C4411 DDAEENHAM The Urban District Council of Dagenham Annual Report OF THE medical officer of health FOR THE YEAR 1936 CECIL HERINGTON, M.B., B.S. (Lond.), D.P.H. The Urban District Council of Dagenham Annual Report OF THE medical officer of health FOR THE YEAR 1936 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 17 Ambulance 19 Clinics 21 Nursing in the Home 24 Laboratory Facilities 26 Legislation in Force 27 Sanitary Circumstances of the Area 30 Disinfection 33 Sanitary Inspection 39 Housing Statistics 41 Statistics of Inspections 41 Inspection and Supervision of Food 46 Infectious and Other Diseases 54 Diphtheria 55 Scarlet Fever 64 Tuberculosis 71 Cancer 74 Maternity and Child Welfare 75 Infant Mortality 76 Maternal Mortality 79 Infant Welfare Centres 81 Ante-Natal Services 86 5 To the Chairman and Members of the Council. Ladies and Gentlemen, I beg to present my report on the work of the Public Health Department for the year 1936. It is based on the suggestions contained in Circular 1561 issued by the Ministry of Health. The year under review has again been one of progress; the services administered by this Department have continued to expand. It is anticipated that this process of growth will not reach maturity for some years to come. Although strictly not covered by this report, it is worthy of mention that by having been entrusted by the Minister of Health with the administration of the Midwives Acts, this Council is now a complete autonomous Authority for the purposes of Maternity and Child Welfare. I take this opportunity of recording my appreciation of the cordial relations which always existed between the County and Urban Councils when the former were the Local Supervising Authority. The scheme for immunising against Diphtheria has again achieved good results. More children received treatment during 1936 than in any year since this campaign was inaugurated. The vital statistics compare very favourably with those for the Country as a whole. The maternal mortality rate, although higher than that for 1935, which was exceptionally low, was 2.05 per 1,000 total births; the rate for England and Wales over the same period was 3.6. 6 Once again I have pleasure in recording the continued loyal support of the staff of the Health Department, many of whom have contributed to the compilation of this report. In conclusion, I desire to thank the Chairman and Members of the Council for their continued confidence and for the helpful manner in which they have dealt with the many problems it has been my duty to bring before them. I have the honour to be, Your obedient servant, CECIL HERINGTON, Medical Officer of Health. Public Health Offices, Becontree Avenue, Dagenham. June, 1937. 7 MEMBERS OF THE COUNCIL. (31st December, 1936). Councillor (Mrs.) L. F. EVANS, J.P., Chairman. Councillor A. ROGERS, Vice-Chairman. Coun. H. G. H. ATKINSON. Coun. W. F. LEGON. „ A. E. BALE, J.P. „ H. L. LYONS. „ J. E. BRADBEER. „ W. C. MARKHAM. „ W. T. CAIN. „ (Mrs.) M. E. MARLEY, J.P. „ A. F. J. CHORLEY. „ (Mrs.) E. McALISTER. „ R. J. D. CLACK. „ R. J. MINCHIN. „ C. DELLOW, J.P.. C.C. „ J. A. PRESTON, J.P. „ H. C. DYER. „ B. H. SAUNDERS. „ E. E. HENNEM. „ G. B. SMITH. „ E. HOWARD. „ (Mrs.) F. E. STOCKBRIDGE. „ W. H. LANGLOIS. PUBLIC HEALTH COMMITTEE. Councillor (Mrs.) E. McALISTER. Chairman. Councillor (Mrs.) M. E. MARLEY, J.P., Vice-Chairman. Coun. R. J. D. CLACK. Coun. A. ROGERS. „ (Mrs.)L. F.EVANS, J.P. „ B. H. SAUNDERS. „ E.HOWARD. „ (Mrs.) F. E. STOCKBRIDGE. „ W. F. LEGON. MATERNITY AND CHILD WELFARE COMMITTEE. Same members as Public Health Committee with the addition of the following co-opted members :— Mrs. H. R. CHORLEY Mrs. F. L. M. ROGERS. (Appointed December, 1936). Mrs. A. R. THOMAS. Mrs. G. DUNHAM Mrs. A. L. WRIGHT. (Resigned December, 1936). 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. Deputy 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: J. W. ALLAM, Certificate of Royal Sanitary Institute. (Appointed December, 1930.) F. W. S. FOX, Certificate of Royal Sanitary Institute; Meat Inspector's Certificate; Sanitary Science as applied to Buildings and Public Works Certificate; Smoke Inspector's Certificate. A. J. JAMES, Certificate of Royal Sanitary Institute. L. E. PRIOR, Certificate of Royal Sanitary Institute ; Meat Inspector's Certificate. Senior Health Visitor: M. SMITH (1, 2, 3). Health Visitors : V. A. EVERITT (1, 2, 3). I. F. RICHARDSON (1, 2, 7). A. K. GIBSON (1, 2, 3). H. A. SHUTT (1, 2, 3). (Appointed March, 1937.) F. N. UDELL (1,2,3,4,5). E. M. HURLEY (1, 2. 3). (Resigned February, 1937.) (Appointed March, 1937.) D. E. WALLER (1, 2, 3). I. PLUMMER (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: F. W. KNIGHT, Certificate of Royal Sanitary Institute. Clerks: I. M. BISHOP. D. J. PIPPETT. H. FIELD. (Resigned June, 1936.) (Appointed July, 1936.) B. L. PARRY. D. I. FLETCHER. (Appointed February, 1936.) P. NUTTALL. G. A. POWER. (Appointed May, 1937.) M. A. WATTS. Part-Time Staff. Consulting Gynaecologist: H. G. EVERARI) WILLIAMS, M.D., M.R.C.P. (Resigned January, 1937.) W. S. O'LOUGHLIN M.D., M.C.O.G. (Appointed January, 1937.) Consulting Obstetrician: W. S. O'LOUGHLIN, M.D., M.C.O.G. Consulting Orthopaedic Surgeon: B. WHITCHURCH HOWELL. F.R.C.S. Dentist: F. C. RITCHIE, L.D.S., R.C.S. (Edinburgh). 10 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Registrar-General's estimate of resident population 1936 102,000 Number of inhabited houses (end of 1936) according to Rate Books 23,994 Rateable value (Dec. 31st, 1936) £527,513 Sum represented by a penny rate (estimated 1936-37) £2,095 Social Conditions of Inhabitants. The influx of industries during 1936 has continued, and the amount of local employment has considerably increased. The tendency now is for residents of the area to find employment within the district or in districts contiguous thereto. This changing condition of affairs is welcomed; formerly Dagenham was largely a dormitory town, but the setting up of local industries is doing much to alter this condition. As in previous years, the building industry has continued to be active; the number of inhabited houses according to Rate Books has increased by 1,194. Several private estates have been and are still being developed. 11 Extracts from Vital Statistics for the Year. Live Births:- Total. Male. Female. Legitimate 1,858 945 913 Birth rate per 1,000 of the estimated resident population. 18.47. Illegitimate 26 12 14 Stillbirths:- Legitimate 60 34 26 Rate per 1.000 total (live and still) births, 32.85. Illegitimate 4 3 1 Deaths 656 345 311 Death rate per 1,000 of the estimated resident population, 6.43. Deaths from puerperal causes:- Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis 3 1.54 Other puerperal causes l 0.51 Total 4 2.05 Death rate of Infants under one year of age :— All infants per 1,000 live births 56.26 Legitimate infants per 1,000 legitimate live births 54.36 Illegitimate infants per 1,000 illegitimate live births 192.3 Deaths from Measles (all ages) 25 ,, ,, Whooping Cough (all ages) 5 ,, „ Diarrhoea (under 2 years of age) 15 12 The mortality from Measles is commented upon later in the report. Population. The Registrar-General's mid-year estimate was 102,000; this is an increase of 1,700 compared with the previous year. The excess of live births over deaths for the year was 1,228 and 1,994 more houses were occupied than in 1935. 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 94,952 19,952 4.71 1933 95,550 20,754 4.60 1934 98,710 21,918 4.50 1935 100,300 22,800 4.40 1936 102,000 23,994 4.25 The above table is interesting in that it shows the progressive decrease in occupation per house since 1932 : this figure may be regarded roughly as an index of the state of overcrowding. It is anticipated that the fall will continue. Births. 1,884 live births were registered during the year. The birth rate per 1,000 population wa's thus 18.47 compared with 14.8 for England and Wales and 14.9 for the 122 large towns including London. The rate compares with that of 24.2, 26.5, 30.6, 23.8, 23.6, 20.4, 18.6, 19.6 and 18.59 for the years 1927 to 1935 inclusive. The illegitimate birth rate continues to be very low, being only 1.4 per cent. of total births. Comparable 13 figures for other districts for the year under review are not to hand, but it would surprise me to learn that there is another large town in the country with a rate as low as that of Dagenham. The rate of illegitimate stillbirths is 6.25 per cent. of total stillbirths. The birth rates of Dagenham since its inception as an Urban District have been high; it is somewhat surprising that the high level is being maintained for so long as the ageing of the population would be expected to diminish this rate. In other words, a number of persons of the reproductive age must necessarily have passed that stage of development. Death Rate. Total deaths in district 361 Outward transfers 69 Inward transfers 364 Deaths of residents 656 Of the 69 deaths of non-residents occurring in the district, 49 took place at the West Ham Sanatorium and 13 at the Joint Isolation Hospital. Of the 364 deaths of local residents taking place outside this area, most occurred in institutions. Of these, 204 occurred at Oldchurch Hospital, 31 at King George Hospital, Ilford, five at the London Fever Hospital, three at East Ham Memorial Hospital, one at Queen Mary's Hospital, Stratford, five at The London Hospital, 26 at Orsett Lodge and five at Mental Hospitals. 656 deaths in a population of 102,000 represent a death rate of 6.43 compared with 12.1 for England and Wales. For the years from 1927 to 1935 inclusive, the local rates were 7.0, 7.3, 8.3, 6.6, 7.2, 6.5, 6.5, 6.6 and 5.63. A table giving the causes of death, and the age periods at which they occurred, is given at the end of the report. 14 Table showing Birth-rate, Death-rate and Analysis of Mortality during the year 1936. 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 14.8 0.61 12.1 0.01 0.00 0.07 0.01 0.05 0.07 0.52 0.14 5.9 59 122 County Boroughs and Great Towns, including London 14.9 0.67 12.3 0.01 0.00 0.09 0.01 0.06 0.08 0.45 0.14 8.2 63 143 smaller towns (1931) resident populations 25,000-50,000 15.0 0.64 11.5 0.00 0.00 0.04 0.01 0.04 0.05 0.39 0.15 3.4 55 London 13.6 0.53 12.5 0.01 0.00 0.14 0.01 0.06 0.05 0.52 0.14 14.4 66 Dagenham (estimated population 102,000) 18.47 0.68 6.43 0.00 0.00 0.25 0.01 0.05 0.24 0.31 0.09 7.96 56.26 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. 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. Cases of Puerperal Fever and Pyrexia and Ophthalmia Neonatorum are now normally admitted to this Hospital. When the building operations above referred to are completed, it should not be necessary to send any infectious cases to other hospitals under ordinary conditions. Reference to Diphtheria, Scarlet Fever and other infectious diseases is made later in the report. (2) Smallpox. In 1936 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. 16 For the county districts within the Metropolitan area, of which Dagenham is one, an agreement has been arrived at with the London County Council, whereby Smallpox cases will be received into the London Smallpox Hospitals. As will be noted in the table showing notification of various diseases, no Smallpox cases were notified in Dagenham in 1936. b. Tuberculosis. The following table shows the hospitals and institutions to which cases of Tuberculosis are admitted through the County Council scheme:- Institution. Type of case treated. Black Notley Sanatorium Women and children—pulmonary. Men, women and childdren—non-pulmonary. Harold Court Sanatorium Men—pulmonary. High Beech Sanatorium Children—non-pulmonary. Chingford Sanatorium Women—pulmonary. Colchester Sanatorium Women—pulmonary. Ilford Sanatorium Men—non-pulmonary. Lord Mayor Treloar Cripples Hospital. Children—non-pulmonary. King George Sanatorium, Bramshott. Men—pulmonary and non-pulmonary. Borrow Hill Colony, Frimley Boys—pulmonary. Church Army Sanatorium, Farnham. Boys—pulmonary and glands. Hawthorndene Sanatorium, Isle of Wight. Women—pulmonary. Liverpool Road Hospital Men—pulmonary (advanced). Oldchurch Hospital, Romford Men and women—pulmonary and non-pulmonary. Papworth Hall Colony Men—pulmonary. Preston Hall Colony Men—pulmonary. Royal National Sanatorium, Ventnor. Men and women—pulmonary. St. Anthony's Hospital, Cheam Men and women—mixed cases. St. Joseph's Hospice, Hackney Men and women—pulmonary (advanced). Victoria Park Hospital, London Men, women and childrenpulmonary. King Edward VII Sanatorium, Midhurst. Men—pulmonary. 17 The following are the numbers of persons admitted from this district during the year:- Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Total. Adults 44 43 9 6 102 Children 3 1 23 8 35 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. 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. 