female, No. on register 1st Jan., 1933 276 256 137 112 During the year:— New notifications 70 53 29 25 Deaths 20 20 2 3 Transfers into area 14 13 7 3 Transfers out of area 55 61 48 23 No. on register 31st Dec., 1933 285 241 123 114 During the year there were notified 123 cases of pulmonary tuberculosis and 54 of non-pulmonary tuberculosis. In addition, there were brought to notice other than by primary notification 27 pulmonary cases and 10 non-pulmonary cases. These latter were mostly cases who had transferred to the district while suffering from the disease. Of the 159 pulmonary cases about whom information was first received during the year (including those cases first learned of from the death certificates), 73 contracted the disease here and 80 transferred here whilst suffering from it. Those whose onset occurred within 6 months of their coming to reside here are not counted as having contracted the disease in this district. Apart from these, there were 5 cases whose onset occurred within one year of their transferring here, 5 in their second year, 9 each in the third and fourth years, 5 in the fifth, and 40 amongst people who had lived here 5 years or over. The sexes were almost equally represented in most age-groups. A close family history was obtained in 15 out of the 42 male cases, and in 12 out of the 31 female cases. Of the 65 non-pulmonary eases first heard of during the year 26 (12 male and 14 female) were original cases. Of these 2 had lived here less than one year, 2 were in their second year, 7 in the third, 2 in the fourth, 5 in the fifth, and 8 had lived here 5 years or more. A close family history was obtained in 10 cases. 8 case, were glandular lesions, out of which 5 gave a family history of tuberculosis. Of 7 abdominal cases, there was a family history in 5. No such history was obtained in the other cases which included three of meningitis and one miliary tuberculosis, the remainer being mostly involvement of the joints. 57 Deaths. 47 persons died from pulmonary tuberculosis during the year, of whom 22 were male and 25 female. Of the 39 cases in respect of whom particulars were obtainable, 26 cases apparently contracted the disease while resident in this district, while 13 deaths occurred amongst those who were suffering from tuberculosis when they removed here. Of the 14 deaths from non-pulmonary tuberculosis, 6 were due to meningitis and two each to peritonitis and renal tuberculosis. Three of these were under one year of age and a further three under five years of age. There were 9 posthumous notifications of pulmonary tuberculosis, including two of patients who died in a mental hospital. Two patients had recently transferred here suffering from the disease; four of the others died in an institution, in one case the diagnosis only being made post-mortem. There was also one death from meningitis of a patient who had not been notified during life. for the country as a whole the ratio of the number of new cases added to the register to the number of deaths is, in the case of pulmonary tuberculosis, 187 to 100, and for non-pulmonary tuberculosis, 273 to 100. The corresponding figures for this district are 315 and 433. This high rate is of course partly attributable to the number of persons who transferred to this district suffering from tuberculosis. The ratios of those who contraeted the disease whilst living here to the total deaths from these diseases are 155 and 185. Sputum Analysis. 312 samples of sputum were submitted for analysis during the year at the Essex County Public Health Laboratories. Public Health Act, 1925, Section 62. No action was taken during the year for compulsory removal hospital of any infectious tuberculous person. Tuberculosis After-Care Association. The Association has held many meetings throughout the year giving grants to necessitous cases. 58 Prevention of Blindness. No special action was taken under Section 66 of the Public Health Act, 1925, for the prevention of blindness, or for the treatment of persons suffering from any disease or injury to the eye Prevention of Deafness. The following is a summary of the report submitted on receipt of circular 1337a:— Although otorrhoea is of frequent occurrence in the infant, it is at this age relatively benign and usually clears up readily. Most of the serious otorrhoeas with impairment of hearing are sequelae of measles and scarlet fever. Although at times the shortage of accommodation at the Isolation Hospital does not permit of the admission of all cases of scarlet fever, all complicated cases, including those with ear involvement, were admitted. During epidemics of measles, the work of t he Health Visitors is largely devoted to visiting infected