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03107af9-4ba4-421a-871a-b74fbe25e01e | The rooms .habitually used as sleeping rooms only in a basement can be closed if they cannot made to comply with the Council's regulations relating to such rooms, but it would be well if the regulations applied equally to rooms used as living rooms or workshops. 10 Under Section 20 of the Housing Act, 1930, proceedings may be taken to close a separate tenement in a house as unfit for human habitation but no such power is given to deal with any particular room in the tenement. Here again it would be advantageous if a separate room of any such tenement which was unfit for habitation whether used for sleeping only or otherwise, could be closed. None of the three and four storied tenement houses in the borough have W.Cs. on the third or fourth floors; nor in most cases is there space to construct one. |
a941b774-2169-4f64-b805-132db226119d | Most of these houses come under the byelaws with regard to houses let in lodging or occupied by members of more than one family, but it is doubtful whether the clause in these byelaws dealing with the adequacy and accessibility of W.Cs. for each family can be construed so as to require an owner to construct a W.C. on each floor, although this is most desirable. HOUSING. Number of Houses erected during the year:— (a) Total (including number given separately under (b)146 (b) With State assistance under the Housing Acts:— (i) By the Local Authority 28 (flats) (ii) By other bodies or persons 62 1. |
3f4ecf69-ca58-4717-acee-52b74d7ecd48 | Inspection of Dwelling-houses during the Year 1934:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts)1959 (b) Number of inspections made for the purpose 4886 (2) (a) Number of dwelling-houses (included under sub-head(l) above), which were inspected and recorded under the Housing Consolidated Regulations, 1925 1548 (b) Number of inspections made for the purpose 3722 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil. (4) Number of dwelling-houses (exclusive of those referred to under the preceding subhead) found not to be in all respects reasonably fit for human habitation 1888 11 2. |
c46501ca-d3ba-4e18-b9e8-4c8bdeff5526 | Remedy of Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses renderered fit in consequence of informal action by the Local Authority or their officers 1753 3. Action under Statutory Powers during the Year:— A.—Proceedings under sections 17, 18 and 23 of the Housing Act, 1930 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs127 (2) Number of dwelling-houses which were ered fit after service of formal notices :— (a) By owners 127 (b) By local authority in default of owners Nil. B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 8 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 8 (b) By local authority in default of owners Nil. |
0edc645d-072d-4182-ae1c-05e98e09a745 | C.—Proceedings under sections 19 and 21 of the Housing Act, 1930 : (1) Number of dwelling-houses in respect of which Demolition Orders were made 8 (2) Number of dwelling-houses demolished in 1934, in pursuance of Demolition Orders17 D.—Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil. 12 (2) Number of separate tenements or underground rooms in respcet of which Closing Orders were determined, the tenement or room having been rencered fit Nil. TABULAR STATEMENT OF INSPECTIONS AND DETAIL OF WORK CARRIED OUT BY THE SANITARY INSPECTORS. Number of Inspections and Action Taken. |
9b15812c-89b6-4e11-8140-f82e9f7e6478 | Total number of dwelling-houses inspected for housing detects (under Public Health or Housing Acts) 1959 (1) Dealt with by service of Informal Notice 1753 (2) Dealt with by service of Statutory Notice under Section 17, Housing Act, 1930 127 (3) Dealt with by service of Statutory Notice under Public Health Acts 8 Premises (other than defective dwelling houses) inspected for nuisances and miscellaneous defects 929 (1) Dealt with by service of Informal Notice 755 (2) Dealt with by service of Statutory Notice under Public Health Act, &c.32 Reinspections subsequent to sen-ice of Notice 6987 Inspection after notification of Infectious Disease 429 Number of Premises under Periodical Inspection. |
835c0533-2b3c-4fa8-9d29-944fecf34d62 | Workshops and Workplaces 135 Bakehouses 29 Slaughterhouses 2 Public House Urinals 37 Common Lodging Houses 1 Butchers' Shops 47 Fish Shops 32 Premises where food is manufactured or prepared 35 Milk Punrveyors110 Cowsheds Nil. Piggeries Nil. Rag and Bone Dealers 7 Mews 4 Schools 13 Caravan Grounds 2 13 Rent Restriction Act. Number of Certificates granted 32 Detail of Work carried out. Sanitary Dustbins provided 546 Yards paved or yard paving repaired 213 Insanitary forecourts remedied 58 Defective drains repaired or reconstructed 67 Defective soil pipes and ventilating shafts repaired or re- ne-vved 89 Defective fresh air inlets repaired or renewed 53 Defective gullies removed and replaced by new 67 Rain water downpipes disconnected from drain 16 Dishing and curb to gullies repaired and new grating fixed 264 Defective W.C. |
fff82685-18d9-4cf3-adf8-4b5ca71e6e3e | pan and traps removed and replaced by new 61 Defective W.C. flushing apparatus repaired or new fixed 585 Defective W.C. |
7939f186-ef7d-4066-a29e-563de3652b29 | seats repaired or new fixed 198 Defective flush pipe connections repaired 157 Insanitary7 sinks removed or new fixed 46 Sink waste pipes repaired or trapped 203 Insanitary wall surface over sinks remedied 145 Ventilated food cupboards provided 10 Drinking water cisterns cleaned 593 Defective covers to drinking water cisterns repaired or new fixed 214 Insanitary sites beneath floors concreted 7 Spaces beneath floors ventilated 183 Dampness in walls from defective damp-proof course remedied 148 Dampness from defective roof, rain water gutterings, &c., remedied 877 Defective plastering repaired (number of rooms) 456 Rooms where dirty walls and ceilings have been cleansed and redecorated 3142 Defective floors repaired 118 Defective or dangerous stairs repaired 33 Defective doors and windows repaired 327 Defective kitchen ranges and fire grates repaired 144 Defective washing coppers repaired 96 Coal cupboards provided or repaired 23 New W.C. |
aa187334-5c7d-418a-983b-5e9a76d15173 | apartments provided 4 Accummulations of offensive matter removed 31 Drains unstopped and cleansed 289 Overcrowding nuisances abated 14 Drains tested, exposed for examination, &c 73 14 Smoke observations taken 163 Smoke nuisance abated on service of notice 18 Nuisances from animals abated 7 Notifications of waste of water sent to Metropolitan Water Board 314 UNSOUND FOOD SURRENDERED DURING 1934. Table 1. Diseased Meat. T uberculosis. 1 Calf's Pluck. Pigs. 2 sets Cows' Lungs with 60 Carcases with Heads. Heart. 5 Forequarters. 1 set Cow's Lungs. 583 Heads. 1 Cow's Liver. 331 Plucks. 1 set Calf's Lungs with 2784-lbs Chitterlings. Heart. Cattle. Sheep. 14 Sheeps' Plucks. |
2dfadb04-a92a-4992-8314-4eed7d96090c | 2 Cows' Carcases with Offal. 74 sets Sheeps' Lungs. 5 Stirks' Carcases with Offal. 13 Sheens' Livers. 16 Calves' Carcases with Offal. 1 set Sheep's Lungs with 6 Forequarters of Veal. Heart. 2 Loins of Veal. 1 Side of Veal. Parasites and Cirrhosis. 2 Stirks' Heads & Tongues. Cattle. 4 Calves' Heads & Tongues. 2 sets Cows' Lungs with Hearts 1 Calf's Pluck. 3 sets Calver' Lungs with Pleurisy. Hearts. 2 Stirks' Plucks. Pigs. 24 Calves' Plucks. 2 Forequarters. 2 Cows' Livers. 5 Ribs. 1 Calf's Liver. Cattle. 2 Calves' Kidneys. |
7fed61dc-54cc-484d-b856-6f5c5daf1ec0 | 1 Calf's Carcase with Offal. Tuberculosis and Pleurisy. 1 Brisket of Beef. 1 Calf's Carcase with Offal. 2 Forequarters of Veal. T uberculosis & Dropsy. 9 Breasts of Veal. 1 Calf's Carcase with Offal. 19 Ribs of Veal. 1 Stirk's Pluck. Parasites. 17 Calves' Plucks. 1 Cow's Liver. 46 sets Calves' Lungs with 1 Calf's Liver. Hearts. 15 Sheep. Adenitis. 1 Breast of Mutton. Cattle. 2 Sheeps' Plucks. 3 Calves' Plucks. 1 Rib of Mutton. 2 Calves' Livers. Pleurisy and Parasites. Arthritis. Cattle. Pigs. 1 Calf's Pluck. 1 Leg of Pork. |
e48a0125-bb18-4828-8a6e-ccb3d18b5b6a | Pleurisy and Pneumonia. Cattle. 1 Calf's Carcase with Offal. 1 Shoulder of Beef. 1 Knuckle of Veal. Suppurating Pleurisy. 1 Shank of Veal. 2 Calves' Carcases with Offal. Pyaemia. Abscesses. 2 Calves' Carcases with Offal. Pigs. 1 Leg of Pork. Leukaemia. Cattle. 1 Calf's Carcase with Offal. 9 Calves' Heads. Cirrhosis. 1 Calf's Pluck. 2 Cows' Livers. 18 Calves' Livers. 3 Stirks' Livers. Sheep. 4 Calves' Livers. 1 Sheep's Head and Scrag of Mutton. Nephritis. 2 Cows' Kidneys. Pneumonia. 13 Calves' Kidneys. Cattle. |
4f09717c-0519-4d58-b730-4f38e769fa83 | Congestion. 1 Calf's Pluck. 2 sets Calves' Lungs with Hearts. 3 Calves' Carcases with Offal. 2 Calves' Plucks. 2 sets Calves' Lungs with Hearts. Jaundice. 5 Calves' Carcases with Offal. Dropsy. Congestion and Bruising. 1 Calf's Carcase with Offal. 2 Calves' Carcases with Offal. Dropsy and Emaciation. Cystic. 1 Cow's Carcase with Offal. 5 Calves' Kidneys. Sheep. Bacterial Necrosis. 5 Sheeps' Carcases with Offal. 4 Calves' Livers. 16 Melanosis. Unsound. 5 Calves' Carcases with Offal. Cattle. 2 Ribs of Veal. 1 Calf's Pluck. 2 Hindquarters of Veal. |
a1fc5dab-e7db-4b4c-a590-68e5409f0d0d | 1 Calf's Liver. Moribund. 1 set Calf's Lungs with Hearts. Pigs. Suffocation. 2 Carcases with Offal. Pigs. Cattle. 12 Pigs Carcases. 12 Calves' Carcases with Offal. Sheep. 4 Sheeps' Carcases. Sheep. 2 Sheeps' Carcases with Offal, Other Foods. Bruised. Bruised, Fractured, etc. 1 Turkey. Pigs. 1 Chicken. 2 Hindquarters. Mastitis. 1 Leg. 12-lbs.Minced Belly of Pork. Cattle. 5 Calves, Carcases with Offal. Unsound. 6 Loins of Veal. 3 Turkeys. 1 Forequarter of Veal. 6 Ducks. 2 Hindquarters of Veal. 42 Chickens. 1 Side of Veal. 50 Rabbits. |
fbb79128-51bd-4efa-b2d0-9526338deb44 | 1 Leg of Veal. 19-lbs. Cod Fillets. 4 Knuckles of Veal. 36 tins Prawns. 3 Calves' Kidneys. 1 (6-lb.) tin Ox. Tongue. 17 TABLE II NUMBER OF PIGS' CARCASES INSPECTED FROM 1st JANUARY TO 31st DECEMBER, 1934 WITH ANALYSIS OF SURRENDERS ON ACCOUNT OF DISEASE. 1934 No. of Carcases Inspected. No. of Heads Diseased. No. of Carcases Diseased. No. of sides Diseased. No. of Fore Quarters Diseased. No. of Hind Quarters Diseased. No. of Legs Diseased. No. of Shoulders Diseased. Plucks (Lungs, Livers and Hearts). Mesenteries, Stomachs and Intestines Pieces of Pork. |