18 During 1936, 1,211 patients were admitted from Dagenham against 710 for the previous year, whilst at the main hospital 7,144 out-patients residing in Dagenham received treatment, and at the Five Elms OutPatient Department there were 8,243 attendances. (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 were admitted to Charing Cross Hospital under a scheme which has been in operation for several years. During 1937, owing to the resignation of the Consultant Gynaecologist and the appointment of Dr. O'Loughlin in his stead, abnormal cases found at the Consultant's Clinic are admitted to Oldchurch Hospital; in these cases this Council is responsible for fees payable, the patients contributing in accordance with an income scale. Dr. O'Loughlin is a member of the Consultant staff of Oldchurch Hospital. (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. (4) Orthopaedic Hospitals. Orthopaedic cases are admitted to the Royal National Orthopaedic Hospital, Queen's Hospital, Hackney, Cheyne Hospital or Brookfield Orthopaedic Hospital. 19 Institutional provision for unmarried mothers, illegitimate infants and homeless children. This Council does not provide for cases of this nature, but when such arise needing admission to an institution, arrangements are in many cases made by Officers of the Council. 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 report for the year 1934. The following are the details of the work done by the ambulances during the year, showing 1935 figures for purposes of comparison:- 1936. 1935. No. of accident cases conveyed 567 383 No. of other cases conveyed 1,679 2,077 No. of journeys made 2,062 2,207 No. of miles run 23,844.2 26,501.2 20 The Council has an agreement with the Borough Councils of Barking and Ilford for the reciprocal use of ambulances and for the conveyance of street cases. In the event of the ambulance of one Authority being called to a case just inside the boundary of one of the other districts, the patient is removed by the ambulance summoned. Both ambulances were out together 289 times, while in addition on five occasions when both vehicles were in commission, the ambulance of one of the neighbouring Authorities was requisitioned. Barking called on Dagenham ambulances 16 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. 21 Clinics and Treatment Centres. The following tables show 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. Methodist Chapel, High Road, Chadwell Heath. Weekly Monday, p.m. 64 3 Becontree Clinic, Beeontree Avenue, Weekly Monday, p.m. 65 4 Dagenham. Weekly Thursday, p.m. 76 5 Ford Road Clinic, Ford Road, Weekly Tuesday, p.m. 83 6 Dagenham. Weekly Wednesday, a.m. 40 2 Weekly Wednesday, p.m. 65 8 Pettit Farm, Heathway, Weekly Thursday, a.m. 51 2 Dagenham. Weekly Thursday, p.m. 66 2 Out-Patient Dept., King George Hospital, Weekly Tuesday, p.m. 71 4 Five Elms, Dagenham. Weekly Wednesday, p.m. 55 4 Rush Green Clinic, 179, Dagenham Road. Weekly (Comm. Friday, a.m. 17 1 18/5/36) Weekly Friday, p.m. 42 2 22 Ante-Natal Clinics. CENTRE. Sessions held. Times Sessions held. Average Attendances. Average New Cases. Methodist Chapel, High Road, Chadwell Heath. Monthly (3rd in month) Friday, p.m. 15 5 Becontree Clinic, Becontree Avenue, Weekly Monday, a.m. 10 2 Dagenham. Weekly Friday, a.m. 14 3 Ford Road Clinic, Ford Road, Weekly Tuesday, a.m. 16 4 Dagenham. Weekly Thursday, a.m. 16 3 Out-Patient Dept., King George Hospital, Weekly Tuesday, a.m. 13 4 Five Elms, Dagenham. Weekly Wednesday, a.m. 15 2 Rush Green Clinic, 179, Dagenham Road. Monthly (1st in month) Friday, a.m. 8 2 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 Tuesday and Friday afternoons at the Becontree Clinic and at the Out-Patient Department on Monday afternoons and Friday mornings. Refraction Clinics and Dental Sessions are held as required at the Dagenham and the Becontree Clinics. 23 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. 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. Further reference to this is made under the Maternity and Child Welfare section of the report. 24 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 1,131 general nursing cases was treated during the year, involving 10,169 visits to the homes. 341 midwifery cases and 124 maternity cases were nursed. In addition, these patients paid a total of 2,759 visits to the ante-natal clinic held at York House. Altogether then, the number of persons attended during the year was 1,596 to whom 19,189 visits were paid. During illness or other unforeseen contingencies in the Health Visiting Staff, the services of nurses from the association are obtainable at our clinics, a fee being payable by this Council. The following is an extract from the Annual Report of the Dagenham District Nursing Association for the year ended 31st March, 1937:- "The Committee have again to report an increase in the work. There has been an increase of over 2,000 visits on last year's figures, and 157 more cases. It is satisfactory to know that the work for the Dagenham Urban District Council has continued, and during the past year the following cases were attended:—224 Ambulance Cases, 28 Cases of Measles, 75 Pneumonia Cases and 109 Influenza Cases, and the nurses attended various Ante-Natal Clinics and Child Welfare Centres. 25 Under the new Midwives Act a complete salaried service of midwives must be provided throughout the country, and the Dagenham District Nursing Association is to assist the Council in carrying out their obligations under the Act. As the work shows promise of increasing still more in the future, the Committee felt that the present Home in Frizlands Lane would be quite inadequate for the needs of the district, and asked the Essex County Nursing Association to consider the extension to York House. A Sub-Committee has therefore been appointed to consider the matter. The Committee have agreed to join in the Greater London Provident Scheme for District Nursing, which it is hoped will greatly benefit district nursing throughout the Greater London area. The scheme is intended to organise district nursing very much on the lines of the hospital contributory scheme, enabling patients by payment of a small weekly sum to obtain general district nursing free of charge should occasion arise." (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. An arrangement has been made whereby nurses on the staff of the Dagenham District Nursing Association are available for attending cases of Pneumonia in their own homes. This has already proved its worth and the records show that such cases as a whole do well. In many cases the removal of an Acute Pneumonia case is followed by untoward happenings. 26 Midwives. There are no midwives in the district employed by the Local Authority. At the end of the year there were 29 midwives whose practices lay within the Urban District. The Midwives Act, 1936 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. The Council having been made a Local Supervising Authority, as from 1st April, 1937, has submitted proposals to the Minister included in which are details of arrangements for this Council to employ 10 midwives, and to enter into arrangements with the Dagenham District Nursing Association and the Salvation Army for the services of 10 further midwives. Laboratory Facilities. Examination of clinical material is undertaken at the Counties Public Health Laboratories, Queen Victoria Street, London. During the year, 572 swabs were examined for the diphtheria bacillus, 567 samples of sputum for the bacillus of tuberculosis, 19 samples of hair for the fungus of ringworm, examination for agglutination of blood against typhoid and allied organisms on three occasions, and in addition, 56 specimens were submitted for examinations of a miscellaneous character. The same laboratory also undertakes the bacteriological examination of milk and ice-cream, of which 123 samples of the former and 19 of the latter were submitted during the year. 810 swabs were examined for the diphtheria bacillus at the Public Health Offices. 27 The County Council has extended the facilities for certain examinations of specimens submitted by general practitioners and Public Health departments. Legislation in Force. The following byelaws were made by the Romford Rural District Council and have been taken over by the Dagenham Urban District Council:- Date of Confirmation. Cleansing of Footpaths January, 1885 Removal of House Refuse January, 1885 Cleansing of Earth Closets, etc. January, 1885 Common Lodging Houses December, 1901 Nuisances May, 1902 Houses Let in Lodgings June, 1902 Tents, Vans, Sheds, etc. March, 1908 Regulation of Certain Offensive Trades. Animal Charcoal Manufacturer; Blood Boiler; Blood Drier; Bone Boiler; Cat Gut Manufacturer; Fat Melter or Fat Extractor; Fish Skin Dresser; Glue Maker; Size Maker; Gut Scraper; Leather Dresser; Manufacture of Manure from fish offal or other putrescible animal matter; Soap Boiler; Tallow Melter; Tanner and Tripe Boiler. Confirming Order July, 1911. Byelaws confirmed August, 1912. Rag and Bone Dealer; Fish Fryer. Confirming Order 25th March, 1927. Byelaws confirmed 26th September, 1928. Slaughter House (Revised). 26th September, 1928. New Streets and Buildings. July, 1925. 28 Regulations with respect to Dairies, Cowsheds, etc. February, 1908. Houses Let in Lodgings. 27th April, 1932. Smoke Abatement. 21st April, 1933. Removal of House Refuse. 23rd August, 1934. Nuisances in connection with the Removal of Offensive and Noxious Matters. 27th November, 1934. Transport and Exposure for Sale of Food. 12th December, 1934. Nuisances from snow, filth, dust, ashes and rubbish and for the prevention of the keeping of animals on any premises so as to be injurious to health. 17th January, 1935. Camping Grounds and Moveable Dwellings. 21st August, 1935. Hairdressers' and Rarbers' Premises. 12th September, 1935. Tents, Vans, Sheds and Similar Structures. 19th November, 1935. Adoptive Acts. Public Health Act (Amendment) Act, 1890 (Part III). 5th December, 1927. Infectious Disease (Prevention) Act, 1890. 1st March, 1923. Private Street Works Act, 1892. 29 Public Health Act (Amendment) Act, 1907 (except Sections 19, 61, 78, 82-86 and 92-94). Small Dwellings Acquisition Acts. Public Health Act, 1925. Local Acts. Dagenham Urban District Council Act, 1928. Dagenham Urban (Water) Order, 1929. Dagenham Urban District Council Act, 1931. Essex County Council Act, 1933. 30 SANITARY CIRCUMSTANCES OF THE AREA. Water. Considerable development has taken place in the area with regard to the water mains. 2,500 yards of twenty-one inch mains will have been laid when the scheme now embarked upon is complete. 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. Drainage and Sewerage and Sewage Works Extensions. The building activity in the area has increased during the year to a considerable extent. In nearly all cases the properties erected are connected to the sewerage system. In outlying portions of the Hog Hill area a few houses have been built which have no access to sewers. Also the scheme mentioned in my previous Report for the sewering of the Manor Farm Estate has not yet been completed, although I understand that at the time of writing this report provisional apportionment notices have been served on the frontagers. The nature of the soil in this area is such that it permits easy percolation from the cesspools which do not in all cases comply with the byelaws which require that they shall be impervious. The work of completing the activated sludge plant at the Riverside Works is almost accomplished and the generation of combustible gas is now taking place. Rivers and Streams. The upper portion of the district is drained by a number of channels which run in a westerly direction, 31 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 Recontree Ward. The eastern side of the district is drained by the Wantz Stream running due south. This ditch became choked with weeds and deposited rubbish and at times of heavy rainfall caused flooding. The ditch has now been cleaned and flows without obstruction. 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, 1937:- Collection. Disposal. Total. Net cost £10,083 £2,781 £12,864 Net cost per ton 12s. 5d. 3s. 5d. 15s. lOd. Net cost per 1,000 population £99 £27 £126 32  Collection. Disposal. Total. Net cost per 1,000 premises £422 £117 £539 Total refuse collected 16,228 tons Weight per 1,000 population per da 8.72 cwts. No. of houses and premises 23,890 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. Refuse Separation and Incineration Plant. This has now been working for several years and its efficiency is proved by the fact that no complaints have been received with regard to effluvia. It will be agreed by those who have knowledge of this method of disposal that it has been worth the financial outlay incurred. Representatives of local authorities frequently pay visits to this plant and state their appreciation of the satisfactory methods of its operation. Pail Closets. The work of night soil collection is carried out entirely by mechanical methods and is free from all nuisance. The number of premises thus served has, due to modernisation and demolition, been reduced to 43. Cesspools. Normally cesspools are emptied by the Councils 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. 