BAR 19 Barking Town Urban District Council. REPORT OF THE Medical Officer of Health AND School Medical Officer For the Year 1925. K. SIMPSON, M.D., Ch.B., M.R.C.P., D.P.H. 75149 2 , TABLE OF CONTENTS SECTION 1—GENERAL. Page Staff 5 Physical Features and General Character of Area 9 Social Conditions 10 Poor-Law Relief 12 Statistical Summary 13 Comparative Statistical Table 14 Table of Vital Statistics from 1920 to 1925 15 Summary of Nursing Arrangements 16 Clinic and Treatment Centres 17 Ambulance Facilities 18 Laboratory Work 18 Local Bye-Laws, Regulations and Adoptive Acts 19 Deaths 20 inquests 22 Causes of Death (Table) 23 Causes of Death at Various Ages under 1 year 24 Marriages 25 Births 25 SECTION 2—SANITARY CIRCUMSTANCES OF THE DISTRICT. Water Supply 26 Rivers and Streams 26 Rainfall 26 Sewerage 26 Closet Accommodation 27 Scavenging 27 Housing Statistics 29 Sanitary Inspection of the Area 31 Summary of Sanitary Work carried out 32 Notices Served 34 Smoke Abatement 35 Offensive Trades 35 Common Lodging Houses 36 Tents, Vans, Sheds, etc. 37 Houses Let in Lodgings 37 Food and Food Places:— (a) Dailies, Cowsheds and Milkshops 37 (b) Milk (Special Designations) Order, 1923 38 (c) Bakehouses 38 (d) Food Premises 38 3 SFCTION 2—Continued. Page (e) Public Health (Meat) Regulations, 1924 39 (f) Markets 40 (g) Fried Fish Shops 40 (h) Ice Cream 40 (i) Unsound Food 41 Sale of Food and Drugs Act. 41 Halt and Mice (Destruction) Act, 1919 41 General Housing Conditions in the Area 42 Unhealthy Area 44 Factories, Workshops, Workplaces, etc. 44 SECTION 3—NOTIFIABLE INFECTIOUS DISEASES. Table of Cast:- of Infectious Diseases notified and removed to Hospital 48 Attack Rates for past Five Years 49 Cases Classified According to Age Groups and Wards 51 Monthly Summary of Receipt of Notifications 52 Scarlet Fever 53 Smallpox and Vaccination 53 Diphtheria 53 Puerperal Fever 54 Acute Primary and Acute Influenzal Pneumonia 54 Non-notifiable Diseases 55 Table of Admissions and Discharges from Hospital 55 Hospital Problems 56 Tuberculosis 57 Tuberculosis After-care 64 SECTION 4—MATERNITY AND CHILD WELFARE. Notification of Births Acts, 1907-1915 66 Maternity Ward 67 Puerperal Sepsis 69 Maternal Deaths 69 Births 70 Still-births 70 Ophthalmia Neonatorum 72 Ante-natal Centres 72 Work of Health Visitors 73 Table of Attendances at Infant Welfare Centres 74 Neonatal Mortality 77 Denial Treatment 79 Provision of Meals 79 Foster Children 79 Convalescent Treatment 80 Illegitimacy 81 Infantile Mortality 81 Provision Fresh and Dried Milk 83 4 SECTION 5—SCHOOL MEDICAL SERVICE. PAGE* Co-ordination 1 School Hygiene 2 Medical Inspection 3 Findings of Medical Inspections 5 Table of Results of Cleanliness Inspections 7 Heights and Weights 8 Infectious Disease 10 Following-up 10 Medical and Surgical Treatment 11 Payments for Clinic Treatment 13 Table of Attendances at Clinics 14 Tabic of Work done in connection with Orthopaedic Clinic IB Open-air Education 17 Provision of Meals 18 School Baths 19 Co-operation of Parents, Teachers, etc. 19 Blind, Deaf, Defective and Epileptic Children 20 Medical Inspection at Abbey School 23 Employment of Children and Young Persons 23 Report of Orthopædic Surgeon 25 Report of Dental Surgeon 27 Statistical Tables:— Table I. Return of Medical Inspections 29 Table II. (A) Return of Defects Found 30 Table II. (B) Number of Children found to require Treatment 32 Table III. Return of all Exceptional Children 33 Table IV. Group I. Treatment of Minor Ailments 3.5 Table IV. Group II. Treatment of Eye Defects 36 Table IV. Gioup III. Treatment of Defects of Nose and Throat 36 Table IV. Group IV. Dental Defects and Treatment 37 Table I\. Group V. Uncleanliness and Verminous Conditions 38 School Medical Officer's Report Section. 6 ANNUAL REPORT OF THE Medical Officer of Health and School Medical Officer *or the Urban District of Barking Town, in the County of Essex, for the Year ended 31st December, 1925. Public Health Offices, Barking', Essex. To the Chairman and Members of the Urban District Council of Barking Town. Mr. Chairman and Gentlemen, I beg to submit my Annual Report op the Public Health and School Medical Services of the District, for the year ended 31st December, 1925. In accordance with the requirements of the Ministry of Health, the Report is a survey, covering the period of the last five years, and being my third Annual Report. Following the death of the late Dr. Ewart, who had been M.O.H. since November 1912, I was appointed to the vacancy in July, 1923. According to the Registrar-General, the estimated population in June, 1925, was 38,450, giving an increase of 560 over 37,890 in 1924, while the excess of births over deaths was 439, contrasted with the average quinquennial figure, which was 488. The birth rate for 1925 was 21.4, a steady annual fall having taken place from 1921 onwards, as follows:—26.0. 24.0. 23.1, 22.3, 21.4. The principal causes of the present birth rate decline are referred to on page 67. 5 STAFF, 1925 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. Asst. Medical Officer of Health and Asst. School Medical Officer: *MURIEL J. . OUGH, M.B., M.S., B.Sc., M.R.C.S., L.R.C.P., D.P.H. Orthopadic Surgeon (Part Time): *B. WHITCHURCH HOWELL, M.B., B.S., F.R.C.S. School Dentist: W. W. F. DAWE, L.D.S., R.C.S. (Eng.). Sanitary Inspectors: *N. BASTABLE (Chief Sanitary Inspector) (b, c and f). *H. WOOD (Sanitary Inspector) (b and c). *H. CARR (Sanitary Inspector (b, c and e). MISS E. PODMORE (Assistant Sanitary Inspector (b and g). School Nurses: *MISS L. F. SWAIN (h and i). *M1SS F. YOUNG (Dental Nurse) (i and j). *MISS S. E. \V. GIBSON. Health Visitors: *MRS. G. STOKES (i). *MISS A. C. KFENAN (g, h and i). *MISS H. M. LYAL (g and i). Matron, Isolation Hospital: MISS M. J. HEDGCOCK (h, i and j). Masseuse, Orthopedic Clinic (Part Time): *MISS A. E. FIXDLAY, C.S.M.M.G. (k). Chief Clerk oi Department: E. W. WINCHESTER (a, c and d). Disiufector and Mortuary Keeper: . H. LONG. (a) Sanitan 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) Sanitary Science C'eitificatc of Royal Sanitary Institute. (g) Health Yisitor's certificate of Royal Sanitary Institute. (h) Certificate of Central Midlives' Board. (i) General Hospital Training. (j) General Fever Training. (k) Certificate M..E. and S..R..E. *Proportion of salary contributed under Public Health Acts or by Exchequer grants. 7 The general death rate for 1925 was 10.0, the annual fluctuations during the past five years, from 1921 onwards, being as follow:—10.8, 9.0, 8.5, 10.0, 10.0. The average rate for the period was 9.8. Important from the Public Health point of view are the Infantile and Tuberculosis death rates, the former for 1925 being per thousand births, whilst the latter was 1.09. Some of the probable reasons for the disproportionately high infantile mortality of the district are discussed on pages 81.84. The tuberculosis death rate still remains high, the average rale for the past five years being 1.1., defective housing, it is now well known, playing the major part in the incidence of this disease. It may be observed, therefore, that though the general death rate for the district is not unduly high, those rates which depend more particularly upon hygienic conditions, such as infantile mortality and deaths from tuberculosis, are considerably above the average. The Chief Sanitary Inspector reports that between six and seven hundred houses in the district are unfit, nearly all of which are still inhabited. Of the above number of dwellings, 51, comprising the "Island" Site, have been the subject of a recent Ivepresentation under the Housing Act. During the Quinquennium 352 houses have been built by private enterprise, while the Authority has added 456 for letting purposes. A scheme for the efficient sewerage of the district now occupies attention, being one of considerable urgency even as regards the present population of the district. The question of refuse disposal, considered more particularly on pages 27-29, still awaits investigation on lines more favoured by present-day sanitarians. The question of hospital accommodation for infectious diseases can hardly be considered satisfactory; fortunately, during 8 the past three years, the district has had to contend with only a small incidence of infection. Some of the main points in connection with the present hospital problem are considered on pages 56-57. It is gratifying to record the satisfactory progress which has been made with respect to the School Medical Service during the past five years. The year 1922 saw the institution of an open-air school, including separate mentally and physically defective departments, among the first in the country. Towards the latter end of 1923 a cleansing and disinfesting station was opened at East Street, for which, and other reasons, the incidence of uncleanliness amongst schooi children has now fallen by nearly 100 per cent. The School Medical Service has been benefited by the acquisition of a full-time dental surgeon. The institution of an orthopædic clinic (including the installation of ultra-violet light), for the treatment of various crippling conditions, has been a boon to the district as a whole. The principal difficulty of the School Medical Service at present, is the lack of more satisfactory premises for the dental, eye, and general-medical examination and treatment of the school population, a question further referred to on pages 14 and 15 of the section of this Report devoted to the School Medical Service. My thanks are more particularly due to Mr. Bastable, Chief Sanitary Inspector, who, since his appointment last year, has been of great assistance in connection with the sanitary work of the Public Health Department; and to Mr. Winchester, my Chief Clerk, who has been responsible for the statistics and certain other of the information required for this Report. I am, Mr. Chairman and Gentlemen, Your obedient servant, KERR SIMPSON, Medical Officer of Health. School Medical Officer. 9 SECTION 1 PHYSICAL FEATURES AND GENERAL CHARACTER OF THE AREA. The Urban District of Barking extends over the area of the parish of that name, and lias an acreage of 4,106, 300 acres being watercourses. It is bounded on the North by liford, on the South by North Woolwich and the River Thames, on the East by Dagenham, and on the West by East Ham, and includes well defined district's spoken of as Rippleside, Faircross, Creeksmouth, and a portion of the L.C.C. Becontree Estate. 450 acres are developed residentially and 320 acres industrially, the number of houses and persons to the acre being 1.8 and 9.3 respectively. Particulars of the parks, pleasure grounds, etc., are afforded by the following table:— Designation of Open Space. Acreage. Longbridge Park 75½* Abbey Playing Field 2¼ Abbey Site 1½ Greatfields Park 14 Victoria Gardens ¾ Vicarage Field 4½ Essex Garden 1/5 Cemetery 16 *66½ acres is situated in the Urban District of liford. 10 The main lines of the Midland Railway to Southend-on-Sea and Tilbury divide the district to a certain extent, having a tendency to isolate various parts from one another. The northern half of the district slopes from north to south, and is suitable for residential purposes. The southern half consists of marshland, and, being practically flat, and. having a general level of from 5 to 6 O.D., is unsuitable for residential purposes. Geologically, the whole district has a gravel subsoil lying generally close to the surface of the ground, which has a general surface declivity from the north towards the rivers and outcrops in the bed of the watercourses. An exception to this statement may be found on the marsh levels, where there is a bed of marsh clay of varying thickness overlying the gravel. In this connection it is of interest to note that recent borings at Abbey Rubber Mills indicated the first 12 feet to be made soil, the next 5 feet sandy clay, and the next 1 feet of gravel resting on London clay. SOCIAL CONDITIONS, ETC. The chief occupations of the residents in the district at the time of the 1921 census are shown by the following table, which is a summary of the census return:— 11 Occupations. Male. Female. Total. Agricultural Occupations 218 97 315 MoKers of Bricks, Pottery and Glass 102 2 104 Workers in Chemical Processes, Makers of Paint, etc-. 348 198 546 Metal "Workers (not electro plate or precious 999 89 1.088 Workers in Precious MotaU and Electro Plate 13 2 15 Electricians and Electrical Apparatus Makers 204 72 276 Workers. in Skin and Leather (not boots and shoes 39 29 68 Textile Workers 26 92 118 Makers of Textile Goods and Articles of Dress 107 365 472 Makers of Food, Drinks and Tobacco 179 136 315 Workers in Wood and Furniture 459 81 540 Makers and Workers in Paper (Printers etc.) 261 116 377 Builders Bricklayers, Stone and Slate Workers 571 1 572 Painters and Decorators 211 2 213 Workers in materials (vulcanite, ebonite, bone, horn etc.) 206 204 410 Workers in Mixed or Undefined Materials 98 50 148 Persons employed in Gas, Water and Electrical Undertakings 546 1 547 Persons Employed in Transport, etc. 1,501 61 1,562 Commercial, Finance and Insurance Occupations (excluding clerks) 774 410 1,184 Persons limpioyed in Public Administration and befence (excluding professional men and typists) 292 38 330 Professional Occupations (excluding clerical saff 160 178 338 persons Employed in Entertainments and Sport 23 11 34 Persons engaged in Personal Service (including institutions, clubs, etc.) 228 713 941 Clerks and Draughtsmen (not Civil Service or locat Authoritv), Tvpists 625 577 1,202 Warehousemen. Storekeepers and Packers 288 257 545 Stationary Engine Drivers, Dynamo and Motor Attendants 304 – 304 ??? and Undefined Workers (general labourers, etc.) 2,342 183 2,525 It will be seen from the foregoing table that Barking is fargely industrial. It was found in the 1921 census that G,7G2 inhabited houses," comprising 31,930 rooms, were occi'pied ky 7.091 " families or occupiers," that 279 families were living in nne room, 614 families in two rooms, and 706 families in ii ' w»ree rooms, and that a population of 4,052 persons were living * "tore than two persons to one room. 12 The amount of out-relief granted during the past five years is indicated in the following table (kindly supplied by the Clerk to the Romford Guardians), which gives for the calendar years stated the amounts spent in outdoor relief, the numbers chargeable in the middle week of each year, and the numbers chargeable in Romford Institution:— Calendar year ending. Amount spent in Barking in the year. Xumbers chargeable in the middle week of the year. Numbers chargeable in Romford Institution in the middle week of the year. 31st Dec., 1921 Ordinary £5,878 0 7 Ordinary 442 135 Unemploymt 11,362 5 2 Unemploymt 503 31st Dec.. 1922 Ordinary £7,151 11 11 Ordinary 457 133 Unemploymt 29,120 9 7 Unemploymt 2,442 31st Dec., 1923 Ordinary £7,437 5 7 Ordinary 512 124 Unemploymt 15,988 13 1 Unemploymt 1,249 31st Dec., 1921 Ordinary £7,741 8 6½ Ordinary 509 141 Unemploymt 6,402 18 4 Unemploymt 540 31st Dec., 1925 Ordinary £8,447 11 3 Ordinary 563 136 Unemploymt 3,112 1 7 Unemploymt 330 13 SUMMARY OF PARTICULARS REQUIRED BY CIRCULAR 648 OF THE MINISTRY OF HEALTH. DATED 10th DECEMBER, 1925. Genera1. 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) 35,523 Population (June, 1925) (Registrar General's estimate) 38,450 Number of inhabited houses (1921) 6,762 Number of Families or separate occupiers (1921) 7,594 Population Density, i.e., No. of persons per acre 9.3 Rateable Value—Houses, Buildings, etc. £263,460 10 0 Lands £3,008 10 0 Sum represented by a penny rate £1,100 0 0 Education rates :— Elementary 3 5 Secondary 5 Assessable Value £244,077 10 0 General District Rate 7 9 Poor Rate 9 8 2. Extracts from Vital Statistics for the Year. Births Males. Females. Total. Birth Rate. Legitimate 408 394 802 20.85 Illegitimate 3 20 23 0.59 Total 411 414 825 21.44 Deaths :— Male. Female. Total. Death Rate. Standard Death Rate (Factor 1'049) 199 187 386 10.03 10.5 Number of deaths of women during, or in consequence of, childbirth:— From Sepsis. From other causes. Total. – 1 1 Number of deaths of infants under one year of age:— Males. Females. Total. Death Rate. Total Infantile Death Rate. Legitimate 35 26 61 76.05 80.0 Illegitimate 1 4 5 217.39 dumber of deaths from Measles (all ages) 1 „ „ Whooping Cough (all ages) 13 „ ,. Diarrhoea (under 2 years of age) 9 14 3. BIRTH RATE, DEATH RATE, AND ANALYSIS OR MORTALITY DURING THE YEAR. Birth Rate per 1,000 Total Population. Annum. Death Rate per 1,000 Population. Rate pf.r 1,000 Births. Percentage of Total 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 Certified by Registered : Medical Practitioners Inquest Cases. Uncertified Causes of Death. England and Wales 18.3 12.2 0.01 0.00 0.13 0.03 0.15 0.07 0.32 0.47 8.4 75 92.1 6.9 1.0 105 County Boroughs and Great Towns including London 18.8 12.2 0.01 0.00 0.17 0.03 0.18 0.00 0.30 0.43 10.8 79 92.1 7.3 0.6 157 Smaller Towns (1921 Adjusted Populations 20,000-50,000) 18.3 11.2 0.01 0.00 0.15 0.02 0.14 0.06 0.31 0.38 7.6 74 93.0 5.9 1.1 London 18.0 11.7 0.01 0.00 0.08 0.02 0.19 0.11 0.23 0.46 10.6 67 91.1 8.9 0.0 BARKING 21.4 10.0 – – 0.02 0.02 0.33 0.05 0.40 0.33 10.9 80 92.0 8.0 – 15 VITAL STATISTICS Of WHOI.E DISTRICT FROM 1920 to 1925. Year. Population estimated to Middle of each Year. Births. Total Deaths Rcgistered in the District. Transferable Deaths Nett Deaths belonging to the District. Nett. Number. Rate. Of Nonresidents registered in the District. Of residents registered out of the District. Under One year of age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Births. Number Rate. 1 2 3 4 5 6 7 8 9 10 11 12 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 1925 38,450 825 21.4 287 7.4 8 107 66 80.0 386 10.0 *Registrar General's Figures. 