AC. 4411 (1) DAGENHAM M (hater Mum. B.) The Urban District Council of Dagenham 1926 Annual Report OF THE medical officer of health FOR THE YEAR 19 3 5 CECIL HERINGTON, M.B., B.S. (Lond.), D.P.H. The Urban District Council of Dagenham 1926 Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1935 CECIL HERINGTON, M.B., B.S. (Lond.), D.P.H. 3 TABLE OF CONTENTS. page. Members of the Council and Committee 7 Officers of the Public Health Services 8 General Statistics 10 General Provision of Health Services for the Area 15 Hospital Provision 15 Ambulance 18 Clinics 20 Nursing in the Home 23 Laboratory Facilities 24 Legislation in Force 25 Sanitary Circumstances of the Area 26 Disinfection 28 Sanitary Inspection 33 Housing Statistics 35 Statistics of Inspections 35 Inspection and Supervision of Food 40 Infectious and Other Diseases 48 Diphtheria 49 Scarlet Fever 58 Tuberculosis 65 Cancer 67 Maternity and Child Welfare 69 Infant Mortality 71 Maternal Mortality 74 Infant Welfare Centres 76 Ante-Natal Services 82 5 To the Chairman and Members of the Urban District Council of Dagenham. Mr. Chairman, Ladies and Gentlemen, I beg to submit herewith my Annual Report on the Health of Dagenham for the year 1935. By direction of the Minister of Health, this is again an " Ordinary Report " limited to a record of alterations, improvements and developments which have taken place during the year under review. Perhaps the most striking feature is the low incidence of maternal mortality, only one maternal death occurred, giving a rate of 0.52 per thousand total births compared with 3.93 for the country as a whole. The general death rate of 5.63 is the lowest ever recorded in this district, and is less than half of that for England and Wales. With regard to alterations in staffing arrangements, it will be remembered that Dr. C. Huss was appointed as an additional whole-time Assistant Medical Officer; he also undertakes the duties of Deputy Medical Officer of Health. Our thanks are due to the part-time Assistant Medical Officers whose services terminated on the appointment of Dr. Huss. I would invite attention to the desirability of an increase in the attendance of mothers for post-natal examination. I have referred in my report to the beneficial results which accrue therefrom. This may be regarded as public health work of the highest importance, which, unlike some of our activities, shows results which are readily apparent. 6 Immunisation against Diphtheria has been steadily pursued. The total attendances at clinics held for this purpose numbered 4,299. The interest shown by Members of the Council and Co-opted Members of the Maternity and Child Welfare Committee in the work of the Public Health Department is highly appreciated. I am pleased again to record my personal thanks to the members of the staff for their continued help and loyal co-operation. 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, 1936. 7 MEMBERS OF THE COUNCIL. Councillor J. A. PRESTON, J.P., Chairman. Councillor (Mrs.) L. TOWNSEND, Vice-Chairman. Coun. H. G. H. ATKINSON. Coun. W. H. LANGLOIS. „ A. E. BALE, J.P. „ W. F. LEGON. „ S. H. BEIGHTON. „ H. L. LYONS. „ J. E. BRADBEER. „ W. C. MARKHAM. „ W.T.CAIN. „ (Mrs.) M. E. MARLEY, J.P „ A. F. J. CHORLEY. „ R. J. MINCHIN. „ R. J. D. CLACK. „ A. ROGERS. „ C.DELLOW, J.P..C.C. „ (Mrs.) M. ROTHWELL. „ H. C. DYER. „ B. H. SAUNDERS. „ E. E. HENNEM. „ G. B. SMITH. „ E. HOWARD. PUBLIC HEALTH COMMITTEE. Councillor (Mrs.) M. ROTHWELL, Chairman. Councillor (Mrs.) M. E. MARLEY, J.P., Vice-Chairman. Coun. A. E. BALE, J.P. Coun. J. A. PRESTON, J.P. R. J. D. CLACK. „ B. H. SAUNDERS. „ E. HOWARD. „ (Mrs.) L. TOWNSEND. „ W. H. LANGLOIS. MATERNITY AND CHILD WELFARE COMMITTEE. Same members as Public Health Committee with the addition °f the following co-opted members :— Mrs- H. R. CHORLEY. Mrs. A. R. THOMAS. Mrs. G. DUNHAM. Mrs. F. L. M. ROGERS. 8 OFFICERS of the PUBLIC HEALTH SERVICES. Full-Time Staff. Medical Officer of Health : CECIL HERINGTON, M.R.C.S., L.R.C.P., M.B., B.S.(Lond.), D.P.H. Assistant Medical Officer : ELEANOR HENDERSON, M.B., Ch.B., D.P.H. Assistant Medical Officer of Health : CHARLES B. HUSS, M.R.C.S., L.R.C.P., M.B., B.S.(Lond.), D.P.H. Senior Sanitary Inspector : G. T. CARTER, Certificate of Royal Sanitary Institute ; Meat Inspector's Certificate. Sanitary Inspectors : F. W. S. FOX, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate ; Sanitary Science as applied to Buildings and Public Works Certificate; Smoke Inspectors 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. Health Visitors : V. A. EVERITT (1,2, 3). M. SMITH (1, 2, 3). I. PLUMMER (1, 2, 3). F. N. UDELL (1, 2, 3, 4, 5). I. F.RICHARDSON (1,2, 7). D. E. WALLER (1, 2, 3). H. A. SHUTT (1, 2, 3). L. WEALE (1, 2, 3, 5, 6). General Trained 1 State Certified Midwife 2 New Health Visitor's Certificate 3 Fever Trained 4 Sanitary Inspector's Certificate 5 M. & C. W. Certificate 6 Health Visitor's Certificate 7 9 Clerical Staff: Senior Clerk : B. E. E. DENNY. Clerk to Sanitary Inspectors : A. W. RAZZELL (Resigned December, 1935). F. W. KNIGHT. Clerks : I. M. BISHOP. G. A. POWER. D. I. FLETCHER. M. A. WATTS. D. J. PIPPETT. Part-Time Staff. Consultant Gynaecologist : H. G. EVERARD WILLIAMS, M.D., M.R.C.P. Consulting Obstetrician : W. S. O'LOUGHLIN, L.R.C.P., L.R.C.S. (Commenced April, 1035.) 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. 10 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Registrar-General's estimate of resident population 1935 100,300 Number of inhabited houses (end of 1935) according to Rate Books 22,800 Rateable value (Dec. 31st, 1935) £501,332 Sum represented by a penny rate (estimated 1935-36) £1,950 Social Conditions of Inhabitants. Several new industries have commenced during 1935, amongst them being a textile factory. One of the large engineering undertakings has extended its premises. It would appear that manufacturers are tending to establish works on the eastern side of London and numerous enquiries are being received for sites within the Urban District. As in previous years, the building industry has continued to be active, and many houses are still being erected by private contractors, also the London County Council is building on various sites within the Dagenham section of the Becontree Estate. The Dagenham and Becontree Personal Service Council continues to operate with a considerable degree of success and works in close co-operation with the members of the Council and the officials. 11 Extracts from Vital Statistics for the Year. Live Births :— Total. Male. Femal Legitimate 1,822 901 921 Birth rate per 1,000 of the estimated resident population, 18.59. Illegitimate 43 19 24 Stillbirths :— Legitimate 54 32 22 Rate per 1,000 total (live and still) births, 28.64 Illegitimate 1 1 — Deaths 565 201 274 Death rate per 1,000 of the estimated resident population. 5.63. Deaths from puerperal causes :— Bate per 1,000 total Deaths. (live and still) births. Puerperal sepsis Nil Nil Other puerperal causes 1 52 Total 1 52 Death rate of Infants under one year of age :— All infants per 1,000 live births 55.23 Legitimate infants per 1,000 legitimate live births 55.43 Illegitimate infants per 1,000 illegitimate live births 46.51 Deaths from Measles (all ages) 2 Whooping Cough (all ages) 7 Diarrhoea (under 2 years of age) 10 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 1934 98,710 21,918 4.50 Births. 1,865 births were registered during the year. The birth rate per 1,000 population was thus 18.59, compared with 14.7 for England and Wales and 14.8 for the 121 12 The mortality from Measles shows a marked reduction compared with the previous year, when it was 21. For many years it has been noted that the incidence of Measles shows a periodicity which is remarkably consistent, and occurs every second year. It is anticipated that for the year 19.36 there will be a marked increase in the fatality of Measles. Population. The Registrar-General's mid-year estimate was 100,300 ; this is an increase of 1,590 compared with the previous year. The excess of births over deaths for the year was 1,267. 882 more houses were occupied than in 1934; it would appear, therefore, that the RegistrarGeneral's estimate is low compared with what might be expected, having the above facts in mind. The average number of persons per house in Dagenham is high compared with that of other areas, as families allotted houses from London are usually given priority partly on account of the number of children in such 13 large towns including London. The rate compares with that of 24.2, 26.5, 30.6, 23.8, 23.6, 20.4, 18.6 and 19.6 for the years 1927 to 1934 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 1.8 percent, of total stillbirths, there being only one illegitimate stillbirth. 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 298 Outward transfers 85 Inward transfers 352 Deaths of residents 565 Of the 85 deaths of non-residents occurring in the district, 50 took place at the West Ham Sanatorium and 13 at the Joint Isolation Hospital. Of the 352 deaths of local residents taking place outside this area, most occurred in institutions. Of these, 211 occurred at Oldchurch Hospital, 31 at King George Hospital, Ilford, 12 at the London Fever Hospital, four at East Ham Memorial Hospital, five at Queen Mary's Hospital, Stratford, 13 at Orsett Lodge and six at Mental Hospitals. 565 deaths in a population of 100,300 represents a death rate of 5.63 compared with 11.7 for England and Wales. For the years from 1927 to 1934 inclusive, the local rates were 7.0, 7.3, 8.3, 6.6, 7.2, 6.5, 6.5 and 6.6. A table giving the causes of death, and the age periods at which they occurred, is given at the end of the report. Table showing Birth-rate, Death-rate and Analysis of Mortality during the year 1935. Provisional Figures.—The mortality rates for England and Wales refer to the whole population, but for London and the towns to civilians only. Rate per 1,000 total Population. Annual Death-rate per 1,000 population. Rate per 1,000 Live Births. Live Births. Still Births. All Causes. Typhoid and Paratyphoid Fevers. Small-pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Violence. Influenza. Diarrhoea and Enteritis (under two years). Total Deaths (under one year). England and Wales 14.7 0.62 11.7 0.00 0.00 0.03 0.01 0.04 0.08 0.52 0.18 5.7 57 121 County Boroughs and Great Towns, including London 14.8 0.68 11.8 0.00 0.00 0.04 0.01 0.04 0.09 0.45 0.16 7.9 62 140 smaller towns (1931) resident populations 25,000-50,000 14.8 0.64 11.2 0.00 0.00 0.03 0.01 0.03 0.07 0.41 0.17 3.8 55 London i 13.3 0.52 11.4 0.00 0.00 0.00 0.01 0.04 0.06 0.51 0.11 11.2 58 Dagenham (estimated population 100,300) 18.59 0.55 5.63 0.00 o.oo 0.02 0.00 0.07 o.21 0.32 0.03 5.36 55.23 14 15 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. Building operations are well in hand for extending the accommodation at Rush Green Hospital; mention of this was made in my report for 1934. Several cases of Measles were nursed at this hospital, and it is hoped that when the extension has been completed, beds will be allocated in times of Measles epidemics for the treatment of complicated or severe cases of this disease. Reference to Diphtheria, Scarlet Fever and other infectious diseases is made later in the report. (2) Smallpox. During 1935 the arrangement outlined in the previous annual report was in operation for treatment of Smallpox cases. In 1936, however, the County Council assumed responsibility for the hospital treatment of this condition and it has been arranged that for the greater part of the county, hospital accommodation will be available at Colchester. For the county districts 16 within the Metropolitan area, of which Dagenham is one, an agreement has been arrived at with the London County Council, whereby Smallpox eases will be received into the London Smallpox Hospital. As will be noted in the table showing notification of various diseases, no cases of Smallpox were notified in Dagcnham in 1935. b. Tuberculosis. For the table of hospitals and institutions into which local cases might, through the Essex County Council, be admitted, see page 13 of Annual Report of 1931. The following are the numbers of persons admitted from this district during the year :— Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Total. Adults 56 32 2 3 93 Children 2 2 13 4 21 Hospitals for General Cases. (1) Hospitals for Medical and Surgical Cases. Oldchurch Hospital, Romford.—This Hospital, formerly a Poor Law Hospital of the Romford Union, has been taken over by the County Council, and now receives patients suffering from all conditions other than infectious and venereal diseases. Considerable alterations have been made as have also improvements in staffing and equipment. The Hospital now possesses modern X-ray and other electrical installations for diagnostic and therapeutic uses. It serves a wide area in which Dagenham is included. Recently the staffing, both resident and consulting, has been reconsidered, and there is now a specialist staff, many of the members of which hold appointments at the teaching hospitals in London. 