33 Disinfection. The experiment referred to in my report for last year is frequently cited by officers of my department to demonstrate the unreliability of terminal disinfection. It is considered that this experiment is of sufficient importance to warrant repetition of the description given last year, which is as follows:- " 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 (192529), 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. Per- Second- centagc Steam Cases i Cases ary of Period. Disinfection. Disease. Noti- Re- Cases Second- fied. moved. After ary 7th Day. Cases. S.F. 2,054 1,315 80 6.08 1925/6/7/8/9 Practised. Diph. 1,538 1,272 59 4.63 Total i 8,592 2,587 139 5.37 S.F. 2,542 1,683 104 5.51 '030/1/2/8/4 Abandoned. I Diph. 1,050 896 33 3.68 Total 3,592 2,579 137 5.31 34 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)." The methods employed with the object of eliminating danger from fomites have not been described of recent years. It may, therefore, be helpful to give a brief resume of the technique employed at the present time:- When making enquiries after a case of infectious disease, the Sanitary Inspector leaves with the person in charge of the premises a pamphlet of instructions which reads as follows:- "The commoner infectious diseases are caught chiefly from an infectious patient, the breath and any nose or ear discharge containing the infective matter. The articles in the house then, which are possibly infectious, are those which are most exposed to the infectious sources, namely, the patient's handkerchiefs, pillow slips and bed linen; other articles which are possibly contaminated are his clothing and to a less extent any article in the room in which he has been at any time since he was in an infectious state. Following the removal of an infectious patient, the person cleansing the room should wear a washable overall and carry out the following procedure:— (1) The patient's handkerchiefs, the pillow slips, small towels, etc., should be placed in a pail 35 containing some disinfectant such as Izal (one teaspoon to a quart of water or two tablespoons to a pail) and allowed to stand overnight. After wringing out they are then washed and boiled in the ordinary way. Sheets, bed clothing, etc., may be dealt with in the same way. (2) Valueless articles which can be disposed of in this way should be burned, e.g., papers, toys, etc. (3) Cleansing of room. All parts of the room should be cleansed. The floor skirtings, doors, window sills, etc., are washed, some preferring to add a disinfectant to the water, though this is not essential. Furniture, bed rails, shelves, etc., to be washed or wiped over with a damp cloth. This cleansing is followed by free ventilation by opening wide the windows and doors and having a fire burning. (4) Clothing, blankets, mattresses, etc., might be exposed outside on the first suitable occasion. (Medicine glasses, crockery and other washable articles handled by the patient should be soaked in a disinfectant solution for an hour and then boiled.) Disinfectant can be obtained at the Public Health Offices." The Inspector revisits the house a day or two after the removal to hospital of the patient in order to see that his instructions have been carried out. When a case is nursed at home, the pamphlet is left in the same way and the person in charge of the patient is informed that all clothing, bedclothes, etc., leaving 36 the sickroom must be left in a disinfectant solution for approximately one hour. The Sanitary Inspector pays weekly visits to such cases. Fumigation is carried out after a case of Smallpox and has been done in a few instances after Tuberculosis in order to satisfy the other occupants of the house. 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 five occasions warning letters were sent to occupiers of factories and it was not necessary to report any firm for prosecution. A total of 25 observations was made, each of 30 minutes duration and the emission was as follows:—black smoke 57½ minutes, moderate 387f minutes and no smoke 304½ minutes. Premises and Occupations which can be controlled by Byelaws. Offensive Trades—Fried Fish Shops. There were 23 fried fish shops in the district at the end of 1936, to which a total of 250 visits was paid during the year. Three new businesses were established. Rag and Bone Dealers. Two persons were seen to be exchanging toys for rags in contravention of section 73 of the Public Health Act, 1925. Warning letters were sent in each case. Section 154 of the Public Health Act, 1936, which will become operative in October, 1937, modifies the 37 previous legislation restricting the exchange of rags for toys. The section provides that no child under the age of 16 shall receive any article whatsoever in exchange for rags, old clothes or similar articles. Tents, Vans and Sheds. Byelaws were allowed during the year 1935 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 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 38 been found that the occupiers are willing and even anxious to comply with the requirements. There are 35 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 efficient ventilation, sanitary conveniences, lighting, washing facilities, facilities for taking meals and the maintenance of a reasonable temperature. During the year, 115 inspections were made and a total of 440 visits was paid. The following table shows the number of notices served and complied with in respect of the requirements of Section 10 which are administered by my Department:— Notices Notices served, complied with. Temperature 53 58 W.C. accommodation (repairs, etc.) 3 10 56 68 Swimming Baths. The popularity of swimming amongst children and adults continues unabated. The water in the bath in Valence Park is periodically analysed and is maintained at a high level of purity. 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. 39 The outstanding example of school construction recently was the opening of the Dagenham County High School which is situate in Parsloes Avenue and abuts on to Parsloes Park. Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and Number of Visits:- Houses 4,615 Nuisances under Public Health Acts 978 Bakehouses 50 Slaughterhouses 754 Milkshops, dairies and vehicles 90 Cowsheds 1 Foodshops and stalls 927 Infectious disease enquiries 2,342 Food poisoning enquiries 7 Visits to foster mothers' premises 23 Smoke observations 25 No. of complaints investigated 608 Outworkers' premises 58 Houses let in lodgings 51 Ice-cream premises and vehicles 197 Factories, workshops, etc. 133 Tents, vans and sheds 39 Stables 52 Dagenham U.D.C. Act, 1931 376 Rats and Mice (Destruction) Act 184 Hairdressers' and Barbers' premises 58 Shops Act, 1934 440 Rooms fumigated 382 Other visits 49 (b) Notices served. Complied with. Statutory 126 132 Informal 975 1,007 40 On the Administration of the Factory and Workshop Act, 1901. In this district there are 57 factories, 110 workshops, and 116 workplaces, to which visits were paid during the year as follows:- Factories 40, workshops 74, workplaces 19. There were 87 premises in which outwork was carried on. At 73 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 and gas with fair results. In addition, 1 statutory and 28 informal notices were served during the year and 32 were complied with. 41 HOUSING. HOUSING STATISTICS FOR THE YEAR 1936. Number of New Houses erected during the year:- Total 966 (1) By the Local Authority 93 (2) By other Local Authorities 202 (3) By other bodies and persons 671 1. Inspection of dwelling-houses during the year:- (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,011 (b) Number of inspections made for the purpose 4,615 (2) (a) Number of dwelling-houses cluded under sub-head (1) above), which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,559 (b) Number of inspections made for the purpose 2,928 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 6 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 502 42 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 542 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 Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices:- (a) By owners 1 (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 6 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:- (a) By owners 11 (b) By Local Authority in default of owners Nil 43 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 2 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 4. Housing Act, 1935—Overcrowding:- (a) (1) Number of dwellings overcrowded at the end of the year 808 (2) Number of families dwelling therein 812 (3) Number of persons dwelling therein 5,478 (b) Number of new cases of overcrowding during the year 25 (c) (1) Number of cases of overcrowding relieved during the year 233 (2) Number of persons concerned in such cases 1,559 44 As required by the Housing Act, 1935, a complete survey of the district was made and with very few exceptions every house in the district received the attention of this department. The basis of the ascertainment was a postal questionnaire. On receipt of the returned cards if either overcrowding was apparent, there was evidence that the particulars were incorrectly given or that the question of overcrowding was doubtful, the house was visited and in many cases the floor area of each room ascertained by direct measurement. In some cases the floor area was recorded by the Rating Officer and in these instances the information was utilised by us for fixing the " Permitted Numbers." With regard to the abatement of overcrowding, alternative accommodation was offered in many cases by this Council. So far as the London County Council Estate is concerned, however, the overcrowded families were offered and accepted houses on other parts of the Estate which very considerably assisted this Council. I should like to record my appreciation of the courtesy and valuable help received from officers of the London County Council. Houses Let in Lodgings. At the end of the year there were 15 premises registered as houses let in lodgings to which 51 visits were paid. Verminous Premises. 21 Dagenham Council houses and 170 other premises were found to be infested with bugs. 14 Council houses and 127 other premises, making a total of 141, were disinfested. The method adopted during the year of ridding houses of vermin has been the application of a fluid by 45 means of a pressure spray. Before applying this fluid, 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 occasions it has been necessary to pay return visits but taken throughout it may be stated that the method has been efficacious. Where reinfestations have been discovered it has usually been in cases where the tenants are careless and have not made any attempt to keep their homes tidy. All the furniture and effects of prospective Council house tenants are examined by the Sanitary Inspector when application for transfer is being considered. The policy of the Council is usually not to accept tenants whose present houses are verminous. On occasions when it has been necessary that applicants whose furniture is verminous should be allocated a Council house, the contents of their houses have been treated with the above-mentioned spray before removal. All disinfestation is carried out by employees of the Local Authority. 