AC 44113 EAS 4 COUNTY BOROUGH OF EAST HAM. PUBLIC HEALTH DEPARTMENT. Annual Report of the Medical Officer of Health and School Medical Officer FOR THE YEAR 1928. W. BENTON, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health. RECORDERS, ILFORD. COUNTY BOROUGH OF EAST HAM. PUBLIC HEALTH DEPARTMENT. Annual Report OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR 1928. W. BENTON, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health. RECORDERS, ILFORD. EAST HAM CORPORATION. PUBLIC HEALTH COMMITTEE Also Committee under Blind Persons Act, 1920, Sec. 2. *The Mayor (Councillor G. W. Boultwood, J.P.). *The Deputy-Mayor (Councillor W. S. Luton). *Alderman H. N. Ridler (Chairman Public Health Committee, Hospital and Sanatorium Sub-Committee, and Maternity and Child Welfare Sub-Committee). *Councillor E. C. Howlett (Vice-Chairman). Alderman E. Edwards, J.P. Alderman H. B. Harper, J.P. Alderman H. Osborn, J.P. *Councillor C. W. Brading. *Councillor J. Brooks, J.P. *Councillor G. W. Durant. Councillor C. F. H. Green. Councillor T. M. McGiff, J.P. Councillor R. W. Moger. *Councillor Mrs. M. Ridler. *Councillor Mrs. A. Taylor. *Councillor Mrs. E. J. Tungate. *Councillor T. Watts. MATERNITY AND CHILD WELFARE SUBCOMMITTEE. Same members as Public Health Committee with— Miss E. R. Davies (co-opted). Mrs. F. Norman (co-opted). *Also Members of the Hospital and Sanatorium Sub-Committee. COMMITTEE FOR THE CARE OF THE MENTALLY DEFECTIVE. The Mayor (Councillor G. W. Boultwood, J.P.). The Deputy-Mayor (Councillor W. S. Luton). Councillor J. Brooks, J.P. (Chairman). Councillor T. M. McGiff, J.P. (Vice-Chairman). Councillor E. Anderson. Councillor G. W. Durant. Councillor A. H. W. Owen. Councillor G. Pottinger. Councillor Mrs. M. Ridler. Councillor Mrs. A. Taylor. Councillor Mrs. E.J. Tungate. Mrs. G. Banks-Martin, J.P. (co-opted). Mrs. C. J. Cross (co-opted). Mrs. A. McGiff (co-opted). WHOLE-TIME STAFF OF THE PUBLIC HEALTH DEPARTMENT. Clerks : *Miss H. E. Ritterspack, *Miss D. Gordon, *G. H. Green, *W. Lank, Cert. R.San.I., *H. G. Luckett, A.R.San.I., *G. W. Friend. *F. J. Kendall, A.R.San.I., Chief Clerk. Home Teacher, Blind Persons Act : *Miss L. Kingston. Mental Deficiency Acts'. Ascertainment and Supervising Officer, *Miss E. L. Hicks. Training Centre Supervisor, *Miss T. A. Gibson. Child, Welfare Clerks: *Miss M. A. McCall, *Miss M. A. R. Gaster. Health Visitors : *Miss K. Bower, S.R.N., Certified Midwife, *Miss L. Barrett, S.R.N., Certified Midwife, *Miss A. E. O'Leary, S.R.N., Certified Midwife, *Miss M. A. Redcliffe, Certified Midwife, and *Miss S. Bowles, Certified Midwife (from December), *Mrs. A. A. Woodman, S.R.N., M.R.San.I., Certified Midwife (Senior). Tuberculosis Dispensary Clerk : *Miss V. Reid. Tuberculosis Nurses : *Miss L. E. Mallon, S.R.N., *Miss E. E. Cook, S.R.N., Certified Midwife. Assistant Nurse : *Miss A. Meadhurst. Matron of Isolation Hospital : Miss H. M. McLoughlin, S.R.N. Matron of Harts Sanatorium : *Miss M. R. Small, S.R.N., Certified Midwife. Shops Act Inspector : C. H. Pursall, A.R.San.I. Assistant Sanitary Inspectors : W. S. C. Tooby, A.R.San.I., M.S.I.A., W. J. Worley, A.R.San.I., M.S.I A., W. H. Thurston, R:P„ A.R.San.I., M.S.I.A. Sanitary and Food Inspectors : *R. A. Basrett, M.S.I.A., *M. J. J. Hillyard, M.S.I.A., *G. D. Lill, M.S.I.A. Chief Sanitary, Food and Shops Act Inspector, Inspector Contagious Diseases (Animals) Act and Supt. Refuse Collection : *Joseph G. Banks, A.R.San.I., F.S.I.A. (to July). School Dentist and Dentist to Maternity and Child Welfare Centre : *C. S. Neame, L.D.S., Eng. Medical Officer to Maternity and Child Welfare Centre, and Inspector of Midwives. *Elsie Thomson, M.B., Ch.B., D.P.H. Tuberculosis Officer and Resident Medical Superintendent, Harts Sanatorium : *G. W. Cheater, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H., Deputy Medical Officer of Health, Senior Assistant School Medical Officer and Resident Medical Superintendent, Isolation Hospital : *F. E. Bendix, M.R.C.S., L.R.C.P., L.D.S. Medical Officer of Health, School Medical Officer, General Medical Superintendent and Chief Administrative Officer to the Borough Hospital and Sanatorium, Chief Tuberculosis Officer, Chief Medical Officer for Maternity and Child Welfare, Medical Officer to Committee for Care of Mentally Defective, and Medical Officer, Blind Persons Act : *W. Benton, M.R.C.S., L.R.C.P., D.P.H. * Proportion of Salary contributed under Public Health Acts or by Exchequer grants. To His Worship the Mayor, Aldermen, and Councillors of the County Borough of East Ham. Mr. Mayor, Ladies and Gentlemen, I beg to submit the Annual Report on the state of the Public Health and the record of sanitary work carried out during the year 1928, together with my Report as School Medical Officer in accordance with the Regulations of the Ministry of Health and the Board of Education. The Borough still occupies a very satisfactory position in regard to mortality statistics—the death-rate being as low as 10, and infant mortality the lowest ever recorded, 49. Statistics for 1904 and the past eight years are given for comparison:— 1904 1921 1922 1923 1924 1925 1926 1927 1928 Death Rate 14.7 10.1 11.0 9.0 9.7 10.6 9.6 9.7 10.0 Birth Rate 31.8 20.3 21.0 19.4 18.3 17.3 17.1 15.8 15.3 Infant Mortality 154 67 62 51 54 53 56 53 49 Zymotic death rate 2.9 0.57 0.66 0.3 0.38 0.4 0.6 0.45 0.72 Pulmonary Tuberculosis death rate 1.68 0.85 0.95 0.88 0.78 0.90 0.96 0.80 0.80 I wish to express my indebtedness to all the members of my staff for their support and loyalty in the way they have carried out their duties. I am, Your obedient Servant, W. BENTON. 6 Summary of Report for 1928. 1. GENERAL STATISTICS. Area in statute acres (land and inland water), 3,324. Population. Census 1921, 143,246 (males 69,342, females 73,904). Adjusted to mid 1928, 145,400. Census, 1921 :— Number of inhabited houses 27,024 Number of families or separate occupiers 33,937 Ward Population. Manor Park 14,786 Little Ilford 17,422 Woodgrange 13,774 Plashet 14,520 Kensington 12,790 Castle 15,240 Central 15,336 Wall End 14,890 Greatfield 11,514 South 15,128 Assessable Value:— General District Rate £604,864 Sum represented by a Penny Rate :— General District Rate £2,468 2. EXTRACTS FROM VITAL STATISTICS OF THE YEAR. Total number of births, 2,219 (males 1,075, females 1,144). Total number of illegitimate births, 51. Total number of still births, 76. Birth-rate, 15'3. Deaths, 1,461 (males 740, females 721). Crude Death-rate, l0.05. 7 Number of women dying in, or in consequence of, childbirth: from sepsis, 2 ; other causes, 5. Deaths of Infants under one year of age per 1,000 births registered : legitimate, 49 ; illegitimate, 59 ; total, 49. Deaths from Measles (all ages), 14. Deaths from Whooping Cough (all ages), 19. Deaths from Diarrhœa (under 2 years of age), 12. Zymotic Death-rate, 0.72. COMPARATIVE STATISTICS. Annual Rate per 1,000 Living. Rate per 1,000 registered Births. Births. Deaths. Diarrhœa & Enteritis (under 2 years). Infant mortality. England & Wales 16.7 11.7 7.0 65 107 Great Towns 16.9 11.6 9.6 70 London 15.9 11.6 10.2 67 EAST HAM 15.3 10.0 5.4 49 East Ham is bounded on the north by Wanstead, south by the River Thames, adjoins West Ham on the west, and Ilford and Barking east. The subsoil is sand and gravel, with the exception of a portion in the south of the Borough, where it consists of alluvium overlying London clay. The altitude is low, the highest point being about 50 feet above ordnance datum. It is well served by railways, viz., District, L. M. & S., and L. & N. E., also by a through service of trams and motor 'buses which convey a large number of the population, chiefly consisting of clerks, warehousemen, mechanics, postal and telephone officials to and from the City of London. 8 COUNTY BOROUGH OF EAST HAM PUBLIC HEALTH DEPARTMENT. REPORT of the MEDICAL OFFICER OF HEALTH For the year 1928. SUMMARY OF NURSING ARRANGEMENTS, HOSPITAL AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. Professional Nursing in the Home. (a) General.—Excellent work is carried out by the Nurses attached to the branch Home in Katherine Road of the Plaistow Maternity Charity to which the Local Authority make no grant. During the year 1928, 39,919 visits were made by the Nurses to 1,012 cases. (b) For Infectious diseases, e.g., Measles or treatment of Scarlet Fever, no provision is made. Midwives. No Midwives are subsidised by the Authority, but a large amount of Midwifery work is undertaken by 36 Nurses of the Plaistow Maternity Charity, in addition to 10 Midwives who have private practice in the Borough, and 3 practising in the North Woolwich area attached to Sir Henry Tate's Home. Clinics and Treatment Centres. The Maternity and Child Welfare Department at the "White House" is under the charge of a Lady Assistant Medical Officer, who also supervises the work of the Health Visitors. For report see pages 45-58. Infant Consultations and Ante-Natal Clinics are conducted daily. Branch Clinics are also held once per week at Wesleyan 9 Church Hall, Manor Park; St. John's Schoolroom, North Woolwich; and St. George's Hall, Masterman Road. At the present time there is no Day Nursery in the Borough. The School Clinks are referred to in the report of the School Medical Service pp. 82-137. Tuberculosis Dispensary. Tuberculosis Officer is in attendance one morning, three afternoons and one evening session each week. For report see pp. 25-31. Venereal Diseases. East Ham forms a part of the joint scheme with the London County Council. For summary, see page 59. A local medical practitioner is qualified to receive free supplies of arseno-benzol compounds. HOSPITALS PROVIDED OR SUBSIDISED BY THE LOCAL AUTHORITY. 1. Tuberculosis. Harts Sanatorium, Woodford Green, has accommodation for 56 patients (for report, see pp. 32-35). Arrangements were made for children to be sent to various Sanatoria as occasions arose and ex-service men admitted to Papworth Hall Tuberculosis Colony. 2. Maternity. Arrangements have been made for cases to be admitted to Plaistow Maternity Home or Queen Mary's Hospital, West Ham. Nursing Homes Registration.— One Home is registered. 3. Fever. (For report, see pp. 35-44.) 4. Small-Pox. The West Ham Corporation, by agreement, deal with cases of this disease arising in the Borough. 5. Other. The general and special hospitals of London, and the Whipps Cross Hospital of the West Ham Board of Guardians, are within easy access. There is no local institutional provision for unmarried mothers, illegitimate infants, and homeless children. 10 AMBULANCE FACILITIES. (a) For Infectious Diseases.— Two motor ambulances are garaged at the Isolation Hospital. (b) For non-infectious and accident cases.—Two motor ambulances kept at the Fire Station, conveyed 994 cases to and from various hospitals. These consisted of 362 accidents and 632 cases of illness. 1,206 journeys were made, and 12,182 miles run. East Ham cases removed by other ambulances numbered 63, viz., by Barking, 33; Ilford, 14; West Ham, 16. HEALTH PROPAGANDA. The Medical Officer of Health has given a number of addresses to the various Women's Guilds in the Borough, and through the good offices of the Borough Librarians book-marks containing Health Maxims issued by the East Ham Insurance Committee, are distributed to borrowers. 2,000 copies of "Better Health" are distributed in the Borough monthly, and are much appreciated by those who read the contents. SPECIAL ACTS OF PARLIAMENT. The following Special Acts of Parliament have been obtained by the Council:— The East Ham Improvement Act, 1898. The East Ham Improvement Act, 1903. The East Ham Corporation Act, 1914. The East Ham Corporation Act, 1919. Special Provisional Orders. The Tramways Orders Confirmation (No. 2) Act, 1898. The Electric Lighting Orders Confirmation (No. 2) Act, 1898. The Tramways Orders Confirmation (No. 3) Act, 1900. The Tramways Orders Confirmation (No. 2) Act, 1904. The Local Government Board's Provisional Orders Confirmation (No. 10) Act, 1904. The Local Government Board's Provisional Orders Confirmation (No. 12) Act, 1907. The Local Government Board's Provisional Orders Confirmation (No. 6) Act, 1908. 11 Acts of Parliament applied to the Borough by order of Ministry of Health. Public Health Acts Amendment Act, 1907, Part 10, Sec. 95. 16th October, 1923. Acts of Parliament Adopted. Date of Date of coming Name of Act adopted, adoption. into operation. Infectious Disease (Notification) Act, 1889 l2th Nov., 1889 1st Jan., 1890 Infectious Diseases (Prevention) Act, 1890 14th Oct., 1890 18th Nov., 1890 Public Health Acts Amendment Act, 1890, Parts 2, 3 and 5 13th Jan., 1891 18th Feb., 1891 Public Baths and Wash- houses Acts 16th Mar., 1897 16th Mar., 1897 Housing of the Working Classes Act, 1890, Part 3 16th Feb., 1897 Kith Feb., 1897 Public Libraries Act, 11892 il8th June, 1895 1st Aug., 1895 Infectious Disease (Notification) Act, 1889 (Extension) Education (Provision of Meals) Act, 1906 24th Nov., 1908 24th Nov., 1908 Local Government and other Officers' Superannuation Act, 1922 17th July, 1923 1st Oct., 1923 Public Health Act, 1925, Part 2, Sec. 25 13th April, 1926 1st June, 1926 Bye-Laws, Regulations, etc. The following Bye-laws, Regulations, etc., are in force in the County Borough of East Ham Defacing Pavements, etc. Removal of House Refuse. New Streets and Buildings. Alteration of Buildings. 12 Common Lodging Houses. Slaughter Houses. Public Pleasure Grounds. Allotments. Isolation Hospital. Employment of Children. Dairies, Cowsheds and Milk Shops. Good Rule and Government. Bakehouses. Tramways. Closing Order for Barbers and Hairdressers. Closing Order for Butchers. Closing Order for Chemists. Closing Order for Corn or Forage Dealers. Closing Order for Grocers and Provision Dealers. Tents, Vans, Sheds and similar structures used for Human Habitation. Standing Orders, Rules of Debate for regulating the Meeting and Business of the Council. Standing Orders re Licences for Cinematograph Exhibitions. Standing Orders re Licences for Public Performance of Stage Plays. Standing Orders re Licences for Music, Dancing and other Public Entertainments of the like kind, and Racecourses. Table of Fees to be taken by the Clerk to the Justices of the Peace. Unauthorised Persons on Elementary School premises. Sale of Coal. Cleansing and Disinfection, Essex (Parasitic Mange) Order, 11909. Lamps Marking Roads Obstructions. Provision of Means of Escape from Fire in case of certain Factories and Workshops. 13 MENTAL WELFARE. The work of Mental Welfare has been carried out in accordance with the provisions of the Mental Deficiency Act, 1913, and the amendments to that Act. All new cases have been carefully investigated; enquiries for the information of the Visiting Justices on home conditions of defectives under Order have been prepared; reports made for the Board of Control where parents have applied for "leave of absence," or for holiday for defectives living in certified institutions. Defectives placed under statutory supervision or under guardianship in their own homes have been regularly visited; advice on training, diet and suitable clothing has been given to the mother where necessary, and a few lessons have been given in the home, where the defective has been unsuitable to be admitted to one of the Training Centres. Suitable and capable foster-parents have been found for urgent cases, when vacancies in certified institutions have not been available. It has been proved by experience that the "Cottage Home" is not in most cases a suitable place in which to place a defective, as a foster-mother with no special training is usually not a very suitable guardian, so that homes have been chosen where the foster-parent has received some recognised training in nursing or teaching, and the results have thoroughly justified the choice. Training Centre. New and suitable accommodation has been found for the Training Centre, at the Church Army Hall in Barking Road. A large, well lighted and comfortably heated room which is used for the big boys' handicrafts class in the mornings and the girls and little boys in the afternoons. There is a good-sized piece of ground attached on which the children can recreate. Besides being taught (boys) woodwork, various kinds of useful mat-making; (girls) plain needlework, knitting, fancy and raffia work, etc.; speech training, drill, and suitable physical exercises are given, which these children need so badly for their physical development. The Training Centre was opened in April with 30 children, divided into two classes. At the end of the year there 14 were 36 on the register, although 3 boys are at work, earning pocket money; 2 were sent to institutions, and 1 moved to another area. The following is an analysis of the case work during the year ended 31st December, 1928:— 19 new cases referred to the Local Authority. 9 defectives were submitted to certified institutions under order. 8 in places of safety. 3 removed to other districts. 3 died. At the close of the year there were 52 in certified institutions. 5 on licence from certified institutions. 86 under statutory supervision in their own homes. 86 under voluntary care. At Christmas the children were given a most enjoyable party and Christmas tree, at which the Worshipful the Mayor presided, accompanied by the Mayoress, the Chairman, and other members and officials of the Mental Deficiency Committee. The interest taken has increased the confidence of the parents in their efforts, which is of so much importance to these young people. WELFARE OF THE BLIND. There are at present 152 technically blind persons on the register, of whom 36 are at school, in training, or at work at home or in workshops, and 5 are ex-service men assisted by St. Dunstan's. There is one blind shorthand-typist employed in a City office, where her work is found most satisfactory. During the past year the Home Visitor has paid 1,827 daily visits, 184 evening visits and meetings, and given 371 lessons, of which 48 were in cane basket work, 74 in Braille, 33 in manual alphabet, 50 in moon type, 55 in knitting, 36 in crochet, 34 in wool ball-making, and 41 in straw bag-making. 15 When necessary, those who wish it are accompanied by the Home Visitor to Hospitals, to the Relieving; Officer, to see the Medical Officer, and also to and from railway stations when going away for holidays. Those who are away in local hospitals are also visited. Numbers of blind persons have been assisted to obtain blind pensions and free wireless licences. The local Association continues its good work, such as providing regular monthly social evenings in the winter, summer outing, and supplying parcels at Christmas. Crystal wireless sets and accessories, when required, are supplied and maintained free of charge. Grants of clothing, extra nourishment, provision of glasses and dentures are made where necessary. Embossed magazines are provided regularly, and cane, wool, straw, etc., are also provided for pastime occupations. Whenever applied for, fares to hospitals, etc., are granted. In June last, by the kind permission of the East Ham Shopping Hall Authorities, a lock-up shop was lent to the Association for a week, and all articles shown were those made by the local blind. Over 600 orders were taken, which kept the blind people busy for some time. INVALID CHILDREN'S AID ASSOCIATION (East Ham Branch). The year's work has again increased in all directions; 275 cases have been dealt with, 197 of which were new. During the 5¼ years of the work of the branch 1,000 children from all parts of the Borough have been assisted. The Association has continued to co-operate successfully with the Public Health Committee, Education Committee, Guardians, Pensions Committee, and most of the London Hospitals. Cases have been referred to them as follows :— Tuberculosis Officer 37 Gt. Ormond Street School Medical Officer Hospital 21 for Schools Recovery 33 East London Hospital 11 School Medical Officer Balaam Street Hospital 7 for General ConvalesQueen Mary's Hospital 6 cence 76 St. Bart's Hospital 5 Ophthalmic Surgeon 4 Other Hospitals and Infant Welfare Centre 17 Agencies 46 Private Practitioners 12 16 The types of new cases dealt with during the year may be summarised as follows:— Tubercular 37 Paralysis 8 Pre-tubercular 19 Chorea 10 Anaemia and Debility 51 Rheumatism 6 Malnutrition 16 Eye diseases 4 Bronchitis and Asthma 22 Various 24 Help has been given during the year as follows:— Sent to Sanatoria or Special Hospitals 37 Schools of Recovery 33 Convalescent Homes 132 Boarded out 3 Provided with surgical appliances 34 Invalid Carriages 6 Visiting and advice on behalf of hospitals 20 Food and Clothing Grants 10 LABORATORY WORK. 2,302 Bacteriological examinations of "swabs" for suspected Diphtheria were undertaken in our own Laboratory, of which 456 gave positive results. 486 "swabs" were examined at the Isolation Hospital. Other pathological and bacteriological specimens were sent to London and provincial laboratories for examination. Diphtheria and other sera and vaccines were supplied free of charge to Medical Practitioners as required. MEDICAL EXAMINATION. 117 examinations have been made during the year upon request of the various committees of the Town Council, in addition to 158 examinations conducted on behalf of the Education Committee as reported on p. 114. OUT-DOOR RELIEF. The amount of poor relief paid by the West Ham Guardians in the East Ham Relief Districts was £43,611, as compared with £68,822 for the previous year. 17 PREVALENCE AND CONTROL OVER INFECTIOUS DISEASES. Small Pox. 17 cases of Small Pox, occurring in 5 families, were notified during the year with no deaths. Date Address Age Years Probable source of infection No. of contacts traced and kept under observation Secondary Cases State of vaccination of patients In same house Elsewhere 1928 March Telham Rd. 34 From visit to Middlesbrough 14 3 Nil Not „ „ 4½ „ „ „ 61 „ „ „ 22 „ July Telham Rd. 16 Unknown 12 5 2 Not „ „ 14 „ Aug. „ 12 „ „ „ 10 „ „ „ 18 Recent „ „ 7 Not „ Telham Rd. 24 Contact with Telham Ed. cases 12 1 — „ Sept. „ 56 Infancy Dec. Cleves Rd. 73 Contact with 2 West Ham cases 6 3 — Infancy „ „ 31 Recent „ „ 2½ Recent „ „ 48 About 20 years ago „ Poulett Rid. 23 Contact with Poplar case 17 — — Recent Scarlet Fever. The number of Scarlet Fever cases notified was 832, of which 325 were admitted to Hospital. Only 2 deaths occurred. Scarlet Fever has changed in character during the past 20 years, from being a disease of considerable severity to one of comparative mildness, and this accounts for the increased number of cases. A case is admitted to the Hospital, and upon enquiry into the source of infection one often finds another member of the family has had a mild attack, which had not been diagnosed. No use has been made of the Schick and Dick tests in Diphtheria and Scarlet Fever. 18 Diphtheria. 669 cases of Diphtheria were notified, with 55 deaths, as against 464 cases with 34 deaths in 1927. 648 cases were treated in Hospital with 46 deaths. For those cases treated at home the Corporation provided antitoxin free to all medical practitioners in the Borough for the patients who were unable to afford the cost. Free bacteriological examination of "swabs" from the nose and throat of suspicious cases and contacts are made for medical practitioners. The majority of practitioners take full advantage of this service, and it is only when they neglect to do so that serious cases are admitted with unfortunate results, as the early administration of antitoxin is a sure remedy for the disease. Enteric Fever (Typhoid and Para-Typhoid). 7 cases were notified, 4 being Para-Typhoid. 1 Enteric case died. Erysipelas. 60 cases were notified. Puerperal Fever. Eight cases were notified during the year, with two deaths. Eleven cases were notified as suffering from Puerperal Pyrexia, but recovered without complications. Meningococcal Meningitis. One case was notified, but three deaths were registered as due to the disease. Encephalitis Lethargica. Three cases notified with two deaths. Pneumonia. There were 93 deaths registered as due to the disease, the majority being a complication of Influenza. Preventive Methods Undertaken to Control the Spread of Infectious Disease. On receipt of the notification of a case the patient is at once removed to Hospital, if this is desired or necessary, and the room 19 previously occupied and its contents are disinfected. Library books, if present, are removed for disinfection. Whether the patient be removed to Hospital or not, the Sanitary Inspector at once calls and obtains all particulars of the case and endeavours to trace the source of infection. He also leaves a printed form giving full instructions as to isolation, etc., and the precautions which should be adopted to prevent the spread of infection. Information is obtained as to the Day and Sunday schools attended, either by the patient or by children in the house, the school authorities are notified, and all children living in the house are for a time excluded. The source of the milk supply, the occupation of the inmates, home work, sanitary condition of the premises, water supply, presence of animals, etc., are all investigated, and a report made to me on the same day. The name of the laundry is also ascertained, the proprietor is notified, and the sending of clothes there is prohibited until the premises are free from infection. Disinfection of premises and articles which have been exposed to infection is undertaken by the Sanitary Department. Disinfectants in every case are supplied free of charge. The Council also supply Anti-toxin gratuitously to all medical practitioners for the treatment of cases in the Borough. DISEASE NOTIFICATION 1923-1928. Disease. 1923 1924 1925 1926 1927 1928 Small Pox - - - - - 17 Scarlet fever 170 215 221 350 798 832 Diphtheria 160 128 246 337 464 669 Enteric Fever (Typhoid and Para-Typhoid) 3 5 9 7 2 7 Erysipelas 32 38 41 41 38 60 Puerperal Fever 5 5 5 5 4 8 Puerperal Pyrexia — — — — 11 11 Cerebro-Spinal Meningitis 1 1 1 1 4 1 Encephalitis Lethargica — 9 6 1 2 3 Ophthalmia Neonatorum 11 11 6 8 10 12 Acute Polio Myelitis 3 1 1 — 5 — 385 413 536 750 1338 1620 Pneumonia 54 79 91 70 114 82 20 TUBERCULOSIS. Notifications, 1923-1928. 1923 1924 1925 1926 1927 1928 Pulmonary Tuberculosis 220 249 254 237 206 232 Other forms do. 76 95 64 50 45 46 296 344 318 287 251 278 New Cases and Mortality during 1928. Particulars of new cases of tuberculosis and of deaths from the disease in the area during 1928:— Age Periods. New Cases. Deaths. Pulmonary. Non-Pulm. Pulmonary. Non-Pulm. M. F. M. F. M. F. M. F. Under 1 — — — 1 — — 2 1 1—5 2 — 3 5 — — 3 2 5 — 10 2 4 5 2 — — — — 10 — 15 1 9 7 5 — 1 — — 15 — 20 11 20 3 2 5 8 2 1 20 — 25 12 25 — 2 6 7 1 1 25 — 35 28 28 1 — 11 19 — 1 35 — 45 26 13 4 4 17 9 2 1 45 — 55 19 11 - 1 18 6 — — 55 — 65 14 4 1 — 7 1 — — 65 and upwards 3 — — - 1 1 1 — Totals 118 114 24 22 65 52 11 7 Public Health (Prevention of Tuberculosis) Regulations, 1925. No action has been taken with regard to tuberculous employees in the milk trade. 21 TABLE I.— TUBERCULOSIS SCHEME. Return showing the work of the Dispensary during the Year 1928. Diagnosis. Pulmonary. Non-Pulmonary. Total. (6) Adults. (6) Children. Adults. Children, Adults. Children. M. F. M. F. M. M. F. F. M. F. M. F. A.— New Cases (7) examined during the year (excluding contacts) :— (a) Definitely tuberculous 69 46 3 6 4 12 6 5 73 58 9 11 (b) Doubtfully tuberculous (8) — — — — — - — — 41 43 15 15 (c) Non-tuberculous - - - - - - - - 23 21 7 2 B.— Contacts examined during the year :— (a) Definitely tuberculous 7 14 1 1 — - 2 2 7 14 3 3 (b) Doubtfully tuberculous (8) - - - - - - - - 23 27 23 34 (c) Non-tuberculous - - - - - - - - 22 62 50 45 C.