3650 leytonstone. AC 4411 (1) LEYTON LEY 60 H Borough of Leyton. HEALTH REPORT FOR THE YEAR 1937. 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 7. HIS WORSHIP THE MAYOR (Alderman Mrs. Shimmin, J.P.), ex-officio Member of Committees. PUBLIC HEALTH COMMITTEE: DISEASES OF ANIMALS ACT COMMITTEE. Chairman: Councillor Cochrane. Members: Alderman Bechervaise. Councillor Dicker. „ Hinton, J.P. „ Flack. „ Russell, J.P. „ Mrs. Hammond. „ Shimmin, B.Sc. „ Hawkins. Councillor Barber. „ Hurry. „ Bass. „ Mrs. Mawer. „ Bell. „ Rayner. „ Biles. „ Rioo. „ Bourne. „ Snell. „ Bull. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman: Councillor Mrs. Mawer. Members: Alderman Bechervaise. Councillor Mrs. Hammond. „ Fitzgerald. „ Hawkins. „ Russell, J.P. „ Hurry. „ Turner. „ Shore. Councillor Bussey. „ Spink. „ Gowar. Co-opted Members : Mrs. Cochrane. Mrs. Sortwell. „ Martin. „ Scarff. „ Mott. EDUCATION COMMITTEE. Chairman: Alderman Bechervaise. Members: Alderman Allanson, J.P. Councillor Cochrane. „ Fitzgerald. „ Mrs. Hammond. „ Hinton, J.P. „ Hawkins. „ Russell, J.P. „ Hurry. „ Shimmin, B.Sc. „ Mrs. Mawer. „ Turner. „ Mills. Councillor Bass. „ Pearce. „ Bell. „ Snell. „ Bussey. „ Spink. Co-opted Members: Mrs. Cochrane. Mrs. Waller. „ Crown. Mr. G. A. Grime. „ Ringer. „ L. Levy. EDUCATION WELFARE SUB-COMMITTEE. Chairman: Councillor Mrs. Hammond. Members: Alderman Fitzgerald. Councillor Spink. „ Hinton, J.P. Mrs. Cochrane. „ Russell, J.P. „ Crown. ,, Turner. „ Ringer. Councillor Bussey „ Waller. „ Hawkins. Mr. G. A. Grime. „ Hurry. „ L. Levy. „ Snell. 3 Borough of Leyton. PUBLIC HEALTH OFFICERS OF THE AUTHORITY. A. MEDICAL—Whole Time. *Forrest, Andrew W., MA., M.D., M.B., Ch.B., D.P.H., Medical Officer of Health, School Medical Officer, Medical Superintendent of Isolation Hospital. *Henderson, Peter, M.D., M.B., Ch.B., D.P.H., Deputy Medical Officer of Health and Deputy School Medical Officer. *Menzies, Hilda F., M.D., M.B., Ch.B., D.P.H., Assistant Medical Officer of Health (Maternity and Child Welfare). *Gilchrist, Mary Lyle, M.D., M.B., Ch.B., D.P.H., Assistant Medical Officer of Health. MEDICAL—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. B. DENTAL SURGEONS. *Horton, James Ernest, L.D.S., R.C.S. (Eng.) 1 School Dentists *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. C. SANITARY INSPECTORS. Senior Sanitary Inspector. *Gray, Edward Henry, Certificate R.S.I., Meat Inspector's Certificate R.S.I. Sanitary Inspectors. *Steeden, Edward James, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Smith, Victor Wynn, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *Reeves, Reginald Alfred, Certificate R.S.I., Meat Inspector's Certificate R.S.I. *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. D. NURSING STAFF. Matron, Borough Isolation Hospital. Ryan, Miss E. Health Visitors. *Bratton, Maud, S.R.N. *Walling, Ethel Winifred, S.C.M., S.R.N., Health Visitor's Certificate R.S.I. *Kittering, Margery, S.C.M., S.R.N., Health Visitor's Certificate R.S.I. *Sizer, Agnes, S.R.N., S.C.M., Health Visitor's Certificate R.S.I. *Neale, Barbara, S.R.N., S.C.M., Health Visitor's Certificate R.S.I. School Nurses. *Crawford, Daisy, S.R.N., Health Visitor's Certificate R.S.I. *Sykes, Martha, S.R.N. *Maye, Marie, S.R.N., Health Visitor's Certificate R.S.I. *Fulcher, Joan, S.R.N. (Resigned 14.10.37). *Edwards, Ruth, S.R.N., S.C.M. *Stiles, Eleanor, S.R.N., S.C.M. *Corby, Elizabeth, S.R.N. Municipal Midwives. Roberts. Elizabeth, S.R.N., S.C.M. Daies, Emily, S.R.N., S.C.M. Dodsworth, Daisy, S.C.M. 4 E. OTHER STAFF. Masseuse. *Findlay, Miss A. E., Cert. Chartered Society of Massage, etc. Chiropodists. O'Brien, John, M.I.S.Ch. Stokes, Miss Florence, M.I.S.Ch. Orthoptist. *Smith, Miss Glennis. F. CLERICAL STAFF. Chief Clerk. *Leserve, George Frederick. Clerks. Jacobs, E. E. Softley, W. D. Brighting, G. Halsey, C. S. Freeman, A. L. Thurlow, G. Clarke, J. Ware, F. *Hayes, Miss A. *Payne, Miss W. * Proportion of Salary contributed under Public Health Acta or by Exchequer Grants. 5 TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF LEYTON. Mb. 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 1937, 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. In previous years I have endeavoured to include in this preamble to my Report a short survey of matter contained in the following pages; but with the ever-increasing scope and duties of the public health, maternity and child welfare, and school medical services it has become more difficult and more invidious to select material for such an introductory survey. The following pages contain of necessity much information in the form of figures and facts required by the Ministry of Health and the Board of Education ; but they also contain general observations—and special reports contributed by members of the medical staff—on many aspects of your medical and health services which are of current interest and merit special attention. On pages 238 to 241 at the end of the Report will be found an index designed to facilitate easy reference. On 30th July, 1937, your Council, as the Local Supervising Authority under the Midwives Acts, put into operation its proposals for the establishment of a domiciliary service of whole-time salaried midwives in the area in accordance with the provisions of the Midwives Act, 1936; and on 1st September your Education Authority took over from the Essex County Council the duties and responsibilities pertaining to the medical and dental examination and treatment of pupils attending County Secondary Schools and Institutions for Higher Education in the area. Detailed reports regarding these new services are submitted. 6 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. The compilation of a comprehensive Report such as this involves a great amount of statistical work and close attention to detail, and I take this opportunity of expressing my appreciation of the most valuable assistance rendered by the Chief Clerk (Mr. G. F. Leserve) and the members of the clerical staff. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, 7 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, 1937) 118,100 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 £779,390 Sum represented by a penny rate for General Rate purposes (as from 1st April, 1938) £3,089 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 8 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:— Males. Females. Total. Birth Rate per 1,000 population. Legitimate 735 654 1,389 12.02 Illegitimate 12 19 31 747 673 1,420 Males. Females. Total. Rate per 1,000 total (live and still) births. Stillbirths 34 26 60 40.54 Males. Females. Total. Death Rate. Deaths 684 665 1,349 11.42 Number of women dying from diseases and accidents of pregnancy and childbirth:— Rate per 1,000 total (live and still) births. From Sepsis 2 1.35 From other causes 1 0.67 Total 3 2.02 Death Rate of Infants under One year of age:— All infants per 1,000 live births 52.81 Legitimate infants per 1.000 legitimate live births 51.83 Illegitimate infants per 1,000 illegitimate live births 96.77 Deaths from Cancer (all ages) 196 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) 2 Deaths from Diarrhoea (under 2 years of age) 8 9 METEOROLOGICAL CONDITIONS, 1937. The weather of the year 1937 was wet and dull with the mean temperature above the average. The summer was warm and dry with a marked deficiency of sunshine in July. Rainfall. Amount in inches. Average annual amount in inches. London,1937 28.79 London, 1881-1915 23.24 Country as a whole, 1937 33.48 Country as a whole, 1881-1915 29.6 In London, the rainfall was 5.5 inches above the average. July was exceptionally dry and February was exceptionally wet. Snow fell on 23 days and hail on 6 days. There were no gales; thunder was heard on 16 days and there was fog on 41 days. Sunshine. Average daily sunshine. Average daily sunshine. London,1937 3.12 hours London, 1906-1935 3.94 hours Country as a whole. 1937 3.66 hours Country as a whole, 1881-1915 4.12 hours In London, sunshine was below the average in every month of the year. June was the sunniest month, with a daily average of 5.72 hours of sunshine. Temperature. Average temperature. Average annual temperature. London,1937 51.1° F. London, 1906-1935 50.5° F. Country as a whole. 1937 48.9° F. Country as a whole, 1881-1915 48.5° F. In London, the mean temperature was below the average only in March, November and December. The mean temperature of the year was 51.5 degrees Fahrenheit—0.6 degrees Fahrenheit above the average of previous years. March was exceptionally cold. August 6th was the hottest day with a maximum temperature of 92 degrees Fahrenheit and the coldest days were March 10th and November 21st when a minimum temperature of 24 degrees Fahrenheit was recorded. TABLE 1.—METEOROLOGICAL TABLE FOR LONDON, 1937. (Deduced from Observations at Greenwich, under the. Superintendence of the Astronomer Royal.) 1937. 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 1 foot depth. At 4 feet depth. Dally Mean. Percentage of Average.† | Per cent. of Possible. Maximum. A Minimum. B Maximum. Day of Month. Minimum. Day of Month. Dry Bulb. Depression of Wet bulb. Vapour Pressure. Humidity. mb. °F. °F. °F. °F. °F. °F. °F. °F. mb. % °F. °F. hr. hr. % January 1003.9 46.8 36.3 41.5 + 1.4 53 3, 6, 24 28 29 41.5 1.3 8.1 89 43.2 45.7 1.18 96 14 February 997.1 48.6 37.8 43.2 + 2.8 57 15 29 12 42.7 1.9 7.9 83 43.0 44.8 1.49 72 15 March 998.8 46.9 33.4 40.1 -3.1 61 20 24 10 39.3 2.1 6.6 80 41.0 43.5 2.96 87 25 April 1005.1 57.5 42.0 49.7 + 2.2 65 3 31 1 48.2 2.4 9.5 83 47.3 46.2 2.73 59 20 May 1010.8 65.1 46.7 55.9 + 1.1 82 25,29 39 6 54.7 3.5 11.5 79 52.5 50.1 5.08 81 33 June 1012.4 71.1 50.2 60.7 + 1.0 85 11 43 21 59.8 4.7 12.8 73 57.8 54.8 5.72 85 35 July 1001.6 73.7 55.3 64.5 + 1.0 89 15 49 30 63.1 4.7 14.8 75 60.3 57.1 3.80 60 24 August 1012.6 77.1 55.9 66.5 + 3.5 92 6 47 16 63.9 3.9 16.1 79 61.6 58.9 5.54 92 38 September 1008.2 68.0 48.9 58.8 + 0.4 83 7 38 21 56.9 3.0 13.1 82 58.5 58.7 4.82 96 38 October 1009.5 59.1 45.6 52.3 + 1.0 69 1.2 36 18 51.4 1.7 11.4 88 54.1 55.7 2.61 81 24 November 1011.4 47.1 36.1 41.6 —1.9 57 4 24 21 41.5 1.1 8.2 90 47.4 51.4 1.04 66 12 December 1005.9 42.3 34.2 38.3 —2.8 53 1,23 25 20 38.3 0.9 7.3 91 42.4 46.1 0.44 45 6 Year 1007.2 58.6 43.5 51.1 +0.6 92 Aug. 6 24 Mar. 10 Nov. 21 50.1 2.6 10.6 83 50.8 51.1 3.12 79 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 (1906-1935). those of rainfall are for the 35 years (1881-1915). Pressure is expressed in millibars (1000 Mb.=29.531 mercury-inches). 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. 10 TABLE 1—continued. 1937 Cloud. Rain and other forms of Precipitation. Weather Number of days of Wind. Number of Observations at 9 a.m., 3 p.m. and 9 p.m. Mean of Observations of amount at 9 a.m. and 9 p.m. (Scale 0-10). Total Fall. Percentage from Average. † Most in a Day. Precipitation (0.2 mm. and above). Precipitation (1 mm. and above). Snow. Hall. Thunder heard Persistently Clear. Generally Clear. ‡ Generally Overcast.‡ Persistently Overcast. Fog at 9 a.m. Gale. Force. Direction. Amount. Day of Month. Gale Moderate and Strong Wind Calm. N. N.E. E. S.E. S. S.W. W. N.W. January 7.5 86 201 mm. 13 1 25 17 3 0 0 0 3 18 4 6 0 0 92 1 3 7 9 7 25 24 14 3 February 6.9 100 251 18 7 22 18 1 2 0 0 0 12 0 2 0 0 84 0 6 0 1 7 9 30 22 9 March 6.4 74 168 17 6 18 13 12 1 0 0 0 13 2 1 0 0 90 3 14 19 11 5 14 12 8 7 April 7.7 62 167 12 2 14 12 0 0 1 0 1 18 3 4 0 0 83 7 13 9 10 4 11 15 11 10 May 6.9 87 197 18 20 14 12 0 1 2 0 0 15 1 1 0 0 86 7 9 12 19 5 11 13 14 3 June 6.6 48 93 20 18 11 6 0 0 4 0 1 12 0 0 0 0 84 6 14 6 7 4 5 22 11 15 July 7.5 18 32 9 15 9 4 0 0 3 0 0 16 0 0 0 0 90 3 8 6 5 0 9 28 22 12 August 5.4 43 77 26 30 8 5 0 1 4 0 3 9 1 0 0 0 81 12 17 8 12 4 8 13 8 11 September 5.2 32 72 6 9 14 11 0 0 1 0 3 9 1 2 0 0 88 2 15 1 2 6 17 28 9 10 October 6.7 59 92 15 23 14 8 0 1 1 0 1 8 0 5 0 0 86 7 20 15 6 7 17 9 9 3 November 5.7 35 59 12 1 8 7 0 0 0 0 2 8 3 13 0 0 82 8 13 9 17 12 5 14 8 4 December 8.4 87 152 17 2 19 10 7 0 0 0 0 23 4 7 0 0 81 12 17 14 6 2 14 16 8 4 Year 6.7 731 122 26 Aug. 30 176 123 23 6 16 0 14 161 19 41 0 0 1027 68 149 106 105 63 145 224 144 91 ‡ 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. 11 12 VITAL STATISTICS. Births.—Fourteen hundred and twenty births were registered during the year:— Males. Females. Total. Legitimate 735 654 1389 Illegitimate 12 19 31 747 673 1420 The birth rate per 1,000 of the population was thus 12.02. The following list shows the population, number of births, and the corrected birth rate per 1,000 during the past five years:— Year. Population. No. of Births. Birth Rate. 1933 125,700 1,499 11.91 1934 123,430 1,454 11.78 1935 121,690 1,493 12.26 1936 119,900 1,421 11.85 1937 118,100 1,420 12.02 On page 25 will be found a table showing the population, number of births and birth rate for each year since 1892—a period of 45 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. 1933 1934 1935 1936 1937 Leyton 11.91 11.78 12.26 11.85 12.02 125 County Boroughs and Great Towns 12.2 14.7 14.8 14.9 14.9 London 13.2 13.2 13.3 13.6 13.3 England and Wales 14.4 14.8 14.7 14.8 14.9 13 Of the total number of births registered (1,420) during the year, 767 (54 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 767 births occurred in the following institutions:— Queen Mary's Hospital 296 Mothers' Hospital, Clapton 120 Forest Gate Hospital 135 City of London Maternity Hospital 20 Plaistow Maternity Hospital 26 East End Maternity Hospital 8 Kingswood Maternity Home 19 Thorpe Coomb Maternity Home 21 London Hospital 11 St. Bartholomew's Hospital 3 Royal Free Hospital 5 German Hospital 5 Middlesex Hospital 2 Queen Charlotte's Hospital 2 Jewish Maternity Hospital 13 Walthamstow District Nursing Association 22 Guy's Hospital 1 St. Thomas's Hospital 1 Bethnal Green Hospital 3 Hackney Hospital 9 Mile End Hospital 4 St. Andrew's Hospital 2 Maycroft Nursing Home 5 Other Institutions 34 767 14 Graph No. 1. TABLE 2. Registered Births. 1937. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Total. January 7 7 5 3 3 2 6 3 4 4 44 February 4 9 4 4 10 6 4 8 5 2 56 March 3 8 7 9 10 9 7 7 1 4 65 April 9 10 7 9 10 5 8 4 4 7 73 May 3 8 3 8 5 8 4 4 5 4 52 June 3 8 10 6 3 6 3 6 5 5 55 July 13 9 3 5 9 10 10 7 6 5 77 August 2 6 4 — 6 6 4 4 5 2 39 September 6 11 4 5 11 9 5 5 6 2 64 October 1 9 5 8 6 6 3 2 2 9 51 November 4 3 5 2 3 3 4 6 4 2 36 December 2 8 1 5 3 4 5 1 8 4 41 Transferables 48 139 72 77 118 93 52 71 56 41 767 Totals 105 235 130 141 197 167 115 128 111 91 1,420 15 16 Deaths.—Thirteen hundred and forty-nine deaths of Leyton residents were registered during the year, including those of 131 males and 132 females (transferable deaths) who died outside the area. Males. Females. Total. 684 665 1,349 The death rate per 1,000 of the population was thus 11.42. The following list shows the population, number of deaths, and the death rate per 1,000 of the population during the past five years:— Year. Population. No. of Deaths. Death Rate. 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 1937 118,100 1,349 11.42 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. 1933 1934 1935 1936 1937 Leyton 11.67 10.67 10.06 10.61 11.42 125 County Boroughs and Great Towns 12.2 11.8 11.8 12.3 12.5 London 12.2 11.9 11.4 12.5 12.3 England and Wales 12.3 11.8 11.7 12.1 12.4 The figure of 1,349 registered deaths represents an increase of 77 (about 5.70 per cent.) when compared with the corresponding number (1,272) registered during the previous year. 17 The following list shows the increase or decrease in the number of deaths from the various causes in 1937 as compared with 1936:— Decrease. Increase. — + Typhoid Fever - 1 Measles 22 - Scarlet fever 2 - Diphtheria 4 - Influenza - 38 Encephalitis lethargica - 3 Cerebro-spinal fever 1 - Tuberculosis of respiratory system 1 - Other tuberculous diseases 5 - General paralysis of the insane 5 - Cancer 9 - Diabetes - 5 Cerebral hæmorrhage - 11 Heart disease - 36 Aneurysm 7 - Other circulatory diseases 15 - Bronchitis - 19 Pneumonia 4 - Other respiratory diseases - 7 Peptic ulcer 2 - Diarrhoea - 1 Appendicitis - 4 Other diseases of liver 12 - Other digestive diseases - 1 Acute and chronic nephritis 5 - Other puerperal causes - 1 Congenital debility, premature birth, malformations, etc. - 4 Senility - 10 Suicide - 6 Other defined causes - 26 Causes ill-defined 2 - 96 173 = + 77 18 It will be seen that the chief increases were in deaths from influenza (38), heart disease (36), bronchitis (19), and senility (10). On the other hand, definite decreases are shown in deaths from other circulatory diseases (15), other diseases of the liver (12), cancer (9), and measles (22). Table 3, page 21, 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 1917. 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 107 11.8 Lea Bridge 215 10.0 Central North 106 9.6 ” South 116 10.1 Forest 174 8.7 Leytonstone 185 13.7 Grove Green 109 10.5 Harrow Green 115 9.3 Cannhall 131 11.5 Wanstead Slip 87 10.6 Zymotic Death Rate.—The deaths during the year from the seven principal zymotic diseases were as follows:— Smallpox — Measles 1 Diphtheria 7 Whooping Cough 2 Diarrhoea 8 Scarlet Fever — Enteric Fever 2 The zymotic death rate for 1937 was 0.17 per thousand of the population compared with a rate of 0.39 for the previous year. 19 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:— 65-70 143 70-75 164 75-80 180 80-85 125 85-90 72 90-95 22 95-100 8 100 1 Of the total number of deaths (1,349) during the year, 715 (53 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-five children died under one year of age, giving an infant mortality rate (number of deaths under one year of age per thousand births) of 52.81. The following figures show the number of births, infant deaths and infant mortality rate during the past five years:— Year. No. of Births. No. of Infant Deaths. Infant Mortality Rate. 1933 1,499 76 50.70 1934 1,454 64 44.02 1935 1,493 60 40.18 1936 1,421 74 52.07 1937 1,420 75 52.81 The following are the corresponding rates for other Great Towns, London, and England and Wales, during the year under review:— Infant Mortality—Leyton 52.81 „ „ 125 County Boroughs and Great Towns, including London 62.00 „ „ London 60.00 „ „ England and Wales 58.00 20 Maternal Mortality.—Three 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. ales. 1933 2 1.33 4.42 1934 5 3.43 4.60 1935 7 4.68 4.10 1936 2 1.36 3.65 1937 3 2.02 3.23 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 45 years. During that period the following are the outstanding facts:— 1. The population has increased from 63,000 to 118,100. 2. The birth rate has decreased from 35.0 to 12.02 births per thousand of the population. 3. The death rate has decreased from 15.4 to 11.42 per thousand of the population. 4. The infantile mortality rate has decreased from 141 to 52.81 deaths of infants under one year per thousand births. TABLE 3. CAUSES OF DEATH AT DIFFERENT PERIODS OF LIFE IN THE BOROUGH OF LEYTON, 1937. Ages at Death in Years. Wards. CAUSES OF DEATH. Male. Female. Total All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 years and upwards. In Public Institutions in the District. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Ward not known. Not belonging to District. Belonging to District. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Typhoid Fever ... 2 2 ... ... ... ... ... 1 1 ... 1 1 ... ... ... 1 ... ... ... 1 ... ... ... Measles ... 1 1 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... Scarlet fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping cough 1 1 2 ... 1 ... 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 1 ... ... Diphtheria 5 2 7 1 1 5 ... ... ... ... 3 3 ... ... ... ... ... 3 4 ... ... ... ... Influenza 15 31 46 1 ... ... ... 2 18 25 24 8 2 5 5 4 9 6 1 5 5 4 ... Encephalitis lethargica 2 1 3 ... ... ... 1 1 1 ... 1 2 ... 2 ... ... 1 ... ... ... ... ... Cerebro-spinal fever 1 ... 1 1 ... ... ... ... ... ... ... 5 1 ... ... ... ... ... ... 1 ... ... ... ... Tuberculosis of respiratory system 33 22 55 ... ... ... 2 9 23 19 2 97 15 2 11 7 5 7 5 5 6 5 2 ... Other tuberculous diseases 4 4 8 ... 1 ... 3 1 2 1 ... 27 4 2 3 1 1 ... 1 ... ... ... ... 21  Syphilis 2 ... 2 ... ... ... ... ... ... 2 1 ... ... 2 ... ... ... ... ... ... ... ... ... General paralysis of the insane, tabes dorsalis 1 ... 1 ... ... ... ... ... 1 ... ... 4 ... ... ... ... ... 1 ... ... ... ... ... ... Cancer, malignant disease 96 100 196 ... ... ... ... ... 13 76 107 302 70 16 30 17 18 19 32 11 16 18 18 1 Diabetes 9 16 25 ... ... ... ... 1 ... 5 19 24 7 4 8 ... 2 5 5 ... ... 1 ... ... Cerebral haemorrhage, etc. 48 48 96 ... ... ... ... 1 ... 22 73 224 46 5 13 6 10 14 10 7 13 10 8 ... Heart disease 184 207 391 ... ... ... ... 5 15 99 269 503 122 39 58 35 33 47 48 35 27 38 31 ... Aneurysm 2 2 4 ... ... ... ... ... l 1 2 4 2 ... 2 ... 1 ... ... 1 ... ... ... ... Other circulatory diseases 13 16 29 ... ... ... ... ... ... 2 27 28 6 ... 8 1 ... 4 8 2 ... 3 2 1 Bronchitis 34 32 66 1 2 ... ::: 2 1 10 50 132 24 5 5 2 9 5 12 7 6 12 2 l Pneumonia (all forms) 48 31 79 17 2 1 ... 2 8 26 23 212 41 7 19 2 5 8 10 5 9 11 3 Other respiratory diseases 13 6 19 1 ... 1 1 7 9 3 3 2 2 1 1 5 3 3 1 1 ... ... Peptic ulcer 8 4 12 ... ... ... ... ... 2 8 2 35 5 ... 3 2 ... 3 2 1 1 ... ... ... Diarrhoea, etc 6 2 8 7 1 ... ... ... ... ... ... 37 3 ... ... ... ... 1 1 1 2 ... 2 1 Appendicitis 10 2 12 ... ... 1 2 2 1 3 3 16 5 2 2 3 1 1 1 ... 1 1 ... ... Cirrhosis of liver 2 2 4 ... ... ... ... ... ... 3 1 7 1 ... ... 1 ... ... 1 1 ... l ... ... Other diseases of liver, etc. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other digestive diseases 9 8 17 3 ... ... ... ... 2 5 7 38 9 3 ... ... 1 5 2 1 2 3 ... ... Acute and chronic nephritis 13 6 19 ... ... ... ... ... 2 7 10 49 4 1 4 1 l 6 2 1 ... 2 1 ... Puerperal sepsis ... 2 2 ... ... ... ... ... 2 ... ... 3 2 ... ... ... l 1 ... ... ... ... ... ... Other puerperal causes ... 1 1 ... ... ... ... ... 1 ... ... 3 ... ... ... ... ... ... ... ... ... 1 ... ... Congenital debility, premature birth, malformations, etc. 23 22 45 42 1 ... 1 ... 1 ... ... 15 5 5 7 9 4 2 6 5 4 2 1 ... Senility 9 16 25 ... ... ... ... ... ... ... 25 41 7 2 1 1 1 5 6 3 2 4 ... ... Suicide 11 7 18 ... ... ... ... 1 7 7 3 9 ... ... 7 2 2 2 1 ... 1 2 1 ... Other violence 18 16 34 1 ... 1 ... 6 6 7 13 67 15 1 6 4 1 6 4 3 3 3 3 ... Other defined causes 64 55 119 1 2 2 3 8 20 40 43 188 44 9 16 7 14 16 17 10 14 7 9 ... Causes ill-defined, or unknown ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 684 665 1349 75 12 6 21 39 113 368 715 2104 422 107 215 106 116 174 185 109 115 131 87 4 22 23 Graph No. 2. 24 Graph No. 3. Comparative View of the Principal Causes of Death during the Year 1937. 25 TABLE 4. Comparative Statistics of Births, Mortality, Etc. LEYTON, 1892-1937. Year. Population. Births. Birth Rate. Deaths. Death Rate. Deaths under 1 year. Infantile Death Rate. 1892 63000 2210 35.08 972 15.4 313 141 1893 64000 2316 36.18 1019 15.7 306 130 1894 70000 2224 31.7 825 11.6 258 116 1895 75000 2292 30.05 1080 14.4 346 150 1896 77000 2372 30.08 926 11.8 326 137 1897 85000 2501 29.3 1011 11.9 356 142 1898 90000 2560 28.4 1125 12.5 374 146 1899 93000 2698 29.0 1262 13.5 420 155 1900 100000 2932 29.32 1179 11.8 410 140 1901 100000 2963 29.63 1243 12.4 404 136 1902 100000 3152 31.52 1183 11.8 336 106 1903 102000 3273 32.08 1112 10.9 322 99 1904 104000 3198 30.07 1370 13.1 444 138 1905 105000 3209 30.05 1177 11.2 303 94 1906 108000 3344 30.9 1327 12.2 382 114.5 1907 120000 3190 26.6 1269 10.6 182 86.6 1908 121200 3071 25.3 1185 9.8 242 78.8 1909 121200 2979 24.6 1208 9.9 244 81.9 1910 123300 3011 24.4 1112 9.0 191 63.4 1911 124736 2931 23.5 1473 11.8 327 116.6 1912 126700 2797 22.1 1343 10.6 223 79.7 1913 129366 2904 22.4 1336 10.3 242 83.3 1914 130847 2800 21.4 1363 10.4 219 78.2 1915 124497 2655 21.3 1510 12.1 225 84.7 1916 B132107* 2560 19.4 D121420* 1471 12.1 197 76.9 1917 B125352* 2005 16.0 Dl12452* 1414 12.6 172 85.8 1918 B125352* 1791 14.3 Dl12452* 1723 15.3 161 89.9 1919 B129062* 2195 17.0 D123896* 1397 11.3 154 70.16 1920 128832 3168 24.6 1330 10.3 207 65.34 1921 128432 2679 20.86 1290 10.04 182 67.94 1922 131600 2416 18.36 1420 10.79 155 64.16 1923 132800 2328 17.53 1228 9.25 106 45.53 1924 133500 2101 15.74 1325 9.92 110 52.36 1925 132700 2091 15.76 1349 10.16 114 54.51 1926 130000 2022 15.55 1261 9.7 131 64.79 1927 128920 1826 14.16 1322 10.25 80 43.81 1928 130300 1853 14.22 1290 9.90 91 49.10 1929 128300 1731 13.49 1510 11.76 100 57.77 1930 128300 1757 13.69 1222 9.52 81 46.09 1931 128600 1812 14.09 1365 10.61 71 39.18 1932 127140 1666 13.10 1341 10.54 89 53.43 1933 125700 1499 11.91 1468 11.67 76 50.70 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 1937 118100 1420 12.02 1349 11.42 75 52.81 * Population as estimated for purposes of B, Birth Rate, D, Death Rate. TABLE 5 Vital Statistics of Whole District during 1937 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. Number. Rate. of Nonresidents registered in the Borough. of Residents not registered in the Borough. Under 1 Year of Age. At all Ages. Number. Rate per 1,000 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 1937 118100 653 1420 12.02 3190 27.0 2104 263 75 52.81 1349 11.42 Kates in columns 5, 7 and 13 calculated per 1,000 of estimated gross population. 26 TABLE 6. Birth-rate, Death-rate and Analysis of Mortality During the Year 1937. (Provisional figures. The rates have been calculated on a population estimated to the middle of 1937. The mortality rales refer to the whole population as regards England and H 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 14.9 0.60 12.4 0.00 — 0.02 0.01 0.04 0.07 0.45 0.54 5.8 58 — — — — 125 County Boroughs and Great Towns, including London 14.9 0.67 12.5 0.01 - 0.03 0.01 0.04 0.08 0.39 0.45 7.9 62 - - - - 148 Smaller Towns. Estimated Resident Populations 25,000 to 50,000 at Census, 1931 15.3 0.64 11.9 0.00 - 0.02 0.01 0.03 0.05 0.42 0.42 3.2 55 - - - - London 13.3 0.54 12.3 0.00 — 0.01 0.01 0.06 0.05 0.38 0.51 12.0 60 — — — — LEYTON 12.02 0.51 11.42 0.01 — 0.00 0.00 0.01 0.05 0.38 0.44 5.63 52 89.84 4.37 5.78 0.0 27 28 SECTION B. GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. NURSING ARRANGEMENTS, CLINICS, HOSPITALS AND OTHER INSTITUTIONS AVAILABLE IN THE BOROUGH. A. Midwives.— Municipal Midwives — (а) Employed directly by Council 3 (b) „ by arrangement with Essex County Nursing Association 5 Employed by Voluntary Associations:— (a) Within the Borough 3 (b) Outside the Borough 3 In Private Practice:— (a) Resident in the Borough 2 (b) „outside„ — Clinics and Treatment Centres. All clinic medical services of the Council are held at the following two centres, each serving half of the Borough:— (1) Park House Clinic, Granleigh Road, E. 11, serves the eastern half of the Borough. (2) Leyton Green Clinic, Leyton Green Road, E. 10, serves the western half of the Borough. B. Maternity and Child Welfare.— Park House Leyton Green Clinic. Clinic. Ante-Natal Clinics Thurs., 10 a.m. Wed., 10 a.m. Infant Welfare Clinics Mon., Tues., and Mon., Wed., and Thurs., 1.45 p.m. Fri., 1.45 p.m. Toddlers' Clinics Tues., 10 a.m. Fri., 10 a.m. 29 C. School Medical Services.— Park Leyton Knotts House Green Green Clinic. Clinic. Special School. Minor Ailments Clinic Daily Daily — Dental Clinic Daily Daily — Ophthalmic Clinic — Twice — weekly Squint Clinic — Twice — weekly Diphtheria immunisation Weekly Weekly — Orthopaedic Clinic — — Monthly Artificial Sunlight Clinic — — Daily D. Day Nurseries.—Nil. 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. 30 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, Leyton 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. (а) Infectious Cases.—An Austin Ambulance is provided for the conveyance of infectious cases to the Isolation Hospital. (6) 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 Date came Adoption. into Force. Infectious Diseases (Prevention) Act, 1890 (Part ) 7-4-91 1-6-91 Public Health Acts Amendment Act, 1890 (Part ) 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 Public Health Acts Amendment Act, 1907 (Part ) 27-10-08 17-11-08 Public Health Acts Amendment Act, 1907 (Part ) 29-9-08 4-10-09 Public Health Act, 1925 15-12-25 1-2-26 Essex County Council Act, 1933 (Registration of Ice Cream Manufacturers, &c.) 5-9-33 6-12-33 31 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. 32 Public Mortuary. Number of bodies deposited, death being due to:— Natural causes 53 Suicide 8 Street accidents 2 Other accidents 4 67 Number of Post-mortem examinations performed 63 Number of Inquests held 14 In 53 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:— Coronary thrombosis 10 „ atheroma 4 „ embolism 1 „ occlusion 5 Aortic incompetence 3 „ stenosis 1 Angina pectoris 1 Myocardial degeneration 6 Ruptured heart 1 Rupture of aneurysm 1 Congenital malformation of heart 3 Chronic bronchitis 3 Acute suppurative bronchitis 1 Asphyxia due to acute bronchitis 1 Lobar pneumonia 1 Acute suppurative pneumonia 1 Cerebral haemorrhage 2 Pontine „ 1 Pulmonary emphysema 3 Carcinoma of oesophagus 2 Collapse of lung due to impaction of diphtheric membrane in trachea 1 Stillborn 1 33 Inquests. The following verdicts on Leyton residents were recorded at inquests held during the year:— Accidental. Knocked down by trolley bus 1 „ „ electric tram 2 „ „ motor car 3 Collision between motor cycle and motor coach 1 „ „ „ „ motor lorry 1 „ „ pedal cycle and motor lorry 1 Thrown from motor cycle while riding pillion 1 Cranial injuries due to collision with postal apparatus on railway 1 Rupture of small intestine due to kick from horse 1 Coal gas poisoning (bathroom geyser) 1 Septicaemia following injury to finger 1 Shock—Stovain anaesthesia 1 Ether anaesthesia 1 Fractures and falls 10 Drowning 1 Burns 3 Suicide. Drowning 2 Hanging 2 Run over by electric train 1 Cut throat 3 Coal gas poisoning 9 Hydrochloric acid poisoning 1 Prussic acid poisoning 1 Open Verdict. Meningitis following septicaemia due to instrumentation of uterus, producing abortion 1 Asphyxia from drowning 1 Natural Causes. Myocardial degeneration 2 Pulmonary embolism 2 Heart failure and senile decay 1 Diabetes 1 Coronary atheroma 1 34 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. Attendances. The following figures show the extent to which the Corporation's Baths were used during the year:— Swimming Baths. 1937. High Road 160,038 Cathall Road 122,204 Whipps Cross Bathing Pool 34,595 Slipper Baths. High Road 121,439 Cathall Road 47,513 Foam Baths. High Road 2,173 Whipps Cross Bathing Pool. This outdoor bathing pool is situated in Epping Forest towards the northern extremity of the Borough. It was opened in May, 1932. At that time no system of continuous filtration and chlorination of the water was installed, and experience during the first few years of its existence showed that, with large bathing loads, the water could not be kept sufficiently free from pollution as to be regarded as both safe and attractive. It was realised that, in the interests of the health of bathers, a continuous filtration and chlorination plant would have to be installed, and the necessary work was put in hand during the winter 1936-37. Whipps Cross Bathing Pool. 35 On account of the unusual shape of the pool this necessitated cutting off a part of the surface area which had been built up to form a sun bathing terrace. The pool was deepened to 3 feet 6 inches at the shallow end, to 5 feet 6 inches at the deep end in the main pool, and 10 feet in the diving pool. The pool is even now one of the largest in the country and the continuous filtration plant is the largest of its kind. It is designed to filter the water in the pool—approximately 1,300,000 gallons—in a 5, 10 or 15-hour turnover. Thus, when working at a maximum it will filter 260,000 gallons per hour. The sterilisation is carried out by the E.C.D. process by means of which a salt solution is electrically connected to sodium hyposulphate which is fed into the water before filtration, and by means of which two parts per million of chlorine can be added to the water without any detrimental effect to eyes, nose, mouth, etc., and thus maintaining safe water for bathing. The installation of the filtration plant necessitated much incidental work, such as concreting of the bottom of the pool, connecting the drainage to the Borough sewage system, etc.; and the whole work was carried out at a cost of £9,061 for incidental works and £5,020 for the Filtration Plant. The pool was re-opened during the first week in July, 1937. After a few initial difficulties had been overcome, the pool contained water which was uniformly clear, attractive and safe during the remainder of the season. Installation of Sun-Ray Apparatus. In June, 1937, I submitted the following report to the Public Health Committee:— Reference—Council Minute 1875—May, 1937. "Resolved that the Medical Officer of Health obtain information from other Authorities who have installed similar apparatus and report further thereon to this Committee (Public Health Committee)." 36 It is now fairly generally recognised that in the majority of persons the exposure of the skin to natural sunlight in properly graduated doses has a tonic and stimulating effect, increasing the sense of well-being and the feeling of vigour. It has been shown, however, that this tonic effect is due not so much to the sunlight as to the stimulating and bracing effect of cold air on the skin. That being so, it will be appreciated that artificial sunlight baths at their best can only be expected to prove a poor substitute for exposure of the body in the open to sunlight, skyshine and fresh air. Although heliotherapy(sun-bathing out of doors)can be practised all the year round in certain places, e.g., South of England, Switzerland, etc., there are relatively few months when the urban dweller in this country can derive much benefit from sun-bathing, due in great part to the smoke pall hanging over our cities and cutting off the sun's rays. It has been shown that much of the weakened resistance to fatigue, general and nervous debility so common in our large cities towards the end of long, dull winters can be prevented by suitably graduated courses of exposure to ultra-violet rays; that young athletes reach a higher level of physical fitness after courses of artificial sunlight; and that the action of ultra-violet rays increases the available supply of vitamin D in the blood-stream. In the year 1928 a small room at Knotts Green Special School was equipped with a single quartz mercury-vapour lamp (Cost—£46); and since that time the Council's Masseuse (Miss Findlay), who possesses the necessary qualification in actinotherapy, has been administering artificial sunlight as an ancillary form of medical treatment in connection with the Council's clinic services. The following figures show the number of women and children who have completed the full course of artificial sunlight treatment at Knotts Green during the last five years:— 1932 122 1934 124 1933 112 1935 157 1936 287 37 These have all been patients referred by your medical staff on account of some defective or debilitated physical condition. From year to year detailed information is given regarding the conditions treated and the results of treatment— in my Annual Reports to the Council. From experience gained in Leyton it may be said that the preponderating majority of patients who complete the course derive appreciable benefit. There are, however, certain defective conditions which do not lend themselves to treatment by artificial sunlight and may be aggravated thereby. Again, there are certain persons on whom sunlight, either natural or artificial, has a distinctly harmful and depressant effect. It will be appreciated, therefore, that the selection of cases and the administration of treatment should be in the hands of persons who are properly qualified. Although many maternity and child welfare and education authorities have equipped and established artificial sunlight clinics as part of their medical services, there are relatively few Councils who have provided facilities for the general population. Recently I have had the opportunity of visiting and inspecting the arrangements at two municipal artificial sunlight clinics; and, inasmuch as they exemplify two very different types of municipal provision, I submit a brief description of each. Borough A. The new light treatment department or "solarium"—opened in 1936—is probably the largest and best equipped municipal clinic of its kind in the world. It occupies the entire first floor of the large new Public Health Centre, and the equipment alone cost over £2,000. The forms of treatment available are artificial sunlight (general and local), diathermy and massage. Any resident in the area may attend the clinic, be examined by the doctor on duty, and receive a full course of the forms of treatment recommended—all free of charge. 38 The clinic exists for the remedial treatment of patients who are recommended for such treatment either by their own medical attendants or by the medical officer on duty at the clinic. The treatment is administered by a staff of five qualified nurses, and as many as 50 persons can be under treatment at the same time. Borough B. The artificial sunlight room at the Public Baths is equipped with four mercury-vapour lamps for general ultra-violet light treatment, and four radiant heat lamps to supply warmth. Each of the mercury-vapour lamps cost about £60. The facilities are available for men and women on alternate days. The staff, who have no special qualification in actinotherapy, consist of two male and two female shampooers who are on duty in the Turkish Baths on alternate days. The maximum number of persons undergoing exposure to ultra-violet light at one time is four. The facilities are available to anyone—whether or not resident in the area—who pays the standard charge of Is. 6d. If, as in Borough A, the artificial light is to be administered as part of a course of medical treatment (e.g., for rheumatism, etc.), it is essential to have a qualified medical and nursing staff. If, on the other hand, the artificial sunlight is to be available merely to provide the general tonic effect (as in Borough B), it is not essential to have a qualified medical and nursing staff. It is suggested, however, that the attendants should have a qualification in actinotherapy. Action Taken by Council. As there is no accommodation at present available in the Public Baths which is considered suitable for the establishment of a sun-ray treatment centre, further consideration of the matter has been deferred meantime. 39 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 treatment 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 10 establishments. FOOT CLINIC. The Municipal Foot Clinic was opened on 3rd March, 1936, and since its inception the number of patients seeking advice and treatment has been steadily maintained. The number of attendances during the year was 6,529, comparing with 4,622 for the preceding ten months. During the year the Council appointed a second Chiropodist (Miss F. I. Stokes, M.I.S.Ch.), in place of Miss B. Reach, who had been acting in a temporary capacity. Miss Stokes took up her permanent duties on 26th July, 1937. The following statistics for the year 1937, 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, 1937. A. All Ages. During the year 6,529 attendances were made, an average of 4.64 attendances per patient. First Attendances (new eases). Subsequent Attendances. Total Attendances. No. Per cent. Average No. of Visits per Patient. Males 204 1,322 1,526 23.37 4.42 Females 558 3,816 4,374 66.99 4.71 Children 117 512 629 9.64 4.73 Total 879 5.650 6.529 - 4.64 40 During the year the numbers of persons who received free treatment was 196, 22.53 per cent. of the total number of new cases. First Attendances (new cases). Subsequent Attendances. Total Attendances. Males. Females. Males. Females. Males. Females. Old age pen-pensioners 45 74 650 1,035 695 1,109 Unemployed 14 22 208 289 222 311 Widows — 41 — 502 — 543 Totals 59 137 858 1,826 917 1,963 Defects Treated. Bursitis 45 Callosities 240 Corns, hard 114 Corns, soft 31 Corns, under nail 22 Hallux rigidus 7 Hallux valgus 55 Metatarsalgia 43 Nails, club 41 Nails, ingrowing 39 Pes cavus 6 Pes planus 113 Verruca pedis 97 Hammertoe 19 Septic conditions 9 Conditions due to sprain 14 Referred for Medical or Surgical Treatment. During the year 26 patients were referred to their own private medical practitioners for the following conditions:— Arterio-sclerosis 1 Arthritis 1 Dislocation (2nd metatarsal head) 1 Hyperkeratosis 1 Poor circulation 3 Septic condition 1 Sublaxation of joint 2 Oedema 6 Ulcer (trophic or perforating) 2 Varicose condition (veins or ulcer) 6 Rheumatoid arthritis 2 41 Five patients were referred to hospital for X-rav or treatment for the following:— Contraction of tendon 1 Talipes valgus 2 X-ray (broken needle in foot)1 X-ray (5th metatarsal)1 Eight patients were referred to hospital and operated upon for the following:— Cyst 1 Exostosis 3 Hallux valgus 2 Pes piano valgus 1 Plantar fasciotomy 1 B.