17 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. (2) Hospitals for Maternity Cases. The majority of normal cases are still admitted to the East End Maternity Hospital; this arrangement continues to work satisfactorily. Cases discovered by the Consultant Gynaecologist to require special treatment are admitted to Charing Cross Hospital under a scheme which has been in operation for several years. Rush Green Hospital still receives cases of puerperal infection from Dagenham. (3) Hospitals for Children. As I mentioned in my report for 1934, Dagenham is conveniently situated as far as hospitals for children are concerned. Many of the children requiring hospital treatment attend Children's Hospitals in London, Stratford and Ilford. During the year, cases of Ophthalmia Neonatorum were admitted to Rush Green Isolation Hospital. Reference to cases of this disease is made later in the report. The following are the details of the work done by the ambulances during the year, showing 1934 figures for purposes of comparison :— 1935. 1934. No. of accident cases conveyed 383 457 No. of other cases conveyed 2,077 1,783 No. of journeys made 2,207 1,963 No. of miles run 26,501.2 20,713.1 18 (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. The Council maintains two well-equipped ambulances and the members of the staff of the fire brigade act as drivers and attendants. These men have all been trained in first-aid and have given evidence of their efficiency over a number of years. A statement of the rules and charges for the use of the Council's ambulances was made in my last report. 19 It will be noted that whilst there was a decrease in the number of accident cases conveyed, the other figures show an all-round increase. The number of miles run exceeds slightly the circumference of the earth. The Council has an agreement with the Borough Councils of Barking and Uford 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 370 times, while in addition on 41 occasions when both vehicles were in commission, the ambulance of one of the neighbouring Authorities was requisitioned. Ilford and Barking called on Dagenham ambulances five times. (c) Maternity Cases. These cases, if requiring the use of an ambulance, are removed either by the Council's ambulance, or in the case of patients being admitted to Oldchurch Hospital, sometimes by the ambulance attached to that institution. In the latter case, a nurse is always in attendance. When the Council's ambulance is requested for a maternity case, a doctor's certificate is required before removal, to the effect that the patient is fit for conveyance. By arrangement with the District Nursing Association, it is now possible for a certified midwife to accompany all maternity cases. 20 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. 57 3 Becontree Clinic, Becontree Avenue, Dagenham. Weekly Monday, p.m. 75 5 Weekly Thursday, p.m. 72 5 Ford Boad Clinic, Ford Road, Dagenham. • Weekly Tuesday, p.m. 77 6 Weekly (Comm. 1/9/35) Wednesday, a.m. 31 2 Weekly Wednesday, p.m. 55 10 Weekly (Discontd. 1/9/35) Friday, p.m. 27 3 Pettit Farm, Heathway, Dagenham. Weekly (Comm. 1/9/35) Thursday, a.m. 42 1 Weekly Thursday, p.m. 79 5 Out-Patient Dept., King George Hospital, Five Elms, Dagenham. Weekly Tuesday, p.m. 80 4 Weekly Wednesday, p.m. 61 4 Rush Green Clinic, 179, Dagenham Boad. Weekly (Comm. 26/1/35) Friday, p.m. 37 3 21 Ante-Natal Clinics. CENTRE. Sessions held. Times Sessions held. Average Attendances. Average New Cases. Wesleyan Chapel, High Road. Chadwell Heath. Monthly (3rd in month) (Comm. 20/9/35) 1st Thursday until Aug., 1935. 3rd Friday, p.m. 11 3 Beeontree Clinic, Becontree Avenue, Dagenham. Weekly Monday, a.m. 11 2 Weekly Friday, a.m. 13 3 Ford Road Clinic, Ford Road, Dagenham. Weekly Tuesday, a.m. 10 4 Weekly Thursday, a.m. 17 3 Out-Patient Dept., King George Hospital, Five Elms, Dagenham. Weekly Tuesday, a.m. 12 7 Weekly Wednesday a.m. 12 2 Rush Green Clinic, 179. Rush Green Road. Monthly (1st in month) (Comm. Feb., 1935) Friday, a.m. 5 1 Owing to the large average attendances at the Infant Welfare Centre at Pettit Farm, the Committee authorised an additional session to be held on Thursday mornings; this commenced in September and the attendances show that the new arrangement was amply justified. At Rush Green Clinic, which was opened in January, 1935, the attendances have steadily mounted and, just before writing this report, the Committee arranged for a morning session to be held every Friday except the first Friday in the month, when the AnteNatal Clinic takes place. 22 School Clinics. A Minor Ailment Clinic is held each morning from 9 to 10 a.m. at the Dagenham and the Becontree Clinics and at King George Out-Patient Department. In addition, an Inspection Clinic is held on Monday mornings and Thursday afternoons at the Dagenham Clinic, on Wednesday mornings and Friday afternoons at the Becontree Clinic and at the Out-Patient Department on Monday afternoons and Friday mornings. Befraction 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. A 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 five years of age. Remedial Exercises and Massage Clinic. Two sessions are held weekly at the Ford Road Clinic, namely, on Monday afternoons and Friday mornings ; and two weekly on Tuesday and Thursday mornings at the Becontree Clinic. 23 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 for 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 new Ultra Violet Ray lamps purchased in 1935 continue to give satisfaction and the results obtained are much better than those when the old type of lamp was in use. This clinic continues to show very good results, the children are kept under close observation by the medical staff and their weights as recorded give proof of the benefits they confer. 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 is the only organisation operating in this district. The figures in the next paragraph will show that its activities continue to extend. The nurses undertake midwifery and maternity nursing, and in addition medical and surgical cases are attended. A total of 1,136 general nursing cases were treated during the year, involving 9,909 visits to the homes. 286 midwifery cases and 78 maternity cases were nursed. In addition, these patients paid a total of 2,027 visits to the ante-natal clinic held at York House. Altogether then, the number of persons attended during the year was 1,500 to whom 16,806 visits were paid. 24 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 24 midwives whose practices lay largely within the Urban District. The Midwives Bill now before Parliament provides that Local Supervising Authorities shall either themselves employ midwives or satisfy themselves that the services of whole-time salaried midwives are available for all confinements. Laboratory Facilities. Examination of clinical material is undertaken at the Counties Public Health Laboratories, Queen Victoria Street, London. During the year, 530 swabs were examined for the diphtheria bacillus, 442 samples of sputum for the bacillus of tuberculosis, 14 samples of hair for the fungus of ringworm, biological examinations for virulence test for diphtheria were carried out on two occasions, and, in addition, 35 specimens were submitted for examinations of a miscellaneous character. 25 The same laboratory also undertakes the bacteriological examination of milk, of which 171 samples were submitted during the year. 716 swabs were examined for diphtheria bacillus at the Public Health Offices. The County Council has extended the facilities for certain examinations of specimens submitted by general practitioners and Public Health staffs. Legislation in Force. See pages 23 and 24 of the Annual Report of 1930, page 21 of the 1931 Report, page 15 of the 1933 Report and page 21 of the 1934 Report. Byelaws governing Camping Grounds and Moveable Dwellings were confirmed on 21st August, 1935. Byelaws governing Hairdressers' and Barbers' Premises were confirmed on 12th September, 1935. Byelaws governing Tents, Vans, Sheds and Similar Structures were confirmed on 1st October, 1935. 26 SANITARY CIRCUMSTANCES OF THE AREA. Water. No material change has taken place in the water supply of the district. With very few exceptions the water is from the supply of the South Essex Water Company. A very small part in the north-west of the district derives its water from the Metropolitan Water Board. One sample of water was taken from a well and the analysis showed that there was no pollution. Drainage and Sewerage and Sewage Works Extensions. The new property which is being constructed in the district is in nearly all cases connected with the sewerage system. A scheme has been approved by the Council and a sum included in the estimates for the sewering of the Manor Farm Estate and it is hoped that at an early date the scheme will be commenced. It is highly desirable that this area should be developed from this point of view, as at present there are many cesspools situate in such positions that it is not possible for them to be emptied by the equipment available. The work of completing the activated sludge plant at the Riverside Works is proceeding. When this plant is in operation it will go far to solve the main difficulty of sewage disposal works in the treatment of the resulting sludge. Rivers and Streams. The upper portion of the district is drained by a number of channels which run in a westerly direction, ultimately finding their way out of the area into the River Roding, which discharges into the Thames. The portion so drained includes the area north of Hog Hill, Marks Gate, Chadwell Heath Ward and part of the Becontree Ward. 27 The eastern side of the district is drained by the Wantz Stream running due south. The largest ditch runs into this near Dewey Road. Another channel runs into it from the Old Dagenham Park. The Wantz Stream then takes an easterly course to connect to the Beam River, by which it empties into the Thames. The third main surface drainage is the Gores Brook. This runs due south in the western portion of the Dagenham Ward and discharges into Dagenham Breach. Closet Accommodation. With very few exceptions drainage is of the water carriage type and connected with sewers. There are, however, houses in the Manor Farm Estate as previously mentioned, and also in the region south of Hog Hill, which are not yet connected up. 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, 1936 :— Collection. Disposal. Total. Net cost £9,853 £3,138 £12,991 Net cost per ton 13s. 1d. 4s. 2d. 17s. 3d. Net cost per 1,000 population £98 £31 £129 Net cost per 1,000 premises £436 £139 £575 Total refuse collected 15,030 tons Weight per 1,000 population per day 8.21 cwts. No. of houses and premises 22,600 All refuse is collected by seven mechanical vehicles. All refuse brought to the Salvage Plant is now weighed. The figures above may, therefore, be taken as accurate for the purpose of costing. 28 Refuse Separation and Incineration Plant. No alterations have been made. The plant, however, continues to attract the attention of outside Authorities as shown by the large numbers of visits which have been paid thereto by representatives of the Local Authorities and their officials. 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 arc 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. Disinfection. An interesting experiment was recently carried out in a large borough in the Home Counties which demonstrates clearly that terminal disinfection is of no value as far as the prevention of secondary cases is concerned. The following is a description of the details :— Five full years have now elapsed since routine steam disinfection was discontinued, and the following table shows in summary form the results of the last five years compared with those of the five years immediately preceding. In the table the results of five years (1925- 29 29), during which steam disinfection had been carried out, can be compared with those of five years (1930-34), during which it had been abandoned. The table shows at a glance the total number and also the percentage of secondary cases occurring in premises from which the original cases had been removed previously. By way of explanation, it should be pointed out that, in the final comparison, secondary cases occurring within a week of the primary case have been excluded, the reason being that such cases occurring within the known incubation stage of the two diseases may have been infected by the primary case before removal to hospital. Period. Steam Disinfection. Disease. Cases Notified. Cases Removed. Secondary Cases After 7th Day. Percentage of Secondary Cases. 1925/6/7/8/9 Practised. S.F. 2,054 1,815 80 6.08 Diph. 1,538 1,272 59 4.68 Total 3,592 2,587 139 5.37 1930/1/2/3/4 Abandoned. S.F. 2,542 1,683 104 5.51 Diph. 1,050 896 33 3.68 Total 3,592 2,579 137 5.31 It will be seen that, in the case of scarlet fever, the percentage of secondary cases has dropped from 6.08 per cent. to 5.51 per cent., whereas the relative figure for diphtheria has fallen from 4.63 per cent. to 3.68 per cent. during the two periods under review. When comparison is made between the total figures (including both scarlet fever and diphtheria) it will be seen that the percentage of secondary cases has diminished from 5.37 (with steam disinfection) to 5.31 (without steam disinfection). 