LEY 32 Borough of Leyton HEALTH REPORT FOR THE YEAR 1938. 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 8. 2 HIS WORSHIP THE MAYOR (Mr. Alderman Fitzgerald, J.P.), ex-officio Member of Committees. PUBLIC HEALTH COMMITTEE: DISEASES OF ANIMALS ACT COMMITTEE. Chairman : Alderman Mrs. Shimmin. Members : Alderman Bechervaise. Councillor Mrs. Crown. ,, Mrs. Hammond. „ Hinton, J.P. „ Mrs. Mawer. ,, Quantrell. ,, Shimmin, B.Sc. ,, Rayner. Councillor Bass. ,, Rigg. „ Bell. ,, Mrs. Warner. ,, Biles. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Alderman Mrs. Mawer. Members : Alderman Mrs. Hammond. Councillor Hurry. „ Mrs. Shimmin. „ Shell. Councillor Bussey. ,, Spink. ,, Mrs. Crown. „ Turner. „ Mrs. Warner. Co-opted Members : Miss Bond. Mrs. Sortwell. Mrs. Burrell. ,, Waller. ,, Martin. EDUCATION COMMITTEE. Chairman : Alderman Bechervaise. Members : Alderman Mrs. Hammond. Councillor Cochrane. „ Mrs. Mawer. „ Hawkins (W. F.). „ Mills. „ Hawkins (H. W.). ,, Shimmin, B.Sc. ,, Hinton, J.P. ,, Mrs. Shimmin. ,, Hurry. Councillor Allanson, J.P. ,, Pearce. ,, Bass. ,, Rayner. „ Burrell. ,, Rigo. ,, Bussey. ,, Turner. Co-opted Members : Miss Bond Mrs. Ringer. Mrs. Cochrane. Mr. L. Levy. ,, Crown. ,, W. C. Russell, J.P. ,, King. „ F. R. Webber. EDUCATION WELFARE SUB-COMMITTEE. Chairman : Alderman Mrs. Hammond. Members : Alderman Mrs. Shimmin. Councillor Rigg. Councillor Burrell. ,, Turner. „ Bussey. Miss Bond. „ Hawkins (W. F.). Mrs. King. „ Hinton, J.P. „ Ringer. „ Hurry. Mr. L. Levy. „ Rayner. ,, W.C. Russell, J.P. 3 Borough of Leyton. PUBLIC HEALTH OFFICERS OF THE AUTHORITY. A. MEDICAL—Whole Time. Forrest, Andrew W., M.A., M.D., M.B., Ch.B., D.P.H., Medical Officer of Health, School Medical Officer, Medical Superintendent of Isolation Hospital. 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., Ophthalmic Surgeon. 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. Sandiford, Cyril Ratcliffe, M.D. (Manch.), M.B., Ch.B., F.R.C.S. (Ed.), Aural Surgeon. Elman, Claude, M.D. (Lond.), M.B., B.S., M.R.C.P. (Lond.), M.R.C.S. (Eng.), L.R.C.P. (Lond.), Physician i/c Heart Clinic. Jardine, Helen Margaret, M.D. (Aberd.), M.B., Ch.B., M.M.S.A. (Lond.), Medical Officer i/c Post Natal and Gynaecological Clinic. B. DENTAL SURGEONS. Senior Denial Surgeon. Hall, Arthur Edward, L.D.S. (Liverpool). Dental Surgeons. Horton, James Ernest, L.D.S., R.C.S. (Eng.) Grant, David Reginald Brash, L.D.S., R.C.S. (Edin.) 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. Kluth, Leslie, Certificate R.S.I., Meat Inspector's Certificate R.S.I., Smoke Inspector's Certificate R.S.I. (commenced 7.7.38). 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. Kitterino, Maroery, 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, (resigned 17.9.38). Hughes, Emily Doreen, S.R.N., S.C.M., Health Visitor's Certificate R.S.I, (commenced 30.11.38). 4 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. Edwards, Ruth, S.R.N., S.C.M. Stiles, Eleanor, S.R.N., S.C.M. Corby, Elizabeth, S.R.N. Acton, Lucy, S.R.N., S.C.M. Municipal Midwives. Roberts, Elizabeth, S.R.N., S.C.M. Daines, Emily, S.R.N., S.C.M. Dodsworth, Daisy, S.C.M. (Resigned 3.8.38). Thompson, Mabel, S.R.N., S.C.M. (Commenced 10.10.38). 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 Orthoplist. Smith, Miss Glennis. Denial Attendant. Grimshaw, Miss Peggy. Mortuary Keeper. Miles, Esau George. F. CLERICAL STAFF. Chief Cleric. Leserve, George Frederick. Clerics. Jacobs, E. E. Softley, W. D, Brighting, G. Halsey, C. S. Freeman, A. L. Thurlow, G. Clarke, J. Ware, F. C. Hayes, Miss A. Payne, Miss W. * Proportion of Salary contributed under Public Health Acts or by Exchequer Grants. 5 TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF LEYTON. Me. Mayor, Ladies and Gentlemen, I submit herewith my Annual Report on the health, sanitary circumstances and vital statistics of the Borough of Leyton during the year 1938, 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. Since the Great War there has been a fundamental change in the duties and responsibilities of a Public Health Department. Prior to 1914 the local Health Authority was concerned almost exclusively with environmental hygiene and preventive medicine. Since that time the Health Authority has organised a most comprehensive scheme of medical services designed to maintain individual health ; and the detachment between preventive and curative medicine is fast disappearing. The wide and comprehensive range of modern public health activities may be judged by reference to the number of medical subjects dealt with in this Report. There are, however, many activities of the Public Health Department which are not included in this Annual Report, e.g., the duties and responsibilities placed on the Public Health Department by the provisions of the Air Raid Precautions Act, 1937. During the year under review the administrative and clerical staff have been actively engaged in the initiation of schemes for the organisation of A.R.P. Casualty Services to be put into operation in the event of war. This work is of a kind absolutely foreign to the previously accepted scope of a public health department and to the duties for which the members of the department have been trained. The organisation of A.R.P. Casualty Services is a formidable undertaking, and it is with sincere thanks that I record my appreciation of the loyal and industrious co-operation of the staff. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, 6 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, 1938) 117,200 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 £792,463 Sum represented by a penny rate for General Rate purposes (as from 1st April, 1939) £3,150 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 7 Physical Features of the Area. See Annual Report for 1934. Social Conditions. See Annual Report for 1934. Extracts from Vital Statistics for the Year. Live Births :— Birth Rate per 1,000 Males. Females. Total. population. Legitimate 744 725 1,469 12.87 Illegitimate 15 25 40 759 750 1,509 Rate per 1,000 total (live and Males. Females. Total. still) births. Stillbirths 20 21 41 26.45 Males. Females. Total. Death Rate. Deaths 592 556 1,148 9.79 Number of women dying from diseases and accidents of pregnancy and childbirth :— Rate per 1,000 total (live and still) births. From Sepsis 2 1.29 From other causes - - Total 2 1.29 Death Rate of Infants under One year of age:— All infants per 1,000 live births 46.38 Legitimate infants per 1,000 legitimate live births 43.56 Illegitimate infants per 1,000 illegitimate live births 150.00 Deaths from Cancer (all ages) 191 Deaths from Measles (all ages) 5 Deaths from Whooping Cough (all ages) ... 2 Deaths from Diarrhoea (under 2 years of age) 7 8 VITAL STATISTICS. Births.—Fifteen hundred and nine births were registered during the year :— Males. Females. Total. Legitimate 744 725 1469 Illegitimate 15 25 40 759 750 1509 The birth rate per 1,000 of the population was thus 12.87. 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. 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 1938 117,200 1,509 12.87 On page 21 will be found a table showing the population, number of births and birth rate for each year since 1892—a period of 46 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. 1934 1935 1936 1937 1938 Leyton 11.78 12.26 11.85 | 12.02 12.87 126 County Boroughs and Great Towns 14.7 14.8 14.9 14.9 15.0 London 13.2 13.3 13.6 | 13.3 13.4 England and Wales 14.8 14.7 14.8 ! 14.9 15.1 9 Of the total number of births registered (1,509) during the year, 860 (56 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 860 births occurred in the following institutions :— Queen Mary's Hospital 282 Mothers' Hospital, Clapton 158 Forest Gate Hospital 197 City of London Maternity Hospital 14 Plaistow Maternity Hospital 36 East End Maternity Hospital 3 Kingswood Maternity Home 12 Thorpe Coomb Maternity Home 16 London Hospital 14 University College 2 St. Bartholomew's Hospital 2 Royal Free Hospital 9 German Hospital 15 Middlesex Hospital 1 Queen Charlotte's Hospital 4 Jewish Maternity Hospital 5 Walthamstow District Nursing Association ... 15 Guy's Hospital ... 1 Charing Cross Hospital 2 Bethnal Green Hospital 2 Hackney Hospital 6 Mile End Hospital 2 St. Andrew's Hospital ... 7 Maycroft Nursing Home 2 Royal Northern Hospital 1 Woodside Nursing Home 4 Other Institutions 48 860 10 Graph No. 1. Leyton Birth Rate 1918-1938 11 TABLE 1. Registered Births, 1938. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Total January 3 13 8 5 5 10 12 9 1 3 69 February 4 11 4 5 7 11 2 5 8 4 61 March 5 6 5 8 5 7 8 3 0 6 55 April 2 11 5 5 6 3 4 8 2 4 50 May 3 5 4 2 13 7 8 4 5 5 56 June 3 10 10 9 12 7 8 6 4 4 73 July 4 4 4 4 4 9 2 5 3 6 45 August 1 6 8 7 5 2 6 1 4 4 44 September 6 7 5 4 4 7 7 7 6 6 59 October 4 6 3 4 8 5 5 — 8 2 45 November 5 7 5 7 7 3 3 2 4 2 45 December 5 6 4 4 8 5 6 5 I 3 47 Transferables 61 156 72 76 145 101 67 71 62 49 860 Totals 106 248 137 140 229 177 138 126 110 98 1,509 12 Deaths.—Eleven hundred and forty-eight deaths of Leyton residents were registered during the year, including those of 144 males and 108 females (transferable deaths) who died outside the area. Males. Females. Total. 592 556 1,148 The death rate per 1,000 of the population was thus 9.79. 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. 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 1938 117,200 1,148 . 9.79 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. 1934 1935 1936 1937 1938 Leyton 10.67 10.06 10.61 11.42 9.79 126 County Boroughs and Great Towns 11.8 11.8 12.3 12.5 11.7 London 11.9 11.4 12.5 12.3 11.4 England and Wales 11.8 11.7 12.1 12.4 11.6 The figure of 1,148 registered deaths represents a decrease of 201 (about 17 per cent.) when compared with the corresponding number (1,349) registered during the previous year. 13 The following list shows the increase or decrease in the number of deaths from the various causes in 1938 as compared with 1937 :— Decrease. Increase. — + Typhoid Fever 2 — Measles — 4 Scarlet fever — — Diphtheria 5 — Influenza 36 — Encephalitis lethargica 1 — Cerebro-spinal fever — — Tuberculosis of respiratory system — 1 Syphilis — 1 General paralysis of the insane — 3 Cancer 5 — Diabetes 8 — Cerebral hæmorrhage 19 — Heart disease 73 — Aneurysm — 4 Other circulatory diseases — 3 Bronchitis 31 — Pneumonia 15 — Other respiratory diseases 5 — Peptic ulcer 2 — Diarrhoea 1 — Appendicitis 7 — Cirrhosis of Liver 3 — Other diseases of liver — 8 Other digestive diseases — 5 Acute and chronic nephritis — 1 Other puerperal causes 1 — Congenital debility, premature birth, malformations, etc. 6 — Senility — 20 Suicide 5 — Other defined causes 3 — Causes ill-defined 23 — 251 50 =- 201 14 It will be seen that the chief decreases were in deaths from heart disease (73), influenza (36) and bronchitis (31). Table 2, page 17, 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 1918. 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. (See page 19.) Distribution in Wards. The distribution of deaths and the death rates in the different wards are given below :— Ward. Total Deaths. Leyton 87 Lea Bridge 177 Central North 80 „ South 97 Forest 159 Leytonstone 170 Grove Green 98 Harrow Green 91 Cannhall 111 Wanstead Slip 77 Zymotic Death Rate.—The deaths during the year from the seven principal zymotic diseases were as follows :— Smallpox — Measles 5 Diphtheria 2 Whooping Cough 2 Diarrhcea 7 Scarlet Fever — Enteric Fever — The zymotic death rate for 1938 was 0.13 per thousand of the population compared with a rate of 0.17 for the previous year. 15 Senile Mortality. In the List of the Principal Causes of Death (Table 2) 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 :— 65-70 141 70-75 124 75-80 170 80-85 117 85-90 55 90-95 21 95-100 5 Of the total number of deaths (1,148) during the year, 633 (5 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 children died under one year of age, giving an infant mortality rate (number of deaths under one year of age per thousand births) of 46.38. 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. 1934 1,454 64 44.02 1935 1,493 60 10.18 1936 1,421 74 52.07 1937 1,420 75 52.81 1938 1,509 70 46.38 The following are the corresponding rates for other Great Towns, London, and England and Wales, during the year under review :— Infant Mortality—Leyton 46.38 ,, ,, 126 County Boroughs and Great Towns, including London 57.00 ,, ,, London 57.00 ,, „ England and Wales 53.00 16 Maternal Mortality.—Two women died from diseases and accidents of pregnancy and childbirth. The figures given below show the variation in maternal mortality during the past five years in Leyton and in the country generally :— Year. No. of Maternal Deaths. Leyton. Maternal 1,000 live Leyton. Mortality Rate per and still births. England and Wales. 1934 5 3.43 4.60 1935 7 4.68 4.10 1936 2 1.36 3.65 1937 3 2.02 3.23 1938 2 1.29 2.97 Comparative Statistics.—Table 3 is of a very comprehensive nature, and has been prepared with a view to throwing some light on Ley ton's progress in the matter of vital statistics since 1892—a period of 46 years. (See page 21). During that period the following are the outstanding facts:— 1. The population has increased from 63,000 to 117,200. 2. The birth rate has decreased from 35.08 to 12.87 births per thousand of the population. 3. The death rate has decreased from 15.4 to 9.79 per thousand of the population. 4. The infantile mortality rate has decreased from 141 to 46.38 deaths of infants under one year per thousand births. 17 TABLE 2. CAUSES OF DEATH AT DIFFERENT PERIODS OF LIFE IN THE BOROUGH OF LEYTON, 1938. 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 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... Measles 4 1 5 ... 4 1 ... ... ... ... ... 7 3 1 2 ... ... ... ... 1 ... 1 ... Scarlet fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping cough 2 ... 2 2 ... ... ... ... ... ... ... 2 1 ... 1 ... ... ... ... ... ... ... 1 Diphtheria 1 1 2 ... ... 2 ... ... ... ... 4 1 ... ... ... ... ... 1 1 ... ... ... Influenza 8 2 10 ... ... ... ... ... ... 3 7 1 ... 2 2 1 1 3 ... ... ... 1 Encephalitis lethargica 1 1 2 1 ... ... ... ... ... ... 1 3 1 ... ... 1 ... ... 1 ... ... ... ... Cerebro-spinal fever 1 ... 1 ... ... ... ... ... 1 ... ... 8 1 ... ... 1 ... ... ... ... ... ... ... Tuberculosis of respiratory system 34 22 56 ... ... ... 1 13 25 16 1 82 15 6 12 3 2 13 4 6 4 3 3 Other tuberculous diseases 2 6 8 ... ... 1 3 3 ... ... 1 11 5 ... 4 2 ... ... 1 ... 1 ... ... 18 Syphilis 1 2 3 ... ... ... ... ... ... 1 2 1 ... 1 ... ... 1 ... ... ... ... 1 ... ... General paralysis of the insane, tabes dorsalis 3 1 4 ... ... ... ... ... 1 3 ... 3 ... ... ... ... 1 1 1 1 ... ... ... Cancer, malignant disease 88 103 191 ... ... ... ... 3 11 71 106 292 71 19 25 9 14 26 26 14 15 30 13 ... Diabetes 5 12 17 ... ... ... ... ... ... 6 11 37 5 1 2 2 3 4 2 2 1 ... Cerebral hæmorrhage, etc. 32 45 77 ... ... ... ... ... ... 17 60 179 39 1 9 9 6 12 13 5 6 9 6 ... Heart disease 156 162 318 1 ... ... ... 1 12 71 232 427 81 23 50 18 31 42 57 32 26 22 17 ... Aneurysm 4 4 8 ... ... ... ... ... ... 4 4 7 ... ... 1 1 1 1 1 1 2 2 ... Other circulatory diseases 17 15 32 ... ... ... ... ... 6 26 41 4 1 5 3 2 8 7 3 1 ... Bronchitis 18 17 35 2 ... ... ... ... 1 5 26 94 14 3 4 2 3 3 8 1 2 4 5 ... Pneumonia (all forms) 38 26 64 14 ... ... 1 1 6 22 17 129 31 3 11 5 7 7 7 6 7 6 5 ... Other respiratory diseases 7 7 14 ... ... ... 1 ... 1 3 9 3 1 1 2 1 4 3 2 ... 1 1 ... Peptic ulcer 7 3 10 ... ... ... ... ... 5 5 25 3 2 1 1 2 ... 1 2 ... Diarrhœa, etc 4 3 7 6 ... ... ... ... ... 27 4 ... 3 ... 1 1 ... 1 1 ... Appendicitis 2 3 5 ... ... ... ... ... 1 i 3 14 4 2 ... 1 1 1 ... ... ... Cirrhosis of liver 1 1 ... ... ... ... ... ... 1 5 ... ... ... ... ... l ... ... ... ... ... ... Other diseases of liver, etc. 2 6 8 ... ... ... ... 1 1 2 4 3 1 1 1 l i 1 1 1 ... Other digestive diseases 15 7 22 2 ... ... ... 4 l 7 7 29 7 2 3 2 2 2 4 3 ... 3 1 ... Acute and chronic nephritis 9 11 20 ... ... ... ... 3 9 8 67 9 4 7 2 1 2 2 ... 1 1 ... Puerperal sepsis 2 2 ... ... ... ... 2 ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 ... Other puerperal causes ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... Congenital debility, premature birth, malformations, etc. 24 15 39 38 1 ... ... ... ... ... ... 2 5 4 5 2 9 5 3 2 5 2 2 ... Senility 21 24 45 ... ... ... ... ... ... 45 177 36 6 7 3 5 6 2 5 5 5 1 ... Suicide 10 3 13 ... ... ... 1 1 8 3 7 3 1 2 2 2 2 1 1 1 1 ... Other violence 18 13 31 1 ... ... 1 5 2 6 16 74 16 2 4 4 2 8 5 1 2 2 1 ... Other defined causes 57 39 96 3 ... ... 1 5 22 26 39 175 35 5 14 8 3 12 10 7 13 14 10 ... Causes ill-defined, or unknown ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 592 556 1148 70 11 5 8 37 91 293 633 1938 395 87 177 80 97 159 170 98 91 111 77 1 19 Graph No. 2. Leyton Death Rate 1918-1938. 20 Graph No. 3. Comparative View of the Principal Causes of Death during the Year 1938. 21 TABLE 3. Comparative Statistics of Births, Mortality, Etc. LEYTON, 1892-1938. 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 ] 908 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 Bl29062* 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 121680 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 1938 117900 1509 12.87 1148 9.79 70 46.38 22 TABLE 4. Vital Statistics of Whole District during 1938 and Previous Years. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered in the Borough. Transferable Deaths Nett Deaths belonging to the Borough. Uncorrected Number. Nett. of Nonresidents registered in the Borough. of Residents not registered in the Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett 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 1938 117200 656 1509 12.87 2934 25.0 1938 152 70 46.38 1148 9.79 Rates in columns 5, 7 and 13 calculated per 1,000 of estimated gross population. 23 TABLE 5. Birth-bate, Death-rate and Analysis of Mortality During the Year 1938. (Provisional figures. The rates have been calculated on a population estimated to the middle of 1938. The mortality rates refer to the whole population as regards England and Wales, but only to civilians as regards London and the group of towns.) Birthrate per 1,000 Total Population. Annual Death-rate per 1,000 Population. Rate per 1,000 Births. Percentage of Total Deaths. All Causes. Enteric Fever. Smallpox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. 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 15.1 0.60 11.6 — — 0.04 0.01 0.03 0.07 0.11 5.5 53 — — — — 126 County Boroughs and Great Towns, including London 15.0 0.65 11.7 — — 0.05 0.01 0.03 0.07 0.10 7.8 57 — — — — 148 Smaller Towns. Estimated Resident Populations 25,000 to 50,000 at Census, 1931 15.4 0.60 11.0 — — 0.03 0.01 0.02 0.06 0.11 3.6 51 — — — — London 13.4 0.48 11.4 — — 0.06 0.01 0.03 0.05 0.06 13.1 57 — — — — LEYTON 12.87 0.35 9.79 — — 0.04 0.00 0.01 0.01 0.08 4.6 46 90.24 4.26 5.48 0.0 24 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 :— (a) Employed directly by Council 3 (b) „ by arrangement with Essex County Nursing Association 5 Employed by Voluntary Associations :— (а) Within the Borough 1 (b) Outside the Borough 3 In Private Practice :— (a) Resident in the Borough 1 (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 Clinic. Leyton Green Clinic. Ante-Natal Clinics Thurs., 10 a.m. Wed., 10 a.m. Infant Welfare Clinics Mon., Tues., and Thurs., 1.45 p.m. Mon., Wed., and Fri., 1.45 p.m. Toddlers' Clinics Tues., 10 a.m. Fri., 10 a.m. Post-Natal and Gynaecological Clinics Second Wednesday in each month 2 p.m. Third Tuesday in each month 2 p.m. 25 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 As required — Orthopedic Clinic — — Monthly Artificial Sunlight Clinic — — Daily Aural Clinic Fortnightly — — Heart Clinic — Monthly — 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. 26 G. Children.— No Hospital provided or subsidised. 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. (b) Non-Infectious and Accident Cases.—Motor Ambulances for non-infectious cases are supplied by the Leyton Town Council and are under the control of the Superintendent of the Fire Brigade. LEGISLATION IN FORCE. Special Acts. Leyton Urban District Council Act, 1898. Leyton Urban District Council Act, 1904. Adoptive Acts. Date of 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 27 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. 28 Public Mortuary. Number of bodies deposited, death being due to :— Natural causes 47 Suicide 7 Street accidents 2 Other accidents 4 60 Number of Post-mortem examinations performed 59 Number of Inquests held . . 14 In 46 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 6 „ occlusion 10 ,, atheroma 1 Aortic insufficiency 2 Myocardial degeneration 3 Ruptured heart 2 Congenital heart defect 1 Ruptured abdominal aneurysm 2 Cerebral haemorrhage 2 Perforated duodenal ulcer 3 Bronchitis 2 Pulmonary tuberculosis 1 Fibroid „ 1 Laryngeal diphtheria 1 Cystic glioma of cerebellum 1 Strangulated hernia 1 Carcinoma of ovary 1 Pyaemia consequent on whitlow of thumb 1 Acute streptococcal pneumonia 1 Atelectasis neonatorum 1 Asphyxia due to inhalation of vomitus during epileptic seizure 1 29 Inquests. The following verdicts on Leyton residents were recorded at inquests held during the year :— Accidental. Knocked down by pedal cycle 2 ,, „ motor bus 1 ,, „ motor lorry 3 ,, ,, motorcar 2 ,, ,, motor cycle 2 ,, „ tram car 2 Collision between motor car and cycle 1 Collision between motor cycle and motor lorry 1 Crushed between motor lorry and trailer 1 Fall from pedal cycle 1 Thrown from motor cycle while riding pillion 1 Run over by railway engine at work 1 Food poisoning 1 Fractures and falls 5 Burns 3 Suicide. Coal gas poisoning 7 Lysol poisoning 2 Drowning 1 Hanging 1 Cut throat 1 Fall from window 1 Open Verdict. Asphyxia from drowning 1 Natural Causes. Coronary atheroma 1 Nephritis 1 Appendicitis 1 Toxic goitre 1 Chronic alcoholic poisoning 1 Septicaemia following gunshot wound received in the Great War 1 Fatty degeneration of heart muscle accelerated by administration of anaesthetic for operation of circumcision 1 Pulmonary embolism following rupture of ankle accelerated by operation (manipulation of ankle joint) 1 30 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. 1938. High Road 166,503 Cathall Road 122,522 Whipps Cross Bathing Pool 61,544 Slipper Baths. High Road 125,567 Cathall Road 51,928 Foam Baths. High Road 1,649 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 8 establishments. 31 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. Eleven sessions are held weekly as follows :— Morning. Afternoon. Evening. Monday — 2.0-4.30 6.0-8.30 Tuesday 9.30-12.0 2.0-4.30 — Wednesday 9.30-12.0 — 6.0-8.30 Thursday 9.30-12.0 2.0-4.30 — Friday — 2.0-4.30 6.0-8.30 Saturday 9.30-12.0 — — The number of attendances during the year was 8,756, comparing with 6,529 for the preceding year. The following statistics for the year 1938 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, 1938. A. All Ages. During the year 8,756 attendances were made, an average of 5.03 attendances per patient. First Attendances (new oases). Subsequent Attendances. Total Attendances. Average No. of Visits per Patient. No. Per cent. Males 178 1,489 1,667 19.04 4.70 Females 490 4,056 4,546 51.92 4.67 Children 386 2,157 2,543 29.04 6.17 Total 1,054 7,702 8,756 — 5.03 32 During the year the numbers of persons who received free treatment was 210, 19.92 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- 56 80 787 1,305 843 1,385 Unemployed 13 22 115 318 128 340 Widows — 39 — 682 — 721 Totals 69 141 902 2,305 971 2,446 Defects Treated. Bursitis 37 Callosities 175 Corns, hard 149 Corns, soft 20 Corns, under nail 17 Hallux rigidus 8 Hallux valgus 47 Metatarsalgia 40 Nails, club 54 Nails, ingrowing 40 Pes cavus 1 Pes planus 69 Verruca pedis 355 Hammer toe 7 Septic conditions 10 Conditions due to sprain 5 Bromidrosis 4 Referred for Medical or Surgical Treatment. During the year 15 patients were referred to their own private medical practitioners for the following conditions :— Arthritis 2 Circulatory disturbance (lower extremities) 1 Hyperhidrosis 1 Oedema 4 Phlebitis 1 Rheumatism 2 Septic condition 1 Varicose ,, 2 Dislocation (2nd digit) 1 33 Two patients were referred to hospital for X-ray or treatment for the following :— Epidermophytosis . 1 Hyperkeratosis 1 Eight patients were referred to hospital and operated upon for the following :— Cyst 2 Exostosis 4 Hallux valgus 6 Hammer toe 1 Pes piano valgus 6 Talipes „ 2 B.—Children under School Age. Attendances Nil Defects Treated. Nil. C.—School Children. No. of children 412 Attendances for treatment 2,543 Average number of treatments per child 6.17 Defects Treated. Bursitis 3 Hammer toe 2 Septic condition 3 Corns, hard 18 Nail, club 1 Metatarsalgia 1 Nail, ingrowing 6 Pes planus 4 Verruca pedis 337 Defects Referred to School Clinics. Contraction of extensor tendons 1 Contusion of nail matrix 1 Hyper-extension of digits 1 Metatarsalgia 1 Pes planus 2 Pes piano valgus 9 Pes varus 1 Taylor's bunion 1 Pes valgus 8 Planter Warts. On pages 167/178 of the section of the report on School Medical Service will be found the results of a special investigation into the incidence of planter warts among school children. 34 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. During the year 24,484 tons of refuse were collected and the net cost of collection per ton for the financial year ended March, 1938, was 10s. 3d. 35 One thousand and eighty-three defective and unsuitable receptacles have been replaced during the year. Statistics as to Refuse Collection, 1937-38. Number of collection days 310 Aggregate number of days vehicles employed 3,410 Average number of vehicles employed per day 11 Total mileage run 51,040 Tonnage collected 24,484 Weight in cwts. per 1,000 population per day 11.36 Average weight collected per van day 7 tons 14½ cwts. Total cost of collection (including loan charges) £12,996 Cost per ton for collection 10s. 7R Income from collection of trade refuse, etc. £468 Income per ton of refuse collected 4½d. Net cost per ton for collection 10s. 3d. SANITARY INSPECTION OF THE AREA. Sanitary Inspectors—Staff. In my last Annual Report attention was drawn to the need for increasing the number of Sanitary Inspectors in the staff of the Department. In January, 1938, your Sanitary Authority decided to appoint an additional Sanitary Inspector, and the newly appointed Inspector (Mr. Leslie Kluth) commenced duty on the 7th July, 1938. Inspections. The table below gives a summary of the Inspections made by the Sanitary Inspectors :— Number of dwelling-houses inspected 3,079 Number of house-to-house inspections 1,077 Miscellaneous inspections 868 Re-inspections 10,016 Piggeries 7 Petroleum stores 51 Places of entertainment 32 Schools 41 Stables 154 Public conveniences 192 Urinals 236 Inspections under Rats and Mice (Destruction) Act 573 Visits in connection with infectious disease 353 Factories without mechanical power 170 36 Factories with mechanical power 815 Offices 54 Outworkers' premises 485 Rag and bone dealers 11 Foster-mothers' premises 93 Hairdressers' premises 172 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 717 Sashcords renewed 337 Plaster repaired 1,228 Roofs repaired or renewed 668 Guttering repaired or renewed 361 Yards paved 283 Drains relaid or partly relaid 279 Choked drains cleared 48 New w.c. pan and traps provided 119 Sinks provided 146 W.C. cisterns repaired or renewed 90 Rain water pipes repaired or renewed 161 Vent pipes repaired or renewed 34 Sink waste pipes renewed 311 Stoves repaired or renewed 234 Coppers repaired or renewed 58 Floors repaired 352 Rooms redecorated 2,619 Windows, sills, etc., repaired 1,138 Miscellaneous defects remedied 2,498 Drainage.—The drains of 279 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. Water Supplies. Samples of Water from Dagenham Brook. Three samples of water were taken, and on analysis were found to be unsatisfactory. Effluent. Pour samples of effluent were taken, and on analysis were found to be unsatisfactory. 37 Samples of water were taken during the year :— From. Result. Public supply from mains Satisfactory. Domestic cisterns Satisfactory. Wells Satisfactory. Swimming baths Satisfactory. Verminous Houses. Infested. Disinfected. Number of Council houses 22 22 Number of other houses 234 234 Eradication of Bed Bugs. The procedure in dealing with infested houses in Leyton is as follows :— Where bugs are found to exist in houses an inspection of the premises is made by one of the Sanitary Inspectors. The subsequent procedure depends on the extent of the infestation. Where it is only slight, advice and instructions regarding bugs are given to the occupier, who is also asked to examine and thoroughly cleanse the pictures, bedding, bedsteads and other furniture. The rooms and furniture are then sprayed with an insecticide solution by a member of the Public Health Department Staff. Where the infestation is extensive the owner of the house is requested to remove all woodwork (i.e., skirting boards, architraves and linings around windows and doors, etc.) and wallpaper (if any) ; and afterwards to apply a blow-lamp to all infested parts. The rooms are then sprayed by the Local Authority and the walls cleansed and distempered by the owner. Should bugs recur the premises are sprayed again. The importance of cleanliness and the danger of infestation by means of second-hand furniture are explained to the tenant. Council Houses.—The disinfestation of Council houses is carried out by the staff of the Borough Engineer and Surveyor. Council houses, on being vacated, are sprayed with insecticide; and the furniture, bedsteads and bedding of incoming tenants are sprayed by the Public Health Department staff prior to new tenants moving into the Council houses. Rag Flock Acts, 1911-1928. There are no premises within the Borough where rag flock is known to be manufactured. 38 Foster-mothers. Ninety-three visits have been made to premises occupied by foster-mothers. Hairdressers. One hundred and seventy-two visits were made to hairdressers' premises to inspect for any contraventions of the Bye-laws made under the Essex County Council Act, 1933. In thirty-two instances it was found necessary to call the attention of occupiers to breaches of the Bye-laws. In all cases the suggestions were complied with. Infectious Diseases. Three hundred and fifty-three visits have been made by the Sanitary Inspectors. Places of Entertainment. Thirty-two visits have been made to cinemas and other places of entertainment. Petroleum (Consolidation) Act, 1928. In May, 1938, the duties under the above Act were transferred to the Superintendent of the Fire Brigade. Game Dealers. Four renewal certificates were issued during the year. Shops Act, 1934. Two hundred and seventy-two visits were made in connection with the above-named Act. Twenty-three 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 33 shops. Ten statutory notices were served, and the notices in respect of 21 shops were outstanding at the end of the year. Shops Act, 1934—Sanitary Conveniences. Exemption certificates—in accordance with the provisions contained in the Shops Act, 1934 (Section 10, subsection 2)— were granted in respect of sanitary conveniences at eight premises. 