COUNTY BOROUGH OF WEST HAM ANNUAL REPORT ON THE HEALTH SERVICES E. ASHWORTH UNDERWOOD M.A., B.Sc, M.D., D.P.H. WHAN 16 COUNTY BOROUGH OF WEST HAM ANNUAL REPORT ON THE HEALTH SERVICES FOR THE YEAR 1937 BY E. ASHWORTH UNDERWOOD, M.A., B.Sc., M.D., D.P.H., Medical Officer of Health and School Medical Officer. London. Published by the County Borough Council of West Ham. To be purchased from The Medical Officer of Health, Public Health Department, West Ham, E.15. 1938. Price 3s. Od. (Paper Edition) Copyright reserved. Printed in Great Britain at The Plaistow Press, London, E.15. 2 CONTENTS page Preface 5 List of Members of Committees 9 List of Staff 12 I. Natural and social conditions. General provision of health services 26 II. Vital statistics 56 III. Infectious diseases:— Epidemiology 118 Report on the Isolation Hospital 152 Venereal diseases 172 IV. Tuberculosis:— General 180 Report of the Tuberculosis Officer 198 Report on the Municipal Sanatoria 203 V. Maternity and child welfare 212 VI. Municipal hospitals 248 VII. Inspection and supervision of food 280 VIII. Sanitary circumstances 314 IX. Housing 338 X. Mental deficiency 344 XI. School medical service 358 Appendix (list of clinics and services) 451 Index 455 3 COUNTY BOROUGH OF WEST HAM. ANNUAL REPORT ON THE HEALTH SERVICES, 1937. Madam Mayor, Ladies and Gentlemen, I have the honour to submit my annual report on the health of the population of this area for the year 1937, this being my first annual report as Medical Officer of Health and School Medical Officer. As I was in office auring only about a quarter of the year under review, I have attempted to give a considered statement of facts relating to the health of the area in this and past years, rather than to make suggestions regarding the future development of the services. With reference to the health of the inhabitants during the year 1937, I have to draw your attention to the following facts, which are dealt with more fully in the text of the report. The population of the area—as estimated by the RegistrarGeneral—continues to decline. This decrease is a logical result of modern social tendencies. Associated with this is the question whether the population is replacing itself to anything approaching an adequate degree. In an area such as West Ham, where the extent of migration, inward and outward, is difficult to assess, it is not easy to answer this question. By inference from figures for other areas it would seem, however, that the position in this area must give rise to some disquietude, and in the report I have discussed briefly some of the problems relating to the low natural increase of the population. In these circumstances it is encouraging to note that the birth rate—namely 16.1 per 1,000 of the population—was an increase on the rate for the year 1936, and was indeed the highest birth rate since 1932. The death rate gives grounds for some satisfaction. The general death rate shows a slight increase over the figure for 1936, but it was still lower than the corresponding figures for London and the country as a whole. The infant mortality rate shows a decrease over the figure for the previous year, and the maternal mortality rate can stand favourable comparison with that for other areas. It is satisfactory to be able to state that the death rate 5 from all forms of tuberculosis was the lowest on record, and that the death rate from cancer was the lowest since 1931 In the light of the supposed increase in the incidence of cancer in the nation, and of the relative increase in the proportion of older persons in the community, this decline in the cancer death rate is very satisfactory. The death rale from violence was lower than that for the country as a whole, but there was a slight increase in the death rate frum heart disease and in that, from respiratory diseases. During the year the foundation stone of the extensions to South Ockendon Colony was laid by the Mayor, Alderman Mrs. Parsons, J.P., in the presence of the Mayor of East Ham and representatives of the J Vest Ham'and East Ham Councils, and a Commissioner of the Board of Control. The work in connection with these extensions is now making rapid progress. With reference to the health of the school child, I have given extensive data from which can be judged the progress effected in this important service. It will be seen that there are gaps in the potentialities of the dental branch, and I have indicated that this matter will receive attention in a later report. Speaking generally it may be said that from the available evidence the health of the school child in West Ham appears to be satisfactory. For example, when the prevailing industrial condition of the area is taken into account, it is satisfactory to note that there is little difference in the state of nutrition of the J Vest Ham children as compared with the nutrition of children in the country as a whole. In the text of the report I have referred to the fact that there is an increase in the proportion of defects in school children which are discovered at special examinations. This does not necessarily mean that there is an increase of such minor defects in school children. It does mean, however, that greater use is being made of the special examination for the purpose of investigating any defects which may be present, and that therefore the routine examination is relatively less productive of results than it was formerly. I have shown that during the last few years there has been a noteworthy decline in the incidence of minor skin diseases in school children, but that unfortunately this decline has been associated with an increase in the incidence of scabies. In the month of June, the extensions to Fyfield Residential Open Air School were completed, so that the school now has accommodation for 100 boys and too girls. 6 The year under review was notable for the coming into force of several important measures. Those which mainly concern this County Borough are the Shops (Sunday Trading Restrictions) Act 1936, which came into force on May 1st, 1937; the Retail Meat Dealers' Shops (Sunday Closing) Act, 1936, which came into force on the 1st January, 1937; the Housing Act, 1936, which came into force on the 1st January, 1937; the Public Health Act, 1936, which came into force on the 1st January, 1937; and the West Ham Corporation Act, 1937, which came into force on 9th November, 1937 It is a matter for general regret that I have to mention the deaths of two gentlemen who were most closely associated with the health of the area. My predecessor, Dr. F. Garland Collins, died on the 30th March, and the Council were thereby bereft of the services of an officer who had served them in the capacity of Medical Officer of Health for thirteen years. It would be invidious of me to comment further on an event which is of such recent date. I have also to mention the death on the 18th December, 1937, of Dr. Charles Sanders, who was Medical Officer of Health of the borough for the long period of thirty-seven years. On his retirement in 1924, Dr. Sanders received many testimonials of the esteem and affection, not only of his colleagues, but also of the members of the Council, of his staff, and of the public in general. It may be said that Dr. Sanders was one of the ''Grand Old Men" of public health, and his election to the Presidency of the Society of Medical Officers of Health in 1917 was an expression of the high regard in which his colleagues held his ability. In a famous essay Walter Savage Landor once wrote: "The present, like a note in music, is nothing but as it appertains to what is past and what is to come." In this report I have endeavoured to give comparative statistics for a number of years, and I have explained in another place the difficulties met with in acquiring this information. Copies of reports of the Medical Officer of Health previous to the year 1900 are very scarce, and I have not yet been able to acquire copies for the years 1887 to 1892 inclusive. From the monetary aspect these copies are worth little, but from the standpoint of anyone who is interested in vital statistics they are invaluable. If any reader of this volume should happen to possess copies of these early reports, I should be most grateful if he would communicate with me. 7 In conclusion, 1 should like to take this opportunity of expressing my gratitude for the kindly manner in which I was received when I undertook my new responsibilities. This appreciation must be extended to ike Chairmen and members of the various committees, and to all the members of staff. The compilation of this report has involved extensive work, and I am especially grateful to those officials who worked with me to this end for their unselfish devotion to the welfare of the department. I am, Madam Mayor, Ladies and Gentlemen, Your obedient Servant, E. ASHWORTH UNDERWOOD, Medical Officer of Health and School Medical Officer. Municipal Health Offices, 88 Romford Road, West Ham, E.15. 8 CONSTITUTION OF COMMITTEES (November, 1937, to November, 1938). The Mayor (Alderman Mrs. E. Bock, j.p.). Health Committee. Councillor Mrs. A. A. Barnes (Chairman). Councillor A. G. Schirn (Vice-Chairman). Councillor St. C. Collins. Councillor W. H. Head. Alderman J. T. Husband, j.p. Councillor P. Hearn. Alderman E. J. Reed, j.p. Councillor Mrs. K. E. James. Councillor E. F. Bradley. Councillor Sidney Lee, m.r.c.s. Councillor E. J. Fox. Councillor G. F. Lennox. Councillor A. C. Gentry. Councillor Mrs. E. E. Wybrew Councillor Mrs. E.J. Gregory. Education Committee. Alderman Mrs. D. Parsons, j.p. (Chairman). Alderman G. Blaker (Vice-Chairman). Councillor St. C. Collins. Councillor W. H. Luscombe. Alderman W. T. Bell. Councillor A. C. Moorey. Alderman G. Croot, j.p. Councillor Mrs. E. Venton. Alderman B. W. Gardner, Councillor A. J. Walker. j.p., m.p. Councillor C.H.W.Ward, j.p. Alderman J. H. Hollins. Councillor F. A. Warner. Alderman-E. J. Reed, j.p. Miss R. H. Cheetham* Alderman W. J. Reed. Reverend W. W. Cotton* Councillor Mrs. A. A. Barnes. Miss A. R. Harbott* Councillor C. A. Bennett. Miss M. S. Jevons* Councillor G. Doherty. Mrs. E. V. Parker* Councillor S. M. Edwards. Reverend A. J. Parry* Councillor A. G. Gay, j.p. Mr. R. Rees* Councillor Mrs. E. J. Gregory. Mr. F. G. Reynolds* Councillor Mrs. J. A. Hollins.Reverend J. Sloane* Councillor G. F. Lennox. * Co-opted members. 9 Maternity and Child Welfare Committee. Councillor A. G. Schirn (Chairman). Councillor E. F. Bradley (Vice-Chairman). Councillor St. C. Collins. Councillor Mrs. K. E. James. Alderman J. T. Husband, j.p. Councillor Sidney Lee, m.r.c.s. Alderman E. J. Reed, j.p. Councillor G. F. Lennox. Councillor Mrs. A. A. Barnes. Councillor Mrs. E. E. Wybrew Councillor E. J. Fox. Miss N. G. Baily* Councillor A. C. Gentry. Miss O. Blanden* Councillor Mrs. E. J. Gregory. Mrs. E. Lawrence* Councillor W. H. Head. Mrs. F. E. Quinn* Councillor P. Hearn. Mrs. D. E. Samuels* * Co-opted members. Hospitals Committee. Councillor Mrs. J. A. Hollins (Chairman). Councillor Mrs. F. A. Wood (Vice-Chairman). Alderman G. Croot, j.p. Councillor Mrs. F. Harris. Alderman Mrs. D. Parsons, j.p. Councillor Sidney Lee, m.r.c.s. Alderman H. J. Rumsey. Councillor A. B. Macgregor. Councillor E. H. J. Adams. Councillor A. J. Walker. Councillor Mrs. A. A. Barnes. Councillor C. H. W. Ward, j.p. Councillor Mrs. E. C. Cook. Councillor E. W. Wordley, j.p. Councillor D. W. Hall. Housing Committee. Councillor E. F. Bradley (Chairman). Councillor A. B. Macgregor (Vice-Chairman). Alderman E. J. Reed, j.p. Councillor A. G. Schirn. Alderman H. J. Rumsey. Councillor G. J. Smith. Councillor J. Doherty. Councillor P. G. Spears. Councillor A. C. Gentry. Councillor M. J. Sullivan. Councillor W. A. Gillman. Councillor E. W. White, j.p. Councillor Mrs. K. E. James. Councillor E.W.Wordley, j.p. Councillor C. F. Lowe. 10 The Executive Committee for the care of the Mentally Defective The Mayor (Chairman). Alderman Mrs. D. Parsons, j.p. (Vice-Chairman). Alderman W. T. Bell. Councillor Mrs. J. A. Hollins. Alderman G. Croot, j.p. Councillor W. C. Ridgewell, j.p Alderman J. H. Hollins. Councillor C. H. W. Ward, j.p Alderman J. T. Husband, j.p. Councillor F. A. Warner. Alderman J. T. Scoulding, j.p. Councillor Mrs. F. A. Wood. Councillor E. F. Bradley. Councillor E.W. Wordley,j.p. Councillor Mrs. E. J. Gregory. Mrs. Cornelius* Councillor D. W. Hall. Mrs. Luscombe* * Co-opted members. Public Assistance Committee. Alderman T. Wooder (Chairman). Councillor Mrs. A. E. Harnwell (Vice-Chairman). Alderman Mrs. D. Parsons, j.p. Councillor Mrs. J. A. Hollins. Councillor Mrs. A. A. Barnes. Councillor H. J. Manners. Councillor Mrs. E. C. Cook. Councillor F. E. Mansford. Councillor G. Doherty. Councillor W.C. Ridgewell, j.p Councillor S. M. Edwards. Councillor Mrs. E. Venton. Councillor A. G. Gay, j.p. Councillor Mrs. E. E. Wybrew Councillor Mrs. F. Harris. m 11 STAFF OF THE HEALTH SERVICES. (a) MEDICAL AND ADMINISTRATIVE STAFF. Medical Officer of Health, School Medical Officer and Chief Administrative Tuberculosis Officer: E. Ashworth Underwood, M.A., B.Sc., M.D., D.P.H. Deputy Medical Officer of Health: T. W. Hill, M.D., D.P.H. Chief Assistant School Medical Officer: Robert J. Reid, M.B., Ch.B., D.P.H. Chief Clinical Tuberculosis Officer: P. A. Galpin, M.D., D.P.H. Senior Assistant Medical Officer for Maternity and Child Welfare: Helen Campbell, M.B., Ch.B., D.P.H. School Medical Service. Assistant School Medical Officers : A. Furniss, L.R.C.P., L.R.C.S., L.R.F.P.S. (Glas.), D.P.H., L.D.S. Jessie H. Fitchett, M.B., Ch.B., D.P.H. B. M. R. West, M.R.C.S., L.R.C.P. Jessie Griffin, M.B., Ch.B., D.P.H. D. L. Pugh, M.R.C.S., L.R.C.P. School Oculist: Agnes A. S. Russell, M.B., Ch.B., D.P.H. School Dental Officers: J. S. Dick, L.D.S. Helene M. Gubb, L.D.S. Dorothy Marsden, L.D.S. G. C. Baird, L.D.S. F. Soper, L.D.S. Consultant Aural Surgeon (Part-time): F. Stoker, F.R.C.S. 12 Tuberculosis Assistant Tuberculosis Officer: w. r. kilgour, m.r.c.s., l.r.c.p. Maternity and Child Welfare. Assistant Medical Officers: Charlotte E. Forsyth, M.B., Ch.B., D.P.H. Muriel Frances Prout, M.D., B.S. (part-time). Angel V. b. Crawford, B.A., M.B., B.Ch., d.p.h. (part-time) Consultants: g. j. sophian, m.r.c.p., f.r.c.s. V. j. f. lack, m.r.c.s., m.b., b.s., f.r.c.s.e., f.r.c.p., f.c.o.g. A. C. McAllister, M.B., B.S., L.R.C.P., F.R.C.S. (Eng.), f.c.o.g. Dental Officer: Evelyn Richardson, L.D.S., R.C.S. Isolation Hospital, Plaistow. Medical Superintendent: Donald MacIntyre, M.C., M.D., D.P.H. Senior Assistant Medical Officer: h. d. Palmer, m.b., Ch.b. Junior Assistant Medical Officer: W. m. j. Laurie, m.b., Ch.b. Dagenham and Langdon Hill Sanatoria. Medical Superintendent: g. m. mayberry, l.A.h., l.r.c.p. Assistant Medical Officer: Dorothy l. m. keats, m.r.c.s., l.r.c.p., d.p.h. Specialist Radiologist (part-time): l. g. blair, m.r.c.s., l.r.c.p., d.m.r.e. 13 Whipps Cross Hospital Medical Superintendent: 0. R. M. Kelly, M.B., B.S., F.R.C.S. Deputy Medical Superintendent: D. G. Sharp, M.R.C.S., L.R.C.P. Assistant Medical Officers: W. E. Joseph, M.R.C.S., L.R.C.P. (Senior). N. H. Skelton-Browne, M.R.C.S., L.R.C.P. I. Mansfield, L.M.S.S.A. G. McKinnon, M.B., Ch.B. C. E. D. H. Goodhart, M.R.C.S., L.R.C.P. I. E. Zieve, M.A., M.R.C.S., L.R.C.P. (resigned 30/11/37) Consultants: W. J. O'Donovan, M.D., B.S., M.R.C.P., M.R.C.S. (Skin diseases). A. Galletly, M.B., Ch.B., F.R.C.S. (Gynaecology). A. Todd, M.B., B.S., F.R.C.S. (Orthopaedics). A. Clifford Morson, L.R.C.P., F.R.C.S. (Urology). A. Ryland, L.R.C.P., F.R.C.S. (Aural conditions). J. Purdon Martin, M.D., B.Ch., F.R.C.P. (Neurology). L. Savin, L.R.C.P., F.R.C.S. (Eye diseases). F. W. Barton, L.M.S.S.A. (Dentist). T. deLacy Walker, L.M.S.S.A. (Anaesthetics). Forest Cate Hospital. Medical Superintendent: H. R. England, M.B., Ch.B., M.M.S.A. Senior Assistant Medical Officer: J. M. Gray, M.D., Ch.B. Junior Assistant Medical Officer: W. F. Whelton, M.B., Ch.B., B.A.O. Central Home. Senior Medical Officer: Ivan B. McCann, M.R.C.S., L.R.C.P. Assistant Medical Officers: J. Henderson, M.B., B.S. R. G. Meyer, M.B., Ch.B. (appointed 5/7/37). 14 Harold Wood Hospital. Visiting Medical Officer (part-time): T. B. Fyans, M.B., Ch.B., B.A.O. South Ockendon Colony. Visiting Medical Officer (part-time): N. MacFarlane, M.B., Ch.B. District Medical Officers. T. L. Dolan, L.R.C.P.I. and L.M., L.R.C.S.I. and L.M. J. P. Robinson, M.B., Ch.B., B.A.O. J. F. Begley, M.B., B.S., R.U. (part-time). R. V. Brews, L.R.C.S.I. and L.M., L.R.C.P.I. and L.M. (part-time). P. G. S. Kennedy, M.A., M.B., B.Chir. (part-time). J. J. McSharry, L.R.C.P.I., L.R.C.S.I. (part-time). M. J. Murphy, M.B., Ch.B., B.A.O. (part-time). Public Vaccinators. T. L. Dolan, L.R.C.P.I. and L.M., L.R.C.S.I. and L.M. P. G. S. Kennedy, M.A., M.B., B.Chir. M. J. Murphy, M.B., Ch.B., B.A.O. J. Waters, M.B., Ch.B. (resigned October, 1937). M. Kyndt, M.D. (appointed October, 1937). Veterinary Officer (for Meat Regulations, 1924): H. E. Bywater, M.R.C.V.S. Assistant Veterinary Officer: J. T. Turney, M.R.C.V.S. Public Analyst (part-time): A. E. Parkes, F.I.C., F.C.S. Chief Sanitary Inspector: H. G. Clinch. 15 Chief Clerk (General Public Health): H. R. Cole. Chief Clerk (School Medical Service): F. W. England. (b) GENERAL HEALTH AND SANITATION. Inspector under Food and Drugs Act and Sampling Officer: E. F. Hughes. Meat inspector: T. E. Harris. District inspectors: B. G. Bannington (senior), R. Dicker, J. F. Mules, J. B. H. Jones, B. J. Driscoll, H. G. Bartram, C. F. Riley, A. B. Holloway (resigned 1/5/37), J. A. Dawson, L. Pinguey (appointed 6/7/37), H. G. Avril, Miss B. M. Keogh, E. J. Cromwell, Miss V. M. Busby, H. Ault, Miss A. Maughan. C. E. Jeffries, Shops inspectors: E. J. Ferrier, C. J. Genery. Vaccination officer: H. H. King. Administrative section—health. Clerks: F. H. Barker (senior), C. R. Sandell, J. Sabin, Miss H. O. Williams, A. F. Clarke, Miss M. Doherty, S. A. Lemmon, J. P. Quinn, D. Thomson, E. J. Wilkins. Miss A. E. Durand, Supervising nurse under Mental Deficiency Acts: Miss H. Swift. 16 (c) SCHOOL MEDICAL SERVICE. School nurses. Miss D. S. Ayton Miss E. K. Jack Miss A. Bredin Miss E. Large Miss H. E. Bredin Miss A. K. McCormack Miss A. Burrows Mrs. M. Mace Miss E. M. Bussell Miss I. B. B. Mann Miss A. J. Costain Miss M. H. Rose Miss M. A. Costain Miss A. Sheeiian Miss I. Cox Miss E. R. Tanner Miss M. M. Empson Miss M. E. Tanner Miss L. C. Glover Miss E. Taylor Miss E. D. Harris Miss M. A. Van Ryssen Miss E. Holly Miss D. Wright Miss C. E. Hutton Miss F. G. Hobbs (Special enquiry nurse). Mrs. C. B. Halls (Knox Road and Crosby Road Special Schools). Mrs. S. Wilder spin (Grange Road Special School). Nursing Staff, Fyfield Residential Open Air School. Miss W. M. Barnes, Matron. Miss M. James, Nurse. Miss R. Aylott, Matron's Llelp. Administrative section. Clerks. R. H. Thomas (senior) Miss P. I. Geaussant Miss G. A. Blackler Miss E. W. Wood T. P. Swatts R. Huxtable Miss E. Laker W. Phillips Messenger. R. Denney 17 (d) MATERNITY AND CHILD WELFARE. Health visitors. Miss R. Alefs Miss E. Norrie Miss A. E. Lunn (resigned April, 1937) Mrs. N. C. Gibbins Miss R. Harrington Miss M. B. Wallace Miss E. A, Edwards Miss A. Connolly Miss P. Bennett Miss L. M. Martin (resigned May, 1937) Miss E. B. Welch Miss P. Carter Miss M. Cross (appointed May, 1937) Miss B. H. Clipstone Miss V. Kusel Miss M. Mackenzie (appointed May, 1937) Miss D. M. White Miss R. M. Ody Miss C. LI. Banks (appointed June, 1937) Miss B. deRochefort Dental nurse: Miss F. M. Davies. Dried milk section. Clerks: Assistant clerks: Packers: Mrs. E. Gunstone Miss D. Bentley Miss V. Cockrell Miss N. Lavell Miss P. Benney Miss I. Thompson Miss E. Taylor Miss M. Milsted Miss G. Massey Investigator: J. W. McCarthy. (e) TUBERCULOSIS DISPENSARY. Nurses: Clerks: Mrs. E. Siggins (sister-in-charge) J. W. Rowe Miss E. J. Egerton Miss L. F. Bush Miss M. Schwer Miss G. Williams Miss E. K. Pottinger (f) HOSPITALS. Isolation Hospital, Plaistow. Matron: Miss I. Tullock. Steward: W. Liddall. 1 assistant matron; 1 sister tutor; 1 night sister; 8 ward sisters; 9 staff nurses; 48 probationers; 5 private nurses; 3'dressmakers; 1 clerk; 3 female cooks; 1 head laundress; 9 laundry maids; 1 laundryman; 46 maids and orderlies; 4 female cleaners; 3 male cleaners; 1 foreman porter; 7 porters; 5 ambulance drivers. 18 Dagenham Sanatorium. Matron: Miss M. Duguid. Steward: H. Bromley, 1 assistant matron and sister tutor; i night sister; 2 day sisters; 1 nurse housekeeper; 5 staff nurses; 2 assistant staff nurses; 15 probationers; 1 steward's clerk; 1 lodge attendant; 6 ward orderlies (female); 1 engineer; 1 engineer's mate; 1 caretaker; 1 handyman; 5 porters; 1 night watchman; 1 gardener; 1 assistant gardener; 1 cook; 1 assistant cook; 1 head laundress; 5 laundry maids; 1 sempstress; 21 maids. Langdon Hill Sanatorium. Matron: Miss P. M. Noble. Steward: H. Bromley. 1 senior sister; 1 staff nurse; 7 probationers; 2 teachers; 1 cook; 7 maids; 1 sempstress; 1 head gardener and caretaker; 1 motor driver and porter; 1 handyman and porter; 2 assistant gardeners; 1 night watchman. Whipps Cross Hospital. Matron: Miss E. Downs. Steward: B. S. Lawrence. 1 assistant matron; 1 radiographer; 1 assistant radiographer; 1 dispenser; 1 assistant dispenser; 1 tutor sister; 1 assistant tutor sister; 3 massage sisters; 3 night sisters; 1 home sister; 1 assistant home sister; 26 ward sisters; 35 staff nurses; 113 probationers; 7 private nurses; 3 male nurses; 1 masseur; 2 male head attendants; 11 attendants; 10 dressmakers; 2 male cooks; 1 female cook; 1 head laundress; 1 assistant laundress; 32 laundry maids; 4 laundry men; 141 maids and orderlies; 34 part-time orderlies; 2 male cleaners; 1 foreman porter; 38 porters; 9 ambulance drivers; 1 barber; 1 deputy steward; 1 medical superintendent's clerk; 7 male clerks; 2 female clerks. Forest Cate Hospital. Matron: Mrs. E. M. Usherwood. Steward: E. J. Miles. 1 assistant matron; 1 home sister; 2 night sisters; 7 ward sisters; 5 midwifery sisters; 8 pupils; 109 assistant nurses; 16 male attendants; '5 handicraft instructresses; 2 cooks; 2 assistant cooks; 5 kitchen maids; 3 scullery maids; 1 matron's maid; 1 doctor's maid; 1 assistant steward; 4 steward's clerks; 1 medical superintendent's clerk; 42 cleaners. 19 Central Home. Matron: Mrs. M. E. Lambert. Master: S. P. Lambert, 1 dispenser; 1 assistant dispenser; 1 assistant master; 2 assistant matrons; 1 superintendent nurse; 1 assistant superintendent nurse; 15 ward sisters; 167 assistant nurses ; 1 head female attendant; 1 female charge attendant; 23 female attendants; 1 head male nurse; 2 male charge nurses; 54 male nurses; 1 head male attendant; 14 attendants; 11 dressmakers; 6 male cooks; 5 female cooks; 1 machinist; .1 head laundress; 1 assistant laundress; 34 laundry maids; 1 head laundryman; 6 laundrymen; 12 maids and orderlies; 106 female cleaners; 3 porters; 1 lodge attendant; 2 motor drivers; 1 barber; 6 clerks. Forest House. Matron: Mrs. E. Rutherford. Master: R. L. Rutherford. 1 master's clerk; 1 head attendant; 1 charge sick attendant; 12 male attendants; 7 female attendants; 3 machinists; 2 cooks; 13 cleaners; 1 barber. Harold Wood Hospital. Matron: Miss L. M. Mackie. 6 ward sisters; 3 staff nurses; 36 assistant nurses; 5 male nurses, 2 dressmakers; 1 acting steward; 1 clerk; 2 female cooks; 1 head laundress; 4 laundry maids; 1 laundryman; 24 maids and orderlies; 6 porters; 1 barber. South Ockendon Colony. Matron-Superintendent: Miss W. S. Butler. 1 female clerk; 2 female charge nurses; 2 deputy female charge nurses; 9 assistant nurses; 1 head male nurse; 1 deputy head male nurse; 7 male nurses; 1 female cook; 3 housemaids; 2 kitchenmaids ; 1 sempstress; 1 assistant sempstress; 3 porters; 1 handyman. District Nurses (Public Assistance): Miss E. Gunn Miss E. Hayes Mortuary keeper: E. Heisterman. Assistant sampler: F. Johnson. Disinfectors: B. Lyons E. Hesselwood H- Howe F. Nottage 20 KEY TO THE WARDS SHOWN ON THE MAP. The map is divided into half mile squares. 1. New Town. 2. Forest Gate. 3. High Street. 4. Broadway. 5. Park. 6. Upton. 7. Plashet Road. 8. West Ham. 9. Plaistow. 10. Bemersyde. 11. Canning Town and Grange. 12. Hudsons. 13. Ordnance. 14. Beckton Road. 15. Tidal Basin. 16. Custom House and Silvertown. This map is based on a publication of Messrs. Wilson & Whitworth Ltd.. Broadway, Stratford, to whom acknowledgments are due for permission to adapt. 21 SUMMARY. 1937. Area of borough 4,689 acres Average height above sea level 25 feet Census population, 1931 (males 143,714) (females 150,564) 294,278 Population, 1937 (Registrar-General's mid-year estimate) 259,500 Estimated number of houses 50,247 Number of families (1931 Census) 72,994 Number of persons per acre 56 Rateable value 1,518,245 Sum represented by a penny rate £5,942 West Ham England & Wales average. average. 1937 1927-1936 1937 1927-1936 Live births 4,148 5,064 610,557* 623,508 Birth-rate (per 1,000 population) 16.1 17.3 14.9* 15.6 Stillbirths 145 165 24,806* 26,242 (1928—1936) (1928—1936) Stillbirth rate (per 1,000 total live and still births) 34 32 39* 40 (1928—1936) Marriage rate (persons married per 1,000 living) 22.3 — 17.4* 16.1 Number of deaths 3,107 3,326 509,571* 485,512 Crude death-rate (per 1,000 population) 12.0 11.4 12.4* 12.1 Adjusted death-rate 13.8 — — — Excess of births over deaths 81 — — — Deaths of infants under one year 259 331 — 39,871 Infantile mortality rate (deaths per 1,000 live births) 62 65 58* 64 Deaths of women in childbirth: Puerperal sepsis 2 6.6 — 1,077 Other causes 3 6.6 — 1,579 Total maternal deaths 5 13.2 — 2,656 Maternal death-rate per 1,000 total births 1.15 2.61 3.11* 4.26 23 Various diseases: cases and deaths during 1937. Cases Case rate per l,000 population. Deaths. Death rate per 1,000 population. Smallpox 0 0.00 0 0.00 Scarlet fever 1,074 4.14 4 0.02 Diphtheria 503 1.94 18 0.07 Enteric fevers 15 0.06 1 0.00 Measles — — 1 0.00 Whooping-cough — — 18 0.07 Diarrhoea and enteritis under 2 years (rate per 1,000 live births) - - 47 11.22 Pneumonia: Acute primary and influenzal 354 1.36 - - All forms — — 250 0.96 Bronchitis — — 160 0.62 Pulmonary tuberculosis 301 1.16 203 0.78 Other forms of tuberculosis 72 0.28 24 0.09 Cancer — — 367 1.41 * Provisional rates from weekly and quarterly returns. 24 1. NATURAL AND SOCIAL CONDITIONS GENERAL PROVISION OF SERVICES 25 NATURAL AND SOCIAL CONDITIONS. The County Borough of West Ham is a large autonomous area which is situated in latitude 51° 30' to 51° 33' N. and longtitude 0° 1' to 0° 3' E., outside the eastern boundary of the Count)' of London. The whole of the area, which is approximately 4 miles from north to south and about 2 miles from east to west, lies in the County of Essex, and it is bounded on the north by the Borough of Leyton and the County Borough of East Ham, on the east by the County Borough of East Ham, on the south by the River Thames and on the west by the Metropolitan Boroughs of Poplar and Hackney. The area is generally very flat, varying from less than 5 feet to 45 feet above sea level, about half the area being not more than 10 feet above that level. The area which constitutes the County Borough of to-day is of great antiquity. The Romans were certainly here at an early date, and numerous Roman remains have been found. In Saxon times the name of "Hamme" came into use, and it is said that Alfred the Great was responsible for the construction of the numerous watercourses which are a notable physical feature of West Ham to-day. From an ecclesiastical point of view this district became important in early times, and the great Abbey of West Ham was founded in the year 1135. The Abbey was surrendered to Henry VIII. in 1538, and few traces of its fabric now remain. The present Parish Church of West Ham was founded in the twelfth century. Until comparatively recent times the area consisted of a number of scattered centres separated by undeveloped land. Of these, the most important were Stratford, Plaistow and Upton. Many industries had been carried on in the area, but with the industrial revolution, and the coming of the railway in 1839, an incredible expansion of these industries occurred. Some idea of the growth of the area in population and wealth may be obtained from the statement that, whereas in 1856 the population was 27,000, in 1886 it was 180,000; and that, whereas the rateable value in 1856 was £8o,ooo, in 1886 it was 26 £652,000. In these thirty years the number of houses increased from 4,500 to 27,000. This rapid expansion was responsible not only for the present importance of the area, but also for many of its present social difficulties. The Borough contains along' its southern boundary some of the finest docks in the world. These are under the control of the Port of London Authority. The last important dock to be constructed—the King George the Fifth Dock—was opened in 1921. Some of the many important industries which arc found in this area are dealt with in later sections. At present the area is largely industrial, commercial and residential—a considerable proportion of the houses being of a type suitable for the workingclasses. There is thus ample scope for the enforcement of the statutes which deal with public health and housing. In recent years many developments have taken place in the lines of communication in the area. The River Lee Backwater Scheme has now been practically completed, and another important artery is the Silvertown Way. The area was constituted a borough by Royal Charter in 1886, and it was then divided into four wards—viz., Stratford, Forest Gate, Plaistow and Canning Town. In 1899 the borough was divided into twelve wards—viz., New Town; Forest Gate; High Street; Broadway; Park; Upton; West Ham; Plaistow; Hudsons; Canning Town; Tidal Basin; Custom House and Silvertown. In 1921 a re-distribution of the area again took place, and the following sixteen wards were constituted:—New Town; Forest Gate; High Street; Broadway; Park; Upton; Plashet Road; West Ham; Plaistow; Bemersvde; Canning Town and Grange; Hudsons; Ordnance; Beckton Road; Tidal Basin; Custom House and Silvertown. No further re-distribution has taken place, so that the statistics for wards given in other sections of this report are strictly comparable from 1921 to date. Further particulars of the historical development of this interesting area will be found in the book "Fifty Years a Borough : 1886-1936. The Story of West Ham" published by the County Borough Council in 1936. Area. The area of the county borough is 4,689 acres. As the area is surrounded by other local authorities, no extension is possible under the present constitution of local government. 27 Population. The Registrar-General's estimate of the resident population at the middle of the year 1937 was 259,500. The allocation of the population to the different wards and the changes in the size of the population through the years, are more fully discussed in a later section. The population of West Ham, as enumerated at the 1931 census, was 294,278 persons, of whom 143,714 were males and 150,564 females. The total population of the Administrative County of Essex, including its associated County Boroughs, West Ham, East Ham and Southend-on-Sea, at that Census was 1,755,459 persons. For further particulars of the Census population, see the section on vital statistics. Dwelling-houses. The total number of dwelling-houses in the borough at the 1931 Census was 48,907, of which 298 were unoccupied. The number of structurally separate dwellings at that date was 49,280. The number of occupied rooms at that date was 253,254, and the average number of persons per room was 1.14. The number of private families in the borough at the 1931 Census was 72,994. The estimated number of dwellings at the end of the year 1937 was 50,247, of which 49,972 were occupied and 275 were unoccupied. Rateable value and finance. The rateable value of this borough in 1937 was £1,518,245, and the estimated product of a penny rate was £5,942. The corresponding figures for 1936 were £1,510,131 and £5,998 respectively. A summary of the income and expenditure of those Committees of the Council which administrate the health services is given in Table I. For this statement I am indebted to the Borough Treasurer, Mr. E. J. Johnson, O.B.E. Principal industries. A comprehensive list of the most important industries in the borough is given in the publication "The Story of West Ham" referred to previously. Some idea of the variety of the industries which have developed may be gathered from the fact that the published list—which is not claimed to be complete—includes 146 separate and distinct trades. The importance of the West Ham docks has already been mentioned, and the London and North Eastern Railway works in Stratford employ a large number of hands. 28 Table 1. Health Services of West Ham: Financial statement for year 1st April, 1937, to 31st March, 1938. Service. Total expenditure Income (excluding Government Net cost of Service £ £ £ (1) General public health:— Infectious diseases (excluding hospitals) 8,029 - 8,029 Sanitation and general public health 14,094 55 14,039 Food and Drugs (Adulteration) Act 1,451 — 1,451 Diseases of Animals Act 1,502 — 1,502 Midwives Acts Shops Acts 820 — 820 Ambulances 2,449 295 2,154 (2) Prevention and treatment of tuberculosis 4,877 - 4,877 (3) Maternity and child welfare service 38,276 8,943 29,333 (4) School medical service 20,002 312 19,690 (5) Venereal diseases 2,527 — 2,527 (6) Mental deficiency service 31,079 91 30,988 (7) Hospitals and institutions: Isolation Hospital 40,859 1,754 39,105 Sanatoria 45,815 151 45,664 Whipps Cross Hospital 187,621 562 82,467* Forest Gate Hospital 84,278 7,787 29,744* Central Home 156,385 428 74,550* Harold Wood Hospital 27,711 5,441 22,270 South Ockendon Colony 18,496 4,755 13,741 Totals 686,271 30,574 422,951 * Net cost after deducting income from user-agreements. 29 Other industries which employ a large number of the population include that of cable making, sugar refining, leather cloth making, oil refining, manufacturing of chemicals, with a host of other smaller trades. Unemployment. The statistics which were compiled for many years with reference to unemployment in the borough included some persons in other areas than West Ham who registered at the two employment exchanges, viz. Canning Town and Stratford. Since 1933, however, special returns have been compiled relating to the number of unemployed persons resident in the County Borough. Table II. gives these figures from 1933-1936. For Tables II. and III., and for the following comments, I have to thank Mr. E. C. Ramsbottom, O.B.E., the Director of Statistics of the Ministry of Labour. The figures for the years 1933-1936 relate to the total number of unemployed (insured and uninsured) aged 14 and over, who were resident in West Ham and who were also on the register of the employment exchange. The figures for 1937 relate only to persons aged 16 and under 65 years who were insured against unemployment. It should be noted, therefore, that the figures for 1937 are not strictly comparable with figures for previous years. With reference to the total number of persons insured against unemployment, statistics are compiled annually showing the numbers whose unemployment books are exchanged at the employment exchanges in West Ham, but these figures also include some residents in West Ham whose books are exchanged at employment exchanges in other districts, and include some residents in other areas whose books are exchanged at employment exchanges in West Ham. In order to provide a basis for the calculation of approximate percentage rates of unemployment, estimates have been made by the Department of the total number of insured persons, aged 16-64, resident in West Ham in July of each year since 1933. Table III. gives the estimated figures for each of the years 1933-1937. It should be observed, however, that these estimates are necessarily only rough approximations, and that the figures given for 1933 to 1936 (relating to insured persons aged 16-64) are not strictly comparable with the unemployment figures given for those years in Table II., which includes juveniles under 16 years of age and uninsured persons registered as unemployed. 30 Table ii. Unemployment among persons resident in West Ham 1933-1937. Date. Unemployed persons aged, 14 and over, insured and uninsured on the registers of employment exchanges at the dates specified Men aged 18 and over. Women aged 18 and over. Juveniles aged 14—17. Total aged 14 and over. 1933 23rd January 16,381 2,102 1,294 19,777 24th April 15,132 2,351 1,051 18,534 24th July 13,436 1,848 532 15,816 23rd October 14,071 1,273 415 15,759 1934 22nd January 14,162 2,055 1,197 17,414 23rd April 12,414 1,615 872 14,901 25th July 11,875 1,665 458 13,998 22nd October 13,001 1,350 437 14,788 1935 28th January 13,512 2,189 1,011 16,712 15th April 11,521 1,677 377 13,575 22nd July 11,298 1,542 378 13,218 21st October 11,088 1,170 312 12,570 1936 20th January 11,507 1,917 869 14,293 27th April 9,982 1,645 625 12,252 20th July 8,986 1,209 324 10,519 26th October 8,683 893 238 9,814 Date Insured persons, aged 16—64, recorded at employment exchanges as unemployed at the dates specified. Males* Females* Total 1937 25th January 8,877 1,708 10,585 19th April 7,588 1,392 8,980 26th July 7,153 1,407 8,560 18th October 8,324 1,142 9,466 * Separate figures for men and boys, and for women and girls, are not compiled for 1937 as regards persons resident in West Ham. 31 Table III. Estimated number of insured persons, aged 16-64, resident in West Ham. Date. Men aged 18—64. Women aged 18—64. Juveniles aged 16—17. Total aged 16—64. July 1933 64,800 23,490 10,410 98,700 July 1934 64,930 23,680 9,010 97,620 July 1935 65,290 23,220 8,200 96,710 July 1936 66,140 23,000 10,080 99,220 Males, aged 16—64. Females aged 16—64. Total, aged 16—64. July 1937 72,530 28,490 101,020 Poor Relief. I am indebted to Mr. E. J. Johnson, the Borough Treasurer, for the following particulars regarding poor relief in 1937. The total number of poor persons who were receiving relief —other than relief of a medical nature—at December 31st, 1937, was 10,943. The amount expended on out-relief during the financial year from 1st April, 1937, to 31st March, 1938, was .£191,668, of which £34,147 was granted to persons ordinarily engaged in some regular occupation, and £157,521 to other persons. The institutions which formerly belonged to the West Ham Board of Guardians were transferred to the Council in March, 1930, and of these the Central Home, which is situated in Leyton, is the only one which is now available for indoor relief. The relieving stations are set out later. The relieving officers attend at these stations between the hours of 9 a.m. and 5 p.m. Central Home. The casual wards which were formerly at this institution, and the casuals, are now dealt with by the Joint Committee for the Northern Home Counties, consisting of the Counties of Middlesex, Hertfordshire and Essex, and the County Boroughs of West Ham, East Ham and Southend-on-Sea. The majority of the children who are orphaned or deserted are placed in the Aldersbrook Children's Home. Others are placed in private homes, and the foster-parents are paid for their maintenance. 32 Table IV. Central Home: Number of admissions, exclusive of medical cases. (a) 1937. Month. Men Women Children 3—16 years. Infants under 3. Total. January 21 9 15 10 55 February 24 7 13 7 51 March 21 7 18 5 51 April 19 6 12 6 43 May 15 4 7 10 36 June 19 9 31 12 71 July 13 9 9 7 38 August 20 11 11 11 53 September 25 7 14 14 60 October 15 10 6 3 34 November 29 9 15 11 64 December 21 2 16 9 48 Total 242 90 167 105 604 (b) 1936. Month. Men Women Children 3—16 years Infants under 3. Total. January 25 11 13 10 59 February 29 8 7 5 49 March 24 7 25 3 59 April 28 9 7 5 49 May 16 5 2 4 27 June 18 6 11 9 44 July 12 7 19 9 47 August 30 9 1 7 47 September 30 7 18 2 57 October 37 8 3 5 53 November 33 7 7 4 51 December 23 8 5 7 43 Total 305 92 118 70 585 c 33 The Central Home has certified accommodation lor 1,807 persons, which includes medical cases. The actual available accommodation on 31st December, 1937, was 1,599, viz.:—790 men, 803 women and 6 children. The number of able-bodied persons in the home on 1st January, 1937, was 673, and the number on 31st December, 1937, was 628. Table IV. gives further details of admissions to the institution exclusive of medical cases which are dealt with elsewhere. National Health Insurance. The total number of insured persons in the borough under the National Health Insurance Acts on 1st January, 1938, was 123,569, as compared with 123,681 on 1st January, 1937. The number of doctors, including their assistants, who were on the panel at the end of the year 1937 was 179, and the number of prescriptions which were dispensed during the year was 632,340. The corresponding figures for 1936 were 178 and 626,439. METEOROLOGY. There is no meteorological station in the borough, but the area is sufficiently near to the Greenwich Observatory to enable complete reliance to be placed upon the records of this station. Table V. gives a climatological summary for the year 1937 for the station, and for this information I am indebted to the Director of the Meteorological Office of the Air Ministry. Data for use with the Table. Greenwich Observatory— latitude 51°, 29 seconds north; maximum temperature relates to the interval 24 hours to 24 hours (G.M.T.); the minimum temperature refers to the similar interval; the rainfall is based on 24 hours period to 9 hours; the earth temperature to a similar period ending at 12 hours; and the other observations relate to the 6 hours period from 15—21 hours. The site of the rain gauge above sea-level was 1.9 feet. The height above ground of the following instruments was: thermometer, 4 feet; sunshine recorder, 50 feet; rain gauge, 5 feet. The normals used were:—(a) mid-temperature—period 1906— 1935; (b) rainfall—period 1881—1915; (c) sunshine—period 1906— 1935. 34 GENERAL PROVISION OF HEALTH SERVICES. This section of the report deals in detail with certain minor aspects of the health services, and introduces the arrangements which are in force at the present time regarding the major services. A full account of these major services will be found in later sections of this report. Laboratory facilities. It has not so far been found practicable to centralize the bacteriological work of the borough, though it is possible that such a scheme, which would undoubtedly have many advantages, will materialize at a later date. At the Isolation Hospital, Plaistow, routine bacteriological work in connection with patients in the wards is carried out, and facilities are also available for practitioners to have the simpler bacteriological examinations—such as the examination of throat swabs, or the carrying out of agglutination reactions using the commoner organisms—performed here. Details of the results of such examinations are given in the report on the hospital. The examination of sputum for the tubercle bacillus is carried out at the tuberculosis dispensary. More complicated bacteriological methods, such as the examination of milk, are usually carried out by the bacteriologist to Queen Mary's Hospital, Stratford, and the Medical Officer of Health may at times direct that samples, the examination of which involves special technique, should be sent to other laboratories. It is regrettable that the other large hospitals which are controlled by the Council are not yet able to carry out their own bacteriological work, or to have this work done for them at a municipal laboratory. Many of the specimens from these hospitals are sent to the laboratory of the Clinical Research Association. Panel practitioners may, by arrangement between the West Ham Insurance Committee and Queen Mary's Hospital, have reports on any pathological material submitted by them for examination. Particulars of the examinations carried out at certain hospitals owned by the local authority will be found in the appropriate sections. The Council employs a part-time analyst to carry out the chemical examination of water, milk and other foodstuffs. This officer is also the official analyst under the Fertilisers and Feeding Stuffs Act, 1926. The analyst's report will be found in the section which deals with the supervision of food. 35 Table V. Climatological Summary, 1937. 1937. Air Temperature in Degrees Fahrenheit. Earth Temperature. Means of Mean of A and B Difference from Average. Absolute Extremes. at l foot At 4 feet A Max. B Min. Highest Max. Date. Lowest Min. Date. Lowest Max. Date. Highest Min. Date. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) . (13) (14) °F. °F. °F. °F. °F. °F. °F. ºF. °F. °F. Jan. 46.8 36.3 41.5 40.1 +1.4 53 3.6 24 28 29 31 29 48 3 43.2 45.7 Feb. 48.6 37.8 43.2 40.4 +2.8 57 15 29 12 37 28 49 3 43.0 44.8 Mar. 46.9 33.4 40.1 43.2 —3.1 61 20 24 10 36 8 44 17 41.0 43.5 April 57.5 42.0 49.7 47.5 +2.2 65 3 31 1 48 29 50 10 47.3 46.2 May 65.1 46.7 55.9 54.8 +1.1 82 25.29 39 6 51 9 56 23 52.5 50.1 June 71.1 50.2 60.7 59.7 +1.0 85 11 43 21 61 19 60 12 57.8 54.8 63.5 July 73.7 55.3 64.5 +1.0 89 15 49 30 64 4 62 3. 13. 60.3 57.1 Aug. 77.1 55.9 66.5 63.0 +3.5 92 6 47 16 65 27 63 10 61.6 58.9 Sept. 68.0 48.9 58.5 58.1 +0.4 83 7 38 21 57 11 61 7 58.5 58.7 Oct. 59.1 45.6 52.3 51.3 +1.0 69 1. 2. 36 18 52 13 52 3. 28. 54.1 55.7 Nov. 47.1 36.1 41.6 43.5 —1.9 57 4 24 21 39 21 46 6. 7. 47.4 51.4 Dec. 42.3 34.2 38.3 41.1 —2.8 53 1. 23 25 20 35 20 45 1 42.4 46.1 Totals 703.3 522.4 612.8 50.5 609.1 613.0 Means or Extremes 58.6 43.5 51.1 +0.6 92 6 Aug. 24 10 Mar. 21 Nov. 31 29 Jan. 63 10 Aug. 50.8 51.1 NOTES—The Symbol S against "length of day" indicates that obstructions of altitudes the possible record being the period when the *Precipitation .01 inch or more when measurement is in inches, .2 mm, or If the average refers to a period less than 30 years, the entry in columns 4, 36 Greenwich Observatory. Rainfall. Number of Days. Bright Sunshine. Total Percentage of Average Most in a day Precipitation * Precipitation, Imm. or more Snow and Sleet Snow lying (morning obs.) Haila or Thunder heard Fog (morning obs.) Ground frost Gale force 8 or more. Total. Percentage Amt. Date. of Average of Possible Length of Day. (15) (16) (17) (18) (19) 20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) in. mm. % in. hr. hr. % % hr. 3.40 86.4 43 .52 1 25 17 3 1 0 0 6 14 0 36.5 1.18 1.23 14 8.34 201 96 3.94 100.2 40 .69 7 22 18 1 0 2 0 2 14 0 41.8 1.49 2.07 15 9.89 251 72 2.92 74.1 44 .65 6 18 13 12 1 1 0 1 25 0 91.7 2.96 3.40 25 11.8 168 87 2.44 61.9 37 .47 2 14 12 0 0 0 1 4 6 0 81.9 2.73 4.60 20 13.8 167 59 3.41 86.5 44 .72 20 14 12 0 0 1 2 1 2 0 157.4 5.08 6.32 33 15.5 197 81 1.87 47.6 51 .80 18 11 6 0 0 0 4 0 1 0 171.5 5.72 6.76 35 16.5 93 85 57 6.32 .71 18.0 32 .35 15 9 4 0 0 0 3 0 0 0 117.9 3.80 60 24 16.1 1.69 42.9 56 1.01 30 8 5 0 0 1 4 0 0 0 171.8 5.54 6.05 38 14.5 77 92 1.28 32.4 45 .24 9 14 11 0 0 0 1 2 1 0 144.7 4.82 5.03 38 12.6 72 96 2.32 59.0 64 .61 23 14 8 0 0 1 1 5 7 0 80.9 2.61 3.21 10.7 92 81 24 1.37 34.7 58 .49 1 8 7 0 0 0 0 13 18 0 31.1 1.04 1.59 12 8.86 59 66 3.41 86.5 57 .68 2 19 10 7 0 0 0 7 15 0 13.6 0.44 0.97 6 7.86 152 45 28.76 730.2 506 176 123 23 2 6 16 41 103 0 1140.8 37.41 3.97 12.21 122 3.12 28.75 1.01 30 3.13 79 26 Aug. greater than 3° reduce the possible record for the month by more than 5 per cent.: sun's altitude is above 3°. more when measurement is in millimetres. 33, is underlined. 37 Ambulance facilities. The following; ambulances are available for use by the public, with certain reservations: (a) For general hospital cases (Whipps Cross Hospital) 5 (b) For infectious cases (Plaistow Hospital) 2 (c) For accidents and maternity cases 3 Two of the three ambulances provided for accidents are owned by the Public Health Committee. They are housed, driven, supplied with petrol and oil, and maintained by a contractor in the borough. These vehicles made 2,698 journeys during the year, including 8 at the request of the East Ham Council. The number of journeys made from one address to another in the district was 1,310, whilst 1,388 journeys were made from an address in the borough to an address outside, or vice versa. Of the total number of journeys made by the ambulances, no less than 839 were for accidents occurring either at home, at work, or in the street. These ambulances are only used for accidents and noninfectious cases requiring immediate removal to hospital for treatment or operation, and in the latter cases a medical certificate is required. The total number of persons removed by these ambulances was 2,902. Information regarding the use of these ambulances is brought to the notice of the general public by means of notices which are placed in Council's fire stations, schools, and other public buildings; in addition to this the police are fully aware of the conditions in force, and on a number of occasions they communicate direct with the ambulance stations. The service has been in operation for some considerable time, and the citizens are fully cognisant of the rules and regulations governing the use of the Council's ambulances. Reciprocal arrangements are in force with the County Borough of East Ham and with the Borough of Barking, for the use of their respective ambulances, on call, in cases of emergency. The journeys made under these arrangements during 1937 are as under:— In 24 cases the ambulance of the East Ham Authority was requisitioned for the removal of West Ham cases, and on 8 occasions the West Ham ambulance was used for East Ham cases. In addition to the Public Health Committee's two ambulances, the Highways Committee of the Council has an ambulance stationed at the Silvertown Fire Station in the Silver- 38 town area, which is available daily between the hours of 7 a.m. and 11 p.m. This vehicle is used mainly for accidents occurring in factories in the Silvertown district, and certain factory owners contribute towards the cost of this service. During the year the number of journeys made by this ambulance was 176. There is also in force a reciprocal arrangement between this Council and the London County Council. This service as a whole has, during the year, worked very satisfactorily, and is quite adequate for the district. No complaints which would bear investigation were received during the year in connection with this service. Table VI. gives a summary of the main causes for which the two ambulances owned by the Public Health Committee and used for accidents, etc., were requisitioned. Table VI. Summary of main causes for which ambulances were used. Cause or condition Number of patients removed. Abdominal disorders 262 Accidents 1,109 Cardiac 34 Eye 6 Ear 30 Fits and nervous 130 Diseases of blood vessels 2 Inflamatory 32 Cerebral 18 Haemorrhage 34 Skin 4 Respiratory 205 Rheumatic 20 Maternity 209 Other illnesses 707 Total cases removed 2,902 Professional nursing in the home. Reference is made later to those nurses who are employed whole-time by the Public 39 Assistance Committee, and who work in association with the whole-time district medical officers. No municipal arrangements are made for the nursing of infectious cases in the home. All such cases who require hospital treatment are removed to the Isolation Hospital, Plaistow, or if this hospital is full, to the London Fever Hospital. Apart from these two nurses the greater part of the homenursing in the borough is carried out by voluntary associations. The district nurses of the Plaistow Maternity Hospital take a large share of this work in the borough generally. The Forest Gate area is supplied with nurses from the Beachcroft Road, Leytonstone, branch of the Essex County Nursing Association, and the Silvertown area is supplied through the Tate Nurses (Queen's Nurses) Home, Saville Road, Silvertown. The home nursing of maternity cases is dealt with in a later section. Clinics and Treatment centres. Full particulars of the available facilities will be found in the following sections: Venereal diseases; tuberculosis; maternity and child welfare; mental deficiency and mental disorders. Hospitals. Particulars of the Council's institutions will be found in the following sections: Hospitals; infectious diseases; tuberculosis; maternity and child welfare; mental deficiency; school medical service. In this section some consideration will be given to the provision of general hospital beds—municipal and voluntary—and to voluntary hospitals which fulfil special functions. Smallpox: Dagenham Smallpox Hospital was built in 1899 for the reception of 300 cases of smallpox, but in 1912 it was taken over for the treatment of adult cases of pulmonary tuberculosis, and it is still being used for this purpose. There is accommodation for 128 cases. Any cases of smallpox occurring in this area are removed by arrangements with the London County Council to one of their hospitals. General voluntary hospitals (a) Queen Mary's Hospital, Stratford. This is a modern hospital with complete facilities for the treatment of medical and surgical cases. There are also children's wards, a dental department, electro-therapeutic, actino-therapeutic, and out-patient departments. The total number of beds is 166. 40 (b) St. Mary's Hospital, London Road, Plaistow. I his is a well-equipped hospital for women and children only. There are 71 beds for the treatment of medical and surgical cases, and in addition there is a large out-patient department. Facilities are also available for X-ray examinations, electrical treatment, massage and exercises. (c) Albert Dock Hospital, Connaught Road, E.16. This hospital has accommodation for 53 medical and surgical cases, including 6 beds for the treatment of venereal diseases. It is one of the participating hospitals under the London County Council Scheme for the treatment of venereal diseases, and men only are treated there. (d) Children's Hospital, Balaam Street, Plaistow. This is a small hospital of 36 beds which specialises largely in orthopaedic and nose and throat work. The Borough Council reserve the use of one ward of 16 beds for the use of its own cases, and the Senior Assistant Medical Officer for maternity and child welfare is in charge of this ward. The Council also reserve four beds in the orthopaedic ward. There is a light clinic and an out-patient department. Plans are now being considered for the extension of the hospital and for the provision of a new light clinic. (e) Plaistow Maternity Hospital, Howards Road, E.13. This hospital belongs to the Plaistow Maternity Charity and has accommodation for 60 beds, of which number 48 are used by West Ham patients. Some of the wards are of modern construction. By arrangement with the Public Health Committee and the Committee of the Plaistow Maternity Hospital, the majority of those children born in this hospital, or attended at birth by nurses from this hospital, are visited by nurses from the institution until they reach the age of four years. In addition, the hospital possesses a very extensive district midwifery practice and is incorporated in the Council's scheme under the Midwives Act, 1936. General hospital accommodation for adults and children. As most of the general hospitals admit patients from areas outside West Ham, it is difficult to estimate the actual number of beds for this purpose which are available for the population of the Count) Borough. In Table VII. an attempt has been made to give this information. 41 Table VII. Provision of general hospital beds for West Ham residents: 1937. Hospital. Total number of beds. Total admissions during 1937. Total admissions of West Ham residents in 1937. General hospital beds available for residents. Individual hospitals. Total Municipal: Whipps Cross 800 — 400 Central Home 1,000 500 Forest Gate 659 330 Harold Wood 160 160 1,390 Voluntary: Queen Mary's 166 3,528 1,519 71 St. Mary's 71 1,382 1,006 52 Albert Dock 47 749 192 12 Children's 36 1,030 742 20 (Balaam Street) 155 1,545 This total gives an allowance of 5.95 general hospital beds available per 1,000 of the population of the county borough. It should be noted that the discrepancy between the numbers of beds in columns 2 and 5 in respect of the municipal hospitals is due to a user agreement with the County of Essex and the County Borough of East Ham. This arrangement is referred to in a later section. Institutional provision for unmarried mothers and children. Arrangements exist whereby the unmarried mother is admitted to Forest Gate Hospital for her confinement, and she is allowed to remain there for twelve months to nurse her child. After this the mother is admitted to the Central Home and the child to the Aldersbrook Children's Home. In addition, practically all the facilities provided under the maternity and child welfare scheme are available equally for married and unmarried mothers, and the many social services in Greater London for the care of the unmarried mother and her child are utilised frequently by patients from this borough. 42 Local Government Act, 1929. The Council has not yet availed itself fully of the powers which were conferred upon it by the Local Government Act, 1929. In 1931 Whipps Cross Hospital, Forest Gate Hospital, and the Central Home were transferred from the West Ham Board of Guardians, and the two hospitals and the hospital section of the Central Home were placed under the administrative supervision of the Medical Officer of Health. These institutions still remain under the control of the Public Assistance Committee, and although considerable development has taken place in the quality of the treatment, the mechanism of admission to these hospitals is still essentially that of the Poor Law. Public Assistance domiciliary medical service. In 1930 the Medical Officer of Health was made responsible for the work of the district medical officers, two of whom are whole-time and five part-time officers. The names and surgery addresses of these officers are given below. District Medical Officer. Situation of Surgery. *Dr. T. L. Dolan North West Ham Relief Station, 82 West Ham Lane, Stratford, E.15. *Dr. J. P. Robinson South West Ham Relief Station, Cumberland Road, Plaistow, E.13. Dr. P. G. S. Kennedy 113 Balaam Street, Plaistow, E.13. Dr. J. F. Begley 184 Barking Road, Canning Town, E.16. Dr. R. V. Brews 10 High Street, North Woolwich, E.16. Dr. J. J. McSharry 24 Freemasons Road, Custom House, E.16. Dr. M. J. Murphy 60 Leytonstone Road, Stratford, E.15. Those officers whose names are preceded by an asterisk are whole-time. In the Appendix a full list of the districts of these medical officers is given. The work of the district medical officers during the year 1937 is shown in Table VIII 43 Table VIII. Work of the District Medical Officers. Number of: Men Women Children New cases seen 1,216 2,939 2,851 Total number of cases seen 5,337 16,402 6,835 No. referred by Relief SubCommittee 497 390 312 Attendances at surgery 5,351 15,185 5,436 Sent to institutions: Voluntary hospitals 9 15 7 Whipps Cross Hospital 112 163 105 Mental hospitals 1 3 — Otherwise 2 — 3 Central Home 67 92 20 Forest House — 2 — Forest Gate Hospital — 5 — Aldersbrook Homes — — — Plaistow Hospital 1 2 86 Discharged as no longer in need of treatment 668 1,318 1,504 New cases seen at domiciliary visit 399 1,141 1,159 Fresh cases transferred from: (a) institutions 4 5 5 (b) general practitioners 1 3 1 Total number of domiciliaryvisits paid 1,538 5,714 2,656 Visits paid by district nurses 183 5,015 1,930 Deaths 20 61 7 Total number on register as receiving treatment from D.M. Officers on 1/1/38 234 1,009 371 The number of prescriptions made up during- the year was 4°>435 (7)353 for men, 26,162 for women, 6,920 for children). Mortuary accommodation. There are two mortuaries in the borough—at Stratford and in Canning Town respectively. Particulars of the bodies received into the mortuaries are given in Table IX. 44 Table IX. Bodies received into mortuaries: 1937. Month. Stratford Mortuary. Canning Town Mortuary. Number received. Sex. Age. Admitted. Number of post-mortems. Number of inquests. Total received. Sex. Age. Admitted. Number of post-mortems. Number of inquests. Remaining in Queen Mary's Hospital. Received to mortuary. Total Male. Female. Under 5. Over 5. By Coroner. By Police. On sanitary grounds. Male. Female. Under 5. Over 5. By Coroner. By Police. On sanitary grounds. January 1 19 20 13 7 3 17 16 4 — 15 6 1 1 — — 1 1 - - 1 — February 1 15 16 13 3 2 14 15 1 — 11 5 2 2 — - 2 1 1 - 1 1 March 4 23 27 12 15 3 24 25 2 - 23 6 - - - - - - - - - - April — 6 6 3 3 — 6 5 1 — 5 1 1 1 - — 1 — 1 — — 1 May 5 23 28 15 13 6 22 24 4 - 21 12 2 2 — — 2 1 1 — 2 1 June — 14 14 11 3 3 11 12 2 — 11 7 3 3 — — 3 — 1 2 1 1 July 3 7 10 7 3 1 9 6 4 — 4 7 1 — 1 — 1 - - 1 — — August 2 12 14 8 6 1 13 10 4 — 11 5 5 3 2 — 5 1 - 4 1 — September 3 10 13 8 5 1 12 8 5 — 7 6 - - - - - - - - - - October 1 15 16 12 4 2 14 7 9 — 10 10 - - - - - - - - - - November 1 20 21 15 6 4 17 14 7 — 17 6 2 1 1 - 2 1 - 1 1 - December 2 17 19 10 9 3 16 14 5 — 16 4 2 — 2 1 1 1 — 1 1 — Total ... 23 181 204 127 77 29 175 156 48 — 151 75 19 13 6 1 18 6 4 9 8 4 45 Supply of Insulin. The Council in December, 1935, made provisions tor the supply of insulin, free of charge, to persons who, owing to lack of means, were unable to obtain this facility otherwise. The economic circumstances of each family arc investigated before assistance is given. No applications were received for assistance during the year under review, but there were, at the end of 1937, five persons receiving help under this scheme. The ages of these persons were 58, 55, 15, 12 and 10 years respectively. The total cost to the Corporation for the supply of insulin varied from 10s. 8d. to £11 10s. 7d. per patient. The total cost for the five patients was £21 17s. 6d. Vaccination Acts. The following is a summary of the work carried out during the year 1937: Number of cases in birth lists received during 1937 5,300 Number of certificates of vaccination received 1,215 Number of certificates of postponement owing to: — Health of child 335 Condition of house — Prevalence of infectious disease — Number of certificates under section 2 of the Vaccination Act, 1898, and number of statutory declarations under section 1 of the Vaccination Act, 1907 3,021 Number of certificates of insusceptibility or of having had smallpox 9 Number of cases:— Parents removed out of district 841 Otherwise not found 283 Number of entries in lists sent to public vaccinators 1,396 Shops Acts, 1912-1936. There are now in force seven Acts of Parliament and four sets of Regulations relating to shops and employment in shops, together with various Closing Orders and Half-holiday Orders made under the principle Act of 1912. Three of these seven Acts came into force during the year 1937:— 46 The Shops Act, 1936, which provides for the application of the Acts of 1912 to 1934 to premises and places where the business of lending books or periodicals is carried on for the purpose of gain; The Retail Meat Dealers' Shops (Sunday Closing) Act, 1936, which provides, with certain exceptions, for the compulsory closing of retail meat dealers' shops and stalls on Sunday; and the Shops (Sunday Trading Restriction) Act, 1936, which restricts the opening of shops and trading on Sunday. The Shops Act, 1936, and the Retail Meat Dealers' Shops (Sunday Closing) Act, 1936, came into operation on the 1st January, 1937, the Shops (Sunday Trading Restriction) Act, 1936, came into operation on the 1st May, 1937. The total number of visits made by the shops inspectors during the year was 8,049, and 1,814 infringements were detected. The majority of these were minor irregularities in respect of which 1,497 verbal cautions were given. In cases of a more persistent nature, 254 written warnings were issued, and in 50 cases it was found necessary to institute legal proceedings. The general provisions of the Shops Acts are dealt with by two shops inspectors appointed for this work, and the sanitary inspectors administer those matters for which the sanitary authority are responsible, namely ventilation, temperature, and the provision and maintenance of suitable and sufficient sanitary accommodation. Further particulars of this work are given elsewhere. An analysis of visits paid to shops by the shops inspectors during 1937 is shown in Table X. Swimming bath water. Report by Mr. J. D. Sutton, Superintendent Engineer of the Municipal Baths. Filter plants are now operating in each bathing establishment which contains a swimming pool. The first plant was installed at the Balaam Street baths and consists of four 8 feet filters with pumps in duplicate. In this system the water is aerated before and after filtration; the first operation is effected by gravity, the second by the venturi tube. Sterilisation is by chlorine injected into the water stream, just before its re-entry into the pool. The filters are capable of dealing with 45,000 gallons per hour. The plant at Silvertown baths is housed in the basement, there being no other available space. 47 Table X. Principle Trade. No. of visits. Infringements. Refused to Serve. Action Taken. Notices not displayed. Open after hours. Y.P's. working after Hours Warnings. Summonses. H-H K. E or F H or J Sunday Act, 1936 Weekly H. H. Evening Closing Sunday Closing Verbal Letter Form 1 Form 7 Bakers 351 36 8 18 20 - 4 26 12 6 5 34 116 14 3 Boots and shoes 190 18 4 8 9 - — 5 19 - 9 15 66 6 — Builders' merchants 85 8 — 1 3 - — — 5 4 - 5 18 2 1 Butchers 452 51 5 19 23 — — 33 52 7 14 46 192 10 2 Caterers 225 8 3 7 9 - — — - - - - 24 3 — Carpets, rugs and linos 68 2 — 2 6 — — — 2 — — 4 12 — — Chemists and druggists 193 6 1 3 4 — — — 2 — — 5 14 2 — China and glass 78 1 — 5 6 — — — 2 - - 6 14 — — Cinemas 66 3 — 2 2 - - - - - - - 7 - - Clothiers 188 12 3 11 11 - - 5 16 - 7 8 63 2 - Confectionery and tobacco 878 12 5 19 20 - 19 - 75 - 13 114 126 28 9 Corn merchants 96 2 5 5 6 - - 2 4 - - 5 21 3 - Cycle dealers 139 3 — 4 7 1 - -_ 2 1 2 5 16 4 — Domestic stores 146 2 2 2 3 - - 3 4 5 2 10 19 1 3 Drapers, milleners and mantle dealers 628 17 4 20 19 - - 7 35 15 5 40 91 31 - Fishmongers 214 4 3 5 8 — — — 10 - 2 7 29 3 —. Florists 103 2 4 3 3 — — — 4 - - 6 16 — — Fruit and greengrocery 541 2 2 10 13 11 2 — 65 — 5 87 85 23 2 Furniture 155 2 — 6 4 — — 3 16 1 2 4 32 2 — Grocers and general 849 13 9 24 23 33 7 40 65 3 5 109 118 61 24 48 d Table X. (contd.) Principle Trade. No. of visits. Infringements. Refused to Serve. Action Taken." H.H Notices not displayed Open after hours. Y.P's. working after Honrs Warnings. Summonses. Verbal Letter k. e or F H or J Sunday Act, 1936 Weekly H-H Evening Closing Sunday Closing Form 1 Form 7 Hairdressers and barbers 366 6 4 16 12 - - 7 16 - 2 6 52 11 - Hosiers and hatters 108 — 2 1 1 — — 4 5 — 1 7 10 1 3 Ironmongers 67 — — 1 — — — — 2 — — 2 3 — — Leather and harness 67 — — — — — — 3 2 — — 3 5 — — Libraries 62 2 2 — — — — 4 16 1 — 10 14 10 — Livestock 33 — — — — — — — — — — 1 — — — Mixed 629 11 3 20 19 10 8 7 63 13 6 61 140 19 1 Newsagents and stationers 149 3 2 9 8 12 4 9 8 5 - 21 65 5 - Opticians 45 — — 1 1 — — — — — — — 2 — —• Photos and pictures 57 — — 1 1 — — — 2 — — — 4 — — Public houses 174 7 3 — — — — — — — — — 8 2 — Tailors 160 5 — 3 3 — — 6 12 — 0 9 28 3 — Toys and fancy goods 137 2 3 2 3 — — 3 16 1 1 5 28 2 1 Undertakers and masons 19 1 - - - - - - - - - - - - - Watches, jewellers and pawn brokers 123 - - - - - - 2 4 - - 5 6 - - Wireless and music 208 13 1 8 8 — — 13 13 1 2 15 52 6 1 Totals 8,049 254 78 236 255 67 44 183 549 63 85 655 1,497 254 50 H-h (Half-Holiday) K (Seats for females) E or F (Hours worked by Young Persons) H or J (Abstract of Act 1934) For results of Police Court Proceedings see Section VIII. (Sanitary Circumstances). 49 These filters are rectangular in shape, and possess the disadvantage of having square corners where it has been generally supposed the filtering media can lie undisturbed and thus become foul. However, after three years' continuous use the whole of the filtering media was removed from the beds, and it was found to be perfectly clean and free from stalcness. This is a proof of the efficiency of the modern method of filter washing. This plant is capable of treating 27,000 gallons of water per hour, which has proved sufficient to maintain the water in the pool in a satisfactory condition. The sterilisation plant in this particular case has failed and is beyond repair, so Chloros and Voxsan are added periodically to the water to maintain a free chlorine content of .3 to .5 parts per million. Four filters have been installed at the Romford Road establishment, and for the general work are so arranged that the water from the major pool is treated in two filters, while the water from the minor and model pools passes through the remaining two filters. Both sets are operated by separate pumps and a stand-by set is available for either service. Chlorine and ammonia are available, forming the chloramine treatment for sterilisation. Two pumps operate this service; each is capable of delivering 60,000 gallons per hour. Pipe lines and valves are so arranged that the whole of the plant can be connected to any single pool. Daily tests are taken of the water in each pool, and an endeavour is made to have .3 to .5 parts per million free chlorine available with a PH value of 7. Samples of water have been taken for bacteriological examination. They were found to be satisfactory. For this purpose water was taken from the pool during ordinary bathing periods. Having in mind the value of a high chlorine content in bath water and also of the irritating effect which this has upon bathers, I have for years made a rule of maintaining a free chlorine content in the bath water at the figure previously given, but in addition to that I have added lime direct to the bath on every Sunday morning immediately the pools have been closed to the public. Sufficient lime had been added to bring the free chlorine content up to well over one part per mlilion. Early on Monday morning the pumps start to circulate the water, and by the time the public are admitted the excess chlorine has gone. By this method I am convinced that the water in the pool is rendered safe and free from harmful bacteria. 50 Legislation in force. During the year the following general acts came into force: The Public Health Act, 1936; the Housing Act, 1936; the West Ham Corporation Act, 1937; Shops (Sunday Trading Restriction) Act, 1936; Shops Act, 1936; Retail Meat Dealers Shops (Sunday Closing) Act, 1936. The West Ham Corporation Act was an important measure which became operative on 9th November, 1937. A list of the local acts and regulations which arc in force is contained in the Appendix. Cremation. There is no crematorium in the borough, the nearest being at the City of London Cemetery, Manor Park. It has not so far been possible to obtain particulars of the number of West Ham residents cremated at this and other crematoria. Disinfection. The Council's disinfection station is situated at the Isolation Hospital, Plaistow. The plant consists of two large steam disinfectors, three motor vans, and the staff consists of five men. The plant deals not only with hospital articles which require disinfection, but also with infected articles belonging to the general public and to Harold Wood Hospital. During the year 1937 the total number of articles disinfected was 42,583. Of these, 22,943 were articles belonging to the hospital. Table XI. sets out the type of article disinfected for members of the general public. Table XI. Disinfection of bedding and clothing, 1937. Type of article. Number of articles disinfected. Beds and mattresses 3,606 Pillows and bolsters 6,659 Blankets 3,461 Sheets 1,234 Quilts 1,917 Clothing and other articles 2,763 Total 19,640 51 The number of miles covered by the disinfecting vans during the year was 25,224; this gives an average of 23.3 miles per day for each van. Disinfection of premises and rooms is also carried out by the Public Health Department. There are four disinfectors whose main duty is to disinfect premises and rooms after the removal to hospital, or death, of a patient suffering from an infectious disease, or by request of relatives in the case of non-infectious disease. During the year 1937 the number of premises disinfected was 2,072, and the number of rooms was 2,596. Further details of this work are given in Table XII. Table XII. Disinfection of premises and rooms : 1937. West Ham (North) West Ham (South) Whole borough Number of premises. Number of rooms. Number of premises. Number of rooms. Number of premises. Number of rooms. Scarlet fever 420 475 624 691 1,044 1,166 Diphtheria 193 248 375 443 568 691 Tuberculosis 138 173 134 158 272 331 Vermin 43 79 15 28 58 107 Cancer 10 18 5 5 15 23 Cerebro-spinal fever 3 3 5 5 8 8 Acute poliomyelitis 6 6 5 5 11 11 Enteric fever 10 12 8 8 18 20 Erysipelas 4 5 2 2 6 7 Chicken-pox 1 1 1 1 2 2 Pneumonia 1 1 - - 1 1 Scabies — — l6 26 l6 26 Dysentery — — 1 1 1 1 Hospitals 7 34 13 56 20 90 Schools 5 25 6 56 11 8l Ambulance — — 1 1 1 1 Request 12 20 8 10 20 30 Total 853 1,000 1,219 1,496 2,072 2,596 52 Disinfestation. A lew cases of infestation by beetles, crickets, and ants were brought to the notice of the inspectors who advised use of a preparation of equal parts of sodium fluoride and flour, or one of the proprietary insecticides. With regard to bug infestation, this is dealt with in two ways. In the case of newly let houses the responsibility of cleansing and freeing the premises from these pests is placed on the owner, who is required to remove all detachable woodwork, strip all walls, apply a blow-lamp to all surfaces, and spray with a suitable insecticide or wood naptha. Tenants are advised to wage constant rather than spasmodic warfare and to observe strict cleanliness. The use of soap and water and a suitable insecticide is usually found to be effective. Where the trouble is found to be caused by a dirty tenant a notice is served upon him requiring him to carry out the necessary cleansing. Hydrocyanic acid gas has not so far been sponsored by this authority. Rats. Under the provision of the Rats and Mice (Dectruction) Act, 1919, the clearing of premises of rats and mice rests with the occupier as well as the owner. Every effort is made, however, by the department to assist occupiers in the attempt to exterminate these pests. National Rat Week was observed during the week ended 6th November, 1937. During the week approximately two hundred large posters were obtained and placarded on the Council's various hoardings throughout the district. A supply of the Ministry of Agriculture's bulletin is constantly available, and is issued throughout the year. In addition to this all industrialists were supplied with a reprint, together with a letter from the Medical Officer of Health inviting their co-operation. It should be noted that in West Ham rat infestation is not treated as a seasonal matter. During the year, of the 312 drainage systems which were placed under test, the majority were examined in an effort to trace the source of ingress of rats. In all cases where drains were found to be defective, action was taken and the necessary repairs or reconstruction enforced. From time to time occupiers arc advised regarding rats and informed as to the best methods and baits to use. Extension of local powers. The West Ham Corporation Act came into force on the 9th November, 1937. It contains several 53 clauses which are of importance in connection with the health of the community. These sections may be briefly summarised as follows:— (a) Registration of the premises of hairdressers and barbers, with power to make bye-laws for the good conduct of these trades. (b) Powers in connection with the cutting off and sealing of disused drains. (c) Powers for the removal of aged, infirm, or physically incapacitated persons from insanitary premises. (d) Registration of hawkers of meat, fish, fruit, vegetables, and of the premises used for their storage, with power to refuse or revoke. (e) Registration of premises used for the manufacture of preserved meat, fish, and similar conditions, with power to refuse or revoke. (f) Prohibition of sale of articles to children at school premises. (g) Fencing of vacant land in certain circumstances. (h) Power to search vehicles conveying meat and other articles of food, with power of inspection and seizure of meat in transit. These clauses are being gradually enforced and are already having good effect. 54 II. VITAL STATISTICS. 55 VITAL STATISTICS. In this section, and in the following section which deals with infectious diseases, I have endeavoured to give accurate data extending over a period of years, in most cases to 1876. I have undertaken this rather formidable task because of the extreme scarcity of sources of information for the years previous to 1896. It seemed advisable to place the data on record before the sources disappeared entirely as a result of the passing of time. For some of the earlier years—1887 to 1890—it has been necessary to reconstruct certain data from monthly sources, and for that reason some of these figures may have to be altered slightly in the future. As the data are given for quinquennial periods the corresponding rates should not be materially affected. It is very essential that the figures given in a report dealing with a certain administrative area should be identical with the corresponding figures given by the Registrar-General. This desideratum is not always easy to fulfil. The Registrar-General did not publish statistics for administrative areas until the year 1911, so that the data for previous years given in this report are of local origin. It should be said that, apart from inaccuracies which were common 10 all vital statistics at these early periods, including those published officially, there is no reason to doubt that the data given are substantially correct. In the following two sections—that is, vital statistics and infectious diseases—for the years 1911 onwards, all the data given for individual years are those published officially by the Registrar-General, and for that reason they may be found to differ slightly from the figures given in previous annual reports. For the main statistics of births and deaths it has been found convenient to print the data in two tables, one giving the local figures to 1910, and the other the official figures after that date. A further note should be made regarding the sources for the years previous to 1911. The local figures which were published annually from the year 1876 to the year 1885 were very meagre, 56 but there was a sudden extension of the scope of the data in 1886 and the years immediately following. This w as the period during which the embryo of local statistics was developing those anatomical features which would later distinguish it as a member of a species, capable of adaptation without alteration of its fundamental character. Many of the detailed original records have fortunately been preserved, and missing data have been completed from these sources as far as the available time permitted. To the best of my know ledge no figures were ever published for the war years, and the tables included in this report probably incorporate the first official record of these figures. It is advisable that separate rates for each period should be given for males and females separately, and for the purpose of calculating these rates, I have—by a method briefly referred to later—divided the estimated population for each year into males and females respectively. It is logical to have some standard wherewith to compare local figures, and for this purpose possibly the best standard is the corresponding rates for England and Wales. Unfortunately the vital statistics by sexes for the country as a whole for quinquennial periods have practically never been published officially. "For the sake of completeness I have thought it worth while to calculate all these quinquennial rates for England and Wales for males, females and persons respectively. It should therefore be mentioned that these figures are not taken directly from any official source, and that I am responsible for any errors which may have crept into the calculations.* As all the rates given in these tables are crude rates, they cannot be used to give a complete expression of the changing incidence of deaths from a particular disease throughout the years. This is due to the altering age constitution of the population, local or national. The process of standardization of the rates is beyond the scope of this report. Corresponding rates for the same periods can, however, be used to indicate the relative mortality from the particular disease locally and for the country as a whole fur that period. The data which I have given here will be examined in more detail in later reports, in which I hope to fill some of the gaps in the present tables. *Each quinquennial rate for England and Wales was computed from the summed deaths (or eases) and populations for the live years in the period. The rates are in all cases given correct to the third decimal place, so that accurate rates per million can be obtained b.v shifting the decimal point. 57 POPULATION. The population of West Ham as enumerated at the 1931 census was 294,278 persons, of whom 143,714 were males and 150,564 females. The Registrar-General's estimate of the resident population at the middle of the year was 259,500. The census population of the area of the present county borough is given in Table I. for each of the census years since 1801. The table, which also gives the intercensal changes of the population, will be referred to later. The marks of interrogation which appear in connection with the figures for the first four decennial census enumerations are reprinted direct from the Registrar-General's official census reports for these years. They probably indicate some difficulty in allocating the residence of certain persons to the area which now constitutes the county borough. The estimated mid-year population of the area for each year since 1876 is given in Table 11(a). The populations for the year 1911 and later years are those which are printed officially in the annual reports of the Registrar-General. For the years before 1911—that is, before the populations for administrative areas were given in official reports—the figures are obtained from local sources, although it is probable that most of these estimates were approved by the Registrar-General. As there is for certain diseases an appreciable difference in the mortality of males and females respectively, I have included in this table my estimate of the numbers of males and females respectively in the population at each of these years. These estimates have been made from the population for each year by the application of the mean of two factors derived respectively from the sex distribution of the population in the two adjacent census years. These sex estimates of the population at each year will be used in future for the calculation of rates by sexes. With the exception of the years 1916—1919 inclusive, the populations shown in Table 11(a) have been used in the calculation of the rates in the tables in this and the following section. In the calculation of death rates from all causes and from individual causes of death for the years 1916—1919 inclusive, special adjusted populations given by the Registrar-General were used. These populations, together with my estimate of their distribution by sexes, are shown in Table 11(b). 58 Table I. Census populations and intercensal changes. Area of West Ham County Borough England and Wales Census year Census population Intercensal increase (+) or decrease (-) (persons) Census population (persons) intercensal increase 1+) per cent, (adjusted) Males Females Persons Actual Per cent. 1801 ? 2,941 ? 3,544 ? 6,485 — .— 8,892,536 — 1811 ? 3,703 ? 4,433 ? 8,136 + 1,651 + 25.46 10,164,256 14.00 1821 ? 4,472 ? 5,281 ? 9,753 + 1,017 + 19.87 12,000,236 18.06 1831 ? 5,436 ? 6,144 ? 11,580 + 1,833 + 18.79 13,896,797 15.80 1841 6,087 6,651 12,738 + 1,158 + 10.00 15,914,148 14.27 1851 9,253 9,564 18,817 + 6,079 + 47.72 17,927,609 12.65 1861 19,404 18,927 38,331 + 19,514 + 103.70 20,066,224 11.90 1871 31,384 31,535 62,919 + 24,588 + 64.15 22,712,266 13.21 1881 65,410 63,543 128,953 + 66,034 + 104.95 25,974,439 14.36 1891 102,341 102,562 204,903 + 75,950 + 58.90 29,002,525 11.65 1001 133,498 133,860 267,358 + 62,455 + 30.48 32,527,843 12.17 1911 142,738 146,292 289,030 + 21,672 + 8.11 36,070,492 10.89 1921 146,201 154,659 300,860 + 11,830 + 4.09 37,886,699 4.93 1931 143,714 150,564 294,278 - 6,582 - 2.19 39,952,377 5.52 Table 11(a). West Ham. Estimated mid-year populations. Year Males Females Persons Year Males F emales Persons 1876 53.961 55,298 109,259 1911 141,875 147,726 289,601 1877 55,583 56,958 112,541 1912 143,001 148,899 291,900 1878 56,868 58,276 115,144 1913 144,139 150,084 294,223 1879 59,636 61,111 120,747 1914 144,263 150,213 294,476 1880 61,415 62,935 124,350 1915 144,224 150,172 294,396 1881 64,303 64,650 128,953 1916* 153,492 159,823 313,315 1882 67,769 68,779 136,548 1917* 148,503 154,627 303,130 1883 71,538 72,605 144,143 1918* 144,286 150,237 294,523 1884 75,307 76,430 151,737 1919* 146,957 153,018 299,975 1885 79,077 80,257 159,334 1920 148,145 154,255 302,400 1886 82,850 84,086 166,936 1921 149,185 157,815 307,000 1887 86,616 87,907 174,523 1922 151,115 159,085 310,200 1888 90,385 91,733 182,118 1923 153,161 161,239 314,400 1889 94,154 95,559 189,713 1924 154,622 162,778 317,400 1890 97,924 99,384 197,308 1925 155,158 163,342 318,500 1891 101,982 104,481 206,463 1926 153,891 162,009 315,900 1892 105,636 107,067 212,703 1927 153,648 161,752 315,400 1893 108,735 110,208 218,943 1928 149,507 157,393 306,900 1894 111,834 113,349 225,183 1929 149,848 157,752 307,600 1895 114.933 116,490 231,423 1930 146,779 154,521 301,300 1896 118,032 119,631 237,663 1931 144,897 151,803 296,700 1897 121,131 122,773 243,904 1932 141,283 148,017 289,300 1898 124,231 125,914 250,145 1933 138,157 144,743 282,900 1899 127,330 129,056 256,386 1934 134,861 141,289 276,150 1900 130,430 132,197 262,627 1935 132,199 138,501 270,700 1901 133,516 135,352 268,868 1936 129,806 135,994 265,800 1902 134,116 135,960 270,076 1937 126,730 132,770 259,500 1903 135,196 137,054 272,250 1904 136,276 138,148 274,424 1905 137,355 139,243 276,598 1906 138,435 140,337 278,772 1907 139,514 141,432 280,946 1908 140,594 142,527 283,121 1909 141,674 143,622 285,296 1910 142,754 144,717 287,471 * For special populations for death rates see Table lib. Table 11(b). Adjusted populations for death rates: 1916—1919- Year Males Females Persons 1916 141,075 146,894 287,969 1917 133,220 138,714 271,934 1918 128,774 134,084 262,858 1919 141,074 146,892 287,966 60 Ward population. The enumerated population, classified by sex, in each of the sixteen wards at the 1931 census, together with my estimate of the number of persons in each ward at the middle of 1937, and the actual number of persons at the 1931 census are set out in Table III. Table III. West Ham. Ward population—1931 Census and mid-1937.* Census population Municipal Ward Acres 1931 Estimated ward populatior 1937 1921 Persons Males Females Persons Beckton Road 146 19,916 10,016 9,676 19,692 17,474 Bemersyde 149 14,681 6,555 6,931 13,486 11,487 Broadway 171 15,257 7,024 7,481 14,505 12,489 Canning Town and Grange 495 23,960 13,347 13,583 26,930 24,514 Custom House and Silvertown 901 21,367 10,416 10,096 20,512 18,176 Forest Gate 258 19,445 8,641 10,056 18,697 16,520 High Street 529 18,141 8,910 8,662 17,572 15,420 Hudsons 319 20,195 9,958 10,493 20,451 18,174 New Town 402 18,584 8,509 8,991 17,500 15,348 Ordnance 109 19,995 9,509 9,784 19,293 16,970 Park 285 15,537 7,207 8,365 15,572 13,527 Plaistow 205 21,232 9,645 10,222 19,867 17,607 Plashet Road 151 15,713 6,963 7,649 14,612 12,585 Tidal Basin 181 21,679 11,463 11,221 22,684 20,481 Upton 241 17,660 7,661 9,197 16,858 14,740 West Ham 147 17,498 7,890 8,157 16,047 13,988 Whole borough 4,689 300,860 143,714 150,564 294,278 259,500 * Reprinted in part from Census of England and Wales 1931 by permission of the Controller, H.M. Stationery Office. 61 Table IV. West Ham. Population at ages, grouped by sex and marital condition. 1931 census. Age last birthday (years) Persons Males Females Total Single ATarried Widowed Divor ced Total Single Married Widowed Divor ced 0- 4 24,892 12,624 12,624 — — — 12,268 12,268 — 5- 9 28,827 14,617 14,617 — — — 14,210 14,210 — — — 10-14 27,555 13,918 13,918 — — — 13,637 13,637 — — — 15-19 29,925 14,962 14,926 35 — 1 14,963 14,708 253 2 — 20-24 28,822 14,337 12,308 2,011 18 — 14,485 10,722 3,747 16 — 25-29 24,982 12,415 5,747 6,609 50 9 12,567 4,820 7,665 73 9 30-34 21,279 10,073 1,950 8,008 103 12 11,206 2,328 8,630 228 20 35-39 18,396 8,537 1,040 7,345 132 20 9,859 1,537 7,870 424 28 40-44 17,306 8,101 775 7,126 187 13 9,205 1,166 7,303 712 24 45-49 16,814 7,940 755 6,883 294 8 8,874 906 6,972 977 19 50-54 15,316 7,313 651 6,203 441 18 8,003 730 6,038 1,224 11 55-59 13,213 6,541 512 5,451 569 9 6,672 568 4,674 1,421 9 60-64 10,424 5,092 367 3,998 720 7 5,332 393 3,236 1,698 5 65-69 7,337 3,435 205 2,441 787 9 3,902 278 1,893 1,728 3 70-74 4,844 2,151 102 1,341 703 5 2,693 200 903 1,589 1 75-79 2,782 1,133 51 575 506 1 1,649 123 374 1,152 — 80-84 1,141 408 12 169 227 — 733 49 83 600 ] 85-89 333 97 5 32 60 — 236 20 10 206 — 90-94 80 19 — 5 14 — 61 9 2 50 — 95 and over 10 1 — 1 — — 9 — — 9 _ All ages 294,278 143,714 80,565 58,233 4,811 105 150,564 78,672 59,653 12,109 130 * See footnote to Table III. 62 Age, sex and marital condition. The only basis for any estimate of the number of persons in the population classified in this manner is the census figures. These figures, as enumerated at the 193.1 census, are given in Tables IV. and V. Table V. West Ham. Ac.es (individual years) under 21. 1931 Census* Males Females Age last birthday (years) No. Per cent, of males at all ages No. Per cent of females at all ages O 2,618 1.82 2,381 1.58 1 2,441 1.70 2,573 1.71 2 2.474 1.72 2,448 1.63 3 2,454 1.71 2,405 1.60 4 2,637 1.83 2,461 1.63 5 2,739 1.91 2,691 1.79 6 2,711 1.89 2,718 1.81 7 2,928 2.04 2,846 1.89 8 3,092 2.15 2,923 1.94 9 3,147 2.19 3,032 2.01 10 3,290 2.29 3,153 2.09 11 3,410 2.37 3,359 2.23 12 2,337 1.63 2,199 1.46 13 2,257 1.57 2,207 1.47 14 2,624 1.83 2,719 1.81 15 2,837 1.97 2,769 1.84 16 3,006 2.09 2,994 1.99 17 3,162 2.20 3,008 2.00 18 3,076 2.14 3,141 2.09 19 2,881 2.00 3,051 2.03 20 2,875 2.00 2,966 1.97 0-21 58,996 4I-°5 58,044 38.55 * Based on the figures in the Census of England and Wales, 1951. See footnote to Table III. 63 The average age of males in West Ham at the 1931 census was 29.3 years, and the average age of females was 30.5 years. The corresponding figures for the administrative County of Essex (including the associated county boroughs) were: males, 31.1 years; females, 32.7 years. The number of males per 1,000 females in West Ham was 1,048. The age distribution per 1,000 of each sex in West Ham and in the larger area, as given by the Registrar-General from the figures for the 1931 census, is set out in Table VI. Table VI. Age distribution of males and females. 