16 . 5. CAUSES OF SICKNESS. No special causes of sickness fall to be discussed. 6. SUMMARY (FOR REFERENCE) OF NURSING ARRANGEMENTS, HOSPITALS, AND OTHER INSTITU. TIOXS AVAILABLE FOR THF 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 cut 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 Midwifery Provision. By agreement dated January 1st, 1924, with the Plaistow Maternity Charity, the Council annually 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 £229, leaving a balance due to the Charity from the Council of £71, such sum ranking for grant. 17 (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. Empress Hall, Ripple Road. Alexandra Centre St. Pauls Road. Accommodation for consultation, weighing of babies, waiting room. etc. „ „ „ „ Local Authority. „ „ „ „ (b) Ante-natal clinic Clinic premises, East Street. Accommodation for consultations. „ „ (c) School Nurseries Nil. Nil. Nil. (d) Day 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. „ „ (d) Orthopedic Clinic Faireross School. Ono room. „ „ III. Tuberculosis 37, Linton Road. Three rooms. Essex County Council. IV. Venereal Diseases London Hospitals, etc. — By arrangement with Essex County Council. 18 (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 ambulancc and fire services being run in conjunction under the Chief Fire Officer. 7. LABORATOR\ 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.4, particulars of the number of specimens submitted for examination .being supplied by the following table: – Specimen Number examined Diphtheria 442 Sputaj 226 Typhoid 6 Ringworm 10 Miscellaneous 15 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. 19 (ii) General Adoptive Acts: Local Government and other Officers' Superannuation Act, 1922. Public Health Acts Amendment Act, 1890, Parts 2, 3 and 5. Public Health Act, 1925. 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. Barking Town (Pneumonia) Regulations, 1924. (iv) Byelaws with respect to: Nuisances, 1884. Ccmmon Lodging Houses, 1884. Offensive Trades, 1907 (revised 1924). Houses let in lodgings, or occupied by members of more than one family, 1921. 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, 1921 (revised 1924). (v) 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, giue maker, size maker, gut scraper, and oil boiler to be offensive trades, the last being so declared in 1925. 20 9. DEATHS. There were 287 deaths registered in Barking in 1925. Of these, 8 were deaths of non-residents. Barking residents to the numoer of 107 died elsewhere during the year. Including the latter and excluding the deaths of visitors, the net number of deaths were as follows:— Males. 199 Females. 187 Total. 336 The death rate for 1925 was 10.0 per 1,000, compared with 10.0 in 1924, calculated on the Registrar-General's estimated population and number of deaths, compared with 12.2 for England nnti Wales, 12.2 for the hundred and five Great Towns, 11.2 for the hundred and fifty-seven Smaller Towns, and 11.7 for London. Sex Mortality. –The 386 deaths of 1925 were divided as. follows:— 199 males, equal to a death rate of 5.17 per 1,000 population. 187 females, equal to a death rate of 4.86 per 1,000 population. Age Mortality.—The deaths in various nge groups, accord ing to the figures obtained locally, were as follows:— Age Group. No. of Deaths. Death Rate per 1,000 Population. Under 1 year 66 1.71 1 to 2 years 6 0.15 2 to 5 years 13 0.33 5 to 15 years 12 0.31 15 to 25 years 22 0.57 25 to 45 years 47 1.22 45 to 85 years 93 2.41 Over 65 years 127 3.30 Causes of death in 1925 The table on page 23 shows the principal causes of death at various ages. Those diseases, etc. 21 Causing Most deaths or important from a Public Health aspect were as follows: – Disease No. of Deaths. Percent age ol total net deaths registered. Cardio-Vascular System 41 10.62 Cancer 47 12.17 Tuberculosis(all forms) 42 10.88 Pulmonary affections. (exclusive, of tuberculosis), viz., Bronchitis 38 9.84 Pneumonies 25 6.47 other respiratory disease 6 1.55 Zymotic Diseases 26 6.73 Of the total deaths, tuberculosis caused one in every 9.1, heart diseases one in every 9.4, bronchitis one in every 10.1, cancer one in every 8.2 pneumonia one in every 15.4, suicide and violence one in every other respiratory diseases one in every 64.3, and Zymotic diseasse one in every 14.8. Deaths from Zymotic Diseases These diseases caused 6.7 Per cent of tfi& total deaths, such deaths being caused in the M'owng proportions:— Enteric fever – Measles 0.25 Whooping Cough 3.36 Scarlet Fever 0.25 Diptheria 0.51 Diarrhœa 2.33 Smallpox – The average death rate for the quinquennium ended 31st December, 1925, was 9.8 per 1,000 population. 22 INQUESTS.—Coroner's inquests were held on 31 deaths. The ages at death and causes assigned were as follows:— Causes 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 – l – 2 4 2 – 2 11 Suicide – – – – 1 – 1 – 2 Senile Decay and Broncho Pneumonia – – – – – – – 1 1 Pulmonary Tuberculosis – – – – – 2 – – 2 Heart Disease – – – – – – 2 5 7 Broncho Pneumonia 2 – – – – – – – 2 Cerebral Hæmorrhage – – – – – – 1 – 1 Chronic Bronchitis – – – – – – – 1 1 Chronic Endocarditis and Pneumonia – – – – – – 1 – – Want of Proper Attention at Birth 1 – – – – – – – 1 Rupture of Blood Vessel in Brain – – – – – – – 1 1 Premature Birth and Debility 1 – – – – – – – 1 Totals 4 1 – 2 5 4 5 10 31 23 CAUSES OF AND AGES OF DEATH DURING YEAR, 1925. (Nett Deaths.) Causes of Death. Deaths at the subjoined ages of Residents '" whether occurring in or beyond the district. I Under one year 1 and under 5 5 and under 15 15 and under 25 25 and under 45 45 an d under <55 05 and upwards Total Encephalitis Lethargica - - - 1 - - - - Influenza 1 1 — - 3 5 9 19 Scaret Fever — 1 — - -— — - 1 Small Pox - - - - - - - - Measles — 1 - - — - - 1 Whooping Cough 8 4 1 - — - - 13 Epidemic Influenza - - - - - - - - Diarrhoea and Enteritis (under 2) 9 - — - - 1 - 9 Diphtheria — 1 1 - - - - 2 Enteric Fever - - - - - - - - Puerperal Fever - - - - -- - - — Phthisis (Pulmonary Tuberculosis) — — - 10 10 9 1 30 Other Tubercular Diseases 2 2 1 — 1 - — 6 Oncer, Malignant Disease — - - 6 23 18 47 Bronchitis 6 — — - 1 5 20 38 Pneumonia 7 5 3 — 3 6 1 25 Other Respiratory Diseases — — 1 — — 2 3 6 Alcoholism (Cirrhosis of Liver) — - - — 2 2 — 4 Premature Birth, Malformation and Debility. 18 - _ - 18 Accidents — 1 2 4 2 — 2 11 Suicides - — 1 1 — 2 Rheumatic Fever - - 1 - - 2 3 Diabetes - - - - 1 1 3 5 Cerebral Hæmorrhage - - 2 - 5 17 24 Heart Disease - - 1 1 5 18 16 41 Artero-Ssierosis - - - - 2 6 8 Ulcer of stomach or duodenum — ; _ - 1 2 3 Appendicitis and typhlites 2 1 1 1 — 5 Acute and Chronic Nephritis 1 - - - 2 2 1 6 Other accidents and diseases of pregnancy and parturition _ - - 1 1 Other defined diseases 14 1 — 4 3 10 20 52 Causes ill-defined or unknown — — — — - — _ Totals 66 19 12 22 47 93 127 386 24 INFANT MORTALITY DURING THE YEAR 1925. 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 weeks. 3—4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. U months and under 9 months. 9 months and under 12 months. Total under one year. Small Pox - - - - - - - - - - Chicken Pox - - - -- Measles - — - - - — - - - _ Scarlet Fever - — - - — - _ - — Whooping Cough - — - - - 4 1 - 3 8 Diphtheria and Croup - — - - - — - - — Erysipelas - — - - - — - - — — Tubercular Meningitis . - - - - - — - - 1 1 Other Tubercular diseases - - - - - - - - 1 1 Meningitis (not tubercular) - - - - - - - 1 1 2 Convulsions - — - - — - 1 - 1 Larvniritis - - - - - - - - - - Bronchitis - - - 1 1 1 3 2 - 6 Pneumonia (all forms) - - - - - 3 2 1 1 7 Diarrhœa 1 - 1 2 3 2 1 9 Gastritis - - - - - - - Syphilis - - 1 1 Rickets - - - _ — — — - — — Suffocation, overlaying —- - - - - - - - - - Injury at birth - 2 - - 2 - - - - 2 Atelectasis 1 - - - 1 - - - - 1 Congenital malformation - - - 1 1 - - - - 1 Premature Birth 8 2 - - 10 1 — - - 11 Atrophy, debility and Marasmus 3 - - 3 2 1 - - 6 Other causes 1 4 - 1 6 2 — 1 — 9 Totals 13 9 - 3 25 - 9 8 8 66 Nett Births in the year :— Legitimate 802 Illegitimate 23 Nett Deaths in the year :— Legitimate 61 illegitimate 5 28 10. marriages. There were 258 marriages registered in the district in 1925. This is equal to a marriage rate of 6.7 per 1,000 population. In 1922 there were 208 marriages, equal to a rate of 5.6, in 1923, 2l9 marriages, equal to a rate of 5.9 per 1,000, and in 1924, 208 marriages, equal to a rate of 5.4. 11. births. The net number of births registered in 1925 was 825, affording an annual birth rate of 21.4 per 1,000 population, compared with 22.3 in 1924 and 23.1 in 1923. Of all births, 23 were illegitimate, or a proportion to total births of 2.7 per cent. The average birth rate for the quinquennium ended 31st December, 1925, was 23*3 per 1,000 population. Notification of Births Act, 1907-1915.—Of the total births recorded in the district during 1925, all except 33 or 3.9 per cent. of the total, were notified to the Medical Officer of Health, 555 being notified by raid wives and 242 by parents and doctors. 28 still-births were notified, 20 being notified by midwives and 8 by doctors and others. 26 SECTION 2 sanitary circumstances of the district. (a) WATER SUPPLY. Water is supplied by the South Essex Water Company from deep wells in the chalk at Dagenham, Chadwell Heath, Ilford and Barkingside. Analytical particulars of a sample appeared in my Report for 1923. (b) RIVERS AND STREAMS. The Rivers and Streams of the district come within the jurisdiction of the Essex Sewers Commissioners (who are the Tidal Flush and Flood Water Drainage Authority) and the Port of London Authority, who are the recognised Navigation Authority for the Thames, as defined by the Port of London Consolidation Act, 1920, and who have also certain powers as to the fouling of streams, etc. The Council's attention during the year was directed to the standard of purity of their sewage effluent as discharged into the Roding, a tributary of the Thames. (c) RAINFALL. The rainfall for the year ended December 31st was 24.7 inches. Rain fell on 179 days throughout the period in question. (d) SEWAGE. A water-carriage system is general, except in certain parts referred to elsewhere. Over the greater part of the area there is a separate sewage and storm water system. Sewage is treated within the district by precipitation and sedimentation, the resulting effluent being discharged into the River Roding. The sewage disposal works (originally erected in 1888 for a population of some 20,000 inhabitants) are now 27 employed to their utmost capacity. The question of extension these works in view of the proposed erection of some 2,000 houses by the London County Council on the Barking part of the Jiecontree Estate, together with anticipated building by private individuals and the Local Authority, received consideration during the latter part of the year. A scheme was selected for the proposed construction of sewage disposal works within the district, but, apart from an application to the Ministry of Health for the acquisition of certain lands for this purpose by Provisional Order, no further progress in the matter had been made at the end of the year. (e) CLOSET ACCOMMODATION. With the following exceptions, the district is served by the water-carriage system:— Ward. Type of Closet. Privy. Pail. Cesspool Drained Abbey - 3 1 West bury — 4 4 Longbridge 1 7 18 Ripple 17 2 46 Totals 18 16 69 Of the above premises, six are factories, three temporary dwellings, two schools, one a workplace, and 91 dwellinghouses. During the year seven premises were sewered, while 47 houses situated at Creeksmouth were provided with adequate flushing arrangements, together with the installation of sanitary pans in place of the long-hopper type. if) SCAVENGING. The question of scavenging (which is closely linked with 'hat of sewage disposal in several respects) comes under the 28 control of the Engineer. Domestic and trade refuse is collected weekly in horse-drawn two-wheeled vehicles, and deposited on low-lying land. During the early part of the year tipping took place directly into stagnant water, some few feet in depth. This practice has now ceased, tipping at present taking place into meadow land adjoining the Cemetery, near the junction of Ripple Road and Upney Lane. Cleansing experts are agreed that the dumping of crude refuse cannot be justified on any grounds, sanitary or otherwise, such a method only "perpetuating and concentrating those evils which would arise from the storage of refuse at the home." Various constituents are present in refuse which can be economically used, and in my opinion any change in the present method of refuse disposal should be along those lines. Many, if not most, Sanitary Authorities, now approach this question with a view to putting down plant to obtain from their refuse all usable material, and apply it in a suitable and economical way rather than destroy it. Were the 5 cwts. of refuse which is produced per head each year treated by methods more favoured by present-da)' sanitarians, much could be salvaged and sold, and I think the Council would be wise in looking ahead for a site suitable for the erection in the near future of refuse disposal plant, prior to the more extended development of their district taking place. As to whether present refuse collection by two-wheeled vehicles is an economic problem, no definite opinion, in the absence of data, can be expressed. To draw any satisfactory conclusions, records of work done are essential, while the weighing of all refuse would provide a valuable index as to loading-time and travelling-time required. The ratio between loading-time, travelling-time and maintenance, would then provide the factor of economy for deciding the haulage system to be adopted. With the dump at its present site, considerable time must obviously be wasted in travelling. There is now little difference of opinion, 1 think, in that four-wheeled horse-drawn vehicles 29 With tow loading line, form the most economical units for house-to-house refuse collection, though motor transport would obviously be preferred for longer distance conveyance, combined, if necessary, with the transference of loads from carts to motors at certain selected depots throughout the district. CESSPOOLS, PRIVYMIDDENS AND PAIL-CLOSETS. For cesspool emptying, a tank vehicle is employed, the contents being pumped out and afterwards discharged into the sewers. Privymiddens, of which there are 24, are emptied into tumbrils and the contents buried; the same remark being applicable to pail-closets. STREET REFUSE. Dustless road construction and the development of motor road transport have materially reduced the quantity and character of street refuse. So far Barking has not yet acquired motor-brooms, vacuum gully cleaners, or combined street sweepers and collectors. Though street cleansing may be said, up to a point, to be satisfactory, its principal defect consists in that heaps of refuse left on streets for later collection, prove at times, a nuisance. This difficulty could be surmounted by the institution of street bins for temporary storage purposes. Housing Statistics for the year 1925. 1. GENERAL. Number of new houses erected during the year:— (i) Total 183 (ii) As part of a municipal housing scheme Nil (iii) Others (including private enterprise and subsidy houses) 183 2. UNFIT DWELLING HOUSES. I.—Inspection. (i) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 3,134 30 (ii) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 1,164 (iii) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 6 (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 1,759 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 1,331 III.