WAL 13 CULN(I)NALIHANSTOW Borough of Walthamstow. REPORT OF THE MEDICAL OFFICER OF HEALTH For the Year 1935 u - ' > x ' 4-- •; o . '< -<• ■ .. .. Borough of Walthamstow. REPORT OF THE MEDICAL OFFICER OF HEALTH For the Year 1935 INDEX. page Section A.—Statistics and Social Conditions of the Area 7 „ B.—General Provision of Health Services in the Area 13 „ C.—Sanitary Circumstances of the Area 19 „ D.—Housing 30 „ E.—Inspection and Supervision of Food 44 „ F.—Prevalence of and Control over Infectious Disease 52 „ G.—Infectious Disease Hospital 72 „ H.—Maternity and Child Welfare 82 „ I.—Thorpe Coombe Maternity Home 113 „ J.—Survey of Health Services 143 page Acreage 7 Adulteration 47 Albuminuria 121 Ambulance 13 Anaesthetics and Analgesia 114, 142 Ante-Natal Clinic 89, 92, 99, 100, 117 Antitoxin 63 Bacteriological Analyses 28 Bakehouses 23 Biological Tests 45 Births 8 „ Notification of 85 „ Registration of 85 Birth Rate 8 Breech Delivery 126 Breast Feeding 90 Brookfield Hospital 94 Cæsarean Section 129 Cancer 11 Caravans 25 Cerebro-Spinal Meningitis 67 Child Welfare 89 Children Act 93 Clearance Areas 37 Clinics 14, 89, 93, 98, 99, 145 Closet Accommodation 20 Committees 4, 82 Comparability Factor 9 Compensation (Midwives') 106 Connaught Hospital 17 Consultants 84, 104, 119 Contracted Pelvis 129 Cowsheds 23 Cremation 80 Dampness 22 Deaths 8,11 „ Infant 87,88 „ Infectious Diseases 10 „ Institutional 12 Death Rate 8 page Dental Treatment 93, 95 Diarrhœa 9, 89 Dick Tests 59 Diphtheria 62, 76 „ Immunisation 55 Diseases of Animals Acts 49 Disinfection 22 District Midwife 117, 121 Drainage 19 Dysentery 64 Eclampsia 123 Encephalitis Lethargica 67 Enteric Fever 64 Erysipelas 66 Essex Public Medical Service 18 Factories & Workshops Acts 50 Fishmongers 23 Food and Drugs 47 „ Poisoning 68 Foot Clinic 14 Forceps Delivery 131 Hæmorrhage— Ante-Partum 123 Post-Partum 123 Health Education 80 „ Services, Survey of 143 „ Visitors 84 Home Helps 92, 101 Hospital Accommodation 16, 102 „ Infectious Disease 72, 144 „ Smallpox 61 House-to-House Inspection 33 Housing 30 Act, 1930 37 Act, 1935 38 „ Conditions 33 Inspection 31, 144 „ Register 35 „ Shortage 35 „ Statistics 30 „ Tuberculosis Cases 35 page Ice Cream 46 Immunisation 55, 59 Industrial Activity 8 Infant Life Protection 93, 146 Mortality 9, 87, 138, 141 Infectious Diseases 52 „ „ Clinic ... 54 Institutional Treatment ... 101 Inquests 79 Invalid Children's Aid Asscn. 97 Isolation Hospital 72 Laboratory Work 60 Massage 92, 93, 98 Maternal Mortality 10, 109, 114, 137 Maternity and Child Welfare 82 „ Homes 102 Measles 9, 68 Measles Serum 68 Meat Inspection 46 Medical Aid 105, 120 Examinations 79 Midwives 104, 145 Milk, Assisted Scheme ... 100 „ and Dairies Order ... 46 „ Shops 45 „ Special Desig. Order... 46 „ Supply 45 Miscellaneous 79 Mortuary 79 Neo-Natal Mortality 87 Notices, Sanitary 20 Notifications and Rates ... 10 Notification of Births ... 85 Nurse Children 93 Nursery School 100 Nursing 14, 64, 69 Homes Registration Act 19 Obstetric Consultants ... 84 Offensive Trades 48 Ophthalmia Neonatorum 109 Ophthalmic Treatment 96 Orthopaedic Treatment ... 94 Outworkers 52 Overcrowding ... 37, 38 Parks 8 Pasteurisation 48 Perineal Lacerations 133 Placenta Prævia 123 Pneumonia 64 Poliomyelitis 67 Population 7 Post-Mortems 79 Post-Natal Clinic 100, 142, 145 Propaganda 80 Public Assistance 18 „ Cleansing ... 20, 144 page Publicity 146 Puerperal Fever and Pyrexia 10, 106, 134 Sepsis 8 Pupil Midwives 116 Rainfall 80 Rateable Value 7 Rats and Mice Destruction Act, 1919 49 Recreation Grounds 8 Refuse Disposal 20 Rent Restriction Act 48 Rheumatism Clinic 54 Rickets 92 Rivers and Streams 19 Sanitary Inspection 20 Scarlet Fever 61, 74, 77 „ Immunisation 59 Schick Tests 55 Schools 25 Sewerage 19 Shops Act 24 Slaughterhouses 44 Smallpox 52 Smoke Abatement 24 Social Conditions 7 Special Premises 22 Staff 6, 72, 84, 113, 144 Statistics 7, 8, 30, 53 Stillbirths 8, 87, 138 Survey—Housing Act. 1935... 38 Health Services ... 143 Swimming Baths 26 Tents, Vans and Sheds ... 25 Thorpe Coornbe Maternity Home 113 Tonsils and Adenoids ... 96 Tuberculosis ... ... 9, 69, 146 „ Order, 1925 ... 49 Tuberculous Meat 46 Twins Delivery 128 Unemployment 7 Unhealthy Areas 37 Vaccination 60 Venereal Diseases 18 Vertex, Posterior 124 Vital Statistics ... 8, 10 Walthamstow Child Welfare Society 97 Walthamstow District Nursing Association 102 Water 19 Whooping Cough 9 Women's Clinic 14 Zymotic Diseases 9 PUBLIC HEALTH AND SANATORIUM VISITING COMMITTEES. Chairman : Alderman G. Gibbons, J.P. Ex-Officio : His Worship the Mayor—Alderman W. H. Shaw, LP. The Deputy Mayor—Alderman Ross Wyld. Chairman of Finance Committee—Councillor E. C. Redhead-. Alderman J. C. Hammond. Alderman Mrs. M. Norrish. „ Mrs. C. McEntee, J.P. „ W. J. Sharp. Councillor Mrs. L. P. Bailey. Councillor G. R. Lowton, J.P. „ Mrs. B. M. Friedberg. „ Mrs. E. M. Miller. _ _ (Chairman, Sanatorium Visiting P. Friedberg. Committee.) „ W. Gillett. Councillor Mrs. E. M. Richards, „ Mrs. E. M. Hammond. „ J. H. Thomason. „ V. S. King. „ Mrs. E. B. Toynbee. Town Clerk : F. G. Garner, Esq. 5 TO THE CHAIRMAN AND MEMBERS' OF THE PUBLIC HEALTH COMMITTEE. Ladies and Gentlemen, I beg to present herewith a report on the work of the Public Health Department for the year 1935. It is arranged in the form suggested by the Ministry of Health. The year under review covered an increasing amount of work. Reference must be made to the favourable vital statistics for the Borough, the decrease in infectious disease, the increase in diphtheria immunisation, and the expansion of services at the Women's Clinic. The work of the Sanitary Section is notable particularly in respect of the inspection and remedy of housing defects, and the action taken with regard to caravan areas. A complete report of the work done in respect of the Housing Act, 1935, is given, although the survey was mainly carried out in 1936. Officers of the Ministry of Health carried out a survey of the Health Services in the Borough, and the report of the Ministry is given in full. Your Engineer and Surveyor, Housing Manager, Cleansing Superintendent, Superintendent of the Fire Brigade and Ambulance Service, have again been good enough to contribute to the report those sections for which they have been responsible in previous years. Mr. Duncan, Chief Sanitary Inspector, has again rendered every help in his power, and has contributed those sections of the report dealing with the work of the Sanitary Inspectorate. I would particularly stress his ready assistance in connection with the Housing Act Survey, and that of Mr. Rose, Chief Clerk. The staff of the Department have given good service, and have assisted in the compilation of the report. I have again to acknowledge every consideration and help from your Committee and, in particular, from your Chairman. I have the honour to be, Your obedient Servant, A. T. W. POWELL, Medical Officer of Health, etc. 6 STAFF. Medical Officer of Health, School Medical Officer and Medical Superintendent, Isolation Hospital and Maternity Home : A. T. W. POWELL, m.c., m.b., b.s. (lond.), m.r.c.s. (eng.), l.r.c.p. (lond.), d.p.h. Assistant Medical Officers: D. BRODERICK, m.b., b.ch., b.a.o., d.p.h., Barrister-at-Law. Miss MARY C. SHEPPARD, b.a., m.b., b.ch., b.a.o., d.p.h., Barrister-at-Law. Miss MARY C. CLARKE, m.b., b.ch., b.a.o. Consultants, Puerperal Fever and Pyrexia Regulations : (See Maternity and Child Welfare Section.) Resident Medical Officer—Isolation Hospital: Miss MARY HAMILTON, m.b., b.ch., b.a.o. H. W. HARDING, m.d., d.p.h. (part-time relief work from 31/5/35). Matron—Isolation Hospital: Miss V. M. WILSON, s.r.n. Women's Clinic : Consultant Surgeon (part-time)—Miss M. M. BASDEN, m.d., f.r.c.s., f.c.o.g. Medical Officer—Miss HELEN RODWAY, m.r.c.s., l.r.c.p., m.c.o.g. (from 31/5/35). Nurse {part-time)—Miss A. M. DUNCAN, s.r.n. Foot Clinic: Chiropodists—Miss M. McCALLUM, s.r.n., c.s.m.m.g., m.c.ch.a. Miss L. K. THOMAS, m.c.ch.a., to 14/8/35. Miss M. SMITH, m.c.ch.a., from 1/7/35. Clerk (part-time)—Mrs. N. MOGER. Chief Sanitary Inspector, Petroleum Inspector, and Chief Inspector, Diseases of Animals Acts: M. E. DUNCAN, m.r.s.i. (a), (b). District Sanitary Inspectors : T. T. BARNES (b), (c). F. NORTHCOTE, a.r.s.i. (b), (c). R. C. BLAND, a.r.s.i. (b), (d). H. D. PERRIN (b), (d). F. W. KEMP, a.r.s.i. (a), (b), (r). T. VAUGHAN (b), (c), (e). H. A. WHIPP (b), (c). Miss O. T. PANTHER (a), (half-time to Factory and Workshops Act duties). (а) Cert. S.I.E.B. (London). (б) Cert. Inspector Meat and other Foods. (c) S.I. Cert, of R.S.I. (d) S.I. Cert, of R.S.I, and S.I.E.J.B. (f) Cert, of Sanitary Science, R.S.I. In addition, some of tile Inspectors hold special Certificates. Miss I. H. JENNINGS, s.r.n., s.c.m. (Infectious Disease Nurse). Veterinary Surgeon (part-time) : BERNARD MOSS, m.r.c.v.s. (lond.). Public Analyst: Dr. BERNARD DYER. Chief Clerk-. R. ROSE. Clerks' G W. WEST, L. R. W. KEMP. Miss'.E. OGILVIE, R. A. C. GREEN, L. RUSHTON, F. J. AYLWARD, A. T. WADE, A. R. KIGGINS. Ambulance Drivers and Disinfecting Staff: W. H. DUNN, E. E. HARBER, R. HIGH, B. WINTER. 7 A.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 4,343 Population (Registrar-General's Estimate, midyear, 1935) 134,490 Number of Assessments, 1st April, 1935 34,457 Rateable value £812,353 Sum represented by penny rate £3,245 Population.—The Registrar-General's estimate of the population at mid-year, 1935, is 134,490, a decrease of 600 on the previous figure. Social Conditions.—No appreciable change from 1931 Report. Unemployment.—The degree of unemployment in the area during 1935 may be estimated from the following data kindly supplied by Mr, W. H. Goodfellow, Manager of the Local Employment Exchange. The total insured work-people of both sexes in Walthamstow is approximately 25,000, and a test showed that roughly two-thirds of the figures given below related to persons residing in Walthamstow (excluding Juveniles). The following data refer to the whole Exchange Area. Date. No. Men. remaining on Women. Register. Total 1935. Total 1934. Amount of benefit paid during month. £ 28.1.35 6,760 1,494 8,254 7,552 22,593 25.2.35 6,225 1,412 7,637 7,295 23,062 25.3.35 5,983 1,565 7,548 6,379 16,377 29.4.35 5,578 1,213 6,791 5,857 24,295 27.5.35 5,276 939 6,215 5,324 18,432 24.6.35 5,141 1,008 6,149 5,158 17,319 22.7.35 4,951 931 5,882 5,178 16,534 26.8.35 4,646 802 5,448 4,791 19,433 23.9..35 4,799 819 5,618 5,049 14,761 21.10.35 4,971 734 5,705 5,142 14,897 25.11.35 5,111 949 6,060 5,504 19,721 30.12.35 5,538 1,173 6,711 6,670 20,918 8 Mr. Dempsey states that the following were the registrations at the Juvenile Employment Bureau:— Fresh Applications— Boys. Girls. Total. 16-17 years 626 537 1,163 14-15 years 759 632 1,391 Re-registrations—- 16-17 years 401 654 1,055 14-15 years 253 240 493 Total Registrations, 1935 2,039 2,063 4,102 1934 2,184 1,566 3,750 Industrial Activity.—Considerable industrial activity has been apparent in the erection of new factories and in the extension of existing works. Particular reference must be made to the new industrial developments on the Lea Bridge site. Several modern factories of attractive design have already been built and they are worked almost entirely by electrical power. Parks and Recreation Grounds.—No change since previous report. Extracts from Vital Statistics:—The Registrar-General's mid-year, 1935, estimate of population (viz., 134,490) has been used for the calculation of all vital statistics:— Total. Males. Females. Live Births Legitimate 1,626 833 793 Birth rate per Illegitimate 44 24 20 1,000' of the estimated sident population 12.4 [Total 1,670 857 813 Stillbirths ... 57 Rate per 1,000 total (live and still) births 33.0 Deaths ... 1,236 Death rate per 1,000 of the estimated resident population 9.2 Deaths from puerperal causes Rate per 1,000 (live and still) births. Puerperal Sepsis Deaths ... 3 1.73 Other Puerperal Causes ... 2 1.16 Total 5 2.89 9 Death-rate of infants under one year of age:— All infants per 1,000 live births 37 Legitimate infants per 1,000 legitimate live births 37 Illegitimate infants per 1,000 illegitimate live births 45 Deaths from Measles (all ages) 1 „ „ Whooping Cough (all ages) 6 „ „ Diarrhoea (under 2 years of age) 7 The comparability factor (see page 9 of 1934 Report) for Walthamstow for 1935 is 1.11 which, applied to the crude death rate of 9.2 for 1935, yields an adjusted death rate of 10.2 as against the rate of 11.7 for England and Wales. Ratio of local crude death-rate to national crude deathrate, 0.78. Ratio of local adjusted death-rate to national crude death-rate, 0.87. The latter ratio means the adjusted death-rate for Walthamstow during 1935 was nearly 13 per cent. below that for England and Wales. The Zymotic Disease death-rate, i.e., the rate per 1,000 population of deaths from the following diseases:—Enteric Fever, Smallpox, Measles, Scarlet Fever, Whooping Cough, Diphtheria and Diarrhœa, etc., under two years, was 0.13 against 0.29 in 1934. The Pulmonary Tuberculosis death-rate was 0.51 per 1,000 population, and the Non-Pulmonary death-rate was 0.044 per 1,000 population. The natural increase of population, i.e., excess of births over deaths, was 434. The usual comparison of vital statistic rates with those for the whole country, is shown in the table on the following page. Births:—Births are dealt with under the Maternity and Child Welfare Section of the Report. Deaths:—The Registrar-General's classification of causes of death by sex totals is given. These have been sub-divided locally, as accurately as possible into age and ward groups. The total number of deaths in 1935 (1,236) compares with 1,393 during 1934, the respective death-rates per 1,000 population being 9.2 and 10.3. 10 Birth-rates, Death-rates, Analysis of Mortality, Maternal Death-rates, and Case-rates for certain Infectious Diseases in the year 1935. England and Wales, London, 121 Great Towns and 140 Smaller Towns. (Provisional Figures based on Weekly and Quarterly Returns.) England and Wales. 121 County Boroughs and Great Towns (including London) 140 Smaller Towns (Resident Populations 25.000 to 50,000 at 1931 Census). London Administrative County. Walthamstow Rates per 1,000 Population. Births— Live 14.7 14.8 14.8 13.3 12.4 Still 0.62 0.68 0.64 0.52 0.42 Deaths— All Causes 11.7 11.8 11.2 11.4 9.2 Typhoid and Para-typhoid Fevers 0.00 0.00 0 00 0.00 0.00 Measles 0.03 0.04 0.03 0.00 0.00 Scarlet Fever 0.01 0.01 0.01 0.01 0.00 Whooping Cough 0.04 0.04 0.03 0.04 0.04 Diphtheria 0.08 0.09 0.07 0.06 0.03 Influenza 0.18 0.16 0.17 0.11 0.07 Violence 0.52 0.45 0.41 0.51 0.37 Notifications— Scarlet. Fever 2.96 3.19 2.75 2.64 4.21 Diphtheria 1 60 1.96 1.34 2.25 1.22 Enteric Fever 0.04 0.04 0.06 0.05 0.03 Erysipelas 0.42 0.48 0.37 0.45 0.37 Pneumonia 1.15 1.36 0.98 0.89 0.95 Rates per 1,000 Live Births. Deaths under 1 year of age 57 62 55 58 37 Deaths from Diarrhœa and Enteritis under 2 years of age 5.7 7.9 3.8 11.2 4.2 Maternal Mortality— Puerperal Sepsis 1.68 Not available 1.80 Others 2.42 1.20 Total 4.10 3.00 Maternal Mortality— Rates per 1,000 Total Births(Live and Still). Not available Puerperal Sepsis 1.61 1.73 Others 2.32 1.16 Totals 3.93 2.89 Notifications— Puerperal Fever 3.60 4.55 2.76 4.32 2.31 Puerperal Pyrexia 9.44 11.14 8.25 11.89 17.95 11 Net Deaths at the subjoined ages of "Residents whether occurring within WARDS. or without the district. Causes of Death. 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 St. James Street High Street Hoe Street Wood Street Hale End Higham Hill 1 M F 3 4 5 6 7 8 9 10 1 Tvphoid and Para-typhoid Fevers – – – – – – – – – – – – – – – – 2 Measles 1 – – 1 – – – – – – – 1 – – – – 3 Scarlet Fever – – – – – – – – – – – – – – – – 4 Whooping Cough 2 4 3 3 – – – – – – – 2 1 1 1 1 5 Diphtheria 1 3 — — 1 3 — — — — — 1 1 1 1 — 6 Influenza 0 4 – – – – – – 4 6 2 2 — 2 3 1 7 Encephalitis Lethargica — 1 — — — 1 — — — — — — — 1 — — 8 Cerebro-spinal Fever — 2 — — 1 — — — 1 — — — — — 1 1 9 Tuberculosis of Respiratory system 39 30 — — — 1 17 25 20 6 12 8 13 12 11 13 10 Other Tuberculous Diseases 3 3 1 — 2 — — 2 — 1 — — 1 1 3 1 11 Syphilis 1 — — — — — — 1 — — 1 — — — — — 12 General Paralysis of the Insane, tabes dorsalis 5 1 – – – – – 2 2 2 – – – – 2 4 13 Cancer, Malignant Disease 114 90 — — — — 1 18 82 103 30 25 42 32 36 39 14 Diabetes 3 11 — — — — 1 3 3 7 1 1 4 3 3 2 15 Cerebral Hæmorrhage, etc. 24 37 1 — — 1 — 3 10 46 17 6 11 9 7 11 16 Heart Disease 155 189 6 — 2 5 5 21 64 241 69 43 73 43 60 56 17 Aneurysm 6 1 – — — – — — 3 4 — — 2 — 2 3 18 Other Circulatory Diseases 24 24 – – – – – 9 17 22 8 9 7 8 9 7 19 Bronchitis 16 22 1 1 — — — 2 8 26 9 2 7 7 7 6 20 Pneumonia (all forms) 31 41 3 1 2 — 1 3 24 38 12 9 20 11 5 15 21 Other Respiratory Diseases 4 7 — — 2 — 1 2 2 4 1 1 2 3 2 2 22 Peptic Ulcer 12 – – – – – 2 7 3 3 4 1 2 — 2 23 Diarrhœa, etc. (under 2 years) 5 2 6 1 — — — — — — 1 — 2 — 1 3 24 Appendicitis 4 1 — — — — 1 2 2 — 1 — 1 — 1 2 25 Cirrhosis of Liver — — — — — – — — — — — — — — — — 20 Other Diseases of Liver, etc. 1 6 — — — 1 — 1 2 3 3 1 — 1 1 1 27 Other Digestive Diseases 15 11 — — — 2 — 1 5 18 6 3 6 3 4 4 28 Acute and Chronic Nephritis 21 24 – – – – – 5 7 33 9 7 10 5 9 5 29 Puerperal Sepsis — 3 — — — — — 3 — — 1 1 — — 1 — 30 Other Puerperal Causes — 2 — — — — — 2 — — — — — — 2 — 31 Congenital Debility and Malformation, Premature Birth, etc. 23 17 39 1 – – – – – – 5 4 6 4 9 12 32 Senility 7 19 – – – – – – – 26 2 4 3 4 5 8 33 Suicide 6 6 – – – – – 5 3 4 4 2 1 — 1 4 34 Other Violence 26 13 — — — 2 3 9 10 15 5 4 4 7 6 13 35 Other Defined Causes 59 47 2 2 1 5 7 5 31 53 21 15 14 15 26 15 36 Causes ill-defined or unknown — 1 — — — — — 1 — — — — — 1 — – Totals 614 622 62 10 11 21 37 127 307 661 223 155 232 176 219 231 12 The main classification of deaths—those for 1934 being given in parentheses—were as follows:— Whooping Cough, 6 (2) ; Diphtheria, 4 (8) ; Pulmonary Tuberculosis, 69 (83) ; Non-Pulmonary Tuberculosis, 6 (15); Cancer, 204 (217) ; Cerebral Haemorrhage, 61 (56) ; Heart Disease, 344 (311); Bronchitis, 38 (58); Nephritis, 45 (43); Congenital Debility, etc., 40 (39) ; Suicide, 12 (22) ; Violence, 39 (34). Infant deaths are analysed by causes, ages and wards under the Maternity and Child Welfare Section of the Report. Institutional Deaths. Whipps Cross Hospital 215 Central Homes, Leytonstone 171 Connaught Hospital 56 Forest Gate Sick Home 16 Brentwood Mental Hospital 13 Thorpe Coombe 12 Tipping Infirmary 11 London Hospital, Whitechapel 9 Middlesex Hospital, London 7 Prince of Wales' Hospital, Tottenham 8 Walthamstow Isolation Hospital 6 Victoria Park Chest Hospital 6 Queen's Hospital, Bethnal Green 6 German Hospital, Dalston 5 St. Bartholomew's Hospital, London 5 The Forest Hydro, Walthamstow 5 The Clock House, Wood Street, Walthamstow 5 Orsett Lodge, Orsett 4 London Fever Hospital, Islington 4 Heathfield Nursing Home, Walthamstow 4 Guy's Hospital, London 3 Royal Northern Hospital, Holloway 3 Eagle House Nursing Home, Woodford Green 3 Severalls Hospital, Colchester 3 St. Joseph's Hospice, Hackney 2 Queen Mary's Hospital, Stratford 2 Westminster Hospital 2 St. Luke's Hospital, London 2 St. Peter's Hospital, Westminster 2 Maycroft Nursing Home, Wanstead 2 London Jewish Hospital, Stepney Green 2 St. Paul's Hospital, Holborn 2 Jubilee Hospital, Woodford 2 Other Institutions 42 13 B.—GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Public Health Officers of the Authority.—The names and qualifications of officers employed ,by your Authority are given at the beginning of the report and also in the Maternity and Child Welfare Section of the report. All are whole-time officers unless otherwise stated. Laboratory Facilities.—These facilities are detailed under the Infectious Diseases Section of the report. There were no changes in the arrangements detailed in previous years. Ambulance Facilities:— (a) Infectious cases.—No change since last report. (b) Non-Infectious and Accident cases, and See below. (c) Maternity Patients. The ambulance services in the area appear to be quite adequate. 1. Municipal Service. Superintendent Camp, A.M.I.Fire E., reports as follows on the work done during 1935:— False Removals. Accidents. Maternity. Alarm. Total. Mileage. Receipts. 1,307 576 135 1 2,019 11,364 £204 17s. 87 maternity cases have been removed to Thorpe Coombe Maternity Home. The oxygen breathing apparatus, with a mixture of 7 per cent. carbon dioxide, has been in use eleven times, for cases of gas poisoning and collapse, and was successful on ten occasions. 2. Whipps Cross Hospital.—Removal of patients is carried out by ambulances attached to the Hospital. 3. St. John Ambulance Corps. The Corps Superintendent, Mr. W. W. Perriton, reports as follows:— First Aid cases attended 1,204 Number of patients removed 837 Mileage 16,413 Number of road accidents 15 14 "The Corps has been honoured by the gift to four members of the Jubilee Medal, in recognition of services rendered -during the reign of King George V. "At the final District Competitions held on 6th April in London, two Corps Officers and one Divisional Superintendent from Walthamstow were selected to assist the Judges. "Members have done duty at cinemas, cricket, rugby and football matches, fetes, children's and old folks entertainments, Epping Road post at the 'Robin Hood' (summer duty) and our sub-stations as usual." Nursing in the Home:— (a) General.—No change since 1931. (b) Infectious Diseases.—No change since 1931. CLINICS AND TREATMENT CENTRES. Foot Clinic. Total attendances were 8,417 and of these 1,824 were by new patients, and 6,593 were re-attendances by old patients. The receipts were £335 7s. 5d. Following the resignation of the temporary assistant chiropodist, it was decided to make a new permanent appointment. Since June 1935, patients have been seen by appointment only. Women's Clinic—In May the Council decided that sessions should be held weekly instead of fortnightly and that one consultant session be held monthly. Miss Basden continued as Consultant-in-Charge and Miss Helen Rodway, M.C.O.G., took charge of the weekly sessions. The attendances have been as follows:— New Cases. Total Attendances. Ante-Natal 25 25 Gynaecological and Medical 182 710 Contraceptive 11 27 Total 218 762 15 Fifty-four cases were referred to the clinic by private practitioners. Dr. Rodway contributes the following report:— Summary of New Cases. No. of Cases. Ante-Natal:— For diagnosis of pregnancy ... 21 For diagnosis of position of fœtus ... 2 Cardiac failure associated with pregnancy ...1 Pregnancy complicated by multiple fibroids ...1 Sterility ... 8 Contraceptive:— Cases advised ... 7 Advice not given owing to lack of medical reason ... 4 Diseases. Vulva:— Pruritis vulvae ... 4 Senile vulvitis ... 1 Leukoplakia ... 2 Bartholin's cyst ... 1 Vagina:— Cystocele and cele 29 Vaginitis ... 3 Dyspareunia ... 3 Rectovaginal fistula 1 Vaginal discharge ... 3 Uterus:— Cervical polypi ... 2 Cervical erosion ... 5 Cervical laceration ... 1 Fibroids 6 Endometritis ... 1 Retroversion ... 24 Endometrioma .... 1 No. of Cases. Fallopian Tubes and Ovaries:— Ovarian cyst ... 2 Salpingo-oophoritis 1 Urethra:— Caruncle 2 Breast:— Mastitis ... 2 Carcinoma 1 Symptomatic Disorders:— Amenorrhœa— (i) anaemia ... 2 (ii) menopausal 8 10 Dysmenorrhœa ... 3 Menorrhagia ... 6 Metrorrhagia ... 3 Hæmorrhage due to miscarriage ... 4 Miscellaneous:— Anal fissure ... 1 Hæmorrhoids ... 2 Varicose veins ... 2 Appendicitis ... 2 Lipoma 1 Visceroptosis 4 Urinary infections ... 2 Medical:— (i.e., cases not appropriate to scope of clinic) Referred to private doctor or hospital 39 Total ... 218 16 The following operations were performed by MissBasden at the South London Hospital for Women forpatients referred from the Clinic:— Diagnosis. No. Operation. Uterine fibroids 4 Subtotal hysterectomy. Sterility 2 Dilatation and insufflation, (lipiodal injection in one case) Cervical laceration 2 Trachelorrhaphy. Ovarian cyst 2 Removal of cyst (Plus Oophorectomy in one case). Retroversion of uterus and sterility 1 Gilliam's suspension of uterus: Retroversion of uterus and Endometrioma 1 Do. do. and removal of cyst. Retroversion of uterus 1 Gilliam's suspension of uterus. Dyspareunia 1 Dilatation. Cystocele and rectocele 1 Anterior and posterior colporrhaphy. Perineorrhaphy.. Menorrhagia 1 Dilatation and curettage. Hospitals.—There were no changes during 1935 in theHospital services used by the inhabitants of the Borough. Public Assistance in Walthamstow is provided by the South Western Area Guardians' Committee of the Essex County Council, which retains a certain proportion of beds in each of the local institutions formerly provided by the County Borough of West Ham. Mr. Pegram, the Clerk to the Committee, has kindly supplied the following particulars of Walthamstow residents admitted to the various institutions during the year ended' 31st December, 1935:— Institutions. Men. Women. Children. Total. Central Home 156 221 68 445 Whipps Cross Hospital 654 735 295 1,684 Forest Gate Hospital 13 64 14 91 Aldersbrook Children's Homes — — 49 49 Note:—The Margate' Convalescent Homes are now closed down. These children were ultimately transferred to Aldersbrook. 17 32 infants were born to Walthamstow mothers in the Forest Gate Hospital during the year. The number of patients from Walthamstow in Mental Hospitals was 428 on the 31st December, 1935. The Connaught Hospital. Captain Ellison, Secretary to the Hospital, has kindly supplied the following information:— "Of the total number of In-patients admitted during the year, 889 were residents of the Borough. "The following figures show the progress of the Hospital during 1935, as compared with the previous year:— In-Patients. Out-Patients. No. Admitted. Average stay. Daily Average. New. Cases. Attendances. 1934 1,787 22.37 108.65 14,523 77,253 1935 1,798 22.29 109.68 16,192 87,296 "Staff (Medical).—There are five Honorary Medical and Surgical Consultants, and sixteen Honorary Visiting Specialists on the Staff, and four Medical Officers are resident. "Staff (Nursing).—The Nursing Staff consists of the Matron, the Assistant Matron and Sister Tutor (combined post), Home Sister and Ward Sister (combined post), 12 Sisters, including 7 in special departments, 6 Staff Nurses, and 36 Probationers. "Beds.—The complement of 118 beds is allocated as. follows:—Medical cases, 31; Surgical, 43; Children, 30; Private one-bed Wards, 10; Observation Beds, 4. "Departments.—There are facilities for operative surgery, X-Ray work, dental, ophthalmic, massage, and electrotherapy. Pathological work is carried out partly at the Hospital, and partly at other institutions. "Operations and Treatments.—During 1935, 1,009 major operations and 2,818 minor operations were performed, making a total of 3,827. 10,474 Radiographs were taken. There were 10,341 massage treatments, also 19,683 electrical treatments, 71 special treatments, and 3,828 artificial sunlight treatments at the Comely Bank Clinic; a total of 33,923; treatments at this Clinic." B 18 Venereal Disease Treatment. Treatment is provided by the Essex County Council and all the facilities of the London County Council are available. Daily treatment is available between 9 a.m. and 8 p.m. at the following:—Guy's Hospital; London County Council (Whitechapel) Clinic, Turner Street, Mile End; Miller General Hospital, Greenwich; St. George's Hospital; St. Paul's Hospital, Endell Street, W.C.2; St. Thomas's Hospital; University College Hospital, W.C.1; West London Hospital, W.6. In addition, treatment is available at special times at eleven other hospitals. Outfits for taking specimens from patients are provided for practitioners, on request, by the Whitechapel (London County Council) Clinic. Essex Public Medical Service. The above service, now some twelve years old, brings to its members benefits roughly analogous to those of the National Health Insurance Act. Twenty-two of the medical practitioners of the Borough accept patients under the scheme. Public Assistance. Out-relief and institutional treatment is provided by the Essex County Council. Mr. Pegram, Clerk to the Essex County Council South-Western Area Guardians' Committee, kindly states that the amount of relief provided in Walthamstow during the two years ended 31st December, 1935, was as follows :— 1935. 