houses. For those cases requiring it, there are arrangements for home nursing, and also convalescent home treatment. The Council has made adequate arrangements with the hospital authorities for the operative treatment of adenoids and enlarged tonsils. Most of these children are detained at the hospital after the operation. Arrangements were made for the admission of a deaf child at the age of 3½ to a residential school for the deaf, the child being detained there at the cost of the Local Authority until she reached school age. Cancer. The number of deaths from cancer is still on the low side, being 55, compared with figures of 45, 37, 52 and 50 for the previous years. With the ageing of the population, this figure will in some years time, become much higher, 59 The following table shows the age and sex distribution of the deaths from cancer of different sites:— MALES. FEMALES. Under 35 35/44 45/54 55/64 Over 65 Under 35 35/44 45/54 55/64 Over 65 Tongue - - - - - - - - - - Oesophagus — — — 2 4 — — — — - Stomach — 3 2 1 1 - 1 2 - 4 Large intestine including rectum - 2 2 - 5 1 - 1 1 1 Larynx — — 1 1 - - - - - - Lung — 1 - 1 — - - 1 - - Liver - - - - - - 1 - - - Kidney — - 1 - - - - 1 - 1 Breast - - - - - - 2 - 5 - Ovary - - - - - - - - 1 - Uterus - - - - - - - 1 1 1 Other sites 1 - - - - - - 1 - 2 Sarcoma and hypernephroma 1 4 2 — — — 1 — — — 60 MATERNITY AND CHILD WELFARE. Notification of Births. 1,707 notifications of live births were received during the year 321 notifications (including stillbirths) were received from medical practitioners and parents, and 1,451 from midwives. In addition, information was received of 291 births outside this area. The following list shows where most of these births occurred:—East End Maternity Hospital 102, Old church Hospital 70, Queen Mary's Hospital, Stratford, 28, Charing Cross Hospital 28, Plaistow Maternity Hospital 17. Illegitimate births accounted for only 2.4 per cent. of the total births. Stillbirths. 39 male and 26 female stillbirths were notified, the corresponding figures for registration being 47 and 28. The rate per 1,000 of total population registered was 0.76, the rate for England and Wales being 0.62. The percentage of illegitimate stillbirths to total was 4.0, compared with a percentage of illegitimate to total births of 2 .4. Out of 45 cases the infant was dead before the onset of labour in 14. There was a history of illness of the mother in three of these cases. Another one suffered from albuminuria, and three suffered from ante-partum haemorrhage. Of those which died during labour, delivery was difficult or obstructed in 15, malpresentation accounting for three of these, breech delivery a further three and contracted pelvis for 5. One stillbirth occurred during a caesaream section, one was due to a cord presenting and in one patient labour had been induced. The mother was eclamptic in two cases. Premature delivery was the cause in three cases; in two of these the onset of labour being attributable to shock and another to a fall. There was one case of severe developmental abnormality spina bifida. Infant Mortality. 86 infants under one year of age died during the year, giving an infant mortality rate of 48.2, compared with that of 64 for 61 England and Wales. The rate amongst legitimate children was 48.8, while for illegitimate children it was the unusually low figure of 22.7. Neo-natal deaths: there were 50 deaths of infants under one month of age, this being a Neo-natal rate of 28.0 and constituting 58 per cent of the total infant mortality rate. Of these deaths, 29 occurred within 24 hours of birth, of which 21 were premature. The premature onset of labour was due to ante-partum haemorrhage in 4 cases, maternal shock in one, fibroid in one, and twins in three ; but no cause was known in the other cases. Four deaths occurred from difficult labour, two being obstructed labour and two breech deliveries. In two cases the cause of death was congenital heart. A further 9 deaths occurred within the first week, two being due to birth injuries, two to congenital heart, and three to prematurity. One death was due to melaena neonatorum and one to broncho-pneumonia. Of the remaining 10 cases which proved fatal within the month, 6 were due to poor general condition of the child since birth, 3 to respiratory affections, and one to congenital abnormalities. Of the 15 cases which died aged between 1 and 6 months, gastro-enteritis occurring during the summer months accounted for 4. Respiratory affections accounted for 10 out of 20 cases of those who died at ages between 6 and 12 months, gastro-enteritis two, whooping cough two, tuberculosis two and meningococcal meningitis one. Most of the neo-natal deaths