30 Disinfection of Library Books. The practice introduced in 1934 and described in the Annual Report for that year has been continued and gives satisfaction. Smoke Abatement. There have been no serious or consistent cases of excessive emission of smoke. On 12 occasions warning letters were sent to occupiers of factories and it was not necessary to report any firm for prosecution. A total of 30 observations was made, each of 30 minutes duration, and the emission was as follows:—black smoke 87½ minutes, moderate 447¾ minutes and no smoke 364¾ minutes. Premises and Occupations which can be controlled by Bye-Laws. Offensive Trades—Fried Fish Shops. There are 23 fried fish shops in the district to which a total of 209 visits was paid during the year. Six new businesses were established. Rag and Bone Dealers. Three 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. Byelaws were allowed during the year by the Minister of Health governing Tents, Vans, Sheds and Similar Structures. A very useful provision is one in which the minimum distance allowed between any two of such structures is 15 feet. The enforcement of this article will preclude the possibility of close aggregation 31 of vans in confined spaces. As was mentioned in the previous report, powers such as these were deemed to be necessary to overcome the difficulty experienced in controlling the proper spacing of moveable structures. Camping Grounds and Moveable Dwellings. Byelaws governing Camping Grounds and Moveable Dwellings made under Section 111 of the Essex County Council Act, 1933, came into force on 1st October, 1935. These byelaws govern the sites of camps and disposal of refuse by the occupiers, among other things. They are intended for the better control of camping grounds and holiday camps, one of which is established in the northern part of the district during the summer months. In fairness to those who frequent this camping site it should be stated that on no occasion has it been necessary to take any action or even to make any complaint. Hairdressers' and Barbers' Premises. These byelaws were made under Section 87 of the Essex County Council Act, 1933 and came into operation on 1st November, 1935. Since then, a register has been compiled of all premises of this nature which are inspected at regular intervals and on the whole it has been found that the occupiers are willing and even anxious to comply with the requirements. There are 36 such premises in the district. Shops. The Shops Act, 1934, came into operation on 30th December of that year and Section 10 of the Act provides for the provision and maintenance of suitable and sufficient ventilation, sanitary conveniences, lighting, cashing facilities, facilities for taking meals and the maintenance of a reasonable temperature. During the 32 year, 386 inspections were made and a total of 479 visits was paid. The following table shows the number of notices served and complied with in respect of the requirements of Section 10 :— Notices served. Notices complied with. Washing facilities 4 2 Temperature 63 17 Facilities for meals 1 1 W.C. accommodation 11 2 (repairs, etc.) 79 22 Swimming Baths. The open air bath at Valence Park was put to full use during the year and in order to check the efficiency of the filtration plant samples of the water were submitted for analysis at least once but frequently twice during each month that it was in use. Schools. As stated in previous reports, with few exceptions the schools in Dagenham are of a modern type and in all cases the sanitation and water supply are satisfactory. During the year Triptons Senior School. Warren Council School, Chadwell Heath and St. Joseph's R.C. School were opened. During the same period under the County Education Committee's reorganisation scheme, Ford's Endowed School, Chadwell Heath was closed. 33 Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Inspections of:— Houses ... ... ... ... ... 4,676 Bakehouses ... ... ... ... 45 Slaughterhouses ... ... ... ... 864 Milkshops and dairies ... ... ... 48 Cowsheds ... ... ... ... 1 Foodshops ... ... ... ... 746 Infectious disease enquiries ... ... 2,651 Food poisoning enquiries ... ... 18 Visits to foster mothers'premises ... 27 Smoke observations ... ... ... 30 No. of nuisances investigated ... ... 607 Outworkers'premises ... ... ... 89 Houses let in lodgings ... ... ... 45 Ice-cream premises ... ... ... 196 Factories, workshops, etc. ... ... 127 Rooms fumigated ... ... ... 326 Other visits ... ... ... ... 119 (b) Notices served. Complied with. Statutory ... 77 82 Informal ... 1,047 840 On the Administration of the Factory and Workshop Act, 1901. In this district there are 52 factories, 125 workshops, and 65 workplaces, to which visits were paid during the year as follows :— Factories 36, workshops 69, workplaces 22. Two written notices were served during the year in respect of factories. 34 It was discovered that in a certain large factory the sanitary arrangements did not comply with the regulations. Action was taken by the Health Department and the necessary alterations were made without the necessity of serving a Statutory Notice. In another large factory the sanitary accommodation was found to be insufficient and unsuitable, and here again the necessary work was carried out as the result of an informal notice. There were 83 premises in which outwork was carried on. At 67 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. A number of rat burrows was treated with smoke by means of rockets with fair results. In addition, 28 notices were served during the year, 16 of which were complied with. 35 HOUSING. HOUSING STATISTICS FOR THE YEAR 1935. Number of New Houses erected during the year:— Total 560 (1) By the Local Authority Nil. (2) By other Local Authorities Nil. (3) By other bodies and persons 560 1. Inspection of dwelling-houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,652 (b) Number of inspections made for the purpose 4,676 (2) (a) Number of dwelling-houses (included under sub-head (1) above), which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,225 (b) Number of inspections made for the purpose 2,526 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 4 (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 255 36 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 213 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 Nil. (b) By Local Authority in default of owners Nil. B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 363 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 368 (b) By Local Authority in default of owners Nil. 37 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 4 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil. 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 12 premises registered as houses let in lodgings to which 45 visits were paid. Byelaws are in force in the district governing these houses. Some provisions of these byelaws will be superseded by the Housing Act, 1935. It is also anticipated that a new series of byelaws will be issued under this Act, and Local Authorities will have discretionary powers as to their being adopted. Verminous Premises. Your officials are constantly dealing with the elimination of vermin and during the period under review their services have been sought on many 38 occasions for this purpose. Latterly, treatment by means of Sulphur Dioxide has been discontinued in favour of a solution marketed by a well-known firm of manufacturers. The results have been encouraging and the application of the fluid is comparatively simple provided that woodwork such as skirting boards, architraves and picture rails is eased. This method possesses the advantage that it is quite harmless to the occupants and also the necessity of hermetically sealing the houses is dispensed with. On several occasions premises have been completely freed from bugs and their eggs and at a later date evidence of reinfestation has occurred. In these cases the reintroduction of bugs has undoubtedly been by the purchase of secondhand furniture. It is also suspected that in some instances the household goods are infested by the contractors' vans which have not previously been carefully cleansed. During the year. 326 rooms were treated, but to eradicate bugs requires incessant warfare to be waged on these pests. 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. Overcrowding. The Housing Act, 1935 laid the duty upon Housing Authorities to ascertain the extent of overcrowding in their areas and submitting proposals to abate this condition. This required a survey of all houses within the urban district ; a survey consisting of an enumeration of the occupants of each dwelling and in many cases ascertaining the floor areas in these dwellings. 39 The results showed that of the 22,304 houses in the district 1,015 or 4.55 per cent. were overcrowded according to the standard laid down in the Act. In a very large number of the houses concerned, it was found that a considerable degree of " uncrowding" existed. In theory the redistribution of the population would enable almost the entire population to live in a house which would not be overcrowded, but it would be manifestly unfair and undesirable to compel householders to remove, especially when they had established comfortable homes and developed their gardens in accordance with their tastes. A fuller account of the action taken under this Act will be submitted in the Annual Report for 1936. It will be noted that overcrowding does not constitute an offence until after the appointed day which has not yet been fixed by the Ministry. Even then it will not be an offence until suitable alternative accommodation has been offered; the nature of this accommodation is defined in the Act. 40 INSPECTION AND SUPERVISION OF FOOD. (a) Milk Supply. There are 55 retailers of milk in the district, three have discontinued during the year, the following being the number of premises from which various classes of milk are retailed :— Ungraded Milk 37 Grade "A" Milk 5 Grade "A" (T.T.) Milk 10 Certified Milk 3 Pasteurised Milk 18 Carton Milk 16 Sterilised Milk 16 The number of company distributing centres is 18. There are now only three cowkeepers in the district, one having discontinued during the year. As a result of copies of the analyst's reports having been sent to the County Medical Officer, it was ascertained that in one instance a cow was suffering from Johne's disease, and in another instance that two cows were suffering from Tuberculosis, these two animals being dealt with under the Tuberculosis Order of 1925. Two precautionary samples were taken from a retailer working from a district in which there were notified cases of paratyphoid fever. 41 Supply of Milk to Schools. Of the 81 schools in the district, 30 participate in the "Milk in Schools" scheme. All the supplies are now pasteurised and delivered to the schools by four dairymen. During the year 35 samples were taken of which 32 were satisfactory and three were not, giving a percentage of 8.57 per cent. unsatisfactory. When this is compared with the 50 per cent. unsatisfactory of the previous year (only eight samples were taken, the scheme being in its infancy) it will be seen that considerable progress has been achieved. In each of the three cases under review, B.Coli was present in 0.1 c.c., the bacteria present ranged from 19,000 to 48,000. Special Designations. Regulations have been issued governing the designations of milk, and it is expected that these will become operative on the 1st June, 1936. The designations will be reduced to three in number, namely:— "Tuberculin Tested," which will replace "Certified" and "Grade A" (T.T.); "Accredited" which is of a similar standard to the present Grade "A"; and " Pasteurised." The present method of determining the purity of milk by plate counts is to be substituted by a colour test in the case of "Tuberculin Tested" and "Accredited " milks. The question of standards of purity of milk has been a subject for debate for some time. As under the Food and Drugs Acts, the setting up of standards may conceivably act to the detriment of the consumer, the less conscientious producers may be inclined to approximate to the standard whereas with a little extra care they might produce an article of a purity far in excess of that legally required. 42 The consumption of "Pasteurised" milk is continuing to increase, and I think it is a fair statement to say that the exclusive use of milk so treated would go far to prevent milk-borne diseases, of which there are many. Milk Sampling. During the year, 136 samples of milk were analysed. The following table shows the result of these analyses. The numbers in the last column indicate, for comparison, the totals in the various counts for the year 1929. SMALL DEALERS. LARGE SCALE. No. of Bacteria Local producer Not local. per c.c. in thousands. Satisfactory. Not. Satisfactory. Not. Satisfactory. Not. Totals 1935. Totals 1920. Under 30 4 — 46 3 25 1 79 37 30-100 2 2 17 7 8 — 36 37 100-200 — 1 — 6 — 2 9 38 200-500 — 2 1 6 — 1 10 20 Over 500 — — — 1 — 1 2 14 0 5 64 23 33 5 136 141 (b) Meat and Other Foods. Meat Inspection. There are four slaughter-houses in the district, one licensed and three registered. To these a total of 864 visits was paid during the year. The carcases inspected numbered 2,774. The following details show the extent of unsoundness existing in these animals, all of which were surrendered :— 43 Beasts : No. slaughtered. 846. No. unsound in some respect, 136. Cause Head Tongue Lung Liver Stomach Fat Kidney Spleen Abscesses 3 10 — — — Actinomycosis 6 3 1 — — — — — Cirrhosis — — — 3 — — — — C. Angioma — — — 1 — — — — Parasitic diseases — — 2 11 — — 4 — Pleurisy — — 4 — — — — — Tuberculosis 52 52 7G 18 1 15 — 1 In addition to the above the following were condemned :— 1 Beast's carcase and offal—Septic Pericarditis. 