1934. Total amount of out-relief granted £ s. d. £ s. d. to Walthamstow residents during year ended 31st December 53,522 0 0 54,225 1 4 Average weekly number of Walthamstow residents in receipt of relief during year ended 31st December . Men ... 811 862 Women 1,187 1,247 Children 927 1,122 Total 2,925 3,231 The reduction in the total number of persons in receipt of relief when considered along with the reduction in the number of unemployed is gratifying. The total amount of relief was £70.3 less than during 1934. 19 Nursing Homes Registration Act, 1927.— The following stable gives information required by the Ministry of Health:— 1. Number of applications for registration (for additional beds) One. 2. Number of Homes registered No new registrations 3. Number of Orders made refusing or ling registration Nil. 4. Number of appeals against such Orders Nil. 5. Number of cases in which such Orders have been made:— (a) Confirmed on appeal Nil. (b) Disallowed Nil. 6. Number of applications for exemption from registration Nil. 7. Number of cases in which exemption has been:— (a) Granted Nil. (b) Withdrawn Nil. (c) Refused Nil. Periodical quarterly inspections are made to each Home, in addition to any visits necessary for special inquiries. The application for the registration of additional beds was in respect of three beds. The application was granted but the beds were not in use by the end of the year. C.—SANITARY CIRCUMSTANCES OF THE AREA. Water.— New mains have been installed in the following roads:—Walthamstow Avenue, The Risings, Prior's Croft, Keynsham Avenue, Forest Drive, Dean Gardens, Longfellow Road. The supply is provided by the Metropolitan Water Board and has been entirely satisfactory in quality aind quantity. No action has been necessary in respect of any form of contamination. Rivers and Streams.— Periodical cleaning of the Dagenham Brook was carried out to the requirements of the Essex Sewers Commissioners. Drainage and Sewerage.— Extensions of the sewerage system were carried out at Low Hall Farm and Walthamstow Avenue, involving in each case the provision of a pumping station. 20 The construction of the relief sewer from Hale End' Road at the junction with Wadham Road to the Sewage Works has been completed. Closet Accommodation.— The number of cesspools in' use is eight, seven of which are situated in The Avenue. It is anticipated that a new sewer will be constructed in TheAvenue next year, which will reduce the number of cesspoolsto one. Public Cleansing.— The Cleansing Superintendent, Mr.. Eric Bell, M.I.P.C., reports as follows:— "The collection of house and trade refuse has been carried out by means of horse-drawn vans and mechanical vehicles; the only improvement in this service during the year being the increased frequency of collection in certain cases where it has been requested. The usual collection has been weekly. Very few requests have been received for the collection' and destruction of bulky articles, such as bedding. The quantity of House Refuse collected during the year was 25,227 tons, Market Refuse amounted to 1,945 tons, whilst refuse delivered by traders amounted to 3,152 tons. Of the total of 30,324 tons of refuse handled, 26,501 tonswere incinerated and 3,823 tons tipped. Street Cleansing was carried out by means of a combination of hand labour and mechanical methods, the area swept during the year amounting to 259,141,560 square yards, air increase of 86,380,520 square yards on the previous year. Owing to a large quantity of the sweepings being used by. allotment holders, it is impossible to obtain accurate weights of the refuse collected, but a close estimate appears to indicate that slightly less was collected than the previous year. Mechanical gully cleansing was continued during the year, and 1,648 tons of sludge were removed." Sanitary Inspection of the Area. Mr. M. E. Duncan, Chief Sanitary Inspector, reports as follows:— No. of Inspections made. No. of nuisances detected. No. of complaints received. No. of Informal Notices. No. of Statutory Notices served. Total Visits. Served. Complied with. 1935 11286 11491 1968 2664 2641 140 26466 1934 11204 984-9 1335 2501 242 4 113 24053 21 Of the 140 Statutory Notices served during 1935, 129 were -complied with. The nature and variety of the work done during 1935 is ,shown in the following tables:— Drains tested 552 „ reconstructed or repaired 443 „ obstructions removed 232 „ means of access provided 69 „ ventilation provided or improved 95 ., ventilation repaired 160 Soil pipes repaired 2S „ „ new, provided 59 Rain water pipes renewed 320 „ „ „ disconnected from drains 33 Roofs repaired or renewed 1,066 Gutterings repaired or renewed 564 W.C. pans or traps provided 520 Gully traps provided 116 W.C. flush cisterns provided 79 „ „ repaired 235 W.C. floors concreted 101 W.C.s repaired and cleansed 555 W.C.s light and ventilation improved 12 Waste pipes renewed or trapped 318 „ „ repaired 175 New sinks provided 234 Water supply reinstated 5 „ „ taken off main 14 Cisterns cleansed and covered 39 Conveniences cleansed or repaired 27 .Sculleries paved 101 Yards and forecourts paved and repaired 567 Dirty houses cleansed 102 Dirty rooms cleansed 3,763 .Floors repaired 480 Ventilations under floors provided 231 New damp-proof courses provided 386 Sites concreted 7 Offensive accumulations removed 52 Animals improperly kept, removed 2 Manure receptacles provided 5 Stables'.cleansed, paved and drained 45 Manholes repaired or re-sealed 132 'Other cases of dampness remedied 590 Separate Sanitary Conveniences provided to shops where both sexes are employed 2 ^Miscellaneous repairs 2,959 22 Infectious Disease. Visits to premises ... 1,166 Re-visits to premises ... 90 Visits in connection with Smallpox ... 6 Premises disinfected ... 910 Articles disinfected at Low Hall ... 12,820 Articles destroyed at Low Hall ... 174 Dampness in Houses. Sites concreted ... 7 Damp-proof courses provided ... 386 Yards and forecourts paved and drained ... 567 Roofs made watertight ... 1,066 Rain-water pipes made good ... 320 Guttering repaired or renewed ... 564 Other cases of dampness remedied ... 590 Ventilation under floors provided ... 231 House-to-house inspections ... 1,192 Special Premises. Visits Number. paid. Factories 205 392 Workshops 184 280 Outworkers 501 388 Slaughterhouses 9 415 Butchers' Shops 98 962 Bakehouses 48 178 Fishmongers, fish fryers and curers, etc. 55 372 Eating-houses and Coffee Stalls 68 197 Ice Cream Vendors 134 98 Cowsheds 1 14 Dairies and Milkshops 198 205 Laundries 8 51 Rag and Bone Dealers 6 55 Elementary Schools 32 15 Private Schools 9 Piggeries 4 43 Street Stalls Numerous 86 Greengrocers ,, 145 Stables ,, 318 23 As a result of the regular periodical visiting of the Special Premises the following works were carried out:— Butchers' Shops and Slaughterhouses. Special cleansings, 35; Paving repaired, 4; Accumulations removed, 1; New Galvanised Bins provided, 6; Drains repaired, 4; W.C.s repaired and cleansed, 6; Yard paving repaired, 12; Floors repaired and ventilated, 3; Roofs repaired, 2; Drains cleared, 4; Light and ventilation improved, 12. Bakehouses. Special cleansings, 62; Drains repaired, 1; W.C.s cleansed and doors repaired, 4; Yards repaved, 3; W.C. cisterns repaired, 1; Floors repaired, 3; New ceilings fixed, 2; Roofs repaired, 4; Premises general repairs, 7; New W.C. pans and traps, 1. Fishmongers. Special cleansings, 33; Yards repaved, 14; Accumulations removed, 5; Roofs repaired, 3; Gutters renewed, 2; Other improvements, 7; Drains cleared, 2. Coffee and Eating Houses. Special cleansings, 20; Yard pavings repaired, 1; W.C. cisterns repaired, 3; Floors renewed, 1; Drains repaired, 2; Kitchen light and ventilation improved, 2. Ice Cream Vendors. Special cleansings, 7; Special cleansing of utensils, 2. Cowsheds and Milkshops. Special cleansings, 8; Pavings relaid, 3; Fittings and other improvements, 4; Roofs repaired, 1; W.C.s repaired, 5; Drains reconstructed, 1. Stable Premises. Cleansings, 40; Accumulations removed, 18; Roofs repaired, 3; Pavings repaired, 4; W.C.s repaired, 1; Manure receptacle provided, 1; Drains reconstructed, 2. Laundries. Special cleansings, 4; Roofs repaired, 1; Other improvements, 1. 24 Rag and Bone Dealers. Cleansings, 10; Paving repaired, 1; Accumulations removed, 2. Piggeries. Cleansings, 4. Shops Act, 1934.— The Council decided that the main work of inspection be carried out by the Shops Act Inspector and his staff. Any breach of the Act in relation to sanitary conditions when discovered by the Shops Act Inspector is transferred to the Public Health Department. In this connection, two such alleged breaches were received by your Chief Sanitary Inspector and the matter of complaint investigated, and as a result one W.C. was provided for males in one instance. The other referred to the want of W.C. accommodation, but it was subsequently found that the accommodation was sufficient for the staff employed. Premises and Occupations which can be Controlled by Bye-Laws or Regulations.— The number of Offensive Trades in the area was:— Fish Curers 29 Fish Fryers 43 Slaughterhouses 9 Rag and Bone Dealers 6 Bakehouses 48 Smoke Abatement.— During the year there have been very few complaints of nuisances from factory premises. Personal contact with stokers and engineers concerned result in better stoking or alteration of fuel supply, with the resulting cessation of smoke. In one instance, overloading the boiler was unquestionably responsible for the issue of smoke in quantities, and in this case an additional Lancashire Boiler is being fixed. As soon as this additional boiler is in work the nuisance should be abated. The cost of such an installation is not less than f i,000, and some patience must be exercised in such cases. In connection with factory premises, it is interesting to note that due to the intervention of the Sanitary Staff quite 25 considerable sums of money are expended yearly and which cannot be accounted for in any Annual Report unless introduced under this heading. As instances of this, I would refer to an extraction plant recently fitted at a certain factory. The existing plant I considered quite inadequate, and the new system I suggested consisted of 24-inch metal trunk lines, with various smaller connecting trunks, discharging into the open air to deal efficiently with fumes from cellulose spraying machines. Here the cost of installation was approximately £450, and a further expenditure of about £200 is now necessary to maintain a working temperature suitable to the trade. Further— although this matter is not a Public Health Nuisance— due to vibration caused by machinery in a certain factory, it has been discovered that ceilings from adjacent house property have fallen. I visited the factory, with the result that the present steam engine will be run at a slower speed pending a new geared electric engine being substituted which, it is claimed, will cause no vibration. The cost of this installation will be in the region of £1,600. Tents, Vans, Sheds, etc.— As reported in 1934, there were four areas in Higham Hill Ward, and the Council took advantage of certain powers given under the Essex County Council Act of 1933. The appeals by the dwellers in three areas were dismissed. One of the owners of the land— himself a dweller on the site— made a further appeal to the Court. Upon hearing his case again the Court dismissed the appeal, but gave an extension of time. Certain hardships apparently were likely to arise, and the Court decided that a certain amount of patience should be borne, and fixed six months as the limit of time for the dwellers to quit. One area has been fully cleared, and the other two are almost clear of dwellers. The fourth area is being dealt with at the time of going to print. (The following sections are contributed by the Medical Officer of Health). Schools.— The sanitary condition of Schools is more fully discussed in the School Medical Officer's report. A detailed sanitary survey is made of each school by the School Medical 26 Inspector at the conclusion of Medical Inspection. Recommendations are sent to the Director of Education. The School Medical Officer's Report gives a detailed account of the sanitary improvements effected during 1935. Swimming Baths and Pools.— (a) Public. (i) Municipal Baths, High Street. These comprise a covered swimming bath erected in July, 1900, and slipper baths added in 1922/3, and modernised in 1934 by the installation of a continuous chlorination and filtration plant. The Baths Superintendent kindly gives the following particulars:—- The length is 127ft. 8ins. and the breadth 35ft. lin. The depth varies from 3ft. 6ins. to 6ft. 7ins., and the capacity is approximately 150,000 gallons. The chlorination and filtration plant was supplied by Messrs. Bell Bros., and has a turnover of three hours (50,000 gallons per hour), 0.3 to 0.5 parts per million of free chlorine being aimed at. The plant was kept in operation for an average of 12.5 hours per day, the bath being open for 150 days. The approximate number of swimmers in 1935 was 67,936 and the estimated maximum load was 1,193. Bacteriological and chemical analyses were carried out on three occasions, with the results shown in the following table (samples 1—3). (ii) Whipps Cross Bathing Pool. This is a large open-air pool situated in Epping Forest in the area of the Borough of Leyton and a few hundred yards from the Walthamstow boundary. It is administered by a joint committee representing the two boroughs. There is no continuous chlorination and filtration plant. Consideration is now being given to the matter. The pool is supervised by the Medical Officer of Health for Leyton, who kindly sends a copy of the analytical findings when samples are taken. 27 Sampling was carried out in June (satisfactory) and inJuly (twice unsatisfactory). The pool will be more fully described in the annual report of the Medical Officer of Health for Leyton. (b) Private. The Kingfisher Pool. This is an open-air pool of recent construction in Epping Forest. The Managing Director kindly gives the following" particulars:— The length is 110ft. and the breadth is 50ft. The depth varies from 3ft. to 9ft., and the capacity is 216,000 gallons. The chlorination and filtration plants were supplied respectively by Messrs. Wallace & Tiernan and Messrs. United Filters, Ltd., and have a turnover of eight hours, with a possible speeding up to six hours. 0.2 parts per million of free chlorine are aimed at for the deep end and 0.6 at the shallow end. The plants were kept in operation for an average of 15 hours per day (and all day and night over the week-ends, if found necessary), the pool being open for 170 days. The approximate number of swimmers in 1935 was 55,000,. and the estimated maximum load was 800. Bacteriological and chemical analyses were carried out on four occasions with the results given in the following table (samples 4-7), from which it will be noted that all the four samples were quite satisfactory. 28 MUNICIPAL BATHS. KINGFISHERS POOL. Number of Samples. (1) (2) (3) W (5) (6) (7) 24.6.35 8.7.35 22.8.35 24.6.35 8.7.35 25.7.35 22.8.35 BACTERIOLOGICAL:— Colonies on agar at 370C (24 hrs.) per c.c — 2 6 — - — 9 ,, ,, ,,(48 hrs.) 195 7 20 230 2 3 98 ,, „ 20OC (72 hrs.) — 7 180 — 3 18 320 ,, gelatine at 22 C (72 hrs.) ,, 341 — — 247 — — — Bacillus coli —50 c.c. —100 c.c. —100 c.c. —50 c.c. -f 100—50c.c. —100 c.c. —100 c.c. ,, welchii - + 100 c.c. -—10 c.c. —100 c.c. — —100 c.c. —100 c.c. —100 c.c. Streptococci — —10 c.c. —10 c.c. — —10 c.c. —10 c.c. —10 c.c CHEMICAL:—(parts per 100,000) Appearance — Clear and bright Clear and bright — Clear and bright Bright Bright Colour — Normal Normal — Normal Normal Normal Cdour — Slight earthy Faint earthy — Faint earthy Faint earthy Faint earthy Reaction (pH) 8.5 7.8 7.8 8.5 7.4 7.5 7.2 Electrical conductivity (20OC) — 935 855 855 900 930 Total solids (180OC) 54.4 62.5 57.0 68.7 57.0 60.0 62.0 Chlorine as chlorides 9.7 10.8 11.2 13.6 18.0 14.8 20.4 Free chlorine — 0.02 0.015 — 0.005 0.015 0.02 Nitrogen as nitrates 0.45 0.52 0.56 0.20 0.76 0.54 0.84 ,, ,, nitrites Nil Nil Nil. T race Nil. Nil. Nil. Hardness:—Permanent . — 7.5 11.5 — 26.0 24.0 24.0 Temporary — 15.0 9.5 — 2.0 2.0 1.0 Total 22.4 22.5 21.0 24.4 28.0 26.0 25.0 Poisonous metals Nil Nil. Nil. Nil. Nil. Nil. Iron 0.005 Free ammonia 0.006 0.0006 0.0026 0.014 0.0036 0.0022 0.0128 Albuminoid ammonia 0.08 0.0094 0.0094 0.10 0.0104 0.011 0.0166 Oxygen absorbed in 4 hrs. at 270C 0.80 0.065 0.060 0.81 0.0450 0.06 0.05 Note:—Samples 1 and 4 were done at a different laboratory from the others. Sample 6 was done by arrangement with the Essex County Council. 29 Opinions— No. 1—From the low free and saline ammonia figure it would appear that this bath had not been used much since the water had been chlorinated, although there was no trace: of free chlorine present on receipt of the sample. It would be interesting to have samples of these waters for examination at the end of a hot day, when the baths had been used to a considerable extent, and. to have fresh samples the next morning, as this would give a better indication of the amount of actual purification taking place. No. 2— This is a clear and bright water of normal colour ancL earthy odour. It is neutral in reaction, hard in character, free from metals, and contained 0.2 parts per million of free chlorine. The water is of satisfactory organic quality and a high degree of bacterial purity, and is suitable and safe for swimming bath purposes. No. 3— This is a clear and bright water of normal colour,, faint earthy odour only, and neutral in reaction. It contains no excess of saline or mineral matter, is free from metals, and contained a trace of residual freechlorine, not excessive in amount. The water is of good organic quality, and a highstandard of bacterial purity, and we are of opinion that it is suitable and safe for swimming bath purposes. No. 4— From the low free and saline ammonia figure it would appear that this bath had not been used much since the water had been chlorinated, although there was no trace of free chlorine present on receipt of the sample. On the whole the water is very satisfactory chemically, but I should like to see the oxygen absorbed even lower, if" possible, as this is largely due to unoxidised organic matter. No. 5— This is a clear and bright water of normal colour and' faint earthy odour. The water contains no excess of saline matter, is free from metals, and of a satisfactory degree of organic quality. Bacteriologically, also, it is of satisfactory quality,, inasmuch as it contains few bacteria and the Bacillus Coli. is absent in 50 c.c. 30 We regard the water as safe and suitable for swimmingbath purposes, but the results suggest that the dose of chlorine could beneficially be slightly increased. No. 6— The water was bright in appearance, contained a few particles of vegetable matter in suspension, and had a faint earthy odour. It was of neutral reaction, hard in character, contained a trace of free chlorine, and was of satisfactory chemical quality. Bacteriologically, it was of a very high standard of purity. The water was of satisfactory quality, therefore suitable and safe for swimming bath purposes. No. 7— This is a reasonably clear and bright water, of normal colour, containing only a few particles of debris in suspension. It is neutral in reaction, contains no excess of saline, mineral or metallic matter, and an appropriate amount of residual free chlorine was present. The water is of satisfactory organic and bacterial purity, and we regard it as suitable and safe for swimming bath purposes. D.— HOUSING. (a) Statistics. The particulars of new houses erected during 1935 was given in the form prescribed for previous years. The following are the figures supplied by the Engineer and Surveyor:— Number of New Houses erected during the year:— (a) Total, including number given separately under (b) :— (i) By Local Authority 8 Houses 12 Flats (ii) By other Authorities Nil (iii) By other bodies or persons 362 Houses 38 Flats 420 (b) With State Assistance under the Housing Acts:— (i) By the Local Authority:— (a) For the purpose of the Act of 1930 8 Houses 12 Flats 31 The 420 houses are situated as follows:—- Hale End Ward 193 (a) High Street Ward 16 Higham Hill Ward 68 (b) Hoe Street Ward 20 St. James Street Ward 30 (c) Wood Street Ward 93 (d) (a) Including 2 Flats; (b) including 12 Flats; (c) including 28 Flats; (d) including 8 Flats. N.B.—Each flat is counted as one house. Schemes for the erection of 130 houses at Chestnut Farm, 14 houses in Forest Road by Holmes Avenue, and 8 flats at Cooper Avenue have been submitted for approval. (b) Inspection. The following information is given in the form required by the Ministry of Health, and is supplied by the Chief Sanitary Inspector:— 1. Inspection of Dwelling-Houses during the Year (1) (a) Total number of dwelling-houses inspected for housing defects (under the Public Health or Housing Acts) 4,153 (b) Number of inspections made for the purpose 15,580 i(2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,192 (b) Number of inspections made for the purpose 4,862 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil {4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 2,664 32 2. Remedy of Defects during the Year without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 2,6411 3. Action under Statutory Powers during the Year:— A. Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 120 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 108 (b) By local authority in default of owners (at a cost of £24 12s. 8d.) 1 B. Proceedings under the Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 20 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 20- (b) By local authority in default of owners — C. Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made Nil (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil. D. Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil 33 In 1930, it was estimated that the number of houses that would be repaired during the next five years would be 11,575. It is gratifying to me to be able now to report that my estimate was slightly exceeded— the actual number of houses repaired was 11,981. Houss-to-House Inspections. During 1935, house-to-house inspections were carried out in the following streets:— Southcote Road. Manor Road. Hazelwood Road. Carlton Road. North Road. Kimberley Road. Back Road. Parts of:— Vallentin Road. Glenthorne Road. Glen Road. Woodlands Road. Boston Road. Exmouth Road. Jewel Road. Ringwood Road. Coleridge Road. Colchester Road. Exeter Road. Cambridge Road. Blenheim Road. Chelmsford Road. Tavistock Avenue. Boundary Road. Pembar Avenue. Fulbourne Road. Queen Elizabeth Road. St. John's Road. Blackhorse Lane. Gaywood Road. Worcester Road. Campbell Road. Higham Hill Road. Somers Road. Claremont Road. Westbury Road. St. Andrew's Road. Pearl Road. Mount Pleasant Road. Hatherley Road. (c) General. During the year all letters addressed to the Public Health Department in support of applications for rehousing were acknowledged and forwarded to the Housing Manager for the attention of the Housing Committee. Mr. J. E. West, your Council's Housing Manager, has kindly contributed the following statement:— "The re-opening of the Housing Register, which was closed in December, 1933, was further considered during the past year, but having regard to the large number of applicants on the register whose requirements remained unfulfilled, and the comparatively small number of houses expected to become available during 1935, it was decided not to register any new applicants. 34 " This decision was no doubt made in the best interests of all parties, it being realised that in all probability the present register of applicants might become redundant as a result of due consideration being given to the survey under the 1935 Housing Act. The formation of a waiting list from the survey might possibly replace the existing Housing Register, and the persons appearing on such waiting list would then be re-housed on such lines as have proved to be equitable and successful from past experience. " Throughout the year there was ample evidence, from enquiries made at the Estate Office, of the demand for houses to let. A very large demand is evident, too, for lower rents, even from the Council tenants themselves. Such demands were received not only from the lower-paid wage-earner or casual worker, but also from persons whose incomes wrere more constant. Even in the latter instance, enquiries show that the rent required is out of all proportion to the income available. This is particularly noticeable in the case of large families where there may be only one wage-earner. In Council houses it is also obvious that in many instances the financial resources available are insufficient to pay even the subsidised rent. "In order to meet this difficulty in some measure, an experiment was instituted during the year 1935 to operate a differential renting scheme on a small scale. The twenty houses built under the 1930 Housing Act for re-housing tenants from clearance areas appeared to be the appropriate houses to inaugurate the scheme. As a result, ten per cent, of the tenants pay rates only. It has thus been possible to provide adequate accommodation for as little as 2/2 per week for the appropriate type of tenant. Such rent relief, Of course, is granted in accordance with the provisions of the 1930 Housing Act, and is only granted to "those who need it, and only for so long as they need it." "A still further step was taken in providing assistance in urgent necessitous cases by supplying such necessarv furniture as beds, bedding, etc., for which the tenants make small weekly payments included in the rent. The reaction of the tenants concerned and their appreciation is evidenced by their regular weekly payments. "A still further extension of the scheme is being explored with a view to submission for consideration by the Housing Committee. 35 "Schemes for the erection of further houses are constantly before the Council, but the lack of available building" land is still a matter of great concern, and until the results of the survey under the 1935 Housing Act are known to the Council, it will not be possible to form any idea as to the number of houses still to be erected to fulfil the requirements of the survey. When such requirements have been fulfilled, it does not follow that housing accommodation would not still be urgently needed, having regard to the comparatively low standard of overcrowding laid down under the Act. "One great problem of the Housing Department is to provide adequate accommodation for the very large families, and cases are known where the family consists of ten, twelve or fourteen persons. Great consideration will no doubt be given to this problem in order to avoid any possibility of the appropriate type of house subsequently becoming a burden on the rates, as and when the size of the family reverts to an average family type, the modern trend, of course, being small families. Cases of Tuberculosis. "The Department still continues to re-house, and has, in fact, re-housed during the year practically the whole of the cases submitted by the Medical Officer of Health under the above heading. Isolated cases still remain to be re-housed in the appropriate type of house, that is, as regards both accommodation and income available. Housing Register. "The number of registered applicants re-housed during the year amounted to 89, including those from clearance areas and cases recommended by the Medical Officer of Health. The whole of the tenants from the first clearance orders have been re-housed, with two exceptions, and in four cases the areas have now been cleared. Transfers. "The Department still continues to transfer Council tenants either within the estate, alternatively with registered applicants. In the latter instance, it is necessary to have the co-operation of the owner of the property, and this is not always possible, the private owner naturally being desirous of placing his own selected tenant in his own property. A certain amount of success, however, was obtained during the year, and where a registered applicant has been re-housed the landlord has co-operated with the Housing Department and allowed either a Council tenant to transfer or has accepted a registered applicant from the Housing Register. 