1370c160-649a-4087-a5a3-cfeb4f4e4993 | January 1687 53 3 - - 2 - - 26 232 lbs. — lbs. February 979 23 4 - - — - - 15 136 „ - , March 1412 59 5 - - — - - 30 256 „ - „ April 1373 34 5 - 1 — - - 22 192 „ 40 „ May — 1179 40 2 - 2 — - - 24 168 „ 34 , June 1223 49 4 - - - - - 20 184 „ - „ July 1295 50 4 - - - - - 27 140 , - , |
604ce43b-58d4-4f16-b5e7-d5a58745b3ee | August 1433 35 3 - — - 1 - 23 108 „ - „ September 1747 60 10 -— 2 - - - 32 248 „ —-„ October 2018 108 11 - 2 - - - 44 432 „ - „ November 2248 71 7 - — - 2 - 31 272 „ 42 „ December 2175 81 6 - - - - - 39 328 „ - „ Total 19369 663 64 — 7 2 3 — 333 2762 „ 116 „ 18 SANITARY CONDITION OF THE SCHOOLS. A complete sanitary survey of the schools has been made by the Sanitary Inspector, and I am pleased to report that the conditions in all the schools are excellent. In none of the schools were there any serious defects found ; there were a few minor conditions which required to be remedied, such as a defective W.C. |
ee909d62-c341-4caa-99fc-852366035340 | seat, &c. Considering that some of the schools are about 40 years of age, the sanitary conditions are astonishingly good. INSPECTION AND SUPERVISION OF FOOD. Milk Supply. There are no cowsheds in the Borough, all the milk being produced outside. There are 119 persons or firms retailing milk in the district under the following categories :— Dairymen. Purveyors of Milk No. with rounds not occupying premises in the Borough. No. with rounds occupying premises in the Borough. No. of General shops from which milk is sold from covered pans only No. of shops from which milk is sold in closed and unopened receptacles only. 11 19 2 87 Special Designated Milk. |
9c238b40-8068-4500-b1aa-013cc6f04d20 | The number of persons or firms licensed to sell Special Designated .Milk are as follows:— 3 " Certified " 5 " Grade A (Tuberculin Tested) " 1 " Grade A " 16 " Pasteurised " 1 " Grade A Pasteurised " BAKEHOUSES. Of the 29 bakehouses in the Borough 5 are underground these were licensed under the Factory Acts of 1901. 19 SMOKE ABATEMENT. Nuisances from the emission of smoke from industrial chimneys in the Borough arise chiefly from the use of unsuitable coal, or through the absence of proper appliances for burning it. In an atempt to reduce overhead charges, most of the laundries and manufacturing companies purchase the cheapest fuel possible, which is known in the trade as "duff", namely, slack, dust, or fine siftings of house or steam coal, costing from 20/- to 22/per ton delivered, and such coal is not always washed. |
1684bc70-d4ea-4148-91cd-d73906c22abe | The siftings of Welsh Steam Coal or semi-anthracite have a high calorific value and give off little smoke, but the slack of coals from Derbyshire and Nottingham—soft house coals—is highly bituminous and gives off as much as one third of its weight in smoke. It is therefore impossible to fire such coal by hand without causing a nuisance. A certain amount of skill is required of the stoker when firing these soft slack coals, and the work is decidedly harder as there is a tendency for the coal to cake or fuse together, and the hard tight crust which is formed prevents air passing through the fire bed. If this is not carefully watched combustion is impeded, except where the crust cracks and air passes through. Any slowing down of combustion naturally affects the amount of steam raised, and manufacturers cannot as a rule meet their requirements for steam unless the boiler is working at its full rated capacity. |
3a42ba0b-75a0-4f98-88d8-512c6ebf09f1 | To burn any soft coal it is necessary to stoke at frequent intervals—not longer than 5 minutes—but this has the decided disadvantage that every time the fire door is opened the cold air which enters the furnace, reduces its temperature and also the temperature in the combustion-chamber, with the consequence that volumes of smoke are emitted from the chimney. It is also necessary to break up with a slice bar the crust on the fire bed at frequent intervals and during this operation volumes of dense smoke are given off. Moreover forced draught is needed for burning this class of coal with a result that coal-dust, grit and ash is blown up the chimney. During the year six cases of nuisances from dust, grit and ash were dealt with. For burning "duff" satisfactorily, mechanical stokers are necessary, and in one laundry where an under-feed mechanical stoker was installed excellent results were obtained. |
03431106-c9c4-49b5-816f-e226d331e3f8 | 20 quiry it was found that a soft Nottingham slack costing about 20/per ton was being burned, whereas formerly semi-anthracite peas costing 30/- per ton had been used. Although the firm was saving £250 per annum on their coal bill the district around the works was subjected to a very bad smoke nuisance. There was one prosecution during the year against the owners of a laundry for emitting black smoke, and a fine was imposed. The nuisance arose through the use of unsuitable coal in a boiler of insufficient capacity to meet the demands for steam. A new boiler of sufficient capacity is now about to be installed. On the investigation of a complaint from the emission of ash it was found that the firm was burning in their boiler as fuel, wood waste and saw dust. Coal is now being burned. Many laundries in the borough are using boilers of the locomotive type. |
1342ef44-c712-44ba-a2d4-e7efb4863431 | These are good smoke producers, and as all efforts to prevent smoke nuisances from this class of boiler have failed, many firms are replacing them by boilers of the Paxman type. Complaints are frequently received of smoke nuisances on vacant land caused through the burning of wood waste, sawdust, old motor tyres, ets. As such offences do not constitute nuisances under the Smoke Clauses of the Public Health Acts, nothing beyond persuasion can be done to abate them. BIRTHS. Table 7 gives particulars of the births registered and notified in the district, and the births belonging to the district, which have occurred and been registered outside the district. The total number of registered births is obtained from the Registrar-General on form S.D.30. The notified births are obtained through the notification of births in the district, and from those Medical Officers of Health of districts in wliich outside births have occurred, and who have sent lists during the year. |
de8e2227-513b-4d66-99c6-5b6c6ae93da2 | The total number of births registered was 943:483 males and 460 females. This figure is equal to a birth-rate of 13.57 per 1,000 inhabitants. In addition 32 still births were registered as belonging to the district. The birth-rate is 1 per 1,000 higher than that of 1933, and the number is 57 higher in 1934 than in 1933. If Table I at the end of the report be examined it will be observed that both the birth-rate and the death-rate of Acton are 21 below those of the whole of England & Wales. Our death-rate has always been lower, but until recently our birth-rate was higher than the rates which obtained in the rest of the country. In some of the districts around London the birth-rate is still higher than in the whole of England and Wales. This fact does not point to a real increase or even to a high birth-rate, but is due to changes in the population. |
225dc90a-faf9-42f5-b1ea-0c93a12da33a | The higher birth-rates occur in those districts which are now in course of development, as these naturally attract newly married couples ; based upon the gross population, their birth-rates appear high. If the birth-rates were standardised according to the age distribution of the population, or based upon the number of married people between ages say of 20 and 45 years of age, it would be found that the extra-metropolitan districts had a lower birth-rate than that of the whole of the Kingdom, and that the rate was a falling one. The birth-rate has been declining regularly since 1880. Except for the abnormality of the years 1915-21, due to war conditions, the birth-rate is a regular slant to 1934. |
08cdb6eb-0a32-49ad-a5e7-ff556daa8b26 | In Acton this phenomenon has not been marked until recently, because of the abnormal agedistribution of the population as a developing district, but now that the borough is almost fully developed, the birth-rate will exhibit the same character as that of the rest of the Kingdom and show a regular decline, probably in an exaggerated degree. Moreover, not only the rate will decline, but the actual number of births will be much less. What is the explanation of the fact that the birth-rate and the number of births last year were higher than they were in the previous year ? This phenomenon, of course, may only Occur in 1934, and as the period is such a short one, is of no significance, but I am of opinion that the cause is due to an underestimate of the population by the Registrar General. Before the last Census it was suspected that the estimate of the population was too low, and the Census proved that our suspicions were well founded. |
3066e753-8c9f-46f3-9b96-75c8ce6ee63a | At the present time also, I think that similar conditions exist, and that instead of the population being lower than it was at the Census, it is higher, and that the birth-rate had not increased last year. 22 Two hundred and ninety-seven deaths of Acton residents occurred outside the area and have been included in our returns. The total number of deaths belonging to the district is therefore 727, which corresponds to a death-rate of 10.46 per 1,000 inhabitants. This rate is what is called the crude death-rate and as such is not comparable to the death-rate in the whole of England and Wales, nor is it comparable to that of other districts, It has been explained in previous reports that the death-rate of a district depends among other things upon the age and sex incidence of its population, and in order to establish a comparison these conditions must be standardised. For this purpose the Registrar-General has supplied each district with a comparability factor for adjusting the local death-rate of 1931 and subsequent years. |
4c17dc94-9999-4cbb-870d-81838e05750e | The comparability factor for Acton before the change of boundaries on April 1st, 1934, was 107 and after April 1st, 108 In order to institute a comparison with other districts the death-rate has to be multiplied by the comparability factor. The standardised death-rate of Acton would therefore be 11.29 per 1,000 inhabitants. The following extracts from the Memorandum issued by the Registrar General will explain how and why the comparability factor is used. The crude death-rate of an area should be multiplied by the comparability factor in order to make it comparable, from a mortality point of view, with the crude death-rate of the country as a whole or with the mortality of any other local area, the crude deathrate of which should be similarly modified with its own factor for the purpose. |
