352 PUBLIC HEALTH SERVICES.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF

HEALTH.THE following are some 1926 statistics for fivecounty boroughs and one borough :-

West Ham.Dr. F. Garland Collins reports that in September a

whole-time assistant was appointed mainly formaternity and child welfare work. An antenatalclinic has been started at the Silvertown centre anda new centre has been opened in West Ham-lane,where both antenatal and postnatal clinics are inoperation. The work of the health visitors has beenreorganised and an arrangement made with thePlaistow maternity charity to prevent overlappingand to promote coordination. Home helps are

employed by the council, and work under the directsupervision of the health visitors. A list of approvedwomen is kept at the town hall, and each homehelp is required to give prompt notice when shehas undertaken a case. During 1926 there were1453 applications for home helps and 1261 of thesewere granted. During the last four years about100 tons per annum of dried milk has been suppliedat cost price for the benefit of nursing and expectantmothers and children under 3. The milk is receivedin hermetically sealed canisters and packed daily incartons, in order to make sure that it is in goodcondition. The Plaistow isolation hospital has beenmade available for cases of puerperal fever, but it isfound that most of the cases are sent into voluntaryinstitutions. So far the existing nursing associationshave provided the nursing required, and it has notbeen necessary to appoint a municipal nurse. A panelof three consultants has been formed so that thenotifying practitioner may have a choice of specialistwhen a second opinion is desired. A sanatorium forchildren suffering from pulmonary tuberculosis, withaccommodation for 40, is now being built on thecouncil’s site at Langdon Hills. This will meet along-felt want..

There is much flagrant overcrowding. No houseswere built with State assistance during the year, butthe council are at present erecting blocks of flats,four storeys high, capable of accommodating 152families. It not infrequently happens, says Dr.Collins, that a tenant renting three rooms from alandlord will sublet two of them to two separatefamilies. If there is only one w.c. much bitter feelingarises between the tenants owing to the ground floorkitchen being converted into a thoroughfare to thebackyard. IDuring Health Week about 35,000 persons visited

the exhibitions. Dr. Collins emphasises the importanceof selecting lecturers who know something of theneighbourhood, and will thus avoid putting forward

impracticable suggestions. He also stresses thedanger of these exhibitions being exploited by rivalfirms. The babel which ensues often tends to minimisethe true purpose of the exhibition. He suggests aninterval of more than one year between health weeks ;the best form of health propaganda, he considers, issteady persistent teaching in the schools and churchesand through the press and in the homes and hauntsof the people. The residential open-air school for80 boys established at Fyfield has been at work fortwo years without a single case of infectious diseaseor any serious illness ; it also kept free from theepidemic of influenza which affected the boroughtowards the end of the year. Seven nurses at theisolation hospital contracted scarlet fever and eightdiphtheria. All new probationers are now tested and,if necessary, immunised against these diseases. Theresults of Dick tests on scarlet fever cases were asfollows : 66 of 71 patients tested in the first five daysof the illness were positive ; 48 of 87 tested on theseventh day were positive ; 57 of 160 tested in thesecond week were positive ; and 57 were retested atweekly intervals. All had become negative by theend of the sixth week except seven, who were positiveon discharge from hospital.

Blackburn.Dr. Oscar M. Holden tells us that Blackburn in

1926 had the highest total rainfall of any large townin England, nearly 41 inches. The hours of brightsunshine totalled 1114, which might be compared withthe 12111 registered at Lytham. The chief industryis cotton-weaving and its subsidiary branches.Normally 748 of every 1000 women and 280 of every1000 men are textile workers, but the year has beenone of depressed industrial conditions with muchunemployment. The respiratory group of diseasesbulks largely in the death returns, and Dr. Holdensuggests that unfavourable climatic conditions, coupledwith a dirty atmosphere, are the predominant causes.He suggests a connexion between the decline in thesediseases and the cleaner atmosphere during the coalstrike of last year. Respiratory diseases are markedlymore prevalent among the cotton operatives. Spinnersand unclassified operatives show the most unfavour-able figures. Winders and warpers are better placed.Female weavers apparently come off better than male.About 50 per cent. of the babies born are exempted