36 "In conclusion, I should like to draw attention to the pressing needs of those not at present overcrowded, but: whose needs are nevertheless a matter of concern for future generations. I refer to the necessity of providing reasonable accommodation for young married couples. Enquiries show that some Councils have now realised this need and are allocating as many as 20% of available houses for young married couples, with a view to giving the future generation a better chance to be reared in other than overcrowded circumstances before they are granted a Council house. In the past it has been the policy of the majority of local authorities to consider only overcrowded families, and it does appear now that the time has come when consideration should be given to the young people, instead of forcing them into what is very often the unhappy position of purchasing their own houses at high prices, which subsequently become millstones round their necks and otherwise a serious financial strain not only on the income, but the subsequent health of the families concerned." Re-housing of Slum Clearance Tenants. "Prior to actual removal of the tenants from the slum clearance area, a personal inspection was made of existing conditions, and I regret to report that much of the tenants' furniture and personal effects were so infested with vermin as to make it very unwise to permit the furniture, etc., being removed to the new premises. In one case a few wooden chairs only were fit to be removed. "Arrangements were therefore made to deal with this matter, and a supply of essential furniture, bedding, and bed linen was obtained through the Buying Department. Every preparation was made for a satisfactory removal for all parties concerned, by taking the strictest precautions to prevent the new premises becoming vermin-infested. This work involved the full and speedy co-operation of the Public Health, Public Cleansing, Borough Engineer's, and Buying Departments. "On the day appointed for removal, personal clothing and bed linen were collected by the Public Health Department, steam disinfected, and re-delivered to the new premises. The Public Cleansing Department collected the infested furniture and bedding at the same time for incineration at the Council's destructor works. The new furniture bedding, etc., were already available for the individual tenants by arrangement with the Building Foreman, the tenants' own removal being undertaken personally. There was no apparent hitch throughout the whole of the proceedings, and the tenants appeared gratified for the assistance rendered by the Council. 37 " It is pointed out, however, that, pending further consideration and instructions, the furniture supplied was the minimum requirement only, as follows:— For a married couple:— Double bed, 2 sheets, 1 bolster, 2 blankets, 2 pillows, 1 table, 2 pillow slips, 2 Windsor chairs, 2 armchairs. "For a single person single bed and appropriate bedding were supplied; otherwise as for a married couple. "In one instance two double beds, etc., were supplied for a family." The Housing Manager continued to notify the Public Health Department in advance of any rooms which were to be vacated owing to the re-housing of the tenant in a Council house. A visit was then paid to the rooms by the District Sanitary Inspector, and a letter was sent either to the landlord of the house or to the principal tenant threatening proceedings in the event of any overcrowding being permitted in the vacated rooms. In this connection, during the year visits were made to premises from which the Council have re-housed tenants. (d) Housing Act, 1930. Second Programme. An Inspector of the Ministry of Health held an Inquiry into the Council's second programme under the 1930 Act on 2nd April, 1935. Confirmation was received on the 11th June as set out below:— Walthamstow (College Place) Clearance Order, 1934, Nos. 2 to 34 17 houses Walthamstow Compulsory Purchase (Wood Street) Order, 1934, Nos. 202 to 216 8 „ Walthamstow (Marlowe Road) Clearance Order, 1934, Nos. 72 to 78 4 „ Walthamstow (Brunner Road) Clearance Order, 1934, Nos. 84 to 88, Brunner Road and Nos. 1 to 5, Lillyfield Cottages 8 „ Walthamstow (Back Road) Clearance Order, 1934, Nos. 17 to 20, Back Road 4 38 Walthamstow Compulsory Purchase (College Place) Order, 1934, Nos. 16 to 23, College Place 7houses- Walthamstow Compulsory Purchase (Church Lane) Order, 1934, Nos. 5 to 13, Church Lane 5 ,, Walthamstow Compulsory Purchase (Iiigham Street Order, 1934, Nos. 38 to 40a and Nos. 42 to 48, Higham Street 6 „ Walthamstow Compulsory Purchase (Chingford Lane) Order, 1934, Nos. 1 to 4, Mill lane, and Nos. 40 to 42, Chingford Lane 6 „ A lock-up shop included in the Chingford Lane Order was excluded, but remained in the Order as land adjoining the area to be purchased by the Council under Section 3 of the Housing Act, 1930. By arrangement with the owner's representative at theinquiry, the Walthamstow Compulsory Purchase (Mitchell's Cottages) Order, 1934, was withdrawn at the Inquiry for consideration at a later date as a Clearance Order, the ownerpromising not to oppose the Order. After the Order was made opposition was entered, and an inquiry was held and the Order confirmed. (e) Housing Act, 1935. Although the major part of the survey required under the Act of 1935 was carried out in 1936, the work done is detailed in this report. The preliminary survey was carried out between 9th December, 1935, and 3rd February, 1936, the subsequent measurements being completed by the 2nd March, 1936. This necessitated the employment of twelve men as enumerators and survey assistants for an approximate period of three months, and of three men as clerks for a period of four months; all were temporary staff, who worked very well. Through the kindness of the Town Clerk, in his capacity as Registration Officer for the Borough, street lists were compiled from the records used by him for the preparation of the Parliamentary Register. The enumerators were instructed to complete one Form A in respect of each structurally separate dwelling in the Borough. The reduction factor employed was one-fifth. Following the completion of the preliminary enumeration by means of Forms A, the enumerators were given special coaching in the accurate measuring of rooms by the Chief 39 Sanitary Inspector, and those who proved efficient after three tests were retained for the measurements required under the Form B survey. Forms B, after completion by the survey assistants, were returned to the office and were then scored by the clerical staff in the prescribed manner. The Tables attached show the result of the survey with respect to the Borough as a whole, and with respect to properties owned by the Local Authority and with respect to clearance areas (2nd Programme) under the Housing Act 1930. The information set out in the attached Tables can only be claimed to be approximately correct in view of the many suspected instances where false information may have been supplied to the survey staff. It must be stressed that the whole accuracy of the survey rests on the information given for the completion of Forms A, which was admittedly only a " doorstep " survey. At the same time, the survey was carried out strictly in accordance with the wishes of the Minister of Health. The approximate cost of the survey to March 31st, 1936, has been £629, against an estimated cost of £750. Form C for the whole Borough is included as an appendix at the end of the report. TABLE I. Number of Forms B completed—2,354. Ward. No. of houses enumerated. No. of houses overcrowded. % houses overcrowded. No. of families No. of families overcrowded. % families overcrowded. Empty Houses. St. Tames Street 4,462 153 3.43 5,508 161 2.92 31 High Street 3,558 67 1.88 4,602 68 1.48 41 Hoe Street 4,689 69 1.47 6,245 73 1.17 70 Wood Street 3,803 98 2.57 4,710 103 2.18 83 Hale End 7,158 57 0.80 7,744 57 0.73 90 Higham Hill 7,029 121 1.72 7,929 121 1.52 53 Borough 30,699 565 1.84 36,738 583 1.59 368 *Council Houses 1,483 48 3.24 1,492 48 3.22 - *Clearance Areas 58 8 13.8 52 8 15.5 6 *Included in total for Borough. 40 TABLE II. Gross New Housing Requirements. The following table has been compiled from Form C relating to the whole of the Borough by adding the numbers appearing on the lines of the form and falling below the diagonal line:— Number of Rooms required. 1 2 3 4 5 6 7 Total. No. of Dwellings required with rooms stated 7 27 158 238 139 13 1 583 All rooms are assumed to be not less than 110 square feet. TABLE III. This Table has been calculated on the basis of "reduced'' permitted numbers, and is obtained by adding the numbers in the columns of Form C and falling below the diagonal line. Existing accommodation to be vacated by rehousing of overcrowded families. No. of Rooms in Dwelling. One. Two. Three. Four. Five. Six. No. of Persons in Family. 1½ 2 2½ 3 3½ 4 4½ 5 5½ 6 6½ 7 7½ 8 8½ 9 9½ No. of Dwellings vacated. 14 27 10 135 — 16 33 183 10 28 18 15 44 11 30 7 2 Total 14 37 151 254 88 39 Grand Total 583 41 TABLE IV. Estimated Accommodation in houses wholly or partly empty at date of Survey. No. of Rooms. Private Houses. Rooms over Business Premises 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Total. 1. 2. 3. 4. 5. 6. 7. St. James St. - 2 8 11 18 7 - 1 - - - - - - - - - - - - 1 - 1 4 2 1 — High Street. 1 6 22 2 10 8 2 1 2 — — - — — — — — — — — 1 2 4 8 5 1 - Hoe Street 3 6 19 9 17 24 10 4 - 1 1 1 - - - - - - - - 1 2 4 8 4 1 - Wood Street. 3 14 20 19 35 9 8 — — 3 2 — — — — — — — — — 2 5 3 2 - — — Higham Hill. 3 7 9 5 43 6 — 1 - - - - - - - - - - - - - - 1 - - - - Hale End 1 16 19 13 80 31 11 2 3 1 — 1 — — 1 — — — — — — 7 5 9 — — — Total 11 51 97 59 203 85 31 9 5 5 3 2 — — 1 — — — 562 — 5 16 18 31 11 3 84 (Omitted form Table V) The total of 562 private houses with vacant accommodation includes the 368 private houses which were totally empty, and 194 houses, partly empty (i.e., vacant sub-lettings). 42 TABLE V. Nett New Housing Requirements. 1. Rooms per House. One. Two. Three . Four. Five. Six. Seven. Eight & over. 2. Gross Require ments (Table 2) 7 27 158 238 139 13 1 - 3. Vacated by Re-housing (Table 3) 14 37 151 254 88 39 Nil - 4. New houses required Nil Nil 7 Nil 51 Nil 1 Nil 5. Empty Houses (wholly or partly) 11 51 97 59 203 85 31 25 6. Houses to be provided under 1930 Act. Nil 7 Nil 1 Nil Nil Nil Nil 7. Totals (lines 5 & 6) 11 58 97 60 203 85 31 25 Nett No. of Houses required (line 4, less line 7) Nil Nil Nil Nil Nil Nil Nil Nil Excess of vacant accommodation (line 7, less line 2) 4 31 -61 -178 64 72 30 25 The Survey appears to show that if the unlet accommodation existing at the date of Survey were available for rehousing purposes, this empty accommodation would suffice to abate all overcrowding in the Borough, provided the overcrowded families could be appropriately re-arranged and rehoused accordingly. The deficiency in 3- and 4-roomed houses is more than counterbalanced by the vacant accommodation in the others, representing an excess of 333 rooms. TABLE VI. The following table shows the overcrowded families occupying the number of rooms shown, and the total units of population in each family:- Families. Units of Pop. Families. Units of Pop 1 room 14 34 4 rooms . 254 1,656½ 2 rooms. 37 126 5 rooms. 88 749½ 3 rooms 151 644 6 rooms . 39 375½ Total Number of Families. 583. Total number of Units of Population 3,585½ 43 The following Tables show the results of the 1935 Surveycompared with those of the 1931 Census:— Private Families:— 1935. 1931. Increase. 36,738 34,973 1,765 Overcrowded Families:— 1935. 1931. Decrease. 583 1,109 526 The 1931 standard was "two persons per room"—a. standard not so exacting as that of 1935. Distribution of Private Families according to Number of Rooms occupied (compared with 1931 Census). Units of Occupation (rooms) 1935 Survey. 1931 Census. 1 724 1,183 2 2,387 3,344 3 7,772 7,635 4 6,894 6,618 5 17,585 10,455 6/7 1,176 5,268 8/9 177 355 10 and over 23 115 Total 36,738 34,973 Distribution of Private Families according to Number of Personsin Family (compared with 1931 Census). No. of persons in family. 1935 Survey. 1931 Census. 1 2,058 1,998 2 9,521 7,274 3 11,144 8,621 4 6,960 7,109 5 3,796 4,600 6/7 2,723 4,035 8/9 449 1,027 10 and over 87 309 Total 36,738 34,973 44 Private families per occupied dwelling. 1935. 1931. 1921. 1.19 1.22 1.2 Distribution of Private Families according to Number of Persons in Family. No. of "persons" in family. No. of Private Families. Distribution per cent. 1935. 1931. 1921. 1935. 1931. 1921. 1 2,058 1,998 1,214 5.6 5.7 4.1 2 9,521 7,274 4,404 25.9 20.9 14.9 3 11,144 8,621 5,838 30.3 24.7 19.8 4 6,960 7,109 5,872 19.0 20.4 20.0 5 3,796 4,600 4,543 10.3 13.1 15.4 6/7 2,723 4,035 5,097 7.4 11.5 17.3 8/9 449 1,027 1,839 1.2 2.9 6.3 10+ 87 309 654 0.3 0.8 2.2 Totals 36,738 34,973 29,461 100.0 100.0 100.0 E.-INSPECTION AND SUPERVISION OF FOOD. (Contributed by Chief Sanitary Inspector.) (a) Slaughterhouses. During the year the Council registered one additional slaughterhouse. These premises were formerly stable premises and were converted. The walls were faced to a height of over six feet in glazed tiling, steel joists and runways were fixed, windows and doors renewed and altered to conform to modern requirements. The cost of conversion of these premises was approximately £350, and they may now be considered as a small model slaughterhouse. The trade carried on is that of a small family butcher, -and no market trade is done or anticipated. At another slaughterhouse the trade increased to an extent that the premises had to be closed until the owner carried out extensive alterations costing about £850. 45 Here, again, the walls of the slaughterhouse and coolingroom were faced to a height of over six feet in glazed tiling and brickwork. The cooling room was entirely rebuilt and extended, as was the boiler-house. New roofs—with natural lighting to the slaughterhouse —were fixed. Girders, steel joists, and runways were alsoprovided and fixed. The lairages also were put in thoroughgood condition, and new flooring and drainage was provided thereto as required. The premises are now fitted with ample artificial lighting. An electric stunning instrument was provided and is used on smaller animals. In this slaughterhouse, a considerable number of animals are prepared for the Central Market, and proper slaughtering and adequate inspection is now available under almost ideal conditions. (b) Milk Supply. The average number of cows kept in the district is seven. There is only one cowshed, and 14 visits were paid by the Sanitary Inspectors, in addition to special visits paid by your Chief Sanitary Inspector. The number of retail purveyors of milk is 198, most of whom carry on a general shop and sell milk in bottles as they receive it. Two hundred and five visits were paid to registered premises of purveyors of milk during the year, and a general improvement in the standard of cleanliness was maintained. During the year 52 samples of milk were taken for bacteriological count, and of these 8 were biologically tested for the presence of the tubercle bacillus with negative results. Of these 52 samples, three were obtained from schools and were satisfactory. In addition, nine samples from schools were submitted for chemical test, and proved to be genuine. The samples taken are summarised below. Grade of Milk. No. of Samples. No. tested for T.B. Grade A (T.T.) 5 1 Grade A (Pasteurised) 2 2 Grade A 1 1 Pasteurised 42 3 Raw 2 1 Total 52 8 46 of the above total of samples submitted for bacteriological count, 13 were unsatisfactory. The County Medical Officer states that five samples of milk relating to Walthamstow firms were tested biologically with negative results for tubercle bacilli. The Milk and Dairies Order, 1926. Much attention was again directed to this Order during the year with a view to minimising the risk of contamination, infection and alteration of the milk supply of the town, and there is a very marked improvement in this direction. The Milk (Special Designations) Order, 1923. The number of licences granted for the Sale of Milk under Special Designations classified in the Fourth Schedule of the above Order was as follows:- Dealers' Licences. Supplementary Licences. In respect of :— In respect of :— Certified Milk 1 Certified Milk 2 Grade A (T.T.) Milk 5 Grade A (T.T.) Milk 3 Grade A Milk 4 Grade A Milk 1 Pasteurised Milk 26 Grade A (Pasteurised) Milk 1 Pasteurised Milk 6 Bottling Licences. In respect of Grade A (T.T.) Milk, 2; Pasteurised Milk, 3. (c) Ice Cream. Thirteen samples of Ice Cream were taken for bacterial analysis, the results being that five were found to be unsatisfactory. (d) Meat and other Foods. A total of 415 visits were paid to slaughterhouses. The following were condemned and destroyed:— (a) Tuberculosis. 46 Ox lungs. 1 top rib Beef. 9 Pigs' livers. 21 Ox hearts. 1 set chuck ribs Beef. 3 chines Pork. 13 Ox heads. 1 loin Beef. 1 loin Pork. 11 Ox livers. 1 clod Beef. 1 hand & spring Pork. 11 Ox fats. 20 lbs. flank Beef. 4 Pig carcases and 7 Ox skirts. 49 Pigs' heads. all organs. 2 Ox spleens. 62 Pigs' fats. 2 Calf carcases and 1 Ox rump. 29 Pigs' plucks. all organs. 7 forequarters Beef. 47 (b) Miscellaneous 16 Ox livers. 5 Pigs' lungs. ½ tin chilled Sheep's 3 Ox lungs. 2 Pigs' heads. livers. 1 Ox heart. 2 Pigs' plucks. 20 lbs. Lobster tails. 1 Ox head. 1 leg Pork. 2 boxes Lobster tails. 1 Ox tripe. 19 Sheep's livers. 1 box Haddocks. 2 legs Veal. 2 Sheep's plucks. 20 boxes Kippers. 1 side Veal. 2 Sheep carcases and 2 boxes Haddock fillets. 1 hindquarter Beef. all organs. 20 boxes Lettuce. 1 forequarter Beef. 3 Calf carcases and 13 boxes Pears. 1 forequarter Mutton. all organs. 10 lbs. Pears. 32 Pigs' livers. (e) Adulteration, etc. (Food and Drugs Adulteration Act, 1928). Seventy-seven samples were submitted for analysis during the year. All were genuine. Although the Council is not a Food and Drugs Authority, such good work has been carried out in the past by continuous sampling under this Act and the Milk and Dairies (Amendment) Act that no real relaxation in this matter is contemplated. Note.-Sections (f), (g) and (h) are contributed by the Medical Officer of Health. (f) Chemical and Bacteriological Examination of Food. Chemical examination is carried out by the Public Analyst -Dr. Bernard Dyer at Great Tower Street, E.C.3. Bacteriological examination of milk is carried out either at The Counties Public Health Laboratories, E.C.4, or at Queen Mary's Hospital, E.15. Specimens of food suspected of causing food poisoning are, when necessary, sent to the Laboratory of the Ministry of Health. (g) Nutrition. The only special work done on the subject of nutrition has been a special enquiry by Dr. M. Clarke, and dealing with the ratio of muscular pull to body weight as determined by the dynamometer. The matter is dealt with in the Report of the School Medical Officer. 48 (h) Pasteurisation of Milk. There are about 2,000 deaths each year in England and Wales as a result of bovine tuberculous infection, and about three-fifths of them are in persons under 15 years of age. Efficient pasteurisation affords the only protection at present available to the public against the conveyance of tuberculosis by milk. In the scheme of the Ministry of Agriculture with regard to the registration of tubercle-free herds, it is required that calves should only be fed with milk which has been pasteurised or sterilised, or with milk from a tubercle-free cow. Surely such a requirement is even more necessary for human beings, especially young children? Your Council during the year considered representations, from the People's League of Health, with regard to pasteurisation. Your Council resolved that it was desirable that legislation be promoted to render compulsory the pasteurisation of all milk intended for human consumption. It was further resolved that a resolution to this effect be tabled in the name of the Council at the next appropriate conference at which the Council was represented. The resolution was duly brought to the notice of the Conference of the Royal Institute of Public Health, at Harrogate, in 1935. (The following sections are contributed by the Chief Sanitary Inspector). OFFENSIVE TRADES. During the year the Council sanctioned the establishing of two Fish Curers, and refused their sanction to the establishing of three Fish Friers. THE RENT AND MORTGAGE RESTRICTIONS ACTS, 1920-1923. During the year fifteen certificates were granted to tenants and six certificates have been issued to owners upon their application and completion of the scheduled works. 49 DISEASES OF ANIMALS ACTS, 1894-1928. Sheep Scab Order, 1920.—No case of this disease occurred in the Borough during the year. The Sheep Scab Order, 1928—During the year, 105 sheep were admitted into the area under Licences for Slaughter. The Regulation of Movement of Swine Order, 1922.— Under this Order, 1,390 pigs for slaughter were admitted into this Borough during the year. All notices of such movements have, as far as practicable, been followed up. In addition, 11 detention and isolation licenses affecting 105 pigs were in operation during the year. The conditions of the licences were duly observed in all cases. Tuberculosis Order, 1925.—Routine quarterly inspections were carried out by your Veterinary Surgeon and Chief Sanitary Inspector. No instance has arisen calling for mention. RATS AND MICE DESTRUCTION ACT, 1919. The County Council resolved that all powers conferred and all duties imposed by the Act, in the Borough, should be delegated to your Council. Your Council further resolved that the Chief Sanitary Inspector be appointed to carry out the provisions of the Act. During the year, 144 complaints as to the presence of rats have been received. Each case was investigated with the result that in 52 cases poison was used (Red Squill), in 86 cases drains were repaired, in 38 instances rat-proofing of premises and out-buildings was enforced, and in 15 instances traps were used. It is difficult to estimate the number of rats destroyed, but it is only fair to state the number must be considerable. The Council did not set aside one week specially as a " Rat Week," having regard to the general action in rat repression throughout the whole of the year, and to the free distribution of Red Squill Poison with instructions in its use to responsible persons upon their complaints. 50 Large-type bills have been posted in conspicuous places in the town drawing attention to this Act, and to the advice and help which may be given by the Chief Sanitary Inspector, at the Public Health Offices. Further, the Council have provided a cyano-gas foot pump, and this has been used with a certain amount of success along the River Ching. Its further use is contemplated at selected open spaces, but the discretion in the use of this gas makes its action limited, but of its efficacy there can be no question. The Sanatorium, Chingford. Due to a settlement to some of the drains, considerable evidence of the presence of rats was discerned at the Sanatorium. Baiting was freely resorted to—old baits removed and replaced with new—until the cessation of these pests. Finally, all runs were wired and cemented along the various pipe lines, and there has been no further evidence of rats. Much time and trouble was taken—as in all cases—but this is more than saved in the long run by the destruction of damaging pests. FACTORY AND WORKSHOP ACT, 1901. The following tables show the work done under the Act during the year:— 1.—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Occupiers Prosecuted. (1) (2) (3) (4) Factories (Including Factory Laundries.) 466 16 Nil. Workshops (Including Workshop Laundries.) 263 9 Nil. Workplaces (Other than Outworkers' premises.) 74 2 Nil. Total 803 27 Nil. 51 2.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. No. of offences in respect to which Prosecutions were inst[]ituted. Found. Remedied Referred to H.M. Inspector. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts :— Want of cleanliness 32 32 — — Want of ventilation — — — — Overcrowding — — — — Want of drainage of floors 2 2 — — Other nuisances 61 61 — — Sanitary accommodation insufficient 4 4 — — unsuitable or defective 35 35 - - not separate for sexes 1 1 - — Offences wider the Factory and Workshobs Acts:— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences — — — — Total 135 135 Nil Nil NUMBER AND TRADES OF OUTWORKERS NOTIFIED DURING 1935. Wearing Apparel, making of 401 Confectionery 3 Brush Making 26 Furs 7 Boxes 11 Artificial Flowers 2 Christmas Crackers and Toys 36 Carnival Hats 12 Handbags 3 Total 501 52 Outworkers were notified from the following areas:— City of London 159 St. Marylebone 1 Bethnal Green 13 Stepney 10 Finsbury 64 Shoreditch 10 Hackney 37 Tottenham 6 Islington 9 Walthamstow 97 Leyton 61 Westminster 13 Poplar 9 Other Areas 12 A total of 439 visits were paid in connection with outworkers as follows:-To Homes, 388; Factories, 22; Workshops, 29. F.-PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. General.—The accompanying tables show the age and ward incidence of the various infectious diseases which are discussed separately in later pages of the Report:— Disease. All ages. Under 1 yr. 1—5 yrs. 5—15 yrs. 15—25 yrs. 25—45 yrs. 45—65 yrs. 65 & over 1935 1034, Smallpox — 1 — — — — — — — Scarlet Fever 569 605 1 132 344 58 32 2 — Diphtheria 163 274 1 51 96 10 3 2 — Enteric Fever 4 2 -— — 1 — 3 — — Pneumonia 131 180 2 9 20 17 36 29 18 Puerperal Fever 4 13 — — — 1 3 — — Puerperal Pyrexia 31 28 — — — 14 17 —- — Ophthalmia Neonatorum 1 5 1 — — — — — — Erysipelas 54 69 — — 5 5 12 25 7 Encephalitis Lethargica 2 1 — — 2 — — — — Chicken Pox — 530 — — — — — — — Cerebro-spinal - Meningitis 4 1 — 2 — 1 — 1 — Tuberculosis 163 196 1 7 14 49 66 17 9 Poliomyelitis 5 — — 4 1 — — — — Measles (under 5 years) 27 870 4 23 — — — — — Dysentery 1 — — — — — 1 — — Totals 1935. 1159 — 10 228 483 155 173 76 34 1934 — 2775 80 1148 997 184 225 111 30 53 Disease. St. James Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. Totals Scarlet Fever 64 66 58 45 134 202 569 Diphtheria 32 33 18 25 25 30 163 Enteric Fever — — — 3 1 — 4 Pneumonia 20 10 25 19 24 33 131 Puerperal Fever — 1 — — 1 2 4 Puerperal Pyrexia 3 2 7 7 8 4 31 Ophthalmia Neonatorum — — 1 — — — 1 Erysipelas 10 8 6 7 9 14 54 Encephalitis Lethargica — — — 1 — 1 2 Cerebro-spinal Meningitis 1 1 — — 1 1 4 Tuberculosis 27 20 28 20 23 45 163 Poliomyelitis 3 — — 1 — 1 5 Measles (under 5 years). 2 6 2 1 1 15 27 Dysentery — — 1 — — — 1 Totals 1935 162 147 146 129 227 348 1159 1934 492 271 370 411 537 694 2775 From the foregoing tables it will be seen that the outstanding features of 1935 were decreases in all the common notifiable diseases. There were small unit increases in regard to enteric and dysentery, and the diseases of central nervous system. The statistics given in the foregoing table are those for the calendar year 1935. The Registrar-General gives the statistics for the 52 weeks ended 28th December,, 1935, and these are given in the following table, together with the case rates per 1,000 population both for England and Wales and for Walthamstow: Disease. Scarlet Fever. Diphtheria. Enteric Fever. Pneumonia. Puerperal Fever. Puerperal Pyrexia. Erysipelas. Number 567 164 4 128 4 31 52 Case Rate— Walthamstow 4.21 1.22 0.03 0.95 0.03 0.23 0.37 England and 2.96 1.00 0.04 1.15 Not Not 0.42 Wales given given The rates for Puerperal Fever and Pyrexia are better expressed in relation to the number of births (i.e., live and stillbirths) registered than to population. When calculated on this basis the rates are:— Puerperal Fever. Puerperal Pvrexia. Walthamstow 2.31 17.95* England and Wales 3.60 9.44 (* See note re puerperal pyrexia in Maternity Home Clinical report.) 