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1923. (i) Number of dwelling houses in respect of which notices were served requiring repairs 49 (ii) Number of dwelling houses which were rendered fit— (a) by owners 49 (b) by Local Authority in default of owners Nil (iii) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations of owners of intention to close Nil 3. Proceedings under Public Health Act. (i) Number of dwelling houses in respect of which notices were served i aquiring defects to be remedied ... ... 355 31 (ii) Number of dwelling houses in which defects were remedied:— (a) by owners ... ... ... 355 (b) by Local Authority in default of owners — C. Proceedings under Sections 11,14 and 15 of the Housing Act, 1925: — (i) Number of representations made with a view to the making of Closing Orders 11 (ii) Number of dwelling houses in respect of which Closing Orders were made 6 (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 — SANITARY INSPECTION OF THE AREA. (Work of Sanitary Inspectors.) I. Inspection of Dwelling Houses. Total under Public Health or Housing Acts 2,851 Housing (Inspection of District) Regulations 1,161 After Infectious Disease 209 Miscellaneous 14 Defects Found 5,432 Notices Served 1,759 Re-inspections re Notices Served 3,803 32 2. Premises Controlled by Bye-Laws and Regulations. Houses Let in Lodgings 134 Common Lodging Houses 84 Offensive Trades 218 Tents, Vans and Sheds 134 Dairies, Cowsheds and Milkshops 274 Slaughterhouses 248 3. Factories, Workshops and Workplaces. Factories 40 Laundries 11 Bakehouses 123 Other Workshops 172 Other Workplaces 47 Outworkers' Rooms 38 Butchers' Premises 407 Fishmongers 45 Restaurants and Dining Rooms 154 Markets 133 Stables and Stable Yards 15 Piggeries 87 4. Miscellaneous. Smoke Observations 116 Rats and Mice (Destruction) Act, 1919 227 Vacant Land and Refuse Dumps 164 Public Lavatories 88 Schools 43 Petroleum Stores 117 SUMMARY OF SANITARY WORK CARRIED OUT. (a) Drainage. Branch drains, opened, repaired, and cleansed 77 Main drains, opened, repaired and cleansed 44 Drains reconstructed 4 New Drains 2 Ventilation Shafts repaired or new fixed New Inspection Covers * 33 Water-Closets. Roofs 54 Walls 72 Floors 13 Doors 49 Seats 39 New Pans Fixed 97 Pans Cleansed or Repaired 53 New Flushing Cisterns 137 Flushing Apparatus Repaired 146 (c) Sinks. New Fixed 43 New Sink Wastepipes 85 Waste Pipes Repaired 11 New Gullies 17 (d) Dampness. Roofs 578 Eavesgutters 357 Rainwater Pipes 131 Damp Walls Remedied 38 (e) Water Supply. Storage Cisterns Abolished 22 Defective Water Fittings Repaired 59 Supply Reinstated 10 Supply provided inside houses 6 (f) 1 ard Paving. Yard paving repaired or relaid 183 (g) Dustbins. New ones provided 207 34 (h) General Repairs. Internal walls repaired 179 Ceilings repaired 121 House floors repaired Windows repaired or renewed 190 Window sills repaired or renewed 36 Fixed windows made to open 10 Sashcords renewed 219 Stoves or coppers repaired or renewed 237 House doors repaired or renewed 97 Stairs repaired 47 Chimney stacks rebuilt 5 Chimney-pots renewed 55 Dirty or infectious rooms cleansed and redecorated 590 Houses painted 6 Connections to main walls rendered watertight 60 External walls repaired 86 (i) Miscellaneous. Offensive accumulations removed 35 Animals kept so as to be a nuisance 7 Insanitary conditions remedied 5 Verminous rooms and persons disinfected 15 Stables cleansed 3 NOTICES SERVED. Informal Notices 1,759 Statutory Notices 423 Section 36, Public Health Act, 1875 Section 94, Public Health Act, 1875 355 Section 49, Public Health Act (Amendment) Act, 1907 1 428 Section 5, Infectious Disease (Prevention) Act, 1980 4 Section 3, Housing Act, 1925 49 35 SMOKE ABATEMENT. The smoke shafts of the district were kept under observation during the year, and 11G inspections recorded. In 4 instances informal notices were served, 11 offenders were reported and warned, while in 1 instance it was necessary to serve formal notice. As a result of continuous pressure, an additional boiler has been erected at the factory of the worst offender. Until existing legislation on smoke abatement is amended, it will be cheaper for the offender to pay any penalty that may be imposed, rather than provide proper coal and improved methods of stoking. Further, the emission of dense smoke of any colour should be a nuisance within the meaning of the Act, and not, as at present, "dense black" smoke only. The Earl of Onslow's Bill contains proposals to increase the maximum penalty for smoke nuisance to £50, while smoke which is not black would be regarded as a nuisance, the term "smoke". including " soot, ashes and grit." OFFENSIVE TRADES. The following shows the nature of the businesses carried on, and the number of premises registered (a) Fish Fryers 17 (b) Fishskin Scrapers 2 (c) Dealers by retail in Rags and Bones 9 (d) Fat Melters and Extractors 2 (e) Gut Scraper 1 (f) Oil Boiler 1 During the year, in addition to my own inspections, the Sanitary Inspectors paid 218 visits, and 50 notices were served for various breaches of the Bye-laws. (a) FISH FRYERS (see page 40.) (b) FISHSKIN SCRAPERS. Both of these premises are situated on marsh land, some considerable distance from dwellings. Every effort is made by the Sanitary staff to secure these businesses being carried on in conformity with the bye-laws, and with a minimum of nuisance. 36 (c) DEALERS IN RAGS AND BONES. In this district the amount of noxious material collected is negligible. Dealers confine themselves to the collection of rags, bottles and newspapers, and these usually in a cleanly condition. There is little or no storage as the dealers find a ready market with a wholesaler at Creeksmouth. (d) FAT MELTERS AND EXTRACTORS. At both premises an efficient apparatus has been installed, and these businesses are now carried on practically without any nuisance. (e) GUT SCRAPER. Some necessary improvements were made during the year, and noxious conditions are now at a minimum. During hot weather, frequent inspections are necessary to ensure the proper covering and disposal of waste matters. (/) OIL BOILER. Bye-laws controlling this business did not, although confirmed, become operative during the year. The owner carried out certain alterations which, although remedying offensive conditions within the factory, have in no way minimized the nuisance without. After constant pressure, negotiations are now in hand for the installation of an efficient oil fume condenser. COMMON LODGING HOUSES. There are two registered Common Lodging Houses, providing accommodation for 30 and 27. male lodgers respectively. These houses are of the dormitory type, and received 84 visits, excluding night inspections, during the year.. Five notices were served in respect of l4 infringements of the bye-laws, and 2 notices for structural defects. There was one change of keeper during the year. The habitues of these houses are not of the usual vagrant type, but more or iess regular customers, and the premises, on the whole, are well conducted. 37 TENTS. VANS, SHEDS, Etc. There are 16 such. premises in the district, which received visits during the year. The defects discovered were mainly: want of proper water supply and sanitary accommodation in 4 instances; absence of proper refuse accommodation in 3; and a filthy condition of the premises also in 3 instances. It was necessary to institute proceedings in the case of one -family, who were in occupation of a hut without provision of water supply, sanitary or refuse provision. A Magistrate's Order was obtained for closure of the premises. HOUSES LET IN LODGINGS. It has so far been found impracticable to register all houses coming within the scope of these Bye-laws. Technically, somewhere between two and three hundred such houses are in occupation within the district, though never intended for the purpose, and with about nine exceptions, totally unsuited therefor. These houses are frequently inspected to secure their being maintained in as good sanitary condition as possible. FOOD. Dairies, Cowsheds and Milkshops.—The number of registered dairies and milkshops is 28. Three dairies and milkshops were registered for the first time during the year, while 8 were removed from the register. In addition to my own inspections, 274 visits were paid by the inspectors, and 3 notices served for defects. In one instance only was milk so stored as to become liable to contamination. At the end of the year one cowshed remained in occupation only, but, although belonging to the old type, I found at the time of my inspection, little to which exception might be taken. The occupier of these premises keeps an average of some 30 cows. The present tendency for distributors to form combines, rather than working as separate units (enabling to a great extent better and more efficient methods of distribution to be 38 adopted, together with the gradual elimination of the small retailer), constitutes in my opinion a decided change for the better. Milk (Spccial Designations) Order, 1923.—Under the above Order licences require to be granted for the sale of milk designated as " Certified," " Grade A Tuberculin Tested," " Grade A," or " Pasteurised." Licences granted expire on 31st December of each year, which, in the case of producers, are issued by the Ministry of Health and County Councils, whilst distributors are licensed by the local sanitary authorities. At the end of the year licences for the sale of designated milk in this area were as follows :— Grade A (Tuberculin Tested) Milk 3 Grade A Milk 1 Grade A (Bottling Licence) 1 Bakehouses.—At the end of the year there were 16 bakehouses on the register, 7 of which were factory bakehouses. In addition to my own inspections, bakehouses received 123 visits, while two informal notices were served. There are no underground bakehouses. Premises where Food is Prepared for Sale.—Excluding bake houses, the number of such places is :— Eating Houses 16 Slaughter Houses 2 Meat Shops and Cooked Meat Shops 36 Fried Fish Shops 17 Fish Shops (wet), additional 3 Ice Cream 38 During the year these premises received 137 visits, whilst 19 notices were served for defects found. It will be recognised that the conditions under which food is sold or prepared for sale is of importance, in order to secure the wholesomeness of the same and the cleanliness of both premises and utensils. Efficient control will only be established 39 Where all premises engaged in the preparation, storage, sale or distribution of food are compulsorily registered throughout the country, controlled by regulations, and provision made for de-registration, a system already adopted in New York. —The Public Health (Meat) Regulations, 1924, came into force on April 1st, 1925. Every butcher in the district was supplied with a copy of these regulations. and advised as to the appropriate manner of their application to his premises. From April 1st to the end of the year 110 notices to daughter were received, and 102 beasts, 519 sheep and 74 pigs emamined. The following parts were found diseased :— Description. Weight. Disease. lbs. 2. Fore Quarters of Beef 400 Tuberculosis 1 Beast's Head 28 Tuberculosis 5 IV asts' Lungs 40 Tuberculosis 3 Beasts' Lungs 24 Congestion 1 Beast's Lung 8 Echinococcus 3 Beasts' Livers 43 Tuberculosis 7 Beasts' Livers 98 Distoma Hepaticum 67 Sheeps' Lungs 201 Strongylus Rufcscens 10 Sheeps' Livers 40 Distoma Hepaticum 3 Sheeps' Livers 12 Cirrhosis 10 Pigs' Heads 140 Tuberculosis 10 Pigs' Plucks 75 T uberculosis Diseased meat, whether surrendered or seized, is destroyed by the Authority. Following the issue of Circular 604 by the Ministry of Health, a conference was held between the Chairman of the Public Health Committee, representatives of the Butchers' Federation and myself. As a result, it was decided inter alia that when side and overhead screens were provided it would ke presum'ed that meat so exposed would be in accordance with Regulations. 40 The somewhat ambiguous phraseology of the Regulations and the practice in adjoining districts, did not strengthen my endeavours to arrange that all meat should be exposed behind glass fronts only, although during the latter part of the year there was a distinct tendency on the part of butchers to provide their shop windows with hygienic fronts. The two slaughter houses in the district are not employed to their full capacity. The licensed slaughter house is mainly used for the slaughtering of calves and sheep, and an occasional bullock, whilst there has been no slaughtering on the registered premises during the past six months. Markets.—The open and closed markets were regularly inspected during the year, receiving 133 visits. In general the market stalls are fairly well conducted, and the stall holders willing to comply with requirements. Fried Fish Shops.—There are 17 fried fish shops in the district. 14 notices were served during the year, mainly with respect to cleansing. In addition to enforcing the provisions of the Bye-laws, a careful look-out is kept on the wholesomeness of the fish and of the oils., etc., used in frying. Ice Cream.—During the year 38 premises where ice cream is manufactured were inspected. Prior to the passing of the Public Health Act, 1925, the powers of Local Authorities for dealing with this commodity were not entirely adequate. It is now, however, possible to secure that ice cream is manufactured under hygienic conditions, Section 72 of the above Act providing that no room shall be used for selling, preparing, storing or keeping in vessels, any foodstulls (which would include ice cream), unless such room is suitable. There has recently been opened in the district an ice cream factory with a capacity for turning out some 500 gallons a day. These premises are constructed on modern and up-to-date lines, and the manufacture of the commodity is carried on under idea! conditions. 41 UNSOUND FOOD. The following is a list of unsound food destroyed during the year:— Commodity. Quantity. Condition. Result of Action Taken. Meat 68 lbs. Decomposed Surrendered Fish —Dabs 12 st. ,, ,, Haddock 12 st. ,, ,, Skate 6 st. ,, ,, Roker 6 st. ,, ,, Whelks 3 bush. ,, " Winkles 2 bush. " " fruit—Apples 400 lbs. ,, " Apples 28 lbs. ,, ,, Tomatoes 8 lbs. ,, ,, Bating Houses.—The number of eating houses is 16, being of the type usually frequented by carmen and others. 154 visits were paid during the year and 3 notices served for sanitary defects. SALE OF FOOD & DRUGS ACTS. I am indebted to Mr. H. C. Card, Chief Food and Drugs Officer of the Essex County Council for the following particulars of samples purchased and submitted for analysis during the year;— Milk. Butter. Miscellaneous. Total. Prosecutions. Fines. 83 58 23 164 3 £22 Proceedings were taken in the case of 2 samples of margarine from bulks not labelled as required, the vendors being each fined £l. Of 4 samples of butter found adulterated proceedings were instituted against the vendor, who was fined £'20 £1 costs. RATS & MICE (DESTRUCTION) ACT, 1019. In accordance with the suggestions of the Ministry of Agriculture and Fisheries, a National Rat Campaign was observed locally from November 2nd to 14th. To emphasise the 42 importance of concerted efforts for the extermination of rats, publicity to the campaign was given in the local press, while special circulars were addressed to all likely to be affected, the occupiers of infested premises being also asked to notify same to the Public Health Department. In order to discover the efficiency of different raticides, various preparations were employed in different wards of the district. As a result, it was found that liquid preparations entailed considerable trouble in preparation, baits being not infrequently improperly laid, and that for all practical purposes paste raticidcs were the more effective. During the period 63 premises were treated with 848 baits, 737 of which were consumed. The occupiers of 24 premises reported total clearance of rats, 26 an improvement, whilst in 13 instances there was no change. (I) GENERAL HOUSING CONDITIONS IN THE AREA. It is with regret that I am unable to report any appreciable improvement in the housing shortage. During the year no houses were erected for letting purposes. A beginning was made by the Authority during the year upon 59 houses, to be erected on Eastbury Estate by direct labour. These may shortly be ready for tenancy, and will, I hope, be immediately followed by many more. (II) OVERCROWDING. As an indication of the present housing shortage I have extracted the following information from the list of applications for houses as on December 1st, 1925. 208 applications appear from families living in one room divided as follows:— No. in Family. Instances. 2 33 3 72 4 73 5 32 6 10 7 1 8 1 9 1 Representing a population of 788. 43 250 applications from families living in 2 rooms were received as foilows :— No. in Family. Instances. 