occurred within a few days, many within a few hours, of birth. Some, such as those due to congenital abnormality, are definitely not preventable. A large number are due to prematurity, in many of which the cause for he onset of labour could not be determined ; in others, however, it was due to some abnormality in the mother and is controllable to some extent by ante-natal supervision. A number of infants are lost annually from birth injuries ; some of these, too, could be prevented by ante-natal care. 62 Of those deaths occurring in the second to the fourth weeks, some are due to the same causes as those occurring in the first week, the infant just possessing the necessary strength to survive the longer period. Towards the end of the first month, however, respiratory affections exert their toll. In some, of course, this affection is merely a terminal condition in a weakly infant; in others, however, it is due to infection by other members of the household, and calls for education of all as to the infectiousness of the common cold and of its seriousness when attacking the very young. The attack on neo-natal mortality then is part of the attack on maternal morbidity and mortality, namely, further propaganda as to the necessity for full medical ante-natal supervision for all expectant mothers. There were in total only 36 deaths amongst infants between one month and one year old. This low rate is part of the general low death rate in childhood. Deaths of Older Children. 12 children died in their second year. Broncho-pneumonia caused 4 of these deaths, three of these being at the time that influenza was prevalent. The infections caused most of the remainder of the mortalities, whooping cough being responsible for two, and tonsillitis, scarlet fever and diphtheria one each. Two children were fatally scalded. Of the 9 who died in their third year, four succumbed to pneumonia, as in the last age-group most of these being at the time of the prevalence of influenza. One died from acute tonsillitis and one from scalds. Tubercular meningitis was the cause of the deaths of two out of 6 who died in their fourth year ; septic tonsillitis, diphtheria an bronchitis one each. The three fatal cases of children dying in their fifth year were due to influenzal pneumonia, meningitis and a road accident. 63 Ophthalmia Neonatorum. Notified. Treated at home. Treated in hospital. Vision Unimpaired Vision Impaired. Total blindness Deaths. 11 9 2 11 — — — There were 76 eases in which a medical aid notice was sent by a midwife to a medical practitioner on account of some eye condition occurring in an infant . In 11 of these the doctor notified the case as one of ophthalmia neonatorum. No case of ophthalmia occurred where the doctor had been in attendance at birth. All cases are investigated by the Health Visitors on receipt of information, and are visited regularly until the eyes are clear. Most cases cleared up in a few days, though one case was not completely clear for two months from the onset. One child was treated at home under the arrangement with the local District Nursing Association. Another child was admitted to Rush Green Hospital and another, with her mother, was admitted to St. Margaret's Hospital. Pemphigus. During the year, 9 notifications of pemphigus were received. They occurred irregularly throughout the year, none being associated, all occurring in the practice of different attendants. All cases were clinically mild, and none required hospital treatment. Maternal Mortality. There were 5 deaths registered as due to or associated with pregnancy, of which two were due to sepsis, giving a maternal mortality rate for sepsis of 1.12, and for other accidents and diseases of pregnancy and parturition a rate of 1.68, being a total rate of 2.80. Per 1,000 live births, the rates for England and Wales were 1.79, 2.63 and 4.42. Two other deaths were indirectly associated with pregnancy. Of the fatal cases of septicaemia, one followed a neglected abortion. The other was a primigravida who had a normal confinement. The earliest symptoms were the absence of breast 64 milk. On the fourth day the patient had a rigor and was admitted to the Isolation Hospital. The haemolytic streptococcus was grown from the cervix, and she died on the 12th day from peritonitis and septicaemia. Of the patients who died of some condition other than sepsis one was due to obstructed labour in whom there had been no ante-natal supervision. Another similar case who had received full ante-natal supervision failed to deliver herself until a craniotomy was performed. One of the fatal cases was due to toxaemia of pregnancy, the patient developing acute yellow atrophy of the liver. The death of one patient occurred through labour overtaxing a damaged heart. It is interesting to note that not one of these patients had attended the local ante-natal clinics. Puerperal Fever and Pyrexia. 