from vaccination. A small outbreak of small-pox ofa mild type gave rise to eight cases in the Queen’sPark Institution. It was attributed to an undetectedcase in a vagrant. A small open-air school, providingbeds for 20 delicate children, is carried on in one ofthe original scarlet fever pavilions at the open-airhospital. Ultra-violet light apparatus is also providedat the hospital for the benefit of the maternity andchild welfare, tuberculosis, and school departments.Dr. Holden thinks that the practice of allowing twovisitors twice a week to see the diphtheria and scarletfever patients is a mistake. Apart from the window-cleaning business, managed by the Charity Organisa-tion Society for ex-sanatorium cases, there is no

system of after-care for consumptives, and Dr. Holdenthinks such a system is greatly needed. The arrange-ments at the hospital for tuberculous patients needconsiderable improvement. There is no dining-hallor recreation-room, all the meals being taken in theward. The records show that of the patients treatedat the corporation hospital and discharged since1913, 13-4 per cent. are at full work with no symptomsand 5-2 per cent. at full work but with difficulty.The corresponding figures for the patients sent fortreatment to Meathop Sanatorium are 19-0 per cent.and 6-8 per cent. respectively.The antenatal clinic has two sessions in the week,

and was attended by 480 prospective mothers. Dr.Holden complains that although 80 per cent. of theconfinements are attended by midwives the numberof cases sent by them to the clinic was only 59. Themunicipal maternity home has accommodation for20 cases, and the medical officer of health is empoweredto remit the minimum fee of ;E1 ills. 6d. per week in

353PUBLIC HEALTH SERVICES.

cases of proved necessity. The patients admittednumbered 212, being 39 fewer than last year. Eachmember of the staff is a fully-trained nurse as wellas a qualified midwife. Dr. Holden would have likedto see more use made of the beds, and it is surprisingthat hospital treatment is not sought more often,seeing that in 1926 27-3 per cent. of the confinementsin private houses took place in the kitchen or living-room. The number of stillbirths in 1926 was 4-8 percent. of the number of live births. The neonatalmortality was 45-8 per 1000. There were 19 cases of

ophthalmia neonatorum and one baby totally blinded.A census taken in March, 1926, did not reveal anyshortage of houses, which is not surprising when it isseen what a small difference there has been betweenthe birth-rate and death-rate in Blackburn of lateyears. Individual cases of overcrowding met withwere due either to bad distribution of the family inthe rooms or to subletting.

Northampton.Dr. Stephen Rowland, formerly tuberculosis officer,

only took up his duties as medical officer of health inDecember after the death of Dr. J. D. McCrindle.Bacterial examination of the town’s water as a rulerevealed a high degree of purity, but occasionally thisstandard was not maintained. The Monarch-roadtip, which was a source of complaint in 1925, causedfurther complaints in 1926 owing to the invasion ofneighbouring houses by crickets bred on the tip.The tip is now disused and a comprehensive schemeis in preparation for the collection and disposal ofhouse refuse by modern appliances. Five samples ofmilk taken from one farm were reported by theanalyst to contain added water varying from 7 per cent.to 19-3 per cent. The farmer successfully prosecuteda servant for adding the water and the summonsagainst himself was withdrawn. In the case of asample alleged to contain 7 per cent. of added waterthe magistrates were satisfied that the milk was soldas it came from the cow.A sudden outbreak of scarlet fever occurred in the

beginning of November after a period of almostcomplete freedom from this disease. It was foundthat nine of the first patients had their milk fromthree retailers, but that these three obtained the milkfrom one wholesaler, who in his turn obtained it froma farm outside the borough. A milker was found atthe farm who had been away ill for 12 days in thesecond half of October. He exhibited, however, nosigns of scarlet fever after repeated examinations,and his medical attendant had seen no signs or

symptoms of scarlet fever during his illness. He wasexcluded from work and the milk was pasteurised.Within three days of the pasteurisation there was asudden drop in the notifications. There were about100 cases in the borough and neighbourhood, whichwere evidently due to the infected milk ; but, as oftenhappens in scarlet-fever-milk epidemics, it was

impossible to show how the milk had become infected.