— Cases written off the Dispensary Register (9) (a) Cured (10) 3 2 1 - 3 2 2 - 6 4 3 - (b) Diagnosis not confirmed or nontuberculous (including cancellation of cases notified in error) - - - - - - - - 94 134 83 69 D.— Number of Persons on Dispensary Register (9) on December 31st:— (a) Diagnosis completed 384 337 55 44 74 50 79 47 458 387 134 91 (b) Diagnosis not completed - - - - - - - - 16 20 26 33 22 1. Number of persons on Dispensary Register(9) on January 1st ... 1089 2. Number of patients transferred from other areas and of " lost sight of "(l1) cases returned 33 3. Number of patients transferred to other areas and cases " lost sight of" 109 4. Died during the year 86 5. Number of observation cases(8) under A (b) and B (b) above in which period of observation exceeded 2 months 38 6. Number of attendances at the Dispensary (including Contacts) 2398 7. Number of attendances of non-pulmonary cases at Orthopaedic Out-stations for treatment or supervision — 8. Number of attendances, at General Hospitals or other Institutions approved for the purpose, of patients for (а) "Light" treatment 553 (b) Other special forms of treatment 139 9. Number of patients to whom Dental Treatment was given, at or in connection with the Dispensary — 10. Number of consultations with medical practitioners (а) At Homes of Applicants 12 (б) Otherwise 262 11. Number of other visits by Tuberculosis Officers to Homes 3 12. Number of visits by Nurses or Health Visitors to Homes for pensary purposes 4387 13. Number of (a) Specimens of sputum, &c., examined 896 (b) X-ray examinations made in connection with Dispensary work 29 14. Number of Insured Persons on Dispensary Register(9) on the 31st December 562 15. Number of Insured Persons under Domiciliary Treatment(4) on the 31st December 124 16. Number of reports received during the year in respect of Insured Persons:— (a) Form G.P. 17 — (b) Form G.P. 36 316 23 NOTES TO TABLE I.— TUBERCULOSIS. (1) Public Medical Treatment.—Treatment at a dispensary or residential institution or "general supervision," under a scheme approved by the Minister of Health for the treatment of tuberculosis, of a person who has been diagnosed to be suffering from tuberculosis. (Note.—A patient under domiciliary treatment is regarded as also under "general supervision" by the Tuberculosis Officer.) (2) Patient.-—A person who has been diagnosed to be suffering from tuberculosis and is under public medical treatment for tuberculosis. (The term does not include a person who is kept under observation pending the establishment of the diagnosis, and who is referred to in the Memorandum as an "observation case," but includes all persons on the Dispensary Register who are under "general supervision," even if not in receipt of any treatment.) (3) Dispensary Treatment.—Treatment by a Tuberculosis Officer in cases where the patient is seen not less frequently than once in every month, and is examined not less often than once in three months. (4) Domiciliary Treatment.—Treatment of an insured patient by his Insurance practitioner on the recommendation of the Tuberculosis Officer. (5) Year.—The calendar year ending on the 31st day of December. (6) Adults.—For the purposes of Tuberculosis Records all patients of 15 years and upwards are classed as adults. (7) New Cases.— (a) All persons examined for the first time at, or in tion with, the Dispensary, except definite cases of tuberculosis transferred from the areas of other local authorities. Persons seen in consultation, who will subsequently be dealt with by their own private practitioners, are included. (b) Persons who have been dealt with previously by the Dispensary and discharged as "cured," or provisionally diagnosed as not, at that time, suffering from tuberculosis, who return to the Dispensary as suspected cases of tuberculosis. (8) Observation Cases.—Persons attending at, or in connection with, the Dispensary, in whose cases the Tuberculosis Officer cannot, within a period of one month from his first examination of the case, come to a definite diagnosis after physical examination and the application of the necessary tests. In completing sections A and B, such cases are entered under sub-head (b) in each section. (9) Dispensary Register.—List containing names of all persons attending at, or seen in connection with, the Dispensary for diagnosis or for treatment for tuberculosis, including patients 24 under "general supervision" (whether or not accompanied by domiciliary treatment), and patients or observation cases in residential institutions, and "contacts." (This is distinguished from the Notification Register kept by the Medical Officer of Health.) (10) Cured.— Patients with tuberculosis are not deleted from the Dispensary Register as "cured" until in the case of nonpulmonary tuberculosis, 3 years, and in the case of pulmonary tuberculosis, 5 years, have elapsed without any symptoms of active disease (i.e., arrest has been maintained for 3 years). (11) Cases " lost sight of."— Patients who have failed to submit themselves for examination during two consecutive calendar years notwithstanding all efforts to trace them. These are written off the Dispensary Register at the end of the year. (Patients who are known to have left the district permanently but who cannot be transferred to another local authority because their destination is not known, and patients seen only in consultation for the purpose of diagnosis, and others who desire no further assistance under the tuberculosis scheme for public medical treatment, are marked off at once.) 25 REPORT ON THE WORK OF THE TUBERCULOSIS DISPENSARY. The regulations concerning the administration of tuberculosis schemes issued by the Ministry of Health in Memo. 37/T continue to work satisfactorily. Co-operation with the Dispensary in the prevention of the disease shows a marked improvement, and the Dispensary can be truly said to be a centre for diagnosis in suspected cases, apart from the advice which is given in the mode of living to tubercular patients generally. Special attention is being paid to those patients who have had a course of sanatorium treatment, more particularly in following them up with regard to their " after care." Emphasis is laid upon their endeavouring to live the sanatorium life at home as far as is practically possible, such patients being kept under regular dispensary supervision and examined at short periodic intervals in order to see that advice is being carefully followed. It is only in this way that the advantage of sanatorium treatment can be made a permanent one, for unless the patient realises that this treatment must be followed up at home as far as possible, there is a risk that the disease will again become active. Then there is the question of such patients endeavouring to avoid repeated colds, which are always a grave danger. In the majority of cases home treatment is difficult to carry out successfully as the houses are overcrowded and the use of a shelter often impracticable. The examination of contacts is an important sphere of work at the dispensary for it is here particularly that preventive work holds the field. This year contacts have presenred themselves for examination in increased numbers and, what, is more satisfactory, many have attended of their own accord for examination, and those whom the nurses have advised to attend for examination have needed less persuasion than hitherto. There are, therefore, obvious signs of improvement in cooperation with the Dispensary by individuals on the lay side—and in this connection one cannot speak too highly of the ever ready support in this " contact " work by the visiting nurses of the dispensary staff. Co-operation with the dispensary on the part of General Practitioners has been highly satisfactory. At 26 tically every session patients are sent up with letters from their doctors asking for an opinion with regard to the patient in question. In many cases, where the diagnosis is doubtful, patients are kept under a period of observation, and in order that the dispensary may give the practitioner the best possible assistance with his suspicious cases—which is one of the objects of the dispensary— certain essential examinations are made. Examination of Sputum. This is carried out in every case where sputum is available. In suspicious cases after two or three negative sputa have been obtained by the ordinary routine method, a more concentrated method of examination has this year been adopted at the dispensary —known as the " antiformin method." This has in several cases proved to- be very helpful and, moreover, economical. For whilst on occasions several sputum examinations have proved negative by the ordinary "carbol-fuchsin method" the "antiformin method" has given a positive result, thus avoiding further repeated examinations by the ordinary method. X-ray examination of the chest. The value of this form of examination in suspected cases is now universally recognised. We have this year at the dispensary made increased use of this form of examination, which has proved to be extremely helpful. We have been fortunate in obtaining the co-operation of Dr. Stanley Melville, Radiologist to the Brompton Hospital, and the photographs obtained have been of immense value in diagnosing- early cases of the disease, where other clinical and pathological examinations have been indefinite. So valuable is X-ray examination of suspected chest cases considered to be, that certain Authorities are adopting the principle of having every suspicious "Contact" case radiographed, and with advantageous results. It is a combination of the use of clinical, pathological and radiological methods which enables us to diagnose the cases in their early and curable state. Temperature observations. This procedure has been made full use of in suspected cases, and patients under observation have been carefully instructed by the nurses to keep temperature charts for a week and bring them to the dispensary. Moreover, the fallacy of keeping the thermometer in the mouth for only half of a minute is pointed out 27 and patients are instructed to keep the thermometer in the mouth for at least five minutes. In this way we are able to secure accurate reading's of the temperature—morning and evening—with satisfactory results. In these different ways we are able to be of service to the practitioner, and no doubt this is responsible for his increased and invaluable co-operation. Observation beds. There is one important item which would be of immense assistance and value in the early diagnosis of the disease in certain cases, and that is the possession of a few beds for suspicious types of cases whom one knows will not follow out the advice given, unless under constant observation. If this could be arrang'ed in connection with the hospital, it would be of immense value. Co-operation has been maintained with the general London Hospitals, and where patients are known to have been in a particular hospital, that hospital has been communicated with for clinical notes and X-ray data, so that we can have all the facts in our possession. With the School Medical Service there has been close cooperation. Certain difficulties have presented themselves during the year with regard to prophylactic measures, especially as to dental treatment for children over ten years of age whose parents have to provide dental treatment when advised by the dispensary. If some help could be given in necessitous cases the advice will be carried out with certainty. Treatment of advanced cases. With regard to advanced cases the only institutional treatment at our disposal is that provided by Whipps Cross Hospital. Certain cases whose homes have been visited have, after advice, consented to go to the hospital, thus removing the danger of infection to other members of their family. Unfortunately many object to the stigma of a poor-law hospital, and of those who go into the Hospital only a few remain for any length of time. It would, therefore, be of great advantage if some provision could be made for these advanced cases, other than that provided at Whipps Cross Hospital, as these cases are such a very grave danger to contacts. 28 The visiting work of the Dispensary nurses has increased enormously with unquestionably satisfactory results. Contact cases have been made a special feature of their work, and for their every ready help and invaluable co-operation I should like to express my indebtedness. Unfortunately, in the working of the Dispensary there is the disadvantage of extremely limited accommodation. Confidential particulars with regard to the taking of a history of a new patient cannot be received in private and the limited dressing-room accommodation for the patients necessitates observation cases coming into close contact with patients suffering from tuberculosis. Another drawback is the situation of the Dispensary on the first floor, which means that surgical cases, requiring crutches, are in danger of falling on the staircase and have always to be escorted by a nurse. Moreover certain pulmonary cases are not fit to undergo the exertion of mounting the staircase. The dispensary clerks have closely co-operated in the general work of the dispensary and have readily given of their best. In this way with the close co-operation of the Dispensary staff the work of the Dispensary has made good progress. TABLE II.—RESIDENTIAL INSTITUTIONS. (A) Average Number of Beds Available for Patients during the Year 1928. Observation. Pulmonary Tuberculosis. Non-Pulmonary Tuberculosis. Total. "Sanatorium " Beds. "Hospital" Beds. Disease of Bones and Joints. Other Conditions. Adult Males 30 8 2 2 42 Adult Females — 15 4 3 3 25 Children under 15 — 13 2 11 5 31 Total — 58 14 16 10 98 29 (B) Return showing the Extent of Residential Treatment during the Year 1928 In Institutions on Jan. 1 Admitted during the year. Discharged during the year. Died in the Institutions . In Institutions on Dec. 31. Number of Pa- tients Adults M. 44 89 89 5 39 F. 23 47 43 3 24 Children M. 19 15 14 — 20 F. 15 13 12 — 16 Number of Observation Cases | Adults M. — — — — — F. — 1 1 .—. — Children M. — — — — — F. — — — — — Total 101 165 159 8 99 30 TABLE III. Return showing the immediate results of Treatment of Patients and of Observation of Doubtful Cases discharged from Residential Institutions during the Year 1928. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Under 3 months. 3-6 months. 6-12 months. More than 12 months. Total. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. Pulmonary Tuberculosis. Class T.B. minus. Quiescent 1 2 1 3 4 4 1 — 3 1 — 3 23 Improved 3 1 1 2 7 2 — — 2 1 — — 19 No material improvement 4 — — — 1 2 1 — — — — — 8 Died in Institution 1 — — — — — — — — — — — 1 Class T.B. plus. Group 1. Quiescent 3 1 — 5 3 — 1 — — — — — 13 Improved 3 1 — 2 — — 1 — — 1 — — 8 No material improvement 1 — — — — — — 1 — — — — 2 Died in Institution — — — — — — — — — — — — — Class T.B. plus. Group 2. Quiescent — — — 4 — — 2 1 — 2 — — 9 Improved 8 1 — 18 3 — o 6 — 1 — — 42 No material improvement 4 — — 5 1 — — 4 — — — — 14 Died in Institution — 1 — 1 — — — — — — — — 2 Class T.B. plus. Group 3. Quiescent — — — — — — — — — — — — — Improved — — — 1 — — 1 — — — — — 2 No material improvement — 3 — 1 2 — 1 — — — — — 7 Died in Institution 2 — — — 1 — — — — — 1 — 4 It should be borne in mind that the definition of " patient " does not include persons in whom a definite diagnosis of tuberculosis has not been made. TABLE III —continued. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Under 3 months. 3-6 months. 6-12 months. More than 12 months. Total. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. Non-Pulmonary Tuberculosis. Bones and Joints. Quiescent or Arrested — — — — — — — — — — — 3 3 Improved — — — — — — — — — — — — — No material improvement — — — — — — — — — — 1 — 1 Died in Institution — — — — — — — — — 1 — — 1 Abdominal. Quiescent or Arrested — — — — — 1 — — — — — — 1 Improved — — — — — — — — — — — — — No material improvement — — — — — — — — — — — — — Died in Institution — — — — — — — — — — — — — Other Organs. Quiescent or Arrested — — — — — — — — — — — — — Improved — — — — — — — — — 1 — — 1 No material improvement — — — — — — — — — — — — — Died in Institution — — — — — — — — — — — — — Peripheral Glands. Quiescent or Arrested — — — 1 — 2 — — — — — — 3 Improved — — — — — — — — 1 — — — 1 No material improvement — — — — — 1 — — — — — — 1 Died in Institution — — — — — — — — — — — — — Under 1 week 1-2 weeks. 2-4 weeks. More than 4 weeks. Observation for purpose of diagnosis. Tuberculous — — — — — — — — — — — — — Non-tuberculous — — — — 1 — — — — — — — 1 Doubtful — — — — — — — — — — — — — 32 HARTS SANATORIUM. Average Number of Beds Available for Patients at Harts Sanatorium. ] Observation. PulmonaryTuberculosis. Non-Pulmonary Tuberculosis. Total " Sanatorium " Beds. " Hospital " Beds. Disease of Bones and Joints. Other Conditions. Adult Males — 27 8 — 35 Adult Females — 15 4 — — 19 Children under 15 — 2 — — — 2 Total — 44 12 — — 56 Return Showing the Extent of Residential Treatment during the Year. [ In Institution on Jan. 1 Admitted during the year. Discharged during the year. Died in the Institution. In Institution on Dec. 31 Number of Pa- tients Adults M. 33 83 80 4 32 F. 19 41 40 3 17 Children M. — — — — — F. 2 3 4 — 1 Number of Ob- servation Cases Adults M. F. — 1 1 Children M. — — — — — F. — — — — — Total 54 128 125 7 50 €>■» GO Return showing the immediate results of Treatment of *Patients and of Observation of Doubtful Cases discharged from Harts Sanatorium during the Year 1928. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution Total. Under 3 months. 3-6 months. 6-12 months. More than 12 months. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. Pulmonary Tuberculosis. Class T.B. minus. Quiescent 1 2 — 3 4 1 1 — — 1 — — 13 Improved 3 1 1 1 6 1 — — 1 — — — 14 No material improvement 4 — — — — — 1 — — — — — 5 Died in Institution 1 — — — — — — — — — — — 1 Class T.B. plus. Group 1. Quiescent 3 1 — 5 3 — 1 — — — — — 13 Improved 3 1 — 2 — — 1 — — 1 — — 8 No material improvement — — — — — — — 1 — — — — 1 Died in Institution — — — — — — — — — — — — — Class T.B. plus. Group 2. Quiescent — — — 4 — — 2 1 — 2 — — 9 Improved 8 1 — 17 3 — 5 6 — 1 — — 40 No material improvement 4 — — 3 1 — — 4 — — — — 12 Died in Institution — 1 — 1 — — — — — — — — 2 Class T.B. plus. Group 3. Quiescent — — — — — — — — — — — — — Improved — — — 1 — — — — — — — — 1 No material improvement — 3 — 1 2 — 1 — — — — — 7 Died in Institution 2 — — — 1 — — — — — 1 — 4 Total 29 10 1 38 20 2 12 12 1 5 1 — 130 Under 1 week 1-2 weeks. 2-4 weeks. More than 4 weeks. Observation for purpose of diagnosis. Tuberculous — — — — — — — — — — — — — Non-tuberculous — — — — 1 — — — — — — — 1 Doubtful — — — — — — — — — — — — — It should be borne in mind that the definition of " patient " does not include persons in whom a definite diagnosis of tuberculosis has not been made. 34 Patients discharged 132 (including 7 deaths). Average duration of stay, 20 weeks. Number of patient days, 20,281. Number of beds available at end of year, 56. Average number of beds occupied, 55.41. The number of patients admitted in 1928 was slightly greater than in 1927. This does not mean that the average duration of treatment has shortened, in point of fact it has somewhat lengthened, but that the new shelters erected in October, 1927, have been fully occupied throughout the year. Of the seven deaths, two were due to causes other than Pulmonary Tuberculosis, viz., one to Cerebral Haemorrhage and one to Endocarditis. Two encouraging facts arise from the table showing the immediate results of treatment at " Harts " :— 1. In 1928 the number of cases discharged as " Quiescent " was 35, as compared with 22 in 1927. 2. In 1928 the number of cases discharged as " Not improved " was 25, as compared with 35 in 1927. One of the reasons, no doubt, for these improved results is the fact that patients are obtaining treatment at an earlier stage of the disease than heretofore, and another is that they are now realising that a long sojourn in a sanatorium in the early stages is preferable to repeated short stays. However, in many cases domestic affairs or economic conditions at home are such as to preclude prolonged sanatorium treatment, and the patients have to resume their ordinary life before they are fit to do so. Artificial pneumothorax treatment has been employed in an increasing number of suitable cases, and the immediate results have been very efficacious and striking. The number of refilling operations performed was 139, an increase of 25 on the previous year. It is necessary to watch the progress of these cases by means of frequent X-ray screenings or photographs, and the arrangement obtaining with authorities of the Forest Hospital, Buckhurst Hill, has again been both convenient and helpful. The bacteriological examinations of patients' sputa numbered 199, and in addition several specimens of pleural effusions and other discharges of a pathological nature were also microscopically investigated. 35 The entertainments given by Concert Parties and a Band at various times during the year were much appreciated by the patients, as also was the rendering of carols by a Choir on Boxing Day. HARTS SANATORIUM.—Year ended 31st March, 1929. Expenditure. Cost per Patient per week. £ S. d. Salaries and Wages 2,367 16 7 Provisions 2,384 16 9 Disinfectants, Drugs and Appliances 93 0 8 Coal, Coke and Firewood 277 1 11 Lighting and Water 373 2 8 Furniture, Bedding and Linen 50 0 4 Uniforms and Dresses 7 0 1 Chandlery and Sundries 266 1 10 General Repairs 773 5 5 Garden Implements, Seeds, etc. 42 0 3 Horse Hire 19 0 2 Printing, Stationery and Advertisement 29 0 2 Rent of Telephones 31 0 3 Rates, Taxes and Insurance 359 2 6 X-Ray Examinations 36 0 3 £7,106 49 10 REPORT ON THE WORK AT THE BOROUGH INFECTIOUS DISEASES HOSPITAL. During the year 1928 the incidence of Diphtheria and Scarlet Fever remained very high; that for Diphtheria being the highest ever known in the district. The patients admitted to Hospital numbered 997, as compared with 984 in the year 1927, but in a large proportion of cases the period of detention in Hospital, for Diphtheria, was above the average. Unfortunately it has been necessary to continue to overcrowd the patients, owing to lack of accommodation and the very high incidence of cases of Diphtheria which it is important should be treated in Hospital, on the other hand a large percentage of the Scarlet Fever patients have been treated in their own homes, with apparently no untoward results either in the direction of the 36 occurrence of complications or of the dissemination of infection. In selecting cases of Scarlet Fever for admission to Hospital consideration has been given to (a) home accommodation, (b) severity of the disease, and (c) social and financial circumstances. Furthermore, the period of detention in Hospital for Scarlet Fever patients has been curtailed, where possible, in accordance with the suggestion of the Ministry of Health. The following table indicates the number of patients admitted for each disease and the number discharged, or who have died, in the year 1928 :— Disease. Remaining at end of 1927. Admitted during 1928. Discharged during 1928. Died during 1928. Remaining at end of 1928. Scarlet Fever 50 315 346 2 17 Diphtheria 62 639 590 45 66 Diph. Scarlet — 11 11 — — Enteric — 6 6 — — Pneumonia — 1 1 — — Cerebro-Spinal Fever — 2 2 — — Measles — 1 1 — — Measles and Pneumonia — 1 — 1 — Laryngitis — 1 1 — — Total 112 977 958 48 83 These cases were subsequently diagnosed as mild heat-stroke and scarlet fever respectively. 1. TREATMENT OF THE ACUTE INFECTIOUS DISEASES. (a) Scarlet Fever. Excluding the 17 patients remaining at the end of the year 1928 there were 348 completed cases of this disease treated. Of these two died, giving a mortality rate of 0.57 per cent., as compared with a rate of 0.38 per cent, for the previous year. In neither case was death due entirely to Scarlet Fever; in one patient Scarlet Fever followed upon a serious accident with injuries, which included a fracture of the femur and complicated by broncho-pneumonia; in the other case septicaemia and bronchopneumonia supervened. 37 The chief complications which occurred in the cases under treatment during- the year were as follows :— Cervical Adenitis 29 Bronchitis 1 Rhinitis 36 Diphtheria 7 Nephritis 7 Erysipelas 1 Otitis Media 23 Jaundice 3 Arthritis 6 Broncho-pneumonia 1 Onychia 21 Septicaemia 1 In 17 of these cases the diphtheria bacillus was isolated and antidiphtheritic serum was administered. The following table gives particulars of the chief diseases and morbid conditions associated with scarlet fever which were present in the patients admitted during the year :— Pertussis 3 Scabies 2 Diphtheria 26 Impetigo 12 Varicella 1 Endocarditis 5 Tuberculosis 1 Septic Wounds, Scalds Fractures 1 and Burns 3 It will be noticed that 8 per cent, of the cases of Scarlet Fever were associated with infection by the diphtheria bacillus, and in these cases isolation and treatment with anti-diphtheritic serum was necessary. In 23 patients suffering from the more severe septic and toxic forms of Scarlet Fever it was considered advisable to administer scarlet fever antitoxin and, with the exception of one case, complicated by septicaemia and broncho-pneumonia, the results were highly satisfactory. Much difficulty continues to be experienced as the result of the persistence of nasal, pharyngeal and aural complications, which necessitate postponing the discharge of patients, often for prolonged periods ; furthermore, the recurrence of these complications, after discharge from Hospital, is not infrequent. There is no doubt that these conditions are most likely to supervene in those patients who have suffered, over lengthy periods, from chronic naso-pharyngeal infection with hypertrophy of the tonsils, and with the presence of adenoidal tissue in the naso-pharynx. Another factor which must not be lost sight of in this respect is the lack of sufficient accommodation to allow of the separation of convalescent from acute cases with the result that re-infection 38 is encouraged ; the discharge of patients directly from an acute ward is also very unsatisfactory, and one looks forward to the time when a discharge block will be provided for this purpose. (b) Diphtheria. Excluding the 66 cases remaining in the Hospital at the end of the year, 635 completed cases of Diphtheria were treated during the year 1928, and of this number 45 died. This equals a case mortality of 7 per cent, as compared with a rate of 6.5 per cent, in the year 1927. Ten of the. fatal cases were of the haemorrhagic type of Diphtheria, four died from post-diphtheritic paralysis of the respiratory muscles, one case was complicated by gangrene of the lower extremities, two cases developed broncho-pneumonia, and in three cases the patients were already suffering from endocarditis, enteritis and marasmus respectively. Of the remaining 25 fatal cases, 11 died within twenty-four hours of admission to Hospital and 14 were suffering from profound toxaemia on admission. The average duration of illness, prior to admission to Hospital, in the 45 fatal cases, was 4.3 days, and the administration of anti-diptheritic serum holds out little hope of recovery in cases so advanced in the disease. The ages at which death occurred were :— At 1 year 3 27 At 6 years 3 14 At 11 years 2 4 „ 2 years 5 „ 7 „ 4 „ 12 „ 1 „ 3 „ 5 ,, 8 ,, 4 „ 13 „ 0 ,, 4 „ 6 „ 9 „ 1 „ 14 „ 0 ,, 5 ,, 8 „ 10 „ 2 ,, 15 „ 1 The cases of Diphtheria throughout the year were, for the most part, of that very severe type which showed itself towards the end of the year 1927 : a type which has not occurred for many years. The majority of the patients exhibited diffuse foul-smelling pharyngeal deposits with marked glandular enlargement, periglandular oedema and severe toxæmia with the only too frequent supervention of vaso-motor paralysis, cardiac dilatation and circulatory failure. In these cases bacteriological examination has revealed the presence of streptococci in addition to the diphtheria bacillus and, for this reason, 43 patients were treated by means of a combined injection of anti-diphtheritic serum and polyvalent anti-streptococcus serum ; the results of this method have been very encouraging. The types of Diphtheria classified according to the site of the local lesion were as follows :— 39 Faucial 416 Nasal 21 Laryngeal 6 Faucial and Nasal 164 Faucial and Laryngeal 22 Faucial, Nasal and Laryngeal 6 635 The chief complications which occurred in the cases of Diphtheria under treatment during the year were :— Paralysis 44 Cervical Adenitis 121 Broncho-pneumonia 4 Otitis Media 1 Epistaxis 29 Gangrene 1 Myocarditis 127 Albuminuria 62 In some instances patients were admitted who were suffering from some other disease in addition to Diphtheria, and the following table gives particulars of these :— Pertussis 1 Impetigo 6 Scarlet Fever 2 Endocarditis 11 Varicella 2 Enteritis 1 Morbilli 4 Marasmus 1 Chorea 1 Mastoid Abscess 1 Rubella 3 Scabies 2 Otitis Media 5 As has been noted in connection with Scarlet Fever, the Diphtheria patients have to convalesce in the same ward as the acute cases and, as a result, in many instances, their convalescence and consequent discharge is considerably retarded. During the summer months this drawback is somewhat negatived, but even during this period the convalescent patients are subjected to an infectious atmosphere during the night. The provision of a small convalescent home in the country, to which carefully selected cases might be sent, for a short period prior to returning home, would be of immense value in ensuring a complete recovery. 