46 INSPECTION AND SUPERVISION OF FOOD. (a) Milk Supply. There are 72 retailers of milk in the district. The following is the number of premises from which various classes of milk were retailed:- Ungraded Milk 12 Grade "A" Milk 4 Grade "A" (T.T.) Milk 7 Certified Milk 2 Pasteurised Milk 15 Carton Milk 21 The number of company distributing centres is eight. The number of shops retailing milk in sealed containers is 40. There are four wholesalers registered in this district for the sale of milk. The number of cowkeepers in the district is three. During the year 1936, the following licences were issued in respect of graded milks:- Grade "A" 5 Grade "A" (T.T.) 11 Certified 3 Pasteurised 18 47 The prevailing tendency is the absorption of small retailing businesses by the larger concerns who deal in Pasteurised milk. Also a number of retailers sell milk which is obviously Pasteurised, the bottle or carton containing the milk in question, however, not bearing any designation to that effect. To illustrate the importance of pasteurising milk, the extensive toll at a popular resort may be mentioned. Five hundred people were affected and 40 deaths occurred as a result. It was found that all the primary cases had had some raw milk supplied by the same dairy, which obtained this milk from several farms. On the advice of the Ministry of Health, steps were taken to ensure pasteurisation of all milk supplied by the dairy and this course immediately arrested the outbreak. The Minister of Health observed when he was considering this outbreak " that there was always great difficulty of ensuring, otherwise than by pasteurisation, a safe milk supply where the milk is derived from many sources and pooled before distribution." Supply of Milk to Schools. Before making arrangements to supply a school, reference is made to the Medical Officer of Health by the County Medical Officer and reports on the supply are submitted. It is the practice in this district to recommend only milk which has been efficiently pasteurised. It will be agreed, I think, that the remarks under the previous heading justify such procedure. Special Designations. Regulations have been issued governing the designation of milk. These took effect from the 1st 48 June, 1936, but dealers were permitted to continue to use the previous designations until the 31st December, 1936. The designations have been reduced to three in number, namely:—"Tuberculin Tested" which has replaced "Certified" and "Grade A" (T.T.); "Accredite" which is of a similar standard to the original Grade "A" ; and " Pasteurised." The method of determining the purity of milk by plate counts has been substituted by a colour test in the case of "Tuberculin Tested" and "Accredited" milks. Milk Sampling. The following table indicates, for comparison, the results of analyses of milk samples submitted during 1936 and 1929 1936. SMALL DEALERS. LARGE SCALE Totals. No. of Bacteria in thousands. Local. Not Local. Satisfactory. Not Satisfactory. Satisfactory. Not Satisfactory. Satisfactory. Not Satisfactory. Under 30 5 - 54 1 18 - 78 30—100 2 - 10 5 1 - 18 100—200 1 - 1 2 - - 4 200—500 - - - 3 - - 3 Over 500 - - - 1 - - 1 8 - 65 12 19 - 104 1929 for comparison 24 2 46 32 28 9 - In the year 1929, there were 43 unsatisfactory and 99 satisfactory samples of milk, the proportion of unsatisfactory samples being one in nearly 31/3. In the year 1936, there were 12 unsatisfactory samples and 92 satisfactory, the proportion of 49 factory samples being one in 8¾. The 12 unsatisfactory samples all relate to non-local retailers, i.e., retailers whose premises are outside this district, four of whom (=eight samples) have now ceased to operate in this district. (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 754 visits was paid during the year. The carcases inspected numbered 3,646. The following details show the extent of unsoundness existing in these animals, all of which were surrendered:- Beasts: No. slaughtered, 937. No. unsound in some respect, 151. Cause. Head Tongue Lung Liver Heart Stomach Spleen Fat Kidney Abscesses - - 2 12 - - - - - Actinomycosis 2 - 1 - - - - - - C. Angioma - - 1 - - - - - - Cirrhosis - - - 1 - - - - - Parasitic diseases - - 1 6 - - - 2 2 Pleurisy - - 5 - - - - - - Tuberculosis 39 39 82 19 3 1 3 15 2 Other Causes - - - 1 - - 1 - - In addition to the above, the following were condemned:- 1 Calf's carcase and offal—Pneumonia. 1 Beast's carcase and offal—Emaciation (T.B.). 1 Beast's carcase and offal—Septic condition. 2 Beasts' carcases and offal—Generalised culosis. 50 1 Beast's carcase and offal—Septicaemia. 1 Beast's carcase and offal—Septic Pericarditis. 1 Forequarter—Tuberculosis. 16 lbs. beef—Tuberculosis. Pigs : No. slaughtered, 1,050. No. unsound in some respect, 92. Cause. Head Tongue Lung Liver Heart Spleen Fat Kidney Blood Aspiration - - 11 - - - - - Cirrhosis - - - 12 - - - - Pericarditis - - - - 6 - - - Parasitic diseases - - - 2 - - - 3 Pleurisy - - 6 - - - - - Pneumonia - - 7 - - - 1 - Tuberculosis 37 37 11 9 - 5 33 - Other causes - - - 1 - - - - In addition to the above, the following were condemned:- 2 Pigs' carcases and offal—Generalised Tuberculosis. 1 Pig's carcase and offal—Emaciation. 40 lbs. Pork—Haemorrhage. 42 lbs. Pork—Injury. Sheep: No. slaughtered, 1,659. No. unsound in some respect, 47. Cause. Lung Liver Abscesses 1 - Parasitic diseases 35 8 Pleurisy 4 - Prosecutions. 1. A District Sanitary Inspector noticed two small pigs' carcases being delivered to a butcher's shop in the district. Examination showed that one carcase was 51 emaciated and poorly set, the kidneys congested and the lungs affected with pleurisy and pneumonia, the carcase being quite unfit for food. The case was referred to the Local Authority in whose district the pig was slaughtered and the owner of the slaughterhouse was prosecuted by them and fined £1 and £l 1s. Od. costs. 2. Two butchers from Battersea carrying on a business in this district were summoned under the: Public Health Act, 1925, for allowing an accumulation of filth to be in a room used for the making of sausages and also for failing to keep the room in a clean sanitary condition. The Manager of the shop was also summoned for having neglected to have the room cleansed. The defendants were convicted and fined £l on each charge and costs. Slaughter of Animals Act, 1933. Ten slaughtermen were licensed during the year in this area. Bakehouses. There are ten bakehouses in the district; to these, 50 visits were paid during the year. Food Shops. 416 visits were paid to butchers' shops, 289 to fish shops, 49 to provision shops, 69 to dairies and milkshops and 18 to greengrocers' shops. The following amounts of foodstuffs were condemned :—31 £ stone of fish, .36 lbs. of whelks, 22 tins of Crabspread," 7 tins of condensed milk. Ice-Cream. During the year, 19 samples were taken, 16 being satisfactory and 3 unsatisfactory. 52 Careful watch is kept on all purveyors and manufacturers of ice-cream. As a result of action under the Essex County Council Act, the standard of purity of ice-cream has definitely been raised. There is a large public demand for this commodity and provided it is a pure product it may be regarded as a valuable article of food. Food Poisoning. Under section 105 (1) of the Dagenham Urban District Council Act, 1931, three notifications of food poisoning were received, details of which are added. None of the cases displayed the clinical symptoms of true food poisoning. 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. The following is a summary of the eases:- No. Date. Sex. Age. Alleged Cause. Symptoms. Recovered Others in . family ill. 1. 18/1/36 M. 45 Meat pudding at cafe. Fever, sickness and diarrhoea. Yes. No. 2. 11/3/36 F. 37 Fried fish or tinned salmon. Diarrhoea and rash. Yes. No. 3. 2/6/36 M. 19 finned salmon Rash only. Yes. No. (This patient gave history of the same trouble from salmon 4 or 5 years previously.) (c) Adulteration, etc. Sale of Food and Drugs. These Acts are administered by the Essex County Council. During the year, 271 samples were analysed. Proceedings in one instance resulted in a fine of £2 and 10s. Od. costs. 53 (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. 54 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 - - 1 - - - - - - - - 1 Diphtheria - 54 149 45 6 6 - 1 - - - 261 Encephalitis Lethargica - — - - - - - - - - - - Enteric Fever - - - 1 - - - - - - - 1 Erysipelas 2 — — 3 — — 5 8 6 4 - 28 Ophthalmia Neonatorum 9 - - - - - - - - - - 9 Pneumonia Acute Primary 9 30 15 8 6 6 8 16 10 4 2 114 Influenzal — 1 — — — 1 1 6 1 1 - 11 Poliomyelitis Acute 1 18 12 2 — — — 1 — — - 34 Puerperal Sepsis — — - — 1 — 2 — — — - 3 Pyrexia — — - — — 2 4 — — - - 6 Scarlet Fever 4 129 227 85 19 5 9 3 1 — — 482 Food Poisoning — — — — 1 1 1 — — — - 3 Pemphigus 7 - - - - - - - - - - 7 Polioencephalitis Acute - - - - - - - - - - - — Smallpox - - - - - - - - - - - - Dysentery - - 2 1 - - 2 - - - - 5 Notified. Admitted to Isolation Hospital, Rush Green. Admitted to other Isolation Hospitals. Admitted to other Hospitals. Deaths Registered. Diphtheria 261 251 7 — 24 Scarlet Fever 482 345 25 — l Puerperal Fever 3 — — 3 3 Puerperal Pyrexia 6 — — 3 1 Pneumonia (Primary) 114 — - 15 54 (Influenzal) 11 1 - Erysipelas 28 5 - 9 l Smallpox - — — — - Food Poisoning 3 — — - - Encephalitis Lethargica — — — — - Poliomyelitis Acute 34 19 15 — 1 Pemphigus 7 — — — - Ophthalmia Neonatorum 9 3 — — - Cerebro-Spinal Fever 1 1 — — 1 Polioencephalitis Acute 1 1 — — 1 Enteric Fever 1 — — — 1 Dysentery 5 - - 1 - 55 Diphtheria. The incidence of this disease has again diminished, the number of notifications received being 261 compared with 293 for the previous year. As in former years the bulk of cases occurred between the ages of one and 15 years. Of the total cases notified. 251 were admitted to the Joint Hospital, seven to other Isolation Hospitals and three remained at home. These latter cases were of a mild type, the parents being willing to pay for the necessary medical attention and were able to provide adequate nursing. Also the homes of the patients received regular visits by the Sanitary Inspector throughout the course of the illness. Home treatment of Diphtheria is not encouraged as it is a disease characterised by surprises, therefore if it presents severe or even moderate symptoms, it should be, and is, removed to hospital. The three cases referred to were kept at home by special request of the parents, and as stated, were of a very mild nature. Death Rate. The second table on the previous page shows that 24 deaths were registered as due to Diphtheria, giving a case mortality rate of 9.19 per cent. Though slightly higher than in the previous year, it is not unduly high. Secondary Cases. There were 23 secondary cases; in one instance four occurred in one family and six in another. One case was notified as suffering from the disease which was also contracted a few months previously. There was only one return case. 56 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 Finnymore Road Infants, the cases were spread fairly consistently throughout the area. An immunization campaign was undertaken at this school during 1937, 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 affected proportionately were those of children under seven years of age. A total of 193 schoolchildren was notified as suffering from Diphtheria. School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13+ Alibon Road I. 1 1 - - - - - - - 2 " B. - - - - - - - - - 3 ,, G. - - - - - - - — — — Arnold Road I. 1 — 2 - - - - - — 3 " B. — — 1 1 1 — — — — 3 " G. - - - - - 1 — — — 1 Beacontree Heath I. 1 - - - - - - - — 1 " M. - - - - - - - — — — Beam Bridge I. - - 2 - — — — — — 2 " M. - - - - - 1 1 — — 2 Chadwell Heath I. - - - - - - - — — — Charlecote Road I. 3 5 5 — — — — — — 13 ,, B. — — — — 1 1 — — — 2 " G. — — — 1 2 — — — — 3 Eastbrook B. - - - - - — — — 1 1 " G. - - - - - - — — 1 1 Fanshawe Crescent I. 2 2 1 — — — — — — 5 " B. - - - - - — — — — - " M. — — — 2 — 3 — — — 5 Finnymore Road I. 8 7 3 — — — — — — 18 " B. — — 3 3 — — 1 — — 7 " G. — — 1 5 — 3 2 — — 11 Five Elms I. 3 1 1 — — — — — - 5 " M. — — — 2 1 — —- - - 3 Ford's Endowed M. — — — 3 — 3 — — - 6 Goresbrook Road B. - - - - - — — 3 — 3 " G. - - - - - - 1 3 3 7 Carried forward 19 16 19 20 5 12 5 6 5 107 57 School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13+ Brought forward 19 16 19 20 5 12 5 6 5 107 Grafton Road I. — 2 2 - - - - - - 4 ,, G. — — — 1 — 1 — — — 2 ,, B. — — 1 1 1 — — — — 3 Green Lane I. — 2 — — — — — — — 2 " M. - - - - - - - - - - Hainault Forest I. — — — — — — — — — — ,, M. - - - - - - - - - - Halbutt Street B. - - - - - - 1 — — 1 ,, G. - - - - - - 2 1 — 3 Heathway Special M. - - - - - - - - 1 1 Hunters Hall I. 3 2 2 - - - - - - 7 ,, B. — — — 2 1 — — — — 3 " G. — — — — 1 — — — — 1 Kingsley Hall M. - - - - - - - - - - Lymington Road B. - - - - - - - - - - " G. — — — — — — — — 1 1 Marley B. - - - - - - 1 — — 1 " G. - - - - - - 1 — — 1 Marsh Green M. — — — — 2 — — — — 2 " I. 2 3 - - - - - - - 5 Park Senior M. — — — — — — — 2 1 3 Rush Green I. — — — — — — — — — — " M. — — — — — — — — — — Spurling Road I. - - 1 - - - - - - 1 " M. — — — — — — — — - — " G. - - - - - - - - 1 1 St. Joseph's R.C. I. 5 2 4 - - - - - - 11 " M. — — — 2 3 — — — — 5 St. Peter's R.C. I. 1 — — — — — — — — 1 " M. - - - - - - - - - - South Wood Lane I. 4 3 5 — — — — — — 12 " B. — — 1 3 — 1 — — — 5 " G. — — 1 1 — — 1 — — 3 Triptons B. — — — — — — — — — — " G. — — — — — — — 1 1 2 Valence Avenue I. — 1 — — — — — — — 1 " B. - — 1 — 1 — — — — 2 " G. - - - - - - - - - — Village I. 1 - - - - - - - - 1 Warren M. — — — — — — — — — — Whalebone M. - - - - - - - - - — " I. — — — — — — — — — — Schools not in District — — — — — — — — — 1 1 35 31 37 30 14 14 11 10 11 193 Schick Testing and Immunization. As in former years this treatment was encouraged for all children between the ages of one year and fourteen. 