—Children under School Age. No. of children 3 Defects Treated. Nil. Referred to Toddler's Clinic. Genu valgum and pes valgus 3 C.—School Children. No. of children 130 Attendances for treatment 626 Average number of treatments per child 4.82 Defects Treated. Bursitis 1 Callosities 2 Condition due to sprain 3 Corns, hard 3 Corns, soft 1 Incipient hammer toe 7 Metatarsalgia 1 Nail, ingrowing 6 Pes planus 12 Verruca pedis 72 Defects Referred to School Clinics. Pes cavus 1 Pes piano valgus 7 Pes planus 1 Pes planus and hallux valgus 1 Subungual exostosis 1 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. The principal river within the Borough is the River Lea, which runs along the extreme South West Boundary. Its tributaries within the Borough are the Waterworks River, the Dagenham Brook and the Fillebrook (now culverted). The whole of the surface water of the Borough finds its way into one or other of these streams. The Rivers Pollution Prevention Act, 1876, makes provision for the prevention of the pollution of rivers, particularly with a view to the prevention of new sources of pollution. Section 9 of that Act gives certain powers to the Conservancy Board appointed under the Lee Conservancy Act, 1868, since when the Lee Conservancy Board has been the responsible body. As far as this Council is concerned the whole of its sewage is taken direct into the L.C.C. system in Hackney, and no effluent passes into the streams. Public Cleansing. (a) Scavenging. See Annual Report for 1936. (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. 43 During the year 24,517 tons of refuse were collected and the net cost of collection per ton for the financial year ended March, 1937, was 8s. l0d. Seven hundred and eighty-five defective and unsuitable receptacles have been replaced during the year. Statistics as to Refuse Collection, 1936-37. Number of collection days 305 Aggregate number of days vehicles employed 3,355 Average number of vehicles employed per day 11 Total mileage run 50,419 Tonnage collected 24,517 Weight in cwts. per 1,000 population per day 11.20 Average weight collected per van day 7 tons 61/4 cwts. Total cost of collection (including loan charges) £10,846 Cost per ton for collection 9s. 31/4d. Income from collection of trade refuse, etc. £516 Income per ton of refuse collected 5d. Net cost per ton for collection 8s. l0d. SANITARY INSPECTION OF THE AREA. Sanitary Inspector's Duties. (Report of Medical Officer of Health). The duties of a sanitary inspector are imposed by a very large and continually increasing number of statutes, orders, regulations and by-laws. The Sanitary Officers' Regulations, 1935 (Article 27) prescribe the following statutory duties:— The sanitary inspector as regards the district for which he is appointed shall, except as provided by Article 28 of these Regulations (1) perform under the general direction of the medical officer of health all the duties imposed on a sanitary inspector by statute and by any orders, regulations or directions from time to time made or given by the Minister, and by any by-laws or instructions of the local authority applicable to his office; (2) by inspection of his district, both systematically and at intervals as occasion requires, keep himself informed of the sanitary circumstances of the district and of the nuisances therein that require abatement; 44 (3) report to the local authority any noxious or offensive businesses, trades or manufactories established within his district, and the breach or non-observance of any by-laws or regulations made in respect thereof; (4) report to the local authority any damage done to any works of water supply or other works belonging to them, and also any case of wilful or negligent waste of water supplied by them, or any fouling by gas, filth, or otherwise of water used or intended to be used for domestic purposes; (5) from time to time, and forthwith upon complaint, visit and inspect the shops and places kept or used for the preparation or sale of any article of food to which the provisions of the statutes and regulations in that behalf apply, and examine any article of food therein, and take such proceedings as may be necessary, provided that in any case of doubt arising under this paragraph, he shall report the matter to the medical officer of health, with a view of obtaining his advice thereon; (6) if so directed by the local authority, carry out the duties of a sampling officer under the Food and Drugs (Adulteration) Act, 1928; (7) if so directed by the local authority, inspect premises used as dairies for the purposes of the Milk and Dairies (Consolidation) Act, 1915, or the Milk and Dairies (Amendment) Act, 1922, or any Act amending those Acts, and any Orders or Regulations made thereunder; (8) give immediate notice to the medical officer of health of the occurrence within his district of any infectious or epidemic disease or other serious outbreak of illness; and whenever it appears to him that the intervention of such officer is necessary in consequence of the existence of any nuisance injurious to health, or of any overcrowding in a house or of any other conditions affecting the health of the district, forthwith inform the medical officer of health thereof; (9) if so directed by the medical officer of health, remove, or superintend the removal of, patients suffering from infectious disease to an infectious diseases hospital, and perform or superintend the work of disinfection after the occurrence of cases of infectious disease : (10) if so directed by the local authority, supervise the scavenging of his district or any part thereof; 45 (11) if so directed by the local authority, act as officer of the local authority under the Canal Boats Acts, 1877 and 1884, and the Rats and Mice (Destruction) Act, 1919, and under any order or regulations made thereunder; (12) if so directed by the local authority, act as designated officer for the purposes of the Housing Consolidated Regulations, 1925 and 1932; (13) if so directed by the local authority, perform duties of inspection under Part I of the Housing Act, 1935; (14) if so directed by the local authority, superintend and see to the due execution of all works which may be undertaken by their direction for the suppression or removal of nuisances; (15) carry out any duties imposed upon him by the local authority with reference to the provisions of the Shops Act, 1934, relating to ventilation, temperature and sanitary conditions; (16) enter from day to day, in a book or on separate sheets or cards provided by the local authority, particulars of his inspections and of the action taken by him in the execution of his duties; (17) at all reasonable times, when applied to by the medical officer of health, produce to him his books, or any of them, and render to him such information as he may be able to furnish with respect to any matter to which the duties of sanitary inspector relate; and (18) as soon as practicable after the 31st December in each year, furnish the medical officer of health with a tabular statement containing the following particulars— (a) the number and nature of inspections made by him during the year; (b) the number of notices served during the year, distinguishing statutory from other notices; (c) the result of the service of such notices. Article 28 of the Regulations of 1935 enables a local authority to distribute among their sanitary inspectors the various duties prescribed in Article 27 above. These Regulations apply to all sanitary authorities outside London. In the Borough of Leyton your sanitary inspectors perform all these duties with the following exceptions:— Paragraph 6. Duties as sampling officers under the Food and Drugs (Adulteration) Act. 46 Paragraph 10. Supervision of scavenging of the district. Public Health Act, 1936. In addition to the above general list of duties, the following are definitely specified in the Public Health Act, 1936, as coming within the province of the sanitary inspector: Section. Subject matter. 38 Drainage of buildings in combination. 39 Provisions as to drainage, etc., of existing buildings. 40 Provisions as to soil pipes and ventilating shafts. 41 Notice to be given of repair, etc., to drains. 42 Alteration of drainage system. 43 Closet accommodation for new buildings. 44 Insufficient closet accommodation. 45 Defective closet accommodation. 46 Sanitary conveniences for factories, etc. 47 Conversion of closet accommodation. 48 Examination and testing of drains. 49 Rooms over closets, etc., not to be used as living, sleeping or work rooms. 50 Overflowing or leaking cesspools. 51 Care of closets. 52 Care of sanitary conveniences used in common. 56 Yards and passages to be paved and drained. 72/82 Removal of refuse, scavenging, keeping of animals, etc. 83/85 Verminous premises, articles and persons. 88 Control over conveniences in, or accessible from, streets. 89 Power to require sanitary conveniences to be provided at inns, refreshment houses, etc. 91/110 Nuisances and offensive trades. 137 New houses to be provided with supply of water. 138 Power of local authority to require any occupied house to be provided with sufficient water supply. 140 Power to close, or restrict use of water from, polluted source of supply. 141 154 Insanitary water cisterns. Rag and bone dealers. 235/241 Common lodging houses. 249/255 Canal boats. 259/266 Watercourses and streams. 267 Ships. 268/270 Tents, vans, sheds, fruitpickers' lodgings. 47 Special Duties. In addition to the general statutory duties outlined above, your sanitary inspectors are also the designated officers under these Acts :— (a) Inspectors under the Shops Act, 1934—relating to ventilation, temperature and sanitary conveniences in shops. (b) Inspectors—Diseases of Animals Acts. (c) Fabrics (Misdescription) Act. (d) Petroleum (Consolidation) Act. (e) Rats and Mice (Destruction) Act. (f) Housing Consolidated Regulations, 1925 (Part IV). Housing Act 1936. This Act, which came into operation on 1st January, 1937, imposes on every Local Authority the duty of carrying out a special survey of their district in order to ascertain the extent of overcrowding in the area, and of reporting to the Ministry of Health their proposals for the abatement of overcrowding. Section 67 of the Aet provides that it shall be the specific duty of the Medical Officer of Health to report annually to the Minister as to conditions in relation to overcrowding, and in particular to furnish details with regard to dwelling-houses in which overcrowding has occurred after being abated by the Local Authority. It will be seen that, even after the two temporary survey assistants have finished the measuring survey of houses in the Borough, there remains a considerable amount of additional visiting to be done for the purpose of following up and reviewing definite and borderline cases of overcrowding in the area. In addition, it will be appreciated that much of the house property in this district— erected mostly about 50 years ago—is already showing evidence of dilapidation, which will get progressively worse as time goes on, and that more intensive supervision and inspection of housing conditions will be required in future. During recent years I have recommended the scheduling for demolition of some 73 houses in the Borough; and it has been found that such action is the most effective weapon the sanitary authority possesses for either demolishing unfit property or forcing landlords to put it in a proper state of repair. The procedure entails a great amount of detailed work, as each property dealt with may be the subject of appeal in 48 court. As time goes by there will be an increasing amount of property which should be dealt with in this manner, but I am satisfied that the present staff of Sanitary Inspectors is not adequate to deal efficiently with the housing needs of the area. Staff. (Extract from Report of Medical Officer of Health— March, 1938). Memorandum 1293 of the Local Government Board (1910) stated that in districts possessing a population of over 10,000 it is generally desirable that an Inspector of Nuisances should devote his whole time to the duties of that office, and in many areas the staff of Sanitary Inspectors complies with that standard. In Leyton the staff of sanitary inspectors consists of 1 Senior Sanitary Inspector and 7 Sanitary Inspectors, two of whom are employed as whole-time meat inspectors at the London Co-operative Society Abattoir. The number available as District Sanitary Inspectors is therefore five. Compared with neighbouring areas, Leyton is relatively understaffed as regards Sanitary Inspectors. In order that the staff may be able to devote the necessary time to housing needs of the area I suggest that steps be taken to appoint at least two additional district Sanitary Inspectors. Even if two additional inspectors be appointed, the population per inspector would still be 18,330. At the end of the year the Council were still giving consideration to the necessity for increasing the staff of Sanitary Inspectors. Inspections. The table below gives a summary of the Inspections made by the Sanitary Inspectors :— Number of dwelling-houses inspected 3,480 Number of house-to-house inspections 1,079 Miscellaneous inspections 620 Re-inspections 10,502 Piggeries 10 Petroleum stores 165 Places of entertainment 21 Schools 49 Stables 151 Public conveniences 182 Urinals 276 49 Inspections under Rats and Mice (Destruction) Act 375 Visits in connection with infectious disease 498 Workshops 125 Factories 91 Outworkers'premises 477 Rag and bone dealers 3 Foster-mothers' premises 109 Hairdressers' premises 171 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 712 Sashcords renewed 271 Plaster repaired 879 Roofs repaired or renewed 825 Guttering repaired or renewed 378 Yards paved 200 Drains relaid or partly relaid 161 Choked drains cleared 55 New w.c. pan and traps provided 93 Sinks provided.. 110 W.C. cisterns repaired or renewed 88 Rain water pipes repaired or renewed 125 Vent pipes repaired or renewed 50 Sink waste pipes renewed 240 Stoves repaired or renewed 141 Coppers repaired or renewed 68 Floors repaired 246 Rooms redecorated 2,453 Miscellaneous defects remedied 2,125 Drainage.—The drains of 161 houses were reconstructed. In some instances the reconstruction related to portions of the public sewers, and in these cases, 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. Infested. Disinfected. Number of Council houses 31 31 Number of other houses 233 233 50 Eradication of Bed Bugs. See Annual Report for the year 193G. Rag Flock Acts, 1911-1928. There are no premises within the Borough where rag flock is known to be manufactured. Foster-mothers. One hundred and nine visits have been made to premises occupied by foster-mothers. Hairdressers. One hundred and seventy-one visits were made to hairdressers' premises to inspect for any contraventions of the By-laws made under the Essex County Council Act, 1933. Infectious Diseases. Four hundred and ninety-eight visits have been made by the Sanitary Inspectors. Places of Entertainment. Twenty-one visits have been made to cinemas and other places of entertainment. Petroleum (Consolidation) Act, 1928. Petroleum. Carbide of Calcium. Licences granted after inspection of storage arrangements 2 1 Licences renewed 103 5 „ transferred 5 — Licences lapsed 2 — Licences amended 3 — Licences refused — — Proceedings were instituted against a Company for infringement of the Petroleum Spirit (Conveyance) Regulations 1932, and the Company was fined £10. 51 Game Dealers. Five renewal certificates were issued during the year. Shops Act, 1934. Six hundred and eleven visits were made in connection with the above-named Act. Sixty-six informal notices were served on owners or occupiers of shops requiring them to provide and maintain suitable and sufficient means of heating in accordance with Section 10 (1) (b) of the Act. Means of heating were provided in 43 shops. Two statutory notices were served, and the notices in respect of 23 shops were outstanding at the end of the year. Smoke Abatement. Systematic observations have been kept on the factory chimneys throughout the district. One hundred and two visits were paid to the premises concerned. In all, sixty " time " observations were made. In consequence of interviews with the parties responsible, and as a result of advice given by the Sanitary Inspectors to manufacturers and stokers regarding the common causes of black smoke and grit emission, much improvement has been effected. In some instances nuisances were caused through the use of inferior coal or improper stoking and in other cases owing to the low height of the chimneys. In connection with two factory chimneys, "gritarresters" were installed with successful results. It was found necessary to issue 21 cautionary letters, and two statutory notices. These were complied with. Schools. Forty-nine routine inspections of the sanitary accommodation and water supply of schools were made. The attention of the Director of Education was called to various matters requiring attention in nine instances. Rats and Mice (Destruction Act), 1919. Three hundred and seventy-five visits were paid in connection with complaints received, and rat biscuits were issued to the occupiers of 67 premises. At 63 premises the source of rat infestation was definitely traced and the premises freed of rats. 52 The following report on the National Rat Week was submitted to the Ministry of Agriculture and Fisheries :— "Attention was given to the suggestions contained in the circular issued by the Ministry of Agriculture & Fisheries. "Posters relating to the question were exhibited throughout the Borough. "This year, instead of baiting the sewers with rat biscuits, traps were used in the sewers. As a result of this method, fifty rats were destroyed. "No complaints of rat or mice infestation, or applications requesting advice were received during the week from occupiers of premises." SECTION D. HOUSING. Complaints. During the year 1,040 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 1,777 Statutory—Housing Acts 19 Public Health Acts Ill Re-drainage 123 Notices complied with—Informal 1,809 Statutory— Housing Acts 27 Public Health Acts 101 Re-drainage. 79 Housing. Number of houses erected during the year:— (a) Total (including numbers given separately under (b)). (i) By the Local Authority Nil (ii) By other Local Authorities Nil (iii) By other bodies and persons: Houses 44 Flats 176 53 (6) With State assistance under the Housing Acts. (i) By the Local Authority :— (a) For the purposes of Part v of the Act of 1936 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) 3,480 (6) Number of inspections made for the purpose 13,982 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,079 (6) Number of inspections made for the purpose 4,202 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (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. 1,777 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 1,809 III.—Action under Statutory Powers during the Year:— (a) Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners . Nil (b) By Local Authority in default of owners Nil 54 (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 11l (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (а) By owners 101 (б) By Local Authority in default of owners Nil (c) Proceedings under Sections 19 and 21 of the Housing Act, 1930 and Sections 11 and 13 of the Housing Act 1936 :— (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: 1930 Act 12 1936 „ 15 (d) Proceedings under Section 12 of the Housing Act, 1936:— (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 . 1 IV.—Housing Act, 1936. Part IV—Overcrowding :— (a) (1) Number of dwelling-houses overcrowded at the end of the year 251 (2) Number of families dwelling therein 262 (3) Number of persons dwelling therein— Adults1,465 Children 363 (b) Number of new cases of overcrowding reported during the year 22 (c) (1) Number of cases of overcrowding relieved during the year 329 (2) Number of families concerned in such cases 357 (3) Number of persons concerned in such cases: Adults 1,919 Children . 394 55 Overcrowding—Provision of Alternative Accommodation. Report by the Medical Officer of Health to Public Health Committee—April, 1937. I beg to submit, for the information and consideration of the Housing Committee, the following observations contained in my last monthly report to the Public Health Committee. Since these observations were made I have visited two additional cases of overcrowding and I take this opportunity of bringing these three cases to the attention of the Committee. Under the provisions of the Housing Act, 1935, Local Authorities have been given considerable powers to secure the abatement of overcrowding. Circumstances arise in which prosecution is the only remedy, but in the recently issued Circular 1591 the Minister of Health relies on Local Authorities to carry out the difficult task of administration with discretion and sympathy and to recognise that the object of the Act is to help overcrowded families and not to injure them. From experience during the last few years it is evident that a large proportion of overcrowded families can and do obtain more suitable accommodation when they realise that the Local Authority intend to take proceedings. On the other hand there are families, overcrowded through no fault of their own, who require and deserve any help the Local Authority can give. Circular 1591 states that such overcrowding should be abated by finding the family a house of suitable size, suitably situated and suitably rented, in which they can lead a healthy and comfortable life. Experience at Papworth Village Settlement (Cambridgeshire) has shown that on a trade union rate of wage it is possible to nourish and bring up a family in such a way as to prevent the children from contracting tuberculosis. In that village of over 400 persons no child has contracted tuberculosis in any known form ; yet these healthy children are the offspring of parents who suffer from active tuberculosis. Much of the success of the village settlement is due to the proper housing conditions (e.g., thorough ventilation of living rooms, isolation of infectious persons in separate bedrooms, etc.), which allow medical advice to be put into practice. Similar encouraging results have been reported at Preston Hall (Kent), at Peamount (Dublin), in America and in France. 56 These reasonably proper housing conditions can be reproduced to a certain extent in the general tuberculous population of the country and—if put into practice—they will assist materially in the prevention of juvenile tuberculosis. Some years ago I suggested that a small proportion of Council houses should be allocated to families recommended on medical grounds, but no action was taken on that suggestion. During recent years increasing interest has been taken by many Local Authorities in the rehousing of households in which a member of the family is suffering from tuberculosis in an infectious stage; and the indications are that these schemes are beneficial. In any case it cannot be disputed that there are no members of the community who more deserve the sympathetic consideration and help of the Local Authority referred to in Circular 1591; and there is no more practical way of showing such consideration than by allocating suitable accommodation to families recommended on medical and public health grounds. Family No. 1. One son (21 years) died of pulmonary tuberculosis some three years ago. A daughter (12 years) is at present undergoing institutional treatment at Ventnor Sanatorium. Two children—a boy aged 9, and a girl aged 6—are attending Knotts Green Open Air School in order to endeavour to build up their delicate constitutions by fresh air and good food. The family consists of:— Father—labourer earning £2 15s. Od. per week. Mother—a delicate woman showing signs of physical deterioration due to worry and anxiety. Son (16 years)—cabinet maker earning 18s. per week. Under medical supervision at the Tuberculosis Dispensary. Daughter (15 years)—Earns 12s. per week. A delicate girl. Daughter (12 years)—in Ventnor Sanatorium temporarily. Son (9 years) Delicate children attending Knotts Green Open Air School Daughter (6 years) . This family of seven persons occupies an upstairs flat consisting of two bedrooms and kitchen. In one bedroom sleep the father and two sons; in the other the mother and three daughters. The bedrooms measure 174 and 99 square feet respectively; and the house is definitely overcrowded on the official standard. They have made application for a Council house, and are prepared to pay the rent. 57 Family No. 2. Father—groundsman—£3 to £4 per week. Mother—sensible, hard-working woman. Sons—6 boys, ages 15, 13, 7, 6, 4 and 3. Eldest boy (15)— van boy. Earns 12s. Rent—7s. Accommodation. First floor bedroom (80 sq. feet). Ground floor kitchen and bedroom (119 sq. feet). Sleeping arrangements. Bedroom upstairs—Father, mother, and four youngest boys. Kitchen—2 eldest boys sleep on made-down beds. All school children (3) in receipt of milk on medical grounds. Been applying for Council house for last seven years. Family No. 3. Father—glassblower. Unemployed since Christmas. Mother—confinement due end of April. Girls—three—ages 12, 10 and 5. Boy—one—age 8. A ccommodat ion. One ground floor front room as bed-living room. Use of kitchen for cooking and meals. Sleeping arrangements. Father, mother and 4 children all sleep in one room. All school children receiving milk on medical grounds. 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. 58 Scheduled in 1937 and Demolished in 1937. 1, 2 and 3, Edwards Cottages, Acacia Road. 59, Beaumont Road. 3 and 4, Pleasant Place, Harrow Green. 17, 19, 29 and 31, Harrow Road. 364, 366, 368, 370 and 372, High Road, Leytonstone. Scheduled in 1936 and Demolished in 1937. Cottage at rear of 822 ; Nos. 822, 824, 826, 828 and 830, High Road, Ley ton. 1, 2, 3, 4 and 5, Harrow Cottages, High Road, Leytonstone. Scheduled in 1934 and Demolished in 1937. 138, Lea Bridge Gardens. Scheduled in 1936, and offers to carry out repairs accepted ; repairs in progress. 15, 17, 19, 21, 23, 25, 27 and 29, Lansdowne Road. Voluntary Demolition undertaken in anticipation of Statutory Action. 1, 2, 81, 117,119,125,126,130,135 and 136, Lea Bridge Gardens Scheduled in 1937 and not yet Demolished. 590, 592, 594 and 596, High Road, Leyton. Closed in 1931 and Demolished in 1937 under road widening scheme. 1, Vicarage Road. Houses voluntarily Demolished by owners. 1 and 2, Pleasant Place, Harrow Green. Repair of Unfit Houses. In 18 instances it was found necessary to take legal proceedings for non-compliance with a notice served to remedy a nuisance in accordance with the Public Health Act, 1875, and the Public Health Act, 1936. 59 (1) The occupier of a house was summoned, and the summons was subsequently withdrawn on the necessary work being carried out. (2) In two oases the owners were required to pay 7s. 6d. costs, and orders were made for the necessary work to be carried out forthwith. (3) In eight cases the owners were fined £1, with £1 Is. Od. costs. (4) In six cases the owners were fined £1, with £1 costs. (5) In one case the owner was fined £1. House-to-House Inspection. The houses in the under-mentioned roads have been inspected during the year :— Auckland Road. Avondale Road. Bromley Road. Canterbury Road. Cheneys Road. Crescent Road (part). Howard Road. Lyttelton Road. Melford Road. Osborne Road. Park Grove Road. Peterborough Road. Primrose Road. Ruckholt Road (part). Russell Road. Short Road. Southwell Grove Road. Steele Road. Theobalds Road. Thornhill Road. Windsor Road. The number of dwelling-houses inspected and recorded under Housing Consolidated Regulations was 1079. Rent and Mortgage Interest Restriction Act, 1920-1933. Two applications for a certificate were received, and granted. 60 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Inspections. The following visits were made to food premises during the year:— Slaughter-houses 1,645 Butchers 747 Bakehouses 100 Fishmongers 140 Milkshops and dairies 620 Provision shops 348 Dining rooms 288 Ice-cream dealers 342 Greengrocers 246 Fish friers 129 MILK. Dairies and Milkshops. Number of premises on register 248 Premises added to register during year 41 Premises removed from register during year 60 Visits of inspection 620 As the result of inspection 36 infringements were found at 14 premises, and the necessary action was taken in each case. Ninteen persons were found to be retailing designated milk although not licensed in that respect, and cautions were given in each case. 61 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 m.l. 1 6,480 2 7,200 3 16,600 4 1,050 5 1,740 6 47,420 7 7,560 8 12,180 9 34,860 10 4,760 11 20,500 12 58,300 13 3,000 14 9,520 15 14,300 16 5,110 17 33,600 18 500 19 207,900 20 28,400 21 32,000 22 8,120 23 640 24 187,900 25 40,400 26 410,000 27 63,200 28 53,200 29 564,000 30 84,000 31 3,420 32 1,300 33 960 34 11,000 35 480 62 Number of Sample. Number of bacteria per m.l. 36 520 37 8,120 38 360 39 1,080 40 800 Designated Milk. Licences. No. Granted No. of Samples taken Result. Satisfactory Unsatisfactory Tuberculin Tested 9 2 2 - Accredited 3 — — - Pasteurised 47 34 23 11 Supplementary Licences Tuberculin Tested 2 — - - Pasteurised 2 — — — Totals 63 36 25 11 The results of the bacteriological examination of the 36 samples of designated milk are shown in the following table:— Grade Sample Number. Bacteria per m.l. Tuberculin Tested 1 Satisfactory 2 Satisfactory Pasteurised 3 1,480 4 5,300 5 170,000* Unsatisfactory 6 24,300 7 1,640* 8 539* 9 24,600* 10 400 11 660 12 823,300* Unsatisfactory 13 12,250* 14 29,600 63 Grade Sample Number. Bacteria per m.l. 15 309,000* Unsatisfactory 16 63,000* 17 36,400* 18 8,000 19 12,600 20 600 21 1,840 22 1,600 23 480 24 3,000* 25 900 26 2,000 27 4,480 28 4,000 29 4,200 30 7,070* 31 13,700 32 240 33 17,500 34 3,850 35 16,400 36 3,900 * B. Coli pre sent. Milk Supplied to Schools. Included in the designated milk samples listed above are seven samples of milk taken in course of delivery to schools. All of these proved satisfactory. Ice Cream. Premises on Register at 31-12-1937 185 Premises registered during 1937 37 Premises removed from Register during 1937 29 Persons on Register at 31-12-1937 189 Persons registered during 1937 40 Persons removed from Register during 1937 28 Visits of inspection by Sanitary Inspectors 342 Samples taken for bacteriological examination 42 64 Results of Samples taken for Bacteriological Examination. Number of Sample. Number of bacteria per m.l. 1 8,000 2 4,000 3 7,000 4 28,000 5 2,000 6 3,000 7 14,000 8 77,000 9 1,774,500 10 4,000 11 7,000 12 72,000 13 37,800 14 24,000 15 3,000 16 34,800 17 49,700 18 2,000 19 30,400 20 670,000 21 4,000 22 18,000 23 1,050,000 24 40,000 25 1,120,000 26 58,800 27 55,600 28 392,000 29 20,000 30 2,920,000 31 56,000 32 3,200 33 15,000 34 9,000 35 10,000 36 9,800 37 1,600 38 6,090 65 Number of Sample. Number of bacteria per m.l. 39 3,200 40 91,000 41 250 42 15,000 MEAT. Slaughter-Houses.—There are eight licensed slaughterhouses in the Borough. One thousand, six hundred and forty-five inspections of these slaughter-houses were made. Carcases and Viscera Inspected.— Animals Inspected. London Co-operative Society Abattoir. Other SlaughterHouses. Cattle 6,606 503 Calves 601 57 Swine 26,701 622 Sheep 19,289 2,685 53,197 3,867 Meat and Other Food Condemned. Total. Tuberculosis. Ox:— Aitchbone 2 - Brisket 16 15 Buttock 1 - Carcase 4 2 Carcase and Offal 22 20 Clod and sticking 15 15 Flank 11 11 Foot 2 - Forequarter 10 9 Head 5 3 Head and tongue 381 248 66  Total. Tuberculosis. Heart 8 2 Hindqua.rter 1 1 Intestines 94 91 Kidney 27 3 Leg 4 — Liver 2,862 142 Loin 11 8 Lungs 827 289 Mesentery 351 226 Omentum 16 4 Ribs 14 12 Rump 5 3 Shin 2 2 Skirt 20 17 Spleen 59 5 Steak 3 3 Stomach 107 23 Tail 3 3 Tongue 22 — Top-piece 2 — Beef 73½ lbs. — Silverside of Beef 2 „ — Calves :— Carcase and offal 3 2 Liver 4 - Loin 2 - Lungs 3 - Spleen 1 - Breast 4 - Carcase 5 - Carcase and offal 2 - Heart 4 - Jacket 2 - Kidney 1 - Leg 12 - Liver 1,460 - Loin 3 - Lungs 1,089 - Omentum 14 - Pluck 2 - 67  Total. Tuberculosis. Scrag 2 - Shanks 4 - Shoulder 1 - Spleen 1 - Target 19 - Swine:— - Belly 11 - Carcase 65 25 Carcase and offal 289 223 Collar 51 51 Forequarter 30 9 Hand 1 — Hand and spring 8 1 Head 2,092½ 2,036 Heart 184 — Intestines 35 13 Kidney 171 — Leg 47 10 Liver 2,949 3 Loin 18 9 Lungs 4,013 4 Mesentery 1,903 1,875 Omentum 2 — Pluck 1,421 234 Shank 3 — Skin 5 — Spleen 33 1 Stomach 27 9 Miscellaneous:— Headless Cod 6 st. Chicken 1 1 Corned Beef 43 lbs. — Currants 56 lbs. — Plaice 5 st. — Rabbits 401 - Rabbits' livers 2 - Raisins 12 lbs. — Skate Wing 1½ St. — Strawberries 2 lbs. - A quantity of grocery, tinned foods, confectionery, etc., which had become contaminated, was removed from empty premises in Harrow Road and destroyed. 68 SUMMARY OF CARCASES INSPECTED AND CONDEMNED. Cattle, excluding Cows. Cows. Calves. Sheep and Lambs. Pigs. Number killed 7,109 Nil 658 21,974 27,323 Number inspected 7,109 Nil 658 21,974 27,323 All diseases except Tuberculosis :— Whole carcases condemned 4 Nil 1 7 106 Carcases of which some part or organ was condemned 3,729 Nil 9 2,451 11.19 8,213 30.45 Percentage of the number inspected affected with disease other than tuberculosis 52.51 Nil 1.52 Tuberculosis only:— Whole carcases condemned 22 Nil 0 Nil 248 Carcases of which some part or organ was condemned 650 Nil Nil Nil 4,207 16.30 Percentage of the number inspected affected with tuberculosis 9.45 Nil .30 Nil Public Health (Meat) Regulations, 1924. Seven hundred and forty-seven visits were made to butchers' shops. Twenty-two letters were sent and 26 verbal notices given in respect of minor infringements, but it was not found necessary to take any Statutory action during the year. Bakehouses. One hundred visits were made to the 40 registered bakehouses. Ten letters were sent and 12 verbal notices given in respect of minor infringements, and these were remedied without the service of Statutory notices. Restaurants, Dining Rooms and Kitchens. Two hundred and eighty-eight inspections of premises and utensils were made. Twenty-nine letters were sent and 30 verbal cautions given in respect of unsatisfactory conditions. Public Houses. Thirty-six visits were made to public houses for inspections as to cleanliness of the premises, cellars, pumps, utensils, etc. Nine letters were sent and 4 verbal cautions given in respect of unsatisfactory conditions. 69 Premises and Occupations which can be Controlled by By-Laws and Regulations. Premises. Slaughter-houses 8 Dairies, Milkshops and Dairymen 248 Butchers' shops, Stalls and Provision shops 277 Ice Cream dealers 189 Chimneys—other than private dwelling-houses approximately 100 Hairdressers' Premises 104 Offensive Trades. Rag and Bone dealers 4 Fish friers 30 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. Three applications to continue the trade of a fish frier were received and permission given for a further limited period. One application for the permission of the Council to establish the trade of a fish frier was made and granted. One hundred and twenty-nine inspections were made of the premises where fish frying is carried on. Contagious Diseases of Animals Acts, 1894-1927. Two hundred and forty-seven licences were issued in respect of the movement of:— Cattle 1,193 Sheep1,719 Pigs . 5,074 from other areas into this district for the purpose of slaughter. 70 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 73 Samples of butter taken . 68 Other samples 248 SECTION F. FACTORIES AND WORKSHOPS. Workshops and Workplaces. One hundred and fifty-three inspections were made during the year. Defects were found to exist and have been remedied in 12 cases. Four notices were received from H.M. Inspector of Factories of nuisances remediable under the Public Health Acts. One hundred and forty-four workshops remain on the Register at the end of the year and are grouped as follows:— Accumulator charging and radio repairs 5 Bakehouses 17 Bedding manufacturers 1 Blacksmiths 3 Boot and shoe makers and repairers 14 Builders' merchants 1 Cabinet makers 5 Cardboard-box manufacturers 1 Confectionery manufacturers 4 Corset makers 1 Cycle repairers 1 Dressmakers 13 Dyers, cleaners and pressers 3 Enameller and plater 1 Carried forward 70 71 Brought forward 70 Fish packers 1 Laundries 1 Leather goods manufacturers 2 Milliners 4 Motor repairers 7 Organ builders 1 Printers. 1 Paper articles and lamp shades manufacturer 2 Piano manufacturers 1 Rag sorters 2 Range repairers 1 Scale makers 1 Tailors 20 Tie makers 6 Upholsterers 7 Wire workers 1 Wood choppers 3 Miscellaneous 13 144 Homework. Foil r hundred and seventy-seven visits were made to premises occupied by outworkers. Five hundred and sixty outworkers now remain on the Register. Factories, Workshops, Laundries, Workplaces & Homework. 1. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. (1) Number of Inspections. (2) Written Notices. (3) Prosecutions. (4) Factories— Including Factory Laundries 126 13 - Workshops— Including Workshop Laundries 153 8 — Workplaces— Other than Outworkers premises included in Part 5l of this Report 279 21 — 72 2. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. (i) Number of Defects. Found. (2) Remedied. (3) Referred to H.M. Inspector. (4) No. of Offences in respect of which prosecutions were instituted. (5) Nuisances under the Public Health Acts :— Want of Cleanliness 32 28 — ,, Ventilation — — — — Overcrowding — — — — Want of Drainage of Floors 1 1 — — Other nuisances 10 8 — — Sanitary Accommodation— Insufficient — — — — Unsuitable or defective 4 4 — — Not separate for sexes — — — Offences under Factory and Workshop Acts : Illegal Occupation of Underground Bakehouse (8. 101) — — — — Other Offences— Excluding offences relating to Outwork which are included in Part 5 of this Report — — — — 47 41 — — 3. HOMEWORK. NATURE OF WORK. Outwork in Unwholesome Premises, Sec. 108. Instances. Notices served. Prosecutions. Nil Nil Nil Nil SECTION G. PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. SMALLPOX. During the year 1937 no case of smallpox occurred in the area. ENTERIC FEVER. Typhoid. The recent serious outbreak of typhoid fever in the Croydon area has awakened the public conscience to the ever-present danger of a widespread outbreak of enteric fever. It has been realised 73 for some considerable time that two successive very dry summers (1934-35) have profoundly disturbed the underground waters and opened up channels of contamination of water supplies which had not existed previously; and epidemics of the kind experienced in Croydon have been forecast. The characteristic of the present epidemic, however, is the amount of criticism—informed and uninformed—levelled against the Medical Officer of Health not only by members of the general public, but by his medical colleagues in private practice. It has been freely suggested that the public has been lulled into a feeling of false security with regard to its alleged freedom from typhoid fever. In order that members of the Council may appreciate the actual position, I consider it expedient to bring to your notice the following facts and suggestions. Incidence. In this and other countries the infection is always present in the community. From time to time we get a sudden and widespread epidemic, and even during recent years we have had the following serious outbreaks in this country. Date. Area. Number of Source of Infection. Cases. Deaths. 