1 Beast's carcase and offal—Generalized Tuberculosis. 2 Ewes' carcases and organs—Emaciation. 1 Calf's carcase and offal—Immaturity. l½ stone Beasts' kidneys—Unsound. 3 Ox tails— Unsound. 25 stone 12 lbs. Beef—Tuberculosis. 8 lbs. Beef— Injury. Pigs : No. slaughtered, 830. No. unsound in some respect, 80. Cause Head Tongue Lung Heart Liver Stomach Fat Spleen Blood Aspiration – – 12 – – – – – Cirrhosis – – – – 9 – – – Parasitic diseases – – 3 – – – – – Pericarditis – – – 8 – – – – Pleurisy – – 6 – – – – – Pneumonia – – 2 – – – – – Tuberculosis 41 41 17 – 22 1 24 10 Other causes — – – – – – – 2 44 In addition to the above, the following were condemned :— 1 Pig's carcase and offal— Leucocythœmia. 3 Pigs' carcases and organs—Tuberculosis. 38 lbs. Pork—Tuberculosis. 7 lbs. Pork— Uticaria. Sheep : No. slaughtered, 1,098. No. unsound in some respect, 26. Cause Lung Liver Abscesses 2 Parasitic diseases 15 5 Pleurisy 2 — Pneumonia 2 — In addition to the above, the following were condemned :— 1 Sheep's carcase and offal—Pleurisy. 3 Sheep's carcases and offal—Emaciation. Slaughter of Animals Act, 1933. 13 slaughtermen were licensed during the year in this area. Bakehouses. There are nine factory bakehouses in the district; to these, 45 visits were paid during the year. Food Shops. 341 visits were paid to butchers' shops, 241 to fish shops, 82 to provision shops, 48 to dairies and milkshops, and 14 to greengrocers' shops. The following amounts of foodstuffs were condemned:—32 stone of fish, 35 lbs. of winkles, two Danish smoked collars, 28 tins of condensed milk, 14 tins of various fruits and 5 lbs. of raspberries. 45 Ice- Cream. There were 38 shop-keepers making ice-cream on their premises during 1935, from whom 51 samples were taken. 40 of which were satisfactory and 11 were not. Where unsatisfactory samples were discovered, it was the practice, after the Inspector had visited and left instructions regarding stringent cleanliness, to take a further sample. In many cases the visit of the Inspector had the desired effect. 18 Itinerant Vendors were registered and from these 17 samples were purchased, 13 being satisfactory and four not. The number of colonies growing on Agar in each of the four unsatisfactory cases was abnormal and neighbouring Authorities concerned were notified. Samples taken in all cases at a later date showed a vast improvement. 37 shop-keepers bought their ice-cream from wholesalers, and during the season seven samples were taken from this source; five of these were satisfactory and two were not. In the two cases here, the shopkeepers took the matter up with their wholesalers, who immediately investigated and advised their clients as to the correct method of storage. In all, 75 samples were taken, 58 being satisfactory and 17 unsatisfactory. When an unsatisfactory report is received, based on pasteurised milk standards, a Sanitary Inspector calls and makes an inspection of the premises instructing the offender to observe the utmost cleanliness from the commencement of the manufacture of the product until it is sold to the consumer. In this connection it is worthy of note that, as a result of the strictest surveillance being exercised by the Inspectors and the large number of samples taken throughout the summer, the cleanliness of the products at the end of the season showed marked improvement. 46 On the whole, the standard of cleanliness of the ice-cream manufactured by the large distributing companies was very high and the tendency seems towards the elimination of small shop-keeper producers in favour of their receiving consignments daily from the above-mentioned distributors. Food Poisoning. Under section 105 (1) of the Dagenham Urban District Council Act, 1931, 9 notifications of food poisoning were received. All occurred between the months of May and October. In only two cases did symptoms occur in more than one person in the same alleged outbreak. 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 traced 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 the 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. 47 The following is a summary of the cases :— No. Date. Sex. Age. Alleged Cause. Symptoms. Recovered. Others in family ill. l. 21/5/35 M. 30 Fish and Chips Sickness and Diarrhoea. Yes. (2 fellow workmen). 2. 28/5/35 M. 36 Meat Sickness and Diarrhoea. Yes. No. 3. 27/7/35 M. — Fried Fish or Cooked Ham. Rash, Fever, Sickness and Diarrhoea. Yes. No. 4. 20/8/35 F. 43 Veal and Ham Pie Fever, Body Swollen, Slight Sickness. Yes. No. 5. 29/8/35 F. 28 Tinned Beans Sickness and Diarrhoea. Yes. No. 6. 9/9/35 M. 23 Fish Sickness and Diarrhoea. Yes. No. 7. 10/9/35 F. 12 Fruit and Nut Chocolate. Fever, Sickness and Diarrhoea.. Yes. No. 8. 28/9/35 F. 31 Tinned Salmon Rash, Sickness and Diarrhoea. Yes. Baby. 9. 7/10/35 F. 55 Rabbit or Plaice Fever, Sickness and Diarrhoea. Yes. No. Summary of suspected causes of illness. Fish 4 Meat 1 Tinned Salmon 1 Cooked Ham 1 Veal and Ham Pie 1 Rabbit 1 Tinned Beans 1 Chocolate 1 (c) Adulteration, etc. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year, 315 samples were analysed. No proceedings were instituted. (d) Chemical and Bacteriological Examination of Food. Bacteriological examination of milk, etc., is carried out at the Counties 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. 48 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. NOTIFIABLE DISEASES (other than Tuberculosis). Under 1 year 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65 and Over Total. Cerebro-Spinal Fever — — — — — — — — — — — — Diphtheria 4 67 139 57 8 7 5 5 1 — — 293 Encephalitis Lethargica — — — — — — — — — — — — Enteric Fever — — — — — — — — — — — 1 Erysipelas — — — — 2 2 8 9 8 2 2 33 Ophthalmia Neonatorum 9 — — — — — — — — — — 9 Pneumonia Acute Primary 7 19 10 3 1 2 4 11 7 6 3 73 Influenzal — 2 — 2 — 1 3 5 4 — — 17 Poliomyelitis Acute — — 2 — — — — — — — — 2 Puerperal Sepsis — — — — — 1 1 2 — — — 4 Pyrexia — — — — — 1 6 3 — — — 10 Scarlet Fever 4 115 203 72 19 8 15 4 1 — — 441 Food Poisoning — — — 1 — 1 3 3 — 1 — 9 Pemphigus 11 — — — — — — — — — — 11 Polioencephalitis Acute — — — — — — — — — — — — Smallpox — — — — — — — — — — — — Notified. Admitted to Isolation Hospital Rush Green. Admitted to other Isolation Hospitals Admitted to other Hospitals. Deaths Registered. Diphtheria 293 275 11 4 21 Scarlet Fever 441 278 39 2 — Puerperal Fever 4 3 — 1 — Puerperal Pyrexia 10 3 — 3 1 Pneumonia (Primary) 73 — — 11 63 (Influenzal) 17 — — 11 63 Erysipelas 33 5 — 7 — Smallpox — — — — — Food Poisoning Encephalitis 9 — — — — Lethargica — — — — — Poliomyelitis Acute 2 2 — — — Pemphigus 11 5 — — 2 Ophthalmia Neonatorum 9 3 — — — Cerebro-Spinal Fever — — — — — Polioencephalitis Acute — — — — — Enteric Fever 1 1 — — — 49 Diphtheria. It will be seen from the table on the previous page that there has been a reduction in the incidence of Diphtheria, there being 293 cases notified compared with 337 for 1934. The age groups most affected are those between the ages of one and 10 years. The figures strengthen the argument in favour of active immunisation, which is dealt with later in the report. Of the total cases notified, 275 were admitted to the Joint Hospital, 11 to other Isolation Hospitals and four to other Hospitals. There has not been any obstruction encountered when attempts have been made to remove patients to hospital, the public are now convinced that Diphtheria is a disease which essentially should be treated in hospital. It is one of those diseases in which, when complications arise and they are not promptly dealt with by correct methods of treatment, fatal results often ensue. Death Rate. The second table on the previous page shows that 21 deaths were registered as due to Diphtheria, giving a case mortality of 7.16 per cent. This is considered to be a remarkably low fatality rate; for the previous two years the figure was approximately 10 per cent. Secondary Cases. There were 22 secondary cases, in two instances lour occurred in one family and five in another. One case was probably caused by contact with a case admitted to a general hospital and primarily diagnosed as Broncho-Pneumonia, but subsequently proved to be one of Diphtheria. 1 wo cases were notified as having suffered from the disease which they also contracted a few months previously. These may be regarded as recurrent attacks. 50 Schools and Diphtheria. A table has been prepared showing the age groups of the children affected and the schools attended by them. With the exception of Marsh Green Infants and Junior Mixed, the cases were spread fairly consistently throughout the area. An immunization campaign was undertaken at this school during 1936, and the response from the parents when this treatment was offered showed that in many cases there was a willingness to have the children protected. As is the general experience with this disease, the age groups most affectcd proportionately were those of children under seven years of age. A total of 189 school-children were notified as suffering from Diphtheria. School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13 13+ Alibon Road 1. — — — — — — — — — — 1 ,, B. — — — — 1 1 — — — — 2 ,, G. — — — 1 1 — — — — — 2 Arnold Road 1. 3 — — — — — — — — — 3 ,, B. — — — 1 — 1 — — — — 2 ,, G. — — — — — 1 — — — — 1 Beacontree Heath M. 1 3 — — — 1 — — — — 5 Beam Bridge M. 1 — — 2 2 1 — — — — 6 Chadwell Heath I. — 1 — — — — — — — — 1 Charlecote Road I. 3 4 1 — — — — — — — 8 ,, B. — — — — — 1 1 — — — — ,, G. — — — — 1 1 — 1 — 3 Eastbrook B. — — — — — — 1 2 — — 3 ,, G. — — — — — — 1 1 1 — 3 Fanshawe Crescent 1. 3 1 — — — — — — — — 4 ,, B. — — — — — 1 — 1 — — 2 ,, M. — — — — — — — — — — — Finnymore Road 1. 1 — 1 — — — — — — — ,, B. — — — — — — — — — — 1 ,, G. — — — — 1 — 1 — — — 2 Five Elms 1. — — — — — — — — — — — ,, B. — — — — — — — — — — — ,, G. — — — — — — — — — — Ford's Endow ed M. — — — 2 — 2 — — — — 4 Carried forward 12 9 3 7 (6 10 4 4 2 — 57 51 School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13 13+ Brought forward 12 9 3 7 6 10 4 4 2 — 57 Goresbrook Road B. — — — — — — — — — — — ,, G. — — — — 1 — — 1 — — 2 Grafton Road I. 2 4 1 — — — — — — — 7 ,, M. — — — 1 1 1 — — — — 3 ,, B. — — — — — — — — — — — Green Lane I. 1 — — — — — — — — — 1 ,, JM. — — — 1 2 — 1 — — — 4 ,, SM. — — — — — — — — — — Hainault Forest M. — — — — — — — — — — 1 Halbutt Street B. — — — — — — 1 — 1 — 2 ,, — — — — — — — — — — — — Heathway Special M. — — — — — — — — — — — Hunters Hall I. 4 2 4 — — — — — — — 10 ,, B. — — — 1 1 2 — — — — 4 ,, G. — 1 — 1 — — — — 2 Kingsley Hall M. 1 — — — — — — — — — 1 Lymington Road I. 1 2 — — — — — — — — 3 ,, — — — — — — — — — — — — ,, B. — — — — — 2 — — 2 ,, G. — — — — — — — — 1 — 1 Marley M. — — — — 1 — 2 1 1 — 5 Marsh Green SM. — — — — — — — — — — — ,, 1 & JM. 7 5 4 3 3 1 — — — — 23 Park Senior — — — — — — — — — — — — Rush Green M. 1 1 — 1 1 — — — — — 4 Spurling Road I. 2 3 — — — — — — — — 5 ,, M. — — — — 1 2 — — — — 3 ,, G. — — — — — — — — 1 — 1 St. Joseph's R.C. I. 2 3 2 — — — — — — — 7 ,, JM. — — — 1 — 1 — — — — 2 St. Peter's R.C. M. 1 — — 1 — — — — — — 2 South Wood Lane I. 5 — 3 1 — — — — — — 9 ,, B. — — — 1 — — — — — — 1 ,, G. — — — 1 — — — — — — 1 Triptons B. — — — — — — — — — — — ,, G. — — — — — — — — — 1 1 Valence Avenue I. 1 3 2 — — — — — — — 6 ,, B. — — — — 1 — — — — — 1 ,, G. — — — — 2 3 1 1 2 — 9 Village I. — 4 1 — — — — — — — 5 Warren M. — — — — — — — 1 — — 1 Whalebone M. — — — — — 2 — — — — 2 ,, I. — — 1 — — — — — — — 1 40 36 21 21 20 23 9 10 8 1 189 Schick Testing and Immunization. As in former years this treatment was encouraged for all children between the ages of one year and fourteen. 