AC 4411 (1) DALENHAM m DAG 8 The Urban District Council of Dagenham 1926 Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1934 CECIL HERINGTON, M.B., B.S. (Lond.), D.P.H. The Urban District Council of Dagenham 19 2 6 Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1934 CECIL HERINGTON, M.B., B.S. (Lond.), D.P.H. 3 TABLE OF CONTENTS. page. Officers of the Public Health Services 6 General Statistics 8 General Provision of Health Services for the Area 11 Hospital Provision 11 Ambulance 13 Clinics 17 Nursing in the Home 20 Laboratory Facilities 20 Legislation in Force 21 Sanitary Circumstances of the Area 22 Disinfection 24 Sanitary Inspection 26 Housing Statistics 27 Statistics of Inspections 27 Inspection and Supervision of Food 30 Food Poisoning 34 Infectious and Other Diseases 37 Diphtheria 38 Scarlet Fever 43 Tuberculosis 46 Cancer 48 Maternity and Child Welfare 49 Infant Mortality 50 Maternal Mortality 52 Infant Welfare Centres 54 Ante-Natal Services 57 5 To the Chairman and Members of the Urban District Council of Dagenham. Mr. Chairman, Ladies and Gentlemen, In presenting my report on the Health Services for the year 1934, I would invite your attention to the fact that I assumed office in October; for nine months, therefore, of the period under review I was not associated personally with your Health Department. Circular 1417 issued by the Minister of Health states that the report for the year 1934 should be an Ordinary report and not a Survey report; it is therefore purposely less comprehensive than some of its predecessors. In January, by arrangement with the County Council, your Medical Officer of Health was given certain duties which gave him supervision of health services in the area which formerly devolved upon the County Medical Officer. This scheme has worked smoothly and has proved of benefit both to the persons directly concerned and the County Staff. The task of taking over administrative control of the Health Services of Dagenham was lightened by the high state of efficiency to which they had been brought by Dr. Caryl Thomas and his Staff, to all of whom I offer my thanks. Finally, I take this opportunity of recording my appreciation of the assistance and interest given by the members of the Council. I have the honour to be, Ladies and Gentlemen, Your obedient servant, CECIL HERINGTON, Medical Officer of Health. Public Health Offices, Becontree Avenue, Dagenham. May, 1935. 6 OFFICERS of the PUBLIC HEALTH SERVICES Full-Time Staff. Medical Officer of Health: E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law (Resigned August, 1934.) CECIL HERINGTON, M.B., B.S.(Lond.), D.P.H. (Appointed October, 1934.) 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. (Resigned June, 1934.) F. W. S. FOX, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate; Sanitary Science as applied to Buildings and Public Works Certificate; Smoke Inspector's Certificate. A. J. JAMES, Certificate of Royal Sanitary Institute. L. E. PRIOR, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate. Assistant to Sanitary Inspectors: J. W. ALLAM (Since November, 1934). 7 Health Visitors: D. G. BRACE, General trained: New H.V.'s Cert. (Resigned November, 1934.) V. A. EVERITT, General trained: C.M.B., New H.V.'s Cert. N. MILBURN, General trained: C.M.B., New H.V.'s Cert. (Resigned March, 1934.) I. F. RICHARDSON, General trained: C.M.B., H.V.'s Cert. H. A. SHUTT, General trained: C.M.B., New H.V.'s Cert. M. SMITH, General trained: C.M.B., New H.V.'s Cert. F. N. UDELL, General and Fever trained; C.M.B., New H.V.'s Cert.: Sanitary Inspector's Cert. (Appointed May, 1934.) D. E. 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. 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 the Sanitary Inspector's Office. Part-Time Staff. Consultant Gynaecologist: H. G. EVERARD WILLIAMS, M.D., M.R.C.P. Consultant Orthopaedic Surgeon: B. WHITCHURCH HOWELL, F.R.C.S. Dentist: F. C. RITCHIE, L.D.S., R.C.S. (Edinburgh). Medical Officers, Infant Welfare Centres: S. GOODWILL, M.B., B.S., D.P.H. J. MARR, M.B., Ch.B. M. TURNER, M.R.C.S., L.R.C.P. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Registrar-General's estimate of resident population 1934 98,710 Number of inhabited houses (end of 1934) according to Rate Books 21,918 Rateable value (Dec. 31st., 1934) £484,108 Sum represented by a penny rate (estimated 1934-35) £1,875 Social Conditions of Inhabitants. A large proportion of residents in this area work in districts outside the Urban District; there are, however, many industries established in Dagenham, the largest of which is the Ford Motor Company. During the past year, several manufacturers have established themselves in Dagenham, and I am informed that negotiations are in progress by industrialists to acquire sites for factories. There has been no marked change in the percentage of employment during the past twelve months. The continued activity in the building industry employs a relatively large number of men, but owing to the weather conditions, employment is often spasmodic. The Dagenham and Becontree Personal Service Council is now firmly established, and its activities extend to the whole of the Becontree housing estate. The number of persons seeking the advice and assistance of this Council continues to increase. The Council is fortunate in having secured the interest of many prominent citizens of the area who continue to evince their interest in the welfare of their less fortunate fellows. Extracts from Vital Statistics for the Year. Live Births:— Total. Male. Female. Birth rate per 1,000 of the estimated resident population, 19.6 Legitimate 1,894 977 917 Illegitimate 44 27 17 Stillbirths:— Legitimate 59 43 16 Rate per 1,000 total (live and still) births. 30.03. Illegitimate 1 — 1 Deaths 653 349 304 Death rate per 1,000 of the estimated resident population, 6.6 9 Deaths from puerperal causes:— Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis 4 2.00 Other puerperal causes 3 1.50 Total 7 3.50 Death Rate of Infants under one year of age:— All infants per 1,000 live births 63.98 Legitimate infants per 1,000 legitimate live births 62.30 Illegitimate infants per 1,000 illegitimate live births 136.36 Deaths from Measles (all ages) 21 ,, Whooping Cough (all ages) 7 ,, Diarrhoea (under 2 years of age) 16 It will be noted that the mortality from Measles is somewhat higher than has occurred of recent years. The same observations apply to deaths from Whooping Cough and Infantile Diarrhoea. The question of hospital treatment for cases of Measles has been considered in some districts and the desirability of this can be supported by the apparent increase in severity of Measles and its sequelae. Population. The Registrar-General's mid-year estimate was 98,710, this is an increase of 3,560 compared with the previous year. The excess of births over deaths for the year was 1,285 and the balance of course is accounted for by the excess of incoming over outgoing population. The following figures give the estimated or census population, the number of houses as ascertained from the rate books and the number of persons per house:— Population. No. of houses. No. of persons per house 1931 Census 89,362 19,457 4.59 1931 Estimated 90,870 19,457 4.67 1932 „ 94,000 19,952 4.71 1933 „ 95,550 20,754 4.60 This gives the lowest yield as 4.59 per house. Using the factor 4.59 and taking the number of inhabited houses according to the rate books on 31/3/35 which is 22,790, the estimated population on that date is 104,606. It will probably be argued that the figure of 4.59 per house is high, but when one considers that applicants for houses on the Becontree estate are given preference when they have large families, the persons per house, at any rate on the Becontree estate, are not comparable with the population generally. 10 Births. 1,938 births were registered during the year. The birth rate per 1,000 population was thus 19.6, compared with 14.8 for England and Wales and 14.7 for the 121 large towns including London. The rate compares with that of 24.2, 26.5, 30.6, 23.8, 23.6, 20.4 and 18.6 for the years 1927 to 1933 inclusive. The illegitimate birth rate continues to be very low, being only 2.3 per cent of total births. The rate of illegitimate stillbirths is 1.66 per cent of total stillbirths. The birth rates of Dagenham since its inception as an Urban District have been high; the rates are largely due to the fact that approximately 90 per cent of the population are under the age of 40 years. Death Rate. Total deaths in district 389 Outward transfers 108 Inward transfers 372 Deaths of residents 653 Of the 108 deaths of non-residents occurring in the district, 62 took place at the West Ham Sanatorium and 38 at the Joint Isolation Hospital. Of the 372 deaths of local residents taking place outside this area, most occurred in institutions. Of these, 274 occurred at Oldchurch Hospital, 24 at King George Hospital, Ilford, 7 at the London Fever Hospital, 5 at East Ham Memorial Hospital, 5 at St. Mary's Hospital, Plaistow, 27 at various general hospitals in London and 7 at children's hospitals. 653 deaths in a population of 98,710 represents a death rate of 6.6 compared with 11.8 for England and Wales. For the years from 1927 to 1933 inclusive, the local rates were 7.0, 7.3, 8.3, 6.6 7.2, 6.5 and 6.5. A table giving the causes of death and the age periods at which they occurred, is given at the end of the report. 11 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. Owing to the increased incidence of both Scarlet Fever and Diphtheria during the period under review, on some occasions it was not possible to isolate all the cases of these diseases at this hospital, and alternative accommodation had to be obtained, usually at the London Fever Hospital, Islington, and in suitable cases, the suitability being determined by the condition of the house and ability to provide nursing and medical attention, a few cases of Scarlet Fever were allowed to remain at home. The Rush Green Isolation Hospital at present has accommodation for approximately 164 patients; plans have, however, received the approval of the Minister of Health for an immediate extension by 50 beds, and at a later date a further extension of from 40 to 50 beds. (2) Smallpox. The Joint Hospital Board has an arrangement with Orsett Hospital Authorities for the admission of Smallpox cases to their hospital. The County Council, however, are making arrangements whereby the hospitalisation of Smallpox shall be undertaken by that body. Detailed arrangements as far as Dagenham is concerned have not yet been completed. 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 Benort of 1931. The following are the numbers of persons admitted from this district during the year:— Pulmonarv. Non-Pulmonary. Male. Female. Male. Female. Total. Adults 43 32 5 5 85 Children 4 5 14 6 29 12 Hospitals for General Cases. (1) Hospitals for Medical and Surgical Cases. Oldchurch Hospital, Romford.—This was originally a Poor Law Hospital of the Romford Union, but has now been acquired by the Public Assistance Committee of the Essex County Council and functions as a general hospital. On page 15 of the Annual Report for 1930, a table is given setting out the allocation of the beds available. Since then, however, the hospital has been enlarged and its scope widened. A fuller report of the accommodation now offered will be given in the survey report for 1935. King George Hospital, Ilford.