e38c807d-78e4-407a-9e48-9609ecc20059 | If the populations of all areas were similarly constituted as regards the proportions of their sex and group conponents, their crude death-rates (deaths per 1,000 population) could be accepted as valid comparative measures of mortalities experienced by the several populations. In practice, however, populations are not thus similarly constituted and their crude rates fail as true comparative mortality indexes in that their variations are not due to mortality alone but arise also from differences in their population constitution, the two elements being combined in indistinguishable proportions. In order to isolate the mortality factor it is first necessary to identify and remove the population variable. For the present purpose, the average mortality rates experienced in England and Wales during the three years 1930-32 divided into 11 sex-age groups have been adopted as the standard and have been applied to the corresponding sex-age groups in the 1931 census population of every 23 Borough, Urban District and Rural District in the country. |
aaae278d-8db4-4e57-83c9-e3b2ff788735 | The adjusting factor now supplied in respect of a given area represents the ratio of the resulting death rate for the national 1931 census population to the similarly obtained hypothetical death-rate for the said area. The factor may be said to represent the population handicap to be applied to the area and, when multiplied by the crude death-rate experienced in the area, modifies the latter so as to make it comparable with the crude death-rate for the country as a whole or with the similarly adjusted death-rate for any other area. Two extreme examples are taken to illustrate the working of the comparability factor—Bournemouth and Dagenham. Bournemouth's crude death-rate for 1933 was 14% above the national average, but by the adjusted comparison it is seen to be 15% below ; the apparent excess in the first comparison being nothing more than a reflection of the elderly nature of the Bournemouth population The abnormal distribution of the population accounts for the remarkably low crude death-rates in some of the rapidly growing districts. |
12c8b1cc-5aeb-48cd-94a6-af8e109fdcc2 | Apart from the abnormal age distribution of the population, the death-rates in some districts would require all persons who died in those districts to be centenarians, and only the method of comparison is by the use of the comparability factor. As the population becomes stabilised, the death-rate must rise. Even at the present time, the death-rate tends to increase, but it may be asserted with confidence that never has the population as a whole been so healthy. The death-rate has declined irregularly since 1880, but it was not until 1900 that the drop became marked. Throughout the Kingdom the rate since 1920 has been fluctuating with a slight tendency to increase. In Acton the death-rate has not yet actually shown an increase. |
7569d513-5202-48e0-a728-fcbfa5d8814b | Were it not that the death-rates at all ages below 80 have been reduced, the death-rate would have started to rise steadily about 1910, but actually it fell during the period 1920-1930 and has not yet started to rise steadily, but inevitably it must do so before many years have passed in spite of a healthier population. Analysed for age periods, we find that in infancy the drop is great, but it is less and less for each successive age-period. For persons over 80, the death-rate is much the same and probably will continue to be so. In 1900 the average age at death was 34 years, and in 1933 it was 64. 24 At the end of the report there is a table giving the age-distribution of the deaths which occurred. From that table it will be seen that only 116 persons under 25 years of age died whilst 336 of the deaths were in people over 65 years of age. |
a27ac040-d2da-4d57-bd5f-3ca6b0d86a17 | Nearly one-half of the deaths—46 per cent.—occur in people over 65 years of age. In previous reports I have pointed out how the increased age at death affects the morbidity of certain diseases. Apart from the diseases which are associated with worn out cells of the body such as old age with 38 deaths, Cerebral Haemorrhage 43 deaths, thickened arteries 44 deaths, there has been a great increase in the number of deaths from other causes such as Heart Disease and Cancer. Although there is an apparent increase in the number of deaths from Heart Disease, there is no reason to assume that post infective heart disease, which may be preventable is on the increase, 103 of the deaths from heart disease were in persons over 65 years of age, and it is fair to assume that most of these are due to a degeneration which is inevitable, and the increase in the number of deaths from heart disease is due to the altered age distribution of the population. |
b4ffc3fa-ef26-4202-814c-b30c2927d8e5 | There was a decrease of 11 in the number of deaths from Cancer as compared with 1933, but there is an increased tendency of death from Cancer. In studying the apparently increased incidence of Cancer, we must also bear in mind the altered age-distribution of the population, and the relative increase of people living to an age in which Cancer claims most of its victims. Only one death was uncertified. This occurred in Glossop. I have pointed out in different annual reports the attitude of the public towards the treatment of disease in institutions, and the increasing number of deaths in Public Institutions. Last year 358 deaths occurred in Public Institutions, and in recent years, nearly one-half of the deaths have occurred in public institutions. Thirty years ago less than one-fifth of the deaths occurred in public institutions. In 1905, 1906 and 1907, the numbers were 118, 119 and 158 respectively. |
7463282f-fb52-433a-90d0-23d12371c909 | The increase has been a gradual one, and at no particular period was there any marked or sudden increase. The increase though has been most marked in the County Hospitals and in the local general hospital. Thirty years ago, less than one-half of the total deaths in public institutions occurred in the old poor law infirmaries. In 1905 out of 118 total deaths in public institutions 54 occurred in the local infirmary, and out of 119 in 1907, 44 occurred in Isleworth Infirmary. In 1932, 1933 and 1934, 179, 195 and 200 deaths respectively occurred in the Middlesex County Hospitals out of totals 25 of 386, 386 and 358 in all public institutions. This increase is due partly but not entirely to the change in the character and control of these institutions. |
0802f1eb-e492-4763-a342-f1ed23eeabef | By the Local Government Act, 1929, these institutions were transferred from the Boards of Guardians to the County Councils, and the old stigma of the Poor Law was removed. But the popularity of these institutions had commenced before the transfer, and even when they were under the control of the Guardians the general public were making increased use of the facilities which they offered. During the last 30 years, as far as this district is concerned the great voluntary hospitals of London have declined in their popularity. With the exception of the West London Hospital, fewer deaths have occurred in the Voluntary London Hospitals in the last 5 years, than occurred in them 30 years ago. Inquests and Coroner's Inquiries. Thirty inquests were held and in 27 instances the Coroner issued a certificate without an inquest after he had ordered a postmortem examination. INFECTIOUS DISEASES. Scarlet Fever. Two hundred and thirty-six cases of Scarlet Fever were notified last year with one death. |
d98d90e0-a480-4831-8262-510d7e05a9a6 | These figures are sufficient to indicate that the type of the disease was mild. For a number of years the mildness of Scarlet Fever has been a subject of comment, but in the Annual Report of 1932, a resume of the history of Scarlet Fever was given, and it is evident from that history that Scarlet Fever throughout some centuries has varied greatly in its severity. A mild type would be followed by one of extreme malignancy, and mild and severe epidemics have alternated throughout the ages. If the prevalent views of Scarlet Fever are accepted, the mild type which now prevails does not mean that there is an alteration in the character of the disease. The behaviour of Scarlet Fever varies considerably not only in different areas but in different districts of the same area. These variations are explicable if we are willing to accept that Scarlet Fever is not a specific disease, but that the Scarlet Fevers are a group of somewhat specialistic reactions to a group of allied parasites. |
a096791d-046e-4aae-a480-0bc5e5aa1fa8 | It has been found that the incidence of the types of streptococci in Scarlet Fever varies in different localities and reflects the clinical character of the prevailing scarlatinal infections. 26 A number of the eases admitted to hospital have a definite train of signs and symptoms. The earliest symptom is usually a sore throat, accompanied by a temperature which frequently reaches 103, 104 and 105 degrees. The throat is congested and the softr palate may be uniformly injected or it may have the appearance of a punctate rash, which may be regarded as the enanthem of the disease. The tongue, at first furred, afterwards assumes the typical strawberry appearance. The rash appears about 24 hours from the onset of the disease and consists of closely set minute points, usually of a brilliant red colour. The rash is general on the trunk and limbs, but does not invade the face. When these signs and symptoms are present there is no difficulty in the diagnosis, but the conditions may be modified to an extraordinary degree. |
76d13a25-bb34-4cfc-ae00-cd4f776d5631 | The temperature may not be above the normal; the throat symptoms may be very mild ; the appearance of the tongue may be quite indefinite, and the rash so evanescent as to have disappeared before admission to hospital. So that although most of the cases are easy, others are difficult, and some are impossible to diagnose correctly at the stage in which they are admitted to hospital. If we admit that Scarlet Fever is not a specific disease, the difficulty of diagnosis is fundamental, and not due to want of skill The conditions are so variable as to warrant the assumption thaf the disease we call Scarlet Fever is not a specific entity but caused by different strains of the Streptococcus. The conditions are to variable to be explained by different degrees of virulence in the same strain. Bacteriologically, the Scarlet Fever reaction may result from infection of numerous kinds of streptococci which are not identical. |