12 notifications were received during the year, 10 being puerperal pyrexia and two puerperal fever. Per 1,000 total births (i.e., live and stillbirths) the rates for these conditions were 5.4 and 1.1, the corresponding figures for the country as a whole being 9.6 and 3.5. One case proved fatal, the patient having, after a normal labour which resulted in a slight tear, a rigor on the 5th day. One case developed scarlet fever on the 4th day from the confinement. In two cases the raised temperature was ascribed to a chill, one following an uncomplicated labour in a primigravida, the temperature being raised on the fourth day ; the other who had a B.B.A. delivery having a one-day rise of temperature on the third day. Two other primigravidae who had straightforward confinements, but who had slight tears, had raised temperatures on the 3rd and 4th days, but made uninterrupted recoveries. A rise of temperature which occurred in one patient on the 9th day was apparently due to a slight mastitis. Another primigravida whose temperature was raised on the 3rd day after a normal confinement, had shortly before suffered from pleurisy and influenza, and subsequently developed pneumonia. It will be noted that five of these cases were primigravidae who had norma labours. The other four cases were complicated labours, three of the® being breech deliveries, one complicated by placenta praevis and another by a perineal tear. The other case was one who developed a post-partum haemorrhage due to an adherent placenta. 65 Five of these patients were treated in hospital, three being at Rush Green Isolation Hospital. Work of the Health Visitors. Routine visits are paid to infants as soon as possible after the tenth day, and special visits are 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 tor 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 667 Total visits 1,623 (b) To children under 1 year of age First visits 2,461 Total visits 7,521 (c) To children between the ages of 1 and 5 years Total visits 9,719 Infant Welfare Centres. There were 10 weekly Infant Welfare Centres held during the year and one fortnightly session. All the Centres are maintained by the Local Authority, there being at each, in addition to the Medical Officer and the two Health Visitors, a clerk for dealing with the distribution of food-stuffs. 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 16,804 (2) By children between the ages of 1 and 5 11,124 Average attendances of children per session at all Centres during the year 59 66 Total number of children who attended at the Centres for the first time during the year:— (1) Children under 1 year of age 1,341 (2) Children between the ages of 1 and 5 62.3 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 78.5% Treatment. Adenoids and Enlarged Tonsils. The same arrangements continue in operation for the treatment of these conditions, namely, agreements with the following hospitals:—King George Hospital, Ilford; Queen Mary's Hospital. Stratford ; St. Mary's Hospital, Plaistow : and Oldchurch Hospital. Most cases, however, are treated at King George Hospital, the majority being detained overnight. During the year a total of 11 cases were treated at a cost of £8 13s. ()d. Orthopaedic Treatment. (a) Ascertainment Clinic : The Consultant Orthopaedic Surgeon paid four visits to the district during the year, when 94 children made 120 attendances. Most children attended once only, 12 attended twice, 4 three times and 3 four times. The commonest conditions for which children were referred were genu-valgum, pes planus, bowed tibiae and talipes. (b) Massage Clinic : The massage and remedial exercises clinic was held twice weekly at the Ford Road Clinic and once weekly at the Becontree Clinic. During the year 109 children under school age received treatment at a cost of £50 2s. 0d., making a total of 501 attendances. Most cases were referred on account of flat foot, knock knee or bowed legs. (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. (d) Hospital Treatment: Three children were sent to hospitals for operative treatment at a total cost of £57 14s. 11d. 67 Ultra Violet Therapy. Light treatment is carried out at the Becontree and at the Dagenham Clinics, two sessions being held weekly at each of the premises. The cases treated are referred from the Infant Welfare Centres and all children are seen by the Medical Officer every fortnight. A few children of school age are referred by the School Medical Officer. A course of treatment commences with a two minutes exposure back and front working up to a 6 minutes double exposure, being 12 exposures in all. Many children had two courses of exposures. The Clinics closed down from May to September. 