58 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 59 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 520 No. Schick Tested 727 Of these 273 were Negative. No. of Schick-positives who received 3 doses 500 No. of Re-Schick tests 839 Of these 823 were Negative. No. of Re-Schick-positives who received 3 doses 13 60 No. of Re-Schick-positives who received 1 dose 1 No. of Re-Schick-positives subjected to a further Schick test after 3 more doses 14 Of these 10 were Negative. No. of Re-Schick-positives subjected to a further Schick test after 1 more dose 9 Of these 8 were Negative. No. of Re-Re-Schick-positives who received 3 doses 2 No. of Re-Re-Schick-positives subjected to a further Schick test after 3 more doses 2 Of these 1 was Negative and 1 Positive. No. of Re-Re-Schick-positives subjected to a further Schick test after 1 more dose 1 This was Negative. Immunization by General Practitioners. No. immunized without preliminary testing 16 No. Schick tested 9 Of these, 8 were Positive and 1 was Negative. No. of Re-Schick tests 16 Of these, 12 were Negative and 4 were Positive. No. of Re-Schick positives who received 3 doses 2 Total number of children found to be immune during the year 1,129 The following figures are those of children dealt with from the time immunization was first started in September, 1930, to December 31st, 1936:— No. subjected to Schick Test Positive 2,691 (Primary) Negative 1,483 61 No. subjected to Re-Schick Test Positive 228 (after having undergone one course of injections) Negative 2,382 No. subjected to Re-Schick Test Positive 9 (after having undergone two courses of injections) Negative 110 No. subjected to Re-Schick Test Positive 1 (after having undergone three courses of injections) Negative 3 No. of children immunized without having been Schick-tested (under 6 years) 2,293 Total number of children found to be immune (including immunization by General Practitioners) 3,948 Immunization by General Practitioners. No. subjected to Schick Test Positive 15 (Primary) Negative 7 No. subjected to Re-Schick Test Positive 4 (after having undergone one course of injections) Negative 13 No. of children immunized without having been Schick-tested (under 6 years) 36 The following table shows details of children notified as suffering from Diphtheria together with observations as to the type and the ultimate result. 62 It will be seen that in all cases the children recovered and in only four, namely, cases number 2, 5, 6 and 14, was there evidence to show that the children might have been expected to have been immune:— No. Age. Particulars of treatment. Notified as Diphtheria. Confirmed ? Severity. Result. 1 6 3 doses T.A.M. in 1934. Not re-tested. 3/1/36 Yes. Mild Faucial. Recovered. 2 10 Schick-Positive and 3 doses T.A.M. in 1933. Re-Schick Negative March, 1934. 6/1/36 Yes. Mild. Recovered. 3 9 Schick-Positive and 3 doses T.A.M. in 1933. Re-Schick Negative March, 1934. 17/3/36 Yes. Carrier of virulent K.L.B. Tonsils and adenoids dissected out. Recovered. 4 7 3 doses T.A.M. in 1931. Not re-tested. 13/6/36 Yes. Severe Faucial. Recovered. 5 10 Schick-Positive and 3 doses T.A.M. in 1933. Re-Schick Negative March, 1934. 16/7/36 Yes. Mild Faucial. Recovered. 6 8 Schick-Positive and 3 doses T.A.M. in 1934. Re-Schick Negative February, 1935. 24/8/36 Yes. Mild Faucial. Recovered. 7 2 3 doses T.A.F. April-June, 1936. 25/8/36 Yes. Moderate Faucial. Recovered. Schick-Positive on admission. 8 7 Schick-Negative May, 1936. 28/8/36 No. — Recovered. Schick-Negative on admission. 9 6 3 doses T.A.M. in 1934. Re-Schick Negative November, 1934. 28/9/36 No. — Recovered. 10 4 3 doses T.A.F. June-July, 1936. 30/9/36 No. — Recovered. 11 11 3 doses T.A.M. in 1931. Re-Schick Positive April, 1932. 3 doses T.A.M. in 1932. Not re-tested. 17/10/36 Yes Moderate Faucial. Recovered. 12 9 Schick-Positive and 3 doses T.A.F. January-March, 1936. Not re-tested. 21/10/36 Yes. Moderate Faucial. Recovered. 13 8 3 doses T.A.M. in 1934. Not re-tested. 22/10/36 Yes. Mild Faucial. Recovered. 14 3 3 doses T.A.M. in 1934. Re-Schick Negative February, 1935. 31/10/36 Yes. Moderate Faucial. Recovered. 15 14 Schick-Positive and 1 dose T.A.F. October, 1936. 7/11/36 Yes. Mild Faucial. Recovered. 16 4 3 doses T.A.M. in 1933. Not re-tested. 1 20/11/36 No. Recovered. 17 6 3 doses T.A.M. in 1932. Not re-tested. 8/12/36 Yes. Moderate Faucial. Recovered. 63 The following table shows the proportion of children of various ages who reacted Schick positively:— Age. Total. No. of Positives. Percentage Positive. Under 6 27 18 66.7 " 7 838 649 77.4 " 8 736 522 70.9 " 9 600 388 64.7 „ 10 576 333 57.8 „ 11 466 278 59.7 „ 12 373 207 55.5 „ 13 266 146 54.9 „ 14 160 66 41.3 „ 16 30 15 50.0 Over 15 78 34 43.6 The following table shows the relation of the number of immunes in the household to the Schick-reactions of the children of various ages:— No. of immunes in family. Under 7. 7 and 8. 9 and 10. 11 and over. 7 and over - 33.3 (3) — (2) 40.0 (5) 6 70.6 (17) 56.0 (25) 34.4 (32) 30.3 (33) 5 60.9 (23) 50.0 (38) 26.8 (41) 37.5 (40) 4 51.6 (62) 44.0 (109) 31.8 (110) 29.4 (102) 3 59.8 (122) 49.4 (243) 38.1 (210) 44.3 (192) 2 83.6 (511) 77.4 (762) 73.7 (525) 61.7 (350) (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 children dealt with is comparatively small, it will be seen 64 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 Schick-reactions of the remaining occupants:— Age. Positive. Negative. Total. Percentage Positive. Percentage Positive in general local population. Under 8 77 46 123 62.6 74.3 8 to 12 117 107 224 52.2 59.9 12 and over 32 29 61 52.5 48.9 These three tables refer to all children dealt with in this district from the time immunizing was started. Below is quoted an extract from a recent report on American health statistics:— "The striking reduction in diphtheria mortality it is claimed is ' undoubtedly due to the extensive employment of active immunization.' Among the five largest cities, Detroit had the lowest rate, 0.6 per 100,000, New York coming second with a rate of 0.9. Neither Rochester (N.Y.) nor Portland (Ore.), cities with a population, the former, of 336,527, and the latter of 315.000, it is worthy of note, had a single death from diphtheria in 1935." The figures for England and Wales are:—Mortality 7 per 100,000 ; Incidence 139 per 100,000. Scarlet Fever. There was a slight increase in the incidence of Scarlet Fever, there being 482 cases notified, compared 65 with 441. Of these, 345 were admitted to Rush Green Isolation Hospital, 25 to other Isolation Hospitals and 112 remained at home. The age incidence resembles closely that exhibited by Diphtheria. It will be recalled that terminal disinfection has not been carried out for a number of years; the figures above referred to bear out the wisdom of this policy. Reference is made to disinfection generally in another section of the report. Deaths. Only one death occurred from this cause, which gives the remarkably low figure of .21. Secondary Cases. There were 34 such cases compared with 32 for the previous year. The primary case in one instance was nursed at home, the remainder were admitted to hospital; four were traced to patients discharged from hospital, the onset of these being within seven to twelve days of such discharge. Two were attributable to contact with cases in other areas. Four cases occurred in one family. 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 age chiefly involved was the five year group, the numbers steadily declining until the 12 year olds after which there was a slight rise. 66 The total number of school children affected was, it will be seen, 298 compared with 261 for the Previous year. School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13+ Alibon Road I. 5 2 2 - - - - - - 9 ,, B. - - - 2 - - - - - 2 ,, G. — - — 1 1 — 1 — — 3 Arnold Road I. 5 5 3 - - - - - - 13 ,, B. — — 1 2 — 2 — — — 5 ,, G. — - - — 2 3 — — — 5 Beacontree Heath I. 1 1 - - - - - - - 2 ,, M. - - - - 1 - - - - 1 Beam Bridge I. 4 - 2 - - - - - - 6 ,, M. - - - - - - - - - - Chadwell Heath I. 5 3 - - - - - - - 8 Charlecote Road I. 3 3 2 - - - - - - 8 ,, B. — — — 1 1 — — — — 2 „ G. — — — 2 — 1 — — — 3 Eastbrook B. - - - - - - - 1 — 1 ,, G. - - - - - - - 1 1 2 Fanshawe Crescent I. 2 - - - - - - - - 2 ,, B. - - - - - - - - 1 1 ,, M. - - - - 1 - - - - 1 Finnymore Road I. 8 7 - - - - - - - 15 ,, B. — — — 2 1 1 — — — 4 ,, G. — — — 2 1 1 — — — 4 Five Elms I. — 3 2 - - - - - - 5 ,, M - - - - - 1 - - - 1 Ford's Endowed M. — — 1 1 1 3 — — — 6 Goresbrook Road B. - - - - - - - - - - ,, G. - - - - - - 3 1 1 5 Grafton Road I. 9 1 - - - - - - — 10 ,, G. — — — 4 2 3 — — — 9 ,, B. — — — 1 1 — — — — 2 Green Lane I. 3 — 4 - - - - - — 7 ,, M. — — — 2 1 1 — — — 4 Hainault Forest I. - - - - - - - - - - ,, M. - - — - - - - — — — Halbutt Street B. - - - - - - - - — — ,, G. - - - - - - 1 2 2 5 Heathway Special M. - - - - - 1 — — — 1 Hunters Hall I. 4 3 2 - - - - - — 9 ,, B. — - — 1 — — — — — 1 ,, G. — — — 1 1 — — — — 2 Kingsley Hall M. - - - - - - - - — - Lymington Road B. - - - - - - - - - - ,, G. - - - - - - 2 1 3 6 Marley B. - - - - - - - — — - ,, G. - - - - - - - - — - Marsh Green M. — — — 3 2 — — — — 5 I. 4 3 2 — — — — — — 9 Osborne Hall M. — - — — — 1 — — — 1 Park Senior M. - - - - - - 1 2 2 5 Carried forward 53 31 21 25 16 18 8 8 12 192 67 School. Dept. AGE GROUP. Total. 5 6 7 8 9 10 11 12 13+ Brought forward 53 31 21 25 16 18 8 8 12 192 Rush Green I. 1 2 1 - - - - - - 4 ,, M. - - — — 2 — 2 - — 4 Spurling Road I. 1 2 2 - - - - - - 5 ,, M. - — — 2 — — — — — 2 ,, G. - — — — — 1 — - — 1 St. Joseph's R.C. I. 1 - - - - - - - - 1 ,, M. - — — — — 1 — - — 1 St.Peter's R.C. I. - - - - - - - - - — ,, M. — — - 1 - — — — — 1 South Wood Lane I. 2 2 1 - - - - - - 5 ,, B. — — - 1 1 — — - — 2 ,, G. — — - 2 1 — - - - 3 Triptons B. — — — — - - 1 — — 1 ,, G. — — - — - — — - 2 2 Valence Avenue I. 12 — 4 - - - - - - 16 ,, B. — — — — 1 2 — - — 3 ,, G. — — — 4 6 4 1 - — 15 Village I. 3 3 1 — — — — - — 7 Warren M. - - - - - - 3 - 1 4 Whalebone M. — — — 7 5 1 — - — 13 ,, I. — 1 1 - - - - - - 2 Schools not in District - 2 1 2 — 1 1 2 2 3 14 75 42 33 42 33 28 17 10 18 298 Enteric Fever. One child aged 10 was notified as suffering from Typhoid Fever; this was notified during December and recovered. The death from Typhoid Fever in a female in the age group two to five included in the last table of the report is that of another child who was assigned to this area by the Registrar-General. The notification of this (transferred) death reads "Toxaemia from ? Typhoid infection of intestines and other organs." With regard to the case under consideration, careful investigation did not reveal the source of infection. 68 Erysipelas. 28 cases were notified, the youngest being in two children under the age of one year. Five were admitted to Rush Green Isolation Hospital and nine to other hospitals. There was one death. Cerebro-Spinal Meningitis. There was one case of this disease notified, but no deaths are attributed to this cause. Acute Anterior Poliomyelitis and PolioEncephalitis. During the year, 35 cases of acute poliomyelitis— including two cases of polio-encephalitis—were notified. One sporadic case appeared in April. In June, six cases were reported, these marking the commencement of a small epidemic which lasted until the end of September. The outbreak thus showed the usual seasonal prevalence for the warm months. In only one instance was there a reliable history that infection was spread directly from one patient to another; in other instances it was presumably transmitted by persons apparently healthy. There was no reason to believe that the virus was conveyed by foodstuffs or by insects, or that the disease was associated with insanitary conditions. Although individual natural immunity is high in the first six months of life, there was one patient aged three months. The largest proportion of cases occurred between the ages of one and five years, with the highest incidence in the second year of life. The average age of those affected with acute anterior poliomeylitis was four years and three months. The ages of the two cases of polio-encephalitis were 10 years and 36 years 69 respectively. Males were affected rather more frequently than females, in the proportion of three to two. The case fatality was 5.7 per cent. One patient aged two died from anterior poliomyelitis, and one aged 36, from polio-encephalitis. Recovery occurred in the second patient affected with polio-encephalitis. Of the 35 cases, 33 were admitted to hospital, whilst two mild cases were nursed at home. The Isolation Hospital at Rush Green received 19 cases, Oldchurch Hospital six cases, and two were admitted to King George Hospital, Ilford. The remaining six cases were received by various London hospitals. There were 53 contacts of school age in the affected households, and these were advised to remain away from school for a period of three weeks after isolation of the patient. No restriction was placed on adult members of the households provided they remained well. A circular letter was sent to all the practitioners in the district informing them of the epidemic, and requesting them to be on the look out for mild and abortive cases. Four cases were notified from the Infant Welfare Centres, and an additional six patients, missed cases, have since been reported from the Orthopaedic clinic. All cases are being followed up at the Infant Welfare Centres and School clinics, and are attending either the Council's Orthopaedic Specialist, or the Orthopaedic Out-Patient Departments of hospitals. Encephalitis Lethargica. No case of this condition was notified. 