—This hospital received its Charter early in the year 1930; it is a modern well-equipped building and serves a thickly populated district. The Out-Patient Department at Five Elms, Dagenham, is administered from the main hospital and deals with casualties and minor ailments chiefly. The main hospital has special departments for dealing with gynaecological, ophthalmic, ear, nose and throat cases; there is also a massage and X-ray department. Patients who are found to be in need of treatment at these special departments may be referred from the Out-Patient Department to the central hospital. The survey report for 1930 may be referred to for fuller details of this hospital. (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 care 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. Situated as Dagenham is within easy reach of the Metropolis, most of the special hospitals in that area are readily accessible. For treatment of such conditions as Tonsils and Adenoids, a large number of patients are referred to King George Hospital, Ilford. I may say in passing, that operative treatment for this condition is less favoured by surgeons than was formerly the case. 13 Such special cases as ophthalmia neonatorum are admitted to St. Margaret's Hospital, Hampstead, there being at that institution special facilities for treatment. Accommodation is also occasionally available at the Isolation Hospital, Rush Green. (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. Two motor ambulances, provided by the Joint Hospital Board, are stationed at the Isolation Hospital at Rush Green. (b) Non-Infectious Cases and Accidents. New rules governing the use and charges of these ambulances have recently been formed and for the information of those who may read this report, they are set forth below in full:— Rules and Charges for the Use of the Council's Ambulances. Rules. 1. The ambulances are housed at the Fire Station, Beacontree Heath, and are available any time throughout the day or night. Ambulance Calls may be given by messenger or telephone, Seven Kings 2222 and Rainham 500. 2. An ambulance may be called by anybody in cases of accident within the Urban District or in cases of sudden illness in the street or other public places in the Urban District necessitating the removal of a person (a) for treatment to a hospital, or (b) to his or her doctor whose surgery is situate within the Urban District. 3. No charge shall be made for the conveyance of persons for whom the ambulance is called in accordance with rule 2. 14. 4. Subject to their prior use for accident cases and cases of sudden illness, the ambulances will be available for the removal of private cases of a non-infectious nature. For the use of the ambulances for private cases, a permit (on the Council's prescribed form) must be obtained from a medical practitioner, or, in cases of emergency, from the Chairman of the Council, subject to the exception in rule 7. Upon the arrival of the ambulance the permit must be handed to the Driver or Attendant. 5. The use of an ambulance is permitted on condition that the Council shall not, under any circumstances, be liable for any delay in the removal or non-removal of any case and shall not be liable under any circumstances for any loss or injury to any patient or person accompanying a patient. 6. A private patient must be ready to be removed upon the arrival of the ambulance and the attendants will assist, if requested, in the removal of the patient to and from the ambulance, and the house or hospital, but neither the Council nor its employees shall be liable for any injury that may happen to any patient from any cause whatever during such removal. 7. The ambulances are not available for the removal of drunken or infectious cases, or for the removal of dead bodies. The use of the ambulances is not permitted for the conveyance of private cases when a public or other means of conveyance can be used. 8. Maternity cases shall not be removed unless an official permit has been obtained from a local medical practitioner or, in respect of cases to be admitted to hospital under the Council's scheme, from the Clinic Medical Officer. In respect of maternity cases of extreme urgency, however, a certified midwife may call the ambulance. In all maternity cases a state-certified midwife must travel with the patient. 9. When a permit has been obtained application for the use of the ambulance for the removal of a private case must be made to the Chief Officer of the Fire Brigade. 10. The attendant in charge of the ambulance is instructed to collect removal fees for which an official receipt will be furnished by him. 15 Scale of Charges for Removal of Private Cases (mileage to be calculated from and to the Fire Station). For Ratepayers and Residents. Charge. (a) To or from all hospitals, institutions, etc.:— (1) Within a radius of 8 miles from Fire Station, and including the following hospitals: Free. Old church Hospital, King George Hospital, East Ham Memorial Hospital, Plaistow Maternity Hospital, Queen Mary's Hospital, Stratford, Poplar Hospital, and London Hospital. (2) Outside a radius of 8 miles and within a radius of 15 miles from Fire Station, and including the following hospitals:— 7s. 6d. Guys Hospital, East End Maternity Hospital (except in cases assisted under the Council's Maternity and Child Welfare Scheme—see (c) below), St. Bart's Hospital, Charing Cross Hospital (except in cases admitted, on account of financial circumstances, free of charge to Charing Cross Hospital—see (d) below), Chelsea Women's Hospital, St. Thomas's Hospital. (3) Outside a radius of 15 miles from Fire Station. 7s. 6d. plus 1s. 3d. per mile for each mile or part of a mile run over 30 miles. 16 For Ratepayers and Residents. Charge. (b) From one private residence to another According to distances and scale in (a) above. (c) Maternity cases, assisted under the Council's scheme, to East End Maternity Hospital Free. (d) Maternity cases admitted, on account of financial circumstances, free of charge to Charing Cross Hospital Free. For NON -Ratepayers and NON -Residents 1s. 3d. per mile, plus any special expenses due to patient's condition. A new motor ambulance of the latest type built on an Austin chassis was purchased during the year; it is equipped with appliances for first aid treatment and carries special quick action jacks to be utilised in extricating persons from road accidents. The drivers and attendants have all received a course of training in ambulance work. The following are the details of the work done by the ambulances during the year, showing 1933 figures for purposes of comparison:— 1934. 1933. No. of accident cases conveyed 457 408 No. of other cases conveyed 1,783 1,370 No. of journeys made 1,963 1,587 No of miles run 20,713.1 17,863 It will be noted that under all headings there is an increase; these figures alone justify the provision of the service. 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 times, while in addition on 33 occasions when both vehicles were in commission, the ambulance of one of the neighbouring Authorities was requisitioned. During the year use was made of the Ilford 17 ambulance on 25 occasions and of the Barking ambulance 8 times. Ilford called on Dagenham ambulance 6 times, and Barking 8. (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. Average Attendances. Average New Cases. Wesleyan Chapel, High Road. Chadwell Heath. Weekly Monday p.m. 46 3 Wesleyan Chapel, Marks Gate. Bi-monthly (Discontd. Nov., 1934). Thursday a.m. 7 — Becontree Clinic, Becontree Avenue, Weekly Monday, p.m. 64 4 Dagenham. Weekly Thursday, p.m. 72 5 Weekly (Discontd. Aug., 1934) Friday p.m. 31 3 Ford Road Clinic, Ford Road, Dagenham. Weekly Tuesday, p.m. 36 6 Weekly (Discontd. Wednesday, a.m. 29 2 Aug., 1934). Weekly Wednesday, 55 4 Weekly Friday, p.m. 37 4 Pettit Farm, Heathway, Dagenham. Weekly (Commenced Aug., 1934) Thursday, p.m. 73 5 Out-Patient Department, king George Hospital, Weekly Tuesday, p.m. 66 5 Five Elms, Dagenham. Weekly Wednesday p.m. 59 5 18 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. 8 2 Becontree Clinic, Becontree Avenue, Weekly Monday, a.m. 9 2 Dagenham. Weekly Friday, a.m. 13 3 Ford Road Clinic, Ford Road, Dagenham. Weekly Tuesday, a.m. 12 3 Weekly Thursday, a.m. 14 3 Out-Patient Department. King George Hospital, Five Elms, Dagenham. Weekly (Commenced July, 1934) Tuesday, a.m. 9 2 Weekly Wednesday, a.m. 15 3 It was found that the attendances at Marks Gate Infant Welfare Centre did not warrant the continuance of that clinic, and an arrangement was made whereby residents in the Hog Hill and Marks Gate part of the area were conveyed by the Council's motor vehicle to the welfare centre at Chadwell Heath. Owing to the continued growth of the new housing estate at Rush Green, the Council purchased two adjoining houses in Dagenham Road and converted them into a public building for use of the Public Health, Rating and Public Libraries departments; the rooms available for a clinic are a waiting room, weighing room, consultant room and convenience. A resident caretaker lives on the first floor. The attendances have been steadily mounting since the clinic was opened. 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 Recontree 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 Recontree Clinic and at the Out-Patient Department on Friday mornings. 19 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 morning and Thursday afternoon at the King George Hospital Out-Patient Department. The Tuberculosis Officer of the Essex County Council is in attendance. Venereal Diseases. There is no local treatment provided for persons suffering from Venereal Diseases. Provision is made under the London and Home Counties Scheme, the nearest treatment centre being the London Hospital. Orthopaedic Clinics. By arrangement with the Essex County Council, children who fall under the provisions of our Maternity and Child Welfare Scheme are referred to the Orthopaedic Surgeon, an allocation of costs is made which is based on the proportion of attendances of school children and those under 5 years of age. It is found that owing to a large increase in attendances, the time is approaching when the holding of clinics for children under 5 years of age will have to receive consideration. Remedial Exercises and Massage Clinic. Two sessions are held weekly at the Ford Road Clinic, namely, on Monday afternoons and Friday mornings; and two weekiy on Tuesday and Thursday mornings at the Becontree Clinic. The provision of massage and remedial exercises is an essential part of orthopaedic treatment, and in many cases prolonged treatment of this nature obviates the necessity of surgical interference. light Clinic. Ultra violet Ray treatment is carried out during two sessions a week at both the Becontree and Dagenham Clinics. It is our practice to hold these clinics from October to May inclusive. The two ultra violet Ray lamps which had been in use for a number of years were found to be obsolete and have been replaced by two instruments of the most modern type containing mercury vapour burners. 20 By arrangement with the Essex County Council, children of school age may be treated, this Council receiving a per capita payment. Professional Nursing in the Home. (a) General. The Dagenham District Nursing Association, the headquarters of which are at York House, Dagenham, continues to fulfil a most useful function in the area. The average number of nurses employed is 10 and in addition there is a matron and a sister. A high standard of professional treatment is attained by this association and the work of the nurses is much appreciated. A total of 1,020 general nursing cases were treated during the year, involving 8,158 visits to the homes. 