BOROUGH OF DAGENHAM INTERIM ANNUAL REPORT of the Medical Officer of Health for the year 1942 CECIL HERINGTON, M.D., (Lond.), D.P.H. 67959 BOROUGH OF DAGENHAM INTERIM ANNUAL REPORT of the Medical Officer of Health for the year 1942 CECIL HERINGTON, M.D., (Lond.), D.P.H. 3 To the Mayor, Aldermen and Councillors of the Borough of Dagenham. Your Worship, Ladies and Gentlemen, In presenting my report of the year 1942, I propose departing somewhat from previous practice inasmuch as the commentary will be found chiefly in this part of the report, and statistical matter will follow in the later pages. The report is compiled in accordance with Circular 2773 issued by the Ministry of Health, wherein Medical Officers of Health are requested to regard it as an interim one as have been those of previous war years, but all statistical matter is preserved for use in a subsequent report which may be required after the end of the war. Certain figures regarding population and other matters which might be considered as prejudicial to the national safety, are excluded. Many subjects which have been dealt with in previous reports are intentionally omitted, as if information is required on these subjects, it is readily available. The vital statistics once more compare very favourably with those of previous years. The birth rate has risen slightly, the maternal death rate is well below that of the country as a whole, as are the infantile mortality and general death rates. Details of all these figures are given statistically in subsequent pages. It is usually assumed that an annual report for a specified year should refer to facts and figures appertaining to that year. As far as the statistical matter is concerned, this principle has been adhered to, but in this 4 section of the report I have made comment on several items which are referable to the current year, as I feel that if delayed until the time strictly appropriate to them, they will lose much of their value. PERSONAL HYGIENE. I would draw attention to the danger, particularly under present conditions, when many people take their meals, at canteens and restaurants, of the spread of infection by food. Several outbreaks of Dysentery, ParaTyphoid and allied diseases have occurred in various parts of the country, which have been attributable to infection from those who prepare the meals. It is an unpleasant subject to dwell upon, but nevertheless it calls for urgent attention that persons handling foodstuffs should, in all cases, wash their hands carefully after going to the toilet. It is clearly demonstrable that by neglecting to do this, the specific organisms concerned are transferred by the hands to the food. It has recently been said by a wellknown physician that the provision of a wash-hand basin in a W.C. is as important as that of a toilet roll. During the year, instructions have been given to persons in communal kitchens to observe this rule of personal hygiene, and it is hoped that when they realise the danger occasioned to their patrons, they will carry out the recommendation made. Suspicion was aroused at a food preparing establishment that Para-Typhoid was being spread from one of the workers. The Medical Officer of Health, after having made an inspection of the premises, accompanied by the Senior Sanitary Inspector, interviewed many persons who might conceivably have been the cause, and after consultation with the manager, notices were displayed in all 5 conveniences that any person discovered leaving this part of the premises without washing his or her hands, did so at the risk of instant dismissal. FOOD POISONING. We still receive a small number of notifiations of Food Poisoning, but on nearly every occasion subsequent investigation reveals that they are not within this category, but are cases of simple diarrhoea or vomiting. True Food Poisoning is an acute condition and is nearly always accompanied by diarrhoea, vomiting and a rise of temperature; there may be, in addition, skin eruptions resembling nettle rash. Notification of Food Poisoning is of value inasmuch as it calls for strict enquiry with regard to origin and treatment of the food suspected. SCABIES. Information available to the Public Health Department shows that there is a tendency for this condition to diminish. No doubt the publicity given to the subject has had good effect. Films have been prepared and shown which clearly demonstrate the ease with which Scabies can be cured if the sufferers will take advice of persons competent to give it. Much research work has been done on this disease, and it is found that, with modern medicaments, it is quite unnecessary to disinfect clothing and bedding, provided that all members of the family undergo treatment at the same time. This matter was reported to the Health Services Committee, and after receiving the sanction of the scheme-making authority for Air Raid Precautions, it was decided to adapt the Cleansing Section of one of the First Aid Posts for this purpose. Patients will be accepted on the recommendation of their own Doctor or a Clinic Doctor, and every endeavour will be made to secure the presence of all members of the household for treatment at the same time. 6 Members of the Civil Defence personnel have volunteered to carry out the treatment under the supervision of trained members of the staff. Powers are given under an order of the Ministry of Health to compel persons who are unwilling to accept treatment to undergo such treatment if required to do so by the Medical Officer of Health. It is hoped, however, that it will not be necessary to have recourse to compulsory powers, as it is far preferable to attain the eradication of this unpleasant condition by persuasion rather than compulsion. FOOT CLINIC. The question of providing a Municipal Foot Clinic was agreed to and arrangements were made for the opening of a Clinic in central and accessible premises in the Borough. The Clinic began to function early in 1943, and at the time of writing this report a whole-time Chiropodist is kept fully employed. DIPHTHERIA IMMUNISATION. In the latter part of the year an intensive publicity campaign was initiated, posters being displayed in shops and other