39 Smoke Abatement. One hundred and twenty-eight observations were kept on factory chimneys throughout the district. It was found necessary to issue thirteen letters of caution, and in nine instances verbal warnings were given to the persons concerned. It was not found necessary to take any statutory action. The Sanitary Inspectors interviewed a number of owners of factories and stokers regarding the question of smoke and grit emission. Advice was given as to the best methods to be employed to minimise the smoke and grit nuisance, and at one factory a grit arrester was installed. Schools. Forty-one routine inspections of the sanitary accommodation and water supply of schools were made. The attention of the Director of Education was called to matters requiring attention in five instances. Rats and Mice (Destruction Act), 1919. Five hundred and seventy-three visits were paid in connection with complaints received, and rat biscuits were issued to the occupiers of 77 premises. At 87 premises the source of rat infestation was definitely traced and the premises freed of rats. The following information was supplied to the Ministry of Agriculture and Fisheries in response to the Ministry's Circular dated September, 1938 :— 1. Name of Committee and SubCommittee, if any, to which the Council's powers and duties under the Act are delegated 2. Name and status of Officer, if any, appointed to supervise the execution and enforcement of the Act. 3. State whether the Rats Officer is employed full-time or part-time. If part-time what are his other duties ? 4. State the number, if any, of trappers or other staff employed The Public Health Committee. The Senior Sanitary Inspector and the District Sanitary Inspectors. Part-time—all duties applicable to the office of Sanitary Inspector. None. 40 5. State the approximate number of rat complaints dealt with in the last twelve months. 6. Have any notices been published recently giving instructions as to the most effective methods of rat destruction ? (Section 4 of the Act). 7. Have any notices been served on individual occupiers within the last twelve months requiring them to destroy rats ? 8. Have any measures been taken to secure collective action for rat destruction? (Section 5 of the Act). 9. Have any prosecutions for offences under the Act been instituted ? If so, with what results ? 10. What is the approximate annual expenditure of the Council in connection with the Act? Has any part of such expenditure been recovered from individual occupiers or otherwise? 11. General observations :— It is difficult to state precisely the degree of rat infestation ; but working on the basis of complaints received per occupied house and the population of the district, the degree of infestation is as follows :— 26,306 inhabited houses—111 complaints; = .42 per cent., roughly 4 per 1,000 houses. 118,100 estimated population—111 complaints; = .09 per cent., roughly 1 per 1,000 population. September 17th, 1937, to September 17th, 1938—111. Posters were displayed throughout the district during Rat Week, 1937. Yes—83. All possible measures are taken. No. £21 14s. Od. (average for last five years). No part of expenditure recovered. 41 Rat infestation is dealt with by the Sanitary Inspectors throughout the year. It is found that most of the infestation is due to defective drains and sewers. Records are kept of each complaint received and of the subsequent action taken. The procedure carried out is as follows :— (1) Each complaint is investigated, and the premises inspected to try and ascertain the cause of infestation. Where there are drains, these are tested for defects, and where found defective they are relaid. (2) When required, buildings are rendered rat proof by concreting. (3) Attention is given to the disposal of garbage and other refuse. (4) All food premises are regularly visited. (5) Advice is given to occupiers and others as to the best methods to be used in case of infestation. (6) Rat biscuits and traps are supplied on application. (7) The sewers are baited from time to time. (8) Where it has been found necessary, joint action has been taken with neighbouring sanitary authorities. The following report on the National Rat Week was submitted to the Ministry of Agriculture and Fisheries :— "As in previous years, attention was given to the recommendations contained in the Circular issued by the Ministry of Agriculture and Fisheries. Throughout the Borough posters were exhibited dealing with the subject. Premises where rat infestation was likely to be found were visited by the Sanitary Inspectors and appropriate action taken. Through the co-operation of the Staff of the Borough Engineer and Surveyor 59 rats were caught in traps and subsequently destroyed." 42 SECTION D. HOUSING. Complaints. During the year 959 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 1,582 Statutory—Housing Acts 5 Public Health Acts 68 Re-drainage 110 Notices complied with—Informal 1,762 Statutory— Housing Acts 8 Public Health Acts 68 Re-drainage 149 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 21 Flats 220 (b) With State assistance under the Housing Acts. (i) By the Local Authority :— (а) For the purposes of Part v of the Act of 1936 Nil (б) 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) 3,079 (b) Number of inspections made for the purpose 13,095 43 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 & 1932 1,077 (6) Number of inspections made for the purpose 4,407 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 8 (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. 1,582 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 1,762 III.—Action under Statutory Powers during the Year :— (а) 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 (б) Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 68 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 68 (b) By Local Authority in default of owners Nil 44 (c) Proceedings under Sections 11 and 13 of the Housing Act 1936 :— (1) Number of dwelling-houses in respect of which demolition orders were made 5 (2) Number of dwelling-houses demolished in pursuance of demolition orders Nil (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 Nil IV.—Housing Act, 1936. Part IV—Overcrowding :— (a) (1) Number of dwellings overcrowded at the end of the year 156 (2) Number of families dwelling therein 156 (3) Number of persons dwelling therein— Adults 850 Children 262 (b) Number of new cases of overcrowding reported during the year 1 (c) (1) Number of cases of overcrowding relieved during the year 96 (2) Number of families concerned in such cases 106 (3) Number of persons concerned in such cases : Adults 615 Children 101 Housing Act, 1936. Information regarding five hundred and forty-three houses and two hundred and thirty-nine flats was supplied in connection with the "permitted number of persons" in dwellings under the Act. 45 The landlord of a house was prosecuted for not complying with the provisions of the Act inasmuch as a statement of the "permitted number of persons" in relation to the house was not inserted in the rent book, and the name and address of the Medical Officer of Health and landlord was not inscribed therein. The landlord was required to pay £1 Is. Od. costs. Demolition. In accordance with the provisions of the Housing Act, 1936, the Local Sanitary Authority—acting on official representations made by the Medical Officer of Health—has continued to deal with the demolition and clearance of existing slum property in the area. Scheduled for demolition in 1938, and not yet demolished. 9a and 10, Forest View. 99 and 101, Harrow Road. 35, Kingston Road. Scheduled in 1937 and not yet demolished. 590, 592, 594 and 596, High Road, Leyton. Scheduled in 1936; offers to carry out repairs accepted and repairs completed in 1938. 15, 17, 19, 21, 23, 25, 27 and 29, Lansdowne Road. Scheduled in 1938; offers to carry out repairs accepted. 103 and 105, Harrow Road. An undertaking was accepted from the owners that the undermentioned house would not be used for human habitation : 97, Harrow Road. House-to-House Inspection. The houses in the under-mentioned roads have been inspected during the year :— Argyle Street. Cathall Road. Chertsey Road. Crescent Road. Eatington Road. Elsham Road. Florence Road. Fulready Road. Goldsmith Road (part). 46 Grange Road. Guernsey Road. Lascelles Road. Norman Road (part). Nottingham Road. Ranelagh Road. Rhodesia Road. Trinity Street. Wallwood Road (part). Wilmot Road. The number of dwelling-houses inspected and recorded under Housing Consolidated Regulations was 1077. Rent and Mortgage Interest Restriction Act, 1920-1933. One application for a certificate was received, and granted. SECTION E. INSPECTION AND SUPERVISION OF FOOD. Inspections. The following visits were made to food premises during the year Slaughter-houses 1,795 Butchers 808 Bakehouses 154 Fishmongers 135 Milkshops and dairies 587 Provision shops 335 Dining rooms 272 Ice-cream dealers 247 Greengrocers 273 Fish friers 104 47 MILK. Dairies and Milkshops. Number of premises on register 245 Premises added to register during year 21 Premises removed from register during year 25 Visits of inspection 587 As the result of inspection infringements were found at 12 premises, and the necessary action was taken in each case. Twenty persons were found to be retailing designated milk although not licensed in that respect, and cautions were given in each case. Bacteriogical Examinations. Undesignated Milk.—Forty-six samples were taken and the following table shows the result of bacteriological examination:— Number of Sample. Number of bacteria per m.l. 1 9,600 2 3,510 3 4,560 4 496,000 5 400,000 6 2,400 7 2,500 8 84,000 9 2,200 10 2,720 11 1,230 12 3,600 13 2,200 14 16,600 15 336,000 16 3,040 17 1,320 18 23,200 19 44,800 48 Number of Sample. Number of bacteria per m.l. 20 3,000 21 3,120 22 10,240 23 8,160 24 6,120 25 13,200 26 21,200 27 5,440 28 4,300 29 9,760 30 8,120 31 11,260 32 1,640 33 6,000 34 48,800 35 800 36 42,000 37 2,800 38 2,600 39 4,120 40 2,800 41 10,960 42 14,480 43 9,600 44 9,440 45 10,080 46 12,160 Designated Milk. Licences. No. Granted No. of Samples taken Result. Satisfactory Unsatisfactory Tubercul in Tested 11 1 1 — Accredited 3 — — — Pasteurised 58 28 25 3 Supplementary- Licences — — — — Tuberculin Tested 2 — — — Pasteurised 2 — — — Totals 76 29 26 3 49 The results of the bacteriological examination of the 29 samples of designated milk are shown in the following table :— Grade Tuberculin Tested Pasteurised Sample Number. Bacteria per m.l. 1 Satisfactory 2 2,400 3 7,680 4 560 5 1,080 6 4,000 7 910 8 900 9 5,280 10 91,200* 11 13,600 12 2,040 13 280 14 3,920 15 14,480 16 29,600* 17 64,000 18 4,680 19 6,480* 20 91,480 21 21,600 22 2,640 23 9,600 24 9,200 25 6,240 26 14,640 27 3,800 28 5,680 29 48,000 * B. Coli present. Milk Supplied to Schools. Included in the designated milk samples listed above are five samples of milk taken in course of delivery to schools. All of these proved satisfactory. 50 Ice Cream. Premises on Register at 31-12-1938 197 Premises registered during 1938 31 Premises removed from Register during 1938 19 Persons on Register at 31-12-1938 203 Persons registered during 1938 33 Persons removed from Register during 1938 19 Visits of inspection by Sanitary Inspectors 247 Samples taken for bacteriological examination 30 Sample taken for pathological examination 1 Results of Samples taken for Bacteriological Examination. Number of Sample. Number of bacteria per m.l. 1 600 2 5,310 3 864,000 4 6,260 5 3,500 6 6,640 7 204,000 8 300 9 2,000 10 600 11 2,300 12 1,100 13 12,000 14 71,000 15 3,000 16 410,000 17 9,000 18 420,000 19 10,000 20 12,700 21 10,000 22 21,500 23 3,000 24 10,500 25 30,000 26 2,0000 27 15,000 28 20,000 29 20,000 30 30,000 51 Result of Sample taken for Pathological Examination. Number of Sample. 1 Satisfactory. Thirty-one premises were registered for the manufacture, storage or sale of ice cream during the year. In one instance an application for the manufacture of ice cream was refused by the Council. An opportunity was given to the applicant to appear before the Council in accordance with Section 158, Sub-section (4) of the Essex County Council Act, 1933, but he failed to appear. MEAT. Slaughter-Houses.—There are eight licensed slaughterhouses in the Borough^ and One thousand seven hundred and ninetyfive inspections of these slaughter-houses were made. Carcases and Viscera Inspected:— Animals Inspected. London Other SlaughterHouses. Co-operative Society Abattoir. Cattle 6,112 438 Calves 429 94 Swine 27,564 1,104 Sheep 20,192 2,998 54,297 4,634 Meat and Other Food Condemned. Total. Tuberculosis. Ox :— Beef 28 stones 9 lbs. — Brisket 21 17 Buttock 1+36 lbs. — Carcase 9 8 Carcase and offal 13 13 Clod and sticking 8 8 52  Total Tuberculosis. Crop 2 2 Flank 12 7 Foot 3 3 Forequarter 24 18 Head 10 6 Head and tongue 337 199 Heart 21 7 Hind quarter 5 4 Intestines 93 89 Kidney 29 + 13 lbs. 7 Liver 2698 J+14 lbs. 110 Loin 13 7 Lungs 881 258 Mesentery 358 246 Offal 1 — Omentum 10 4 Ribs 7 7 Rump 9 4 Skin 1 1 Skirt 28 22 Spleen 74 5 Steak 2 2 Stomach 74 25 Tail 4 4 Tongue 31 5 Top-piece 1 — Calves:— Carcase and offal 7 6 Liver 2 Lungs 4 1 Sheep :— Breast 6 — Carcase 1 — Carcase and offal 1 — Heart 26 — Kidney 1 — Leg 3½ — Liver 932 — Loin 3 — 53 Total Tuberculosis. Lungs 1067 — Omentum 8 — Pluck 1 — Shoulder ½ — Spleen 4 — Target 10 — Swine :— Belly 14 1 Carcase 34 11 Carcase and offal 211 176 Chump 2 — Collar 33 31 Forequarter 24 9 Hand 2 2 Hand and spring 5 — Head 1,761 1,642 Heart 229 — Hindquarter 3 — Intestines 22 11 Kidney 145 — Leg 58 13 Liver 2,779 — Loin 33 6 Lungs 4,507 10 Mesentery 1,911 1,827 Pluck 995 162 Ribs 2 — Spleen 12 2 Stomach 14 4 Miscellaneous :— Apples, cases of 32+50 lbs. — Cod, fillets of 14 lbs. — Corned Beef 55 lbs. — Fowls 5 3 Peaches, boxes of 20 — Skate 2 stones Skate wings 4 „ — Tongue 14 lbs. — Jellied veal 7 „ — 54 SUMMARY OF CARCASES INSPECTED AND CONDEMNED. Cattle, excluding Cows. Cows. Calves. Sheep and Lambs. Pigs. Number killed 6,550 Nil 523 23,190 28,668 Number inspected 6,550 Nil 523 23,190 28,668 All diseases except Tuberculosis :— Whole carcases condemned 1 Nil 1 2 58 Carcases of which some part or organ was condemned 3,515 Nil 18 1,976 8,223 Percentage of the number inspected affected with disease other than tuberculosis 53.68 Nil 3.65 8.53 28.88 Tuberculosis only :— Whole carcases condemned 21 Nil 6 Nil 187 Carcases of which some part or organ was condemned 484 Nil 6 Nil 3,722 Percentage of the number inspected affected with tuberculosis 7.71 Nil 2.29 Nil 13.63 Slaughter of Animals Act, 1933. Thirty-seven persons were licensed as slaughtermen during the year. One application was refused by the Council owing to lack of information as to the qualifications of the person concerned. Public Health (Meat) Regulations, 1924. Eight hundred and eight visits were made to butchers' shops. Fifteen letters were sent and 37 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 and fifty-four visits were made to the 40 registered bakehouses. Thirty letters were sent and 11 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 seventy-two inspections of premises and utensils were made. Twenty-seven letters were sent and 15 verbal cautions given in respect of unsatisfactory conditions. 55 Public Houses. Fifty visits were made to public houses for inspections as to cleanliness of the premises, cellars, pumps, utensils, etc. Eleven letters were sent and 2 verbal cautions given in respect of unsatisfactory conditions. Premises and Occupations which can be Controlled by By-Laws and Regulations. Premises. Slaughter-houses 8 Dairies, Milkshops and Dairymen 245 Butchers' shops, Stalls and Provision shops 281 Ice Cream dealers 203 Chimneys—other than private dwelling-houses approximately 100 Hairdressers' Premises 104 Offensive Trades. Rag and Bone dealers 4 Fish friers 29 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. Four applications to continue the trade of a fish frier were received and permission given for a further limited period. Two applications for the permission of the Council to establish the trade of a fish frier was made and granted. One hundred and four inspections were made of the premises where fish frying is carried on. 56 Contagious Diseases of Animals Acts, 1894-1927. One hundred and twenty-four licences were issued in respect of the movement of:— Cattle 347 Sheep 642 Pigs 1,864 Calves 42 from other areas into this district for the purpose of slaughter. Food and Drugs Act, 1938. This Act comes into operation on 1st October, 1939. It is based upon the draft Bill prepared by the Local Government and Public Health Consolidation Committee. The Act includes the Food and Drugs (Adulteration) Act, 1928, the food sections of the Public Health Act, 1875 and amending Acts, the Milk Acts, 1915 and 1922, the Artificial Cream Act, 1929, and provisions with regard to Slaughter-houses and Markets. The Act deals with :— (a) Composition of food and drugs. (b) Regulations as to foods. (c) Unsound food. (d) Precautions against contamination of food. (e) Food poisoning. (f) Milk and Dairies. (g) Artificial cream. (h) Bread and flour. (I) Margarine, margarine cheese, butter and milk-blended butter. (J) Ice cream and preserved food. (k) Sale of horseflesh. (l) Inflation of carcases. (m) Cleansing of shell-fish. (n) Provisions as to importation of certain produce. (o) Markets, slaughter-houses, and cold-air stores. 57 Under the Act the Medical Officer of Health and the Sanitary Inspector are authorised Officers for all purposes of the Act. Included in the duties imposed upon the Sanitary Inspector is the taking of samples of food and drugs. In Leyton in the past, these duties have been administered by. the Essex County Council. The expression "Food and Drugs Authority" means:— "as respects a county borough, and also as respects any non-county borough or urban district which has according to the last published census for the time being a population of forty thousand or upwards, the local authority; Provided that— (a) if a county council satisfy the Minister that the area or areas in respect of which they would be the Food and Drugs Authority would be rendered inconvenient in size, shape or situation for the efficient performance of their duties as the Food and Drugs Authority, the Minister may direct that the county council shall be the Food and Drugs Authority as respects the district or districts of any one or more of the local authorities, who, but for such a direction, would be Food and Drugs Authorities under this Act, but were not such authorities under the law in force immediately before the commencement thereof; (b) on the application of the local authority of any noncounty borough or urban district which has according to the last published census for the time being a population of twenty thousand or upwards but less than forty thousand, the Minister may direct that the local authority shall, in lieu of the county council, be the Food and Drugs Authority as respects their district." At the end of the year it was not known what attitude the Essex County Council would adopt with regard to the matter. 58 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. A. Horsnell) for the following information regarding samples taken in Leyton during the year under review. Samples of milk taken 68 Samples of butter taken 45 Other samples 244 SECTION F. FACTORIES. THE FACTORIES ACT, 1937. This Act came into force on 1st July, 1938. It consolidates the law regarding factories, replaces the Factory and Workshop Acts of 1901 and 1907, and repeals partially some other smaller enactments. The term Workshop is now abolished, and factories are divided into two categories :—Power Factories and Non-Power Factories. In regard to all factories the provisions of Part I of the Act which relate to sanitary conveniences are to be enforced by District Councils. As regards the provisions dealing with cleanliness, overcrowding, temperature, ventilation, and drainage of floors—these are to be enforced by the District Councils only in the case of non-power factories. The Act prohibits the use as bakehouses of basement bakehouses other than those in use on 30th July, 1937, and which had been previously certified. A basement bakehouse not used 59 as a bakehouse for twelve months must not be so used again. Existing basement bakehouses must be re-examined within a year of the Act coming into force and every succeeding five years. If as a result of the examination certain conditions exist, the Council may terminate the certificate. The occupier has a right of appeal to the Courts. There are five basement bakehouses within the Borough. These have been examined and a report is being submitted to the Council for consideration. The local authority is required to keep a register of all factories situated within its district. A register has been prepared, there being at the end of the year in Leyton two hundred and ninety-three power factories and ninety-one non-power factories. The coming into force of this Act has given rise to additional work and responsibility, the Sanitary Inspectors having inspected during the year three hundred and eighty-four such places, this necessitating nine hundred and eighty-five visits. 1. INSPECTIONS FOR PURPOSES OF PROVISIONS AS TO HEALTH. Including inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Occupiers Prosecuted. (1) (2) (3) (4) Factories with mechanical power 865 66 — Factories without mechanical power 208 25 — Other Premises under the Act (including works of building and engineering construction but not including outworkers' premises) — — — Total 1,073 91 — 60 2. DEFECTS FOUND. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. No. of defects in respect of which prosecutions were instituted. (1) (2) (3) (4) (5) Want of cleanliness 140 64 — — Overcrowding — — — — Unreasonable temperature — — — — Inadequate ventilation 2 1 — — Ineffective drainage of floors 3 3 — — Sanitary Conveniences: Insufficient 2 — — — Unsuitable or defective 22 12 — — Not separate for sexes — — — — Other offences— (Not including offences relating to Home Work, etc.) 35 13 — — Total 204 93 — — OUTWORK IN UNWHOLESOME PREMISES. (Section 108 of Act of 1901; Section 111 of Act of 1937). Nature of Work. Instances. Notices served. Prosecutions. (1) (2) (3) (4) Wearing Apparel :— Making, etc. 1 1 — SECTION G. PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. SMALLPOX. During the year 1938 no case of smallpox occurred in the area. ENTERIC FEVER. No case of enteric fever occurred during the year. 61 SCARLET FEVER. Year. Cases Notified. Deaths. Case Fatality per cent. 1934 681 3 0.44 1935 409 1 0.24 1936 367 2 0.54 1937 309 0 0.00 1938 293 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 204 Walthamstow Isolation Hospital 6 Plaistow Fever Hospital 3 London Fever Hospital 2 L.C.C. Hospitals 2 Whipps Cross Hospital 7 224 Treated at home 69 293 Incidence of Complications. 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 three years and the nature of such complications. 62 1936 1937 1938 Total. No. of cases treated at home 109 85 69 263 Complications— Albuminuria 7 3 3 13 Rhinitis 4 — — 4 Cervical adenitis 4 1 2 7 Otitis media 5 9 4 18 Endocarditis 1 — — 1 Myocarditis — 1 1 2 Arthritis 1 — — 1 Bronchitis 1 — — 1 Cervical glands — 1 — 1 Acute nephritis — 5 — 5 Unilateral otitis — 1 2 3 Tonsillitis — 1 — 1 Totals 23 22 12 57 Percentage Incidence of Complications 21.1% 25.8% 17.3% 21.3% The 1938 complication percentage incidence rate (17.3 per cent.) of home-treated patients compares with the comparative rate of 36 per cent, for patients treated in hospital during the same period. DIPHTHERIA. Year. Cases Notified. Deaths. Case Fatality per cent. 1934 257 11 4.28 1935 276 8 2.89 1936 231 11 4.76 1937 161 7 4.34 1938 188 2 1.06 Treated in hospitals— Leyton Isolation Hospital 143 L.C.C. Hospitals 7 Walthamstow Isolation Hospital 4 Plaistow Fever Hospital 6 Whipps Cross Hospital 20 East Ham Isolation Hospital 2 182 Treated at home 6 188 63 Date of Death. Sex. Age. Cause of Death. Where death occurred. 7. 3.38 M. 2 Laryngeal Diphtheria ... Home. 17 10.38 F. 4 Cardiac paralysis Diphtheria ... Isolation Hospital. ARTIFICIAL IMMUNISATION AGAINST DIPHTHERIA. 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 Practitioners. 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 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 ... ... ... 8 Number of children immunised ... ... ... 13 Record of Attendances during 1938. The following figures give particulars regarding the children dealt with at the municipal diphtheria immunisation clinics during 64 1938. 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 1939 Under 2 yrs. 2-5 years. 5-10 years. 10-15 years. Total. Number of children who attended for immunisation 105 178 236 33 552 ,, ,, who completed course 105 169 223 27 524 „ „ naturally immune ... — — 2 — 2 ,, ,, immune after one jection — — — — — „ „ immune after 2 injections 100 157 162 21 440 „ ,, immune after 3 injections 1 3 1 5 ,, ,, immune after 4 injections 4 11 47 5 67 „ „ immune after 5 injections _ _ 1 1 „ „ immune after 6 injections _ 1 8 9 Removed from district — — — Failed to attend for Final Schick Test ... 5 10 1 16 ,, ,, Schick Reading — — — 3 3 ,, „ after 1 injection — 4 3 2 9 Total number of Attendances during 1938 435 743 1,146 143 2,467 During the previous year (1937) the number of children who attended for immunisation was 959, and the total number of attendances made during that year was 3,898. From these figures it is evident that there has been a marked decrease (42.4 per cent.) in the number of children who attended during 1938. 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. Incidence of Diphtheria Among Protected Persons. It is not claimed that artificial immunisation will prevent a person from infection by diphtheria organisms. What is claimed is that successful artificial immunisation will prevent the immunised person from developing the dangerous toxaemic manifestations of diphtheria. 65 Age. Sex. Date of Immunisation. Schick Test Negative. Date of Notification. Swab Results. T=Throat. N=Nose. E=Ear. N — Clinical faucial 8 yrs. F. 31.10.35 21. 5.36 9.9.38 T — diphtheria. 3yrs. M. 1. 6.35 4.10.35 1.9.38 T + Not clinical diphtheria. 6 yrs. M. 2.12.37 Not done 11.1.38 T + Clinical case of faucial diphtheria only received one immunising injection (2.12.37). 10 yrs. M. 1. 6.35 4.10.35 9.1.38 T + Clinical case of faucial diphtheria Developed palatal paralysis. 8 yrs. F. 8.10.36 1. 2.37 29.8.38 T + Severe clinical case of faucial diphtheria. N — Not clinical 6 yrs. F. 6. 3.36 10. 7.37 15.5.38 T — diphtheria (Tonsillitis). 10 yrs. F. 20. 3.36 11. 9.36 15.9.38 T + Not clinical diphtheria (Temporary carrier). MEASLES EPIDEMIC, 1938. In and around London widespread outbreaks of measles occur with explosive suddenness at regular intervals of two years. The first cases of the 1938 epidemic came to my notice about the middle of January. Thereupon there was put into operation the procedure, outlined in my Annual Report for the year 1932, which had been found to be effective during the previous epidemics. Daily information was obtained from head teachers and school attendance offioers regarding all cases of measles or suspected measles coming to their notice. In addition, information was received from the health visitors regarding pre-school children. 66 Incidence. January. February. March. April. May. Number of cases reported 31 101 290 40 12 It will be seen from these figures that the epidemic reached its highest point during the month of March, after which time there was a rapid decline. The total number of cases was 474, comparing with the corresponding number of 1,539 during the epidemic of 1936. The age distribution was as follows :— Under 1 year ... 4 1—2 years 13 2—3 years 7 3—4 years 9 4—5 years 24 Over 5 years ... 417 474 The following list shows how the cases were distributed among the different wards in the Borough :— Leyton 32 Lea Bridge 114 Central North ... 32 Central South ... 52 Forest ... 33 Leytonstone 54 Grove Green ... 33 Harrow Green 38 Cann Hall 79 Wanstead Slip 7 474 67 Home Visits. Five hundred and three visits to houses were made by members of the nursing staff of the Department. At the time of the primary visits it was found that doctors were already in attendance in 372 (i.e., 78.48 per cent.) of the cases. In homes where no doctor was in attendance the visitors were able to give advice regarding isolation and treatment. Institutional Treatment. Measles is one of the most highly infectious of all infectious diseases, and it is dangerous to admit a case of measles to a ward containing susceptible children suffering from scarlet fever or diphtheria. In providing for measles cases, no accommodation less than a whole ward can be considered. As it was impossible to devote a whole ward to measles cases in Leyton Isolation Hospital, it was necessary to find accommodation in outlying institutions, and cases were admitted to the following institutions :— Walthamstow Fever Hospital 21 Eastern Hospital (L.C.C.) 2 23 They were admitted for the following reasons :— Bronchopneumonia 10 Unsatisfactory home conditions 2 Congestion of Lungs 5 Whooping Cough 1 Abscess in neck 1 Mumps 1 Meningitis 1 Transfer from General Hospital 2 23 68 Mortality. Of the 474 cases of measles reported in Ley ton during 1938, 5 (i.e., 1.05 per cent.) died. The following table shows the ages and places of death of these 5 fatal cases. Under 1 Year. 1-2 Years. 2-3 Years. 3-4 Years. 4-5 Years. Over 5 Years. Total At Home — 1 — — — — 1 Whipps Cross Hospital ... — 3 — — — — 3 Isolation Hospital — — 1 — — — 1 — 4 1 — — — 5 Comparison with Previous Epidemic. 1936. 1938. Number of cases 1,539 474 „ „ visits by Nursing Staff 1,873 503 Percentage of cases under care of Doctor 84.23 % 78.48% Number of cases admitted to Hospitals 53 23 Number of Deaths 23 5 It will be seen from these figures that the 1938 epidemic of measles was less widespread and milder in type than that of 1936. TUBERCULOSIS. Notifications.—One hundred and twenty-nine patients were notified for the first time in 1938 as suffering from tuberculosis. The number was made up as follows :— Males. Females. Total. Pulmonary Tuberculosis ... 55 51 106 Non-Pulmonary Tuberculosis 11 12 23 66 63 129 69 During the year it was found possible to remove from the tuberculosis register the names of 16 children and 4 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, 1938 :— Pulmonary. Non-Pulmonary. total M. F. Total. M. F. Total. Number on Register at commencement of year ... 275 207 482 48 52 100 582 Number first notified during the year 55 51 106 11 12 23 129 Number of cases entered in Register otherwise than by Notification 14 18 32 3 6 9 41 Number removed from the Register during the year... 62 43 105 16 21 37 142 Number remaining at the end of the year 282 233 515 46 49 95 610 Details of cases removed from the Register during the year:— Died 34 21 55 4 8 12 67 Removed from the district 25 18 43 5 7 12 55 De-notified 3 4 7 7 6 13 20 Deaths.