287 midwifery cases and 111 maternity cases were nursed. In addition, these patients paid a total of 1,739 visits to the ante-natal clinic held at York House. Altogether then, the number of persons attended during the year was 1,318 to whom 16,902 visits were paid. During illness or other unforeseen contingencies in the Health Visiting staff, the services of nurses from the association are obtainable at our clinics, a fee being payable by this Council. (b) Nursing of Cases of Infectious Diseases. Cases of notifiable infectious disease are normally removed to the Isolation Hospital; certain cases, however, of non-notifiable infections are nursed by special nurses employed by the Nursing Association. Midwives. There are no midwives in the district employed by the Local Authority. At the end of the year there were 22 midwives living in the district whose practices were confined almost entirely to this area. Laboratory Facilities. Examination of clinical material is undertaken at the Essex County Public Health Laboratory, Queen Victoria Street, London. During the year, 591 swabs were examined for the diphtheria bacillus, 253 samples of sputum for the tuberculosis bacillus, 2 samples for typhoid organisms and 18 samples of hair for ringworm. 21 The same laboratory also undertakes the bacteriological examination of milk, of which 139 samples were submitted during the year. 683 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 and page 15 of the 1933 Report. Byelaws governing Removal of House Refuse were confirmed on 23rd August, 1934. Byelaws governing Nuisances in connection with the Removal of Offensive and Noxious Matters were confirmed 27th November, 1934. Byelaws governing the Transport and Exposure for Sale of food were confirmed 12th December, 1934. 22 SANITARY CIRCUMSTANCES OF THE AREA. Water. See Annual Reports, 1930 and 1932. Despite the unprecedented drought which occurred in both the years 1933 and 1934, there was no shortage of water in the district which could be considered detrimental to health, the only restrictions imposed by the water undertakings were those with regard to the watering of gardens and washing of vehicles. Drainage and Sewerage and Sewage Works Extensions. Reference has been made to this in the reports of 1927, 1928, 1931 and 1932, no material changes having taken place during the past year. Further reference will be withheld until the survey report to be published in 1936. Rivers and Streams. See 1930 report, page 26. In the northern part of the district some fouling of the Seven Kings Stream has taken place owing to the overflowing of cesspools. This matter has received consideration and notices served on certain owners to prevent effluent from their cesspools polluting this water course. The contours of the land in this area render the installation of a sewer a somewhat difficult problem, but it is hoped that it will be possible to deal with sewage from this area in a satisfactory manner. Closet Accommodation. I am in full agreement with the observations of my predecessor with regard to the issue of habitation certificates for houses which cannot be connected with a sewer. On the one hand builders are urged to provide for such amenities as water closets and baths, and on the other, in certain cases there is no possibility of waste water being dealt with adequately. It would therefore appear that the passing of plans for dwelling-houses should be held over until a sufficient sewer can be completed to serve the area concerned. 23 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, 1934:— Collection. Disposal. Total. Net cost £9,492 £4,752 £14,244 Net cost per ton 14s. Od. 5s. 3d. 19s. 3d. Net cost per 1,000 population £99 £38 £137 Net cost per 1,000 premises £440 £167 £607 Total refuse collected 13,576 tons Weight per 1,000 population per day 7.76 cwts. No. of houses and premises 21,553 All refuse collected by 7 mechanical vehicles. The difference in the net cost per ton for 1934 against 1933 is accounted for by the fact that last year the weight of refuse was estimated, whereas this year it was weighed on the Council's weighbridge. Refuse Separation and Incineration Plant. A description of this was included on page 26 of the Annual Report for 1932. It appears that the establishment of this plant enables the refuse collected to be dealt with in a satisfactory manner and at the same time a not inconsiderable revenue is derived from the salved material. 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. Normally cesspools are emptied by the Council's gully emptier at monthly intervals. If occasion should arise for emptying more frequently, this is done and the occupier of the premises charged for the work. The contents of the gully emptier are now discharged down the manhole at the separation plant; formerly this was done down manholes elsewhere in the district and I am informed occasionally gave rise to complaint. 24 Disinfection. Full reference to disinfection was made in the previous report and the procedure described is being continued. Opinion with regard to infectivity of fomites has changed as far as the medical profession is concerned, and I am pleased to say is changing amongst members of the lay public. At one time is was thought that germs were harboured and waited an opportunity of descending upon some unwilling victim and thus infecting him. The nature of infecting matter is now known to be more complicated and the organisms indicted as causes of many of the infectious diseases are now known to lose their power when separated from their normal host, i.e., man. In areas where terminal disinfection has been discontinued for many years, e.g., the County Borough of Brighton, it has not been found that any increase of zymotic diseases has been noticed. Disinfection of Library Books. During the year the whole question of the method of collecting library books for disinfection after a case of infectious disease was under review. In the past, the procedure has been that upon visiting a case, the Sanitary Inspectors have instructed the occupiers of the houses to bring the books to this office. This arrangement was not altogether satisfactory owing, in a few cases, to people not troubling to return books. The procedure now is for the Libraries to be informed of all cases of infection, whereupon they send a notice, together with a label addressed to this office, to the occupiers of the premises. The notice requests the householder to bring the books either to this office or to the nearest branch library. This arrangement is far more satisfactory. So far as private libraries are concerned, they are notified of houses where eases of infection exist, and are requested to arrange for the books to be brought to this office for disinfection if desired. In all cases, whether public or private libraries, instructions are given to the borrower that no more books are to be borrowed until those have been given up. Smoke Abatement. As in previous years, there was only one persistent case of excessive emission of smoke in the district. Improvement during the year was maintained and a total of 13 observations was carried out showing that in 390 minutes there were 51¼ minutes of no smoke, 245 minutes of moderate smoke, and 93¾ minutes of black smoke. 25 8 other observations on five other factory premises showed for a total of 240 minutes, the emission of black smoke for 20 minutes, moderate 185¾ minutes, and no smoke 34¼ minutes. Premises and Occupations which can be controlled by Bye-Laws. Offensive Trades—Fried Fish Shops. There are 17 fried fish shops in the district to which a total of 119 visits was paid during the year. One business was discontinued and three new ones were established. Rag and Bone Dealers. Eight 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. Tents, Vans and Sheds. At the time of writing this report correspondence is taking place with the Ministry requesting confirmation of new bye-laws dealing with tents, vans, sheds and similar structures. On certain sites in this area there are colonies of caravans and the tendency is for these to crowd together and thus become potential causes o ill-health by restricting air space and light between the vans. A bye-law is sought which will prohibit these vans being placed less than a specified distance apart. 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. In August, 1934, the Council's cemetery at Marks Gate was opened. The land, comprising approximately 20 acres, set aside for the cemetery has not yet all been developed, but the religious denominations have been allocated sites and a cemetery chapel has been built. Graves may be purchased 1st, 2nd or 3rd class, according to position. Schools. With very few exceptions, the schools in Dagenham are of modern construction and therefore being equipped with new appliances do not call for any special comments. There is no evidence that schools play any part in the dissemination of infection. 26 Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections of:— Houses 5,702 Bakehouses 31 Slaughterhouses 805 Milkshops and Dairies 67 Cowsheds 16 Foodshops 765 Infectious Disease enquiries 3,220 Food poisoning enquiries 20 Visits to foster mothers' premises 23 Smoke observations 28 No. of nuisances investigated 277 Outworkers' premises 43 Houses let in lodgings 57 Ice-Cream premises 173 Factories, Workshops, etc. 246 Rooms fumigated 100 Other visits 147 (b) Notices served. Complied with. Statutory 13 8 Informal 766 695 On the Administration of the Factory and Workshop Act, 1901. In this district there are 48 factories, 85 workshops, and 82 workplaces, to which visits were paid during the year as follows:— Factories 37, workshops 45, workplaces 120. Two written notices were served during the year in respect of factories, and 3 in respect of workshops. The sanitary accommodation was found to be defective at one factory and insufficient at two factories, and notices under the Public Health Acts were served and complied with. Notices were also served in respect of two other nuisances. These were both complied with. There were 93 premises in which outwork was carried on. At 71 of these the work done was the making up of wearing apparel. There was no outwork in unwholesome premises. Rats and Mice (Destruction) Act, 1919. The same procedure operated during the year as in the past in connection with rats and mice. Poisons were supplied upon request and during Rat Week posters were exhibited and circular letters sent out. A number of rat burrows were treated with smoke by means of rockets with fair results. In addition, 11 notices were served during the year, seven of which were complied with. 27 HOUSING. HOUSING STATISTICS FOR THE YEAR 1934. Number of New Houses erected during the year :— Total 1,061 (1) By the Local Authority 66 (2) By other Local Authorities 26 (3) By other bodies and persons 969 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) 2,025 (b) Number of inspections made for the purpose 5,702 (2) (a) Number of dwelling-houses (included under sub-head (1) above), which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,606 (b) Number of inspections made for the purpose 3,815 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (excluding those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 292 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 348 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 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners 2 (b) By Local Authority in default of owners Nil. 28 B. Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 432 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 312 (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 6 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 6 D. Proceedings under Section 20 of the Housing Act, 1930 :— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil. (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil. Houses Let in Lodgings. At the end of the year there were 11 premises registered as houses let in lodgings to which 57 visits were paid. Verminous Premises. A problem which has long confronted Sanitary Authorities throughout the country, and has not, owing to the finger of scorn being pointed at the harbourer of vermin, received the consideration that such evil merits, is now being tackled in every way possible. In this district, disinfestation is undertaken by the Local Authority in the case of occupied houses, by means of Sulphur Dioxide. Two applications are given at intervals of 10 or more days, all woodwork having previously been pulled away from the walls and carefully gone over with a blowlamp. 