suitable buildings throughout the Borough; co-operation of Head Teachers was obtained and consent forms bearing a message from the Minister of Health were distributed throughout the schools to parents of each family in which any of the children were not immunised. A film was exhibited at the Chain Stores, Heathway, and slides were shown in the cinemas. Many parents agreed to have their children immunised, but unfortunately the parents of very young children did not respond as freely as those of the older ones. Diphtheria Immunisation should be carried out at or immediately after the age of twelve months. This 7 ment can be had at all the Infant Welfare Centres for children under five years of age, and arrangements are made to treat the remainder either at a school clinic or in the schools. When children attain the age of five they should receive one further dose, which in nearly all cases will protect them for several additional years. DIPHTHERIA SWABS. For many years it has been the practice to examine Diphtheria swabs in the Public Health Department; some are also sent to the laboratory at Oldchurch and other hospitals. I would draw attention to the fact that the diagnosis of Diphtheria by means of swabs is a practice which should be discouraged. If a child is sufficiently ill to require a swab to be taken, he should be given serum immediately or admitted to hospital. Much valuable time may be lost in waiting for the result of the swab; the process of investigation usually takes about 24 hours. Of course, many occasions arise when swabs are taken from apparently healthy noses and throats in order to trace carriers or before sending children to such institutions as convalescent homes, but this is quite another matter. CIVIL DEFENCE PERSONNEL. Local Authorities are encouraged and empowered to employ Civil Defence workers in work associated with the social services, and on many occasions during the year members of the Ambulance, First Aid Post and Mortuary personnel have been called upon to assist at War-Time Nurseries and other activities of the Public Health Department. The operation of the Millbank disinfestor is carried out by the Mortuary personnel, and now the gas/air analgesia scheme is in full operation, assistance is given by Ambulance 8 dants and women attached to First Aid Posts. In nearly all cases those concerned have been willing volunteers and welcomed the opportunity of employing their time usefully. GAS/AIR ANALGESIA. The Council has decided to afford facilities for the administration of gas/air analgesia to women in childbirth attended by the Council and Association Midwives. Six apparati have been purchased and are distributed in the three major sub-divisions of the Borough. As these machines are somewhat bulky, a difficulty was encountered with regard to transport. The Civil Defence authority was therefore approached, and sanction given to transport them by means of Civil Defence vehicles, either light mobile units or sitting-case casualty cars, with the clear understanding that this form of transport would not be available in the event of an "alert." The Central Midwives Board requires that a second person in addition to the midwife should be in attendance, and that these persons should either be trained nurses, midwives or members of the British Red Cross Society or St. John Ambulance Association. Owing to the many onerous duties of the midwives, it was not thought possible to rely on being able to obtain their services on all occasions. Therefore members of the Casualty Service who had joined one or other of the aforementioned organisations were approached and asked to volunteer for this work. I am pleased to say that they readily responded, and several members have been enrolled on the panel of "second persons." The thanks of the Council are due to these ladies for their kind offer of help. 9 It should be clearly appreciated that this aid to childbirth is not an anaesthetic in the accepted sense of the word. It is claimed, rightly, that it does lessen the acuity of labour pains, and therefore from humane considerations is of much value. The gas and air are administered by the patient herself who grasps the appliance, breathes deeply and inhales the gas and air in fixed ratio. The service will be offered to those who come within the scheme and who desire to have it. They must, however, undergo a medical examination four weeks before the date of the expected confinement in order to ascertain that there is no lesion which would contra-indicate the administration of this form of analgesia. WAR-TIME NURSERIES. The War-Time Nurseries at Heathway Special School and Kingsley Hall have been in operation for a sufficient period to assess their value. They certainly have fulfilled a useful purpose, and there is a large waiting list for admission. At the present time three additional nurseries are under construction and near completion; two of these will accommodate 70 children each and the third S'A. They are built in accordance with the recommendations of the Ministry of Health. One of these nurseries is to be run in conjunction with a First Aid Post at which the cooking will be carried out and the regular staff of the nursery will be supplemented by those attached to the post; the nursery referred to is that at Chadwell Heath. The nursery being built in the Leys Field is close to a Civil Defence Depot, and it is envisaged that the Ambulance personnel will assist. The nurseries receive regular visits by the medical staff and all the children undergo frequent medical inspections. Apart from one or two outbreaks of zymotic 10 eases, which fortunately have not been severe in character, the general health has been maintained at a high level. These nurseries have an educational value in that they train the children in good habits and also afford them companionship, this being of particular value when there is only one child in a family. PEMPHIGUS. During the year there were 17 notifications of children suffering from Pemphigus Neonatorum, all of whom were removed to hospital. For some years Pemphigus Neonatorum has not given rise to severe clinical symptoms. It is highly infectious and causes