1931 Census* Age distribution per 1,000 of each sex. Area Males Females 0-4 5-19 20-39 40- 0-4 5-19 20-39 40- West Ham County Borough 88 303 315 294 81 284 320 315 Essex Administrative County (with associated county boroughs) 83 270 319 328 75 246 325 354 * Sec footnote to Table III. Size of population. It will be seen from Tables I. and II. that the population of the area increased slowly but continuously from 1801 to 1831. Between 1831 and 1841 there was a decline in the rate of growth, but in the next decade began the period of very rapid expansion which lasted for over thirty years. The population still continued to increase rapidly, but the rate of growth showed a progressive decrease. The peak year of population growth was reached in 1925, when the estimated population was 318,500. Since that year there has been a steady decline in the resident population. The effect of migration in producing this decline will be briefly discussed in a later section. At present the population of the area is declining by about 6,000 persons per year. 64 MARRIAGES. Owing to the fact that the registration areas are not coterminous with the area of the county borough, data regarding the number of marriages solemnised in the county borough area are not available until the year 1936. In that year the number of marriages which took place in the county borough area was 2,857, which gives a marriage rate of 21.5 per 1,000 of the population, as compared with a rate of 21.5 for the administrative county of London, and a rate of 17.4 for the whole of England and Wales. The marriage rate for West Ham for 1937 was 22.3 per 1,000 of the population. BIRTHS. The births registered during the year 1937 in West Ham numbered 5,305, of which 2,696 were of male children, and 2,609 of females. The inward and outward transfers are shown in Table VII. (supplied by the Registrar-General), and the actual births Table VII. Birth Transfers, 1937. Live births registered (excluding re-registrations) Inward transfers Outward transfers Live births allocated to bo rough (1937) Total live births (legitimate and illegitimate): Males 2,696 205 761 2,140 Females 2,609 177 738 2,048 Total 5,305 382 1,499 4,188 Illegitimate live births: Males 82 10 31 61 Females 76 5 28 53 Total 158 15 59 114 e 65 allocated to the borough consisted of 2,140 males and 2,048 females, making a total of 4,188. Compared with 1936 this represents a decrease of 9 males and an increase of 14 females, or a total increase of 5 births. The birth-rate for 1937 was 16.1 per 1,000 of the population, as compared with a rate of 15.7 for the previous year. Table VIII. West Ham. Birth-rates in Wards, 1937. Municipal Ward Nett live births Illegitimate births Birth rate per 1,000 ward population Increase ( + ) or decrease (-) compared with 1936 rate Male. Female. Male. Female Beckton Road 136 128 5 4 15.1 — I.I Bemersyde 69 78 — — 12.8 — 2.0 Broadway 96 81 2 1 14.2 + 1.1 Canning Town and Grange 163 174 4 3 13.7 — 0.2 Custom House & Silvertown 146 136 3 4 15.5 — 1 .6 Forest Gate 125 121 3 4 14.9 + 1.0 High Street 117 129 3 3 16.0 + 2.5 H udsons 175 141 4 2 17.4 + 3.0 New Town 139 117 3 2 16.7 + 1.1 Ordnance 137 119 3 3 15.1 + 0.5 Park 151 126 2 5 20.5 +0.5 Plaistow 152 169 — 3 18.2 + 1.3 Plashet Road 137 129 2 3 21.1 + 3.1 Tidal Basin 172 168 5 3 16.6 — 1.0 Upton 138 126 4 7 17.9 + 1.7 West Ham 90 103 1 — 13.8 - 3.0 Unallocated — — 17 6 — — Whole borough 2,143 2.045 61 53 16.1 + 0.4 The births in the different wards of the borough are given in Table VIII., together with the estimated birth-rate for each ward and certain particulars regarding illegitimacy. The estimated populations on which these rates are calculated are given in Table III. It will be seen from this table that, generally speaking, there were no marked variations in the birth-rates in the different wards. The lowest rate, 12.8, was in Bemersyde ward, this rate representing a decrease on the 1936 figure. The highest rate, 21.1, occurred in the Plashet Road ward; it represented the highest increase shown by any ward over the 1936 figures. The data in column 7 show that the wards which were most responsible for the increase in the total birth-rate in West Ham for 1937 over that for 1936 were Plashet Road, Hudsons, and High Street. These increases were counterbalanced by certain decreases, notably the marked fall in the birth-rate in West Ham ward. Secular changes in the birth rate. The birth rate for each year since 1876 is set out in Tables IXa and IXb. (The figures given in Table IXb are those published for the area by the Registrar-General.) The birth rate for the country as a whole began to decrease in the year 1877, and since then the declinc has been progressive. The situation is reflected in the experience of West Ham. The highest birth rate—43.3 per 1,000 of the population—occurred in the years 1882 and 1884. Since then the downward trend of the rates has continued, until it is now less than half what it was at the beginning of the century. Rates for quinquennial periods—given in Table X.—show clearly the extent of the decline. The lowest birth rate so far recorded for the area was 15.5 in 1935. The slight increase during the last two years is welcome, but not sufficiently large to be regarded with satisfaction. It may be that the increase is due to an increase in the number of marriages, but the data regarding marriages in the county borough area are meagre. On the other hand the increase in the birth rate must also be viewed in the light of the fact that the population is gradually growing " older," and that therefore, if fertility remained constant, a further decline in the birth rate would be expected. Data for further years will bp required before any tentative conclusions can be reached. 67 Table IX(a). West Haw. Births and birth rates (1876—1910). West Hum. Live births iJirt.ii rate per 1,000 population Year Mules Females Total West Ham London England and Wales 1876 — — 3,894 35.6 35.9 36.3 i 877 — — 4,149 36.9 35.6 36.0 1878 — — 4,491 39.0 35.5 35.6 1879 — — 4,862 40.3 35.5 34.7 1880 — — 5,164 41.5 35.3 34.2 1881 — — 5,488 42.6 34.7 33.9 1882 — — 5,907 43.3 34.2 33.8 1883 — — 6,014 41.7 34.0 33.5 1884 — — 6,563 43.3 33.7 33.6 1885 — — 6,547 41.1 32.6 32.9 1886 — — 7,075 42.4 32.4 32.8 1887 — — 6,865 39.3 31.6 31.9 1888 — — 6,867 37.7 30.7 31.2 1889 — — 6,947 36.6 30.4 31.1 1890 — — 7,063 35.8 30.7 30.2 1891 — — 7,911 38.3 31.9 31.4 1892 — — 8,013 37.7 30.9 30.4 1893 — — 8,026 36.7 30.9 30.7 1894 — — 8,089 35.9 30.2 29.6 1895 — — 8,591 37.1 30.6 30.3 1896 — — 8,519 35.8 30.2 29.6 1897 —. — 8,761 35.9 30.1 29.6 1898 — — 8,750 35.0 29.5 29.3 1899 4,475 4,304 8,779 34.2 29.3 29.1 1900 4,566 4,319 8,885 33.8 29.2 28.7 1901 4,721 4,713 9,434 35.1 29.0 28.5 1902 4,970 4,583 9,553 35.4 28.5 28.5 1903 4,901 4,577 9,478 34.8 28.5 28.5 1904 4,735 4,541 9,276 33.8 27.9 28.0 1905 4,635 4,383 9,018 32.6 27.0 27.3 1906 4,699 4,494 9,193 23.0 26.8 27.2 1907 4,464 4,295 8,759 31.2 25.8 26.5 1908 4,651 4,563 9,214 32.5 25.3 26.7 1909 4,515 4,215 8,730 30.6 24.4 25.8 1910 4,428 4,218 8,646 30.1 25.7 25.1 68 Table IX(b). West Ham. Births and birth rates (1911—1937)- Year Legitimate Illegitimate Total live births Birth rate per 1,000 population Males Females Males Females West Ham London England & Wales 1911 4,274 4,212 120 109 8,715 30.1 24.7 24.4 1912 4,307 4,223 121 105 8,756 30.0 24.7 23.8 1913 4,522 4,278 122 118 9,040 30.7 24.5 23.9 1914 4,488 4,172 112 108 8,880 30 .2 24.3 23.8 1915 4,218 3,952 98 112 8,380 28.5 22.6 22.0 1916 4,197 3,950 109 120 8,376 28.7 21.5 20.9 1917 3,234 3,173 114 107 6,628 21.9 17.9 17.8 1918 2,952 2,795 139 lie 6,002 20.4 160 17.7 1919 3,568 3,262 130 118 7,078 23.6 18.2 18.5 1920 4,805 4,647 149 122 9,723 32.2 26.9 25.5 1921 4,094 3,903 116 129 8,242 26.8 221 22.4 1922 4,004 3,769 93 93 7,959 25.7 20.9 20.4 1923 3,898 3,680 120 105 7,803 24.8 20.1 19.7 1924 3,540 3,461 102 99 7,202 22.7 18.6 18.8 1925 3,505 3,343 94 75 7,017 22.0 17.9 18.3 1926 3,393 3,154 86 77 6,710 21.2 17.1 17.8 1927 2,993 2.840 75 83 5,991 19.0 . 161 16.7 1928 2,939 2,802 87 85 5,913 19.3 16.2 16.7 J 929 2,820 2,773 74 99 5,766 18.7 15.8 16.3 1930 2,834 2,638 63 71 5,606 18.6 15.8 16.3 1931 2,631 2,512 64 59 5,266 17.7 150 15.8 1932 2,490 2,346 68 76 4,980 17.2 14.3 15.3 1933 2,178 2,111 65 52 4,406 15.6 13.2 14.4 1934 2,187 2,038 49 59 4,333 15.7 13.4 14.8 1935 2.045 2,043 51 61 4,200 16.5 13.3 14.7 1936 2,098 2,000 51 34 4,183 15.7 13.6 14.8 1937 2,079 1,995 61 53 4,188 16.1 13.3 14.9 69 Table X. Quinquennial birth rates. Period Total live births Rates per 1,000 living Males Females Persons West Ham England and Wales 1876-1880 — — 22,560 38.8 35.3 1881-1885 — — 30,519 42.3 33.5 1886-1890 — — 34,817 38.2 31.4 1891-1895 — — 40,630 37.1 30.5 1896-1900 — — 43,694 34.9 29.3 1901-1905 23,962 22,797 46,759 34.3 28.2 1906-1910 22,757 21,785 44,542 31.5 26.3 1911-1915 22,382 21,389 43,771 29.9 23.6 1916-1920 19,397 18,410 37,807 25.0 20.1 1921-1925 19,566 18,657 38,223 24.4 19.9 1926-1930 15,364 14,622 29,986 19.4 16.7 1931-1935 11,828 11,357 23,185 16.4 15.0 Birth rates in quarters. The quarterly birth rates for the last ten years are shown in Table XI. Examination of this table shows that for any individual year the lowest birth rate generally occurs in the fourth quarter—a feature which is not confined to West Ham. The gradual manner in which the birth rate is falling does not permit of any definite generalization, but there is some indication that the decline has perhaps been most marked in the first quarter of the year. Illegitimate births. Of the 4,188 births registered, 114— 61 males and 53 females—were illegitimate. This is equal to a percentage of 2.7 of the nett births registered, and to a rate of 0.44 per 1,000 of the population. Corresponding figures for previous years are given in Table XII., from which it will be seen that during the last fourteen years there has been no change in the proportion of registered births which are illegitimate. When compared with the figures for other areas, this proportion must be regarded as low. 70 Table XI. Birth rates in quarters. Year I. II. III. IV. Whole year 1928 20.3 19.4 19.1 18.7 19.3 1929 20.2 18.8 20.0 16.7 18.7 1930 20.0 18.9 18.8 16.9 18.6 1931 17.6 19.0 17.7 16.3 17.7 1932 17.4 17.9 17.0 16.5 17.2 1933 16.9 16.8 15.2 13.5 15.6 1934 16.0 16.5 15.4 15.1 15.7 1935 15.3 15.3 15.9 15.8 15.5 1936 16.6 16.3 15.9 14.4 15.7 1937 16.0 18.0 16.5 14.3 16.1 Table XII. 4 Illegitimate births. Year Illegitimate births Per cent, of liett births registered Rate per 1,000 estimated population 1924 201 2.8 0.63 1925 169 24 0.53 1926 163 2.4 0.52 1927 158 2.6 0.50 1928 172 2.9 0.56 1929 173 3.o 0.56 1930 134 2.4 0.45 1931 123 2-3 0.41 1932 144 2.9 0.50 1933 117 2.7 0.41 1934 108 2.5 0.39 1935 112 2.7 0.41 1936 85 2.0 0.32 1937 114 2.7 044 71 In Table VIII. the illegitimate births are allocated by sex to the different wards of the borough. Owing to certain registration difficulties it has not been possible to allocate in this way all the births accepted by the Registrar-General as illegitimate, and those which have not been so allocated are shown. Stillbirths. The number of stillbirths registered during the year 1937 was 223, of which 123 were males and 100 females. The inward and outward transfers are shown in Table XIII. (supplied by the Registrar-General), and the actual stillbirths allocated to the borough consisted of 80 males and 65 females, making a total of 145. Compared with 1936, this represents a decrease of one male and four female stillbirths. Table XIII. Stillbirth transfers, 1937. Still births registered. Inward transfers. Outward transfers. Still births allocated to borough (1937) Total stillbirths (legitimate and illegitimate): Males 123 7 50 80 Females 100 2 37 65 Total 223 9 87 145 Illegitimate stillbirths: Males 2 — — 2 Females 5 — 1 4 Total 7 — 1 6 The stillbirth rate per total (live and still) births for 1937 was 33.5, as compared with a rate of 34.6 for the previous year. The rate for 1937 may also be expressed as 0.56 per 1,000 of the population at all ages. Of the 145 stillbirths allocated to the borough, 6—or 4.1 per cent.-—were illegitimate. Further details regarding the notification and investigation of stillbirths are given in the section dealing with maternity and child welfare. 72 Comparative figures for the stillbirth rate over a series of years are given in Table XIV. From this table it will be seen that, during the ten years for which information regarding stillbirths is available for West Ham and the country generally, there has been no significant change in the proportion of stillbirths to total births. As the numbers concerned are relatively small, yearly fluctuations are to be expected. It should be noted, however, that there is a slight relative decrease in the number of stillbirths which are illegitimate. Rates or proportions for this feature are apt to be misleading, and they are therefore not given. If the figures do indicate a real decrease in illegitimate stillbirths, they may reflect the increased attention which has been given in recent years to the needs of the unmarried mother. Table XlV. Still births. Year Legitimate Illegitimate Total still births Rate per 1,000 population Rate per 1,000 total births Males Females Males Females West Ilam London England and Wales West Ilam London England and Wales 1927 — — — — — — — 0.64* — — 38* 1928 97 77 6 7 187 0.61 0.54 0.70 31 32 40 1929 97 88 8 2 195 0.63 0.53 0.68 33 32 40 1930 107 71 8 4 190 0.63 0.56 0.69 33 34 41 1931 107 74 5 1 187 0.63 0.50 0.67 34 32 41 1932 82 63 1 3 149 0.52 0.46 0.66 29 31 41 1933 84 68 4 9 165 0.58 0.45 0.62 36 33 41 1934 78 57 4 1 140 0.51 0.44 0.62 31 31 40 1935 58 60 5 2 125 0.46 0.44 0.63 29 32 41 1936 79 69 2 — 150 0.56 0.45 0.61 35 32 40 1937 78 61 2 4 145 0.56 0.54 0.60 33 33 39 * Rates based on figures for half-year only. Comparative birth rates. The average of the birth rates for the twenty greattowns shown in Table XXXIX. is 15.2. The rate for West Ham is considerably above this figure. Six of the other nineteen towns had a rate higher than that of West Ham. 73 DEATHS FROM ALL CAUSES. The gross number of deaths registered in the borough during the year 1937 was 1,745. The number of inward transfers —i.e. the deaths of West Ham residents registered elsewhere— was 1,551, and the number of outward transfers—i.e. deaths of non-residents registered in West Ham—was 189. The nett deaths allocated to the borough are therefore 3,107, which gives a crude death rate of 12.0 per 1,000 of the population. Of these 3,107 deaths, 1,629 were of males and 1,478 of females respectively. The death rates from all causes by sex are therefore 12.9 and 11.1 respectively per 1,000 of each sex living. Table XV. Deaths and infant mortality in wards. Municipal ward. Nett deaths Death rate per 1,000 population (both sexes) Deaths under one year Infant mortality rate per 1,000 live births (both sexes Males Females Male female Beckton Road 111 103 12.25 10 9 72 Bemersyde 68 70 12.01 5 4 61 Broadway 94 75 13.53 4 3 40 Canning Town and Grange 148 100 10.12 20 9 86 Custom House & Silvertown 106 93 10.95 10 4 50 Forest Gate 106 120 13.68 7 6 53 High Street 91 76 10.83. 7 8 61 Hudsons 136 103 13.15 6 5 35 New Town IOI 89 12.38 6 4 39 Ordnance 92 72 9.66 16 9 98 Park 88 101 13-97 9 5 51 Plaistow 105 109 12.15 11 13 75 Plashet Road 62 79 11.20 7 6 49 Tidal Basin 129 85 10.45 14 6 59 Upton 89 123 I4-38 14 10 91 West Ham 103 80 13.08 6 6 62 Whole borough 1,629 1,478 11.97 152 107 62 74 Deaths in wards. The number of deaths and the death rates from all causes in the wards of the borough are given in Table XV. The table also shows the allocation of infant deaths by sex to the different wards. The ward with the highest general death rate was Upton (14.4), while the lowest rate was given by Ordnance ward (9.7). The difference between the highest and the lowest rates (4.7) was somewhat greater than the corresponding difference for the year 1936 (3.9). Deaths in quarters. The quarterly death rates from all causes are shown in Table XVI. The annual death rate has not varied much in this period, but more variation is shown in the quarterly rates. In the last ten years the highest rate has always occurred in the first quarter and the lowest in the third; in certain years the rate for the first quarter has been double that for the third quarter of the same year. Table XVI. Death rate in quarters. Year. I. II. III. IV. Whole year. 1928 13.4 10.4 9.2 10.6 10.9 1929 21 .7 10.0 8.1 11.4 12.8 1930 13.2 10.3 9.0 11.0 10.8 1931 16.1 9.6 8-3 11.8 11.4 1932 15.4 10.4 9.1 11.0 11.5 1933 17.3 10.2 8.4 11.4 11.8 1934 16.2 11.3 8.5 10.8 11.7 1935 12.2 11.0 9.0 11.0 10.8 1936 14.3 10.5 9.6 12.2 11.6 1937 15.9 11.4 8.8 12.5 12.0 Deaths at ages. The actual number of deaths which took place at different periods of life are set out for each year since 1921 in Table XVII. In Table XVIII. the number of deaths in each age group is expressed as a percentage of the total number of deaths in that year. Consideration of this latter table brings out certain features which are perhaps seen here more clearly than in many other areas. The most interesting change is a decrease in the proportion of deaths which occur at the threshold of life, 75 Table XVII. West Ham . Deaths in age groups. Year Ago groups (years) All ages 0— 1— 2— 5— 15— 25— 45— 65— 75— 1921 615 203 82 167 212 460 883 605 485 3,712 1922 641 385 283 165 164 478 865 604 539 4,124 1923 466 110 92 114 189 437 860 575 488 3,331 1924 564 224 198 120 174 404 882 554 532 3,652 1925 463 129 118 111 181 429 841 591 565 3,428 1926 418 134 108 109 169 408 880 609 570 3,405 1927 404 116 114 99 167 411 905 674 591 3,481 1928 380 113 128 129 164 397 806 620 603 3,340 1929 427 138 147 118 214 388 1000 765 729 3,926 1930 353 98 87 102 180 382 855 630 576 3,263 1931 330 70 55 80 157 374 937 722 659 3,384 1932 358 112 84 99 166 325 877 669 623 3,313 1933 284 60 84 105 170 378 903 659 694 3,337 1934 284 104 92 106 171 286 837 694 645 3,219 1935 191 46. 51 68 136 318 776 658 670 2,914 1936 294 59 54 62 116 296 803 709 693 3,086 1937 259 39 47 58 129 273 823 736 743 3,107 say before the age of 15 years, and a marked increase in the proportion of deaths which take place in old age. Both changes reflect the results of improvements in public health measures and probably also the workings of other factors which are more difficult to assess. The child welfare movement has certainly done much to lessen the toll of child deaths, and the general advance of medical services has contributed largely to the postponement of death. From'Table XVIII. it will be seen that in sixteen years the proportion of deaths which occurred below the age of one year was halved, but in the same period there was a substantial increase in 76 Table XVIII. West Ham. Percentage of total deaths in age groups. Year Age groups (years) 0— 1— 2— 5— 15— 25— 45— 65— 75— 1921 16.57 5.47 2.21 4.50 5.71 12.39 23.79 16.30 13.07 1922 15.54 9.34 6.86 4.00 3.98 11.59 20.97 14.65 13.07 1923 13.99 3.30 2.76 3.42 5.67 13.12 25.82 17.26 14.65 1924 15.44 6.13 5.42 3.29 4.76 11.06 24.15 15.17 14.57 1925 13.51 3.76 3.44 3.24 5.28 12.51 24.53 17.24 16.48 1926 12.28 3.94 3.17 3.20 4.96 11.98 25.84 17.89 16.74 1927 11.61 3.33 3.27 2.84 4.80 11.81 26.00 19.36 16.98 1928 11.38 3.38 3.83 3.86 4.91 11.89 24.13 18.56 18.05 1929 10.88 3.52 3.74 3.01 5.45 9.88 25.47 19.49 18.57 1930 10.82 3.00 2.67 3.13 5.52 11.71 26.20 19.31 17.65 1931 9.75 2.07 1.63 2.36 4.64 11.05 27.69 21.34 19.47 1932 10.81 3.38 2.54 2.99 5.01 9.81 26.47 20.19 18.80 1933 8.51 1.80 2.52 3.15 5.09 11.33 27.06 19.75 20.80 1934 8.82 3.23 2.86 3.29 5.31 8.88 26.00 21.56 20.04 1935 6.55 1.58 1.75 2.33 4.67 10.91 26.63 22.58 22.99 1936 9.53 1.91 1.75 2.01 3.76 9.59 26.02 22.97 22.46 1937 8.34 1.26 1.51 1.87 4.15 87.9 26.49 23.69 23.91 the proportion of deaths between the ages of 65 and 75 years, and that after the age of 75 years the proportion was nearly doubled. The table also reflects indirectly the fact that the population is gradually becoming older, and that relatively there are more persons who must succumb at the later ages. Secular changes in the death rate. The death rates of both sexes for the years 1876—1910 are given in Table XIX(a), and in Table XIX(b) full details of deaths and death rates by sexes are set out for 1911 and subsequent years. The highest death rate in the records is that for 1885, viz. 22.0 per 1,000 living, and the 77 Table XIX(a). Deaths and death rates from all causes. Year West Ham deaths Crude death rate per 1,000 population West Ham London Persons England and Wales Males Females Persons Males Females Persons Males Females Persons 1876 - - 1,682 - - 15.4 21.9 22.3 19.6 20.9 1877 - - 1,817 - - 16.1 21.5 21.7 18.9 20.3 1878 - - 2,147 - - 18.6 23.1 22.9 20.3 21.6 1879 - - 2,113 - - 17.5 22.6 22.0 19.6 20.7 1880 - - 2,371 - - 19.1 21.7 21.8 19.3 20.5 1881 - - 2,409 - - 18.7 21.2 20.0 17.8 18.9 1882 - 2,586 - - 18.9 21.3 20.7 18.5 19.6 1883 - - 2,693 — — 18.7 20.5 20.8 18.5 19.6 1884 - - 3,057 — — 20.1 20.4 20.8 18.5 19.7 1885 — — 3,503 — — 22.0 19.7 20.3 18.2 19.2 1886 - - 3,151 - - 18.9 19.9 20.6 18.5 19.5 1887 — — 3,286 — — 18.8 19.5 20.2 18.1 19.1 1888 - — 2,848 — — 15.6 18.4 19.2 17.0 18.1 1889 - — 2,883 — — 15.2 17.5 19.3 17.2 18.2 1890 - — 3,977 — — 20.2 21.0 20.8 18.3 19.5 1891 - - 3,952 - - 19.1 21.1 21.5 19.0 20.2 1892 - - 4,019 - - 18.9 20.3 20.0 18.0 19.0 1893 - — 4,565 — — 20.9 20.8 20.3 18.1 19.2 1894 - — 4,026 — — 17.9 17.4 17.6 15.6 16.6 1895 — — 4,656 — — 20.1 19.5 19.7 17.7 18.7 1896 - - 4,395 - - 18.5 18.2 18.1 16.1 17.1 1897 - - 4,486 - - 18.4 17.8 18.6 16.2 17.4 1898 - — 4,594 — — 18.4 18.3 18.6 16.5 17.5 1899 - — 5,213 — — 20.3 19.4 19.4 17.2 18.2 1900 - — 5,156 — — 19.6 18.7 19.5 17.1 18.2 1901 2,571 2,339 4,910 19.3 17.3 18.3 17.2 18.1 15.8 16.9 1902 2,560 2,298 4,858 19.1 16.9 18.0 17.0 17.4 15.2 16.3 1903 2,387 2.007 4,394 17.7 14.6 16.1 15.2 16.5 14.4 15.5 1904 2,542 2,294 4,836 18.7 16.6 17.6 16.2 17.4 15.3 16.3 1905 2,392 2,182 4,574 17.4 15.7 16.5 15.1 16.3 14.4 15.3 1906 2,427 2,183 4,610 17.5 15.6 16.5 15.4 16.5 14.5 15.5 1907 2,286 2,126 4,412 16.4 15.0 15.7 14.7 16.0 14.2 15.1 1908 2,281 2,083 4,364 16.2 14.6 15.4 14.0 15.8 13.9 14.8 1909 2,285 2,150 4,435 16.1 15.0 15.5 14.2 15.5 13.8 14.6 1910 1,983 1,790 3,773 13.9 12.4 13.1 13.9 14.4 12.7 13.5 78 Table XIX(b). Deaths from all causes (1911—1937). Year West Ham deaths Cr ude death rate per 1,000 population Males Females Persons West Ham London Persons Entrland and Wales Males Females Persons Males Females Persons 1911 2,389 2,180 4,569 16.7 14.9 15.8 15.2 15.6 13.7 14.6 1912 2.244 1,952 4,196 15.6 13.2 14.4 13.8 14.2 12.6 13.4 1913 2,293 1,981 4,274 15.8 13.3 14.5 14.3 14.8 12.9 13.8 1914 2,343 2,090 4,433 16.2 14.0 15.1 14.6 14.9 13.1 14.0 1915 2,529 2,218 4,747 17.5 14.8 16.1 16.8 17.7 14.0 15.7 1916 2,299 1,939 4,238 16.3 1 3.2 14.7 14.7 16.7 12.5 14.3 1917 2,317 1,912 4,229 17.4 13.8 15.6 15.7 17.1 12.1 14.2 1918 2,762 2,705 5,467 21.4 20.2 20.8 19.2 20.1 15.2 17.3 1919 2,034 1,810 3,844 14.4 12.3 13.3 13.6 15.7 12.6 14.0 1920 2,093 1,795 3,888 14.1 11.6 12.9 12.8 13.5 11.5 12.4 1921 2,020 1,692 3,712 13.5 10.7 12.1 12.5 13.0 11.3 12.1 1922 2,155 1,969 4,124 14.3 12.4 13.3 13.5 13.6 12.0 12.8 1923 1,803 1,528 3,331 11.8 9.5 10.6 114 12.4 10.9 11.6 1924 1,913 1,739 3,652 12.4 10.7 11.5 12.2 13.0 11.5 12.2 1925 1,799 1,629 3,428 11.6 10.0 10.8 11.9 12.9 11.4 12.2 1926 1,796 1,609 3,405 11.7 9.9 10.8 11.6 12.4 10.9 11.6 1927 1,805 1,676 3,481 11.7 10.4 11.0 12.1 13.1 11.6 12.3 1928 1,797 1,543 3,340 12.0 9.8 10.9 12.1 12.5 10.9 11.7 1929 2,074 1,852 3,926 13.8 11.7 12.8 14.2 14.2 12.7 13.4 1930 1,745 1,518 3,263 11.9 9.8 10.8 11.6 12.3 10.7 11.4 1931 1,794 1,590 3,384 12.4 10.5 11.4 12.4 13.0 11.6 12.3 1932 1,772 1,541 3,313 12.5 10.4 11.5 12.3 12.7 11.4 12.0 1933 1,843 1,494 3,337 13.3 10.3 11.8 12.5 12.9 11.7 12.3 1934 1,710 1,509 3,219 12.7 10.7 11.7 12.2 12.5 11.1 11.8 1935 1,551 1,363 2,914 11.7 9.8 10.8 11.4 12.5 11.1 11.7 1936 1,664 1,422 3,086 12.8 10.5 11.6 12.3 12.9 11.4 12.1 1937 1,629 1,478 3,107 12.9 11.1 12.0 12.3 13.2 11.7 12.4 lowest rate—10.6—occurred in 1923. Since the war years there has been no marked fluctuation. It should be noted that the rate for 1918 was very little below the highest death rate recorded in the period of this investigation. This high rate was due to the influenza epidemic. The death rates for males have been consistently higher than the corresponding rates for females. These tables show that the death rates compare very favourably with those for London and for the country as a whole. 79 The downward movement of the death rate through the years is shown more clearly in Table XX., which gives the rates in quinquennial periods. In connection with this table and the tables giving the death rates for individual years, it should be noted that there is considerable doubt whether the true death rate at the early part of the period under review was really as low as the rates given here would seem to indicate. For example, it is probable that the low rate of 15.4 in 1876 was due to the fact that the system of transferring deaths to the place in which the patient was ordinarily resident had not then reached the necessary degree of efficiency. Apart from the first quinquennial period shown in Table XX., it is seen that the general death rate for persons exhibits through the next twenty-five years a downward tendency. For the period 1881—1905 this trend was gradual. Then there was a slight but sudden drop, and the death rate was maintained at the new level until the early years after the war. Thereafter there was another marked fall, and from that date the general death rate has tended to become more or less established on its new low plane. The differential death rates for males and females respectively, so far as can be judged from the records at present at my disposal, exhibit corresponding tendencies. These features are also shown, though to a less marked extent, in the death rate of England and Wales as a whole. Adjusted death rates. Since 1934 the Registrar-General has supplied to each authority an area comparability factor (A.C.F.) which compensates for local variations in the age constitution of the population. The use of this factor enables the local crude death rate from all causes to be compared directly with the adjusted death rates for other areas or with the crude rate for the country as a whole. For the year 1934 this factor was 1.15, and there has been no change in succeeding years. The adjusted death rates for the years 1934—37 inclusive are therefore 13.4, 12.4, 13.3, and 13.8 respectively. As judged on this basis the death rates for West Ham are not quite so favourable as those for the country as a whole. 80 Table XX. Quinquennial death rates. Period No. of deaths (West Ilam) Crude death rate per 1,000 living Males Females Persons West Ham England and Wales Males Females Persons Males Females Persons 1877-1880 - - 8,448 - - 17.9 22.1 19.5 20.8 1881-1885 - - 14,248 - - 19.8 20.5 18.3 19.4 1886-1890 - - 16,145 - - 17.7 20.0 17.8 18.9 1891-1895 - - 21,218 — — 19.4 19.8 17.7 18.7 1896-1900 - - 23,844 — — 19.1 18.8 16.6 17.7 1901-1905 12,452 11,120 23,572 18.4 16.2 17.3 17.1 15.0 16.0 1906-1910 11,262 10,332 21,594 16.0 14.5 15.3 15.6 13.8 14.7 1911-1915 11,798 10,421 22.219 16.4 13.9 15.2 15.4 13.3 14.3 1916-1920 11,505 10,161 21,666 16.6 14.1 15.3 16.5 12.8 14.4 1921-1925 9,690 8,557 18,247 12.7 10.6 11.6 12.9 11.4 12.1 1926-1930 9,217 8,198 17,415 12.2 10.3 11.3 12.9 11.4 12.1 1931-1935 8,670 7,497 16,167 12.5 10.3 11.4 12.7 11.4 12.0 Causes of death. The causes of death at all ages and at different periods of life are given in Table XXI., as supplied by the Registrar-General. The chief causes of death in order of importance were as follows (the figures in brackets indicate the percentage of all deaths during the year):—Heart diseases, 787 (25.3); cancer or other malignant disease, 387 (12.5); pneumonia, 250 (8.0); tuberculosis of respiratory system, 203 (6.5); cerebral haemorrhage, 183 (5.9); bronchitis, 146 (4.7); arterial diseases, 118 (3.8). The statistics of these diseases are discussed in greater detail later in this section. 81 Table XXI. Causes of death at ages. 1937. (As supplied by the Registrar-General) Causes of death Sex All ages 0— 1— 2— 5— 15— 25— 35— 45— 55— 65- 75- 1. Typhoid and para- typhoid fever M. 1 ... ... ... ... 1 ... ... .... ... .... ... F. ... .... .... .... .... .... .... .... .... .... ... .... 2. Measles M. l ... .... 1 ... ... ... ... ... ... ... ... F. 3.Scarlet fever M. 1 ... .... ... 1 ... ... ... ... ... ... ... F. 3 ... 1 1 1 ... ... ... ... ... ... ... 4. Whooping cough m. 5 2 2 ... 1 ... ... ... ... ... ... ... F 13 3 4 6 ... .... ... ... ... ... ... ... 5. Diphtheria m. 6 ... ... 2 4 ... ... ... ... ... .... ... F. 12 1 1 3 6 1 6. Influenza m. 49 3 .... 1 ... ... .... 3 15 15 8 4 F. 44 .... .... .... ... ... 4 2 2 10 15 11 7. Encephalitis lcthargica M. 2 ... ... .... ... ... 1 1 ... ... ... ... F. 4 .... .... .... ... ... ... ... 2 2 ... ... 8. Cerebrospinal fever M. 5 3 ... .... 1 ... 1 ... ... ... ... ... F 3 ... ... 1 ... 1 ... ... ... 1 ... ... 9. Tuberculosis of respiratory system M. 127 .... .... 1 .... 27 22 17 28 25 6 .... F. 76 4 ... ... 1 27 19 7 9 7 2 ... 10. Other tuberculous diseases M. 11 ... 5 2 ... 1 ... 2 ... 1 ... ... F. 13 .... 1 1 ... 4 ... 2 ... 1 2 .... 11. Syphilis M. 2 ... .... .... .... ... ... 1 .... 1 ... .... F. 2 .... .... .... .... .... .... ... 1 1 ... .... 12. General paralysis of the insane, tabes dorsalis m. 4 .... .... .... ... ... ... ... 1 2 ... ... F. 2 ... ... ... ... ... .. ... 1 ... 1 ... 13. Cancer, malignant disease m. 181 1 ... .... 1 3 10 4 25 49 54 34 F. 186 .... .... ... 1 ... 5 6 27 59 66 22 14. Diabetes M. 7 ... .... ... 1 1 ... .... ... 2 1 2 F. 22 1 ... .... ... ... .... .... .... 5 9 7 15. Cerebral haemorrhage, etc m. 87 ... .... ..... .... .... ... .... 6 17 35 27 F. 96 .... .... .... ... ... .... ... 7 16 36 36 16. Heart disease M. 384 ... ... ... 4 7 7 13 23 62 144 124 F. 403 ... .... ... 2 5 9 14 29 59 115 170 17. Aneurysm M. 7 .... .... .... ... .... 1 ... 1 3 1 1 F 2 .... .... ... ... ... ... ... ... ... 2 .... 18. Other circulatory diseases M. 47 ... .... .... .... ... ... ... 2 4 19 22 F. 62 ... ... ... ... ... ... ... 2 17 19 24 19. Bronchitis m. 84 8 ... .... .... ... 3 2 9 20 18 24 F. 76 4 .... .... .... ..... .... .... ... 8 18 46 20. Pneumonia (all forms) M. 146 33 16 5 1 2 9 5 22 29 15 15 F. 104 18 10 5 2 2 3 5 9 14 2 14 21. Other respiratory diseases m. 23 .... ... .... ... 2 .... 1 ... 5 9 6 F. 11 ... .... ... .... 1 1 1 1 1 2 4 22. Peptic ulcer M. 26 ... .... .... ... ... 2 4 8 5 4 3 F. 5 ... .... ... .... .... .... ... 1 2 1 1 23. Diarrhoea, etc. M. 34 28 3 .... ... 1 .... .... ... .... .... 1 F 19 16 ... 1 .... 1 ... .... .... ... .... .... 24. Appendicitis m. 13 ... .... .... 4 2 ... 1 3 ... 2 .... F. 5 .... .... .... ... .... ... 2 ... ... 1 .... 25. Cirrhosis of liver M. 6 ... .... .... .... ... ... 1 3 1 1 F. 3 .... .... .... .... .... .... .... 2 .... 1 .... 26. Other diseases of liver, etc M. 3 .... ... .... .... .... .... ... ... ... 2 .... F. 11 ... .... .... ... ... 1 ... l 2 3 4 27. Other digestive diseases M. 26 4 1 1 2 1 2 4 2 4 2 3 F. 21 1 ... ... 4 ... 1 2 2 6 4 1 28. Acute and chronic nephritis M. 51 .... .... ... ... 2 1 2 7 5 38 16 F. 50 ... .... .... .. 3 2 3 5 8 20 9 29. Puerperal sepsis F. 2 ... .... ... ... ... 2 ... ... ... ... ... 30. Other puerperal causes ... ... ... F. 3 .... .... .... ... .... 2 1 ... ... ... .... 31. Congenital debility, premature birth, malformation, etc. M. 59 58 ... .... .... 1 ... ... ... ... ... ... F. 53 50 ... 1 1 ... ... .... ... ... ... ... 32. Senility M. 26 ... .... .... .... ... ... ... .... ... 3 23 F. 38 ... .... ... ... ... ... ... ... 1 3 34 33. Suicide M. 20 ... .... ... .... 1 ... 4 5 5 5 ... F. 7 ... .... .... ... 1 ... .... 1 3 1 ... 34. Other violence M. 59 3 ... 2 3 9 6 5 10 11 3 7 V. 32 1 1 3 3 3 ... 1 2 5 3 10 35. Other defined diseases M. 126 9 ... 4 6 12 8 13 8 17 23 26 F. 95 8 ... 4 6 6 8 9 15 11 16 12 36. Causes ill defined, or unknown m. .. ... ... ... .. ... ... ... ... ... ... ... F. ... .... .... .... ... .... ... ... .... ... ... ... All causes M. 1629 1629 21 20 30 73 74 84 178 285 374 338 F. 1478 107 18 27 28 56 60 55 120 240 362 405 82 Deaths in public institutions. Table XXII. shows particulars of the deaths which took place in the public institutions in the County Borough area during- 1937. Table XXII. Deaths in public institutions. 1937. Under one year One year and upwards Deaths in Council's Institutions. Whipps Cross Hospital 44 587 Central Home — 407 Harold Wood Hospital — 33 Dagenham Sanatorium — 56 West Ham Mental Hospital — 73 Plaistow Fever Hospital 11 37 Forest Gate Hospital 11 24 Deaths in other institutions. Queen Mary's Hospital for the East End 14 52 St. Mary's Hospital, Plaistow 14 21 Plaistow Maternity Hospital 14 4 Royal Albert Dock Hospital — 10 Children's Hospital, Balaam Street 29 2 Other places, e.g. docks, etc — 11 Residents dying in outside institutions 40 271 Totals 177 1,588 Non-residents dying in West Ham institutions 48 143 Nett West Ham deaths occurring in institutions 129 1.445 The above figures show that 50.66 per cent, of the deaths of West Ham residents took place in public institutions. NATURAL INCREASE OF THE POPULATION. The natural increase of the population for any year is the excess of births over deaths, and is normally expressed as an increase per 1,000 of the estimated mid-year population of that 83 year. This figure is important, since it shows to what extent a population is growing by natural means. It does not give any indication of the extent to which the population is growing by immigration or declining by emigration. Table XXIII. gives the mean annual birth rates and death rates for each five year period since the creation of the borough. The table also gives the mean annual natural increase of the population per 1,000 living for each period. Examination of this table will show that, while the disquieting features which are so evident in the figures for the country as a whole are not so marked in the case of West Ham, there are nevertheless several factors which are shown up in their true light when they are examined over periods of several years. The fall in the death rate from all causes is highly praiseworthy, but the maximum extent of this decline—as judged by the difference between the highest and the lowest quinquennial rates—has been in the region of only 42 per cent. The corresponding decline in the birth rate has been 56 per cent. It is obvious that, although the population of West Ham is continuing to grow slightly apart from the influence of immigation, the time is not far distant when the slight natural Table XXIII. Natural increase'of population. Period Mean annual birth rate per 1,000 living Mean annual death rate per 1,000 living Natural increase per 1,000 living West Ham England and Wales 1887-1890 37.3 17.5 19.8 12.5 1891-1895 37.1 19.4 17.7 11.8 1896-1900 34.9 19.1 15.9 11.6 1901-1905 34.3 17.3 17.0 12.1 1906-1910 31.5 15.3 16.2 11.6 1911-1915 29.9 15.2 14.7 9.3 1916-1920 25.0 14.3 10.7 5.7 1921-1925 24.4 11.6 12.7 7.7 1926-1930 19.4 11.3 8.1 4.6 16.4 l1 .4 5.0 3.0 j936 15.7 12.1 4.1 2.2 1937 16.1 I2.4 4.2 — 84 increase will be transformed to a decrease. Even at the present time the rate of growth is greater than that for the country as a whole, but this comparison hardly serves as a compliment to the capacity for increase of the population of the borough. INFANT MORTALITY. The infant mortality of the area is summarised by sexes in Table XXIV. This table shows that the highest mortality in infants under one year of age was reached in the quinquennial period 1896-1900, when the rate was 182 per 1,000 live births, The rate for the country as a whole was also very high during this period. The fact that the rates for the preceding quinquennial periods were lower than this is possibly due to the fact that infants who were almost one year old at death were registered as having been "1 year old," and that hence a number of infants who died were classified in the next highest age group. A substantial decline occurred in the war years, and since 1920 the decline has been maintained and on the whole accelerated. It is worthy of note that in all but the most recent years of the post-war period the quinquennial rates for West Ham have been lower than those for England and Wales. The mortality rates for male infants has been consistently higher than the corresponding rates for female infants. The infant mortality rate for the year 1937 was 62 per 1,00c live births. The highest rate in the records—though, as explainec above, not necessarily the highest true rate—was 201 in 1899 The lowest rate so far recorded was 45 in 1935. The infant mortality rates, according to the legitimacy or illegitimacy of the infant, are set out in Table XXV. It is seer from this table that in West Ham in recent years the rate for illegitimate infants is approximately double that for legitimate infants. Apart from the immediate post-war years there has no1 been any considerable change in this ratio. The experience of the County of London approaches very closely to that of West Ham The same feature was seen in the country as a whole, but in recent vears there has been a tendency for the rate for illegitimate infants to approximate to that for legitimate infants These figures are sufficient to suggest that the illegitimate child does run a substantially greater risk of death in infancy. Too much importance should not be attached to comparisons betweer 85 Table XXIV. Infant mortality. Period West Ham England and Wales Rate per 1,000 live births Deaths under one year Rate per 1,000 live births Males Females Infants Males Females Infants Males Females ants 1877-1880 — — 2,744 — — 147 159* 130* 145* 1881-1885 — — 4,621 — — 151 152 125 139 1886-1890 — — 4,737 — — 136 159 131 145 1891-1895 — — 6,378 — — 157 165 135 151 1896-1900 — — 7,935 — — 182 170 141 156 1901-1905 — — 7,426 — — 159 151 124 138 1906-1910 — — 5,652 — — 127 129 105 117 1911-1915 2,754 2.242 4,996 123 105 114 121 97 110 1916-1920 2,036 1,524 3,560 105 83 94 101 79 90 1921-1925 1,573 1,176 2,749 80 63 72 86 66 76 1926-1930 1,138 844 1,982 74 58 66 77 59 68 1931-1935 845 602 1,447 71 53 62 70 1 54 62 1921 358 257 615 85 64 75 93 72 83 1922 358 283 641 87 73 81 87 66 77 1923 272 194 466 68 51 60 78 60 69 1924 319 245 564 88 69 78 85 65 75 1925 266 197 463 74 58 66 84 66 75 1926 236 182 418 68 56 62 79 61 70 1927 235 169 404 77 58 67 79 60 70 1928 207 173 380 68 60 64 74 56 65 1929 256 171 427 88 60 74 83 65 74 1930 204 149 353 70 55 63 68 51 60 1931 194 136 330 72 53 63 75 57 66 1932 215 143 358 84 59 72 73 56 65 1933 164 120 284 73 55 64 72 55 64 1934 172 112 284 77 53 66 65 51 59 1935 100 91 191 48 43 45 64 50 57 1936 164 130 294 76 64 70 66 50 59 1937 152 107 259 71 52 62 65 50 58 * Based on the period, 1876—1880. 86 local illegitimate rates, such as those for West Ham or London, and those for the country as a whole, since the local rates are calculated on a very much smaller number of births and deaths. Infants' deaths at ages. The actual numbers of deaths of infants at different periods of the first year of life are set out for a series of years in Tables XXVI. and XXVII. These tables will be subjected to more detailed analysis later. Meanwhile, it may be said that the table which deals with all infants shows that the decrease in the infant mortality rate which has occurred since 1921 Table XXV. Infant mortality bv legitimacy. Year Rate per 1,000 live births West Ham London England and Wales Legitimate Illegitimate Total Legitimate Illegitimate Total Legitimate Illegitimate Total 1911 141 125 244 130 125 245 130 1912 — 103 87 209 91 91 181 95 1913 — — 107 100 238 106 104 213 108 1914 — — 107 98 260 104 100 207 1 05 1915 — — 112 106 261 112 105 203 110 1916 100 83 231 89 87 183 91 1917 - - 107 94 275 104 90 201 96 1918 109 239 115 97 260 108 91 186 97 1919 81 230 86 77 233 85 84 173 89 1920 70 159 74 71 197 76 76 156 80 1921 72 155 75 76 199 81 79 158 83 1922 79 140 81 71 163 75 7.4 139 77 1923 58 120 60 58 139 61 67 132 69 1924 77 124 78 66 144 69 73 133 75 1925 65 118 66 65 148 68 72 136 75 1926 61 117 62 60 150 64 68 130 70 1927 67 70 67 56 132 59 67 120 70 1928 62 145 64 63 145 67 63 115 65 1929 72 133 74 68 133 71 72 126 74 1930 62 97 63 56 114 59 58 105 60 1931 61 138 63 62 121 65 64 111 66 1932 70 125 72 63 137 67 63 112 65 1933 64 85 64 56 127 60 62 107 64 1934 65 102 66 64 130 67 57 95 59 1935 44 89 45 55 114 58 56 90 57 1936 68 188 70 63 114 66 57 88 59 1937 60 114 62 57 119 60 56 88 58 87 has been due largely to a decline in the rate of mortality over the first month of age. There is really no significant difference between the rates for deaths in the first month—the neo-natal period. It has been recognised for some time that a further reduction in the infant mortality rate will probably only be affected satisfactorily by an attack on the mortality at this early period. More detailed Table XXVI. West Ham. Infant mortality—all infants. Year Deaths at ages Deaths per 1.0C0 live births Legitimate deaths Under 1 day 1—7 days 1—4 weeks 4 weeks to 3 m'this 3—6 m'ths 6-9 m'ths 9—12 m'ths Total under 1 year Under 4 weeks Total under 1 year 1921 89 73 89 104 118 78 64 615 30 75 577 1922 68 52 93 111 98 95 124 641 27 81 615 1923 86 68 55 81 91 48 37 466 27 60 439 1924 55 67 64 100 96 83 99 564 26 78 539 1925 51 57 65 90 85 62 53 463 25 66 443 1926 51 60 54 64 63 64 62 418 25 62 399 1927 44 54 51 49 71 72 63 404 25 67 393 1928 57 47 46 65 69 47 49 380 25 64 355 1929 43 48 43 71 92 75 55 427 23 74 404 1930 46 50 32 68 55 63 39 353 23 63 340 1931 51 38 27 71 65 42 36 330 22 63 313 1932 42 53 54 59 64 45 41 358 30 72 340 1933 47 42 25 43 46 45 36 284 26 64 274 1934 36 33 40 40 50 40 45 284 25 66 273 1935 34 36 19 30 36 21 15 191 21 45 181 1936 34 32 48 44 48 52 36 294 27 70 278 1937 36 32 23 57 51 34 26 259 22 62 246 88 consideration of the question cannot be given in this report, but it may be said that many of the deaths at this early age do not fall within the category of "preventable diseases," and that methods of attack must be concerned with the welfare of the infant before birth and of the pregnant mother. The data for illegitimate infants are so scant}' that conclusions cannot be readily drawn from them. Table XXVII. West Ham. Infant mortality: illegitimate infants. Year Deaths at ages reaths per 1,000 live births Under 1 (lay 1—7 days 1—4 weeks 4 weeks to 3 m'ths. 3-6 m'ths. 6—9 m'ths. 9—12 m'ths. Total under 1 year Under 4 weeks Total under 1 year 1921 9 1 5 6 12 1 4 38 61 155 1922 5 2 2 7 5 3 2 26 48 140 1923 8 3 1 6 4 3 2 27 53 120 1924 2 4 3 4 3 7 2 25 45 124 1925 6 3 1 5 2 1 2 20 59 118 1926 6 2 — 4 2 2 3 19 49 117 1927 2 4 1 — 2 1 1 11 44 70 1928 6 4 2 4 4 3 2 25 70 145 1929 5 2 2 6 5 2 1 23 52 133 1930 2 — - 3 4 2 2 13 15 97 1931 6 1 1 5 2 1 1 17 65 138 1932 4 4 1 4 3 1 1 18 63 125 1933 3 4 — — 1 — 2 10 60 85 1934 2 2 3 — 1 1 2 11 65 102 1935 2 — 2 1 2 3 — 10 36 89 1936 4 2 1 1 4 2 2 16 82 188 1937 1 2 2 3 4 — 1 13 44 114 89 Table XXVIII. West Ham. 1937. Causes of deaths in infancy and childhood. Cause of death Sex Under one month Under one year Under one day 1—7 days 1 and under 2 weeks 2 and under 3 weeks 3 and under 4 weeks Total under one month 1 and under 3 months 3 and under 6 months 6 and under l2 months Smallpox M. .... .... .... .... .... .... .... .... ... F. .... .... ... ... ... ... ... ... ... Chickenpox M. .... ... ... ... ... ... ... ... ... F. ... .... ... ... ... ... ... ... .. Measles M. .... ... ... ... ... ... .... .... ... F. .... .... .... .... ... .... .... .... ... Scarlet fever M. ... .... ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... ... ... Whooping cough M. .... .... .... ... .... ... ... 1 1 F. ... .... .... .... .... .... ... ... 3 Diphtheria M. ... .... .... ... .... ... .... ... .... F ... .... .... .... ... ... ... ... ... Influenza M. ... ... ... ... ... ... ... ... ... 3 F. ... .... .... .... .... ... ... ... Erysipelas M. ... .... .... ... .... ... ... 1 ... F ... .... ... ... ... ... ... ... ... Meningitis (tuberc.) M. .... .... .... .... .... .... 1 .... .... F. .... .... .... ... .... ... .... ... .... Tabes mesenterica and tuberc. peritonitis M. F. ... .... .... .... .... .... .... .... ... Respiratory tuberculosis M. .... .... .... .... .... .... .... ... .... F. ... .... .... ... .... .... .... 2 2 Other tuberculous diseases M. .... .... .... .... .... .... .... .... .... F. ... .... .... .... .... .... ... ... ... Meningitis (nontuberculous) M. .... .... .... .... .... ... ... 1 2 F. .... .... .... .... .... 1 ... ... ... Nervous diseases (other) M. ... .... ... ... .... ... 1 ... ... F ... .... ... ... ... ... Diarrhoea and enteritis M. ... .... .... .... ... 2 7 111 ... F. ... ... ... ... ... ... 4 3 9 Gastritis M. .... .... ... ... ... ... 1 ... ... F. ... ... .... ... ... ... ... ... 1 Hernia and intestinal obstruction M. ... .... .... ... ... ... 1 1 1 F. ... ... ... .... ... ... ... ... 1 Icterus M. ... .... .... .... ... .... ... .... ... F ... ... ... ... ... ... ... ... .... ... .... .... .... ... ... ... ... ... Umbilical diseases M. ... ... ... ... ... ... ... ... ... Bronchitis F. M. ... .... ... ... ... 2 4 2 ... F. ... .... ... .... .... ... 1 3 ... Pneumonia (all forms) M. ... 1 ... ... ... 3 7 7 16 F. ... .... ... ... ... ... 8 5 5 Other respiratory diseases M. F. ... .... .... ... ... ... ... ... ... Rickets M. ... .... ... .... .... .... ... ... ... F. ... .... .... ... ... ... ... ... 1 Syphilis M. ... ... ... ... ... ... ... ... .. F. ... ... ... .... ... Convulsions M. 1 ... ... ... ... 1 3 1 ... Congenital malformations F. ... ... ... ... ... ... .... 1 1 M. 2 4 ... ... ... 7 1 1 .... Prematurity F 2 2 4 4 2 2 M. 10 8 4 2 ... 24 5 ... ... Injury at birth F. 10 13 2 1 ... 27 2 ... ... M. ... ... ... ... ... ... 2 ... ... Atelectasis F. .... ... ... ... ... ... ... ... ... M. 3 3 ... .... ... 6 1 ... ... Atrophy, debility and marasmus F. 4 2 ... .... .... 6 ... ... ... M. 1 ... .... 1 ... 2 3 6 ... F. ... ... ... ... ... 1 ... 1 .... Found dead in bed (overlaying) M. ... .... ... ... ... ... ... ... .. F ... ... ... ... ... ... ... ... ... Suffocation M 1 ... ... ... ... 1 ... ... ... F ... ... .... ... ... ... ... ... ... Violence (other forms) Other defined diseases M. 1 ... ... ... ... 2 ... ... ... F. 1 ... .... ... ... 1 ... ... ... M ... .... ... ... ... ... ... 2 ... F ... .... ... ... ... ... 1 ... 1 III-defined M. .... .... .... ... ... ... .... ... ... F. ... ... .... ... ... ... ... ... ... All causes M. F. 19 17 17 15 5 4 6 3 3 2 50 41 36 21 34 17 32 28 90 Table XXVIII. (continued) West Ham. 1937. Causes of deaths in infancy and childhood. Cause of death Sex Total under 1 year One year and under five years Total under five years 1 and under 2 years 2 and under 3 years 3 and under 4 years 4 and under 5 years Total 1—5 years Smallpox M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Chickenpox M. ... ... ... ... ... ... ... F ... ... ... ... ... ... ... Measles M. ... ... ... 1 ... 1 1 F. ... ... ... ... ... ... ... Scarlet fever M. ... ... ... ... ... ... ... F. ... 1 1 ... ... 2 2 Whooping cough M. 2 2 ... ... ... 2 4 F. 3 4 2 4 ... 10 13 Diphtheria M. ... ... 2 ... ... 2 2 F. 1 1 2 1 ... 4 5 Influenza M. 3 ... 1 ... ... 1 4 F. ... ... ... ... ... ... ... Erysipelas M. 1 ... ... ... ... ... 1 F. 1 ... ... ... ... ... 1 Meningitis (tuberc.) M. ... 4 ... ... 2 6 6 F. ... 1 ... ... 1 2 2 Tabes mesenterica and tuberc. peritonitis M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Respiratory tuberculosis M. ... ... ... 1 ... 1 1 F. 4 ... ... ... ... ... 4 Other tuberculous diseases M. ... 1 ... ... ... 1 1 F. ... ... ... ... ... ... ... Meningitis (nontuberculous) M. 3 ... 1 1 ... 2 5 F. 1 ... 1 1 ... 2 3 Nervous diseases (other) Diarrhoea and enteritis M. 1 ... ... ... ... ... 1 M. 28 3 ... 1 ... 4 32 Gastritis F. 16 ... 1 ... ... 1 17 M. 1 ... ... ... ... ... 1 F. 1 ... ... ... ... ... 1 Hernia and intestinal obstruction M. 3 ... ... ... ... ... 3 F. 2 ... ... ... ... ... 2 Icterus M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Umbilical diseases M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Bronchitis M. F. 8 4 ... ... ... ... ... 8 4 Pneumonia (all forms) M 33 10 1 2 ... 15 48 F. 18 10 3 ... ... 15 33 Other respiratory diseases M. ... ... ... ... ... ... ... F ... ... ... ... ... ... ... Rickets M. ... ... ... ... ... ... ... F. 1 ... ... ... ... ... 1 Syphilis M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Convulsions M. 6 ... ... ... ... ... 6 F. 2 ... ... ... ... ... 2 Congenital malformations M. 9 ... ... ... ... ... 9 F. 12 ... 1 ... ... 1 13 Prematurity M. 29 ... ... ... ... ... 29 F. 30 ... ... ... ... ... 30 Injury at birth M. 2 ... ... ... ... ... 2 F. ... ... ... ... ... ... ... Atelectasis M. 7 ... ... ... ... ... 7 F. 6 ... ... ... ... ... 6 Atrophy, debility and marasmus M. 11 ... ... ... ... ... 11 F 2 2 Found dead in bed (overlaying) M ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... Suffocation M. 1 ... 1 ... ... 1 2 F ... ... ... ... 1 1 1 Violence (other forms) M. 2 ... ... ... 1 1 3 F. 1 i ... ... ... 3 4 Other defined diseases M. 2 1 1 ... 2 4 6 F. 2 ... 2 2 ... 4 6 Ill-defined M. ... ... ... ... ... ... ... F. ... ... ... ... ... ... ... All causes m. 152 21 7 6 7 41 193 f. 107 18 14 9 4 45 152 91 Details of the causes of the deaths of infants and of young children are given in Table XXVIII. This table brings out the fact that, of the 259 deaths under one year, no fewer than 154, or 59.5 per cent., were due to three causes. These three causes— diarrhoea and enteritis, pneumonia, and prematurity—are a potent cause of death at the beginning of life. Prematurity caused 59 deaths, pneumonia 51, and enteritis 44. The mortality in the two zymotic groups was relatively much greater in male than in female infants, but in the case of prematurity there was no difference in mortality between the sexes. With reference to age, the greatest number of deaths from pneumonia occurred between 1 and 3 months and between 6 and 12 months. The mortality under one month was low. The mortality from enteritis was most noticeable after the first month of age. The majority of the deaths from prematurity occurred under one month of age, and nearly 79 per cent, of these neo-natal deaths occurred during the first week of life. Reference to another section will show that there has been a considerable decrease in the mortality from infectious diseases among young infants, and that this decrease has been most striking in the case of diarrhoeal diseases. It is possible that we are reaching the lower limit of mortality from this condition. Nevertheless, it is striking that a considerable reduction in the death rate from diarrhoeal diseases and from pneumonia would effect a very marked improvement in the infant mortality rate. These remarks apply equally to the country as a whole. Consideration of the congenital group of conditions— namely, congenital malformations, prematurity, injury at birth, and atelectasis—will show that this group contributed 95 deaths, or 36.7 per cent. towards the total. Further reduction in the mortality from this group lies in the realm of ante-natal care. Of the 86 deaths between the ages of one and five years it is notable that pneumonia contributed 30, or 34.9 per cent. towards the total. Of the other diseases which contributed relatively largely, whooping-cough, tuberculous meningitis, and diphtheria were the most important. 92 MATERNAL MORTALITY. The number of women who died in childbirth in 1937 was 5. Two of these deaths were due to sepsis, and three to other conditions associated with childbirth. 1 he maternal mortality rate for all causes was 1.15 per 1,000 births. This is the lowest rate in my records. Detailed figures for the maternal mortality of the area are set out in Table XXIX. It will be seen from this table that, although the trend of the rate has generally been downward since 1896, the decline has not been continuous, and within the last twenty years there has even been a slight rise. The true significance of these facts is brought out by comparing the West Ham rates with the rates for the country as a whole. Throughout the whole of the period since 1896 the maternal mortality rate for West Ham has been considerably below the corresponding rate for England and Wales, and in the period since 1921 especially the latter rate has been almost double that for the borough. Even more important is the fact that the death rate from puerperal sepsis has nearly always been considerably below the sepsis rate for the country as a whole. In view of the fact that where figures for an individual authority are being considered, one additional death may give a substantial increase in the rate, this consistently low mortality is very satisfactory. Recent years have rightly seen much increase in propaganda directed towards the reduction of maternal mortality, and it is not unknown for a certain area to have no maternal deaths in one year. Yet for the country as a whole there is probably an irreducible minimum, below which the maternal mortality rate cannot be expected to remain consistently. In an area of any size, therefore, a rate which remains persistently below that for the standard area of the country as a whole must be a better indication of the excellence of the results than evidence provided by isolated low rates in a series of years. The notifications of puerperal fever and puerperal pyrexia, and the case rates for these conditions, are given in Table XXX. The latter condition was made notifiable in 1927. It is satisfactory to note that the percentage of puerperal fever patients who are treated in hospital has been rising steadily in the last 40 years. 93 Table XXIX. Maternal mortality. Period West Ham No. of deaths Mortality per 1,000 births.' West Ham England and Wales. Puerp. sepsis. Other puerp. All causes Puerp. sepsis. Other puerp. All causes Puerp. sepsis. All causes 1896-1900 37 111 148 0.85 2.54 3.39 2.12 4.69 1901-1905 54 92 146 1.15 1.97 3.12 1.95 4.27 1906-1910 32 64 96 0.72 1.44 2.16 1.56 3.74 1911-1915 36 60 96 0.82 1.37 2.19 1.42 4.03 1916-1920 42 44 86 1.11 1.16 2.27 1.51 4.12 1921-1925 34 56 90 0.89 1.47 2.35 1.40 3.90 1926-1930 41 34 75 1.37 1.13 2.50 1.73 4.27 1931-1935 31 31 62 1.34 1.34 2.68 1.69 4.13 1921 4 12 16 0.49 1.46 1.94 1.38 3.92 1922 6 12 18 0.75 1.51 2.26 1.39 3.81 1923 11 13 24 1.41 1.67 3.08 1.30 3.82 1924 5 7 12 0.69 0.97 1.67 1.39 3.90 1925 8 12 20 1.14 1.71 2.85 1.56 4.08 1926 9 4 13 1.34 0.60 1.94 1.60 4.12 1927 9 9 18 1.50 1.50 3.00 1.57 4.11 1928 6 7 13 0.98 1.15 2.13 1.72 4.25 1929 8 7 15 1.34 1.17 2.52 1.73 4.16 1930 9 7 16 1.55 1.21 2.76 1.84 4.22 1931 7 9 16 1.28 1.65 2 93 1.59 3.95 1932 9 6 15 1.75 1.17 2.92 1.55 4.04 1933 5 3 8 1.09 0.66 1.75 1.75 4.32 1934 4 5 9 0.89 1.12 2.01 1.95 4.41 1935 6 8 14 1.39 1.85 3.24 1.61 3.94 1936 3 5 8 0.69 1.15 1.85 1.34 3.65 1937 2 3 5 0.46 0.69 1.15 0.94 3.13 * The rates are given per 1,000 live births up to and includins 1927. From 1928 onwards they are per 1,000 total (i.e. live and still) births. 94 Table XXX. Notifications of puerperal fever and puerperal pyrexia Period Puerperal fever Puerperal pyrexia Cases Removed to Cases Removed to No. Rate hospital No. Rate hospital No. Per cent. No. Per cent. 1896-1900 67 1.53 3 4.48 — — — — 1901-1905 83 1.78 9 10.84 — — — — 1906-1910 65 1.46 19 29.23 — — — — 1911-1915 59 1.35 36 61.02 — — — — 1916-1920 61 1.61 24 39.34 — — — — 1921-1925 61 1.60 41 67.21 — — — — 1926-1930 101 3.31 65 64.36 296 12.41 166 56.08 1931-1935 61 2.55 51 83.61 230 9.60 141 61.30 1921 8 0.97 5 62.50 - - - - 1922 12 1.51 3 25.00 — — — - 1923 16 2.05 14 87.50 — — - — 1924 15 2.08 13 86.67 — - — 1925 10 1.43 6 60.00 — — — — 1926 20 2.98 13 65.00 - - - - 1927 17 2.84 16 94.12 70 11.68 36 51.43 1928 27 4.43 17 62.96 94 15.41 46 48.94 1929 17 2.85 10 58.82 64 10.74 43 67.19 1930 20 3.45 9 45.00 68 11.73 41 60.29 1931 14 2.57 11 78.57 63 11.55 37 58.73 1932 14 2.73 11 78.57 47 9.16 28 59.57 1933 15 3.28 13 86.67 26 5.69 20 76.92 1934 10 2.24 8 80.00 46 10.28 29 63.04 1935 8 1.85 8 100.00 48 11.10 27 56.25 1936 17 3.92 15 88.24 44 10.15 33 75.00 1937 4 0.92 4 100.00 75 17.31 55 73.33 * The rates are given per 1,000 live births up to and including 1927. From 1928 onwards they are per 1,000 total (i.e. live and still) births. 95 DEATHS FROM RESPIRATORY DISEASES. This group of diseases covers diseases of the nasal passages, diseases of the larynx, bronchitis, all forms of pneumonia, pleurisy (including empyema), asthma, congestion and emphysema of the lungs. For practically the whole of the period covered by the table it refers to those diseases at present included in Nos. 104 to 114 inclusive of the International List—or their equivalent. During the year 1937 the number of deaths from this group of diseases was 444, of which 253 were of males and 191 ol females. This number was a considerable increase on the figure for the previous year, and was the highest since 1933. The rate per 1,000 living was .1.71, which was the highest rate since 1931. Of all the respiratory deaths registered, 410, or 92.3 per cent., were allocated to the bronchitis and pneumonia group. Pneumonia constituted the highest single cause of mortality in this group. Of the 250 deaths from pneumonia, 146 (58.4 per cent.) were of males, and 104 (41.6 per cent.) of females. In infants the excess male mortality was very great; under the age of one year 33 male infants died from pneumonia compared with 18 female infants at a similar age. Broncho-pneumonia was responsible for a much larger number of deaths than lobar pneumonia, the deaths from the former condition being 117 males and 90 females, and for the latter condition 22 males and 9 females. Even when allowance is made for the high frequency of bronchopneumonia in children by excluding deaths of persons under the age of 25 years, it is found that of the pneumonia deaths which could be classified definitely to one or other of these two types, broncho-pneumonia constituted 123 (69 males and 54 females) of the 150 deaths, and lobar pneumonia only 27 deaths (19 males and 8 females). Bronchitis caused the death of 160 persons (84 males and 76 females). Of these the type of bronchitis was not clearly defined in 60 cases. Of the remaining 100 persons, acute bronchitis was responsible for the deaths of 73 (37 males and 36 females), and chronic bronchitis for the deaths of 27 (19 males and 8 females). In infancy acute bronchitis caused 4 deaths, and bronchitis of an ill-defined type 8 deaths. Of the remaining bronchitis deaths, 94.6 per cent. were over the age of 55 years. Of the 46 deaths which were allocated to other causes, 20 fell within the group of congestive diseases such as hypostatic 96 Table XXXI. Deaths from respiratory diseases (excluding phthisis). Period West Ham No. of deaths Crude death-rates per 1,000 living West Ham London (both sexes) England and "Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 1,911 — — 3.23 4.679 4.333 3.599 3.956 1881-1885 — — 2,642 — — 3.67 4.242 4.084 3.367 3.716 1886-1890 — — 3,451 — — 3.79 4.166 4.136 3.422 3.768 1891-1895 — — 4,707 — — 4.30 4.381 4.059 3.408 3.723 1896-1900 — — 4,756 — — 3.80 3.449 3.424 2.793 3.098 1901-1905 — — 4,553 — — 3.34 3.072 3.051 2.509 2.771 1906-1910 — — 4,272 — — 3.02 2.813 2.789 2.314 '2.544 1911-1915 2,482 2,217 4,699 3.46 2.97 3.21 2.822 2.743 2.186 2.452 1916-1920 2,803 2,253 5,056 4.05 3.13 3.58 2.878 3.179 2.145 2.603 1921-1925 2,249 1,953 4,202 2.95 2.43 2.68 2.258 2.295 1.831 2.053 1926-1930 1,698 1,466 3,164 2.25 1.85 2.05 1.883 1.952 1.499 1.716 1931-1935 1,254 982 2,236 1.81 1.36 1.58 1.467 1.536 1.181 1.351 1921 447 338 785 3.00 2.14 2.56 2.233 2.212 1.722 1.956. 1922 612 544 1,156 4.05 3.42 3.73 2.739 2.572 2.065 2.307 1923 371 293 664 2.42 1.82 2.11 1.930 2.102 1.653 1.867 1924 458 429 887 2.96 2.64 2.79 2.285 2.359 1.924 2.132 1925 361 349 710 2.33 2.14 2.23 2.103 2.234 1.788 2.001 1926 331 316 647 2.15 1.95 2.05 1.895 1.961 1.530 1.736 1927 389 345 734 2.53 2.13 2.33 1.995 2.164 1.720 1.933 1928 300 233 533 2.01 1.48 1.74 1.680 1.744 1.289 1.507 1929 444 379 823 2.96 2.40 2.68 2.491 2.358 1.871 2.104 1930 234 193 427 1.59 1.25 1.42 1.351 1.539 1.088 1.304 1931 333 263 596 2.30 1.73 2.01 1.701 1.795 1.422 1.601 1932 264 194 458 1.87 1.31 1.58 1.450 1.521 1.218 1.363 1933 246 202 448 1.78 1.40 1.58 1.455 1.564 1.237 1.394 1934 242 193 435 1.79 1.37 1.58 1.508 1.441 1.051 1.238 1935 169 130 299 1.28 0.94 1.10 1.150 1.364 0.977 1.163 1936 195 173 368 1.50 1.27 1.38 1.426 1.457 1.026 1.233 1937 253 191 444 2.00 1.44 1.71 1.460 1.500 1.064 1.273 g 97 pneumonia. All except two of these persons were over the age of 55 years. Two deaths—both of males—were allocated to the asthma group. The mortality from the respiratory group of diseases since 1876 is given in Table XXXI. From this table it is seen that the local death rate from these conditions has been steadily falling during these 60 years. The quinquennial period 1916-1920 was an exception to this general statement, but the high death rate in this period was due to the influenza epidemics of 1918 and 1919, and was reflected in similar high rates elsewhere. This statement holds even though deaths certified as due to "influenza" are not included in this group of respiratory diseases. Rates for individual years are liable to show considerable fluctuation owing to variations in climatic and other conditions, but it is seen that generally the downward trend was maintained until a year ago. The differential rates show that the respiratory mortality has been consistently higher in males than in females in West Ham. This feature is also shown very definitely in the differential rates for the country as a whole. The excess mortality of males is generally considerable, and is especially marked towards the later decades of life, when the increased exposure of males to adverse weather conditions is liable to be followed by a fatal issue. Comparison of the respiratory death rates of this area with those for the country as a whole is throughout the period of sixty odd years unfavourable. This excessive mortality from respiratory conditions is to be expected in a large industrial area, where the inhabitants are constantly subjected to the adverse influence of smoke, fog, and other atmospheric impurities. It can, however, be easily shown that the excess of the local rates over the national rates has decreased considerably within recent years, and it is perhaps justifiable to assert that this decrease is associated with national and local measures which have been taken in this period to free the atmosphere of its impurities. Some support for this theory is obtained from an examination of the respiratory death rates for the Administrative County of London. These rates show even better than do the local rates the progressive downward trend, so that the rate for the last quinquennial period given was only about a third of the rate for the period 1876-1880. The interesting point is that, at almost every quinquennial period, the London rates are approximately 98 the mean of the local rates and the rates for the country as a whole. The larger population upon which the London rates are based would probably tend to reduce the high peaks shown by the local rates in certain years. Despite this smoothing, it would seem that the London rates do reflect the fact that, while much of the county area is of an industrial type similar to West Ham, other large areas are residential and commercial in nature. In these latter parts the adverse environmental factors which serve to raise the respiratory death rates in the industrial sections are operative to a much smaller degree. The study of respiratory death rates opens up a field of investigation which is of great importance in the assessment of the effect of invironmental factors. Reference should also be made to the notes on pneumonia, influenza, and bronchitis in the section on infectious diseases. DEATHS FROM CIRCULATORY DISEASES, (a) Diseases of the heart. This group of diseases covers pericarditis, acute and chronic endocarditis—including all forms of valvular disease, myocarditis, disease of coronary arteries, disordered action of the heart, dilatation, and heart disease—ill-defined and not allocated to some other primary condition. The group now refers to those diseases included in headings 90 to 95 inclusive of the International List. There have been during the course of the last fifty years considerable changes in the method of allocating deaths due to heart diseases. It is impracticable to give full details here, but it may be said that in computing the number of deaths due to these conditions I have attempted to take these changes into consideration as much as possible. During the year 1937 the number of deaths from heart disease was 787, of which 384 were of males and 403 of females. This number was a decrease of 35 persons compared with the figure for the previous year, which incidentally showed the highest number of deaths so far allocated to these conditions. The rate per 1,000 of the population was 3.03 as compared with a rate of 3.09 for the previous year. Of the total of 787 heart disease deaths registered, 558 were due to myocarditis or other diseases of the myocardium, and 124 to chronic endocarditis or valvular disease. 99 The myocardial group constituted 70.9 per cent. of all deaths due to heart disease. The sex distribution was fairly equal, 264 deaths occurring in males and 294 in females. No less than 167 of the total myocardial deaths were allocated to the group which covers myocarditis of an ill-defined nature (93.c.). The greater part of the myocardial group was constituted by 299 deaths from myocardial degeneration (93.b.3). Of these deaths, 134 were of males and 165 of females. Of all myocardial deaths 433, or 77.6 per cent. occurred in persons over the age of 65 years. Of the 124 deaths from chronic endocarditis, or valvular disease, 60 occurred in males and 64 in females. A large proportion—99 deaths—of these were allocated definitely to one or other of the valves of the heart. Of these 99 cases 26—20 males and 6 females—were due to aortic disease; 66—26 males and 40 females—were due to disease of the mitral valve; and 7 deaths—5 males and 2 females—were due to disease of both these valves. The earliest record of valvular disease during 1937 was one death from mitral disease in a female between the ages of 5 and 10 years. Twenty-nine of the 60 male deaths from myocarditis of all forms occurred over the age of 65 years; andy of the corresponding 64 female deaths, 28 occurred above this age. Diseases of the coronary arteries constituted 41 deaths, of which 30 were of males and 11 of females. Among the males, 27 of the deaths were of persons over the age of 55 years, and among the females all except one of the 11 deaths were of persons over this age. Two deaths were certified as due to pericarditis during' the year. One of these persons was a male between the age of 20 and 25 years, and the other was a female between the age of 45 and 55 years. Of all deaths from heart diseases, 553, or 70.3 per cent., occurred in persons over 65 years of age. The mortality from heart disease since 1891 is given in Table XXXII. It will be seen from this table that the local death rate from these conditions rose irregularly up to the decade 19211925, since when there has been a substantial and progressive increase. It is doubtful whether deaths from heart disease are really more frequent than they were previously. A part at least 100 of the increase in the rate can be explained by changes in the methods of classifying deaths, and the fact that the population is gradually becoming older also does much to explain the increase. It will be seen that the national rates show similar tendencies. The rates for London are peculiar in that, whereas in the first forty years of the period quoted they were midway between the rates for West Ham and those for the country as a whole, the London rates began to exceed the national rates in the quinquennium 1916-1920, and since that period they have been considerably in excess of the rates for the country as a whole. On the whole the death rates for females from heart diseases tend to be higher than the corresponding rates for males. The difference is not very substantial, but it is borne out by the national rates. (b) Other circulatory diseases. The diseases which 1 have included in this group are: aneurysm; diseases characterised by a hardening' of the arteries (arterio-sclerosis, atheroma, etc.) with and without cerebral arterial lesions; gangrene, both senile and that due to other causes; and other diseases of the arteries. It also includes diseases of the veins and lymphatics, and abnormalities of blood pressure. The group is covered by Nos. 96 to 103 of the International List. It thus includes certain cases of the important group of diseases popularly known as " shock " or " apoplexy," but the majority of these cases are included under another heading, and will be dealt with in later reports. During the year 1937 the number of deaths from these vascular diseases was 118, of which 54 were of males and 64 of females. The death rate was 0.45 per 1,000 of the population. Diseases characterised by some process of hardening of the arteries (group 97) accounted for 100 of these deaths—42 being deaths of males, and 58 of females. Cerebral lesions accounted for 64 of the deaths, 21 of these being of males and 43 of females. The excess mortality of the female sex was here much more marked than in the main group "cerebral haemorrhage." Of the 100 deaths ascribed to arterio-sclerosis, 77 occurred in persons over the age of 65 years. The number of deaths from aneurysm was 9, of which 7 were of males, and 2 of females. One of the male deaths occurred in the age group 25 to 35 years, and 4 between the age of 45 and 101 Table XXXII. Deaths from heart disease. Period West Ham No. of deaths Crude death-rates per 1,000 living West Ham London (both sexes) England and Wales Males Females Persons Males Females Persons Males Females Persons 1886-1890 - - - - - - 1.411 1.518 1.608 1.564 1891-1895 — — 1,145 — — 1.05 1.424 1.508 1.598 1.555 1896-1900 — — 1,548 — — 1.24 1.350 1.489 1.542 1.517 1901-1905 — — 1,368 — — 1.00 1.285 1.416 1.481 1.450 1906-1910 — — 1,402 — - 0.99 1.211 1.404 1.439 1.422 1911-1915 768 884 1,652 1.07 1.18 1.13 1.415 1.485 1.498 1.492 1916-1920 776 846 1,622 1.12 1.17 1.15 1:607 1.683 1.465 1.562 1921-1925 835 954 1,789 1.09 1.19 1.41 1.663 1.486 1.582 1.537 1926-1930 1,254 1,422 2,676 1.66 1.79 1.73 2.281 1.981 2.072 2.028 1931-1935 1,692 1,838 3,530 2.45 2.54 2.49 2.990 2.655 2.660 2.658 1921 156 180 336 1.05 1.14 1.09 1.561 1.381 1.451 1.418 1922 157 171 328 1.04 1.07 1.06 1.701 1.512 1.619 1.568 1923 182 202 384 1.19 1.25 1.22 1.596 1.430 1.528 1.481 1924 166 164 330 1.07 1.01 1.04 1.687 1.510 1.616 1.565 1925 174 237 411 1.12 1.45 1.29 1.708 1.596 1.694 1.647 1926 208 233 441 1.35 1.44 1.40 1.790 1.606 1.691 1.650 1927 216 262 478 1.41 1.62 1.52 2.005 1.774 1.891 1.835 1928 261 275 536 1.75 1.75 1.75 2.l-11 1.893 2.004 1.951 1929 289 357 646 1.93 2.26 2.10 2.923 2.373 2.493 2.436 1930 280 295 575 1.91 1.91 1.91 2.506 2.252 2.274 2.264 1931 340 375 715 2.35 2.47 2.41 2.856 2.503 2.564 2.535 1932 302 323 625 2.14 2.18 2.16 2.907 2.550 2.565 2.558 1933 311 347 658 2.25 2.40 2.33 3.062 2.656 2.700 2.679 1934 365 415 780 2.71 2.94 2.82 3.010 2.716 2.671 2.693 1935 374 378 752 2.83 2.73 2.78 3.122 2.847 2.797 2.821 1936 404 418 822 3.11 3.07 3.09 3.426 3.153 3.051 3.100 1937 384 403 787 3.03 3.04 3.03 3.501 3.193 3.085 3.137 65 years. Relatively speaking, aneurysm claimed its victims at an earlier age than did the arterio-sclerotic group of diseases. The number of cases of senile gangrene which were certified was 6, 3 being males and 3 females. All occurred above the age of 55 years. 102 DEATHS FROM VIOLENCE. The total number of deaths from violence which occurred during 1937 was 118, of which 79 were of males and 39 of females. Suicide accounted for 27 of these deaths—20 males and 7 females—and the remainder, which were due to accidents and other forms of violence, were made up of 59 males and 32 females. The death rate from all forms of violence was 0.45 per 1,000 living. The death rate from accidents, etc., was 0.35 per 1,000 living, and the rate from suicide was 0.10. Suicide. Ten of the deaths (6 males and 4 females) were due to coal-gas poisoning. All the female deaths due to this cause occurred over the age of 55 years. The next most common mode of committing suicide was by hanging, which accounted for the deaths of 6 males and one female. The remainder of the male deaths were made up as follows: cut-throat, 2; poisoning by lysol, 2 ; poisoning by aspirin, 1 ; drowning, 1; death through falling under a train, 1; death by fall from window, 1. One of the two remaining female deaths was due to a fall under a train, and the other to the severance of an artery. Accidents, etc. Of the 91 deaths, the most frequent cause was accidental death at work, which accounted for 18 deaths of males and 4 of females. Home accidents and falls caused the deaths of 5 males and 9 females; 12 of these persons were over 75 years of age. Five males—ages ranging from 15 upwards—were found drowned, and in the case of the other 2 males and 1 female the verdict at the inquest was accidental drowning. One death was attributed to war wounds. Mechanically propelled vehicles caused the deaths of 25 persons. Particulars of these accidents are given in Table XXXIII. Trend of deaths from violence. Particulars of the deaths from and the death rates from violence are given in Table XXXIV. This table shows that in the last 46 years there has been a decline in the death rate from all forms of violence—a decline which really appeared suddenly in the period 1921-1925. The reduction in West Ham has been considerable, and is much greater than the corresponding reduction for the country as a whole. For all forms, the death rate for males has been approximately three times that for females—a ratio which is somewhat greater than that for the country as a whole. 103 104 Table XXXIII. Accidental deaths due to mechanically propelled vehicles. Type of vehicle Sex Age at death All ages 0— 1- 2— 3— 4— 5- 15— 25— 35— 45— 55— 65— 75— Males Females Trolley-bus M - - - - - - - - - - - - - - F - - - - - - - - - - - - - — Tram-car M - - - - - - - - - 1 — - 1 F - - - - - - - - - - - 1 — 1 Motor buses and coaches M - - - - - - 1 - - - 2 - - 3 F - - - - - 1 - - - - - - - 1 Private and other cars M - - - - - - 1 - - - 1 1 - 3 F — — — 1 — — 2 — 1 — 1 — — 5 Motor lorries M - - - - - 3 1 - 1 1 - - - 6 F - - 1 - - 1 - - - - - - - 2 Other vehicles M - - - - - - - - - - - - - - F - - - - - - - - - - - - - — Motor cycles M - - - - - - 1 2 - - - - - 3 F - - - - - - - - - - - - - — All vehicles M - - - - - 3 4 2 1 1 4 1 - 16 F — — 1 1 — 2 2 — 1 — 1 1 — 9 Pedal cycles M - - - - - - - - - - - - 1 1 F - - - - - - - - - - - - — Other street accidents M - - - - - - - - - - 1 1 1 3 F - - - - - - - - - - 1 — 1 2 The rates for the two main groups—accidents and suicides respectively—are not given in the table as they may tend to be based on small numbers. The accident rates are, however, very low considering the industrial nature of the area. This applies especially to females—a point upon which the Registrar-General commented recently. Table XXXIV. Deaths from violence. Period West Ham: No. of deaths. All violence. Crude death-rates per 1.000 living Accidents, etc. Suicide West Ham England and Wales Male Female Persons Male Fem'ls Persons Male Female Persons Male Female Persons 1891-1895 — — 622 — — 72 — — 0.63 0.937 0.365 0.642 1896-1900 — — 992 — — 56 — — 0.84 0.916 0.364 0.631 1901-1905 — — 752 — - 86 — — 0.62 0.857 0.341 0.591 1906-1910 — — 742 — — 131 — — 0.62 0.799 0.325 0.554 1911-1915 603 261 864 79 20 99 0.95 0.38 0.66 0.860 0.316 0.576 1916-1920 604 230 834 65 33 98 0.97 0.36 0.66 1.008 0.285 0.605 1921-1925 412 158 570 100 33 133 0.67 0.24 0.45 0.660 0.26] 0.452 1926-1930 405 142 547 105 57 162 0.68 0.25 0.46 0.770 0.318 0.534 1931-1935 362 121 483 125 46 171 0.70 0.23 0.46 0.770 0.346 0.550 1921 76 41 117 25 8 33 0.68 0.31 0.49 0.651 0.253 0.443 1922 78 37 115 15 6 21 0.62 0.27 0.44 0.637 0.253 0.436 1923 82 31 113 26 2 28 0.71 0.20 0.45 0.667 0.255 0.452 1924 78 20 98 17 8 25 0.61 0.17 0.39 0.652 0.266 0.451 1925 98 29 127 17 9 26 0.74 0.23 0.48 0.694 0.278 0.477 1926 81 25 106 19 7 26 0.65 0.20 0.42 0.695 0.291 0.484 1927 72 23 95 23 17 40 0.62 0.25 0.43 0.753 0.304 0.519 1928 83 36 119 18 10 28 0.68 0.29 0.48 0.784 0.328 0.546 1929 87 26 113 21 6 27 0.72 0.20 0.46 0.800 0.336 0.558 1930 82 32 114 24 17 41 0.72 0.32 0.51 0.817 0.330 0.563 1931 78 27 105 29 8 37 0.74 0.23 0.48 0.759 0.338 0.540 1932 75 23 98 21 10 31 0.68 0.22 0.45 0.777 0.329 0.544 1933 78 23 101 28 7 35 0.77 0.21 0.48 0.790 0.352 0.562 1934 67 28 95 24 13 37 0.67 0.29 0.48 0.782 0.359 0.562 1935 64 20 84 23 8 31 0.66 0.20 0.42 0.744 0.353 0.540 1936 63 36 99 22 13 35 0.65 0.36 0.50 0.750 0.372 0.553 1937 59 32 91 20 7 27 0.62 0.29 0.45 0.756 0.371 0.556 105 CANCER. The number of deaths from cancer and other malignant tumours during 1937 was 367, of which 181 were deaths of males and 186 of females. This gives a death rate of 1.41 per 1,000 of the population. The actual number of persons who died from these conditions is the lowest since 1927, and the death rates show that the incidence of these deaths was the lowest since 1931. The death rate for males (1.43) was slightly higher than the death rate for females (1.40). The statistics for malignant disease since 1896 for West Ham and the country as a whole are given in Table XXXV. It will be seen from this table that both series of death rates have shown a progressive increase during this period, and that in both the rates have been practically doubled. It has not so far been definitely decided whether this increase is due to an actual increase in the number of persons who die as a result of malignant disease. It is certain that a part at least of the increase is due to the fact that diagnosis of these conditions is now more easily and satisfactorily carried out than was the case three or four decades ago. There is some evidence, however, that certain types of cancer are definitely increasing in frequency. It should be noted that the differential sex rates for the country as a whole show that at all periods during the last forty years malignant disease has been a more fruitful cause of death in females than in males, but that this sex difference appears to be less marked now that it was formerly. In West Ham the process of equalization established itself during the early post-war period, and the death rate for males is now considerably greater than the rate for females. It is probable that this phenomenon is in part due to the increasing frequency of deaths from malignant disease of the lungs or of other parts of the respiratory tract. It is satisfactory to note that the death rates from cancer for West Ham have been uniformly lower than the corresponding death rates for London and the country as a whole. Details of the deaths from malignant disease for the year 1937 are given in Tables XXXVI(a) and XXXVI(b). Of the 181 male deaths, 16—or 8.8 per cent.—occurred in persons under 40 years of age, and 57—or 31.5 per cent.—in persons over 70 years of age. Of the 186 female deaths, the corresponding percentages are 3.8 and 25.8 respectively. The incidence in males 106 under 40 years is high, and is accounted for almost entirely by carcinoma of the lung or associated parts, by carcinoma of the lower part of the large bowel, and by sarcomata of the bones and other sites. Malignant tumours which caused death under 25 years of age were more common in males (5 deaths) than in females (1 death). Table XXXV. Deaths from cancer (malignant disease). Period West Ham No. of deaths Crude death-rates per 1,000 living West Ham London (both sexes) England anil Wales Males Females Persons Males Females Persons Males Females Persons 1896-1900 — — 843 — — 0.67 0.917 0.650 0.942 0.801 1901-1905 — — 984 — — 0.72 0.994 0.725 1.000 0.867 1906-1910 — — 1,110 — — 0.78 1.066 0.819 1.053 0.940 1911-1915 620 703 1,323 0.86 0.94 0.90 1.205 0.964 1.141 1.056 1916-1920 624 717 1 ,341 0.90 0.99 0.95 1.281 1.188 1.191 1.190 1921-1925 905 907 1,812 1.19 1.13 1.16 1.380 1.210 1.325 1.270 1926-1930 957 951 1,908 1.27 1.20 1.23 1.515 1.363 1.455 1.411 1931-1935 1,072 960 2,032 1.55 1.33 1.44 1.662 1.510 1.557 1.534 1921 177 172 349 1.19 1.09 1.14 1.328 1.142 1.281 1.215 1922 175 175 350 1.16 1.10 1.13 1.331 1.167 1.286 1.229 1923 184 165 349 1.20 1.02 1.11 1.389 1.203 1.326 1.267 1924 197 209 406 1.27 1.28 1.28 1.414 1.246 1.351 1.300 1925 172 186 358 1.11 1.14 1.12 1.437 1.290 1.377 1.336 1926 186 206 392 1.21 1.27 1.24 1.456 1.307 1.413 1.362 1927 170 191 361 1.11 1.18 1.14 1.489 1.332 1.417 1.376 1928 192 188 380 1.28 1.19 1.24 1.516 1.377 1.469 1.425 1929 188 183 371 1.25 1.16 1.21 1.550 1.386 1.483 1.437 1930 221 183 404 1.51 1.18 1.34 1.570 1.411 1.494 1.454 1931 215 193 408 1.48 1.27 1.38 1.637 1.450 1.516 1.484 1932 195 216 411 1.38 1.46 1.42 1.611 1.495 1.524 1.510 1933 245 161 406 1.77 1.11 1.44 1.650 1.490 1.559 1.526 1934 198 194 392 1.47 1.37 1.42 1.720 1.534 1.590 1.563 1935 219 196 415 1.66 1.42 1.53 1.694 1.578 1.595 1.587 1936 242 175 417 1.86 1.29 1.57 1.778 1.612 1.636 1.625 1937 181 186 367 1.43 1.40 1.41 1.788 1.634 1.632 1.633 107 Table XXXVI(a). Sites and forms of fatal cancer. 1937. All ages 0- 5- 15- 25- 35— 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- (a) Deaths of males All sites 181 1 1 3 10 1 3 4 21 18 31 31 23 21 8 5 Carcinoma 160 — — 2 6 1 3 3 19 18 29 29 19 19 8 4 Sarcoma 8 — 1 1 4 — — — 1 — 1 — 1 — — — Others, and ill-defined 13 1 - - 1 - - 1 1 - 1 2 3 2 — 1 45 Lip 1 - - - - - - - - - - - - 1 - - Tongue 6 — — — — — — — 1 — 1 — — 2 - 2 Mouth 3 — — — — — — — — 1 — — 1 — 1 - Tonsil 3 - - - - - - - - - 1 1 1 — — — Jaw 1 - - - - - - - - - 1 - - - - - Pharynx 1 - - - - - - - - 1 - - - - - - Others (1) - - - - - - - - - - - - - - - - Total 15 - - - - - - - 1 2 3 1 2 3 1 2 46 Oesophagus 10 - - - - - - - 1 3 2 3 1 - - - Stomach 32 — — — — 1 — 1 4 5 4 9 3 3 1 1 Small intestine - - - - - - - - - - - - - - - - Cæcum - - - - - - - - - - - - - - - - Hepatic flexure 1 - - - - - - - - - - - - 1 - - Splenic flexure - - - - - - - - - - - - - - - - Sigmoid flexure - - - - - - - - - - - - - - - - Large intestines (colon) 19 — — 1 — — — — 2 2 3 3 4 2 2 — Rectum (excluding anus) 18 — — — 1 — — 1 2 — 4 3 4 2 1 — Liver 1 — — — — — — — — — — — — 1 - — Gall bladder 3 - - - - - - - 1 - 1 - - 1 - - Pancreas 10 - - - - - - - 3 — 2 2 1 1 1 - Others (2) - - - - - - - - - - - - - - - - Total 94 — — 1 1 1 — 2 13 10 16 20 13 11 5 1 47 Larynx 5 - - - 1 - - - - 1 1 1 1 - - - Trachea - - - - - - - - - - - - - - - - Bronchus 6 - - - - - - - 2 1 1 2 — — - - Lung 15 — — — 2 — 1 2 1 3 2 2 1 1 — — Mediastinum 4 — — 1 1 — — — — — 2 — — — — — Pleura 1 - - - - - - - - - - - - 1 — - Total 31 — — 1 4 — 1 2 3 5 6 5 2 2 — — 50 Breast - - - - - - - - - - - - - - - - 51 Kidney, suprarenal 3 - - - 2 - - - - - - 1 - - - - Bladder, urethra ureter 9 1 - - - - - - 1 1 3 1 — 1 1 — Prostate 13 - - - - - - - 2 — 3 2 2 1 1 2 Testis - - - - - - - - - - - - - - - - Penis - - - - - - - - - - - - - - - - Scrotum - - - - - - - - - - - - - - - - Total 25 1 — — 2 — — — 3 1 6 4 2 2 2 2 52 Skin 3 - - - - - - - - - - - 2 1 - - 53 Brain, meninges - - - - - - - - - - - - - - - - Thyroid 1 - - 1 - - - - - - - - - - - - Bones (except jaw) 5 — — — 3 — — — 1 — — — — 1 — — Lymph glands 1 - 1 - - - - - - - - - - - - - Others (3) and unspeci- fied 6 - - - - - 2 - - - - 1 2 1 - - Total 13 — 1 1 3 — 2 — 1 — — 1 2 2 — — (1) Includes palate, cheek (internal surface), salivary glands, gums. (2) Includes intestine undefined, peritoneum, omentum, mesentery, anus (3) Includes abdomen, eye, muscles, etc. 108 Table XXXVI(b). Sites and forms of fatal cancer. 1937. All ages 0- 5- 15- 25- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- (b) Deaths of females All sites 186 — 1 - 5 1 5 10 17 27 32 40 26 11 8 3 Carcinoma 175 — — 4 1 5 10 1 25 31 39 22 11 8 3 Sarcoma 5 — 1 — 1 — — — 1 1 — — 1 — — Others, and ill-defined 6 - - - - - - - - 1 1 1 3 - — — Lip - - - - - - - - - - - - - - - - Tongue 1 - - - - - - - 1 - - - - - - - Mouth - - - - - - - - - - - - - - - - 45 Tonsil - - - - - - - - - - - - - - - - Jaw 2 - - - - - - - 1 - - 1 - - - - Pharynx - - - - - - - - - - - - - - - - Others (1) 2 - - - - - - - 1 - - - - 1 — — Total 5 — - — — — — — 3 — — 1 — 1 — — 46 Oesophagus 2 - - - - - - 1 1 - - - - - - - Stomach 30 — — 1 — — 1 2 3 6 5 6 4 2 - Small intestine 4 — — — — — — 1 — — 1 2 — — - Caecum 2 — — — — — — 1 1 — — — — — - Hepatic flexure 3 — — — — — — — - 2 1 — — - - Splenic flexure 1 - - - - - - - - - - 1 - - - - Sigmoid flexure - - - - - - - - - - - - - - - - Large intestine (colon) 20 - — — 1 — 1 — 4 5 5 1 1 1 1 Rectum (excluding anus) 24 — — 2 — — 2 — 5 2 5 6 2 - - Liver 4 — — — — — — — - 1 2 — — 1 - Gall bladder 4 - - - - - - - - 1 1 1 — — - 1 Pancreas 5 - - - - - - - 1 1 — 1 1 1 - - Other (2) 2 - - - - - - - 1 - - 1 - - - - Total 101 — — — 3 1 - 5 7 15 17 23 10 8 4 2 47 Larynx 1 - - - - - - - - - - - - - 1 - Trachea 1 - - - - - - - - - - - 1 - - - Bronchus 1 - - - - - - - - - - - - - - - Lung 6 — — 1 — — — 1 2 1 1 - - - - Mediastinum 2 — — — — — — — - — 1 1 - - - Pleura - - - - - - - - - - - - - - - — Total 11 — - — 1 - — - 1 2 1 3 2 — 1 — 48 Uterus 23 - - - - - - 4 5 2 4 4 1 2 1 - 49 Ovary and Fallopian tube 6 - - - - - 2 - - 2 1 1 - - - - Valva and vagina 1 - - - - - - - - - 1 - - - - - Others - - - - - - - - - - - - - - - — Total 7 — - - — — 2 — — 2 2 1 — — — — 50 Breast 30 — - — 1 — 3 1 1 5 6 5 5 — 2 1 52 Skin - - - - - - - - - - - - - - - - 53 Brain, meninges - - - - - - - - - - - - - - - - Thyroid - - - - - - - - - - - - - - - - Kidnev, suprarenal 1 — - — — — — — — — — 1 - - - - Bladder, urethra - - - - - - - - - - - - - - - - Bones (except jaw) 2 — 1 - - - - - - - 1 - - - - - Lymph glands - - - - - - - - - - - - - - - - Others (3) and unspecified 6 - - - - - - - - 1 1 2 2 — — — Total 9 - 1 - - - - - - 1 2 3 2 - — - (1) Includes palate, cheek (internal surface), salivary glands, gums. (2) Includes intestine undefined, peritoneum, omentum, mesentery, anus. (3) Includes abdomen, eye, muscles, etc. 109 In both sexes the most common seat of malignant tumours was the digestive tract. The sex incidence of these tumours was very similar, and the relative frequency in the two sexes of tumours at different parts of the digestive tract was also similar. An exception to this statement was constituted by tumours of the pancreas, which accounted for the deaths of twice as many males as of females. Of the males, 19.1 per cent. of the deaths from malignant disease of the alimentary tract were of persons under 55 years of age, and of the females 15.8 per cent. Cancer of the digestive tract tended, on the whole, to kill at a slightly earlier age in males than in females. Fatal malignant disease of the respiratory tract was approximately three times as common in males than in females. Of the 31 male deaths, 11 occurred in men under the age of 55 years. As a recorded cause of death in the prime of life, these conditions are now of considerable importance. In females, all except 2 of the 11 deaths were of women over 55 years of age. In females, cancer of the breast accounted for the second highest number of all cancer deaths. It should be noted that almost half of these deaths were of women over 65 years of age. Cancer of the uterus and of the other genital organs gave a combined total which was equal to the number of deaths from cancer of the breast. About a third of these deaths occurred in women below the age of 55 years. Of all the deaths from malignant disease, 335 were due to carcinomata, 13 to sarcomata, and 19 to other forms of malignant tumour, or tumours of undefined type. TUBERCULOSIS. The number of new cases of tuberculosis which came to the notice of the department during 1937 was 407. Of these cases, 324 (182 males and 142 females) suffered from the pulmonary form of the disease, and 83 cases (50 males and 33 females) from the non-pulmonary forms. The case rate for all forms of tuberculosis was 1.57 per 1,000 of the population. Further details of the notifications are given in the section of this report devoted to tuberculosis. During the year the number of deaths ascribed by the Registrar-General to all forms of tuberculosis was 227, of which 138 were deaths of males and 89 of females. The number 110 of deaths due to tuberculosis of the respiratory system—including pulmonary tuberculosis and tuberculosis of the larynx—was 203, of which 127 were deaths of males and 76 of females. The death rate for all forms of tuberculosis was 0.87 per 1,000 of the population, as compared with rates of 0.89 for 1936, 0.92 for 1935, and 0.98 for 1934. The death rate for the respiratory forms of the disease was 0.78 per 1,000 of the population as compared with the rates of 0.78 for 1936, 0.83 for 1935, and 0.87 for 1934. Data regarding the deaths from all forms of tuberculosis since 1896 are given in Table XXXVII., and in Table XXXVIII. corresponding data are given for deaths from respiratory forms since 1876. The most outstanding feature which is brought out by these two tables is the very considerable decline which has occurred in the mortality from this disease. There is some doubt regarding the accuracy of the causes of death, as stated on death certificates, so far as the returns for tuberculosis during the last century are concerned. Post-mortem examinations were not then made so frequently as they are at the present time, and patients did not then have the opportunities for accurate diagnosis which exist to-day. Hence it is probable that in the earlier years of the tables the numbers given are an understatement of the true position. It is seen that the death rate from all forms of tuberculosis and from the respiratory form have both been approximately halved. On the whole, this decline has been continuous, but it is noteworthy that the fall was greatly accelerated during the immediate post-war years. This post-war reduction in the tuberculosis death rate was a significant example of the result of increasing care of the tuberculous patient and of an augmentation of the health consciousness of the community. It is satisfactory to note that the rates are still declining. The local rates are higher than those for the country as a whole. This is understandable, since in a large urban community the tuberculosis rates often reflect the conditions which are insepcrable from urban and industrial life. In this respect the West Ham rates compare favourably with the rates for other large urban centres of population. What is more important is the fact that, after the period ending with the war, the local rates have shown a decline which is roughly proportional to those for the country as a whole. Thus, the local rates have made good running after a delayed start. 111 Table XXXVII. Deaths from tuberculosis (all forms). Period West Ham No. of deaths Crude death-rates per million living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1896-1900 — — 2,473 — — 1,977 2,175 1,657 1,907 1901-1905 — — 2,654 — — 1,948 2,011 1,185 1,584 1906-1910 — — 2,485 — — 1,755 1,798 1,351 1,567 1911-1915 1,412 1,038 2,450 1,968 1,389 1,673 1,652 1,206 1,419 1916-1920 1,339 1,030 2,369 1,934 1,429 1,676 1,782 1,208 1,462 1921-1925 1,086 797 1,883 1,423 991 1,201 1,230 946 1,082 1926-1930 991 765 1,756 1,315 964 1,135 1,089 810 943 1931-1935 886 575 1,461 1,281 794 1,032 945 680 807 1921 233 158 391 1,562 1,001 1,274 1,267 998 1,127 1922 201 169 370 1,330 1,062 1,193 1 ,279 977 1 ,121 1923 202 168 370 1,319 1,042 1,177 1,205 932 1,062 1924 220 158 378 1,423 971 1,191 1,205 928 1,061 1925 230 144 374 1,482 882 1,174 1,195 895 1,039 1926 209 152 361 1,358 938 1,143 1,106 828 961 1927 194 155 349 1,263 958 1,107 1,112 843 972 1928 194 150 344 1,298 953 1,121 1,067 800 928 1929 202 144 346 1,348 913 1,125 1,122 810 959 1930 192 164 356 1,308 1,061 1,182 1,037 770 898 1931 187 109 296 1,291 718 998 1,041 762 896 1932 192 140 332 1,359 946 1,148 972 713 837 1933 192 121 313 1,390 836 1,106 968 692 824 1934 166 104 270 1,231 736 978 899 638 763 1935 149 101 250 1,127 729 924 848 599 718 1936 138 98 236 1,063 721 888 825 570 692 1937 138 89 227 1,089 670 875 824 576 695 An interesting feature which is shown by the West Ham rates is the fact that the deaths from respiratory tuberculosis among females are tending to show a more pronounced and continuous decline than are the corresponding rates for males. This feature is contrary to the experience of many other large areas, in which there has been a tendency for the female rates to decline much more slowly than the corresponding male rates. I shall deal with this matter again in later reports. 