—Sixty-four deaths from tuberculosis were recorded — Males. Females. Total. Pulmonary Tuberculosis 34 22 56 Non-Pulmonary Tuberculosis 2 6 8 64 This is equivalent to a death rate of 0.54 per thousand of the population, as compared with a figure of 0.53 for the previous year. 70 The following table gives particulars regarding the new cases and deaths which have occurred during the year :— Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 0 1 1 5 — 1 1 1 — — — 2 10 1 — 3 3 — 1 — 1 15 1 1 5 1 2 6 1 — 20 7 13 1 1 3 2 1 1 25 8 7 1 1 10 8 — — 35 10 24 — 4 6 1 — — 45 7 3 — — 6 1 — — 55 14 1 1 6 3 — — 65 and upwards. 7 1 — — 1 — — 1 6 Totals 55 51 11 12 34 22 2 Dispensary.—A tuberculosis dispensary is provided by the Essex County Council at 180, High Road, Ley ton. Six sessions per week are held, viz. :— Monday (2—4 p.m.), Children only. ,, (6—8 p.m.), Adults (working). Tuesday (10—12 a.m.), Women. Thursday (10—12 a.m.), Adults. „ (2—4 p.m.), Men. Friday (2—4 p.m.), Contacts. During the year close co-operation has existed between the Tuberculosis Officer appointed by the Essex County Council (Dr. T. L. Ormerod) and the Medical Officer of Health. Institutional Treatment. During 1938 the following Ley ton patients were sent to sanatoria or other institutions for the treatment of Tuberculosis :— Pulmonary. Non-Pulmonary. Total. Males. Females. Males. Females. Adults 48 48 5 2 103 Children 2 — 7 9 18 71 CANCER. Males. Females. Digestive organs and peritoneum— Stomach ... ... 13 12 Colon 8 13 Intestine ... 2 1 Rectum 9 7 Caecum 1 1 Gallbladder — 1 Liver 4 1 Ileum — 1 (Esophagus 2 Pancreas ... 1 11 Ventriculi... 2 1 Respiratory organs— Lung 4 2 Larynx 5 1 Mediastinum 1 1 Bronchus 2 1 Epiglottis 1 — Female genital organs— Cervix — 2 Uterus — 7 Ovary — 4 Breast ... ... ... ... ... — 23 Male genito-urinary organs— Prostate ... ... ... ... ... 11 — 72 Males. Females. Buccal cavity and pharynx— Tongue 6 1 Lip 1 — Other sites 15 10 Diabetes—Supply of Insulin. During the year three patients were supplied with Insulin at a cost to the Council of £14 4s. 4d. Bacteriological Diagnosis.—The arrangements made by the County Council of Essex with the Counties' Public Health Laboratories, 91, Queen Victoria Street, E.C. 4, for the examination of specimens sent by any Authority throughout the County, is being continued. The following specimens were sent:— Diphtheria swabs ... 1,499 Ringworm ... 1 Sputum 480 Widal test (Enteric Fever) 9 Water 12 Sewage 7 Miscellaneous 139 Total 2,147 ^3 co TABLE No. 6. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1938. 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 188* 6 9 6 15 10 55 47 14 11 9 5 1 Erysipelas 68 — — — — — 1 2 4 16 12 21 12 Scarlet Fever 293f 1 5 14 18 29 130 42 15 27 10 2 — Pemphigus Neon. — — — — — — — — — — — — — Pulmonary T.B. 106 — — — —■ - — 2 3 17 51 10 14 9 T.B. Others 23 — — 1 1 1 2 5 6 6 — 1 — Pneumonia 110 1 4 6 1 3 11 3 8 13 13 36 11 Ophthalmia Neon. 2 2 — — — — — — — — — — — Enteric Fever ... — — — — — — Puerperal Pyrexia 20 — — — — 17 3 Cerebrospinal Meningitis 2 — — — 1 — — — 1 — — — Poliomyelitis ... 4 — — — 1 1 2 — — — — — — Enc. Lethargica 1 1 — — — — — — — — — — — Dysentery 27 2 I 2 1 3 6 4 — 6 2 — Totals 844 13 19 29 38 47 209 106 64 148 59 79 33 * Including 20 cases which occurred in Wliipps Cross Hospital, t .. 7 „ TABLE 6a. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1938. DISEASE. Total. Leyton. Lea Bridge. Central North. Central South. Forest. Leytonstone. Grove Green. Harrow Green. Cann Hall. Wanstead Slip. Removed to Hospitals. Smallpox Diphtheria 188* 10 33 3 11 48 13 21 25 12 12 182 Erysipelas 68 2 12 7 2 16 10 3 5 6 5 27 Scarlet Fever 293f 21 44 30 40 43 20 22 28 28 17 223 Pemphigus Neon. — — — — — — — — — — — — Pulmonary T.B. 106 9 12 9 12 20 9 9 8 10 8 — T.B. Others 23 1 6 4 1 2 3 1 3 — 2 — Pneumonia 110 8 39 4 7 28 8 2 5 4 5 70 Ophthalmia Neon 2 — — — — — 2 — — — — 2 Enteric Fever — — — — — — — — — — — — Puerperal Pyrexia 20 1 2 2 2 5 4 — 2 — 2 9 Cerebrospinal Meningitis 2 — — 1 — — — — — — 1 1 Poliomyelitis 4 — — 2 — 1 — — 1 — •— 4 Enc. Lethargica 1 — — — — — 1 — — — — 1 Dysentery 27 1 8 6 5 2 3 — — — 2 — Totals 844 53 156 68 80 165 73 58 77 60 54 519 * Including 20 cases which occurred in Whipps Cross Hospital. i* »» ^ »» »» »» »» »» >» Isolation Hospital. 76 ISOLATION HOSPITAL. Statistical Returns 1938. Admissions:— At all Ages. Under 1 year. 1 and under 5yrs. 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 204 1 44 127 14 17 1 Diphtheria 151 5 33 88 8 15 2 — Totals 355 6 77 215 22 32 3 — The total number of patients admitted during the year was 355, as compared with 354 during the previous year. SCARLET FEVER. Of 293 persons notified during the year 204 (69 per cent.) were admitted to Leyton Isolation Hospital for treatment. Of that number 105 were males and 99 females. The average period of treatment in hospital was 34.12 days. 1934 1935 1936 1937 1938 Number of cases notified 681 409 367 309 293 Number of cases treated in Leyton Isolation Hospital ... 391 260 232 212 204 Percentage ... 58% 63% 63% 68% 69% Deaths in Hospital 1 0 2 0 0 Hospital case fatality 0.25% Nil. 0.86% Nil. Nil. Incidence of Complications. (Results of Investigation by Dr. Henderson, Deputy Medical Officer of Health.) During the year 204 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 191 patients definitely diagnosed as scarlet fever, 18 had complications on admission. The following table shows these complications :— Rhinitis 11 Otorrhcea 2 Albuminuria... 1 Sores 3 Bronchitis ... 1 77 Complications during Course of Disease. Sixty-eight patients (36 per cent.) developed complications during their stay in hospital. Forty-two had one complication, nineteen had two, five had three, and two had four 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 9 4 2 15 7.8 Rhinitis 5 7 - 12 6.3 Cervical adenitis 2 16 2 3 23 12.0 Arthritis 1 2 3 1.6 Measles 3 2 5 2.6 Secondary tonsillitis and quinsy 1 6 1 8 4.2 Second attack of scarlet fever 2 4 1 7 3.7 Endocarditis 2 2 1.0 Albuminuria 2 3 3 8 4.2 Nephritis 1 1 2 1 5 2.6 Boils 1 1 2 1.0 Whitlows 1 3 4 2.1 Mumps 2 2 1 5 2.6 Diphtheria 1 1 2 1.0 Broncho pneumonia 1 1 0.5 Sinusitis (Maxillary antrum) 1 1 0.5 Total 30 49 15 9 103 half (48.5 per cent.) of the total complications. The incidence of nephritis and albuminuria for the past five years is shown in 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 1938 2.60 4.20 6.80 Cases of otorrhœa, rhinitis and adenitis comprised almost half (48.5 per cent.) of the total complications. 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. 8 38 29 28 103 7.8% 36.9% 28.1% 27.2% 100% 78 time. Of that number, 70 were males and 81 females. The average period of treatment in hospital was 29.56 days per case. 1933 1934 1935 1936 1937 1938 Number of cases notified 94 257 276 231 161 188 Number treated in Leyton Isolation Hospital 70 193 188 187 136 151 Percentage 74% 75% 68.1% 80% 84% 80% Deaths in Hospital 4 10 6 9 4 1 Hospital case fatality 5.70% 5.18% 3.19% 4.81% 2.94% 0.66% DIPHTHERIA. Of 188 persons notified during the year, 151 (80 per cent.) were admitted to Leyton Isolation Hospital. The figure of 151 includes 8 cases re-admitted to hospital and not notified a second time. Of that number, 70 were males and 81 females. Deaths.—One death due to diphtheria occurred in Leyton Isolation Hospital during the year, the following being the relevant particulars :— Sex. Age. Cause of Death. In Hospital. f. 4 years Cardiac paralysis, diphtheria 12 days Massage and Special Treatment. The Council's Masseuse, Miss Findlay, attends at the Isolation Hospital during one morning per week, and the following list shows the numbers of the different types of patients dealt with. Number of patients treated Number of treatments. Under School Age 26 42 School Children 79 126 Adults 21 25 126 193 Miss Findlay's services at the Isolation Hospital have been greatly appreciated ; and as a result of the treatment given it has been possible to ensure that patients suffering from orthopaedic defects leave the hospital in a more fit condition. In addition, Miss Findlay has been able to follow up these cases by arranging for their attendance at the special orthopaedic clinic. Maternity and Child Welfare. 80 MATERNITY AND CHILD WELFARE. INFANT WELFARE. Notification of Births.—Fourteen hundred and eighty-five notifications of births were received during the year. By medical practitioners 408 By midwives 1,077 By parents and others Nil. Child Welfare Clinics. LEYTON GREEN CLINIC. Leyton Green Road, Leyton, E.10. Mondays 1.45 p.m. Wednesdays 1.45 p.m. Fridays 10 a.m. Fridays 1.45 p.m. PARK HOUSE CLINIC. Granleigh Road, Leytonstone, E.11. Mondays 1.45 p.m. Tuesdays 10 a.m. Tuesdays 1.45 p.m. Thursdays 1.45 p.m. During the year under review, the total attendances at the Council's Infant Welfare Centres were 18,581, an increase of 756 compared with the figure (17,825) for the previous year. The number of children examined by the Clinic Medical Officers was 7,040 as compared with 6,674 examined during the previous year. 81 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 „ D. Jacobs. Leyton Green. 1934 „ F. Reeve. „ ,, 1937 „ J. Murray. ,, ,, 1937 „ 0. R. Kelly. „ „ 1937 Miss Berry. ,, ,, 1938 Mrs. Hanscombe. ,, „ 1938 ,, Carter. ,, ,, 1938 „ Elliott. Park House. 1920 ,, Wagstaff. ,, ,, 1924 Miss H. S. Holl. „ „ 1927 „ E. H. Holl. „ „ 1927 Mrs. J. Oates. ,, ,, 1929 Miss Muddiman. „ ,, 1934 „ Goodman. ,, ,, 1937 Mrs. W. Brighting. ,, ,, 1938 „ Gooding. ,, „ 1938 ,, Day. „ „ 1938 82 TABLE 8. ATTENDANCES, EXAMINATIONS, ETC., 1938. Leyton Green. Park House. p.m. Hon. p.m. Wed. a.m. Toddlers. Fri. p.m. Fri. p.m. Mon. a.m. Toddlers, † Tues. & † Fri. p.m. Tues. p.m. Thurs. All Centres Under 1 year— 1st attendances 158 237 192 188 145 205 1 ,125 Subsequent attendances 1,67!) 2,493 2,066 2,549 1,894 2,434 13,115 Total attendances 1,837 2,730 2,258 2,737 2,039 2,639 14,240 1-5 years— 1st attendances 10 28 94 16 20 83 17 12 289 Subsequent attendances 469 802 288 387 845 215 548 498 4,052 Total attendances 488 830 382 403 865 298 565 510 4,341 Total attendances, both age groups 2,325 3,560 382 2,661 3,602 298 2,604 3,149 18,581 Average attendance per session 48.43 74.16 11.23 55.43 75.04 8.51 54.25 65.60 64.51 Number examined by clinic M.O. 879 1,236 342 994 1,277 266 965 1,081 7,040 Average numberexamined per doctor per session 18.31 25.75 10.05 20.70 26.60 7.60 20.10 22.52 24.44 Number weighed 2,333 3,529 372 2,657 3,597 290 2,572 3,049 18,399 * The averages at all centres in final column are exclusive of the Toddlers' Clinics, † Jan. to April and Nov.-Dec. Clinic held on Tuesdays. May to Nov. Clinic held on Fridays. 83 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 17,015 visits to homes, as follows:— (а) To expectant mothers:— First visits 197 Total visits 228 (b) To children under 1 year of age :— First visits 1,512 Total visits 7,376 (c) To children between the ages of 1 and 5 years:— Total visits 9,411 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:— 1934 273 1935 283 1936 291 1937 295 1938 267 The record of such treatment undertaken during the year 1938 is:— Expectant Children. Mothers. Patients treated 107 160 Attendances 309 276 Extractions 404 325 Fillings 23 70 Other dental operations 36 10 Advice only 13 11 Anaesthetics— General 92 80 Local 12 41 84 Dentures supplied— Full upper and lower 3 Partial upper and lower 1 Full upper 6 Full upper and partial lower 3 Partial upper 2 Partial lower 1 16 Orthopaedic Treatment. Primary Examinations.—During the year 42 children were referred from the Infant Welfare Clinics to the Council's Orthopsedio Surgeon. The orthopaedic defects included :— Congenital. Torticollis . 4 Spastic hemiplegia 2 Deformity digit (foot) 1 Facial paralysis 1 Talipes 2 Hemihypertrophy 2 Intra-uterine constriction forearm 1 Acquired. Genu valgum 11 „ varum 1 Bowed tibiœ 11 Bowed femora 1 Genu recurvatum 1 Pes piano valgus 16 Re-examinations.—In addition to the 42 new cases mentioned above, 65 children under five years of age attended for re-examination by the Orthopaedic Surgeon. Treatment.—Eighty children made 388 attendances at Knotts Green Special School for special treatment by the Council's Masseuse (Miss Findlay). 85 Provision of Surgical Appliances.—Sixty-four children were supplied with surgical appliances on the recommendation of the Orthopaedic Surgeon, and the following is a list of the appliances supplied under the Authority's scheme:— Genu valgum braces, tunnels and wedges to boots 2 pairs Tibial splints, pockets and wedges to boots 3 ,, Talipes splint 1 pair Wedges, valgus pads and stiffening to boots 2 pairs Minor alterations to ordinary boots and shoes 55 ,, Night splint (talipes) 1 pair 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 60 attendances for examination and treatment. The ophthalmic defects found in these 34 children were:— Myopic astigmatism 2 Hypermetropia 2 Hypermetropic astigmatism 4 Hypermetropia with squint 7 Myopia with squint 1 Squint only 5 Various diseases 14 No defect 1 " Various diseases " include:— Conjunctivitis 2 Epicanthus 7 Ptosis 3 Epiphora 2 14 The following forms of treatment were recommended:— Spectacles supplied 11 „ not prescribed 22 Referred to squint clinic 1 86 Artificial Sunlight Treatment. Number of cases treated 78 Total number of attendances 1,305 Convalescent Home Treatment. Children. During the year 40 children, recommended by the Clinic Medical Officers, were sent to Convalescent Homes by the Maternity and Child Welfare Authority through the agency of the Invalid Children's Aid Association. The illnesses for which convalescence was recommended were:— Debility (12 cases). Scarlet fever (1 case). Whooping cough (3 cases). Pneumonia (4 cases). Bronchitis (5 cases). Measles (7 cases). Blepharitis (1 case). Cough (1 case). Pyelitis (1 case). Otitis media (2 cases). Asthma (1 case). Rheumatic pericarditis (1 case). Malnutrition (1 case). Twenty-three of the 40 children were between the ages of two and four years ; 8 were over four years ; and 9 were under two years. Nursing Mothers. Four mothers were sent away for two weeks convalescence to " Child Haven," Hutton, near Brentwood, after they had had their babies. 87 Ophthalmia Neonatorum. No. of Cases Notified. Treated At Home. In Hosp. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. 2 — 2 2 — — Treatment.—These 2 cases were treated as follows:— At home St. Margaret's Hospital 2 2 Infant and Foetal Mortality. There were 70 registered deaths of infants under one year of age, giving an infantile mortality rate of 46.38 per thousand live births. Neo-natal Mortality (deaths of infants under one month).— Of the 70 deaths under one year, 43 occurred in the first four weeks ; and of the 43 deaths under four weeks, 32 occurred in the first week. The following figures show the variations in the infantile and neo-natal mortality rates and in the number of stillbirths during the last five-year period. Year. Births. Deaths under Mortality Rate. Stillbirths. 1 year. 4 weeks. Infantile. Neo natal. 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 1938 1,509 70 43 46.38 28.56 41 Reference to Table 8 will show that the chief cause of neonatal deaths was premature birth (24). 88 TABLE 8. Infantile Mortality, Year 1938—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 ... ... ... ... ... ... ... ... ... Scarlet fever ... ... ... ... ... ... ... ... ... ... Whooping cough ... ... ... ... ... ... ... ... ... Diphtheria and croup ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... 1 1 ... ... ... ... 2 Pneumonia (all forms) 1 2 ... 1 4 4 2 2 2 14 Diarrhoea ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... 1 4 1 ... 6 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... Injury at birth 1 ... ... ... ... ... ... ... ... 1 Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Congenital malformations 3 2 ... ... 6 ... 1 ... ... 7 Premature birth 20 3 1 ... 24 1 ... ... ... 25 Atrophy, debility and marasmus 1 ... ... ... 1 ... ... ... ... 1 Other causes 4 ... ... ... 4 ... 2 ... 1 10 Totals 32 7 1 3 43 7 9 6 5 70 Nett Births registered during Legitimate 1,469 the calendar year Illegitimate 40 Nett Deaths registered during Legitimate infants ... 64 the calendar year Illegitimate infants 6 89 TABLE 8a Infantile Mortality During the Year 1938—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 Leaths under 1 Year. Smallpox ... ... ... ... ... ... ... ... ... ... ... ... Chicken pox ... ... ... ... ... ... ::: ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... Scarlet fever ... ... ... ... ... ... ... ... ... ... ... ... Whooping cough ... 1 ... ... ... ... ... ... ... 1 ... 2 Diphtheria and croup ... ... ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous meningitis ... ... ... ... ... ... ... ... ... ... ... ... Abdominal tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... Other tuberculous diseases. ... ... ... ... ... ... ... ... ... ... ... ... Meningitis (not tuberculous) ... ... ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... 2 ... ... ... ... ... 2 Pneumonia (all forms) 1 2 2 1 ... 2 1 3 ... ... ... 14 Diarrhœa ... ... ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... 2 ... 1 1 ... ... 1 ... 6 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... ... ... Injury at birth ... ... ... ... ... ... ... ... ... 1 Atelectasis ... ... ... 1 ... ... ... ... ... 1 ... 2 Congenital malformations 1 1 ... 3 1 ... ... 1 ... ... ... 7 Premature birth 3 3 ... 5 4 3 1 4 2 ... ... 25 Atrophy, Debility and Marasmus ... ... ... ... ... ... ... ... ... 1 ... 1 Other causes ... 1 2 ... ... 3 ... 2 1 ... 1 10 Totals 5 8 4 12 6 11 4 10 5 4 1 70 90 Public Health Act, 1936. Child Life Protection. On 1st January, 33 foster mothers and 33 children—and at the end of the year 29 foster mothers and 30 children—were subject to insnection. The Council's Child Protection Visitors made 200 visits of inspection during the year. Summary, Year 1938. Number of nurse children on Register, 1st January 33 Number of nurse children notified by foster mothers during the year 30 Nurse children removed:— To parents or relatives 16 To another foster mother 3 With foster mother to another area 3 Adopted 3 To institutions 2 Attained 9 years of age 6 Number of nurse children on Register on 31st December 30 Ante-natal Clinics— (1) Park House Clinic, Granleigh Road, E.ll.—Thursdays, 10 a.m., and alternate Wednesdays, 2 p.m. (by appointment only). (2) Leyton Green Clinic, Leyton Green Road, E.10.— Wednesdays, 10 a.m. (3) Maternity Department, Queen Mary's Hospital. Attendances.—During 1938, the attendances were:— First Subsequent Centre. Attendances. Attendances. Total. Park House Clinic, 306 579 885 Leyton Green Clinic 244 487 731 550 1,066 1,616 The average number in attendance at the Ante-Natal Clinics held at the Council's two Centres during 1938 was 16.04 per session. 91 The number of home visits made by Health Visitors to expectant mothers during the year was 228. This is less than last year (243) and is due to the increased number of ante-natal visits made by the Council Midwives. (See page 110). The results of all cases examined and tabulated below. Percentage of Finished Number. Cases. Normal 380 86.95 Instrumental delivery 18 4.12 Twins 11 2.51 Prematurity 9 2.06 Breech presentation 5 1.14 Miscarriage 5 1.14 Stillborn 3 0.68 Post partum haemorrhage 3 0.68 Triplets 1 0.23 Caesarian section 1 0.23 Placenta prævia 1 0.23 Total 437 Not pregnant 11 Removed 23 Grand Total 471 Analysis of Abnormal Cases. (Report by Dr. Hilda Menzies.) (a) Instrumental Delivery (18 Cases). Of the instrumental deliveries, 16 occurred in primigravidae ; of these fourteen had booked with midwives, one had arranged to go into hospital, and one arranged with a private medical practitioner to have her confinement in a nursing home—this last case did not continue attendance at the ante-natal clinic. Of the midwives' cases, two were referred to hospital for further advice on account of suspected disproportion. One was admitted to hospital for trial labour and the other was considered 92 suitable for delivery at home. A third case was admitted to hospital at the 34th week on account of toxaemia. This was a women of 29 years, adipose and short in stature. Two other cases were under special observation for raised blood pressure. In two cases it was noticed that the head was not fixed, one a post occipital position. One woman of 32 years was advised originally to go into hospital on account of her age, stoutness and rather high blood pressure, but her husband decided he would prefer her to have the baby at home. In two cases no definite abnormality was detected. One of these was sent into hospital during labour on account of slow progress and was delivered of a live child. Two were cases with heart lesions, and had been referred to their private medical attendants for observation in the last few weeks of pregnancy. One of these was a woman of 28 years with mitral incompetence, not quite compensated. She stood the labour very well, but it was considered that she ought not to have a second child. Two patients did not attend the clinic during the last four weeks of pregnancy. The ages of these primigravidse ranged from 20 to 32 years. Five were under 25 years, eight between 25 and 30 years, and three over 30 years. Of the two multiparse who had instrumental deliveries, one had had a previous stillbirth in hospital, cause unknown. On this occasion she was sent to hospital during labour on account of slow progress and was subsequently delivered of a live child. The second was a woman of 30 years, small in stature, with stretched abdominal muscles. There was no stillbirth among the instrumental deliveries. (6) Cæsarean Section (1 Case). This was a woman of 39 years who became pregnant for the first time after fifteen years of married life. She had been told that it was impossible for her to have any children. She had a very marked dorsal scoliosis with some degree of obliquity of the pelvis, and she was referred to hospital when she first attended the clinic. 93 (c) Stillbirths (3 Cases). All three stillbirths occurred in primigravidse, aged 24, 27 and 29 years respectively. The first had arranged to have her confinement in hospital. The second was a midwife's case who was not sent to the clinic until she was 37 weeks pregnant, the midwife having previously understood that the patient was being examined by her private medical attendant. When she attended the clinic the head was completely above the brim and she was referred to hospital for further advice. The specialist recommended her admission for trial labour. This was done, but unfortunately resulted in a stillbirth (prolapsed cord). The third had arranged to have her confinement in hospital. She had small pelvic measurements and when she failed to keep her appointment about one week before her expected date of confinement she was visited and urged to re-attend. Actually she went four weeks longer than she expected, and as the labour was normal it is possible that the stillbirth was due to post maturity. (d) Breech Presentation (5 Cases). Four of these five cases occurred in primigravidse, and three of the five were breech with extended legs. Two had arranged to go into hospital for their confinements. One of these made only one attendance at the clinic when she was diagnosed vertex. She failed to keep her second appointment a few days before she was due. As she was an extended breech, it is unlikely that she was a vertex four weeks earlier. The second case was queried as a breech and sent to hospital early. Two cases were referred to hospital for version. One was admitted, as version under anaesthesia failed, and was delivered as an extended breech. The second was delivered at home, 2-3 weeks premature, before version was attempted. The final case occurred in a multipara of 34 years. The presentation was queried, but version was not attempted. The babies were born alive in all five cases. 94 (e) Prematurity (9 Cases). Of the nine cases of premature birth, four occurred in primigravidse and a fifth in a woman whose only other pregnancy had terminated in a three months' miscarriage. This last was a woman of 31 years who had been married seven years. She was found to be suffering from raised blood pressure on her first attendance at 29 weeks. After a week she was sent into hospital. She remained there about three weeks and then discharged herself. When her private medical practitioner examined her subsequent to discharge, he found increased albuminuria and raised blood pressure. She had a premature stillbirth two weeks later. Of the four primigravidae, two showed no obvious cause to account for the premature births—one at 32 weeks, and the other at 34 weeks. Both babies died in the first twenty-four hours, one diagnosed as congenital atelectasis. In the third case the mother (aged 22 years) had developed optic neuritis of sudden onset when she was about 12 weeks' pregnant. She was in hospital four weeks. The cause could not be ascertained, and on discharge she had almost complete unilateral blindness. When she was 28 weeks she felt giddy and fell downstairs. Her doctor sent her into hospital where she commenced labour the following day, resulting in a premature stillbirth. The fourth case was a girl of 18 years who was delivered of a premature child at 34 weeks, followed by the death of the child nine days later. Of the four multiparse, two had ante-partum haemorrhage about 30 weeks. In one of these cases the general physical condition was not good and there was a history of a three months' miscarriage the previous year. In the third case the mother gave a history of pleurisy with effusion in her previous pregnancy, and her physical condition was not satisfactory in this pregnancy, which terminated at about 30 weeks. The fourth case was a premature stillbirth in a woman (45 years) who had previously had eight living children. Maternity Beds. In addition to the 550 expectant mothers who attended the Council's clinics, 281 attended the Out-patient Department of Queen Mary's Hospital, Stratford, for ante-natal supervision. 289 mothers had their confinements in the Margaret Lyle Wards of the hospital. 95 The complications dealt with included— Ruptured perineum 58 Forceps delivery 22 Prolonged labour 19 Pre-eclamptic 16 Episiotomy 21 Trial labour 13 Post partum hæmorrhage 11 Medical induction 10 Surgical induction 7 Albuminuria 3 Ante-partum haemorrhage 2 Placenta prævia 2 Eclampsia 1 Cardiac 4 Hyperemesis gravidarum 1 Hypertension 2 Pyelitis 1 Maternal distress 2 Disproportion 1 Breech 4 Uterine inertia 1 Uterine fibroids 1 Manual removal of placenta 4 Stillborn 2 (Edema 1 Anenoephalic foetus 3 Macerated foetus 2 Icterus Neonatorum 1 Sticky eyes 1 Foetal distress 5 Prolapsed cord 1 Congenital heart 2 Post-Natal and Gynaecological Clinic. Review of First Year's Work. In August, 1937, I submitted to the Maternity and Child Welfare Committee a report drawing attention to the recommendations contained in Ministry of Health Circular 1622 (May, 1937) with regard to the establishment of post-natal services in connection with the schemes of local authorities for maternity and 96 child welfare; and in October, 1937, the Council decided to inaugurate Post-natal and Gynaecological Clinics to be held once a month at each of the municipal maternity and child welfare centres. Dr Helen Jardine, M.D., Ch.B., M.M.S.A., was appointed medical officer in charge of the special clinic. In December, 1937, the Council decided:— (1) that for a period of one year the dispensing service be free in all cases where in the opinion of the Medical Officer of Health the patient is unable to afford the cost; (2) that arrangements be made with three firms of chemists in the area to dispense such drugs as may be ordered ; (3) that at the expiration of one year the Medical Officer of Health submit a report on the cost of the drugs, etc. With regard to the procedure adopted, the register of births is scrutinised regularly by Dr. Hilda Menzies, who extracts the names and addresses of all mothers who have been confined at home under the care of a midwife, in Forest Gate Hospital, or in a nursing home where the services of a doctor have not been booked for the confinement. A letter is then sent to these mothers inviting them to attend at the post-natal clinic in order to ensure that they have completely recovered from the effects of their recent confinements. No such invitations have been sent to mothers who have booked private medical attendants for their confinements, or to those who have occupied maternity beds in Queen Mary's Hospital. With the valuable help and co-operation of Dr. Menzies and Dr. Jardine, arrangements were made for the inauguration of the post-natal clinic services at Park House Centre on 12th January, and at Leyton Green Centre on 18th January, 1938. The following figures during 1938 show in statistical form the attendances Leyton Green. Park House. Total. Number of Sessions 14 14 28 Letters of Invitation 302 325 627 First Attendances 116 107 223 Re-attendances 34 32 66 97 I am convinced that the post-natal clinic scheme is a valuable extension of your maternity and child welfare services, and that authority should be given for increasing the number of sessions to meet requirements as the service becomes—as I feel it will become— more widely appreciated by mothers in the area. As the result of experience during the past year I suggest that Council Minute 329 (ii) of December, 1937, be modified to allow of patients having prescriptions dispensed by chemists of their own choice. Dr. Helen Jardine has kindly submitted the following report on the first year's work at the special clinic, and I take this opportunity of recording my appreciation of her valuable services. Report bt Dr. Helen Jardine, M.D., Ch.B., M.M.S.A. An attempt has been made to arrange the appointments between six and eight weeks after confinement—because this is the best time for a post-natal examination—but this has not always been possible with a monthly clinic. During two months extra clinics were held to overtake the waiting list. The 223 mothers who attended during 1938 did so for these reasons:— In response to letters of invitation 188 Referred by midwives 3 Referred by health visitors 7 Referred by clinic medical officers 19 Referred by general medical practitioners 2 Attended on own initiative 4 223 Of these patients, 195 (Leyton Green, 100 ; Park House, 95) were " post-natal," i.e., had their confinements within the previous three months ; 26 (Leyton Green, 16 ; Park House, 10) were " gynaecological " ; 2 were found to come under neither category (one suffered from neurasthenia and the other from rheumatism) and were referred elsewhere for treatment. 