considerable disorganisation in the midwifery service owing to the fact that when a midwife has been in contact with a case, it is necessary to prohibit her from visiting other cases, and to remain off duty for a period after she has been in contact. It may be considered as "a nuisance disease," but it cannot be stated definitely that it will not revert to a more malignant type. At one time it was regarded very seriously, and a high mortality was experienced. HOSPITALS. The Borough is principally served by Rush Green Emergency Hospital and Oldchurch County Hospital, together with King George Hospital, Ilford. Rush Green Hospital continues to accept medical and surgical cases and has been of much assistance to the Borough by accepting such cases as Puerperal Pyrexia, Ophthalmia Neonatorum and Pemphigus. In many cases of the last two named diseases the mothers are admitted with their children when the latter are breast fed. Very valuable service 11 is rendered to the Borough by the willing co-operation of the Hospital Authority. The tendency is for hospitals which were formerly exclusively used for infectious diseases to admit patients suffering from other conditions; also this policy is generally favoured by Medical Superintendents as it not only enlarges the scope of the activities of the medical and nursing personnel, but it is found in practice that many border line cases occur in which it is difficult to draw a sharp distinction as to whether or not they should be regarded as infectious. The maternity cases in which complications are anticipated are admitted to Oldchurch County Hospital, and I take this opportunity of making reference to the help received from the Medical Superintendent and staff. Hospital beds for maternity cases are increasingly difficult to obtain throughout the country, and one frequently encounters patients who show every sign of being normal, who, for domestic reasons, find it difficult to have their confinements at home. The need, however, is impossible to meet without a considerable extension of hospital facilities. The suggestion of providing ad hoc maternity homes has been widely discussed, the Ministry of Health discourages the establishment of such homes, however, as it is felt that the provision of maternity beds in conjunction with a general hospital is preferable from all points of view. To give an instance, it is often difficult or impracticable to obtain the services of physicians and surgeons of consultant status in such homes. Furthermore, facilities for pathological and X-ray investigations are usually not available except at general hospitals. I am aware that there is a body of opinion which favours municipal maternity homes which undoubtedly present certain advantages, but these, in my view, are outweighed by lack of the desiderata mentioned. 12 CLINICS AND TREATMENT CENTRES. There has been no marked change in the arrangements for holding AnteNatal and Infant Welfare Centres, but owing to the large numbers at York House Ante-Natal Clinic, an additional session is held there on Tuesday mornings. Another alteration is that the Ante-Natal and Infant Welfare Centre formerly held at the Co-operative Hall, Whalebone Lane, has been transferred to the First Aid Post situate in the High Road. This possesses certain advantages amongst which are the assistance afforded by the personnel of the post. The sessions are well attended as the position of the post is readily accessible to all parts of the Borough north of the L.N.E. Railway. Conveyance is still provided for mothers and children living in Marks Gate, Hog Hill and Chigwell Row. MIDWIVES. The domiciliary midwifery service in the district is still carried out by nine Council midwives, seven midwives employed by the Dagenham District Nursing Association, and two Salvation Army midwives, added to these are three independent midwives practising within the Borough. The report of the Midwives Salaries Committee prepared under the chairmanship of Lord Rushcliffe, will, if widely adopted, improve the status of midwives. Recommendations are adoptive as far as local authorities are concerned. They should attract trained midwives, this in its turn should tend to raise the standard of midwifery. It is not suggested that this standard calls for adverse comment. Our local experience is that midwifery as 13 tised in Dagenham is very satisfactory, as we have been fortunate in securing a competent staff. It cannot, however, be overlooked that healthy competition is bound to raise the level of any skilled occupation. HEALTH VISITORS. The duties imposed upon Health visitors continue to increase, the figures later in the report will show the very large number of visits carried out by the Health Visiting staff. Recently an order has been received from the Ministry of Health suggesting that these ladies should devote a proportion of their time to investigation and advice regarding head lice. This entails visits outside their normal working hours as the idea of paying occasional early morning and evening visits is encouraged. They have also undertaken additional duties regarding the immunisation against Diphtheria, and perform a valuable service in persuading parents of those who have not been immunised to accept this treatment. Certain additional duties also devolve upon them regarding the Adoption of Children (Regulation) Act, 1939, which was made effective from 1st June, 1943. Under this Act certain visits and enquiries are necessary which are similar to those undertaken under the provisions for foster children made in the Public Health Act, 1936. Our Health Visitors certainly have gained the confidence of the people of Dagenham; it is a rare occurrence for them to be received other than with a friendly welcome. This is in marked contrast to what was the usual experience when this valuable service was first introduced. NURSING IN THE HOME. The Borough is very well served by the Dagenham District Nursing Association which covers the whole of the area. District nursing is one of the less spectacular 14 of the health activities, but it is probably, from the point of view of the old and sick, the most highly appreciated of all. The difficulty in