29 In unoccupied houses on the London County Council's Estate Cyanide gassing is performed. The operation is carried out by experts and the tenants of the houses on either side of the infested house are requested to open all their windows for the day. During the year 100 rooms were fumigated with Sulphur, but to eradicate bugs requires incessant warfare to be waged on these pests. 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 the houses in this district which are privately owned, routine housing inspections are carried out by the Sanitary Inspectors, 30 INSPECTION AND SUPERVISION OF FOOD (a) Milk Supply. There are 55 retailers of milk in the district, including eight company distributing centres. The following is a classification of the milk retailed :— Ungraded Milk 34 Grade " A" 2 Grade " A" (T.T.) 6 Grade " A" Pasteurized 2 Certified 2 Pasteurized 9 Sterilised 12 Carton 15 Eight retailers were registered during the year, while six discontinued business. Eight dairies were registered and four businesses changed hands. There are now only four cowkeepers in the district, two having discontinued during the year. A firm of dairymen with an address outside the district applied to be registered as Retail Purveyors and Wholesale Dealers, 3rd June, 1931. Their connection with this district ceased 9th June, 1934. During this period this firm changed its name seven times, presumably as a means of escape from fines inflicted by the Police Court. This change of name also made it necessary to commence all over again, especially with respect to analysis. The Council were fortunately able to obtain convictions— in spite of the rapid changes of designation—in six instances, viz., for using unregistered premises as a dairy, two instances, fines 50s. 0d. and £5 ; for filling bottles in the street, two instances, fines 20s. and 40s. 0d. For reconstituting milk, £5 and £5 5s. 0d. costs ; for obstruction, two defendants, £5 each. Twenty-five samples of milk were purchased from this firm for Bacterial analysis. Twelve of these were not satisfactory by reason of dirt or presence of B. Coli in large quantities. Special reports were made with respect to these samples. It was also found necessary to communicate frequently with the adjoining authorities regarding the activities of this firm, also with the Milk Marketing Board and the Food and Drugs Authority with respect to the quality of the milk retailed. 31 Supply of Milk to Schools. The " Milk in Schools " scheme was in operation at the end of the year. Eight samples of the milk supplied were purchased for Bacterial analysis. Four of these were unsatisfactory, B. Coli being present in 0.001 c.c. The two dairy firms in question have now installed Pasteurizing plants since the operation of which analyses of the various samples have been satisfactory. Milk Sampling. During the year 139 samples of milk were analysed. The following table shows the results of these analyses, divided into those produced by small dealers in this and adjoining districts and those distributed by the larger companies :— No. of Bacteria per c.c. in thousands. Small Dealers. Large Scale. Totals. Local producer Not local. Satisfactory. not Satisfactory not Satisfactory not Satisfactory not Under 30 6 2 33 3 25 5 64 10 30—100 6 2 17 7 11 2 34 11 100—200 2 1 4 2 8 6 6 200-500 2 3 3 g Over 500 — — — — — — — 14 7 54 15 36 13 139 With respect to the Bacteriological examination of milk a steady improvement is noticeable when the results of previous years are taken as a comparison as is illustrated by the following details of the years 1929 and 1934 :— Bacteria in thousands per c.c. Year No. of samples. Under 30 30—100 100—200 200—500 Over 500 1929 141 37 37 33 20 14 1934 139 74 45 12 8 — (b) Meat and Other Foods. Meat Inspection. There are four slaughter-houses in the district, one licensed and there registered. To these a total of 805 visits was paid during the year. The carcases inspected numbered 2,437. 32 The following details show the extent of unsoundness existing in these animals, all of which were surrendered :— Beasts : No. slaughtered, 640. No. unsound in some respect, 137. Cause Head Tongue Lung Heart Liver Stomach Fat Kidney Abscesses 1 1 3 — 16 — — — Actinomycosis 3 1 3 — — — — — Cirrhosis — — — — 9 — — Parasitic diseases — — 2 — 16 — 3 1 Pleurisy — — 6 — — — — Tuberculosis 24 24 59 — 14 1 18 — Other causes — — 3 — 11 — — 4 In addition to the above, 810 lbs. of beef were condemned for various reasons, the chief of which were septic metritis (650 lbs.), and unsoundness (101 lbs.). Pigs : No. slaughtered, 729. No. unsound in some respect, 86. Cause Head Tongue Lung Heart Liver Stomach Fat Kidney Blood Aspiration — — 10 — — — — — Cirrhosis — — — — 4 — — — Parasitic diseases — — — — — — 1 — Pericarditis — — — 2 — — — — Pleurisy — — 5 — — — — — Pneumonia — — 9 — — — — — Tuberculosis 35 35 1 — — — 33 — Other causes 1 — — — — — — — In addition, one pig's carcase and offal was condemned (swine erysipelas). Sheep : No. slaughtered, 1,048. No. unsound in some respect, 32. Cause Head Tongue Lung Heart Liver Stomach Fat Kidney Abscesses — — 1 — 1 — — — Parasitic diseases — — 16 — 9 — — 2 Pleurisy — — 3 — — — — — Pneumonia — — 4 — — — — — Pericarditis — — — 1 — — — — In addition, 3 sheep's carcases and offals were condemned (shot animals), and one carcase and offal (lymphatic leukaemia), also 47 lbs. of mutton (unsoundness). 33 Legal Proceedings. One prosecution was taken during the year against a grocer who was summoned on two charges for having in his possession unsound tins of tomatoes and tins of condensed milk intended for the food of man. The number seized was 119 tins of tomatoes each weighing 2½ lbs., and 41 tins of condensed milk. The defendant was fined £10 on each summons or one month's imprisonment in default. Slaughter of Animals Act, 1933. This Act came into force on 1st January, 1934. The requirements affecting this district are briefly as follows :— (1) Animals to be slaughtered by a mechanically operated instrument, except where by resolution of the Local Authority certain animals are exempted. (2) All slaughtermen must be licensed. The rest of the Act provides for provisions to be observed as to slaughterhouses, penalties for contravention of the Act and inspection of slaughterhouses. 12 slaughtermen were licensed during the year in this area. Bakehouses. There are four factory and three retail bakehouses in the district; to these, 31 visits were paid during the year. Food Shops. 361 visits were paid to butchers shops, 234 to fish shops, 106 to provision shops, 67 to dairies and milkshops and 34 to greengrocers shops. The following amounts of foodstuffs were condemned :— 18 lbs. of sausages—unsound. 2 fowls—unsound. 24 stone of fish. 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 are now in force. 34 During the year 168 visits were paid to premises used for the sale or manufacture of ice-cream. 51 samples were purchased and submitted for bacterial analysis, of which 41 were satisfactory, 10 were not. The number of manufacturers or vendors registered during the year was 10.3. A manufacturer outside this area applied to be registered as a vendor in this district, but in view of unsatisfactory samples and the fact that the Authority in which the premises are situated had deferred registration, the application was suspended. Upon further unsatisfactory samples being submitted the applicant was interviewed by the Public Health Committee and advised regarding the improvement of methods of manufacture. Food Poisoning. Under section 105 (1) of the Dagenham Urban District Council Act, 1931, 17 notifications of food poisoning were received. There were 4 instances in which two or more members of the same family suffered from symptoms suggesting food poisoning. In order to assist the enquiries in the source of poisoning, the medical practitioner is required, when notifying a case, to include particulars of the food he suspects. The 17 reported cases were spread throughout the year and at no particular time was there any outstanding incidence of this condition. It will be noticed from the table that foods alleged to have caused poisoning were of very assorted natures. Each case, on being reported, is visited and the origin of the suspected food trace when possible. None of the cases reported could be regarded as true instances of food poisoning. At the foot of the table will be found a summary of the suspected cause of illness. None of food examined showed any evidence of decomposition. The value of notification of food poisoning may not immediately be apparent, but on closer examination of the subject it will be recognised that the Health Department is able to glean valuable information with regard to the wholesomeness of the food supply of the area, as the fact that certain foods are suspected initiates an inspection of the methods of production, storage and retail of the commodity under consideration. 35 The following is a summary of the cases :— No. Date. Sex. Age. Alleged Cause. Symptoms. Recovered. Others in family ill. 1 7/1/34 F 39 Fried Fish. Rash, sickness and Diarrhoea. Yes. No. 2 27/1 /34 F 14 Fried Fish. Rash. Yes. No. 3 5/2/34 F 9 Fried Fish or Corned Beef or Chewing Gum. Rash and slight sickness. Yes. No. 4 5/2/34 M 5 Chewing Gum. Rash. Yes. No. 5 19/3/34 M 1 Boiled Fish. Rash. Yes. No. 6 27/3/34 F — Corned Beef. Rash and Diarrhoea. Yes. No. 7 13/4/34 M 44 Tinned Salmon. Diarrhoea. Yes. No. 8 19/5/34 M 44 Kippers. Diarrhoea. Yes. No. 9 23/5/34 F 30 Fried Fish. Rash, sickness and Diarrhoea. Yes. Son. 10 14/8/34 F 10 Cockles. Rash and Fever. Yes. No. 11 12 21/8/34 22/8/34 M M 54 73 Salt Beef. Meat Pie. Sickness and Diarrhoea. Diarrhoea. Yes. Yes. No. Wife. 13 5/9/34 F 8 Sausages. Sickness, Diarrhoea and Fever. Yes. No. 14 15 1/10/34 14/11/34 F F 19 34 Ice-Cream. Fish Paste. Rash, sickness and Diarrhoea. Rash and Diarrhoea. Yes Yes No. No. 16 6/12/34 M 5 Sausages or Fish Paste. Rash and Diarrhoea Yes Brother and Sister. 17 13/12/34 F 11 Fish Paste. Rash. Yes 2 Brothers and a friend. Summary of suspected causes of illness. Fish paste 3 Corned beef 2 Ice-cream 1 fried fish 3 Meat pie 1 Cockles 1 Chewing gum. 2 Tinned salmon 1 Salt beef 1 Sausages 2 Kippers 1 Boiled fish 1 36 (c) Adulteration, etc. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year 255 samples were analysed. The following proceedings were taken, all in respect of milk :—6 persons were fined £5 and 6s. Od. costs each, 1 person was fined £2 on each of 3 cases and costs £3 8s. 6d. ; 1 case was withdrawn. (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. 37 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. NOTIFIABLE DISEASES (other than Tuberculosis) Under 1 1 year 1/5 5/10 10/15 15/20 20/25 25/35 35/45 45/55 55/65 65 & over Total. Amoebic Dvsentery — — — — — — — 1 — — — 1 Cerebro-Spinal Fever — — — — — — — — — — — — Diphtheria — 77 156 62 10 8 16 7 1 — — 337 Encephalitis Lethargica — — — — — — — — — — — — Enteric Fever — — — — — — — — — — — Erysipelas — — — 3 2 1 4 12 5 1 1 29 Ophthalmia Neonatorum 1 — — — — — — — — — — 1 Pneumonia Acute Primary 14 32 14 7 4 3 8 14 9 5 2 112 „ Influenzal 2 — — 1 2 2 7 4 2 2 2 24 Poliomyelitis Acute — 1 — — — — — — — — — 1 Puerperal Sepsis — — — — — — 3 1 — — — 4 „ Pyrexia — — — — 1 1 3 — — — — 5 Scarlet Fever 1 175 384 129 22 9 21 14 — — — 755 Food Poisoning — 2 3 3 1 — 4 3 1 — 1 18 Pemphigus 6 — — — — — — — — — — 6 Polioencephalitis Acute — 2 1 — — — — — — — — 3 Undulant Fever — — — — — — — 1 — — — 1 Smallpox — — — — — — — — — — — — Cases Notified. Admitted to Isolation Hospital. RushGreen Admitted to other Isol. Hosp. Admitted to other Hospitals. Deaths Registered. diphtheria 337 324 6 — 34 Scarlet Fever... 