54 Disease. Total. Removed to Hospital. Per cent, removed to Hospital. Deaths. Deaths per cent, of cases notified. Scarlet Fever 569 456 80.14 Nil Nil Diphtheria 163 151 92.7 4 2.4 Enteric Fever 4 4 100.0 Nil Nil Pneumonia 131 67 51.14 72 55.0 Puerperal Fever 4 4 100.0 2* 5.7 Puerperal Pyrexia 31 10 32.2 Ophthalmia Neonatorum 1 - — — Nil Erysipelas 54 15 27.7 Not a classified cause of Death. Cerebro-spinal Meningitis 4 4 100.0 2 50.0 Tuberculosis 163 139 85.3 75 46.0 Measles 27 2 7.4 1 3.7 Encephalitis Lethargica 2 1 50.0 1 50.0 Anterior Poliomyelitis 5 5 100.0 Nil Nil Dysentery 1 1 100.0 Nil Nil * These deaths refer only to those occurring in notified fever and pyrexia cases. The total number of maternal deaths in the area was 5. Infectious Disease Clinic.—As in previous years this Clinic was held weekly on Tuesdays at 2p.m. The work done at the Clinic is roughly that of an Out-Patient Department to the Infectious Disease Hospital, and was specified in detail in the Report for 1934. The following table gives particulars of the work done during 1935:— Number of patients attended 2,972 Number of attendances made 4,454 Number of Scarlet Fever cases discovered 3 Number of Diphtheria cases discovered 7 Number of virulence tests taken in Diphtheria carriers 26 Number of children referred to Rheumatism Clinic 24 Number of children referred to Ear Clinic 14 Number of attendances for Diphtheria Immunisation (included above) 2,330 Particular care was taken to refer all cases with any suspicion either of rheumatism or of cardiac involvement to the next following rheumatism clinic. The following extract from Dr. Sheldon's report of the work of the clinic is taken from the School Medical Officer's report for 1935:— "The practice of referring children to the clinic whohave been thought to manifest some rheumatic condition after discharge from the isolation hospital has been continued. 55 Twenty-three cases were referred during 1935, and of these twelve were found to have some early cardiac defect. It was shown in last year's report that the detection of early cardiac mischief should be encouraged, as the outlook for such children is immeasurably better if treatment is instituted before the disease has got far under way." DIPHTHERIA IMMUNISATION, (a) At Clinic.—The Clinic was continued on Tuesdays at 3 p.m. following the Infectious Disease Clinic. During the early part of the year an additional session was held on Friday afternoons. As in previous years, the practice has been to Schick test children over five years of age, and only to immunise those yielding a positive result. All children under five years of age were immunised without a pre-Schick test. Since February, Alum Precipitate'd Toxoid has been used for all children under five years of age, and in Schick positive children between five and eight years of age. One single dose of 0.5 c.c. has been given by deep subcutaneous injection into the left deltoid muscle. Schick positive subjects over eight years of age have been given three doses of 1.0 c.c. of Toxoid Antitoxin Floccules. Posterior Schick tests were done from one to three months after the last injection of prophylactic. Schick control injections were not used unless a positive result had been obtained following the use of prophylactic. The following is a summary of the work done and includes cases done at Brookfield Orthopaedic Hospital:— Schick tested for first time 509 Negative (including pseudo and negative) 164 Positive (including pseudo and positive) 345 Number immunised after positive Schick (21 refusals) 324 Immunised without being Schick tested 477 Number of partly immunised cases brought forward from 1934 71 Total number given one or more immunising doses during 1935 872 Results of Schick tests following immunisation:— Negative (including 71 from 1934) 676 Number of immunisations awaiting final Schick test 172 Number not completing immunisation course 24 Total 872 56 Number of children of school age immunised completed 419 Number of children of pre-school age immunised completed 185 (i.e., 1935 cases only.) Five hundred and ninety-eight children had Alum Precipitated Toxoid, the remainder having Toxoid Antitoxin Floccules. The names and addresses of all children leaving the area before completion of immunisation were reported forward to the Medical Officers of Health of the respective areas. Included in the total number of persons immunised with Alum Precipitated Toxoid were eight children aged 1 to 5 years who were given 0.1 c.c. A.P.T. on two occasions at approximately four weeks' interval. Posterior Schick tests were done four weeks after the last injection, and all were negative. Twenty persons who had either been immunised or naturally Schick negative in previous years were re-tested during 1935, with the result that ten persons immunised between 1932 and 1934 were still immune, and of the ten naturally Schick negative in previous years, seven had become Schick positive, showing a loss of natural immunity. Of the cases immunised with Alum Preciptated Toxoid, and excluding three who have not attended for posterior Schick test, eight showed pseudo reactions three months after injection of prophylactic. There was no case of a definite failure to obtain a negative posterior Schick test. During 1936, however, there have been frequent failures to obtain a negative posterior Schick test after one dose of A.P.T. Out of a total of 495 cases, 88.1 per cent, were negative. The remainder have been given a further dose of 0.2 to 0.4 c.c. A.P.T. and up to the present there has been no failure. Present experience suggests that the method of choice is to give 0.1 c.c. A.P.T. as a "detector" dose, followed by 0.2 to 0.4 c.c. two or three weeks later. One dose of A.P.T. cannot be relied upon to produce immunity and the posterior Schick test should not be omitted. In nineteen persons immunised with A.P.T. over one year previously, repeat posterior Schick tests were done and 57 were found to remain negative (i.e., immunity had not been lost). Since beginning immunisation in March, 1932, and up to the end of 1935 (i.e., 3 years 9 months), a total of 457 persons had been found to be naturally Schick negative, and a total of 996 had been completely immunised (i.e., had yielded negative posterior Schick tests), a grand total of 1,453. (b) At School.—Towards the end of the year the Education Committee decided that the School Medical Officer (acting in the capacity of Medical Officer of Health) should carry out diphtheria immunisation at the schools, and that parents attending with their children should be allowed to bring children of pre-school age. A commencement was made with Infants' Departments. The procedure adopted consisted of issuing a circular to each child in attendance at the Infants' Department to take home to the parent or guardian, and stating that the Medical Officer of Health would attend at a certain day and time to offer immunisation to any child whose parent was agreeable. Parents were invited to attend, and were particularly encouraged to bring any children between the ages of one and five years. Commencing in November, 1935, only two schools were visited during 1935, and out of an attendance of 332 at Selwyn Avenue Infants' Department, a total of 205 consents, including seven in pre-school children, were obtained. At Thorpe Hall Infants' Department there were 120 consents, including 12 of pre-school age, out of 275 in attendance. The children were immunised with a single dose of Alum Precipitated Toxoid. Schick testing was carried out after an interval of three months. During the course of 1936, eight further infants' departments have been visited, and percentage acceptances have varied from 30.8 to 51.8 and totalling 696 acceptances out of 1,710 in average attendance, or 40.7 per cent. In addition, 108 pre-school children were Immunised at these schools. During the year seven cases were reported amongst immunised or naturally Schick negative children as having sore throats suggestive of diphtheria. The routine in such cases has been for the patients to be swabbed (a) for the presence of diphtheria bacilli, and if found positive, for a virulence test to be carried out, and (b) for the presence of streptococci—particularly hemolytic streptococci. 58 Details of the cases follow:— (1) E.C. (6 years). 3/10/34 Schick pos. 10/10/34 Immunised with one (0.5 c.c.) dose A.P.T. (Alum Precipitated Toxoid) 24/10/34 and 24/1/35 Schick neg. 8/2/35 sore throat,, diphtheria bacilli present but non-virulent. Hemolytic streptococci present. Diagnosis—streptococcal tonsillitis. 30/3/35 contracted scarlet fever. Virulent diphtheria carrier up to 8/5/35. 19/9/35 Schick neg. (2) M.W. (5 years). Immunised by general practitioner, but no posterior Schick test performed. Diphtheria bacilli present 31/3/35—no clinical symptoms. (N.B.-Tests outlined above unfortunately omitted.) Diagnosis-" bacteriological diphtheria." (3) P.C. (13 years). 19/6/34 Schick pos. Immunised June-July, 1934, with three (1 c.c.) doses Toxoid Antitoxin Floccules. 25/9/34 Schick neg. 21/6/35 sore throat, Schick neg. Diphtheria bacilli present, but non-virulent. Hemolytic streptococci present. Pseudo membrane both tonsils. Throat clear in 36 hours. Diagnosis—streptococcal tonsillitis and non-virulent diphtheria carrier. (4) E.B. (12 years). 18/12/34 Schick pos. Immunised January, 1935, with three (1 c.c.) doses of T.A.F. 26/2/35 Schick neg. 29/3/35 sore throat. Diphtheria bacilli present (virulent). Hæmolytic streptococci present. Considerable " pseudo " membrane present, but little toxæmia, and condition gave rise to no anxiety such as would have been the case if the same throat condition had been met with in an unimmunised child. (5) E.L. (10 years). 26/11/35 Schick pos. 3/12/35 0.2 c.c. A.P.T. 10/12/35, 0.4 c.c. A.P.T. 19/12/3S (i.e., when, immunisation not completed) sore throat, virulent diphtheria bacilli present. Hæmolytic streptococci absent. Clinical condition resembled that of a mild tonsillitis, and the case caused no anxiety. (6) D.H. 5/2/35 Schick pos. Immunised with three 1 c.c. doses of T.A.F. 2/4/35 Schick neg. 26/11/35 sore throat,., diphtheria bacilli absent. Hemolytic streptococci present. Pseudo membrane present on both tonsils. Patient quite fit in four days. Diagnosis-streptococcal tonsillitis. (7) L.S. 19/6/34 Schick neg. (i.e., a natural Schick immune). 5/12/34 tonsillitis (diphtheria bacilli absent). 8/12/35 Schick neg., follicular tonsillitis. Non-virulent diphtheria bacilli present. Hæmolytic streptococci present. Diagnosis-streptococcal tonsillitis and non-virulent diphtheria carrier. (Note by M.O.H.-Any quotation from this page and the following paragraph must give the case history in full). 59 Only cases (4) and (5) could in any way be regarded as. resembling diphtheria. Case (4) would have caused grave anxiety in the absence of previous immunisation, while in case(5) immunisation had not been completed. Extract from "The Medical Officer," dated 25/1/36:— THE HEALTH OF MONTREAL. We are still unable to find a case of fatal diphtheria in a person fully "immunised" and proved by post-Schick to be immune, and even in persons partially immunised, fatal diphtheria is very rare. Extract from "Mother and Child,'' dated December, 1935:— THE CASE FOR IMMUNISATION AGAINST DIPHTHERIA "It is estimated that one in every ten children born will suffer from diphtheria before he is fifteen years old, and that one in every 300 children will die of it. In Birmingham it has been shown that among the immunised children only one in 2,500 suffers from the disease, and that no. child dies of it." (c) By General Practitioners.—In March your Council authorised the issue of diphtheria prophylactic to general practitioners for gratuitous injection. Schick material and prophylactic was issued to ten practitioners as follows:— Schick material, 2 c.cs. (sufficient to test 10 persons). T.A.F. prophylactic, 31 c.cs. (sufficient to protect 10 persons). T.A.M. prophylactic, 29 c.cs. (sufficient to protect 10 persons). A.P.T. prophylactic, 2.0 c.cs. (sufficient to protect 4 persons). Scarlet Fever Immunisation and Testing. Dick testing and immunisation of susceptibles were carried out at Brookfield Orthopa?dic Hospital, 29 cases being completed, and yielding negative posterior Dick tests. The full immunising course consists of five doses, and in several cases the course had to be discontinued after the third injection owing to rather troublesome reactions. Of 54 Dick tests, 20 were negative and 34 positive. Four young children were immunised without a preliminary Dick test. Immunisation was begun in 38 cases, but nine were discharged from hospital before completion. Dick testing was also carried out at a children's convalescent home in connection with a small outbreak of scarlet 60 fever. A total of 50 tests was done, 15 being positive and 35 negative. MUNICIPAL LABORATORY. The following numbers of diphtheria swabs were examined during 1935:— Swabs. Negative. Positive. Totals. Private Practitioners 1,039 77 1,116 Health Department. 361 41 402 'School Medical Department 677 28 705 Totals 2,077 146 2,223 The total number of diphtheria specimens in 1934 2,818. Direct examinations were done on 1,176 smears from diphtheria specimens, and 23 were positive and a further 55 were positive on culture, although negative on direct examination. In addition, 198 specimens of urine were examined as compared with 180 in 1934. A total of 3,673 tubes of culture media were made by Mr. West, and of these, 1,416 were sent to the Sanatorium. The Essex County Council also provide facilities for examination of pathological specimens, and the County Medical Officer states that 482 specimens were examined for local Practitioners during 1935 as follows:— Diphtheria Swabs, 127; Sputa, 239; Typhoid Specimens, 22; Ringworm Specimens, 10; Miscellaneous Specimens, 83; Diphtheria Virulence Tests, 1. The total for the previous year was 700. VACCINATION. ' Mr. E. Sharp, Vaccination Officer for the Area, has furnished the following return for 1935:— Births Registered. Successfully Vaccinated. Percentage Vaccinated. Insusceptible. Exemptions. Deaths before Vaccinated. Postponed. 1,613 365 22.6 11 968 32 41 In addition to the above, 14 primary vaccinations were recorded, and 9 re-vaccinations. During 1935 the vaccinal condition of all school children examined at Routine Medical Inspection was recorded, and a summary of the findings for the year showed that 26.7 per cent. were vaccinated. 61 HOSPITAL TREATMENT OF SMALLPOX. No case of Smallpox was admitted to your Smallpox Hospital under the agreement with the Corporation of Leytom for six beds to be retained for the use of Smallpox patients from their area at a retaining fee of £100 per annum, and a maintenance charge of £6 per patient per week. SCARLET FEVER. A total of 569 cases of Scarlet Fever was notified in 1935, as compared with 605 in 1934. The following tables show the incidence by months, ages and wards:— Month. All Ages. Under l yr. 1-5 yrs. 5-15 yrs. 15-25 yrs. 25-45 yrs. 45-65 yrs. 65 & over. January 52 - 17 26 4 5 - - February 51 - 13 27 5 5 1 - March 45 - 7 28 7 3 - - April 52 - 5 34 7 6 - - May 40 - 8 19 11 2 - - June 52 - 14 33 5 - - - July 38 - 7 28 3 — - - August 39 - 9 27 3 - - - September 43 - 12 25 4 2 - - October 67 - 18 41 3 4 - - November 41 - 8 26 3 4 - - December 49 - 14 30 3 1 1 - Totals 1935 569 1 132 344 58 32 2 - 1934 605 2 115 385 56 40 4 - Month St. James' Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. January 6 5 3 7 24 7 February 9 6 12 5 16 3 March 2 6 7 7 17 6 April 12 13 4 6 15 2 May 5 9 4 2 10 10 June 4 3 8 5 12 20 July 6 2 1 4 4 21 August 3 6 2 - 3 21 September 4 5 4 2 6 22 October 6 3 2 2 11 43 November — 2 6 1 10 22 December 5 6 5 4 4 25 Totals 1935 64 66 58 45 134 202 1934 96 47 70 73 175 144 62 The percentage of cases removed to Hospital during 1935 was 80.1, against 75.2 in 1934. No case was refused admission. Reference is made in the report for the year 1933 by the Chief Medical Officer of the Ministry of Health to the growing realisation that scarlet fever is only one manifestation of infection with the hæmolytic streptococcus, others being tonsillitis and puerperal fever. The question of return cases is discussed; stress is laid on the part played by antitoxin in expediting cure, and lessening the risks of cross-infection by discharge from hospital in the fourth week: The occurrence of cross-infection or a return case is not evidence of neglect, and discharge of an uncomplicated case in the fourth week is good practice. Recent American experience suggests that the strict quarantine (i.e., hospital isolation) of scarlet fever patients prevents neither endemics nor epidemics, because too many patients remain carriers after release from quarantine (up to 45 per cent.four months after release). The statement further claims that scarlet fever quarantine is based more on tradition and expediency than on scientific facts. DIPHTHERIA. A total of 163 cases of Diphtheria was notified during 1935, as compared with 274 in 1934. The following tables show the incidence by months, ages and wards:— Month. All Ages. Under 1 yr. 1-5 yrs. 5-15 yrs. 15-25 yrs. 25-45 yrs. 45-65 yrs. 65 & over. January 24 - 9 14 1 - - - February 30 - 6 24 - - — — March 11 - 3 7 1 - - - April 17 - 7 6 2 - 1 - May 4 - 1 3 — - — — June 1 -- — 1 - - — - July 3 - — 3 - - — — August 22 - 10 9 1 2 — — September 8 - 4 3 - — 1 — October 12 - 1 10 1 — — — November 18 - 2 14 1 1 — - December 13 - 8 2 3 — — — Totals 1935 163 1 51 96 10 3 2 — 1934 274 7 57 171 26 11 2 — 63 Month. St James' Street High Street. Hoe Street. Wood Street. Hale End. Higham Hill. January 5 3 1 5 6 4 February 6 5 5 8 3 3 March 1 4 — 3 1 2 April 6 1 4 2 2 2 May — 2 1 1 — — June — — — 1 — — July 1 1 — 1 — — August 5 4 4 — 5 4 September 1 2 1 — — 4 October 2 3 1 3 1 2 November 1 6 1 — 6 4 December 4 2 — 1 1 5 Totals 1935 32 33 18 25 25 30 1934 25 20 44 54 50 51 The percentage of cases removed to Hospital in 1935 was 92.7, against 90.8 in 1934. No case was refused admission, and whenever possible pressure was exerted to secure the admission of all cases to Hospital unless cases were of the non-clinical variety. Home treatment of diphtheria can rarely be adequate unless the disease is extremely mild. Antitoxin continued to be available for free issue to medical practititioners at the Public Health Department during office hours and at all times at the Fire Station, Forest Road, and at Mr. Gaze's, 10, The Avenue, Highams Park. During 1935, a total of 174 phials, containing 1,216,000 units of Diphtheria Antitoxin, and 23 phials, containing 230 c.cs. of Scarlet Fever Antitoxin, was issued. Diphtheria notifications have shown a progressive decline since 1932 when, by coincidence, immunisation was begun. In view of the comparatively small number of immunisations carried out in the area, it would not be fair to claim more than a contributory effect for this practice. At the same time, in the absence of immunisation to the extent of some 50 per cent.of the population under, say, 15 years, the incidence of diphtheria will almost certainly show an increase in future years. The table below shows the number of immune (i.e., Schick negative and protected) persons each year, diphtheria notifications, attack rates and mortality:— 64 Year. No. immunised + Schick neg. Notified cases. Attack rate per 1,000 population. Deaths. Percentage of deaths to notifications. 1935 840 163 1.21 4 2.4 1934 282 274 2.03 8 2.9 1933 278 334 2.47 7 2.1 1932 53 356 2.64 5 1.4 1931 — 324 2.44 11 3.4 1930 — 509 4.08 22 4.3 ENTERIC FEVER. Four cases were notified. No. Ward. Age. Date of Notification. Diagnosis. Para Where treated. Result. 1 Hale End 34 9.3.35 Typhoid B. Hospital Recovered 2 Wood St. 43 10.8.35 Typhoid „ „ 3 „ 43 10.8.35 „ „ „ 4 „ 11 10.8.35 „ „ „ No definite source of infection could be found in any of the cases. Cases 2, 3 and 4 were in one family—the husband being the first affected, followed by his wife and then a daughter. BACILLARY DYSENTERY. One case of Bacillary Dysentery (Flexner) was notified' in a female aged 31 years, who had lived in China for four years until fifteen months before notification. PNEUMONIA The tables following show the incidence by months, ages and wards. Most of the cases removed to Hospital received treatment at Whipps Cross Hospital:— Month. All ages. Under 1 year 1-5 years. 5-15 years. 15-25 years. 25-45 years. 45-65 years. 65 & over. January 9 - 4 - 2 3 - - February 18 — — 5 3 4 4 2 March 17 — — 2 2 5 5 3 April 19 — — 2 4 7 3 3 May 12 1 — 3 — 1 5 2 June 6 — 1 1 — 2 2 July 6 1 — 2 1 2 — — August 3 — — — 1 2 — — September 4 — 1 — — — 2 1 October l5 — 1 1 1 3 5 4 November 12 — — 2 4 2 2 December 10 — 2 2 1 3 1 1 Totals 1935 131 2 9 20 17 36 29 18 1934 180 8 29 36 15 44 31 17 65 Month. St. James Street. High Street. Hoe Street. Wood Street. Hale End Higham Hill. January 1 2 3 2 1 - February 3 2 6 1 5 1 March 4 1 2 3 6 1 April 3 1 4 2 2 7 May 1 1 1 3 1 5 June — — 1 1 1 3 July 1 — 2 1 — 2 August 1 — — — 2 — September 2 - - - — 2 October — 1 2 4 1 7 November 3 2 2 1 1 3 December 1 — 2 1 4 2 Totals 1935 20 10 25 19 24 33 1934 49 27 18 24 25 37 Acute primary and influenzal pneumonia have been notifiable diseases since 1919, but it would appear that there is little evidence that much useful purpose has been served. Circular 1499 and Memorandum 189/Med. were issued* by the Ministry of Health in October, and draw attention to the need for skilled nursing assistance, for facilities for the bacteriological examination of sputum, and the typing of the causal organism. At the beginning of the current year your Council decided to increase the grant to the Walthamstow District Nursing Association to £100, in return for which the Association was, amongst other services, required to provide home nursing facilities for cases of pneumonia. Bacteriological examination of sputum and . typing is available through the medium of the excellent laboratory service provided by the Essex County Council. The local practice is for the District Sanitary Inspector to visit on receipt of a notification and to make the necessary enquiries. A leaflet of advice is left at the house, and opportunity is taken to deal with any obvious defect in sanitation which may be found. PUERPERAL FEVER AND PYREXIA. See Maternity and Child Welfare Section. E 66 OPHTHALMIA NEONATORUM. See Maternity and Child Welfare Section. ERYSIPELAS. The following tables show the incidence by months, ages and wards:- Month. All ages. Under 1 year 1-5 years. 5-15 years. 15-25 years. 25-45 years. 45-65 years. 65 & over. January 2 - - — - 1 - 1 February 7 - — — 1 1 5 — March 4 - — 2 — — 2 — April 4 — — — — 1 3 — May 3 - — — — 1 2 — June 5 - — — 1 2 2 — July 2 - - - - - 1 1 August 3 - — — 1 — 1 1 September 3 - — — — 2 1 — October 9 - — 3 1 2 1 - November 8 - — — - 2 4 1 December 4 - - - - - 3 1 Totals 1935 54 — — 5 5 12 25 7 1934 69 1 4 3 5 17 28 11 Month. St. James Street. High Street. Hoe Street. Wood Street. Hale End Higham Hill January 1 — — - - 1 February 2 — 1 1 1 - March 2 — — 1 — 1 April 2 1 — — 1 — May — 2 — — — 1 June — 1 1 1 2 — July — — — — 2 — August — — 1 1 — 1 September — 1 — 2 - — October 1 1 1 — 3 3 November 2 2 1 1 — 2 December — — 1 — - 3 Totals 1935 10 8 6 7 9 14 1934 9 8 16 6 8 22 67 CEREBRO-SPINAL MENINGITIS. Four cases were notified:— No. Ward. Age. Date of Notification. How notified. Result. (i.e., recovered or died). 1 High St. 28 7.1.35 Hospital. Diagnosis not confirmed. Notification not withdrawn. 2 Higham Hill 2½ 15.4.35 Do. Died. 3 St. James' Street 2½ 13.9.35 Do. Recovered. 4 Hale End 60 3.12.35 Do. Died. ANTERIOR POLIOMYELITIS. Five cases were notified:— No. Ward. Age. Date of Notification. How notified. Result. (i.e., recovered or died). 1 St. James' Street 1 22.7.35 Hospital. Recovered. 2 Do. 2 2/12 13.9.35 Do. In Hospital at end of year. 3 Wood St. 8 25.9.35 M.O.H. Recovered. 4 St. James' Street 1 11/12 26.9.35 Hospital. Recovered. 5 Higham Hill 1 2/12 13.10.35 Private Practitioner In Hospital at end of year. ENCEPHALITIS LETHARGICA. Two cases were notified:— No. Ward. Age. Date of Notification. How notified. Remarks. 1 Higham Hill 14 2.4.35 General Practitioner Refused Hospital treatment. 2 Wood St. 6 28.9.35 Hospital Died. P.M. Diagnosis. 68 FOOD POISONING. One death occurred in a male aged 59 years who had been admitted to Hospital for suspected food poisoning after a stay at a seaside resort at which full enquiries were made, but the source of infection could not be traced. The coroner's verdict following a post-mortem was that death was due to acute gastro-enteritis, from food poisoning resulting from an organism of the Salmonella group. MEASLES. Under the Walthamstow (Measles) Regulations, 1932, all cases of Measles in children under five years of age are notifiable, except secondary cases in the same household or institution within two months of the primary case. The year 1935 was a non-epidemic year, the number of notifications being: 27 against 870 in 1934 (an epidemic year). In addition, there were 236 cases of Measles reported by Head Teachers, and mainly in school children of 5-14 years. Month. Total. Under 1 yr. 1-5 yrs. St. James' St. High St. Hoe St. Wood St. Hale End. Higham Hill. January 1 - 1 - - - - - 1 February 1 1 — - - - - - 1 March - - - - - - - - - April 1 - 1 - — - — - 1 May 3 1 2 1 1 - — — 1 June 3 - 3 - 1 - - — 2 July 7 - 7 - 2 1 - — 4 August 2 - 2 - 1 - — — 1 September 1 - 1 - — - - — 1 October 1 1 — - — 1 - — — November 3 1 2 1 - - - 1 1 December 4 — 4 — 1 — - — 2 Totals 1935 27 4 23 2 6 2 1 1 15 1934 870 48 822 182 108 100 110 130 240 Measles Serum.—The arrangements detailed in the report for 1932 were continued. Local practitioners were asked to notify the names of any healthy adults convalescent after Measles, and willing to give blood for the preparation of serum. None were available in 1935, but eight such donors were forthcoming in 1936. The serum was prepared at Great Ormond Street Hospital, one-half being earmarked for use in Walthamstow patients. It is gratifying to record the great help received from the private practitioners of the town in persuading adult convalescents to act as donors. The donors have the satisfaction of having performed a great public service. 69 Home nursing is provided where necessary by the Walthamstow District Nursing Association. Prevention of Blindness.—No action was necessary under Section 66 of the Public Health (Amendment) Act, 1925, for the prevention of blindness or the treatment of persons suffering from any disease of, or injury to, the eyes. TUBERCULOSIS. The table given below shows particulars of new cases of Tuberculosis and of all deaths from the disease in the Borough during 1935:— Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. Under 1 year — — 1 — - - 1 - 1—5 years 1 - 3 3 — — 1 1 5—10 years — 1 4 2 - — - - 10—15 years 1 2 3 1 — 1 - - 15—20 years 3 17 2 1 2 4 - - 20—25 years 10 10 3 3 5 6 - - 25—35 years 17 11 6 3 9 5 1 1 35—45 years 17 8 1 3 7 4 — - 45—55 years 6 2 1 — 5 5 — - 55—65 years 4 4 — — 5 5 — - 65 years and upwards 5 3 1 - 6 — — 1 64 58 25 16 39 30 3 3 Totals 122 41 69 6 163 75 The seventy-five deaths represent a death-rate of 0.55 per 1,000 population. The returns for the past two years are compared below:- Year. New Cases. Total. Deaths. Total. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 1935 64 58 25 16 163 39 30 3 3 75 1934 104 58 20 14 196 55 28 6 9 98 70 The periods elapsing between notification and death, and the number of cases not notified were as follows:— Under 3 months. 3 to 6 months. 6 to 9 months. 9 to 12 months. Over 12 months. Not Notified. Notified after death. Pul. NonPul. Pul. NonPul. Pul. NonPul. Pul. NonPul. Pul. NonPul. Pul. NonPul. Pul. NonPul. 