15,072,000 units of anti-diphtheritic serum were administered to patients during the year, the average dosage per head thus being about 24,000 units. 40 The following operations were performed in connection with the cases of Scarlet Fever and Diphtheria under treatment during the year :— For Acute suppurative Cervical Adenitis 7 ,, Acute superficial Mastoid Abscess 3 ,, Paronychia 11 ,, Submental Abscess 2 ,, Laryngeal obstruction 2 25 2. LABORATORY WORK. 486 bacteriological examinations of "swabs" for the identification of the diphtheria bacillus were carried out at the Hospital, as compared with 449 in the year 1927. 3. THE PREVENTION OF ACUTE INFECTIOUS DISEASE. In my report for last year I endeavoured to emphasise the importance of prophylactic inoculation (immunisation) and vaccination as the chief modus operandi in any attempt to prevent the occurrence of acute infectious disease. I also dealt with the necessity for maintaining a high degree of natural immunity, more especially in connection with dietary in early life and I laid special stress on the part played by unhealthy naso-pharyngeal conditions in allowing the infective virus a ready pathway into the tissues of the body. The following facts will serve to indicate the difficulties which beset us in trying to bring people to realise the very great importance of immunity, whether actively or passively acquired. The occurrence of four cases of small-pox in children of school age in the district called for increased care and vigilance in the admission of patients to Hospital and, arising out of this fact, statistics have been kept in regard to the condition as to vaccination of the patients admitted. The figures are instructive and serve (a) as a warning as to what might happen should small-pox infection be introduced accidentally into the Hospital and (b) as an indication of the attitude of so many people towards the question of immunisation. 41 Of 313 children admitted to the Diphtheria Wards only 107 had been vaccinated, whilst 70 children, out of a total of 151 admitted to the Scarlet Fever Wards, showed evidence of successful vaccination. Vaccinated 177 Not vaccinated 287 Total 464 That is to say, approximately 62 per cent. of these children are probably susceptible to small-pox and only 38 per cent. are satisfactorily protected. 4. LIGHT TREATMENT. The use of a single arc lamp—carbon has been used for general irradiation and tungsten for local treatment—has continued to afford a very valuable means of dealing with debilitated patients and those in whom localised septic complications, especially cervical adenitis and otitis media, have arisen. Unfortunately it is only possible to treat one patient at a time with general ultraviolet radiation and the installation of a large quadruple arc lamp would prove a great boon during the winter months. 5. ILLNESS AMONGST MEMBERS OF THE STAFF. Taking into consideration the conditions under which the staff carry out their duties and the fact that the type of diphtheria has been particularly virulent and infectious, it is very gratifying to be able to report a comparatively low incidence of illness. It must be remembered, however, that a high degree of physical fitness is demanded in candidates for appointment to the nursing or domestic staff and that we are fortunate in having a low percentage of staff changes. Seven members of the nursing staff contracted Diphtheria and one contracted Scarlet Fever, whilst one member of the domestic staff contracted Diphtheria and one Scarlet Fever. All of the cases were mild in type, treated early and made an uneventful recovery. 42 6. STATE EXAMINATIONS. During the year 1928 lectures and instruction in practical nursing- and hygiene have been carried out in accordance with the syllabus of the General Nursing Council and courses of lectures upon Infectious Diseases, Anatomy, Physiology, Hygiene, and Practical Nursing have been delivered. It has long been felt that the little time which the Matron and Sisters can spare during off-duty time for teaching the probationers is quite insufficient to ensure that systematic instruction and sound groundwork in the practical side of nursing which is so essential to their success. Towards the end of the year, after very carefully reviewing the position, a report was presented to the Hospital SubCommittee advising consideration of the necessity for the appointment of a Sister Tutor and for the supply of up-to-date teaching material and equipment. There is no doubt that such provision will operate to the advantage of the treatment of the patients in the hospital inasmuch that improved teaching facilities will attract a keener staff of probationers who, in turn, will be more skilled and efficient on account of the careful, regular, and systematic instruction which they will receive. 7. ACCOMMODATION FOR PATIENTS AND STAFF. This question is one which has been discussed on almost countless occasions, and last year a very full account, setting forth the exact position, was included in the annual report; the matter becomes more acute each year and in epidemic times, such as those which we have experienced during the past two years, the difficulties are almost insurmountable. Were it not for the loyalty and unselfishness of the Staff there is no doubt that a serious crisis might have occurred on many occasions. Fortunately there is no necessity to reiterate the unfavourable conditions under which patients are treated nor the former reports dealing with the very unsatisfactory accommodation available for the Staff, for I am pleased to report that the present Committee have attacked the problem thoroughly and there appears to be every prospect that the recommendations, made by the Ministry ot Health in the year 1922, will be carried out in the very near future. 43 This is an appropriate place to stress a matter which has been frequently reported and which deserves immediate and earnest consideration, viz., the very unsatisfactory condition of the surfaces of the roads approaching the Hospital from east and west; there is no doubt that even if the ambulances were of the best type available—and they are far from being so—the uneven travelling from either approach is jeopardising the chances of recovery in every severe case of acute infectious disease admitted. 8. CONCLUSION. The result of the year's work at the Hospital, taking all the circumstances into consideration, is satisfactory and, although the total mortality rate has increased (3.2 in 1927, 4.8 in 1928), when one looks back on the many battles which have been waged against very long odds, it seems remarkable that the increase is not double or even treble this figure. The type of Diphtheria under treatment during the year has meant very hard, unselfish, devoted and loyal work on the part of the Matron and Staff in order to bring about the excellent results which have been obtained. The treatment of cases of typhoid fever also furnishes us with a criterion of nursing skill and ability ; the six cases of this disease recovered, although one was complicated by intestinal hæmorrhage, another patient had recently undergone a severe abdominal operation, whilst a third developed pelvic complications. The duties and responsibilities of the Matron at the Isolation Hospital are not generally appreciated, but, with the absence of a full-time Medical Officer, a Steward and a Clerical Assistant, her position is by no means a sinecure, for she has to fulfil the functions of these offices in addition to her recognised duties—and these are numerous and onerous—as occasion arises. In this connection I should like to quote from my annual report for the year 1921 :— " I beg to remind the Council that before we became a County Borough in 1914, with about half the number of beds we now have, the Local Government Board and the Essex County Council pointed out the necessity for a full-time Resident Medical Officer at the Institution. This advice has not been acted upon." The further extensions which are contemplated warrant an early consideration of all these facts and make the appointment of at least one full-time Resident Medical Officer imperative. 44 In conclusion, I wish to place on record my very great appreciation of the work performed by the Matron and the Staff acting under her supervision and guidance. ISOLATION HOSPITAL.—Year ended 31st March, 1929. Expenditure Cost per Patient per week. Salaries and Wages £ s. d. 4,075 17 2 Provisions 3,155 13 4 Anti-Toxin 788 3 4 Disinfectants, Drugs and Appliances... 260 1 1 Coal, Coke and Firewood 758 3 2 Lighting and Water 787 3 4 Furniture, Bedding and Linen 265 1 1 Uniforms and Dresses 109 0 6 Chandlery and Sundries 463 2 0 General Repairs 653 2 9 Garden Implements, Seeds, etc. 43 0 2 Maintenance and Upkeep of Ambulances 598 2 6 Printing, Stationery and Advertisements 88 0 4 Rent of Telephones 51 0 3 Rates, Taxes and Insurance 227 1 0 £12,320 52 0 45 REPORT ON THE WORK OF THE MATERNITY AND CHILD WELFARE DEPARTMENT. The work of Maternity and Child Welfare is carried on under the provisions of the Maternity and Child Welfare Act, 1918. The Act includes the following clauses :— I. Arrangements for :— (a) Ante-Natal Clinic for expectant mothers. (b) Home visiting of expectant mothers. (c) Maternity Hospital or beds at a Hospital in which complicated cases of pregnancy can receive treatment. 2. Arrangements for :— (a) Such assistance as may be needed to ensure the mother having skilled and prompt attention during confinement at home. (b) The confinement of sick women, including women having contracted pelves or suffering from any other conditions involving danger to mother or infant at a Hospital. (c) The treatment in a Hospital of Post-Natal conditions of mother or infant. (d) Provision of systematic advice and treatment for infants at Clinics—up to school age. (e) Systematic home visitation of infants and children up to five years of age. 3. Provision of nurses for infectious cases among children in their own homes. 4. Home Helps may be provided at the Council's expense. 5. Milk and food to necessitous cases of expectant and nursing mothers and children under five years of age. 6. Grants are available for provision of beds for children up to five years. This includes cases which require supervision as regards dietetics and general conditionOphthalmia Neonatorum and epidemic Diarrhoea. 7. Provision of facilities for obtaining a Specialist's opinion in complicated cases; before and after confinement. The main centre is at White House, Plashet Grove, and there are subsidiary centres in Manor Park, Greatfield, and South Wards. 46 Staff. The Staff of the Centre at present consists of the Assistant Medical Officer in charge, six Health Visitors, and two Clerks. The work of the Maternity and Child Welfare Department suffered a great loss in the death of Dr. Elsie Thomson. During the four years she was in charge of this section the work made wonderful progress, largely due to the individual attention and sympathy shown by her to the mothers, and the loyal, capable administration with which she managed this department. Although the number of Health Visitors is at present only six, a comparison of the 1928 figures with those of 1927 show a large increase in the number of home visits and clinic attendances. The serious problem of the children between three and five years of age has still to be faced, and with the present small number of staff it is almost impossible to pay a sufficient number of visits to ensure that every child between four and five years old attends at the Clinic for a complete examination before entering school. When circumstances render it possible, an enlargement of the Staff of Health Visitors for this purpose is greatly to be desired. An extract from the Ministry of Health's Report, dated August, 1924, reads:— "It would appear that the services of seven Health Visitors are necessary if the work is to be carried out efficiently in all parts of the Borough." Since 1924 the work of the Centre has increased enormously. Subsidiary Centres have been added, and special Morning and Light Clinics; instituted. Infant Welfare Clinics. Infant Welfare Clinics are held as under :— At White House, Plashet Grove, on Monday, Thursday, and Friday, at 2 p.m. Thursday, at 9 a.m. At St. John's Church Hall, North Woolwich, on Tuesday, at 2.30 p.m. At Wesleyan Church Hall, Manor Park, on Tuesday, at 9 a.m. At St. George's Church Hall, Masterman Road, on Wednesday, at 2 p.m. 47 Attendances at Infant Welfare Clinics. Number of General Clinics held during the year 348 Total number of attendances 18,196 Number of medical consultations at General Clinics 9,054 Number of medical consultations at Special Clinics 1,233 The daily average of attendances at the Clinics were as follows :— White House, Monday afternoon 64 Manor Park, Tuesday morning 54 North Woolwich, Tuesday afternoon 17 Masterman Road, Wednesday afternoon Til White House, Thursday morning 36 White House, Thursday afternoon 71 White House, Friday afternoon 73 White House, Special Clinics 16 At the Clinic every child is undressed before weighing, and is carefully observed by the Health Visitor as regards clothing, general nutrition, condition of the skin, and any defects in development, and the mother advised with regard to general management and feeding of the child. A selected number of children is seen by the Medical Officer at each Clinic for specialised examination and advice. An effort is being made to examine each child thoroughly, within the last three months of attendance at the Clinic, before reaching school age. The teeth and throat receive special attention. As pointed out in 1927 Report, the Infant Welfare Clinics are not dispensaries for the treatment of sick children, but seek to maintain the health of the healthy child, and to afford guidance towards its normal and successful upbringing. Yet, while this is so, many departures from the normal are discovered at the medical examination of children, and such cases, medical or surgical, are referred to their own doctors for treatment, or to hospitals or dispensaries suitable for their conditions. Simple ailments of infancy in children attending the Centres are treated at the Morning Clinics at the White House. It is a significant fact that of the 11 children under the age of five who were notified during 1928 in East Ham as suffering from Tuberculosis, in all forms, were cases referred by the Medical Officer of the Infant Welfare Clinics to the Tuberculosis Officer. 48 On the other hand, young children under the age of five are frequently being referred to the Infant Welfare Clinics by the Tuberculosis Nurses from homes in which Tuberculosis has occurred, for examination as contacts by the Clinic Medical Officer, and observation, if desirable, at the Clinics themselves. The co-ordination and co-operation between the departments named well illustrates the relationship that exists, wherever possible, between the Maternity and Child Welfare Department and other public services in the Borough. It is also an illustration of the value of the Infant Welfare Clinics in reference to the detection of incipient illness in young children. Tonsils and Adenoids. When, in children attending the Clinics, operation for enlarged Tonsils and the presence of Adenoids is found to be desirable, the mothers are encouraged to choose hospitals on their own account, and are recommended accordingly. When, however, after careful inquiry into the family circumstances of such a case, financial aid is found to be necessary, the child is referred, at the cost of the Borough Council, to St. Mary's Hospital, Plaistow, or to the Balaam Street Children's Hospital, Plaistow, for the needful surgical treatment. During 1928, 21 children received treatment at St. Mary's Hospital, and 18 at the Balaam Street Hospital, at the expense of the Council. In such cases, on the day following operation, a Health Visitor visits the home, and gives the mother general advice as to after-treatment of the child. 66 visits of this character were made by the Health Visitors. It is encouraging to note that marked improvement in the general health of the children is observed in many cases after the removal of Tonsils and Adenoids. Ringworm. Two cases of Ringworm of the Scalp were referred to the School X-ray Department for radical treatment. Dental Treatment. Children referred from the Maternity and Child Welfare Centres are treated by the School Dentist, one afternoon in each week being set apart for this purpose. It is encouraging to find 49 that a second School Dentist and Nurse have been appointed, as during this year only urgent cases have been able to obtain immediate treatment, owing to pressure of work. The great disadvantage in treating expectant and nursing mothers is the difficulty encountered in the provision of dentures—and it would be a great advantage if facilities were provided to enable them to be obtained at a reduced rate. Details of the work done for dental cases referred from this Department will be found in Mr. Neam's Annual Report, p. 124. Many thanks are due to the Dental Staff for their unfailing courtesy and ready co-operation. Ophthalmic Treatment. Ophthalmic defects requiring special consideration are seen at the Special Clinic each week by the School Ophthalmic Surgeon. Details of the work done will be found in Mr. Gimblett's Annual Report, p. 121. Treatment by Artificial Sunlight. This special form of treatment, begun in 1927, has been continued throughout the winter and spring months. At present two sessions are held weekly—Tuesday, 3.30-5 p.m., and Thursday, 2-4 p.m. The short time in which the School Clinic premises are available for the use of the Maternity and Child Welfare Centre is quite inadequate for the large number on the waiting list, and for the requisite number of exposures. The arrangements for the convenience of mothers bringing the children for Sunlight treatment to the Town Hall are by no means ideal. They are obliged to carry one or more children to the top of the building, and the limited space in the waiting room makes it difficult for the accommodation and care of other children of the family who cannot be left at home. An ideal Clinic would include a lamp of a suitable height for babies, and a small arm chair for each child, thus avoiding- the necessity, unless desirable, for mothers to take the exposure with the child. If these facilities were provided at the Maternity and Child Welfare Centre, three full sessions per week could be allotted to this branch of the work, and one of the large rooms used as a playing room for other children accompanying their mothers. 50 Morning Clinics. The special morning Clinics, initiated during 1927, have more than justified their existence, as shown by an average attendance of 16 at each Clinic. The cases dealt with are chiefly test feeds, cases of difficult feeding, and children between three and five years who have been referred to the Medical Officer by the Health Visitors from their district visits. Comparing the number of visits paid to these older children during 1927 and 1928, it will be seen that a big effort has been made to concentrate, as far as the limited staff will allow, upon children nearing school age. The Work of the Health Visitors in the Homes of the Borough. The visiting of young infants and children under school age was the primary object of the appointment of Health Visitors, and remains the most important part of their work. Information (within 36 hours after confinement) as to all births in the Borough reaches the Medical Officer of Health under the requirements of the Notification of Births Acts, 1907 and 1915, and is by him passed on to the Medical Officer of the Infant Welfare Department. A fortnight later, i.e., after the doctor or midwife has probably ceased to attend, the Health Visitor of the district in which a birth has occurred calls at the home, and does what she can to help the mother with regard to the care, management, feeding and clothing of the child, and of other young children in the house. This arrangement for advice by the Health Visitors is especially valuable in the case of young mothers with their first babies, and in poor homes where a trained nurse has not otherwise been available. Thereafter, periodic visits are made to the homes of infants during the first two years of life, and, as far as possible, at wider intervals, during the next three years, up to the time when the child comes under the observation of the School Medical Service. The limitations that exist to this further visiting are, however, very great, and have already been touchfed upon at the beginning of this report. In addition to the routine work of the Health Visitors, special visits to the homes are made in reference to cases of enlarged 51 Tonsils and Adenoids, cases of Pneumonia notified in infants, Ante-natal cases, cases of Puerperal Fever and Pyrexia, cases of Ophthalmia Neonatorum, etc. The visits made by the Health Visitors during 1928 were 17,074 as against 12,484 in the previous year. Particulars of Visits made by Health Visitors. Visits to infants under one year of age 7,259 Visits to children over one year of age 9,333 Visits to Tonsils and Adenoids cases 66 Visits to Ante-natal cases, first visits 156 Visits to Ante-natal cases, revisits 45 Special visits, not included in above groups 215 Total 17,074 Ante-natal Work. An Ante-natal Clinic is held at:— White House, Plashet Grove, on Friday, at 9.30 a.m. The Health Visitors follow up expectant mothers in their homes to advise regarding arrangements for confinement, preparation of infant clothing and general hygiene of the mother. The sanitary conditions of the home are also noted. Ante-natal supervision may be counted amongst the most important work of the Centre. The welfare of the child is provided for by the Maternity and Child Welfare Centre from now up till five years of age. To complete the system, the Ministry of Health urge the institution of a Post-natal Clinic, for immediate following-up after the confinement of the mother, thereby preventing many minor disabilities and much ill-health and worry. Great stress is laid on the Report on Maternity and Child Welfare, October, 1928, on the need for an adequate supply of maternity beds:—"It is pointed out that the number of mothers whose home circumstances are unsuitable for confinement at home is very large. Owing to pressure on the beds many cases are sent in too late." 52 Difficulties are often encountered by patients in obtaining admission to hospitals in the neighbourhood. It is not desirable for expectant mothers to have to book up at a hospital, where a long journey has to be taken before admission. The number of beds reserved by the Council are quite inadequate to accommodate a sufficient number of cases. If a Municipal Maternity Home could be provided locally, these defects could be overcome. Mothers in East Ham who are under the care of the Nurses of the Maternity Charity and District Nurses' Home, Plaistow, or any of its branches, or of Queen Mary's Hospital, Stratford, attend the Ante-natal Clinics in connection with those Hospitals. No cases already under the care of private doctors are examined at the White House Clinic, unless such patients bring to the Medical Officer of the Clinic letters from their doctors requesting examination for purposes of consultation. Maternity Accommodation. Under the provisions of the Maternity and Child Welfare Act, 1918, empowering Local Authorities to make arrangements for the institutional treatment of complicated midwifery cases, and for women whose homes are unsuitable for their confinement, the East Ham Borough Council have arrangements for the accommodation of necessitous cases requiring in-patient treatment, at Queen Mary's Hospital, Stratford, and at the Maternity Charity and District Nurses' Home, Plaistow. During 1928, four cases thus provided for were confined in Queen Mary's Hospital, and one at the Maternity Charity. 53 Infant Mortality and Deaths of Children under 5 Years. The following Table shows the causes of death at the different periods of infant life during the year 1928:— Causes of Death. Sex. Under 1 year 1—2 2—5 ALL CAUSES M. 61 22 24 F. 48 16 21 Measles M. 1 2 1 F. 3 3 1 Scarlet Fever M. – – – F. – – 1 Whooping Cough M. 4 4 1 F. 4 3 2 Diphtheria M. – 3 14 F. – 1 7 Influenza M. 1 – – F – – – Meningococcal Meningitis M. – 1 – F. – – – Tuberculosis of Respiratory System M. – – – F. – – – Other Tuberculous Diseases M. 2 2 1 F. 1 1 1 Cerebral Haemorrhage M. – 1 – F. – – – Bronchitis M. 1 – 1 F. 2 1 1 Pneumonia (all forms) M. 5 7 3 F. 8 5 3 Heart Disease M. – – – F. – – 2 Diarrhoea, &c. M. 6 – – F. 6 – – Nephritis M. – 1 2 F. – – – Congenital debility and malformation, premature birth M. 29 – – F. 18 1 – Deaths from violence M. – – – F. 1 – 1 Other defined diseases M. 12 1 1 F. 5 1 2 Legitimate. Illegitimate. Number of deaths under 1 year M. 58 3 F. 48 — 54 COMPARATIVE INFANT MORTALITY RATE—YEAR 1928. Birth-rate per 1,000 total population. Rate per 1,000 Births. Diarrhoea and Enteritis (under 2 yrs.) Total deaths under 1 year England and Wales 16.7 7.0 65 107 County Boroughs and Great Towns (including London) 16.9 9.6 70 156 Smaller Towns (1921 adjusted populations, 20,000—50,000) 16.6 4.8 60 London 15.9 10.2 67 EAST HAM 15.3 5.4 49 The comparative infant mortality rate for the year 1928 shows that East Ham continues to be greatly more healthy than England as a whole, and more healthy than London. The total number of deaths under one year per 1,000 registered births in England and Wales was 65, in London the figure was 67, in East Ham only 49 infants under one year of age per 1,000 births died. The comparative rate for Diarrhoea and Enteritis in young children is also very favourable, being 5.4 per 1,000 births in East Ham, as compared with 7.0 in England and Wales, and 10.2 in London. Inspection of Midwives. The Assistant Medical Officer of Maternity and Child Welfare is also Inspector of Midwives under the Borough Council, and in that capacity maintains a general supervision over the work of all midwives practising in East Ham, under the requirements of the Midwives Acts, 1902 and 1918, and the Midwives and Maternity Homes Act, 1926. Forty-one visits of inspection were made by the Inspecting Medical Officer during the year. Six midwives were interviewed by the Inspecting Medical Officer at White House Centre in connection with particular cases. On the whole their work was found to be satisfactory. By the rules of the Central Midwives' Board, midwives must send for medical aid in certain specifically named conditions. 