98 The disposal of these cases was as follows:— Discharged after one attendance 125 Re-attended for examination and treatment 42 Referred with letters to medical practitioners 51 Referred to hospital 3 Not post-natal cases 2 223 Free medical prescriptions were issued in 48 cases (Leyton Green, 28 ; Park House, 20) at a total cost to the Council of £5 14s. 3id. ; and 49 prescriptions were issued for payment by the patient. The average attendance per session was 10.3—with a maximum of 18 and a minimum of 7. The number of patients who can be dealt with satisfactorily during one session depends on the type of treatment found necessary, e.g., birth control cases take much longer than ordinary examinations. On the average, I think that 10-12 patients per session is a reasonable number. The following are the main conditions which have been found on examination. A number of patients had more than one defect. In considering this list it should be kept in mind that those women who felt ill would be more likely to respond to the letters of invitation than those who felt well, and also that the ante-natal and infant welfare medical officers definitely selected some cases which they thought ought to have treatment or birth control advice, and persuaded them to attend. Total Leyton Green. Park House. Subinvolution of uterus or vagina 33 23 10 Retroversion of the uterus 34 15 19 Prolapse 25 15 10 Vaginitis 10 3 7 Cervical erosion 11 4 7 Menorrhagia 1 1 — Pregnancy 3 1 2 Sterility 2 2 — Ovarian cyst 1 1 — Pyelitis 1 — 1 Chronic nephritis 1 1 — Anal fissure 3 2 1 Marked anaemia 20 10 10 Birth control 31 17 14 99 Of the three patients referred to hospital during the year, one has had a repair operation for prolapse ; one has had a cervical dilatation and insufflation of the fallopian tubes for sterility ; and the third is now having medical treatment at Queen Mary's Hospital. General Observations. The maternal mortality rate is accurately known. Maternal morbidity is often vague and illdefined ; its full effect may not develop until years later. It is, therefore, difficult to assess its prevalence or degree. In the latest Ministry of Health Report on Maternal Mortality it is stated that it had been hoped to consider maternal morbidity, but that the necessary data could not be found. The onty records available were the reports from the gynaecological departments of several large hospitals and they deal only with women who were ill enough to seek advice. Much minor disability, which is preventable or curable if the patient is seen soon enough, goes undetected. A post-natal clinic has two purposes:— 1. To diagnose and arrange treatment for disabilities arising from childbirth in their early and more readily curable stages. 2. To collect information about the nature and frequency of maternal morbidity which will enable measures to be taken for its prevention. Disability arising from childbirth may be:— 1. Gynaecological—a local lesion due to trauma or infection. 2. General—the general health may be affected by the stress and strain of labour, by loss of blood or by some complication of pregnancy such as albuminuria. 3. These two forms of disability often exist together, e.g., a severely anæmic woman may have a prolapse. Much good can be done by even one post-natal examination, but in many cases it is necessary to give continued observation and treatment over a period of time. It is often quite as important to treat the general as the local condition. A knowledge of the home circumstances in individual patients is a great help, e.g., one patient may need extra nourishment more than medicine ; the recuperation of another may be retarded because she is worrying about her ailing child. The maximum value can be obtained only 100 from a post-natal clinic if the Medical Officer who examines the patients has a knowledge of their condition during pregnancy and confinement, and if co-operation in treatment is sought with other agencies, e.g., the general practitioner, the infant welfare clinic, the hospital gynaecological department. As far as possible the patient's ante-natal and natal notes are made available for reference in the Leyton clinic. Two of the three municipal midwives attend each session (unless prevented by their other work), and they thus have the opportunity of following up some of their own cases. The clinic medical officers and the health visitors have given additional information about individual patients. When the patient is found to have some non-gynaecological condition which requires treatment and has a private medical attendant, she has been referred to him. When, as in Leyton, attendance at the clinic is possible only once a month, such reference is not only advisable but necessary. In some cases local gynaecological treatment has been given at the clinic in co-operation with general treatment by the patient's general medical practitioner. Prescriptions are issued to those patients who have no general practitioner and require medical treatment. Prescriptions have also been issued for contraceptives. I do not think that the percentage of patients (35 per cent.) who have taken advantage of the appointments offered to them by letter is satisfactory, though I understand that 30 per cent. is the proportion of confinement cases who are found to come for postnatal examination in other districts. As the clinic becomes better known I hope this proportion will increase. In conclusion I should like to take this opportunity of saying that the Public Health staff—doctors, health visitors, midwives and clerks have all without exception been most helpful and cooperative in their attitude to this new clinic. Nursing Homes Registration Act, 1927. There are three registered nursing homes in the Borough. These institutions were inspected on 21 occasions. Home Helps. Under the Council's scheme for the provision of home helps, 99 applications for home helps were dealt with. In 73 cases (12 of whom made application in 1937), home helps were provided, 25 of these cases having the charges remitted in accordance with the 101 Council's scale. In the 38 remaining cases, 18 made other arrangements for the confinement, 17 cases had not been confined at the end of the year, two were found to be not pregnant, and one was refused owing to unsuitable accommodation. At the end of the year there were 13 names on the Council's approved list of home helps. Report by the Medical Officer of Health. In 1929, at the request of the Council, I submitted a scheme for the provision of home helps in which the following conditions were incorporated:— (а) Expectant mothers shall be allowed to select only from the Council's approved list of home helps. (b) The home help shall attend daily at the home from 8 a.m. to 6 p.m., (or for not less than ten hours daily to be arranged) over a period of 14 days. (c) Home helps will be paid at the rate of 5s. 6d. per day on certificate of satisfactory service. Since the inauguration of the scheme in 1931 some 360 applications for home helps have been received, and the following list shows how the demand has increased. Number of applications for Year. Home Helps received. 1931-2 32 1933 19 1934 33 1935 38 1936 57 1937 82 1938 99 360 102 There can be no doubt of the beneficent value of a reliable home help in any home where the mother is confined to bed from any incapacitating illness, and as the result of experience I am of opinion that the scope of the provision should be extended rather than curtailed. With that end in view I take this opportunity of bringing to your notice certain features of your present scheme which might be modified as the result of experience. List of Approved Home Helps. There is difficulty in obtaining enough experienced and reliable women who are willing to have their names put on the Council's approved list owing to the spasmodic and casual nature of the employment. During recent years the number of names in the list has varied from 10 to 14. At certain times the number of available home helps is insufficient to meet applications for their services; and at other times a home help may not be employed for months at a time. Casual employment of this type is not likely to attract the best type of woman, who generally prefers more regular employment. Time of Duty. The Council's regulations specify that the home help shall attend daily at the home from 8 a.m. until 6 p.m., or for not less than ten hours daily to be arranged. As the result of experience I find that in some homes (e.g. in families with many young children) the home help may be fully occupied for at least ten hours daily; whereas in other cases (e.g. first confinements) there is not sufficient work to keep her occupied for more than a few hours daily. Payment. Before the present scheme was put into operation a questionnaire addressed to 34 Maternity and Child Welfare Authorities throughout the country revealed that the average wage paid to municipal home helps was £1 103. 6d. per week ; and your Council later fixed the wage in this Borough at 5s. 6d per day (i.e. £1 18s. 6d. per week). Since the scheme has been in operation, some 360 Leyton mothers have applied for the services of municipal home helps. In 158 cases the charge to the patient has been remitted, and in all 103 these cases home helps have been supplied. Of the remaining 202 cases, of whom 144 were assessed to pay some proportion of the cost, 69 were cancelled for various reasons. It is evident therefore that the provision is taken advantage of chiefly in the poorest homes. Of course it is in the poorest homes that the services of a home help are most necessary, but there are many poor homes in which the conditions are unsuitable for a confinement ; and I submit that it is wrong to encourage mothers to be confined under such conditions. On the other hand the high assessment encourages mothers in a better financial position, in whose homes there are suitable accommodation and facilities, to have their confinements in hospital because it is less expensive. In this area the services of unofficial home helps can be obtained for 25s. to 30s. per case (i.e. from 12s. 6d. to 15s. per week). Some expectant mothers engage such unofficial home helps privately at 15s. per week, and later make application to my department for financial assistance. They then discover that if they wish assistance from the Council, such " assistance " will cost them much more than 15s. per week. It will therefore be appreciated that the Council's present scheme is not taken advantage of as it should be in view of the great disparity between the payment of municipal and unofficial home helps. General Observations. When a home help is put on the Council's approved list she becomes to all intents and purposes a Council employee, and this Council is responsible for her conduct. Under the circumstances it is the duty of your medical and nursing staff to investigate complaints made either by the mother or the home help. The frequency with which trifling and pettifogging complaints are made on both sides testifies to the ingenuity of the human mind, but your medical and nursing staff have neither the time nor the training to sift evidence which is so sublimely conflicting and to compose differences which are so fundamental. An inefficient and domestically untidy mother often resents the strenuous efforts of a capable home help in cleansing her home and her children, and is inclined to regard such efforts as a reflection on her past conduct of the home. After the home help has completed her service in such a home the mother may complain for the first time that the home help must have been "helping herself" to such things as tea, sugar, bars of soap, or even small sums of money. In my opinion petty complaints of that kind would not be made if mothers were allowed to choose their own helps. 104 Considerable difficulty is experienced in trying to arrange the work. The best home helps are well booked in advance ; but confinements do not always occur at the expected times and mothers often complain bitterly if they cannot have the services of the home help of their choice, even although they have miscalculated their dates of confinement. In special cases home helps may have to continue at one home for longer than the specified 14 days; in other cases the expectant mother may have to be admitted to hospital for her confinement. Such unforeseen circumstances make it difficult to arrange for mothers to have the home helps of their choice ; and the patient who has to make a second choice at the last minute is often resentful, especially if she feels that she is paying more than if she had engaged unofficial help privately. At one time, about two months ago, all the Council's home helps were engaged ; at other times the majority have been disengaged. Even although the approved list contained 100 names, instead of 14, it would still be impossible to guarantee that mothers could have the home help of their choice. After consideration of the above report the Council Resolved:— (1) That the present scheme be modified in the following manner— (a) That the existing principle of keeping an approved list of home helps be continued, and in addition applicants be allowed to provide their own home helps, whose employment will be subject to the approval of the M.O.H. when for any reason it is not possible to supply a home help from the Council's approved list. (b) That the applicants providing their own home helps must notify the M.O.H. of the name and address of the persons chosen at least six weeks before the date of confinement. (c) That grants up to a maximum of £1 1s. per week be made to the applicants providing their own home helps in accordance with the following scale:— Amount of grant. Where total income from all sources after deduction of rent is below the scale of remission, adopted by the Council for use in connection with Maternity and Child Welfare service 21s. per week. 105 Amount of grant. Where total income after deduction of rent is in excess of scale of remission by not more than— £ s. d. 5 0 18s. per week. 10 0 15s. 15 0 12s. 10 0 9s. 15 0 6s. 1 10 0 3s. (d) That the stipulation of ten hours attendance at the home daily be not insisted upon, providing that the work is carried out to the satisfaction of the Health Visitor, who must be granted access to the home at all convenient times. (e) That payment by the Council be conditional on the receipt of a satisfactory report from the Health Visitor. Puerperal Pyrexia. Of the 21 cases of puerperal pyrexia notified during the year, 19 were Leyton residents. The causes of pyrexia were considered to be:— Pyelitis 6 Puerperal septicaemia 1 Subacute bacterial endocarditis 1 (died) Influenzal septicaemia 1 Influenza 1 Following Cæsarean section 1 Local uterine sepsis 3 Mastitis 2 Retained placenta 1 Parametritis 1 Abortion 1 Cause not known 2 The only fatality was the case of subacute endocarditis of which the circumstances are described in detail under the heading of " Obstetric Consultant." 106 There were two deaths of infants in the series. One in a primipara (aged 23) suffering from pyelitis—the baby died in the first 24 hours of life. The other infant death occurred at ten days old in the case of pyrexia following Csesarean Section. No information is available as to the reason for performing Cæsarean section. The mother's age was 29 years. The case of abortion was not a Leyton resident. Eight cases were confined in hospital. Eight were attended by their private medical practitioners, and of these, two were removed to hospital for treatment. Three were midwives' cases and of these two were transferred to hospital. One was confined in a nursing home outside the Borough. The advice of the Obstetric Consultant was sought in two cases. Obstetric Consultant. Report by Dr. Hilda Menzies. The advice of the Council's Consultant Obstetrician was sought on five occasions during the year. On two occasions assistance was requested on account of difficulty in labour, and on three occasions on account of rise of temperature during the puerperium. The details of these five cases are as follows:— 1. Multipara—3rd pregnancy—age 37. Home circumstances good. Ante partum haemorrhage three days previously—30 weeks pregnant—no presenting part felt—membranes ruptured—hand presenting—labour pains ceased—1 c.c. pituitrin administered— no further pains. Consultant called—stillborn baby weighing 5 lbs. born before arrival of consultant. Mother's condition satisfactory. 2. Primigravida, age 28. Home circumstances good. Under care of private medical practitioner throughout pregnancy—nil abnormal noted—external measurements normal—head engaged—when labour commenced the presenting part was rather high, but considered to be engaged—slow progress for 36-48 hours, when all pains ceased—no foetal heart sounds heard—cervix two-fifths dilated. Consultant called. Head very high—foetal heart not heard—primary uterine inertia present—patient transferred to hospital for X-ray investigation and stimulation of labour—after stimulation by medical means cervix fully dilated 18-24 hours later—presenting part with very extreme moulding coming down 107 to pelvic outlet—perforation of dead fetus followed by moderately difficult extraction of large shoulders—foetus after perforation weighed 8½ lbs. and in a state of early maceration—placenta normal —some general contraction of the pelvis was present, but although disproportion to some extent contributed to the fetal death, it was not considered to explain it entirely. 3. Multipara—2nd pregnancy—age 29. Home circumstances good—normal confinement—one vaginal examination before membranes ruptured. Temperature 99 deg. on two occasions in first ten days, but it did not remain up for twelve hours. Medical aid summoned on 11th day on account of rise of temperature to 100.6 deg. (p. 90), with evening temperature 102.2 deg. (p. 118)—temperature down for two following days but pulse between 90-116. On 14th day morning temperature 102.4 deg. (p. 128). Consultant called—tenderness in right iliac fossa and right-sided hard thickening, typical of parametritis—rest, hot vaginal douche twice daily, and prontosil twice daily and fluids prescribed. Patient made good recovery. 4. Primigravida—age 28. Home circumstances good— normal full term labour—one vaginal examination—duration of labour under 12 hours—third stage normal—no P.P.H.—36 hours after delivery, onset of pyrexia and tachycardia—24 hours later consultant called. On examination clinical condition very suggestive of primary hæmolytic streptococcal septicaemia, with punctate erythematous generalised rash and marked suppression of lochia— patient received prontosil by mouth from onset of pyrexia—removed to hospital and was fit to be discharged two months later. 5. Multipara—2nd pregnancy—age 33. Home circumstances good—history of rheumatic fever with cardiac involvement at 20 years—1st confinement normal—in this pregnancy patient's physical condition unsatisfactory during last two months—bronchial catarrh, loss of weight—pulse 90-100, mitral incompetence, slight rise of temperature—4 weeks before confinement sore throat and acute pain in left lower costal region—10 days before confinement acute lumbago and sciatica—baby born two weeks prematurely— normal confinement—no undue loss of blood—attended by doctor and midwife, both wearing masks—one vaginal examination— membranes ruptured artificially shortly before delivery—satisfactory progress until 3rd day following delivery—patient complained of return of acute pain in left lower costal region—evening 108 temperature 103.4 deg.—no uterine tenderness—lochia normal, no cough, no rigors—in the subsequent four days the record of four-hourly temperature showed a swinging temperature reaching a maximum of 102 deg. on0ce in 24 hours, pulse 90-100. At first rise of temperature (3rd day) patient received salicylates—on 5th day given sulphonamide, gr. XV. four-hourly—on 6th day 10 c.c. intrauterine glycerine—haemoglobin 68 per cent. Consultant summoned on 7th day following delivery—clinical examination failed to reveal any abnormal physical signs other than intermittent pyrexia, some tachycardia, slight increase of respiration rate, pain and tenderness in left loin, a few moist crepitations at bases of both lungs—lochia normal—uterus well involuted—no abnormal physical signs in pelvis—initial differential diagnosis between left-sided pyelitis and mild puerperal sepsis—catheter specimen negative—cervical swab culture grew sporing aerobic bacilli with a few non-haemolytic streptococci—patient transferred to Queen Charlotte's Hospital Isolation Block on 8th day following delivery—remained there three weeks and was considered to be suffering from puerperal septicaemia with tuberculosis of the urinary tract—no improvement in her clinical condition and she was transferred for further investigation to St. Mary's Hospital, Paddington, where she was finally diagnosed as a subacute bacterial endocarditis, with streptococcus viridans grown from the blood culture. She died two and a half months after confinement. This last was a particularly interesting and puzzling case. It was investigated fully from the standpoint of puerperal infection but the subsequent history pointed to the old heart lesion as the primary cause of the patient's condition. Maternity Mortality. There were two maternal deaths of Leyton residents during the year—one from toxaemia of pregnancy at 20 weeks ; and the second from puerperal septicaemia following instrumental delivery of a post-mature stillborn macerated foetus. The details of these cases were as follows:— 1. Multipara—aged 38—4th pregnancy. Home circumstances fair—admitted to hospital at 14 weeks with history of severe vomiting—albumen, bile and acetone in urine—slightly jaundiced— 109 very deaf and lethargic—given routine treatment for hyperemesis gravidarum—little change in condition for five weeks—vomited small amounts twice daily—jaundice cleared—no increase in dehydration—persistent mild albuminuria—B.P. never above 130/70—examination of optic discs ten days before death showed blurring of edges but no retinal haemorrhages—later, marked papilledema with some retinal haemorrhages, slight nystagmus, speech slurred, no reflexes, vomiting projectile. Patient became comatose and died at 20 weeks pregnancy. Post mortem examination revealed toxaemia of pregnancy only. 2. Primigravida, aged 44—home circumstances good—under care of private medical practitioner for last two months of pregnancy—said to be " frail " but showed no abnormality during pregnancy—commenced labour in nursing home—two weeks overdue—according to hospital report, transferred to hospital after almost five days in labour—onset of labour had been slow with early rupture of membranes—later pains became severe for a day and a half, subsided, and returned early on day of admission— foetal movements not felt for 48 hours. On examination—toxic appearance—furred tongue—T. 99.5 deg. P. 156—B.P. 130/85— urine, ¼ volume albumen—vomited thick black fluid like altered blood—large baby (R.O.P.) head deeply engaged—os fully dilated liquor foul smelling—tense tender uterus with well-marked distension of lower segment—given omnopon and scopolamine—slept 5½ hours—no improvement—pulse irregular—general condition very poor—manual rotation—mid forceps delivery under gas and oxygen—macerated stillborn foetus 10½ lbs.—promontory felt at 4½ inches, outlet small—patient moribund at termination of delivery. MIDWIVES' ACT, 1936. Council's Scheme foe Domiciliary Midwifery. A full report of the arrangements made by the Council in accordance with the above Act appeared in my Annual Report for the year 1937. The following figures show in tabular form particulars regarding the work done during the year 1938. One of the Council's Municipal Midwives resigned in August, 1938, and another appointment was made. The new Midwife commenced duties on 10th October. During the intervening period arrangements were made with the Essex County Nursing Association to provide a temporary Midwife. 110 Record of Cases Attended by Council Midwives—1st January to 31st December, 1938. Midwives (8) employed by Total. 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 Mid wives Act, 1936. Case8 attended— (a) As Midwives 122 271 393 (b) As Maternity Nurses 38 130 168 Ante-natal Visits 328 474 802 Ante-natal Examinations 898 1,601 2,499 Post-natal Visits 3,251 7,529 10,780 Report by the Medical Officer of Health, September, 1938. Twelve months have now elapsed since the establishment of your domiciliary midwifery service, which came into operation on 1st August, 1937 ; and I take this opportunity of submitting sundry observations on the working of the scheme during the first year of its operation. It will be remembered that, in formulating your proposals for submission to the Ministry of Health, the estimate of staff requirements was based on the average annual number of domiciliary confinements in the area during the previous five-year-period 1931-35 (inclusive) and at that time I drew attention to the difficulty of forming any reliable estimate of the annual number of future domiciliary confinements owing to the operation of such variable factors as the future trend of the population and birth rate, and to the possible increase or decrease in the proportion of women confined in institutions. In the official Memo. (200/M.C.W.) accompanying the Midwives' Act, 1936, the Minister suggested that, in arriving at their estimates, local authorities should consider whether the establishment of the new domiciliary service may not result in an increase in the number of domiciliary confinements; and in my initial report I gave it as my opinion that the future demand for the services of domiciliary midwives would depend, not so much on the efficiency and status 111 of the new municipal midwives, as on the housing conditions and family circumstances of expectant mothers and on the relative cost of domiciliary and institutional confinements. During the first year of operation of your domiciliary midwifery scheme (i.e., 1st August, 1937 until 31st July, 1938) the number of domiciliary confinements has decreased from 653 in 1937 to 552 in the year ended 31st July last. For the purpose of calculating staff requirements it was assumed that each municipal midwife should be capable of attendance on 90 cases per year; and on that basis you appointed three municipal midwives for duty in the western part of the Borough and arranged with the Essex County Nursing Association for the provision of five midwives to serve that part of the Borough lying to the east of Leyton High Road and Hoe Street. The following figures show the number of cases attended during the year ended 31st July, 1938, by these midwives. Municipal Midwives. Nurse Daines 56 Nurse Dodsworth 50 Nurse Roberts 50 Essex County Nursing Association. (Five Midwives) 396 Total 552 With regard to the three municipal midwives, in addition to attendance on their actual cases they are also employed in connection with the work of your ante-natal clinics; but even so they have not been so fully employed as was intended during the year under review. In the light of the first year's experience it appears that some modification of the original scheme is advisable. It may be suggested that steps should not be taken to fill the vacancy caused by the resignation of Nurse Dodsworth; but that would create difficulties with regard to off-duty times and would necessitate the employment of Essex County Nursing Association midwives for relief duty. 112 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. Ante partum haemorrhage 4 Oedema 3 Poor condition during pregnancy 2 Albuminuria 2 Threatened miscarriage 2 Abnormal position of foetus 2 Hydramnios 1 Small pelvic measurements 1 Severe pains—pregnant 1 Abortion 1 During Labour. Ruptured perineum 38 Prolonged labour 22 Post partum haemorrhage 3 Extended breech 2 B.B.A 2 Uterine inertia 1 Obstructed labour 1 Hysteria 1 During Puerperium. General condition of mother 10 Rise of temperature 12 Cracked nipples 1 Conditions Associated with Infants. Discharging eyes 8 Poor condition of infants 5 Prematurity 4 Frenum of tongue 2 Collapse—died 1 Rash on body 1 Jaundiced condition 1 Circumcision 1 Abnormality of palate 1 113 Fees paid to Doctors under Section 14 (1) of the Midwives' Acts, 1918. One hundred and eight accounts were received from general medical practitioners for assistance rendered to midwives under the provisions of this section. The total amount paid to medical practitioners during the year was £153 12s. 0d. NUTRITION. Assisted Milk Supply. As it is a condition of grant that the mothers or infants must attend the Authority's Centres—unless when unable to attend, in which case the home is visited by a Health Visitor—all mothers and infants in receipt of milk free or at reduced price are under medical supervision. MILK SUPPLY, 1938. Pints of Packets of Cost to Council. Year. Fresh Milk. Dried Milk. £ s. d. 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 1938 78,352 736 1,106 2 9 Applicants Granted Free Milk During 1938. January 182 February 195 March 191 April 184 May 188 June 188 July 197 August and September 226 October and November 223 December 196 School Medical Service. 116 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 1,484 1,368 92 Senior Girls' 7 1,499 1,365 91 Junior Boys' 4 968 894 92 Junior Girls' 4 954 878 92 Junior Mixed 6 1,896 1,750 92 Infants' 15 4,205 3,595 85 Non-provided (Mixed) 1 257 220 86 Central (Mixed) 2 940 883 94 Totals 46 12,203 10,953 90 Schools— Roman Catholic 1 257 220 86 Council 18 11,946 10,733 90 Totals 19 12,203 10,953 90 The figures given above relate to the financial year ended March 31st, 1939. During the financial year specified, attendances for a total of six sessions in respect of one 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 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. 117 Close co-operation exists between your Health Department and your Education Office, and I have to acknowledge the cordial co-operation and valuable help rendered by your Director of Education (Wm. Staton, M.A., B.Sc.) in all matters pertaining to the health and welfare of children attending public elementary schools in the Borough. Alterations and Additions to School Premises, JanuaryDecember, 1938. School. Description of Work. Capworth Street Electric light installation. Newport Road Extensions to Boiler House and installation of additional Oil Storage Cylinder. Knotts Green Special Additional heating apparatus. Tom Hood Central Floor planing. Remodelling of existing Latrines. Additional heating installation. Cann Hall Road Heating installation and new Flue and Stack. Farmer Road Floor Planing. Ruckholt Central Alterations and additions. Various Internal painting of 7 Schools. „ External painting of 4 Schools. ,, Annual re-desking. ,, Hot water supplies to lavatory basins. 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. 118 (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 1,660 Second Age Group 1,223 Third Age Group 1,200 Total 4,083 It will be seen from the above that the number of such code group inspections was 4,083 representing 33 per cent. of the number of children on the school registers. Of 4,083 children who were examined in the code age-groups, 3,465 (or over 84 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 7,106, comparing with 6,191 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 1938 was 11,650. 