W. Lowrence. LEY 31 Borough of leyton HEALTH REPORT FOR THE YEAR 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 6. 2 HIS WORS H IP THE MAYOR (Mr. Alderman Thorn, J.P.), ex-offlcio Member of Committees. PUBLIC HEALTH COMMITTEE: DISEASES OF ANIMALS ACT COMMITTEE. Chairman : Councillor Hinton. Members : Alderman Bechervaise. Councillor Mrs. Hammond. „ Russell, J.P. „ Hawkins. „ Shimmin, B.Sc. „ Hurry. „ Mrs. Shimmin. „ Mrs. Mawer. Councillor Barber. „ Pearce. „ Bass. „ Rayner. „ Bell. „ Rigg. „ Biles. „ Shore. „ Cochrane. „ Snell. „ Flack. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Alderman Mrs. Shimmin. Members : Alderman Bechervaise. Councillor Hawkins. „ Russell, J.P. „ Hurry. „ Turner. „ Mrs. Mawer. Councillor Bussey. „ Peck. „ Gowar. „ Shore. „ Mrs. Hammond. Co-opted Members : Mrs. Cochrane. Mrs. Sortwell. „ Martin. „ Waller. „ Peck. EDUCATION COMMITTEE. Chairman : Councillor Pearce. Members : Alderman Allanson, J.P. Councillor Cochrane. „ Bechervaise. „ Mrs. Hammond. „ Fitzgerald. „ Hawkins. „ Russell, J.P. „ Hinton. „ Shimmin, B.Sc. „ Hurry. „ Mrs. Shimmin. „ Mrs. Mawer. „ Turner. „ Mills. Councillor Bass. „ Snell. „ Bell. „ Spink. Co-opted Members : Mrs. Barber. Mrs. Ringer. „ Cochrane. ,, Waller. „ Moles. Mr. G. A. Grime. EDUCATION WELFARE SUB-COMMITTEE. Chairman : Councillor Mrs. Hammond. Members : Alderman Fitzgerald. Councillor Spink. „ Russell, J.P. Mrs. Barber. „ Mrs. Shimmin. „ Cochrane. „ Turner. „ Moles. Councillor Bell. „ Ringer. „ Hawkins. „ Waller. „ Hinton. Mr. G. A. Grime. „ Hurry. 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. (Resigned 30.9.36.) *Henderson, Peter, M.D., M.B., Ch.B., D.P.H., Deputy Medical Officer of Health and Deputy School Medical Officer. (Commenced 1.10.36.) *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., D.P.H., 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. *Brews, Richard Alan, F.R.C.S. (Eng.), M.D. (Lond.), M.S., M.B., B.S., M.R.C.P. (Lond.), M.R.C.S. (Eng.), 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. CHIROPODIST. O'Brien, J., M.I.S.Ch. 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 Inspeetor's 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.I., Meat Inspector's Certificate R.S.I *Nightingale, A. G., Certificate R.S.I., Meat Inspector's Certificate R.S.I. HEALTH VISITORS. *Bratton, Maud, Trained Nurse. *Walling, Ethel Winifred, S.C.M., Trained Nurse, Health Visitor's Certificate R.S.I. *Kittering, Margery, Trained Nurse, S.C.M., Health Visitor's Certificate R.S.I. *Sizer, Agnes, Trained Nurse, S.C.M., Health Visitor's Certificate R.S.I. *Neale, Barbara, Trained Nurse, S.C.M.. Health Visitor's Certificate R.S.I. SCHOOL NURSES. *Crawford, Daisy, Trained Nurse, Health Visitor's Certificate R.S.I. *Sykes, Martha, Trained Nurse. *Ma ye, Marie, Trained Nurse, Hoalth Visitor's Certificate R.S.I. *Fulcher, Joan, Trained Nurse. *Edwards, Ruth, Trained Nurse, S.C.M. *Stiles, Eleanor, Trained Nurse, S.C.M. MASSEUSE. *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., Budd, E. W., Thurlow, G., Freeman, A., Clarke, J. * Proportion of Salary contributed under Public Health Acts or by Exchequer Grants. 4 TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF LEYTON. 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 1936, together with my Annual Report to the Education Authority on the work of the school medical service during the year. These reports are drawn up on the lines required by the Ministry of Health and the Board of Education. Meteorological. The summer of 1936 was a very wet one, the rainfall being excessive during the months of June, July and September. The daily hours of sunshine were also well below the average during the summer months ; and although December was unusually sunny, September was the dullest month on record since 1880. The mean temperature of the year was 50.5 degrees Fahrenheit, being 0.2 degrees Fahrenheit above the average of previous years. Vital Statistics. The last official census return—that of the year 1931—showed the population in the Borough of Leyton to be 128,313 persons. To-day the Registrar General's estimate of the population is 119,900 persons. The number of births registered in the Borough during 1936 was 1,421, the birth rate per thousand of the population being 11.85. Although the number of births (1,421) is the lowest ever recorded, the birth rate (11.85) does not quite reach the low record (11.78) of the year 1934. This apparent anomaly is due to the decrease in the estimated population from 123,430 in the year 1934 to 119,900 in the year 1936. The marked and progressive fall in the birth rate will be seen from the following Leyton annual figures at intervals of ten years:— 1896. 1906. 1916. 1926. 1936. Population 77,000 108,000 132,107 130,000 119,900 Births 2,372 3,344 2,560 2,022 1,421 Birthrate 30.08 30.90 19.40 15.55 11.85 The deaths of Leyton residents certified during the year numbered 1,272, giving a general death rate of 10.61 per thousand 5 of the population. The number of deaths is greater by 47 than the corresponding number of the previous year ; the increase being accounted for chiefly by rises in the number of deaths from measles and cancer. Sanitary Circumstances. The Housing Act, 1935, imposed on every Local Authority the duty of making an overcrowding survey of dwelling houses in the area and of reporting to the Minister of Health the result of the survey and the action proposed to be taken. The survey revealed that overcrowding (according to the official standards laid down) existed in 551 (i.e., 2.07 per cent.) of the 26,608 dwellings surveyed ; and that in this area by far the greatest amount of overcrowding exists in families of six persons and in dwellings with a permitted number of five persons. Detailed information and statistical results of the special overcrowding survey will be found on pages 48 to 55. During the year some 14 dwelling houses were demolished as the result of demolition orders made by the Council. Infectious Diseases. There has been a progressive fall in the incidence of scarlet fever in the area during the last four years, and the disease continues to be of the prevalent mild type to which we have become accustomed during recent years. During recent years our former conceptions of the nature of infection and epidemiology of scarlet fever have been shattered at such a rate that we cannot afford to disregard the results of experience of any method of dealing with the disease, however unorthodox it may appear. On pages 74 to 89 of this report will be found extracts from my recent Presidential Address to the Home Counties Branch of the Society of Medical Officers of Health, in which i dealt with the results of certain local modifications of orthodox methods of control. A summary of these investigations appears on page 89. Although the incidence of diphtheria was not so great as during 1935, there was an increase in the case fatality rate. Of 231 persons notified to be suffering from diphtheria during the year, eleven died as the result of the disease. The average age of the fatal cases was 4 years. These deaths from diphtheria are all the more lamentable in view of the fact that the Council has established a special clinic 6 where children over one year of age can be protected against diphtheria free of charge. During the year some 1,268 children were immunised against diphtheria at the Council's special diphtheria immunisation clinic ; but it is to be regretted that a much larger proportion of parents in the area do not avail themselves of the facilities offered on behalf of their children. The biennial epidemic of measles began in February and lasted unt' l June. Measles is one of the most highly infectious and dangerous of all infectious diseases, especially in the case of infants and young children. Of 1,556 cases reported during the epidemic, 23 died. Isolation Hospital. The total number of patients admitted to Leyton Isolation Hospital during the year was 419, of whom 232 were notified as suffering from scarlet fever and 187 from diphtheria. In addition, it was necessary to find accommodation in fever hospitals outside the area for 8 Leyton residents suffering from scarlet fever and 17 suffering from diphtheria. Maternity and Child Welfare. Although there has been a marked fall in the birth rate during recent years, there has been no corresponding decrease in the number of children attending the Council's infant welfare centres. During the year under review 969 infants under one year attended the clinics for the first time. The total attendances during the year were 16,220. The number of deaths of infants under one year of age was 74, an increase of 14 compared with the corresponding number of the previous year. The infantile mortality rate was 52.07 ; the comparative rate for London was 66, and for England and Wales 59. For ante-natal supervision 430 expectant mothers made 1,158 attendances at the two municipal ante-natal clinics during the year. In addition, 324 expectant mothers resident in Leyton attended for ante-natal supervision at Queen Mary's Hospital prior to confinement in that hospital under the Council's maternity and child welfare scheme. Of 1,421 Leyton mothers who gave birth to children during 1936, some 760 (53 per cent.) had their confinements in residential institutions. 7 Two women died from diseases and accidents associated with pregnancy and childbirth. The Leyton maternal mortality rate of 1.36 per thousand live and still births compares favourably with the corresponding rate of 3.65 for England and Wales. In September, 1935, a special weekly clinic for the health supervision and special medical examination of " toddlers " (i.e., children between two and five years of age) was instituted at each of the Council's infant welfare centres. A short account of the first complete year's working of the special toddlers' clinics is incorporated in the body of this Report. In September, 1936, your Maternity and Child Welfare Authority extended their scheme for provision of Home Helps to apply to any expectant or nursing mother who may be certified by your medical officer to need domestic assistance on account of illness. In October, 1936, the Maternity and Child Welfare Authority were able to put into operation their scheme for the provision of meals to expectant and nursing mothers recommended for such extra nourishment on medical grounds. School Medical Service. When the school medical service was established in 1907, its declared function was medical "inspection" for the purpose of discovering, enumerating and cataloguing defects. Although, in the early days, Local Education Authorities were warned by the Board of Education against embarking on schemes of treatment, the results of medical inspection soon showed the need of extending the scope of the medical services to include facilities for treatment at special school clinics. These facilities for treatment have become so comprehensive and so much used that the school clinics are now performing many of the functions of hospital out-patient departments. In spite of the rapid development and fundamental changes in the function of the school medical service, the methods of making and recording the results of routine medical inspections in school have remained unchanged. Following a special report submitted by me in 1935 the Education Authority has now established a special clinic for the treatment and orthoptic training of children suffering from squint. 8 Staff. At the end of September Dr. F. W. Gavin relinquished the appointment of Deputy Medical Officer of Health and Deputy School Medical Officer on his appointment as Medical Officer of Health of another Authority. Dr. Gavin, during his 4½ years' service as a member of the Health Department, won the respect and confidence of colleagues and members of the public by virtue of his sterling qualities and professional ability. His successor, Dr. Peter Henderson, took over his duties on 1st October. Dr. Mary Gilchrist, who was granted leave of absence to attend a post-graduate course of instruction, gained the Diploma in Public Health of London University with Distinction. 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, Me. Mayor, Ladies and Gentlemen, Your obedient servant. 9 SECTION A. STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area in acres 2,594 Population (Census 1931) 128,313 Population (Registrar-General's estimate, June, 1936) 119,900 Number of families (Census 1931) 34,368 Number of inhabited houses (Census 1931) 26,306 Number of persons per house (Census 1931) 4.87 Assessable value for General Rate purposes £771,776 Sum represented by a penny rate for General Rate purposes (as from 1st April, 1937) £3,021 Summary of Dwellings, Rooms and Private Families. Housing Census 1931. Dwellings occupied by private families 26,306 Percentage of vacant unfurnished dwellings 1.00 Rooms occupied by private families 143,147 Private families 34,368 Population in private families 123,522 Rooms per occupied dwelling 5.44 Families per occupied dwelling 1.31 Persons per family 3.59 Persons per room 0.86 Percentage living more than 2 persons per room— Private families 2.94 Population 5-61 10 Physical Features of the Area. See Annual Report for 1934. Social Conditions. See Annual Report for 1934. Extracts from Vital Statistics for the Year. Live Births:— Birth Rate per 1,000 Males. Females. Total. population. Legitimate 759 624 1,383 Illegitimate 21 17 38 11.85 780 641 1,421 Rate per 1,000 total (live and Males. Females. Total. still) births. Stillbirths 24 20 44 30.03 Males. Females. Total. Death Rate. Deaths 639 633 1,272 10.61 Number of women dying from diseases and accidents of pregnancy and childbirth:— Rate per 1,000 total (live and still) births. From Sepsis 2 1.36 From other causes 0 0.00 Total 2 1.36 Death Rate of Infants under One year of age:— All infants per 1000 live births 52.07 Legitimate infants per 1000 legitimate live births 50.61 Illegitimate infants per 1000 illegitimate live births 105.26 Deaths from Cancer (all ages) 205 Deaths from Measles (all ages) 23 Deaths from Whooping Cough (all ages) 2 Deaths from Diarrhoea (under 2 years of age) 7 11 METEOROLOGICAL CONDITIONS, 1936. The weather of the year 1936 was distinguished by more than the average amount of rainfall and by a marked deficiency of sunshine. The summer was excessively wet and the daily hours of sunshine were well below the average for previous years. September was the dullest month on record since 1880. Rainfall. Average Amount annual in amount inches. in inches. London, 1936 24.37 London, 1881-1915 23.24 Country, as a whole, Country, as a whole, 1936 31.5 1881-1915 29.6 In London, the rainfall was 1.13 inches above the average. Of the total rainfall (24.37 inches) 9.5 inches fell in the months June, July and September. The months of May and August were exceptionally dry. There was excessive rainfall in January, February, June, July, September and November. In London, snow fell on 18 days, hail on 8 days, thunderstorms occurred on 16 days, 41 days were foggy, and there were gales on 2 days. Sunshine. Average Average daily daily sunshine. sunshine. London, 1936 3.2 hours London, 1901-1930 4.01 hours Country, as a whole, Country, as a whole, 1936 3.79 „ 1881-1915 4.12 „ In London, the hours of sunshine were above the average only in February and December. The month of December was unusually sunny. June was the sunniest month, with a daily average of 6.04 hours of sunshine. 12 Temperature. Average Average annual temperature. temperature. London, 1936 50.5° F. London, 1901-1930 50.3° F. Country, as a whole, Country, as a whole, 1936 47.6° F. 1880-1915 48.5° F. In London, the mean temperature of the year was 50.5 degrees Fahrenheit—0.2 degrees Fahrenheit above the average of previous years. August was the warmest month, with a mean temperature of 63.5 degrees Fahrenheit. The highest temperature recorded was 88 degrees Fahrenheit on June 21st. February was the coldest month, with a mean temperature of 37.3 degrees Fahrenheit. The coldest day was February 12th, when a temperature of 19 degrees Fahrenheit was recorded. I—' CO TABLE 1.— METEOROLOGICAL TABLE FOR LONDON, 1936. {Deduced from Observations at Greenwich, under the Superintendence of the Astronomer Royal.) 1936. 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 Average. Absolute Maximum and Minimum. Mean of Observations at 9 a.m. and 9 p.m. At li'oot depth. At 4 feet depth. Daily Mean. Difference from Average. Per cent, of Possible. A B Maximum. Day of Month Minimum. Day of Month. Dry Bulb. Depression of Wet bulb. Vapour Pressure. Humidity. Maximum. Minimum. January mb. 996.3 °F. 45.1 °F. 36.2 °F. 40.7 °F. + 0.6 °F. 56 9 °F. 25 15. 19 °F. 40.3 °F. 1.3 mb. 7.7 % 89 tF. 41.4 tF. 44.1 hr. 0.74 hr. —0.55 % 9 February 1002.1 42.7 31.8 37.3 —3.0 54 18 19 12 36.3 1.3 6.5 87 38.8 42.0 2.25 + 0.12 23 March 1006.7 53.2 38.7 45.9 +2.6 65 21, 22 28 4 44.9 2.1 8.7 83 42.8 43.0 2.52 —0.76 21 April 1010.7 52.3 37.4 44.9 —2.4 63 28, 29 28 21 44.5 3.3 7.5 74 45.1 45.6 3.55 —1.20 26 May 1012.9 64.6 45.2 54.9 + 0.2 80 6 34 29 53.5 3.9 10.5 75 53.0 50.1 5.55 —0.95 36 June 1013.1 71.4 52.6 62.0 + 2.8 88 21 41 3 60.5 3.9 14.1 78 58.4 54.6 6.04 —0.69 37 July 1008.1 70.6 54.0 62.3 —1.0 78 17 47 27, 28 60.7 3.5 14.5 81 61.4 58.8 4.44 —1.96 28 August 1017.3 73.3 53.7 63.5 + 1.0 85 29 46 23 61.9 3.5 15.1 81 61.5 59.4 5.55 —0.54 38 September 1014.2 67.3 52.6 59.9 + 2.1 80 2 42 29 58.3 2.3 14.5 85 60.1 59.5 2.82 —2.20 22 October 1016.0 56.8 42.0 49.4 —1.7 67 15 30 29 49.3 2.7 9.7 81 52.4 55.1 2.80 —0.37 26 November 1008.8 48.6 38.7 43.7 + 0.5 56 17 32 11,25,29 43.9 1.5 8.6 87 47.7 50.8 0.78 —0.88 9 December 1015.5 46.9 36.9 41.9 + 1.1 55 2,17,18 26 7, 8 41.7 1.5 7.9 87 44.2 47.4 1.32 + 0.32 17 Year 1010.1 57.6 43.3 50.5 + 0.2 88 June 21 19 Feb.12 49.7 2.6 9.9 81 50.6 50.9 3.20 —0.81 26 • The hours of observation are 9 a.m. and 9 p.m. local time. The averages of temperature and sunshine used are obtained from observations extending over 30 years (1901-1930), those of rainfall are for the 35 years (1881-1915). Pressure is expressed in millibars (1000 mb.= 29.531 mercury-indies). Wind Force.—The summary is obtained from the records of a cup anemograph having 5 in. cups and 15 in. arms. The factor used is 3. Winds above 43 miles per hour are reckoned as gales and winds between 21 and 43 miles per hour as moderate or strong winds. Direction is not tabulated when the speed of the wind is less than 5 miles per hour and winds of less than that velocity are counted as calm. TABLE 1—continued. 1936 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.) Most in a Day. Precipitation (0.2 mm and above). Precipitation (1 mm. and above). Snow. Hail. Thunderstorm. Persistently Clear. Generally Clear.! Generally Overcast.t Persistently Overcast. Fog at 9 a.m. Gale. Force. Direction. Total Fall. Difference from Average Amount. Day of Month. Gale Moderate and Strong Wind Calm. N. N.E. E. S.E. S. S.W. W. N.W. January 7.1 mm. 89 mm. + 46 mm. 13 28 22 19 6 0 0 0 1 14 1 8 1 1 90 2 4 6 7 6 18 34 14 2 February 6.0 36 — 4 9 17 14 12 1 1 0 0 4 10 2 8 1 0 83 4 8 6 22 13 9 12 6 7 March 8.3 25 — 19 5 31 13 10 2 0 0 0 2 23 1 3 0 0 93 0 6 6 20 13 22 15 9 2 April 6.9 38 + 1 9 20 14 7 6 2 0 0 0 14 3 0 0 0 90 0 27 25 8 1 6 10 6 7 May 6.7 10 — 34 4 22 6 4 0 0 2 0 2 6 1 0 0 0 92 1 23 22 25 3 6 5 5 3 J une 6.9 87 + 36 15 19 18 16 0 2 5 0 1 11 0 0 0 0 88 2 11 6 9 6 14 23 15 4 July 7.9 74 + 14 12 14 22 16 0 0 3 0 0 18 0 0 0 0 93 0 4 4 0 3 12 49 19 2 August 5.9 14 — 42 9 10 9 3 0 0 1 1 4 10 1 1 0 0 89 4 13 3 12 4 2 27 18 10 September 7.1 80 + 35 30 20 18 12 0 0 4 0 0 15 0 3 0 0 88 2 18 6 11 8 9 14 14 8 October 6.3 46 — 18 14 31 15 8 0 1 1 0 3 11 0 3 0 0 88 5 11 12 6 5 1 21 23 9 November 7.7 77 + 19 20 11 18 13 0 0 0 0 2 17 4 10 0 0 78 12 13 9 7 0 10 24 11 4 December 6.8 50 — 7 16 14 18 10 3 2 0 0 4 15 2 5 0 0 90 3 5 2 4 5 21 31 17 5 Year 7.0 625 + 29 30 Sept. 20 187 130 18 8 16 1 23 164 15 41 2 1 1062 35 143 107 131 67 130 265 157 63 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. 15 VITAL STATISTICS. Births.—Fourteen hundred and twenty-one births were registered during the yea:— Males. Females. Total. Legitimate 759 624 1383 Illegitimate. 21 17 38 780 641 1421 The birth rate per 1,000 of the population was thus 11.85. The following list shows the nonulation. number of births, and the corrected birth rate per 1000 during the past five years:— Year. Population. No. of Births. Birth Rate. 1932 127,140 1666 13.10 1933 125,700 1499 11.91 1934 123,430 1454 11.78 1935 121,690 1493 12.26 1936 119,900 1421 11.85 On page 28 will be found a table showing the population, number of births and birth rate for each year since 1892—a period of 44 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 lower level than in any of the other three comparative areas. 1932 1933 1934 1935 1936 Leyton 13.10 11.91 11.78 12.26 11.85 122 County Boroughs and Great Towns 15.4 12.2 14.7 14.8 14.9 London 14.2 13.2 13.2 13.3 13.6 England and Wales 15.3 14.4 14.8 14.7 14.8 16 Of the total number of births registered (1,421) during the year, 760 (53 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 760 births occurred in the following institutions:— Queen Mary's Hospital 304 Mothers' Hospital, Clapton 145 Forest Gate Hospital 104 City of London Maternity Hospital 18 Plaistow Maternity Hospital 28 East End Maternity Hospital 10 Kingswood Maternity Home 20 Thorpe Coomb Maternity Home 17 London Hospital 18 Royal Free Hospital 5 University College Hospital 3 Queen Charlotte's Hospital 2 Jewish Maternity Hospital 4 Walthamstow District Nursing Association 17 Guy's Hospital 1 St. Thomas's Hospital 2 Hackney Hospital 7 St. Andrew's Hospital 3 Woodside Nursing Home, Woodford 3 Other Institutions 49 760 17 Graph No. 1, Levton Birth Rate. 1916-1936. 18 TABLE 2. Registered Births, 1936. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Total. January 6 9 7 3 10 6 4 4 5 7 61 February 4 9 5 2 2 10 5 6 9 2 54 March 4 12 5 6 8 9 10 10 — 4 68 April 7 13 9 5 10 7 8 3 4 4 70 May 7 8 6 4 8 5 2 3 2 — 45 June 4 3 2 4 5 5 5 6 4 2 40 July 4 16 5 3 9 9 3 11 3 3 66 August September October November December Totals 2 9 3 6 8 4 8 7 3 5 55 2 9 5 6 4 3 5 5 2 — 41 2 13 5 2 11 2 5 7 5 1 53 5 4 4 2 2 5 4 6 4 6 42 6 13 5 3 11 9 4 5 6 4 66 Transferases 70 125 68 72 120 102 55 49 51 48 760 Total 123 243 129 118 208 176 118 122 98 86 1,421 19 Deaths.—Twelve hundred and seventy-two deaths of Leyton residents were registered during the year, including those of 144 males and 118 females (transferable deaths) who died outside the area. Males. Females. Total. 639 633 1272 The death rate per 1000 of the population was thus 10.61. The following list shows the population, number of deaths, and the death rate per 1000 of the population during the past five years:— Year. Population. No. of Deaths. Death Rate. 1932 127,140 1,341 10.54 1933 125,700 1,468 11.67 1934 123,430 1,317 10.67 1935 121,690 1,225 10.06 1936 119,900 1,272 10.61 The figures below show how, during the five-year period, the death rate in Leyton has compared with corresponding rates in the Great Towns, in London, and in England and Wales. During each of the five years, the Leyton death rate has remained at a lower level than in the case of any of the other three comparative areas. 1932 1933 1934 1935 1936 Leyton 10.54 11.67 10.67 10.06 10.61 122 County Boroughs and Great Towns 11.8 12.2 11.8 11.8 12.3 London 12.3 12.2 11.9 11.4 12.5 England and Wales 12.0 12.3 11.8 11.7 12.1 The figure of 1,272 registered deaths represents an increase of 47 (about 3.69 per cent.) when compared with the corresponding number (1,225) registered during the previous year. 20 The following list shows the increase or decrease in the number of deaths from the various causes in 1936 as compared with 1935:— Decrease. Increase. — + Measles - 23 Scarlet fever - 1 Diphtheria - 3 Influenza 4 - Encephalitis lethargica 1 - Cerebro-spinal fever - 2 Tuberculosis of respiratory system 13 — Other tuberculous diseases - 5 Syphilis - 2 General paralysis of the insane 1 Cancer - 26 Diabetes - 2 Cerebral haemorrhage 10 - Heart disease - 15 Aneurysm - 2 Other circulatory diseases - 9 Bronchitis 8 — Pneumonia - 12 Other respiratory diseases - 7 Peptic ulcer - 1 Diarrhoea - 1 Appendicitis - 1 Cirrhosis of liver - 2 Other diseases of liver - 4 Other digestive diseases 1 - Acute and chronic nephritis 13 — Puerperal sepsis 2 - Other puerperal causes 3 - Congenital debility, premature birth, malformations, etc. - 7 Senility 11 - Suicide 7 - Other violence 1 - Other defined causes 4 - Causes ill-defined - 1 79 126 = + 47 21 It will be seen that the chief increases were in deaths from heart disease (15), cancer (26), and measles (23). On the other hand, definite decreases are shown in deaths from cerebral haemorrhage (10), nephritis (13), and tuberculosis of respiratory system (13). Table 3, page 24, gives the official list of the principal causes, of death in the different age groups. Graph 2 shows the variation in the death rate in Leyton since the year 1916. 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 105 11.6 Lea Bridge 182 8.4 Central North 106 9.6 ,, South 115 10.0 Forest 191 9.6 Leytonstone 149 11.0 Grove Green 133 12.8 Harrow Green 120 9.7 Cannhall 98 8.6 Wanstead Slip 69 8.3 Zymotic Death Rate.—The deaths during the year from the seven principal zymotic diseases were as follows:— Smallpox — Measles 23 Diphtheria 11 Whooping Cough 2 Diarrhoea 7 Scarlet Fever 2 Enteric Fever 1 The zymotic death rate for 1936 was 0.39 per thousand of the population compared with a rate of 0.14 for the previous year. 22 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. 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:— 65-70 134 70-75 157 75-80 145 80-85 125 85-90 56 90-95 18 95-100 1 Of the total number of deaths (1,272) during the year, 636 (50 per cent.) occurred in persons of 65 years and upwards. The figures above show the proportion of residents of the area who live to a very mature age. Infant Mortality.—Seventy-four children died under one year of age, giving an infant mortality rate (number of deaths under one year of age per thousand births) of 52.07. The following figures show the number of births, infant deaths and infant mortality rate during the past five years:— No. of No. of Infant Year. Births. Infant Deaths. Mortality Rate. 1932 1,666 89 53.43 1933 1,499 76 50.70 1934 1,454 64 44.02 1935 1,493 60 40.18 1936 1,421 74 52.07 The following are the corresponding rates for other Great Towns, London, and England and Wales, during the year under review :— Infant Mortality—Leyton 52.07 „ „ 122 County Boroughs and Great Towns, including London 63.00 „ „ London 66.00 ,, ,, England and Wales 59.00 23 Maternal Mortality.—Two women died from diseases and accidents of pregnancy and childbirth. The figures given below show the variation in maternal mortality during the past five years in Leyton and in the country generally :— No. of Maternal Deaths Maternal Mortality Rate per 1,000 live and still births. England Year. (Leyton). Leyton. and Wales. 1932 4 2.40 4.24 1933 2 1.33 4.42 1934 5 3.43 4.60 1935 7 4.68 4.10 1936 2 1.36 3.65 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 44 years. During that period the following are the outstanding facts:— 1. The population has increased from 63,000 to 119,900. 2. The birth rate has decreased from 35.08 to 11.85 births per thousand of the population. 3. The death rate has decreased from 15.4 to 10.61 per thousand of the population. 4. The infantile mortality rate has decreased from 141 to 52.07 deaths of infants under one year per thousand births. TABLE 3. CAUSES OF DEATH AT DIFFERENT PERIODS OF LIFE IN THE BOROUGH OF LEYTON, 1936. 