AC 4365 HAC 31 Borough of Hackney. REPORT on the SANITARY CONDITION of the hackney district, FOR THE YEAR 1916, by J. KING WARRY, M.D. LOND., M.R.C.P., Diplomate in Public Health ; Licentiate of the Society of Apothecaries; Fellow of the Society of Medical Officers of Health; Member of the Lister Institute of Preventive Medicine; Foreign Associate Member of the Society of Hygiene of France. Medical Officer of Health for the Borough. London: Chas. Straker & Sons, Ltd., 5-9, Bishopsgate Avenue, E.C1.3. 1917. INDEX. page Alcoholism 20 Anthrax 18&24 Birth Hate 6 By-laws—Houses let in Lodgings 23 Cancer 19 Cerebro-Spinal Meningitis 17 Cleansing of Persons Act, 1897 34 Combined Drainage and Sewers 33 Constitutional Diseases 19 Cowhouses, Dairies, and Milkshops 21 Customs and Inland Revenue Act 23 Death Rate 8 Deaths in Public Institutions 10 Diarrhœa 19 Diphtheria 15 Disinfection 33 Enteric Fever 16 Erysipelas 17 Estimated Population 6 Factories 28 Factory and Workshops Act, 1901 28 Glanders and Farcy Order 24 Glanders, Anthrax and Hydrophobia in Man 18 Home Work and Home-Workers 30 Housing and Town Planning Act, 1909 24 Ice Cream Vendors 23 Illegitimacy 7 Infant Mortality 8 Influenza 19 Marriage Rate 6 Measles 18 Mortuary 36 Notification of Births Act 7 Notifiable Diseases 15 Non-Notifiable Diseases 18 A 2 INDEX. page Offensive Trades 22 Ophthalmia Neonatorum 1* Plague 17 Polio-myelitis 17 Population 6 Prosecutions under Food and Drugs Acts 38 Prosecutions under Public Health (London) Act 39 Public Health (London) Act, 1891 20 Public Health (Tuberculosis) Regulations, 1912 24 Puerperal Fever 17 Removal of House Refuse 36 River Lee 24 Senile Mortality 10 Scarlet Fever 15 Shelter 34 Slaughter-Houses 22 Small-pox 15 Smoke Nuisances 23 Tuberculous Disease 19 Tuberculosis Dispensaries 2G Typhus 17 Vaccination 20 Verminous Children 34 Whooping Cough 18 Workshops 28 Zymotic Diseases 15 Tables— Articles Disinfected during 1916 34 Births 7 Causes of Infant Mortality 9 Death Statistics, according to Causes and Ages13&14 Infectious Sickness 12 Inquests 36 Samples of Foods and Drugs Purchased 37 metropolitan Borough or hackney. REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1916. PUBLIC HEALTH DEPARTMENT, Town Hall, Hackney, E. 8. July, 1917. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Hackney. Gentlemen, I beg to present herewith my Twenty-fifth Annual Report on the Public Health of the Borough of Hackney. The general death-rate for the year 1916 was 13.8 per 1,000 of the population, and the infant mortality rate 84 per 1,000 births. These figures show a slight decrease in the general death-rate and a considerable decline in the infant death-rate, compared with the year 1915. During the year measles and German measles were added to the list of compulsorily notifiable diseases. Including cases of these diseases there were 2,631 cases of acute infectious disease notified during the year, giving an attack rate of 12.5 per 1,000 for the year. The number of deaths from the seven chief zymotic diseases numbered 176, which is equivalent to a zymotic death-rate of .8 per 1,000 living. A slight decline in the mortality from tuberculosis took place during the year, the mortality rate for the year being 17 per 1,000 living. This subject is dealt with in detail on page 19, and that of infant mortality on page 8 of this Report. 6 Detailed reference to the preventive measures taken in connection with the prevention of the spread of tuberculosis is made on page 26. I have pleasure in stating that the Officers of the Department have, on the whole, carried out the duties entrusted to them to my satisfaction. Population.—The Registrar-General has thought it desirable to adopt the following estimates of population for the calculation of the death rate and birth rate of the Borough of Hackney for the year 1916, viz.:— For the death rate 209,636 For the birth rate 228,088 The former is an estimate of the civil population; the latter of the total population based on the assumption that the ratio between the total and the civil population is the same in the borough as in England and Wales as a whole. With a view to approximation to the population amongst which the births have occurred, the total population of England and Wales for this purpose has been calculated by adding to the published estimate for 1914, the natural increase up to the middle of the year 1916. Marriages and Marriage Rate.—During 1916 there were 2,206 marriages solemnized in the Borough of Hackney, being a decrease of 517 on the previous year. The annual rate for persons married during this period is therefore 21.0 per 1,000 of the population. Births and Birth-rate.—The births registered in Hackney during the year 1916 numbered 5,331 of which 2,792 were males and 2,539 females. The total shows an increase of 204 compared with the number registered during 1915. This total is the actual number of births registered in Hackney, but this figure must be corrected by the proper allocation of transferable births. The Registrar-General has supplied me with the necessary figures, viz., 7 448 births to be transferred to other districts and 143 to Hackney. After making these corrections the total of registered births amongst Hackney residents is 5,026. From this figure I calculate the birthrate during 1916 to be 22.0 per 1,000 of the population. For this calculation I have used the Registrar-General's estimated population of 228,088. Notification of Births Act, 1907.—Under the provisions of this Act, I received 5,396 notifications of births occurring in the Borough during 1916. This total includes notifications from medical practitioners, midwives, and other persons. It also includes still births. Still Births.—Amongst the births notified were 132 still-born. This is equal to 2.4 per cent. of those notified. I give here a table showing the number of notifications received, with other details in connection with the same. NOTIFICATION OF BIRTHS ACT, 1907. Notifications of Births (Live or Still-born) received, during the year 1916. Year 1916. Medical Practitioners. Midwives. Parents and Others. Total. Live. Still. Live. Still. Live. Still. Live. Still. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Totals. 828 787 27 19 1,413 1,317 45 32 506 413 5 4 2,747 2,517 77 55 Illegitimate Births and Birth-rate.—The total number of illegitimate births registered in the Borough during the year 1916 was 505; but of these, I am informed by the Registrar-General, 369 should be transferred to districts outside Hackney, as the mothers were not Hackney residents, and 21 births, taking place in other districts should be transferred to Hackney. Making these 8 corrections, there remain 157 illegitimate births amongst Hackney residents. This is an increase of 35 on the number during 1915. The illegitimate birth-rate for Hackney during 1916 is 31.2 per 1,000births, that for 1915 was 25.2 per 1,000 births; so that during last year illegitimacy increased in the Borough to the amount of 23 per cent. on that of 1915. Deaths.—The deaths registered in the Borough during 1916 numbered 2,917, but of these 617 were deaths of non-residents dying in institutions and other places in the Borough. There were, however, 581 residents of Hackney who died, during the year in institutions in other districts. On making the necessary corrections, I find the correct number of deaths amongst Hackney residents during 1916 was 2,881. This is a decrease of 350 upon the number occurring during 1915. The general death rate from all causes for the year 1916 is 13.7 per 1,000 of the population. For the calculation of this rate I have used the Registrar General's estimated population of 209,636. On further correcting this rate for age and sex distribution by means of the factor 1.0066, I obtained the corrected general death-rate of 13.8 per 1,000 of the population for the year 1916. Compared with the corrected general deathrate for 1915 that of 1916 is 1.1 per 1,000 lower. Infantile Mortality.—The deaths under one year of age in the Borough during 1916 numbered 423. This is a decrease of 97 upon the number of infants deaths recorded during 1915. The infant mortality rate for the year is 84 per 1,000 births. The decreased rate is due chiefly to a decrease in the number of deaths from pneumonia and infantile diarrhoea. Other special causes of infant deaths deserving mention are premature birth (70), atrophy, debility and marasmus (75). 9 INFANT MORTALITY. 