AC4411(1) LEYTON PUBLIC HEALTH LEY 28 DIVISION Borough of Leyton HEALTH REPORT FOR THE YEAR 1933. ANDREW W. FORREST, M.A., M.D., Ch.B„ D.P.H., Medical Officer of Health, School Medical Officer, :: Medical Superintendent of Isolation Hospital. :: Borough of Leyton. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH, SCHOOL MEDICAL OFFICER, AND MEDICAL SUPERINTENDENT OF THE ISOLATION HOSPITAL FOR THE YEAR 19 3 3. 2 HIS WORSHIP THE MAYOR (Mr. Alderman Allanson, J.P.), ex-officio Member of Committees. PUBLIC HEALTH COMMITTEE: DISEASES OF ANIMALS ACT COMMITTEE. Chairman: Alderman Read, J.P. Members: Alderman Bechervaise. „ Mrs. Campbell. „ Russell, J.P. „ Shimmin. Councillor Barber. „ Bass. „ Biles. „ Cochrane. „ Mrs. Crown. Graham-Stevenson. Councillor Mrs. Hammond. „ Hinton. „ Hurry. „ Markwick. „ Mrs. Mawer. „ Pearce. „ Mrs. Read, M.B.E. „ Mrs. Shimmin. „ Snell. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Councillor Mrs. Read, M.B.E. Members ; Alderman Bechervaise. „ Mrs. Campbell. „ Read, J.P. „ Russell, J.P. Councillor Barber. „ Mrs. Crown. Councillor Graham-Stevenson. „ Mrs. Hammond. „ James. „ Peck. „ Mrs. Shimmin. Co-opted Members : Mrs. Cochrane. „ Peck. „ Smith. Mrs. Sortwell. „ Waller. EDUCATION COMMITTEE. Chairman : Alderman Russell, J.P. Members : Alderman Bechervaise. „ Fitzgerald. „ Wayward. „ Read, J.P. „ Shimmin. „ Turner. Councillor Bass. „ Cochrane. „ Graham-Stevenson. Councillor Mrs. Hammond. „ Hinton. „ Marlow. „ Mrs. Mawer. „ Pearce. „ Mrs. Read, M.B.E. „ Mrs. Shimmin. „ Shore. „ Thorn. Co-opted Members : Mrs. Ringer. Mr. G. H. Perry. „ W. Hurry, J.P. Mr. B. Rayner. „ J. A. Whatnall. „ A. G. Serpell. SPECIAL SCHOOLS (MEDICAL SERVICES) SUB-COMMITTEE. Chairman: Councillor Mrs. Read, M.B.E. Members: Alderman Fitzgerald. „ Russell. „ Turner. Councillor Mrs. Hammond. „ Hinton. „ Marlow. „ Mrs. Mawer. „ Mrs. Shimmin. Councillor Shore. Mr. W. A. Hurry, J.P. „ J. A. Whatnall. Mrs. Ringer. Mr. Perry. „ Serpell. „ Rayner. 3. Borough of Leyton. PUBLIC HEALTH STAFF. MEDICAL OFFICERS— Whole Time: *Forrest, Andrew W., M.A., M.D., M.B., Ch.B., D.P.H., Medical Officer of Health, School Medical Officer, Medical Superintendent of Isolation Hospital. *Gavin, Frederick William, M.D., M.B., Ch.B., D.P.H., Deputy Medical Officer of Health and Deputy School Medical Officer. *Menzies, Hilda F., M.D., M.B., Ch.B., D.P.H., Assistant Medical Officer of Health (Maternity and Child Welfare). *Gilchrist, Mary Lyle, M.D., M.B., Ch. B., Assistant Medical Officer of Health. Part Time : Kennedy, John, M.B., Ch.B. (Glasg.), Emergency Medical Attendant at Isolation Hospital. *Cardell, John Douglas Magor, M.B., B.S. (Lond.), F.R.C.S. (Eng.), M.R.C.S., L.R.C.P., School Oculist. *Howell, Bernard Whitchurch, M.B., B.S. (Lond.), F.R.C.S. (Eng.), M.R.C.S., L.R.C.P. (Lond.), Orthopaedic Surgeon. *Rivett, Louis Carnac, M.C., M.A., F.R.C.S. (Eng.), M.R.C.S., L.R.C.P. (Lond.), Consultant Obstetrician. VETERINARY INSPECTOR UNDER THE DISEASES OF ANIMALS ACT. Scott, Eustace Edward, M.R.C.V.S. MATRON, ISOLATION HOSPITAL. Miss E. Ryan. DENTAL SURGEONS— Whole Time: *Horton, James Ernest, L.D.S., R.C.S. (Eng.) *Grant, David Reginald Brash, L.D.S., R.C.S. (Edin.) School Dentists. Mr. Grant also does the dental work in connection with the Maternity and Child Welfare Scheme. SENIOR SANITARY INSPECTOR. *Gray, Edward Henry, Certificate R.S.I., Meat Inspector's Certificate R.S.I. SANITARY INSPECTORS. *Steeden, Edward James, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Smith, Victor Wynn, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Reeves, Reginald Alfred, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Miller, Agnes Mabel, Certificate R.S.I. *Turbitt, Wilfred, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Reeve, Frederick William, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Barnes, Arthur Edward, Certificate R.S.T., Meat Inspector's Certificate R.S.I. HEALTH VISITORS. *Bratton, Maud, Trained Nurse. *Walling, Ethel Winifred, C.M.B., Trained Nurse, Health Visitor's Certificate R.S.I. *Kittbring, Margery, Trained Nurse, C.M.B., Health Visitor's Certificate R.S.I. *Sizer, Agnes, Trained Nurse, C.M.B., Health Visitor's Certificate R.S.I. *Neale, Barbara, Trained Nurse, C.M.B., Health Visitor's Certificate R.S.I. SCHOOL NURSES. *Crawford, Daisy, Trained Nurse, Health Visitor's Certificate R.S.I. *Sykes, Martha, Trained Nurse. *Maye, Marie, Trained Nurse, Health Visitor's Certificate R.S.I. *Fulcher, Joan, Trained Nurse. *Edwards, Ruth, Trained Nurse, C.M.B. *Stiles, Eleanor, Trained Nurse, C.M.B. MASSEUSE—Part Time: *Findlay, Miss A. E., Cert. Chartered Society of Massage, etc. CHIEF CLERK. *Leserve, George Frederick. CLERKS. Jacobs, E. E., *Hayes, Miss A., *Payne, Miss W., Baxter, C. W., Softley, W., Brighting. G., Pinches, G., Budd, E. W., Freeman, A. *Proportion of Salary contributed under Public Health Acts or by Exchequer Grants. 4 TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF LEY TON. Mr. Mayor, Ladies and Gentlemen, I have the honour to present herewith my Annual Report on the health, sanitary circumstances and vital statistics of the Borough of Leyton during the year 1933, together with my Annual Report to the Education Authority on the work of the school medical service during the year. Meteorological. From a meteorological point of view the year 1933 will be remembered for its very warm, sunny and dry summer. During nine successive months (February-October) the mean temperature remained well above normal at Greenwich. Thundery conditions were prevalent during May and June, and several deaths occurred from lightning during the latter month. The months of July, August and September were unusually warm and sunny, with deficiency of rain; and we experienced the driest August since the year 1818. Fogs were very prevalent during January and December. Vital Statistics. The number of births registered during the year was 1,499, giving a birth rate of 11.91 per thousand of the population—the lowest ever recorded in the area. The lowest birth rate previously recorded was that (13.10 per thousand) of the previous year; and the graph shown on page 16 shows in diagrammatic form the extent and rapidity of the fall in the Leyton birth rate since the year 1920, when the rate was more than double that of 1933. It will be seen from the statistics on page 14 that the birth rate in Leyton remains at a consistently lower level than in London or in the country generally. The deaths of Leyton residents certified during the year were 1,468. The general death rate (11.67 per thousand) shows a slight increase when compared with the rate (10.54) recorded during the previous year, the causes of death contributing to the relative increase being influenza, heart disease, cerebral haemorrhage and cancer. The Leyton death rate (11.67) compares with corresponding rates of 12.3 for England and Wales and 12.2 for London. Of the total number of deaths certified during the year, 48 per cent. occurred in persons of 65 years and over. 5 The rate of increase of the population is the amount by which the birth rate exceeds the death rate. Forty years ago the natural increase was at the rate of 20.48 per thousand of the population; twenty years ago it was 12.1 per thousand; and in 1933 it was 0.24. For the first time in the history of the area it may be said that we have reached the stage of a stationary population. The decrease in the birth rate, accompanied by the increase in the expectation of life, has—during more than a generation—been causing a marked and progressive decrease in the proportion of children in the community, accompanied by a progressive increase in the proportion of persons past the prime of life. The effect of such a change in the age constitution of the community should be to cause a gradual but progressive rise in the crude death rate, as a larger proportion of the population will be alive in late middle and old age, and subject to a relatively higher rate of mortality. Infectious Diseases. During the first three months of the year influenza was epidemic in the country and, although the infection was of a milder type than that of the more widespread epidemic of 1929, it took a heavy toll of lives. Some 59 deaths in Leyton were certified as directly attributable to influenza during the first quarter of the year; but that figure does not indicate the full extent of the damage done. The chief danger in influenza lies in the complications to which it gives rise, and it is the complications (and not the initial attacks of influenza) which figure in the death returns. There is welcome evidence of the abatement of the mild type of smallpox which has been endemic in East London since 1928. In Leyton the "peak" year of the infection was 1930, when 138 cases were notified and removed to hospital. Since then the annual numbers of Leyton cases have been: 27 in 1931, 14 in 1932 and 2 in 1933. No case of smallpox has been notified in Leyton since May, 1933. On the other hand, there was a widespread outbreak of chicken-pox in the area, and its possible confusion with smallpox entailed constant vigilance and much home visiting. (See page 42.) The year under review was noteworthy on account of the widespread epidemic of scarlet fever in London and neighbouring areas. The number of patients notified as suffering from scarlet fever during the year was 743, the greatest number in any year since 1921. The disease was of the mild type which has been prevalent 6 for a considerable number of years. Although measures directed against scarlet fever have effected only a very slight reduction in incidence, a marked and progressive decline in mortality has been going on over a considerable period. In comparing the latest five-year period (1929-33) with that (1892-96) preceding the opening of Leyton Isolation Hospital it is found that, whereas the reduction in the number of cases has been only 12 per cent., the corresponding reduction in the number of deaths has been 82 per cent. Only 94 persons were notified to be suffering from diphtheria during the year—the smallest number ever recorded in the history of the area. The marked fall in incidence, however, was accompanied by an increase in the severity of the type of infection. Fever Hospital. Although the number of patients admitted suffering from diphtheria was exceptionally low, the percentage of severe cases was greater than in any year since 1928. During the widespread epidemic of scarlet fever of 1933 the abnormal incidence of the disease presented a difficult problem. However, by a merciful dispensation of providence, the incidence of diphtheria was low at the time; and it was found possible to put at the disposal of scarlet fever patients accommodation normally reserved for cases of diphtheria. By increasing the number of beds per ward beyond the standard accommodation and exercising a judicious selection of cases for admission it was found possible to treat in hospital some 443 of the 743 scarlet fever cases notified during the year. In the appropriate section of this Report will be found details of valuable alterations in the Hospital buildings which were undertaken during the year. Maternity and Child Welfare. The number of women who died during the year as the result of childbirth reached the low figure of two, as compared with four such deaths during the previous year. The Leyton maternal mortality rate was therefore 1.33 per thousand births, comparing very favourably with the rate of 4.42 for England and Wales. 7 The death rate of infants under one year of age per thousand live births (i.e., infantile mortality rate) was 50.70, comparing with the previous year's rate of 53.42 and the rate of 64 for England and Wales. At the Maternity and Child Welfare Authority's Infant Welfare Clinics the total attendances were 16,316; the number of children examined by the Clinic Medical Officers was 7,228; and 17,467 visits to homes were made by the Health Visitors. With regard to ante-natal supervision, 406 expectant mothers attended the Council's Ante-natal Clinics, making 958 attendances. In addition, 352 expectant mothers attended for ante-natal supervision at Queen Mary's Hospital. During the year some 327 Leyton mothers occupied maternity beds in the Margaret Lyle Wards, Queen Mary's Hospital, and 360 had their confinements in other hospitals. Of 1,499 Leyton women who gave birth to children during 1933, some 687 (45 per cent.) had their confinements in residential institutions. Sanitary Circumstances. In accordance with the provisions of the Housing Act, 1930, the Local Sanitary Authority—acting on official representations made by the Medical Officer of Health—has dealt with the demolition and clearance of existing slums in the area. One area, comprising 12 houses inhabited by 58 persons, was declared a "clearance area" during 1932. During 1933 the houses were demolished and the site was cleared. Two areas were dealt with as comprising "individual unfit houses" and demolition orders were made by the Council. These two areas comprised 21 houses inhabited by 96 persons, and by the end of the year both areas had been cleared of houses unfit for human habitation. On pages 71 and 73 will be found photographs of these three areas showing the conditions obtaining prior to demolition. During the year the Local Authority has continued to deal with individual cases of overcrowding in the area. Fifty-four cases of overcrowding were reported to the Public Health Committee. In 27 cases the overcrowding was abated as the result of informal or statutory action. In three of these cases proceedings wore instituted, and in each case the Court made an order requiring the tenants to abate the nuisance. 8 As in previous years, there has been maintained a very high standard in meat inspection; and strict supervision is maintained over places where food is prepared and sold. New Leyton Green Clinic. On page 133 will be found a description of the new Clinic premises which were formally opened by His Worship the Mayor (Alderman F. M. Read, J.P.) on 16th September, 1933. The building, one of the most modern of its kind, contains accommodation for the joint clinic medical services administered by the Council as an Education and as a Maternity and Child Welfare Authority. School Medical Service. On pages 138-205 will be found my Annual Report to the Local Education Authority on the medical inspection and treatment of children attending public elementary schools in the area, and the Appendix to the Report contains the statistical tables required by the Board of Education. It is my privilege to acknowledge again the support accorded to me by the members of the Council and the interest shown by the Chairmen and members of the Committees concerned with the work of the Health Department. It is with sincere thanks that I record my appreciation of the industry and loyalty of the members of the staff of the Health Department. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, 9 Extracts from Vital Statistics for the Year. Live Births:— Males. Females. Total. Birth Rate. Legitimate 762 701 1463 11.91 Illegitimate 16 20 36 778 721 1499 Males. Females. Total. Rate per 1000 total births. Stillbirths 26 22 48 32.02 Males Females. Total. Death Rate. Deaths 724 744 1468 11.67 Number of Women dying from diseases and accidents of pregnancy and childbirth:— From Sepsis 2 From other causes Total 2 Death Rate of Infants under One year of age:— All infants per 1000 live births 50.70 Legitimate infants per 1000 legitimate live births 49.2 Illegitimate infants per 1000 illegitimate live births 111.1 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) 4 Deaths from Diarrhoea (under 2 years of age) 6 10 SOCIAL CONDITIONS AND VITAL STATISTICS* General Statistics. Area, 2,594 acres. Population, census 1931, 128,313. Population, June, 1933 (Registrar-General's estimate), 125,700. Number of families (1931), 34,368. Number of inhabited houses (1931), 26,306. Number of persons per house (1931), 4.87. Assessable value for General Rate purposes, £765,481. Sum represented by a penny rate for General Rate purposes, £3,005 (as from 1st April, 1934). Social Conditions.—Leyton is classified as one of the 107 great towns in England and Wales. Situate in the extreme south-west of the County of Essex, and separated from the County of London by the River Lea, it forms part of Greater London. By rail it is only 5½ miles from the City of London, and to this feature it owed its rapid growth, for no large staple industries are carried on in the area. Inasmuch as a very large proportion of the inhabitants work in the City and County of London, it is aptly described as a "dormitory of the Metropolis." 11 METEOROLOGICAL CONDITIONS, 1933. The following is a brief summary of the local meteorological conditions month by month:— January.—The year opened with mild, dull and foggy conditions, and the month was colder than the average with sunshine slightly deficient. Fogs were recorded at 9 a.m. on 12 days. February.—The weather was very variable, being mild at first with rain and strong S.W. winds; later cold Northerly winds were experienced and snow fell on the 24th. March.—This month was unusually sunny and very mild, the diurnal range of temperature was sometimes very great and actually exceeded 40° Fah. Rainfall was 17 mm. above normal. April.—Dry and warm weather was enjoyed for the most part, except for a spell of cold N.E. winds from the 17th to the 22nd. Sunshine was however slightly below the average. May.—Thundery conditions were prevalent. The days were dull and warm with mild nights, and the rainfall was above the normal. The deficiency of bright sunshine was 2.19 hours below normal. June.—The month was distinguished by the abnormal incidence and severity of thunderstorms—several deaths occurring from light ning. The weather was, however, mostly dry and sunshine records were above normal. July.—The weather was notably warm and sunny with a deficiency of rain. August.—This was unusually warm and sunny as well as notably dry and the warmest August at Greenwich since 1841 (apart from August, 1911). The driest August since 1818. September.—The weather was unusually warm and sunny. Thunder with heavy rain on the 19th. The wettest month in London during an abnormally dry year. October.—This was the ninth successive month with a mean temperature well above normal at Greenwich. Rainfall was deficient and sunshine somewhat below the normal. November.—Cloudy, cold and sunless weather prevailed with a marked deficiency of rainfall. December.—The weather was exceptionally dry and abnormally cold, being the coldest December at Greenwich since 1890. Fogs were prevalent during the month. 12 TABLE 1.—METEOROLOGICAL TABLE FOR LONDON 1933. (Deduced from Observations at Greenwich, under the Superintendence of the Astronomer Royal.) 1933. Barometer. Air Temperature. Hygrometer. Earth Temperature. Bright Sunshine. Mean Pressure at Station Level. 152 ft.* (Average Correction to Sea Level + 5.6 mb.) Mean of Mean of A and B Difference from Normal.† Absolute Maximum and Minimum. Mean of Observations at 9 a.m. and 9 p.m. At 1 foot depth. At 4 feet depth. Daily Mean. Difference from NormaL† Per cent. of Possible. Maximum. A Minimum. B Maximum. Day of Month. Minimum. Day of Month. Dry Bulb. Depression of Wet bulb. Vapour Pressure. Humidity. mb. °F. °F °F. °F. °F. °F. °F. °F. mb. % °F. °F. hr. hr. January 1016.3 41.6 32.2 36.9 -1.6 53 3 20 23 36.7 1.3 6.7 87 41.2 44.9 1.10 -0.14 13 February 1011.0 46.3 35.3 40.8 + 1.0 57 5 22 24 40.0 1.9 7.2 83 39.6 43.0 1.55 —0.49 16 March 1010.2 55.7 36.1 45.9 + 3.4 66 29 26 26 44.7 2.5 8.1 81 43.4 43.8 5.41 + 2.01 46 April 1016.3 60.1 39.9 50.0 + 2.4 73 8 31 19.23 49.3 3.9 8.8 72 47.5 46.5 4.42 -0.60 32 May 1011.9 66.0 46.0 56.0 + 2.0 79 23 38 15 54.7 4.0 10.9 75 52.8 50.2 4.28 -2.19 28 June 1009.1 72.7 50.8 61.7 + 1.8 86 4.5 44 22 61.3 5.4 13.0 71 57.8 54.5 7.80 + 1.10 47 July 1015.6 78.4 56.8 67.6 + 4.1 95 27 52 1,15 65.9 4.9 16.3 75 62.0 58.0 7.20 + 0.70 45 August 1015.9 79.4 55.8 67.6 + 5.0 96 6 47 24 66.0 5.9 15.3 70 63.4 60.4 7.78 + 1.58 54 September 1015.3 70.4 52.1 61.3 + 3.3 81 3 41 15 60.1 3.5 14.1 81 60.2 59.8 6.34 + 1.39 50 October 1009.7 58.2 44.7 51.5 + 1.3 70 6 31 28 51.1 2.3 11.1 84 54.0 56.6 3.09 -0.03 29 November 1009.3 47.5 38.4 42.9 -1.1 56 7 32 13 42.4 1.5 8.1 87 46.5 50.9 0.80 -0.92 9 December 1016.9 38.4 31.1 34.7 -5.5 45 22 25 6,10,14 34.7 1.5 5.8 85 39.7 45.4 0.80 -0.26 10 Year 1013.1 59.6 43.3 51.4 + 1.3 96 Aug. 6 20 Jan. 23 50.6 3.2 10.5 79 50.7 51.2 4.21 + 0.18 32 The hours of observation are 9 a.m. and 9 p.m. local time. † The normals used are obtained from observations extending over 35 years (1881-1915). *Pressure is expressed in millibars (1000 mb. = 29.531 mercury-inches). 13 TABLE 1—continued. 1933 Cloud. Rain and other forms of Precipitation. Weather Number of days of Wind. Number of Observations at 9 a.m., 3 p.m. and 9 p.m. Mean of Observations of amount at 9 a.m. and 9 p.m. (Scale 0-10.) Total Fall. Difference from Normal.† Most in a Day. Precipitation (0.2 mm and above). Precipitation (1 mm. and above). Snow. Hall. Thunderstorm. Persistently Clear. Generally Clear.* Generally Overcast.* Persistently Overcast. Fog at 9 a.m. Gale. Force. Direction. Amount. Day of Month. Gale Moderate and Strong Wind Calm. N. N.E. E. S.E. S. S.W. W. N.W. January 6.7 mm. 27 mm. 16 mm. 4 4 7 14 9 2 0 0 0 3 13 3 12 0 0 91 2 8 20 12 2 12 20 12 5 February 7.1 42 + 2 10 10 14 7 10 1 1 0 1 15 3 3 0 0 83 1 24 5 1 9 7 20 10 7 March 4.3 61 + 17 12 16 15 12 0 1 1 6 12 9 0 4 0 0 92 1 1 3 20 9 14 34 9 2 April 5.7 19 — 18 5 25 8 6 1 1 1 0 3 8 1 0 0 0 89 1 5 11 7 2 15 24 19 6 May 6.9 57 + 13 18 23 17 10 0 0 4 0 1 14 1 0 0 0 92 1 13 14 10 11 15 8 10 11 June 5.5 39 — 12 11 24 9 7 0 0 6 0 5 8 0 0 0 0 89 1 18 5 17 13 6 13 11 6 July 5.5 35 — 22 8 11 11 9 0 0 3 0 2 7 0 0 0 0 93 0 3 5 16 3 10 33 17 6 August 4.9 13 — 43 3 31 7 5 0 0 0 0 4 8 0 0 0 0 93 0 7 6 17 6 7 21 22 7 September 5.3 68 + 23 21 19 10 8 0 0 1 0 6 5 1 1 0 0 90 0 12 25 18 7 8 10 4 6 October 5.8 38 — 26 7 28 18 12 0 0 0 0 4 11 2 4 0 0 93 0 9 13 11 8 9 18 17 8 November 7.9 22 — 36 5 14 15 6 2 0 0 0 0 17 4 8 0 0 89 1 23 16 8 6 9 6 7 14 December 8.5 9 — 48 4 30 7 3 3 0 0 0 0 20 4 12 0 0 91 2 10 21 24 7 3 14 10 2 Year 6.2 430 —166 21 Sept. 19th 145 94 18 3 17 6 41 135 19 44 0 0 1085 10 133 144 161 83 115 221 148 80 *A day is reckoned as "generally clear" if the average of the estimates of the fraction of sky covered by cloud at 9 a.m., 3 p.m., and 9 p.m. is less than .2, and as "generally overcast" if the average is greater than .8. Days persistently cloudless and days persistently overcast refer to the period midnight to midnight. 14 VITAL STATISTICS. Births.—Fourteen hundred and ninety-nine births were registered during the year Males. Females. Total. Legitimate 762 701 1463 Illegitimate 16 20 36 778 721 1499 The birth rate per 1,000 of the population was thus 11.91, the lowest ever recorded in the area. The following list shows the population, number of births, and the corrected birth rate per 1000 during the past five years:— Year. Population. No. of Births. Birth Rate. 1929 128,300 1731 13.49 1930 128,300 1757 13.69 1931 128,600 1812 14.09 1932 127,140 1666 13.10 1933 125,700 1499 11.91 On page 27 will be found a table showing the population, number of births and birth rate for each year since 1892—a period of 41 years. The figures below show how, during the five-year period, the birth rate in Leyton has compared with corresponding rates in the Great Towns, in London, and in England and Wales. It is evident that during each of the five years, the Leyton birth rate has remained at a substantially lower level than in the case of any of the other three comparative areas. Leyton 1929 1930 1931 1932 1933 13.49 13.69 14.09 13.10 11.91 118 County Boroughs and Great Towns 16.6 16.6 16.0 15.4 12.2 London 15.7 15.7 15.0 14.2 13.2 England and Wales 16.3 16.3 15.8 15.3 14.4 15 Of the total number of births registered (1,499) during the year, 687 (45 per cent.) occurred in institutions outside the district. The figures show to what extent expectant mothers in Leyton avail themselves of institutional accommodation for their confinements. These 687 births occurred in the following institutions:— Queen Mary's Hospital 327 Mothers' Hospital, Clapton 130 Forest Gate Hospital 67 City of London Maternity Hospital 20 Plaistow Maternity Hospital 31 East End Maternity Hospital 10 Kingswood Maternity Home 17 London Hospital 6 Royal Free Hospital 7 Jewish Maternity Hospital 4 Dowries Nursing Home 5 Walthamstow District Nursing Association 6 Other Institutions 57 687 16 Graph No. 1. Leyton Birth Rate 1913-1933. 17 TABLE 2. Registered Births, 1933. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Total. January 6 13 5 4 10 5 9 7 9 3 71 February 6 13 9 6 10 4 6 7 3 1 65 March 6 12 6 7 10 9 7 9 3 3 72 April 3 12 5 7 8 6 5 6 7 2 61 May 5 14 4 8 8 7 10 7 6 5 74 June 5 9 4 10 13 5 9 8 10 9 82 July 6 13 6 12 9 7 8 4 5 4 74 August 6 9 7 4 12 11 3 8 7 5 72 September 7 9 5 4 4 7 8 6 5 8 63 October 2 12 4 7 3 9 5 4 5 5 56 November 2 17 7 4 13 4 6 4 5 5 67 December 4 6 3 5 9 6 5 8 3 6 55 Transferables 68 119 46 74 112 67 51 47 51 52 687 Totals 126 258 111 152 221 147 132 125 119 108 1,499 18 Notification of Births.—Fourteen hundred and fifty-five notifications of births were received during the year. By medical practitioners 339 By midwives 1114 By parents and others 2 Deaths.—Fourteen hundred and sixty-eight deaths of Leyton residents were registered during the year, including those of 141 males and 145 females (transferable deaths) who died outside the area. Males. Females. Total. 724 744 1468 The death rate per 1000 of the population was thus 11.67. Death rate, Leyton 11.67 „ ,, 118 County Boroughs and Great Towns 12.2 „ „ London 12.2 „ ,, England and Wales 12.3 The figure of 1468 registered deaths represents a increase of 127 (about 9.47 per cent.) when compared with the corresponding number(1341)registered during the previous year. The following list shows the increase or decrease in the number of deaths from the various causes in 1933 as compared with 1932:— Decrease. Increase. — + Measles 27 - Scarlet Fever 1 - Whooping Cough 1 - Diphtheria - 4 Influenza - 36 Encephalitis Lethargica — 1 Cerehro - Spinal Fever - 1 Tuberculosis of Respiratory System — 12 Other Tuberculous Diseases - 4 Syphilis - 1 General paralysis of the insane tabes dorsalis 2 - Cancer, malignant disease — 21 Diabetes - 1 Cerebral hæmorrhage, etc. - 39 Heart disease - 46 Carried forward 31 166 19  Decrease. Increase. — + Brought forward 31 166 Aneurysm - 5 Other circulatory diseases - 4 Bronchitis 3 - Pneumonia (all forms) - 1 Other respiratory diseases — 9 Peptic Ulcer — 2 Diarrhoea, etc. 10 - Appendicitis - 7 Cirrhosis of Liver - 1 Other diseases of Liver, etc. 1 - Other Digestive diseases 10 - Other Puerperal causes 2 - Congenital Debility, Premature Birth, Malformations, etc. - 2 Suicide 4 - Other Violence - 4 Other defined causes 14 - Causes ill-defined or unknown - 1 75 202 = + 127. It will be seen that the chief decreases were in deaths from measles (27), diarrhoea (10), other digestive diseases (10), and other defined causes (14). On the other hand, definite increases are shown in deaths from influenza (36), tuberculosis (16), cancer (21), cerebral haemorrhage (39), and heart disease (46). Table 3, page 22, gives the official list of the principal causes of death in the different age groups. The following list shows the population, number of deaths, and the death rate per 1000 during the past five years :— The following list shows the population, number of deaths, and the death rate per 1000 during the past five years:— Year. Population. » No. of Deaths. Death Rate 1929 128,300 1510 11.76 1930 128,300 1222 9.52 1931 128,600 1365 10.61 1932 127,140 1341 10.54 1933 125,700 1468 11.67 20 Graph 2 shows the variation in the death rate in Leyton since the year 1913. The diagram shows in striking fashion the effect of the great epidemic of Influenza in 1918, and also that of the Influenza epidemic of 1929, which was responsible in great measure for the increased mortality during that year. Distribution in Wards. The distribution of deaths and the death rates in the different wards are given below:— Ward. Total Deaths. Deaths per 1,000 of Population. Leyton 127 14.1 Lea Bridge 198 9.0 Central North 115 10.4 ,, South 115 10.1 Forest 224 11.3 Leytonstone 192 14.2 Grove Green 128 12.4 Harrow Green 98 7.9 Cannhall 141 10.2 Wanstead Slip 113 13.7 Zymotic Death Rate.—The deaths which occurred during the year from the seven principal zymotic diseases were as follows:— Smallpox — Measles 1 Diphtheria 7 Whooping Cough 4 Diarrhœa 6 Scarlet Fever 4 Enteric Fever — The zymotic death rate for 1933 was 0.17 per thousand of the population compared with a rate of 0.45 for the previous year. « Senile Mortality. In the List of the Principal Causes of Death (Table 3) the deaths are classified in eight age-groups, of which the last includes all deaths occurring in persons of 65 years of age and upwards. 21 The age-group "65 and upwards" has been sub-divided in periods of five years and the following figures show the number of persons who died in each of these five-yearly sub-groups:— 65-70 175 70-75 167 75-80 158 80-85 106 85-90 83 90-95 19 95-100 3 100 1 Of the total number of deaths (1468) during the year, 712 (48 per cent.) occurred in persons of 65 years and upwards. The figures above show that quite a definite proportion of the residents of the area live to a very mature age; one death occurred of a centenarian during the year. TABLE 3. CAUSES OF DEATH AT DIFFERENT PERIODS OF LIFE IN THE BOROUGH OF LEYTON, 1933. Ages at Death in Years Wards. CAUSES OF DEATH. Male. Female. Total 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 years and upwards. In Public Institutions in the District. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Ward not known. Not belonging to District. Belonging to District. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Measles 1 ... 1 ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... Scarlet fever 3 1 4 ... ... 1 2 ... 1 ... ... ... 4 3 1 ... ... ... ... ... ... ... ... ... Whooping cough 2 2 4 2 2 ... ... ... ... ... ... 22 1 ... 1 ... ... ... 1 ... 2 ... ... ... Diphtheria 3 4 7 ... 1 4 2 ... ... ... ... 1 4 3 ... 2 ... ... 2 ... ... ... ... ... Influenza 29 36 65 1 ... ... 1 1 13 15 34 33 10 5 9 3 4 12 6 5 5 4 11 1 Encephalitis lethargica ... 3 3 ... ... 1 ... 1 1 ... ... 2 ... ... 1 1 ... ... 1 ... ... ... ... ... Cerebro-spinal fever 1 ... 1 ... ... ... ... 1 ... ... ... 4 1 ... ... ... ... 1 ... ... ... ... ... ... Tuberculosis of respiratory system 44 34 78 1 1 ... ... 21 35 18 2 111 16 5 9 5 5 11 12 5 6 10 10 ... Other tuberculous diseases 5 7 12 2 ... 2 2 2 1 2 1 22 1 1 2 1 ... 2 1 3 1 ... 1 ... 22 Syphilis 2 ... 2 ... ... ... ... ... ... 2 ... 1 ... ... ... ... 1 ... ... ... ... 1 ... ... General paralysis of the insane, tabes dorsalis 4 ... 4 ... ... ... ... ... 2 2 ... 3 1 ... ... ... 1 ... 2 ... 1 ... ... ... Cancer, malignant disease 93 107 200 ... ... ... 1 ... 13 93 93 273 54 13 32 21 18 32 24 11 14 23 10 2 Diabetes 9 11 20 ... ... ... 1 ... 4 6 9 25 8 2 4 2 3 3 1 1 2 2 ... Cerebral hæmorrhage, etc. 58 57 115 ... ... ... ... ... 2 39 74 197 55 8 16 8 12 18 18 12 5 9 7 2 Heart disease 172 190 362 ... ... ... 5 5 19 85 248 321 68 40 40 20 31 57 45 41 26 35 20 7 Aneurysm 6 5 11 ... ... ... ... ... ... 3 8 4 2 ... 3 2 ... 1 2 ... ... 3 ... ... Other circulatory diseases 14 16 30 ... ... ... ... ... ... 9 21 35 7 3 3 ... 2 7 8 1 ... 2 3 1 Bronchitis 39 41 80 2 ... ... ... ... 1 14 63 96 20 6 6 9 5 8 14 7 7 8 8 2 Pneumonia (all forms) 37 37 74 4 6 2 1 2 9 25 25 166 36 4 12 8 6 8 9 5 6 4 11 1 Other respiratory diseases 15 6 21 2 ... 1 ... ... 3 10 5 8 8 1 3 2 1 2 4 2 2 3 1 ... Peptic ulcer 9 3 12 ... ... ... ... ... 5 5 2 26 9 1 1 ... 1 4 1 ... ... 3 1 ... Diarrhoea, etc. 2 4 6 6 ... ... ... ... ... ... ... 27 1 ... 2 1 1 ... 1 1 ... ... ... ... Appendicitis 5 8 13 ... ... 2 1 1 1 6 2 19 4 2 1 2 ... 3 2 1 1 1 ... ... Cirrhosis of liver 5 1 6 ... ... ... ... ... ... 5 1 1 1 ... ... ... ... 1 1 2 ... 1 1 ... Other diseases of liver, etc. 2 4 6 ... ... ... ... ... 1 4 1 3 2 ... ... ... 2 1 1 ... ... 1 1 ... Other digestive diseases 12 18 30 1 ... 1 1 ... 4 11 12 34 10 2 5 2 2 5 6 3 3 2 ... ... Acute and chronic nephritis 20 18 38 ... ... ... 3 4 5 9 17 67 10 2 5 2 4 6 5 3 4 3 3 1 Puerperal sepsis ... 2 2 ... ... ... ... 1 1 ... ... 10 1 ... ... ... ... 1 ... ... ... ... 1 ... Other puerperal causes ... ... ... ... ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... ... ... ... ... ... Congenital debility, premature birth, malformations, etc. 27 24 51 49 1 ... l ... ... ... ... 16 1 6 6 3 3 10 6 7 2 5 3 ... Senility 11 32 43 ... ... ... ... ... ... 1 42 101 19 3 6 1 5 5 6 3 1 5 8 ... Suicide 15 6 21 ... ... ... ... 1 7 9 4 13 4 3 3 2 ... 2 4 3 2 ... 2 ... Other violence 30 13 43 ... ... 2 5 5 6 12 13 69 23 4 7 4 3 6 3 2 5 6 3 ... Other defined causes 49 53 102 5 2 ... 6 3 22 29 35 174 39 10 19 14 5 17 7 10 4 10 6 ... Causes ill-defined or unknown ... 1 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... Totals 724 744 1468 76 13 17 32 48 156 414 712 1888 420 127 198 115 115 224 192 128 98 141 113 17 23 24 Graph No. 2. Leyton Death Rate 1913-1933. 25 Graph No. 3. Comparative View of the Principal Causes of Death during the Year 1933. 26 Infant Mortality.— Seventy-six children died under one year of age, giving an infant mortality rate (number of deaths under one year of age per thousand births) of 50.70. The following figures show the number of births, infant deaths and infant mortality rate during the past five years:— Year. No. of Births. No. of Infant Deaths. Infant Mortality Rate. 1929 1,731 100 57.77 1930 1,757 81 46.09 1931 1,812 71 39.18 1932 1,666 89 53.43 1933 1,499 76 50.70 The following are the corresponding rates for other Great Towns, London, and England and Wales, during the year under review. Infant Mortality— Leyton 50.70 ,, ,, 118 County Boroughs and Great Towns, including London 67.00 ,, „ London 59.00 „ „ England and Wales 64.00 Comparative Statistics.— Table 4 is of a very comprehensive nature, and has been prepared with a view to throwing some light on Leyton's progress in the matter of vital statistics since 1892—a period of 41 years. During that period the following are the outstanding facts:— 1. The population has increased from 63,000 to 125,700. 2. The birth rate has decreased from 35.08 to 11.91 births per thousand of the population. 3. The death rate has decreased from 15.4 to 11.67 per thousand of the population. 4. The infantile mortality rate has decreased from 141 to 50.70 deaths of infants under one year per thousand births. 27 TABLE 4. Comparative Statistics of Births, Mortality, Etc. LEYTON, 1892-1933. Year. Population. Births. Birth Rate. Deaths. Death Rate. Deaths under 1 year. Infantile Death Rate. 1892 63000 2210 35.08 972 15.4 313 141 1893 64000 2316 36.18 1019 15.7 306 130 1894 70000 2224 31.7 825 11.6 258 116 1895 75000 2292 30.05 1080 14.4 346 150 1896 77000 2372 30.08 926 11.8 326 137 1897 85000 2501 29.3 1011 11.9 356 142 1898 90000 2560 28.4 1125 12.5 374 146 1899 93000 2698 29.0 1262 13.5 420 155 1900 100000 2932 29.32 1179 11.8 410 140 1901 100000 2963 29.63 1243 12.4 404 136 1902 100000 3152 31.52 1183 11.8 336 106 1903 102000 3273 32.08 1112 10.9 322 99 1904 104000 3198 30.07 1370 13.1 444 138 1905 105000 3209 30.05 1177 11.2 303 94 1906 108000 3344 30.9 1327 12.2 382 114.5 1907 120000 3190 26.6 1269 10.6 182 86.6 1908 121200 3071 25.3 1185 9.8 242 78.8 1909 121200 2979 24.6 1208 9.9 244 81.9 1910 123300 3011 24.4 1112 9.0 191 63.4 1911 124736 2931 23.5 1473 11.8 327 116.6 1912 126700 2797 22.1 1343 10.6 223 79.7 1913 129366 2904 22.4 1336 10.3 242 83.3 1914 130847 2800 21.4 1363 10.4 219 78.2 1915 124497 2655 21.3 1510 12.1 225 84.7 1916 B132107* 2560 19.4 D121420* 1471 12.1 197 76.9 1917 B125352* 2005 16.0 Dl12452* 1414 12.6 172 85.8 1918 B125352* 1791 14.3 Dl12452* 1723 15.3 161 89.9 1919 B129062* 2195 17.0 D123896* 1397 11.3 154 70.16 1920 128832 3168 24.6 1330 10.3 207 65.34 1921 128432 2679 20.86 1290 10.04 182 67.94 1922 131600 2416 18.36 1420 10.79 155 64.16 1923 132800 2328 17.53 1228 9.25 106 45.53 1924 133500 2101 15.74 1325 9.92 110 52.36 1925 132700 2091 15.76 1349 10.16 114 54.51 1926 130000 2022 15.55 1261 9.7 131 64.79 1927 128920 1826 14.16 1322 10.25 80 43.81 1928 130300 1853 14.22 1290 9.90 91 49.10 1929 128300 1731 13.49 1510 11.76 100 57.77 1930 128300 1757 13.69 1222 9.52 81 46.09 1931 128600 1812 14.09 1365 10.61 71 39.18 1932 127140 1666 13.10 1341 10.54 89 53.43 1933 125700 1499 11.91 1468 11.67 76 50.70 * Population as estimated for purposes of B, Birth Rate, D, Death Rate. 28 TABLE 5. Vital Statistics of Whole District during 1933 and Previous Years. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the Borough. Transferable Deaths Nett Deaths beloncing to the Borough. Uncorrected Number. Nett. of Nonresidents registered in the Borough. of Residents not registered in the Borough. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate per 1000 Nett Births. Number. Rate. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1927 128920 1377 1826 14.16 2824 21.8 1727 225 80 43.81 1322 10.25 1928 130300 1341 1853 14.22 2764 21.2 1714 240 91 49.10 1290 9.90 1929 128300 1233 1731 13.49 3008 23.4 1751 253 100 57.77 1510 11.76 1930 128300 1199 1757 13.60 2692 20.9 1688 218 81 46.09 1222 9.52 1931 128600 1264 1812 14.09 2872 22.3 1770 263 71 39.18 1365 10.61 1932 127140 1029 1666 13.10 2913 22.7 1808 236 89 53.42 1341 10.51 1933 125,700 812 1499 11.91 3070 24.4 1888 286 76 50.70 1458 11.67 Rates in columns 5, 7 and 13 calculated per 1000 of estimated gross population. 