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 kpown. Not belonging to District. Belonging to District. I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Typhoid Fever 1 1 1 1 1 Measles 15 8 23 3 10 8 2 6 6 1 5 5 2 3 1 2 3 1 Scarlet fever 2 2 1 1 2 1 Whooping cough 2 2 2 7 2 1 1 Diphtheria 7 4 11 7 4 9 1 1 1 2 1 4 1 Influenza 4 4 8 1 1 1 1 3 1 1 2 1 3 1 Encephalitis lethargica 3 Cerebro-spinal fever 1 1 2 1 1 2 2 1 1 Tuberculosis of respiratory system 38 18 56 14 24 17 1 109 13 2 7 4 9 10 6 6 4 2 6 Other tuberculous diseases 9 4 13 3 3 3 3 1 26 4 1 2 3 3 1 1 2 K> IsS Ox Syphilis 2 2 2 1 1 1 General paralysis of the insane, tabes dorsalis 5 1 6 1 5 4 1 2 1 1 1 1 Cancer, malignant disease 98 107 205 15 78 112 310 64 15 24 18 13 27 32 19 22 20 14 1 Diabetes 11 9 20 5 15 32 11 3 3 3 1 5 1 2 9 Cerebral haemorrhage, etc. 40 45 85 3 20 62 194 42 5 12 8 12 14 7 11 2 9 5 Heart disease 162 193 355 1 1 3 15 81 254 586 99 32 46 34 37 47 40 42 37 20 19 1 Aneurysm 7 4 11 1 8 2 5 3 1 3 1 1 1 2 2 1 1 1 Other circulatory diseases 12 32 44 1 7 36 63 14 10 2 10 3 5 2 7 2 Bronchitis 28 19 47 2 1 1 11 32 81 15 2 5 2 5 8 8 6 6 4 1 Pneumonia (all forms) 36 47 83 14 3 1 I 1 7 20 36 134 31 4 18 9 6 13 14 7 6 5 1 Other respiratory diseases 8 4 12 1 1 1 7 2 8 3 1 1 2 3 1 1 1 Peptic ulcer 11 3 14 1 3 6 4 29 8 2 2 2 1 1 1 3 2 Diarrhoea, etc 5 2 7 7 23 1 1 1 1 1 l 2 Appendicitis 3 5 8 1 4 1 i 1 19 6 1 1 2 2 1 1 Cirrhosis of liver 1 3 4 1 3 3 1 1 2 1 Other diseases of liver, etc. 4 8 12 2 3 7 9 5 o 1 2 2 1 3 1 Other digestive diseases 9 7 16 1 1 1 2 2 4 5 32 6 2 3 o 2 1 1 2 Acute and chronic nephritis 9 15 24 2 1 4 8 9 58 9 2 4 2 4 1 4 5 2 Puerperal sepsis 2 2 1 1 4 2 Other puerperal causes . 3 Congenital debility, ture birth, tions, etc. 30 11 41 40 1 18 6 2 6 4 11 5 3 3 5 2 Senility 4 11 15 15 25 5 1 2 3 1 1 2 2 3 Suicide 9 3 12 4 5 3 5 3 5 2 1 1 1 1 1 Other violence 20 14 34 1 1 4 2 5 5 16 72 12 6 5 3 2 4 5 4 2 1 2 Other defined causes 47 46 93 3 3 4 4 9 17 31 22 146 39 9 16 5 10 15 7 10 11 6 4 Causes ill-defined, or unknown 1 1 2 1 1 1 1 Totals 639 633 1272 74 20 29 23 43 115 332 636 2018 425 105 182 106 115 191 14!) 133 120 98 69 4 26 Graph No. 2. Leyton Death Rate 1916-1936. 27 Graph No. 3. Comparative View of the Principal Causes of Death during the Year 1936. 28 TABLE 4. Comparative Statistics of Births, Mortality, Etc. LEYTON, 1892-1936. 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 D112452* 1414 12.6 172 85.8 1918 B125352* 1791 14.3 D112452* 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 1934 123430 1454 11.78 1317 10.67 64 44.02 1935 121690 1493 12.26 1225 10.06 60 40.18 1936 119900 1421 11.85 1272 10.61 74 52.07 * Population as estimated for purposes of B, Birth Rate, D, Death Rate. 29 TABLE 5 Vital Statistics of Whole District during 193(3 and Previous Years. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the Borough. Transferable Deaths Nett Deaths belonging 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 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 10.54 1933 125700 812 1499 11.91 3070 24.4 1888 286 76 50.70 1468 11.67 1934 123430 819 1454 11.78 2864 23.2 1774 227 64 44.02 1317 10.67 1935 121690 777 1493 12.26 2671 21.9 1789 243 60 40.18 1225 10.06 1936 119900 661 1421 11.85 3028 25.2 2018 262 74 52.07 1272 10.61 Rates in columns 5, 7 and 13 calculated per 1000 of estimated gross population. 30 TABLE 6. Birth-rate, Death-rate and Analysis or Mortality During the Year 1936. (Provisional figures. The rates have been calculated on a population estimated to the middle of 1936. 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 of 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 14.8 0.61 12.1 0.01 0.00 0.07 0.01 0.05 0.07 0.14 0.52 5.9 59 — — — — 122 County Boroughs and Great Towns, including London 14.9 0.67 12.3 0.01 0.00 0.09 0.01 0.06 0.08 0.14 0.45 8.2 63 — — — — 143 Smaller Towns. Estimated Resident Populations 25,000 to 50,000 at Census, 1931 15.0 0.64 11.5 0.00 0.00 0.04 0.01 0.04 0.05 0.15 0.39 3.4 55 — — — — London 13.6 0.53 12.5 0.01 0.00 0.14 0.01 0.06 0.05 0.14 0.52 14.4 66 — — — — LEYTON 11.85 0.36 10.61 0.01 0.00 0.19 0 01 0.01 0.09 0.06 0.38 4.92 52 88.75 4.08 7.15 0.0 31 SECTION B. GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. 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 14 midwives residing in the district, including 8 attached to the Essex County Nursing Association in Beachroft Road, Leytonstone. In addition to these, 7 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) Park House Health Clinic, Granleigh Road, E.ll.— Thursdays, 10 a.m. (2) Leyton Green Health Clinic, Leyton Green Road.— Wednesdays, 10 a.m. Infant Welfare Clinics— (1) Park House Health Clinic, Granleigh Road, E.ll.— Mondays, Tuesdays and Thursdays, 1.45 a.m. (2) Leyton Green Health Clinic, Leyton Green Road.— Mondays, Wednesdays and Fridays, 1.45 p.m. Toddlers' Clinics.— (1) Park House Health Clinic, Granleigh Road, E.ll.— Tuesdays, 10 a.m. (2) Health Clinic, Leyton Green Road.—Fridays, 10 a.m. C. Day Nurseries.—Nil. D. School Clinics. (1) Park House Health Clinic, Granleigh Road, E.ll.— Medical Inspection and treatment of minor ailments. 32 (2) Health Clinic, Leyton Green Road.—Medical Inspection and treatment of minor ailments. (3) Park House Health Clinic.—Dental treatment. (4) Health Clinic, Leyton Green Road.—Dental treatment. (5) Health Clinic, Leyton Green Road.—Ophthalmic treatment. (6) Health Clinic, Leyton Green Road.—Diphtheria Immunisation. (7) Park House Health Clinic.—Diphtheria Immunisation. (8) 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 Orthopaedic Surgeon of children recommended by the School Medical Officers and the Medical Officers at the Infant Welfare Centres. (9) 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 Essex County Council for the treatment in Colchester Hospital 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. G. Children.—No Hospital provided or subsidised. 33 H. Orthopaedic.—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, Ley ton is 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.—Motor Ambulances for non-infectious cases are supplied by the Leyton Town Council and are under the control of the Superintendent of the Fire Brigade. 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 4-10-09 34  Date of Adoption. Date came into Force. 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.) 5-9-33 6-12-33 Bye-laws, Regulations, etc. Allotments.—As to. Common Lodging Houses. Diseases of Animals.—Sheep Scab Order. Employment of Children and Street Trading by Young Persons. Hairdressers' and Barbers' Premises.—As to Cleanliness of Instruments, Towels and Materials. Libraries.—As to use of. Good Rule and Government of the Borough. 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. Petroleum Filling Stations. Pleasure Grounds.—With respect. Employment Agencies.—For the regulation of. Massage Establishments.—For the registration of. 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. All Shops not exempted by Shops Act. 35 Public Mortuary. A public mortuary, maintained by the Corporation, is situated in Church Road, Leyton. The following are the figures for the year:— Number of bodies deposited, death being due to:— Natural causes 68 Suicide 3 Street accidents 5 Other accidents 3 Other causes 1 80 Number of Post mortem examinations performed 74 Number of Inquests held 12 In 68 instances no inquest was considered necessary in view of the post mortem findings that death was due to natural causes. The causes of death in these cases were certified as follows:— Pneumonia 6 General arterio-sclerosis 4 Atheroma of coronary artery 4 Interstitial myocarditis 6 Mitral stenosis 1 Coronary thrombosis 12 Aortic incompetence 7 Rheumatic carditis 1 Ruptured heart 1 Myocardial infarct 3 ,, degeneration 1 Rupture of aneurysm 3 Congenital abnormality of heart 3 Malignant glioma of cerebellum 1 Diaphragmatic hernia 1 Cerebral haemorrhage 3 Pulmonary tuberculosis 3 Stillborn 2 Membranous tonsillitis—diphtheritic 1 Asphyxia during eplipeptic convulsion 1 Sub-arachnoid haemorrhage 1 Pulmonary embolism 1 ,, atelectasis 1 Toxic myocarditis due to hyperthroidism 1 36 Inquests. The following verdicts on Leyton residents were recorded at inquests held during the year:— Accidental. Knocked down by motor car 5 „ ,, motor lorry 2 ,, „ train 1 Collision between pedal cycle and motor car 2 ,, ,, ,, horse van 1 „ „ „ motor lorry 2 Injuries due to collision between two trains 1 Crushed by falling gate 1 Drowning 2 Fractures and falls 11 Burns 4 Suicide. Lysol poisoning 3 Coal gas poisoning 3 Hydrochloric acid poisoning 1 Hanging 2 Run over by train 2 Septicaemia from self-inflicted wounds 1 Cut throat 1 Open Verdict. Aspirin poisoning 1 Natural Causes. Broncho pneumonia 1 Oedema of lungs 1 Pulmonary tuberculosis 2 Pulmonary embolism 1 Cancer 1 37 PUBLIC BATHS. For description of Corporation's Public Swimming Pools see Annual Report for the year 1934. Tests of Purity of Water. In addition to the daily tests for clarity, alkalinity and chlorine content undertaken by the Baths Superintendent and his staff, periodic samples of the water from the pools were taken by the Health Department for more detailed chemical and bacteriological examination. These samples were taken at times when the bathing load was high and when the water might be expected to show the maximum amount of pollution. In all, some 10 samples were taken during the year. Attendances. The following figures show the extent to which the Corporation's Baths were used during the year:— Swimming. 1936. High Road 192,556 Cathall Road 132,242 Whipps Cross Bathing Pool 21,997 Slipper Baths. High Road 11,586 Cathall Road 48,782 Foam Baths. High Road 2,723 ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT. Since 1st April, 1934, it has been illegal for any person in this area to carry on an establishment for massage or special treatme nt without a licence from the Council. During the year the Medical Officer of Health visited and inspected all such establishments of which he became aware and the licences were granted in respect of 8 establishments. 38 FOOT CLINIC. I was instructed to report to the Public Health Committee on the establishment of a Municipal Foot Clinic. Extract from report of Medical Officer of Health, March, 1935 In accordance with instruction of the Council at its last meeting I submit the following observations and suggestions on the establishment of a municipal foot clinic in the Borough. The ideal form of health education is the effective administration of the health services in the area, and all municipal clinics should be standing object lessons to the public. Under the provisions of the Essex County Council Act, 1933, this Corporation is now the Authority responsible for the licensing and supervision of Establishments for Massage and Special Treatment (including Chiropody) in the area; and it is therefore more than ever desirable that any foot clinic established by the Council should be a model to practising chiropodists with regard to premises, equipment, staffing and administration. Staff.—Judging from the success which has attended the establishment of other municipal clinics, I do not think it would be possible for one chiropodist to deal with the number of patients likely to attend for treatment. The success or otherwise of the arrangements for treatment will depend primarily on the qualifications and experience of the chiropodist in charge; and both chiropodists should possess the qualification of a recognised teaching school of chiropody. Senior chiropodist (preferably male). Assistant chiropodist (preferably female). Clerk receptionist. Accommodation Required. Office. Waiting room. Two treatment rooms. Rest room. Sessions. Eleven sessions per week, three to be held in evenings. Appointments. To be made at the rate of 3 to 4 per hour per operator. Charges. Treatment limited to residents in Borough. No charge to old age pensioners and unemployed. Full charge:—1s. 6d. for one foot, 2s. 6d. for two feet. This scheme was approved in principle and the Medical Officer of Health was requested to report on premises which could be suitably adopted. Eventually accommodation was secured in the recently-erected Public Baths premises situated in the High Road, 39 Leyton. A large room (24 ft. 6 in. by 30 ft. 6 in.) lent itself to easy conversion. Sufficient equipment was purchased to equip two cubicles, and in January, 1936, the Council appointed, as Chiropodist, Mr. J. C. O'Brien, M.I.S.Ch. The Clinic was opened to the public on March 3rd, 1936, treatment being available on eleven sessions per week. Morning. Afternoon. Evening. Monday — 2.0-4.30 6.0-8.30 Tuesday 9.30-12.0 2.0-4.30 — Wednesday 9.30-12.0 — 6.0-8.30 Thursday 9.30-12.0 2.0-4.30 — Friday — 2.0-4.30 6.0-8.30 Saturday 9.30-12.0 — — Before the Clinic had been open one month the rush of applicants for treatment was so great that appointments were being made for as long ahead as five weeks. As a consequence of the large waiting list the Council decided to engage a temporary female chiropodist to enable the arrears to be cleared. The following statistics for the year 1936 give an idea of the amount of treatment carried out and a clear indication of the popularity of the Clinic. Summary of Attendances and Treatment, 1936. A. All Ages. During the ten months the Clinic has been open 1,281 patients have made 4,622 attendances, an average of 3.61 attendances per patient. First Attendances (new cases). Subsequent Attendances. Total Attendances. Average No. of Visits per Patient. No. Per cent. Males 328 869 1,197 25.90 3.65 Females 877 2,194 3,071 66.44 3.50 Children 76 278 354 7.66 4.66 Total 1,281 3,341 4,622 — 3.61 40 Payment for Treatment. No. of cases paying for treatment 3,018 (65.30 per cent.) No. of free cases 1,417 (30.65 „ ) No. of return visits of children where no charge was made 187 ( 4.05 „ ) Receipts £329 1 9 Free Treatment. Free treatment is given to persons who are unemployed, old age pensioners and women who are in receipt of widows' pension. During the year the numbers of such persons who received free treatment was 266, 20 per cent. of the total number of new cases. These 266 patients made 1,006 attendances. First Attendances (new cases). Subsequent Attendances. Total Attendances. Males. Females. Males. Females. Males. Females. Old age penpensioners 70 93 298 443 368 536 Unemployed 26 35 91 150 117 185 Widows — 42 — 169 — 211 Totals 96 170 389 762 485 932 Defects Treated. Bursitis 69 Callosities 282 Corns, hard 226 Corns, soft 66 Corns, under nail 27 Hallux rigidus 20 Hallux valgus 102 Metatarsalgia 64 Nails, club 45 Nails, ingrowing 55 Pes cavus 8 Pes planus 168 Teno synovitis 1 Verruca pedis 31 Hammer toe 25 Perforating ulcer 1 Sinus (chiropodial) 5 Septic conditions 25 Conditions due to sprain 12 41 Referred for Medical or Surgical Treatment. During the year 36 patients were referred to doctors or hospitals for advice and treatment for the following conditions:— Acrocyanosis 1 Achilles bursitis 1 Adhesions 1 Arthritis 4 Dermatitis 3 Exostisis 1 Ganglion 1 Gout 1 Kohler's disease 1 Oedema 11 Osteo arthritis 1 Pes cavus 1 Pes piano valgus 2 Subluxation of joint 1 Subungual exostosis 2 Syringomyelia 1 Trophic ulcer 1 Varicose condition 2 B.—Children under School Age. No. of children 5 Attendances for treatment 5 Defects Treated. Incipient hammer toe 2 Incipient hallux valgus and overlapping toes... 1 Incipient pes varus 1 Incipient pes planus 1 C.—School Children. No. of children 71 Attendances for treatment 354 Average number of treatments per child 4.66 Defects Treated. Verruca pedis 41 Incipient flat foot 9 Trigger toe and incipient hammer toe 8 Ingrowing nail 6 Hard corn 4 Hallux valgus 2 Metatarsalgia 1 Defects Referred to School Clinics. Subungual exostosis 2 Talipes valgus 1 Pes piano valgus 2 42 SECTION C. SANITARY CIRCUMSTANCES OF THE AREA. Water Supply. The Leyton area is supplied from the mains of the Metropolitan Water Board. Rivers and Streams. See Annual Report for year 1932. Closet Accommodation. There are three houses where pail-closets are still in existence. Public Cleansing. (a) Scavenging. I am indebted to the Borough Engineer and Surveyor for the following particulars relative to Street Cleansing The total mileage of streets cleansed by this section of the Borough Engineer's Department Staff is over 74 miles. The staff engaged on this work is : 2 foremen, 38 sweepers, 4 men and 2 electric collecting vehicles: and one mechanical road sweeping and collecting machine with a driver and 2 attendants. The system used in Leyton is known as the "beat system." The Borough is divided into 38 beats and again into 2 divisions of one foreman and 19 sweepers with one collecting vehicle to each division. Each sweeper has a beat of approximately 1½ to 2 miles, and a collecting vehicle visits each sweeper on his beat 4 times daily. The street refuse is emptied directly into the vehicle, which conveys the refuse directly to the disposal shoot. By adopting this collecting system a great deal of time is saved, as formerly each sweeper took his own sweepings to a depot where they were dumped and collected later in the day. The time saved is spent by the sweepers on their work, and the effect is that all roads in Leyton are now swept not less than 3 times weekly, and where necessary 4 and 5 times weekly as against 2 and 3 times weekly under the old system. During the past year the Council installed as near as possible a dustless system of emptying the street refuse barrows, for this purpose purchasing two new lorries with special bodies and 80 new bins to suit the bodies; the refuse now being emptied into ihe vehicles without complaints of dust escaping. 43 The main roads of the Borough are cleansed twice daily—once by the mechanical road sweeping and collecting machine, which commences its work at midnight, and again directly after 3 p.m. by hand sweeping. The object of the afternoon service is to give the roads a clean appearance in the evening. Gully and street drain emptying is carried out by mechanical means— two machines of 1,150 gallons capacity are engaged every day on this work. This enables a service of gully cleansing on main roads once each month, and on district roads every 7 to 8 weeks. Each gully is sealed with clean water after being emptied. There are nearly 8,000 street gullies in the district. (b) House Refuse Collection and Disposal. The collection of house refuse is not under the control of the Public Health Department, but is carried out under the direction of the Borough Engineer and Surveyor. There are over 27,000 houses in the Borough and refuse is collected from each house twice weekly. The collection is undertaken by mechanically propelled vehicles, of which there are 12. All refuse is burnt in the Corporation's Refuse Destructor. During the year 25,935 tons of refuse were collected and the net cost of collection per ton for the financial year ended March, 1936, was 8s. 1d. Eight hundred and twenty-eight defective and unsuitable receptacles have been replaced during the year. Statistics as to Refuse Collection, 1935-36. Number of collection days 305 Aggregate number of days vehicles employed 3,355 Average number of vehicles employed per day 11 Total mileage run 49,386 Tonnage collected 25,935 Weight in cwts. per 1,000 population per day 11.64 Average weight collected per van day 7 tons 14½ cwts. Total cost of collection (including loan charges) £10,475 Cost per ton for collection 8s. 4½d. Income from collection of trade refuse, etc. £353 Income per ton of refuse collected 3¾d. Net cost per ton for collection 8s. 1d. 44 Refuse Dumps. No complaints were received during the year regarding the refuse dump in Lammas Road. The dump is now nearly filled in, and plans are to be deposited for the erection of factories on this site. SANITARY INSPECTION OF THE AREA. The table below gives a summary of the Inspections made by the Sanitary Inspectors:— Number of dwelling-houses inspected 3,640 Number of house-to-house inspections 980 Miscellaneous inspections 457 Re-inspections 9,460 Piggeries 15 Petroleum stores 216 Places of entertainment 42 Schools 54 Stables 83 Public conveniences 75 Urinals 260 Inspections under Rats and Mice (Destruction) Act 467 Visits in connection with infectious disease 552 Workshops 83 Factories 87 Outworkers' premises 200 Rag and bone dealers 2 Foster Mothers' premises 89 Hairdressers' premises 180 Nature of Work Executed and Improvements Effected in Dwelling-houses and other Premises under the Provisions of the Housing and Public Health Acts. Dampness remedied 478 Sashcords renewed 226 Plaster repaired 799 Roofs repaired or renewed 520 Guttering repaired or renewed 222 Yards paved 131 Drains relaid or partly relaid 284 Choked drains cleared 106 New w.c. pan and traps provided 108 Sinks provided 84 W.C. cisterns repaired or renewed 79 45 Rain water pipes repaired or renewed 89 Vent pipes repaired or renewed 43 Sink waste pipes renewed 158 Stoves repaired or renewed 106 Coppers repaired or renewed 70 Floors repaired 164 Rooms redecorated 2,013 Miscellaneous defects remedied 1,688 Drainage.—The drainage of 284 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 the staff of the Borough Engineer and Surveyor's Department, the expenses incurred thereby being recovered from the owners. Verminous Houses. Number of Council houses infested 26 Number of other houses infested 204 The procedure in dealing with infested houses in Leyton is as follows:— Where bugs are found to exist in houses an inspection of the premises is made by one of the Sanitary Inspectors. The subsequent procedure depends on the extent of the infestation. Where it is only slight, advice and instructions regarding bugs are given to the occupier, who is also asked to examine and thoroughly cleanse the pictures, bedding, bedsteads and other furniture. The rooms and furniture are then sprayed with an insecticide solution by a member of the Public Health Department Staff. Where the infestation is extensive the owner of the house is requested to remove all woodwork (i.e., skirting boards, architraves and linings around windows and doors, etc.) and wallpaper (if any); and afterwards to apply a blow-lamp tp all infested parts. The rooms are then sprayed by the Local Authority and the walls cleansed and distempered by the owner. Should bugs recur the premises are sprayed again. The importance of cleanliness and the danger of infestation by means of second-hand furniture are explained to the tenant. Council Houses.—The disinfestation of Council houses is carried out by the staff of the Borough Engineer and Surveyor. 46 Council houses, on being vacated, are sprayed with insecticide ; and the furniture, bedsteads and bedding of incoming tenants are sprayed by the Public Health Department staff prior to new tenants moving into the Council houses. Rag Flock Acts, 1911-1928. There are no premises within the Borough where rag flock is known to be manufactured. Foster Mothers. Eighty-nine visits have been made to premises occupied by foster-mothers. Hairdressers. One hundred and eighty visits were made to hairdressers' premises to inspect for any contraventions of the Bye-laws made under the Essex County Council Act, 1933. Infectious Diseases. Five hundred and fity-two visits have been made by the Sanitary Inspectors. Places of Entertainment. Forty-two visits have been made to cinemas and other places of entertainment, and in all instances the premises were found to be satisfactory. Petroleum (Consolidation) Act, 1928. Petroleum. Carbide of Calcium. Licences granted after inspection of storage arrangements 7 — Licences renewed 104 5 Licences lapsed 9 — Licences amended 5 — Licences refused 1 — 47 In May, 1936, the Council passed the following resolution:— Resolved that persons to whom permission has been granted for the use of swing-arms over the public footpath be informed that in cases where a draw-in is available the Council consider the same should be used, and that in such cases the Council desire that the use of the swing arm over the footpath should cease. Pharmacy and Poisons Act. Under the Pharmacy and Poisons Act, 1933, the Councils of Municipal Boroughs ceased to perform any functions in regard to the control of poisons after 1st May, 1936. Game Dealers. Four renewal certificates were issued during the year, and two new ones granted. Shops Act, 1934. Six hundred and sixty-four visits were made in connection with the above-named Act. One certificate was granted exempting a shop from Sub-section 2 of Section 10 of the Act, regarding the provision of suitable and sufficient sanitary conveniences. One statutory and ten informal notices were served on owners of shops, requiring them to provide and maintain suitable and sufficient means of heating in accordance with Section 10 (1) (b) of the Act. Smoke Abatement. Observations have been made on chimney shafts in the Borough throughout the year, and thirteen "time" observations were made in cases where infringements of the Bye-laws were suspected or alleged. Eleven cautionary letters were sent and seven verbal cautions given during the year. Schools. Fifty-four routine inspections of the sanitary accommodation and water supply of schools were made. 48 Rats and Mice (Destruction Act), 1919. Four hundred and seventeen visits were paid in connection with complaints received, and rat biscuits were issued to the occupiers of 107 premises. At 89 premises the source of rat infestation was definitely traced and the premises freed of rats. The following report on the National Rat Week was submitted to the Ministry of Agriculture and Fisheries:— "The suggestions contained in the Circular issued by the Ministry of Agriculture and Fisheries received consideration. "Posters drawing the attention of the public to the importance of 'Rat Week' were exhibited throughout the Borough. "Places where it was known that rats were likely to be present were visited and advice was given. "The sewers of the town were baited and in each case with successful results. "During the week six enquiries were received and appropriate action was taken to deal with them." SECTION D. HOUSING. HOUSING ACT, 1935. The Housing Act, 1935, received the Royal Assent on 2nd August. Overcrowding Survey. Section 1 of the Act makes it the duty of every Local Authority "before such dates as may be fixed by the Minister" as respects their district, to cause an inspection thereof to be made with a view to ascertaining what dwellinghouses therein are overcrowded, and to prepare and submit to the Minister a report showing the result of the inspection and of the action which the Local Authority propose to take. The Act does not define any more closely the form which the inspection is to take; it must be such an inspection as will bring to light all cases of overcrowding. As the Act does not prescribe any particular method in which the inspection is to be carried out, Local Authorities are at liberty 49 to use the method they consider most suitable. Whatever method is used, it is important to bear in mind that, in order to get an accurate picture of the position the inspection, once started, should be completed within the shortest possible time. Otherwise the movement of the population and other factors might invalidate the results. In November, 1935, the Minister fixed the appropriate dates as follows:— (1) For completion of inspection, 1st April, 1936. (2) For submission of report, 1st June, 1936. (3) For submission of Authority's proposals, 1st August, 1936. In view of the hope expressed by the Minister of Health that each Local Authority, without waiting for further communication, should at once take the necessary steps to commence the survey in their area and complete it in the shortest possible time, the Council appointed a temporary staff of 20 enumerators, 7 survey assistants and 6 clerks. Fortunately the premises in the Town Hall vacated in September, 1935, by the school dental and minor ailment treatment clinic were vacant, and it was possible to accommodate the temporary staff in these premises. Mr. G. F. Leserve, Chief Clerk of the Department, had rendered most valuable assistance in making the preliminary administrative arrangements, and the temporary staff was therefore put under his direct supervision and control. It will be appreciated that a comprehensive survey of this nature involved a tremendous amount of attention to detail ; and the smooth, efficient and expeditious manner in which the survey has been carried out reflects great credit on the organising ability and supervision devoted to the work by Mr. Leserve, who submits the following description of the procedure adopted in making the survey. Preliminary House-to-house Survey. The general scheme contemplated a preliminary house-to-house survey of all working class houses in the area designed primarily to ascertain the amount of overcrowding. The preliminary survey was commenced on 30th December, 1935. A temporary staff of 20 enumerators was engaged to carry 50 out a house-to-house survey of all houses in the area in order to determine and record in respect of each house:— (a) Whether it is empty; (b) If occupied— (1) The number of families and of persons in each family. (2) The number of rooms occupied by each family. The information obtained was scheduled on Form A, to which the following standards laid down in the Act were applied. Number of Habitable Rooms. Permitted Number. Actual. Reduced. 