BARK 18 Barking Town Urban District Council. REPORT OF THE Medical Officer of Health AND School Medical Officer For the Year 1924. K. SIMPSON, M.D.. Ch.B., MR.C P., D.P.H. CONTENTS. PAGES Section 1—Vital Statistics 8 to 22 Section 2.—Infectious Diseases 23 „ 40 Section 3.—Sanitary Administration 40 ,, 54 Section 4.—Maternity and Child Welfare 55 „ 71 Section 5.—School Medical Service 72 „ 106 3 STAFF, 1924. Medical Officer of Health School Medical Officer, Medical Superintendent, Isolation Hospital, and District Tuberculosis Officer : K. SIMPSON. M.D., Ch.B., M.R.C..P., D.P.H. Deputy Medical Officer of Health and Deputy School Medical Officer MURIEL J. LOUGH. M B., B.S., B.Sc., M.R.C.S., L.R.C.P., D.P.H. School Dentist : G. M. HICK, L.D.S.. R.C.S. (Eng.). Sanitary Inspectors : H. WOOD (Chief Sanitary Inspector) (b and c). H. CARR (Sanitary Inspector) (b, c and e). MISS E. PODMORE (Assistant Sanitary Inspector) (b & g). School Nurses : MISS L. F. SWAIN (g & h). MISS S. E. W. GIBSON (i). Health Visitors: MRS. G. STOKES (h). MISS A. C. KEENAN (g, h & f). Matron, Isolation Hospital : MISS M. J. HEDGCOCK (h, i & g). Chief Clerk of Department : E. W. WINCHESTER (a, c & d). Disinfector and Mortuary Keeper : H. LONG. (a) Sanitary Inspector's certificate of Sanitary Inspectors' Examination Board. (b) Sanitary Inspector's certificate of Royal Sanitary Institute. (c) Meat, etc., Inspector's certificate of Royal Sanitary Institute. (d) Meat, etc., Inspector's certificate of Sanitary Inspectors' Examination Board. (e) Building Inspector's certificate of Worshipful. Company of Carpenters. (f) Health Visitor's certificate of Royal Sanitary Institute. (g) Certificate of Central Midwives' Board. (h) General Hospital Training. (i) General Fever Training. 5 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE URBAN DISTRICT OF BARKING TOWN, IN THE COUNTY OF ESSEX, FOR THE YEAR ENDED 31st DECEMBER, 1924. Public Health Offices, Barking, Essex. To the Chairman and Members of the Urban District Council of Barking Town. Mr. Chairman and Gentlemen, In accordance with the requirements of the Ministry of Health and Board of Education, I beg to submit my Annual Report on the Public Health and School Medical Services of this district for the year ended 31st December, 1924. According to the Registrar-General's estimate the population of Barking in June, 1924, was 37,890, being an increase of 680 over that of the corresponding period in 1923. The Birth, General Death and Infantile Mortality rates for the year were 22.3, 10.0 and 85.1, showing a percentage decrease of 3.4 in the Birth Rate, and percentage increases of 17.6 and 70.8 in the General Death and Infantile Mortality rates over those of the preceding year. A disquieting feature of the period is the inordinarily high mortality rate among children under one year of age, and mainly to be accounted for by deaths from pneumonia and prematurity. During 1924, the Birth, General Death, and infantile Mortality rates for England and Wales were 18.8, 12.2 and 75, and for London, 18.7, 12.1 and 69. 6 The general death rate being subject to various influencing factors is not perhaps in itself a strict criterion of communal health, so that for comparative purposes certain individual death rates are more important, especially those of Tuberculosis and the Infantile and Zymotic death rates, which were 1.2, 85.1 and 0.95 respectively for the district, compared with 0.7, 52.2 and 0.6. for the Administrative County of Essex, and as regards the Tuberculosis and Infantile Mortality rates of the Country as a whole, 1.05 and 75. The year under review has been one of considerable progress. Increased attendances at the Maternity and Child Welfare and Ante-natal Centres necessitated the provision of extra sessions and the appointment of an additional health visitor, developments which at the time of writing are complete. The housing of the working classes continues to present the most engrossing problem, the comparatively large number of houses added by the Council to the district still leaving much of that problem unsolved. Overcrowding was conspicuous in all of the poorer parts of the district, occurring in not a few instances in dwellings practically beyond repair, and did circumstances allow, fit only to be closed. Despite much overcrowding the incidence of infectious disease was low, notifiable infections, exclusive of tuberculosis, numbering 179, and equalling an attack rate of 4.7 per : ,000 population. Marked progress has been the feature of the School Medical Service throughout the year, signalised in but to mention outstanding features, the appointments of full-time dental surgeon and nurse, the complete equipment of the dental clinic, the equipment of premises for the efficient treatment of crippled children by massage, radiant heat and electricity, while a qualified masseuse and orthopa:dic surgeon, Mr. B. Whitchurch Howell, F.R.C.S., have been appointed. An efficient cleansing and disinfesting station became available for use early in the year. 7 The number of school children inspected under the three age groups, exclusive of "specials," was 1931, while re-inspections numbered 899, of which number 417 or 46.38 were found to have received treatment. Although 80 to 90 per cent. of children are born healthy, school entrants were found on examination defective to the extent of 34.54 per cent., a circumstance attributable in my opinion in some measure to the still unsatisfactory housing conditions experienced by a large number of the growing population, for whom the curative measures of the School Medical Service now afford the surest hope of building up a stronger and healthier race of men and women. On the whole I am satisfied with the progress made, and tender my thanks and appreciation for your continued confidence and support. I am, Mr. Chairman and Gentlemen. Your obedient servant, KERR SIMPSON, Medical Officer of Health and School Medical Officer. 8 SECTION 1 SUMMARY OF PARTICULARS REQUIRED BY CIRCULAR 359 OF THE MINISTRY OF HEALTH, DATED 10th JANUARY, 1923. 1. General Statistics. Area (acres) 4,100 Ward areas 3,806 Tidal Water H.W.M. Thames 240 Roding 58 Loxford Water 2 300 4,106 Population (Census, 1921) 35,543 Population (June, 1924) (Registrar General's estimate) 37,890 Number of inhabited houses (1921) 6,716 Populatior Density, i.e.. No. of persons per acre 9.2 Rateable Value—Houses £228,177 10 0 Lands £3,182 10 0 Sum represented by a penny rate £840 0 0 Education rates :— Elementary 3 1 Secondary 5½ Assessable Value £206,313 0 0 General District Rate 7 0 Poor Rate 9 0 2. Extracts from Vital Statistics for the Year. Births :— Males. Females. Total. Birth Rate. Legitimate 417 409 820 21.79 Illegitimate 9 11 20 0.52 Total 420 420 840 22.31 Number of deaths of infants under one year of age :— Total Infantile Death Death Males. Females. Total. Rate. Rate. Legitimate 47 22 69 83.53 85.1 Illegitimate 2 1 3 150.0 Number of deaths from Measles (ail ages) 14 „ ,. Whooping Cough (all ages) 1 „ ,, Diarrhoea (under 2 years of age) .... 15 Number of deaths of women during, or in consequence of, childbirth :— From Sepsis. From other causes. Total. 1 2 3 Deaths :— Male. Female. Total. Death Rate. 211 108 379 10.0 9 x birth rate, death rati;, and analysis or mortai.iia during THE YEAR. Birth Rate per 1,000 Total Population. Annual Death Rate per 1,000 Population. Rate per 1,000 Births. percentage of Totat Deaths. All Causes. Enteric Fever. Small Pox Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under Two years). Total Deaths under One year. Causes of Deaths Cer. tified by Registered Medical Practitioners Inquest Cases. Uncertified Causes of Death. England and Wales 18.8 12.2 0.01 0.00 0.12 0.02 0.10 0.00 0.49 0.44 7.3 75 92.3 0.0 l.1 105 County Boroughs and Great Towns including London ... 19.4 12.3 0.01 0.00 0.18 0.03 0.12 0.08 0.45 0.40 9.2 80 92.5 0.9 0.0 157 Smaller Towns (1021 Adjusted Populations 20,000 50,000) 18.9 11.2 0.01 0.00 0.08 0.02 0.09 0.06 0.50 0.36 6.2 71 93.3 5.5 1.2 London 18.7 12.1 0.01 — 0.29 0.03 0.11 0.12 0.30 0.44 8.4 69 91.3 8.0 0.1 BARKING 22.3 10.0 — — 0.36 — 0.10 0.07 0.42 0.30 17.7 85.1 92.1 7.9 — 10 VITAL STATISTICS OF WHOLE DISTRICT FROM 1019 to 192-1. Year. Popula- tion estimated to Middle of each Year Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Nett. Number. Rate. On Nonresidents registered in the District. Of residents registered out of the District. Under One year of age. At all Ages. Number. Kate. Number. Rate per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 1919 33,804 815 33.0 277 8.1 — 95 54 65.0 372 11.0 35,214 1920 35,151 1,086 30.9 339 9.6 — 110 92 83.0 449 12.6 1921 36,250 968 26.0 297 7.1 — 97 74 74.1 394 10.8 1922 36,680 882 24.0 308 8.1 — 56 49 55.5 364 9.9 1923 37,210 862 23.1 234 6.2 5 86 *43 *49.8 *318 *8.5 1924 37,890 846 22.3 273 7.2 3 109 72 85.1 379 10.0 * Registrar General's Figures. 11 5. CAUSES OF SICKNESS. No special causes of sickness fall to be discussed. 6. SUMMARY (FOR REFERENCE) OF NURSING ARRANGEMENTS, HOSPITALS, AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. (a) Nursing in the Home. (i) The Plaistow Maternity Charity provide a staff of nurses, who attend at the homes of the sick once or twice a day, carry out such skilled nursing as is required, and offer instructions where advisable in hygienic home practices in relation to the sick. (ii) For infectious diseases. In the event of an epidemic, the Council can provide nurses for such cases as may require to be nursed in their own homes. Of late years this has not been necessary. No other provision of home nursing is carried out by the Department, but Health Visitors and School Nurses regularly advise parents as to the nursing and general care of children. (b) District Midwiferv Provision. By agreement dated January 1st, 1924, with the Plaistow Maternity Charity, the Council subsidise the Charity on any deficit from £300 in respect of 300 District Midwifery cases attended by the Charity reckoned at the rate of £1 per case. The takings of the Charity for the year amounted to £248, leaving a balance due to the Charity from the Council of £5l 13s. 6d., such sum ranking for grant. 12 (c) CLINIC AND TREATMENT CENTRES. Name and Situation. Nature of Accommodation. By Whom Provided. I. Maternity and Child Welfare :— (a) Centres Clinic premises, East Street. Accommodation for consultations, weighing of babies, waiting room, etc. Local Authority. Kennedy Hall, Gordon Road. ,, ,, ,, ,, Abbey Hall, Abbey Road. ,, ,, ,, ,, (b) Ante-natal clinic Clinic premises, Accommodation for consultations. ,, ,, (c) School Nurseries Nil. Nil. Nil. (d) Dav Nurseries Nil. Nil. Nil. II. School Medical Service :— (a) Inspection Clinic and treatment of minor ailments Clinic premises, East Street. Three rooms. Local Authority. (b) Eye Clinic ,, ,, One room. ,, ,, (c) Dental Clinic ,, ,, Two rooms. ,, ,, III. Tuberculosis 37, Linton Road. Three rooms. Essex County Council. IV. Venereal Diseases London Hospitals, etc. — By arrangement with Essex County Council. 13 (d) Hospitals provided or subsidised by the Local Authority : (i) Smallpox.—An arrangement exists with the neighbouring County Borough of West Ham whereby an unlimited number of beds are available at Dagenham for the reception and treatment of cases of smallpox which may occur in the Barking area. (ii) The only hospital provided by the Local Authority is that for the isolation and treatment of infectious diseases situated in Upney Lane, where 40 beds are available for such cases. Twelve additional beds are available for maternity cases in a separate portion of the hospital buildings. (e) Ambulance Facilities :— (i) A horse ambulance is provided for the removal of infectious cases to the Isolation Hospital, Upney Lane. (ii) For non-infectious and accident cases, two motor ambulances are kept at the Fire Station, the ambulance and fire services being run in conjunction under the Chief Fire Officer. 7. LABORATORY WORK. The necessary laboratory work of the district is carried out by arrangement with the Essex County Council at the Counties' Laboratory, situated in Queen Victoria Street, London, E.C.L 8. List of Adoptive Acts, Byelaws, and Local Regulations relating to Public Health in force within the district. (i) Local Acts : Barking Town Wharf Act, 1893, Barking Parish Act, 1888. (ii) General Adoptive Acts : Local Government and other Officers' Superannuation Act, 1922. Public Health Acts Amendment Act, 1890, Parts 2, 3 and 5. 14 Baths and Washhouses Acts, 1847, etc. Infectious Diseases (Prevention) Act, 1890. Public Health Acts Amendment Act, 1907, Parts 2, 3, 4, 5, 6 and 9, and Section 95 of Part 10. (iii) Regulations : Regulations as to Dairies, Cowsheds and Milkshops, 1900 (revised 1924). Regulations as to Cemetery, 1902. (iv) Byelaws with respect to : Nuisances, 1884. Common Lodging Houses, 1884. Offensive Trades, 1907 (revised 1924). Houses let in lodgings, or occupied by members of more than one family, 1924. Public Baths, 1900. Tents, Vans, Sheds and similar structures, 1909. Paving of Open Spaces, 1901. Nuisances in connection with the removal of offensive matter, 1908. Employment of Children and Young Persons, 1920. (v) Special Acts and Orders : Among the Special Acts and Orders in force within the district, and important from a Public Health standpoint, are :— 1910.—Orders declaring the trades of fish-skin scraper, fish fryer, dealer by retail in rags, bones, skins, fat or other like articles in an offensive condition, blood drier, tanner, leather dresser, fat melter or fat extractor, glue maker, size maker, and gut scraper, to be offensive trades. 1924.—The Barking Town (Pneumonia) Regulations. 15 9. DEATHS. There were 273 deaths registered in Barking in 1924. Of these, 3 were deaths of non-residents. Barking residents to the .umber of 109 died elsewhere during the year. Including the '.titer and excluding the deaths of visitors, the net number of deaths were as follows :— Males. Females. Total. 211 168 379 The death rate for 1924 was 10.0 per 1,000, compared with 8.5 in 1923, calculated on the Registrar-General's estimated population and number of deaths, compared with 12.2 for England and Wales, 12.3 for the hundred and five Great Towns, 12.1 for London, and 11.2 for the hundred and fifty-seven Smaller Towns. Sex Mortality.—The 379 deaths of 1924 were divided as follows:— 211 males, equal to a death rate of 4.4 per 1,000 population. 168 females, equal to a death rate of 5.5 per 1,000 population. Age Mortality.—The deaths in various age groups, according to the figures obtained locally, were as follows:— Age of Group. No. of Deaths. Death Rate per 1,000 Population. Under 1 year 72 1.90 1 to 2 years 15 0.39 2 to 5 years 16 0.42 5 to 15 years 13 0.34 15 to 25 years 23 0.60 25 to 45 years 45 1.18 45 to 65 years 83 2.19 Over 65years 112 2.95 Causes of death in 1924.—The table on page 18 shows the Principal causes of death at various ages. Those diseases, etc., 16 causing most deaths or important from a Public Health aspect were as follows :— Disease. No. of Deaths. Percentage of total net deaths registered. Cardio-vascular system 43 11.34 Cancer 32 8.44 Tuberculosis (all forms) 39 10.29 Pulmonary affections, (exclusive of tuberculosis), viz. : Bronchitis 29 7.65 Pneumonia 34 8.97 Other respiratory disease 3 0.79 Zvmotic Diseases 36 9.49 Of the total deaths, tuberculosis caused one in every 9.7, heart disease one in every 8.8, bronchitis one in every 13.0, cancer one in every 11.8, pneumonia one in every 11.1, suicide and violence one in every 27.1, other respiratory diseases one in every 126.3, and zymotic diseases one in every 10.5. Deaths from Zymotic Diseases.—These diseases caused 9.49 per cent, of the total deaths, such deaths being caused i:i the following proportions :— Enteric fever Measles 3.69 Whooping Cough 1.05 Scarlet Fever — Diphtheria 0.79 Diarrhœa 3.95 Smallpox — 17 INOUESTS.—Coroner's inquests were held on 30 deaths. The ages at death and causes assigned were as follows: Couses of Death. under one year. 1-2 years. 2-5 years. 5-15 years. 15-25 years. 25-45 years. 