2 33 3 79 4 83 5 33 6 9 7 7 10 1 Representing a population of 910 persons. There were also 246 applications from families occupying three or more rooms. These 706 applications do not represent the total shortage, as, in many instances, owing to inability to pay higher rents, many of the poorer families do not trouble to apply. It is unnecessary to further emphasise the question of overCrowding. Under such conditions as, unfortunately, too frequently exist, the ideals of Preventive Medicine are impossible, and I am led to wonder how, in many instances, the occupants keep fit at all in their sordid atmospheres of social and moral destitution. The causes of overcrowding appear to be threefold:— (a) Rate of building not consistent with increase of population; (b) Gradual encroachment of surplus population from adjoining districts. This is unavoidable in the , extension of the greater London area; (c) Poverty. (III) FITNESS OF HOUSES. (a) The general standard of housing in the district is, on whole, only fair. Of an estimated number of 7,613 dwellings, 630 are unfit in that they are worn out and beyond reconditioning, Surroundings faulty, structures bad, rooms damp and insufficiently lighted and ventilated, with an almost general 44 absence of food cupboard accommodation. In addition, many of the houses are dirty, infested with rats and vermin, and, did circumstances permit, fit only to be closed. A reference to the summary of work carried out during the year in the case of defective houses generally will show that they are chiefly in connection with roofs, eavesgutters, rain, waterpipes, floors, internal walls and woodwork. (b) MEASURES TAKEN FOR THE ABATEMENT OF OVERCROWDING. This question received the serious consideration of the Council during the year, and the erection of 59 houses was commenced by direct labour as an experiment. Others are contemplated. (IV) UNHEALTHY AREA. At the December meeting of the Public Health Committee I submitted a Representation in accordance with Section 35 of the Housing Act, 1925, that the area known as the " Island Site was an unhealthy one, and should be dealt with under an Improvement Scheme. This question will be more fully dealt with in my next Report. FACTORY AND WORKSHOP ACT, 1901. Factories, Workshops, Laundries, Workplaces and Homework. 1. Inspections (including inspections made by Sanitary Inspectors). Premises. Number of Inspections. Written Intimations. Notices. Statutory. Prosecutions. Factories 72 8 — — Workshops 154 10 1 - Workplaces 926 5 - - Total 1152 23 1 — 45 2. DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions. Found Remedied Referred to H.M. Ins. Nuisances under the Public Health Acts :— Want of cleanliness 9 9 - - Want of ventilation — — — — Overcrowding — — — — Want of drainage of floors 1 1 — — Other nuisances 4 4 — — Sanitary accommodation:— Insufficient 3 3 Unsuitable or Defective 9 9 — - Not separate for sexes - — - Offences under the Factory and Workshop Acts :— Illegal occupation of underground bakehouse (S.101) — - - - Breach of special sanitary requirements for bakehouses (SS. 97 to 100) - - - - Other offences (excluding offences relating to outwork which are included m Part 3 of this Report) - - - - Total 26 26 - — Including those specified in Sections 2, 3, 7 and 8, of the Factory and workshop Act as remediable under the Public Health Acts. HOME WORK. Nature of Work. Outworkers' Lists (Section 107). Outwork in Unwholesome Premises (Section 108). Outwork in Infected Premises (Sees. 109. 110). List received from Employers. Notices served on occupiers as to keeping or sending lists. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made (Sec. 110). Prosecutions (Secs. 109. 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send list. Lists. Outworkers. Lists. Outworkers. Contrac tors. Workmen. Contrac tors. Workmen. Wearing Apparel:— Making, etc. 1 - 3 1 — 6 3 — - - - - - — — Total 1 3 1 6 3 46 47 REGISTERED WORKSHOPS. Workshops on the Register (Sec. 131) at the end of the year. Number. (1) (2) Bakehouses (including seven factory bakehouses) 16 Other Workshops 64 Total number of Workshops on Register 80 OTHER MATTERS. Class. N umber. (1) (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act (Sec.133) - Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Acts (Sec. 5) 6 Other — Underground Bakehouses (Sec. 101):— Certificates granted during the year - In use at the end of the year - OUT-WORKERS. The following list shows the nature of the homework carried out in this district by 24 out-workers :— Wearing apparel 7 Ties 4 Umbrella makers 3 Collar makers 1 Boot makers 1 Paper bag makers 2 Life belt covering 6 During the year 20 lists of out-workers were received from other Authorities in respect of addresses in Barking. 3 lists were received from employers within the district. In all instances the premises of out-workers were kept in a satisfactory state. 18 SECTION 3 NOTIFIABLE INFECTIOUS DISEASES. The following table shows the number of notifications of infectious disease received during 1925 :— TABLE 1. Males. Females. Total Total cases rem'd to Hos. Deaths Scarlet Fever 29 31 60 58 1 Diphtheria 29 46 75 70 2 Puerperal Septicemia . — 4 4 4 — Pneumonia (Acute primary and influenzal) 37 21 58 25 (All Forms) Erysipelas 10 8 18 3 1 Ophthalmia Neonatorum 8 4 12 *1 — Encephalitis Lethargica — — — — — Enteric — — — — — Cerebro Spinal Fever 2 — 2 1 2 Anterio Poliomyelitis 1 — 1 — — Totals 116 114 230 137 31 * Baby born in maternity ward of hospital. The following table i;ives particulars of the various infectious diseases notified during the preceding 5 years, together with the notification rate per 1,000 population, and the average for the quinquennium ending the 31st December, 1925. 49 Disease. 1921. 1922. 1923. 1924. 1925. Average for five years. No. Notified. Rate. No. Notified. Rate. No. Notified. Rate. No. Notified. Rate. No. Notified. Rate. No. Notified. Rate. Scarlet Fever 150 4.1 53 1.4 18 0.4 40 1.0 60 1.5 64 1.68 Diphtheria 118 3.2 51 1.3 30 0.8 50 1.3 75 1.9 65 1.7 Pneumonia 101 2.7 103 2.8 92 2.4 50 1.4 58 1.5 82 2.16 Puerperal Fever — — 2 0.05 4 0.1 3 0.07 4 0.1 3 0.06 Erysipelas 60 1.6 36 0.9 36 0.9 18 0.4 18 0.4 34 0.84 Ophthalmia 9 0.2 10 0.2 10 0.2 7 0.1 12 0.3 10 0.2 no The average annual death rate of notifiable infectious disease per 1,000 population during the quinquennium ending December 31st, 1925 was 0.88. The following diseases were notifiable in 1925 under the original Infectious Disease (Notification) Act, 1889 and 1899:- Smallpox, diphtheria, relapsing fever, cholra, erysipelas, typhus, plague, puerperal fever, enteric fever Strict fever and continued fever, and by Orders or Regulations framed under Section 180, Public Health Act, 1875 :— Tuberculosis (all forms), ophthalmia neonatorum, cerebrospinal fever, acute polio-myelitis, encephalitis lethargic. influenzal pneumonia, acute primary pneumonia, malaria, dysentery, trench fever. The Barking Town (Pneumonia) Regulations, 1924. provides for the notification of Pneumonia supervening upon Measles. The total notifications of infectious disease numbered 230 exclusive of tuberculosis, compared with 179 the previous year. During 1025 the number of notifications of Tuberculosis (all forms) was 80 compared with 97 in 1924. 51 TABLE II. Notifiable Disease. No. of cases notified at age groups. Cases classified according to Wards. Under one year. 1 to 2 years. 2 to 3 years. 3 to 4 years. 4 to 5 years. 5 to 10 years. 10 to 15 years. 15 to 20 years. 20 to 35 years. 35 to 45 years. 45 to 05 years. Over 65 years. Abbey. Gascoigne. Central. Ripple. Long bridge Westbiiry. Scarlet Fever — 3 3 1 1 20 11 2 2 — — — 10 6 0 14 14 10 Diphtheria — 2 6 5 7 27 10 5 10 2 1 — 12 23 2 14 9 15 — — —. 4 — 2 1 1 Pneumonia (primary and influenzal) 3 6 5 5 1 9 2 4 4 5 12 2 19 7 16 2 8 6 Erysipelas — — — — — — — 1 3 3 8 3 3 1 4 — — 5 Ophthalmia Neonatorum 12 — — — — — — — — — — 2 5 2 — 1 2 Encephalitis Lethargic — — — — — — — — — — — — — — — — — — Enteric — — — — — — — — — — — — — — — — — — Cerebral Spinal Fever — — — — — 1 — 1 — — — — — 1 — — 1 Anterio Poliomyelitis — — — — 1 — — — — — — — — — 1 — — Totals 15 10 14 13 20 63 23 13 23 10 21 5 48 44 31 33 35 39 52 TABLE III. Monthly summary of notifications of infectious disease : , Month. Scarlet Fever. Diphtheria. Puerperal Fever. Pneumonia. Erysipelas. Ophthalmia Neonatorum. Enteric Fever. Anterio Poliomyelitis Cerebro Spinal Meningitis. Encephalitis Lethargica. Totals. January 7 11 1 3 5 2 - - - - 29 February 3 4 - 3 - - - - - - 10 March 3 5 - 8 1 2 - - - - 19 April 3 5 - 14 1 - - - - - 23 May 1 2 l 2 1 - - - - - 7 June 5 4 - - 2 1 - - 1 - 13 July 3 5 - 7 - 2 - - 1 - 18 August 10 2 1 - 1 4 - - - — 18 September 2 9 - 4 1 - - - - - 16 October 10 5 - 4 1 - - 1 - - 21 November 5 7 - 6 2 1 - - - - 21 December 8 16 1 7 3 - - - - - 35 Totals 60 75 4 58 18 12 - 1 2 - 230 53 (a) Scarlet fiver.—The number of coses notified was 60, Compared with 40 the previous year. One fatal case occurred. 58 cases were isolated at the Infectious Hospitnl. The average day of scarlet fever cases in hospital was 40.6 days, compared with 3d."J days in 1024. .The longest period of detention was 105 days and the shortest 19 days. Twenty-nine cases treated in hospital developed complications as follows:— Otorrhœa 4 Albuminuria 1 Khinorrhœa 5 Bronchitis 1 Mastoiditis 1 Impetigo 1 Arthritis 1 Septic Sores 2 Adenitis 13 Of all cases notmed, five were found to be mistaken diagnoses as follows :— Measles 2 Otorrhœa 1 Pneumonia 1 Nil diagnosed 1 Of cases treated in hospital, the age incidence was as follows:— 1—2 years 2 5—10 years 25 2—3 years 3 10—15 years 11 3—4 years 3 15—20 years 1 4—5 years 11 20—35 vears 2 Sex.—29 cases were male and 31 female. (b) Small Pox.—No case of Small Pox occurred in 1925. Notifications of two persons who had been in contact with cases of Small Pox were received and kept under supervision for the usual periods. The following particulars are appended of vaccinations during 1920 :— Certificates of successful vaccinations 299 Postponed 20 Conscientious objections 489 Left District 21 The vaccination rate per 1,000 births was therefore 394.8, Compared with 452.1 fot the preceding year. (c) Diphtheria.—75 cases were notified, compared with 50 the preceding vear. Of cases notified, 70 were removed and treated in hospital. Two deaths occurred—one in hospital and one amongst cases treated at home. The average stay of diphtheria cases in hospital was 38.3 days, the longest stay being 86 and the shortest 20 days, excluding one case removed from hospital after only seven days' stay. The duration of the one fatal case was 66 days. Three cases of laryngeal diphtheria were admitted to hospital, but in only one instance was the performance of tracheotomy necessary, the patient making a somewhat prolonged but otherwise satisfactory recovery. The type of diphtheria present on examination was as follows :— Faucial 53 Naso-Pharyngeal 5 Laryngeal 3 Of all cases notified as diphtheria and removed to hospital, nine on examination were found to be mistaken diagnoses. Three cases of diphtheria admitted to hospital developed complications—two paralysis and one albuminuria. Of diphtheria patients treated in hospital, the age incidence was as follows 1 to 2 years 2 10 to 15 years 10 2 to 3 years 5 15 to 20 years 5 3 to 4 years 4 20 to 35 years 10 4 to 5 years 7 35 to 45 years 2 5 to 10 years 24 45 to 65 years 1 Sex.— 29 cases were male and 46 female. (d) Enteric Fever.— No notification of enteric fever was received throughout the year. (e) Puerperal Fever.—Four cases were notified during the year, all of which were admitted to hospital. One case, however, so notified being found to be pulmonary tuberculosis only was transferred elsewhere. All of the other cases recovered. (f) Malaria and Trench Fever.—No cases were notified during the. year. (g) Acute Primary Pneumonia and Acute Inpucnral Pneumonia.—-58 cases were notified during 1925, compared with 55 85 for the preceding year. The case mortnlity from pneumonia (all forms) was 45.4 per cent. (i) Encephalitis Lethargica.—One case of encephalitis was notified: (ii) non-notifiable infectious diseases. The most important of these are measles, whooping cough and summer diarrhoea. There were no serious epidemics of these diseases, and the deaths registered were as follows:— Measles 1 Whooping Cough 13 Summer Diarrhoea 9 Measles ami Whooping Cough.—Cases amongst school children are reported to the School Medical Officer by school teachers, attendance officers and nurses, appropriate action being taken as regards exclusion and supervision of contacts. Further particulars of action taken will be found on page 10 of the School Medical Officer's Report. ISOLATION HOSPITAL. The following is the table of admissions, etc., in rcspect of infections diseases during 1925 :— Disease. In Hospital January, 1st, 1924. Admitted during the year. Died. charged In Hospital Dec. 31st. 1924 Scarlet Fever 7 58 1* 54 10 Diphtheria 3 70 2† 50 15 Pneumonia — — — — Puerperal Fever — 4 — 3 1‡ Measles — 2 — 2 Chicken Pox — — — — — Mumps — — — — — Whooping Cough — — — — — Enteric Fever — — — — — Ophthalmia Neonatorum — 1 — 1 — Erysipelas — 3 1 2 — Cerebrospinal Meningitis — 1 1 — — *Case diagnosed as Pneumonia. † One Case diagnosed as Scarlet Fever. ‡ Case diagnosed as Phthisis. 56 One case of mixed infection was admitted to hospital, and one instance of cross-infection occurred during the year. The ward buildings and other appurtenances comprising the isolation accommodation of the district are now inadequate and inefficient, lacking more or less all of the essential requirements of the modern Infectious Hospital, while the steady development of the district would appear to render necessary the formulation of some definite scheme providing sufficient and efficient accommodation for the segregation and treatment of infectious disease Including a ward reserved for maternity work, the actual number of beds available, based on modern standards, for infectious disease is only 30. While several different schemes present themselves for consideration, it is necessary to remember that at least one bed per 1,000 is required as a hospital district basis for infectious disease, and that this proportion should be provided according to whatever population area would necessarily be served. The present hospital site in Upney Lane, if considered sufficiently central and otherwise suitable lor further building operations, could be extended, or, alternatively, a more suitable site selected elsewhere. A "squaring off" of the present site, however, by an extension of certain boundaries would be a sine qut non of any scheme affccting that particular site. The present hospital buildings are unsuitable and unsatisfactory for the treatment of the infectious sick and could be satisfactorily reconstructed, re-planned and extended only at considerable expense, while entirely new buildings to be erect on the same or some other site on modern and up-to-date lines— in my opinion, the only satisfactory solution to the problem —would mean still greater expenditure. A further alternative presents itself, which deserves some. consideration in so far as capital commitments could be to some extent avoided and upkeep charges lessened, by the formation of a Joint Hospital Board with one or more neighbouring districts, the policy of the large centrally-placed hospital commending itself or. other lines than those merely of finance. The present hospital, however, could be rendered suitable for treating advanced tuberculosis only, from Barking and by 57 arrangement probably also from neighbouring districts, at considerable less expense than it could be reconstructed tor the treatment of infectious disease. The continued use for maternity work of part of the limited space at the district's disposal forr the treatment of infectious disease should, of course, be remedied as soon as circumstances permit. TUBERCULOSIS. Administrative Arrangements.— Under the Essex County Council (the responsible authority for the treatment of tuberculosis), the Medical Officer of Health of Barking continued 2& Tuberculosis Officer for the district during the year. The administrative arrangements for dealing with tuberculosis in the area include:— (a) A dispensary used on two half-days per week, (b) Garden shelters for suitable cases, (c) Sanatorium accommodation for surgical tuberculosis, (d) Sanatorium accommodation for suitable early pulmonary cases, and in some instances the more advanced, (e) Accommodation for a number of bedridden and advanced cases at St. Joseph's Hospice, Hackney. A suggestion was made towards the end of the vear that certain cubicles at the Infectious Hospital he set apart by arrangement with the County Council for the segregation of advanced cases of pulmonary tuberculosis where home conditions were unsatisfactory and not conducive to the best interests of the patient's family. This question, an urgent one as concerns this district, was under consideration at the end of the year. I he number of notified cases on the register on December 3lst, 1925, was 793, compared with 746 for the corresponding Period of the preceding year. During the year 1925 80 notifications were received of all forms of tuberculosis—pulmonary 57, and non-pulmonary 23— representing a notification rate of 2.08, compared with an average notification rate of 2.5 for the quinquennium ending December, 1925. Information was received of the removal into the district of wee tuberculous persons, whilst one case not counted the previous year was traced in the district. 