1 2 l½ 2 3 2½ 3 5 4 4 7½ 6 5 10 8 6 12 9½ 7 14 11 8 16 13 The above table is based on the assumption that in the ordinary dwelling some of the rooms will be below 110 square feet in area; and that consequently the permitted number ascertained solely from number of rooms without regard to their size would normally be in excess of the exact permitted number. The allowance for this factor in the table is about one-fifth. In cases where the number of persons in occupation was greater than the permitted number allowed in Table I (i.e., definite overcrowding) the particulars were transferred to Form B for further inspection and measurement of the rooms. This procedure was adopted also in all cases where the families, though not overcrowded when regard is had solely to the number of rooms occupied, would nevertheless be found to infringe the standard if based on the assumption that some of the rooms were below 110 square feet in area. The preliminary survey was completed on 30th January, it having taken just over four weeks to enumerate 26,608 houses. Overcrowding Survey. On 3rd January 7 survey assistants commenced duty. Their work was to inspect all houses which had been found on the preliminary survey to be either "definitely overcrowded" or "possibly 51 overcrowded" and to record in detail the measurements of each room used as a living room or bedroom and the sex and age of each occupant. In every case where it was found necessary to send a survey assistant a notice was posted to the occupier giving 24 hours' notice of intention to visit and measure. In cases where it was not possible to inspect during the normal working hours, on account of special domestic or business reasons, arrangements were made for the inspection to be made in the late evening at the convenience of the occupier. The floor area in square feet of each room measured was computed by the office staff and the standards of Tables 1 and 2 applied. Table 2 is as follows:— Size of Rooms. Permitted number of Persons 110 square feet or over 2 90 square feet or over, but under 110 square feet 1½ 70 square feet or over, but under 90 square feet l 50 square feet or over, but under 70 square feet ½ Under 50 square feet Nil Due regard was also paid to cases where insufficient rooms allowed of proper segregation of the sexes of persons over ten years of age. Houses not overcrowded at the time of the survey, but likely to become overcrowded within the next two years, have been scheduled for review at a date when a child will reach the age of 10 years and consequently counts as an adult. The number of such cases is 66. The survey assistants completed the records on Form B on 17th February. The number of houses measured was 2,604. Results of Survey. (1) Whole Area (Table 8). The detailed results of the survey are shown on appended Table 8 in the form prescribed by the Minister of Health for submission to the Local Authority and to him. Table 8 has been completed by the process of addition of the facts disclosed by the separate returns on Forms A and B in respect of individual houses. It will be seen that Table 8 is intersected by 52 a diagonal line, by the help of which the completed form gives a picture of the housing conditions (so far as density is concerned) of the residents in the area. The figures to the left of the diagonal line show the overcrowded families—those to the right the families which are not overcrowded. Further, the entries on the form show as regards each size of overcrowded family the accommodation which it occupies, and consequently the extent of the housing deficiency which has to be made up. There are many other directions, such as the selection of the most pressing needs requiring immediate alleviation, in which information of importance to the housing authority can be derived from the information contained in Table 8. (2) Separate Wards and Summary (Table 7). This appended summary shows the main results of the survey for each ward separately and for the Borough as a whole. General Observations. There is a wealth of information now available as the result of the survey, and I have already found the available information regarding individual houses to be of great help in the daily work of the Department. With regard to the examination of the results of the survey, that will be due for more detailed consideration at a later date in connection with the Authority's proposals for housing. It will be noted from Table 8, however, that in this area by far the greatest amount of overcrowding occurs in families of six persons (113 such families overcrowded) and in dwellings with a permitted number of five persons (250 such dwellings overcrowded). 53 TABLE 7. Overcrowding Survey. Summary of Results. [##]Ward. No. of Dwellings Enumerated. No. of Dwellings Overcrowded. Per cent. No. of Families. No. of Families Overcrowded. Per cent. Population. No. of Empty Houses. Over 10. Under 10. Leyton 1,845 42 2.27 2,335 46 1.97 7,231 995 31 Lea Bridge 4,832 89 1.82 5,950 93 1.54 17,440 2,277 37 Central North 2,418 59 2.44 2,971 64 2.15 8,647 1,225 25 Central South 2,661 31 1.17 3,310 33 0.99 9,491 1,160 24 Forest 4,037 59 1.43 5,283 61 1.17 15,508 1,889 88 Leytonstone 2,917 19 0.65 3,937 21 0.53 11,261 1,225 70 Grove Green 1,840 83 4.51 2,511 90 3.57 7,618 1,115 15 Harrow Green 1,917 74 3.86 2,686 80 2.97 8,047 1,204 31 Cann Hall 2,534 34 1.34 3,095 36 1.16 9,090 1,036 9 Wanstead Slip 1,607 61 3.80 2,177 66 3.03 6,364 841 10 26,608 551 2.07 34,255 590 1.72 100,697 12,967 340 54 55 table 8. overcrowding survey.—summary. Number of "Persons" in Family Number of Families containing the Number of Persons in the First Column occupying Dwellings with the Permitted Number shown at the Head of this Column Families ½* 1 2 2i 3 3i 4 4i 5 5i 6 6i 7 7i 8 8i 9 9i 10 10½ 11 11½ 12 Overcrowded Uncrowded Total (a) (b) (c) 1 2 5 1297 62 593 57 — 549 11 33 — 261 1 1 — 153 — 1 113 — — 18 — 12 2 3167 3169 1½ — — - 9 17 5 — 12 — 2 — 11 — — — 5 — — 1 — — — - — — 62 62 2 — 1 8 56 1044 119 3 3127 23 196 2 1832 4 8 13 1351 2 — 821 — 1 238 — 63 9 8903 8912 2i - 1 4 5 8 305 2 1328 28 144 1 623 3 4 6 386 — — 174 1 1 37 — 5 10 3056 3066 3 — — 2 9 8 166 2 1541 37 236 2 1818 19 10 25 1766 1 2 1065 2 1 353 — 85 19 7131 7150 3i — — - 3 — 51 — 337 13 71 — 374 8 6 9 370 — — 178 2 - 38 — 6 54 1412 1466 4 - — - 2 — 32 1 14 57 504 6 987 32 23 46 1263 7 2 1008 2 — 296 3 99 35 4349 4384 4½ — — — 1 — 5 — 2 13 118 — 191 6 4 10 255 4 2 189 3 2 62 2 8 8 869 877 5 - - - - - 13 2 1 19 205 1 421 14 16 25 708 3 4 575 5 3 202 1 84 35 2267 2302 5½ - - - - - - - 2 5 59 7 96 8 5 8 143 4 - 125 1 1 35 - 20 66 453 519 6 - - - 1 - 5 - 2 12 91 - 7 25 36 60 376 11 4 303 2 2 117 1 43 113 987 1100 6½ - - - - - 1 - 1 2 30 1 5 8 8 12 86 4 2 61 3 4 23 1 16 40 228 268 7 - — - - 1 2 - - 4 37 1 6 15 14 28 163 6 2 136 6 2 45 1 27 66 430 496 7½ - - - - - 1 — 1 2 12 — 2 2 10 16 25 5 - 30 1 1 5 1 10 30 94 124 8 - - - - - - - - 2 11 — 5 5 6 9 4 15 12 47 - 4 19 4 13 38 118 156 8½ - - - - - - - - - 4 — 2 1 2 1 4 9 7 25 2 2 6 - 7 14 58 72 9 - - - - - - - - - 5 - 1 2 2 6 3 4 3 21 3 1 11 — 5 23 44 67 9i - — — — — — — - - 1 - 1 2 - 1 - 5 2 2 2 2 2 - 5 12 13 25 10 - - - - - - - - - - - 1 - - - - 1 2 - 2 2 6 1 5 4 16 20 10½ - - - - - - - - - - - 1 1 - - - 1 - - 1 - 4 - - 4 4 8 11 - - - - - - - - - - - - - - 2 — 1 2 — 1 — — - 1 6 1 7 11½ - - - - - - - - - - - - - - - - - - - - - 1 - - 1 - 1 12 - - - - - - - - - - - - - - - - - - - - - - 1 3 1 3 4 Dwellings (a) Uncrowded - 5 1297 127 1662 652 7 6908 182 1509 19 6621 128 135 258 7054 71 41 4874 37 29 1517 15 517 - 33665 - (b) Overcrowded d 2 2 14 21 9 110 3 9 46 250 4 24 28 20 19 7 12 6 - 2 — 1 1 — 590 — — (c) Total 2 7 1311 148 1671 762 10 6917 228 1759 23 6645 156 155 277 7061 83 47 4874 39 29 1518 16 517 - - 34255 *½ = a dwelling of 1 room between 50 and 70 square feet. NOTE.—The numbers of overcrowded families are shown below the stepped diagonal line. 56 Complaints. During the year 2,562 complaints of nuisances 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 1,558 Statutory—Housing Acts 19 Public Health Acts 45 Re-drainage 107 Notices complied with—Informal 1,751 Statutory— Housing Acts 15 Public Health Acts 40 Re-drainage 126 Housing. Number of houses erected during the year:— (a) Total (including numbers given separately under (6)). (i) By the Local Authority Nil (ii) By other Local Authorities Nil (iii) By other bodies and persons: Houses 24 Flats 82 (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 Nil (b) For other purposes Nil (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) 3,640 (b) Number of inspections made for the purpose 13,100 57' (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 980 (b) Number of inspections made for the purpose 3,825 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 54 (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 1,558 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 1,751 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:— (а) By owners Nil (b) By Local Authority in default of owners 1 (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 45 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 40 (b) By Local Authority in default of owners Nil 58 (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 19 (2) Number of dwelling-houses demolished in pursuance of demolition orders 14 (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 IV.—Housing Act, 1935. Overcrowding:— (а) (1) Number of dwellinghouses overcrowded at the end of the year 558 (2) Number of families dwelling therein 597 (3) Number of persons dwelling therein— Adults 3,181 Children 753 (b) Number of new cases of overcrowding reported during the year 548 (c) (1) Number of cases of overcrowding relieved during the year Nil (2) Number of persons concerned in such cases Nil Demolition. 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 continued to deal with the demolition and clearance of existing slum property in the area. Scheduled in 1935 and Demolished in 1936. 99 and 101, Church Road. 24 and 26, Grange Road. 29, Holloway Road. 74, Lea Bridge Gardens. 59 Scheduled and Demolished in 1936. 37 and 39, Chester Street. 9, 11, 13 and 15, Lincoln Street. 43, Wilmot Road. 1, Wood Street. Scheduled in 1934, not yet Demolished. 138, Lea Bridge Gardens. Scheduled in 1936, not yet Demolished. Cottage at rear of 822 and Nos. 822, 824, 826, 828 and 830, High Road, Leyton. 1, 2, 3, 4 and 5, Harrow Cottages, High Road, Leytonstone. Scheduled in 1936. Offers to carry out Repairs accepted. 15, 17, 19, 21, 23, 25, 27 and 29, Lansdowne Road. 3, 5, 7, 9, 11, 13 and 15, Montague Road. Scheduled in 1936. Offers to Close Premises accepted. 131 and 133, Cathall Road. Voluntary Demolition undertaken in anticipation of Statutory Action. 34, Argyle Road. 28, Grange Road. Under consideration during 1936, no action taken before end of yenr. 3 and 4, Pleasant Place, Harrow Green. 1, 2 and 3, Edwards Cottages, Acacia Road. 590, 592, 594 and 596, High Road, Leyton. 17, 19, 29 and 31, Harrow Road. 364, 366, 368, 370 and 372, High Road, Leytonstone. Repair of Unfit Houses. A notice in respect of 40, William Street, which was served last year under Section 17 of the Housing Act, 1930, was completed by the Local Authority in default of the owner. In three instances it was found necessary to take legal proceedings for non-compliance with a notice served to remedy a nuisance in accordance with Section 94 of the Public Health Act, 1875. (1) A summons against the occupier of a house was adjourned for one month and subsequently withdrawn on the necessary work being carried out. 60 (2) An owner was fined £1, with £1 costs. (3) An owner was fined £2 and an Order was made for the necessary work to be completed forthwith. House-to-House Inspection. The houses in the under-mentioned roads have been inspected during the year Acacia Road, Edwards Cottages. Belton Road. Bickley Road. Byron Road. Gary Road. Colworth Road. Dunton Road. Dyers Hall Road. Eve Road, The Flats, Emma Terrace. Gladstone Street. Granville Street. Halford Road. Harrington Road. Harrow Green—Back Harrow Cottages. Harrow Green, Pleasant Place. Harrow Road (part). High Road, Leyton (part). High Road, Leytonstone (part). James Lane. Kings Road. Madeira Road. Newcomen Road. Pearcroft Road. Russell Road. Shortlands Road. Simonds Road. Vernon Road. Windsor Road. The number of dwelling-houses inspected and recorded under Housing Consolidated Regulations was 980. Rent and Mortgage Interest Restriction Act, 1923. One application for a certificate was received, but was not granted. 61 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Inspections. The following visits were made to food premises during the year:— Slaughter-houses 1,726 Butchers 670 Bakehouses 115 Fishmongers 132 Milkshops and dairies 494 Provision shops 236 Dining rooms 206 Ice-cream dealers 269 Greengrocers 243 Fish friers 138 MILK. Dairies and Milkshops. Number of premises on register 267 Premises added to register during year 28 Premises removed from register during year 34 Visits of inspection 494 As the result of inspection 15 infringements were found at 11 premises, and the necessary action was taken in each case. Fifteen persons were found to be retailing designated milk although not licensed in that respect, and cautions were given in each case. 62 Bacteriological Examinations. Undesignated Milk.—Twenty-nine samples were taken and the following table shows the result of bacteriological examination:— Number of Sample. Number of bacteria per c.c. 1 22,470 2 11,900 3 6,930 4 161,000 5 6,020 6 1,281,000 7 96,450 8 2,310 9 107,800 10 4,200 11 129,100 12 4,800 13 7,600 14 13,860 15 31,500 16 350,000 17 61,320 18 22,075 19 188,930 20 10,010 21 8,680 22 1,637,550 23 2,440 24 15,100 25 15,120 26 593,140 27 6,440 28 14,210 29 8,540 63 Designated Milk. Licences. No. Granted No. of Samples taken Result. Satisfactory Unsatisfactory Certified 4 - - - Grade A "T.T." 10 4 4 - Grade A Pasteurised 1 - - - Grade A 4 Pasteurised 31 29 20 9 Supplementary Licences - - - - Certified 1 - - - Grade A "T.T " 2 - - - G rade A - - - - Pasteurised 2 - - - Totals 55 33 24 9 The results of the bacteriological examination of the 33 samples of designated milk are shown in the following table:— Grade Sample Number. Bacteria per c.c. Grade A "T.T." 1 7,700 2 5,530 3 21,600 4 3,480 Pasteurised 5 174,300* Unsatisfactory 6 7,000 7 4,830 8 146,300* Unsatisfactory 9 2,990 10 2,320 11 21,000 12 4,000 13 5,000 14 8,800* 15 7,000 16 8,710 17 5,490* 18 8,770 19 10,110* 20 25,480* 21 15,340* 22 6,440 23 10,570 24 9,800 * B. Coli present. 64 Grade Sample Number. Bacteria per c.c. Pasteurised... 25 13,260 26 660 27 500 28 2,560 29 10,500* 30 300 31 3,480* 32 4,620 33 8,100 * B. Coli present. Six of the above samples were subjected to a tuberculin test and all proved satisfactory in that respect. In December, 1936, the Council decided to dispense with the payment of fees for licences to retail designated milk under the Milk (Special Designations) Order, 1936. Milk Supplied to Schools. Included in the designated milk samples listed above are six samples of milk taken in course of delivery to schools. All of these proved satisfactory. Ice Cream. Premises on Register at 31-12-1936 175 Premises registered during 1936 37 Premises removed from Register during 1936 17 Persons on Register at 31-12-1936 177 Persons registered during 1936 37 Persons removed from Register during 1936 17 Visits of inspection by Sanitary Inspectors 269 Samples taken for bacteriological examination 25 Results of Samples taken for Bacteriological Examination. Number of Sample. Number of bacteria per c.c. 1 1,580 2 57,720 3 7,420 4 7,280 65 Number of Sample Number of bacteria per c.c. 5 3,010 6 54,620 7 140,000 8 6,930 9 308,000 10 854,000 11 861,000 12 2,345,000 13 810 14 6,860 15 11,000 16 13,000 17 4,240,000 18 1,820,000 19 322,000 20 4,000 21 749,000 22 60,000 23 2,000 24 154,000 25 3,980,000 MEAT. Slaughter-Houses.—-There are eight licensed slaughterhouses in the Borough. Inspections of these slaughter-houses have been made regularly. Carcases and Viscera Inspected.—There are 2 Inspectors on whole-time duty at the London Co-operative Society's Abattoir, and the other slaughter-houses are visited regularly by the District Sanitary Inspectors. The number of animals examined and the amount of meat subsequently condemned gives some idea of the able manner in which this work is done by the Inspectors concerned. Animals Inspected. Cattle 8,329 Calves 1,189 Swine 24,729 Sheep ... * 28,979 63,226 66 Meat and Other Food Condemned. Total. Tuberculosis. Ox:— Ox carcase and offal 21 21 Carcase 14 13 Hindquarters 3 3 Forequarters 20 19 Brisket 25 19 Clod and sticking 17 17 Top-piece 7 5 Crop 3 3 Back ribs 5 5 Middle ribs 2 2 Fore ribs 8 4 Sticking 2 2 Leg 2 2 Shin 2 2 Flank 24 11 Rump 9 8 Head and tongue 430 266 Tongue 33 — Steak 4 6 Loin 12 10 Skirt 19 12 Foot 7 6 Heart 18 6 Intestines 104 95 Kidney 34 18 Liver 2,126 123 Lungs 811 295 Mesentery 386 295 Omentum 20 6 Spleen 45 8 Stomach 111 32 Tail 7 6 Beef 144 st. 6 lbs. Brisket 2 st. 2 lbs. Sirloin 3 st 2 lbs. 67  Total. Tuberculosis. Calves:— Carcase and offal 12 11 Forequarter 1 — Liver 1 — Pluck 2 1 Lungs 3 — Veal 12½ lbs. Swine:— Carcase and offal 182 141 Carcase 63 14 Fore-end 24 7 Hindquarters 6 — Blade-bone 2 2 Hand and spring 1 — Hand 1 — Side 1 — Leg 66½ 16 Head 1,921 1,905 Collar 126 123 Loin 21 13 Belly 13 5 Knuckle 3 — Ribs 2 2 Heart 254 — Intestines 47 30 Kidney 156 3 Liver 3,035 4 Lungs 2,905 — Mesentery 1,736 1,700 Omentum 2 — Pluck 1,263 260 Spleen 15 1 Stomach 40 21 Pork 18 st. 2 lbs. Sheep:— Carcase and offal 8 — Carcase 2 — Forequarter 2 — 68 Sheep:— Total. Tuberculosis. Breast 14 — Hindquarter 4 — Target 18 — Leg 11 — Shoulder 4½ — Jacket 1 — Loin 9 — Head 2 — Heart 13 — Mesentery 1 — Liver 1,565 — Lungs 770 — Omentum 3 — Pluck 6 — Spleen 3 — Scrag 6 — Intestines 1 — Stomach 1 — Neck 2 — Miscellaneous— Skate wings 9 st. 4 lbs. Roker wings 5 st. Monk fish 5 st. Dog fish 3 st. Eels 40 lbs. Shrimps 1 basket Potatoes 30 cwts. Asparagus 12 bundles Rolled oats 72 x 1 lb. pkts. Public Health (Meat) Regulations, 1924. Six hundred and seventy visits were made to butchers' shops and stalls. Eleven letters were sent and 27 verbal notices given in respect of minor infringements. One butcher was prosecuted for an infringement of the Public Health (Meat) Regulations, 1924, his premises being in a dirty condition. A fine of £10 was imposed. 69 Bakehouses. One hundred and one visits were made to the 40 registered bakehouses. Twenty minor infringements were observed, and these were remedied without the service of statutory notices. Restaurants, Dining Rooms and Kitchens. Two hundred and six inspections of premises and utensils were made. Eighteen letters were sent and fifteen verbal cautions given in respect of unsatisfactory conditions. Public Houses. Twenty-two visits were made to public houses for inspections as to cleanliness of the premises, cellars, pumps, utensils, etc. In all cases these were found to be satisfactory. Premises and Occupations which can be Controlled by Bye-Laws and Regulations. Premises. Slaughter-houses 8 Dairies, Milkshops and Dairymen 267 Butchers' shops, Stalls and Provision shops 266 Ice Cream dealers 175 Chimneys—Other than private dwelling-houses approximately 100 Hairdressers' Premises 102 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 An application to continue the trades of tripe boiler, fat melter, fat extractor, gut scraper, bone boiler, blood boiler and blood drier was received, and permission given to carry on the trades for a further twelve months. 70 Three applications to continue the trade of a fish frier were received and permission given for a further limited period. Five applications for the permission of the Council to establish the trade of a fish frier were made. One of these was refused and three granted for a period of twelve months. The remaining application was withdrawn. One hundred and thirty-eight inspections were made of the premises where fish frying is carried on. Contagious Diseases of Animals Acts, 1894-1927. One licence was issued for the movement of one sow out of this district. Adulteration, etc. The Essex County Council is the responsible Authority for the administration of the following Acts and Regulations Food and Drugs (Adulteration) Act, 1928; Artificial Cream Act, 1929; Public Health (Condensed Milk) Regulations, 1923 and 1927; Public Health (Dried Milk) Regulations, 1923 and 1927; and the Public Health (Preservatives, etc., in Food) Regulations, 1925 to 1927. I am indebted to the Chief Inspector (Mr. H. C. Card) for the following information regarding samples taken in Leyton during the year under review. Samples of milk taken 24 Samples of butter taken 48 Other samples 288 SECTION F. FACTORIES AND WORKSHOPS. Workshops and Workplaces. Eighty-three inspections were made during the year. Defects were found to exist and have been remedied in 11 cases. Eight notices were received from H.M. Inspector of Factories of nuisances remediable under the Public Health Acts. 71 One hundred and sixty-eight workshops remain on the Register at the end of the year and are grouped as follows:— Accumulator charging and radio repairs 5 Bakehouses 18 Bedding manufacturers 1 Blacksmiths 3 Boot and shoe makers and repairers 16 Builders' merchants 1 Cabinet makers 5 Cardboard-box manufacturers 1 Confectionery manufacturers 4 Corset makers 1 Cycle repairers 1 Dressmakers 18 Dyers, cleaners and pressers 5 Enameller and plater 1 Fish packers 1 Laundries 2 Leather goods manufacturers 2 Milliners 5 Motor repairers 7 Organ builders 1 Printers 1 Paper articles and lamp shades manufacturer 1 Piano manufacturers 1 Rag sorters 2 Range repairers 1 Scale makers 1 Tailors 21 Tie makers 8 Upholsterers 5 Wire workers 1 Wood choppers 4 Miscellaneous 24 168 Homework. Two hundred visits were made to premises occupied by outworkers. Five hundred and eight outworkers now remain on the Register. 72 Factories, Workshops, Laundries, Workplaces & Homework. 1. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances Premises. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) Factories— Including Factory Laundries 147 11 ... Workshops- Including Workshop Laundries 124 11 ... Workplaces— Other than Outworkers premises included in Part 5 of this Report 271 22 ... 2. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Found. Remedied. (1) (2) (3) Nuisances under the Public Health Acts:— Want of Cleanliness 29 29 „ Ventilation 1 1 Overcrowding - - Want of Drainage of Floors - - Other nuisances 1 1 Sanitary Accommodation Insufficient - - Unsuitable or defective 5 5 Not separate for sexes - - Offences under Factory and Workshop Acts:— Illegal Occupation of Underground Bakehouse (S. 101) - - Other Offences— Excluding offences relating to Outwork which are included in Part 5 of this Report - - 36 36 73 3. HOMEWORK. NATURE OF WORK. Outwork in Unwholesome Premises, Sec. 108. Instances. Notices served. Nil Nil Nil SECTION G. PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. SMALLPOX. During the year 1936 no case of smallpox occurred in the area. ENTERIC FEVER. Four persons were notified to be suffering from enteric fever. No. Month. Sex. Age. Address. Nature of Infection. 1 August F. 56 Canterbury Road Paratyphoid B. 2 M. 33 Ruckholt Road Typhoid 3 September F. 37 Violet Road Typhoid 4 F. 12 Davies Lane Paratyphoid B. Case 1 was treated in Connaught Hospital. „ 2 „ „ Whipps Cross Hospital. (Died 4.9.36.) „ 3 „ „ Eastern Hospital (L.C.C.). „ 4 „ „ Queen Mary's Hospital, Stratford. SCARLET FEVER. Year. Cases Notified. Deaths. Case Fatality per cent. 1932 360 5 1.38 1933 743 4 0.54 1934 681 3 0.44 1935 409 1 0.24 1936 367 2 0.54 From these figures it will be seen that during the last four years there has been a progressive fall in the incidence of scarlet fever. 