55 During' the year medical help was obtained in 178 cases, as follows:— For the Mothers— Ruptured perineum 46 Prolonged labour 36 Post-partum haemorrhage 5 Retained placenta 1 Ante-partum hæmorrhage 9 Miscarriage 1 Rise of temperature 9 Inflammation of breasts 2 Malpresentations 3 Phlebitis 2 Uterine inertia 2 Other causes 6 For the Infants — Prematurity and dangerous feebleness 20 Deformities 1 Discharging eyes 7 Baby found dead on arrival of midwife 4 Born before arrival 2 Rash, undefined 1 Unsatisfactory condition of infant 14 Other causes 7 Visits have been paid as required to one registered Nursing Home in the district. Puerperal Fever and Puerperal Pyrexia. Notification of all feverish conditions occurring soon after a confinement, by doctors attending such cases, is required by regulations for the control of Puerperal Fever and Puerperal Pyrexia that came into force in October, 1926. The object of these Regulations is to secure that women who suffer from such conditions may as quickly as possible come under special treatment, if necessary, or may be provided with skilled nursing or with institutional treatment. 56 Eight cases of Puerperal Fever and 11 of Puerperal Pyrexia were notified. Twelve of these occurred in private practice, and seven were notified from hospitals. Maternal Deaths. Much attention has been paid to the question of Maternal Mortality, which in spite of all efforts, has not appreciably diminished. Full particulars of each maternal death are now entered on special Forms and reported to the Ministry of Health, and it is hoped by this means that new factors will be brought to light. During the year 1928, seven deaths in connection with turition occurred to East Ham cases as follows:— Puerperal septicaemia 2 Abortion 1 Pulmonary embolism 2 Post-partum haemorrhage 1 Shock 1 In addition to these there were four deaths due to diseases associated with childbirth. Ophthalmia Neonatorum. Ophthalmia Neonatorum (i.e., inflammation of the eyes of new-born babies) has in past years been terribly injurious to the sight of infants who contracted it, frequently leaving them permanently blind; and every effort is now made to control and eradicate this disease, under Regulations for its notification that came into force in October, 1926. Any doctor attending such a case is required to notify to the Medical Officer of Health. A midwife meeting the case of an infant having discharging eyes is required to summon a doctor, who then becomes responsible for notification, if he diagnose this disease. The information is passed by the Medical Officer of Health to the Medical Officer of the Child Welfare Department, and she keeps the case under observation, directly or through one of the Health Visitors. During 1928, 12 cases of Ophthalmia Neonatorum were notified in East Ham, visited and treated with no impairment of vision, as shown:— 57 Notified. Cases Treated Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. At Home. In Hospital Lathom Road 1 – 1 – – – First Avenue – 1 1 – – – Kimberley Avenue – 1 1 – – – Walton Road – 1 1 – – – Shrewsbury Road – 1 1 – – – Fourth Avenue – 1 1 – – – Albert Road 1 – 1 – – – Alverstone Road 1 – 1 – – – Strone Road – 1 1 – – – Flanders Road 1 – 1 – – – Fourth Avenue 1 – 1 – – – High Street North 1 – 1 – – – Cots for Babies. The provision of some cots for Clinic babies who are suffering from malnutrition, dietetic errors, infantile diarrhoea, rickets, etc., and requiring careful medical supervision for a short period, would be of great assistance in those cases where home conditions are unsuitable, and the mother unable, for various reasons, to attend the Clinic at frequent intervals. This is done with great success in many Boroughs. Free Milk. Under the Council's scheme £900 worth of free milk was supplied to expectant and nursing mothers and young children during the past year. In every case careful investigation of the family circumstances is made, to secure that only really necessitous cases shall receive, this benefit. Voluntary Associations. Thanks are again gratefully accorded to the Invalid Children's Aid Association for arranging periods of convalescence in the country for delicate children referred from the Clinics. Seventeen young children were sent away through the auspices of the Association during 1928. The Infant Welfare Centre in East Ham is affiliated with the Association of Infant Welfare and Maternity Centres, and the late Assistant Medical Officer, Dr. Elsie Thompson, was a 58 ber of the Committee of the National Baby Week Council and of the Local Committee of the Invalid Children's Aid Association. Co-ordination. There is very considerable co-ordination between the Maternity and Child Welfare work of the Borough and other Departments of the Public Health Service. The records of Clinic children on reaching the age of five years are sent to the School Medical Department for information regarding entrants to school life. Expectant and nursing mothers and young children requiring dental treatment are referred to the School Dental Surgeon from the Infant Welfare Clinics. Cases of Ringworm of the Scalp occurring in children under school age are referred to the School X-ray Department. Cases of Tuberculosis discovered at the Maternity and Child Welfare Centres are at once referred to the Tuberculosis Officer. The treatment of Tonsils and Adenoids is carried out under the same arrangements existing for School Medical Service cases. Ophthalmic cases are referred from the Infant Clinics to the School Ophthalmic Surg-eon. The treatment of infants by Artificial Sunlight is carried out at the School Clinic, the apparatus being shared with the School Medical Service. The use of the public ambulance is granted, when required, to convey expectant mothers to the maternity wards of hospitals. Financial investigations into the circumstances of parents applying for grants of milk, etc., are referred to the Financial Officer. Premises found in an unsanitary condition by Health Visitors in connection with their routine work are reported to the Senior Sanitary Inspector for further investigation and such action as he may find desirable. 59 VENEREAL DISEASES. Summary of work done by the Hospitals during the Year 1928. London Middlesex Essex Surrey Kent Herts. Bucks. E. Ham W. Ham Croydon Total Other Places Grand Total New Patients:— Syphilis 3,679 382 187 145 118 46 37 26 139 24 4,783 487 5,270 Soft Chancre 167 11 5 4 3 – – 3 5 – 198 37 235 Gonorrhoea 7,921 874 347 293 173 114 49 73 219 45 10,108 788 10,896 Not Venereal 6,913 814 366 331 199 82 49 93 246 70 9,163 432 9,595 Total 18,680 2,081 905 773 493 242 135 195 609 139 24,252 1,744 25,996 Total Attendances 620,583 49,658 20,604 20,260 10,034 4,989 2,507 4,837 11,498 3,080 748,050 15,485 763,535 No. of " In-patient" days 40,415 2,192 2,714 1,199 1,868 956 502 134 615 148 50,743 14,363 65,106 Salvarsan Substitutes, doses given 40,927 4,402 1,831 1,502 1,168 526 445 441 1,225 351 52,818 1,734 54,552 Pathological Examinations. For or at Centres:— Spirochaetes 859 72 15 19 9 2 2 5 17 – 1,000 51 1,051 Gonococci 51,621 2,977 2.208 1,831 1,823 517 249 449 1,136 447 62,758 2,318 65,076 Wasserraann 24,910 1,775 869 942 606 285 175 201 497 189 30,449 1,687 32,136 Others 7,324 466 224 382 197 74 59 20 53 80 8,879 268 9,147 Total 84.714 5,290 3,316 3,174 2,135 878 485 675 1,703 716 103,086 4,324 107,410 For Practitioners:— Spirochaetes 31 16 – 1 – – – – 2 – 50 – 50 Gonococci 4,256 202 136 1,376 20 17 10 34 45 302 6,398 7 6,405 Wassermann 16,456 2,030 1,155 747 91 67 150 185 298 263 21,442 293 21,735 Others 1,060 229 47 107 26 15 18 4 5 5 1,516 79 1,595 Total 21,803 2,477 1,338 2,231 137 99 178 223 350 570 29,406 379 29,785 60 TOTAL CASES NOTIFIED DURING 1928. Disease. Under 1 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 45—65 65 and over Total all ages Cases admitted to Hosp. Total Deaths Small Pox 1 ... 1 ... 1 1 2 2 5 ... 3 1 17 17 ... Scarlet Fever 2 16 29 49 67 438 131 42 42 13 3 ... 832 325 2 Diphtheria 5 25 36 34 56 338 116 25 27 4 3 ... 669 648 55 Enteric Fever (Typhoid & Paratyphoid) ... ... ... ... ... ... 3 ... 4 ... ... ... 7 7 1 Erysipelas 1 1 ... ... ... 1 5 1 9 10 22 10 60 16 3 Puerperal Fever ... ... ... ... ... ... ... ... 5 3 ... ... 8 7 2 „ Pyrexia ... ... ... ... ... ... ... ... 7 4 ... ... 11 3 ... Meningococcal Meningitis ... 1 ... ... ... ... ... ... ... ... ... ... 1 1 3 Malaria (induced in Institution) ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... *Ophthalmia Neonatorum 12 ... ... ... ... ... ... ... ... ... ... ... 12 6 ... Encephalitis Lethargica ... ... ... ... ... ... ... 1 ... ... 2 ... 3 3 2 Pneumonia 2 5 5 4 2 13 1 5 16 7 15 7 82 23 93 Total 23 48 71 87 126 791 258 76 115 41 49 18 1703 1056 161 Tuberculosis:— (a) Pulmonary M ... ... ... 1 1 2 1 11 40 26 33 3 118 168 65 F ... ... ... ... ... 4 9 20 53 13 15 ... 114 104 52 Total ... ... ... 1 1 6 10 31 93 39 48 3 232 272 117 (b) Non-Pulmonary M ... ... ... 2 1 5 7 3 1 4 1 ... 24 22 11 F 1 1 ... 2 2 2 5 2 2 4 1 ... 22 17 7 Total 1 1 ... 4 3 7 12 5 3 8 2 ... 46 39 18 * The twelve cases of Ophthalmia Neonatorum were visited and treated with no impairment of vision. Notification of Tuberculosis is not completely satisfactory inasmuch that cases are frequently un-notified until the disease is well advanced. In cases where death occurs in a non-notified case the attention of the Medical Practitioner is drawn to the fact and the explanation is usually satisfactory. The ratio of non-notified tuberculosis deaths to total tuberculosis deaths was 1 to 7. 61 CAUSES OF DEATH AT DIFFERENT PERIODS OF LIFE IN EAST HAM, 1928. CAUSES OF DEATH. Net Deaths at the subjoined ages of "Residents" whether occurring within or without the Borough. Sex. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and under 75 years. 75 and upwards. All Causes M 740 61 22 24 41 32 86 217 147 110 V 721 48 16 21 32 25 87 180 140 172 1. Enteric Fever M ... ... ... ... ... ... ... ... ... ... F 1 ... ... ... 1 ... ... ... ... ... 2. Small-pox M ... ... ... ... ... ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... 3. Measles M 5 1 2 1 1 ... ... ... ... ... F 9 3 3 1 2 ... ... ... ... ... 4. Scarlet Fever M ... ... ... ... ... ... ... ... ... ... F 2 ... ... 1 1 ... ... ... ... ... 5 Whooping Cough M 9 4 4 1 ... ... ... ... ... ... F 10 4 3 2 1 ... ... ... ... ... 6. Diphtheria M 35 ... 3 14 17 1 ... ... ... ... F 20 ... 1 7 12 ... ... ... ... ... 7. Influenza M 6 1 ... ... ... 1 1 2 1 ... F 6 ... ... ... 1 ... 3 1 1 ... 8. Encephalitis Lethargica M ... ... ... ... ... ... ... ... ... ... F 2 ... ... ... ... ... ... 1 1 ... 9. Meningococcal Meningitis M 2 ... 1 ... ... ... ... 1 ... ... F 1 ... ... ... 1 ... ... ... ... ... 10. Tuberculosis of Respiratory System M 65 ... ... ... ... 11 28 25 1 ... F 52 ... ... ... 1 15 28 7 1 ... 11. Other Tuberculous Diseases M 11 2 2 1 ... 3 2 ... l ... F ... 1 1 1 ... 2 2 ... ... ... 12. Cancer, Malignant Disease M 93 ... ... ... ... 1 3 46 34 9 F 120 ... ... ... ... ... 13 60 31 16 13. Rheumatic Fever M 4 ... ... ... 2 2 ... ... ... ... F 3 ... ... ... 1 ... 1 l ... ... 14. Diabetes M 3 ... ... ... ... 1 ... ... 1 1 F 12 ... ... ... ... 1 ... 3 5 3 15. Cerebral Haemorrhage, &c. M 29 ... 1 ... ... ... 1 8 11 8 F 34 ... ... ... ... ... 2 8 11 13 16. Heart Disease M 127 ... ... ... 2 3 9 53 34 26 F 144 ... ... 2 1 2 6 41 42 50 17. Arterio-sclerosis M 24 ... ... ... ... ... ... 6 8 10 F 13 ... ... ... ... ... ... 3 6 4 18 Bronchitis M 30 1 ... 1 ... ... ... 3 11 14 F 36 2 1 1 ... ... ... 4 9 19 19. Pneumonia (all forms) M 47 5 7 3 2 ... 8 14 6 2 F 46 8 5 3 ... 1 2 3 15 9 20. Other Respiratory Diseases M 8 ... ... ... ... ... ... 5 3 ... F 6 ... ... ... ... ... 1 3 1 1 21. Ulcer of Stomach or Duodenum M 10 ... ... ... ... ... 1 6 2 1 F 1 ... ... ... ... ... ... 1 ... ... 22. Diarrhoea, &c. M 8 6 ... ... ... l 1 ... ... ... F 6 6 ... ... ... ... ... ... ... ... 23. Appendicitis and Typhlitis M 5 ... ... ... 1 1 2 ... 1 ... F 4 ... ... ... ... ... 1 3 ... ... 24. Cirrhosis of Liver M 1 ... ... ... ... ... ... 1 ... ... F 2 ... ... ... ... ... ... 1 1 ... 25. Acute and chronic nephritis M 25 ... 1 2 1 ... 4 10 3 4 F 12 ... ... ... ... ... 4 5 1 2 26. Puerperal Sepsis M ... ... ... ... ... ... ... ... ... ... F 2 ... ... ... ... ... 2 ... ... ... 27. Other Accidents and Diseases of Pregnancy and Parturition M ... ... ... ... ... ... ... ... ... ... F 5 ... ... ... ... ... 5 ... ... ... 28. Congenital debility and malformation, premature birth M 30 29 ... ... ... 1 ... ... ... ... F 19 18 1 ... ... ... ... ... ... ... 29. Suicide M 9 ... ... ... ... ... ... 6 2 1 F 5 ... ... ... ... ... 2 3 ... ... 30. Other deaths from violence M 42 ... ... ... 8 5 14 6 7 2 F 12 1 ... 1 2 ... 1 3 2 2 31. Other defined diseases M 112 12 l 1 7 1 12 25 21 32 F 129 5 l 2 8 4 14 29 13 53 32. Causes ill-defined or unknown M ... ... ... ... ... ... ... ... ... ... F ... ... ... ... ... ... ... ... ... ... METEOROLOGICAL RECORD—YEAR 1928. Rain Gauge 5-in. in diameter, placed 1-foot above ground, 15 feet above sea level. Temperature taken in the shade of a Stevenson's Screen, 5 feet from the ground. Months. Temperature of Air during the Month. Mean Temperature of Air. Rainfall. Highest Maximum. T.owest Minimum. Mean of No. of Days on which Rain fell, o.oi inches and over. Amount collected in inchcs. Mean rate of fall for Rainy Days. Greatest fall in 24 hours. Date of greatest fall. All Highest. All Lowest. January 56° 23° 42°.3 40°.5 42°.6 20 3.04 0.15 0.54 2nd February 56° 29° 49°.9 37°.5 42°.7 12 1.32 0.11 0.44 2nd March 66° 25° 50°.9 38°.8 44°.8 17 1.46 0.08 0.27 29th April 71° 43° 55°.6 41°.4 48°.5 16 1.13 0.07 0.32 15th May 77° 36° 61°.2 45°.2 53°.2 11 1.92 0.17 0.32 3rd June 76° 41° 67°.3 50°.4 58°.8 12 2.24 0.19 0.79 13th July 88° 51° 75°.8 57°.2 61°.6 7 1.95 0.27 0.75 27th August 80° 47° 70°.3 54°.9 62°.6 16 2.44 0.15 0.77 3rd September 82° 36° 64°.1 48°.2 56°.2 6 0.69 0.11 0.41 9th October 68° 33° 59°.5 46°.2 52°.9 20 3.28 0.16 0.77 22nd November 59° 32° 53° .3 42°.5 47°.9 17 1.91 0.11 0.26 24th December 55° 27° 44°.6 35°.2 39°.9 18 2.44 0.14 0.61 27th Means and Totals for the Year. 88° 23° 57°.9 50°.7 50°.9 172 23.72 0.14 0.79 June 13th The Rainfall for the Year was 4.76 ins. below, and the number of days on which rain fell 4 above the year 1927, at East Ham. 62 63 REPORT OF THE WORK PERFORMED BY THE SANITARY, FOOD AND DRUGS AND SHOPS INSPECTORS. The ex-Chief Inspector, Mr. J. G. Banks, retired on age limit under the Local Government and other Officers Superannuation Act, 1922, on the 8th July, 1928. For the period January 1st to July 8th the Inspectorate consisted of one Chief Inspector, three District Inspectors, and three Assistants, these last working; under the direction of the District Inspectors. Mr. G. D. Lill succeeded Mr. Banks as chief of the Inspectorial Staff on 9th July, 1928, and to the end of the year under review the staff consisted of one Senior, two District Inspectors, and three Assistants. It is hoped that when the re-organisation of the Sanitary Section is completed the Council will have an efficient staff capable of carrying out effectively the many duties of the present-day Sanitary Inspector. 64 PRIMARY INSPECTIONS. Month Manor Park Little Ilford Woodgrange Plashet Kensington Castle Central Wall End Greatfield South Total Ord H. to H Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H to H. Ord. H to H. Ord. H. to H. Ord. H. to H. Ord. H to H. Ord. H. to H. Ordinary House to House January 46 — 53 6 57 5 59 — 24 — 58 131 71 1 36 — 16 — 68 — 488 143 February 49 — 38 10 29 — 27 — 24 — 35 90 66 17 27 4 24 68 57 22 376 211 March 54 — 16 8 53 — 22 31 14 — 40 54 61 60 81 — 8 — 51 32 400 185 April 37 — 33 — 23 — 22 45 11 — 30 5 48 — 28 — 15 — 84 8 331 58 May 32 — 35 — 42 — 32 64 17 — 47 — 62 26 27 — 20 — 57 25 371 115 June 38 — 27 33 40 — 50 5 20 — 40 150 62 42 50 — 21 — 39 2 387 232 July 68 — 90 6 37 2 33 3 37 — 42 140 83 1 63 34 31 — 64 4 548 190 August 78 — 78 65 37 — 37 1 29 — 39 107 104 35 71 25 23 — 99 — 595 233 September 59 — 56 64 44 — 58 — 24 — 47 61 93 10 73 — 31 — 53 — 538 135 October 70 — 99 191 49 — 68 — 27 — 113 64 115 46 102 — 16 — 106 76 765 377 November 55 — 56 128 46 — 38 — 34 — 53 42 95 30 75 — 29 74 78 63 559 337 December 50 — 33 55 38 — 26 — 29 — 43 22 75 — 36 20 26 20 36 13 392 130 636 — 614 566 495 7 472 149 290 — 587 866 935 268 669 83 260 162 792 245 5,750 2,346 65 Nuisances. As a result of the inspections shown in the foregoing table, 12,192 nuisances were discovered and dealt with by the Sanitary Inspectors. A detailed list is given in the inset table, page 79. To secure abatement the following notices were served:— Preliminary 3,630 Statutory 436 Dust Bin 998 5,064 Complaints. 2,185 complaints were received. 574 written and 1,611 oral, all of which received prompt attention. COMPLAINTS RECEIVED. Manor Park Little Ilford Wood grange Plashet Kensington Castle Central Wall End Greatfield South Total January 12 59 16 25 17 25 38 24 12 22 250 February 17 22 12 14 9 25 31 22 8 21 181 March 17 24 9 15 12 28 25 19 10 11 170 April 9 17 9 15 15 30 27 6 6 11 145 May 9 25 9 12 15 25 30 13 18 14 170 June 24 24 16 16 15 33 33 14 13 16 204 July 12 31 9 18 13 37 36 11 9 15 191 August 9 37 10 15 8 33 32 14 13 20 191 September 30 41 11 17 7 61 26 19 10 13 235 October 12 48 4 19 9 15 26 20 8 12 173 November 11 23 12 8 21 19 20 18 4 24 160 December 10 21 3 15 7 6 26 13 2 12 115 172 372 120 189 148 337 350 193 113 191 2,185 66 INSPECTIONS FOR THE YEAR. Ordinary House-to-house Total January 488 143 631 February 376 211 587 March 400 185 585 April 331 58 389 May 371 115 486 June 387 232 619 July 548 190 738 August 595 233 828 September 538 135 673 October 765 377 1,142 November 559 337 896 December 392 130 522 Total for Year 5,750 2,346 8,096 House-to-House Inspection. Special attention has been given to this important branch of the Sanitary Inspectors' work. Efforts have been directed to concentrate on special areas in order to limit time spent in travelling and so on, and there has been a satisfactory increase in the number of inspections under this head for the last half of the year. For the whole year 2,346 house-to-house visits were made; at 80 per cent. of these sanitary defects were found and notices were served upon the owners to abate. Rent Restrictions (Notice of Increase) Act, 1923. Only three applications were made by tenants for certificates under this Act and two were granted, one certificate being- refused for the reason that, in my opinion, the condition of the house did not warrant such action. 67 Food and Drugs (Adulteration) Act, 1928. 409 samples of food and drugs were taken under the above Act, of which 246 were milk. 403 were reported by the Public Analyst to be genuine articles of food. 5 samples of milk were deficient in fat. One sample of mincemeat was found to contain sulphur dioxide. Result of prosecutions, see page 77. The following is a detailed list of the articles sampled:— Number of samples: 409. Milk 246 Bread 1 Butter 42 Rice 1 Lard 16 Lump Sugar 1 Cheese 9 Demerara Sugar 1 Cream 8 Icing Sugar 1 Coffee 8 Beer 1 Sausages 7 Dutch Cheese 1 Ground Almonds 5 Custard Powder 1 Ground Ginger 5 Gin 1 Whisky 4 Syrup of Figs 1 Fish Pastes 4 Ice Cream 1 Dripping 3 Camphorated Oil 1 Mincemeat 3 Powdered Almonds t Vinegar 3 Minced Beef 1 Sponge Cake 3 Mixed Peel 1 Pepper 3 Jam 1 Tea 2 Mustard 1 Preserved Ginger 2 Ginger Wine ... 1 Margarine 2 Puff Paste 1 Tripe 2 Sultanas 1 Cocoa 2 Relish 1 Meat Pastes 2 Cream of Tartar 1 Lemon Squash 2 Peas 1 Total ... 409 Scone 1 Lime Water 1 Orange Flavour 1 Milk Supply. The whole of the Milk supply is imported and the greater bulk is distributed by three or four large firms who have adopted the latest hygienic methods of storing and cleansing. They have also their own Inspectorate, who take frequent samples from the milk carriers to ensure the milk being delivered as it comes from the cow. 68 An increasing; number of consumers is being supplied with their milk—much of it sterilised or Pasteurised—in capsuled bottles, thus avoiding' any contamination in transit or in the house. I believe the time is not far distant when the old insanitary milk-can will be as rare as the old Hansom cab. Dairies. There are 87 registered premises for the sale of milk in the Borough. This number includes a few shops other than dairies where milk is sold. It is hoped that in the near future general shops will sell milk only in capsuled bottles. These premises have been periodically inspected and are maintained in good condition. Milk and Cream Regulations. Milk and Cream Not Sold as Preserved Cream. (a) Number of samples examined for the presence of a preservative. (b) Number in which preservative was reported to be present, and percentage of preservative found in each sample. Milk 246 — Cream 8 — Cream Sold as Preserved Cream. Correct statements made 8 Statements incorrect — 8 Percentage of preservative found in each sample. Percentage stated on statutory label. .25 .40 .33 .40 Determination made of Milk Fat in Cream sold as Preserved Cream. (1) above 35 per cent. — (2) below 35 per cent. — Total — 69 Milk (Special Designations) Order, 1923. Supplementary licences were granted for the Sale of Milk under this Order. 1 for Grade A. 10 for Grade A (Tuberculin Tested). 19 for Pasteurised. 9 for Certified. Offensive Trades. There are two small traders in the Langdon Crescent area who carry on businesses under the above heading. The premises are satisfactory and no cause for service of sanitary notices has arisen. In one instance a trader was summoned and fined £30 for establishing an offensive trade without permission. Disinfection. 2,390 premises were disinfected; 1,843 for infectious disease, 437 for tuberculosis, and 110 for other causes. Infectious Diseases. In all cases of infectious disease notified the Inspector at once visits the premises, the sanitary arrangements and general condition of the houses are examined and, where necessary, sanitary notices are served upon persons responsible. If the case is nursed at home, printed directions are given as to isolation and prevention of spread of the disease, and a postcard is immediately sent by the Inspector to the school attended by any child in the house. A report of each case is prepared by the Inspector for the Medical Officer of Health. The infected part of the house is disinfected at the termination of the case. The Librarians are notified of all infected premises and books from infected houses are returnable direct to the Public Health Department and disinfected before return to the respective libraries. All Head Teachers of schools and all pawnbrokers in the Borough are notified weekly of infected houses 70 Dust Bins. Under the provisions of the East Ham Improvement Act, 1903, 998 dwelling houses have been reported to the Public Health Committee as not being furnished with a suitable dust bin. The Council authorised the service of notices upon the persons responsible. Factories, Workshops and Outworkers' Premises. There are 254 factories and workshops in the Borough, including bakehouses and laundries. During the year 322 inspections have been made, of which 133 were to homes of outworkers. Public Water Closets and Urinals. There are 11 public conveniences in the Borough under the supervision of the Cleansing Superintendent of the Borough Engineer's Department. No complaint has been received during the year and they have been well maintained in a satisfactory condition. There are 34 public houses and beer houses in the Borough, the majority of which are well equipped with sanitary conveniences and, with a few exceptions, these are also well maintained. Attention is being given to two houses in particular in which the conditions are not satisfactory. Public Health (Meat) Regulations, 1924. Considerable time has been spent by the Inspectors on this important branch of the work of the section. All owners and occupiers of slaughter-houses are supplied with printed and addressed notification forms. During the year 839 notifications to slaughter were received referring to:— Cattle 1,611 Sheep 1,529 Pigs 9,079 Lambs 1,899 Calves 449 Total 14,567 71 Slaughtering is carried out at all hours to ten in the evening and on Sundays. At the end of the year under review I arranged a rota for the district Inspectors to take extra office hours and Sunday duty in turn so as to ensure that all carcases were inspected before being sent to market. In my next report I hope to be in a position to report on the success of this plan. Slaughter-Houses. Following is a list of slaughterhouses in the Borough:— Beckton Road. Manor Way Farm, New Beckton. 319, Green Street. 14, High Street North. 170, High Street North. 167, Plashet Grove. 843, Romford Road. 524, Romford Road. 638, Romford Road. 737, Romford Road. Shaftesbury Road. 28, Station Road. 6, Station Road. Forest View Road. Food Supplies. The food supplies of the Borough are, generally speaking, exceedingly good. Probably the fact that East Ham is quite close to the great Central Markets of London to some extent accounts for this satisfactory condition. There has been an increasing demand for the better class of all foodstuffs since the war, and the greater vigilance of the housewife in selecting her goods has been met by the shopkeepers stocking only sound articles of food. It is very infrequent, having regard to the number of shops in the Borough, to receive any complaint as to the quality of foods bought, only 11 parcels being condemned during the year. The shops and market places are regularly inspected at least one Evening in the week as well as during the day. Shops Act. On 3rd August, 1928, the new Shops (Hours of Closing) Act came into operation. 