70 Pneumonia. There has been a slight increase in the notifications from this group of diseases, there being 125 notifications received. The number of deaths registered was 54 compared with 63 for the previous year. The case mortality was reduced from 70 per cent. in 1935 to 44 per cent in 1936. It may reasonably be assumed that either the Pneumonias are being more completely notified or that the severity of the disease for the past year was lessened. I would once more invite attention to the fact that only Acute Primary and Acute Influenzal Pneumonia is notifiable; the secondary Pneumonias other than Influenzal are not required by law to be notified. Smallpox. Smallpox did not occur in Dagenham during 1936. 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 545 2. Insusceptible 2 3. Conscientious objectors 813 4. Died before vaccination 49 5. Postponed by medical certificate 42 6. Removed 40 7. Unaccounted for at present 155 There is no striking deviation from the normal in the above enumeration. 71 No vaccinations were performed during the year by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. Tuberculosis. New Cases. Deaths. Primary Notification. Brought to notice other than by Form A. Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 - - - - - - - - - - - - 1- 2 1 2 1 1 - 2 - — — 3 2 5- — — 8 4 2 - 2 — — - 1 1 10- 2 1 2 4 1 1 1 1 — 1 — — 15- 3 12 1 1 1 1 — 2 1 3 — — 20- 1 6 4 — 3 6 — 1 3 6 1 — 25- 14 11 — — 9 5 — 3 6 4 — — 35- 12 10 2 4 3 5 — — 11 9 — — 45- 8 3 1 — 3 1 — — 5 3 — 1 55- 6 - — 2 1 — — — 5 — — — 65 & upwards - - - - - - - - - - - - 48 44 15 16 25 19 5 7 31 26 5 4 Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register 1st Jan., 1936 320 255 132 117 During the year:— New nbtificafions 46 36 15 14 Deaths 33 22 2 1 Transfers into area 25 19 5 7 Transfers out of area 52 40 29 22 No. on register 31st Dec., 1936 806 248 121 115 The total number of new cases of tuberculosis notified during the year was 111; of these, 46 males 72 and 36 females suffered from the pulmonary and 15 males and 14 females from the non-pulmonary type. In addition, there were brought to notice other than by primary notification, 44 pulmonary and 12 nonpulmonary cases ; these were transferred to the district. Also 92 pulmonary cases and 51 non-pulmonary cases were transferred out of the area. The second table shows that at the end of the year there were 790 cases on the register compared with 824 on the 1st January, 1936. Deaths. 55 persons died from pulmonary tuberculosis, of whom 33 were males and 22 females. This compares with 32 males and 10 females for the previous year. Nine deaths from non-pulmonary were registered, there being five male and four female; in 1935 there were 11 deaths registered as being due to this cause. With regard to notification of this disease, when it comes to our knowledge that a patient has died from this cause and no notification has been received, the medical practitioner who last attended is approached, and an explanation of the omission requested. In most cases the reason given is that the doctor was of the opinion that the case had already been notified. In 14 instances, deaths attributed to tuberculosis were registered in cases in respect of which no notification under the regulations had been received; eight of these were pulmonary and six non-pulmonary. This gives a ratio of 25.45 per cent. of un-notified to total deaths due to tuberculosis. Sputum Analysis. 567 samples of sputum were submitted for analysis during the year at the Counties' Public Health Laboratories. 73 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 throughout 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. Its activities however, are unfortunately curtailed by scarcity of funds; this is to be deplored as the assistance afforded to patients is not only of great material value, but it also must contribute to a large extent to the chances of the patients making a recovery. 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. Prevention of Blindness. No special action was taken under section 66 of the Public Health Act, 1925, for the prevention of blindness, °r for the treatment of persons suffering from any disease or injury to the eye. I am very pleased to be able to report that a local association for the welfare of the blind has been formed in Dagenham, and is receiving the active support of 74 Members and Officers of the Council and many of the general public are also giving their assistance. The preliminary figures evince that the number of blind persons in the area is somewhat larger than might be expected in what is in many respects a selected people, Whilst these latter remarks do not strictly fall under the heading of "prevention" of blindness, they are worthy of mention in the hope that further interest in the work of this association will be stimulated. Cancer. Cancer was assigned as the cause of death in 71 persons, the affected sites are tabulated in the table:— MALES. FEMALES. Total UNDER 35 35-44 45-54 55-64 OVER 65 UNDER 35 35-44 45-54 55-64 OVER 65 Oesophagus - - - - - - - - - - - Stomach — 1 4 3 — — 1 2 4 1 16 Large intestine incl. rectum - - 1 1 1 1 - - 1 - 5 Larynx — — — — - - - - - — — Lung — 2 — — — — — 1 1 1 5 Liver 1 1 2 — 1 — — 1 1 2 9 Breast — — — — - - - 1 1 2 4 Ovary — — — — — — 1 - 2 — 3 Uterus — — — — — — - - 1 1 2 Other sites 1 2 4 3 5 2 1 3 1 5 27 2 6 11 7 7 3 3 8 12 12 71 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, 87, 52, 50, 55, 63 and 60. The number of deaths assigned to Cancer by the RegistrarGeneral was 72, 33 of these being males and 39 females. The increase from 60 to 71 is to be expected having regard to the ageing of the population and the Consequent increase in the number of persons attaining the " cancer age." 75 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. I regret to say that in many instances the practice of prompt notification is not carried out. Attention has on various occasions been called to this. It will readily be observed that without the information required by this Act being in our possession at an early date, it is impossible to arrange for newly born babies to be visited as soon as the midwife concerned has finished with her case. 1,801 notifications of live births were received during the year. 241 notifications (including stillbirths) were received from medical practitioners and parents, and 1,191 from midwives. Information was received of 435 births outside this afea. The following list shows where most of these occurred:— East End Maternity Hospital 207, Oldchurch Hospital 90, Charing Cross Hospital 46, PlaistoW Maternity Hospital 24, Queen Mary's Hospital, Stratford 15. 76 Illegitimate births accounted for 1.4 per cent. of the total births. Stillbirths. 35 male and 31 female stillbirths were notified, the corresponding figures for registration being 37 and 27. The rate per 1,000 of total population registered was 0.63, the rate for England and Wales being 0.61. The percentage of illegitimate stillbirths to the total was 6.25 compared with a percentage of illegitimate to total births of 1.4. The stillbirths which occurred in the district, the alleged causes and other associated details are shown in the opposite table. Infant Mortality. 106 infants under one year of age died during the year, giving an infant mortality rate of 56.26 per 1,000 live births, compared with that of 59 for England and \\ ales and 66 for London. The rate amongst legitimate children was 54.36 while for illegitimate children it was 192.3. At first sight this latter figure might give cause for alarm, but the reason for it being so high is the very marked reduction in the number of illegitimate children born; in 1935 the number of illegitimate births was 44, whereas in 1936 it was 26. The actual number of illegitimate children who died under the age of one year in 1936 was five, the figure for the previous year being two. Alleged Cause. Gestation. Presentation. Duration of Labour. . Previous. Ante-Natal Supervision. Further Remarks. Stilbirths. Live Births. Miscarriages. Fall 39 weeks Vertex 24 hours - 8 - None Macerated foetus A.P.H 32 weeks Vertex 10 hours — 12 1 Doctor (private) — ? Toxaemia of Pregnancy Term Vertex 4 hours - 5 — Midwife — Cord round neck Term Vertex 40 hours — — — Doctor (private) — Premature detachment of Placenta Term ? ? — — — Ante-natal clinic — Complicated breech Term Breech 40 hours — 1 — Midwife — ? Term Vertex ? — — — Ante-natal clinic Birth in hospital Prolapse of cord Term Vertex 24 hours — — — Hospital Birth in hospital Malpresentation Term Transverse 79 hours — — — Ante-natal clinic Birth in hospital ? Term Breech 48 hours — — — Ante-natal clinic — Prolonged labour Term Vertex 12 hours — 4 — None — Toxaemia of pregnancy Term ? ? — — — Ante-natal clinic and hospital Hospital case (maternal death) ? Term ? ? — — — Ante-natal clinic — Prolonged labour Term Vertex 24 hours — 2 1 Ante-natal clinic — Partial detachment of placenta Term Vertex ? — 3 — Ante-natal clinic Hospital case A.P.H Term Vertex ? — 1 — Hospital Hospital case ? Term Vertex 10 hours — 2 1 Midwife — A.P.H 30 weeks Vertex 4 hours — 4 4 Ante-natal clinic Hospital case Poor general health Term Breech ? — 9 - Ante-natal clinic and hospital Hospital case A.P.H 38 weeks ? 16 hours — 5 - Midwife Removed to hospital ? Fall Term Vertex ? — 4 - Ante-natal clinic and midwife Macerated foetus ? Term ? ? — 2 - Ante-natal clinic and hospital Macerated foetus ? Term Breech 7 hours — — - Midwife — A.P.H Term Vertex 5 hours — 5 - Midwife — ? ? Post mature Vertex ? — 2 - Midwife Macerated foetus ? Term Footling 6 hours — 3 - Ante-natal clinic — ? Term Posterior position 8 hours 1 2 - Ante-natal clinic and midwife — Poor general health 8 months Vertex 26 hours — 3 — Midwife — ? Term Vertex — — — - Doctor (private) Removed to hospital ? 8 months Breech 2 hours — 1 1 Midwife — Malpresentation Term Hand presentation — — 1 - Doctor (private) - Complicated breech 8 months Breech 7 hours 3 4 - Doctor (private) — Partial placenta praevia 38 weeks Vertex 12 hours — 6 - Midwife Removed to hospital Pyelitis Term Breech 5-6 hours — — - Doctor (private) — ? Term Vertex 24 hours — — - Midwife — ? Term Face 20 hours — — - Ante-natal clinic, Doctor (private) and Hospital. Macerated foetus Malpresentation Term ? ? — — - None Removed to hospital ? Term Vertex 4 hours — 3 - Midwife — A.P.H. Term Vertex 20 hours — 2 - Doctor (private) — - ? Post mature — 6 hours — 7 - None B.B.A. Fall Term Vertex 6 hours — 2 — None Macerated foetus ? Anaemia 8 months Vertex 3 hours 1 3 - Ante-natal clinic — Cord round neck Term Vertex — 1 7 - Ante-natal clinic and midwife Macerated foetus Fall Term Vertex 12 hours — — - Doctor (private) — ? Influenza 36 weeks Vertex 12 hours 1 3 1 Ante-natal clinic — ? Term Vertex 4 hours — 5 1 Midwife Macerated foetus Albuminaria during pregnancy (Eclampsia) Term Vertex ? — — - Ante-natal clinic and midwife — ? Term Footling 16 hours 1 2 — Ante-natal clinic early in pregnancy ... — Poor general health Term ? Vertex 6 hours 1 3 - Doctor (private) Macerated foetus Placenta praevia 7 months ? Footling Labour induced — — - Ante-natal clinic Removed to hospital 77 In order to give a clear picture of the causes of infant deaths and the ages at which they occurred, the following table has been prepared:— Cause of death Under 1 week. 1—2 weeks. 2—3 weeks. 3—4 weeks. Total under Four weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. Bronchial Pneumonia - 2 - 2 4 4 6 4 6 24 Hydrocephalus - — - 1 1 — — — — 1 Septic Umbilicus 1 — 1 - 2 — — — — 2 Prematurity 26 — 1 1 28 — — — — 28 Gastro Enteritis — — 2 1 3 2 4 4 2 15 Congenital Heart Disease 3 1 - 2 6 2 1 - - 9 Asphyxia Neonatorum 2 — — — 2 — — — — 2 Marasmus - - - — - 2 2 - - 4 Spina Bifida 2 - 1 - 3 - - - - 3 Measles — — - — - - 3 - - 3 Fracture of Skull - - - - - - - 1 - 1 Meningitis - - - - - - 1 2 2 5 Haemorrhagic disease of the new born 1 - - - 1 - - - - 1 Congenital Obliteration of Bile Ducts - - - - - 1 - - - 1 Cerebral Haemorrhage 1 - - - 1 - - - - 1 Bronchial Pneumonia following operation for Intussusception - - - - - - 1 - 1 2 Atelectasis 1 - - - 1 - - - - 1 Prematurity with Multiple Deformities - 1 - - 1 - - - - 1 Toxaemia, Secondary to Haemorrhage at Birth - - 1 - 1 - - - - 1 Gastro Enteritis (b) Congenital irregular Colon — — 1 — 1 — — — — 1 Totals 37 4 7 7 55 11 18 11 11 106 Deaths of Older Children. 