obtaining the services of nurses has made the work of the Association very onerous, but the situation has been boldly faced and my attention has not been drawn to any patient who has been refused the services of a nurse. A provident scheme is now in full operation, members of which are entitled to call in a nurse after a certain period of membership and visits will continue under the direction of the family doctor without further financial obligation. This scheme does not, however, afford facilities for nursing conditions associated with pregnancy. MILK. The rationalisation of distribution of milk has worked satisfactorily, the only difficulty experienced has been with one retailer who had a very limited supply of bottles when the scheme was introduced; this difficulty has apparently been overcome. The regulations governing the pasteurisation of milk require that it should be raised to a temperature of between 145° Fahrenheit and 150° and held at that temperature for at least 30 minutes. In some instances it has not been possible to obtain the necessary plant, which is of a highly specialised nature. The Ministry of Health has issued a regulation which permits pasteurisation to be carried out by raising the temperature for at least 15 seconds to 162° and immediately cooling to 55° Fahrenheit. In this district there is only one pasteurising plant in use. Premises which were formerly used as a cowshed were unoccupied for a period, 15 but permission has been requested to re-commence the business of cow-keeping at this farm. Certain improvements were desired and the occupier willingly carried these out. Samples of milk taken at intervals have proved that the milk is of good quality and production methods are satisfactory. RODENT CONTROL. Recently the Ministry of Food has given much attention to the eradication of rats and mice, and all local authorities have been urged to deal with these pests. A course was arranged in London for the instruction of Sanitary Inspectors. All the Inspectors including the Senior attended, the main feature of which was to demonstrate the application of a scientific method adopted on the suggestion of experts attached to the Ministry of Food The essential features for extermination of these vermin are setting of traps for mice at strategic points and in given concentrations and the "pre-baiting" and subsequent poisoning of rats. There is only one major infestation in this Borough, which is now being dealt with. HOUSING. In common with most other districts, the housing shortage is shared by Dagenham. The main contributing causes to this shortage are the return of families from evacuation and the influx of people from more severely bombed areas. There are many cases of gross overcrowding, the most urgent feature of this being the presence of more than one family in a house. Another difficulty is created by the marriage of serving men who, unable to obtain accommodation, are compelled to reside with 16 parents. In cases where the husband has returned, the position is rendered even more acute. Concurrently with the increase of overcrowding, there has been a growth in the number of houses which have been discovered to be verminous. Here again, we have experienced difficulty, as the re-agents used for killing are in short supply. VERMINOUS HEADS. The presence of lice and nits has undoubtedly increased, so much so, that the Ministry of Health has issued a Circular which gives additional powers to Local Authorities, particularly with regard to dealing with children up to school leaving age. It is difficult to convince some parents that the presence of nits amounts to a verminous condition. It is sometimes stated that the child "grows them." This of course, is absurd, as the fact that nits are the eggs of lice, is conclusive evidence that a visitation must have taken place. Unfortunately, verminous heads are not confined to children; they are of no infrequent occurrence among adults. The attention of my department has on numerous occasions been directed to this by factory nurses and hairdressers. The fashion of wearing short hair, which at one time one hoped would mitigate this, has been more than offset by the still more recent fashion of artificial waving. I am informed that thorough combing of waved hair is inimical to the preservation of the wave. Fortunately a new preparation has recently been made available for dealing easily with nits and lice, this is an oily product which is easily applied and is very effective. The neglect, however, of thorough combing is a bad habit which should be corrected, as, in spite of the lethal action of the oil referred to, the omission of thorough brushing and combing at least once daily is likely to damage the hair. 17 I conclude by asking you to accept iny thanks for your continued interest in the health and well-being of the people of this Town. In particular are these remarks addressed to the Chairman and Members of the Health Services Committee, and I once more record my appreciation of the willing help received from my colleagues and staff. I am, Your Worship, Ladies and Gentlemen, Your obedient servant, CECIL HERINGTON, Medical Officer of Health. Public Health Department, Civic Centre, Dagenham. 18 MEMBERS OF THE COUNCIL. (31st December, 1942.) Mayor : Alderman (Mrs.) L. F. EVANS, J.P., E.C.C. Deputy Mayor : Councillor F. BROWN. Aldermen : A. F. J. CHORLEY, J.P., E.C.C. R. J. D. CLACK, J.P. E. E. HENNEM. W. F. LEGON. W. C. MARKHAM. M. E. MARLEY (Mrs.), J.P. B. H. SAUNDERS, E.C.C. Councillors : J. R. ANDREWS. W. E. BELLAMY. D. E. BROWN. J. W. BURRIDGE. A. A. BUTTERS. S. W. DEEKS. E. EDWARDS. A. E. GIBBS. F. T. GRINDROD. H. L. LYONS. J. E. MUNN. R. G. MURRELL. J. NEISH (Mrs.) F. J. PERFECT. A. E. PRENDERGAST (Mrs.) E. S. REDDY (Mrs.). M. REDDY. F. L. M. ROGERS (Mrs.). E. R. SAYWOOD. A. R. THOMAS (Mrs.). F. G. THOMAS. C. A. THORNEYCROFT. M. A. E. WARREN (Mrs.). HEALTH SERVICES COMMITTEE. Councillor (Mrs.) A. E. PRENDERGAST, Chairman. Alderman (Mrs.) M. E. MARLEY. I.P.. Vice-Chairman. The Worshipful the Mayor (Aid. (Mrs.) L. F. EVANS, J.P., E.C.C.) Deputy Mayor (Coun. F. BROWN) Coun. E. S. REDDY (Mrs.). Coun. M. A. E. WARREN (Mrs.). Coun. A. E. GIBBS. Coun. J. NEISH (Mrs.). 