Lincoln.Dr. H. Gordon Smith thinks the existing unemploy-

ment can hardly fail to affect the health of thecommunity. In dealing with the condition of thechildren attending the centre he points out that 80(or 2-9 per cent.) suffered from marked rickets, while244 suffered from respiratory complaints, 148 fromgastro-intestinal disorders, and 82 from debility.141 out of 838 infants were bottle-fed at the time ofthe first visit of the health visitor, apparently becausethe mothers often were not in a fit state to nurse them.Many men have been unemployed for years, othersare working part time and the weekly wage is oftenless than 22. In the family dietary white bread isprominent, and potatoes, margarine, sugar, and tea arewell to the fore. Meat is not a big item, and milkmay average a pint per day for everybody. Theex-baby, therefore, " will probably receive at homefilling starchy food, just the sort to give it rickets."The milk and other foods supplied by the maternityand child welfare committee prevents things frombeing worse than they are. Of the 86 infant deaths

27 occurred in the first week and 46 in the first fourweeks (a neonatal mortality of 42). Of the eight mid-wives three are municipal. The city maternity homeprovided for 260 confinements in the home and for428 through the district service, the total births duringthe year being 1089. Sixteen antenatal cases andtwo postnatal cases were also admitted to the home.Thirty-two babies born in the home were not entirelybreast-fed while in the institution ; nine because themother was returning to work, two because the milkwas unsuitable, and 12 because there was insufficientsecretion of milk. Of the 17 stillbirths in the hometwo were due to breech delivery and three to placentaprsevia. The attendance at all the centres and clinicsis increasing, and more centres and more sessions areneeded in order to do justice to the work. Dr. Smithcomplains of the pollution of the rivers by houseboatsand by lazy people throwing in refuse, making thewater impossible for bathing purposes. The veterinarysurgeon began his inspection of the milch cows onNov. 1st, and in two months found two tuberculousudders among 90 cows.A block of ten cubicles is to be provided at the

isolation hospital, and will greatly increase its efficiencyfor dealing with a larger variety of diseases and withmixed infections. There were 17 cases of encephalitislethargica during the year with five deaths, andeight cases of anterior poliomyelitis with two deaths.

Eastbourne.Dr. W. G. Willoughby tells us that the infant

mortality-rate was the lowest of any of the largetowns of the country with the exception of someLondon suburbs, and that the hours of brightsunshine (1659-1) were the eighth highest recorded forthe United Kingdom. The most welcome feature ofthe year was a larger addition to the housing accom-modation. There are still a number of families lacking _

proper accommodation-the number is estimated at472-but at the end of 1926 there were 254 houses incourse of construction or planned, leaving a deficiencyof 218. A house-to-house inquiry now in progresswill verify the last-named figures. The army huts,which were occupied in May, 1919, are being graduallyclosed. Originally there were 188 tenements, but atthe close of 1926 only 70 were occupied. Thematernity home dealt with more cases than in anyprevious year. There were 189 confinements and191 children born, of whom four died and eight werestillborn. There were two maternal deaths; one

patient was admitted moribund from puerperaleclampsia and the other died of peritonitis afterCaesarean section. Five of the infants were notentirely breast-fed, one owing to insufficient milk andanother owing to blood in the milk secreted. In onecase the mother had chronic nephritis, in anotherphthisis, and the fifth infant was going to a foster-mother. The antenatal clinic at the home wasattended by 198 expectant mothers, and the otherantenatal clinic by 17 (total 215, the births for theyear being 727). The six deaths from childbirth weredue to puerperal fever, eclampsia, perinephric abscess,peritonitis after operation, and embolism (2). Theone day-nursery in the borough was permanentlyclosed in March, 1926. The only patient with verifiedencephalitis lethargica died ; the only patient withacute poliomyelitis, an infant of 39 days, recovered.

Colchester.Dr. W. F. Corfield says that an unsuccessful

endeavour has been made to secure accommodationfor maternity cases by taking a building from theguardians, to which separate access could have beenmade. Negotiations are now in progress to obtainthis accommodation through the District NursingAssociation. An arrangement has been made forinfants suffering from a crippling defect to beattended by the specialist at the orthopaedic clinic ofthe education committee. During the year four casesof rickets, four of congenital deformities, and one ofparalysis were so treated. The schemes for theconversion of privies and pail-closets, for the provisionof a water-supply for hand-flushed closets, and for the