45-65 years. Over 65 years Total Accidental Cause 2 1 1 3 2 2 - 1 12 Rupture of gastric ulcer (general peritonitis) - - - - - 1 - - 1 Suicide - - - - - 1 1 - 2 Misadventure - - - - - - 2 - 2 Pneumoccal infectionseptic miscarriage— general peritonitis - - - - - 1 — - 1 Heart Disease — - — — - — 2 3 5 Atelectasis 1 - - - - - - - 1 Tubercular Meningitis - 1 - - - — — — 1 Pneumonia 1 — — - _ — — — 1 Cirrhosis of Liver - - — — — — — l 1 shoock of hænorrhage from stomach rupture of Wood vessel in stomach - - - - - - - l 1 Status Epilepticus - - - 1 - — — - 1 Exhaustion (gangrene of lung) - — _ - - 1 - - 1 Totals 4 2 1 4 2 6 5 6 30 13 CAUSES OF AND AGES OF DEATH DURIXG YEAR, 1024. (Nett Deaths.) Causes of Death. Deaths at the subjoined ages of " Residents " whether occurring in or beyond the district. All ages Under one year 1 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 05 05 and upwards Encephalitis Lethargica 2 - - — 1 - 1 - influenza 16 3 1 - 1 3 3 5 Scarlet Fever — — — - - — - - Small Pox — - - - - - - - Measles 14 4 8 2 - - - - Whooping Cough 4 1 3 - - - — - Epidemic Influenza — - - - - - - - Diarrhoea and Enteritis (under 2) 15 12 3 - - - - - Diphtheria 3 — 1 1 1 - - - Enteric Fever — — — - - - - - Puerperal Fever 1 - — - - - - - Phthisis (Pulmonary Tuberculosis) 35 — 2 — 9 14 9 1 Other Tubercular Diseases 4 — 2 1 1 — — - Cancer, Malignant Disease 32 — — — 1 2 19 10 Bronchitis 29 4 — — — 1 8 10 Pneumonia 34 13 7 — 2 1 9 2 Other Respiratory Diseases 3 1 — 1 — 1 — — Alcoholism (Cirrhosis of Liver) 3 — — — — 1 — 2 Premature Birth, Malformation and Debility 24 24 - - - - Accidents 12 2 2 3 2 2 — 1 Suicides 2 — — — 1 1 — Rheumatic Fever 2 — — 1 — — — 1 Diabetes 2 — — 1 — — 1 Cerebral Hemorrhage 22 1 — — 4 5 12 Heart Disease 43 — — - 1 4 9 29 Arterio-Sclerosis 4 — — - — — — 4 Ulcer of stomach or duodenum 3 — — — 3 — — Appendicitis ^nd typhlites 4 — — 1 1 1 1 — Acutc and Chronic Nephritis 9 — — — 1 2 3 3 Other accidents and diseases of pregnancy and parturition 2 _ 2 Other defined diseases 55 7 2 3 1 2 15 25 Causes ill-defined or unknown — - — — - — — Totals 379 72 31 13 23 45 38 112 19 INFANT MORTALITY DURING THE YEAR 1924. The following table gives the actual causes of death of children dying under one year of age. Net deaths from stated causes at various ages under one year:— Causes of Death. (.All causes certified.) Under 1 week. 1—2 weeks. 2—3 weejvs. 3—4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under ti months. (> months and under 9 months. 9 month? and under 12 months. Total under one year. Small Pox - - - - - - - - - - Chicken Pox - - - - - - - - - - Measles - - - 1 1 - - 2 1 4 Scarlet Fever - - - - - - - - - - Whooping Cough - - - - - 1 - - - 1 Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - 1 - - - 1 Tubercular Meningitis - - - - - - - - - - Other Tuburcular diseases - - - - - - - - - - Meningitis (not tubercular) - - - - - - - - - - Convulsions 1 - - - 1 - 1 - - 2 Laryngitis - - - - - - - - - - Bronchitis - - - - - 3 1 - - 4 Pneumonia (all forms) - - - 1 1 1 5 2 4 13 Diarrhœa - - - - - 3 4 2 3 12 Gaslritis - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - — Suffocation, overlaying - - - - - - - - - - Injury at birth - - - - - - - - - - Atelectasis 4 - - - 4 - - - - 4 Congenital malformation - - 2 - 2 1 - - - 3 Premature Birth 13 3 2 1 19 - - - - 19 Atrophy, debility and Marasmus - - - - 1 - 1 2 Other causes 1 1 1 - 3 1 1 - 2 7 Totals 19 4 5 3 31 12 12 7 10 72 Nett Uirths in the year :— Legitimate 826 Illegitimate 20 Nett Deaths in the year Legitimate 09 Illegitimate 3 20 10. MARRIAGES. There were 208 marriages registered in the district in 1021. This is a marriage rate of 5.1 per 1,000. In 1022 there were 208 marriages, equal to a rate of 5.6. and in 1023 210 marriages, equal to a rate of 5.9 per 1,000. 11. BIRTHS. The nett number of births registered in 1021 was 846, affording an annual birth rate of 22.3 per 1.000 population, compared with 21.0 in 1022 and 23.1 in 1923. Of all births. 2ft were illegitimate, or a proportion to total births of 2.3 per cent. Notification of Births Act, 1907-1915. -Of the total births registered in the district during 1021, all except 32, or 3.7 per cent. of the total, were notified to the Medical Officer of Health, 596 being notified by midwives and 233 by parents and doctors; 13 still-births were notified, 0 being notified by midwives and 4 by doctors. 12. SANITARY CIRCUMSTANCES OF THE DISTRICT. (a) Water Supply; Vide Annual Report, 1023. (b) Rivers and Streams. Vide Annual Report, 1923. (c) Rainfall.—The rainfall for the year ended 31st March, 1924. was 32.85 inches. Rain fell on 170 days throughout the period in question. (d) Sewage : Vide Annual Report. 1023. (e) Scavenging : Vide Annual Report, 1923. 21 (!) Housing: 1. GENERAL. Number of new houses erected during the year :— (i) Total 173 (ii) As part of a municipal housing scheme 92 (iii) Others (including- private enterprise) 81 2. UNFIT DWELLING HOUSES. I.—Inspection. (i) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 2,367 (ii) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations,. 1910 837 (iii) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unlit for human habitation 9 (iv) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1,700 II.—Remedy of Defects without Service of Formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 1,305 III.—Action under Statutory Powers. V—Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919 :— (i) Number of dwelling houses in respect of which notices were served requiring repairs 28 22 (ii) Number of dwelling houses which were fit— (a) by owners 25 (b) by Local Authority in default of owners 3 (iii) Number of dwelling houses in respcct of which Closing Orders became operative in pursuance of declarations of owners of intention to close 9 B.—Proceedings under Public Health Act. (i) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 367 (ii) Number of dwelling houses in which defects were remedied:— (a) by owners 367 (b) by Local Authority in default of owners- C.—Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909:— (i) Number of representations made with a view to the making of Closing Orders — (ii) Number of dwelling houses in respect of which Closing Orders were made- (iii) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit- (iv) Number of dwelling houses in respect of which Demolition Orders were made- (v) Number of dwelling houses demolished in pursuance of Demolition Orders- 23 SECTION 2 (1) NOTIFIABLE INFECTIOUS DISEASES. The following table shows the number of notifications of infectious disease received during 1921 TABLE 1. Males. Females. Total Total eases rem'd to HoS. Deaths. Scarlet Fever 17 23 40 34 — Diphtheria 25 25 50 45 3* Puerperal Septicemia — 3 3 - 1 Pneumonia (Acute primary and influenzal) 35 20 55 3 34 (All Forms) Erysipelas 12 6 18 1 - Ophthalmia Neonatorum 4 3 7 — - Encephalitis Lethargica 2 2 4 1 2 Enteric - 1 1 — — Cerebro Spinal Fever 1 - 1 — 1 Totals 96 83 179 84 41 *Includes the death of a Barking resident which occurred in an institution outside the district. The following diseases were notifiable in 1921 under the original Infectious Disease (Notification) Acts 1889 and 1899 :— Smallpox, diphtheria, relapsing fever, cholera, erysipelas, typhus, plague, puerperal fever, enteric fever, scarlet fever and continued fever. 21 and by Orders or regulations framed under Section 180, Public Health Act, 1875 :— Tuberculosis (all forms), ophthalmia neonatorum, cerebrospinal fever, acutc polio-myelitis, encephalitis letharyica, influenzal pneumonia, malaria, dysentery, trench fever, and acute primary pneumonia. The Barking Town (Pneumonia) Regulations, 1924, provides for the notification of Pneumonia supervening upon Measles. The total notifications of infectious disease numbered 179, exclusive of tuberculosis, compared with 190 the previous year. During 1923 the number of notifications of tuberculosis (all forms) was 81, while in 1921 the number was 97. 25 TABLE XI. Notifiable Disease. at all ages. Xo. of cases notified at ages. Cases classified according to Wards. Under 1 year. 1—5 5—15 15—25 25-45 45—65 05 and over. Abbey. Gascoigne. Longbridge. Ripple. Westbury. Central. Scarlet Fever 40 — 7 33 — — — — 9 10 9 6 3 3 Diphtheria 50 — 17 26 3 4 — — 9 8 16 5 7 5 Puerperal Septicemia 3 — — — I 2 — — 2 — — — 1 — Pneumonia (primary and inHuenzal) 55 7 19 4 7 4 12 2 27 6 5 2 3 12 Ervsipelas 18 — — — 2 8 7 1 5 3 3 1 4 2 Ophthalmia Neonatorum 7 7 — — — — — — — 3 1 2 1 — Encephalitis Lethargica 4 — — 3 1 — — 1 — — — 2 1 Enteric 1 — — — — — 1 — — — — — — 1 Cerebro Spinal Fever 1 — — 1 — — — — 1 — — — — — Totals 179 14 43 64 16 19 20 3 54 30 34 16 21 24 26 TABLE III. Monthly summary of notifications of infectious disease :— Month. Scarlet Fever. Diphtheria. Puerperal Fever. Pneumonia. Erysipelas. Ophthal ma Neonatorum. Enteric Fever. Cerebro Spinai Menirjitis. Encephalitis Lethargica. Totals. January 1 2 - 12 3 — 1 - - 19 February 1 4 — 9 2 - - - - 16 March 1 5 — 2 2 1 - 1 - 12 April 5 3 — 1 1 2 - - 1 13 May — 5 1 1 4 — - - 1 12 J une 2 4 — 1 — 1 - - — 8 July 3 6 — 1 — — - - 1 11 August 2 3 — 3 1 — - - 1 10 September 6 4 1 2 1 — - - — 14 October 12 8 — 5 1 1 - _ - 27 November 3 4 — 6 1 — - - 14 December 4 2 1 12 2 2 - - — 23 Totals 40 50 3 55 18 7 1 1 4 179 27 (a) Scarlet Fever.—The number of cases notified was -10, compared with 18 the previous year. No fatal cases occurred. There were no cases connected with any special milk supply, infection being mainly spread, as is usually the case, through school attendance. 34 cases were isolated at the Municipal Hospital. The average stay of scarlet-fever cases in hospital was 36,2 days, the longest period being 63 and the shortest 26 days. There were 4 return cases of scarlet fever during the year. (b) Small Pox.—No case of Small Pox occurred in 1921. Notifications of 5 persons who had been in contact with cases of Small Pox were received and kept under supervision for the usual period. The following particulars arc appended of vaccinations during 1921 :— Certificates of successful vaccinations 340 Postponed 10 Conscientious objections 424 Left District 20 The vaccination rate per 1,000 births was therefore 452.1. (c) Diphtheria.—50 cases were notified rs compared with 30 the previous year. 3 deaths occurred (including one in an outlying institution). 45 cases were isolated at the Municipal Hospital. The average stay of diphtheria cases in hospital was 35.1 days, the longest stay being 61 days and the shortest 24 days. Of fatal cases, one died the same day as admitted, whilst the other remained 5 days in hospital. As usually happens, the principal medium of the spread of the disease was school attendance. Patients are discharged cured trom hospital only after bacteriological investigation, and in only one case was a long delay incurred. Two cases of laryngeal diphtheria were admitted to hospital. In one tracheotomy was performed, the other being moribund, died shortly after admission. 28 (d) Enteric Fever.—There was one case of enteric fever notified during the year, in the case of a patient admitted to the London Hospital for observation. (e) Puerperal Fever.—3 cases were notified during the year; no case was admitted to hospital. (f) Malaria.—There were no cases of malaria notified during the yea (g) Pneumonia.—33 cases were notified during 1921 as compared with 92 the previous year. 3 cases were isolated at the hospital. There were 34 deaths from all forms of pneumonia during 1921. (h) Encephalitis Lethargica.—1 cases were notified, two of which proved fatal. One case, a mild one, was admitted to hospital and after a short stay discharged cured. One case of mixed infection was admitted to hospital, but no instance of cross infection occurred in the wards during the year. (II) NON-NOTIFIABLE INFECTIOUS DISEASES. The most important of these are measles, whooping cough and infantile diarrhoea. There were no serious epidemics of these diseases, and the deaths registered were as follows :— Measles 14 Whooping Cough 4 Diarrhoea 15 Measles and Whooping Cough.—Cases amongst school children are reported to the School Medical Officer by teachers, attendance officers and school nurses, and appropriate action taken as regards exclusion and supervision of contacts. Further particulars of action taken will be found on page <j] of the School Medical Officer's Report. 29 ISOLATION HOSPITAL. The following is the table of admission, etc., in respect of infectious disease for 1924 :— Disease. in Hospital J anuary, 1st, 1924. Admitted during the year. Died. Dis charged In Hospital Dec. 31st.. 1924. Scarlet Fever 3 34 — 30 7 Diphtheria 2 45 2 42 3 Pneumonia — 3 — 3 — Puerperal Fever — — — — — Measles — 8 1 7 — Chicken Pox — — — Mumps — — — Whooping Cough — — — — — Enteric Fever — — — — Ophthalmia Neonatorum — — — Erysipelas — 1 1 Encephalitis Lethargica — 1 — 1 — Totals 5 92 3 84 10 TUBERCULOSIS. Under the County of Essex Combined Medical Service scheme the Medical Officer of Health, Barking, 5s Tuberculosis Officer for the district, an arrangement from a public health standpoint possessing obvious advantages. The Essex County Council are the responsible authority for the treatment of tuberculosis under the Public Health (Treatment of Infectious Disease) Act, 1913. The number of notified cases on the Register on December 21st, 1923, was 727, 365 being males and 362 females. During the year 1924, 97 notifications were received of all forms of tuberculosis, including 64 pulmonary cases; 32 deaths of notified cases occurred, 46 cases left the district or could not otherwise be traced, leaving 746 cases on the Register on the 31st December, 1924, 364 males and 382 females. 30 The fallowing table corresponding to Forms A and B, shows the cases notified during the year classified as to age and sex:— Disease. Under one year. 1 to 5 years. 5 to 10 years. 10 to 15 years. 15 to 20 years. 20 to 2.", years. 25 to 3 c years. 35 to 45 years. 45 to 55 years. 55 to 05 years Over 65 years. Totals. Pulmonary Tuberculosis M — 1 4 2 – 1 9 2 4 2 — 30 F 1 3 3 3 5 3 7 7 — 1 1 34 Tuberculosis (Other Forms) M – 5 5 2 2 – – – — — — 14 F – 4 4 3 – 2 2 1 — — — 19 Totals ••• 1 13 10 10 15 6 18 10 4 3 1 97 The notification rate per thousand population was 2-5 compared with 21 the previous year. 31 As regards the occupations of notified cases during the year, the following table is of interest % Packers 1. Labourers 12 School Children 25 Storekeepers 1 Clerks 3 Housewifery 14 Newsagents 1 Factory Hands 5 Shop Assistants 3 Machinists 1 Field Workers 1 Bricklayer 1 Builder's Boy 1 Domestic Servants 2 Carpenters 2 Rubber Workers 1 Butchers 1 Nil 21 Shopkeepers 1 32 The following figures, kindly supplied by the County Medical Officer of Health, indicate for the four quarters of the year the percentage attendances of cases per 10.COO of population at ihe Tuberculosis Dispensary and of those admitted to sanatoria under the County Council :— Attendances at Dispensary. Admission to Sanatoria. No. Rate per 10,000 population. No. Rate per 10,000 population. 1st quarter 389 109.50 26 7.32 2nd quarter 396 111.40 18 5.00 3rd quarter 230 64.75 12 3.38 4th quarter 419 117.95 14 3.94 the average for the vear being' 100.f) and 4.Pi' compared with 83.31 and 3.14 respectively for 1923. In the former instance, tlie highest corresponding- clistrict figure within the administrative County of Kssex during 1921. counted on the same basis, was 103.64, whilst in the latter no district exceeded that of Barking. The proportion of sanatoria admissions to eases notified was 72.1 per cent. Oniv two cases on Form B were notified by the School Medical Officer, explained by the fact that practically all suspicious cases are sent for further examination by the Tuberculosis Officer before actual notification. 33 The following are particulars of cases notified under Forms "C " and "D" during the year :— FORM C. FORM IX Pulmonary. X on-Pulmonary. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Male. Female, Male. Female. 31 27 6 2 17 21 1 — 39 deaths occurred from tuberculosis all forms, 35 of these being pulmonary cases. The number of deaths in institutions was 14. During the year 1921, 7 deaths from tuberculosis were registered of persons not previously notified as suffering from the disease. The importance of notification is that the necessary steps can be taken as to the care of patients and contacts and the prevention of spread of the disease. Delay in notification is had for both patients and public. Of deaths registered due to tuberculosis, notifications received by the Medical Officer of Health were as follows :— No. not notified at time of death 7 No. notified less than 3 months before death 14 No. notified 3 to 6 months before death 4 No. notified (6 to 9 months before death 2 No. notified 9 to 12 months before death 1 No. notified 12 to 18 months before death 1 No. notified 18 to 24 months before death 1 No. notified more than 21 months before death 9 Calculated on the Registrar General's estimated population, the death rate due to tuberculosis during 1924 was 1.2 compared with the same figure in 1923, while the percentage ratio of deaths notifications was 40.2 compared with 55.5 for the previous year 34 The following table shows the number of deaths from tuberculosis in Barking together with the death rate per thousand persons living during the last six years :— 1919. 