1931 Epping 686 23 Milk supply. 1932 Molton 272 25 Water supply. 1936 Bournemouth 718 29 Milk. 1936 Liverpool 123 11 Bread (?) That the disease is always with us may be seen from the following figures of incidence and mortality:— Cases. Deaths. Leyton. England and Wales. Leyton. England and Wales. 1932 6 2,545 258 1933 4 1,758 — 222 1934 1 1,213 — 159 1935 6 1,750 1 174 1936 4 2,490 1 257 Total 21 9,756 2 1,070 74 Modes of Spread. The organisms of the disease are contained in the excretions of persons who are suffering, or have suffered, from the disease. It has been estimated that one person in every thousand of the population is a "carrier," and that 25 per cent. of all chronic carriers have had the disease in such a mild form that it has never been suspected or diagnosed. The disease is generally spread by some article of food or drink which has become infected by the excretions of a patient or carrier, although it may also be conveyed by flies, infected clothing or bedding, dust, etc. Polluted water may cause enteric fever either directly or by way of infection of milk utensils ; and enteric organisms may be recovered from sewage effluents even after the most modern methods of treatment. In spite of the evidence of the efficiency of pasteurisation in controlling the Epping and Bournemouth outbreaks, much of the milk sold in this and other areas is still unpasteurised. Such foodstuffs as celery, watercress, ice-cream, shell-fish, fried fish and bread have been the cause of widespread epidemics. Control. It will be evident that, as in the case of other infectious diseases, the possibilities of infection are enormous. The relative immunity from typhoid fever which the community enjoys is the result of unceasing vigilance on the part of the public health service ; and the present Croydon epidemic should serve as a reminder of the danger which efficient health administration has served to obscure. In spite of the great increase in our knowledge of the bacteriology and causation of enteric fever, reliance should be placed first and foremost on the well-tried sanitary measures which prevent pollution of water, food and soil. Every effort should be made to ensure that food is not prepared by persons whose hands have not been thoroughly cleansed before they commence work. 75 Institutional Treatment. In November, 1928, I drew attention to the fact that no provision existed for the institutional treatment and isolation in Leyton Isolation Hospital of such infectious diseases as enteric fever, cerebro-spinal meningitis, poliomyelitis, encephalitis lethargica and other notifiable infectious diseases. In 1930 your Council entered into an agreement with Connaught Hospital for the reservation of two beds for the treatment of enteric fever cases from this area; but as the result of experience during the last year I do not regard the arrangement as being satisfactory, even in times when enteric fever is not epidemic. Should a widespread outbreak occur, the arrangement would be hopelessly inadequate to cope with the number of cases requiring isolation. During 1937 seventeen persons were notified to be suffering from typhoid. No. Month. Sex. Age. Address. Nature of Infection. 1 January M. 7 Vicarage Road Para B. 2 January F. 4i Albany Road ,, 3 January M. 11 Skeltons Lane ,, 4 February F. 14 Vernon Road ,, 5 February F. 27 Richmond Road ,, 6 February F. 52 Vernon Road ,, 7 February M. 53 Vernon Road ,, 8 February F. 16 Claude Road ,, 9 February F. 18 Melbourne Road ,, 10 March F. 3 Ramsay Road ,, 11 April F. 14 Huddlestone Road ,, 12 April M. 3 Wallwood Road ,, 13 June M. 18 Hainault Road Typhoid 14 July F. 38 Union Road Para B. 15 August F. 48 Newport Road ,, 16 August F. 18 Forest Drive East ,, 17 October M. 39 Grove Green Road ,, Case 1 was treated in Connaught Hospital. ,, 2 ,, ,, ,, Infants' Hospital, Vincent Square. „ 3 „ „ ,, Whipps Cross Hospital. ,, 4 ,, ,, ,, L.C.C. Brook Hospital. „ 5 „ „ ,, Connaught Hospital. ,, 6 ,, ,, at home. ,, ' ,, ,, at home. ,, 8 ,, ,, in St. Bartholomew's Hospital. ,, 9 ,, ,, ,, Whipps Cross Hospital. „ 10 „ „ ,, St. Mary's Hospital. Plaistow. ,, 11 ,, ,, ,, Connaught Hospital. ,, 12 ,, „ ,, Whipps Cross Hospital. „ 13 „ „ ,, Connaught Hospital. ,, 14 „ ,, „ Whipps Cross Hospital. (Died 4.8.37). ,, 15 ,, ,, ,, Connaught Hospital. (Died 11.9.37). ,, 16 „ ,, ,, Connaught Hospital. „ 17 „ ,, „ Connaught Hospital. (Died 21.11.37). 76 Bacillary Dysentery. On 20th November I was consulted by a local medical practitioner with regard to an outbreak of "query food poisoning" in a house in Birkbeck Road. Bacteriological investigation showed that two children were suffering from bacillary dysentery. Three other children in the house had suffered from similar symptoms during the previous week. On 23rd November I addressed a circular letter to all medical practitioners in the area drawing attention to the clinical features of these cases and asking to be notified of any similar cases among their patients. As the result of my own visits, of notifications and messages from medical practitioners, of reports from school nurses and school attendance officers I found that a mild type of bacillary dysentery was very widespread in this area. The majority of cases have been so mild that the parents have never even deemed it necessary to call in a medical practitioner; and in many cases the children have continued attending school. The onset of the illness is sudden, with diarrhoea and colic lasting about 48 hours. Recovery is generally complete in from a few days to a week. None of the patients I saw was seriously ill, and removal to hospital would not be called for, even if the accommodation were available. Institutional treatment, however, will have to be provided for serious cases should they occur. In the meantime the only available measures of control are isolation at home (as far as is possible), school exclusion of patients and contacts (as far as is possible), exclusion of contacts engaged in the handling and distribution of food, and disinfection of infected premises. During the year 1937 some 35 cases of Dysentery were notified; of these 31 were treated at home and four in hospitals as follows:— 1. L.C.C. (N.W.) Hospital Transfer from Elizabeth Garrett Anderson Hospital. 1. L.C.C. (E.) Hospital Notified as Dysentery whilst being treated for Poliomyelitis in Queen's Hospital. 1. L.C.C. (Grove) Hospital Transfer from Hospital for Sick Children, Gt. Ormond Street. 1. Hospital for Sick Children Child taken to O.P. and admitted as an In-patient. 77 SCARLET FEVER. Year. Cases Notified. Deaths. Case Fatality per cent. 1933 743 4 0.54 1934 681 3 0.44 1935 409 1 0.24 1936 367 2 0.54 1937 309 0 0.00 From these figures it will be seen that during the last five years there has been a progressive fall in the incidence of scarlet fever. The disease continued of the mild type to which we have become accustomed during recent years. No death was certified as due to scarlet fever. Treated in Hospitals:— Leyton Isolation Hospital 208 Walthamstow Isolation Hospital 2 Plaistow Fever Hospital 3 East Ham Fever Hospital 1 London Fever Hospital 5 L.C.C. Hospitals 2 Whipps Cross Hospital 3 224 Treated at home 85 309 Incidence of Complications. With regard to the incidence of complications in scarlet fever, it is generally held that a definite correlation exists between overcrowding of hospital wards and increased incidence of complications; but I have never been able to find any published results in support of that view. 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. 78 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. A detailed analysis of the incidence of complications during that year revealed 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. 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. Since 1st January, 1936, therefore, no overcrowding of patients has occurred. The following figures show the percentage incidence rate of complications during a period of four years. During the first two-year period (1934-35) the wards were overcrowded during the greater part of each year ; whereas in the second two-year period (1936-37) no gross overcrowding occurred. Year. Cases treated in Scarlet Fever Wards. Period Wards Overcrowded. Percentage Incidence of Complications. Albuminuria and Nephritis. Total. 1934 391 10 mths. 17.83% 51.4% 1935 260 7 mths. 10.50% 51.75% 1936 232 Nil. 4.09% 30% 1937 212 Nil. 3.00% 27% 79 In previous Annual Reports I have given the detailed results of investigation into the incidence of complications in the Scarlet Fever Wards of Leyton Isolation Hospital, and the results of such an investigation by Dr. Henderson are shown on page 98. 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 six years 1932-37 (excluding cases occurring in institutions), 65.13 per cent. of patients have been removed to hospital, and 34.87 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 ? During the six-year period 1932-37 the case fatality rate in Leyton was 0.72 per cent. for hospital cases and 0.22 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. In Leyton Isolation Hospital, during the three years 1934-37, the complication incidence rate has varied between 27 per cent. and 51 per cent. (See page 79). 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. Since 1st January, 1936, I have been investigating the incidence of complications among these home treated cases. The following figures show the incidence of complications among scarlet fever patients nursed at home during these two years and the nature of such complications. 80 1936. 1937. Total. No. of cases treated at home 109 85 194 Complications— Albuminuria 7 3 10 Rhinitis 4 — 4 Cervical adenitis 4 1 5 Otitis media 5 6 11 Endocarditis 1 — 1 Myocarditis — 1 1 Arthritis 1 — 1 Bronchitis 1 — 1 Cervical glands — 1 1 Otorhoea — 3 3 Acute Nephritis — 5 5 Unilateral otitis — 1 1 Tonsillitis — 1 1 Totals 23 22 45 Percentage Incidence of Complications 21.1% 25.88% 23.19% The complication percentage incidence rate (25.88 per cent.) of home-treated patients compares with the comparative rate of 27 per cent. for patients treated in hospital during the same period. Contact Attack Rate During Period of Isolation. Table 7 shows the results of a statistical analysis of the occurrence of secondary cases among Leyton contacts during the six-year period 1932-37. 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. TABLE 7. BOROUGH OF LEYTON. SCARLET FEVER. ANALYSIS OF CONTACT ATTACK RATES OF HOSPITAL-TREATED AND HOME-TREATED CASES (1932-1937). 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 1,786 956 2. Contacts. (a) Under School age 765 202 (b) School age 2,017 558 (c) Over School age 5,686 2,814 All ages 8,468 3,574 3. Contacts Attacked. (a) Under School age 55 14 35 20 55 6 8 14 (b) School age 55 36 31 24 55 18 18 36 (c) Over School age 33 17 15 18 33 6 11 17 All ages 143 67 81 62 143 30 37 67 4. Percentage of Contacts Attacked. (a) Under School Age 7.19 6.93 4.58 2.61 7.19 2.97 3.96 6.93 (b) School age 2.72 6 45 1 53 1 19 2 72 3.22 3.22 6.45 (c) Over School age 0.58 0.60 0.26 0.32 0.58 0.21 0.39 0.60 All ages 1.68 1.87 0.95 0.73 1.68 0.84 1.03 1.87 81 82 Reference to the table shows that the percentage of home contacts (of all ages) who developed scarlet fever was slightly greater in the home-treated (1.87 per cent.) than in the hospitaltreated group (1.68 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 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 (Table 8) show the comparative incidence of return cases in Leyton following hospital and home isolation during the last six years. TABLE 8. BOROUGH OF LEYTON. SCARLET FEVER. INCIDENCE OF RETURN CASES (1932-1937). Year. Following Hospital Treatment. Following Home Treatment. Primary Cases. Return Cases. Primary Cases. Return Cases. 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 1937 208 11 5.28 85 2 2.35 Total 1,786 108 6.04 956 11 1.15 83 84 These results show the percentage return-case rate after hospital treatment (6.04 per cent.) to be greater than after home treatment (1.15 per cent.). 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. 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. 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. 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. Four 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 . the four-year period since the modification of the regulations. (1) Primary Cases. (2) Contacts of School Age. (3) Ratio of (2) to (1). (4) No. of Contacts Attacked. (5) Percentage of contacts Attacked. 1932-3 Hospital 662 816 1.23 19 2.3 Home 369 214 0.58 12 5.6 Total 1,031 1,030 0.99 31 3.0 1934-7 Hospital 1,124 1,201 1.06 36 2.9 Home 587 344 0.58 24 6.9 Total 1,711 1,545 0.90 60 3.8 85 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 1934-37 it was 1.06 for hospital and 0.58 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. The important point, however, is whether the shortening of the school exclusion period was followed by any significant change in the risk. It will be seen from the figures that during the second period the contact-attack rate was slightly greater in respect of both hospital-treated and home-treated cases; but the differences are not sufficiently great as to be statistically significant. DIPHTHERIA. Year. Cases Notified. Deaths. Case Fatality per cent. 1933 94 7 7.44 1934 257 11 4.28 1935 276 8 2.89 1936 231 11 4.76 1937 161 7 4.34 Treated in hospitals— Leyton Isolation Hospital 136 L.C.C. Hospitals 2 Walthamstow Isolation Hospital 4 Plaistow Fever Hospital 9 Whipps Cross Hospital 1 152 Treated at home 9 161 86 The following list shows the particulars regarding the seven deaths certified as due to diphtheria during the year. Date of Death. Sex. Age. Cause of Death. Where death occurred. 27.1.37 Male 9 mths. Laryngeal Diphtheria Whipps Cross Hospital. 6.2.37 Male 5 yrs Collapse of lung following impaction of diphtheria membrane. At Home. 19.2.37 Male 7 „ Toxcemia. Diphtheria Isolation Hospital. 22.3.37 Male 5 „ „ „ „ „ 23.4.37 Female 7 „ „ „ „ „ 30.4.37 Female 11 „ Laryngeal Diphtheria, tracheotomy. „ „ 14.4.37 Male 8 „ Diphtheria Ottershaw Infecious Disease Hospital, Chertsey. ARTIFICIAL IMMUNISATION AGAINST DIPHTHERIA. 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. Inoculations. The preliminary Schick Test of susceptibility is omitted in children under ten years of age unless the parents express a definite wish to have the preliminary test carried out. The preparation which has been in routine use 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. Immunisation by Private Medical Practiitoners. 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 87 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 3 Number of children immunised 7 Record of Attendances during 1937. The following figures give particulars regarding the children dealt with at the municipal diphtheria immunisation clinics during 1937. 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 1938. Under 2 yrs. 2-5 years. 5-10 years. 10-15 years. Total. Number of children who attended for immunisation 87 260 524 88 959 ,, ,, who completed course 84 247 492 76 899 ,, ,, naturally immune — — 3 — 3 ,, ,, immune after one injection - 2 - - 2 ,, „ immune after 2 injections 79 236 455 74 844 ,, „ immune after 3 injections 4 4 19 1 28 „ „ immune after 4 injections 1 4 14 1 20 ,, ,, immune after 5 injections - 1 1 - 2 ,, „ positive after 4 injections - - 3 3 Removed from district 3 2 2 2 9 Failed to attend for Final Schick Test — 7 22 10 39 ,, ,, Schick Reading — 1 1 — 2 ,, ,, after 1 injection — 3 4 — 7 Total number of Attendances during 1937 353 1,043 2,163 339 3,898 During the previous year (1936) the number of children who attended for immunisation was 1,309, and the total number of attendances made during that year was 5,215. From these figures it is evident that there has been a marked decrease (26.7 per cent.) in the number of children who attended during 1937. 88 Children attending the infants and junior departments of elementary schools were supplied with printed pamphlets containing information regarding the Council's diphtheria immunisation clinics, along with acceptance of treatment forms for signature by parents. Circular letters were sent by post to 1,000 parents of infants who had just reached the age of one year. The leaflets enclosed with the circular letters drew particular attention to the danger of diphtheria in young children, to the desirability of having children protected between one and two years of age, and to the facilities available. Of 1,000 parents who received these letters, only 71 took advantage of the facilities offered. 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 toxsemic manifestations of diphtheria. During 1937, some 8 Leyton children, who had been immunised previously, 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. 10 yrs. M. 6. 3.36 10. 7.36 22. 2.37 — Not Clinical Diphtheriatonsillitis). 7 yrs. F. 15.10.36 1. 2.37 27. 2.37 T + Do. 7 yrs. M. 24. 1.36 18. 9.36 16. 3.37 T + Nasal diphtheria (mild). 5 yrs. M. 30. 3.35 18. 7.35 28. 6.37 N — T — Not clinical diphtheria(Tonsillitis). 7 yrs. F. 8.10.36 1. 2.37 25. 9.37 T — Not clinical diphtheria(Acute bronchitis). 4 yrs. F. 27.10.36 7. 5.37 17.12.37 T — Not clinical diphtheria. 8 yrs. F. 13. 7.35 31.10.35 14. 9.37 N + T — Faucial diphtheria. 6 yrs. F. 23.10.36 7. 5.37 11.11.37 Not clinical diphtheria 89 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 1910 101 .82 32 .26 1911 118 .94 53 .42 1912 115 .90 44 .34 535 4.32 208 1.66 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. 1933 78 .63 12 .09 1934 68 .55 8 .06 1935 69 .56 8 .06 1936 56 .46 13 .10 1937 55 .46 8 .06 326 2.66 49 .37 It will be observed that the death rate from pulmonary tuberculosis has been reduced by 38.42 per cent., and from nonpulmonary tuberculosis by as much as 77.70 per cent. in the comparatively short space of twenty-four years. 90 Notifications.—One hundred and thirty-one patients were notified for the first time in 1937 as suffering from tuberculosis. The number was made up as follows:— Males. Females. Total. Pulmonary Tuberculosis 61 49 110 Non-Pulmonary Tuberculosis 9 12 21 70 61 131 During the year it was found possible to remove from the tuberculosis register the names of 14 children and 17 adults in whom evidence of active disease had ceased to exist. The following is a statement of particulars appearing in the Register of Notifications of Cases of Tuberculosis for the year ended 31st December, 1937:— Pulmonary. Non-Pulmonary. total M. F. Total. M. F. Total. Number on Register at commencement of year 253 187 440 46 52 98 538 Number first notified during the year 61 49 110 9 12 21 131 Number of cases entered in Register otherwise than by Notification 16 16 32 6 4 10 42 Number removed from the Register during the year 55 45 100 13 16 29 129 Number remaining at the end of the year 275 207 482 48 52 100 582 Details of cases removed from the Register during the year:— Died 33 22 55 4 4 8 63 Removed from the district 11 11 22 4 8 12 34 De-notified 10 12 22 4 5 9 31 91 Deaths.—Sixty-three deaths from tuberculosis were recorded:— Males. Females. Total. Pulmonary Tuberculosis 33 22 55 Non-Pulmonary Tuberculosis 4 4 8 63 This is equivalent to a death rate of 0.53 per thousand of the population, as compared with a figure of 0.57 for the previous year. The following table gives particulars regarding the new cases and deaths which have occurred during the year Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 0 — — — — — — — — 1 — 3 — 1 — — 1 — 5 3 2 — 4 1 — 1 1 10 — 1 2 1 1 — — 1 15 3 8 1 1 o 2 — — 20 9 12 2 — 1 4 — 1 25 19 15 1 1 9 5 1 — 35 10 3 3 1 5 4 1 45 6 1 — 1 7 4 1 — 55 7 3 — — 6 2 — 65 and upwards. 4 1 — 2 1 1 — — Totals 61 49 9 12 33 22 4 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. 92 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 1937 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 54 33 5 6 98 Children 2 3 5 7 17 CANCER There were 196 deaths during the year, giving a death rate of 1.66 per thousand of the population. The various organs affected in their order of frequency may be gauged from the following list of deaths from cancer occurring during the year under review:— Males. Females. Digestive organs and peritoneum— Stomach 19 20 Colon 7 13 Intestine 1 2 Rectum 7 8 Caecum 2 3 Bile duct — 1 Gall bladder 3 1 Liver 9 4 Pylorus — — Oesophagus 8 1 Pancreas 1 1 Ventriculi 2 — Splenic Flexure 1 — Respiratory organs— Lung 10 4 Larynx 2 1 Mediastinum — 1 Bronchus 1 — 93 Diabetes—Supply of Insulin. During the year three patients were supplied with Insulin at a cost to the Council of £11 19s. l1d. 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 1,689 Ringworm 5 Sputum 541 Widal test (Enteric Fever) 44 Miscellaneous 119 Biological examinations for virulence test 2  Males. Females Female genital organs— 5 Cervix Uterus — 7 Ovary — 1 Vulva — 1 Breast — 20 Male genito-urinary organs— Bladder 2 — Prostate 8 — Kidney 1 — Buccal cavity and pharynx— Pharynx 1 — Maxilla — 1 Tongue 4 1 Palate 1 — Jaw — 1 Other sites 6 3 TABLE No. 9. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1937. DISEASE. At All Ages Under 1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 and up Smallpox — — — — — — — — — — — — — Diphtheria 161 1 5 11 6 11 72 33 :i 16 2 — 1 Erysipelas 71 — — — 1 — — — 2 3 12 29 24 Scarlet Fever 309 1 12 25 18 28 146 42 13 19 3 1 1 Pemphigus Neon. 1 1 — — — — — — — — — — — Pulmonary T.B. 110 — — 1 2 1 3 1 11 55 14 16 6 T.B. Others 21 — — — — 1 4 3 2 4 4 1 2 Pneumonia 122 5 5 5 4 4 9 5 11 20 10 31 13 Ophthalmia Neon. 5 5 — — — — — — — — — — — Enteric Fever 17 — — — 2 1 1 3 4 1 2 3 — Puerperal Fever — — — — — — — — — — — — — Puerperal Pyrexia 12 — — — — — — — — 11 1 — — Cerebrospinal Meningitis 1 1 — — — — — — — — — — — Poliomyelitis 12 1 — — — 1 9 — 1 — — — — Enc. Lethargica 1 — — — — — — 1 — — — — — Dysentery 35 2 — 2 — 5 16 6 — 2 2 — — Totals 878 17 22 44 33 52 260 94 47 131 50 81 47 94 TABLE 9a. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1937. DISEASE. Total. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Removed to Hospitals. Smallpox — — — — — — — — — — — Diphtheria 161 10 29 8 15 28 19 19 12 12 9 153 Erysipelas 71 2 18 8 4 12 4 4 11 6 2 27 Scarlet Fever 309 36 40 31 38 28 27 47 25 18 19 224 Pemphigus Neon. 1 — — — — — — — — — 1 — Pulmonary T.B. 110 9 18 8 20 8 11 7 12 10 7 — T.B. Others 21 2 — 3 — 5 2 1 5 1 2 — Pneumonia 122 16 34 5 13 17 15 3 6 5 8 61 Ophthalmia Neon. 5 — 3 1 1 — — — — — — 3 Enteric Fever 17 — 4 2 3 1 4 — 1 2 — 15 Puerperal Fever — — — •— — — — — — — — — Puerperal Pyrexia 12 1 2 2 1 4 2 — — — — 9 Cerebrospinal Meningitis 1 — — — — — — 1 — — — 1 Poliomyelitis 12 1 5 1 — 2 1 1 — 1 — 10 Enc. Lethargica 1 — — — — — — — 1 — — 1 Dysentery 35 — 7 11 1 4 5 2 2 1 2 4 Totals 878 77 160 80 96 109 90 85 75 56 50 508 95 96 ISOLATION HOSPITAL. Statistical Returns 1937. Admissions:— At all Ages. Under 1 year. 1 and under 5 yrs. 5 and under 15 yrs. 15 and under 25 yrs. 25 and under 35 yrs. 35 and under 45 yrs. 45 yrs. & up wards Scarlet Fever 212 - 63 127 11 6 4 1 Diphtheria 136 — 23 95 7 8 2 1 Whooping Cough 4 1 1 2 — — — — Chicken-pox 1 — — — 1 — — — Mumps 1 — 1 — — — — — Totals 354 1 88 224 19 14 6 2 The total number of patients admitted during the year was 354, as compared with 419 during the previous year. SCARLET FEVER. Of 309 persons notified during the year 212 (68 per cent.) were admitted to Leyton Isolation Hospital for treatment. Of that number 104 were males and 108 females. The average period of treatment in hospital was 33.42 days. 1933 1934 1935 1936 1937 Number of cases notified 743 681 409 367 309 Number of eases treated in Leyton Isolation Hospital 443 391 260 232 212 Percentage 59% 58% 63% 63% 68% Deaths in Hospital 4 1 0 2 0 Hospital case fatality 0.90% 0.25% Nil. 0.86% Nil. Included among the number of 212 patients admitted to the scarlet fever wards were:— Re-admissions 1 Other diseases 3 It was necessary to arrange for admission to institutions outside the area of 3 Leyton residents suffering from scarlet fever. No patient died in the scarlet fever wards of the hospital during the year. 97 Incidence of Complications. (Results of Investigation by Dr. Henderson, Deputy Medical Officer of Health). During the year 1937 some 208 patients, diagnosed as scarlet fever, were admitted to Leyton Isolation Hospital. In 13 of these patients the diagnosis was not confirmed. Complications Present on Admission. Of the 195 patients definitely diagnosed as scarlet fever, 14 had complications on admission. The following table shows these complications :— Rhinitis 6 Otorrhœa 4 Abscess of knee 1 Burns 1 Bronchitis 1 Impetigo 1 Complications during Course of Disease. Fifty-two patients (27 per cent.) developed complications during their stay in hospital. Forty-four had one complication, and eight had two 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 years. 5-10 years. 10-15 years. 15 years & over. Number. Percentage Otorrhœa 2 1 - 1 3 1.5 Rhinitis 6 4 - - 10 5.0 Cervical adenitis 8 5 1 2 15 7.7 Arthritis 1 — — — 1 0.5 Measles 5 1 — — 6 3.0 Secondary tonsillitis and quinsey 3 1 2 1 7 3.5 Second attack of scarlet fever 1 3 — - 4 2.0 Endocarditis — 1 — - 1 0.5 Albuminuria — 1 — — 1 0.5 Nephritis 1 3 1 — 5 2.5 Boils ... 1 — — — 1 0.5 Whitlows 2 2 — — 4 2.0 Glossitis — 1 — — 1 0.5 Buttock Abscess 1 — — — 1 0.5 Total 31 23 3 3 60 98 Cases of otorrhœa, rhinitis and adenitis comprised almost half (47 per cent.) of the total complications. For the past few years there has been a steady decline in the incidence of renal complications as can be seen from the following table:— Nephritis per cent. Albuminuria per cent. Total per cent. 1934 1.29 16.02 17.83 1935 2.33 8.17 10.50 1936 0.90 3.18 4.09 1937 2.50 0.50 3.00 Time 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 9 15 13 23 60 15% 25% 22% 38% 100% Serum-Treated Cases. Twenty-five patients received anti-scarlet fever serum and of these fourteen developed serum rashes; none developed complications. Sulphonamide. Some 129 patients received sulphonamide and of these 32 (25 per cent.) developed complications. Operation. On one patient who developed an otitis media a radical mastoid operation had to be performed. DIPHTHERIA. Of 161 persons notified during the year, 136 (84 per cent.) were admitted to Leyton Isolation Hospital. Of that number, (57 were males and 69 females. The average period of treatment in hospital was 42.98 days per case. 1933 1934 1935 1936 1937 Number of eases notified 94 257 276 231 161 Number treated in Leyton Isolation Hospital 70 193 188 187. 136 Percentage 74% 75% 68.1% 80% 84% Deaths in Hospital 4 10 6 9 4 Hospital case fatality 5.70% 5.18% 3.19% 4.81% 2.94% 99 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 161 cases were notified. Deaths.— Four 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. 7 years Toxaemia, Diphtheria 2 days 2 M. 5 „ „ 15 „ 3 F. 7 ,, ,, ,, 9 „ 4 F. 1½ „ Laryngeal diphtheria, tracheotomy ... 1 hour Massage and Special Treatment. 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. 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 21 42 School Children 87 180 Adults 17 90 125 312 Maternity and Child Welfare. 102 MATERNITY AND CHILD WELFARE. INFANT WELFARE. Notification of Births.— Fourteen hundred and twenty-one notifications of births were received during the year. By medical practitioners 350 By midwives 1,067 By parents and others 4 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. Toddler's Clinic, Fridays, 10 a.m. During the year under review, the total attendances at the Council's Infant Welfare Centres were 17,825, an increase of 1,605 compared with the figure (16,220) for the previous year. The number of children examined by the Clinic Medical Officers was 6,674 as compared with 6,323 examined during the previous year. 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 and Park House 1918 Mrs. Wag staff Leyton Green and Park House 1924 Mrs. D. Jacobs Leyton Green 1934 Mrs. F. Reeve Leyton Green 1937 Mrs. J. Murray Leyton Green 1937 Mrs. o. R. Kelly Leyton Green 1937 Miss H. S. Holl Park House 1927 Miss E. H. Holl Park House 1927 Mrs. J. Oates Park House 1929 Miss Muddiman Park House 1934 Miss Goodman Park House 1937 103 TABLE 10. ATTENDANCES, EXAMINATIONS, etc., 1937. Leyton Green. Park House. All Centres 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. Under 1 year— 1st attendances 125 236 2 159 192 - 158 152 1,024 Subsequent attendances 1,754 2,543 1 1,634 2,308 — 1,986 1,955 12,181 Total attendances 1,879 2,779 3 1,793 2,500 — 2,141 2,107 13,205 1 -5 years—- 1st attendances 15 38 129 12 18 112 18 13 355 Subsequent attendances 484 890 277 364 1,007 240 527 476 4,265 Total attendances 499 928 406 376 1,025 352 545 489 4,620 Total attendances, both age groups 2,378 3,707 409 2,169 3,525 352 2,689 2,596 17,825 Average attendance per session 49.54 77.23 8.52 45.18 73.43 7.33 54.87 52.98 46.17 Number examined by clinic M.O. 833 1,163 363 859 1,243 318 902 993 6,674 Average number examined per doctor per session 17.35 24.23 7.56 17.89 25.89 6.62 18.40 20.26 17.29 Number weighed 2,370 3,669 374 2,142 3,525 352 2,686 2,592 17,710 104 During the year these ladies have continued to render valuable assistance at the infant welfare centres, where their services are greatly appreciated. Without their assistance it would be impossible to cope with the large numbers attending. Health Visitors. During the year the Health Visitors have made 17,790 visits to homes, as follows:— (а) To expectant mothers :— First visits 219 Total visits 243 (б) To children under 1 year of age:— First visits 1,427 Total visits 7,471 (c) To children between the ages of 1 and 5 years:— Total visits 10,076 Dental Treatment. During the past five years the annual numbers 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 have been:— 1933 292 1934 273 1935 283 1936 291 1937 295 The record of such treatment undertaken during the year 1937 is:— Expectant Mothers. Children. Patients treated 101 194 Attendances 273 314 Extractions 434 399 Fillings 23 78 Other dental operations 45 6 Advice only 6 20 Anaesthetics— General 83 73 Local 12 98 105 Dentures supplied— Full upper and lower 5 Partial upper and lower 3 Full upper 5 Partial upper 2 Full upper and partial lower 1 16 Orthopaedic Treatment. Primary Examinations.— During the year 48 children were referred from the Infant Welfare Clinics to the Council's Orthopædio Surgeon. The orthopaedic defects included:— Congenital. Torticollis 3 Deformity digit (hand) 2 „ (foot) 2 Talipes 5 Acquired. Genu valgum 23 Bowed tibiœ 7 Bowed femora 1 Pigeon chest 1 High shoulders 1 Valgus ankles 2 Pes piano valgus 22 Re-examinations.— In addition to the 48 new cases mentioned above, 65 children under five years of age attended for re-examination by the Orthopaedic Surgeon. Treatment.— Eighty-seven children made 294 attendances at Knotts Green Special School for special treatment by the Council's Masseuse (Miss Findlay). 106 Provision of Surgical Appliances.— Sixty-eight 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 pairs Talipes splint 1 ,, Wedges, valgus pads and stiffening to boots 1 ,, Minor alterations to ordinary boots and shoes 64 ,, Surgical Operations.— During the year two children under school age were admitted to hospital and the following operations were performed by Mr. Whitchurch Howell:— Manipulation digit 1 hand R. and L. with plaster 1 „ foot with plaster (3) 2 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 34 pre-school children, who made 58 attendances for examination and treatment. The ophthalmic defects found in these 34 children were:— Myopic astigmatism 2 Hypermetropia 3 'Hypermetropic astigmatism 3 Hypermetropia with squint 9 Squint only 7 Anisometropia 1 The following forms of treatment were recommended :— Spectacles supplied 19 Spectacles not prescribed 12 Squint referred to Orthoptic Clinic 3 Artificial Sunlight Treatment. Number of cases treated—Infants 89 Number of cases treated—Adults 2 Total number of attendances 1,822 107 Convalescent Home Treatment. Children. During the year 47 children, recommended by the ClinicMedical Officer, were sent to Convalescent Homes by the Maternity and Child Welfare Authority through the agency of the Invalid Children's Aid Association. The illnesses for which convalescence was recommended were:— Debility (15 cases). Scarlet fever (3 cases). Whooping cough (3 cases). Pneumonia (6 cases). Bronchitis (6 cases). Measles (2 cases). Tonsillitis (1 case). Fibrosis (1 case). Catarrh (1 case). Otitis media (1 case). Diphtheria (1 case). Rheumatism (1 case). Influenza (1 case). Otorrhœa (1 case). Marasmus (1 case). Recurrent styes (1 case). Chronic rheumatism (1 case). Anaemia (1 case). Thirty-two of the 47 children were between the ages of two and four years; 12 were over four years ; and 3 were under two years. Nursing Mothers. Five mothers were sent away for two weeks convalesence to "Child Haven" Hutton, near Brentwood, after they had had their babies. 108 Ophthalmia Neonatorum. No. of Cases Notified. Treated Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. At Home. In Hosp. 5 2 3 5 — — — Treatment.— These 5 cases were treated as follows :— . At home 2 St. Margaret's Hospital 2 St. Thomas's Hospital 1 5 Infant and Foetal Mortality. There were 75 registered deaths of infants under one year of age, giving an infantile mortality rate of 52.81 per thousand live births. Neonatal Mortality (deaths of infants under one month).— Of the 75 deaths under one year, 37 occurred in the first four weeks; and of the 37 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. Neonatal. 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 1937 1,420 75 37 52.81 26.05 60 Reference to Table 11 will show that the chief cause of neonatal deaths was premature birth (20). i—- o o TABLE 11. Infantile Mortality, Year 1937—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 ... ... ... ... ... ... ... ... ... ... Chicken pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... 1 Scarlet fever ... ... ... ... ... ... ... ... ... ... Whooping cough ... ... ... ... ... ... ... ... ... ... Diphtheria and croup ... ... ... ... ... ... ... ... 1 1 Influenza ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) ... 1 ... ... 1 ... ... ... 1 2 Convulsions ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... 1 ... ... 1 Pneumonia (all forms) ... ... ... ... ... 2 5 5 5 17 Diarrhoea ... ... ... ... ... 1 ... ... 1 2 Enteritis ... ... ... ... ... ... 5 ... ... 5 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... Injury at birth 1 ... ... ... 1 ... ... ... ... 1 Atelectasis 5 ... ... ... 5 ... ... ... ... 5 Congenital malformations 5 ... ... 2 8 ... 2 ... ... 12 Premature birth 16 ... ... 2 18 ... 2 ... ... 20 Atrophy, debility and marasmus 1 ... ... ... 1 ... ... ... ... 1 Other causes 3 ... ... ... 3 2 1 ... 1 7 Totals 31 2 — 4 37 8 16 5 9 75 Nett Births registered during (Legitimate 1,389 Nett Deaths registered during Legitimate infants 72 the calendar year 1 Illegitimate 31 the calendar year (Illegitimate infant.3 110 TABLE 11a. Infantile Mortality During the Year 1937—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 Ik aths under 1 Year. Smallpox ... ... ... ... ... ... ... ... ... ... ... ... Chicken pox ... ... ... ... ... ... ... ... ... ... ... ... Measles ... 1 ... ... ... ... ... ... ... ... ... 1 Scarlet fever ... ... ... ... ... ... ... ... ... ... ... ... Whooping cough ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria and croup ... ... ... ... ... ... 1 ... ... ... ... 1 Influenza ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases. ... ... ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) 1 ... ... ... ... ... 1 ... ... ... ... 2 Convulsions ... ... ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... 1 ... ... ... ... ... ... 1 Pneumonia (all forms) 3 3 ... ... 3 1 1 1 2 ... ... 17 Diarrhoea ... ... ... ... ... ... I 1 ... ... ... 2 Enteritis ... ... ... ... ... 1 ... 1 ... 2 1 5 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... ... ... Injury at birth ... ... ... 1 ... ... ... ... ... ... ... 1 Atelectasis ... ... ... 1 1 2 ... 1 ... ... ... 5 Congenital malformations 2 1 2 ... 2 3 1 1 ... ... 12 Premature birth 3 3 7 1 1 4 ... 1 ... ... ... 20 Atrophy, Debility and Marasmus ... ... ... ... ... 1 ... ... ... ... 1 Other causes ... 2 ... ... 2 ... ... 1 1 1 ... 7 Totals 9 10 10 5 8 10 8 7 4 3 1 75 Ill Public Health Act, 1936. Child Life Protection. On 1st January, 46 foster mothers and 48 children—and at the end of the year 33 foster mothers and 33 children—were subject to inspection. The Council's Child Protection Visitors made 224 visits of inspection during the year. Summary, Year 1937. Number of nurse children on Register 1st January 48 Number of nurse children notified by foster mothers during the year 23 Nurse children removed :— To parents or relatives 18 To another foster mother ... 8 With foster mother to another area 2 Adopted 1 To National Children's Home 1 To other institutions 4 Attained 9 years of age 3 Removed from Register—kept without reward 1 Died — Number of nurse children on Register on 31st December 33 ANTE-NATAL SUPERVISION. Ante-natal Clinics— (1) Park House Clinic, Granleigh Road, E.ll.— Thursdays, 10 a.m. (2) Leyton Green Clinic, Leyton Green Road, E.10.— Wednesdays, 10 a.m. (3) Maternity Department, Queen Mary's Hospital. Attendances.— During 1937, the attendances were:— Centre. First Attendances. Subsequent Attendances. Total. Park House Clinic, 260 530 790 Leyton Green Clinic 205 393 598 465 923 1,388 112 The total number of first attendances was 465, the corresponding figure for 1936 being 430. The total number of attendances at all clinics during the year was 1,388, the average attendance per session being 13.09. Of the 465 expectant mothers who made first attendances, 116 had not been confined by the end of the year and the results of these cases will be included in the Annual Report for 1938. On the other hand, 148 cases were carried over from 1936, and, when 21 cases are excluded who removed before confinement, details of 476 cases are available. Of that number 11 were not pregnant, and the following table deals with the attendances of the remaining 465 cases. Number of Expectant Mothers who attended. 465 Percentage of Primigravidae. 42.15 Percentage of Multipara. 57.85 %* %* 1. Attended before 24th week of pregnancy 45.92 (33.54) 31.22 (35.81) 2. Attended after 24th week and before 30th week 15.30 (21.74) 26.76 (15.81) 3. Attended after 30th week and before 36th week 8.16 (11.18) 7.43 (8.83) 4. Transferred 21.94 (22.98) 15.61 (14.41) 5. Unsatisfactory '8.67 (10.62) 18.96 (25.11) * Figures for previous year (1936) 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, 69 per cent. of the primigravidae and 65 per cent. of the multiparas 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-nine point nought-seven per cent. of expectant mothers attended of their own accord or on the advice of a friend or relative. Forty-six point sixty-three per cent. were sent by their midwives and 8 cases were advised to attend by their own doctors. 