74 The disease continued of the mild type to which we have become accustomed during recent years. Two deaths were certified as due to scarlet fever:— Male, 25 years. Valvular disease of heart. Scarlet fever. Male, 2 years. Septicemia. Scarlet fever. Treated in hospitals:— Leyton Isolation Hospital 226 Whipps Cross Hospital 1 Plaistow Fever Hospital 9 Walthamstow Isolation Hospital 3 London Fever Hospital 7 East Ham Hospital 2 L.C.C. Hospitals 10 258 Treated at home 109 367 SOME ASPECTS OF SCARLET FEVER AND CURRENT METHODS OF CONTROL. In 1927 Sir Geo. Newman concluded his preface to a Special Report on "Some Administrative Aspects of Scarlet Fever" with these words :— "A practice or tradition in regard to a particular disease all too readily becomes established, fixed and static; yet in view of their purpose and growth, scientific measures of disease-prevention continually call for critical re-examination as to their truth and necessity, and for vigilant reconsideration from the point of view of the legitimacy and expediency of the expenditure incurred." A generation ago scarlet fever was considered to be a specific infectious disease of fixed type, and the orthodox measures used in its control were applied in a fixed manner. Since that time there has taken place a profound change, not only in the prevalent type of the disease, but also in our knowledge of its nature and epidemiology; yet we continue to apply some routine methods of control which were designed to deal with the much more serious 75 type of scarlet fever which was prevalent so long ago. Unfortunately some of these methods result in widespread loss of time, energy, work and schooling; and they give rise to substantial public expenditure. During recent years our former conceptions of the nature of infection and epidemiology of scarlet fever have been shattered at such a rate that we cannot afford to disregard the results of experience of any method of dealing with the disease, however unorthodox it may appear. What is Scarlet Fever ? During recent years bacteriologists have been very active in their efforts to throw light on the nature of the infection in scarlet fever and allied diseases. The great increase in new forms and types of streptococci, and the ingenuity displayed in their nomenclature—well described by Topley and Wilson as a "riot of christening"—are sufficient to confuse the physician who is faced with the actual clinical and administrative problems connected with these diseases. There is conclusive evidence that uncomplicated scarlet fever is due to infection by one or other of many different strains of the hæmolytic streptococcus; but organisms with the same morphological and biochemical reactions are to be found, not only in widely varying forms of disease and in those who have recovered from these diseases, but also in anything up to 36 per cent, of apparently healthy persons. The Dick test and the Schultz-Charlton Reaction may be useful in diagnosis; but they are of limited value, and least reliable in the very type of case in which their help is most needed. On what, then, is the clinician to rely in trying to arrive at a diagnosis ? Medical practitioners have always regarded the typical scarlatiniform punctuate erythematous rash as the diagnostic feature "par excellence," and subsequent consistent desquamation as clinching the diagnosis; but experienced observers have always been baffled to find patients with typical rash and strawberry tongue who did not peel, and other patients with typical peeling who have had no previous rash. In a recent bacteriological investigation of 100 suspicious cases Brown and Allison found that the incidence of rashes was almost equal in the bacteriologically positive and negative cases; that 76 evidence from the tongue, temperature and pulse rate was of no diagnostic value; and that only 40 per cent. of the positive cases eventually showed consistent desquamation. Even after the most thorough clinical and bacteriological investigation, the diagnosis of scarlet fever may be beset with extreme difficulty; and with the mild type of the disease now prevalent it is recognised to be one of the most difficult to diagnose of all infectious diseases. It is the busy general medical practitioner however—with little or no time and facilities for bacteriological and serological tests—who has the responsibility of not only diagnosing but notifying a condition which cannot be regarded as a specific epidemiological entity. It is therefore not a matter for surprise that in a large percentage of patients, notified and admitted to hospital, the diagnosis of scarlet fever is not confirmed—Brown and Allison estimate that 39 per cent. of doubtful cases of scarlet fever are not infectious and do not require hospital treatment of any kind. Notification. In view of the acknowledged difficulties in the diagnosis of scarlet fever, the presence of virulent strains of streptococcus scarlatinæ in so many non-notifiable types of infection and in such a large proportion of apparently healthy persons, it cannot be expected that the present system of notification of scarlet fever can result in the ascertainment of more than a very small proportion of persons who are capable of conveying infection. Hospital Isolation. Towards the end of last century Isolation Hospitals, many of a temporary nature, were built for the isolation of the infectious sick. In the first place their function—as the name "Isolation Hospital" implies—was "segregation" rather than "treatment." It was difficult to persuade patients to enter them. Frequent resort was had to the power of compulsory removal, and the element of compulsion was ever present in the minds of infectious patients and their relatives. Nowadays there is a complete reversal of the position. The modern fever hospital is—or should be—soundly constructed, efficiently staffed and well equipped with every facility for the effective isolation, diagnosis and treatment of all forms of infectious disease. The difficulty one meets nowadays is not that of coaxing 77 or compelling patients to enter hospital, but of persuading them that removal to hospital is not a necessary measure of control. As a result of the acknowledged benefits to be derived from hospital treatment, members of the general public now regard any suggestion of home isolation and treatment as a furtive attempt to deprive them of a social service to which they have a legitimate right. It is a matter for gratification that during recent years such rapid progress has been made in the design, equipment and staffing of so many fever hospitals, and that the Local Government Act of 1929 (Sec. 63) is likely to put an end to the parochial attitude which has been responsible for the multitude of small isolation hospitals throughout the country; for the small two-disease isolation hospital is the relic of a past age, and has been aptly described as a "costly shrine of an exploded superstition." Unfortunately there are still many such small hospitals, and they raise problems and difficulties in administration which are not appreciated in areas served by more modern fever hospitals. Incidence and Mortality. Experience throughout the country has shown that there has occurred during the last forty years a marked and progressive decline in the severity of and mortality from scarlet fever, but no marked reduction in incidence. The decline in severity and mortality are undisputed facts, and very welcome; but the decline began before removal to hospital became general as a method of control, and it has continued in all parts of the country irrespective of the extent and nature of the institutional accommodation and treatment provided. Period of Isolation. A belief, apparently traditional, that scarlet fever desquamation was per se infective, was responsible for prescribing for generations the traditional minimum isolation period of six weeks; and it required the upheaval of the Great War, with its unprecedented demand for every available bed, to shake our belief in the necessity for six weeks isolation. Now we know from experience that in uncomplicated cases no useful purpose is served by prescribing a detention period of more than four weeks, and that a much shorter detention period can be adopted with safety. Indeed, it is now generally recognised that it is not the patient released after four weeks detention who gives rise to return cases so much as the 78 patient who has been detained for a much longer period. Nevertheless, the older members of the general public still view with suspicion any detention period less than six weeks; and quite recently it was reported that in a village in the north of England "widespread distress and something like a state of panic" existed among parents who refused to send their children to school for fear of contact with other children alleged to have been prematurely and improperly released from the local isolation hospital. Complications and Overcrowding of Wards. With regard to the incidence of complications, it is reasonable to suppose that, with all the expert care of patients in hospital, complications are more quickly detected and more adequately treated than they would be at home; but I know no facts or figures to support that supposition. As the result of a questionnaire on this subject addressed by the Ministry of Health to Medical Officers of Health and Medical Superintendents of Infectious Disease Hospitals in 1923, it was found that only a minority (28 per cent.) considered that hospital treatment had any effect in reducing the incidence of complications. On the other hand there have always been observers who have maintained that the mixing of different types of infection in hospital wards tends toward the development of complications and cross infections by patients who would have had uncomplicated attacks if they had remained at home; and recent investigations appear to provide bacteriological evidence in support of that contention. For example, as the result of weekly bacteriological examination of 200 consecutive cases it was found by Allison and Gunn that, whereas 54 per cent. showed no change in type, as many as 46 per cent. showed a second or third type of hsemolytic streptococcus during their stay in hospital. Of those who did not show change in type, 16 per cent. were carriers on discharge after 6.5 weeks in hospital; whereas of those who showed change in type, 62.6 per cent. were carriers after 7 weeks detention in hospital. It is very significant that patients nursed in cubicles showed no change in type. It has been shown conclusively by Griffiths, by Gunn and by Allison and Brown that infection by one strain of hsemolytic streptococcus does not protect against subsequent infection by another 79 strain, and that what we know as "relapses" or "second attacks" are really new infections by streptococci of different types. It is generally agreed that a definite correlation exists between overcrowding of wards and increased incidence of complications. Like an axiom of Euclid, the association of cause of effect appears to have been accepted as a self-evident truth requiring no proof. Experienced Medical Superintendents have given their opinion that complications become more common whenever the standards of bed-spacing and nursing efficiency were reduced during epidemics; but I have never been able to find any published results of the comparative incidence rates of complications in wards which were, and those which were not, overcrowded during the same epidemic. In the estimation of complication incidence rates much depends on the standard accepted by the observer, for one will accept and schedule as a complication a slight departure from normal which would be disregarded by another; and for that reason such rates are not strictly comparable unless their estimation is carried out by the same observer. In a recent investigation of 808 cases in a large, well-equipped hospital with modern facilities for isolation and treatment, Brown and Allison found that 243 patients (i.e., 30 per cent.) showed complications during their stay in hospital. It is of interest to compare that rate with the complication incidence rate of a small temporary isolation hospital in which the total accommodation and facilities for isolation are inadequate (e.g., of the total accommodation, only 5.8 per cent. is in the form of separate cubicles). During 1934 the incidence of scarlet fever in Leyton was very high and, as measles and diphtheria were both prevalent, the available number of hospital beds was insufficient to meet the demand. Even after the most rigorous selection of cases for admission, the number of patients in hospital was in excess of the standard accommodation during the whole year. My colleague, Dr. F. W. Gavin, undertook a detailed analysis of the incidence of complications during that year, and found that of 387 scarlet fever patients treated in hospital as many as 199 (i.e.,. 51.4 per cent.) suffered from one or more of the recognised complications during their stay in hospital. That is an alarmingly high figure even when allowance is made for the fact that some 23 per cent. of the complications were present on admission. 80 Comparison of Hospital and Home Isolation. The practice of different Authorities varies within the widest possible limits with regard to the hospitalisation of notified cases of scarlet fever. In some large cities and health resorts the rate of hospitalisation is as high as from 98 to 100 per cent., whereas in many rural areas and smaller towns home isolation is the rule. In most areas, however, the extent of hospitalisation varies between these extremes. In Leyton, during the five years 1932-36 (excluding cases occurring in institutions), 64.4 per cent, of patients have been removed to hospital, and 35.6 per cent, have been treated at home. Is there any relative increase in the risk to patients or contacts when one or other of these methods is practised ? Case Fatality. During the five-year period 1932-36 the case fatality rate in Leyton was 0.77 per cent, for hospital cases and 0.23 per cent, for home-treated cases. Of course, the great increase in the fatality rate is to be expected in view of the circumstances taken into consideration in the selection of cases for admission to hospital. Complication Incidence Rate. In Leyton Isolation Hospital, during the three years 1934-36, the complication percentage incidence rate was found to vary between 30 per cent, and 51 per cent. I have no knowledge of any published results showing the incidence of complications among scarlet fever patients treated at home, and there are obvious difficulties in the collection of reliable evidence where the personal factors of so many different medical attendants are concerned. On 1st January, 1936, I began investigating the incidence of complications among these home treated cases. During the year some 109 scarlet fever patients were nursed at home, and the following complications occurred:— Albuminuria 7 Rhinitis 4 Cervical adenitis 4 Otitis media 5 Endocarditis 1 Arthritis 1 Bronchitis 1 23 81 The complication percentage incidence rate (21.1 per cent.) of home-treated patients compares very favourably with the comparative rate of 30 per cent, for patients treated in hospital during the same period. Contact Attack Rate During Period of Isolation. As far as I am aware, there are no published results of the comparative percentage attack rate of contacts of hospital-treated and home-treated cases during the same epidemic. Comparison has been made between the two groups on the basis of houses infected, but I am advised that the incidence rate of secondary cases among contacts is the proper basis of comparison. Table 9 shows the results of a statistical analysis of the occurrence of secondary cases among Leyton contacts during the five-year period 1932-36. It shows not only the risk to all contacts and to contacts of three different age groups, but also the risk during the first week as compared with that during the remaining weeks of isolation. As it was found impossible to form any reliable estimate of the number of contacts or primary cases occurring in institutions, these cases have been omitted from the analysis, which deals only with cases of scarlet fever notified from private houses in Leyton. 82 TABLE 9. BOROUGH OF LEYTON. SCARLET FEVER. ANALYSIS OF CONTACT ATTACK RATES OF HOSPITAL-TREATED AND HOME-TREATED CASES (1932-1936). Hospital Treated. Home Treated. Date of Onset of Attack. Hospital-treated. Home-treated. 1-7 day. 8-36 day. Total. 1-7 day. 8-36 day. Total. 1. Cases 1,678 871 2. Contacts. (a) Under School age 655 190 (b) School age 1,801 522 (o) Over School age 5,091 2,589 All ages 7,547 3,301 3. Contacts Attacked. (a) Under School age 52 11 32 20 52 3 8 11 (b) School age 51 25 29 22 51- 13 12 25 (c) Over School age 33 16 15 18 33 5 11 16 All ages 136 52 76 60 136 21 31 52 4. Percentage of Contacts Attacked. (a) Under School Age 7.94 5.78 4.89 3.05 7.94 1.57 4.21 5.78 (b) School age 2.83 4.78 1.61 1.22 2.83 2.49 2.29 4.78 (c) Over School age 0.64 0.61 0.29 0.35 0.64 0.19 0.42 0.61 All ages 1.80 1.57 1.01 0.79 1.80 0.63 0.94 1.57 83 Reference to the table shows that the percentage of home contacts (of all ages) who developed scarlet fever was slightly less in the home-treated (1.57 per cent.) than in the hospital-treated group (1.85 per cent.); but whereas the risk to pre-school contacts was greater in the case of hospital-treated group, the risk to school contacts was greater with home treatment. With regard to the date of onset of secondary cases among contacts, it will be seen that—except in the adult group—the percentage of contacts attacked was greater during the first week after removal of the primary case to hospital than during the whole of the remaining period of isolation. In home-treated cases, however, the risk to pre-school children was much greater after the end of the first week. As regards adults, the risk and the differences are so small as to be of no statistical significance. Return Case Rate—After Release from Isolation. At one time the return-case rate was regarded as an index of the efficiency of fever hospital administration, and legal proceedings for alleged negligence have been taken by parents of children who have developed scarlet fever following the return home of a patient from hospital. Although the return-case rate may be increased by negligence and inefficiency, it is now recognised that the rate remains fairly constant throughout the country. Different authorities vary widely in their interpretation of what is meant by a "return case," but the majority regard it as a case of scarlet fever occurring in a house in which a patient has been released from isolation within the preceding 28 days. On that basis the following figures show the comparative incidence of return cases in Leyton following hospital and home isolation during the last five years. 84 TABLE 10. BOROUGH OF LEYTON. SCARLET FEVER. INCIDENCE OF RETURN CASES (1932-1936). Following Hospital Treatment. Following Home Treatment. Primary Cases. Return Cases. Primary Cases. Return Cases. Year. Number. Number. Percentage. Number. Number. Percentage. 1932 215 13 6.04 94 0 0.00 1933 447 28 6.26 275 2 0.72 1934 404 14 3.46 270 2 0.74 1935 277 19 6.85 123 2 1.62 1936 235 23 9.80 109 3 2.75 Total 1,578 97 6.14 871 9 1.03 85 These results show the percentage return-case rate after hospital treatment (6.14 per cent.) to be more than 7 times greater than after home treatment (1.03 per cent.). Of the return cases following patients discharged from hospital, 20 occurred in the first week, 30 in the second, 16 in the third, and 8 in the fourth (i.e., 65 per cent, occurred within 14 days of discharge from hospital). There is no evidence of any increase in return cases during periods of pressure and overcrowding of hospital beds—in fact, the year with the lowest hospital return-case rate, 1934, was one in which the complication incidence rate was exceptionally high. Disinfection. The elaborate ritual of terminal disinfection owes its origin to the assumption that infection is conveyed by inanimate objects handled by the patient, by his clothing, and by the very furniture and walls of the rooms in which he lived. Bacteriologists have demonstrated the existence of hemolytic streptococci in all these situations; but these micro-organisms are parasites requiring warmth and moisture for their existence, and outside the body they perish quickly. As long as the infectious person is in the house or hospital, he can infect others; but when he goes the risk of infection generally goes with him and, except in a few special cases, it may be said that soon after the patient has been removed any germs he may have left behind are so moribund that the need for terminal disinfection has passed. It is surprising how little is claimed for disinfection, even by its staunch advocates. There are many who take up the attitude that, even although it does no good, it can do no harm; but can it not do harm? Dr. Forbes (Medical Officer of Health, Brighton) has drawn attention to serious harm which may be done by the spraying of living rooms with liquid disinfectant; to the overcrowding of the family caused by the closing of rooms which have been sprayed; and to the sense of false security conveyed to the public, who have been led to regard municipal "spraying and baking" as the last word in disease prevention. Prior to January, 1930, the Leyton Sanitary Authority carried out the traditional programme of municipal terminal disinfection of bedding, clothing, etc., from infected households. Since that time these measures have been discontinued in the commoner notfiable diseases. 86 During the five-year period 1925-29, when routine steam disinfection was practised, the percentage of secondary cases of scarlet fever from infected households was 6.08 per cent., compared with a rate of 5.51 per cent, during the five-year period since 1930, when steam disinfection was abandoned. Supervision of Contacts. There must be few areas in which any restrictive control is exercised over the movements or attendance at work of adult contacts, unless they happen to be teachers, school caretakers or persons engaged in the handling and distribution of food. On the other hand, all Education Authorities throughout the country apply regulations for the exclusion from school of all contacts of school age from infected households. Exclusion of School Contacts. The "Memorandum on Closure of and Exclusion from School" is an official document issued under the joint auspices of the Ministry of Health and the Board of Education; and the Regulations of Local Education Authorities are based on the procedure recommended in that Memorandum. With regard to school children suffering from scarlet fever, the procedure suggested in the Memorandum implies an official belief in the necessity for a six weeks detention period in hospital, and an even more surprising belief in the efficacy of terminal disinfection. These, I submit, are the cast-off tenets of an outworn creed. It is with the exclusion of contacts, however, that I am more concerned at present. The Rules suggest that, when a person suffering from scarlet fever is being treated at home, all school children living in the same house (which may contain two or more families) should be excluded from school during the whole period of illness and for a week thereafter. The reasons given in the Memorandum for such exclusion of contacts are:— (a) "Because such children, if unprotected by a previous attack, might attend school while suffering from the disease in a latent form or at an unrecognised stage." But the suggested Rules for exclusion—appearing later in the Memorandum—do not differentiate between children who have and those who have not been protected by a previous attack. 87 (b) Because it is known thatthe infection may attach itself to, and be conveyed by, the throat secretions or the clothes of a person living in an infected dwelling, even although the person himself remain unaffected." There is every reason to believe that the danger formerly attributed to the conveyance of infection on the clothes of healthy persons has been considerably overestimated. It is, of course, a possibility; but if it constitutes a real danger, surely the danger is as real in the case of adult contacts, on whose movements no restriction is placed—for the hsemolytic streptococcus, as far as I am aware, shows no predilection for " attaching itself " to the clothes of the school child in preference to those of younger or older members of the family. Although excluded school contacts may not go to school, they are free to play in the streets and frequent other public places as much as they choose; and they generally enjoy much more than their usual amount of freedom out of doors due to the fact that they are too much "in the way" of the already harassed mother, who acts generally as sick-nurse. If the infectious patient is isolated satisfactorily in the home, there should be no need to exclude school contacts for more than a week. If, on the other hand, home isolation is unsatisfactory, the patient should be removed to hospital. In any case, the long period of exclusion from school of contacts of home-treated cases is a serious matter from an educational point of view and a frequently-used argument against the home treatment of scarlet fever. There are many parents who are both able and willing to provide the necessary facilities for home isolation and treatment, but they naturally hesitate and decline to make such provision when they are told that it entails the loss of six weeks education for all school children in the house. The Efficacy of School Exclusion. Since 1st January, 1934, Leyton school contacts have been excluded for only one week, irrespective of whether the patient has been isolated in hospital or at home; whereas previously school contacts of home-treated cases were excluded for six weeks. Three years have now elapsed since the modified procedure was adopted, and Table B shows a statistical comparative analysis of the incidence of scarlet fever among school contacts during the two-year period before and the three-year period since the modification of the regulations. 88  (1) (2) (3) (4) (5) Primary Cases. Contacts of School Age. Ratio of (2) to (1). No. of Contacts Attacked. Percentage of contacts Attacked. 1932-3 Hospital 662 816 1.23 19 2.3 Home 369 214 .58 12 5.6 Total 1,031 1,030 .99 31 3.0 1934-6 Hospital 916 985 1.07 32 3.2 Home 502 308 0.61 13 4.2 Total 1,418 1,293 .91 45 3.4 The outstanding difference between the hospital-treated and home-treated groups is the ratio of contacts to primary cases. For instance, in the period 1932-33 the ratio was 1.23 for hospitaltreated cases and 0.58 for home-treated cases; in 1934-36 it was 1.07 for hospital and 0.61 for home cases. This is to be expected when one considers that many cases are admitted to hospital simply because the number of home contacts makes isolation at home difficult. However, by accepting as the basis of comparison the percentage of contacts attacked, the two groups are comparable. When comparison is made between the percentage contactattack rates of hospital-treated and home-treated cases it will be seen that in each of the two periods the percentage was greater when the primary cases were treated at home; but although the difference is statistically significant in the first period, it is not so in the second. The important point, however, is whether the shortening of the school exclusion period was followed by any significant change in the risk, and it will be seen that such was not the case; for although the resulting contact-attack rate during the second period was slightly greater in respect of hospital-treated cases, it was slightly less in respect of home-treated cases. With regard to the loss of school attendance in the two periods, the new regulations in force during the second period apply only to contacts of home-treated cases; but it will be observed that whereas in the first period 214 contacts lost at least 12,840 school attendances, in the second period 308 contacts lost only 3,080 attendances. 89 Summary. Although the prevalent type of scarlet fever is a mild disease with a very low direct fatality rate, its complications—and other infections by the same organism—are conditions responsible for serious subsequent morbidity and a high remote fatality. Scarlet fever patients aggregated in multiple-bed wards are exposed to serious risk from secondary infection and complications, especially when the standards of bed-spacing and nursing efficiency are diminished during epidemic periods. Removal to hospital merely for the purpose of isolation is not a necessary measure of control, and there is no evidence of increased risk to patients or contacts when isolation is carried out in the home. In view of the evidence of the extent of secondary infection in multiple bed wards, separate cubicles for all patients must be regarded as the ideal form of hospital provision. At present the most practicable method of cubicle isolation is in the home. When scarlet fever patients are isolated at home, routine exclusion of school contacts appears to be unnecessary. DIPHTHERIA. Year. Cases Notified. Deaths. Case Fatality per cent. 1932 155 3 1.93 1933 94 7 7.44 1934 257 11 4.28 1935 276 8 2.89 1936 231 11 4.76 90 Treated in hospitals— Leyton Isolation Hospital 182 L.C.C. Hospitals 19 Walthamstow Isolation Hospital 6 Plaistow Fever Hospital 10 East Ham Fever Hospital 3 London Fever Hospital 1 Whipps Cross Hospital 1 222 Treated at home 9 231 The following list shows the particulars regarding the eleven deaths certified as due to diphtheria during the year. Date of Death. Sex. Age. Cause of Death. Where death occurred. 10. 2.36 Male 5 Diphtheria Eastern Hospital, L.C.C. 24. 2.36 Female 4 Membranous Tonsillitis (Diphtheritic). P.M. without Inquest. At Home. 26. 2.36 Male 2 Diphtheria Isolation Hospital. 29. 2.36 Male 3 Diphtheria „ „ 2. 4.36 Female 5 Toxaemia. Diphtheria „ „ 2. 6.36 Male 4 Endocarditis. Diphtheria „ „ 19. 6.36 Female 8 Heart failure. Diphtheria „ „ 30. 6.36 Male 4 Heart failure. Diphtheria „ „ 4. 7.36 Male 2 Toxaemia. Diphtheria „ „ 5. 8.36 Male 5 Heart failure. Diphtheria. Hemiplegia. „ „ 14.12.36 Female 3 Toxaemia. Diphtheria „ „ ARTIFICIAL IMMUNISATION AGAINST DIPHTHERIA. In February, 1935, the first municipal clinic for immunisation of children against diphtheria was established. To begin with it was possible to deal with all cases at one weekly clinic, but it soon became evident that two weekly clinics would be necessary in order to deal with the large numbers of children presented for treatment. Since the opening of the new Park House Clinic in September, 1935, one special weekly session at each of the clinics has been devoted to diphtheria immunisation, viz.:— Leyton Green Clinic.—Thursday afternoons. Park House Clinic.—Friday afternoons. 