52 The scheme is brought to the notice of parents chiefly by two methods, namely, consent forms are posted so as to arrive on the child's first birthday and schools are visited by the Medical Officer of Health and the Head Teachers are asked to co-operate by explaining the methods to parents anxious for their children to be protected. In addition, the Medical Officer of Health has on many occasions during the year addressed meetings of Co-operative Guilds, Women's Labour Sections and Mothers' Unions and during the course of his remarks has brought to the notice of the audience the facilities offered. In 1935 the Council agreed that the extension of the scheme to General Practitioners was desirable. Accordingly a notice was drafted and a copy of this is appended:— "I am writing to solicit your interest and cooperation in regard to the question of immunization against Diphtheria. The Council of the Local Authority have authorised me to offer this form of protection to all those who are desirous of availing themselves of the opportunity, but it is quite obvious that any endeavour to launch a campaign of this nature must depend, for its success, upon the encouragement and support of the local General Practitioners. "Children to be treated may be separated into two groups (a) those under 6 years of age; to be immunized without preliminary testing; and (b) those over 6 who should be subjected to a Schick Test. All those coming within the latter group should be referred to me for the purpose of the test, after which the positive reactors will be sent to their Family Doctor for the three injections. "A free supply of Diphtheria Prophylactic can be obtained from the Public Health Department for 53 those cases which you intend to treat privately on condition that you are willing to furnish, on a card provided for the purpose, the names, ages, addresses, etc., together with the dates of injection, in order that immunity may be subsequently tested and that necessary statistical data may be available. "If you are in sympathy with this attempt to reduce the incidence of Diphtheria in Dagenham, I should be grateful if you would exhibit one of the enclosed notices in your Surgery or Waiting Room, and according to circumstances and your desire, either carry out the treatment yourself or refer applicants to the Public Health Department. "In conclusion, may I say that your help and any suggestions upon this matter, which may occur to you, will be very acceptable to me, and that I shall be only too glad to furnish any further information that you may require." The reagent used for promoting immunity was Toxoid Antitoxin Floccules. This material has proved highly effective for attaining immunity and at the same time gives rise to practically no local or general reaction. The following is a summary of the work carried out during the year:— No. immunized without preliminary testing 402 No. Schick Tested 504 Of these 165 were Negative. Of the Schick-positives, number who received 3 doses 331 No. of slight-positives who received 1 dose 10 54 No. of Re-Schick tests 418 Of these 403 were Negative. Of the positives, number who received 3 doses 5 Of the positives, number who received 1 dose 8 No. of Re-Schick positives subjected to a further Schick test after 3 more doses 1 This was Positive. No. of Re-Schick positives subjected to a further Schick test after 1 more dose 4 These were all Negative. Immunization by General Practitioners. No. immunized without preliminary testing 20 No. Schick tested 13 Of these, 7 were Positive and 6 were Negative. No. of Re-Schick tests 1 This was Negative. Total number of children found to be immune during the year 579 The following figures are those of children dealt with from the time immunization was first started in September, 1930, to December 31st, 1935:— No. subjected to Schick Test (Primary) Positive 2,237 Negative 1,160 No. subjected to Re-Schick Test (after having undergone one course of injections) Positive 212 Negative 1,559 55 No. subjected to Re-Schiek Test (after having undergone two courses of injections) Positive 4 Negative 02 No. subjected to Re-Schick Test (after having undergone three courses of injections) Positive Nil Negative 1 No. of children immunized without having been Schiek-tested (under 6 years) 1,773 Total number of children found to be immune 2,819 Immunization by General Practitioners. No. subjected to Schick Test (Primary) Positive 7 Negative 6 No. subjected to Re-Schick Test (after having undergone one course of injections) Positive Nil Negative 1 No. of children immunized without having been Schiek-tested (under 6 years) 20 Only two children who had received any form of treatment under this scheme were notified as Diphtheria, neither of whom had completed the prescribed course. In the first ease, one dose only had been given less than a month before the onset of the disease and in the second case the first dose only had been given and that five days before the onset. In both instances, insufficient time had elapsed in which immunity could be established. It is satisfactory to be able to report that complete recovery occurred in each case. 56 The following table shows the proportion of children of various ages who reacted Schick positively:— Age. Total. No. of Positives. Percentage Positive. Under 6 23 16 69.6 „ 7 691 529 76.5 ,, 8 595 427 71.8 „ 9 493 317 64.3 „ 10 486 285 58.6 „ 11 379 231 60.9 „ 12 321 186 57.9 „ 13 223 128 57.4 „ 14 133 56 42.1 „ 15 25 12 48.0 Over 15 60 25 41.7 The following table shows the relation of the number of immunes in the household to the Schickreactions of the children of various ages:— No. of immunes in family. Under 7. 7 and 8. 9 and 10. 11 and over. 7 and over — 50.0 (2) — (1) 50.0 (4) 6 68.8 (16) 59.1 (22) 36.6 (30) 3303 (30) 5 61.9 (21) 54.5(33) 28.6(35) 42.9 (35) 4 47.2 (53) 41.2 (97) 35.4 (96) 31.7(82) 3 59.4 (101) 49.2 (199) 37.5 (168) 46.9(162) 2 82.9 (391) 78.2 (583) 75.0 (412) 63 7 (278) (The numbers in brackets are the total number of children dealt with in the group.) The figures given in this table indicate the percentages of children found to be positive in the various age groups in relation to the numbers who are considered to be immune. The immunes consist of members of the family who either have given a primary Schick negative reaction or for other reasons may be regarded as insusceptible. Although the number of 57 children dealt with is comparatively small, it will be seen that the tendency is to show that the greater the number of immunes per family, the greater will be the number who give a negative primary Schick reaction. The following table shows the influence of a case of diphtheria occurring in the home on the Schickreactions of the remaining occupants:— Age. Positive. Negative. Total. Percentage Positive. Percentage Positive in general local population. Under 8 63 44 107 58.9 74.3 8 to 12 95 93 188 50.5 60.7 12 and over 27 27 54 50.0 50.1 These three tables refer to all children dealt with in this district from the time immunizing was started. Hitherto, it has been the practice to introduce a table showing the relation of the period of residence in Dagenham with the Schick reactions of children at three selected age groups. Owing, however, to the population becoming more settled and comparatively less immigration from the congested London boroughs, this table does not demonstrate any marked relationship between susceptibility to Diphtheria and environment. I give below an extract from a commentary on a recent Annual Report of the City of Providence, U.S.A., which contains a population of approximately 290,000 :— "Diphtheria gave the low record of 43 cases with no deaths. No death from diphtheria has been registered in Providence since April, 1932. Fifty per cent. of children 0-4 and 95 per cent. of children 5-14 are known to be immune to diphtheria, so the 58 immunization campaign can be said to have reached a point not very far short of its practical possibility and in theory should have brought the herd immunity nearly to the point of maximum resistance. In fact, during the past two years the toll has been 88 cases (excluding non-residents) and 0 deaths. In these years there were 9,989 births, so the toll of diphtheria has apparently reached the theoretical minimum (1 notification and 0 deaths)—per 100 births— obtainable by immunization." For comparison, a certain city in this country, having a population of almost the same as that of Providence, gave an incidence of Diphtheria of 845 cases, resulting from which were 206 deaths. In this British city immunization has received little encouragement. Scarlet Fever. As in Diphtheria, there has been a marked diminution in the number of cases notified, viz., 441, as compared with 755. Of these, 278 were admitted to Rush Green Isolation Hospital, 39 to other Isolation Hospitals and two to other Hospitals, and I am pleased to be able to add that there was no mortality from this disease in 1935. The age incidence is somewhat similar to that shown for Diphtheria, the difference being that the most susceptible age appears to be somewhat higher than that in the former disease. I would refer once more to ray remarks made under the heading of disinfection. The mildness of the type of the disease is also shown by the absence of any fatal case. No difficulty has been experienced in obtaining the removal of cases of Scarlet Fever to hospital. There was, however, one which proved somewhat troublesome to the Health Department, brief notes of which are appended:— 59 A case of Scarlet Fever was diagnosed ; the type being mild and facilities for treatment apparently available it was considered that the child could be safely treated at home, an undertaking having been given by the mother that all precautions would be taken with regard to isolation. The Sanitary Inspector observed that the mother was not honouring her pledge and that the child was being allowed to mix freely with others. The mother was then interviewed by the Medical Officer of Health, and she reaffirmed her intention of observing all the conditions laid down for isolation. These she failed to carry out and the Medical Officer of Health arranged for the child to be admitted to the Isolation Hospital. The Inspector was present when the ambulance arrived and the removal was carried out under his supervision. Deaths. 72 per cent. of the cases were admitted to hospital, and the remainder were visited in their homes from time to time by Sanitary Inspectors. It appears that the infectivity of Scarlet Fever, as well as its fatality, is either decreasing or remaining stationary : the idea once widely held that isolation hospital treatment tended to prevent epidemics should be contradicted. The value of these institutions lies in the facilities they offer for correct treatment, the part they play in preventing infectious disease is a minor one. Secondary Cases. There were 32 such cases compared with 84 for the previous year. The primary cases in three instances were nursed at home, the remainder were admitted to hospital, five were traced to patients discharged from hospital, the onset of these being within seven to 11 days of such discharge. Three were attributable to contact with cases in other areas. 60 Dick Test. No children were Dick-tested during the year. Schools. The 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 markedly responsible. The ages chiefly involved were those from five to seven years, the numbers declining from entrants to those of 18 and upwards, except in the ease of 11-year olds. The total number of school children affected was, it will be seen, 261 compared with 475 for the previous year. School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13 13+ Alibon Road I. 7 3 — — — — — — — — 10 „ B. — — — — — — — — — — — „ G. — — — — 1 — — — — — 1 Arnold Road I. 1 1 1 — — — — — — — 3 „ B. — — — — — — — — — — — „ G. — — — — 2 — — — — — — Beacontree Heath M. 1 2 — 2 1 1 — — — — 7 Ream Bridge M. 1 — — 1 — 1 — — — — 3 Chadwcll Heath I. — 4 — — — — — — — — 4 Charlecote Road I. 7 4 1 — — — — — — — 12 „ B. — — — — 1 2 2 — — — 5 „ G. — — — 1 1 — — — — 1 3 East brook B. — — — — — — 2 — 1 — 3 „ G. — — — — — — 1 2 2 — 5 Fanshawe Crescent I. 1 1 1 — — — — — — — 3 „ B. — — 1 — — — 1 1 — — 3 „ M. — — — — — — — — — — — Finnymore Road I. 5 7 3 — — — — — — — 15 „ B. — — — — 1 — 1 — — — 2 „ G. — — — 2 — — — 1 — — 3 Five Elms I. 1 2 — — — — — — — — 3 „ B. — — — — — — — — — — — „ G. — — — 1 1 — — — — — 2 Ford's Endowed M. — — — 1 1 — — — — — 2 Goresbrook Road B. — — — — — — 1 — 1 — 2 „ G. — — — — — — — 1 — 1 2 Grafton Road I. 3 3 3 — — — — — — — 9 „ M. — — 1 1 2 — — — — — 4 „ B. — — — — — — — — — — — Carried forward ... 27 27 11 9 11 4 8 5 4 2 108 61 School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13 13 + Drought forward ... 27 27 11 ft 11 4 8 5 4 2 108 Green Lane I. 4 — 4 1 — — — 9 „ JM. — — 1 1 2 a — — — — 7 „ SM. — — — — — — — — 1 — 1 Hainault Forest M. — — — — — — — — — — — Halbutt Street B. — — — — — — — — — — — „ G. — — — — — — 1 2 1 — 4 Heath way Special M. — — — 1 1 — — — — — 2 Hunters Hall I. 4 8 4 — — — — — — — 10 „ B. — — — — — — — — — — — „ G. — — — 1 — — — — — — 1 Kingsley Hall M. 2 — — — — — — — — — 2 Lymington Road I. — 1 1 — — — — — — — 2 „ M. — — — 1 1 — — — — — 2 „ B. — — — — — — — — — — — „ G. — — — — — — 1 2 2 1 6 Marley M. — — — — — — — 3 — — 3 Marsh Green SM. — — — — — — 1 — — — 1 „ I & JM. 1 — — 4 1 — — — — — 6 Park Senior M. — — — — — — — — — — — Hush Green M. 2 3 — 3 — 1 — — — — 9 Spurling Road I. — 2 1 — — — — — — — 3 „ M. — — 1 1 — 1 — — — 3 „ G. — — — — — — — — 1 1 2 St. Joseph's R.C. I. 2 — — — — — — — — — 2 „ M. — — — 7 — — — — — — 1 St. Peter's R.C. M. — — — — — — — — 1 — 1 South Wood Lane I. 14 4 — — — — — — — — 18 „ B. — — 1 2 — — — — — — 3 „ G. — — — 1 1 I 1 — — — 4 Triptons B. — — — — — — 2 l — 1 4 „ G. — — — — — — — — 2 1 3 Valence Avenue I. 12 — 4 — — — — — — — 16 „ B. — — — 1 1 l — — — — 3 „ G. — — — 3 1 1 — — — — 5 Village I. 5 1 1 — — — — — — — 7 Warren M. — — — — — — — l 1 — 2 Whalebone M. — — — — 2 1 — — — — 3 „ I. — 1 1 — — — — — — — 2 73 47 29 30 22 12 15 14 13 6 261 Measles. Reference has already been made to this disease • ailier in the report. No action has been taken by Officers of the Local Authority with regard to the use meas'es serum for prophylaxis or attenuation. 62 Enteric Fever. One case occurred in August in the person of a female aged 19 years. She presented a typical ease of this condition and the disease ran a normal course. Careful investigations were undertaken and no clue was obtained as to the source of her infection. She came from a modern house which had main water supply and drainage ; no other member of the family was in any way affected. On enquiry, it was stated that she had not taken a meal outside her house for six weeks and she had not consumed any article of food which could be suspected. Fortunately, she made a complete recovery and suffered from 110 complications. Erysipelas. 