1920. 1921. 1922. 1923. 1924. No. Rate. No. Rate. No. Rate. No. Rate. No. Rate. No. Rate. T.B. (all forms) 49 1.3 49 1.3 48 1.3 43 1.1 45 1.2 39 1.2 Pulmonary Tuberculosis 35 0.99 38 1.08 41 1.1 33 0.89 38 1.02 35 0.92 35 The incidence and death rate from tuberculosis form an index to a very great extent of the sanitary conditions of a neighbourhood, defective housing and other circumstances of distress usually keeping close company with a high incidence and high death rate from the disease. The following table has been compiled from the figures obtained from the five wards into which the Urban District of Barking is divided : — Abbey. Gascoigne. Central. Ri pple. I.ongbridge. West bury. Notifications 18 18 13 16 7 25 Ratio to 1,000 Population 2.1 1.9 2.2 4.0 1.2 5.2 Deaths 8 12 8 2 3 6 Ratio to 1,000 Population 0.9 1.3 1 1 3 I 0.5 0.5 1.2 While a specific bacterium universally distributed in all civilised communities exists as the direct cause of tuberculosis, it must not be forgotten that the indirect or predisposing factors are engendered by poverty, want of fresh air, etc., and that a community situated under favourable environmental and other conditions is less prone to the ravages of tuberculosis than a community living under less favourable circumstances. Quoting from the last Annual Report of the Medical Officer of Health for Newcastle-on-Tyne, it is found that, over a period of 9 years, the average tuberculosis death rate in two of the st wards of the City was 2.55 and 2.53 compared with 0.81 and 0.70 for two better class neighbourhoods. Apart from certain dangerous trades as a predisposing factor in tuberculosis, the prime cause is admittedly life spent under defective and insanitary home conditions combined with, in many cases, insufficient food and other privations associated with unemployment and industrial depression, although it would not, I think, be correct to say that the scale of outdoor relief is sufficiently inadequate 36 throughout the country as a whole, or any particular part, to enact any serious r61e, apart from other considerations in the etiology of the disease. Tuberculosis in children is in the majority of cases directly due to the ingestion of milk from tuberculous cows, though at the moment no legislation exists requiring milk purveyors to provide milk, free from tubercle bacilli. 37 A table of comparative tuberculosis notification and mortality rates for Barking and surrounding districts is as follows :— COMPARATIVE TABLE OK TUBERCULOSIS NOTIFICATION AND MORTALITY RATES FOR BARKING AND SURROUNDING DISTRICTS. District. Population Density (per acre). Notification Rate (per 1.000 population). Death Rate (per 1.000 population). Notification Mortality Rate (per cent.). 1910 1920 1021 1922 1923 1919 1920 1921 1922 1923 1019 1020 1921 1922 1923 1919 j 1920 1921 1922 1923 Larking 0.2 9.2 9.5 9.6 0.7 4.5 3.3 4.1 1.9 2.1 1.3 1.3 1.3 1.1 1.2 30.8 142.2 32.2 58.9 55.5 Ilford 0.9 10.2 10.0 10.1 10.5 2.3 1.5 1.2 1.2 1.4 1.0 0.7 0.7 0.0 0.7 46.0 143.1 [00.9 50.4 51.1 Last Ham 42.5 42.8 43.0 43.8 43.9 2.2 2.1 2.1 2.9 2.0 0.8 1.0 1.0 1.2 1.1 38.8 50.9 J 3.3 03.3 54.0 West Ham 61.l 03.6 03.9 04.7 66.8 3.1 3.1 2.5 2.0 3.0 1.4 1.3 1.2 1.1 1.1 45.5 141.2 49.2 44.2 38.7 Poplar 74.9 74.8 76.7 77.1 77.9 5.1 4.0 3.0 2.9 2.3 1.4 1.6 1.3 1.3 1.2 23.5 37.8 40.5 41.2 46.4 Stepney 120.7 147.0 131 2 132.5 133.3 3.9 2.1 2.8 2.5 2.3 1.7 1.1 1.3 1.4 1.2 43.2 47.9 18.5 45.4 52.3 38 AFTER-CARE; Tuberculosis in the great majority of cases is a curable disease provided the patient is seen at a sufficiently early stage of the malady, undergoes sanatorium treatment and subsequently passes his life under reasonably hygienic conditioi s. It is with regard to the latter that the activities of the AfterCare Association in this district particularly exist consisting inter alia, in providing special splints, clothing, boots, nourishment, etc., for necessitous cases and in obtaining if possible suitable homes and employment for the tuberculous. During the year 12 cases were so assisted. Apart from a grant of £20 from the County Council, the funds of the Association are practically dependent upon voluntary contribution. Equally important in the matter of after-care is that of dealing with the large number of advanced cases who are, in tin majority of instances, in a highly-infectious condition, and not infrequently living under overcrowded home conditions. For these at the moment practically no remedy exists except, perhaps, that of the workhouse. The strongest opposition (and perhaps quite naturally so) is generally offered by such cases and their relatives against such a course, many of the latter of whom in turn become infected with the disease. The necessity for some form of local remedy is evident, and might be provided by arrangement with the County Council of Essex with the concurrence of the Ministry of Health, whereby the Urban District of Barking might set apart a number of beds at the local infectious hospital for the detention of these cases, and the suggestion, if adopted would. my opinion, prove a distinct financial saving for the communit. At the request of the medical practitioners of the district, compulsory disinfection of all homes after death from tuberculosis was adopted by the Council during the year, under Section Prevention of Infectious Diseases Act, 1890. 39 DISINFECTION. The methods in use for disinfection within the district were explained in my previous report. As to the actual efficacy of disinfection by chemical agents, it is only fair to mention the change of opinion which has taken place within the past few years. While the efficacy of steam disinfection is admitted, the same testimony can hardly be put forward on behalf of the many chemical substances used for the purpose of disinfection of room surfaces, etc. The main argument against the need for room disinfection at all exists in the fact that apart from certain exceptions hereafter mentioned, infection consists in a personal transference from the infected to thers and not through fomites or Infected articles, rooms, etc., due to the further fact that the various causative organisms of many of these diseases, either cannot exist apart from their particular pabulum in the human host or can only do so under special laboratory conditions. The only exceptions to this statement so far as this country is concerned are small pox, where fomites undoubtedly convey infection ; tuberculosis, where the dust of rooms tenanted by consumptives is infectious; water, milk, oysters, etc., in the typho-dysenteric group; and bodyvermin and consequently clothing, etc., in the case of typhus, relapsing and trench fever. With the exception of recently soiled articles, which may harbour infection for short periods, it may be said that scarlet fever, measles, whooping cough, cerebro-spinal fever, diphtheria, etc., are only infectious in the individual sufferer, and that any need for chemical disinfection of the home may be safely abandoned, as has to some extent already been done in this country and to a very considerable extent both in Germany and America without the incidence of untoward after-effects, provided the necessity has been inculcated of thoroughly airing and cleaning with soap and water the apartments exposed to infection. 40 In the case of small pox, tuberculosis, typhoid, dysentery, typhus, relapsing fever and some others, steam disinfection of bedding, clothing, etc., should be rigorously practised, while the applications of disinfectant solutions to ail room surfaces, including vermin destruction in appropriate cases would be similarly indicated, although it must be remembered that, strictly speaking, complete disinfection must be, not only very difficult but very expensive. Fortunately, the life of disease-producing organisms under the influence of sunlight and cleanliness is a short one. SECTION 3 SANITARY ADMINISTRATION. The following table gives a record of the work of the anitary staff in respect of housing:— Total houses in district (Estimated) 7214 Total No. of houses inspected for the first time during the year under the Public Health and Housing Acts 2367 Percentage of such houses inspected to total in district 32.8 Average No. of defects per house 3.7 Total No. of Preliminary Notices served 1709 Total No. of Preliminary Notices uncomplied with and Statutory Notices issued 367 Percentage of Statutory Notices to Preliminary Notices 21.4 Number of Statutory Notices complied with in scheduled period 136 Ditto in one month 122 Ditto in two months 58 Ditto in three months and over 51 No. of cases under Housing Acts dealt with by L. A. in default of owners 3 No. of actual prosecutions under the Public Health Acts 7 No. of prosecutions which under ordinary circumstances would have been instituted 109 RE-INSPECTIONS. Total re-inspections during the year 4971 Average No. of rc-inspections per house 2 9 Total re-inspections per Statutory Order 1155 Average No. of re inspections per Statutory Order 308 Cases hear before Justices during January, 1925. 41 On an average of various districts, while little variation appears to exist between the actual number of primary and subsequent inspections, re-inspections in Barking during the year were necessitated at the rate of 2.9 to every primary inspection. Whilst six weeks appears to be an average period for the time of compliance from the date of Preliminary Notice the average time required in Barking last year was 15½ weeks. 70 per cent, may be regarded as a fair average of defective houses in a district, while the corresponding figure for Barking last year was 72.2 of the total inspected. The following table gives particulars of Statutory Notices served for the remedy of various defects :— Acts and Sections. Xo. issued. No. complied with. No. lapsed. No. outstanding (a) Public Health Act, 1875, tion 91 324 324 — — (b) Public Health Act, 1875, tion 36 43 43 — — (c) Public Health Act, 1875, tion 46 — — — — (d) Public Health Act, 1875, tion 49 7 2 — 5 (e) Public Health Act, 1875, tion 41 — — — Factory and Workshop Act, 1901 9 2 — — Housing and Town Planning Act, 1909 — — — Housing and Town Planning Act, 1919 28 28 — — Totals 404 399 5 (a) To abate nuisance of various descriptions including over- crowding. (b) To provide proper closets, dustbins, etc. (c) To cleanse, disinfect, etc., houses. (d) To remove offensive accumulations. (e) To relay drains. 42 RETURN AS TO STRUCTURAL ALTERATIONS. Drains examined and tested 180 Drains re-laid and amended 12 Drains—ventilation improved 3 New w.c. apparatus provided 40 W.C. apparatus repaired 85 W.C. flushing- power improved 80. New soil pipes fixed Soil pipe ventilators enlarged 2 New main taps provided 51 Sanitary dustbins provided 269 Backyards paved or repaired 247 New sink wastes 70 W.C. cisterns fixed 147 94 complaints were received from householders during the year of defective and choked drains. In 19 cases preliminary tests were carried out by the sanitary staff, with a result that 3 noticeswere served upon owners that such premises would be entered and the ground opened up for the purpose of examining the drains. In 3 instances defects were discovered, while in 3 instances it became necessary for the local authority in default of owners to carry out the necessary work. SMOKE OBSERVATIONS. Compared with the previous year when eight observations were made of nuisance caused through the emission of black smoke within the meaning of the Act, 136 observations were carried cut during 1024. No actual pressure was brought to bear upon responsible parties, with a result that little or no noteworthy amelioration of the nuisance occurred. To a very great extent the present preponderence of smoke nuisance is due either to the quality of coal used or bad firing, defects within the power of those responsible to remedy. Injury to health and property through the continuous discharge of black smoke into the atmosphere was commented upon in my last year's Report. 43 The following table gives particulars of smoke observations made during the year:- No. of Chimney9 watched 12 No of Observations made 130 No. of Chimneys from which black smoke issued in such quantity as to be a nuisance for a period of for over six minutes to the aggregate during the hour 32 No. of notices served for the abatement of smoke nuisance:— (a) Informal •> (b) Statutory — No. of prosecutions — The public health policy of the department towards recalcitrant property owners was dwelt upon at some length in my previous Report, and need not be referred to again this year. To put matter upon a sound and satisfactory footing, may 1 reiterate for a change of present policy whereby the Chief Sanitary Inspector be instructed that when the statutory time limit has been passed in respect of compliance with nuisance abatement demands, he should take out the necessary summons for enforcement and for the recovery of penalties. As a practical result, time at present spent over re-inspections might easily be halved, and the energies of the inspectors more usefully directed in other channels. MEAT INSPECTION'. During the year a quantity of offal and other foodstuffs to the amount of 3 cwt. 27 lbs. was surrendered and destroyed. the difficulties commented upon in my Report for 1923 incidental to the satisfactory inspection of slaughtering in privately-owned avattoirs continued during 1924, although the issue of draft Public Health (Meat) Regulations during the year made for improvements which might be regarded as a step at least towards theoretical institution of public abattoirs. Provision has been made in these Regulations—which would come into force on 44 April 1st, 1925—lor notices of times of slaughtering to be sent to Medical Officers of Health, for protection of meat, including offal, sausages, etc., from contamination exposed on stalls or in shops, stores, etc., for the general cleanliness of the same, and for precautions against contamination during transport, and, lastly—though only possible in public abattoirs—where a local authority show to the satisfaction of the Minister of Health that they have made suitable arrangements for the inspection at time of slaughter of all animals slaughtered within their district, the Minister may, on the application of the authority and subject to such conditions as he may impose, authorise them to use for the purpose and in the manner specified a distinctive mark of a design approved by him and so devised as to indicate the identity of the local authority, and of the inspector using the mark. Regulations, it may be added, applicable to meat should equally apply to other foodstuffs such as fish, game, poultry, bakery goods, sweets, ice-cream and confectionery of all kinds, which are just in many cases as urgently needed as a public health security. Slaughter-houses received 368 visits during the year, and 2 pairs of lungs and one liver were condemned, and the presence of tuberculosis in two instances detected. Prosecution for the Sale of Unsound Fruit. On September 16th. 1924, two baskets of unsound pears and one basket of unsound apples, of a total weight of 33½ 1bs., were seized from a retailer's shop in the district, where the fruit was being exposed for sale. The Council authorised proceedings to be taken against the vendor, and the subsequent prosecution resulted in his being fined 20s. and 8s. costs. CONSERVANCY SYSTEM OF THE DISTRICT. See Annual Report for 1923. 45 FACTORY AND WORKSHOP ACT, 1901. 1. Inspection of Factories, Workshops and Workplaces. Premises. Number Inspections. Written Notices. Prosecutions. Factories Including Factory Laundries) 57 4 — Workshops 149 5 Including Workshop Laundries) Workplaces 41 1 Other than Outworkers' Premises.) 46 2. Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects. Number of Prosecutions. Found Remedied Referred H.M.Ins. Nuisances under the Public Health Acts:— Want of cleanliness 3 3 — — Want of ventilation 2 2 — Overcrowding — — — — Want of drainage of floors 1 1 — — Other nuisances 6 0 — — Sanitary accommodation:— Insufficient 4 4 — — Unsuitable or Defective 7 7 — — Not separate for sexes — — — — Offences under the Factory and Workshops Acts:— Illegal occupation of underground bakehouse (S.101) — — — — Other offences 2 2 — — (Excluding offences ing to outwork and ces under the Sections mentioned in the dule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921). Total 25 25 — — 47 FACTORIES. Of the 64 factories on the register the industries engaged in are as follows:— Wharfingers 2 Wood Flooring Makers 2 Maltsters 1 Rubber Manufacturers 1 Match Manufacturers 1 Pipe Makers 2 Engineers 9 Chemical Manufacturers 3 Timber Merchants 4 Letter File Makers 1 Dust Shoots 2 Tar Distillers 2 Dye Manufacturers I Boot Factor I Laundriers 2 Varnish Manufacturers 1 Ironfounders 2 Petrol Distributors 1 Builders 2 Tin Box Manufacturers 1 Life Belt Makers 1 Cotton Clothing Makers 1 Brewers 1 Glass Workers 1 Gut Scrapers 1 Mineral Water Manufacturers 1 Sausage Makers 5 Manure Manufacturers 1 Patent Light Makers 1 Furniture Maker 1 Printer 2 Sewage Disposal Works 1 Collar Makers1 Brass Workers 1 Asbestos Manufacturers 1 Paint Manufacturers 3 48 Officially factories do not come within the jurisdiction of the Medical Officer of Health, except indirectly where a sanirtary inspector or other official authorised by the Council can visit factories for the purpose of examining employers' lists of outworkers. The question of sanitary conveniences are generally referred to the Medical Officer of Health by factory inspectors. Means of escape from fire in factories, which is imposed as a distinct responsibility on local authorities by the Factory and Workshop Act. is dealt with by the Chief Fire Officer. The present position regarding responsibilities of local author ities in factories is somewhat indeterminate except as regards bakehouse factories, which are now under local authorities b\ the Ministry of Health Order 95S, of October, 1921, unless notified by H.M. Inspector of Factories under Section of the Factory and Workshop Act, 1901. While admitting that Section 125 of the Factory and Workshop Act, 1901, does not empower local authorities to enter factories, there is, on the otherhand, nothing in the Act to indicate that they must not or cannot enter. In fact, as already mentioned, Section 11, regarding means of escape from fire, places a definite duty upon the local authority as regards factories, but gives no right of entry, while again, offensive trades when carried on in factories must be periodically visited under their respective bye-laws. 49 WORKSHOPS. The 30 workshops on the register are made up as follows :— Dressmakers, Tailors, etc 5 Basket Makers 1 Cocoa Packer 1 Resin Manufacturer 1 Undertakers 3 Milliners l Cake Powder Packer 1 Motor Repairers 1 Joiners 1 Upholsterers 2 Blacksmiths 2 Boot Repairers 5 Varnish Works 1 Cycle Repairers 1 Florists 1 Laundriers 1 Leather Goods Makers 1 Harness Repairers 1 50 Local sanitary authorities are responsible for sanitary defects arising in connection with workshops where remediable under the Public Health Acts, while offences under the Factory and Workshop Act are reported for remedy to H.M. Inspector of Factories. 157 visits were paid to workshops during the year, or on an average 5.2 per workshop. It cannot be stated that full information has yet definitely been obtained respecting the workshops of the district, so that no detailed statement regarding them from a public health point of view can yet be made, as, for example, a number of those inspected during the year were found to lack ordinary sanitary accommodation for their employees. Considerable progress had been made towards the close of the year in preparing a card index record of all workshops and workplaces within the district. To some extent lack of supervision of these places has resulted from time spent on housing re-inspections, a system which still continues to prove a heavy and perfectly useless drag upon the time of the inspectors. OUTWORKERS. The following are the occupations of outworkers in the district during 1924 Fancy Leather Goods 1 Wearing Apparel 6 Covering of Tennis Balls 1 Boot and Shoe Repairing 2 Brush Maker 1 Tie Makers 4 Umbrella Maker 1 Paper Bag Maker 1 During the year 23 lists of outworkers were received from authorities outside the district in respect of outworkers residing in Barking, whilst from employers within this district two lists were similarly received. All the workplaces of outworkers in the district were inspected during the year. 51 HOUSING. The various difficulties encountered under the subject of housing directly coming within the purview of the Medical Officer of Health were fully dwelt upon in my Report for the previous vear. Private enterprise does not appear to be sufficient to meet housing requirements, because in practically every instance such houses are built for sale, leaving the poorest of the district— who are generally unable to afford the rent of houses built on subsidy—to continue the use of premises in many cases quite unfit for habitation, although undoubtedly many such houses could be rendered better through more drastic action under the Public Health and other Acts. TENTS, VANS, ETC. The absence of sufficient surveillance on the part of the sanitary staff owing to the many other calls upon their time, inevitably allows bye-laws regulating the use of temporary dwellings to be from time to time transgressed. During the early part of the year four families of gipsies, living under adverse sanitary conditions near Movers Lane from the previous autumn, were visited by diphtheria, and one case removed to the Isolation Hospital. Throughout the year 67 inspections were carried out of temporary dwellings and 4 contraventions of the bye-laws detected. COMMON LODGING HOUSES. Two registered common lodging-houses of the old, or common cubicle type, one in North Street, with accommodation for 27 lodgers, and one in Heath Street, providing accommodation for 36 lodgers, continued in use and received 102 inspections during the year, a total of 4 infringements of the bye-laws being detected. Night visits during the period numbered 2. No provision exists for female lodgers or married couples. 52 HOUSES LET IX LODGINGS. Bve-laws regulating houses let in lodgings or occupied by members of more than one family belonging to the working classes and framed under Section 29 of the Housing, Town Planning, Etc., Act, 1919, came into force during the year, but lack of time prevented attention being given to the question of registering houses suitable for action under these bye-laws, which would include a large number of the houses in the poorer parts of the district, wherein definite improvements from a public health point of view could be effected. OFFENSIVE TRADES. The number of offensive trades on the register is 31, and the businesses indulged in include one tripe boiler, one gut scraper, two fish skin scrapers, one fat melter, one fat extractor, 16 fish fryers, and 9 dealers in rags and bones. During the year it was found that a gut scraper and a fish skin scraper had been for some period carrying on the additional offensive trades of fat melter and fat extractor respectively without being registered therefor by the sanitary authority. In the latter case the premises were the reverse of satisfactory; while a fish skin scraper, who had never been registered, was similarly carrying on that trade without any serious attempt at compliance with the bye-laws regulating the business. After the lapse of some time it became possible to register the fat melter and fat extractor, whilst the fish skin scraper under the threat of legal proceedings left the district. Fish frying gives rise to considerable nuisance, but, as the business is mostly carried on during the evening, it has been found difficult to exercise that amount of supervision necessary to abate any nuisance which is generally the result of carelessness on the part of fryers, their premises otherwise conforming to the requirements of the bye-laws. 53 During the year noxious odours prevalent in the district presented some difficulty as to seat of origin, but eventually the nuisance was located in premises where linseed oil was being boiled to a high temperature as a preliminary in the preparation of a gelatinous product required for the manufacture of printer's ink. The process is one of gradual oxidation, and is accompanied by a certain disintegration of the oil and the evolution of acrolein and acrylic acid, highly irritating products, besides various amounts of volatile fatty acids, such as propionic, valeric and butyric. The process was being carried on in open boilers, and, as no serious attempt was made to incinerate or condense the fumes, the cause of nuisance became obvious. The trade was scheduled by the Council as an offensive one under Section 51 of the Public Health Acts (Amendment) Act, 1907, and submitted for confirmation to the Ministry of Health towards the close of the year. SUPERVISION OF FOOD SUPPLY. (1) There are 33 dairies and milkshops on the Register, 371 inspections of these premises being carried out during the year. In 10 cases the premises are used as dairies only, while in the remaining instances they are of the type of small general shop, an undesirable combination from a health point of view, and for the better regulation of which amended Regulations were issued and brought into use during the year. There are two cowkeepers in the district, who are also retail purveyors of milk. No licences were applied for during the year under the Milk (Special Designations) Order, 1923. (2) Slaughter-houses.—Licences were granted in respect of two slaughter-houses during the year, in addition to which there is one registered slaughter-house in use since 1847. These premises received 368 inspections during the year, and one instance noted in which infringements of the bye-laws had arisen. 54 (3) Bakehouses.—The question of bakehouses has been reviewed under the Section devoted to factories and workshops. Here it may be mentioned that there are 16 bakehouses on the Register, 7 of these conforming to factory and the remainder to workshop bakehouses. There are no underground bakehouses in the district. (4) Premises where food is prepared—There are 25 shops where various articles of diet are prepared, in addition to 15 small restaurants and eating-houses throughout the district. In general these premises seem to be fairly well conducted and received 90 inspections during the year. (5) Sale of Food and Drugs Act.—These Acts are administered by the Essex County Council, and Mr. H. C. Card, the Chief Inspector, has kindly given me certain particulars which are here appended:— Number of samples taken in Barking during 1924 and submitted for analysis. Milk. Butter. Miscellaneous. Total. Prosecutions. Fines. 47 51 41 139 1 10/- 55 SECTION 4 MATERNITY AND CHILD WELFARE. Midwifery and Midwives.—The arrangement foreshadowed in my Annual Report for 1923. providing for closer co-operation between the Maternity and Child Welfare staff of the Council and the District Midwives of the Plaistow Maternity Charity took effect from 1st January, 1924. Health visitors and certain midwives have co-operated during the year, with the result that a substantial and satisfactory increase has already taken place in the number of expectant and nursing mothers availing themselves of the antenatal and welfare centres of the district, while it is to be hoped that in the near future a similar arrangement will be reached between the remaining district midwives, an arrangement the importance of which from an ante-natal aspect cannot be overestimated. During the year 9 midwives notified their intention of practising in Barking to the Local Supervisory Authority, which is the Essex County Council, the Medical Officer of Health for Barking filling, as formerly, the place of Assistant Supervisor in accordance with the County scheme. 31 quarterly visits were paid to midwives for the purpose cf inspecting their outfits and records, while 10 cases were investigated where the midwife had sought medical assistance on account of rise of temperature, discharging eyes, etc., as required by the regulations of the C.M.B. Generally speaking, the result of these investigations showed that the work of the midwives was satisfactory. Although actual delegation of supervisory powers cannot be effected from county to urban authorities under the Midwives' Act, 1918, the present arrangement—the best compromise under existing circumstances—has much to commend it, compared with any alternative scheme. 56 Although it may be said that the old type of uncertified handy women has probably now officially disappeared from the neighbourhood, it must be admitted that unqualified women to some extent still minister to the needs of the puerperal period, a circumstance which falls considerably short of the ideal of district midwifery. NOTIFICATION OF BIRTHS ACT, 1907 to 1915. The above Acts form the basis of all maternity and child welfare efforts carried out, and require that all live births and still-births of seven months and over be notified to the Medical Officer of Health within 3G hours, being thus an additional requirement to the Registration Act, 1836, by which all live births must be registered within six weeks. Of the total births registered within the district during 1924, all except 32, or 3.7 per cent., of the total were notified, particulars of from whom notifications were received being supplied by the following table:— By whom notified. Live Births. Still Births Medical Practitioners 203 4 Certified Midwives 596 9 Parents and Others 30 - The actual number of births within the district during the year was 861, the net total of 816 being reached by adjustment of inward and outward transfers, etc. Of the total births occurring during the year, 596, or 69.2 per cent., were attended by midwives, the remainder being attended by medical practitioners. The average per centage of still-births was 1.5, while 20, or 2.3 per cent., of children were illegitimate. As usually happens the male sex in point of number preponderated over the female, the actual number of all births registered being 426 male and 420 female, or 50.3 per cent. male and 49.6 per cent. female. 57 MATERNITY WARD. One of the wards at the Isolation Hospital continued to be used for maternity cases, 113 cases being admitted and 124 babies born, as compared with 120 in 1923, or 14.2 per cent. of the total births during the year, took place in the maternity ward. The low percentage of beds occupied is some matter for regret, considering the present overcrowded state of the district and the unsuitable conditions under which in many cases confinement takes place, points dwelt upon at some length in my last year's Report. Although the economic factor may be regarded as the main obstacle to further advantage being taken of the above provision, allowance must be made for the prejudice which still exists against an infectious hospital being used for maternity purposes, whilst it must further be admitted that particular midwives may not for financial reasons care to lose too many cases considering the number of midwives now practising in the district. The following return required by the Ministry of Health for the year ended 31st December, 1924, in respect of the Maternity Ward should serve to remove many of the existing fears and prejudices in the minds of m..ny with respect to the use made of part of an infectious hospital for maternity work. The almost entire freedom from complications and necessities for medical aid are worthy of notice:— (1) Total number of cases admitted 143 (2) Average duration of stay 1.34 days (3) Number of cases delivered by— (a) Midwives 124 (b) Doctors — 58 (4) Number of cases in which medical assistance was sought by the midwife with reason for requiring assistance— (a) Ante-natal: (i) Albuminuria Nil (ii) Rise of temperature Nil (b) During Labour: (i) Premature Labour Nil (ii) Obstructed Labour Nil (iii) Delayed Labour Nil (iv) Adherent Placenta Nil (c) After Labour: (i) Torn Perineum Nil (ii) Thrombosed Vein in Leg Nil (d) For Infant : (i) Prematurity Nil (ii) Slight Inflammation of Eye Nil (iii.) Feebleness 1 (5) Number of cases notified as puerperal sepsis with result of treatment in each case. —Nil. (6) Number of cases in which temperature rose above 100.4 for 24 hours with rise of pulse rate.—Nil. (7) Number of cases notified as opthalmia neonatorum with result of treatment in each case.—Nil. (8) Number of cases of " inflammation of the eyes " however slight.—Five. (9) Number of infants not entirely breast-fed while in the Institution, with reason why they were not breast-fed.