91 Inoculations. Experience has shown that, whereas the great majority of children under ten years of age are susceptible to diphtheria, the majority of urban school children have acquired a natural immunity towards the end of their school life. Therefore, in order to save time and inconvenience, the preliminary Schick Test of susceptibility has been omitted in children under ten years of age unless the parents have expressed a definite wish to have the preliminary test carried out. The preparation which has been in routine use throughout the year at the Council's special clinics has been T.A.F., of which two intramuscular injections are given, with an interval of four weeks between the two inoculations. As a period of a few months must elapse from the time of inoculation until the child is sufficiently protected to resist an attack of diphtheria, the Final Schick Test is performed three months after the date of the last inoculation. Attendances. The great drawback to more widespread advantage being taken of immunisation against diphtheria is the number of attendances to be made. In children submitted to the initial Schick Test and found to be susceptible, the full course of immunisation entails five attendances spread over a period of about 31/2 months. By dispensing with the initial Schick Test the number of attendances is reduced to four, and the period is reduced by one week. Immunisation by Private Medical Practioners. In order to encourage the protective inoculation by private medical practitioners of Leyton children whose parents do not wish to attend the municipal clinics, the Council decided that facilities should exist for the supply of diphtheria toxoid-antitoxin, free of charge, to local medical practitioners on condition that they supply the Medical Officer of Health with the necessary particulars regarding 92 the persons immunised and adequate proof of the results of immunisation. The following are the particulars regarding Leyton children who attended private medical practitioners during the year:— Number of private medical practitioners who applied for supplies of toxoid-antitoxin 6 Number of children immunised 11 Record of Attendances during 1936. The following figures give particulars regarding the children dealt with at the municipal diphtheria immunisation clinics during 1936. The figures refer only to children who have finished—or failed to complete—the full course of innoculations during the year. Children who had commenced—but had not yet completed—the course at the end of the year will be shown in the report for 1937. Under 2 yrs. 2-5 years. 5-10 years. 10-15 years. Total. Number of children who attended for immunisation 43 234 782 250 1,309 ,, ,, who completed course of immunisation 40 230 752 246 1,268 ,, ,, naturally immune — — 5 10 15 ,, ,, immune after 1 injec,, ,, tion 1 1 — — 2 ,, ,, immune after 2 injections 38 227 721 226 1,212 ,, ,, immune after 3 or more injections 1 2 20 8 31 ,, ,, Positive after 3 injections — — 6 2 8 ,, Removed from district 1 1 16 — 18 ,, ,, Failed to attend for Final Schick Test 1 1 9 3 14 ,, ,, Failed to attend after 1 injection 1 2 5 1 9 Number of attendances during 1936 — — — — 5,215 These figures show that parents in the area are anxious to have their children protected against diphtheria. Incidence of Diphtheria Among Protected Persons. It is not claimed that artificial immunisation will prevent a person from infection by diphtheria organisms. What is claimed is that successful artificial immunisation will prevent the immunised person from developing the dangerous toxaemic manifestations of diphtheria. 93 During 1936 some 12 Leyton persons, who had been immunised, were notified to be suffering from diphtheria. The following table gives in summary form the" information regarding these cases. Age. Sex. Date of Immunisation. Schick Test Negative. Date of Notification. Swab Results. T=Throat. N=Nose. E=Ear. 5 yrs. M. 22.11.35 20. 1.36 N + Diphtheria. E + Nose and Ear. 11 yrs. F. 10. 1.36 8. 5.36 4. 2.36 T + Not Clinical. Diphtheria. 5 yrs. M. 9. 1.36 — 2. 5.36 T — N — Do. 6 yrs. M. 12. 6.35 14.10.35 14. 5.36 T — N — Do. 7 yrs. F. 7. 5.36 22. 7.36 29. 7.36 N — T + Mild Clinical Diphtheria. 6 yrs. M. 4.10.35 20.12.35 7. 8.36 T + Not Clinical Diphtheria. 3 yrs. M. 18. 9.36 — 28. 9.36 T— N — Do. 11 yrs. F. 10. 1.36 22. 5.36 22.10.36 T + Do. 9 yrs. M. 11. 5.35 29. 8.35 29.10.36 T + Do. 11 yrs. M. 11. 5.35 29. 8.35 31.10.36 T + Do. 5 yrs. F. 11. 5.35 29. 8.35 3.11.36 N + Do. 9 yrs. M. 12. 3.36 9. 7.36 12.12.36 N + Do. MEASLES EPIDEMIC, 1936. In and around London widespread outbreaks of measles occur with explosive suddenness at regular intervals of two years. The first cases of the 1936 epidemic came to my notice about the middle of February. Thereupon there was put into operation the procedure, outlined in my Annual Report for the year 1932, which had been found to be effective during the previous epidemics. Daily information was obtained from head teachers and school attendance officers regarding all cases of measles or suspected measles coming to their notice. In addition, information was received from the health visitors regarding pre-school children. Incidence. During the whole year there were brought to my notice from these sources 1,556 cases, of which 1,539 occurred during the epidemic period (i.e., approximately February-June). The age distribution was as follows:— Under 1 19 1 to 2 years 59 2 to 5 years 267 Over 5 years 1,211 1,556 94 The following list shows how the cases were distributed among the different wards in the Borough:— Leyton 146 Lea Bridge 266 Central North 122 Central South 180 Forest 208 Leytonstone 92 Grove Green 130 Harrow Green 152 Cann Hall 150 Wanstead Slip 110 1,556 Home Visits. One thousand eight hundred and seventy-three visits to houses were made by members of the nursing staff of the Department. At the time of the primary visits it was found that doctors were already in attendance in 1,311 (i.e., 84.23 per cent.) of the cases. In homes where no doctor was in attendance the visitors were able to give advice regarding isolation and treatment; but in 6 cases it was found necessary to make arrangements for daily visits by nurses of the Essex County Nursing Association. Institutional Treatment. Measles is one of the most highly infectious of all infectious diseases, and it is dangerous to admit a case of measles to a ward containing susceptible children suffering from scarlet fever or diphtheria. In providing for measles cases, no accommodation less than a whole ward can be considered. As it was impossible to devote a whole ward to measles cases in Leyton Isolation Hospital, it was necessary to find accommodation in outlying institutions, and 53 cases were admitted to the following institutions:— London County Council Hospitals 34 London Fever Hospital 19 53 95 They were admitted for the following reasons:— Broncho pneumonia 40 Unsatisfactory home conditions 7 Ear complications 4 Eye complications 1 Heart disease 1 53 Mortality Of the 1,556 cases of measles reported in Leyton during 1936, 23 (i.e., 1.47 per cent.) died. The following table shows the ages and places of death of these 23 fatal cases. Where Died. Under 1 year. 1 and under 2 yrs. 2 and under 5 yrs. 5 and under 10 yrs. Total. At Home 1 3 2 6 Isolation Hospital, Leyton — — — 1 1 Whipps Cross Hospital — 5 — — 5 Eastern Hospital (L.C.C.) 1 1 2 — 4 Brook Hospital (L.C.C.) — — 1 — 1 North Eastern Hospital (L.C.C.) — 1 — — 1 Southern Hospital (L.C.C.)(... 1 — — — 1 East Ham Hospital ... — — 1 — 1 London Fever Hospital — — 2 1 3 3 10 8 2 23 TUBERCULOSIS. Improved Leyton Mortality Rates. The following figures have been compiled to show the marked fall in the number of deaths due to tuberculosis since the passing of the Tuberculosis Regulations (1912). For purpose of comparison the five-year period preceding 1912 is compared with the last five years. Pulmonary. Non-pulmonary. Deaths. Death rate. Deaths. Death rate. 1908 102 .84 43 .35 1909 99 .82 36 .29 1010 101 .82 32 .26 1911 118 .94 53 .42 1912 115 .90 44 .34 535 4.32 208 1.66 96 Pulmonary. Non-pulmonary. Deaths. Death rate. Deaths. Death rate. 1932 66 .52 8 .06 1933 78 .63 12 .09 1934 68 .55 8 .06 1935 69 .56 8 .06 1936 56 .46 13 .10 337 2.72 49 .37 It will be observed that the death rate from pulmonary tuberculosis has been reduced by 37.03 per cent., and from nonpulmonary tuberculosis by as much as 77.70 per cent, in the comparatively short space of twenty-four years. Notifications.—One hundred and thirty-three patients were notified for the first time in 1936 as suffering from tuberculosis. The number was made up as follows Males. Females.  Pulmonary Tuberculosis 52 56 108 Non-Pulmonary Tuberculosis 17 8 25 69 64 . 133 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 15 children and 92 adults in whom evidence of active disease had ceased to exist. 97 The following is a statement of particulars appearing in the Register of Notifications of Cases of Tuberculosis for the year ended 31st December, 1936:— Pulmonary. Non-Pulmonary. . M. F. Total. M. F. Total. Number on Register at commencement of year 314 224 538 74 82 156 694 Number first notified during the year 52 56 108 17 8 25 133 Number of cases entered in Register otherwise than by Notification 10 15 25 7 3 10 35 Number removed from the Register during the year 123 108 231 52 41 93 324 Number remaining at the end of the year 253 187 440 43 52 98 538 Details of cases removed from the Register during the year:— Died 55 29 84 13 7 20 104 Removed from the district 40 45 85 14 14 28 113 De-notified 28 34 62 25 20 45 107 Deaths.—Sixty-nine deaths from tuberculosis were recorded:— [ Males. Females. Total. Pulmonary Tuberculosis 38 18 56 Non-Pulmonary Tuberculosis 9 4 13 69 This is equivalent to a death rate of 0.57 per thousand of the population, as compared with a figure of 0.63 for the previous year. 98 The following table gives particulars regarding the new cases and deaths which have occurred during the year:— Age Periods. New Cases. Deaths. Pumonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. #] 0 1 — — 4 — 1 — 1 2 5 1 — 3 4 — — 2 1 10 2 1 1 15 4 13 3 1 2 1 2 — 20 4 10 — 1 5 5 — 1 25 13 20 3 1 9 5 2 — 35 8 5 — 1 7 5 1 — 45 12 6 1 — 7 1 — — 55 8 — 2 — 7 1 1 — 65 and upwards. 1 Tota's 52 56 17 8 38 18 9 4 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. 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 1936 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 46 40 2 1 89 Children 2 2 4 8 16 99 CANCER, There were 205 deaths during the year, giving a death rate of 1.71 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 :— Digestive organs and peritoneum— Males. Females. Stomach 19 11 Colon 10 14 Intestine — 4 Rectum 15 12 Caecum — 1 Bile duct — 2 Gall bladder — 1 Liver 3 9 Pylorus 2 — Oesophagus 5 1 Pancreas 5 — Ventriculi 4 4 Respiratory organs— Lung 4 2 Larynx 4 1 Mediastinum 1 — Bronchus — — Uterus— Cervix — 2 Uterus — 5 Female genital organs— Ovary — 3 Vulva —• 1 Breast — 25 Male genito-urinary organs— Bladder 1 — Prostrate 8 — Testes 1 — Kidney 3 — Skin— Face — 2 Skin — 1 100 Buccal cavity and pharynx— Males. Females. Pharynx 1 — Maxilla 1 1 Tonsil 1 Mandible 1 — Other sites 9 5 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 seven patients were supplied with Insulin at a cost to the Council of £28 19s. 4d. 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 2,014 Ringworm 6 Sputum 508 Widal test (Enteric Fever) 5 Miscellaneous 38 Biological examinations for virulence test 7 Water 9 101 TABLE No. 11. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR l«J36. DISEASE. At All Ages. Number of Cases Notified. At Ages — Years. 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 ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria 231 61 144 13 12 1 9 37 10 9 31 27 21 21 47 19 222 Erysipelas 60 1 3 17 26 12 5 5 8 11 4 3 14 4 6 22 Scarlet Fever 367 86 210 42 26 1 36 33 31 49 42 31 33 46 35 31 258 Dysentery 1 1 1 1 Pulmonary T.B 108 5 29 47 26 1 11 18 9 9 15 13 7 12 5 9 T.B., other forms 25 4 8 5 5 3 5 4 2 1 8 4 1 Pneumonia 114 19 21 9 31 23 9 10 15 11 14 29 13 4 7 7 4 37 Ophthalmia Neonatorum 6 1 1 2 1 1 3 Enteric Fever 4 1 2 1 1 1 1 1 ... 4 Puerperal Fever 4 1 2 1 1 1 2 4 Puerperal Pyrexia 14 4 10 2 1 4 1 3 1 2 13 Cerebro Spinal Meningitis 5 2 1 1 ... 1 1 1 1 5 Piliomyelitis 1 1 1 ... 1 Enc. Lethargica Pemphigus Neonatorum 1 1 1 Totals 941 13 175 390 106 153 82 22 75 115 69 91 137 93 75 110 105 71 ISOLATION HOSPITAL. 103 Statistical Returns 1936. Admissions:— At all ages. Under 1 year. 1 year to 5 years. 5 years to 15 years. 15 years to 25 years. Over 25 years. Scarlet Fever Wards 232 2 63 128 24 15 Diphtheria Wards 187 1 47 120 12 7 Totals 419 3 110 248 36 22 The total number of patients admitted during the year was 419, as compared with 448 during the previous year. The following list shows the numbers of the respective diseases dealt with :— Scarlet Fever. Diphtheria. Admitted 232 187 Discharged 241 155 Died 2 9 SCARLET FEVER. Of 367 persons notified during the year 232 (63 per cent.) were admitted to Ley ton Isolation Hospital for treatment. Of that number 121 were males and 111 females. The average period of treatment in hospital was 32.83 days. 1932 1933 1934 1935 1936 Number of cases notified 360 743 681 409 367 Number of cases treated in Leyton Isolation Hospital 223 443 391 260 232 Percentage 62% 59% 58% 63% 63% Deaths in Hospital 4 4 1 0 2 Hospital case fatality 1.79% 0.90% 0.25% Nil. 0.86% Included among the number of 232 patients admitted to the scarlet fever wards were:— Re-admissions 2 Other diseases 3 104 It was necessary to arrange for admission to institutions outside the area of 8 Leyton residents suffering from scarlet fever. The outlying institutions to which these patients were sent were:— London Fever Hospital 7 Park Hospital (L.C.C.) 1 8 Two patients died in the scarlet fever wards of the hospital during the year. 1. Male, 25 years. Endocarditis, scarlet fever. 2. Male, 2 years. Scarlet fever, septicaemia. INCIDENCE OF COMPLICATIONS. During the year 1934, a year of abnormally high incidence of both scarlet fever and diphtheria, the number of scarlet fever patients accommodated in the scarlet fever wards was considerably in excess of the standard accommodation available ; and, in order to determine whether any correlation existed between the density of occupation of wards and the rate of incidence of complications Dr. F. W. Gavin (then Deputy Medical Officer of Health) undertook a special detailed investigation of the records of patients treated in hospital during that year. The results of Dr. Gavin's investigations were published in my Annual Reports for 1934 and 1935. His successor, Dr. P. Henderson, has continued the investigation of the records for 1936. Incidence of Complications Among Scarlet Fever Patients in the Isolation Hospital. During the year 1936 some 232 patients, diagnosed as scarlet fever, were admitted to Leyton Isolation Hospital. In 12 of these patients the diagnosis was not confirmed. Complications Present on Admission. Of the 220 patients definitely diagnosed as scarlet fever, 19 had compli cations on admission. The following table shows these complications Rhinitis. Otorrhoea. Cervical adenitis Total. 14 4 1 19 Complications During Course of Disease. Sixty-six patients (30 per cent.) developed complications during their stay in hospital. Fifty-one had one complication, 12 had two complica- 105 tions, and 3 had three complications. These complications, with the number in each age group, are set out in the following table:— Nature of Complications. Age Group Incidence. Total Incidence. 0-5 5-10 10-15 15 and over. Number. Percentage. Otorrhoea 7 13 1 1 22 10.0 Rhinitis 2 9 2 13 5.0 Cervical Adenitis 4 6 1 1 12 5.4 Arthritis — 3 1 3 7 3.2 Measles 5 2 — 7 3.2 Albuminuria 3 3 1 7 3.2 Secondary Tonsillitis and Quinsy 1 2 1 2 6 2.7 Nephritis — — 2 — 2 0.9 Second attack of S. F. 1 — — 1 2 0.9 Endocarditis — 1 1 0.4 Styes 1 1 — — 2 0.9 Broncho-pneumonia 1 — — — 1 0.4 Balanitis 1 — — — 1 0.4 Buttock Abscess 1 — — — 1 0.4 Total 27 39 9 9 84 Cases of otorrhoea, rhinitis and adenitis comprised more than half (55.95 per cent.) of the total complications. Two patients developed nephritis, one having previously received 20 c.c. scarlet fever antitoxin. Seven patients had albuminuria without other evidence of nephritis, and none of the seven received scarlet fever antitoxin. A small outbreak of measles occurring in the period March-April, 1936, seven children being affected. Ttme of Onset of Complications. During 1st week in Hospital. During 2nd week in Hospital. During 3rd week in Hospital. During 4th week and later in Hospital. Total. 20 24 per cent. 17 20 per cent. 21 25 per cent. 26 31 per cent. 84 Serum-treated Cases. Fifty-nine patients received serum and of these fourteen developed at urticarial serum rash. Eight (13.55 per cent.) patients who received scarlet fever antitoxin developed complications; six were cases of otorrhoea, one was a case of rhinitis, and one was a case of nephritis. The walls of the hospital buildings were constructed of corrugated iron lined by matchboarding, with a layer of felt between the external and internal coverings. With the lapse of time (over 40 years) the external metal and middle felt coverings became perished, the result being that cold draughts of air were penetrating 106 into the wards. During 193-1 it was found that the incidence of renal complications (nephritis and albuminuria) was greater among females (21 per cent.) than among males (8 per cent.), and that these complications occurred mostly in patients occupying beds on the north-east side of the wards. The renovation of the outer and middle coverings of the walls was begun in May and finished in November, 1935. The following figures show the percentage incidence rate of renal complications during the last three years. Renal complications. Nephritis. Albuminuria. Total. Per cent. Per cent. Per cent. 1934 1.29 16.02 17.83 1935 2.33 8.17 10.50 1936 0.90 3.18 4.09 In 1934 overcrowded conditions occurred in the scarlet fever wards during the whole year with the exception of the months of May and September. In 1935 overcrowding occurred during the periods January to March, late May and early June, and midOctober to the end of December. In view of the apparent correlation between overcrowding and high incidence rate of complications steps were taken to ensure that (from 1st January, 1936) the standard bed space of 12 linear feet was maintained. Durinsr 1936, therefore, no overcrowding of patients occurred. 1936, therefore, no overcrowding of patients occurred. The following figures show the percentage incidence rate of complications during these three vears. Per cent. 1934 51 1935 41 1936 30 Of 231 persons notified during the year, 187 (80 per cent.) were admitted to Leyton Isolation Hospital. Of that number, 110 were males and 77 females. The average period of treatment in hospital was 40.28 days per case. 1932 1933 1934 1935 1936. Number of cases notified 155 94 257 276 231 Number treated in Leyton Isolation Hospital 115 70 193 188 187 74% 74% 75% 68.1% 80% Deaths in Hospital 2 4 10 6 9 Hospital case fatality 1.74% 5.70% 5.18% 3.19% 4.81% 107 Included among the number of 231 patients admitted to the diphtheria wards were:— Transfers from other hospitals 3 Other diseases 2 The incidence and severity of diphtheria are liable to marked fluctuation from year to year. As regards incidence, the low water mark was reached in 1933, when only 94 cases were notified; but the tide of diphtheria incidence has been on the "flow" since that time. During the year some 231 cases were notified. In addition to the 187 patients admitted to Leyton Isolation Hospital, it was necessary to find accommodation for 17 cases in the following fever hospitals:— Eastern Hospital (L.C.C.) 9 North Eastern Hospital (L.C.C.) 5 London Fever Hospital 1 North-Western Hospital (L.C.C.) 1 Walthamstow Isolation Hospital 1 17 Deaths.—Nine deaths due to diphtheria occurred in Leyton Isolation Hospital during the year, the following being the relevant particulars:— No. Sex. Age. Cause of Death. In Hospital. 1 M. 2 years Diphtheria 32 days 2 M. 3 „ 34 „ 3 F. 5. Toxaemia, Diphtheria 1 day 4 M. 5 Endocarditis, Diphtheria 6 days 5 F. 8 Heart Failure, Diphtheria 23 „ 6 M. 4 ,, 5 „ 7 M. 2 Toxaemia, Diphtheria 1 day 8 M. 5 Heart Failure, Diphtheria, Hemiplegia 41 days 9 F 4 Toxaemia, Diphtheria 9 „ 108 Massage and Special Treatment. The Council's Masseuse, Miss Findlay, attends at the Isolation Hospital during one morning per week, and the following list shows the numbers of the different types of patients dealt with. Number of patients treated Number of treatments. Under School Age 35 65 School Children 107 251 Adults 16 32 158 348 Miss Findlay's services at the Isolation Hospital have been greatly appreciated; and as a result of the treatment given it has been possible to ensure that patients suffering from orthopaedic defects leave the hospital in a more fit condition. In addition, Miss Findlay has been able to follow up these cases by arranging for their attendance at the special orthopaedic clinic. Maternity and Child Welfare. 110 MATERNITY AND CHILD WELFARE. INFANT WELFARE. Voluntary Workers. 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 Leyton Green 1918 Mrs. Wagstaff Leyton Green 1924 Mrs. E. Carter Leyton Green 1929 Mrs. E. Garton Leyton Green 1933 Mrs. V. Softley Leyton Green 1933 Mrs. D. Jacobs Leyton Green 1934 Miss M. Grant Leyton Green 1934 Miss H. S. Holl Park House 1927 MissE. H. Holl Park House 1927 Mrs. J. Oates Park House 1929 Miss Muddiman Park House 1934 Notification of Births.—Thirteen hundred and fifty-eight notifications of births were received during the year. By medical practitioners 340 By mid wives 1,017 By parents and others 1 Infant Welfare Clinics. 1. Park House Clinic, Granleigh Road, Leytonstone.—Mondays, Tuesdays and Thursdays, at 1.45 p.m. Toddler's Clinic, Tuesdays, 10 a.m. 2. Leyton Green Clinic, Leyton Green Road.—Mondays, Wednesdays and Fridays, at 1.45 p.m. Toddlers Clinic, Fridays, 10 a.m. During the year under review, the total attendances at the Council's Infant Welfare Centres were 16,220, a decrease of 150 compared with the figure (16,370) for the previous year. The number of children examined by the Clinic Medical Officers was 6,323 as compared with 6,820 examined during; the previous vear. 1ll TABLE 12. ATTENDANCES, EXAMINATIONS, ETC., 1936. | Leyton Green. Park House. p.m. Mon. p.m. Wed. a.m. Toddlers. Fri. p.m. Fri. p.m. Mon. a.m. Toddlers. Tues. p.m. Tues. p.m. Thurs. All Centres. Under 1 year— 1st attendances 150 177 4 157 157 — 151 171 969 Subsequent attendances 1,748 2,225 6 1,378 2,280 — 1,482 1,595 10,714 Total attendances 1,898 2,402 10 1,535 2,437 — 1,633 1,766 11,683 1-5 years— 1st attendances 22 29 95 27 16 112 21 18 338 Subseq uent attendances 371 879 236 352 1,048 285 513 515 4,199 Total attendances 393 908 331 379 1,064 397 534 533 4,537 Total attendances, both age groups 2,291 3,310 341 1,914 3,501 397 2,167 2,299 16,220 Average attendance per session 47.72 67.55 6.95 39.06 71.44 8.27 45.14 46.91 41.18 Number examined by clinic M.O. 794 1,166 299 782 1,208 357 747 970 6,323 Average number examined per doctor per session 16.54 23.80 6.10 15.95 24.65 7.43 15.56 19.79 16.22 Number weighed 2,288 3,266 324 1,909 3,503 377 2,166 2,286 16,119 112 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. During the year the Authority lost the valuable services of two Voluntary Workers, who have rendered faithful service since 1917. Mrs. Muddiman died in March, 1936 ; and at the end of the year Mrs. A. Tallack resigned owing to ill-health. Health Visitors. Miss Barbara Neale, who had been incapacitated from duty owing to illness since August, 1935, was not able to resume her duties until March, 1936. Another member of the health visiting staff, Miss Walling, was incapacitated from 24th March until 4th May, 1936. Miss McNeill acted as temporary health visitor from 30th December, 1935, until 8th April, 1936. During the year the Health Visitors have made 18,803 visits to homes, as follows:— (a) To expectant mothers:— First visits 168 Total visits 183 (b) To children under 1 year of age First visits 1,399 Total visits 7,733 (c) To children between the ages of 1 and 5 years:— Total visits 10,886 Dental Treatment. 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:— 1932 300 1933 292 1934 273 1935 283 1936 291 113 The record of such treatment undertaken during the year 1936 is as follows:— Expectant Mothers. Children. Patients treated 100 191 Attendances 291 287 Extractions 474 332 Fillings 20 75 Other dental operations 74 13 Advice only 7 26 Anaesthetics General 94 57 Local 3 90 Dentures supplied Full upper and partial lower 3 Full upper and lower 8 Full upper 2 Partial upper 8 Partial upper and lower 4 25 Orthopaedic Treatment. Primary Examinations.—During the year 33 children were referred from the Infant Welfare Clinics to the Council's Orthopsedic Surgeon. The orthopaedic defects included:— Congenital. Torticollis 1 Scoliosis 1 Flexion deformity digit hand 1 Amputation digits hand 1 Talipes 1 Divarication recti (hernia) 1 Hemihypertrophy rt. 1 Hemiplegiart 1 114 Acquired. Genu valgum 14 Genu varum Bowed tibiae Injury tibia and fibula Pes piano valgus 17 Deformity—digit foot Deformity—digit hand Fracture humerus 1 Re-examinations.—In addition to the 33 new cases mentioned above, 116 children under five years of age attended for re-examination by the Orthopaedic Surgeon. Treatment.—Eighty-eight children made 358 attendances at Knotts Green Special School for special treatment by the Council's Masseuse (Miss Findlay). Provision of Surgical Appliances.—Eighty-four children were supplied with surgical appliances on the recommendation 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 2 Genu valgum splints 5 Equinus splint 1 Minor alterations to boots (wedges, etc.) 70 pairs Alterations and repairs to splints, etc. 2 Tunnels and wedges to boots 1 pair and 3 singles and 3 singles Surgical Operations.—During the year three children under school age were admitted to hospital and the following operations were performed by Mr. Whitchurch Howell:— Manipulation foot and plaster 1 Splintage and diet 1 McEwen's osteotomy femur (R. and L.) 1 Tenotomy tendo achilles (L.) and plaster 1 Special Eye Clinic. During the year the Council's Ophthalmic Surgeon (J. D. Magor Cardell, M.B., F.R.C.S.) had referred to him by the Clinic Medical Officers 33 pre-school children, who made 57 attendances for examination and treatment. 115 The following list shows the ophthalmic defects found in these 33 children:— Myopia with sqint 1 Hypermetropia 1 Hypermetropia with squint ... 