4266273c-aea5-48d0-b511-03d3a2304fe2 | In the majority of the cases of Scarlet Fever, the organism found is a haemolytic streptococcus belonging to one of four types. In some epidemics scarlatinal types 1, 2, 3 and 4 represent over 75 per cent of the strains isolated, and it is confidently stated in some quarters that the severity or mildness of the disease depends on the type of streptococcus present in the epidemic. But although the assumption of the causation of the disease by different strains of streptococci may explain some of the clinical manifestations of Scarlet Fever, it leaves certain phenomena obscure. For instance, we should on this assumption expect that a fair proportion of the cases admitted to hospital would develop secondary attacks during their stay in the hospital. But if a definite diagnosis of Scarlet Fever has been made on admission, secondary rashes and throats 27 are very rare. |
3668cc85-c49f-49b1-b63f-15a84cc0258a | Last year in only two instances did we have a secondary rash and throat symptoms in a person who had had what we had diagnosed as Scarlet Fever, on admission to hospital. It has also been suggested that the return case may be caused not by a continuance of the original infection, but by another disease picked up in hospital by the patient and taken home with him or her. The objection to this suggestion is that these patients frequently show no other symptoms before their discharge from the hospital. Besides patients of certain ages very rarely give rise to return cases. An adult hardly ever gives rise to a return case; neither does a child under 3 years of age. It is the children between the ages of 3 and 13 years who normally give rise to return cases. Last year only one person over 15 years gave rise to a return case, one in 1933 and 2 in 1932. |
c5fff887-c429-4b87-b821-3bf42aca17cb | The ages of the infecting cases in 1934 were 16, 7, 4, 4|, 7, 5, and 2. In 1933, the ages of the infecting cases were 11, 13, 12, 11 and 34, and in 1932, 10, 10, 11, 12, 12, 16 and 20. In most hospitals the acute cases are separated from the convalescent. In the third week the patients are usually removed to a clean convalescent ward. The only patients who are not subject to this regime are the adult cases and the very young children, and these are the ones who seldom give rise to return cases. Return cases always cause a good deal of annoyance, and also inconvenience. Many theories have been advanced of the cause of return cases, but no theory will fit all the conditions. |
ef13960b-ebc9-43a1-bf36-d781b7ec5f8e | The subject has been discussed for over 30 years, and though improvements in hospital management may have reduced the numbers, we have not yet found out the true cause. It was at one time suggested that return cases occurred because the quarantine period in the hospital had been too short, and that the infection still persisted in the patient. That the latter was correct was obvious, but it was not so evident that the persistent infection was due to too short a stay in the hospital. In recent years the tendency has been to shorten the stay of uncomplicated cases of Scarlet Fever in hospital. A few years ago the minimum stay of a Scarlet Fever case in hospital was six weeks, or until all peeling had finished. We now ignore the question of peeling and the hospital quarantine has been reduced to a month. Every uncomplicated Scarlet Fever case is now discharged at the end of the fourth week. The number of return cases has not increased, and it has been suggested that these cases would be reduced if the period of quarantine be lessened. |
36772623-e581-42ed-9ec3-b7b1e643f203 | The more recent views on immunity have been responsible for the suggestion that the sooner the case is returned from the hospital the less is the likelihood of return cases, upon the grounds 28 that at the time of removal the other members of the family will be immunized by sub-reacting doses of the parasite, and that the longer the case is retained the weaker will be this primary immunization. At the present time the return case is almost entirely a hospital phenomenon, but that is because a case is nearly always removed to hospital if there are any children or susceptible persons in the house. If a case is nursed at home, it is usually an only child. It is therefore unfair to compare the figures because the conditions are entirely different. Some years ago, when a fair percentage of cases were nursed at home, in one of the annual reports I worked out the figures based upon the number of susceptible persons in the house, and these showed that there was practically no difference between hospital and home treated cases. |
b99f8af2-9d8e-4bb0-b52b-04e16db57fa4 | At the present time for the reasons stated above, it is almost impossible to make a comparison. Measles. Eleven deaths occurred from Measles during the year. Since the War measles in this district has been a less fatal disease. Part of this improvement had been due to the altered age incidence of the population ; this will be referred to in a later paragraph. During the last 25 years measles in Acton has occurred in regular periods. This, of course, has been the experience of most other towns. But our experience has been different to other towns if a longer period still is taken into consideration. During the past 55 years there have been 4 distinct, eras as far as periodicity is concerned. As these periods form an interesting study in the epidemiology of measles I am giving these in different columns. Year. Deaths. Year. Deaths. Year. Deaths. Year. Deaths. 1879 01892 24 1906 27 |
b080c3df-0deb-4054-a955-7af44dd00a33 | 1910 1 1880 0 1893 2 1907 20 1911 44 1881 3 1894 15 1908 38 1912 0 1882 3 1895 6 1909 40 1913 25 1883 2 1896 24 1914 0 1884 1 1897 2 1915 2 1885 25 1898 6 1916 11 1886 3 1899 0 1917 39 1887 8 1900 16 1918 7 29 1888 1 1901 0 1919 0 1589 25 1902 32 1920 9 1590 11 1903 0 1921 0 1891 9 1904 15 1922 5 1905 4 1923 0 1924 |
94a41fe2-9d68-4144-a97c-d82c8a65f565 | 16 1925 0 1926 12 1927 0 1928 12 1929 0 1930 9 1931 3 1932 12 1933 1 1934 11 During the 13 years 1879-1891, measles did not show any regular periodicity. This was followed by the 14 years 1892-1905, in which measles regularly appeared in epidemic form every other year. Then follows a curious period of 4 years—19061909, in which measles occurred every year. The epidemic of 1904 extended into the spring and summer of 1905 and caused 15 deaths in 1904 and 4 in 1905. In January 1906 another epidemic started which caused 27 deaths. In 1907 there was another outbreak in January, February, March and April, which caused 20 deaths. |
acaf1823-456c-46b6-a4fa-a69131566349 | In March 1908 another epidemic occurred which prevailed during the months of April, May and June. In November 1908, measles again appeared in epidemic form and continued throughout the early spring of 1909. These two epidemics caused 38 deaths in 1908 and 40 in 1909. Since 1909 measles has for a quarter of a century almost regularly appeared every other year. It is difficult to explain the behaviour of measles in Acton during the four years 1906-1909, but during the past 25 years it has invariably followed a measles epidemic in London. Many theories have been propounded to account for the regular periodicity of measles. Formerly it was believed by many that an epidemic was always due to the properties of the organism, and that the periodicity of epidemics which occur at regular intervals depends for the most part on the life history of the organism. |
319ffa9d-9137-412b-a4aa-ade12fc8e5c7 | It is now generally admitted that the character of an epidemic of measles, the severity and fatality of the disease, the speed with which it travels and the 30 means which bring it to an end depend upon the interaction of a number of variable factors. One of the most important factors the immunity factor or the total quantity of immunity in the population which may delay the speed or spread or even entirely prevent the disease establishing itself. It. had been known for many years that an outbreak would not spread in a school or a class, if the number of children in that school or class who were protected by a previous attack of measles exceeded a certain proportion of the total in the school or class. But it is now believed that in addition to the permanent immunity which an attack of measles usually confers, a certain amount of temporary latent immunity also occurs during ever}- epidemic amongst the child population of populous areas and that this immunity may be the main factor responsible for bringing an epidemic to an end and determining its periodi city. |
6fe90e9a-a26a-43bb-9d69-372fdf60e4a6 | For every 100 children suffering from a clinical attack of measles in a densely populated area about 300 others become temporarily immunized, and of these 250 lose their immunity again before the next epidemic is due. Starting with 300 children so immunized at the end of one epidemic, 225 would still be immune after three months, 168 after a year and 112 after 1½ years and 50 after 2 years. We may assume therefore that the children at risk at the the beginning of the next epidemic will be the sum of the children who have attained the susceptible ages of one to two years plus those older children who have lost their immunity and that the latter, when attacked, will convey the disease to the former. This may afford a possible explanation of the age mortality of measles. It has been pointed out for years that measles is much more fatal to children in their second and third years than in the other age groups. |
54e0047f-4e8e-4da6-af00-928d75eb13ff | It was formerly assumed that the lower fatality at later ages was due simply to the increased physiological resistance which came with years, but in view of recent research, it is more probable that the children who get measles later in life showed a lower case mortality because they had survived small doses of the disease ; they had been naturally vaccinated, as it were, from the disease. With our modifications of view of the epidemiology of measles, there has been a change in our administrative scheme in the control of the disease. Formerly the elementary school was supposed to play the most important part in the spread of the disease, an ! school closure was very frequently resorted to. Now, a school of department is never closed. If we were fortunate in discovering the first case in the school before the first crop fell, a class migh' 31 be closed towards the end of the incubation period. It is doubtful whether this would be very effective, and even this modified Procedure was not adopted during the recent epidemic. |