119 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. 149 5 ... 91 20 247 72 8 309 Cann Hall Rd. 96 ... ... 56 10 216 70 ... 231 Capworth St 120 6 ... 94 23 308 82 17 279 Church Road 109 14 ... 76 11 212 87 7 200 Connaught Rd. ... ... ... 97 0 176 78 4 132 Da vies Lane 132 6 4 95 12 269 78 3 285 Downsell Rd. 79 3 1 69 4 185 49 3 249 Farmer Rd. 103 1 ... 70 23 247 79 5 252 Goodall Rd. 111 4 8 78 7 210 64 9 110 Kirkdale Rd 98 3 ... ... ... 37 ... ... 38 Lea Bridge Rd. 42 2 7 ... ... 30 ... ... 24 May ville Rd 126 6 ... 69 9 267 75 9 243 Newport Rd. 129 1 3 92 6 213 64 10 210 Norlington Rd. 146 5 ... 82 18 275 66 8 259 Ruckholt Rd. ... ... ... ... 2 165 95 2 179 Sybourn St. 104 4 ... 116 14 176 63 4 261 St. Joseph's 26 5 ... 29 2 81 16 ... 75 Trumpington Rd. 90 4 ... 109 20 185 110 3 106 Tom Hood ... ... ... ... 12 130 52 6 217 KnottsGreenS.S. ... ... ... ... ... ... ... ... 304 Totals 1660 69 23 1223 199 3737 1200 98 3963 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 1660 285 17.1 Second Age Group 1223 298 24.3 Third Age Group 1200 202 16.8 Total (Code Groups) 4083 785 19.2 Return of Defects found by Medical Inspection in the Year ended 31st December, 1938. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. i (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... ... ... Body ... ... 24 ... Scabies 1 ... 66 ... Impetigo ... ... 164 ... Other diseases (non-T.B.) 17 4 491 ... Eye Blepharitis 33 5 100 ... Conjunctivitis 14 ... 92 ... Keratitis ... ... 5 ... Corneal Opacities ... ... 2 ... Other conditions 15 2 218 4 Defective Vision 203 134 143 8 Squint 28 6 16 1 Ear Defective Hearing 4 11 26 2 Otitis Media 18 6 119 2 Other Ear Diseases 13 3 189 4 Nose & Throat Chronic Tonsilitis only 79 74 130 ... Adenoids only 18 13 25 1 Chronic Tonsilitis and Adenoids 69 66 51 1 Other Conditions 29 8 208 ... Enlarged Cervical Glands (non-T.B.) 38 26 107 ... Defective Speech ... 3 9 1 Heart and Circulation Heart Disease— Organic 4 ... 27 ... Functional 8 53 18 5 Anæmia 13 6 121 1 Lungs 1 Bronchitis 47 52 157 2 Other non-T.B. Diseases 12 29 57 1 Pulmonary— Tuberculosis Definite ... ... ... ... Suspected 1 10 ... ... Non-Pulmonary— Glands ... I 8 ... Bones and Joints ... ... 4 ... Skin ... ... ... ... Other Forms ... 1 1 ... Nervous System Epilepsy 3 1 6 ... Chorea ... 3 27 ... Other Conditions 10 18 101 6 Deformities Rickets 43 1 1 ... Spinal Curvature 2 ... 4 ... Other Forms 69 22 196 ... Other Defects and Diseases 71 59 2548 27 Totals 862 617 5463 66 120 121 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. Number. Per cent. Entrants 1,660 245 14.7 1,030 62.0 363 21.9 22 1.3 Second Age Group 1,223 190 15.5 770 62.9 252 20.6 11 0.9 Third Age Group 1,200 318 26.5 702 58.5 178 14.8 2 0.2 Other routine inspections - - - - - - - - - Total 4,083 753 18.4 2,502 61.2 793 19.3 35 0.9 Uncleanliness and Verminous Conditions.—At the special inspections held by the school nurses, 1,385 children were found to be unclean out of a total number of 29,763 examined (i.e., 4.6 per cent.). Cleanliness Surveys in Individual Schools. School. Number of Examinations. Number Cautioned. Number Excluded. Canterbury Road 2,472 34 10 Capworth Street 2,565 169 32 Cann Hall Road 1,775 21 8 Church Road 1,999 143 32 Connaught Road 1,207 29 9 Downsell Road 1,228 39 18 Davies Lane 1,959 57 22 Farmer Road 2,032 187 14 Goodall Road 1,647 62 13 Kirkdale Road 471 9 5 Lea Bridge Road 319 13 — Mayville Road 1,323 68 12 Norlington Road 2,430 79 6 Newport Road 1,435 8 1 Ruckholt Road 709 5 1 Sybourn Street 2,130 83 13 St. Joseph's 1,022 59 28 Trumpington Road 1,461 14 5 Tom Hood 913 7 2 Knotts Green 666 47 21 Total 29,763 1,133 252 Number of individual children found unclean 1,385 of whom 252 were referred to the Minor Ailments Clinics. 122 A Comparison of Heights and Weights, 1911 and 1938. Report by Dr. Mary L. Gilchrist. It is interesting to compare the heights and weights of the school children of Leyton in 1938 with those of 1911, and also with the figures published in 1927 by the Anthropometric Committee (appointed by the Board of Education) giving an average height and weight for each age group for the whole of England and Wales. It is rather difficult to compare the " entrants " age group of 1938 with 1911 as, though the majority of the childern are between 5 and 6 years of age, there are some in the 1938 group who are between 6 and 7 years and a very few between 7 and 8. If children miss, through absence, their entrance examination they are included in the next year's group so that the figures are slightly higher than they might otherwise be. For the sake of comparison two figures have therefore been given for the 1911 "entrants." TABLE I. ENTRANTS. Groups. Height (inches). Weight (pounds). Boys. Girls. Boys. Girls. Leyton—1911. Ages 5—6 years 40.6 40.75 34.3 37.2 6-7 42.6 42.7 40.5 39.9 1927. Anthropometric Committee. 6½ to 6½ years 43.0 42.8 41.3 40.1 Leyton—1938. Entrants 43.0 42.8 44.3 43.0 It can be seen from Table I that the claim which has been made in other areas that the children of to-day are taller and heavier when they enter school than they were when the school medical services began is justified in Leyton also. There is no significant difference between the 1927 figures and Leyton's 1938 figures for height, but the Leyton weights are better in the case of both boys and girls. 123 Unfortunately the Leyton " intermediate " group for 1911 is a year younger than that assessed to-day, so it was possible only to give the figures for the country as a whole and for Leyton in 1938 in Table II. TABLE II. INTERMEDIATES. Group. Height (inches). Weight (pounds). Boys. Girls. Boys. Girls. Leyton—1938. 8 to 9 years 49.8 49.5 59.2 57.2 Anthropometric Committee— 1927. 8 to 9 years 49.2 48.9 54.8 52.6 This table also shows an improvement over the averages for 1927. The most striking gains are, however, recorded in the " Leaver " group, as is shown in Table III. TABLE III. LEAVERS. Group. Height (inches). Weight (pounds). Boys. Girls. Boys. Girls. Leyton—1911. 13—14 years 56.5 57.9 77.9 81.5 Anthropometic Committee-1927 12½—13½ years 56.2 56.9 76.5 79.0 13½—14½ 58.0 58.9 86.1 88.2 Leyton—1938. 12 9/12—13 11/12 59.0 59.9 93.4 95.6 The ages are not strictly comparable, but there is no doubt about the increase in height and weight in both the boys and girls. It could be said that the Leyton schoolboy of to-day leaves his school 2.5 inches taller and 15.5 pounds heavier than he did in 1911. The girls show a gain only slightly less ; 2 inches taller and 14.1 pounds heavier. 124 This gain in height and weight, particularly in the leaving age group, has been noted all over the country and in other parts of the world as well—in the Dominions, in America and on the Continent. It would seem, therefore, that the Anthropometric Committee's figures are out of date and the time has come to revise them. In considering these figures it is well to remember that they are only averages which means that they are compounded of the best and the worst in each group. If we wanted a picture of the best, these figures would not give it. The range in weight of the leaver group was from 61 to 165 pounds, and in height from 49 to 69 inches, but the children who had the most pleasing as well as the best nutrition were about 60 to 62 inches in height and 100 to 110 pounds in weight. The exceptionally tall or heavy were by no means the best. Of course this is purely a matter of opinion, as what is the best in the assessment of nutrition differs with every observer ; so these figures must be taken only as showing the progress made in Leyton over a period and do not suggest that we have reached the peak of nutrition for our school children. To raise those who are below the average up to the average is the work which has now to be done, and the knowledge which nutritional science now can give us may help the school medical service in that task. 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. 125 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 4,108 children attended the clinic, and 18,510 attendances were registered. 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. 1934 2,223 10,724 1935 2,453 12,144 1936 2,820 13,937 1937 3,577 14,673 1938 4,108 18,510 Defects Treated During 1938. Ringworm of scalp 2 Ringworm of body 23 Scabies 66 Impetigo 164 Other skin conditions 479 Blepharitis 97 Conjunctivitis 92 Keratitis 5 Corneal opacities 2 Carried forward 928 126 Brought forward 928 Defective vision 109 Squint 14 Other eye conditions 211 Defective hearing 25 Otitis media 114 Other ear diseases 187 Chronic tonsilitis 125 Adenoids 22 Chronic tonsilitis and adenoids 45 Other throat conditions 206 Enlarged cervical glands 104 Organic heart disease 26 Functional heart disease 17 Malnutrition 307 Uncleanliness—Head 343 Anaemia 118 Bronchitis 154 Tuberculosis—Bones 4 „ Glands 8 „ Other forms 1 Other non-tuberculous diseases of lungs 57 Epilepsy 6 Chorea 25 Other nervous diseases 101 Rickets 1 Spinal Curvature 4 Other deformities 192 Rheumatism 90 Debility 918 Defective speech 9 Miscellaneous (minor injuries, septic sores, etc.) 1,503 5,976 127 Investigation into the Incidence of Hypochromic Anaemia in Pale Children. I. Report by Dr. Henderson. The diagnosis of " anaemia " is often made solely by clinical examination. In view of the fact that in urban areas a large number of pale children are seen at routine medical inspections and at minor ailment clinics, it was decided to estimate the blood haemoglobin of all pale children who attended the Leyton school minor ailments clinics. Unfortunately, as this investigation proceeded, it was found impossible, from lack of time, to make blood tests of all the pale children attending the Leyton minor ailments clinics. Some 528 children were tested. It must be made clear that the children tested were specially selected on account of the pallor of their skin and mucous membranes and that most of them suffered from some physical defect. It is reasonable to assume that the incidence of anaemia in this specially selected group of children is substantially higher than in the Leyton elementary school population as a whole. Blood was obtained from the thumb, and Sahli's Hæmoglobinometer was used. The number of children tested, the defects from which they suffered, and the percentage of haemoglobin present in each child's blood are shown in the following table:— Defect. Haemoglobin per cent. 70-74 75-79 80-84 85-89 90-95 95 & over. Totals. " Anaemia " 4 3 22 23 28 54 134 Debility 3 13 29 21 32 68 166 Undernourished 5 8 17 17 17 39 103 Boils — — 3 1 1 3 8 Styes — 2 1 3 9 12 27 Blepharitis — — 2 4 1 9 16 Sores — — 11 8 9 30 58 Gingivitis — — — 1 — 3 4 Muscular pains — 1 — 1 — 10 12 Totals 12 27 85 79 97 228 528 2.3% 5.1% 16.1% 15% 18.3% 43.1% Of the 528 children tested, 124 (23.5 per cent.) had a blood haemoglobin level of less than 85 per cent. whilst only 39 (7.4 per cent.) had a blood haemoglobin level of less than 80 per cent. It 128 would appear that, in Leyton, the incidence of hypochromic anaemia in elementary school children is low. It is interesting to note that of the 134 children sent to the school clinics by parents, teachers and school medical inspectors on account of " anaemia," only 7 (5 per cent.) had a haemoglobin level of less than 80 per cent. and only 29 (21.6 per cent.) had a haemoglobin level of less than 85 per cent. The highest incidence of anaemia in this specially selected group of children was found in undernourished children. But even in the case of the 103 undernourished children tested, only 30 (29 per cent.) had a haemoglobin level of less than 85 per cent. and only 13 (12 per cent.) had a haemoglobin level of less than 80 per cent. Of the 166 " debilitated " children tested, 45 (27 per cent.) had a haemoglobin level of less than 85 per cent. and 16 (9.6 per cent.) had less than 80 per cent. of haemoglobin. Children whose haemoglobin level was below 85 per cent. was given iron and ammonium citrate in doses of 30-90 grains daily (according to age). This method of treatment gave such quick and satisfying results that, despite the low incidence of hypochromic anaemia found in this investigation, it is considered that a haemoglobin estimation should be almost a routine procedure in school medical work. Summary. (1) 529 specially selected pale children had their haemoglobin estimated by Sahli's method. (2) 124 (23.5 per cent.) of them had a haemoglobin level of less than 85 per cent. (3) 39 (7.4 per cent.) had a haemoglobin level of less than 80 per cent. II. Report by Dr. Mary Gilchrist. Simultaneously with the above series of cases a similar group was being investigated, though—owing to much less time being available for clinic work—the numbers are much smaller. On the broad basis of overall percentages however, the findings are approximately the same as in the case of Dr. Henderson's series. Table II sets out the results. Although it had been agreed that a haemoglobin estimation should be done in all children with the classic appearance of " anaemia," lack of time soon narrowed the choice to those showing 129 symptoms of fatigue, listlessness, etc. This probably accounts for the higher percentage of "anaemic" children who had a low haemoglobin index in the smaller series of cases. The figures for undernutrition and debility are too few to be able to draw conclusions, and indeed it was very difficult to separate the group of "debility," "undernutrition" and "anaemia" from each other. It was surprising at times to find that a badly undernourished child, well below average height and weight, flabby and with poor muscle tone, had a haemoglobin index of over 100 per cent. In this group of cases 85 per cent, has not been taken as the lower limit of normal haemoglobin level. In my opinion 90 per cent, appears to be a more reasonable limit, since it was found that children under this level raised from 10 per cent, to 15 per cent, by the administration of iron and ammonium citrate. If it is possible in from three to six weeks to raise a haemoglobin level by this amount, then one is entitled to suggest that the original level was below normal. Only a few children were unable to take the iron tonic. Table II. Defect. Haemoglobin percentage. 70— 75— 80— 85— 90— 95— 100— Total. "Anaemia" 3 9 10 13 15 10 19 79 Debility 1 1 1 6 7 6 11 33 Undernourished — 1 4 6 7 6 10 34 Boils — — — 1 —' 1 — 2 Styes — — — — 1 — 2 3 Blepharitis — — — — 1 — 2 3 Sores — — — 1 — — 2 3 Bronchitis — — 1 — 1 — 1 3 Anaemia and adenitis 1 — — 1 — 1 2 5 Anaemia and monorrhagia — — 2 2 — — 1 5 Muscular rheumatism — — — — — 1 1 2 Totals 5 11 18 30 32 25 51 172 2.9% 5.3% 10.4% 17.4% 18.6% 14.5% 29.6% — Table II shows in tabular form the haemoglobin level of 172 children in the smaller series. The close agreement between Tables I and II is evident, though this does not extend to the subdivisions of "debility" and "undernutrition." 130 Table III. No. of cases Anaemia. Haemoglobin level. Under 80% Under 85% Under 90% Series I 134 7 cases. 5% 29 cases. 21.6% 52 cases. 38.8% Series II 79 12 cases. 15.2% 22 cases. 27.7% 35 cases. 44% Table III shows the number and percentage of the "anaemic" group who actually showed low haemoglobin levels. It would be interesting to compare these results with a sample table from all school children irrespective of health or appearance so that we should have an idea just what percentage of the school population as a whole suffers from hypochromic anaemia. Defective Vision.—Of the 4,082 children subjected to routine code group inspection in the schools, 293 (7.17 per cent.) were found to be suffering from some eve defect requiring treatment. Of 7,106 children referred for special inspection, 576 (8.10 per cent.) manifested some eye defect requiring treatment. The nature and incidence of such defects were:— Routine Inspections. Special Inspections. Defect or Disease. Number requiring Treatment. Observation. Number requiring | Treatment. Observation. (•) (2) (3) (4) (5) Blepharitis 33 5 100 — Conjunctivitis 14 — 92 — Keratitis — — 5 — Corneal opacities — — 2 — Other conditions 15 2 218 4 Defective Vision 203 134 143 8 Squint 28 6 16 1 Special Eye Clinic.— During the year, the Ophthalmic Surgeon had referred to him 1,003 children, who made 1,523 attendances for examination and treatment. 131 Report by the Authority's Ophthalmic Surgeon (J. D. Magor Cardell, M.B., B.S., F.R.C.S.). The following list shows the ophthalmic defects found in the 1,003 children examined at the Special Eye Clinic. Myopia 153 Myopic astigmatism 118 Hypermetropia 120 Hyper astigmatism 281 Mixed astigmatism 69 Hypermetropia with squint 81 Myopia with squint 3 Squint only 17 Anisometropia 2 No defect 14 Spasm of accommodation 128 Various diseases 60 Referred to Minor Ailments Clinic 22 1,068 "Various diseases" included:— Epicanthus 4 Epiphora 10 Dacryocystitis 1 Foreign body 4 Injury to Eye 3 Meibomean cyst 1 Migraine 16 Nystagmus 2 Photophobia 1 Ptosis 5 Phylctenular ophthalmia 13 60 It has been possible, by having additional sessions, to examine more children in the special Eye Clin'c than last year. 132 The incidence of myopia (3.2 per cent, of the school population) is higher than in former years. This figure has been slightly increasing during the last 12 years I have been in charge of the clinic, but has not reached the point when special notice should be taken of it. It is hardly necessary to stress in this connection the importance of posture in reading and writing. Though not a direct cause of myopia, a bad reading or writing position cannot fail to have an evil influence in subjects prone to myopia or to progressive myopia. The report of the Board of Education recently published gives prominence to the establishment of a Squint Clinic at Leyton. As a result of the assistance given to me by the Orthoptic training which it makes available, I am able to operate on squinting children at an earlier age. Self-conscious children thus suffer less at the hands of their fellows and there is a greater possibility of obtaining stereoscopic vision. I wish to acknowledge the great assistance given to me by the Authority's Orthoptist, Miss Montague Smith, whose report is appended. Squint Clinic. 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 109 Number of attendances made 1,160 Observation cases—no detectable squint 3 Left district 14 Refused or discontinued treatment 3 Treated for defective vision 17 Cured 5 Improved 5 No improvement 7 Treated for squint 41 Cured Stereoscopic vision 12 23 Cosmetic only 11 Rest from active treatment 6 Still under treatment 12 Awaiting treatment 35 133 When a case first attends the clinic, any existing defective vision (amblyopia) must first be treated by covering and/or instilling atropine into the good eye until the " lazy " eye has learnt to see normally. When the vision is equal in both eyes, the patient commences orthoptic exercises which strengthen the defective muscles and straighten the eyes by training them to super-impose their separate images into one single image. Seven of the above-named have received operative treatment in conjunction with orthoptic exercises. These exercises should be commenced before the operation in order to establish some binocular vision first. This procedure has been found to give better results than when operation has been undertaken without previous orthoptic training. Exercises are given after operation to maintain the corrected position of the eyes. School Dental Service. The number of children inspected in school by the school dental surgeons was 7,738, i.e., 63 per cent. of the number of children on the school rolls. The numbers inspected in each age group were:— Aged 3 41 4 186 5 572 6 689 7 847 8 852 9 836 10 859 11 783 12 854 13 862 14 303 15 43 16 11 In addition, the School Dental Surgeons made 1,613 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 9,351, i.e., 74 per cent, of the number of children on the school rolls. 134 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 536 290 395 212 394 64.8 Cann Hall 504 83 347 54 235 58.6 Capworth 228 501 183 396 385 66.5 Church 94 524 69 404 243 51.3 Connaught 123 381 87 251 248 73.4 Da vies Lane ... ... ... ... ... ... Downsell 493 96 363 60 253 59.8 Farmer 590 105 421 66 305 62.8 Goodall 132 557 78 348 248 58.2 Kirkdale 86 93 38 50 62 70.7 Knotts Green 115 94 84 72 94 60.2 Lea Bridge 48 36 37 25 51 63.8 Mayville 106 510 56 323 223 58.5 Newport 647 98 353 56 300 73.3 Norlington ... ... ... ... ... ... Ruckholt ... ... ... ... ... ... Sybourn ... ... ... ... ... ... St. Joseph's 130 115 105 90 101 51.7 Tom Hood 231 192 157 134 187 64.2 Trumpington 4,063 3,675 2,773 2,541 3,329 62.6 It will be seen that, of the 7,738 children inspected, only 2,424 (32 per cent.) had perfectly sound sets of teeth, while 5,314 (68 per cent.) were found to require treatment. Of the 5,314 who were offered treatment, 3,329 accepted, the percentage of acceptance of treatment being 62 per cent. The figures show that in individual schools there is a considerable difference in the response of parents to the offers of skilled dental treatment on behalf of their children. For instance, in Connaught Road School the percentage of acceptances was as high as 73.4 per cent., whereas in Church Road School it was as low as 51.3 per cent. In 210 cases (4 per cent.) the parents actually refused treatment, while in 1,775 cases (33 per cent.) the acceptance of treatment papers were not returned by the parents. 135 The following figures give some idea of the dental treatment undertaken at the dental clinics during the year:— Fillings :— Permanent teeth 5,459 Temporary teeth 219 Total 5,678 Extractions:— Permanent teeth 1,641 Temporary teeth 6,170 Total 7,811 Other operations:— Permanent teeth 782 Temporary teeth 286 Total 1,068 Administrations of general anaesthetics for extractions—1,940. Report of the School Medical Officer—January, 1938. On 6th January, 1936, the Board of Education issued to Education Authorities Circular No. 1444 entitled " Administrative Programme of Educational Development." In the part 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. In September, 1936, I submitted to the Public Health, Maternity and Child Welfare and Education Committees a special report from which I submit the following extracts dealing with dental treatment. (Extract from Report of School Medical Officer—September, 1936). Board of Education Circular 1444 states : " 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 anunal 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 childern in an urban area and 4,000 children " in a rural area, although this is insufficient where a high percentage 136 " of parents accept 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. I recommend that the Local Education Authority appoint an additional Dental Surgeon and Dental Assistant; and that arrangements be made for an additional Dental Surgery. After consideration of the above your Committee requested a further report indicating the cost of appointing an additional Dental Surgeon and Dental Assistant and providing and equiping an additional dental surgery. Report of School Medical Officer—February, 1938. The School Dental Service forms part of the School Medical Service, but it is recognised that the dental service is a specialised branch. Although it is administered by the School Medical Officer and is closely associated with the work of the school medical officers, the members of the medical staff are not qualified dental surgeons. Under the circumstances your medical officers cannot be regarded as qualified judges of the actual quality of the dental work performed, nor are they in a position to dictate as to the nature of the methods to be employed in the work of dental surgery. Efficient supervision and control of dental work can be exercised only by a dental surgeon who is conversant with modern methods. Whenever two or more dental surgeons are employed by a Local Authority, it is customary for one to be designated as Senior Dental Surgeon. I therefore recommend that, when dealing with the question of increasing the dental staff, consideration should be given to appointing a Senior Dental Surgeon who will be responsible to the Medical Officer of Health and School Medical Officer for the supervision and control of all dental work undertaken by your Council. 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 also allow of certain sanitary and acoustic improvements which experience has shown to be necessary in the existing premises. By carrying the right flank wall out a distance of four feet provision could be made for an additional dental surgery. This would enable the two dental surgeons to make use of the same recovery room (extended) for 137 patients, the same waiting room for interviewing parents, and the services of the same record clerk. In addition, it would provide sanitary accommodation next to the waiting room—a very necessary improvement, and provide double walls as shown with the object of making the walls more sound proof. A further improvement embodied in the proposed plan is that the whole dental annexe will be separated from the rest of the building. Your Education Authority thereupon decided that, subject to approval of the Board of Education, arrangements be made as follows :— (1) Appointment of an additional Dentist to be designated Senior Dental Surgeon. (2) Appointment of an additional School Nurse to act as Dental Assistant. (3) Provision of an additional Dental Surgery by altering the existing premises at Park House Clinic. The Board of Education approved items 1 and 3, but suggested the appointment of a full time Dental Attendant instead of a School Nurse as recommended in item 2. As the Board was definitely opposed to the employment of a School Nurse as Dental Attendant your Education Authority decided to appoint an unqualified Dental Attendant. In September Mr. A. E. Hall, L.D.S., was appointed as Senior Dental Surgeon and commenced duty on 14th November, 1938. Report by the Authority's Senior Dental Surgeon. Development. Good progress has been made during 1938 in the development of the School Dental Service in Leyton by the opening of a new Dental Surgery at Park House Health Clinic, and by the appointment of a Senior Dental Officer and Dental Attendant, bringing the numerical strength of the staff up to : The Senior Dental Officer, two full-time School Dental Officers, two Dental Nurses and one Dental Attendant. With a school population, including Secondary Schools, of 13,240, this gives one dental officer to 4,413 children, thus more nearly approaching the conditions of a satisfactory dental scheme as laid down by the Board of Education. Factors likely to upset this ratio in the future are the raising of the school leaving age, and an increase in the percentage rates of acceptances for treatment. 138 As the new surgery was not opened until mid-November, the working time has been too short to be of much benefit to the dental service as a whole during the year under review. Inspection. In future it should be possible to inspect and treat all children needing treatment in the schools of the Borough within a period of twelve months, instead of an average period of 16.85 months (vide Borough of Leyton Health Report, 1937). This in itself is very important, as the defects accumulating over a period of 16.85 months require longer to treat, and consequently the interval between inspections tends to increase. As little as possible of the educational time of the child is taken up at inspection. A very thorough examination of the mouth is necessary only in the apparently sound mouths. Those obviously needing treatment are more thoroughly examined at the time of treatment. Larger numbers can therefore be dealt with at an inspection session. Secondary Schools. An interesting development of the service is the routine inspection and treatment of Secondary School children, some of whom have not received any treatment for periods up to five years. The Leyton County High School for Girls, and also that for Boys, were inspected late in the year, and treatment had only just begun during the period covered by this report. The percentage of children requiring treatment was found to be 87.08 per cent, in the girl's school, and 85.55 per cent, in the boys' (comparative figure for the elementary schools of the Borough being 68 per cent.). These high percentages, however, do not tell the whole story. Many of the children were found to require as many as six permanent fillings, and one or two permanent extractions. A few individual cases need even more work than this. Very clear evidence is thus afforded of the need for regular and continuous attention to the adolescent. A real service has been done for the local community by including these secondary school pupils in the School Dental Scheme as much of the work done in the past by the Authority's Dental Officers for these children was rapidly being wasted. 