29 TABLE 6. Birth-rate, Death-rate and Analysis of Mortality During the Year 1933. (Provisional figures. The rates have been calculated on a population estimated to the middle of 1933. The mortality rales refer to the whole population as regards England and Wales, but only to civilians as regards London and the group of towns.) Birthrate per 1,000 Total Population . Annual Death-rate per 1,000 Population. Rate per 1,000 Births. Percentage or Total Deaths. All Causes. Enteric Fever. Smallpox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. | Violence. Diarrhoea and Enteritis (under 2 Years). Total Deaths under 1 Year. Certified by Registered Medical Practitioners. Inquest Cases. Certified by Coroner after P.M. No Inquest. Uncertified Causes of Death. Live Births. Still Births. England and Wales 14.4 0.62 12.3 0.01 0.00 0.05 0.02 0.05 0.06 0.57 0.54 7.1 64 90.9 6.3 1.9 0.9 118 County Boroughs and Great Towns, including London 14.4 0.67 12.2 0.00 0.00 0.06 0.02 0.06 0.08 0.55 0.49 9.4 67 91.0 6.0 2.5 0.5 132 Smaller Towns. Estimated Resident Populations 25,000 to 50,000 at Census, 1931 14.5 0.63 11.0 0.00 0 00 0.04 0.02 0.04 0.04 0.53 0.44 4.9 56 91.7 5.8 1.5 1.0 London 13.2 0.45 12.2 0.00 0.00 0.02 0.02 0.08 0.08 0.51 0.58 11.6 59 88,3 6.3 5.4 0.0 LEYTON 11.91 0.38 11.67 0.00 0.00 0.01 0.03 0.03 0.05 0.51 0.51 4.00 5.0 92.44 4.35 3.20 0.00 30 Inquests. The following verdicts on Leyton residents were recorded at Inquests held during the year:— Natural Causes— Diseases of heart 2 Septicaemia arising from left tonsil 1 Toxæmia following acute appendicitis 1 Pernicious anæmia 1 Acute encephalitis 1 Chronic nephritis 1 Accidental— Knocked down by a motor car 5 Knocked down by a motor van 1 Knocked down by a motor cycle I Knocked down by a motor lorry 2 Knocked down by a motor bus 1 Knocked down by a pedal cycle 1 Knocked down by a railway engine 1 Collision between motor cycle and motor lorry 1 Collision between motor cycle and tramcar 1 Collision between motor cycle and motor coach 1 Fall from pedal cycle 1 Fall from crane 1 Fall from ladder 2 Fall down hatchway 1 Electrocution whilst working at switchboard 1 Injuries caused through falling astride a fence 1 Injuries caused by being struck by handle of winch 1 Drowning 1 Streptococcal septicaemia following abrasion of leg 1 Streptococcal septicaemia following abrasion of heel 1 Streptococcal septicaemia following wound of hand 1 Burns and scalds 3 Influenzal broncho-pneumonia following ether for operation 1 Confluent broncho-pneumonia following chloroform for operation 1 Shock from immersion whilst bathing 1 Multiple injuries—found on railway 1 Multiple injuries received from motor cars overturning 1 Fractures and falls 14 31 Suicides— Coal gas poisoning 5 Lysol poisoning 5 Spirits of salts poisoning 1 Prussic acid poisoning 1 Drowning 2 Cut throat 4 Hanging 1 Jumping in front of railway engine 2 Public Mortuary. In any large centre of population a public mortuary is necessary to accommodate dead bodies removed there either (a) Compulsorily, on the instructions of the coroner, police, Justices or Medical Officer of Health, e.g., in cases of sudden death, accident, homicide, suicide, dangerous infectious disease ; or (b) Voluntarily, in cases where accommodation does not exist at home for keeping dead bodies awaiting burial. In the relatively overcrowded state of many premises and in view of the modern tendency towards flats and tenements as dwelling houses, it should be realised that conditions are not always suitable or convenient for the retention in the home of a dead body awaiting burial. In March, 1931, the Medical Officer of Health drew the Authority's attention to the existing arrangements for the reception of dead bodies before interment; the following being an extract from the report submitted:— Section 141 of the Public Health Act, 1875, states that— "Any Local Authority may, or if required by the Local Government Board must, provide a mortuary, and may make bye-laws as to its management and the charges for its use." In April, 1927, authority was given by this Council for the use as a temporary mortuary of a disused coach-house at the Council's Sewage Disposal and Destructor Works. The approach to and situation of the premises are unfortunate, and the arrangements for the viewing of bodies by recently-bereaved relatives are objectionable. The mortuary fittings and equipment are of a crude and makeshift nature ; there is no separate room where post-mortem examinations can be conducted with convenience, decency and cleanliness ; and altogether the arrangements are not such as to convey the impression of due respect for the dead. 32 Although it may have been deemed expedient in 1927 to allocate these premises as an emergency measure for the purpose of serving as a temporary mortuary, I suggest that the time has now arrived when the Council should consider the acquisition of a more permanent public mortuary in keeping with modern requirements and the needs of the Borough. The Borough Surveyor, in consultation with the Medical Officer of Health, was thereupon instructed to prepare plans and estimates for the erection of a public mortuary and post-mortem room. The site chosen by the Local Authority was one on the Council's Depot at Ive Farm, Church Road, and the building was completed in May, 1933, since when it has been in use. Hereunder is a sketch plan of the new mortuary and postmortem room. From the photographs shown in the following page some idea may be gained of the improvement in the facilities available in the new as compared with the old premises. Number of bodies deposited 54 Post mortems performed 45 Inquests 10 33 Old Mortuary, Destructor Works, Auckland Road, Leyton. CO Ol New Mortuary, Church Road, Leyton. 37 LEGISLATION IN FORCE. Special Acts. Leyton Urban District Council Act, 1898. Leyton Urban District Council Act, 1904. Adoptive Acts. Date of Adoption. Date came into Force. Infectious Diseases (Notification) Act, 1889 ... ... ... 31-12-89 10-2-90 Infectious Diseases (Prevention) Act, 1890 7-4-91 1-6-91 Public Health Acts Amendment Act, 1890 7-4-91 1-6-91 Libraries Act, 1885-1890... 23-11-91 23-11-91 Private Street Works Act, 1892 ... 20-12-92 1-2-93 Baths and Washhouses Act, 1896 7-12-97 7-12-97 Public Health Acts Amendment Act, 1907, Sections 85 and 86 and Part 8 ... 27-10-08 17-11-08 Public Health Acts Amendment Act, 1907, whole of Part 5 and certain sections in Parts 2, 3, 4 and 10 29-9-08 16-8-09 Public Health Act, 1925, Parts 2-5 inclusive (certain sections) ... 15-12-25 1-2-26 Essex County Council Act, 1933 (Registration of Ice Cream Manufacturers, &c.) 26-9-33 6-12-33 Bye-laws, Regulations, etc. Animals.—-For the prevention of keeping on any premises so as to be injurious to health. Common Lodging Houses. Dairies, Cowsheds and Milkshops. Good Rule and Government of the Borough. House Refuse.—As to removal of. New Streets and Buildings. Nuisances arising from snow, filth, dust, ashes and rubbish. Nursing Homes Registration Act, 1927. Offensive and Noxious Matters.—As to'nuisances in connection with removal of. 38 Offensive Trades.— For the regulation of. Public Baths.— For the management, use and regulation of. Sanitary Conveniences.— As to decent conduct of persons using. Slaughter Houses. Smoke Abatement. Tanks, Cisterns and other Receptacles used for storing water. Closing Orders for Butchers. Chemists. Hairdressers and Barbers. Bakers. Grocers, Provision Dealers, Oilmen, etc. NURSING ARRANGEMENTS, CLINICS, HOSPITALS AND OTHER INSTITUTIONS AVAILABLE IN THE BOROUGH. A. Midwives.— No practising midwives are employed or subsidised by the Local Authority. There are some nineteen midwives residing in the district, including seven attached to the Essex County Nursing Association, in Beachcroft Road, Leytonstone. In addition to these, nine midwives from adjoining areas practise in the Borough. B. Clinics and Treatment Centres.— Maternity and Child Welfare Centres— Provided by the Borough Council. Ante-Natal Clinics— (1) The County Nurses' Association Home, Beachcroft Road, Leytonstone.—Thursdays, 10 a.m. (2) Health Clinic, Leyton Green Road.—Wednesdays and Fridays, 10 a.m. Infant Welfare Clinics— (1) The "People's Hall," Harrow Green, Leytonstone.— Tuesdays, 10 a.m. and 1.45 p.m. (2) Health Clinic, Leyton Green Road.—Wednesdays and Thursdays, 1.45 p.m. (3) Christ Church Institute, Francis Road, Leyton.— Mondays and Fridays, 1.45 p.m. C. Day Nurseries.— Nil. 39 D. School Clinics. (1) Town Hall, Leyton.— Medical Inspection and treatment of minor ailments. (2) Health Clinic, Leyton Green Road.— Medical Inspection and treatment of minor ailments. (3) Town Hall, Leyton.—Dental treatment. (4) Health Clinic, Leyton Green Road.—Dental treatment. (5) Health Clinic, Leyton Green Road.—Ophthalmic treatment. (6) Knotts Green Special School.—A special Orthopaedic Clinic is held at Knotts Green Special School once a month. Provision is made by the Local Authority for the examination and treatment by the Council's Orthopædic Surgeon of children recommended by the School Medical Officers and the Medical Officers at the Infant Welfare Centres. (7) Knotts Green Special School.—Artificial Light Clinic. Available for school children on two days a week, and for children under school age on Saturday mornings. E. Hospitals provided or subsidised by the Local Authority. (1) Fever.—Borough Isolation Hospital. (2) Smallpox.—Agreement with the Walthamstow Corporation for the treatment of cases of smallpox arising in the Borough. (3) Tuberculosis.—The County Council is the Authority responsible for the institutional treatment of Tuberculosis. (4) Ophthalmia Neonatorum.—Agreement with the London County Council for the institutional treatment of cases of Ophthalmia Neonatorum. (5) Enteric Fever.— Agreement with the Connaught Hospital, Walthamstow, for the reservation of two beds for cases of Enteric Fever. F. Maternity.— Agreement with the Queen Mary's Hospital, West Ham, for women to be received into the Margaret Lyle Wards for their confinements. 40 G. Children.— No Hospital provided or subsidised. H. Orthopædic.— Arrangements with Brookfields Orthopaedic Hospital, Hale End, for the admission of children requiring orthopaedic treatment. I. Other.— The Whipps Cross Hospital is within the Borough area, and has accommodation for 760 patients. In addition, Leyton is well served by many hospitals in the surrounding neighbourhood, viz., Walthamstow, Hackney and West Ham. J. Institutional Provision for Unmarried Mothers, Illegitimate Infants and Homeless Children.— No provision. K. Ambulance Facilities. (a) Infectious Cases.—An Austin Ambulance is provided for the conveyance of infectious cases to the Isolation Hospital. (b) Non-Infectious and Accident Cases.—A Motor Ambulance for non-infectious cases is supplied by the Red Cross Society and is under the control of the Superintendent of the Fire Brigade. INFECTIOUS DISEASES* Smallpox. Since the year 1929 smallpox of mild type has been endemic in London, especially in East London and neighbouring areas. The disease slowly succeeded in establishing itself notwithstanding preventive measures which had been found successful in dealing with the more virulent type of the disease to which we in this country had become accustomed previously. After the mild type had become well established, its extinction by the usual preventive measures became more and more difficult. The figures for previous epidemics of similar mild type in the Northern Counties suggested that the numbers tended to increase up to a maximum in the fourth or fifth year, after which they declined. The extent of the infection in Leyton is shown by the number of cases notified during the last six years:— 1928 7 cases 1929 9 „ 1930 138 „ 1931 27 „ 1932 14 „ 1933 2 „ 41 It is evident that the epidemic in Leyton reached the "peak" of incidence during 1930, since when the decline has been very marked. Notifications.— During the year 1933, the number of patients notified as suffering from smallpox was 2—of whom 1 was notified by a local medical practitioner and 1 by your Medical Officer of Health as the result of investigations made by him. Both patients were sent to hospital. Case No. 1. Male 60 years. Vacc. in infancy. Central North Ward. Case No. 2. Male 6 years. Not vaccinated. Grove Green Ward. Institutional Treatment.—In 1932 the Leyton Corporation entered into a three years' agreement with Walthamstow Corporation whereby the latter reserve six beds at their Smallpox Hospital for the reception and treatment of Leyton patients suffering from smallpox. Details of the terms of that agreement were shown in my Annual Report for 1932. Chicken Pox. In view of the possible confusion of the two conditions, and in order to aid in the discovery of missed or undetected cases of smallpox, the Council—on the advice of the Medical Officer of Health— passed a resolution in January, 1930, making chicken-pox compulsorily notifiable under the provisions of the Infectious Disease (Notification) Act, 1889. The order was a temporary one for a period of six months in the first place, but it has been renewed and been in force since that time. During 1933 notifications were received from medical practitioners in respect of 621 persons considered to be suffering from chicken-pox. In order to verify that these were not mild cases of smallpox, or cases of that disease modified as a result of vaccination, the patients were visited and examined in their homes by members of the medical staff. In 36 instances visits by school nurses were sufficient to obtain the necessary information, while in many cases home visiting was not considered to be necessary, as the information on the notification form regarding recent successful vaccination and the occurrence of previous verified cases in the same house was sufficient to exclude the possibility of smallpox. 42 The following figures show the extent of the home visiting of notified cases of chicken-pox by members of the staff during 1933. Number of patients visited by Medical Officer of Health 434 ,, ,, ,, Assistant Medical Officers 32 ,, „ not visited (Contact cases, etc.) 155 621 Of the 621 persons notified to be suffering from chicken-pox, the Medical Officer of Health, as a result of his visits to the homes, diagnosed definite smallpox in one case (i.e., 0.16 per cent.). Number of cases occurring in private houses 523 „ „ „ Leytonstone Childrens' Home 78 ,, ,, ,, Hutchinson House 20 621 With regard to the value of the notification of chicken-pox in the detection of smallpox it is of interest to record the findings of the past four years, viz.:— Year. No. of C.P. notifications received. No. found to be suffering from smallpox. 1930 514 8 (1.55 per cent.) 1931 1,387 3 (0.21 per cent.) 1932 728 4 (0.54 per cent.) 1933 621 1 (0.16 per cent.) Enteric Fever. Four persons were notified to be suffering from Enteric Fever during 1933. No. Month. Sex. Age. Address. Nature of Infctn. 1. June. Male 11 High Road, E.ll. Paratyphoid B. 2. July Male 7 Manby Road. — 3. August Female 49 Shortlands Road. Typhoid. 4. December Male 4 Clementina Road. Paratyphoid B. Cases 2 and 4 were nursed at home. Case 1 was treated in Connaught Hospital, Walthamstow. Case 3 was treated in Whipps Cross Hospital. 43 The result of the bacteriological examinations showed the causative organism to be Bacillus Paratyphosus B. in 2 cases and Bacillus Typhosus in one case. In case No. 2 (treated at home) the parents declined to have blood samples taken for bacteriological examination. Scarlet Fever. These figures show that the incidence of Scarlet Fever was extremely high during 1933, as many as 743 cases having been notified. On consulting the records it is found that the number of cases (743) notified in 1933 is the greatest in any year since 1921, when 1,320 cases were notified. It is of interest to compare the scarlet fever figures for the last five years with those of the fiveyear period commencing in 1892, the first year for which complete comparative records are available. As the Council's present Temporary Isolation Hospital was opened for the reception of scarlet fever patients (43) in the year 1896, a comparison of these two five-year periods should provide material from which some inferences may be drawn with regard to the efficacy of hospital isolation and treatment. Year. Cases Notified. Deaths. Case Fatality per cent. 1929 489 1 0.20 1930 461 2 0.43 1931 297 2 0.67 1932 360 5 1.38 1933 743 4 0.54 Totals 2,350 13 0.55 1892 646 19 2.94 1893 541 24 4.3 1894 486 11 2.2 1895 507 12 2.3 1896 501 6 1.1 Totals 2,681 72 2.68 In my Annual Report for the year 1930 I pointed out that "Although neither hospital isolation nor any other form of public control has been successful in effecting any marked reduction in the incidence of this disease (scarlet fever), there is no doubt that a marked and progressive decline in the mortality from scarlet fever has been going on over a fairly long period." 44 When comparison is made between the total figures of these two five-year periods, it is seen that the reduction in the total number of cases notified is from 2,681 to 2,350 (i.e., 12 per cent.); whereas the corresponding reduction in the number of deaths is from 72 to 13 (i.e., 82 per cent.). Scarlet Fever During 1933. lst Epidemic Period (May-July). During the week ended 20th May there occurred a sudden increase in the number of scarlet fever cases in the area; and from that time until 29th July (a period of 11 weeks) scarlet fever assumed epidemic form in part of the Borough. Over the period of eleven weeks some 178 persons were notified to be suffering from scarlet fever. Of that number 42 (23 per cent.) were children between one and five years of age; 123 (69 per cent.) were between five and fifteen years; while only 13 (7 per cent.) cases occurred at other ages. As will be seen from these figures, the outbreak occurred chiefly among children of school age; and the schools chiefly affected were Norlington, Kirkdale, Newport and Connaught. (In that order of incidence.) The outbreak lasted just over two months, and abated as suddenly as it began. During the week ended 5th August there was a marked fall in the incidence of cases, and from then until the end of August the weekly number of notified cases was not abnormal. 2nd Epidemic Period (September-November). During the week ended 2nd September there recurred a sudden increase in the incidence of scarlet fever in the Borough and in London generally. During the following 13 weeks as many as 289 persons in the area were notified as suffering from scarlet fever. In this outbreak there was nothing to suggest any particular means of spread of infection, e.g., milk, etc., nor was the outbreak confined to any particular schools or wards in the Borough. As regards the severity of the disease, the preponderating majority of the cases were of the mild type to which we have been accustomed during recent years. Institutional Treatment. As is usual in sudden outbreaks of infectious disease, the normal accommodation for scarlet fever patients in the Isolation Hospital was insufficient to meet requirements. However, by 45 devoting to scarlet fever all the hospital wards except one (reserved for diphtheria), by increasing the number of beds in each ward beyond the standard accommodation, and by the judicious selection of cases prior to admission—it was found possible to treat in hospital 286 (61.24 per cent.) of the cases notified during these two epidemic periods. As the result of initial visits and enquiries it was considered that the remaining 181 (38.76 per cent.) notified persons could be adequately nursed and isolated at home. The following figures show the comparative numbers and percentages of cases treated in hospital and at home during the epidemic and non-epidemic periods of 1933. Total Notified. Treated in Hospital. Treated at Home. During the year 743 468 275 During epidemic periods 467 286 181 (percentage) 100% 61.24% 38.76% During non - epidemic periods 276 182 94 (percentage) 100% 65.94% 34.06% With a view to modifying the Regulations of the Local Education Authority for the exclusion of children from school on account of scarlet fever in such manner as to interfere as little as possible with school attendance while safeguarding against the conveyance of infection in accordance with modern ideas regarding epidemiology the Medical Officer of Health and School Medical Officer submitted to the appropriate Committees in December, 1933, a special report on the subject of home treatment and school exclusion. An extract from that report will be found on page 186 in the section of the Report dealing with School Medical Service. Diphtheria. The following table gives particulars regarding the incidence and fatality rates of diphtheria during the past five years:— 1929 1930 1931 1932 1933 Cases Notified 242 313 231 155 94 Deaths 13 12 6 3 7 Case fatality per cent. 5.37 3.85 2.6 1.93 7.44 Death rate per 1000 0.101 0.093 0.046 0.023 0.055 Attack rate per 1000 1.88 2.43 1.77 1.21 0.73 From these figures it is evident that the incidence of diphtheria (i.e., cases notified) was exceptionally low during 1933; in fact, the 46 number of cases notified (94) during the year is the lowest ever recorded in the area. It will be seen, however, that the case fatality rate (i.e., number of deaths per 100 cases notified) increased from 1.93 in 1932 to 7 per cent. in 1933. This agrees with reports from other parts of the country to the effect that during 1933 there occurred a marked increase in the severity of the prevalent type of the disease. In my Annual Report for 1932 I stated that the abnormally low case fatality rate recorded in that year afforded no grounds for complacency, as the wave of diphtheria infection is liable to fluctuate markedly from year to year. The following list shows particulars regarding the seven deaths due to diphtheria during the year:— Date of Death. Sex and Age. Cause of Death. Where Death Occurred. 21-1-33 Male 4 years Diphtheria. Eastern Hospital. 23-1-33 Female 2 years Diphtheria. Plaistow Fever Hospital. 30-1-33 Male 15 months Laryngeal diphtheria. Whipps Cross Hospital. 12-6-33 Female 5 years Hæmorrhagic diphtheria Isolation Hospital. 23-9-33 Female 11 years Diphtheria. Isolation Hospital. 6-11-33 Male 4 years Diphtheria. Isolation Hospital. 22-11-33 Female 4 years Diphtheria. Isolation Hospital. Bacteriological Diagnosis.— The arrangements made by the County Council of Essex with the Counties' Public Health Laboratories, 91, Queen Victoria Street, E.C. 4, for the examination of specimens sent by any Authority throughout the County, is being continued. The following specimens were sent:— Diphtheria swabs 1428 Ringworm 7 Sputum 757 Widal's test (Enteric Fever) 15 Miscellaneous 21 INFLUENZA. In Europe during the past half century influenza has played a part somewhat comparable to that played by plague in the seventeenth century. In fact, there is much resemblance between the type of the Great Plague of 1665 and the more recent influenza plague of 1918-19, which caused actually more—and possibly porportionally more—deaths than the great plague of the seventeenth century. An epidemic of influenza started suddenly in the north (Glasgow) during the first week of December ; the maximum was reached shortly after Christmas and the decline was rapid. In England 47 the wave of infection spread rapidly from north to south, but differed from previous epidemics in that certain tracts of country escaped infection almost entirely. In Greater London no indication of unusual incidence was observed until the week ended 31st December, 1932. Type.— The influenza was of the two familiar types, alimentary and respiratory. Although the infection was generally of a much milder type than in the pandemic of 1918-19 and the widespread epidemic of 1929, it has taken a heavy toll of lives throughout the country. An interesting feature of the 1933 epidemic was the comparatively low fatality from associated pneumonia when compared with previous widespread epidemics; and the fact that recoveries were recorded in a few toxic pneumonia cases— a type which had been invariably fatal previously. Incidence.— Influenza is not one of the diseases which are notifiable to the Medical Officer of Health under the Infectious Diseases (Notification) Act. The only statistical criterion of the extent and severity of the outbreak is, therefore, the weekly list of deaths attributed to influenza. Even that list does not show the full extent of the damage, because the chief danger in influenza lies in the complications to which it gives rise, and it is generally the complications (and not the initial attacks of influenza) which figure in the death returns. Eor these reasons the extent of the damage caused by an influenza epidemic is reflected in the mortality from respiratory and circulatory diseases. Leyton Figures.— The following table shows the number of deaths in Leyton attributable to influenza, respiratory and circulatory diseases during the period under review, the totals being compared with those of the same period of the preceding year. Influenza. Pneumonia and Bronchitis. Heart and Circulatory Diseases with Respiratory Complications. Month. All ages. 65 years and upwards. All ages. 65 years and upwards. All ages. 65 years and upwards. January 39 18 39 24 23 16 February 17 10 34 22 15 11 March 3 2 13 7 8 5 Total for 3 months 59 30 86 53 46 32 Corresponding period 1932 22 14 73 48 27 19 48 TABLE No. 7. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1933. DISEASE. At All Ages. Number of Cases Notified. At Ages — Yeaks. Total Cases Notified in each Locality — Wards. Total cases removed to Hospital. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. 1 2 3 4 5 6 7 8 9 10 Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Smallpox 2 ... ... 1 ... ... 1 ... ... ... 1 ... ... ... 1 ... ... ... 2 Diphtheria 94 1 ... 29 49 7 8 ... 3 23 14 10 13 8 6 8 2 7 83 Erysipelas 71 1 2 2 3 20 27 16 1 11 3 4 16 8 5 12 6 5 29 Scarlet Fever 743 1 166 508 29 35 4 ... 22 102 96 79 96 88 73 71 68 48 408 Chicken Pox 621 21 172 396 23 6 2 1 24 87 35 25 66 132 22 71 68 91 77 Pulmonary T.B. 117 ... ... 2 42 49 23 l 11 13 9 10 16 18 7 8 10 15 ... T.B., other forms 37 1 6 10 7 7 6 ... 3 7 3 2 5 2 5 5 4 1 ... Pneumonia 106 3 6 14 18 24 27 14 12 15 13 8 18 10 9 15 1 5 44 Ophthalmia Neonatorum 7 7 ... ... ... ... ... ... 1 2 ... 1 1 1 1 ... ... ... 2 Enteric Fever 4 ... 1 2 ... ... 1 ... ... 2 ... ... ... 1 ... ... ... 1 2 Puerperal Fever 2 ... ... ... ... 2 ... ... ... ... ... ... ... 2 ... ... ... ... 2 „ Pyrexia 9 ... ... ... 2 7 ... ... 1 4 1 1 1 ... ... ... ... 1 5 Cerebro Spinal Meningitis 2 ... ... ... 2 ... ... ... ... ... ... ... 1 ... ... ... 1 ... 2 Poliomyelitis 2 ... 1 1 ... ... ... ... ... ... ... ... 1 ... 1 ... ... ... 2 Enc. Lethargica 1 ... 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 Pemphigus Neonatorum 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... Totals 1819 36 355 965 175 157 99 32 78 266 176 140 234 270 130 190 160 175 719 49 TERMINAL DISINFECTION. Prior to January, 1930, this Council, in common with most Sanitary Authorities throughout the country, carried out the routine, traditional, elaborate and expensive programme of municipal disinfection after the removal to hospital or recovery at home of persons suffering from infectious disease. On the assumption that the infectious person left behind him germs capable of infecting others, such routine municipal disinfection included (a) the removal of infected clothing, bedding, etc., for special treatment in the Council's steam disinfector ; (b) the spraying of infected premises with liquid disinfectant. Since January, 1930, this Authority has discontinued the routine steam disinfection of bedding and clothing from households infected by the commoner infectious diseases such as scarlet fever, diphtheria, etc. Four full years have now elapsed since routine steam disinfection was discontinued, and it is of interest to compare the results of the last four years with those of the four years immediately preceding. In the following table four years (1926-29), during which steam disinfection had been carried out, can be compared with four years (1930-1933) during which it had been abandoned. 50 STEAM DISINFECTION PRACTISED. 1926 Cases Notified. Cases Removed 198 Day on which Subsequent Case Occurred. Total after Seventh Day. Scarlet Fever 297 0-7 8-14 15-21 22-34 35-42 16 9 6 3 1 19 Cases per 100 8.08 4.54 3.03 1.51 0.5 9.59% Diphtheria 289 Cases Removed 234 20 8 3 1 - 12 Cases per 100 8.54 3.42 1.28 0.42 - 5.12% 1927 Scarlet Fever 475 Cases Removed 276 7 10 3 5 0 18 Cases per 100 2.53 3.62 1.08 1.81 0 6.51% Diphtheria 370 Cases Removed 298 22 7 2 4 4 17 Cases per 100 7.38 2.34 0.67 1.34 1.34 5.70% 1928 Scarlet Fever 585 Cases Removed 369 24 9 2 4 1 16 Cases per 100 6.50 2.43 .54 1.08 .27 4.33% Diphtheria 346 Cases Removed 291 18 5 3 3 I 12 Cases per 100 6.18 1.71 1.03 1.03 .34 4.12% 1929 Scarlet Fever 489 Cases Removed 317 8 12 5 4 0 21 Cases per 100 2.52 3.78 1.57 1.26 — 6.62% Diphtheria 242 Cases Removed 203 7 5 3 1 0 9 Cases per 100 3.44 2.46 1.47 .49 — 4.43% 51 STEAM DISINFECTION ABANDONED. Cases Notified. Cases Removed 307 Day on which Subsequent Case Occurred. Total after Seventh Day. 1930 Scarlet Fever 461 0-7 8-14 15-21 22-34 35-42 20 3 4 0 2 9 Cases per 100 6.51 .97 1.30 — .65 2.93% Diphtheria 313 Cases Removed 240 10 8 2 1 1 12 Cases per 100 4.16 3.33 .83 .41 .41 5.0% 1931 Scarlet Fever 297 Cases Removed 231 8 2 0 3 0 5 Cases per 100 3.46 .86 0 1.30 0 2.16% Diphtheria 231 Cases Removed 207 7 2 3 1 1 7 Cases per 100 3.38 .96 1.44 .48 .48 3.38% 1932 Scarlet Fever 360 Cases Removed 266 14 8 2 2 12 Cases per 100 5.26 3.0 — 0.75 0.75 4.51% Diphtheria 155 Cases Removed 142 6 - 1 1 - 2 Cases per 100 4.22 — 0.70 0.70 — 1.40% 1933 Scarlet Fever 743 Cases Removed 468 30 18 7 8 2 35 Cases per 100 6.41 3.84 1.5 1.7 0.42 7.47% Diphtheria 94 Cases Removed 87 - - - - - Nil Cases per 100 - - - - - Nil 52 The table shows at a glance the total number and also the percentage of secondary cases occurring in premises from which the original cases had been removed previously. By way of explanation, it should be pointed out that, in the final comparison, secondary cases occurring within a week of the primary case have been excluded, the reason being that such cases occurring within the known incubation stage of the two diseases may have been infected by the primary case before removal to hospital. Although of interest from the epidemiological point of view, much of the detail in the above table may be omitted in assessing the general results from a practical standpoint. The following table gives these results in summary form for purposes of comparison. Period. Steam Disinfection. Disease. Cases Notified. Cases Removed. Secondary Cases After 7th Day. Percentage of Secondary Cases. S.F. 1,746 1,160 74 6.38 1926/7/8/9 Practised. Diph. 1,247 1,026 50 4.87 Total 2,993 2,186 124 5.67 S.F. 1,861 1,272 61 4.79 1930/1/2/3 Abandoned. Diph. 793 676 21 3.1 Total 2,654 1,948 82 4.20 It will be seen that, in the case of scarlet fever, the percentage of secondary cases has dropped from 6.38 per cent, to 4.79 per cent, whereas the relative figure for diphtheria has fallen from 4.87 per cent, to 3.1 per cent, during the two periods under review. When comparison is made between the total figures (including both scarlet fever and diphtheria) it will be seen that the percentage of secondary cases had diminished from 5.67 (with steam disinfection) to 4.20 (without steam disinfection). 53 TUBERCULOSIS. Notifications.— One hundred and fifty-four patients were notified for the first time in 1933 as suffering from tuberculosis. The number was made up as follows:— Males. Females. Total. Pulmonary Tuberculosis 59 58 117 Non-Pulmonary Tuberculosis 15 22 37 74 80 154 During the year steps were taken, in conjunction with the local Tuberculosis Officer and the Tuberculosis Consultant, Essex County Council, to review as many as possible of the persons notified to be suffering from Tuberculosis in the area. As a result it was found possible to remove from the tuberculosis register the names of 8 children and 73 adults in whom evidence of active disease had ceased to exist. The following is a statement of particulars appearing in the Register of Notifications of Cases of Tuberculosis for the year ended 31st December, 1933:— Pulmonary. Non-Pulmonary. total M. F. Total. M. F. Total. Number on Register at commencement of year 5C5 403 908 160 130 290 1198 Number first notified during the year 59 58 117 15 22 37 154 Number of cases entered in Register otherwise than by Notification 16 16 32 4 3 7 39 Number removed from the Register during the year 157 137 294 47 30 77 371 Number remaining at the end of the year 423 340 763 132 125 257 1020 Details of cases removed from the Register during the year:— Died 50 43 93 10 6 16 109 Removed from the district 72 72 144 22 15 37 181 De-notified 35 22 57 15 9 24 81 54 Deaths.— Ninety deaths from tuberculosis were recorded:— Males. Females. Total. Pulmonary Tuberculosis 44 34 78 Non-Pulmonary Tuberculosis 5 7 12 90 This is equivalent to a death rate of 0.71 per thousand of the population, as compared with a figure of 0.58 for the previous year . The following table gives particulars regarding the new cases and deaths which have occurred during the year:— Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 0 - - - 1 1 - - 2 1 — — 4 2 1 — 1 1 5 — — 4 4 — — — 1 10 — 2 — 1 — — — 1 15 4 5 1 3 1 6 1 — 20 18 15 1 3 8 6 — 1 25 15 23 2 4 16 11 — 1 35 7 4 1 — 5 3 — — 45 11 7 1 2 6 5 1 — 55 3 2 1 2 5 2 1 — 65 and 1 — — — 1 1 1 — upwards. Totals 59 58 15 22 44 34 5 7 Dispensary.— A tuberculosis dispensary is provided by the Essex County Council at 180, High Road, Leyton. Six sessions per week are held, viz.:— Monday (2—4 p.m.), Children only. ,, (6—8 p.m.), Adults (working). Tuesday (10—12 a.m.), Women. Thursday (10—12 a.m.)., Adults. „ (2—4 p.m.), Men. Friday (2—4 p.m.), Contacts. 55 During the year close co-operation has existed between the Tuberculosis Officer appointed by the Essex County Council (Dr. T. L. Ormerod) and the Medical Officer of Health. Institutional Treatment. During 1933 the following number of Leyton patients were sent to sanatoria or other institutions for the treatment of Tuberculosis:— Pulmonary. Non-Pulmonary. Males. Females. Males. Females. Total. Adults 36 33 5 5 79 Children 1 — 6 3 10 CANCER. There were 200 deaths during the year, giving a death rate of 1.59 per thousand of the population. The various organs affected in their order of frequency may be gauged from the following list of deaths from cancer occurring during the year under review:— Males. Females. Stomach 13 20 Oesophagus 6 1 Liver 7 7 Gall Bladder — 1 Rectum 11 11 Intestines 12 16 Uterus — 18 Ovary — 6 Breast — 15 Tongue 3 — Pancreas 4 2 Bladder 8 3 Prostate 4 — Larynx 2 — Lung 5 — Mediastinum 1 —. Glands 2 1 Lip 1 — Other Sites 14 6 93 107 50 Diabetes— Supply of Insulin. In December, 1929, application was made to the Ministry of Health to sanction (under Section 133 of the Public Health Act) the provision by the Leyton Borough Council for a period of six months of a temporary supply of Insulin for patients suffering from diabetes among the poorer inhabitants of the Borough. The Insulin is issued by the Medical Officer of Health, and is supplied only to the Medical Practitioner undertaking the treatment of the patient. The Minister is furnished with a quarterly report by the Medical Officer of Health giving an abstract of the reports forwarded by the medical practitioners, the cost of the Insulin supplied by the Borough Council and any general remarks as to the working of the arrangements. At the expiration of the sanctioned period of six months, the sanction of the Ministry has been renewed for further periods. During the year three patients were supplied with Insulin at a cost to the Council of £41 17s. ISOLATION HOSPITAL Statistical Returns 1933. Admissions:— At all ages. Under 1 year. 1 year to 5 years. 5 years to 15 years. 15 years to 25 years. 25 years to 45 years. 45 years and upwards Scarlet Fever 443 1 104 294 15 25 4 Diphtheria 70 1 18 42 4 5 — Measles 2 — — 2 — — — Tota's 515 2 122 338 19 30 4 The total number of patients admitted during the year was 515, as compared with 391 during the previous year. The following list shows the numbers of the respective diseases dealt with:— Scarlet Fever. Diphtheria. Measles. Admitted 443 70 2 Discharged 389 55 2 Died 4 4 — Under treatment at end of year 50 11 — 57 Scarlet Fever.— Of 743 persons notified during the year 1933, 443 (59 per cent.) were admitted to hospital for treatment. Of that number 225 were males and 218 females. The average period of treatment in hospital was 33.20 days. 1929 1930 1931 1932 1933 Number of cases notified 489 461 297 360 743 Number of cases treated in Hospital 308 303 219 223 443 Percentage 63% 65% 73% 62% 59% Deaths in Hospital 1 2 3 4 4 Hospital case fatal ity 0.32% 0.66% 1.36% 1.79% 0.90% The disease continues to be of the mild type to which we have been accustomed for many years. Fifty-two scarlet fever patients received varying doses of diphtheria antitoxin owing to the intervention of suspicious signs of diphtheria in nose or throat. It will be seen from these figures that the incidence of scarlet fever was very high during 1933, the number of cases notified being the highest since 1921. The number (443) of patients treated in hospital is also greater than in any year during the past five years. In spite of the abnormal incidence of the disease during the year, it was possible to find accommodation in hospital for 59 per cent, of the cases notified. During the height of the epidemic it was found necessary to increase the number of beds per ward beyond the standard accommodation ; and, as happens invariably when fever hospital beds are too close together, there was an increase in the number of patients who developed complications. During the year 1929, treatment by means of intramuscular injection of scarlet fever antitoxin was commenced in the hospital. At first the treatment was reserved for the most serious cases, and it was found that the antitoxin had a marked effect in cutting short the period of acute fever. During the years 1931 and 1932 this form of treatment was administered to cases of less severe type with satisfactory results and, at the beginning of 1933, all cases admitted with scarlet fever received an injection of scarlet fever antitoxin. 58 The increase in the use of scarlet fever antitoxin may be seen from the following list showing the number of patients who received injections of scarlet fever antitoxin during the last five years. 1929 15 cases 1930 10 „ 1931 30 „ 1932 94 „ 1933 217 „ During the period January-July, 1933, some four patients in the scarlet fever wards developed " relapses " of the fever. These relapses occurred from 18 to 39 days after admission to hospital. It was also found that during these months there had been an increase in the number of return cases, i.e., cases from homes to which a scarlet fever patient had been discharged within 28 days. On consulting the literature on the subject it was found that Drs. Burton and Balmain had a similar experience at Ilford, and were of opinion that the use of scarlet fever antitoxin definitely increases the liability to relapses. Burton and Balmain also found evidence that cross-infection with different types of heemolytic streptococci occurs ; and that these streptococci persist longer in the throats of patients nursed in hospital than in those nursed at home. There are those who contend that— in view of these circumstances— if patients suffering from scarlet fever have to be removed to hospital, they should be treated in cubicle wards at least until their immunity can be accurately determined. Unfortunately the accommodation available for nursing patients in separate cubicles in Leyton Isolation Hospital is very inadequate and far below the officially recommended minimum standard ; the result being that the number of Leyton patients subjected to risk by cross-infection in scarlet fever wards is much greater than in modern fever hospitals equipped with adequate accommodation in the form of single cubicles. The following are particulars of the four patients who died in the scarlet fever wards during the year:— No. Sex. Age. Cause of Death. In Hospital. 