dda7c425-44a8-41ec-9af6-720530babf09 | The first cases were reported in January, but these were not school children. Cases in the school did not occur until late in the Spring term. The disease had not become general in any of the departments before the Easter holidays. With the closure of the schools for the Easter holidays, there was a slight break in the spread of the disease. More cases were reported from the schools when they were reopened for the summer term, and cases were recorded iss all the schools almost until the time the schools were closed for the summer holidays. One peculiarity which we noticed, and I believe was also noticeable in the London epidemic, was—the epidemic took a longer time to reach its peak and to spread throughout the district. This may have been due to the fact that the Easter holidays occurred early in the outbreak and affected its course. At any rate Cases cropped up until the schools closed for the summer holidays Returning to the tables another interesting feature in the figures appears in the sudden drop in the morbidity of measles which occurerd 20 years ago. |
797caa44-3371-4a88-8092-5240d786d0e4 | It is difficult to measure the mortality from measles. Owing to the altered age incidence of the population on account of the declining birth rate, it would not be a fair comparison if the number of deaths were assessed as a proportion of the population. If this method were adopted a very great imProvement could be recorded, but such figures would be useless because the incidence of measles in Acton is almost entirely among children under 10 years of age ; a fairer way would be to assess the mortality on the basis of the number of births. If we take a fairly large number of years this method is not liable to a high margin of error. An examination of the table giving the number of deaths in last 55 years shows that this may be divided into4 periods, viz.:— 1879-1888; 1888-1905; 1905-1913'; and 1914-1934. |
7990900d-8b87-4d00-8c97-3c06b45d2e5e | The births and deaths from measles in these periods were as follows:— Period Total births Deaths from Measles Deaths from Measles per 1,000 births 1879-1888 7042 44 6.24 1889-1905 16364 201 12.29 1905-1913 12012 195 16.23 1914-1934 23616 112 4.74 32 The increased mortality from measles commences in 1889 and continued with few intermissions to 1913. There was then a sudden drop which continued until 1924. There was a slight rise in that year and although, compared with the period 1889-1913, there has been a vast improvement we have not succeeded in attaining the high standard reached in the decennium 1914-1923. Various explanations have been given for this behaviour of measles. |
95c80090-b6fd-4d57-91d2-0de3626a6cf7 | The most obvious explanation of the phenomenon is that the varying fatality of the disease depends upon the virulence of the organism or virus which causes measles. As the causative agent has not been isolated this theory cannot be proved or controverted. From a long experience of the disease, and in the last ten years, this experience has included treatment of cases in hospital, I am inclined to doubt this supposition. The initial symptoms in those cases which were removed to hospital in 1934 in an early stage were severe in almost every instance ; a temperature ranging from 103 to 105 degrees was usual and continued for several days. The rash was intense, general and profuse. The initial symptoms did not differ materially from those observed in the beginning of this century, and there is not safe ground for the assertion that the virulence of the causative agent has varied. The alternative theory to an increasing or diminishing virulence of the germ has to do with the improved resistance of the child. |
0dc037d9-09be-4ad3-9369-56f7e1ae3c09 | It is unlikely from the history of measles that the improvement has been secured by an increasing immunity on the part of the children. It has been previously stated that in the older children a certain amount of immunity has been established, but this does not apply to the children in the second and third years of life, amongst whom the majority of deaths occur. It has been suggested that the increased attention paid to infant welfare has been the means of increasing the resistance to infectious disease or at any rate has enabled the child to escape the complications associated with these diseases, and especially those of measles. It is well known that the special attention paid to infant welfare has been instrumental not only to reduce the infantile mortality or mortality in infants under twelve months old, but has been almost as successful in reducing the mortality amongst older children,—in those between 1 and 5 years of age. It is sometimes assumed that our efforts to reduce infantile mortality have left us with a legacy of weaklings at later ages. But this is far from the truth. |
7d8f8ceb-c70f-42fc-b015-de4ceccb2867 | The conditions which formerly killed a large number • ufants, scarred and maimed many of those who survived beyond 33 the age of twelve months, and these fell ready victims of ailments which attacked them between the ages of 2 and 5 years, of which measles was one of the most important. In this manner, probably our infant welfare efforts did affect the mortality from measles. Moreover our propaganda work has resulted in a realization of the seriousness of measles. But this is not the only factor which has operated. The reduction in the mortality from measles did not take effect for a decade after the appointment of Health Visitors in London and the Home Counties. A joint appointment of School Nurse and Health Visitor was made in Acton in 1904, but not only was there no reduction in measles mortality until 1914, but a most marked rise commenced in 1906 and continued for about 8 years. Other factors which may have been mentioned as likely to be operative are improved housing conditions, and increased institutional treatment. |
55150d14-894d-45eb-8f7a-fa33bd6893bc | These would not result in the abrupt improvement which was noticed about 1914, and the improvement took place before these were in operation. During the war, dwelling-house erection was practically at a standstill, and naturally the conditions at the end of the war were worse than they were in the pre-war period. In Acton, removal of cases to the fever hospital did not start until 1924, and extensive hospital treatment of measles did not commence in London before that date. There is something more than a coincidence in the fact that a fall in measles morbidity followed closely on the discovery of vitamins. In saying this I know that one lays oneself open to the old gibe of " post hoc, propter hoc" Neither do I forget the well-known gibe about the increase in Cancer and the increased consumption of hananas. But there are good reasons for assuming that measles morbidity may be associated with deficiency of vitamins. |
f074d1f5-89bf-4347-9f27-ce4e268c35dc | As often happens in the development of science, a fundamental idea is foreshadowed in many quarters, but has long to wait before it emerges as a basis of accepted knowledge. The existence if vitamins was suggested long ago, but it was the publication of Professor Gowland Hopkins' researches in 1912 which served the purpose of gaining for vitamins a universal recognition. The 22 years since the appearance of Professor Hopkins' paper have been a truly remarkable progress in the study of vitamins. I may mention only two of the vitamins. When severe deficiency of vitamin A is present records nearly always mention a high morbidity rate from various infections, and undoubtedly A—deficiency itself is in part responsible. A deficiency of vitamin D is probably particularly associated with infections of the respiratory tract. |
35c8ac4c-a2b7-44f2-8754-946666eb41c9 | 34 On the positive side, we have evidence that one of the most hopeful modes of the treatment of measles is with a fish-liver oil concentrate rich in vitamins A and D. In the London County Council Report on the measles epidemic of 1931-32, Dr. Ellison reports favourably on this treatment which was tried in the case of 300 patients. The mortality of the treated group was rather less than half that of the controls, suggesting that the vitamins exert a specific beneficial action on acutely inflamed lung tissues. Whether this apparent action is real or merely accidental can only be determined by a further and larger series. We treated the majority of the cases admitted into our hospital in the epidemic last year with Cod-liver oil, and, though our figures are too small on which to base any conclusions, we were satisfied that the treatment was well worth further trial. Of the 78 cases admitted into hospital there were 5 deaths. |
722acbcd-3ddc-4d72-9274-3eaa4e5eecac | Most of our cases were admitted on account of complications, severity of attack, or unfavourable home conditions. In the circumstances, therefore, they are very favourable figures. If we turn again to the mortality figures on a former page, it will be seen that the worst period was in the later years of the last century, and the earlier years of this century, and the best period toward the end of the war and in the boom period following the war. It is known that in the former period sophistication of food was rampant. Milk and dairy products were treated unscientifically and substituted, and cod-liver oil was used chiefly as a medicine in tubercular diseases, and these are the chief sources of vitamins A and D. Margarine was very largely used instead of butter, and in those days margarine contained no vitamins. So little care was taken in the production and distribution of milk, that prolonged boiling had to be resorted to in order to prevent its souring. |