— Five. (a) Depressed Nipples 5 (10) Number of maternal deaths, with causes.—Nil. 39 (11) Number of foetal deaths (still-born or within 10 days of birth) and their causes, and the results of the postmortem examinations, if obtainable : (a) Still-born 3 (b) Prematurity2 Total 5 (12) Number of cases remaining in ward on 31st December, 1924:— (a) Women 8 (b) Babies 5 Total 13 As previously, advantage was taken of the Maternity Ward for the treatment of suitable cases referred from the ante-natal clinic. Thirty-one cases were admitted during the year, and the average length of stay was 17.16 days. PUERPERAL SEPSIS. Three cases of puerperal sepsis were notified compared with four in 1923, none of which were admitted to the Infectious Hospital. Of the cases notified one had been attended by a midwife. Special investigations were carried out by the health visitors in all notified cases, but in no instances was it possible to arrive at any specific cause for the condition. MATERNAL DEATHS. Three deaths occurred attributable to the puerperal state, giving a maternal mortality rate calculated on the number of deaths per 1,000 births of 3.54. During 1924, the maternal mortality rate for England and Wales was 3.90, the significant fact emerging that this rate has varied very little as a whole during the past quarter of a century. 60 BIRTHS. The birth rate is calculated on the number of births registered per 1,000 population, and during 1924, 846 (426 males and 420 females) were registered, giving a birth rate of 22.3, compared with 23.1 in 1923. The more apparent causes for the falling birth rate generally and locally were discussed at some length in my Report for the previous year. Of the total number of births registered 20, or 2.3 per cent., were illegitimate, compared with 25, or 2.9 per cent., for the previous year. STILL-BIRTHS. Of the net total of notifications received under the Notification of Births Act, still-births formed 1.5 per cent., compared with 2.6 per cent. for 1923. The actual number of still-births notified for the year were 13, of which 8 were attended by midwives. Special visits of investigation were made in all still-births, and the following details elicited as far as accurately could be established:— (1) Duration of pregnancy:— (a) Less than seven months 4 (b) More than seven months 9 (2) Presentation:— (a) Vertex 8 (b) Breach 4 (c) Footling 1 61 (3) Supposed cause of still-birth:— (a) Abnormal presentation 1 (b) Overwork 3 (c) Accident, etc. 5 (d) Not known 4 (4) Occupation of mother:— (a) Household duties8 (b) Factory hand 1 (c) Shop assistant 1 (d) Office work 1 (e) Skin dresser 1 (f) Worker in fields 1 Of the mothers who had still-born babies, four had worked up to the time of confinement. Of the total number of mothers who had still-births, 2, or 15.3 per cent had attended the ante-natal clinic once or oftener. OPHTHALMIA NEONATORUM. Seven cases of ophthalmia neonatorum were notified, as compared with ten in 1923. Of these five occurred in the practices of midwives, the remaining cases being attended by medical practitioners. No case of the disease was admitted to the Infectious Hospital for treatment. No mother whose infant suffered from Ophthalmia neonatorum had attended the ante-natal clinic. Particulars of the cases, are afforded by the following table :— Age Group Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified. Treated. At Home. At Hospital under one year 7 7 - 7 - - - 62 ANTE-NATAL CLINIC. Compared with 192 and 208 respectively during 1923, the total attendances made by new cases were 325, while re-attendances numbered 434 during 1924. The average number of casei attending per session and re-attendances per patient amounted respectively to 14.8 and 2.3. It is mainly, if not entirely, through the ante-natal clinic that a further reduction of infantile mortality, especially the neonatal or that occurring during the first month of life, which is again closely connected with the question of maternal death, still-birth and abortion, is to be looked for, and where, unlike the infantile mortality as a whole, very little reduction has taken place in the country during the past 25 years. It is therefore expedient that every expectant mother, not under the care of a medical practitioner, should realise the importance of placing herself under adequate ante-natal supervision throughout pregnancy, a fact all important in first pregnancies, and little less so in any subsequent pregnancy which may occur. As already mentioned, an important lead in this connection has now been taken by the local staff of the Plaistow Maternity Charity in the co-operation established between their district midwives and the ante-natal clinic of the Council, a lead which it is hoped will be followed in the near future by the remaining midwives of the district. The post-natal care of cases attended by midwives or confined in the Maternity Ward cannot be undertaken as a routine measure at ordinary infant welfare meetings, and such work consequently comes to form an important item in the extended duties of the ante-natal clinic. It is impossible from the post-natal aspect to over-estimate the significance of child birth as a factor in the causation of gynaecological morbidity, in fact such conditions as arise unconnected with the puerperal state are comparatively few, emphasising accordingly the need for more attention being paid to the early diagnosis and rectification of post-natal defects while in the majority of cases they are in an early and more remediable condition soon after labour. 63 Ante-nalal attention was given throughout the year to venereal infedions complicating pregnancy, and treatment either offered where possible locally or necessary arrangements made for its being carried out at neighbouring hospitals. Syphilis is the great cause of still-birth and abortion, and at a later period of several Varieties of insanity and mental defect, while gonorrhæ causes Steriiity in both male and female, and is followed by many of the more serious gynæcological and obstetric complications. The average number of attendances at the ante-natal clinic during the months of October, November and December reached 19.2, and the necessity became obvious for the opening of one additional clinic per week, the question being under the consideration of the responsible committee at the end of the year. WORK OF THE HEALTH VISITORS. The duties of the health visitor fall broadly under two head ings—in the home and at the centre, the former ranking in importance over the latter. An attempt is made to visit as far as possible all notified births before the tenth day after finement, when under normal circumstances the attendances of the midwife cease, a liason being in this way established between the midwives and health visiters, which has been followed by satisfactory results. Regular subsequent visitation is carried out by Health visitors of all cases which cither do not attend a centre regularly or not at all, and herein lies the more important part of the health visitor's work, home visiting therefore occupying the,major part of her time and attention. Owing to the numbers attending the various centres it was found impossible for the staff to do much more than keep pace with the weighing of babies; health talk to mothers, sewing and Knitting demonstrations, etc., although forming an important part of the work, becoming impossible, and proving the inadequacy of present arrangements as regards sufficiency of staff and accommodation, as will be easily apparent from the following table:— Kennedy Hall. Clinic premises. Abbey Hall Total attendances:— 1 to 12 months 1,913 2,125 2,388 1 to 5 years 1,144 1,423 2,070 Average No. of attendances per session 63.0 70.9 90.9 No. of new cases 151 257 227 No. of old cases 2,90(5 3,291 4,231 Average No. of attendances per mother 20.2 13.8 19.0 The need of six sessions per week instead of three for infant welfare work will become apparent from the above figures, a suggestion, however, only practicable when the present staff of two health visitors is augmented to three. The lack of suitable accommodation for welfare meetings at both the Abbey and Kennedy Hall, and the desirability of improving upon the premises at present used for that purpose has already been reported upon to the Maternity and Child Welfare Committee. Although 400 births in an average or not-entirely industrial ised district has been adopted as the maximum of births which can adequately be supervised by one health visitor per annum. Barking with its 846 births last year cannot be regarded as other than exceptional in so far as in most entirely industrial and therefore requiring additional assistance to cope with its present needs, which are obviously more than two health visitors can satisfactorily cope with. 65 Particulars of the work of the health visitors and centres will be found in the following tables :— No. of ante-natal visits 10 No. of first visits to children under one year 872 No. of subsequent visits to children under one year :— (a) Attending a Centre 372 (b) Not Attending a Centre 2,303 No. of visits to children 1 to 5 years of age :— (a) Attending a Centre 119 (b) Not attending a Centre 751 No. of special visits in connection with Ophthalmia Neonatorum 7 Ditto Deaths of children up to 3 years of age 89 Ditto Still-births 9 Ditto Puerperal Sepsis 2 Ditto Foster Children 42 Other visits (not specified) 194 Average No. of home visits per working day equal to 27.4 It may be pointed out that the number of children seen is obviously greater than the number of visits might imply, e.g., there may be two or more children seen under five years of age in one home where the visit thereto is simply recorded as one. dental al treatment, including the provision oe dentures for expectant and nursing mothers and massage and remedial treatment for CHILDREN' UNDER FIVE YEARS OF AGE. Ihe following scheme for submission to the Maternity and C hiid Wellare Committee was prepared by the Medical Officer Health towards the close of the year, and the following recommendations made :— (I) That arrangements be made for taking advantage of the massage and remedial, etc., clinic, established by the Education Committee at the Special School for the treatment of physical defects in children under 5 years of age, and that the Education Committee be re-imbursed by the Public Health Committee on the percentage of such attendances to the total; 66 (2) That the present charges made for dental treatment be revised, and that the usual hospital charges in such cases be adopted, namely, Is. for one or more extractions, Is. each for fillings, and 2s. 6d. in the case of the administration of gas; (3) That one session per week be devoted to dental treatment and one to propaganda, the School dentist visiting one Infant Welfare Centre per week, giving talks to mothers, examining mothers and children offering themselves therefor, and offering treatment to those requiring it; (4) That the Public Health Committee pay the Education Committee in respect of«the services of their dentist, two-elevenths of his salary, plus cost of maintenance ; (5) That arrangements be made for the mechanical work in connection with the provision of dentures to be undertaken locally. PROVISION OF DRIED MILK AT THE CENTRES. Cost Price, (lbs.) Reduced Price, (lbs.) Free, (lbs.) Total, (lbs.) Glaxo (Full Cream) 5,865 60 635 6,560 Glaxo (Half Cream) 96 28 124 Ambrosia 2,900 50 252 3,202 Cow and Gate 6,424 35 536 6,995 Trufood 114 2 — 116 PROVISION OF FREE MILK TO MOTHERS AND CHILDREN. No. of pints supplied at reduced price. No. of pints supplied free. Total. Total cost of milk supplied. Council's liability in respect of fresh milk supplied. 612 18,132 18,744 f, 9. d. f s d. 260 6 8 256 1 8 67 PROVISION OF MEALS TO EXPECTANT AND NURSING MOTHERS. This provision is not valued, probably for sentimental reasons as much as it ought to be, only five mothers availing themselves of its advantages during the year, 68 dinners having been supplied. FOSTER CHILDREN. Cases of foster children received in the district are notified to the Medical Officer of Health by the Guardians under Part I. of the Children Act, 1908, thirty-two children being so notified during the year. Special visits in all such cases are made by the Health Visitors, and the foster mothers as far as possible are induced to attend a Welfare Centre with the children. As a general rule the care of foster children in the district appears to be -satisfactory. ILLEGITIMACY. Twenty illigitimate children were born during the year, giving an illegitimate birth rate of 0.52 per 1,000 population, illegitimacy thus forming 2.3 per cent, of the total birth rate compared with 2.9 for the previous year. While the infantile death rate among legitimate children was 83.53 per thousand births, that among illegitimate children was equal to 150.0. Ignorance, the age of the mother and other causes, probably account for such a disproportionate mortality amongst illegitimate compared with legitimate children, and the need has recently been emphasised in the Medical Press for legislation to deal with the whole question of illegitimacy and the closely connected one of foster parentage, and to include, inter alia, the state registration of foster parents, of institutions receiving illegitimate children with powers of refusal of registration in certain cases, their regular and systematic inspection, and the notification of all migrant children and deaths to the Local Sanitary Authority. 68 INFANTILE MORTALITY. While the birth rate for the district in 1924 was 22.3, the infantile, mortality rate was 85.1, compared with 23.1 and 49.? respectively in 1923. The number of deaths from diarrhoaji diseases under two years of age per thousand births was 17.7 forming 41.6 per cent, of the zymotic death rate, which was 0.9. The actual number of deaths from all causes under one year was 72, 23 being female and 49 male children. During the same period the infantile mortality rate for England and Wales was 75, for the 105 Great Towns 80, for the 157 smaller towns 71, while in London it was 69. Special visits were made to all deaths up to 3 years of age by health visitors. The importance of breast feeding and the regular use of dried milk, instruction in mothercraft, demonstrations in infant clothing, etc., at the Centres, have been emphasised in the part which they have played in the lessened infantile mortality rate which has occurred since the beginning of the present century by nearly 10<> per cent., although the great centres of industry still continue to maintain a higher than the average rate. MOUSING CONDITIONS. The Table on the following page is an analysis of the conditions under which births and death up to one year occurred during .he year, the infantile death rates for the various wards of the district, varying diiectly with overcrowding and housing conditions, being as follows: Abbey 153.8, Gascoigne 64.5, Longbridge 72.7, Rippic 38.4, Westbury 52.9, Central 90.9. 69 LIVING IN 1 room. 2 rooms. 3 rooms. 4 or more rooms. Births. Deaths. Births. Deaths. Births. Deaths. Births. Deaths.   184 19 170 15 80 6 406 32' DEATH RATE PER THOUSAND BIRTHS. 103.2 88.2 69.7 78.8 70 Particulars of feeding of certain children who came un< supervision during 1924 are as follows :— Breast Fed. Mixed. Artificis No. of children under supervision— feeding at the end of first month 510 43 41 Children who died during first year of life—feeding during first month 57 12 3 Children who died from diarrhoeal diseases—feeding at time of death 5 3 7 DEATHS AMONG NOTIFIED AND UN-NOTIFIED BIRTHJ 97.2 per cent, of the deaths under one year of age were not fied births, the remainder being un-notified. SEX. The death rate among male children was 113.02 per thousand births, and among females 04.76, the excessive male death rate ! during the year btring noteworthy. NEONATAL MORTALITY. The neonatal mortality rate is calculated on the number of deaths of children under four weeks per thousand births, and during 1924 was equal to a rate of 36.6 compared with 18.5 the previous year. From the following table it will be seen that out of a total of 31 deaths during the first four weeks of life, 19 occurred during the first seven days, and 13, or 68.4 per cent, of these resulted from prematurity or debility. The question of further neonatal care has been already emphasised as an important factor in further reducing the disproportionate incidence of infantile deaths during the neonatal period :— 71 DEATHS UNDER FOUR WEEKS. Under seven days. Under fourteen days. Under twenty-one days. Under twentyeight days .  