58 Thirty-five deaths of notified cases occurred (including one certified due to bronchiectasis!. Two cases left the district or could not otherwise be traced, leaving 793 on the register on December 31st, 1925, 384 being male and 409 female. Particulars of new cases of tuberculosis notified and of deaths from the disease during 1925 is afforded by the following table :— New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. N'onPulmonary Male. Female Male. Female. Male. Female- Male. Female Under 1 Year — — 1 1 — — 1 l 1 to 5 years — — 3 2 — — 1 1 5 to 10 years 3 2 3 2 — — — — 10 to 15 years — — _ 2 — — 1 — 15 to 20 year 5 o — 3 2 — — — 20 to 25 years. 3 8 — 1 2 — — 25 to 35 years 3 5 — — 2 2 — — 35 to 45 years 6 5 — — 5 7 1 — 45 to 55 years 5 3 — — 2 1 — — 55 to 65 years 2 1 — — 4 — — — 65 yrs. & upwards — 1 — — 1 — — — Totals 27 30 12 11 18 18 4 2 PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS REGULATIONS, 1925. 1 hese regulations, which came into force on July 31st, 1*526, give power to a local authority to prevent any person sulTrnn| from tuberculosis of the respiratory tract entering upon any employment or occupation in connection with a dairy whi"1 would involve the milking of cows, the treatment of milk, or the handi ng of vessels used for containing milk. An) person vvbo deems himself aggrieved by a requirement under these regutot*** mav appeal to a Court of Summary Jurisdiction,"and may urtk/ certain circumstances bo compensated for any damage sustained- In one ease only was it found necessary to take action u dC these regulations, the affected person ceasing his employ*!^ as a milk roundsman upon request. No appeal or claim made. 59 PUBLIC HEALTH ACT. 19-25, SECTION 62. In no instance was it found necessary to take action under this section to secure the compulsory removal to hospital of it tuberculous person in an infective state. As regards the occupations of notified cases during the year, the following table is of interest:— Retired Policemen 1 Milliners 1 Nophtha Distillers 1 Packers 2 Asbestos workers 3 Steel Erectors 1 Salesmen 1 Bricklayers 1 Machinist 1 Carpenters 2 School Children 10 Gatekeepers 1 Labourers 8 Clerks 2 Housewifery 16 Insurance Agents 1 "^op-lauys ... 1 Barmen 1 Typists 1 Painters and Decorators 1 Factory hands ... 6 Nil 10 Warehousemen 2 The following figures indicate for the four quarters of the year the percentage attendances of cases per 10,000 population at the Tuberculosis Dispensary and of those admitted to sanatoria undo the County Council :— Attendances at Dispensary. Admission to Sanatoria. No. Kate per 10,000 population. No. Rate per 10,000 population. 1st Quarter 425 110.5 15 3.9 2nd Quarter 307 79.8 12 3.1 3nl Ouarter 270 70.2 20 5.2 4th Quarter 424 110.2 20 5.2 the average for the year being 92.6 and 4.3, compared with 100.9 and 4.92 for the preceding year, and 83.31 and 3.41 respectively for 1923. 60 The proportion of sanatoria admissions to cases notified was 83.7 per cent., and the incidence of tuberculosis per 10,000 population in respect of notified cases 206.2. The following are particulars of cases notified under Forms C and D during the year :— Form C. Form D. Pulmonary. Non-Pulmonary Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Male. Female. Male. Female 31 24 3 5 18 19 6 1 Forty-two deaths occurred from tuberculosis (all forms), 36 of these being pulmonary cases. The number of deaths in institutions was 16. The death rate for tuberculosis (all forms) during ]925 was 1.09, compared with 1.02 for the previous year, and an average death rate of 1.1 during the preceding five years. During 1925 eight deaths from tuberculosis were registered of persons not previously notified as suffering from the disease. The importance of notification is that the necessary steps car be taken with regard to the care of patients and contacts and the prevention of spread of the disease. Delay in notification is bad for both patients and public. Of deaths registered due to tuberculosis, notifications received by the Medical Officer of Health were as follows:— Number not notified at time of death 8 Number notified less than 3 months before death 12 Number notified 3 to 6 months before death 2 Number notified 6 to 9 months before death 3 Number notified 9 to 12 months before death 2 Number notified 12 to 18 months before death 4 Number notified 18 to 24 months before death — Number notified more than 21 months before death 11 61 The incidence of tuberculosis amongst cases attending the Tuberculosis Dispensary is shown from the following table:— Insured. Not Insured. Ex-Service Men. Pulmonary M 70 60 58 F 34 90 — Non-Pulmonary M 5 37 1 F 7 27 — Five hundred and four patients made 1,426 attendances at the dispensary during the year for the purpose of medical examination, 179 being new cases. Of new cases attending during the year, 50 were notified as suffering from tuberculosis. At the end of the year 342 cases on the Dispensary Register Mere definitely diagnosed as suffering from tuberculosis, whilst in 162 C;ises the diagnosis still remained in abeyance. MEMORANDUM 37/T (TUBERCULOSIS). In accordance with the requirements of the above Memorandum, all patients on the Dispensary Register at the end of the year were classified in the following manner :— Pulmonary Cases.—These cases were divided into two classes, viz.( T.B. Minus and T.B. Plus, the former class including those in whom tubercle bacilli had never been demonstrated in the sputum, and the latter class those in whom tubercle bacilli had been tound. The latter class (T.B. Plus) was further sub-divided into three groups as follows:— Group 1.—Cases with slight constitutional disturbance, if viz., those cases with no marked acceleration of pulse nor elation of temperature except of very transient duration. Group 2.—All cases which could not be placed in Groups 1 and 3. 62 Group 3.—Cases with profound systematic disturbance or constitutional deterioration; with marked impairment of function either local or general, and with little or no prospect of recovery Son-Ptihnouary Cases.—These cases were classified accordir g to the site of the lesion as follows:— (1) Tuberculosis of bones and joints. (2) Abdominal tuberculosis (i.e., tuberculosis of peritoneum, intestines or mesenteric glands). (3) Tuberculosis of other organs. (4) Tuberculosis of peripheral glands. In addition, each case was classified as to whether disease was "arrested" or "not arrested," an "arrested" case being one whose condition had been "quiescent" for a period of two years. It is of interest to here note that no "arrested" case should be discharged as "cured" until the arrest of the disease had been maintained for a period of three years after the period of two years "quiescence," and that in non-pulmonary cases the term "arrested" may be used as soon as there is rtaspn to believe that the disease is unlikely to recur. The following tables give in tabulated form details of the above classification of patients at the Barking Dispensary:— (a) Number of persons on Dispensary Register on 31st December, 1925. Pulmonary. Non-Pulmonary Totals. Adults. Children. Adults. Children. Adults Children M. F. M. F. M. F M. F. M. F. M. F. (i) Diagnosis completed 97 88 39 42 8 12 34 22 105 100 73 64 (ii) Diagnosis not completed 0 14 62 74 — 1 — 2 9 15 62 76 63 Summary showing the condition of all patients whose records are in the session of Barking Dispensary at the end of December, 1925. ??? at the time the last record made ??? the year to which ??? Return relates. Pulmonary. Non-Pulmonary Class T. B. Plus Other Organs. Class T. B. Minus. Group 1. Group 2. Group 3. Total (class T. B. plus). Bones and Joints. Abdominal. Peripherialil Glands Total Adults M 1 — — — — — — — — — ???charged as ??? F — — — — — — — — — — Chldn. M — — — — — — — — — — F — — — — — — — — — — Adults M 52 4 6 — 10 1 2 — 1 4 ??? F 39 4 2 1 7 4 — 1 3 8 Chldn. M 18 — — — — — 1 — 6 12 F 20 — — — — 1 2 — 10 13 Adults M 17 7 11 — 18 2 — 1 1 4 ??? not arrested F 31 3 5 3 11 — — 1 1 4 Chldn. M 21 — — — — 13 2 1 6 22 F 13 — — — — 6 — — 3 9 Adults M 3 — — 8 8 — — — — — F — — — 9 9 — — — — - C hldn. M — — — — — — — — — — F — — — — — — — — — — ??? M — — — — — — — — — — F 3 — — — — 1 — — — - Totals 227 18 24 21 63 35 7 4 31 — Number of Insured persons on Register at 31st December,1925 116 Number of insured persons receiving Domiciliary treatment en 31st Dec. 1925 9 64 AFTER-CARE. Tuberculosis in the great majority of instances is a curable infection provided the patient is seen sufficiently early, undergoes sanatorium treatment and subsequently is able to pass his life under reasonably hygienic conditions. 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 16 new cases were so assisted, whilst 23 old cases were further assisted from the previous year. The funds of the Association are mainly dependent upon :— (a) Essex Insurance Committee. (b) Romford Board of Guardians. (c) Annual donations from certain Friendly Societies and Trade Unions. (d) Donations from various local Sports Clubs. (e) Donations from private individuals and from proceeds raised at Whist Drives and Dances organised by the Social Sub-Committee. Equally important in the matter of after-care is that of dealing with the large number of advanced cases who are, in the majority of instances, in a highly infectious condition and net infrequently living under overcrowded home conditions. for these practically no remedy hitherto existed, except the workhouse, but by virtue of Section 62 of the Public Health Act, 1925, local health authorities have become vested with powers where, in the opinion of the Medical Officer of Health the conditions of a tuberculous patient at home are inimical to the best interests of a his or her dependents, to secure such patient's removal compulsorily pr otherwise to a suitable institution and to there detain 65 him or her until circumstances have changed. It only remains to point out that where such steps become necessary, local institutional arrangements should be available. Compulsory disinfection of all houses after death from tuberculosis is now practised throughout the district under Section 5 of the Infectious Disease (Prevention) Act, 1890. DISINFECTION. This subject was discussed at considerable length in my report for last year. 66 SECTION 4. MATERNITY AND CHILD WELFARE. The Local Supervisory Authority for the district under the Midwives Acts, 1902 and 1918 is the Essex County Council. B\ arrangement a number of inspections and investigations were carried out by the Medical Officer of Health regarding- the work of 7 midwives who had notified the Local Supervisory Authority of their intention to practice within the district during the year. It is gratifying to report that there has been an increasing tendency amongst local midwives to co-operate in the Authority's Ante-natal and Infant Welfare schemes as regards the care of expectant and nursing mothers not under the supervision of a medical practitioner. Reference was made in my Report for last year to the practic e of unqualified women acting in the capacity of maternity nurses during the lying-in period, an undesirable arrangement, and one which falls considerably short of the ideal. Although definite figures are not available, it might be stated that in Barking during 1925 23 per cent, of confinements were nursed by unqualified women. NOTIFICATION OF BIRTH ACTS, 1907 and 1915. The above Acts require all live births and still births of seven months and over to be notified to the Medical Officer of Health within 30 hours, being an additional requirement to the Registration Act of 1836, by which all live births must be registered within six weeks. 67 Of the total live births which occurred during the year all except 33, or 3.9 per cent., were notified, particulars of from whom notifications were received being supplied by the following table:— By whom notified. Live Births. Still Births Medical Practitioners 136 ??? 4 ??? Certified Midwives 555 ??? 20 ??? Parents and Others 106 ??? 4 ??? The actual number of births within the district during the year was 830, the net total of 825 being reached by adjustment of inward and outward transfers, etc. Of the total live births during the year 519, or 66.1 per cent., were attended by midwives, the remainder being attended by medical practitioners. The percentage of still births was 3.2. The actual number of all births registered included 411 males and 414 females, of which number 23, or 2.7 per cent, were illegitimate. On comparison with 1024, 21 fewer births were registered during 1925, a fall equivalent to 2.4 per cent. There can be little doubt that a considerable proportion of this fall is intentional, though partly resulting from industrial distress and the housing shortage, factors which have ever prolonged the mean age at carriage, and have in turn paved the way to the now growing practice of birth control. MATERNITY WARD. One ward at the Infectious Hospital continued to be used for maternity work during the year. 206 cases were admitted and 167 babies born (compared with 143 and 124 respectively in 19241 or 20.1 per cent. of the total births of the district. Although the percentage number of occupied beds during the year showed an increase, there is still matter for regret, considering the over- 68 crowded state of the district generally, and the undesirable conditions under which in many cases confinements take place that more advantage is not taken of the facilities in this respect placed at the district's disposal. It has to be remembered, however, in drawing comparisons, that as present situated the Maternity Ward cannot cater for cases other than what would generally be considered "straight-forward," little local facilities existing for dealing efficiently with more than minor deviations from the normal. The following return required by the Ministry of Health for the year ended 31st December, 1925 is included as under, the comparative freedom from the more usual complications of childbirth and necessity for the intervention of outside aid being partly explainable from the preceding context. (1) Number of cases admitted (39 of which Ante-natal.) 206 (2) Average duration of stay 14.5 days (3) Number of cases delivered by:— (a) Midwives 166 (b) Doctors 1 (4) Number of cases in which medical assistance was sought by the midwife with reason for requiring assistance:— (a) Ante-natal Nil (b) During Labour 1 (c) After Labour 10 (d) For Infant 6 (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.A for 24 hours with rise of pulse rate.—Nil. (7) Number of cases of pemphigus neonatorum.—One. (8) Number of cases notified as ophthalmia neonatorum with result of treatment in each case.—One (recovered). (9) Number of cases of " inflammation of the eyes," however slight.—One. 69 (10) Number of infants not entirely breastfed while in the Institution, with reasons why they were not breastfed.— Four. (a) Weakness of mother 1 (b) Prematurity 2 (c) Depressed nipples 1 (11) Number of maternal deaths.