112 Table XXXVIII. Deaths from tuberculosis of respiratory system. Period West Ham No. of deaths Crude death-rates per million living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 917 — — 1,575 2,138 1,948 2,041 1881-1885 — — 1,060 — — 1,471 1,928 1,739 1,831 1886-1890 — — 1,481 — — 1,626 1,782 1,498 1,636 1891-1895 — — 1,697 — — 1,550 1,633 1,302 1,462 1896-1900 — — 1,643 — — 1,314 1,530 1,131 1,324 1901-1905 — — 1,829 — — 1,343 1,438 1,013 1,218 1906-1910 — — 1,741 — — 1,230 1,299 927 1,107 1911-1915 1,065 747 1,812 1,484 1,000 1,237 1,246 872 1,051 1916-1920 1,071 820 1.891 1,547 1,138 1,338 1,384 916 1,124 1921-1925 887 637 1,524 1,621 792 972 984 741 857 1926-1930 851 648 1,499 1,129 817 969 898 651 770 1931-1935 775 506 1,281 1,121 699 905 795 557 672 1921 185 126 311 1,240 798 1,013 1,003 777 884 1922 163 134 297 1,079 842 957 1,024 766 889 1923 164 135 299 1,071 837 951 958 724 836 1924 184 124 308 1,190 762 970 969 729 844 1925 191 118 309 1,231 722 970 967 709 833 1926 174 127 301 1,131 784 953 897 655 771 1927 164 134 298 1,067 828 945 914 678 791 1928 165 124 289 1,104 788 942 879 641 755 1929 181 120 301 1,208 761 979 938 661 793 1930 167 143 310 1,138 925 1,029 863 624 739 1931 157 97 254 1.084 639 856 872 622 742 1932 166 114 280 1,175 770 968 806 578 687 1933 175 107 282 1,267 739 997 819 571 690 1934 149 92 241 1,105 651 873 759 520 635 1935 128 96 224 968 693 827 722 498 605 1936 118 88 206 909 647 775 703 472 583 1937 127 76 203 1,002 572 782 702 475 584 H 113 114 Table XXXIX. Comparative statistics of other areas. Name of town Population as estimated by the RegistrarGeneral. mid-1937 Per 1,000 population Comparability factor (a.c.f.) Adjusted death rate Tuberculosis Death rate per 1,000 population Infantile nortalty rate Maternal mortality (per 1,000 total births) Birth rate Crude death rate From sepsis From other causes Total Pulmonary Other forms Birmingham 1,043,000 16.30 11.70 1.10 12.90 0.72 0.08 60 0.74 2 22 2.96 Bradford 289,510 13.85 14.74 1.00 14.74 0.65 0.12 70 0.95 1.67 2.92 Bristol 415,100 14.46 11.44 0.98 11.21 0.67 0.13 46 1.12 2.41 3.53 Cardiff 220,200 15.40 12.60 1.06 13.30 0.82 0.17 65 0.85 2.82 3.67 Croydon 242,300 13.50 11.56 0.96 11.08 0.56 0.08 60 0.30 3.28 3.57 Hull 319,400 18.20 12.60 1.10 13.80 0.92 0.20 77 0.83 1.65 2.48 Leeds 491,800 14.80 13.36 1.07 14.30 0.72 0.11 67 0.79 1.45 2.24 Leicester 262,900 14.48 12.46 1.02 12.71 0.82 0.14 63 1.27 0.00 1.27 Liverpool 867,110 19.29 13.21 1.15 15.19 0.79 0.13 82 0.58 1.73 2.31 London 4,094,500 13.44 12.52 1.02 12.77 0.71 0.09 60 0.81 1.41 2.22 Manchester 751,371 14.31 13.52 1.14 15.41 0.88 0.15 76 1.34 2.85 4.19 Newcastle 290,400 16.50 13.30 1.13 15.03 0.93 0.19 91 1.00 3.21 4.21 Nottingham 278,800 15.96 13.44 1.03 13.84 0.84 0.15 80 0.87 1.95 2.82 Plymouth 210.460 14.60 13.06 0.98 12.79 0.69 0.07 46 2.19 3.13 5.32 Portsmouth 256,200 14.88 11.50 0.99 11.38 0.55 0.07 44 0.00 1.51. 1.51 Salford 201,800 15.10 14.60 1.18 17.23 0.88 0.13 84 0.94 3.47 4.41 Sheffield 518,200 15.37 12.53 1.13 14.16 0.69 0.11 55 1.57 1.81 3.37 Stoke-on-Trent 272,800 16.70 13.10 1.22 16.00 0.80 0.14 81 0.84 3.75 4.59 Sunderland 182,900 19.70 14.00 1.12 15.70 0.80 0.23 85 1.06 2.39 3.45 West Ham 259,500 16.10 12.00 1.15 13.80 0.78 0.09 62 0.46 0.69 1.15 COMPARATIVE STATISTICS OF OTHER AREAS. Comparative figures for West Ham and for nineteen other large urban areas are given in Table XXXIX. The main features of this table may be summarised as follows: — (a) Only six other towns—namely: Birmingham, Hull, Liverpool, Newcastle, Stoke-on-Trent, and Sunderland—had a higher birth rate than West Ham. (b) As judged by the adjusted death rate, eight other towns had a lower death rate than this area. (c) Nine other towns had a lower death rate from pulmonary tuberculosis. (d) The infant mortality rate was the eighth lowest amongst the towns quoted. (e) Two other towns had a slightly lower death rate from puerperal sepsis, but the maternal mortality rate from all causds was the lowest of the towns quoted. When considered in relation to the fact that West Ham is almost entirely an industrial area, these results may be considered as very satisfactory. 115 III. INFECTIOUS DISEASES 117 INFECTIOUS DISEASES. During the year 1937 the number of notifications of all infectious diseases (excluding tuberculosis) received was 2,239, as compared with 1,690 for the year 1936. The figure for 1937 represents an increase of 32.5 per cent. on the figure for the previous year. The increase is largely accounted for by an increase in the number of cases of scarlet fever notified, and by a less evident increase in the number of cases of diphtheria and of pneumonia. The deaths from notifiable diseases (excluding tuberculosis and pneumonia) during 1937 numbered 44, compared with 31 deaths in the previous year. Main data on the weekly incidence, age grouping, and ward distribution of the principal infectious diseases are given in Tables I., II., and III. These tables do not include particulars regarding the following diseases: Malaria, cholera, relapsing fever, continued fever, typhus, plague. During the year under review, 5 cases of malaria were notified. There were no deaths from this or any of the other diseases mentioned, and no notifications were received in respect of these other conditions. No case of anthrax or of rabies came to the notice of the department. The following was the quarterly distribution of notifications of all notifiable infectious diseases (exclusive of tuberculosis) during the year: 1st quarter, 523; 2nd quarter, 412; 3rd quarter, 631; 4th quarter, 673. Of the 2,239 notifications, 27.7 per cent. referred to patients under 5 years of age, 61.3 per cent. to patients under 10 years, and 73.0 per cent. to patients under 15 years. The deaths from the seven principal zymotic diseases—viz. smallpox, scarlet fever, diphtheria, enteric fever, measles, whooping cough, and diarrhoea and enteritis (under two years)— numbered 89, which gives a death rate of 0.34 per 1,000 living. For the years 1936, 1935 and 1934 the respective number of deaths from these seven conditions were 161, 82, and 206; and the death rates per 1,000 living were 0.61, 0.38 and 0.74. As judged by 118 Table 1. Weekly and quarterly notifications of infectious diseases. Week Smallpox Scarlet fever Diphtheria Enteric fevers Puerperal fever Puerperal pyrexia Acute pneumonia Erysipelas Cerebrospinal fever Ophthalmia neonatorum Poliomycl. & polioenceph Encephalitis lethararica Dysentery Tuberculosis Measles (1) Whooping cough (2) Pulmonary Other l - 17 6 - - 3 23 3 — — — - — 6 2 2 — 11 5 — 1 — 36 3 — — 1 — — 7 — 3 — 9 7 2 — 2 27 4 - - - - - 8 3 4 — 13 2 — 1 1 16 2 - - - - - 7 4 5 — 14 V — — — 9 6 1 — — — — 6 1 6 - 8 9 2 — 1 4 6 1 — 1 — — 4 1 7 — 11 8 — — 1 3 4 — — — — — 7 2 8 — 10 8 — 1 3 8 1 1 — — — — 3 2 9 — 10 10 — — 1 4 2 — — — — — 6 1 10 — 17 11 1 — 1 2 6 — — — — 1 7 1 11 — 26 7 — — 3 9 2 — — — — 1 8 4 12 — 19 8 — — 1 12 — — — — — — 8 1 13 — 15 8 — — 3 14 4 — — — — — 3 1 1st qr. — 180 96 5 3 20 167 43 3 — 2 — 2 80 23 14 — 6 7 — 1 2 7 2 — 1 — — — 5 — 15 — 17 6 — - — 4 4 — 1 — — 1 9 3 16 — 20 3 — — — 8 2 — — — — — 11 2 17 — 15 5 — — 2 8 3 — — — — — 5 3 18 — 15 7 1 — — 5 — 1 — — — — 8 1 19 — 8 11 — — 2 7 3 1 — 1 — — 5 1 20 — 11 8 — — 2 4 2 — — 1 — — 5 2 21 — 9 10 — — 3 4 5 1 1 1 — — 10 4 22 — 6 4 — — 2 7 — — — 1 — — 10 2 23 — 11 6 — — — 7 3 — — — — — 7 2 24 — 10 7 — — 2 3 2 — 1 1 — — 8 4 25 — 24 6 — — 1 3 7 — 1 3 — — 8 3 26 — 25 12 2 - 2 5 2 - - 1 — - 1 1 2nd qr. — 177 92 3 1 18 72 29 3 5 9 - 1 92 28 27 - 26 11 — — 9 6 2 — — 1 — — 3 1 28 — 26 14 — — 3 1 3 - - - - - 8 1 29 — 26 13 — — — 5 — — — — — — 3 1 30 — 30 9 — — 2 4 3 — — 1 — — 3 — 31 — 18 3 — — 1 4 4 — 1 — — — 9 1 32 — 15 6 1 — 1 1 4 — — 1 — — 5 1 33 — 14 9 — — — 1 — — — — — 5 1 34 — 9 7 — — 2 4 — — — — — — 5 3 35 — 32 18 — — 1 4 3 — — 1 — — 7 — 36 — 33 19 1 — 1 4 2 — — 1 — — 2 — 37 - 42 19 1 — - 2 4 — — 1 — — 3 — 38 — 39 10 — — 5 4 5 — — — — — 3 1 39 — 48 19 — — 4 4 6 — — 1 — — 9 — 3rd qr. — 358 157 3 — 22 44 38 — 1 7 — — 65 10 40 — 36 14 — *- 1 3 — — — 2 — 1 8 1 41 — 31 1/ 3 — 2 6 5 - - - - - 8 1 42 — 37 13 1 — 2 4 3 - - - - - 3 — 43 — 37 15 — — — 3 9 — — — — — 1 2 44 — 31 8 — — 1 1 6 — 2 — — — 7 3 45 — 25 12 — — 2 12 1 1 — — — — 6 — 46 — 26 10 — — — 6 3 — 1 — — — 7 2 47 — 30 14 — — 2 6 2 — — — — — 6 1 48 — 33 14 — — — 4 2 — — — — — 5 1 49 — 21 12 — — — 8 6 — 1 — — — 5 - 50 — 21 5 — — 2 4 10 — — — — — 4 — 51 — 15 12 — — 2 6 4 — .— — — — 4 — 52 — 16 12 — — 1 8 6 1 - - - - - - 4th qr. — 359 158 4 — 15 71 57 2 4 2 — 1 64 11 Whole year - 1074 503 15 4 75 354 167 8 10 20 — 4 301 72 *Puerperal fever ceased to be notifiable on 3rd October, 1937. (1), (2). These diseases were not notifiable during 1937. 119 120 Table II. Infectious diseases. 1937. Cases and deaths by age and sex. Ages (years) Scarlet fever Diphtheria Enteric fever Erysipelas Pneumonia Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases (acute) Deaths (all forms) M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Under 1 4 5 — — 4 4 . — 1 — — - - 1 1 1 1 15 12 33 18 1— 30 27 — 1 11 14 — 1 — — — — — 1 — — 10 18 10 10 2— 29 30 — 1 19 11 2 1 1 — — — 1 — — — 7 7 2 9 3— 35 35 — — 26 13 — 1 — 1 — — 1 — — — 8 2 1 2 4— 65 64 — — 37 29 — 1 1 — — — — — — — 5 4 9 1 5— 65 86 — — 22 32 3 1 - - - - - - - - 4 4 1 — 6— 50 72 — — 34 24 — 1 — — — — — — — — 7 5 - - 7— 56 51 — — 35 22 — 2 — — — — — — — — 7 4 - 1 8— 33 32 — — 13 13 — — — — — — — 2 — — 1 1 - — 9— 25 23 — 1 10 15 — — — — — — — — — - 2 2 - - 10— 65 81 1 — 30 57 1 2 — 2 — — 3 6 — — 10 4 - 1 15— 27 24 — — 3 12 — 1 2 3 1 — 4 7 — — 16 6 1 - 20— 11 13 — — — 3 — — — 2 — — 3 6 — — 13 5 1 9 25— 8 19 — — 9 6 — — 1 — — — 6 7 — — 23 13 9 3 35— 1 3 — — - 2 — — — 2 — — 9 15 — — 29 14 5 5 45— 2 2 — — - — — — — — — — 13 25 — — 22 14 22 9 55— - 1 - - - - - - - - - - 15 22 2 1 18 14 29 14 65 - - - - - - - - - - - - 6 7 — — 6 12 15 22 75— - - - - - - - - - - - - 2 4 — — 6 4 15 14 All ages 506 568 1 3 246 257 6 12 5 10 1 — 64 103 3 2 209 145 146 104 121 Table II. (continued). Infectious diseases. 1937. Cases and deaths by age and sex. Ages (years) Cerebrospinal fever Acute poliomyelitis and polio-encephalitis Encephalitis Iethargiea Dysentery Puerperal pyrexia Puerperal fever Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths M. F. M. F. M. F. M. F. m. f. m. f. m. f. m. f. Under 1 3 — 3 — 4 — 1 — — — — — - 1 - - 1— - - - - 2 - - - - - - - - - - - 2— - 1 - 1 1 1 - - - - - - - - - - 3— 1 1 - - 2 - - - - - - - - - - - 4— - - - - 1 2 - - - - - - - - - - 5— - - - - - - - - - - - - - - - - 6— - - - - 1 1 - - - - - - - - - - 7— 1 — 1 — 1 1 - - - - - - - - - - 8— - - - - - - - - - - - - - - - 9— - - - - - - - - - - - - - - - - 10— - - - - - 1 - - - - - - - - - - 15— - - - 1* - - - - - - - - - - - - 2 - 20— - - - - - - - - - - - - - - - - 20 - 25— 1 - 1 - - - - - - - 1 - 1 - - 47 - 35— - - - - - - - - - - 1 - 1 - - - 10 - 45— - - - - - 1 - 1 - - - 2 - - - - - - 55— - - - 1 - - - - - - - 2 - - - - - - 65— - - - - - - - - - - - - 1 - - - 75— - - - - - - - - - - - - - - - — All ages 6 2 5 3 13 7 1 1 — — 2 4 3 1 — — 79 — *Death of case notified in 1936. 122 Table III. Infectious diseases in wards. 1937. No. of cases (C): No. removed to hospital (R): No. of deaths (D). Ward Scarlct fever Diphtheria Enteric fevers Erysipelas Acute pneumonia Cerebrospinal fever Acute poliomyelitis and encephalitis Encephalitis Iethargiea Dysentery Ophthalmia neonatorum Puerperal fever and pyrexia C R D C R D C It D C R D C R D C R D C R D C R D C R D C R D C R D New Town 58 47 — 15 15 1 — — — 16 7 — 14 8 14 — — - - — - - - 1 1 1 - - - - 3 2 - Forest Gate 68 53 1 11 10 1 — — — 9 3 — 15 7 19 — — — 1 — — — — — - — — 1 1 — 14 14 — High Street 53 47 — 21 21 — — — — 10 6 1 21 12 16 1 1 1 2 2 - - - - - - - - - - 4 4 — Broadway 23 21 — 21 21 — 1 1 — 6 2 2 15 6 15 — — — 1 1 — - - 1 - - - - - — 13 13 — Park 40 38 — 26 24 3 — — — 5 2 — 17 6 16 — — — 2 2 - - - - - - - - - - 8 6 - Upton 41 33 — 11, 10 1 1 1 — 8 2 — 15 6 22 — — — 1 1 - - - - - - - - - - 4 3 — Plashet Road 94 75 - 14 13 — — — — 5 1 — 12 3 8 1 1 *2 1 1 1 - - - - - - 2 2 - 2 1 - West Ham 50 40 — 45 45 — 3 — 5 1 — 16 10 15 - — - 2 2 - - - - - - - - 1 1 — 3 3 — Plaistow 155 118 — 38 38 1 1 1 — 12 2 - 23 6 17 - - - - - - - - - - - - - - - 4 4 — Bemersyde 37 30 — 11 11 1 1 1 — 6 2 — 14 1 8 - - - - - - - - 1 - - - - - - 2 - - Canning Town and Grange 117 92 1 67 67 3 1 1 - 14 5 - 34 15 21 2 2 1 4 4 1 - - 1 - - - - - - 1 1 - Hudsons 95 75 1 70 69 1 - 3 — 16 6 1 23 10 14 — — — 1 1 — — — - - — — 1 — — 8 4 — Ordnance 55 45 — 52 51 1 2 2 1 10 2 - 31 17 13 1 1 1 1 1 - - - 1 - - - 1 1 — 6 — — Beckton Road 44 37 — 30 30 1 — — — 16 8 1 35 16 20 1 1 1 1 1 - - - - - - - 2 - - 3 2 - Tidal Basin 63 52 — 19 19 1 1 1 — 16 12 — 34 14 16 1 1 1 - - - - - 1 - - - 2 - - 1 - - Custom House and Silvertown 81 69 1 52 52 3 1 1 — 13 8 — 35 20 16 1 1 1 3 3 — — — — 3 3 — — — — 3 2 — Totals 1,074 872 4 503 496 18 15 15 1 167 69 5 354 157 250 8 8 8 20 19 2 — — 6 4 4 — 10 5 — 79 59 — *One case notified in 1936 these conditions the year 1937 must be considered a healthy year. This zymotic death rate takes no account, however, of deaths from pneumonia and influenza, which together contribute considerably to the total mortality of any area. The total number of the notified cases removed to hospital was 1,709. This gives a removal rate of 76.3 per cent., as compared with rates of 70.8 for 1936, 73.7 for 1933, and 65.6 for 1934. It is satisfactory to note that the removal rate is on the whole increasing, although the conditions to which this state gives rise are not unassociated with certain difficulties. The accommodation at the isolation hospital is sometimes taxed to the utmost, and at certain seasons a few cases of scarlet fever and diphtheria have to be treated in the London Fever Hospital. During the year 1937 the number of patients who were admitted to that institution was 104, of whom 99 suffered from scarlet fever and 5 from diphtheria. It should be noted that, a's in the tables in the section on Vital Statistics, the rates given in the tables in this section are crude rates. Therefore, the reservations which are mentioned on page 57 should be borne in mind in the study of these tables. SMALLPOX. No case of this disease was notified during the year. In connection with the diagnosis of smallpox, three requests for a consultant's opinion were received from practitioners during the year. In each instance the final diagnosis was chicken-pox. Particulars of the work carried out in connection with vaccination are given on page 46. SCARLET FEVER. The number of cases of scarlet fever which were notified during the year was 1,074, as compared with 666 in 1936 and 1,057 in 1935. Of the 1,074 cases, 506 were males and 568 were females, The case rate was 4.14 per 1,000 of the population. The number of deaths from this disease was 4, of which one was the death of a male, and 3 were deaths of females. The death rate per 1,000 of the population was 0.02, and the fatality rate was 0.37 per cent. The number of patients removed to hospital was 872, which gives a removal rate of 81.19 per cent. The disease was of a mild type and the fatality was the lowest since 1925. 123 Table IV. Notifications of scarlet fever. Period Notifications Removals to hospital Fatality Per cent. England and Wales. Case rate per 1.000 living No. Rate per 1,000 living. No. Per cent. 1888-1890 1,822 3.20 — — 9.50 - 1891-1895 7,414 6.77 — — 3.47 — 1896-1900 5,203 4.16 920 17.68 2.69 — 1901-1905 5,480 4.02 2,115 38.59 3.12 — 1906-1910 7,412 5.24 3,939 53.14 2.94 — 1911-1915 4,351 2.97 3,051 70.12 1.52 3.50 1916-1920 4,103 2.90 1,944 47.38 0.83 2.13 1921-1925 3,837 2.45 2,855 74.41 0.96 2.64 1926-1930 7,182 4.64 4,829 67.24 0.40 2.53 1931-1935 5,286 3.73 3,974 75.18 0.68 2.82 1921 1,695 5.52 1,119 66.02 0.65 3.64 1922 746 2.40 592 79.36 1.21 2.85 1923 530 1.69 412 77.74 1.32 2.24 1924 388 1.20 320 82.47 1.03 2.16 1925 478 1.50 412 86.19 1.26 2.36 1926 1,311 4.15 934 71.24 0.53 2.10 1927 1,987 6.30 1,230 61.90 0.35 2.16 1928 1,513 4.93 923 61.00 0.33 2.61 1929 1,455 4.73 1,032 70.93 0.41 3.05 1930 916 2.99 710 77:51 0.44 2.76 1931 657 2.21 551 83.87 0.76 2.05 1932 672 2.32 598 88.99 0.45 2.12 1933 1,356 4.79 1,034 76.25 0.44 3.21 1934 1,544 5.59 996 64.51 1.04 3.75 1935 1,057 3.90 795 75.21 0.57 2.96 1936 666 2.51 494 74.17 0.60 2.56 1937 1,074 4.14 872 81.19 0.37 2.33 124 Table V. Deaths from scarlet fever (all ages). (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 327 — — 0.56 0.716 0.648 0.681 1881-1885 — — 391 — — 0.54 0.451 0.419 0.435 1886-1890 — — 238 — — 0.26 0.248 0.234 .0.241 1891-1895 — — 257 — — 0.23 0.186 0.179 0.182 1896-1900 — — 140 — — 0.11 0.140 0.129 0.134 1901-1905 — 171 — — 0.13 0.132 0.121 0.126 1906-1910 — — 218 — — 0.15 0.091 0.082 0.086 1911-1915 27 39 66 0.04 0.05 0.05 0.065 0.059 0.062 1916-1920 15 19 34 0.02 0.03 0.02 0.037 0.030 0.033 1921-1925 21 16 37 0.03 0.02 0.02 0.029 0.029 0.029 1926-1930 19 10 29 0.03 0.01 0.02 0.017 0.016 0.017 1931-1935 21 15 36 0.03 0.02 0.03 0.016 0.017 0.017 1921 6 5 11 0.04 0.03 0.04 0.035 0.034 0.034 1922 5 4 9 0.03 0.03 0.03 0.036 0.037 0.036 1923 5 2 7 0.03 0.01 0.02 0.027 0.024 0.026 1924 1 3 4 0.01 0.02 0.01 0.022 0.023 0.023 1925 4 2 6 0.03 0.01 0.02 0.026 0.025 0.025 1926 3 4 7 0.02 0.02 0.02 0.019 0.016 0.017 1927 5 2 7 0.03 0.01 0.02 0.015 0.014 0.015 1928 4 1 5 0.03 0.01 0.02 0.014 0.015 0.015 1929 5 1 6 0.03 0.01 0.02 0.019 0.017 0.018 1930 2 2 4 0.01 0.01 0.01 0.018 0.019 0.019 1931 1 4 5 0.01 0.03 0.02 0.012 0.014 0.014 1932 2 1 3 0.01 0.01 0.01 0.012 0.014 0.013 1933 2 4 6 0.01 0.03 0.02 0.018 0.019 0.018 1934 12 4 16 0.09 0.03 0.06 0.024 0.024 0.024 1935 4 2 6 0.03 0.01 0.02 0.013 0.015 0.014 1936 1 3 4 0.01 0.02 0.02 0.013 0.012 0.012 1937 1 3 4 0.01 0.02 0.02 0.009 0.008 0.009 125 Incidence by age and! season. From Table I. it will be seen that one-third of the cases occurred in the first half of the year, one-third in the third quarter, and one-third in the fourth quarter. The weekly incidence reached its maximum in the last three weeks of the third quarter, and from then onwards there was no marked change in the weekly incidence until the end of November. There was no definite epidemic at any period during the year. The largest number of cases—viz. 155—occurred in Plaistow ward, and this ward actually had the highest incidence with a case rate of 8.80 of the population. The wards with the next highest incidence were Plashet Road (7.47), Canning Town and Grange (6.40), Hudsons (5.23), Custom House and Silvertown (4.46), and Forest Gate (4.12). The lowest incidence was in Broadway (1.76). From the point of view of age grouping, 30.3 per cent. of the cases occurred in persons under the age of 5 years, 45.3 per cent. between the ages of 5 and 10 years, and 13.6 per cent. between the ages of 10 and 15 years. The percentage of males attacked throughout the year was 47.3, but this percentage was by no means constant in different age groups. At certain age periods the excess percentage of females was considerably higher. The statistics of scarlet fever are set out fully in Tables IV. and V. The statistics for incidence show that there has been considerable variation in the prevalence of this condition during the last fifty years. The highest incidence was reached in the period 1881-1895, and the lowest quinquennial rate was in the period 1916-1920. Annual rates show that there has been an increase of prevalence at intervals of about six or seven years. The general trend of incidence is certainly downwards. Comparison of the local rates with those for England and Wales show the slight excess incidence associated with an urban area. The death rate from scarlet fever has decreased enormously in the last sixty years. From the figures given it will be seen that the highest death rate—0.56 per 1,000 living—occurred in the earliest period, namely 1876-1880. During the period 1886-1895 the death rate was reduced to a half of what it had been, and in the ensuing fifteen years the death rates were again approximately halved. Sintce 1911 there has been a further marked decrease in the rate, so that the number of deaths which are due to this disease 126 now number very few indeed. The reduction has been so considerable that the death rates for individual years are now of little value except to show broadly that deaths have been few. A comparison of these local figures with the rates for the country as a whole shows that the decline has been very comparable in the two areas. Only in the period 1906-1910 is there any indication that there was some excess mortality in the local rates. There has been little difference in the death rates for the two sexes in the country as a whole. The local figures are based on so few deaths that a definite statement on this point is hardly warranted, but the figures suggest that mortality in males in this area is somewhat higher than in females. The case mortality has shown a corresponding decline in the last fifty years. In the period before 1890 scarlet fever was a serious disease which was fatal in about ten per cent, of cases. Between 1890 and 1910 there was a considerable decline in fatality, but an even more marked decline occurred during the war period. The mortality at the present day is less than a tenth of what it was in the "eighties." The fatality rates for individual years being based upon small numbers of deaths are liable to misinterpretation. The figures which I have given for this area present very emphatically one aspect of the problem of scarlet fever. There is, however, a more sinister aspect. This condition was equally mild three centuries ago, and at that period the most famous physician of the day referred to it contemptuously as "this name of a disease." Yet about a hundred years later scarlet fever occupied a high place among the causes of death. Although it is to be hoped that the present low mortality will continue, false optimism should not be encouraged. The serum treatment of the condition has given the physician a weapon which was unknown to our ancestors, but the lesson of diphtheria shows that the introduction of a new and very virulent strain of an organism into the community will tax the resources of even the most modern methods of treatment. DIPHTHERIA. The number of cases of diphtheria notified during the year was 503, as compared with 468 in 1936 and 771 in 1935. Of the 503 cases, 246 were males and 257 were females. The case rate 127 Table VI. Notifications of diphtheria (including membranous croup). Period Notifications Removals to hospital Fatality per cent. England and Wales. Case rate per 1.000 living No. Rate per 1,000 living. No. Per cent. 1888-1890 389 0.68 — — 32.13 — 1891-1895 2,747 2.51 — — 23.19 — 1896-1900 5,103 4.08 1,231 24.12 16.97 — 1901-1905 3,968 2.91 1,926 48.54 12.83 — 1906-1910 2,646 1.87 1,803 68.14 12.06 — 1911-1915 2,089 1.43 1,705 81.62 10.91 1.41 1916-1920 3,810 2.70 2,921 76.67 9.97 1.49 1921-1925 3,600 2.30 3,312 92.00 4.28 1.29 1926-1930 4,381 2.83 3,957 90.32 3 65 1.53 1931-1935 2,749 1.94 2,672 97.20 6.00 1.36 1921 659 2.15 560 84.98 4.86 1.76 1922 673 2.17 611 90.79 6.54 1.37 1923 701 2.23 671 95.72 3.85 1.05 1924 801 2.48 751 93.76 4.12 1.07 1925 766 2.41 719 93.86 2.35 1.23 1926 698 2.21 669 95.85 1.86 1.31 1927 954 3.02 802 84.07 4.19 1.33 1928 1,049 3.42 913 87.04 3.24 1.55 1929 815 2.65 767 94.11 4.79 1.59 1930 865 2.82 806 93.18 3.93 1.84 1931 356 1.20 356 100.00 3.09 1.26 1932 303 1.05 295 97.36 3.96 1.08 1933 515 1.82 498 96.70 10.49 1.18 1934 804 2.91 788 98.01 6.09 1.70 1935 771 2.85 735 95.33 5.06 1.60 1936 468 1.76 464 99.15 3.21 1.41 1937 503 1.94 496 98.61 3.58 1.49 128 Table VII. Deaths prom diphtheria and membranous croup (all ages). (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1s80 — — 47 — — 0.08 0.117 0.127 0.122 1881-1885 — — 158 — — 0.22 0.152 0.161 0.157 1886-1890 — — 231 — — 0.25 0.164 0.175 0.170 1891-1895 — — 637 — — 0.58 0.253 0.254 0.253 1896-1900 — — 866 — — 0.69 0.275 0.270 0.272 1901-1905 — — 509 — — 0.37 0.205 0.203 0.204 1906-1910 — — 319 — — 0.23 0.153 0.154 0.154 1911-1915 106 122 228 0.15 0.16 0.16 0.144 0.137 0.140 1916-1920 206 174 380 0.30 0.24 0.27 0.157 0.133 0.143 1921-1925 70 84 154 0.09 0.10 0.10 0.090 0.086 0.088 1926-1930 67 93 160 0.09 0.12 0.10 0.081 0.079 0.080 1931-1935 76 89 165 0.11 0.12 0.12 0.077 0.074 0.076 1921 13 19 32 0.09 0.12 0.10 0.127 0.125 0.126 1922 20 24 44 0 13 0.15 0.14 0.112 0.102 0.107 1923 13 14 27 0.08 0.09 0.09 0.072 0.070 0.071 1924 17 16 33 0.11 0.10 0.10 0.065 0.064 0.065 1925 7 11 18 0.05 0.07 0.06 0.072 0.070 0.071 1926 7 6 13 0.05 0.04 0.04 0.076 0.077 0.077 1927 19 21 40 0.12 0.13 0.13 0.071 0.068 0.070 1928 11 23 34 0.07 0.15 0.11 0.084 0.078 0.081 1929 17 22 39 0.11 0.14 0.13 0.086 0.088 0.087 1930 13 21 34 0.09 0.14 0.11 0.090 0.085 0.088 1931 4 7 11 0.03 0.05 0.04 0.070 0.064 0.067 1932 4 8 12 0.03 0.05 0.04 0.058 0.058 0.058 1933 28 26 54 0.20 0.18 0.19 0.067 0.065 0.066 1934 24 25 49 0.18 0.18 0.18 0.102 0.100 0.101 1935 16 23 39 0.12 0.17 0.14 0.088 0.084 0.086 1936 7 8 15 0.05 0.06 0.06 0.078 0.073 0.075 1937 6 12 18 0.05 0.09 0.07 0.070 0.074 0.072 I 129 was 1.94 per 1,000 of the population. The number of deaths from this disease was 18, of which 6 were of males and 12 of females. The death rate per 1,000 of the population was 0.07, and the fatality rate was 3.58 per cent. The number of patients removed to hospital was 496, which gives a removal rate of 98.61 per cent. Age and seasonal incidence. Reference to Table I. will show that, as is usually the case with this disease, three-fifths of the attacks occurred during the third and fourth quarters of the year. The incidence in the early part of the third quarter was perhaps a little higher than is often found to be the case, but there was nothing to suggest epidemic prevalence during any particular week. Table III. shows that the greatest number of cases occurred in the Hudsons Ward. The case rate here was 3.85 per 1,000 of the population, and the wards with the next highest incidence rates were West Ham (3.22), Ordnance (3.06), Custom House and Sivertown (2.86), Canning Town and Grange (2.73), and Plaistow (2.16). The lowest incidence (0.67) was found in Forest Gate ward, but several other wards had low rates. From the standpoint of age incidence it can be shown from Table II. that 77.1 per cent. of the cases occurred under the age of ten years, and that 77.8 per cent. of the deaths occurred under this age. On the other hand, there was no marked variation in the case mortality at different age periods. Under 3 years this rate was 4.16 per cent.; from five to ten years it was 3.18 per cent.; and over ten years 3.48 per cent. A notable feature of the figures for this year was the great excess of females in cases over the age of ten years. At these ages 80 females were attacked as against 35 males. The statistics of diphtheria are set out fully in Tables VI. and VII. The figures for incidence which are given in Table VI. show considerable variation in the quinquennial periods. The low rate in the first period is probably explained by the fact that the practice of notification had not then been adopted by practitioners as fully as it might have been. During the period 18911905 the case rate was high, with a peak towards the middle of the period, and since the latter date there has been some reduction in the case rates. In many areas diphtheria shows peak periods which are separated by about eight or ten years, and the same factor can be shown to be operative in the local rates. This factor 130 also serves to lessen the value of a comparison between the local rates and those for the country as a whole. Diphtheria is not at its maximum incidence throughout the country in any one year, and the rates for England and Wales therefore tend to show less marked variations than do the local rates. It is nevertheless significant that the local rates are often almost double the national rates. This excess incidence is partly accounted for by the urban nature of the local community. The death rates reflect a more satisfactory state of affairs. In the early periods covered by Table VII. deaths from diphtheria were often attributed to other diseases, and consequently the mortality was comparatively low. The true mortality from this disease is apparent in the period 1891-1900, when it averaged over 0.6 per 1,000 of the population. Improvements in treatment, especially the introduction of antitoxin treatment, led to a progressive reduction in mortality, and the average rate during the last fifteen years is only about one-sixth of the rate for the closing years of last century. It should be noted that until the post-war period the local rates were often more than double the national rates, but that within recent years this difference has tended to disappear. Locally there has been no significant difference in the rates for males and females respectively, and this similarity in the effects of the disease on the two sexes is borne out by the national rates. An instructive demonstration of the results of efficient treatment in this disease is given in column 6 of Table VI. It will be seen that the fatality rate in the pre-antitoxin era was very high, and that a quarter or more of all affected persons died. Since the closing years of last century this rate has decreased rapidly and progressively—with the exception of the rate for the years 19311935. The excess fatality in this period was caused by the very high rate in 1933, and by slightly lower rates in the two succeeding years. I have so far not obtained any direct bacteriological evidence on this point, but there appears to be no reason to doubt the fact that these high rates were caused by the introduction of a new and very virulent strain of the organism into the community in the year 1933, and it is probable that the strain was the gravis strain, which was then prevalent in certain other cities. This occurrence points to the fact that no definite conclusion should ever be drawn regarding the future behaviour of this disease. 131 Supply of antitoxin to practitioners. A supply of diphtheria antitoxin is kept at the Health Department for the use of practitioners who may desire to begin treatment before the patient is removed to hospital. After office hours antitoxin may be obtained from the Isolation Hospital. During the year 1937 seven requests for antitoxin were received by the department from local practitioners, and the average amount issued per patient was 18,000 units. The number of requests for the years 1932 to 1936 inclusive were 8, 15, 31, 26 and 3 respectively. It would seem that there is normally little demand for this service, and that it is only when diphtheria becomes especially prevalent or virulent that any large call is made upon it. From the point of view of treatment there is no doubt that the most satisfactory procedure is to admit the patient to hospital at the earliest possible moment. Immunization against diphtheria. Immunization against diphtheria is carried out at three clinics; the majority of the children are immunized at West Ham Lane clinic. In addition, immunization of children who have been admitted to Plaistow Hospital for various reasons is carried out at the hospital. Particulars of the latter service are given in the report of the medical superintendent. Immunization is also carried out by general practitioners who receive the immunizing reagent from the Public Health Department. During the year 1937 the total number of children immunized at the clinics was 557. Of these, 349 were under five years of age and 208 were over five years of age. The number of final Schick tests carried out at the clinics was 389. Of these only 11 gave a positive result. In each of these cases further doses were given and further tests were carried out. The number of children immunized by practitioners was 19. The question of diphtheria in immunized children is dealt with in the report of the medical superintendent of Plaistow Hospital. I do not propose to deal further with the question of the prevention of diphtheria in this report. A brief review of the position is sufficient to show that the proportion of the child population which has been immunized is low, and that the number of susceptible children in the community must be large. 132 ENTERIC FEVER. The number of cases of enteric fever notified during the year was 15 as compared with 5 during the previous year and 3 during 1935. Of these cases 5 were males and 10 females. The case rate was 0.06 per 1,000 living. One death in a male was registered, and the death rate was 0.004 Per 1,000 of the population. The fatality rate was 6.67 per cent. All the patients notified were treated in hospital. The cases were spread fairly equally throughout the year, 5 occurring in the first quarter, 3 in the second quarter, 3 in the third quarter, and 4 in the fourth quarter. The ward distribution was also fairly broad, as will be seen from Table III. In considering this table it should be mentioned that two cases occurred in the same house in Ordnance ward, and a similar happening took place in West Ham ward. Ten of the 15 cases were between the ag'es of 15 and 45 years, but 3 of the cases were between the ages of 2 and 5 years. In Tables VIII. and IX. the statistics of enteric fever arc set out since the last years of last century. The enormous decrease in the number of notifications is well seen. The incidence in the closing years of the nineteenth century was about eighty times greater than what it was in the period 1931-1935. A comparison with the incidence rates for England and Wales so far as they are available shows a corresponding decline. The death rates which are set out in Table IX. give an even more significant illustration of the changes which have been effected in the comparatively short space of fifty years. The death rate from enteric fever in West Ham for the period 1881-1885 was almost 120 times greater than what it was in the period 1931-1935. There is 110 doubt that the decline in mortality from this disease is a striking piece of evidence of the beneficial results of an enlightened system of public health practice. The statement refers especially to the great improvement in water supply, which was effected in the early years of the present century, and to the concurrent and subsequent improvement in the methods of disposal of faecal matter. The abolition of the privy, in itself an event apparently only distantly related to the science of medicine, was fraught with results which were farreaching in their effect on the health of the nation. The sporadic cases which occur nowadays are usually due to carriers or to infected food, and their origin is therefore often difficult to trace. 133 Table VIII. Notifications of enteric fever. Period Notifications Removals to hospital Fatality per cent. England and Wales Case rate per 1,000 living No. Rate per 1,000 living No. Per cent. 1888-1890 451 0.79 — — 27.72 — 1891-1895 1,301 1.19 — — 18.91 — 1896-1900 1,945 1.56 192 9.87 17.58 — 1901-1905 1,737 1.28 754 43.41 16.23 — 1906-1910 827 0.58 582 70.37 14.75 — 1911-1915 427 0.29 330 77.28 19.67 0.25 1916-1920 220 0.16 140 63.64 14.55 0.12 1921-1925 93 0.06 41 44.09 13.98 0.09 1926-1930 77 0.05 61 79.22 15.58 0.08 1931-1935 31 0.02 18 58.06 9.68 0.05 1921 22 0.07 7 31.82 9.09 0.10 1922 14 0.05 3 21.43 14.29 0.06 1923 25 0.08 10 40.00 4.00 0.08 1924 19 0.06 16 84.21 21.05 0.11 1925 13 0.04 5 38.46 30.77 0.07 1926 18 0.06 16 88.89 16.67 0.07 1927 22 0.07 20 90.91 22.73 0.09 1928 20 0.07 13 65.00 5.00 0.09 1929 11 0.04 7 63.64 18.18 0.07 1930 6 0.02 5 83.33 16.67 0.07 1931 9 0.03 9 100.00 11.11 0.06 1932 9 0.03 5 55.56 0.00 0.06 1933 — — — — — 0.04 1934 10 0.04 3 30.00 10.00 0.03 1935 3 0.01 1 33.33 33.33 0.04 1936 5 0.02 5 100.00 20.00 0.06 1937 15 0.06 15 100.00 6.67 0.05 134 Table IX. Deaths from enteric fevers (all ages). (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 103 — — 0.177 0.281 0.273 0.277 1881-1885 — — 169 — — 0.234 0.230 0.203 0.216 1886-1890 — — 204 — — 0.224 0.195 0.164 0.179 1891-1895 — — 246 — — 0.225 0.194 0.154 0.173 1896-1900 — — 342 — — 0.273 0.205 0.147 0.175 1901-1905 — — 282 — — 0.207 0.135 0.092 0.113 1906-1910 — — 122 — — . 0.086 0.084 0.056 0.070 1911-1915 46 38 84 0.064 0.051 0.057 0.059 0.037 0.048 1916-1920 21 11 32 0.030 0.015 0.023 0.028 0.020 0.024 1921-1925 9 4 13 0.012 0.005 0.008 0.013 0.012 0.013 1926-1930 9 3 12 0.012 0.004 0.008 0.010 0.009 0.009 1931-1935 1 2 3 0.001 0.003 0.002 0.006 0.005 0.005 1921 1 1 2 0.007 0.006 0.007 0.017 0.015 0.016 1922 2 — 2 0.013 — 0.006 0.013 0.011 0.012 1923 1 — 1 0.007 — 0.003 0.012 0.011 0.012 1924 3 1 4 0.019 0.006 0.013 0.013 0.012 0.013 1925 2 2 4 0.013 0.012 0.013 0.010 0.010 0.010 1926 3 - 3 0.019 - 0.009 0.010 0.009 0.009 1927 3 2 5 0.020 0.012 0.016 0.010 0.009 0.009 1928 1 — 1 0.007 — 0.003 0.011 0.011 0.011 1929 1 1 2 0.007 0.006 0.007 0.010 0.009 0.010 1930 1 — 1 0.007 — 0.003 0.009 0.007 0.008 1931 - 1 1 - 0.007 0.003 0.007 0.006 0.006 1932 - - - - - - 0.007 0.006 0.006 1932 — — - — — — 0.006 0.005 0.006 1934 — 1 1 — 0.007 0.004 0.004 0.004 0.004 1935 1 — 1 0.008 — 0.004 0.004 0.004 0.004 1936 1 — 1 0.008 - 0.004 0.006 0.006 0.006 1937 1 - 1 0.008 - 0.004 0.005 0.005 0.005 135 MEASLES. The year 1937 was not a "measles year," and only one death occurred from this cause. The disease was not then notifiable, and no accurate information is available regarding the actual number of cases which occurred in the area. Measles was made notifiable in the County Borough of West Ham by an Order of the Ministry of Health, dated 29th September, 1938. The mortality statistics of measles are set out in Table X. This table shows that in the period 1931-1935 the death rate was roughly about a third of what it was in the period 1876-1880. This large decline was not a continuous process, since the mortality in the period 1876-1880 was almost doubled in the decade 1886-1895, and a marked decline did not occur until the years which succeeded the war. The decline in the death rate is apparently continuing, but such a conclusion should be accepted with some reservation. Measles, like several of the other infections of childhood, is apt to behave in a paradoxical manner. It is regrettable that I have not so far been able to obtain data for the years before 1876, since these data would probably be of considerable interest. In several areas the mortality from measles was comparatively low towards the middle of last century, and a gradual increase took place during the third and fourth quarter of the century. This increase is reflected in the rates for the country as a whole for the period 1876-1890. It is possible that Table X. starts at a period when the local rates were on the increase after a period of lowmortality, and that at the present time we are approaching the trough between two waves of high mortality, the crest of the first wave having been in the period 1891-1895. It should not therefore be assumed-that the present low rates will necessarily continue. The rates as a whole compare favourably, so far as the rate of decline is concerned, with those for England and Wales, though the local rates for individual periods are, perhaps naturally, above the national rates. As for the country as a whole, the local rates show that the mortality is nearly always slightly higher in males than in females. WHOOPING COUGH. Whooping cough is not at present a notifiable disease in this area, and no accurate information is available regarding the number of cases which occurred during the year. The number of 136 Table X. Deaths from measles at all ages. (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 205 — — 0.35 0.406 0.366 0.386 1881-1885 — — 349 — — 0.48 0.439 0.391 0.414 1886-1890 — — 581 — — 0.64 0.499 0.439 0.468 1891-1895 — — 731 — — 0.67 0.432 0.384 0.407 1896-1900 — — 689 — — 0.55 0.445 0.398 0.420 1901-1905 — — 717 — — 0.53 0.348 0.308 0.327 1906-1910 — — 820 — — 0.58 0.309 0.274 0.291 1911-1915 422 412 834 0.59 0.55 0.57 0.374 0.315 0.343 1916-1920 301 290 591 0.43 0.40 0.42 0.246 0.177 0.208 1921-1925 150 136 286 0.20 0.17 0.18 0.136 0.109 0.122 1926-1930 129 124 253 0.17 0.16 0.16 0.106 0.087 0.096 1931-1935 104 76 180 0.15 0.10 0.13 0.075 0.062 0.068 1921 3 7 10 0.02 0.04 0.03 0.066 0.053 0.059 1922 69 49 118 0.46 0.31 0.38 0.164 0.136 0.149 1923 7 5 12 0.05 0.03 0.04 0.157 0.121 0.138 1924 51 63 114 0.33 0.39 0.36 0.138 0.112 0.125 1925 20 12 32 0.13 0.07 0.10 0.153 0.122 0.137 1926 42 36 78 0.27 0.22 0.25 0.098 0.081 0.089 1927 2 4 6 0.01 0.02 0.02 0.102 0.083 0.092 1928 38 31 69 0.25 0.20 0.22 0.121 0.098 0.109 1929 6 16 22 0.04 0.10 0.07 0.092 0.080 0.086 1930 41 37 78 0.28 0.24 0.26 0.119 0.093 0.105 1931 1 2 3 0.01 0.01 0.01 0.092 0.073 0.082 1932 45 32 77 0.32 0.22 0 27 0.093 0.077 0.085 1933 — 1 1 0.00 0.01 0.01 0.053 0.044 0.048 1934 56 38 94 0.42 0.27 0.34 0.102 0.085 0.093 1935 2 3 5 0.02 0.02 0.02 0.036 0.031 0.033 1936 27 23 50 0.21 0.17 0.19 0.075 0.061 0.067 1937 1 — 1 0.01 0.00 0.00 0.028 0.023 0.026 137 Table XI. Deaths from whooping cough at all ages. (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1876-1880 379 — — 0.65 0.491 0.563 0.528 1881-1885 — — 521 – — 0.72 0.426 0.491 0.459 1886-1890 — — 700 – — 0.77 0.413 0.473 0.444 1891-1895 — — 547 – — 0.50 0.366 0.427 0.397 1896-1900 — — 629 — — 0.50 0.333 0.382 0.358 1901-1905 — — 651 — — 0.48 0.281 0.320 0.301 1906-1910 — — 583 — — 0.41 0.231 0.274 0.253 1911-1915 191 229 420 0.27 0.31 0.29 0.194 0.222 0.209 1916-1920 163 205 368 0.24 0.28 0.26 0.156 0.157 0.157 1921-1925 171 229 400 0.22 0.28 0.26 0.125 0.137 0.131 1926-1930 114 138 252 0.15 0.17 0.16 0.091 0.103 0.097 1931-1935 59 79 138 0.09 0.11 0.10 0.051 0.061 0.056 1921 11 26 37 0.07 0.16 0.12 0.113 0.128 0.121 1922 74 101 175 0.49 0.64 0.56 0.157 0.176 0.167 1923 13 10 23 0.08 0.06 0.07 0.104 0.112 0.108 1924 37 47 84 0.24 0.29 0.26 0.101 0.105 0.103 1925 36 45 81 0.23 0.28 0.25 0.149 0.162 0.156 1926 12 8 20 0.08 0.05 0.06 0.100 0.110 0.105 1927 28 45 73 0.18 0.28 0.23 0.088 0.099 0.094 1928 15 11 26 0.10 0.07 0.08 0.071 0.079 0.075 1929 50 64 114 0.33 0.41 0.37 0.147 0.172 0.160 1930 9 10 19 0.06 0.06 0.06 0.047 0.055 0.051 1931 16 19 35 0.11 0.13 0.12 0.058 0.067 0.063 1932 10 19 29 0.07 0.13 0.10 0.068 0.079 0.074 1933 21 26 47 0.15 0.18 0.17 0.051 0.061 0.056 1934 7 8 15 0.05 0.06 0.05 0.044 0.056 0.051 1935 5 7 12 0.04 0.05 0.04 0.035 0.042 0.039 1936 11 7 18 0,08 0.05 0.07 0.049 0.053 0.051 1937 5 13 18 0.04 0.10 0.07 0.041 0.045 0.043 138 deaths which took place was 18, of which 5 were of males and 13 of females. The death rate was 0.07 per 1,000 of the population. The statistics of whooping cough are given in Table XI. This table shows that, though the number of deaths which occurred in any individual year recently was comparatively small, yet the total adds up to a considerable number of young children who succumbed to a malady for which there is a possibility that prevention may be before long a practical proposition. In the last ten years the number of deaths from this disease was 333. This represents almost as many deaths as occurred in the corresponding period from diphtheria and scarlet fever combined. Table XI. shows that the downward trend of mortality which is seen in the whooping cough rates for the country as a whole is reflected in the local rates, though the latter are considerably higher than the former. In the period under review the local rates reached their peak in the period 1886-1890, when a rate of 0.77 per 1,000 living was attained. Thereafter a decline took place, mainly by three steps. The first step occurred between the period 1886-1890 and the period 1891-1895, and the lower rate persisted with little change until 1910. During the pre-war and early war years a further decline took place, and there was again little change in the new rates until after, 1925. In the most recent period, beginning in the year 1926, a further notable decline in the death rate occurred. It is possible that this step-effect has been accentuated by the periodic years of increased prevalence and mortality, but on the whole it seems that the figures do bring out a feature which is real. The rates for the country as a whole show a corresponding decline of a much more gradual and progressive nature. The differential rates for the two sexes bring out the fact that the mortality is slightly greater in females than in males. It is possible that the decline in the mortality from whooping cough is associated with the increasing practice of sending patients to hospital—especially if they are suffering from certain complications. This practice is to be highly commended, and it is a pity that it is not more widely recognised by parents that many lives could be saved if medical advice were obtained early in the course of the disease, so that the patient could be admitted to hospital if necessary. 139 ERYSIPELAS. The number of cases of erysipelas notified during the year was 167, of which 64 were males and 103 females. This gives a case rate of 0.64 per 1,000 living. The corresponding numbers of cases for the years 1934, 1935, and 1936, were 174, 126, and 145 respectively. The number of deaths was 5, which gives a death rate of 0.02 per 1,000 of the population. The number of patients removed to hospital was 69, so that the removal rate was 41.32 per cent. Age and seasonal incidence. Table I. shows that the cases occurred fairly regularly throughout the year. The highest incidence was in the fourth quarter. From Table II. it will be seen that the largest proportion—77.7 per cent.—of the patients were over the age of 45 years. From the figures for the year 1937 it is evident that the disease was especially fatal under 1 year of age, and in the decade 55 to 65 years. The incidence was highest in the New Town ward (1.04 per 1,000 living), and the wards with the next highest incidence were Beckton Road (0.92), Hudsons (0.88), Tidal Basin (0.78), and Custom House (0.72). The lowest incidence (0.36) occurred in the West Ham Ward. The statistics of erysipelas since 1891 are given in Table XII. The case rate has shown a slight reduction from a maximum of 0.94 in the period 1911-1915 to 0.60 in the period 1931-1935. The rates are about 50 per cent. higher than the corresponding case rates for England and Wales. The death rates on the other hand have shown a marked decline from a rate of 0.08 forty years ago to a rate of 0.02 in the last quinquennial period. The decline is more obvious in the local than in the national rates. These data for erysipelas are particularly interesting if they are viewed together with the data for scarlet fever. In both diseases a relatively enormous decline in the death rate has been effected in the space of forty or fifty years, but in the same period there has been only a slight reduction in the attack rate. In both diseases the decline in the mortality is due largely to a reduction of the fatality in individual cases. The fatality of scarlet fever declined to about one-fifth of what it was in the period 1901-1905, and the fatality of erysipelas declined to about a third of what it was at that period. In both diseases these features were associated with an increasing removal rate—though in the cases of erysipelas this increase was intermittent. 140 Table XII. Erysipelas. Notifications and deaths. Period West Ham Crude rates per million living Cases Deaths Fatality per cent. Removed to hospital West Ham England and Wales No. Per cent. Case rate Death rate Case rate Death rate 1891-1895 — 82 — — — — 75 — 48 1896-1900 — 62 — — — — 50 — 35 1901-1905 992 71 7.16 52 5.24 728 52 — 36 1906-1910 1,214 53 4.37 123 10.13 858 37 — 28 1911-1915 1,381 49 3.55 264 19 12 943 33 669 27 1916-1920 1,012 38 3.75 68 6.72 716 27 434 20 1921-1925 848 26 3.07 158 18.63 541 17 347 19 1926-1930 1,027 20 1.95 180 17.53 664 13 414 23 1931-1935 844 24 2.84 310 36.73 596 17 423 28 1921 165 13 7.88 19 11.52 537 42 349 19 1922 153 — 0.00 32 20.92 493 0 345 18 1923 138 4 2.90 17 12.32 439 13 321 16 1924 177 8 4.52 32 18.08 558 25 332 17 1925 215 1 0.47 58 26.98 675 3 385 22 1926 213 2 0.94 41 19.25 674 6 373 21 1927 197 8 4.06 27 13.71 625 25 374 21 1928 200 4 2.00 30 15.00 652 13 414 23 1929 188 6 3.19 41 21.81 611 20 447 26 1930 229 — 0.00 41 17.90 760 0 460 26 1931 188 13 6.91 73 38.83 634 44 381 25 1932 158 — 0.00 59 37.34 546 0 361 25 1933 198 3 1.52 78 39.39 700 11 446 30 1934 174 8 4.60 55 31.61 630 29 510 36 1935 126 — 0.00 45 35.71 465 0 416 26 1936 145 – 0.00 48 33.10 546 0 403 24 1937 167 5 2.99 69 41.32 644 19 370 14 141 The significance of these findings lies in the fact—the importance of which has been recognised only within recent years —that erysipelas and scarlet fever are both due to the same type of organism. These "streptococci" may be very widespread in the throats of apparently healthy individuals, and while many escape with mild and ill-defined infections, others develop a disease which can be given a name. In both diseases increasing hospitalization has done little to reduce the incidence, but in both this factor has been accompanied by a significant reduction in the proportion of fatal cases. Whether these two features stand to each other in the relation of cause and effect is a matter which cannot be dealt with here. ENCEPHALITIS LETHARGICA. No cases of this disease were notified during the year. There were six deaths of patients who had been notified in previous years as having contracted the disease. ACUTE POLIOMYELITIS. There was a slight increase in this condition during the year 1937. The number of cases notified was 18, of whom 13 were males and 5 females. This gives a case rate of 0.07 per 1,000 of the population. The number of cases notified during the year 1936 was 3. No definite connection between the cases was traced in the year 1937. Most of the cases were notified in the second half of the sccond quarter and in the third quarter of the year. The ages of the patients ranged from 11 months to 17 years in the case of males, and from two-and-a-half to seven years in the case of females. Two of the patients died, but in neither case was death due to the disease notified. In one case death was due to pneumonia and in the other to meningitis. The most recent enquiries show that three of the patients have apparently recovered, and the remainder are in various stages of recovery either in hospital or attending hospital for appropriate treatment. 142 ACUTE POLIO-ENCEPHALITIS. Two cases of this disease occurred during the year—one in Plashet Road ward and one in Canning Town and Grange ward. One case was in a male aged 1 year; this patient recovered. The other was in a female of 50 years; the patient died. CEREBRO-SPINAL FEVER. The number of cases of this disease which occurred during the year was 8, of which 6 were males and 2 females. The case rate was 0.031 per 1,000 living. As is seen in Table I., most of the cases occurred in the first half of the year. Six of the eight cases were under 4 years of age. All of the patients were removed to hospital. The actual number of deaths from this disease which occurred during the year was 8, but one of these deaths referred to a patient who was notified as suffering from cerebro-spinal fever in 1936. Based on the deaths of cases notified during 1937, the death rate is 0.27 per 1,000 living, and the fatality rate 87.50 per cent. MALARIA. During the year 5 cases of this disease were notified. In each instance the disease was believed to have been contracted abroad. All the patients were seamen and all were admitted to the Seamen's Hospital. Two of the cases were notified during the tenth week, two during the twenty-second week, and one during the thirty-second week. There were no deaths. DYSENTERY. Four cases of dysentery were notified during the year. Three of these patients were seamen who were admitted to the Seamen's Hospital. The fourth patient was a child of six months. There were no deaths. DIARRHOEA AND ENTERITIS. During 1937 the number of deaths of children under two years of age from diarrhoea and enteritis was 47. The corresponding figures for the years 1934, 1935, and 1936 were 31, 19, and 73 respectively. Of the 47 children who died, 31 were males and 16 females. The death rate per 1,000 of the population was 0.18, and the death rate per 1,000 live births was 11.22. 143 Table XIII. Deaths from Diarrhoea and enteritis (under two years). (Rates based upon less than 20 deaths are printed in italic type.) Period West Ham England and Wales Rate per 1.000 live births No. of deaths Bate per 1,000 living Rate per 1,000 live births Males Females Persons Males Females Persons Males Females Persons 1876-1880 — — 379 — — 0.65 — — 16.80 18.68 1881-1885 — — 467 — — 0.65 — — 15.30 15.41 1886-1890 — — 697 — — 0.77 — — 20.02 17.18 1891-1895 — — 872 — — 0.80 — — 21.46 17.32 1896-1900 — — 1,744 — — 1.39 — — 39.91 23.79 1901-1905 — — 1,864 — — 1.37 — — 39.86 21.03 1906-1910 — — 1,336 — — 0.94 — — 29.99 15.25 1911-1915 785 652 1,437 1.09 0.87 0.98 35.07 30.48 32.83 23.56 1916-1920 337 259 596 0.49 0.36 0.42 17.37 14.07 15.76 11.19 1921-1925 249 197 446 0.33 0.24 0.28 12.73 10.56 11.67 9.58 1926-1930 158 112 270 0.21 0.14 0.17 10.28 7.66 9.00 7.52 1931-1935 119 75 194 0.17 0.10 0.14 10.06 6.60 8.37 6.07 1921 85 77 162 0.57 0.49 0.53 20.19 19.10 19.66 16.06 1922 25 21 46 0.17 0.13 0.15 6.10 5.44 5.78 6.58 1923 40 30 70 0.26 0.19 0.22 9.96 7.93 8.97 8.12 1924 48 27 75 0.31 0.17 0.24 13.18 7.58 10.41 7.58 1925 51 42 93 0.33 0.26 0.29 14.17 12.29 13.25 8.77 1926 52 41 93 0.34 0.25 0.29 14.95 12.69 13.86 9.16 1927 14 20 34 0.09 0.12 0.11 4.56 6.84 5.68 6.69 1928 26 19 45 0.17 0.12 0.15 8.59 6.58 7.6) 7.22 1929 35 22 57 0.23 0.14 0.19 12.09 7.66 9.89 8.26 1930 31 10 41 0.21 0.06 0.14 10.70 3.69 7.31 6.15 1931 22 19 41 0.15 0.13 0.14 8.16 7.39 7.79 5.90 1932 39 20 59 0.28 0.14 0.20 15.25 8.26 11.85 6.60 1933 29 15 44 0.21 0.10 0.16 12.93 6.93 9.99 6.98 1934 21 10 31 0.16 0.07 0.11 9.39 4.77 7.15 5.36 1935 8 11 19 0.06 0.08 0.07 3.82 5.23 4.52 5.56 1936 42 31 73 0.32 0.23 0.27 19.54 15.24 17.45 5.75 1937 31 16 47 0.24 0.12 0.18 14.49 7.81 11.22 5.54 144 The statistics of this important condition are set out fully in Table XIII. Before the closing years of the nineteenth century deaths which were undoubtedly due to "epidemic" or "summer" diarrhoea were often attributed to some other cause—either as the result of the cause of death which was filled in on the certificate, or of the manner of allocating the cause of death certified. The true importance of this condition as a cause of death of infants and young children is therefore not seen until the period 1896-1900, when the rate was 39.91 per 1,000 live births. No reduction took place until the period 1916-1920, when the rate was halved, and since that date the rate has again been practically halved. In other words, whereas in this area at the beginning of the century epidemic diarrhoea caused on an average about 370 deaths of young children every year, it now causes about 40 deaths. The actual number of deaths in any year naturally shows great variation. After a hot dry summer more deaths are supposed to occur than after a wet summer. Nevertheless, epidemic prevalence of this disease is now a comparatively trivial affair to what it was forty years ago. There is no doubt that increasing attention to the proper care of the young infant has contributed considerably to this decline. In this way the establishment of infant welfare clinics has played a part. Another important factor in the decline is the reduction of horse-drawn traffic, and consequently in the amount of stable manure and the number of flies. Urban areas nearly always have a higher rate of mortality than rural areas, and in this respect the local rates should be higher than those for less dense centres of population. It is therefore satisfactory to note that the West Ham five year rate has been proportionately much more reduced than the corresponding rate for England and Wales. A study of the number of deaths which has been caused yearly by this condition in the last ten years should be sufficient to convince the reader that, though it does not warrant the attention of one of the "notorious" or "popular" infections, it is nevertheless a very potent cause of death. Continued attention by each individual and by the local authority to the cleanliness of the district, and continued care on the part of each mother in the feeding of her infant, are the most likely means of ensuring a further reduction in the mortality. J 145 INFLUENZA. Influenza in itself is not a notifiable disease in this country. The number of notifications received in respect of one of its major complications—influenzal pneumonia—is dealt with in the section on pneumonia. During the year 1937 the number of deaths from influenza was 93, of which 49 were of males and 44 of females. The death rate per 1,000 of the population was 0.36. The corresponding number of deaths for the years 1934, 1935, and 1936 were 24, 19, and 20 respectively; and the death rates for these years were 0.09, 0.07, and 0.11. It might be said that 1937 was almost an " influenza year," since the number of deaths indicated that the disease was present almost in epidemic proportions. Influenza is one of the most baffling of diseases from the standpoint of the epidemiologist, and it is therefore difficult to discuss its vagaries in a short note. From Table XIV. it is immediately apparent that the death rate has not diminished during the last forty years, and the figures at their face value suggest that the mortality has not decreased. This fact is partly explained by changes in the method of allocating deaths. Whatever the statistical difficulties, it is evident that influenza is a serious cause of death in any five year period. The table unfortunately starts at a period just after the passing of the peak of a great epidemic wave, and it is seen that the reduction in mortality was gradual. The period 1916-1920 shows a very high mortality rate, which is due almost entirely to the great pandemic of 1918-1919. After this event the mortality again declined gradually. More detailed analysis of the_ figures for the post-war years shows that smaller epidemics occurred at irregular intervals. If we take as a rough measure of epidemic proportions a death rate of 0.50, it is seen that the disease was prevalent to this degree in the country as a whole in the years 1922, 1927, 1929 and 1933, and for practical purposes also in the year 1924. Applying the same criterion to the local rates it is seen that the disease was also present in epidemic proportions locally in the years 1922, 1929, and 1933. In 1924 and in 1927 the mortality was much less than in the country as a whole, so that it might be said that this area escaped some of the expected consequences of the epidemic. It is characteristic of influenza that it spreads as rapidly as the fastest means of human travel—whatever that may be at the particular period under discussion. In the London area escape from infection can sometimes be anticipated but never assured, and the 146 Table XIV. Deaths from influenza (all ages). (Rates based upon less than 20 deaths are printed in italic type) Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1891-1895 — — 286 — — 0.26 0.423 0.405 0.414 1896-1900 — — 231 — — 0.18 0.312 0.309 0.310 1901-1905 — — 152 — — 0.11 0.196 0.189 0.192 1906-1910 — — 204 — — 0.14 0.235 0.234 0.235 1911-1915 145 89 234 0.20 0.12 0.16 0.192 0.168 0.179 1916-1920 728 834 1,562 1.05 1.16 1.11 1.167 0.953 1.047 1921-1925 247 291 538 0.32 0.36 0.34 0.377 0.359 0.368 1926-1930 207 188 395 0.27 0.24 0.26 0.382 0.360 0.370 1931-1935 178 174 352 0.26 0.24 0.25 0.317 0.312 0.315 1921 34 42 76 0.23 0.27 0.25 0.250 0.226 0.237 1922 101 125 226 0.67 0.79 0.73 0.568 0.559 0.563 1923 25 22 47 0.16 0.14 0.15 0.235 0.207 0.220 1924 60 67 127 0.39 0 41 0.40 0.493 0.487 0.490 1925 27 35 62 0.17 0.21 0.19 0.339 0.316 0.327 1926 38 23 61 0.25 0.14 0.19 0.243 0.216 0.229 1927 59 60 119 0.38 0.37 0.38 0.575 0.559 0.567 1928 20 14 34 0.13 0.09 0.11 0.216 0.178 0.196 1929 80 86 166 0.53 0.55 0.54 0.731 0.737 0.734 1930 10 5 15 0.07 0.03 0.05 0.144 0.110 0.126 1931 45 52 97 0.31 0.34 0.33 0.360 0.360 0.360 1932 23 42 65 0.16 0.28 0.22 0.320 0.334 0.327 1933 91 56 147 0.66 0.39 0.52 0.564 0.570 0.567 1934 13 11 24 0.10 0.08 0.09 0.151 0.128 0.139 1935 6 13 19 0.05 0.09 0.07 0.193 0.171 0.182 1936 15 14 29 0.12 0.10 0.11 0.162 0.136 0.148 1937 49 44 93 0.39 0.33 0.36 0.456 0.452 0.454 147 death rate is frequently a measure of the extent of infection. We may ask why the local death rates were so comparatively low in the years 1924 and 1927. Much discussion has centred round the question whether an attack of influenza gives immunity to later infection, and a commonly accepted view is that it may do so—but only for a short period. In the period 1916-1920, and again in the year 1922 this area suffered more severely from influenza than did the country as a whole. There is perhaps a suggestion here that the immunizing effect was of a more prolonged character, and that this accounted for the comparatively low local rates in the succeeding epidemic years. Throughout this tabulated history of influenza males have invariably had a higher death rate than females, but in West Ham in the period 1916-1925 the opposite was the case. The behaviour of influenza resembles that of several other infectious diseases which affect primarily the throat or the respiratory passages. Even the most enlightened community can do little to prevent the introduction of a new strain of the virus into its midst, with consequences which on a smaller scale resemble the catastrophe which ensues when a new disease finds its way into virgin soil. PNEUMONIA. The number of notifications of acute pneumonia—primary and influenzal—which were received during 1937 was 354, of which 209 were in respect of males and 145 of females. The case rate was 1.36 per 1,000 living. The corresponding number of cases in the years 1934, 1935, and .1936 were 453, 290 and 320 respectively, and the case rates for these years were 1.64, 1.07, and 1.20. Of the 354 cases, the number removed to hospital was 157. This gives a removal rate of 44.35 per cent. The distribution of these cases by season, age, and wards is given in Tables I.—III. inclusive. Almost half the cases occurred in the first quarter of the year, and after that the second and fourth quarters were almost equally affected. It should be noted that the number of cases in the first four weeks of the year were so large as to constitute epidemic prevalence in these weeks. The percentage of the cases which occurred in the age groups under 5, 5—15, 15—25, 25—45, and over 45 years, were 24.9, 14.4, 11.3, 22.3, and 27.1 respectively. 148 Table XV. Deaths from pneumonia, all forms (all ages). Period West Ham No. of deaths Crude death rates per 1,000 living West Ham England and Wales Males Females Persons Males Females Persons Males Females Persons 1896-1900 — — 1,333 — — 1.07 1.440 0.984 1.205 1901-1905 — — 2.011 — — 1.48 1.496 1.069 1.275 1906-1910 — — 1,875 — — 1.32 1.439 1.043 1.235 1911-1915 1,209 967 2,176 1.69 1.29 1.49 1.332 0.910 1.112 1916-1920 1,525 1,109 2,634 2.20 1.54 1.86 1.575 0.931 1.216 1921-1925 1,254 991 2,245 1.64 1.23 1.43 1.152 0.790 0.963 1926-1930 934 761 1,695 1.24 0.96 1.10 1.054 0.706 0.873 1931-1935 690 567 1,257 1.00 0.78 0.89 0.875 0.610 0.737 1921 240 158 398 1.61 1.00 1.30 1.104 0.745 0.916 1922 355 304 659 2.35 1.91 2.12 1.280 0.883 1.073 1923 210 129 339 1.37 0.80 1.08 1.051 0.704 0.870 1924 260 234 494 1.68 1.44 1.56 1.192 0.835 1.006 1925 189 166 355 1.22 1.02 1.11 1.134 0.784 0.951 1926 172 156 328 1.12 0.96 1.04 0.986 0.683 0.828 1927 201 159 360 1.31 0.98 1.14 1.135 0.776 0.948 1928 177 135 312 1.18 0.86 1.02 0.964 0.622 0.786 1929 250 195 445 1.67 1.24 1.45 1.322 0.909 1.107 1930 134 116 250 0.91 0.75 0.83 0.863 0.543 0.696 1931 161 142 303 1.11 0.94 1.02 0.989 0.702 0.840 1932 161 115 276 1.14 0.78 0.95 0.857 0.623 0.735 1933 129 111 240 0.93 0.77 0.85 0.876 0.624 0.745 1934 149 117 266 1.10 0.83 0.96 0.856 0.570 0.707 1935 90 82 172 0.68 0.59 0.64 0.796 0.532 0.659 1936 107 96 203 0.82 0.71 0.76 0.841 0.551 0.690 1937 146 104 250 1.15 0.78 0.96 0.876 0.576 0.720 149 The number of deaths from all forms of pneumonia was 250, of which 146 were of males and 104 of females. The death rate from all forms of pneumonia was 0.96 per 1,000 of the population. From Table XV. it is seen that the death rates from all forms of pneumonia have not shown any great variation during the last forty years. During the period 1916-1920 the influenza epidemic was accompanied by an increased death rate from other forms of pneumonia. If this period is excluded, the crude rates seem to suggest that there is a slight downward trend in the rates. During the whole of the period studied the local rates have been higher than the national rates, and the excess has on the whole been most marked in those years in which influenza was prevalent. The death rates for males are consistently higher than the corresponding female rates. BRONCHITIS. The number of deaths which were due to bronchitis was 160, of which 84 were of males and 76 of females. This gives a death rate of 0.62 per 1,000 of the population. The corresponding number of deaths for the year 1936 was 134, which gives a death rate of 0.52. This disease is further discussed on page 96. TROPICAL AND RARE DISEASES. Under this general heading are included the following diseases: cholera, plague, anthrax, rabies, relapsing fever and continued fever. No cases of any of these diseases occurred in the area during the year. PUERPERAL FEVER AND PUERPERAL PYREXIA. Puerperal pyrexia was defined in the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926, as " any febrile condition (other than a condition which is required to be notified as puerperal fever) occurring in a woman within twenty-one days after childbirth or miscarriage in which a temperature of 100.4°F.(38°C.) or more has been sustained during a period of twenty-four hours, or has recurred during that period." Under the Public Health Act 1936 which came into force on the 1st October, 1937, puerperal fever ceased to be notifiable, and on and after that date any condition which would have been notified previously as puerperal fever was to be notified as 150 peral pyrexia. In this section notification of the two conditions are treated together. During- the year the number of notifications received was 79, which gives a rate of 13.59 Per 1,000 total notified births. The number of these cases removed to hospital was 59. This gives a removal rate of 74.70 per cent. The distribution of cases in the first three quarters of the year was fairly equal (Table I.), and almost 60 per cent. of the cases occurred in the age group 25—35 years (Table II.). No deaths occurred from puerperal fever. The epidemiology of the condition is further discussed under the heading " Maternal Mortality " in the section on Vital Statistics. OPHTHALMIA NEONATORUM. This disease, the duty of notifying which was, under the Public Health (Ophthalmia Neonatorum) Regulations, 1926, placed solely upon the medical practitioner in charge of the case, consists of a purilent discharge from the eye of an infant occurring within twenty-one days of birth. The number of cases of this condition which were notified during the year 1937 was 10. This gives a case rate of 1.78 per 1,000 total notified live births. Five of the cases were removed to hospital. No case occurred in the first quarter of the year; in the succeeding three quarters the number of cases notified were 5, 1, and 4 respectively. There were no deaths. Further notes on these cases appear in the section on Maternity and Child Welfare. 151 PLAISTOW FEVER HOSPITAL. Report for the year ended 31st December, 1937. by Donald MacIntyre, m.d., d.p.h., Medical Superintendent. This hospital has available 210 beds for the treatment of eases of the common infectious diseases. It is built in seven twostorey blocks. Six of these blocks comprise two large wards, giving an average accommodation of 15 beds each, and each large ward has a side-ward attached providing separate accommodation for one or two patients. The seventh block has three wards on each floor. Two of the ground-floor wards have accommodation for two and four patients respectively, and the third is a singlebedded ward. The upper floor is reserved for the treatment of staff cases. The diseases commonly treated are scarlet fever, diphtheria, cnteric fever, measles, whooping cough, chicken-pox, erysipelas, pneumonia, cerebro-spinal fever, influenza, and puerperal fever. The number of beds allocated to any particular disease is varied from time to time according to the prevalence of the different infections. The "barrier" method of nursing is practised in the main wards for the isolation of cases with infectious complications, and one of the wards is equipped for the nursing of cases of different infections by the "bed-isolation" method. A receiving-room is available for the examination of cases of suspected infectious disease which have been sent in by medical practitioners, or brought along by relatives. This room is also used for the swabbing of children who have been recommended for admission to a convalescent home. A disinfecting station, equipped with two large steam disinfectors, is attached to the hospital, and a garage provides accommodation for five motor vehicles. 152 Summary of the conditions treated. The number of patients under treatment during 1937 was 1,916. This is an increase of 229 over the number treated in the previous year, and was due mainly to a rise in the prevalence of scarlet fever. There was a slight fall in the number of fatal cases. These numbered 48, as compared with 54 in the previous year and 56 in 1935. The admissions of scarlet fever cases rose to 797 from 522 in the previous year, and during part of the year all the cases notified could not be admitted owing to lack of accommodation. The type of disease showed no appreciable change; it continued generally mild and the fatality rate remained low. A decrease occurred during 1936 in both the prevalence and the virulence of diphtheria as compared with the two previous years; the admissions fell to 469 from 722 in 1935 and 777 in 1934, and the deaths also decreased to 14 from 35 and 37 respectively. During 1937 there was no appreciable change in the prevalence or the virulence of the infection. The admissions showed an increase of only 10 over the number in 1936, and there were 14 deaths, the same number as in 1936. The occurrence of streptococcal infection in diphtheria cases was not quite so common as in the previous two years. During 1937, the number of patients who contracted scarlet fever was 17, and 24 others developed tonsillitis during convalescence; of these, 9 developed otorrhoea. During the year, 11 children who had been previously immunized against the disease were admitted as suffering from diphtheria. One of these proved to be a case of septic pharyngitis, and one suffered from laryngitis. The remaining 9 cases had definite clinical attacks of diphtheria with positive swabs. In 5 of these the attack was mild and in 4 it was moderately severe. After the administration of a small dose of antitoxin the patients all made a rapid and satisfactory recovery. Ten cases of enteric fever were under treatment. All made a satisfactory recovery. As 1937 was an inter-epidemic year, the number of measles cases treated was small. In the autumn and winter months the admissions began to increase; the cases were mostly of a mild type. Whooping cough was more than ordinarily prevalent during the year, and severe cases with complications were admitted as accommodation became available. This disease 153 was responsible for more deaths than any other infection except diphtheria. As compared with the previous three years, there was an increase in the number of patients who were treated for pneumonia, and the fatality rate was high in 1937. Erysipelas was not unusually prevalent and the majority of the cases were of a mild type. At the beginning of the year 183 patients were in residence and 1,733 were admitted during the year, making a total of 1,916 cases under treatment. Of these, 1,659 were discharged, 48 died, and 209 remained under treatment at the end of the year. The chief causes of death during the year are briefly summarised in Table I. Table I. Deaths in the hospital in 1937. Disease. Number of deaths. Diphtheria 14 Whooping cough 13 Pneumonia 10 Meningitis 5 Scarlet fever 2 Measles 1 Chicken-pox 1 Other diseases 2 Total deaths 48 The fatality rate, calculated on all the cases admitted during the year, was 2.77 per cent. Table II. shows the admissions and deaths for each month of the year, and in Table III. the annual admissions and deaths from the principal infectious diseases since the hospital was opened are set out. Scarlet fever. The number of notified cases admitted during the year was 839. Of these, the diagnosis was amended after admission in 42 cases, or 5.0 per cent. of the admissions. 154 Table II. Plaistow Fever Hospital. Admissions (Adm.) and deaths in 1937. Month. Scarlet fever. Diphtheria. Typhoid fever. Measles. Pneumonia. Erysipelas. Chicken-pox Whooping cough. Puerperal fever. Other diseases. All diseases Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths January 43 — 5 — 1 — 1 — 19 4 1 — 1 — 5 — — — 20 — 96 4 February 39 — 26 1 2 — 1 — 4 2 5 — 8 — 6 2 — — 26 1 117 6 March 55 — 35 1 1 — 2 — 6 2 5 — 4 — 8 1 — — 17 1 113 5 April 74 1 30 2 — — 1 — 6 1 2 — 5 — 13 4 — — 24 1 155 9 May 34 — 34 2 1 — 6 — 3 — 1 — 6 — 9 3 1 — 19 — 114 5 June 37 — 30 4 — 3 — 1 1 3 — 3 — 8 — — 29 2 114 7 July 104 — 52 2 — — — 1 — 1 — 1 — 1 1 — — 33 — 193 3 August 58 1 29 — 1 — 1 — 1 — — — 2 — 3 — — — 18 1 113 2 September 90 — 62 1 — 1 — 1 — 1 — 1 — 3 1 — — 20 — 180 1 October 112 — 83 1 3 — — — — — 2 — 1 — 2 1 — — 24 — 227 2 November 50 — 32 — — — — — 1 — 1 — 2 — 1 — — — 11 — 98 — December 87 — 61 1 — — 5 1 2 — 4 — 6 — 4 — — — 24 2 193 4 Whole year 783 2 479 14 10 — 21 1 45 10 26 — 40 — 63 13 1 — 265 8 1733 48 155 Table III. Plaistow Fever Hospital. Admissions (adm.) and deaths (D'ths) since 1896. Year. Scarlet fever. Diphtheria. Typhoid fever. Measles. Pneumonia Whooping cough. Erysipelas Other diseases. All diseases Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths 1896 170 8 114 23 ... ... ... ... ... ... ... ... ... ... ... ... 284 31 1897 188 6 163 21 ... ... ... ... ... ... ... ... ... ... ... ... 351 27 1898 206 4 249 42 ... ... ... ... ... ... ... ... ... ... ... ... 455 46 1899 192 2 309 49 ... ... ... ... ... ... ... ... ... ... ... ... 501 51 1900 177 4 269 36 ... ... ... ... ... ... ... ... ... ... ... ... 446 40 1901 203 16 310 66 47 4 ... ... ... ... ... ... ... ... ... ... 560 86 1902 257 12 431 72 138 30 ... ... ... ... ... ... ... ... ... ... 826 114 1903 370 10 334 48 84 17 ... ... ... ... ... ... ... ... ... ... 788 75 1904 679 29 351 31 95 15 ... ... ... ... ... ... ... ... ... ... 1125 75 1905 747 18 438 53 62 14 ... ... ... ... ... ... ... ... ... ... 1247 85 1906 806 18 421 70 127 18 ... ... ... ... ... ... ... ... ... ... 1354 106 1907 667 29 422 82 68 12 ... ... ... ... ... ... ... ... ... ... 1157 123 1908 665 26 373 47 73 12 ... ... ... ... ... ... ... ... ... ... 1111 85 1909 990 32 337 35 34 5 ... ... ... ... ... ... ... ... ... ... 1361 72 1910 655 17 260 45 71 14 ... ... ... ... ... ... ... ... ... ... 986 76 1911 491 13 295 52 70 15 ... ... ... ... ... ... ... ... ... ... 856 80 1912 562 17 291 35 49 10 ... ... ... ... ... ... ... ... ... ... 902 62 1913 782 13 333 24 42 6 ... ... ... ... ... ... ... ... ... ... 1157 43 1914 699 10 380 43 36 7 ... ... ... ... ... ... ... ... ... ... 1115 60 1915 575 8 403 60 40 11 ... ... ... ... ... ... ... ... ... ... 1018 79 1916 310 7 533 64 23 2 ... ... ... ... ... ... ... ... ... ... 866 73 1917 304 8 559 67 27 4 ... ... ... ... ... ... ... ... ... ... 890 79 1918 213 4 464 70 25 ... ... ... ... ... ... ... ... ... ... ... 702 74 1919 373 3 601 57 15 2 18 2 5 2 ... ... ... ... 24 3 1036 69 1920 748 6 769 62 14 3 11 ... 2 2 ... ... 1 ... 25 5 1570 78 Table III. (continued). Plaistow Fever Hospital; Admissions (adm.) and deaths (d'ths) since 1896. Year. Scarlet fever. Diphtheria. Typhoid fever. Measles. Pneumonia Whooping cough. Erysipelas Other diseases. All diseases Adm. D'ths Adm D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths Adm. D'ths 1921 1,119 10 560 32 7 ... 1 ... 2 0 ... ... ... ... 21 1 1 1710 55 1922 592 8 611 40 3 1 15 ... 5 1 21 4 1 ... 23 9 1271 63 1923 412 7 671 23 10 ... 33 ... 12 6 ... ... 10 ... 34 7 1182 43 1924 317 4 713 27 2 1 100 19 24 7 44 15 8 ... 137 7 1345 80 1925 412 4 719 18 5 1 81 6 24 2 22 8 14 1 150 9 1427 49 1926 899 6 647 13 7 ... 85 17 25 5 5 2 15 2 189 11 1872 56 1927 1250 3 816 34 12 2 19 1 17 5 13 5 5 ... 96 7 2228 57 192s 916 3 901 29 7 ... 60 9 16 3 13 4 17 1 122 9 2052 58 1929 983 5 741 33 4 ... 20 2 19 5 17 9 15 1 150 4 1949 59 1930 670 1 719 24 5 ... 86 15 11 1 12 1 14 1 133 9 1650 52 1931 540 4 327 10 ... ... 33 2 62 12 108 13 51 8 222 14 1343 63 1932 590 2 293 9 ... ... 282 33 214 37 118 14 42 4 326 29 1865 128 1933 913 6 535 49 ... ... 9 ... 54 17 44 11 52 ... 207 19 1814 105 1934 798 9 777 37 ... ... 76 8 21 9 4 1 14 1 174 10 1864 75 1935 702 4 722 35 ... ... 34 3 5 2 30 2 ... ... 217 10 1720 56 1936 522 3 469 14 3 ... 223 26 25 3 24 3 19 1 182 4 1467 54 1937 797 2 479 14 10 ... 21 1 45 10 63 13 26 ... 292 8 1733 48 Totals 24461 401 20109 1695 1215 206 1207 144 588 131 538 105 304 23 2724 185 51146 2890 Fatality per cent. 1.64 8.43 16.95 11.93 22.28 19.52 7.57 6.7 5.65 157 The number of accepted cases was therefore 797. A scarlatiniform rash was present in 74 per cent. of the cases on the day of admission, but 27 per cent. of these did not show any desquamation afterwards. Eight per cent. of the admissions had no rash or desquamation during their period of residence, and of these cases five developed scarlet fever in the wards. In six cases a relapse occurred during the second and third week of illness. At the beginning of the year there were in residence 77 patients suffering from scarlet fever, making a total of 874 cases under treatment. Of these, 777 were discharged, 2 died, and 95 remained under treatment at the end of the year. Age distribution. The age incidence of the 797 patients who were accepted as suffering from scarlet fever is Shown in Table IV. Table IV. Scarlet fever. Age incidence of hospital cases. Age (years) Number of cases. Percent. Under I 7 0.88 1 251 31.49 5 342 42.92 10 110 13.80 15 39 4.89 20 48 6.02 All ages 797 100.00 The duration of illness on the day of admission is shown in Table V. Table V. Scarlet Fever. Day of illness. 1st 2nd 3rd 4th 5th 6th 7th Over 7. No. of Cases 47 218 243 125 75 32 20 37 Percent.of total 5.9 27.4 30.5 15.7 9.4 4.0 2.5 4.6 The average duration of illness on admission was 3.43 days. 158 Corrected diagnosis. The 42 cases in which the diagnosis was amended after admission were found to be suffering from the following complaints:—Urticaria, 2; toxic rash, 5; transient erythema, 2; tonsillitis, 6; rubella, 4; drug rash, 2; influenza, 2; rhinitis, 1; diphtheria, 2; cellulitis, 1; bronchitis, 1; pneumonia, 1 ; tuberculous meningitis, 1; chicken-pox, 2 ; gastritis, 1; pharyngitis, 2 ; malnutrition, 1; no appreciable disease, 6. Three cases admitted as diphtheria and two admitted as measles proved to be suffering from scarlet fever. Fatality rate. One of the two fatal cases was a girl aged 3 years, who was suffering from septic scarlet fever complicated by faucial diphtheria. In the other case, a boy aged 2 years, the disease developed three days after he had a severe sunburn of the chest and shoulders, and he succumbed to toxaemia within a fortnight of admission. The fatality rate was 0.25 per cent, of the admissions. Scarlet fever antitoxin. This was administered intramuscularly to 92 cases suffering from a severe attack. The dosage varied from 10 to 70 c.cs., the average being 16 c.cs. per patient. Sidphanilamide drugs. Encouraging results were obtained early in the year from the oral administration of proseptasine tablets in the treatment of some of the common complications of scarlet fever, particularly otorrhoea and septic sores. All the cases of otorrhoea however did not respond to the treatment. One interesting case was that of a boy, aged 5 years, who developed profuse double otorrhoea in the fourth week of his illness. He was treated by a course of proseptasine tablets (one tablet four hourly for four days). No appreciable improvement in the otorrhoea resulted, and six weeks later he developed acute streptococcal meningitis. This was treated vigorously with proseptasine and prontosil, given partly by intrathecal injection and partly by oral tables. About 30 c.c.s of turbid cerebro-spinal fluid were withdrawn once daily and this was replaced by 10 c.c.s of soluseptasine or prontosil soluble; this was continued for seven days. The patient also received two prontosil tablets by mouth every four hours for four days. For five days his temperature was swinging up daily to 103° and his pulse rate to 140. On the sixth and seventh days there was a definite improvement in his condition, and by the eighth day his temperature had dropped to normal and did not rise again. The cerebro-spinal fluid also cleared, and a few days later 159 the discharge from both ears dried up. He ultimately made a complete recovery. A trial was also made of the value of prontosil and proseptasine for the prevention of the complications of scarlet fever when administered early in the disease. The two drugs were used in about an equal number of cases, and the dosage employed was 5 to 10 c.c.s of the soluble preparation injected intramuscularly on admission, followed by the oral administration of one tablet three times a day for four days. In 150 cases so treated no beneficial effects were observed. There was no diminution of toxic symptoms during the acute stage, and the incidence of complications was not reduced when compared with non-treated cases. Four cases developed a papular rash a fortnight after the administration of the drug, but no other toxic effect was observed. Of the 777 cases discharged, 264, or 33.98 per cent., suffered from complications as shown in Table VI. Table VI. Scarlet fever. Frequency of complications. Complication. No. of cases. Per cent. of all cases. Adenitis 64 8.23 Albuminuria 17 2.18 Arthritis 8 1.02 Nephritis 5 0.64 Otorrhoea 61 7.85 Rhinitis 62 7.97 Septic sores 18 2.32 Tonsillitis 23 2.95 Vaginitis 6 0.77 All complications 264 33.98 The average duration of residence of all cases was 38.47 days. Return cases. The number of "return cases" of scarlet fever which were admitted to this hospital during the year was 28. When considered in relation to the 777 scarlet fever patients discharged during the year, this number gives a return case rate of 3.60 per cent. The monthly incidence is shown in Table VII. 160 Table VII. Scarlet fever. Return cases, 1937. Monthly incidence. Month. Number of patients discharged. Return cases to Plaistow Hospital. Percentage. January 48 — — February 57 2 3.51 March 37 5 13.51 April 48 1 2.08 May 70 2 2.86 June 41 2 4.88 July 70 1 i-43 August 65 - - September 70 4 5.71 October 128 6 4.69 November 56 — — December 87 5 5.75 Whole year 777 28 3.60 Diphtheria. The number of notified cases which were admitted during the year was 606. The diagnosis was amended after admission in 127 of these cases, or 20.96 per cent, of the admissions. The number of accepted cases was therefore 479. At the beginning of the year 82 patients were in residence, and the total number under treatment was 561. Of these 454 were discharged, 14 died, and 93 remained under treatment at the end of the year. The average duration of residence was 59.54 days. Age incidence. The age incidence of the 479 accepted cases of diphtheria is shown in Table VIII. Corrected diagnosis. The 127 cases which proved to be wrongly diagnosed were found after admission to be suffering from the following complaints:—Tonsillitis, 84; laryngitis, 15; pharyngitis, 5; Vincent's angina, 6; scarlet fever, 3; measles, 2; stomatitis, 2 ; no apparent disease, 2 ; rhinitis, 3; gastro-enteritis, 1; tuberculous meningitis, 1 ; catarrhal jaundice, 1; otitis media, 1; asthma, 1. The patients who were discharged or who died during the year are classified in Table IX. 161 Table VIII. Diphtheria. Age incidence of hospital cases. Age (years) Number of cases. Per cent. Under 1 9 1.88 1— 151 31.52 5— 214 44.68 10— 80 16.70 15— 14 2.92 20— 11 2.30 Total 479 100.00 Table IX. Diphtheria. Type of disease. (a) All cases. Type of disease. Cases admitted Deaths. Fatality per cent. Number. Per cent. of total. Faucial 373 79.71 12 3..21 Laryngeal 23 4.91 2 8.69 Nasal 44 9.40 - — Bacteriological 28 5.98 - — All forms 468 1oo.oo T4 2.99 (b) Faucial cases. Faucial eases. Number. Per cent. Mild 124 33.24 Moderate 147 39.41 Severe 102 27.35 Paralysis. Post.diphtheritic paralysis occurred in 35 of the above cases. It was mild in 24 cases and severe in 11 cases. 162 Laryngeal diphtheria. Forty-one eases were admitted as laryngeal diphtheria, but 18 of these proved to be wrongly diagnosed. Of the 23 true cases, 8 required tracheotomy, and 2 of these patients died. One of the fatal cases was complicated by whooping cough and broncho-pneumonia, and the other had broncho-pneumonia. Fatal cases. The 12 deaths which occurred among the faucial cases were of children whose ages varied from 9 months to 15 years; the average age was 6 years. All of these proved fatal within the first three weeks of the disease, and the average duration of illness on admission was 3.5 days. The amount of antitoxin administered to these patients averaged 130,000 units per patient. Further particulars of the patients who died from diphtheria in the hospital during the year are given in Table X. Table X. Diphtheria. Particulars of fatal cases. (a) Faucial cases. Age. Sex. Date of admission. Duration of illness on admission (days). Amount of antitoxin given. (units). Duration of illness at death. (days). 2 yrs. 9 mths. F 13.2.37 3 112.000 5 6 yrs. F 24.3.37 4 200,000 21 5 yrs. M 1.5.37 4 200,000 7 7 yrs. F 11 .5.37 3 240,000 14 15 yrs. 6 mths. F 29.5.37 5 100,000 6 10 yrs. M 22.5.37 3 100,000 16 7 yrs. F 11.6.37 3 200,000 8 3 yrs. 3 mths. F 16.6.37 2 132,000 3 2 yrs. 8 mths. M 23.6.37 3 220,000 6 6 yrs. F 19.7.37 4 120,000 4 5 yrs. M 4.10.37 3 200,000 7 9 mths. F 28.3.37 2 80,000 6 (b) Laryngeal cases. 1 yr. 6 mths. M 25.11.36 14 44,000 67 5 yrs- M 26.11.37 1 —- 1 163 Treatment. The amount of antitoxin administered to the nasal and mild faucial cases averaged 13,000 units per case. The moderate faucial cases received an average of 35,000 units. To the severe faucial cases, the antitoxin was administered partly by intravenous and partly by intramuscular injection, and the amount averaged 116,000 units per patient. Typhoid fever. Of 21 cases which were admitted as suspected typhoid fever, 10 proved to be suffering from the disease. The other 11 cases suffered from the following complaints:— Ulcerative colitis, 1; enteritis, 4; ulcerative stomatitis, 1; acute rheumatism, 1; cholecystitis, 1; influenza, 1; broncho-pneumonia, 1; constipation, 1. The case of ulcerative colitis proved fatal; this patient was a man aged 23 years. Of the 10 positive cases, 3 suffered from typhoid fever and 7 from a paratyphoid B infection. With one exception, all the cases were comparatively mild, and all made a satisfactory recovery. The exception was a girl of three years Mho, two days before admission, suffered a severe intestinal haemorrhage for which a blood transfusion had been administered. On admission she was weak and anasmic. Diarrhoea persisted during the following ten days, and she had an irregular temperature, with occasional rises over 103°, until the fifth week of the disease. Her general condition, however, slowly improved. Towards the end of the fifth week of illness she complained of slight pain in the right groin on movement. This pain gradually increased, and a week later a swelling appeared over the right hip-joint. An X-ray examination showed the swelling to be due to a dislocation. The condition was caused by arthritis, which is a very rare complication of typhoid fever. The patient was transferred to Whipps Cross Hospital for surgical treatment. Measles. This was not an epidemic year and the majority of the patients admitted were suffering from a mild type of infection. Of 22 patients who were under treatment during the year, 17 were discharged, one died, and four remained under treatment at the end of the year. The fatal case was a child aged three years whose illness was complicated by broncho-pneumonia. Whooping cough. The numbers of cases under treatment was 64. Of these, 49 were discharged, 13 died, and 2 remained 164 under treatment at the end of the year. Broncho-pneumonia was present as a complication in all the fatal cases, and their ages varied from five months to five years, the average being two years. Five cases of diphtheria, four cases of scarlet fever, and one case of mumps were incubating whooping cough on the day of admission. Erysipelas. Twenty-six cases were under treatment, in all of which the attack was mild or of moderate severity, and all recovered. The face was the part affected in 21 of the cases, the arm in 3 cases, and the leg in 2 cases. Pneumonia. The cases in this group were all children suffering from broncho-pneumonia and bronchitis. The number under treatment Vvas 52. Of these, 40 were discharged, 10 died, and 2 remained under treatment at the end of the year. The fatal cases were all infants under two years of age. Chicken-pox. This disease continued rather prevalent throughout the year, and secondary cases occurred in the scarlet fever and diphtheria wards from patients admitted in the incubation stage of the infection. The majority of the cases were of moderate severity. The number under treatment was 43, and of these 41 were discharged, one died, and one remained under treatment at the end of the year. The fatal case w as a child aged 15 months who suffered from "varicella gangrenosa." The gangrenous lesions appeared on the scalp, and resulted in extensive areas of sloughing. Meningitis. At the end of January a girl of two years was admitted suffering from meningococcal meningitis, and two days later her young brother aged nine months was admitted suffering from the same disease. Both were infected with the type II. meningococcus. The boy was moribund on admission and died twelve hours later. The girl was treated with serum intravenously and intrathecally, and made satisfactory progress during the first fortnight of the illness. At this period, however, she suffered from severe serum sickness, and subsequently she drifted into the chronic stage from which she succumbed three months later. A girl of 18 years died from pneumococcal meningitis five days after admission, and two children of four years and eight months respectively died of tuberculous meningitis. 165 Acute anterior poliomyelitis. Five cases of this disease were under treatment. Four of them were children under five years of age, and one was a boy aged 17 years. All made some improvement, but it was not complete, a varying amount of paralysis remaining in each case on discharge. The left arm was the part affected in two cases and the leg in two cases. In the fifth case the part affected was the musculature of the right side of the neck and face. Other diseases. Included in this group are the following: — Rubella, 8; mumps, II; diphtheria contacts, 2; puerperal pyrexia, 1; otorrhoea, 2; scabies, 1; septic rash, 1; meningism, 1; anaemia, 1; empyema, 1; encephalitis, 1; acute mastoid, 1; babies (with mothers), 2; endocarditis, 2; re-admitted, 4. One case suffering from endocarditis proved fatal. All the others recovered. Cross infection. During the year four patients who were admitted in the incubation stage of chickenpox infected 13 others, and one scarlet fever patient admitted incubating mumps infected five others. Seventeen diphtheria patients contracted scarlet fever, and 16 scarlet fever patients developed nasal diphtheria during convalescence. One scarlet fever patient contracted measles. Gate cases. Particulars of the patients suspected to be suffering from infectious diseases who were brought to the hospital for diagnosis, together with particulars of the disease which affected those patients who were admitted, are set out in Table XI. Staff. The medical staff of the hospital consists of one medical superintendent and two assistant medical officers. The nursing staff consists of one matron, one assistant matron, one night sister, one sister-tutor, eight ward sisters, six staff nurses, and 57 probationers. The administrative staff consists of one steward and one clerk. The domestic staff consists of 60 maids, three seamstresses, and two lodge attendants. The out-door staff consists of one engineer, eight porters, four stokers, five motor-drivers, two gardeners, one laboratory assistant, one disinfector, and eight other workers. 166 Staff sickness. Two Dick-positive nurses contracted scarlet fever before they were immunized, and two Schick-positive nurses contracted mild attacks of diphtheria during the period of immunization. All recovered. Two other nurses contracted rubella, and one maid contracted facial erysipelas. During the year 26 nurses and maids were warded with tonsillitis and 20 with influenza. Forty-one others were oft duty for short periods with minor ailments. All recovered. The number of nurses upon whom the Schick test was performed was 56. Of these 22—or 39.28 per cent.