19 OFFICERS of the PUBLIC HEALTH SERVICES. Full-Time Staff : Medical Officer of Health : CECIL HERINGTON, M.D., B.S. (Lond.), D.P.H , M.R.C.S., L.R.C.P^ Deputy Medical Officer of Health : JAMES A. C. FRANKLIN, M.B., B.S. (Lond.), D.P.H. M.R.C.S., L.R.C.P. Assistant Medical Officer . HARRY B. CARTER-LOCKE, M.B., B.S. (Lond.), D.P.H. M.R.C.S., L.R.C.P., Senior Sanitary Inspector : L. E. PRIOR (1, 2). Sanitary Inspectors : J. W. ALLAM (1, 2). F. W. S. FOX (1, 2, 3, 4). A. J. JAMES (1). F. W. KNIGHT (1, 2). Senior Health Visitor: M. SMITH (5, 6, 7). Health Visitors: V. A. EVERITT (5, 6, 7). A. K. GIBSON (5, 6, 7). P. SILBY (5, 6, 7). E. SINGLE (5, 6. 7), D. B. STEWART (5, 6, 7). E. THOMAS (5, 6, 7). D. E. WALLER (5, H, 7). L. WEALE (1, 5, 6, 7, 8). (One Vacancy) Senior Midwife: E. M. BEDFORD (5, 6). Midwives: D. K. ANKER (6). M. HALL (6). C. HURRY (6). M. GOODBUN (5, 6) O. M. LISSAMORE (6). H. MITSON (5, 6). M. ROBSON (6). M. J. STOREY (6). 20 Clerical Staff : Senior Clerk : B. E. E. DENNY. Clerk to Sanitary Inspectors : H. FIELD (1). Clerks : I. M. BISHOP. K. BRIMBLECOMBE (9). G. K. HARRIS. E. HIGHAM (9). B. JONES (9). K. W. SKEATES. M. A. WATTS. Certificate of Royal Sanitary Institute 1 Meat Inspector's Certificate 2 Sanitary Science as applied to Building and Public Works Certificate 3 Smoke Inspector's Certificate 4 General Trained Nurse 5 State Certified Midwife 6 New Health Visitor's Certificate 7 M. & C. W. Certificate 8 Temporary War-Time Appointment 9 Part-Time Staff s Consulting Gynecologist : R. L. DODDS, M.Ch., F.R.C.S. (Eng.). Consulting Orthopaedic Surgeon : £. WHITCHURCH HOWELL, F.R.C.S. (Eng.). Dentist : F. C. RITCHIE, L.D.S., R.C.S. (Edinburgh). Public Analysts : BERNARD DYER, D.Sc., F.I.C. J. HUBERT HAMENCE, Ph.D., M.Sc., F.I.C. 21 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 6,556 Number of inhabited houses (end of 1942) according to Rate Books 25,864 Rateable value (December 31st, 1942) £598,464 Sum represented by a penny rate (approximate 1942-43) £2,290 Extracts from Vital Statistics for the Year. Live Births :— Total. Male. Female. Legitimate 1,834 948 886 Birth rate per 1,000 of the estimated resident population, 20.37. Illegitimate 64 28 36 Stillbirths :— Legitimate 40 24 16 Rate per 1,000 total (live and still) births, 22.15. Illegitimate 3 2 Deaths 638 346 292 Death rate per 1,000 of the estimated resident population, 6.85. Deaths from puerperal causes - Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis — 0.00 Other puerperal causes 2 1.03 Total 2 1.03 22 Death rate of Infants under one year of age :— All infants per 1,000 live births 44.26 Legitimate infants per 1,000 legitimate live births 45.26 Illegitimate infants per 1,000 illegitimate live births 15.62 Deaths from Cancer (all ages) 106 Measles (all ages) 1 „ Whooping Cough (all ages) 7 ,, „ Diarrhoea (under 2 years of age) 3 Births. 1,898 live births were registered during the year, there being 976 males and 922 females. There is an increase of total births from 1,692 in 1941 to 1,898. The birth rate per thousand population was 20.37 compared with 15.8 for England and Wales and 17.3 for the 126 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, 18.59, 18.47, 18.7, 18.06, 17.61, 18.77 and 19.08 for the years 1927 to 1941 inclusive. The illegitimate birth rate continues to be very low, being only 3.37 per cent, of total births. The rate of illegitimate stillbirths is 6.98 of total stillbirths. Death Rate. Total deaths in district 405 Outward transfers 122 Inward transfers 355 Deaths of residents 638 23 Of the 122 deaths of non-residents occurring in the district, 53 took place at the West Ham Sanatorium, 55 at the Joint Isolation Hospital, and one at Hainault Lodge. Of the 355 deaths of local residents taking place outside this area, most occurred in institutions. Of these 161 occurred at Oldchurch Hospital, 34 at Orsett Lodge, 15 at The Retreat, Great Burstead, 11 at New Hall, Boreham, 10 at King George Hospital, 10 at Ilford Isolation Hospital, nine at Severalls Mental Hospital, eight at 142, Rayne Road, Braintree, seven at 48, Wood Street, Chelmsford, seven at Harold Court Sanatorium, six at the London Hospital, six at Warley Wood Emergency Hospital, five at Black Notley Sanatorium, five at St. Michael's Hospital, E.l, and four at 32a, Spital Road, Maldon. 638 deaths are equivalent to a death rate of 6.85 compared with 11.6 for England and Wales. For the years from 1927 to 1941 inclusive, the local rates were 7.0, 7.3, 8.3, 6.6, 7.2, 6.5, 6.5, 6.6, 5.63, 6.43, 6.24, 6.19, 5.96, 8.90, and 8.51. A table giving the causes of death, and the age periods at which they occurred, is given at the end of the report. -24 Table showing Birth-rate, Death-rate and Analysis of Mortality during the year 1942. 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. Influenza. Diarrhoea and Enteritis (under two years) Total Deaths (under one year). England and Wales 15.8 0.54 11.6 0.00 — 0.01 0.00 0.02 0.05 0.09 5.2 49 126 County Boroughs and Great Towns, including London 17.3 0.66 13.3 0.00 — 0.02 0.00 0.03 0.06 0.09 7.5 59 148 smaller towns (1931) resident populations 25,000-50,000 18.4 0.62 12.1 0.00 — 0.01 0.00 0.02 0.04 0.10 4.8 46 London 14.0 0.48 13.9 0.00 — 0.01 0.00 0.04 0.02 0.07 8.6 60 Dagenham 20.37 0.46 6.85 0.00 — 0.01 0.00 0.07 0.01 0.01 0.03 44.26 25 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Infant Welfare Centres. CENTRE. Sessions held. Times Sessions held. Average Attendances. Average New Cases. Co-operative Hall, Whalebone Lane North, Chadwell Heath. Weekly Wednesday, p.m. 54 4 Valence Club, Corner of Becontree Weekly Monday, a.m. 49 3 Avenue and Bennetts Castle Lane, Dagenham. Weekly Monday, p.m. 65 6 Arnold Road (Temp.) School, Weekly Thursday, a.m. 51 4 Arnold Road, Dagenham. Weekly Thursday, p.m. 73 8 Osborne Hall, Osborne Square, Weekly Tuesday, a.m. 54 4 Dagenham. Weekly Tuesday, p.m. 72 8 Rush Green Clinic, 179, Dagenham Road, Rush Green. Weekly Friday, p.m. 33 2 26 Ante-Natal Clinics. CENTRE. Sessions held. Times Sessions held. Average Attendances. Average New Cases. Co-operative Hall, Whalebone Lane North, Chadwell Heath. Weekly Monday, a.m. 14 3 Becontree Clinic, Becontree Avenue, Weekly Tuesday, p.m 16 4 Dagenham. Weekly Weekly Wednesday a.m. Friday, a.m. 13 15 2 3 Arnold Road (Temp.) School, Weekly Monday, p.m. 13 3 Arnold Road, Dagenham. Weekly Tuesday, a.m. 18 4 Weekly Wednesday a m. 13 2 Rush Green Clinic, 179, Dagenham Road, Rush Green. Monthly (1st in month) Friday a.m. 12 3 York House, Frizlands Lane, Weekly Thursday, a.m. 20 5 Dagenham. Weekly Thursday, p.m. 22 5 School Clinics. Clinic. Inspection. Minor Ailment. Co-operative Hall, Whalebone Lane North, Chadwell Heath. Tuesday morning. Friday morning. Green Lane School, Dagenham. Tuesday and Thursday afternoons. Monday, Wednesday and Friday mornings. Five Elms School, Wood Lane, Dagenham. Monday and Friday mornings. Tuesday, Wednesday and Thursday mornings Arnold Road School, Arnold Road, Dagenham. Every second Tuesday afternoon and every Friday afternoon. Wednesday morning. 