235 children commenced treatment, of whom 131 completed the course. The commonest condition for which children were referred was rickets, though a large number of convalescents from whooping cough were also treated. The greatest improvement from this treatment appears to be those children in their second year suffering from rickets. Dental Treatment. 8 extraction sessions were held, at which 102 children were treated and 183 mothers, making a total of 318 attendances. A charge is made for each ease (not per attendance), the amount depending upon the financial circumstances of the family. The amount received was £9 12s. Od. and the nett cost of this service was £13 14s. 7d. Dentures are provided, usually only to those cases referred from the ante-natal clinic. The amount recovered as patients' contributions was £13 9s. 9d., leaving a sum of £173 4s. 3d. as the cost to the Council. Convalescent Home. Two mothers with their babies, and 2 children, were admitted to Convalescent Homes at a cost of £8 16s. 6d. Other Provisions. One child under 5 years of age was supplied with spectacles at a cost of 5s. 10d. One child was maintained at the Royal Deaf and Dumb School Margate, until 20/7/33 at a cost of £23 14s. l1d. 68 One mother and baby was admitted to Babies Hostel at a cost of £2 2s. 0d. and one child was admitted to the Children's Dietetic Hospital at a cost of £2 2s. 0d. Ante-Natal Services. Ante-Natal Clinics : 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-Patients Department. In addition, one monthly session was held in the Chadwell Heath Ward. At the Five Elms Out-Patients Department the Consultant Gynaecologist paid fortnightly visits throughout the year, seeing a total of 125 women who made 197 attendances. 114 cases were referred to hospital for confinement, 108 of these being under the Council's scheme, of whom 75 were admitted to the East End Maternity Hospital, 25 to Charing Cross Hospital under the care of the Consultant Gynaecologist, 6 to Oldchurch Hospital and 2 to Queen Mary's Hospital, Stratford. The cost, to the Council for these patients, after the receipt of the patients fees, amounted to £404 12s. 9d. 45 women who attended were found to be not pregnant, and there were 18 post-natal cases. Of the 617 attendances, 222 women came of their own accord, 102 were referred by Health Visitors, 16 by medical practitioners, 11 by Relieving Officers and 141 by midwives. This last figure is a marked decline, in spite of the fact that compensation is paid to the midwife for loss of a case referred to hospital, and also that it is a condition of the payment of the midwives fee in necessitous cases that the patients shall have attended the antenatal clinic. 152 patients paid 6 or more visits, 59 attended once only, 79 twice, 69 thrice, 72 four times and 78 five times. These figures include the attendances at the ante-natal clinics of the hospitals to which the patients were referred, and also include those who had a miscarriage or who left the district before confinement. The 5th month of pregnancy was the commonest time this year for the first attendance, 95 attending at this stage ; the 6th month with 92, and the 4th with 85 were the most common. 73 attended first in their 3rd month, 64 in the 7th, 56 in the 2nd. and 33 in the 8th month. 69 Confinements at Home : Amongst the women who attended the ante-natal clinic regularly and who were confined at home, 302 had normal uncomplicated deliveries. A further 12 were delivered by forceps, one being a persistent R.O.P. and one a face presentation. A slight rise in temperature followed in three cases, and two cases of puerperal fever followed normal deliveries, while one patient had an A.P.H. There were 8 stillbirths. Three of these were due to A.P.H., one to a prolapsed cord in a breech case, one due to craniotomy performed for a persistent R.O.P. ; and three cases in which the cause was undetermined. One patient was removed to hospital for a successful caesarian section following a face presentation. There were 19 miscarriages and one premature infant died. There were complications amongst 9 cases who did not continue attendance at the clinic, some of these being cases who were referred to their own medical attendants on account of some abnormality. In two of these premature induction of labour was successfully performed. Two had a P.P.H. following forceps delivery, and another two were delivered by forceps on account of face presentation. Of three stillbirths, one was due to an A.P.H., one to an extended breech, and in another the cause was not known. One patient by whom the advice of induction was not accepted was delivered of a stillbirth due to intracranial haemorrhage. Hospital Cases : Of the 114 eases referred to hospital, 57 were sent in on other than medical grounds. The commonest sole reason for this was unsuitable domestic circumstances which accounted for 18, followed by 17 sent in on economic grounds. 