139 At the end of the year 1938 the acceptance rate at the Boy's school was found to be 50 per cent., and that at the Girl's school 58.8 per cent. These are not final figures, however, as small numbers of acceptances were still being received at the end of the year. Orthodontics. Many of the comparatively simple cases of irregularity are dealt with at the treatment centres, i.e., cases not needing the manufacture of appliances. Judicious extraction in many cases cures or improves the condition. Long cases needing appliances are referred to dental hospitals for treatment, X-ray photographs being sometimes necessary to determine the presence or absence of permanent tooth germs, dilacerated roots, or other conditions likely to interfere with successful treatment. I should like to see such work done in the clinics when all arrears of treatment have been overtaken, as the need for it seems to be increasing amongst school children, who are finding it increasingly difficult to accommodate a full dentition in correct occlusion, in part, no doubt, due to lack of hard foods needing much chewing, and the full use of the muscles of mastication. Maternity and Child Welfare. Dental treatment of mothers and children attending Infant Welfare Clinics is now carried out at Park House and Leyton Green Clinics. All cases referred by the Medical Officers are treated and the mothers encouraged to bring their young ones along for regular inspection and advice. Even should no treatment be necessary, such visits have much value in influencing future acceptances and making friends with the children. Treatment. During the year the main items of operative work were as follows:— Fillings—Permanent teeth 5,459 Temporary teeth 219 Total 5,678 Extractions—Permanent teeth 1,641 Temporary teeth 6,170 Total 7,811 140 Other operations—Permanent teeth 782 Temporary teeth 2S6 Total 1,068 Administrations of a general anaesthetic 1,940 Administrations of a local anaesthetic 2,226 Total 4,166 Too much stress cannot be laid upon the fact that anaesthetics are used as a routine method whenever the operative procedures are of such a nature that any unpleasant recollection might remain in a child's mind, and be connected with its clinic visits. The number of casual cases seen at the dental clinics has again reached the high figure of 1,614. This number, however, should fall as the time between successive dental inspections decreases, and when the 1937 scheme of restriction of casual treatment has had longer to make itself felt. An endeavour is now being made to treat these cases without in any way interfering with the routine treatment of children, whose parents appreciate conservative dentistry, by seeing them on any school morning of the week, thus spreading the numbers and causing less delay on any one morning. It must readily be seen that an odd, and infrequent visit to have an aching tooth extracted is a waste of public money, and defeats the declared objects of the school dental service, viz., 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. It will be seen that some such method of selection is thoroughly in agreement with official opinion by reference to the 1937 report of the Chief Medical Officer of the Board of Education, page 115, where he states that selection is necessary to ensure that the resources of the service are utilised to the best advantage, e.g., by " exclusion from the scheme of certain schools, age groups, or children whose parents have refused to allow them to receive treatment." While on the subject of the 1937 report of the Chief Medical Officer of the Board of Education, it might be of interest to note his remarks on page 117, where he states:— "Much education in dental matters is carried out which "may be described as direct education. Indirectly, however, 141 " appreciation of the school dental service can be increased in " various ways, for example, by the provision of bright, up-to" date premises and the installation of equipment, the appear" ance of which suggests the excellence of the treatment given." I would suggest that in Leyton our dental surgeries are well able to claim a place in the front rank in these respects. Orthopaedic Clinic. The following figures show the number of school children examined and treated during the last five years. Examinations. 1934 1935 1936 1937 1938 Primary examinations 115 105 99 89 112 Re-examinations 298 249 230 236 249 Treatment. 1934 1935 1936 1937 1938 Number of children who attended for 189 231 257 209 255 Attendances made 1,199 2,109 2,188 1,832 1,413 It will be seen that, during 1938, some 361 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 112 Re-examinations 249 The findings at the primary examinations were as follows:— Deformities—Bones and Joints. (a) Congenital. Cervical Rib 5 Scoliosis 2 Abnormal cervical spine 1 142 (b) Acquired— Deformities digits (hand) 3 „ ,, (foot) 8 Hallux valgus 8 Bowed tibiae 1 Injury metatarsals 2 Genu valgum 8 Injury—knee 2 Hallux rigidus 3 Exostosis rigidus (foot) 8 Old T.B. knee 1 Schlatter's disease (R. and L.) 1 Epiphysitis metatarsal 1 Periostitis metatarsal 1 Fracture—clavicle 1 ,, radius 1 „ radius and ulna 1 ,, patella 1 Dislocation—Elbow joint 2 Muscular. (a) Congenital. Talipes, R. and L. 1 Elephantiasis hand 1 (b) Acquired. Scoliosis kypho—scoliosis 1 Kyphosis—winged scapulae 1 Pes cavus 1 Pes piano valgus 44 Injury—ankle 4 ,, wrist 1 Paralysis. (a) Congenital Spastic hemiplegia 1 (b) Acquired. Anterior poliomyelitis 5 Pseudo hypertrophic paralysis 1 Also— Bursitis os calcis 2 Ganglion wrist 2 Synovitis knee, R. and L. 1 Treatment. Number of school children who attended for treatment 225 Number of attendances for treatment 1,413 143 Admission to Hospital and Operations. During the year eight children were admitted to hospital and the following surgical operations were performed. Removal Cyst—thenar eminance 1 Manipulation foot, R. and L. 1 Removal Ganglion—wrist 1 ,, of F.B. (Bone)—knee 1 Tenotomy—Hammer toe, R. and L. 1 Plaster bed (for scoliosis) 1 Observation—hip joint 1 Arthrodesis (scaphoid astragalus) 1 Tenotomy tendo Achillis and plaster 1 Surgical Appliances. The following have been supplied:— Leg iron 1 Caliper splint (leg) 1 Surgical boots 3 single Wedges, valgus pads, stiffening boots 1 pair & 1 single Minor alterations to ordinary boots 124 pairs Alterations and repairs to surgical boots, splints and appliances 7 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 1938 there was a marked increase in the work of the clinic. Both the number of patients treated and the total attendances exceeded the highest total of any previous year. The following table gives this information:— No. of Cases. No. of New Cases. Attendances. 1934 87 40 2,151 1935 110 74 3,310 1936 222 142 5,674 1937 263 177 5,519 1938 337 222 6,783 144 More than half of the 337 patients treated first started treatment in the months October-December, 1938. As they had not completed a full course of treatment before the end of the year, their response to treatment will not now be commented on. Some 20 children failed to complete a full course of treatment. Of the 137 children who were re-examined after having at least three months' treatment, 103 (75 per cent.) had either improved or were cured, 31 (23 per cent.) derived no benefit from treatment, and 3 (2 per cent.) were worse. The following table shows these results : Cured. Improved. Stationary. Worse. Total. Colds ... 6 5 10 — 21 Bronchitis 3 16 5 — 24 Nervous Children — 2 1 — 3 Debility 11 12 4 — 27 Undernourished — 3 2 2 7 Styes 12 3 3 — 18 Boils and sores 11 3 — — 14 Rheumatism 9 4 1 — 14 Enlarged glands 2 1 2 — 5 Asthma — — 3 1 4 Total 54 49 31 3 137 Aural Clinic. The following is an abstract from a report submitted by your School Medical Officer to the Local Education Authority in January, 1938 :— 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 acu,te stage middle ear disease often endangers life ; in the chronic stage it may cause deafness or lifelong invalidity and disability. 145 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 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. I recommend:— 1. That the Local Sanitary Authority appoint a Consultant Aural Surgeon to be available for consultations and emergency surgical operations at Leyton Isolation Hospital as required; 2. That the Maternity and Child Welfare and Education Authorities establish a special Aural Clinic—to be held once a month in the first place and more frequently if found necessary—where the Aural Surgeon could examine and advise as to the treatment of children referred by the medical staff of the Authorities concerned, and that arrangements be made with a neighbouring hospital for the admission and treatment of children referred for such residential treatment by the surgeon in charge of the Aural Clinic. After consideration of the above report the Council resolved :— " That subject to the approval of the Board of Education, an aural clinic be established in the existing premises, and that a part-time Aural Consultant be engaged for a minimum of one session per month." The suggested arrangement was approved by the Board of Education and the Council appointed Mr. Cyril Ratcliffe Sandiford, M.D., M.B., B.Ch., F.R.C.S., as part-time Aural Consultant. 146 The first session was held at Park House Clinic on 4th July, 1938, and during the six months ended 31st December, 1938, the Aural Surgeon had referred to him 89 children who made 169 attendances for examination and treatment. In December, 1938, I reported to the Education Authority that, with the rapidly accumulating number of old cases attending for re-inspection and treatment plus the new cases on the waiting list, it was becoming impossible to provide the necessary treatment for all children in need of it and that in addition many children requiring special forms of treatment, such as ionisation, should attend at least once a fortnight. The Authority accepted my suggestion that the Aural Clinic be held fortnightly instead of monthly and approval of the Board of Education was sought to this new arrangement. Report by the Aural Consultant (Mr. C. R. Sandiford, F.R.C.S.). The inauguration of a special clinic for the treatment of diseases of ear, nose and throat has disclosed a fact already well known— the widespread incidence of and disability from these diseased conditions in a Borough such as Leyton. The following list gives particulars regarding the 89 children examined and treated at the Aural Clinic. 147 AURAL CLINIC. School Cases. Nature of Disease. Still under treatment. Recommended Hospital treatment. Recommended Special School. Discharged as cured. Discharged as improved. Discharged as no treatment required Discharged as left district. Discharged as left school. Totals. (i) Acute Suppurative Otitis Media 1 — — 2 — — — — 3 (ii) „ Catarrhal „ „ 1 — — 1 — — — — 2 (iii) Chronic Suppurative Otitis Media due to:— 1. Tympanic Sepsis 2 — — 1 — — — — 3 2. ,, „ and Granulations 2 — — — — — — 1 3 3. „ „ and Polypi — — — — — — — — — 4. „ „ and previous Mastoid Operation 2 — — — — — — — 2 5. Other Causes 2 — — 1 — — — — 3 (iv) Mastoid Disease (previous operation) 1 1 — — — — — — 2 (v) Partial Deafness due to:— 1. Nerve Deafness 2 — — — — 1 — 3 2. Tonsils and Adenoids 2 — — 2 — — — — 4 3. Retraction of Membrana Tpmyani — — — — — — — — — 4. Scarring 3 — — 2 — — — — 5 5. Catarrhal Rhinitis — — — 2 — — — — 2 6. Wax 1 — — — — — — — 1 7. Other Causes 2 — — 1 — — — — 3 (vi) Nasal Cases:— 1. Hypertrophic Rhinitis 3 — — 2 — — — — 5 2. Sinusitis — — — — — — — — — 3. Atrophic Rhinitis 1 — — — — — — — 1 4. Deviated Septum 6 — — — — — — — 6 5. Foreign Body 2 — — — — — — — 2 6. Polypus — — — — 1 — — — 1 (vii) Tonsils and Adenoids — 14 — 5 — — 1 — 20 (viii) Other Diseases or Defects 13 — — 5 — — — — 18 Totals 46 15 — 24 1 1 1 1 89 148 Attention should be drawn to the common incidence of nasal and catarrhal diseases, sinus infections, badly infected discharging ears, and disabilities of the hay-fever type. It is hoped that as time goes on there will be a clearing-up of these common infections, leaving the clinic more time to devote to the earlier treatment of acute conditions and thereby preventing the development of chronic disease. Arrangements have been made for the examination and supervision at the clinic of children who have had aural or nasal complications while in-patients of your Isolation Hospital in order to provide the necessary treatment for the relapses to which such children are prone. More extensive accommodation is required for the hospital treatment of children requiring surgical operations for unhealthy tonsils and adenoids, and it is hoped that soon a scheme may be evolved whereby such cases can be dealt with in the Borough by arrangement with your Medical Officer of Health. Heart Clinic. In January, 1936, the Board of Education issued a Circular (No. 1444) which stated :— " There is need for increased provision for the special institutional treatment of children suffering or convalescent from acute rheumatism, since this condition, if not suitably treated, may lead to heart disease. This problem is an important one." In December, 1936, I submitted (with your Director of Education) a Joint Report on Circular 1444 from which the following is an extract:— " It is felt that a rheumatic clinic, with a visiting specialist, would do much to provide early detection and treatment of the disease and so reduce the need for institutional treatment of children who, under present conditions, often suffer serious and permanent damage before institutional treatment becomes an obvious necessity. We suggest that the Authority revives its previous proposals for a Rheumatic Clinic for school children." 149 The Education Authority took no action at that time ; but in January, 1938, the question was again considered and the Education Authority agreed to the establishment of a Heart Clinic subject to the approval of the Board of Education. In May, 1938, the Board approved in principle the Authority's proposal to establish a Heart Clinic; and the Education Authority appointed Dr. Alfred Claude Mitchell Elman,'M.D., M.B., B.S., M.R.C.P., M.R.C.S., L.R.C.P., to attend once monthly. The first session was held at Leyton Green Clinic on 25th June, 1938. During the six months ended 31st December, 33 children made 66 attendances. Dr. Elman submits the following observations. Report by Physician in Charge of Heart Clinic (Dr. A. C. Elman). The Leyton Heart Clinic was opened on 25th June, 1938, and cases are seen monthly. From the date of inception until 31st December, 1938, I have examined 33 new cases of whom 17 were boys and 16 girls. In all, 66 attendances have been made, this figure including new cases and " re-inspections." I have classified the cases into the following groups:— Normal 7 Congenital Morbus Cordis 3 Mitral Regurgitation 12 Mitral Stenosis 3 Doubtful 8 It can be seen that the largest number of cases are classified as having Mitral Regurgitation. It has been my experience that such cases may gradually develop the more serious lesion Mitral Stenosis, and observation of these cases over a long period is essential. The cases described as "Doubtful" include children suffering from tachycardia, extra systoles, slight changes in the heart sounds, etc.—most of which I expect to become normal in the course of time. 150 I have been greatly helped in this work by the invaluable advice of Dr. Forrest and Dr. Henderson, and have made use of such facilities as haemoglobin estimations and medicines. For special investigations outside the scope of the Clinic I have transferred special cases to hospital (temporarily). It is, of course, too early to estimate the results of the work, but I am convinced that many cases will improve and children who might develop serious cardiac conditions may be prevented from so doing. Finally, may I express my thanks to the nursing staff for their most active co-operation in this work. PHYSICALLY AND MENTALLY DEFECTIVE CHILDREN. Mentally Defective Children : Statutory Medical Examinations. During the year, some 80 children were referred for statutory medical examination. As the result of examination these 80 children were classified as follows:— Idiots 0 Imbeciles 3 Moral defectives 0 On attaining 16 years of age—for supervision under the M.D. (Notification of Children) Regulations 9 Certified to Local Education Authority as feebleminded 12 Remained under certificate 9 Certificate withdrawn 2 Dull and backward 22 Backward 4 Borderline cases—to be re-assessed in six months 18 Normal 1 80 Knotts Green Special School for Mental Defectives. Admitted 8 Discharged 15 On roll at end of year 68 151 Eight children, certified to the Local Education Authority as feeble-minded, were admitted to Knotts Green Special School during the year and four children were admitted to Residential Schools for Mental Defectives. Of the 15 children whose names were removed from the roll, 9 reached the statutory leaving age of 16 years and were notified to the Local Control Authority for supervision in accordance with the Mental Deficiency (Notification of Children) Regulations ; 1 was allowed to leave on withdrawal of certificate of mental deficiency, 2 removed from the district, 2 transferred to Residential Special Schools and one was notified to the Local Control Authority as an imbecile. Physically Defective Children. Knotts Green Open Air School. Accommodation is provided for 150 physically defective children. Admitted during the year 55 Discharged 55 „ —on withdrawal of certificates 33 „ —on removal from district 17 „ —on reaching statutory leaving age 4 ,, —admitted to Residential Schools 1 On roll at end of year 171 Report by Dr. Henderson—Deputy School Medical Officer. Some 162 children were examined on two or more occasions during 1938. Of that number, 142 (87 per cent.) children improved in health, 16 (10 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 two previous years, and to compare the results of treatment in these three years with the results of former years. The following table gives this information Percentage of Children. 1933 1934 1935 1936 1937 1938 Improved 59 68.6 75.5 86.2 85 87 Stationary 36.3 26.1 18.3 8.8 12 10 Worse 4.5 3.2 6.1 4.8 3 3 152 During the past three years there has been a steady increase in the number of under-nourished children attending the Open Air School. In 1938 some 68 under-nourished children attended the school, compared with 54 in 1937, and 19 in 1936. With the exception of the group of under-nourished children, the number of children in the various disease groups differed, but little from the corresponding figures for the year 1937. 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 21 20 1 — Undernourished 68 62 4 2 Bronchitis 6 5 1 — Bronchietasis and 6 5 1 — Pulmonary Fibrosis Asthma 6 4 1 1 Tuberculous Adenitis 5 5 — — Rheumatic Carditis 21 16 4 1 Congenital Heart Disease 2 2 — — Crippled Children 27 23 4 — Totals 162 142 16 4 Under-nourished and delicate children did well at the school. Two of the undernourished children became worse, and were transferred to a residential open-air school. Children with rheumatic heart disease did surprisingly well at the Open Air School. Care was taken in the selection, but, even so, one child after admission to the School became worse, and was transferred to a Heart Home. One of the asthmatic children became definitely worse in his general health, and his asthmatic attacks increased in frequency. He was 10 years old, and weighed only 38 lbs. when last examined. He regularly attended one of the London hospitals, but, unfortunately, derived no benefit from the hospital treatment. He was six months in a convalescent home, and was 14 months in a residential school at Ventnor ; and in neither institution did his health improve. Such a case is rare, and the great majority of children attending the Open Air School have less serious defects and do very well. Defective Children. Blind and Partially Blind Children. Two children were admitted to White Oak Residential Ophthalmic School, and two were discharged. 153 Responsibility was taken over from Walthamstow Education Authority for the education of two children at the Wood Street, Myope School, E.17, upon the removal of the parents into this area ; and two children left this school on attaining the statutory leaving age of 16 years. Responsibility was taken over from the London County Council for the education of a child at a day partially-sighted school on the removal of the parents into this area. Deaf and Dumb Children. Two children were admitted to a residential special school for deaf and dumb children. Two children were admitted to a day special school for deaf and dumb children. Responsibility for the cost of the education of a child at a day deaf school ceased on the removal of the parents from the area. Child Guidance. During the year 8 children have been referred to the Child Guidance Clinic, and the reports received from the Medical Director have been most helpful in assisting me to decide on the future treatment and care of these children. Convalescent Home Treatment. During the year under review the Education Committee accepted responsibility for the cost of maintenance and treatment of 50 children in convalescent homes, heart homes or open air schools recognised by the Board of Education. In addition, 24 children attending Leyton schools were sent away for varying periods through the agency of the Tuberculosis Care Association and 87 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. 154 Average cost per child. Average rate cost per child. £ s. d. £ s. d. (1) Cost in Leyton Elementary Schools (based on average attendance) 21 10 4 11 2 10 (2) Blind Children— (1) In Special Day School (a) 20 0 0 20 0 0 (2) In Special Residential School (a) 80 0 0 40 0 0 (3) In Residential Ophthalmic School (a) 168 0 0 100 0 0 (3) Deaf Children— (1) In Special Day School (a) 15 0 0 15 0 0 25 0 0 25 0 0 (2) In Special Residential School (a) 75 0 0 37 10 0 (4) Other Defective Children— (1) In Knotts Green Special School (b) 42 8 8 21 4 4 (2) Mentally Defective Child in Residential Institution (a) 70 0 0 35 0 0 61 0 0 30 10 0 (3) In Epileptic Colony (a) 74 0 0 37 0 0 (4) Residential Orthopaedic Treatment (a) 146 0 0 73 0 0 (5) Residential P.D. School Treatment (a) 91 0 0 45 10 0 78 0 0 39 0 0 (6) Residential O.A. 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. (6) 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. 155 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. In the Junior, Senior and Central Schools the time allotted to Physical Training includes physical exercises, organised games, swimming and dancing. Physical Exercises. The Board of Education's 1933 Syllabus of Physical Training is followed, in its simplest form in Nursery Classes, and in its full form in Infants' Schools, with the addition of musical work, in both cases ; and in Junior Schools and in Senior Schools. In certain Senior Schools, and in the Selective Central Schools, more advanced work, including exercises with portable gymnastic apparatus, is taken. The standard of work has risen during the year, in particular in the classes taken by teachers who attended the courses held during 1937. Tables of exercises are now more complete and purposeful. There are an increased number of classes in which the children come out prepared and eager for the work. Head Teachers continue to show appreciation of the importance of the work by their readiness to procure the necessary equipment and by allotting suitable time to the subject. The teachers show willingness and keenness to make full use of the opportunities provided for the physical education of their pupils. Their lessons have improved in continuity of movement, activity and precision. There is a noticeable improvement in the grasp of the aim of the work and in the response aroused in the children. All the teachers welcome and respond to the suggestions and practical help given by the Organisers. A steady improvement is noticeable in the alertness, suppleness and posture of the children, and in the happy spirit in which they co-operate in the work. In a large number of classes the children remove surplus clothing voluntarily in preparation for the lesson which is an interesting indication of the influence of the teaching. 156 Organised Games. The present facilities for organised games remain as last year, but the filling up of the Ballast Pit (Oliver Road Playing Field) is progressing and one portion will be ready for use as soon as the grass is sufficiently well grown. The available grass areas are fully used for the Field Games by both boys and girls. Swimming. The policy of making swimming a recognised subject of instruction (referred to in last year's Report) was successfully introduced for the summer season of 1938. With the exception of children exempted for medical reasons all pupils in the highest year of the Junior Schools and also those in the lowest year of the Senior and Central Schools attended the Baths for instruction in their normal school classes. Thus, children will receive a two years' course of instruction in swimming during their school course. All children above the lowest year in Senior and Central Schools continue to attend the Baths during their school careers and thus have opportunities of consolidating the instruction received during the two years' course and of acquiring a liking for swimming as a healthy recreation. The co-operation of the Baths Superintendent and Staff is much appreciated in initiating the new swimming scheme, as is the helpful attitude of Head Teachers in drafting time-tables to fit in with the swimming arrangements. An increase was experienced in the number of pupils who attended the Baths during the winter months. This seems to indicate that the new swimming scheme has increased interest in swimming. Ive Farm Gymnasium. During the year under review a fully equipped gymnasium, 70 feet by 40 feet, was opened on the Ive Farm Playing Field. The building also contains two classrooms. Ten Senior Schools, five Boys' and five Girls', each spend a weekly session there making full use of the building. The visit to the gymnasium is very popular with both teachers and children. Footwear. Plimsols have now been supplied by the Education Committee for all children in Junior, Senior and Central Schools, while replacements have been made in Infants' Schools of worn out shoes 157 The action of the Education Committee in supplying plimsols for physical training calls for special mention as being most helpful and progressive. Clothing. The Education Committee has also supplied all children in the first year of the Central and Senior Schools with complete clothing for physical training, consisting of shorts and vests for the boys and knickers and shirt for girls. Here again the action of the Committee calls for special mention. Storage. The footwear and clothing supplied to Schools calls for suitable storage. Experiments have been made, and in certain cases suitable storage cupboards have been supplied to Schools, while further experiments are in hand at the moment to meet other needs. Voluntary Organisations. The good work carried on in their own time by the teachers for the physical welfare of the children was repeated during 1938. The Leyton Schools' Sports Association again held most successful meetings, while the Schools' Football, Cricket and Netball Associations had busy and successful seasons. The September crisis interfered, unfortunately, with the Gala of the Leyton Schools' Sw.'mming Association, causing the Gala to be cancelled, but later on a modified form of gala was held in order to minimise disappointment to the children. School Camp. The tenth School Camp for children attending Leyton public elementary schools was held at Dymchurch from 17th June to 15th July. During the week prior to departure, all children were subjected to medical examination in order to ensure, as far as possible, that they were clean, free from infectious disease, and otherwise able to stand camp conditions. Some idea of the life in camp may be gained from the following extracts from reports submitted by the Heads of the Camps. 158 Girls' Camp. The Tenth Annual School Camp for Girls commenced on June 17th, 1938. As in the three previous years, the weather seemed to favour the camp, and after several weeks of indifferent weather June 17th was warm and sunny. Although there was no heat-wave, which perhaps was fortunate, the fortnight was bright and dry. One evening only was wet, although there was a considerable amount of windy weather. Again this year the girls were responsive to the combination of discipline and freedom which is the essence of camp life, and settled down with a speed which surprised those in charge. Their behaviour at all times was such that it reflected credit on the schools from which they came. This is possibly due to the fact that as much freedon as possible is allowed, and the few rules made are such which are necessary to the happiness and safety of the girls. The time is well filled with interesting and enjoyable activities so that there are few opportunities for getting into mischief. The party consisted of 280 girls, 178 of whom were camping for the first time, 79 for the second, 18 for the third and 5 for the fourth ; and 19 teachers. Of the staff, six were newcomers. The work is strenuous and tiring, but interesting and enjoyable, giving as it does unique opportunities of getting to know the girls in a way which is not offered in school. This year we were glad to welcome four mistresses from Infants' Schools. They were valuable assets to the staff. As far as possible teachers were placed in charge of girls from their own school. On the whole, health was very good. It was found necessary to have the doctor's advice for a girl who fell and hurt her elbow, another whose finger was pinched in a door, and another who developed a high temperature. Again this year minor ailments and accidents were dealt with by a member of the Camp Staff. Girls attended at the First Aid Station each morning and evening, being sent on to the Camp Hospital when necessary. For each dormitory, one ablution shed, fitted with benches, cold water and basins, was situated nearby. Each girl was obliged 159 to wash with hot water every night before retiring to bed. Each team teacher held a thorough inspection of the girls in her charge on the Saturday of the second week. The majority of the girls wore shorts and blouses, by far the most suitable wear for camp. It is unfortunate that circumstances prevent every child from possessing a mackintosh. Although in previous years the food had been very good, this year it was excellent, there being considerably more variety in diet. Sea-bathing took place on every day with two exceptions. Boys' Camp. The Tenth Leyton School Camp was held at St. Mary's Bay from the 1st to the 15th July. As formerly, the children were drawn from the Senior and Central Schools, the basis of selection being strictly on age only. Age grouping at camp was again adopted and again proved a success. School and age grouping combined was possible for several schools. It is our policy to keep the boys up until 10.30 on the first night at camp as they can then settle in fairly quickly and make a quiet night. We also find that next morning they are awake early, and this was no exception, more particularly among the first year campers who were awake and ready to get up at 5 a.m. They settled down again on learning the time, but were all up early and ready for their breakfast at 8 a.m. The Time Table was arranged as formerly on the following lines, with minor alterations to suit tide and weather:— (a) Morning School work with P.T. and swimming. (b) Afternoons Visits, walks, free exercises on beach, games, specimen gathering, swimming. (c) Evenings Walks and games. The lessons were again enjoyed as much as any part of camp life. 160 Owing to the storms of the week preceding our arrival there were many sea-shore specimens to be collected, and the collections generally this year were the most comprehensive we have had. The evenings were fully occupied with Bank, Library Books, games of football, cricket and rounders, nature rambles and indoor games. Indoor games were appreciated this year. There is nothing to report regarding conduct. Very few boys gave any trouble ; in the main they follow a tradition set up by former Leyton boys. Generally speaking the health of the boys was excellent, and all derived much benefit from camp. We had the usual small crop of stomach cases, but nothing serious. The nursing staff was very efficient. Clinic parade was held twice daily and a close watch kept on all cases needing attention. There were several minor accidents such as " hit by cricket ball," " cut finger," " cut leg," " slight cut on head by bed," " twisted foot on field " and " sprained thumb," and these were attended to at Clinic, but there was only one case needing hospital attention, and this happened on the last day at camp, a boy falling on his arm in a game. This lad was at once sent to Folkestone Hospital by staff car. In eight years at Dymchurch this was certainly the coldest and most unsettled period we have experienced, and swimming suffered. (In connection with the swimming I should like to say how much we valued the discarded mended towels lent to the needy boys through the kindness of the Chairman of the Baths Committee). A considerable portion of work had to be taken indoors this year, but we were able to carry through our full programme of work and visits without a hitch. A pleasing feature of camp this year was the fact that Knotts Green boys became part of the Leyton group. They were under their own teachers for work and visits, but much of their play-time 161 was spent with the other Leyton boys, and they formed part of a full Leyton section in the dining hall. Further collaboration for visits might profitably take place. Knotts Green Special School—Girls' Camp. Nineteen girls with two teachers camped at New Romney from June 17th to July 1st. For the fortnight the weather was good. The splendid mackintoshes settled the weather problem. The food, which was plentiful, was much enjoyed by all. Sea bathing, swimming and paddling were thoroughly enjoyed. The seashore and lanes afforded happy hunting for collections of sea creatures and wild flowers. Sheep-shearing greatly interested the girls. Knotts Green Special School—Boys' Camp. The Boys' Party, consisting of 24 boys and 2 masters, stayed during the second fortnight of the Leyton Schools' Camp period at Dymchurch. The importance of Hygiene was stressed and a high standard of cleanliness and neatness was maintained throughout the Camp period. The personal appearance, kit and bedding of each child was inspected daily and team marks were given for the best efforts. The weather was unsettled and too cold for much sea bathing, consequently arrangements were made for the boys to have warm baths. We were unable to air the beds and blankets out in the sun more than once. The waterproof capes which had been provided by the Committee, enabled us to adhere to our programme and the anxiety of having to deal with damp clothes was avoided. There were two clinic parades daily and no accidents to report. Midday rest is an important part of the Open Air School curriculum and the boys continued the practice of resting for one hour daily while at Camp. REPORT BY BOARD OF EDUCATION ON LEYTON SCHOOL MEDICAL SERVICE—JULY 1938 I am directed to state that the Board have had under consideration a report made by one of their Medical Officers, after his recent visit of inspection to the Authority's area and they are 162 glad to learn that the School Medical Service is efficiently administered and generally comprehensive. The Board also note with satisfaction that the medical staff are taking a particular interest in the scientific investigation of cases of anaemia and debility and have also assisted in the drawing up of a dietary for the provision of free meals which is based on modern research work. I am to invite the Authority's attention to the following observations and suggestions. " (i) With the object of securing improved co-operation between the School Medical Service and the Public Health Services, it would be of advantage if the School Nurses were also Health Visitors and devoted part of their time to each service. The Authority might well bear this point in mind in making future appointments to the nursing staff. " (ii) Arrangements should be made for the retention in hospital, for at least one night, of children who have had tonsil and adenoid operations. " (iii) It seems probable that some increase in the medical staff would be needed to carry out inspection and treatment work for secondary school children. " (iv) It would probably be more satisfactory for the routine inspection cards to be kept at the school clinics instead of at the schools. " (v) It is desirable to make provision for the treatment of speech defects." The Board would be glad to receive the Authority's observations on the above matters in due course. Observations by the School Medical Officer and Medical Officer of Health—August 1938. (i) Co-ordination of Duties. During 1930, when the Council had under consideration the appointment of School Nurses, I suggested that—in order to avoid much unnecessary visiting and duplication of effort—nurses with health visitors' qualifications should be appointed. 