72 This Act, inter alia, repealed the whole of the 1920 and 1921 Acts and made the general closing hours for all shops (with certain exceptions) at nine in the evening on the late day and eight in the evening on other days. The principal effect of the new Act was that whereas Greengrocers and Fruiterers could sell all fruits under the 1921 Act till 10 p.m. on the late day and 9.30 p.m. on other days, under the new Act they were compelled to close at 9 p.m. on the late day and 8 p.m. on other days. Soon after the operation of the 1928 Act it became necessary to send out a circular letter to all the Fruiterers and Greengrocers in the Borough. The effect of this letter was satisfactory, as nearly all the tradesmen affected immediately complied with the provisions of the Act. The following Closing Orders have been made for the Borough:— Fridays. Saturdays. Other days. Butchers 8 p.m. 9 p.m. 7 p.m. Grocers and Provision Dealers 8 p.m. 8 p.m. 7 p.m. Corn Chandlers 8 p.m. 8 p.m. 7 p.m. Barbers 9 p.m. 8 p.m. Half-holiday Closing Orders:— Chemists Thursday or Saturday 1 p.m. Bakers Thursday or Saturday 2 p.m. There are 2,661 shops registered in the Borough comprising:— Grocers and Provision Dealers 389 Confectioners and Tobacconists 290 Drapers 194 Boots and Shoes Salesmen 146 Tailors 126 Fruiterers and Greengrocers 113 Butchers 101 Licensed Houses 86 Barbers and Hairdressers 88 Bakers 54 Domestic Stores 52 Chemists 44 Corn Chandlers 3 Others 946 2,661 73 The Inspector regularly visited these shops for the purpose of compiling trade registers and seeing that the provisions of the Shops Act and Early Closing Orders were being complied with. During the year 172 contraventions were reported, necessitating letters of caution being sent to offenders, and in 21 instances, legal proceedings were instituted. (See page 78.) Dust Collection and Petroleum Licences. Reports on these two items will no longer be included as both these duties were transferred to the Engineer's Department on re-organisation of the work of the office. Bakehouses. 68 inspections were made of the 44 bakehouses in the Borough. We have still eight underground, but 36 are above ground and generally of satisfactory structure and condition. Explosives Act, 1875. 212 visits were made for the purpose of enquiring if the provisions of the Act were complied with. 32 cautions were given for offences and in three instances legal proceedings were instituted and penalties imposed. See page 77. Contagious Diseases of Animals Acts. No notification has been received of any contagious disease among animals in this Borough for the year. Two suspected cases of swine fever were not confirmed. Rats and Mice (Destruction) Act, 1919. The Council entered into a contract with a firm of professional rat-catchers, who carry out work at the Isolation Hospital, the Sewage Works and other premises as required. Private houses which are rat infested are usually cleared by one of the drain clearing gang. It is impossible to state the total number of rats and mice destroyed as poison is used as well as traps, but the actual numbers recorded are:— Rats, 2,168, and Mice, 221. 74 Cinemas, Music Halls and Dancing Licenses. A thorough annual inspection of all premises in the Borough licensed for dancing, singing, music, cinematograph, and stage plays is made by the Borough Engineer and myself prior to the annual licensing. Frequent evening visits are also paid to these premises to inspect for any breaches of the bye-laws. At one cinema at which the ventilation and one gangway were not satisfactory alterations were made and there has been no further complaint. It is occasionally found that there has been some slight overcrowding of gangways, but on reference to the Manager the breach of the regulation has been remedied. On no occasion has it been necessary to summons the licence holder. HOUSING STATISTICS FOR THE YEAR 1928. New houses erected during the year :— (a) Total 1171 (b) As part of a municipal housing scheme 24 1. Dwelling Houses. Inspection—(1) Dwelling houses inspected for housing defects (under Public Health or Housing Acts) 6,806 (2) Dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil. (3) Dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation Nil. 2. Defects remedied without service of formal Notices. Defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their Officers 2,127 3. Action under Statutory Powers. A.—Proceedings under Section 28 of the Housing, Town Planning, Etc., Act, 1919. (1) Dwelling houses in respect of which Notices were served requiring repairs Nil. 75 (2) Dwelling houses which were rendered fit:— (a) By owners Nil. (b) By Local Authority in fault of owners Nil. (3) Dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil. B.—Proceedings under Public Health Acts. (1) Dwelling houses in respect of which Notices were served requiring defects to be remedied 3,630 (2) Dwelling houses in which defects were remedied:— (a) By owners 1,679 (b) By Local Authority in default of owners Nil. C.—Proceedings under Section 17 and 18 of the Housing, Town Planning, Etc., Act, 1909. (1) Representations made with a view to the making of Closing Orders Nil. (2) Dwelling houses in respect of which Closing Orders were made Nil. (3) Dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit Nil. (4) Dwelling houses in respect of which Demolition Orders were made Nil. (5) Dwelling houses demolished in suance of Demolition Orders Nil. Mortuaries. The Council have two mortuaries. The central at High Street South and the other at North Woolwich. 78 bodies have been admitted and 60 post-mortem examinations held during the year. Common Lodging Houses. There is only one common lodging house in the Borough, with accommodation for 42 beds, situated in Albert Road, North Woolwich. 76 Police Court Proceedings. On 59 occasions it has been necessary to have recourse to legal proceedings, viz.:— Under Public Health Acts for non-compliance with Sanitary Notice, etc. 21 Under Explosives Order—dangerously exposing fireworks 5 Under Shops (Early Closing) Act and Closing Orders for contraventions 21 Under Gipsy Bye-laws for failing to provide sufficient water supply 4 Under Food and Drugs (Adulteration) Act 8 Fines and costs have been imposed in all amounting to £169 11s. See tables, pp. 76-78. PROSECUTIONS UNDER THE PUBLIC HEALTH ACT FOR THE YEAR 1928. Date. Situation of Premises. Offence. Result. January Plashet Grove Non-compliance with sanitary notice Withdrawn. 3/6 costs. March Byron Avenue do. do. 3/6 do. March St. Dunstan's Road do. do. 17/6 do. April Claremont Street do. do. 7/6 do. April Grantham Road do. do. 3/6 do. May Dorset Road do. do. 3/6 do. May Park Avenue do. do. 10/6 do. May Talbot Road do. Withdrawn. July — Establishing offensive trades i.e.,tallow melting and bone boiling Fined £30. Costs £4 4s. July — Carrying on tallow melting business Fined £5. Octcber Barking Road Non-compliance with sanitary notice Withdrawn. October Welstead Road do. Withdrawn. 3/6 costs. October Central Park Road do. Adjourned. 77 PROSECUTIONS UNDER THE SALE OF FOOD AND DRUGS ACT FOR THE YEAR 1928. Date. Offence. Result. March Minced Meat preservation 200 parts per million Fined £10. March Milk—6 per cent. added water Fined £2. March Milk—5 per cent. added water Fined £5. March Milk—10 per cent. added water Fined £5. March Bottling milk in Public Highway Fined £1. June Milk—5 per cent. deficient in milk fat Fined £25. November Milk—8 per cent. deficient in milk fat Fined £2. Costs 10/6 PROSECUTIONS UNDER THE EXPLOSIVES ACT. Date. Offence. Result. March Failing to furnish Local Authority with name, address, and nature of business Fined £25. March Storing quantity of celluloid exceeding 1 cwt. Fined £25. March Failed to observe regulations contained in 1st schedule Fined £25. November Exposing blank cartridges for sale Fined £3. November Unregistered premises Fined £2. November Failed to keep fireworks in proper receptacle Fined 10s. MARGARINE ACT, 1887. Date. Offence. Result. May Selling butter-like substance wrapped in butter paper Fined £2. Costs 10/0 78 PROSECUTIONS UNDER SHOPS ACT DURING 1928. Date. Offence. Fines. £ s. d. April Shops (Early Closing) Acts, 1912 and 1928 1 0 0 April do. 0 10 0 April do. 1 0 0 April do. 1 0 0 April do. 1 0 0 April do. 1 0 0 April do. 1 0 0 June do. 0 10 0 June do. 0 10 0 June do. 0 10 0 August Grocers' and Provision Dealers' Closing Order, 1923 0 10 0 September do. 2 0 0 September Shops (Early Closing) Acts, 1912 and 1928 1 0 0 October do. 1 0 0 October Grocers' and Provision Dealers' Closing Order, 1923 0 10 0 October Shops (Early Closing) Acts, 1912 and 1928 1 0 0 November do. 1 0 0 November do. 1 0 0 November do. 1 0 0 November Grocers' and Provision Dealers' Closing Order, 1923 1 0 0 November Sections 1 and 2 of Shops' Acts, 1912 and 1928 Withdrawn. PROSECUTIONS UNDER GIPSY BYE-LAWS Date. Offence. Result. January Vacant Land, Langdon Crescent Fined £1. January do. Fined £1. January do. Fined £1. January do. Not served. 79 The Following is a Record in Detail of the Inspections made during the Year 1928:—- Manor Park Ward. Little Ilford Ward. Woodgrange Ward. Plashet Ward. Kensington Ward. Castle Ward. Central Ward. Wall End Ward. Greatfield Ward. South Ward. Total. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H. to H. Ord. H.to H. Premises found in fair condition 421 ... 203 58 218 ... 235 44 145 ... 266 197 420 83 269 14 134 63 285 26 2596 485 Factory and workshop premises inspected... 8 ... 8 ... 10 ... 12 ... 6 ... 23 ... 18 ... 20 ... 4 ... 12 ... 121 ... Outworkers premises inspected 3 ... 3 ... 21 ... 22 ... 9 ... 22 ... 24 ... 12 ... 13 ... 4 ... 133 ... Bakehouses inspected 10 ... 4 ... 6 ... 5 ... 7 ... 7 ... 20 ... 3 ... ... ... 6 ... 68 ... Slaughter-houses inspected 268 ... ... ... 192 ... 96 ... ... ... ... ... 93 ... ... ... ... ... 103 ... 752 ... Dairies inspected 7 ... 19 ... 12 ... 5 ... 4 ... 11 ... 10 ... 4 ... 7 ... 7 ... 86 ... Urinals inspected 11 ... 5 ... 1 ... 10 ... 8 ... 4 ... 7 ... 4 ... ... ... 15 ... 65 ... Walls and ceilings dirty and dilapidated 71 ... 136 383 60 6 101 73 60 ... 149 490 205 106 118 48 50 36 185 113 1135 1255 Yards improperly paved and dilapidated 23 ... 47 207 13 3 10 2 21 ... 19 41 38 15 30 24 7 3 17 19 225 314 No forecourt paving 6 ... 23 71 5 ... 6 4 1 ... 6 10 4 29 2 ... 2 4 5 48 60 166 Defective drains 1 ... 5 ... 1 1 1 ... 4 ... 3 ... 7 ... 1 ... 4 ... 3 1 30 2 Defective w.c. connections 2 ... 1 2 ... ... ... ... 1 ... ... 1 3 ... ... ... ... 1 1 ... 8 4 Defective w.c. traps 12 ... 17 14 2 ... ... 2 8 ... 5 16 9 5 13 2 2 ... 6 4 74 43 Defective flushing apparatus 13 ... 37 96 13 ... 9 9 11 ... 13 42 45 18 18 16 11 7 17 15 187 203 Soil pans foul and broken 13 ... 17 43 3 1 9 10 7 ... 13 41 17 7 8 9 7 2 10 8 104 121 Defective vent pipes 5 ... 19 62 8 ... 2 2 12 ... 7 26 18 16 15 2 1 2 11 10 98 120 R.W. pipes and eaves gutters defective 24 ... 56 178 19 3 38 4 31 ... 53 157 70 50 57 34 40 51 85 128 473 606 R.W. pipes connected to drain 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... Roofs leaky 33 ... 46 111 27 3 37 12 25 ... 75 157 108 28 74 18 24 19 109 68 558 416 Defective sink waste pipes 13 ... 19 100 11 ... 4 3 7 ... 17 29 22 20 12 12 5 6 15 36 125 206 Houses without water (M.W.Bd.) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cisterns without covers ... ... ... ... 1 ... 2 2 1 ... 3 3 3 2 ... 1 ... ... ... 1 10 9 Drinking water improperly stored 3 ... 5 ... ... ... ... ... 2 ... 6 4 1 ... 1 1 2 ... 3 3 23 8 Dilapidated floors 8 ... 31 163 2 ... 7 2 8 ... 13 18 13 6 10 5 ... ... 19 9 111 203 Insufficient underfloor ventilation 8 ... 14 61 8 l 5 2 9 ... 9 21 14 16 5 3 8 2 8 24 88 130 Dampness 31 ... 62 37 20 4 25 3 21 ... 51 83 81 30 55 15 15 6 79 107 440 285 Accumulations 12 ... 16 4 11 ... 6 ... 3 ... 10 2 14 ... 35 ... 2 ... 21 2 130 8 Defective sashcords and windows 20 ... 42 82 12 1 24 21 27 ... 29 166 43 51 38 3 10 16 51 27 296 367 Overcrowding 4 ... 6 ... ... ... ... ... ... ... 2 ... 1 ... 2 ... 1 ... 3 2 19 2 Unsound food 26 ... ... ... 122 ... 26 ... ... ... ... ... 12 ... 3 ... ... ... 69 ... 258 ... No dust bins 14 ... 23 13 6 ... 14 10 7 ... 17 96 26 26 51 2 5 7 32 19 195 173 Defective stoves 12 ... 30 29 12 3 20 19 3 ... 35 129 28 30 23 3 9 5 29 23 201 241 Defective coppers 2 ... 18 54 5 ... 9 12 5 ... 16 91 22 25 20 2 12 4 22 12 131 200 Animals improperly kept ... ... 4 2 1 ... ... ... ... ... 2 1 3 2 12 1 3 1 5 1 30 8 Temporary buildings found ... ... ... ... ... ... 4 ... ... ... ... ... ... ... 2 ... ... ... ... ... 6 ... Smoke nuisances ... ... 4 ... ... ... 2 ... 2 ... 13 ... 7 ... 2 ... 4 ... 1 ... 35 ... Rear passages unpaved or undrained ... ... ... ... 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 6 ... Gipsies ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 61 ... ... ... 3 ... 65 ... Breaches of Bye-Laws and Regulations ... ... ... ... ... ... ... ... 1 ... 1 ... 6 ... ... ... ... ... ... ... 8 ... Other nuisances 86 ... 166 426 49 3 71 25 87 ... 129 166 174 57 227 16 35 37 167 50 1191 780 Drains unstopped and cleansed 99 ... 228 ... 62 ... 120 ... 113 ... 156 ... 276 ... 105 ... 72 ... 217 ... 1448 ... Drains tested 37 ... 77 ... 38 ... 50 ... 40 ... 56 ... 74 ... 78 ... 26 ... 43 ... 519 ... Inspections 636 ... 614 566 495 7 472 149 290 ... 587 866 935 268 669 83 260 162 792 245 5750 2346 Total Inspections 636 1180 502 621 290 1453 1203 752 422 1037 8096 COUNTY BOROUGH OF EAST HAM. EDUCATION COMMITTEE. Annual Report OF THE School Medical Officer FOR THE YEAR 1928. 82 EAST HAM EDUCATION COMMITTEE. Alderman W. G. Davie, J.P. (Chairman). Alderman N. A. Papworth, J.P. (Vice-Chairman). Councillor G. W. Boultwood, J.P. (Mayor). Councillor Mrs. H. N. Ridler. Alderman F. P. Cross, J.P. ** Alderman C. L. E. Masset. Alderman H. Osborn, J.P. Alderman H. N. Ridler. Alderman E. Shanahan, J.P. Councillor W. W. Bagot. †Councillor J. Brooks, J.P. Councillor T. W. Burden. Councillor A. E. Dennington. Councillor C. F. H. Green. Councillor T. J. Hawkins. Councillor E. C. Howlett. Councillor H. J. Kybert. Councillor T. I. Lethaby, J.P. Councillor G. H. Manser. Councillor R. W. Moger. Councillor G. Montford. Councillor W. T. Newling. Councillor A. H. W. Owen. *Councillor H. Perry. Councillor J.J. Pope. Councillor G. Pottinger. Councillor E. H. Thompson. Councillor T. Watts. Miss L. Butcher. E. T. Andrews, Esq., B.A. E. J. Sullivan, Esq. R. Whitfield, Esq. **Appointed February, 1928. 'Resigned February, 1928. †Co-opted Member of Libraries Sub-Committee. School Nurses : Mrs. Nears, S.R.N., Miss Kekwick, S.R.N., A.R.San.I., Mrs. Sorrel, S.R.N., A.R.San.I., Miss Case, R.F.N., A.R.San.I., Mrs. Childs, S.R.N. A.R.,San.I., Certified Midwife, Miss Olifent, R.F.N.. Miss Maltby, R.R.C., and Miss Young, S.R.N., Certified Midwife. Administrative and Clerical Staff: F. Read, M.S.M. (Chief). Miss A. M. Dean, Miss F. E. Hales and Miss O. E. Griffin. Dentist (full-time) : C. S. Neame, L.D.S., R.C.S. Ophthalmic Surgeon : C. L. Gimblett, M.D., M.R.C.P., F.R.C.S. (Three sessions per week.) Aural Surgeon: L. G. Brown, M.D., F.R.C.S.Eng. (One session per week.) Assistant Medical Officers : Miss M. M. Thomson, L.R.C.P., L.R.C.S., D.P.H. (full time). (Temporary), T. P. Evans, M.R.C.S., L.R.C.P. (part-time). (Temporary), T. J. Clayton, M.R.C.S., L.R.C.P. (part-time). Deputy and Senior-Assistant-Medical Officer : F. E. Bendix, M.R.C.S., L.R.C.P., L.D.S. Medical Officer: W. Benton, M.R.C.S., L.R.C.P., D.P.H. 83 County Borough of East Ham Education Committee. TO THE CHAIRMAN AND MEMBERS OF THE EDUCATION COMMITTEE. Ladies and Gentlemen,— I have the honour to present my Annual Report upon the School Medical Service of the County Borough of East Ham for the year ended 31st December, 1928. The average school attendance during' the year approximated closely to 18,750. The number of routine and special cases of elementary school children examined totalled 13,663, as compared with 11,122 in 1927, and a medical inspection of all children in the Girls' Department of the Secondary School has also been carried out. The percentage of children found, at routine medical inspection, to require some form of medical or surgical treatment, was 10.4 and, although this figure somewhat exceeds that for the year 1927 (8.6)—it will be remembered that I indicated, in my report for last year, that the latter figure appeared to be rather exceptional—there is a definite downward trend in the number of defective and unhealthy children in the schools. (See table showing Finding's of Medical Inspection on page 91). There has been no outstanding development or new departure in the School Medical Service during the year and, whilst the apparatus and other facilities are available for considerable elaboration and extension of the activities of the service, the possibility of increasing its scope is prevented by the insufficiency and inadequacy of clinic and office accommodation. The question of providing suitable premises for the conduct of the Medical Services of the Borough is a very pressing one. I have endeavoured, so far as staff and equipment are concerned, to ensure that no useful means of preventing the occurrence of disease, ill-health and invalidity has been overlooked, but with the provision of suitable and adequate accommodation a much wider application of these methods could result. 84 Handicapped as we are in possessing no open-air schools or schools for physically defective children, the work of the local branch of the Invalid Children's Aid Association has proved of the utmost value ; 33 children have been sent to Schools of Recovery through this Association by arrangement with the local Authority, and 132 children have received open-air and convalescent treatment as the result of the direct activity of the Association and its cooperation with the Authority's Medical Officers. The Staff of the School Medical Service are to be congratulated upon the excellent work accomplished throughout the year (under conditions which are far from ideal), and I wish to express my appreciation of their keen interest and loyal co-operation. My sincere thanks are extended to the teachers for their great help and courtesy, and to Mr. Thompson and his staff for their invaluable assistance. In conclusion, I respectfully beg to express my indebtedness to the Chairman and Members of the Local Education Authority for the interest, assistance, and earnest consideration they have given to the work of the School Medical Service, and to the many suggestions and recommendations which I have placed before them from time to time. I have the honour to be, Ladies and Gentlemen, Your obedient servant, W. BENTON, School Medical Officer. 85 1. STAFF. A list of the Staff of the School Medical Department will be found on page 82 of this Report. 2. CO-ORDINATION. Suggestions for the co-ordination of the various health services of the County Borough have been fully discussed in previous reports, and I have indicated the general outline of an administrative scheme which should result in complete co-ordination, greater efficiency and, ultimately, a very apparent economy. One of the most urgent problems facing us at the present time is the supervision of the health, and the prevention of physical defect in infants and children under school age. Although the School Medical Service is fully equipped for dealing with these children, and the School Medical Staff is continually in contact with them, difficulties arise out of the fact that supervision and administration are performed by two Authorities, one of which is concerned with the pre-school child and the other with the school child. It appears desirable that administrative procedure in connection with the pre-school children, that is to say, the potential scholars of the Borough, should be directed and supervised by the Local Education Authority. In this connection Sir George Newman has stated that " We cannot divide the child up into watertight compartments on an age basis, neglecting its health up to five years of age and then hopingto deal with it effectually when it arrives at school age. It may be necessary to subdivide our methods of administration for the mother, the infant, the school child, the adolescent and the adult; but, if so, it is incumbent upon us so to co-ordinate and harmonise our efforts as to cover evenly, completely and continuously the whole life of the child—using wherever possible the same record of its physical history, the same premises, the same staff and similar methods." One frequently hears and reads the criticism that the duties of the members of the various sections of the Medical Services involve an appreciable amount of overlapping; such criticism may be justified to a certain extent, but consideration must be given 86 to the fact that the necessity for each main branch of preventive medicine was not conceived at one and the same time, that they arose piecemeal, as it were, and it was not deemed advisable to jeopardise the working of the young growing services by repeated experimental reorganisations: Moreover, the accommodation for our Medical Services—in old store rooms, dwelling houses, church halls and what not—has been pure improvisation. As a result, complete co-ordination, although one of the foremost aims throughout, has not been achieved entirely, and one looks forward to the time when the economic conditions will allow of the residents of each of the four quarters of the Borough being served by one Medical Officer, a team of two or three trained nurses and its own satisfactorily equipped clinic building, where the parents, the infant, and the school child may receive the necessary advice and treatment on all those matters which are undertaken by the medical services of the Public Health Department, the most central of these clinics being equipped for the carrying out of specialised work, e.g., Ophthalmic treatment, Aural treatment, X-ray and Light treatment, etc. Such an arrangement would simplify central administration, increase that very important interest and personal contact between the staff and the inhabitants of East Ham, prove of great convenience to the latter (it is not uncommon for members of one family to be visiting three or four different clinics nor for the home to be visited by two or three different members of the nursing staff), and, apart from the initial outlay, for buildings and equipment, should result in a considerable reduction in expenditure. 3. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. During the year 1928 a complete survey of the sanitary and hygienic conditions pertaining to all the schools of the Authority has been carried out. Reports upon matters requiring attention have been submitted month by month to the Committee. In most instances my recommendations have received careful con sideration, and an endeavour has been made to remedy defects where possible, but a good deal remains to be done in connection with improvements in the lighting and heating of. school premises. 87 4. MEDICAL INSPECTION. The following is a synopsis of School Medical Work for the year 1928. The figures for the years 1924 to 1927 are also given for comparison:— COMPARATIVE STATEMENT OF WORK. 1924. 1925. 1926. 1927. 1928. Routine and Special Inspection (on School Premises) 7,284 10,728 10,944 8,483 10,408 Re-inspection 3,951 3,784 4,737 4,175 4,061 Consultations at Inspection Clinic 13,080 13,445 14,575 13,530 16,533 Number of Treatments at Clinic 18,319 18,665 15,810 14,873 19,140 General Cleanliness Visits to Schools 291 335 297 257 274 Nurses' Visits to Homes 3,541 3,840 4,948 4,547 4,239 Children Examined for Cleanliness 57,936 58,090 58,683 58,588 55,351 (a) (i.) Medical Inspection and Re-inspection. At the commencement of the year arrangements were made for the. Medical Inspection of all children admitted to the schools during the year, of all children between 8 and 9 years of age, and of all children between 12 and 13 years of age, together with children over 13 years of age who had not already been examined after reaching the age of 12. Routine Medical Inspection was completed in all the schools with the exception of the Boys' Department of the. Secondary School and of the Wakefield Central School. Furthermore, it was found impossible to carry out re-inspection in ten of the schools. Unfortunately, therefore, the work for the year 1929 must be commenced with a debit balance. The work of the School Medical Service has been greatly handicapped by unavoidable staffing and administrative difficulties consequent upon the absence on sick leave of Dr. Cheater, the Tuberculosis Officer, and the resignation of the two temporary Assistant Medical Officers, Dr. Clayton (4th February, 1928) and Dr. Evans (30th September, 1928). 88 It became necessary to allocate Dr. Evans for duty at the Tuberculosis Dispensary during the period from January 1st to June 21st, and thus from February 4th to June 21st the normal Medical Staff of the School Medical Service was reduced by five sessions per week. Moreover, during the early part of the year, and prior to his resignation, Dr. Clayton was engaged upon work in connection with Maternity and Child Welfare upon two sessions per week, which resulted in a further depletion of the staff of the School Medical Service. Dr. Douglas Benton commenced duty as a temporary Assistant School Medical Officer, in place of Dr. Evans, on the 1st October and continued until the end of the year. (a) (ii.) Administration and Clerical Staff. The importance of the class and nature of the work carried out by the Administrative Clerical Staff is not generally appreciated, and it is well to point out that many new administrative measures have been introduced of late, in order to successfully apply the decisions of the Education Authority. The extension of the Dental Section, contemplated by the Committee, will call for additional administrative measures, and various facilities for treatment which have been introduced during the past two years have decidedly increased responsibility, and brought about a material change in duties. The success of all schemes depends in no small measure upon the foresight and thought given to their application, and the ability of the Officers concerned to make them effective. I desire to congratulate Mr. Read and his Staff upon the efficient conduct of the administration of the School Medical Service. It will be remembered that in the year 1926 I endeavoured to convince the Committee that the grading of the clerical staff should be equitable with the character of the duties involved but, unfortunately, the time was considered inopportune for making much alteration in the existing position. One feels, however, that it is unfair to trespass upon the ability of efficient staff without making some endeavour to provide adequate grading. 