9 1 8 — 3 1 7 — 29 — 9 2 4 2 The ratio of deaths in non-notified cases (i.e., columns to right of double line) to total deaths from Tuberculosis was 17 to 75 or 1 to 4.4. Appropriate action was taken, when necessary, with regard to non-notification. The table given below shows the number of cases on the Register at the beginning and end of 1935:— Pulmonary Total. NonPulmonary Total. Grand Total. M. F. M. F No. on Register 1st January 968 859 1,827 490 444 934 2,761 Notified during 1935 64 58 122 25 16 41 163 Total 1,032 917 1,949 515 460 975 2,924 Removed from Register, 1935 75 60 135 23 16 39 174 No. on Register, 31st December 957 857 1,814 492 444 936 2,750 One hundred and seventy-four removals from the Register were made up as follows:— Deaths. Removals. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 32 24 3 3 43 36 20 13 56 6 79 33 62 112 174 71 The discrepancy between the number of deaths recorded here and the number of registered deaths during the calendar year is accounted for by transferable deaths, and by cases not notified prior to death. Treatment of Tuberculosis. Treatment is given under the Essex County Council's Scheme. The admissions to Hospital during 1935 were:— Pulmonary. Non-Pulmonary Total. M. F. M. F. Adults 57 44 6 5 112 Children 6 10 5 6 27 No action was necessary under the Public Health (Prevention of Tuberculosis) Regulations, 1925, or Section 62 of the Public Health Act, 1925. Following the survey visit paid by a medical officer of the Ministry, it was pointed out modifications could, with advantage, be made in the method of carrying out the duties imposed ,by the Public Health Tuberculosis Regulations, 1930, and Circular 1107. Arrangements were then made whereby the County Council's Tuberculosis Nurse fills in at her first visit an enquiry card supplied by the Borough Council and, at the same time, issues a leaflet calling attention to the patient's part in the prevention of tuberculosis. The leaflet advises the patient how to minimise the spread of infection. After completion, the enquiry card is sent to the Public Health Department, and is passed on to the Chief Sanitary Inspector, who arranges for the district inspector to pay routine halfyearly visits. Opportunity is then taken to remedy any sanitary defect which may be found. Your Council also decided to supply pocket sputum flasks free of charge. Infectious Diseases notified by Medical Staff:—Scarlet Fever, 14; Diphtheria, 44. Total, 58. 72 G.—INFECTIOUS DISEASES HOSPITAL. Renovations, etc.—The following works of renovation and maintenance were carried out during 1935:— Extensive underpinning and interior renovations of A. and D. Blocks. Interior renovations of F. Block. Renovations of cubicles, lavatories, and sluices, also exterior renovations of G. Block. Provision of doors and screen to verandah at rear of T. Block. Interior renovations, repairs to lantern light, provision of store room, sorting bins; heating of sorting room, and new starching tank to Laundry. Exterior and interior renovations of Lodge. Repair of fences. Repair of roadways. Staff.—The staff at the end of the year consisted of a Resident Medical Officer, Matron, 6 Sisters (1 Home, 1 Tutor, 4 Ward), 1 Senior Staff Nurse, 9 Staff Nurses, 18 Probationers, 1 Needlewoman and 18 Domestics. The non-resident staff consisted of 2 Clerical, 1 Assistant Needlewoman, 4 Laundry maids, 5 Charwomen and 10 Males. Nine Probationers were successful in the first part of their Fever Certificate examination, and three obtained the Certificate on completion of training. In March your Council decided to provide part-time medical relief, and Dr. H. W. Harding was later appointed to relieve the Resident Medical Officer on two half-days per week, four week-ends per annum, and four weeks' annual leave. Dr. Hamilton's name was added to the Essex Insurance Committee's panel list for the purpose of staff medical service. General.—The death-rate per hundred admissions of infectious disease patients was 0.87. During the year the County Council continued the amount of the grant payable by them in respect of infectious disease beds. The grant was made up as follows:— (1) £5 per bed on a basis of 2,000 cubic feet per £ bed (i.e., 81 beds) 405 (2) £10 per ambulance 20 Total £425 73 The draft plans of a new cubicle block have been agreed to in principle between the Ministry of Health and your Council, and provide twelve cubicle beds and an operating suite. The completion of this block is a continued and urgent necessity. The County Council have formulated a scheme for Isolation Hospital accommodation in the County, and this provides for a Joint Hospital of 261 beds to serve the Boroughs of Walthamstow and Leyton. Negotiations are still proceeding. Financial Statement.—A financial statement for the year vended 31st March, 1935, is given below:— LOAN CHARGES. Amount of Loan outstanding on 31st March, £ s. d. 1935 12,872 4 4 EXPENDITURE. Repayment of Loan 536 0 9 Interest on Loan 575 17 6 Structural Repairs 2,467 8 10 Food for Patients and Staff 4,001 3 1 Establishment and other Expenses 12,252 8 1½ £19,832 18 3½ INCOME. Patients 362 14 0 County Council 3,025 0 0 Other sources 85 13 1 £3,473 7 1 Fees for cases front other Authorities are included. The following table shows the admissions, discharges and deaths during 1935:— Scarlet Fever. Diphtheria. Other Diseases. Tuberculosis. Totals. Remaining in Hospital 1st Jan. 33 21 7 20 81 Admitted during year 454 184 8 40 686 Discharged during year 443 189 13 40 685 Died during year - 3 2 1 6 Remaining in Hospital 31st December 44 13 - 19 76 74 DAILY AVERAGE NUMBER OF PATIENTS IN HOSPITAL. (including Tuberculosis cases.) January 75.1 July 65.8 February 96.3 August 68.6 March 91.3 September 68.9 April 92.9 October 84.6 May 77.2 November 81.4 June 65.2 December 80.3 Average whole year 78.1 Epping Urban District Council. The agreement with this Authority was extended to March, 1936, since when it has again been extended pending completion of the extensions to Waltham Joint Hospital. OTORRHŒA. At the request of Dr. A. R. Friel, your Council's Consultant Aural Surgeon, the Resident Medical Officer has compiled the following table showing the incidence of Otorrhœa in scarlet fever cases since 1930:— 1930 434 cases Scarlet Fever; 52 Otorrhœa 11.98% 1931 393 „ „ 23 5.82% 1932 392 „ „ 9 „ 2.28% 1933 551 „ „ 46 „ 8.34% 1934 465 „ „ 6 „ 1.28% 1935 454 „ „ 14 3.08% Towards the end of the year, and at Dr. Friel's suggestion, a trial was made of the use of grieswold dye, applied on a nasal plug in order to try and diminish nasal discharge and, in time, middle ear disease. The trial of this method continues. Indefinite Cases of Scarlet Fever. Increasing use is made of the suggestion of the Chief Medical Officer to the Ministry of Health (Annual Report, 1933), that "by swabbing all clinically doubtful cases of 75 scarlet fever on admission, and isolating them till the report of the cultures is received next day, a considerable number could be discharged almost immediately with a consequent large economy and without danger to the public health." CLINICAL REPORT. Dr. Hamilton, Resident Medical Officer, reports as follows:— AGE AND SEX OF PATIENTS ADMITTED DURING 1935 Disease. Under 5 years. 5—10 years. 10—15 years. Over 15 years. Total. Total. M. F. M. F. M. F. M. F. M. F Diphtheria 36 24 34 41 16 17 6 10 92 92 184 Scarlet Fever 62 50 86 102 42 33 32 47 222 232 454 Other Diseases 2 — 1 3 - 2 - - 3 5 8 Pulmonary Tuberculosis - - - - - - - 40 - 40 40 Staff — — — — — — — 19 — 19 19 Totals 100 74 121 146 58 52 38 116 317 388 705 Other diseases include Measles (2), Chicken Pox (3), Mixed Infection (2) and Anaphylaxis (1). AGE AND SEX AT DEATH. Disease. Under 5 years. 5—10 years. 10—15 years. Over 15 years. Total. Total. M. F. M. F. M. F. M. F. M. F. Diphtheria (Nephritis & Convulsions) - 1 - - - - - - - 1 1 Hæmorrhagic Diphtheria - - - 2 - - - - - 2 2 Acute Leukaemia — — — - 1 - - - 1 — 1 Measles & Broncho-Pneumonia 1 - - - - - - - 1 - 1 Pulmonary Tuberculosis - - - - - - - 1 — 1 1 Totals 1 1 — 2 1 — — 1 2 4 6 76 MONTHLY ADMISSIONS OF DIPHTHERIA CASES. Month. Under 5 years. 5—10 years. 10—15 years. Over 15 years. Total. Total. M. F. ' M. F. M. F. M. F. M. F. January 7 2 4 5 2 2 2 1 15 10 25 February 3 5 5 8 3 5 - — 11 18 29 March 2 — 3 2 1 1 - 3 6 6 12 April 3 5 1 5 1 - — 2 5 12 17 May — 1 1 2 — 1 1 — 2 4 6 June — — 2 — 1 — — — 3 — 3 July 1 1 2 1 2 l - — 5 3 8 August 7 3 5 I 1 l 1 1 14 6 20 September 4 2 3 5 1 1 — 1 8 9 17 October 4 1 2 3 1 l - 1 7 6 13 November 1 1 3 7 3 2 1 1 8 11 19 December 4 3 3 2 - 2 1 — 8 7 15 Totals 36 24 34 41 16 17 6 10 92 92 184 The cases of Diphtheria were classified as follows:— Bacteriological, 85; Mild Faucial, 77; Severe Nasal, 5; Mild Nasal, 9; Mild Laryngeal, 6; Hemorrhagic, 2. Cases Transferred to Cubicle Block from Diphtheria Block. Scarlet Fever, 5; Whooping Cough, 4; Tonsillitis, 3; Influenza, 5; Whooping Cough contacts, 3; Mumps contacts, 2; Ringworm, 3; Vaginal Discharge, 2. Complications. Late cardiac paralysis—severe—good recovery 1 Palatal Paresis 4 Palatal and Pharyngeal Paresis 1 Two children, brother and sister, developed Cough within the incubation period after their admission to the Diphtheria Ward. It was stated that they had had Whooping Cough in the previous winter. Four children developed Whooping Cough; one had concurrently some pharyngeal paralysis. Fourteen patients were given intravenous antitoxin, the dosage being as follows:—16,000 units to twelve cases and 32,000 units to two fatal lisemorrhagic cases. Intramuscular antitoxin was, of course, given in addition. 77 MONTHLY ADMISSIONS OF SCARLET FEVER CASES. Month. Under 5 years. 5—10 years. 10-15 years. Over 15 years. Total. Total. M. F. M. F. M. F. M. F. M F. January 7 6 9 4 4 1 7 2 27 13 40 February 6 6 4 6 5 6 3 7 19 25 44 March 1 5 5 9 4 7 4 4 14 25 39 April 3 1 5 10 7 3 2 5 17 19 36 May 5 3 3 8 3 2 5 6 17 19 36 June 7 4 8 11 4 3 1 3 20 21 41 July 1 2 10 7 3 2 1 3 15 14 29 August 8 — 9 7 4 4 - 3 21 14 35 September 4 4 5 6 — - 1 3 10 13 23 October 10 0 11 13 1 — 2 5 24 27 51 November 3 4 5 10 4 3 3 4 15 21 36 December 7 6 12 11 2 2 2 2 23 21 44 Totals 62 50 86 102 42 33 32 47 222 232 454 Complications:—Cervical Adenitis in 20 per cent.of the cases admitted. Otitis media with otorrhœa, 14; vaginal discharge, 4; acute rheumatism, 1; acute mastoid disease, 3; purulent rhinitis, 7 (all streptococcal). One patient, a male, aged 20, was admitted with a mild attack of Scarlet Fever. A fortnight later there was complaint of pain in the calf of the left leg. This was followed in twelve hours by a considerable attack of hæmoptysis lasting for three days—there was a strong family history of phthisis. This, in turn, was followed twelve hours afterits cessation by venous thrombosis of one of the deep veins, draining the left lower limb as evidenced by great œdema of the leg and thigh. As soon as removal was free from danger, the patient was transferred to Whipps Cross Hospital, where he was detained for some months. No evidence of tubercle was found on X-ray examination. There was never at any time any evidence of cardiac involvement. Cases Transferred to Cubicle Block from Scarlet Fever Block.—Thirty patients were transferred for the following reasons:—Whooping Cough, 4 Impetigo, 2; Vaginal discharge, 4; Rubella, 1; Observation, 3; Septic Scarlet Fever, 3; Venous Thrombosis of leg, 1; Abscess of leg, 1 ; Mumps, 2; Mastoiditis, 3; Otitis media, 1; Common cold, 3; Acidosis, 1; Recurrent Tonsillitis, 1. Staff.—Members of the Staff were admitted to hospital beds suffering from the following complaints:—Tonsillitis, 6; Common cold, 4; Sub-acute rheumatism, 2; Septic leg, 1;. Influenza, 1; Sprained ankle, 1; Rubella, 1; Observation, 3. 78 One member of the Staff was removed to the Connaught Hospital following an attack of renal colic. The kidney was subsequently removed. Another member of the Staff developed Whooping Cough. She was not treated at the hospital, but went home and returned to the hospital when the illness had terminated. Operations at Hospital.—Eight operations were performed. A total of five operations was done on two patients in respect of deep abscesses of the limbs. One was a member of the Staff, whose leg was saved from amputation by an admirable combination of surgical and nursing skill. There was one mastoid operation and two incisions of the drum. Specialist Consultations.—Six Consultants attended on 28 occasions for 13 patients as follows:—Otorrhcea, 7; Heart •complications, 4; Keratitis, 1; Incision of foot, 1. Swabs.—1,056 swabs were taken and examined during the year in the laboratory at the hospital. Number of Outside Authorities' Cases and Nature:— Diphtheria. Scarlet Fever. Total. From Whipps Cross Hospital 8 2 10 From Epping U.D.C. 5 14 19 Total 13 16 29 The following cases were transferred to Whipps Cross Hospital:—Venous thrombosis of leg, 1 (occurring in a case of Scarlet Fever); Nerve injury to arm, 1 (this patient developed Diphtheria while undergoing treatment for the nerve injury at Whipps Cross and was, at their request, re-admitted there when free of Diphtheritic infection) Paronychia, 1. One case notified as Diphtheria proved to be a fatal case of acute my eloblastic leukæmia. One patient transferred to Guy's Hospital, notified as Diphtheria (?) malignant growth. One patient was transferred to Guy's Hospital for treatment of a temporal abscess. 79 Duration of Treatment.— The average duration of treatment in Hospital was as follows:— Diphtheria 33.4 days. Scarlet Fever 25.8 days. Mixed Infection 18.2 days. The County Medical Officer has kindly furnished the following return of patients treated in the Tuberculosis Pavilion during 1935 Classification in accordance with Ministry of Health Memorandum 37.T. (Rev.). In Hospital on 1st January, 1935. Admitted during year. Discharged during year. Died during year. In Hospital 31st Dec. 1935. T.B. Minus 5 3 7 - 1 T.B. Plus Group 1 — 2 2 — — T.B. Plus Grout) 2 14 32 28 1 17 T.B. Plus Group 3 1 3 3 — 1 Totals 20 40 40 1 19 Eight of the 40 admissions were Walthamstow cases. MEDICAL EXAMINATIONS. During the year 167 examinations were carried out by the Medical Staff in respect of the Superannuation Scheme. MISCELLANEOUS. Your Council made the following grants during the year to voluntary organisations :— Invalid Children's Aid Association £100 Walthamstow Association of Tuberculosis Care Helpers £25 Mortuary.— A Coroner's Court, mortuary (with special provision for Infectious Disease cases), and a post-mortem room is provided by your Council at Queen's Road Cemetery. The number of inquests and post-mortems is given below:— Inquests only 46 Post-Mortems 66 Post-Mortems and Inquests (not included in above) 15 Total 127 80 CREMATION. Facilities for cremation are available at the Crematoriumprovided by the Corporation of the City of London, at Manor Park, Little Ilford. Full particulars can be obtained from the Superintendent, City of London Cemetery, Little Ilford. PROPAGANDA. (a) Posters.— A poster hoarding at the corner of Farnan Avenue and Forest Road has been taken over from the late Empire Marketing Board for the display of health posters supplied by the Central Council for Health Education. Your Council makes an annual grant of five guineas to the Central: Council. (b) Health Education.— Every opportunity is taken by all the Staff of the Department to give individual instruction in Health Education as a normal part of their routine work. In addition, several members of the Staff have lectured on various subjects to organisations in the town. Rainfall.— In view of the deficient rainfall of the years 1933 and 1934, the following information has been obtained from the Meteorological Office, Air Ministry, and refers to the rainfall at the Ferry Lane recording station:— Average rainfall, 1900-1909 23.21 inches. Average rainfall, 1910-1919 24.82 inches. Average rainfall, 1920-1929 28.23 inches. which represents a yearly average of 25.2 inches over the thirty years. Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Year. 1930 2.30 0.98 1.36 1.53 2.82 1.79 1.66 2.66 2.90 1.15 4.48 2.03 25.66 1931 1.21 1.78 0.14 3.20 2.54 1.04 2.24 5.11 2.20 0.58 1.81 0.78 22.63 1932 1.52 0.15 1.15 2.11 2.79 0.61 2.16 2.52 2.25 4.81 1.08 0.49 21.64 1933 1.35 1.02 2.09 0.70 1.43 3.45 0.85 0.41 2.84 1.30 0.72 0.28 16.44 1934 1.22 0.08 1.77 1.82 0.51 1.01 1.36 1.92 1.09 0.92 1.70 4.73 18.13 1935 1.18 2.05 0.45 2.93 1.10 3.31 0.99 1.72 3.15 3.18 3.55 2.59 26.20 MATERNITY AND CHILD WELFARE E 82 SECTION H. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Councillor Mrs. E. M. Richards. Ex- Officio: His Worship the Mayor—Alderman W. H. Shaw, J.P. The Deputy Mayor—Alderman Ross Wyld. Chairman of Finance Committee—Councillor E. C. Redhead. Alderman G. Gibbons, J.P. „ J. C. Hammond. „ Mrs. C. McEntee, J.P. „ Mrs. M. Norrish. „ W. J. Sharp. Councillor Mrs. L. P. Bailey. „ Mrs. B. M. Friedberg. Councillor Mrs. E. M. Hammond. „ Mrs. A. L. Meadows. „ Mrs. E. M. Miller. „ G. M. Page. „ Mrs. E. A. Smith. T. H. Tee. Mrs. E. B. Toynbee. Councillor Miss D. Wrigley, B.A. Co-opted Members: Dr. J. L. Mackenzie Brown. Mrs. V. Cossey. Mrs. M. A. Cross. Mrs. I. M. Jackson. Mrs. Hatton. Mr. W. H. Kindell. Mrs. W. H. Kindell. Mrs. W. J. Sharp. 83 TO THE CHAIRMAN AND MEMBERS OF THE MATERNITY AND CHILD WELFARE COMMITTEE. Ladies and Gentlemen, The following report on the work done in 1935 in respect of Maternal and Child Welfare is presented for your consideration. Once more the work performed shows an increase in volume and, I trust, in usefulness. The year is notable for the establishment of a new low record in infant mortality (37 per 1,000), for increased ante-natal and welfare attendances and home visits, and for increasing use of the home help scheme. The work done at the Maternity Home continued to increase until capacity was reached in August, 1935, when bookings were restricted. Draft plans for future extensions have already been approved in general principle. A very full clinical report on the work of the Home has been compiled by the Resident Medical Officer. The staff responsible for maternal and child welfare service—official and voluntary—have worked unremittingly. I would again record my appreciation of your Committee's help and consideration. I have the honour to be, Your obedient Servant, A. T. W. POWELL, Medical Officer of Health. 84 STAFF. Medical Officer of Health, Administrative Maternity and Child Welfare Officer and Medical Superintendent, Maternity Home:— A. T. W. Powell, m.c., M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Assistant Medical Officer and Inspector of Midwives: Miss Mary C. Sheppard, B.A., M.B., B.Ch., B.A.O., D.P.H., Barristerat-Law. Obstetric and Puerperal Fever and Pyrexia Consultants (part-time) :— J. B. Banister, Esq., M.D., F.R.C.S., F.C.O.G. Miss M. M. Basden, M.D., F.R.C.S., F.C.O.G. Alan Brews, Esq., M.D., F.R.C.S., M.C.O.G. Eardley Holland, Esq., M.D. F.R.C.S., F.R.C.P. V. Lack, Esq., F.R.C.S., F.R.C.P., F.C.O.G. W. McAllister, Esq., F.R.C.S., M.C.O.G. W. McKim H. McCullagh, Esq., d.s.o., m.c., F.R.C.S., M.C.O.G. Dame Louise McIlroy, d.b.e., M.D., D.Sc., F.C.O.G. H. G. Everard Williams, Esq., M.D., M.R.C.P., M.C.O.G. Maternity Home. Resident Medical Officer: Miss Helen Rodway, M.R.C.S., L.R.C.P., M.C.O.G. Miss Helen Jardine, M.B., Ch.B., M.M.S.A. (part-time relief) Miss Annie S. Clark, M.B., Ch.B., (part-time relief). Ancesthetists (part-time): D. R. Blunn, Esq., M.R.C.S., L.R.C.P. J. H. T. Challis, Esq., M.R.C.S., L.R.C.P. A. D. Woolf, Esq., M.D., L.R.C.P., L.R.C.S., L.R.F.P.S. Matron. Miss F. Bambridge, S.R.N., S.C.M. Health Visitors: Miss A. C. Keenan, S.R.N., S.C.M., H.V. Cert. (Superintendent). Miss M. B. Cassidy, S.R.N., S.C.M., H.V. Cert. Miss C. R. Douglas, S.R.N., S.C.M., H.V. Cert. Miss H. M. Gurnett, S.R.N., S.C.M., H.V. Cert. (Half-time). Miss D. E. Laidler, S.R.N., S.C.M., H.V. Cert. (Half-time) (from 21st October, 1935). Miss D. G. Legg, S.R.N., S.C.M., H.V. Cert. (Half-time). Miss M. Page, S.R.N., S.C.M., H.V. Cert. (to 12th September, 1935). Miss O. J. Panther, Cert. S.I.E.B. (Lond.) (Half-time). Miss A. Stuart, S.R.N., S.C.M., H.V. Cert. T.B. Cert. (Half-time). Miss A. O. Wright, S.R.N., S.C.M., H.V. Cert. (Half-time) (from 21st October, 1935). Miss M. A. Young, S.R.N., S.C.M., H.V. Cert. (Half-time). (Six of the Half-time Nurses give the remainder of their time to School Nursing Duties and one to Public Health Duties). Masseuse (Half-time): Miss Kathleen M. Hill, C.S.M.M.G. Record Clerk : Miss V. Lecomber. 85 1. NOTIFICATION OF BIRTHS. 1,647 births (129 of which belonged to other areas) were notified during the year under the Notification of Births Acts, 1907 and 1915. Notifications were received from Doctors and Parents, 438; Midwives, 1,209. Included in the above are 189 births which were notified as having occurred outside the Borough. Also included are 45 stillbirths, two of which did not belong to the area. Ten were notified by Doctors and 35 by Midwives. Of the total, three occurred outside the area. The stillbirth rate per 1,000 population was 0.42. 2. REGISTRATION OF BIRTHS. The Registrar-General's returns show the following registrations during the calendar year:— (a) Live Births. Males. Females Totals. Legitimate 833 793 1,626 Illegitimate 24 20 44 857 813 1,670 (b) Stillbirths. Legitimate 29 27 56 Illegitimate — 1 1 29 28 57 Of 1,628 birth registrations received in the Department between 29th December, 1934, and 28th December, 1935, a total of 284 were not notified in this area, but some may possibly have been notified elsewhere, especially in view of the fact that of the 1,628 registrations, 171 referred to births which belonged to other areas. In addition, it will be seen that the Registrar-General's figure (1,670) is 42 more than the local registrations. Presumably these were births registered and notified in other areas. Of the 1,628 local registrations, 171 are excluded, leaving a net total of 1,457, which are allocated to the Wards as follows:— 86 Births Registered Locally, 1935. St. James' Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. Totals. Grand Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. January 4 12 9 12 6 12 4 6 8 10 14 20 45 72 117 February 6 6 8 5 6 8 11 10 7 16 18 14 56 59 115 March 12 4 7 14 10 10 8 7 17 21 22 9 76 65 141 April 11 7 4 8 5 8 4 12 18 11 13 12 55 58 113 May 11 4 10 8 15 12 8 7 13 17 14 9 71 57 128 June 11 14 6 4 5 4 10 5 10 5 14 15 56 47 103 July 11 10 11 9 14 15 15 14 15 16 18 18 84 82 166 August 6 7 7 5 4 7 9 5 12 16 12 7 50 47 97 September 12 9 12 7 16 13 5 8 10 14 16 23 71 74 145 October 12 8 14 9 12 11 6 10 18 13 20 16 82 67 119 November 4 9 10 7 9 6 8 11 6 7 12 8 49 48 97 December 7 5 5 6 7 3 6 5 9 14 7 12 41 45 86 Totals 107 95 103 94 109 109 94 100 143 160 180 163 736 721 1,457 Grand Totals 202 197 218 194 303 343 1,457 The local registrations for 1935 were 167 more than in 1934. 87 3. INFANT MORTALITY. The deaths of infants under one year of age were:— Males. Females. Totals. Legitimate 30 30 60 Illegitimate 1 1 2 Total 31 31 62 The death-rates of infants under one year of age per 1,000 live births when calculated on the totals given by the Registrar-General are therefore :— Legitimate, 37; Illegitimate, 45. Total, 37. The rate of 37 creates a new low record for the Borough, the previous lowest rate being 39 in 1930. The provisional return of the Registrar-General for 1935 shows that there are only two lower rates in the whole of Greater London, viz., Beckenham (32) and Wembley (34). The Infant Mortality Rate for other areas during 1935 was as follows :— England and Wales 57 121 County Boroughs and Great Towns (including London) 62 140 Smaller Towns (25,000 to 50,000) 55 London 58 Neo-Natal Mortality. The neo-natal mortality is the number of deaths of infants under one month per 1,000 live births. During 1935, 36 infants died in the first four weeks of life, yielding a rate of 21.5. For the last ten years in England and Wales the neonatal deaths have been approximately one-half of the total deaths under one year of age. Infant Deaths Neo-Natal Mortality and Stillbirths:— Year. Live Births Birth Rate Stillbirths. Neo Natal Deaths Infant Deaths. No. per 1000 live births per 1000 population No. per 1000 live births No. per 1000 live births 1935 1670 12.4 57 34.1 0.42 36 21.5 62 37 1934 1715 12.6 60 33.8 0.44 35 20.4 77 44 1933 1670 12.3 65 37.4 0.47 49 29.3 89 53 1932 1789 13.2 82 43.8 0.60 55 30.8 103 57 1931 1947 14.5 59 29.4 0.43 51 26.2 110 56 The neo-natal mortality for England and Wales for the decennium 1921/30 was 33, and for the years 1931/3 it was 32. Reduction in the rate can only be expected from intensive and skilled ante-natal care. The following table shows the causes of death of children under one year of age during 1935:— 88 SUMMARY, 1935. Causes of Death of Children under 1 year of age. Cause of Death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total Deaths under 1 year. WARDS. St. James Street High Street Hoe Street Wood Street Hale End Higham Hill Influenza - - - - - - - - - - - - - - - - Smallpox - - - - - - - - - - - - - - - - Chicken-pox - - - - - - - - - - - - - - - - Measles - - - - - - - - - - - - - - - - Scarlet Fever - - - - - - - - - - - - - - - - Whooping Cough - - - 1 1 - - 1 1 3 - 1 1 - 1 - Diphtheria and Croup - - - - - - - - - - - - - - - - Erysipelas - - - - - - - - - - - - - - - - Tuberculous Meningitis - - - - - - - - 1 1 - - - 1 - - Abdominal Tuberculosis - - - - - - - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - - - - - - - Phthisis - - - - - - - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - 1 - 1 1 - - - - - Convulsions 1 - - - 1 - 1 - - 2 — 1 - 1 - - Laryngitis - - - - - - - - - - - - - - - - Bronchitis - - - - - 1 - - - 1 - 1 - - - - Pneumonia (all forms) — — — - — — 1 i 1 3 — — 1 1 — 1 Diarrhoea — — — — - 1 — - - 1 — — - — 1 - Enteritis — — — — - 3 2 — - 5 1 — 2 — — 2 Gastritis - - - - - - - - - - - - - - - - Syphilis - - - - - - - - - - - - - - - - Rickets - - - - - - - - - - - - - - - - Inattention at Birth, wilful neglect - - - - - - - - - - - - - - - - Suffocation, overlaying - - - - - - - - - - - - - - - - Injury at Birth - - - - - - - - - - - - - - - - Atelectasis 6 — — — 6 — — — - 6 1 — 1 — 1 3 Congenital malformations 4 1 2 1 8 — 1 1 - 10 1 — 2 2 3 2 Premature Birth 9 — — — 9 - — — - 9 2 1 1 — 1 4 Atrophv, Debilitv, Marasmus — — 1 — 1 — 1 1 2 5 — 1 1 — 2 1 Inanition 5 — — — 5 2 — — — 7 1 1 1 1 2 1 Heart Failure 2 — 1 — 3 1 — — 2 6 2 1 1 2 — — Other causes — 1 — 1 2 — — — - 2 — 1 — — 1 — 89 The death-rate from Diarrhoea and Enteritis in children Tinder one year of age per 1,000 live births was 3.6. 4. CHILD WELFARE. The equivalent of whole-time Municipal Health Visitors is 6.5, equal to one whole-time Health Visitor per 253 notified births, and one whole-time Health Visitor per 266 registered births during: 1935. The following table gives a list of the current Ante-Natal and Welfare Clinics:— MATERNITY AND CHILD WELFARE CLINICS. Monday 2 to 4 p.m. Expectant Mothers Low Hall Lane, Markhouse Road. Tuesday 9.30 a.m. ,, ,, (new cases only) Low Hall Lane, Markhouse Road. Tuesday 2 to 4 p.m. Child Welfare Estate Office, 1, Guildsway, Billet Road. Tuesday 2 to 4 p.m. ,, ,, The Memorial Hall, Winchester Rd., E.4 Wednesday 2 to 4 .p.m. ,, ,, Low Hall Lane, Markhouse Road. Thursday 2 to 4 p.m. ,, ,, Low Hall Lane, Markhouse Road. Thursday 2 to 4 pin. ,, ,, Estate Office, 1, Guildsway, Billet Road. Thursday 1.30 to 6 p:m. ,, ,, "Brookscroft" 564, Forest Road, E.17. Friday 2 to 4 p.m. ,, ,, Low Hall Lane, Markhouse Road. In addition, the Walthamstow Child Welfare Society at "Brookscroft" has 'special' Clinics, e.g., massage and light sessions. A. MUNICIPAL SCHEME. The detailed findings at first visits paid during 1935 are given in the following table:— 90 WARD. How Fed. Sleeping Accommodation. Condition of Baby. Accommodation Breast. Breast and Hand. Hand. With Mother. Cot or Cradle. Good. Fair. Bad. Whole House. Flat. Half-house. 3 Rooms. 2 Rooms. 1 Room. St. James Street 201 14 22 17 220 221 16 — 53 64 32 53 33 2 High Street 187 13 23 12 211 210 12 1 29 79 81 28 6 — Hoe Street 212 23 24 3 256 248 10 1 62 30 153 8 5 1 Wood Street 179 14 35 5 223 210 18 — 61 12 127 8 17 3 Hale End 291 23 43 12 350 325 35 2 198 37 99 9 15 4 Higham Hill 320 25 23 46 322 306 61 1 183 85 75 3 10 12 Total 1,360 112 175 95 1,582 1,520 152 5 586 307 567 109 86 22 From the above table it will be seen that of 1,677 children,. 