81 children died between the ages of one and five years; of these, 42 were males and 39 females. The largest individual cause of death was Measles which was assigned as the reason for 24 deaths in children under 78 the age of five, Whooping Cough one, Scarlet Fever four, and Pneurnonia seven between the ages of one and two and six between the ages of two and five. There has been an increase in the number of deaths of older children, this being largely accounted for by the epidemic of Measles which occurred during the year. It is well known that Measles has a regular cycle which in this country almost invariably occurs at two year intervals. It was mentioned in my report for last year, on page 12, that increased mortality from this disease was expected in 1936. Ophthalmia Neonatorum. Notified. Treated at home. Treated in hospital. Vision Unimpaired. Vision impaired. Total blindness. Deaths. 9 0 3 9 — - - By a coincidence the figures in the above table are identical with those relating to the previous year. There were 49 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 nine were notified 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 ; it will be known that this area being now the Local Supervising Authority, the notifications are sent direct to the Medical Officer of Health. Pemphigus. During the year there were seven notifications of children suffering from Pemphigus, all of whom were treated at home and recovered. 79 Maternal Mortality, Four deaths were registered as being due to pregnancy or associated with that condition, which is equivalent to a maternal mortality rate of 2.05 per thousand total births, compared with 3.65 for England and Wales. The actual causes of death as stated on the certificates were:— Case 1. a. Broncho-pneumonia. b. Caesarean section. c. Obstructed labour. Case 2. Septicaemia following septic traumatic abortion. Self induced. (Inquest.) Case 3. Septicaemia following a septic abortion. (Inquest.) Case 4. a. Pulmonary Embolism. b. Childbirth one month previous. c. Perineal tear, mild sepsis. A full investigation was made in each case; it was not possible to gain any information with regard to case 2, It will be seen that with the exception of case 4, these maternal deaths might be considered as preventable; the remark particularly applies to case 2. The only case which received ante-natal examination was case 4. 1 he maternal deaths for 1936 once more underline the importance of ante-natal supervision. 80 Puerperal Fever and Pyrexia. Nine notifications were received during the year; of these, six were those of puerperal pyrexia and three puerperal fever. Per 1,000 total births (i.e., live and stillbirths) the rates for these conditions were 3.08 and 1.54, the corresponding figures for the country as a whole being 9.64 and 3.27, a truly remarkable contrast. Every case of this condition is investigated by a Health Visitor and in addition many of them are visited by the Medical Officer of Health. Work of Health Visitors. The new scheme introduced for planning and recording visits by Health Visitors has been in operation sufficiently long to show that it has enhanced the efficiency of this branch of the service. 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 cases of ophthalmia neonatorum, puerperal fever and pyrexia, stillbirths, infant deaths, etc., and subsequent to operative treatment of tonsils and adenoids. The Health Visitors also attend the various clinics. In the case of infant welfare centres and ante-natal clinics, the Health Visitor is, as far as possible, in charge of the session at which the mothers from her district attend, thus preserving the personal association of the Health Visitor with the mother and children who live in her area. 81 The following table shows the number of visits paid by Health Visitors during the year:— (a) To expectant mothers First visits 537 Total visits 1,209 (b) To children under 1 year of age First visits 2,356 Total visits 5,276 (c) To children between the ages of one and five years Total visits 8,787 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 two at Rush Green. During the year it was found that the attendances at Rush Green 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 on Friday mornings except the first Friday in the month. No doctor is in attendance at this session, but as most of the mothers attending this clinic reside quite near the centre, if the Health Visitors should notice that a child should be seen by the Doctor, the mother is requested to attend for that purpose in the afternoon. 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. We are very pleased once more to record our appreciation of the services of the ladies who 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. 82 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 20,427 (2) By children between the ages of 1 and 5 14,399 Average attendances of children per session at all centres during the year 66 Total number of children who attended at the centres for the first time during the year:— (1) Children under 1 year of age 1,412 (2) Children between the ages of 1 and 5 572 Percentage of total notified births represented by the number of children under 1 year who attended for the first time 78.4% Treatment. Adenoids and Enlarged Tonsils. The same arrangements continue in operation for the treatment of these conditions, namely, agreements with the following hospitals:— King George Hospital, Ilford; Queen Mary's Hospital, Stratford; St. Mary's Hospital, Plaistow; and Oldchurch Hospital. Most cases, however, are treated at King George Hospital, the majority being detained overnight. During the year a total of three cases was treated at a cost of £3 0s. 0d. It will be noticed that the tendency to delay operating for these conditions is maintained and that unless pathological conditions definitely attributable to diseased tonsils and adenoids are manifest, surgical interference is not advocated. 83 Orthopaedic Treatment. (a) Ascertainment Clinic.— The Consultant Orthopaedic Surgeon paid six visits to the district during the year, when 89 children made 137 attendances. Most children attended once only, 27 attended twice, four three times, three four times and one five times. The commonest conditions for which children were referred were genu valgum, pes planus, bowed tibiae, talipes and poliomyelitis. The cost allocated to this Council was £19 9s. 11d. (b) Massage Clinic.— The massage and remedial exercises clinic was held twice weekly at the Ford Road and Becontree Clinics. During the year, 199 children under school age received treatment at a cost of £66 18s. 6d. making a total of 670 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 for these according to the financial circumstances of the family. Four appliances were supplied at a total cost of £7 15s. 9d. (d) Hospital Treatment.— Four children were sent to hospital for operative treatment at a total cost of £77 7s. 0d. 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 cases treated are referred from the Infant Welfare Centres and all children are seen by the Medical Officer every fortnight. A few children of 84 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. 269 children commenced treatment of whom 144 completed one course, 17 completed two courses, four completed three courses and one four courses. Dental Treatment. 22 extraction sessions were held, at which 169 children were treated and 158 mothers, making a total of 427 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 £16 0s. Od. and the nett cost of this service was £39 0s. 0d. Dentures are provided, usually only to those persons referred from the ante-natal clinic. The amount recovered as patients' contributions was £26 0s. 0d., leaving a sum of £103 0s. 0d. as the cost to the Council. Convalescent Home. 15 mothers and children were admitted to convalescent homes at a cost of £99 7s. l0d. 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 Secretaries of these organisations have rendered valuable assistance on many occasions. The same number of mothers and children were dealt with as in the previous year, but owing to the duration of the average stay at convalescent homes being longer, the cost has increased. 85 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. 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. It was not until late in the year that the constitution of this fund was finally approved, and for the year under review one pair of boots only was supplied. Other Provisions. One child was supplied with an artificial eye by this Council at a cost of 7s. 6d. Consultant Obstetrician. The Consultant Obstetrician has been called into consultation on 17 occasions. This service is very much valued and there is no doubt that the efficiency of the maternity and child welfare organisation has been much enhanced by this addition. Originally patients were requested to refund to the Council a portion or the whole of the assessed cost of each consultation, but having in mind that patients in certain instances might hesitate to call in the services of the Consultant for fear of incurring a debt, the Council decided that these emergency consultations should be free to all except those who would, in the ordinary course of events, call in a Consultant in a private capacity. 86 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 185 women who made 241 attendances. 120 cases were referred to hospital for confinement under the Council's scheme, of whom 98 were admitted to the East End Maternity Hospital, 18 to Charing Cross Hospital under the care of the Consultant Gynaecologist, and four to Oldchurch Hospital. The cost to the Council for these patients, after the receipt of the patients' fees, amounted to £784 0s. 0d. 45 women who attended were found to be not pregnant and there were 124 post-natal cases. Details of the attendances at Ante-Natal Clinics are set out in the following tables:— Of the 903 women who attended the Ante-Natal Clinics the following are included:— Came of their own Accord. Referred by Midwife. Referred by Health Visitor. Referred by Neighbour Referred by Medical Practitioner. Referred by Oldchurch Hospital. Referred by Relieving Officer. 848 159 152 106 27 16 7 Summary of attendances at Ante-Natal Clinics (these figures exclude the attendances at the Ante-Natal 87 Clinic of the Hospitals to which the patients were referred):— One Visit. Four Visits. Five Visits. Six visits or more. 147 95 70 217 The majority of patients who attended for the first time were between the third and fourth month of pregnancy. 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. In fact this point has been specially stressed in circular 1622, issued by the Minister in May of the present year. Hospital Cases. Of the 312 cases referred to hospital, 151 were admitted on other than medical grounds. 120 were assisted under the Maternity and Child Welfare Scheme. Abnormal cases are referred to their own medical attendants; or where the patient desires, and her condition demands, arrangements are made for her confinement to take place in an institution. When patients are referred for admission to Oldchurch Hospital they continue to attend the Consultant at our Ante-Natal Clinic, unless some special investigation such as an X-ray examination is required, when they attend at Oldchurch Hospital for that purpose. Furthermore, the Consultant sees on behalf of any local medical practitioner, any patients referred to him by them. 88 Post Natal. Post Natal examinations have markedly increased. Mothers have been advised by the Health Visitors to attend for examination approximately six weeks after their confinement. 124 mothers took advantage of this service and there are indications that as these facilities become more widely known, they will be accepted to a greater extent. I mentioned in my report for last year how many women become chronic invalids owing to the fact that repairs to damage received during parturition had not been effected. Gynaecological Clinic. As has been mentioned earlier, a separate gynaecological clinic has been established which takes place on the first Saturday morning of each month. Dr. Henderson has prepared some statistics on cases attending the gynaecological clinic which was formerly held in conjunction with the ante-natal clinic on Tuesday mornings at Five Elms. The figures include all those patients who attended from July, 1934 to May, 1937:— Age Incidence. 