—Nil. (12) Number of foetal deaths (a) stillborn, and (b) within 10 days of birth and their causes—and the results of the post mortem examination if obtainable:— (a) Stillborn 6 (b) Prematurity 1 As in previous years advantage was taken of the above Ward for the treatment of suitable cases referred from the Ante-natal Clinics, 39 cases being admitted compared with 31 in 1924. PUEPERAL SEPSIS. Four cases of puerperal sepsis were notified compared with 3 in 1924, all of which were admitted to the Infectious Hospital. Three of these had been attended by midwives. A case notified on the 31st December as "puerperal sepsis" was on admission found suffering from advanced pulmonary tuberculosis, and transferred to another institution. As in previous years special investigations were carried out by health visitors in all notified cases, though in no instance was it possible to arrive at any specific cause for the disease. MATERNAL DEATHS. One death occurred attributable to the puerperal state, giving a maternal mortality rate of 1.2, compared with 3.54 for the previous year, and 3.90 for the country as a whole. Maternal mortality is a question occupying the serious consideration of the Ministry of Health, it being evident that the mortality rate of England and Wales has remained practically stationary during 70 the past quarter of a century, amounting to approximately four maternal deaths in every 1,000, without taking- account of tinamount of injury, disability and subsequent illhealth resulting from child bearing. It is satisfactory to note the increasing inteiesi taken respecting this problem, with which is so closely allied the one feature of infant welfare in which very little orogress has hitherto been made, viz., deaths due to ante-natal conditions and occuring during the first month of life, and where disease of the mother has been variously estimated as being responsible for the occurrence in some 50 per cent, of cases. BIRTHS. The birth rate is calculated on the number of births registered per 1,000 population and during 1925 was 21.4 compared with 18.3 for England and Wales, the lowest figure yet recorded for the country as a whole. Attention was directed to the main causes of our falling Birth Rate in the opening paragraphs of this Section of my Report. Of (he total births recorded, 23 or 2.7 per cent, were illegitimate compared with 2.3 per cent, in 1924 Primary visits were paid to 829 of the total births during the year. STILL-BIRTHS. Of the total notifications received under the Notification of Births Act, still-births formed 3.2 per cent., compared with 1.5 per cent, in 1924: and 2.6 in 1923. The actual number of still births notified for the year was 28, of which 20 were attended by midwives. Of these 3 referred to non-residents, while 2 Barking women had still births outside the district in addition to the 28 which occurred in the district. 71 Special visits of investigation in all still-births were paid, and the following details elicited as far as accurately could be established:— (1) Duration of pregnancy:— (a) Less than seven months 1 (b) More than seven months 29 (2) Presentation:— (a) Vertex 22 (b) Breach 3 (c) Footling 1 (d) Not elicited 4 (3) Supposed cause of still-birth:— (a) Abnormal presentation 1 (b) Overwork 2 (c) Accident, etc. 7 (d) Not known 14 (e) Ill health, etc. 4 (f) Malformation 2 (4) Occupation of mother:— (a) Household duties 22 (b) Factory hand 4 (c) Shop assistant 2 (d) Flower seller 1 (e) Machinist 1 Of the mothers who had still-born babies 9 had worked up to the time of confinement. Of the total number of mothers who had still-births 10, or 35.7 per cent, had attended the Ante-natal Clinic once or oftener. As already pointed out disease of the mother probably accounts for some 50 per cent, of still-births throughout the country. 72 OPHTHALMIA NEONATORUM. The number of cases notified was 12 compared with 7 in 1924. Of these 7 occurred in the practices of mid wives, the remainder having- been attended by medical practitioners. One mother whose infant suffered from ophthalmia neonatorum had attended the ante-natal clinic. Particulars of these cases are afforded from the following table:— Age . Group. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Treated. Notified. At Home. At Hospital Under 3 weeks 12 11 1 12 — — — ANTE-NATAL CENTRES. Owing to the increasing' number of expectant mothers avail ing themselves of ante-natal supervision during the year, an additional session was opened on the 1st May, 1925, at the Central Clinic in East Street. The average number of new cases seen per session was 3.8 while on an average the number of subsequent attendance per session was 7.5, making an average attendance of 11.3 expectant mothers per session. During 1924 the average attendance of expectant mothers per session was 14.8. Ante-natal measures continued to be adopted locally where possible in venereal complications, otherwise arrangements were made for treatment being carried out at neighbouring hospitals. Syphilis remains the great cause of still-birth and abortion. Gonorrhoea causes sterility in both male and female, being at the same time causative of many of the more serious obstetrical and gynaecological complications. The following table affords particulars of cases referred from the ante-natal clinic for hospital and other treatment:— 73 Cause. No. of Cases. Contracted Pelvis 2 Syphilis 1 Gonorrhœa 1 Heart Disease 1 Phthisis 3 Threatened Abortion 4 Toxæmias of Pregnacy 5 Hyperemesis 1 Pelvic Peritonitis 2 The foregoing; total does not include patients who received ante-natal treatment in the Maternity Ward of the Infectious Hospital, 39 of whom were admitted during the year. The number of primigravidæ attending the ante-natal clinic during the year was 114, and the number of ante-natal visits paid by the Health Visitors 128. WORK OF THE HEALTH VISITORS. The number of health visitors was increased from 2 to 3 by the appointment of an additional visitor, who commenced on 14th April, but who ceased work on the 5th October, leaving two health visitors to carry on for the rest of the year. The number of weekly sessions was increased from three to six, an additional afternoon session being first held at each of the three welfare centres on the following dates:— Abbey Hall6/5/1925 Empress Hall 5/5/1925 Central Clinic, East Street 7/5/1925 The premises used as a Welfare Centre in Abbey Road, long considered unsuitable for the purpose, were vacated on 25-11-25 when new premises, known as the Alexandra Centre, which had been erected by the Authority, were officially opened by the Chair- 74 man of the Public Health Committee on 26-11-1925. The first session at the new Centre following the opening- ceremony was held on 2-12-1925. Kennedy Hall, which had been used as a Centre since 1920 was vacated on 16-2-25 and another Centre opened on lease of the Empress Hall, Ripple Road, for use on two afternoons per 1 week, the first session at Empress Hall being held 23-2-25. Duri.ig the year it was proposed to devote a number of these extra sessions to sewing and knitting classes, demonstrations in model garments, and the sale of wool, the earlier part of the meeting to be given up to baby-weighing, health talks, etc. It was found, however, that the unavoidable absence of a mcdical officer at many of these sessions was not followed by the success which had been originally anticipated. Eight hundred and twenty-nine births were visited and 2,990 re-visfts paid, being on an average 4.6 visits per child.during the first year of life, while 1,242 visits were paid between 1 and 5 years. To some extent the relatively fewer visits paid to older children was due to diminished staff, a circumstance which it is hoped will be rectified when the full number of health visitors is again restored.  Kennedy and Empress Halls. Clinic premises. Abbey Hall and Alexandra Centre. Total attendances:— 1 to 12 months 1,833 2,195 2 322 1 to 5 years 1,536 1,648 1,991 Average No. of attendances per session 41.5 47.4 53.2 No. of new cases 173 175 179 No. of old cases 3,196 3,668 4,134 Average No. of attendances per mother 33.4 36.6 42.6 The addresses of 44 children who left the district were sent to the Medical Officers of Health for the districts to which' they had gone. During the year the number of births and deaths of children up to one year of age occurred as follows:— 75 LIVING IN 1 room. 2 rooms. 3 rooms. 4 or more rooms. Births. Deaths. Births. Deaths. Births. Deaths. Births. Deaths. 131 12 104 18 91 11 439 25 DEATH RATE PER THOUSAND BIRTHS. 91.0 109.7 120.8 50.9 76 Particulars of the work of the Health Visitors and Centres will be found from the following table:— No. of ante-natal visits 128 No. of first visits to children under one year 829 No. of subsequent visits to children under one year:— (a) Attending a Centre 446 (b) Not Attending a Centre 2.544 No. of visits to children 1 to 5 years of age:— (a) Attending a Centre 97 (b) Not Attending a Centre 1,145 No. of special visits in connection with Ophthalmia Neonatorum 20 Ditto Deaths of children up to 3 years of age 79 Ditto Still-births 22 Ditto Puerperal sepsis 4 Ditto Foster Children 20 Other visits (not specified) 104 The following table is of interest respecting infant feeding:— Ureast Fed. Mixed. Artificial. No. of children under supervision— feeding at the end of first month 501 47 29 Children who died during first year of life—feeding during firet month (where elicited) 37 10 1 Children who died from diarrhoeal diseases—feeding at time of death 1 2 6 Special visits were made to all deaths up to 3 years of age by Health Visitors. 77 DEATHS AMONG NOTIFIED AND UN-NOTIFIED BIRTHS. 92.4 per cent, of the deaths under one year of age were notified, the remainder being un-notified. SEX. The death rate among male children was 87.5 per thousand births, and among females 72.4, the excessive male death rate during the year being noteworthy. NEONATAL MORTALITY. The neonatal mortality rate is calculated on the number of deaths of children under four weeks per thousand births, and (luring 1925 was equal to a rate of 30.3 compared with 36.6 for the previous year. From the following table it will be seen that out of a total of 25 deaths during the first four weeks of life 13 occurred during the first seven days and 8, or 61.5 per cent, of these resulted frcm prematurity or debility. The question of further ante-natal care was emphasised in my Report for the previous year as an important factor in further reducing the disproportionate incidence of infantile deaths during the neonatal period. 78  Deaths Under Four Weeks. Under seven days. Under fourteen days. Under twentyone days. Under twentyeight days. Total. Bronchitis — — — 1 1 Piarrhœa — 1 — — 1 Injury at Birth — 2 — — 2 Atelectasis 1 — — — 1 Congenital Malformation — — — 1 1 Premature Birth 8 2 — — 10 Debility 3 — — — 3 Intestinal Obstruction — 1 — — 1 Nephritis — 1 — — 1 Pemphigus Neonatorum — 1 — — 1 Absces (Pyæmia) — — — 1 1 Want of proper attention at Birth 1 — — — 1 Icterus Neonatorum — 1 — — 1 79 dental treatment of mothers, and children UNDER 5 YEARS. This question has been discussed in the Dental Surgeon's Report, which appears on page 27 of the School Medical Officer's Report. Eighteen mothers were supplied with dentures during the year. 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 12 mothers availing themselves of its advantages during the year, 381 dinners being supplied. FOSTER CHILDREN. Cases of foster children received in the district are notified to the Mcdical Officer of Health by the Guardians under Part 1 of the Children Act, 1908, 20 children being so notified during flic year. Special visits in all cases were made by the Health Visitors, and the foster-mothers as far as possible induced to attend a Welfare Centre regularly with the children. As a general rule the care of these foster children continues to be satisfactory, it being only necessary in one instance to make any complaint during the year. 80 CONVALESCENT TREATMENT. Seven mothers with young babies, and two children received convalescent treatment during the year, particulars of length of stay, patients' contributions, net cost to Council, etc., being afforded by the following table: Cass No. Description of Patient. Situation of Convalescent Home. Charge made by Home, (per week) Length of Patient's stay. Patient's contribution. Council's net responsibility. Rly. Fares Home. Total. f. s. d. f, s. d. 747 Mother & Baby Limps field, Surrey 15/- 1 week Own travelling expenses only — 0 15 0 0 15 0 776 Mother & Baby Limpsfield, Surrey 15/- 3 weeks Ditto — 2 5 0 2 5 0 801 Child- St. Leonards-on-Sea 25/- 2 weeks 5/- per week 7/6 2 0 0 2 7 6 819 Mother & Baby Limpsfield, Surrey 15/6 4 weeks Nil 7/1 3 2 0 3 9 1 889 Mother & Baby Birchington-on-Sea 25/- 2 weeks 15/- per week — 1 0 0 1 0 0 893 Child Arkley, Barnet 12/6 8 weeks 5/- per week 3/- 3 0 0 3 3 0 892a Mother & Baby Birchington-on-Sea 25/- 3 weeks 10/- per week — 2 5 0 2 5 0 907 Mother & Baby Limpsfield, Surrey 15/6 2 weeks 5/- per week 7/1 1 1 0 1 8 1 OH) Mother & Baby Limpsfield, Surrey 15/6 2 weeks Nil 7/1 1 11 0 1 18 1 81 ILLEGITIMACY. Twenty-three illegitimate children were born during the year, giving an illegitimate birth rate of 0.59 per thousand population, illegitimacy thus forming 2.7 per cent, of the total birth rate compared with 2.3 per cent, for the previous year. While the infantile death rate among legitimate children was 76.05, that among illegitimate children was equal to 217.39. INFANTILE MORTALITY. While the birth rate for the district in 1925 was 21.4, the infantile mortality rate was 80 compared with 22.3 and 85.1 repectively in 1924. The number of deaths from diarrhœal diseases under two years of age per 1,000 births was 10.9, forming 34.6 per cent, of the zymotic death rate, which was 0.67. The actual number of deaths from all causes under one year was 66, 30 being , female and 36 male children. During the same period the infantile mortality rate for England and Wales was 75, for the 105 Great Towns 79, for the 157 smaller towns 74, while in London it was 67. Deaths during the neonatal period have been considered in a previous section. Sixteen children died over a month and under three months, 9 over three months and under six months, 8 over six months and under nine months, and the remainder between the ages of nine months and one year. In 6 cases death was due to debility and marasmus, in 1 case to convulsions, in 9 cases to diarrhoea, and in 13 cases to bronchitis and pneumonia. From July to September 10 eases of summer diarhœa were visited. The preponderance of artificial feeding among fatal eases is noteworthy. The infantile mortality rates for 1924 of 85.1 and of 80 for 1925 cannot be considered otherwise than high, and are attributable partly to defective environment and sanitary conditions, but it is well known that given the above conditions and a big percentage of breast fed babies the infantile mortality rate will be 82 low, breast feeding protecting the infant against one of its most deadly contingencies—infection through the milk, while further a known protection against various infections (which is probably quite specific) is afforded by the mother's milk. In Berlin from 1900-1904 only 10 per cent, of infants' deaths occurred in breast fed babies while Laling analysing over 13,000 infants in Baudeloque's Clinic found that of the total deaths 14 per cent, occurred in breast fed compared with 85 per cent, in bottle fed babies. Without further stressing this important point, of 1,000 fatal cases investigated by the Health Department of New York City in 1908 it was found that fatal cases in breast fed infants numbered only 9 per cent, of the total number of deaths. ORTHOPAEDIC TREATMENT FOR CHILDREN UNDER 3 YEARS OF AGE AND CO-ORDINATION OF WORK WITH THE SCHOOL MEDICAL SERVICE. This has been discussed at length in the report on the School Medical Service on pages 1, 2 and 16. MEASLES, WHOOPING COUGH AND DIARRHOEA. During the year 105 visits were paid in connection with the incidence of the above diseases as under:— Disease. No. of Visits. Measles and German Measles 9 Diarrhœa 10 Whooping Cough 86 PROVISION OF FRESH AND DRIED MILK. The three brands of dried milk in use, "Glaxo," "Cow and Gate." and "Ambrosia," arc generally recognised as being amongst the best, and experience of them locally justifies this opinion. 