89 The elevation of the grade of the Chief Clerk (Mr. F. Read) is long overdue, and the necessity for the regrading of the Grade "A " Senior Woman Assistant's (Miss Dean) post has made itself felt by reason of the growth of the School Clinics and the necessity for supervision in connection with the clerical work, collection of fees, and the issue of stock and additional nourishment. The marking of children's attendance cards, and the checking of same, is an important point to bear in mind, because the amount of grant to the Authority from the State is considerably affected by this provision. It should be remembered that the employment of women clerks does not necessarily point to the work of the Service being less important than other Services, in fact it rather adds to its status—it is essential that women should attend the school clinics in a clerical capacity because of the large number of mothers who attend the clinics with their children, and the advice and assistance which has to be given them in regard to a child's physical development and matters of this description. It would be undesirable for male clerks to carry out this work. In conclusion, it should be stated that the general tendency of the School Medical Service, and the Committee's policy towards it, is for increase and expansion, and the appointment of an additional clerical assistant is imperative. My proposals for the reorganisation of the Department will be placed before the Education Authority at an early date, and I hope that they will meet with unqualified support. (b) Exceptional Children. Towards the termination of routine medical inspection in each school, teachers are requested to bring before the School Medical Officer any special cases who may require examination, and to include amongst these all cases falling within the category of " exceptional children " (Table III). In this way an annual census of all cripples is rendered possible, whilst particulars may be obtained and advice given as to their progress and treatment. As was reported last year, a special visit was made to all the schools with a view to ensuring that no " exceptional children " had been overlooked, and tables, indicating the results of 90 the survey, were appended. This investigation revealed the fact that a number of children were suffering from speech defect of a degree which required more or less prolonged treatment and training, and although it had been possible to arrange for the attendance of a very few children at St. Thomas's Hospital! Speech Centre it was obvious that the majority of these children were unlikely to obtain treatment. At the request of the Education Committee a census was taken of the children in the Borough suffering from definite speech defect, for whom treatment and training were of importance. As a result 46 cases of this type were reported upon and, arising out of the report, it was decided that the formation of a Speech Centre or Class should receive early consideration. A suggestion was put forward that it might be possible to set free a classroom at High Street School for the training of these children, but no further development has taken place in regard to the matter. (c) Places of Medical Inspection. The work of medical inspection is carried out during school hours and on school premises in every case, and disturbance of school arrangements is reduced to a minimum. 5. FINDINGS OF MEDICAL INSPECTIONS. The following comparative table serves to indicate the definite tendency towards a reduction in the number of physically defective children in the schools. To a certain degree the reduction in the percentage of children found to require treatment is only apparent and, in reviewing the figures, we must not overlook the fact that the Local Authority is arranging for the treatment each year of a larger number of physically defective children in institutions, residential schools and schools of recovery. Unfortunately, a large majority of the defects found have had their inception before the children have reached school age and, in many cases, the defect is of such a nature that definite cure is impossible, and all that can be expected is to check its progress. Obviously, under these circumstances, the discovery of physical defects in school " leavers " will not be eliminated until a more systematic medical supervision of the pre-school child is introduced. 91 FINDINGS OF MEDICAL INSPECTION. Group. NUMBER OF CHILDREN. Percentage of Children found to require Treatment. Inspected. Found to require Treatment. 1923 1924 1925 1926 1927 1928 1923 1924 1925 1926 1927 1928 1923 1924 1925 1926 1927 1928 Entrants 1,459 1,171 2,960 3,345 2,468 3,197 215 187 340 454 244 354 14.7 15.97 11.5 13.6 9.9 11.1 Intermediates 2,131 2,172 2,961 1,991 1,295 2,424 550 384 445 270 133 291 25.8 17.68 15.0 13.6 10.3 12.0 Leavers 3,717 3,116 3,118 3,877 2,717 2,848 681 385 370 520 180 237 18.3 12.36 11.9 13.4 6.6 8.2 Totals 7,307 6,459 9,039 9,213 6,480 8,469 1,446 956 1,155 1,244 557 882 19.7 14.8 12.8 13.5 8.6 10.4 92 (a) Uncleanliness. The School Nurses have carried out 3 cleanliness surveys of all the children in the elementary schools during the year. During the year the School Nurses made 55,351 examinations, as compared with 58,588 in 1927. Of this number 387 children showed vermin and many nits in the hair (479 in 1927), whilst 2,020 children showed only a few nits (2,110 in 1927). Comparative table:— Year Number Examined Number with Nits Number with Head Vermin No. of Exclusion Certificates 1924 57,936 2,648 826 80 1925 58,090 2,856 652 45 1926 58,683 2,527 668 49 1927 58,588 2,140 479 50 1928 55,351 2,020 387 40 93 TABLE VII. TABLE OF VERMINOUS CONDITIONS FOUND AT EXAMINATIONS FOR GENERAL CLEANLINESS. SCHOOLS. Dept. Number Exam'd. Few Nits. Many Nits and Vermin. SCHOOLS. Dept. Number Exam'd. Few Nits. . Many Nits and Vermin. Brampton Infants 1768 31 11 Plashet Infants 1053 61 18 J. Girls 1151 32 9 J. Boys 992 15 4 S. Girls 1082 32 2 S. Boys 780 4 2 Castle Street R.C Infants 234 8 — Storey Street J. Mixed 877 55 32 Mixed 483 18 — S. Mixed 1061 52 32 Central Park Infants 1140 60 7 Silvertown R.C. J. Mixed 457 34 25 J. Boys 1300 9 2 S. Mixed 588 20 16 S. Boys 1046 7 3 St. Michael's R.C. Mixed 356 18 5 Dersingham Mixed 861 36 7 St. Winefride's R.C. Mixed 898 51 10 Essex Road Infants 930 27 12 Sandringham Road J. Mixed 1318 30 3 Girls 1116 51 10 S. Mixed 1238 24 2 Boys 1083 8 1 Shaftesbury Road Infants 1083 56 5 Fourth Avenue Infants 648 32 4 Girls 1196 79 2 Girls 984 62 3 Boys 1154 2 — Boys 972 24 1 "Salisbury" Primary 1409 47 7 Hartley Infants 1084 66 12 Inter 709 12 — J. Girls 982 81 10 Shrewsbury Road Special 202 10 1 S. Girls 876 39 5 Vicarage Infants 1127 47 6 High Street J. Mixed 830 58 11 J. Girls 1009 93 13 S. Mixed 673 32 3 S. Girls 894 64 14 Kensington Avenue Infants 839 18 — Walton Road Infants 1402 69 17 Girls 1001 32 1 Girls 1268 73 11 Boys 1091 11 1 Boys 1173 16 4 Lathom Road Infants 1269 63 6 "Winsor" Primary 1189 53 4 Girls 1197 56 3 Inter 664 33 4 Boys 1178 1 — Wakefield Central Girls 170 5 1 Monega Road Infants 985 10 5 Girls 994 25 — Total 55351 2020 387 Boys 1251 — — Myope Class — 30 — — Pee cent 3.6 .7 Napier Infants 947 60 13 J. Boys 353 9 1 Per cent in 1927 3.7 .8 S. Boys 706 9 6 94 It will be noted that there is again a reduction in the percentage of children suffering from verminous conditions, and great credit is due to the School Nurses, whose untiring efforts have been entirely responsible for ensuring this diminished incidence in cases of uncleanliness, but there is no doubt that systematic and practical instruction in hygiene by the teachers would tend to eliminate completely such conditions. In addition to the routine general cleanliness survey, some hundreds of children have been examined by the School Nurses at the request of the Authorities of the Children's Country Holiday Fund and other voluntary organisations. The examinations have been conducted just prior to the departure of the children for summer holiday camps. (b) Minor Ailments. As has been the case in former years, few minor ailments were discovered at routine medical inspection, owing to the vigilance displayed by teachers and nurses, and to the growing interest of parents in such matters. Such cases, frequentlyrecognised in the early stages, have been immediately referred to one of the School Clinics. Chief Minor Ailments Discovered at Routine Medical Inspection. Discovered by Teachers and Nurses and sent to Clinic 1927 1928 1927 1928 Scabies 2 1 5 16 Impetigo 11 27 496 427 Conjunctivitis 5 2 52 57 Blepharitis 3 4 59 54 Ear Disease 41 50 154 187 Ringworm (Scalp) 2 3 48 61 Ringworm (Body) 1 31 36 (c) Tonsils and Adenoids. 4.8 per cent. of the children examined during the year were referred for treatment for " tonsils and adenoids," either separate or combined, as compared with 3.1 per cent. in the year 1927. Of these, much enlarged tonsils accounted for 0.7 per cent. ; definite 95 adenoids were present in 0.5 per cent., and the combined defect was diagnosed in 3.6 per cent. ; the figures for 1927 were 0.4 per cent., 0.3 per cent., and 2.4 per cent., respectively. The percentage of children moderately affected and requiring to be kept under observation was 7.3, the corresponding percentage in 11927 being 5.5. In this case 6.4 per cent. had moderately enlarged tonsils, 0.5 per cent. exhibited signs of the presence of adenoids, whilst 0.4 per ccnt. showed enlarged tonsils and adenoids of moderate degree, as compared with 4.2 per cent., 0.5 per cent., and 0.8 per cent., respectively in the year 1927. (.d) Tuberculosis. The total number of cases of tuberculosis, occurring in children of school age, notified to the Medical Officer of Health during the year, was as follows:— Boys. Girls. Total. Pulmonary Tuberculosis 6 12 18 Other forms of Tuberculosis 7 6 13 Totals 13 18 31 (e) Skin Disease and (f) External Eye Disease. The number of these cases, although less than last year, still remains high. At medical inspection during the year 844 children were found to be suffering from skin affections (as compared with 951 in the year 1927). Cases of external eye disease also continue to show a high incidence, 117 in the year 1928 and 119 in the year 1927. (g) Vision. Only children with marked visual defect have been referred for treatment and these, including cases of strabismus, numbered 737. In addition there were 116 children in whom there was evidence of a lesser degree of visual defect and these are being kept under observation. (See report of Ophthalmic Surgeon on p. 119.) 96 (h) Ear Disease and Hearing. .02 per cent. of the children examined were found to be suffering from otitis media, as compared with 0.1 per cent. in 1927. The percentage of deaf children was 0.4, the corresponding number for last year being 0.7. (i) Dental Defects. (See report of Dental Surgeon on p. 122). (j) Crippling Defects. Reference to Table III on page 131 will furnish information with regard to the occurrence of crippling defects in the area. 24 cases of crippling due to tuberculosis and 105 cases due to other causes were discovered at routine medical inspection during the year. 6. INFECTIOUS DISEASES. A detailed account of the scheme adopted for the detection and prevention of infectious diseases has been submitted in previous reports, and the accompanying table will furnish statistics in regard to the incidence of the acute infectious diseases during the year 1928. There has been a marked increase in the incidence of scarlet fever, diphtheria, measles and whooping cough. The marked increase in the incidence and severity of diphtheria is a matter for grave concern (29 children of school age and 25 children under school age died from this disease during the year), and it is proposed to ask the Local Authority to adopt the principle of immunisation with a view to offering such treatment to those who make application. A very wide response is not anticipated at the outset, as the growing public attitude against vaccination is bound to have a deterrent effect. On the other hand the absence of any suggestion of compulsion, together with the distribution of suitably worded propaganda, may result in the protection of a fair percentage of children. One appreciates that treatment should be concentrated primarily upon children under school age and this question will be raised at the Maternity and Child Welfare Committee. 97 In regard to Small-pox there were four actual cases and twelve contact cases in children attending schools in the Borough. Five schools were involved and, in addition to the usual precautions, it was thought desirable to circularise the parents of all the children attending these Schools and to advise them that, whilst everything possible had been done by the Local Authority to prevent the spread of infection, the only real safeguard was vaccination and revaccination. The result of this action is encouraging and a large number of children have been vaccinated. 98 Table of the Chief Infectious Diseases, Showing the Monthly Incidence in Children of School Age. Month Measles Chicken Pox Whooping Cough Mumps Scarlet Fever Diphtheria January 52 22 1 2 48 41 February 255 43 14 6 34 48 March 164 11 52 9 34 49 April 189 5 38 1 37 35 May 67 10 38 4 58 34 June 1 38 14 7 38 23 July 6 40 45 5 47 36 August — — — — 23 27 September — 2 46 2 46 39 October 3 2 26 4 76 38 November — 6 19 7 56 35 December — 6 3 3 68 21 Totals 737 185 296 50 565 426 99 In addition to the acute infectious diseases, the following infectious conditions have occurred during the year: Nature of Complaint. Number Excluded. Number of Sessions involved. 1927 1928 1927 1928 Ringworm of Scalp 50 54 1968 1966 Ringworm of Body 43 46 446 1324 Impetigo Contagiosa 78 158 1111 1696 Infective Eye Inflammation 62 72 834 1246 Septic conditions 125 156 1314 1540 Verminous conditions 23 34 254 252 Scabies 11 30 176 560 Other Skin conditions 65 46 958 558 Acute Throat conditions 33 48 804 1000 490 644 7868 10142 7. FOLLOWING UP. The arrangements for following up defects found at medical inspection were set out fully in the report for 1920, and these have been continued throughout. The School Nurses have paid 4,239 visits to the homes of children in whom defects were found at medical inspection, and for special investigation purposes. Of the 1,093 children referred for treatment, 750 or 68.6 per cent. have obtained treatment. The School Nurses have also paid 342 special visits to the Schools, and 32 visits to the Feeding Centres, and have undertaken 22 journeys in connection with the admission and discharge of children to Institutions. All children, referred for the operative treatment of tonsils and adenoids (506), have been visited by the School Nurses both prior to and after the operation. The value of the work of the School Nurses cannot be overestimated: it is they who come in close touch with the children and parents in the home, and to the School Nurses belongs the satisfaction of knowing that it is largely owing to their efforts that the incidence of disease amongst the children is declining year by year. 100 The duties of the School Nurses are becoming: much more elaborate and their responsibilities have increased, and are increasing very considerably. Special investigation and report by the School Nurse upon individual school children is becoming more important, and the number of cases dealt with is increasing rapidly; very full reports are required, and these necessitate careful preparation and a high standard of technical (nursing and sanitary) knowledge. In this connection also the large London General Hospitals are seeking the co-operation of the School Medical Service to a greater and greater extent with a view to ensuring the best possible line of treatment for children attending as OutPatients, and' also as In-Patients prior to admission and after discharge. The duties of the School Nurses in East Ham are very varied and include much specialised work in connection with treatment by means of ultra violet radiation, the X-ray treatment of ringworm, ophthalmic treatment, aural treatment, dental treatment, etc., duties, which in many areas, are performed by specially appointed Nurses. It seems unfortunate that no standard has been indicated by the Board of Education in regard to the qualification and status of School Nursess along the lines taken by the Ministry of Health in connection with Health Visitors. There is no doubt that such a standard would be to the advantage of the School Medical Service generally, would certainly be a source of satisfaction to the more highly qualified members of the Nursing Staff and would remove any obstacle to complete co-ordination in the near future. The County Borough of East Ham is fortunate in possessing a very keen, efficient and well-qualified staff of School Nurses, upon whose work has depended, to a large extent, the highly satisfactory results obtained by the School Medical Service, both in the direction of ensuring the adoption by the parents of the advice given by the Medical Officers and of determining and securing for the children the necessary preventive and curative treatment required. 101 8. MEDICAL TREATMENT. The following clinics are held weekly for the treatment of defects in school children:— (1) General Clinic (Minor Ailments and Observation Cases), Town Hall—Mondays, Wednesdays and Saturdays, 9 a.m. (2) General Clinic (Minor Ailments and Observation Cases), St. Michael's Institute, Manor Park—Tuesdays and Thursdays at 9 a.m. (3) General Clinic (Minor Ailments and Observation Cases), North Woolwich—Mondays and Fridays, at 2 p.m. (4) General Ear Clinic, Town Hall—Fridays, at 2 p.m. (5) Eye Specialist Clinic, Town Hall—Tnursdays at 9 a.m., Tuesdays at 9 a.m., and Fridays at 9 a.m. (6) Ear Specialist Clinic, Town Hall—Tuesdays, at 3 p.m. (7) Light Clinic, Town Hall—Mondays and Wednesdays, at 2 p.m. A full account of these clinics was set forth in my report for 1922. During the year 1928, 19,140 attendances were made for treatment at the various clinics, and there were 16,533 attendances for consultation of the Medical Officers. (a) Minor Ailments. An analysis of the chief minor ailments treated at the School Clinics, and otherwise, will be found in Table IV, Group 1, p. 134 (b) Tonsils and Adenoids. In the case of children moderately affected and requiring to be kept under observation advice has been given as to general hygiene, diet, the necessity for dental treatment, and for breathing exercises, etc. Of the children referred for treatment, 506 have received operative treatment with marked beneficial results to their general health. Arrangements for the performance of these operations are in force with three hospitals, viz., St. Mary's, Plaistow; Balaam Street Children's Hospital and Queen Mary's Hospital, Stratford. 102 Arrangements have been made to carry into effect the recommendation of the Board of Education in regard to the visitation of children after the operation. An agreement has been reached with the Hospital Saving Association which became effective on 1st October, 1928, by which the children of Hospital Saving Association contributors are issued with authorities for operative treatment of tonsils and adenoids on presentation of the necessary Hospital Saving Association voucher in lieu of the usual fee of 5s. required from the parent. Quarterly accounts are subsequently sent to the Hospital Saving Association. The arrangement has proved satisfactory and has eliminated many difficulties which were previously experienced with Hospital Saving Association cases. (c) Tuberculosis. The arrangements for the treatment of Tuberculosis have been continued on the lines fully set forth in my reports for previous years. (d) Skin Diseases. For the most part these are treated at the General Clinic, but some cases of chronic and of the rarer skin diseases are referred to hospital. The application of X-rays in cases of ringworm is performed at the School Clinic, and 19 children received this form of treatment during this year. (e) External Eye Disease. 176 cases (196 in 1927) of external eye disease were treated at the School Clinics. The observations of the School Ophthalmic Surgeon, with regard to the best means of dealing with these cases, will be found in his report on p. 119. (/) Vision. During the year 1928 the Ophthalmic Clinic was held on five sessions per fortnight. 103 737 cases were referred for treatment in respect of visual defect during the year 1928 and, including 72 cases awaiting treatment at the termination of the year 1927, 747 cases have been treated in the past year. On the 31st of December, 1928, there were 143 children with markedly defective vision who had not been seen by the Ophthalmic Surgeon. A waiting list such as this results in considerable delay, and in many cases a period of from three to four months intervenes between the discovery of the defect and attendance for treatment. Unfortunately it has not been possible to give an opportunity of attending the Ophthalmic Clinic to all the children with lesser degrees of visual defect. There were 116 such cases discovered during the year and it is hoped that these children will be dealt with as soon as the more urgent cases have been treated. A Sight-saving Class at Monega Road School was opened by the Education Committee in June, 1928. 20 children are in attendance at this class, and they are all kept under observation by the Ophthalmic Surgeon at certain intervals. The class is certainly a success, and the Ophthalmic Surgeon's report and observations in regard thereto will be found on page 119. (g) Ear Disease. 334 consultations were given and 246 children were treated at the General Ear Clinic. (See report of Aural Surgeon, p. 118). (h) Dental Defects. I again respectfully advise the Committee to consider the necessity for extending their activities in endeavouring to ensure dental health and banish so many of those ills which originate in the mouth. To this end the appointment of at least one additional Dental Surgeon is a matter of extreme urgency. It is estimated that one Dental Surgeon can deal satisfactorily and efficiently with a school population of 5,000, that is to say, he should be able to give complete treatment to all cases found to require attention as the result of the dental inspection of 5,000 children, and subsequently to examine and treat all entrants and to re-inspect and re-treat where necessary, at annual intervals, all the children previously dealt with. This is the only way to ensure freedom from oral sepsis and dental decay. (See also Report of Dental Surgeon, p. 122.) 104 (i) Crippling Defects. Orthopædic treatment has been continued under arrangement made with the Balaam Street Children's Hospital of the Invalid and Cripple Children's Society. The treatment at the hospital includes operative, electrical and massage treatment, remedial exercises and the supply of surgical appliances, and is carried out under the direction of an orthopaedic surgeon. Payment is made to the Hospital Authorities by a per capita grant contribution in respect of East Ham scholars sent to the Hospital through the School Medical Service. All children referred by the Authority's Medical Officers to the Hospital for treatment are kept under observation at frequent intervals at one or other of the School Clinics, in order that the progress of the cases may be watched and recorded, and to ensure that treatment has not been allowed to lapse. If at any time such a case fails to attend the School Clinic it automatically becomes included in the following-up list of one of the School Nurses. A large amount of work has been undertaken at the Hospital and has been highly satisfactory. During the year 1928, 20 out-patients and 4 in-patients have received orthopædic treatment. The total out-patients' attendances was 464, whilst the average number of weeks involved in the case of each in-patient was 11.8. (j) The Light Clinic. For the purpose of carrying out artificial light treatment there are two arc lamps in the Town Hall Clinic: a quadruple carbon are lamp of the radial type for general therapeutic purposes and a single tungsten arc lamp for local treatment. Although the Clinic is only available on two sessions per week for this form of treatment we have continued to experience very satisfactory results. A further twelve months' experience of actino-therapy does not warrant any change of opinion as to the superior value of this form of treatment, in the type of cases selected, over all other measures which have been given a trial, and I can only reiterate and confirm my report of last year. A certain amount of unwarrantable disrepute has fallen upon actino-therapy and, in all probability, this is due to the fact that the general public, and 105 unfortunately also some medical practitioners, have formed the opinion, as is so often the case with newly introduced therapeutic agents, that ultra-violet radiation is a panacea. Whereas, as a matter of fact, much harm may be done in certain cases by unskilled and injudicious use, and careful examination and complete diagnosis is a very essential preliminary to actino-therapy, frequent re-examination to determine the effect and to assess the dosage being also essential. In this connection it is obviously highly important in cases of malnutrition, debility, anaemia and so-called pretuberculosis to eliminate at the outset definite underlying organic or constitutional disease which may require specific treatment; for whilst in some of these cases ultra-violet radiation may be of value when combined with specific treatment, in others it is definitely contra-indicated. Where, however, such conditions are hereditary, dietetic, environmental or catarrhal in origin the general application of ultra-violet radiation is of great value, and it is cases of this type which have been treated at the Town Hall Light Clinic. It has been suggested that the administration of cod liver oil produces comparable results in this type of case, but this has not been our experience, and a large number of children who have received prolonged treatment with cod liver oil and malt or with virol, either alone or in combination with Parrish's food, have shown little or no improvement, whereas the subsequent treatment with artificial light has resulted in a very rapid improvement in the physical condition of these children. In this connection the fact must not be overlooked that on the one hand the child is receiving ready-made vitamin, whilst on the other hand the vitamin is manufactured within the tissues of the body as the result of stimulating a metabolic process which has become sluggish. Furthermore, the production of vitamin is only one of many of the proven beneficial results of exposure to ultra-violet radiation. The treatment has also been used with very marked benefit in cases of chronic bronchial catarrh, bronchitis, rheumatism and adenitis. Children suffering from hypertonia of the nervous system, the highly strung, excitable, irritable and choreic types do not in all cases appear to respond very satisfactorily to ultra-violet radiation. Throughout general irradiation has been used chiefly as an adjunct to natural sunlight, during the period from September to May, and parents have been instructed and persuaded in regard to the importance of taking full advantage of natural sunshine and fresh 106 air. The tungsten arc lamp has been used mainly in the local treatment of chronic cervical adenitis (in conjunction with general irradiation), and there is no doubt that the results achieved are far superior to those following; any other form of treatment. Extremely satisfactory results have been obtained also in cases of alopecia. The following is a brief summary of the cases treated by general irradiation throughout the year:— CONDITION. Boys. Girls. Anæmia 15 19 Debility 39 30 Malnutrition 21 26 Malnutrition and Anaemia 9 6 Pretuberculosis 5 4 Rheumatism 6 3 Bronchial Catarrh and Bronchitis 27 11 Adenitis 17 12 Alopecia 3 2 Number of children treated 255 (132 in 1927) Number of attendances 3,206 (2,706 in 1927) Average number of attendances per child 13 Average gain in weight per month per child 1 lb. 6 oz. Number treated by local application 18 The marked general improvement, both physical and mental, in the cases under treatment has been amply verified by parents and teachers, and the former have exhibited a very firm conviction as to the efficacy of the treatment, both verbally and by their assiduous attendance at the Clinic; it has been noteworthy that there have been very few absentees. (See also the Report of the Ophthalmic Surgeon, p. 119.) The daily use of the artificial light apparatus would be a great asset in our endeavours towards the prevention of ill-health and disease in early life, and the provision of specific accommodation 107 would make this possible. A much larger waiting room is urgently necessary to enable the children to have a comfortable period of rest after treatment before they leave the building. 