1,390, or 82.9 per cent., were breast-fed on first being visited,, but 95, or 5.6 per cent., had no separate sleeping accommodation. The particulars in respect of housing accommodation show that only 586 of the families visited had a house ta themselves, while 22 families were living in one room. The1934 figures were 567 and 20 respectively. 91 The following table shows the number and nature of visits paid in Wards during 1935:— WARD. Visits to Children under 1 year. Visits to Children 1-5 years Grand Total. Unsuccessful Visits. Visits to Nurse Children. Ante-Natal Visits Other Visits. Total Visits. First. Re-visits. Total. Not at home. Dead. Removed. Visits re Milk Scheme. First Visit. Subsequent Visits Total Visits. 1 2 3 4 5 6 7 8 9 10 11 12 Cols. 5-12. St. James Street 237 396 633 777 1,410 184 6 82 57 172 50 7 57 49 2,017 High Street 223 347 570 799 1,369 124 4 48 85 105 22 8 30 34 1,799 Hoe Street 259 335 594 805 1,399 93 3 85 52 63 27 2 29 41 1,765 Wood Street 228 351 579 1,051 1,630 207 7 148 64 211 16 — 16 21 2,304 Hale End 362 1,001 1,363 2,157 3 520 232 13 212 200 400 58 25 83 41 4,701 Higham Hill 368 989 1,357 2,091 3,448 232 10 201 207 200 56 27 83 88 4,469 Total, 1935 1,677 3,419 5,096 7,680 12,776 1,072 43 776 665 1,151 229 69 298 274 17,055 Total, 1934 1,69! 2,393 4,084 5,648 9,732 693 60 622 738 1,167 207 57 264 881 14,157 92 Dr. Sheppard reports as follows:— "1935 has been a very successful year at the Welfare Centres. Six Welfare Sessions are held weekly, and at all but one there is a doctor in attendance. "The ante-natal clinic has been kept busy for the past twelve months. The Midwives of the district have taken advantage of this clinic better than in previous years. "The number of applications for 'Home Helps' during the year has greatly increased. This is very gratifying as it shows that the expectant mothers are becoming more aware of the facilities offered by the Council, and are taking advantage of them. "The co-operation between the school clinics and the child welfare centres continues to be satisfactory. Dr. Friel had a large attendance of babies at his clinics for ear troubles. A number of children suffering from eye defects, including strabismus, were seen at the eye clinics. Many children under five years of age obtained treatment from the "dental surgeons. "The mothers attending the ante-natal clinic are each year becoming more amenable to dental treatment. Now any mother who sees the dental surgeon before the sixth month of pregnancy, and is found to require dentures, can lave assistance in obtaining them. This is a great inducement for early treatment. "Mr. Whitchurch Howell saw a large number of children under school age at the Orthopaedic Clinic. Unfortunately, most of these cases were suffering from defects due to rickets. Miss Hill, as usual, attends each welfare centre during the week to give massage treatment to the children of that district. Her five weekly sessions are all well attended, and the results she obtains are very satisfactory, and in many cases she has prevented her little patient from having to attend the Orthopaedic Clinic later. "The Council's thanks are again due to the voluntary workers at the centres, who have given faithful service during at the year, and have been very helpful to the Health Visitors." The attendances at the various Welfare Centres can be seen from the following table:— 93 SUMMARY OF ATTENDANCES AT WELFARE CENTRES. Centre. First Attendances of new cases. Re-attendances. Under 1 yr. of age 1—5 yrs. of age. Total. Under l yr. of age. 1—5 yrs. of age. Total. Grand Total. Low Hall Lane 692 14 706 10,508 9,745 20,253 20,959 Higham Hill 292 121 413 4,094 4,476 8,570 8,983 Highams Park 202 66 268 3,096 3,645 6,741 7,009 Total (1935) 1,186 201 1,387 17,698 17,866 35,564 36,951 (1934) 1,090 211 1,301 15,952 15,814 31,766 33,067 Nurse Children.— At the end of 1935 there were 122 nurse children on the Register as compared with 144 at the end of 1934. During the year 89 removed, 4 were adopted, 9 reached the age of nine years, and 2 ceased to come under the Act. 82 new children were registered and one re-registered. There was one death among nurse children during 1935. Massage.—163 cases attended for massage, and these made 2,147 attendances. Sale of Milk, etc., at Clinics.— The quantity and value of milk and food sold and issued free during 1935 was as follows:— Sales. Value. Free Issue. Lbs. ozs. £ s. d. Lbs. ozs. Virol 1,572 12 133 12 8 6 8 Prune and Banana Syrup 112 4 11 4 6 Nil. Parrish's Food 372 4 12 8 2 Nil. Malted Honey 1 0 0 0 10 Nil. Maltoleine 34 0 1 2 8 1 0 Cod Liver Oil 478 12 16 12 6 2 0 Cod Liver Oil Emulsion 771 0 38 11 0 0 4 Ambrosia 556 0 46 6 8 226 0 Virol Containers 3,176 13 4 8 7 Ostermilk 1,764 0 147 0 0 577 0 Almata 59 0 4 11 2 Nil Roboleine 507 0 38 0 6 9 0 Cod Liver Oil and Malt 760 0 22 3 4 1 0 Cow and Gate 6,955 0 551 8 1 1,087 0 Lactogen 670 0 53 0 10 100 0 Hemolac 351 0 29 5 0 88 0 Trufood 666 0 71 1 6 83 0 £1,189 14. 1 94 TREATMENT. (a) Orthopaedic.— The facilities provided by the Education Authority's Orthopaedic Scheme is available for all children attending the Welfare Centres. Miss Garratt has kindly furnished the following information with respect to children under five years of age:— Defects seen at Orthopedic Clinic in Children under 5 Years of Age. Anterior Poliomyelitis 2 Scoliosis 9 Rickets— Pes Piano Valgus 52 (a) Genu Varum 51 Spastic Paralysis 8 (b) Genu Valgum 62 Congenital Defects 5 Arthritis 1 Digitus Varus 1 Torticollis 7 Hydrocephalus 2 Talipes—Equino Varus 7 Erb's Paralysis 1 Calcaneous 3 Miscellaneous 9 Total 220 Admissions to Brookfield Orthopedic Hospital. (Under 5 Years of Age.) Rickets— Talipes Equino Varus 3 (a) Genu Varum 3 Hemiplegia 2 (b) Genu Valgum 2 Coxa Vara 1 Congenital Dislocation of hip 1 Epiphysitis 1 Total 13 Number and Classification of Operations, at Brookfield Orthopedic Hospital. (Under 5 Years of Age.) Tenotomy— Osteotomy— Tendo Achilles 4 McEwan's 3 Tensor Fasciæ Femoris 1 Ball and Socket 1 Manipulation—Feet 3 Osteoclasis 2 Congenital Dislocation of hip—Reduction 4 Total 18 (b) Dental.—The following work was done by the Education Committee's Dental Surgeons:— 95  Mothers. Children under 5 Cases Treated 174 187 Attendances 276 263 Fillings 73 132 Extractions 485 278 General Anaesthetics 190 148 Scalings 10 3 Dressings 13 78 Dentures 12 - The Senior Dental Surgeon submits the following report from Mrs. W. R. Thorne, L.D.S.:— "During the past year 174 maternity cases have been treated. Over three hundred special appointments have been sent out, but nearly half of these appointments have not been kept. These failures consist of cases for inspection and conservative treatment. Appliances are always popular, and there have been no failures to attend for dentures. It is to be deplored that mothers set so low a value on their natural dentitions. Extractions under a general anæsthetic have been successfully undertaken at all stages of gestation. "There is a widespread belief, entirely without foundation, that performing dental operations during pregnancy may have injurious effects on the mother and foetus. The regular treatment of these cases is gradually dispelling this fear and making treatment more acceptable. "The sliding scale of fees for prosthetic treatment is very much appreciated, and enables the poorer mother to have the necessary dentures. This need is barely met by treatment during pregnancy. The patient is not referred to the clinic until pregnant. The whole preparation of the mouth, such as multiple extractions, must take place; then the waiting period of healing and shrinkage of gums before the dentures are fitted. Thus almost the whole period of gestation may pass before the patient is supplied with the means of proper mastication. "To those whose circumstances preclude them from affording dentures, there is a real need for municipal dental work, that is, for the potential mothers. With such a scheme an expectant mother would be able to have had dental treatment and not be obliged to wait until she was 'in benefit.' "It is inadvisable to fit dentures immediately after the removal of teeth because the dentures very soon become loose, and the patient is then faced with the additional expense of renewal. "There has been a steady increase in the number of patients receiving conservative treatment. Such treatment is of great educational value. 96 "Few patients are free from periodontal disease. The indifference to it is due to the absence of pain until the condition is very advanced. The young mother of to-day was the school-girl of yesterday. Many of the patients were children who received dental treatment while at school. During the gap between leaving school and marriage there must be a great neglect of oral conditions. That oral disease may be passed on to the baby is matter of surprise to many mothers. Some mothers are in the habit of tasting the infant's food, and with the same spoon proceed to feed the child. There is much work to be done in this respect, and it is here where the health visitor in her professional visits is able to do so much valuable propaganda." (c) Tonsils and Adenoids.—Seven cases were operated on under the arrangement made by the Education Committee with the Connaught Hospital. (d) Ophthalmic Defects and Minor Ailments.—Children are given treatment either at the School Clinics or by special appointment. (e) Invalid Children's Aid Association.—Miss Lewis, Secretary of the local Branch of the Invalid Children's Aid Association, kindly reports that the following cases under five years of age were dealt with by her Association:— Referred by:— Medical Men, Hospitals and Dispensaries 36 Orthopaedic Clinics 93 Others 4 133 Suffering from :— Anaemia and Debility 9 Marasmus and Malnutrition 4 Pneumonia, Bronchitis, Asthma, etc. 6 Bone Disease (non-T.B.) 75 Congenital Deformities 15 Paralysis 6 Hernia 2 Diseases of:—Glands, non-T.B 2 Digestive Organs 2 Nervous Conditions 4 Ear 2 Eye 2 Various 4 133 97 HELP GIVEN TO OLD AND NEW CASES, 1935. Sent to Special Hospitals and Convalescent Homes *19 Provided with Surgical Boots and Appliances 69 Referred for Visiting and Advice 54 * Includes 11 admissions to Brookfield Hospital. 142 B. WALTHAMSTOW CHILD WELFARE SOCIETY. The Society came of age during 1935, having been founded by the late Dr. Elliott in 1914—four years before the operation of the Maternity and Child Welfare Act. The Headquarters are at "Brookscroft," Forest Road, one of the few remaining old mansions of Walthamstow, and which has been adapted to suit its present function. A large and well-planned annexe has been built for massage and artificial sunlight treatment. The original house contains waiting, weighing and consultation rooms on the ground floor, three wards with seven cots for the in-patient treatment of infants on the second floor, and staff quarters above. The grounds are both extensive and attractive, and the property has been made available to the Society by the generosity of the late Sir William Mallinson, Bart., who continued to be a generous benefactor until his death. The objects of the Society are the physical and moral welfare of infants and children up to five years of age; and the training of children's nurses. Systematic lectures for the voluntary works and trainees are given. Mrs. Maud Cross has acted as Honorary Secretary since the inception of the Society, has given unstinted service and has, throughout, inspired the work. The number of voluntary workers on the active list is about sixty, and many have given unbroken service from the beginning—a wonderful record! The Medical and Nursing Staff consists of Dr. Forbes Buchan (Physician and Lecturer), Dr. W. Cuthbertson (Assistant Physician), Miss Hughes, S.C.M. (Superintendent and Health Visitor), Miss Morley, S.R.N., S.C.M. (Matron), Miss Dockree, S.R.N., S.C.M. (Sister), and Miss Latimer, S.R.N., S.C.M., and three probationers. Clinics are held as follows:— Tuesday and Friday, 2-4 p.m. Massage and Sunlight Treatment. Wednesday, 2.0-4.30 p.m. Weighing Clinic and Dispensary Treatment. Thursday, 1.30-6 p.m. Infant Consultations. 98 The work done during the calendar year is shown in the following table compiled from information kindly supplied by Miss Coulston:— CLINICS. First Attendances of New Cases Re-Attendances. Grand Total. Under 1 yr. 1—5 yrs. Total. Under l yr. 1—5 yrs. Total. 1935 387 81 468 5526 4759 10285 10753 1934 400 275 675 5720 4,737 10457 11132 1933 372 79 451 5843 4786 10629 11080 SPECIAL TREATMENT, ETC. Attendances at Lectures. Massage Treatments. Sunlight Treatments. Total cases admitted to Observation Ward. Local Authority's cases admitted to Observation Ward. 1935 608 2197 1727 27 - 1934 713 1919 2292 32 1 1933 707 1602 1508 31 1 HOME VISITS. Visits to Children under 1 year. Visits to Children 1—5 years. Grand Total. First. Subsequent Total. 1935 338 1,441 1,779 2,672 4,451 1934 363 1,303 1,666 2,736 4,402 3933 336 1,128 1,464 2,943 4,407 Your Council, under the Scheme approved by the Ministry of Health, make an annual grant of £644 1s. 8d. towards the funds of the Society. 99 SUMMARY OF MUNICIPAL AND VOLUNTARY SCHEMES. The following tables give the total number of attendances at clinics and home visits :— ATTENDANCES AT CLINICS. First Attendances. Re-attendances. Grand Total. Under 1 year of age. 1—5 years of age. Total. Under 1 year of age. 1—5 years of age. Total. Municipal Scheme 1,186 201 1,387 17,698 17,866 35,564 36,951 Brookscroft 3.87 81 468 5,526 4,759 10,285 10,753 Total 1935 1,573 282 1,855 23,224 22,625 45,849 47,704 1934 1,490 486 1,976 21,672 20,551 42,223 44,199 HOME VISITS. To Children under 1 year of age To Children 1—5 years of age. Total. First. Subsequent. Total. Municipal Scheme 1,677 3,419 5,096 7,680 12,776 Brookscroft 338 1,441 1,779 2,672 4,451 Total 1935 2,015 4,860 6,875 10,352 17,227 1934 2,054 3,696 5,750 8,384 14,134 Percentage of notified live births represented by number of children under one year of age who attended the Centres for the first time (i.e., new cases) 1935 98.3 1934 97.2 Percentage of total notified births represented by number of expectant mothers attending Ante-Natal Clinics 1935 65.7 1934 44.1 100 Ante-Natal Attendances.— The large increase- under the latter heading is due to the number of patients attending the Ante-Natal Clinic at the Maternity Home. The percentages, for the past six years have been as follows:— 1935 65.7 1932 22.9 1934 44.1 1931 16.5 1933 25.6 1930 16.7 The numbers do not represent the total amount of antenatal care which is given, because of the number of mothersreceiving ante-natal care from their private doctors and from the institutions in which they are confined, both within and1 without the area. Post-Natal Attendances.—280 mothers made 580 postnatal attendances, a percentage of 17.1 of the total notified1 births (live and still). The totals include five sessions per month provided by the Public Health Committee, at which 11 mothers made 23 ante- and post-natal attendances. Nursery School and Classes.— Apart from the children at the Nursery School, 484 children born in 1931/32 (i.e., under 5 years of age) were on the School Registers on 31st December,. 1935. 6. ASSISTED MILK SCHEME. Milk is supplied under this scheme to expectant and nursing mothers and to children under three years of age. It is not a. condition that the applicants should attend the Welfare Centres,, although, in practice, many do so. Applications are made on special forms which give particulars of income and rent and are scrutinised each week by lady members of the Maternity and Child Welfare Committee who attend in rotation. Milk may be either granted free or at reduced cost, and the following shows the amount and approximate cost of milk, granted by the Committee during 1935 :— Number of applications during 1935 6,051 Number of families assisted 1,047 101 Of the 6,051 applications, approximately 47 per cent. were from families where the father was unemployed. Scale. Amount. Approximate Cost to Authority. £ s. d. Free 328 pints 4 8 5 ½d. per pint 79,319 „ 926 4 3 1d. per pint 91,249 „ 873 10 6 2d. per pint 56 „ 7 0 Half-cost 21,071 „ 144 5 5 192,023 pints £1,948 15 7 At the suggestion of the Ministry of Health, and in order to minimise overlapping between the Council's assisted milk scheme and the work of the Public Assistance Committee, it was decided that milk for expectant and nursing mothers and young children should be provided primarily under the Maternity and Child Welfare assistance rather than as public assistance. 7. HOME HELPS. Applications for the provision of Home Helps are considered by the Milk Rota Committee and, if approved, a payment of 12/6 per week for two weeks is made. In addition to the 60 Home Helps approved during 1935, many mothers attending the Clinic made their own arrangements to obtain the help of suitable women whose names were supplied by the Health Visitors. The demand for Home Helps has grown progressively during the past five years: 1931 (3), 1932 (12), 1933 (18), 1934 (21), 1935 (60). 8. INSTITUTIONAL TREATMENT, ETC. A total of 7 children were sent to Institutions under arrangements approved by your Committee. The details were as follows :—Brookfield Orthopædic Hospital, 5; Herne Bay, 2. One mother was sent away for post-natal convalescent home treatment. 102 9. HOSPITAL ACCOMMODATION FOR CONFINEMENTS. The following numbers of confinements occurred at the Institutions specified (Walthamstow residents only) :— Thorpe Coombe Maternity Home 646 Nursing Homes in Walthamstow 200 Mothers' Hospital, Clapton 55 Forest Gate Hospital 32 City of London Maternity Hospital 10 Other Hospitals, etc. 9 952 There are five Nursing Homes in the Borough with a total maximum accommodation of 29 beds for maternity cases. In addition, the Municipal Maternity Home has 35 lying-in beds and 4 isolation beds, making a total for the Borough of 64 lying-in beds and 4 isolation beds. 10. WALTHAMSTOW DISTRICT NURSING ASSOCIATION. Mrs. Drury, the Honorary Secretary, kindly reports as follows:— "During 1935, 149 in-patients (19 Maternity and 130 Midwifery) were admitted, as against 154 in 1934. "142 Midwifery and Maternity cases were attended on the District, against 158 in 1934. " The general work of the District shows an increase. "The year 1935 has seen many changes in the Association. In September the Committee affiliated to the Queen's Institute of District Nursing and one 'Queen's' nurse was appointed to do the general works The Committee felt that if a sufficient number of 'Queen's' nurses was to be obtained efficiently to meet the demands of the Borough, they must aim at getting a definite annual income. They therefore took the step of engaging a trained Organiser (Miss C. A. Lee from the Queen's Headquarters) who assumed duty at the end of December. "Miss Lee has launched the Provident Scheme of payments, and up to date there are 5,000 members, all paying regularly sums varying from 4/4 a year to £1 1s. Od. a year. This subscription entitles the head of a family and all dependents to free service. "The Committee still retain the unalterable rule regarding the free service for necessitous cases and old age pensioners. 103 "The growth of the membership has necessitated an increase of nurses and at the end of March, 1936, the Staff consisted of the following :— 1 Queen's Superintendent. 1 Queen's Sister-in-Charge of Midwifery Wards. 3 Trained Midwives. 3 Queen's Nurses. "In January Miss Ross, our Matron for many years, retired owing to ill-health. "The Committee would like to place on record their great appreciation of the splendid work of Miss Ross, done during her time of office. She takes with her into her retirement the best wishes for her future from everybody. "Miss Lee agreed to undertake the duties of Matron temporarily. "The Association again expresses thanks to the Council for their continued help and confidence." Note by Medical Officer of Health. Two notable achievements require comment in connection with the Association's work. Angela Moreton, born in 1934, and weighing only 16¾ ozs. at birth, has successfully passed her first birthday, and at 19 months of age weighed 18 lbs. Although 1,642 cases of maternity and midwifery were attended bv the midwives of the Association during the years 1930 to 1935 inclusive, no notification of puerperal fever or pyrexia has been received. In fact, no such notification has been received at least since 1922, from which date the registers have been searched. Dr. Cecilia Cohen, acting for the Association, arranged a further course of post-graduate lectures for midwives. The lecturers were as follows : — 1935. January 31st "Obstetrical Emergencies" Dame Louise McTlroy, D.B.E., M.D.. D.Sc., F.C.O.G., M.R.C.P. February 28th "The Relations of the Midwife with the Local Supervising Authority and the Public Health Department." A. W. Forrest, M.A., M.D., D.P.H. March 21st "Puerperal Sepsis" A. T. W. Powell, M.B., B.S., D.P.H. 104 11. CONSULTANT OBSTETRICIANS. The services of a Consultant Obstetrician were requested by General Practitioners on five occasions (i.e., apart from the Maternity Home). The table below gives particulars in respect of each case :— No. Diagnosis. Where treated. Infant. 1 Prolonged labour Admitted to Hospital. Live baby. 2 Prolonged labour— forceps delivery. ,, ,, ,, ,, ,, 3 Prolonged labour forceps delivery. Locked twins. ,, ,, ,, Live twins. 4 Concealed accidental hæmorrhage. ,, ,, ,, Stillbirth. 5 Prolonged labour— ,, ,, ,, One live baby. One stillborn. There were no maternal deaths in any of these cases. 12. MIDWIVES ACTS, 1902—1926. Number of Notices of Intention to Practice January, 1935 28 Number of Notices of Intention to Practice during 1935 17 Total 45 Number of Midwives ceasing practice during 1935 18 Number of Midwives practising at end of 1935 27 There was no change in the arrangements for the employment or subsidy of Midwives by the Council. Dr. Sheppard has acted as Inspector of Midwives and has carried out the routine quarterly inspections, the results of which have been satisfactory. Additional inspections in respect of emergencies such as Ophthalmia Neonatorum, Puerperal Fever and Pyrexia, and Maternal Mortality, have been made by your Medical Officer of Health. Of the 27 Midwives in active practice during 1935, an average of 14 were employed at the Maternity Home and 5 by the Walthamstow District Nursing Association, leaving a total of 8 independent Midwives in active practice. Of these 8, one practised at her own registered maternity home, and the other 7 had the following number of cases: 85, 75, 44, 36, 23, 6 and nil within the Borough (Midwifery and Maternity). 105 The following table shows the work clone by the midwives, including those employed at Thorpe Coombe Maternity Home, during 1935 :—- No. of confinements attended as a midwife 1,071 „ „ „ „ „ maternity nurse 197 ,, „ Medical Aid Notices sent 419 „ „ Notifications of Deaths 5 ,, „ Twin Births notified 4 „ „ Stillbirths notified 9 „ „ Notifications of liability to be a source of infection 7 „ ,, „ ,, laying out a dead body 1 „ „ „ „ artificial feeding 1 „ „ „ „ disinfection 7 The table includes the following numbers with regard to -work done at Thorpe Coombe:— Midwifery cases, 564 in Home and 35 on District. Maternity cases, 82 in Home and 9 on District. Medical Aid Notices, 329. The percentages of medical aid summonses were :— Total, 39.1. Maternity Home, 52.1. Domiciliary Midwives, 19.5. The conditions for which Medical Aid was summoned by Midwives in domiciliary practice have been summarised and were as follows :— Ante-Natal. Labour. Threatened miscarriage 6 Ruptured perineum 27 A.P. Haemorrhage 1 Delayed labour 9 Albuminuria 1 Malpresentation 8 Foetal death 1 Adherent placenta 3 Phlebitis 1 P.P. Hæmorrhage 3 Contracted pelvis 1 50 11 Infant. — Eye conditions 8 Puerperium. Feebleness 7 Eclampsia 2 Rash 4 Subinvolution 1 Stillbirth 2 Phlebitis 1 Jaundice 2 — Other conditions 25 4 48 Details of medical aid notices issued by midwives employed at Thorpe Coombe are given in the Maternity Home report. 106 Compensation for Loss of Cases.— During the year the Council decided to compensate midwives by the payment of 10/per confinement lost by reason of the reference of the patient from the Council's Ante-Natal Clinic to hospital on account of' any abnormality. No claims for compensation were made during 1935. Assistance re Midwives' Fees.—In order to endeavour to eliminate the handywoman by the provision of a certified midwife acting as a maternity nurse, the Council adopted a scale of fees for the assessment of any application so received. The scale adopted was similar to the one in use for the assessment of medical aid fees under the Midwives Acts. No applications were received during 1935. Nursing Homes Registration Act, 1927. — See Public Health Section of the Report. 13. PUERPERAL FEVER AND PYREXIA. Thirty-five cases of Puerperal Fever and Pyrexia were notified during 1935. The notifications were received from the following sources: Maternity Home, 26; Hospitals outside the area, 5 (in 3 of these the confinements occurred in Walthamstow) ; and General Practitioners, 4. The puerperal fever and pyrexia rate for 1935 was 20.26 per 1,000 total births, and the mortality due to puerperal sepsis; was 8.6 per cent. of the cases of puerperal fever and pyrexia notified. The Registrar-General has issued the following rates with regard to the notification of Puerperal Fever and Pyrexia. The Walthamstow rates are set out in comnarison : — Area. Per 1,000 live and still-births. Puerperal Fever. Puerperal Pyrexia. Total. England and Wales 3.60 9.44 13.04 121 County Boroughs and Great Towns including London 4.55 11.14 15.69 140 Smaller Towns (25/50,000 population) 2.76 8.25 11.01 London Administrative County 4.32 11.89 16.21 Walthamstow 2.31 17.95 20.26 107 Of the 35 notifications (Puerperal Fever 4 and Puerperal Pyrexia 31) received during 1935, 26 were from the MaternityHome. The Resident Medical Officer, after careful analysis of the temperature charts of these 26 patients, found that 10 of the notifications would have been excluded had the temperatures been taken twice daily instead of four-hourly. It can therefore be claimed that even if the total notification rate is 4.05 per 1,000 total births in excess of the rate in the London Administrative County area, the excess is probably due rather to more accurate notification than to an increase in the incidence of puerperal morbidity. The notifications and rates for Walthamstow for the past five years have been as follows :— Per 1,000 Total Births (Live and Still). Year. Puerperal Fever. Puerperal Pyrexia. Total. No. Rate. No. Rate. No. Rate. 1935 4 2.31 31 17.95 35 20.26 1934 13 7.31 28 15.78 41 23.09 1933 8 4.61 22 12.61 30 17.22 1932 6 3.39 20 11.29 26 14.68 1931 11 5.43 30 14.90 41 20.33 108 PUERPERAL FEVER AND PYREXIA INCIDENCE, 1935 (Excluding Maternity Home). No. of case. Fever or Pyrexia. Date of Notification. Date Notification Received. Age. Ward. Facilities requisitioned as per notification. Date of Birth or Miscarriage Cnset of Pyrexia. Date removed to Hospital. Remarks. 1 Fever 24.1.35 25.1.35 27 Higham Hill All facilities available 18.1.35 ? 22.1.35 Notified from Hospital. 2 Pyrexia 18.2.35 22.2.35 25 Hoe Street ,, ,, ,, 1.2.35 18.2.35 Already in Hospital Due to Influenza. 3 ,, 29.4.35 29.4.35 38 Hale End That the patient be admitted to Hospital 24.4.35 27.4.35 29.4.35 4 ,, 18.5.35 22.5.35 22 Hale End All facilities available 3.5.35 13.5.35 Not removed Thrombo-phlebitis. 5 ,, 18.6.35 19.6.35 37 St. James Street ,, ,, ,, 10.6.35 14.6.35 Already in Hospital Notified from Hospital. Died Puerperal Endometritis, Cerebral embolism, 22.6.35. 6 Fever 29.7.35 30.7.35 21 Higham Hill To be admitted to Hospital 20.7.35 26.7.35 28.7.35 7 Pyrexia 21.8.35 21.8.35 25 Higham Hill All facilities available 2.8.35 20.8.35 Not removed Mastitis. 