83 Particulars of amounts used are provided by the following table:— Cost Price, (lbs.) Reduced Price, (lbs.) Free, (lbs.) Total, (lbs.) Glaxo (Full Cream) 3,331 45 265 3,641 Gtaxo (Half Cream) 2 — — 2 Glaxo (Humanised) 50 — — 50 Ambrosia 2,728 45 203 2,976 Cow and Gate 10,048 75 935 11,058 frufood 12 — — 12 Fresh milk is supplied free and at reduced price to necessitous mothers and children, particulars of which are supplied by the following table:— 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. £ 9. d. £. s d. 2,050 16,373 18,423 249 9 7 235 12 0 Although it is gratifying to record the general increase in natural as distinct from bottle feeding throughout the country, there is still a great deal of unnecessary bottle feeding practiced. There are, however, many formidable obstacles in the path of natural feeding advocates, and one of the most serious is that commonly known as vested interests. The manufacture of dried milk has become an extensive and lucrative one in which much capital is invested and one of the principal sources from which interest on this capital can accrue is the mother of the family of one or more children. No time in many instances is lost in bringing to the notice of a young mother after the birth of her child the virtues of one or more brands of dried milk. A circular 84 letter by post or a carefully worded advertisement in the public press can be very convincing to the wife of an unemployed man especialiy when accompanied or followed quickly by the receipt of some alluring sample, when to use the women's own words "She is not getting her proper support" and who there[???] cannot see how she can possibly naturally feed her offspring successfully, and in many such cases the damage is done before the opportunity is given to interfere. If to this commercialisation of the diet of infants there were no counteracting influence in the shape of Maternity and Child Welfare Centres it can readily be imagined that the day would soon come when artificial feeding would be a national custom to be quickly followed by the day when women, through neglect to use it, would be unable to perform one of their most essential functions. BAR 19 1 ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER. (1) STAFF. During the year Dr. Simpson continued as School Medical Officer. Mr. W. W. Dawe commenced his duties as full-time Dental Surgeon in January, and Miss F. Young those of Dental Nurse in April. The remaining personnel of the School Medical Service suffered no change throughout the year. (2) CO-ORDINATION. (a) Infant and Child Welfare. The School Medical Officer and Assistant School Medical Officer arc also Medical Officer of Health and Assistant Medical Officer of Health respectively. The nursing staff of the Education Authority is not engaged in the work of the Sanitary Authority, so that co-ordination in the fullest sense of the word is not complete. Although the present position is unavoidable, a distinct gain would result were the school nurses employed also as part-time health visitors, so that the care of children of ail ages up to 14, and in some cases even titer, could be carried out by the same nursing staff. The School Medical Service is run in close touch with the Maternity and Child Welfare schemes of the district, the Tuberculosis Dispensary, and the Barking Tuberculosis After-care Committee. 2 (b) Nursery Schools—There are no nursery schools in the district, but in certain selected cases children between 4 and 5 years of age were admitted to the Infants' Departments of certain elementary schools during the year. (c) Care of Debilitated Children under School Age.— Orthopaedic treatment where necessary is available for children under school age, joint arrangements existing therefor between the Education and Public Health Committees, any treatment required being given at the Orthopaedic Clinic of the Special School. Dental trertment and that for enlarged tonsils and adenoids is provided, the former, by arrangement with the Education Committee and available at the School Dental Clinic, the latter under similar arrangements to those for children of school age. No children under school age were admitted to the open air classes of the Special School, but sanatorium or hospital treatment was arranged for tuberculous cases through the Harking Dispensary. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. (3) SCHOOL HYGIENE. Excepting the Roman Catholic and Church of England Schools, the general hygienic conditions of the remaining elementary schools can be considered satisfactory, the two excepted being the oldest schools in the district. Hygienic defects are more keenly felt in the case of the Roman Catholic School, which has been considerably overcrowded of late. Both schools lack, to some extent, open surroundings, and from the points of view of lighting, ventilation and heating leave something to be desired. 3 A site has been secured for an additional Roman Catholic School which, on completion, will go some way in minimising existing overcrowding. The question of types of desks, blackboards, sanitary conveniences, water supply, etc., were dealt with at some length in my Report for 1923 With the exception of the Special School, no facilities exist at any of the others for the drying of children's clothes or boots. PROVISION OF MEALS. (i) A hot mid-day meal of two courses is provided for children attending the Special School, parents contributing to the cost thereof according to means. Meals are served in the Dining Hall of the School under the supervision of certain teachers, who, at the close of the children's dinner, are supplied with meals at a nominal charge. Pood is cooked in the Municipal Kitchen, arrangements existing for keeping food hot during transit and at the school before service. The actual service of meals is in the hands of assistants, although selected children take part in its distribution. (ii) It is possible for children in attendance at all other of the elementary schools to return home for the mid-day meal. (4) MEDICAL INSPECTION. The first table in the appendix shows the number of children inspected and ages at inspection, the Board's scheme being followed throughout. Every child is submitted to routine, medical inspection three times during its school life as one of the fundamental functions of the School Medical Service, the system employed ensuring that no child is omitted. 4 The number of children examined as entrants, intermediates and leavers, besides those examined otherwise than during routine inspection, together with the percentage of defectives found, is furnished by the subjoined table :— Entrants. Intermediates Leavers. Specials. Other Routine Examinations. Total. No. of children examined 1015 437 640 49 205 2,346 No. referred for treatment 265 124 141 34 27 591 No. referred for observation 82 40 22 10 11 165 Percentage of defective children 34.1 37.5 25.4 89.7 18.5 32.2 The proportion of children, whose parents were present at school examination, was 65.5 per cent., compared with 53.1 per cent. during the preceding year. The number of children ou the school register on 31st December, 1925, was 6,791, compared with 6,539 oil 31st December, 1924. From a large series of general examinations of over a million children throughout the country it has been found that 19.4 per cent, required treatment, compared with the figure which for Burking in 1925 was 25.1 per cent. During the year, the Medical Officer paid 114 visits to 22 departments for inspection purposes, examinations being conducted throughout the year on the various school premises. Curtain cases of defect were, as in previous years, referred to the School Clinic for further examination and treatment. Very little disturbance of school routine is occasioned by these inspections, the convenience of teachers being followed as far as possible. 5 The following table shows the number of children examined at routine and special inspections during 1925, 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 24 276 282 367 North St 23 220 198 292 Castle 3 35 17 29 Creeksmouth 1 3 3 6 Westbury 18 180 197 269 Ripple 17 181 163 246 Faireross 7 107 08 127 VOLUNTARY SCHOOLS. Church of England 13 132 111 127 Roman Catholic 8 69 74 75 (5) FINDINGS OF MEDICAL INSPECTIONS. Table II., Appendix (a), gives a return of defects found during the course of routine examination. Of those examined at routine and special inspections, 756, or 32.2 per cent., had some defect, and the actual percentage requiring treatment was 25.1. t (a) Malnutrition.—Twenty-one cases were found on inspection sufficiently serious to require treatment, and 23 others were specially watched, most of the cases found being already in attendance at the open-air classes of the Special School. The main causes of malnutrition are probably environmental in origin, followed to a minor extent by improper or insufficient food. The belief is gaining ground that one of the principal causes of malnutrition in young children, apart from other obvious cause, is tuberculosis, usually contracted at an earlier period of 6 life. The value of an open-air school for such cases is very great, playing, as it does, the part of a preventorium where children while attending usually remain remarkably free from further evidence of activity of the disease. (b) Uncleanliness.—This defect in more recent years has shown a constant and satisfactory decline. Owing to the condition of some of the homes from which the children come, and of the other inmates, this defect cannot be stamped out by the School Medical Service alone. In this connection, close cooperation with the sanitary authority is valuable. Surveys under the above heading were carried out at (a) routine medical inspections, and (b) special inspections conducted oy the school nurses. (a) At the former, 305 children out of a total of 2,316, or 13 per cent., had nits in their hair, while 6 of 0.25 per cent. had head or body vermin. As formerly, cases were seen at the School Clinic after exclusion by nurses or teachers, of which number 108 had nits and 58 head or body vermin. (b) During the vear the school nurses made 17,504 individual investigations, compared with 13,632 in 1924, of which number 2,170 children were found to have nits in the hair only, 170 harboured nits and head vermin, whilst 21 had verminous bodies and clothing. 7 Every school in the area covered by each school nurse is fully inspected during each term, the results of these examinations being as follows :-r- School. Dept. Nits only. Nits and Vermin (head). Body and clothing verminous. Gascoigne Infants 139 15 1 Boys 58 7 1 Girls 304 15 2 North St. Infants 100 8 — Boys 39 4 1 Girls 159 6 — Castle Infants Boys Girls 44 6 10 Creeksmouth Infants Boys Girls 20 2 — Westbury Infants 138 22 — Boys 21 2 — Girls 211 7 — Ripple Infants 91 8 2 Boys 26 3 1 Girls 146 7 — C. of E Infants 120 17 — Boys 46 19 1 Girls 257 9 — R.C Infants 43 3 2 Boys Girls 138 5 — Faircross — 67 6 — Printed instructions are in all cases sent to parents or guardians of children excluded from school as result of verminous conditions, cleansing of the verminous person and clothing being subsequently undertaken at the School Cleansing Station. During 1925, 169 cases were so dealt with. (c) Clothing.—Children with dirty clothing numbered 10 or 0.47 per cent., compared with 47 or 2.11 per cent. in 1924. Children with defective footgear numbered 14 or 0.66. Cases of children with defective footgear were as heretofore referred 8 to the Boots Minor Sub-Committee, who considered applications for the provision of boots in 133 cases, compared with 19 in 1924. (d) Heights and Weights.—The following table gives the average heights and weights of children examined at the three undermentioned age periods in four of the schools, compared with the results at similar age periods in 1924. Age Period. Average Height in inches. Average Weight in pounds. 1924. 1925. 1924. 1925. 5 years 41.5 42.1 39.3 41.1 8 years 48.1 49.05 52.4 54.1 12 years 56.7 56.5 78.2 78.8 (e) Minor Ailments.—Minor ailments are seen daily at 9 a.m., excepting Sundays, at the Clinic premises in East Street the staffing of this Clinic being provided by nurses of the Plaistow Maternity Charity. For particulars of cases treated, see Table IV, Group I. Instances of uncleanliness found amongst children seen at this Clinic were those excluded by teachers, school nurses, or attendance officers prior to being re-admitted to school. (f) Skin Disease.—Apart from two cases of psoriasis, the remaining affections belonged to and were dealt with as minor ailments. (g) Eye Diseases.—Apart from errors of refraction, there were few cases of. external eye disease, as the figures in Table II show. Disorders of vision, however, were again prevalent, 97 children, or 4.1 percent., of those seen at routine inspection being found suffering Irom vision so defective as to require treatment, f his is a national as well as a local disaster, and is receiving the attention at present of the Board of Education as well as that of School Medical Officers throughout the country. 9 (h) Ear Disease.—Ten children, or 0.4 per cent., were found to he deaf, while 34, or 1.4 per cent., suffered from ear disease, the latter generally having discharging ears and a certain amount of deafness in consequence. Running ears still remain the most intractable condition found amongst children at the Minor Ailments Clinic, the condition being complicated in many cases with a degree of deafness liable to piove of serious consequence in afterlife. (i) Tonsils and Adenoids.—246 children, or 10.4 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 treatment or further observation. Of cases referred for treatment, 176 were found on re-inspection to have been treated. As in former years arrangements existed for the operative treatment of post-nasal growths at the Throat Departments of St. Mary's Hospital, Plaistow, and Queen Mary's Hospital, Stratford, parents contributing to the cost of such treatment according to means. The defects of the existing scheme as outlined in my report for the previous year still remain except that home visits by the school nurses to children operated upon are now paid on the patient's return home. In certain cases children have been brought home by ambulance after operation. (j) Tuberculosis.—The total number of cases of tuberculosis in school children notified to the Medical Officer of Health during the year was 14. During the year 46 cases were referred to the Tuberculosis Officer, of whom 3 were subsequently notified as tuberculous. The total number of attendances by children of school age at the Dispensary amounted to 484, while during the year 5 children were recommended through the Essex County Council for hospital or sanatorium treatment. Quiescent cases of the disease were as in previous years admitted to the Open-air School, Faircross, and numbered 32. 10 (6) INFECTIOUS DISEASE. As the School Medical Officers are also the Public Health Medical Officers, the occurrence of infectious disease is known to them at once and steps taken accordingly. Code : Articles 45 (b), 53 (b) and 57.—No schools were closed during 1923 for infectious disease, nor was the School Medical Officer required to submit any certificate under the Board of Education Amending Regulations, No. 2 (a), 1924, for purposes of apportioning grant. (a) Scarlet Fever.—35 cases were reported in 1925, compared with 31 in 1924. (b) Diphtheria.—37 cases were reported in 1925, compared with 23 in 1924. (c) Measles and German Measles.—61 cases were reported from schools during the year, compared with 192 in 1924. (d) Chicken-pox and Whooping Cough.—160 cases of chicken-pox and whooping cough were reported during the year. 318 home visits were paid by the school nurses in connection with infectious disease during the year, whilst 144 visits were made by the sanitary inspectors in connection with notifiable cases. (7) FOLLOWING UP. Arrangements for following up cases of defect are ns follows: Children subjects of defects other than minor ailments are seen at their own homes, and advice offered the parents by the school nurses as how best whatever treatment may be necessary can be obtained. Following-up cards are kept in respect of all children referred for treatment from routine or special examination, and on subsequent visits of the medical officer to the school such children are re-inspected as to whether treatment has been carried out and its results. 11 It is gratifying to notice that of the number of children referred for treatment during- the year, 56.79 were found to have been -treated, compared with 16.38 in 1924. A summary of work of the two school nurses during the year is as follows :— No. of visits to schools 241 No. of visits to schools for medical inspection 114 No. of home visits in connection with :— (a) Routine Inspection 2837 (b) Infectious Disease 318 (c) Non-attendance for treatment, etc., 628 No of children cleansed at cleansing stations 169 (8) MEDICAL AND SURGICAL TREATMENT. The presence of defects having been ascertained, provision is made for treatment as follows :— Parents are notified as to what has been found, and requested to make arrangements for medical attention either locally, if possible, or with neighbouring hospitals or institutions. There are numerous conditions, minor ailments especially, which would escape attention altogether unless the authority arranged for their official attention. The number of cases referred for treatment will be found in the sub-divisions of Table IV, while the numbers treated, and whether by the authority's scheme or not are there set forth. These tables refer to treatment as result of inspection. The methods adopted to secure treatment are the consistent following up of cases; the provision of clinics (set forth as under), and other items referred to in this Report such as transference to the Open-air School, etc. In regard to dental work, there were as usual too many refusals. Parents do not yet appreciate the necessity of proper 12 attention to teeth. It has not been necessary to institute anv legal proceedings in 1925, but much pressure has been necessary in some cases to secure that treatment is received even when offered free. In 1925 the various clinics established included :— 1. Minor Ailments Clinic, East Street.