9 Squint only 13 Various diseases 5 Hyper astigmatism 4 33 The following forms of treatment were recommended:— Spectacles supplied 15 Spectacles not prescribed 4 Squint treated with atropin 8 Squint referred to Orthoptic Clinic 5 Recommended ultra violet light 1 Artificial Sunlight Treatment. Number of cases treated—Infants 63 Number of cases treated—Adults 2 Total number of attendances 1,614 Clinics for Toddlers. In September, 1935, a special weekly morning clinic for the health supervision and special medical examination of toddlers (i.e., children between two and five years of age) was instituted at each of the Council's infant welfare centres. The following report by Dr. Hilda Menzies gives some indication of the work which is undertaken in connection with the scheme. (Report by Dr. Menzies). At the commencement appointments were sent by post, but the response was poor, and this method of securing attendance was discontinued. It was found, however, that less formal measures worked better. Health visitors advised mothers of the existence of the clinics and in certain cases recommended attendance at the session following their visits. Mothers who had been taking several children to the infant clinics were advised to bring the older child or children to the Toddlers' Clinic for examination. Children 116 discharged from the Isolation Hospital were referred, and in some cases the School Medical Officers or Teachers made a recommendation regarding younger children in the family. The majority came through the efforts of the Health Visitors. The early attendances were small. In the first three months (until the end of 1935) the average attendance per session at Leyton Green Centre was 3.5, and at Park House Centre 6.3; but during 1936 the numbers increased considerably, and the average attendances for 1936 were 6.9 and 8.2 respectively. At the first visit a detailed physical examination is made, but emphasis is not laid on the physical examination. A discussion on the child's diet, regularity of bowels, hours of sleep, any peculiarities of behaviour, and observation and enquiry as to whether the mother is allowing the child scope to develop mentally, focusses the mother's attention on points she may have considered too trivial to mention. The mother is accustomed to take her child to a doctor for a "thorough examination" when he develops any obvious physical ailment, but the idea of consulting a doctor to make sure that the child's mental and physical development is sound is novel to the majority. Another may bring a child of 3 to 4 years to the clinic because he has a few urticarial spots which alarm her. He has not been brought before because" he has been getting on all right," but he has an obvious lack of self-confidence, and enquiry may reveal that he screams if the mother leaves him for a short time. The mother explains his behaviour by describing him as "nervous" or "shy," but does not often realise that it is the lack of orderliness and security in the child's immediate environment, or her own over-solicitous care which is either producing or aggravating the child's symptoms. This is where the nursery school or class does such valuable work if the child can be removed from constant association with his emotionally unstable parent at a sufficiently early age to prevent permanent damage. Public opinion here is in advance of administrative action. The mother may not realise the cause of the child's unrest, but she is quick to appreciate the improvement in his behaviour and general health when he attends a nursery class— and the demand for admission to school greatly exceeds the supply of accommodation. The more intelligent mother is ready to admit that her knowledge of the needs of the young child's mind may not be wide enough to provide suitable occupation for him throughout the day. 117 Children from the age of two years are seen at the toddlers' clinics. Roughly five-twelfths of the children who attended during 1936 were between 3-4 years; and rather more of the remaining seven-twelfths were between 2-3 than between 4-5. No attempt has been made to compile any statistics of defects, as it is considered that they would not give a true picture of the health of 2-5-year-old children in Leyton. Only a small proportion of the children of these years can be dealt within two weekly sessions, and the mother who recognises there is something wrong with her child's health is more likely to attend the clinic than the mother who considers her child is in good health. The commonest physical defect is undoubtedly carious teeth, although unfortunately it is exceptional for a mother to bring her child for dental treatment before there is toothache and the tooth is too far gone to be filled. It is amazing how an apparently careful, reasonably intelligent mother will leave her child's teeth until there are abscesses in the gums before coming for treatment. Education on this point has a long way to go. It is often difficult to understand why the teeth have decayed. There is often no apparent fault in the feeding from infancy onwards, and the nutrition may be otherwise good. Convalescent Home Treatment. Children. During the year 44 children, recommended by the Clinic Medical Officer, were sent to Convalescent Homes by the Maternity and Child Welfare Authority through the agency of the Invalid Children's Aid Association. In two cases the convalescence had to be curtailed : in one case because of illness of the matron, and in the second because the child (a boy aged 21 years) did not settle and it was reported by the matron that he seemed to delight in attacking the other babies. The remaining 42 children had periods of convalescence varying from four to eighteen weeks. Two-thirds of the children were away at least eight weeks, and of these half were away twelve weeks or longer. The majority did extremely well. There were some striking differences in the results, as shown by the gain in weight, even in children of the same age. Two girls of 4 years 3 months happened to be sent away at the same time—in the first quarter of the year. One was at Basingstoke for two months and gained 5 lbs.—as much as she had gained in the previous two years. The other was at Southbourne for four months and gained only 1/2 lb.; 118 but this child had gained 3 lbs.—immediately before convalescence— during a stay in hospital as the result of a street accident. In spite of her negligible gain in weight she was considered to have benefited in health. On return her colour was good, and she was more talkative. Previous to convalescence she had been rather silent, even in her own home. Another child of 4 years 9 months, whose failure to gain weight at home was considered to have a nervous rather than a physical origin, gained 4 lbs. during five weeks' convalescence. She was one of many who had not had any definite illness which might explain their slow progress. Infections of the respiratory tract and the prevalent epidemic of measles accounted for the majority of cases recommended for convalescence following definite illness. A few children were unfortunate to contract measles on their return from convalescence. The illnesses for which convalescence was recormmended were:— Measles (7 cases). Bronchitis (5 cases). Whooping cough (2 cases). Influenza (2 cases). Pneumonia. Pleurisy. Asthma. Scarlet fever. Diphtheria. Mastoiditis. Mastoiditis and tuberculous glands. Early rickets. Anaemia. Tonsillitis. Operation (tonsils and adenoids). Twenty-four of the 44 children were between the ages of two and four years; 17 were over four years; and three were under two years. Nursing Mothers. Three mothers were sent away for two weeks convalescence to "Child Haven," Hutton, near Brentwood, after they had had their babies. One had been in hospital eight weeks with puerperal fever, so she was sent without the baby, for whom arrangements were 119 made elsewhere. The other two took their babies with them. One was an unmarried girl, who had a subacute appendicitis following the confinement, and who required further rest. The other suffered from nervous debility. All three stated that they felt considerably stronger after the short period of convalescence. Ophthalmia Neonatorum. Cases. Treated At Home. In Hosp. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified in the area. 6 3 3 6 — — — Notified outside the area. — — — — — — Totals 6 3 3 6 — — — Treatment.—These 6 cases were treated as follows:— At home 3 St. Margaret's Hospital 2 St. Thomas's Hospital 1 6 Infant and Foetal Mortality. There were 74 registered deaths of infants under one year of age, giving an infantile mortality rate of 52.07 per thousand live births. Neo-natal Mortality (deaths of infants under one month).— Of the 74 deaths under one year, 38 occurred in the first four weeks ; and of the 38 deaths under four weeks, 31 occurred in the first week. The following figures show the variations in the infantile and neo-natal mortality rates and in the number of stillbirths during the last five-year period. Year. Births. Deaths under Mortality Rate. Stillbirths. 1 year. 4 weeks. Infantile. Neo-natal. 1932 1,666 89 51 53.42 30.61 58 1933 1,499 76 47 50.73 31.35 48 1934 1,454 64 38 44.02 26.13 46 1935 1,493 60 31 40.18 20.76 44 1936 1,421 74 38 52.07 26.74 44 Reference to Table 8 will show that the chief cause of neonatal deaths was premature birth (21). 120 TABLE 13. Infantile Mortality, Year 1936—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 ... ... ... ... ... ... ... ... ... ... Chiekenpox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... 1 1 ... 3 Scarlet fever ... ... ... ... ... ... ... ... ... ... Whooping cough ... ... ... ... ... ... ... ... ... ... Diphtheria and croup ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) ... ... ... ... ... 1 1 1 ... 3 Convulsions ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... 1 1 2 Bronchitis ... ... ... ... ... ... ... 1 i ... Pneumonia (all forms) ... ... ... 2 ... 3 4 1 4 14 Diarrhoea ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... 2 4 ... 1 7 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... 5 Injury at birth ... ... ... ... 5 ... ... ... ... 1 Atelectasis ... ... ... ... 1 ... ... ... ... 8 Congenital malformations 2 ... ... 1 4 3 ... 1 ... Premature birth 20 ... ... ... 21 ... ... ... ... 21 Atrophy, debility and marasmus ... ... ... ... ... 1 ... 1 ... 2 Other causes 3 2 ... ... 5 1 1 1 ... 8 Totals 31 3 1 3 38 11 11 7 7 74 Nett Births registered during (Legitimate 1,383 Nett Deaths registered during (Legitimate infante 70 the calendar year ( Illegitimate 38 the calendar year (Illegitimate infants 121 TABLE 13a. Infantile Mortality During the Year 1936—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 ... ... ... ... 1 ... ... ... ... ... ... 3 Whooping cough ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria and croup ... ... ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) ... ... ... ... ... ... ... ... ... ... ... 3 Convulsions ... ... ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... 1 ... ... 2 Pneumonia (all forms) ... ... ... ... 2 ... ... ... 1 ... ... 14 Diarrhoea ... ... ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... 1 ... ... ... ... ... ... 7 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... ... ... Injury at birth ... ... ... ... 1 ... ... ... ... ... ... 5 Atelectasis ... ... 1 ... ... ... ... ... ... ... ... 1 Congenital malformations ... ... 2 ... 2 ... 1 2 ... ... ... 8 Premature birth ... ... 2 ... 6 2 1 2 ... 1 ... 21 Atrophy, Debility and Marasmus ... ... ... ... ... 1 ... ... ... 1 ... 2 Other causes 2 1 ... ... 2 1 1 1 ... ... ... 8 Totals 5 12 8 2 15 9 7 6 5 5 ... 74 122 Children and Young Persons Acts, 1908-1932. Infant Life Protection. On 1st January, 1936, 52 foster mothers and 57 children were subject to inspection in the area. At the end of the year 46 foster mothers and 48 children were subject to systematic inspection by this Council's Visitors. The Council's Infant Life Protection Visitors made 300 visits of inspection during the year. Summary, Year 1936. Number of nurse children on Register 1st January 57 Number of nurse children notified by foster mothers during the year 34 Nurse children removed:— To parents or relatives 16 To another foster mother 7 With foster mother to another area 4 Adopted 3 To National Children's Home 5 To other institutions 6 Attained 9 years of age 2 Died Number of nurse children on Register on 31st December 48 ANTE-NATAL SUPERVISION. Ante-natal Clinics— (1) Park House Health Clinic, Granleigh Road, days, 10 a.m. (2) Leyton Green Health Clinic, Leyton Green Road, E.10.— Wednesdays, 10 a.m. (3) Maternity Department, Queen Mary's Hospital. Attendances.—During 1936, the attendances were as follows : Centre. First Attendances. Subsequent Attendances. Total. Park House Clinic, 226 379 605 Leyton Green Clinic 204 349 553 430 728 1,158 123 The total number of first attendances was 430, the corresponding figure for 1935 being 427. The total number of attendances at all clinics during the year was 1,158 the average attendance per session being 11.81. Of the 430 expectant mothers who made first attendances during 1936, 148 had not been confined by the end of the year and the results of these cases will be included in the Annual Report for 1937. On the other hand, 133 cases were carried over from 1935, and, when 30 cases are excluded who removed before confinement, details of 385 cases are available Of that number 9 were not pregnant, and the following table deals with the attendances of the remaining 376. Number of Expectant Mothers who attended. 376 Percentage of Primigra vidæ. 42.82 Percentage of Multiparæ. 57.18. 1. Attended before 24th week of pregnancy % * 33.54 °(36.47) % * 35.81 (27.12) 2. Attended after 24th week and before 30th week 21.74 (21.38) 15.81 (17.40) 3. Attended after 30th week and before 36th week 11.18 (6.28) 8.83 (6.47) 4. Transferred 22.98 (27.67) 14.41 (23.48) 5. Unsatisfactory 10.62 (8.17) 25.11 (25.50) * Figures for previous year (1935) 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, 66 per cent, of the primigravidæ and 60 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 in 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. Thirty-five point thirty-two per cent, of expectant mothers attended of their own accord or on the advice of a friend or relative. Forty-nine point sixty-one per cent, were sent by their midwives and 6 cases were advised to attend by their own doctors. 124 The number of home visits made by Health Visitors to expectant mothers during the year was 183. The results of all cases examined are tabulated below. Number. Percentage of Finished Cases. Normal 307 86.47 Prematurity 10 2.81 Stillborn 8 2.25 Instrumental delivery 16 4.50 Breech presentation 2 0.56 Miscarriage 2 0.56 Twins 3 0.84 Induction 4 1.12 Caesarean section 3 0.84 Total 355 Not pregnant 9 Removed 51 Grand Total 415 Analysis of Abnormal Cases. (Report by Dr. Menzies). (a) Instrumental Delivery (16 Cases). Of the instrumental deliveries, 14 occurred in primigravidas. Of these, six had arranged to enter hospital for their confinements. The remaining eight had booked with midwives. One was sent to hospital for advice as a possible disproportion. In two cases it was noticed that the head was not fixed at the thirty-eighth week, but no definite disproportion was found. A third developed mild pre-eclampsia at the thirty-sixth week, and labour occurred at the thirtyninth week, resulting in the birth of a living child weighing lbs. The only case which resulted in a stillbirth was a woman aged 34 who failed to attend the clinic after the thirty-sixth week, and may have been one week overdue when she was sent into hospital as an emergency by her private medical practitioner. The ages of these 14 primigravidæ ranged from 22 to 36 years. Five were under 25 years, and six were over 30 years. As a separate investigation shows that 52 per cent, of the primigravidse attending the clinics are under 25 years, and only 11 per cent, over 30 years, this demonstrates the truth of the assumption that the risk of instrumental delivery in a first confinement increases markedly as the woman's age reaches 30 years and over. 125 Of the 2 multigravidæ who had instrumental deliveries, one was a woman of 4-1 years having her eleventh child. There were various reasons why she ought to have been in hospital. She had a varicose ulcer of nine years' duration on her leg; she had very inadequate and overcrowded accommodation at home; her blood pressure was raised, and she had attacks of giddiness; but she refused to follow the advice of either the medical officer or of the midwife, who would have preferred to give up the case. She had a long, difficult labour, and the midwife reported that her general condition was not good ; but she survived. The second instrumental delivery of a multipart was a second confinement in hospital of a woman aged 24 years, who had had a normal first confinement. (b) CÆsarean Section (3 Cases). Caesarean section was performed in two primigravidse, and one multigravidae. One of the primigravidse was referred from the clinic to hospital with evidence of clinical disproportion. The second consulted her private medical practitioner because of haemorrhage at 20 weeks, and he recommended that she should have her confinement in hospital. The multigravida was a woman aged 32, having her third child. When she attended the clinic first at 24 weeks she was found to have an indefinite swelling on the left side above the uterus. She had no symptoms. As pregnancy advanced the swelling increased in size and was obviously cystic. The woman was referred to hospital, where Csesarean section was performed, and a large multilocular ovarian cyst was removed. She was delivered of a living child weighing 9 lbs. (c) Induction (4 Cases). Three of these cases were primigravidse who were not in regular attendance at the clinics. One (aged 35) came to the clinic at 16 weeks to obtain a letter for admission to hospital. She was very stout and was surgically induced at 36 weeks. The other two were in regular attendance at hospital ante-natal clinics, and attended the municipal clinic once to obtain free milk. Both had inductions on account of pre-eclampsia. The fourth case was a multigravida, aged 36, who gave a history of a stillbirth five years previously. She had not been examined during that pregnancy (the first) and she was sent into hospital where she was delivered of a stillborn child weighing 111/2 lbs. She attended the clinic regularly from 14 weeks, and was under observation at hospital from 36 weeks. She was delivered naturally, at term, following medical and surgical induction (Krause's) of a living child weighing 9 lbs. 31/2 ozs. (d) Stillbirths (8 Cases). Of the eight stillbirths, one was a premature birth at 32 weeks in a second pregnancy. Although the woman (aged 31) had attended the clinic and engaged with a midwife, she did not consult either when she developed swelling of her feet. A week later she had three eclamptic fits and the 126 practitioner who was called in had difficulty in persuading the patient and her husband that immediate hospital treatment was essential. One stillbirth followed a placenta prævia in a woman of 42 years—seventh pregnancy. Another, which occurred near the end of the child-bearing period, was in a woman of 42 years—twelfth pregnancy. One stillbirth occurred in a woman aged 34 who had had three live births followed by four self-induced abortions. The remaining four stillbirths occurred in primigravidæ, two of whom were over 30 and had been married nine years before becoming pregnant. In only one was there an obvious cause for the stillbirth and this was a case of acute hydramnios which developed in a woman aged 21 years. All four were delivered in hospital. (e) Breech Presentation (2 Cases). Both cases of breech delivery occurred in multigravidse. One made one attendance only at the ante-natal clinic when she was 20 weeks pregnant. The second attended regularly. This woman appeared to be malnourished —poor masculature, and very little subcutaneous tissue—but her condition was apparently not due to lack of means. Her husband had been in regular employment and she stated that she had always been able to have any food she wanted. (/) Prematurity (10 Cases). Of the ten cases of premature birth, five occurred in primigravidæ and five in multigravidæ Of the primigravidse, none occurred before the 36th week, and in one only was any abnormality found—a blood pressure above average but with no other signs or symptoms. All five babies survived. Of the five multigravidse, one was suffering from attacks of gall stone colic. The pregnancy terminated at 36 weeks in the birth of a living child. One had a raised blood pressure for six weeks before the pregnancy terminated, and showed evidence of albuminuria three weeks before labour, when she was referred to her private practitioner. The baby survived. In a third case the woman was so inaccurate over her dates that there was some doubt as to whether the pregnancy was 38 weeks. Her only physical abnormality was a mouth full of septic teeth. The fourth case followed an ante-partum hæmorrhage at 24 weeks in a woman of 39 years who had had three living children and one miscarriage. Her most obvious abnormality was in her mouth—the majority of the molar teeth consisted of septic roots. The fifth case was in a woman of 21 years whose first pregnancy terminated at 26 weeks, the baby living one hour. This pregnancy terminated at 36 weeks and the baby lived 5 hours. In the first pregnancy the premature birth was thought to be due to a fall, and in the second to a fright. Neither seems a sufficient reason; or if it is allowed that the fright (which was due to a thunderstorm) might have induced labour at 36 weeks, it hardly explains why the baby's vitality was so poor that it lived only 5 hours. The woman's pelvis is generally contracted. She will be visited so that she may be under supervision if she becomes pregnant again. (g) Miscarriage (2 Cases). One miscarriage occurred in a primigravidse (aged 21) nine days after her first attendance at the clinic, when it was queried if the foetus was dead. 127 The second occurred in a multigravidæ (aged 27) who had had one living child sixteen months before. In this case also the fœtus had died by the time she attended the clinic, and a six months' macerated foetus was born five days later. Both these cases require further investigation. Maternity Beds. In addition to the 430 expectant mothers who attended the Council's clinics, 324 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 9 Ruptured perineum 72 Cesarean section 3 Ante partum haemorrhage 6 Post partum haemorrhage 10 Placenta prœvia 4 Eclampsia 4 Epilepsy 1 Surgical induction 3 Medical induction 3 Prolonged labour 15 Forceps delivery 18 Occipito posterior presentation 8 Nephritis 1 Toxaemia of pregnancy 12 Pulmonary tuberculosis 1 Bronchitis 1 Cardiac 5 Prolapsed cervix 1 Episiotomy 11 Mastitis 1 Pyrexia 3 Hypertension 1 Trial labour 2 Breech 1 Stillborn 4 Fœtal distress 3 Hare lip 1 Premature 5 Prolapsed cord 2 Anencephalic 1 128 The average duration of stay in hospital was 12.9 days, and the cost per case was £4 10s. 7d., of which an average of £2 3s. 2d. was paid by the patient and the remaining £2 7s. 5d. by the Council. Nursing Homes Registration Act, 1927. There are four registered nursing homes in the Borough. Of these, one is a maternity home only. These institutions were visited on 9 occasions. Home Helps. Under the Council's scheme for the provision of home helps, 57 applications for home helps were dealt with. In 51 cases home helps were provided, 31 of these cases having the charges remitted in accordance with the Council's scale. In the 6 remaining cases, 5 made other arrangements for the confinement and one case had not been confined at the end of the year. At the end of the year there were 10 names on the Council's approved list of home helps. In September, 1936, the Maternity and Child Welfare Authority extended the scheme for the provision of home helps to apply to any expectant or nursing mother certified by the Medical Officer of Health to need domestic assistance on account of illness. MATERNAL MORBIDITY AND MORTALITY. (Report by Dr. Menzies). Four cases of puerperal fever and 14 cases of puerperal pyrexia were notified during the year. The confusion which exists as to the distinction between the terms "puerperal fever" and "puerperal pyrexia" is shown by the occurrence among the notified puerperal pyrexias of a case who developed clinical signs of septicaemia within 36 hours of labour and died 5 days later. Puerperal Fever. Of the 4 cases notified as puerperal fever, two followed abortions in married women. One ended fatally— 129 1. This was a ten weeks' abortion in a woman aged 45, who had five previous pregnancies—the last being a twin pregnancy in 1933 which terminated at 36 weeks. The woman had developed phlegmasia alba dolens following this confinement and was ill for six months. The home circumstances were poor. Before the abortion occurred other members of the family had been under treatment for influenza, and the woman's first symptoms—of sore throat with rise of pulse and temperature—were diagnosed as influenza. The doctor was recalled two days later because complete abortion had occurred, and the following day the patient complained of pain in the epigastrium and left side of the abdomen (T. 99. P. 120. Resp. 32). She was sent to hospital the same day as a case of pleurisy. On admission she was gravely ill (Temp. 101.6 deg.) with dyspnoea. An offensive discharge was washed out of the uterus, and in spite of treatment the patient died four days later of septicaemia. There was no evidence that the abortion was procured. 2. The non-fatal case associated with abortion occurred in a woman of 37 years who had five previous full time pregnancies, and was apparently in good health when this incomplete abortion occurred at 15 weeks. Part of the placenta was removed manually two days later, and she was sent to hospital for further treatment. She remained in hospital two weeks. The available information regarding the two notified cases of puerperal fever following full time deliveries is as follows:— 3. Primigravidae, age 22. Normal delivery, attended by midwife. Doctor called for moderate post-partum haemorrhage one hour after completion of third stage. Slight rise of temperature on fourth day—attributed to congested state of breasts. On eighth day rise of temperature and rigor. On ninth day seen by obstetric consultant—tenderness and rigidity in left iliac fossa— indefinite swelling in pelvis—uterus involuting normally—lochia normal—sent to hospital as a case of ascending salpingo-oophoritis (?) or parametritis (?) Diagnosis in hospital—moderately severe infection with haemolytic streptococci and other pathogenic organisms of the genital tract, with some spread to the pelvic peritoneum and pelvic cellular tissues. In hospital five weeks. Complete recovery. 130 4. Multipara (3), age 24. Confined in hospital, normal delivery. On ninth day developed symptoms of endometritis. In hospital six weeks. Sent for two weeks convalescence. Good recovery. Puerperal Pyrexia. As a result of investigations regarding the 14 notified cases of puerperal pyrexia, the causes of pyrexia were considered to be Pyelitis 2 Local uterine sepsis 2 Local uterine sepsis and breast abscess 1 Mastitis 2 Mastitis and bronchitis 1 Acute appendicitis 1 Colitis 1 Perineal stitch abscess 1 Tracheitis 1 Puerperal Septicaemia 1 (died) Unknown 1 Thirteen mothers recovered. The fatal case of septicaemia occurred in a primigravidae, aged 28. Father and sister died of pulmonary tuberculosis. Patient had influenza one month before confinement. Normal delivery at home by doctor and trained maternity nurse—3 vaginal examinations by maternity nurse and 2 by doctor—neither gloves nor masks worn—slight perineal tear— one suture—rigor on second day after delivery—seen by obstetric consultant—Temp. 104 deg. P. 160—tenderness in lower abdomen —erythematous rash on abdomen and thighs—clinically diagnosed as virulent acute puerperal primary septicaemia (probably infection with hemolytic streptococcus)—prognosis grave. Removed to hospital—hæmolytic streptococci grown from blood stream within 24 hours of admission—physical signs of generalised peritonitis—died five days later. There was one stillbirth, and one child died following Cæesarean section. The stillbirth was in a case where the child was born before the mother realised she was in labour, although she had had pains for several hours. This was her first child. The mother had a 131 temperature of 102.2 deg. immediately after labour, and it fluctuated between 98.4 deg. and 102 deg. for the first four days. The condition was diagnosed as pyelitis. On the eleventh day the woman took lysol and was removed to hospital. She subsequently recovered. Eight of the 14 cases of puerperal pyrexia were confined in hospital. Five were attended by midwives, and one by a doctor assisted by a midwife. Four of the six domiciliary cases were transferred to hospital for treatment. The advice of the obstetric consultant was sought in three of the six cases. Obstetric Consultant. The advice of the Council's Consultant Obstetrician was sought on eight occasions during the year. 1. Case described under Puerperal Fever, No. 1 (40 weeks pregnancy). 