8 Fever 22.10.35 23.10.35 33 High Street ,, ,, ,, 30.8.35 7.9.35 Already in Hospital Miscarriage. Death from Septic Endocarditis. 9 ,, 3.12.35 4.12.35 35 Hale End Already in Hospital 23.11.35 ? 27.11.35 Abortion. 109 14. OPHTHALMIA NEONATORUM. The number of cases notified during the last two years were : — Year. Totals. St. James' Street. High Street. Hoe Street. Wood Street. Hale End. Higham. Hill. 1935 1 - - 1 - - - 1934 5 - 1 1 1 1 1 Year. Treated Vision unimpaired. Vision impaired. Total Blindness. Deaths. At Home. in Hospital 1935 1 - 1 - — — 1934 1 4 5 — — — The single notification of 1935 creates a new low record. The average number of cases notified annually during the previous nine years to 1936 was 8.5. 15. MATERNAL MORTALITY. Corrections.— The second maternal death referred to at the foot of page 102 in the report of 1934 should be excluded. The death had been classified by the Registrar-General as being due to Puerperal Sepsis on the grounds that the endometritis had been associated with recent parturition, which was in fact incorrect. This exclusion reduces the number of deaths due to Puerperal Sepsis in 1934 from 7 to 6, and the total to 11. The net result is to alter the maternal mortality rates for 1934 as follows :— Births Registered. Deaths of Women due to Pregnancy and Child-Bearing. WALTHAMSTOW. England and Wales. Puerperal Sepsis. Other Puerperal Causes. Total. Rates per 1,000 Births Registered. Rates per 1,000 Births Registered. Puerperal Sepsis. Other Puerperal Causes. Total. Puerperal Sepsis. Other Puerperal Causes. Total. Live 1,715 6 5 11 3.49 2.91 6.40 203 2.57 4.60 Live and Stillbirths 1,775 6 5 11 3.37 2.81 6.18 1.95 2.46 4.41 110 During 1935 a total of six maternal deaths were investigated for the completion of inquiry forms. One of these (case No. 3) was not classed by the Registrar-General to Pregnancy and Child-bearing, but was returned as associated therewith. Particulars relating to the six deaths are given in the accompanying table. The first was an "unavoidable" death, two were operative deaths—operations being indispensable in both cases —two were post-abortive deaths and the other was a streptococcal septicaemia apparently autogenous in origin. Unemployment and/or malnutrition was only noted in one case. This patient had declined the offer of assistance under the assisted milk scheme. The following table shows the maternal mortality rates for 1935 (calculated on five deaths) :— Births Registered. Deaths of Women due to Pregnancy and Child- Bearing. WALTHAMSTOW. England and Wales. Puerperal Sepsis. Other Puerperal Causes. Total. Rates per 1,000 Births Registered. Rates per 1,000 Births Registered. Puerperal Sepsis. Other Puerperal Causes. Total. Puerperal Sepsis. Other Puerperal Causes. Total. Live 1,670 3 2 5 1.80 1.20 3.00 1.68 2.42 4.10 Live and Stillbirths 1,727 3 2 5 1.73 1.16 2.89 1.61 2.32 3.93 The following table sets out the maternal mortality, stillbirth, and neo-natal death rates for the past five years. The normal expectation is that these three rates should show correlation Rate (per 1,000 live births) 1935. 1934. 1933. 1932. 1931. Maternal Mortality 3.00 6.40 5.39 4.47 0.51 Stillbirths 34.1 33.8 37.4 43.8 29.4 Neo-Natal Deaths 21.5 20.4 29.3 30.8 26.2 111,112 DEATHS DUE TO PREGNANCY AND CHILDBEARING AND ASSOCIATED THEREWITH. Case No. Date of Death. Certified Cause of Death and Classification. Age. Ward. Circumstances. Pregnancy. Ante-Natal Care. Physical Condition. Date of Confinement or Abortion. Doctor called. Admission to Hospital. Remarks. Prev. Duration of Doctor Midwife. 1 22.6.35 Cerebral embolism due to puerperal endometritis (P.M.) (Puerperal Sepsis.) 37 J. Poor 5 38 weeks — Yes Good 10.6.35 10.6.35 10.6.35 Declined Midwife's advice re medical ante-natal care. Apparently unavoidable death. 2 17.7.35 Ruptured ectopic gestation (Other Puerperal causes.) 34 H.E. Comfortable Nil. 12 „ — — Good 17.7.35 17.7.35 17.7.35 Died a few hours after operation in hospital. 3 9.8.35 General Shock. Cæsarean section. Myomectomy for multiple fibroids. (Not counted by Registrar-General) 32 H.H. Comfortable Nil. 39 „ Yes Yes Good 9.8.35 In-patient Do. do. 4 26.10.35 Toxaemia due to acute pyelonephritis which had caused abortion. (P.M. without inquest.) (Other Puerperal causes.) 35 H.E. Poor Multipara 8 „ — — Malnourished 25.10.35 25.10.35 25.10.35 Declined assistance under milk scheme. Death classified as "puerperal albuminuria." 5 13.11.35 General peritonitis and sepsis following full term. Normal delivery. (P.M.). (Puerperal Sepsis.) 34 H.E. Comfortable 1 40 „ Yes Good 5.11.35 4.11.35 8.11.35 Patient had sore throat. Normal delivery. Death due to general infection with hæmolytic streptococcus. 6 15.11.35 Septicæmia due to sub-acute bacterial endocarditis (P.M. without inquest) (Puerperal Sepsis.) 33 Hi. Poor 6 4 „ — — Heart Disease 23.8.35 (a) 23.8.35 (b) 7.9.35 7.9.35 Advised re induction and sterilization at last confinement owing to heart disease. Death classified as "post abortive sepsis." 113 I. THORPE COOMBE MATERNITY HOME. Structural Alterations.— In view of the recent opening of the Home no major alterations have been carried out. A water softening plant was installed during 1935 and is housed in a small building adjoining the laundry. At the time of writing, draft plans for extensions have been approved by your Council and the Ministry of Health. The extensions include a new wing to the nurses' home, a new antenatal clinic in a separate building, a new post-natal block of six cubicles with staff quarters over, and a small chapel and postmortem room. The extensions are urgently necessary owing to the existing inadequate facilities for the observation and treatment of cases of puerperal pyrexia and in view of the refusal of bookings at the rate of some 200 per annum. Bookings have been restricted to 65 per month since August, 1935. Staff. (a) Medical.—Dr. Helen Rodway, M.C.O.G., assumed duty as Resident Medical Officer on April 1st, 1935. Dr. Rodway devotes her whole time to the work at the Maternity Home except for two outside clinics per week. Following the Council's decision to appoint a whole-time resident, the 29 general practitioners who had previously formed a rota for the purpose of answering medical aid notices, gave notice of their intention to resign. Dr. Helen Jardine, M.M.S.A., was then appointed as parttime relief Medical Officer. Consultants (chiefly obstetric) were called on 24 occasions. Particulars appear in the Clinical Report. (b) Nursing.—The progressive increase in bookings necessitated additional staffing, notably following the survey visit paid by the officers of the Ministry of Health. At the end of the year the nursing staff consisted of the Matron, Assistant Matron and Sister Tutor, 4 Sisters (including 1 for district work), 8 Staff Nurses, 6 Pupils and 6 Probationers. (c) Clerical, Domestic and Male.—At the end of the year the general staff consisted of 2 clerks, cook, 13 maids, 4 laundresses, a temporary needlewoman and a part-time laundress. The male staff consisted of three whole-time and one halftime stokers, one general assistant and one part-time gardener. 114 In order to accommodate the increased nursing and domestic staff, sleeping-out allowances were paid where necessary and until 21 Hoe Street was made available as an annexe to the Nurses' Home. Up to 16 persons can be accommodated in the annexe. General. (a) Anæsthesia.—A Minnitt's Gas and Air apparatus was provided during the year and has been used for each patient desiring it. (b) Maternal Mortality.— Two maternal deaths (for which clinical particulars are given later in the report) occurred during 1935, out of a total of 631 live births in the Home. This represents a rate of 3.17 per 1,000 live births. One of the deaths is classed' as " associated with Pregnancy and Child-hearing." The maternal death rate calculated on the number of live births at the Home from the date of opening to the 31st December, 1935, was 3.5 per 1,000 live births. (e) Admission of Emergency (unbooked) Cases. — Since June, 1935, these cases have been admitted subject to the following conditions :—• (1) No case of pyrexia, abortion, or threatened abortion before the 28th week shall be admitted. (2) The Private Practitioner shall communicate with the Resident Medical ©fficer before the patient's admission. The patient will be admitted to the isolation block in the first instance. (3) The patient will be admitted to the Home under the care of the Private Practitioner and the Resident Medical Officer shall be called into active co-operation in the treatment to be adopted. In the event of any anxiety, or of any difference of opinion, the services of a Consultant on the Panel of the Home shall be summoned. (4) No unbooked emergency case shall be admitted from outside the Borough. (5) The patient will be expected to pay the fees of the Home on the same basis as if she had been a booked case. During the year 12 such cases were admitted. (d) Form M.C.W. 96A (Ministry of Health). 1. Name and address of Institution—Thorpe Coombe Maternity Home, 714, Forest Road, Walthamstow, E.17. 115 2. Number of maternity beds in the Institution (exclusive of isolation and labour beds)—35. 3. Number of maternity cases admitted during the year—747 (including 94 Ante-Natal cases and 4 Post-Natal cases). 4. Average duration of stay—13.5 days. 5. Number of cases delivered by :— (a) Midwives—564. (b) Doctors—82. 6. Number of cases in which medical assistance was sought by a midwife in emergency—329.* 7. Number of cases notified as :— (•a) Puerperal fever—Nil. (b) Puerperal pyrexia—26. 8. Number of cases of pemphigus neonatorum—Nil. 9. Number of infants not entirely breast-fed while in the Institution—45. 10. (a) Number of cases notified as ophthalmia neonatorum— Nil. 11. (a) Number of maternal deaths—2. (b) Cause of death in each case—-(i) Eclampsia; (ii) Shock, Caesarean Section and myomectomy. 12. (a) Number of infant deaths—(i) Stillborn—22; (ii) Within 10 days of birth—9. (b) Cause of death in each case, and results of post-mortem examination (if obtainable)—See Clinical Report. The stillbirth rate was 34.9 per 1,000 live births, and the infant mortality within 10 days of birth was 15.8 per 1,000 live births. (e) Occupation of Beds.— The average daily occupation of beds was as follows :— January 23.1 May 30.0 September 30.0 February 25.6 June 28.8 October 31.5 March 23.6 July 30.2 November 27.6 April 23.7 August 29.0 December 29.2 The average for the whole year was 27.7, equal to 71.0 per cent, beds occupied (calculated on 39 beds). *Maternity Home, 294 (including one after discharge) ; District, 9. For general anaesthetics by 2nd Doctor, 26. Total 329. H 116 There were 35 or more patients in the Home on 21 days (35 being the number of maternity beds excluding isolation beds) the maximum being 41 on August 28th, after which date bookings were restricted to 65 per month and bookings of patients from outside the Borough were refused. (f) Financial. — Costing returns in respect of Maternity Homes are required by the Ministry of Health for each financial year. The return for the year ending 31st March, 1935, is as follows :— Average number of beds 31 Percentage of beds occupied 54.2 Number of patients 380 Average stay 14. 6 days. Average number of nursing staff 11 Average number of resident staff 18 Average cost per patient per week (in shillings): — Salaries : Medical 16/6.9 Nursing 24/9.4 Other staff 25/10.9 Provisions 19/3.3 Drugs and appliances 4/9.0 Fuel, light, laundry 22/8.2 Domestic renewals 3/6.1 Structural additions, etc. 8/3.9 Rent, rates, taxes, etc. 2/0.6 Loan charges 57/3.6 Other expenditure 11/6.2 Totals: Including loan charges 196/8.1 Excluding loan charges 139/4.5 (g) Training.— The Home was inspected by the Chairman of the Central Midwives Board, Dr. J. S. Fairbairn, F.R.C.S., F.R.C.P., Sir Comyns Berkeley, M.D., F.R.C.S., F.R.C.P., F.C.O.G., and the late Secretary, in March, 1935. Approval was given for the training of six pupils at any one time with effect from 1st April, 1935. One pupil had completed her training by the end of the year. The pupils carry out district midwifery training during residence with the Walthamstow District Nursing Association. Lectures are taken with the Essex County Nursing Association in Leyton. Following the resignation of the senior sister towards the end of the year, a new combined appointment of assistant matron and sister tutor was instituted. 117 (h) District Maternity and Midwifery.—A total of 44 confinements were attended by the district sister during 1935, 35 being midwifery and 9 maternity cases. The visits paid were as follows : Ante-Natal, 88; Natal, 561; Post-Natal, 58; Total, 707. (i) Clinical.— The very full clinical report following has been compiled by the Resident Medical Officer, Dr. Helen Rodway, M.C.O.G.:- THORPE COOMBE MATERNITY HOME CLINICAL REPORT. The statistical detail is arranged in the form recommended by the Royal Society of Medicine for the unification of clinical reports of Maternity Hospitals (1928). Statistics for 1934 are included in the report for comparison with the present year. Ante-Natal Supervision. Number of Ante-Natal Clinics held : — 1935 1934 Consultants' Clinics 21 39 Doctors' Clinics 125 - Midwives' Clinics (a) Booking 121 - (b) Examination 104 165 Total 371 204 Number of expectant mothers who attended the Ante-Natal Clinics :— (i) Primiparæ 457 187 (ii) Multipara 305 184 Total 762 371 Total attendances made :— (a) New Cases 762 371 (b) Old Cases 4,543 1,745 Total 5,305 2,116 Average attendance per session 14.3 12.8 Number of cases admitted to the Maternity Home during the Ante-Natal period 97 29 118 In- Patient Treatment. Number of cases admitted to the Maternity Home :— (a) Confinements:— (i) Primiparse 380 112 (ii) Multipara 266 117 Total 646 229 Delivered by a doctor 82 34 Delivered by a midwife 564 195 Total 646 229 (b) Ante-Natal cases 97 29 (c) Post-Natal cases 4 - Total admissions 747 258 Average duration of stay in the Maternity Home in days 13.5 14.0 Emergency Cases admitted (included in total admissions) 12 Nil REASONS FOR ADMISSION. Placenta prævia; Hydramnios, twins; Locked twins; Albuminuria; For diagnosis of presentation; Prolonged labour (2); Eclampsia (2); Adherent Placenta; Investigation—? cause of foetal death. Summary of Ante-Natal Cases Admitted to the Maternity Home. No. of Cases. No. of Cases. Albuminuria 26 Ante-Partum haemorrhage 3 Hyperpiesis 6 Bronchitis 2 Œdema 1 External version 2 Persistent vomiting of pregnancy 3 Premature rupture of membranes 2 Pyelitis and urinary infection 2 Induction of labour 6 Debility; anæmia 7 Varicose veins 1 Carditis 2 Miscarriage 2 Patients admitted for observation and discharged because not in labour 32 Total ante-natal cases 97 119 Conditions Chiefly Natal. Presentations :— Vertex. Primiparse. Multipara. No. of Cases V.L.O.A 197 156 353 V.R.O.A 128 98 226 Y.R.O.P 18 2 20 V.L.O.P 3 — 3 346 256 602 Breech 23 6 29 Face — 1 1 Twins 5 2 7 Unknown (B.B.A.) — 1 1 Caesarean Section 5 1 6 Total deliveries 646 Some cases appear in more than one category in the summary. Placenta Prsevia 3 Post-Partum haemorrhage 9 Locked twins 1 Manual removal of placenta 6 Contracted Pelvis (including Puerperal pyrexia 26 disproportion between Mastitis 3 pelvis and foetal head) 23 - Maternal deaths 2 Forceps delivery 41 Still-births— Prolapse of cord 1 Full term 16 Perineal lacerations— Premature 6 Primiparae 169 — 22 Multipara 41 210 Infant deaths 10 Post-natal Admissions— Phlebitis 1 Mastitis 1 Post-Partum haemorrhage 1 For condition of infant 1 PANEL OF CONSULTANTS. During the year a Consultant was called in 25 times by medical practitioners and 7 times by the Resident Medical Officer, making a total of 32 visits. 120 The cases were as follows :— Consulting Obstetricians. Consulting Surgeon. No. of No. of Cases. Cases. Albuminuria 4 Paralytic Ileus 1 Abortion 1 Ante-Partum Consulting Physician. Haemorrhage 5 Postpartum Shock 1 Eclampsia 2 For examination of chest 1 Delay in labour (twins) 1 Aplastic Anaemia of Locked twins 1 lnfant 1 Disproportion 1 Pyrexia of infant 1 Puerperal Pyrexia 6 *Csesarean Section 6 total 32 ^Reasons.—Disproportion, 2; Multiple Fibroids, 2; AntePartum Haemorrhage, 1; Ante-Partum Haemorrhage and Asymmetric Pelvis, 1. MEDICAL AID NOTICES. In 293 cases medical aid was sought by midwives in the Home. During the first three months these cases were treated by General Practitioners; in the later months by the Resident Medical Officer. No. of Cases. No. of Cases. (a) Ante-Natal— (b) In Labour— Albuminuria 4 Persistent occipito posterior 3 Urinary disturbance 1 Foetal distress 1 Ante-Partum haemorrhage 2 Premature labour 1 Uterine fibroids 1 Delay in labour 26 Nervous debility 1 Twins 2 Cardiac disease 1 Cardiac failure 1 Advised induction of labour 1 Breech presentation 19 Strange manner of patient 1 Retained placenta 3 Disproportion 1 Prolapsed cord 1 Early rupture of membranes 2 Impacted shoulders 1 Varicose veins 1 Perineal lacerations 161 Vaginal lacerations 30 16 249 (c) After Labour— (d) For Infant— Pyrexia 4 Phlebitis 2 Asphyxia 2 Delusions 1 General condition 6 Herpes zoster 1 Still-birth 2 Post-Partum haemorrhage 9 Death 1 17 11 Grand Total 293 121 MATERNITY HOME DISTRICT. (a) Ante-Natal— (b) In Labour— Nil. Perineal lacerations 1 Adherent placenta 1 (c) After Labour— (d) For Infant— Pyrexia 1 Sticky eyes 2 Jaundice 1 Feebleness 2 Infant dying 1 Total 9 A total of 26 general anaesthetics (administered by a General Practitioner) were necessary in connection with medical aid in midwives' cases. Summary of Medical Aid Notices: Home, 293; District, 9; Anaesthetics, 26; Post-Natal, 1; Total, 329. ALBUMINURIA. Every patient attending the Ante-Natal Clinic has the urine tested, the blood pressure recorded and the weight taken at each visit. Where there is the slightest albuminuria, hypertension or an excessive gain in weight, the patient is seen twice weekly. If the condition does not improve, the patient is admitted to the Home. It is of interest to note that in some cases a marked increase in weight may be the earliest sign of pregnancy toxaemia. Number of cases admitted 26 Number of still-births 6 Foetal Mortality 20.7% There were 3 cases of twins in this series of cases. 122 CASES OF ALBUMINURIA ADMITTED FOR TREATMENT. Case No. Parity. Age. Past History. Onset of Symptoms. Oedema. Headaches Albumen. Maximum Blood Pressure. Blood Urea. No. of days in home before Labour or Discharge. Maturity when Delivered Type of Delivery. Result. Mother. Child. 1 1 36 Scarlet Fever 38 weeks. No No Heavy cloud 148/98 — 6 40 weeks Spontaneous. L L 2 1 29 do. 36 „ Yes Yes Heavy 140/96 — 11 40 weeks Spontaneous following L L 3 1 19 — 37 „ Yes No trace 0.25 160/110 - 21 40 weeks medical induction. Spontaneous. L L 4 4 37 — 36 „ Yes Yes per cent. Cloud 140/100 — 15 38 weeks. Spontaneous following L S.B. L 5 1 31 — 36 ,, Yes Yes 0.5 140/110 — 10 38 weeks. medical induction. Spontaneous following L L 6 32 Albuminuria in second pregnancy. 38 „ No Yes per cent. Trace 182/88 25 mgs. per cent. 5 39 weeks medical induction. Spontaneous. L L 7 3 34 28 ,, Yes Yes Cloud 158/110 13 30 weeks Spontaneous. L S.B. 8 35 — 30 „ No No Trace 112/88 - 6 39 weeks Spontaneous. L L 9 1 27 - 38 „ No No Trace 142/90 18 mgs. per cent. 11 40 weeks Spontaneous. L L 10 1 23 - 39 „ Yes No Trace 156/100 22 mgs. per cent. 7 40 weeks Spontaneous. L L 11 1 30 - 38 „ Yes No 0.15 per cent. 190/100 29 mgs. per cent. 16 40 weeks Spontaneous following medical induction. L L 12 1 32 = 37 Yes Yes Trace 140/80 32 mgs. per cent. 6 40 weeks Forceps. L L 13 1 26 Scarlet Fever 28 No No Trace 142/110 32 mgs. per cent. 6 40 weeks Spontaneous. L L 14 2 37 — 32 No No Trace 170/108 18 mgs. per cent. 5 40 weeks Spontaneous. L L 15 1 30 — 36 „ No No 0.2 per cent. 152/98 31 mgs. per cent. 6 40 weeks Spontaneous. L L 16 1 21 - 36 „ Yes Yes 0.5 ner cent. 170/120 28 mgs. per cent. 21 40 weeks Spontaneous. L L 17 1 25 - 32 Yes Yes Heavy cloud 160/100 27 mgs. per cent. 21 38 weeks Spontaneous. L L 18 1 27 - 34 Yes Yes T race 160/110 30 mgs. per cent. 8 38 weeks Spontaneous. L S.B. 19 1 33 - 37 No No Trace 150/90 36 mgs. per cent. 7 40 weeks Spontaneous. L L 20 2 29 — 36 „ Yes Yes Cloud 162/88 25 mgs. per cent. 3 40 weeks Spontaneous following medical induction. L I S.B 21 1 20 Scarlet Fever 38 „ Yes No Heavy trace 120/90 20 mgs. pei' cent. 1 38 weeks Spontaneous following rupture of membranes. L L 22 5 40 - 28 „ Yes Yes Trace 210/120 20 mgs. per cent. 15 17 36 weeks Spontaneous. L S.B. 23 1 °8 - 39 No Yes Trace 132/100 38 mgs. per cent. 2 40 weeks Spontaneous. L L 24 1 24 - 38 „ Yes Yes Cloud 192/120 41 mgs. per cent. 4 40 weeks Forceps. L L 25 1 28 - 32 ., Yes Yes 0.4 per cent. 200/100 31.5 mgs per cent. 15 40 weeks Spontaneous. L L 26 1 26 - 35 ,, Yes Yes Trace 160/100 32 mgs. per cent. 16 40 weeks Forceps. L S.B. REMARKS—Case 2, Post-Partum Eclamptic fit, cases 3, 4 and 21. twins; case 18, Post-Partum Haemorrhage; case 26, Antc-Partum Haemorrhage; case 21, emergency admission—marked Hvdramnios. Eve signs were present in cases 2 and 22. 123 ECLAMPSIA (2 Cases). Case No. Age Parity Past History. No. of Fits. Albumen CEdema Headaches. Eye Signs. Maximum Blood Pressure. No. of Days in Home before labour Maturity when Delivered. Type of Delivery. Result to before Admission. Total. Mother. Child. 1 29 1 Scarlet Fever — After labour, 1 Heavy Cloud No No No 140/96 11 40 weeks. Spontaneous following medical induction L. L. 2 25 1 - 1 During labour, deep coma, 7. Cloud Marked Yes Yes 184/90 40 weeks. Forceps D. L. The second case was an emergency admission after the onset of eclampsia. Further details of the case are given under Maternal Deaths. PLACENTA PREVIA (3 Cases). ANTE PARTUM HHEMORRHAGE. Case No. Age Parity Maturity. Condition on Admission. Variety. Treatment. Result. Remarks. Mother. Child. 1 34 1 40 weeks. Good Marginal Willett and Sfalp forceps L. L. 2 35 3 40 weeks. Good Lateral Cesarean Section L. L. Six weeks in Home during Ante-Natal period. 3 35 2 40 weeks. Good Marginal Nil. L. L. 124 TREATMENT AND RESULTS OF POSTERIOR POSITION OF THE VERTEX. Method of Treatment. Number of Cases. Results. L. Child. S.B. D. Spontaneous rotation and delivery 5 5 — — Manual rotation and spontaneous delivery l 1 - - Spontaneous delivery. Face to pubes 4 4 — — Manual rotation, forceps delivery 14 11 2 1 Total 24 21 2 1 Infant Mortality, 12.5 per cent.Maternal Mortality, Nil. 125 POSTERIOR POSITION OF VERTEX. No. Age of Patient. Parity. Method of Treatment. Duration of Labour. Weight of Infant. Result Child. 1st stage. 2nd stage. 3rd stage. Hrs. Mins. Hrs. Mins. Hrs. Mins. Lbs. Ozs. 1 27 1 Manual rotation Forceps 36 30 4 - 50 6 8 L 2 30 I Ditto 51 30 3 30 25 8 4 L 3 33 1 Ditto 31 0 3 45 25 7 2 L 4 26 1 Ditto ? ? 5 7 13 L 5 27 1 Ditto ? ? 15 - - S.B 6 31 1 Ditto 23 30 3 27 19 7 9 L 7 27 1 Ditto 27 0 4 0 20 6 15 L 8 29 1 Ditto 32 0 4 0 40 7 2 L 9 25 1 Ditto 23 0 3 20 25 — D 10 29 1 Ditto 12 0 3 50 1 25 6 14 L 11 25 1 Ditto 64 30 3 25 25 — — S.B. 12 31 1 Ditto ? ? 10 4 4 L 13 21 1 Spontaneous rotation and delivery 19 0 2 15 20 7 14 L 14 25 1 Ditto do. 32 0 55 22 6 12 L 15 25 2 Spontaneous delivery. Face to pubes 11 30 35 20 8 0 L 16 20 1 Ditto do. 5 0 1 50 40 6 0 L 17 33 3 Spontaneous rotation and delivery 37 15 35 10 7 2 L 18 21 1 Ditto 13 30 2 20 25 6 14 L 19 26 1 Ditto 7 0 1 10 10 6 3 L 20 24 1 Manual rotation Forceps 29 30 3 20 20 7 0 L 21 30 1 Manual rotation in 1st Stage. Spontaneous delivery 45 45 2 45 20 6 0 L 22 24 1 Manual rotation. Forceps delivery 30 0 1 50 10 7 8 L 23 27 l Spontaneous delivery. Face to pubes 10 0 1 35 15 7 10 L 24 25 l Ditto do. 7 0 1 10 10 6 3 L REMARKS.—Maturity: 40 weeks in all cases. Cases 4 and 5: failed forceps from District. Emergency admission during labour. Case 9: cause of infant death, intracranial haemorrhage. Case 10: manual removal of placenta. Case 11: delay in delivery owing to impaction of shoulders. Case 12: foetal death during the first stage of labour. Case 13: first infant of locked twins. Case 21 : moulding of infant's head very pronounced, 126 BREECH DELIVERY. An uncomplicated breech is one where an additional risk to the life of the foetus is not present, e.g., such conditions as locked twins, ante-partum haemorrhage or prematurity. (a) Uncomplicatec cases, 21. 1 (b) Complicated cases, 8. Stillbirths. Infant Deaths. Stillbirths. Infant Deaths. (i) Result of delivery 1 2 - '(ii) Not the result of delivery - 3 1 - 1 5 1 Foetal and Infant Mortality :— Uncomplicated Cases, 4.8% Complicated cases, 75.0% All cases, 24.1%; Maternal mortality, Nil. uncomplicated breech presentations. No. Age of Patient. Parity Method of Delivery. Result. Child. Remarks. 1 38 7 Spontaneous L. Flexed legs. 2 25 1 Do. L. Extended legs. 3 32 1 Do L. Flexed legs. 4 31 1 Do L. Extended legs and arms. 5 32 1 Do D. Infant death undetermined. 6 27 1 Do L. Extended legs. 7 29 1 Legs brought down L. Extended legs. 8 23 1 Spontaneous L. Flexed legs. 9 34 1 Do L. Extended legs. 10 29 1 Do L. Episiotomy. Extended legs. 11 38 1 Do L. Do do. 12 31 1 Do L. Extended legs. 13 25 1 Do L. Extended legs. 14 32 1 Do L. Extended legs. IS 29 1 Do L. Extended legs. 16 31 1 Spontaneous. Arms brought down L. Extended legs and arms. 17 28 1 Spontaneous L. Flexed legs. 18 39 4 Do L. Flexed legs. 19 25 1 Do L. Footling presentation. 2U 34 2 Do L. Extended legs and arms. 21 39 5 Do L. Footling. -Maturity—40 weeks fn each cise, except No. 5. There was no maternal death. 127" COMPLICATED BREECH DELIVERY.. No. Age of Patient. Parity. Complications. Method of Delivery. Result. Child. Cause of Still-birth or Infant Death and Remarks. 1 19 1 Pregnancy toxaemia. Spontaneous L. 1st infant of twins. 2 31 1 Multiple fibroids. Cesarean section. L. 3 37 3 (a) Pregnancy Albuminuria. Assisted S.B. Shock. 1st infant of twins. (b) Locked Twins. 1 21 1 Placental separation Spontaneous S.B. Asphyxia from placental separation. Extended legs and arms. 5 30 1 Pregnancy .toxamia. Spontaneous S.B. (a) Maternal toxaemia. (,b) Asphyxia frpm .slight delay during delivery of head. 6 20 1 (a) Pregnancy t,ox;umia. Spontaneous S.B. Extended legs and arms. Weight—2 lbs. 4 ozs.: Prematurity. l,st infant of twins. (b) Hydramnios. 7 39 11 (a) Prolapsed cord. Spontaneous S.B. Asphyxia due to prolapsed cord. Flexed legs. (b) Uterine inertia. 8 29 1 Premature labour. Spontaneous I.D. Prematurity. Weight—2 lbs. 15 ozs. Flexed legs. Maturity—40 weeks in each case except eases 3, 6 and 7, S6 weeks; and case 8, 28 weeks. There was no maternal death. 128 TWINS. Nttmber of cases 7 Number of infants discharged alive 12 Number of still-births 2 Foetal mortality 14.3% Maternal mortality Nil Cause of still-births Births. (i) Shock, prematurity 3 lbs. 8ozs. (ii) Prematurity 2 lbs. 4 ozs. No. Age. ,Parity. Presentation & Position. Sex. Weight. Result. Remarks. 1st 2nd 1st 2nd 1st 2nd Infants. lbs. ozs. lbs. ozs. 1st 2nd 1 19 1 B.R.S.P. V.L.O.A. M. M. 5 10 6 5 L. L. Toxaemia. 2 37 4 B.R.S.A. V.L.O.A. M. M. 3 8 5 10 S.B. L. Locked twins. 3 31 1 V.L.O.P. V.R.O.A. F. F. 4 4 5 11 L. L. Locked twins. 4 30 3 V.R.O A. V.R.O.A. M. F. 6 11 5 3 L. L. Hyperpiesis. 5 27 1 V.L.O.A. V.R.O.A. M. F. 5 1 5 11 L. L. 6 19 1 V.L.O.A. V.L.O.A. M. F. 7 2 4 15 L. L. Post-partum shock 7 20 1 B.L.S.A. V.R.O.A. F. F. 2 4 3 15 S.B. L. Toxaemia. Hydramnios. Maturity—40 weeks except cases 2, 5 and 7, 36 weeks. There was no maternal death. 129 CESAREAN SECTION. Caesarean Section was performed six times. No. of Cases. Indication. Mother. Child. L. D. L. S.B. D. 2 Disproportion 2 — 2 — — 2 Multiple fibroids 1 1 2 — — 1 Ante-partum Haemorrhage 1 - 1 - — 1 Ante-partum Haemorrhage, Asymmetric pelvis 1 - - 1 - 6 5 1 5 1 - There was one maternal death and one still-birth. Multiple myomectomy was performed in the fatal case. A detailed report is included under Maternal Deaths. C/ESAREAN SECTION. No. Age of Patient Parity. Indication. Weight of Infant. Result. Mother. Child. 1 24 2 Disproportion lbs. 9 ozs. 11 L. L. 2 31 1 Fibroids 7 2 L. L. 3 35 2 Disproportion 6 3 L. L. 4 35 4 Ante-partum haemorrhage 7 1 L. L. 5 32 1 Fibroids 5 2 D. L. 6 36 1 (a) Ante-partum hemorrhage Not weighed L. S.B. (b) Asymmetrical pelvis Maturity.