—gave a positive result. The number of the positives who were immunized was 14. Table XI. Gate cases . Number examined and admitted. How sent. No. seen at gate. No. admitted. Diphtheria Scarlet fever. Other diseases. Total. By medical practitioner 148 33 19 8 60 Bv relatives 451 29 31 16 76 From other hospitals 74 7 2 6 !5 For swabbing (convalescent patients) 523 - - - - The number of nurses upon whom the Dick test was performed was 56. Of these 21—or 37.5 per cent—gave a positive result. The number of the positives who were immunized was 14. Prophylaxis of diphtheria and scarlet fever. (a) Diphtheria. The number of patients upon whom the Schick test was performed was 493. Of these 290—or 58.82 per cent.—gave a positive result. The number of these positives who were immunized was 268. (b) Scarlet fever. The number of patients upon whom the Dick test was performed was 237. Of these 110—or 46.41 per cent.—gave a positive result. The number of the positives who 167 Table XII. Examination of swabs (diphtheria). Source of swab. Number examined. Number positive. Per cent, positive.[/$$$] (i) Medical practit.: — (a) faucial 2,105 223 I0.59 (b) nasal 208 31 14.90 (c) aural 5 1 20.00 Total 2,318 255 11 .OO (2) Other instit'ns.:— (a) faucial 293 26 8.87 (b) nasal 69 13 18.84 (c) aural 2 — — Total 364 39 IO.71 (3) Gate cases: — (a) faucial 118 12 IO.17 (b) nasal 94 17 18.09 (c) aural 2 1 50.00 T otal 214 30 14.02 (4) Health Dept.: — (a) faucial 162 22 13-58 (b) nasal 110 26 23.64 Total 272 48 17.64 (5) I.C.A.A.:- (a) faucial 323 11 3-40 (b) nasal 320 39 12.19 Total 643 50 7-77 (6) I.C.C.S.: — (a) faucial 58 — — (b) nasal 52 7 J3-46 Total 110 7 6.36 (7) YV.H.C.M.*: — (a) faucial 257 8 3" (b) nasal 254 22 8.66 Total 511 30 5.87 Total examinations 4.432 459 10.35 *West Ham Central Mission. 168 were tully immunized was 36, and the number partly immunized was 59. Disinfection. During 1937 the number of articles which were removed from infected houses for disinfection was 19,640. The number of hospital articles disinfected was 22,943. Further details of these articles arc given in another section. Laboratory work. Details of the swabs examined for the presence of the diphtheria bacillus during the year are set out in Table XII. Diphtheria in the inoculated. During the year there were 11 cases of diphtheria in children who had been previously immunized. Details of these cases are given in Table XIII. 169 Table XIV. Particulars of children who developed diphtheria after inoculation. 193/. Case No. Age. years Sox. Initial Schicl Immunization Final Schick Dale and result Date Doses Date and result i 7 M. Not done 28. 2.35 Ic.c.T.A.M. 6.6.35 Negative 2. 3.35 Ic.c.T.A.M. 14. 3.35 Ic.c.T.A.M. 2 4 F. Not done 26. 1.35 Ic.c.T.A.M. 9. 5.35 Negative 2. 2.35 Ic.c.T.A.M. 9. 2.35 Ic.c.T.A.M. 3 6 M. 22.10.36 Pos. 13. 5.36 Ic.c.T.A.M. Diph. con tracted before final test. 20. 5.36 Ic.c.T.A.M. 27. 5.36 Ic.c.T.A.M. 22.10.36 l.Sc.c.T.A.M 4 4 M. Not done II. 9.36 Ic.c.T.A.M. Did not attend. 2.10.36 Ic.c.T.A.M. 9.10.36 Ic.c.T.A.M. 5 6 M. Not done 8.ii.35 Ic.c.T.A.M. 17. 4.36 Negative 15.11.35 Ic.c.T.A.M. 22.11.35 Ic.c.T.A.M. 6 7 M. I7.4.36 Pos. 8.11.35 Ic.c.T.A.M. 30.4.36 Negative I5.11.35 Ic.c.T.A.M. 22.11.35 Ic.c.T.A.M. 7 11 F. Not done !6. 4.35 Ic.c.T.A.M. 17.10.35 Negative 30. 4.35 Ic.c.T.A.M. 8. 5.35 Ic.c.T.A.M. 8 11 M. 10.10.35 Pos. 17.10.35 l.Sc.c.T.A.M Did not attend. 9 2 M. Not done 2.10.36 Ic.c.T.A.M. Did not attend. 9.10.36 Ic.c.T.A.M. 16.10.36 Ic.c.T.A.M. 10 2 M. Not done 1. 7.36 Ic.c.T.A.M. 21. 1.37 Negative 8. 7.36 Ic.c.T.A.M. 15. 7.36 Ic.c.T.A.M. 11 4 M. Aug. 1937 Pos. August, 19 37. Ic.c.T.A.M. 6.11.37 Slt. pos. 170 Table XIV. (continued). Particulars of children who developed diphtheria after inoculation. 1937. Case No. Date of onset Type of disease Serum given (units) Severity Period in Hosp. (weeks) Result C.cure I 7. 9.36 Faucial 20,000 Mild 9 c 2 20. 1.37 Faucial 40,000 Moderate 10 c 3 10. 5.37 Laryngeal 12,000 Proved laryngitis 8 c 4 29. 8.37 Faucial 120,000 Severe 13 c 5 4. 9.37 Nasal 32,000 Mild 6 c c 6 2. 9.37 Faucial 60,000 Moderate 6 7 22. 9.37 Tonsillitis Nil Mild 3 c 8 9.10.37 Faucial 120,000 Severe 12 c 9 3. 9.37 Faucial 38,000 Moderate 6 c 10 5.11.37 Faucial 12,000 Mild 4 c 11 4.11.37 Faucial 12,000 Mild 8 C 171 VENEREAL DISEASES. The West Ham Council does not itself administer a scheme for dealing with venereal diseases. Under the Public Health (Venereal Diseases) Regulations, 1916, a joint scheme was inaugurated in 1917 for the Greater London area, the participating authorities being the London County Council, the counties of Middlesex, Essex, Hertford, Buckingham, Surrey, and Kent, and the county boroughs of West Ham, East Ham, and Croydon. The London County Council is responsible for the administration of the scheme. In addition to paying its proportionate share of the cost of the scheme, which is approximately one twenty-fifth of the total expenses incurred, the Council makes a grant to the British Social Hygiene Council to further propaganda work in this area. Free treatment can be obtained by anyone at any of the twenty-one hospitals approved under the joint agreements. There are also six hostels, assisted by financial grants, where women suffering from these diseases can be accommodated with a view to facilitating continued treatment. These institutions are as follows: — Royal Free—20-22 Highbury Quadrant, N. Royal Free—62 Regents Park Road, N.W. St. Thomas'—148 Lambeth Road, S.E. Salvation Army—122-4 Lower Clapton Road, E. Salvation Army—126-8 Lower Clapton Road, E. West London Mission—35 Parkhurst Road, N.7. No West Ham residents attended any of these hostels during 1937. The particulars of the above-mentioned scheme have been brought to the notice of the inhabitants of the district by the exhibiting of enamel plaques, which give a list of the participating hospitals and urge the necessity for immediate treatment. Local medical practitioners are fully conversant with the facilities for diagnosis and treatment of venereal diseases. There are thirteen practitioners who are qualified to receive supplies of 172 arseno-benzol compounds. These compounds are also supplied on request to St. Mary's Hospital, Plaistow, E.13, and to Queen Mary's Hospital, Stratford, E.15, hut no request was made during 1937. Table I. sets out particulars of the attendances at the various hospitals of West Ham residents during the year under review. Table I. West Ham patients . Attendances at clinics. Disease. New patients. Total attendances. 1937. Syphilis 49 24,979 Soft chancre 3 Gonorrhoea 170 Non-venereal 239 All conditions 461 24,979 It is interesting to note that very few of the 461 new cases who were seen at the clinics visited the health department for advice. This suggests that particulars of treatment facilities are now well known. Pathological examinations. With regard to the pathological examinations of various material or specimens, for or at the centres, particulars will be found in Table II. Table II. Pathological examinations. Type of exam. No. of examinations. Spirochaetes 46 Gonococci 3,573 Wassermann 883 Others 1,554 Total 6,056 173 Particulars of examinations carried out on specimens submitted by general practitioners will be found in Table III. Table III. Pathological examinations. For practitioners. No. of examinations. Spirochaetes — Gonococci 6 Wassermann 25 Others 35 Total 66 For reference purposes the work carried out at the various hospitals and institutions of the scheme are set out in Tables IV. to VIII. Table VI. Venereal diseases (joint scheme). Utilisation of facilities at hostels, 1937. Area. No. of patients. Aggregate No. of days in residence. Percentage (days). London County 128 13,912 49.6 Middlesex 34 3,998 14.2 Essex 20 2,412 8.6 Surrey 15 2,556 9.1 Kent 22 3,691 13.2 Herts 9 851 3.0 Bucks 9 655 2.3 East Ham — — — West Ham — — — Croydon — — — 237 28,075 100% 174 Table IV. Venereal diseases (joint scheme). Summary of work done by the hospitals during the year 1937. London. Middlesex. Essex. Surrey. Kent. Herts. Bucks East Ham. West Ham. Croydon. Total. Other Places. Grand Total. Syphilis 1,964 332 105 113 85 28 18 13 49 7 2,714 213 2,927 Soft Chancre 82 4 5 6 1 1 ... 2 3 1 105 114 219 Gonorrhoea 0,532 1,115 463 402 148 133 64 93 170 27 9,147 805 9,952 Not venereal 8,239 1,647 643 643 254 172 81 123 239 93 12,134 593 12,727 Total 16,817 3,098 1,216 1,164 488 334 163 231 461 128 24,100 1,725 25,825 Total attendances 728,459 99,687 54,974 31,214 13,970 8,050 3,530 13,770 24,979 3,407 982,040 18,402 1,000,442 No. of in-patient days 31,583 3,470 3,581 1,862 1,815 1,306 305 110 434 40 44,506 10,523 55,029 A.B.C. doses ... ... ... ... ... ... ... ... ... ... ... ... 50,724 Pathological Examinations. For or at Centres:— Spirochaetes 1,935 162 117 44 11 16 9 15 46 2 2,357 161 2,518 Gonococci 100,415 16,490 11,411 6,319 2,489 1,461 753 2,315 3,573 666 145,892 4,458 150,350 Wassermann 34,060 4,241 2,773 3,058 793 469 270 460 883 268 47,275 1,754 49,029 Others 42,894 5,199 4,561 3,323 1,148 601 301 764 1,554 377 60,722 3,509 64,231 Total 179,304 26,092 18,862 12,744 4,441 2,547 1,333 3,554 6,056 1,313 256,240 9,882 266,128 For Practitioners:— Spirochaetes 8 ... 1 ... ... ... ... ... ... ... 9 ... 9 Gonococci 4,317 126 245 117 39 115 18 2 6 1,092 6,077 10 6,087 Wassermann 14,686 673 1,338 308 216 87 134 33 25 686 18,186 432 18,618 Others 9,248 313 522 191 50 40 18 6 35 1,071 11,494 467 11,961 Total 28,259 1,112 2,106 616 305 242 170 41 66 2,849 35,766 909 36,675 175 Table V. Venereal diseases (joint scheme). Summary of work done at the London Clinics for all areas from 1917. Year. New cases. Total venereal cases. Total non-venereal cases. Total attendances In-patient days. Pathological examinations for Syphilis. Soft chancre. Gonorrhoea. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Clinic. Practition ers. 1917 4,427 3,351 199 11 3,830 1,207 8,456 4,569 1,192 1,168 120 ,659 63 ,923 13,988 3,649 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1,345 1,348 169 ,485 60 ,095 25,973 6,380 1919 6,394 3,391 463 18 10,441 2,440 17,298 5,849 3,418 1,700 201,626| 106,096 24,025 49,186 51,554 10,464 1920 6,988 3,579 766 25 10,669 2,427 18,423 6,031 4,403 2,189 329,940 134,093 29,430 52,182 58,920 14,027 1921 5,088 3,100 458 13 8,573 2,136 14,119 5,249 3,696 2,354 357,503 138,706 30,272 49,420 66,134 18,472 1922 4,207 2,600 309 12 8,233 2,402 12,749 5,014 3,759 2,191 387,631 141,372 28,809 83,755 74,022 19,836 1923 4,497 2,631 311 4 9,043 2,520 13,851 5,155 4,167 2,477 412,915 142,594 29,661 77,001 69,784 24,4 03 1924 4,174 2,452 301 4 8,565 2,785 13,040 5,241 4,869 2,423 424,850 164,152 31,620 70,836 79,005 24,797 1925 3,556 2,346 268 11 8,464 2,857 12,288 5,214 5,726 2,954 459,011 187,120 29,313 73,141 106,064 26,346 1926 3,725 2,013 301 2 8,825 2,858 12,851 4,873 5,830 3,158 490,578 196,497 31,258 70,477 100,543 27,565 1927 3,886 2,209 203 7 9,637 2,859 13,726 5,075 6,799 3,365 554,171 213,107 21,268 91,145 107,512 27,046 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 6,369 3,226 544,969 218,566 23,821 41,285 107,410 29,785 1929 3,303 1,628 276 4 8,271 2,503 11,850 4,135 5,656 3,145 557,747 211,125 23,121 28,399 114,840 32,605 1930 3,389 1,826 347 12 8,620 2,503 12,356 4,351 6,305 3,857 623,820 212,399 21,033 30,183 125,177 33,309 1931 3,009 1,521 326 12 7,713 2,260 11,048 3,793 6,853 4,253 699,752 230,596 23,408 33,133 161,092 35,498 1932 3,270 1,671 172 15 8,566 2,656 12,008 4,342 7,286 4,316 737,558 246,363 22,774 31,249 196,357 40,026 1933 3,072 1,638 185 10 8,791 3,313 12,048 4,961 7,325 4,350 804,042 293,172 23.504 29,077 219,852 39,649 1934 2,673 1,506 159 6 8,689 3,031 11,521 4 543 7,620 4,539 820,469 321,818 22,928 31,161 261,116 37,286 1935 2 578 1,352 336 14 8,184 2,768 11,098 4,134 8,575 4,596 826,122 312,370 21,654 33,912 255,403 38,354 1936 1.806 1.055 275 21 7,724 2,319 9,865 3,395 8,076 4,741 807,397 294,981 23,214 34,128 263.050 37,748 1937 1,783 1,144 211 8 7,636 2,316 9,630 3,468 7,718 5,009 726,120 274,322 22,666 32,363 266,128 36,675 176 177 L Table VII. Venereal diseases (joint scheme). Utilisation of treatment facilities during 1937. Hospital. Syphilis. Soft chancre. New cases. Total. No. of Persons. Total attendances. No. of inpatient days. Gonorrhoea. Not V. D. Ceased to attend. Discharged Albert Dock 85 33 325 207 650 43 430 11,018 2,569 Gt. Ormond St. 22 — 9 532 563 16 543 2,578 1,956 tGuy's . 157 8 492 956 1,613 329 1,393 57,096 3,199 King's College 139 — 124 280 543 128 366 13,404 706 L.C.C. Clinic (Whitechapel) 337 13 1,425 1,890 3,665 970 2,441 257,581 6,183 Metropolitan 43 6 173 126 348 117 201 29,326 240 Miller General 103 3 180 76 362 225 142 14,207 284 Royal Free 155 — 388 987 1,530 161 1,538 30,568 3,282 Royal Northern 119 7 457 460 1,043 213 817 54,969 68 St. George's . 97 3 538 386 1,024 291 796 39,705 750 St. John's (Lewisham) 56 4 124 285 469 46 395 8,287 483 St. Mary's 347 — 1,196 891 2,434 613 1,690 94,318 2,198 *St. Paul's 34 1 165 261 461 174 173 22,465 52 St. Thomas' 512 23 1,938 3,085 5,558 1,130 3,816 183,130 3,703 Seamen's 151 114 688 298 1,251 916 270 14,853 10,242 S. London for Women 43 — 97 247 387 39 251 11,239 651 University College 141 2 362 152 657 332 331 30,735 646 West Londo 270 —- 861 1,249 2,380 737 1,899 87,929 1,730 Westminster 111 2 208 128 449 149 343 30,579 189 S.A. Mothers' 2 —. 160 231 393 93 187 6,455 6,217 Children's, Waddon 3 — 42 — 45 — 50 — 9,681 Totals 2,927 219 9,952 12,727 25,825 6,722 18,072 1,000,442 55,029 * Three months only. -J oo Table VIII. Venereal diseases (joint scheme). Pathological examinations and- specific treatment, iq17. Hospital. Pathological examinations. ABC. doses given. Spirochaetes. Gonococccci Wassermann Others. Total. (a) (b) (a) (b) (a) (b) (a) (b) Albert Dock 24 - 844 45 692 291 1,384 582 3,862 753 Gt. Ormond St. 1 - 1,110 56 839 224 586 161 2,977 261 Guy's 164 - 13,252 1,126 3,269 2,731 6,661 1,274 28,477 3,157 King's College 13 3 918 63 1,305 2,720 249 93 5,364 1,560 L.C.C. Clinic (Whitechapel) 730 4 36,377 2,286 8,116 3,284 14,542 3,872 69,211 14,483 Metropolitan 21 - 935 107 627 333 677 591 3,291 1,029 Miller General 3 - 1,316 13 271 1,050 96 91 2,840 1,119 Royal Free 39 - 19,644 154 2,945 1,408 4,734 1,557 30,481 2,494 Royal Northern 41 3,605 63 998 1,288 339 79 6,413 2,385 St. George's 72 1 1,535 36 1,890 60 2,104 15 5,713 2,223 St. John's (Lewisham) 6 - 306 43 532 219 450 29 1,585 501 St. Mary's 185 - 15,426 415 4,292 1,917 3,864 92 26,191 5,804 *St. Paul's 33 - 1,745 44 837 97 910 36 3,702 734 St. Thomas' 683 1 24,148 626 14,730 389 16,541 376 57,494 234 Seamen's 143 - 3,949 75 1,079 110 2,935 42 8,333 1,719 S. London for Women 2 - 3,924 677 597 374 664 224 6,462 435 University College 180 - 1,756 26 963 19 241 3,185 2,199 West London 143 - 14,650 201 3,962 1,285 5,633 1,272 27,146 5,427 Westminster 33 - 2,284 31 736 819 1,091 1,575 6,569 4,187 S.A. Mothers' 2 - 2,626 - 349 - 530 - 3,507 20 Children's, Waddon - - - - - - - - - - Totals 2,518 9 150,350 6,087 49,029 18,618 64,231 11,961 302,803 50,724 * Three months only. (a) For centre, 266,128 (b) For practitioners, 36,675 IV. TUBERCULOSIS TUBERCULOSIS. INTRODUCTION. It will be seen from the following seetions that there was a slight increase in the number of notifications of all types of tuberculosis during the year, but that there was a fall in the death rate from the disease. Fluctuations of small extent may be expected, and these slight increases in no way vitiate the conclusion that the disease is steadily becoming less prevalent. Nevertheless, in a large industrial area such as West Ham the low rates which have been recorded within recent years are a very satisfactory feature. Attention has repeatedly been directed to the fact that in the large towns in the country there is a definite increase in the incidence of pulmonary tuberculosis in young adults. Several theories have been advanced to explain this unpleasant tendency. From the figures which are given in Table V. it will be seen that during the year 1937 the total number of new cases of all forms of tuberculosis in the area was 407, and that of these 115—or 28.3 per cent.—referred to patients between the ages of 15 and 25 years. When this proportion is regarded from the comparative aspect, it must be considered as high. It should be noted that of the 142 new cases of pulmonary tuberculosis in females of all ages, 33—or 23.2 per cent.—were girls between 15 and 20 years, and 26—or 18.3 per cent.—were girls between 20 and 25 years, so that in females 41.5 per cent, of the new cases suffering from the pulmonary form of the disease were young adult females. Expressed in another way, new cases of pulmonary tuberculosis in young adult females between the ages of 15 and 25 years constituted 14.5 per cent, of all new cases of tuberculosis—pulmonary and non-pulmonary—at all ages. This result is probably an expression of the mode of life of the young adults of our time. The problem cannot be discussed further in a report of this nature, but it is one which merits the attention of both the scientist and the social worker. 180 STATISTICS. The general trend of incidence of and mortality from tuberculosis is dealt with on page 110. The total number of cas.es of tuberculosis on the register the corresponding date in the previous year. This represents an increase of 32 cases. There were added to the register during the year, on account of fresh notifications and inward transfers, 407 cases. As a result of death, removal from the area, or change in diagnosis, 375 names were removed from the register. (See 'Table X.) Notifications. During the year, 301 cases of pulmonary and 72 cases of non-pulmonary tuberculosis were formally notified, making a total of 373 cases (212 males and 161 females). The 1936 figures were: pulmonary, 295; non-pulmonary, 60. Table I. Tuberculosis. Formal notifications, 1937. Age (years) Primary notifications (new cases) Total new cases. Pulmonary. Non-pulmonary. Both sexes. Males. Females. Males. Females. Pulmonary. Non-pulmonary. 0— - - 1 1 — 2 2 1— 4 5 10 4 9 14 23 5— 4 1 7 4 5 11 16 10— 4 3 6 1 7 7 14 15— 16 33 5 6 49 11 60 20— 22 23 4 1 45 5 50 25— 36 33 6 3 69 9 78 35— 28 J4 1 5 42 6 48 45— 30 12 2 — 42 2 44 55— 19 4 I 2 23 3 26 65— 5 5 i 1 10 2 12 All ages 168 133 44 28 301 72 373 All notifications (primary & secondary) 295 239 63 58 534 121 655 181 From the point of view of age grouping, it is found that 7.0 per cent. of the total notifications of pulmonary tuberculosis which were received were in respect of children under 15 years, and 93.0 per cent. were in respect of persons over 15 years. As regards non-pulmonary tuberculosis, 47.2 per cent. were children under 15 years, and 52.8 per cent. were individuals over 15 years. The corresponding figures for the previous year were 5.4 per cent. and 94.6 per cent. in respect of pulmonary tuberculosis, and 46.7 per cent. and 53.3 per cent. in respect of non-pulmonary tuberculosis. Table I. gives details regarding the ages of notification of pulmonary and non-pulmonary cases respectively. The figures for primary notifications at all ages represent the total new cases of tuberculosis which were formally notified to the medical officer of health during the year. These figures are printed in bold type. Table II. gives the age grouping of cases of tuberculosis which came to the notice of the medical officer of health, otherwise than by formal notification, during the year. Table II. Tuberculosis. Cases not formally notified,1937. Age (years) Pulmonary. Non-pulmonary. Both sexes. Total not notified. Males. Females. Males. Females. Pul- monary. Non-pulmonary. 0— — 1 — — 1 — 1 1— 1 — 1 1 1 2 3 5— — 1 1 — 1 1 2 10— — — — 3 — 3 3 15— — — — — — — — 20— 1 3 1 — 4 1 5 25— 5 1 1 — 6 1 7 35— 2 — 2 — 2 2 4 45— 4 2 — — 6 — 6 55 1 — — — 1 — — 65— — 1 — 1 1 1 2 All ages 14 9 6 5 23 11 34 182 The source of information in respect of these 34 cases is given in Table III. Table III. Tuberculosis. Non-notified cases. Sources of information. Source of information as to the above-mentioned cases. Number of cases. Pulmonary. Non-pulmonary. Death returns: (a) from local registrars 9 5 (b) transferable deaths from Registrar General .. 1 - Posthumous notifications .. — — "Transfers" from other areas (other than transferable deaths) 13 6 Other sources (if any) — — Total 23 11 Pulmonary and non-pulmonary 34 Ward incidence of notified cases (primary notification). Table IV. gives the distribution in the various wards of the borough of the 373 cases notified in 1937, according to site affected. It will be seen that generally the variation of the incidence rate in different wards was slight. No definite conclusions can be drawn from the rates shown, but the data are of some importance for reference purposes. Age incidence of new cases. In this section a distinction has hitherto been made between cases formally notified to the medical officer of health and cases which came to his notice through other channels. The true incidence of new cases is given by the sum of these two separate groups of cases, and for comparative purposes it is more accurate to take this combined figure. Table V. shows the true incidence of new ca:ses in 1937, distributed according to the age and sex of the patients, and to the main type of the disease from which the patients suffered. 183 Deaths. The total deaths from tuberculosis of all types during the year was 227, of which 138 were of males and 89 of females. In the previous year the total number was 236, of which 138 were of males and 98 of females. Of the total deaths from tuberculosis, the pulmonary form of the disease accounted for 203, or 89.43 Per cent. the non.pulmonary form for 24, or 10.57 per cent. The death rate from pulmonary tuberculosis was 0.7S Table IV. Tuberculosis. Primary notifications, 1937. Distribution in wards. Ward. Pulmonary. Non. pulmonary. Total. Rate per 1,000 population 1. New Town 15 6 21 1.37 2. Forest Gate 14 6 20 1.21 3. High Street 2 1 6 27 1.75 4. Broadway 14 0 16 1.28 5. Park 15 6 21 1.55 6. Upton l8 1 19 1.29 7. Plashet Road 12 7 19 1.51 8. West Ham 11 5 l6 1.14 9. Plaistow 15 4 19 1.08 10. Bemersyde ii 5 16 1 .39 11. Canning Town and Grange 29 6 35 1.43 12. Hudsons 35 2 37 2.04 13. Ordnance 18 2 20 1.18 14. Beckton Road 26 5 31 1.77 15. Tidal Basin 27 4 31 1.51 16. Custom House and Silvertown 20 5 25 1.38 Whole borough 301 72 373 1.44 per 1,000 of the population, and from non.pulmonary tuberculosis 0.09 per 1,000 of the population, making a total death rate from all forms of the disease 0.87 per 1,000. The corresponding figures for 1936 were:—pulmonary 0.78 per 1,000, non-pulmonary 0.11 per 1,000, making a total of 0.89 per 1,000. The figures for 1937 therefore present a decrease of 0.02 per 1,000 in the non-pulmonary rates. 184 Comparative death rates. I am indebted to the RegistrarGeneral for the following information. The provisional death rates from tuberculosis for England and Wales for the year 1937 were: respiratory 0.58 per 1,000 of the population; non-respiratory 0.12 per 1,000; all forms 0.70 per 1,000. The pulmonary death rate for West Ham is therefore considerably above the respiratory death rate for the country as a Table V. Tuberculosis. Incidence of new cases (notified and non-notified), 1937. (years) Pulmonary. Non-pulmonary. All forms. Males. Females. Males. Females. N umber. Rate per 1,000 population at ages. 0— i 1 1 3 0.68 1- 5 5 11 5 26 1.48 5— 4 2 8 4 18 0.71 10— 4 3 6 4 17 0.70 15— 16 33 5 6 60 2.27 20— 23 26 5 1 55 2.16 25— 41 34 7 3 85 2.08 35— 30 14 3 5 52 1.65 45— 34 14 2 — 50 1.76 55- 20 4 1 2 27 1.30 65— 5 6 1 2 14 0.96 All ages 182 142 50 33 407 1.57 whole, but the non-respiratory rate is somewhat below the corresponding rate for England and Wales. Since the respiratory death rate refers to persons who died from laryngeal tuberculosis in addition to tuberculosis of the lungs and pleura, the death rate from respiratory tuberculosis is not strictly comparable with the death rate from pulmonary tuberculosis. As the number of patients who die as a result of laryngeal tuberculosis unaccompanied by tuberculosis of the lungs and pleura is very small, the two rates may therefore be used for comparative purposes in this way. 185 From Table XXXIX. on page 114 it will be seen that, so far as pulmonary tuberculosis was concerned, nine towns had lower rates. So far as the death rate from other forms of tuberculosis was concerned, the death rate for London was equal to that for West Ham, and only four other towns had a lower rate than that of West Ham. When account is taken of the fact that the area is almost entirely industrial, these rates are not unsatisfactory. The general epidemiology of the disease in relation to the country as a whole is dealt with in another section. Deaths at ages. The distribution of the 227 deaths, according to age, and sex, and type of disease, is shown in Table VI. Table VI. Tuberculosis : age distribution of deaths, 1937. Age (years) Pulmonary. Non-pulmonary. All Forms. Males. Females. Males. Females. Number. Rate per 1,000 population at ages. 0- 4 - - 4 0.91 1 1 - 7 2 10 0.57 5— 1 — — 1 2 0.08 10— — 1 — - 1 0.04 15— 12 1 1 2 29 1.10 20— 15 13 — 2 30 1.18 25— 22 1 — - 41 1.01 35- 1 7 2 2 28 0.89 45— 28 9 — 1 38 1.34 55— 2 7 1 i 34 1.63 65- 6 2 — 2 10 0.69 All ages 12 76 11 13 227 0.87 Further particulars of the deaths from non-respiratory tuberculosis are give in Table VII. Deaths in wards. The actual deaths from different forms of tuberculosis which took place in the different wards of the borough, together with the ward death rates, are set out in Table VIII. 186 Duration of disease before death. The year of notification of each of the patients who died from tuberculosis in 1937 is given in Table IX. The following discussion relates especially to pulmonary cases, and the table does not give the percentage calculated for these cases only. The non-pulmonary deaths are, however, so few that they do not vitiate the conclusions. It is seen—excluding the 7 per cent. of deaths which occurred in persons who had not been notified as suffering from tuberculosis— Table VII. Deaths from non-respiratory tuberculosis, 1937. Disease Age (years) All ages 0- 1- 2_ 5- 10- 15- 20- 25- 35- 45- 55- 65- Tuberculous meningitis 4 3 3 1 1 12 Tuberculous peritonitis — 2 — - — — 1 — 2 1 1 — 7 Miliary tuberculosis - - - 1 - - 1 - - - - - 2 Tuberculosis of sacro-iliac joint - - - - - - - - - - 1 1 Tuberculous ulcer of neck - - - - - - - - - - - 1 1 Lupus - - - - - - - - 1 - - - 1 Total — 6 3 1 — 3 2 — 4 1 2 2 24 that about 41 per cent. of the persons who died from the disease during the year had been notified within the previous twelve months. Further, about 62 per cent. of the persons who died from the disease during the year had shown symptoms sufficiently suggestive to warrant notification within the previous two years. These figures indicate a type of the disease which shows considerable activity. From the table it is seen also that only about 13 per cent. of the patients who died from tuberculosis in 1937 had survived, for five years or longer from the date of first notification. There is no doubt that certain factors must contribute to 187 the rapidity with which death took place. It is unwise to dogmatize on figures for a single year, but it is possible that two factors may be responsible: (a) asocial conditions, and (b) a failure on the part of the patients to take full advantage of the excellent facilities for diagnosis and treatment which are offered by the local authority. Of the relationship between social conditions and tuberculosis I do not intend to speak in this report. If the second factor Table VIII. Tuberculosis. Deaths in wards and death rates PER 1,000 WARD POPULATION. Ward. Pulmonary. Non-pulmonary. All forms. Deaths Deathrate. Deaths. Deathrate. Deaths Deathrate. 1. New Town 11 O.72 1 0.06 12 0.78 2. Forest Gate 11 0.67 2 O.12 13 O.79 3. High Street 13 0.84 1 0.06 14 0.90 4. Broadway 10 0.80 1 0.08 11 0.88 5. Park .. .. 10 0.74 2 O.14 12 0.89 6. Upton 9 0.61 1 0.07 IO 0.68 7. Plashet Road 9 0.72 2 O.15 11 0.87 8. West Ham 12 0.85 2 0.14 !4 0.99 9. Plaistow 14 0.80 2 O.11 16 0.91 10. Bemersyde 8 0.70 1 0.08 9 0.78 11. Canning Town and Grange 23 0.94 2 0.08 25 1.02 12. Hudsons 0.94 1 0.06 18 0.99 13. Ordnance 12 0.71 1 0.05 13 0.77 14. Beckton Road 12 0.69 1 0.05 13 0.74 15. Tidal Basin 20 0.97 2 0.09 22 1.06 16. Custom House and Silvertown 12 O.66 2 0.11 14 0.77 Whole borough 203 0.78 24 0.09 0.87 is responsible, even in part, every effort should be made to induce the sufferers to improve their condition by constant attention to the recommendations which are made to them by the Council's specialists in tuberculosis work. 188 Table IX. Year of notification of all deaths from tuberculosis in 1937 Year of notification. Number of deaths in 1937. Percentage of total leaths from ubereulosis Male. Female. Total. 1 Pulmonary Nonpulmonary. Pulmonary Nonpulmonary Died outside the Borough. Died in the Borough. 1923 — — 1 — 1 0.44 1925 - - 1 — 1 0.44 1926 — 1 — — 1 0.44 1927 2 — — - 2 0.88 1928 - - 2 - 2 0.88 1930 1 — - - 1 0.44 1931 1 - - - 1 0.44 1932 2 — - - 2 0.88 1933 1 - 1 1 8 1.32 1934 3 - 3 - 6 2.65 1935 5 - 3 — 8 3.52 1936 12 — 10 1 23 10.14 1937 1o — 14 i 25 11.01 1925 - — 1 — 1 0.44 1926 2 — — — 2 0.88 1927 2 - — — 2 0.88 1928 — — 1 — i 0.44 1929 i — — — i 0.44 1930 3 — — — 3 1.32 1931 2 — — — 2 0.88 1932 i — 5 — 6 2.65 1933 3 — 1 1 5 2.20 1934 7 _ 1 — 8 3.52 1935 8 — 3 1 12 5.29 1936 14 1 8 1 24 10.57 1937 42 6 16 5 69 30.40 122 8 71 11 212 93.39 1937 Not notified 5 3 5 2 15 6.61 Total 127 11 76 13 227 100.00 189 THE TUBERCULOSIS REGISTER. The tuberculosis register is an accurate record of the number of notified cases. Tables X gives particulars of the cases added to and removed from the register during the year 1937- Table X. Notification Register. Pulmonary. Non-pulmonary. Total cases. Males. Females Total. Males. Females Total. Number of cases of tuberculosis on register on 31st December, 1936 709 838 1,547 217 303 522 2,067 Number of cases removed from the register during the year by reason of (a) Withdrawal of notification - - - - - - - (b) Recovery from the disease 32 28 60 20 14 34 94 (c) Death 109 74 183 13 6 19 202 (d) Otherwise 21 41 62 7 10 17 79 Total removed from register 162 143 305 40 30 70 375 Number of cases added to the register during the year (a) New cases 168 133 301 44 28 72 373 (b) Posthumous notifications 6 4 10 3 o' 5 15 (c) Transfers 8 5 13 3 3 6 19 Total added to register 182 142 324 50 33 83 407 Number of cases of tuberculosis on register on 31st December, 1937 729 837 1,566 227 306 533 2,099 For comparative purposes, particulars regarding the number of persons on the register in each year since 1931 are given in Table XI. 190 Table XI. Number on tuberculosis register. Year. Number on register. Increase (+) or decrease (-) as compared with previous yeai Pulmonary. Nonpulmonary. Total. Actual. Percent, of previous years. 1931 2,373 991 3.364 — — 1932 2,002 974 2,976 -388 -11.5 1933 1,751 1,020 2,771 -205 - 6.8 1934 1,690 603 2,293 -478 -17.2 1935 1,648 605 2,253 - 40 - 1.7 1936 1.547 520 2,067 - 86 - 3.8 1937 1,566 533 2,099 + 32 + 1.5 WORK OF THE DISPENSARY. Special features of the work of the dispensary are discussed later in the report of the Chief Clinical Tuberculosis Officer. In Table XII. I give certain details of the work carried out at the dispensary in the year 1937. This table is modified from Form T. 145, which is required by the Ministry of Health. Contacts. The number of new contacts examined during the year was 423, of whom 6 were found to be suffering from tuberculosis. The corresponding figures for the previous year were 464 and 8. Further particulars arc given in Table XIII. Table XIII. , Contacts first examined during 1937. New contacts, examined. Found sputum t.b. + Diagnosed tuberculous but sputum negative. Diagnosed nonpulmonary tubercle. Entirely nontuber culous. Lost sight of. Removed from area. Remaining under observation. Admitted sanatoria for observation or treatment. Men 69 2 — — 66 1 1 Women 133 1 — 128 4 — Boys 121 - 2 I 112 6 2 Girls too - — — 89 11 I Total 423 3 2 I 395 22 4 191 192 Table XII. Tuberculosis Dispensary. State of diagnosis at the end of the year 1937. (Modified from Ministry of Health Return, Form T/145, Table A.) A. New cases examined during the year (excluding contacts) PULMONARY NON-PULMONARY TOTAL Adults Children Adults Children Adults Children M. F. M. F- M. F. M. F. M. F. M. F. Definitely tuberculous 125 90 7 10 12 15 12 4 137 114 19 14 Di agnosis not completed — — — — — — — — 77 66 68 29 Non-tuberculous - - - - - - - - 118 151 175 144 Totals 332 331 252 187 B. New contacts examined during the Definitely tuberculous 3 - 2 - - - 1 - 3 - 3 - Diagnosis not completed - - - - - - - 1 4 11 8 Non-tuberculous - - - - - - - - 65 129 107 92 Totals 69 133 121 100 C. Cases written off Dispensary Register Recovered 27 22 13 10 4 3 10 6 31 25 23 309 16 249 Diagnosis not confirmed or non-tuberculous (including cancellation of cases notified in error) 207 ; 299 Totals 238 324 332 265 Number of persons on Dispensarv register:— Diagnosis completed 1,578 Diagnosis not completed 223 Total 1,801 The number of contacts who were still under observation on the 31st December, 1936, was 27: of these, 11 were diagnosed definitely tuberculous during the year; 14 were diagnosed as nontuberculous ; one was lost sight of; one remained under observation ; and 7 were admitted to sanatoria for observation or treatment. INSTITUTIONAL ACCOMMODATION FOR TUBERCULOSIS. The Council possesses two institutions for the treatment of tuberculous patients—Dagenham Sanatorium, which accommodates 128 adults, and Langdon Hill Sanatorium, which has 40 beds for the treatment of children. These institutions are further described in the report of the medical superintendents. Table XIV . gives further details regarding the allocation of these beds. Table XIV. Allocation of beds at Dagenham and Langdon Hill Sanatoria. Age (years) Type of tuberculosis. Dagenham. Langdon Hill. Total. Male. Female. Male. Female. — 15 I'ulmona rv •— — 15 30 Non-pulmonarv — — 5 5 io 15— Pulmonary 80 48 — — i 28 Non-pulmonarv Total 80 48 20 20 168 In addition 92 beds at Whipps Cross Hospital arc at present used for the treatment of tuberculosis—more especially cases of an advanced nature. There were 110 extensive alterations or additions to these, sanatoria during the year, and other structural alterations are described later in this section. Treatment in the Authority's institutions during igjy. The number of patients treated in Dagenham and Langdon Hill Sanatoria is shown in tabular form in Tables XV. and XVI. m 193 Table XV. Tuberculosis . Treatment in Dagenham Sanatorium, 1937. (Ministry of Health Form T. 145 (D)—modified.) Adults (15-) Remaining 1st January, 1937 Admitted. Discharged. Died. Remaining 31st December 1937 Pulmonary— Males 76 136 116 40 56 Females 43 85 72 16 40 Non-pulmonary— Males - - - - - Females — - — — — Observation— Males — 9 9 — — Females 1 10 10 — 1 Total 120 240 207 56 97 Table XVI. Tuberculosis. Treatment in Langdon Hill Sanatorium, 1937. (Ministry of Health Form T. 145 (D)—modified.) Children (-15) Remaining 1st January, 1937 Admitted. Discharged. Died. Remaining 31st December 1937 Pulmonary— Males 11 15 13 — 13 Females 11 13 12 — 12 Non-pulmonary— Males i 4 2 — 3 Females 2 4 3 — 3 Observation— Males 8 6 11 — 3 Females 4 2 2 — 4 Total 37 44 43 — 38 194 Duration of treatment. The duration of treatment in these institutions and the results of the treatment which the patients received are shown in Tables XVII. and XVIII. Table XVII. Dagenham Sanatorium . Analysis of cases discharged. (Ministry of Health Form T. 145 (G)—modified) Period of treatment (adults). Pulmonary. Non-. pillion a ry. Total. T.B. minus. T.B. plus. Quiescent. Improved. Not improved. Quiescent. Improved. Not improved. Males 6 — — 4 — 10 Females — — 1 — — 3 - 4 1—3 months Males 1 5 — — 10 3 — 19 Females 4 3 — 0 2 3 — 14 3—6 months Males 14 3 — 9 15 3 — 44 Females 5 1 — 3 12 0 — 26 6—12 months Males 3 0 - 15 7 3 — 30 Females 3 — — 2 5 2 — 12 Over J 2 months Males 2 4 4 2 — 12 Females 1 — — 5 3 1 — 10 Total 33 14 7 40 58 29 — 181 Occupational therapy. Since the proportion of advanced or moderately advanced cases admitted to Dagenham Sanatorium is fairly high, it has not so far been found practicable to introduce any elaborate system of graded exercises. The actual amount of work which is allocated to different patients is decided more by the condition of the patient than dictated by any pre-arranged system. Table XX. gives an indication of the proportion of the patients who were in a condition to do work of this type. Results of treatment in institutions. The results of treatment are further analysed in Table XIX. 195 Table XVIII. Langdon Hill Sanatorium . Analysis ok cases discharged. (Ministry of Health Form T. 145 (G)—modified) Period of treatment Children (-15 years). Sex. Pulmonary. Non-pulmonary. non t.b. Total T.B. minus. T. IS. plus Q. Imp. Not Imp. Q. Imp. Not Imp. Q. Imp. Not Imp. Under 28 days Under 5 Males - - - - - - - 1 - 1 Females - - - - - - - - 1 — 1 Over 5 Males - - - - - - - - - - - Females - - - - - - - - - - 1—3 months Under 5 Males - - - - - - - - - - - Females - - - - - - - - - - - Over 5 Males - - - - - - - - - 1 1 Females - - - - - - - 1 - - 1 3—6 months Under 5 Males - - - - - - - - - - - Females - - - - - - - - - - Over 5 Males 3 — — — — — — .— 1 4 Females 1 - - - - - 1 - - - 2 6—12 months Under 5 Males —. 1 - - - - - - - - 1 Females - - - - - - - - - - Over 5 Males 8 - - - - - 1 - - - 9 Females 4 - - 1 - - 1 - - - 6 Over 12 months Under 5 Males Females - - - 1 - - - - - - 1 - - - - - - - - - - Over 5 Males 8 - - 1 - - - - - - 9 Females 6 - - - - - 1 - - - 7 Total 30 1 — 3 — — 4 1 2 2 43 Q.—quiesccnt. Imp.—improved. Not imp. —not improved. ADMINISTRATIVE ACTION. Public Health (Prevention of Tuberculosis) Regulations, 1925. These regulations prohibit any person who is aware that he is suffering from tuberculosis of the respiratory tract to enter upon any employment or occupation in connection with a dairy which would involve the milking of cows, the treatment of milk, or the handling of vessels used for containing milk. It was not necessary to take any statutory action under these regulations during the year. 196 Public Health Act, 1925. Section 62. The local authority has power under this section to apply to a court of summary jurisdiction for an order for the compulsory removal to a hospital or institution of any person who is suffering from pulmonary tuberculosis, and is in an infectious state, and is liable to spread infection to others. No action was taken in this connection during the year. The above-mentioned section has now been repealed by section 172 of the Public Health Act, 1936, which came into operation on 1st October, 1937. Table XIX. Dagenham and Langdon Hill Sanatoria. Results of treatment in discharged cases (including deaths). Excluding- patients in residence under 28 days. Group. Adult males pulmonary. Adult females pulmonary. Children pulmonary. Children nonpulmonary Total. No. Percent. No. Percent. No. Percent. No. Percent. No. Percent. Quiescent 48 34.78 25 32.89 33 97.05 4 80.00 110 43.47 Improved 46 33.33 26 34.21 1 2.95 1 20.00 74 29.24 Stationary 3 2.17 3 3.94 — — — — 6 2.37 Worse 8 5.79 8 10.54 — — — — 16 6.35 Died 33 23.93 14 18.42 — — — — 47 18.57 Total discharges 138 100.00 76 100.00 34 100.00 5 100.00 253 100.00 Table XX. Dagenham Sanatorium . Grade of exercise attained by adult patients. Males. Females. Total. No exercise 34 29 75 Walking 46 11 45 Work 36 32 68 Total 116 72 188 No exercise—Either confined to bed or up only for a few hours daily. Walking—Up, but no exertion. Able to take short walks or do very limited work. Work—On full exercise. 197 REPORT ON THE WORK OF THE TUBERCULOSIS DISPENSARY BY P. A. GALPIN, M.D., D.P.H., Chief Clinical Tuberculosis Officer. The work of the dispensary has been carried out as usual during the year. Clinical examinations. The number of cases examined is shown in Table XXI., in which figures for other years are also shown for comparison. The table also gives the number of persons examined as request cases or contacts. Table XXI. Tuberculosis. Examinations at dispensary. Type of case. Number examined at dispensary. 1927 1933 1934 1935 1936 1937 Examination by request 760 553 5l6 537 521 479 Contacts 699 507 351 401 464 423 Notified cases 198 98 104 74 69 48 Definitecases 516 419 328 276 301 284 Total exams. 2,173 1,577 1,299 1,288 1,355 1,234 Six of the contacts were diagnosed as tuberculous, or 1.42 per cent, of the contacts examined. Pulmonary tuberculosis. Institutional treatment. The number of beds at Dagenham Sanatorium was adequate for the patients who accepted treatment there. The demand for beds necessarily fluctuates periodically, and at the end of the year 32 beds were unoccupied. The decline in the demand for beds is partly due to the decrease in the total number of cases needing this form of treatment. Whereas in 1927 the number of definite cases examined was 516, in 1937 only 284 were seen. There has also been a considerable decline in the number of children notified, as the following figures show: — 198 Table XXII. Tuberculosis. Notification in children. Year. Pulmonary. Nonpulmonary. Miliary. Total. 1927 43 67 2 112 1937 20 42 — 62 Of the 20 pulmonary cases two only were found to have a positive sputum. If this decline continues, and there are good reasons to lead one to believe that it will, then it will be increasingly difficult to fill the beds at Langdon Hill Sanatorium with definite lung cases. At the end of the year 39 cases were under treatment at this sanatorium, and an analysis of these showed the following types of cases— Pulmonary (T.B. plus) 2 Pulmonary (T.B. minus) 26 Observation 11 Total 39 It will be observed that the proportion of observation cases is high, and if this ratio continues it may be necessary to review the uses to which the institution is put. In this way it might be possible to utilize the sanatorium for types of cases for which there is at present difficulty in obtaining beds. Table XXIII. Tuberculosis . Domiciliary treatment. 1933 1934 1935 1936 1937 Number of insured persons under treatment at end of the year 372 315 282 224 221 Number of reports rerecived from panel doctors (G.P. 36) 635 615 435 374 329 Reports per patient 1.7 1.9 1.5 1.6 1.4 199 Domiciliary treatment. Particulars regarding the domiciliary treatment of tuberculous patients are given in Table XXIII. The following suggestions may explain the decline in the number of reports received. In the past when a patient was referred to his panel doctor for domicilary treatment he would not attend at the dispensary again until twelve months had elapsed, or until his doctor sent him or recommended his re-examination on the quarterly report G.P. 36. In recent months this practicc has been modified by recommending, in addition to domicilary treatment, dispensarv supervision—i.e., the patient attends the dispensary at intervals of two to four weeks or longer. In such cases the quarterlv report is not required. The object of this change in procedure is twofold. In the first place, it is an attempt to ascertain whether the patient is pursuing the regime of life commenced in the sanatorium, and more particularly whether he has established the sound dietetic habits recommended. These consist mainly of the eating of a breakfast before commencing work, and the eating of fat with meat. The patients are advised to have, at least once a day, a meal of meat or fish, with vegetables, including green vegetables, and to eat green salads, summer and winter, three or four times a week. They are also advised to take wholemeal bread and a pint of milk daily. When the patient is not able to purchase the necessary food, a grant is made. In the second place an attempt is made to discover how the patient thinks about the complaint, which he commonly refers to as "It." Some patients worry about their condition, and others try to forget it. A few, only a small number, learn to face and accept facts and to make the disease a part of themselves and their way of life. Most patients realise that worrying is harmful and even fatal, and endeavour to try to find things to do to take their mind off their condition. There is evidence that this method is only partially successful, and leads to unsatisfactory results. An attempt is made to persuade the patient to face realities by doing daily those things which help him to overcome the disease. Dispensary treatment. Children and non-insured persons, able to attend at the dispensary, have been given treatment. At the end of the year 575 patients were under treatment. During the year 748 sputum tests were made, and 304 X-ray examinations were carried out at Whipps Cross Hospital. 200 Artificial pneumothorax. Nine cases received this form of treatment and, during, the year, 85 refills were given at the dispensary. Non-pulmonary cases. Adults were treated mainly at the Royal Sea-Bathing Hospital, Margate, and the majority of the children at the Lord Mayor Treloar Cripples' Hospital, Alton. Table XXIV. Institutional treatment of non-pulmonary tuberculosis Margate. Alton. Number of cases admitted 12 4 Number of cases discharged 14 8 Tuberculosis of the skin. Twelve cases have been receiving treatment at the London Hospital; two of these are new. After-care. Extra nourishment. At the end of the year 243 patients were in receipt of grants of extra nourishment. Colonies and settlements. Details are given in Table XXV. of patients who received treatment at training colonies and village settlements. Table XXV. Treatment at colonies and settlements. Name of institution. Admitted. Discharged. Died. Away at 31.12.37. Male, female. Male. Female Male Female. Male. Female. British Legion Village Preston Hall 3 — 2 — — — 4 — Papworth Village Settlement 6 — 1 1 1 — 7 1 Burrow Hill Colony 2 — 1 — — — 3 — Total 11 — 4 1 1 — 14 1 201 Disposal of cases. An analysis of primary notifications and transfer of patients suffering from pulmonary tuberculosis, showing the disposal of the cases during the year 1937, is given in Table XXVI. Table XXVI. Pulmonary tuberculosis. Men. Women. Children. Total. Admitted to Dagenham or Langdon Hill Sanatoria 68 42 10 120 Admitted to other institutions 18 19 2 39 Unable to accept institutional treatment r4 23 37 Dispensary treatment 5 8 — 13 Dispensary supervision 3 4 2 9 Domiciliary or home treatment 15 8 _ 23 Diagnosis not confirmed 1 2 — 3 Removed from West Ham area — — — — Not examined 45 17 6 68 Total 169 123 20 312 An analysis of the 68 cases which were not examined is shown below: Notified deaths 19 Cases in institutions (e.g. mental hospitals) n -> O J Declined to attend dispensary 9 Left West Ham area 2 Notification withdrawn 1 Lost sight of 4 The percentage of notified deaths to total deaths (169) i 11.2 and to the total notifications and transfers (312)—6.0. 202 REPORT ON THE WORK AT THE WEST HAM SANATORIA, by G. m. mayberry, l.a.m., l.r.c.p., Medical Superintendent. (a) Dagenham Sanatorium. The institution, which was originally opened as a temporary sanatorium, consists of permanent and temporary buildings standing in an area of approximately seven acres. The accommodation for male patients consists of two permanent main buildings, each having two wards. On the hospital side there is a balcony, and the wards are divided into one- two- and three-bedded cubicles, to accommodate 28 patients. On the convalescent side there are 32 beds. In addition, there is accommodation for eight other convalescent patients in two-bedded rooms, and twelve in a temporary building. The accommodation for female patients is in two temporary buildings, both of which contain cubicles, one with 21 beds for hospital cases, and the other with 27 beds for convalescent patients. There is a small balcony at the end of each ward. All new patients are admitted to the hospital side, and after examination and observation, if suitable are transferred as soon as possible to the convalescent side. This rule is strictly adhered to, and does much to prevent patients from feeling that their condition is incurable. There is a large dining room for the patients, separate recreation rooms for both sexes, a church, a concert room, a laundry, a sputum sterilizer, disinfecting plant, an X-ray department, and a mortuary. Alterations. During the year 1937 several important improvements and additions were carried out, such as a balcony to the male hospital block, and a re-construction of the sluice and ablution room on the female side, including the installation of a modern bed-pan sterilizer. A recreation room for the domestic staff was also provided. A brick building was erected adjoining the disinfector. This building now contains a sputum sterilizer which works under steam pressure, with boiler house and lavatory accommodation for male staff attached. A water softener was also installed in a self-contained building; already its advantages are being felt. 203 Admissions. During the year, 221 cases were admitted— 136 males and 85 females. The average length of stay was 25 weeks. The percentage of bed cases was 55.3. The cases admitted were of the usual type. The patients could generally be divided into the following classes:—- (a) The chronic fibroid type of case which generally deteriorates at intervals. These patients gladly return to conditions which they realise will build them up again. (b) The stage II. class of patients who for economic reasons remained at work too long, did not consult a doctor, or refused to avail themselves in the first instance of treatment when it was offered to them. (c) Early cases, or cases with a limited lesion, and a little constitutional disturbance, the first symptom of which was often an early haemoptysis. These patients constitute the smaller proportion. The average patient who has had an initial haemoptysis will readily go to an institution, while a limited number will place health before everything and seek early diagnosis and treatment. Treatment. Treatment first and foremost consists of fresh air, rest, graduated exercise, and good food constituting a strictly balanced diet, which it is often difficult to obtain in many homes. The lack of a satisfactory diet is often one of the pre-disposing causes of the disease. Drugs are used as accessories to treatment; guaiacol, calcium, and iron have been found beneficial. Intra-muscular injections of gold were tried in 25 cases, several cases having two courses. The results are certainly encouraging. While in some cases there has been no apparent change, taking everything into consideration it is reasonable to conclude that others have improved with carefully regulated doses. We have had no bad results. Artificial pneumothorax. Though many advanced cases have been admitted, few have been found suitable for this form of treatment. In all 10 successful inductions were carried out, and 192 refills were done. Unilateral cases are undoubtedly the most suitable, and the more limited the disease the more successful the result is likely to be. As a large proportion of these cases do well with conservative treatment, it does not seem justifiable to attempt an induction before a reasonable period of observation. 204 With few exceptions, the more advanced cases should not be subjected to this treatment without very serious consideration. Over a number of years we have had the opportunity of observing the end results in the more advanced type of case. They were far from encouraging compared with the results in those patients who received prolonged conservative treatment. This method ol treatment may be very valuable in a limited number of cases, but the selection requires very careful consideration. Gas replacement was done in one case; the result was highly satisfactory. Operative treatment. The present accommodation is not entirely suitable for carrying out this type of treatment, and where it is necessary arrangements are made for the transfer oi the patient to hospital. Suitable cases are likely to be few, but considering the satisfactory results which are obtained in many cases, it is likely that surgical measures will be more frequently adopted in the future. Light. A carbon arc lamp has been in use for a number ol years. As a method of treatment for pulmonary tuberculosis we do not employ it, but it is a very useful adjuvant in the treatment of special cases. Some years ago a considerable number of the staff were off duty with influenza. Each of the others were given 5 minutes' exposure to the rays as a prophylactic measure, and there were no further cases. This measure has been several times repeated with success. Results of treatment. The results are frequently disappointing. There are many factors that contribute to this, and the following suggestions refer to the particular patients who were under treatment. (a) The human element. The patient will often, for economic and other reasons, not remain long enough in the institution, and he imagines that he should, by medicine or some of the modern methods of treatment, be cured in quite a short period. He is ignorant of the fact that in about 90 per cent, of cases these methods are contra-indicated. (b) The return to conditions which in many instances are quite unsuitable. (c) Many patients would remain to complete their treatment to the 205 best advantage if they could be satisfied that those who are dependent on them would be sufficiently provided for during their absence. I fear that in many instances this is not so. (d) There is no practical method of compelling a patient to remain in an institution, although his discharge may be a grave danger to his family and the public at large. Grade work. No elaborate grading of patients is carried out. For male patients on outdoor work there are three grades : — (1) Light work. For 2 hours in the morning. (2) Heavier work such as digging for 2 hours in the morning. (3) Same work as in grade 2, but the patients work both in the morning and afternoon. Several patients are also employed polishing floors, and in looking- after the billiards room and tables. The gardener is responsible for seeing that the patients carry out the work allotted to them. The female patients are employed in domestic work, washing up, dusting, and cleaning lockers, and in addition a number do light gardening. When the weather is favourable we aim at keeping patients occupied out of doors as much as possible. Radiology. During the year 601 films were taken, and 55 patients were screened. Three barium meals were given. In addition, 43 films were taken of children from Langdon Hill sanatorium. Lipiodol was used in one case. Dental treatment. Two patients received treatment from the dental surgeon at Whipps Cross Hospital, and were fitted with dentures. Many patients arrive at the institution with their teeth in a very decayed condition. Where the patient is not well enough to attend a dentist outside, a number of extractions are done annually in the institution with and without a local anaesthetic. It would be helpful if patients would visit a dentist before they are admitted. Diet. Three substantial meals are served daily—at 8.30 a.m., 1.30 and 6.0 p.m. In addition milk is given in the morning and at bed time. The quantity of the food is not limited in any way, and there is plenty of variety. No special diets are recognised, but they are ordered for each individual case as required. 206 Bacteriological and other examinations. With the admission of a large number of sputum positive cases, the more exacting bacteriological methods, beyond the scope of routine examination of sputum and repeated examination in negative cases, are seldom necessary. A blood sedimentation test has been carried out in a number of cases, mostly in those having gold injections. In many cases its usefulness would appear to be somewhat limited. Recreation. During the winter months the usual arrangements were made by the Hospitals Committee for concert parties to visit the institution monthly. Whist drives and billiards handicaps are also held at intervals. There are three billiards tables, two of which are full-sized, and also a bagatelle table. There are two putting greens. Dart boards, dominoes, and chess are among other games supplied. Wireless is available for the patients, head-phones for the sick, and loud speakers mostly for the convalescent. The wireless set on the female side was provided through the generosity of Councillor Mr. A. G. Gay, J.P. Staff. During the year the health of the stalf as a whole has been satisfactory. Unfortunately one member of the nursing staff contracted pulmonary tuberculosis. I am glad to report that, after treatment in the institution, she has now been on full duty for some time. Great difficulty has been experienced in obtaining probationers, and for the first time in the history of the institution it became necessary to engage the services of private nurses. Three nurses passed Part I. of the examination for the certificate of the Tuberculosis Association, and three obtained their final certificate. Of recent years many leave before completing their course of training, often to take up private work. (6) Langdon Hill Sanatorium. This institution was officially opened in October, 1927, for the admission of children suffering from pulmonary tuberculosis. It stands on a site of 99 acres, its elevation being one of the highest in Essex. There is accommodation for forty children—twenty of each sex. The main building, which is connected up with the dining room and kitchen, has two wards of 14 beds each, with three two-bedded cubicles at each side, and a nurses' duty kitchen 207 between the two wards. There is an isolation ward on each side. There are sliding doors to each ward, and a covered verandah under which beds can be brought out. Adjoining the institution is an orchard, and in this and the surrounding woods the children can have very pleasant walks. Other buildings include a nurses' home, maids' quarters, playroom, and a schoolroom. Two school teachers attend daily to give instruction to the children. The school is recognised by the Board of Education, and is inspected at intervals by one of their medical officers. Admissions. During the year 44 cases were admitted, 25 males and 19 females. We get few advanced cases with positive sputum. The other cases consist of those who show radiologically an old standing focus, heavy root shadows, or evidence of pleurisy. While others show no definite signs they often have a cough and appear generally debilitated. In some cases there is a definite history of tuberculosis in the home. In addition we had a number of children with abdominal tuberculosis and glands, a few of whom were operated on before admission. In 23 cases the Mantoux test was carried out. The average length of stay was approximately 61 weeks. The percentage of bed patients was 3.94. Treatment. Beyond the ordinary open-air methods and the administration of drugs and adexolin in a few cases, active treatment has not been found necessary. Results. The results can be considered highly satisfactory . Children with positive sputum have rarely any sputum after a short period of treatment. We have not found that children with a positive sputum and advanced disease are hopeless cases. With prolonged treatment the results are amazing at times. Manv who have had treatment are now at work "after a number of years. Unfortunately, others who were discharged in a hopeful condition, were later admitted to Dagenham Sanatorium. Children are much more amenable to treatment than adults, and, after a sufficient period of treatment, if they could return to favourable conditions or be kept in an institution such as a colony for some years, a large proportion would be restored to a satisfactory state of health. In conclusion, I feel that enough is not done for the definite tuberculous child in the way of after-care. 208 Radiology. This has been extremely helpful from the point of view of diagnosis. During the year the number of films of Langdon cases taken at Dagenham Sanatorium was 43. Dental treatment. All children who require this treatment are seen by the school dentist before admission, and not admitted until it is completed. It has, however, been necessary to perform a few extractions at the institution. Diet. A generous diet is provided, with a liberal supply of fresh vegetables and fruit. Fresh fruit is available during the greater part of the year from the orchard and green-houses. Recreation. Suitable cases are taken for nature study walks by the school teachers. In their absence the children are taken for walks by the nursing staff. During the summer months picnics are arranged for those well enough to go. During the winter, films are hired from the Kodak Library and shown weekly. There is wireless installation in all the wards and staff quarters. Staff. During the year we lost a number of our nursing staff who had been with us for several years. It has been difficult to fill their places adequately. Fortunately the acute shortage of nurses has not been felt so much as at Dagenham Sanatorium. 209 V. MATERNITY AND CHILD WELFARE. 811 MATERNITY AND CHILD WELFARE. INTRODUCTION. The scheme which is administered by the County Borough Council for the care of the mother and her infant has been officially recognised as giving excellent results. The extent of the scheme and the nature of the results may be appreciated from the information which is given in the following pages. In this sectnon I have confined the text to information relating to the practical aspects of the service, and I have dealt with the statistical aspect of the diseases of infancy and of motherhood—expectant or realized— in another section. In this way the data which are of interest to the statistician appear together in one section, but those who are concerned mainly with maternity and child welfare work should refer also to the appropriate tables in the section on Vital Statistics. Where so much is good, the indication of certain chinks in the armour might appear to savour of an act of derogation. Yet no service can be perfect, and those who arc familiar with this service will understand that any suggestions for improvement must be taken as guides for future progress rather than admissions of present weaknesses. My predecessor, the late Dr. F. Garland Collins, set out in an excellent report certain improvements which could be effected in the maternity service. I have recently attempted to give effect—though in a slightly different manner—to certain of these suggestions, and other aspects of this service will have my attention in the near future. With reference to the care of the child, there does appear to be a gap between the end of infancy and the beginning of school life. The health of the toddler is a matter which deserves the attention of a large and progressive authority, and at a later date I hope to put forward certain suggestions for the improvement of this service. In the preparation of this part of the report I have to acknowledge my indebtedness to Dr. Helen Campbell, Senior 212 Table I. Distribution of all births occurring in the Borough. Place of confinement. Residence of mother. Total West 11am. East 11am. Essex County Other areas I. Births in patients' homes (a) Attended by doctor 298 — — — 298 (b) Attended by midwife 2,069 3 6 7 2,085 (c) Others — — — — — Total in home 2,367 3 6 7 2,383 II. Births in Council's hospitals — — — — — (a) Forest Gate Hospital 445 261 212 1 919 (b) Other institutions — — — — — Total in Council's hospitals 445 261 212 1 919 III. Births in voluntary hospitals (a) Plaistow Maternity Hospital 804 294 96 11 1,205 (b) Queen Mary's Hospital 320 131 538 15 1,004 (c) Other voluntary hospitals — — — — — Total in voluntary hospitals 1,124 425 634 26 2,209 IV. Private nursing homes 6 6 2 3 17 V. Other institutions — — — — — VI. Other births — — — — — Grand total 3,942 695 854 37 5,528 213 Assistant Medical Officer for Maternity and Child Welfare, who is responsible for the administration of this section. DISTRIBUTION OF ALL BIRTHS. In an area such as West Ham, surrounded as it is by other urban areas, it is inevitable that many of the births which take place in homes and hospitals are to mothers whose ordinary place of residence is outside the area of the County Borough. The distribution of all the births—whether to West Ham residents or not—which occurred in the area during 1937 are given in Table 1. It should be noted that the figures relate to the number of children born—both live and still births—and not to the number of confinements. This table brings out the fact that, of the 2,383 births which occurred in private houses, 99.3 per cent, related to mothers ordinarily resident in West Ham. Of the births which occurred in the hospitals belonging to the local authority, 48.4 percent. were to mothers residing in West Ham, 28.4 per cent, to mothers residing in East Ham, and 23.1 per cent, to mothers resident in the County of Essex. The corresponding figures for voluntary institutions are: West Ham residents, 50.9 per cent.; East Ham residents, 19.2 per cent.; Essex County residents, 28.7 per cent. The relative proportion of West Ham residents who are confined in the Council's hospitals is therefore approximately the same as the proportion confined in voluntary hospitals. Of the patients resident outside the Borough area, the proportion resident in East Ham is higher in the case of the municipal hospitals than in the case of the voluntary hospitals. Taking the figures in the last line of this table, it is seen that of the 5,528 births which took place in the area of the County Borough, 71.3 per cent, were to mothers ordinarily resident in the West Ham area, 12.6 per cent, to East Ham women, and 15.5 per cent, to women resident in the County of Essex. MATERNITY SERVICE. Midwives. The total number of midwives on the register on 31st December, 1936, was 54. During 1937 the number of midwives who gave notice of their intention to practise was 103. The total number of midwives on the register on 31st December, 1937, was 60. The apparent discrepancy between the figures 103 and 60 is accounted for by the fact that a certain number of mid- 214 wives practise from their training schools in the borough for a short period after passing the examination of the Central Midwives' Board. Of the 60 midwives, only 9 were in private practice; 46 were employed by the various voluntary associations, and 5 by the local authority in Forest Gate Hospital maternity unit. Five of the private midwives resided in the borough; the remaining four midwives lived in adjoining areas, and conducted respectively a varying number of cases in West Ham. Plaistow Maternity Hospital. This hospital is situated in the centre of a densely populated district, and it has for many years carried out excellent work in obstetrics. Further notes upon this institution appear on page 225. During the year 1937 the number of births of West Ham residents in this institution was 804. In addition, nurses from this hospital attended 1,242 mothers whose confinement took place in their own homes. The number of midwives employed by this institution at any one time varies, but at the end of the year the number was 11 in hospital and 15 on the district. During the course of the year 54 different midwives were in residence. Queen Mary's Hospital. This hospital—further notes on which appear on page 255—has 50 beds for maternity purposes, 10 of which are subsidised by the Borough Council. The number of births of West Ham residents which took place in this hospital during the vear was 320. The average number of midwives in residence at any one time is 7. Forest Gate Hospital. Maternity unit. The number of beds in this unit varies according to the demand, but in general it may be said that the average number of patients in residence is about 70. The number of births which took place in the hospital during the year was 919. This number has been increasing progressively during the last few years, and the time has now arrived for a complete re-organisation of the unit. A report dealing with this matter was recently presented to the appropriate committee. In addition to the midwives employed by the above institutions, midwives belonging to certain other organisations practise in the borough. These are clearly detailed in Table II. Analysis of cases attended by midwives. Table II. gives an analysis of the cases attended by midwives during 1937. Fifteen midwives from the Plaistow Maternity Hospital 215 Table II. Analysis of cases attended by midwives. Classification of midwives. Average number of midwives throughout the year. Attended as Total cases. Percent. of local births. Midwife. Maternity nurse. I. Births in the homes. (1) Midwives in practice. (a) Private midwives (resident in West Ham) 3 140 23 163 3.07 (b) Private midwives (resident outside West Ham). 3 27 2 29 0.55 (c) Certificated and on register but did not work. 2 — — — — (2) Midwives employed by nursing associations. (a) Plaistow Maternity Hospital and District Nurses' Home. 15 1,242 173 1,415 26.67 (b) Queen Mary's Hospital. 2 202 2 204 3.85 (c) Mothers' Hospital Branch Home, 19. Chandler Road, E.16. 2 163 11 174 3.28 (d) Essex County Nursing Association. 8 69 32 101 1.90 (e) Silvertown and North Woolwich District Nursing Assoc. 2 66 1 67 1.26 Total in homes 37 1,909 244 2,153 40.58 II. Births in institution (1) Private nursing homes 2 — 17 17 0.32 (2) Maternity hospitals (a) Forest Gate Hospital 5 855 52 907 17.11 (b) Plaistow Maternity. 11 1,117 88 1,205 22.72 (c) Queen Mary's 5 890 106 996 18.77 Total in institutions 23 2,862 263 3,125 58.92 Grand total 60 4,771 507 5,278 99.50 216 and two midwives from Queen Mary's Hospital are always reserved for practise as district midwives. The above numbers include also those who practised partly in hospital and partly on the district during the year 1937. The local births—5,305 in number—are those actually returned by the Registrar General as having been registered in the borough. They include the births of non-residents which occurred within the borough. The number of cases attended by midwives (excluding cases delivered in hospitals or nursing homes by midwives) during the year was 2,153. Of these, 1,909 were attended as midwives, and 244 as maternity nurses. This number is a decrease of 57 cases as compared with the figures for 1936. Records of calling in medical aid. Medical aid was summoned by midwives under section 14(1) of the Midwives Act, 1918, in 628 cases. Details for the summoning of medical aid are shown in Table III. Table III. Midwives practice. Reasons for medical aid being summoned. Pregnancy. Unsatisfactory condition of patient 4 Toxaemia, albuminuria 4 Varicose veins 1 Abdominal pains 5 Threatened miscarriage 10 Ante-partum haemorrhage 4 Prolapsus uteri 1 Miscarriage 11 40 Labour. Prolonged labour 100 Abnormal presentation 34 Retained products 17 Prolapsed cervix 2 Ante-partum haemorrhage 34 Post-partum haemorrhage 9 Unsatisfactory condition 16 217 Ruptured perineum 131 Foetal distress 3 346 Puerperium. Rise of temperature 53 Phlebitis, varicose ulcer, etc. 14 Breast conditions 8 General condition unsatisfactory 13 Secondary post-partum haemorrhage 3 Sub-involution 2 Vaginal tear 1 94 Infants. Birth injury 1 Congenital deformity or defect 14 Prematurity, feebleness 25 Asphyxia, cyanosis 14 Discharging eyes 30 Skin eruptions 15 Unsatisfactory condition 32 Stillbirth 7 Death of baby 7 Circumcision 3 Total 148 628 Number of medical aid forms sent by independent midwives 56 Number of medical aid forms sent by midwives practising from hospitals or nursing associations 572 Total 628 During 1937 application was made to the local supervising authority in 510 instances by medical practitioners for payment of fees under the Midwives Act, 1918. Table IV. gives particulars of the extent to which these records were sent, and the number of applications for payment. 218 Table IV. Records of medical aid. No. of midwives cases. No. of records sent. Records per 100 eases. No. of applications for payment. Application per 100 cases. 2,153 628 29.2 510 23.7 Iuspection of midwives. Routine supervision and inspection of the homes and work of the midwives is carried out by the senior assistant medical officer for maternity and child welfare, who is also the supervisor of midwives. No disciplinary action was necessary in this connection during- 1937. Nursing in the home. The Council has no arrangement for the provision of district nurses other than midwives to undertake nursing in the homes. District nursing is carried out by nurses attached to several nursing associations working from homes in or adjacent to this area, viz. Plaistow District Nurses' Homes, The Silvertown and North Woolwich District Nursing Association, and the Essex County Nursing Association. Table V. Infectious diseases in mothers and infants. Puerperal fever. Puerperal pyrexia. Ophthal- mia neonatorum. Pemphigus neonatorum. Number of cases notified 4 75* 10 — Number of cases removed — 73 9 — Number of cases who died — 2 1 — Number occurring in doctors' practice 2 8 — - Number occurring in midwives' practice — 38 5 - Number occurring in institutions 2 29 5 - Number nursed in hospital 4 55 5 — * 23 of these 75 patients were women who were not ordinarily resident in West Ham. 219 220 Table VI. Notified cases of puerperal pyrexia and puerperal fever. West Ham residents. No. of cases. Stage of pregnancy. Where delivered. Nature of delivery. Where treated. Result. Abortion Premature. Fullterm. Home. Hospital Normal. Difficult Instrumental. Home. Hospital Recovered. Died. Puerperal fever 4 — — 4 3 1 2 — 2 — 4 4 — Puerperal pyrexia 52 1 7 44 37 15 36 5 11 24 28 49 3* The cause of death of the three patients who died was pulmonary tuberculos's, 2; meningitis, 1. Infectious diseases in mothers and infants. The statistics of puerperal fever and puerperal pyrexia are dealt with more fully in the section on Vital Statistics, and notes on ophthalmia neonatorum appear in the section on Infectious Diseases. Table V. gives in brief the main particulars regarding these conditions during the year 1937. In Table VI. an analysis is given of the notified cases of puerperal pyrexia and of puerperal fever which occurred in West Ham residents in 1937. It will be appreciated that in the case of puerperal pyrexia the cause of the fever was not ascertained in each instance. The following were the results in the 26 cases in which the cause of the pyrexia was known:—Mastitis, 6 cases; influenza, 4 cases; phlebitis, 3 cases; tuberculosis, 2 cases; tonsillitis, 2 cases; bronchitis, 2 cases; septic perineal tear, 2 cases; pneumonia, 1 case; pyelitis, 1 case; rheumatism, 1 case; meningitis, 1 case; retained products, 1 case. Home Helps. The number of cases in which home helps were provided during 1937 was 566. The home help is a woman chosen by the patient, subject to the approval of the health visitor, who attends daily in the home of the patient for fourteen days from and including the day of confinement. As the duties of such a woman are purely domestic she may be employed where required whether the patient is confined at home or in hospital. The home help is supervised by the health visitor, and, subject to a satisfactory report of her work, payment is granted by the local authority. The Council do not re-claim from the applicant any part of this grant. Only those persons whose income falls within the limits of a prescribed scale are eligible for the services of these home helps. This scheme is satisfactory on the whole. To the mother herself it is of great benefit to have a known friend in the home rather than a stranger appointed specially for the work. There is not only the knowledge that her home and children are being cared for, but there is greater peace of mind from the fact that the home help knows intimately her home and her children. Minor difficulties arise from time to time, but it is seldom that these cannot be adjusted by the health visitor to the satisfaction of all concerned. 221 The Midwives Act, 1936. Municipal Midwifery. The Midwives Act, 1936, placed the responsibility upon the local authority "to secure that the number of certified midwives so employed who are available in its area for attendance on women in their own homes as midwives or as maternity nurses during childbirth and from time to time thereafter during a period of not less than the lying-in period, is adequate for the need of the area." For many years domiciliary midwifery in West Ham had been undertaken chiefly by midwives working under the ægis of various voluntary organisations in the borough, viz:— (a) Plaistow Maternity Hospital. (b)) Queen Mary's Hospital. (c) Silvertown and North Woolwich District Nursing Association. (d) Mothers' Hospital, Clapton—Branch Home. (e) Essex County Nursing Association, Leytonstone. In addition a varying number of private midwives practised in the borough, of whom three only were resident in West Ham. The Midwives' Act, 1936, did not come into force in West Ham until the 1st April, 1938. All the above-named associations except those referred to under (e) are in the borough and have been utilised in the arrangements for the provision of domiciliary midwives under the Midwives' Act, 1936. Pupil midwives are trained in district midwifery by these hospitals and associations, so that their methods and practice are up-to-date and efficient, and the results eminently satisfactory. The number of midwives employed by these associations in pursuance of their agreements with the Council under the Act are:— Plaistow Maternity Hospital 15 Queen Mary's Hospital 2 Mothers' Hospital (Salvation Army) 2 North Woolwich and Silvertown district Nursing Association 1 It is anticipated that each of these midwives will be capable of undertaking 100 cases per year. In addition the Council have appointed, as full-time officers, four municipal midwives, whose districts have been so arranged 222 that they may work in close co-operation with the medical officers and health visitors of Grange Road and Maybury Road maternity and child welfare clinics respectively. Each of these midwives will be allowed to attend 80 cases per year. The scheme came into force on 1st April, 1938, and the municipal midwives started their duties on the same day. The work of this section will be dealt with more fully in my next annual report. ANTE-NATAL WORK, The ante-natal work which is carried out under the control of the Council may be divided broadly into three sections:— (a) Home visiting by the health visitors. (b) Medical examinations and supervision at ante-natal clinics at the Council's welfare centres. (c) Medical examinations and supervision at ante-natal clinics conducted by voluntary associations with grants from the Council. (a) Home Visiting. This is carried out by the health visitors employed by the Council, of whom there are eighteen, and by twenty-eight nurses employed by the Plaistow Maternity Hospital for the purpose of health visiting. The health visitors "follow up" in their homes all expectant mothers who attend the clinics. As a result of home visiting mothers are brought into touch with the services of the Council available for them at such a time, e.g. home help, dried milk, free meals. In addition, since 1st April, 1938, any woman who has engaged one of the municipal midwives to attend her at confinement is visited by the midwife during her pregnancy)'. This work is shown in Table VII. Table VII. Work of the health visitors. Employing organisation. First visits. Total visits. Municipal health visitors 1,828 3,560 Plaistow Maternity Hospital nurses 3,140 13,207 (b)) and (c) Medical examination at clinics. There are five municipal maternity and child welfare clinics in the borough, each of which is so situated as to be easily accessible to the women of the 223 surrounding area. Six sessions for expectant mothers are held weekly at these clinics, a doctor and health visitor being present at each session. At Grange Road and Maybury Road clinics the municipal midwife also attends, and is present with the doctor at the examination of her cases. Pupil midwives from Forest Gate Hospital attend West Ham Lane and Forest Gate ante-natal clinics. Ante-natal sessions are held at three of the voluntary clinics, a doctor being present at four sessions per week at these clinics. Ante-natal sessions are held weekly at Queen Mary's Hospital for the examination of women who intend to be confined in the hospital or at home by the hospital midwives. During 1937 a total of 6,117 expectant mothers attended at the ante-natal clinics, and 28,808 attendances were made. The average attendance per individual in 1937 was 4.7. Table VIII. shows particulars of the ante-natal attendances for a period of six years. Table VIII. Attendances at ante-natal clinics. Year. First visits by expectant mothers. Total attendances. Average attendance per individual. 1932 8,871 29,867 3.5 1933 7,864 28,589 3.6 1934 7,890 28,807 3.7 1935 8,137 31,230 3.9 1936 7,024 29,055 4.1 1937 6,117 28,808 4.7 Abnormal cases are referred for advice to the local maternity hospitals, viz. Forest Gate Hospital, Queen Mary's Hospital, and Plaistow Maternity Hospital. There is no difficulty in obtaining immediate admission of a case to the ante-natal ward of Forest Gate Hospital, when in-patient treatment and observation is considered advisable, and there is close co-operation between the medical officers of the clinics and the medical superintendent of Forest Gate Hospital in regard to patients who have attended the municipal clinics and are later admitted to that hospital for confinement or treatment. 224 Consultants. Three consultants are available in respect of puerperal fever cases. During- 1937 their services were called upon on three occasions. NATAL WORK. Notification of Births Act, 1907. As from October 1st, 1937, notification was carried out under sec. 203 of the Public Health Act, 1936. A few particulars of the notifications of births received during the year, and of the patients to which they referred, are given in the following statement. It should be noted that the figures for notifications do not agree very closely with the figures for births given in the section of this report which deals with vital statistics. The discrepancy is due partly to the fact that many notifications referred to women who were not ordinarily resident in West Ham, and partly to other factors. For accurate work the figures for births registered should be used. Total number of births notified during 1937 5,809 Total number of livebirths notified during 1937 5,605 Total number of stillbirths notified during 1937 204 Number of birth notified by midwives 4,510 Number of births notified by doctors and parents 1,299 5,809 Total number of births occurring in maternity hospitals in the borough 3,128 Total number of births in nursing homes in the borough 17 Total number of births occurring at home 2,383 Total number of births notified by outside authorities 281 5,809 There are three large maternity hospitals in West Ham admitting patients from West Ham and adjacent areas, viz., Queen Mary's Hospital for the East End, Stratford, E.15; Plaistow Maternity Hospital, Howards Road, Plaistow, E.13; and the maternity wards of Forest Gate Hospital, Forest Lane, E.7. Subsidies are granted by the Council to the two voluntary maternity hospitals in respect of the treatment at confinement of approved cases. There is one nursing home in the borough which admits maternity cases; 17 women were confined in this home during 1937. 225 O An ambulance is available for the transfer of women in labour to the maternity hospitals, for which no charge is made to the patient. During 1937 the ambulance was used for this purpose in 207 cases. Maternal mortality. The statistics of maternal mortality for the year 1937 and previous years are given on page 93. In 1928 the Maternal Mortality Committee of the Ministry of Health issued a form of enquiry to be completed in respect of every maternal death. As a result of the enquiries into the maternal deaths for the year 1937, it was found that, of the nine deaths in, or in consequence of, childbirth, seven took place in institutions and two at home. Six of the patients who died in hospital were admitted as emergency cases, the remaining patient having been under treatment in hospital. Table IX. gives details of the conditions which caused death. Table IX. Class 1. Deaths directly due to child-bearing. (a) Puerperal sepsis 0 (b) Toxaemia, including eclampsia 2 (c) Other causes, e.g. haemorrhage, difficult labour, etc. 7 Total 9 Details of the maternal deaths. The following brief summary will give some indication of the conditions which were present in the fatal cases, and of the degree to which death might have been prevented:— (1) Age, 32 years. Married. General health satisfactory, poor home circumstances. Had not had supervision during pregnancy. Labour—premature (28 weeks) at home. Patient died suddenly on the 7th day. Cause of death—pulmonary embolism. (2) Age 40 years. Married. General health good, home circumstances fairly good, but patient worked daily in charge of a vegetable stall. Was under hospital clinic during pregnancy for treatment for chronic nephritis complicating pregnancy. She suffered from albuminuria, with excessively high blood pressure, 226 but she refused to enter the medical ward for treatment. In the twenty-eighth week of pregnancy this patient suddenly developed symptoms of uraemia, and was admitted immediately to hospital where she died two days after admission. Cause of death: (a) coma, (b) uraemia, (c) nephritis, (d) pregnancy, about 28 weeks. (3) Age, 42 years. Married. General health not good, home conditions comfortable. Ante-natal care during pregnancy satisfactory. At sixth month of pregnancy patient developed marked oedema of arms, legs, and abdominal wall, for which she was admitted to hospital. On the day of admission she had a slight vaginal haemorrhage; the urine was loaded with albumen. Within twenty-four hours of admission to hospital, patient had a severe ante-partum haemorrhag'e, and died 12 hours later. Cause of death: (a) chronic parenchymatous nephritis; (b) ante-partum haemorrhage. (4) Age, 29 years. Married. General health poor, patient being very stout; subject to asthma and gastric symptoms. Home circumstances poor. The patient had received satisfactory antenatal supervision. In the thirty-sixth week of pregnancy the patient had ante-partum haemorrhage due to central placenta praevia. She was admitted at once to a maternity hospital, where Caesarian section was performed on the following day. The result was a living child. On the third day after the operation the patient developed symptoms of paralytic obstruction, from which she died four days later. A post-mortem examination was not performed. Cause of death: (a) cardiac failure; (b) paralytic intestinal obstructions; (c) Caesarian section for placenta praevia. (5) Age, 25 years. Married. General health unsatisfactory, home conditions poor. Ante-natal supervision adequate from the third month of pregnancy. At four-and-a-half months she began to have slight jaundice, with irritation of the skin. One month later there was slight albuminuria, but normal blood pressure. The patient felt well and was kept under observation at home. At six-and-a-half months she was admitted to hospital for further treatment for persistent jaundice. Five days later labour commenced, and during it she had an eclamptic fit. After delivery she had six fits, and she died twelve hours later. Cause of death: (a) eclampsia; (b) toxaemia of pregnancy; (c) acute yellow atrophy of liver. (6) Age, 40 years. Married. General health good, home conditions 227 poor. Ante-natal supervision unsatisfactory, in that the patient refused to attend an ante-natal clinic or to co-operate in any way with those in charge of her case. Full-time pregnancy when labour commenced at home. The midwife sent for a doctor owing to delay in the second stage. After two unsuccessful attempts to deliver with forceps at home, the patient was admitted to a maternity hospital and delivered by forceps two hours later. Her condition on admission was very poor, with symptoms of shock. Death occurred on the third day. Post-mortem examination showed rupture of the uterus and early peritonitis. Cause of death: (a) ileus paralyticus; (b) obstructed labour; (c) rupture of uterus. Table x. Year. Live births notified. Stillbi. ths notified. Total notified births. Percent, of stillbirths to total notified births. 1927 6,297 219 6,516 3.4 1928 6,671 189 6,860 2.8 1929 6,316 210 6,526 3.2 1930 6,428 195 6,623 2.9 1931 6,194 190 6,384 3.0 1932 6,223 192 6,415 3.0 1933 5,662 173 5,835 3.0 1934 5,576 207 5,783 3.6 1935 5,158 156 5,314 2.9 1936 5,689 214 5,903 3.6 1937 5,605 204 5,809 3.5 (7) Age, 32 years. Married. General health good, home conditions poor. Adequate ante-natal supervision. She had slight ante-partum haemorrhage at the third month. At the eighth month the patient had concealed ante-partum haemorrhage, which caused collapse due to a marginal placenta praevia. She was seen and treated by a doctor at home, and delivered of a stillborn premature baby four hours after the onset of the haemorrhage. She died two hours later. Cause of death: (a) shock and syncope; (b) concealed accidental haemorrhage; (c) pregnancy—stillbirth of foetus. 228 (8) Age, 32 years. Married. General health and home circumstances satisfactory. Early pregnancy, hence no ante-natal supervision was obtained. She was admitted to hospital for treatment of haemorrhage. Operation revealed extra-uterine gestation. She died soon after operation. Cause of death: ruptured ectopic gestation. (9) Age, 40 years. Married. General health and home conditions poor. Adequate ante-natal supervision. At the eighth month the patient was admitted to hospital in labour with a history of slight vaginal haemorrhage. Delivery of a stillborn foetus occurred some hours after admission. There had been constant slight loss of blood throughout labour. This persisted after the delivery of the child, and the placenta was not expelled. The patient died two hours after delivery. Post-mortem examination revealed accidental haemorrhage. Cause of death: (a) obstetric shock; (b) accidental haemorrhage. Stillbirths. Table X. gives a comparison between notified live and stillbirths. Pemphigus. No case of this disease occurred in the borough during the year. Post-natal supervision. At present there is no separate clinic for the supervision of the condition of mothers after their confinement, but mothers are referred in special instances for postnatal examination and advice to the medical officers of the antenatal clinics. It is anticipated that separate sessions will be established in the near future so that all women may be urged to attend for routine examination after confinement in order to prevent or relieve later suffering and ill health. CHILD WELFARE. There are eleven maternity and child welfare clinics in the borough, of which five are municipal and six are voluntary but subsidised by the Council. Municipal clinics. These clinics are situated in different areas of the borough; West Ham Lane and Forest Gate clinics on the north side; Grange Road, Maybury Road and Silvertown clinics on the south side. With the exception of Silvertown clinic, the buildings belong to the Council and are used only for the purpose of maternity and child welfare. The clinic at Silvertown was 229 230 Table XI. Work of the clinics. Attendances. Name of Clinic. First attendances. Total attendances. Medical consultations Total attendances. Under 1 year. Over 1 year. Under 1 year. Over 1 year. Under 1 year. Over 1 year. (a) Municipal. West Ham Lane 522 255 4,342 3,067 2,786 2,274 Grange Road 247 144 1,917 1,904 1,498 1,431 Forest Gate 387 163 4,582 2,713 2,797 1,922 Maybury Road 311 123 2,536 2,756 1,880 2,063 Silvertown 74 23 763 975 670 891 (b) Voluntary. Chesterton House 1,314 277 10,490 3,121 1,218 582 Docks Centre 1,039 133 7,363 3,819 1,194 793 Lees Hall Clinic 305 82 3,055 2,349 948 602 Trinity Mission Clinic 165 40 2,100 2,887 1,513 1,548 Stratford Day Nursery Clinic 194 91 2,505 1,184 1,015 781 Given-Wilson Clinic 80 21 996 825 626 483 Total 4,638 1,352 40,653 25,600 16,145 13,370 established in 1920 as the first Council clinic. The work there is carried on in suitable premises belonging to St. Barnabas Church, West Silvertown. Grange Road, Forest Gate, and Maybury Road clinics are modern buildings erected for the purpose, being fully equipped for all maternity and child welfare work, including dental treatment. Voluntary clinics. There are six voluntary clinics situated in areas of the borough not served by the Council clinics. Three of these clinics are buildings used for maternity and child welfare work only, the other three being held in rooms adapted for the purpose. A municipal health visitor attends at two of the clinics, so that the clinic work is carried on in close co-operation with the district visiting. It is important to note this inter-relation between the two services. Twenty-three sessions are held weekly. A table in the Appendix gives the days and times of the clinics, both municipal and voluntary. At the municipal clinics the rule is that every new case, infant or toddler, should be examined by the doctor on the first visit and afterwards at regular intervals, for example, monthly, until the child attains one year of age; thereafter it should attend quarterly. Special cases are seen more frequently according to the wishes of the doctor and the needs of the child. "Absentee" post cards are sent in respect of every child who is not brought to the clinic within three months from the date of the previous visit. The health visitors who staff the clinics work in the districts immediately adjoining their respective clinics. This arrangement is of material assistance to the clinic medical officers and to the health visitors. Of the total notified live births in 1937, it was found that 79.8 per cent. attended the infant welfare centres throughout the year. Table XI. gives details of the work carried out at the clinics during the course of the year. Special facilities. Dental treatment. Dental treatment is provided for expectant and nursing mothers and for the pre-school child through attendance at the various clinics in the borough. The dental scheme for mothers includes the provision of dentures in cases selected by the dental surgeon. There is no charge for dental treatment, but payment is claimed from the patient for dentures supplied, according to a scale approved by the Council. 