163 Extract from Report by Medical Officer of Health to Maternity and Child Welfare Committee—February 1935. The problems connected with health and the arrangements for dealing with disease are essentially the same whether we happen to be dealing with a pre-school or a school child ; and each child carries its health or infirmity with it from one age-group to another. Medical supervision of the pre-school and of the school child form integral parts of the Public Health Service of the area. Nevertheless the work of the Public Health Department is controlled by three differently constituted Committees whose respective and independently appointed staffs are engaged in dealing with the same problem and the same child in different ways. The Chief Medical Officer of the Ministry of Health and the Board of Education applies the following apt description. " There is confusion in areas and authorities, but there is no less confusion in the family. It is all anomalous, extravagant and redundant, with a result which is ineffective and financially wasteful." With the ever-increasing scope and activities of the health services it is becoming increasingly difficult to any one of the three Committees dealing with the work of the Health Department—-or their respective staffs—to take any action which does not concern the other two, the result being delay and confusion. Extract from Report by Medical Officer of Health and School Medical Officer to the Public Health, Maternity and Child Welfare and Education Committees—-August 1936. The recently issued Circular 1550 of the Ministry of Health states that it is clearly desirable that the Medical Officer who will supervise the health of children after they enter school would be responsible for their supervision during pre-school years. It is equally clearly desirable that such continuity of supervision should apply to the dental and nursing staff of the two responsible Authorities. The ideal way to ensure co-ordination is to do away with the necessity for it. In spite of these and other suggestions contained in my Annual Reports with the object of securing improved co-operation between the School Medical Service and the Public Health Services your School Nurses are still appointed independently by the Education Authority and are not required to have the qualifications of Health Visitors. 164 (ii) Operative Treatment of Tonsils and Adenoids. In January, 1935, I submitted to the Education Committee a special report in which I drew attention to the opinion of the Board of Education that post-operative retention of patients in hospital for at least one night should be arranged. After consideration of that report your Committee decided that arrangements be made for post-operative retention in hospital for one night where necessary. Since that time recourse has been had to overnight retention in hospital only in cases where the hospital surgeon considers such retention necessary. (iii) Medical Inspection and Treatment of Secondary School Pupils. In February, 1937—on the instruction of your Education Authority—I submitted a special report with regard to the proposal of the Essex County Council that your Authority should undertake the medical and dental inspection and treatment of County Secondary and Technical Schools in your area. After furnishing detailed information regarding the increases, during the past five years, in the health services generally and particularly in the amount and intensity of medical inspection and treatment of school children, I concluded my report as follows :— " It will be seen that the present medical staff cannot deal adequately with existing services, and could not undertake the medical inspection and treatment of County Secondary School Pupils unless your Council should decide to curtail existing services and arrangements." After consideration of that report your Authority decided— " That the Essex Education Committee be informed that the Authority are prepared to carry out the medical inspection and treatment of pupils attending day schools for higher education in Leyton, such arrangements to be made without any increase in the medical staff and without additional equipment ; 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." 165 Under the circumstances I was obliged to inform the County School Medical Officer, prior to the scheme being put into operation, that it would be impossible to devote to County Secondary School Pupils in this area the amount and quality of medical inspection and treatment considered to be necessary. Last January I had occasion to report that, after consulting the head teachers of County Secondary Schools in the area I agreed to make arrangements for the medical inspection of certain County scholars in whose cases it was considered that inspection and treatment could be delayed no longer without hardship to the children concerned. These arrangements were made possible by curtailing existing services for the time being, but it would be idle to pretend that the necessary medical inspection and treatment of County pupils is being or can be carried out satisfactorily with the available staff. (iv) Disposal of Records of Routine School Medical tion. It is laid down by the Board of Education that routine medical inspection must take place in school premises within school hours ; and the form of card, on which the results of inspection must be recorded, is specified by the Board. These cards, which are used only for the extraction of information required for completion of the Board's Annual Statistical Tables, are kept by the head teachers in school ; but a special medical defect and treatment card is completed in respect of each child found to be suffering from any defect, however slight. These are the records which are of value in following-up children with defects. They are filed at the clinics, and they are taken to the schools when children are submitted to medical re-inspection. I am aware that the practice of keeping routine medical inspection cards at school clinics is becoming much more common, especially among large Education Authorities with independent clerical staffs for school medical service and adequate accommodation for storage of records ; but under existing circumstances I prefer to keep the routine inspection cards in schools. (v) Treatment of Speech Defects. During 1936 your Director of Education and I conducted an investigation into the incidence of stammering and other speech defects among children attending your elementary schools, and 166 found that 1.1 per cent, of the children were affected—the defect being twice as common among boys as among girls. In November, 1936, I submitted to your Director a special report on " Stammering and Other Speech Defects," and in the following month your Director and I submitted to the Education Committee a joint report containing details of the results of the above investigation and suggestions for the appointment of a specially qualified teacher to undertake the training and teaching of children with speech defects. In February, 1937, your Education Committee " adopted as the basis of a programme of future development " the following resolution (Council Minute 1377):— " That the Board of Education be asked to sanction the appointment of a specially qualified assistant teacher to enable stammerers to be grouped at convenient schools for full-time courses of speech training and normal education." Since that time, however, no further action has been taken with regard to children suffering from speech defects. After consideration of the above report the Education Authority resolved :— (1) That the Education Committee be recommended to adopt the principle of appointing School Nurses with Health Visitors' qualifications, to allow the School Medical Officer to interchange the nursing staff as necessary. (2) That formal application be made to the Board of Education for approval of an arrangement for the retention in hospital, for at least one night, of all children who have had tonsil and adenoid operations. (3) That the School Medical Officer be empowered to engage temporary medical assistance as necessary to cope with the increased work caused by the medical inspection and treatment of Secondary School pupils. (4) That no alteration be made in the present method of storing routine inspection cards. 167 PLANTAR WARTS IN SCHOOL CHILDREN. Report by the Medical Officer of Health and Senior Chiropodist. An Investigation of Incidence and Etiology. During recent years observers in different parts of the country have reported outbreaks of plantar warts ; but, so far as I am aware, no investigation has been undertaken to show their prevalence or mode of spread. In April, 1938, I submitted to the Health Authority a report drawing attention to the sudden increase in the number of school children found to be suffering from painful warts on the soles of the feet, and the Authority sanctioned the engagement of additional part-time temporary assistance at the Municipal Foot Clinic in order to allow the Senior Chiropodist (Mr. F. J. O'Brien) to conduct an inspection of the feet of children attending public elementary schools in the Borough and arrange for the necessary treatment of those found to be affected. Before dealing with the findings of inspection it is considered advisable to submit a brief review of current medical opinion regarding the nature and causation of the plantar wart (verruca plantaris). Pathology. Roxburgh considers that the plantar wart is a variety of the common wart or verruca vulgaris. After showing the mechanical effect of pressure in their formation, he states :— "It is generally accepted that warts are contagious and inoculable. The various types are all due to the same filter passing virus." Lake, on the other hand, is of opinion that the verruca or wart is a benign neoplasm or new growth. "Verruca are true neoplasms and are called papillomata or papillary neoplasms. If, owing to extraordinary overgrowth, the basement membrane is destroyed, then the hypertrophy of epidermal cells extends downwards and inwards and we have a malignant neoplasm, an epithelial " cancer," 168 a carcinoma, which consists of flattened squamous cells. The process of verruca formation is indirect. It is not the actual micro-organism that produces the damage, but it may be its toxins which give rise to irritation of the living cells, the toxins resulting from the bacterial growth may so irritate the virile reproducing layers as to bring about overgrowth of the papillary layers of the skin. The fundamental and underlying cause of verruca is irritation. It is the most potent cause of new growths." Sampson Handley and Stopford Taylor favour the view that infection is caused by a filter passing virus ; but consider that the infection occurs through a blockage of the lymphatics. The former states :— " A very large percentage of all cancers are preceded by some form or other of papillary hypertrophy. Therefore to ascertain the cause of cancer it seemed essential to find out the cause of verruca." McLeod, in his textbook, writes:— "Verruca pedis plantaris is a peculiar type of wart which is a hybrid between a corn and a wart." The theory that deficiency of calcium in the blood was a possible cause was exploded several years ago by various research workers and dermatologists. To quote R. B. Fisher :—- " It is highly unlikely that a localised lesion can be attributed to an abnormality in the composition of the blood supplied to that particular locality, since any such abnormality can obviously not persist if the blood supplied to the rest of the body is normal. On the other hand, if the composition of the blood as a whole is abnormal it is not possible to explain a local lesion in the terms of it, unless there is a local cause as well." It is evident from these quotations that among recognised authorities there exists a considerable diversity of opinion with regard to the actual pathological significance of wart formation. 169 Etiology. With regard to the predisposing and exciting causes of plantar warts there has been much speculation, but no single causal factor has been established. Infection. If, as has been suggested by various observers, the condition be due to a filter-passing virus, there should be present some evidence of dissemination of infection by contagion or by some medium conveying the infection. Irritation. If, as Lake avers— " The fundamental and underlying cause of verruca is irritation "— it is reasonable to expect that in a widespread outbreak among school children some common irritative factor should be operative. Injury. It is a well-recognised clinical fact that a plantar wart often develops at the site of a previous puncture or abrasion of the skin. MacLachlan has observed :— " Some rubber contains spicules of steel which would wear through and probably cause injury. . . . Children playing on the sands get small particles of the sand or silica driven into the skin and it is not uncommon to find plantar warts apparently arising from such trivial injury." Whitfield suggests trauma as a cause apart from infection :— " They (warts) are most common in those who wear very thin soles thus allowing the sole (of the foot) to be bruised by gross unevenness of the ground, and in those who wear boots with studs in the sole as is the case with football players." Seasonal Prevalence. Eleven years' experience as a practising chiropodist in Liverpool has led your Senior Chiropodist to associate the autumn and early winter months with an increase in the number of patients attending for treatment of plantar warts, but no statistical evidence is available in support of this observation. 170 The following figures show in tabular form the month of the year during which patients attended Leyton Municipal Foot Clinic for the first time for treatment of plantar warts during 1936-37. 1936 1937 Children Adults Children Adults January — — 14 3 February — — 6 3 March 3 6 2 3 April — 2 4 3 May 5 5 6 4 June 2 6 5 2 July 5 1 4 1 August — 6 3 1 September 5 — 5 1 October 11 1 5 3 November 5 3 14 1 December 4 1 6 4 As the Municipal Foot Clinic was established only as recently as March, 1936, the number of cases dealt with is relatively small. Although there is no apparent special seasonal incidence in the case of adults, it will be seen that in the case of children there was a marked increase in the number of cases who first attended for treatment during the months of October, 1936 ; January, 1937; and November, 1937. Incubation Period. The generally accepted view is that the period of incubation is from four to six weeks. At first the condition is regarded as a corn, and it is only when it spreads and does not yield to " corn paint " and home treatment that advice is sought—usually from two to four months after infection. Indications foe Investigation. If there had occurred a marked increase in the incidence of plantar warts among school children during the autumn and early winter months, the occurrence might have been accepted as being attributable to the abnormal irritation, injury and exposure to infection of the soles of the feet during the summer vacation when so many children run about either bare-footed or wearing cheap rubber shoes with thin soles ; but the outbreak occurred in the month of April, at a time when the usually accepted causative 171 factors could not be accepted as being operative. Of the first cases reported in April, no child gave a history of having suffered from plantar warts long enough to have contracted or developed the trouble during the previous summer. It was therefore possible that some other unknown or unsuspected agent might be responsible. In April, 1938, the Leyton Education Authority decided to put into operation during the following month a scheme whereby swimming instruction—at the Council's Public Baths—should be a compulsory subject in the school curriculum for junior and senior pupils attending public elementary schools. About that time certain dermatologists and chiropodists had expressed the opinion that outbreaks of plantar warts were probably attributable to dissemination of infection at public swimming pools. Under the circumstances some investigation into possible sources of infection was clearly indicated in an area in which swimming was part of the school curriculum, even if only for the purpose of finding out the children suffering from plantar warts and excluding them from attendance at swimming instruction. Scope of Investigation. The investigation was undertaken in order to ascertain the number of children, attending public elementary schools in the Borough of Leyton, who were suffering from plantar warts and to make arrangements for the necessary treatment. The first school inspection was made on 3rd May, 1938, and the last on 14th October, 1938. The investigation therefore deals with pupils attending public elementary schools in an extra-metropolitan Borough during that period. The first school to be inspected was Sybourn Street, as that was the school in which the greatest number of cases had been found by the medical staff of the Health Department. The inspection was begun in the infants' department where, of 312 infants examined, only one was found to be suffering from plantar warts in very mild form. On the other hand, in that school 26 junior and 17 senior pupils were discovered to be severely affected. On account of the apparent relative immunity of children in the infants' department, and in order to arrange in the first place for the treatment of the age-groups chiefly affected, it was decided to confine the investigation to children in the junior and senior departments (i.e., to children of 8 years of age and over). 172 Results of Inspection. Statistical Summary. The following table shows in tabular form the results of inspection—classified according to sex and school department—in each of the Council's schools. Table I. Number Inspected Number of Cases Senior Junior Senior Junior Boys Girls Boys Girls Boys Girls Boys Girls Cann Hall 223 — 176 — 9 — 4 — Canterbury 200 — 168 139 7 — 3 6 Capworth — 193 145 158 — 11 4 16 Church — 210 — 190 — 9 — 3 Connaught — 190 123 148 — 17 1 — Davies Lane 227 — 207 85 11 — 3 — Downsell 151 — 200 — 7 — — — Farmer 198 — 231 — 9 — 1 — Goodall — 181 — 223 — 6 — 4 Mayville — 185 — 190 — 11 — 4 Newport 221 — 265 — 5 — — — Norlington — 204 — 252 — 9 — 3 Ruekholt 263 205 — — 5 14 — — Sybourn 201 — 214 128 17 — 14 12 St. Joseph's 50 53 47 36 — — 1 2 Tom Hood 226 181 — — 10 9 — — Trumpington — 157 68 182 — 9 — 2 Totals 1,960 1,759 1,844 1,741 80 95 31 52 3,719 3,585 175 83 7,304 258 Of 7,304 children inspected, 258 (3.53 per cent.) were found to be suffering from plantar warts. It will be seen that all schools were affected in varying degree ; the maximum incidence (7.91 per cent.) being at Sybourn Street School, and the minimum (1.02 per cent.) at Newport Road. Within these two extremes the cases were fairly evenly distributed over the schools in the area. With regard to distribution in individual schools there are some unexpected findings. For instance, in Connaught Road School, where 8.89 per cent, of senior girls were affected, no case was found among junior girls. Again, in Downsell Road School, 7 cases were found among 151 senior boys, but no case was found 173 among 200 junior boys. On the other hand in St. Joseph's School, although 3 cases were found among junior pupils, no case was detected among senior pupils. Age Distribution. Number inspected Number of Cases Incidence Juniors 3,585 83 2.31 per cent. Seniors 3,719 175 4.70 per cent. Total 7,304 258 3.53 per cent. The incidence rate among senior pupils (4.70 per cent.) is more than double that among juniors (2.31 per cent.). Of 312 infants inspected before the investigation began, only one child was found to be suffering from plantar warts in a very mild form—giving an incidence rate among infants of 0.32 per cent. As the classification of children into senior and junior groups is not strictly on an age basis, the cases have been classified according to age ; and the following figures show the age distribution of the 258 children who attended for treatment. Age Number of Cases 8 years 11 9 „ 25 10 „ 38 11 „ 61 12 „ 69 13 „ 43 14 „ 10 15 „ 1 258 These figures show a progressive increase from 8 to 12 years of age, after which there is a progressive decline. 174 The following is an age group analysis of children, suffering from plantar warts, who have attended the Municipal Foot Clinic for treatment during the first 22 months after its establishment:— Age Male Female 6 years — 1 7 „ 1 1 8 „ — 1 9 „ 3 10 10 „ 3 7 11 „ 5 12 12 „ 8 23 13 „ 6 26 14 „ 3 4 29 85 Total 114 It will be seen that, of the 114 patients, 63 (i.e., over 55 per cent.) were aged 12 or 13 years. Sex Incidence. Number inspected Number of Cases Incidence Boys— Junior 1,844 31 1.68 per cent. Senior 1,960 80 4.08 per cent. Total 3,804 111 2.91 per cent. Girls— Junior 1,741 52 2.98 per cent. Senior 1,759 95 5.40 per cent. Total 3,500 147 4.20 per cent. It is evident from these figures that the percentage incidence rate among all girls (4.20 per cent.) is greater than that among all boys (2.91 per cent.), and that the greater relative incidence among girls is found both in the junior and the senior departments. 175 Of 114 children who attended the foot clinic for treatment of plantar warts during 1936-37, the number of girls (85) was almost three times as great as the number of boys (29). School Class Distribution. In one school, in which 3 per cent. of all pupils suffered from plantar warts, 80.7 per cent. of the affected children were in one classroom. Such a high percentage grouped in one class was exceptional, but it was customary to find from 50 per cent. to 60 per cent. of affected children in a particular school grouped in one classroom. In that particular class there was always to be found one child who had been suffering from plantar warts for a period of from 4 to 6 months previously. Possible Predisposing Causes. Malnutrition. There is no reliable standard for the estimation of the state of nutrition, and no steps were taken to investigate the financial and social circumstances of each child ; but careful attention was paid to these circumstances. The majority of the children were apparently well nourished, and there was no evidence that children from poor homes were more liable to develop plantar warts. On consulting the figures of individual schools it is found that similar percentage incidence rates are found in schools situated in both the poorer and the better class parts of the Borough. Colour. It was also found that blondes and brunettes were affected in almost equal proportion. Condition of Skin. There are certain skin troubles which affect persons with abnormally dry skin, and others which affect people with moist skin ; and attention was given to the condition of the skin of the soles of the feet. Of 258 children affected, the following are the findings:— Skin abnormally moist 20 (7 per cent.) „ ,, dry 1 (0.4 per cent.) „ apparently normal 237 (91 per cent.) 176 Possible Exciting Causes. In order to ascertain whether there might be any predisposing or exciting cause operative in the production of plantar warts, arrangements were made for the completion of a form of questionnaire in respect of each child who attended for treatment. Public Swimming Pools. It has been suggested that the infection is probably spread at swimming pools, and more probably when persons are walking or running about on the surrounds of the pools. It was found, however, that of 258 cases investigated, only 195 (75 per cent.) had been attending swimming pools. Footwear. Of the 258 cases, 248 (96 per cent.) had instruction in Physical Training as part of the school curriculum. Of these, some 241 (97 per cent.) had been wearing rubber plimsol shoes while taking part in physical training at school. In order to determine whether infection might be spread by the wearing of the same plimsols by different children, enquiry was made as to whether the rubber shoes were worn only by the affected child. It was found that, of 241 children who had been wearing rubber shoes, the shoes were private property in 165 cases and school property in 76 cases. In 68 per cent, of the children who wore rubber shoes there was therefore no possibility of spread of infection from rubber shoes worn at school. Wellington boots had been worn by only 70 (27 per cent.) of the children affected. The footwear of each affected child was examined for the presence of nails or uneven surfaces which might cause abrasion of the plantar skin ; but in only 90 cases (34 per cent.) was there either evidence or history of the presence of nails or sharp projections where the warts developed. It has been suggested that cheap footwear of foreign manufacture may be responsible for the increase in plantar warts, and attention was therefore directed to the source of the footwear. It was found, however, that the boots and shoes of affected children had been bought from as many as 49 vendors, and that the three 177 firms who supplied the greatest number of children (18.9 per cent., 7.7 per cent. and 7.3 per cent, respectively) were all well-known British firms. Barefoot Dancing. It is possible that children who practice barefoot dancing are more liable to abrasions of the skin of the soles of the feet from small wood splinters in the floor ; but of the 258 cases investigated, only 2 children had practised dancing barefoot. Tar Compounds. In view of the well-known irritant action of tar and its compounds, attention was directed to school playgrounds recently resurfaced. It was found, however, that no incidence greater than the average occurred in the three schools where playgrounds had been re-surfaced recently. Summary and Conclusions. Of children attending junior and senior departments of public elementary schools in an extra-metropolitan area from April to October, 1938, 3.53 per cent, were found to be suffering from plantar warts. There is a progressive increase in incidence up to the age of twelve years, after which there is a progressive decline. The percentage incidence among girls is greater than among boys. There is no evidence that social conditions, general state of nourishment, colour or moisture of the skin are of significance as predisposing causes. As 25 per cent, of affected children had not attended public swimming pools, the evidence of possible spread of infection at such pools is not conclusive. Ninety-three per cent, of affected children were in the habit of wearing thin rubber shoes, but in 68 per cent, of these cases the shoes had not been worn by other children. Injury from defective footwear was a possible exciting cause in 34 per cent, of the cases. 