1916. Nett Deaths from stated, causes at various ages under 1 Year of Age. CAUSE OF DEATH. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 year. Small-pox ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... 1 2 1 4 Scarlet Fever ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... 4 4 4 5 17 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... 3 2 ... ... 5 Tuberculous Meningitis ... ... ... ... ... ... ... 1 5 6 Abdominal Tuberculosis ... ... ... ... ... ... 1 2 1 4 Other Tuberculous Diseases ... ... ... ... ... ... 1 ... ... 1 Meningitis (not Tuberculous) ... ... ... ... ... ... ... 2 2 4 Convulsions 1 2 2 1 ... 8 5 3 ... 22 Laryngitis ... ... ... ... ... ... 1 ... ... 1 Bronchitis ... ... 1 ... 1 13 9 5 3 31 Pneumonia (all forms) ... ... 1 1 2 6 18 6 16 48 Diarrhœa ... 1 ... 1 2 6 9 10 6 33 Enteritis ... 2 ... ... 2 6 10 3 3 24 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... 1 1 2 1 3 ... ... 6 Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying 3 ... ... 1 4 3 4 ... ... 11 Injury at Birth 4 1 ... ... 5 1 ... ... ... 6 Atelectasis 6 l ... ... 7 ... ... ... ... 7 Congenital Malformations 4 3 1 1 9 6 2 0 ... 19 Premature Birth 45 5 10 3 63 5 2 ... ... 70 Atrophy, Debility and Marasmus 19 2 2 4 27 25 19 3 1 75 Other Causes 3 2 1 3 9 3 8 4 5 29 Total 85 19 19 16 139 90 99 47 48 423 During the year Mrs. Rhodes, Health Visitor, made 1,394 primary visits to the homes of nursing mothers and their infants, and 803 subsequent visits. There were also 206 fruitless visits, the mothers being either out at the time, or having changed their address. The weekly weighing meetings have been continued during the year. The actual number of meetings was 51 and the total number of infants weighed 1,527. 10 Senile Mortality.—The deaths which occurred in Hackney at 65 years of age and upwards during 1916 numbered 973, and of these 444 were between the ages of 65 and 75 years, 400 between 75 and 85 years, and 129 at 85 years and upwards. The annual mortality rate of persons at 65 years and upwards is 4.6 per 1,000. Deaths in Public Institutions.—There were 1,365 deaths in public institutions in the Borough during 1916; of these 617 were residents of other districts, and the remaining 748 were residents of Hackney. 11 TABLE I.—HACKNEY DISTRICT, Vital Statistics of Whole District during 1916 and Previous Years. Year. Population estimated to middle of each year. Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncorrected Number. Nett. of Nonresidents registered in the District. of residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate. Number. Hate per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1910 222,384 5,493 5,240 23.5 2,878 12.9 506 450 543 104 2 822 12 6 1911 222,674 5,410 5,243 23.5 3,546 15.9 779 443 633 120 3,210 144 1912 223,022 5,425 5,267 23.6 2,952 13.2 663 431 426 79 2,720 122 1913 223,369 5,733 5,523 24.7 3,156 14.1 665 563 549 99 3,054 13 6 1914 223,718 5,708 5,460 25.5 3,233 14.4 662 557 492 85 3,128 139 1915 217,883 5,091 4,827 22.1 3,402 15.6 723 552 520 107 3,231 14 8 1916 209,636 5,331 5,026 22.0 2,917 13.9 617 581 • 423 84 2,881 137 12 TABLE II.—HACKNEY DISTRICT. Cases of Infectious Disease Notified, during the Year 1916. Notifiable Disease. Cases Notified in whole Districts. * Total Cases Notified in each Locality. Total cases removed to Hospital. At all Ages. At Ages—Years. 1 2 3 4 Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. North. Central South-East South-West Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) 351 4 125 171 34 13 4 ... 63 88 102 98 336 Erysipelas 165 9 10 12 28 47 42 17 40 32 57 36 35 Scarlet Fever 397 2 111 237 36 9 2 ... 106 91 92 108 373 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 22 ... 2 5 8 4 2 1 7 3 6 3 24 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever 3 ... ... 1 ... 1 1 ... 1 2 ... ... ... Puerperal Fever 8 ... ... 1 7 ... ... ... 2 1 4 1 6 Cerebro-Spina Meningitis 24 7 6 8 2 l ... ... 3 7 8 6 20 Polio Myelitis 21 3 15 3 ... ... ... ... 3 6 6 6 12 Ophthalmia Neonatorum 30 30 ... ... ... ... ... ... 7 9 11 3 ... Pulmonary Tuberculosis 575 1 11 62 124 263 103 11 108 124 192 151 348 Other forms of Tuberculosis 158 10 25 86 17 15 4 1 28 34 51 45 67 Measles 1,412 68 749 556 32 7 ... ... 203 391 460 358 36 German Measles 230 12 37 122 30 27 2 ... 133 21 41 35 ... Totals 3,396 146 1,091 1,264 318 387 160 30 704 1,109 1,033 1,250 1,257 13 TABLE III.—HACKNEY DISTRICT. Causes of, and Ages at, Death during the Year 1916. CAUSES OF DEATH. Deaths in whole Districts at Subjoined Ages. Deaths in Public Institutions. All Ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Enteric Fever 2 ... ... ... 1 ... ... ... 1 4 Small Pox ... ... ... ... ... ... ... ... ... ... Measles 36 4 13 14 4 1 ... ... ... 20 Scarlet Fever 5 ... ... 3 ... 1 ... 1 ... 17 Whooping-cough 32 17 10 4 1 ... ... ... ... 9 Diphtheria and Croup 23 ... 3 13 6 ... 1 ... ... 53 Influenza 30 1 ... ... 1 1 5 4 18 3 Erysipelas 10 5 ... ... ... ... 1 3 1 7 Phthisis (Pulmonary Tuberculosis) 274 1 2 0 ... 45 127 80 8 140 Tuberculous Meningitis 37 7 2 8 19 1 ... ... ... 17 Other Tuberculous Diseases 48 6 8 9 14 5 6 ... ... 29 Cancer, Malignant Disease 245 ... ... 1 1 1 29 127 86 134 Rheumatic Fever 4 ... ... 1 1 1 1 ... ... 2 Meningitis 13 4 3 2 2 1 ... 1 ... 7 Organic Heart Disease 327 2 ... 2 12 18 39 117 137 149 Bronchitis 278 31 2 3 1 1 10 74 156 65 Pneumonia (all forms) 266 48 47 24 9 7 29 60 42 81 It TABLE III.—HACKNEY DISTRICT—continued. Causes of, and Ages at, Death during the Year 1916. CAUSES OF DEATH. Deaths in whole Districts at Subjoined Ages. Deaths in Public Institutions. All Ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Other Diseases of Respiratory Organs 29 1 1 2 ... ... 5 11 9 7 Diarrhœa and Enteritis 78 57 4 2 ... 3 3 6 3 29 Appendicitis and Typhlitis 8 ... ... 1 1 1 2 2 1 10 Cirrhosis of Liver 21 ... ... ... ... ... 1 12 8 8 Alcoholism 1 ... ... ... ... ... 1 ... ... ... Nephritis and Bright's Disease 101 ... ... ... 2 4 14 42 39 58 Puerperal Fever 4 ... ... ... ... 1 3 ... ... 3 Other Accidents and Diseases of Pregnancy and Parturition 9 ... ... ... ... 3 6 ... ... 6 Congenital Debility and Malformation, including Premature Birth 172 169 1 1 1 ... ... ... ... 83 Violent Deaths, excluding Suicide 55 6 3 5 5 3 9 10 14 72 Suicides 8 ... ... ... ... 1 3 3 1 1 Other Defined Diseases 550 64 9 10 19 11 68 132 237 265 Diseases ill-defined or unknown 215 ... ... ... ... ... ... 3 212 136 Totals 2,881 423 108 107 109 110 363 688 973 1,415 Sub-Entries (included in above figures) — Cerebro-Spinal Meningitis 19 7 1 4 4 2 1 ... ... 19 Poliomyelitis 3 ... ... 1 2 ... ... ... ... 1 15 SPECIFIC INFECTIOUS DISEASE. During 1916 there were 2,663 cases of acute infectious disease notified in the Borough; of these 32 were subsequently found not to be suffering from notifiable infectious disease, thus reducing the number of genuine cases to 2,631. This total shows an increase of 1072; but this increase is due to the fact that the total includes 1,412 cases of measles and 230 cases of German measles, these diseases having been made notifiable on the 1st January, 1916. The attack rate in respect of the acute notifiable infectious diseases for the year is 12 5 per 1,000 persons living. The deaths from the chief zymotic diseases numbered 176, This is equivalent to a zymotic death-rate of .8 per 1,000 living in the Borough. A.—NOTIFIABLE INFECTIOUS DISEASES (ACUTE). Small-pox.—No case of this disease was notified in the Borough during 1916. Scarlet Fever or Scarlatina.—The number of cases of scarlet fever notified during 1916 was 412, but of these 15 were found afterwards not to be suffering from this disease, thus reducing the genuine cases to 397. This is a decrease of 335 upon the number of genuine cases notified during 1915. The attack rate for scarlet fever is 1.8 per 1,000 persons living. The number of cases of scarlet fever removed to hospital was 373. This is equal to nearly 94 per cent. of the total notified. The deaths from scarlet fever numbered 5, which is equal to mortality of 1.7 per cent. attacked and .03 per 1,000 living. Diphtheria and Membranous Croup.