231 A child referred to the Council's dental clinic for treatment is supervised thereafter at regular intervals until he goes to school, and every effort is made by those who deal with young children and their parents to encourage the preservation of the temporary teeth. Extractions are done under local anaesthetics for mothers, but in the case of children, de Trey's apparatus is used for the administration of gas and oxygen. Table XII. Work of the dental clinics. Year. Mothers. Children under 5 years. 1st attendances. Total attendances. No. of dentures supplied. 1st attendances. Total attendances. Attendances, Extractions. Fillings. 1933 404 1,258 - 840 3,134 621 1,611 1934 353 1,299 — 694 2,732 651 1,406 1935 468 1,679 73 708 2,531 839 1,176 1936 580 2,739 434 657 2,351 747 958 1937 534 2,699 870 678 2,231 763 883 Artificial sunlight treatment. Artificial sunlight treatment is provided for selected cases by agreement with the Committee of the Stratford Day Nursery. The children are referred from the various child welfare clinics in the borough. Treatment is provided twice weekly, under the supervision of Dr. Eva Morton assisted by a municipal health visitor. In addition, the centre is open three times weekly for the treatment of children not eligible under the Council's scheme. Attendances at the sunlight clinic. (1) Municipal clinic (2 sessions per week). Total number of new cases 83 Total attendances for treatment 1,634 (2) Day Nursery clinic. Total number of new cases 72 Total attendances for treatment 2,423 The children are referred for such conditions as persistent anaemia, malnutrition, bronchial catarrh, or for nervous manifestation, e.g. restlessness, excitability. Attendances are fairly regular, 232 but it is always necessary to impress on the mothers when such treatment is first suggested, that rapid improvement cannot follow after a few attendances. Without the co-operation and interest of the mothers it is impossible to obtain any benefit from this treatment. Institutions. Hospitals for children under 5 years. Children under five years of age who require hospital treatment can be admitted to St. Mary's Hospital, Plaistow, or to the Children's Hospital, Balaam Street, Plaistow. The admissions to St. Mary's Hospital are chiefly of acute medical and surgical cases. At the Children's Hospital the Council retain a ward of 16 cots, which is supervised by the Senior Assistant Medical Officer for maternity and child welfare. Cases are admitted to this ward from the various infant welfare centres, those admitted mainly requiring prolonged treatment for such conditions as marasmus, rickets, and the dietetic disturbances of infancy. In addition, at this hospital four beds are reserved for young children who require in-patient orthopaedic treatment, while there are also facilities in the out-patient department of the hospital for the treatment of less serious deformities common to this age, viz. torticollis, bow-legs, knock-knees, and slight talipes. Arrangements for dealing with children requiring treatment for nose and throat or ear conditions, are in force at Queen Mary's Hospital and St. Mary's Hospital. The number of admissions to these institutions are shown in Table XIII. Table XIII. Admissions of children to voluntary hospitals. 1937. Hospital. No. of beds. No. of admissions. Throat and nose operations St. Mary's Hospital 10 277 43 Children's Hospital:— (a) Babies' ward 16 189 — (b) Orthopaedic ward 4 18 — Queen Mary's Hospital - — 98 233 Particulars of the cases admitted to these hospitals, and of the deaths which occurred, are given in Tables XIV. to XVIII. Table XIV. St. Mary's Hospital, Plaistow. Admissions, 1937. Condition for which admitted. Under one year. One to five years. Total. Male Female Male Female Tonsils and adenoids — — 33 27 60 Otitis media, mastoid, etc 1 2 8 10 21 Pneumonia and empyema 8 5 10 5 28 Bronchitis and asthma 5 1 4 2 12 Gastro-enteritis, diarrhoea, constipation 13 6 3 4 26 Appendicitis 1 — — — 1 Pyloric stenosis 3 — — — 3 Intussusception, rectal prolapse, etc 4 2 1 3 10 Jaundice — - 2 2 4 Hernia, hydrococle 4 - 7 2 13 Burns and scalds 2 — 8 2 12 Skin conditions 2 2 3 5 12 Osteomyelitis, abscesses, etc 2 3 6 4 15 Rheumatism — — 1 — 1 Diseases of brain, etc. 1 1 6 3 11 Injury - 2 5 1 8 Cervical adenitis 1 — 6 1 8 Surgical tuberculosis — — 2 1 3 Circumcision 3 — 4 — 7 Improper feeding 2 1 - — 3 Malnutrition 1 1 1 4 7 Other diseases 4 5 11 9 29 Totals 57 31 121 85 294 234 Table XV. St. Mary's Hospital, Plaistow. Deaths under 5 years, 1937. Cause of death. Under one year. One to five years. Total. Male Female Male Female Pneumonia 6 1 1 1 9 Burns — — 1 — 1 Hydrocephalus — 1 — 1 2 Osteomyelitis — - 1 — 1 Tuberculous meningitis — — 1 — 1 Intussusception 1 - — — 1 Marasmus 1 — — — 1 Bronchitis, rickets — 1 — — 1 Totals 8 3 4 2 17 Table XVI. Children's Hospital, Balaam Street, Babies' Ward. Admissions, 1937. Condition for which admitted. Under one year. Over one year. Total. Male Female Male Female Pneumonia 1 2 3 5 11 Gastro-enteritis, gastritis, constipation 12 3 4 7 26 Malnutrition and marasmus 15 12 5 7 39 Skin conditions 4 3 6 3 16 Otorrhoea, mastoid, etc. — — — 3 3 Convulsions, epilepsy 1 — 2 — 3 Anaemia and debility 1 — 3 1 5 Bronchitis 8 3 1 2 14 Abscess — — — 3 3 Adenitis — - 4 4 8 Burns - — — 1 1 Dentition 2 1 1 1 5 Observation 5 6 9 5 25 Pyloric stenosis 1 — — — 1 Rickets 1 — 7 6 14 Tonsillectomy — — 1 1 2 Umbilical hernia — 1 1 — 2 Other diseases 6 — 3 2 11 Totals 57 31 50 51 189 235 Table XVII. Children's Hospital, Balaam Street, Plaistow. Babies' Ward. Deaths 1937. Cause of death. Under one year. Over one year. Total. Pneumonia 4 1 5 Bronchitis 3 — 3 Gastro-enteritis 9 — 9 Marasmus 9 — 9 Eczema 1 — 1 Diabetes 1 — 1 Prematurity 1 — 1 Pyloric stenosis 1 — 1 Tuberculous meningitis 1 — 1 Totals 30 1 31 CONVALESCENCE OF MOTHERS, CHILDREN AND INFANTS. (a) Mothers. Four beds are reserved by the Council for the use of nursing mothers with their young infants, three at "Child Haven," Brentwood, Essex, by agreement with the West Ham Central Mission, and one at "The London Mothers' Convalescent Home," Sunningdale, Berks. The mothers are admitted throughout the whole year, each mother having a period of two weeks' convalescence. The majority of the mothers are recommended for this treatment by the medical officers of the clinics, or by the health visitors. A detailed report is received from the matron of the home on the discharge of each mother. This report gives information regarding the progress of both mother and infant while they were in residence. During 1937 it was possible to send away under this scheme 90 mothers with their infants, of whom 69 went to "Child Haven," and 21 to Sunningdale. (b) Children. Children under five years of age are referred for convalescence through the Medical Officer of Health to the Invalid Children's Aid Association, and the Invalid and Crippled Children's Society, by whom the children are admitted to approved convalescent homes. In addition the Council retains 20 beds at 236 Table XVIII. Children's Hospital, Balaam Street, Plaistow. Orthopaedic and surgical cases. Admissions, 1937. Condition for which admitted. Under one year. Over one year. Total. Male Female Male Female Tuberculosis of bones and joints - - 4 4 8 Tuberculous glands — 1 3 — 4 Injury — - 1 4 5 Burns and scalds - -— — 1 1 Congenital dislocation of hip - - - 2 2 Bow legs - — 2 - 2 Flat feet — — 1 - 1 Arthrodesis — — 3 - 3 Metatarsal valgus — — — 1 1 Talipes varus - — 2 3 5 Osteomyelitis — — 1 1 2 Torticollis - — 1 2 3 Tenotomy and tendon stretching - - 1 2 3 Traumatic synovitis - — — 2 2 Anterior poliomyelitis - — 3 1 4 Erbs paralysis - — — 1 1 Facial paralysis - — — 1 1 Diplegia - — — 1 1 Rickets - - 1 1 2 Phimosis 6 — 12 — 18 Hernia 2 1 7 5 15 Observation — — — 1 1 Others 1 — 5 2 8 Totals 9 2 47 35 93 237 "Child Haven," Brentwood; these are reserved mainly for young children. The number of children under school age who were sent to various homes during 1937 was 282. The duration of convalescence varies from four to twelve weeks, the children being recommended by private doctors, from clinics and hospitals, for debility after acute illness, or for those more chronic conditions such as rickets, persistent bronchial catarrh, or failure to gain weight. Great benefit is derived from a holiday under the ideal conditions which prevail in these homes. Table XIX. gives particulars of the number of mothers and children sent to convalescent homes during a number of years. Table XIX. Admissions to convalescent homes. 1929 1930 1931 1932 1933 1934 1935 1936 1937 Mothers 18 3 2 33 26 44 44 85 96 90 Children 82 68 97 219 262 228 336 248 282 It will be evident from this table that the demand for these facilities still remains high. Stratford Day Nursery. (he Stratford Day Nursery is controlled by a voluntary association, but subsidised by the Council. It provides daily accommodation for 50 infants and small children whose mothers are obliged to go to work, and it is the only institution of its kind in the borough. The number of children admitted to the nursery in 1937 was 194. These children made 8,568 attendances. The average daily attendance was 35 children. The parents pay Sd. per day per child, which charge includes three meals. WORK OF THE HEALTH VISITORS. Routine visiting of infants, pre-school children, expectant and nursing mothers in their homes, is carried out by: — (a) 18 municipal health visitors, who are engaged solely on this work. 238 (b) 28 nurses employed by the Plaistow Maternity Hospital. The latter nurses undertake visiting of the majority of women attended at confinement by midwives from that institution. In addition, a certain amount of supervision of special cases attending voluntary clinics is carried out by the superintendent nurses of these clinics. Routine visits by municipal health visitors. Children. Up to two years of age the young child is visited quarterly; thereafter half-yearly until he goes to school. Premature infants and special or sick babies are visited each month or more frequently until their condition is satisfactory. Expectant mothers. Visits are paid to supplement the supervision and advice given at the clinics. In addition the health visitors visit women who fail to keep their appointments for examination, and many visits are paid in connection with the arrangements for home helps, admission to hospital for confinement, and for similar reasons. Infant Life Protection. Foster children are visited at least every two months by the municipal health visitors of their respective districts. Special investigation visits. All notified cases of puerperal pyrexia, ophthalmia neonatorum, and pemphigus neonatorum, are visited and reported upon at regular intervals until the patient's condition is satisfactory. Infant deaths, stillbirths, and maternal deaths are investigated by the health visitors. Co-operation with school medical service. Immediately a child attends school (including the two nursery schools provided by the Council) a summary card is completed for transfer to the school medical section of the department. This card contains the history of the child from birth to school age with reference to home conditions, method of feeding in infancy and early childhood, development of the child physically and mentally, and any illnesses from which he may have suffered. These cards are available for use by the assistant school medical officers when these children first attend for medical examination. Visits of health visitors. Some details of the work of the health visitors are set out in Table XX., and particulars of special visits are given below. 239 Table XX. Work of the health visitors. Employing body. Expectant mothers. Infants. Children up to school age. First visits. Revisits. First visits. Revisits. First visits. Revisits. Total. Local authority Voluntary 1,828 3,568 2,841 12,232 835 21,205 43,509 organisations 3,142 13,270 2,364 22,573 511 22,016 63,876 Totals 4.97° 16,838 5,205 34,805 1,346 43,221 106,385 Special visits (Municipal health visitors only): — Home helps, investigations into special cases Infant life protection visits 10,877 Number of first visits 40 Total number of visits 349 Total visits. (a) Municipal health visitors 53,735 (b) Other health visitors 63,876 Total number .. 117,611 Infant life protection. Under the Children Act, 1908, Part I., as amended by the Children and Young Persons Act, 1932, and after 1st October, 1937, by Part VII. of the Public Health Act, 1936, the supervision of foster children and of the homes in which they reside is carried out by the municipal health visitors on their respective districts. Application for registration as a foster mother is sanctioned by the Council on the recommendation of the Maternity and Child Welfare Committee. Only in exceptional circumstances is a foster mother allowed to have more than one foster child in her care at any one time. Before a foster mother's application is approved, a detailed report is received from the health visitor, and from the relieving officer of the district when the applicant is known to him. The 240 register of patients notified as suffering from tuberculosis is consulted in order to eliminate any possibility of introducing a child into an infected family. The foster mother must comply with all rules of the Act, and with the regulations of the Council, such as the provision of a fire-guard, separate and suitable sleeping accommodation, and regular attendance at an infant welfare centre until the child goes to school. The homes are visited at least once every two months by the health visitor, and any difficulty is reported at once to the senior assistant medical officer for maternity and child welfare. During 1937 the number of visits paid by health visitors, acting as infant life protection visitors under this Act, was 349 The number includes 40 first visits. Number of foster mothers on register at beginning of 1937 44 Number of fosters mothers on register at end of 1937 34 Number of foster children on register at beginning of 1937 44 Number of foster children placed on register during 1937 21 Number of foster children who ceased to come under the provisions of the Act during 1937 28 Number of foster children on register at end of 1937 39 Number of deaths occurring in foster children during 1937 - Those children who ceased to come under the provisions of the Act had either reached the age of nine years, or had been legally adopted by the foster parent, or returned to the care of their own parent or a near relative. In most cases the parent or parents of the child pay the weekly charge direct to the foster mother; the amount varies on an average from five shillings to twelve-and-six per week. The local authority accepts no responsibility for the regular weekly payment or for the amount charged to the child's parent. Free meals for expectant and nursing mothers. This scheme, which commenced in January, 1936, provides for a free dinner daily, including Sundays and public holidays, to necessitous expectant mothers from the time when their condition is diagnosed, and to necessitous nursing mothers. Application for this help can only be made to the medical officers of the maternity and child welfare clinics, who are required to sign the medical certificates accompanying the applications sent to the medical officer of health. 241 B There are thirteen dining centres in the borough, and by agreement with the Education Committee the mothers attend these for dinners. Mothers and children attend at different times. The menus are varied and suitable for the mothers. Special diet can be arranged when such a recommendation is made by the doctor at the clinic. The number of dinners provided in 1937 was 16,506, as compared with 15,971 in 1936. Birth control. There has been no alteration in the arrangements commenced in December, 1936, for the provision of this facility to selected cases. Those women for whom further pregnancy would be detrimental to health are referred by the clinic medical officers to the East London Women's Welfare Centre, Burdett Road, E.3, where they receive, free of charge, all necessary advice and treatment. During 1937 the number of women who attended the clinic under the Council's scheme was 41. DRIED MILK. Under the Milk (Mothers and Children) Order, 1919, the Council were empowered to grant milk to mothers and children, and in January, 1920, they commenced to distribute liquid milk through local purveyors. This scheme was operated on an income basis, and the milk was supplied on voucher to expectant and nursing mothers, and to children from one to five years. In August, 1920, dried milk was substituted for liquid milk. The supply was obtainable at the various centres, in accordance with a scale of income approved by the Council. In 1921 the Milk (Mothers and Children) Order, 1919, was revoked by the Ministry of Health Circular 185, and any scheme for the supply of milk had to receive the sanction of the Minister under the Maternity and Child Welfare Act, 1918. This circularstated that milk could only be supplied at less than cost price in necessitous cases to: — (a) Nursing mothers. (b) Expectant mothers in the last three months of pregnancy. (c) Children up to 3 years of age, and exceptionally to children between 3 and 5 years of age. The dried milk is obtained in bulk and packed in 1 lb. packets at the centre in West Ham Lane, and the milk has to be a full-cream dried milk with a guaranteed fat content of 26 Per 242 cent. It is distributed free or at a cheap rate to the mothers. It is packed in special cartons, each carton bearing directions for mixing and the quantities to be used in infant feeding. Samples from each consignment of milk have been submitted for bacteriological and chemical examination with satisfactory results. This large and important health measure is run at a comparatively low cost to the Council, details of which are set out in Table XXI. Table XXI. Cost of milk scheme . 1937. Expenditure £ s. d. Cost of dried milk 8,527 18 10 Cartons and packing 357 8 10 Wages 902 19 2 Rent of offices and packing rooms 131 18 3 Cartage 67 11 5 Printing, stationery and sundries 6 9 10 Total 9,994 6 4 Income £ s. d. Milk sales 8,266 8 6 Sale of empty tins and cartons 3 7 4 Balance (being net cost of service) 1,724 10 6 Total 9,994 6 4 During 1937, dried milk was supplied from the various centres as set out in Table XXII. Table XXII. Distribution of milk (assisted only). Centre. Number of persons receiving dried milk Total. Antenatal. Under one year. One to three years. West Ham Lane 194 660 647 1,501 Forest Gate 36 132 128 296 Public Hall 229 515 888 1,632 Silvertown 12 20 50 82 Howards Road 3 8 5 16 Total 474 1,335 1,718 3,527 243 Table XXIV. No. of packets of dried milk issued. 1937. Centre. Full price. Half price. Free. Total packets.* West Ham Lane. 1 st quarter 24,446 434 9,819 2nd ,, 21,073 394 9,OOI 3rd ,, 21,490 406 8,328 4th ,, 24,332 458 8,432 91,341 1,692 35,580 128,613 Public Hall. 1 st quarter 23,685 408 13,358 2nd ,, 20,173 418 11,979 3rd ,, 19,984 394 10,292 4th „ 23,217 420 10,668 87,059 1,640 46,297 134,996 Forest Gate. 1st quarter 2,191 42 1,743 2nd ,, 1,851 28 1,598 3rd ,, 1,858 40 1,519 4th ,, 2,520 6 1,776 8,420 116 6,636 15,172 Howards Road. 1st quarter 814 — 93 2nd ,, 796 — 103 3rd ,, 792 — 113 4th ,, 698 2 91 3,100 2 400 3,502 Silvertown. 1st quarter 593 25 698 2nd ,, 369 38 652 3rd ,, 342 42 492 4th ,, 43i 50 486 i,735 155 2,328 4,218 Other services. 286,501 1st quarter 840 2nd ,, 840 3rd ,, 896 4th ,, 896 3,472 3,472 195,127 3,605 9I,24i 289,973 * Each packet is approximately 1ib. in weight. 244 Particulars of the number of applications for dried milk at less than cost price received during the year are set out in Table XXIII. Table XXIII. Applications for dried milk at reduced cost. First quarter. Second quarter. Third quarter. Fourth. quarter. Whole year. New applications: (granted). (a) Free 824 652 725 744 2,945 (b) Half-price 30 25 37 27 119 Total assisted 854 677 762 771 3,064 New applications: (refused) 30 57 42 44 173 Total applications 884 734 804 815 3,237 Details of the number of packets of dried milk distributed at the various centres is set out in Table XXIV. Table XXV. shows the amount of dried milk distributed during the past eight years. Table XXV. Year. Milk distributed in tons (approximate) 1930 87 1931 102 1932 102 1933 102 1934 105 1935 108 1936 128 1937 129 245 VI. HOSPITALS. 247 HOSPITALS. General statement. The institutions owned and controlled by the County Borough Council are the following:—(1) Whipps Cross Hospital; (2) Forest Gate Hospital; (3) Central Home; (4) Forest House; (3) Harold Wood Hospital; (6) Isolation Hospital, Plaistow; (7) Dagenham Sanatorium; (8) Langdon Hill Sanatorium; (9) South Ockendon Colony. Of these (1) to (5) are controlled by the Public Assistance Committee, and a proportion of the beds are allocated on a User-agreement with the Essex County Council and the East Ham County Borough Council. The proportions are 34.00 per cent. for Essex and 16.00 per cent. for East Ham respectively. Nos. (6) to (8) are controlled by the Hospitals Committee, and are for the use of West Ham residents only. No. (9) is controlled by the Committee for the Care of the Mentally Defective, and a proportion of the beds are allocated for the use of East Ham residents. All these institutions are under the administrative control of the medical officer of health. This section of the report deals with all these institutions except the isolation hospital, the two sanatoria, and South Ockendon Colony, which are more completely dealt with in the sections devoted to infectious diseases, tuberculosis, and mental deficiency. A complete statement of the available hospital beds in the borough is given in Table 1. This table includes the voluntary hospitals in the borough, since the facilities for treatment can only be properly considered by taking these institutions into consideration. It should be understood that large voluntary hospitals in the County of London, more especially the London Hospital, Poplar Hospital, Princess Elizabeth of York Hospital, and the Hospital for Sick Children, Great Ormond Street, also contribute their quota to available facilities. Further details of the beds available for West Ham residents are contained in the general statement on hospitals on page 42. 248 Table I. Bed accommodation. Municipal and voluntary hospitals. Institution. No. of beds. Remarks. (1) Whipps Cross Hospital 744 Including 64 maternity beds, excluding cots in maternity wards (2) Forest Gate Hospital 723 (3) Central Home 951 (4) Forest House 95 Including 20 beds for children convalescing after infectious diseases (5) Harold Wood Hospital 180 (6) Infectious Diseases Hospital, Plaistow 210 (7) Dagenham Sanatorium 128 (8) Langdon Hill Sanatorium 40 (9) South Ockendon Colony 134 (10) Queen Mary's Hospital 216 Including 50 maternity beds (11) St. Mary's Hospital 71 (12) Children's Hospital, Balaam Street 36 (13) Albert Dock Hospital 47 (14) Plaistow Maternity Hospital 60 Total 3,635 Municipal Hospitals and Institutions. Institutions (1) to (4) in Table I were transferred from the West Ham Board of Guardians in 1930, under the powers of the Local Government Act, 1929. In the sense that these hospitals are still controlled by the Public Assistance Committee and that the admissions are governed largely by the relieving officers, appropriation has not yet been carried out. The first hospital on the list is, however, to all intents and purposes a general hospital, and there is ample evidence of the increasing use to which these institutions are being put by the general population. General summary of buildings and services. (a) Capital expenditure:—During the year a residence 249 Was erected and furnished for the Medical Superintendent, Forest Gate Hospital, at a cost of approximately f1,836. At the Central Home a residence was erected and furnished for the Senior Medical Officer, at an approximate cost of f1,187. At Whipps Cross Hospital the new nurses' home and maids' quarters were completed and furnished at a cost of approximately f52,000. The roadway to the nurses' home and the approach to the incinerator were constructed at a cost of £600, and two new tennis courts were laid down at a cost of f443. These last two items are part of the scheme for the new extension. (b) Whipps Cross Hospital extension. It was hoped that the extension to Whipps Cross Hospital would have been commenced during 1937, but various matters held up the project. At the time of writing, however, the building is in course of erection. The extension will be dealt with more fully in my next annual report. (c) Notes on any alterations contemplated immediately. At Forest Gate Hospital it is proposed to extend the laundry and reconstruct the nurses' dining and recreation rooms, and the sanction of the Ministry of Health for the necessary loan is awaited. (d) Hospital report. In the present period of transition it is highly desirable that consideration should be given to all aspects of the hospital question before any further extensions to the existing services are contemplated. I have been requested to furnish a complete report on this matter. The present section on the work carried out in the hospitals serves as a basis for this investigation, and at a later date I hope to put before the authority a scheme dealing with the hospital question. (e) Nursing services. The number of different grades of nurses in municipal hospitals and institutions are as follows: — Whipps Cross Hospital. One matron, one assistant matron ; one sister-tutor; one assistant sister-tutor; one home sister; one assistant home sister; 3 massage sisters; 3 night sisters; 26 ward sisters; 35 staff nurses; 113 probationers; 7 private nurses; 3 male nurses; one masseur (male); 2 male head attendants; 11 male attendants. Forest Gate Hospital. One matron; one assistant matron ; one home sister; 2 night sisters; 7 ward sisters; 5 midwifery sisters ; 8 pupil-midwives ; 109 assistant nurses; 16 male attendants. Central Home. One matron: 2 assistant matrons;one super 250 intendent nurse; one assistant superintendent nurse; 15 ward sisters; one head female attendant; one female charge attendant; 23 female attendants; 167 assistant nurses (female); one head male nurse; 2 male charge nurses; 54 male nurses; one head male attendant; 14 male attendants. Forest House. One matron; one female attendant; one head male attendant; one charge sick attendant (male); 12 male attendants. Harold Wood Hospital. One matron; 6 ward sisters; two female staff nurses; 37 assistant nurses; 5 male nurses. Shortage of nurses. The national problem of the shortage of nurses is very acute in West Ham owing" to the large number of beds available for sick cases, viz:—5.9 per 1,000 of the population. Various reasons have been given for this shortage, but the main reasons may be briefly grouped under four headings: — (a) Pre-hospital training. The gap between the age of leaving school and entering hospital for training is probably the cause of many suitable candidates not taking up nursing as a career. This is especially true of the girl who leaves school at 14 years of age and is compelled to earn her living immediately. While engaged on other work she is probably earning a fair wage, usually more than she would obtain as a probationer nurse, and the desire to take up nursing as a profession is soon lost in many instances. (b) Scale of salaries. The salary paid to nurses is not attractive in comparison with that which may be obtained in other tvpes of employment, even in factories. (c) Hours of work. Long working hours are the cause of much dissatisfaction amongst nurses. (d) Conditions of service. In many hospitals nurses are unduly burdened with the performance of unskilled domestic work, and in the nurses' home her personal affairs are often subjected to a degree of interference which would not be tolerated elsewhere. The Council are, however, endeavouring to overcome this very difficult problem in hospitals and institutions under their control. The above difficulties are being dealt with as follows. (a) The Education Committee are formulating a scheme in which selected girls who are desirous of entering the nursing profession may continue their education and take various subjects to cover the syllabus of the Preliminary State Examination for 251 tioner nurses, and a graduated maintenance grant may be made in certain cases. At the appropriate age, the student will commence her work at one of the hospitals owned by the Council. (b) The scale of salaries has been revised in certain Council hospitals, and the London County Council scale of salaries has been adopted. (c) This matter has been fully dealt with by the Council, and most of the nursing staff work a forty-eight hour week. Although it is not always possible to apportion the work within rigid limits, considerable progress has been made in this direction. (d) The appointment of ward orderlies and assistant nurses in various hospitals tends to relieve the trained nurse of certain unskilled domestic work. Assistant nurses. A considerable number of assistant nurses are engaged in the Council's institutions, more especially at the Central Home and Forest Gate Hospital, at which institutions, owing to the type of patients, only a small number of fully trained nursing staff is essential. They work under the supervision of the trained staff. Ward orderlies. During the year it was found necessary to appoint non-resident ward orderlies at Plaistow Hospital and Dagenham Sanatorium. At Plaistow Hospital, owing to the institution of a forty-eight hour working week for the nursing staff, six ward orderlies had to be appointed. At Dagenham Sanatorium six were appointed owing to the shortage of nursing staff. The salary of an orderly is £2 3s. 4d. per week, less 10s. per week in respect of meals supplied. WHIPPS CROSS HOSPITAL. Buildings and staff. This hospital is situated at Whipps Cross in the Borough of Leyton, and is contained within an area of approximately 46 acres. The buildings are comparatively modern, having been built in 1903. The main building consists of a central administrative block and four three-storey blocks, each with two wings leading from a main corridor. These blocks contain 24 wards for the accommodation of acute medical and surgical cases, two observation wards for mental cases, and a well-equipped operating theatre. The hospital was built to accommodate 744 patients, but it is rarely that the number of patients falls below 800, and there are 252 often over 1,000 patients in residence. New extension. A new extension to the hospital is now in course of erection, and it is connected to the existing building by the main corridor. It is a two-storey building with four blocks, each with two wings, and it contains sixteen 24 bed wards, thirty-two two bed wards, and thirty-two one bed wards. In addition there is a separate isolation block containing 24 single wards, bringing the total additional accommodation to 504 beds. Included in the scheme is also a new operating theatre, a new receiving block, residence for five medical officers, and extensions to the kitchens, laundry, boiler house and mortuary. New accommodation for nurses and maids. The new accommodation for nurses and maids is now completed. The nurses' home, which is connected to the existing nurses' home, is a fourstorey building, and has accommodation for 135 nurses and 8 sisters. The bedrooms are fitted with hand-basins and hot and cold water, radiators, and built-in wardrobes. Each is furnished with dressing table, bedstead, easy chair, linen basket, and rug. Each floor has ample bathroom and lavatory accommodation. On the ground floor is a class-room, a lecture-room, and a demonstration room, and these rooms can be opened to form a recreation room measuring 29 feet by 82 feet. The maids' home is adjacent to the nurses' home and is of similar type. It contains 51 bedrooms for maids and 4 bed-sitting rooms for sisters. The bedrooms are furnished and fitted in a manner similar to the nurses' bedrooms, but they have no hand-basins, and a wash-stand is provided in place of running water. On the ground floor is a recreation room measuring 28 feet by 45 feet. Medical staff. The staff of the hospital consists of one medical superintendent; one deputy medical superintendent; and 6 resident medical officers. In addition there is a visiting staff of 7 consultants; one dentist; and one anaesthetist; whose names will be found on page 14 of this report. During the year one additional resident medical officer was appointed. Nursing staff. The full complement of the nursing staff was 196, the daily average number of patients in 1937 was 905.23, which gives an average of 4.62 beds per nurse. The average daily strength of nurses was approximately 136. 253 Admissions. During the year 1937, the number of patients admitted to the hospital was 10,717, the number who died was 1,592, and 9,107 were discharged. On 31st December, 1937, the number of patients in residence was 975. Of the admissions, 4,396 Table II. Whipps Cross Hospital. Admissions, 1931-1937. 1931 1932 1933 1934 1935 1936 1937 Per cent. increase (+) or decrease (-) on 1931 figures Males 3,278 3,269 3,906 3,676 3,613 4,018 4,396 + 34.11 Females 3,336 3,386 3,833 3,722 3,825 4,155 4,299 + 28.87 Children 1,980 1,961 2,055 2,204 1,680 1,978 2,022 + 2.12 Total 8,594 8,616 9,794 9,602 9,118 10,151 10,717 + 24.70 Admitted by : District medical officer & relieving officer 856 775 951 862 878 622 575 - 32.83 General practitioner and relieving officer 6,743 6,743 7,753 7,549 7,151 8,381 8 819 + 30 79 Transferred from voluntary hospitals and Council institutions 520 563 480 482 480 504 454 - 12.69 Medical officer of health 2 2 17 20 15 12 Medical superintendent 54 108 164 177 187 173 180 - 233.33 Accidents 287 305 285 319 211 275 471 + 64.11 Police cases 120 108 141 175 174 170 194 +61.67 Others 14 12 18 21 17 11 12 - 14.29 Number of operations 1,591 1,747 1,764 1,815 1,665 1,844 2,011 + 26.40 were adult males, 4,299 adult females, and 2,022 children. Of the adult males admitted 4,330 were acute cases and 66 chronic. Of the adult females admitted 4,237 were acute cases and 62 chronic. Of the children admitted 2,021 were acute cases and one was a chronic case. The number of cases seen as out-patients but not 254 admitted were 601 men, 250 women, and 186 children. These figures show an increase of 566 admissions over the corresponding figures for 1936, viz., 10,151. The hospital was transferred to the County Borough Council in 1930. In a period of transition such as the present it is necessary to have a clear idea of the increasing use to which this hospital is being put, and of the changes in the methods of admission. Table II gives the numbers of admissions and the route by which the patients entered the hospital since 1931. The table also Table III. Whipps Cross Hospital. Patients seen by consultants, 1937. Consultant. 1931 1932 1933 1934 1935 1936 1937 Per cent. increase ( + ) or decrease (-) on 1931 figures. Dermatologist No record prior to May, 1936. 422 684 — Ophthalmologist 316 347 329 389 521 595 517 + 63.6 Aural Surgeon 461 500 550 475 445 390 447 - 3.0 Light treatment 1,208 1,240 1,475 1,879 1,971 1,933 1,815 + 50.2 Gynecologist 28 42 75 125 117 77 77 + 175.0 Orthopaedic Surgeon 233 183 259 347 287 353 426 + 82.8 Neurologist 228 240 231 217 194 177 317 + 39.0 Urologist 177 202 190 187 257 249 290 + 63.8 Totals 2,651 2,754 3,109 3,619 3,792 4,196 4,573 + 72.5 shows the number of operations performed. Table III shows the number of cases seen by the various consultants. One of the most obvious features of these tables is the progressive increase in the amount of work carried out in the hospital. The admissions increased from 8,594 in 1931 to 10,717 in 1937—an increase of 24.7 per cent. Despite this, there has been an apparent decrease of 32.8 per cent. in the number of patients admitted by the district medical officers through the relieving officers, and taking into account the large increase in the 255 number of admissions, the actual decrease in the number of patients admitted through the mechanism of the poor law is very much greater. On the other hand, there has been an increase of 30.8 per cent. in the number of patients who were admitted by general practitioners through the relieving officers during the period 19311937. It is obvious that under the present constitution the relieving officers must be directly involved in all admissions. These figures mean that the institution is yearly developing more as a first class general hospital, and that every year the "poor law case" is becoming less in evidence. In 1937 this type of case constituted only 5.4 per cent. of the total admissions. From the data which are set out in Table III it is evident that there has been a considerable increase in the work of the consultants who are attached to the hospital. In the case of consultations for ear disorders there has been no change since 1931In all the other departments the increases have been very marked, even when allowance is made for the increase in the number of admissions. The following percentage increases for the patients seen in 1937 over those seen in 1931 in the different departments are illuminating: ophthalmic, 63.6; light, 50.2; gynaecological, 175.0; orthopaedic, 82.8; neurology, 39.0; urology, 63.8. The conclusion which must be reached after examination of these figures is that the hospital is yearly being used to a greater degree by those members of the community who, as a result of acute illness, are placed in the position of requiring the services of specialists in a large general hospital. The admissions are yearly becoming even more representative of that section of the community which is prepared to contribute to a first-class voluntary hospital for the services which it can render. Anaesthetics. During 1937, the number of anaesthetics given by the visiting anaesthetist was 627. Dentist. The number of cases seen by the visiting dentist was 265. Diseases treated. Table IV gives in tabular form a classification by disease groups of the diseases for which patients were discharged from or died in the hospital during the year. A particularly noteworthy feature of Table IV is the large proportion of admissions of patients whose illnesses were due to violence. This indicates the facilities which are available for the 256 257 Table IV. Classification by disease groups of patients discharged from or dying in whipps cross hospital during 1937. Disease classification. Men. Women. Children. Total. Discharg ed. Died. Discharg ed. Died Discharg ed. Died Discharg ed. Died. 1. Infectious diseases 30 6 37 3 115 14 182 23 2. Cancer and other tumours 79 101 66 78 - 2 145 181 3. Diseases of circulatory system 192 129 272 120 95 11 559 260 4. Diseases of the respiratory system (excluding tuberculosis) 565 170 377 84 407 74 1,349 328 6. Pulmonary tuberculosis 89 63 73 34 5 6 167 103 6. Diseases of digestive system 764 74 564 49 358 20 1,686 143 7. Diseases of the nervous system and sense organs 221 82 302 77 203 7 726 166 8. Diseases of the skin 91 2 50 1 148 - 289 3 9. Rheumatic diseases— acute and chronic 84 - 151 - 76 1 311 1 10. Diseases of nutrition 7 - 7 4 - 1 14 4 11. Diseases of blood and blood-forming organs 14 - 11 3 1 - 26 3 12. Diseases of genito-urinary system 223 67 225 24 36 - 484 91 13. Non-tuberculous disease of bones, etc. 12 - 3 1 13 - 28 1 14. Non-pulmonary tuberculosis 10 7 16 8 4 13 30 28 15. Disease of pregnancy, childbirth and the puerperium - - 512 13 — — 512 13 16. Diabetes 34 6 54 10 7 1 95 17 17. Old age, senility and senile decay 7 6 31 9 - - 38 14 18. Congenital malformations — — — — — 4 — 4 19. Diseases of early infancy — — — — 86 40 86 40 20. Violence 676 32 380 38 267 2 1,323 72 21. Ill-defined causes 128 58 136 4 14 - 278 62 22. Convalescence — — — — — — — — 23. Mental 328 28 450 7 1 - 779 35 Totals 3,554 830 3,717 567 1,836 195 9,107 1,592 Q 258 treatment of this type of case, which is often admitted to the large voluntary hospitals. Apart from this feature, the major emphasis in the table is on non-tuberculous diseases of the respiratory tract, and on diseases of the digestive, nervous, and genito-urinary systems respectively. Deaths. The number of deaths which occurred in the hospital was 1,592. This was an increase of 90 over the number for the previous year, viz. 1,502. The number of deaths which occurred within twenty-four hours of admission was 251, and a further 148 took place within the second twenty-four hours after admission. The corresponding figures for 1936 were 211 and 111. Table V shows the age groups in which deaths occurred in the seven years since the transfer of the hospital. Table V. Whipps Cross Hospital. Deaths by ages. Ages. 1931 1932 1933 1934 1935 1936 1937 Under 73 85 59 80 51 72 96 1— 54 58 51 55 23 26 37 2— 23 28 21 27 17 19 19 5— 51 45 34 53 26 37 42 15— 91 94 118 82 63 80 77 25— 117 114 126 104 93 104 98 35— 150 99 157 90 108 124 135 45— 189 183 220 210 172 216 225 55— 244 241 304 279 282 330 367 65— 173 165 215 248 240 324 340 75— 71 64 125 109 115 150 137 85— 15 23 16 9 22 20 19 Totals 1,251 1,199 1,446 1,346 1,212 1,502 1,592 In Table VI the deaths at different ages are expressed as percentages of all deaths in the hospital for that year. This table shows that during the last six years there has been only 259 a slight change in the age distribution of the deaths. For ages under 15 years—that is, the period of childhood—the percentage has fallen, and the same feature is found in the age group 15-35 years. During middle adult life—35-55 years—there has been little change in the percentage, but in late adult life—over 55 years—the percentage has increased from 40.2 in 1931 to 54.2 in 1937. Without further analysis of more detailed data it is difficult to say what these figures mean. It is possible that there is here again an expression of the fact that advances in medical treatment have rendered it possible for death to be postponed to the later ages of life. Consideration of Table IV will show the high proportion of deaths which were due to malignant diseases, diseases of the circulatory system, and diseases of the nervous system respectively. Table VI. Whipps Cross Hospital. Percentage Distribution of deaths by ages. Ages. 1931 1932 1933 1934 1933 1936 1937 Under 1 5.84 7.09 4.08 5.94 4.21 4.79 6.03 1— 4.32 4.84 3.53 4.09 1.90 1.73 2.32 2 1.84 2.34 1.45 2.01 1.40 1.26 1.19 5— 4.08 3.75 2.35 3.94 2.15 2.46 2.64 15— 7.27 7.84 8.17 6.09 5.20 5.33 4.84 25— 9.35 9.50 8.71 7.73 7.67 6.92 6.16 35— 12.00 8.26 10.86 6.68 8.90 8.26 8.48 45— 15.10 15.26 15.21 15.60 14.19 14.39 14.13 55— 19.50 20.10 21.02 20.73 23.27 21.97 23.05 65— 13.82 13.76 14.87 18.42 19.80 21.57 21.36 75— 0.68 5.34 8.64 8.10 9.49 9.99 8.61 85— 1.20 1.92 1.11 0.67 1.82 1.33 1.19 100.00 100.00 100.00 100.00 100.00 100.00 100.00 Many of these conditions are especially fatal in elderly persons, and it is probable that they were largely responsible for the increased mortality in the later years. 260 Table VII. Whipps Cross Hospital. Operations performed, 1937. Operations performed. Operations performed. Abdominal operations:— Eye, ear, nose and throat operations:— Appendix—emergency 299 „ —interval 67 Operations on eyes 20 „ —abscess 1 Mastoid operation 79 Perforated gastric ulcer 25 Myringotomy 2 ,, pyloric ulcer 10 Operations on nose 9 ,, duodenal ulcer 19 „ on sinuses 10 Gastro-enterostomy 5 „ on ear 1 ,, -jejunostomy 4 For tonsils and adenoids 54 Other gastric 4 Small gut obstruction 9 175 Colostomy 26 Caecostomy 6 Closure of caecostomy 2 Intussusception 6 Volvulus 4 chest operations:- Diverticulitis 5 For empyema 28 Gall bladder operations 16 Acute pancreatitis 4 28 Other laparotomy:— emergency 47 interval 27 Operations for abscesses:— 586 Pelvic 2 Breast 31 Bartholin's 5 Ischio-rectal 18 Hernia operations:— Retro-pharyngeal 3 Scrotal 1 Femoral hernia 32 Strangulated femoral hernia 2 60 Inguinal hernia 25 Strangulated inguinal hernia 45 Incisional hernia 2 Ventral hernia 5 Rectal operations:— 111 For haemorrhoids 20 Other rectal 5 25 Genito-urinary operations:— Exploration of kidneys 3 Nephrectomy 5 Amputations:— Perinephric abscess 4 Lithotomy 2 Of thigh 4 Lithotcrity 1 „ leg 14 Cystotomy 3 if finger 7 Cystoscopy 1 Prostatectomy 17 25 Orchidectomy 1 Circumcision 7 For hydrocele 1 ,, ectopic pregnancy 9 Orthopaedic operations:- ,, tubal pregnancy 1 ,, salpingitis 2 Application of plaster 145 Caesarean section 8 Wiring 24 Hysterectomy—total 15 Removal of wiring 2 „ —sub total 12 Plating 2 Uterine curettage 29 For compound fractures 21 Other uterine operations 4 „ correction of talipes 1 Colporraphy 6 dislocations 26 Colpo-perineorraphy 2 „ exostoses 1 Ovarian operations:— ,, hallux valgus 1 deliberate 7 ., osteomyelitis 9 emergency 5 „ removal of nails 13 Other operations 9 ,, removal of patella 2 ,, removal of head of radius 2 154 „ slipped epiphysis 1 261 Operations. During the year 2,011 operations were performed under general anaesthetics in the hospital. Of these 119 were performed by visiting consultants, and 1,892 by the resident staff of the hospital. Table VII gives a classification of these operations. In addition, 425 operations were performed under local anaesthetics by the consultants. Diagnostic facilities. Radiology. The present radiological department is a very complete unit which is staffed by one radiographer and an assistant radiographer. It consists of a 10 K.V.A. four-valve X-ray plant, a separate screening room and a modern shock-proof ward plant. Table VIII shows the number of X-ray examinations and treatments carried out during the last seven years. The marked increase in the number of X-ray examinations in 1937 should be noted. Table VII. (contd.) Whipps Cross Hospital. Operations performed, 1937 Operations performed. Operations performed. Excision of head of femur 2 Electro-cautery 1 ,, of semi-lunar cartilage 11 Exploring hip 1 Arthrodeses 4 Dental operations 3 Drilling of tibia 1 Diathermy 1 Insertion of Watson-Jones nail 3 For burns and scalds 12 ,, of Smith-Peterson pin 4 ,, hydatidiform mole 1 Osteotomy 1 ,, tumours and cysts 16 Sequestrotomy 13 Foreign bodies 5 Manipulations 42 Inflammation of cellular tissue 271 Lumbar puncture 1 331 Minor operations 29 Oesophagoscopy 6 Removal of bone-clavicle 1 Operations on skull, brain and nerves :— of glands of neck 2 Resections 9 Cerebral abscess 5 Sections 1 ,, compression 3 Skin graft 5 Trephine 1 Suturing 68 Lateral sinus thrombosis 2 Removal of sutures 1 Nerve stretching 1 Tendon freeing 1 Tendon sutures 5 12 Thyroidectomy 3 Tracheotomy 2 Weil's disease 3 Miscellaneous operations:— Dressings 10 Blood transfusions 2 Ward anaesthetics 27 Breast—biopsy 4 Examinations 8 ,, —radical 5 504 Total 2011 262 Table VIII. Whipps Cross Hospital. Radiological department. Year. No. of X-ray examinations. No. of treatments. 1931 4,014 65 1932 3,977 93 1933 4,557 82 1934 4,499 102 1935 4,160 63 1936 4,226 90 1937 5,460 94 Pathological services. Number of post-mortems during 1937: (a) complete 89 ,, ,, ,, (b) partial 97 Number of histological examinations carried out during 1937: (a) post-mortems 15 (b) operations 51 Number of specimens sent to the Clinical Research Association 4,181 Ultra-violet ray treatment. The light department consists of 2 Westminster arc lamps; 3 mercury vapour lamps; 3 infra-red lamps; 1 Kromayer lamp; 2 sun lamps; and 2 alpine arc lamps. During the year 1937 the total number of patients seen by the consultants was 2,499. Of this number 684 were seen for diagnostic purposes; these consisted largely of patients suffering from skin conditions. The cases treated in the light department are mainly the following:—General debility and anaemia; skin cases; chronic sinuses, by the Kromayer lamp; compounds fractures; chronic rheumatism, sciatica, lumbago, by the infra-red rays; rickets. Treatment of fractures. During the year, 470 patients were admitted suffering from fractures of various bones. These fractures are grouped according to site in Table IX. 263 Table IX. Treatment of fractures. Site of fracture. Cases. Deaths. Femur 77 29 Tibia and (or) fibula 119 2 Ankle or foot 26 - Humerus 33 3 Radius and (or) ulna 53 - Wrist or hand 6 - Ribs 31 - Spine 16 - Skull 30 6 Pelvis 12 — Scapula and (or) clavicle 33 — Patella 19 — Jaw, face, etc 15 — Totals 470 40 Medical notes on the treatment of fractures. The treatment of fractures is on the most modern lines, and is re-inforced by the use of the Joseph frame, the Zimmer appartus, and the Hawley table. Intra-capsular fractures of the hip are treated by the use of the Smith-Peterson pin and the Watson-Jones nail, thus reducing the mortality and enabling the patient to become ambulant in a few weeks, irrespective of the advanced age of many patients with this injury. Excision of the patella for fracture is being performed with good results. Mental wards. Two wards, one for males and one for females, are reserved for the observation of patients under the Lunacy Act, 1890. The medical care of these patients is carried out by the medical superintendent or by the deputy medical superintendent, and a justice usually attends on three occasions weekly for the purpose of this Act. The staff of these two wards consists of 9 male nurses and 9 female nurses. 264 During the year 1937 the number of patients admitted to these wards was 814, of whom 356 were males and 458 females. These patients were dealt with as shown in Table X. Table X. Method of disposal of mental observation cases. Males. Females. Total. Certified and transferred to mental hospitals 59 66 125 Transferred as temporary patients 35 82 117 Transferred as voluntary patients 5 110 225 Transferred for further observation - - - Transferred to other institutions 52 101 153 Discharged 67 92 159 Died 28 7 35 Total 356 458 814 The duration of residence of these patients in the observation wards is shown in Table XI. Table XI. Duration of residence of mental cases. Weeks. Total. —1 —2 —3 —4 —5 —6 —7 —8 Patients certified before transfer 61 57 4 - 1 - - 2 125 Patients transferred as temporary or voluntary patients 248 89 5 - - - - 342 Patients discharged 104 47 6 1 1 - - - 159 Transferred to institutions other than mental hospitals 61 66 23 2 1 - - - 153 Died 25 10 - - - - - - 35 265 There is no doubt that the administration of these observation wards, and the amount of time which the clinical supervision of the patients demands, is a serious drain on the energy of the officials concerned. There appears to be no incontravertible argument in favour of the retention of these wards at Whipps Cross Hospital. This type of ward is much better left to an alienist of experience. In the past much good work has been carried out in these wards, but it should be remembered that each year the general administration of the hospital increases, and the time* which the medical superintendent must give to this work in the observation wards is therefore more and more an impediment to the general running of the hospital. In December, 1937, a meeting of the Visiting Committee of the Mental Hospital was held to consider the transfer of these observation patients to Goodmayes Mental Hospital. The general concensus of opinion was that the transfer was desirable, but difficulties in dealing with certain types of cases made it necessary to delay any effective measures. The position will be reconsidered at a later date. FOREST GATE HOSPITAL. Buildings and staff. This is a comparatively old building which was transferred in 1930. The institution consists essentially of a central administrative block which is surrounded by three-storey buildings for the accommodation of mental defectives and epileptics. Behind these main buildings is a maternity unit, which consists of two blocks with a nominal accommodation for 64 lying-in beds. At the rear of the institution there is a considerable area of unbuilt land, and in 1931 four additional wards of a temporary nature were erected for the accommodation of the chronic sick. The whole institution now has accommodation for 723 patients. Medical staff. The staff consists of the medical superintendent, two assistant resident medical officers, and one visiting psychiatrist. Nursing staff. The nursing staff of the hospital as a whole is 24 trained nurses, 109 assistant nurses, and 16 male attendants. The nursing staff of the maternity unit is 5 midwives, 8 pupil midwives, and 4 assistant nurses. 266 Admissions. During the year 1937, 2,127 patients, including 876 infants born in the hospital, were admitted, 1,997 were discharged, and 94 died. On December 31st, 1937, the number of patients in residence was 793 (including 62 infants under 3 years of age). Of the admissions, 56 were adult males, 1,146 adult females, and 49 children. Of the adult males admitted, 56 were mental defectives or epileptics. Of the adult females admitted, 68 were chronic sick, 47 mental defectives or epileptics, 24 nursing mothers, and 1,007 maternity cases. Of the children, 24 were admitted with nursing mothers, and 25 were mental defectives or epileptics. These figures show an increase of 167 admissions over the corresponding figures for 1936, viz., 1,084. Table XII gives the number of admissions and an analysis of the routes by which they entered the hospital. Table XII. Forest Gate Hospital. Admissions:— Males 56 Females 1,146 Children admitted 49 Children born in the hospital (live births) 876 Total 2,127 Admitted by means of:— Relieving Officer and district medical officer 53 General practitioner and relieving officer 46 Medical officer of health and relieving officer 444 Relieving officer 250 Transferred from institutions 190 Medical superintendent 268 Total 1,251 Diseases treated. Table XIII gives in tabular form a classification by disease groups of the diseases for which patients were discharged from or died in the hospital during the year. 267 Table XIII. Classification of disease groups of patients discharged from or dying in Forest Gate Hospital during 1937. Disease classification Men. Women. Children. Total. Discharg ed. Died. Discharg ed. Died. Discharg ed. Died. Discharg ed. Died. 1. Acute infectious disease - 1 — — — 1 — 2 2. Influenza — — — 1 — — — 1 3. Malignant disease — — — 3 — — — 3 4. Puerperal pyrexia — — 15 — — — 15 — 5. Puerperal fever (women confined in hospital) — — 2 — — — 2 — 6. Other diseases and accidents connected with pregnancy and childbirth - - - 1 22 - 23 7. Mental diseases (mental defectives and epileptics) 67 1 40 2 20 1 127 4 8. Senile decay — — 11 38 — — 11 38 9. Diseases of the nervous system and sense organs — 1 — 5 — — — 6 10. Diseases of the respiratory system — — — 9 — 2 - 11 11. Diseases of the circulatory system — — — 5 — — — 5 12. Diseases of the digestive system — — — 1 — — — 1 Totals 67 3 68 65 20 26 155 94 13. Nursing mothers and infants - - 41 — 37 — 78 — 14. Mothers and infants from maternity wards - - 945 — 819 — 1,764 — Grand totals 67 3 1,054 65 876 26 1,997 94 268 Deaths. The number of deaths which occurred in the hospital was 94. This was an increase of 14 over the number for the previous year, viz., 80. The number of deaths which occurred within 24 hours of admission was one; the corresponding figure for 1936 was two. Table XIV shows the age groups in which deaths occurred in the seven complete years since the transfer of the hospital. Table XIV. Forest Gate Hospital. Deaths by ages. Age. 1931 1932 1933 1934 1935 1936 1937 Under 1 21 26 24 23 20 18 23 1— - - - - - - - 2— - - - - - 1 1 5— 4 1 1 1 — 2 2 15— 1 - 3 3 1 1 3 25— 4 1 2 4 1 2 1 35— 3 2 4 4 5 1 3 45— 2 1 2 4 2 1 3 55— 12 6 9 5 10 3 4 65— 23 10 18 14 13 15 8 75— 29 16 18 26 26 26 29 85— 10 9 10 13 15 10 17 Totals 109 72 91 97 93 80 94 Mental defectives and epileptics. The number of mental defectives admitted during 1937 was 50, of whom 19 were adult males, 14 adult females, and 17 children. The number of discharges was 72, of which 33 were of adult males, 20 of adult females, and 19 of children. The number of deaths was 7, of which 3 were of adult males, 2 of adult females, and 2 of children. The corresponding figures for epileptics were: admissions 77, of which 35 were of adult males, 34 of adult females, and 8 of children. The number of discharges was 55, of which 34 were of adult males, 20 of adult females, and one child. There were 4 deaths—3 adult females and one child. 269 Notes on the clinical features of these cases will be found in the section on mental deficiency. The maternity unit. This unit, as above mentioned, is housed in two separate blocks. Each block is provided with a properly equipped labour ward, but the nursing accommodation is far from being adequate. The lying-in wards are larger than is dictated by modern practice, and the general lay-out of the two sections of the unit render administration difficult. There is no satisfactory accommodation for the isolation of patients who show pyrexia. As a result of the great expansion of this part of the work of the hospital, the Table XV. Forest Gate Hospital. Admissions to the maternity unit. 1931 1932 1933 1934 1935 1936 1937 Total number of admissions (including infants born in the hospital) 967 1,049 1,081 1,218 1,343 1,601 1,883 Number of women confined in the hospital 480 512 523 590 640 779 907 Number of live births 434 476 489 560 615 740 876 Number of stillbirths 46 36 34 42 34 51 43 Number of deaths of babies under four weeks, born in the hospital 19 25 23 21 14 16 15 Number of deaths of women confined in the hospital 5 2 1 5 2 1 1 Total deaths 24 27 24 26 16 17 16 Total number of discharges (including infants born in the hospital) 976 956 1,060 1,162 1,298 1,513 1,764 Average number of days residence of women confined in the hospital 21 23 22 19 17 17 17 270 maternity wards have gradually become more overcrowded, and the lack of accommodation is always sufficient to tax the resources of the resident staff. Admissions. The great increase in the work of the unit is well shown in Table XV. The number of twin births during 1937 was 12. Abnormal births. The following were the major causes of abnormality in the patients confined in the hospital during the year:—Ante-partum haemorrhage, 12; post-partum haemorrhage, 6; eclampsia, 1. Apart from these conditions the following abnormal presentations were noted:—Breech, 40; transverse, 3; prolapse of cord, 1. There were no face presentations during the year. Induction of labour had to be performed in 105 cases, 6 by surgical and 99 by medical means. Forceps were applied in 45 cases. Patients who required major surgical measures were transferred to Whipps Cross Hospital, and in 1937 the number of patients so transferred was 7. In all of these cases Caesarian section was carried out. The indication for this operation in these cases was the disproportion between the size of the foetus and the size of the pelvis. The number of premature births was 42. Peurperal pyrexia was notified in 15 cases, and puerperal fever in 2 cases. Both patients were treated in Forest Gate Hospital and made a complete recovery. One maternal death occurred during the year. The following are brief particulars of this case:—The chief cause of difficulty was prolonged labour in the first and second stages which lasted over 72 hours, and slow dilation of the os. The method employed was slow forceps delivery under general anaesthesia with antishock treatment consisting of intravenous gum glucose saline (300 c.c.), electric hot blanket and cardiac stimulants. The patient was delivered at 5.10 p.m. The shock increased from 7 p.m. and she died at 4.40 a.m. The interval between admission and death was thirteen and three-quarter hours. The causes of the 43 stillbirths are classified as follows: — Breech (of which 5 were "extended") 6 Toxaemia in mother 10 271 []$$$Ante-partum haemorrhage 4 (placenta praevia) Foetal deformities 2 Impacted shoulders 1 Transverse lie 1 Prolapsed cord 1 Prematurity 8 Cause not ascertained 9 Obstructed labour 1 Total 43 The number of children who died within ten days of birth was 15 (all born in the hospital). The number of cases of ophthalmia neonatorum was one. This case was transferred to Whipps Cross Hospital. No case of pemphigus occurred during the year. Pupil midwives. These pupils are generally obtained from Whipps Cross Hospital where they have received their general training. During 1937 the number of pupils who passed through the wards of the maternity unit was 16. Further developments. It has been recognised for some time that the maternity unit is inadequate for its purpose, and that a scheme of expansion will have to be formulated in the near future. At the time of writing a temporary scheme for the improvement and expansion of the existing accommodation, together with a scheme for increasing the staff, and the improvement of administrative methods and teaching facilities are under consideration. CENTRAL HOME. This institution, situated in the Borough of Leyton, was built in 1840, and consists of a series of blocks of buildings, some separate and some adjoining each other, which are used as administrative buildings and for housing chronic sick, mental, and able-bodied persons. The blocks used for the chronic sick are mainly two-storey buildings containing 22 wards, and have accommodation for 951 patients. Many of the wards are unsuitable for the treatment of chronic sick. The able-bodied section of the institution has accommodation for approximately 1,000 men and women. 272 Medical staff. The staff of the institution consists of one senior medical officer and two assistant resident medical officers. During the year there was one change in the medical staff, and one additional assistant resident medical officer was also appointed. Nursing staff. The nursing staff consists of 15 trained nurses, 138 assistant nurses, and 50 male attendants. Admissions. During the year 1937, the number of patients admitted to the institution was 1,935. The number who died was 964, and 911 were discharged. On December 31st, 1937, the number of patients in residence was 924. Of the patients admitted, 874 were adult males, 1,054 adult females, and 7 children. Of the adult males admitted, 854 were chronic sick, 4 mental cases, and 16 epileptic cases. Of the adult females admitted, 1,039 were chronic sick, 5 mental cases, and 10 epileptic cases. Of the children admitted, 2 were chronic sick, 3 mental and 2 epileptic. The figures show an increase of 95 admissions over the corresponding figures for 1936, viz., 1,840. Table XVI gives the number of admissions and analysis of the routes by which they entered the institution. Table XVI. Central Home. 1937. Admissions:— Male 874 Female 1,054 Children 7 Total 1,935 Admitted by means of:— Relieving officer and district medical officer 164 General practitioner and relieving officer 1,276 Medical officer of health 1 Transferred from other institutions 425 Otherwise 69 Total 1,935 273 Table XVII. Classification by disease groups of patients discharged from or dying in Central Home during 1937. Men. Women. Children. Total. Discharg ed. Died. Discharg ed. Died. Discharg ed. Died. Discharg ed. Died. 1. Infectious diseases — — — — - — - - 2. Cancer and other tumours 20 76 28 96 - - 48 172 3. Diseases of circulatory system 42 73 58 95 - - 100 168 4. Diseases of the respiratory system excluding tuberculosis 257 84 293 96 - - 550 180 5. Pulmonary tuberculosis - - - - - - - - 6. Diseases of digestive system 18 8 12 8 - - 30 16 7. Diseases of nervous system and sense organs 27 20 13 12 - - 40 32 8. Diseases of skin — — — — - — — — 9. Rheumatic diseases, acute and chronic - - - - - - - - 10. Diseases of nutrition - - - - - - - - 11. Diseases of blood and blood - forming organs - - - - - - - - 12. Diseases of genitourinary system 15 24 5 9 - - 20 33 13. Non-tuberculous disease of bones, etc. - - - - - - - - 14. Non-pulmonary tuberculosis - - - - - - - - 15. Diseases of pregnancy, childbirth and the puerperium - - - - - - - - 16. Diabetes - - - - - - - - 17. Old age, senility and senile decay 89 212 34 151 - - 123 363 18. Congenital malformations - - - - - - - - 19. Diseases of early infancy - - - - - - - - 20. Violence — — — — - — — — 21. Ill-defined causes - - - - - - - - 22. Convalescence — — — — — — — — Totals 468 497 443 467 — — 911 964 R 274 Diseases treated. Table XVII gives in tabular form a classification by disease groups of the diseases for which patients were discharged from or died in the hospital during the year. Deaths. The number of deaths which occurred in the hospital was 964. This was an increase of 37 over the number for the previous year, viz., 927. Table XVIII shows the age groups in which deaths occurred in the seven years since the transfer of the hospital. Table XVIII. Central Home. Deaths by ages. Ages. 1931 1931 1933 1934 1935 1936 1937 Under 1 - - - - - - - 1— - - - - - - - 2— — - - - - - - 5— - 1 - - - - - 15— 1 3 1 3 2 1 - 25— 9 5 7 6 4 3 9 35— 17 9 8 11 8 8 8 45— 34 41 32 36 35 33 29 55— 134 144 104 139 110 113 99 65— 307 377 313 333 324 310 317 75— 323 351 315 375 378 354 367 85— 104 91 105 95 99 105 135 Totals 929 1,022 885 998 960 927 964 FOREST HOUSE. This institution is situated in the same grounds as Whipps Cross Hospital. It consists of a large centre building—originally an old mansion—surrounded by a series of out-buildings which serve as day rooms and dormitories. There are 13 wards and 396 beds. The accommodation provides mainly for aged men, but there is in addition accommodation for 38 epileptics, 22 cases under Section 24 of the Lunacy Act, and 35 mental patients not 275 certified. Forest House Cottages, which form an annexe to Forest House, have accommodation for 90 aged women. This combined institution is under the charge of the Master of Forest House, and the Medical Superintendent of Whipps Cross Hospital acts as medical advisor to the inmates. The nursing staff consists of 14 male attendants and 7 female attendants. During 1937 the number of patients admitted to the institution was 22, and the number discharged was 12. These admissions and discharges are shown in Table XIX. Table XIX. Forest House . Admissions and discharges, 1937. Males. Total. Mental. Epileptic. Admissions 17 5 22 Discharges 4 8 12 Of the patients admitted, 17 were transferred from other institutions, and of those discharged, 9 were sent to other hospitals. There were no deaths. On December 31st, 1937, the total number of sick in this institution was 81. HAROLD WOOD HOSPITAL. The hospital is situated at Harold Wood, Essex, and consists of an administrative block and four large single-storey buildings. It has accommodation for 160 chronic sick patients and 20 children convalescing after infectious diseases. The hospital was originally used as a convalescent home for cases recovering from scarlet fever or diphtheria, but in March, 1933, owing to the overcrowding at the Central Home, the Ministry of Health sanctioned the temporary use of the hospital for public assistance purposes. Staff. The staff consists of one visiting medical officer, one matron, 6 sisters, 3 staff nurses, 36 assistant nurses, and 5 male nurses. 276 Daring the year, 75 adults were admitted from the Central Home. The number of deaths was 39, and 37 were discharged. On December 31st, 1937, the number of patients in residence was 171 adults and 20 children. Of the adult patients admitted, 46 were males and 29 females. These figures show a decrease of 3 over the corresponding figure for 1936, viz., 78. The number of children admitted from Plaistow Hospital was 198; 197 were discharged and one died. Of the admissions, 105 were males and 93 females. These figures show an increase of 6 over the corresponding figure for 1936, viz., 192. Diseases treated. Table XX gives in tabular form a classification by disease groups of the diseases for which patients were discharged from or died in the hospital during the year. Deaths. The number of deaths which occurred in the hospital was 40. This was an increase of 7 over the number for the previous year, viz., 33. No deaths occurred within 48 hours of admission. Tabic XXI shows the age groups in which deaths occurred during the year. Table XXI. Harold Wood Hospital. Deaths by ages, 1937. Age. Deaths. Under 1 — 1— — 2— — 5— 1 15— — 25— — 35— 1 45— — 55— 3 65— 11 75— 19 85— 5 Total 40 Table XX. Harold Wood Hospital. Classification by disease groups of patients discharged from or dying in the hospital during 1937. Men. Women. Children. Total. Discharg ed. Died. Discharg ed. Died. Discharg ed. Died. Diacharg ed. Died. 1. Infectious diseases — — - — 197 — 197 — 2. Cancer and other tumours - 2 - 1 - — — 3 3. Diseases of circulatory system 5 6 2 8 — — 7 14 4. Diseases of the respiratory system excluding tuberculosis 3 2 - 4 - - 3 6 5. Pulmonary tuberculosis - - - - - - - — 6. Diseases of digestive system - 1 - - - - - 1 7. Diseases of nervous system and sense organs 1 1 - 1 - - 1 2 8. Diseases of skin - - - - - - - - 9. Rheumatic diseases, acute and chronic 1 - - - - 1 1 1 10. Diseases of nutrition - - - - - - - - 11. Diseases of blood and blood-forming organs - - - 1 - - - 1 12. Diseases of genitourinary system - - - - - - - - 13. Non-tuberculous disease of bones - - - - - - - - 14. Non-pulmonary tuberculosis - - - - - - - - 15. Diseases of pregnancy, childbirth and the puerperium - - - - - - - - 16. Diabetes - - - - - - - - 17. Old age, senility and senile decay 3 4 — 6 — — 3 10 18. Congenital malformations 1 - - - - - 1 - 19. Diseases of early infancy - - - - - - - - 20. Violence - - - - - - - - 21. Ill-defined causes - - - - - - - - 22. Convalescence - - - - - - - - 23. To other institutions 17 — 4 — — — 21 — Totals 31 16 6 23 197 1 234 40 277 ALLOCATION OF BEDS. It has been mentioned in previous sections that 34 pet cent, of the beds in Whipps Cross Hospital, Forest Gate Hospital, Forest House, and Central Home are allocated to the Essex County Council, and 16 per cent, to East Ham County Borough Council. This arrangement was entered into in 1930, and is on the basis of a user-agreement for 25 years. Table XXII shows the number of West Ham cases and the cases from the other two authorities who participate in the user-agreement, which were admitted to the various municipal hospitals. Table XXII. Municipal Hospitals. Total admissions, including live births in the hospitals, 1937. Hospital. West Ham. Essex. East Ham. Total. Whipps Cross Hospital 4,588 4.464 1,665 10,717 Forest Gate Hospital (a) cases admitted 618 317 316 1,251 (b) births 430 248 198 876 Central Home 864 741 330 1,935 Forest House 13 7 2 22 Totals 6,513 5,777 2,511 14,801 278 VII. INSPECTION AND SUPERVISION OF FOOD. 279 INSPECTION AND SUPERVISION OF FOOD. Staff. The inspector under the Food and Drugs Acts is responsible for the work in connection with the sampling of milk and other foods, and the veterinary officers and the meat inspector for the inspection of meat in slaughter-houses. The sanitary inspectors are responsible for the general supervision of foods in the shops, on stalls, and in factories, and for the disposal of condemned foodstuffs. In the preparation of this section I have had the active support of the officers responsible. In addition, as a matter of interest, I include in this section a report from the veterinary officer on that part of his duties for which he is responsible to the Public Health Committee, and also the report of the public analyst. CONTROL OF MILK SUPPLY. Milk Shops and Dairies. Milk and Dairies (Consolidation) Act, 1915. Milk and Dairies (Amendment) Act, 1922. Milk and Dairies Order, 1926. During the year the number of inspections of dairies and milk purveyors' permises was 381. There are now 112 premises registered as dairies and their occupiers as dairymen, and 660 persons registered as purveyors of bottled milk only. The bulk of the milk sold in this borough is pasteurised and sold under licence; some is heat treated, bottled and sold as sterilised, but a certain quantity of raw milk is being bottled by retailers. In these cases steam sterilisers for the treatment of the bottles are insisted upon in compliance with Article 21 of the Milk and Dairies Order, 1926. Examination of milk for tubercule. During the year 55 samples of milk were examined for the presence of the tubercule bacillus. Of this number three samples gave a positive result (see later). 280 Table I. Persons and Premises Registered under the above Acts and Orders. Number of registered dairies on 31st December, 1936 109 Number of registered dairies on 31st December, 1937 112 Number of persons registered as purveyors of bottled milk on 31st December, 1936 649 Number of persons registered as purveyors of bottle milk on 31st December, 1937 660 Number of persons removed from the register — Number of dairies removed from the register — Number of applications for registration refused — Table II. Action taken in respect of the above Premises. Number of visits by inspectors 381 Number of premises found satisfactory 366 Number of premises found dirty 11 Number of premises found with dirty milk vessels 4 Number of premises found with unsatisfactory washing facilities Number of prosecutions for selling without being registered — Number of prosecutions for neglecting precautions to prevent contamination - Table III. Biological Tests. Type of milk. No. Examined. Result. Positive. Negative. Raw. Delivered at institutions 14 3 11 Purveyors 8 — 8 Producers on delivery 10 — 10 Pasteurised. Delivered at institutions 10 — 10 Delivered at schools (third-pint bottles) 13 — 13 Totals 55 3 52 281 Milk (special designations) Order, 1936. This Order became operative on 1st June, 1936, and displaces the previous Orders of 1923 and 1924. It transfers from the Minister of Health to local authorities the duty of granting licences to producers of certain designated milks, and simplifies the designations of milk. There are now only three grades:—"Tuberculin Tested," " Accredited " and " Pasteurised." "Tuberculin Tested" replaces "Certified" and "Grade A (Tuberculin Tested)" and is raw milk from tuberculin tested cows. It may be pasteurised, subject to certain conditions, and sold as "Tuberculin Tested (Pasteurised)," and when bottled on the farm it may be described as "Tuberculin Tested (Certified)." "Accredited" replaces "Grade A" and is raw milk from cows which are regularly inspected by a veterinary surgeon, but are not tuberculin tested. "Pasteurised" retains its title, which indicates that the treatment affords protection against all forms of milk-borne disease. Table IV. Licences issued under the Milk (Special Designations) Order, 1936. Description of licences. No. in force on 31st December, 1937. "Tuberculin Tested" milk (a) To produce and bottle 0 (b) To produce, but not bottle 0 (c) To sell by retail 13 "Accredited" (a) To produce, bottle and sell 1 (b) To produce, but not bottle 0 (c) To sell by retail 4 "Pasteurised" (a) Pasteuriser's licence 0 (b) To sell by retail 20 Examination of graded milk samples. Under this Order new tests as to the standard for graded milks were introduced. The Order came into force on 1st June, 1936, but the coliform count 282 test for the new grades of "tuberculin tested" and "accredited" milk was not replaced by the methylene blue reduction test until ist June, 1937. This new test replaces the plate-count method, and is now the main bacteriological test used; but in addition it is permissible to apply the test for the presence of coliform organisms, the standard being that these grades of milk should not contain such organisms in one-hundredth of a millilitre. The Memorandum 139/Foods, January, 1937, states that it is not necessary for both tests to be performed on every sample. "Tuberculin Tested" milk. The number of samples which were submitted to the methylene blue reduction test was 14. Of these 13 were satisfactory and one failed to pass the test. The time taken to decolorize in the sample which failed to pass was two and a half hours. These samples were also submitted to the test for coliform organisms. Of these, 12 passed the test and 2 failed, one of which also failed to pass the methylene blue test. Of the samples which failed to satisfy the test, coliform bacilli were Table V. Biological tests in milk since 1928. Year. No. of samples. No. positive. Per cent. positive. 1928 15 1 6.66 1929 16 4 25.00 1930 28 2 7.14 1931 32 2 6.25 1932 65 11 16.92 1933 65 9 13.85 1934 59 11 18.64 1935 60 1 1.66 1936 54 4 7.41 1937 55 3 5.45 present in one hundredth of a millilitre in three tubes in one sample and in two tubes in the other. "Tuberculin Tested (Certified)" milk. Thenumberof samples which were submitted to the methylene blue reduction test was 25. Of these 23 were satisfactory and two failed to pass the test. The time taken to decolorize in the samples which failed was four hours. 283 These samples were also submitted to the test for coliform organisms. Of these, the same two samples failed to pass the test, coliform bacilli being present in one hundredth of a millilitre in three tubes in each case. "Accredited" milk. The number of samples which were submitted to the methylene blue reduction test was five. All of these samples passed the test. These samples were also submitted to the coliform bacillus test, one of which failed to pass on account of the presence of the coliform bacillus in one hundredth of a millilitre. "Tuberculin Tested (Pasteurised)" milk. Of two samples of this grade of milk submitted for examination, one passed the test and one failed owing to the presence of excessive bacteria. "Pasteurised" milk. During the year, 61 samples were obtained, one of which failed to pass the prescribed test owing to the presence of excessive bacteria. Table V shows the results of biological tests in milk samples over a period of ten years. Table VI. Bacteriological examination of milk. Type of milk. Bacterial content per millilitre. Total. 1— 50,000— 100,000— 200,000— 500,000 1 million and over. Raw: Producer on delivery 9 - — - 1 — 10 Purveyor 9 - - - - - 9 Institution 10 1 2 1 - — 14 Pasteurised: Bottles 51 4 1 - - — 56 Institution 10 — - - - — 10 Schools (onethird pint) 44 3 2 1 1 2 53 Tuberculin Tested: (Pasteurised) 1 — 1 — — — 2 Total samples 134 8 6 2 2 2 ' 154 284 Bacteriological examination of milk. The bacteriological examination of milk is carried out locally at the laboratory of Queen Mary's Hospital. The close proximity of this laboratory facilitates despatch, as samples can be delivered from any part of the borough within twenty minutes. Table VI. gives the result of examination of the samples submitted during the year. Especial interest attaches to four samples which were taken from the supply provided for Harold Wood Hospital. These samples were examined biologically and bacteriologically and the results showed that in three of the four samples tubercule bacilli, and in addition the coliform bacillus in one tenth of a millilitre, were present. These facts were reported to the medical officer of health of the supplying area. Subsequently one animal was dealt with under the Tuberculosis Order, 1925. Pasteurised milk is now being supplied to this institution. Table VII shows the result of examination of samples of milk submitted for examination for the presence of the coliform bacillus. Table VII. Coliform bacillus content. Type of milk. Coliform bacilli present absent in 1 millilitre. Total. l/10th millilitre. 1/l00th millilitre. 1/1,000th millilitre. 1 millilitre. Raw: (a) Delivered at institutions outside this area 4 3 3 2 2 14 (b) Purveyor 2 — — — 7 9 (c) Outside producer on delivery at retailers - 0 - - 8 10 Total samples 6 5 3 2 17 33 (a) Supply discontinued and pasteurised milk now being supplied. (b) Letter of warning. (c) Facts reported to the medical officer of the producing area. Analysis of milk samples. During the year 1937 the number of samples submitted to the public analyst for examination was 417. Of this number 30 were graded milks; all were satisfactory. Of the other 387, 10 were unsatisfactory. 285 Further particulars of the examination of these milk samples are given on pages 311 and 312. Table VIII shows, for a number of years, the percentage of milk samples found to be adulterated, as compared with all food samples. Table VIII. Adulteration of milk and other foods. Year. Percentage of samples adulterated. Milk. All foods and drugs. West Ham. Avorage for England and Wales. West Ham. Average for England and Wales. 1928 2.5 8.2 3.0 5.8 1929 3.1 7.8 3.4 5.4 1930 3.9 6.6 4.8 4.8 1931 1.3 6.4 2.2 4.6 1932 3.9 7.3 3.8 5.1 1933 6.6 7.7 4.3 5.5 1934 2.0 7.2 2.4 5.3 1935 2.1 7.4 3.1 5.5 1936 1.9 7.1 1.3 5.3 1937 2.4 - 2.5 - The variation in the fat content of milk at different seasons is shown, in Table IX, which gives the average monthly and quarterly composition of milk samples during 1937. No pasteurisation has been carried out in this area since 1930, when a large company transferred their plant to a neighbouring borough. Condensed milk Regulations. During the year, 38 samples of condensed milk were examined. Of 26 samples of condensed machine skimmed milk sweetened, 19 were submitted for the purpose of testing the "equivalent." This test determines whether the contents of the tin will, when converted, give the amount of milk which is declared on the label. Of these, three proved unsatisfactory and appropriate action was taken. The remainder were satisfactory. 286 287 Table IX. Monthly composition of milk samples. Average composition. Average composition. (1937) Month. No. of samples. Fatty solids per cent. Non.fatty solids per cent. Total solids per cent. Quarter. No. of samples. Fatty solids per cent. Non-fatty solids per cent. Total solids per cent. January 43 3.45 8.87 12.32 I. 117 3.43 8.83 12.36 February 29 3.44 8.83 12.27 March 45 3.39 8.80 12.19 April 52 3.33 8.80 12.13 II. 119 3.32 8.91 12.23 May 35 3.36 9.08 12.44 June 32 3.2 7 8.84 12.11 July 42 3.39 8.78 12.17 III. 93 3.41 8.90 12.31 August 15 3.42 8.80 12.22 September 36 3.43 9.12 12.55 October 22 3.62 8.79 12.41 IV. 78 3.52 8.86 12.38 November 40 3.52 8.86 12.39 December 16 3.41 8.93 12.34 Whole year 407 3.42 8.87 12.29 All 26 samples were tested for milk solids and proved satisfactory. The number of samples of condensed full cream sweetened milk submitted for examination was five. Of these one was examined for the equivalent and proved satisfactory. In addition, this sample and the other four were tested for the fat and milk solids content. All proved satisfactory. Of seven samples of condensed full cream milk unsweetened submitted for the purpose of testing the equivalent, all proved satisfactory. Ice Cream. During the year, 26 samples of ice cream were obtained from shopkeepers and itinerent vendors and submitted for bacteriological examination. Table X gives the results of these examinations. Table X. Bacteriological examination of ice cream. Source of sample. Bacterial content per millilitre. Total. 1 50,000 100,000 200,000 500,000 1 million and over. Shopkeeper 1 3 2 2 1 1 10 Itinerant vendor 1 4 1 3 2 5 l6 Totals 2 7 3 5 3 6 26 In all cases of unsatisfactory results, letters of warning were sent and the premises inspected generally, special attention being given to the utensils. In every case subsequent samples proved satisfactory. Late in the year the West Ham Corporation Act, 1937, became operative, section 67 of which requires all premises used for the purpose of the sale or manufacture of ice cream to be registered. One hundred and forty-nine applications for this purpose have been dealt with and in one case the application was refused. Upon receipt of an application for registration, the premises are inspected by the sanitary inspectors, who give all possible assistance and advice regarding the suitability of the premises. 288 MEAT INSPECTION. Slaughter-houses. No change occurred in the number of slaughter-houses during the year. The number in use over a period of years is shown in Table XI. Table XI. Slaughter-houses in West Ham. Type of premises. No. in use at 31st December. 1920 1932 1933 1934 1935 1936 1937 Private slaughterhouses (registered) 7 6 6 6 6 5 5 Private slaughterhouses (licensed) 17 10 10 10 10 10 10 Knackers'-yards 3 3 3 2 2 2 2 In addition there are three registered slaughter-houses in the occupation of butchers; for a number of years these have been used for purposes other than slaughtering. One registered knacker's yard, not shown above, is not now used for knackering but for storage purposes. The licensed slaughter-houses are visited annually, and any defects observed are brought to the notice of the occupier for attention before the renewal of the licence is recommended. Defects in the premises noticed during visits for meat inspection are brought to the notice of the licencees for action as they are observed. The slaughter-houses generally have been kept in a reasonably clean state, but the more frequent removal of refuse material has had to be stressed on a number of occasions. Slaughter of Animals, Act, 1933. Fifty-three licences were renewed for 1937 and five new licences were issued. It was not found necessary to suspend or revoke any of these licences or to institute any proceedings for slaughtering without stunning with a mechanically operated instrument. Times of slaughtering. Slaughtering occurred on all days of the week, including Sunday, and took place at all times of the 289 s day. Thus the work" of inspection frequently had to be continued until a late hour, and to be carried out on Sundays and public holidays. Meat inspection. The system of meat inspection adopted conforms with Memo. 62/Foods of the Ministry of Health. (1) Ante-mortem inspections. The object of ante-mortem inspection is to ascertain that the animals which it is intended to slaughter are in a satisfactory state of health. During the year ante-mortem inspections involving 6,939 animals were made by the veterinary officers. (2) Post-mortem inspections. The general principles of post-mortem inspection set out in the memorandum require that: — (a) all organs comprising the viscera shall be examined by the eye and by palpation, and by an efficient examination of the lmyph glands where necessary. (ft) the carcase shall be examined for (i) condition of nutrition; (ii) evidence of bruising, haemorrhage or discoloration; (iii) local or general dropsy; (iv) the efficiency of bleeding; and (v) swellings or deformities of bones or joints or swellings or other abnormality in the musculature. (c) the serous membranes, and after the carcase is split, the sternum, ribs, vertebrae and spinal cord are to be examined. Further detailed instructions for the routine inspection of bovines and porcines indicate the method of examining each organ and the lymphatic glands to be incised. Where evidence of tuberculosis is discovered in bovines or swine, additional inspection is required and further lymphatic glands must be examined. The action to be taken in the event of evidence, of other disease such as actinomycosis, bruising, dropsy, emaciation, etc., being found is also indicated. Meat condemned as unsound. Table XII shows in compact form the work of this section during the year 1937. Tables XIII to XVII enumerate the meat condemned for diseases other than tuberculosis, and Table XVIII the tuberculous meat condemned. All meat condemned for disease was voluntarily surrendered. 290 Table XII. Carcases Inspected and Condemned. Cattle, excluding cows. Cows. Calves. Sheep and lambs. Pigs. Number killed 1,086 878 110 8,432 7,007 Number inspected 1,086 878 110 8,432 7,007 All diseases except tuberculosis Whole carcases condemned - — — 2 6 Carcases of which some part or organ was condemned 128 107 335 1,112 Percentage of the number inspected affected with disease other than tuberculosis 11.78 12.18 - 3.99 15.95 Tuberculosis only:— Whole carcases condemned Carcases of which some part or 3 8 — — 10 organ was condemned Percentage of the number 141 521 — — 1,030 spected affected with tuberculosis 13.25 60.25 — — 14.84 Table XIII. Meat condemned . diseases other than tuberculosis. (a) Bovines (bulls, bullocks and heifers only). Disease. Extent of condemnation. Head. Tongue. Heart. Lung. Diaphragm. Mesentery Liver. Spleen. Kidney. Actinomycosis Echinococcus veterinprum 2 3 — 1 — 1 1 1 — cysts — — — 2 — — 2 — — Distomatosis — — — — — — 87 — — Parasitic conditions — — — — — 2 — — — Pleurisy — — — 5 — — — — — Nephritis - - - - - - - - 2 Endocarditis - - 1 - - - - - - Abscesses — — — 1 1 — 7 — 2 Total 2 3 1 9 1 3 97 1 4 291 Table XIV. Meat condemned, diseases other than tuberculosis. (b) Bovines (cows only). Disease. Extent of condemnation. Head. Tongue. Lung. Liver. Spleen. Kidney. Mammary Gland. Actinomycosis 2 2 - - - - - Echinococcus veterinorum cysts - - 1 2 - - - Cystic conditions — — - — 1 2 — Parasitic conditions — — - 1 — — — Distomatosis — — - 127 — — — Pleurisy — — 4 — — — — Hepatitis — — — 1 — — — Mastitis - - - - - - 271 Nephritis - - - - - 32 — Abscesses — — — 5 — — — Fatty degeneration — — — 1 — — — Cavernous angioma — — — 0 — — — Emphysema — — 1 — — — — (Edema 1 1 - - - - - Total 3 3 6 143 1 34 271 Table XV. Meat condemned, diseases other than tuberculosis. (c) Bovines (calves only). No meat from calves was condemned during the year. 292 Table XVI. Meat condemned, diseases other than tuberculosis. Porcines (boars, sows and porkers). Disease. Extent of condemnation. Entire carcase and viscera Belly. Leg. Heart. Lung. Stomach. Intestine. Mesentery Liver. Spleen. Kidney. Œdema 1 - - - - - - - - - - Toxoemia 2 - - - - - - - - - - Pyrexia 1 - - - - - - - - - - Echinococcus veterinorum cysts - - - - - - - - - - - Cystic conditions - - - - - - - - i — 10 Cavernous angioma - - - - - - - - - - - Pneumonia - - - - - - - - - - - Pleurisy - - - - - - - - - - - Pericarditis — — — 111 — —- — — — —- — Peritonitis - - - - - 12 5 5 16 9 — Nephritis - - - - - - - - - - 49 Mastitis - 1 - - - - - - - - - Cirrhosis - - - - - - - - - - - Emaciation 1 - - - - - - - - - - Haemorrhage — — — — 36 — — — —- — — Bruises and fractures 1 — 2 - - - - - - - - Fatty degeneration — — — — — — — — 1 — — Total 6 1 2 111 822 12 5 5 271 9 59 Table XVII. Meat condemned, diseases other than tuberculosis. 