27 Sanitary Inspection of the District. Report of the Sanitary Inspectors. (a) Nature and number of visits: — Houses 1,102 Nuisances under Public Health Acts 3,055 Bakehouses 48 Slaughterhouses 27 Milkshops, dairies and vehicles 71 Foodshops and stalls 1,292 Cafes 361 Infectious disease enquiries 1,817 Food poisoning enquiries 5 Visits to foster mothers' premises 37 Number of complaints investigated 872 Outworkers' premises 79 Ice-cream premises and vehicles 14 Factories 194 Workplaces 60 Tents, vans and sheds 54 Stables 37 Hairdressers' and Barbers' premises 68 Shops Act, 1934 56 Rooms fumigated 61 Inspection of air-raid shelters 11 Inspections re billeting of war workers 463 Other visits 55 (b) Notices served. Complied with. Statutory 89 49 Informal 567 462 28 INSPECTION AND SUPERVISION OF FOOD. Legal Proceedings. (a) A sample of minced meat was purchased from a local butcher who was suspected of selling horseflesh. The sample was submitted to the Ministry's Regional Pathologist who reported that his examinations revealed the presence of a large percentage of horseflesh. Legal proceedings were instituted. Fines totalled £150 together with £10 10s. costs. (b) An uncovered box of cooking fat grossly contaminated with dust and mice excreta was found in the basement of a confectioner's shop. The facts were reported to the local Food Executive Officer and proceedings were taken by the Corporation under the Food and Drugs Act and also by the Food Control Committee. Defendants were fined in all £24 and £10 10s. costs. Slaughterhouses. Arrangements were made early in the year for a District Sanitary Inspector to be loaned to a neighbouring Borough one day per fortnight to carry out meat inspection at the Regional Slaughterhouse. This procedure was found necessary because of the shortage of Inspectors in this Borough and the failure to obtain additional wholetime staff. 29 FOOD AND DRUGS ACT, 1938. Analyses. Article. Number Examined. Number Adulterated, etc. Formal. Informal Total Formal. Informal Total Milk 38 38 8 - 8 Milk, Condensed — 1 1 — —r Milk. Malted — 1 1 — — Milk Substitute — 1 1 — — - Egg Substitute 4 2 6 1 1 2 Marmalade, Jams, eto. 13 — 13 — — — Banana Spread 1 — 1 — — — Orange Flavoured Yeast 1 — 1 — — — Meat and Vegetable Extract — 3 3 — — — Soup Tablet — 1 1 — — — Cordials 13 4 17 2 1 3 Sauce 3 3 — — Salad Oil 1 3 4 — — Salad Cream 1 1 — Ground Nut Oil 1 1 — Fish and Meat Pastes 6 2 8 — — Flour 3 3 1 1 Flour Mixtures, etc. 4 4 8 — Pea Flour 2 2 — Bread. 1 1 Baking Powder 7 1 8 — — Custard Powder 2 2 - — — Jelly Crystals — 1 1 - 1 1 Cereals 4 4 — Herbs 1 1 2 — Pepper — 1 1 1 1 Spice 1 — 1 - — — Parsley, Thyme and Lemon Stuffing 1 1 2 1 1 2 Turmeric l'owder 1 1 — — Curry Powder 1 1 2 — Sausage Meat 37 1 38 3 1 4 Minced Meat 1 — 8 — — Black Pudding Suet; 1 — 1 o — — — Edible Gelatine 1 - I 1 - 1 Vinegar 5 1 6 — — — Pea Nut Butter 1 1 — Saccharine Tablets 1 1 Glucose Liquid - 1 1 — - — Sugar of Milk 1 1 - — Coffee 1 3 4 Cafe au lait 1 1 — Anti Gas Ointment 6 6 Glycerine - 1 1 — — — „ Lemon and Honey 1 1 2 — — — ,, ,, & Ipecachuana 1 1 2 — — — Quinine and Cinnamon 1 1 — — Syrup of Figs 1 - 1 — — — Cod I.iver Oil 1 1 Halibut „ „ & Orange 1 - 1 — — — Carried forward 166 52 218 16 7 23 30 Analyses—continued. Article. Number Examined. Number Adulterated, etc. For mal. Informal Total Formal Informal Total Brought forward 166 52 218 16 7 23 Herbal Cough Mixture 1 1 — — Honey and Lemon Tincture 1 1 — — Tonic Wine 2 2 — — Tonic Tablets I 1 — Vitamin Tablets 1 1 — Whisky 3 3 — — — Aspirin Tablets — 1 1 — „ & Phenacetin Powder 1 1 — Bicarbonate of Soda 1 1 - Bismuthated Magnesia 1 1 Cascara Sagrada Tablets 1 1 Castor Oil I 1 Compound Syrup of Figs 1 1 — Eucalyptus Oil — 1 1 — Glauber Salts 1 1 Infants' Powders 1 1 Seidlitz Powder 1 1 - - - Bone Marrow & Malt 1 1 - - - Total 177 62 239 16 7 23 31 Adulterated Samples, etc. Serial Number Article Formal or Informal Nature of Adulteration or Irregularity Observations 478 Milk Formal 2% added water No action 489 Milk Formal 7% deficient in fat and also contained 1% of water by Freezing Point Further samples to be taken 490 Milk Formal 3J% added water do. 555 Milk Formal 3% deficient in fat do. 661 Milk Formal 3% added water Vendor cautioned. 562 Milk Formal 2% added water do. 569 Milk Formal 29% deficient in (at do. 670 Milk Formal 9% deficient in fat do. 545 Egg Substitute Formal Exaggerated claim for egg equivalent Referred to Local Food Executive Officer 175a Egg Powder Informal Consisted of wheat en flour containing only 3% of dried pgg Withdrawn from sale 12 Lemon Flavour Cordial Formal A coloured and flavoured citric acid solution, sweetened «ith saccharin, containing no sugar Proceedings aban doned in view of adverse decision in higher oourt in respect of similar case 133 Sweetened Orange Cordial Formal Solution of citric acid flavoured with Orange Oil, coloured with a dye and sweetened with saccharin but containing no sugar Vendor warned-— produce relabelled 216a Concentrated Lime Fruit Flavour Cordial Informal Consisted of a concentrated solution of citric acid, flavoured with essential oil and coloured with a yellow dye but contained no sugar Vendor warned— withdrawn from sale 32 Adulterated Samples, etc.