—There were 359 cases of diphtheria and 3 cases of membranous croup notified during the year, but of these 11 cases were found subsequently not to be 16 suffering from diphtheritic disease, thus reducing the genuine cases to 351. This is a decrease of 4 upon the number of cases occurring during 1916. There were 333 cases of diphtheria and 3 of membranous croup removed to hospital during 1916. This is equal to 80 per cent of the cases notified. The attack rate for diphtheria is 1.6 per 1,000 living. The deaths from diphtheritic disease numbered 23. This is equal to a mortality rate of 6.4 per cent. attacked and 11 per 1,000 living. During the year 415 swabbings from throats of persons suspected to be suffering from diphtheria were bacteriologically examined, 68 of which gave positive results, 342 negative results and 5 were doubtful. Diphtheria Anti-toxin Order.—In accordance with the above order 5 bottles of anti-toxin of 2,000 units each were supplied to medical practitioners during the year 1916, of which 2 were for curative treatment and 3 for prophylaxis. Typhoid Fever or Enteric Fever.— During the period under consideration 25 cases of typhoid were notified, but of these 3 cases were afterward found not to be suffering from this disease, thus reducing the genuine cases to 22. This is a decrease of 12 on the number of genuine cases notified during 1915. The attack rate is T per 1,000 living. Only 2 deaths were registered in the Borough from this disease. Of the 25 cases notified 24 were removed to hospital. During 1916 specimens of blood from 32 persons suspected to be suffering from enteric fever were submitted to Widal's test of which 9 gave a positive and 23 a negative reaction. 17 Continued Fever.—Three cases of fever were notified as continued fever during the year. Typhus Fever.—No case of this disease was notified during 1916. Puerperal Fever.—There were 8 cases of puerperal fever notified during 1916, of which 6 were removed to hospital. The deaths from puerperal fever numbered 4. The annual attack-rate is 1.5 per 1,000 births, and the deathrate .79 per 1,000 births. Plague.—No case of this disease occurred in the Borough last year. Erysipelas.—There were 165 cases of erysipelas notified during the year 1916; of which 35 were removed to hospital. This is equal to an attack rate of .79 per 1,000 living. The deaths from this disease numbered 10. This gives a mortality of 6 per cent. attacked and .05 per 1,000 living. Cerebro-spinal Meningitis.—During 1916 there were 24 cases of this disease notified in the Borough, 20 of which were removed to hospital. Three other cases came to my knowledge which had not been notified. The deaths numbered 19, which is equal to a mortality of 09 per 1,000 living. Polio-myelitis or Polio-encephalitis. — There were 21 cases of this disease notified during 1916, all of which more or less recovered from the disease. Ophthalmia Neonatorum.—The number of cases of this disease notified during the year was 30. All the cases recovered without permanent impairment of sight. B 18 Glanders, Anthrax and Hydrophobia in Man.—No case of these diseases was notified during the year. THE PUBLIC HEALTH (MEASLES AND GERMAN MEASLES) REGULATIONS, 1915. The above regulations making measles and German measles notifiable diseases came into operation on the 1st January, 1916. Measles.—During the year 1,412 cases of measles were notified by medical practitioners under the Regulations, and 285 other cases were brought to my notice by parents and others. Of the total 36 cases were removed to hospital. The deaths from measles during the year numbered 36, of which no less than 31 were under 5 years of age. The annual mortality is equivalent to .17 per 1,000 of the population. German Measles.—During the same period there were 240 cases of this disease notified, three of which were removed to hospital. There were no deaths registered from this disease. B.—NON-NOTIFIABLE INFECTIOUS DISEASES. Chicken-pox.—No death from this disease was registered in the Borough during 1916. Whooping-cough.—There were 32 deaths from this cause during 1916. This is a decline of 5 upon the number registered during the previous year. No less than 31 of the deaths occurred in children under 5 years of age. The annual mortality is .15 per 1,000 living. I received information from the head masters and mistresses of Elementary schools in the Borough of 436 cases of whooping cough occurring amongst their scholars during the year. 19 Influenza.—During 1916 there were 30 deaths in the Borough due to influenza. This is an increase of 6 on the deaths due to this cause in 1915. The annual mortality rate is.14 per 1,000. Diarrhoea.—There was a decline in the number of deaths in the Borough due to this cause during 1916. The total number of deaths was 78 of which 45 were registered as diarrhoea and 33 as enteritis or gastro-enteritis, and of the total, 57 were under 1 year of age. The annual mortality for diarrhoeal disease is .37 per 1,000 living. CONSTITUTIONAL DISEASES. Tuberculosis.—During 1916, I received 1,322 notifications of tuberculosis, details of which are given on page 25 of this report. Bacteriological examination of sputa from 326 cases was made during the same period. In 50 of these examinations the specific organism of the disease was found; in 276 the results were negative. The number of deaths from tuberculous disease in Hackney during 1916 was 359, a decrease of 22 upon the deaths during 1915. These deaths are classified as follows :— Tuberculous phthisis 234 Phthisis 40 General Tuberculosis 23 Tuberculous meningitis 37 „ peritonitis 12 Tabes mesenterica 7 Tubercle of other organs 6 359 This number of deaths gives an annual mortality of 1.7 per 1,000 living. Cancer.—There were 245 deaths during 1916 due to the different varieties of malignant disease. This is a decrease of B 2 20 31 on the number registered during 1915. The annual mortalityrate from malignant disease for last year is 1-16 per 1,000 living. Alcoholism.—During the year under consideration there was 1 death registered as due to acute alcoholic poisoning. There were also 21 deaths due to cirrhosis of the liver, a condition regarded as being caused by excessive indulgence in alcohol, extending over lengthy periods. VACCINATION. During the year 1916, there were 5,341 birth lists and 1,989 certificates of vaccination received by the Vaccination Officers, i.e., 37.4 per cent. of the infants born during that period were vaccinated and 62.6 per cent. escaped vaccination. There were 1,942 certificates and declarations of conscientious objection received during the same period. PUBLIC HEALTH (LONDON) ACT, 1891. (a) Complaints of Nuisance.—During the year 1916 there were 1851 complaints of nuisance made to the Public Health Department and investigated by Sanitary Inspectors of the Borough. Defects or nuisance were discovered in 1405 of the complaints. Notices for the remedy or abatement of these were served upon the owner or person responsible under the above Act. (b) Infectious Disease.—The occupied dwellings inspected during the year after infectious disease numbered 2,983. This is a increase of 913 upon the number inspected during 1915. Any nuisances or defects found were dealt with under the provisions of the above Act. (c) House-to-House Inspections.—The number of house-to-house inspections made by the Inspectors during the year was 211. These 21 inspections are in addition to those made under (a) and (b), The nuisances or sanitary defects found were dealt with in the same manner as those under (a) and (b). Nuisances or defects found on inspection were remedied in most cases on service of an intimation notice only. The total number of such notices served during 1916 was 2,910. The number of Statutory Notices served was 188. Legal proceedings were initiated in 12 cases. ARTICLES OF FOOD SEIZED OR SURRENDERED AS UNFIT FOR FOOD. During the year the following articles of food were seized by the Inspectors or surrendered as being unfit for food, viz. : 3 cwts. 3 qrs. 18 lbs. meat; 9 cwts. 14 lbs. fish; 2 cwts. 3 qrs. 21 lbs. fruit and vegetables. COW-HOUSES, DAIRIES, AND MILKSHOPS. (a) Cow-Houses.—At the end of 1916 there were 13 licensed cowkeepers in the Borough with 15 sheds. Inspector Bobbitt reports that he made. 190 inspections of these during the year, and found it necessary to serve one notice for repairs, which was immediately complied with. On the 7th October, the Public Health Committee made their annual inspection of the cow-houses in the Borough. These were found on the whole to be in a satisfactory condition. (b) Dairies and Milkshops.