9. OPEN-AIR EDUCATION. (a) Playground Classes. In a few cases playground classes continue to be held occasionally. (b) School Camps. The Education Committee sent 139 Scholars to the Dymchurch Holiday Camp during the year 1928, and in addition the following School Journeys were undertaken:— Walton Road Boys 28 Piashet Senior Boys 40 Lathom Road Boys 25 Kensington Avenue Boys 40 Hartley Senior Girls 25 Fourth Avenue Boys 36 Central Park Senior Boys 27 Brampton Senior Girls 30 Sandringham Central 100 Total 351 (c) Open-Air Classrooms in Public Elementary Schools. None of the classrooms in the schools of the Borough have been constructed on the open-air principle. (d) Open-Air Day Schools. There are unfortunately no open-air schools in the Borough. (See also 17 page 111). (e) Residential Open-Air Schools. There are no such schools under the direct control of the Local Education Authority; the Committee, however, have continued to send a certain number of children, for whom such treatment would be beneficial, to the Ogilvie School of Recovery at Clacton-on-Sea. 108 Arrangements have also been made for the admission of children to the Russell Cotes School of Recovery at Parkstone, and to the Institutions of the Invalid Children's Aid Association. The accompanying table gives particulars in connection with these children. In addition, the Invalid Children's Aid Association have rendered assistance in 132 cases, financial responsibility for which was not undertaken by the Local Education Authority. (See also 17 page 111.) 109 Particulars of the number of Children who were resident in Schools of Recovery between 1st January and 31st December, 1928, and the periods of their stay between those two dates. School No. of Months Totals 1 2 3 4 5 6 7 8 9 10 11 12 B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. Total Ogilvie — — — — 3 1 6 2 2 2 — 1 — 3 4 o 1 1 — — — — 7 6 23 18 41 I.C.A.A 2 — 2 6 5 7 2 9 2 1 1 1 — — — — — — — — — — — — 14 24 38 No. of Weeks Russell- Cotes — — — — — — — — — — — — — — — — 6 — — — 5 — 5 — No. of Weeks 13 14 15 16 17 18 23 26 28 RussellCotes (Cont.) — — — — 6 — — — — — — — 1 — 1 — 1 — 25 — 25 110 10. PHYSICAL TRAINING. Physical training has been continued on similar lines to those quoted in previous reports, and instruction in swimming has been conducted as heretofore. 11. PROVISION OF MEALS. During the year 139,588 meals were provided for 545 children, as compared with 123,645 meals for 485 children in 1927. The School Medical Officer suggests a suitable menu for the children's meals, and the Medical Officers and School Nurses visit the various feeding centres periodically. On these occasions the quality of the food and the preparation, distribution and service of the meals have been satisfactory. 12. SCHOOL BATHS. There are no baths used at the schools for the bathing of school children. 13. CO-OPERATION OF PARENTS. During the year 1928 the number of parents who were present at the routine medical inspections was 5,685 (3,603 in 1927), that is, in 57.4 percent. of the cases examined (46.7 per cent. in 1927). The growing interest which parents take in the work of the School Medical Service demonstrates the value which they place upon this work, and assists greatly in ensuring that our advice and directions are carefully carried out. 14. CO-OPERATION OF TEACHERS. The Teachers render most valuable assistance to the School Medical Service, and the great interest which they exhibit in regard to all matters affecting the physical and mental condition of the scholars is extremely stimulating and encouraging to the School Medical Officers and Nurses. 15. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. The co-operation of School Attendance Officers and the coordination of the School Medical Service with that of the School Attendance Department has been fully discussed in previous reports. 111 Many cases have been referred for special examination by the Attendance Officers on forms 21, and of these cases 102 were medically examined, reports and advice in each case being sent to the Secretary of the Education Committee. 16. CO-OPERATION OF VOLUNTARY BODIES. Reference to 8 (i) on page 104 and to 9 (e) on page 107 will give some measure of the scope of the work carried out in association with Voluntary Bodies. 17. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Physically Defective Children. Table III reveals the very regrettable fact that 63 children suffering from physical defects are receiving no education owing to their being totally unfit to attend public elementary schools. In addition it will be seen that 539 children, who are considered physically defective, are attending public elementary schools, and since suitable treatment is not available for some of these cases it is highly probable that a number of them will ultimately join the ranks of the unfit. The 301 children classified as delicate (in Table III) are all suffering from a chronic form of defect due to unsatisfactory environmental, nurtural and congenital conditions, and the only treatment which holds out any hope of lasting benefit is their admission to residential schools of recovery for periods varying from three to twelve months or longer. Whilst there are many children who enter school in a fairly advanced stage of invalidity from the above causes, there are also a great number who exhibit early signs and predisposing conditions and for whom the routine, hygiene and education in a day open-air school, in addition to medical supervision and treatment at the School Clinic, would go far in the prevention of a more serious defect. These cases have not been classified in Table III in view of the fact that there is insufficient accommodation for the severer types of defect in residential open-air schools, and no openair school is available for their reception. As reported on previous occasions 112 "The provision of a day open-air school, erected on a suitable site within the Borough, would tend markedly towards reducing the number of definitely physically defective children, with the result that, at no distant date, the present serious need for a large number of places in a Physically Defective Centre and a Residential Open-air School would be less urgent." In regard to the 109 children suffering from glandular and non-infectious pulmonary tuberculosis, and the 24 children suffering from active non-pulmonary tuberculosis, who are attending ordinary elementary schools, it is obvious that all these cases would benefit far more from an open-air school life and the liability of relapses occurring would be almost eliminated. It will also be noticed that 105 crippled children (many of whom are suffering from severe heart disease) are attending ordinary elementary schools only because no special school is available for their reception. This appears to be a very appropriate section under which to make mention of "Health Teaching in Schools." It is very regrettable that no routine instruction is g'iven by the teachers in the simple laws of health and hygiene. In the year 1925, a scheme was submitted to the Head Teachers' Association which embodied suggestions for a "School Children's Health Service," but the scheme was "considered impracticable" and no alternative suggestion was put forward. The following matters deserve very careful consideration in determining upon the question of the most satisfactory action to be taken in regard to defective, delicate and tubercular children:— 1. A more intensive health campaign in regard to children under school age, together with complete medical supervision and treatment of children up to the age of five years. 2. The systematic instruction and interesting study and practice of hygiene in the elementary schools. 3. The erection of a day open-air school to accommodate at least 500 children. 4. The provision of a Special School for Physicallv Defective Children to accommodate at least 200 children. 5. The improvement of home conditions, especially in the direction of reducing overcrowding. 113 Mentally Defective Children. During the year 1928, the number of cases examined, for purposes of the Mental Deficiency Act of 1913, was 66 (93 in 1927). Of these 19 were classified as mentally deficient, and 7 as dull and backward, recommendations being made as shown in the following table:— Number examined 66 Classified as mentally deficient 14 19 Classified as morally deficient — Classified as imbeciles 4 Classified as idiots 1 Classified as dull and backward 7 Recommended for Special School 14 A reference to Table III will show that out of 112 children who have been certified as mentally defective but educable in a special school, 4 (7 in 1927) are having no education, and 108 have been satisfactorily placed. 18. NURSERY SCHOOLS. There are at present no Nursery Schools in East Ham. 19. SECONDARY SCHOOLS. There is only one secondary school in East Ham, and tables relating to the work carried out in connection with the Girls' Department of this school are appended. It is to be regretted that it was found impossible to arrange for the medical inspection in the Boys' Department for the reasons given on page 87 (4 a (i) ). 20. CONTINUATION SCHOOLS. There are no Continuation Schools in East Ham. 21. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. All children in their final medical examination prior to leaving school have a note placed on their medical card if there is any special point in their medical history likely to affect the choice of employment. In cases of definite disability steps are also taken to interview the parent and advise as to the choice of suitable employment. 114 During school medical inspection no children were discovered whose health was considered to be adversely affected through employment outside school hours. Fourteen boys have been specially examined in accordance with the Bye-laws, and these were found to be fit for employment. In addition, 21 school children were examined under the Regulations dealing with the employment of children at entertainments and certified fit for participation in such employment. 22. SPECIAL ENQUIRIES. Again the amount of work undertaken by the staff of the School Medical Service during the year has been so great that no time was available for satisfactorily carrying out any of the special inquiries suggested by the. Chief Medical Officer of the Board of Education. 23. MISCELLANEOUS. During the year 1928 the following special medical examinations were made:— Teachers 50 Officers 6 Student Teachers ... 12 Scholarship Candidates 69 Workmen 21 W. BENTON, Medical Officer of Health and School Medical Officer. 115 MEDICAL INSPECTION RETURNS. SECONDARY GIRLS' SCHOOL. TABLE I. RETURN OF MEDICAL INSPECTIONS (see note a). For the Year ended 31st December, 1928. A.—ROUTINE MEDICAL INSPECTIONS. Number of Code Group Inspections— (see note b). Entrants ... — Intermediates — Leavers 124 Total 124 Number of other Routine Inspections (see note c). 96 B.—OTHER. INSPECTIONS. Number of Special Inspections (see note d). 14 Number of Re-Inspections (see note e). 31 Total 45 116 TABLE 11. SECONDARY GIRLS' SCHOOL. A.—Return of Defects found by Medical Inspection in the Year Ended 31st December, 1928. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition — — — — Uncleanliness: See Table IV., Group V. — — — — Skin ^Ringworm: Scalp — — — — Body — — — Scabies — — — — Impetigo — — — — Other Diseases non-Tuberculous — 2 1 2 Eye Blepharitis — — — — Conjunctivitis — — — 1 Keratitis — — — — Corneal Opacities — — — — Defective Vision (excluding Squint) 19 2 1 Squint — — — — Other Conditions 1 1 1 — Ear Defective Hearing — — — — Otitis Media — — — — Other Ear Diseases 2 — — — Nose and Throat Enlarged Tonsils only — 3 — — Adenoids only — — — — Enlarged Tonsils and Adenoids — — — — Other Conditions 1 — — — Enlarged Cervical Glands (Non-Tuberculous) — 1 — — Defective Speech — — — — 117 Table II.—(continued.) (1) (2) (3) (4) (5) Teeth—Dental Diseases (see note a) See Table IV., Group IV. — 4 — — Heart and Circulation 'Heart Disease: Organic — — — — Functional — — — — Anæmia — 4 2 — Lungs Bronchitis — — — — Other Non-Tuberculous Diseases — 2 — — Tuberculosis Pulmonary: Definite — — — — Suspected — — — — Non-Pulmonary: Glands — — — — Spine — — — — Hip — — — — Other Bones and Joints — — — — Skin — — — — Other Forms — — — — Nervous System Epilepsy — — — — Chorea — — — — Other Conditions — 2 — — Deformities Rickets — 2 — — Spinal Curvature — 8 — — Other Forms 1 4 — — Other Defects and Diseases 1 2 2 1 B.—Number of individual children (see note b) found at Routine Medical Inspection to Require 'Treatment (excluding Uncleanliness and Dental Diseases). GROUP. (1) Number of Children. Percentage of Children found to require. Treatment. (see note d). (4) Inspected (see note c) (2) Found to require Treatment. (3) Code Groups:— Entrants — — — Intermediates — — — Leavers 124 22 17.7 Total (Code Groups) 124 22 17.7 Other Routine Inspections 96 5 5.2 118 REPORT OF THE WORK DONE IN THE AURAL CLINIC. To the School Medical Officer, Education Committee, County Borough of East Ham. 11th January, 1929 Sir, I have the honour to submit my Report for the year ended December 31st, 1928. The following is a list of Ear, Nose and Throat cases, indicating the nature of the disease, the form of treatment undertaken, and the results of treatment:— Number of Cases seen by Specialist 372 Number of Boys 193 Number of Girls 179 Number of Visits made to Specialist 812 Number of Visits made to the Treatment Clinics 2,040 Number of Cases of Deafness 88 Number of Cases of Discharging Ears 140 Number of Cases showing improvement in Hearing 80 Number of Tonsils and Adenoids Operations Ordered 154 Number of Cases discharged during 1928 120 Number of Cases of Mastoid Disease and Nasal Obstruction operated upon by Specialist in Hospital 20 Under existing conditions, the results of treatment, on the whole, may be considered satisfactory. There is, however, considerable scope still left for improvement in this respect, but this can only be taken advantage of when better facilities for the treatment of each individual patient are afforded. The existence of the new hospital at East Ham should considerably improve matters. I am, Sir, Your obedient Servant, L. GRAHAM BROWN. 119 REPORT OF THE OPHTHALMIC SURGEON. To the School Medical Officer, County Borough of East Ham, Education Committee. February, 1929. Sir, I have the honour to present my Sixth Annual Report. During the past year I have examined 688 children for defective vision. I also have under observation, apart from these, 710 children, and 197 no longer require supervision. The work of the clinic divides itself into three main groups:— (1) The treatment of cases of long sight—Hypermetropia— for symptoms of headache and the complication of squint which so frequently accompanies this condition. Operative treatment for squint has been continued during the past year under difficulties. The Royal Westminster Ophthalmic Hospital has moved to a new site in Broad Street, Bloomsbury, and a shortage of beds—acute for many months—has not yet been overcome. However, I have been able to admit 6 cases for operation with, I think, satisfactory results. (2) The treatment of cases of short sight—Myopia—developing during the school period and dangerous because of their tendency to get worse as the result of (a) Hereditary tendency (b) Illnesses from which the children may suffer, (c) Pressure put upon them by normal competition both in work and games. I have been making a special study of cases of myopia attending the clinic during the past five years and hoped to present a special report on this matter, but the facts have taken longer to collect than I anticipated, and I shall have, Sir, to present this during the coming year. (3) The treatment of cases of eye disease—chiefly external eye disease, due to poor general health resulting from lack of fresh air, food and sunlight, and dependent to a large extent upon overcrowding and the conditions of the labour market. 120 Two main lines of treatment which I fear I have stressed often already are (a) the education and interest of the parents and children as to hygienic facts presented by School Medical Officers, and (b) the constant, untiring and kindly help and supervision given by School Nurses, both at school inspections and in the Homes themselves. It is necessary to bring out these points which are apt perhaps to be forgotten by those not actually engaged in the work. There is not the least doubt that this type of disease is a disappearing quantity, a large percentage of the attendances beingaccounted for by the repeated appearance of one or two children who may be almost described as haunting the clinic. The faith with which these arrive time after time to have their discomfort relieved is as encouraging as one's inability to keep them permanently well is disappointing. It is in this type of case especially that the sunlight clinic has proved of real value by (a) promoting the general sense of wellbeing in the child (b) increasing its resistance to infective disease, (c) raising the general tone by improving the appetite, eliminating constipation and enabling the child to put on weight. Much too much general publicity has been given to the treatment by artificial light as a "cure all," but in skilled hands these effects have been sufficiently constant to give this treatment a very definite place amongst our methods against eye disease. The Myope Class was started last year to provide special sight saving educational methods for 20 of the worst cases of myopia. At its inception several children were brought home from residential schools where they had been for some time, and started in the class. This necessary economic measure may make it rather difficult in the near future to accommodate cases of serious shortsight which arise in the Borough. The class has naturally suffered from the loss of the very intelligent teacher who started it. With the long waiting list of eye cases which exists, it is difficult to see how it will be possible for the Ophthalmic Surgeon to give time for the personal inspection of the work of this class, but each child attending it is seen in the ophthalmic clinic every three months and progress carefully watched. 121 The Infant Welfare Centres send specially selected cases to see me on Friday mornings. 59 have been sent in the past year. This provides in the simplest possible manner for one side of the co-operation between the centres and the special departments of medicine, which is of sufficient importance to be dealt with by a Special Committee of Hospital Surgeons and Physicians and Infant Welfare Medical Officers which sat at the Society of Medical Officers of Health in London. At this Committee I recommended the plan in force at East Ham, but one felt that perhaps the importance of the Ophthalmic Surgeon at the Infant Welfare Centre had been recognised more fully in East Ham than elsewhere. May I, in conclusion, Sir, once more thank you for the cordial co-operation invariably extended to me by the School Medical Officers and draw attention to the invaluable work done by the School Nurses and Health Visitors who attend my clinic and help so materially with the treatment. These, together with the kindly efficiency of the optician and the clerical staff, have made possible the measure of success attained. I have the honour to remain, Sir, Your obedient Servant, CHARLES LEONARD GIMBLETT. 122 REPORT ON THE WORK DONE IN THE SCHOOL DENTAL CLINIC. To the School Medical Officer, County Borough of East Ham Education Committee. Sir, I beg to submit to you my report for the year 1928. The age groups inspected were from 5 to 9 years inclusive. The number of children inspected was 9,786, and the number referred for treatment was 6,799; to these must be added those cases of toothache and aural sepsis, referred by the School Medical Officers, Nurses, and Head Teachers, which numbered 247. Details will be found in the following table:— TABLE IV. Group IV.—Dental Defects. (1) Number of Children who were:— Age. Routine Age Groups. Specials (see note d) Grand Total. 5 6 7 8 9 Total. 10 11 12 13 14 (a) Inspected by the dentist 1767 2075 2306 2527 1111 9786 — — — — — 247 10033 (b) Found to require treatment 6799. (c) Actually treated 2040. (d) Re-treated during the year as the result of periodical examination 1582 {see note e) (2) Half-days devoted to:— Inspection 69 Total 395 Treatment 326 (3) Attendances made by children for treatment 4799. (4) Fillings:— Permanent teeth 377 Total 986 Temporary teeth 609 (5) Extractions:— Permanent teeth 591 Total 6659 Temporary teeth 6068 (6) Administrations of general anæsthetics for extractions 328. (7) Other operations:— Permanent teeth 261 Total 463 Temporary teeth 262 I should like to stress the point that all pain in dental operations is reduced to a minimum. Local injections are given for the extraction of all temporary teeth and permanent teeth, except where it is contra-indicated, such as in cases of abscess, aural 123 sepsis, etc., when a local application of ethyl-chloride is given for temporary teeth, and a general anaesthetic, nitrous-oxide, for permanent teeth. Small cavities in temporary teeth are filled in order that they will function for the remainder of their short existence. Great importance is laid on filling the permanent teeth, especially the six-year molars. Some permanent teeth are very sensitive when being filled, so a local injection is then given in order that the operation will be painless. Every little patient that visits the Clinic has his or her mouth put into a sound condition, whether it means one visit or six visits. Thus, when the child leaves the Clinic its mouth is entirely free from dental decay and aural sepsis, and for some months at least it is in a far better condition to battle against illness and disease than it otherwise would be. The dental health of children is very important, insomuch that it is so closely related to their general health ; bad teeth, in the majority of cases, means bad health and not vice-versd as is so often supposed. Dentistry is the great outpost of Preventive Medicine, and as such its importance should be duly recognised by parents, teachers, and others who have the care of children. It is with great pleasure that one records the appointment of another school dentist in the near future—a good step in the right direction. One would like to record this in each annual report until we have four school dentists, the number required to deal adequately with the school children of East Ham. The age groups to be inspected during the year 1929 will be from 5 years to 11 years inclusive. The work of the Dental Nurse is very important because upon her attitude depends a great deal the behaviour of the children in the Clinic, and the co-operation of the parents. Occasionally parents come along with a marked antipathy to clinics, and it rests with the nurse primarily to overcome this. Courtesy, patience, tact, and gentleness are four important attributes of the successful dental nurse. Nurse Olifent has developed these virtues, which fact has added considerably to the success of the Dental Service. Details of treatment accorded the mothers and babies referred from the Maternity and Child Welfare Centre will be found in the following table:— 124 Maternity and Child Welfare Figures for 1928. No. of Half Days devoted to Treatment. No. of Attendances. No. of Permanent Teeth. No of Temporary Teeth. Total No. of Extractions. Total No. of Fillings No. of Adminis trations of General Anaesthetics. No. of other Operations. Adults Children. Extrac ted. Filled. Extrac ted. Filled. Permanent Teeth. Temporary Teeth. 40 85 404 154 11 610 77 764 88 38 33 •20 The dental treatment of babies and mothers is of primary importance, and one is glad to note that there is a considerable increase in attendances over 1927. All the babies have injections or local application of ethyl-chloride for extractions, and great importance is laid upon the filling of temporary teeth where possible. In conclusion, I should like to thank the Medical Officer of the Maternity and Child Welfare Centre, the School Medical Officers, the Nurses, the Clerical Staff, and the teachers for their valuable co-operation and assistance during- the year 1928. I have the honour to be, Sir, Your obedient servant, CYRIL S. NEAME. 125 TABLES GIVING SUMMARY OF WORK OF SCHOOL MEDICAL SERVICE from 1st JANUARY, 1928, to 31st DECEMBER, 1928. PUBLIC ELEMENTARY AND CENTRAL SCHOOLS. TABLE I. RETURN OF MEDICAL INSPECTIONS (see note a For the Year ended 31st December, 1928. A.—ROUTINE MEDICAL INSPECTIONS. Number of Code Group Inspections— (see note b). Entrants 3,197 Intermediates 2,424 Leavers 2,848 Total 8,469 Number of other Routine Inspections (see note c). 1,210 B.—OTHER INSPECTIONS. Number of Special Inspections (see note d). 3,984 Number of Re-Inspections (see note e). 4,030 Total 8,014 NOTES ON TABLE I. (a) The return refers to a complete calendar year. (b) This heading relates solely to the routine medical inspection of the three ordinary age groups, i.e., to medical inspection carried out :— (i) in compliance with Article 7 of the Consolidated Regulations relating to Special Services—Grant Regulations No. 19; (ii) on the school premises (or at a place specially tioned by the Board under Article 44 (h) of the Code); (iii) for the purpose of making a report on each child on the lines of the approved Schedule set out in Circular 582. 126 (c) Under this heading may be recorded routine inspections, if any, of children who do not fall under the three code agegioups, e.g., routine inspections of a fourth age-group or of other groups of children, as distinct from those who are individually selected on account of some suspected ill-health for " Special " Inspection. ((/) A Special Inspection is a medical inspection by the School Medical Officer himself or by one of the Medical Officers on his staff of a child specially selected or referred for such inspection, i.e., not inspected at a routine medical inspection as defined above. Such children may be selected by the Medical Officer during a visit to the School or may be referred to him by the Teachers, School Nurses, Attendance Officers, Parents, or otherwise. It is immaterial for the purpose of this heading; whether the children are inspected at the School or at the Inspection Clinic or elsewhere. If a child happens to come before the School Medical Officer for special inspection during a year in which it falls into one of the routine groups, its routine inspection should be entered in Part A. of Table I. and its special inspection in Part B. The inspection to be recorded under the heading of special inspections should be only the first inspection of the child so referred for a particular defect. If a child who has been specially inspected for one defect is subsequently specially inspected for another defect, such subsequent inspection should be recorded as a Special Inspection and not as a Re-inspection. (e) Under this heading should be entered the medical inspections of children who as the result of a routine or special inspection come up later on for subsequent re-inspection, whether at the School or at the Inspection Clinic. The first inspection in every case will be entered as a routine or special inspection as the case may be. Every subsequent inspection of the same defect will be entered as a re-inspection. Care should be taken to see that nothing is included under the head of special inspections or re-inspections except such inspections as are defined above. Attendances for treatment by a Nurse, or for examinations by anyone other than a Doctor on the staff of the School Medical Service, should not be recorded as medical inspections. If, however, at any such attendance a child is also examined by one of the Authority's Medical Officers, this should be recorded as a special inspection or re-inspection as the case may be, even if treatment is also given; but such attendance may also of course be recorded as an attendance for treatment. 