113 The number of home visits made by Health Visitors to expectant mothers during the year was 243. The results of all cases examined are tabulated below. Number. Percentage of Finished Cases. Normal 371 84.12 Prematurity 11 2.49 Stillborn 11 2.49 Instrumental delivery 23 5.21 Breech presentation 7 1.58 Miscarriage 7 1.58 Twins (1 not viable) 5 1.13 Induction 1 0.22 Cæsarean section 3 0.68 Placenta prævia 1 0.22 Adherent placenta 1 0.22 Total 441 Not pregnant 11 Removed 45 Grand Total 497 Attendances at Municipal Ante-Natal Clinics. Since 1930 the ante-natal records have been scrutinised year by year to compile the above Table. It is not proposed to continue it each year, although it may be worth comparing the figures in another five years. There has been a very definite improvement in the attendances since 1930. Although the annual number of births has decreased from 1,757 to 1,420 in eight years, the percentage of institutional births has increased from 30.73 to 53.9 (and the majority of these cases do not attend the municipal ante-natal clinics), the total of completed cases has increased from 327 in 1930 to 460 in 1937. There is an even greater improvement in the nature of the attendances. In 1930, 16.78 per cent, of the primigravidse and 40.52 per cent, of the multiparas were unsatisfactory in their attendance, while in 1937 the percentage of unsatisfactory attendances had dropped to 8.76 per cent, of primigravidae and 19.17 per cent, of multiparas. For the purpose of this table 114 a woman has been reckoned as a primigravida if she has not previously had a viable child. This gives a higher percentage of primigravidae than is shown in the analysis of ante-natal records from 1930-34, which is included elsewhere in this report. Analysis of Abnormal Cases. (Report by Dr. Menzies). (a) Instrumental Delivery (23 Cases). Of the instrumental deliveries, 18 occurred in primigravidae. Of these, nine had arranged to enter hospital for their confinements. The remaining nine had booked with midwives. Of the midwives cases, two were referred to hospital for further advice. In one case version was performed ; in the second arrangements were made for admission to hospital as the presentation was left occipito-posterior and the promontory was felt at inches. In two cases the head was not fixed at 38-39 weeks, but no definite disproportion was found. Three cases did not attend in the last month of pregnancy although urged to do so by the midwife or health visitor. The ages of these 18 primigravidae ranged from 22 to 35 years. Three were under 25 years, and eight were over 30 years. A separate analysis of ante-natal records shows that 52 per cent, of the primigravidae attending the clinics are under 25 years, and only 11 per cent, over 30 years. Of the 5 multiparae who had instrumental deliveries, one was having her second child fifteen years after her first; and a second was having her fifth child after a nine year interval, the first three having occurred in four years, and the mother's general musculature being poor. The third case was in a woman of 46, of poor physique, who was having her sixth child after a five year interval. The fourth case was referred to hospital as she had a small pelvis, and had already had one stillbirth followed by a live birth by instrumental delivery. The fifth case was unable to attend during the last six weeks of pregnancy, but it was noted at 34 weeks that the head was large. There were no stillbirths among the instrumental deliveries. 115 (b) Cæsarean Section (3 Cases). Cæsarean section was performed on 3 primigravidæ. One was referred to hospital at 34 weeks as a breech, with a soft mass at the brim of the pelvis. External version was performed with considerable difficulty, and the patient was discovered to have a fairly large cystic swelling in the hollow of the sacrum which would definitely obstruct labour. The second case was a woman of small stature, who had one leg shorter than the other without any obvious tilting of the pelvis. She was referred to hospital at 33 weeks as "disproportion" and was kept in hospital from the 35th week. The third was a woman of 35 years with an excessive amount of abdominal fat. She made one attendance at the clinic at 36 weeks. Two weeks later she was sent to hospital by her private medical practitioner as a case of disproportion, breech presentation. Although she had large external measurements, and the baby weighed only 6¼ lbs., it was considered advisable to perform Cæsesarean Section at term. (c) Induction (1 Case). Surgical induction was performed at 38½ weeks in a multiparae aged 24 years. She had had two previous inductions at 36-38 weeks, and a living child resulted in each case. In this pregnancy she was referred to hospital at 34 weeks because she was developing hydramnios. (d) Breech Presentation (7 Cases). Of the breech presentations 4 occurred in primigravidae and 3 in multiparae. None of the four in primigravidae was diagnosed definitely in pregnancy although two were queried. One resulted in a stillbirth ; it was a footling, with the cord prolapsed. Of the 3 multiparae, one was a woman of 41 years who was having her sixteenth child. The second failed to attend in the last six weeks although urged to do so. The presentation was an extended breech and the baby was stillborn. The third was sent by her midwife at 38-39 weeks and was found to be a breech. She was a woman of 41 years having her seventh child after a six-year interval. She had a very solid abdomen and said she usually had 9 lb. babies. There was no possibility of doing a version and she was given a letter to attend hospital six days later if labour had not commenced. She turned out to be a breech with extended legs and when she was admitted to hospital surgical induction was performed. This resulted in a living child. When she was 116 examined at the ante-natal clinic her blood pressure was 130/86 with no symptoms suggesting toxæmia; but when she was examined at hospital six days later she was found to be suffering from a degree of toxæmia sufficient for her immediate admission to hospital. (e) Stillbirths (11 Cases). Four of these cases occurred in primigravidæ; and in a fifth the only other pregnancy had terminated in a three months' miscarriage. This last case (aged 24) was referred to hospital for further advice at 35 weeks because of slight ante-partum haemorrhage with a rise in blood pressure to 150/100 and was considered to have a sufficient degree of toxaemia for admission to hospital. Of the four primigravidae, one (aged 21 years) developed symptoms of toxaemia between 30-34 weeks, with albuminuria and a rise in blood pressure to 140/90, and was referred to her general medical practitioner who sent her to hospital. The second, aged 34 years, made only one attendance at the clinic. She failed to keep her second appointment when disproportion might have been suspected. She had a long and difficult instrumental delivery, and, in addition to losing her baby, the mother developed infection of the lower genital tract and had a long convalescence. The third case attended the clinic regularly, and as the head was in the pelvis at the last examination no abnormality was suspected, but when she was in hospital for her confinement it was discovered under general anaesthesia that there was some obstruction to delivery and it seems likely that she will be able to have a living child only by Caesarean Section. The fourth primigravida made one attendance at the clinic before booking at hospital and no details are available as to the cause of the stillbirth. Of the six multiparae, one was advised to book at hospital because she developed toxaemia at 34 weeks in her first pregnancy. Her first pregnancy resulted in a live birth, but this one (5 years later) of which no details are available, terminated in a full term stillbirth. The second case was a multipara (1) (previous child living), in which the baby was already dead when she made her only attendance at the clinic after 36 weeks amenorrhœa. The third case was referred to hospital because of a suspicious vaginal discharge. The result was negative, but she had a stillborn anencephalic monster. The fourth case was a woman of 38 years who had had two living children followed by a three months miscarriage and in this, her fourth pregnancy, she developed slight 117 toxaemia at 36 weeks, and had a macerated foetus at full term. The fifth case was a woman of 31 years, whose first pregnancy terminated in a four months' miscarriage, her second in a stillbirth at 36 weeks, and this was the third. The foetal heart sounds were heard at her last attendance when she was thought to be 35 weeks. Unfortunately she did not keep her next appointment, and although the pregnancy continued four weeks longer than was expected, her midwife did not induce her to re-attend. She made no advance in labour and was sent to hospital. The sixth case was a multipara (4) of 28 years. The stillbirth was due to a large sacral meningocele which prevented delivery of the buttocks. A general anaesthetic was given and the meningocele punctured. The confinement took place in hospital. (f) Prematurity (11 Cases). Of the eleven cases of premature birth, five occurred in primigravidae and six in multiparae. The primigravidae ranged from 22 to 36 years. None of the premature births occurred before the 36th week. In two cases, only one attendance had been made at the clinic and there was some doubt as to the accuracy of their dates. The only abnormalities found antenatally in these five cases was a slight rise in blood pressure at the 37th week in one case (she had her baby two days later), and in a second disproportion was suspected at 36 weeks. She was sent to hospital and had her baby two weeks later following an accidental haemorrhage. The only baby who did not survive was one who had hydrocephalus. Of the six multiparae, two made only one attendance late in pregnancy. A third was found to have albuminuria and raised blood pressure at her first attendance when she was 24-26 weeks pregnant, and was referred to her private medical practitioner. She was sent to hospital and had a premature stillbirth two months later. She was 39 years of age, and had had six children—all normal labours. Of the other three, two were in poor financial circumstances and were allowed free milk. One of the two was obviously in a poor state of nutrition. Her baby was born at 34 weeks and lived six hours. The third was in poor physical condition, thin and nervous, and suffered from excessive vomiting. She had three weeks' rest in a convalescent home during pregnancy. Her husband was working, but not at a good wage. The baby was born in hospital, about two weeks premature and did not survive. 118 Analysis of Ante-Natal Records for a Five-year Period. Report by Dr. Hilda Menzies. This analysis was undertaken primarily to discover the proportion of pregnancies occurring in the different age groups in women who attended the municipal ante-natal clinics in the Borough of Leyton throughout a five-year period. As the result of the pregnancy was recorded in each case, the abnormalities were grouped similarly according to the age of the patient and the number of the pregnancy. The records numbered 2,088, of which the distribution according to previous fertility is shown in Table I. When the order of birth was tabulated, miscarriages and abortions were included as previous pregnancies. TABLE I. No. of Pregnancy. No. of Cases. Percentage of Total 2,088. 1 778 37.2 2 467 22.3 3 242 11.6 4 191 9.1 5 115 5.5 6 96 4.6 7-14 199 9.5 2,088 100.0 I had not considered that these percentages could be taken as representative of the fertility of Leyton women in general, as it might be argued that figures taken from clinic attendances were weighted with primiparse. While I have been engaged on this analysis, information regarding the previous fertility of child-bearing women in certain areas has been published in the Ministry of Health " Report on an Investigation into Maternal Mortality." Thus in Manchester in 1934 the percentage of primiparous live births was 36.6. The birth-rate for that year in Manchester was 15.3, while the Leyton birth-rate was 11.78. One would therefore expect the proportion of primiparse in Leyton to be higher than in Manchester, so that the percentage of 37.2 in this series may be representative of Leyton. 119 TABLE II. No. of Pregnancy Age of Patient. Total. Under 20 yrs. 20—25 years 25—30 years 30—35 years 35—40 years 40 + years 1st 65 359 266 63 19 6 778 (8.3%) (46.1%) (34.2%) (8.1%) (2.4%) (0.8%) 2nd 6 127 205 89 34 6 467 (1.1%) (24.1%) (38.9%) (16.9%) (6.5%) (1.1%) 3rd 39 64 91 40 8 242 (16.5%) (26.4%) (37.6%) (16.5%) (3.3%) 4th — 5 51 89 34 12 191 (2.6%) (26.7%) (46.6%) (17.8%) (6.3%) 5th — — 20 46 40 9 115 (17.4%) (40.0%) (33.9%) (7.8%) 6th — — 8 35 41 12 96 (8.3%) (36.5%) (42.7%) (12.5%) 7th and sub. — — 10 37 77 75 199 (5.0%) (18.6%) (38.6%) (37.6%) Total 71 530 624 450 285 128 2088 Percentage (3.4) (25.4) (29.9) (21.6) (13.6) (6.1) (100) In Table II the numbers are subdivided according to agegroup and previous fertility. The age-grouping is by five-yearly periods, e.g., under 20 years, 20-25 years, etc. The percentage figures read horizontally, e.g., of 778 women who attended during their first pregnancy, 65 or 8.3 per cent, were under 20 years when they first attended. The percentage figure at the foot of the table shows the percentage in the different age-periods, irrespective of the degree of fertility. This table shows that 54 per cent, of the primiparæ were pregnant before they were 25 years old, and that only 11 per cent, were over 30 years old. There is no reason to suppose that these percentages are not representative of primiparæ in Leyton generally. The percentage of all women attending before 30 years of age was 58.7. Dr. Stocks, in the Ministry of Health "Report on an Investigation into Maternal Mortality" gives a table showing the age distribution of mothers of legitimate children born in certain years in England and Wales. Out of 1,000 births in 1931, 537 of the mothers were under 30 years of age, i.e., 53.7 per cent. Although my table is not strictly comparable with his because the age was taken during pregnancy (two-thirds in the last 16 weeks of pregnancy) and not after childbirth, the figures suggest that the age of 120 motherhood in Leyton is younger than in England and Wales. Dr. Stocks shows that the median age of motherhood has been getting slightly younger in both New Zealand and England and Wales in the last twenty years. This contradicts the general uninformed opinion on this subject. TABLE III. Abnormalities. No. of Pregnane v . Age of Patient. Total. Under 20 yrs. 20—25 years 25-30 years 30—35 years 35-40 years 40 + years 4 1st 7 42 30 13 4 100 (40.0%) 2nd 2 9 13 14 8 — 46 (18.4%) 3rd — 2 11 14 2 4 33 (13.2%) 4th — - 1 12 1 2 16 (6.4%) 5th — - 2 8 2 1 13 (5.2%) 6th — - 1 5 3 3 12 (4.8%) 7th and sub. — - 3 4 14 9 30 (l2.0%) Total. 9 53 61 (24.4) 70 34 23 250 Percentage (3.6) (21.2) (28.0) (13.6) (9.3) (100) Table III shows the incidence of abnormalities in the result of the pregnancy, grouped according to the age of the patient and her previous fertility. It includes abnormalities of all kinds, viz., twins, congenital malformations, stillbirths, instrumental deliveries, breech presentations, premature deliveries and miscarriages. One might have expected to find a greater proportion of abnormalties among primiparse— with 37.2 per cent, of the total births they account for 40 per cent, of the abnormalities; and it is rather surprising to find third pregnancies with 13.2 per cent, of the abnormalities from 11.6 per cent, of the births. It is probably a chance finding as there were as many as six pairs of twins and two congenital abnormalities (the latter out of a total of four in the 2,088 cases) in the third pregnancies. When the percentage of abnormalities in each age-group is compared with the percentage of cases in the corresponding agegroup, it would seem that the age of the mother is more significant than her previous fertility, the 30-35 age-group having 28 per cent. 121 of abnormalities with 21.5 per cent, of cases, and the over 40 age-group having 9.3 per cent, of abnormalities with 6.1 per cent, of cases. Table IV shows the distribution of the chief abnormalities according to age and pregnancy, although it is not suggested that TABLE IV. Sub-Grouping of Abnormalities. Twins. No of Pregnancy. Age of Patient. Total. Under 20 yrs. 20—25 years 25—30 years 30-35 years 35—10 years 40+ years 1st 1 4 5 1 - - 11 (1.41%) 2nd — 1 3 — 1 — 5 (1.07%) 3rd — 3 3 - — - 6 (2.48%) 4th — — 1 1 — — 2 (1.05%) 5th — — — 2 1 — 3 (2.61%) 6th — — _ 1 1 (1.04%) 7th and sub. — — — 9 3 1 6 1 triplets. (3.01%) Total ... 1 8 12 6 5 2 34 Percentage (1.40 (1.51) (1.92) (1.33) (1.75) (1.56) (1.62) Stillbirths. No. of Pregnancy. Age of Patient. Total. Under 20 yrs. 20—25 years 25- 30 years 30—35 years 35—40 years 40+ years 1st 1 5 5 1 1 1 14 (1.79%) 2nd — 1 4 1 4 — 10 prem. 2 prem. (2.14%) 3rd — 1 3 2 — 1 7 1 breech (2.89%) 4th — — — 1 - 1 2 (1.05%) 5th — — — 2 — — 2 (1.73%) 6th — — — 2 — — 2 (2.08%) 7th and sub. — — 2 — 3 6 11 (5.53%) Total 1 7 14 9 8 9 48 Percentage (1.4) (1.32) (2.24) (2.00) (2.80) (7.03) (2.29) 122 Instrumental. No. of Pregnancy. Age of Patient. Under 20 yrs. 20—25 years 25—30 years 30—35 years 35-40 years 40+ years Total. 1st - 18 13 7 2 3 43 (5.01%) (4.88%) (11.11%) (10.52%) (50.0%) (5.52%) 2nd — - 1 3 3 - 7 (1.52%) 3rd — — 1 2 — 1 4 (1.65%) 4th — — — — — — - 5th — — — — — — — 6th — — — — 1 — 1 (1.04%) 7 th and sub. - - - - 1 - 1 (.50%) Total — 18 15 12 7 4 56 Percentage — (3.39) (2.40) (2.66) (2.45) (3.12) (2.68) Breech. No. of Pregnancy. Age of Patient. Total. Under 20 yrs. 20—25 years 25—30 years 30—35 years 35—40 years 40 + years 1st — 3 1 — 1 — 5 (•64%) 2nd 1 1 1 3 - — 6 (1.28%) 3rd - - 1 1 1 — 3 (1.24%) 4th - - - 5 - - 5 (2.62%) 5th - - - 1 - — 1 (1.87%) 6th - - 1 1 - — 2 (2.08%) 7th and sub. - - - 1 1 - 2 (1.00%) Total 1 4 4 12 3 — 24 Percentage (1.40) (.75) (.64) (2.66) (1.05) — (.15) 123 Prematurity. No. of Pregnancy. Age of Patient. Total. Under 20 yrs. 20—25 years 25—30 years 30—35 years 35—40 years 40 + years 1st 3 6 — 1 — — 10 (1.28%) 2nd 1 5 A.P.H. 2 2 — — 10 (2.14%) 3rd — — 2 — — - 2 (.83%) 4th - - - 2 1 - 3 (1.56%) 5th - - 1 1 1 1 4 (3.47%) 6th - - - - A.P.H. 2 A.P.H. — 3 (3.12%) 7 th and sub. - - - 1 1 1 3 (1.50%) Total 4 11 5 8 5 2 35 Percentage (5.63) (2.07) (.80) (1.77) (1.75) (1.56) (1.67) Miscarriage. No. of Pregnancy. Age of Patient. Under 20 yrs. 20—25 years 25—30 years 30—35 years 35 -40 years 40+ years Total. 1st - 3 2 1 — — 6 2nd — — 1 2 — — 3 3rd - — — 2 1 1 4 4th — — — 2 — — 2 5th - — — 2 — — 2 6th — — — 1 — 2 3 7th and sub. — — 1 — 2 1 4 Total — 3 4 10 3 4 24 Percentage — — — — — — (1.2) the distribution has any special significance. The majority of the figures have not been examined statistically and it is possible that the differences in the various groups are not greater than may be due to chance. I am able, by the courtesy of a member of the staff of the London School of Hygiene, to say that this is so in the case of the stillbirth figures with the apparent increase from the first to the third pregnancy. 124 The figures in brackets are the percentages calculated on the total from the appropriate column in Table II. The percentage of miscarriages (1.2 per cent.) is not a fair estimate of the proportion of pregnancies in the district which terminate in abortion, as only 36 per cent. of primiparæ and 28 per cent. of multipara attend the clinics before the twenty-fourth week. In the case of breech presentations, version is attempted if the condition is diagnosed ante-natally, so that the original incidence of breech presentations in the series cannot be estimated from these figures. Maternal Mortality. From the 2,088 eases there were two deaths which were classified as maternal deaths, both from puerperal septicaemia following normal delivery in two women under 25 years of age. This gives a maternal mortality rate of 0.95. The mean of the maternal mortality rate for the Borough of Leyton during the same period was 3.1. There were two other deaths in women who had attended the ante-natal clinics, neither of which was classified as a maternal death although one was almost certainly associated with the pregnancy. This was in a multipara (4) aged 37 years, who showed signs of ill-health in pregnancy—slight failure of compensation with a trace of albumen and swelling of feet during the last two months of pregnancy. She had various domestic difficulties, but she was eventually persuaded to enter hospital five weeks before the baby was expected. She had a normal labour three weeks later and died after twenty-two days from mesenteric thrombosis. Additional Information regarding Economic Circumstances, etc., of Women of High Fertility. I enlisted the co-operation of the health visitors to obtain some information about the economic circumstances and health of the women who comprised the 199 cases from seventh and subsequent pregnancies. Some of the women had attended during three different pregnancies in the five years and the 199 cases represented 164 women. The information I asked was the standard of employment of the husbands (a) skilled (b) unskilled (c) chronic unemployment, and the physical health and mental capacity of the woman. Excluding removals, the employment of the husband in 125 156 families was grouped as follows:—Skilled, 20=13 per cent. ; unskilled, 88=56 per cent.; chronic unemployment, 30=20per cent.; unknown, 18=11 per cent. The percentage of unskilled workers and of those living below the poverty line is given in the New Survey of London Life and Labour (1932) as 18.4 and 6.9 respectively, in the Borough of Leyton. The marked difference in the proportion of the combined unskilled and unemployed groups among families of seven and more children compared with the proportion of these two groups in the Borough generally, viz., 76 per cent. as against 25 per cent., demonstrates the existence of differential fertility in Leyton. It'may be argued that percentages taken from clinic attendances are loaded with the poorer families, but on the other hand mothers from the lowest social level are less likely to attend an ante-natal clinic. The health of the mother was estimated in 148 cases as:Good, 25 per cent.; fair, 47 per cent.; poor, 27 per cent. The mental capacity was considered to be under average in 31 per cent. I have no figures showing the health of the main body of women attending the clinics, but I have little doubt that the percentage in poor health (27 per cent.) in this group is considerably in excess of the average. Maternity Beds. In addition to the 481 expectant mothers who attended the Council's clinics, 479 attended the Out-patient Department of Queen Mary's Hospital, Stratford, for ante-natal supervision. 311 mothers had their confinements in the Margaret Lyle Wards of the hospital. The complications dealt with included— Albuminuria 2 Ruptured perineum 48 Cæsarean section 5 Accidental haemorrhage 4 Post partum hæmorrhage 8 Placenta prævia 1 Eclampsia 1 Pre-eclamptic 17 Surgical induction 2 Medical induction 3 Prolonged labour 15 Forceps delivery 15 126 Occipito posterior presentation 5 Nephritis 1 Toxaemia of pregnancy 9 Pyelitis 1 Diabetes 1 Cardiac 4 Oedema 2 Episiotomy 13 Complete procidentia 1 Pyrexia 1 Hyperemesis 1 Trial labour 4 Breech 1 Stillborn 4 Foetal distress 1 Hare lip 1 Macerated foetus 6 Prolapsed cord 1 Spina bifida 1 Sticky eyes 1 Payment to Queen Mary's Hospital. In February, 1937, the Council considered a letter from the Secretary, Queen Mary's Hospital, stating that the cost to the Hospital of Leyton patients occupying maternity beds varied from £4 15s. Od. to £5 5s. Od. per week, and asking if this Authority would consider increasing the present payment of 7s. per day (£2 9s. Od. per week) in respect of Leyton patients to 10s. per day (£3 10s. Od. per week). He pointed out that several other Authorities, including the County of Essex, are paying the Hospital 10s. per day. Report by Medical Officer of Health to Maternity and Child Welfare Committee—February, 1937. The Margaret Lyle Maternity Block of Queen Mary's Hospital was opened in 1919. In the first year of its existence some 51 Leyton mothers were confined in the Hospital. In 1920 West Ham Maternity and Child Welfare Authority entered into an agreement with the Hospital for the payment of 7s. per day in respect of maternity cases from that area ; and in 1925 this Authority—with the approval of the Ministry 127 of Health—entered into a similar arrangement with regard to Leyton mothers. It was agreed to begin with that the Hospital should retain the maternity benefit, but owing to difficulties which have arisen subsequently, the Hospital agreed to waive its claim to maternity benefit. After women "book" for their confinements at the Hospital, they attend there regularly for ante-natal supervision as it is generally agreed to be desirable that the antenatal supervision should be conducted by those who will be responsible for the subsequent confinement; and the high average number of ante-natal attendances made by patients is a credit to the supervision exercised by the Hospital staff. The time devoted to the ante-natal supervision of Leyton women in the Hospital is equivalent to that of at least two ante-natal clinic sessions per week ; and to that extent this Council is relieved of the responsibility of providing antenatal clinic sessions. As the Hospital has the medical, surgical and obstetric staff and facilities available for dealing with all complications and emergencies, Leyton women occupying maternity beds are spared the possible inconvenience and risk of being transferred in a critical state to another institution for specialist treatment. In the past the Hospital has given preferential consideration in booking to West Ham and Leyton cases, but the demand for emergency beds from other areas and the increased payment made by these Authorities may influence the Hospital in according to Leyton cases that preferential consideration which has been given in the past. In December, 1929—when this Authority was considering the building of a municipal maternity home—I submitted the following observations on the advantages in the present arrangement with Queen Mary's Hospital:— (a) The patient is treated in a modern well-equipped Hospital with every facility for the treatment of emergencies and complications. (b) The medical and nursing staff as regards qualifications and experience is better than one would be likely to obtain in a smaller home with fewer beds. 128 (c) The Council is not saddled with the upkeep of empty beds. (d) The cost per patient per week is much less than in any small maternity home of which I have any knowledge. The Final Report of the Departmental Committee on Maternal Mortality and Morbidity (issued in July, 1932), contains the recommendation that new maternity accommodation should, where practicable, be associated with general hospitals on grounds of efficiency as well as to facilitate specialist treatment of non-obstetric conditions associated with pregnancy and childbirth. In Ministry of Health Circular 1433 (issued in October, 1934), the Minister advises that:— "Recent experience has shown that it is in general undesirable to provide small maternity homes as separate units." During 1935 some 308 Leyton expectant mothers attended the out-patient department of Queen Mary's Hospital for ante-natal supervision and subsequently had their confinements in the Margaret Lyle maternity wards. The average stay in hospital was 13.48 days; and the average cost per case was £4 14s. 4d., of which £2 4s. Id. was paid by the patient and £2 10s. 3d. by the Council. The following figures show—on the basis of the 1935 figure of 4,153 bed days—the annual payment to the Hospital at the present rate of 7s. per day, and at rates per day of 8s., 9s. and 10s. At 7s. per day £1,453 11s. 0d. „ 8s. „ £1,661 4s. 0d. „ 9s. „ £1,868 17s. 0d. ,, 10s. „ £2,076 10s. 0d. On consulting the Costing Returns of the Ministry of Health for the year ended 31st March, 1935, I find that there are 22 Maternity Homes in England and Wales administered by Municipal Boroughs. Particulars extracted from the official Costing Returns show the net total average cost per 129 patient per week in three extra-metropolitan MaternityHomes administered by Municipal Boroughs to be £8 14s. 11d. per patient per week. After consideration of that report the Council decided that the charge of 10s. per day be agreed to. In view of the increased payment to Queen Mary's Hospital, the Council reconsidered the scale of patients' contributions for institutional treatment and it was resolved that where the total weekly income of the family from all sources, after deduction of rent, is in excess of the Scale of Remission adopted by the Council for use in connection with maternity and child welfare services, the following scale be applicable. When total weekly income after deduction of rent is in excess of scale of remission by not more than Total amount of contribution for maintenance at the Margaret Lyle Maternity Home, Queen Mary's Hospital. £ s. d. £ s. d. 0 5 0 1 5 0 0 10 0 1 10 0 0 15 0 1 15 0 1 0 0 2 10 0 1 5 0 2 16 3 1 10 0 3 2 6 1 15 0 3 15 0 5 0 0 5 0 0 Exceeding £5. Full cost. The Scale of Remission, approved by the Council in May, 1934, is as follows:— Scale for Remission of Fees. Fees for all services will be remitted or assistance provided gratis where the total income from all sources after deduction of rent is not in excess of the following income:— Number in Family (including all members). (1) (2) (3) (4) (5) (6) £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. 0 10 0 1 0 0 1 5 6 1 12 0 1 17 6 2 2 0 (7) (8) (9) (10) (11) (12) £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. 2 3 9 2 8 0 2 9 6 2 15 0 2 17 9 3 0 0 130 Ambulance Service for Maternity Cases. In July, 1937,1 submitted the following report to the Maternity and Child Welfare Committee:— At the last meeting of the Maternity and Child Welfare Committee I reported the case of a Leyton mother whose baby was born in a taxicab while the mother was being conveyed to The Mothers' Hospital, Clapton, for her confinement. In accordance with the instruction contained in the above Council Minute I have discussed the matter fully with your Fire Brigade Superintendent and submit the following observations and suggestions. Of 1,421 Leyton mothers who gave birth to children during last year (1936), some 760 (i.e., 53 per cent.), had their confinements in the following maternity homes or hospitals outside the district:— No. of Institution. Births. 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 Coombe 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 49 760 131 Expectant mothers who have arranged to have their confinements in institutions do not book the services of either doctor or midwife. The fact that, in years gone by, such a large number of Leyton mothers have made their own arrangements for transport without the occurrence of any serious accident suggests that the proportion of ordinary maternity cases in which emergency transport is absolutely necessary must be relatively small. On the other hand, it would be idle to pretend that all these women have been conveyed to hospital in circumstances free from discomfort, worry and obstetric risk. Of all forms of transport to hospital, the modern motor ambulance with up-to-date equipment is the most convenient, safest and best for the patient or passenger. It is therefore reasonable to assume that this form of conveyance, if available, would supersede those used in the past—unless the charges were made such as to prevent that happening. I suggest that the Highways Committee consider the advisability of extending the Council's motor ambulance service so that it may be available on application by women resident in Leyton who desire to be conveyed to maternity institutions for their confinements. After consultation between the Committees concerned the Council decided that the Council's motor ambulance service shall be available at the usual charge for the conveyance of expectant mothers to hospital for their confinement in cases of emergency. Arrangements. Copies of the following printed card are now available in neighbouring maternity hospitals for distribution to Leyton women who have booked maternity beds. 132 Not Transferable. BOROUGH OF LEYTON. Public Health Department. EMERGENCY AMBULANCE SERVICE. Under the Council's Maternity and Child Welfare Scheme the Borough of Leyton Ambulance Service is available for the conveyance to certain Hospitals of expectant mothers resident in the Borough who have made arrangements for confinement in Maternity Hospitals or Homes. Conditions. 1. Application for conveyance by the Leyton Ambulance Service should be made only in cases of emergency or in circumstances where other modes of public transport are not available. 2. A doctor, nurse, or female friend must accompany the patient to Hospital. 3. The patient should be wrapped in blankets ready for removal. 4. This card—after completion and signature (see back of card) must be preserved carefully and handed to the Ambulance Attendant at the time of removal. 5. Any change in address must be notified immediately to me. 6. A charge of 5s. will be made for use of the ambulance. To Summon Ambulance by Telephone. Ask for—or dial—telephone number LEYtonstone 2222. When connected, state clearly the name and address of the patient, and the name and address of the Hospital which has arranged for her admission. A. W. FORREST, Medical Officer of Health, Town Hall, Leyton, E. 10. 133 Nursing Homes Registration Act, 1927. There are three registered nursing homes in the Borough. These institutions were inspected on 14 occasions. Home Helps. Under the Council's scheme for the provision of home helps, 93 applications for home helps were dealt with. In 64 cases home helps were provided, 28 of these cases having the charges remitted in accordance with the Council's scale. In the 29 remaining cases, 10 made other arrangements for the confinement, 12 cases had not been confined at the end of the year, one removed, one refused to pay the scale fee, one had not engaged a midwife and 4 were refused owing to unsuitable accommodation. At the end of the year there were 12 names on the Council's approved list of home helps. MATERNAL MORBIDITY AND MORTALITY. Ministry of Health Circular 1622.—Administrative Arrangements. In May, 1937, the Minister of Health issued Circular 1622, in which the attention of Maternity and Child Welfare Authorities was drawn to the Report on Maternal Mortality recently presented to Parliament. After referring to the great amount of attention devoted during recent years to the question of deaths in childbirth, the Minister considers it important that the subject should be regarded in its proper perspective. The number of women who die in childbirth in this country is relatively small, and it can be said that motherhood here has reached a comparatively high level of safety. The young married woman can be told with confidence that if she is in normal health and will take the ordinary and sensible precautions which her doctor or the medical staff at the ante-natal clinic advise, the risk she will run in childbirth need be no matter of anxiety. Report by the Medical Officer of Health to Maternity and Child Welfare Committee—September, 1937. In accordance with the suggestion contained in Council Minute 2070 I submit the following observations and suggestions on such official Recommendations contained in the above Circular as are not in operation in connection with the Council's maternity and child welfare scheme. 134 Consultant Services. Recommendation in Circular 1622. The establishment, under the direction of the Medical Officer of Health, of an adequate service of obstetric consultants:— (a) To assist medical practitioners, who undertake domiciliary midwifery, in cases of doubt or difficulty in the ante-natal period, at the time of confinement and during the puerperium; (b) to conduct consultative ante-natal and post-natal clinics, to which patients may be referred, by general practitioners or from the routine antenatal and post-natal clinics; (c) to exercise clinical supervision over the in-patient treatment of the maternity patients for whom the Local Authority assumes responsibility; (d) to supervise the treatment of patients suffering from puerperal sepsis; (e) to be responsible for the emergency domiciliary service for cases of grave obstetric abnormality in which removal to hospital is contra-indicated (e.g., certain cases of shock, eclampsia or haemorrhage); (f) to assist the Medical Officer of Health in the confidential investigation of the circumstance® associated with each maternal death occurring in the area. Present Arrangements. Council Minute 1759 of May, 1928, authorises your Medical Officer of Health to call in extra consultative opinion whenever he may deem it necessary. The following figures show the annual number of cases in which the advice of the Council's Obstetric Consultant has been sought:— 1932 5 times. 