1. Male. 2 years. Septic scarlet fever. Broncho-pneumonia. 5 days. 2. Male. 27 years. Rheumatic fever. Scarlet fever. 38 days. 3. Female. 5 years. Scarlet fever; pneumonia. 4 days. 4. Male. 6 years. Meningitis; scarlet fever. 3 days. 59 Case 1.— The child had been ill at home for a week prior to admission to hospital. Case 2.— This patient developed a severe attack of acute rheu matic fever just as he was about to be discharged from hospital. During the acute stage of the rheumatic infection— i.e., at the very time when his weakened heart required rest— he became violently maniacal and succumbed to heart failure caused by excessive exertion during a maniacal outburst. Case 3.— This child was treated at home for 8 days, as there was no accommodation in hospital at the time. I saw her at home when her case was notified, and the home conditions appeared to be satisfactory for home treatment. Case 4.— This boy was transferred from another hospital in a seriously ill condition. Bacteriological examination of the cerebrospinal fluid revealed evidence of meningitis of a type which is invariably fatal. BUILDINGS AND EQUIPMENT. Open-air Balconies.— The open-air balconies, erected during 1932, proved of great value in hastening the recovery of patients suffering from scarlet fever and diphtheria. The climatic conditions during the summer of 1933 were exceptionally favourable, and the patients were able to derive undoubted benefit from the facilities for exposure to fresh air and sunshine. In order to protect patients from sudden rain or from the scorching rays of the mid-day sun, canvas awnings were erected over the balconies attached to the scarlet fever wards. Operating Theatre.— The operating theatre, erected during the previous year, allowed surgical emergencies to be dealt with in accordance with modern ideas on surgical asepsis. Sanitary Annexes.— In July the Council decided to erect five new sanitary annexes to replace the existing annexes, which were found to be inadequate and unsatisfactory. During the summer months it was possible to erect three of the five new annexes ; but the high incidence of scarlet fever during the year has prevented the work from being finished in the two scarlet fever wards. 60 Diphtheria.— Of 94 persons notified during the year, 70 (74 per cent.) were admitted to hospital. Of that number, 31 were males and 39 females. The average period of treatment in hospital was 43.96 days per case. 1929 1930 1931 1932 1933 Number of cases notified 242 313 231 155 94 Number treated in Hospital 180 203 183 115 70 Percentage 74% 64% 79% 74% 74% Deaths in Hospital 8 9 6 2 4 Hospital case fatality 4.44% 4.43% 3.27% 1.74% 5.70% These figures indicate that, although 1933 was a very quiet year as regards diphtheria admissions to hospital, the percentage of severe cases was the greatest during the last five years. One child required surgical operation (tracheotomy) for laryngeal obstruction due to diphtheria, and made a good recovery. Deaths.— Four deaths due to diphtheria occurred in hospital during the year, the following being the relevant particulars:— No. Sex. Age. Cause of Death. In Hospital. 1. Female. 5 years. Hæmorrhagic diphtheria. 2 hours. 2. Female. 11 years. Diphtheria. 4 days. 3. Male. 4 years. Diphtheria. 5 days. 4. Female. 4 years. Diphtheria. 11 days. In addition to the deaths shown above as due to diphtheria, three persons died in the diphtheria wards of the hospital due to causes other than diphtheria, the following being the relevant particulars:— No. Sex. Age. Cause of Death. In Hospital. 1. Female. 11 months. Broncho-pneumonia. 6 hours. 2. Male. 1 year 9 months. Broncho-pneumonia. 3 days. 3. Female. 36 years. Pneumonia. 1 day. These three cases were all admitted to hospital in a moribund condition by local medical practitioners who considered the symptoms were compatible with a diagnosis of diphtheria ; but in each of the three cases— as the result of further investigation (clinical and bacteriological) in hospital— the original diagnoses of diphtheria were not confirmed. 61 Measles. Measles was not epidemic during 1933. Sporadic cases occurred, but in only two cases were the home conditions such that the children could not be treated at home. These two cases were admitted to the Isolation Hospital during the months of May and June and both were discharged home after three weeks' stay in hospital. Permanent Isolation Hospital. In September, 1930, the Minister of Health, in Memorandum L.G.A. 40, instructed County Councils (other than London) to make a survey of the hospital accommodation available in the County for the treatment of infectious diseases (including smallpox) and to prepare a scheme for the provision of adequate hospital accommodation within the County. The Minister stated that experience had shown that a large hospital serving a wide area formed a more satisfactory administrative unit than a number of smaller hospitals serving smaller areas ; and that the removal of patients to a hospital situated at some distance from their homes presented little difficulty with modern means of transport. It was suggested that County Councils should therefore consider whether it would be desirable to close any smaller hospitals found to be unsatisfactory and to enlarge those hospitals which were satisfactory in all respects and could be extended without inconvenience so as to serve a wider area. On completion of the survey, the County Council was directed to submit to the Minister a scheme for the provision of adequate hospital accommodation for infectious disease within the County. In July, 1932, the Essex County Council forwarded Part I of draft scheme which had been prepared pursuant to Section 63 of the Local Government Act, 1929, under which the County Councils are under an obligation to make a survey of the hospital accommodation for the treatment of infectious diseases provided by the Council and by Local Authorities within the County and to prepare and submit to the Ministry of Health a scheme for the provision of adequate hospital accommodation for the treatment of infectious diseases within the County and requesting to be furnished with the observations of the Council upon such draft Scheme. 62 So far as the Borough of Leyton is concerned, the Scheme provides that there shall be provided for the Boroughs of Leyton and Walthamstow a minimum of 261 beds ; that such accommodation shall be provided by the Walthamstow and Leyton Joint Hospital Board which it is proposed by the Scheme shall be set up, and that the Councils of Leyton and Walthamstow shall take all necessary steps for the formation of such Joint Board. The Essex County Council was duly informed that the Leyton Corporation concurred in the terms of the proposed scheme, but since that time no progress has been made in the direction of the formation of a Joint Hospital Board. Sanitary Circumstances of the Area. 64 SANITARY CIRCUMSTANCES OF THE AREA. The following is the report of the Senior Sanitary Inspector for the year 1933. Inspection of the District. The table below gives a summary of the Inspections made by the Sanitary Inspectors:— Inspections. Number of dwelling-houses inspected 3,760 Number of house-to-house inspections 1,099 Miscellaneous inspections 413 Re-inspections 9,822 Slaughter-houses 1,674 Butchers 586 Bakehouses 89 Fishmongers 180 Milkshops and dairies 457 Cowsheds 6 Provision shops 190 Dining rooms 73 Ice-cream dealers 76 Greengrocers 189 Tripe boilers 607 Gut scrapers 606 Bone boilers 606 Fat melters and extractors 606 Blood driers and blood boilers 606 Rag and bone dealers 52 Fish friers 171 Piggeries 39 Petroleum stores 112 Places of entertainment 44 Schools 53 Stables 166 Public conveniences 158 Urinals 754 Inspections under Rats and Mice (Destruction) Act 315 Visits in connection with infectious disease 1,169 Workshops 257 Factories 613 Outworkers' premises 561 65 One thousand and ninety-seven complaints were received and investigated. The nature of the complaints included sanitary defects in houses, drains choked or defective, premises infested with vermin, etc. Notices. Notices served— Informal 1,590 Statutory— Housing Acts 15 Public Health Acts 40 Re-drainage 90 Result of Service of Notices. Notices complied with— Informal 1,855 Statutory— Housing Acts 22 Public Health Acts 28 Re-drainage 96 Housing. Number of houses erected during the year:— (a) Total (including numbers given separately under (b)). (i) By the Local Authority 60flats (ii) By other Local Authorities Nil (iii) By other bodies and persons:— Houses 45 Flats 24 (b) With State assistance under the Housing Acts. (i) By the Local Authority:— (а) For the purposes of Part iii of the Act of 1925 35flats (б) For other purposes 25flats (ii) By other bodies or persons Nil I.— Inspection of Dwelling-houses during the Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,760 (b) Number of inspections made for the purpose 13,582 66 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 1,099 (b) Number of inspections made for the purpose 3,333 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 13 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 1,695 II.— Remedy of Defects during the Year without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action taken by the Local Authority or their officers 1,855 67 III.— Action under Statutory Powers during the Year:— (a) Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners Nil (b) By Local Authority in default of owners Nil (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied Nil (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (а) By owners Nil (б) By Local Authority in default of owners Nil (c) Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which demolition orders were made ... 15 (2) Number of dwelling-houses demolished in pursuance of demolition orders 22 (d) Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil (e) Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil 68 (2) Number of dwelling-houses which were rendered fit after service of formal notice:— (a) By owners Nil (b) By Local Authority in default of owners Nil (3) Number of dwelling-houses in which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil (/) Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which Closing Orders were made Nil (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil (3) Number of dwelling-houses in respect of which Demolition Orders were made Nil (4) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil Lea Bridge Gardens.— These are situated at the Hackney end of Lea Bridge Road, near the L.N.E.R. station. Some are on the north and others on the south side of the road. The ground upon which the houses stand is very much below the level of the main road. It is reputed that the houses were originally built and used by certain Hackney residents as week-end bungalows over fifty years ago. The houses, except in three instances on the south side and five on the north side, are built mainly of wood. Owing to age, wear and tear they have gradually become damp, dilapidated and dangerous. Perhaps the worst feature is the fact that the sanitary conveniences, except in three of the brick houses, consist of the archaic " pail closet " system, the contents of the pail having to be disposed of by burying in the front gardens. The water supply is also inadequate. As far back as the year 1920, owing to the bad conditions then prevailing, most of the houses were represented to the Council for closing, but owing to the housing shortage little progress was made. The question of the houses in Lea Bridge Gardens was further reported to the Public Health Committee in January, 1932, when the Council decided to deal with them individually under the 69 Housing Act, 1930. During 1932 by this means six houses were demolished, and at the beginning of 1933 there remained twenty-two houses on the south side and fourteen on the north (six of the latter being temporary-licensed buildings in a good state of repair). Sixteen houses have been demolished in consequence of Demolition Orders during 1933, and in addition three have been demolished voluntarily by the owner in anticipation of statutory action by the Council. The south side of the Gardens has now been cleared of houses, with the exception of the three brick buildings. These are in a fair state of repair and are provided with the water-carriage system of drainage. Steps are being taken, however, by the owner to get possession of the houses (one is already vacant) so that the whole of the site may be used for the building of factories. The houses on the north side of the road are to be dealt with during the coming year. The photographs on page 71 give some idea of the type and condition of the houses referred to. Clearance Areas.— One small area ("Nursery Cottages" in Hiteham Road) consisting of twelve houses, declared by the Council as a Clearance Area in 1932, was finally dealt with during the year. The houses have been demolished and the site cleared. A photograph is given on page 73. Demolition.— In addition to Demolition Orders referred to under Lea Bridge Gardens, Orders were made by the Council regarding Nos. 1, 2, 3, 4 and 5, Coopers Cottages, High Road, Leytonstone ; No. 153, Cathall Road ; and No. 12, Browning Road. All the houses were demolished by the end of the year except the last named, the Order not having expired. A photograph is given on page 73 of the Coopers Cottages houses, which were situated in a narrow court leading from the main road, with stables immediately in front of them. House-to-Hottse Inspection.— The houses in the undermentioned roads have been inspected during the year. Apart from those scheduled and referred to under Demolition, it has not been found necessary to take statutory action. The defects found are among those mentioned in the table following, and these were remedied as the result of preliminary notices served on the owners concerned. 70 It is found that much improvement can be effected in property by means of appointments and interviews with owners, without resorting to legal measures. Amberley Road (continued). Atkins Road. Belgrave Road. Belmont Park Road (part). Boundary Road (Council houses). Coopers Cottages, High Road, E.ll. Downsell Road (part). Dyson Road. Etloe Road. Farmilo Road (Council houses). Ferndale Road (continued). Forest Glade. Harold Road (part). Kings Road (part). Lea Bridge Gardens (part). Livingstone Road. Maple Road. Morley Road (continued). Northumberland Road (Council houses). Odessa Road (continued). Onra Road (Council houses). Rochdale Road (Council houses). St. Hehers Road. Shaftesbury Road. Shrublands Road. Stanley Road. Tavistock Road. Twickenham Road (part). Waterloo Road (continued). William Street. Nature of Work executed and Improvements effected at Dwelling-Houses and other Premises under the Provisions of the Housing and Public Health Acts. Dampness remedied 518 Sashcords renewed 357 Plaster repaired 1,003 Roofs repaired or renewed 549 Guttering repaired or renewed 251 49/52, Lea Bridge Gardens, Leyton. 4/11, "Nursery CottagesHitcham Road, Leyton. 75 Yards paved 317 Drains relaid or partly relaid 189 Choked drains cleared . 93 New w.c. pan and traps provided 75 Sinks provided 59 W.C. cisterns repaired or renewed 71 Rain water pipes repaired or renewed 113 Vent pipes repaired or renewed 94 Sink waste pipes renewed 149 Stoves repaired or renewed 100 Coppers repaired or renewed 76 Floors repaired 206 Cement-work to sink waste gullies repaired 133 Rooms redecorated 2,445 Miscellaneous defects remedied 1.603 Drainage. —The drainage of 189 houses has been reconstructed. In certain instances the drains formed portions of combined systems, and in such cases, in default of the owners, the work was carried out by Council workmen under the Borough Engineer's Department, the expenses incurred thereby being recovered from the owners. Rent and Mortgage Interest Restriction Act, 1923.— No applications having been received during the year, it has not been found necessary to issue any certificates under the above Act. Legal Proceedings. Public Health Act, 1925.—A summons against a builder in respect of failure to give notice to the Urban Authority under Section 39 of the Public Health Act, 1925, of the reconstruction of a drain, was heard at the Stratford Police Court and was dismissed on payment of costs. Public Health Act, 1875.—A summons against the occupier of a dwelling-house (82, Wallwood Road) for non-compliance with an Order of a Justice of the Peace for admission to the premises was heard at Stratford Police Court, and a fine of twenty shillings was imposed; a summons taken out at the same time for failure to abate a nuisance was adjourned for five weeks, at the end of which time the nuisance was abated. 76 Overcrowding. —This question has received careful attention throughout the year. The following summary shows the number of cases of overcrowding dealt with:— Cases outstanding at end of 1932 19 New cases investigated, 1933 35 54 Cases abated—Informal action 10 Statutory action 17 27 Cases where notice has not expired 13 Cases under consideration (special circumstances, unemployment, etc.) 14 27 54 It was found necessary in three instances to institute legal proceedings. The summonses were heard at the Stratford Police Court. The particulars and results of the action taken are as follows:— (1) Man, wife and seven children sleeping and living in two rooms. Summons against owner, who also resided on the premises, dismissed. Order obtained requiring tenant to abate nuisance within two months, and to pay costs. (2) Man. wife and seven children sleeping and living in two rooms. Order obtained requiring tenant to abate nuisance within three months, and to pay costs. (3) Five adults and one child (of different sexes) sleeping in one room. Order obtained requiring tenant to abate nuisance within one month, and to pay costs. In each case the Order was complied with. In addition to the above-mentioned cases, forty-one visits were paid to premises where overcrowding was reported to exist, but upon investigation being made the facts were not substantiated. The problem of overcrowding is a difficult one. There appears to be no simple remedy for this evil, which has been prevalent throughout the country for many years. Much has been written 77 upon the subject. Social workers have tried, and are still trying, to find a cure. In the meanwhile a good deal can be done by public health propaganda, advice and influence by all concerned. There are, amongst others, three types of overcrowding, or classes of overcrowded conditions, worth noting. The first relates to houses where the number of occupants is large and the family income on a low level. The difficulty which arises in these cases is that removal to better accommodation and happier conditions means higher rent, and, consequently, less to spare for the absolute necessities of life. The second is that class of case where the wage earner is unemployed. This type of person is generally willing to move if employment can be more or less permanently secured. The third class is that of the person who, irrespective of income or employment, takes little or no interest in improving his conditions of living, and resists to the full any encroachment by public health officials. The only solution which has been found effective in these cases is to take statutory action for the abatement of the nuisance. It is found that when pressure is exerted, good results are obtained. Verminous Houses.—The Bed Bug.—This somewhat distasteful, though nevertheless important, subject has received attention during the year. It may be of interest to mention that during his visit to a certain town, whilst inspecting the housing conditions, the Prince of Wales asked the question as to what is done to get rid of these pests— bugs. The question is one which has occupied the minds of sanitarians for many years. The statutory powers given to Local Authorities to deal with verminous houses is contained in the Public Health Act, 1925, as follows :— Section 46.—(1) If it appears to the Local Authority, on the certificate of the medical officer or sanitary inspector, that any premises used for human habitation in the district are infested with vermin, the local authority may give written notice to the occupier of the premises, or if the premises be vacant to the owner of the premises, requiring him within a period specified in the notice to cleanse the premises, and the notice may require among other things, the removal of 78 wallpaper or other covering on the walls, and the taking of such steps as the local authority may require for the purpose of destroying or removing vermin : Provided that, where any work required by the notice is work for which the owner of the premises is under the tenancy responsible, the notice requiring the work to be performed may be given by the local authority to the owner of the premises. (2) If the person on whom a notice under this section is served fails within the period specified in the notice to comply with the requirements thereof, he shall be liable to a penalty not exceeding five pounds and to a daily penalty not exceeding ten shillings, and the local authority may, after the expiration of the said period, themselves carry out the work required by the notice, and recover the reasonable costs and expenses incurred by them in a summary manner from that person. Various methods of dealing with bug infestation are adopted by different Local Authorities. These include the removal of bedding and clothing for disinfection by means of steam, and the removal of skirting boards, architraves and woodwork in the house and subsequent fumigation of the premises by sulphur, cyanide gas or other gases, and by other chemical reagents. Advice is given to the occupiers of the houses, and the Local Authorityco-operates with the owner regarding his reponsibility in the matter. In Leyton, during 1933, bugs were found to be present in 263 houses ; and steps were taken by the Department to deal with them. The following table gives the number of houses infested, and also the wards, percentage of houses affected and the ratio of verminous houses to the total. Ward. Total Premises in Ward. Premises Found to be Verminous, † Percentage of Verminous Premises. Ratio of Verminous Premises. Cann Hall 2,528 27 1.068 1 in 94 Grove Green 1,953 30 1.536 1 in 65 Harrow Green 1,979 40 2.021 1 in 49 Leytonstone 3,052 13 .426 1 in 235 Wan stead Slip 1,682 28 1.665 1 in 60 Central North 2,109 14 .664 1 in 151 Central South 3,238 11 .340 1 in 294 Forest 4,219 35 .830 1 in 121 Lea Bridge 4,903 44 .897 1 in 111 Leyton 1,924 21 1.092 1 in 92 Totals 27,587 263 .953 1 in 105 As a result of complaints, house-to-house visits, etc. 79 The practice of dealing with infested houses in Leyton is as follows:— Where bugs are found to exist in houses, an inspection is made of the premises by one of the Sanitary Inspectors. The procedure followed depends upon the extent of the infestation. Where it is only slight, advice and instruction regarding bugs are given to the occupier, who is also told to examine the pictures, bedding, bedsteads and other furniture, and to thoroughly cleanse the same. The rooms are then sprayed by a member of the Public Health Department staff with a special insecticide solution. Where the infestation is extensive, the owner of the house is written to requesting him to remove all woodwork, i.e., skirting boards, architraves, etc., and to use a blow-lamp when these are removed. The room is afterwards sprayed with the special solution and the walls (if papered) stripped, cleansed and distempered. Should bugs recur, the premises are again sprayed. The importance of cleanliness and the danger of re-infestation by means of second-hand furniture is emphasised to the tenant. It was found necessary in 62 cases this year to have the rooms sprayed a second time. The average cost to the Council of this method of dealing with verminous houses amounts approximately to a little more than four shillings per case; the total cost during the year, including the cost of chemicals and labour, amounting to £71 7s. 6d. To deal efficiently and effectively with bug infestation much time is required, great care must be exercised and expense is a factor to be borne in mind when adopting new methods. T It is essential that not only the owners, but also the occupiers must be made to realise their responsibilities in the matter. Much can be accomplished by advice, persuasion and co-operation with all concerned. From experience it is learned that where there is absolute cleanliness there is very little evidence of the presence of bugs. On the other hand, bugs are very often brought into clean houses by means of second-hand clothing, books and furniture. The greatest difficulty is to find an easy and quick way of getting rid of bugs in old and dilapidated property. Soap, water and paraffin is a cheap and easy method of dealing with slight infestation. 80 Premises and Occupations which can be Controlled by Bye-Laws and Regulations. Premises. Slaughter-houses 9 Dairies, Milkshops and Dairymen 261 Cowsheds 1 Butchers' shops, Stalls and Provision shops 177 Hairdressers 77 Ice Cream dealers 87 Chimneys—Buildings other than private dwelling houses, approximately. 100 Offensive Trades. Rag and Bone dealers 6 Fish friers 34 Tripe boiler 1 Fat, melter 1 Fat extractor 1 Gut scraper 1 Bone boiler 1 Blood boiler and blood drier 1 The use of one slaughter-house in the Borough was discontinued during the year, and the name of the premises was removed from the Register. Six applications for the permission of the Council to establish the trade of a fish frier were made, and three were granted. An application to continue the trades of tripe boiler, bone boiler, fat extractor, fat melter, blood boiler and blood drier was received, and permission given to carry on the trades for a further limited period. Two applications for permission to carry on the trade of a dealer in rags and bones were received, one of which was granted. The premises where offensive trades are carried on have been inspected systematically during the year in order to ensure that the bye-laws are adhered to. No infringements of the bye-laws were found to occur. Smoke Abatement.—This subject is of far reaching importance as it vitally concerns the health and well being of the people. In addition, atmospheric pollution has a deleterious effect upon the buildings in the district. 81 Few complaints have been received in connection with any particular factory chimney in the town. Observations have been made but it has not been necessary to take legal action. Among the chief causes of black smoke are insufficient draught to furnace, neglect and careless firing, defective flues and the burning of unsatisfactory fuel. The question of expense is one always stressed by owners when any suggestions for improvement are made. There is no control permissible regarding smoke emitted from domestic chimneys. Rag Flock Acts, 1911-1928. As there are no premises within the Borough where rag flock is known to be manufactured, samples were not taken during the year. Foster Mothers.—Visits have been paid to the premises occupied by foster mothers, of whom there are now 48 on the Register, and with only one exception the premises were found to be in a satisfactory condition. Allotments and Refuse Dumps.—Two complaints were received regarding the dump in Seymour Road. On investigation no nuisance, remediable under the Public Health Acts, was found to exist. The annoyance created by fires on the dump was minimised to some extent after the owner's attention had been called to the matter. Infectious Diseases. One thousand one hundred and sixty-nine visits have been made by the Sanitary Inspectors in connection with infectious diseases. Disinfection. Premises disinfected 1,234 Loads of bedding steam disinfected 39 Books belonging to public institutions534 Various articles of clothing, etc. Places of Entertainment. Forty-four visits have been made to cinemas and other places of entertainment, and one defect regarding ventilation in a cinema was remedied after informal action. 82 Petroleum Acts. Petroleum. Carbide of Calcium. Licences granted after inspection of storage arrangements 11 — Licences renewed. 97 6 Licences lapsed during year 10 1 Poisons and Pharmacy Act, 1908. Two existing licences were renewed under this Act. Game Dealers. Three certificates were granted during the year. Shops Acts. The revision of the Register of Shops in the Borough was completed during the year. There are 2,151 shops in the district,, carrying on the following trades:— Bakers 45 Barbers 37 Booksellers 8 Boot and shoe stores 35 Boot and shoe manufacturers 12 Boot and shoe repairers 76 Builders' merchants 20 Butchers 82 Cabinet makers 4 Chemists 38 Cleaners and dyers 16 Coal merchants 35 Confectioners 230 Corn chandlers 29 Costumiers 26 Cycle dealers 22 Dairies 48 Drapers 85 Dressmakers 5 Eating houses 67 Electric equipment dealers 13 Estate agents 10 Fancy goods dealers 14 Fishmongers 51 83 Florists 22 Furniture dealers 34 General stores 134 Greengrocers 104 Grocers 248 Hairdressers . 50 Hardware dealers 14 Hosiers and hatters 17 Ironmongers 19 Jewellers .21 Laundries 25 Leather goods merchants 6 Marine store dealers 3 Milliners 20 Music stores 15 Newsagents 58 Motor accessories and petroleum 29 Off licenses 49 Oilmen 27 On licenses 25 Opticians 7 Pawnbrokers 9 Photographers. 7 Piano dealers 5 Poultry and game dealers 5 Printers. 6 Provision dealers 91 Stationers 57 Tailors 51 Timber merchants 14 Tobacconists 383 Toysellers 28 Upholsterers 5 Wardrobe dealers 12 Wireless dealers 40 Miscellaneous . 146 The shops have been kept under observation, and 1,794 visits were made. It was found necessary to serve 131 notices regarding infringements of the Shops Acts, and three prosecutions were taken at the Stratford Police Court with the following results:— (1) Dismissed. (2) Fined 20 shillings. (3) Fined 10 shillings. 84 Factory and Workshops Acts, 1901 and 1907. Workshops and Workplaces. Two hundred and ninety-three inspections were made during the year during the course of completely revising the Register. Defects were found to exist and have been remedied in 36 cases. Pour notices were received from H.M. Inspector of Factories of nuisances remediable under the Public Health Acts. One hundred and fifty-one workshops remain on the Register at the end of the year, and are grouped as follows:— Accumulator charging and radio repairs 5 Bakehouses 17 Bedding manufacturer 1 Blacksmiths 2 Boot and shoe makers and repairers 17 Builders' merchant 1 Cabinet makers 3 Cardboard-box manufacturer 1 Confectionery makers 14 Corset maker 1 Cycle repairer 1 Dressmakers 16 Dyers, cleaners and pressors 4 Enameller and plater 1 Fish packer 1 Laundries 5 Leather goods manufacturer 1 Milliners . 5 Motor repairers 6 Organ builder 1 Printer 1 Paper articles and lamp shades manufacturer 1 Paint mixer 1 Piano manufacturer 1 Rag sorters 2 Range repairer 1 Scale maker.. 1 Tailors 21 Carried forward 122 85 Brought forward 122 Tie makers 9 Upholsterers . 4 Wire worker 1 Wood choppers 4 Miscellaneous 11 151 Homework. Whilst revising the Register of Outworkers, 561 visits were made during the year. Two hundred and seventy outworkers now remain on the Register. Sanitary defects have been remedied in 51 instances without the service of statutory notice. 86 Factories, Workshops, Laundries, Workplaces & Homework. 1. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. (1) Number of Inspections. (2) Written Notices. (3) Prosecutions. (4) Factories— Including Factory Laundries 666 13 ... Workshops— 293 32 ... Including Workshop Laundries Workplaces— Other than Outworkers premises included in Part 5 of this Report 959 45 2. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. (1) Number of Defects. Found. (2) Remedied. (3) Nuisances under the Public Health Acts :— Want of Cleanliness 23 15 „ Ventilation 1 - Overcrowding — — Want of Drainage of Floors 2 3 Other nuisances 7 10 Sanitary Accommodation Insufficient 2 1 Unsuitable or defective 8 8 Not separate for sexes — — Offences under Factory and Workshop Acts:— Illegal Occupation of Underground Bakehouse (S. 101) - - Breach of Special Sanitary Requirements for Bakehouses (S.S. 97 to 100) 19 19 Other Offences— Excluding offences relating to Outwork which are included in Part 5 of this Report — — 62 56 87 3. REGISTERED WORKSHOPS. Workshops on the Register (S. 131) at the end of the year. (1) Number. (2) Ordinary Workshops 129 Laundries 5 Bakehouses 17 Total Number of Workshops on Register 151 4. OTHER MATTERS. Class. (1) Number. (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factories and Workshop Acts (S. 133, 1901) 6 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (S. 5, 1901):— Notified by H.M. Inspector 4 Reports (of action taken) sent to H.M. Inspector 3 Other — Underground Bakehouses (S. 101):— Certificates granted during the year In use at the end of the year 5 5. HOMEWORK. NATURE OF WORK. Outwork in Unwholesome Premises, Sec. 108. Instances. Notices served. Wearing Apparel:— 51 Making, etc 47 Cleaning and washing . 2 Brush making Furniture and upholstery 1 Paper bags and boxes 1 88 Food—Inspection and Supervision. Milk Supply.—Although some progress has been made regarding the cleanliness of milk through the introduction of the "Graded" system, the time has come when a definite standard of cleanliness should be fixed for all milk. On the Register there are 261 dairies and milkshops, and one cowshed. There have been fifty new registrations, and thirty-six names have been deleted from the Register. The premises have been visited regularly during the year. Thirty-eight minor infringements were found at twenty-one of the premises, and these were abated after informal notice was given. The taking of samples for adulteration is carried out by the officers of the Essex County Council. Designated Milk -The number of designated licences granted during the year under the Milk (Special Designations) Order, 1923, is as follows :— Licences. No. Granted No. of Samples taken Result. Satisfactory Unsatisfactory Certified 3 — — — Grade A "T.T." 12 3 3 — Grade A Pasteurised 7 1 1 — Grade A 1 2 o — Pasteurised 28 15 15 — Supplementary Licences — — — - Certified 1 — — — Grade A "T.T." 3 — — — Grade A - — — — Pasteurised 3 - — — Totals 58 21 21 — 89 Samples were taken as shown in the following table, and letters of warning were sent out in four cases. Results. No. of Sample. No. of Bacteria per c.c. GRADE A. "T.T." 196 970 206 1,925 209 4,570 GRADE A. PASTEURISED 193 3,555 199 2,315 GRADE A. 201 2,450 PASTEURISED 194 5,260 195 5,445 197 7,255 198 12,920 200 6,410 202 9,475 203 5,520 204 7,065* 205 6,690 207 24,350* 208 5,515 210 3,730* 211 6,605 212 2,030 213 18,646* * B. Coli present. Ice Cream.—Under the provisions of the Essex County Council Act, 1933, important progress has been made. The Act provides for the registration of vendors of ice cream and the premises used by them, and also regulates the manufacture and sale of ice cream. These restrictions, which came into operation towards the end of the year, are of great value and enable the Local Authority to see that the manufacture of this popular commodity is carried out under hygienic conditions, and that the place of storage is suitable. Seventy-six visits were made to premises where the sale of ice cream was known to take place during the past year. Now that registration is compulsory, routine visits and inspections of all premises will now be made. 90 Four licences under the new Act were issued in the last month of the year. Bakehouses.—Regular inspection has taken place of the thirty-nine registered bakehouses. Nineteen minor infringements were noticed, and all of these were remedied without the service of statutory notices. Meat.—There are now nine slaughter-houses in the Borough, one registered and eight licensed. (One licensed slaughter-house was discontinued during the year.) These have all been inspected regularly, necessitating 1,674 visits, and no infringements of the bye-laws have been observed. Humane Slaughtering.—The bye-laws made by the Council in 1924 require the effectual stunning of all animals in slaughterhouses by a mechanically operated instrument, the only exception being animals the food of which is intended for persons of the Jewish and Mohammedan religions. Since the adoption of the bye-law in 1924, this method of slaughtering has proved to be very satisfactory, and no opposition is now offered to its application. Slaughter of Animals Act, 1933.—In October, 1933, the Council resolved "That Section 1 of this Act, shall, on and from 1st January, 1934, apply to sheep, ewes, wethers, rams and lambs." Carcases and viscera inspected:— Cattle 7,459 Calves 43 Swine 20,810 Sheep and lambs 46,703 Total 75,015 The following table shows the amount of meat and other food which, being found upon inspection to be unfit for the food of man, was surrendered and subsequently destroyed. Carcases and Viscera Condemned. Bovines Carcase and offal 20 Hindquarters 5 Forequarters 16 Ribs 16 Brisket 30 Clod and sticking 15 Top-piece 3 91 Flank 28 Rump 8 Aitch-bone 1 Head and tongue 345 Head 8 Tongue 4 Steak 10 Loin 12 Crop 1 Skirt 18 Heart 10 Intestines 83 Kidney 21 Liver 4,116 Lungs 768 Mesentery 546 Offal (complete) 3 Omentum 17 Spleen 11 Stomach 37 Udder 1 Beef 211 lbs. Veal 48 lbs. Kidneys 218 lbs. Livers 15 lbs. Swine :— Carcase and offal 202 Carcase 4 Forequarters 2 Hindquarters 4 Hand and spring 3 Leg 31 Flank 2 Head 1,831 Collar 14 Loin 15 Shoulder 1 Side 1 Ribs 2 Belly 10 Skin 2 Heart 126 Offal (complete) 3 92 Intestines 35 Kidney 174 Liver 2,095 Lungs 1,577 Mesentery 1,680 Omentum 9 Pluck 526 Spleen 34 Stomach 25 Pork 14 lbs. Sheep :— Carcase and offal 15 Carcase 4 Forequarters 2 Breast 3 Target 15 Leg 1 Head 3 Scrag 2 Heart 5 Kidney 2 Liver 2,711 Lungs 1,843 Omentum 1 Pluck 20 Intestines 3 Spleen . 2 Stomach 5 Lamb livers 66 lbs. Miscellaneous :— Rabbits 171 lbs. (80 plus 1 case) Bream fillets 6 stones Cod fillets 56 lbs. Codlings 11 stones Kippers 56 lbs. Skate 14½ stones Mussels 1 bag Apples . 