5 were admitted because it was their first pregnancy, and two single women were sent in. In the remaining cases, more than one factor operated, domestic circumstances being the part reason in 12 and first pregnancy in another 11. Apart from one case of a presenting cord in which a stillborn child was delivered, the confinements were normal in these cases, though three were followed by complications, one being due to phlebitis, one to a P.P.H., and one case of adherent placenta. 57 cases were referred to hospital on medical grounds. instances the reason was some pelvic abnormality ; most of these had normal confinements. 10 were successfully induced, 6 were delivered by caesarian section and one by forceps. 8 eases were sent tp hospital because of some cardiac condition ; 4 of these had normal confinements, 2 were delivered by caesarian section, one by forceps and in one case pregnancy had to be terminated. 70 8 cases sent in because of a previous poor obstetric history had normal confinements. The other medical reasons for admitting cases to hospital included raised blood pressure—three cases, in one of whom labour was prematurely induced—oedema, debility and toxaemia. One persistent breech case was admitted, but was delivered of a stillborn child. One patient was admitted on account of A.P.H. and one for an ectopic pregnancy. Amongst the patients who regularly attended the clinic, there were no maternal deaths, but there were 11 stillbirths. Consultant Ante-natal Clinic : The 125 women seen by the Consultant paid a total of 196 visits. The commonest conditions for which these patients were referred were contracted or flat pelvis, cardiac abnormality and breech presentation. The ante-natal service, for those who avail themselves of it, provides the necessary co-operation between those responsible for the ante-natal examination and those who carry out the delivery. In all cases the attendant is informed of the clinic findings. Normal cases attending the clinic would not be under the care of a medical attendant, the confinement being undertaken by a midwife. Arrangements are made for the midwife to report to the clinic doctor when referring her patient in the first place, the doctor sends reports to the midwife of her findings, and finally the midwife is encouraged to send after the confinement an account of it to the clinic. Further co-operation with the midwives is ensured by the payment by the Local Authority of compensation to the midwife for loss of her patient when her condition demands hospital treatment, and also by the payment of the midwives fees in eases of necessitous patients. Abnormal cases are referred to their own medical attendants, or where the patient desires, and her condition demands, arrangements are made for her confinement to take place in an institution. In the latter event, she is transferred to the ante-natal clinic of the hospital at which she will be - confined. Furthermore, the Consultant sees on behalf of any local medical practitioner, am patients referred to him by them. 35 per cent of the women confined last year attended the ante natal clinic. It is unknown what proportion of women receive ante-natal care because some will attend their own private doctors and some are attending hospitals. It will be noted that altoghter 291 confinements took place outside the district, of which most 71 were in institutions. A certain proportion will have attended the out-patient ante-natal clinic. Also 321 notifications were received from doctors. There is still a large field not yet touched. Out of the 1,451 midwives cases, only 141 were referred to the elinie. Possibly some were referred to local medical practitioners, but many would have had no ante-natal supervision. The success of the midwife in persuading her patient to obtain medical supervision seems to depend more on the midwife herself than on the patient, as most are dealing with similar persons. Apart from the advantage of obtaining medical supervision by attending the clinic, patients are offered other facilities, such as dental treatment, etc. To make these services known to the expectant mothers, a leaflet has been prepared comprising a list of the services provided by the Maternity and Child Welfare Authority. These have been distributed to the midwives