354 PUBLIC HEALTH SERVICES.

substitution of sanitary bins for ash-pits continue tomake progress. 266 houses were erected with Stateassistance, 98 being municipal. The housing positionis getting a little easier, and notices of houses to letare beginning to appear. For the last three years thenurses at the isolation hospital have been immunisedagainst diphtheria and there have been no cases ofthe disease among them. During the year the patientsand staff of the Royal Eastern Counties Institutionfor the Mentally Defective were immunised. The"

positive " patients dealt with numbered 248 out of1037, and the "positive" members of the staffnumbered 47. No bad arms followed the tests, andonly three persons had a moderately severe reaction.Dr. Corfield complains that infectious cases receivedinto the Essex County hospital from outside districtsand notified from there are counted as Colchestercases. All of the five cases of encephalitis lethargicaand 11 of the 58 notifications of pneumonia were ofthis description.

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REPORTS OF SCHOOL MEDICAL OFFICERS.

I I I I I

* Not given. t Exeluding dental defects and unoleanliness.

Edmonton.

Dr. H. W. Harding describes the increase in facilitiesfor treatment at Edmonton during 1926 and wondersif a time will come when there will be nothing freshto chronicle. Later in the report he indicates thatfuture preventive and curative measures will bedirected towards the pre-school child. The neworthopaedic clinic was opened in March and themassage and remedial clinic in April. Treatment ofotorrhoea by ionisation is now employed and a classfor stammerers has been started. Attention is calledto the need for drying-rooms for wet boots and clothesand for the supply of slippers ; the lack of themcauses much invalidity among school-children. Inspite of the trade depression of 1926 the condition ofthe children compared favourably with that of theprevious year. Although there is no special schoolfor cripples, the exceptional children are well providedfor ; a special class is held for partially blind andmyopic ; the deaf and dumb are sent by tram to aspecial school at Tottenham, and the feeble-mindedattend the special school under the joint committeeof Enfield and Edmonton. Dr. Harding arguesthat special day schools for mentally defectivechildren should be abolished and special classes Ishould be started in the elementary schools for dulland backward, borderline, and feeble-minded children.Much can be said for the establishment of classes forthe dull and backward in the ordinary schools, butmental defectives often become the butt of theirnormal fellows, and recognising their inferioritythey sometimes react by antisocial behaviour, andmany children who show early antisocial signs willdevelop into self-helping amenable citizens when putto work which they can do and which interests them.To exclude these children from school, notifying themto the authority under the Mental Deficiency Act,is merely to shift responsibility often to the detrimentof the child since institutional accommodation is quiteinadequate.

Norfolk.Coordination of the various health activities is

now well established, and during the year manyalterations of, and additions to, the schools have been

effected. The difficulty of providing efficient treat-ment in a large scattered area is well met in Norfolkby six clinics in the larger villages, their work beingsupplemented by the issue of vouchers for attendanceby approved practitioners and consultants and byarrangements with some of the local hospitals.Cases requiring to be nursed are attended by thelocal nurse and after-care is given by voluntaryworkers. Motor vans are used as- mobile dentalclinics. Physical training is now part of the routinein all schools, and it is reported that all children takepart in the organised games and exercises. Theorthopaedic scheme is now maturing, and Mr. M. W.Bulman has been appointed part-time orthopaedicsurgeon. The close cooperation existing between theschool medical service and practitioners in Norfolkis shown by the record of 49 cases of parenchymatousgoitre treated by thyroid medication under the jointsupervision of the school medical officer and localpractitioners. This is excellent, for success inpreventive and curative measures depends on theinterest and active assistance of all medical men.Dr. J. T. C. Nash, the school medical officer, associatesthe decrease in the mortality from tuberculosis withthe rising standard of national nutrition, and advocatesthe giving of milk to selected under-nourished school-children.

Colchester.