33 cases were notified, the youngest being in the age group 15 to 20. Five were admitted to Rush Green and seven to other hospitals. There were no deaths. Cerebro-Spinal Meningitis. There were no cases of this disease notified during the year. Acute Anterior Poliomyelitis. Two children were notified as suffering from this in the 5-10 year age group. They were both treated at the Isolation Hospital and both recovered. Acute Polio Encephalitis. No notification was received of the above condition. 63 Encephalitis Lethargica. No case of this condition was notified, but one death of a male is attributed to this cause in the list supplied by the Registrar-General. Presumably this case was notified elsewhere and when he died his placc of normal residence was given as Dagenham. Pneumonia. Here again, there has been a reduction in incidence from 136 to 90. The number of deaths registered as due to Pneumonia was 63, compared with 100 for 1934. It is evident that Pneumonia in its notifiable forms, i.e., Acute Primary and Acute Influenzal, is not fully notified, except possibly in the more severe types, as the figures given, if complete, would show a case mortality of 70 per cent. It is common knowledge that the mortality from the group of diseases known as Pneumonia does not approach this high rate. When a death from Pneumonia is recorded, steps are taken by my department to ascertain whether the case has been notified, and the medical practitioner concerned is, in every instance, requested to furnish us with an explanation for the omission. It must be borne in mind that Secondary Pneumonia such as those complicating epidemic diseases are not notifiable, irrespective of whether the disease giving rise to the complication is included in the schedule of such diseases. Psittacosis. A letter was received from Poplar on 17/5/35 stating that a female patient aged 26, resident in that Borough, had been admitted to the London Hospital on 29/4/35 as a case of suspected Psittacosis. It was stated that the patient handled budgerigars which were recently kept in the house. These birds belonged to her 64 brother-in-law, living off Romford Road, but within the last few days had been sold to a person residing in Dagenham. A representative of the Ministry of Health visited the patient in hospital and endeavoured to trace the history of the birds in question. The Sanitary Inspector visited the address given and saw the birds and was told that one of them appeared to sleep most of the time, one eye was closed as though suffering from a cold, the other bird was lively. There was no illness in the family at the time of visit, 17/5/35. The owner was quite willing to take the birds to the London Hospital, the two birds were received there on 17/5/35. The complement fixation test was negative, the test was repeated and again proved negative. Smallpox. Smallpox did not occur in Dagenham during 1935. On several occasions, 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 577 2. Insusceptible 3 3. Conscientious objectors 805 4. Died before vaccination 54 5. Postponed by medical certificate 45 6. Removed 64 7. Unaccounted for at present 76 No vaccinations were performed during the year by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. 65 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- — — 4 2 — — — — — — 3 1 5- 1 — 2 1 1 — 2 — — — — 1 10- 1 — 2 2 — — 3 1 — — — — 15- 4 5 1 1 — 1 2 — 4 4 — 1 20- 7 0 — — 5 2 1 1 — — — — 25- 15 14 2 4 6 9 2 — 6 3 — — 35- 13 7 1 — 4 4 1 — 17 3 1 — 45- 12 — — — 1 1 — — 4 — 3 — 55- 2 1 — — — — — — — — — 1 65 & upwards 1 — — — — — — — — — — — 56 33 12 10 17 17 11 2 32 10 7 4 Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register 1st Jan., 1935 311 249 126 125 During the year:— New notifications 50 33 12 10 Deaths 24 8 — 1 Transfers into area 17 17 11 2 Transfers out of area 40 36 17 19 No. on register 31st Dec., 1935 320 255 132 117 The total number of cases of tuberculosis notified during the year was 111; of these, 56 males and 33 females suffered from the pulmonary and 12 males and 10 females from the non-pulmonary type. In addition, there were brought to notice other than by primary 66 notification, 34 pulmonary and 13 non-pulmonary cases; these latter were mostly cases transferred to the district. These figures compare favourably with those of the previous year, when the total number notified was 141, there being 34 non-pulmonary cases in all. Deaths. 42 persons died from pulmonary tuberculosis, of whom 32 were males and 10 females. This compares with 33 males and 13 females for the previous year. Eleven deaths from non-pulmonary were registered, these being seven male and four female; in 1934, there were two deaths registered as being due to this cause. There was, however, an increase in the non-pulmonary cases, but the figure was less than for the year 1933. 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 of the opinion that the case had already been notified. In 11 instances, deaths attributed to tuberculosis were registered in eases in respect of which no notification under the regulation had been received; six of these were pulmonary and five non-pulmonary. This gives a ratio of 20.75 per cent. of un-notified to total deaths due to tuberculosis. Sputum Analysis. 442 samples of sputum were submitted for analysis during the year at the Counties' Public Health Laboratories. 07 Pemphigus, Puerperal Sepsis and Puerperal Pyrexia. Remarks concerning the above notifiable diseases are contained in the section of the report dealing with Maternity and Child Welfare. 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 continued its activities thioughout the year. Members of the Association are allotted certain patients, on whom they report periodically, when the results of their visits are communicated to the Committee, and in many cases milk and other supplements to their diet are granted. This Association does a great deal of most valuable work in the area, and the members deserve the thanks of the community. Prevention of Blindness. No special action was taken under section 66 of the Public Health Act, 1925, for the prevention of blindness, or lor the treatment of persons suffering from any disease or injury to the eye. Cancer. Cancer was assigned as the cause of death in 60 Persons, the affected sites are tabulated in the table on the following page:— 08  MALES. FEMALES. Total Under 85 35-44 45-54 55-64 Over 65 Under 35 35-44 45-54 55-64 Over 65 Oesophagus — — — — 1 — — — 1 — 2 Stomach — 1 1 1 3 — 1 2 1 3 13 Large intestine incl. rectum — — 2 1 1 — — 1 — 1 6 Larynx — — — 1 — — — — — — 1 Lung — — 1 — — — — 1 1 — 3 Liver — — — — — — — — 3 1 4 Breast — — — — — 2 3 — — 2 7 Ovary — — — — — — — — 1 — 1 Uterus — — — — — — 1 1 1 — 3 Other sites 1 1 5 — 1 2 2 1 1 6 20 Apart from the item "other sites," it will be seen that the organ most frequently attacked was the stomach. In previous years the figures of Cancer mortality have been 45. 37, 52, 50, 55 and 63. The number of deaths assigned to Cancer by the Registrar-General was 56, 18 of these being male and 38 females. The Cancer death rate in Dagenham remains low, attributable, as has been mentioned on former occasions, largely to the very young average age of the population, Cancer being a disease which attacks persons chiefly above middle age. 69 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 six weeks of birth. 1,776 notifications of live births were received during the year. 252 notifications (including stillbirths) were received from medical practitioners and parents, and 1,571 from midwives. Information was received of 384 births outside this area. The following list shows where most of these occurred:—East End Maternity Hospital 201, Oldchurch Hospital 80, Charing Cross Hospital 27, Plaistow Maternity Hospital 24, Queen Mary's Hospital, Stratford 14. Illegitimate births accounted for only 2.3 per cent. of the total births. Stillbirths. 29 male and 18 female stillbirths were notified, the corresponding figures for registration being 33 and 22. The rate per 1,000 of total population registered was 0.548, the rate for England and Wales being 0.62. The percentage of illegitimate stillbirths to the total was 1.S5 compared with a percentage of illegitimate to total births of 2.3. 70 There were 18 eases all full-time and normal labour (under 12 hours), 12 of which were of vertex presentation, three breech, one footling and two particulars not given. The alleged causes were given as follows:—two instrumental deliveries (one Hydrocephalus and Spina Bifida), one fell over dog in first three months of pregnancy, one mother had influenza a few weeks before the birth, two Ante Partuni Haemorrhage, one Ovarian inflammation (Hydraminos), one Haemorrhage at 6½ months and mother ill in spasms ever since, one hand up and cord twice round neck. For the remaining nine, no particular cause is stated. In three eases, all full-time, it was the second pregnancy and the second stillbirth, in one of these instances the previous pregnancy was stillborn twins. In a fourth case pregnancy, with two previous stillbirths and one miscarriage. The causes of these four are given as breech presentation in two instances, cord twice round neck, and the remaining one was said to be due to the mother lifting heavy furniture before previous confinement. There were three instances in which no information could be obtained. There were three cases in which labour occurred at seven months, one was macerated, the possible cause being given as "mother had fall about three weeks before," for one the cause is unknown and the third was one in which it was the second pregnancy and second stillbirth, the cause being given as syphilis, the Wasserman reaction being positive. There were 16 cases in which the period of labour varied from 15 hours to six days. One was. stated to be due to eclampsia, nine no cause was known, one fall six weeks before birth, one obstructed labour, two Albuminuria, one Ante Partum Haemorrhage, one Persistent Oceipito Posterior. 71 In three eases labour occurred at six months, 28 weeks and 38 weeks, one of which was an induction— no cause is given for one of six months gestation, for the 28 weeks Albuminuria is given and a macerated foetus represented the 38 weeks gestation. 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 reduced. Infant Mortality. 103 infants under one year of age died during the year, giving an infant mortality rate of 55.23 per 1,000 live births, compared with that of 57 for England and Wales and 58 for London. The rate amongst legitimate children was 55.43, while for illegitimate children it was 46.51, There has been a marked drop in the infant mortality of illegitimate children; it will be noticed that this is below that for legitimate infants. Usually one expects the illegitimate infant mortality rate to be high. Various circumstances, most of which arc economic, account for this. It must be remembered also, that as the figures to be considered are comparatively small, a slight variation in the number of deaths materially alters the rate per thousand. These figures are those supplied by the Registrar-General. Neo-natal deaths: there were 45 deaths of infants under one month of age, this giving a neo-natal rate of 24.13 and constituting 43.7 per cent. of the total of the infants who died before attaining the age of one year. It will be seen that the total number of neo-natal deaths has increased by three, but as the infant deaths taken 72 as a whole are materially less than during the corresponding period last year, the percentage of neo-natal to total infant deaths has increased; it was 35 per cent. in 1934. 13 of these deaths occurred within the first week, one due to Heart Disease and 12 to Prematurity. Of the remaining 16 cases which proved fatal within the month, seven were due to Prematurity, four to Broncho Pneumonia, four to ill defined causes, and one to Heart Disease. Of the 40 cases who died aged between one and six months, Broncho Pneumonia accounted for 14, Prematurity, etc., nine and Diarrhoea seven. Respiratory affections accounted for nine out of 23 cases of those who died at ages between six and 12 months, four to Diarrhoea and three to Whooping Cough. Deaths of Older Children. 41 children died between the ages of one and five years; of these, 22 were males and 19 females. The largest individual cause of death was Pneumonia, which was assigned as the reason for 11 deaths in children between the ages of one and two, and Whooping Cough caused three. The total deaths attributed to Measles was one under the age of five years. Ophthalmia Neonatorum. Notified. Treated at home. Treated in hospital. Vision Unimpaired. Vision impaired. Total blindness. Deaths. 9 6 3 9 — — — This table shows an increase in incidence of this disease, fortunately, however, one is able to record again that no permanent damage was caused. The operation 73 of the regulations framed for the control of Ophthalmia Neonatorum has, since their inception, proved to be a most effective Public Health measure. There were 45 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. Of these only 9 were not ified as suffering from true Ophthalmia. 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 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. In all cases, however, a medical practitioner is called in and undertakes the treatment until recovery. Pemphigus. During the year, 11 notifications of Pemphigus were received, five of whom were removed to hospital. From January to July, three cases only were notified, the remaining eight cases being notified between the end of October and the end of November, two of which proved fatal. The cause was traced to a child attended by a Doctor who omitted to diagnose Pemphigus, the midwife in this case was acting as a maternity nurse. Subsequent investigation proved that this child was undoubtedly a case of true Pemphigus. This midwife attended seven other cases, all of whom contracted the disease. 