0vines (sheep and lambs only). Disease. Extent of condemnation. Entire carcase and viscera Breast. Heart. Lung. Liver. Spleen. Kidney. Distomatosis — — — — 223 — — Echinococcus veterinorum cysts - - 4 4 4 - - Strongylosis — — — 56 — — — Parasitic conditions — — 1 5 24 — — Pneumonia — — — 2 — — — Pleurisy — — — 29 — — — Pericarditis — — 1 — — — — Nephritis - - - - - - 6 Hepatitis - - - - 2 - - Splenitis - - - - - 1 — Cirrhosis — — — — 2 — — Necrosis — — — —■ 1 — Abscesses — 1 — 1 2 — — Bruises and fractures 1 - - - - - - Asphyxia 1 - - - - - - Total 2 1 6 97 258 1 6 293 Table XVIII. Tuberculous meat condemned. Extent of condemnation. Bovines. Porcines. Bulls, bullocks and heifers. Cows. Calves. Boars, sows and porkers. Entire carcase and viscera 3 8 - 10 Heart 5 11 — 190 Lung 89 452 — 300 Liver 49 94 — 321 Pancreas 5 12 — — Spleen 4 11 — 9 Kidney 1 4 — — Mammary gland — 6 — — Stomach 2 6 — 13 Intestine 2 2 — 7 Head 43 147 — — Tongue 43 147 — — Head and collar — — — 299 Forequarter 2 7 — — Brisket 1 1 — — Flank — 2 — — Rib — 1 — — Top piece — 1 — — Diaphragm 1 4 — — Kidney knob — 2 — — Mesentery 47 167 — 797 Omentum 4 9 — — Total 301 1,093 — 1,946 294 Tuberculosis. Tables XIX and XX show the deposition of tuberculous lesions observed in (a) the lymphatic system and (b) the bones, organs, etc., respectively. Table XIX. Deposition of tuberculous lesions . (a) Lymphatic system. Bovines. Porcines. Bulls. Bullocks. Cows. Heifers. Calves. Boars. Sows. Porkers. Animals affected 1 119 529 24 — 4 23 1,013 Glands affected:— Sub-maxillary — 3 18 2 — 2 12 292 Retro-pharyngeal — 31 129 9 — — — — Parotid — 3 19 1 — — — — Pre-scapular - - - - - - - - Pre-pectoral — — 2 — — — — — Pre-sternal — — 2 — — — — — Supra-sternal — 1 - - - - - - Sub-dorsal - - - - - - - - Renal — — 1 — — — — — Lumbar — — 1 — — — — — Iliac — — 1 — — — — — Pre-crural - - - - - - - - Sub-mammary or subinguinal — — — 1 — — — — Ischiatic - - - - - - - - Popliteal — — 1 — — — — — Xiphoid — 1 10 1 — — — — Bronchial 1 59 447 20 — 1 4 248 Anterior mediastinal 1 37 228 9 — — — 4 Posterior mediastinal 1 37 214 11 — — — 3 Gastric — — 7 11 — 1 — — Splenic — — 9 1 — — — 2 Hepatic — 20 68 5 — 1 1 197 Pancreatic — 2 11 1 — — — — Mesenteric — 44 163 9 — 2 9 789 The proportion of carcases showing tuberculous or other lesions over a period of years is set out in Table XXI. It should be noted that this table is not in itself sufficient to warrant definite conclusions. Reference should be made to 295 Table XX. Deposition of tuberculous lesions . (b) Bones, Organs, etc. Bovines. Porcines. Bulls. Bullocks. 1 Cows. Ileifcrs. Calves. Boars. 1 Sows. Porkers. Animals affected 1 119 529 24 — 4 23 1,013 Parts affected:— Vertebra - - - - - - - - Adrenal body - - - - - - - - Kidney — 2 10 — — — 1 4 Mammary gland — — 7 - - - - - Pleura — 3 17 — — — — 4 Peritoneum — 2 15 1 — — — 1 Heart (a) Pericardium — 4 19 - - - - - (b) Epicardium - - - - - - - - (c) Myocardium - - - - - - - - (d) Endocardium - - - - - - - - Lung:— (a) Pleura — 3 17 — — — — 3 (b) Parenchyma — 5 37 3 — — — 38 Liver:— (a) Capsule — 2 14 — — — — 1 (6) Substance — 4 16 1 — 1 3 122 Pancreas:— («) Capsule — 2 10 - - - - - (b) Substance - - - - - - - - Stomach:— (a) Outer surface — 2 13 1 — — - - (fc) Inner surface Omentum — 2 15 1 — — — — Spleen:— (a) Capsule — 2 14 1 — — — - (6) Substance - - - - - - — 9 Intestine:— (a) Outer surface - 2 11 1 - - - - (b) Inner surface - - - - - - - - Mesentery — 2 11 - - - - - Uterus and Ovaries:— (a) Capsule - - 9 - - - - - (b) Substance - - - - - - - - Testicles and penis - - - - - - - - 296 Table XXI. Percentage of the number inspected in each year SHOWING (a) TUBERCULOSIS, (b) OTHER DISEASES. Year. (a) Tuberculosis. (b) Other diseases. Cattle excluding cows. Cows. Calves. Pigs. Cattle excluding cows. Cows. Calves. Sheep and lambs. Pigs. 1930 9.89 60.98 0.98 5.01 18.14 18.43 0.98 3.46 6.13 1931 8.38 64.45 5.45 6.96 10.14 14.41 1.81 1.82 3.82 1932 6.34 61.71 — 7.10 11.23 15.16 — 3.06 6.40 1933 7.85 57.83 2.43 9.08 9.71 13.00 1.21 3.62 6.92 1934 7.66 58.36 — 9.46 10.72 15.50 - 5.22 6.48 1935 12.24 52.31 1.38 9.62 7.04 12.06 — 4.32 9.51 1936 15.09 50.59 0.52 13.60 5.53 9.55 0.91 3.24 11.14 1937 13.25 60.25 — 14.84 11.78 12.18 — 3.99 15.95 the actual numbers of animals in the different classes. These figures will be found in previous reports. Disposal of diseased meat. Diseased meat surrendered as unfit for human food was released for industrial purposes after a dye or disinfectant had been sprinkled over it. Legal proceedings. No infringements of the meat regulations or of the bye-laws for slaughter-houses and knacker's yards warranting the institution of legal proceedings were observed. DISEASES OF ANIMALS ACTS. by H. E. Bywater, m.r.c.v.s., Veterinary Officer. These Acts, and the Orders made thereunder by the Minister of Agriculture and Fisheries, are designed to control infectious diseases of animals, including poultry, on grounds of national economy, but there are also regulations for the prevention of 297 suffering of animals during transit, on land and sea, and whilst exposed in markets. Although not primarily intended as public health measures some of these Acts and Orders serve as useful corollaries. The Diseases of Animals Acts are administered by the Veterinary Officer who reports to the Public Health Committee, acting as the Diseases of Animals Sub-Committee of the Council. The following account of the work performed under these enactments during 1937 must not be regarded as a report of the proceedings under the Diseases of Animals Acts, but as comments on aspects which have a bearing on public health or are of epidemiological or general interest. Anthrax Order of 1928. Owners of animals which have died or are suffering from suspected anthrax are required to report the facts. The information is then transmitted to the medical officer of health in order that he may take any measures which lie may consider necessary with respect to persons who have been in contact with the animal. Reports were received on two occasions that material from, or in contact with, animals which had died from confirmed anthrax, in the areas of other authorities, had been brought into the borough. Visits were made in order to trace the material, and in one case the vendors of cats' meat in the borough were warned not to sell any such meat pending investigations. Following upon this latter case a report was received that a cat, which had previously received such meat, had died. It was not possible, or expedient, to recover the body since it had been removed by the cleansing department and had been deeply buried, under several feet of refuse, at one of the Council's dust shoots. Epizootic Abortion Order of 1922. Epizootic or contagious abortion (Bang's disease) is not a notifiable disease, but this Order aims at lessening the spread of the disease amongst cattle by prohibiting the exposure of cows which have prematurely calved within the preceding two months. It also prohibits the sale or service of such animals without written notice of the fact being previously given to the buyer or the owner of the bull used for such service. There are great difficulties in administering this Order and it would appear that its provisions are, in the main, ignored. The Order does not aim at protecting the public from the 298 infection of Bang's disease, which is very prevalent in cattle and has of recent years been recorded in human beings and investigated by the Ministry of Health. The incidence in man, however, is very small indeed as compared with cattle, in spite of the widespread dissemination of the infective agent. Foot and Mouth Disease. No case of foot and mouth disease occurred in the borough, but on the 9th November, 1937, owing to the rapid spread of foot and mouth disease in the surrounding areas, the Minister of Agriculture and Fisheries made the Foot and Mouth Disease (Regulation of Movement) Order of 1937, which prohibited the movement of susceptible animals in the eastern and south-eastern counties. The spread of the disease was so effectually controlled by this measure that it was found possible to revoke the Order as from the 9th December, 1937. Licences were issued under this Order authorising the movement in this area of 365 cattle, 833 sheep, and 1,440 pigs, whilst 123 permits were issued for the collection in the controlled area of slaughter-house refuse for treatment at approved premises, to which frequent visits of inspection were made. Foot and Month Disease (Boiling of Animal Foodstuffs) Order of 1932. Foot and Mouth Disease (Packing Materials) Orders of 1925-26. Importation (Raw Tongues) Order of 1913. Importation of Meat, etc. (Wrapping Materials) Order of 1922. Movement of Animals (Records) Order of 1925. Importation of Carcases (Prohibition) Orders of 1926 and, 1927. Foreign Hay and Straw Orders of 1912-1937. Disease of Animals (Disinfection) Order of 1936. Various Orders with respect to importation of animals. These Orders are designed to prevent the introduction and spread of foot and mouth and other diseases. Visits of inspection were frequently made to shops, slaughter-houses, railway sidings, docks, piggeries, food and other factories, and fat and bone collectors' premises under these Orders. In connection with the first of these Orders it is of interest to record that all swill and waste food from hotels, hospitals, etc., must be boiled for one hour before being fed to pigs and, since fat is detrimental to pigs, care is taken by pig feeders to remove as much fat as possible from the swill after cooking. This process 299 is not dissimilar, in some ways, to that of bone and fat melting and may on rare occasions give rise to an offensive odour which cannot be controlled by the powers conferred by the Public Health Acts with respect to "offensive trades." Rabies Order of igig. No case of rabies has occurred in this country for some years past, but owners of animals suffering from so-called specific hysteria, or fits, occasionally report illness and death in dogs as suspected rabies. This is largely due to the notice drawing attention to the Rabies Order which appears on all dog licences and is commendable, for if a case of rabies remained unreported this disease might' once again become established in this country. Tuberculosis Order of 1925. This Order makes it obligatory for owners to notify any bovine animal which is affected with tuberculous emaciation, or with chronic cough-accompanied by definite clinical signs of tuberculosis, or with tuberculosis of the udden, indurated udder or other chronic disease of the udder, or which is giving tuberculous milk. There are many cattle affected with other forms of tuberculosis which are not amenable to the provisions of this Order, and it is regrettable that, in spite of the experience gained as a result of routine inspection of dairy cattle and work under this Order (it was first introduced in 1913 but was suspended during the late war), the provisions of the Order have not been extended. Cows which have been proved to be affected with tuberculosis as a result of the tuberculin test, are allowed to be used in milking herds and may be sold in the open market without notification of the fact having been made. The Tuberculosis Order is worked in conjunction with the Milk and Dairies (Consolidation) Act 1915, the Milk and Dairies (Amendment) Act 1922, and the Milk and Dairies Order 1926. All dairy cattle and cowsheds were inspected monthly and as other occasions required, and at the same time the hygienic conditions governing the production of milk were supervised. During the year 1,282 examinations of dairy cattle were made and, as a check on the clinical examinations, herd samples of milk were taken at each visit for microscopical and biological examination; 29 samples were submitted for examination during the year, all of which were certified negative for tuberculosis. Several cows were removed for slaughter by the owners 300 following advice given at the time of inspection. One cow was found to have lost condition and to be affected with a chronic cough. A microscopical examination of a sample of sputum from this cow showed that the animal was affected with tuberculosis. This animal was forthwith slaughtered under the provision of the above Order, and a post-mortem examination showed the diagnosis to be correct—the disease not being advanced within the meaning of the Order. Incidentally it may be mentioned that measures were similarly taken in respect of the three milking herds maintained at the farms attached to the Council's institutions. All samples taken from the Council's farms were negative for tuberculosis. FOOD INSPECTION. (Excluding the inspection of meat in slaughter-houses.) The sanitary inspectors have, during the year, made 3,968 visits of inspection to food shops, stalls and to food factories, etc. General speaking, there is remarkably little attempt to sell unsound food in West Ham. This is 110 doubt partly accounted for by the fact that there is a co-operative arrangement whereby any trader may bring to the office for inspection any food in respect of which he has any doubt, and may surrender and receive a receipt for any found to be unfit for human consumption. This being the case, there can be no excuse for any person who is found to be selling or exposing for sale any unsound or diseased foodstuffs. A very sharp watch has been maintained during evenings— Saturday afternoons and evenings particularly—over a few traders who are known to deal in job lots of food, especially tinned foods, either damaged at sea or rejected by more reputable traders. Such foods present a constant danger to the health of the consumer. One such trader has on two occasions, when warned verbally, produced copies of certificates which he stated had been granted by other authorities. These certificates vouched for the fitness for sale of a definite number of tins. The certification of fitness of unidentifiable tins is a very dangerous practice, and it should be obvious to any officer that the mere release of the tins after sorting is in itself a dangerous practice, so long as a certificate of fitness can be used, and in fact has been used, by unscrupulous traders to cover the sale of quite different tins in huge 301 quantities. This certificate of fitness must not be confused with the certificate of release, for technical purposes, of unsound foods despatched to approved fat melters and fertiliser makers, by mutual arrangement between authorities. An interesting point was raised by the defence in a prosecution for selling from a street stall an unlabelled tin of milk which was alleged to be unsound and unfit. A person purchased the tin of milk late on a Saturday evening and handed it to the Chief Sanitary Inspector on the following Monday morning. As the tin was obviously unfit, it was then submitted to a justice who condemned it and ordered it to be destroyed. In case the blown condition was due to metallic absorption, the tin was not opened before it was condemned by the Justice, as it was intended to submit it to analysis to ascertain precisely the extent of the metallic content. Submitted by the defence:— (a) That the Justice had no right to condemn tinned food without seeing the food concerned. (/.)) That the tin was not seen by the Chief Inspector or the Justice until 36 hours after purchase, and that although the milk was unsound on the Monday, it was not necessarily so at the time of purchase on the Saturday evening. Held by the Stipendiary:— (a) That the Justice acted properly in condemning a badly blown tin of food although it had not been opened. (b) That tinned food must be dealt with by a Justice as soon as practicable after purchase or seizure. The case was dismissed but no order was made as to costs. Disposal of condemned foodstuffs. (1) Foodstuffs condemned within West Ham. The usual procedure adopted by the sanitary inspector is set out as follows:— (a) Meat. After seizure and condemnation by a justice or after voluntary surrender of meat, the practice is to permit delivery to a selected fat melter within the borough after treatment by colour, paraffin, chloride of lime or heavy coal tar disinfectant, and to supervise its breaking down to liquid fat and a residual meal. (b) Fish. In this case the practice is for the owner of the fish to deliver it to a fish meal factory situated in the Borough. 302 The owner is required to obtain and produce a receipt for the fish from the firm before he is provided with a certificate of condemnation. The fish is broken down to a fish meal. (c) Poultry. Similar to fish. (d) Tinned foods (fruit, fish, milk and meat paste). It is sometimes difficult to dispose of this class of goods. The cans are emptied, or at least thoroughly punctured, and delivered by the refuse disposal section of the Borough Engineer's department to one of the tips. They are thoroughly covered. (e) Fruit pulp (usually in casks or barrels). Usually treated with poisonous disinfectant and burnt in the boiler furnace of the firm in whose premises it is discovered. This process has, on occasion, occupied several days. (2) Imported foodstuffs. Condemned at the port of entry and released for destruction or for use other than for human consumption. As the Imported Food Regulations provide for the release of condemned food under guarantee by the consignee that it will not be used for human consumption, it is possible to keep an efficient check on consignments, particularly as arrangements have been made whereby the Port Sanitary Authority permit release to West Ham only on approval by their own officers. Carcases of meat are dealt with as described under paragraph (1 )(a). At one time, considerable quantities of condemned tinned milks were released to West Ham under guarantee that they would be used for the manufacture of confectionery, but after a period of suspicion, it was found that some tins were being re-labelled by the consignee in such a way as to give strong grounds for the belief that the intention was to pass them into the retail trade for human food. The Port Authorities were requested to stop the release of such milk to West Ham, and they did so. This led to the reciprocal arrangement already referred to. (3) Foods condemned by other authorities. Quantities of meat and other foodstuffs condemned by a number of other local authorities are released to West Ham for destruction by treatment at local fat melters. Arrangements exist in all these cases whereby the inspectors concerned communicate by telephone with the West Ham inspectors. Information is given regarding the time of release and the description of the foods, and these consignments are checked at the premises of the local fat melter or the fish 303 Table XXII. Samples Ainalysed by Borough Analyst during 1937. Article. Analysed Genuine Adulterated Official. Unofficial Official. Unofficial Official. Unofficial. Milk 411 6 402 5 9 1 ,, condensed 12 26 10 25 2 1 ,, dried 32 — 32 — — — Butter 63 48 60 47 3 1 Margarine 20 — 20 — — — Cheese 5 3 5 3 — — Lard 18 — 18 — — Dripping 6 5 6 6 — — Cooking fats . 7 1 6 1 1 — Pepper 25 15 25 15 — — Pickles 3 — 3 — — — Sauce 1 2 1 2 — — Vinegar 28 1 20 1 2 — Cocoa 10 — 10 — —s — Coffee 7 — 7 — — — Tea 25 — 25 — — — Flour 48 1 48 1 — — Bread 6 — 6 - — — Cakes 10 — 10 — — — Pearl barley 4 2 4 2 — — Rice 9 2 9 2 — — Sago 2 — 2 1 — — Baking powder 1 1 1 — — Jams 12 8 10 5 2 3 Lemon curd 3 — 3 — — — Sugar 13 — 13 — — — Sweets 15 16 14 16 1 — Dried fruits 19 1 19 1 — — Peas 5 — 5 — — — Meat 30 39 30 37 — 2 Canned meat 1 — 1 — — — Cooked meats 11 — 11 — — — Sausages 16 — 16 — — — Bacon 8 — 8 — — — Meat and fish pastes 3 1 3 1 — — Sardines 1 2 1 2 — — Camphorated oil 1 7 1 7 — — Epsom salts — 3 — 3 — — Sulphur ointment — 2 — 2 — —-1 Zinc ointment — 1 — 1 — — Cream 8 5 8 5 — — Suet 2 1 2 1 — — French capers 1 — 1 — — — Honey - 2 - 2 - - Carried forward 902 201 882 193 20 8 304 Table XXII.—continued. Article. Analysed Genuine. Adulterated. Official. Unofficial Official. Unofficial Official. Unofficial Brought forward 902 201 882 193 20 8 Ground almonds 6 5 6 5 - - Cornflour 2 — 2 — — — Cordials 7 4 7 4 — — J unket crystals 1 — 1 — — — Beer 3 1 1 2 — — Whiskey 1 2 1 2 — — Infants' food 1 — 1 — — — Lemonade powder 1 — 1 — — — Ground ginger 2 2 2 2 — — Dried herbs 3 — 3 — — — Salt 1 — ] — — — Herb stuffing — 1 — 1 — — Arrowroot 4 — 4 - — — Chocolate -— 1 — 1 — — Table jelly 1 1 1 1 — — Compound syrup of figs 1 1 Boric ointment — 1 — 1 — — Olive oil 1 — 1 — — — Spices — 1 — 1 — — Macaroni 1 — 1 — — — Pudding powder 1 — 1 — — — Mincemeat 6 5 6 5 — — Table cream 1 1 -— — 1 1 Gravylets 1 — 1 — — — Lung syrup 2 — 2 — — — Witch hazel 1 — 1 — — — Totals 949 227 928 218 21 9 meal consignees. Meat is treated by indelible colour and in other ways before release. It may be noted that considerable quantities of condemned frozen and chilled meats, tinned tongues and beef were discovered at a charcoal maker's in West Ham. Representations were made to the local authorities concerned, and such meat is now only released to approved firms who possess plant capable of dealing efficiently and rapidly with it. Supervision of foods (exclusive of milk products). Condemnation of unsound food. During the year 1937, the following articles of food were condemned: 202 lbs. tinned 305 t meat; 261 lbs. chestnuts; 92 rabbits; 2 lbs. bacon; 8| lbs. mutton; 31 lbs. cooked meat; 1 beef kidney; 18 st. skate; 1 ton apples, cauliflowers and onions; 390 pears; 10 boats tomatoes; 1 barrel crabs; 1 pig's head; 53 barrels horse-radish; 7 cwt. gooseberries; 5 tins fish; 4½ tons potatoes; 11 ½-lb. bags currants; 2 st. mackerel; 21 lbs. pork; 1 tin jellied veal; 7 cwt. sweets; 1 6-lb. tin of ox tongue; 3 chickens; 1 tin evaporated milk. The number of articles submitted to the Borough Analyst for analysis, together with the results of his examination, are shown in Table XXII. I give below a few remarks upon the action taken in respect of certain articles which proved to be unsatisfactory. Malt vinegar. A sample of malt vinegar proved to be deficient in acetic acid to the extent of 50 per cent, (equivalent to the addition of at least 50 per cent. of water). An arrangement was made with the vendor for a sample of this commodity to be taken from a fresh barrel "in course of delivery" from his supplier. This sample proving genuine, an information was laid.against the vendor in respect of the sample purchased from him, and a fine of forty shillings was imposed. "Table Cream." An informal sample of a commodity labelled "Table Cream" was found to be a mixture of starch and cocoa powder. An official sample was obtained, and in view of the fact that a purchaser would be inclined to think that the article was a milk product or a cream substitute, whereas it was similar in all respects to custard powder or blanc-mange powder, a letter was addressed to the manufacturers regarding the misleading description applied to the wrapper. A repl}- was received to the eifect that the label complained of was quite inadvertent, and new cartons were already in print with amended wording. Table vinegar. A sample bottle of table vinegar proved to be 100 per cent, artificial vinegar. A letter of warning was sent to the manufacturer who replied that the label would be amended forthwith. Cooking fat. Ready packed vegetable cooking fat proved to contain 7.6 per cent, of water. A letter of warning was sent to the vendor, and a reply was received from the manufacturers who stated that the wording on the wrapper would be amended. Straws. Two samples of straws as used by school children for the drinking of milk gave a satisfactory bacteriological test. 306 Milk. None of the 417 samples of milk submitted for analysis was reported to contain preservative or colouring matter. Dried milk-—Full cream. All of the 32 samples which were submitted for analysis proved satisfactory. Butter. Of 111 samples of butter submitted for analysis, 63 were formal and 48 were informal samples. Of the formal samples, 3 were reported upon as containing excessive water. Letters of warning were sent and subsequent samples obtained were found to be genuine. Of the informal samples, one was reported upon as containing excessive water to the extent of 1.0 per cent. Further samples were obtained and proved genuine. Preservatives in food regulations. There were five contraventions of these regulations. Two informal samples of meat were reported as containing 150 and 120 parts of sulphur dioxide per million respectively. Formal samples were obtained from the same source and these proved satisfactory. Two informal samples of strawberry jam were reported as containing 44 and 37 parts of sulphur dioxide per million respectively. Formal samples were obtained, one of which was found to be satisfactory, whilst the other was proved to contain 30 parts of sulphur dioxide per million. In this case legal proceedings were instituted against the manufacturer, who was fined £4, and in addition £4 for giving a false warranty to the retailer. Pharmacy and Poisons Act, 1933. This Act became operative on 1st May, 1936. It contains 31 sections and is divided into three parts. Part I. This part deals with the Pharmaceutical Society and its members (registered pharmacists) and their position under the Act, and prohibits the carrying on of the business of a chemist, druggist, or pharmacist except by pharmaceutical chemists. It explains the conditions to be fulfilled by pharmacists and corporate bodies in order to become "authorised sellers of poisons," and makes provision for the continuation of the business of a pharmacist by representatives in case of death, unsoundness of mind, or bankruptcy. Part 11. This part provides for the establishment of a Poisons Board. The Board was constituted and prepared a list of poisons, which is divided into two parts. Part I of the list consists of those poisons which may be sold only by "authorised sellers of poisons," i.e. registered pharmacists. Part II of the 307 list consists of those poisons in common use, for example, ammonia, carbolic disinfectants, sulphuric and nitric acids, spirits of salts, salts of lemon, insecticides, and also certain forms of arsenic and mercury used in agriculture. These may be sold only by "authorised sellers of poisons," i.e. registered pharmacists, and also those persons whose names are entered on a list which is to be kept in the prescribed manner by a local authority. This list includes the names of persons who are not entitled to sell those poisons included in Part I of the poisons list, but who are entitled to retail those poisons included in Part II of the poisons list— for example, ironmongers, oilmen, garage keepers, seedsmen, nurserymen, and agriculture merchants. The fee to be paid for Table XXIII. Pharmacy and Poisons Act, 1933. Number of persons entitled to sell Part II. Poisons at December, 1936 138 Number of persons removed from the list during 1937: — (a) business closed 9 (b) ceased to sell poison 10 19 119 Number of persons added to list during 1937 7 Number of persons included in the list on December 31st, 1937 126 the original entry in the local authority's list is 7s. 6d., and for the annual renewal of such entry the fee is 5s. The Act imposes upon the local authority the duty of enforcing the provisions of Part II and of the rules made under the Act, in so far as they relate to Part II of the Poisons List, and this duty includes the keeping of a list of persons other than "authorised sellers of poisons." Power is given to the local authority to refuse to enter in, or remove from, the list of names, the name of any person provided that the authority has sufficient reason for its action. Part III. This part deals with the inspector and sampling. 308 During the year 1937 the number of samples which were taken under this Act was four. All of these proved to be satisfactory. Further details in connection with the working of this Act are shown in Table XXIII. Fertilisers and Feeding Stuffs Act, 1926. The first Act to impose specific requirements upon sellers of fertilisers and feeding stuffs was the Fertilisers and Feeding Stuffs Act, 1893. This was replaced by the Fertilisers and Feeding Stuffs Act, 1906, which in turn has been superseded by the above-mentioned Act. This Act controls in some measure the sale of fertilisers and feeding stuffs and protects the purchaser against adulteration of these articles. Table XXIV. Fertilisers and Feeding Stuffs Act. Type of sample. No. of samples taken. Analysis agreed. Analysis disagreed. Fertilisers: (a) official 23 12 11 (b) unofficial 15 7 8 Feeding stuffs: (a) official 16 10 6 (b) unofficial 13 9 4 Totals 67 38 29 It provides that every person, who sells for use a fertiliser of the soil or a food for cattle or poultry, is required to give to the purchaser a statement (which may form part of the invoice) containing particulars as to the name of the article and its composition, in order that the buyer shall know as much as is necessary and practicable to enable him to judge of the efficacy and value of the article. The manufacturer having supplied the particulars to the retail seller, he in turn is required to pass them on to his customer. Unofficial and official samples of these commodities for analysis are obtained from retail sellers for the purpose of testing 309 the warranty. Visits are also paid to the manufacturers' premises for samples for analysis, and documents and registers are inspected with the object of checking- the warranties which are passed on to the merchant and retailer. Details of samples taken during the year are shown in Table XXIV. REPORT OF THE PUBLIC ANALYST FOR 1937 by Albert E. Parkes, f.i.c., f.c.s. During the year 1937, the number of samples which were examined under the Food and Drugs (Adulteration) Act was 1,176. These were all submitted by the medical officer of health, and no samples were submitted by the public. Of these samples, 30 were found to be adulterated. The adulteration was at the rate of 2.55 per cent, of samples submitted as compared with 3.38 per cent, for the whole of England and Wales in 1936. The adulteration of the samples submitted during the past ten years is shown in Table XXV. Table XXV. Adulteration of samples submitted. Year. No. of samples. Per cent, adulterated. Genuine. Adulterated. Total. 1928 1,414 44 1,458 3.0 1929 1,210 42 1,252 3.4 1930 1,172 54 1,226 4.8 1931 1,268 28 1,296 2.2 1932 1,109 44 1,153 3.8 1933 1,116 50 1,166 4.3 1934 1,145 28 1,173 2.4 1935 1,140 36 1,176 3.1 1936 1,160 15 1,175 1.3 1937 1,146 30 1,176 2.5 Average per year 1,188 37 1,225 3.1 310 Table XXVI. Adulterated milk samples. Year. Genuine. Adulterated. Per cent, adulterated. 1928 541 14 2.5 1929 373 12 3.1 1930 343 14 3.9 1931 443 6 1.3 1932 445 18 3.9 1933 495 34 6.4 1934 481 10 2.0 1935 426 9 2.1 1936 414 8 1.9 1937 407 10 2.4 Average per year 437 13 2.9 The average milk adulteration for the whole of London was at the rate of 2.45 per cent.. and for the whole of England and Wales 7.1 per cent, in 1936. The composition of the adulterated milk samples is shown in Table XXVII. Table XXVII. Adulterated milk samples. No. of sample. Fat per cent. Non-fatty solids per cent. Total solids per cent. Comments. 12 2.8 8.5 11.3 6.6 per cent, deficient in fat 13 2.8 8.5 11.3 6.6 per cent, deficient in fat 190 3.5 7.9 11.4 7.0 per cent, added water 205 2.8 8.6 11.4 6.6 per cent, deficient in fat 302 3.1 8.2 11.3 3.5 per cent, added water 350 2.7 8.5 11.2 10.0 per cent, deficient in fat 399 2.8 8.6 11.4 6.6 per cent, deficient in fat 617 2.5 8.8 11.3 16.6 per cent, deficient in fat 628 2.5 8.7 11.2 16.6 per cent, deficient in fat 637 2.9 8.5 11.4 3.3 per cent, deficient in fat 311 The number of samples examined was at the rate of 4.42 per 1,000 of the population, as compared with the 1936 figures of 9.92 per 1,000 for the whole of London, and 3.6 per 1,000 for the whole of England and Wales. The number of samples of milk which were examined during the year was 417, of these 10, or 2.4 per cent. were reported as adulterated. The proportion of milk samples found adulterated during the past ten years is shown in Table XXVI. Condensed milk. Thirty-eight samples of condensed milk were examined, three of which were unsatisfactory, all being deficient in milk solids. Preservatives. There were four contraventions of the Preservatives Regulations:— Two samples of jam, both of which contained excess of sulphur dioxide. Two samples of meat, both of which contained sulphur dioxide. In addition to the above the following samples were analysed during 1937:—35 samples of rag flock, 8 of which were unsatisfactory; 3 samples of cleansing liquids; 1 sample of water; 5 samples under the Pharmacy and Poisons Act, 1933. The following were analysed for the Borough Engineer's department:—122 samples of sewage; 4 samples of water; 1 water scale. 312 VIII. SANITARY CIRCUMSTANCES. 313 SANITARY CIRCUMSTANCES. Water. Except for industrial purposes, such as the supply of condensers, every house in the borough is supplied with water by the Metropolitan Water Board. Unsatisfactory storage cisterns are dealt with as they are discovered. As opportunity offers, services are altered to provide one tap with direct connection to the rising main and the remainder of the supply through a storage cistern. Several of the Council's institutions are supplied with water from wells. Within recent months I have had occasion to carry out a complete investigation into the condition of these wells and the wholesomeness of the water supplied. The result of the investigation was satisfactory, and certain recommendations which were made were adopted for the conditions concerned. This matter will be referred to in more detail in my next annual report. It is perhaps not a matter of common knowledge that there are in the borough a number of wells owned by private persons and firms. In most instances the water supplied is used for industrial purposes. A close watch is being kept on those wells which are known to the local authority. There is no doubt that the trend of action at the present time is against the use of wells for any purposes excepting those relating to industry. A difficulty which merits consideration arises from the fact that it is sometimes difficult to prevent a few individuals from using such water for drinking purposes. In this connection a case recently dealt with in my department illustrates how difficult it is to ensure that the water supply to houses in connection with factories is, so far as wholesomeness is concerned, beyond reproach. A firm which has large works in the area have on the premises a well, the water from which is used for commercial purposes. Towards the close of 1937 the firm adapted three flats for occupation by their employees. The manufacturing process includes the use of a large supply of water which is obtained from the well, and the firm wished to supply the cottages 314 from this well. This course appeared to be undesirable and representation was made to the firm requesting them to connect up the cottages with the public mains. This the firm were quite willing to do, but they discovered that if this course was adopted the assessment for water rate would be in respect of the whole factory and not in respect of the few cottages to which the water from the main would be supplied. A representation was made .to the Metropolitan Water Board asking them to reconsider the matter of assessment, and at the time of writing negotiations are still proceeding. Sewerage and sewage disposal. The water carriage system of sewage removal is almost universal throughout the borough. Houses are provided with properly flushed waterclosets, discharging by modern drainage into the public sewers which also convey the surface water. That part of the borough lying south of the Victoria and Albert Docks is drained into a main sewer which passes through portions of East Ham and North Woolwich, and discharges into the London County Council's sewer at North Woolwich. The whole of the sewage of the borough is water-borne, with the exception of that from a few isolated cottages on the north side. Excepting' this comparatively small area, the whole district north of the Victoria and Albert Docks is drained by gravitation sewers to the Corporation's pumping station at Abbey Mills, where it is pumped into the northern outfall sewer which crosses the borough obliquely to the London outfall at Barking. Provision is made for the pumping of storm water into the Channelsea river. Certain storm sewers are provided, and these discharge into the rivers and ditches. Refuse collection and disposal. 1 am indebted to the Borough Engineer, Mr. W. Lionel Jenkins, O.B.E., for the following report: — "The 'Pagefield' system of refuse collection is made up of a number of complete units, each consisting of one mechanically propelled vehicle and three horse-drawn containers. Each unit operates to a strict time-table on a carefully worked out route. The horse-drawn containers are low-loading, and when filled are hauled mechanically on to the motor driven vehicle for conveyance to the shoot, an empty container being left with the fillers. This process is repeated to each of the three containers in turn, 315 and by this means the fillers are able to continue at work for the whole of the day, instead of having to await the return of their vehicle from the shoot, as would be the case were self-contained vehicles employed. The Council are alive to the necessity for keeping the system of refuse collection as up-to-date as possible, and recent replacements of Pagefield vehicles have been made with containers of the latest dustless-loading type. The total amount of refuse collected annually is approximately 75,000 tons, and the whole of this is disposed of by controlled tipping, either within or immediately outside the borough. The working faces of the shoots are covered with earth at the close of every working day, in accordance with the regulations suggested by the Ministry of Health, and in this connection I have to report that no complaints were received." Dustbins. I am indebted to the Borough Engineer for the following information: — "There are no ash-pits in the borough. The house refuse is collected twice weekly, and under a scheme for the supply and maintenance of standard dustbins by the Corporation which was inaugurated a few years ago by the Highways and Parks Committee, this collection is now carried out under greatly improved conditions. The number of bins at present supplied by the Council under this scheme is 15,700, at a charge of is. 6d. per bin per annum." Closet accommodation. The closet accommodation in the borough is wholly on the water carriage system, and with a few isolated exceptions drainage is to the borough sewerage system. REPORT OF THE CHIEF SANITARY INSPECTOR by H. G. Clinch, f.s.i.a., m.r.s.i. District sanitary inspectors. There was one change in the members of the staff of district sanitary inspectors during the year. As a result of the coming into force of the Public Health Act 1936, it was found that the new powers of appeal given involved considerable extensive work on the part of the staff. Work of the women sanitary inspectors. There are three women sanitary inspectors on the staff of the public health department. During the year their duties were revised, and they are now 316 employed almost entirely on work in connection with infectious diseases, cafe-kitchens, women's workshops, factories in which women are employed, offices, and with outworkers. The work done in these directions is separately dealt with under the appropriate headings. Work of the district inspectors. Full details of the visits made by the district inspectors during the year are given in Table 1, and in Table II special visits are similarly dealt with. An analysis of the work done by the district inspectors is given in Table III. Table I. Visits made by inspectors. 1937- Investigations of cases of notifiable infectious diseases 2,263 Houses inspected following infectious diseases 1,962 Visits to factories 498 ,, workshops 259 „ workplaces 176 ,, bakehouses 230 ,, dairies 381 ,, offices (as workplaces), P.H.A. 1936 26 ,, outworkers 397 ,, common lodging houses 41 ,, houses let in lodgings 20 ,, cellar dwellings, underground rooms 72 ,, slaughter-houses — ,, scheduled offensive trades 550 ,, fish-fryers 191 ,, other noxious trades 17 ,, knackers' yards 14 ,, registered hairdressers and barbers, W.H.C.A.,* section 49 27 ,, registered premises wherein food is manufactured, W.H.C.A.,* section 67 127 ,, registered premises occupied by vendors of food, W.H.C.A.,* section 66 29 ,, cafe and restaurant kitchens, P.H.A., 1925 522 ,, ice cream makers or dealers, W.H.C.A.,* section 66, and P.H.A. 248 ,, other food purveyors 3,841 *W.H.C.A. = West Ham Corporation Act, 1937. 317 Exhumation of human remains, Burial Act, 1857, section 25 - Visits to shops (Shops Act, 1934) 40 ,, canal boats — Visits re-overcrowding provisions of Housing Acts 72 Drainage inspections 5,999 House to house inspections under Public Health or Housing Acts 2,462 Visits under Rats and Mice Destruction Act 198 ,, ,, Rent Restriction, etc., Acts 34 ,, ,, bye-laws—tents, vans, sheds 97 ,, to private houses to investigate complaints 5,851 Houses inspected under the Housing Act 1936, reclosing and demolition orders or reconconstructions or re-schedules of evidence . 590 Smoke observations 122 Visits to factories re smoke 93 ,, factories re Steam Whistles Act 1872 - ,, places of public amusement, theatres, music halls, cinemas, etc., Ministry of Health circular 120, 1920 307 ,, licensed premises 183 Other visits 859 Re-inspections 33,012 Total visits 61,810 Apart from general repairs the most important items dealt with from the numerical point of view were cleansing of walls and ceilings, roofs, gutters, various defects to water-closets, and dampness. During the year the total number of notices served was 6,923, and the number complied with was 5,962. Houses let in lodgings. It is becoming increasingly common for large houses in better class districts to be let off in separate tenements, no further provision being made for the additional families. Thus in many instances there is a deficiency of suitable and sufficient washing and cooking facilities and of sanitary accommodation. New overcrowding in these houses is being prevented by prosecution. Rents, over which the department has no control, are frequently excessive in relation to the accommodation provided. 318 The conditions found in these old houses which have been split up into tenements are often far from satisfactory, and some amelioration can only be effected by means of bye-laws, which have not yet been adopted. Common lodging houses. There are now eight common lodging houses in the borough, containing a total number of 419 beds, all of which are for males. Table 11. Special visits by inspectors. 1937. Samples taken under Rag Flock Act 35 Samples of domestic water supplies taken for analysis or bacteriological examination - Number of notices served 6,923 Warning letters sent re-matters not dealt with by notice 70 Defective houses dealt with 6,818 Other defective or insanitary conditions dealt with 6 Drain tests carried out 312 Certificates granted under Rent Restrictions, etc. Acts 16 Number of notices complied with (1) by owner 6,381 (2) by occupier 20 Summonses issued 863 These premises are all old buildings adapted for the purpose of receiving lodgers. No application was received for registration of new premises, and the number of lodgers continues to fall. The keepers were changed in two instances. During the year 41 visits were paid by the sanitary inspectors to these premises and minor defects were dealt with verbally. One common lodging house was closed during the year, following proceedings at court for infringement of bye-laws. A fine of 10s. was imposed in respect of each of five summonses. Further proceedings were taken later for a continued offence after notice. At the second hearing the defendant stated that he had an average of only 22 lodgers at 9d. per night each, and that he would prefer to close the house rather than be compelled to comply with the bye-laws. The chief sanitary inspector, conducting the prosecution, applied for an adjournment on an undertaking to close, and as the business was duly discontinued, the case was eventually withdrawn on payment of costs. 319 320 Table III. Analysis of work done by district inspectors in the various wards, 1937. Type of work. Beckton Road. Bemersyde. Broadway. Canning Town and Grange. Custom House and Silvertown. Forest Gate. High Street. Hudsons. New Town. Ordnance. Park. Plashet Road. Plaistow. Tidal Basin. Upton. West Ham. Totals. Drainage and sanitary arrangements:— W.C's, general repairs to 53 56 20 65 26 39 38 45 30 48 20 18 69 64 15 18 624 ,, apartments cleansed 44 45 56 80 27 40 51 45 45 60 12 18 82 60 21 35 731 „ flushing apparatus repaired 45 12 28 51 18 27 20 15 39 33 22 12 45 36 18 30 451 ,, pedestals renewed — — — — 2 1 — — — — 3 — — — 7 1 14 ,, provide and fix pan and trap 50 14 19 40 9 32 15 24 52 25 12 15 30 23 14 25 339 ,, additional acc. provided — — - — — — — — — — — — — — - - — New sinks and waste pipes provided 43 38 19 84 30 24 52 60 45 66 30 30 60 60 20 38 699 Vent shafts repaired or renewed — — — — — 7 — 2 — 3 — - — - 3 - 15 Defective gutters and down pipes 63 77 60 180 92 93 90 122 114 75 65 69 1ll 117 31 100 1,459 Public sewers repaired or improved 5 — 1 — — — — — — 2 2 2 8 — — - 20 Repairs to water fittings 18 12 11 22 15 6 14 12 14 14 9 4 24 16 21 11 223 Drains repaired, amended, or renewed 51 8 3 36 20 22 15 17 8 14 18 12 24 33 14 4 299 Rainwater pipes disconnected — — — — — — — — — — — — — - — - — Soil pipes repaired or renewed — — — — — — — — — — — — - - - - - Dustbins renewed 39 20 30 46 33 20 21 26 41 42 11 11 80 36 8 23 487 Urinals, cleansed, amended, or screened — — 1 - 9 — — - — - - - - - - - 3 ,, remodelled — — — — — — — — — - — — — — — - — ,, provision of new - — — — — — — — — - — — — — — — — Dwelling-houses:— Houses or parts cleansed or limewashed 301 136 181 435 194 185 309 176 213 303 117 114 400 314 78 219 3,775 General repairs executed 106 107 64 378 90 50 90 64 95 186 48 54 243 276 80 96 2,027 Roofs 128 98 203 467 150 156 240 129 186 270 90 95 273 366 56 171 3,108 Dampness excluded 76 68 32 144 120 90 54 60 46 105 54 40 135 144 44 66 1,278 Carried forward 15,612 321 Table III (continued). Type of work. Beckton Road. Bemersyde. Broadway. Canning Town and Grange. Custom House and Silvertown. Forest Gate. High Street. Hudsons. New Town. Ordnance. Park. Plashet Road. Plaistow. Tidal Basin. Upton. West Ham. Totals Brought forward Dwelling-houses—contd. 15,612 Window frames, sills and sashes, repaired or renewed 51 24 18 180 40 52 36 30 48 80 38 23 106 131 23 42 1,022 Sash-lines repaired and renewed 60 33 43 165 68 52 81 42 75 67 23 45 90 92 14 54 1,004 Staircases repaired 27 4 6 48 9 9 18 15 4 18 3 2 17 22 8 10 220 Hand-rails repaired and renewed 3 9 — 63 18 3 4 15 4 23 12 3 11 38 8 3 217 Chimney stacks repaired 30 18 10 32 11 6 15 34 9 15 9 12 45 21 5 8 280 Sub-floor ventilation 21 33 9 96 7 38 30 36 20 20 18 14 27 8 20 30 427 Ventilation improved 15 6 3 12 — 4 2 3 8 6 — 15 3 2 3 3 85 Kitchen ranges repaired or renewed 48 40 30 123 50 57 87 45 54 42 26 21 159 75 20 60 937 Washing coppers repaired and renewed 48 12 23 56 21 6 22 16 34 30 6 12 54 45 13 45 443 Walls rebuilt 3 3 5 21 — 13 30 — 2 9 3 4 7 4 5 — 109 Walls repointed 21 16 9 63 27 30 24 12 33 12 20 11 24 36 9 21 368 Fire-grates repaired or renewed 36 10 16 54 7 3 3 3 24 25 18 18 51 39 22 37 362 Floors repaired or renewed 66 18 6 153 33 41 69 25 36 57 18 30 57 105 12 48 776 Flues repaired 6 3 4 12 — 10 - 6 10 — 9 — 12 6 4 7 89 Rats 9 2 2 30 2 — — 10 3 9 3 3 3 10 4 2 92 Verminous houses dealt with 2 - 2 3 3 - - - 4 15 — 2 6 6 2 3 48 Lighting improved 2 — — 2 — — — — 2 — 2 — — 3 — - 11 Houses supplied with water 2 — 2 2 — — — 4 — 2 2 — 2 4 2 3 25 Cellar areas cleansed - - - - - - - — — — — — — — — — — Courts, backyards, stables, etc.:— Forecourt and yard paving repaired or renewed 40 30 45 154 52 48 21 32 53 99 24 24 96 96 27 40 882 Yards cleansed — - - - - - - - — — — — - — — — — Manure pits repaired or provided — — — 2 — — — 2 — 4 — — - — — — 8 Carried forward 23,006 U 322 Table III (continued). Type of work. Beckton Road. Bemersyde. Broadway. Canning Town and Grange. Custom House and Silvertown. Forest Gate. High Street. Hudsons. New Town. Ordnance. Park. Plashet Road. Plaistow. Tidal Basin. Upton. West Ham. Totals. Brought forward 23,006 Courts, backyards, stables, etc.—contd. Manure pits emptied - - - - - - - - - 2 - - - - - - 2 Accumulation of rubbish removed 15 4 9 28 6 9 4 3 2 9 4 6 6 22 8 7 142 Keeping of animals:— Improper keeping of animals - - - - - - - 2 - - - - - - - - 6 Accumulation of offensive matter removed - - - 2 2 3 - 3 - 3 - - - - - 2 15 Miscellaneous:— Smoke nuisance abated — 1 6 3 — — — — 2 — — - 2 - - - 14 Vacant land cleared 1 - - 3 — — — — — — — — — - - - 4 ,, ,, enclosed — - — — — — — — — — — — - - - - - Caravans removed — - — - - - - - - - - - - - - - - Stables cleansed — - — — — — — — — 2 - - - - - - 2 Overcrowding abated - - - - - - - - - - - - - - 2 2 4 Bakehouses, cleansing, (F.&W. Act 1901) — - — 3 - - 1 2 - - - - - - - - 6 Temperatures in shops — 4 — — — 2 — 2 — 4 - 2 - - - - 14 Food shops, cleansing, etc. - - - - - 2 - - - - - - - - - - 4 Shops Acts, 1912-36 - - - - - - - - - - - 2 - - - 2 4 Provide sanitary accommodation for shop employees - - - - - - - - - - - - - - - - - Common lodging-houses, cleansed or repaired - - - - - - - - - - - - - - - - 2 Total 23,225 Tents, vans and sheds. Apart from the provisions of the Public Health Act 1936 dealing with these premises, bye-laws have been made under the powers conferred by the Municipal Corporations Act, 1882. There are no approved fair-grounds or licensed campinggrounds within the borough. The chief difficulty arises from travelling showmen occupying sites in contravention of the byelaw prohibiting such action within two hundred yards of any street or dwelling house. This chiefly occurs during the winter off-season. During the year 97 visits were made. Legal proceedings were taken in 8 cases for breaches of the bye-laws. It has been generally found that the conditions of the van dwellings and of the sites they occupy are exceptionally good, and no offence has arisen apart from the breach of the bye-laws. Underground rooms. The number of such rooms in the borough is not large, and very few of those existing are occupied apart from the rooms above. They vary so much in character and facilities that it is impossible to generalise about their conditions; but it can be said that by action under the Housing Act, by means of which many have been diverted from use for living purposes, the standard has been considerably raised. Every effort is made to secure their closure, or failing that, to ensure that such rooms are not used for sleeping purposes. During the year 72 special inspections of basement dwellings were made, resulting in 39 Closing Orders being made under section 12 of the Housing Act, 1936. Nuisances. During the year 6,923 notices were served for the abatement of nuisances, in addition to which many defects were remedied after verbal representations. In respect of such notices it was found necessary to institute proceedings in 809 cases. Many people are under the impression that the department can deal with noises arising from the keeping of animals, running machinery, or loud speakers, and many complaints—verbal and written—were received of such nuisances. This department has no power to deal with any of these conditions. Verminous houses. During the year it was found necessary to serve 48 notices in respect of verminous houses, and in every case the action taken was successful. 323 Rent and Mortgage Interest Restrictions Acts, 19201933. During the year the number of certificates applied for and granted was 16. Offensive trades. There are 27 premises in the borough in which offensive trades or trades analogous thereto are carried on. These are shown in Table IV. Table IV. Offensive trades. Nature of trade. No. Fat melters and bone boilers 17 Chemical fertiliser manufacturers 1 Soap boilers 2 Gut scrapers 2 Fish meal makers 1 Tripe dressers 1 Animal charcoal makers 1 Glue makers 1 Fellmongers 1 Total 27 Supervision. All these premises are visited very frequently by the sanitary inspectors, not merely to ensure compliance with the bye-laws, but by friendly co-operation to prevent the occurrence of carelessness during the collection and handling of raw materials. The employees are encouraged to exercise care at each stage of the process. The attitude of coercion has been abandoned, and although these trades, which are usually considered very offensive, are carried on in a comparatively small area of the borough, it is now quite customary to find an entire absence of offensive odour or smoke pollution. These results were not achieved by a policy of restricting the action of the inspectors to a rigid enforcement of the bye-laws. All such factories, except one, have adopted the vacuum system of cooking. The time factor is considerably reduced by this process and it is now seldom necessary to store new material. The great benefit derived is the lessening of the fly nuisance, and it is 324 Table V. Workshops on the register . 1937. Amusement arcade 1 Laundry receiving office 17 Artificial manures 1 Leatherwork 4 Asbestos mats 1 Marine store dealer 3 Basket makers 2 Medicine packing 1 Battery-charging 4 Millinery 10 Billiards tables 1 Monumental mason 7 Boot repairs 1 Motor repairs 1 Bone boiling 1 Metal refining 1 Bread and pastry 8 Oil-blending 8 Brush makers 1 Pickle making 1 Builder's yard, contractors 13 Printers 1 Cat and dog skinning 1 Packing (provisions) 1 Clothes pressing and renovating 10 Photographers 4 Perfume 1 Confectionery 1 Posters and showcards 3 Coopers 4 Rag-sorting, scrap-metal, etc. 10 Corset making 2 Cycle repairs 6 Sacks and bags 1 Cork making 1 Safety lamps 1 Disinfectants 1 Sewing machine repairs 2 Dress-making 18 Sheet metal working 3 Dressing gowns 1 Shirt making 1 Enamellers 1 Shop blinds and shutters 1 Flavouring essences 1 Stables 1 Florists 1 Soap makers 1 Fruiterers (dealer) 1 Tailors 24 Galvanisers 2 Tile slabbing 1 Glaziers 1 Timber merchant 2 Games manufacturers 1 Waterprofing compounds 1 General engineers 10 Wire-working 1 Gut-scraping 1 Wood preservatives 1 Harness makers 1 Funeral furnishers 8 Jewellery repairs 1 Farrier 7 Joinery 18 325 remarkable how few of these pests are found in the vicinity of the factories. The system also offers better facilities for dealing with the noxious fumes generated during the cooking of animal and fish offal. This is due to the fact that the fumes are mainly discharged at low temperatures. The improved efficiency of condensers is obvious. New types of condensers are continually being tried, and two have proved very effective in still further eliminating unpleasant odours. One which employs chlorine as a deodorant is automatic in action and requires little attention. The other type employs charcoal as the deodorizer and appears to be effective. A disadvantage is its tendency to become saturated, but it is possible that this will be overcome by slight mechanical adjustment. Factories and workshops. Factories are dealt with by H.M. Inspector of Factories and Workshops and by the officers of the Borough Council. Defects in the sanitary accommodation in the case of factories, and all sanitary defects in workshops coming to the notice of H.M. Inspector of Factories are referred by him to the Public Health Department. The number of workshops, exclusive of bakehouses, on the register at the end of 1936 was 244, the number added to the register during the year was 22, the number removed was 19, and the number on the register at the end of 1937 was 247. A classification of the workshops on the register at the end of 1937 is shown in Table V. Particulars of inspections made by the sanitary inspectors during the year are set out in Table VI. During the year 11 sanitary notices were served on workshops. Table VIII is a statement of the work carried out as a result of these notices. The defects found and dealt with are shown in Table VII. 326 Table VII. Defects in factories, workshops and workplaces. 1937. Particulars. No. of defects No. of offences in respect of which prosecutions were instituted Found Remedied Referred to h.m. Inspector. *Nuisances under the Public Health Acts: — Want of cleanliness 50 56 1 - Want of ventilation 7 7 — - Overcrowding — — — - Want of drainage of floors 2 2 — - Other nuisances 34 28 1 - Sanitary accommodation: (a) insufficient 2 2 1 - (b) unsuitable or defective 21 11 — - (c) not separate for sexes — — — - Offences under Factory and Workshops Acts: — Illegal occupation of underground bakehouses (s. 101) - - - - Other offences (excluding offences relating to outwork and offences under the sections mentioned in the schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order 1921) - - - - Total 116 106 3 - * Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. 327 Table VI. Inspection of factories, workshops and workplaces. 1937. Premises. No. of Inspections. Written notices. Occupiers prosecuted. Factories (including factory laundries) 498 25 - Workshops (including workshop laundries) 359 - - Workplaces (other than outworkers' premises) 176 1 — Total 933 26 — Table VIII. Action in respect of workshops. Premises cleansed throughout 4 Roofs, guttering, etc., repaired 1 Defective flushing apparatus repaired 1 General repairs to water-closets 3 Light and ventilation provided 1 Window sashes, etc. 1 Bakehouses. There are 98 bakehouses in the borough, of which 22 are underground bakehouses within the meaning' of the Factory Act, 1901. During the year no new bakehouses were erected and none was disused. These bakehouses are inspected at irregular intervals, 230 inspections having been made during the course of the year. It was found necessary to serve 15 notices for cleansing, but generally a verbal warning was sufficient to secure the rectification of minor defects. A constant effort is made to raise the standard of these premises. This varies greatly, and the tendency is for the less satisfactory to fall gradually out of use. Restaurants and cafe-kitchens. These vary from the premises of the large multiple caterers to the small coffee stalls, and cooking arrangements are on a scale varying with the nature and size of the trade done. 328 During the year 522 visits were paid to these premises, and although the proprietors are usually amenable to advice or warning, it was found necessary to serve four notices to secure satisfactory conditions. Particular attention is paid to the cleanliness of the cooking apparatus and utensils, the storage of foodstuffs, and the disposal of waste matters. During the year these duties were performed by the women sanitary inspectors. Fried fish shops. The business of fish-frying is not scheduled as an offensive trade in West Ham, but under the West Ham Corporation Act, 1937, section 67, no premises may be used for the purpose unless they are registered. Before registration the premises are visited by the sanitary inspector, and if they are found to be unsatisfactory, registration is refused until such time as the conditions complained of are remedied. The structures of the premises and the type of apparatus used vary considerably, but great improvement in both has been effected under the advice and guidance of the sanitary inspectors. During the year the sanitary inspectors made 318 inspections. Up to the end of the year 47 such premises had been registered. Fish offal which is a potential source of nuisance on these premises is stored in impervious containers and removed by private contractors in the early hours of the morning. Most of this matter is taken to a large modern works within the borough. This firm specialises in dealing with refuse of this nature. As a result of this arrangement, in which the sanitary inspectors closely cooperate, complaints are reduced to a minimum and statutory action was not found necessary. Open markets. There are five open-street-markets in the borough. These are held in High Street and Angel Lane, Stratford; Stratford Road, Plaistow; Queens Road, Upton Park; and Rathbone Street, Canning Town. All stall holders are licensed and their refuse is removed daily by the Corporation cleansing department. Foodstuffs of all kinds are sold at a large number of the stalls, and those persons who sell meat, fish, fruit or vegetables, and the premises at which they store such commodities, must be registered under the West Ham Corporation Act, 1937, section 66. This requirement extends to street hawkers, and has proved useful in raising the standard of storage of unsold foodstuffs. The foods 329 sold are subject to constant surveillance by the inspectorial staff, a supervision which is carried on during Saturday evening by the sanitary inspectors acting in rotation. Vendors of foodstuffs are encouraged to seek the advice of the inspectors whenever they are doubtful about the wholesomeness of these commodities, and to surrender anything that is not up to the standard of fitness. Cinemas. There are 25 cinemas and 2 theatres in the borough, to which during the year, 307 visits were made by the sanitary inspectors. An annual report on sanitary conditions is made to the Town Clerk for the purposes of the Licensing Committee, and other visits are made at irregular intervals to ensure that satisfactory conditions are maintained. No statutory action has been necessary, the managers invariably being found willing to meet any reasonable request. Sale of beer in public houses. During the months of July and August, 1937, inspections were made of all the premises in the borough which were concerned with the sale of beer and other alcoholic beverages. These inspctions numbered 183, and included 123 fully-licenced premises, and 60 premises with an off-licence. In a few of the off-licenced houses the beer was drawn direct from the cask. In all other cases the liquid was drawn by pumps through pipes to taps over drip-sinks. In three cases the pumps were found to be in an unsatisfactory condition, but were subsequently remedied. The pipes were invariably found to be clean. More than two-thirds of them were made of glass or porcelain sections jointed with rubber, and many of the latter had one or more glass sections, enabling observation of the condition of pipes and contents to be made. Cleaning of pipes and pumps (without dismantling) was carried out at intervals of a week or less by drawing through them a soda solution followed by a salt solution, together with the use of pipe brushes. In many cases proprietary cleaners were used. In some instances the brewers periodically dismantle the pumps and do any necessary adjustment or repair. The drip-sinks, with three exceptions which were of glazed stoneware, were made of pewter and were generally in good condition. The majority of the washing sinks were of pewter, a 330 few of glazed stoneware, and one of hard wood, with pewter or hard wood draining boards or racks. They were all in good condition. In every case they were supplied with constant cold water, and in about half the premises with constant hot water in addition. In a few of the others a supply of hot water was available from outside the bar. Glasses and tankards were rinsed in the washing-sink and set to drain immediately after use. After closing time they were washed with a brush, drained, and polished with a cloth the following morning. In the majority of cases the waste water was carried to a gully connected to the drain, but in a few cases it was drained to the sump and pumped to the gully. A few defects in the pipes were found and rectified. The methods of dealing with waste beer varied considerably. In a few cases it was all drained to the sewer. In the majority of cases it was collected in enamel receptacles, barrelled, and returned to the brewers, whilst in others the "pull-off" and overflow from glasses of best beer was received in enamel containers, filtered into a utiliser, and re-pumped into the main stream. In every case the condition of the receptacles used was satisfactory. Invariably the temperature in the cellars was satisfactory, cooling apparatus having been installed in several cases. In a small minority of cases limewashing of the cellars was found to be necessary, and this, with a few minor defects, was remedied under verbal instructions from the sanitary inspector, notices being required in about half-a-dozen cases where defects were more serious. On the whole the condition of the premises, apparatus, and utensils of the trade in beer were found to be excellent. The premises were subject to the periodical visits of the brewers' inspectors. SMOKE ABATEMENT. The many industrial chimneys in the borough are under the constant observation of the sanitary inspectors, who by visits and advice are able to secure considerable reduction in the emission of smoke. Where this fails, notice is served upon the offending firm, and this has had the desired effect without resorting to 331 ings in court. During the year 122 definite observations were made, and 14 notices of offence given. One prosecution was taken in connection with smoke nuisance at a factory within the borough. This was withdrawn as a result of negotiations between the authority and the owners, who promised to effect many major improvements in the boiler plant. This work was carried out and since then there have been no further complaints. Considerable attention was devoted during the year to a large engineering works in the Stratford area which was referred to in the last report. About ten steam raising plants were adapted for the use of coke fuel, and greater attention was paid to the various annealing and hardening furnaces. A sustained effort was made to reduce emissions of smoke from railway locomotives to the practicable minimum, whilst engaged in working under load and on starting up after repair, or on standing at the repair works. Numerous observations were taken and the results, with engine numbers and times, have been reported to the District Locomotive Running Superintendent. The legal position in regard to railway locomotives is not free from difficulty. The Railway Clauses Consolidation Act, 1845, provides that every locomotive-steam engine used on a railway must be constructed on the principle of consuming, and so as to consume, its own smoke. The Regulations of Railways Act, 1868, provides that if the engine is so constructed as to consume its own smoke, but fails to do so through any fault of the company or of any of their servants, the company shall be deemed guilty of an offence against the earlier Act. The enforcement of these clauses is not, however, a statutory duty of the local authority, and all proceedings must be instituted by an informer, to whom half of any penalty may be paid. Usually when officers of the department institute proceedings under authority of the Local Government Act, 1933, the informations are so drafted as to incorporate the clause "acting for and on behalf of the Council of the County Borough of West Ham." This cannot be done when acting as informer—see Lake v. Smith, 1911 (76 J.P. 71)—nor apparently may the Council authorise an officer to act as informer on their behalf. The only satisfactory method appears to be for the informer to pay over to the borough fund 332 any penalty, and to rely upon the Council's promise to pay any costs involved in a contrary decision by the courts. Such a course might meet with criticism by the auditors. RAG FLOCK ACTS, 1911—1928. There are five premises in the borough in which rag flock is manufactured, and a number in which flock is used in the making of bedding and furniture. The Rag Flock Acts provide merely for the taking of samples of flock for analysis and for the prosecution of any person selling or possessing for use flock which contains more than 30 parts of soluble chlorine per 100,000 parts. The action taken in this borough goes beyond these statutory powers. The Acts are administered with enthusiasm, and the makers' premises are visited frequently but irregularly. As water for washing costs money, and the amount used is a sure indication of the makers' intention to produce a clean flock, their water accounts are examined in relation to their observed output, and every effort is made to induce makers to sell the whole of their output under warranty and in sealed bags, so that there may be no confusion at other towns with flocks produced elsewhere. Samples are taken at irregular intervals and provide a useful indication of the fallacy of the present legal standard of cleanliness using soluble chlorine as the indicator. A sample was taken of a flock consisting of new and unused sugar bags, which had been rejected by the users owing to faulty mesh. These bags had been dressed with the usual solution, tin chloride, before sale, and the resulting flock was certified to contain 82 parts per 100,000 of soluble chlorine. In these circumstances no proceedings were instituted but the makers were informed that all flocks must conform to the legal standard. No doubt later consignments consisted of rags of possibly undesirable origin, which could be washed by immersion down to the required chlorine standard. During the year 35 samples were taken for analysis, and seven of these proved to contain soluble chlorine in excess of the limit provided. Five summonses were issued. One case was dismissed on payment of forty-shillings costs, on proof that the defendant had purchased the flock elsewhere, and fines of forty shillings were imposed in each of the other four cases. 333 Table IX. Prosecutions. 1937. Statute under which prosecution taken. Result of hearing Total summonses issued. Penalties imposed Magistrate's Order to do work. Adjourned sinedie. Dismissed Withdrawn. Nuisances (Public Health acts) 112 261 2 — 412 787 West Ham Corporation Acts 1 — — — 4 5 Shops (Hours of Closing) Act 1928 5 — — 12 (on payment of costs) — 17 West Ham Grocers', General Shopkeepers' and Provision dealers' Closing Order 1919 14 - - 4 (2 on payment of - 18 Sections 116-117, Public Health Act 1875, and section 28 P.H.A.(A) Act 1890 (unsound food) 1 - - 1 - 2 West Ham Bakers' Half Holiday Order 1913 2 — — 1 — 3 West Ham Butchers' Half Holiday Order 1922 1 — — — — 1 Retail Meat Dealers' Shops (Sunday Closing) Act 1936 — — — 1 (on payment of costs) — 1 Shops (Sunday Trading Restrictions) Act 1936 8 — — 1 — 9 Rag Flock Acts 4 — — 1 (40/costs) — 5 Municipal Corporations Acts 1882 (Dwelling vans on land) - - 8 - - 8 Public Health Act and Public Health (Smoke Abatement) Act 1936 — — — — 1 (with costs) 1 Bye-laws of the Corporation of West Ham (Common Lodging Houses) 6 — - - - 6 Totals 154 261 10 21 417 863 334 It is hoped that future legislation will provide for the better control, by registration, of all rag flock factories, with power to cancel registration in cases of wilful evasion of the law. PROSECUTIONS. During the year 863 prosecutions were taken under various Acts. It should be noted that summonses listed as dismissed do not represent lost cases, but merely that the court dismissed the cases under the First Offenders Act, on payment of the Council's costs. This feature is particularly noticeable in cases taken under the various shops acts. Particulars of the prosecutions taken are shown in Table IX. 335 IX. HOUSING. V 337 HOUSING. The number of houses in the borough at the 1931 Census was 48,907, and the number of occupied houses was 48,609. In 1937 the number of houses in the borough was 50,247. The density of the population was 56 persons per acre. Particulars of the work carried out in connection with housing matters during 1937 are given in Table I. Table 1. Summary of work in connection with housing. 1937. Particulars of work done. No. dealt with. 1. Inspection of dwelling houses during the year:— (1) (a) dwelling houses inspected for housing defects under the Public Health or Housing Acts 8,903 (b) inspections made for the purpose 29,047 (2) (a) dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 271 (b) inspections made for the purpose 1,355 (3) dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 15 (4) dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 6,811 2. Remedy of defects during the year without service of formal notices:— 338 Defective dwelling houses rendered fit in consequence of informal action by the local authority or their officers 51 3. Action under statutory powers during the year:— (1) proceedings under sections 9, 10 and 16 of the Housing Act, 1936:— (a) dwelling houses in respect of which notices were served requiring repairs nil (b) dwelling houses which were rendered fit after service of formal notices:— (i) by owners nil (ii) by local authority in default of owners nil (2) Proceedings under the Public Health Acts:— (a) dwelling houses in respect of which notices were served requiring defects to be remedied 6,923 (b) dwelling houses in which defects were remedied after service of formal notices (i) by owners 6,381 (ii) by local authority in default of owners nil (3) Proceedings under sections 11 and 13 of the Housing Act, 1936:— (a) dwelling houses in respect of which demolition orders were made 18 (b) dwelling houses demolished in pursuance of demolition orders 22 (4) Proceedings under section 12 of the Housing Act, 1936:— (a) separate tenements or underground rooms in respect of which closing orders were made 39 (b) separate tenements or underground rooms in respect of which closing orders were determined, the tenement or room having been rendered fit 2 339 4- Housing Act, 1936. Part IV. Overcrowding:— (1) (a) dwellings overcrowded at the end of the year 5,698 (b) families dwelling therein 5,698 (c) persons dwelling therein 32,049 (2) new cases of overcrowding reported during the year — (3) (a) cases of overcrowding relieved during the year 66 (b) persons concerned in such cases 350 (4) Particulars of any cases in which dwelling houses have become overcrowded after the local authority have taken steps for the abatement of overcrowding nil Table II. Inspection of dwelling houses. Ward. No. of inspections made. No. of notices, served. Beckton Road 514 526 Bemersyde 350 206 Broadway 695 411 Canning Town and Grange 825 672 Custom House & Silvertown 474 422 Forest Gate 345 302 High Street 569 501 Hudsons 580 422 New Town 457 374 Ordnance 616 531 Park 259 239 Plashet Road 307 267 Plaistow 679 574 Tidal Basin 877 694 Upton 224 211 West Ham 340 313 Whole borough 8,111 6,665 340 Inspection of dwelling houses. Table II shows the number of inspections and sanitary notices served in the sixteen wards of the borough during the year 1937. (These figures do not include inspections for the purpose of testing drainage or supervising works incidental thereto.) OVERCROWDING. The provision of certificates of permitted numbers to landlords was continued and a certificate has now been supplied in respect of every working-class house. The policy of giving permitted numbers in respect of tenancies and not of houses has proved to be wise and has been continued. As tenancies change and rooms are added or otherwise, new certificates are provided. It was found possible to relieve 66 cases of overcrowding, and there can be no doubt that proceedings must be instituted in all cases where, despite the insertion of permitted numbers in rent books, occupiers sub-let, or landlords let and persons occupy, rooms in contravention of the Act. There were no prosecutions in this connection during 1937. SLUM CLEARANCE. During the year no representations of unhealthy areas were made by the medical officer of health. The slowing up of slum clearance was due largely to local difficulties presented by the Tidal Basin No. 1 Clearance Area. As these difficulties are considered to be of general importance, they are discussed more fully below. Work in connection with four other areas was held up pending the decision on the Tidal Basin case. The particulars regarding these four areas are given below:— Area No. of houses. Persons to be displaced. White Hart Cottages 6 19 Castle Buildings 11 149 Cam Road 30 122 Abbey Road 12 43 Tidal Basin Clearance Area. The decision of the Minister of Health regarding the Tidal Basin Clearance Area has been 341 erably delayed by an objection laid by an interested owner. The case was considered in June, 1937. Under section 63(1) of the Housing Act, 1935 (which has been replaced by Section 41(1) of the Housing Act, 1936), it is provided that when a person has made objection to a clearance order or compulsory purchase order on the grounds that a building included in that order is not unfit for human habitation, the Minister shall not cause a local enquiry to be held until after it has been shown to his satisfaction that the local authority have served upon the objector a notice in writing stating what facts they allege as their principal grounds for being satisfied that the building is so unfit. The first question was whether, in view of section 11 of the Housing Act, 1930 (now the second schedule to the Act of 1936— see section 29(3) of that Act), prohibition could be sought. It was agreed by the Solicitor General that it could be; but the Divisional Court did not decide this point, although they were apparently in favour of the plaintiff's contention. The decision turned on the amount of information given by the local authority. So far the case may be said to decide that the local authority are bound to give such information as might be put in a statement of claim if they were bringing an action, but not the evidence they proposed to advance in support of that claim. The forms of notice used were substantially those recommended by the Association of Municipal Corporations and separate forms were served in respect of each house. Following the decision the Inquiry was commenced by the Minister of Health on September 30th, 1937, and continued for several days. The Minister's findings had not been received by the end of the year. 342 X. MENTAL HEALTH SERVICES. 343 MENTAL HEALTH SERVICES. MENTAL DEFICIENCY. The material for this section has been largely supplied by Dr. T. W. Hill, Deputy Medical Officer of Health, who is responsible for this work in the area, and to him I am indebted for his interest in the welfare of the defectives and in the progress of the Authority's scheme. Statistics. On 31st December, 1936, there were 757 defectives on the register. During the year 1937 the number of new cases dealt with was 59, and the number of cases removed from the register was 24. On 31st December, 1937, the number of defectives on the register was 792. Distribution of defectives. The manner in which the defectives who were on the register at the end of the year had been dealt with is shown in Table I. It will be seen from the above table that 245, or 30.9 per cent., of the total number of defectives on the register are receiving institutional care and training, while 547, or 69.1 per cent., are being cared for in private homes. While the number of cases in institutions at present is approximately one-third of the total cases on the register, this is not a true indication of their needs, since if sufficient accommodation were available the number of patients receiving institutional care and training would be considerably increased. New cases dealt with. The method of disposal of the new cases who came to the notice of the local authority during the year is shown in Table II. Of the 59 cases which were placed on the register during the year, 33—21 males and 12 females—were notified by the local education authority under section 2(2) of the Act of 1913. The source of information in respect of the remaining cases was as 344 Table I. Distribution of defectives. Males. Females. Total. Number in institutions under order 138 106 244 Number on licence from institutions 22 11 33 Number under guardianship under order - 6 6 Number in "places of safety" — 1 1 Number under statutory supervision 233 275 508 Total 393 399 792 Table II. Disposal of new cases. Males. Females. Total. Recommended for institutional care 15 15 30 Recommended for supervision at home 17 12 29 Total 32 27 59 Table III. Removals from register. Males. Females. Total. Removed to other areas 8 5 13 Died 8 3 11 Total 16 8 24 345 follows:—Public Assistance Officer, 14 cases (6 males and 8 females); removals from other areas, 3 cases (one male and 2 females); local police court, one male; Board of Control, one male; local hospital, one female; Maternity and Child Welfare Committee, one female. In addition, 6 cases—2 males and 4 females—were cases who had been under friendly supervision. Removed from register. Table III shows the reasons because of which 24 cases were removed from the register during the year. Particulars of the cases shown in the above table as having removed from West Ham were forwarded to the area to which the defective had removed. Of the 8 males and 3 females who died, the cause of death in each case was as follows:—Males: broncho-pneumonia, 1; bronchiectasis, 1; hypostatic pneumonia and spastic paraplegia, 1; lobar-pneumonia and severe epilepsy, 1; Little's disease and idiocy, 1; bronchitis and cardiac failure, 1; acute enteritis, bronchopneumonia and pseudo-hypertrophic paralysis, 1; heart failure, fatty degeneration and chronic constipation, 1. Females: Intestinal statis, 1; meningitis and cystitis, 1; status epilepticus, 1. Continuation orders. During the year 70 Continuation Orders were received:—For five years: males, 24; females, 25; total, 49. For one year: males, 12; females, 9; total, 21. Work of this section. Ascertainment. The number of mental defectives dealt with for the first time during the year was 59. In addition to these, 16 cases (8 males and 8 females) were investigated but proved to be not certifiable at present. Of these 14 (7 males and 7 females) were cases who were allowed to leave the special schools between the ages of 14 and 16 years in order that they could take up employment. These cases are kept under friendly supervision until the age of 16 years, when they are re-examined and placed on the register if found certifiable. Of the other two cases (one male and one female) the female was reported by the police, having appeared before the court charged with petty larceny, and the male was reported by his employer. Both of these cases were definitely not certifiable under the Mental Deficiency Acts. The case reported by his employer was, however, drafted to the Psychological Clinic for treatment. 346 Many difficulties are met in the carrying out of this duty, as in many cases the parents either refuse to recognise their child's mental condition or endeavour to hide the fact. These cases are specially visited by the supervising nurse, who usually succeeds in overcoming the scruples of the parents and persuading them to carry out the advice given. The types of cases dealt with are as follows — (a) Feeble-minded persons. Included in this grade there were 21 males and 19 females, of whom 3 males were admitted into institutions. With regard to their physical condition, 2 males were epileptic, and one male and one female were paralysed. (b) Imbeciles . These numbered 11 males and 7 females, of whom one female was admitted to an institution. Regarding their physical condition, one male was paralysed, one male and one female suffered from epilepsy. (c) Moral defectives . One moral defective—a male—was dealt with during the year. He was physically sound and was admitted to an institution. (d) Licence. During the year 7 patients (2 males and 5 females) were granted licence, 2 females were recalled from licence, and one female was discharged. One of the cases was recalled to the institution at the request of the mother and the other because she had been found to be pregnant. There are 33 cases—22 males and 11 females—on licence, of whom 17—12 males and 3 females—are residing within the borough. The remaining 16—10 males and 6 females—are placed in private homes outside the borough. The latter cases were placed outside the borough because they had no suitable home in West Ham. Among the cases on licence, 13—11 males and 2 females—are in regular employment and making good progress. The others are behaving quite well and giving no trouble. Supervision. On 31st December, 1937, there were 508 patients under supervision at home. In addition there were 17 patients — 12 males and 5 females — on licence from institutions and residing within the borough. These cases are visited at varying intervals by the visiting nurse according to the circumstances of the individual case. The parents are advised as to the best methods of training and caring for the patient, and endeavours are made to assist him in every possible way. Since a large number of cases have to be visited, very little time can be given.to individuals, but 347 it is remarkable how well they respond to the assistance given. It would be of great benefit if there was a centre at which the higher grade and able-bodied cases could attend for specialised training. In the majority of cases these visits are welcomed, but in a few instances, generally in the case of the higher grade feebleminded defectives who are at work, resentment is felt against this visiting. Generally in these cases the parents consider their children to be normal, and feel that supervision casts a stigma on them. Although in many instances the homes of the defectives are poor, in most cases the parents care for the patients to the best of their ability. Institutional accommodation. General. The number of West Ham mental defectives detained in institutions under Order is 244. Of these 96 are in South Ockendon Colony and 55 in Forest Gate Hospital. The remainder are in various outside institutions. South Ockendon Colony and Forest Gate Hospital are both under the control of this Council, but approximately one-third of the beds at South Ockendon Colony are allocated to patients from the County Borough of East Ham, while a proportion of the beds at Forest Gate Hospital are allotted to patients from the County Borough of East Ham and Essex County Council. Great difficulty is still being experienced in obtaining beds for mental defectives in suitable institutions owing to the lack of accommodation, but this will be very largely overcome when the present extension scheme which is in progress at South Ockendon is completed. (a) South Ockendon Colony. The present accommodation at South Ockendon consists of 134 beds—44 beds for male adults, 30 for female adults, 40 for male children, and 21 for female children. The extension scheme at this Colony is now nearing complc tion, and the new buildings will probably be ready for occupation in the summer of 1939. The scheme as approved will provide facilities for training and care of an additional 340 patients of various grades. In the Colony there will be three villa blocks, each accommodating 60 adult male patients, one villa block for 60 adult female patients, one villa block for 50 male children and one for 50 female children, together with male and female 348 shops, laundry, boiler-house, central kitchen, recreation hall, with offices, nurses' home, medical superintendent's house, administration block with matron's quarters, and 12 staff cottages. These additional buildings, with the existing three villa blocks, will provide accommodation for 520 patients in all. It is hoped that this will suffice to provide for all cases from West Ham and East Ham, although facilities are available for further extensions if necessary. (b) Forest Gate Hospital. This hospital is approved by the Board of Control for the reception of 75 mental defectives—20 male adults, 30 female adults, 10 male and 15 female children. At present 82 mental defectives are detained under Order in this hospital; of these 55 are West Ham patients. South Ockendon Colony. Report by Miss W. S. Butler, S.R.N., R.M.P.A., Matron-Superintendent. On 31st December, 1937, there were 146 patients on the register, namely, 67 male adults, 45 female adults, 26 male and and 8 female children. During the year one male adult, one female adult, 6 male and one female children were admitted to the colony, while 4 patients were transferred—one adult male to Forest Gate Hospital, one female adult to Cell Barnes Colony, and one female adult and one male child to Rampton State Institution. One patient—an adult female—was discharged, and 3 patients died—2 male adults, one from pneumonia, and one from status epilepticus; and one female adult from acute bronchitis. There are 15 patients on licence to parents and guardians, 10 male adults, 3 female adults, and 2 male children. The progress reports relative to these patients have all been very satisfactory. Health. Early in the year an epidemic of scarlet fever, which commenced during the previous November, affected three male and eight female patients. These cases were treated at the Isolation Hospital, Plaistow, and the East Ham Isolation Hospital, and all made a good recover)'. During February, 69 patients and the majority of the staff suffered from influenza. All recovered. During the year two female patients were treated at Whipps Cross Hospital for acute rheumatism, and one female 349 patient for carcinoma of the breast. One male patient died of status epilecticus at the Colony, and one female patient of acute capillary bronchitis. I regret to report one fatal accident. A young lad, while working at the farm, slipped into a pond. He was admitted to Whipps Cross Hospital, but he died of septic pneumonia the following day. Employment. All the patients continued to be usefully employed. The carpentering section, with the aid of the nursing staff, has built a sports pavilion. All the boots and shoes at the Colony are mended exclusively by the patients. The sewing room turned out 3,422 new articles. The new knitting machine produced 480 pairs of men's and children's socks. The small girls learned to weave most attractive articles. Recreation. The scout and guide troops, and the cub pack, continue to flourish. During a fortnight in July, 15 scouts held a summer camp at Clacton. The Guide Captain having succeeded in obtaining the necessary Camp Mistresses' Certificate, the guides were able to hold a camp in Thorndon Park, Brentwood. Both camps were a great success. The annual Sports'Day was blessed with glorious weather, and again we were honoured by the presence of Her Worship the Mayor and many Aldermen and Councillors. In honour of the Coronation 86 of the higher grade patients went by coach to Dovercourt and enjoyed a day of fine weather. A week later the remainder of the patients went for a coach ride to Eppitig Forest and held a picnic in the grounds of Harold Wood Hospital. Christmas Day was celebrated in the traditional manner. The dense fog prevented the arrival of an entertainer who had been engaged, but this in no way damped the festivities, as the staff gave an impromptu entertainment. Her Worship the Mayor honoured us with a visit on the 30th December, and she was loudly cheered on her tour through the wards. Periodically the higher grade patients visited the cinema at Grays and the children attended special Saturday morning children's programmes at Upminster. Foundation stone. On 28th October, 1937, the foundation stone of the extensions was laid by Her Worship the Mayor. The ceremony was attended by a large and representative 350 ing of councillors from several boroughs, together with the chief officials of West Ham. Miss Darwin, a Senior Commissioner of the Board of Control, honoured the occasion with her presence. Visits to the institution. On the 23rd April, 1937, a visit was paid by members of the Board of Control. In conclusion I would like to express my gratitude for Dr. Hill's unfailing guidance and support, and for the devoted loyalty and willing co-operation of all the staff. Forest Gate Hospital. Mental Defective and Epileptic Section. Report by H. R. England, m.b., m.s.a., Medical Superintendent. The approximate number of beds provided for patients who are mentally defective, or who are both mentally defective and epileptic, is 453. The number of such patients in the hospital was invariably in excess of the number of beds provided. Overcrowding exists in all the wards, but owing to the lack of adequate accommodation every effort is made to limit the admission of this class of patient. Only a partial success is achieved in this direction. Although the local authorities of West Ham and East Ham request the admission of cases of extreme urgency only, a large number have to be admitted, irrespective of accommodation being available, through the relieving officers and by transfer from other institutions. This is the method by which all Essex County Council cases, without exception, are admitted. Thus it will be seen that considerable difficulties stand in the way of the prevention of continued overcrowding. The following is a classification of patients in residence on 31st December, 1937. Degree of defect. Male. Female. Total. Feeble-minded 94 108 202 Imbecile 49 128 177 Idiot 19 26 45 Total 162 262 424 351 In addition to the above, there are 42 sane epileptics—11 males and 31 females—in residence. It should be noted that the classification of these patients is only approximate. A large number of them are elderly and would be unsuitable for admission to a mental defective colony. Mental Deficiency Acts, 1913-27. The hospital is approved by the Board of Control for the reception of 75 certified mental defectives, as follows:—Adult males, 20; adult females, 30; males under 16 years, 10; females under 16 years, 15. On 31st December, 1937, the number in the hospital was: adult males, 32; adult females, 35; males under 16 years, 11; females under 16 years, 7; total, 85. During the year 2 male adults and 2 male juveniles were admitted to the hospital, 2 male adults were discharged, 3 male adults were transferred—one to South Ockendon Colony, one to the Royal Hostel, Godalming, and one was placed under guardianship. One male adult patient died, the cause of death being Little's disease. There are two patients on licence from other institutions, one male adult from South Ockendon Colony, and one female adult from the guardianship of her mother. Three patients are 011 licence from the hospital—one male adult and 2 female adults. On 31st December, 1936, there were 4 patients—3 male adults and one female adult—in the hospital under section 15 of the Act. During the year 10 cases were admitted under this section—5 male adults, 3 female adults, and 2 male children. These were dealt with as follows:—Orders obtained for 2 male adults who were transferred to Stoke Park Colony; 2 male adults discharged to parents; 2 female adults transferred to South Ockendon Colony under Order; 2 male children detained at the hospital under Order ; one female child discharged to care of parent; and one remained under this section. On 31st December, 1937, the number of patients in the hospital under this section was 5—one male adult, two female adults, and 2 male children. An outbreak of scarlet fever occurred during the year and 4 certified cases were involved—one male adult, one female adult and 2 male children. They all recovered after treatment in the Isolation Hospital, and were returned to this hospital. 