1933 1 „ 1934 5 „ 1935 5 „ 1936 8 „ 135 Consultative Ante-Natal Clinic. Recommendation in Circular 1622. The Minister draws attention to the importance of establishing for each area a consultative ante-natal clinic—preferably at a maternity hospital—which should be conducted by an obstetric specialist, and to which should be referred all cases of doubt or difficulty discovered at the routine ante-natal clinics or by general medical practitioners. Present Arrangements. In the past your Council's Obstetric Consultant (Mr. R. Alan Brews, F.R.C.S., M.D.), has been good enough to examine at Queen Mary's Hospital cases (20 to 30 per annum) of doubt and difficulty referred by Dr. Menzies from your ante-natal clinics; but as these examinations have been made voluntarily and unofficially, the arrangement cannot be regarded as constituting a consultative ante-natal clinic "established" by the Local Authority. Leyton expectant mothers referred by Dr. Menzies to Queen Mary's Hospital attend the out-patient department of the Hospital, where they may be kept waiting for several hours before being examined. Such a state of affairs is objectionable and undesirable both from the standpoint of patients and consultant ; but, in the absence of a definite arrangement between the Local Authority and the Hospital, it cannot be avoided. Maternity Accommodation. Recommendation in Circular 1622. Properly constructed, adequately equipped and suitably staffed maternity accommodation (including a sufficient number of beds allocated to and reserved for ante-natal patients) should be provided to meet the needs of every area. Wherever practicable the accommodation should be provided in association with general hospitals. Present Arrangements. Since 1925 your Authority has had an arrangement for the provision of maternity beds in the Margaret Lyle Wards, Queen Mary's Hospital; and in previous reports I have suggested that you have every reason to be satisfied with the nature of the accommodation, equipment and staffing available at such a reasonable cost. With the great increase 136 during recent years in the number of women desiring to have their confinements in hospital it is becoming increasingly difficult to find accommodation for all who do not wish to have their confinements at home. This difficulty has been accentuated by the recent alteration in the Rules of the Central Midwives Board whereby the official lying-in period has been extended from ten to fourteen days. Even if there were no increase in the number of women desiring admission to maternity beds, the extension of the lying-in period alone would warrant a 40 per cent. increase in accommodation. With regard to the recommendation of the Ministry regarding the necessity for the provision of a sufficient number of beds allocated to and reserved for ante-natal patients, there are in Queen Mary's Hospital only five such beds to accommodate cases from the wide area served by the hospital. This number of beds is, of course, quite inadequate. The Minister considers that it is necessary that each Authority should review the position in its area with special regard to the need for antenatal wards, and should bear in mind the desirability of arranging for the accommodation to be provided in association with a general hospital where facilities for diagnosis and treatment are readily available. Suggestion. I suggest that your Authority should confer with the Governors of Queen Mary's Hospital with a view to possible extension of existing maternity accommodation, including beds allocated to and reserved for ante-natal and post-natal patients. Post-Natal Services. Recommendation in Circular 1622. The development of post-natal services, including the establishment of clinics and arrangements for in-patient treatment, is a matter of urgent necessity. The development of post-natal clinics has never kept pace with the expansion of ante-natal clinics. Arrangements should be made for holding post-natal sessions at every ante-natal clinic centre; no effort should be spared to persuade women who attend at the antenatal clinic to return after confinement for medical examination; and the clinic should be associated with some institution at which facilities are available for the treatment of gynecological conditions in general, e.g., a women's hospital or a 137 general hospital. It is stated that such a post-natal clinic would be available for the treatment of women suffering from gynecological conditions and for giving contraceptive advice to women attending the clinic in whose cases further pregnancy would, in the opinion of the medical officer, be detrimental to their health. Present Arrangements. In the past no organised post-natal clinic has been held under your Council's maternity and child welfare scheme. Your clinic medical officer has referred special cases found to be suffering from gynecological defects to be examined at Queen Mary's Hospital, and individual women requiring contraceptive advice to The East London Women's Welfare Centre, 6, Burdett Road, E.3. In Queen Mary's Hospital only four gynecological beds are available for post-natal cases. Suggestion. For such a post-natal clinic it would be necessary to engage the part-time services of a medical officer with special experience in gynecology and contraceptive technique. It is estimated that, to begin with, one post-natal clinic session per month should be held at each of the Council's two maternity and child welfare centres. Emergency Units. Recommendation in Circular 1622. The necessity for arranging in certain types of cases for the services of skilled hospital staff to be brought to the patient instead of subjecting her to the risk of transport to hospital. It is suggested that the emergency unit or "flying squad" should consist of a consultant obstetrician and a nurse with all the necessary equipment for dealing with emergencies at short notice, and that the unit can best be operated from a maternity hospital or the maternity department of a general hospital. Present Arrangements. The idea of such "emergency units" is a relatively new one. In the past every endeavour has been made to have patients removed to hospital, even when gravely ill; and I know of no case in which the advantages of in-patient treatment in hospital were outweighed by the risk of transport to 138 Hospital in a modern well-equipped motor ambulance. I have discussed this matter with several obstetricians, and I find that a considerable diversity of opinion exists regarding the relative advantages of transport to hospital and "emergency units." Suggestion. It is conceivable that a rare emergency may occur in which a patient's condition is too grave to justify removal to hospital; and, in order to meet such a contingency, it would be advisable to have an arrangement with Queen Mary's Hospital for an "emergency unit" to be available at short notice. Puerperal Fever. Under the provisions of the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations 1926, Puerperal Fever and Puerperal Pyrexia were scheduled as notifiable infectious diseases. Under the Public Health Act, 1936, which came into operation on 1st October, 1937, the term Puerperal Fever has been omitted from the definition of notifiable diseases in Section 343. The effect of the omission of Puerperal Fever is that Puerperal Fever ceased to have effect outside the County of London and that the obligation to notify cases of Puerperal Pyrexia included the obligation to notify conditions notifiable as Puerperal Fever. No cases of Puerperal Fever were notified during the nine months that Puerperal Fever remained notifiable. Puerperal Pyrexia. Twelve cases of Puerperal Pyrexia were notified during the year. The causes of pyrexia were considered to be :— Puerperal septicaemia following abortion 1 (died) Puerperal pyaemia following abortion 1 (died) Pyelitis 3 Acute Mastitis 3 Endometritis 2 Pleurisy 1 Influenza 1 139 Report by Dr. Hilda Menzies. It is noteworthy that the two fatal cases were due to infection following abortion. The information concerning them is scanty. In both cases delay in obtaining treatment was due to the woman failing to send for a doctor ; the doctors in each case transferred the patient to hospital without further delay. The first was a woman of 35 years with two children, circumstances fairly good. She consulted the doctor at his surgery on account of pain following a three months' abortion six days previously. The doctor suspected interference and transferred her to hospital where she died eleven days later from typical septicaemia. The second fatal case was in a woman of 29 years, who had had two living children and one previous miscarriage—home circumstances poor. She had lost a considerable amount of blood before sending for the doctor in the evening—at the shortest estimate she had been losing for 15 hours. According to the hospital report she had been losing for 30 hours. The explanation of the delay in sending for the doctor was that the patient was alone in the house until the husband came home. The patient was in bed when the doctor arrived, not losing much blood and the pulse was good. An examination was made with a sterile glove. The os was patent, nothing else abnormal, but the patient complained of much pain. The placenta had been expelled (? 12 weeks pregnancy) but the foetus was not found. The patient was transferred to hospital as a case of incomplete abortion. On admission the temperature was 101.2 degrees, pulse 108, uterus somewhat enlarged but apparently empty. The temperature remained irregular. Swellings developed on hands and legs. The patient was treated with douches, prontosil, etc., but died nine days later from puerperal pyaemia. These two deaths are calculated as maternal deaths and are included in the maternal mortality rate which is based on the number of births in the Borough of Leyton, whereas they are actually two deaths occurring out of an unknown number of abortions having no ascertainable relation to the number of births. They are deaths over which the present Maternity and Child Welfare Scheme has no direct control. Out of the ten cases of puerperal pyrexia following the birth of a child, the baby survived in nine cases. The tenth was a case 140 of premature birth following ante-partum haemorrhage in a primigravidse, aged 33, in good home circumstances. The case of the haemorrhage was unknown. Seven of the ten cases were confined in hospital and the remaining three were attended by midwives. None of the domiciliary cases required hospital treatment. The advice of the Obstetric Consultant was sought in one case. Obstetric Consultant. The advice of the Council's Consultant Obstetrician was sought on seven occasions during the year, but on one of these occasions it was the condition of the baby (three days old) which was causing anxiety. The child had had recurring attacks of melæna, starting 48 hours after an apparently normal breech delivery. By the time the Consultant was called the child was gravely ill but still moderately warm, and with a fair degree of colour. The Consultant injected 20 c.c. of citrated blood from the mother intramuscularly into the left thigh. This was effective in controlling the bleeding and the baby made a good recovery. Of the six cases in which advice was sought in respect of the mother's condition, on three occasions assistance was requested before the termination of labour and in the remainder on account of puerperal complications. The details of these six cases are as follows:— 1. Primigravida, age 26—home circumstances good—in labour 36 hours—failure to progress—impacted breech—foetal heart sounds not heard—mother's condition good—legs brought down and child delivered under anaesthesia—9 lb. baby, stillborn —third stage normal—no haemorrhage. 2. Multipara, age 26—home circumstances fair. First labour rapid and normal—at time of consultation alleged to have been in labour five days. On examination, cervix not taken up—internal os closed—no evidence of real labour—medical induction advised. Baby born normally less than 24 hours later. 3. Primigravida, age 25—home circumstances good. Labour started three days previously—membranes ruptured six hours previous to consultation—cervix thinned out and dilated to about 141 two-fifths—presentation normal—foetal heart normal—no evidence of disproportion—medical methods of stimulation increased rate of labour at home—to be admitted to hospital if reasonable progress not made, but baby born normally less than 12 hours later. 4. Primigravida, age 34—home circumstances good. Instrumental delivery after four days labour—stillbirth-—9 lb. baby— severe lacerations of lower genital tract—considerable post partum haemorrhage and some anaesthetic complications. Consultant called in five days later—patient showing evidence of severe general debility from recent shock and haemorrhage and in addition some toxaemia from infection of the lacerations of the lower genital tract—no clinical evidence of a blood infection or of infection of the upper genital tract—patient made a satisfactory recovery at home. 5. Multipara, age 35 years—home circumstances fairly good. Developed mastitis of right breast on ninth day of puerperium—one abscess opened under general anaesthetic on 11th day —second abscess opened under local anaesthetic six days later— whole breast became brawny and unsatisfactory. Seen by Consultant nine days later—evidence of defective drainage of infected tissues in the lower and outer quadrant of right breast—left breast normal—child had been weaned—patient unwilling to go to hospital—patient eventually recovered. 6. Multipara, age 32—fifth pregnancy in four years—home circumstances good. Normal labour—pyrexia of 100.6 deg., P. 100 with general pains developed on evening of fourth day— intravaginal glycerine given—no localising symptoms or signs in pelvis—on fifth day patient complained of pain in chest. Kaolin poultice applied—evening temp. 103 deg., P. 126. Seen by Consultant on seventh day—heart, lungs and throat clear—nothing abnormal discovered in abdomen—some subinvolution of uterus— lochia slightly purulent—no clinical evidence of septicaemia. Diagnosis ? purulent endometritis. ? puerperal pyelitis—patient refused hospital treatment—massive alkalis advised—bacteriological investigations of blood, genital secretions and urine recommended if pyrexia continued. The pyrexia was subsiding by the time the Consultant saw the patient and although it rose to 101 deg. on the evening of the tenth day, it was normal again by the twelfth day and there was no further rise. When the urine was examined microscopically on the fourteenth day, no pus was found. 142 Maternal Mortality. There were three maternal deaths of Leyton residents during the year. Two, which resulted from infection following abortion, have been discussed above under the heading Puerperal Pyrexia. The details of the third death were as follows:— Multipara, age 26.—Home circumstances comfortable—under hospital supervision during pregnancy—frequent nose bleeding— toxaemic symptoms developed between 30-34 weeks—oedema present at 32 weeks—admitted at 34 weeks with albuminuria, B.P. 186/78—did not improve much despite treatment—developed hydramnios-—membranes ruptured artifically at 37 weeks—three hours later patient delivered of normal infant—second foetus in uterus—placenta of first foetus did not separate—no further pains—patient allowed to rest and fluids and glucose given by mouth—seven hours after birth of first child few pains began— considerable loss with each pain—two hours later second bag of membranes ruptured artifically as patient becoming blanched— second baby delivered under ansethesia as a breech, stillborn— patient somehat shocked—no haemorrhage, but inertia returned— given saline per rectum and later intravenously—blood transfusion arranged but patient died before it could be given—the placentae were not delivered. Cause of death—Shock and haemorrhage : Inertia ; Toxaemia. MIDWIVES' ACTS, 1902-1936. Until just over 100 years ago the practice of midwifery was almost entirely in the hands of women, and at as late a date as the beginning of the present century anyone who chose to do so could act as a midwife. The Midwives' Act, 1902—under whose provisions the Central Midwives' Board was constituted—was the first statute designed to secure better training and regulate the practice of midwives ; but the legal status granted by that Act was merely a license to monthly nurses to assume a new designation, as the Act allowed bona fide midwives (i.e., unqualified women who had been practising midwifery) to continue in practice. The Midwives' Act, 1918, made certain alterations in the Act of 1902; and the Act of 1926 made it an offence for an unqualified person to attend a woman in childbirth otherwise than under the direction and personal supervision of a doctor—unless in a sudden and urgent necessity. 143 Report of Joint Council of Midwifery (1935). In January, 1934, the Joint Council of Midwifery (composed of representatives of local authorities, hospitals, medical, nursing and obstetrical organisations) was appointed to consider means by which the services rendered by midwives could be improved. The investigation showed that, of all agencies concerned in rendering motherhood safer, none was more important than the work of the midwife, for she attends about 60 per cent. of all confinements. The Committee summarised its recommendations as follows:— 1. That this Committee concurs with the views expressed in the reports that, although adequate hospital accommodation for ante-natal cases and abnormal confinements is essential, normal confinements can be satisfactorily, safely, and preferably conducted in the patient's own home, except where this is unsuitable. 2. That the nursing of every maternity case should be conducted by a qualified midwife, and unqualified persons should not be permitted to nurse maternity cases for gain. It should be the duty of the local authority to provide that midwives are available to act as maternity nurses in the case of any patient who has engaged a doctor for her confinement, but is unable, in addition, to afford the services of a trained nursing attendant. 3. That a salaried midwives' service should be established under the appropriate local authority in all areas not already served by salaried midwives. It is not intended to interfere with the continuance in practice of independent midwives. 4. That it should be the duty of every appropriate local authority to provide, or secure the provision of, an adequate domiciliary service of midwives in its area, and for this purpose: (a) to employ the requisite number of whole-time midwives at adequate salaries; and/or (b) to aid approved voluntary organisations (including provident societies) that employ salaried midwives for service in its area. 144 5. That the local supervising authority (Midwives' Acts) should be the unit of administration for the proposed service. 6. That the cost of the service should so far as practicable be met by the fees charged by, and payable to, the authority or the voluntary organisation for the services of the midwife. The remaining recommendations dealt with:— (а) The steps which should be taken by the local supervising authority before initiating a scheme in its area; (б) the status, salary and appointment of midwives entering municipal service; (c) the compensation of midwives not accepted for service; (d) the necessity for refresher courses of study by practising midwives ; (e) the right of appeal by midwives; (/) the freedom of choice of midwife by the patient. The remuneration of individual midwives is entirely inadequate, and compares most unfavourably even with that of nurses who, as a class, are admittedly underpaid. The average salaries of village nurse-midwives, Queen's nursemidwives, hospital nurses, and health visitors all considerably exceed the £80 which the Committee has ascertained to represent the average yearly earnings of a midwife dependent upon her profession. In certain areas this figure may sink as low as £50, and out of this meagre sum the midwife is expected to provide equipment, necessary drugs, and disinfectants, and even in some cases dressings, for her patients. There is evidence that the low standard of comfort and cleanliness in the houses or lodgings occupied by midwives in certain areas militates against the maintenance of a high standard of professional work, particularly where ante-natal examinations have to be undertaken in unsuitable rooms normally utilised for other purposes. In the East End of London the fee is as low as 16s. for multipara, and the great majority of patients pay no more than 30s. 145 The main causes of the low remuneration of midwives are:— (a) The economic position of those persons in the community who principally employ midwives. (b) The part-time practice carried on by large numbers of midwives as an aid to another source of income. (c) The excessive number of midwives qualified, arising from the shortness of the present period of training and the low educational standard required from entrants. Reforms and extensions of training designed to raise the status and efficiency of the service of midwives to its proper level will, however, inevitably involve the candidate in additional expense which cannot be met by the present type of entrant. If such extensions were introduced before other reforms had made the profession attractive to a better class of candidate, the probable result would be a shortage of midwives within a few years. The Midwives' Act, 1936—Formulation of Proposals. Report Submitted by the Medical Officer of Health in December, 1936. The Midwives Act, 1936, came into operation on 31st July, 1936. The principal object of the Act is to secure the organisation throughout the country of a domiciliary service of salaried midwives under the control of local supervising authorities as an important step in the improvement of the maternity services and in the campaign for reducing maternal mortality. At the same time, the whole status of the midwifery profession will be raised by providing adequate salaries and secure prospects for those midwives who enter the new service, and by compensating those who retire within a specified period and so reducing the present overcrowding in the ranks of the profession. The Act provides for the establishment by local supervising authorities of a salaried midwives' service ; the payment by those authorities of compensation to midwives who voluntarily retire from practice and to those who are required to retire owing to old age or infirmity ; the payment by the Exchequer of grants towards the cost of the new service and towards the amounts expended in compensation ; the prohibition of maternity nursing by unqualified 146 persons in any area by order of the Minister as soon as he is satisfied that the new service in the area is adequate ; and the periodical attendance at post-certificate courses of all practising midwives. The opportunity has also been taken to make a number of amendments of the existing law relating to midwives. The Act requires that the proposals of local supervising authorities be submitted to the Minister of Health not later than the 30th January, and be brought into operation not later than 30th July, 1937. Estimate of Staff Requirements. The first step in the formulation of proposals is for each local supervising authority to estimate by reference to existing statistics the number of domiciliary confinements likely to be attended in their area each year by midwives and by medical practitioners. The following figures give the required statistical information relative to the Borough of Leyton during the period covered by the last five complete years. (By way of explanation a midwife acts as a "midwife" when she has been engaged to deliver a woman, and as a "maternity nurse" when she is employed to assist a medical practitioner who has been so engaged). Year. 1931 1932 1933 1934 1935 Average. 1. Birth Rate 14.09 13.10 11.91 11.78 12.26 12.63 2. Number of Registered Births— (a) In Institutions 546 585 687 630 716 633 (b) At Home 1,266 1,081 812 824 777 952 Total 1,812 1,666 1,499 1,454 1,493 1,585 3. Number of Domiciliary Confinements attended : (a) By midwives alone 663 623 494 487 472 548 (b) By doctors with midwives acting as maternity nurses 188 181 147 197 163 175 (c) By doctors alone 415 277 171 140 142 229 Total 1,266 1,081 812 824 777 952 It is necessary to include in our assessment the number of domiciliary confinements attended by midwives acting as maternity nurses (i.e., item 3 (b)). 147 In view of the impending prohibition of unqualified persons envisaged in the Act (Section 6) medical practitioners will no longer be able to employ the services of unqualified "handywomen" at confinements. It will therefore be necessary to include a proportion of domiciliary confinements attended by doctors alone (i.e., item 3 (c)). Nor can we disregard altogether the number of women confined in institutions, as the maternity hospital of the future will no doubt make increasing use of the services of domiciliary midwives for help and co-operation during the periods of supervision both before and after confinement. It is considered that a hospital case will require about one-fifth of the attendance given by a domiciliary midwife to a case dealt with at home. In endeavouring to form any reliable estimate of the probable annual number of future domiciliary confinements there are certain variable factors which give rise to a very wide margin of possible error, e.g.— (a) The birth-rate in Leyton has decreased from 24.6 per 1,000 of the population in 1920 to 11.78 per 1,000 in 1934. In 1935, however, the rate increased slightly to 12.26 per 1,000, and it would be rash to attempt any prognostication of the future trend of the birth-rate in the area. (b) In Leyton, as elsewhere throughout the country, there has occurred during recent years a marked and progressive increase in the proportion of mothers who have their confinements in institutions. For instance, in the relatively short period of five years the proportion of institutional confinements has increased from 30.13 per cent. in 1931, to 47.95 per cent. in 1935. In the official Memorandum (200/M.C.W.) accompanying the new Act the Minister suggests that, in arriving at their estimates, local authorities should consider whether the establishment of the new service of midwives may not residt in a diminution in the number of cases confined in hospital. Maternity beds in hospitals were intended primarily for cases requiring admission on medical grounds (e.g., emergencies and cases requiring special medical observation and treatment) or on account of the lack of adequate accommodation and facilities at home. Nowadays, however, a large proportion of women go into hospital for confinement merely because it is more convenient —and, in this area, less expensive—to be confined in hospital than 148 at home. If, as it appears, one of the objects of the new Act is to encourage domiciliary midwifery, the responsible Authority should take steps to ensure that institutional midwifery is not being subsidised at the expense of domiciliary in framing their necessity scale and scale of remissions for payment of midwives' fees. In my opinion the future demand for the services of domiciliary midwives will depend, not so much on the efficiency and status of the personnel of the new service, as on the housing conditions and family circumstances of expectant mothers in the area, and on the relative cost of home and institutional confinements. (c) It is difficult to forecast with any degree of certainty the probable proportion of domiciliary confinements likely to be attended by independent midwives in private practice, but I estimate that in this area the proportion is not likely to exceed 5 per cent. (d) In view of the impending prohibition of unqualified persons envisaged in the Act (Section 6), medical practitioners will no longer be able to employ the services of unqualified handywomen at confinements. With regard to the number of women attended by doctors alone (item 3 (c)) it is possible that the extra expense entailed in engaging a maternity nurse instead of a handywoman may influence a certain proportion of these women to have their confinements in hospital. Taking all these circumstances into consideration, I suggest that the provisional figure of 720 domiciliary confinements per year be accepted as the basis on which to formulate your proposals. In Circular 1569 it is stated that:— "The Minister is advised that for the purposes of their calculations local authorities might assume that in populous districts each midwife should usually be capable of attendance on 70 cases as a midwife and 30 cases as a maternity nurse during the year." For the reasons stated above there appears to be no purpose in differentiating between the number of cases attended as a " midwife" and as a "maternity nurse" in estimating the annual number of cases one midwife is capable of attending. The Joint Council of Midwifery consider that 80 cases per annum are as many as one midwife may reasonably be expected to attend; and this opinion is reiterated by the Midwives' Institute in their recent Memorandum to Local Supervising Authorities. 149 In considering the number of midwives to be employed it will be necessary to allow for annual and sick leave, and for such emergencies as the suspension of a midwife from duty in order to prevent the spread of infection; and authorities are advised to frame their proposals in such a way as to allow choice of midwife to women availing themselves of the new service. Under the present Rules of the Central Midwives' Board (made under Section 3 of the Midwives Act, 1902), a midwife or maternity nurse must attend women in their homes during childbirth and the "lying-in period." This period is at present defined to be not less than 10 days, but under the amended Rules of the Central Midwives' Board the period is extended to a minimum of 14 days. It is suggested that attendance on 90 cases (whether as midwife or maternity nurse) per year per midwife be accepted as a reasonable standard in the calculation of initial staff requirements. Assuming— (a) that the birth-rate remains at about its present level; (b) that there is no marked change in the proportion of women entering institutions for their confinements; (c) that the proportion of domiciliary confinements likely to be attended by independent midwives is not greater than 5 per cent; I estimate that the initial services of eight full-time salaried midwives will be required for domiciliary service in the area. Existing Midwifery Arrangements. The following statistical summary shows how, during the past five years, the domiciliary midwifery work in the area has been apportioned between (a) Essex County Nursing Association Midwives, (b) Other midwives resident in Leyton, and (c) Midwives resident outside Leyton. 150 1931 1932 1933 1934 1935 as Midwife. as Mat. Nurse. as Midwife. as Mat. Nurse. as Midwife. as Mat. Nurse. as Midwife. as Mat. Nurse. as Midwife. as Mat. Nurse. 1. Midwives Resident in Leyton. (a) E.C.N.A 220 130 230 110 194 102 229 130 230 128 (b) Others 358 38 353 60 275 36 231 42 219 30 Total 578 168 583 170 469 138 460 172 449 158 2. Midwives Resident Outside Leyton 85 20 40 11 25 9 27 25 23 5 Grand Total 663 188 623 181 494 147 487 197 472 163 851 804 641 684 635 151 It will be seen from these figures that, during the period under review, there has been a progressive increase in the proportion of confinements attended by Essex County Nursing Association midwives, and a progressive decrease in those attended by midwives resident outside the area. In this area we have in Beachcroft Road the Headquarters and Nurses' Training Home of the Essex County Nursing Association, a voluntary organisation which employs salaried midwives who have been conducting an extensive midwifery practice in this and other areas throughout the County for a period of over 40 years. The Essex County Nursing Association is a recognised school of training for midwives and has been set up to co-ordinate the services provided by the various District Nursing Associations in the County. Being a recognised training school for pupil midwives, the Association's midwives are also engaged in the practical teaching of pupil midwives. A close liaison has always existed between the Nursing Association and your Authority. For instance, the Association's pupil midwives attend and assist at your Maternity and Child Welfare Centres as part of their training, an arrangement which is mutually helpful ; and your Maternity and Child Welfare Authority has an arrangement with the Association for the home nursing of cases of puerperal fever and pyrexia, and for the supply of midwives to deputise for midwives in the area who may be suspended from duty to prevent spread of infection. It is therefore evident that a close association has existed between the two Authorities ever since your Council has existed as a Maternity and Child Welfare Authority. The present salaried staff of the Essex County Nursing Association midwives in residence at Beachcroft Road Nurses' Home is:— Matron 1 Sister 1 Nurses 1 Double qualification. (State- Registered, General-trained Nurses with Certificate of Central Midwives Board.) Nurses 7 C.M.B. Certificate only. 152 There are at present only three independent midwives resident in Leyton and attending domiciliary confinements. One (Midwife A), has been in private practice as a midwife in Leyton and West Ham over a period of 32 years. She will reach the age of 65 years in August, 1937—the month following that on which the provisions of the Act will come into operation. The remaining two midwives notified their intention to practice in the area in April, 1935. Organisation of New Service. Local Sanitary Authorities may arrange for the establishment of a domiciliary service of salaried midwives by one or other of the following methods:— (а) By the appointment of municipal midwives employed directly by the Authority. (b) By arrangement with a voluntary organisation employing salaried midwives in the area. (c) By a combination of these two methods. The Act requires that midwives employed in the new service, whether by local supervising authorities or voluntary organisations, shall be the whole-time servants of these bodies; but it does not require that they shall devote the whole of their time to midwifery and maternity nursing. It will be necessary for your Council to consult with the bodies specified in Section 1 (2) of the Act [i.e., (1) the Essex County Nursing Association; (2) the local branch of the British Medical Association; and (3) the local branch of the Midwives' Institute], before submitting your proposals; and to decide the extent to which the number of midwives considered to be necessary shall be employed by you or by the Essex County Nursing Association exclusively or jointly. 153 In order that I might be able to ascertain their views, I have held informal consultations with representatives of the bodies mentioned, and may state that the suggestions I am making are such as would be likely to meet with their approval. As the result of the improved conditions of service and status of midwives envisaged in the Act it can be foreseen that in years to come the municipal service will no doubt attract midwives of the highest training and experience; but for the time being the service must be staffed by the midwives available, few of whom can be described as in all respects ideal. However experienced and reliable they may be, they have not been trained to official duty; and, being for the most part of middle age, they may not take kindly to office work and administrative routine. The administration of these women, who are more or less the free-lances of their profession, may not be easy. Inasmuch as firmness will be required in the Authority's interest and humanity in that of the midwives, their supervision and control will call for more than the ordinary amount of tact; and supervision will be much easier in the case of midwives directly employed by the Council than in the case of those employed by voluntary organisations. In view of the long experience of the midwives of the Essex County Nursing Association in attending domiciliary confinements in this area, their reputation among Leyton mothers, their cooperation in the work of your Council's maternity services and their association with the maternity department of Queen Mary's Hospital, I suggest that your Council consider the advisability of making an initial arrangement with the Association for the provision of a domiciliary service of five salaried midwives under your control to serve that part of the area which is within a reasonable distance from the Association's Nurses' Home in Beachcroft Road. It may be found necessary to increase the number later in the event of the demand for their services justifying such increase. The Association retains a staff of midwives available for emergency duty in the County area, and this emergency staff could be available in this area if required. As the Essex County Nursing Association Home in Beachcroft Road is at too great a distance from the western part of the Borough, it will be necessary to appoint three municipal midwives for duty in the western part of the Borough. 154 In Circular 1569 the Minister stresses the importance of ensuring that as many as possible of the midwives at present in practice should be absorbed into the new service, and suggests that local authorities—when making their first appointments of salaried midwives—will naturally desire to give preference to the most efficient of the independent midwives practising in their areas. I suggest that Midwife A be required to surrender her certificate under Section 5 of the Act. She will then be entitled to compensation amounting to five times the average net annual emoluments from her practice during the preceding three years. In the event of your Council deciding to require Midwife A to surrender her certificate, only two independent midwives resident in the Borough are available for private practice. These two midwives are possessed of good qualifications and experience; and, in the opinion of your Inspector of Midwives and of medical practitioners with whom they have worked, they are competent midwives. I suggest therefore that these two Midwives be given favourable consideration when you are making the three municipal appointments. Under Section 3 of the Act it shall be the duty of the Authority to fix a scale of fees payable for attendance as midwives and as maternity nurses, and to recover the fees except where remitted in whole or in part on grounds of necessity. At present the fees charged by midwives in the area vary considerably, as may be seen from the following examples. First Confinement. Subsequent Confinement. Essex County Nursing Assocn. 42s. 30s. Midwife A 35s. 25s. Midwives B and C 52s. 6d. 42s. I suggest that the full fee chargeable in respect of the services of any midwife directly employed or subsidised by the Council be fixed at 40s. per case, whether in respect of attendance as midwife or maternity nurse. Details with regard to arrangements for payment could be fixed at a later date. 155 With regard to the operation of any income scale for remission of fees in whole or in part, I have suggested (vide supra) that if your Authority wish to encourage domiciliary midwifery, it will be necessary—in framing such scale—to ensure that the woman who is confined at home is not at a financial disadvantage compared with the woman who chooses to go into an institution for her confinement. The full cost of maintenance for 10 days in your Margaret Lyle Maternity Home Scheme is £3 10s. 0d. On the other hand, the following would be the cost of a home confinement with provision of home help:— Midwife's Fee £2 0s. 0d. Home Help £3 17s. 0d. £5 17s. 0d. Some 25 per cent. of women confined at home have the additional expense of medical fees in the event of the midwife requiring to summon medical aid (average £1 7s. Od.). In addition, a home confinement entails sundry expenses (e.g., medical and nursing requisites, upkeep of patient, etc:), which are avoided in the case of an institutional confinement. Under these circumstances it is not a matter for surprise that there has been such a marked increase in the proportion of institutional confinements during recent years. It is for the Council to decide, as a matter of policy, whether they wish to subsidise institutional at the expense of domiciliary midwifery, and to frame their scales of recovery accordingly. It is suggested that further consideration be given to your scales of recovery in operation with respect to both domiciliary and institutional midwifery. One of the main objects of the Act is to improve the status of the midwifery profession, and in the accompanying Circular it is stated that— "The Minister regards it as of the utmost importance that the midwives employed in the new service should be adequately remunerated. The work to be carried out by them is in his view at least as important as the work carried out by health visitors, and he feels confident that local authorities will in respect of the midwives appointed by them adopt scales 156 of salaries which are comparable with those applicable to health visitors employed in the same district, together with appropriate allowances for travelling expenses, and that their contributions to voluntary organisations will be sufficient to enable those organisations to pay adequate salaries to all the midwives they employ." All Health Visitors appointed since 1928 must possess the following qualifications:— (а) State Registered Nurse (general-trained). (b) State Certified Midwife (Certificate of C.M.B.). (c) New Health Visitor's Certificate of Ministry of Health. The remuneration of your Health Visitors is— (1) Salary £200 to £300. (2) Uniform allowance—£5. It is suggested that the salary scale for State Certified Midwives who are also State Registered Nurses should be the same as that of your Health Visitors (£200 by £15 to £300), and that a deduction of £25 per annum be made in the commencing and maximum salary rates of State Certified Midwives who are not State Registered Nurses. Uniform, travelling and telephone facilities, equipment, drugs and dressings should be provided. Details of the terms and conditions of service could be framed and submitted for your approval at a later date. With regard to the amount of grant payable to the Essex County Nursing Association, you will no doubt consider that the amount should be such as to enable the Association to provide adequate salaries and allowances to the midwives provided for domiciliary service in the area. Section 6 of the Act provides for the prohibition—with certain specified exceptions—of maternity nursing by unqualified persons in any area by order of the Minister as soon as he is satisfied that the local authority has secured the provision of an adequate service of salaried midwives in the area. 157 Section 7 of the Act confers on the Central Midwives' Board the power to frame rides requiring midwives to attend periodically courses of instruction approved by the Board, and local supervising authorities are required to provide, or arrange for the provision of, the necessary courses for midwives practising in their areas. Under the - Act local supervising authorities are required, before submitting their proposals to the Minister, to consult:— (а) Voluntary associations which employ, or are willing to employ, salaried midwives in their areas; (b) the local organisation of medical practitioners; and (c) the local organisation of midwives. I have already consulted each of these three bodies unofficially, but it will be necessary for your Council to consult them officially. Council's Scheme for Domiciliary Midwifery. After consideration of the above Report the Council decided:— 1. That the recommendations of the Medical Officer of Health be approved with the exception of the suggested salary to be paid to midwives appointed by the Council : and that he report further thereon at the next meeting. 