25 lbs. White grapes 40 lbs. 93 Tuberculosis in Meat. Generalised. Localised. Bovine carcases 0.3% 4% Pig carcases 1% 10% Public Health (Meat) Regulations, 1924.—The attitude of the majority of butchers towards these Regulations is still far from satisfactory. The reason is that the Regulations are framed in such a way as to give rise to much diversity of opinion as to their meaning and application. In order that meat shall be kept clean and free from flies, the provision of glass fronts should be made compulsory to all butchers' shops, and meat stalls out in the open should be prohibited. Legislation is also urgently needed requiring all articles of food to be properly and effectively protected from dirt and contamination by flies. Many visits and inspections have been made to this class of shoj) and stall, and one firm were reported to the Council for not taking steps to protect their meat, the meat being found to be very dirty. Proceedings were pending at the close of the year. Diseases of Animals Acts, 1894-1927. Forty-three movement licences regarding the movement of 473 cattle, 1,413 sheep and 1,606 pigs were issued during the year under the Foot and Mouth Disease (Regulation of Movement Order), 1933, following an outbreak of foot and mouth disease over a large part of the country in the early part of the year. Rats and Mice (Destruction) Act, 1919. Three hundred and fifteen visits have been made to premises in connection with complaints of rats, and rat biscuits have been issued to 314 occupiers of premises. During National Rat Week the recommendations of the Ministry of Agriculture and Fisheries were again observed, and posters exhibited calling attention of residents to the provisions of the Act. Bait was laid in the man-holes of sewers throughout the town with successful results. It is very doubtful whether any useful practical purpose is served by holding a Rat Week, in view of the fact that steps are taken regularly during the year to deal with this menace. Maternity and Child Welfare. 96 MATERNITY AND CHILD WELFARE* The following section constitutes my Annual Report to the Maternity and Child Welfare Authority and deals with the work undertaken by the Council in the interests of maternal and child welfare. In its preparation, I have to acknowledge the valuable assistance of Dr. Hilda Menzies, who—in the capacity of Clinic Medical Officer and Inspector of Midwives—has furnished the observations on the actual work of the clinics. INFANT WELFARE. Centres.—-There are three Infant Welfare Centres in the Borough, two sessions being held weekly at each Centre, as follows : Infant Welfare Clinics— (1) The "People's Hall," Harrow Green, Leytonstone.— Tuesdays, 10 a.m. and 1.45 p.m. (2) All Saints' Church, Capworth Street, Leyton.— Wednesdays and Thursdays, 1.45 p.m. (From January to September.) Health Clinic, Leyton Green Road.—Wednesdays and Thursdays, 1.45. (From September to December.) (3) Christ Church Institute, Francis Road, Leyton.— Mondays and Fridays, 1.45 p.m. 97 Attendances, Examinations, etc. Christ Church. Harrow Green. Capworth Street, Leyton Green All Centres. p.m. Mon. p.m. Fri. a.m. Tues. p.m. Tues. p.m. Weds. p.m. Thurs. Under 1 year 1st attendances 168 115 122 252 191 143 991 Subsequent attendances. 2009 1122 1248 2752 1765 1704 10600 Total attendances 2177 1237 1370 3004 1956 1847 11591 1—5 years 1st attendances 30 45 25 43 56 33 232 Subsequent attendances. 743 683 513 1150 72(1 684 4493 Total attendances 773 728 538 1193 776 717 4725 Total attendances—both age groups 2950 1965 1908 4197 2732 2564 16316 Average attendance per session 61.45 40.90 39.75 87.43 56.91 53.41 56.65 Number examined by Clinic Medical Officer 1189 983 821 2167 1021 1047 7228 Average number examined per doctor per session 24.77 20.47 17.10 22.57* 21.27 21.81 21.51 Number weighed 2943 1973 1907 4186 2684 2507 16200 * Two doctors in attendance, the figures shown being the average number examined by each doctor. During the year under review, the total attendances at the Council's Infant Welfare Centres were 16,316, an increase of 307 over the figure (16,009) for the previous year. The number of children examined by the Clinic Medical Officers was 7,228 as compared with 7,309 examined during the previous year. The rapid fall in the number of births, by 146 in 1932, and by 168 in 1933, would lead one to expect a decrease in the attendances at the Infant Welfare Centres; but, although the number of first attendances decreased by 40 in children under 1 year and by 70 in children from 1.5 years, the total attendances increased in both groups. It is therefore evident that the children are attending more regularly. Voluntary Workers. During the year the Corporation was unfortunate in losing two voluntary workers who have rendered long and valuable service at the Centres. 98 Mrs. E. Harvey, who had assisted at the Harrow Green Infant Welfare Clinic since its inception in 1917, died in November after a short illness. In the following month the death occurred of Miss E. Knight, who had assisted at the Town Hall and Francis Road Clinics over a period of several years. The following is a list of the ladies who act as Voluntary Workers at the maternity and child welfare centres :— Name. Centre. Since. Mrs. M. Hawkey. Francis Road and Leyton Green 1918 Mrs. Wagstaffe. Francis Road 1924 Mrs. Wood Francis Road 1917 MissH. S. Holl Francis Road 1927 MissE. H. Holl. Francis Road 1927 Mrs. F. Clarke Francis Road 1928 Mrs. Forrest Harrow Green 1929 Mrs. Muddiman Harrow Green 1917 Mrs. Blake Harrow Green 1930 Mrs. E. M. Carter . Ley ton Green 1929 Mrs. E. Garton Ley ton Green 1933 Mrs. V. Softley Francis Road. 1933 Mrs. A. Tallack Harrow Green 1917 Mrs. J. Oates Francis Road 1929 During the year these ladies have continued to render valuable assistance at the infant welfare centres, where their services are greatly appreciated. Without their assistance it would be impossible to cope with the large numbers attending. Health Visitors. One of the Health Visitors attended a fortnight's course of instruction at the Twelfth Winter School, held under the auspices of the Women Public Health Officers' Association at Bedford College. These refresher courses of instruction are of undoubted value from an educational point of view. Clinics.-—Each of the five Health Visitors is on duty at three clinic sessions per week. Visits.—During the year the Health Visitors have made 17,467 visits to homes, as follows :— (a) To expectant mothers First visits 109 Total visits .. 113 99 (b) To children under 1 year of age :— First visits 1,513 Total visits 7,258 (c) To children between the ages of 1 and 5 years :— Total visits 9,736 (d) Visits not included above :— Children Act—Infant Life Protection 322 Whooping cough 37 Puerperal pyrexia 1 The number of children between the ages of 1 and 5 visited in their homes by health visitors was 9,736, an increase of 423 over the number of such children visited during the previous year. Dental Treatment. In January, 1933, the Medical Officer of Health was directed to submit to the Maternity and Child Welfare Committee a scheme for the provision of dentures for expectant and nursing mothers. After consideration of the report of the Medical Officer of Health, the Maternity and Child Welfare Authority approved the following scheme for adoption. 1. That the provision be limited to expectant and nursing mothers referred by the Clinic Medical Officer for dental treatment by the Council's Dental Surgeon, and recommended by the latter for the provision of dentures. 2. That patients requiring dentures be offered choice of treatment by one of the local dental practitioners on the Council's approved list. 3. That the Council's approved list of dental practitioners contain only the names of duly qualified dental surgeons in possession of a registrable dental qualification. 4. That the Council reserves the right to add names to or remove names from the approved list. 5. That the payment for such services be based on the national scale of fees chargeable by dental practitioners for dentures supplied to insured persons under the provisions of the National Health Insurance (Dental Benefit) Regulations, 1930, viz.:— £ s. d. Maximum fee for upper or lower denture 2 15 0 Maximum fee for upper and lower dentures 5 10 0 100 6. That payment of fees to dental practitioners be conditional on the quality and fitting of the dentures being approved by the Council's Dental Surgeon. 7. That, when the provision of dentures is recommended, patients be required to fill up and sign a form giving particulars of the financial circumstances of the family. That, before the work is put in hand, the patient be informed of the contribution which she will be required to make towards the cost of the dentures; and that the patient and husband be required to sign an undertaking to pay the sum assessed. 8. That the amount of such contributions be regulated by the follow ing scale of family income :— To be remitted Where after deNumber if after deduc- ducting rent and in tion of rent the allowances for Assessment . Family. income does children the innot exceed come is £ s. d. 1 0 10 0 Up to £1 5s. 50 per cent. of first £1 or 2 10 0 part thereof, plus 25 per 3 15 6 cent. of amount ing £1. 4 112 0 £1 5s. to £1 15s. 60 per cent. of first £1 or 5 1 17 6 part thereof, plus 40 per 6 2 2 0 cent. of amount ing £1. 7 2 2 0 £1 15s. to £2 5s. 75 per cent, of first £1 or 8 2 8 0 part thereof, plus 50 per 9 2 9 6 cent. of amount exceed- ing £1. 10 2 15 0 £2 5s. to £2 15s. Whole cost if under £1. If 11 3 0 6 over, 100 per cent. of 12 3 0 0 first £1, plus 50 per cent. of amount over. £2 15s. and over The whole cost. Deductions.—Rent and 6s. for 1 child. 10s. for 2 children. 15s. for 3 children. £1 for 4 children, and 2s. 6d. for each additional child. 9. That this scheme shall not apply to women who are entitled to benefit under the National Health Insurance (Dental Benefit) Regulations, and that H.S.A. vouchers be not accepted by the Council in respect of treatment or dentures supplied. Qualified dental practitioners resident in the area were given the opportunity of stating whether they were prepared to undertake 101 the provision of dentures on terms specified by the Council. As a result the names of 7 local dental practitioners were placed on the approved list. During the past five years the number of expectant mothers and children under five years of age who have received dental treatment in connection with the Council's scheme for maternity and child welfare has been as follows :—• 1929 140 1930 207 1931 265 1932 300 1933 292 The record of such treatment undertaken during the year 1933 is as follows :— Espectant Mothers Children. Patients treated 87 205 Attendances 134 233 Extractions 290 276 Fillings 16 54 Other dental operations 19 24 Ansesthetics— General 62 11 Local 7 145 Dentures supplied— Full upper and partial lower 1 — Orthopaedic Treatment. Examinations. 1930 1931 1932 1933 Primary 55 80 91 80 Re-examinations 83 126 140 165 Total 138 206 231 245 Treatment. Number attending for 56 126 115 129 Attendances made for 337 474 569 448 Total 393 600 684 577 102 Primary Examinations. During the year 80 children were referred from the Infant Welfare Clinics to the Council's Orthopaedic Surgeon. Last year it was noted in the Annual Report that there had been an increase each year in the number of children referred for advice and treatment from the Infant Welfare Centres since 1929, when the service was first available. The numbers increased from 31 in 1929 to 91 in 1932. This year there is a fall in cases referred from 91 to 80. One hopes that—as the residt of the individual teaching in the homes by the Health Visitors and at the Clinics by the Medical Officers and Health Visitors—the mothers are beginning to realise the importance of straight limbs. Only with the mothers' co-operation is it possible to ensure that deformities do not become serious. A mother who has been told to watch a bowed leg, and later reassured regarding it, may be quite unconscious of a definite knock knee in the same child 6-12 months later. The arguments that " the father has bow legs "or" the mother has knock knee " are still advanced as explanations of the children's deformities, or even as reasons for disregarding them. The orthopaedic defects found were :— Webbed digits 2 Scoliosis 1 Talipes 3 Digitus flexus 2 Bowed tibiae 41 Genu valgum 30 Genu varum 1 Bowed femora 1 Pes piano valgus 52 Be-examinations. In addition to the 80 new cases mentioned above, 165 children under five years of age attended for re-examination by the Orthopaedic Surgeon. Treatment. One hundred and twenty-nine children made 448 attendances at Knotts Green Special School for special treatment by the Council's Masseuse (Miss Findlay). Provision of Surgical Appliances.—One hundred and five children were supplied with surgical appliances on the 103 tion of the Orthopaedic Surgeon, and the following is a list of the appliances supplied under the Authority's scheme Tibial splints, pockets and wedges to boots 14 Genu valgum braces 12 Valgus pads, stiffening and wedges 1 Minor alterations to boots (wedges, etc.) 78 Surgical Operations.—During the year eight children under school age were admitted to hospital and the following operations were performed by Mr. Whitchurch Howell:— Osteoclasis (right and left) and plaster 1 Tenotomy of tendo achillis and plaster 3 Manipulation of foot and plaster 4 Macewen's osteotomy femur (right and left) 2 Median stoffel 1 Plaster bed 1 Investigation and treatment 1 Artificial Sunlight Treatment. Forty-two children were submitted to a course of treatment by ultra violet rays during the year, and made a total of 597 attendances. Twelve did not attend with sufficient regularity to justify their attendances being regarded as full courses of treatment; and in eight cases the full course of treatment had not been completed at the end of the year. It was found, as in previous years, that children with delayed dentition showed the most marked improvement following ultra violet radiation. Dr. Menzies submits the following clinical observations on 22 children who completed their courses of treatment during the year Delayed Dentition (16 cases).—Of the 22 children who completed full courses of treatment during the year, 16 were cases of delayed dentition. Of the latter, all—with one exception—appeared to cut their teeth more rapidly after artificial sunlight treatment had been instituted. The one doubtful result was the first case of the following series. 1. Breast fed for 9 months—no teeth at 10 months—perspired freely and had wide anterior fontanelle. Ultra violet ray treatment commenced—Cut 2 teeth—excessive perspiration ceased—anterior fontanelle closing. After 3 months' treatment family left district. 104 2. Breast fed 8 months—allowed free milk (1 pint daity) and cod liver oil —no teeth at 8 months—weight 18 lbs. ozs. Ultra violet ray treatment commenced—7 teeth at 13 months—11 teeth at 18 months—weight 25 lbs. 7 ozs. 3. Breast fed 5 months—Nestles milk and barley water for 4 months—no teeth at 9 months—diet changed to cow's milk and water (5/3)— vegetable soup, orange juice, cod liver oil and malt in feeds—no teeth at 10 months—weight 21 lbs.—rachitic. Ultra violet ray treatment commenced—6 teeth at 14 months—weight 24 lbs. 2 ozs.—had whooping cough—12 teeth at 21 months—weight 28 lbs. 2 ozs. 4. Partly breast fed for 4 months—Ostermilk and cod liver oil for 4 months —cows' milk at 9 months—Radiostoleum at 9 months—no teeth at 10 months—weight 19 lbs. 3½ ozs. Ultra violet ray treatment commenced—No teeth at 12 months— weight 20 lbs. 13 ozs.—2 teeth at 13 months—weight 21 lbs. 9 ozs.— 6 teeth at 15 months. 5. Breast fed 8-9 months—Radiostoleum from 6 months—weight 16 lbs. 11 ozs.—cod liver oil from 8 months—no teeth at 11 months—weight 19 lbs. 2 ozs. Ultra violet ray treatment commenced—5 teeth at 13 months—8 teeth at 15 months—weight 21 lbs. 2 ozs. 6. Entirely breast fed 6 months—complementary feed of milk and water with small amount cod liver oil until weaned at 9 months—no teeth— weight 17 lbs. 3 ozs. Radiostoleum from 9-10 months—Kalzana 10-12 months—no teeth at 12 months—weight 19 lbs. 1 oz. Ultra violet ray treatment commenced—2 teeth at 13 monthsweight 19 lbs. 14£ ozs.—8 teeth at 14 months—12 teeth at 17 months— weight 23 lbs. 13 ozs. 7. Breast fed 9 months—free milk supplied from 4 months—cod liver oil from 9 months—no teeth at 10 months—2 teeth at 11 months—3 teeth at 12 months—weight 20 lbs. Ultra violet ray treatment commenced—7 teeth cut by 14 months— when child developed whooping cough which interrupted treatment for 8 weeks. Ultra violet ray treatment recommenced—child had 8 teeth (16 months)—16 teeth at 21 months. 8. 7| lbs. at birth—breast fed—pneumonia at 3 months—no teeth at 8 months—cod liver oil—2 teeth at 10 months—weight 20 lbs. £ oz.— otorrhcea—Radiostoleum—5 teeth at 15 months—weight 25 lbs. 5J ozs. Ultra violet ray treatment commenced—7 teeth at 17 months—weight 25 lbs. 5 ozs.—14 teeth at 21 months—weight 27 lbs. 10 ozs. 105 9. Breast fed 4 months—cows' milk and cod liver oil from 4 months— no teeth at 12 months—rachitic—4 teeth at 15 months (2 incisors, 2 molars)—weight 22 lbs. 7 ozs. Ultra violet ray treatment commenced—8 teeth at 17 months—weight 24 lbs—cod liver oil—11 teeth at 19 months—16 teeth at 2 years—weight 25 lbs. 11 ozs. 10. Breast fed—cod liver oil from 6 months—weight 16 lbs. 8 ozs.—no teeth at 8 months—weight 18 lbs. 5 ozs.—4 teeth at 10 months— weight 17 lbs. 11 ozs.—7 teeth at 15 months—weight 21 lbs. 4 ozs. Ultra violet ray treatment commenced—16 teeth at 21 months— ultra violet ray treatment ceased—17 teeth at 28 months—weight 29 lbs. 9 ozs. 11. Breast fed 9 months—Radiostoleum from 7 months—4 teeth at 9 months—weight 19 lbs 13 ozs.—6 teeth at 12 months—weight 21 lbs. 8J ozs.—9 teeth at 14 months—weight 22 lbs. 13½ ozs.—12 teeth at 16 months—12 teeth at 18 months—weight 25 lbs. 4½ ozs.—mother anxious because child not walking alone. Ultra violet ray treatment commenced—19 teeth at 28 months— weight 30 lbs. A oz.—colour improved. 12. Breast fed 3 months—cows' milk and barley water from 3 months— free milk from 5 months—weight 19 lbs. 12 ozs.—cod liver oil from 5 months—no teeth at 10 months—weight 19 lbs. 6 ozs. Ultra violet ray treatment commenced—8 teeth at 19 months—cod liver oil—weight 24 lbs. 13 ozs.—11 teeth at 20 months—general condition thought to have improved since ultra violet ray. 13. Partly breast fed 6 months—weight 15 lbs. 9J ozs.—1st tooth at 11 months—8 teeth at 15 months—takes ½ pint milk daily—cod liver oil— 8 teeth at 17 months—weight 24 lbs. 13 ozs.—Radiostoleum—8 teeth at 19 months—weight 25 lbs. 6 ozs.—gums septic—rachitic. Ultra violet ray treatment commenced—12 teeth at 21 months—had attended for ultra violet ray twice only in this period—weight 26 lbs. 4 ozs. Ultra violet ray recommenced at 21 months—attended continuously until 31 months when dentition complete. 14. Seen first at 12 months—weight 19 lbs. 14½ ozs.—no teeth—put on cod liver oil mixed diet—2 teeth at 14 months—bowing of legs—8 teeth at 21 months—weight 23 lbs. 13 ozs. Ultra violet ray treatment commenced—16 teeth at 26 months— weight 26 lbs. 10 ozs.—16 teeth at 30 months—weight 27 lbs. 15½ ozs. 15. Artificial feeding from early months—" Cow & Gate " with small quantity cod liver oil from 6 months—2 teeth at 10 months—weight 18 lbs. 14 ozs.—6 teeth at 14 months—weight 22 lbs. 9^ ozs.—13 teeth at 21 months—weight 25 lbs. 12 ozs.—abdomen protruberant—frequent attacks of bronchitis—rachitic. Ultra violet ray treatment commenced—20 teeth at 34 months—weight 30 lbs. 1 oz. 106 16. Weight at birth said to be 7 lbs. 12 ozs.—weight at 1 month 6 lbs. 5½ ozs. —on milk feed with cod liver oil from 1 month—no teeth at 8 months— weight 14 lbs. 11 ozs.—Radiostoleum—no teeth at 10 months—weight 16 lbs. 4 ozs.—3 teeth at 13 months weight 18 lbs.—overactive child— 1£ pints milk daily—does not eat much solid food—12 teeth at 24 months —weight 21 lbs. 5 ozs. Ultra violet ray treatment commenced—14 teeth at 28 months—weight 22 lbs. 14£ ozs.—recurring otorrhoea for 6 months—16 teeth at 31 months weight 22 lbs. 11½ ozs.—18 teeth at 33 months—weight 23 lbs. 14 ozs. These cases cannot be classified. In some one would expect to find delayed dentition, e.g., in No. 15, where the general progress of the child had been poor; in No. 2, where the diet had been unsatisfactory; in No. 7 (pneumonia at 3 months) where a general illness had occurred in the first twelve months. In others there was no apparent cause for the delayed dentition, e.g., breast fed children who had made good progress in other respects and who had no other obvious signs or symptoms of rickets. An -attempt will be made to examine the teeth of these children before they reach school age to find out if delayed dentition is associated with a greater amount of dental caries than is met with in the average child of 5 years in the area. As regards the effect of ultra violet radiation, it is difficult to be dogmatic. The records show that the rate of eruption of teeth was accelerated while ultra violet radiation was continued. Case No. 6 is particularly interesting in that the child cut the first three teeth between 10-12 months. Ultraviolet radiation was commenced at 12 months, and four teeth appeared in the next two months. At that point the child developed whooping cough, which interrupted treatment for eight weeks and in that time only one tooth erupted. Treatment was recommenced at 16 months, and in the following five months eight teeth appeared, making a total of sixteen teeth at 21 months. Thus the rate of eruption was definitely greater while the child was having ultra violet radiation. On the other hand it may be argued that the occurrence of a general systemic disease was a more important factor in modifying the eruption of the teeth than the temporary cessation of ultra violet radiation. Two cases, in which the children did not attend regularly, illustrate the danger of attributing improvement categorically to any form of treatment which may have been instituted. One was a child who had cut twelve teeth at 18 months. He did not cut any teeth between 18 months and 2 years in spite of having received Radiostoleum from 20-24 months. At 2 years the mother was advised to stop Radiostoleum and take the child for ultra violet ray treatment instead. He was seen two months later, but it was found that he had made only one attendance at the ultra violet light clinic ; but in these two months he had cut four teeth and one month later he had cut another two, making 18 teeth at 27 months. The second case was a child who had 3 teeth at 12 months and 6 teeth at 14 months. She refused cod liver oil. Ultra violet radiation was advised at 14 months, but three attendances only were made, yet two months later that child 107 had 11 teeth and at 20 months 16 teeth. Had these two children received a course of ultra violet radiation as advised, the improvement in dentition would have been attributed to the treatment. General Debility (6 cases). The remaining six cases were given ultra violet radiation in order to improve their general condition. Two had abdominal symptoms—enlarged glands with attacks of diarrhoea. Three were underweight and restless children with poor appetites. The sixth child was suffering from debility following whooping cough and broncho pneumonia. In all six cases definite improvement followed ultra violet radiation. Convalescent Home Treatment. During the year 24 children recommended by the Clinic Medical Officers were sent to Convalescent Homes by the Maternity and Child Welfare Authority through the agency of the Invalid Childrens' Aid Association. Dr. Menzies has submitted the following clinical observations on the children recommended by her for convalescence during the year The periods of convalescence varied from three to fourteen weeks except in one special case. This was a case of congenital dislocation of the hip which was taken over from West Ham Maternity and Child Welfare Authority after three months convalescence. After the child had a further period of seven months' convalescence the parents returned to West Ham and the case was therefore transferred back to West Ham. The hip was then in plaster and the condition was greatly improved. No child was recommended for less than four weeks, although two children were discharged at the parents' request after three weeks. Unfortunately, both were children who ought to have had at least two months rest from their parents. In the first case the mother gave an inaccurate account of the child's habits, and in addition the child developed an impetiginous rash on her face which led to her being discharged from the Home. The mentality of the mother may be judged from the fact that, at years, the child had not been trained in habits of cleanliness. In the short time the child gained 1 lb. in weight and added a second pound in the month following her return. It may be possible to send this child away again later, although the mother delayed six months before agreeing to convalescence before. The second case who returned after three weeks was equally unfortunate. The father's selfishness was such that he refused to allow the child to stay longer. The child was considerably underweight and even in three weeks' convalescence her gain in weight Avas equal to her gain in the previous nine months at home. The father was unemployed and he did not suggest that the child was not benefitting by convalescence. 108 His sole reason was that he missed the child too much to allow her to stay away for a longer period. This so-called parental love is responsible for a great deal of mental instability and poor physical health in children. Where it occurs, the pleasure of the parent in the child is placed before the welfare of the child. Any attempt to remove the child even temporarily from the influence of the parent is resisted, the reason given being that " the child would fret." Sixteen of the twenty-four cases were at convalescent homes eight weeks or longer; and of these, eight were away twelve weeks or longer. Two-thirds of the total number were children under three years, and the remainder were aged 3-5 years. With two exceptions, definite improvement was recorded in all cases. The children were all underweight before they were sent away, and the rapidity with which they gained weight in the more stable environment of the convalescent home was often remarkable. It is found advisable to warn mothers that this weight may not be maintained after the children return home after convalescence. Mothers who consider that they are giving the children exactly the same diet as they received in the convalescent home are dismayed to find that, instead of a continued gain in weight, there may actually be a loss in the months immediately following convalescence. The majority of the children were labelled "debility." In 10 cases there was a previous history of some catarrhal infection—measles, whooping cough, bronchitis, pneumonia or otitis media. In one the debility followed diphtheria. In 3 cases the home conditions were deplorable, the mothers being of the uneducable type, and the fathers unemployed. In several cases the change in the child's general condition was so great that the mother herself stated he/she "looked a different child." One case is worth discussing in greater detail. The circumstances were similar to those of the unfortunate child whose father removed her after three weeks. The father was unemployed, the child aged 1 year 10 months, and—according to the mother—the father "spoiled the child." The child was receiving one pint of milk free each day through the maternity and child welfare scheme, which ensured that I saw the mother at intervals. It was several months before I obtained, through her, the father's permission to arrange convalescence for the child. The child at that time was fretful, had a poor appetite and was not gaining weight. The first week in the convalescent home she screamed day and night whenever she was left to herself and the authorities were afraid they would have to send her home. In two weeks she had settled down, but then the parents intervened—as in the other case, and it was only with difficulty that they were persuaded to leave the child in the Home. When she was eventually discharged from the Home—after 14 weeks—the change in her appearance was amazing. She looked happy, whereas formerly she had looked miserable ; she had a good appetite and she had gained 3½ lbs. in weight. The Matron of the Convalescent Home wrote that she considered the child one of the most interesting and successful cases she had ever had under her care. 109 Ophthalmia Neonatorum. Cases. Treated Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. At Home. In Hosp. Notified in the area. 7 5 2 7 - - - Notified outside the area. 1 - 1 1 - - - Totals 8 5 3 8 — — — During the year 7 cases of ophthalmia occurred within the area and were duly notified to the Medical Officer of Health. In addition, later information was received regarding one infant of a Leyton mother who developed ophthalmia in an institution outside this area and was notified to the Medical Officer of Health of the area in which it occurred, viz, :— Royal Free Hospital 1 case Treatment.—These 8 cases were treated as follows :— At home 5 St. Margaret's Hospital 3 (mother and infant) 8 In December, 1930, this Maternity and Child Welfare Authority entered into an arrangement with the London County Council for the admission of Leyton cases requiring special institutional treatment to St. Margaret's Hospital. As from the 1st October, 1933, the rate of charge by the London County Council for the maintenance of patients in St. Margaret's Hospital was reduced from £4 2s. 4d. to £3 14s. 8d. per patient per week. 110 PEMPHIGUS NEONATORUM. In March, 1933, the Medical Officer of Health submitted to the Maternity and Child Welfare Committee the following observations :— Pemphigus Neonatorum is a rare but highly contagious disease of the skin occurring in the new-born, usually between the 4th and the 14th day after birth. Although the infection is often of mild type, serious outbreaks have been reported in which cases terminate fatally. In October last I reported to this Authority and to the Ministry of Health regarding a series of five cases which occurred in the practice of a midwife in this area; and during the past month two further cases have been dealt with. The cause of Pemphigus Neonatorum is not known accurately, but the infection seems to cling to clothing, medical appliances and equipment, etc.; and we do know that the midwife or medical attendant may be the source of infection and the means of spread. According to the rules of the Central Midwives Board a midwife must summon medical aid and notify the Local Supervising Authority at once in the case of any serious rash in a new-born child attended with the formation of watery blisters. She is also bound to undergo disinfection to the satisfaction of the Local Supervising Authority. There is, however, no obligation on medical practitioners to notify such cases, as Pemphigus Neonatorum is not one of the diseases scheduled as compulsorily notifiable in the Infectious Disease (Notification) Act. Inasmuch as it calls for more energetic public health action than most contagious diseases, I suggest that this Committee submit to the Public Health Committee a recommendation that steps be taken to extend the list of diseases notifiable under the Infectious Disease (Notification) Act to include Pemphigus Neonatorum. In April the Council made an Order extending the application of the Infectious Diseases (Notification) Act to include Pemphigus Neonatorum subject to the approval of the Minister of Health, who formally approved the Order during the following month. Cases during Year (Report by Dr. Menzies). Four definite cases of Pemphigus Neonatorum occurred during 1933. One case was notified on discharge from Queen Mary's Hospital, and the remaining three cases occurred at intervals of two months (from February to June) in the practice of different private midwives. There was no apparent connection between any of the cases. The first case, notified from hospital, had developed on the 6t,h day after birth, and when the child was visited six days later the remains of nine superficial bullæ were found. No further lesions developed. 111 The second case occurred in the practice of a private midwife in February. The midwife notified that the child was suffering from " watery blisters " when the child was six days old. The midwife was suspended from duty pending disinfection, and swabs were taken of nose and throat (with negative results). Arrangements were made for a nurse from the Essex County Nursing Association to attend the case and twenty-five visits Avere made. No other cases developed, although it was discovered subsequently that a case which the midwife had attended outside the Borough about a month previously had developed Pemphigus after the midwife had ceased attendance. The third case occurred in the practice of a midwife in April. The first vesicles appeared when the child was four days old, and the lesions became more numerous and more extensive until the child was twelve days old. The child was twenty-four days old before the lesions had entirely disappeared. The handywoman in attendance was considered to be capable, so she was allowed to complete her fourteen days with the patient, after which she was required to disinfect herself and her clothing. A nurse from the Essex County Nursing Association subsequently attended until the child had recovered. Nineteen visits were paid. The midwife— employed temporarily by another midwife—had actually left the patient to nurse a woman who had had a baby fourteen days previously before the diagnosis of Pemphigus was made. Of six cases with which this midwife had been in contact, two developed skin lesions, but both were very slight and neither was considered to be Pemphigoid. It was considered advisable to suspend the midwife from duty for one week and she received £2 2s. as compensation for loss of work during that week. Swabs were taken of her nose and throat with negative results. The fourth case occurred in the practice of a private midwife in June. It was discovered at the Infant Welfare Clinic when the child wras 15 days old. According to the mother the first blister developed on the 7th day, but the midwife stated that, although there was a small pustule on the face, no blisters had developed by the tenth day when the midwife ceased attendance on the patient. The midwife had already undergone disinfection by the time she was interviewed. No further cases of Pemphigus developed in her practice. Arrangements were made for a nurse from the Essex County Nursing Association to attend twice daily for eight days, and once daily for the subsequent four days. Twenty visits were paid. The four cases of Pemphigus Neonatorum recorded above made good recoveries. In none were there any toxic symptoms. Infant and Fœtal Mortality. There were 76 deaths of infants under one year registered in 1933, giving an infantile mortality rate of 50.73. Table 8 shows that the annual decrease in the number of births was greater in 1933 than in any of the last five years. In spite of that fact, the infant mortality is lower than in 1932 (53.42). 112 The infant deaths in 1933 were 13 less in number than in 1932. The high proportion of deaths under four weeks (47 out of 76) demonstrates the importance of measures for the reduction of neo-natal mortality. In 1927 the Borough of Leyton was awarded the first prize (see page 28, 1928 Annual Report) for the greatest percentage reduction in the neo-natal mortality rate during the previous year. At that time no special effort had been made to effect a reduction in neo-natal mortality. There were in the Borough at that time two ante-natal clinics—one of which had been established in 1926 ; but no effort was then being made to follow up the cases, and many of the expectant mothers had made only one attendance at an ante-natal clinic. Neo-natal Mortality (Report by Dr. Menzies). Stillbirth as a Factor in Neo-natal Mortality. It will be seen from the following figures that the Neo-natal death rate in Leyton during the last five years has fluctuated considerably. It ought to be studied in conjunction with the rise and fall in the number of births and the birth rates in the years under review. Year. No. of Births. Increase or Decrease over Previous Year. Birth Rate. Deaths under 4 Weeks. Neo-natal Death Rate. 1929 1,731 —122 13.4 54 31.19 1930 1,757 +26 13.69 48 27.32 1931 1,812 +56 14.09 38 20.97 1932 1,666 —146 13.1 51 30.61 1933 1,499 —168 11.91 47 31.35 It probably ought also to be studied in conjunction with the still births, as there is little cause for congratulation in having fewer neo-natal deaths if the number of stillbirths is correspondingly greater. Year. Neo-natal Death Rate. Infant Mortality Rate. No. of Deaths under 4 Weeks. No. of Deaths under 1 Year. No. of Stillbirths. 1929 31.19 57.77 54 100 53 1930 27.32 46.09 48 81 81 1931 20.97 39.18 38 71 59 1932 30.61 53.42 51 89 58 1933 31.35 50.73 47 76 48 1929.—An analysis of the details available concerning the 53 stillbirths notified in Leyton in 1929 emphasised the relationship between foetal and neo-natal deaths. In 14 cases there was evidence that the death of the fœtus was intra-natal ; and in 12 other cases the foetus was prematurely born. As regards the 54 neo-natal deaths, 24 were certified as due to " prematurity " and 4 to " injury at birth." 113 Only one-third of the stillbirth cases had received any degree of ante-natal treatment. A point of interest, elicited from the histories of the mothers who had stillbirths in 1929 was that 24 per cent, showed •evidence of repeated failure to produce living children. 1933.—When a similar analysis is made of the 48 stillbirths notified in 1933, the details are as follows. In 15 cases no reliable information as to the cause of the stillbirth was available. The remaining 33 stillbirths may be classified in three groups :— 1. Where general disease of the mother existed. Cardiac disease 2 (1 had 3 previous stillbirths) Syphilis 1 3 "2. Where an abnormality associated with pregnancy occurred. Ante partum hsemorrhage 3 (1 premature) Twins 1 (premature) Pyelitis 1 Albuminuria 1 (premature) Excessive vomiting 1 Prematurity 6 (no other cause known) 13 Where labour was abnormal. Instrumental delivery 7 (4 primigravidse) Breech presentation 7(4 primigravidse) Prolonged labour 2 (1 primigravida) Transverse presentation 1 (primigravida) 17 It is impossible, without a post mortem examination, to decide if the associated abnormality was the cause of the stillbirth : but one is probably justified in assuming that in Group 3 the death of the foetus occurred during labour. Of the seven instrumental deliveries, four had received no antenatal care—one had definitely refused to be examined by her doctor. All the seven breech presentation cases had some degree of ante-natal care— four were breech cases with extended legs. The transverse presentation case, and one of the prolonged labour cases, failed to re-attend for ante-natal examination. Of the total of 48 stillbirths, only 8 of the mothers had received no ante-natal treatment. This is a definite improvement since 1929, when the proportion was 23 out of 53. 