—During the year 11 premises were removed from the Register and 7 new premises added, thus making the total on the Register at the end of the year 292. The proprietors of milk premises were changed in 31 instances. Inspector Bobbitt reports that he made 1696 visits of inspection to these premises during the year. He served three notices for repairs and cleansing, which were immediately attended to. 22 Offensive Trades.—Twelve visits of inspection were made by Inspector Bobbitt to the only offensive trade premises in the Borough, viz. : a tripe boiler. Slaughter-houses.—-The number of slaughter-houses in the Borough at the end of 1916 was 20. Inspector Bobbitt reports that he made 293 visits of inspection to these during that period, during which he examined the carcases and organs of 183 oxen, 1,879 sheep or lambs, 20 pigs and 8 calves and found the following parts and organs diseased, viz.:— Six ox and four sheep livers affected with distomatosis. Seven ox livers affected with abscess. Four sheep plucks affected with parasitic cysts. On the 7th of October, the Public Health Committee made their annual visit to the slaughter-houses of the Borough. These were all found in a satisfactory condition. The following statement refers to the milk-places, cow-sheds, slaughter-houses and offensive trades in the Borough:— Premises. Number of Places. Number of Inspections, 1916. Number of Notices, 1916. Number of Prosecutions. On Register at end of 1915. Added in 1916. Removed in 1916. On Register at end of 1916. Milk premises 296 7 11 292 1,696 3 — Cow-sheds 15 — — 15 190 1 — Slaughter-houses 20 — — 20 293 — — Other offensive trade premises 1 — — 1 — — — Preserved Provision Factories.—During the year 1916, I was requested by the Food Department of the Local Government Board to keep under periodical inspection, the food manufactories 23 in the Borough supplying preserved provisions to the War Office. These consisted of the following:— Two wholesale preserved meat manufactories. Two black pudding manufactories. One potted meat paste manufactory. One pickle manufactory. Two sauce manufactories. One wholesale baker and confectioner. These were all visited at least once a month during the past year by Inspector Bobbitt. Smoke Nuisances.—The Smoke Inspector made 75 observations of chimneys of factories, workshops, and other places in the Borough during the year. Water Supply.—No certificates of proper and sufficient water supply under section 48 (2) of the Public Health (London) Act, 1891, were applied for during the year. Bye-laws for Houses Let in Lodgings.—The number of these houses on the Register at the end of 1916 was 459. Of these 226 were inspected during the year. Any defects found were remedied on the service of a notice. CUSTOMS AND INLAND REVENUE ACT, 1890. One application to make inspection of premises under the above was made to me during 1916. The premises consisted of two tenements. ICE-CREAM VENDORS. At the end of 1916 there were 172 ice-cream premises in the Borough, 136 of which were inspected during the year. 24 GLANDERS AND FARCY ORDER, 1907. No notification of this disease was received during the year. DISEASE OF ANIMALS ACTS.—ANTHRAX ORDER of 1910. No notification of anthrax in animals in the Borough was received during 1916. HOUSING, TOWN PLANNING, &c., ACT, 1909. No action under the above was taken during 1916. THE RIVER LEE. No complaints of serious nuisance from this River were received during 1916. PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Notifications. Under these Regulations, I received 1,113 notifications of cases of pulmonary tuberculosis, during the year 1916, of which 538 were duplicates; also 209 non-pulmonary notifications, of which 51 were duplicates. The following Tables A and B give the age and sex distribution of the notified cases :— A—Pulmonary Tuberculosis. Notifications received, during the Year 1916. Under 5. 5 to 15. 15 to 25. 25 to 35. 35 to 45. 45 and upwards. Duplicates. Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Form A 6 2 16 23 41 66 83 53 55 26 62 33 48 47 311 250 Form B — — 4 7 — — — — — — — — — — 4 7 Form C 2 2 8 2 9 6 15 9 9 4 14 5 143 97 200 125 Form D — — — 2 1 1 4 2 1 2 — — 131 72 137 79 Totals 8 4 28 34 51 73 102 64 65 32 76 38 322 216 652 461 B—Non-Pulmonary Tuberculosis. Notifications received during the Year 1916. Under 5. 5 to 15. 15 to 25. 25 to 35. 35 to 45. 45 and upwards. Duplicates. Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Form A 19 11 27 32 8 9 6 2 2 3 3 2 6 5 71 64 Form B — — 9 10 — — — — — — — — 1 2 10 12 Form C 4 1 4 3 — — — — 1 — — — 12 4 21 8 Form D — — 1 — — — — — — 1 — — 8 13 9 14 Totals 23 12 41 45 8 9 6 2 3 4 2 27 24 111 98 25 20 The following table shows the number and percentage of insured and non-insured of primary cases of tuberculosis notified during 1916:— National Insurance Act. 1911. Tuberculosis, 1916. Sex. Insured Cases. Non-Insured Cases. Percentage Insured. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. Male 179 13 151 71 54% 15% Female 80 6 165 68 33% 8% Total 259 19 316 139 45% 12% ACTION TAKEN DURING THE YEAR 1916. The action taken includes disinfection of rooms and the articles infected by tuberculous patients, inspection of dwellings occupied by tuberculous persons, and the removal of any condition prejudicial to health, instruction of patients in measures to prevent the spread of the disease, and the gratuitous supply of sputum flasks, the number of these supplied during the year being 208. TREATMENT—TUBERCULOSIS DISPENSARIES. A.—Dispensary at Victoria Park Hospital.—During the year 1916 there were 629 new patients examined at the Dispensary, 300 males and 329 females. Of the total 291 were insured and 338 uninsured persons. The result of examination shows 242 to have pulmonary tuberculosis, 19 non-pulmonary tuberculosis, 29 were doubtful and 339 not suffering from tuberculosis. Contact Cases.—There were 249 contact cases examined, of which 19 were found to be tuberculous, 9 doubtful and 221 non-tuberculous. 27 Attendances.—The total number of attendances during the year was 3,963. B.—Dispensary at Metropolitan Hospital. During the same period 328 new patients were examined at this Dispensary, 134 male and 194 female. Of the total, 142 were insured and 186 were uninsured persons. The result of examination shows 89 to have pulmonary tuberculosis, 20 non-pulmonary tuberculosis, 97 were doubtful, and 122 not suffering from tuberculosis. Contact Cases.—There were 141 contact cases examined, of which I was found to be tuberculous, 51 were doubtful, and 89 nontuberculous Attendances.—The total number of attendances during the year was 1,439. MATERNITY AND CHILD WELFARE. In April of last year I presented a report to the Public Health Committee on the circular letter of the Local Government Board, dated July, 1914, on the above subject (this report is given in the appendix). The Committee, after careful consideration of the whole subject, reported in July to the Council in favour of establishing certain Infant Welfare Centres in the Borough. Their recommendations, which were approved of by the Borough Council, were as follows :— (1) That two Infant Welfare Centres be established in suitable localities in the Borough. (2) That two medical practitioners be temporarily appointed for the purpose of the examination and treatment of children attending the Centres. (3) That four Health Visitors be temporarily appointed for home visitation, &c. 28 (4) Your Committee further recommend that the question of providing an Ante-natal Clinic be adjourned until after the war, when experience will have been gained of the Infant Welfare part of the scheme. (5) That it be an instruction to the Medical Officer of Health to include amongst the duties of certain of the Health Visitors appointed, that of visiting and advising any expectant mothers desiring such attention. The two Centres were established and the Health Visitors appointed in accordance with the above resolutions by the end of the year. At the beginning of 1917 the Centres were opened and the Health Visitors began their duties. THE FACTORY AND WORKSHOP ACT, 1901. Factories.—During the year 127 factories were inspected by the officers of the Public Health Department, 3 being factory laundries and 124 factories in which articles of clothing, &c., were made and altered. In 30 factories, the sanitary accommodation was defective, unsuitable or insufficient:— Nuisance. Found. Abated by Workshop Inspector. Abated by District Inspector. Outstanding. Total. Unsuitable or Defective w.c.'s 24 23 1 — 24 Insufficient „ 6 4 — 9 6 Not separate for the sexes. — — — — — Workshops.