755 399 44 — 1 Puerperal Fever 4 3 — — 4 Puerperal Pyrexia 5 3 — — 3 Pneumonia (Primary) 112 — — 69 100 „ (Influenzal) 24 — — Erysipelas 29 5 — 9 1 Smallpox — — — — — Amoebic Dysentery 1 — — — — Food Poisoning 18 — — — — Encephalitis Lethargica — — — — — Poliomyelitis 1 — — 1 — Pemphigus 6 — — — — Ophthalmia Neonatorum 1 — — — — Cerebro-Spina Fever — — — — — Polioencephalitis Acute 3 — — 3 — Undulant Fever 1 — — 1 — 38 Diphtheria. There was a marked increase in the incidence in diphtheria in 1934, as compared with the previous year, during which the prevalence in this disease in the area was extremely low. The number of notifications received was 337; this gives a rate of 3.4 per thousand of estimated population; all but 42 of these cases occurred in persons under the age of 15 years. There were no return cases, but 37 secondary cases occurred. One case was notified as nasal diphtheria wherein an evident error of diagnosis occurred as 3 other members of the family subsequently contracted scarlet fever. There was no difficulty with regard to the removal of patients to hospital as when accommodation was not available at Rush Green, it was possible to arrange alternative accommodation at the London Fever Hospital or elsewhere. Death Rate. There were 34 deaths registered as due to diphtheria, giving a case mortality of 10.08 per cent., which is almost the same as the case mortality for the previous year. Bacteriological Examination. 591 diphtheria swabs were examined during the year at the Counties Public Health Laboratories, and 683 at the Public Health Offices. Schools and Diphtheria. The following table has been prepared, showing age groups of children affected and the schools attended by them. It will be noted that there is no marked incidence in any particular school Fanshawe Crescent Infants and South Wood Lane Infants show the largest total numbers, otherwise the occurrence of diphtheria appears to have been fairly uniform. The age group chiefly concerned is that of the five year olds, but the incidence of the children of 5, 6 and 7 years is fairly uniform. 198 schoolchildren were infected. 39 School. Dept. AGE GBOUP. Total 5 6 7 8 9 10 11 12 13 13+ Alibon Road I 4 5 1 1 — — — — — — 11 ,, B — — — — — — — — — — — ,, G — — — — — 1 — — — — 1 Arnold' Road I 3 2 4 — — — — — — — 9 ,, B — — 1 — — — — 1 — — 2 ,, G — — — — — — — — — — — Beacontree Hth. Mxd. — 1 — — — — — — — — 1 Beam Bridge Mxd. 1 — — 2 — — — — — — 3 Charlecote Road I 2 3 — — — — — — — — 5 ,, B — — — — — 1 — — — — 1 ,, G — — — — — — — — — — — Eastbrook B — — — — — — 1 1 1 — 3 ,, G — — — — — — 2 — — — 2 Fanshawe Crescent I 10 8 5 3 — — — — — — 26 ,, B — — — — — — — — — 1 1 ,, Mxd. — — — 2 2 1 — — — — 5 Finnymore Road I 1 1 1 — — — — — — — 3 ,, B — — 1 — — 1 — — — — 2 ,, G — — 1 — — 2 1 — 1 — 5 Five Elms I 1 1 3 — — — — — — — 5 ,, B — — 1 — — — — — — — 1 ,, G — — 1 — — — — — — — 1 Ford Endowed Mxd. — — — 1 — — — — — — 1 Goresbrook Road B — — — — — — 2 — 1 — 3 ,, G — — — — — 3 — — — — 3 Grafton Road I 1 1 1 — — — — — — — 3 ,, Mxd. — — — — — — — — — — — ,, B — — — — — — — — — — — Green Lane I 2 — 4 — — — — — — — 6 ,, J. Mxd. — — — — 1 — 2 — — — 3 ,, S. Mxd. — — — — — — 1 — 1 — 2 Hainault Forest Mxd. — 1 1 — — — — — — — 2 Halbutt Street B — — — — — 1 2 — 1 — 4 „ G — — — — — — — — 2 — 2 Heathway Special Mxd. — — — 1 — — — — 1 — 2 Hunters Hall I 3 — — — — — — — — — 3 ,, B — — 1 1 — — — — — — 2 ,, G — — — — 1 — — — — — 1 Lymington Road I 3 1 1 1 — — — — — — 6 ,, Mxd. — — 1 2 — — — — — — 3 ,, G — — — — — — 1 — — 1 2 Marley Mxd. — — — — — — — — — — — Marsh Green S. Mxd. — — — — — — 1 3 — — 4 ,, I&JMxd. 1 1 1 1 — — — — — — 4 Park Senior Mxd. — — — — — — — — — — — Rush Green Mxd. — — — 3 — — — — — — 3 Spuring Road ,, I Mxd. 4 — — — 1 — — — — 1 — — — — — — — — — — 5 1 ,, G 1 1 St. Peters R.C. Mxd. 1 — — — — — — — — — 1 South Wood Lane I 7 3 4 — — — — — — 14 ,, B — — — 8 2 1 — — — — 6 ,, G — — 1 1 1 1 — — — — 4 Valence Avenue I 1 3 1 — — — — — — — 5 ,, B — — — — — 1 — — — — 1 ,, G I — 3 2 1 1 — — — 1 — 3 5 Village Mxd. — — — — — — — — — — Warren Mxd. — — — — — 1 1 — — — 2 Whalebone I 2 2 — — — — — — — — 4 47 36 38 23 9 15 14 5 9 2 198 40 Schick Testing and Immunization. Sessions were held regularly throughout most of the year at the Infant Welfare Centres, the Out-Patients' Department, Five Elms, and at the Wesleyan Chapel, Chadwell Heath. In addition sessions were held at 10 schools in the district. This proved to be very useful for, apart from the fact that after the first visit parents allowed the children to come straight from their classrooms by themselves, the number of non-attenders diminished considerably. A greater number of children accepted also, probably owing to the fact that they received first-hand information from their schoolfellows regarding the treatment. The presentation of a toffee to each child upon attendance was also instituted during the year. Two good effects were forthcoming as the result of this: (1) more children accepted the treatment, and (2) there has been much less fuss when children have been told that they would get no toffee if they persisted in crying. During the latter part of the period under review, the immunizing agent formerly used, toxoid antitoxin mixture, was replaced by toxoid antitoxin floccules. With the latter agent it was found that there is no general reaction caused and local reaction, if any, is negligible in severity. It is also maintained that a higher percentage of those treated with the new product give a negative Re-Schick Test. The following is a summary of the work carried out during the year:— No. immunized without preliminary testing 454 No. Schick Tested 986 Of these 306 were Negative. Of the Schick-positives, number who received three doses 596 No. of Re-Schick tests 495 Of these 458 were Negative. Of the Schick-positives, number who received three doses 23 No. of Re-Schick positives subjected to further Schick test 35 Of these 29 were Negative. Of the Schick-positives, number who received further treatment 3 Of those above who received further treatment, number subjected to a further Schick test This was Negative. 1 41 The following figures are those of children dealt with from the time immunization was first started in September, 1930, to December 31st, 1934. No. subjected to Schick Test (Primary) Positive 1,898 Negative 995 No. subjected to Re-Schick Test (after having undergone one course of injections) Positive 197 Negative 1,156 No. subjected to Re-Schick Test (after having undergone two courses of injections) Positive 3 Negative 88 No. subjected to Re-Schick Test (after having undergone three courses of injections) Positive Nil Negative 1 Number of children immunized without having been Schick-tested (under 6 years) 1,371 The following table shows the cases who contracted diphtheria after having undergone the whole or part of the immunizing course:— No. M.orF. Age. Immunization history Notified. Severity.[/##] 1 Male 4 3 doses, April, 1934 17/5/34 Mild. 2 Female 14 Schick negative, 1931 10/10/34 Moderate. 3 Male 11 Positive and 1 dose, 9/3/34 15/3/34 Moderate. 4 Female 6 Positive and 1 dose, 19/6/34 25/6/34 Severe. 5 Male 7 Positive and 3 doses, April, 1933. Not re-tested 18/6/34 Mild. 6 Female 5 1 dose, April, 1934 27/4/34 Moderate. 7 Male 6 1 dose, April. 1934 14/5/34 Died 20/5/34. 8 Male 10 Schick-positive and 3 doses, February, 1932. Re-tested 21 2/33, Negative 10/8/34 Moderate. The following table shows the proportion of children of various ages who reacted Schick positively :— Age. ——- Total. No. of Positives. Percentage Positive. Under 6 19 13 68.5 ,, 7 592 452 76.2 ,, 8 505 357 70.7 ,, 9 424 274 64.6 ,, 10 420 252 60.0 ,, 11 323 198 61.6 ,, 12 273 156 57.1 ,, 13 182 99 54.4 ,, 14 109 43 39.4 ,, 15 18 8 44.4 Over 15 49 21 42.8 42 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 (15) 59.1(22) 36.6 (30) 33.3 (30) 5 50.0 (16) 51.6 (31) 28.6 (35) 25.0(24) 4 47.8 (46) 41.2 (85) 39.0 (84) 32.8 (73) 3 58.6 (87) 49.1 (177) 38.0 (150) 44.6 (148) 2 83.4 (321) 74.0 (469) 76.8 (327) 60.9 ( 205) (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 52 39 91 57.1 73.7 8 to 12 73 79 152 48.0 61.1 12 and over 18 25 43 41.9 47.8 It will be seen from the above two tables that the number who are naturally immune bears a direct relationship to the number of persons who have acquired immunity with whom they are in close contact. 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 64.4 (45) 53.2 (47) 45.4 (11) 57.3 (103) 6 to 12 months 76.9 (39) 62.3 (53) 45.4 (11) 66.0 (103) 1 year 80.4 (46) 62.9 (62) 41.6(12) 67.5 (120) 2 years 85.2 (88) 64.6 (116) 43.5 (23) 70.5 (227) 3 „ 75.2 (117) 60.8 (166) 40.7 (27) 67.4 (310) 4 „ 74.0 (100) 78.8 (104) 35.7 (28) 71.1 (232) 5 „ 75.0 (76) 51.7 (85) 31.2 (16) 59.9 (177) 6 „ 71.5(77) 55.6 (106) 53.5 (28) 61.1 (211) 7 „ 45.8 (24) 68.8 (77) 46.4 (28) 59.7 (129) 8 „ 85.7 (14) 55.1 (49) 38.8 (18) 56.8 (81) 9 and over 66.6 (45) 50.0 (14) 62.7 (59) These four tables refer to all children dealt with in this district from the time immunizing was started. 43 Scarlet Fever. 755 cases were notified during the year. This is an incidence of 7.6 per thousand population. In 1933, the number of notified cases was 574, showing a total increase of 181. As in diphtheria, the children most affected were those between 1 and 15 years of age, there being a marked falling off in the numbers affected above this age, and only one in a child of less than one year. Of the total number of cases, 443 were removed to hospital, of whom 399 were admitted to Rush Green, the remaining 44 were admitted to other Isolation Hospitals, chiefly the London Fever Hospital. There was a total of 16 return cases; in 15 instances primary cases were discharged from hospital a few days before the onset of secondary cases, the remaining primary case was nursed at home. One case was discharged from hospital and notified again as suffering from scarlet fever 18 days later; this was evidently a reinfection, a condition which does occur in a small proportion of cases. Unfortunately there is no means of ascertaining that such reinfection will take place. Secondary Cases. There were 84 secondary cases ; in 53 instances the primary cases were removed to hospital, but the remaining 31 were nursed at home. Deaths. Only one death occurred, giving a mortality rate of .0101 per thousand of the population: this is just half the annual death rate occurring in the total population of England and Wales, and may be considered as an indication that in Dagenham the disease presented a mild form during the year. It will be evident that nursing a comparatively large proportion "f the cases at home has, if anything, lowered the mortality rate, thereby allaying the fears held by some that a risk was being run • adopting this procedure. Dick Test. No children were Dick-tested during the year. Schools. 