74 Maternal Mortality. One death was registered as being due to pregnancy or associated with that condition, which is equivalent to a maternal mortality rate of 0.52 per thousand total births, compared with 3.93 for England and Wales. The actual cause of death as stated on the certificate was:— 1. (a) Myocardial failure. (b) Ante partum haemorrhage. 2. Confinement. An enquiry was made and it was ascertained that this patient had never attended any of the Council's Ante-Natal Clinics. The medical practitioner called in to her confinement diagnosed Placenta Previa, and arranged for her immediate removal to hospital. It is fair to assume that had she been medically examined before labour commenced, her life could have been saved. Puerperal Fever and Pyrexia. Fourteen notifications were received during the year; of these 10 were those of puerperal pyrexia and four puerperal fever. Per 1,000 total births (i.e., live and stillbirths) the rates for these conditions were 5.2 and 2.08, the corresponding figures for the country as a whole being 9.44 and 3.60. The compulsory, notification of these conditions has done much to draw attention to cases presenting abnormal features during the puerperium, who otherwise and formerly, received but scant attention. It is found that in many cases the rise of temperature is attributable to some cause which is not directly associated with pregnancy or parturition; the fact, however, remains that the investigation which follows in all cases does 75 much to remove conditions which are likely to have a graver 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 14 eases, 10 patients were admitted to hospital, four of these being to Rush Green Isolation Hospital and six to Oldchurch Hospital. Work of Health Visitors. During the latter part of the year a scheme was introduced by which the records of Health Visitors' visits were kept by the clerical staff and re-visits were arranged by means of a card index system. By this method all children under the age of five receive visits at fixed intervals, or should circumstances otherwise dictate they are visited more frequently. The whole of the clerical work is taken from the Health Visitors, thus enabling them to devote more time to the duties for which they were appointed. This scheme ensures that no children shall be overlooked and allows a continuous record of their history to be filed, which is subsequently passed on to the County Council for the information of the School Medical Officers. In addition to the routine visits, special visits are paid to eases of ophthalmia neonatorum, puerperal fever and pyrexia, stillbirths, infant deaths, etc., and subsequent to operative treatment of tonsils and adenoids. The Health Visitors also attended 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, thus preserving the personal association of the Health Visitor with the mother and children who live in her area. 76 The following table shows the number of visits paid by Health Visitors during the year:— (a) To expectant mothers First visits 587 Total visits 1,342 (b) To children under 1 year of age First visits 2,110 Total visits 5,290 (c) To children between the ages of 1 and 5 years Total visits 8,274 Infant Welfare Centres. There are two weekly infant welfare centres at the Becontree Clinic, three at Ford Road, two at Five Elms, two at Pettit Farm, one at Chadwell Heath and one at Rush Green. During the year it was found that the attendances at Pettit Farm had increased to such an extent that it was not possible to carry on the clinic efficiently with one session per week. The Committee agreed to hold an additional session and this has proved of great advantage, as more individual attention is now possible. It might be mentioned that the same circumstances arose at Rush Green Infant Welfare Centre in 1936, when similar action was taken by the Committee. Each of these centres is attended by two Health Visitors with the exception of Rush Green, at which there is only one in attendance owing to the limited accommodation. A Medical Officer is present for consultations at each clinic. W e are very pleased once more to record our appreciation of the services of the ladies w ho kindly attend some of the centres and assist with the teas. From time to time the profits derived from these teas are handed over to the Committee and they are utilised for purchasing foods and other necessities for some of the children who are in need. 77 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 18,368 (2) By children between the ages of 1 and 5 13,158 Average attendances of children per session at all centres during the year 62 Total number of children who attended at the centres for the first time during the year:— (1) Children under 1 year of age 1,165 (2) Children between the ages of 1 and 5 years 650 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 82.48% It will be seen that the percentage of children who attended the clinics has now reached the high figure of 82.48 per cent., evidence that the facilities offered at the Council's Clinics are increasingly appreciated. 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 eases, however, are treated at King George Hospital, the majority being detained overnight. During the year a total of 13 cases was treated at a cost of £11 0s. 0d. 78 With regard to treatment of enlarged tonsils by operation, I remarked previously on the opinion now commonly held determining whether or not surgical interference was indicated. It would appear that during the period that has elapsed since writing my last report, reluctance to operate, except where there is clear indication to the contrary, persists. Orthopaedic Treatment. (a) Ascertainment Clinic.—The Consultant Orthopaedic Surgeon paid five visits to the district during the year, when 98 children made 141 attendances. Most children attended once only, 26 attended twice, four three times and three four times. The commonest conditions for which children were referred were genu valgum, pes planus, bowed tibiae and talipes. The cost allocated to this Council was £12 8s. 5d. (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 £57 6s. 0d., making a total of 562 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 usually attends on the Monday following the visit of 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. Three appliances were supplied at a total cost of £9 7s. 6d. (d) Hospital Treatment.—Five children were sent to hospital for operative treatment at a total cost of £92 8s. Od. It will be observed that there has been a 79 considerable increase in the cost of hospital treatment, as compared with 1934. This money is, however, in my opinion, well spent, as the provision of such treatment to children in very many cases has the effect of rendering what otherwise might have been cripples, useful members of society, who become self-supporting and in many cases physically quite normal. Ultra Violet Ray Therapy. Light treatment is carried out at the Becontree and Dagenham Clinics, two sessions being held weekly at each of the premises. The eases 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, payment for which is made by the County Education Committee to the Dagenham Council. A course of treatment commences with a two minutes exposure back and front, working up to a six minutes double exposure, being 12 exposures in all. The clinics close down from May to September. 243 children commenced treatment of whom 133 completed one course, 28 completed two courses and one completed three courses. The commonest condition for which children were referred was rickets. Dental Treatment. 17 extraction sessions were held, at which 167 children were treated and 168 mothers, making a total of 415 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 £14 0s. 0d., and the nett cost of this service was £50 0s. 0d. 80 111 recent months it has been found expedient to hold two clinies per month, one at Ford Road and one at Becontree Avenue. By holding sessions at regular intervals, frequently much suffering is obviated. At one time sessions were held as numbers accumulated, but in some instances this resulted in lengthy intervals between sessions and consequent pain. Dentures are provided, usually only to those cases referred from the ante-natal clinic. The amount recovered as patients' contributions was £15 0s. 0d., leaving a sum of £102 0s. 0d. as the cost to the Council. Convalescent Home. 15 mothers and children were admitted to convalescent homes at a cost of £59 13s. 5d. As in former years, the local branch of the Invalid Children's Aid Association and the Personal Service Council have been most helpful in arranging convalescent treatment for mothers and children. The demand for such treatment has been less than in the previous year, but I suggest that provision should be continued for this form of treatment, as the results in most cases arc valuable and usually lasting in their effect. Jubilee Boot Fund. As a part of the celebration of the Silver Jubilee of His late Majesty King George V, the Council decided to invest a sum of £1,000, the interest on which was to be devoted to the provision of boots and similar necessities which could not otherwise be obtained through public funds. A Trust Fund was formed, but at the time of writing, interest was not yet available. The establishment of this Trust will be of material benefit to many of the families in the district who have fallen on bad times, and will meet a long felt want in the area. 81 Other Provisions. Two children tinder five years of age were supplied with spectacles at a cost of 18s. 6d. One child was maintained at the Royal Sea Bathing Hospital, Margate, at a cost of £75 4s. 8d. She has nowattained the age of five years and her maintenance will therefore now be chargeable to the Education Committee. Consultant Obstetrician. As was mentioned on page 60 of my report for the previous year, a Consultant Obstetrician has been appointed, and since the commencement until the end of the year, his services were obtained on 15 occasions. In each case an income enquiry form was sent to the husband, but it was found that owing to other necessary expenses incurred, it was not considered that the families were in a position to reimburse the Council for his services. Any medical practitioner attending a confinement of a resident of the district may communicate with the Consultant by telephone, and arrange for his attendance at any time of the day or night. After such attendances, the Consultant forwards a form to the Medical Officer of Health on which is stated the circumstances occasioning his presence and the result of the confinement. I regard this appointment as a long step forward towards the completion of our maternity arrangements. Not only is the safety of the mothers enhanced, but also the knowledge that specialist assistance is available is most advantageous to the medical practitioner. 82 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 two at the Five Elms Out-Patients Department. In addition, one monthly session was held at Chadwell Heath and one at Rush Green. At the Five Elms Out-Patients Department the Consultant Gynaecologist paid fortnightly visits throughout the year, seeing a total of 146 women who made 238 attendances. 120 cases were referred to hospital for confinement under the Council's scheme, of whom 105 were admitted to the East End Maternity Hospital, nine to Charing Cross Hospital under the care of the Consultant Gynaecologist, six to Oldchurch Hospital and one to Queen Mary's Hospital, Stratford. The cost to the Council for these patients, after the receipt of the patients' fees, amounted to £719 Os. Od. 26 women who attended were found to be not pregnant, and there were 15 post-natal eases. Of the 884 women who attended, 337 came of their own accord, 112 were referred by health visitors. 15 by medical practitioners, five by Oldchurch Hospital, 92 by neighbours, 184 by midwives and eight by the Relieving Officer. The co-operation of medical practitioners and midwives is increasing as the figures given above will show; in the previous year 142 cases were referred by midwive's against 184 in 1935. It is obviously to the advantage of patients, doctors and midwives if a close association is maintained with the ante-natal services provided by the Local Authority. The aim of all concerned is to safeguard motherhood and prevent conditions which might give rise to maternal morbidity. 