114 Twenty of the stillbirths occurred in primigravidse ; and of the remaining 28 multipara,eight (29 per cent.) had previous miscarriages or stillbirths. Of nine previous pregnancies, one woman had seven stillbirths, one miscarriage, and one living child. Forty of the forty-seven neo-natal deaths in 1933 were from causes of intra-natal or pre-natal origin. Twenty-seven were certified as due to prematurity; and of these twenty-four died during the first week. Of the infant deaths from 1-12 months, eight were presumably of pre-natal origin, viz., six from congenital malformations and two from marasmus. These developmental deaths (48 in all), representing as they do 63 per cent, of the total infant mortality, suggest some defect in pre-natal health. Eighteen occurred in primigravidse : and of the remaining thirty multiparse, six had previous stillbirths. Routine Steps Taken with View to Possible Reduction in Neo-natal Mortality. Since 1929, Health Visitors have been instructed that, on making a routine visit after a stillbirth or a death under four weeks, they must question the mother particularly regarding :— 1. Health during pregnancy. 2. Health previous to pregnancy. 3. Previous abortions, stillbirths or premature births. 4. Attendance at ante-natal clinic. 5. Any other ante-natal treatment. 6. Condition of teeth. 7. Existence of vaginal discharge. The question regarding the teeth is included, not because it is thought to have a direct bearing on the subject of stillbirths and neo-natal deaths, but because experience at the ante-natal clinics has shown that an astonishing number of expectant mothers harbour obvious sepsis in their mouths and are very difficult to convince that it exerts a harmful effect on their own health and that of their baby. Efficient ante-natal supervision is recognised to be a factor in the reduction of neo-natal mortality. In order to encourage midwives to send their patients to the municipal ante-natal clinics, the following steps have been taken :— 1. A report on the patient's condition is sent to the midwife by the Clinic Medical Officer in every case. 2. If the patient does not keep her appointment, or if any abnormality develops, the midwife is notified. 3. If the abnormality is such that it is considered necessary that the patient should be admitted to hospital for her confinement, the midwife is compensated to the extent of 10s. per case. 115 4. Home helps are available, and assistance towards payment of the midwife's fee is given in necessitous cases provided that the patient is willing to attend an ante-natal clinic. 5. Applicants for free milk and/or free accouchment sets are expected to attend an ante-natal clinic. Since the Borough Council became the Local Supervising Authority for midwives in 1931, it has been easier to ensure that the majority of midwives' cases are under supervision during pregnancy. Expectant mothers who have not booked with midwives and have not kept their appointments at the ante-natal clinic are visited by a health visitor and urged to re-attend unless ante-natal supervision is being undertaken elsewhere. Visits are made also to expectant mothers who apply for home helps in order to find out if the home conditions are suitable for the confinement to take place at home. If not, arrangements are offered for admission to an institution. The services of a Consultant Obstetrician are available to any general practitioner in the Borough. When a midwife sends in a medical aid notice in which the abnormality is " prematurity," a health visitor visits before the tenth day to give advice regarding the importance of keeping a premature baby warm. Midwives are encouraged to make special requests for early visits by health visitors in cases where there is any difficulty with the feeding, but these requests are not often made. 116 TABLE 8. Infantile Mortality, Year 1933—Ages. CAUSES 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. Smallpox ... ... ... ... ... ... ... ... ... ... Chickenpox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... Scarlet fever ... ... ... ... ... ... ... ... ... ... Whooping cough ... ... ... ... ... ... ... 1 1 2 Diphtheria and croup ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... 1 ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... 1 1 Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... 1 ... ... 1 2 Meningitis (not tuberculous) ... ... ... ... ... ... ... 1 ... 1 Convulsions ... ... ... ... ... ... 1 ... ... 1 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... 1 1 2 ... ... ... ... 2 Pneumonia (all forms) ... ... ... ... ... 1 ... ... 3 4 Diarrhœa ... ... ... 1 1 ... 1 ... ... 2 Enteritis ... ... ... ... ... 2 2 ... ... 4 Gastritis ... ... ... ... ... ... ... ... 1 1 Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... Injury at birth 4 1 ... ... 5 ... ... ... ... 5 Atelectasis 1 1 ... ... 2 ... ... ... ... 2 Congenital malformations 1 1 2 ... 4 4 ... 1 1 10 Premature birth 24 ... 2 1 27 ... ... ... ... 27 Atrophy, debility and marasmus 1 ... 1 ... 2 2 ... ... ... 4 Other causes 1 2 1 ... 4 1 1 1 ... 7 Totals 32 5 7 3 47 11 6 4 8 76 Nett Births registered during the calendar year Legitimate 1,463 Nett Deaths registered during the calendar year Legitimate infants 72 Illegitimate 36 Illegitimate infants 4 117 TABLE 8a. Infantile Mortality During the Year 1933—Wards. CAUSE OF DEATH. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Ward not known. Total Deaths under 1 Year. Smallpox ... ... ... ... ... ... ... ... ... ... ... ... Chickenpox ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... Scarlet fever ... ... ... ... ... ... ... ... ... ... ... ... Whooping cough ... 1 ... ... ... 1 ... ... ... ... ... 2 Diphtheria and croup ... ... ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... ... ... 1 ... 1 Tuberculous meningitis ... 1 ... ... ... ... ... ... ... ... ... 1 Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... 1 1 ... ... ... ... ... 2 Meningitis (not tuberculous) ... ... ... ... ... ... ... ... ... 1 ... 1 Convulsions ... ... 1 ... ... ... ... ... ... ... ... 1 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... 1 ... ... 1 ... ... ... 2 Pneumonia (all forms) ... ... ... ... ... ... ... 1 1 2 ... 4 Diarrhœa ... ... 1 1 ... ... ... ... ... ... ... 2 Enteritis ... 2 ... ... ... 1 1 ... ... ... ... 4 Gastritis ... ... 1 ... ... ... ... ... ... ... ... 1 Syphilis ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... ... ... Injury at birth ... 1 ... ... 2 1 1 ... ... ... ... 5 Atelectasis 1 ... ... 1 ... ... ... ... ... ... ... 2 Congenital malformations ... 1 ... 1 1 ... 4 1 2 ... ... 10 Premature birth 4 4 ... ... 6 6 2 ... 2 3 ... 27 Atrophy, Debility and Marasmus ... ... 1 1 1 ... ... ... 1 ... ... 4 Other causes 1 3 1 ... ... ... 1 1 ... ... ... 7 Totals 6 13 5 4 12 10 9 4 6 7 ... 76 118 Children and Young Persons Acts, 1908-1932. Infant Life Protection. On 1st January, 1933, 49 foster mothers and 52 children were subject to inspection in the area. At the end of the year 56 foster mothers and 60 children were subject to systematic inspection by this Council's Visitors. During the year under review the Council granted permission to 4 foster mothers to undertake the care and maintenance of more than one child. The Council's Infant Life Protection Visitors paid 322 visits of inspection during the year ended 31st December, 1933. Summary, Year 1933. Number of nurse children on Register 1st January, 1933 52 Number of nurse children notified by foster mothers during the year 1933 59 Nurse children removed during 1933 :— To parent or parents 21 To another foster mother 18 With foster mother to another area 2 To relatives 2 Adopted by foster mother — To National Children's Home 2 To other institutions 5 Attained 9 years of age — Died 1 Number of nurse children on Register on 31st December, 1933 60 The Children and Young Persons Act, 1932, which came into operation on 1st January, 1933, amends and strengthens the law as to infant protection laid down in the Children Act of 1908. The Ministry of Health has issued to Maternity and Child Welfare Authorities two Memoranda (165 and 165a, M.C.W.), one summarising the provisions of the new Act and the other setting out the law on the subject—for which reference has to be made both to the Act of 1908 and that of 1932—for the guidance of infant protection visitors. Notification must now be made of the reception for reward of children under the age of 9, instead of, as formerly, under the age of 7; and the notification has to be made, save in the case of a child received in an emergency, before instead of after its reception. It is also provided that notification of the death or transfer of the child must be made, not only to the Local Authority, but to the person from whom the child was received. Notification of death has also to be made to the Coroner. The power of the Authority 119 to limit the number of children in a foster home has been extended, as also the power to secure the removal of children kept on unsuitable premises or by unsuitable persons ; unsuitable persons include those unfit to have care of such children by reason of old age, infirmity or ill-health, as well as ignorance, inebriety, immorality or criminal conduct. Detrimental environment is recognised, as well as unsuitable premises or foster parents, as a ground for action either before or after reception. The exemptions to be granted to hospitals, convalescent homes and institutions have been more closely defined in the new Act. Every Maternity and Child Welfare Authority has to provide for the administration of the Act in its area, and whenever children are kept for reward the Authority must appoint one or two health protection visitors who have to satisfy themselves as to the health and well-being of the children and give any necessary advice or direction. The wider terms "health and well-being " have replaced the narrower ones " nursing and maintenance " in the Act of 1908. Other provisions in the Act relate to delinquent children, and the substitution of what is known as residential schools for the old industrial reformatories. ANTE-NATAL SUPERVISION. Ante-natal Clinics— (1) The County Nurses' Association Home, Beachcroft Road, Leytonstone.—Thursdays, 10 a.m. (2) Health Clinic, Leyton Green Road, Wednesdays, 10 a.m. (3) Do. do. —Fridays, 10 a.m. Attendances.—During 1933, the attendances were as follows: Centre. First Attendances. Subsequent Attendances. Total. Town Hall 161 211 372 Beachcroft Road 146 193 339 Capworth Street Health Clinic, Leyton 99 148 247 Road Green 406 552 958 120 The total number of first attendances during 1933 was 406, the corresponding figure for 1932 being 487. The total number of attendances at all clinics during the year was 958, the average attendance per session being 6.65. Of the 406 expectant mothers who made first attendances during 1933, 109 had not been confined by the end of the year and the results of these cases will be included in the annual report for 1934. On the other hand, 146 cases were carried over from 1932, and, when these are included, details of 443 cases are available. Of that number 21 were not pregnant, and the following table deals with the attendances of the remaining 422. Number of Expectant Mothers who attended. 422 Percentage of Primigravidse. 36.50 Percentage of Multipara. 63.50 % * % * 1. Attended before 24th week of pregnancy 23.37 (36.47) 26.49 (26.90) 2. Attended after 24th week and before 30th week 26.62 (20.58) 22.38 (25.45) 3. Attended after 30th week and before 36th week 6.49 (7.64) 5.59 (5.45) 4. Transferred 27.27 (18.82) 16.41 (16.72) 5. Unsatisfactory 16.22 (16.47) 29.10 (25.45) *Figures for previous year (1932) shown in brackets. In the above table the percentages shown (1, 2 and 3) include only those who continued to attend and who made from two to eight attendances. That is to say, 56 per cent. of the primigravidae and 54 per cent. of the multiparæ were, on the whole, satisfactory in their attendance; (4) includes those who were transferred to hospital after one attendance, or who ceased to attend for some other known reason, e.g., removal from district, etc. The unsatisfactory group (5) includes both those who attended early hi pregnancy but did not attend regularly, and those whose first attendance was made so late in pregnancy that it was possible to see them once only. The percentage of transferred cases in primigravidæ has increased from 19 to 27. This reduces the other percentages and gives an apparently unfavourable comparison with last year, but the percentage of unsatisfactory cases remains the same as last year. The multiparæ have not attended quite so well. 121 Twenty-four per cent of expectant mothers attended of their own accord or on the advice of a friend or relative. Sixty-two per cent were sent by their midwives and 3 cases were advised to attend by their own doctors. The number of home visits made by Health Visitors to expectant mothers during the year was 113. The results of all the cases examined are tabulated below. Number. Percentage of Finished Cases. Normal (1 child died) 355 88.08 Prematurity (5 infants and 1 mother died) 13 3.22 Stillborn 9 2.23 Instrumental delivery (1 child died) 6 1.48 Breech presentation 6 1.48 Miscarriage 6 1.48 Twins 3 0.74 Caesarean section 2 0.49 Surgical abortion 1 0.24 Induction 1 0.24 Placenta prævia 1 0.24 Total 403 Not pregnant 21 Removed 19 Grand total 443 Analysis of Abnormal Cases. (report by Dr. Menzies). (a) Prematurity (13 cases). Of the thirteen cases of premature birth, eleven occurred in multipara, and two in primigravidæ. In the case of the two primigravidæ, the pregnancies termined at 6½ and 7 months respectively and the babies lived only a few hours. One case was particularly tragic, as the mother lost her life also. She was a woman of 24 years with 1½ inches shortening of the right leg and resultant tilting of the pelvis from an uncorrected pes cavus 122 She had booked with a midwife, but was advised to attend Hospital regarding the advisability of having her confinement at home. Unfortunately she did not attend Hospital as advised. Labour commenced ten days later and resulted in the death of both mother and child. Details of the case are given under maternal mortality. Of the eleven multiparae, three gave a history of previous premature births or abortion. One had given birth to five full term children followed by a six weeks' miscarriage after an interval of five years. The premature birth (36 weeks) followed two years later. The child died at the age of two weeks from bronchitis. The second mother was a girl of eighteen years who was having her second child (born at 34 weeks) when her first (born at 32 weeks) was only 14 months old. The third patient was a woman who was very anxious to have a live child. This was the third premature birth she had had, and none of the children had survived. There was no obvious cause for the repeated early termination of pregnancy and the case will be sent to hospital for a fuller investigation. Of the eight remaining multiparae, one developed pneumonia at eight months and that brought on labour prematurely. Another had had several attacks of ante-partum haemorrhage and the pregnancy terminated at 7 months. No obvious abnormality was found in the other six cases, and only one of the babies died. (b) Stillbirths (9 cases). Four of the stillbirths were in primigravidse, and five in multiparae. Of the four primigravidse only one attended more than once and even she did not make her first attendance until she was 35 weeks pregnant. She was found to have a raised blood pressure and slight swelling of the leg, but no albuminuria ; the presentation was a breech with extended legs. A second case was known to have a difficult labour. She was an elderly primigravida (40 years) who had a malpresentation and was admitted to hospital in labour after her medical attendant had pulled down an arm. A third case was an unmarried girl who gave a history of an inflammatory pelvic condition during pregnancy. No details were available regarding the fourth case. Of the five multiparae, two gave a history of previous miscarriages. Of these, one had suffered from salpingitis several years previously, and the second showed signs of pre-eclampsia when she attended at 8 months—a week before labour commenced. The latter had been warned two months previously that the condition of her mouth was a source of danger to her, her teeth being particularly septic. The third case was a breech presentation which was sent to hospital for version. Version was performed under eneral anaesthesia, and a macerated foetus was born ten days later. In the fourth case no abnormality could be found to account for the stillbirth. The fifth case was in a woman with an excess of abdominal fat, who attended once only at six months. She had a large stillborn child. (c) Instrumental Delivery (6 cases). Of the six instrumental deliveries, none were in regular attendance at the ante-natal clinic. 123 Four were primigravidæ, one of whom was advised to have her confinement in hospital because of risk of disproportion. The second made arrangements herself to go to hospital. The third booked with a general practitioner and was under his supervision. The fourth ceased attending the clinic at the most important time (during the last month) and had a long and difficult labour from which the child died (asphyxia pallida). One of the multiparæ was a very fat woman who had an instrumental delivery in her first pregnancy. With one exception, all the babies survived. (d) Breech Presentation (6 cases). Of the six breech deliveries, one was in a primigravida and five in multipara. Of these six, four (including the primigravida) made only one attendance at the ante-natal clinic. One booked with a doctor, a second had her confinement outside the district; and the remaining two were midwives' patients who failed to keep their appointments for a second -examination. Of the two who attended regularly, one had a breech delivery nine years previously, and a four months' miscarriage in 1930. She was advised to arrange to have her confinment in hospital, but she preferred to engage a. doctor and midwife. She was sent to hospital by her doctor and delivered of a breech with extended legs. In the other ease the breech presentation was not diagnosed ante-natally. All six children survived. (e) Miscarriages (6 cases). Of the six patients whose pregnancy terminated in miscarriage, five had previous premature births or miscarriages. One had two full-term children, one premature and three miscarriages. The second had six fullterm children, two six months pregnancies (children born alive) and one miscarriage. The third had one full-term child and two premature (one stillborn). The fourth had four full-term children, three premature and two miscarriages. The fifth had had one premature seven months' child (died at 3 days). The sixth, who had five full-term children, was 42 years of age and appeared to be in very poor condition. Cases Referred to Hospital. Fifteen cases were referred to hospital for the following medical reasons:— 9 threatened disporportion (2 confined in hospital). 2 ante-partum haemorrhage. 1 hyper-thyroidism with glycosuria (admitted for investigation). 1 version. 1 X-ray of chest. 1 for diagnosis. In addition, 35 cases were referred to hospital for admission because of lack of accommodation or lack of suitable arrangements in their own homes. 124 Maternity Beds. In addition to the 406 expectant mothers who attended the Council's clinics, 352 attended the Out-patient Department of Queen Mary's Hospital, Stratford, for ante-natal supervision. These mothers had their confinements in the Margaret Lyle Wards of the hospital. The complications dealt with included— Albuminuria 6 Ante-partum haemorrhage 2 Post-partum haemorrhage 2 Retro-placental haemorrhage 1 Ruptured perineum 10 Breech presentation 11 Forceps delivery 15 Induction 7 Foetal distress 2 Caesarean section 2 Episiotomy 7 Eclampsia 2 Mastitis 5 Prolonged labour 5 Obstructed labour 1 Pyrexia 3 Pyelitis 6 Embolism 1 Manual rotation 5 Occipito-posterior 5 High blood pressure 1 Prolapsed cord 2 Stillborn 2 Mitral stenosis 1 Glycosuria 1 Renal deficiency 1 Pemphigus 5 Discharging eyes 3 Sticky eyes 4 Macerated foetus 4 Cleft palate 1 Hare lip 1 Spina bifida 1 Hydrocephalus 1 125 Hydramnios 1 Fractured humerus 1 Talipes 1 Hypospadias 1 Melæna 1 Cord around neck 1 Bullous impetigo 1 The average duration of stay in hospital was 12.56 days, and the cost per case was £4 7s. 8d. of which an average of £2 0s. 9d. was paid by the patient and the remaining £2 6s. 11d. by the Council. Compensation to Midwives.—Compensation to midwives for the loss of cases referred from the ante-natal clinics to hospital was paid in one instance:— Primipara. Caesarean section. Live birth. Payment of Midwives' Fees in Necessitous Cases.— During the year no fees of midwives were paid by the Council in necessitous cases. MATERNAL MORBIDITY AND MORTALITY. Three cases of Puerperal Fever and 8 cases of Puerperal Pyrexia were notified during the year, and an endeavour was made in each case to obtain particulars regarding the cause of the rise of temperature. Puerperal Fever. Of the three cases notified as Puerperal Fever, in two cases both mother and baby survived, and in the third case both mother and child died. The fatal case was the one previously mentioned under the heading "Prematurity" in the analysis of ante-natal cases. The patient was a primigravida—age 24 years—28 weeks pregnant— and died in Whipps Cross Hospital. Of the two non-fatal cases, one was a case of sapræmia following instrumental delivery of an occipito-posterior presentation—head 126 rotated manually—severe perineal tear. Masks worn by both doctor and certified midwife in attendance. Not admitted to hospital. The second was a case of purulent endometritis following instrumental delivery of a primigravida—manual removal of retained placenta—perineal tear. Doctor in attendance wore gown and gloves. Certified midwife wore mask, white cap and gloves. Swabs were taken from the nose and throat of the midwife and from the nose, throat and cervix of the patient—no hæmolytic streptococci were found. The patient was admitted to Whipps Cross Hospital. Puerperal Pyrexia. As a result of investigations regarding the 8 notified cases of Puerperal Pyrexia, the causes of the pyrexia were considered to be:— Mastitis 2 Parametritis 1 Endometritis 1 Pyelitis 1 Bacilluria 1 Influenza 1 Cause unknown 1 All the mothers recovered and all the babies survived. Six were confined in hospital and two at home. Consultations. The advice of the Council's Consultant Obstetrician was sought on one occasion during the year, viz.:— Primigravida—25 years—normal labour—slight perineal tear —puerperium normal until 17 days after confinement—complained of sudden severe epigastric pain—temperature 101°, pulse 100— painful and frequent micturition—seen by Consultant two days later. Diagnosis—cystitis. Treatment—hot fomentations and alkaline mixture—to be admitted to hospital in 2 days if not improved. Made uneventful recovery at home. Maternal Mortality. Two women died during the year as the result of childbirth, giving a maternal mortality rate of 1.33 per thousand births. 127 The figures given below show the variation in maternal mortality during the past five years in Leyton as compared with the country generally. Year. Number of Maternal Deaths (Leyton). Maternal Mortality Rate. Leyton. England and Wales. 1933 2 1.33 4.42 1932 4 2.40 4.24 1931 9 4.96 4.11 1930 6 3.41 4.40 1929 4 2.31 4.33 It will be seen from these figures that—with the exception of the year 1931—the Leyton rate is substantially lower than that of England and Wales. The details of the first case have been described in the series of cases of puerperal fever. The patient was a primigravida, the cause of death being puerperal septicaemia. The details of the second case were:Primigravida—age 24— under ante-natal care of general practitioner—urine tested each month—two abdominal examinations—normal presentation— L.O.A. presentation. Patient admitted to hospital as an emergency 25th September, 1933. On 26th September the patient was delivered of a premature foetus, which died a few hours after birth. After delivery she became rapidly worse and developed abdominal distention, hæmaturia, with a rising temperature and pulse rate. Laparotomy was performed, which revealed generalised streptococcal peritonitis, which was drained. The patient died on 30th September. A post mortem examination confirmed the findings at operation. MIDWIVES' ACTS, 1902-1926. Supervision of Midwives.—During the year 57 midwives notified their intention to practise in the Borough. The existence in Leytonstone of the Beachcroft Road Training School of the Essex County Nursing Association increases considerably the return of midwives practising in the area. Twelve independent midwives residing in the Borough and seven resident outside the Borough notified their intention to practise in the area. Of these, five midwives did not undertake any cases during the year a fourth 128 undertook one case, and nine attended less than ten cases each. That is to say, the majority of the cases attended by independent midwives were undertaken by four midwives resident in the Borough. Of 33 midwives (attached to the Essex County Nursing Association) who notified their intention to practise during the year, an average of five were in practice throughout the year. The remainder were pupils who notified their intention to practice after passing the examination of the Central Midwives Board, but were not practising in the Borough for longer than six weeks before being sent to another district in Essex. In accordance with arrangements made with Medical Officers of Health of neighbouring Supervising Authorities for Midwives, visits of routine inspection by the Inspector of Midwives were paid only to midwives residing in the Borough. Twenty-eight such visits to the homes of midwives were paid during the year. In addition, the Inspector made special visits to, or had interviews with, midwives on 21 occasions. The results of the inspections were satisfactory. Pemphigus Neonatorum.—Three cases of Pemphigus Neonatorum occurred in the practices of midwives during the year. Details of the cases and the action taken in each case have been described under a separate heading. In accordance with the Rules of the Central Midwives Board a midwife must notify the Local Supervising Authority within 36 hours on every occasion on which she sends for medical aid. One hundred and twelve such notifications were received, and the following table shows the various complications for which medical assistance was summoned:— During Pregnancy. Ante-partum haemorrhage 3 Albuminuria 2 Distressing cough 1 Carried forward 6 129 Brought forward 6 During Labour. Ruptured perineum 35 Delayed labour 17 Extended breech 1 Prolapse of cord 2 Post-partum haemorrhage 2 Uterine inertia. 2 Transverse presentation 1 Occipito posterior presentation 2 Malpresentation 2 During Puerperium. General condition of mother 8 Rise of temperature 4 Conditions Associated with Infant. General condition of infant 6 Haemorrhage of infant 1 Discharging eyes 8 Watery blisters 3 Infant vomiting blood 2 Asphyxia pallida 4 Cleft palate 1 Jaundice 2 Prematurity 3 112 Fees paid to Doctors under Section 14 (1) of the Midwives' Acts, 1918. Ninety-one accounts were received from general medical practitioners for assistance rendered to midwives under the provisions of this section. The details of such accounts during the year 1933, were £ s. d. Fees of Medical Practitioners during above period 76 3 0 Proportion recoverable 40 2 0 Nett cost to Local Supervising Authority £36 1 0 130 Nursing Homes Registration Act, 1927. On 1st October, 1930, the Essex County Council delegated; to this Council their powers and duties under the above Act. The Act provides for the registration and inspection of nursing homes by the Local Supervising Authority. There are three registered nursing homes in the Borough. Of these, one is a maternity home only. One home closed during the year (18th August, 1933). These institutions were visited on 13 occasions, the result of inspection being satisfactory in each case. Home Helps. Under the Council's scheme for the provision of home helps, 19 applications for home helps were dealt with during 1933. In 15 cases home helps were provided, 14 of these cases having the charges remitted in accordance with the Council's scale. In the 4 remaining eases municipal home helps were not provided, as other arrangements for the confinements were made. At the end of the year there were 10 names on the Council's approved list of home helps. ASSISTED MILK SUPPLY. As it is a condition of grant that the mothers or infants must attend the Authority's Centres—unless when unable to attend, in which case the home is visited by a Health Visitor—all mothers and infants in receipt of milk free or at reduced price are under medical supervision. MILK SUPPLY, 1928-1933. Year. Pints of Fresh Milk. Packets of Dried Milk. Cost to Council. £ 8. d. 1928 38,543 7,204 983 17 5½ 1929 40,755 6,937 940 1 3¼ 1930 44,902 3,722 838 16 2¼ 1931 65,149 2,006 944 13 4 1932 88,002 758 1,143 5 5 1933 87,149 645 1,119 11 6 131 Applicants Granted Free Milk During 1933. January 254 February 268 March 279 April 244 May 250 June 233 July 226 August and September 222 October 184 November 177 December 180 NUTRITION (MINISTRY OF HEALTH CIRCULAR, 1290). In October, 1932, the Minister of Health issued Circular 1,290 to Maternity and Child Welfare Authorities throughout the country. The circular contained evidence that nutritional anaemia of infants could be greatly reduced by the administration of iron ammonium citrate, and gave practical advice regarding its administration. The circular further drew attention to results obtained in the mitigation or prevention of rickets and dental disease by an adequate supply of Vitamin D and calcium rich foods (e.g., milk, eggs, cod liver oil) in the diets of infants and children and of expectant and nursing mothers. During the year under review the Clinic Medical Officers have recommended the administration of iron in the form of iron and ammonium citrate to expectant mothers with a history of too frequent pregnancies, and to expectant and nursing mothers who appeared to be suffering from anaemia. A few of the mothers complained of indigestion and nausea after taking the medicine, but the majority derived great benefit and in some cases the improvement in the general appearance of the women after a course of 4 to 6 weeks' treatment was very marked. In addition, iron ammonium citrate has been recommended in the case of infants who appear to be suffering from nutritional anaemia. 132 Meals for Expectant and Nursing Mothers. Circular 1,290, issued by the Minister of Health in October, 1932, states that:— "it is of the utmost importance that the diet of pregnant and nursing mothers should include a sufficient supply of calcium, phosphorus and Vitamin D. Of these, Vitamin D is the most likely to be deficient, especially during pregnancy and lactation. The aim, therefore, should be to secure an increased consumption of foods containing that vitamin. The main foods containing Vitamin D are fat fish, fish fivers, egg yolk, milk and butter. "All Medical Officers, and particularly those in charge of Welfare Centres, Ante-natal Clinics, etc., should, therefore, take all possible steps to ensure that expectant and nursing mothers are advised of the importance in the diet of an adequate supply of foods containing Vitamin D." The common defects in the diets of expectant and nursing mothers are deficiencies in vitamins, calcium, iron and iodine; and these are obtainable in milk, egg yolk, cod liver oil, green vegetables and fresh fruit. Milk, cod liver oil and iron are already supplied on the recommendation of the Clinic Medical Officer to expectant and nursing mothers who are considered to be in need of extra nourishment. As no adequate facilities exist in this area for the provision of meals at feeding centres, the Maternity and Child Welfare Authority proposed to supply eggs, fresh fruit and vegetables on the recommendation of the Medical Officer of Health, such articles being in the nature of accessories to supplement deficient diets in necessitous cases. In May, 1933, the Maternity and Child Welfare Authority decided that application be made to the Ministry of Health for sanction to provide extra nourishment in the form of eggs, vegetables and fruit for expectant and nursing mothers in cases where the Medical Officer of Health is satisfied that such extra nourishment is advisable on medical grounds, the same scale of necessity to be applied as that in operation in connection with the assisted milk supply. As no adequate facilities exist in the area for the provision of meals at feeding centres the Local Authority proposed that the articles of diet recommended by the Medical Officer should be purchased by means of vouchers. 133 After repeated interviews and a somewhat protracted correspondence on the matter, the Minister of Health finally indicated in December that he was unable to sanction the arrangements proposed by the Council unless he could be satisfied that the food would be supplied under conditions which would ensure that it is actually consumed by the women for whom it is prescribed. NEW JOINT CLINIC PREMISES. Leyton Green Road. In February, 1929—as the result of inspection by one of the Medical Officers of the Ministry of Health of the Council's arrangements for Maternity and Child Welfare—the Minister of Health drew the attention of the Council to the unsuitable accommodation provided and requested that the possibility of obtaining the use of more convenient premises, especially in the Harrow Green area, might receive the Council's consideration. In December, 1929—as the result of inspection of the Education Authority's arrangements for school medical service by a Medical Officer of the Board of Education—the Board addressed a letter to the Authority in which it was stated that the existing clinic premises were inadequate for the work to be done. At that time, in my capacity as School Medical Officer, I submitted to the Education Authority the following observations:— Since its inception in 1907, the School Medical Service has shown its tendency to develop along the lines of a healthy living organism by exhibiting marked growth and expansion, often in directions which could not have been foreseen accurately. Requirements have been met spasmodically as they have arisen; systems have been devised piecemeal; arrangements have often been necessarily of a makeshift nature. The school clinic, which just over twenty years ago was intended exclusively as a centre for the treatment of certain physical defects, has undergone sweeping changes and acquired complex functions undreamed of at the time of its inception. Unfortunately the accommodation, staffing and equipment adequate for such functions have not increased pari passu with the development of the service. In considering the question of future accommodation, staffing and equipment the Local Education Authority should not lose sight of the fact that it has a deep concern in the care of infancy and the prevention of disease in the pre-school child. Every effort should therefore be made to bring infant welfare work into closer relationship with the activities of the school medical service. 134 In December, 1929, a Joint Circular (No. 1,054) was addressed to all Local Authorities by the Minister of Health and the President of the Board of Education, pointing out that there is a gap of from three to four years in the systematic attention given to the bodily health of many children between the time when they are under the care of the Local Authority under the provisions of the Maternity and Child Welfare Act and the time when, at the age of five onwards, the health and education of all children becomes the responsibility of the State; that it is grossly uneconomic to allow the health and stamina of infants to deteriorate till five years old and then spend large sums of money in trying to cure them between the ages of 5 and 15, and urging Local Authorities where necessary to extend their service in this direction, and making various suggestions for the effectual filling of this gap. After consideration of that joint circular, and the report of the Medical Officer of Health thereon, the Council decided, in May, 1930, that having regard to the fact that the premises used by both Committees for their Clinics and services are far from ideal, and it being essential for the effective working of the co-ordinated services that the Maternity and Child Welfare Centres and the School Clinics should occupy the same building, the Borough Engineer and Surveyor, in consultation with the Director of Education and the Medical Officer of Health, be asked to view suitable sites in the Borough and report as to the erection of two buildings, one in East Leyton and one in West Leyton, to accommodate the co-ordinated services. 135 Owing to the scarcity of suitable sites in the Borough, some time elapsed before it was possible to acquire the necessary land for the purpose. In April, 1931, the Council accepted the offer by the Housing Committee of a piece of land on the White House Estate, almost opposite Knotts Green Special School. The site is in a quiet neighbourhood and yet easily accessible from the main 'bus and tramway routes. 136 In January. 1932, the final plans submitted by the Borough Surveyor were adopted by the Council and submitted for the approval of the Board of Education. After somewhat protracted correspondence with the Board of Education the scheme for the erection of a combined clinic on the White House Estate was approved by the Ministry of Health and the Board of Education. The original plans of the Borough Surveyor and Medical Officer of Health were prepared on the assumption that a rectangular site would be available; but these plans had to be modified when it was found that the available site was triangular in shape. This modification necessitated giving up the idea of an inner uncovered quadrangle in favour of a triangle; and the sizes of the rooms in the clinic premises had to be diminished accordingly. Building.