1 he incidence at the various schools with the ages of the children concerned is set out in tabular form. No conclusion can be drawn from this that any particular school was markedlv responsible. The ages chiefly involved were those from 5 to 7 years, the numbers decliming from entrants to those of 13 and upwards, except in the case of 11 year olds, when there was a slight increase on those of the previous year. 44 School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13 134 Alibon Road I 10 9 1 - - - - - - - 20 ,, B - - - 1 - 1 - - - - 2 ,, G - - - 2 1 1 - - - - 4 Arnold Road I 5 5 1 - - - - - - - 11 ,, B - - - 2 - - 1 - - - 3 ,, G - - 1 1 - - - 2 - 1 5 Beacontree Hth. Mxd. 4 1 1 - - - 1 - 1 - 8 Beam Bridge Mxd. 2 2 1 3 1 1 1 - - - 11 Charlecote Boad I 8 10 3 - - - - - - - 21 ,, B - - - - 2 2 4 2 - - 10 ,, G - _ - 2 1 1 2 - 1 - 7 Eastbrook B - - - - - - - 1 1 2 4 ,, G - - - - - - 2 4 - - 6 Fanshawe Cresc. I 17 8 4 - - - - - - - 29 „ B - - - - - - 3 - - - 3 ,, Mxd. - - - - 2 2 1 - - - 5 Finnymore Boad I 2 5 3 - - - - - - - 10 ,, B - - - 2 1 - - 1 - - 4 ,, G - - - 1 1 3 - 1 - 6 Five Elms I 6 3 5 - - - - - - - 14 ,, B - - - 1 - - - - - - 1 ,, G - - 2 3 1 1 1 - - - 8 Fords Endowed Mxd. - - 1 2 1 - - - - - 4 Goresbrook Boad B - - - - - - 1 1 - 1 3 ,, G - - - 1 - 2 1 - - - 4 Grafton Boad I 14 9 4 - - - - - - - 27 ,, Mxd. - - 1 4 - - - - - - 5 ,, B - - - - - 1 2 1 1 - 5 Green Lane I 4 3 4 2 - - - - - 13 „ J Mxd. - - - 1 5 - - - - - 6 ,, S Mxd. - - - - - - 1 1 - 1 3 Hainault Forest Mxd. - - - - - - - - - - — Halbutt Street B - - - - - - - - 1 - 1 ,, G - - - - - - - - 2 - 2 Heathway Special Mxd. - - - 1 - - 1 - - - 2 Hunters Hall I 8 7 6 - - - - - - - 21 „ B - - 2 1 4 1 - 1 - - 9 „ G - - - 2 9 2 - 1 - - 14 Lymington Boad I 4 6 5 - - - - - - - 15 ,, Mxd. - - - 1 3 1 2 - - - 7 ,, G - - - - - 1 1 - 2 1 5 Marley Mxd. - - - - - - - - - - — Marsh Green S Mxd. - - - 1 1 - - 3 2 - 7 ,, I & J Mxd. 1 4 4 1 - - - - - - 10 Park Senior Mxd - - - - - - 3 3 - - 6 Bush Green Mxd 1 2 1 5 2 - - - - - 11 Spurling Boad I 1 3 5 - - - - - - 9 ,, ,, Mxd - - - 1 1 - - - 7 - 2 ,, ,, G - - - - - - 3 1 1 5 St. Peter's B.C. Mxd 1 - 1 - 1 2 1 - - - 6 South Wood Lane I 8 7 1 - - - - - - - 16 ,, ,, ,, B - - 2 3 - - - - - - 5 ,, ,, ,, G - - - 3 1 1 - - - - 18 Valence Avenue I 8 5 5 - - - - - - - 12 ,, ,, B - - 3 - 3 2 1 2 1 12 ,, ,, G - - 1 5 3 1 - - 2 - 8 Village I 5 1 2 - - - - - - - — Warren Mxd - - - - - - - - - - 4 Whalebone Mxd - - 2 - - - 1 - l 1 1 ,, I - - 1 - - - - - - - 109 90 73 52 44 26 34 25 16 6 475 45 Enteric Fever. No notifications of this disease were received during the year. Erysipelas. 29 cases of erysipelas were notified, five of whom were admitted to Rush Green Isolation Hospital and 9 to other hospitals. One case proved fatal. Cerebro-Spinal Meningitis. There were no cases of this disease notified during the year. Acute Anterior Poliomyelitis. One case was notified, being a child under 5, who was admitted to hospital and this case did not prove fatal. Acute Polio Encephalitis. Acute polio encephalitis occurred in 3 instances, all the cases being admitted to hospital and none terminated fatally. Amoebic Dysentery. A case was notified of a male of 43 in June. On enquiries being made it was found that the man contracted dysentery during army service in France in 1916 and he was discharged as being a carrier. Undulant Fever. A case was notified by a physician at a large London hospital in February. Investigation showed that the onset occurred in Member, 1933. It was not possible to ascertain the true cause of the disease ; the milk supply was satisfactory, but information was volunteered that the patient frequently drank quantities of raw milk. Unfortunately it was not possible to gain any information after the patient was admitted to hospital. Pneumonia. 112 cases of primary and 24 cases of influenzal pneumonia wrer notified; of this total number of 136, 69 were removed to hospital and 100 deaths were registered as due to one or other of these types of the disease. Pneumonia is notifiable only when it occurs as a primary disease or is of influenzal origin. Secondary pneumonias are not notifiable. From the comparatively large number of deaths registered as compared with those notified, it is evident that in 46 many instances the duty of notifying pneumonia is omitted. From the figures given, it would appear that the case mortality from pneumonia is 73 per cent.; this, however, is not supported by our experience of this disease. Smallpox. Smallpox did not occur in Dagenham during 1934. On several instances, however, the Medical Officer of Health was called by general practitioners to see cases suspected of this disease, but in no instance was the diagnosis confirmed. The following table shows the position of vaccination for the last year :— 1. Successfully vaccinated 427 2. Insusceptible 4 3. Conscientious objectors 782 4. Died before vaccination 60 5. Postponed by medical certificate 46 6. Removed 76 7. Unaccounted for at present 125 No vaccinations were performed during the year by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. 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 M F M F Under 1 — — 1 — — — — — — — — — 1— 1 — 2 1 — — — 1 — — — 1 5— 2 2 6 3 1 — — 2 — — — — 10— 3 3 4 1 1 2 2 1 — 1 1 — 15— 10 11 — — — — — — — — — — 20— 10 5 — 1 2 4 2 4 1 — — 25— 15 7 — 4 7 5 1 1 7 6 — — 35— 13 11 3 5 5 3 — — 11 4 — 45— 10 2 1 2 2 1 — — 7 1 — — 55— 2 — — — — 3 — — 3 — — — 65 & upwards — — — — — — — — 1 — — — 60 41 17 17 18 18 3 7 33 13 1 1 47 Register. Pulmonary Non-Pulmonary Male. Female. Male. Female. No. on register 1st Jan., 1934 285 241 123 114 During the year :— New notifications 60 41 17 17 Deaths 23 15 1 Transfers into area 18 18 3 7 Transfers out of area 35 36 16 13 No. on register 31st Dec., 1934 311 249 126 125 The total number of cases of tuberculosis notified during the year was 141; of these 66 males and 41 females suffered from the pulmonary and 17 males and 17 females from the non-pulmonarv type. In addition, there were brought to notice other than by primary notification, 36 pulmonary and 10 non-pulmonary cases; these latter were mostly cases transferred to the district, etc. Deaths. 46 persons died from pulmonary tuberculosis, of whom 33 were males and 13 females. This compares with 22 males and 25 females for the previous year. Only two deaths from non-pulmonary were registered, these being 1 male and 1 female; in 1933 there were 14 deaths registered as being due to this cause. With regard to notification of this disease, when it comes to our knowledge that a patient has died from this cause and no notification has been received, the medical practitioner who last attended is approached, and an explanation of the omission requested. In most cases the reason given is that the doctor was °f the opinion that the case had already been notified. In 9 instances deaths attributed to tuberculosis were registered incases in respect of which no notification under the regulation had been received, 8 of these were pulmonary and 1 non-pulmonary. This gives a ratio of 18.8 per cent. of un-notified to total deaths due to tuberculosis. Sputum Analysis. 253 samples of sputum were submitted for analysis during the year at the Counties Public Health Laboratories. 48 Public Health (Prevention of Tuberculosis) Regulations, 1925 and Public Health Act, 1925, Section 62. No case arose during the year requiring action under the above Regulations and Act. Tuberculosis After-Care Association. This Association has held many meetings throughout the year, giving grants to necessitous cases. 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. Cancer. The number of deaths from cancer is 63, compared with figures of 45, 37, 52, 50 and 55 for the previous years. The number of deaths assigned to the disease by the Registrar-General is 62, but the copies of certificates received by this department show the figure to be 63. 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 Total Tongue — — 1 — 2 — — — — — 3 Oesophagus 1 — — 1 — — — — 1 — 3 Stomach 1 2 2 2 3 — — — 2 2 14 Large intestine incldng rectum — 2 1 1 1 — — 1 1 2 9 Larynx — — 1 — — — 1 — — — 2 Lung — — — — — — 1 — — — 1 Liver — — — — 1 — 1 1 1 — 4 Kidney — — — — — — — — — — — Breast — — — — — — — 1 1 — 4 Ovarv — — — — — — — — — — — Uterus — — — — — — — 1 1 2 4 Other sites 2 — 3 1 2 2 — 2 2 15 Sarcoma and hypernephroma — — — — — 2 1 1 — 4 It will be seen that the organ most commonly affected was the stomach, the next in order of frequency being the large intestine, The cancer mortality for this area is remarkably low, the explanation being that by far the larger number of inhabitants are below middle age. As the age of the community increases, one may expect the incidence of cancer to increase correspondingly. 49 MATERNITY AND CHILD WELFARE. Notification of Births. Confusion sometimes exists between notification and registration of births. The figures below refer, unless otherwise specified, to notifications received under the Notification of Births (Extension) Act, 1915, which requires that all births should be notified to the Medical Officer of Health of the district concerned, within 36 hours of their occurrence. This duty is in addition to and not in substitution of registration of births, which must be made within 6 weeks of birth. 1,827 notifications of live births were received during the year. 296 notifications (including stillbirths) were received from medical practitioners and parents, and 1,581 from midwives. Information was received of 335 births outside this area. The following list shows where most of these occurred:—East End Maternity Hospital 134, Oldchurch Hospital 64, Queen Mary's Hospital, Stratford 14, Charing Cross Hospital 43, Plaistow Maternity Hospital 33. Illegitimate births accounted for only 2.27 per cent, of the total live births. Stillbirths. 37 male and 13 female stillbirths were notified, the corresponding figures for registration being 43 and 17. The rate per 1,000 of total population registered was 0.607, the rate for England and Wales being 0.62. The percentage of illegitimate stillbirths to the total was 1.66 compared with a percentage of illegitimate to total births of 2.3. Of the total stillbirths, there were 27 of those patients who had gone to term, the duration of labour averaged 11 hours, the extreme limits being 3 days and 25 minutes. Of these 7 attended the Council's Ante-Natal Clinic, 13 received ante-natal supervision elsewhere; the remaining 7 apparently received no ante-natal care. The alleged causes were : contracted or deformed pelvis, albuminuria, malpresentation, prolonged labour, condition of mother, strangulation, fall, and scar from Caesarian section. 50 In those of 7 to 8 months duration of pregnancy (i.e., 19), the average duration of labour was 9 hours, 2 received ante-natal supervision at the clinic, 10 elsewhere, and 7 apparently received no ante-natal care at all. The alleged causes were given as condition of mother, albuminuria, "fright," macerated anencephalic, fall, delayed delivery of head. 2 other cases gave a history of two previous stillbirths and 1 miscarriage in one instance, and in the other 1 previous stillbirth and twins dying at 1 hour. Two were under 6 months gestation, 12 and 8 hours labour respectively. These patients had received ante-natal care elsewhere. The alleged cause was given as condition of mother in first case, the cause of the second being unknown, but the foetus was reported to have been dead two days. No particulars were obtainable concerning the remaining 2. It has been the practice of this department for some years, to obtain a history of the pregnancy, confinement and puerperium in all cases where stillbirths have occurred; this information, in course of time, should prove of value and will, we hope, enable causes predisposing to stillbirths to be removed. 124 infants under one year of age died during the year, giving an infant mortality rate of 63.98 per 1,000 live births, compared with that of 59 for England and Wales and 67 for London. The rate among legitimate children was 62.30, while for illegitimate children it was 136.36. This latter figure is high and bears out the experience of the majority of areas and shows that the expected illegitimate infant mortality is normally much greater than that occurring among legitimate births. Social factors enter largely into the explanation of this. These figures are those supplied by the Registrar-General. The figures following are those taken from our records of notifications received in this office and do not strictly agree with the total of children who died under the age of one year. Neo-natal deaths : there were 42 deaths of infants under one month of age, this giving a neo-natal rate of 21.67 and constituting 35 per cent, of the total of the infants who died before attaining the age of one year. Relatively this neo-natal death rate has diminished, the reduction being from 58 per cent, of the total infant deaths in 1930 to 35 per cent, in the year under review. This may be considered as an indication of the care the mothers are bestowing on their newly born infants, which in turn to some extent, is assignable to the maternity and child welfare service. Infant Mortality. 