178 Of the three factors (infection, irritation and injury) which have been quoted as possible exciting causes, none was found to be operative in a percentage of cases sufficiently large as to justify its being regarded as causative. PROVISION OF MEALS. The provision of meals to children attending the elementary schools is undertaken by the Education Authority under powers granted by Sections 82-85 of the Education Act, 1921. The average number of children fed per week during the past five years:— 1934 323 1935 327 1936 305 1937 282 1938 375 The number of individual children fed under the Authority's arrangements during 1938 was as follows:— Ordinary Meals. Milk Meals. Free 676 1,891 For payment 76 Totals 752 1,891 Number of meals supplied Ordinary Milk Meals. Meals. Free 92,083 483,590 For payment 6,518 — Totals 98,601 483,590 The above figures relate to the financial year ended 31st March, 1939. 179 School Dinners. During recent years much valuable research work has been undertaken in investigating such subjects as nutrition, foodstuffs, meals and catering, and valuable contributions have been made to the literature of these subjects by the League of Nations, Ministry of Health, British Medical Association and other recognised authorities. Last summer I conferred with Dr. Mary Gilchrist with regard to the modification of the present school dinner menu in the light of recent knowledge regarding nutrition and dietetics. At that time Dr. Gilchrist submitted suggestions for improving the dietetic value of the menu, and I had intended to submit her new dietary to the Education Committee for approval in September last; but about that time I began to have some doubts about the condition in which certain meals, after transport from the Harrow Green Central Kitchen, arrived at the Capworth Street Feeding Centre and at Knotts Green Special School. Certain meals arrived in a sodden and unattractive state due to the condensation of water inside the hot containers, and towards the end of September it was found that some children attending the Authority's Open-Air School were not showing the expected gain in weight. On enquiry into the matter I found that some of the children at the special school were not eating their dinners as they had done formerly, and that considerable wastage of food was taking place in consequence. Inspection of the menu and the meals did not lead very far in tracing the fault. The proof of the pudding is proverbially in the eating, and it appeared that the only reliable method of investigation was to get some experienced person to eat the dinners and report the experience gained. Dr. Gilchrist kindly volunteered to eat the dinners daily at Knotts Green Special School, and she furnished me with a report on each meal. Her experience confirmed some of the complaints made by the children and revealed certain deficiencies in the dietary which had not been appreciated as the result of inspection. On receipt of that report I interviewed Miss Thomas, Supervisor of Domestic Science, and discussed at length the arrangements for the provision of school meals in general, and Dr. Gilchrist's report in particular. Thereupon arrangements were made for the collaboration of Miss Thomas and Dr. Gilchrist in the preparation of a new dietary adapted to existing arrangements. Dr. Gilchrist prepared a dietary which on paper fulfilled dietetic requirements 180 from the point of view of modern physiological and medical knowledge, and Miss Thomas rendered valuable assistance and advice in trying out the various dishes with regard to cooking, condition after transport in containers, consumption, etc. Dr. Gilchrist has also been visiting the feeding centres in order to obtain firsthand knowledge of the reasons why the children like or dislike certain dishes. At the same time she has given short informal talks to the children on feeding and food. Mrs. Hannon, Cook, reports that—as the result of these talks—the children are now eating greens and fresh vegetables with greater relish than formerly, and that there is an improvement both in their appetites and in their conduct at table. After much close collaboration on the part of Miss Thomas, Dr. Gilchrist and Mrs. Hannon they have now succeeded in completing a four weeks menu for school dinners in which each meal is properly balanced as regards dietetic requirements, is appetising after transport in containers, and is relished by the children. I submit hereunder Dr. Gilchrist's report to me, along with a copy of the suggested four-weeks menu of school dinners. Report by Dr. Mary Gilchrist to School Medical Officer. In accordance with your suggestion I ate the school dinners at Knotts Green School daily from 13th to 29th October, with the exception of two days—21st and 28th October. Of the thirteen dinners eaten during the period, four were very good in every respect. The other meals failed in one or other of the following respects:— Too much carbohydrate. Not enough greens and root vegetables. Not enough fruit, fresh or stewed. More crisp pastry required. Insufficient chewing value. I do not think that there is any fault to find with the actual cooking of the meals, but their transport in closed hot containers makes certain valuable foods (e.g., fish and liver) sodden and unappetising. For instance, on 29th October, thirty children at the open-air school did not eat the fish and potatoes provided on that day. 181 Fish, especially fried fish, did not carry well, the flavour being spoiled and the appearance unpleasant. There were not enough green or root vegetables of the carrot or turnip variety, and fruit was insufficient in quantity when given in the second course. In addition to these defects it was noticed that the children did not have enough chewing to do, certain of the meals being "sloppy" in character. This defect in chewing value is recognised to be one of the contributory causes of dental caries. In order to remedy these defects of balance in the diet the following changes were made in the menu. Green vegetables were increased from an average of once per week to three times a week ; the amount of carrots and turnips was increased from one to three ounces; another vegetable in addition to potatoes was added to the Friday and Saturday diets; an increase of fruit was made in the second course ; and short pastry was added twice a week. I reduced the amount of potatoes rather drastically as I wished the children to eat the greens, etc. ; and this they might not have done if they could have had all the potatoes they wanted. I was a bit too drastic and there occurred a shortage one day so I increased them again, though not quite to the full amount. The reports from the centres is encouraging and the children are eating their "greens" and other vegetables better than formerly. I have gone into each of the centres and spoken to the children about eating the meals and the reason why they should eat green vegetables. Mrs. Hannon considers that these informal talks have had a good effect on the conduct of the children and the justice they do the meals. The Health Committee of the League of Nations in its " Report on the Physiological Bases of Nutrition " recommended that certain protective and body-building foods were necessary for children, and suggested the following quantities per child required for various ages. Children aged 5-7 years 12-14 years Meat, fish, liver or cheese 30 grammes 90 grammes Green leafy vegetables 100 „ 250 „ Potatoes and other roots 150 „ 300 182 Taking one ounce as the equivalent of 30 grammes this worked out as follows per child:— 5-7 years 12-14 years Meat, etc. 1 oz. 3 oz. Greens 3.3 oz. 8 oz. Potatoes, etc. 5 oz. 10 oz. These values are only approximate, but accurate enough for the purpose of large scale cooking. Since the children are of all ages from 5 to 14 years it seems reasonable to assume that the mean of these two quantities should give a reasonable diet, and this we have tried to supply. The amounts given per head per meal are at present— Meat 2 oz. (cooked). 3½ ozs. (uncooked and with bone) Greens (cooked) 5 ozs. Potatoes (cooked) 5 ozs. It will be seen that potatoes fall short by 2½ ozs. of the required amount, but I do not propose to increase this unless I, guided by the experience of those in charge of the centres, find that the children are not having sufficient. As I have explained above, we felt that the children might go on eating too much potato without taking the new vegetables. In addition to the above, each child has 1½ ozs. of pastry, 3 ozs. of stewed fruit, a third of a pint of milk pudding, 1½ oz. of dried fruit in the sponge or steamed pudding, and occasional raw fruit. The days and number of times they have these in the diet can be seen by referring to the menu. These additions are an attempt to provide the fruit, amounts of milk and fat which are recommended for the diet of the growing child. In the short pastry, sponge and steamed pudding there is ½oz. of fat in each portion. In the Annual Report for 1936 of the Chief Medical Officer of the Board of Education it is stated that the diet of the necessitous child is deficient in vitamins, first class protein, and calcium, so that the supplementary nourishment should be rich in milk, cheese, eggs, butter, green vegetables, fruit and meat. I can see no way of adding butter to the meals except to supply it in the short pastry, or to ensure that the margarine contains sufficient Vitamin D. Eggs are given once a week in the sponge pudding. Cheese cooked 183 is very unpopular and should be left to the parents to add to the menu at home. In order to ensure a sufficient supply of milk, all children receiving free meals should be allowed two bottles of milk in school. The appended menu, compiled with the help of Miss Thomas and Mrs. Hannon, has been tested out for four weeks. I have eaten 21 of the meals myself and found them to be satisfactory. Before this menu was finally settled, certain meals which I had suggested had to be left out because they were found not to carry well in containers or were not eaten by the children. One of these unfortunately was the meal with herrings in it. The appended menu, therefore, has been well tried out and in my opinion all the meals are quite appetising as well as being nourishing. The one change which may be required later is an increase in the quantity, but this would not affect the composition of the meals. Appended is the list of meals for a four-weeks period. WINTER MENU. First Week. 1. Mince and onions, greens, potatoes. Fruit sponge pudding. 2. Roast mutton, greens, potatoes, gravy. Stewed fruit and custard. 3. Haricot mutton, mixed carrot and turnip, potatoes. Eccles cake. 4. Liver and bacon, tomatoes, potatoes. Milk pudding and raw fruit. 5. Fish, creamed potatoes, greens. Raisin pudding. 6. Sausages, greens, potatoes. Fruit tart and custard. Second Week. 1. Stewed steak and kidney, greens, potatoes. Stewed fruit and short pastry. 2. Boiled bacon, pease pudding, carrots and turnips, potatoes. Raw fruit. 3. Roast beef, yorkshire pudding, greens, potatoes and gravy. Oranges. 4. Liver and bacon, tomatoes, potatoes. Sultana sponge. 5. Fish, creamed potatoes, greens. Milk pudding and fruit. 6. Boiled mutton, mixed vegetables, potatoes. Treacle tart. Third Week. 1. Mince and onions, greens, potatoes. Steamed fruit pudding. 2. Boiled beef, carrots, potatoes. Stewed fruit and short pastry. 3. Roast mutton, greens, potatoes. Milk pudding and raw fruit. 4. Brown stew, mixed vegetables, potatoes. Raw fruit. 5. Fish, creamed potatoes, butter beans or peas. Steamed syrup pudding. 6. Liver and bacon, greens, potatoes. Bananas. 184 Fourth Week. 1. Meat pasties, greens, potatoes, gravy. Oranges. 2. Baked steak and onions, mashed carrots, and turnips, potatoes. Sultana sponge pudding. 3. Liver and bacon, tomatoes, potatoes. Fruit and custard. 4. Roast mutton, greens, potatoes, gravy. Fruit tart. 5. Fish, creamed potatoes, beans or peas. Steamed currant pudding. 6. Boiled bacon, pease pudding, carrots and swedes, potatoes. Fresh fruit. SUMMER MENU. First Week. 1. Minced beef and onions, greens, potatoes. Jellies and custard. 2. Cold roast mutton, beetroot salad, creamed potatoes. Steamed cherry sponge pudding. 3. Braised liver and bacon, tomatoes, potatoes. Fresh fruit. 4. Mutton and vegetable casseroles. Fruit or jam tart. 5. Cold fried fish, green salad, creamed potatoes. Rice pudding, fresh fruit. 6. Sausages, greens, potatoes. Fruit batter. Second Week. 1. Meat pasties, gravy, greens, potatoes. Fresh fruit. 2. Baked steak and onions, mashed carrots and swedes, potatoes. Date sponge pudding. 3. Cold roast mutton, green salad, creamed potatoes. Milk pudding, fresh fruit. 4. Boiled bacon, pease pudding, carrots, potatoes. Fresh fruit. 5. Fish cakes, butter beans, tomato sauce. Steamed golden pudding. 6. Liver and bacon, green marrowfat peas, potatoes. Fresh fruit. Third Week. 1. Minced beef and onions, greens, potatoes. Eccles cakes. 2. Roast beef, yorkshire pudding, greens, potatoes. Fresh fruit. 3. Braised liver and bacon, tomatoes, potatoes. Jelly and custard. 4. Boiled beef, carrots, potatoes. Trifle. 5. Cold fried fish, green salad, creamed potatoes. Steamed sponge pudding, jam sauce. 6. Cold roast mutton, beetroot salad, potatoes. Syrup or jam tart. Fourth Week. 1. Sausages, greens, creamed potatoes. Banana custard. 2. Cold boiled bacon, beetroot salad, potatoes. Rice pudding. 3. Roast mutton, gravy, greens, potatoes. Stewed apricots and semolina custard. 4. Meat and vegetable casserole. Stewed fruit and short pastry. 5. Boiled egg, green salad, creamed potatoes. Steamed apple pudding. 6. Baked steak and onions, green marrowfat peas, potatoes. Fresh fruit. 185 EMPLOYMENT OF CHILDREN and STREET TRADING BY YOUNG PERSONS. 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 „ „ 1938 124 „ „ SECONDARY SCHOOLS and INSTITUTIONS FOR HIGHER EDUCATION. My Annual Report for 1937 contained a full account of the arrangements made by your Authority and the Essex County Council for the medical and dental inspection and treatment by your school medical and dental staff of children attending County Secondary Schools in the Borough. Returns of Medical Inspection. In the Statistical Appendix on pages 196 to 200 will be found a statistical summary of the results of medical and dental inspection and treatment of secondary school pupils. During the year the following medical inspections were made Routine medical inspections 619 Special inspections 145 Re-inspections 197 Total 961 With regard to the findings of medical inspection, the percentages of secondary school pupils suffering from defects requiring treatment were:— County High School for Girls 30.6 per cent. County High School for Boys 19.7 per cent. Total 23.7 per cent. 186 It will be seen that the percentage incidence of defects among girls (30.6 per cent.) is much greater than among boys (19.7 per cent.). When comparison is made between the percentage incidence of defect of elementary and secondary school children it is found that 19.2 per cent. of elementary school children and 23.7 per cent. of secondary school children examined during the year were found to require treatment. The incidence of defect among secondary school pupils was also greater than among senior department pupils in Leyton elementary schools. As the medical examinations were conducted by the same medical officers in each case the figures are significant. With regard to individual defects, of 619 secondary school pupils submitted to routine medical inspection, 100 (16.1 per cent.) were found to be suffering from defective vision. This defective vision incidence rate of 16.1 per cent. is greatly in excess of the comparative rate of 4.9 per cent. found among elementary school children during the same year. As far as the state of nutrition is concerned, however, the secondary school pupils compare very favourably with children attending elementary schools, as is shown by the following figures based on the four official grades of nutrition. State of Nutrition Secondary Schools Elementary Schools A Excellent 48.4 per cent. 18.4 per cent. B Normal 46.5 per cent. 61.2 per cent. C Slightly subnormal 5 per cent. 19.3 per cent. D Bad Nil 0.9 per cent. Another type of defect from which the secondary school pupils suffered relatively badly was dental defect. Of 931 pupils inspected, 802 (86 per cent.) were found to require dental treatment. The comparative incidence figure for dental defects among elementary school children was 68 per cent. Your Senior Dental Surgeon deals with this subject in his report (see page 138). 187 PUBLIC ELEMENTARY SCHOOLS. STATISTICAL APPENDIX. TABLE I.—Returns of Medical Inspections. a. Routine Medical Inspections. Number of Code Group Inspections:— Entrants 1,660 Second Age Group 1,223 Third Age Group 1,200 Total 4,083 b. Other Inspections. Number of Special Inspections 7,106 Number of Re-inspections 11,650 Total 18,756 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 8 277 285 17.1 Second Age Group 110 188 298 24.3 Third Age Group 85 117 202 16.8 Total (Prescribed Groups) 203 582 785 19.2 Other Routine Inspections — — – — Grand Total 203 582 785 19.2 188 TABLE II—A. Return of Defects found by Medical Inspection in the Year ended 31st December, 1938. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... 2 ... Body ... ... 24 ... Scabies 1 ... 66 ... Impetigo ... ... 164 ... Other diseases (non-T.B.) 17 4 491 ... Eye Blepharitis 33 5 100 ... Conjunctivitis 14 ... 92 ... Keratitis ... ... 5 ... Corneal Opacities ... ... 2 ... Other conditions 15 2 218 4 Defective Vision 203 134 143 8 Squint 28 6 16 1 Ear Defective Hearing 4 11 26 2 Otitis Media 18 6 119 2 Other Ear Diseases 13 3 189 4 Nose & Throat Chronic Tonsilitis only 79 74 130 ... Adenoids only 18 13 25 1 Chronic Tonsilitis and Adenoids Other Conditions 69 29 66 8 51 208 1 Enlarged Cervical Glands (non-T.B.) 38 26 107 ... Defective Speech ... 3 9 1 Heart and Circulation Heart Disease— Organic 4 ... 27 ... Functional 8 53 18 5 Anaemia 13 6 121 1 Lungs Bronchitis 47 52 157 2 Other non-T.B. Diseases 12 29 57 1 Tuberculosis Pulmonary— Definite ... ... ... ... Suspected 1 10 ... ... Non-Pulmonary— Glands ... 1 8 ... Bones and Joints ... ... 4 ... Skin ... ... ... ... Other Forms ... 1 1 ... Nervous System Epilepsy 3 1 6 ... Chorea ... 3 27 ... Other Conditions 10 18 101 6 Deformities Rickets 43 1 1 ... Spinal Curvature 2 ... 4 ... Other Forms 69 22 196 ... Other Defects and Diseases 71 59 2548 27 Totals 862 617 5,463 66 189 TABLE II—B. Classification of the Nutrition of Children Inspected during the Year in the Routine Age Groups. Age Groups. No. of Children Inspected. A. (Excellent). B. (Normal). C. (Slightly Subnormal). D. (Bad). No. % No. 0/ /o No. % No. % Entrants 1,660 245 14.7 1,030 62.0 363 21.9 22 1.3 Second Age Group 1,223 190 15.5 770 62.9 252 20.6 11 0.9 Third Age Group 1,200 318 26.5 702 58.5 178 14.8 2 0.2 Other Routine Inspections – – – – – – – – – Total 4,083 753 18.4 2,502 61.2 793 19.3 35 0.9 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. 14 — — 1 15 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 3 – — – 3 MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 70 – 5 – 75 190 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 5 2 — 2 9 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 1 — 9 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. — 16 4 — 20 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 128 — — — 128 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 24 1 — — 25 191 D. Children with Heart Disease. At Certified Special Schools. At Public ElementarySchools. At other Institutions. At no School or Institution. Total. 30 — — 4 34 Children Suffering from Multiple Defects. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At School or Institution. Total. Feeble Minded and Heart Disease 1 – – – 1 Feeble Minded and Crippled 2 – — — 2 Crippled and Epileptic 1 – – – 1 TABLE IV.—Return of Defects Treated during the Year ended 31st December, 1938. TREATMENT TABLE. Group T.—Minor Ailments (excluding Uncleanliness, for which see Table VI). Number of Defects treated or under treatment during the year. Disease or Defect. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin— Ringworm— Scalp—(1) X-ray treatment 2 — 2 (2) Other — — — Body 21 — 21 Scabies 66 1 67 Impetigo.. 164 — 164 Other skin diseases 479 — 479 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 369 369 Minor Ear Defects 286 — 286 M iscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 1,503 5 1,508 Total 2,890 6 2,896 192 TABLE IV.—contd. Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as minor ailments.—group I.). Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Errors of refraction (including squint) 844 53 897 Other defect or disease of the eyes (excluding those recorded in Group I.) 188 — 188 Total 1,032 53 1,085 Under the Authority's Scheme. Otherwise. Total. No. of Children for whom Spectacles were :— (a) Prescribed 740 53 793 (6) Obtained 738 55 793 TABLE IW.—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) 20 10 92 42 13 3 8 14 33 13 100 56 110 312 (1) Tonsils only. (2) Adenoids only. (3) Tonsils and adenoids. (4) Other defects of the nose and throat. 193 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-rosidential treatment at an orthopaedic clinic. Residential treatment with education. Residential treatment without education. Non-residential treatment at an orthopaedic clinic. (1) (2) (3) (1) (2) (3) No. of children treated 7 1 225 — — 7 230 TABLE V. Dental Inspection and Treatment. (1) Number of children who were:— (a) Inspected by the Dentist:— Age Groups Aged 3 41 Total 7,738 4 186 5 572 6 689 7 847 8 852 9 836 10 859 11 783 12 854 13 862 14 303 15 43 11 Specials (Casuals) 1,613 Grand Total 9,351 (b) Found to require treatment 6,927 (c) Actually treated 5,230 (2) Half-days devoted to Inspection 37 Treatment 802½—Total 839½ 194 (3) Attendances made by children for treatment 9,013 (4) Fillings, Permanent Teeth 5,459 Temporary „ 219—Total 5,678 (5) Extractions, Permanent Teeth 1,641 Temporary „ 6,170—Total 7,811 (6) Administrations of general anaesthetics for extractions ... 1,940 (7) Other operations, Permanent Teeth 782 Temporary ,, 286—Total 1,068 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 29,763 (3) Number of individual children found unclean 1,385 (4) Number of children cleansed under arrangements made by the Local Education Authority — (5) Number of cases in which Legal proceedings were taken :— (a) Under the Education Act, 1921 — (b) Under the School Attendance Bye-laws — 195 STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1938, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total number of children notified: 11. 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 — — (6) Imbeciles 2 2 (c) Others — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (a) Moral defectives — — (b) Others – – 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 3 4 3. Feeble-minded children notified under Article 3, i.e., "special circumstances" cases Note.—No child should be notified under Article 3 until the Board have issued a formal certificate (Form 308M) to the Authority. — — 4. Children who in addition to being mentally defective were blind or deaf ... Note.—No blind or deaf child should be notified without reference to the Board—see Article 2, proviso (ii). — — Grand Total 5 6 196 SECONDARY SCHOOLS. STATISTICAL APPENDIX. TABLE I.—Returns of Medical Inspections. a. Routine Medical Inspections. Number of Code Group Inspections:— County High School for Boys 390 ,, ,, ,, „ Girls 229 Total 619 Number of other Routine Inspections — b. Other Inspections. Number of Special Inspections 145 Number of Re-inspections 197 Total 342 197 TA-D-Liii 11. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1938. Defect or Disease. Routine Inspections. Special Inspections. Number requiring Treatment. Observation. Number requiring Treatment. Observation. (1) (2) (3) (4) (5) Skin Ringworm—Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... ... ... Impetigo ... ... 1 ... Other diseases (non-T.B.) 4 ... 5 ... Eye Blepharitis 3 1 ... ... Conjunctivitis 2 ... 1 ... Keratitis ... ... ... ... Corneal Opacities ... ... ... ... Defective Vision 100 18 1 ... Squint 2 ... ... ... Other conditions 1 2 4 ... Defective Hearing 1 2 1 ... Ear Otitis Media 2 2 ... ... Other Ear Diseases ... ... ... Nose & Throat Chronic Tonsilitis only 8 2 ... ... Adenoids only ... ... ... ... Chronic Tonsilitis and Adenoids 1 ... ... ... Other Conditions 5 ... 1 ... Enlarged Cervical Glands (non-T.B.) ... 1 2 ... Defective Speech ... ... ... ... Heart and Circulation Heart Disease— Organic ... ... 1 ... Functional ... 5 1 ... Anæmia 2 1 3 1 Lungs Bronchitis ... 1 ... ... Other non-T.B. Diseases 2 ... ... ... Tuberculosis Pulmonary— Definite ... ... ... ... Suspected ... ... ... ... Non-Pulmonary— Glands ... ... ... ... Bones and Joints ... ... ... ... Skin ... ... ... ... Other Forms ... ... ... ... Nervous System Epilepsy ... 1 ... ... Chorea ... 1 ... ... Other Conditions ... 3 1 ... Deformities Rickets ... ... ... ... Spinal Curvature 1 ... ... ... Other Forms 11 2 6 ... Other Defects and Diseases 10 ... 29 ... Totals 155 42 57 1 198 Children Found to Require Treatment. Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment. (1) (2) (3) (4) County High School for Girls 229 70 30.6 County High School for Boys 390 77 19.7 619 147 23.7 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. % County High School for Girls 229 50 21.8 154 67.2 25 10.8 ... ... County High School for Boys 390 250 64.1 134 34.3 6 1.5 ... ... Total 619 300 48.4 288 46.5 31 5.0 ... ... 199 TABLE IV.—Return of Defects Treated during the Year ended 31st December, 1938. TREATMENT TABLE. Group I.—Minor Ailments (excluding Unoleanliness). Disease or Defect. Number of treatn Defects treated oi lent during the yez under ir. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin— Ringworm— Scalp—(1) X-ray treatment — — — (2) Other — — — Body — — — Scabies — —• — Impetigo 1 — 1 Other skin diseases 5 — 5 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 6 6 Minor Ear Defects 1 — 1 M iscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 29 — 29 Total 42 — 42 TABLE IV.—cntd. Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as minor 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) 110 21 131 Other defect or disease of the eyes (excluding those recorded in Group I.) 18 — 18 Total 128 21 149 Total number of children for whom spectacles were prescribed— (а) Under the Authority's Scheme 71 (b) Otherwise 21 200 TABLE V. Dental Inspection and Treatment. (1) Number of children who were:— (a) Inspected by the Dentist:— Aged: Age Groups 11 184 Total 930 12 171 13 163 14 171 15 165 16 47 17 22 18 7 Specials (Casuals) 1 Grand Total ... 931 (6) Found to require treatment 802 (c) Actually treated 119 (2) Half-days devoted to Inspection 4 Treatment 12—Total 16 (3) Attendances made by children for treatment 191 (4) Fillings, Permanent Teeth 217 Temporary „ 1—Total 218 (5) Extractions, Permanent Teeth 58 Temporary ,, 11—Total 69 (6) Administrations of general anaesthetics for extractions 36 (7) Other operations, Permanent Teeth 51 Temporary „ —Total 51 201 INDEX. PAGE Section A. Statistics and Social Conditions of the Area 6/23 „ B. General Provisions of Health Services for the Area 24/33 „ C. Sanitary Circumstances of the Area 34/41 „ D. Housing 42/46 „ E. Inspection and Supervision of Food 46/58 „ F. Factories and Workshops 58/60 „ G. Prevalence of, and Control over Infectious Diseases 60/74 Isolation Hospital 76/78 Maternity and Child Welfare 80/113 School Medical Service 116/201 PUBLIC HEALTH. Acts, Adoptive 26 Adulteration 58 Ambulance service 26 Ante-natal Clinics 90 ,, ,, Abnormal Cases 91 Artificial Sunlight Treatment (M. & C. W.) 86 Bacteriological Examinations 47,72 Bakehouses 54 Baths—Swimming 30 Births 8 Bye-laws and Regulations 27 Cancer 71 Children and Young Persons Act 90 Clinics and Treatment Centres 24 Convalescent Home Treatment 86 Dairies and Milkshops 47 Deaths 12 „ Maternal 16 „ Infantile 15 Demolition Orders 45 Dental Treatment (M. & C. W.) 83 Diabetes—Supply of Insulin 72 Dining Room and Restaurants 54 Diphtheria 78 ,, Immunisation 63 Diseases of Animals Acts 56 Drainage 36 Domiciliary Midwifery Service 109 Enteric Fever 60 202 PAGE Factories 58 Foods, Inspection of 46 Foster Mothers 38 Foot Clinic 31 Food and Drugs Act 56 Hairdressers 38 Health Visitors, Visits 83 Home Helps 100 Hospital Provision -5 House to House Inspection 45 Housing Statistics 42 Ice Cream 50 Infant Welfare Clinics 80 „ „ „ Attendances 82 „ Mortality 87 ,, Life Protection SO Infectious Diseases "0 Inquests -9 Insulin, Supply of 72 Isolation Hospital 76 Legislation in force -•> Massage Establishments 30 Maternal Morbidity and Mortality 108 Maternity Beds 04 Measles 65 Meat Inspection 51 Midwives'Act, 1936 109 „ Fees paid to Doctors 113 „ Medical Aid H2 Milk, Scheme for Supply of 113 Mortuary 28 Neo Natal Mortality 87 Notification of Births 80 Nursing Homes 100 Nutrition 113 Obstetric Consultant 106 Offensive Trades 55 Ophthalmia Neonatorum 87 Ophthalmic Clinic (M. & C. W.) 85 Orthopaedic Clinic (M. & C. W.) 84 Overcrowding 44 Petroleum Acts 38 Population 6 Post-Natal and Gynaecological Clinic 95 203 PAGE Public Cleansing 34 Puerperal Pyrexia 105 Public Houses 55 Rag and Flock Act 37 Rats and Mice Destruction Act 39 Refuse Collection 35 Rent Restriction Act 46 Restaurants and Dining Rooms 54 Sanitary Inspectors' Visits 35 Scarlet Fever 61,76 ,, ,, Incidence of Complications 61 „ ,, Complications amongst Patients in Isolation Hospital 77 Scavenging 34 Schools 39 Shops Act, 1934 38 Slaughter Houses 51 Smoke Abatement 39 Social Conditions 7 Staff 3,4 Stillbirths 93 Swimming Baths 30 Tuberculosis 68 Typhoid Fever 60 Unsound Food 51 Verminous Premises 37 Voluntary Workers 81 Water Supply 34, 36 TABLES. Table 1—Births 11 ,, 2—Deaths 17 „ 3—Comparative Statistics 21 ,, 4—Vital Statistics of Whole District 22 ,, 5—Analysis of Mortality 23 ,, 6—Infectious Disease Notifications 73 „ 7—Infant Welfare Clinic Attendances 82 „ 8—Infant Mortality ... 88 204 PAGE SCHOOL MEDICAL SERVICE. Accommodation 116 Artificial Sunlight Clinic 143 „ „ Effect on Haemoglobin Content of Blood 127 Anaemia—Investigation into incidence of 127 Aural Clinic 144 Blind Children 152 Board of Education Report on School Medical Service 161 Child Guidance 153 Convalescent Home Treatment 153 Co-ordination 116 Deaf Children 153 Defective Vision 130 Dental Clinic 133 „ „ Report of Senior Dental Surgeon 137 Employment of Children 185 Eye Clinic 130 Heart Clinic 148 Heights and Weights 122 Knotts Green Special School 150 Malnutrition 121 Meals, Provision of 178 Medical Inspection 117 „ Treatment 124 Mentally Defectives 150 Milk Meals 178 Minor Ailments Clinic 124 Orthopaedic Clinic 141 Ophthalmic Clinic 130 Plantar Warts in School Children 167 Physically Defective Children 150 Physical Training 155 School Camp 157 „ Population and Attendance 116 „ Premises—Alterations and Additions 117 Secondary Schools—Medical Inspection 185,164 Speech Defects 165 Squint Clinic 132 Statistical Tables 187 Tonsils and Adenoids 145,164 Uncleanliness 121