2. That the Medical Officer of Heath consult with the organisations and bodies mentioned in the Act. In the following month (January, 1937) the Council came to the following decision with regard to the salaries to be paid to Municipal Midwives:— 1. That State Certified Midwives who are State Registered Nurses (General Trained) be paid a salary at the rate of £200 per annum, rising by annual increments of £15 to a maximum salary of £300 per annum. 2. That State Certified Midwives who are not State Registered Nurses (General Trained) be paid a salary at the rate of £160 per annum, rising by annual increments of £15 to a maximum salary of £260 per annum. 158 3. That State Certified Midwives with a minimum of three years' continuous practical experience in midwifery since the issue of their Certificate who are not State Registered Nurses (General Trained) be paid a salary at the rate of £180 per annum, rising by annual increments of £15 to a maximum salary of £260 per annum. 4. That uniform, travelling and telephone facilities, equipment, drugs and dressings be provided by the Council. After consultation with the local branches of the British Medical Association and the Midwives' Institute, these professional associations agreed to the Authority's proposals. Agreement with Essex County Nursing Association (June, 1937). Following on consultations between the Leyton Corporation and the Essex County Nursing Association, a formal agreement was made whereby the Association undertakes to employ five certified midwives to be available for domiciliary service in the area of the Borough which lies on the eastern side of Hoe Street and Leyton High Road, the midwives to be the whole time servants of the Association, the Council to make an annual payment of £1,000 to the Association in respect of salaries and emoluments, including indoor and outdoor uniforms, drugs, dressings, equipment, travelling expenses, board and lodging. Conditions of Service of Municipal Midwives. 1. That for the purposes of the initial appointments all Midwives shall be State Certified Midwives, but in all such subsequent appointments Midwives will be required to be State Certified Midwives and State Registered Nurses. 2. That for the purposes of the initial appointments the maximum age of new entrants into the Council's service be fixed at not exceeding 50 years, but in all subsequent appointments the maximum age of new entrants into the Council's service be that fixed by the Council at not exceeding 40 years. 159 3. That for the purpose of inaugurating the new service no sort of discrimination against married women be made. 4. That the appointments shall be subject to the provisions of the Local Government and Other Officers' Superannuation Act, 1922, as varied by Section 2 Sub-sections (3), (4), (5) and (6) of the Midwives' Act, 1936. 5. That the place of residence of each midwife shall be approved by the Council, and the dwelling shall contain a consulting room for ante-natal examination. 6. That all duties shall be arranged under the direction of the Medical Officer of Health. 7. That each Midwife shall be allowed three weeks' annual holiday, one day off duty each week, and one week-end off in every three. Record of Cases Attended by Council Midwives—1st August to 31st December, 1937. The Council's scheme came into operation on 1st August, 1937, and the following figures show in tabular form particulars regarding the work done from that date until 31st December, a period of five months. Midwives (8) employed by Council (3) E.C.N.A. (5) Midwives employed by the E.C.N.A. under arrangement made with the Local Supervising Authority in pursuance of Sec. 1 of the Midwives' Act, 1936. Total. Cases attended— (a) As Midwives 50 97 147 (b) As Maternity Nurses 14 59 73 Ante-natal Visits 196 315 511 Ante-natal Examinations 441 445 886 Post-natal Visits 1,164 3,072 4,236 160 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. One hundred and twenty-eight such notifications were received and the following table shows the various complications for which medical assistance was summoned :—- During Pregnancy. Pre-eclamptic toxaemia 5 Threatened miscarriage 1 Small pelvic measurements 1 Inevitable abortion 1 Ante-partum haemorrhage 2 Poor general condition during pregnancy 1 Abortion 1 During Labour. Ruptured perineum 44 Footling and cord presentation 1 Prolonged labour 18 Post partum haemorrhage 3 Hysteria 2 Delayed delivery of second twin 1 Transverse lie (? twins) 1 Adherent placenta 1 Lacerated labia 1 / During Labour. Placenta præevia 1 Retained chorion 1 Retained placenta 1 Impacted shoulder 1 Unreduced occipito posterior 1 Rigid outlet 1 Complicated breech 1 Shoulder presentation 1 During Puerperium. General condition of mother 4 Rise of temperature 12 Inflamed vagina 1 161 Conditions Associated with Infants. White asphyxia 2 Poor condition of infants 6 Inability of infant to pass urine 1 Premature birth—hydrocephalus 1 Malformation and dangerous feebleness 1 Discharging eyes 2 Prematurity 3 Hæmatemesis and melæna stool 1 Blue asphyxia 1 Abdominal hernia 1 Fees paid to Doctors under Section 14 (1) of the Midwives' Acts, 1918. Ninety-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 £. s. d. Fees of Medical Practitioners 132 6 0 *Proportion recoverable 59 18 0 Nett cost to Local Supervising Authority £72 8 0 *In November, 1937, the Council resolved that in future these fees be not recovered. 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. 162 MILK SUPPLY, 1937. Year. Pints of Fresh Milk. Packets of Dried Milk. Cost to Council. £ s. d. 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 1937 61,598 395 824 11 11 Applicants Granted Free Milk During 1937. January 141 February 148 March 160 April 151 May 141 June 148 July 147 August and September 158 October 161 November 159 December 161 School Medical Service. 164 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 1,574 1,446 92 Senior Girls' 7 1,637 1,485 91 Junior Boys' 4 1,020 934 91 Junior Girls' 4 991 907 92 Junior Mixed 6 1,882 1,712 91 Infants' 15 4,315 3,597 83 Non-provided (Mixed 1 277 241 87 Central (Mixed) 2 960 901 94 Totals 46 12,656 11,223 89 Schools— Church of England — — — — Roman Catholic 1 277 241 87 Council 18 12,379 10,982 89 Totals 19 12,656 11,223 89 The figures given above relate to the financial year ended March 31st, 1938. During the financial year specified, attendances for a total of sixteen sessions in respect of two Infants' Departments were disregarded under the Board of Education Regulations owing to the attendance falling below 60 per cent. in consequence of epidemic sickness. Co-ordination.—The health of the school child is so closely connected with that of the whole community that the School Medical Service cannot be regarded as other than part of the Public Health Service. 165 The Medical Officer of Health is also School Medical Officer, and the other members of the medical staff of the Public Health Department are all actively engaged in school medical work. All medical and specialist services available for the school child are available for the pre-school child. Close co-operation exists between the school medical service and the County Council's Tuberculosis Scheme. Children suspected to be suffering from tuberculosis are referred by the school medical officers to the Tuberculosis Officer (Dr. Ormerod), who is always pleased to put his expert knowledge and facilities for diagnosis at the disposal of the school medical service. During the past year 57 school children referred to the Tuberculosis Officer in this area have been sent away to Convalescent Homes on the recommendation of Dr. Ormerod; and in this connection I have pleasure in acknowledging the kindly assistance and consideration shown by the Leyton Tuberculosis Care Association in making the necessary arrangements for such convalescent home treatment. Judging by the results, this is one of the activities in connection with the County Council's Tuberculosis Scheme which has a most salutary and beneficent influence. The National Society for the Prevention of Cruelty to Children —through the medium of Inspector G. Luff—has continued to render most valuable assistance in dealing with parents who either neglect their children or fail to provide such treatment as is considered necessary for their children's welfare. Inspector Luff handles these cases with praiseworthy firmness and tact, and his valuable assistance is greatly appreciated by the staff of the school medical service. Alterations and Additions to School Premises, JanuaryDecember, 1937. During the year the following schools were redecorated internally:— Davies Lane. Sybourn Street. Knotts Green Special School. 166 Central heating systems were installed at:— Farmer Road School. Goodall Road School. Domestic hot water supplies to lavatory basins were installed at:— Farmer Road School. Goodall Road School. Davies Lane School. Newport Road School. Church Road School. Lea Bridge School. New lavatory washing troughs were supplied at:— Sybourn Street Senior School. Sybourn Street J.M. School. The latrines were re-modelled and modernised at:— Canterbury Road J.M. (Boys) School. Norlington Road Senior Girls' School. New modernised electric light systems were installed at:— Cann Hall Road School. Sybourn Street Senior School. Sybourn Street J.M. School. 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. 167 (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 1,920 Second Age Group 1,249 Third Age Group 1,233 Total 4,402 It will be seen from the above that the number of such code group inspections was 4,402 representing 34 per cent. of the number of children on the school registers. Of 4,402 children who were examined in the code age-groups, 3,693 (or over 83 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 6,191, comparing with 4,909 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 1937 was 13,571. 168 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. 1ll 1 125 4 244 60 10 186 Cann Hall Rd. 105 2 64 19 192 67 5 196 Capworth St. 144 2 106 13 224 72 14 292 Church Road 107 15 63 7 214 79 17 205 Connaught Rd. ... 3 56 81 6 118 59 2 60 Davies Lane 145 4 87 9 275 85 8 249 Downsell Rd. 128 14 127 79 2 216 62 6 56 Farmer Rd. 172 3 74 ... 201 65 28 232 Goodall Rd. 160 7 153 84 3 205 69 4 78 Kirkdale Rd. 92 13 41 ... 6 40 ... ... ... Lea Bridge Rd. 64 11 33 ... ... ... ... ... 33 Mayville Rd. 139 4 55 9 152 53 3 235 Newport Rd. 139 7 132 95 4 202 61 1 63 Norlington Rd. 164 ... ... 105 9 240 85 25 204 Ruckholt Rd. ... ... ... ... 1 182 148 14 114 Sybourn St. 100 3 ... 129 5 223 68 15 192 St. Joseph's 53 ... 33 32 2 69 27 1 61 Trumpington Rd. 97 7 ... 70 3 165 65 16 218 Tom Hood ... ... ... ... 5 125 108 7 53 Knotts GreenS.S. ... ... ... ... ... ... ... ... 373 Totals 1920 96 575 1249 107 3287 1233 176 3100 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 1920 350 18.2 Second Age Group 1249 236 18.8 Third Age Group 1233 220 17.8 Total (Code Groups) 4402 806 18.3 169 Return of Defects found by Medical Inspection in the Year ended 31st December, 1937. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... 3 ... Body ... ... 17 ... Scabies 1 ... 37 ... Impetigo 2 ... 114 ... Other diseases (non-T.B.) 9 ... 303 ... Eye Blepharitis 27 1 86 ... Conjunctivitis 1 ... 49 ... Keratitis ... ... 1 ... Corneal Opacities ... ... 3 ... Other conditions 13 o 179 1 Defective Vision 216 59 121 3 Squint 30 3 23 2 Ear | Defective Hearing ... 6 25 6 Otitis Media 14 5 88 ... Other Ear Diseases 5 1 189 ... Nose & Throat Chronic Tonsilitis only 116 90 117 3 Adenoids only 18 12 8 1 Chronic Tonsiiitis and Adenoids 46 20 61 ... Other Conditions 48 7 115 ... Enlarged Cervical Glands (non-T.B.) 40 18 80 ... Defective Speech 2 1 7 2 Heart and Circulation Heart Disease— Organic 5 23 28 3 Functional 1 29 5 4 Anaemia 11 5 93 2 Lungs Bronchitis 56 35 113 ... Other non-T.B. Diseases 23 18 71 4 Tuberculosis Pulmonary— Definite ... ... ... ... Suspected ... 9 ... ... Non-Pulmonary— Glands ... 2 ... ... Bones and Joints 1 ... 1 1 Skin ... ... ... ... Other Forms ... ... ... ... vous System Epilepsy 3 ... 7 ... Chorea ... 3 19 1 Other Conditions 7 17 79 4 Deformities Rickets 22 5 1 ... Spinal Curvature 1 ... 4 ... Other Forms 79 18 92 2 Other Defects and Diseases 98 35 2536 11 Totals 895 424 4675 50 170 CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN ROUTINE AGE GROUPS. Age Group. Number of Children Inspected. A (Excellent). B (Normal). c (Slightly subnormal). D (Bad). Number. Per cent. Number. Per cent. Number. Per cent. Num. ber. Per cent. Entrants 1,920 180 9.3 1,451 75.5 276 14.3 13 0.6 Second Age Group. 1,249 123 9.8 949 75.9 169 13.5 8 0.6 Third Age Group 1,233 225 18.2 837 67.8 170 13.8 1 0.1 Other routine inspections - - - - - - - - - Total 4,402 528 11.9 3,237 73.5 615 13.9 22 0.5 Uncleanliness and Verminous Conditions.—At the special inspections held by the school nurses, 1,108 children were found to be unclean out of a total number of 29,564 examined (i.e., 3.7 per cent.) Cleanliness Surveys in Individual Schools. School. Number of Examinations. Number Cautioned. Number Excluded. Canterbury Road 2,464 21 14 Capworth Street 2,061 101 15 Cann Hall Road 1,718 23 2 Church Road 2,187 66 17 Connaught Road 1,633 29 19 Downsell Road 1,708 49 26 Davies Lane 2,269 46 29 Farmer Road 1,814 52 9 Goodall Road 2,116 100 4 Kirkdale Road 513 7 4 Lea Bridge Road 214 7 — Mayville Road 2,197 147 54 Norlington Road 1,925 39 23 Newport Road 2,057 23 3 Ruckholt Road 491 4 — Sybourn Street 897 21 6 St. Joseph's 685 41 10 Trumpington Road 1,738 48 6 Tom Hood 120 — — Knotts Green 757 28 15 Total 29,564 852 256 Number of individual children found unclean 1,108 of whom 256 were referred to the Minor Ailments Clinics. 171 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 3,577 (2,820) children attended the clinic, and 14,673 (13,937) attendances were registered. The increase in attendances may be judged by comparing these figures with those of the previous year, shown in brackets. The progressive increase in the attendances may be judged from the following record of attendances during the past five years. Year. No. of Children who attended. No. of Attendances. 1933 1,816 8,234 1934 2,223 10,724 1935 2,453 12,144 1936 2,820 13,937 1937 3,577 14,673 172 Defects Treated During 1937. Ringworm of scalp 3 Ringworm of body 17 Scabies 37 Impetigo 113 Other skin conditions 298 Blepharitis 84 Conjunctivitis 48 Keratitis 1 Corneal opacities 3 Defective vision 63 Squint 19 Other eye conditions 173 Defective hearing 22 Otitis media 87 Other ear diseases 187 Chronic tonsilitis 108 Adenoids 7 Chronic tonsilitis and adenoids 54 Other throat conditions 107 Enlarged cervical glands 75 Organic heart disease 28 Functional heart disease 5 Malnutrition 152 Uncleanliness—-Head 410 Anaemia 89 Bronchitis 107 Tuberculosis—Bones 1 Other non-tuberculous diseases of lungs 69 Epilepsy 7 Chorea 19 Other nervous diseases 74 Rickets 1 Spinal Curvature 4 Other deformities 88 Rheumatism 64 Debility 719 Defective speech 5 Miscellaneous (minor injuries, septic sores, etc.) 1,165 4,513 173 Defective Vision.—Of the 4,402 children subjected to routine code group inspection in the schools, 287 (6.52 per cent.) were found to be suffering from some eye defect requiring treatment. Of 6,191 children referred for special inspection, 462 (7.46 per cent.) manifested some eve 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. (1) (2) (3) (4) (5) Blepharitis 27 1 86 - Conjunctivitis 1 — 49 - Keratitis — — 1 - Corneal opacities — — 3 - Other conditions 13 2 179 1 Defective Vision 216 59 121 3 Squint 30 3 23 2 Special Eye Clinic.— During the year, the Ophthalmic Surgeon had referred to him 878 children, who made 1,219 attendances for examination and treatment. The following list shows the ophthalmic defects found in the 878 children examined at the Special Eye Clinic. Myopia 112 Myopic astigmatism 116 Hypermetropia 136 Hyper astigmatism 291 Mixed astigmatism 65 Hypermetropia with squint 171 Myopia with squint 4 Squint only 22 Anisometropia 3 No defect 18 Spasm of accommodation 124 Various diseases 40 Referred to Minor Ailments Clinic 36 1,138 174 "Various diseases" included :— Choroiditis 1 Nystagmus 1 Photophobia 1 Epicanthus 3 Meibomean cyst 1 Injury to eye 2 Ptosis 8 Migraine 12 Phlyctenular ophthalmia 11 40 Report by the Authority's Ophthalmic Surgeon (J. D. Magor Cardell, M.B., B.S., F.R.C.S.). The number of attendances at the Special Eye Clinic shows no appreciable change as compared with previous years. The incidence of myopia, calculated on the total school population, is 2.3 per cent., a figure which has been gradually increasing during the past 13 years. It has not reached a point when special notice should be accorded to it. More attention might be paid to the ocular habits of the children in school. At a time when it is difficult to deal with all the cases requiring attention at the clinic, 124 cases could be attributed to the results of reading and writing at a distance too close to the book or paper. If these cases could be eliminated an equal number of children with ocular defects would receive attention at the clinic. One hundred and twenty children suffering from squint attended the squint clinic—a percentage of about 1 per cent. The squint clinic, conducted by Miss Montague Smith, has again been active and has a waiting list. This department is greatly appreciated, since it renders unnecessary the time and money wasted in journeying to a Hospital in Central London. At the Central London Ophthalmic Hospital I operated upon 12 of these children who attended the squint clinic. In a few cases it is difficult to determine whether a squint is present. Eight such cases were sent for accurate measurement to the squint clinic and 175 found to have no squint. The cases labelled as "amblyopia" receive no actual squint training until the visual acuity has been improved to 6/12 or better. Thirty cases received squint training and of these 7 were cured; in 10 cases the treatment had not been completed, some of them being in sight of cure. Considering the high standard required before a case is considered cured and the comparable results obtained at other clinics, the figure of 23 per cent. is very gratifying. Copy of Circular Letter to all Head-Teachers. Children easily contract bad habits in reading and writing. They tend to crouch over their books and get their heads down when writing. Such habits are difficult to break. There are several ways in which children fall into these bad habits. Often it is a perverted form of hero-worship, the attitude adopted being that of some school-fellow who is the subject of admiration. Sometimes the children believe they will create an appearance of studiousness and a favourable impression on their teachers. Again, the child may have discovered that by getting closer to print he/she obtains larger images and prefers this state of affairs even though the outlines are not so clear. Many cases are short-sighted, and cannot read or write in a proper position. Of the cases mentioned, those who are not short-sighted will be able, provided the habit has not become fixed and led to spasm of the focussing muscles of the eyes, to read perfectly well when the book is gradually withdrawn from their eyes. Such children do not require an ophthalmic examination ; but those who, by reason of myopia or spasm of their focussing muscles, cannot read when usual print has reached a point of 24 inches from the eyes should be referred to an oculist. One of the evils that can effect children's eyes by close reading and writing has already been indicated—spasm of the focussing muscle which leads to abnormal congestion of the eyes and may result in short-sight. Short-sighted eyes tend to become more shortsighted, such tendency being increased by the lowered position of the head. It is a matter of prime importance that children, when reading and writing, should be trained to sit in a position which does not allow of the eyes being closer than 16 inches to the page. 176 Squint Clinic. 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 squint clinic was established in June, 1936, but 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, 1936. Report by School Medical Officer to Education Authority— February, 1937. The special clinic for the treatment and orthoptic training of children suffering from squint was established in June, 1936. 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 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. 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 6i 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. 177 It is evident that the 38 cases requiring and waiting for treatment will not be able to have the necessary treatment and training for a very long time unless arrangements are made for additional sessions. In view of the importance of arranging for the necessary treatment as soon as possible after the defect is ascertained, I suggest that the Authority consider increasing the number of sessions from two to four weekly. Your Education Authority thereupon decided that, subject to approval of the Board of Education, the Council's Orthoptist be engaged for two further sessions per week. Report by Orthoptist (Miss P. Montague Smith). The following figures show the number and disposition of cases dealt with at the special squint clinic during the year. Number of children who attended clinic 118 Number of attendances made 1,039 Observation cases—no detectable squint 8 Left district 4 Refused or discontinued treatment 11 Treated for defective vision 20 Cured 10 Improved 7 No improvement 3 Treated for squint 30 Cured 11 Rest from active treatment 9 Still under treatment 10 Awaiting treatment 45 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. Of the 30 cases (treated with orthoptic exercises) mentioned above, 12 have had surgical operations on the eyes. In dealing with cases of this type it is advisable for the patient to have orthoptic 178 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 8,043, i.e., 63 per cent. of the number of children on the school rolls. The numbers inspected in each age group were:— Aged 3 13 4 198 5 546 6 755 7 762 8 814 9 813 10 788 11 916 12 908 13 931 14 538 15 57 16 4 In addition, the School Dental Surgeons made 1,602 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 9,645, i.e., 76 per cent. of the number of children on the school rolls. 179 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 ... ... ... ... ... ... Cann Hall 499 114 299 64 194 53.4 Capworth 298 541 234 442 393 58.1 Church ... ... ... ... ... ... Connaught 135 326 87 176 129 49.0 Davies Lane 527 183 338 97 211 48.5 Downsell 556 88 360 57 227 54.4 Farmer 596 100 452 83 278 51.9 Goodall 115 591 63 351 247 59.6 Kirkdale 82 92 47 50 85 87.6 Knotts Green ... ... ... ... ... ... Lea Bridge ... ... ... ... ... ... Mayville ... ... ... ... ... ... Newport ... ... ... ... ... ... Norlington 131 690 90 530 460 74.2 Ruckholt 257 229 174 152 166 50.0 Sybourn 542 280 391 203 343 57.7 St. Joseph's ... ... ... ... ... ... Tom Hood 238 188 140 115 151 59.2 Trumpington 156 489 107 352 284 61.8 4,132 3,911 2,782 2,672 3,168 58.1 It will be seen that, of the 8,043 children inspected, only 2,589 (32 per cent.) had perfectly sound sets of teeth, while 5,454 (67 per cent.) were found to require treatment. Of the 5,454 who were offered treatment, 3,168 accepted, the percentage of acceptance of treatment being 58 percent. 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 Kirkdale Road School the percentage of acceptances was as high as 87.6 percent., whereas in Davies Lane School it was as low as 48.5 per cent. In 249 cases (4 per cent.) the parents actually refused treatment, while in 2,051 cases (37 percent.) the acceptance of treatment papers were not returned by the parents. 180 The following figures give some idea of the dental treatment undertaken at the dental clinics during the year :— Fillings :— Permanent teeth 6,108 Temporary teeth 499 Total 6,607 Extractions:— Permanent teeth 1,382 Temporary teeth 6,410 Total 7,792 Other operations:— Permanent teeth 995 Temporary teeth 460 Total 1,455 Administrations of general anaesthetics for extractions—1,641. Conditions of a Satisfactory Dental Scheme. Under the above title the Chief Medical Officer of the Board of Education published in his Annual Report for the year 1933 the aim and functions of the School Dental Service, along with suggestions and recommendations as to procedure. The following are extracts from that publication:— "The aim of the School Dental Service should be to secure that as many children as possible shall leave school without the loss of permanent teeth, free from dental disease, and trained in the care of the teeth. The scheme should begin, as regards each child, with its entrance into school life, and should provide for an annual re-examination of each child up to the end of school life, with the opportunity for treatment if necessary after each inspection. No school dental scheme can be regarded as complete which does not make this provision for the whole school population. 181 To devote much time to the treatment of children other than those who attend as the result of systematic dental inspection tends to interfere with the routine work and to impair the efficiency of the Service. Anæ sthetics should be employed as a routine measure in the extraction of permanent teeth. In septic cases the use of local anaesthetics is liable to be attended with risk; some provision for the administration of general anaesthetics should therefore always be made. These should not be administered by the operator except in cases of special urgency; the services either of a qualified medical practitioner or of a second dentist should be secured for this duty. In all urban areas, and in the larger centres of population in county areas, permanently equipped dental clinics should be provided. The accommodation should include as a minimum—(a) waiting room, (b) operating room, preferably with a north light, (c) rinsing room, which should communicate directly with the operating room, and which can be used also for recovery after the administration of an anaesthetic. The operating room should be suitably equipped with dental chair, fittings and instruments, and both this and the rinsing room should be provided with lavatory basins with a supply of hot and cold water. Exit from the rinsing room should not be through the waiting room. In every area where several school dentists are employed, it is desirable that one should be appointed to act, under the School Medical Officer, as supervisor and administrator of the Dental Service. Such duties would not ordinarily debar the dentist appointed from sharing in the clinic work. The dental scheme should be appropriately co-ordinated with the whole scheme of treatment devised by the Authority, particularly that part of it concerned with the therapeutics of the ear, nose and throat, institutions such as Open Air Schools, and Residential Recovery Schools, with schemes for Maternity and Child Welfare, Tuberculosis, and other activities of the Local Authority." Report by School Medical Officer to Education Authority— May, 1934. It is always a difficult matter to decide on the policy to be adopted with regard to the casual treatment of children whose 182 parents have refused the offer of routine dental treatment on previous occasions; and Local Education Authorities throughout the country differ widely in the amount of treatment afforded to " casuals." In his Annual Report for 1932, the Chief Medical Officer of the Board of Education (Sir George Newman) states that :— "The School Dental Service is an integral part of "the School Medical Service, and both of them are "educational in purpose. They are not designed to "treat disease indiscriminately, but to fit the child to "receive the education which the State provides, and to "safeguard and build up his health. The aim of the "School Dental Service should be to secure that as many "children as possible should leave school with a complete "and sound set of permanent teeth, free from disease, "and that they should be trained in the care of their "teeth, and taught such principles of dental health as " will conduce to that end." Provided that the dental staff is sufficient to cope with the needs of the area—and to arrange for the inspection and treatment of all children roughly once a year—there may be something to be said in favour of "casual" treatment. But when, as in Leyton, the dental surgeons cannot cope with the needs of children requiring conservative treatment (i.e., fillings), it is obvious that all treatment of "casuals" must be at the expense of—and to the detriment of—children requiring and prepared to have conservative treatment. Of 6,211 children actually treated under the Leyton Education Authority's dental scheme during 1933, some 2,167 were "casuals" who attended for urgent treatment. This means that roughly one child was treated as a "casual" for every two children treated by appointment; and that the School dental clinic is not fulfilling its declared function. In this connection the Chief Medical Officer of the Board of Education states:— "The broad fact is that the purpose of school den"tistry is not to provide a scheme of extraction for "a never-ending stream of casuals, so large that the "dental officers would be employed whole-time alle"viating the sufferings of youth and profiting them 183 "nothing in the greater and more far-reaching problem "of good health resulting from a sound dentition.' It is "an educational scheme of conservative dentistry, and "that alone is its justification. The school clinic is not "an out-patient dental department, and any casual work "should be deferred or declined in accordance with the "purpose of the general scheme, already enough and more " than enough for most Local Education Authorities." In order to enable the dental surgeons to devote their energies to conservative dentistry and to prevent the school dental clinic from developing into an out-patient dental department, I suggest that the Leyton Education Authority should decline to afford urgent dental treatment to children whose parents have consistently failed to take advantage of the conservative treatment recommended by the school dental surgeons. The extent to which parents are prepared to accept offers of conservative dental treatment on behalf of their children depends on their appreciation of the value and importance of such treatment. If parents know that their children can have teeth extracted whenever they are the seat of pain, then they tend to refuse offers of early conservative treatment "with an easy conscience." If, however, they understand that, by consistently refusing conservative treatment, they render their children ineligible for urgent casual treatment, parents will undoubtedly begin to appreciate the real purpose and value of the school dental scheme. Of course, from a humane point of view, it may be contended that it is unfair to punish a child for the ignorance or foolishness of its parents. On the other hand, it is much more unfair to penalise parents and children who are prepared to take advantage of the facilities for which the School Dental Service was instituted. Report by School Medical Officer to Education Authority— May, 1935. At your last meeting I drew attention to the time wasted in inspecting and endeavouring to treat children whose parents consistently decline or fail to take advantage of the treatment offered; and I have already referred to the fact that all 184 treatment of casuals must be at the expense of—and to the detriment of—children requiring and prepared to have conservative treatment. Of the 9,659 children subjected to routine dental inspection in schools during 1934, 6,989 (72 per cent.) were found to require treatment. Of the 6,989 who were offered treatment, 3,228 (46 per cent.) accepted. In individual schools there is wide variation in the acceptance rate. For instance, in Kirkdale Road School the acceptance rate was as high as 68.6 per cent., whereas in Downsell it was as low as 35.8 per cent. In 1,122 cases (16 per cent.) the parents actually refused treatment, while in 2,708 cases (38 per cent.) the parents took no notice whatever of the offers of treatment made on behalf of their children. This means that, of the school children inspected by the dental surgeons during the year, the inspection was a waste of time in 54 per cent. of the cases examined as the parents failed to avail themselves of the treatment offered. Unfortunately, these are the parents who attend at a later date for urgent treatment (casual) for relief of toothache and extraction of teeth which might have been saved by acceptance of treatment when offered. Of 8,437 attendances for treatment in 1934, some 2,063 were by " casuals." As long as casual treatment is given by the Authority, so long will parents feel more or less justified in failing to accept treatment when offered. If, however, they are given to understand that their failure to accept treatment when offered will render their children ineligible for urgent casual treatment at a later date, parents will undoubtedly begin to appreciate the real purpose and value of the school dental scheme. I suggest, therefore, that the Education Authority should decline to afford casual dental treatment to parents who have failed—on two consecutive occasions—to take advantage of the conservative treatment recommended. After consideration of that report your Education Committee agreed with the suggestions made by the School Medical Officer with regard to the restriction of facilities. 185 Before putting into operation the suggested restriction it was felt that it would be advisable to give parents adequate warning; and since September, 1935, the routine letter sent by post to parents has been worded as follows:— Dear Sir (or Madam), I have to report that your child has been found by the School Dental Surgeon to have defective teeth requiring treatment. If you desire to have the treatment carried out by the School Dental Surgeon, please sign and return the notice on the back of this form to the Head Teacher. A letter of appointment will be sent to you in due course. The charge for all necessary treatment is one shilling. If you are unable to pay, please state reasons. The School Dental Service exists primarily for the preservation of school children's teeth; not for the extraction of unsaveable teeth. If, therefore, you fail or refuse to take advantage of two consecutive offers of dental treatment without good reason, it will be presumed that you do not wish to avail yourself of the services of the School Dental Surgeon for the preservation of your child's teeth. It will then be necessary for you to take your child either to a private dental practitioner or to the dental department of a hospital in the event of any urgent dental treatment being necessary. A. W. FORREST, School Medical Officer. As the average period between two successive dental inspections in school is 16.85 months, it was not until late in 1937 that the scheme of restriction could be put into operation. The following letter is now being sent by post to parents who have failed to take advantage of the facilities offered. Dear Sir (or Madam), Your child was examined in school by the School Dental Surgeon on and again on After each of these examinations I addressed to you a letter drawing attention to the fact that your child was found to have defective teeth requiring treatment, and requesting you to sign and return the consent-totreatment form if you wished the necessary treatment to be carried out by the School Dental Surgeon. Each of my letters contained the following statement:— "The School Dental Service exists primarily for the preservation of school children's teeth; not for the extraction of unsaveable teeth. If, therefore, you fail or refuse to take advantage of two consecutive offers of dental treatment without good reason, it will be presumed that you do not wish to avail yourself of the services of the School Dental Surgeon for the preservation of your child's teeth." 186 In view of the fact that you have now failed on two consecutive occasions to take advantage of the offers of dental treatment made on your child's behalf, I have to inform you that your child now becomes ineligible for further school dental inspection and treatment by the Education Authority's dental surgeons. A. W. FORREST, School Medical Officer. In November, 1937, the Director of Education sent to all Headteachers in the Borough the following letter drafted by the School Medical Officer:— "CASUAL" DENTAL TREATMENT. The function of the School Dental Service has been defined by the Chief Medical Officer of the Board of Education :— "The purpose of school dentistry is not to provide a scheme of extraction for ' a never-ending stream of casuals, so large that the dental officers would be employed whole-time alleviating the sufferings of youth and profiting them nothing in the greater and more far-reaching problem of good health resulting from a sound dentition.' It is an educational scheme of conservative dentistry, and that alone is its justification. The school clinic is not an out-patient dental department, and any casual work should be deferred or declined in accordance with the purpose of the general scheme, already enough and more than enough for most Local Education Authorities." It has been laid down by the Board of Education that one dental surgeon cannot deal effectively with the inspection and treatment of more than from 3,500 to 5,000 school children, depending on the rate of acceptance; and that the aim of the School Dental Service should be to provide for the dental inspection and treatment of each child once a year. In the service of Leyton Corporation there are two dental surgeons, of whom one devotes part of his time to dental work in connection with the dental scheme of the Maternity and Child Welfare Authority. Under the circumstances it is impossible to provide effective dental treatment for all children requiring it; and the interval between two consecutive dental inspections in Leyton elementary schools varies from 15 to 18 months. It is therefore obvious that, with the available staff, any treatment of "casual" dental cases must be at the expense of—and to the detriment of— children requiring and prepared to have conservative dental treatment (i.e., fillings, etc.) by appointment. If parents know their children can have teeth extracted whenever they cause pain, they are inclined to refuse offers of early conservative treatment" with an easy conscience." Of course it may be contended that, from a purely humane point of view, it is unfair to let a child suffer due to the ignorance or foolishness of its parents. On the other hand, it is manifestly more unfair that the treatment of " casuals " should interfere with the regular 187 inspection and conservative treatment of children whose parents are prepared to take advantage of the facilities for the provision of which the School Dental Service exists. In order to provide some urgent dental treatment to children whose parents have not consistently refused or failed to accept conservative treatment, I have arranged that " casuals " will be seen by the dental surgeons at certain times, i.e., Tuesday, Wednesday and Friday mornings at 8.50 a.m. It should be understood, however, that the treatment of "casuals" must not interfere with the treatment of children for whom appointments have been made; and I shall be glad of the help and co-operation of head-teachers in what is admittedly a difficult problem by ensuring that children are referred for urgent casual dental treatment at these times only. A. W. FORREST, School Medical Officer. Interval between Successive Dental Inspections. School. Period between inspections (in months). Cann Hall 15 Canterbury 19 Capworth 20 Church 20 Connaught 14 Davis Lane 14 Downsell 14 Farmer 22 Goodall 15 Kirkdale 15 Lea Bridge 18 Mayville 14 Newport 16 Norlington 19 Ruckholt 18 St. Joseph's 20 Sybourne 18 Tom Hood 15 Trumpington 15 Knotts Green Special School 16 188 Orthopaedic Clinic. The following figures show the number of school children examined and treated during the last five years. Examinations. 