be9cc88a-1ea6-496c-b5a0-f25647eb76a0 | In the summer, milk would not keep unless it was boiled, and even in the winter it was not considered too safe to drink raw milk. Pasteurization, in the sense that it is now done, was hardly ever carried out. The prolonged boiling of the milk destroyed the vitamins, and the margarine contained none. It is only since the war that the use of cod-liver oil in the feeding of infants and young children has become so common. So that in the years during which measles was so fatal the infants and young children were suffering from vitamin deficiency and more especially vitamins A and D. It is also possible that in the boom years which followed the war, the food contained the (Note—Of the 78 cases admitted to hospital, 6 came from outside the Borough and 1 death was of an out-patient). 35 necessary vitamins. |
efd631f3-d542-4de4-85a5-71a28797a536 | It is true that butter was difficult to obtain during the war, but by that time cod-liver oil had been recognised as a valuable source of vitamins A and D. Although, not to the extent which prevailed at the beginning of the century, it is possible that the depression of recent years may have had some effect in the slight rise on morbidity which has been noticed in the last ten years. There was no noticeable change in our administrative methods. When accommodation permits, certain selected cases are admitted into the fever hospital. During the spring and summer circumstances permitted us to admit all urgent cases. Altogether 78 cases were admitted to hospital. Diphtheria. Eighty-six cases of diphtheria were notified during the year, and there were 7 deaths. These figures compare with 161 notifications and 23 deaths in 1933, and 151 cases with 21 deaths in 1932. |
64c44ba1-6107-43ae-a3bc-581ea8a11e81 | Although there has been a great reduction in the number of notifications and deaths compared with the two previous years the figures show that the type of disease which is present in the district is of the same virulent character as that experienced in 1932 and 1933. The virulent type of Diphtheria is not a recent mutation. Ever}7 one with a long experience can recall outbreaks of a virulent type of the disease. But whereas formerly the virulent type of the disease occurred not only in a few towns, but was limited to a small part of the town, recent reports show that this type is now prevalent in all parts of the country ; in the southern parts as well as in the northern towns, and the outbreaks are scattered broadly in the towns affected. I can recall limited outbreaks at different times in Acton, but in the last 30 years no outbreak of a virulent type (before the present one) was found to exist throughout the district. |
a11b762c-80d4-4a52-a7f0-7fb48c3e5026 | These graver forms were limited to a school or small circumscribed area. Since the autumn of 1932, cases of the graver type have been found in all parts of the district and among pupils of all the schools in the borough. Within the last few years Medical Officers of Health in several parts of the country have been faced with outbreaks of diphtheria characterised by unusually high incidence and mortality. Whatever may be the full explanation of the phenomenon, it is wellknown that the case mortality of diphtheria in many areas has risen in late years. The graver form of the disease has been present not 36 in isolated towns only, but it has been reported from many towns in almost every part of the kingdom. Another recent development has been the bacteriological differentiation of types. Professor MacLeod and his co-workers in 1931 described three types of diphtheria bacilli—the gravis, mitis and the intermediate. |
15f5c5c4-6a22-46f9-98a2-b68250526f6b | That these types exist is agreed, and it is also generally acknowledged that the clinical type of disease is closely correlated to the particular Corynbacterium isolated from the patients. The soil alone does not determine the character of the symptoms. The severity of the symptoms depends upon several factors which are independently variable,—individual immunity, virulence of the organism, and the stage at which antitoxin is given. From an administrative as well as the treatment point of view, the former methods appear in a great many instances to have failed. The early administration of serum, the swabbing of contacts, and the separation of carriers formerly controlled the spread of the disease and averted a fatal issue. Antitoxin given within 48 hours of the onset of symptoms would result in neutralizing the toxin. But the graver form is an intensely rapid disease.and antitoxin given as early as 24 hours after the onset of the symptoms is frequently of no avail. |
9493b7e4-daa3-4306-a24c-301e14b239ad | It has been stated that serum prepared from Park 8 strain is effective against the bacillus gravis as well as the bacillus mitis, if injected early; that is, if the antitoxin is administered soon after the dose of toxin has been given. Large amounts of toxin or culture of gravis and mitis strains have been injected into guinea 'pigs and ordinary antitoxin given at intervals of two hours after infection saved all animals ; after eight hours it saved none. In the intervening periods there was no significant difference between the percentage saved in the gravis and the mitis group of animals. In spite of this, many if not most clinicians now admit that recently there have been admitted to hospital a large number of severe cases which formerly were few and far between and that the increase of these severe cases was found to coincide with the appearance of the gravis and intermediate type of bacilli in the throat. In these severe cases antitoxin does not have the same beneficial effect even when it is administered early. |
b3dc462d-ef8c-4322-be2b-87297ce1154b | We have seen cases in which the disease has progressed so rapidly that death has occurred within 24 hours and even 12 hours of the time a doctor was called in. The following cases may be given as examples. A girl of 7 years of age, from a good home and where a doctor was always called in early for almost every illness was taken ill of diphtheria. On Saturday she went to a party and afterwards to a pantomime. On 37 Sunday she appeared fairly normal, possibly a little listless, which would be accounted for by the activities of the previous day. On Monday morning she complained of a sore throat and vomitted, and a doctor was called in. He examined the throat and took a swab. Some people might blame him for this, but hav ing had experience of these graver forms, and that there were at the time none of the characteristic signs of diphtheria in the throat, we do not think he was in any way to blame. |
86c8fa26-862e-46ae-b362-2b43ab205740 | He was again sent for in the afternoon and when he arrived between 4 and 5 the picture had entirely changed. The tonsils and soft palate were swollen, the glands of the neck swollen, and the child was obviously desperately ill. He sent her to hospital at once, but on arrival her condition was hopeless,—bull-neck, foetid breath, profuse nasal discharge, grevish toxic appearance of throat. She died about 8.30 p.m. A boy of 16 years, a pupil at a local secondary school, was admitted to hospital one morning. He was quite definite that his throat was first sore on the previous afternoon at school. The illness was thus of less then 24 hours' duration and yet on admission to hospital a thin membrane extended over the fauces and soft palate and there was a profuse nasal discharge. The glands in the neck were also very large. |
ac5d1d1a-4f21-48ca-8293-f4a08088d01a | The boy was given 80,000 units of antitoxin intravenously immediately and the dose was repeated the same evening. In spite of this he died within 48 hours of the first onset of sore throat. Another boy of 15 years was admitted to hospital on the same night as the previous boy. He had a history of sore throat commencing that morning. There was a patch of membrane on each tonsil but no further extension. In view of the fact that he attended the same school as the previous boy, he was given 56,000 units of antitoxin intravenously on admission at 10 p.m. The following morning at 9 a.m. the membrane had spread on to the soft palate and into the nose, and the glands of the neck were very much swollen. The dose of antitoxin was repeated and, as the membrane still apappeared to be extending, that evening another dose of 50,000 units if antitoxin was given. |
c0d21bc1-33e2-43dc-81b8-39db657dd9a2 | This boy ultimately recovered. I have mentioned these cases as examples, but we have had many others in which the symptoms had advanced almost as rapidly, and where death had occurred in a few days after admission, in spite of the intravenous administration of 80,000 and 100,000 units of antitoxin. In the graver forms of diphtheria, fatality is not going to be abolished or even greatly reduced by means of antitoxin treatment alone ; our hope lies in immunization as a means of prevention, and our experience of immunization since we started in 1932 may be of interest. 38 A full account of the outbreak of diphtheria was given in the Annual Report of 1932, and it is unnecessary to give the details of its origin. It will be recalled that in the autumn of 1932, and the spring of 1933, we experienced an outbreak of diphtheria of a particularly virulent character. |
ead2fd8b-3751-45a5-a7bb-ee21e943adc5 | The records of the incidence of the disease in Acton since 1890 show that there have been irregular periods of maximum and minimum prevalence of the disease. Prior to 1932, the last period of maximum prevalence had been in 1921, 1922 and 1923, and this followed a short period of only four years of minimum prevalence. Between 1923 and 1932 the district had been comparatively free of the disease. We therefore had a favourable soil for the introduction of a virulent organism in a gradual accumulation of susceptible persons in the population. Until September 1932, the disease followed a fairly normal course. Its incidence was slightly higher than that observed in inter-epidemic years, but there were no cases of extreme virulence in the early part of the year. The virulent cases occurred at the end of September and beginning of October, 5 cases occurring in different classes in one week, 3 of which proved fatal. |
bf258049-6771-4fcd-b1b4-fdf53682a80d | These cases occurred not in an infants' department, but in a junior department, and the next cases occurred in a Secondary School. Formerly our deaths had usually occurred in young chilren, either in those under school age or in the infants' department. Dr. O'Brien of the Wellcome Research Laboratory kindly examined some swabs from the severe cases, and of 10 swabs examined, 6 were of the gravis type, 2 of the mitis type and 2 contained bacilli of both the gravis and mitis types. We therefore had two of the conditions which would conduce to the occurrence of severe symptoms—a probable herd susceptibility and the presence of virulent organism. The following table gives the number of notifications and deaths, and it is given because it throws a light on the probable effect of immunization on the course of the disease Date. Notifications. Deaths. 1932 September. |