—The number of workshops registered in Hackney at the end of 1916 was 1,100, an increase of 14 on the number registered at the end of 1915. Of this total, 815 were workshops in 29 which females were employed. Of these latter, 552 were workshops in which articles of wearing apparel were manufactured, altered or prepared for sale, &c., 231 in which other articles were manufactured, &c., and 32 were domestic workshops. Amongst the workshops manufacturing wearing apparel, there were 391 employing females alone, and 154 employing both males and females. In workshops of other occupations, there were 143 employing females alone, and 88 employing both males and females. Of the domestic workshops, females alone were employed in 19 and both males and females in 13. During the year notices and complaints were received from H.M. Inspectors of Factories, as follows:— Complaints Factories 5 „ Workshops 18 Notices „ 124 30 Analysis of Occupations Carried On in the Registered Workshops of Hackney. (a) Wearing Apparel. Occupations. No. of Workshopps. Occupations. No. of Workshops. Artifical Flower Makers 10 Hats 7 Baby Linen 3 Infants' Millinery 7 Beading 1 Mantles 63 Belts 2 Millinery 46 Blouses 42 Needlework 2 Boot and Shoe Manufacturers 63 Pinafores 1 Shirts 7 Boot Machinists 111 Stays 7 Children's Costumes 11 Tailoring 68 Clerical Robes 1 Ties 40 Clothing 7 Trimmings 13 Collars 1 Underclothing 16 Dressmakers 81 Vests 7 Dressing and Tea Gowns 5 Waterproofs 5 Fancy Bows on Shoes 6 657 Fall Net Chenilling 1 Furriers 63 (b) Other Occupations. Bakers and Confectioners 36 Rubber Goods 6 Baskets 4 Toy Makers 9 Box Makers 21 Trunk and Bag Makers 6 Brush Makers 11 Umbrella Makers 3 Cabinet Makers 61 Upholsterers 14 Doll Manufacturers and Dressers 7 Upholsterers' Trimmings 3 Miscellaneous 115 Fancy Leather Goods 32 410 Laundries 62 Pianoforte Makers 20 During 1916 Miss Teebay, the Workshops Inspector, made 2,393 inspections and re-inspections of factories and workshops where females are employed. In connection with these inspections 371 intimation and statutory notices were served for the abatement of the nuisances found. Outworkers.—The number of outworkers on the register at the end of 1916 was 2,868, against 2,768 at the end of 1915. There were thus 100 outworkers added to the register during the past year. 31 The following analysis shows the trades followed by these outworkers :— Trade. No. of Outworkers Trade. No. of Outworkers. Artificial Florist 82 Hats 6 Baby Linen 19 Lace Trimmed Goods 5 Belts 27 Millinery 190 Blouses 236 Pinafores 1 Boots and Shoes 518 Shirts 65 Boxes 204 Shoe Bows 13 Braces 7 Skirts and Mantles 274 Brushes 198 Tailoring 131 Canvas Goods 2 Ties 189 Children's Costumes 18 Trimming 73 Clothiers and Outfitters 117 Umbrellas 27 Collars and Bibs 14 Underclothing 119T Confectionery Packing 10 Upholsterers' Trimmings 14 Corsets 7 Vests 1 Dolls 123 Miscellaneous 57 Dressing and Tea Gown 13 2,868 Fancy Goods 23 Fur Trade 85 The local authorities from which I have received names and addresses of outworkers during the year 1916 are the following:— Battersea 6 Lambeth 2 Bermondsey 1 Leyton 11 Bethnal Green 355 Paddington 4 Bromley (Kent) 2 Poplar 64 Camberwell 5 St. Marylebone 51 Chelsea 16 St. Pancras 2 City of London ,292 Shoreditch 215 Deptford 3 Southgate 2 Edmonton 1 Southwark 11 Finchley 1 Stoke Newington 60 Finsbury 610 Tottenham 8 Greenwich 2 Walthamstow 14 Hammersmith 1 West Ham 4 Hampstead 6 Stepney 108 Holborn 17 3,254 Hornsey 3 Islington 369 Kensington 8 32 On examination of the lists of outworkers sent in by employers in this Borough during 1916, I found 2,929 whose addresses were in other districts. The names and addresses of these were forwarded to their respective local authorities, as given in the following list:— Acton 1 Islington 292 Alperton 1 Lambeth 11 Amersham 2 Leeds 1 Axminster 19 Lewisham 13 Barnstaple 1 Leyton 183 Battersea 7 Loughton 1 Bermondsey 4 Mitcham 1 Bethnal Green 573 Newport (Essex) 2 Birmingham 1 Poplar 241 Brentford 1 Richmond 2 Brentwood 2 Rickmansworth 1 Bridlington 2 Romford 2 Bristol 1 St. Marylebone 1 Buckingham 1 St. Pancras 3 Camberwell 28 Shoreditch 490 Chard 36 Southall 1 Charmouth 1 Southend 3 Chingford 12 Southgate 3 City of London 6 Southwark 15 Chulmleigh (Devon) 1 Stepney 172 Croydon 5 Stokenchurch 2 Deptford 4 Stoke Newington 203 East Ham 19 Taunton 6 Edmonton 21 Tottenham 161 Enfield 5 Twickenham 1 Exeter 2 Waltham 1 Fermanagh (Ireland) 2 Walthamstow 200 Finchley 3 Wandsworth 7 Finsbury 19 Watford 5 Fulham 2 Wellington (Somerset) 2 Hammersmith 4 Wembley 1 Hampstead 5 West Ham 29 Harrow 1 Westminster 3 Hastings 2 Willesden 3 Holborn 6 Woodford 3 Honiton 10 Wood Green 10 Hornchurch 2 Wycombe 3 Hornsey 17 Yeovil 1 Ilford 16 2,929 Kensington 4 Kingston 1 33 During the year 1916, Miss Portlock (the inspector appointed for the inspection of outworkers premises) made 1,268 inspections and 1,010 re-inspections. She also made 467 visits without inspections, the outworkers having left the premises (145), or having given up homework (74), or being out at the time of visit (188), or owing to a wrong address being given (42), or the premises being workshops (17), or male workers alone being employed (1). Miss Portlock also discovered 2 new workshops and handed their addresses in for registration. During her visits of inspection Miss Portlock discovered 483 outworkers' premises with sanitary defects. For the abatement of these she served 362 intimation notices. Of the 1,251 outworker's premises inspected, in only 65 was a room set apart entirely for work. was a room set apart entirely for work. In the remainder, work was carried on in rooms used for other purposes, as set out below :— Workroom, bedroom, kitchen and living rooms 61 „ ,, and living room 49 „ „ ,, kitchen 32 ,, and kitchen 871 ,, ,, bedroom 114 „ „ parlour 47 „ „ scullery 9 „ „ bath room 2 „ „ landing 1 Workroom provided separate 65 Total 1,251 COMBINED DRAINAGE WORKS REFERRED TO THE BOROUGH ENGINEER AND SURVEYOR DURING 1916. During this year 12 notices of defective systems of combined drainage works were referred for consideration to the Surveyor. DISINFECTION. (a) Rooms.—During 1916 there were 2.261 rooms fumigated and 369 rooms cleansed in the Borough by the staff of the Public c 34 Health Department. These totals include disinfections after measles, whooping cough and tuberculosis, in addition to those in connection with notifiable infectious diseases. (b) Articles of Clothing, Furniture, &c.—The number of articles under this head disinfected during last year was as follows:— House, linen and furniture 13,618 Men's clothing 519 Women's clothing 451 Children's clothing 104 Other articles 2,276 Total 16,968 There were also 144 articles destroyed on request from the owners. (c) Public Library Books.—During the past year 184 books from homes in which infectious diseases had occurred were disinfected. Of this number 177 had been borrowed from the Hackney Borough Public Library and 7 from other libraries. THE SHELTER. During 1916 there were 5 persons admitted to the shelter whilst their homes were being disinfected. The cost of maintenance for the 5 persons thus admitted was £1 9s. 6d. CLEANSING OF PERSONS ACT, 1897. The baths provided by the Borough Council under the above Act for the cleansing of verminous persons were in constant use during last year, 1,287 baths being given during that period. This total shows an increase of 99 upon the number given during 1915. Of the 1,287 baths given, 726 were sulphur baths for scabies and 561 for pediculi. The great majority of those persons presenting themselves for baths were children from the elementary schools in the Borough. These children received 1,234 baths, an increase of 119 upon the number given during 1915. Of those persons receiving hot baths, 28 were men and 533 children; of those receiving sulphur baths, 16 were men, 9 women and 701 children. 