—40 weeks in each case. Case No. 5, died from post operative shock, following multiple myomectomy. CONTRACTED PELVIS. (Including relative disproportion between the pelvis and the foetal head.) Number of Cases 23 Number of Still-births 2 Foetal Mortality 8.7% Maternal Mortality Nil One case was an emergency admission during labour. 130 CONTRACTED PELVIS (including relative disproportion between the Pelvis and the Foetal Head). No. Age of Patient Parity. Method of Delivery. Duration of Labour. Weight of Infant. Result. Child. Remarks. 1st Hrs. Stage. Mins. 2nd Hrs. Stage. M.ns. 3rd Hrs. Stage. Mins. lbs. ozs. Medical Induction. 1 24 2 Caesarean Section — — — 9 11 L. 2 36 1 Forceps ... 21 30 1 30 25 7 2 L. 3 25 2 Forceps ... 78 30 1 30 25 8 6 L. 4 26 1 Spontaneous ... 21 30 1 50 30 8 11 L. 5 25 1 Do ... 15 30 1 30 15 7 11 L. 6 26 1 Do ... 45 0 2 10 35 7 4 L. Do. do. 7 35 1 Do ... 72 0 3 25 45 6 14 L. 8 21 1 Forceps ... 57 0 4 30 15 8 3 L. 9 23 1 Spontaneous ... ? 1 30 15 8 0 L. 10 26 1 Forceps ... ? ? 5 7 13 L. Emergency admission during labour. Failed forceps (from District) 11 30 1 Spontaneous ... 20 30 ? 3 27 19 6 13 L. Medical Induction. 12 27 1 Forceps ... 57 30 4 0 10 9 6 L. 13 29 1 Do ... 32 0 4 30 40 7 2 L. 14 20 1 Spontaneous ... ? 1 50 20 7 0 L. Do. do. 15 29 1 Do ... 15 0 3 50 25 6 14 L. Manual removal of placenta. IP 25 } Forceps ...••• 64 30 3 25 25 S.B. Delay in delivery owing to impaction of shoulders. 17 24 1 Spontaneous ... ? ? 25 8 1 L. 18 20 1 Forceps ... 95 0 1 0 2 8 — S.B. Toxaemia. Manual removal of placenta. 19 32 1 Do ... 57 0 3 45 20 8 3½ L. 20 30 1 Spontaneous ... 45 0 2 45 20 6 0 L. 21 31 1 Forceps ... 31 45 3 45 25 7 8 L. P.O.P. Moulding of head very pronounced. 22 26 1 Do ... 22 0 3 20 10 7 3 L. 23 27 1 Do ... ?9 30 3 50 10 7 15 L. Maturity.—40 weeks in all cases. There was no maternal death. 131 FORCEPS DELIVERY. Forceps were applied 41 times; the details of the cases are given in the following table. The forceps rate is 6.3 per cent. Number of infants delivered, 42, including one pair of twins. Number of stillbirths, 5. Number of infant deaths, 2. Foetal mortality rate, 16.6 per cent. There was one maternal death, a case of Fulminant Eclampsia admitted as an emergency case during labour. Analysis of Forceps Cases. No. of Cases. Delay in second stage of labour 10 Disproportion; delay in second stage of labour 10 Persistent occipito-posterior 14 Prolapse of cord 1 Foetal distress 2 Cardiac disease 1 Pre-eclamptic toxaemia 1 Eclampsia 1 Maternal distress 1 Total 41 Two cases were admitted to the Home after failed forceps. 132 FORCEPS DELIVERY. No. Age of Patient. Parity. Indication. Duration of Labour. Weight of Infant. Result. Child. Remarks. 1st stage. 2nd stage 3rd stage. Hrs. Mins. Hrs. Mins. Hrs. Mins. Lbs. Ozs. Severe albuminuria. 2nd infant of twins. 1 24 1 Delay in 2nd stage 18 45 ? 15 6 11 L 2 21 1 Prolapse of cord 26 0 3 0 ] 5 8 0 S.B. 3 31 1 Toxaemia 36 0 30 45 6 14 L 4 32 3 Fœtal distress 14 30 4 20 15 5 10 L 5 27 1 Disproportion. Delay in 2nd stage. ? 9 30 3 50 10 7 15 L 6 26 Fcetal distress 21 0 10 15 7 8 L Placenta Praevia 7 24 1 Delay in 2nd stage 13 30 2 30 45 6 6 L 8 34 l Delay in 2nd stage . 27 0 3 40 50 6 3 L 9 30 l Delay in 2nd stage 12 45 ? 4 0 30 7 14 L 10 27 i Disproportion. Delay in 2nd stage. 57 30 4 0 10 9 6 L 11 25 do. 78 30 1 30 25 8 6 L Diabetic. 12 37 l Delay in 2nd stage ? 3 40 15 7 4 L 13 27 l Persistent occipito posterior 86 30 4 0 50 6 8 L 14 35 Disproportion. 21 30 ? 30 7 2 L 15 30 l Delay in 2nd stage. Persistent occipito posterior 51 30 3 30 25 8 4 L Emergency admission. Toxaemia. Failed forceps. 16 17 29 31 l l Delay in 2nd stage Maternal distress 10 0 ? 3 5 25 .10 9 4 3 0 4 11 L Admitted in 2nd stage of labour Locked twins. 18 32 l Disproportion. 57 0 3 45 20 8 3 J L Emergency admission in labour. Fulminant Eclampsia. 19 25 l Delay in 2nd stage. Eclampsia ? ? 20 10 3 L 20 21 1 Disproportion. 57 0 4 0 15 8 3 L 21 32 l Delay in 2nd stage. Cardiac Failure 38 30 1 45 30 4 L Mitral Stenosis. Infant died from inanition. Disproportion. No difficulty in forceps delivery. 22 31 i Delay in 2nd stage 29 30 1 50 10 — — D 23 33 l Persistent occipito posterior 31 0 3 45 25 7 8 L 24 29 l Delay in 2nd stage. 30 15 3 30 30 — — S.B. 25 24 l Persistent occipito posterior Delay in 2nd stage. 29 30 3 20 20 7 0 L T 1 20 26 l Persistent occipito posterior Disproportion. ? ? 5 7 13 L S.B. J Emergency admission during labour. Failed forceps. 27 27 i Persistent occipito posterior ? ? 15 — — 28 30 l Delay in 2nd stage Disproportion. 20 30 ? 3 27 19 6 13 L 29 31 i Persistent occipito posterior 23 30 3 35 15 7 9 L 30 27 i do. 27 0 ? 4 0 20 6 15 L 31 29 I do. 32 0 ? 4 0 40 7 2 L Disproportion Infant died from intracranial haemorrhage. 32 25 l do. 23 0 3 20 25 - D 33 29 l do. small pelvis 12 . 0 ? 3 50 1 25 6 14 L 34 26 l Disproportion. 22 0 9 10 10 7 3 L Pre-eclamptic toxaemia. 35 24 l Delay in 2nd stage. Persistent occipito posterior Delay in 2nd stage. 30 0 1 eo 10 7 8 L 36 36 l Delay in 2nd stage 13 0 ? 3 15 25 6 13 L Impaction of shoulders 37 25 i Persistent occipito posterior 64 30 3 25 25 — — S.B. \cl/ ± III LIUI1 ui aiiuiuuti (b) Disproportion. 38 27 l Delay in 2nd stage 11 0 3 35 25 7 10 L 39 24 l Disproportion. ? ? 25 8 1 L 40 26 i Delay in 2nd stage Delay in 2nd stage 14 0 3 0 55 8 11 L Manual removal of placenta on account of haemorrhage. 41 26 i Persistent occipito posterior 95 0 1 0 2 8 S.B. (a) Toxaemia. (b) Disproportion. (c) Manual removal of placenta. 133 LACERATIONS OF THE PERINEUM. Primiparse : — (a) Doctors' cases— Spontaneous delivery. Forceps. Total. Vertex, 7: Breech, 6. 29 42 (b) Midwives' cases— Vertex, 126; Breech, 1. - 127 Multipara :— 169 (a) Doctors' cases— Spontaneous delivery. Forceps. Total. Vertex, 3: Breech, 2. 2 / (b) Midwives' cases— Vertex, 34; Breech, - - 34 41 Total 210 POST-PARTUM HEMORRHAGE. Case No. Age Parity. Character of Labour. Predisposing Cause. Treatment. 1 24 1 Spontaneous Retained placenta Manual removal. Subcutaneous and rectal saline. Pituitrin, 10 units. Pitocin, 10 units. Femergin, 1 c.c. 2 21 1 do. Uterine inertia Pituitrin, 10 units and Femergin, 1 c.c. Ergot extract. 3 38 6 do. Adherent placenta Manual removal. Intrauterine glycerine. Intravenous saline. Blood transfusion. Pituitrin, 10 units. 4 22 2 do. Debility Intra-uterine glycerine. Pitocin, 10 units and Femergin, 1 c.c. Intravenous saline. 5 27 1 do. Adherent placenta Manual removal. Intrauterine glycerine. Pit-, uitrin, 10 units. Ergometrine, 1 c.c. 6 29 1 Forceps Uterine inertia Retained placenta Manual removal. Intrauterine glycerine. Ergometrine, 1 c.c. Pituitrin, 10 units. 7 25 1 Spontaneous Precipitate labour Intra-uterine glycerine. Pituitrin, 10 units and Femergin, 1 c.c. 8 28 1 Forceps Adherent placenta Manual removal. Intrauterine glycerine. Ergometrine, lc,c. Pituitrin 10 units. Intravenous saline. 9 26 1 do. Uterine inertia Retained placenta Manual removal. Intrauterine glycerine. Intravenous saline. Ergometrine, 1 c.c. Coramine, 1 c.c. 134 Maturity.—All were 40 weeks, except case 7 (38 weeks). There was no maternal death and all had live births except case 9. Case 3 was an emergency admission on account of retained! placenta. The foetal mortality was 11.0 per cent. SUMMARY OF PUERPERAL PYREXIA. The standard adopted for the estimation of Puerperal' Pyrexia is that of the Ministry of Health, namely, a temperature of 100.4 deg. or more, sustained for 24 hours or recurring during; that period in the first 21 days of the puerperium. The temperature in every case is recorded four-hourly following a rise of 99 deg. or more. The pyrexia is notified if 100.4 deg. or more occurs in any two of the four-hourly readings, in 24 hours. An analysis of the cases shows the following 634 Booked Cases. Number of cases notified 24 = 3.8% 12 Unbooked Cases. Number of cases notified 2 = 16.7% Total 26 = 4.0% Number of cases included in the above series which did not reach 100.4 deg. in any two of the bi-daily readings— 10. Primigravidse 19 Multigravidae 7 Total 26 135 Cause:— Cases. Uterine infection 5 Urinary infection 6 .Engorged breasts 2 Thrombo-phlebitis 2 Ante-partum hemorrhage followed by Cesarean section 2 Tonsillitis 1 Influenzal cold 1 Pleurisy 1 Respiratory/Urinary infection 1 Undiagnosed 5 Total 26 Labour— Delivery— Prolonged 1st stage 1 Forceps 5 Prolonged 2nd stage 4 Caesarean section— Prolonged 1st and 2nd stage 1 (a) before labour 2 Normal 18 (b) in labour 1 — Normal 18 24 — — 26 (2 cases of Caesarean section not in labour.) —• Ante-Natal Condition of Patients. Albuminuria, Hyperpiesis 1 Ante-partum haemorrhage 2 Albuminuria, Hyperpiesis, Vaginal discharge 2 CEdema 3 Anaemia 2 Hyperpiesis, Urinary infection 1 Normal 10 Hyperpiesis, Ante-partum No records 2 haemorrhage 1 — Dental sepsis 1 Total 26 Catarrhal jaundice 1 — 136 PUERPERAL PYREXIA. Booked Cases. No. Date of Notification. Age. Gravida. Ante-Natal Condition. Type of Labour. Method of Delivery. Onset of Pyrexia. Duration. Cause. Remarks. 1 3/1/35 40 8 Albuniinuria CEdema Normal Normal 4th day 4 days Uterine Perineal laceration. 2 1G/2/35 21 1 Hyperpiesis Normal Prolonged 2nd stage Forceps 3rd day 7 days infection Urinary infection Membranes imperfect. 3 22/2/35 21 1 Normal Prolonged 2nd stage Normal 6th day 6 days Uterine infection Retained portion of placenta 4 26/2/35 29 1 Albuminuria CEdema Normal Normal 1st day - Urinary (i) Post-partum eclampsia. 5 20/3/35 18 1 Hyperpiesis Pyorrhoea Normal Normal 3rd day - infection Uterine (ii) Perineal laceration. Membranes imperfect. 6 15/4/35 32 2 Alveolaris Hyperpiesis: Pus, organisms, albumin in Urine Normal Normal 2nd day — infection Urinary infection Perineal laceration. 7 30/4/35 30 2 Catarrhal jaundice Normal Normal 3rd day 2 days Undiagnosed Perineal laceration. 8 14/5/35 20 1 Ante-partum Normal Normal 2nd day 5 days Urinary (i) Membranes imperfect. 9 21/5/35 35 3 hemorrhage Normal - Cesarean 2nd day - infection 1 hrombo- (ii) Perineal laceration. 10 27/7/35 25 2 Ante-partum - Section Caesarean 1st day 6 days Phlebitis Placenta praevia. 11 22/7/35 23 1 haemorrhage Albuminuria Normal Section Normal 1st day - Urinary Perineal laceration. 12 24/7/35 23 1 Hyperpiesis Vaginal discharge Normal Normal 13th day 11 days infection Perineal laceration. 13 12/8/35 24 1 Vaginal discharge Normal Normal 12th day - phlebitis Undiagnosed Vaginal lacerations. 14 2/9/35 27 1 Normal Normal Normal 4th day 7 days Urinary 15 16/9/35 28 1 Anaemia Normal Normal 8th day 3 days infection Engorged 16 16/9/35 19 1 Anaemia Normal Normal 7th day 7 days Breasts Uterine 17 7/10/35 21 1 Normal Normal Normal 8th day 3 days infection Tonsillitis 18 28/11/35 30 1 Normal Normal Normal 14th day Pl^urisv Manual removal of placenta. Perineal laceration. 19 1/11/35 29 1 Normal Prolonged 2nd stage Forceps 3rd day — (a) Respiratory infection 20 3/12/35 24 1 Albuminuria Hyperpiesis CEdema Normal Forceps 3rd day 5 days (b) Urinary infection Uterine infection Manual rotation. Vaginal lacerations. 21 16/12/35 20 1 Normal Normal Normal 4th day 4 days Undiagnosed Perineal laceration. Heroes Labialis. 22 10/12/35 23 1 Normal Normal Normal 6th day 4 days Influenzal Cold 23 23/12/35 36 2 (a) Ante-partum haemorrhage Prolonged 1st stage Cesarean Section — — (i) Manual removal of placenta. (ii) Herpes Labialis. 24 27/12/35 28 1 (b) Hyperpiesis Normal Prolonged 2nd stage Forceps 7th day 9 days Engorged Breasts Unbooked Cases. 25 13/7/35 24 3 No ante-natal supervision No records Normal Normal 3rd day — Undiagnosed 26 24/8/35 £7 1 Prolonged Forceps 1st day 32 days Uterine infection (a) Manual rotation. (b) Perineal laceration. The maturity was 40 weeks in each case except Nos. 6 and 10 (38 weeks) and Nos. 14 and 17 (36 weeks). Cases 4, 5, 6, 9, 11_ 12, 13, 137 MATERNAL MORTALITY. There were two maternal deaths— one a booked case, the other unbooked. Details of Maternal Deaths. Tit. 25 years, primipara, was admitted to the Maternity Home in labour on account of eclampsia. The patient had one fit before admission. Blood pressure 184/90. Cloud of'albumen. Moderate degree of cedema. A combination of the Dublin and Stroganoff methods was used in treatment with the addition of intravenous calcium gluconate. A series of six fits occurred with intervening periods of coma. Forceps were applied when the patient was fully dilated. A living female infant was delivered. Shortly after delivery the patient's condition improved, but eventually became worse, coma and later collapse occurred. The patient died ten hours after delivery. /Et. 32 years, primipara. Private doctor's booked case. Admitted for operation on account of fibroids of the uterus. On admission, general condition very good, cedema of feet, urine— no abnormal constituents, blood pressure 110/68. An operation for Qesarean section and multiple myomectomy was performed, a living female infant being delivered. Haemorrhage was moderate. Following the operation the patient showed signs of severe shock, there was no response to treatment. Death occurred an hour and a half after the operation. This death was classified by the Registrar General to the group "Non-malignant tumours of female genital organs" and not to "pregnancy and childbearing" but returned as associated therewith. The death, therefore, is not included in the calculations of Maternal Mortality statistics. INFANTS. Total. Per cent. Number of live births, still-births and Infants admitted with mother 653 100 Living on discharge from Maternity Home 621 95.14 Stjill-births (recent)—Full term 10 1.53 Premature 5 0.76 (macerated) Full term 6 0.90 Premature 1 0.15 Infant deaths— Under 5 lbs. 3 0.45 Over 5 lbs 7 1.07 138 CAUSES OF STILLBIRTHS (22 Cases). FULL TERM. PREMATURE. Recent. Macerated. Recent Macerated. No. Asphyxia following placental separation 1 No. Hydrocephaly 1 No. Asphyxia due to prolapsed cord and uterine inertia 1 No. Nil. Asphyxia due to delay in delivery of shoulders 1 Anen- cephaly 1 Asphyxia due to prolapsed cord 1 Unknown 4 Unknown 3 With associated complications of pregnancy. Toxaemia and prolonged labour 2 Albuminuria and shock 1 Toxaemia 1 Toxaemia and asphyxia 1 Chronic nephritis and placental separation 1 Toxaemia 1 Toxaemia and prematurity 1 Toxaemia and asphyxia 1 Totals 10 6 5 1 N.B.—Post-Mortem examination was not held in any of the above cases. CAUSES OF INFANT DEATHS. FULL TERM. PREMATURE. No. Congenital malformation of the heart 4 No. Multiple malformations 1 Inanition 1 Prematurity 1 Intracranial haemorrhage ... 1 Broncho-pneumonia 1 With associated complications of Pregnancy. Ante-partum haemorrhage undetermined 1 Totals 6 4 N.B.—Post-Mortem examinations in two of the above cases were held— Congenital malformation of the heart being' found in both cases. 139 FULL TERM (16 Cases). STILLBlRTHS. No. Sex. Method of Delivery. Maternal Complications. Cause of Death. Recent or Macerated. Remarks. 1 M. Spontaneous Nil. Unknown Macerated 2 M. Spontaneous Nil. Hydrocephaly Macerated 3 M. Extended breeth assisted Nil. Placental separatioh. Asphyxia. Recent 4 F. Forceps Nil. Prolapse bf cord. Recent 5 F. Spontaneous Nil. Unknown Recent 6 M. Spontaneous Nil. Unknown Macerated 7 M. Spontaneous Nil. Unknown Macerated 5 M. Forceps Nil. Unknown Recent 8. No difficulty in forceps delivery. 9 M. Forceps Toxaemia Toxaemia. Prolonged labour. Recent 9. Failed forceps from District emergency case. 10 M. Spontaneous Nil. Unknown Recent 4.. 11. Gas and air administered during the delivery. There was restlessness and difficulty in controlling patient during the birth of the head. 11 M. Extended breech assisted Toxaemia Toxaemia. Asphyxia. Recent 12 F. Assisted Nil. Unknown Macerated 12. Vertex presentation. Impaction of shoulders. 13 F. Spontaneous Nil. Anencephaly Macerated 14. Early rupture of membranes. Persistent occipito-posterior. Manual rotation. Impaction of shoulders. 14 F. Forceps Nil. Delay in delivery of shoulders. Asphyxia. Recent 15 F. Ccesarean section. Toxemia Toxaemia. Recent 16 F. Forceps Hyperpiesis Toxa?mia Ante-partum haemorrhage prolonged labour. Toxaemia. Recent 16. Early rupture of membranes. Foetal heart-sounds absent in later part of first stage of labour. Persistent occipito-posterior. Manual rotation. 140 PREMATURE. STILLBIRTHS. No. Sex. Maturity. Method of Delivery. Maternal Complications. Cause of Death. Recent or Macerated. 1 M. 36 weeks. Toxaemia Albuminuria Shock Recent 2 F. 36 weeks. Spontaneous Chronic Nephritis Placental separation Recent 3 M. 36 weeks. Spontaneous Toxaemia Toxaemia. Macerated 4 F. 36 weeks. Spontaneous Toxaemia Hydramnios Toxaemia. Prematurity. Recent 5 F. 36 weeks. Spontaneous Uterine inertia Asphyxia. Prolapsed cord. Recent 6 M. 32 weeks. Spontaneous Toxaemia Toxaemia. Asphyxia. Recent REMARKS.—Case 1, First infant of locked twins. 4. First infant of twins, weight 3 lbs. Emergency case, 5. Labour prolonged. 141 INFANT DEATHS. No. Month. Maternal Complications. Method of Delivery. Maturity of Infant. Sex. Birth Weight. Duration of life. Cause of Death. PostMortem. 1 March Ante-partum haemorrhage Assisted breech 38 weeks. M. lbs. ozs. Not weighed Days. Hrs. 6 Undetermined Not held. 2 August Flat pelvis Forceps Full Term F. Not weighed 2 Inanition Not held. 3 June Nil. Spontaneous Full Term 7 12 2 12 Congenital disease of heart. Held. 4 September Nil. ,, 38 weeks. F. 4 6 IS Multiple malformations Not held. 5 September Nil. ,, 38 weeks. F. 4 10 12 Broncho- Pneumonia Not held. 6 October Nil. ,, Full Term M. 8 1 3 Congenital disease of heart. Not -held. 7 December Nil. ,, Full Term M. 7 8 3 Congenital disease of heart. Held. 8 December Nil. ,, About 28 weeks F. 2 15 IS Prematurity Not 'held. 9 December Nil. ,, Full Term F. 6 10 12 Congenital disease of heart. Not held. 10 October Nil. Forceps Full Term F. 4 Infra-cranial haemorrhage Not -held. 142 POST-NATAL CLINIC. On discharge from the Maternity Home every patient is given an appointment for an examination at the Post-Natal Clinic six weeks from the date of confinement. This Clinic has been held weekly since the appointment of the Resident Medical Officer in April. The majority of patients were discharged with health unimpaired. Where there is disability suitable treatment is given. An attempt is made to follow up any case where health is seriously impaired as a result of confinement, e.g., pregnancy rtoxaemia, or chronic nephritis, etc. Number of sessions held 39 Number of patients who attended— (a) New cases 256 (b) Old cases 210 Total attendances 466 Average attendance per session ... 12.2 GAS-AIR ANALGESIA. The clinical report would not be complete without mention •of the Minnitt Gas-Air apparatus which has been in use at the Home during the past year. This apparatus has been designed for self-administration by the patient of gas mixed with air for the relief of pain during labour. Every healthy patient, if she chooses, may administer the -mixture to herself at a time which is considered suitable by the doctor or midwife in charge of her case. When the patient has "been given a few simple instructions it is usually found that she can administer enough gas and air to herself to provide at least some relief from her pain; in a great number of cases quite definite relief from pain results. A certain number of patients, however, refuse to take the gas, but with an experienced doctor or midwife in charge of the "apparatus the timidity can usually be overcome so that the gas ns taken with confidence and lessening of pain occurs. There is no doubt that the use of the apparatus has done -much to ease and lessen the strain and suffering of women in labour. 143 J. SURVEY OF PUBLIC HEALTH SERVICES. A complete survey of the public health services of theBorough was carried out by Medical Officers of the Ministry of" Health, beginning on 14th February, 1935, and lasting for several! days. Subsequently a report was received by the Town Clerk, and,, after submission to your Council, specific action was taken on the points raised. At a later date a full report was made by the Town Clerk to the Ministry. The report and memorandum received from the Ministry,, and the action taken, are set out below. Ministry of Health, IIIa.1769/4201/1. Whitehall, S.W.I. 12th August, 1935. sir, I am directed by the Minister of. Health to state that he has had under consideration the report of his Medical Officer who recently visited Walthamstow for the purpose of carrying out a survey of the public health services of the Town Council. It appears that,, so far as can be judged from a general survey, the Council are maintaining a reasonable, and for the most part, a high standard of efficiency and progress in the discharge of their functions relating to public health. In particular, the Minister is glad to learn that good work is being done under the Council's Maternity and Child Welfare Scheme both through their own officers and in co-operation with voluntary agencies. The provision of a Foot Clinic and the arrangements for immunisation against diphtheria are also noteworthy features of the Council's health work. A memorandum is enclosed with regard to matters which need the attention of the Council, and the Minister will be glad to be informed in due course of the result of their consideration of the memorandum. If the Council consider that the discussion of any of these matters would be of advantage, the Minister will be happy to arrange for an interview between representatives of the Council and officers of the Department on being informed of the particular points which it is desired to discuss. The Minister desires me to express his appreciation of the assistance which was given to his Officers throughout thesurvey. I am, Sir, The Town Clerk, Your obedient servant, Town Hall, Dudley Ward. Walthamstow, E.17. 144 (A) MEMORANDUM FROM MINISTRY OF HEALTH RE SURVEY OF HEALTH SERVICES, AND (B) ACTION TAKEN. A. Isolation Hospital.— The isolation Ihospital accommodation for the Borough is inadequate. The Town Council should take steps to implement at an early date the scheme made by the Essex County Council and approved by the Minister under the provisions of Section 63 of the Local Government Act, 1929, in so far as it relates to Area No. 10 of which the Borough forms part. Public Cleansing.— (a) The refuse tip at Low Hall Farm was in an unsatisfactory condition at the time of inspection, the refuse being on fire and the precautions for tipping recommended by the Department not being observed. Steps should be taken forthwith to extinguish the fire, to see that future tipping is conducted strictly in accordance with the abovementioned precautions, and (to ensure successful management) to exclude " totters." (b) It is desirable that the Council should take measures to secure the provision of proper dustbins where existing receptacles are unsatisfactory. Housing Inspection.— It is recommended that more complete records should be kept of housing inspections and repairs, and that the work should be so organised that eventually all the houses in the Borough are inspected. Thorpe Coombe Maternity Hospital.— At the time of the survey the nursing staff at this hospital was inadequate for the number of patients received. If this matter has not already received attention, immediate steps should be talcen to engage additional nurses. B. Negotiations are at present taking place with the Leyton Borough Council with reference to the Scheme for the joint provision of additional isolation hospital accommodation. (a) Steps have been taken to control the tip on the lines suggested by the Ministry and to extinguish the fires. (b) This matter Is receiving the constant attention of the Council. Notices are served on the owners of property to supply bins, and in the event of non-compliance bins are supplied by the Council at the owner's expense. This matter will receive attention. It may be possible to combine the necessary records with those which will be required under the Housing Act, 1935, and the Council are considering the question of engaging additional clerical assistance for the Public Health Department. The nursing staff at the date of inspection (20th February, 1935) consisted of 5 sisters, 3 staff nurses, 1 assistant nurse and 4 probationers. The nursing staff now approved consists of 5 sisters, 7 staff nurses, 6 pupil midwives and 6 probationers, so that the matter has now been dealt with. 145 Maternity and Child Welfare.— (a) The Council should consider the payment of compensation to midwives when patients who attend the ante-natal clinic on the advice of the midwife are subsequently admitted to the Maternity Hospital for confinement on the recommendation of the Medical Officer of the Clinic. (b) Attention is drawn to the importance of post-natal examination for all women recently confined, and every effort should be made to persuade such women to take advantage of the facilities provided for this purpose. (c) The Council should consider the desirability of arranging that a specific area within the Borough should be allocated to the voluntary organisations for clinic purposes and home visiting. (d) There appears to be a need for more sessions attended by a doctor at the Infant Welfare Centres. (e) Some re-organisation and adjustment of the work of the Health Visiting Staff could be effected with advantage. The Minister is advised that an undue proportion of the time of the Health Visitors is devoted to clerical work. (a) The Council have already decided that compensation shall be fixed at 10/- per case lost to the midwife. (b) A post-natal clinic has been in operation for some time at Thorpe Coombe, and mothers are now beginning to attend fairly well. The Chairman of the Walthamstow District Nursing Association has been asked to request the Matron and Staff of the Association to refer all their midwives' cases to the Clinic at Low Hall Lane. All midwives practising in the area have been similarly circularised. The Health Visiting Staff has been asked to emphasise the importance of post-natal examination at their first visit. If the numbers of post-natal cases attending at Low Hall Lane become sufficient, it may be necessary to institute a special clinic. (c) The Council have given very careful consideration to this suggestion, but they are of the opinion that it would not be desirable to allocate a specific area within the Borough to voluntary organisations for clinic purposes and home visiting. (d) The number of sessions attended by a doctor have been increased to the number suggested by the Ministry's Inspector. (e) Pending the time when all the nursing staff will be carrying out combined health visiting and school nursing duties, some anomalies must exist. The re-organisation and adjustment suggested by the Ministry's Inspector have already been carried out. The present clerical staff is not sufficient to undertake any of the clerical work of the Health Visitors, but the Council are going into the question of engaging additional clerical assistance generally for the Public Health Department. 146. Infant Life Protection.— As there are a considerable number of nurse children in the Borough, it is suggested that a special form of record should be adopted, in which appropriate notes on the fosterparents and their home conditions could be included. Notification of Tuberculosis.— The Minister is advised that the Notification Register appears to be in need of revision, and he suggests that the Medical Officer of Health should confer on this matter with the medical officers of the Ministry. Publicity.— It is suggested that the clinics and other health facilities available in the Borough should be better advertised by means of posters, handbills, etc. The appropriate and: special formof record is being prepared and will be put into use. The Medical Officer of Health, will confer with the Medical Officers as suggested. The Council have in hand the preparation of a Handbook setting out the Health and other servicesavailable in the Borough, which will be circulated amongst the public. It is expected to be published this month (October, 1935). All other steps pos-sible will betaken.