27ae9a2c-4bf6-4b9a-b3ff-7f1b472fb9cc | 17 3 October 33 4 November 48 9 December 17 2 1933 January 29 3 February 17 7 March 26 4 April 15 3 May 19 2 June 17 2 39 July 13 — August 4 — September 4 October 7 — November 2 — December 7 1 1934 January. 8 1 February. 11 — March. 10 2 April. 5 1 May. 4 — June. 9 — July. 2 — . August. 3 1 September. 8 2 October. 10 — November. 7 — December. 8 — We commenced our immunization at the school where the outbreak originated, and the response was most encouraging. The junior and infants' departments were tested on 10th October, 1932, and the first dose of the immunizing agent given on 17th October, 1932. |
47cea407-53ab-4f6b-9c46-8942380c8fd8 | In the junior department 68.8% of the children were schicktested and in the infants' department 61.8%. Before the end of the Christmas term of 1932 we had started immunization in 5 of our schools and at the beginning of June 1933, we had visited the 9 schools in the Borough and given 3 doses of the immunizing agent. We were then ready to do the post-schick testing in the schools which had been the earlier ones to be visited. Until recently we used Toxoid Antitoxin mixture (Burroughs Wellcome T.A.M.) for children and Toxoid-Antitoxin-Floccules (T.A.F.) for adults. Recently for children of pre-school age (under 5 years) we have used Burroughs Wellcome's Formol Toxoid. We have not used any Alum-Toxoid. |
6a9a1e29-f27d-45bd-8187-e94ea26f7ba7 | We have not used Formal Toxoid generally throughout the schools, owing to the extra time involved in the use of the Malonev test. For children between 5 and 11 years of age, we give 3 doses of 1 c.c. each of T.A.M. In children between 11 and 14 years we give only ½ c.c. of the T.A.M. for the first dose. If no reaction occurred the second and third doses were 1 cc. each. In adults we we gave as a first dose .2 c.c. of the T.A.F. In children under 5 years of age we gave 3 doses of 1 c.c. each of Formol Toxoid. In 1932 we gave the second dose in 2 weeks after the first, and the third three weeks after the second. |
2cdf81ce-9424-4e15-b7e1-ad70b5b78e8c | In 1933 we revised the interval periods and we now allow three weeks between the first and second dose and 4 weeks between the second and third dose. In the first school which we visited both the infants' and the junior departments were schick-tested. In the infants' department S4.9 per cent, of the children were found to be schick-positive. In the light of this experience we decided to immunize all children under seven years of age without a preliminary Schick test, but a posterior Schick test is done on children of all ages. We have been fortunate in the absence of any marked reactions—local or constitutional. In some cases the arms have become red and swollen ; sometimes the swelling has reached as far as the elbow. In every insrance swelling has completely disappeared at the end of two or three days. In no instance have we heard of or seen the swelling and redness persisting more than four days. In only three cases did we know of any constitutional disturbance. |
39af29dd-568c-4aea-9912-f9a9a9e9fca8 | We saw two of these, and the disturbance was not sufficiently marked to keep the children away from school. We did not see the third child, as he was attended by his own doctor. Because of the necessity of controlling the outbreak in the schools we had to concentrate at first our attention very largely on the children of school age. It was recognised though, that if preventive measures are undertaken to stamp out diphtheria, it is essential that a large proportion of the most susceptible children— those of pre-school age—should be immunized. Since the summer of 1933, we have concentrated our efforts upon the infants' departments and the Infant Welfare Clinic, and the majority of the children immunized in the autum of 1933 and the whole of 1934 have been under 7 years of age. We endeavour as far as possible to prevent the addition of non-immune entrants to the infants' department, and so lower the herd immunity. |
9dfcb939-4315-4606-8d2f-29c028fe466e | An immunizing clinic is held every Saturday morning at the school clinic for children under school-age. The health visitors distribute circulars to the mothers at the infants welfare centres. The numbers on these Saturday mornings vary, the lowest attendance being 9 and the highest 108. At the beginning of each term, a list of the non-immunized entrants is sent to the Headmistress of every infants' department, who have greatly assisted us in obtaining consents. The head teachers have not forgotten the sad results of the outbreak and are convinced of the efficacy of our efforts. In the spring of 1934, we were given some unsolicited publicity which helped us considerably. The Anti-Vaccination League 41 circularised the district, pointing out the danger of immunizing. During the following week we had a great increase in the number of requests for consent forms from parents of pre-school age and on the next Saturday morning there was a large increase in the number at the school clinic. |
4811fe5a-38d3-47b9-a73f-a658df0a0e4c | The League had quite unintentionally awakened the parents to the fact of the existence of diphtheria, had taught many whom we had not reached, and that the public health authority was doing something in the matter. We have not felt the necessity of an elaborate system of propaganda ; we have found the quiet efforts of the officers of the local authority, including, of course, the education authority, to have been more effective. We are fortunate that we are an automonous education authority. We are therefore in close contact with both the infant welfare centres and the schools. We are given every facility by the education authority. The school routine has been very little disturbed. When immunization takes place in the school, there is little or no commotion, and very seldom is there any crying. The numbers dealt with in the 26 months November, 1932, to December, 1934, inclusive were as follows:— Preliminary Schick Tests :—2469. Reactions—Positive : 1394. |
54aafd38-0ef7-441e-a0bc-4e8dc986f06b | Negative: 1075. . Posterior Schick Tests :— Positive: 13. Negative: 2050. The total number immunized were — Is/ Dose—4052. 2nd Dose:—3840. .. 3rd Dose—3631. 91 refused after the 1st dose and 71 after the 2nd dose. 2 were schick-negative after the 1st dose and 3 after the second dose. 119 were awaiting their 2nd and 3rd doses and 135 were awaiting their 3rd dose. 42 Of more importance are the ages of those who have been immunized. In the 14 months November, 1932 to December, 1933, the ages were as follows:— Under 5—406. 5-7—619. 7-15—1678. In 1934 the ages of those who were immunized were as follows :— Under 5—328. |
8adf7032-a6c7-43e6-beaf-ea83ecf66631 | 5-7—377. 7-15—203. It will be seen that the relative number under 5 who were immunized was much higher than in the first year. This is due to the fact that we have been concentrating upon the lower ages. At the end of 1933 the percentage immunized in the infants' departments was as follows:— AAV. 24.3 J.P. 63.1 B.P. 64.7 P. 43.1 B. 37.6 R. 35.5 D. 75.3 S. 58.8 At the end of 1934 the figures were as follows :— AAV. 44.6 J.P. 58.0 B.P. 52.9 P. 50.0 B. 24.9 R. 33.8 D. 51.4 S. 52.3 It has been previously explained that artificial immunity is only gradually developed in the inoculated. |
9f279e3e-4129-46a9-bcb9-a0ff7a82eb7e | It has been claimed for some of the immunizing materials—such as Alum Toxoid—that immunity can be obtained from one dose. As previously explained we have not used Alum Toxoid because of the risk of local reactions. In the case of Formol Toxoid and T.A.M. three injections of the prophylactic are needed to develope gradually an immunity against diphtheria. It is estimated that about 95% of the schick-positives become schick-negative in less than six months after inoculation. In 1933, 8 cases occurred amongst those who had had one inoculation. Of these one died, two were severe, 3 were mild and 2 were carriers only. In 1934,4 cases occurred amongst those who had had one inoculation. All these were mild attacks. 43 In all these except three, the disease occurred within a month of the inoculation. |
f2ddc363-75fb-41bc-83a1-94d1beaa41c5 | In two the interval was five weeks, in the third it was 8 weeks. In the child who died she received the first dose on February 23rd, 1933, the case notified on March 17th and she died March 22nd. Of the children who received 2 doses, six developed diphtheria in 1933 and 1 in 1934. In 1933 one of the children died, 1 had a severe attack, one a moderately severe and 3 were mild. The 1934 case was a moderately severe attack. In 1933, 12 cases were notified amongst children who had had three doses. Four of these were carriers only, two were very mild, 4 were mild, and two were moderately severe. There were no deaths. In only one of these had a sehick-negative reaction been given. |
6925ae6a-5b42-4da3-9a76-85f398f530b4 | All the others occurred before thay were post-schicked, although in one instance over seven months had elapsed since the third dose had been given. There were also five cases in those who had given a schicknegative reaction. These were all mild cases. In 1934, five cases occurred amongst those who had had 3 doses, 4 of these has given a schick-negative reaction ; the fifth contracted the disease eleven weeks after the third dose. They were all very mild cases. What results can we hope for from this work? As far as we are concerned, at the end of six months after the last dose, three doses are for all practical purposes a protection against the disease, though it is not an absolute protection. We have given all the figures and we do not desire to exaggerate the results which can be obtained. Certain questions remain obscure. The Schick test is the most usual method of distinguishing between immunity and susceptibility, and we cannot escape using the Schick test for want of a better. |