83 It is to he desired that facilities for post-natal examination should be taken advantage of to a greater extent than at present; all parturient women should be examined approximately six weeks after their confinement by a medical practitioner, whether their own family doctor or one of the Assistant Medical Officers of the Council is immaterial. It is well known in the profession that conditions caused by parturition which were easily remediable in the early stages are extant. Many middle aged and elderly women go through the declining years of their lives suffering pain and discomfort which would have been prevented by appropriate treatment at the opportune time; the opportune time, of course, being the time following closely upon their confinement. The Health Visitors have been requested to explain to all newly confined mothers the advantages to be obtained by undergoing post-natal examinations. In all cases where a midwife sends her patient to an ante-natal clinic and the Medical Officer there decides that hospitalisation is necessary, the midwife receives compensation from the Council. It is also a condition of the payment of the midwife in necessitious cases that the cases shall have attended an ante-natal clinic. 222 patients paid six or more visits, 180 attended once only, 145 twice, 102 thrice, 86 four times and 80 five times. These figures exclude the attendances at the ante-natal clinics of the hospitals to which the patients were referred, but include those who had a miscarriage or who left the district before confinement. The sixth month of pregnancy was the commonest time this year for the first attendance, 143 attending at this stage; the fifth month with 136, and the seventh with 112 were the next most common. 110 attended first in their fourth month, 100 in the third, 56 in the eighth and 48 in the second month. 84 Hospital Cases.—Of the 174 cases referred to hospital. 120 were assisted under the Maternity and Child Welfare Scheme, 124 of which were admitted on other than medical grounds. The commonest sole reason for this was unsuitable domestic circumstances which accounted for 65, followed by 57 sent in because it was their first pregnancy, and two were admitted on economic grounds. In the remaining cases, more than one factor operated, domestic circumstances being the part reason in 26, first pregnancy in another 19, and five on economic grounds. Abnormal eases 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. Gynaecological Cases. Gynaecological cases are seen at the ante-natal clinic held on Tuesday mornings at Five Elms. This arrangement was primarily established for women who are approaching the menopause; it has been somewhat loosely described as the "clinic for women over 40. This term is misleading and may deter some of those who are in need of advice from attending. The time of incidence of the menopause varies within wide limits. The total number of attendances of gynaecological cases was 86. Although increasing, the numbers do not yet warrant the establishment of a special clinic for this purpose. 85 Foster Children. The following tables show the number of foster children and foster mothers in the distriet:— Foster Children — No. on register, December 31st, 1934 36 No. added to register 37 No. deducted owing to refusal, removal, deaths, or reaching age of nine 30 No. on register, 31st December, 1935 43 Foster Mothers- No. on register, 31st December, 1934 34 No. of additions during year 15 No. taken off during year 14 No. on register, 31st December, 1935 35 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 86 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 be taken for reward by a foster mother. For the purpose of the Children and Young Persons Act, 1932, all the Health Visitors are Infant Life Protection Visitors and visit foster children in their district at regular intervals, and in addition, all foster children below the age of five are required to attend the Infant Welfare Centres. Maternity Homes. 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, 1934, 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 1,171 0 0 (b) For dried milk ... 256 0 0 Education. On several occasions during the year the Medical Officer of Health has addressed meetings of Co-operative Guilds, Women's Labour Sections, Women's Fellowships 87 and other social bodies. It is found that at these meetings many intelligent questions are asked which show that the desire for knowledge of health matters is well marked in this district. A number of pamphlets are distributed at the Infant Welfare Centres by the Health Visitors. The experiment of sending out birthday cards accompanied by appropriate pamphlets which was commenced during 1933 has shown that although in a few cases the dissemination of health knowledge has proved of value, the repetition on the second, third and fourth anniversaries has been much less effective than that on the first birthday. Also the pressure of work on the clerical staff has made the original scheme impracticable. Of recent months, therefore, the scheme has been restricted to the first year and the results are being carefully noted in order to ascertain whether or. not the issue of birthday cards should be continued. In October the Council decided to hold an exhibit ion in Valence House as a part of the celebration of the Local Government Centenary. One section of this exhibition was devoted to Public Health and Maternity and Child Welfare. For the latter sub-section, the assistance of the Central Council for Health Education was sought, and this body supplied an exhibit showing in miniature the various phases of home life and infant management. Those who attended will remember that during the whole time that the exhibition was opened, there was very marked interest evinced in the health section. Approximately 35,000 persons attended, most of whom were local residents, but in addition many persons from long distances made journeys to Dagenham for this purpose. 88 The success attending the above augurs well for the time when a health week and exhibition is held in the district. It will be remembered that provisional arrangements were made for this purpose in 1935, but owing to there not being a hall of sufficient size to accommodate the exhibition, it was decided to postpone the event pending the building of suitable premises. Birth Control Clinic. A Birth Control Clinic under the auspiccs of a voluntary committee is held once a fortnight. The Local Authority makes a per capita grant to this body for persons who attend in whom pregnancy would be detrimental on medical grounds. During the year payments amounting to £16 2s. 6d. 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 — 1 — — — — — 1 — — — — — — — — — — — — — — — 2 — 2 3. Scarlet Fever — — — — — — — — — — — — — — — — — — — — — — — — — — 4. Whooping Cough 3 1 — 3 — — — — — — — — — — — — — — — — — — 3 4 3 4 5. Diphtheria — 1 — — 6 2 9 4 — — — — — — — — — — — — — — 15 7 13 8 6. Influenza — — — — — — 1 — — — — — — — 1 — — — — — — — 2 — 2 1 7. Encephalitis lethargica — — — — — — — — — — — — — — — — — — — — — — — — 1 — 8. Cerebro-spinal fever — 1 — — — — — — — — — — — — — — — — — — — — — 1 — 2 9. Tuberculosis of respiratory system — — — — — — — — 4 4 6 3 17 3 4 — 1 — — — — — 32 10 36 9 10. Other tuberculous diseases — — 2 1 1 — — 1 — 1 — — 1 — 3 — — 1 — — — 7 4 4 4 11. Syphilis 1 — — — — — — — — — — — — — — — — — — — — — 1 — 1 1 12. General paralysis of the insane, tabes dorsalis — — — — — — — — — — — — 1 — 1 — — — — — — — 2 — 2 — 13. Cancer, malignant disease 1 — — — — — — 1 — — — 3 2 7 9 6 3 9 4 9 2 4 21 39 18 38 14. Diabetes — — — — — — — 1 — — — 1 — — — — — 1 1 1 — — 1 4 1 4 15. Cerebral haemorrhage, etc. — — 1 — — — — — — — 1 — — — 2 2 1 6 5 4 6 5 16 17 7 11 18. Heart Disease — 2 — — — — 2 4 — 1 — 2 1 8 5 4 3 6 5 11 5 16 43 44 61 17. Aneurysm — — 1 — — — — — — — — — 1 — — 1 — — 2 — — — 4 1 5 2 18. Other circulatory diseases — — — — — 1 1 — — — — 1 — 2 1 1 1 — — 1 2 1 5 7 2 6 19. Bronchitis 1 — — — — — — — — — — 1 2 — 2 1 — 3 1 4 6 13 8 6 5 20. Pneumonia (all forms) 17 14 7 4 1 4 5 4 2 3 1 2 9 3 4 3 1 1 1 4 2 2 50 44 36 27 21. Other respiratory diseases — — — 1 — — — — — — — — 1 1 1 — — — — — — 2 2 4 2 4 Peptic Ulcer — — — — — — — — — — — — 2 2 3 — — — — 1 — — 5 3 6 3 23. Diarrhoea, etc. (under 2 years) 6 5 — 1 — — — — — — — — — — — — — — — — — — 6 6 3 7 34. Appendicitis — — — — — — 1 — — — — — — — — 1 — — 1 — — — 2 1 3 3 25. Cirrhosis of liver — — — — — — — — — — — — — — — — — — — — — — — — — — 26. Other diseases of liver, etc. — — — — — — — — — — — — — — — — — — — — — — — — — 2 27. Other digestive diseases — — — — — — — — — — 1 — — — — — — 1 — — — — 1 1 6 5 Acute and chronic nephritis — — — — — — — — — — — — — 1 — 1 2 4 3 — 3 — 8 6 4 6 Puerperal sepsis — — — — — — — — — — — — — — — — — — — — — — — — — — 30. Other puerperal diseases — — — — — — — — — — — — — 1 — — — — — — — — — 1 — 1 31. Congenital debility, premature birth, malformations, etc. 21 17 — — — — — — — — — — — — — — — — — — — — 21 17 24 22 32. Senility — — — — — — — — — — — — — — — — — — 1 2 9 16 10 18 4 7 33. Suicide — — — — — — — — 1 — — — — — — — 1 — — — 1 — 3 — 3 — 34. Other violence — — 1 — 1 — 1 — 5 — 4 — 8 — — — 1 1 2 3 1 — 24 4 24 5 35. Other defined diseases 2 8 1 — 1 1 8 4 1 1 1 1 3 1 3 1 1 1 — 2 — 1 21 21 31 23 36. Causes ill-defined or unknown — — — — — — — — — — — — — — — — — — — — — — — — — 1 52 50 13 10 10 8 28 20 13 10 14 14 48 29 39 20 16 31 28 39 30 42 291 273 291 274 INDEX. A Page Acute Anterior Poliomyelitis 62 Acute Polio Encephalitis 62 Adenoids 77-78 Ambulance Facilities 18 Ante-Natal Clinics 21,82-83 Artificial Sunlight 23,79 B Bacteriological Examination 47 Baths 32 Birth-rate 11,14 Births 88 Birth Control 11,12-13,67 Births, Illegitimate 11,69 Births,Still 11,69 Blindness—Prevention of 67 Boot Fund 80 Byelaws—Premises and Occupations controlled by 30-31 C Camping Grounds 25,31 Cancer 67-68 Cerebro-Spinal Fever 62 Cesspools 28 Children's Act, 1908-32 86 Children's Invalid Aid Association 80 Closet Accommodation 27 Committees 7 Contents—Principal 3 Convalescent Home 80 Council—Members of 7 D Dairies 40 Deaths 11,13,14,71-72,89 Death-rate, General 11,13,14 Death-rate, Infantile 11,14 Deaths, Causes of 89 Deaths, Infants 11,14,71-72 Dental Treatment 79-80 Diarrhoea (Deaths from—under two years of age) 72 Diphtheria 49 Disinfection 28-29 District Nursing Association 19,23 Drainage and Sewerage 26 Dried Milk 86 Dust Collection 27 INDEX—Continued. E Page Earth Closets 28 Education in Health 52,86-88 Encephalitis Lethargica 63 Enteric Fever 62 Erysipelas 62 Extracts from Vital Statistics 11 F Factories and Workshops 33-34 Food and Drugs 47 Food Inspection 40-46 Food Poisoning 46-47 Food Shops 44 Foster Children and Mothers 85-86 Free Supplies of Milk 86 G General Provision—Health Services 15 Gynaecological Cases 84 H Hairdressers' and Barbers' Premises 25,31 Health Committee 7 Health Services—General Provision of 15 Health Visitors 75-76 Hospitals—General and Special 16-17 Hospitals—Infectious Diseases 15 Hospital—Maternity 17,84 Hospital—Smallpox 15 Houses Let in Lodgings 37 Housing Act, 1930 35-37 Housing Statistics 35-37 I Ice-Cream 45-46 Illegitimate Births 11,69 Immunization Clinics 51-58 Infant Deaths 11,14,71-72 Infant Welfare Centres 20,76-77 Infantile Mortality 11,14,71-72 Infectious Diseases Hospital 15 Infectious Diseases 24,48 Institutional Provision for Unmarried Mothers, Illegitimate Infants, etc. 18 Invalid Children's Aid Association 80 INDEX—Continued. L Page Laboratory Facilities 24-25 Legal Proceedings 47 Legislation in Force 25 Library Books 30 Light Treatment 23,79 M Maternity Mortality 74 Maternity and Child Welfare 69-88 Maternity and Child Welfare Committee 7 Maternity Homes and Hospitals 17,86 Measles 12 61,72 Meat Inspection 42-44 Meningitis, Cerebro-Spinal 62 Midwives 24 Milk—Free Supplies 86 Milk in Schools 41 Milk (Special Designation Order) 41-42 MilkSupply 40 Mortality, Analysis of 89 Mortality, Infantile 71-72 Mortality, Maternal 74 Mortality, Neo-Natal 71 N Neo-Natal Mortality 71 Notices Served and Complied with 32 33 35-36 Notifications of Births 69 Nursing Arrangements 23-24 O Obstetrician-Consultant 81 Offensive Trades 30 Ophthalmia Neonatorum 72-73 Orthopaedic 18,22,78-79 Overcrowding 38-39 P Pemphigus 67,73 Personal Service Council 10 Physical Features of Area 26-27 Pneumonia 63,72 Population 10,12 Post-Natal Examination 83 Preface 5-6 Premises and Occupations Controlled by Byelaws 30-31 Principal Contents 3 INDEX.—Continued. P Page Prosecutions. Sale of Food and Drugs Act 47 Psittacosis 63-64 Public Health Committee7 Puerperal Fever and Pyrexia 67,74-75 R Rateable Value 10 Rats and Mice (Destruction) 34 Refuse Removal and Disposal 27-28 Rivers and Streams 26-27 Refraction Clinic 22 S Sanatoria 16 Sanitary Circumstances of the Area 26 Sanitary Inspection of Area 33 Scarlet Fever 58-61 Scavenging 27 Schick Immunization Clinics 51-58 School Clinics 22 Schools 32 Sewerage 26 Shops Act, 1934 31-32 Slaughterhouses 42-44 Slaughter of Animals Act, 1933 44 Smallpox 15,64 Smoke Abatement 30 Social Conditions of Area 10 Staff 8-9 Statistics 11 Stillbirths 11,69 Streams 26-27 T Table, Birth-rate, etc. 14 „ Cancer 68 „ Death-rate, etc. 14 „ Deaths, Causes of 89 „ Diphtheria Immunization 53-57 „ Housing 35-37 „ Infectious Diseases, Notifiable 48 „ Infectious Diseases Removed to Hospital 48 „ Infectious Diseases in School Children 50-51, 60-61 „ Inspections for Year 33 Meat Inspection 43-44 „ Ophthalmia Neonatorum 72 „ Record of Inspections 33 „ Tuberculosis Deaths 65 INDEX—Continued. T Page Table, Tuberculosis Notifications 65 „ Vaccination 64 Tents, Vans and Sheds 25,30 Tonsils and Adenoids 77-78 Treatment 20,77-80 Tuberculosis 16,22,65-66,67 Tuberculosis After Care Committee 67 Typhoid Fever 62 U Unmarried Mothers 18 V Vaccination 64 Vermin 37-38 Venereal Diseases 22 Vital Statistics, Extracts from 11 Visits, Health Visitors' 76 Visits, Sanitary Inspectors' 33 W Water Supply 26 Workshops 33 Z Zymotic Diseases 48-64