Prematurity 7 2 2 1 . 12 Prematurity and Debility 6 1 — — 7 Asphyxia by Accident — — 1 — 1 Congenital Malformation — — 2 — 2 Convulsions 1 — — — 1 Abscesses and Broncho-Pneumonia — — — 1 1 Colitis — 1 — 1 Atelectasis 4 4 Cerebral Hemorrhage 1 — — — 1 Measles — — — 1 1 Totals 19 4 5 3 31 THE Annual Report OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1924. 72 ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER. (1) STAFF. During the year Dr. Simpson continued as School Medical Officer, while the remaining staff engaged in medical work amongst school children consisted as formerly of whole and part time officers. An important staff change more fully considered on Page 82 consisted in the replacement on retirement of Mr. G. M. Hick, L.D.S., part time dental surgeon since 22nd August, 1921, by Mr. W. W. F. Dawe, L.D.S., a school dentist to the Southampton Education Committee, as a full time denta! surgeon for the District. (2) CO-ORDINATION. Vide Annual Report of 1923. (3) SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. (a) Schoo' Hygiene.—The general hygienic conditions of the various Barking schools can be considered satisfactory. The question of school hygiene in the district was fully reviewed in my previous Report, and need not now be further dwelt upon. Periodic inspections of school buildings and premises are carried out by one of the sanitary stall, and defects requiring attention brought to the notice of the Director of Education. 73 In 1924 there were in Barking (a) seven Council schools, in eluding seventeen departments, and (b) two voluntary schools including five departments. The total provision in the district in 1924 for elementary school children thus amounted to nine schools with 22 departments, affording accommodation, exclusive of Faircross School, for 8,02C children, of which number 6,539 were on the register on December 31st, 1924, as compared with 6,647 on December 31st, 1923. (4) MEDICAL INSPECTION. (Reference should here be made to Table 1, appendix (a).) (a) This has been carried out in accordance with Article ot> (b) of the Code of Regulations. ROUTINE INSPECTIONS. Entrants. Intermediates Leavers. Specials. Other Routine Examinations. Total. No. of children examined 550 828 553 115 179 2,225 No. referred for treatment 135 190 121 88 78 612 No. referred for observation 55 67 15 8 17 162 Percentage of defective children 34.54 31.03 24.59 83.47 53.07 34.78 Routine medical inspections were conducted throughout the year on the various elementary school premises, while exceptional Children were seen from time to time at the school clinic. 74 The interest of parents and guardians was elicited by inviting them to these inspections, and by directing their attention to defects requiring supervision or treatment. During the year 53.47 per cent, of parents or guardians were present at inspections. During the year the number of visits paid by the Medical Officer to 22 departments of nine schools (including Faircross Special School) for the purpose of routine medical inspection was 109. The number of children examined during the year falling within the above age groups totalled 1,931 (979 boys and 952 girls). In addition, 115 children (60 boys and 55 girls) of varying ages were presented for special medical examination, while 899 re-examinatior.s (487 boys and 412 girls) were made at school to ascertain the results of treatment. The following table shows the number of children examined at routine inspections during 1924 classified according to the schools attended, the number of inspections held in each school and the number of parents or guardians present :— COUNCIL SCHOOLS. School. No. of inspections. Numbers inspected. No. of parents present. Boys. Girls. Gascoigne 21 238 246 262 North St 18 190 155 196 Castle 3 35 27 35 Crecksmouth 3 12 13 13 We9tbury 20 211 199 242 Ripple 16 188 164 208 VOLUNTARY SCHOOLS. Church of England 14 113 131 91 Roman Catholic 7 52 72 47 75 (b) The following are, as in previous years, the sources from which early ascertainments of crippling defects have been obtained :— (i.) As result of medical inspection, either " routine " or " special." (ii.) From information obtained by health visitors, school nurses, and school attendance officers, as result of their district work; (iii.) From the various Maternity and Infant Welfare Centres with which the School Medical Service works in close administrative control, and (iv.) From the Tuberculosis Dispensary and Barking Tuberculosis After-care Committee. (5) FINDINGS OF MEDICAL INSPECTIONS. The arrangement was commenced in January, 192-1, of keeping medical inspection cards at the various schools in preference to the central office, and the practice continued throughout the year. The medical records of individual children are now available at school, and the teacher has first-hand information of cases requiring his particular notice, an individual record of previous infectious disease—important in exclusion of doubtful contacts fiom an infected household—and furthermore a complete record of all children referred from routine inspections for treatment, whereby he may at times be able to exercise his influence with otherwise indifferent parents. In the case of local migrant children, the difficulty is avoided of finding respective medical inspection cards under the old system from the central office, in so far as the necessary interchange will take place between schools on the part of attendance officers. Inspection cards need only be brought to the central office for record purposes after inspection, so that particulars may be available for statistical purposes. Table 6, appendix (a), gives a return of defects found in the course of routine medical inspections during the year, some of the noteworthy defects so discovered being considered more particularly below. 76 Of all children inspected during the course of the year the percentage of those vaccinated was as low as 39.39 per cent., an important point in connection with the recent continued endemicity of smallpox in various parts of England. This question is more particularly referred to under the Section devoted to infectious disease in the report of the Medical Officer of Health. Of "entrants" inspected during the year 190 were found defective and referred for treatment or observation, equivalent to 34. 134 per cent. a somewhat excessive figure if one remembers that 80 to 90 per cent. of such children are born healthy. From a consideration of the percentage incidence of defects present, it will become apparent that the main responsible cause is probably an environmental one, followed, but probably to a minor extent, by improper or insufficient food. Defects in "entrants" referred for treatment or observation were found present in the following proportions in respect of particular schools attended :— 77 Chief Defects. Percentage to total defects. Percentage to total defects at each Individual School. Gascoigne. North Street. Westbury. Ripple. National. Catholic. Castle. Creeksmouth. Enlarged T. & As 40.90 30.84 51.21 54.28 47.82 48.57 29.41 50.00 100.00 Enlarged Cervical Glands 2.57 7.89 2.43 Nil Nil 2.85 Nil Nil Nil Lung9 (non T.B.) 5.67 2.63 2.43 5.71 13.04 5.71 11.70 Nil Nil Defective Vision 1.54 Nil 4.87 Nil Nil Nil 5.88 Nil Nil Malnutrition 3.09 2.03 2.43 5.71 Nil 2.85 5.88 Nil Nil Otitis Media 4.63 10.52 2.43 Nil Nil 5.71 11.76 Nil Nil Heart Disease 5.15 2.03 2.43 8.57 4.34 2.85 11.76 25.00 Nil Suspected T.B. 2.57 Nil 4.87 2.85 Nil 5.71 Nil 25.00 Nil Other Defects (not specified) 27.83 36.34 26.82 22.85 34.78 25.71 23.52 Nil Nil 78 The following table indicates the number of children re inspected during the year, and the number and percentage found to have obtained treatment. Routine. Specials. Total. No. of children re-inspected and found to have been treated. Boys. Girls. Boys. Girls. Boys. Girls. Total. Percentage 441 405 40 13 899 221 196 .417 46.38 The secret of successful treatment in the great majority of instances is efficient following up on the part of the school nurse, and, although parental obstinacy may account for a certain percentage of cases not dealt with, the fact that the task in its present proportions is beyond the capacity of two school nurses undoubtedly accounts for the poverty of the above results, a difficulty which it is hoped will be remedied in 1925, when a full time dental nurse will be appointed who will be able to relieve the present two school nurses of a considerable part of work in so far as the following up of cases referred for dental treatment is concerned. Where school nurses undertake all of the district work required of the school mcdical service the allocation of 2,000 children per nurse cannot be regarded as much of an underestimate, while during the past year in Barking the number of children per school nurse was 3.269. CLEANLINESS.—Surveys under this heading are carried out at (a) routine medical inspections, and (b) special inspections conducted by the school nurses. (a) At the former 376 children out of a total of 2,225, or 16.89 per cent., were found to have nits in their hair, while 7, or 0.31 per cent. were found infested with head vermin. No children were found with body vermin. In considering these figures it must be remembered that some effort is generally made by parents and others that children attending for medical inspection are presented in a clean condition, so that a comparison cannot fairly be made with results of surveys carried out by the 79 school nurses, where schools are visited and inspected without previous warning. It is matter for regret that the worst cases are frequently absented from routine inspections for this or other reason, so that the figures under this heading do not show the necessary corresponding reduction. (b) During the year the school nurses made 13,632 individual examinations as compared with 16,296 in 1923. Of this number, 1,911 children were found to have nits only in the hair, 290 harboured nits and vermin in the hair, whilst 36 showed the presence of verminous bodies and clothing. Every school in the area covered by each school nurse is fully inspected each term, the resuits of such examination being reported in tabular form as under:— School. Dept. Nits only. Nits and Vermin (head). and clothing verminous. Gascoigne Infants 146 48 1 Boy9 18 15 2 Gills 344 51 1 North St. Infants 95 8 2 Boys 27 3 4 Girls 199 9 2 Caatle Infants 41 12 4 Boys Girls Creeksmouth Infants 33 — — Boys Girls Westbury Infants 84 23 — Boys 16 2 — Girls 153 13 — Ripple Infants 72 6 2 Boys 30 3 1 Girls 136 9 — C. of E Infants 65 23 3 Boys 18 16 2 Girls 159 14 — R.C. Infants 39 5 3 Boys 180 23 9 Girls Faircross — 56 7 — 80 It is matter for gratification that a decrease in verminous conditions as noted in the district during the past year, has resulted from in the main:— (a) Regular systematic surveys of all schools and the exclusion of infested children. (b) The establishment during the year of an efficient cleansing and disinfesting station. (c) The progressive application of the cleansing scheme to every school. (d) Steady development of educational methods and the pressure of public opinion. (e) Legal proceedings as a last resort in dealing with recalcitrant parents or guardians. Two obstacles, however, still obstruct the path to more rapid coping with this difficulty—the housing problem and, excepting in the Spccial School, the lack of bathing facilities at school. Printed instructions are in all cases sent to parents or guardians of children excluded as result of verminous conditions. Where the person and clothing is verminous, cleansing and disinfecting is undertaken at the Cleansing Station, 38 cases during the year being so dealt with. Nits and head vermin require as a general rule to be dealt with by parents at home. SKIN DISEASES.—Three cases of scabies and nine cases of impetigo and nine cases of other skin disease were discovered at routine inspection and dealt with at the School Clinic. The necessity of a Cleansing and Disinfecting Station for the efficient treatment of scabies apart from verminous conditions cannot be overestimated. CLOTHING.—Children with dirty clothing numbered 47. or 2.11 per cent., compared with 155, or 5.06 per cent. in 1923. Children with defective footgear numbered 19, or 0.85 per cent The question of defective footgear was, as in previous years, met by the Boots Minor Sub-Committee, who received and considered applications for the provision of boots in necessitous cases. During the year 159 cases were so supplied. 81 WEIGHTS AND HEIGHTS.—The following table gives the average weights and heights of children examined at the three under mentioned age periods in four of the schools, compared with the results at similar age periods in 1923:— Period. Age Average Height in inches. Average Weight in pounds. 1923. 1924. 1923. 1924. 5 years 41.4 41.5 38.8 39.3 8 years 46.9 48.1 50.4 52.4 13 years 59.8 58.7 74.7 82.4 TONSILS AND ADENOIDS.—228 children, or 10.24 per cent. of those examined, were found suffering from enlarged tonsils or adenoids, or both, with such symptoms that it was found necessary to refer them for observation or treatment. Of eases referred for treatment 92, or 48.42 per cent, were found on reinspect ion to have been treated. An arrangement existed as formerly with Queen Mary's Hospital, Stratford, and St. Mary's Hospital, Plaistow, whereby such treatment can be carried out, parents contributing to the cost thereof according to means. A defect exists in the scheme whereby greater facilities might exist for the over-night detention of cases following operation, but in the present dearth of sufficient hospital accommodation throughout the Eastern part of the extra Metropolitan area, it must be felt that the final consideration of this question must stand pending the provision of a large general hospital of not less than some 500 to 800 beds, or alternatively the extension of existing hospital accommodation to much the same extent. The treatment of tonsils and adenoids is only one question of several, none of Which could be remedied with reasonable efficiency by, for example, providing a cottage hospital in Barl ing. An arrangement, however, exists with the hospitals above mentioned respecting tonsil and adenoid operations, whereby cases exhibiting untoward after effects can be detained over-night, or where existing home conditions are unsatisfactory, or some other factor contra indicates the advisability of the patient's returning home the same right. 82 EAR DISEASE.—Twenty-three children, or 1.03 per cent. were fouud to be deaf, while 40, or 2.0(i per cent. suffered from ear disease, the latter generally having discharging ears, and a certain amount of deafness in consequence. Otorrhoae, although essentially a chronic condition, usually exhibits signs of improvement on treatment, but little can usuaily be done to restore hearing to normal. It is well known that several chronic conditions, more especially those affecting the middle ear, frequently originate in and are maintained by septic conditions of the nose and throat uch as enlarged tonsils and adenoids, treatment of the atter being usually one of the most effective steps of dealing with the trouble. In all cases the dictum of " prevention being better than cure " should be practiced as far as possible. DENIAL DEFECTS.—As all children are annually inspected by the dental surgeon, a regular inspection of the teeth, except in special cases is not generally undertaken as part of routine medical inspection in every instance, although special cases brought to the notice of the Medical Officer are where necessary seen and referred to the dental surgeon for treatment. Consequent upon the retirement of Mr. Hick at the end of December, the whole question of dental inspection and treatment was reviewed by a special Committee of the Council, composed of members of the Education and Public Health Committees, who, with the approval of the Board of Education and Ministry of Health, proceeded to the appointment of a full time dentist, who would thus cope more effectively in future with the combined question of dental treatment in school children and expectant and nursing mothers, Mr. Dawe, as already mentioned, being appointed to the vacancy. During the year the school dentist paid visits to schools and inspected all the age groups in attendance. The extent to which dental disease is prevalent is shown by the fact that of a total of 4,483 children, 3,052, or 68.07 per cent. were found to require treatment, of which numbers, however, only 1,181, or 38.69 per cent. actually accepted treatment. Had the full number of children referred for treatment actually been treated, the school dentist could not have fully coped with the question in his allotted sessions, it being now generally recognised that a school popula- 83 tion of 6,000 and over requires the services of a full time dentist, Full details of the work can be seen in Table IV., Group iv., Page 105. AFFECTIONS OF THE HEART.