—On consulting the plan shown on page 135 it will be seen that the building consists of a large waiting hall on the road frontage, with a series of inspection and treatment rooms forming the other two sides of the triangle. A corridor giving access to the rooms run around a central open courtyard, and by this means the maximum of light and air is admitted to the building. As the Clinic serves two Health Services, the Maternity and Child Welfare Service and the School Medical Service, the rooms have been arranged so that each service is separate. The staff room is placed at the rear of the building where the treatment rooms of the two services converge. The large waiting hall has two entrances—one at each end— and is divided in two by a sliding and folding wooden screen which reaches the ceiling. These two waiting halls may be used as a lecture hall by folding back the moveable partition. The waiting halls seat 60 persons and for the purposes of a lecture 140 persons can be accommodated. The School Medical Service section includes premises for the following: Dental Clinic; Minor Ailments Treatment Clinic; Ophthalmic Clinic, and Special Medical Inspection Clinic. The Maternity and Child Welfare Section includes weighing room, ante-room, ante-natal room with dressing cubicles and consulting room. The new Leyton Green Clinic was opened officially by His Worship the Mayor (Alderman F. M. Read, J.P.) in September, 1933. School Medical Service. 138 SCHOOL MEDICAL SERVICE. School Population and Attendance.—I am indebted to the Director of Education for the following information regarding school population and attendance:— Elementary Schools. No. of Schools. (Departments). No. on Rolls. Average Attendance. Percentage Attendance. Senior Boys' 7 2,472 2,268 92 Senior Girls' 7 2,334 2,090 90 Junior Boys' 4 1,323 1,209 91 Junior Girls' 4 1,288 1,169 91 Junior Mixed 6 2,341 2,108 90 Infants' 16 4,978 4,174 84 Non-provided (Mixed) 1 285 245 86 Central— Boys' 1 297 281 95 Girls' 1 295 277 94 Mixed 1 356 336 94 Totals 48 15,969 14,157 89 Schools— Church of England — — — — Roman Catholic 1 285 245 86 Council 19 15,684 13,912 89 Totals 20 15,969 14,157 89 The figures given above relate to the financial year ended March 31st, 1934. Six certificates were granted to the effect that the fall in the average attendance to below 60 per cent. could reasonably be attributed to the prevalence of epidemic disease in the district. 139 SCHOOL PREMISES. Alterations and Additions.—I am indebted to the Director of Education for the following list of the chief alterations and additions to school premises during the past year:— Connaught Road School.—A new school has been erected on this site, on three floors, the two upper floors for Senior Girls, the lower floor for a Junior Mixed School. For the Senior School domestic science, science and practical rooms are provided, and provision made to use the hall for gymnasium. Shower baths and dressing room are provided for the general use of the school, and everything has been done to secure light and ventilation in every part of the school. The lavatories and sanitary accommodation are up to the best modern standard. Hot and cold water is provided to the children's lavatories, which are fitted with circular spray wash fountains. The rails holding the hat and coat hooks in the cloak rooms are heated, and, in addition, there is a drying room for clothes on each floor. A room for medical inspection, fitted with sinks, etc., is also provided and is large enough for eye testing, etc. A library is provided on the ground floor. The domestic science room is fitted for coal, gas and electric cooking, with coppers and electric ironing points. A small flat consisting of sitting room, bedroom, bathroom and w.c., adjoins the domestic science room. The w.c.'s are all lined with white glazed bricks or tiles 5 feet high, the Senior Girls having w.c. accommodation in the building, whilst the Junior Boys adjoin the entrance at the east, and the Junior Girls adjoin the entrance at the west end of the school. Each w.c. has a separate flushing arrangement from a gravity tank and can be flushed 3 or 4 times in 5 minutes. Drinking fountains are provided both inside and outside the schools, the drinking water being taken direct from the mains. The floors throughout are either wood block or granolithic with special skirtings to make sweeping easy, and are fireproof throughout, whilst every care has been taken to reduce the number of ledges, etc., that might hold dust. 140 The clocks are synchronised and worked from a trickle charged battery; this also supplies energy for the fire bells, which are rung simultaneously from any floor. The central heating boilers and domestic hot water boiler are oil-fired, with automatic controls. The playgrounds are covered with tar paving, but provision has been made for flower beds the length of the building and at the west end. Knotts Green Special School.—Closing in end and one side of rest shed. Davies Lane Junior Mixed School and Infants.—Replacement of lavatory basins, by washing trough and spray taps. Ruckholt Central School.—Composition flooring to corridors to replace worn out floor. Newport Road School.—Forming a medical inspection room and waiting room adjoining. Newport Road School, Senior Boys.—Replacing wash basins with washing troughs. Capworth Street School.—Additional w.c.'s for Girls, with modern apparatus. School Painting.—Four schools painted and redecorated internally. Three schools decorated externally. Re-desking.—Various schools. MEDICAL INSPECTION. A.—Routine Medical Inspections. Code Group Inspection.—These medical inspections are carried out on the school premises for the purpose of making a report on each child on the lines of the approved Schedule set out 141 in Circular 582. It will be seen from Table I in the Statistical Appendix at the end of this Report that the number of such code group inspections was 4,917, representing 30 per cent. of the number of children on the school registers. Of 4,917 children who were examined in the code age groups during the year, 4,016 (or over 82 per cent.) were accompanied by their parents. Other Routine Inspections.—In addition, other routine inspections were made of 876 children who did not fall under the three code age groups, e.g., routine inspections of a fourth age group or of other groups of children as distinct from those who are selected individually on account of some suspected ill-health for "special" inspection. The total number of children subjected to routine medical inspection during the year was therefore 5,793. With the exception of Knotts Green Special School, Canterbury Road School and the new Connaught Road School, no separate accommodation exists for medical inspection. In most of the schools the head teachers are prepared to put special accommodation at the disposal of the medical staff, even at considerable personal inconvenience : and in certain schools the accommodation leaves much to be desired. B.—Other Inspections. Special Inspections.—A special inspection is a medical inspection of a child specially selected by the Medical Officer during a visit to the school or referred to the Medical Officer by the Teachers, School Nurses, Attendance Officers, Parents or otherwise, i.e., an inspection other than a routine medical inspection. The number of such special inspections during the year was 2,103. Re-inspections.—These are medical inspections of children who, as a result of a routine or special inspection, come up later on for subsequent re-inspection either at the school or at the Inspection Clinic. The number of re-inspections during 1933 was 9,389. 142 RETURN OF ROUTINE MEDICAL INSPECTIONS. School. Entrants. Intermediates. Leavers. Code Group. Specials. Re-inspections. Code Group. Specials Re-inspections. | Code Group. Specials. Re-inspections. Canterbury Rd. 149 4 ... 100 10 168 114 16 306 Cann Hall Rd. 76 6 10 70 ... 62 130 9 209 Capworth St. 125 6 28 149 19 185 143 3 238 Church Road 76 1 ... 100 15 218 122 15 248 Connaught Rd. ... ... ... ... ... 73 106 1 149 Davies Lane 123 ... ... 118 11 189 95 3 182 Downsell Rd. 109 ... ... 114 5 290 130 12 190 Farmer Rd. 99 6 10 107 4 279 134 8 266 Goodall Rd. 121 1 ... 77 4 305 128 2 174 Harrow Green 40 4 ... ... ... 44 ... 8 42 Kirkdale Rd. 70 1 ... 95 ... 96 ... ... ... Lea Bridge Rd. 44 ... 33 ... ... ... ... ... 37 Mayville Rd. 97 9 26 91 13 305 110 3 220 Newport Rd. 100 4 20 75 ... 203 113 5 207 Norlington Rd. 132 5 15 119 5 280 123 2 227 Ruekholt Rd. ... ... ... ... ... 50 135 ... 52 Sybourn St. 123 " 7 43 108 9 269 113 19 262 St. Joseph's 35 ... ... 8 6 72 42 3 43 Trumpington Rd. 37 12 39 110 8 192 100 3 128 Tom Hood ... ... ... ... ... 56 82 ... 62 KnottsGreenS.S. ... ... ... ... ... ... ... ... 492 Totals 1556 66 224 1441 109 3336 1920 112 3734 The Findings of Medical Inspection. Table II. B in the Appendix shows the number of individual children found at routine medical inspection to require treatment (excluding uncleanliness and dental disease). The corresponding figures for the past five years have been:— 1929 26.64 per cent. 1930 24.65 „ 1931 25.36 „ 1932 23.50 „ 1933 18.22 „ Of the 876 other routine inspections, 66 (7.53 per cent.) were found to be in need of treatment. Taking these two groups together, it will be seen that, of the total of 5,793 children examined, 962 (16.60 per cent.) showed evidence of some defect or other requiring medical attention. 143 From Table II B of Appendix, it will be seen that the percentage of children found at routine medical examination to require treatment were as follows:— Entrants 18.70 per cent. Intermediates 17.68 „ Leavers 18.22 ,, In former years there has always been found to be a marked decrease in the incidence of physical defect with the advance in school life, the percentage of defectives among "entrants" having been much greater than among "leavers." It is, however, noteworthy that during 1933 the percentage incidence among "entrants" approximates closely to that of "leavers." The following list shows the comparative figures for the last five years 1929. 1930. 1931. 1932. 1933. Entrants 34.64 27.41 30.37 24.34 18.70 Intermediates 24.01 24.53 26.73 27.36 17.68 Leavers 21.05 19.26 14.51 17.87 18.22 Total 26.64 24.65 25.36 23.50 18.22 These figures show that in the five-year period under review the percentage incidence of defect has been reduced in the case of Entrants from 34.64% to 18.70%, i.e., by 15.94% Intermediates from 24.01% to 17.68%, i.e., by 6.33% Leavers from 21.05% to 18.22%, i.e., by 2.83% Total. From 26.64% to 18.22%, i.e., by 8.42% It is evident that, although there has been a total all-round reduction of 8.42 per cent. in defect incidence, the reduction has taken place chiefly in the "entrant" group. Although it is never safe to draw definite conclusions from statistical findings of one year, especially in view of the many and diverse factors involved, it is reasonable to assume that the marked reduction in defects found among school entrants during the last few years may be due to the increasing care and attention which the Maternity and Child Welfare Authority has been devoting to the pre-school child during that time. Time alone will tell whether the improvement is merely a temporary variation, but the figures recorded above are certainly encouraging. 144 Even more encouraging than the reduction in incidence is the noticeable reduction in the degree of these defects. The majority of the defects and deformities now recorded are trivial when compared with those found in the early days of school medical inspection. We now register and treat slight departures from the normal which would have been ignored in earlier days. Percentage Incidence of Defects in Individual Schools. (By Dr. F. W. Gavin.) Deputy School Medical Officer. With a view to determining the percentage incidence of defect among comparable age groups in the different schools in the area, Dr. F. W. Gavin has prepared the following tables and observations regarding the percentage incidence of defects found in individual schools among the three code groups submitted to routine medical examination during 1933. A similar analysis—by Dr. Gavin— the first of the kind undertaken—appeared in last year's Annual Report; and the value of these annual analyses should increase as the figures for successive years become available. I.—"Entrants." School. Percentage found to require treatment. St. Joseph's 31.42 Newport Road 22.00 Norlington Road 16.66 Goodall Road 9.91 Farmer Road 29.29 Church Road 13.15 Kirkdale Road 10.00 Harrow Green 15.00 Cann Hall Road 19.73 Downsell Road 14.67 Trumpington Road 13.51 Lea Bridge 20.45 Canterbury Road 25.50 Sybourn Street 17.88 Capworth Street 21.6 Davies Lane 18.69 Mayville Road 17.52 Average of Group 18.70 Specials 80.30 145 When the percentages given above are compared with the corresponding figures for the year 1932, it will be observed that the average percentage of children found to require treatment in this (i.e., " Entrants ") group for the year 1933 is actually 5.64 per cent. lower than for the year 1932. While this indicates improvement for the majority of the schools in the area, there are four schools which show increased percentages requiring treatment, viz.:— (i) St. Joseph's from 19.04% in 1932 to 31.42% in 1933 (ii) Farmer Road from 17.92% in 1932 to 29.29% in 1933 (iii) Harrow Green from 9.25% in 1932 to 15.00% in 1933 (iv) Canterbury Road from 22.50% in 1932 to 25.50% in 1933 All the remaining schools have improved their 1932 record, and of these Goodall Road School shows the best return and also the most marked improvement, having improved from 26.31 per cent. in 1932 to 9.91 per cent. in 1933. This school occupies first place in the group with a slightly better percentage than Kirkdale Road. Trumpington Road and Church Road Schools are among the first four schools for the year under review. Other notably improved schools are:— (i) Downsell Road from 28.84% in 1932 to 14.67% in 1933 (ii) Kirkdale Road from 21.87% in 1932 to 10.00% in 1933 (iii) Davies Lane from 29.00% in 1932 to 18.69% in 1933 (iv) Norlington Road from 26.31% in 1932 to 16.66% in 1933 (v) Sybourn Street from 27.35% in 1932 to 17.88% in 1933 (vi) Capworth Street from 30.72% in 1932 to 21.60% in 1933 Again, as in 1932, there are ten schools with a lower percentage than the average for the group, and seven schools are above that average. The total number of children inspected in a group varies from school to school and from year to year, and therefore fairly wide fluctuations may be expected, especially in the smaller schools, 146 e.g., St. Joseph's and Lea Bridge. Another less important factor is climatic—schools inspected during a spell of fine dry summer weather should have somewhat better figures than schools inspected during a period of damp, cold weather, as the latter predisposes to catarrhal conditions, e.g., bronchitis, enlarged tonsils and adenoids, conjunctivitis and otitis media. If we examine the commonest defects requiring treatment in this group we find that:— (i) Dental Defect is found to be by far the most common defect, being found in 47.23 per cent. of children examined. (ii) Nose and Throat Defects constitute 16.30 per cent. of the total. (iii) Eye Defects = 7.69 per cent. (iv) Mentally Retarded 4.76 per cent. (This is an amazingly high percentage, and a most disturbing fact disclosed by this percentage analysis of the " Entrants' " defects.) (v) Lung Defects = 4.61 per cent. (vi) Enlarged Cervical Glands = 3.84 per cent. (vii) Subnormal Nutrition == 3.38 per cent. (viii) Deformities = 3.38 per cent. (ix) Heart and Circulatory Defects — 3.07 per cent. (x) Ear Defects = 2.46 per cent. It will be noted from the above figures that no less than 63.53 per cent. of all the defects marked up for treatment at the "Entrants" routine school medical inspection are due to dental and nose and throat defects added together. That there is some relation between serious dental decay and unhealthy tonsils has been suggested, and certainly one cannot fail to be impressed by the frequency with which these two conditions are found to be present together in the same child. 147 II. "Intermediates." School. Percentage found to require treatment. St. Joseph's 37.5 Newport Road 17.33 Norlington Road 26.05 Goodall Road 22.07 Farmer Road 12.14 Church Road 16.00 Kirkdale Road 15.78 *Harrow Green Cann Hall Road 21.42 Downsell Road 16.66 Trumpington Road 18.18 *Lea Bridge Canterbury Road 10.00 Sybourn Street 26.85 Capworth Street 14.76 Davies Lane 12.71 Mayville Road 18.68 Average of Group 17.69 Specials 57.79 * Under the school re-organisation of May 25th, 1932, these schools were restricted to Infants' Departments only. When the percentages for the "Intermediates'" Group in the year 1932 are compared with the figures set out above for 1933, a very striking improvement will be noted. This group average has actually declined from 27.36 per cent. requiring treatment in 1932 to 17.69 per cent. in 1933, a gratifying improvement. With two exceptions, all the schools show a fairly substantial improvement which is set out below. St. Joseph's show a worse position than in 1932, having 37.5 per cent. defects in 1933 as against 20.68 per cent. in 1932; but the total number of children examined in this school is small and therefore these percentages are liable to rather wide fluctuations. The only large school with a poor return, compared with 1932, was Goodall Road, giving 22.07 per cent. in 1933 contrasted with 18.51 per cent. in 1932. Canterbury Road has the best return with only 10 per cent. found to require treatment, and it is closely followed by Farmer Road with 12.14 per cent. and Davies Lane with 12.71 per cent.; both Newport 148 Road and Kirkdale Road show the most marked improvement from 39.09 (1932) to 17.33 (1933), and 35.63 (1932) to 15.78 (1933) respectively. Other schools showing considerable improvement were:— Capworth Street from 30.50% (1932) to 14.76% (1933) Mayville Road from 31.57% (1932) to 18.68% (1933) Trumpington Road from 28.12% (1932) to 18.18% (1933) Church Road from 23.07% (1932) to 16.00% (1933) On examining the total numbers of the various defects marked as requiring treatment one finds that again:— (i) Dental Disease is by far the commonest type of defect and = 34.70 per cent. of the total defects for the group. (ii) Eye Defects — 23.30 per cent., and it will be observed that dental and eye defects together account for no less than 58 per cent. of the total. (iii) Nose and Throat Defects = 11.65 per cent., and this is only somewhat better than the corresponding percentage for the " Entrants' " Group (i.e., 16.30 per cent.). (iv) Other Diseases and Defects = 6.79 per cent. (v) Deformities — 6.31 per cent., and these are mostly minor orthopaedic disabilities such as valgus ankles, knock knee, round shoulders and the like. (vi) Heart and Circulation = 3.39 per cent., a percentage which is of considerable importance when one recalls the position of heart disease as a principal cause of death in the returns of the Registrar General. (vii) Subnormal Nutrition = 3.39 per cent. This percentage is almost identical with the figures for the " Entrants' " Group (3.38 per cent. (1933)). These figures added together are slightly lower than the corresponding figures for 1932, which were 2.61 per cent. for " Entrants " and 4.55 per cent. for " Intermediates." (viii) Lungs (i.e., Bronchitic and Other Non-tuberculous Disease) = 2.42 per cent. This is a marked improvement on the figures for 1932. (ix) Ear Defects (including Defective Hearing)=2.18 per cent. (x) Nervous Conditions = 2.18 per cent. 149 III. "Leavers." School. Percentage found to require treatment. St. Joseph's 11.90 Newport Road 8.84 Norlington Road 13.00 Goodall Road 18.75 Farmer Road 23.13 Church Road 25.40 Connaught Road 19.81 Cann Hall Road 15.38 Downsell Road 21.53 Trumpington Road 15.00 Canterbury Road 28.07 Sybourn Street 15.92 Capworth Street 25.17 Davies Lane 21.05 Mayville Road 28.18 *Tom Hood 21.95 *Ruckholt Road 16.29 Average of Group 19.68 Specials 73.21 * These are Central Schools. While the birth rate in Leyton was 17.0 in the year 1919, it had risen to 24.6 in the year 1920; and this year's was actually the largest "Leaver" Group inspected since the children born in 1907 were medically examined in 1920. It is a well-known fact that with a high birth rate the mortality and morbidity rates tend also to be high, and the percentages set out above seem to support this thesis. Further, the "Leaver" Group were inspected during the autumn term following an exceptional summer which had been characterised by long periods of excessively high temperatures and lack of rain, factors which may not necessarily favour good health. During the autumn there was much fog with a highly polluted atmosphere tending to cause catarrhs and ill-health. The average defect incidence for the group is 19.68 per cent. requiring treatment, and in the year 1932 it was 17.8 per cent. Eight schools were above the group average and nine schools were below that average. Eleven of the seventeen Senior Schools show worse figures for 1933 than for 1932. Mayville with 28.18 150 per cent. requiring treatment (21.68 per cent. in 1932) and Canterbury Road with 28.07 per cent. (23.75 per cent. in 1932) have the worst records for 1933. Capworth Street had 25.17% (15.21% in 1932) Church Road had 25.40% (18.47% in 1932) Farmer Road had 23.13% (26.66% in 1932) Tom Hood Central had 21.95% (21.76% in 1932) and of these schools, only Farmer Road showed any improvement on 1932. (i) Newport Boys' School easily heads the list with the good figures of 8.84% (12.04% in 1932) (ii) St. Joseph's comes next with 11.90% ( 9.09% in 1932) (iii) Norlington Road had 13.00% (16.45% in 1932) (iv) Trumpington Road had 15.00% (11.59% in 1932) (v) Cann Hall Road had 15.38% ( 6.89% in 1932) (vi) Sybourn Street had 15.92% (23.37% in 1932) (vii) Ruckholt Road had 16.29% (21.25% in 1932) (viii) Goodall Road had 18.75% (13.92% in 1932) (ix) Connaught Road had 19.81% (16.27% in 1932) Newport Road, Norlington Road, Cann Hall Road and Trumpington Road are, in general, the schools with the best records for 1932 and 1933. On examining the individual defects marked up for treatment at the " Leaver " Group inspection it is found that:— (i) Dental Defects = 25.59 per cent. of the total defects in the "Leaver" Group, and this is also the commonest form of defect in the other two Routine Groups for 1933, constituting 47.23 per cent. of the "Entrants'" defects and 34.70 per cent. of "Intermediates" defects. It is noteworthy, however, that these percentages decline pari passu with advancing school age, thus demonstrating the valuable work carried out by the School Dental Surgeon. 151 (ii) Visual Defects = 24.57 per cent. Visual and dental defects together account for no less than 50.16 per cent, of all the "Leavers" defects. (In 1932 these defects made up 46.69 per cent, of all defects.) (iii) Subnormal Nutrition — 10.58 per cent.; and Malnutrition (5 cases) = 0.85 per cent. (iv) Other Defects and Diseases = 8.02 per cent. (v) Deformities = 7.67 per cent. (10.54 per cent, in 1932). (vi) Nose and Throat Defects = 6.99 per cent. (6.32 per cent. in 1932). (vii) Heart and Circulation = 5.63 per cent. Rheumatism (5 cases) = 0.85 per cent. cf. Heart and Circulation = 3.39 per cent, in the " Intermediates' " Group and 3.07 per cent, in the " Entrants' " Group. Rheumatic fever is a disease with " a long arm," and its evil effect on the myocardium and endocardium of the heart may not be at once apparent, yet in later years the patient may suffer severely from the crippling effects of heart disease due to an unrecognised smouldering rheumatic poison in childhood. These percentages are of special importance and demonstrate the need for a constant effort directed against this disease. (viii) Ear Conditions = 5.10 per cent. (ix) Skin Defects = 1.02 per cent. (x) Speech Defects — 1.02 per cent. In conclusion it is interesting to compare the average percentage requiring treatment for each group in 1933 with the corresponding figures for 1932 :— 1933. 1932. (i) Intermediates 17.69% (i) Leavers 17.87% (ii) Entrants 18.7% (ii) Entrants 24.34% (iii) Leavers 19.68% (iii) Intermediates 27.36% Uncleanliness.—At the special inspections held by the school nurses for the detection of uncleanliness, 1,540 children were found to be unclean out of a total number of 35,461 examined (i.e., 4 per cent.). 152 Cleanliness Surveys in Individual Schools. School. Number of Examinations. Number Cautioned. Number Excluded. Canterbury Road 2,916 41 14 Capworth Street 2,820 77 13 Cann Hall Road 792 15 1 Church Road 2,971 129 16 Connaught Road 339 5 2 Downsell Road 1,648 129 7 Davies Lane 2,866 128 10 Farmer Road 1,129 26 5 Goodall Road 2,948 145 15 Harrow Green 499 55 4 Kirkdale Road 986 24 3 Lea Bridge Road 337 7 — Mayville Road 3,685 242 32 Norlington Road 2,612 123 18 Newport Road 2,502 68 7 Ruckholt Road 1,761 9 3 Sybourn Street 1,520 35 12 St. Joseph's 683 20 1 Trumpington Road 1,835 73 6 Tom Hood 82 — — Knotts Green 430 17 3 Total 35,461 1,368 172 Number of individual children found unclean 1,540 of whom 172 were referred to the Clinic at the Town Hall. The Local Education Authority has no aarangement for cleansing verminous children at a special cleansing station. MEDICAL TREATMENT. Minor Ailments Clinic.—Prior to the opening of the new Leyton Green Clinic in September, 1933, a minor ailment clinic was held every week-day (except Friday) at the Town Hall. Since the new Leyton Green Clinic premises have been available the schools in the area are now served by two minor ailment clinics as follows:— Town Hall—-Tuesday, Thursday and Saturday mornings (Doctor in attendance). Schools served: Newport Road, Connaught Road, Cann Hall Road, Downsell Road, Goodall Road, Kirkdale Road, Trumpington Road, Davies Lane, Harrow Green, Mayville Road, Tom Hood. 153 Leyton Green—Monday, Wednesday and Friday mornings (Doctor in attendance). Schools served: Farmer Road, Lea Bridge, Sybourn Street, St. Joseph's, Canterbury Road, Capworth Street, Church Road, Knotts Green, Norlington Road, Ruckholt Road. Although a School Medical Officer is in attendance at each clinic only at the times stated above, one of the school nurses is on duty daily at each clinic for dressings and other medical treatment. During the year 1,816 children attended the clinic and 8,234 attendances were registered. The following conditions were dealt with during the year:— Ringworm of scalp 5 Ringworm of body 13 Scabies 18 Impetigo 98 Other skin conditions 152 Blepharitis 78 Conjunctivitis 28 Keratitis 2 Corneal ulcer 2 Defective vision 6 Squint 2 Other eye conditions 52 Defective hearing 15 Otitis media 6 Other ear diseases 229 Enlarged tonsils 32 Adenoids 3 Tonsils and adenoids 20 Other throat conditions 54 Enlarged cervical glands 52 Defective speech 2 Dental diseases 38 Organic heart disease 11 Functional heart disease 5 Carried forward 923 154 Brought forward 923 Anæmia 68 Bronchitis 46 Other non-tuberculous diseases of lungs 25 Pulmonary tuberculosis 2 Suspected pulmonary tuberculosis 6 Tuberculous glands 5 Tuberculous hip 1 Epilepsy 4 Chorea 16 Other nervous diseases 19 Spinal curvature 1 Other deformities 22 Gastritis 1 Arthritis 2 Appendicitis 1 Scarlet fever 2 Diphtheria 3 Albuminuria 1 Miscellaneous (minor injuries, septic sores, etc. 796 1,944 Defective Vision.—Of the 4,917 children subjected to routine code group inspection in the schools, 290 (5.89 per cent.) were found to be suffering from some eye defect requiring treatment. Of the 2,103 children referred for special inspection, 346 (16.4 per cent.) manifested some eye defect requiring treatment. The nature and incidence of such defects are shown in Table II of the Appendix. The number of these minor eye defects treated at the Minor Ailment Clinic was 170. Special Eye Clinic.—The Authority's Ophthalmic Surgeon (J. D. Magor Cardell, M.B., B.S., F.R.C.S.) attends on two sessions per week to examine and prescribe treatment for children referred by the school medical officers. During the year, the Ophthalmic Surgeon had referred to him 1,200 children, who made 1,390 attendances for examination and treatment. 155 The following list shows the ophthalmic defects found in the 1,200 children examined by Mr. Cardell at the Special Eye Clinic. Myopia 186 Myopic astigmatism 134 Hypermetropia 139 Hyper astigmatism 245 Mixed astigmatism 69 Hypermetropia with squint 147 Myopia with squint 3 Squint only 25 Anisometropia 31 No defect 78 Spasm of accommodation 9 Various diseases 34 Referred to Minor Ailments Clinic 100 1,200 "Various diseases" included:— Albinism 1 Amblyopia exanopsia 2 Congenital cataract 8 Fröhlich's syndrome 1 Ectropia of uvea 1 Leucoma 1 Meibomean cyst 1 Nystagmus 4 Optic atrophy 2 Ptosis 12 Vitreous opacities 1 34 Number of children for whom spectacles were (1) Prescribed (a) Under Authority's scheme 848 (b) Otherwise 24 (2) Obtained (a) Under Authority's scheme 845 (b) Otherwise 27 150 The School Ophthalmic Surgeon makes the following observations on the work of the Special Eye Clinic during the year:— The department has now been moved to more up-to-date quarters in the new Leyton Green Clinic. The figures for the year show an increase —though the school population has fallen to 15,806. To these figures must he added the number of cases referred from the Maternity and Child Welfare Clinic, amounting to 30, with 46 attendances. The proportion of myopic children has risen slightly to 2.49 per cent. of the school population. This figure need give rise to no anxiety as the average for the last seven years has been in the region of 2.1 per cent.—a much lower figure than in many parts of this country and considerably lower than in Armenia or Germany. A fair number of cases are still found to have a spasm of accommodation and are cured without the use of glasses by attention to the child's posture in reading and -writing. In this the co-operation of teachers and parents has been sought and gladly given. Dental Clinic.—The number of children belonging to the routine age groups inspected at school by the School Dental Surgeons was 8,002, i.e., 56 per cent, of the average number of children in attendance at the schools. The numbers inspected in each age group were :— Aged 5 447 6 795 7 755 8 647 9 848 10 844 11 939 12 1,090 13 1,108 14 529 In addition, the School Dental Surgeons made 2,167 special inspections of children otherwise than in the course of routine age group inspection covered by the Authority's approved scheme, i.e., children specially selected by the dental surgeons, or referred to them by school medical officers, parents, teachers, etc., on account of urgency. The total number of children submitted to special dental inspection during the year was therefore 10,169. 157 The number of children found to be in need of dental treatment was 8,442, the incidence of dental disease being 83 per cent. The need for a continuous dental scheme is shown by the fact that some dental treatment is considered to be necessary in over fourfifths of the children inspected. The total number of cases actually treated was 6,211. Fillings:— Permanent teeth 6,264 Temporary teeth 612 Total 6,876 Extractions:— Permanent teeth 914 Temporary teeth 3,426 Total 4,340 Other operations:— Permanent teeth 796 Temporary teeth 294 Total 1,090 Administrations of general anaesthetics for extractions—675. The value of the service is in the saving of permanent teeth which it effects. The number of permanent teeth extracted was 914, whereas the number of fillings of permanent teeth was 6,264 ; so that for every permanent tooth extracted, nearly 7 were rendered serviceable by filling. Details of the school dental work are shown in Table IV, Group IV of the Appendix. CASUAL DENTAL TREATMENT. (Report by the School Medical Officer.) It is always a difficult matter to decide on the policy to be adopteed with regard to the casual treatment of children whose parents have refused the offer of routine dental treatment on previous occasions; and Local Education Authorities throughout the country differ widely in the amount of treatment afforded to "casuals." 158 In his Annual Report for 1932, the Chief Medical Officer of the Board of Education (Sir George Newman) states that:— "The School Dental Service is an integral part of the School Medical Service, and both of them are educational in purpose. They are not designed to treat disease indiscriminately, but to fit the child to receive the education which the State provides, and to safeguard and build up his health. The aim of the school dental service should be to secure that as many children as possible should leave school with a complete and sound set of permanent teeth, free from disease, and that they should be trained in the care of their teeth, and taught such principles of dental health as will conduce to that end." Provided that the dental staff is sufficient to cope with the needs of the area—and to arrange for the inspection and treatment of all children roughly once a year—there may be something to be said in favour of "casual" treatment. But when, as in Leyton, the dental surgeons cannot cope with the needs of children requiring conservative treatment (i.e., fillings)", it is obvious that all treatment of "casuals" must be at the expense of— and to the detriment of—children requiring and prepared to have conservative treatment. Of 6,211 children actually treated under the Leyton Education Authority's dental scheme during 1933, some 2,167 were "casuals" who attended for urgent treatment. This means that roughly one child was treated as a "casual" for every two children treated by appointment; and that the school dental clinic is not fulfilling its declared function. In this connection the Chief Medical Officer of the Board of Education states :— "The broad fact is that the purpose of school dentistry is not to provide a scheme of extraction for ' a never ending stream of casuals, so large that the dental officers would be employed wholetime alleviating the sufferings of youth and profiting them nothing in the greater and more far-reaching problem of good health resulting from a sound dentition.' It is an educational scheme of conservative dentistry, and that alone is its justification. The school clinic is not an out-patient dental department, and any casual work should be deferred or declined in accordance with the purpose of the general scheme, already enough and more than enough for most Local Education Authorities." The extent to which parents are prepared to accept offers of conservative dental treatment on behalf of their children depends on their appreciation of the value and importance of such treatment. If parents know that their children can have teeth extracted whenever they are the seat of pain, then they tend to refuse offers of early conservative treatment '"with an easy conscience." If, however, they understand that, by consistently refusing conservative treatment, they render their children ineligible for urgent casual treatment, parents will undoubtedly begin to appreciate the real purpose and value of the school dental scheme. 159 Of course, from a humane point of view, it may be contended that it is unfair to punish a child for the ignorance or foolishness of its parents. On the other hand, it is much more unfair to penalise parents and children who are prepared to take advantage of the facilities for which the school dental services was instituted. Orthopædic Clinic. The Orthopaedic Clinic at Knotts Green Special School was staffed and equipped by the Local Education Authority in 1927 for the treatment of school children with orthopaedic defects. As, however, it was found uneconomic to postpone the treatment of pre-school children until they attain school age, the existing facilities have been available for the pre-school child since 1929. The following figures are submitted to show the number of pre-school and school children who have been examined and treated during the last five years. Examinations. 1929 1930 1931 1932 1933 Primary— School children. 74 62 75 110 118 Infant welfare 31 55 80 91 80 Total 105 117 155 201 198 Re-examinations— (school children 119 160 197 207 269 Infant welfare 22 83 126 140 165 Total 141 243 323 347 434 Treatment. 1929 1930 1931 1932 1933 Number attending for— School children 53 86 112 118 156 Infant welfare 5 56 126 115 129 Total 58 142 238 233 285 Attendances made— School children 1,026 1,289 938 940 1,296 Infant welfare 33 337 474 569 448 Total 1,059 1,626 1,412 1,509 1,744 160 It will be seen that during 1933, some 632 children were examined or re-examined by the Council's Orthopaedic Surgeon, who attends once per month during the year. That means that about 58 children are examined or re-examined per session—and it will be appreciated that, with such large attendances per session, the amount of time available per child is very short to allow of the amount of individual attention which is desirable in such cases. The following is a resume of the work of the School Medical Service Orthopaedic Clinic during the year:— Primary Examinations 118 Re-examinations 269 The findings at the primary examinations were as follows Deformities—Bones and Joints. (a) Congenital— Congenital dislocation of hips 1 Congenital absence of digits of hand 1 Congenital absence of left forearm 1 (b) Acquired— Polyarthritis 1 Old osteitis—femur 1 Genu varum 1 Genu valgum 9 Genu recurvatum 2 Injury knee 1 Hallux valgus 3 Hallux rigidus 1 Hammer Toe 3 Digitus varus 1 Old fracture—elbow joint 1 Injury—carpus 2 Fractured nose 2 Scoliosis 1 Muscular. (a) Congenital—Nil. (b) Acquired— Contracture—digits hand 1 Injury—sterno-mastoid muscle 1 Torticollis 2 Pes cavus 2 1C1 Pes piano valgus 36 Winged scapulae 2 Kyphosis 17 Kypho-lordosis 7 Kypho-scoliosis 1 Scoliosis 4 Talipes 1 Paralysis. (a) Congenital— Spastic diplegia 1 Spastic tetraplegia 1 (b) Acquired— Facial paralysis 1 Injury digit—hand 1 Anterior poliomyelitis 3 Also- Bursa 2 Ganglion—foot 1 Lipoma 1 Multiple scars — Baker's cyst 2 foot and leg 1 Ganglion—wrist 4 Treatment. Number of school children attending for treatment 156 Number of attendances for treatment 1,296 During the year, 14 school children were admitted to hospital, and the following surgical operations were performed:— Tenotomy—tendo Achilles and plaster 1 Arthrodesis—digit—foot (hammer toe) 3 Arthrodesis—mid-tarsal joint and plaster 1 Transplantation of tendon—foot 2 Manipulation of foot and plaster 1 Mobilisation of spine 1 Plaster bed 1 Plaster spica—hip 4 Excision of scar—hand 1 Removal of phalanx—hand 1 * Arthroplasty—elbow joint 1 17 162 *From the surgical aspect this case was of particular interest. A girl with severe arthritis affecting both elbows, so that they were stiff and useless, had one elbow operated on at Brookfield Orthopædic Hospital and a new joint fashioned. A short time afterwards a request was made for a similar operation to be carried out on the other elbow, an example of the co-operation of the patient in the line of treatment mapped out for her. Surgical Appliances, etc.