0e98f100-9975-4e37-8d97-e955bff61ba2 | It is impossible in the case of mass immunization to estimate the anti-toxin present in the blood, and even if we could, we should not know what exact amount would be necessary to avoid an attack. This would only give us a measure of one of the factors. But if the Schick test is negative, the person concerned probably has at least 1/30 anti-toxin units per cubic centimetre of blood, and this should usually be a sufficient protection. But schick-negative children who showed an anti-toxin content of one of more anti-toxin units per c.c. have been said to develop diphtheria. It is also possible that a schick-negative who is immune from the milder form of diphth- 44 eria may suffer from the graver form, but experience has shown that even if an immunized child does develop diphtheria, the attack is usually a very mild one. This has been our experience. |
845905f4-8dd7-4557-a097-d59491b9f410 | All the cases which occurred in immunized children in 1934, were very mild, and in the latter half of the year no immunized child has contracted the disease, even in a mild form. Tuberculosis. 82 cases oi Pulmonary Tuberculosis and 22 cases of other forms of Tuberculosis were notified during the year. There were 50 deaths from Pulmonary Tuberculosis and 12 deaths from other forms of Tuberculosis. |
3966ccd9-0bd3-4de8-9087-822c8a125c6c | The death notification interval of the 50 patients who died of Pulmonary Tuberculosis in 1934 was :— Information from Death Returns 10 Died within 1 month after notification 7 Died between 1 and 3 months after notification 2 Died between 3 and 6 months after notification 3 Died between 6 and 12 months alter notification 7 Died between 1 and 2 years after notification 7 Died between 2 and 3 years after notification 6 Died over 3 years after notification 8 The following is a statement of the particulars appearing in the Register of cases of Tuberculosis on 31st December, 1934— Pulmonary. Non-Pulmonary. Total Males Females M ales Females Number of Cases of T.B. |
b0dfce8c-fb0d-4fdc-b7b2-a67d0dcf7f22 | on the Register at the commencement of the year 162 161 37 27 387 Number of Cases notified for the first time during the year 34 30 14 8 86 45 Number of Cases previously removed from the register which have been restored thereto during the year 1 - 1 - 2 Number of Cases added to the Register other than by notification 5 12 1 - 18 Number of Cases removed from the Register during the year 50 60 22 15 147 Number of Cases remaining on the Register at the end of the year 152 143 31 20 346 In 1934, the Tuberculosis Officer examined 50 new cases of nulmonarv tuberculosis and 6 new cases of non-nulmonarv tuberculosis. Thirty-one patients were admitted to Sanatoria under the County Scheme and 20 were admitted to hospitals. 46 Age Periods New Cases. Deaths. Respiratory. Non-Respiratory Respiratory. |
99dd37db-5cad-4394-9045-0050cbb33773 | Non-Respiratory M. F. M. F. M. F. M. F. 0- - - - - - - - - 1- - - - 1 - - - l 5- 1 2 5 2 - 1 3 1 15- 7 17 3 1 6 8 2 1 25- 9 13 2 1 4 6 - - 35- 12 8 3 1 7 2 1 - 45- 7 1 - 1 4 2 1 1 55- 3 2 1 - 8 2 - 1 65 and upwards - - 1 - - - - - - - - - - - - - Totals 39 43 15 7 29 21 7 5 47 ISOLATION HOSPITAL. |
dcd38df5-36ba-4df5-9180-02291bc07d28 | 718 cases were admitted during the year compared with 738 cases during 1932. On January 1st, 1934, there were 64 cases in the hospital and on January 1st, 1935 there were 61. The following is a list of the cases admitted for the different diseases. Scarlet Fever. Diphtheria. Measles. Acton 194 83 69 Wembley 275 73 5 Other Outside Districts 4 14 1 Total 718 There were 16 deaths which were distributed as fellows:— Scarlet Ferer. Diphtheria. Measles. Acton 2 6 3 Wembley — 4 — Other Outside District — — 1 BACTERIOLOGICAL EXAMINATIONS. (a) For Diphtheria Positive. Negative. Total Examinations 1970 165 1805 Sent by Medical Practitioners 61 506 do. |
cf57edf6-334c-4610-aa48-c137c7eb20f8 | (re-examinations) 1 10 Sent from Isolation Hospital 63 754 Convalescents (1st Swabs) — 14 Contacts 22 263 do. (2nd examinations) 1 22 Carrier's Swab. 6 12 Precautionary Swabs — 69 School Sore Throats 17 165 48 (b) For Ringworm. Positive. Negative. Total Examinations—13 7 6 (c) For Tubercle. Positive. Negative. Total Examinations—142 25 117 MATERNITY AND CHILD WELFARE. Infantile Mortality. Thirty-nine deaths occurred in infants under one year, corresponding to an infantile mortality of 41 per 1,000 births. This is the lowest number of deaths under one year of age on record for the district. |
3abfca97-a30d-4c7f-8c28-9b8730f60bd2 | There is a drop of 9 deaths from Premature Birth, but an increase of 4 in the deaths from Congenital Heart Disease. Eighteen of the deaths occurred before the baby had reached the age of 1 month. Twelve of the deaths were in the North East Ward, 9 in the North West, 3 in the South East and 15 in the South West Ward. This is the lowest infantile mortality recorded in the district; the next lowest was that of 1933, when it was 46 per 1,000 births. On no other occasion has the infantile mortality been below 50 per 1,000 births. There were 3 more deaths in infants over 1 month, and 3 less in infants under one month. If the Infantile Mortality tables for several years be examined, it will be seen that if further advance be made in infantile mortality it must be by the reduction of deaths under 1 month, the so-called neo-natal mortality. |
836dd8f8-1b6b-4f9d-afb5-2ed0fcb7b146 | So far the factors which have played a part in bringing down the under-one-year rate have hitherto had much less effect upon the loss of life of infants under one month. The great reduction in infantile mortality has been effected in the period 1-12 months. It will be easily understood that the measures first adopted for Infant Welfare—such as health-visiting and its attendant activities—would have more effect upon the older babies than in those under the age of one month. It is upon the 49 older babies that the instruction on feeding, clothing, and other aspects of infant nurture would have most effect, a large proportion of the babies have already died before the health visitor has visited the home, or at any rate before her instructions could have had any effect. The chief if not the only method by which the neo-natal mortality can be reduced is by increased attention to ante-natal care and nurture. |
d559a12c-72aa-4388-8632-cd73df7d4a77 | In a subsequent paragraph, the extension of this part of our Maternity and Child Welfare Scheme has been outlined, and we feel that this aspect of the work has an important bearing not only on the Maternal but also on the Infantile Mortality. Maternal Mortality. Five deaths occurred in child bearing women, 2 from Puerperal Sepsis and 3 from other diseases or accidents of Parturition. The cause of the first death was given as (a) Septicaemia (b) Septic abortion. The information of the conditions which obtained prior to the confinement was vague and not satisfactory as the husband had left the district when we made the inquiries and he could not be traced. The husband and wife had only recently come to Acton, and had not attended the AnteNatal Clinic. They had two other children, and we were given to understand that the wife was very worried on account of the fact that she was again pregnant. |
d66f48fc-651c-4ee7-989b-562f54227583 | The doctor who was called in found an incomplete abortion, and he advised her removal to a hospital. The wife at first refused, and she did not consent to removal for two days. She died 10 days after removal to hospital. In one of the other cases, the patient had not been under the care of a doctor before her confinement. It was stated the patient was unaware that she was pregnant. No doctor or midwife had been engaged. In the three other cases, the patients were in comfortable circumstances, a doctor had been engaged for the confinement, and the patients had been under the care of the doctor throughout the confinement. One of these died of Eclampsia, the second of Post-partrem nephritis, and the third was suffering from a long standing heart disease. Circular 1433 was issued by the Ministry of Health in October, 1934, and reference was made to Circular 1167 of December 1930, and the accompanying Memorandum 156/M.C.W. |
0845c9a5-34d9-400d-9056-fd74c695c777 | on the subject of Maternal Mortality. The Minister reviewed the action taken throughout the country to give effect to the suggestions in Memorandum 156 and 50 lie recognised that on the whole there has been a widespread response. After citing instances in which the work has been done, he stated that in spite of developments during the past three years to improve and develop the maternity sen-ices, the maternal mortality has not yet begun to fall. In all areas there is probably need for more intensive efforts to educate women as to the importance of ante-natal supervision and to persuade them to make use of the facilities provided for this purpose. It was suggested that each local authority should forthwith review the position in their area by reference to the suggestions made in Memorandum 156 and take such steps as are necessary to complete the local organisation and ensure its effective working. In particular he wished to urge the authorities of those areas in which the maternal mortality is persistently high to give consideration to further efforts to reduce the avoidable risks of child-bearing. |
73d2a6f0-7a83-4e5b-aa5e-2a9f75290e78 | The Minister deemed it desirable that a special report on the subject should be made, showing to what extent effect has already been given to the suggestions made in the Memorandum, and in the recommendation of the Maternal Mortality Committee in their final report for 1932. This report was submitted to the Cliild Welfare Committee in December and though consideration of the question was postponed to January and the suggestions made were not carried out last year, a summary of that report is now given. Maternal Mortality in Acton. During the year there were five maternal deaths and the following table gives the maternal deaths in the past 10 years:— Year Total Deaths Deaths from Sepsis. Deaths from other causes Births. |
dab40902-50c8-4703-9dde-eaba19f3c3b3 | 1925 5 4 1 1047 1926 5 2 3 1098 1927 4 3 1 1026 1928 4 2 2 1003 1929 3 1 2 1026 1930 4 2 2 1105 1931 5 4 1 1018 1932 7 3 4 970 1933 5 3 2 886 1934 5 2 3 943 51 It will be seen that the maternal mortality has been persistently high and has recently shown a slight tendency to rise. Ante-Natal Service. Until the autumn of 1934, the ante-natal clinic was held at the School Clinic every other Wednesday morning by Dr. Bell, but towards the end of the year Dr. Howell attended on the other Wednesday morning, and her report is appended here. |
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