35 The expenditure incurred during the year in connection with the Disinfecting Station and Shelter was as follows:— £ s. d. Disinfecting Station 581 14 10 Shelter 91 2 5 Cleansing of verminous persons 60 18 2 Total £733 15 5 LONDON COUNTY COUNCIL (GENERAL POWERS) ACT, 1904. During the year my attention was drawn by the Medical Officer (Education) of the London County Council to 516 houses in the Borough from which children were attending school in a verminous condition, and I was asked to deal with them under the above Act. I had all these inspected and found that of the 516 homes, 46 had verminous rooms and 12 had both verminous rooms and bedding or clothing. The remainder were clean and free from vermin. REMOVAL AND DISPOSAL OF HOUSE REFUSE. The total quantity of refuse removed from occupied houses in the Borough to the Destructor by the Council's contractors during the year 1916 amounted to 31,424 tons 16 cwts. During the same period the prices paid by the Borough Council for its removal were, for the North Division 4s. 2d., and for the South Division 4s. 3d., per ton. On the 1st April, 1916, the contractors were granted by the Borough Council a 6 per cent, increase on the above prices. The total cost for removal for the whole year amounted to £7,631 16s. Id. Owing to the difficulty of removing the clinker and labour troubles, it became necessary to deposit some of the house refuse on shoots in the neighbourhood of the Borough. The quantity so deposited during the year was 6,688 cubic yards. The cost of this is included in the total given above. c 2 36 DUST REFUSALS AND NO ANSWERS FOR THE YEAR 1916. During the year the dustmen met, during their weekly calls, with an average of 292 " refusals " and an average of 592 " no answers " per week. REQUESTS FOR REMOVAL OF HOUSE REFUSE. Requests for the removal of house refuse were received to the number of 913 during the year. This increased number was due to the contractors not being able to carry out a thorough weekly collection, owing to their difficulty in getting sufficient dustmen, caused by war conditions. THE MORTUARY. The following tables give the number of bodies deposited in the Mortuary during the year, also the number of inquests held there, with the causes of death, &c. Number of bodies deposited in the Mortuary 425 1. To await inquests—(a) Infectious 6 (b) Non-infectious 386 2. To await burial 33 Number of post-mortems made 144 INQUESTS. Verdicts. Sex. Male. Female. Natural causes 127 118 Accidental death 75 51 Suicide 8 3 Open Verdict 5 1 Murder 1 1 Misadventure 2 ... Totals 218 174 37 SALE OF FOOD AND DRUGS ACTS. Samples purchased during 1916. Article. Number Purchased. Number Adulterated. Number where proceedings taken. Milk 516 58 19 Butter 246 19 1 Margarine 24 — — Cocoa 31 — — Coffee 20 — — Arrowroot 9 – Lard 13 — — Olive Oil 3 — — Sugar 1 — — Tea 12 — — Meat Paste 6 — – Peas 3 — — Pepper 2 — — Cream 3 1 1 Medicine 2 1 1 Baking Powder 6 — — Cornflour 3 – — Dripping 2 — — 902 79 22 38 Prosecutions under the Sale of Food and Drugs Acts during the year 1916. No. of Sample. Article. Adulteration or Offence. Result of Legal Proceedings. Fine. Costs. £ s. d. £ s. d. 61h Milk 7.3% added water Fined 0 10 0 0 10 6 55j Butter 64% excess of water „ 1 0 0 1 1 0 1l Milk 6.6% fat abstracted „ 0 9 6 1 11 6 6l „ 6% added water „ — 1 11 6 49l „ 6.24% Withdrawn on payment of – 2 2 0 11m „ 6.66% fat abstracted Fined 1 0 0 — 56m „ 5% „ — 0 10 6 1n „ 6.66% Withdrawn. — — 3n „ 19.33% „ Fined 5 0 0 2 2 0 49n „ 7.33% „ 1 1 0 1 1 0 65n „ 8.01% added water „ 0 5 0 1 1 0 19p „ 11.6% fat abstracted Withdrawn on payment of – 2 2 0 46p „ 12.71% added water Withdrawn. (Warranty proved). – – 57p Cream 41% boric acid Withdrawn on payment of – 2 2 0 10r Milk 5.41% added water Fined 0 5 0 1 1 0 12r 12r Medicinal prescription. 60% deficient in potassium iodide Not composed of the ingredients demanded. Withdrawn by order of P.H. Committee. – – 58r Milk 7.06% added water Withdrawn. (Warranty proved.) – — 63r 6.35% Fined 1 0 0 — 64r 5.88% Withdrawn. (Warranty proved.) — — 57p Cream Alleged false warranty. Withdrawn — — 58r Milk Alleged false warranty. Dismissed. (Warranty proved.) — — 64r False warranty Fined 3 3 0 3 3 0 65t Margarine Served in plain wrapper. Fined 0 10 0 0 10 6 1v Milk 3.53% added water Fined 1 0 0 1 1 0 4 „ 4% No name and address on vehicle. Fined Withdrawn on payment of 0 10 0 0 1 10 14 6 6 67v „ 9.06% added water Fined 2 0 0 1 1 0 68v „ 8% fat abstracted „ 2 0 0 1 1 0 Total 19 13 6 25 17 6 39 Prosecutions under the Public Health (London) Act, 1891, during the year 1916. Address. Complaint. Magistrate's Decision. Penaltv. Costs. £ s. d. £ s. d. 29. Buckingham Road. General insanitary condition. Order to abate nuisance in 21 days. l 13 0 1, Clarence Cottages Roof defective Order to abate nuisance in 14 days. l 1 0 „ „ Owner failed to comply with Magistrate's order. „ „ — 3 3 0 39 a, Cadogan Terrace. Accumulation of offensive trade refuse Order to abate nuisance in 14 days. — 1 5 0 „ „ „ „ „ „ — 1 6 0 55, London Road General insanitary condition. Order to abate nuisance in 21 days. — 1 5 0 4, Walsingham Road Roof leakv Order to abate nuisance in 14 days. – 1 5 0 245, Rushmore Road General insanitary condition. Withdrawn. (Work done). — 1 13 0 17, Hackney Grove „ „ Withdrawn. (Work done) . — — 10b, Elizabeth Buildings. Broken and leaky sink waste. „ „ ] 3 0 70, Berkshire Road General insanitary condition. Order to abate nuisance in 21 days. — 1 5 0 Total £14 IS 6 40 (APPENDIX.) REPORT ON MATERNITY AND CHILD WELFARE. Public Health Department, Town Hall, Hackney, N.E. 20th April, 1916. To the Chairman and Members of the Public Health Committee. Gentlemen, In accordance with your reference, I beg herewith to submit my report on the Circular letter and accompanying Memorandum of the Local Government Board, dated 30th July, 1914, on the subject of Maternity and Child Welfare. The letter of the Local Government Board states, that an estimate has been laid before Parliament, for a grant to be distributed by the Board in aid of expenditure of local authorities and voluntary agencies, in respect of institutions and other provision, for maternity and child welfare. This grant will be made in aid of expenditure in respect of clinics, dispensaries and other institutions primarily concerned with the provision of medical and surgical advice and treatment, and the salaries of Health Visitors and other officers engaged for this work. The Board observe with much satisfaction that efforts have been made by many local authorities and voluntary agencies to deal with infant welfare, and that those efforts have played an important part in the reduction of infant mortality ; but it is evident, that more extended and systematic measures, than have hitherto been generally adopted are necessary, and it is hoped that the grant from the Exchequer above referred to will stimulate local authorities to develop this work still further. 41 Up to the present, local authorities in their infant welfare have concerned themselves more especially with the child in its first year of life ; the matter is, however, one which needs to be dealt with on a more comprehensive basis, and it is clearly desirable that there should be continuity in dealing with the whole period, from before birth until the child is entered upon a school register. Extension of the existing work is therefore needed in two directions ; on the one hand it is necessary that means should be taken for securing improved ante-natal and natal conditions, and on the other hand provision should be made for continuing the work in relation to children beyond the first year of life. The Board further state, that in order to assist the formulation of schemes, or the extension of work already undertaken, a Memorandum by the Board's Medical Officer accompanies their Circular, which sets forth in outline the matters needing consideration in the preparation of a comprehensive scheme. This Memorandum contemplates that medical advice, and where necessary treatment, should be continuously and systematically available for expectant mothers, and for children, till they are entered on a school register, and that arrangements should be made for home visitation throughout the period. The Board attach very great importance to the work of home visitation, and state, that in promoting schemes on the lines laid down in their Memorandum, the first step should be the appointment of an adequate staff of Health Visitors. It is also desirable that consultation centres, or maternity centres, should be established to which expectant mothers, and mothers with infants and little children may be referred for advice and treatment, such maternity centres co-operating if possible with the midwives of the district, and any local hospital having a midwifery department. Other necessary steps will also include the appointment of a medical officer to sueh a centre, the attendance at this centre of those engaged in home visitation, and the keeping