in the hope that they will hand them to their patients at the time of booking, so that they will know what help is available for them as expectant mothers, and also what assistance is provided in connection with the confinement. Cases of gross abnormality attending the clinic are provided for by the arrangements made for admission to hospital, financial assistance being afforded where circumstances demand. Ihere is however, the class of patient with some slight abnormality for whom institutional treatment is not necessary, but in whose case it is most desirable that a doctor should be in attendance at the confinement. Such cases should not be allowed to go into labour without previously being seen by the medical attendant who will be present at delivery. Those patients whose financial circumstances permit it, are referred to their own doctors and continue under their supervision. There are however some patients falling into this class who will not, on account of expense, go to their doctors tor the necessary ante-natal supervision, and, in default ot more desirable arrangements, continue attendance at the clinic. As previously pointed out, it is most desirable that arrangements be made for this class by the Local Authority undertaking to pay the cost of the patient's ante-natal supervision by her own doctor father than that she should continue to attend the clinic. Apart from other considerations, it is uneconomic to arrange, in the only satisfactory alternative manner, namely, institutional treatment, for the ante-natal care and for the confinements of such patients when they can be dealt with at their homes. Furthermore, here are some mothers who will not go to hospital, and for them the existing arrangements are definitely unsatisfactory. One of the desirable facilities which is not yet at present available, is that of the services of a consultant to be called out 72 when necessary to a confinement. It is hoped that arrangements can he made with the Essex County Council to permit of the Medical Superintendent of their nearby institution acting in this capacity, more particularly as it is to this hospital that emergencies are admitted. On occasion the condition of the patient does not admit of her removal to hospital, and one would like to see established an emergency ambulance unit operating from an institution by which the immediate services of a specialist and nurses would be obtainable, ready to carry out, in the patient's home, any desirable measures, including blood transfusion. The desirability of abolishing the handywoman is admitted on all sides. The difficulty in effecting this is largely on financial grounds in that the mother is unwilling, often unable, to pay the fees of a doctor and of a maternity nurse ; also the assistance of the handywoman acting as a home help in helping in the management of the home is a consideration. It would be justifiable to assist those patients who require the attendance of a doctor on medical grounds, by subsidising the payment of the maternity nurse and home help. The difficulty arises in those cases where the patient elects to have a medical attendant though a normal confinement is expected. To endeavour to prevent home helps developing into handywomen, the Council has decided that a home help will not be granted to any woman unless she has engaged a trained midwife to attend her at the confinement, or unless a trained maternity nurse is to be present with the doctor. Foster Children. The following tables show the number of foster foster mothers in the district :— children and Foster Children. Number on register, December 31st, 1932 44 Number added to register 39 Number deducted owing to refusal, removal, deaths, or reaching age of nine 41 Number on register, December 31st, 1933 42 Foster Mothers. Number on register, 31st December, 1932 38 Number of additions during year 27 Number taken off during year 28 Number on register, 31st December, 1933 37 73 Proceedings were taken against one woman for failure to notify the Local Authority that she had foster children in her care. This woman was well known to the Council as an unsatisfactory foster mother who had previously discontinued acting in that capacity on being informed that steps were being taken to remove her from the register. Owing to the failure to prove that she was receiving anything for the care of the child, the case was lost. This appears to be a serious defect in the law, as by collusion between the parents and the persons caring for the children, it would be difficult to prove that any child was received for reward. A preferable arrangement would be to act on the assumption that any child in the care of those not his parents should be presumed to be looked after for reward until the contrary is proved to the satisfaction of the Authority. 