2. Case described under Puerperal Pyrexia (Septicaemia). 3. Primigravidae, aged 24—home circumstances good—normal labour, attended by midwife—afebrile until seventh day when temp. 103 deg. P. 108—rigor—nipples painful—temp, and pulse remained high—seen by Consultant on ninth day—no urinary symptoms—lochia normal—uterus well involuted—no clinical evidence of puerperal sepsis. Diagnosis—diffuse parenchymatous mastitis. Removed to hospital for treatment. Good recovery. 4. Multiparae (2), age 30. Home circumstances fair. Normal labour of four hours—no laceration—haemorrhage not excessive— attended by midwife—afebrile until sixth day when temperature rose to 102.4 deg. P. 120—intermittent pyrexia continued until ninth day with slight cough and intermittent pain low down in right iliac fossa—seen by Consultant. Temp. 99.8 deg.—-P. 80— general appearance fairly good—clean, moist tongue—no abnormal physical signs in chest—no abnormal congestion of breasts—no abnormal physical signs in abdomen beyond slight deep tenderness in right iliac fossa—uterus well involuted—no abnormal tenderness or swelling in pelvis—provisionally diagnosed as puerperal sepsis 132 because of lack of positive physical signs to allow of an alternative diagnosis—catheter specimen of urine examined for B. Coli—result negative. Patient improved on administration of potassium citrate and made a complete recovery. 5. Multipart (13), age 44. Severe bronchitis for 14 days and shivering attack on day before delivery—premature birth—no excessive haemorrhage—attended by doctor—raised temperature during puerperium. Seen by Consultant on sixth day—Temp. 101 deg. P. 100—moist crepitations in lower lobes of both lungs, especially left—nothing in pelvis to indicate diagnosis of any form of puerperal sepsis—pulmonary condition regarded as primary— hospital treatment advised but refused. Mother and baby both died subsequently. 6. Primigravidae, age 40. Six days overdue—in Maternity Home—seen by Consultant after 30 hours' labour on account of (1) slow progress, (2) failure of head to descend into pelvis, (3) cedema of legs. Hyperpiesis 115/110 oliguria and haematuria— decided to continue treatment in home for 12 hours—six hours later labour was concluded successfully with forceps by the general practitioner. Birth of a live child. 7. Primigravidae, age 39. In labour 40 hours when seen by Consultant—presentation right occipito—transverse—head engaged —foetal heart, heard—membranes ruptured—-cervix three-fifths dilated—patient distressed more mentally than physically. Home conditions good—trained nurse in attendance—patient reassured— given one-third gr. Omnipon, 1/150 gr. Scopolomine—labour concluded successfully with forceps by general practitioner 17 hours later—living child. 8. Primigravida, age 19. Thirty-six weeks—fairly severe pre-eclamptic toxaemia (S.B.P. 170)—breech presentation with extended legs—seen by Consultant—immediate admission to hospital advised—living child born the following day. It is encouraging that this service is being used to an increasing degree by general practitioners, and particularly that in three of eight cases the advice of the Consultant was sought before the second stage of labour and therefore before any obstetrical interference had been undertaken. 133 Maternal Mortality. There were two maternal deaths of Leyton residents during the year. The death from puerperal septicæmia described under puerperal pyrexia is not included, as this patient was subsequently discovered to reside in another area. Of the two deaths, one was due to septicaemia following abortion. This has been discussed already under the Puerperal Fever cases. The second was due to peritonitis following abortion at 24 weeks. The details of the other deatli was as follows:— 1. Primigravidse, age 21. Home conditions poor. One year previously discovered to have sarcoma of femur—leg amputated at mid-thigh—married six months later—was advised by general practitioner against becoming pregnant—became pregnant almost immediately—sent to hospital when 13 weeks pregnant—termination of pregnancy not recommended—at 24 weeks developed Temp. 102 deg., sore throat, generalised aching—influenza diagnosed— ? labour pains started next day—sent to hospital—temp, fluctuated between 99.4 deg. and 103 deg.—occasional pains for five days after admission—regular labour pains started on fifth day, and patient developed an offensive discharge. The following day was delivered of a 61/2 months foetus and placenta—patient remained extremely ill and died three days later. Post mortem examination revealed toxic softening of myocardium, liver, kidneys, spleen. Peritoneum acutely inflamed throughout—slight "split" in pouch of Douglas— severe endometritis—no retained products—scanty deposits of hard fibrosarcoma in root glands—numerous flat deposits over the pleural membranes. MIDWIVES' ACTS, 1902-1926. Supervision of Midwives. During the year 37 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. Six independent midwives residing in the Borough and four resident outside the Borough notified their intention to practise in the area. Of these, two midwives did not undertake any cases during the year, 134 and five attended less than ten cases each. That is to say, the majority of cases attended by independent midwives were undertaken by three midwives resident in the Borough. Of 24 midwives (attached to the Essex County Nursing Association) who notified their intention to practice 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 other districts 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. Eleven such visits to the homes of midwives were made during the year. In addition, the Inspector made special visits to, or had interviews with, midwives on 19 occasions. Suspension of Midwives from Practice. During the year it was not necessary to suspend from practice any midwife practising in the area. Medical Aid. In accordance with the Rules of the Central Midwives Board, a midwife must notify the Local Supervising Authority within 36 hours of every occasion on which she sends for medical aid. Ninetyone such notifications were received and the following table shows the various complications for which medical assistance was summoned :— During Pregnancy. Ante-partum haemorrhage 6 Albuminuria 4 Pre-eclamptic toxaemia 1 Miscarriage 2 135 During Labour. Prolonged labour 11 Post-partum haemorrhage 3 Ruptured perineum 16 Retained placenta 3 Oedema of vulva 1 Breech presentation 1 Collapse following delivery 1 Stillbirth 1 Impacted shoulders 1 Prolapsed vaginal wall 1 Collapse before delivery 1 Uterine inertia 1 During Puerperium. General condition of mother 8 Rise of temperature 9 Conditions Associated with Infants. Feebleness of infant 3 Asphyxia 2 Discharging eyes 5 Infant cyanosed 1 Jaundice 2 Malformation of infant 2 Prematurity 3 Skin condition of infant 1 Unsatisfactory condition of baby—convulsed 1 Fees paid to Doctors under Section 14 (1) of the Mid wives Acts, 1918. Sixty-eight 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 were £ a. d. Fees of Medical Practitioners 98 1 6 Proportion recoverable 47 13 0 Nett cost to Local Supervising Authority £50 8 6 136 NUTRITION. 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, 1931-1936. Year. Pints of Fresh Milk. Packets of Dried Milk. Cost to Council £ s. d. 1932 88,002 758 1,143 5 5 1933 87,149 645 1,119 11 6 1934 64,727 498 845 9 9 1935 63,192 762 862 13 5 1936 64,624 356 757 12 8 Applicants Granted Free Milk During 1936. January 157 February 167 March 176 April 162 May 151 June 138 July 140 August and September 157 October 139 November 142 December 144 Meals for Expectant and Nursing Mothers. In June, 1935, the Minister of Health approved the Authority's scheme for the provision of meals to expectant and nursing mothers recommended for such extra nourishment by the Medical Officer of Health, the same scale of necessity to be applied as that in operation in connection with the assisted and free milk scheme. In October, 1936, the scheme was put into operation. The dietary, in the preparation of which a considerable amount of care was devoted by the Clinic Medical Officer (Dr. Menzies), 137 is such as will supply to expectant mothers those articles of diet which are found to be so often deficient, e.g., milk, egg yolk, green vegetables and fresh fruit. The meals are prepared and cooked in the Central Feeding Centre of the Local Education Authority, and transported in insulated containers to the two infant welfare centres at Park House and Leyton Green, where arrangements have been made for the meals to be consumed, between noon and 1 p.m. Since the scheme has been in operation some 209 meals have been provided to 6 expectant mothers. Report by Dr. Menzies. These six expectant mothers attended for varying periods of time. Four were regular in their attendance and apparently appreciated the meals provided, as they continued to attend every day (except Sunday) for 2-3 months. The remaining two were unsatisfactory. One attended for two days only, and failed to attend for the remainder of the week, although she was visited and promised to re-attend. The reason she gave was that she could not make arrangements for her only child of 12 months ; but as each mother is allowed to bring one young child with her, this cannot be accepted as the main reason. A second mother attended for two weeks only, and although she appeared to enjoy the meals she said it was too far for her to attend the clinic every day. She was then six months pregnant and had no obvious physical abnormality. She had three children, but her husband was said to be willing to look after them while the mother was out. It is admittedly unsatisfactory to take the mother away from her home at the time when her husband and children are returning for their mid-day meal, and it may be possible at a future date to provide the meal at an hour more convenient to the mothers. One or two mothers have suggested that if the meal was given at II a.m. it would be possible for them to take advantage of it. The difficulty of arranging this is that at one of the two centres, the room is in use for clinics on certain mornings of the week. From October until the end of the year the clinic medical officer suggested the necessity for meals to 16 expectant mothers, of the 16, only 4 accepted the offer of meals and attended regularly. 138 The low acceptance rate of 25 per cent. does not suggest great enthusiasm on the part of expectant mothers to avail themselves of the facilities provided. The commonest reason for refusing the offer was either that the school children in the family were not entitled to school dinners, or that they refused to take school dinners. One woman with eight children, whose husband was earning an inadequate wage as a labourer in the building trade, stated that her husband did not like the idea of his wife receiving free meals. As she had three children under five years, it was doubtful whether she would have been able to attend. Another woman stated that her husband was too jealous to allow her to have anything which he did not share. Even in the short time in which the scheme has been in operation it has been noted that a large family does not prevent a mother from attending—one of the regular attenders had five children, two of whom were under five years. In preparing the menus an effort was made to supply a variety of dishes, including articles of food which the average mother attending the clinic either does not use at all, or uses in small quantity. The most obvious examples are cheese and herring. These foods are both cheap and nourishing and could be used more in households where milk and meat are too costly. Cheese has been introduced in a number of the menus in conjunction with egg, fish (in sauce), potato or other vegetable. The only dish which has been refused by the mothers was tripe and onions, although one woman announced after two weeks that she would not be coming any more because her husband did not consider the food was what she ought to have—it was not nourishing enough. In other words, she was disappointed not to be offered meat and two vegetables every day. Later she decided to return and has attended regularly. School Medical Service. 140 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 1,750 1,599 91 Senior Girls' 7 1,761 1,589 90 Junior Boys' 4 1,096 1,004 92 Junior Girls' 4 1,082 990 91 Junior Mixed ... 6 2,022 1,844 91 Infants' 15 4,439 3,772 85 Non-provided (Mixed) 1 271 227 84 Central— Boys' Girls' 3 1,526 1,439 94 Mixed Totals 47 13,947 12,464f 89 Schools— Church of England — — — — Roman Catholic 1 271 227 84 Council 18 13,676 12,237 89 Totals 19 13,947 12,464f 89 * Ruckholt Central (Boys') and Ruckholt Central (Girls') Schools amalgamated into one School (Mixed) as from the 24th August, 1936. +Total average attendance for grant purposes—11,946. The figures given above relate to the financial year ended March 31st, 1937. During the financial year specified, attendances for a total of six sessions in the case of one Infants' Department were disregarded under Board of Education Regulations owing to the attendance falling below 60 per cent, in consequence of epidemic sickness. 141 Alterations and Additions to School Premises, JanuaryDecember, 1936. Canterbury Road S. B.—Painting of Dadoes, etc. Capworth Street Down sell Road Newport Road Sybourn Street Trumpington Road Church Road Davies Lane Farmer Road Goodall Road Mayville Road Norlington Road . Construction of Nursery Class Room, etc. Mayville Road.—Provision of new (playground) gateway. Church Road.—Adaptation of room as a flat for Domestic Science. Cann Hall Road J. B. & 1.—Replacement of wash-basins by modern type troughs. Newport Road I. Planing of floors. Sybourn Street J. M. Lea Bridge Road.—Replacement of wash-basins by modern type troughs. Goodall Road.—Improvement of Electric Lighting. Church Road Improvement of Latrines. Sybourn Street S. B. J Capworth Street.—Renewal of asphalt roof. Downsell Road. Renewal of boiler. Sybourn Street. Cann Hall Road S. B.—Redecoration of Exterior. Canterbury Road J. M. & I.-—Redecoration of Interior. Capworth Street.—Redecoration of Interior. Church Road J. G. & I.—Redecoration of Exterior. Goodall Road.—Redecoration of Exterior. Mayville Road.—Redecoration of Exterior. Norlington Road.—Redecoration of Interior. Newport Road I.—Redecoration of Interior. Mayville Road.—Improvements of Electric Lighting. Newport Road.—Improvements of Electric Lighting. 142 MEDICAL INSPECTION. A.—Routine Medical Inspection. This heading relates solely to the routine medical inspection of the three ordinary age groups, i.e., to medical inspection carried out:— (1) In compliance with Article 17 of the Consolidated Regulations relating to Special Services—Grant Regulations No. 19. (2) On the school premises (or at a place specially sanctioned by the Board). (3) For the purpose of making a report on each child on the lines of the approved schedule. Number of Inspections in the prescribed groups. Entrants 1,666 Second Age Group 1,260 Third Age Group 1,354 Total 4,280 It will be seen from the above that the number of such code group inspections was 4,280 representing 31 per cent, of the number of children on the school registers. Of 4,280 children who were examined in the code age-groups, 3,511 (or over 82 per cent.) were accompanied by their parents. 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 4,909, comparing with 3,804 during the previous year. 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 1936 was 13,109. 143 RETURN OF ROUTINE MEDICAL INSPECTIONS IN INDIVIDUAL SCHOOLS. School. Entrants. Second Age Group. Third Age Group. Code Group. Specials. Re-inspections. Code Group. Specials. Re-inspections. Code Group. Specials. Re-inspections. Canterbury Rd. 134 ... ... 97 12 242 70 10 231 Cann Hall Rd. 128 5 ... 71 8 181 83 4 231 Capworth St 133 9 ... 121 7 284 95 13 227 Church Road 103 9 7 65 43 203 79 20 219 Connaught Rd. ... ... ... 95 1 167 78 2 157 Da vies Lane 178 2 ... 106 1 298 102 4 300 Downsell Rd. 94 3 ... 68 10 272 75 11 271 Farmer Rd. 92 63 79 3 297 86 2 246 Goodall Rd. 93 3 ... 72 3 235 70 4 217 Kirkdale Rd 127 2 ... ... 1 40 ... ... 52 Lea Bridge Rd. 35 2 10 ... 3 32 ... 2 35 Mayville Rd. 115 3 ... 76 6 265 75 4 251 Newport Rd. 99 4 ... 109 8 231 75 10 254 Norlington Rd. 133 1 ... 84 8 212 61 4 249 Ruckholt Rd ... ... ... ... 5 148 128 6 113 Sybourn St. 105 4 ... 111 7 295 81 6 266 St. Joseph's 24 ... ... 25 2 51 26 4 43 TrumpingtonRd. 73 2 ... 81 9 188 74 10 230 Tom Hood ... ... ... ... 1 125 96 6 113 Knott sGreenS. S. ... ... ... ... ... ... ... ... 507 Totals 1666 49 80 1260 138 3766 1354 122 4212 The Findings of Medical Inspection. Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Defects of Nutrition, 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 1666 155 9.3 Second Age Group 1260 183 14.5 Third Age Group 1354 200 14.7 Total (Code Groups) 4280 538 12.5 144 Return of Defects found by Medical Inspection in the Year ended 31st December, 1936. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... 4 ... Body ... ... 14 ... Scabies ... ... 27 ... Impetigo 1 ... 120 ... Other diseases (non-T.B.) 1 1 182 ... Eye Blepharitis 12 1 78 ... Conjunctivitis 1 ... 51 ... Keratitis ... ... ... Corneal Opacities ... ... 6 ... Other conditions 11 2 176 ... Defective Vision 248 11 82 ... Squint 11 2 20 1 Ear Defective Hearing 8 9 27 3 Otitis Media 7 6 44 ... Other Ear Diseases 5 3 211 ... Nose & Throat Chronic Tonsiiitis only 60 108 78 6 Adenoids only 13 21 7 1 Chronic Tonsiiitis and Adenoids 47 35 101 1 . Other Conditions 21 5 110 ... Enlarged Defective Cervical Glands (non-T.B.) 16 18 66 1 Speech 6 1 l Heart and Circulation Heart Disease— Organic 8 28 11 l Functional 4 42 14 6 Anaemia 35 9 111 ... Lungs Bronchitis 15 48 74 2 Other non-T.B. Diseases 13 18 49 1 Tuberculosis Pulmonary— Definite 1 ... Suspected 3 5 ... Non-Pulmonarv— Glands 1 1 1 ... Bones and Joints 2 ... Skin ... ... Other Forms 1 ... 1 Nervous System Epilepsy 1 1 7 ... Chorea 2 7 2 Other Conditions 4 18 35 4 Deformities Rickets 1 1 ... ... Spinal Curvature 2 2 3 ... Other Forms 44 20 61 1 Other Defects and Diseases 49 36 1608 2 Totals 645 152 3394 34 145 CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN ROUTINE AGE GROUPS. Age Group. Number of Children Inspected. A (Excellent). t B (Normal). C (Slightly subnormal). D (Bad). Number. Per cent. Number. Per cent. Number. Per cent. Num. ber. Per cent. Entrants 1,668 279 16.7 1,282 77.0 97 5.8 8 0.5 Second Age Group. 1,260 244 19.3 863 68.5 153 12.1 — — Third Age Group 1,354 251 18.5 886 65.4 213 15.7 4 0.3 Other routine inspections — — — — — — — — — Total 4,280 774 18.1 3,031 70.8 463 10.8 12 0.3 Uncleanliness and Verminous Conditions.—At the special inspections held by the school nurses, 1,242 children were found to be unclean out of a total number of 33,458 examined (i.e., 3 per cent.) Cleanliness Surveys in Individual Schools. School. Number of Examinations. Number Cautioned. Number Excluded. Canterbury Road 2,691 15 7 Capworth Street 2,462 103 21 Cann Hall Road 1,997 38 13 Church Road 1,963 89 13 Connaught Road 1,689 13 10 Downsell Road 2,060 49 . 23 Davies Lane 2,853 50 34 Farmer Road 1,970 59 9 Goodall Road 2,486 105 27 Kirkdale Road 598 7 3 Lea Bridge Road 308 8 1 Mayville Road 1,985 159 53 Norlington Road 2.516 65 29 Newport Road 1,927 50 14 Ruckholt Road 655 6 — Sybourn Street 1,631 35 6 St. Joseph's 560 21 2 Trumpington Road 2,178 61 13 Tom Hood 408 3 — Knotts -Green 521 24 4 Total 33,458 960 282 Number of individual children found unclean 1,242 of whom 282 were referred to the Minor Ailments Clinics. 146 MEDICAL TREATMENT. Minor Ailments Clinic.—The schools in the area are served by two minor ailment clinics as follows :— Park House—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, Mayville Road, Tom Hood. 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. Attendances. During the year 2,820 (2,453) children attended the clinic, and 13,937 (12,144) attendances were registered. The increase in attendances may be judged by comparing these figures with those of the previous year, shown in brackets. Defects Treated. Ringworm of scalp 4 Ringworm of body 14 Scabies 26 Impetigo 119 Other skin conditions 178 Blepharitis 77 Conjunctivitis 51 Carried forward 469 147 Brought forward 469 Corneal opacities 6 Defective vision 37 Squint 9 Other eye conditions 171 Defective hearing 24 Otitis media 43 Other ear diseases 206 Chronic tonsiiitis 74 Adenoids 6 Chronic tonsiiitis and adenoids 93 Other throat conditions 100 Enlarged cervical glands 62 Organic heart disease 11 Functional heart disease 13 Malnutrition 61 Uncleanliness—Head 366 Anaemia 101 Bronchitis 72 Tuberculosis—Glands 1 Tuberculosis—Bones 2 Other non-tuberculous diseases of lungs 45 Epilepsy 7 Chorea 7 Other nervous diseases 34 Other deformities 63 Rheumatism 38 Debility 676 Defective speech 1 Miscellaneous (minor injuries, septic sores, etc.) 871 Tuberculosis—Pulmonary 1 Tuberculosis—Pulmonary (suspected) 5 3,675 148 Defective Vision.—Of the 4,280 children subjected to routine code group inspection in the schools, 283 (6.61 per cent.) were found to be suffering from some eye defect requiring treatment. Of the 4,909 children referred for special inspection, 413 (8.4 per cent.) manifested some eye defect requiring treatment. The nature and incidence of such defects were :— Routine Inspections. Special Inspections. Defect or Disease. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (2) (3) (4) (5) Blepharitis 12 1 78 — Conjunctivitis 1 — 51 — Keratitis — — — — Corneal opacities — — 6 — Other conditions 11 2 176 — Defective Vision 248 11 82 — Squint 11 2 20 — Special Eye Clinic.— During the year, the Ophthalmic Surgeon had referred to him 973 children, who made 1,289 attendances for examination and treatment. Report by the Council's Ophthalmic Surgeon (J. D. Magor Cardell, M.B., B.S., F.R.C.S.). The following list shows the ophthalmic defects found in the 973 children examined at the Special Eye Clinic. Myopia 148 Myopic astigmatism 152 Hypermetropia 102 Hyper astigmatism 273 Mixed astigmatism 23 Hypermetropia with squint 148 Myopia with squint 3 Carried forward 849 149 Brought forward 849 Squint only 49 Anisometropia 1 No defect 55 Spasm of accommodation 40 Various diseases 43 Referred to Minor Ailments Clinic 68 1,105 " Various diseases " included :— Keratitis 7 Diplopia 3 Congenital cataract 1 Epicanthus 2 Meibomean cyst 4 Injury to eye 2 Ptosis 2 Ophthalmia neonatorum 1 Migraine 15 Optic atrophy 1 Phlyctenular ophthalmia 5 43 The number of cases attended at the clinic maintains the average. A certain proportion of the cases of defective vision is due to the bad habit of reading and writing at too close a distance to the eyes. Such cases rarely require glasses and, indeed, should never have required attention. They obviously crowd out cases of more importance, and can be eliminated by attention to the habits of the children, though this is not so simple a matter as it appears. Taking all the cases in which myopia occurred, including mixed astigmatism, and expressing them as a percentage of the total school population, the figure is 2.4. Previous years show an average percentage of about 2. The percentage of squints among the school children of Leyton is 1.4, as against 0.9 over a period of 150 8 years. The health of the children's eyes is well shown by these figures for myopia and squint. We may take it that we need have no anxiety on this point. As it becomes more generally known that, by reason of the newly instituted Squint Training or Orthoptic Clinic, there are now facilities in the Borough which formerly could be obtained only in Central London, the numbers of cases with squint will probably rise. Squint Clinic. In my last Annual Report to the Authority I outlined the difficulties encountered by the Ophthalmic Surgeon in trying to make arrangements for Leyton children suffering from squint to attend at the Central London Ophthalmic Hospital for special treatment and training under his supervision. Following a special report, containing the observations of your Ophthalmic Surgeon, submitted by me in 1935, the Council decided to establish a special squint clinic for the treatment and training of children suffering from squint. The special clinic for the treatment and orthoptic training of children suffering from squint was established in June, 1936. Owing to the great number of new cases to be examined with a view to their classification and selection for appropriate treatment it was not possible to begin the actual orthoptic treatment and exercises until 7th September. Since that time the Council's Orthoptist (Miss P. Montague Smith), under the supervision of the Authority's Ophthalmic Surgeon, has held two sessions per week at Leyton Green Clinic. As each child's training in binocular vision requires at least twenty minutes at each attendance, it is not possible to deal with more than eight cases per session ; and, as the necessary treatment and training requires regular attendance twice a week over a period 151 of from three months to two years, it will be appreciated that it is not possible to deal thoroughly with a large number of cases per year. Both the Ophthalmic Surgeon and the Orthoptist require a very high standard of visual acuity and freedom from squint before any case is discharged cured ; and, during the short time the clinic has been in operation, only two children have been so discharged. Report by Orthoptist (Miss P. Montague Smith). The following figures show the number and disposition of cases dealt with at the special squint clinic from its inception (11.6.36) until the end of the year, i.e., over a period of some 6A months. Cases examined 62 Cases treated by orthoptic training 9 Cases treated for defective vision (amblyopia) 18 Cases unsuitable for treatment 3 Cases awaiting treatment 32 Attendances for treatment 325 Results of Treatment. Cured. Improved. Defective vision 6* 5 Squint 2 7 * These children, who have now been cured as regards defective vision, are now awaiting a course of orthoptic training ; and their number, when added to the 32 cases on the waiting list, makes a total of 38 children awaiting treatment. In those cases in which defective vision (amblyopia) exists in one eye, the good eye is covered and/or treated with atropin until the defective or " lazy " eye has learned to see properly. The patient is then ready for orthoptic exercises designed to strengthen the defective eye muscles and training both eyes to see simultaneously so that they will be able to superimpose into one single object the images seen by each eye. Each child receives from 20 to 30 minutes treatment twice weekly. 152 Of the 9 cases (treated with orthoptic exercises) mentioned above, 4 have had surgical operations on the eyes. In dealing with cases of this type it is advisable for the patient to have orthoptic training before operations in order that binocular vision may be acquired then. It has been found that the final results are much better than those obtained either by operation alone or by operation followed by—but not preceded by—orthoptic training. School Dental Service. The number of children inspected in school by the school dental surgeons was 9,083, i.e., 65 per cent, of the number of children on the school rolls. The numbers inspected in each age group were :— Aged 3 4 5 6 7 8 9 10 11 12 13 14 15 16 5 195 682 888 861 894 908 1,004 939 1,037 1,041 437 131 61 In addition, the School Dental Surgeons made 1,593 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 routine and special dental inspection during the year was therefore 10,676, i.e., 76 per cent, of the number of children on the school rolls. 