of records in such a 42 form as to be available for the information of the school medical officer when the child is entered at a school. While the Board do not expect local authorities at once to initiate complete schemes, it is important that any partial arrangements that may be made shall be such as can ultimately form part of a more extended organisation. The Board are willing to consider applications for grants in respect of any work falling within the scope of the scheme outlined in their Memorandum ; such grants will normally amount to half of the approved expenditure on any of these purposes, but may be less if the Board so decide. Grants to institutions of the nature of schools for mothers, the object of which is primarily educational, which provides training and instruction for mothers in the care and management of infants and little children, will be administered by the Board of Education. Application for grants should be accompanied by an account of the work undertaken by the authority, and a detailed statement of the .expenditure incurred, certified by the officer of the local authority in charge of the accounts. The above gives in condensed form the substance of the Board's circular letter. The Memorandum, which sets out in outline the elements of a complete scheme, I give at the end of this Report. I assume that your reference includes an instruction to report as to the desirability of compliance with the Board's letter, by the formulation of a scheme, complete or in part, for the Borough of Hackney. Before proceeding with the consideration of such a scheme, I think it will be desirable in the first place, to put before the Committee the facts showing the annual loss of maternal and child life in the Borough, and to what extent a scheme, such as that proposed, may be expected in time to reduce this mortality. 43 It is matter of common knowledge that infants under one year of age suffer from a very high death rate ; but it is not so generally known that a large part of this mortality is directly traceable to conditions affecting the mother during child-bearing, and at birth. Again, although the death rate is high under one year of age, it is also very considerable up to five years of age. The mortality amongst mothers during child-bearing and child-birth is also considerable. The Mother during Child-bearing and Child-birth. Both mother and child are exposed to special perils during this period, which may lead to the death of either or both, or to subsequent ill-health and suffering of the mother, and feeble vitality of the infant. The dangers threatening the mother are chiefly puerperal fever and other complications. The annual death rates per 1,000 births for the County of London and the Borough of Hackney from these causes during the four years 1911-1914, were as follows:— Puerperal fever. Other complications of child-birth. Total mortality from child birth. London 1.48 1.86 3.06 Hackney 1.54 1.54 3.08 Expressed in words, these figures mean that during the four years in question (1911-1914) there died in London 1,356 mothers and in Hackney 66 mothers, from puerperal fever and other complications of child-birth. On this subject the Chief Medical Officer of the Local Government Board, Dr. A. Newsholme, C.B., makes the following remarks in his report on Maternal Mortality in connection with childbearing:— 44 "The majority of the deaths of mothers from childbearing are caused by puerperal fever, haemorrhage and convulsions. Most cases of these conditions are well within the range of preventive medicine, including in this the early treatment of illness. The prevention of early infant mortality is inseparable from that of maternal mortality of mothers in childbearing. Excessive mortality of mothers in child-bearing means also an excessive proportion of still-born infants, and an excessive proportion of deaths of infants in the early weeks after the birth." The figures above quoted refer only to the mortality amongst mothers ; they take no account of deaths associated with, but not classed as due to pregnancy and child-bearing, the commonest of which are heart disease, pneumonia and tuberculosis ; nor do they take account of cases of partial recovery, with subsequent suffering and ill-health. The infant before, during and after birth up to five years of age. The factors influencing infant mortality mav be divided into the three following classes:—1. Ante-natal, acting through the mother and dependent on her health. 2. Natal, also to a great extent due to the condition of the mother, e.g., causes of difficult and delayed parturition, as well as to want of skill on the part of the doctor or midwife. 3. Post-natal, due to environmental conditions. 1. Ante-natal period.—The maintenance of the health of the mother during the ante-natal, or child-bearing period, is of vast importance to the future of both mother and child. During the period in question the life of the future child may be lost, shortened, or permanently affected by neglect of the laws of hygiene ; on the other hand, care on the part of the mother, and an observance of hygienic rules, will establish the health of the mother and preserve the life of the child to the nation. 45 The chief dangers affecting the life of the infant during this period are : (a) Miscarriage, (b) Still-birth. (a) There is no statistical evidence to show the proportion of miscarriages to live births in the Borough, but there is no reason to believe they are more or less numerous than in other parts of the country. Estimates have, however, been made of the proportion of miscarriages to still births, and the average estimate arrived at is four miscarriages to one stillbirth. If we apply this rate to Hackney, we shall get a local rate which will be rather startling as to the loss in infant life due to this cause alone. During the year 1914 there were 174 still-births notified to me ; therefore, on the basis of the above estimate, there were 696 miscarriages. (b) The causes leading to still-births are very complex ; but in great measure they are connected with the health of the mother during the child-bearing period, and may be expressed in general terms, as due to the diseases and complications of pregnancy, which may be largely controlled by early treatment of the mother before serious symptoms arise. Summing up the loss to infant life during the pre natal period, we find it amounts, approximately, in Hackney to an annual loss of 870 infant lives. 2. Natal period.—It is not possible to separate entirely this period in its effects from the earlier period. This is borne out by the statement by Dr. Newsholme already quoted. Experience, moreover, shows that many deaths occur from conditions arising during the birth of the infant. It is not necessary to go into details. It is sufficient to recognise that this period is one requiring skilled attention and watchfulness, in order to prevent any of the incidents of this period from being harmful, either to mother or child. 3. Post-natal period and mortality.—This includes all deaths of infants during the first five years of life. This period is usually 46 divided into that under the first year of life and from one to five years of age. There is a great convenience in this division, because some causes, which are operative with great intensity on infants under one year of age, are less operative on those at higher ages, and other causes are more operative at ages above one year. The chief causes of death under five years of age are grouped as follows:— 1. Premature birth and congenital defects. 2. Atrophy, debility and marasmus. 3. Convulsions. 4. Diarrhoeal diseases. 5. Measles and whooping cough. 6. Bronchitis and pneumonia. The majority of the deaths under these first three headings are probably due to ante-natal conditions ; but a large portion also to want of care at, and after birth. Many of these deaths occur during the first week of life. Diarrhoeal diseases in childhood are mostly confined to the first year of life, and are especially diseases of environment, and as such, largely preventable. Measles causes most deaths between the age of one and five years. Whooping cough most under one year. These deaths are largely preventable, being mostly due to want of proper care and treatment, during the course of the disease. Bronchitis and pneumonia are most fatal at the two extremes of life. At the beginning of life, bronchitis is very fatal under one year, but causes a considerable number of deaths between one and five years. Pneumonia is extremely fatal, both under one year and between one and five years. These diseases in young children arise mostly during the course of some febrile affection, and are largely preventable. 