—Eighteen children, or 08 percent., were found to be the subjects of organic disease of the heart. Of all cases of heart affections referred for treatment or observation from routine inspection, seven, or 39.44 per cent., on reiinspection, were found to have received treatment. AFFECTIONS OF THE LUNGS.— Forty-five children, or 2.02 per cent., suffered from pulmonary affections exclusive of tuberculosis, most of the cases suffering from some mild form of bronchial catarrh. Of cases referred for treatment in routine medical inspection 25, or 55.55 per cent., were found on reinspection to have been treated. TUBERCULOSIS.—The total number of cases of tuberculosis occurring in school children notified to the Medical Officer of Health during the year on Form B was two. This is explained by the fact that all suspected cases of the disease are referred to the Tuberculosis Officer for examination or observation befort notification, such officer being in a position to recommend admission to either hospital, sanatorium or to the local open-air school. During the vear 79 cases were referred to the Tuberculosis Officer, of whom 8 were subsequently notified as tuberculous. The total number of attendances made at the Dispensary by children of school age amounted to 415, while during the year 28 school children were recommended through the Essex County Council for hospital or sanatorium treatment. One case of pulmonary tuberculosis was detected among school children during the year, the remainder, apart from surgical tuberculosis, being affections of the bronchial and mediastinal glands. RINGWORM.—One child was found to be suffering from tinea capitis, whilst no children were found infected with the body fungus. The former case was referred for X-ray treatment, and treated. 84 EXTERNAL EYE DISEASE.—Eight cases of blepharitis were discovered and appropriately dealt with. Other forms of external eye disease amounted to six cases of conjunctivitis. VISION.—126 children, or 5.66 per cent. of those examined at routine inspection, were found to be suffering from vision so defective as to require treatment. Further particulars of these cases will be found in tabular form on page 104. It is becoming increasingly apparent that the prescribing of spectacles in most of these cases—many of whom are myopes—although an important detail, is secondary to that of preventing further increase in the degree of defect present, a point remediable by attention to the hygiene of the mouth and throat, and, as far as possible, by improvement in the general hygienic environment of the home. Higher degrees of myopia cannot with any degree of success be dealt with in the ordinary elementary school class, or by the provision of spectacles, a class or school, preferably of the residential type, where special modification of the curriculum can be instituted, being practically a necessity in all such cases. CRIPPLING DEFECTS AND ORTHOPÆDICS.—The existing need referred to in my last Annual Report for dealing with this question has now been remedied by the establishment of a Remedial Centre in conjunction with the cripple class at the Special School, such provision being required both for cripples attending this School and other defectives at ordinary schools either unable to meet the expense of regular hospital attendance in town, or who for some other reason have ceased regular attendance thereat. A complete Remedial Clinic has been formed in Barking consisting of an Orthopaedic Surgeon, Mr. B. Whitchurch-Howell, F.R.C.S., Weymouth Street, W.1., who attends the centre one session per month in order to examine cases and where suitable refer them for operative treatment to Brookfield Orthopaedic Hos pital, where he is a member of the honorary staff and has consequently a certain proportion of beds at his disposal, or for X-ray or other special examination, while cases requiring massage, 85 rodiont heat, electrical treatment, ctc., obtain such locally, a masseuse attending for the purpose three sessions per week. A Centre or Centres for breathing exercises in rickety and other subjects and those recent!) operated upon for post-nasal growths will be required, whilst to complete the scheme, exercises on a regular basis should be instituted at the various elementary schools for the correction of round shoulders and minor degrees of spina! Cunvatore under the instruction of a physical training teacher. As Sir George Newman points out in his report on the School Medicol Services for 1923, the correction of Orthopa;dic defects should begin not in many cases when the child enters school, but during the earliest years, or even months of life, a suggestion which it is hoped the Maternity and Child Welfare Committee will avail themselves of now that full facilities for the same exist in the district. There re is accommodation at the Physically Defective Class of the Special School for 14 children, .'38 cases being on the register during the year. 7 cases were examined and certified by the School Medical Officer as suitable for admission, whilst five cases attending the school were, after examination, found to have sufficiently improved to warrant their return to ordinary school. The following extract from a preliminary report submitted by the Orthopaedic Surgeon is appended :— "The following groups come within the scope of the work of the Orthopædic Surgeon, and can be conveniently dealt with at in Orthopædic Clinic established in connection with the School Medical Service of a district:— (1) Congenital and acquired deformities of the spine and extremities, i.e., wry-neck, club foot, rickets, etc. (2) Infantile paralysis. (3) Arthritis with all its varieties, joint tuberculosis, rheumatoid arthritis and osteo-arthritis. (4) Deformities of adult paralysis type, i.e., spastic hemiplegia. (5) Injuries to bones and joints. 86 It will thus now be seen that orthopaedic surgery is both preventive and curative; hence it will be readily understood that any scheme for the prevention and curing of cripples must b. very comprehensive, and should consist of:— (a) An orthopædic team. (b) An orthopaedic clinic. (c) An orthopaedic hospital. "Where it is possible to combine treatment and education, a Cripple School and Orthopædic Hospital School, i.e., Brookfield, should be attended. The value of early consultation with the orthopædic surgeon cannot be too strongly emphasised, e.g., a case of club foot should be treated from the moment of birth, similarly with a case of wry-neck. "An orthopaedic Clinic consists in brief of a consultation room, a treatment room, a gymnasium, and a plaster room added where necessary. "The orthopædic team consists of (1) orthopaedic surgeon, (2) masseuse, (3) school medical officer, (4) local medical practitioners. (5) infant welfare centre workers, (6) school nurses, (7) voluntary association, i.e., Invalid Children's Aid Association, etc. All personnel should be under the direct training and supervision of the orthopaedic surgeon, and this applies in particular to the masseuse. Co-operation of local medical practitioners should be sought and difficult cases brought by them for consultation. (Signed) B. Whitchurch-Howell, F.R.C.S." DEFECTIVE AND SUB-NORMAL CHILDREN.—Local Education Authorities are responsible under the Education Acts for all educable defectives between the ages of seven and sixteen years, the School Medical Officer under the M.D. (Notification of Children) Regulations being the certifying officer. Educable defectives are feeble minded children, whose mental deficiency does not amount to imbecility, yet is so pronounced that they are incapable of receiving proper benefit in an ordinary elementary school, although not incapable by reason of such defect of being instructed in a special class or school. Ineducable defectives, on 87 the. other hand, are those, who are incapable of further improvement in a special class, or those who cannot be so dealt with Without detriment to others, including besides idiots, imbeciles, and moral imbeciles, defectives over and under school age, all of whom, under the provisions of the Mental Deficiency Act, 1913, come within the jurisdiction of the Mental Deficiency or Local control Committee of the Essex County Council. In assessing the degree of defect present and the suitability or otherwise of any case for special school, besides the consideration of various psychological factors, the pedagogic or educational attainments of the child are considered in respect of his age in years, the resultant of which forms the mental age, intelligence quotient or educable value of the individual. Although objection may be taken to the use of the word " ineducable," as applied to lower grade types of deficiency, it is equally true that no child, even an idiot, is untrainable if suitable methods are used. On the other hand, the word does imply a condemnation of one method of dealing with the problem of the ineducable, i.e., by retaining them in special schools for the higher grade feeble-minded. Although such schools are by statute reserved for children who are not imbeciles and not incapable of receiving benefit, the benefit intended is not merely a training in body and discipline which would apply to all grades of defectives, but substantial progress in the subjects of the curriculum. At the same time, the oft-expressed dictum, "once a defective, always a defective," must be remembered, and even grade cases, although not incapable of improvement, are unlikely to prove successes in after life from any educational proficiency which may have been attained at school. The introduction of manual instruction, such as boot-mending, basket and wicker work, mat making, etc., as an important part of the educational training in all such schools is thus to be commended as an essential item in the fitting out of the defective for his appropriate place in the sphere of after-life. Apart from the slow rate of progress made by lower grade defectives if admitted to special schools, the practice has other positive disadvan- 88 tages as pointed out by Dr. Fairfield, Divisional Medical Officer. London County Council, as follows:— "It destroys the reputation of the school with parents, and enhances the stigma ; it prejudices the whole case for the education of defectives with the Local Education Authority, and, moreover, seriously interferes with the teaching of the higher grade feeble-minded whose education has a wholly different purpose. The true feeble-minded child must have a chance to float if not to swim in the world, and will want to know all that his teacher can impart of roughly the three R's, the handling of money and skilled handicraft." The institution by the Essex Voluntary Association of an Occupation Centre in this district during the past year thus seems to go far in solving the question of what to do with the ineducable child. DULL AND BACKWARD CHILDREN.—While the mentally-deficient child is defective not only pedagogically but psychologically, the defect of the truly dull and backward child is pedagogic merely. Of a total of 48 children between the ages of seven and nine years, notified by head teachers as suspected dull and backward, 18 on examination were found to be mentally defective, and certified as such under the Education Act, 15 were mentally delayed on account of prolonged absence from school or as a result of neglected physical defects, such as enlarged tonsils and adenoids, defective vision, hearing, etc., while the remainder were found to be merely dull and backward. To meet the need of the last group, a special class for dull and backward children was opened in October at the Special School. While some schools of opinion would regard all children not socially certifiable as mentally defectives but merely backward, and would assert that it should be possible to give them the benefit of a special school education without certification, and that what we now have to do is to commence at the other end and establish a properlyorganised scries of backward classes and only certify cases as defectives after prolonged observation, it is well to remember that other authorities on this question have taken quite the 89 opposite view. In the opinion of the latter, the establishment of anything like backward classes is deprecated as serving no useful purpose, on the assumption that children of inferior mental capacity will probably be unable to acquire any very much better grasp of the very simplest subjects of education without in the main its being lost in the years immediately following their leaving school. The recommendation in the latter case is that such children irrespective of age should be retained in the ordinary elementary school class which accords with their mental attainments and until these attainments are such as would allow them to "pass up," the object of the special backward class being thereby obtained. Personally, 1 feel that there is something to be said for the latter view, although it resolves itself into having smaller classes and special teachers, an object not at all times practicable nor possible in every school. MINOR AILMENTS.—As formerly, minor ailments were mainly discovered through the vigilance of teachers and school nurses, and when recognised referred to the school clinic for treatment. The following table gives in detail the numbers of cases dealt with:— Minor Ailment. New Cases. Old Cases (re-attendances) . Ringworm—Scalp 10 19 Body 17 68 Scabies 36 71 Impetigo 329 2,084 Other skin diseases 127 643 Minor Eye Defects 140 816 Minor Ear Defects 194 1,559 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 780 2,528 90 FOLLOWING UP. Vide Annual Report for 1923. INFECTIOUS DISEASE. The procedure carried out in regard to infectious disease, notifiable or otherwise, was considered in detail in my Annual Report for last year. Teachers contributed their assistance from time to time by excluding suspicious cases and contacts, and notifying the School Medical Officer of such exclusions. As in previous years, most reliance was placed on intelligence received from school attendance officers, more particularly when dealing with non-notifiable infections. During the months of January and February, a severe outbreak of measles occurred, necessitating the closure of all schools for three weeks. During the last quarter of the year mumps gave rise to a troublesome outbreak, 195 cases and 127 contacts being notified and excluded from school. By virtue of the Board of Education Amending Regulations, No. 2(a), 1924, now in force, "when the average attendance of a school or department for any week has fallen below 60 per cent. of the number of children on the registers, and the Local Education Authority are satisfied by a certificate from the School Medical Officer that the fall in attendance to so low a percentage may reasonably be attributed to the prevalence of epidemic illness in the district, the meetings and attendances for that week need not be reckoned in calculating the average attendance for the purpose of the Board's grant." Such action as suggested may thus be undertaken as opportunity offers instead of the hitherto more general practice of school closure, a practice, it may be said, which tended to deprive the Medical Officer of Health of much essential fact regarding the ebb and flow of non-notifiable infections amongst school children, besides being obviously of considerably less utility in urbanised than rural areas, while, for example, in the case of diphtheria, these recent. Regulations would appear distinctly superior to that of school closure in coping with the average type of outbreak. 91 (a) Scarlet Fever.—31 cases were reported in 1924, compared with 10 in 1923. (b) Diphtheria.—23 cases were reported in 1924, compared with 16 in 1923. (c) Measles and German Measles.—192 cases were notified from the schools in 1924. (d) Chickenpox and Whooping Cough.