—School Children. The following have been supplied :— Caliper splint—leg 1 Special splint for wrist 1 Spinal brace 1 Surgical boots 2 pairs Wedges, valgus pads and stiffening to boots 3 ,, Minor surgical alterations to boots, etc. 42 „ Alterations and repairs to calipers 2 Special elbow crutch 3 Ordinary crutch 1 Artificial Light Clinic. (Report by Dr. F. W. Gavin.) The routine application of treatment by means of ultra-violet rays is performed by the Authority's Masseuse (Miss A. E. Findlay) under the supervision of the medical staff. I am indebted to Dr. Gavin (Deputy School Medical Officer) for the following report on the work of the Clinic during the year. Number of cases treated in 1933 70 Number of new cases treated in 1933 29 Total number of attendances in 1933 2,174 Seventy cases averaged 31 attendances per case. Twenty-nine new cases in year 1933 averaged 20 attendances per case. Forty-one old cases averaged 38 attendances per case. 163 One new case, a child attending the Open Air School because of a crippling condition, had been recommended for the Light Clinic by the Authority's Ophthalmic Surgeon, but made only 5 attendances before admission to hospital for an orthopaedic operation. All other cases made attendances varying from 7 to 70. Type of Lamp Employed.—During the summer of 1933 the local electricity supply was changed over from direct current to alternating current. This change-over put the tungsten lamp permanently out of commission, and it was decided to replace the old quartz mercury vapour lamp by another of modern type suitable for use with alternating current. Strength of Dose.—The treatment is graduated, each patient commencing with a minimum 2/2 exposure by 3/2, 4/2, 5/2, 7/2, 9/2 to a maximum of 10/2, i.e., 10 minutes to each side of the body. There are four weekly sessions for school children, two for boys and two for girls. Each child attends twice a week and a course consists of at least twelve exposures, after which the case is reviewed and repeat courses given as considered advisable. Other Forms of Treatment.—Of the 70 cases treated in 1933, 18 were children attending the Open-air School at Knotts Green, and five of these children were new cases. Two cases were known to have received treatment by a private practitioner, and five children were under other forms of treatment by various London hospitals. Cod liver oil and malt had been prescribed for 23 cases, and nine patients had some kind of iron tonic in addition to light treatment. Only 14 children were known to have been treated by artificial light alone. Progress in General Health. In estimating the effect of treatment, in addition to the results of medical inspection and re-inspection, the independent opinions of both parents and head teachers were obtained regarding improvement or otherwise in brightness, alertness, etc. The following 164 summary shows the estimates of school medical officer, parents and teachers as to the results of treatment:— (a) New Cases, 1933. Medical Officer. Parents. Teachers. Very marked improvement 5 3 6 Definite improvement 11 11 6 Slight improvement 2 3 2 No improvement — — 7 No data available* 11 12 8 29 29 29 *Eight new cases since November, 1933, were not re-examined in 1933 owing to the fact that they had only just commenced treatment when re-inspection was carried out in December, 1933. Three cases were absent during re-inspection ; of these, two were in hospital. (b) Old Cases, 1933. Medical Officer. Parents. Teachers. Very marked improvement 8 4 8 Definite improvement 27 25 18 Slight improvement 2 7 3 No improvement 3 1 10 No data available* 1 4 2 41 41 41 *One child, sufiering from anaemia, was absent during reinspection, but his teacher's report stated that he had improved. The child made only nine attendances at the light clinic in 1933. 165 Progress as Regards Special Symptoms. (a) New Cases, 1933. Cured. Improved. Slight Improvement. No Improvement. Debility 1(27)* 1(22) — — Anæmia 1(38) 1(21) — — Subnormal nutrition — 1(25) 2(35) 2(40)* Cervical adenitis — 2(16) 1(10) — Multiple warts 1(25)* — — — Styes 1(22) — — — Phlyctenules, corneal ulcer, styes — — 1(19) — Bronchitis 1(31) — 1(15) — Asthma and bronchitis — — — 1(16)* 5 5 5 3 Figures within brackets show the number of attendances made at the light clinic. An asterisk indicates a child in attendance at the Open-air School. No data are available for 3 cases—one a case of anaemia, and two cases of anæmia and debility. (b) Old Cases, 1933. Cured. Improved. Slight Improvement. No Improvement. Debility 2(45) 5(37)* — — Subnormal nutrition 1(10)* 2(61) 1(59) 1(46) Alopecia — — 1(70) 1(68) Anæmia 3(20)* 3(30)* 1(46) 1(31) Chorea and rheumatism — 1(63) 1(18) — Styes 2(47) — — — Cervical adenitis 2(14)* — — — Tic — 1(67)* — 1(14) Chronic bronchitis 2(40)* 2(45)* — 1(59)* Asthma 1(51) 2(48) — 1(53) 13 16 4 6 An asterisk indicates an Open-air School case. 166 Figures within brackets refer to the number of attendances made at the light clinic. No data are available for 2 old cases. One of these was a child with anaemia who was absent from re-inspection after making attendances at the light clinic ; the other was a child who developed rheumatic fever and was sent to hospital. She had made 7 attendances and was the only case to complain of lassitude and sickness following treatment with light. Knotts Green Open-air School Cases. Eighteen children attending this school received artificial light treatment during the year 1933. Medical Officer. Parents. Teachers. Very much improved 4 3 2 Definite improvement 13 9 7 Slight improvement — 3 1 No improvement — — 8 No data 1 3 — 18 18 18 It is interesting to note that only eighteen out of the total of seventy cases treated with ultra violet light were in attendance at Knotts Green Special (Open Air) School. When the light clinic was established some years ago the only patients treated were Open-air School cases, but as time went on it was thought that this form of treatment should be available for those children in the ordinary elementary schools who might benefit in their general health, or that certain diseased conditions might be improved. Children attending Knotts Green Special School have a well-cooked dinner on the school premises at mid-day, and, in addition, the open-air scholars enjoy the benefits of natural sunlight, particularly during the summer months. Note of Any Unfavourable Symptoms. Only one child complained of lassitude and sickness after ultra violet ray treatment (see above). 167 Depression following artificial light treatment is an indication for ceasing the treatment. General Conclusions. General Health. 51 cases out of 58 showed definite or much improvement according to medical officer 87.9% 43 cases out of 54 showed definite or much improvement according to parents 79.6% 38 cases out of 60 showed definite or much ment according to teachers 63.3% Special Symptoms. 39 cases out of 57 showed definite or much ment or were cured 68.2% Only 14 cases received ultra violet ray therapy alone and of these:—- 11 cases (78.5%) showed improvement from medical review. 12 cases (85.7 %) showed improvement from parents' statements. 11 cases (78.5%) showed improvement from teachers' reports. Ultra violet ray therapy appears to be a type of " tonic " which undoubtedly benefits some children, and just as certainly is quite valueless to others. It is the duty of school medical officers to select cases suitable for this form of treatment and to reject cases in which experience has shown that failure is probable. Prevention of Deafness. At the request of the Maternity and Child Welfare and Education Committees for reports on Circular 1,337a—issued by the Ministry of Health in May, 1933—the Medical Officer of Health and School Medical Officer submitted the following observations to the Committee concerned:— Report by the Medical Officer of Health and School Medical Officer. Special Report entitled "A Study of the Deaf." Recently a special report entitled " A Study of the Deaf " was presented by the late Dr. Eicliholz to the Minister of Health and the President of the Board of Education. The report is a very lengthy one of over 200 pages 168 dealing exhaustively with the nature, diagnosis, prevalence, causes and prevention of deafness ; and the following is a brief summary of the recommendations:— (1) The Ministry of Health should urge upon Local Authorities under the Maternity and Child Welfare Act to give close attention to the early and continuous treatment of infants suffering from ear defects in order to prevent the havoc of deafness and deaf-mutism which are certain, otherwise, to ensue during school age and adult life. (2) The Board of Education should present to Local Education Authorities the magnitude and seriousness of the problem of deafness and invite them:— (a)To improve their arrangements for the detection of defects of hearing by the use of suitable acoumetric apparatus in the course of routine medical inspection with a view of ascertaining the incidence of deafness in cases many of which appear not to come to light under the methods now adopted, that is to say, by the whisper and watch tests. (b) To bring and keep under treatment all cases of detected ear defect under the supervision of medical practitioners with adequate otological experience. (3) That the Board of Education should, through its inspectorate, or wise, emphasise before Local Education Authorities the detriment to the deaf and dumb child of delay in the beginning of education and urge upon them the need of an early commencement in all cases. (4) That an agreed standard should be laid down to be applied in all cases presented for admission to a school or class for the partially deaf, and that the matter be referred by the Board of Education for investigation to a competent body of otologists. (5) That the services of an expert interpreter should be sought in all deaf and dumb cases coming up for certification where there is any suggestion of mental deficiency or incapacity. Ministry of Health Circular 1,337a. Acting on the suggestions contained in (1) and (2) above, the Minister of Health has issued Circular 1,337a to Maternity and Child Welfare Authorities in order to draw attention to the necessity for— (a) The early and effective treatment of ear disease resulting from infectious diseases such as measles, scarlatina, diphtheria and meningitis; and (6) The particular observation and treatment of nose and throat defects. The Minister suggests that the Maternity and Child Welfare Authority will take into consideration at an early date— (1) What use can be made of existing facilities (e.g., infant welfare centres and health visiting) and what additional measures are necessary in their area to ensure the early detection of these defects and diseases in infants; and (2) What arrangements can best be made for providing the necessary treatment. 169 Local Arrangements. 1. Preschool Children.—Infants and toddlers found by the Clinic Medical Officer to be suffering from ear defects are referred for treatment to the school minor ailments clinic, to private medical attendants or to hospitals according to circumstances. By co-operation with neighbouring hospitals no difficulty has been experienced in making the necessary arrangements for treatment, either as out-patients or in-patients. 2. School Children.—Children found at routine medical inspection to be suffering from defects of ear, nose or throat are referred for treatment as in the case of pre-school children. The Education Authority has arrangements, approved by the Board of Education, (a) For the treatment of minor ailments such as running ears, etc. (b) For the operative treatment of defective tonsils and adenoids. No ad hoc clinic exists for the electrical treatment (ionisation) of special cases by an ear specialist; but—as in the case of pre-school children—no difficulty has been experienced so far in arranging special treatment for such cases at neighbouring hospitals. 3. Following-up of Fever Hospital Cases.—When discharged from the isolation hospital, special following-up cards are completed in respect of children who have suffered from any ear complications, and such children are kept under observation by the Clinic Medical Officer or the School Medical Officer. Extent of Ear Defects. During last year .26 per cent, of children examined in Leyton at routine school medical inspection were found to be suffering from defective hearing; the comparative figure for England and Wales being .39 per cent. In addition, 77 school children were found at routine medical inspection to be suffering from other diseases of the ear requiring treatment. During 1932 the number of children actually treated in the school minor ailments clinic for ear defects was 267. At the end of the year there were 8 Leyton school children in certified schools for the deaf, and 3 at certified schools for the partially deaf. The percentage of Leyton school children in certified special schools is 0.05 per cent, as compared with 0.07 per cent, in the country generally. Suggestions and Recommendations. The official report of Dr. Eichholz states that:— "It must be emphasised that all methods for testing hearing power lead to the conclusion that more professional supervision and treatment are necessary to secure prevention of deafness and the proper handling of deaf persons, and that nothing short of the adequate provision of expert otological advice is pertinent to that end." "It is hoped that the use of the audiometer will receive wide encouragement from authorities in this country as a means of disclosing ear defects which remain undetected by present methods." 170 In Circular 1,337a the Minister of Health suggests that:— " Wherever practicable it is, of course, desirable that the treatment of ear diseases should be entrusted to a medical practitioner who has special experience of this work, and in areas where such a specialist is engaged for the School Medical Service, arrangements could no doubt be made for his services to be available to the Maternity and Child Welfare Authority." When judged by these official pronouncements it will be seen that the arrangements in this area are lacking in:— (1) The provision of an "audiometer" for ascertaining the presence of deafness in children ; (2) The services of an ear specialist for the treatment of special cases. The "Audiometer" is an instrument which has come to the front in this country during the last two years. It is practically a gramophone reproducing the graded pitch of the human voice. Earphones test each ear separately, and as many as 40 children can be tested at a time. Valuable results are said to have been obtained in many American cities. Investigations in this country show that, of all children tested by means of the audiometer, from 6 per cent. to 10 per cent. are found to have defective hearing. After consideration of these observations the appropriate Authorities decided to purchase an audiometer at a cost of £26 10s. for use in special cases; but it was not considered that the services of an ear specialist were necessary at present. UNHEALTHY TONSILS AND ADENOIDS. An Investigation into the Results of Surgical Operation for Removal. (By Dr. Mary Gilchrist.) The removal of diseased or enlarged tonsils and adenoids has been for some years one of the most frequently performed surgical operations, especially in children of school age. Lately certain members of the medical profession have suggested that, as with all new forms of treatment, the pendulum had swung too far in one direction and that operations were being performed in cases which would, if left alone, clear up without any surgical interference. The school medical officer is in a particularly favourable position to note both the progress of these cases and the results of the performance or non-performance of operation in the case of children who have suffered from enlarged tonsils and adenoids. The present investigation was undertaken, not so much in the hope 171 of contributing new knowledge, as with a view to obtaining information which might be of guidance in recommending appropriate forms of treatment in the case of school children seen in the course of medical inspection. My experience in a children's hospital (both as a Resident and as an Out-patient Physician) had led me to believe that unhealthy tonsils were the direct or contributing cause of various illnesses and that, if such tonsils were not removed, then the child's health would be seriously impaired. As a school medical officer, however, I examined many apparently healthy children who had tonsils just as pathological in appearance as those whose removal seemed so necessary in the case of the sickly hospital child. What, therefore, was the true state of affairs ? Was the unhealthy tonsil the precursor of debility, otorrhœa, nasal catarrh and bronchitis; and did these apparently healthy children ultimately develop such ailments ? Previous Preliminary Investigation. In his Annual Report for last year the Medical Officer of Health published the results of my preliminary investigation of some 2,750 cases. Although no attempt was made to draw any conclusions from the results of that investigation, the figures showed that, among children recommended for surgical operation, the symptoms cleared up in half of the cases without the operation having been performed. Scope of Present Investigation. This analysis of the different clinical types of tonsillar and associated defect, and of the progress made a-s the result of different forms of treatment, is an endeavour to supply answers to the following questions:— 1. Which type of tonsillar defect is most permanently harmful to the child? 2. Which type of defect is most likely to improve without surgical operation? 3. To what extent can the unhealthy condition of the tonsils be regarded as the cause of the other defects (e.g., bronchitis, otorrhoea, debility, etc.) which may be found in children with unhealthy tonsils? 4. What harm, if any, results from surgical removal of the tonsils? 172 The scientific value of this investigation is considerably diminished due to the fact that no single medical examiner has been responsible for all the clinical notes in any one ease. None of the medical officers was aware of the need for special care in investigation and certain facts, which would have been of importance, may have been omitted in some cases. It is thought, however, that these statistics and conclusions may be of some value because, on examining carefully the records of some 2,750 children, sufficient continuity in the clinical histories was obtained to justify the view that most school medical officers agree regarding the state of the nose, throat and general health of a child although they may not always agree regarding the type of treatment indicated. Procedure in Individual Cases. At the initial inspection cases were classified in one or another of the main groups and sub-groups (detailed below), and recommended for either "observation" or "operation." At subsequent re-inspections progress was recorded in one or other of the three categories "improved," "stationary" or "worse." After re-consideration of the progress of cases originally recommended for observation, a revised or subsequent recommendation was made as at the initial inspection. The appropriate records of progress were then made. Of course, a large number of these children, when the records were examined, had ceased to be seen by the school medical officer, having either left school or left the district ; but roughly 1,220 of these are children who are at present under observation or have recently ceased to be so. The remaining 1,500 case records were of children who had either been discharged as "clear" or had left school within the period 1929-1932. The figures show that, out of a school population of over 15,000 8 per cent. of the children are kept under observation for defects of throat and nose. Classification of Cases. The cases under review were classified into five main groups, each group being divided into four sub-groups, as follows:— Group I. Enlargement of tonsils—first degree. i.e., tonsils extending beyond anterior pillars of fauces but not obscuring posterior pillars, with no undue increase in depth of tonsillar tissue. 173 Group II. Enlargement of tonsils—second degree. i.e., tonsils partly obscuring posterior pillars of fauces. Group III. Enlargement of tonsils—third degree. i.e., tonsils protruding beyond posterior pillars of fauces into nasopharynx. Group IV. Nasal obstruction only. i.e., cases with mouth breathing, but without appreciable tonsillar defect. Group V. Tonsils septic. i.e., with pus exuding from tonsillar crypts. Each group has been divided into four sub-groups as follows:— Sub-group A.—Only tonsils defective. Sub-group B.—Tonsils defective and tonsillar glands enlarged. Sub-group C.—Tonsils defective and mouth breathing. Sub-group D.—Tonsils defective, enlarged tonsillar glands, and mouth breathing. Group I (650 Cases). Tonsils Enlarged—First Degree. Table I. No. of Cases Group I 650 Cases Sub-group (A) 359 (B) 152 (C) 107 (D) 32 Initial Recommendation. Observation 275 101 41 1 Operation 84 51 66 31 Performed 34 19 29 15 Improved 31 (91%) 19 (100%) 29 (100%) 15 (100%) Stationary 3 (9%) 0— 0— 0— Worse 0— 0— 0— 0— Not performed 50 32 37 16 Improved 30 (60%) 19 (59%) 20 (54%) 8 (50%) Stationary 12 (24%) 8 (25%) 13 (35%) 4 (11%) 4 (25%) Worse 8 (16%) 5 (16%) 4 (25%) Subsequent Recommendation. Observation 188 87 31 1 Improved 93 (49%) 53 (61%) 18 (58%) 1 (100%) Stationary 93 (49%) 32 (37%) 13 (42%) 0— Worse 2 (2%) (2%) 0— 0— Operation. 87 14 10 0 Performed 24 3 3 0 Improved 22 (92%) 3 (100%) 3 (100%) 0— Stationary 2 (8%) 0— 0— 0— Worse 0— 0— 0— 0— Not performed. 63 11 7 0— Improved 13 (20%) 1 (10%) 1 (14%) 0— Stationary 4 (7%) 1 (10%) 0— 0— Worse 46 (73%) 9 (80%) 6 (86%) 0— 174 Sub-group A (359 Cases). Only tonsils defective. Observation Cases.—In this section 31.6 per cent, of the cases were ultimately recommended operation; but of the children (188) under observation throughout, 49 per cent, improved, 49 per cent, remained stationary, and only 2 per cent, became slightly worse. Operation Cases.—The results of operation were very satisfactory (over 90 per cent, improved) whether operation was recommended at the first or at a subsequent inspection. Of the children not operated on after the initial recommendation for operation, 60 per cent, improved; whereas of those not operated on after subsequent recommendation for operation as the result of further observation, 73 per cent, became worse. These results appear to suggest that the best procedure, in dealing with children of this type, is to keep them under observation for some time before recommending for or against operation. Experience suggests that a year is roughly the length of time necessary to show what the ultimate condition is going to be. By thus waiting a number of unnecessary operations will be avoided. In this group operations were performed in only 34 per cent, of the cases recommended, an indication that the parents were not convinced that the children's health was impaired sufficiently to justify operation. Sub-geoup B (152 Cases). Tonsils defective and tonsillar glands enlarged. Observation Cases.—13.8 per cent, of these cases were subsequently recommended operation; but of those continuing under observation throughout, 61 per cent, improved, 37 per cent, remained stationary and 2 per cent, became slightly worse. Operation Cases.—Of the cases operated on, 100 per cent, improved. Of those not operated on after the initial recommendation, 59 per cent, improved; whereas of those recommended operation as the result of subsequent observation and not carried out, 82 per cent, became worse. There is a marked similarity between the results in subgroups A and B, and one is led to the conclusion that, in both types of defect, operation should not be recommended until the condition 175 has been kept under observation for some time. The percentage of operations performed (35 per cent.) is roughly similar in both sub-groups. These results seem to suggest that the presence of enlarged glands does not necessarily indicate a more serious defect than when the tonsils alone are involved. Sub-group C (107 Cases). Tonsils defective and mouth breathing. Observation Cases.—In this section 24.4 per cent, of the cases were recommended operation subsequently; but of the children under observation throughout, 58 per cent, improved and 42 per cent, remained stationary. Operation Cases.—100 per cent, of the cases operated on improved. Of those not operated on, in the section where this was the initial recommendation 54 per cent, improved; whereas, in the section where the recommendation came as the result of subsequent observation, failure to have the operation performed resulted in 85 per cent, becoming worse. As in the previous sub-groups, observation is still advisable before operation is recommended, although the likelihood of the condition clearing up is slightly less in this sub-group. The nasal obstruction producing the mouth breathing was, in practically all cases, due to adenoidal enlargement. This subgroup forms only 16.4 per cent, of the cases in Group I and is smaller than one would have expected considering how prone we are to suggest that most cases of tonsillar enlargement are allied to "adenoids." The percentage recommended operation was higher than in the previous groups; and the number of operations performed (42 per cent.) was also greater, the need for operation being more obvious to the parents if mouth breathing is at all marked. A notable feature of this sub-group is that many of the cases operated on took a year or more before the mouth breathing ceased. The children require to be taught to breathe properly, and should be instructed to do breathing exercises after the operation. Sub-group D (32 Cases). Tonsils defective, tonsillar glands enlarged and mouth breathing. 176 In this small group only one case was not recommended operation on first examination, and that case improved. Operation Cases.—100 per cent, of the cases operated on improved, and 50 per cent, of those not operated on also improved. The percentage improvement in this sub-group is, however, not so high as in the previous sub-groups. It is interesting to note that in this sub-group operations are performed within a shorter period of time than in the other subgroups. The majority of the operations were performed within the first year after recommendation. Since a considerable proportion of these cases clear up without operation, the question of treatment by this method might be postponed for six months. If there is then no improvement, operation should be recommended. Group II (1,462 Cases). Tonsils Enlarged—Second Degree. Table II. No. of Cases. Group 11 1,462 Cases Sub-group (A) (B) (C) (D) 935 269 188 70 Initial Recommendation. Observation 304 36 16 — Operation 631 233 172 70 Performed 276 92 63 37 Improved 270 (98%) 91 (99%) 56 (89%) 36 (97%) Stationary 3 (1%) 1 (1%) 7 (11%) 0 — Worse 3 (1%) 0 — 0 — 1 (3%) Not Performed 355 141 109 33 Improved 199 (56%) 73 (52%) 43 (39%) 13 (39%) Stationary 98 (28%) 42 (30%) 50 (46%) 14 (43%) Worse 58 (16%) 26 (18%) 16 (15%) 6 (18%) Subsequent Recommendation. Observation 203 28 8 — Improved 101 (50%) 20 (71%) 5 (62.5%) 0 — Stationary 99 (49%) 8 (29%) 3 (37.5%) 0 — Worse 3 (1%) 0 — 0 — 0 — Operation 101 8 8 — Performed 34 — 5 — Improved 34 (100%) — 5 (100%) — Stationary 0 — 0 — 0 — 0 — Worse 0 — 0 — 0 — 0 — Not performed 67 8 3 — Improved 19 (28%) 3 (37.5%) 1 (33%) 0 Stationary 9 (14%) 0 — 0 — 0 — Worse 39 (58%) 5 (62.5%) 2 (67%) 0 — 177 Sub-group A (935 Cases). Only tonsils defective. Observation Cases.—33 per cent, were recommended operation subsequently. Of those under observation throughout, 50 per cent, improved, 49 per cent, made no improvement, and 1 per cent, became slightly worse. Operation Cases.—The results of operation were very good, over 98 per cent, having improved. Of those not operated on after the initial recommendation, 56 per cent, improved; whereas of those recommended operation as the result of subsequent observation, only 28.3 per cent, improved. There were three cases who gained no benefit from the operation. One developed chronic catarrh with nasal obstruction; one had enlarged sub-maxillary and cervical glands after the operation; and one developed middle ear disease, the discharge continuing two years, but eventually clearing up. Of the operations recommended, 44 per cent, were performed. Though the results of non-operation are not quite so good as in the same section of Group I, they are sufficiently impressive to suggest that observation be continued for a year before operation is advised. Sub-group B (269 Cases). Tonsils defective and tonsillar glands enlarged. Observation Cases.—In this section only a small proportion (13.4) were not recommended operation; and of these, 22 per cent, were advised this treatment subsequently. Of those kept under observation throughout, 71 per cent, improved and 29 per cent, remained stationary. Operation Cases.—Over 98 per cent, of the children operated on improved. Of those not operated on after the initial recommendation, 52 per cent, improved; whereas of those not operated on as the result of subsequent examination, only 37.5 per cent, improved. The results of non-operation are not quite so good as in the previous sub-groups with the exception of Group I (Sub-group D). Operation should not be recommended immediately; and probably a period of observation of from six months to one year is advisable. 178 Sub-group C (188 Cases). Tonsils defective and mouth breathing. Observation Cases.—Only 8.5 per cent, of this sub-group were observations cases, and of these, 50 per cent, were recommended operation later. The numbers are too small (16 altogether) to draw conclusions but the figures conform roughly to those of Group I (C). Operation Cases.—Of those operated on 95 per cent, improved. Only 39 per cent, of those not operated on improved. Of those recommended operation at a subsequent examination and not operated on, only 33 per cent, improved. (Numbers here are again small.) Of the seven cases remaining stationary, four continued mouth breathing because of a deflected septum, and three took two years before nose breathing was established satisfactorily. It was noted in this group that the cases took much longer to improve without operation than in any of the previous sub-groups. It seems desirable, therefore, that in this type of case, though operation is not the only form of treatment, it has to be considered from the outset as a probable necessity depending largely on the severity of the nasal obstruction. When this is slight, the child should be kept under observation for some months, probably a year. Sub-group D (70 Cases). Tonsils defective, enlarged tonsillar glands and mouth breathing. There were no children recommended for observation in this group. Operations were performed on 52.8 per cent. Of these, 97.3 per cent, improved after the operation. Of those not operated on, 39 per cent, improved. One child, instead of deriving benefit from the operation, developed nasal catarrh and bronchitis after it. As in the sub-group II (C), where the nasal obstruction is slight, observation should be allowed for a period of about a year. Where the obstruction is marked, operation should be recommended at the first inspection. 179 Group III (423 Cases). Tonsils Enlarged—Third Degree. Table III. No. of Cases. Group III 423 Cases Sub-group (A) (B) (C) (D) 246 90 62 25 Initial Recommendation. Observation 21 4 3 — Operation 225 86 59 25 Performed 123 45 32 20 Improved 121 (98%) 43 (95.5%) 28 (81.8%) 20 (100%) Stationary 2 (2%) 1 (2.25%) 4 (12.2%) 0 — Worse 0 — 1 (2.25%) 0 — 0 — Not performed 102 41 27 5 Improved 47 (46%) 14 (34.1%) 11 (40.8%) 0 — Stationary 29 (28%) 16 (38.9%) 13 (48.1%) 3 (60%) Worse 26 (26%) 11 (27%) 3 (11.1%) 2 (40%) Subsequent Recommendation. Observation 10 1 1 — Improved 8 (80%) 1 (100%) 1 (100%) 0 — Stationary 2 (20%) 0 — 0 — 0 - Worse 0 — 0 — 0 — 0 — Operation 11 3 2 — Performed 4 — — — Improved 4 (100%) 0 — 0 — 0 — Stationary 0 — 0 — 0 — 0 — Worse 0 — 0 — 0 — 0 — Not performed 7 3 2 — Improved 2 (29%) 1 (33%) 0 — 0 — Stationary 0 — 0 - 2 (100%) 0 — Worse 5 (71%) 2 (67%) 0 - 0 — Sub-group A (246 Cases). Only tonsils defective. Observation Cases.—There were only 21 such cases, and 52 per cent, of these were recommended operation subsequently. Of those continuing under observation, 80 per cent, improved and 20 per cent, remained stationary. Operation Cases.—Of those operated on, 99 per cent, improved. Of those not operated on after the initial recommendation, 46 per cent, improved; whereas in the small group recommended operation on a subsequent examination, only 28.6 per cent, improved. In this group of cases observation for six months should be the rule, for quite a large percentage clear up without operation. It has been noticed that these excessively enlarged tonsils often "clear 180 up0" to almost normal size very quickly. The percentage of operations in this sub-group was high (54.6 per cent.) and indicates that the parents were aware of the need for treatment. Sub-group B (90 Cases). Tonsils defective and tonsillar glands enlarged. Observation Cases.—In this group there were only four cases, of whom three were subsequently recommended operation. Operation Cases.—95 per cent, of those operated on improved. Of those not operated on, only 34 per cent, improved. 52.3 per cent of the operations recommended were carried out. The result of non-operation here is not so good as in any of the other sub-groups considered so far. If there is any doubt about the child's health being affected by the condition of the throat, it is probably better to recommend operation even at first inspection. If, however, the child's health seems to be in no way impaired, the child may be kept under observation for some months. Sub-group C (62 Cases). Tonsils defective and mouth breathing. Observation Cases.—There were only three cases, two of which were recommended operation later. Operation Cases.—52 per cent, of the operations recommended were performed; but only 80 per cent, improved, four of the children requiring nearly two years before giving up mouth breathing. 40 per cent, improved without operation—a higher proportion than one might have expected. The numbers in this sub-group are small, but where the condition is likely to be due to any temporary cause, observation for some months might be indicated. Otherwise, operation should be considered. 181 Sub-group D (25 Cases). Tonsils defective, tonsillar glands enlarged and mouth breathing. In this group there were only 25 cases, of whom 80 per cent, were operated on with complete success. None of the non-operation cases improved. The numbers here are small, but seem to indicate that operation is the only possible treatment. Group IV (29 Cases). Nasal Obstruction Only. This small group consists of the cases with nasal obstruction producing mouth breathing, and showing no tonsillar defect whatsoever. The small number of these cases is rather surprising, as one had supposed this condition to be much more common. The number of cases amounts to little over 1 per cent, of the whole number of cases analysed. Table IV. No. of Cases Group IV 29 Initial Recommendation. Observation 11 Operation 18 Performed 6 Improved 5 (84%) Stationary 1 (16%) Worse 0 — Not performed 12 Improved 4 (33.3%) Stationary 5 (41.6%) Worse 3 (25%) Subsequent Recommendation. Observation 10 Improved 8 (80%) Stationary 2 (20%) Worse 0 — Operation 1 Performed — Improved 0 — Stationary 0 — Worse 0 — Not performed 1 Improved 0 — Stationary 0 — Worse 1 — Observation Cases.—Only one case in this group was recommended operation later. The numbers are small, but 8 out of 10 cases improved, two remaining stationary. 182 Operation Cases.—Five out of the six cases operated on improved, and only four of the 12 not operated on improved. The numbers here are small, but it is noteworthy that the cases clearing up without operation took a long time to do so, and two of those who did not improve developed serious defects. One child had nasal catarrh, otitis media and eventually mastoiditis 2½ years after having been recommended operation. The other child had recurrent otorrhcea over a period of 9 years. It is suggested, therefore, that if the obstruction seems at all of an established nature, operation is the treatment of choice. Group V (125 Cases). Septic Tonsils. There are only 125 cases in this group and the degree of enlargement of the tonsils has not been taken into consideration when analysing them. All degrees of tonsillar enlargement, therefore, are in Group V and this has been sub-divided into sub-groups A, B, C and D as in the previous groups. Table V. No. of Cases. Group V 125 Cases Sub-group (A) (B) (C) (D) 75 33 15 2 Initial Recommendation. Observation 5 4 3 — Operation 70 29 12 2 Performed 30 13 6 2 Improved 28 (94%) 13 (100%) 6 (100%) 2 (100%) Stationary 2 (6%) 0 — 0 — 0 — Worse 0 — 0 — 0 — 0 — Not performed 40 16 6 — Improved 10 (25%) 6 (38%) 2 (33.3%) 0 — Stationary 23 (57%) 7 (43%) 2 (33.3%) 0 — Worse 7 (18%) 3 (19%) 2 (33.3%) 0 — Subsequent Recommendation. Observation 3 4 3 — Improved 2 — 3 — 2 - 0 — Stationary 1 — 1 — 1 — 0 — Worse 0 — 0 — 0 — 0 — Operation 2 — — — Performed - — — — Not performed 2 — — — Improved 0 — 0 — 0 — 0 — Stationary 2 - 0 — 0 — 0 — Worse 0 — 0 — 0 — 0 — 183 Sub-group A (75 Cases.) Tonsils septic. Observation Cases.—There are only five children, of whom two were recommended operation later. Two cleared up under observation and one remained stationary. Operation Cases.—94 per cent, of the cases operated on improved. Only 25 per cent, of the cases not operated on improved. Operation appears to be the treatment of choice here providing the tonsils are not being infected by septic teeth—a condition which should always be looked for. Sub-group B (33 Cases). Tonsils septic and tonsillar glands enlarged. Observation Cases.