47 For convenience I add here a table showing at a glance the number of deaths due to the several causes mentioned, both under one year and from one to five yrars. Table of special causes of deaths in children under one year of age and from one to five years of age, during 1914, in the Borough of Hackney. Causes of deaths. Under one year. One and under five years. Total under five years. Premature births 81 – 81 Congenital defects 29 — 29 Atrophy, debility and marasmus 54 6 60 Convulsions 19 2 21 Diarrhoeal diseases 109 20 129 Measles 10 83 99 Whooping cough 24 24 48 Bronchitis 26 7 33 Pneumonia 54 64 118 412 206 618 Leaving out of account the maternal mortality, and taking the year 1914 as an average year, there is an annual loss of infant life before birth of 870, and after birth up to five years of age, 618, making a total annual loss of 1,488 infant lives. The facts above given will enable the Committee to realize the extent of the annual loss of maternal and infant life in the Borough ; but it must also be remembered that the birth-rate in the Borough is progressively declining. In the year 1904 the birth-rate was 27.9 per 1,000 ; in the year 1915, the rate had declined to 21.5 per 1,000 of the population. This is equal to a decline of over 1,400 births per annum. These facts will, I am sure, convince the Committee of the pressing necessity for the immediate institution of a Maternal and Infant Welfare Scheme in the Borough. 48 The following is the outline of a scheme which I am of opinion will be found adequate for the present time, and in agreement with the skeleton scheme drawn up by the Medical Officer of the Board. Maternity and Child Welfare Scheme. A scheme of this nature should consist of the following elements :— 1. An Anie-natal Clinic for expectant mothers. (a) This should be provided, if possible, at some hospital in the Borough at which a physician for diseases of women would attend one afternoon a week to see expectant mothers. Cases of complication arising after parturition, in the mother, might be examined by the same physician and dealt with by him ; or referred to the appropriate physician or surgeon at the hospital. The Metropolitan Hospital fulfils the condition of being in the Borough, and it has a department for diseases of women. If the hospital authorities are willing, I have no doubt, the Clinic might be arranged with this department. Negotiations would be necessary to ascertain if such an arrangement would be made, and at what cost. (b) In connection with the Clinic, one or more Health Visitors should be appointed. This officer should have the qualification of a midwife, with some knowledge of sanitation of the home. Her duties would be to visit the homes of expectant mothers, advise them to attend the Clinic for consultation with the physician, to hear the physician's instructions to the expectant mothers, and to see, if possible, that his advice is followed. She would also see if the sanitary condition of the home is satisfactory. 2. Arrangements with the London County Council, which is the authority for the registration and supervision of midwives in London, to ensure that expectant mothers shall have skilled and prompt attendance during confinement at home. 49 3. Arrangements after birth for the infant. These should take the form of (a) one or more " Infant Welfare Centres," where infants would be taken periodically and examined by a doctor, who would advise as to their feeding and general health, and where the infants are suffering from minor complaints prescribe the proper treatment. The centre would be open to all infants and children up to the age when they would be entered on a school register, and be periodically examined during school life, by the school medical officer. The completeness or otherwise of this scheme will largely depend upon the number of these Welfare Centres established in the Borough. If these are to serve for children up to the age of five years, it is obvious the number must be rather generous. There are between 5,000 and 6,000 births in Hackney during the year. There are also 800 deaths yearly amongst infants up to the age of five years. Therefore, if the centres are to serve for all infants up to five years of age, provision, to be complete, must provide for the examination and treatment of about 20,000 children. But the Board in their Memorandum of 31st July, 1914, state that they do not expect local authorities at first to initiate complete schemes, but if partial arrangements are made, they must be such as can ultimately form part of a more complete scheme. At present I would suggest the establishment of two " Infant Welfare Centres " in the Borough. For a commencement this will be sufficient, and later on, when conditions are more normal, the number may be increased. The two centres should be situated at places near the poor and crowded part of the Borough. (b) Arrangements made with the authorities of a children's hospital to receive cases too severe for treatment at the Centre. A conveniently situated hospital is the Queen's Hospital for Children, Hackney Road, which is just beyond the boundary of the Borough, but not too distant for the purpose mentioned. There 50 would, I am sure, be no difficulty in arranging for the reception in this hospital of suitable cases of illness in infants and young children. (c) The appointment of a sufficient number of properly qualified Health Visitors, for visiting infants at their homes, and advising mothers as to the care and feeding of their children. It would also be the duty of certain of these officers to attend at the Centres to assist the doctor in attendance. Estimated Annual Cost. An estimate of this at the present stage must be more or less approximate, and will vary of course with the completeness or otherwise of the scheme. otherwise of the scheme. The following estimate has been carefully considered and will, I believe, be sufficient to meet the expenditure of a scheme as above outlined. Ante-natal Clinic. £ £ Honorarium to physician per annum 100 Health Visitor 120 Payment to hospital 50 Sundry expenses ... 30 300 Four Health Visitors at £100 per annum each 400 Infant Welfare Centres. £ Honorarium to medical attendant per ann. 50 Premises, rates, &c. 50 Lighting, heating, &c 10 Drugs 20 Sundries 20 150 Summary. £ Ante-natal work ... 300 Four Health Visitors • 400 Uniform, allowances, &c. 30 Two Infant Centres 300 Total .. £1,030 51 Of this total the Local Government Board will make grants approximately to the amount of 50 per cent, of the total. This would leave an annual cost to the Borough of £515. I remain Yours obediently, J. KING WARRY, M.D., D.P.H., &c. Medical Officer of Health. Memorandum of the Medical Officer of the Local Government Board on Maternity and Child Welfare. A complete scheme would comprise the following elements, each of which will, in this connection, be organised in its direct bearing on infantile health. 1. Arrangements for the local supervision of midwives. 2. Arrangements for:— Ante-natal. (1) An Ante-natal Clinic for expectant mothers. (2) The home visiting of expectant mothers. (3) A maternity hospital or beds at a hospital, in which complicated cases of pregnancy can receive treatment. 3. Arrangements for Natal. (1) Such assistance as may be needed to ensure the mother having skilled and prompt attendance during confinement at home. 52 (2) The confinement of sick women, including women having contracted pelvis or suffering from any other condition involving danger to the mother or infant, at a hospital. 4. Arrangements for:— Post-natal. (1) The treatment in a hospital of complications arising after parturition, whether in the mother or in the infant. (2) The provision of systematic advice and treatment for infants at a Baby Clinic or Infant Dispensary. (3) The continuance of these Clinics and Dispensaries, so as to be available for children up to the age when they are entered on a school register, i.e., the the register of a public elementary school, nursery school, creche, day nursery, school for mothers or other school. (4) The systematic home visitation of infants and of children not on a school register as above defined.