127 TABLE 11. A. --A Return of Defects found by Medical Inspection in thf. Year Ended 31st December, 1928. Defect or Disease. (1) Routine Inspections. Special Inspections. No. of Defects. No. of Defects (2) Requiring Treatment. Requiring to be kept underobservation,but (3) not requiring Treatment. (4) Requiring Treatment. Requiring to be kept (5)underobservation,but not requiring Treatment. Malnutrition 37 5 22 3 Uncleanliness : (See Table IV., Group V.) — — — — Ringworm : Skin Scalp 3 1 61 — Body — — 36 — Scabies 1 — 16 — Impetigo 27 24 427 2 lOther Diseases (non- Tuberculous) 20 49 253 8 Eye fBlepharitis 4 9 54 — Conjunctivitis 2 2 57 — Keratitis — — 1 — Corneal Opacities — — 2 — Defective vision (excluding Squint) 236 73 421 22 Squint 25 18 55 3 Other conditions 6 15 77 6 Ear Defective Hearing 18 12 33 1 Otitis Media 1 3 1 1 Other Ear Diseases 49 102 186 2 Nose and Throat Enlarged Tonsils only 84 867 23 2 Adenoids only 39 62 33 6 Enlarged Tonsils and Adenoids 333 58 150 2 .Other conditions 29 120 115 12 Enlarged Cervical Glands (Non- Tuberculous) 10 868 24 5 128 Table 11.—(continued). (1) (2) (3) 4) (5) Defective Speech 6 45 7 29 Teeth—Dental Diseases 1see note a) (see Table IV., Group IV.) 65 438 78 7 Heart and Circulation. Heart Disease : Organic 3 15 1 1 Functional 1 12 8 2 Anaemia 16 55 54 4 Lungs Bronchitis 19 105 33 4 Other Non- Tuberculous Diseases 8 56 75 _ T uberculosis Pulmonary : Definite 1 1 1 — Suspected ... — 3 1 1 Non-Pulmonary: _ _ _ _ Glands 1 2 2 — Spine — 2 — — Hip 1 2 — 1 Other Bones and Joints — — — Skin — Other Forms 3 5 — — Nervous System Epilepsy 1 7 8 2 Chorea 9 14 30 3 .Other conditions 2 26 21 7 Deformities Rickets 5 2 _ Spinal Curvature 16 12 1 — Other Forms ... 3 29 19 6 Other Defects and Diseases . 91 354 1052 71 B.—Number of Individual Children (see note b) found at Routine Medical Inspection to Require Treatment (excluding Unc.leanliness and Dental Diseases). GROUP. (1) Number of Children. Percentage ot Children found to require Treatment (see note d). (4) Inspected (see note c). (2) Found to require Treatment. (3) Code Groups :— Entrants 3197 354 11.1 Intermediates 2424 291 12.0 Leavers 2848 237 8.3 Total (Code Groups) 8469 882 10.4 Other Routine Inspections 1210 164 13.6 129 NOTES ON TABLE II. (a) The figures to be included in this space should refer to the findings of the Medical Officer and not those resulting from dental inspection in the schools by the School Dentist. The findings of the School Dentist should be recorded in Table IV., Group IV. (b) No individual child should be counted more than once in this part of Table II., i.e.., under B, even if it is found to be suffering from more than one defect. (c) The figures in this column will of course be the same as those given in Table I. A. (d) The figure in this column will be the percentage of the figure in column (3) of that in column (2). 130 TABLE III. Return of all Exceptional Children in the Area for the Year ended 31st December, 1928 (See note a). Boys. Girls. Total Blind (including partially blind) (see note b). (i.) Suitable for-training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 2 2 4 Attending Public Elementary Schools (see note c) At other Institutions — — — At no School or Institution — — — (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind 15 17 32 Attending Public Elementary Schools (see note c) — — At other Institutions — 2 2 At no School or Institution 1 1 Deaf (including deaf and dumb and partially deaf) (see note d.) (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 7 4 11 Attending Public Elementary Schools (see note c) — — — At other Institutions — — — At no School or Institution — — — (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf — 1 1 Attending Public Elementary Schools (see note c) 1 1 2 At other Institutions — — — At no School or Institution — — — Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority). (Sec note e.) Attending Certified Schools for Mentally Defective Children 67 35 102 Attending Public Elementary Schools (see note c) — — — At other Institutions 4 2 6 At no School or Institution 1 3 4 Notified to the Local Control Authority during the year. Feebleminded 1 2 3 Imbeciles 2 3 5 Idiots — — — Epileptics Suffering from severe epilepsy. (See note f.) Attending Certified Special Schools for Epileptics 1 5 6 In Institutions other than Certified Special Schools 1 1 2 Attending Public Elementary Schools (see note c) At no School or Institution 2 1 3 131 TABLE III.—continued. Boys. Ciirls. Total. Epileptics (continued). Suffering from epilepsy whi h is not severe. (See note g.) Attending Public Elementary Schools (see note c)... At no School or Institution ... 3 4 7 Physically Defective. Infectious pulmonary and glandular tuberculosis. (See note h.) At Sanatoria or Sanatorium Schools approved by the Min istry of Health or the Board 14 8 22 At other Institutions ... 1 1 2 At no School or Institution ... 5 5 10 Non-infectious but active pulmonary and glandular tuberculosis. (See note h.) At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools ... — 1 1 At Certified Day Open Air Schools At Public Elementary Schools (See note c) 66 43 109 At other Institutions — 1 1 At no School or Institution 2 1 3 Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, anaemia, etc). (See note h.) At Certified Residential Open Air Schools 24 19 43 At Certified Day Open Air Schools — — — At Public Elementary Schools (see note c) 148 153 301 At other Institutions 11 13 24 At no School or Institution — — — Active non - pulmonary tuberculosis. (See note h.) At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 5 5 10 At Public Elementary Schools (see note c) 18 6 24 At other Institutions 3 2 5 At no School or Institution 4 3 7 Crippled Children (other than those with active tuberculous disease) e.g., children suffering from paralysis, etc., and including those with severe heart disease. (See note h.) At Certified Hospital Schools 1 1 At Certified Residential Cripple Schools 7 8 15 At Certified Day Cripple Schools 2 — 2 At Public Elementary Schools (see no'e c) 51 54 105 At other Institutions 5 3 8 At no School or Institution 21 22 43 132 NOTES ON TABLE III. (a) This Table is a return of all children in the area for whom the Local Education Authority are itsponsible, and who (except in the case of children suffering from epilepsy which is not severe) have been ascertained to be blind, deaf, defective or epileptic within the meaning of Part V. of the Education Act, 1921. It is the statutory duty of every Local Education Authority formally to ascertain all defective children in their area irrespective of the actual provision now made for their instruction in Special Schools. It is assumed that every Authority will have a complete list of such children compiled from returns made continuously during the year and kept constantly up to date. In order to secure uniformity, Authorities are requested to make up this Table from their list of defective children as it stands on the last day of each calendar year. Children who are living in residential schools in the area but who come from other areas, should not be included in this Table; but children should be included who are living in residential schools outside the area and who are being maintained there by the Authority. For the purpose of this Table, no child should be included whose defect has not been ascertained by the School Medical Officer or a medical member of the Authority's staff. The definitions of defective children as given in the Act are as follows and must be very carefully borne in mind. A blind child is a child who is too blind to be able to read the ordinary school books used by children. A deaf child is a child who is too deaf to be taught in a class of hearing children in an elementary school. Mentally and physically defective children are children who, not being imbecile and not being merely dull and backward, are defective, that is to say, children who bv reason of mental or physical defect are incapable of receiving proper benefit from the instruction in the ordinary public elementary schools, but are not incapable by reason of that defect of receiving benefit from instruction in such special classes or schools as under Part V. of the Act may be provided for defective children. Epileptic children are children who, not being idiots or imbeciles, are unfit by reason of severe epilepsy to attend the ordinarypublic elementary schools. (b) For the purpose of this return the Board require that children who are blind within the meaning of the Act should be divided into two categories, i.e., (1) those who are totally blind or so blind that they can only be appropriately taught in a school or class for totally blind children, and (2) those who though they cannot read ordinary school books, or cannot read them without injury to their eyesight, have such power of vision that they can appropriately be taught in a school or class for the partially blind. It should be understood that children who are able by means of suitable glasses to read the ordinary school books used by children without fatigue or injury to their vision, should not be included in this Table. 133 (c) It should be understood that none of the children in this Table (except children suffering from epilepsy which is not severe) should in fact be attending public elementary schools. When the heading is retained, it is merely because at present the insufficiency of Special School accommodation makes it impossible to do better for some defective children than to allow them to attend the ordinary school. No space is left for the entry of children with infectious pulmonary tuberculosis attending public elementary schools, as these children should of course be promptly excluded fiom such schools. (d) Children who are deaf within the meaning of the Act should be classified for the purpose of this Table as (1) totally deaf or so deaf that they can only be appropriately taught in a school or class for the totally deaf, and (2) partially deaf, i.e., those who can appropriately be taught in a school or class for the partially deaf. (e) This category includes only those children for whose education and maintenance the Local Education Authority are responsible, and who are not eligible for notification to the Local Control Authority under the Mental Deficiency Act. (/) In this part of the Table only those children should be included who are epileptic within the meaning of the Act. For practical purposes the Board are of opinion that children who are subject to attacks ot major epilepsy in school should be recorded as " severe " cases and excluded from ordinary public elementary schools. (g) In this part of the Table should be entered the remainder of the epileptic children in the area, i.e., children whose disease is of such a kind as not to unfit them for attendance at an ordinary public elementary school. (h) The exact classification of physically defective is admittedly a matter of difficulty. Valuable information, however, will be obtained if School Medical Officers will record these defective children as accurately as possible under the selected sub-headings, taking care that no child is entered under more than one subheading. 134 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1928 (see note a). TREATMENT TABLE. Group I.— Minor Ailments (excluding; Uncleanliness, for which see Group V.). Disease or Defect. (1) Number of Defects treated, or under treatment during the year. Under the Authority's Scheme, (see note b). (2) Otherwise. (3) Total. (4) Skin— Ringworm—Scalp 58 3 61 Ringworm—Body 35 2 37 Scabies 22 2 24 Impetigo 402 9 411 Other skin disease 199 22 221 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 176 8 184 Minor Ear Defects (See note c.) 183 15 198 Miscellaneous (e.g.. minor injuries, bruises, sores, chilblains, etc.) 1392 255 1647 Total 2467 316 2783 135 TABLE IV.—continued. Group II.—Defective Vision and Squint (excluding- Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease, (1) No. of Defects dealt with. (2)Under the Authority's Scheme (see note 6). (3)Submitted to refraction by private practitioner or — at hospital, apart from the Authority s Scheme. (4)Otherwise. (5)Total. Errors of Refraction (including Squint) (Operations for squint fhould be recorded separately in the body of the Report.) 688 50 3 741 Other Defect or Disease of the Eyes (excluding those recorded in Group i.) 15 _ _ 15 Total 703 50 3 756 Total number of children for whom spectacles were prescribed— (a) Under the Authority's Scheme 625 (b) Otherwise 45 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 622 (b) Otherwise 45 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Under the Authority's Scheme inClinic or Hospital. (see note b.) (i) By Private Practitioner or Hospital apart from the Authority'sScheme. (2) Total. (3) Received other forms of Treatment. (4) Total number Treated. (5) 405 101 506 43 549 136 Group IV.—Dental Defects. (1) Number of Children who were : — (o) Inspected by the Dentist Age. Routine Age Groups. Specials (see note d) Grand Total. 5 6 7 8 9 Total. 1767 2075 2306 2527 1111 9786 247 | 10033 (fc) Found to require treatment ... 6799 (c) Actually Treated... ... ... ... 2040 (d) Re-treated during the y»ar as the result of \ periodical examination (see note e) J (2) Half-days devoted to :— Inspection 69 Treatment 326 (3) Attendances made by children for treatment ... 4799 (4) Fillings : — Permanent Teeth 377) Total 986 T emporary Teeth ...609 (5) Extractions:— Permanent Teeth 591) Total 6659 Temporary Teeth 6068 (6) Administrations of general anaesthetics for extractions 328 (7) Other operations :— Permanent Teeth 261) Temporary Teeth 202) Group V.—Uncleanliness and Verminous Conditions (see note f). (i.) Average number of visits per school made during the year by the School Nurses 3 (ii.) Total number of examinations of children in the Schools by School Nurses 55,351 (iii.) Number of individual children found unclean 1,295 (iv.) Number of children cleansed under arrangements made by the Local Education Authority Nil. (v.) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 Nil. (b) Under School Attendance Byelaws Nil. 137 NOTES ON TABLE IV. (a) The Table should deal with all defects treated during; the year, however they were brought to the Authority's notice, i.e., whether by routine inspection, special inspection, or otherwise, during the year in question or previously. (b) This heading should include all cases that received treatment under definite arrangements or agreements for treatment made by the Local Education Authority and sanctioned hy the Board of Education under Sections lfi and 80 of the Education Act, 1921. Cases which, after being recommended for treatment or advised to obtain it, actually received treatment bv private practitioners, or by means of direct application to Hospitals, or by the use of hospital tickets supplied by private persons, etc., should be entered under other headings. (c) If any treatment is given for more serious diseases of the ear (e.g., operative treatment in hospital) it should not be recorded here but in the body of the School Medical Officer's Annual Report. (d) The heading " Specials " in this Table relates to all children inspected by the School Dentist otherwise than in the course of the routine inspection of children in one of the age groups covered by the Authority's approved scheme, namely, to children specially selected by him, or referred by Medical Officers, Parents, Teachers, etc., on account of urgency. The number inspected in each age group should be separately shown, as well as the total, but under " Specials " only the total number should be given. (e) It should be understood that all the cases entered under this head are also entered under head c. (/) A statement as to the arrangements made by the Local Education Authority for cleansing verminous children and a record of the cases in which legal proceedings were taken, should be included in the body of the School Medical Officer's Report. N.B.—Groups I.—V. above cover all the defects for which treatment is normally provided as part of the School Medical Service. Particulars as to the measures adopted by the Authority for providing treatment for other types of defect (e.g., for orthopaedic treatment) or for securing improvement in types of defect which do not fall to be treated under the Authority's own scheme and for which the Authority neither incur expenditure nor accept any responsibility, together with a statement of the effect of the measures taken, should be included in the body of the School. Medical Officer's Report. It is convenient for such t>articulars to follow the headings of Table II. 138 INDEX. A. Acute Polio-Myelitis 19 Abatement of Nuisances 65,75 Abattoirs 70, 71, 79 Acreage 6 Acts of Parliament 10, 11 Adenoids 48, 51, 58, 94, 99, 101, 118 Air temperature 62 Alleys 79 Altitude 7 Ambulance service 10,58 Antitoxin 18, 19, 39 Area 6 Assessable value 6 Attendance Officers, co-op. of 110 Aural Clinic 86,100,118 Ante-Natal Clinics 8, 45, 51 B. Bacteriology 16, 18, 40 Bakehouses 73, 79 Baths 110 Births 6, 50 „ Illegitimate 6 Still 6 Birth-rate 5, 6, 7 Blind persons 14, 130, 132 Boundaries 7 Bye-laws 11, 12, 76, 79, 114 C. Cancer 61 Cerebro-Spinal Meningitis 18, 19, 36, 60 Chicken-pox 98 Children, Medical Inspection of 87, 91, 115, 125 Chorea 16, 117, 28 Cinemas and Music Halls 74 Cleanliness of School Children 92 Clinic, Ante-Natal 8, 45, 51 Clinics, Infant 8, 46, 47, 50 Clinics, School 101, 102, 106, 118, 119, 122, 134, 135, 136 Clinic, Artificial Sunlight 101, 104, 106 120 Climate 62 Closing Orders (Shops) 72 Common Lodging Houses 75 Communicable Diseases (non- notifiable) 98, 99 Complaints of Nuisances 65 Contagious Diseases (Animals) Act 73 Continuation Schools 113 Convalescent Treatment 16, 39, 107-9 Co-ordination 48, 58, 85 Cripples 89, 96, 104, 112, 128, 131 Case Mortality 36, 38, 43 D. Dairies 67, 79 Day Nursery 9 Deafness 111, 118, 130 Deaths, Causes of 53, 56, 61 Deaths, No. of 6, 53 Death-rate, General 5, 6, 7, 54 Death-rate, Infantile 5, 7, 54 Death-rate, Tuberculosis 5 Death-rate, Zymotic 7 Deaths in Large Towns 7, 54 Dentistry 48, 49, 58, 100, 136 Diarrhoea 7, 45, 54, 57, 61 Diphtheria 18, 19, 36, 38, 43, 60, 61, 96, 98 Dirty premises 79 Disinfection 19, 69 Dispensary 9, 21, 22, 25-31 Dispensary attendances 21, 22 Drainage Works 79 Dust Bins 70, 79 E. Ear Disease 96,101,103,127,134 Employment of Children 113 Encephalitis Lethargica 18, 19, 60, 61 Enteric Fever 18, 19, 36, 60, 61 Epileptic Children 111, 130, 131, 133 Erysipelas 18, 19, 60 Exclusions 99 Eye Diseases'of Children 95, 99, 101, 102, 103, 116, 119, 127, 134 Eye, External Inflammation of 102, 116, 119, 120 Explosives Act 73, 76, 77 F. Feeble minded 13, 130 Factory and Workshop Act 70 Following-up 99 Food and Drugs Act 67, 76 Food Inspection 71 Food Supply 71 Food, Unsound and Diseased 71 G. Gipsies 78, 79 Glands, enlarged 128, 131 H. Harts Sanatorium 9, 32-35 Health Propaganda 10 Hearing of School Children 96, 103, 111, 118, 127 Heart Diseases 112, 117, 128 Hospital Accommodation 9, 15, 27, 35, 101 Hospital, Children's 9, 16, 57, 90, 94, 101, 104, 108, 109 139 IND EX—continued. Hospital Staff, Health of ... 41 Hospitals, Maternity ... ... 9,52 House Refuse removal ... 73 House to House inspection ... 64,66 Housing ... ... ... 74, 75 Hospital Staff-training ... 42 I. Immunisation ... ... 40 Imbecile Children ... ... 13, 130 Impetigo ... ... 39, 94, 99, 102 Increase of Rent (Restriction) Acts ... ... ... 66 Infant Consultations 8, 46, 47, 50, 121 Infantile Mortality ... ... 5, 7', 53 Infectious Diseases 7, 10, 17, 18, 19, 35-43, 53, 60, 69, 96 Infectious Diseases (non-notifiable) ... ... ... 96, 98 Influenza ... ... ... 18, 61 Inspection of Borough ... 64 Inspection of School Children 87, 91, 115, 125 Invalid Children's Aid Association ... ... ... 15, 57, 84, 108 Isolation Hospitals ... 9, 16, 35-44 Industries ... ... ... 7, 72 K. Kinemas ... ... ... 74 L. Laboratory work ... ... 16 Legal proceedings ... 69, 73, 76, 136 Licences, Petroleum ... ... 73 " Light " Treatment 22, 41, 49, 58, 86, 101, 104-106, 120 Lung Diseases 20-35, 95, 102, 117, 128 M. Malaria ... ... ... 60 Malnutrition ... ... ... 116, 127 Market places ... ... ... 71 Maternal Deaths ... ... 56, 61 Maternity and Child Welfare 45-58 Maternity Homes and Hospitals ... ... ... 9, 45, 52 Meals, provision of ... ... 99, 110 Measles ... ... 7, 36, 61, 96, 98 Meat Regulations ... ... 70 Medical examination ... ... 16, 114 Mental Defects of School Children 113, 130 Mental Defectives, Statutory supervision ... ... 13 Margarine Act ... ... 77 Mental Defectives, voluntary care ... ... ... ... 14 Mental Welfare ... 13, 14, 113, 130 Meteorology ... ... ... 62 Midwifery ... ... ... 8, 52, 54 Milk and Cream Regulations 68 Milk and Dairies Act ... 67, 68, 69 Milk, Free supplies ... ... 45,57 Milk Order ... ... ... 69 Minor Ailments ... ... 94, 134/6 Mortuaries ... ... ... 75 Mumps ... ... ... 98 Music Halls ... ... ... 74 Myopia 63, 111, 119, 120 N. Nasal Diseases ... ... 118 Nervous Diseases ... ... 117, 128 Notices served... ... ... 65 Notification of Births ... 50 Notification of Infectious Diseases ... ... ... 17, 19, 60 Nuisances abatement ... 65,75 Nuisances discovered ... 65 Nursing arrangements ... 8,42 Nursery Schools ... ... 113 0. Occupations ... ... ... 7, 72 Offensive trades ... ... 69, 76 Open-air Education 84, 107, 112, 131 Ophthalmia Neonatorum 19, 45, 56, 58, 60, 100 Ophthalmic Clinics ... ... 49, 86, 119 Orders ... ... ... ... 10, 12, 72 Orthopaedic treatment 89, 96,104,112,128 Outdoor Relief ... ... 16 Outworkers ... ... ... 70, 79 Overcrowding ... ... ... 79 P. Para-Typhoid Fever ... ... 18, 19, 60 Parents, co-operation of ... 110 Post-Mortems ... ... ... 75 Petroleum storage ... ... 73 Physical training ... ... 110, 131 Playground classes ... ... 107 Pneumonia ... ... 18, 19, 36, 60, 61 Population ... ... ... 6 Pre-tubercular patients ... 131 Prosecutions, Public Health Act ... ... ... ... 76 Prosecutions, Sale of Food and Drugs Act ... ... 77 Prosecutions, Shops Act ... 78 Provisional Orders ... ... 10 Puerperal Fever, 7, 18, 19, 51, 55, 56, 60 61 Puerperal Pyrexia ... 18, 19, 51, 55, 60 140 INDEX—continued. R. Rainfall 62 Rateable Value ... ... 6 Rat extermination ... ... 73 Refraction cases ... ... 116, 127 Refuse Removal and Disposal 73 Regulations ... ... 11, 12, 79, 114 Re-inspection ... ... 87, 115 Rent (Restriction) Act ... 66 Ringworm ... 48, 58, 94, 99, 102, 127 Roofs, leaky ... ... ... 134 S. Sale of Food and Drugs Act 67, 77 Sanatoria 9, 25, 32-35, 131 Scabies ... 39, 94, 99, 116, 127 Scarlet Fever, 17, 19, 36, 39, 41, 53, 60, 61, 96, 98 School Attendance Officers Co-operation ... 110 ,, Baths ... ... 110 ,, Camps ... ... 107 „ Children, Blind ... Ill, 130 „ Cripples 89, 96, 104, 112, 128, 131 Children, Diseases of Nose and Throat 116, 127, 135 Children, Defective Speech ... ... 128 „ Children, exclusions ... 99 „ Children, general cleanliness ... 92, 136 „ Children, Heart Diseases ... 112, 117, 128 „ Children, Hearing, 96, 103, 111, 127 „ Children, Minor Ailments ... 94, 101, 134 „ Children, No. of Medical Examinations 83, 87, 91, 115, 125 ,, Children, Nutrition of 106, 110, 116, 127, 131 „ Children, Physical Training of ... 110 ,, Children, Skin Diseases 94, 95, 99, 102, 116, 127, 134 ,, Children, Teeth of 100, 103, 128, 136 „ Children, Verminous Conditions ... ... 99, 136 „ Continuation ... ... 113 „ Dentistry 88, 103, 122, 123, 124 136 „ Hygiene ... ... 86 „ Meals 99, 110 „ Medical Treatment 116, 117, 118, 127, 128, 134, 135 ,, Nursery ... ... 113 ,, Open-air ... 107, 112, 131 Schools of Recovery ... ... 108 School, Secondary ... 113, 115-117 Schools, Survey of 86 Shops Act 71, 72, 76 Skin Diseases ... 95, 102, 127, 134 Slaughter Houses ... ... 70, 71, 79 Small-pox ... 9, 17, 19, 40, 60, 61, 97 Smoke abatement ... ... 79 Special enquiries ... ... 114 Special examination 83, 87, 114, 115, 125 Spectacles, supply of ... 135 Speech, defective ... ... 116, 128 Sputum examination ... 26 Squint 116, 127 Staff 4, 46, 82, 85, 88, 89 Subsoil ... ... ... 7 Summary of Report ... ... 6, 7 Surgical appliances ... ... 16 Swimming ... ... ... 110 Swine Fever ... ... ... 73 T. Table—Air temperature ... 62 Birth-rate ... ... 5, 7, 54 Cattle Slaughtering ... 70 Causes of Death ... 61 Clinics, Treatment at 122, 124, 134, 135, 136 Comparative Statistics 5, 7, 54, 87, 92, 94, 99 „ Complaints received ... 65 ,, Deaths ... ... 5, 60, 61 ,, Dental Treatment 122, 124, 136 ,, Eye examinations 116, 127, 135 „ Exceptional children... 130, 131 ,, Exclusion Forms issued ... ... 92 ,, Food and Drugs Act, Legal Proceedings 77 ,, Food and Drugs Act, samples taken ... 67, 68 „ Housing ... ... 74, 75 ,, Infantile Mortality 5, 7, 53, 54 ,, Infectious Cases notified ... 17, 19, 60, 98 „ Infectious Cases removed to Hospital 36, 60 Invalid Children's Aid Association ... 15, 16 ,, Maternity and Child Welfare 47, 51, 53, 54, 55, 57, 124 Medical Help ... 55 ,, Mental Defectives ... 130 ,, Meteorological record 62 ,, Minor ailments ... 94, 134-6 „ Notes to 23, 24, 125, 126, 129, 132, 133, 137 ,, Notifications 17, 19, 20, 60, 98, 99 „ Nuisances ... ... 79 „ Ophthalmia Neonatorum ... ... 57 141 INDEX—continued. Table—Public Health Act prosecutions ... 76 „ Rainfall ... ... 62 Records of inspections 64, 66, 79, 87, 91, 92, 93, 94, 106, 113, 115-117, 118, 122, 124, 125, 127, 128 School Children Crippled 131 „ School Children, Defects of 116, 117, 127, 134-6 ,, School Children examined ... 87, 91, 115, 125 ,, School Children excluded ... ... 92, 99 ,, School Children found to require treatment 117, 128, 136 „ School of Recovery admissions ... ... 109 „ Secondary School ex- examinations ... 115-117 ,, Shops Acts prosecutions ... ... 78 ,, Sunlight Treatment ... 106 ,, Tuberculosis, Classific- tion of Patients ... 30, 31, 33 „ Tuberculosis deaths ... 5, 20 ,, Tuberculosis 20, 21, 22, 28-33 ,, Tuberculosis Dispensary cases ... 21, 22 „ Tuberculosis Notifications ... ... 20 ,, Tuberculosis, Residential treatment ... 32, 33 Venereal Diseases ... 59 Verminous condition of School Children 87, 92, 93, 99, 136 „ Vision of School Children 116, 127, 130, 134, 135 „ Zymotic Death-rate ... 5 Teaching Staff, co-operation of 110 Teaching Staff, Medical Examination ... ... ... 114 Teeth of School Children 122, 123, 128, 136 Temperature ... ... 62 Throat affections ... 116, 118, 127 Tonsils ... 48, 51, 58, 94, 99, 101, 118 Training Centre, Mental Defectives ... ... ... 13 Transit, Means of ... ... 7 Tuberculosis 20-35, 37, 47, 48, 58, 60, 61, 69, 95, 102, 112, 128, 131 Tuberculosis Deaths ... 5, 20, 60, 61 Tuberculosis Dispensary 9, 21, 22, 25-31 Tuberculosis, treatment of 25-35, 131 Tuberculosis Visits ... ... 22 Typhoid Fever ... ... 18, 19, 60 Tubercular contacts ... ... 21 U. Unsound Food ... ... 79 Urinals 70, 79 Ultra Violet Radiation 22, 41, 49, 58, 80, 100, 101, 104, 105, 106, 120 V. Vaccination ... ... 40, 41, 96, 97 Venereal Diseases ... ... 9, 59 Verminous Persons 87, 92, 93, 99, 136 Vision of School Children 95, 102, 103, 116, 119, 127, 130, 135 Visits, Nurses ... 22, 50, 51, 87, 136 Voluntary Workers 15, 57, 84, 108, 110 W. Whooping Cough ... 7, 53, 61, 96, 98 Workshops ... ... ... 70 X. X-rays 26, 48, 58, 86, 100, 102 Z. Zymotic Deaths ... 5, 7, 60, 61 .