—Only four cases under observation, of whom three improved and one remained stationary. Operation Cases.—Of the 13 cases operated on, all improved. Six (38 per cent.) cleared up without operation—a better result than the last sub-group showed. It has been suggested by some observers that, when tonsillar glands are enlarged, it is evidence that the infection is being dealt with and that there is more likelihood of the condition clearing up ultimately. The results here may be taken as some slight evidence in support of that contention. If, however, a period of observation is recommended before operation, it should be short. Sub-group C (15 Cases). Tonsils septic and mouth breathing. The numbers here are small, but the results agree with those of the two previous sub-groups. Sub-group D (2 Cases). Tonsils septic, tonsillar glands enlarged and mouth breathing Both cases were operated on with excellent results. 184 Associated Defects. Five hundred and nineteen cases in this investigation suffered from defects other than abnormalities of the naso-pharynx. The defects are tabulated in Table VI. The small incidence of these defects (found in only 19 per cent, of the whole group), bears out the impression one had already formed as the result of school medical inspection, viz., that many children with enlarged and sometimes unhealthy tonsils and adenoids are not affected in their general health. It also emphasises the conclusion already stated, that observation for some time can be advised in most cases of tonsillar defects. Table VI. Defects. I. Groups. IV. V. Total Defects. II. III. No. Percentage. Bronchitis 32 65 15 1 6 119 23% Catarrh 24 51 15 4 1 95 18% Tonsilitis 18 43 16 — 3 80 15% Debility 11 23 7 — 6 47 10% Colds 4 21 9 — 5 39 8% Rheumatism 8 18 4 — 2 32 6% Deafness 8 13 4 4 3 32 6% Otorrhœa 12 14 2 1 3 32 6% Earache 5 7 2 — — 14 3% Poor nutrition 2 6 5 — — 13 2% Ansemia 2 4 2 — — 8 1.5% Other defects 4 2 1 — 1 8 1.5% Total defects in each group 130 267 82 10 30 519 Percentage defects in each group 20% 18% 19% 34°/ 24% An examination of the table reveals the following facts:— Bronchitis is the commonest defect, and accounts for 23 per cent of the whole number. It is more frequent in the slighter tonsillar defects. In the latter respect it differs from tonsilitis, catarrh, debility and colds, which are all proportionately more common in Group III than in Groups I and II. Deafness and catarrh are the commonest defects found in Group IV (the nasal obstruction group), a fact which one would expect. Septic tonsils seem to play an important part in causing debility and the tendency to frequent colds found in some children. The position occupied by otorrhcea in this investigation is rather surprising. Only 6 per cent, of the defects are attributable 185 to it, and it is relatively more common in the milder cases of tonsillar enlargement. The connection between otorrhcea and an unhealthy naso-pharynx is certainly not established in this group of cases. With regard to the results of operation in the cases with the above defects, catarrh, tonsilitis, debility and colds benefit markedly from the operation. Bronchitis, rheumatism and deafness show nothing conclusive, as equally good results were obtained from both operative and conservative treatment. Otorrhcea is not influenced by the operation, except in a very few cases. Indeed, in some cases it was considered to be the result of operative treatment. Of 30 cases coming under observation after the operation had been performed, seven were found to have developed otorrhcea and five were still suffering from otorrhcea some years after the operation which had been performed as a curative measure. The removal of tonsils and adenoids should not, therefore, be hastily recommended in children with otitis media, as its efficacy is doubtful. Conclusions. As already explained, this investigation was undertaken with a view to supplying answers to four questions. The subsequent analysis of cases appears to furnish answers to these questions as follows:— 1. Which type of defect is most permanently harmful to the child? Only one type of defect did not clear up without operation, viz., tonsils enlarged to the third degree with tonsillar glands defective and mouth breathing. If one considers the percentage of defects (34.5 per cent.), nasal obstruction is relatively harmful and in a slightly less degree septic tonsils. At least 33.3 per cent, of all other cases cleared up without operation, the proportion of recoveries becoming progressively greater as the defect became less marked. 2. Which type of defect is most likely to clear up without surgical operation? The cases in Group I and sub-groups A and B of Group II show the most favourable results. Sub-group A of Group III shows a fairly high percentage of recoveries and suggests that all cases of tonsillar enlargement, no matter to what extent (if there are no allied defects) should be put under observation for an appreciable period of time before advising operation. 3. To what extent can the condition of the tonsils be regarded as the cause of the other defects? 186 As only 19 per cent, of the cases exhibited other defects, unhealthy tonsils cannot be regarded as the invariable precursor of such ailments as are detailed above. However, cases suffering from catarrh, tonsilitis, debility and frequent colds benefit from the removal of tonsils and adenoids; and children with such defects and an unhealthy condition of the naso-pharynx should be advised operation. 4. What harm, if any, results from surgical removal of the tonsils? It appears that the risk to the child's health is slight. Five children in this analysis suffered adversely from the operation and 24 appeared to derive no benefit from it. The operation can therefore be regarded as relatively safe. SCARLET FEVER. School Exclusion and Home Treatment. In view of the comparatively mild type of scarlet fever now prevalent, the Medical Officer of Health and School Medical Officer submitted the following report in December to the Education and Public Health Committees:— Memorandum on Closure oe and Exclusion from School. This Memorandum is issued under the joint auspices of the Ministry of Health and the Board of Education. It contains suggestions regarding the closure of public elementary schools and the exclusion of individual children from such schools on account of infectious disease; and the "Regulations" in force in this area for the exclusion of school children on account of infectious disease are based on the procedure recommended in the Memorandum. The Memorandum lays down as a general principle that if the power to exclude individual children be used to the best advantage, it is only in special and quite exceptional cases that it will be necessary to close a school in the interests of public health. Later it states that school closure interferes seriously and unjustifiably with the education of the scholars, and it deprives the Medical Officer of Health and the School Medical Officer of information respecting attacks in their early stage or illness of a doubtful nature which would be obtainable if the schools were kept open, and I contend that the same objection applies to the exclusion of individual children. When a person is notified to be suffering from infectious disease (e.g., scarlet fever) and the home conditions are considered satisfactory for isolation at home, all school contacts in the house are excluded from school for a period of six weeks, whereas contacts other than school children are allowed to go to work, etc. To me such procedure appears to be ridiculously inconsistent. If the patient is isolated satisfactorily, then there should be no need to exclude school children from school. If, on the other hand, the isolation at home is unsatisfactory, then the other contacts should be excluded from work, etc., i.e., if we believe in the conveyance of 187 infection by third persons. Again, the school contact may not go to school, but he is free to play about in the streets and frequent other public places as much as he chooses. In fact, excluded school contacts enjoy much more than their usual amount of freedom out-of-doors due to the fact that they are too much " in the way " when at home. The only possible reasons for the exclusion of school contacts are:— (а) That the child might convey infection to school from the infected home; or (б) That the child might develop the disease and infect other children at school. With regard to (a) that is a relic of epidemiological theory we have grown out of; and one which is not put into practice in the case of contacts other than school children. As regards (6) there is no reason to suppose that the symptoms of onset of infectious disease are less likely to be detected in the case of a child attending school, or that an infectious child does more harm in school than "in the street." If both parents and school teachers were on the look-out for the first symptoms of infection there would be more chance of illness being detected in its early stage. The Efficacy of School Exclusion. As a test of whether the "game is worth the candle," I have investigated the records for scarlet fever during the year 1932—a year when the incidence of the disease was relatively low. The figures for the year were:— Number of notified cases 309 Number removed to Isolation Hospital 180 Number treated at home 129 Analysis of Secondary Cases. (i.e., Cases occurring in households in which a previous case had occurred within a period of six weeks.) No. of days After Primary Case on which Second Case Occurred. Age Groups. 1-5 5 6 7 8 9 10 11 12 13 14 15 and upwards. 1 1 - - 1 - - - - - - - 1 3 1 - - 1 - - - - - - - - 4 1 - - - - - - - - - - 1 5 1 1 1 1 - - - 1 - - - 2 8 - - - - 1 1 - - - - - 2 11 - - 1 - - - - - - - - 1 14 - - - - - - - - - - - 1 17 - - - - - - - - - - - 1 31 - - 1 - - - - - - - - - 36 - - - - - - - 1 - - - - 183 If we exclude secondary oases occurring within the limits of the incubation period (i.e., within 8 days after the occurrence of the primary case)—it will be seen that, of all the school children excluded as contacts, only three developed scarlet fever. Of these three, one was secondary to a primary case which had been removed to hospital. From the records available I find that, under the existing regulations, over 6,000 attendances were lost by children excluded from school as scarlet fever contacts during 1932. So that—as a safeguard against the possible conveyance of infection to school by three contacts who later became infectious—over 6,000 attendances were lost in one year in respect of only one (scarlet fever) of the notifiable infectious diseases. On dealing in similar fashion with the scarlet fever records for the first 10 months of 1933, the following are the relevant figures:— Number of notified cases 536 Removed to hospital 348 Treated at home 188 Number of secondary cases of school age 6 Number of school attendances lost by contacts (approx.) 11,000. General Observations. In the case of scarlet fever, as in other infective processes, there are from time to time great fluctuations in incidence and severity. Although scarlet fever—a generation ago—was a very fatal disease, over a fairly long period the mortality has been almost negligible. Nevertheless its isolation and treatment still involves the expenditure of much public money and causes serious interference with the education of children. The measures taken for the treament and control of infectious diseases have tended in the past to become established practices and fixed traditions, and that in spite of the growth of medical knowledge as to the particular channels of infection. Our methods of disease prevention call for constant and critical re-consideration as to their necessity and expediency. For example, four years ago the traditional routine steam disinfection of bedding and clothing from infected houses was discontinued in this area: and instead of an increase in the number of secondary cases since that time we have had a decrease. Now we have the Ministry of Health recommending (Circular 1,311, March, 1933) that Local Authorities should consider as to the advisability of continuing their routine methods of disinfection. Conclusions and Suggestions. The annual loss of school attendance due to the routine exclusion of contacts is enormous, and I am of opinion that it is in great measure unnecessary in the interests of public health. By confining the exclusion of scholars to the incubation period of the disease (e.g., a week in the case of scarlet fever and diphtheria), parents will be more willing to agree to home treatment; thus permitting of the use of available hospital beds for more serious cases of infection, (e.g. measles). 189 I propose to redraft the existing "Regulations for the Exclusion of Children from School " in such manner as to interfere as little as possible with school attendance while safeguarding against the conveyance of infection in accordance with modern ideas regarding epidemiology. As far as I know, there is no area in the country where school exclusion has been dispensed with to such an extent so far; but, after giving the matter serious consideration from all poits of view, I am convinced that such action has much to commend it both from a public health and from an educational point of view. PHYSICALLY AND MENTALLY DEFECTIVE CHILDREN. Mentally Defective Children: Statutory Medical Examinations. During the year, Some 69 children were referred for statutory medical examination. As the result of examination these 69 children were classified as follows:— Notified to the Local Control Authority under M.D. Acts:— Idiots 0 Imbeciles 5 Moral defectives 0 On attaining 16 years of age—for supervision under the M.D. (Notification of Children) Regulations 7 Certified to Local Education Authority as feebleminded 17 Remained under certificate 7 Certificate withdrawn 3 Dull and backward 20 Backward 3 Borderline cases—-to be re-assessed in six months 7 No appreciable mental defect 0 69 190 Knotts Green Special School for Mental Defectives. Admitted 17 Discharged 24 On roll at end of year 89 Fifteen children, certified to the Local Education Authority as feeble-minded, were admitted to Knotts Green Special School during the year and two children attending the Open Air School were transferred to the School for Mental Defectives. Of the 24 children whose names were removed from the roll, 7 reached the statutory leaving age of 16 years and were notified to the Local Control Authority for supervision in accordance with the Mental Deficiency (Notification of Children) Regulations; 3 were allowed to leave on withdrawal of certificate of mental deficiency ; 13 removed from the district; 1 was notified to the Local Control Authority as an imbecile. Re-examinations.—In addition to the statutory medical examinations under the Mental Deficiency Regulations detailed above, it was possible during the year to submit 43 of the children in this section of the school to more detailed examination and intelligence tests with a view to determining improvement or deterioration in their mental condition, the results being:— Improved 0 Stationary 35 Deteriorated 8 Physically Defective Children. Knotts Green Special School. Accommodation is provided for 150 physically defective children. Admitted during the year 58 Discharged 53 ,, —on withdrawal of certificates 39 „ —-on removal from district 11 ,, —on reaching statutory leaving age 1 „ —on transfer to M.D. School — „ —for residential treatment 2 „ —unsuitable for 0.A. School — On roll at end of year 157 191 The following table shows the types of physical defect, the number of children in each category, and the progress recorded in the cases of 154 children subjected to medical survey by Dr. F. W. Gavin (Deputy School Medical Officer) during the year. Improved. Stationary. Worse. Total. Debility (including Anaemia) 22 8 - 30 Bronchitis 12 5 1 18 Asthma 6 5 2 13 Bronchiectasis 2 3 — 5 Subnormal Nutrition 2 5 —. 7 Quiescent or Arrested Tuberculosis 6 3 — 9 Major Epilepsy 2 1 1 4 Minor Epilepsy — 3 — 3 Nervous (Tic, etc.) 2 — — 2 Rheumatism (including Quiescent, Carditis and Chorea) 19 13 2 34 Congenital Heart Disease 1 2 — 3 Other defects 1 — - 1 Cripples (Orthopaedic cases) 16 8 1 25 91 56 7 154 192 With regard to the records of progress, 18 children admitted to the school during the last term of the year are entered under the heading "Stationary," because it is impossible to make a fair re-assessment of cases which have had only a few weeks' treatment at this school. It will be noted that the percentage of children labelled as "Improved" was 59.09 per cent, in 1933 as compared with 63.76 per cent, in 1932; that 36.36 per cent, were stationary (34.90 per cent, in 1932); and 4.54 per cent, were worse (1.34 per cent, in 1932). It will be observed that 22 cases of debility (including cases of ansemia) improved out of 30, and none were worse— 6 cases of quiescent or arrested tuberculosis improved out of 9, and none were worse; 2 nervous cases improved out of 2; 16 cripples improved out of 25, and only 1 case was worse; 12 cases of bronchitis improved out of 18, and only 1 case was worse. On the other hand only 6 asthmatic children improved out of 13, and 2 were worse; only 2 epileptics improved out of 7, and 1 case was worse; 19 cases of rheumatism (including quiescent carditis and quiescent chorea) improved out of 34, and 2 were worse. These findings are very similar to those of 1932 and indicate the type of physically defective child who is most likely to derive benefit from attendance at the Open-air School. Defective Children. Blind and Partially Blind Children. Arrangements were made for two children to attend a day special school for myopic children. Responsibility was taken over for two children at day special schools for myopic children on removal of the parents into this area. One child left a day special school for myopic children on removal from the area, and one on attaining the statutory leaving age. Two children were certified and admitted to residential blind schools. One child left a residential blind school on attaining the statutory leaving age, and one on withdrawal of the certificate. Deaf and Dumb Children. Three children were certified and admitted to day special schools for deaf children. Responsibility was taken over for one child at a day special school on removal of the parent into this area. One child left a day special school for deaf children on attaining the statutory leaving age, and one on withdrawal of the certificate. One child was allowed to leave a day special school (temporarily) having regard to her age (under seven). Responsibility ceased for two children at residential deaf schools on removal of the parents from the area. Responsibility was taken over for one child at a residential deaf school on removal of the parents into this area. One child was transferred from a residential special school to a day special school. 193 Convalescent Home Treatment. During the year under review the Education Committee accepted responsibility for the cost of the maintenance and treatment of 42 children in Convalescent Homes, Heart Homes or Open-air Schools recognised by the Board of Education. In addition, 34 children attending Leyton Schools were sent away for varying periods through the agency of the Tuberculosis Care Association, and 45 through the agency of the Invalid Children's Aid Association. Exceptional Children—Cost of Education.—The Director of Education has supplied the following information showing the annual cost per child to the Education Authority of educating the undermentioned types of children. Rate Cost Per Child. Per Child. (1) Cost in Leyton Elementary Schools (based on average attendance) £15 17 8 £8 4 1 (2) Blind Child— (i) In Special Day School (a) £20 0 0 £20 0 0 (ii) In Special Residential Sehool(a) £72 10 0 £36 5 0 (3) Deaf Child— (i) In Special Day School (a) £29 8 0 £29 8 0 (ii) In Special Residential School(a) £70 0 0 £35 0 0 (4) Defective Child— (i) In Knotts Green Special School (6) £37 0 0 £18 10 0 (ii) Mentally Defective Child in Residential Institution (a) £60 0 0 £30 0 0 Notes.—(a) Charge made by the particular Institution or Authority —not necessarily the gross cost of education. (b) Cost of educating both physically and mentally defective children at Knotts Green. Not possible to differentiate cost as between each type, as many of the services are common to both in varying proportions. 194 MILK SUPPLY IN SCHOOLS. The two largest milk distributors in the area now make a special effort to cater for milk service schemes in schools, and I am obliged to the Director of Education for the following information regarding the schools in the area where such voluntary schemes are in existence:- Approximate number School. of scholars receiving milk. Cann Hall Road Junior Boys 100 „ ,, ,, Infants 112 Canterbury Road Junior Mixed 180 Church Road Infants 100 Davies Lane Senior Boys 40 „ „ Junior Mixed 59 ,, „ Infants 180 Downsell Road Junior Boys 120 Farmer Road Senior Boys 100 „ ,, Junior Boys 120 „ „ Infants 130 Goodall Road Senior Girls 90 „ „ Junior Girls 150 Harrow Green Infants 44 Kirkdale Road Infants 130 Lea Bridge Road Infants 105 Mayville Road Senior Girls 16 „ „ Junior Girls 16 ,, „ Infants 140 Norlington Road Senior Girls 96 Sybourn Street Senior Boys 80 ,, „ Junior Mixed 150 ,, ,, Infants 130 Trumpington Road Junior Mixed 75 „ „ Infants 70 Total 2,533 During the year 43 children were recommended by the School Medical Officers to receive a supply of milk in school on medical grounds. OPEN AIR EDUCATION. Playground Classes—Open Air Instruction.—Apart from the daily use for recreation purposes a few of the school departments use the playgrounds for suitable lessons when the weather permits. 195 School Camps. The Fifth Annual School Camp organised by the Local Education Authority was held at Dymchurch, Kent, from 16th June to 14th July. During the week prior to departure, all children were subjected to medical examination in order to ensure, as far as possible, that they were clean, free from infectious disease, and otherwise able to stand camp conditions. Children Attending Public Elementary Schools.—In order to afford the opportunity of an educational holiday at the seaside to as many children as required such a holiday the parents of children over 10i years of age were given the opportunity to avail themselves of the facilities offered. The school camps for these children were held as follows:— Girls (216) 16th to 30th June. Boys (266) 30th June to 14th July. Children Attending Knotts Green Special School (64 Boys and Girls). Realising the health and educational value of school camps in the case of ordinary school children, the Education Authority wisely decided to extend the facilities of 1932 to include physically and mentally defective children attending Knotts Green Special School. Considerable care is necessary in the selection of such children, but after the encouraging results of the first camp in 1932, there was a 50 per cent, increase in the number of children at the second camp in 1933. These defective children were under the able supervision and control of Mr. Brewster, who has submitted these observations on the special school camp:— "These physically and mentally defective children improved considerably and enjoyed wonderful health. They achieved enormous appetites and did ample justice to the camp food, which again was excellent in quality and quantity. "The cripples and physically weak—especially in one case whose "chair" existence has always curtailed his outlook and activities—enjoyed every minute. This enlargement of their environment and vision, I am certain, will have a lasting and markedly helpful effect in our efforts to combat the narrow, cramped and selfish outlook that their physical deformities foster. The extra work, time and care expended by the staff was thus amply repaid. 196 "The opportunity of imparting valuable practical health education to these physically weak was used to the uttermost. It is my opinion that all the defective children now at Knotts Green Special School could be transferred to Dymchurch Camp for a longer period with confidence that their residential stay there would be beneficial." After the encouraging results of these two camps I suggest that, in the interests of these defective children, it would be wise to extend the camp facilities to include a greater number of defective children and to increase their length of stay in camp. Dymchurch Holiday Camp—Observations by School Medical Officer. On 28th June last I visited the camp during the residence there of the Leyton school girls, and had the opportunity of making a tour of inspection of the arrangements. The camp is situated within 100 yards of the sea. and at low tide a very large expanse of fine sandy beach is available. The extent of the sandy beach and the safety of the sea bathing make it an ideal resort for . children. The halls and dormitories are built of brick with concrete floors; and they are dry, well-lighted and well-ventilated. The children sleep in the dormitories on hammock trestle beds, each child being provided with thick blankets, a pillow and slip. Ablution sheds and latrines, easy of access from all parts of the camp, are kept in a very cleanly and sanitary condition. The water supply from company's mains is subjected to periodical analysis, and the drainage system is efficient and modern. The whole camp is lit by electricity generated in the camp power house. I was much impressed by the excellence of the catering arrangements, by the cleanliness of the kitchens and dining halls, by the quality and quantity of the meals provided, and by the apparent absence of tinned foods. The five fundamental conditions on which the human body depends for health are:— Good food, well cooked. Abundance of fresh air and sunshine. Regular exercise. Warmth. Adequate rest . I have never seen a camp which is better situated and equipped to supply these essentials on such a large and liberal scale. One of the greatest health-giving agents available is the combined action (in moderation) of salt water, sunshine and fresh air on the human skin; and the Dymchurch camp certainly offers incomparably better facilities in that direction than an inland holiday camp. 197 EMPLOYMENT OF CHILDREN and STREET TRADING BY YOUNG PERSONS. In August, 1931, the Bye-laws made by the Leyton Local Education Authority pursuant to the provisions of the Employment of Children Act, 1903, as amended by the Education Act, 1921, regulating (a) the employment of children generally, and (b) street trading by persons under the age of sixteen years, within the Borough of Leyton were confirmed by H.M. Minister and put into operation forthwith. Since these Bye-laws came into operation, medical certificates have been granted as follows:— 1931 89 certificates granted 1932 72 „ „ 1933 65 „ „ PROVISION OF MEALS. The provision of meals to children attending the elementary schools is undertaken by the Education Authority under powers granted by Sections 82-85 of the Education Act, 1921. The average number of children fed per week during the past five years:— 1929 216 1930 247 1931 289 1932 356 1933 303 The number of individual children fed under the Authority's arrangements during 1933 was 805, as follows :— Ordinary Milk Meals. Meals. Free 622 43 For payment 128 12 Totals 750 55 198 Number of meals supplied:— Ordinary Milk Meals. Meals. Free 79,316 8,199 For payment 11,496 1,286 Totals 90,812 9,485 The average cost of food per meal was 2.59 pence; the total average cost (including overhead charges) being 5.41 pence. The total cost for the year amounted to £2,259 lis. 8£d. The above figures relate to the financial year ended 31st March, 1934. STATISTICAL APPENDIX. TABLE I.—Returns of Medical Inspections, a. Routine Medical Inspections. Number of Code Group Inspections :— Entrants 1,556 Intermediates 1,441 Leavers 1,920 Total 4,917 Number of other Routine Inspections 876 b. Other Inspections. Number of Special Inspections 2,103 Number of Re-inspections 9,389 Total 11,492 199 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1933. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Malnutrition 103 2 54 ... Uncleanliness— ... ... ... ... (See Table IV., Group V.) Skin Ringworm—Scalp 1 ... 5 ... Body ... ... 14 ... Scabies 1 ... 18 ... Impetigo 2 ... 102 ... Other diseases (non. T.B.) 10 ... 155 ... Eye Blepharitis 23 ... 113 ... Conjunctivitis 1 ... 46 ... Keratitis ... ... 5 ... Corneal Opacities ... ... 8 ... Defective Vision 234 1 67 ... Squint 26 3 3 ... Other conditions 6 1 104 ... Ear Defective Hearing 14 1 20 ... Otitis Media 34 5 16 ... Other Ear Diseases 7 9 233 ... Nose & Throat Chronic Tonsilitis only 88 200 41 6 Adenoids only 30 14 5 ... Chronic Tonsilitis and Adenoids 55 21 26 ... Other Conditions 22 5 62 ... Enlarged Cervical Glands (non. T.B.) 34 37 56 ... Defective Speech 9 2 3 ... Heart and Circulation Heart Disease— Organic 5 1 11 ... Functional 28 57 6 5 Anaemia 34 10 71 ... Lungs Bronchitis 29 52 48 1 Other non. T.B. Diseases 14 51 26 1 Pulmonary— Tuberculosis Definite 1 7 2 ... Suspected ... ... 6 ... Non-Pulmonary— Glands 4 ... 6 ... Bones and Joints 1 1 2 ... Skin ... ... ... ... Other Forms ... ... ... ... Nervous System | Epilepsy 3 5 4 1 Chora 1 3 16 2 Other Conditions 12 11 22 2 Deformities Rickets 1 ... ... ... Spinal Curvature 5 1 2 ... Other Forms 87 12 17 3 Other Defects and Diseases 120 41 623 16 200 TABLE II. B.—Number of Individual Children found at Routine Medical Inspection to require treatment (excluding uncleanliness and dental diseases). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment. (1) (2) (3) (4) Code Groups- Entrants 1566 291 18.70 Intermediates 1441 255 17.68 Leavers 1920 350 18.22 Total (Code Groups) 4917 896 18.22 Other Routine Inspections 876 66 7.53 TABLE III.—Return of All Exceptional Children in the Area. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Children suffering from the following types of multiple defects, i.e., any combination of total blindness, total deafness, mental defect, epilepsy, active tuberculosis, crippling, heart disease 6 BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 6 — — — 6 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 15 — 2 — 17 201 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 7 — 1 2 10 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 3 — — — 3 MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for Mentally Defective Children. At PublicElementary Schools. At other Institutions. At no School or Institution. Total. 89 — 1 — 90 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 4 - — 1 5 PHYSICALLY DEFECTIVE CHILDREN. A. Tuberculous Children. 1.—Children Suffering from Pulmonary Tuberculosis. (Including pleura and intra-thoracic glands.) At Certified Special Schools. At Public Elementary Schools. At other Intitutions. At no School or Institution. Total. 1 5 1 — 7 202 11. Children Suffering from NoN-Pulmonary Tuberculosis. (This category should include tuberculosis of all sites other than those shown in (I) above.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 5 20 1 — 26 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 119 9 — 1 129 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 63 50 1 2 116 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 21 1 — 1 23 203 TABLE IV.—contd. Group II.—Defective Vision and Squint (excluding Mincr Eye Defects treated as minor allments.—Group I.). Defect or Disease. (1) Number of Defects dealt with. Under the Authority's Scheme. (2) Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. (3) Otherwise. (4) Total. (5) Errors of Refraction (including Squint). (Operations for Squint should be recorded separately in the body of the Report) 1066 16 8 1090 Other Defect or Disease of the Eyes (excluding those recorded in Group I.) 34 - — 34 Total 1100 16 8 1124 Total number of children for whom spectacles were prescribed- (а) Under the Authority's Scheme 848 (b) Otherwise 24 Total number of children who obtained or received spectacles- (a) Under the Authority's Scheme 845 (b) Otherwise 27 TABLE IV.—contd. Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Other Forms of Treatment. (4) Total Number Treated. (5) Received Operative Treatment. Under the Authority's Scheme in Clinic or Hospital. (1) By Private Practitioner or Hospital, apart from the Authority's Scheme. (2) Total. (3) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4) — — 118 21 — — 34 9 — — 152 30 86 268 (1) Tonsils only. (2) Adenoids only. (3) Tonsils and adenoids. (4) Other defects of the nose and throat. 204 TABLE IV.—contd. Group IV.—Dental Defects. (1) Number of children who were:— (a) Inspected by the Dentist:— Aged: Routine Age Groups 5 447 Total 8,002 6 795 7 755 8 647 9 848 10 844 11 939 12 1,090 13 1,108 14 529 Specials 2,167 Grand Total 10,169 (b) Found to require treatment 8,442 (c) Actually treated 6,211 (2) Half-days devoted to Inspection 50 Treatment 770—Total 820 (3) Attendances made by children for treatment 7,264 (4) Fillings, Permanent Teeth 6,264 Temporary ,, 612—Total 6,876 (5) Extractions, Permanent Teeth 914 Temporary ,, 3,426—Total 4,340 (6) Administrations of general anaesthetics for extractions 675 (7) Other operations, Permanent Teeth 796 • Temporary ,, 294—Total 1,090 Group V.— Uncleanliness and Verminous Conditions. (1) Average number of visits per school made during the year by the School Nurses 3 (2) Total number of examinations of children in the Schools by School Nurses 35,461 205 TABLE I V.—contd. (3) Number of individual children found unclean 1,540 (4) Number of children cleansed under arrangements made by the Local Education Authority (5) Number of cases in Which Legal proceedings were taken:— (a) Under the Education Act, 1921 — (b) Under the School Attendance Bye-laws — STATEMENT OF THE NUMBER OK CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1 933, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total number of children notified: 11. Analysis of the above Total. Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots - - (b) Imbeciles 3 - (c) Others - - (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (a) Moral defectives — - (b) Others - - 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 6 2 3. Feeble-minded children notified under Article 3, i.e., "special circumstances" cases Note.— No child should be notified under Article 3 until the Board have issued a formal certificate (Form 308M) to the Authority. — — 4. Children who in addition to being mentally defective were blind or deaf Note.—No blind or deaf child should be notified without reference to the Board—see Article 2, proviso (ii). — — Grand Total 9 2 206 INDEX. GENERAL. Page Area and Population 10 Bacteriological Examinations 46 Births and Birth Rate 9,14 Birth Chart illustrating Birth Kate since 1012 16 „ Distribution in Wards 17 Cancer 55 Chicken-pox 55 Committees 41,42 Comparative Statistics 20,27 Deaths and Death Rate 9,18,10,20,21 Death Chart illustrating Death Rate since 1912 24 „ Classified Causes, Table of 22,23 „ Distribution in Wards 22,23 „ Infantile Rate 9 „ Principal Causes 25 Diabetes, Supply of Insulin. 50 Diphtheria 45,40 Disinfection, Terminal 49,52 Enteric Fever 42 Hospitals Subsidised by Local Authority 38/40 Infantile Mortality 9,26 Infectious Diseases 40/48 ,, ,, Table of Notifications 48 Influenza 46,47 Inquests 30,31 Insulin, Supply of 56 Legislation in force 37,38 Meteorological Conditions 11 Table 12, 13 Mortuary 31/35 Notification of Births Act 18 Population 10 Scarlet Fever 43,44,45 Smallpox 40, 41 Social Conditions of Area 10 Staff 3 Terminal Disinfection 49/52 Tuberculosis 53/55 207 Tables:- PAGE Table 1. Meteorological 12, 13 ,, 2. Registered Births, 1933 17 „ 3. Deaths, Ages and Wards 22, 23 „ 4. Comparative Statistics, 1892-1933 27 ,, 5. Vital Statistics of Whole District 28 „ 0. Analysis of Mortality 29 ,, 7. Infectious Disease Notifications 48 „ 8. Infant Mortality—Ages 110 „ 8a. „ „ Wards 117 ISOLATI0N HOSPITAL. Admissions 56 Buildings and Equipment 59 Diphtheria 60 Measles 61 Operating Theatre 59 Permanent Isolation Hospital 61,62 Scarlet Fever 57,58,59 MATERNITY AND CHILD WELFARE. Abnormal Cases, Ante-natal 121,122,123 Ante-natal Clinics 119 Artificial Sunlight Treatment 103/107 Attendances at Clinics—Ante-natal 119,120 ,, ,, ,, Infant Welfare 97 Children and Young Persons Acts 118,119 Clinic Premises, New Joint 133/136 Convalescent Home Treatment 107,108 Deaths, Maternal 125,126 Dental Treatment 99,100,101 Foetal Mortality 111 Health Visitors—Summary of Visits 98, 99 Home Helps 130 Infant Life Protection 118,119 „ Mortality 111 Maternal Morbidity and Mortality 125,126 Maternity Beds 124,125 Meals for Expectant and Nursing Mothers 132 Midwives, Acts 127, 128, 129 „ Compensation to 125 ,, Fees paid to Doctors 129 ,, Payment of Fees in Necessitous Cases 125 „ Supervision of 127 Milk, Scheme for Supply of 130/131 208 Page Neo-Natal Mortality 112/115 Nursing Homes Registration Act 130 Nutrition 131 Obstetric Consultant 126 Ophthalmia Neonatorum 109 Orthopaedic Treatment 101,102,103 Pemphigus Neonatorum 110,111,128 Puerperal Fever 125 „ Pyrexia 126 Stillbirths 112 Voluntary Workers 97,98 SANITARY CIRCUMSTANCES OF THE AREA. Allotments 81 Bakehouses 90 Clearance Areas 69 Demolition Orders 69 Diseases of Animals Acts 93 Disinfection 81 Drainage and Sewerage 75 Factory and Workshop Acts 84/87 Food, Inspection of 88/93 House to House Inspection 69,74 Housing Statistics 65/68 Ice Cream 89 Inspection of District 64 Lea Bridge Gardens 68 Legal Proceedings 75,76 Meat Inspection 90/93 Meat Regulations 93 Milk, Special Designation Order 88, 89 Offensive Trades 80 Overcrowding 76,77 Petroleum Acts 82 Poison and Pharmacy Acts 82 Rag and Flock Act 81 Rats and Mice Destruction Act 93 Refuse Dumps 81 Rent Restriction Act 75 209 Page Shops Act 82,83 Slaughterhouses 90 Slaughtering, Humane 90 Smoke Abatement 80 Unsound Food 90,91,92 Verminous Premises 77,78,79 SCHOOL MEDICAL SERVICE. Artificial Light Clinic 162/170 Blind Children 192 Convalescent Home Treatment 193 Deaf and Dumb Children 192 Dental Clinic 156/159 Employment of Children 197 Exceptional Children, Cost of Education 193 Eye Clinic 154/156 Knotts Green Special School 190 Medical Inspection 140,141,142 Table 142 „ „ Findings of 142/152 „ Treatment 152 Mentally Defective Children 189,190 Milk Supply in Schools 194 Minor Ailments 152/154 Open Air Education 194 Orthopaedic Clinic 159/162 Physically Defective Children 190/192 Provision of Meals 197,198 Scarlet Fever—School Exclusion 186/189 School Camp 195/196 „ Population and Attendance 138 „ Premises—Alterations and Additions 139/140 Tables, Statistical 198/205 Tonsils and Adenoids (Special Report) 170/186 Uncleanliness 152