1933 1934 1935 1936 1937 Primary examinations 118 115 105 99 89 Re-examinations 269 298 249 230 236 Treatment. 1933 1934 1935 1936 1937 Number of children who attended for 156 189 231 257 209 Attendances made 1,296 1,199 2,109 2,188 1,832 It will be seen that, during 1937, some 325 school children were examined or re-examined by the Council's Orthopaedic Surgeon, who attends on one session per month during the year. The following is a summary of the work of the School Medical Service Orthopaedic Clinic during the year:— Primary Examinations 89 Re-examinations 236 The findings at the primary examinations were as follows:— Deformities—Bones and Joints. (а) Congenital. Sprengel's Shoulder, R.1 Cervical Rib, R. and L.1 Dislocation—hip 1 Scoliosis 1 (б) Acquired— Deformities digits (hand) 2 „ „ (foot) 6 Hallux valgus 5 Bowed tibiae 2 Genu varum 1 Genu valgum 9 Injury—knee 1 189 Coxa vara, R. and L.1 Slipped epiphysis1 Shoemaker's chest 1 Pigeon chest 2 Epiphysitis metatarsal 5 2 Periostitis metatarsal 1 Fracture—metatarsal 1 „ ulna 1 „ elbow joint 1 Muscular. (а) Congenital. Torticollis 3 (b) Acquired. Scoliosis 3 Kyphosis 7 Rupture—hamstrings 1 Pes cavus 3 Pes piano valgus 41 Talipes—equinus 2 Paralysis. (а) Congenital Hemiplegia 2 (б) Acquired. Anterior poliomyelitis 3 Also— Baker's Cyst—knee 1 Cyst—hand 1 Plantar bursitis 1 Treatment. Number of school children attending for treatment 209 Number of attendances for treatment 1,832 Admission to Hospital and Operations. During the year twelve children were admitted to hospital and the following surgical operations were performed. Tenotomy—sterno-mastoid 3 Arthrodesis—scaphoid joint 1 „ sub-astragaloid 1 190 Amputation—digit 5. Foot R. and L. 1 Arthrodesis—digit 2. Foot 1 Removal axostosis—digit 4. Foot 1 Sequestrectomy—digit 2. Foot 1 Manipulation of foot. R. and L.1 Plaster of Paris (foot) 3 Surgical Appliances. The following have been supplied:— Spinal brace 1 Caliper splint (leg) 1 Surgical boots 1 pair & 5 single Wedges, valgus pads, stiffening boots 1 pair & 3 single Minor alterations to ordinary boots Alterations and repairs to surgical boots, 94 pairs splints and appliances 15 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. 1933 70 29 2,174 1934 87 40 2,151 1935 110 74 3,310 1936 222 142 5,674 1937 263 177 5,519 The following interesting report by Dr. Henderson contains the results of a valuable investigation undertaken by him regarding the effect of artificial sunlight on the body weight and on the hæ moglobin content of the blood of children undergoing courses of treatment. 191 Report by Dr. Henderson—Deputy School Medical Officer. Patients treated 263 New patients treated 177 Attendances 5,519 During the year 1937 the number of new patients and the total number of children attending the artificial sunlight clinic increased over the previous year's total. The number of attendances made in 1937 was slightly less than those of 1936. Of the 263 children treated during 1937, some 21 failed to complete two months' treatment and 68 were either absent on the days of medical re-examination or had begun treatment after September 30th, 1937. Of the 174 children who were re-examined after treatment, 148 (85 per cent.) had either improved or were cured, 23 (13 per cent.) derived no benefit from treatment, and 3 (1.7 per cent.) were worse. The following table shows these results:— Cured. Improved. Stationary. Worse. Total. Debility 30 32 6 2 70 Adenitis (tubercular) — 5 — — 5 Muscular rheumatism 7 4 4 — 15 Bronchitis 6 7 — 1 14 Asthma — 3 7 — 10 Blepharitis 5 2 1 — 8 Styes 20 — — — 20 Boils 4 1 — — 5 Frequent Colds 12 5 2 — 19 Skin Diseases 2 3 2 — 7 Nervous Children — — 1 — 1 Totals 86 62 23 3 174 Of the 11 asthmatic children treated, 8 improved in general health ; but only 3 (according to the parents) had either less frequent or less severe attacks. Of the 14 children who suffered from repeated attacks of bronchitis each winter, 6 kept free from attacks, 7 had less frequent or less severe attacks and one child was worse. Of the 20 children who were subject to frequent attacks of the common cold, 12 had no colds during treatment, 5 had less frequent colds and, according to their parents, "seemed to throw them off more quickly," 2 derived no benefit and one child was worse. 192 Children with recurring styes responded well to sunlight treatment and so, too, did those with boils. Children with chronic blepharitis required a long course of treatment; and of the 8 children in this series 7 had improved or were cured. Debilitated children formed the largest group treated. Of the 70 debilitated children re-examined, 30 were cured, 32 had definitely improved, 6 derived no benefit from treatment and 2 were worse. A debilitated child was considered cured when he ate and slept well, was bright and "full of spirits" (a description frequently given by parents). Debilitated children who were also undernourished were improved rather than cured. Effect on Body Weight. Each child was weighed before and after the course of treatment. Some 104 children were weighed, and of these 84 (81 per cent.) gained weight, 16 (15 per cent.) remained stationary and 4 (4 per cent.) lost weight. From observations made in various parts of the country by members of the School Medical Service it would appear that the average yearly gain in weight made by an elementary school child is 4-5 lbs. It is not suggested that every child adds to its weight by equal monthly or yearly increments, but a yearly gain in weight of between 4 and 5 pounds can be taken as a reasonable estimate for an elementary school child. In this investigation it is found that, of the 84 children who gained in weight, 21 gained at a yearly rate of between 4 and 5 lbs., 52 gained at a yearly rate of more than 5 lbs. whilst only 11 gained at a yearly rate of less than 4 lbs. The fact that, of the 104 physically defective children here reviewed, 20 per cent. gained weight at a yearly rate of between 4 and 5 lbs. and that 50 per cent. gained weight at a yearly rate of more than 5 lbs. is strong evidence in favour of artificial sunlight treatment. The criticism is often made that in assessing the results of treatment by artificial sunlight too much reliance has of necessity to be placed on the opinion of parents as to whether their children have or have not improved. In the case of children with styes and boils this criticism does not hold, and these children do well with artificial sunlight treatment. So, too, in the case of a debilitated, listless child. There can be no mistaking the progress made under sunlight treatment provided one knows that no other form of additional treatment is being given. 193 Effect on Hæ moglobin Content of Blood. As an additional aid to the objective assessment of the results of treatment it was decided, early in 1937, to estimate the amount of haemoglobin present in the blood of children before and after a course of artificial sunlight. Some 121 children were tested, and of these 82 (68 per cent.) had less than 95 per cent, and 62 (51 per cent.) had less than 90 per cent, haemoglobin. The following table gives the information in tabular form. Haemoglobin per cent. 60—64 65—69 70—74 75—79 80—84 No. of children — 1 2 11 20 Haemoglobin per cent. 85—89 90—94 95—99 100+ Total. No. of children 28 20 10 29 121 Anaemia was found most often in debilitated children. Of the 48 debilitated children tested, 35 (73 per cent.) had less than 95 percent. of haemoglobin and 31 (65 per cent.) had less than 90 percent. haemoglobin. The numbers here reviewed are too few to permit of a definite opinion being formed, but they do suggest that a haemoglobin estimation should be made in all "debilitated" children. The degree of anaemia, the number of children and the diseases for which they were treated are given in the following table:— Disease. Number of Children tested. Percentage of haemoglobin present in blood. 95% or over. 90—94 Under 90 Total. Colds 10 6 1 3 10 Stves 12 4 5 3 12 Boils 5 2 2 1 5 Blepharitis 8 3 1 4 8 Adenitis 6 3 2 1 6 Asthma 6 1 1 4 6 Bronchitis 11 3 3 5 11 Rheumatism 9 4 1 4 9 Skin conditions 6 1 1 6 6 Debility 48 13 4 31 48 Totals 121 39 (32%) 20 (17%) 62 (51%) 121 Of the 121 children tested, 71 were re-tested. Of the 50 children not re-tested, 29 had an initial haemoglobin level of 100 194 percent. or over and 21 were either absent on the days of reexamination or had attended irregularly. Of the 71 children re-tested, 10 had an initial haemoglobin level of between 95 per cent. and 99 percent.; and it was found that artificial sunlight treatment had no appreciable effect on the haemoglobin level of these children. As these 10 children cannot be regarded as being anaemic, they must be excluded from the total of 71. Of the remaining 61 children re-tested, the percentage of haemoglobin was less in 3 (5 percent.), stationary in 15 (25 percent.) and increased in 43 (70 percent.). As there may be a normal daily variation of as much as 8 percent. in the amount of haemoglobin only those children whose haemoglobin increased more than 8 per cent. may be considered to have benefited from artificial sunlight treatment. It was found that, of the 61 anaemic children re-tested, 31 (51 percent.) had a haemoglobin increase of more than 8 per cent., and 28 (46 per cent.) of these 61 children had reached a haemoglobin level of 95 per cent, or more and could be considered cured. The following table gives these results Before Treatment. After Treatment. Haemoglobin per cent. No. of children. No. of children with 95% haemoglobin or over. No. of children with 90-94% haemoglobin. No. of children with less than 90% haemoglobin. Less than 80% 9 1 - 8 80—84% 14 9 2 3 85—89% 23 11 5 7 90—94% 15 7 6 2 Totals 61 28 13 20 When considering the therapeutic effect of artificial sunlight on anaemic children it is important to know the duration of treatment and the length of period over which treatment was given. A quartz mercury vapour arc lamp was used and treatment was given twice weekly; the initial dose was two minutes back and front increasing to a maximum of ten minutes back and front. The course of treatment extended over several months. The following table shows the percentage of haemoglobin before treatment, the number of children, the duration of treatment, and the percentage of haemoglobin after treatment:— Before Treatment. After Treatment. Haemoglobin per cent. No. of children. Duration of treatment in months. 2 3 4 5 6 7 8 9 10 11 12 60—79 9 No. of children with 95% haemoglobin or over 1 — — — — — — — 1 — — — No. of children with 90— 94% haemoglobin — — — — — — — — — 1 — — No. of children with less than 90 % hemoglobin 8 1 - 3 2 1 1 - - - - - Totals (a) 9 1 - 3 2 1 1 - 1 - - - 80—94 52 No. of children with 95% haemoglobin or over 27 1 1 1 2 4 6 3 4 4 - 1 No. of children with 90— 94% haemoglobin 13 4 1 1 1 3 3 - - - - - No of children with less than 90 % haemoglobin 12 1 2 2 1 2 1 — 1 1 1 - Totals (b) 52 6 4 4 4 9 10 3 5 5 1 1 Total 61 Totals (a & b) 61 7 4 7 6 10 11 3 6 5 1 1 195 196 Thus, of the 28 children who had not less than 95 percent. haemoglobin after treatment, 23 had six or more months' treatment, 3 had between four and six months' treatment, and only 2 had less than four months' treatment. Of the 33 children who were still anaemic after treatment, 14 had six or more months' treatment, 10 had between four and six months' treatment and 9 had less than four months' treatment. Though the series of cases here described is a small one as yet, the fact that only 46 percent. of ansemic children were cured by artificial sunlight and that 82 percent. of these children had four or more months' treatment suggests that artificial sunlight is not a method of treatment to be recommended for hypochromic anaemia. Large doses of iron would have cured the anaemia of all these children in a short period of time. PHYSICALLY AND MENTALLY DEFECTIVE CHILDREN. Mentally Defective Children: Statutory Medical Examinations. During the year, some 84 children were referred for statutory medical examination. As the result of examination these 84 children were classified as follows :— Idiots 0 Imbeciles 4 Moral defectives 0 On attaining 16 years of age—for supervision under the M.D. (Notification of Children) Regulations 15 Certified to Local Education Authority as feebleminded 13 Remained under certificate 19 Certificate withdrawn 2 Dull and backward 21 Backward 3 Borderline cases—to be re-assessed in six months 6 Normal 1 84 Knotts Green Special School for Mental Defectives. Admitted 13 Discharged 24 On roll at end of year 75 197 Twelve children, certified to the Local Education Authority as feeble-minded, were admitted to Knotts Green Special School during the year and one child attending the Open Air School was transferred to the School for Mental Defectives. Of the 24 children whose names were removed from the roll, 15 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 ; 2 were allowed to leave on withdrawal of certificate of mental deficiency, and 7 removed from the district. Physically Defective Children. Knotts Green Special School. Accommodation is provided for 150 physically defective children. Admitted during the year 80 Discharged 59 „ —on withdrawal of certificates 40 „ —on removal from district 14 „ —on reaching statutory leaving age 1 ,, —admitted to Residential Schools 3 Deceased 1 On roll at end of year 171 Report by Dr. Henderson—Deputy School Medical Officer. Some 146 children were examined on two or more occasions during 1937. Of that number, 124 (85 per cent.) children improved in health, 18 (12 per cent.) remained stationary and 4 (3 per cent.) were worse. It is interesting to note the close correspondence between these figures and those of the year 1936, and to compare the results of treatment in these two years with the results of previous years. The following table gives this information:— Percentage of Children. 1932 1933 1934 1935 1936 1937 Improved 63.7 59 68.6 75.5 86.2 85 Stationary 34.9 36.3 26.1 18.3 8.8 12 Worse 1.3 4.5 3.2 6.1 4.8 3 198 The number of children in the various disease groups differed but little from the corresponding figures for the year 1936; with the single exception of the group of under-nourished children in which there was a considerable increase. In 1937 some 54 undernourished children attended the school compared with 19 children in 1936. The type of physical defect, the number of children in each category and the progress recorded are shown in the following table:— Defect. No. of Children. Improved. Stationary. Worse. Delicate 13 11 2 Bronchitis 10 9 1 - Bronchitis and Malnutrition 4 3 1 — Asthma 5 3 1 1 Bronchiectasis 4 3 1 - Quiescent Pulmonary Tuberculosis 1 1 - - Fibrosis of Lungs 2 2 — - Subnormal Nutrition 54 48 6 - Tuberculous Adenitis 3 3 - Major Epilepsy 3 1 — 2 Minor Epilepsy 1 1 — — Rheumatic Carditis 16 13 3 — Chorea 1 1 — Congenital Heart Disease 2 2 - - Nervous Children 2 1 — 1 Severe Anaemia 1 1 — Goitre 1 1 — Haemophilia i 1 — — Healed Lupus 1 1 — — Ichthyosis 1 1 — — Crippled Children 20 17 3 — Totals 146 124 18 4 Delicate and under-nourished children made really good progress, and also children with rheumatic heart disease. Some of these children whose hearts are permanently damaged by rheumatism have, at the best, a short expectation of life; and in these cases there can be no doubt that the less strenuous life of the ope-nair school improves their health and prolongs their life. Of the 3 children with major epilepsy, 2 became worse and were transferred to a residential institution for epileptic children. During the year particular attention was paid to the children's weight. The amount of weight gained is, probably, the best single indication of a child's response to an open-air school environment. It is known that an elementary school child makes, on an average, a yearly gain in we'ght of 4-5 lbs. Most of the children here 199 reviewed, prior to admission to the Open-Air School, gained less than 4-5 lbs. a year. All the children attending the Open-Air School were regularly weighed; and in the case of 135 of these children complete weight records are available. By taking a yearly gain in weight of 4-5 lbs. as a standard, and experience shows this to be a reasonable estimate, it is found that of the 135 children, 16 gained less than, 88 gained more than, whilst 31 gained at, the standard rate. Of the 16 children who gained less than the standard amount, 12 suffered from severe and longstanding under-nutrition, 2 were cripples in poor health on admission, one was a delicate child from a tuberculous family and one was an exceedingly nervous lad whose nervousness followed severe concussion resulting from a motor accident. 200 The average monthly gain in weight was 9 ounces. Of the 135 children weighed, 72 gained less than 9 ounces whilst 63 gained that amount or over. The following table shows the number of children, the amount of weight gained by them and the length of stay made by them in the Open Air School:— Gain of Weight in pounds. Length of Stay (in months). 3 6 12 18 24 30 36 42 48 54 60 72 84 Totals. Less than 1 lb. - 2 - - 1 - - - - - - - - 3 1 lb. 1 2 2 - - - - - - - - - - 5 2 lbs. 3 2 3 - - - - - - - - - - 8 3 lbs. 5 9 3 - - - - - - - - - - 17 4 lbs. 2 4 3 1 - - - - - - - - - 10 5 lbs. — 1 4 1 - - - - - - - - - 6 6 lbs. 1 2 3 1 — — — — - — — — — 7 7 lbs. — — 3 1 — 4 8 lbs. — — — 3 1 - - - - - - - - 4 9 lbs. - 1 1 10 lbs. — — 1 1 3 1 - - - - - - - 6 11 lbs. — 1 — 2 — 2 - - - - - — — 5 12 lbs. — — — 1 1 2 1 - - - - - - 5 13 lbs. — — — 1 — — 2 — - — — — — 3 14 lbs. — — — 2 2 1 — — — — — — 5 16 lbs. - - - 1 - - 1 - - - - - - 2 17 lbs. — — — 2 1 2 1 - - - - - - 6 18 lbs. - - - - - 1 - - - - - - - 1 19 lbs. - - - - - - - - - - - - - - 20 lbs. — — — — — — — — 1 — 1 — — 2 21 lbs. - - - - - - 1 - - - - - 1 22 lbs. — — — — 1 — 2 — 3 23 lbs. — — — — 1 — 1 2 — 1 — — — 5 24 lbs. — — — — 1 — 1 — — — — 1 — 3 25 lbs. - - - - - - - - - - - - - - 26 lbs. - - - - - - - 1- - - - 1 — 2 27 lbs. — — — — — — — — — — — — — 28 lbs. - - - - - - - - - - - - - - 29 lbs. - - - - - - - 1 - - - - - 1 30 lbs. - - - - - - - - - 1 - - 1 2 31 lbs. - - - - - - - - - 1 - - - 1 32 lbs. — — — — — — — — 2 — — — 2 33 lbs. - - - - - - - - - - - - - - 34 lbs. - - - - - - - 1 1 1 — — — 3 35 lbs. - - - - 1 - - - - - - - - 1 36 lbs. - - - - - - - - - - - - - - 37 lbs. - - - - - - - - 1 1 1 3 38 lbs. — — — — — — — — — — 1 — 1 39 lbs. - - - - - - - - - - - - - - 40 lbs. - - - - - - - - - 1 - - - 1 41 lbs. - - - - - - - - - - - - - 42 lbs. - - - - - - - - - - 1 - - 1 43 lbs. - - - - - - - - - - - - - - 44 lbs. - - - - - - - - - - - - - - 45 lbs. - - - - - - - - - - - - 1 1 46 lbs. - - - - - - - - - 1 - - 1 2 Totals 12 23 23 16 13 9 10 6 7 7 4 2 3 135 201 The fact that 65 per cent, of the 135 physically defective children who were regularly weighed gained more than the average amount usually gained by an elementary school child, whilst only 12 per cent, gained less, is striking evidence of the value of the Open Air School. Defective Children. Blind and Partially Blind Children. Two children were admitted to White Oak Residential Ophthalmic School, and 2 were discharged. One child was admitted to a day special school, and one child left upon attaining the statutory leaving age of 16 years. Deaf and Dumb Children. Two children were transferred from day special schools to a residential special school. One child was admitted to a day special school, and in one case responsibility was taken over from the Maternity and Child Welfare Committee upon attaining the age of 5 years. One child left a day special school upon removal of the parents from the area. Responsibility for the maintenance of 3 children at a residential special school ceased upon the removal of the parents from the area. Epileptic Children. Two children were admitted to a residential epileptic colony. Child Guidance. Report by School Medical Officer—July, 1937. The members of your School Medical Staff have realised for some considerable time the need for special facilities for the examination and treatment of "mal-adjusted" or " difficult " children (i.e., children whose behaviour causes serious inconvenience, trouble and worry to their teachers, parents or school medical officers). It has been found that ordinary methods of treating their symptoms have been of little use, and that there is an urgent need for specialist treatment. The idea of child guidance work has long passed the socalled experimental stage ; and there are now Child Guidance Clinics established as special departments of London and other hospitals or as separate voluntary organisations. 202 The following extract from the Annual Report of the Child Guidance Council describes the methods of investigation. " The methods employed are simple and straightforward, and have stood the test of time and of critical examination. The general principle is to use the simplest possible procedure which will attain the desired results. The psycho-analytical method is not applied. In certain cases, simple advice is all that is required ; as when the parent or teacher is in doubt on some point of management, or when, as sometimes happens, there is some physical cause, and the means of obtaining appropriate treatment can be indicated. Often there is need for special teaching to overcome a peculiar difficulty in learning. Many clinics are able to supply this by giving individual tuition, or teaching in small groups. Where the case is more involved, and the relations between the child and his family have become strained and unhappy, or the child himself is becoming neurotic, treatment is much less simple. The complications in the home must be unravelled bit by bit, and the child's neurosis must be treated. No extravagant claims are made for the results of the work in Child Guidance Clinics, but the case work is, actually, very successful and compares most favourably with that in any other branch of medicine. Careful demonstration of the results which can be obtained in clinic work has won the confidence of those who have had sufficient opportunities of judging them, and a growing realisation of the need for expert effort to prevent nervous disease and mal-adjustments of personality has hastened the demand for such service." During recent years members of your School Medical Staff have availed themselves of the facilities at the London Child Guidance Clinic, Canonbury; and the excellent reports received from the staff of that clinic have been most useful in dealing with individual difficult cases. The London Child Guidance Clinic, one of the pioneer clinics of its kind in the country, is a voluntary organisation which depends on the raising of voluntary funds. If that 203 clinic is to grow and extend its services to meet the needs of school medical officers who refer cases, it is obvious that it cannot depend entirely on voluntary contributions. Since 1932 the Board of Education has been approving the establishment of child guidance clinics by local education authorities, the expenditure being recognised for grant purposes as part of the provision of the school medical service. Since that date several applications for recognition by the Board for grant have been received, and in 1934 the Board established the principle that a Local Education Authority may contribute to voluntary child guidance clinics for services rendered to children referred by the school medical officer. I estimate that the number of cases likely to be referred by your School Medical Staff would not be likely to exceed a dozen a year, and I suggest that consideration be given to the advisability of applying to the Board for approval of a scheme for reference of cases to a Child Guidance Clinic. After consideration of the above report of the School Medical Officer the Education Authority authorised the reference by their School Medical Officer of special cases to the London Child Guidance Clinic at a fee of 15s. for the initial consultation and a subsequent fee of 5s. per visit for treatment. During the remainder of the year two children were referred to the Child Guidance Clinic. Convalescent Home Treatment. During the year under review the Education Committee accepted responsibility for the cost of maintenance and treatment of 37 children in convalescent homes, heart homes or open air schools recognised by the Board of Education. In addition, 57 children attending Leyton schools were sent away for varying periods through the agency of the Tuberculosis Care Association and 69 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. 204 Average Average cost per rate cost child. per child. £ s. d. £ s. d. (1) Cost in Ley ton Elementary Schools (based on average attendance) 2018 3 11 4 1 (2) Blind Children— (1) In Special Day School (a) 20 0 0 20 0 0 (2) In Special Residential School (a) 74 0 0 37 0 0 (3) In Residential Ophthalmic School (a) 159 5 0 94 5 0 (3) Deaf Children— (1) In Special Day School (a) 26 8 0 26 8 0 (2) In Special Residential School (a) 75 0 0 37 10 0 (4) Other Defective Children— (1) In Knotts Green Special School (6) 33 14 0 16 17 0 (2) Mentally Defective Child in Residential Institution (a) 75 10 0 37 15 0 (3) In Epileptic Colony (a) 74 0 0 37 0 0 (4) Residential Orthopaedic Treatment (a) 127 15 0 63 17 6 (5) Residential P.D. School Treatment (a) 70 0 0 35 0 0 (6) Residential OA. School Treatment (a) 72 0 0 36 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. PHYSICAL TRAINING. I am indebted to the Director of Education for the following information regarding the description of arrangements for physical training in the Authority's Elementary Schools:— Every school under the Authority includes Physical Training as a recognised subject of the curriculum. The following details show the position at the present time. 205 Physical Exercises. The 1933 Syllabus of the Board of Education is followed in all Infant and Junior Schools and in some of the Senior Schools. In certain Senior Schools, and in the Selective Central Schools, more advanced work, including exercises with portable gymnastic apparatus, is being taken. On the whole the playgrounds are satisfactory for the purpose of physical exercises. Some schools contain suitable halls in which physical exercise lessons can be taken satisfactorily during inclement weather, but certain schools lack suitable indoor accommodation for physical training. In general, suitable times have been allotted to physical training in the time-tables of the schools. Following the recommendations of the Organisers of Physical Training all schools have an adequate supply of equipment, which is maintained at standard by requisition, for following the 1933 Syllabus and more advanced work of similar type, and some Senior Schools are equipped with portable gymnastic apparatus. The removal of surplus clothing for the physical exercise lesson is becoming a recognised feature of the work and, indeed, in some schools is a well-established practice. The attitude of the Head Teachers is a most pleasing feature of the work. Head Teachers generally appreciate the importance of physical training and are anxious to have it taught effectively. It is pleasing to record that the teachers concerned with physical training are keen and welcome help towards the improvement of their lessons, the standard of which is rising steadily. This attitude is typical not only of younger teachers but of older teachers, many of whom merit commendation for their conscientious teaching. Organised Games. Provision for organised games during school hours is made in all Junior, Senior and Central Schools. For some years the Authority has maintained a playing field at Ive Farm, on which a gymnasium is nearing completion. Another playing field is in preparation on the site of the old Ballast Pit off Oliver Road. Some schools are situated inconveniently for Ive Farm and take organised games on Wanstead Flats. A high degree of keenness for games exists in the schools and recognised games are played during the period on the games field. 206 Swimming. Two baths are used for teaching our children to swim—the excellent modern bath at High Road which contains a Learners' Pool reserved exclusively for children and Cathall Road Baths, which is also a good bath of older type. Beginning with the 1938 season the Authority has approved the policy, which has been endorsed by the Borough Council, of making swimming a recognised subject of instruction for all children who are not exempted for medical reasons. It has been decided to apply the policy to all children in the top year of the Junior School and the lowest year of the Senior and Central Schools. After receiving this two years' course the children will continue to take swimming while they remain in the Senior and Central Schools. Teachers' Courses. During the year 1937 courses of instruction were conducted by the Organisers of Physical Training for teachers in Infant, in Junior and in Senior and Central Schools. The courses, which were of a voluntary nature, were held in the evenings. Short courses of lecture-demonstrations of typical lessons with progressive teaching were given for Head Teachers of all types of school. In the course of visits to schools many demonstrations for teachers have been given with the teachers' own classes. Footwear. During the past year the Education Committee allotted a sum of money to the provision of plimsols for children whose parents were unable to provide them for physical training. In addition, many children are provided with plimsols by their parents, so that a considerable advance has been made towards their use by all children—a real necessity if they are to derive full benefit from the work and follow it with safety. In this connection the provision of suitable storage for shoes and clothing for physical training is an important question and is under consideration. Equipment for the purpose is at the moment being tried out. Voluntary Organisations. There is a very marked spirit of voluntary effort on behalf of the children among Leyton teachers. This is exemplified by flourishing School Cricket and Football Associations which receive the active support of many teachers, who coach and train the 207 children. There is also a School Athletic Association, the members of which devote a great deal of their spare time to assisting the children's athletics and conduct a well-organised annual athletic sports meeting. Again there is an energetic School Swimming Association which is responsible for much voluntary work for the children's swimming and holds capably managed and stimulating annual galas. In addition to the general athletic meeting and galas, several schools conduct their own annual athletic meetings and swimming galas. In conjunction with the adjoining Borough of Walthamstow a branch of the English Folk Dance Society is maintained and is doing good work. NURSERY CLASSES. Board of Education Circular 1444 (January, 1936). This official Circular states that in normal circumstances children under five years of age benefit more from being in their home surroundings, under parental care, than in school. There are, however, many young children whose mothers, through no fault of their own, are unable to give them at home the care and attention which they need. In certain cases the greater attention which can be given to the physical as well as to the mental requirements of a child who may be delicate, or whose mother is preoccupied by the care of a large family or the necessity of going out to work, fully justifies the admission of the child to school instead of keeping it at home. In other cases, for example where there is only one child in the family, educational benefit will be derived from the companionship of other children and the more varied activities and training which are possible in a Nursery School or in the infants' department of an Elementary School. At present the extent to which children under five are admitted to a Nursery School or to the infants' department of an Elementary School varies widely from one area to another, and often appears to depend as much on local practice and tradition as on the needs of the children. The Board are anxious, therefore, that all Authorities, and particularly those Authorities in whose areas few such facilities at present exist, should survey the local needs and consider how far they call for expansion and improvement, whether in Nursery Schools or in Elementary Schools. In either case, it is of the first importance that simplicity should characterise both the planning and equipment of the premises and their maintenance; 208 and, in order to avoid unnecessary expenditure on staffing and upkeep, the accommodation should, so far as practicable, be in units of an economical size. For both types the main requirements are sunny, well-lighted, warm and airy premises, sufficiently spacious for the development of activities of mind and body, convenient accommodation for training in personal hygiene and opportunities for playing in safety out of doors. The two alternatives mentioned above are not mutually exclusive, and the extent to which either of them is adopted will depend on local conditions. There will, in the first place, be children whose physical condition and surroundings necessitate the continuous medical care and the feeding which are characteristic of a Nursery School. For such children the Nursery School has the further advantages that they can be admitted from the age of 2, and that provision of meals is more readily arranged. The present cost of provision and upkeep of Nursery Schools is not generally extravagant, but there is little doubt that the high cost in individual cases has acted as a serious deterrent to a more rapid increase in the number of Nursery Schools. There are, however, a large number of children whose needs will be met by less specialised provision, and for whom accommodation can most readily be found in separate classes in the infant departments of Public Elememtary Schools. Experience shows that where these young children are accommodated in Public Elementary Schools the arrangements need not be costly or elaborate, and that parts of the existing premises of many infant departments can be adapted at comparatively small expenditure so as to provide all that is required for the training, play and rest of the children. The essentials for this purpose are adequate and suitable space indoors and outdoors including ready access to the playground, and, wherever possible, a separate playground, however small. There should also be easily accessible cloakroom, lavatory and washing accommodation with hot and cold water, the means of preparing and serving a simple milk meal in the middle of the morning, and suitable equipment, including beds for use during the rest period and play material. Report by Medical Officer of Health to the Maternity and Child Authority (March, 1936). The Maternity and Child Welfare Authority is the health Authority responsible for children from birth until the age of five years. 209 In December, 1929, a Joint Circular (No. 1054) was addressed to all Local Authorities by the Minister of Health and the President of the Board of Education. This Circular drew attention to the lack of medical supervision of children between the ages of two and five years, urged Local Authorities to extend their services in that direction, and made suggestions for the effectual filling of the gap in medical supervision. The following is an extract from a special report I was asked to submit at that time as to the manner in which the request of the Ministers could be complied with:— " Broadly speaking, the problem can be tackled in one or other of the following ways:— (1) By the Extension of Existing Services. This could be done either by extending the scope of the infant welfare work of the Maternity and Child Welfare Authority up to the age of five; or by bringing school medical inspection and treatment under the Education Authority down to serve the needs of children from two to five. Although each child carries on its physical attributes or defects from one stage to the next, there is no continuous supervision by the same Authority. After all is said, the arbitrary distinction between the medical services of the Health Authority and the Education Authority is unnecessarily artificial, and defective co-ordination of all the means available should be by no means impossible to obtain, especially where—as in Leyton—the Local Authority has both health and educational powers and the Medical Officer of Health is also School Medical Officer. In such an area the problem should be one merely of arrangement and administration. A more complete scheme for the pre-school child should include:— (a) A more comprehensive scheme for the following up by the health visitors of children between two and five years of age who are found to require medical advice and treatment. 