—continued. Serial Number Article Formal or Informal Nature of Adulteration or Irregularity Observations 103 Parsley, Thyme & Lemon Forcemeat Formal Contained no lemon or lemon flavouring Vendor cautioned. 181a Parsley, Thyme & Lemon Stuffing Informal Yielded nocvidence of any appreciable quantity of lemon or lemon flavouring Vendor warned 11 Sausages Formal Consisted of pre served sausages containing 150 parts per million sulphur dioxide Vendor warned 17 Sausages Formal Consisted of preserved sausages containing 50 parts per million sulphur dioxide Vendor warned 479 Sausages Formal Consisted of preserved sausages containing 300 parts per million sulphur dioxide Vendor warned 189 a Sausage Meat Informal Consisted not of sausage meat but of minced meat Information passed to Food Executive Officer _ Jelly Crystals Informal Jelly prepared according to directions failed to set owing to poor grade gelatine Vendor cautioned 108 Gelatine Formal Contained traces of arsenic amounting to 7 parts per million or l/20th grain per lb. Vendor cautioned 166a Flour Informal Consisted of wheaten flour containing an admixture of 18% of cream of Tartar Withdrawn from sale 174 a Pepper Informal Consisted not of pepper but of ground ginger Vendor warned 33 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 I 65 and over Total Cerebro-Spinal Fever — 2 1 - - - 2 3 - - - 8 Diphtheria — 6 16 3 5 - 1 - - - - 31 Dysentery — — 1 - - - - - - - - 1 Encephalitis Lethargica - - - - - - - - - - - - Enteric Fever - - - - - - - - - - - - Erysipelas — — 3 1 — 3 2 5 8 2 3 27 Food Poisoning — — — — - 3 1 - - - - 4 Measles 22 261 352 4 1 - - - 1 - - 641 Ophthalmia Neonatorum 7 - - - - - - - - - - 7 Pemphigus 17 - - - - - - - - - - 17 Pneumonia— Acute Primary 10 18 8 2 6 3 6 9 11 8 2 83 Influenzal — 1 — - - - - 1 1 3 Poliomyelitis Acute _ — 1 - - - - - - - 1 Polioencephalitis Acute - - - - - - - - - - Puerperal Pyrexia — — — - 8 15 - - - - 23 Scarlet Fever 3 109 222 27 9 3 3 1 - - - 377 Smallpox — — — - - - - - - Whooping Cough 29 97 52 3 2 - 1 - - - - 184 Notified. Admitted to Isolation Hospital, Rush Green. Admitted to other Isolation Hospitals. Admitted to other Hospitals. Deaths Registered. Cerebro-Spinal Fever 8 8 - - 4 Diphtheria 31 30 - 1 Dysentery 1 1 - - - Encephalitis Lethargica - - - - - Enteric Fever - - - - - Erysipelas 26 11 - - - Food Poisoning 4 - - - - Measles 641 12 — — 1 Ophthalmia Neonatorum 7 4 - - 1 Pemphigus 17 17 - - - Pneumonia— Acute Primary 83 32 1 2 Influenzal 3 - - -1 54 Poliomyelitis Acute 11 - - 1 Polioencephalitis Acute - - - - - Puerperal Pyrexia 23 12 - 1 1 Scarlet Fever 377 179 2 - - Smallpox - - - - - Whooping Cough 184 11 2 1 7 34 DIPHTHERIA IMMUNISATION. The following is a summary of the work carried out during the year: — Number of SCHOOL children immunised without preliminary testing 3,820 Number of PRE-SCHOOL children immunised without preliminary testing 1,595 Number of SCHOOL children re-Schick tested Of these two were positive. 202 . Number of PRE-SCHOOL children re-Schick tested Of these one was positive. 178 Number of SCHOOL children who received Primary Schick test Of these one was negative. 5 Number of SCHOOL children who received one dose after Primary Schick test positive 4 Number of PRE-SCHOOL children who received one dose after Primary Schick test positive y 2 Number of SCHOOL children who received two doses after Primary Schick test positive 3 Number of PRE-SCHOOL children who received two doses after Primary Schick test positive 1 35 IMMUNISATION BY GENERAL PRACTITIONERS, Number of SCHOOL children immunised without preliminary testing 7 Number of PRE-SCHOOL children immunised without preliminary testing 11 Total number of children found to be immune during the year—378. The following table shows details of children who attended for immunisation and were subsequently notified as suffering from Diphtheria, together with observations as to type and the ultimate result: — Age Particulars of treatment Notified as Diphtheria Confirmed Severity Result 11 2 doses A.P.T. 10th Dec. 41 16th Jan. 42 7.4.42 Yes Moderate Recovered 5 Immunised at York. Cannot trace. 7.12.42 Yes Moderate Recovered 8 Ditto 7.12.42 Temporary Carrier Recovered Scarlet Fever. 377 cases were notified, and of these 181 were admitted to hospital. The disease still shows a very low level of virulence, complications are rare and no deaths occurred. The tendency to treat Scarlet Fever at home is becoming widespread, and there is evidence to support the contention that domiciliary treatment of this disease contributes to the lowering of the virulence, the explanation being that a large section of the population receives "subclinical" infections which stimulate the production of anti-bodies. 36 In view of the limited hospital accommodation, and after consultation with the patient's doctor, it was decided that a case of Scarlet Fever should be nursed at home. The parents objected and desired removal to hospital. When the District Sanitary Inspector visited to ascertain if effective isolation was being maintained, admittance to the house was refused. A warrant was obtained from a Justice of the Peace and presented to the tenant's wife, but admittance was still refused. Legal proceedings were instituted and the defendant fined 20s. Tuberculosis. New Cases. Deaths. Primary Notification. Brought to notice other than by Form A Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 — — — — — — — — — — — — 1- — — 1 2 — — — — — — — 1 5- 3 — 2 — 1 — — — — — — — 10- 2 1 1 3 1 1 1 1 — 1 — 1 15- 17 15 3 1 — 3 — 1 2 6 — — 20- 8 11 3 2 3 5 1 — 4 6 1 — 25- 21 9 2 3 7 9 1 — 6 5 — — 35- 9 1 — 2 2 3 1 2 8 5 — 1 45- 11 5 — 2 1 1 — — 5 1 — — 55- 4 1 — — 1 — — — 5 — — — 65 and upwards - — — — — — — — — — — — 75 43 12 15 16 22 4 4 30 24 1 3 Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register 1st Jan., 1942 393 293 140 131 During the year :— New Notifications 75 43 12 15 Deaths 30 24 1 3 Transfers into area 16 22 4 4 Transfers out of area 20 22 5 5 No. on Register 31st December, 1942 434 312 150 142 87 MATERNITY AND CHILD WELFARE. Notification of Births. 1,782 notifications of live births were received during the year; the majority of these were notified by midwives. Stillbirths. 