153 Findings of Dental Inspection. The following table shows in statistical form the results of school dental inspection in individual schools and over the whole area. School. Number inspected. Number referred for treatment. Number accepting treatment. Percentage of acceptances. Boys. Girls. Boys. Girls. Canterbury 517 292 360 215 348 60.5 Cann Hall 562 99 354 51 228 56.3 Capworth ... ... ... ... ... ... Church 92 582 70 424 256 51.8 Da vies Lane 711 242 397 118 237 46.0 Downsell ... ... ... ... ... ... Farmer ... ... ... ... ... ... Goodall 112 685 56 378 249 57.3 Lea Bridge 39 55 28 43 39 54.9 Mayville 124 551 84 341 174 41.0 Newport 694 87 363 44 249 60.1 Ruckholt 272 249 182 188 215 58.1 Sybourn ... ... ... ... ... ... St. Joseph's 126 100 97 84 106 58.5 Tom Hood 230 190 124 100 122 54.4 Trumpington 159 467 89 265 185 52.2 Knotts Green 102 90 78 71 79 53.7 Norlington 135 734 116 594 529 74.5 Kirkdale 108 111 42 47 54 60.6 Connaught 429 137 262 88 192 54.8 4,412 4,671 2,702 3,051 3,262 56.7 It will be seen that, of the 9,083 children inspected, only 3,330 (36 per cent.) had perfectly sound sets of teeth, while 5,753 (63 per cent.) were found to require treatment. Of the 5,753 who were offered treatment, 3,262 accepted, the percentage of acceptance of treatment being 56 per cent. The figures show that in individual schools there is a considerable difference in the response of parents to the offers of skilled dental treatment on behalf of their children. For instance, in Norlington Road School the percentage of acceptances was as high as 74.5 per cent., whereas in Mayville Road School is was as low as 40.94 per cent. In 299 cases (5 per cent.) the parents actually refused treatment, while in 2,203 cases (38 per cent.) the acceptance of treatment papers were not returned by the parents. 154 The following figures give some idea of the dental treatment undertaken at the dental clinics during the year :— Fillings :— Permanent teeth 4,971 Temporary teeth 475 Total 5,446 Extractions :— Permanent teeth 1,282 Temporary teeth 4,789 Total 6,071 Other operations :— Permanent teeth 1,025 Temporary teeth 502 Total 1,527 Administrations of general anaesthetics for extractions—1,441. Orthopaedic Clinic. The following figures show the number of school children examined and treated during the last five years. Examinations. 1932 1933 1934 1935 1936 Primary examinations 110 118 115 105 99 Re-examinations 207 269 298 249 230 Treatment. 1932 1933 1934 1935 1936 Number of children who attended for 118 156 189 231 257 Attendances made 940 1,296 1,199 2,109 2,188 It will he seen that, during 1936, some 329 school children w ere examined or re-examined by the Council's Orthopaedic Surgeon, w ho attends on one session per month during the year. 155 The following is a summary of the work of the School Medical Service Orthopaedic Clinic during the year :— Primary Examinations 99 Re-examinations 230 The findings at the primary examinations were as follows Deformities—Bones and Joints. (a) Congenital— Synostosis—radius and ulna 1 Intra-uterine amputation arm (elbow joint) 1 (b) Acquired— Arthritis—shoulder 1 Deformity—digitis (foot) 3 Hammer toe 3 Genu valgum 6 Injury to feet 3 Bowed tibiae 1 Injury to digit (hand) 2 Hallux valgus 3 Old fracture—tibia 3 Old fracture—wrist 1 Exostosis digit (foot) 2 Muscular. (а) Congenital— Absence of pectoralis major 2 Talipes 2 Torticollis 2 Webbed digits (hand) 1 Flexion deformity digit (hand) 1 (б) Acquired— Scoliosis 6 Kyphosis 6 Kypho-lordosis 1 Pes cavus 1 Pes piano valgus 54 Paralysis. Congenital— Spastic hemiplegia 2 Old Erb's paralysis 1 150 Acquired— Anterior poliomyelitis 1 Also— Ganglion—wrist 3 Ganglion—foot 1 Baker's cyst 1 Fibroma 1 Injury to nail (hand) 1 Tabes mesenterica 1 Treatment. Number of school children attending for treatment 257 Number of attendances for treatment 2,188 During the year, 11 school children were admitted to hospital, and the following surgical operations were performed :— Osteotomy—tibia and plaster 1 Tenotomy-tendo achilles (right and left) 1 Tenotomy adductors (right and left) 1 Arthrodesis digit (2) foot 1 Arthrodesis scaphoid joints and plaster 1 Amputation digit (5) foot 1 Rotatory osteotomy—humerus (right) 1 Removal cervical rib (right and left) 1 Removal of fibroma—-hip 1 Removal ganglion—wrist 1 Laparotomy (tabes mesenterica) 1 Spinal manipulation and plaster bed 1 Surgical Appliances. The following have been supplied :— Caliper splint—leg 7 Iron and strap to boot 1 Surgical boots 3 singles Minor surgical alterations to boots, etc. 58 pairs Alterations and repairs to surgical boots and splints 2 pairs and 2 singles Alterations and repairs to splints and appliances 8 Insoles with valgus pad and stiffening 1 pair Crutches 1 pair 157 Artificial Sunlight Clinic. 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 Dr. Henderson (Deputy School Medical Officer). During recent years there has been a marked increase in the work of this clinic, as is evident from the following figures showing the numbers treated annually during the last five years. No. of Cases. No. of New Cases. Attendances. 1932 68 37 1,673 1933 70 29 2,174 1934 87 40 2,151 1935 110 74 3,310 1936 222 142 5,674 It will be seen that the number of children treated in 1936 was more than double that of the previous year. With the increase in the work of this clinic it has been impossible to devote to the children in attendance that amount of medical supervision which is considered desirable. In addition, the one mercury vapour lamp available is insufficient to deal effectively with the numbers attending for treatment. The following is Dr. Henderson's report on the school children treated during 1936. (Report by Dr. Henderson). Cases treated in 1936 222 New cases treated in 1936 142 Attendances in 1936 5,674 Of the 158 children who were re-examined after treatment, 136 (86 per cent.) had either improved or were cured. This is a 158 very satisfactory result. The following table gives these results Cured. Improved. Stationary. Worse. No data. Totals. Debility (including anaemia and malnutrition) 39 60 12 — 34 145 Bronchitis — 9 1 — 4 14 Asthma — 3 5 — 2 10 Boils — 1 — — 1 2 Styes and Blepharitis 10 5 1 — 12 28 Rhinitis — — 1 — — 1 Frequent colds — 2 — — 5 7 Nervous children 1 . 2 — — 1 4 Skin diseases — 2 1 — — 3 Adenitis — 2 — — 2 4 Muscular Rheumatism — — — — 3 3 Other conditions — — 1 — — 1 Totals 50 86 22 — 64 222 Of these 158 children, 99 came under the heading of " Debility." Artificial light treatment is an excellent tonic ; and in the case of debilitated children it often acts like a charm. The child who was listless and easily tired, pale, low-spirited and with a poor appetite becomes—after a course of treatment varying in length for different children—zestful and hungry, alert and happy. " Light " treatment is helpful and often curative in certain skin diseases (boils, styes, etc.), and in alopecia. Of the 18 children treated in 1936 for boils, styes and blepharitis, 10 were cured, 6 improved, and only 2 derived no benefit from the treatment. Of the 10 asthmatic children treated, 8 were re-examined and only 3 improved. In the case of these 3 children it was the child's general health that improved, the asthmatic condition being uninfluenced. Of the 14 children with bronchitis, 10 were re-examined and of these 9 had improved. It is unfortunate that, in the case of 64 children, no data were available at the end of the year. This group included those children who began treatment after October 31st, 1936 ; those who we re absent on the days of medical re-examination; and those who failed to complete the course of treatment. Nineteen children failed to complete the full course. It might be suggested that the se nineteen children ceased attending the clinic because their paren ts 159 observed no benefit resulting from the treatment. The fact is that these 19 children made so few attendances that the treatment was not given a fair trial. The following table gives the attendances made by these 19 children :— Number of attendances 0-5 6-10 11-15 16-20 Total. Number of children 8 8 1 2 19 During 1936, 95 children were discharged. Of these, 50 were cured, 20 improved, 6 showed no improvement and 19 failed to complete the course. No ill effects were shown by the children and, on the whole, the attendance was regular. A quartz mercury vapour arc lamp was used and treatment was given twice weekly. The initial dose was two minutes back and front, and the dose increased to a maximum of 10 minutes back and front. Given a suitable type of patient and regularity of attendance, artificial light treatment will produce results that are satisfactory. PHYSICALLY AND MENTALLY DEFECTIVE CHILDREN. Mentally Defective Children : Statutory Medical Examinations. During the year, some 62 children were referred for statutory medical examination. As the result of examination these 62 children were classified as follows :— Idiots 0 Imbeciles 5 Moral defectives 0 On attaining 16 years of age—-for supervision under the M.D. (Notification of Children) Regulations 4 Certified to Local Education Authority as feebleminded 14 Remained under certificate 7 Certificate withdrawn 1 Dull and backward 22 Backward 3 Borderline cases—-to be re-assessed in six months 6 62 160 Knotts Green Special School for Mental Defectives. Admitted 14 Discharged 20 On roll at end of year 86 Eleven children, certified to the Local Education Authority as feeble-minded, were admitted to Knotts Green Special School during the year and three children attending the Open Air School were transferred to the School for Mental Defectives. Of the 20 children whose names were removed from the roll, 8 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; 1 was allowed to leave on withdrawal of certificate of menta deficiency, 7 removed from the district, and 4 were notified to the Local Control Authority—three as imbeciles and 1 as ineducable. Physically Defective Children. Knotts Green Special School. Accommodation is provided for 150 physically defective children. Admitted during the year 47 Discharged 42 ,, —on withdrawal of certificates 20 „ —on removal from district 15 ,, —on reaching statutory leaving age 6 „ —unsuitable 1 On roll at end of year 150 161 The following table shows the types of physical defect, the number of children in each category, and the progress recorded in the cases of 149 children subjected to medical survey by Dr. P. Henderson (Deputy School Medical Officer) during the year. Defect. No. of Children. Improved. Stationary Worse. No Data. Total. Delicate children 22 15 1 — 6 22 Bronchitis 13 11 — — 2 13 Bronchitis and Malnutrition 10 6 1 — 3 10 Asthma 9 6 3 — — 9 Bronchiectasis 6 3 2 — 1 6 Fibrosis of Lungs 4 3 — 1 — 4 Subnormal Nutrition 19 16 — — 3 19 Quiescent Pulmonary Tuberculosis 1 — — — 1 1 Tuberculous adenitis 5 3 — — 2 5 Major Epilepsy 4 2 — 1 1 4 Minor Epilepsy 2 1 1 — — 2 Rheumatic Carditis 17 13 2 1 1 17 Chorea 5 5 — — — 5 Congenital Heart Disease 3 3 — — — 3 Nervous Children 1 — 1 — — 1 Severe Anæmia 2 2 2 Pernicious Anæmia 1 1 1 Exophthalmic Goitre 1 1 — — — 1 Hæmophilia 1 — — — 1 1 Skin Disease (Ichthyosis) 1 1 — — — 1 Orthopaedic Cases 22 15 — 3 4 22 149 107 11 6 25 149 Number of children improved 107 (71.8%) Number of children stationary 11 (7.3%) Number of children worse 6 (4.0%) Observations by Dr. P. Henderson. The heading "No Data" in the above table includes those children who entered the school after 30th September, 1936, those who were absent on the days of the medical re-examinations and those who left the district before they were re-examined. If the 25 children for whom no data are available are deducted from the total number (149) of children attending the Open Air School during 1936, it is found that of the remaining 124 children, 86.2% improved, 8.8% remained stationary and 4.8%were worse. 162 It is interesting to compare these figures with those of previous years and the following table gives this information (children for whom no data were available were omitted from the calculations) :— 1932 1933 1934 1935 1936 Percentage improved 63.7 59.0 68.6 75.5 86.2 Percentage stationary 34.9 36.3 26.1 18.3 8.8 Percentage worse 1.3 4.5 3.2 6.1 4.8 Thus, for the past five years, there has been a steady increase in the number of children attending the school whose physical condition improved, a steady decrease in the number whose condition remained stationary, whilst the number whose physical condition deteriorated has remained fairly constant at about 4 per cent. Most of the children gain weight steadily during their stay at the school and the gain is usually substantial. The following table shows the average monthly gain in weight (ounces) made by the children in the main disease groups :— Monthly gain in ounces. Bronchitis 13 Chorea Rheumatic Carditis 12 Malnutrition 11 Deformities Asthma 10 Bronchiectasis Delicate children 9 T.B. Adenitis 7.5 Bronchitis and Malnutrition 7 It is a striking fact that children with bronchitis do much better than those who, in addition to suffering from chronic bronchitis, are also undernourished. Even though the undernourished child who suffers from bronchitis gains less than his fellows, his physical condition does improve during his attendance at the open air school. The children with rheumatic carditis who attended the school in 1936 did surprisingly well. Children with inactive rheumatic infection only are admitted to the school; occasionally, a doubtful case is met with and the child is sometimes given a trial at the open 163 air school. During 1936 there was one such child : she became worse and was admitted to hospital. Throughout the country there is some difference of opinion as to whether a child with rheumatic carditis does well at an open air school. The following extract from " The Health of the School Child," 1935, is of interest in this connection :—At the London County Council's Queen Mary's Hospital, Carshalton, 300 rheumatic children sleep on verandahs in full open air conditions, both winter and summer, and day and night, with almost complete freedom from colds and infectious diseases." The experience, in Leyton, is that children with inactive rheumatic disease of the heart do well in an open air school. There is no demonstrable change in the heart lesion but the general health of the child improves greatly. Care in the selection of rheumatic children for admission to the open air school is, perhaps, the essence of the problem. That 86 per cent. of the children medically re-examined greatly improved in health is a sufficient indication of the need for, and value of, the Open Air School. Defective Children. Blind and Partially Blind Children. One child left a day special school for myopic children on attaining the statutory leaving age, and one on removal from the area. One child died. Responsibility ceased in the case of a child at a residential blind school on removal of the parents from the area. Four children were admitted to a residential ophthalmic school, and 3 discharged. Deaf and Dumb Children. One child was admitted to a day special school for deaf children, and 2 to a residential deaf school. One child left a day special school for deaf children on attaining the statutory leaving age. Epileptic Children. One child was discharged from an Epileptic Colony on attaining the statutory leaving age. 164 Convalescent Home Treatment. During the year under review the Education Committee accepted responsibility for the cost of maintenance and treatment of 48 children in convalescent homes, heart homes or open air schools recognised by the Board of Education. In addition, 64 children attending Leyton schools were sent away for varying periods through the agency of the Tuberculosis Care Association and 64 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 to the Education Authority of educating the undermentioned types of children. Per Child. Rate Cost Per Child. (1) Cost in Leyton Elementary Schools (based on average attendance) £18 15 8 £9 13 7 (2) Blind Child— (i) In Special Day School(a) £20 0 0 £20 0 0 (ii) In Special Residential School(a) £74 0 0 £37 0 0 (iii) In Residential Ophthalmic School (a) £144 14 8 *£73 0 0 (3) Deaf Child— (i) In Special Day School (a) £26 6 6 £26 6 6 (ii) In Special Residential School (a) £75 0 0 £37 10 0 (4) Defective Child— (i) In Knotts Green Special School (b) £32 16 6 £16 8 3 (ii) Mentally Defective Child in Residential Institution(a) £61 0 0 £30 10 0 (iii) Child in Epileptic Colony (a) £71 4 10 £36 12 5 (iv) Child receiving Residential Orthopaedic Treatment (a) £70 0 0 £35 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. * Estimated. 165 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 (6) 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 „ „ 1934 73 „ „ 1935 136 „ „ 1936 141 „ „ 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:— 1932 356 1933 303 1934 323 1935 327 1936 305 The number of individual children fed under the Authority's arrangements during 1936 was as follows :— Ordinary Meals. Milk Meals. Free 544 1101 For payment 50 — Totals 594 1101 166 Number of meals supplied :— Ordinary Milk Meals. Meals. Free 77,654 237,966 For payment 4,519 — Totals 82,173 237,966 The above figures relate to the financial year ended 31st March, 1937. STATISTICAL APPENDIX. TABLE I.—Returns of Medical Inspections. A. Routine Medical Inspections. Number of Code Group Inspections :— Entrants 1,666 Second Age Group 1,260 Third Age Group 1,354 Total 4,280 B. Other Inspections. Number of Special Inspections 4,909 Number of Re-inspections... 13,109 Total 18,018 C. Children Found to Require Treatment. Number of individual children found at Routine Medical Inspection to require treatment (excluding defects of Nutrition, Uncleanliness and Dental Diseases). Group. For Defective Vision (excluding Squint). For all other Conditions recorded in Table II.A. Total. Percentage of children found to require Treatment. Entrants 17 138 155 9.3 Second Age Group 91 92 183 14.5 Third Age Group 140 60 200 14.7 Total (Prescribed Groups) 248 290 538 12.5 Other Routine Inspections — — — — Grand Total 248 290 538 12.5 167 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1936. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... 4 ... Body ... ... 14 ... Scabies ... ... 27 ... Impetigo 1 ... 120 ... 'Other diseases (non-T.B.) 1 1 182 ... Eye Blepharitis 12 1 78 ... Conjunctivitis 1 ... '51 ... Keratitis ... ... ... Corneal Opacities ... ... 6 ... Other conditions 11 2 176 ... Defective Vision 248 11 82 ... Squint 11 2 20 ... Ear Defective Hearing 8 9 27 ... Otitis Media 7 6 44 ... Other Ear Diseases 5 3 211 ... Nose & Throat Chronic Tonsilitis only 60 108 78 6 Adenoids only 13 21 7 1 Chronic Tonsilitis and Adenoids 47 35 101 1 Other Conditions 21 5 110 ... Enlarged Defective Heart and Circulation Cervical Glands (non-T.B.) 16 18 66 1 Speech 6 ... 1 1 Heart Disease— Organic 8 28 11 1 Functional 4 42 14 6 Anæmia 35 9 111 ... Lungs Bronchitis 15 48 74 2 Other non-T.B. Diseases 13 18 49 1 Tuberculosis Pulmonary— Definite ... ... 1 ... Suspected ... 3 5 ... Non-Pulmonary— Glands 1 1 1 ... Bones and Joints ... ... 2 ... Skin ... ... ... ... Other Forms ... 1 ... 1 Nervous System Epilepsy 1 1 7 ... Chorea ... 2 7 1 Other Conditions 4 18 35 4 Deformities Rickets 1 1 ... ... Spinal Curvature 2 2 3 ... Other Forms 44 20 61 1 Other Defects and Diseases 49 36 1,608 2 Totals 645 452 3,394 34 168 TABLE II—B. Classification of the Nutrition of Children Inspected during the Year in the Routine Age Groups. Age Groups. No. of Children Inspected. A. (Excellent). B. (Normal). C. (SlightlySubnormal). D. (Bad). No. % No. % No. % No. % Entrants 1,666 279 16.7 1,282 77.0 97 5.8 8 0.5 Second Age Group 1,260 244 19.3 863 68.5 153 12.1 — — Third Age Group 1,354 251 18.5 886 65.4 213 15.7 4 0.3 Other Routine Inspections — — — — — — — — — Total 4,280 774 18.1 3,031 70.8 463 10.8 12 0.3 TABLE III. Return of all Exceptional Children in the Area. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 1 — — — 1 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted At Public Elomentary Schools. At other Institutions. At no School or Institution. Total — 17 1 1 — 19 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 9 — — — 9 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 — 2 — — — 2 MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 86 — 5 — 91 169 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 6 2 — — 8 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 Institutions. At no School or Institution. Total. — 0 — 1 7 II.—Children Suffering from Non-Pulmonary Tuberculosis. (This category should include tuberculosis of all sites other than those shown ii (I) above.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 20 10 — 31 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools.' At other Institutions. At no School or Institution. Total. 93 — — — 93 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 27 8 1 1 37 170 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 19 3 1 5 28 Children Suffering from Multiple Defects. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At School or Institution. Total. Feeble Minded and Epileptic 1 — — — 1 Feeble Minded and Crippled 1 — — — 1 Crippled and Epileptic 1 — — — 1 TABLE IV.—Return of Defects Treated during the Year ended 31st December, 1936. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Table VI) • Disease or Defect. (1) Number of Defects treated or under treatment during the year. Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) Skin— Ringworm- Scalp— (1) X-ray treatment.. 3 — 3 (2) Other 1 — 1 Body 14 — 14 Scabies 26 1 27 Impetigo 118 — 118 Other skin diseases 174 1 175 Minor Eye Defects—(External and other, but excluding cases falling in Group II.) 220 — 220 Minor Ear Defects 253 — 253 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 1147 2 1149 Total 1,956 4 1,960 171 TABLE IV.—contd. Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments.—Group I.). Defect of Disease. (1) Number of Defects dealt with. Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) Errors of refraction (including squint) 899 25 924 Other defect or disease of the eyes (excluding those recorded in Group 1.) 44 — 44 Total 943 25 968 Under the Authority's Scheme. Otherwise. Total. No. of Children for whom Spectacles were :— (a) Prescribed 670 25 695 (6) Obtained 663 32 695 TABLE IV.—cod. 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. (J) 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) 79 8 33 2 24 3 3 3 103 11 36 5 294 449 (1) Tonsils only. (2) Adenoids only. (3) Tonsils and adenoids. (4) Other defects of the nose and throat. 172 TABLE IV.—contd. Group IV.—Orthopaedic and Postural Defects. Under the Authority's Scheme. Otherwise. Residential treatment with education. (1) Residential treatment without education. (2) Non-residential treatment at an orthopaedic clinic. (3) Residential treatment with education. (1) Residential treatment without education. (2) Non-residential treatment at an orthopaedic clinic. (3) Total number treated. No. of children treated 9 2 253 — — 4 261 TABLE V. Dental Inspection and Treatment. (1) Number of children who were :— (a) Inspected by the Dentist:— Age Groups Aged ( Total 9,083 3 5 4 195 5 682 6 888 7 861 8 894 9 908 10 1,004 11 939 12 1,037 13 1,041 14 437 15 131 16 \ 61 / Specials (Casuals) ... ... 1,593 Grand Total 10,076 (b) Found to require treatment ... ... ... 5,753 (c) Actually treated ... ... ... ... ... 4,381 (2) Half-days devoted to Inspection 45 Treatment 742—Total ... 787 173 (3) Attendances made by children for treatment 7,646 (4) Fillings, Permanent Teeth 4,971 Temporary „ 475—Total 5,446 (5) Extractions, Permanent Teeth 1,282 Temporary ,, 4,789—Total 6,071 (6) Administrations of general anaesthetics for extractions 1,441 (7) Other operations, Permanent Teeth 1,025 Temporary ,, 502—Tota 1,527 TABLE VI. 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 33,458 (3) Number of individual children found unclean 1,242 (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 — 174 STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1936, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total number of children notified: 16. 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 — — (6) Imbeciles 2 2 (c) Others 1 (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 8 3 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 10 6 175 INDEX. PAGE Section A. Statistics and Social Conditions of the Area 9/30 „ B. General Provisions of Health Services for the Area 31/41 ,, C. Sanitary Circumstances of the Area ... 42/48 ,, D. Housing 48/60 ,, E. Inspection and Supervision of Food. 61/70 ,, F. Factories and Workshops . 70/73 „ G. Prevalence of, and Control over Infectious Diseases 73/101 Isolation Hospital 102/108 Maternity and Child Welfare 109/138 School Medical Service 139/174 PUBLIC HEALTH. Acts, Adoptive 33 Adulteration 70 Ambulance service 33 Ante-natal Clinics 122 ,, ,, Abnormal Cases 124 Artificial Sunlight Treatment, M. & C. W. 115 Bacteriological Examination 100 Bakehouses 69 Baths—Swimming 37 Births. 15 Bye-laws and Regulations 34 Cancer 99 Children and Young Persons Act 122 Clinics and Treatment Centres 31 Convalescent Home Treatment 117 Dairies and Milkshops 61 Deaths 19 ,, Maternal 23, 128 ,, Infantile 22,119 Demolition Orders 58 Dental Treatment, M. & C. W. 112 Diabetes—Supply of Insulin 100 Dining Room and Restaurants 69 Diphtheria 89, 106 „ Immunisation. 90 Diseases of Animals Acts 70 Drainage 45 Enteric Fever 73 176 PAGE Factories and Workshops 70 Foods, Inspection of 61 Foster Mothers 46 Foot Clinic 38 Hairdressers 46 Health Visitors, Visits 112 Home Helps 128 Hospital Provision 32 House to House Inspection 60 Housing Statistics 56 Housing Act 1935 48 Ice Cream 64 Infant Welfare Clinics 110 „ „ „ Attendances 111 „ Mortality 22,119 ,, Life Protection 122 Infectious Diseases 73 Inquests 36 Insulin, Supply of 100 Isolation Hospital 102 Legislation in force 33 Massage Establishments 37 Maternal Morbidity and Mortality 23,128 Maternity Beds 127 Meals for Expectant Mothers 136 Measles 93 Meat Inspection 65 Meteorology 11 Midwives 133 ,, Fees paid to Doctors 135 „ Medical Aid 134 ,, Supervision of 133 Milk, Scheme for Supply of 136 Mortuary 35 Neo Natal Mortality 119 Notification of Births 110 Nursing Homes 128 Nutrition 136 Obstetric Consultant 131 Offensive Trades 69 Ophthalmia Neonatorum 119 Ophthalmic Clinic (M. & C. W.) 114 Orthopaedic Clinic (M. & C. W.) 113 Overcrowding 56 Overcrowding Survey 48 177 PAGE Petroleum Acts 46 Pharmacy and Poisons Act 47 Population 9 Public Cleansing 42 Puerperal Fever 128 „ Pyrexia 130 Public Houses 69 Rag and Flock Act 46 Rats and Mice Destruction Act 48 Refuse Collection 43 ,, Dumps 44 Rent Restriction Act 60 Restaurants and Dining Rooms 69 Sanitary Inspectors Visits 44 Scarlet Fever 73,103 ,, ,, Current Methods of Control 74 ,, ,, Complications amongst Patients in Isolation Hospital 104 Scavenging 42 Schools 47 Shops Act, 1934 47 Slaughter Houses 65 Smoke Abatement 47 Social Conditions 10 Staff 3 Stillbirths 10,125 Swimming Baths 37 Tuberculosis 95 Toddlers' Clinic 115 Unsound Food 66 Verminous Premises 45 Voluntary Workers 110 Water Supply 42 TABLES. Table 1—Meteorology 13/14 „ 2—Births 18 „ 3—Deaths 24 „ 4—Comparative Statistics 28 „ 5—Vital Statistics of Whole District 29 ,, 6—Analysis of Mortality 30 ,, 7—Overcrowding Survey 53 „ 8— „ „ 54/55 178 page Table 9—Scarlet Fever. Analysis of Contact Rates, Hospital Treated and Home Treated Cases 82 ,, 10—Scarlet Fever. Incidence of Return Cases 84 ,, 11—Infectious Disease Notifications 101 „ 12—Infant Welfare Clinic Attendances 11l ,, 13—Infant Mortality 120,121 SCHOOL MEDICAL SERVICE. Accommodation 140 Artificial Sunlight Clinic 157 Blind Children 163 Convalescent Home Treatment 164 Deaf Children 163 Defective Vision148 Dental Treatment 152 Employment of Children 165 Eye Clinic 148 Knotts Green Special School 160 Malnutrition 145 Meals, Provision of 165 Medical Inspection 142 ,, Treatment 146 Mentally Defectives 159 Milk Meals 165 Minor Ailments Clinic 146 Orthopaedic Clinic 154 Ophthalmic Clinic 148 Physically Defective Children 160 School Population and Attendance 140 ,, Premises—Alterations and Additions 141 Squint Clinic 150 Statistical Tables 166 Uncleanliness 145