352 During the year 1937, 78 patients—28 males and 50 females—were certified under the Lunacy Acts (Section 24), 2 female patients were removed under this Act, one died from carcinoma of the stomach, and one was discharged to the care of her son. Employment. All the patients are usefully employed in a suitable form of occupation therapy. During the year a daily average number of 42 patients worked at the morning session and 72 in the afternoon session in the female handicraft centre at such occupations as needlework (including fancy needlework), rugmaking, ward linen mending. There were also 14 female patients working under supervision in the laundry, and a further number engaged in various forms of ward work. The male patients, numbering approximately 98, were employed in such occupations as boot repairing, brush making, gardening, stores duties, and general cleaning work under the supervision of the head male attendant. Great difficulty was experienced in finding a suitable form of occupation for the low grade imbeciles. An average daily number of 24 children attended the school for mental defectives attached to the hospital. Recreation. Scout and guide troops have been in existence at Forest Gate Hospital for a number of years. Great interest is shown in these organisations, which stimulate physical exercises and games in the evenings. The scouts had their usual annual camp at Hatfield Broad Oak, and the guides had their camp at Battle, Sussex. Both camps were thoroughly enjoyed, and as the weather was excellent the patients who were privileged to attend the camps returned bronzed and much benefitted by their holiday. Both camps were visited by the Chairman and Members of the Public Assistance Committee. A special word of praise is due to the matron (Mrs. E. M. Usherwood), Mr. Rendell (head male attendant), and Mr. Stanton (barber attendant), for their work and interest during the year in connection with the guide and scout troops. The hospital has a brass band which was formed several years ago. This affords an excellent hobby for an average of 16 male patients, including 3 certified under the Mental Deficiency Acts, and 7 members of the male staff, during the year. The band is highly successful, and attends the annual outings of the male and female patients of the hospital and the outings of the patients 353 w of the Central Home and Forest House. In addition, during the winter, band concerts with male patient artists are arranged each month, at which all the male and female patients who are able to do so attend. These concerts are very popular and are eagerly looked forward to by the patients, and the entertainment given is very good. During the Christmas festivities a female patients' dance is arranged and the hospital band provides the dance music. The band is under the direction of Mr. Mason, the head gardener. Mr. Mason is deserving of special mention for his work in this direction. The work he undertakes in connection with the running of the band is purely voluntary, and is done in his own time. The main dining hall is fitted with a sound apparatus, and every Friday evening during the months October to March, a two-and-a-half hours' film show is given. This is attended by the made and female patients with the appropriate staff in attendance, and is eagerly looked forward to each week. In addition, the patients, in the care of members of the stall", are permitted to attend a cinema outside the hospital once each week. They usually attend in parties of 25 to 30. The female patients are also permitted to take exercise walks outside the hospital for the purpose of shopping. These outings are much appreciated, and are beneficial to the patients. During the year a large number of the patients were allowed out on holiday leave in the care of their parents. Denial treatment. The hospital is visited weekly by the dentist, and cases referred by the medical officers are dealt with by him. Psychiatrist. During the year the services of a visiting psychiatrist were approved, and this has proved a great help in dealing with the difficult cases. Dr. Somerville, Medical Superintendent of the West Ham Mental Hospital, or one of his assistants, acts in this capacity. PSYCHOLOGICAL CLINICS. Reference has been made in previous annual reports to the West Ham Nerve Clinic which was opened six years ago as a centre at which preliminary investigation could be made into minor nervous disorders, either with a view to the treatment of the patient at the clinic or to facilitating his admission to the 354 mental institution as a voluntary patient. The clinic speedily began to serve a useful purpose in dealing with behaviour problems in children. I am glad to be able to include a report on the activities of the clinic. Report on the West Ham Nerve Clinic. By George Somerville, m.d., d.p.h. During the year ended 31st December, 1937, 70 new cases were treated at the West Ham Nerve Clinic. The majority of these were sent for diagnosis and disposal. A limited number were treated psychologically at the clinic. The number of psychological interviews which were held was 354. Two cases were treated by the analytical technique. In one case the treatment extended over a period of more than forty-eight hours, and in the other cases of thirty-two hours. Good results were obtained in both these cases. Up to the present the clinic has been held on Wednesday and Saturday mornings at 11 o'clock, but, from now on, the times have been changed to 3 p.m. on Mondays and Wednesdays, as it has been found that the other times were inconvenient to a great number of patients. In future, we will therefore be able to spend more time with the patients. This will be of great advantage, as the work of the clinic is steadily increasing. We hope during the next year to improve the amenities of the clinic and to extend the services. We have to thank the doctors of West Ham and the staffs of the Public Health Department and welfare centres for their co-operation. We think that on the whole our most useful work has been done in consultation with general practitioners, who refer to us cases of early mental disorder for diagnosis and suggestions for treatment. In all such cases, a report has been sent to the doctor and, where advisable, the patient has been encouraged to go into the mental hospital on a voluntary basis, or else he has been referred to the observation ward at Whipps Cross Hospital. Twenty-three cases in all came to the Mental Hospital after visiting the clinic, 18 coming in directly from the clinic as voluntary patients. In 3 cases of definite mental disorder the patients or their relatives refused the advice given, but in each of these cases very full letters of advice were sent to the doctors concerned, with suggestions for management in the home. 355 Fourteen cases of psychological disorder in children were referred to the clinic. Nine of these were sent to the London Child Guidance Clinic, the West End Hospital Child Guidance Clinic, or the East End Child Guidance Clinic, either for intelligence testing, or for more specialised treatment than is possible at our clinic because of the absence of a social worker and an intelligence testing department. Four cases of congenital mental defect of such an order as to require institutional treatment were seen and appropriate instructions were given to the relatives. It is interesting to note that in six cases sent to us the trouble was physical, and these patients were referred to general hospitals for pathological investigation and treatment. We have heard from three of these patients, and they have derived considerable benefit from the treatment of their physical condition. Appended is a summary of the cases dealt with. Work of the West Ham Nerve Clinic. Types of mental illness. Psychoses— Schizophrenia 6 Paranoia 2 Cyclothymia 14 Cerebral arteriopathy 2 Epilepsy 3 General paralysis of the insane 2 — 29 Psycho neuroses,— Anxiety states 4 Compulsion 2 Hysteria 2 Neurasthenia 4 Sex abnormality 1 Various neuroses and organic states 14 — 27 Behaviour problems and maladjusted children— Behaviour disorders 3 Morbid fears 2 Tantrums 3 Eneuresis 2 Congenital mental defect 4 — Total 70 Cases recommended to the mental hospital as voluntary patients 23 Actually admitted as voluntary patients 18 356 XI. SCHOOL MEDICAL SERVICE. 357 SCHOOL MEDICAL SERVICE. SUMMARY OF MAIN STATISTICS, 1937. Population of borough (mid-year estimate) 259,500 Elementary schools:— Number of schools 63 Number of departments 162 Average number on registers 457 Average attendances 36,082 Schools for higher education:— Number of schools 6 Number of departments 6 Average number on registers 2,123 Average attendance 1,963 Special schools:— Number of schools 10 Average number on registers 773 Average attendance 610 Work of the assistant medical officers:— Number of completed visits to schools 97 Number of half-days devoted to school inspection 1,150 Number of children examined at routine inspections 16,911 Number of children examined as "Specials" 16,149 Number of re-examinations in schools Number of re-examinations at clinics 8,049 Work of the dental surgeons:— Number of children examined 23,387 Number of children treated 10,383 Total attendances at the dental clinics 17,301 Work of the school nurses:— Number of visits to schools 1,531 Number of children visited in schools 4,499 Number of home visits 11,013 Number of inspections with reference to cleanliness 79,476 358 INTRODUCTORY In general it may be said that the school medical service in West Ham provides for all the requirements which are laid down by the Board of Education, and that in certain directions institutions have been established which can with justice be claimed as models for other authorities. Detailed reference is made elsewhere in this section to the work which is carried out at the residential open-air school at Fyfield, and in my next annual report I hope to give a full description of the new deaf centre which was recently opened in Tunmarsh Lane. The Authority may well take pride in these institutions. The routine work of the section, if less spectacular, is nevertheless fundamentally sound, and it should not be forgotten that the number of complaints and defects which are dealt with in the course of this routine work is immeasurably greater, and this work consequently more important, than the special methods which serve to attract the attention of many who are ignorant of basic principles. During the course of the year no changes were introduced in the methods of routine inspection and the general conduct of treatment. It is evident from the observations of certain school medical officers of repute that some doubt exists regarding the desirability of confining inspection rigidly to routine examinations at the three chosen age-periods, but the detailed consideration of the local effects of such a change will require time. For the detailed work of the school medical service Dr. Robert J. Reid, the Chief Assistant School Medical Officer, is responsible. SCOPE OF THIS REPORT This report is divided into nineteen parts, as follows:— I. School population. II. Staff. III. Co-ordination of the health services. IV. Hygiene of school premises. V. Medical inspection. VI. The findings at medical inspection and results of treatment. VII. Special treatment services. VIII. Following-up. 359 IX. Infectious diseases. X. Open-air education. XI. Physical training. XII. Provision of meals. XIII. Co-operation of parents, teachers, school ance officers and public bodies. XIV. Blind, deaf, defective and epileptic children. XV. Higher education for defective students. XVI. Nursery schools. XVII. Secondary schools and other institutions of higher education. XVIII. Parents' payments. XIX. Miscellaneous. I. SCHOOL POPULATION. The number of children on the elementary school registers on 31st December, 1937, was 41,571, as compared with 43,970 on 31st December, 1936. These children, together with children who attended institutions for higher education and special schools, were distributed as in Table I. The average attendance of children at elementary schools for the year ending March 31st, 1937, was 36,082. This figure does not include attendances at open-air, nursery, and special schools maintained by the Authority. The estimates of the "school population" of elementary schools at each year since 1920 are set out in Table II, together with the percentage increase or decrease each year, calculated on the population for the previous year. The estimates for the school population at each year are those given by the Chief Medical Officer of the Board of Education in his annual reports. It will be seen that the school population has been falling steadily since 1922, and that in recent years there has been an acceleration of the rate of decrease. The total decrease since 1922 has been equivalent to 16,930 school children, which gives an average annual decrease of 1,129 on 1922 figures. II. STAFF. The staff is set out on pages 12 to 17 of this report. Apart from my appointment as School Medical Officer, there have 360 Table I. Distribution of school population in 1937. Type of School. No. of schools. No. of departments. No. on registers. Elementary:— Provided 49 134 35,600 Central 2 2 768 Non-provided 12 26 5.203 Higher:— Maintained 4 4 1,769 Part-maintained 2 2 354 Special:— Mental defectives 2 2 155 Physical defectives 2 2 108 Deaf 2 2 71 Nursery* 2 2 240 Open-air (day) 1 1 58 „ (residential)† 1 1 141 Total 79 178 44,467 These figures refer only to those nursery schools under the administration of the Authority. † This school was extended to 200 beds in June, 1937. Table II. School population. Year School population. Increase(+)or decrease (—) percent. Year School population. Increase (+)or decrease (—) percent. 1920 52,306 — 1929 47,278 -3.39 1921 52,678 + 0.71 1930 46,511 — 1.62 1922 53,012 + 0.63 1931 45,911 — 1.29 1923 52,995 — 0.00 1932 45,282 - 1.37 1924 51.135 - 3.51 1933 44,72o - 1.24 1925 50,653 - 0.95 1934 43,227 - 3.34 1926 50,279 - 0.74 1935 40,625 — 6.02 1927 49,660 - 1.23 1936 38,434 - 5.39 1928 48,939 - 1.45 1937 36,082 - 6.46 361 been few changes during the year. Miss I. Cox and Miss E. Holly were appointed as school nurses in January, 1937, to fill the vacancies caused by the retirement of Miss L. F. Manning and the transfer of Mrs. C. B. Halls to the Knox Road and CrosbyRoad Special Schools, consequent on the retirement of Miss E. Eraser. During the year eight members of the staff were absent, through illness for a period of one month or over. No temporary assistance was necessary except at the Fyfield Open-air School, where Miss L. Shepherd was appointed to assist on the nursing staff during the holiday period. Nurse Taylor, of the school medical staff, was also drafted there temporarily in the early part of the year, while the matron was away on sick leave. III. CO-ORDINATION OF THE HEALTH SERVICES. "Co-ordination" as a name may be used so frequently as to be virtually a shibboleth as a practice, if it is to be effective it should be exercised as completely as possible. In West Ham it may be said that co-operation between the various sections of the health services is practised extensively, but that the co-ordination of the school service with the health services generally, in so far as the fusion of staff and clinic premises are concerned, has not yet been effected. With reference to the practice of co-operation, it may be said that the School Medical Officer is also Medical Officer of Health and Chief Tuberculosis Officer, and that in this way a united control of the various clinical services is attained. It should however be remembered that the co-ordination of the personnel ought to apply to assistants as well as to the head of the department. The true advantages of co-ordination can only be achieved if those officers who have to examine and treat the school child are able at times to engage practically in work which is somewhat outside their own particular field. There is no doubt that the complete pooling of the resources of an Authority, so far as personnel and premises are concerned, has long had considerable support in official circles. For example, Sir George Newman wrote in 1928 "It would be inexpedient, and indeed wasteful, for an Education Committee to establish a properly equipped clinic for children of school age and a Health 362 Committee another one in an adjoining street for children under school age. It is obvious that there should be economic use of medical, surgical and dental clinics, of dispensaries, of X-ray or artificial light installations, of maternity and child welfare centres, of disinfecting stations, etc. Similarly, there should be appropriate employment of technical staff, doctors, dentists, consultants, school nurses, health visitors and sanitary inspectors, whatever Committee of the Authoritv be responsible for their appointment and the discharge of their major duties." Since these words were written the principle of complete co-ordination has been successfully carried out by many authorities, with a resultant increase in the experience and enthusiasm of the members of the respective staff, and an economic advantage to the authorities themselves. IV. HYGIENE OF SCHOOL PREMISES. During the year no new departures were introduced in connection with the hygiene of schools, but various minor improvements were effected in many schools. Any structural defects or matters relating to the heating, lighting, and ventilation of school premises are referred to the Authority's architect-J. H. Jacques, Esq., F.R.I.B.A.—to whom I am indebted for the following particulars. At Three Mills School a central heating system was installed, and a new dining room was provided for the children. At Elmhurst Road and Hilda Road Schools the latrines were remodelled and modernised. Domestic hot water was installed at Grange Road, Tunmarsh Lane and Gainsborough Road Schools. At Cave Road, Credon Road, Drew Road, Odessa Road and Silvertown Infants' Schools the obsolete lavatory basins were removed, and lavatory troughs with spray taps were installed. In the sphere of personal hygiene emphasis continued to be placed on the necessity for keeping the body clean. In the matter of cleanliness, habits can be inculcated at school which are of value in adult life, and it must be said that every encouragement is given to the children to use the baths which are installed in many schools. For example, at five schools, viz., Gainsborough Road, Rosetta Road, South Hallsville, Pretoria Road and Tollgate, spray baths are provided, and selected children are taken during school hours, with the consent of their parents, to the Corporation slipper baths 363 at Romford Road, Balaam Street, Plaistow Road, Siivertown and Fen Street. In addition, school children made 33,846 attendances at the Corporation's washing baths during the year—20,039 of these attendances having been made by boys and 13,807 by girls. V. METHODS OF MEDICAL INSPECTION. The current practice of routine examination of children in schools is based on the provisions of section 17 of the Board of Education (Special Services) Regulations, (18th August, 1925). This section makes it incumbent upon the authority to provide for the medical inspection of all children in public elementary schools as soon as possible in the twelve months following (a) their first admission into public elementary schools, and (b) their attaining- the age of eight years, and (c) their attaining the age of twelve years. During the year there was no departure from the practice of carrying out the routine examination of all children in the three code age-groups. For practical purposes these are interpreted as follows:— (a) children admitted to school for the first time during the year (entrants). (b) children of eight years of age (intermediates). (c) children who are expected to leave school, and who have not been previously inspected since they attained the age of twelve years (leavers). The borough is divided into five sections for the purpose of school medical inspection. Each section is served by a school clinic, which is the headquarters of an assistant school medical officer, a school dentist, and a staff of nurses. The schools in each area are visited in rotation, and the head teachers in each school send out notices informing the parents when to attend for the medical inspection of their children. Those children who are absent are examined at a later visit. Owing to the absence of adequate rooms in which medical inspection can be carried out, arrangements have had to be made for the inspection to be held in other premises in certain cases. 364 The following table gives the names of these schools and the premises which are used for inspection. School. Premises used for medical inspection Clarkson Street Public Hall, Canning Town St. Margaret's Public Hall, Canning Town Holy Trinity Public Hall, Canning Town St. Luke's The Boyd Institute, Tidal Basin St. Francis' Wesleyan Hall, The Grove, Stratford St. Paul's Mechanics' Institute (L.N.E.R.) Colegrave Road Mechanics' Institute (L.N.E.R.) Rosetta Junior Bancroft Hall, Custom House St. James' Hanford Memorial Hall, Forest Lane St. Antony's St. Antony's Hall, Forest Gate In addition to the routine medical examination of children at schools, "special" examinations are carried out where necessary. These "specials" may be classified as follows:- (a) children who do not fall within the three code agegroups, but who are examined at the school at the request of the head teacher during a routine visit; (b) children who are sent by head teachers to the school clinics for the treatment of minor ailments; (c) healthy children—classified as "other routines"—who are examined specially to decide their fitness for sport, for camp life, for school journeys; children may also be examined to decide their fitness for certain types of employment; (d) other children who are referred in any way to the School Medical Officer for examination, advice, or treatment; (e) children who are examined for the purpose of the compilation of a census of exceptional children (see Table III. of Appendix to this section). During 1937 the number of visits to schools for the purpose of routine inspection of children—each completed inspection of the whole of the children in the code age-groups in the school counting as one visit—was 97*. The number of children examined as "routines" and "other routines" was 14,340, of whom 7,208 were boys and 7,132 girls. This figure represents an increase of 615 over the corresponding figure for the previous year. The details of these figures are given in Table III. The figures given in sections V to XVI of this report relate to elementary schools only. 365 Table III. Routine inspections. Code group Boys Girls Total Entrants (within 12 months of admission) 2,154 2,256 4,410 Intermediates (8 years) 2,090 1,852 3,942 Leavers (over 12 years) 1,999 2,068 4,067 Other routine inspections 965 956 1,921 Total 7,208 7,132 14,340 In addition to the above, special inspections, as defined above, were made on, 16,062 children, of whom 8,690 were boys and 7,372 girls. This figure represents an increase of 46 on the corresponding figure for the previous year. Details of these special inspections, and of re-inspections, are given in Table IV. Table IV. Special inspections and re-inspections. Boys Girls Total Special inspections (a) in schools 349 458 807 (b) at clinics 8,341 6,914 15,255 Totals 8,690 7,3 72 16,062 Total re-inspections — — 7,452 The variation in the numbers of routine examinations, special examinations, and re-examinations during the last ten years are shown in Table V. The rates which are given in this table bring out the interesting feature that, while there has been no significant variation in the proportion of children who are examined at routine inspection, there has apparently been a slight increase in the proportion who are examined as "specials". Reference has already been made to the fact that in certain quarters there is a feeling that the time-honoured method of 366 detecting children who require treatment-namely, by routine medical inspection at long-term intervals in the school life of the Table V. Routine and special inspections. Year School population (*) Routine inspections. (†) Special inspections. Re-inspections. No. Rate percent. No. Rate percent. 1928 48,939 19,861 40.6 17,334 35.4 7,069 1929 47,278 17,071 36.1 15,654 33.1 7,335 1930 46,511 17,516 37.7 15,508 33.3 7,966 1931 45,911 18,807 41.0 9,843 21.4 9,825 1932 45,282 19,837 43.8 17,420 38.5 9,965 1933 44,720 17,164 38.4 18,593 41.6 7,451 1934 43,227 14,558 33.7 15,776 36.5 6,638 1935 40,625 15,440 38.0 15,609 38.4 7,243 1936 38,434 13,725 35.7 16,016 41.7 5,733 1937 36,082 14,340 39.7 16,062 44.5 7,452 (*) The "school population" is that given by the Chief Medical Officer of the Board of Education in liis Report for the year indicated. (†) Includes "other routine inspections." Table VI. Defects found which required treatment. Year At routine examination At special examination. No. Percentage.* No. Percentage.* 1928 6,424 13.1 13,178 26.9 1929 4,095 8.7 13,711 29.0 1930 4,513 9.7 13,880 29.8 1931 5,456 11.9 13,432 29.3 1932 5,164 11.4 14,986 33.1 1933 3,614 8.1 14,927 33.4 1934 3,001 6.9 14,978 346 1935 2,774 6.8 15,327 37.7 1936 2,600 6.8 15,863 41.3 1937 2,802 7.8 17,177 47.6 * The percentages in these columns are calculated on the school populations given in Table V. individual—has perhaps outlived its usefulness. There is no doubt that this method has given good results in the past, but 367 there is some evidence that under present day conditions it is perhaps somewhat wasteful. For example, Table VI shows the number of defects which were discovered on routine examination and at special examinations respectively for the ten years 1928— 1937. The table also shows those figures expressed as percentages of the school population for each year. This table brings out quite clearly the fact that routine inspections are becoming less and less fruitful of results as the years pass, while the number of defects which are discovered as a result of special examinations is increasing steadily. In fact, the proportion of defects found at special examinations per 100 of the school population in 1937 was 77.5 percent, greater than the corresponding figure for 1928. When account is taken of the fact—as is shown in Table V—that during this period there has been only a slight increase in the proportion of children who arc examined as "specials", this increase in the positive findings at examinations is remarkable. It can hardly be that doctors are more efficient at spotting defects. The only other alternative which seems to merit serious consideration is the suggestion that teachers are becoming more adept in recognising those children who should have a special examination. A casual inspection of treatment tables for a series of years will show that the bulk of the defects which are discovered at routine examinations is made up of cases of visual defects, squint, enlarged tonsils and adenoids, otitis media, anaemia, and simple lung diseases. When these conditions—which, with the possible exception of diseases of the throat and nose, can often be suspected by a nurse or a teacher—are excluded, little remains, and the question arises whether it is economic to ask a doctor to devote a considerable proportion of his time to the detection of the residue by routine examination. The School Medical Officer of Manchester has expressed his dissatisfaction with the existing procedure, and he has suggested that the lime of the school doctor would be better employed in schools if the present system of routine medical inspection were made less rigid and severe, so that the doctor could, by more frequent attendance at his schools, pass under review any child who appeared to merit his attention. A similar scheme has been tried unofficially with considerable success by the School Medical Officer of Leicester. The results which have emerged regarding 368 the efficiency of routine examination in West Ham have not served to alter my opinion that some modification of the present system might give better results. VI. THE FINDINGS OF MEDICAL INSPECTION AND RESULTS OF TREATMENT. The following sections deal with groups of diseases, and for convenience the arrangements for treatment and its results are discussed under each condition. General Discussion of the Findings on Inspection. Of the 14,340 elementary school children who had routine inspections in schools, 2,605, or 18.1 percent. were found to require treatment (excluding uncleanliness, malnutrition, and dental disease). The percentages of children in the three prescribed age groups who required treatment are given in Table VII. Table VII. Percentage of children examined who required treatment. Age groups. West Ham. England & Wales, 1936. London, 1936. Entrants 17.21 16.1 14.8 Intermediates 21.74 18.5 16.6 Leavers 20.94 16.9 16.3 It will be seen from this table that at all ages inspected the proportion of West Ham school children who required treatment was slightly greater than the corresponding proportions for London children and for children in England and Wales as a whole. This slight excess is no doubt due, at least in part, to the industrial character of the district. Certain defects will now be considered in detail. (a) Nutrition. The popular conception of nutrition is connected mainly with the height, weight, and general "build" of the individual. Within recent years it has come to be recognised that the detection of malnutrition is a very complex problem, and it seems desirable therefore to discuss this question from two distinct angles. 369 x (i) Height and weight. The average height and weight of children examined in the three age groups is given in Table VIII. Table VIII. Average height and weight, 1937. Age (years) Boys Girls No. examined Average height in inches Average weight in pounds No. examined Average height in inches Average weight in pounds 5 744 43 41.0 635 42.2 40.1 8 15 535 49.0 56.0 1,479 49.0 54.2 12 1,076 563 80.1 1,724 57.1 82.8 In this table the figures given for the number examined at each age refer to both heights and weights. Many investigations have demonstrated the relative increase in the heights and weights of the children of to-day as compared with children at corresponding age groups in pre-war years. The figures for West Ham children are set out in Table IX, which shows the average heights and weights of children in the three code age-groups for each year since 1930. The table also gives the corresponding figures for the year 1927, and also for the year 1914, in respect of children at ages 5 and 12 years. (Mean heights and weights are also available for the 8 year group, but the observations upon which these are based are too small to make the results significant.) All the means given in the table were calculated from samples which were large enough for the purpose; the smallest sample consisted of 635 children, and the largest of 2,891. The average heights and weights for 1937 are compared with the corresponding figures for 1914 and for 1927 respectively in Table X. Further examination of these figures is necessary in order to reach detailed conclusions, but in certain cases the differences are sufficiently striking to warrant some comment. The remarkable increase in the weight of 12-year old children, as compared with the average weight of children at this age in 1914, is considerably greater than the increase observed in many other areas. 370 Table IX. Average Heights and Weights in Different Age-groups. Year 5 years 8 years 12 years Boys Girls Boys Girls Boys Girls Ht. (ins) Wt. (lbs) Ht. (ins) Wt. (lbs) Ht. (ins) Wt. (lbs) Ht. (ins) Wt. (lbs) Ht. (ins) Wt. (lbs) Ht. (ins) Wt. (lbs) 1914 39.9 37.6 39.5 37.3 — — — — 54.2 70.3 54.9 72.6 1927 41.3 41.1 41.1 38.9 47.5 52.0 47.3 51.0 55.0 75.7 55.7 76.2 1930 40.9 40.2 41.2 38.9 47.9 54.1 47.7 53.3 55.3 76.7 55.9 78.9 1931 41.6 40.0 41.4 39.0 48.1 54.8 47.3 52.2 55.3 77.4 56.3 79.5 1932 41.7 39.6 41.5 39.2 47.5 52.5 48.8 53.4 55.6 76.9 56.1 78.9 1933 42.2 40.6 42.4 40.0 48.0 55.6 47.4 54.0 55.8 77.9 56.1 80.2 1934 41.8 40.2 41.6 39.2 47.4 57.4 48.3 53.2 55.8 78.1 56.5 82.1 1935 41.8 40.4 41.8 39.8 48.7 57.6 48.5 54.1 56.0 79.8 56.6 83.0 1936 42.0 41.0 41.0 39.8 48.6 56.0 48.8 54.4 56.4 80.3 57.1 83.0 1937 43.0 41.0 42.2 40.1 49.0 56.0 49.0 54.2 56.3 80.1 57.1 82.8 Table X. Comparative heights and weights. Age. Increase or decrease compared with 1914. Increase or decrease compared with 1927. Height (inches) Weight (pounds) Height (inches) Weight (pounds) 5 years (i) Boys + 3.1 + 3.4 + 1.7 — 0.1 (ii) Girls + 2.7 + 2.8 + 1.1 + 1.2 8 years (i) Boys — — + 1.5 + 4.0 (ii) Girls — — + 1.7 + 3.2 12 years (i) Boys + 2.1 + 9.8 + 1.3 + 4.4 (ii) Girls + 2.2 +10.2 + 1.4 + 1.4 371 The greater part of this increase can evidently be assigned to the years between 1914 and 1927, and although detailed figures are not available for these years, it would seem that the increase probably began several years after the end of the war. It is strange that in the last ten years boys of 12 years should have shown such a disproportionate increase in weight as compared with girls at this age. It will be noted that a decrease in the average figures is found in only one group, and that this decrease is so small as to be insignificant. (ii) Nutrition surveys. Two years ago the Board of Education made some alterations in the method of classifying varying degrees of nutrition, and the complete results of the assessment of the children in this area will be found in Table II of the Appendix to this section. The percentages of children who were assessed as falling in the four categories in the various agegroups are shown in Table XI. Table XI. Percentage Distribution of Grades of Nutrition. Age. A. (Excellent) B. (Normal) c. (Slightly subnormal) D. (Bad) 5 years 12.97 75.51 11.43 0.09 8 years 13.93 73.01 12.83 0.23 12 years 21.24 69.29 9.37 0. 10 Other routines 24.41 68.87 6.66 0.05 Total (1937) 17.11 72.16 10.59 0.13 Total (1936) 15.02 72.51 12.15 0.32 England and Wales (1936) 14.6 74.2 10.5 0.7 Superficially the figures for West Ham compare favourably with those for England and Wales. It should however be noted that the opinion is gradually gaining ground that the grade of nutrition, as gauged in the usual way by clinical examination, is possibly not of great value. In a recent investigation Mr. R. Huws Jones adduced some convincing statistical evidence on this point, and the discrepancies which he showed to exist between the findings, not only of different doctors who examined the same children, but also of the same doctors who examined the same 372 children after an interval of time, are possibly sufficient to discredit attempts at accurate work in this direction. It is obvious that the correct method of dealing with "malnutrition" is to give the child adequate "nourishment." This practice is not quite so simple as the description seems to imply. Emphasis is now constantly placed on the fact that the child's state of nutrition depends not only on the quality and quantity of the food which he eats, but also on important factors such as fresh air, sunlight, and adequate exercise. The word "nutrition" means "the nourishment of the child or the general well-being of the child. It is the process of normal growth and healthy maintenance of the child's body in function as well as in substance." In treating the child who is suffering from deficient nutrition, therefore, an endeavour is made to compensate him for his previous lack of all or any of these factors. Severe cases may be admitted to a day or residential open-air school such as Fyfield, and the results obtained will be found in the appropriate section of this report. Other children may be sent to convalescent homes. In necessitous cases free meals may be provided, and those who can do so may participate in the voluntary milk scheme which is in operation in the schools. (b) Uncleanliness. Dirty and verminous children who are discovered at routine or special inspections, or during cleanliness surveys, are followed up at their homes until they are clean. A certain number are cleansed at the school clinics, the consent of the parents having been first obtained. The number of children examined was 79,476. The conditions found were as follows:— Ova 6,805 Ova and pediculi 1,230 Body pediculi 1 Head and body pediculi 15 Sores 379 Dirty 113 The percentages for head and body vermin were 1.56 and 0.02 respectively. The number of children who were visited at their homes was 4,260, and the number visited at school was 7,614. In connection with this work 1,554 unclean heads were dealt with. In addition 9 cases in which the body was unclean, 373 and 10 cases of skin disease were dealt with. Defective clothing' was remedied in 31 instances. It was not found necessary to cleanse any children under Section 122 of the Children's Act, but 86 heads were cleansed at the school clinics by nurses. (c) Minor ailments. The treatment of minor ailments and diseases of the skin is undertaken at the school clinics. Details of the treatment carried out during 1937 are given in Table IV of the Appendix to this section. The table shows that the total number of cases who were treated at these clinics during the year was 12,937. This figure may be compared with a total of 12,896 for 1936. It is of course necessary for many patients to attend on more than one occasion, and some indication of the work carried out at these clinics will be obtained from the following table. (The Stratford Clinic is served by two doctors.) Clinic. No. of attendances for treatment. Stratford (a) 12,279 Stratford (b) 10,698 Balaam Street 12,966 Swanscombe Street 13,7" Rosetta Road 15,864 Total attendances 65,518 Skin diseases. A comparison of the incidence of various skin diseases, as judged by the number of patients who attended for treatment at the clinics, is instructive. Table XII gives these figures for twelve years. This table brings out certain satisfactory features. Ringworm, both of the scalp and of the body, has shown a progressive and marked decline, and the incidence of impetigo has been halved in ten years. These facts may indicate an improvement in the handling of patients by their mothers, so that children who are infected are kept away from others. On the other hand, the incidence of scabies has increased three fold since 1927. This increase is very regettable, but is quite analogous to a similiar increase which has been noted in other large areas. 374 Ringworm. Only 23 cases of ringworm of the scalp were treated during the year. This low incidence is satisfactory. The authority has an arrangement with the London Hospital for X-ray treatment, and each patient is seen by a school doctor before the commencement of treatment and later before he is re-admitted to school. The number of patients treated by X-rays during the year was 13. The incidence of ringworm of the body fell considerably ; the number of cases treated during the year was 98, as compared with 149 in 1936. As a result of complaints which were received regarding Table XII. Cases of Skin Diseases Treated. Year. Ringworm of scalp. Ringworm of body. Scabies. Impetigo. Other skin diseases. 1926 107 277 64 1,053 2,631 1927 84 254 82 1,271 2,986 1928 80 208 97 1,202 2,823 1929 62 179 97 1,164 2,945 1930 53 151 119 1,142 2,725 1931 48 142 165 1,174 2,087 1932 46 136 242 1,025 2,127 1933 27 116 213 1,052 1,959 1934 13 109 221 802 2,495 1935 13 146 168 679 3,476 1936 23 149 216 701 3,992 1937 23 98 254 637 3,233 the spread of ringworm during the year 1937, it was decided to exclude from school any child who was suffering from ringworm of the body, in addition to cases of ringworm of the head. Scabies. Reference was made above to the regrettable increase in the incidence of this disease. So far as the household is concerned, this complaint is a particularly difficult one to deal with. The individual patient usually reacts rapidly to proper treatment and frequent changes of clothing, but it is well known that adults are frequently infected, and treatment in these cases is most difficult. There is no doubt that the only satisfactory method of dealing with the condition is by continuous treatment of all the 375 members of the household simultaneously, together with disinfection, repeated if necessary, of all infected clothing and bedding. At the present time it can hardly be said that the Authority has a complete scheme for the treatment of scabies. The usual method suggested is the application of sulphur ointment by the parent. From what has been said above, however, it will be Table XIII. Elementary schools. Eye conditions. Results of routine and special inspections. Year Minor eye conditions Defective vision (excluding squint) Squint Requiring treatment. Requiring observation. Total Requiring treatment. Requiring observation. Total Requiring treatment. Requiring observation. Total 1926 1,479 43 1,522 1,649 138 1,787 343 32 375 1927 1,371 20 1,391 1,664 183 1,847 381 75 456 1928 1,204 26 1,230 1,974 144 2,118 397 25 422 1929 1,203 19 1,222 1,572 127 1,699 328 14 342 1930 1,214 19 1,233 2,049 134 2,183 361 4 365 1931 828 35 863 2,106 275 2,381 335 23 358 1932 1,250 29 1,279 2,528 236 2,764 418 56 474 1933 1,396 18 1,414 1,979 252 2,231 364 11 375 1934 1,261 27 1,288 1,564 226 1,790 302 22 324 1935 1,163 36 1,199 1,210 130 1,340 285 23 308 1936 1,167 29 1,196 1,072 112 1,184 240 19 259 1937 1,018 19 1,037 1,281 95 1,376 415 17 432 realised that the provision of one or more cleansing stations by the Local Authority would probably serve to reduce the duration of the disease in individual cases and to prevent the spread of infection to other members of the family. (d) Visual defects and eye diseases. A summary of the 376 results of routine and special inspections with reference to eye conditions for the last twelve years is given in Table XIII. Further information regarding the incidence of eye conditions may be obtained from Table XIV, which deals with those children who were treated for eye conditions during the same period. Table XIV. Elementary Schools. Summary of Treatment of Visual Defects and Eye Diseases. Year Minor eye defects Errors of refraction Other defects Spectacles prescribed Spectacles obtained 1926 1,231 1,989 14 1,790 1,663 1927 1,060 2,082 22 1,953 1,740 1928 1,089 2,086 13 1,965 1,530 1929 1,123 1,835 21 1,710 1,558 1930 1,073 2,959 25 2,850 2,517 1931 1,191 3,016 — 2,809 2,632 1932 1,208 3,621 12 3,068 2,717 1933 1,303 3,653 31 2,961 2,813 1934 1,259 3,484 — 2,849 2,604 1935 1,153 3,483 — 2,693 2,560 1936 1,11 1 2,853 — 2,472 2,312 1937 969 2,043 — 1,877 1,790 The actual incidence of these eye conditions, based on the total cases requiring treatment and observation for last year, and on the school populations given in Table II is set out in Table XV. It may be inferred from this table that there has been no marked change in the incidence of minor eye defects. It would appear that defective vision was definitely more frequently found six years ago than it is to-day. Apart from the years 1932 and 1937 the incidence of squint showed no marked variations. The high incidence of this condition in 1937 is remarkable, and suggests 377 that the personal factor of the oculist is partly responsible. No definite conclusions can be drawn from these figures without the application of more advanced methods. (i) Minor eye diseases. Although there was no marked change in the actual incidence of these conditions, as found at routine and special inspections, there was a welcome reduction of the number of children who required treatment at the clinics. So far as secondary school pupils were concerned, 9 required treatment at the clinics, and 5 were treated otherwise. (ii) Defective vision and squint. Reference has already Table XV. Incidence of Eye Conditions per 1,000 School Population. Year. Minor defects. Defective vision (excluding squint). Squint. 1926 30.3 35.5 7.5 1927 28.0 37.2 9.2 1928 25.1 43.3 8.6 1929 25.8 35.9 7.3 1930 26.5 46.9 7.8 1931 18.8 51.9 7.8 1932 28.2 61.0 10.5 1933 31.6 49.9 8.4 1934 29.8 41.4 7.5 1935 29.5 33.0 7.6 1936 31.1 30.8 6.7 1937 28.7 38.1 12.0 been made to the incidence of this condition in the population of the elementary schools. In secondary schools the number of children who were found to require treatment was 358, of whom 29 had their vision assessed as defective as a result of a special inspection. The number of children in these schools who were found to require observation but not treatment was 19. The incidence of squint in secondary school children was very low, only eleven cases of this type having been observed. This was probably due to the fact that children suffering from squint had had the defect corrected before they entered the scondary school. 378 Treatment of eye conditions. All cases of visual defect are examined by the school oculist. This specialist devotes ten sessions per week to these refractions. Each case is re-examined by the respective assistant school medical officer within three months after the primary examination. Satisfactory dark rooms for ophthalmological work have been constructed at two of the school clinics. The following table gives a resumd of the work of the school oculist during 1937:— Elementary Schools. Higher Education. Special Schools. Cases referred to oculist 2,531 559 40 Number who attended 2,018 479 32 Percentage attendance 79.7 85.7 80.0 Glasses ordered 1,835 450 30 The total number of clinic sessions devoted to refraction work was 362. Those children who did not keep the first appointment were followed up by the school nurses, and in most cases further appointments were made. The following is a report by Dr. Agnes A. S. Russell, the school oculist:— "The work of the ophthalmic clinic includes the examination of the eyes of all school children referred by the assistant school medical officers. The children examined are mostly those who require glasses because of defective vision, or strabismus, or because of headaches due to eyestrain; they also include a number of cases of eye diseases which require treatment. Where glasses are prescribed the children are re-inspected after obtaining them, either in the ophthalmic clinic or at a school clinic by the assistant school medical officers, who have been provided with a copy of the report of the ophthalmic examination. I have found that the number of children with strabismus forms a large proportion of the children attending the ophthalmic clinic. As the majority of these cases benefit by treatment additional to the correction of the refractive error, I have all such cases under observation. These children attend the clinic at frequent intervals, and the nature of the condition and the 379 sary care are explained carefully to the parents. Orthoptic training has also been started in the clinic for a few of the suitable cases, but much more can be done in this direction. The following are Some figures regarding the special work on cases of strabismus during 1937. Among the children who attended the eye clinic during 1937, there were 543 cases of strabismus, and of these 306 attended more than once during the year. Some had as many as eight or nine visits for advice and following up of treatment by occlusion. The ages of children suffering from strabismus are given hereunder:— Age. Under 6. 6— 8— 11— No. 123 127 200 93 The number of children who attended for orthoptic exercises was 20; these children made a total of 170 attendances. The carrying out of occlusion in cases of strabismus requires the active co-operation of the teachers in schools. This has been freely given, and the results are satisfactory in many cases." I agree with the suggestions of Dr. Russell that an extension of orthoptic treatment is desirable. This matter will have my attention in the near future. (e) Nose and throat defects. A summary of the results of examination and of the treatment carried out in children suffering from nose and throat defects, and also in children who had diseases of the ear, during 1937 will be found in Table XVI. No secondary school children received any other form of treatment under these headings. No direct arrangements are made by the Authority for treatment of defects of the throat and nose. All children who are recommended for operative treatment are, by arrangement with the respective hospitals, referred to Queen Mary's Hospital for the East End, to St. Mary's Hospital, Plaistow, and to the Children's Hospital, Balaam Street. During the year 627 children were operated on for these conditions, and 87 received treatment by private practitioners or in hospitals outside the Authority's 380 Table XVI. Nose and throat work. 1937. (a) Elementary education. Enlarged tonsils. Adenoids. Enlarged tonsils and adenoids. Other Conditions. Total. Cases referred by School Medical Officer for treatment 188 56 812 287 1,343 No. of children who received operative treatment— (a) under Authority's scheme 58 25 537 2 622 (b) by general practitioner or local hospital 2 2 75 7 86 Other forms of treatment - - — 143 143 Totals 248 83 1,424 439 2,194 (b) Secondary schools. Enlarged tonsils. Adenoids. Enlarged tonsils and adenoids. Other Conditions. Total. Cases referred bySchool Medical Officer for treatment 13 1 5 - 19 No. of children who received operative treatment— (a) under Authority's scheme 2 — 3 — 5 (b) by general practitioner or local hospital - — 1 — 1 Other forms of treatment - - - - - Totals 15 1 9 — 25 381 scheme. In addition to these children who had operative treatment, 171 children were treated by other methods. (f) Ear disease Ai\d defective hearing. Some indication of the incidence of these conditions will be found in Table XVII, which gives for a series of twelve years the number of children who were found to be suffering from these conditions. In this table the numbers refer to children who required either treatment or observation, and the rates are expressed per 1,000 of the school population given in Table II. The results of routine'and special inspections at institutions for higher education show the following:— Requiring treatment. Requiring observation. Total. Defective hearing 3 2 5 Otitis media 14 2 16 Other ear diseases 7 1 8 Total 24 5 29 Of the total cases referred for treatment, 875 children suffering from ear diseases or defective hearing were treated at the school clinics; of these 6 were children attending institutions for higher education. The number of children who received treatment privately was 73, of whom 4 were attending schools for higher education. In 1937 there were two deaf centres in the Borough, situated respectively at Water Lane and Frederick Road. Further notes on these centres appear on page 417. The children at these centres are examined once a year by the Authority's consultant aural surgeon. The following is a report by Mr. Fred Stoker, F.R.C.S.:— "The deaf children who came up for examination in July, many of whom have been under my observation for some years, may be classified as coming under one of the following categories: (a) Cases of inherited deafness in which total absence of hearing has been evident from birth. 382 (b) Cases of congenital deafness in which the defect has been absolute since birth. (c) Cases of total deafness secondary to acute infectious fevers in infancy. (d) Cases of partial deafness due to the sequelae of local inflammatory conditions. Classes (a) and (b) are caused by developmental defects in the labyrinth or cochlear nerve, (c) to disorganization of the same Table XVII. Elementary Education . Ear Defects. Year Defective hearing Otitis media Other ear disease Total ear conditions No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 1926 367 7.3 769 15.3 262 5.2 1,398 27.8 1927 349 7.0 780 15.7 268 5.4 1,397 28.1 1928 267 5.5 780 15.9 251 5.1 1,298 26.5 1929 199 4.2 819 17.3 202 4.3 1,220 25.8 1930 161 3.5 836 18.0 228 4.9 1,225 26.3 1931 134 2.9 730 15.9 181 3.9 1,178 25.7 1932 235 5.2 880 19.4 363 8.0 1,478 32.6 1933 177 4.0 852 19.0 459 10.3 1,488 33.3 1934 96 2.2 770 17.8 376 8.7 1,242 28.7 1935 99 2.4 659 16.2 401 9.9 1,159 28.5 1936 114 3.0 588 15.3 435 11.3 1,137 29.6 1937 88 2.4 493 13.7 484 13.4 1,065 29.5 structures, and (d) to the residua of simple inflammation of the labyrinth or to simple or suppurative inflammation of the middle-ear. Cases coming under (a), (b) and (c) cannot be remedied, so far as the hearing is concerned, by any treatment. Those included under (d) can frequently be benefited to the extent of the sufferers regaining at least useful hearing. The (d) category forms the minority of the cases seen. 383 In the circumstances, therefore, the problem lies chiefly in converting the totally and permanently deaf into useful members of society. This difficult task, it is my privilege to say, is being carried out with conspicuous and often astonishing success by the staff of the West Ham centres for deaf children. There are, it is true, certain cases that do not respond satisfactorily even to the most meticulous care and skill. These children unhappily suffer from congenital mental defects in addition to deafness, but even they, I have observed, benefit materially from the environment in which they are placed." (g) Dental defects. My report on school dental work will be found on pages 389-396 of this report. (h) Orthopaedic and postural defects. The Authority has a comprehensive scheme for the treatment of children suffering from orthopaedic defects. The arrangement is with the Children's Hospital, Balaam Street, which specializes largely in work of this type, and the Authority undertakes financial responsibility for patients treated at the Hospital. During the year 1937 the number of children who were in-patients in the hospital was 24, and the number treated as out-patients was 91. In addition to these elementary children, 5 secondary school children and 14 children from special schools attended as out-patients, so that the total number of children treated under the Authority's Scheme at this hospital was 134. Those cases of orthopaedic and postural defects which were not treated under the Authority's scheme were dealt with in other ways, and it has been ascertained that 41 elementary and 7 secondary school children were treated thus during the year. In addition to this hospital treatment for early cases, the Committee from time to time maintain special cases at orthopaedic hospital schools approved by the Board of Education. Any children who are found to be suffering from minor postural defects are reported to their head teachers on confidential lists. Recommendations regarding any definite exercises or drill which may be required are given according to the nature of the defect. The following report is based upon data supplied by Mr. Kenneth Heritage, F.R.C.S., the orthopaedic surgeon to the Children's Hospital, Balaam Street, Plaistow. In-patients. During the year 1937 the number of West Ham school children who received treatment as in-patients of this 384 hospital was 32, 28 of whom were admitted during the year. The number of patients who were in residence on the 1st January, 1937, was 4. There was one death in the hospital during the year. Twenty-eight patients were discharged and two patients were still under treatment on the 31st December, 1937. Of the patients who were treated, fifteen were males and sixteen females. The patient who died was a female of six years who was suffering from acute osteomyelitis; the cause of death was staphylococcal septicaemia. Of the patients who were discharged ten were cured, eight were much improved, seven improved and three showed no improvement. The duration of treatment is shown in the following table:— —2 weeks —4 weeks —2 months —3 months —6 months Over 6 months Total 5 8 9 6 2 2 32 Table XVII (a). Condition Cured Much improved Improved Not improved Total Flat foot 7 10 7 — 24 Spastic paralysis — 8 6 — 14 Scoliosis 4 5 4 — 13 Anterior poliomyelitis — 7 4 — 11 Hammer toe 3 3 2 — 8 Kyphosis 4 3 — — 7 Knock knee 3 1 — — 4 Lordosis — 4 — — 4 Torticollis 2 - — — 2 Congenital dislocation of hip - 2 - - 2 Asthma - 2 — — 2 Chest deformity - — 2 — 2 Other conditions 8 6 2 1 17 Total 31 51 27 1 110 385 Y The cases treated consisted of the following:—Tuberculous joints 6; anterior poliomyelitis 4; spastic diplegia 3; osteomyelitis 2; torticollis 2; talipes 2; erb's paralysis 1; sclatter's diseases 1; congenital facial paralysis 1; congenital dislocation of hip 1; other conditions 9. Treatment consisted of operative measures, conservative treatment by plaster and other appliances, and other measures. Out-patients. The number of West Ham children who attended the Remedial Clinic as out-patients during the year was 110. These children made 2,324 attendances, giving an average of 21 attendances per patient. The results of treatment were as follows:— Cured 31, much improved 51, improved 27, not improved 1. Table XVII(a) gives the result of treatment in the more important groups of cases. In many cases treatment was mainly by remedial exercises and massage, but a few patients were treated by diathermy. (i) Heart disease and rheumatism. During the year 1937 the number of children who were discovered to be suffering from organic heart lesions sufficiently severe to require treatment was 123. Of these 74 were discovered at routine inspections and 49 at special inspections. In addition 117 children were found to be suffering from organic lesions which were not sufficiently severe to require treatment. Among children attending secondary schools only one was discovered with a heart lesion which was sufficiently severe to require treatment. Table XVIII gives particulars of the incidence of organic heart lesions during the last 12 years. A special clinic for the treatment of heart disease and rheumatism has not yet been established in the borough. For a number of years, however, an attempt has been made to give these children the careful attention which they merit. Cases of this type, from whatever source referred, are examined by the Chief Assistant School Medical Officer and recommendations are made to parents and teachers regarding the treatment which should be adopted. In addition certain children are sent for in-patient treatment at various heart hospital schools; the majority of the girls being sent to West Wickham and of the boys 386 to the St. John's Open-air School for Heart Gases, Woodford Bridge. During the year 1937 the number of children treated as in-patients in these special institutions was 31. The following is a report from Dr. Wilfrid Sheldon, who was in charge of the patients treated at the St. John's Open-air School for heart cases. It should be noted that this is a general report, which applies also to patients other than those admitted from West Ham. The report is useful in that it indicates the main dangers in the treatment of patients who are suffering from Table XVIII. Elementary Education. Incidence of Organic Heart Lesions. Year. Organic lesions. Total. Rate per 1,000 school pop. For treatment. For observation. 1926 41 149 190 3.8 1927 63 126 189 3.8 1928 103 154 157 3.2 1929 61 110 I71 3.6 1930 46 92 138 3.0 1931 56 163 219 4.8 1932 67 175 242 5.3 1933 83 139 222 5.0 1934 45 133 178 4.1 1935 72 193 265 6.5 1936 85 173 258 6.7 1937 123 117 240 6.6 rheumatic heart disease, and the most recent methods of treatment. "It is a pleasure to record the completion of another year of useful work at St. John's School. The School is a residential home for convalescent boys, and contains 124 beds, of which 40 are reserved for boys with rheumatic heart disease, and it is with this latter group that this report is concerned. During the last year 66 cases of rheumatic heart disease have been admitted and about an equal number discharged. During the year two of the children have succumbed to progressive cardiac failure, associated with a fresh exacerbation of acute rheumatic inflammation, and it may be added that in view of the advanced state of the rheumatic process in some of the boys, it is perhaps a matter for 387 lation that the mortality rate should be so low. This reflects great credit on the patience and skill of the sisters who have to look after these cases. During the winter a long epidemic of diphtheria occurred, necessitating the removal of several of the boys to the local isolation hospital. The epidemic is now over, and the boys have all returned to the school, and the condition of their hearts seems none the worse for this additional infection. The children in the heart beds are managed along the lines customary in residential heart homes, that is to say, they are slowly worked through a series of grades, the first consisting of complete rest in bed, and the fifth and last grade being reached when they are up all day and leading what amounts to a normal life, with the exception of a mid-day rest and curtailment of vigorous exercises. The time occupied in each grade varies considerably with the individual children, the passage from one grade to the next being governed by the rate of the heart, the increase in weight, and the general well-being. A blood-sedimentation-rate test is not employed in this home, because there are no satisfactory facilities for performing the test. This may perhaps mean that the boys pass a little more slowly from grade to grade than might otherwise be the case, but with regard to heart children this can simply mean erring on the side of safety. The clinical observation, already made .in other similar institutions, to the effect that a streptococcal sore throat in a child with a rheumatic heart disease is likely to lead to a relapse of fresh rheumatism after an interval of two or three weeks, has been amply confirmed at St. John's school during the past five years—that is, since heart cases were particularly catered for. This would appear to be one of the most important recent additions to our knowledge of rheumatic heart disease. During the coming year it is hoped to co-operate with the rheumatic home at Baskerville, Birmingham, and the Cheyne Hospital, Chelsea, in an effort to determine whether drugs of the salicylate group, given at the time of the sore throat and continued for a period of one month, can do anything to mitigate or abort an ensuing rheumatic relapse. Although this aspect has already been mooted in medical literature, a decisive opinion awaits expression, and this is a question which homes such as St. John's are in a position to answer." 388 (j) Tuberculosis. All definite cases of tuberculosis found by assistant school medical officers are notified to the medical officer of health. Suspicious cases are always referred to the tuberculosis officer for examination and report. The number of cases so referred during this year was 29. The Council have a special sanatorium for children at Langdon Hill, Essex, with accommodation for 40 children. The tuberculosis officer is responsible for all children who are admitted to and discharged from this institution. All cases are examined by a school dental surgeon and treated where necessary before they are admitted. Particulars of the work of this institution are given in another section of this report. Close co-operation between the tuberculosis section and the school medical section is maintained relative to school children who are considered by the tuberculosis officer to be unfit for school. These cases are notified to the school medical officer who officially excludes them from school attendance until they are considered to be fit for school. Many of these children do not show signs of active tuberculosis. During the year 121 cases were reported by the tuberculosis officer as being unfit for school. VII. SPECIAL TREATMENT SERVICES. School Dental Service. The staff of the Authority's school dental service consists at present of five whole time dentists, to each of whom an area is allotted, and each of whom carries out treatment in a school dental clinic. These dental clinics are distinct from any other dental clinics which may be conducted by the local authority. The dental clinics are not all equally suitable for the purpose for which they are being used, and the type of equipment also varies to a slight degree. General anaesthetics have not so far been used for extraction purposes. Recently I have given considerable attention to all aspects of school dental work, and a report suggesting certain alterations in staffing, equipment and procedure was adopted by the Education Committee. In my next annual report I shall deal with this question in detail, and in the present report I intend to discuss the work which has been done during the last eighteen years—that 389 is, since the year in which the present type of statistical return was adopted. It is only by considering data for a series of years that any true appreciation can be obtained of the amount and type of work which is being done in an area. Similarly, it is only by such methods that the observer is able to appreciate the gradual change in the incidence of certain conditions. Tables XIX and XX set out certain data which are essential for an appreciation of the incidence of dental conditions in the children of the area. These two tables show the progress which has been made in the extension of the service. From 1920 to 1927 inclusive, inspection of school children was confined to those at the ages of 6, 7, and 8 years respectively. After the latter date children at other ages came to be examined more frequently. Although in 1937 the numbers examined in these other age groups were considerable, 11,909—or 65.6 per cent—of the 18,182 children who were examined at routine inspection fell within the age group 6—8 years. A complete dental service should provide equal facilities for examination of children in all age groups, and it is hoped that some progress in this direction will be made at an early date. The figures in the last column of Table XIX show a progressive increase. The high ratios in the last few years are probably due to two factors—an actual increase of the inspection work carried out by the school dentists, and a fall in the school population. Table XX brings out the fact that there has been an increase in the proportion of children inspected who required treatment. The figures for West Ham do not differ very markedly from those for other areas, and the increase is probably due to a change in the conception of the type of lesion which is suitable for treatment. The seventh column of this table, in that it shows the degree to which parents are responding to the offer of treatment for those children who have been shown to require it, has points of interest. This figure is fairly constant for the country generally, and the ratios for West Ham are somewhat above those for other similar areas. In an ideal dental service, the full cooperation of hypothetical ideal parents would raise the figures in this column to approximately 100 per cent., but it will probably be long before even an approach to this high figure is attained. 390 391 Table XIX. Elementary Education . Age Grouping of Children inspected by Dentists. Year No. of children at ages (years) who had routine inspections Total routine inspections Special inspections Total inspections Total inspections per cent. school population 4 5 6 7 8 9 10 11 12 13 14 1920 - - 4,936 1,901 1,046 - - - - - - 7,883 305 14,188 27.4 1921 — — 8,063 11,189 2,654 - - - - - - 21,906 530 22,436 42.6 1922 — — 7,883 10,724 5,421 — — — —. — — 24,028 1,042 25,070 47.3 1923 — — 4,972 6,706 2,874 — — — — — — 14,552 1,127 15,679 29.6 1924 —. — 5,453 6,951 3,685 - - - - - - 16,089 1,045 17,134 33.5 1925 — — 6,078 6,301 3,609 - - - - - - 15,988 1,421 17,409 34.4 1926 — — 7,083 6,598 2,483 - - - - - - 16,164 1,794 17,958 35.6 1927 — — 5,499 7,102 2,478 — — — — —. — 15,079 2,958 18,037 36.3 1928 37 105 5,245 5,895 2,562 66 71 84 104 146 11 14,326 3,537 17,863 36.5 1929 261 437 4,336 4,565 2,490 578 434 364 439 454 34 14,392 3,820 18,212 38.5 1930 576 1,224 6,053 6,206 3,591 1,333 1,356 832 721 842 149 22,883 3,706 26,589 57.2 1931 396 851 5,812 5,576 3,343 1,011 1,009 1,333 855 790 129 21,105 3,551 24,656 53.7 1932 461 957 6,357 6,258 3,347 1,072 1,076 950 820 542 80 21,920 4,189 26,109 57.7 1933 521 1,064 5,452 4,728 2,997 964 964 1,151 993 1,189 79 20,102 4,736 24,838 55.5 1934 406 720 4,455 4,372 3,828 821 887 728 721 656 91 17,685 3,843 21,528 49.8 1935 378 688 4,049 3,899 3,820 673 672 697 854 900 44 16,674 3,890 20,564 50.6 1936 459 697 3,743 3,721 3,835 1,039 1,099 1,036 861 1,087 57 17,634 4,791 22,425 58.3 1937 375 779 3,742 4,040 4,127 1,021 934 944 1,033 1,081 106 18,182 4,559 22,741 63.0 England and Wales, 1936 . Routine inspections — 3,199,592 Special inspections — 264,356 Total inspections —- 3,463,948 Total average attendances (1935-36) — 4,748,453 Total inspections per cent. of school population — 73.1 Table XX. Elementary education. Dental inspection and treatment. Year. Total inspections No. requiring treatment. Percent age of inspected who required treatment. No. treated. Percent age of inspected who were treated. Percent age of those who required treatment who were treated No. who required treatment as rate percent. of school population. 1920 14,188 6,493 45.8 4,353 30.7 67.0 12.4 1921 22,436 9,453 42.1 2,831 12.6 29.9 180 1922 25,070 14,779 58.8 3,487 13.9 23.6 28.0 1923 15,679 8,692 55.4 6,241 39.8 71.8 16.4 1924 17,134 8,489 49.5 7,097 41.4 83.6 16.6 1925 17,409 7,528 43.2 6,321 36.3 84.0 14.9 1926 17,958 7,933 44.3 6,912 38.6 87.1 15.2 1927 18,037 7,266 40.3 6,707 37.2 92.3 14.6 1928 17,863 7,228 40.5 7,213 40.4 99.8 14.8 1929 18,212 8,619 47.3 8,370 460 97.1 18.2 1930 26,589 12,700 47.8 10,101 38.0 79.5 27.3 1931 24,656 14,668 59.5 10,401 42.2 70.9 31.9 1932 26,109 15,409 59.0 10,805 41.4 70.1 34.0 1933 24,838 13,857 55.8 10,628 42.8 76.7 310 1934 21,528 12,505 58.1 9,875 45.9 79.0 28.9 1935 20,564 13,518 65.7 10,684 52.0 79.0 33.3 1936 22,425 15,046 671 10,489 46.8 69.7 39.1 1937 22,741 14,258 62.7 10,095 44.4 70.8 39.5 England and Wales, 1936. 3,463,948 2,425,299 70.0 1,536,627 45.3 63.4 51.2 392 Certain aspects of the arrangements made for inspection and treatment are set out in Table XXI. It will be seen that the number of half-days which are devoted to inspections has not Table XXI. Elementary education. Dental inspection and treatment. Year Half-days devoted to Total halfdays Total attendances for treatment Average No. inspected per inspection session Average No. treated per treatment session Inspection Treatment 1920 224 515 739 6,348 63.3 8.5 1921 392 338 730 3,674 57.2 8.4 1922 451 259 710 4,014 55.7 13.4 1923 175 491 666 8,148 89.6 12.7 1924 249 1,129 1,378 11,333 68.8 6.3 1925 239 1,147 1,386 11,314 72.8 5.5 1926 222 1,151 1,373 11,529 80.1 6.0 1927 200 1,168 1,368 11,903 90.2 5.7 1928 180 1,234 1,414 12,112 99.2 5.8 1929 182 1,612 1,794 14,081 100.1 5.2 1930 276 1,923 2,199 17,360 96.3 5.3 1931 255 1,988 2,243 18,419 96.7 5.2 1932 262 2,068 2,330 18,812 99.7 5.2 1933 233 1,958 2,191 16,892 106.6 5.4 1934 198 2,024 2,222 17,267 108.7 4.9 1935 191 2,001 2,192 16,883 107.7 5.3 1936 194 2,079 2 273 17,346 115.6 5.0 1937 195 1,996 2,191 16,720 116.6 5.1 altered very materially during the past eighteen years. On the other hand the number of sessions devoted to treatment is now four or five times what it was about the beginning of this period. It should be remembered that time spent in discovering defects 393 394 Table XXII. Elementary education. Treatment at dental clinics. Year Fillings Fillings in temp, teeth per 1,000 inspected Extractions Extractions of permanent teeth per 1,000 inspected Other operations Total operations Perm. teeth Temp. teeth Total Perm. teeth Temp. teeth Total Perm. teeth Temp. teeth Total 1920 1,024 . 1,024 - 135 9,770 9,905 9.5 - - 235 11,164 1921 500 27 527 1.2 135 5,249 5,384 6.0 - - 213 6,124 1922 565 119 684 4.7 120 4,335 4,455 4.8 - — - - 1923 517 151 668 9.6 127 8,570 8,697 8.1 — - 103 9,468 1924 786 762 1,548 44.4 58 10,291 10,349 3.4 339 377 716 12,613 1925 1,042 602 1,644 34.6 118 10,325 10,443 6.8 634 386 1,020 13,107 1926 865 688 1,553 28.3 85 10,681 10,766 4.7 844 379 1,223 13,542 1927 871 578 1,449 32.0 163 10,806 10,969 9.0 929 526 1,455 13,873 1928 753 566 1,319 21.7 267 11,689 11,956 14.9 745 398 1,143 14,418 1929 1,890 469 2,359 25.8 718 12,976 13,694 29.4 1,310 1,047 2,357 18,410 1930 2,224 789 3,013 29.7 792 17,686 18,478 29.8 1,314 668 1,982 23,473 1931 1,955 907 2,862 36.8 1,175 19,402 20,577 47.7 1,626 490 2,116 25,555 1932 2,501 1,158 3,659 44.4 1,439 19,525 20,964 55.1 1,816 581 2,397 27,020 1933 1,876 648 2,524 26.1 1,672 16,941 18,613 67.3 1,805 445 2,250 23,387 1934 1,636 327 1,963 15.2 1,336 16,451 17,787 62.1 1,879 1,097 2,976 22,726 1935 1,825 538 2,363 26.2 1,566 16,356 17,922 76.2 2,125 585 2,710 22,995 1936 2,047 282 2,329 12.6 1,497 15,539 17,036 66.8 1,943 576 2,519 21,884 1937 2,152 341 2,493 15.0 1,756 15,846 17,602 77.2 1,691 621 2,312 22,407 which cannot be treated is time wasted. The present number of treatment sessions possibly represents the number which is necessary to treat the defects found at the present number of inspection sessions. Any increase in the latter will have to be accompanied by a corresponding increase in the number of treatment sessions. Table XXI also shows the increase through the years of the average number of children inspected per session devoted to inspection. It has been shown that the keeping of detailed records of the findings at these inspections is not Table XXIII. School Dentistry. England and Wales, 1936. Fillings: Permanent teeth 1,45,051 Temporary teeth 105,418 Total 1,250,469 Fillings in temporary teeth per 1,000 inspected 30.3 Extractions: Permanent teeth 545,886 Temporary teeth 2,441,784 Total 2,987,670 Extractions of permanent teeth per 1,000 inspected 157.5 Other operations 503,180 necessary, and the gradual increase in the figures in column 6 probably represents the change in the attitude of dentists to this question. As column 7 shows, there has been little change throughout the years in the average number of children treated per treatment session. There is, on the whole, a tendency for more detailed work to be carried out, and this figure will probably not tend to rise—apart from the operation of extraneous factors. Details of the actual treatment carried out are contained in Table XXII. The most conspicuous feature shown in this table is the fact that there has been a rather rapid increase in the 395 number of permanent teeth extracted. Nine years ago the increase was sudden, and since that date there has been only a partial diminution in the rate of increase. In column 9 the permanent teeth extracted each year are expressed as a rate per 1,000 of the children inspected. From these figures, and from the data given in Table XXIII, which refers to England and Wales, it will be seen that the frequency of extractions of permanent teeth is below that for the country as a whole. No doubt many of these teeth were extracted for orthodontic purposes, and the practice of performing extractions rather than fillings in certain cases is in accordance with current opinion. Nevertheless, it does seem to be rather distressing that this practice is on the increase. Surely the children could be taught that a permanent tooth which has been saved is a valuable possession, and that they should look after it accordingly. A further interesting feature which is shown in Table XXII is the great increase in the frequency of "other operations." No doubt this practice is to be highly commended. Reports from the school dentists contain information on certain points. For example most of the dentists refer to the persistently large number of children who have to be treated as "specials." Mr. Baird attributes this to the fact that routine inspection ceases when the children reach the age of 9 years. Miss Gubb suggests, with considerable reason, that many children are forced to become "specials" because of the fact that from the beginning of June until the end of September they are absent from the district with their parents, who are at that season employed as fruit-pickers and hop-pickers. With reference to the interest displayed in conservative work, opinion seems to differ. For example Miss Marsden expresses the opinion that extraction is still more acceptable than conservative treatment in most cases, whereas Mr. Soper comments on the fact that there has been an increased demand for conservative work, a demand which is sometimes difficult to cope with. Mr. Soper also expresses the opinion that the children are becoming more conscious of their duty to care for their teeth. Ultra Violet Light. Artificial sunlight treatment for school children who require it is carried out at the Children's Hospital, Balaam Street, under an arrangement whereby the Authority accept financial responsibility for any children who are sent for treatment. 396 The following is the report oi' Dr. Eva Morton who is in charge of this work at the hospital: — "The number of children of school age receiving ultra violet light treatment at the West Ham Clinic during the year 1937 was 112, the smallest number since the clinic was started. As before, a large number of these children were cases of debility, often associated with anaemia. The conditions for which treatment was carried out in these 112 cases were as follows: — Debility 44 Psoriasis and other skin conditions 16 Bronchial catarrh 15 Alopecia 12 Malnutrition 9 Cervical adenitis 6 Rheumatism 5 Other conditions 5 Improvement or cure was noted in practically all the skin cases which completed their course of treatment, and this was also true in respect of the alopecia cases, although some of these were still under treatment at the close of the year. Eleven children, most of whom were suffering from debility, attended on less than 12 occasions—many of them on less than 6; but apart from these, by far the greater number of children who attended with some degree of regularity were discharged as ' greatly improved.' The smaller number of school children attending has, for the past two years necessitated a reduction in the number of weekly sessions which are set apart for them. Two sessions are now sufficient for this purpose instead of three as formerly." VIII. FOLLOWING UP. The system of following-up is intended to secure the attendance at the clincs of all children who have been recommended for treatment. When information has been received that a certain child requires medical treatment an appropriate card is filled up. Two different cards are in use, namely for minor ailments and for defects of vision respectively. In the event of the child failing to keep an appointment or ceasing to attend the clinic a follow-up card is filled up and the appropriate nurse visits the home and makes a report upon the card. A separate following-up card is made out for every defect which may develop in the future. The 397 following-up cards used for children with defective vision sets out a complete history of the oculist's notes. Duties of School Nurses. Generally speaking the duty of a school nurse is concerned mainly with the treatment of children at clinics, with the giving of assistance to the medical officers in connection with inspections at schools, with the following-up of children and with duties regarding uncleanliness surveys. A special enquiry nurse is attached to the office, her chief duties being in connection with children attending special schools, with out-of-school children and with assisting at medical inspections carried out at the office. These inspections include the examination of children who are recommended for admission to special schools or to Fyfield Open-air School. Other examinations carried out at the office include those of mental defectives, children requiring licences under the Children and Young Persons Act for singing and dancing and all cases referred for admission to institutions. The following gives an indication of the work of the school nurses during the year: — Number of visits to schools 1.531 Number of children visited in schools 4.499 Number of home visits 11,013 Number of inspections with reference to uncleanliness 79,476 IX. INFECTIOUS DISEASES. The "General Regulations for the Management of Provided and Non-Provided Public Elementary Schools" contains full particulars of the exclusion periods which have been approved by the Board of Education, and this booklet is in the hands of all head teachers. No teacher or pupil is allowed to attend school while he is suffering from any disease which is regarded as being infectious or contagious. A teacher who suspects that any pupil is suffering from any such disease must immediately report the fact to the head teacher, who should exclude the child from school and notify the school medical officer of his action. Exclusion of contacts is also practised in every case in which the presence of an infectious disease in the household warrants this action. Knowledge of the existence of infectious cases may be obtained from 398 various sources. For example, a list of infectious cases notified under the Public Health Act is supplied daily to the school medical section, and daily returns of children who are absent from school on medical grounds are made to the medical officer of health by the school attendance officers. The assistant school medical officers may also diagnose infectious or contagious diseases at the school clinics, and in this way patients who would otherwise have been missed are dealt with. Notifiable infectious diseases which are notified to the medical officer of health are dealt with in the manner indicated in previous sections of this report. Generally, in the case of infectious diseases the homes of the patients are visited by the sanitary inspectors or health visitors. In the case of measles especially, advice is given to the parents regarding the care of the patients. During the year 1937 there was no outstanding outbreak of infectious disease among school children. Detailed information regarding the incidence is contained in the section of this report which deals with infectious disease. The following table gives particulars of 399 excluded children who were found at clinics and elsewhere to be suffering from infectious or contagious diseases: these conditions were, of course, exclusive of the many cases of notifiable diseases which were notified in the normal way. Impetigo 67 Anaemia and Debility 1 Scabies 182 Bronchitis 7 Other skin diseases 33 Verminous 10 Conjunctivitis 6 Ringworm of head: treated by X-ray 13 Mumps 4 Enlarged glands 2 treated at clinic 10 Chicken pox 11 Ringworm of body 20 Tonsillitis 5 Other defects and diseases 39 Diphtheria 4 Exclusion notices were sent by the school medical officer to the appropriate schools and the superintendent of visitors in connection with the above cases. During the year the following cases were brought to the 399 notice of the medical officer of health by the school attendance officers: — Measles (including Whooping cough 461 German measles) 217 Chicken pox 980 Tonsillitis 261 Other diseases 470 Mumps 359 It was not found necessary to close any schools 011 account of infectious disease during the year. X. OPEN-AIR EDUCATION. (a) Playground classes. Opportunity is taken, weather permitting, of holding classes in the playgrounds, and physical exercises are taken in the open-air whenever possible. Some schools hold classes during the warmer months in the open-air on the flat roofs available, and certain schools hold classes in the neighbouring parks and recreation grounds. (b) Open-air classrooms. In three of the most modern schools in the borough, viz. Tollgate, Pretoria Road and the reconstructed South Hallsville schools, special provision has been made for open-air classrooms. (c) School journeys and camps. During the year several departments undertook school journeys to different places lor varying periods. The children were accommodated in boarding houses or hostels, while some went under canvas. All children before going on a school journey are examined by an assistant school medical officer as to their fitness to undertake the journey. The holiday camps which have been held in the summer for some years, already sufficiently described in previous reports, were again held in 1937. In this year the camp for girls was again held at East Cowes, Isle of Wight, but the boys' camp was transferred from Shoeburyness, where it had been held for eleven years, to Dovercourt. The children who are selected to go to these camps all have a thorough medical and dental examination before their departure, and special attention is paid to cleanliness and freedom from contagion. It would appear from the report of Mr. Pannell, the Superintendent of the boys' camp, that the change to the new camp was a great success. The site was a sixteen acre meadow in Upper Dovercourt within ten minutes' walk from the sea; it thus combined the advantageous features of sea and country. The journey 400 was made without incident, and the railway company agreed to collect all the camp gear and deliver it on the site at a cost of 6/8d. per ton. The weather was on the whole very good. During the first fortnight 200 boys went to the camp and the second party consisted of 173 boys. Mr. Pannell comments upon the excellent appetites of the boys and on the fact that they were much improved in their physical appearance by the time they returned home. He also draws attention to the fact that in a camp of this type a satisfactory boiler for hot water is a necessity. The camp for girls, which was again in the charge of Miss Wise, was also a great success. The quarters consist of four well built dormitories, with attached accommodation for staff and for bathing; all the buildings are connected by a covered way. One of the dormitories is used as a dining hall. There is also a house with a staff dining room, kitchen, and some additional accommodation. The number of girls who attended the camp during the first fortnight was 202, and the number during the second fortnight was 187. Miss Wise comments on the fact that walks were sometimes made less enjoyable by unsuitable or poor footwear. In the camp, games were again popular. A good library has been established. It was found that packed lunches were very popular. (d) Children's Country Holidays Fund. A further activity which should be mentioned under this heading is the work of the Children's Country Holidays Fund. All children sent away by the local branches of this Fund are examined by the nursing staff as to their cleanliness and freedom from infectious or contagious conditions. The number of children who were inspected for this purpose during 1937 was 2,114. XI. PHYSICAL TRAINING. An inspector of physical training was appointed by the West Ham Education Committee in October, 1935. This officer left to take up an appointment with the London County Council during the summer of 1938. I am indebted to Mr. Irvine G. Jardine, the chief inspector of schools, for the following report upon the progress of physical education in the area during the year 1937: — West Ham Schools' Sports Association. West Ham is 401 fortunate in possessing one of the oldest and strongest schools' sport associations in the country, built up over many years by a public spirited body of teachers who have given their time and energy freely in order to provide for the children of West Ham opportunities to take part in all kinds of games and sports. Ihere has been a happy spirit of co-operation between the officers of this association and the inspector of physical training. The association's activities cover a very wide field, and include football, netball, cricket, athletics, boxing and swimming.. The following statistics give an indication of the extent of the work undertaken. Football, 1937-38. Four local leagues were arranged during this season. Senior (under 14) 30 teams in 4 sections Intermediate (under 13) 18 ,, ,, 2 ,, Minor (under 12) 19 ,, ,, 2 ,, Junior (under 11) 26 ,, ,, 3 ,, Representative teams were successful in capturing the Cook Cup (Essex) and reaching the third round of the Dewar Shield competition. In the English Schools' Shield and the Corinthian Shield competitions West Ham boys reached the last sixteen and the final respectively. One boy was awarded international caps against Wales and Scotland, while six boys played for London and Essex during the season. Netball (Girls). In the league competitions 46 teams took part. Of these, 17 teams were in the senior division, 15 in the intermediate, and 14 in the junior division. Cricket. In the league competitions 51 teams took part— 32 in the senior division, 5 in the intermediate, and 14 in the junior division. Three boys played for London and Essex. Athletics. The activities of this branch of the association include (a) Individual school sports. (b) Championships. (c) Non-competitive examinations. (d) Sports' Day for infants' schools. In the season 1936-37, 83 departments took part in the individual school sports as against 65 in the previous season. Season 1937-38 has again seen an increased entry in this section. In the Sports' Day for infant schools, over 5,000 children were 402 entered. The best aggregate at the Essex Schools A.A. meeting was won by a West Ham girls' team. Boxing. During the season 1936-37 the following were the entries for the championships: — Senior championships 182 boys from 20 schools Junior championships 177 ,, ,, 22 ,, The corresponding figures for the 1937-38 season were: — Senior championships ,, 143 boys from 25 schools Junior championships 121 ,, ,, 16 ,, In the National Championships of Great Britain the following successes were obtained: — Season 1936-37 3 (6 stone, 7 stone, 7½ stone) Season 1937-38 3 (6½ stone, 7 stone, 8 stone) Swimming. A brief summary of the activities in this sphere of sport and of the successes obtained are given below: — Attendances at Baths (Winter Season 1936-37). Boys Girls Total Romford Road Baths 4,672 4,687 9.359 Balaam Street ,, 12,475 9,189 21,664 Silvertown ,, 359 — 359 Totals 17,506 13,876 31,382 Summer Season, 1937. Boys Girls Total Romford Road Baths 28,206 24,876 53,082 Balaam Street ,, 23,094 16,940 40,034 Silvertown ,, 2,863 2,603 5.466 Y.M.C.A. ,, 7,032 6,552 13,584 Dockland ,, 6,243 7.237 l3,48o Totals 67,438 58,208 125,646 Awards (1936-37). Boys Girls Total 40 yds. Certificates 674 992 1,666 100 yds. ,, 704 840 1,544 440 yds. ,, 566 415 981 R.L.S.S. Awards: Elementary 9 37 46 Intermediate 145 148 293 Bronze Medallion 26 33 59 403 Apparatus and accommodation. All schools in West Ham have been provided with an adequate supply of apparatus for both gymnastics and games. The majority of the Council schools are fortunate in having large halls for indoor physical training. Every opportunity is being taken to improve and add to the existing accommodation. The aim is, as schools are being reorganised, to provide, where possible, each department with a hall of adequate size. During the current year a gymnasium has been erected at Gainsborough Senior School, and at the Deanery School the hall is being fitted with fixed apparatus. Lister Day Continuation Institute (also used for classes of unemployed juveniles) is now provided with fixed apparatus, changing room and shower baths. Clothing. This presents a major problem in areas like West Ham. Children cannot derive full benefit from their exercises unless they are suitably clothed. It is desirable that all pupils should make a complete change of clothing for the physical training lesson, and it is essential that light rubber shoes should be worn during exercises. Unfortunately only in a few schools in West Ham is this complete change of clothing made. In too large a proportion of schools, especially in boys' departments, many of the children are dangerously overclothed and can derive little, if any, benefit from their physical training. It would be a great step forward if all children could be persuaded to provide themselves with rubber shoes, or have them provided by the Authority. Teachers' classes. All teachers in the Borough have been afforded opportunities to attend demonstrations in physical exercises and games. Several special courses have also been arranged for teachers to attend during school time so that it is now possible to utilise the services of trained teachers in a specialist capacity in the majority of senior schools and to a lesser extent in junior schools. Organised games. West Ham is very inadequately provided with playing fields. During the last year, however, by the courtesy of the Highways and Parks Committee, schools are now allowed to send classes to the local parks and recreation grounds. In addition, the City Corporation has given permission for West Ham Park to be used for this purpose; and the Epping Forest Conservators have similarly allotted a portion of Wanstead Flats for the use of the Authority. With this increased accommodation it has been found possible to arrange for an additional 10,000 404 children to pay a weekly visit to a playing field for an hour's period of games. Swimming. Arrangements are made for children to attend the baths in school time to receive instruction in swimming from fully qualified specialist instructors, and the baths are used to capacity. Both summer and winter swimming is arranged for. In addition life-saving classes are conducted by several teachers; children who are sufficiently competent may attend the baths free of charge for life-saving instruction. Swimming proves to be a very popular and successful part of the physical education activities, as is indicated by the figures given above in the paragraph dealing with the West Ham Schools' Sports Association. Curriculum. The majority of schools in West Ham have allocated a generous time allowance for sports. Many head teachers have remarked on a better spirit, increased concentration and higher state of alertness in the children since more physical training was introduced into the curiculum. Physical recreation for those who have left school. "Keepfit" classes are organised in connection with evening institutes. Independent clubs are also assisted by the Authority in this work, either by the provision of a block grant or the services of an instructor. A new development is the formation of "keep-fit" classes in connection with Old Scholars' Clubs. This movement is developing rapidly. West Ham Juvenile Organisations Committee (J.O.C.). This important committee organises and controls the sports activities of the majority of the boys and girls between fourteen and eighteen years of age. It publishes a magazine which is much in demand. XII. PROVISION OF MEALS. Since 1908 a scheme has been in existence in West Ham for the provision of meals for necessitous children. There have been many fluctuations during the ensuing years in the number of meals provided annually, largely due to economic circumstances. At the present time there are twelve centres, one having been opened at Elmhurst Road School during the year. All these centres are so situated as to be easily accessible from any part of the Borough. The menus are arranged by the superintendent of the dining centres. Fresh fruit and vegetables are always 405 supplied when in season. Since 1933 there has been a steady decrease in the number of meals provided. The following figures summarise the extent of this undertaking during 1937: — Breakfasts. Dinners. Free meals provided 301,927 633,130 Meals provided on part or full payment 5,286 32,780 Total 307,213 665,910 The average number of children fed each week was 18,714. The above figures relate to elementary school children only. School milk. The scheme instituted by the Milk Marketing Board became operative in October, 1934. One-third of a pint of pasteurised milk was supplied daily to approximately 22,000 children during the year 1st April, 1936, to 31st March, 1937. XIII. CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND PUBLIC BODIES. (a) Parents are always notified when their children are due to be medically inspected, and the fact that last year the percentage of parents who were actually present at the elementaryschool examinations amounted to 90.2 indicates the interest taken in the work of the school medical service. The number of parents who refuse to have their children medically examined is extremely low. In 1937 the number of children who were affected by this parental objection amounted to 63. Parents are always encouraged to accompany their children when they are being inspected at school, or treated at the clinics. (b) The assistance rendered by teachers has always been greatly appreciated by the staff of the school medical service. The facilities, which are invariably afforded doctors, dentists and nurses whenever they have occasion to go to a school, help considerably in the smooth running of the department. In selecting special cases for examination, urging attendance at clinics and impressing upon parents the need for carrying out advice given, 406 or recommendations made, the teachers play an invaluable part. Children who show some defect and are considered by the doctor to need individual supervision by the teacher are reported to the head teacher on a special confidential form. All cases such as bad vision, defective hearing, heart trouble, etc., are so reported. To the members of the school inspectorate I tender my thanks for their enthusiastic co-operation. (c) There is complete co-ordination between the school medical service and the school attendance officers. The work done by these officers in connection with the health services of the borough is of great value, particularly in regard to cases of nonnotifiable infectious diseases, which are brought by them daily to the notice of the medical officer of health. (d) The school medical service is in close touch with certain voluntary associations and societies in connection with the welfare of individual children. The Invalid Children's Aid Association and the Invalid and Crippled Children's Society notify the school medical officer of children coming to their notice who require new or altered surgical appliances. The Authority assists in the purchase or alteration of instruments. These societies also report cases requiring convalescent treatment. During the year a large number of school children were reported to the medical officer of health, and sent away for periods of convalescence. Assistance in the purchase or repair of surgical appliances was rendered to 34 children. I am also indebted to the National Society for the Prevention of Cruelty to Children and the Central Association for Mental Welfare, as well as to the almoners of a number of voluntary hospitals for their valuable help. (e) In addition to the voluntary hospitals of West Ham and of the County of London, I am also indebted to a number of other voluntary bodies for their valuable work for the welfare of school children. XIV. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. (a) Ascertainment. Information regarding the incidence of children who are suffering from these defects is obtained from various sources; for example, from head teachers, from the school 407 attendance department, from hospitals and other voluntary associations. All such children are kept under close supervision. They may be examined in the first instance by one of the assistant school medical officers. All children are examined by the chief assistant school medical officer, who decides their fitness for certain activities and the desirability of admitting them to special institutions—such as those dealt with later in this section. The school nurse, who is specially designated for this purpose, visits the homes of the children and advises the parents regarding their care. The permanent out-of-school cases are visited from time to time by the nurse, and should there be any changes in the condition which justify re-examination, arrangements are made accordingly. In addition to these arrangements, the head teachers, at the end of each year, submit a report on all children who in their opinion are exceptional. These are dealt with in the manner described above. (b) Blind children. A blind child is defined, by Section 69 of the Education Act, 1921, as one who is too blind to be able to read the ordinary school books used by children. A partially sighted child is one who, though he cannot read ordinary school books, or cannot read them without injury to his eyesight, has such power of vision that he can appropriately be taught in a school for the partially sighted. Children who are able by means of suitable glasses to read the ordinary school books used by children without fatigue or injury to their vision are not included under this heading. The Authority has made no direct arrangement for the education of blind and partially sighted children, but where possible arrangements are made for these children to be admitted to residential schools conducted under other auspices. During the year 1937 it was necessary to make arrangements for only one blind child; this child was accommodated in a certified school for the blind. The number of partially sighted children known to the Authority was 17. Of these 10 were in certified schools for the blind, 6 were at public elementary schools, and 1 was at home. (c) Deaf children. Information regarding deaf children is received from the assistant school medical officers, or from 408 voluntary hospitals and other sources. When the information is received at the office, arrangements are made for the child to be examined by the chief assistant school medical officer, who decides its fitness to attend a deaf centre. A deaf child is defined, by section 69 of the Education Act, 1921, as one who is too deaf to be taught in a class of hearing children in an elementary school. This definition covers some children who are totally, or almost totally deaf and can only be appropriately taught in a school for deaf children. Partially deaf children are defined as children who have partial hearing and can be appropriately taught in a special school for such children. In the year 1937 the Authority had information of 21 deaf children; all of these were at certified schools for the deaf. In the same year the Authority had information of 18 partially deaf children; 7 of these were at certified schools for the deaf and 11 were at public elementary schools. (d) Mentally defective children. All mentally defective children of school age who have not been certified are under the care of the Education Authority. These children are medically examined by the chief assistant school medical officer, and if suitable they are recommended for attendance at one of the special schools. While they are at these schools they have periodical medical examinations. Whether or not such children are attending special schools they are kept under close observation, and a school nurse who is designated for this work attends frequently at their homes to advise the parents regarding the care of these children. On reaching the age of sixteen years, or before that date if necessary, these children may be notified to the medical officer of health, who is officially responsible for the care of mental defectives brought to the attention of the Local Authority. For the purpose of this section mentally defective children arc children who, not being imbecile and not being merely dull or backward, are incapable by reason of mental defect of receiving proper benefit from the instruction in the ordinary public elementary schools, but are not incapable by reason of that defect of receiving benefit from instruction in special schools for mentally defective children. The following figures relate to all such children, except those who have been notified to the Local Authority under the 409 Mental Deficiency Act, in accordance with Article 3 of the Mental Deficiency (Notification of children) Regulations, 1928. In 1937 the total number of feeble minded children known to the Education Authority was 179. Of these 156 were at certified schools for mentally defective children; 10 were at public elementary schools, and 13 were not attending any school or institution. (e) Epileptic children. The definition of an epileptic child for this purpose is one who is epileptic within the meaning of the Act, i.e. a child who, not being an idiot or an imbecile, is unfit by reason of severe epilepsy to attend the ordinary public elementary school. Only severe cases of epilepsy are excluded from attendance at the elementary schools. With reference to treatment, arrangements are made for cases of major epilepsy to be boarded out in suitable institutions. In the year 1937 the total number of cases of epilepsy—as defined above—which were under the notice of the Authority was 16. Of these five were at certified special schools, two were at public elementary schools, one was at an institution of another type, and eight were at home, under the supervision of the school medical and nursing staff. (/) Physically defective children. This group of defective children includes those suffering from tuberculosis of the lungs and (or) other organs, delicate children, crippled children, children with heart diseases, and children with multiple defects. Tuberculous children. This sub-group includes only those children who are diagnosed as tuberculous, and who require treatment for this condition at a sanatorium, a dispensary, or at another similar institution. Children who are suffering from crippling due to tuberculous disease who are no longer in need of treatment are classified below as "crippled children"—provided that the degree of crippling conforms to that classification. All other tuberculous children who are regarded as being no longer in need of treatment are grouped as "delicate children" below, provided that it can be certified under section 55 of the Education Act, 1921, that they are incapable by reason of physical defect of receiving proper benefit from instruction in the ordinary public elementary schools. It will thus be seen that the figures given here for tuberculous children bear little relationship to the figures given in the section of this report which deals with 410 culosis. The classification "pulmonary tuberculosis" includes tuberculosis of the pleura and of the intra-thoracic glands, and the classification "non-pulmonary tuberculosis" includes tuberculosis of all sites other than these. In 1937 the number of cases of pulmonary tuberculosis which were under the supervision of the Authority was 48. Of these 41 were in certified special schools, 5 were in public elementary schools, and 2 were at home. The number of cases of non-pulmonary tuberculosis under the Authority's supervision was 50. Of these 39 were at certified special schools, 10 were at public elementary schools, and 1 was at home. Delicate children. This sub-group includes all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an open-air school, and in respect of whom the medical officer is prepared to certify under section 55 of the Education Act, 1921, that they are incapable by reason of physical defect of receiving proper benefit from instruction in the ordinary public elementary schools. Such children are included in this classification irrespective of the practicability of sending them to residential schools at the time when the diagnosis is made. In the year 1937 the number of delicate children who were under the supervision of the Authority was 640. Of these 263 were at certified special schools, 371 were at public elementary schools, and 6 were not at school. Crippled children. This classification is confined to children (other than those diagnosed as tuberculous and in need of treatment for that disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life, i.e., children who generally speaking are unable to take part, in any complete sense, in physical exercises or games or such activities of the school curriculum as gardening or forms of handwork usually engaged in by other children, and in whose case the medical officer would be prepared to certify under section 55 of the Education Act, 1921, that they are incapable by reason of such physical defect of receiving proper benefit from the instruction in the ordinary public elementary schools. In the year 1937 the number of crippled children who were under the supervision of the Authority was 103. Of these 68 411 were in certified special schools, 23 were in public elementary schools, 2 were in other institutions and 10 were not at school. Children with heart disease. This classification is confined to children in whose case the medical officer would be prepared to certify, under section 55 of the Education Act, 1921, that they are incapable by reason of such physical defect of receiving proper benefit from the instruction in the ordinary public elementary schools. In the year 1937 the number of children who were suffering from such defects and were under the supervision of the Authority was 98, of these 31 were at certified special schools, 49 were at public elementary schools, 17 were at home/and one child was in an institution of another type. Children suffering from multiple defects. This classification includes children suffering from any combination of the following types of defect: blindness (excluding partially sighted children); deafness (excluding partially deaf children); mental defect (feeble-minded); severe epilepsy; active tuberculosis; crippling (as defined above); and heart disease. In the year 1937 three such children were known to the Authority. Particulars of these three cases are given in Table III of Appendix (g) Incidence of exceptional children. The incidence of children showing these defects in the years 1920—1937 inclusive is set out in Table XXIV. In this table the number of mentally defective children includes those notified to the Local Authority for appropriate action. The total number of defects includes children who showed multiple defects. The number of children classified as having multiple defects is not clearly stated before 1931, but in any case the numbers are always small. It will be seen from this table that the incidence of deaf children and physically defective children was very high in the years 1920—1922 inclusive. This fact is hardly in accord with the findings in other parts of the country and it would seem that some external factor must have been responsible. Consideration has, of course, been given to the possibility that the high incidence may have been due to the practice of the medical officers at the time, but this theory does not entirely explain the facts. The point is interesting, and I intend to examine it further at a later date. 412 413 Table XXIV. Elementary Education. Incidence of Exceptional Children (rates per 1,000 of school population). Year Blind and partially blind Deaf and partially deaf Mentally defectives (including cases notified to Local Authority) Epileptic Physically defective Total defectives (including multiple defects) No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 1920 26 0.50 342 6.54 265 5.07 97 1.85 2,429 46.44 3,159 60.39 1921 116 2.20 349 6.62 353 6.70 69 1.31 2,204 41.84 3,091 58.68 1922 158 2.98 343 6.47 359 6.77 76 1.43 1,497 28.24 2,433 45.90 1923 47 0.89 93 1.75 251 4.74 63 M9 819 15.45 1,273 24.02 1924 37 0.72 57 111 262 5 12 85 1.66 482 9.43 923 18.05 1925 41 0.81 87 1.72 252 4.98 60 1.18 538 10.62 978 19.31 1926 36 0.72 82 1.63 252 5.01 64 1.27 651 12.95 1,085 21.58 1927 44 0.89 68 1.37 262 5.28 68 1.37 681 13.71 1,123 22.61 1928 50 1.02 89 1.82 283 5.78 32 0.65 633 12.93 1,087 22.21 1929 45 0.95 85 1.80 304 6.43 29 0.61 528 11.17 991 20.96 1930 44 0.95 70 1.51 296 6.36 26 056 580 12.47 1,016 21.84 1931 36 0.78 74 1.61 279 6.08 31 0.68 644 14.03 1,072 23.35 1932 26 0.57 68 1.50 255 5.63 28 0.62 629 13.89 1,015 22.42 1933 22 0.49 46 1.03 265 5.93 19 0.42 774 17.31 1,131 25.29 1934 18 0.41 39 0.90 234 5.41 16 0.37 735 17.00 1,048 24.24 1935 18 0.44 39 0.96 232 5.71 15 0.37 768 18.90 1,078 26.54 1936 19 0.49 41 1.07 212 5.52 13 0.34 755 19.64 1,046 27.22 1937 18 0.50 39 1.08 211 5.85 16 0.44 942 26.11 1,229 34.06 From 1923 onwards the figures show comparison with those for other areas, and the following remarks refer to these latter figures. It will be seen that the incidence of blind children has not varied much during the years, but that on the whole there is a tendency for such children to be less frequent than formerly. The same statement would apply to the incidences of deaf and partially deaf children, and to mentally deficient children. On the other hand the incidence of epileptic children has shown a definite decline though the figures on which the rates are based are in all cases small. The most significant feature of the table, however, is the rapid increase in the incidence of physically defective children. This increase is similar to that which was recently found for London children by Dr. W. Allen Daley. (h) Special schools. The special schools for which the Authority is responsible are shown hereunder: — Name of School. No. of places or beds Purposes for which used. Knox Road 175 Mental defectives Physically defectives Grange Road 167 Mental defectives Physically defectives Frederick Road Deaf Centre 40 Deaf and partially deaf Water Lane Deaf Centre 40 Deaf and partially deaf Crosby Road Day Open-air School 60 Debilitated children Fyfield Residential Open-air School 200 do. Schools for mentally defective and physically defective children. All the children attending these special schools have annual routine inspection, and any patients found to require treatment for minor ailments are referred to the clinics as in the case of elementary school children. Cases also found to be in need of 414 dental treatment are sent to a school dental clinic and treated, where possible, under the Authority's scheme. A certain number of cases are referred for treatment at the dental department of a local hospital. Children found with defective vision are seen by the Authority's oculist, and assistance given in the purchase of glasses, if necessary, as in the case of elementary school children. During the year 1937, 213 children were medically examined at these schools. The following tables give some information regarding the type of medical work which was carried out at these two schools during the year 1937. The following table shows the number of defects treated during the year: — Skin diseases (non T.B.) 33 Blepharitis 1 Minor eye defects 4 Minor ear defects 29 Other defects and diseases 328 Two voluntary After-Care Committees sit to consider the welfare of children who have recently left these schools. Further progress of leavers. During the year 1937, the number of mentally defective children who left the special schools was 38 and the number of physically defective children was 31. The reasons for leaving are given in Table XXVI. Table XXVI. Reasons for leaving special schools. School. Age limit (16 years) Returned to elementary school. Admitted to residential school. Obtained employment. Removed from district. Unfit for any school. Knox Rd. M.D. 3 — — 6 6 1 P.D. — 1 1 6 3 — Grange Rd. M.D. 4 — — 12 3 3 P.D. 2 2 3 8 3 2 Of the 9 children referred to in column 1, 6 are employed as factory hands or errand boys, 2 are in hospital and 1 is unemployed. The occupations taken up by children referred to in column 415 Table XXV. Defects found at special schools. Defect. Recommended for Treatment. Observation. Unclean head 3 Unclean body 6 — Impetigo 1 — Other skin diseases 7 1 Blepharities 1 — Minor eye defects — — Defective vision 3 20 Squint 2 13 Otitis media 10 2 Other ear diseases 1 — Defective hearing — 4 Teeth—oral sepsis 4 9 Deformities (other forms) 1 24 Spinal curvature — 1 Rickets — 1 Enlarged tonsils and adenoids 2 6 Enlarged tonsils only — 10 Adenoids only — 3 Other conditions nose and throat — 3 Enlarged cervical glands — 6 Defective speech — 20 Tuberculosis—non pulmonary — 25 Lungs—other diseases (not T.B.) — 1 Heart disease—organic — 15 ,, ,, functional — 2 Anaemia 1 2 Other conditions—nerves — 19 Other defects and diseases — 4 416 John H. Jacques, F.R.I.B.A. FVFIELD RESIDENTIAL OPEN-AIR SCHOOL. FYFIELD RESIDENTIAL OPEN-AIR SCHOOL. John H.Jacques, F.R.I.B.A. FYFIELD RESIDENTIAL OPEN-AIR SCHOOL. 4 include factory work, work in shops, clerking, dressmaking, domestic and laundry work, and work as page boy at an hotel or cinema. Deaf Centres. The two deaf centres have the following accommodation:—Frederick Road, 40; Water Lane, 40. All the children are examined annually by an assistant school medical officer and a school dental surgeon, and arrangements are also made for an annual examination by the specialist aural surgeon. A number of children from outside areas are admitted to these schools by arrangement with the local Education Authority, when vacant places occur. During the year 1937, 66 children were medically examined at these schools. The following table shows the number of children found to require treatment or observation. Table XXVII. Defects found at deaf centres. Defect. Recommended for Treatment. Observation. Defective vision 9 — Otitis media 2 — Heart disease — 1 Bronchitis 2 — Deformity 1 1 Adenoids 1 — Skin disease — 1 Other defects 2 1 Some of the defects mentioned above occurred in children from outside areas, and these Authorities were informed. The nutritional state of the children continues to be satisfactory. Further progress of leavers. During the year 1937, ten children left the deaf centres. The reasons for leaving are set out in Table XXVIII. Of the five children referred to in column 1, four are employed as factory hands, etc., and one is at home. The child referred to in column 4, left the school to be apprenticed to a dental surgeon. 417 AA Crosby Road Open-air School. This is a day open-air school, situated in Forest Gate. It has accommodation for 60 girls and junior boys aged 7 years and upwards. The children are recommended by the school medical staff for attendance at the school, and periodic medical examinations are made while they are there. While they are at the school, the children have the benefit of spray baths, breathing exercises and handkerchief and tooth-brush drill. The children attend the swimming baths at Romford Road, and the girls the domestic centre for cookery and housecraft. Good Table XXVIII. Name of deaf centre. Age limit (16 years). Returned to elemenary schools Admitted to residential schools. Obtained employment. Removed from district. Frederick Rd. 4 — — 1 — Water Lane 1 1 1 — 2 meals are provided, and in the morning they have milk. Lessons take place largely in an open-air environment. During the year 16 children were admitted, and 15 were discharged. I am indebted to the headmistress (Miss Davies) for the following note on the work of the school. "The year ended with 34 girls and 18 boys in attendance. The average age of the children is lower than that of previous years. The wide age range—6 years to 14 and over—and the fact that there are only two classes, increase the difficulty of teaching, and individual methods are the only ones practicable. In addition to the usual school subjects, gardening is a most important and useful form of handwork. This year, added attention has been given to art and weaving. Physical training and country dancing are enjoyed, and help, with well balanced meals, a daily rest period, and the maximum of fresh air, to improve the health of the children, and render possible their return to ordinary school. Great stress is laid on personal hygiene, and valuable social training is given. Adequate warm clothing, blankets, and good shoes are provided for the winter months, while during the summer the children wear light cotton sun suits. 418 Ten children returned to ordinary schools during the year, and all the girls who left, having attained the age of 14 years, have obtained suitable employment." Fyfield Residential Open- Air School. This school, which is maintained by the Authority, is situated near Ongar, and now has accommodation for 100 boys and 100 girls. The extensions to the building were completed in June, and the additional 20 boys and 40 girls were admitted thereafter. The additions consisted mainly of sleeping accommodation, additions to the kitchen, and additional class room shelters. Sleeping accommodation. For the sleeping accommodation for twenty extra boys the room under the dormitory was adapted. This involved the clearing away of the existing class room which enclosed the south front, and the provision of a master's bedroom and two w.c.'s, one for the boys at night and one for the master. For the girls a new dormitory was erected in the west side of the quadrangle. This new dormitory is reached from the playground or through the rest room. At the south end of this new dormitory are two staff bedrooms, two store rooms, a staff w.c. and bathroom. At the other end are two staff bedrooms, night w.c.'s for the children, shoe-cleaning room, staff w.c. and bathroom, and lavatories for forty girls. Six additional w.c.'s were added to the existing range. Rest room. The rest room was extended to 164 feet long by 24 feet wide. It is now a very pleasant room which can accommodate the whole of the children in the school. Dining room and kitchen. An addition to the dining room— measuring 23 feet 6 inches by 30 feet—was erected at right angles to the existing room and connected to it. The kitchen was also enlarged. A coal fire range was removed and electrical appliances installed. These consisted of two large ovens, a large boiling plate, a steamer, six boiling coppers and two hot cupboards. Class room shelters. Three additional class room shelters were erected in the neighbourhood of the present shelters, separated from each other by a distance of twenty feet. Staff rooms. Five new staff bedrooms were provided, making a total of thirteen in all. A new staff common room, measuring 25 feet by 11 feet 6 inches, was constructed adjoining the extension of the dining room. 419 Spray balks. A domestic hot water boiler was enlarged, as also was the central heating boiler. Cost. The total cost of these reconstructions and additions was £8,165, which sum £7,245 was spent on the buildings. As this school is sufficiently large and well adapted for its purpose to serve as a model, it is desirable to include here a review of the main points in its design. These are shown in the following table. Particulars of Fyfield Residential Open-air School. Points. Remarks. Site. Size Approximately 32 acres. Proportion to site of:— (a) Buildings 7/8ths of an acre. (b) Playground Tarred. Boys 105 ft. x 101 ft. (10,605 sq. ft.) Girls 100 ft. x 145 ft. (14,500 sq. ft). (c) Garden 10 acres approximately, balance playing field, etc. Classrooms Seven. Size Four, 24 ft. x 24 ft. Three, 23 ft. x 23 ft. Type Open-air (on three sides). Means of heating Low pressure hot water. Position of solid Timber built open-air type; one wall or walls wall with no openings. Verandahs None. Grass or asphalt Small gardens between and in plots in front of front of class rooms with paved paths. Practical instruction rooms None. Hall. Size 41 ft. x 37 ft. x 15 ft. high (1,517 sq. ft.). 420 Uses to which put Used as boys' play-room, etc. Dining room Area 2,325 sq. ft. Not used for other purposes. Kitchen. Accessibility to Adjoins dining room, 25 ft. x 33 ft. dining room Water closet and lavatory provision for kitchen staff 1 lavatory basin and 1. w.c. Resting shed 163 ft. 9 in. x 25 ft. (4,093 sq. ft.) Use of for other Used as girls' recreation room, purposes music room, drill room, etc. Methods of closing Folding doors. and provision for Heated by low pressure hot water. drying Cloakrooms. Arrangements of hat and coat pegs Around lavatories. Warming of and provision for Drying room 16 ft. 6 in. x 10 ft. drying clothes 4 in. Closets and urinals Boys. 8 day and 3 night. Adequacy of Urinals: 2—32 ft. and 20 ft. run; provision 1—6 ft. night urinal. Girls. 14 day and 4 night. Baths and lavatory basins. Type of Troughs with hot and cold water, and with 80 spray taps. Adequacy of Spray baths. Considered ample. provision Girls 1—3 double washing troughs 6 ft. long; 1 double washing trough 9 ft. long; 1 double washing trough 15 ft. long. Boys 4 double washing troughs, 16 ft. long. 421 Medical inspection room. How warmed Coal fire and also electric fire. Use of for other Used as dispensary for treatment purposes of girls. Head teacher's room Office in main building. Dormitories or wards Six*. Ventilation Cross ventilation. Means of Separate supervising officer's bed- supervision room with window overlooking each dormitory. Dimensions Rest room is used as playroom for girls. Hall is used for boys, and there is a ping-pong room. Locker Separate locker for each boy and accommodation girl (200). Sick rooms. Number Two. 10 ft. x 13 ft. Number of beds in each Two. Fioor space per bed 65 sq. ft. Isolation Separate building. Ward for 4 accommodation beds, cubicle for one bed. Nurse's room, bath-room and w.c. Staircases 1 internal, 1 external (fireproof). Exits in case of fire Boys' dormitory. I internal emergency staircase; I external fireproof staircase. Other dormitories, etc., are on ground floor. All doors on front open outwards. Staff accommodation Teachers Bedroom for each and joint use of sitting- and dining-rooms. * For further particulars of these dormitories see table on page 423. 422 Fyfield Open-air School. Large girls' dormitory. 423 Dimensions of dormitories at Fyfield Open-air School. Name of ward Lea. Chelmer. Koding. Thames. Fyfield. Moreton. Number of beds in each 22 22 36 20 60 40 Dimensions 51' 6" x 18' 51' 6" x 18' 63' x 23' 38' x 23' 99' x 25' 90' x 25' 914 sq. ft. 914 sq. ft. 1,449 sq.ft 874 sq. ft. 2,250 sq. ft. 2,475 sq.ft. Floor space for bed 42 sq. ft. 42 sq. ft. 40¼ sq. ft. 43¾ sq. ft. 37½ sq. ft. 61¾ sq. ft. Spaces between the edges of adjacent beds 2' 3" 2' 3" 2' 0" 2' 3" and 6' 2' 3" and 8' 2' 3" and 8' Total accommodation 100 boys 100 girls Matron Nurses Domestic Dining accommodation and common rooms Clothing stores Ward class cupboards for daily storage Rooms for medical treatment Bedroom, sitting-room and bathroom. Bedroom each and joint use of sitting- and dining-rooms. Non-resident, except cook and two maids who have a bedroom each. I domestic staff dining room and common room; I senior staff dining-room. There are three cottages for staff. 12 clothing stores. One cupboard for each child. (a) Dispensary in old building for boys; (b) medical inspection room used for girls. The routine of work and play in the school has been sufficiently described in previous reports. During the year 188 boys and 165 girls were admitted, and 190 boys and 148 girls were discharged. The children are reexamined a few months after they leave school to ascertain if their improvement has been maintained. Of the 289 children who were requested to attend for re-examination, 39 did not attend for various reasons. Of the 250 who were examined, 222 showed continued improvement, but 28 children had had intercurrent illnesses, and their condition at the time of examination was not so satisfactory. Ogilvie School of Recovery, Clacton-on-Sea. The Authority also retains 10 beds for girls at the Ogilvie School of Recovery, Clacton-on-Sea. The selected cases are delicate children found at routine and special examinations. The children selected for admission are further examined medically before going to Clacton, and the discharged cases are examined soon after their return home. During the year 12 cases were admitted and 10 discharged. Speech defects. Special classes of from eight to ten weeks' duration have been carried out at Cave Road School during the year. They are under the supervision of a qualified teacher 424 and the results have been very promising. In the case of children who did not make sufficient improvement during the first course, a repeat course was recommended. The following table sets out the general daily routine at the stammering class:— 9.30 to 10.30 a.m. Breathing, voice and articulation exercises, followed by individual difficulties. 10.30 to 10.4s a.m. Break. 10.45 to 11.30 a.m. Reading, poetry or conversation. 11.30 to 12 noon Arithmetic or written answers to questions on English, geography, history, or general knowledge. 2.0 to 3.0 p.m. Voice and articulation exercises. Reading, poetry or conversation. 3.10 to 3.15 p.m. Break. 3.15 to 4.0 p.m. Handwork, composed of bookbinding, paper-modelling or drawing. Girls encouraged to bring needlework or knitting. Solving of children's crossword puzzles. The children are examined by an assistant school medical officer before and at the end of each course. During the year 12 boys and 4 girls attended the first class; 10 boys and 3 girls took a second course, and 2 boys and 4 girls a third class. One boy was considered to be in need of a further course. Four classes were held during the year. Children from outside areas are accepted when vacancies are available. The children were re-inspected about six months after attending the class, and the improvement made had been maintained with he exception of four boys and one girl, who were recommended to attend the class for stammerers for a further course. XV. HIGHER EDUCATION FOR DEFECTIVE STUDENTS. In 1937 vocational training was being provided for three blind men—one at the School for the Blind, Swiss Cottage, and two at the Royal School for the Blind, Leatherhead. 425 In addition two adult blind persons were receiving training at the West Ham Municipal Workshops for the Blind. This institution is administered by the Local Authority. The following are a few particulars of these two blind persons:— Initials. Trade. Date admitted to workshops. A.N G.S.C. Brush making do. 7.9.36 18.8.36 These blind persons whilst in training are in receipt of the Council's unemployed grant. On completion of their training they are usually given employment in the Council's workshops. XVI. NURSERY SCHOOLS. The Authority has two nursery schools—the Rebecca Cheetham nursery school in the north of the Borough and the Edith Kerrison nursery school in the south. These schools have been sufficiently described in previous annual reports. Rebecca Cheetham Nursery School. Dr. West reports as follows on his work at the school during the year:— "During the year 1937 four quarterly routine medical inspections were made. The following particulars indicate the findings:— Examination. Boys. Girls. Total. Parents present. Defects. No. Percent. March 54 56 110 84 20 18.1 June 62 52 114 92 22 19.2 September 47 40 87 80 18 20.6 December 52 51 103 85 13 12.6 In March the attendance was good and the condition of most of the children satisfactory. There were no cases of infectious disease amongst the absentees. In June the general condition of the children remained good and with few exceptions all showed increase of weight. A particularly high attendance is to be noted. Some of the new children admitted were found to be slightly below normal nutrition, 426 Fyfield Opex-air School. "After dinner rest a while." 427 and were accordingly recommended for a course of malt and oil. There were again no cases of infectious disease amongst the absentees. In September the attendance was much lower than at the corresponding period in the previous year, due to a number of children being away with their parents hopping, or in convalescent homes. The general condition of those in attendance was satisfactory. Some loss of weight was noted in certain instances, which may be attributed to alteration in diet and especially rest periods during the previous holiday. There was only one case of infectious disease, viz. diphtheria, amongst the absentees. In December the general health and condition of the children continued to be good and their weight records satisfactory. A noteworthy feature was the low percentage of defects. Amongst the absentees there were two cases of chicken pox, two of diphtheria, and two of mumps. During the year 40 children received malt and oil, or cod liver oil. These were cases of slightly subnormal nutrition, debility, slight rickets and bronchial catarrh." Miss Gubb in her report comments on the beneficial effect of training in nose blowing on the mouths of the children. Edith Kerrison Nursery School. Dr. Furniss reports as follows on his work at the school during the year: — "The Edith Kerrison Nursery School has now completed its seventh year. During the year 1937 four quarterly medical inspections were carried out. The following report relates to the chief findings at these inspections: — Examination. Boys. Girls. Total. Parents present. Defects. No. Percent. March 61 52 113 93 21 18.5 June 65 49 114 89 18 15.7 September 57 43 100 80 16 16.0 December 59 51 110 90 16 14.5 The number in column 5 relates to individual children found to be defective and not to the number of defects discovered. As in previous years, extracts from the four quarterly reports will give a good idea as to the condition of the children. 428 March: The condition of the children is satisfactory. This is noteworthy, as this is usually the worst quarter of the year. Only three children were found to have bronchitis—none severe. June: The attendance at this inspection is particularly good, only six children being absent. Most of the children have a good colour and the nutritional condition is satisfactory. September: The attendance at this inspection is satisfactory. The children are in good condition, very few of the defects being of a really serious nature. There were three cases of rickety deformity among the new children of age two years. They were sent to the orthopaedic surgeon. Only three children lost weight: this is very satisfactory as it is usually found that quite a number lose weight during the long summer vacation. This loss of weight has been referred to in previous reports, and is probably due to alterations in their diet and rest periods. There are no cases of infectious disease among the absentees. December: The results of this examination are most gratifying. The percentage defective is the lowest recorded during the year. The nutritional state of the children remains good. During the last quarter the average gain in weight has been 2¼ lbs. per child. General report. Using the Board's classification for nutrition, the returns are as follows: — Percent. of children examined. 1936. 1937. Excellent 26.0 32.7 Normal 70.0 65.5 Slightly subnormal 4.0 1.8 The fact that the Rosetta Road Clinic is situated next to the nursery school enables all children who require treatment to receive it promptly. During the course of the year 45 children were given cod liver oil. These children were suffering from very slight subnormal nutrition, debility, bronchitis, or slight rickets. It is now three years since cod liver oil was first given to certain special cases, and it is found that between forty and fifty children need the preparation every year. The use of the oil is discontinued during the summer months. There is no doubt as to the good the oil does in these special cases." 429 Voluntary Day Nursery Schools. There are two voluntary day nursery schools in the Borough. No statutory medical examinations have taken place in the schools, but children under five years for whom operative treatment of tonsils and adenoids is required are referred for treatment by the maternity and child welfare section. XVII. SECONDARY SCHOOLS AND OTHER INSTITUTIONS OF HIGHER EDUCATION. This section refers to the work carried out in the following institutions : — Type of school. Name of school. Relation to Authority. No. oil roll. Average attendance Technical West Ham Municipal College Maintained 344 292 Secondary West Ham Municipal Secondary Maintained 632 596 Secondary The Plaistow Secondary Maintained 570 550 High St. Angela's High School Part-maintained 157 154 High The West Ham High School Part-maintained 197 192 *Central The Grove Maintained 384 365 *Central The Russell Maintained 381 374 * The figures relating to the examination of children in the central schools arc included in the tables relating to higher education in the Appendix to this section on pages 438 to 448. The average attendance at these schools, however is included in the average attendance at elementary schools, bringing the total from 35,354 to 36,082 as returned on page 360. Arrangements for examination. (a) Municipal College. The Authority undertakes the medical inspection of certain students in attendance at this College, provided by them. The students examined are those attending (i) junior courses in engineering, first and second year; (2) Trade School for Girls, (a) preparatory, (b) dressmaking, first and second year, (c) cookery, first and second year; (3) Junior Art Trade School for Boys and Girls. 430 Three visits are made during the year, and re-inspections are made of examinees from each previous medical inspection. The examinations are fuller in detail than those carried out in the elementary schools, colour vision, chest measurements, and other enquiries incidental to the age period being noted. Arrangements have been made for the girl students to be examined by a lady doctor. The procedure of following-up by nurses' visits and by reinspection by the assistant school medical officers is the same as in the elementary schools. The school clinic and hospital arrangements for the treatment of tonsils and adenoids, defective vision, and ringworm of the scalp by X-ray treatment are available if required. (b) Secondary schools. The children who are about to enter these schools are examined specially before the schools open. All the scholars in the secondary schools also have an annual medical examination, in addition to which the assistant school medical officers make one visit a year for the purpose of reinspecting those pupils who were found to have defects at a previous examination. The girl students in these schools are examined by a lady doctor. The procedure of following-up by nurses' visits is the same as in the elementary schools. Every facility provided by the Authority for the treatment of children is available for these pupils. Many of the pupils, however, have their defects remedied privately. Treatment is obtainable by all the scholars, i.e. scholarship holders and fee payers. (c) High schools. On the request of the respective Governors, the Authority provides for the medical inspection of West Ham scholars in the West Ham High School for Girls, and in St. Angela's High School, with the exception of the preparatory departments of those schools. These schools are visited each year by a lady doctor, and the same medical services are available for the scholars as for those children attending elementary schools. (d) Continuation institutes. There is now only one continuation school in the borough, viz., the Lister Institute. Routine medical inspection of the pupils attending this continuation school is now undertaken by the Authority. Arrangements have been made for the examination of the girl students by a lady doctor. (e) Central schools. There are two central schools—The Grove School, Forest Gate, and The Russell School, Plaistow. 431 The children who are about to enter these schools are examined specially before the schools open. The second examination takes place during the second quarter of the year, and all scholars who are in their third year and due to leave at midsummer are then examined. At the latter examination the headmaster may submit as "specials" any scholars who exhibit features of some ailment or of retarded progress. At the request of the headmaster special arrangements may also be made for the examination of such children. The routine procedure of following-up by nurses' visits and by re-inspection by the assistant school medical officer, is the same as in the case of the elementary schools. The Authority's specialists, school clinics, and arrangements for the operative treatment of tonsils and adenoids are available where necessary. Scholarship children. These children have a medical examination before they take up their scholarship. The schools at which such scholarships are held are The Grove Central School, The Russell Central School, The West Ham Secondary School, The Plaistow Secondary School, St. Angela's High School for Girls and the West Ham High School for Girls. A few boys hold their scholarships at St. Bonaventure's. Results of inspection. Table XXIX gives the results of the inspection of children at these various schools. It will be seen that there was some slight variation in the frequency of defects in different schools, but that in several cases this can be accounted for by the small numbers of children examined. The percentage of defects found at the Plaistow Secondary School is definitely larger than that found in other schools. This comparatively high percentage is due mainly to the fact that defects in the girls in this school were much more frequent than in the boys. On the whole there is no marked difference in the frequency of defects in boys and in girls respectively in the other schools. With reference to individual defects it will be seen from Table XXX. that defective vision was by far the commonest. This condition was present in 12.0 per cent. of the boys examined, and in 17.1 per cent. of the girls examined. The frequency of other defects is shown in the table. None of these was sufficiently common to warrant any mention. It will be realised that no definite conclusions can be 432 Table XXIX. Higher education and central schools. Frequency of defects, 1937. Type of school and name Frequency of all defects Boys Girls Persons No. examined. No. defective. Per cent. defective. No. examined. No. defective. Per cent. defective. No. examined. No. defective. Per cent. defective. Technical institutions : Municipal College 194 29 14.9 160 34 21.3 354 63 17.8 Secondary schools : West Ham Secondary School 354 68 19.2 268 53 19.8 622 121 19.5 Plaistow Secondary School 328 76 23.2 220 92 41.8 548 168 30.7 High schools : St. Angela's — — — 165 31 18.8 165 31 18.8 West Ham High School tor Girls — — — 184 38 20.7 184 38 20.7 Continuation : Lister Institute 55 5 9.1 119 27 22.7 174 32 18.4 931 178 19.1 1116 275 24.6 2047* 453 22.1 Central Schools : The Grove: Entrants 52 12 23.1 40 7 17.5 92 19 20.7 Leavers 40 8 20.0 29 7 24.1 69 15 21.7 The Russell: Entrants 52 14 26.9 45 7 15.6 97 21 21.6 Leavers 38 4 10.5 42 3 7.1 80 7 8.8 182 38 20.9 156 24 15.4 338* 62 18.3 * The total of these two entries differs from the total number of higher school children inspected, as set out in Table I. of the Appendix, as a result of the exclusion of certain individual children who had special examinations. 433 Table XXX. Higher education and central schools. Details of defects, 1937. Nature of defect Higher Education Central Schools All Schools Defects present per 1,000 examined Municipal College West Ilam Secondary School Plaistow Secondary School St. Angela's High School West Ham High School for Girls Lister Institute The Grove The Russell No. examined No. showing defects Defective vision : (a) Boys 16 39 46 — — 2 17 14 1,113 134 120.39 (b) Girls 19 39 74 16 24 17 12 6 1,272 217 170.60 Squint — 1 5 1 — 1 1 1 2,385 10 4.19 Other eye conditions 1 — 4 — 1 — 1 — 2,385 7 2.94 Skin diseases 3 6 10 1 1 4 — 2 2,385 27 11.32 Enlarged tonsils and (or) adenoids 1 2 10 — 2 1 — 1 2,385 17 7.13 Other nose and throat conditions 5 4 3 7 3 2 1 — 2,385 25 10.48 Ear conditions 3 1 9 2 2 1 — — 2,385 18 7.55 Chest conditions — 2 — — — — — — 2,385 2 0.84 Nervous conditions — — — 1 — — — — 2,385 1 0.42 Heart disease — — 1 — — — — — 2,385 1 0.42 Anaemic 8 9 1 2 6 — 1 — 2,385 27 11.32 Spinal curvature 4 — 3 — 1 1 — 1 2.385 10 4.19 Deformities 8 — 7 — — 2 — — 2,385 17 7.13 Minor orthopaedic defects 1 — — — — 1 — — 2,385 2 0.84 Other conditions 18 5 14 2 3 3 2 3 2,385 50 20.97 434 Table XXXI. Higher education and central schools. State of nutrition, 1937. Type of school and name Boys Girls Subnormal nutrition Excellent Normal Subnormal Excellent Normal Subnormal No. (boys and girls) Percentage of children examined No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. Technical institutions : Municipal College 72 37.1 113 58.2 9 4.6 50 31.3 104 65.0 6 3.8 15 4.2 Secondary schools : West Ham Secondary School 130 36.7 202 57.1 22 6.2 39 18.5 165 78.2 7 3.2 29 5.1 Plaistow Secondary School 111 33.8 213 64.9 4 1.2 54 24.5 148 67.3 18 8.2 22 4.0 High schools : St. Angela's — — — — — — 44 26.7 111 67.3 10† 6.1 10 6.1 West Ham High School for Girls — — — — — — 49 26.6 126 68.5 9 4.9 9 4.9 Continuation : Lister Institute 19 34.5 31 56.4 5 9.1 32 26.9 75 63.0 12 10.1 17 9.8 332 35.7 559 60.0 40 4.3 268 25.3 729 68.8 62 5.9 102 5.1 Central Schools : The Grove: Entrants 8 15.4 33 63.5 11 21.2 12 30.0 23 57.5 5 12.5 16 17.4 Leavers 13 32.5 26 65.0 1 2.5 8 27.6 20 69.0 1 3.4 2 2.9 The Russell: Entrants 8 15.4 34 65.4 10 19.2 8 17.8 27 60.0 10 22.2 20 20.6 Leavers 23 60.5 15 39.5 0 0.0 15 35.7 23 54.8 4 9.5 4 5.0 52 28.6 108 59.3 22 12.1 43 27.6 93 59.6 20 12.8 42 12.4 * Details of nutrition in respect of 57 girls examined at this school are unavailable, †This figure includes one girl whose nutritional state was classified as D (bad). 435 drawn from the figures in these tables, but the figures are published here for reference purposes and for use later. State of nutrition. The state of nutrition in these children is set out in Table XXXI. Comparison of the percentages in this table with those in Table II B of the Appendix on page 442 will show that the children attending higher institutions were definitely much better nourished than children attending elementary schools. The percentage of children with subnormal nutrition in the former schools was 5.0 per cent. In the reports from individual assistant school medical officers mention is made of certain features which are worthy of comment. For example, in the West Ham Secondary School Dr. Fitchet reports that of five heart cases, three were allowed to take part in games and drill; one in exercises, but no games; and that one had to continue with the prescribed restrictions. At the Plaistow Secondary School Dr. Griffin reports that very few of the dental cases who had been recommended for dental treatment had obtained it. Dr. Fitchet also reports that at the St. Angela's High School for Girls, one case of malnutrition was admitted to a nursing home for observation and treatment, and that of three heart cases, two are now allowed to take part in all games and systematic exercises, but that the third is still restricted. It is noted that two girls, one attending the West Ham Secondary School and the other St. Angela's High School, refused to obtain the glasses prescribed. XVIII. PARENTS' PAYMENTS. The arrangements made for recovering the cost of treatment from parents of children attending public elementary schools and pupils attending secondary schools and other institutions of higher education are as follows: — Medical and denial treatment. Lists of cases treated are periodically sent to the Superintendent of Visitors. The school attendance officers visit each case and ascertain the income of the parents. The cases are then assessed in accordance with the Committee's scale and the amount is collected by weekly instalments. The following amounts were paid by parents during the year in respect of the treatment stated: — 436  £ s. #] Dental treatment 163 12 3 Treatment for tonsils and adenoids 71 9 6 X-ray treatment for ringworm 1 1 0 Artificial sunlight treatment 24 1 0 Orthopaedic in-patient treatment 1 19 2 Fyfield Open-air School .. 568 11 6 Other residential institutions 200 2 6 Spectacles. Parents claiming assistance in respect of the supply of spectacles to children attend the School Attendance Department and state particulars of their income. Upon this information, an order is given to the optician to the Education Committee to supply the spectacles at contract price, the parents contributing according to their means. The sum of £24. 2s. 2d. was contributed by the Council in connection with these necessitous cases. XIX. MISCELLANEOUS. Employment of Children and Young Persons. The employment of school children out of school hours is subject to certain restrictions governed by bye-laws under section 9 of the Education Act, 1921. These restrictions limit the age at which a child can commence such work, and the hours of employment. The child must be medically examined and a certificate given that the work will not injure the child's health or prejudice his education. The greater part of the work undertaken by children in this borough consists of newspaper delivery and other errand rounds connected with provision stores. The Bye-laws under the Education Act, 1921, relating to the employment of children have been recently revised and adopted by the Council. In the main they give greater elasticity to child employment without essentially altering the hours of employment or encroaching on the conditions. Moreover they bring these conditions more into line with those of the London County Council and neighbouring boroughs. During 1937, the number of children examined was 244. During the same period certificates of fitness under the Employment of Children in Entertainments Rules (section 101, Education Act, 1921), were granted in respect of 55 girls and one boy. Juvenile Instruction Centre. In accordance with the 437 Ministry of Labour's Memorandum on the provision of medical inspection for juveniles attending the authority's course of instruction, arrangements were made by the Authority for a medical inspection to be carried out at the Juvenile Instruction Centre, which was held in the premises of the Y.M.C.A. in Greengate Street. Unfortunately the Centre was closed in September, 1937. Dr. West reports that he examined the boys on five occasions during the period that the Centre was in operation. The total number of boys examined at these inspections was 65, and of these 8 were found to be defective. The most common defect was defective vision. The standard of nutrition was satisfactory, 36.9 per cent. being above the average, 58.5 per cent. of average nutrition, and 4.6 per cent. showed slightly subnormal nutrition. Dr. Griffin reports that during the six months from April to September she examined 40 juveniles at the Centre. Of these five had defective vision, and eight suffered from other defects. The parents of ten of the juveniles examined were present at the examination. The children were classified as far as nutrition was concerned as follows: — Above average 15.0 per cent. Average nutrition 67.6 per cent. Below average 17.4 per cent. The number of juveniles re-inspected was thirteen, and treatment recommended was obtained in many cases. Dental appointments were made for six cases with the authority's dentist, and of these three did not attend for treatment. Dr. Griffin notes that a considerable proportion of the defects were of the type which improved little, if at all, as a result of treatment, and which therefore interfere with the constant employment of these juveniles. Short lectures and advice were given at every opportunity in order to encourage the girls to take an interest in their health. An excellent and inexpensive midday dinner was provided daily at the Centre, and physical instruction in the gymnasium was provided as part of the education. Pathological Work. The microscopical examination of sputum for the presence of the tubercle bacillus is undertaken by the Tuberculosis Officer. Throat swabs are taken by the school medical staff as required, and sent to the Superintendent of Plaistow Fever Hospital for culture and report. 438 APPENDIX TO REPORT ON SCHOOL MEDICAL SERVICE. TABLE I. RETURN OF MEDICAL INSPECTION. A. Routine medical inspections. Code Group. Boys. Girls. Total. Entrants 2,154 2,256 4,410 Second age group 2,090 1,852 3,942 Third age group 1.999 2,068 4,067 Totals 6,243 6,176 12,419 Other routine inspections .. 965 956 1,921 Elementary schools : Grand totals 7,208 7,132 H,340 Special schools 129 84 213 Nursery schools 457 394 851 Secondary schools 1,206 1,365 2,571 B. Other inspections. Special inspections Re- inspections. Total. Elementary schools 16,062 7,452 23,514 Secondary schools 87 597 684 Totals 16,149 8,049 24,198 439 Table I—continued. C. Number of individual children found at routine medical inspection to require treatment (excluding malnutrition, uncleanliness and dental disease). Group. Number of children Percentage of children found to require treatment. Inspected. Found to require treatment. Entrants 4,410 759 17.21 Second age group .. 3,942 857 21.74 Third age group 4,067 852 20.95 Total (prescribed groups) 12,419 2,468 19.87 Other routine inspections 1,921 137 7-i3 Elementary schools : Grand totals 14,340 2,605 18.17 Secondary schools (including bursars) 2,571 490 19.06 Nursery schools 851 144 16.92 440 TABLE II. A.— Return of Defects found by Medical Inspection in the year ended 31ST December, 1937. Defect or disease Elementary schools Secondary schools Routine inspections Special inspections Routine inspections Special inspections No. ot defects No. of defects No. of defects No. of defects Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment Skin : Ringworm, scalp — — 23 — — — — — Ringworm, body 7 — 99 — — — — — Scabies ... 7 — 253 — 3 — 1 — Impetigo 7 1 637 — — — 1 — Other diseases (nontuberculous) ... 100 18 3,204 — 25 6 • 16 — Total (skin diseases) 121 19 4,216 — 28 6 18 — Eye : Blepharitis 44 2 237 — 5 — 1 — Conjunctivitis 11 4 409 1 2 — 4 — Keratitis 1 — 8 — — — — — Corneal opacities 1 1 17 — — — — — Other conditions (excluding defective vision and squint) 15 11 275 — — — 4 — Total (eye diseases) 72 18 946 1 7 — 9 — Defective vision (excluding squint) 617 92 664 3 329 19 29 Squint 195 15 220 2 11 — — — Ear : Defective hearing 26 9 51 2 2 2 1 — Otitis media 56 10 427 — 11 2 3 — Other ear diseases 54 4 426 — 6 1 1 — Nose and Throat : Chronic tonsillitis only 136 114 52 — 13 6 — — Adenoids only 30 29 26 3 1 2 — — Chronic tonsillitis and adenoids 434 102 378 — 2 1 3 — Other conditions 125 24 162 3 25 1 1 — Enlarged cervical glands (non-tuberculous) 32 39 165 1 1 1 — — 441 TABLE II.— continued. Defect or disease Elementary schools Secondary schools Routine inspections Special inspections Routine inspections Special inspections No. of defects No. of defects No. of defects No. of defects Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept' under observation but not requiring treatment Defective speech 9 25 34 15 — 1 — — Heart and circulation: Heart disease : Organic 74 101 49 16 1 20 — — Functional — 39 8 1 — 10 — — Anæmia 79 17 79 3 28 6 — — Lungs : Bronchitis 111 92 92 2 1 2 — — Other non-tuberculous disease 31 43 42 5 1 1 — — Tuberculosis : Pulmonary : Definite — 10 1 3 — — — — Suspected 2 11 11 3 — — — — Non-Pulmonary : Glands 8 8 26 2 — 1 — — Bones and joints — — 9 — — — — — Skin — — — — — — — — Other forms — — — — — — — — Total (non-pulm. tuberculosis) 8 8 28 2 — 1 — — Nervous system : Epilepsy 6 11 17 8 — 2 1 — Chorea 10 14 28 3 — 1 — — Other conditions 36 25 68 2 2 4 — — Deformities : Rickets 10 11 7 1 — — — — Spinal curvature 31 6 8 1 8 1 — — Other forms 51 49 49 6 20 6 2 — Other defects and diseases (excluding defects of nutrition, uncleanliness and dental diseases) 446 254 8,923 33 47 34 21 — Total number of defects 2,802 1,191 17,177 119 544 130 89 — 442 TABLE II.— continued. B.— Classification of the Nutrition of Children inspected during the year in the routine age groups. Age groups. Number of children inspected A. (Excellent) B. (Normal) C. (Slightly sub-normal) D. (Bad) No. Per cent. No. Per cent. No. Per cent. No. Per cent. Entrants 4,410 572 12.97 3,330 75.51 504 11.43 4 .09 Second age group 3,942 549 13.93 2,878 73.01 506 12.83 9 .23 Third age group 4,067 864 21.24 2,818 69.29 381 9.37 4 .10 Other ages 1,921 469 24.41 1,323 68.87 128 6.66 1 05 Totals (elementary) 14,340 2,454 17.11 10,349 72.16 1,519 10.59 18 .13 Secondary schools 2,571 971 37.77 1,467 57.06 132 5.13 1 •04 Totals (all groups) 16,911 34,25 20.25 11,816 69.84 1,651 9.76 19 .11 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Blind children. At certified schools for the blind At public elementary schools At other institutions At no school or institution Total 1 — — — 1 Partially sighted children. At certified schools for the blind At certified schools for the partially sighted At * public elementary schools At other institutions At no school or institution Total. 10 — 6 — 1 17 443 TABLE III.— continued. Deaf children. At certified schools for the deaf At public elementary schools At other institutions At no school or institution Total. 21 — — — 21 Partially deaf children. At certified schools for the deaf At certified schools for the partially deaf At public elementary schools At other institutions At no school or institution Total. 7 — 11 — — 18 Mentally defective children— feeble-minded children. At certified schools for mentally defective children At public elementary schools At other institutions At no school or institution Total. 156 10 — 13 179 Epileptic children—children suffering from severe epilepsy. At certified special schools At public elementary schools At other institutions At no school or institution Total. 5 2 1 8 16 Physically defective children. A. Tuberculous children : — 1—Children suffering from pulmonary tuberculosis (including pleura and intra-thoracic glands). At certified special schools At public elementary schools At other institutions At no school or institution Total. 41 5 — 2 48 444 TABLE III— continued. 2—Children suffering from non-pulmonary tuberculosis. At certified special schools At public elementary schools At other institutions At no school or institution Total. 39 10 — 1 50 B. Delicate children. At certified special schools At public elementary schools At other institutions At no school or institution Total. 263 371 — 6 640 C. Crippled, children. At certified special schools At public elementary schools At other institutions At no school or institution Total. 68 23 2 10 103 D. Children with heart disease. At certified special schools At public elementary schools At other institutions At no school or institution Total. 31 49 1 17 98 Children suffering from multiple defects. Combination of defect. At certified special schools. At public elementary Schools. At other institutions. At no school or institution. Total. Deaf and dumb and mental defect 1 — — — 1 Heart and crippling — — — 1 1 Epilepsy and mental defect — — — 1 1 445 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31ST DECEMBER, 1937. Treatment Tables. Group I. Minor ailments (excluding uncleanliness for which see Group VI). Defect or disease. Number of defects treated, or under treatment during the year. Elementary schools. Secondary schools. Special schools. Nursery schools. Under Local Authority's scheme. Otherwise. Total. Under Local Authority's scheme. Otherwise. Total. Under Local Authority's scheme. Under Local Authority's scheme. Skin :— Ringworm: scalp (a) X-rays 13 — 13 — — — — — (b) otherwise 7 3 10 — — — — 1 Ringworm, body 96 2 98 — — — — 1 Scabies 251 3 254 3 — 3 — 1 Impetigo 620 17 637 1 — 1 1 4 Other skin diseases 3,160 73 3,233 15 5 20 40 29 Minor eye defects (External and other, but excluding cases falling in Group II) 926 43 969 9 5 14 6 26 Minor ear defects 869 69 938 6 4 10 40 34 Miscellaneous (e.g. minor injuries, bruises, sores, chilblains, etc.) 6,248 537 6,785 14 2 16 328 196 Totals 12,190 747 12,937 48 16 64 415 292 446 TABLE IV.— continued. Group II. Defective vision and squint (excluding minor eye defects treated as minor ailments. Group I). Number of defects dealt with. Elementary schools. Secondary schools. Special schools. Nursery schools. Under the Authority's scheme. Otherwise. Total. Under the Authority's scheme. Otherwise. Total. Under the Authority's scheme. Under the Authority's scheme. Errors of refraction (including squint, but excluding operations for squint) 2,018 25 2,043 479 22 501 32 7 Other defects or disease of the eyes (excluding those recorded in Group I) — — — — — — — — Totals 2,018 25 2,043 479 22 501 32 7 Number of children for whom spectacles were :— (a) prescribed 1,835 42 1,877 450 22 472 30 7 (b) obtained 1,748 42 1,790 437 22 459 30 5 TABLE IV.—continued. Group III. Treatment of defects of nose and throat. Number of defects. Type of school. Received operative treatment. Received other forms of treatment. Total number treated. Under the Authority's scheme in clinic or hospital. By private practioner or hospital apart from the Authority's scheme. Total. (1) (2) (3) 4 (1) (2) (3) (4) (1) (2) (3) (4) Elementary schools 58 25 537 2 2 2 75 7 60 27 612 9 143 851 Secondary schools 2 — 3 — — — 1 — 2 — 4 — 28 34 Special schools — — 3 — — — — — — — 3 — — 3 Nursery schools — — 17 — — — — — — — 17 — — 17 (1) Tonsils only. (2) Adenoids only. (3) Tonsils and adenoids. (4) Other defects of the nose and throat. Group IV. Orthopaedic and postural defects. of school. Under the Authority's Scheme. Otherwise. Residential treatment with education. Residential treatment without education Non-Residential treatment at an orthopaedic clinic. Residential treatment with education. Residential treatment without education Non-Residential treatment at an orthopaedic clinic. Total. Number of children (elementary) 24 — 91 — — 41 156 Number of children (secondary) — — 5 — — 7 12 447 TABLE V. DENTAL DEFECTS. (i) Number of children inspected by dentists: Elementary. Secondary. Routine 18,182 — Specials 4.559 142 Total 22,741 142 (2) Found to require treatment 14,258 117 (3) Actually treated 10,095 112 (4) Attendances made by children for treatment 16,720 274 (5) Number of half-days devoted to (a) inspection 195 — (b) treatment 1,996 — Total half-days 2,191 — (6) Number of fillings : — (a) permanent teeth 2 15 2 Il8 (b) temporary teeth 341 — Total fillings 2.493 Il8 (7) Number of extractions : — (a) permanent teeth I.756 54 (b) temporary teeth 15,846 20 Total extractions 17,602 74 (8) Administrations of general anaesthetics for extractions — (9) Other operations : — (a) permanent teeth 1,691 99 (b) temporary teeth 621 — Total of "other operations" 2,312 99 448 TABLE V.—continued. Details of elementary school children inspected by dentists as routines: — Routine age groups Age Total 18,182 4 375 5 779 6 3.742 7 4,040 8 4,127 9 1,021 10 934 11 944 12 1,033 13 1,081 14. 106 TABLE VI. UNCLEANLINESS AND VERMINOUS CONDITIONS. Elementary schools. (1) Average number of visits per school made during the year by the school nurses 11.93 (2) Total number of examinations of children in the schools by the school nurses 79,476 (3) Number of individual children found unclean 1,246 (4) Number of children cleansed under section 87, Education Act, 1921 (5) Number of cases in which legal proceedings were taken: — (a) Under the Education Act, 1921 — (b) Under the school attendance bye-laws — 449 SCHOOL CLINICS — MEDICAL AND DENTAL. Day Clinic Where held Time Monday to Friday Saturday School children Stratford Clinic, 84 West Ham Lane. 9.15—12.0 2.0 — 4.0 9.15—12.0 Monday to Friday Saturday Plaistow Clinic, Balaam Street. 915—12.0 2.0 — 4.0 915—12.0 Monday to Friday Saturday Canning Town Clinic, Swanscombe Street. 9.15—12.0 2.0 — 4.0 9.15—12.0 Monday to Friday Saturday Custom House Clinic, Rosetta Road. 9.15—12.0 2.0 — 4.0 9.15—12.0 During school holidays (excluding bank holidays) Custom House Clinic is open daily from 9.0 a.m. to 12.0 noon and Stratford Clinic is open Monday to Friday from 2.0 to 4.0 p.m. 450 APPENDIX. List of clinics and services. MATERNITY AND CHILD WELFARE CLINICS. Day Clinic Where held Time Monday Infant welfare West Ham Lane Clinic. 2.0 5.0 ,, Ante-natal Maybury Road Clinic. 9.30 1.0 ,, Infant welfare ,, ,, ,, 2.0 5 0 ,, ,, ,, Stratford Day Nursery. ,, ,, ,, Welfare Road. 1.30 5.0 ,, ,, ,, Given Wilson Institute, ,, ,, ,, Telly Road. 2.0 50 ,, Ante-natal Plaistow Maternity Clinic, Chesterton House, Balaam Street. 2.0 4.0 ,, Dental (mothers) Maybury Road Clinic. 9.30 1.0 ,, (mothers and children) ,, ,,, ,, 2.0 5.0 Tuesday Ante-natal West Ham Lane Clinic. 9.30 1.0 ,, Infant welfare ,, ,, ,, 2.0 50 ,, Ante-natal Forest Gate Clinic, Forest Street. 9.30 1.0 ,, Infant welfare ,, ,, 2.0 50 ,, ,, Plaistow Maternity Clinic, Hoy Street, Tidal Basin. 2.0 4.0 ,, Sunlight treatment Stratford Day Nursery, Welfare Road. 9 30 12.0 ,, Ante-natal Plaistow Maternity Clinic, Chesterton House, Balaam Street. 2.0 4.0 ,, Infant welfare Maybury Road Clinic. 2.0 50 ,, Dental (mothers) Forest Gate Clinic, Forest Street. 9.30 1.0 ,, ,, (children) ,, ,, 2.0 50 Wednesday Infant welfare Forest Gate Clinic, Forest Street. 2.0 50 ,, Ante-natal Grange Road Clinic. 9.30 1.0 ,, Infant welfare ,, ,, ,, 2.0 50 ,, Ante-natal St. Barnabas's Church, Westwood Road, Silvertown. 9.30 1.0 ,, Infant welfare ,, ,, ,, 2.0 50 ,, ,, ,, Plaistow Maternity Clinic, Chesterton House, Balaam Street. 4.30 5.:o ,, Ante-natal Lees II all. Barking Road. 10.0 1.0 ,, Infant welfare ,, ,, 2.0 5.0 ,, ,, ,, Plaistow Maternity Clinic, Hoy Street, Tidal Basin. 10.0 12.0 ,, ,, ,, Trinity Mission, Oxford Road. 130 5.0 ,, Dental (mothers) Grange Road Clinic. 9.30 1.0 ,, ,, (children) ,, 2.0 50 Thursday Infant welfare West Ham Lane Clinic. 2.0 5.0 ,, ,, ,, Forest Gate Clinic, ,, ,, ,, Forest Street. 9 30 12.30 ,, ,, ,, ,, ,, 2.0 50 ,, ,, ,, Maybury Road Clinic. 2.0 50 ,, ,, ,, Plaistow Maternity Clinic, Chesterton House, Balaam Street. 12.0 1.0 ,, Sunlight treatment Stratford Day Nursery, Welfare Road. 9.30 12.0 ,, Infant welfare Trinity Mission, Oxford Road. 1.30 5.0 ,, Dental (children) Forest Gate Clinic, Forest Street. 9.30 1.0 ,, ,, ,, ,, ,, 2.0 50 451 Day Clinic Where held Time Friday Diphtheria immunisation West Ham Lane Clinic. 9.30-12.0 ,, Infant welfare ,, ,, ,, 2.0 — 5.0 ,, ,, ,, Grange Road Clinic. 2.0 — 5 0 ,, ,, ,, Trinity Mission, Oxford Road. 1.30— 5.0 ,, ,, ,, Stratford Day Nursery, Welfare Road. 1.30— 5.0 ,, Ante-natal Plaistow Maternity Clinic, Chesterton House, Balaam Street, 2.0 — 4.0 ,, ,, ,, Plaistow Maternity Clinic, Hoy Street, Tidal Basin. 2.0 — 4.0 ,, ,, ,, Forest Gate Clinic, Forest Street. 9.30— 1.0 (alternate Fridays) ,, Dental (mothers) Grange Road Clinic 9.30— 1.0 ,, ,, ,, ,, ,, ,, 2.0 — 5 0 Saturday Dental (children) Grange Road Clinic 9.30— 1.0 V.D. CLINICS. Day Clinic Where held Time Monday Venereal disease. Royal Albert Dock Hospital 2.0 — Men only. Wednesday ,, ,, ,, ,, 4.0 — Women only Friday ,, ,, ,, ,, 2.0 — Men only. Daily ,, ,, L.C.C. Clinic, Turner Street, White-chapel. 10.0— 9.0 Both sexes. TUBERCULOSIS. Day Clinic Where held Time Monday Tuberculosis consultations and treatment. Dispensary, Balaam Street. 9.30— 1.0 Women and children. ,, ,, ,, ,, ,, 2.0 —4.30 ,, ,, Tuesday ,, ,, ,, ,, 9.30— 1.0 Men only. Wednesday ,, ,, ,, ,, 9.30— 1.0 Women and ,, ,, ,, ,, ,, 2.0 —4.30 ,, ,, Thursday ,, ,, ,, ,, 9.30— 1.0 Men only. Friday Special treatment and examination of contacts. Tuberculosis consultations and treatment. ,, ,, 2.0 —4.30 9.30— 1.0 Men, women and children. Women and children. ,, ,, ,, ,, ,, 2 0 —4.30 " " 452 LIST OF DISTRICTS OF DISTRICT MEDICAL OFFICERS Name and Address. Dr. T. L. Dolan, North West Ham Public Assistance Sub-Office, 82 West Ham Lane, Stratford, E.15. Dr. J. P. Robinson, South West Ham Public Assistance Sub-Office, Cumberland Road, Plaistow, E.13. Dr. P. G. S. Kennedy, 113 Balaam Street, Plaistow, E.13. Dr. J. F. Begley, 184 Barking Road, Canning Town, E.16. Dr. R. V. Brews, 10 High Street, North Woolwich, E.16. Dr. J. J. McSharry, 24 Freemasons Road, Custom House, E.16. Dr. M. J. Murphy, 60 Leytonstone Road, Stratford, E.15. District. Broadway, Park, West Ham, Plashet Road and Forest Gate Wards. Beckton Road, Ordnance, Custom House, Hudsons, Canning Town and Grange Wards and part of Silvertown Ward. Plaistow and Bemersyde Wards. Part of Tidal Basin Ward. Part of Custom House and Silvertown Ward. Part of Tidal Basin Ward New Town Ward. 453 LIST OF LOCAL ACTS AND REGULATIONS WHICH ARE IN FORCE. West Ham Corporation Act Improvements Act, 1888. West Ham Corporation Act, 1893. ,, ,, ,, ,, 1898. ,, ,, ,, ,, 1902 ,, ,, ,, ,, 1920. ,, ,, ,, ,, 1925 ,, ,, ,, ,, 1931 ,, ,, ,, ,, 1937 Bye-laws made under the Municipal Corporations Act, 1882, in respect of Tents, Vans, Sheds, etc. Bye-laws made under the Public Health Acts in respect of: — (a) Common lodging houses. (b) Knackers'-yards. (c) Offensive trades. (d) Nuisances. (e) Houses let in lodgings. (f) Slaughter-houses. (g) Removal of offensive matter. West Ham Corporation Act, 1931—Trading in streets. Theatres Act, 1843—Music, dancing and stage plays licences. INDEX. Accidents, road, deaths from 103-104. Acts, Regulations, etc., 51,53-54,454. Adjusted death rates, 30. Adulteration of food, 310-312. After-care, for tuberculous, 201. Albert Dock Hospital, 41. Ambulance facilities, 38-39. Analyst, Public, report of, 310-312. Aneurysm, 101. Animals, contagious diseases of, 298-301. Ante-natal work, 223. Anthrax, 118,298. Appendix, general, 451. to school section, 438. Area comparability factor (A.C.F.), 80. Area of borough, 26-27. Arterio-sclerosis, 101. Artificial pneumothorax, 201,204. Artificial sunlight, 232. Atmospheric pollution, 98, 331-332. Aural surgeon, report of, 382-384. Bacteriological examinations, 168, 284-285,288. Bakehouses, 328. Baths, swimming, 47,50,403. Beer, sale of, 330-331. Birth control, 242. Births, 65-73,213-214,225. distribution of, 213-214. illegitimate, 70-71. in wards, 66. notification of, 225. (stillbirths), 72-73,228-229,270-271 Blind children, 408. Bronchitis, 96-99, 150. Bugs, disinfestation, 53. Camps, school, 400-401. Cancer, ,106-110. Caravans, 323. Casual wards, 32-34. Causes of death, 82,90-91. Census figures, 58-59,61-64. Central Home, 32-34,271-274. Central schools, 431. Cerebro-spinal fever, 119,121-122, 143,165. Chicken-pox, 165. Chief Sanitary Inspector, report of, 316-335. Childbirth, deaths in, 226-229. Children's Hospital, Balaam Street, 41,235-237,384-386,396-397. Child welfare, 229-236. Cinemas, 330. Circulatory diseases, 99-102. Cleansing services, 315-316. Clearance areas, 341-342. Climatology, 36-37. Clinics, list of, 450-452. Closet accommodation, 316. Committees, constitution of, 9-11. Common lodging houses, 319. Comparative statistics, 114-115. Condemned food, 302,305-307. Consultants, 255-256. Contagious Diseases (Animals) Acts, 298-301. Continuation institutes, 430. Continued fever, 118. Convalescence, 236,238. Co-ordination of health services, 362-363. Cost of health services, 29. Country Holiday Fund, 401. Cows and cowsheds, 300-301. Crippled children, 411. Crosby Road Day Open-air School, 414, 418. Cross infection, 166. Dagenham Sanatorium, 193-195,197, 203-207. Dairies, 280-281. Day nurseries, 238. Deaf centres, 414,417. Deaf children, 382-384,409,417. Deaths, 74-83. causes of, 82,90-91. from all causes, 78-79. bronchitis, 150. cancer, ,106-110. cerebro-spinal fever, 121-122, 143,165. circulatory diseases, 99-102. diarrhoea and enteritis, 144. diphtheria, 120-122,129-130,163. encephalitis lethargica, 121-122. 455 1NDEX—contintied. Deaths, continued : enteric fever, 120,122,125. erysipelas, 120,122,141. infectious diseases, 120-122,154. influenza, 147. measles, ,136-137. pneumonia, 120,122,149. polio-encephalitis, 121-122. respiratory diseases, 96-99. scarlet fever, 120-125,159. tuberculosis, 110-113,184-189. violence, 103-105. whooping-cough, 138-139. in age groups, 76. in Central Home, 273-274. in Forest Gate Hospital, 267-268. in Harold Wood Hospital, 276-277. in isolation hospital, 154-157. in public instittiuons, 83. in wards, 74. in Whipps Cross Hospital, 257-259. of infants, 74,85-92. Defective hearing, 382-384. Defective students, higher education, 425-426. Delicate children, 411. Density of population, 23. Dental inspection and treatment, 231-232, 389-396,448-449. Designated milk, 282-284. Diabetes (insulin), 46. Diarrhoea and enteritis, 143-145. Dick test, 167. Dining centres for children, 405-406. mothers, 241-242. Diphtheria, 119-122,127-132,161-164. after immunization, 170-171. examination of swabs, 168. immunization, 132,170-171. Diseases of Animals Acts, 297-301. Disinfection, 51-52,169. Disinfestation, 53,323. Dispensaries, tuberculosis, 198-202,452. District medical officers, 43-44,453. Domicilary medical service, 43. Drainage, 315. Dried milk, 242-245. Dustbins, 316. Dwelling houses, 28,338,340-341. Dysentery, 119,122,143. Ear diseases, 382-384. Edith Kerrison Nursery School, 427-428. Education, open-air, 400-401. Employment of children and young persons, 436. Employment, state of, 28,30-31. Encephalitis lethargica, 121-122,142. Enteric fever, 119-120,122,133-135,164. Epileptics, 268,410. Erysipelas, 119-120,122,140-142,165. Exceptional children, 412-414,442-444. Excess of births over deaths, 83-84. Exhumations, 317. Eye, diseases of, 376-380, 446. Factories and workshops, 325-328. Farms, 301. Fertilisers and Feeding Stuffs Act, 309. Fever hospital, report, 152-171. Finance, 28-29. Food, adulteration, 310-312. bacteriological examinations, 284-285,288. condemnation of, 302,305-307. inspection, 280-312. preparing premises, 328-329. preservatives in, 307,312. samples analysed, 285-288,304-305. Foot and mouth disease, 299. Forest Gate Hospital, 215,225,265-271, 278. maternity unit, 269-271. mental defectives and epileptics, 268,351-354. Forest House, 274-275,278. Fractures, treatment of, 262-263. Frederick Road Deaf Centre, 414,417. Free meals for children, 405-406. expectant mothers, 241-242. Fried fish shops, 329. Fyfield Open-air School, 414,419-424. Gangrene, 101. Grange Road Special School, 414. Haemorrhage, cerebral,101. Harold Wood Hospital, 275-277. Health Services, co-ordination, 362-363. Health visitors, 223,238-240. Hearing, defective, 382-384. Heart disease, 99-102,386-388,412. 456 INDEX—continued. Heights and weights, 370-371. Higher education for defective students, 425-426. High schools, 430. Home helps, 221. Home nursing, 39-40. Home visiting, 223. Hospitals, 247-278. Albert Dock, 41. Central Home, 32-34,271-274,278. Children's Hospital, Balaam Street, 41,235,384-386,396-397. Forest Gate, 215,225,265-271,278, 351-354. Forest House, 274-275,278. Harold Wood, 275-277. Isolation, report on, 152-171. Plaistow Maternity, 41,215,225. Queen Mary's, 40,215,225. St. Mary's, 41,234-235. Seamen's, Royal Albert Dock, 41. South Ockendon Colony, 349-351. Whipps Cross, 252-265,278. bed accommodation, 42,249. municipal, 249-278. nursing services, 250-252. voluntary, 40-41,233-237. Hostels for v.d., 174. Houses-let-in-lodgings, 318. Houses, number of, 28,338. Housing, 337-342. Hygiene of school premises, 363. Ice cream, 288. Illegitimate births, 70-71. Immunization, diphtheria, 132,167, 170-171. scarlet fever, 167. Industries, 28. Infant life protection, 240-241. Infant mortality, 85-92. Infant welfare, 229-236. Infantile diarrhoea, 143-145. Infectious diseases, 118-178. cases, 120-121. cross infection, 166. deaths, 120-122,154. in mothers and infants, 219-221. in wards, 122. notifications of, 118-123,181-184,190. removed to hospital, 122-123. Infectious diseases, continued : report on isolation hospital, 152-171. schools, 398-400. weekly and quarterly notifications, 119. Influenza, 146-148. Inquests, 45. Inspection, of food, 280-312. meat, 289-297. milk, 280-288. school children, 364-389,431-434, 438-449. Inspectors, work of, 317-322. Institutions, municipal, 249-278. Insulin, supply of, 46. Insured persons, 32,34. Invalid Children's Aid Association,407. Invalid and Crippled Children's Society, 407. Isolation Hospital, 152-171. admissions, 155,157. deaths, 154,157. gate cases, 166-167. laboratory, 35. staff, 166. Juvenile Instruction Centre, 436-437. Knox Road Special School, 414. Laboratories, 35,168,284-285,288. Lavatories, etc., 320. Langdon Hill Sanatorium, 193-194, 196-197,207-209. Legal proceedings, 334-335. Legislation in force, 51. Light treatment, 262,396-397. Local Government Act, 1929, 43. Local powers, extension of, 53-54. Lodging houses, 319. Lymphatics, diseases of, 101. Malaria, 143. Malignant diseases, deaths from 106-110. Markets, 329-330. Marriages, 65. Maternal mortality, 93-94,226-229,270. Maternity and child welfare, 211-245. attendances at clinics, 224. clinics, 229-231, 451-452. dental clinics, 231-232,451-452. maternity service, 214-223. 457 INDEX—continued. Maternity hospitals, 225. Maternity unit, Forest Gate Hospital, 269-271. Meals,provision of, to children,405-406. to mothers, 241-242. Measles, 136-137,164. Meat inspection, 289-297. carcases condemned, 291-297. Medical Aid (Midwives Act), 217-218. Medical inspection in schools, 364-389. Medical inspection of school children, 364-389,431-432,438-449. findings and results of treatment, 369-389. Meningitis, 119,121-122,143,165. Mental defectives, 268,343-356,409. Mental deficiency, 343-356. Forest Gate Hospital, 351-354. institutional accommodation, 348-349. South Ockendon Colony, 349-351. statistics, 344-346. supervision, 347. types of cases dealt with, 347. Mental wards, 263-265. Meteorology, 34,36-37. Midwives, 214-218,222. Midwives Act, 1936, 222. Milk, adulteration, 286,310-312. analysis of, 285-288. bacteriological examinations, 284-285. condensed, 286-287. in schools, 406. licences issued, 282. premises registered, 281. tuberculous, 280-284. Milk and Dairies Order, 280. Milk shops, 280. Milk supply, control of, 280-288. Minor ailments, 374-376,445. Mortuaries, 44-45. Municipal clinics, 229-231,450-452. Municipal College, 429-430. Municipal hospitals, 247-278. allocation of beds, 278. Municipal midwives, 222. Myocardial disease, 99-101. Natal work, 225. National Health Insurance, 32,34. Natural and social conditions, 26-34. Natural increase of population, 83-84. Neo-natal mortality, 88-92. Nose and throat defects, 380-381,447. Notification of Births Act, 225. Notification of infectious diseases, 118-123,181-184,190. Nuisances, 323. Nurseries, day, 238. Nursery schools, 426-428. Nursing homes, 225. Nursing services, 250-252. Nutrition, school children, 372-373, 435,442. Oculist, school, 379. Offensive trades, 324,326. Ogilvie School of Recovery, Clacton, 424. Open-air education, 400-401. Open markets, 329-330. Operations, Whipps Cross Hospital, 260-261. Ophthalmia neonatorum, 119,122,151, 219,271. Outworkers, 317. Overcrowding, 341. Paratyphoid fevers, 119-122,133-135,164. Parents, co-operation of, 406. Parents' payments, 435-436. Pathological work, 168,178,200,207, 262,437. Pemphigus neonatorum, 229. Pharmacy and Poisons Acts, 307-309. Physical training, 401-405. Physically defective children, 410. Pig-keeping, 299-300. Plague, 118. Plaistow Fever Hospital, report, 152-171. Plaistow Maternity Hospital, 41,215, 225. Pneumonia, 96-99,119-122,148-150,165. Polio-encephalitis, acute, 119,121-122, 143. Poliomyelitis, acute, 119,122,142,166. Poor relief, extent of, 32. 458 INDEX—continued. Population, 28,58-64. by ages, sex and marital condition, 62. census and intercensal changes, 59. natural increase of 83-84. school, 360-361. ward, 61. Postural defects, 384-386,447. Preservatives in food, 307,312. Prosecutions, 334-335. Psychological clinics, 354-356. Public analyst, report of, 310-312. Public Assistance, 32. Public baths, 47,50,403. Public houses, 330-331. Public vaccinators, 15. Puerperal fever, 95,119,122,150-151,219220,270. Puerperal pyrexia, 95,119,122,150-151, 219-220, 270. Pupil midwives, 271. Queen Mary's Hospital, 40,215,225. Rabies, 118. Radiology, 206,209,262. Rag Flock Acts, 333-334. Rateable value, 28. Rats and Mice (Destruction) Act, 1919, 53. Rebecca Cheetham Nursery School, 426-427. Records (medical aid), 217-218. Refuse collection and disposal, 315-316. Relapsing fever, 118. Rent Restriction Acts, 324. Respiratory diseases, deaths, 96-99. Restaurants and cafe kitchens, 328-329. Return, of defects treated, 445. of exceptional children, 442-444. of medical inspection, 438-449. Rheumatism in children, 386-388. Ringworm, 375. Road accident deaths, 103-104. Routine inspection, schools, 366-367. St. John's Open-air School, 387-388. St. Mary's Hospital, 41,234-235. Sanatoria, 193-197,203-209. Sanitary circumstances, 313-335. Sanitary inspectors, work of, 317-322. Scabies, 375-376. Scarlet fever, 119-122,123-127,154-161. return cases, 161. Schick test, 167. School, attendance officers, 407. camps, 400-401. children, defects treated, 445. following up, 397-398. medical inspection of, 364-389, 431-434,438-449. clinics, 450. clinics, attendances, 374. dental service, 389-396,448-449. journeys, 400-401. medical service, 357-450. nurses, duties of, 398. oculist, work of, 379. population, 360-361. premises, hygiene of, 363. Sports Association, 402-403. statistics, summary, 358. Seamen's Hospital, 41. Secondary schools, 429-431. Sewage and sewage disposal, 315. Shops Acts, 1912-1926, 46-49. Skin diseases, 374-375. Slaughter-houses, 289. Slaughter of Animals Act, 289. Slum clearance, 341-342. Smallpox, 40,123. Smoke abatement, 331-333. Social conditions, 26-27. South Ockendon Colony, report on, 349-351. Special schools, 414-417. Spectacles, provision of, 379,436. Speech defects, 424-425. Sputum examinations, 200. Staff, 12-20,166,362. Stammerers, 424-425. Statistics, vital, 55-115. Stillbirths, 72-73,228-229,270-271. Suicide, 103-105. Sulphanilamide drugs, 159. Sunlight, artificial, 232. Sunlight treatment, 232. Sunningdale Convalescent Home, 236. Swimming baths, children attending, 403. Swimming bath water, 47, 50. 459 INDEX—continued. Teachers, co-operation of, 406. Tents, vans and sheds, 323. Throat work, 380-381,447. Tropical and rare diseases, 150. Tuberculosis, 110-113,179-209. administrative action, 196-197. age incidence, 183,185. and milk, 280-284. contacts examined, 191. deaths, 110-113,184-189. deaths at ages, 186-188. dispensary, 191-192,198-202,452. dispensary treatment, 200. disposal of cases, 202. domiciliary treatment, 199-200. examinations, 198. institutional accommodation, 193. non-notified cases, 182-183. notifications, 181-182,190,199. register, 190-191. results of treatment, 197. school children, 389,410-411. state of diagnosis, 192. statistics, 110-113,181-182. ward incidence, 183-184. Tuberculosis Officer, report of, 198-202. Tuberculous meat condemned, 294-297. Typhoid (enteric) fever, 133-135,164. Typhus fever, 118. Ultra-violet light treatment, 262,396397. Uncleanliness, 373,449. Underground rooms, 323. Unemployment, 30-31. Unmarried mothers, 42. Vaccination, 46. Vaccinators, public, 15. Veins, diseases of, 101. Venereal diseases, 172-178,452. Verminous houses, 323. Violence, deaths from, 103-105. Visual defects, 376-380,446. Vital statistics, 55-.115. Voluntary clinics, 231. hospitals, 40-41,233-237. Ward statistics, 61,66-67,74-75,122,183184, 188. Water-closets, 316,320. Water Lane Deaf centre, 414,417. Water supply, 314-315. Weight and height, comparative tables, 370-371. West Ham Corporation Act, summary of, 53-54. West Ham Nerve Clinic, 354-356. Whipps Cross Hospital, 252-265,278. admissions, 254-256,278. deaths, 257-259. deaths, by ages, 258-259. diagnostic facilities, 261-262. discharges, 254,257. diseases treated, 256-257. mental wards, 263-265. operations, 260-261. pathological services, 262. radiological department, 262. treatment of fractures, 262-263. ultra-violet light treatment, 262. work of consultants, 255-256. Whooping-cough, 136,138-139,164. Workshops, 325-328. X-ray diagnosis, 261. treatment, 261. 460