—41 cases of chickenpox and 7 cases of Whooping Cough were reported from the schools during the year. 340 home visits were paid by the school nurses in connection with non-notifiable disease during the year, whilst 108 visits were made by one of the sanitary inspectors in connection with notifiable cases. OPEN-AIR EDUCATION. Playground Classes.—All schools have playground classes during the summer months when weather is suitable. School Journeys.—No school journeys were undertaken during the year under review, the last one being to the Isle of Wight by the Westbury Girls' School in 1922. Holiday Camps.—Four were spent at the holiday camp at Hainault organised by the Barking Town Education Committee for necessitous children. 48 boys and 48 girls were housed in four teams each fortnight, and many interesting events took place during the period. The method of selecting children for holiday camp is in process of revision, so that I hope in future less robust and frequently less cleanly cases will be enabled to take advantage of these holiday facilities in preference to their more fortunate neighbours, where in many instances change of scene and environment would appear of less urgent character from a medical standpoint. 92 Open-air School.—Barking is fortunate as being at present one of the few local Education Authorities who possess an openair school, providing accommodation for 120 children. During the year 114 children were on the register, whilst 56 children were admitted and 31 children found on examination to have sufficiently improved to permit of their return to ordinary school. This school, which is under the same roof as the accommodation for physically and mentally defectives, is supplied from routine medical inspection, the Inspection Clinic and the Tiberculosis Dispensary, and so comes to enact the part of a preventorium for suitable cases of the school population which, generally speaking, are made up of suspected or quiescent cases of tuberculosis, malnutritional, debilitated, anaemic and rickety subjects, etc. The general routine of the school consists of, apart from life under open-air conditions to the fullest extent, an early lunch, dinner at noon, and in certain cases chemical food and cod-liver oil, the latter containing an anti-rachitic and growth-promoting vitamine, Fat Soluble A, which is of great benefit to children suffering from rickets and other allied conditions. Children are encouraged to sleep after dinner, and, when weather permits, to do so in the open air There is a nurse-attendant attached to the school, who attends to minor injuries, besides caring for younger children in their passage to and from school by ambulance. Weekly spray baths are provided, whilst clogs and jerseys are available in the colder months, no serious attempt being made to maintain any particular temperature in the class rooms. A defect exists in the present construction of the school, which might later be remedied, namely, the provision of a glass verandah roof, and the conversion of the present windows into those of the casement, or French type, whereby the class rooms could become at all times open-air rooms in the fullest sense of the word. PHYSICAL TRAINING. The general scheme outlined in the report by the Organiser of Physical Training dealing with minor postural defects, etc., published in my Annual Report for last year, has remained to some extent in abeyance pending the completion of the scheme bv the establishment of a Remedial Centre for more advanced 93 oases at the Special School. Now that the latter has been established, it is hoped that the full scheme will be taken advantage of during the ensuing year. PROVISION OF MEALS. Under the provisions of the Meals Acts, 1906-1914, the feeding of necessitous children has been continued at the Municipal Restaurant. Dinners and breakfasts were provided at the cost of 5d. and 2½d. per head respectively, and during the year 27,331 dinners and 2,093 breakfasts were supplied to 598 children. As in previous years, a selection of suitable children was made by the medical officers, school teachers, school nurses, attendance officers, etc., such recommendations being considered and in suitable cases approved of by the Meals Minor Sub-Committee. SCHOOL BATHS. An arrangement exists whereby the swimming baths are available for children attending the elementary schools on certain week-days, when swimming instruction is given. As already mentioned, with the exception of the Special School, where spray baths have been instituted, no bathing facilities exist at any of the other schools. CO-OPERATION OF PARENTS. As in previous years, the attendance of parents at the routine medical inspections was invited, and 53.47 per cent. responded, as compared with 55.2 per cent. in 1923. CO-OPERATION OF TEACHERS. Much of tne success of school medical inspection is due to the sympathetic assistance shown by teachers. In all schools considerable personal interest is shown, and valuable information made available regarding the children. Through the tactful influence of teachers, difficult parents are often induced to obtain or accept treatment for defective children. It is hoped that this practice will be further facilitated by the recent arrangement of keeping medical inspection cards at schools. 94 CO-OPERATION' OF VOLUNTARY BODIES. Valuable information in regard to crippled and other defective children has been supplied from time to time by the school nurses, health visitors and Tuberculosis Dispensary, while close contact has been maintained with the local branch of the National Society for the Prevention of Cruelty to Children. The following is a brief resume of the work done by the Society in Barking during the past year:— Total number of cases investigated 12 (a) neglect 10 (b) ill-treatment 2 BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Table 3, Appendix (a), gives an account of defective chiidren under the age of sixteen. All such children are specially examined as to their suitability for special schools, and recommendations made in appropriate cases. Blind and deaf children, after certification by the School Medical Officer, are admitted to special schools, day or residential, according to recommendation. NURSERY SCHOOLS. No nursery schools have yet been established in this district, although in certain selected cases children of 4 to 5 years have been admitted to the Infants' Departments of certain elementary schools. The institution of Nursery Schools has never been regarded by many Local Education Authorities with favour mainly from the tendency thereby created to relieve parental responsibility, and from a social standpoint the encouragement of female labour. It cannot be too strongly emphasised that the ordinary elementary school is in no way suitable for the child of pre-school age, while the provision of suitable nursery school accommodation for the limited number who might appropriately be admitted, would far outweigh financially any benefit which might accrue from the practice. 95 CONTINUATION SCHOOLS. There are no continuation schools in the district. SECONDARY SCHOOLS. There is one secondary school in this district, which is under the administrative control of the Essex County Council. An arrangement exists as in previous years whereby routine medical inspections are undertaken by the school medical officer of the district, particulars of which are to be found in the subjoined tables:— Entrants. Intermediates. (12 years old.) Leavers. (15 years old.) Boys. Girls. Boys. Girls. Boys. Girls. No. examined 32 20 18 17 8 7 Referred for Treatment 12 9 6 6 – 5 Referred for observation – 2 – 3 – – Re-Inspections. Number re-inspected. Number found to have been treated. Boys 14 6 Girls 17 9 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Milk and newspaper deliveries, general errands, hawking and newspaper selling, are the usual forms of employment of children of school age. Bye-laws governing the employment of children and young persons and providing for the medical examination of would-be applicants came into force during the year, 8 such eases being submitted for medical examination. In no case was it necessary to refuse any applicant on medical grounds. 96 SPECIAL ENQUIRIES. At the request of Sir George Newman, Medical Branch. Board of Education, records have been kept with a view to contributing to the obtaining of accurate information as to the incidence of goitre throughout the country. The need for this information arose out of a special investigation of conditions associated with enlargement of the thyroid glaad, and it was suggested that a record of the result of the examination for this purpose of all children on uniform lines on the occasion of routine examination at the age of twelve years would be valuable. The result of the record kept since the request was made, namely, the 13th March, 1921, to the end of the vear, is as follows:— No. of children examined for the purpose. 423 No. of children in whom the thyroid was sufficiently enlarged for the increase in the size of the neck to be noticed on casual inspection (without measurement or palpation). 12 MISCELLANEOUS. Four young persons who desired to become bursars and student teachers were medically examined during the year, out of which number one was rejected on medical grounds. Home and Mothercraft.—This subject continued to be taught under the heading of Domestic Science. 97 TABLE 1.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections: Entrants 550 Intermediates 828 Leavers 553 Total 1,931 Number of other Routine Inspections 179 B.—Other Inspections. Number of Special Inspections 115 Number of Re-inspections 899 Total 1,014 98 TABLE II.—A RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED, 31st DECEMBER. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition 5 9 1 1 Uncleanliness – – – – Skin Ringworm—Scalp 1 – – – Body – – – Scabies 3 – — – Impetigo 7 – 2 – Other Diseases (NonTuberculous) 7 – 2 – Eye < Blepheritis 8 – – – Conjunctivitis 4 – 2 – Keratitis – – – – Corneal Opacities – – – – Defective Vision (excluding Squint) 94 4 28 – Squint 13 1 1 – Other Conditions – – – – Ear 'Defective Hearing 10 2 11 – Otitis Media 37 – 7 – Other Ear Disease – – 2 – Nose and Throat Enlarged Tonsils only 101 33 8 – Adenoids only 17 4 2 – Enlarged Tonsils and Adenoids 53 1 9 – Other Conditions 21 3 5 – Enlarged Cervical Glands (Non- T.B.) 3 6 1 – Defective Speech – – I – Teeth—Dental Diseases(see note a) – – – – (Set Table IV., Group IV.) Heart and Circulation. Heart Disease: – Organic – 18 – – Functional – – – – Anæmia 36 7 4 1 Lungs Bronchitis 3 0 10 3 – Other Non-Tuberculous Diseases – 1 1 – 99 TABLE III.—Continued. Defect or Disease. Routine Inspections. Special Inspections . No. of Defects. No. of Defects. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment Requiring Treatment. Requiring to be kept under observation, but not requiring Treatmert. (1) (2) (3) (4) (5) Tuberculosis Pulmonary: Definite 1 – – – Suspected 4 11 – – Non-Pulmonary: Glands 4 14 – 1 Spine – – – – Hip 1 – – – Other Bones and Joints – 1 – – Skin – – – – Other Forms – – – – Nervous System mites Epilepsy 3 1 2 – Chorea 1 – – – Other Conditions 1 – 1 1 Rickets 1 – – – Spinal 21 8 3 – Other Forms 19 7 2 – Other Defects and Diseases 25 6 3 1 100 B.—Number of Individual Children FOUND AT Routine MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DISEASES). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment (1) (2) (3) (4) CODE GROUPS: Entrants 550 135 24.54 Intermediates 828 190 22.94 Leavers 553 121 21.88 Total (Code Groups) 1,931 446 23.09 Other Routine Inspections 179 78 43.57 101 TABLE—RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys. Girls. Total. Blind including partially blind.) (I.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 1 1 2 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — (11.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind — 1 1 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Deaf (including deaf and partially deaf. (I.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 2 4 6 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — (If.) Suitable for training in a School or Class for partially deaf. Attending Certified Schools or Classes for the Deaf — 2 2 Attending Public Elementary Schools — — — At ether Institutions — — — At no School or Institution — — — Mentally Defective Feeble Minded (cases not notifiable to the Local Control Authority. Attending Certified Schools for Mentally Defective Children 14 21 35 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Notified to the Local Control Authority during the year. Feebleminded — — — Imbeciles 4 — 4 Idiots 2 1 3 Epilepsy. Suffering from severe Epilepsy. Attending Certified Special Schoools for Epileptics — — — In Institutions other than Certified Special Schools — — — Attending Public Elementary Schools — — — At no School or Institution 1 — 1 Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 2 4 6 At no School or Institution — — — 102 TABLE III.—continued. Boys. Girls. Total. Infectious pulmonary and glandular Tuberculosis. At Sanatoria or Sanatorium School approved by the Ministry of Health or the Board 1 1 2 At other Institutions — — — At no School or Institution — — — Noninfectious, but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Physically Defective. Delicate children [e.g., preor latent tuberculosis, malnutrition debility, anaemia, etc.) At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools 59 55 114 \t Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 3 1 4 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Crippled Children (other than those with active tuberculous disease). e.g., children suffering from paralysis, etc and includin| those with severe heart disease. At Certified Hospital Schools — — — At Certified Residential Cripple Schools — — — At Certified Day Cripple Schools 21 17 38 At Public Elementary Schools At other Institutions 7 2 9 At no School or Institutio 3 1 4 103 TABLE IV.—TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Disease and Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin:— Ringworm—Scalp 10 — 10 Body 17 — 17 Scabies 36 — 36 Impetigo 329 — 329 Other Skin Diseases 127 — 127 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 140 — 140 Minor Ear Defects 194 — 194 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 780 — 780 Total 1,633 — 1,633 104 Group II.—Defective Vision and Squint (excluding Minor Eve Defects Treated as Minor Ailments—Group I.—. Defect or Disease. (i) Number of defects dealt with. Under Authority's Scheme. (2) Submitted to refraction byprivate practitioner or at hospital apart from the Authority's Scheme. (3) Otherwise (4) Total. (5) Errors of Refraction (including Squint) 143 12 — 1.35 Other Defects or Diseases of the eyes (excluding those recorded in Group I.) 1 — — 1 Total 144 12 — 156 Total number of children for whom spectacles were prescribed:— (a) Under the Authority's Scheme 123 (b) Otherwise 9 Total number of children who obtained or received spectacles:— (a) Under the Authority's Scheme 123 (b) Otherwise 9 Group III.—Treatment of Defects of Nose and Throat. NUMBER' OF DEFECTS. Received Operative Treatment. Under the Authority's Schema in. Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. Received other forms of treatment. Total number treated. (1) (2) (3) (4) (5) 146 — 146 114 260 105 Group IV.—Dental Defects. (1) Number of children who were:— (a) Inspected by the Dentist: Routine Age Groups. Aged 3 — 4 15 5 431 6 451 7 512 8 393 9 529 10 536 11 433 12 579 13 517 14 83 15 4 Total 4,483 (b) Found to require treatment 3,052 (c) Actually treated 1,181 (d) Re-treated during the year as the result of periodical examination — (2) Half-days devoted to Inspection 38 Treatment 188 Total 226 (3) Attendances made by children for treatment 1,796 (1) Fillings—Permanent Teeth 343 Temporary Teeth 669 Total 1,012 (5) Extractions—Permanent Teeth Temporary Teeth 352 1,488 Total 1,840 (•>) Administrations of general anaesthetics for extractions 1,012 (7) Other operations—Permanent Teeth — Temporary Teeth 26 Total 26 106 Group V.—Uncleanliness and verminous conditions. (i) Average number of visits per school made during the year by the School Nurses 3 (ii) Total number of examinations of children in the schools by School Nurses 13,632 (iii) Number of individual children found unclean 2.237 (iv) Number of children cleansed under arrangements made by the Local Education Authority 38 (v) Number of cases in which legal proceedings were taken : (a) Under the Education Act. 1921 — (b) Under School Attendance Byelaws 1