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 :— £ s. d. (a) For ordinary milk 1,665 7 2 (b) For dried milk 307 12 4 74 Possibly there are few districts in which the difficulties in carrying out this are so great as here, where with the steady growth of the population following on the erection of new houses, fresh children are learnt of But the major difficulty arises from the continued transfer of residents on the London County Council Estate. Weekly returns are obtained of the deaths of locai residents in two adjoining districts in which there are hospitals, but there is more delay in learning of the deaths of those in some of the London hospitals. This will result occasionally in card going out in respect of deceased children. It is too early to assess the results. Some parents arc sufficiently appreciative to send their thanks. In some case children are definitely brought to the clinic who otherwise would not have attended, and it is hoped that others similarly have been taken to their own medical attendants for the same purpose. Also there have been some acceptances for diphtheria immunization. In any event, none of those concerned can plead ignorance of the facilities available under the Maternity and Child Welfare Services. Birth Control Clinic. In the latter part of the year a Birth Control Clinic was established in the district by voluntary agencies. The Local Authority agreed to make a per capita contribution in respect of those patients attending in whose cases further pregnancy would be detrimental to their health. Up to the end of the year no applications were made for the grant. CAUSES OF DEATH Under 1 year Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 and under 75 75 and over Total RegistrarGeneral's Allocations m F m F m F m F m F m F m F m F m F m F m F m F m F 1. Typhoid and paratyphoid fevers - - - - - - - - - - - - - - - - - - - - - - - - - - 2. Measles — — — — — — 1 — — — — — — — — — — — — — — — 1 — 1 — 3. Scarlet Fever — — — 1 — — 1 — — — — — — — — — — — — — — — 1 1 1 1 4. Whooping Cough 1 1 2 - - 1 - - - - - - - - - - - - - - - 3 2 3 2 5. Diphtheria — — 1 — — 2 1 7 - - - - - - - - - - - - - - 2 9 2 9 6. Influenza 1 — — — 1 — — — 1 — — 2 5 2 1 2 1 1 — 1 1 1 11 9 11 10 7. Encephalitis lethargica - - - - - - - - - - - - - - - - - - - - - - - - - - 8. Cerebro-spinal fever 1 - - - - - - - - - - - - - - - - - - - - - - - - - 9. Tuberculosis of respiratory system - - - - - - - - 3 9 3 9 7 4 3 2 4 — 2 1 — — 22 25 22 25 10. Other tuberculous diseases 2 1 — — — 2 1 1 1 1 — — 2 1 — — — — — 1 — — 6 7 6 8 11. Syphilis — — — — — — — — — — — — — — — 1 — — — — — — — 1 — — 12. General paralysis of the insane, tabes dorsalis 1 1 1 1 13. Cancer, malignant disease 1 — 2 13 7 6 5 5 10 9 4 3 4 36 33 36 33 14. Diabetes — — — — — — — — — — — — — 1 1 — — — 1 — — — 2 1 2 2 15. Cerebral haemorrhage, etc. 3 1 3 4 2 6 — 2 8 14 6 10 16. Heart Disease — 1 1 — — — 5 2 1 5 1 5 6 4 7 4 10 9 6 9 4 12 41 51 51 70 17. Aneurysm — — — — — — — — — — — — — 2 — — — — 1 — — — 1 2 2 2 18. Other circulatory diseases - - - - - - - - - - - - — 1 1 — 1 3 2 — 1 — 5 4 5 4 19. Bronchitis 1 — 1 — — — — — — — — — 2 — — — 3 1 1 2 2 6 10 9 11 13 20. Pneumonia (all forms) 15 1 2 1 1 2 1 1 1 — 4 1 6 3 4 3 1 5 1 5 — 2 36 24 31 14 21. Other respiratory diseases - 1 — — — — — — — 1 — 1 — — — 5 1 2 - - - - - 10 1 7 2 22. Peptic Ulcer — — — — — — — 1 — — — 2 3 — — — — 1 1 — — 4 4 6 1 23. Diarrhoea, etc. (under 2 years) 3 3 - - - - - - - - - - - - - - - - - - - - 3 3 3 3 24. Appendicitis — — — — 1 — 1 1 - - - - - - - - - - - - - 1 2 4 2 3 25. Cirrhosis of liver - - - - - - - - - - - - - - - - - - - - - - - - - - 26. Other diseases of liver, etc. - - - - - - - - - - 1 - - - - 1 - - - - - - 1 1 1 2 27.Other digestive diseases — — — — — — — — — — — — - - — — — — — 1 — — — 1 11 11 28. Acute and chronic nephritis — — — — 1 — 1 - 2 - 1 - 2 3 1 — 1 — 1 1 — — 10 4 12 3 29. Puerperal sepsis — — — — — — — — — — — 2 — — — — — — — — — — — 2 — 2 30. Other puerperal diseases - - - - - - - - - - - 2 - 2 - - - - - - - - - 4 — 3 31.Congenital debility, premature birth, malformations, etc. 25 22 - - - - - - - - - - - - - - - - - - - - 25 22 29 20 32- Senility - - - - - - - - - - - - - - - 1 — 4 6 6 20 11 26 1 6 33.Suicide — — — — — - - - - - 2 1 3 2 - - - - - - - - 5 3 5 3 34.Other violence 1 — 2 — 1 1 3 — 6 2 6 1 — — 2 1 2 1 — 2 1 1 24 9 23 9 35.Other defined diseases 5 1 1 — 1 4 8 4 3 — 6 2 4 4 2 2 5 3 3 1 3 — 41 21 34 24 36.Causes ill-defined or unknown - - - - - - - - - - - - - - - - - - - - - - - - - - 56 30 10 2 6 12 23 18 20 17 25 29 52 39 36 23 39 37 35 41 21 49 323 297 326 296