23 male and 20 female stillbirths were notified, the corresponding figures for registration being 26 and 17. The rate per 1,000 of total population registered was 0.46 the rate for England and Wales, being 0.54. The percentage of illegitimate stillbirths to the total was 6.98, compared with a percentage of illegitimate to total births of 3.37. Infant Mortality. 84 infants under one year of age died during the year, giving an infant mortality rate of 44.26 per 1,000 live births, compared with that of 49 for England and Wales and 60 for London. The rate amongst legitimate children was 45.26, while for illegitimate children it was 15.62. Ophthalmia Neonatorum. Seven cases of this disease were notified, four of which were treated in hospital; all made complete recoveries. 38 There were 40 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. All these cases were visited by the Medical Officer of Health and a Health Visitor. Of the total cases investigated, only seven were notified as suffering from true Ophthalmia Neonatorum. Maternal Mortality. Two maternal deaths were assigned to this district, which give a maternal mortality rate of 1.03 per thousand births. This is a remarkably low figure; that for England and Wales for the corresponding period was 2.01, which also is low. It is not so many years since a figure of 5 per thousand was regarded as an average. Work of Health Visitors. The following table shows the number of visits paid by the Health Visitors during the year: — (a) To expectant mothers First visits 409 Total visits 627 (b) To children under one year of age First visits 2,062 Total visits 6,880 (c) To children between the ages of one and five years Total visits 14,780 (d) Ineffective visits Total visits 2,999 Grand Total 25,286 39 Supervision of Midwives. The following is a summary of the reasons for sending for medical help by midwives: — Perineal Tear 118 Prolonged Labour 44 Rise of Temperature 41 Discharging Eyes 40 Miscarriage 29 Feebleness of Infant ... 20 Malpresentation 15 Watery Blisters ... 15 Post-Partum Haemorrhage 13 Ante-Partum Haemorrhage 10 Retained Placenta 7 Albuminuria 6 Circumcision 2 Other Causes 49 1' ' I H * \M 99 409 Notices summoning medical aid 409 For (a) Mothers ,315 For (b) Infants 94 Notification that they had been associated with the undermentioned conditions were received from midwives as under: — Liable to be sources of infection 60 Substitution of artificial feeding 19 Stillbirths 13 Infant Deaths 8 Laying out dead bodies 3 40 Domiciliary Midwifery Service. Below is a table setting forth in statistical form the work of the Corporation Midwives, Dagenham Nursing Association and Salvation Army Midwives for the year 1942: — Municipal Midwives. Dagenham Nursing Association. Salvation Army Nurses. Births Attended: As Midwife 587 452 130 As Maternity Nurse 97 53 20 Miscarriages Attended 20 7 6 Visits Paid: As Midwife 11,473 9,428 3,554 As Maternity Nurse 1,364 813 380 Ante-Natal 3,854 1,979 445 Ante-Natal Clinics Attended 424 217 100 41—42 CAUSES OF DEATH Under Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 and under 75 75 and over TOTAL RegistrarGeneral's Allocations. M F M F M F M F M F M F M F M F M F M F M F M F M F 1. Typhoid and Paratyphoid Fevers — — — — — — — — — — — — — — — — — — — — — — — — — — 2. Cerebro-spinal Fever 1 — — — — 1 — 1 — — — — — — — — — — — — — — 2 2 2 2 3. Scarlet Fever — — — — — — — — — — — — — — — — — — — — — — — — — — 4. Whooping Cough 1 3 1 — — 2 — — — — — — — — — — — — — — — — 2 5 2 5 5 Diphtheria — — — — — 1 — — — — — — — — — — — — — — — — — 1 — 1 6. Tuberculosis of Respiratory System — — — — — — — 2 6 10 8 6 8 7 6 3 6 — 1 1 — — 35 29 34 32 7. Other forms of Tuberculosis 1 — 1 1 — 1 1 1 — — 1 — 1 2 — — — — — — — — 5 5 5 4 8. Syphilitic Disease — — — — — — — — 2 — — — — 1 3 1 1 — — — 1 1 7 3 8 3 9. Influenza — — — — — — — — — — — — — — — — — — — — — — — — — 1 10. Measles 1 — — — — — — — — — — — — — — — — — — — — — 1 — 1 — 11. Acute Poliomyelitis and Polio-encephalitis — — — — — — — 1 — — — — — — — — — — — — — — — 1 — 1 12. Acute Infectious Encephalitis — — — — — — — — 1 — — — — — — 1 — — — — — — 1 1 1 — 13.m. Cancer of Buccal Cavity & Oesophagus (Males only) — — — — — — — — — — — — — — — — — — — — — — — — 1 9 13.f. Cancer of Uterus — — — — — — — — — — — — — — — 2 — 2 — 1 — 2 — 7 14. Cancer of Stomach and Duodenum — — — — — — — — — — 1 — — — 4 2 6 2 1 — 1 — 13 4 15 4 15. Cancer of Breast — — — — — — — — — — — 1 — — 1 1 — — — 1 — 1 1 4 1 5 16. Cancer of all other sites — 1 — — — — — — — — — — 5 3 9 6 8 8 11 8 7 5 40 31 45 26 17. Diabetes — — — — — — — — — 1 1 — 1 — — 1 1 — — 1 — — 3 3 2 — 18. Inter-cranial Vascular Lesions 1 1 — — — — 1 — — 1 — — 1 2 4 2 1 7 4 6 5 1 17 20 15 16 19. Heart Disease - 1 1 — 1 1 2 2 1 1 1 — 2 5 13 9 21 2 16 20 17 19 75 60 57 57 20. Other diseases of the Circulatory System — — — — — — — — — — — — — — — — — — 3 — — 2 7 2 16 7 21. Bronchitis 2 — — — — — — — — — — — — 1 1 — 1 2 2 1 3 7 10 11 25 15 22. Pneumonia 12 10 1 1 — 1 1 1 — 1 1 — 1 — 3 2 6 2 4 2 3 2 32 22 21 20 23. Other Respiratory diseases — — — — — — — — — 1 1 2 3 — 1 1 1 1 1 2 — 2 7 9 1 4 24. Ulceration of the Stomach or Duodenum — — — — — — 1 — — — — — — — — — — — — — — 1 3 l 0 1 25. Diarrhoea (under 2 years) — 1 — — — — — — — — — — — — — — — — — — — — — 1 — 3 26. Appendicitis — — — — — — — — — — — 1 1 — — — — — — — — — 1 2 1 3 27. Other Digestive Diseases 1 1 — — — — — 1 — 1 — — — 1 — — 1 1 4 — 1 — 7 5 8 3 28. Nephritis — — — — — — — 1 — — — — — — 4 1 6 5 1 — 1 — 12 8 11 12 29. Puerperal and post Abortive Sepsis — — — — — — — — — — — 1 — — — — — — — — — — — 1 — — 30. Other maternal causes — — — — — — — — — — — 1 — 1 — — — — — — — — — 2 — 2 31. Premature Birth 13 8 — — — — — — — — — — — — — — — — — — — — 13 8 11 8 32. Congenital malformation, birth injury, infantile disease 11 12 — — — — — — — — — — — — — — — — — — — — 11 12 19 10 33. Suicide — — — — — - — - - — 2 1 — — 2 — 1 — — 1 — — 5 2 5 2 34. Road Traffic Accidents — — — — - - 2 1 - 1 1 — 1 — 1 — - — 1 — 1 — 7 2 7 2 35. Other Violent Causes — — — — 1 - - - 1 1 — 1 1 1 — 1 — 1 1 — — 2 4 7 4 6 36. All Other Causes 1 — 1 1 1 — 1 2 — 2 1 1 1 2 4 — 2 1 1 3 10 11 23 23 22 28 45 38 5 3 4 8 9 13 11 20 19 16 27 26 56 33 62 34 52 47 54 56 344 294 346 292