51 10 of these deaths occurred within the first week, two being due to congenital disease and 5 to prematurity. Myocarditis, "lack of animation" and difficult delivery were the causes assigned to the remaining 3. Of the remaining 12 cases which proved fatal within the month, 5 were due to poor general condition of the child since birth, 2 to respiratory affections and one each to congenital malformation, convulsions, jaundice, myocarditis and broncho-pneumonia with spina bifida. Of the 47 cases who died aged between 1 and 6 months, gastroenteritis accounted for 6 and broncho-pneumonia 14. Respirator affections accounted for 15 out of 31 cases of those who died at ages between 6 and 12 months, gastro-enteritis 1, measles 5 and congenital heart 3. Deaths of Older Children. 59 children died between the ages of one and five years; of these, 33 were males and 26 females. The largest individual cause of death was pneumonia, which was assigned as the cause of 14 deaths in children between the ages of 1 and 2, measles caused 13 deaths, diphtheria 10 and scarlet fever 1 only. The total deaths attributed to measles was 21, all of whom died under the age of 5 years, they were almost equally distributed among the sexes, 11 being boys and 10 girls; this once more demonstrates the danger of measles in children under school age. Ophthalmia Neonatorum. Notified. Treated at home. Treated in hospital. Vision Unimpaired. Vision impaired. Total blindness. Deaths. 1 1 — 1 — — — There were 48 cases in which a medical aid notice was sent by a midwife to a medical practitioner on account of some eye condition occurring in a newly born infant, but as will be seen from the table above, only one case of true ophthalmia occurred and happily recovery was complete without impairment of vision. Discharge from the eye of a newly born infant, however slight, must be notified to the Medical Officer of the Local Supervising Authority, who, in the case of Dagenham, is the County Medical officer. The present arrangement is that all such cases are referred to your Medical Officer of Health who personally examines each 52 child and, in addition, a report is made by the Health Visitor of the district concerned ; in nearly all cases the discharge is of a mild catarrhal nature which readily responds to treatment. Undoubtedly operation of the regulations governing ophthalmia has, since their inception, saved the vision of countless children. Pemphigus. During the year, 6 notifications of pemphigus were received. They do not appear to have been other than of a mild character and all recovered without giving rise to anxiety. Maternal Mortality. 7 deaths were registered as being due to pregnancy or associated with that condition, which is equivalent to a maternal mortality rate of 3.5, compared with 4.60 for England and Wales. In each case an investigation was made to ascertain the age, parity, cause of death, standard of living, including nutrition and any other possible contributory cause. It was found that 4 cases were attributable to sepsis and 3 to other causes, the Registrar-General, however, allocates them so that 5 are assigned to sepsis and 2 to other causes. It is not clear how this difference has arisen, as copies of extracts from the death certificates are in our possession. These causes are set out as follows:— 1. (1) (a) Cerebral haemorrhage. (b) Puerperium. (c) Acute mania. (2) Pregnancy—confinement. 2. (a) Acute paralytic ileus. (b) Obstructed labour. (c) Caesarian section. 3. (a) Toxaemia. (b) Peritonitis following torn vagina. (c) Broncho pneumonia. 4. (a) Post partum haemorrhage. (b) Myocarditis. 5. Puerperal septicaemia. 6. Puerperal septicaemia. 7. (a) Septicaemia. (b) Endometritis. (c) Incomplete abortion. 53 It is manifest to me that cases Nos. 3, 5, 6 and 7 were due to sepsis, but the causes as stated of the remaining 3 cases do not appear attributable to that cause. The standard of living enjoyed appears to have been good or average in all cases, and the question of deficient diet does not appear to bear any relationship to the deaths. It is interesting to note that, with one exception, none of the patients concerned attended our ante-natal clinic; this bears out what has been stated on many previous occasions, that ante-natal care is one of our greatest allies in our fight to reduce maternal mortality and morbidity. In support of this contention, the following extract from a letter written by Sir Percy W. Everitt, Vice-Chairman of the Plaistow Maternity Hospital, which recently appeared in the London press, clearly illustrates the value of ante-natal supervision:— "During the past 24 years our mid wives have attended to 114,148 maternity cases, and only 119 of the mothers died in childbirth—a rate of maternal mortality of only 1.04 per 1,000. This is a record which I think is unsurpassed by any maternity hospital in the kingdom. Our hospital is situated in West Ham. It serves districts in which poverty, real want, and overcrowding prevail—where conditions of life are so hard that a high rate of maternal mortality might be expected. ''One of the conditions we make when a case is booked is that the expectant mother must attend regularly at our ante-natal clinics That condition, combined with a highly skilled staff of midwives and an expert medical staff who can be called on in case of need is, I think, the real explanation of the very low rate of maternal mortality which our records show." Puerperal Fever and Pyrexia. 9 notifications were received during the year; of these, 5 were those of Puerperal pyrexia and 4 puerperal fever. Per 1,000 total birth(i.e., live and stillbirths) the rates for these conditions were 2.5 and 2.0, the corresponding figures for the country as a whole being 2.46 and 1.95. The compulsory notification of these conditions has done much to draw attention to cases presenting abnormal features during the puerperium who other wise and formerly, received but scant attantion. it is found that in many cases the rise of temperature is attributable to some cause which is not directly associated with pregnancyor parturition, the fact, however, remains that the 54 investigation which follows in all eases does much to move conditions which are likely to have a greater issue. As in the case of maternal deaths, all cases notified under the Puerperal Fever and Puerperal Pyrexia Regulations are investigated by a Health Visitor and in addition the majority of cases are visited by your Medical Officer of Health. Of the 9 cases, 6 patients were admitted to hospital, 3 of these being to Rush Green Isolation Hospital, 2 to Oldchurch Hospital and 1 was a patient in the East End Maternity Hospital. Work of 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 has been appointed Infant Protect ion Visitor for her own area. The Health Visitors also attend the various clinics. In the case of infant welfare centres and ante-natal clinics, the Health Visitor is, as far as possible, in charge of the session at which the mothers from her district attend. The following table shows the number of visits paid by Health Visitors during the year :— (a) To expectant mothers First visits 636 Total visits 1,483 (b) To children under 1 year of age First visits 2,271 Total visits 6,088 (c) To children between the ages of 1 and 5 years Total visits 7,952 Infant Welfare Centres. There are 2 weekly infant welfare centres at the Becontree Clinic, 3 at Ford Road, 2 at Five Elms, 1 at Pettit Farm, 1 at Chadwell Heath and 1 at Rush Green. Each of these centres is attended by two Health Visitors, with the exception of Ruse Green, at which there is only one in attendance. Also a Medical Officer is present for consultations. The clinic commenced at Pettit Farm in August shows signs of continued growth, and it will be necessary, if the increase in attendances is maintained, to consider the necessity of holding another session there. At some of the centres ladies who kindly give their services to assist with the teas are present, and I have pleasure in recording our thanks to them for undertaking these duties. From time to time a profit is made which is handed over 55 to the Committee and is used to assist in providing foods among other things for those in need. The following table shows the work done at the infant welfare centres during the year:— Total attendances at all centres during the year:— (1) By children under 1 year of age 14,080 (2) By children between the ages of 1 and 5 11,449 Average attendances of children per session at all centres during the year 50 Total number of children who attended at the centres for the first time during the year:— (1) Children under 1 year of age 1,343 (2) Children between the ages of 1 and 5 years 678 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 73.5% 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 14 cases was treated at a cost of £11 4s. od. In my opinion it is highly desirable that all cases should be detained in hospital for one night at least. This operation, often considered as a trivial one, in many cases gives rise to shock which is sometimes deferred. I therefore consider that a period of complete rest under nursing supervision is necessary. The question of the removal of enlarged tonsils and adenoids has recently wen the subject of much controversy, it is now considered by those closely associated with the diseases of children, that enlarged tonsils per se do not require surgical interference. At certain Periods of growth, especially before the onset of puberty, there is a natural enlargement and increase of certain groups of lymphoid tissue; after puberty has been established, in many cases a natural recession of this tissue occurs. It may be taken to be a fairly safe guide that tonsils and adenoids should be treated by conservative methods unless they give rise to secondary conditions such as enlarged cervical glands, otorrhoea or other evidence that they are septic foci. 56 Orthopaedic Treatment. (a) Ascertainment Clinic: The Consultant Orthopaedic Surgeon paid three visits to the district during the year, when 60 children made 99 attendances. Most children attended once only, 24 attended twice and 1 three times. The commonest conditions for which children were referred were genu-valgura, pes planus, bowed tibiae and talipes. (b) Massage Clinic: The massage and remedial exercises clinic was held twice weekly at the Ford Road and Becontree Clinics. During the year 145 children under school age received treatment at a cost of £50 0s. 0d., making a total of 500 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: One child was sent to hospital for operative treatment at a total cost of £7 9s. 5d. 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. The clinics close down from May to September. 231 children commenced treatment, of whom 120 completed one course, 23 completed two courses and 1 completed three courses. The commonest condition for which children were referred was rickets. 57 Dental Treatment. 