20—25 11 25—30 27 30—35 24 35—40 30 40—45 19 45—50 19 50 5 135 89 Patients attended clinic because of the following complaints:— 1. Vaginal Discharge 38 2. Disorder of menstruation 34 3. Backache 20 4. Pain in Iliac Fossa 14 5. Sterility 13 6. Prolapse 9 7. Pruritis Vulvae 9 also 1. Dysparennia 2. Swelling (L side of abdomen=Floating Kidney) 3. Dragging Pain (L side of abdomen=Cancer of Colon) 4. Laceration of Vulva and Vaginal Wall (caused by fall) 5. Swelling on Labia (Cyst) 6. Pain in breast (had had breast amputated) 7. Swelling over Sacrum (naevo Lipoma) 8. Debility 9. Hernia 10. Dysuria Clinical Findings. Cervicitis and Cervical Erosion 40 Retroversion 15 Normal 14 Menopause (no complications) 10 Endometritis 8 Pruritis Vulvae 8 Prolapse 7 Cervical polypus 6 Fibroid 4 Salpingitis 3 Infantile Type of Uterus 3 90 also Abdominal Tumour (Cancer of descending colon, diagnosed on operation) Floating Kidney (operation in Oldchurch Hospital) Perforated Ulcer of lower Vaginal Wall (due to fall) Leucoplakia 1 Prolapsed Ovary 1 Hypo-Thyroidism 1 Hernia 1 Lipoma 1 Labial cyst 1 Appendicitis 1 Pain after amputation of breast 1 Cystitis 3 Not Examined (referred back to Hospital previously attended by patient) 3 Treatment Advised. Royal Free Hospital 47 Charing Cross Hospital 6 London Hospital 3 Queen Mary's Hospital, Stratford 3 King George's O.P. Dept. 2 Elizabeth Garrett Anderson Hospital 1 University College Hospital 1 St. Mary's, Paddington 1 64 1. Advised at Clinic (home douching, pessaries, exercises, tonic, etc.)28 2. Private Doctors 21 3. District Nurses 12 4. The Consulting Gynaecologist 9 91 Hospital reports received on 44 cases. No. of visits 255 Average number of visits per patient 2 The provision of in-patient hospital treatment for post-natal cases is recommended; this extension of the Maternity and Child Welfare Service is now under consideration by the Committee. Foster Children. The following tables show the number of foster children and foster mothers in the district:— Foster Children— No. on register, December 31st, 1935 43 No. added to register 35 No. deducted owing to refusal, removal, deaths, or reaching age of nine 44 No. on register, 31st December, 1936 34 Foster Mothers— No. on register, 31st December, 1935 35 No. of additions during year 14 No. taken off during year 17 No. on register, 31st December, 1936 32 Those who intend to receive foster children, 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. 92 According to the existing law, when notification is received that a woman intends to accept a foster child, the Local Authority has no power to refuse except under certain specified conditions. If however, it is subsequently considered that the environment of the foster mother may be prejudicial to the child, the procedure is to obtain an order from the Court of Petty Sessions to prohibit the foster mother from continuing to act as such. It is also competent for, the Authority to fix the maximum number of children which may 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 Maternity Homes in the district, but one Nursing Home which is licensed to receive eight medical or chronic cases has been established in Whalebone Lane. The Minister of Health, has, by circular 1433, issued in October, 1934 and by circular 1622 dated May, 1937, 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 925 0 0 (b) For dried milk 294 0 0 93 Education. During the year the Medical Officer of Health and his Deputy addressed meetings of local organisations on health matters. It is found that these addresses are always well received and that there is a genuine desire on the part of the majority of people to gain a knowledge of health matters. At a recent meeting of the Health Committee it was decided to distribute copies of the publication entitled " Better Health." The practice of sending out birthday cards accompanied by appropriate pamphlets to reach infants on the first anniversary of their birth has been continued. There is no evidence to show that the restriction of sending cards only on the first birthday has in any way curtailed the efficiency of this method of propaganda. When the contemplated assembly hall in the district has been erected, it should be possible to hold a Health Week and Exhibition commensurate with the size of the population, should the Council so desire. Birth Control Clinic. A Birth Control Clinic under the auspices of a voluntary committee is held once a fortnight. The Local Authority makes a per capita grant to this body for persons who attend in whom pregnancy would be detrimental on medical grounds. During the year payments amounting to £6 15s. 0d. were made for this purpose. CAUSES OF DEATH Under 1 year Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 and under 75 75 and over TOTAL RegistrarGeneral's Allocations. M F M F M F M F M F M F M F M F M F M F M F M F M F 1. Typhoid and paratyphoid fevers - - - - - 1 - - - - - - - - - - - - - - - - - 1 — 1 2. Measles 4 2 7 5 5 1 — 1 — — — — — — — — — — - — — — 16 9 16 9 3. Scarlet Fever — - — — 1 - — — — — — — — — — — — — - — — — 1 — 1 — 4. Whooping Cough — — 1 - 1 2 — — — — — — — — — — — — 4 — — — 2 2 3 2 5. Diphtheria — — — — 4 1 11 6 — 2 — — — — — — — — — — — — 15 9 15 9 6. Influenza — — — — — — — — — — — — 1 — — — — 1 2 2 — — 3 3 4 5 7. Encephalitis lethargica - - - - - - - - - - - - - - - - - - - - - - - - - - 8. Cerebro -spinal fever — 1 — — — — — — — — — — — — — — — — - — — — — 1 — 1 9. Tuberculosis of respiratory system - - - - - - - 1 4 9 6 4 11 9 5 3 5 - - - - - 31 26 31 26 10. Other tuberculous diseases — — 1 2 2 - - 1 2 - - - - - - 1 - - - - - - 5 4 6 5 11. Syphilis — — — — — — — — — — — — — — — — — — — — — — — — — — 12. General paralysis of the insane, tabes dorsalis - - - - - - - - - - - - - - 1 - - - - - - - 1 — 1 — 13. Cancer, malignant disease — — — — — — — 1 1 — 1 2 6 3 10 8 7 12 8 7 — 5 33 38 33 39 14. Diabetes — — — — — — — — — — — — — — — — 1 - 2 — 1 1 4 1 3 3 15. Cerebral haemorrhage, etc. 1 — — — — — — 1 — — 1 — 1 3 4 3 2 8 2 3 5 2 16 20 9 13 16. Heart Disease — 1 — — — 1 2 1 2 — — 2 2 2 6 — 9 6 7 13 4 7 32 33 59 60 17. Aneurysm — — — — — — — — — — — — — — — — — — 2 — — — 2 — 3 1 18. Other circulatory diseases — — 1 — 1 — 1 — — — — — 1 — — 2 1 — 2 1 — 1 7 4 8 6 19. Bronchitis 3 1 1 — — — — — — — — — 2 1 2 — 5 — — 4 8 5 21 11 10 2 20. Pneumonia (all forms) 12 15 3 4 6 — 3 — 2 1 3 2 4 4 7 2 3 — 1 10 4 3 48 41 30 24 21. Other respiratory diseases - - - - - - - - - - 1 1 1 — 1 - - - - - 1 — 4 1 3 1 22. Peptic Ulcer - - - - - - - - - - - - 1 — 3 — — 1 - — — 1 4 2 4 — 23. Diarrhoea, etc. (under2 years) 9 3 - 1 - - - - - - - - - - - - - - - - - - 9 4 10 5 24. Appendicitis - - - - - 2 2 - - - - - - 1 - - - - - 1 — - 2 4 2 2 25. Cirrhosis of liver - - - - - - - - - - - - - - 1 - - - - - - 1 1 1 - 2 26. Other diseases of liver, etc. - - - - - - - - - - - - - - - - - - - - - - - - - 1 27. Other digestive diseases - - - - - - - - - - - - - 1 — — — — — — — — — 1 7 8 28- Acute and chronic nephritis — — — — — - — - — - — - 2 3 1 — 1 1 4 4 1 1 9 9 6 7 29, Puerperal sepsis — — — — — — — — — 1 — 2 — — — — — — — — — — — 3 — 3 30. Other puerperal diseases - - - - - - - - - - - - - 1 - - - - - - - - - 1 - 1 31. Congenital debility, premature birth, malformations, etc. 23 27 1 - - - - - - - - - - - - - - - - - - - 24 27 26 27 32. Senility - - - - - - - - - - - - - - - - 1 - - - 10 13 11 13 9 3 33. Suicide - - - - - - - - 1 1 1 - 1 - 1 - 2 - - - 1 1 7 2 5 2 34. Other violence - - - - 1 1 2 2 5 - - - 2 - - 2 2 - 1 - 2 1 15 6 18 7 35. Other defined diseases 7 - - 3 1 3 4 1 - 5 - 3 5 6 1 5 2 2 3 3 — 2 23 33 22 36 36. Causes ill-defined or unknown - - - - - - - - - - - - - - - - - - - - - - - - 1 — 59 50 15 15 22 12 25 15 17 19 13 16 40 34 43 26 41 31 34 48 37 41 346 310 345 311 INDEX. A Page Acute Anterior Poliomyelitis 08-09 Acute Polio Encephalitis 68-09 Adenoids 82 Ambulance Facilities 19-20 Ante-Natal Clinics 22, 86-87 Artificial Sunlight 23, 83-84 B Bacteriological Examination 53 Bakehouses 51 Baths 38 Birth-rate 11, 14 Births 11,12-13,75 Birth Control 93 Births, Illegitimate 11,76 Births, Still 11,76 Blindness—Prevention of 73-74 Boot Fund 85 Byelavvs—Premises and Occupations controlled by 30-38 C Camping Grounds 37 Cancer 74 Cerebro-Spinal Fever 68 Cesspools 32 Children's Invalid Aid Association 84 Clinics and Treatment Centres 21-22 Closet Accommodation 31 Committees 7 Contents—Principal 3 Convalescent Home 84 Council—Members of 7 D Deaths 11, 13-14, 76-77, 79, 94 Death-rate, General 13-14 Death-rate, Infantile 11,14 Deaths, Causes of 94 Deaths, Infants 11,14,76-77 Dental Treatment 84 Diarrhoea (Deaths from—under two years of age) 11 Diphtheria 55-64 Disinfection 33-36 District Nursing Association 20, 24, 25, 26 Drainage and Sewerage 30 Dried Milk 92 Dust Collection 31—32 INDEX.—Continued. E Page Education in Health 58,93 Encephalitis Lethargica 69 Enteric Fever 67 Erysipelas 68 Extracts from Vital Statistics 11 F Factories and Workshops 40 Food and Drugs 52 Food Inspection 46-53 Food Poisoning 52 Food Shops 51 Foster Children and Mothers 91-92 Free Supplies of Milk 92 Fried Fish Shops 36 G General Provision—Health Services 15 Gynaecological Cases 88-91 H Hairdressers' and Barbers' Premises 37-38 Health Committee 7 Health Services—General Provision of 15 Health Visitors 80-81 Hospitals—Children Hospitals—General and Special 17-18 Hospitals—Infectious Diseases 15 Hospitals—Maternity 18 Hospitals—Orthopaedic 18 Hospital—Smallpox 15-16 Houses Let in Lodgings 44 Housing Statistics 41-43 I Ice-Cream 51 -52 Illegitimate Births Immunization Clinics Infant Deaths 11,14, 76, 77 Infant Welfare Centres 21,81-82 Infantile Mortality 11,14,76-77 Infectious Diseases Hospital 15 Infectious Diseases 54-73 Institutional Provision for Unmarried Mothers, Illegitimate Infants, etc. 19 Invalid Children's Aid Association 84 INDEX.—Continued. L Page Laboratory Facilities 26-27 Legal Proceedings 50-52 Legislation in Force 27-29 Library Books 30 Light Treatment 23, 83-84 M Massage Clinic 23 Maternal Mortality 79 Maternity and Child Welfare 75-93 Maternity and Child Welfare Committee 7 Maternity Homes and Hospitals 18,92 Measles 11, 77—78 Meat Inspection 49-51 Meningitis, Cerebro-Spinal 68 Midwives 20 Milk—Free Supplies 92 Milk in Schools 47 Milk (Special Designation Order) 47-48 Milk Supply 46-49 Mortality, Analysis of 94 Mortality, Infantile 11, 14; 76-77 Mortality, Maternal 79 Mortality, Neo-Natal 11,14,76-77 N Neo-Natal Mortality 11, 14, 76-77 Notices Served and Complied with 38, 39, 41-43 Notifications of Births 75 Nursing Arrangements 24-25 O Obstetrician-Consultant 85 Offensive Trades 30 Ophthalmia Neonatorum 78 Orthopaedic 18,28,83 Overcrowding 43-44 P Pail Closets 32 PemphiguS 73 78 ersonal Service Council 84 ysical Features of Area 30-31 Pneumonia 70,78 Population 10,12 INDEX.—Continued. P Page Post-Natal Examination ... ... ... ... ... 88 Preface ... ... ... ... ... ... 5-6 Premises and Occupations Controlled by Byelaws ... 36-38 Prevention of Blindness ... ... ... ... ... 73-74 Principal Contents ... ... ... ... ... ... 3 Prosecutions—Unsound Food ... ... ... ... 50-51 Prosecutions, Sale of Food and Drugs Act ... ... 52 Public Health Committee ... Puerperal Fever and Pyrexia ... ... ... ... 73,80 R Rag and Bone Dealers ... ... ... ... ... 36 Rateable Value Rats and Mice (Destruction) Refuse Removal and Disposal ... ... ... ... 31-32 Rivers and Streams ... ... ... ... ... ... 30-31 Refraction Clinic ... ... ... ... ... ••• 22 S Sanatoria Sanitary Circumstances of the Area Sanitary Inspection of Area ... ... ... • • • Scarlet Fever ... ... ... ... ... 7,78 Scavenging 31-32 Schick Immunization Clinics ... ... ... ••• School Clinics ... ... ... ... ••• „ Schools 38-39 Sewerage ... ... ... ... ... Shops Act, 1934 ... ... ... ... ... ••• . Slaughterhouses ... ... ... ... ... Slaughter of Animals Act, 1933 ... ... ... Smallpox 15-16.70-71 Smoke Abatement ... Social Conditions of Area ... ... ... Staff Statistics ... ... ... ... ... ... • • • Stillbirths 1° Streams ... ... ... ... ... ••• ••• 38 Swimming Baths T 14 Table, Birth-rate, etc. ... ... ... ^ „ Cancer ... ... ... ... „ Death-rate, etc. ... ... ... ••• „ Deaths, Causes of ... ... ... ••• ea-64 „ Diphtheria Immunization ... I INDEX.—Continued. T Page Table, Gynaecological Cases 88-91 „ Housing 41-43 „ Infant Mortality 77 „ Infectious Diseases, Notifiable 54 „ Infectious Diseases, Removed to Hospital 54 „ Infectious Diseases in School Children 56-57, 66-67 „ Inspections for Year 39 „ Meat Inspection 49-50 „ Milk Samples 48 „ Ophthalmia Neonatorum 78 „ Record of Inspections 39 „ Stillbirths 76 „ Tuberculosis Deaths 71 „ Tuberculosis Notifications 71 „ Vaccination 70 Tents, Vans and Sheds 37 Tonsils and Adenoids 82 Treatment 21-22, 82-84 Tuberculosis 16-17,23,71-73 Tuberculosis After Care Committee 73 Typhoid Fever 67 U Ultra Violet Ray Therapy 23,83-84 Unmarried Mothers 19 V Vaccination 70 Vermin 44-45 Venereal Diseases 23 Vital Statistics, Extracts from 11 Visits, Health Visitors' 81 Visits, Sanitary Inspectors' 39 W Water Supply 30 Whooping Cough 11,78 Workshops 40 Z Zymotic Diseases 54-73