Dr. W. F. Corfield reports that although thereare no blind children, there are 15 partially blind,for whom there is a special class. Educable mentaldefectives are adequately provided for in a day schooland in a residential school forming part of the RoyalEastern Counties Institution. There are 31 ineducablechildren, of whom 11 are in the Royal Eastern CountiesInstitution, whilst the rest live at home. Dr. Corfielddeplores the lack of accommodation for them; inmany cases it means, he says, that one of the parentsis tied to the house and sometimes younger childrenare scared or imitate the bad habits of the defective.The occupation centre is often a partial solution ofthe difficulty of dealing with imbeciles. On the futureof the ex-pupils of the special school for mentaldefectives a candid-almost a pessimistic-report isgiven, showing that only 17 out of 61 are at work.The figures are thought to suggest that the standardof intelligence for admission to the school is on thelow side. There is no open-air school in the borough,nor a school for cripples, of whom 85 are mentioned,but the list includes defects such as cleft-palate andfacial paralysis. The report of the organiser of

physical training is included in the annual report,and we should like to see this generally done.

MENTAL HOSPITAL REPORTS.THE Cheshire County Hospital at Macclesfield had

1311 patients on its books at the end of last year,21 in excess of the normal accommodation, so thatthe question of providing more room has already becomeacute. The shortage is on the male side. Of the 224admissions during the year, 101 were classed as hope-less. Nevertheless, there was a recovery-rate of28’1 per cent., well above the average for the previousquarter century, and the death-rate was also one ofthe lowest on record-6’1 per cent. Post-mortemexaminations were made on nearly 90 per cent. ofthe fatal cases. Four of the deaths were due totyphoid fever, which attacked 32 patients. It arose,apparently, through the infection of a nurse by anold typhoid carrier, whose habits were very dirty.Water from the villa in which the nurse was lying illwas drunk by patients on the cricket field, and theinfection was spread further by old aluminiumutensils which had got too battered to be readily keptclean. The water-supply was, of course, investigatedthoroughly, and a defective tank was found and putright. Further alterations are desirable, the superin-tendent thinks, to put the whole supply abovesuspicion. Otherwise the general health was good.A " Vitaglass " hammock has been erected and

355PUBLIC HEALTH SERVICES.

others are to be supplied ; many patients have beentreated by ultra-violet rays. Some nurses volunteeredfor an experiment on the part played by cool air inlight therapy. Those who had exposure to light gainedin weight, and there was an increase in blood pressureand in the leucocyte count and colour-index. Thosewho had cool air treatment only did not show thesechanges ; indeed, the leucocytes were diminished,while the red cells increased. Both sets, however,experienced tonic effects, increase of appetite andsleep, and a slight increase in basal metabolism.Small rooms are to be set apart as clinical rooms ;club wards and open-door wards are in practice, andmany patients have full parole or parole within thegrounds. Out of eight cases of general paralysis Itreated with malaria, four were subsequentlydischarged and continue well. Two othersimproved considerably. Hyoscine treatment for post-encephalitic cases is the subject of a special note ;the results were not very gratifying. Other researchwork carried on includes an investigation into thepsychological origin of schizophrenia, manic-depressivepsychosis, and paranoia ; a great deal of routineand blood culture work has been done in the labora-tory. In the occupation department 64 women weretaught handicrafts and 16 men were employed inbrush-making, in upholstery, and in boot-repairing.Twelve nurses and three attendants obtained theirdiploma and 26 more passed the preliminary examina-tion of the Medico-Psychological Association. Thisbrings the total of certificated female nurses up to42 per cent., a figure which the superintendentbelieves to be a record. A nurses’ lecture-room hasbeen equipped with models, lantern, and epidiascope.It is gratifying to learn that the standard of proba-tioners continues to improve. New tennis andbadminton courts have been made.

The County and City of Worcester Mental- Hospitalat Powick houses 1129 patients and has about 130vacancies. The recovery-rate for the year was

28’1 per cent., and the death-rate 6-4 per cent.,with an autopsy percentage of 56’2. The generalhealth was good, except for three cases of enteric,the origin of which was not traced. Plans have beenapproved for the erection of a verandah for maletuberculous patients ; this will be a great advantage,as at the present these men have to be nursed in theinfirmary ward. A dentist has been appointed tovisit the hospital fortnightly, and a small laboratoryhas been fitted up. The lack of electric current makesit impossible to employ certain modern aids toinstitutional work-a cinematograph, kitchen devices,and so on. The farm showed a profit last year ofnearly 2700.The Middlesbrough Borough Mental Hospital houses