10 extraction sessions were held, at which 136 children were treated and 153 mothers, making a total of 324 attendances. A charge is made for each case (not per attendance), the amount depending upon the financial circumstances of the family. The amount received was £12 2s. 3d., and the nett cost of this service was £35 5s. Id. Dentures are provided, usually only to those cases referred from the ante-natal clinic. The amount recovered as patients' contributions was £12 19s. 9d. leaving a sum of £168 3s. 6d. as the cost to the Council. Convalescent Home. 20 mothers and children were admitted to convalescent homes at a cost of £156 lls. 8d. The demand for convalescent home treatment has shown a marked increase recently and I am pleased to say that the Committee has authorised an additional amount in the estimates for this purpose. It will be apparent that many debilitating illnesses are cleared up and normal health re-established after a period of stay at convalescent homes. There are many such homes and each individual case is considered, and a home suitable for the disease from which the patient is recovering is sought before the final selection is made. Close co-operation with the local branch of the Invalid Children's Aid Association has been maintained for this purpose and I am pleased to record our thanks to this Association for their valuable help. Other Provisions. One child under 5 years of age was supplied with spectacles at a cost of 8s. 6d. One child was maintained at the Royal Sea Bathing Hospital, Margate, at a cost of £90 4s. 2d. 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. It 58 was found, however, that the attendances at this latter clinic were so large that an additional weekly clinic was begun. In addition, one monthly session was held at Chadwell Heath, and at the beginning of the present year a session was instituted at Rush Green once a month. At the Five Elms Out-Patients Department the Consultant Gynaecologist paid fortnightly visits throughout the year, seeing a total of 145 women who made 208 attendances. 110 cases were referred to hospital for confinement under the Council's scheme of whom 76 were admitted to the East End Maternity Hospital, 28 to Charing Cross Hospital under the care of the Consultant Gynaecologist, 5 to Oldchurch Hospital and 1 to Queen Mary's Hospital, Stratford. The cost to the Council for these patients, after the receipt of the patients' fees, amounted to £712 9s. 2d. 43 women who attended were found to be not pregnant, and there were 26 post-natal cases. Of the 754 attendances, 222 women came of their own accord, 128 were referred by health visitors, 12 by medical practitioners, 12 by Oldchurch Hospital, 91 by neighbours and 142 by midwives. The co-operation of medical practitioners and midwives is highly desirable as we look to these ladies and gentlemen for their assistance in our efforts to promote the welfare of expectant mothers. May I refer to my remarks under the heading of maternal mortality, wherein I stated the fact that 6 of the 7 mothers who died as the result of childbirth did not attend an ante-natal clinic. In all cases where a midwife sends her patient to an antenatal clinic and the Medical Officer there decides that hospitalisation is necessary, the midwife receives compensation from the CouncilIt is also a condition of the payment of the midwife in necessitous cases that the cases shall have attended an ante-natal clinic. 181 patients paid 6 or more visits, 126 attended once only, 98 twice, 68 thrice, 89 four times and 63 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 fifth month of pregnancy was the commonest time this year for the first attendance, 130 attending at this stage; the 6th month with 114, and the seventh with 91 were the next most common. 59 89 attended first in their fourth month, 70 in the third, 31 in the eighth and 30 in the second month. A clinic for gynaecological cases for women over 40 was commenced in July. These patients attend with the ordinary ante-natal patients until such time as the numbers justify a special clinic being held for them. The total number of attendances of gynaecological cases from July to December was 21. The numbers now attending this clinic do not yet warrant the holding of a special clinic for dealing with these cases. Hospital Cases: Of the 152 cases referred to hospital, 110 were assisted under the Maternity and Child Welfare Scheme, 71 of which were admitted on other than medical grounds. The commonest sole reason for this was unsuitable domestic circumstances which accounted for 34, followed by 21 sent in because it was their first pregnancy, and 16 were admitted on economic grounds. In the remaining cases, more than one factor operated, domestic circumstances being the part reason in 19, first pregnancy in another 17, and 12 on economic grounds. 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 cases 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, any Patients referred to him by them. 60 With reference to the remarks at the foot of page 71 of the report for 1933, regarding the appointment of a Consultant to be called in obstetric emergency, arrangements have been made to meet this demand in 1935, and will be fully described in the report for that year. Foster Children. The following tables show the number of foster children and foster mothers in the district:— Foster Children. Number on register, December 31st, 1933 42 Number added to register 27 Number deducted owing to refusal, removal, deaths, or reaching age of nine 33 Number on register, 31 st December, 1934 36 Foster Mothers. Number on register, 31st December, 1933 37 Number of additions during year 13 Number taken off during year 16 Number on register, 31st December, 1934 34 Those who desire to be registered as foster mothers, on making application to the Authority (the Dagenham Urban District Council), receive a visit by a Health Visitor and Sanitary Inspector. A full examination is made of the conditions obtaining in the home and a report on the prospective foster mother is made by the Health Visitor; further, if the foster mother should have recently moved into the district and previously acted in this capacity, a report is obtained from the Medical Officer of Health of the district in which she formerly lived. It will be seen that every effort is made to maintain a high standard of foster parent. According to the existing law, when application is made for registration in the case of the first child, the Local Authority has no power to refuse except under certain specified conditions. If, however, it is subsequently considered that the environment of the foster mother may be prejudicial to the child, the procedure is to obtain an order from the Court of Petty Sessions to prohibit the foster mother from continuing to act as such. It is also competent for the Authority to fix the maximum number of children which may taken for reward by a foster mother. Unless there are special circumstances attending the case, this number is fixed at on 61 There are no Nursing or Maternity Homes in the district, and considering the facilities available within easy distance of the district, the necessity for establishing such homes does not appear to be pressing. The Minister of Health has, by circular 1433, issued in October, 1034, suggested that new maternity homes should not be established unless they are in association with general hospitals. Assisted Milk Scheme. The expenditure incurred by the Council under the assisted milk scheme for the year was:— £ s. d. (a) For ordinary milk 1,372 0 0 (b) For dried milk 242 0 0 Education. A number of pamphlets are distributed at the Infant Welfare Centres by the Health Visitors, and members of the medical staff from time to time address gatherings in the district on matters pertaining to health. The institution of birthday cards during 1933 has been continued, and from time to time direct evidence is received that the cards and education leaflets which accompany them produce the effect which was intended. This scheme has received the notice of other Local Authorities and we have been pleased to co-operate and send specimens of the literature issued. This scheme is particularly valuable in a district in which there is constantly occurring an influx of residents from outside as the opportunity is taken of acquainting these families with the health services offered in the district. As a direct result of birthday cards having been sent out, over 200 children took advantage of the scheme for immunization in the district. The Council provisionally decided to hold a Health Week in 1935, but difficulty was met with in finding premises which were adaptable for the holding of such an event on a scale large enough to be of value in a district containing the population of Dagenham. The scheme has been deferred pending the building of a hall which will suffice. 62 Birth Control Clinic. A Birth Control Clinic under the auspices of a voluntary committee is held once a fortnight. The Local Authority makes a per capita grant to this body for persons who attended in whom pregnancy would be detrimental on medical grounds. During the year payments amounting to £10 19s. 0d. were made for this purpose. 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 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 4 4 4 4 3 2 — — — — — — — — — — — — — — — — 11 10 11 10 3. Scarlet Fever — — — — 1 — — — — — — — — — — — — — — — — — 1 — 1 — 4. Whooping Cough 1 3 1 — — — 1 1 — — — — — — — — — — — — — — 2 5 2 5 5. Diphtheria — — 1 1 4 4 13 10 — 1 — — — — — — — — — — — — 17 17 17 16 6. Influenza — — — — — — — — — — — 1 1 — — — 1 — 1 1 — 1 3 3 3 5 7. Encephalitis lethargica — — — — — — — — — — — — — — — — — — — — — — — — — — 8, Cerebro-spinal fever — — — — — — — — — — — — — — — — — — — — — — — — — — 9. Tuberculosis of respiratory system — — — — — — — 1 4 1 7 6 11 4 7 1 3 — 1 — — — 33 13 33 12 10. Other tuberculous diseases — — — 1 — — — — — — 1 — — — — — — — — — — — 1 1 1 2 11. Syphilis — — — — — — — — — — — — — — — — — — — — — — — — 1 — 12. General paralysis of the insane, tabes dorsalis — — — — — — — — — — — — — — — — — — — — — — — — — — 13. Cancer, malignant disease — 1 — — 1 1 — — — — 3 2 4 4 9 6 5 10 6 7 2 2 30 33 29 33 14. Diabetes — — — — — — — — — — — — 1 — — — 2 — 1 — — — 4 — 4 2 15. Cerebral haemorrhage, etc. — — — — — — — — 2 1 1 — 1 2 2 2 5 4 7 2 6 5 24 16 15 6 16. Heart Disease — 1 — — — — 4 3 3 2 — 4 3 7 8 4 8 5 12 6 6 4 44 36 53 63 17. Aneurysm — — — — — — — — — — — — — — — — — — — — — — — — — — 18. Other circulatory diseases — — — — — — — — — — — — — — 1 — — — — 1 1 — 2 1 4 4 19. Bronchitis 2 1 — 1 — 1 — — — — — — 1 — — — 2 1 3 4 1 4 9 12 11 11 20. Pneumonia (all forms) 14 13 6 8 1 — 3 3 2 3 1 1 9 10 3 5 3 4 2 2 1 6 45 55 39 41 21. Other respiratory diseases 1 — — — 1 — 2 1 — — — — 3 — 1 — — — — 1 — — 8 2 5 1 22. Peptic Ulcer 1 — — — — — — — — — — — 1 — 1 — — — — — — — 3 — 4 — 23. Diarrhoea, etc. (under 2 years) 7 5 4 — — — — — — — — — — — — — — — — — — — 11 5 11 5 24. Appendicitis — — — — 1 — 1 — — — — — — — — — — — — — — — 2 — 4 — 25. Cirrhosis of liver — — — — — — — — — — — — — — — — — — — — — — — — — — 26. Other diseases of liver, etc. — — — — — — — — — — — — — — — — — — — — — — — — — 4 27. Other digestive diseases — — — — — — — — — — — — — — — — — — — — — — — — 7 7 28. Acute and chronic nephritis 1 — — — — — 1 — 1 — — — 2 — 2 1 1 1 — — 1 2 8 5 7 5 29. Puerperal sepsis — — — — — — — — — — — 3 — 1 — — — — — — — — — 4 — 5 30. Puerperal diseases — — — — — — — — — — — 2 — 1 — — — — — — — — — 3 — 2 31. Congenital debility, premature birth, malformations, etc. 31 22 — — — — — — — — — — — — — — — — — — — — 31 22 32 25 32 Senility — — — — — — — 3 4 3 21 6 25 1 3 33. Suicide 2 — 2 1 — — — — — — 4 1 4 1 34. Other violence 1 — 1 5 4 4 — 3 — 2 1 2 — 1 — 1 3 1 1 21 9 22 9 35. Other defined diseases 5 2 2 2 3 6 3 1 — 1 3 2 3 3 4 2 — 1 1 — 2 25 21 28 27 36 Couses ill-defined or unknown — — — — — — — — — — — — — — — — — — — — — — — — — — 68 52 18 15 15 11 36 26 17 8 17 22 43 33 41 24 33 25 38 32 22 48 345 299 349 304