210 (b) Facilities whereby all clinics and all forms of treatment available for the school child should be made available for the preschool child by arrangement between the two Committees concerned. Such co-ordination of effort would be greatly facilitated if the Maternity and Child Welfare Centres and the School Clinics occupied the same building, and this should receive consideration when the question of premises for either of these services is contemplated. (2) By the Creation of Special Institutions. The Maternity and Child Welfare Authority may provide centres, Day Nurseries and domiciliary visitation out of the rate, aided by consolidated grant; whereas the Education Authority may establish Nursery Schools or Nursery Classes in Elementary Schools out of the Education Rate with the current 50 per cent, grant. From a purely medical point of view, the best system is that which subjects a child to routine medical inspection—as in the case of school entrants—at the earliest age. For that reason I am of opinion that Nursery Schools or Nursery Classes in Elementary Schools are preferable to Day Nurseries, inasmuch as they would be more likely to provide for a larger proportion of pre-school children." Since 1930, the activities of the Maternity and Child Welfare Committee have been extended to include the systematic home visiting by their health visitors of children up to the age. of five years and the establishment of special " Toddlers' Clinics " for the medical inspection and treatment of children between the ages of two and five. For such preschool children the Maternity and Child Welfare Authority now provides all the clinic facilities and forms of special medical treatment which are available for the school child. In 1930, the Education Authority decided to remove the age limit for entry of children into schools so as to bring as many children as possible within the scope of the school medical service. In December, 1933, I had occasion to report 211 to the Maternity and Child Welfare Committee regarding the difficulty experienced by mothers in arranging for the admission to schools in the area of children between 3 and 5 years of age. In that report it was suggested that, if it was impossible to have these children admitted to the infants' departments of ordinary elementary schools, the question of a Nursery School or Day Nursery to accommodate the more urgent cases ought to be considered. The Education Authority has recently taken steps to increase the number of nursery classes in ordinary Elementary Schools in the area. In previous reports I have dealt with the administrative confusion and duplication of effort which result from the fact that we have two differently constituted Committees and their independently appointed staffs dealing with the same child from a health point of view. The ideal arrangement would undoubtedly be for one or other authority to have the whole responsibility for the care of the pre-school child placed upon it. As long as we have two authorities sharing the responsibility, careful definition and co-ordination of their respective functions is necessary for smooth working ; and I suggest that the relative responsibilities of the two Committees with regard to the health supervision of children attending Nursery Classes and schools might be considered. Nursery Classes in Leyton Public Elementary Schools. The Education Authority has made special provision for Nursery Classes in the following Schools. School. No. of Children on Roll. Cann Hall Road 34 Cap worth Street 30 Church Road 32 Davies Lane 26 Downsell Road 33 Farmer Road 29 Goodall Road 33 Kirkdale Road 30 Mayville Road 30 Newport Road 27 Norlington Road 34 Sybourn Street 30 Trumpington Road 29 212 Return of Routine Medical Inspection in Nursery Classes during 1937. School. No. of Children. Inspected. Found to require treatment. Canterbury Road 11 1 Cann Hall Road 49 14 Capworth Street 69 3 Church Road 49 10 Connaught Road — — Davies Lane 52 6 Downsell Road 35 6 Parmer Road 78 10 Goodall Road 35 4 Kirkdale Road 20 6 Lea Bridge Road 33 12 Mayville Road 45 10 Newport Road 38 3 Norlington Road 27 3 Ruckholt Road — — Sybourn Street 41 10 St. Joseph's — — Trumpington Road 33 9 Tom Hood — — Knotts Green S.S. — — Totals 615 107 Of 615 children submitted to routine medical inspection during the year, 107 (i.e., 17.4 per cent.) were found to require treatment. Classification of Nutrition. No. of Children Inspected. A. (Excellent). B. (Normal). C. (Slightly Subnormal). D. (Bad). No. % No. % No. % No. % 615 53 8.6 451 73.3 106 17.2 5 08 213 ADMINISTRATIVE PROGRAMME OF EDUCATIONAL DEVELOPMENT BOARD OF EDUCATION CIRCULAR 1444—JANUARY, 1936. On 6th January, 1936, the Board of Education issued to Education Authorities the above Circular entitled " Administrative Programme of Educational Development." In that par.t of the Circular dealing with School Medical Service the Board suggested that Education Authorities would do well to survey the needs of their areas and to consider what further steps should be taken to remedy any deficiencies which may be discovered in their present arrangements. As certain of the recommendations contained in the Circular could be carried out only in conjunction with the Local Sanitary and Maternity and Child Welfare Authorities, the Medical Officer of Health and School Medical Officer submitted a special joint report on the matter to each of the three Committees of the Council concerned. Report of Medical Officer of Health and School Medical Officer, September, 1936. Nursery Schools and Children under Five. Section 21 (a) of the Education Act, 1921, defines the type of children for whom provision may be made in nursery schools (" which expression shall include nursery classes ") as those— " whose attendance at such a school is necessary for their healthy, physical and mental development." Circular 1444 states that in normal circumstances children under five years of age benefit more from being in their home surroundings under parental care than at school, and suggests consideration of facilities for the admission to a nursery school or the infants' department of an elementary school of children found to be delicate or those whose mothers are unable to give them at home the care and attention they need. From a health point of view it is recognised that other conditions (e.g., bad housing, overcrowding, etc.), often make the home an unsatisfactory environment for the pre-school child, and that many young mothers lack the knowledge or ability to train their children properly. 214 " Bad housing, bad home environment and economic hardship may be palliated and even ameliorated through nursery schools and classes; but their remedy calls for other action by the State and Local Authorities. The provision of schools, whatever be the scale on which it is made, so long as these conditions survive, leaves untouched the problem of the child's early environment."— (Hadow Report). From these official statements it is clear that the fundamental purpose and function of the nursery school or class is the safeguarding of the health of young children rather than their formal education, and that—until the available accommodation in special nursery classes is sufficient to meet the requests for admission made by parents—the selection of children for admission should be made on the recommendation of the Maternity and Child Welfare Authority's medical officers. In the past many attempts have been made to draw an arbitrary line of demarcation between the nursery school and the nursery class with regard to their respective origin, organisation and status. Nursery schools are ad hoc establishments designed, built, equipped and staffed to suit their special purpose; whereas nursery classes have generally been makeshift arrangements in infants' schools not designed originally for pre-school infants. From the health point of view, however, both forms of institution have the same purpose—to ensure adequate medical supervision and provide satisfactory conditions for nurture in its widest sense. They are both extensions of child welfare work from the school side designed to bridge the gap in the medical supervision of pre-school children between the age when they cease to attend the infant welfare centre and the age of compulsory school attendance. If an education authority so desires, it can establish nursery classes quite as suitable for their special purpose as the most up-to-date nursery school ; and this some authorities have done and are now doing. The Maternity and Child Welfare Authority is statutorily responsible for the health and welfare of children who have not attained the age of five years and are not being educated in schools recognised by the Board of Education. So long, however, as attendance at school below five years of age is voluntary, the nursery school or class cannot be regarded as 215 being the chief agency for ensuring adequate medical supervision of children between two and five years. With regard to children under five years who may be attending nursery classes, it will be necessary for the Maternity and Child Welfare and Education Authorities to come to some definite understanding as to their respective responsibilities relative to health supervision. In coming to a decision on this matter it should be appreciated that the nursery school or class is not a substitute for the home, but a supplement which works best when it is in close touch with home influences. The official Report of the Consultative Committee on Infant and Nursery Schools (1933) states that:— " There are certain aspects of physical care which are common to all nursery schools; of these the principal are inspections by the school doctor once a term and sometimes once a month, frequent visits by the school nurse,, the systematic weighing and measuring of children, and the exercise of great care in the detection and isolation of cases of infectious illness." In addition, it is stated in the recent publication by the Board of Education on " Nursery Schools and Nursery Classes " that " These children are kept under observation in their homes by Health Visitors." Should the responsible Authority wish to put into operation the intensive medical and nursing supervision (outlined above) in the case of all children attending nursery classes, it should be realised that additional medical and nursing assistance may be necessary. School Dental Service. Circular 1444 states that— " The School Dental Service is seriously incomplete in most parts of the country. Authorities should aim at securing an initial dental inspection of every child on its entry into school life, to be followed by an annual re-examination until the child ceases to attend school. On this basis the Board estimate that, with a normal number of acceptances for treatment, a minimum standard should consist of one dentist for 5,000 children in an urban area and 4,000 children in a rural area, although this is insufficient where a high percentage of parents accept 216 treatment for their children. The Board looks to Authorities to examine their present arrangements with a view to securing that their dental staff does not fall short of the requirements of their areas." The dental staff of Leyton Education Authority consists of two dental surgeons, of whom one also undertakes dental work in connection with the Maternity and Child Welfare Scheme. Each dentist is responsible for the inspection and treatment of over 7,000 school children, and I have drawn attention repeatedly in my Annual Reports to the fact that it is impossible for a dental surgeon to inspect and treat efficiently that number of children each year. Based on the Board's standard, the present dental staff of the Local Education Authority falls short of requirements and should be increased by the appointment of an additional dental surgeon. Treatment of Ear Diseases. Board of Education Circular 1444 states:— " In view of the need for expert treatment of ear diseases, which may result in deafness, it is very desirable that Authorities, which have not yet done so, should arrange for the services of part-time aural specialists who would visit the areas periodically and advise as to the treatment of such cases. The work of the specialists should be closely co-ordinated with that of the aural surgeons employed by Authorities responsible for the maintenance of Isolation Hospitals, since so many ear defects in children are the result of attacks of acute infectious disease." Acute middle ear disease is generally due to septic infection of the nose and throat, the commonest causes being the common cold, scarlet fever, measles, diphtheria, whooping cough, etc. Chronic middle ear disease is due to lack of adequate skilled treatment during the acute stage. In the acute stage middle ear disease often endangers life ; in the chronic stage it may cause deafness or lifelong invalidity and disability. During last year some 314 Leyton school children were found at school medical inspection to require observation or treatment for ear diseases, and 273 children were actually treated in the school minor ailments clinics for minor ear 217 defects. In addition, 481 children were found at school medical inspection to require observation or treatment for defects of nose and throat, which often prove to be predisposing causes of subsequent ear disease. It is considered by the Ministry of Health and the Board of Education that the adequate examination and treatment of these cases require the services of an ear, nose and throat specialist, that the Local Authority should have a certain number of beds reserved in a hospital where operative treatment can be carried out, and that the services of an aural specialist should be available in connection with the Hospital for Infectious Diseases. The nucleus of any scheme for the successful treatment of ear diseases must be an Aural Clinic in charge of a specialist. To such a clinic children would be referred from the Council's Maternity and Child Welfare and School Clinics. Obviously it is advantageous if the Aural Surgeon of the special clinic is also the surgeon in charge of the hospital beds to which the cases referred from the clinic are admitted, and that he should combine this office with that of Consultant Aural Surgeon to the fever hospital. Co-ordination of Duties. In February, 1935, I submitted a special report drawing attention to the difficulty, delay and duplication of effort caused by the Council's health services being controlled by three differently constituted Committees whose respective and independently appointed staffs are engaged in dealing with the same child and the same problem in different ways at different age periods. In that report I pointed out that, with the ever increasing scope and activities of the health services, it is becoming increasingly difficult for any one of these Committees dealing with the work of the health department to take any action which does not concern the other two, the result being delay and confusion occasioned by the increasing necessity of referring matters from one Committee to another. The following observations of Sir George Newman (Chief Medical Officer of the Ministry of Health and Board of Education) illustrate the difficulty of trying to deal with the health of children in watertight groups. 218 " Although the School Medical Service was established primarily as a means of ensuring that the school child was physically and mentally fit to take advantage of the education provided by the State, it has, during its twenty-five years' existence as an organised system, widened its scope of utility. In a word, it has become almost automatically an essential part of the public health service of the nation. Whilst every year it has become more integrated in itself, it has also become an organic link in the national health, even one of its principal foundations. It is a link between all the children under five years of age and the adolescent population above fourteen years of age. We cannot isolate or " block off" the child population, as if it were a watertight group having no relation to those who come before and those who come after school age. We cannot deal with the troubles of childhood as and when they arise ; we must deal with their origins and their results, with a continuing process. We cannot divide the child up on a calendar basis any more than the adult; nor can we separate the disease liability of the one from the disease experience of the other. Hence, we must beware of thinking in compartments and providing some make-shift remedy as the need arises, for ascertainment has demonstrated a process, a succession and a continuity of disease from one age period to the next." Even with regard to the recommendations contained in the two Circulars under consideration it is clear that no one of the three Committees concerned can take action which does not concern the other two. The recently issued Circular 1550 of the Ministry of Health states:— "It is clearly desirable, whenever possible, that the Medical Officer who will supervise the health of children after they enter school should be responsible for their supervision during pre-school years." It is equally clearly desirable that such continuity of supervision should apply, not only to the medical, but also to the dental and nursing staff of the two responsible Authorities. The way to ensure co-ordination is to do away with the necessity for it by the formation of a single Health Committee, 219 responsible to the three existing statutory Committees; for dealing with all matters pertaining to the Council's health services and the work of the health department. Instead of having three sets of officers appointed to carry out the work of three different Committees it would then be possible to ensure the co-ordination and continuity of supervision considered by the Ministry to be so clearly desirable. Such an arrangement would also bring the practice of preventive medicine into line with modern knowledge regarding it. SECONDARY SCHOOLS AND INSTITUTIONS FOR HIGHER EDUCATION. Extract from Annual Report of School Medical Officer— 1935. Situated within the Borough of Leyton are three schools for higher education, viz.:— Leyton County High School for Boys, Essex Road. Leyton County High School for Girls, Colworth Road. Leyton Technical Institute, Adelaide Road. The last-named Institute contains (a) a Junior Technical School, and (b) a Junior Art School. These schools are administered by the Essex County Council which is the Authority for Higher Education. Admission is by competitive examination at the age of 11 years to the two County High Schools, and at 12½ years to the Technical Institute. Mr. R. J. Geldart, District Clerk, has kindly supplied the following information regarding the number of Leyton children on the roll of these schools at the end of 1935. School. No. on Roll. Resident in Leyton. Previously attended Leyton Elementary Schools. Number Percentage. Number Percentage. Boys' High School 533 356 66.79 345 64.73 Girls' High School 449 373 83.07 355 79.06 Junior Technical School 350 44 12.57 46 13.14 Junior Art School 60 18 30.00 18 30.00 220 It will be seen that, of the 1,392 pupils in attendance at these secondary schools in the area, 791 (56.89 per cent.) are actually resident in Leyton, and 764 (54.56 per cent.) previously attended Leyton elementary schools. These figures do not include Leyton elementary school children who are now in attendance at County High Schools outside the Borough. Until they reached the age of 11 years these children had been eligible to take advantage of the Leyton Education Authority's comprehensive scheme of clinic medical services for the treatment of minor ailments, eye defects, orthopaedic defects, dental defects, unhealthy tonsils and adenoids, ringworm, etc.; and arrangements are in existence for the treatment in approved convalescent homes of children in need of it. As soon, however, as a Leyton elementary school child has shown sufficient scholastic ability to gain admission to a County Secondary School, he becomes ineligible for any of the forms of medical treatment outlined above unless there should happen to be a special arrangement in existence for the treatment by the Local Education Authority on behalf of the County Authority. Although the County arranges for the routine medical inspection of secondary school children, it provides no facilities for the treatment of ascertained defects. The child of more than average ability is therefore penalised from a health service point of view owing to the fact that he has gained admission to a County High School. The secondary school child who conscientiously performs all his allotted homework belongs to one of the overworked sedentary occupations. Although Education Authorities have some control over the general hygienic conditions in schools, e.g., lighting, ventilation, etc., they do not concern themselves with the conditions in which the children have to work for two or three hours every night at home. Unfortunately these conditions are often so unsatisfactory as to impose a considerable strain on the health of the children ; and it is in the case of such children, debilitated by the lack of fresh air and exercise, that the correction of existing defects is of great importance. In after life a child may suffer no inconvenience whatever by the loss of much of the knowledge he has acquired in the classroom, but the loss of his teeth or his health will assuredly prove a handicap to him all through life. It should be recognised that the price of scholastic success is too great if it is bought at the expense of health. 221 In March, 1935, the Essex County Council approached the Leyton Education Authority to ascertain whether, and on what terms, the Leyton Authority would co-operate in the provision of medical and dental inspection and treatment of Secondary and Technical School Pupils attending County Council Schools situated within the Borough of Leyton. On the instruction of the Education Authority, your School Medical Officer submitted the following report on the matter in February, 1937. Report of School Medical Officrr—February, 1937. Number of Pupils attending County High Schools situated in Leyton:— (a) County High School for Girls 454 (b) County High School for Boys 524 (c) Junior Technical School 343 (d) Art School 56 Total 1,377 Of the pupils in attendance at these secondary schools at the end of 1935, some 57 per cent, were actually resident in Leyton, and 55 per cent, had attended Leyton elementary schools previously. Under present arrangements County secondary and technical scholars are submitted to routine medical inspection three times during their school careers. I estimate that such routine medical inspection, special inspection and re-inspection of 1,377 scholars would require the services of a full-time school medical officer and school nurse for about five weeks. I understand that the County Council are considering the advisability of arranging for routine medical inspection annually (instead of every second year). Such an arrangement would require the services of the school doctor and nurse for nearly double the period specified above. In 1935 the number of County children found at routine medieal inspection to require treatment was 12.72 per cent, of those inspected, the comparative figure for Leyton elementary school children being 18.5 per cent. 222 Of the County scholars submitted to dental inspection during 1935, some 59.6 per cent, were found to be in need of dental treatment (comparative Leyton figure—70 per cent.). Of County children requiring and offered treatment, only 25 per cent, accepted. This acceptance rate compares very unfavourably with the rate of 53 per cent, in Leyton elementary schools ; but the low County figure is no doubt due to the comparative lack of facilities for treatment. During recent years, as a result of the falling birth rate, there has been a marked decrease in the number of children attending Leyton elementary schools. That there has been no corresponding decrease in the work of school medical and dental inspection is evident from the following comparative figures for the years 1931 and 1935. 1931. 1935. Number of Children on School Rolls 16,667 14,332 Medical Inspection in Schools— (a) Routine medical inspections 5,973 5,122 (b) Special medical inspections 2,335 3,804 (c) Re-inspections (medical) 8,866 12,109 (d) Dental Inspections 10,178 13,222 (e) Cleanliness inspections by nurses 31,013 35,016 Total 58,365 69,274 These figures show that, in the five-year period 1931-35, there has been a substantial increase in the amount of medical and dental inspection of school children in the area; and during that period there has been no addition to the personnel of the medical, dental and nursing staff to cope with the increasing scope of the medical services and the increasing intensity of medical supervision. The opening of the two joint clinics at Leyton Green (in 1933) and at Park House (in 1935) necessitated a general increase in the number of sessions devoted to the medical services of the Maternity and Child Welfare and Education Authorities. In September, 1935, special diphtheria 223 tion clinics were established at sessions held twice a week; and since 1935 special Toddlers' Clinics have been held twice weekly. The annual number of general anaesthetics administered in connection with the school dental scheme has increased from 252 in the year 1931 to 1,441 in the year 1936. In the Board of Education's "Conditions of a Satisfactory Dental Scheme " it is stated that— "the proper course for a Local Education Authority is to appoint a qualified medical man as anaesthetist, but if more than one qualified dentist is employed there is no objection to one dentist administering nitrous oxide gas for another dentist." With the available medical staff a school doctor is not available for the administration of all dental anaesthetics ; and in Leyton (except in special cases) one dental surgeon anaesthetises for the other. It will be appreciated that the employment of your dental surgeons as anaesthetists diminishes the time available for dental inspection and treatment. The present dental staff of Leyton Education Authority (two dental surgeons, of whom one devotes 1½ sessions per week to Maternity and Child Welfare work) cannot deal adequately with the children in Leyton elementary schools. The Board of Education estimate that the minimum staff should consist of one dental surgeon for 5,000 children in an urban area, and state that even that standard of staffing is insufficient where a high percentage of parents accept treatment for their children. Obviously the treatment acceptance rate depends on the facilities available. The efficient dental inspection and treatment of Leyton elementary and County secondary school children require the services of an additional dental surgeon and dental attendant, and the provision of the necessary premises and equipment. The premises at Leyton Green Clinic could not be converted to accommodate an additional dental surgery and annexe; but at Park House Clinic a very desirable dental surgery could be constructed as an annexe to the existing dental premises. This would allow of certain acoustic and sanitary improvements which experience has shown to be desirable in the existing premises. The Borough Surveyor estimates that the necessary constructional work would cost £500. 224 In view of the above-mentioned increase in clinic sessions and in the scope of the work difficulty is now being experienced in completing the annual routine medical inspections and re-inspections in the time available; a school doctor is no longer able to be in attendance at all school minor-ailment treatment sessions; a doctor is not available for the administration of general anaesthetics for dental extractions; the children attending the artificial sunlight clinic are not under adequate medical supervision; and it has recently been found necessary to discontinue one of the two weekly sessions for diphtheria immunisation. It will be seen that the present medical and dental staff cannot cope adequately with existing services, and could not undertake the medical and dental inspection and treatment of County Secondary and Technical School Pupils unless your Council should decide to curtail existing services and arrangements. After consideration of the above report your Authority asked for a further report by the School Medical Officer showing the cost of a scheme based on the appointment of an additional full-time School Medical Officer, School Dental Surgeon and School Nurse, together with the provision of additional accommodation and equipment at Park House Clinic, and indicating the probable allocation of cost as between the two Authorities. After consideration of that further report your Authority decided that— "The Essex Education Committee be informed that the Authority are prepared to carry out the medical inspection and treatment and dental inspection and treatment of pupils attending day schools for higher education in Leyton, at a total annual cost of £440 (£260 for medical inspection and treatment and £180 for dental inspection and treatment), such arrangements to be made without any increase in the medical staff and without additional equipment, and to include the following services, viz. Minor ailments, eye clinic, provision of spectacles, X-ray examination, X-ray treatment for ringworm, orthopaidic clinic, orthoptic clinic, remedial exercises and ' light' treatment 225 (but exclusive of any services under Part V. of the Education Act, 1921, or the provision of surgical appliances). RESOLVED: That a report on this matter be submitted from time to time, together with a culminating report at the expiration of twelve months from the inception of the arrangements." In June the Essex Education Committee accepted the offer of the Leyton Education Authority to carry out the medical inspection and treatment of pupils attending schools for higher education within the Borough of Leyton, subject to review at the end of one year. In July, following a request by your School Medical Officer for information, your Authority decided that the scheme commence on 1st September, 1937; that no curtailment be made in the existing services for elementary school children ; and that priority of treatment, if necessary, be given to Leyton elementary school children. Prior to the scheme being put into operation your School Medical Officer communicated with the County School Medical Officer regretting that, under existing arrangements, it would be impossible to devote to County Council pupils the amount and quality of medical and dental inspection and treatment which may be considered necessary. Medical and Dental Inspection and Treatment—1st Sept. to 31st Dec., 1937. After consulting the Head Teachers of County Schools in the area, arrangements were made for the medical inspection and dental treatment of certain County School scholars in whose cases it was considered that such inspection and treatment could be delayed no longer without hardship to the children concerned. These arrangements were made possible by curtailing the number of medical re-inspections and dental appointments of children attending Leyton elementary schools. 226 The following list shows the amount of medical inspection and dental treatment of County Secondary School Scholars undertaken since 1st September, 1937:— Medical Inspections in Schools. Routine Group Inspections 73 Special Inspections 3 Re-inspections 117 Medical Treatment at Clinics. Minor Ailments 4 Dental Inspections in Schools Nil Dental Treatment at Clinics. Number of children treated 24 Number of attendances 30 Extractions 27 Fillings 31 Anaesthetics—local 5 general 12 Other operations 3 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. 227 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 „ „ 1937 148 „ „ PROVISION OF MEALS. The provision of meals to children attending the elementaryschools 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 1933 303 1934 323 1935 327 1936 305 1937 282 The number of individual children fed under the Authority's arrangements during 1937 was as follows:— Ordinary Meals. Milk Meals. Free 626 1,392 For payment 78 - Totals 704 1,392 Number of meals supplied:— Ordinary Meals. Milk Meals. Free 75,488 340,400 For payment 5,220 — Totals 80,708 340,400 The above figures relate to the financial year ended 31st March, 1938. 228 STATISTICAL APPENDIX. TABLE I.—Returns of Medical Inspections, a. Routine Medical Inspections. Number of Code Group Inspections:— Entrants 1,920 Second Age Group 1,249 Third Age Group 1,233 Total 4,402 b. Other Inspections. Number of Special Inspections 6,191 Number of Re-inspections 13,571 Total 19,762 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 24 326 350 18.2 Second Age Group 78 158 236 18.8 Third Age Group 114 106 220 17.8 Total (Prescribed Groups) 216 590 806 18.3 Other Routine Inspections — — — — Grand Total 216 590 806 18.3 229 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1937. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... 3 ... Body ... ... 17 ... Scabies 1 ... 37 ... Impetigo 2 ... 114 ... Other diseases (non-T.B.) 9 ... 303 ... Eye Blepharitis 27 1 86 Conjunctivitis 1 ... 49 ... Keratitis ... ... 1 ... Corneal Opacities ... ... 3 ... Other conditions 13 2 179 i Defective Vision 216 59 121 3 Squint 30 3 23 2 Ear Defective Hearing ... 6 25 6 Otitis Media 14 5 88 ... Other Ear Diseases 5 1 189 ... Nose & Throat Chronic Tonsilitis only 116 90 117 3 Adenoids only 18 12 8 1 Chronic Tonsilitis and Adenoids 46 20 61 ... Other Conditions 48 7 115 ... Enlarged Cervical Glands (non-T.B.) 40 18 80 ... Defective Speech 2 1 7 2 Heart and Circulation Heart Disease— Organic 5 23 28 3 Functional 1 29 5 4 Anæmia 11 5 93 2 Lungs Bronchitis 56 35 113 Other non-T.B. Diseases 23 18 71 4 Tuberculosis Pulmonary— Definite ... ... ... ... Suspected ... 9 ... ... Non-Pulmonary— Glands ... 2 ... ... Bones and Joints 1 ... 1 1 Skin ... ... ... ... Other Forms ... ... ... ... Nervous System Epilepsy 3 ... 7 ... Chorea ... 3 19 1 Other Conditions 7 17 79 4 Deformities Rickets 22 5 1 ... Spinal Curvature 1 ... 4 ... Other Forms 79 18 92 2 Other Defects and Diseases 98 35 2 536 11 Totals 895 424 4,675 50 230 TABLE II—B. Classification of the Nutrition of Children Inspected during the Year in the Routine Aoe Groups. Age Groups. No. of Children Inspected. A. (Excellent). B. (Normal). C. (Slightly Subnormal). D. (Bad). No. % No. % No. % No. % Entrants 1,920 180 9.3 1,451 75.5 276 14.3 13 0.6 Second Age Group 1,249 123 9.8 949 75.9 169 13.5 8 0.6 Third Age Group 1,233 225 18.2 837 67.8 170 13.8 1 0.1 Other Routine Inspections — — — — — — — — — Total 4,402 528 11.9 3,237 73.5 615 13.9 22 0.5 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 Elementary Schools. At other Institutions. At no School or Institution. Total. — 17 — — — 17 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 - 8 - 94 231 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. _ 3 2 5 — 10 PHYSICALLY DEFECTIVE CHILDREN. A. Tuberculous Children. I.—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. — 8 2 — 10 II.—Children Suffering from Non-Pulmonary Tuberculosis. (This category should include tuberculosis of all sites other than those shown in (I) above.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 27 2 — 29 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 96 — — — 96 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 20 8 — — 28 232 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 25 — — 2 27 Children Suffering from Multiple Defects. Combination of Defect. At Certified Special Scnools. 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, 1937. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Table VI) Disease or Defect. Number of Defects treated or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin— Ringworm- Scalp—(1) X-ray treatment 2 — 2 (2) Other 1 — 1 Body 17 1 18 Scabies 37 — 37 Impetigo 113 — 113 Other skin diseases 293 1 294 Minor Eye Defects—- (External and other, but excluding cases falling in Group II.) 274 - 274 Minor Ear Defects.. 279 2 281 M iscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 994 21 1,015 Total 2,010 25 2,035 233 TABLE IV.—contd. Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as mlnor ailments.—group I.). Defect of Disease. Number of Defects dealt with. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Errors of refraction (including squint) .. 920 28 948 Other defect or disease of the eyes (excluding those recorded in Group I.) 164 — 164 Total 1,084 28 1,112 Under the Authority's Scheme. Otherwise. Total. No. of Children for whom Spectacles were:— (a) Prescribed 654 28 682 (6) Obtained 649 33 682 TABLE IV.—contd. Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Other Forms of Treatment. Total Number Treated. Received Operative Treatment. Under the Authority's Scheme in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4) 146 351 65 9 75 13 19 5 12 7 84 14 87 20 (1) Tonsils only. (2) Adenoids only. (3) Tonsils and adenoids. (4) Other defects of the nose and throat. 234 TABLE IV.—contd. Group IV.—Orthopædic and Postural Defects. Under the Authority's Scheme. Otherwise. Total number treated. Residential treatment with education. Residential treatment without education. Non-residential treatment at an orthopaedic clinic. Residential treatment with education. Residential treatment without education. Non-residential treatment at an orthopjedic clinic. (1) (2) (3) (i) (2) (3) No. of children treated 12 — 223 — — 6 223 TABLE V. Dental Inspection and Treatment. (1) Number of children who were:— (a) Inspected by the Dentist:— Aged : Age Groups 3 13 Total 8,043 4 198 5 546 6 755 7 762 8 814 9 813 10 788 11 916 12 908 13 931 14 538 15 57 16 4 Specials (Casuals) 1,602 Grand Total 9,645 (6) Found to require treatment 7,056 (c) Actually treated 5,625 (2) Half-days devoted to Inspection 37½ Treatment 763½— -Total 801 235 (3) Attendances made by children for treatment 8,775 (4) Fillings, Permanent Teeth 6,108 6,607 Temporary ,, 499—Total (5) Extractions, Permanent Teeth 1,382 7,792 Temporary ,, 6,410—Total (6) Administrations of general anaesthetics for extractions 1,641 (7) Other operations, Permanent Teeth 995 1,455 Temporary „ 460—Total 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 29,564 (3) Number of individual children found unclean 1,108 (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 — (6) Under the School Attendance Bye-laws — 236 STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31ST DECEMBER, 1937, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total number of children notified: 19. Analysis or the above Total. Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School : (a) Idiots - - (b) Imbeciles 3 1 (c) Others - - (ii) Children unable to be instructed in a Special School without detriment to the interests of other children: (a) Moral defectives - - (6) Others - - 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 7 8 3. Feeble-minded children notified under Article 3, i.e., " specia.1 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 9 237 INDEX. PAGE Section A. Statistics and Social Conditions of the Area . 7/27 „ B. General Provisions of Health Services for the Area 28/41 ,, C. Sanitary Circumstances of the Area 42/52 „ D. Housing 52/59 ,, E. Inspection and Supervision of Food 60/70 „ F. Factories and Workshops70/72 „ G. Prevalence of, and Control over Infectious Diseases 72/95 Isolation Hospital 96/99 Maternity and Child Welfare101/162 School Medical Service 163/236 PUBLIC HEALTH. Acts, Adoptive 30 Adulteration 71 Ambulance service 30 ,, ,, for Maternity cases 130 Ante-natal Clinics Ill „ ,, Abnormal Cases 114 Ante-natal Records—Analysis for a 5-year period 118 Artificial Sunlight Treatment (M. & C. W.) 106 Bacteriological Examinations 61,93 Bakehouses 68 Baths—Swimming 34 Births 12 Bye-laws and Regulations 31 Cancer 92 Children and Young Persons Act 1ll Clinics and Treatment Centres 28 Convalescent Home Treatment 107 Dairies and Milkshop3 60 Deaths 16 „ Maternal 20,133 ,, Infantile 19,108 Demolition Orders 57 Dental Treatment (M. & C. W.) 104 Diabetes—Supply of Insulin 93 Dining Room and Restaurants 68 Diphtheria 85,98 ,, Immunisation 86 Diseases of Animals Acts 69 Drainage 49 Dysentery 76 Domiciliary Midwifery Service 157 238 page ]$nteric Fever 72 Factories and Workshops 70 Foods, Inspection of 60 Foster Mothers .50, 111 Foot Clinic 39 Hairdressers 50 Health Visitors, Visits 104 Home Helps 133 Hospital Provision 29 House to House Inspection 59 Housing Statistics 52 Ice Cream 63 Infant Welfare Clinics 102 „ „ „ Attendances 103 „ Mortality 19,108 ,, Life Protection 111 Infectious Diseases 72 Inquests 33 Insulin, Supply of 93 Isolation Hospital 96 Legislation in force 30 Massage Establishments 39 Maternal Morbidity and Mortality 20,133 ,, ,, ,, ,, Administrative arrangements 133 Maternity Beds 125 Meat Inspection 65 Meteorology 9 Midwives' Act, 1936 142 ,, Fees paid to Doctors 161 „ Medical Aid 160 Milk, Scheme for Supply of 162 Mortuary 32 Neo Natal Mortality 108 Notification of Births 102 Nursing Homes 133 Nutrition 161 Obstetric Consultant 140 Offensive Trades 69 Ophthalmia Neonatorum 108 Ophthalmic Clinic (M. & C. W.) 106 Orthopaedic Clinic (M. & C. W.) 105 Overcrowding 55 Petroleum Acts 50 Population 7 239 PAGE Public Cleansing 42 Puerperal Fever 138 „ Pyrexia 138 Public Houses 68 Queen Mary's Hospital. Payment for Maternity Beds. ... 126 Rag and Flock Act. 50 Rats and Mice Destruction Act 51 Refuse Collection 43 Rent Restriction Act 59 Restaurants and Dining Rooms 68 Sanitary Inspectors' Duties 43 Sanitary Inspectors' Visits 48 Scarlet Fever 77,96 „ „ Incidence of Complications 77 ,, ,, Complications amongst Patients in Isolation Hospital 97 Scavenging 42 Schools 51 Shops Act, 1934 51 Slaughter Houses 65 Smoke Abatement 51 Social Conditions 8 Staff 3 Stillbirths 8,116 Swimming Baths 34 Tuberculosis 89 Typhoid Fever 72 Unsound Food 65 Verminous Premises 49 Voluntary Workers 102 Water Supply 42 TABLES. Table 1—Meteofology 10,11 ,, 2—:Births 15 ,, 3—Deaths 21/22 „ 4—Comparative Statistics 25 ,, 5—Vital Statistics of Whole District 26 „ 6—Analysis of Mortality 27 „ 7—Scarlet Fever. Analysis of Contact Rates, Hospital Treated and Home Treated Cases 81 ,, 8—Scarlet Fever. Incidence of Return Cases 83 ,, 9—Infectious Disease Notifications 94 „ 10—Infant Welfare Clinic Attendances 103 ,, 11—Infant Mortality 109 240 page SCHOOL MEDICAL SERVICE. Accommodation 164 Artificial Sunlight (Clinic 190 ,, ,, Effect on Haemoglobin Content of Blood ... 193 Blind Children 201 Child Guidance 201 Convalescent Home Treatment 203 Co-ordination 164 Deaf Children 201 Defective Vision 173 Dental Clinic 178 „ „ Conditions of a Satisfactory Dental Scheme 180, 215 Educational Development—Administrative Programme 213 Employment of Children 226 Eye Clinic 173 Knotts Green Special School 197 Malnutrition Meals, Provision of Medical Inspection „ Treatment Mentally Defectives Milk Meals Minor Ailments Clinic Nursery Classes 207,213 Orthopaedic Clinic 188 Ophthalmic Clinic 173 Physically Defective Children 197 Physical Training 204 School Population and Attendance 164 „ Premises—Alterations and Additions 165 Secondary Schools—Medical Inspection 219 Squint Clinic 176 Statistical Tables 228 Uncleanliness 170