476 patients, an increase of 24. The recovery-ratewas 39’6 per cent. and the death-rate 8-7 per cent.Sixty-six per cent. of the patients were kept usefullyemployed, and day or week-end leave and parolewere granted wherever possible. The general healthin 1926 was good. There were only half a dozen casesof tuberculosis. Operations for hernia and pyloricstricture were performed by the visiting surgeons.The Visiting Commissioner, remarking that " thereis a manifest desire here to progress on modern lines,"notes the excellent arrangements for electrical and"

light " treatment, and urges provision for separatetreatment of recent and presumably recoverablecases, and of out-patient treatment. He commentson the fact that 77 per cent. of the direct admissionscame from the Poor-law institution instead of straightfrom their homes, suggesting that this means ofcertification is too often resorted to. Seventeen maleattendants and two nurses are certificated and11 have passed their preliminary examination.

MENTAL DEFECTIVES.

The Royal Eastern Counties Institution for thementally defective at Colchester issues its sixty-eighthannual report for 1926, illustrated . by excellent

photographs of the buildings, games, and theatricalgroups. The accommodation for 1120 patients isnearly all occupied, and there is urgent need forextension. Plans have been approved for some enlarge-ment, but progress is slow. The general health andnutrition was good and there were only four cases oftuberculosis. Day service and living-in service havebeen continued, the chief development during theyear was the increasing use of foster-mothers forquiet, well-behaved cases. The children go out onlong leave of absence ; this is preferable to puttingthem out under guardianship, because if anythinghappens, either to patient or foster-mother, theformer can be brought back to the institution at amoment’s notice. The medical superintendent findsfrom experience that, for the great majority of defec-tives, life in an institution is happier and more success-ful than any other scheme. Daily service is better,too, than boarding-out. Once a beginning of libertyis made, the defective generally thinks all restrictionsare gone, and parents or employers will not enforcethe terms of licence. The superintendent confessesto a considerable degree of pessimism about thepossibility of getting the higher-grade cases back intothe world. The only high-grade cases that ever comeinto an institution are those which have failed manytimes to adapt to an outside environment, and willfail again. The only class he sends out without mis-giving is the quiet, well-behaved medium grade whois mentally a child and content to live for always as achild, under a good foster-mother. The schoolgirl guide company had a fortnight’s summer campat Langham Hall and have taken 133 second-classand proficiency badges. The scout troop came outfifth in the ambulance competition for Colchesterscouts. The patients make every article of clothing,every bit of furniture, every brush, mat, or basketneeded by the institution, as well as selling productsoutside. More orders would be welcomed, but it isgratifying to learn that the coal strike did not producethe drop in income that might have been anticipated.As diphtheria had given a good deal of trouble forsome years previously, the Schick test was tried onall those whose guardians gave consent. All thepositive cases were immunised and there has beenno more diphtheria. There were no mishaps amongall the 1084 persons dealt with. There was a mildepidemic of influenza during the year and twopatients died, but the tuberculosis death-rate was only0-81 per cent. Epileptics were treated with luminal;the conclusion was that it helped to modify the attackswhile not curing the patient.

INFECTIOUS DISEASE IN ENGLAND AND

WALES DURING THE WEEK ENDEDJULY 30TH, 1927.

Notifications.-The following cases of infectiousdisease were notified during the week:-Small-pox, 185(last week 195) ; scarlet fever, 1623 ; diphtheria, 801 ;enteric fever, 78 ; pneumonia, 562 ; puerperal fever,45 ; puerperal pyrexia, 97 ; cerebro-spinal fever, 7 ;acute poliomyelitis, 20 ; acute polio-encephalitis, 1 ;encephalitis lethargica, 23 ; dysentery, 3 ; ophthalmianeonatorum, 93. There was no case of cholera, plague,or typhus fever notified during the week.Deaths.-In the aggregate of great towns, including

London, there was no death from small-pox, 1 (0)from enteric fever, 25 (2) from measles, 9 (1) fromscarlet fever, 12 (1) from whooping-cough, 21 (4) fromdiphtheria, 68 (8) from diarrhoea and enteritis undertwo years, and 15 (2) from influenza. The figures inparentheses are those for London itself.

Registration of Stillbirths.-Under the Birth andDeath Registration Act, 1926, which came into forceon July 1st last, 980 stillbirths were registered upto the 30th of the month in the great towns of Englandand Wales, including 171 registered in London, givinga weekly average of 229 and 40 respectively.