—Mornings on days at S.30 o'clock. 2. Ophthalmic Clinic (mainly for refractions), Central Clinic, East Street.—Half-day, Saturday mornings. 3. Throat and Xose.—Operations for tonsils and adenoids are carried out by arrangement with neighbouring institutions, no facilities for the purpose being available in the district. 4. Examination Clinic, East Street.—For the further nation of special cases and cases referred from routine inspections which are seen at the closc of the Minor Ailments Clinic. Examination of backward children and the subjects of suspected mental or physical defect are carried out by the School Medical Officer at the Public Offices, where arrangements are made to suit the convenience of parents and others. 5. Dental Clinic, East Street.—Held twice daily except one session per week employed on dental inspections at school. 6. Tuberculosis.—By arrangements with the Essex County Council, the Medical Officer of Health is Tuberculosis Officer for the district. Suspected cases of tuberculosis are referred from routine inspections or from any of the special clinics to the Tuberculosis Dispensary at 37. Linton Road. The Tuberculosis Dispensary is run in close touch with the open-air classes of the Special School, while arrangements are made through the County Council for necessary cases being admitted to hospital or sanatorium. 13 7. Ring-worm Clinic.- Attendance at the rooms in Ilford of the X-ray operator by arrangement. 8. Orthopaidic clinic.—Massage, electricity, radiant heat, remedial exercises, etc., are provided for cripples and others at the Orthopaedic clinic of the Special School during three sessions per week, when a masseuse is in attendance. Artificial sunlight treatment is being installed as part of the now recognised treatment for rickets, surgical tuberculosis, and various other debilitating states. Advantage is taken of the facilities provided at this clinic by the Public Health Committee for children under school age by arrangement with the Education Committee. Monthly visits to the clinic-are paid by the orthopaidic surgeon for purposes of examining fresh cases and those undergoing treatment. Where necessary children from the Orthopaidic Clinic are admitted to Brookfield Orthopaedic Hospital, Walthamstovv, and Queen's Hospital, Hackney, for operation or other special surgical treatment. Payment for Clinic Treatment.—By instruction of the Board of Education, the following scale of charges has been made :— (a) Spectacles—2/9 per pair. (b) Tonsils and Adenoids operations-—5/- per operation. (c) X-ray Treatment—Xo charge. (d) Minor Ailments—1 /- per 3 months after 14 days free treatment. (e) Dentistry—6d. per extraction, and 1/- fillings or wiring. (f) Orthopeedic Treatment—Xo charge. Free medical treatment will continue to be given where parents cannot afford to pay. During 1925 payments made in accordance with scale amounted to ,£.77 Gs. Gd. Without careful enquiry into circumstances the process of charging is difficult, but it might be that 14 such enquiry might be more costly than results would warrant. The arrangement will probably give better results as it becomes less new. CLINICS.—Numbers attending in 1925 were as follows:— Clinic. No, of children seen. Total No. of attendances. Minor Ailments 1865 7489 Ophthalmic 131 434 Dental 2461 3211 Ringworm 1 2 Orthopaedic 84 854 Minor Ailments Clinic. No. of days clinic was open 302 Total No. of attendances 7489 Daily average attendance 247 No. of cases treated 1865 In the absence of local hospital facilities, this clinic has supplied among school children an undoubted need within recent years. Three nurses on the staff of the Plaistow Maternity Charity attend daily from a.m. to 11.30 a.m. The work of the practitioner is encroached upon as little as possible, although cases do at times arise which must under certain circumstance he relieved. There car be little doubt, I think, that the ultimate utility of the various medical and surgical measures prosecuted is impaired to an appreciable extent by the faulty arrangement and structural condition of the premises. The building, which is of a temporary character, is disposed Court-wise, forming three sides of a square, efficient lighting and ventilation of the different rooms being in consequence almost impossible. Added to this 15 premises overlook the town yard, and arc in consequence exposed to dust and other objections connected therewith. An up-to-date clinic on a suitable site is a pressing need of the School Medical Service. Skin Diseases.—Most skin diseases fall within the group of Minor. Ailment, the following being under treatment during the year:— Ringworm. Scabies. Impetigo. Other Skin Diseases. injuries. Hefld Body. 10 20 34 347 123 1001 As previously, the cleansing; station proved a valuable adjunct in the treatment of scabies. Dental Defects.—Statistics dealing with the year's work will be found under Table IV, Group IV, of the Appendix, while the Dental Surgeon's Report appears separately on pages 27 and 23. Crippling Defects and Orthopædics.—This subject has been specially dealt with by Mr. Whitchurch Howell, F.R.C.S., Orthopædic Surgeon, whose report appears separately on pages 25 and 26. Eleven monthly visits were paid by Mr. Howell luring the year, while 110 sessions of 2½ hours were attended by the masseuse. 8 children were treated by massage, 7 by electricity, 20 by re-educational exercises, while 4 children were admitted to Brookfield Orthopædic Hospital or Queen's Hospital Hackney, for special surgical treatment. Total attendances at this clinic during the year numbered 854. 16 Particulars of work done in connection with Orthopædic Clinic. No of Visits tby . Orthopædic Surgeon No. of visits by Masseuse ATTENDANCES Primary Examination Re-Examinatlion For Treatment Total School i Children Under School Age School Children Under School Age School Children Under School Age 11 110 49 11 108 3 683 — 854 TREATMENTS Massage Electricity Remedial Exercises Other No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No. of Treatments No. of Children No of Treatments School Children ... 8 115 7 190 20 632 5 47 Undc School Age — — — — — — — — Admission to Orthopædic Hospitals On waiting List for Admission 31/12/25. School Children Under School Age Total School Children Under School Age Total 2 2 4 4 1 5 17 Children on the Physically Detective Register may be classified under the following groups - Atrophic and paralyse. Spastic. Tuberculosis (Surgical) Injuries. Congenital defects. Severe heart affections. Others (including marked postural defects. 12 8 10 1 4 5 1 A further advance in orthopaedic treatment is being made in the equipment of this clinic with apparatus for the provision of artificial sunlight treatment available for children of and under school age. The use of ultra-violet radiation in the treatment of rickets, surgical tuberculosis, and certain chronic inflammatory slates is now generally recognised as a most valuable adjuent. (9) OPEN-AIR EDUCATION. (a) Playground Classes.—All schools including the Openair School have playground classes during the summer months when weather is suitable. It is in connection with open-air classes in summer that future steps may confidently be taken for securing the healing and stimulant properties of natural sunlight, while ultra-violet radiation will be available at times when natural sunlight cannot be utilised for therapeutic purposes. (b) School Journeys.—No school journeys were undertaken, although educational visits were paid, and much appreciated, to the National Exhibition at Wembley, the South Kensington Museum, The Tower of London, etc. (c) School Camps.—No school camps were held, but four holiday camps were again held at Hainault for necessitous children where short holidays of two weeks were followed by improvement in general health and physique. 18 (d) Open-air Class-rooms in Public Elementary Schools.— Apart from the class-rooms of the Special School which belong to the type of open-air rooms, none of the elementary schools of the district possesses open-air class-rooms, a defect which it is hoped will be anticipated in the near future when the Authority may be expected to add to the existing school accommodation of the district. (e) The Authority possesses an Open-air School at Faircross, situated centrally and upon probably what is the highest ground of the district. During the year 119 children were on the register, 32 were admitted, and 22 sufficiently improved to permit of their return to ordinary elementary school. The school combines separate departments for delicate children and mentally and physically defectives, such cases being found from routine and special inspections at school, besides those referred from the inspection clinic and tuberculosis dispensary. The general routine of the school was described in my last Report. (f) Residential Open-air Schools. The Authority possesses no residential open-air schools. (10) PHYSICAL TRAINING. Since the resignation of Mr. Hoare, in 1921, no area organiser of physical training has yet been appointed. Physical training, which forms an important item in the child's school life is but at present represented in exercises on the Swedish drill principle which are given by teachers, no other satisfactory means existing for dealing with the minor pastoral defects met with during school life and remediable by simple appropriate exercises by a competent instructor. (11) PROVISION OF MEALS. Extra feeding in the form of milk, cocoa, etc., is supplied to the children attending the open-air classes of the Special School throughout the year, while all children at this school receive a hot mid-day meal. 19 Under the provisions of the Meals Act, 1906-14, the feeding of necessitous school children was continued as heretofore at the Municipal Restuarant. Dinners and breakfasts were provided at a cost of 5d. and 2½d. each respectively, and during the year 22,347 dinners and 909 breakfasts were supplied to 362 children, suitable cases therefor being selected by the medical officers, school teachers, nurses and attendance officers. The menues in use are from time to time submitted for the approval of the School Medical Officer, and the various arrangements continue suitable and adequate for the purpose. (12) SCHOOL BATHS. With the exception of the Special School which is provided [ with spray baths, no baths exist in any of the other schools. In connection with verminous conditions and scabies, baths and disinfestation are provided at the cleansing station. Public swimming baths in East Street, belonging to the Council, are available for children attending the elementary schools on certain week-days during part of the year, when suitable instruction is given. (13), (14), (15) & (16). CO-OPE RATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS, AND VOLUNTARY BODIES. The attendance of parents at the medical inspections throughout the year was 65.5 per cent., compared with 53.47 per cent. in 1924. The teachers take a kindly interest in the work of medical inspections in spite of the educational interruption in the course of duties, and their help is most valuable, while communication and mutual assistance are constant between the medical staff and the school attendance department. 20 The following- is a brief resume of the work done by the Society for the Prevention of Cruelty to Children in the district during the year :— Total number of cases investigated 16 (a) neglect 16 (b) ill-treatment — (c) proceedings instituted — There are no Children's Care Committees, but the additional duties which are usually carried out by such voluntary bodies, are carried out as far as possible by appropriate Sub-Committees of the Education Authority. (17) BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. (a) Children subjects of the above defects are ascertained through routine medical inspection or in more severe cases necessitating school absence through the activities of the attendance officers, the information so acquired being passed to the school medical officer, when any subsequent arrangements necessary for the child's disposal are made. Arrangements exist whereby exceptional children may, if necessary, attend non-residential certified schools or classes outside the district, and 7 deaf and dumb children so attended at Frederick Road Centre, Custom House during the year. The number of blind and deaf children maintained at residential institutions during the year was 4. The number of blind and deaf children in this district is insufficient to justify the provision of special classes for these defects locally. The number of known epileptics of all grades is 13. Unless the defect is of quite a minor character (when the child may attend an ordinary elementary school), epileptic children can only be satisfactorily educated in special residential schools or colonies Where epilepsy is combined with mental defect, the disposal of 21 such cases is difficult, sincc few institutions throughout the country are prepared to receive them. The number of epileptic children examined during the year was 3, and the recommendations made for their disposal as follows :— Residential school for epileptic children 2 Unsuitable for special school (epileptic imbecile) 1 The question of mentally sub-normal and mentally and physically defective children was considered at length in my lastyear's Report, further detailed reference to the subject being at present unnecessary. During the year, suspected mentally sub-normal and backward children were referred from various elementary schools to a temporary class at the Special School, and after a few months' observation submitted for more detailed examination by the School Medical Officer. During the year 12 such children came before the School Medical Officer, out of which number, and including those whose period of observation expired during the year, 7 were certified mentally deficient, and arrangements made for their admission to the special class for such children. Mentally Defective Children.—15 children were examined as to mental condition during the year, out of which number 7 were certified educable and arrangements made for their admission to the special class, 2 were certified ineducable and submitted under the Notification of Children Regulri:ons, Section 2, for confirmation to the Board of Education, while 6 were found to be idiots or imbeciles within the meaning of the Act, and accordingly notified to the Local Control Authority. During the year no children attending the Special School were notified to the Local Control Authority as having attained the age of 16 years, one was excluded from further attendance at the class on the grounds of ineducability, while 2 cases left school on attaining the age of 16 years. 22 The number of physically defective children in attendance at the cripple class was 41; 9 cases left the class on attaining the age of 16 years. The School Medical Officer examined and certified 18 cases suitable for admission to the cripple class, in addition to one case certified and allowed to continue at ordinary elementary school. (b) There are no educable mentally defective children in the district for whom the Education Authority is responsible and who are not either at the Special School or in residential institutions. Ineducable mentally defective children of school age come within the responsibility of the Essex County Council, who through the Essex Voluntary Association have begun in a small way an occupation centre for these children in this district. (c) The question of the after-care of mentally defective children, i.e., after attaining the age of 16 years becomes the statutory duty of the Local Control Authority, and is carried out by the Essex County Council who arrange for guardianship or institutional care in necessary cases. No provision up to the present has been made for the after-care of blind or deaf children or cripples, although in the case of the two latter, an occupation centre might with advantage be formed with the object of their being employed at certain periods during the week, either in order to learn the rudiments of a trade, such as boot-mending or basket-making, or merely finding them a form of temporary employment which would ensure some small monetary return. (18) NURSERY SCHOOLS. There are no nursery schools in the district. (19) SECONDARY SCHOOLS. The only secondary school in the district is the Abbey School, under the Essex County Council. Arrangements exist wherein routine inspection is carried out by the School Medical Officer of 23 the district. No arrangement exists with this authority either for " following up " or treatment of necessary cases. Details of inspections carried out are supplied from the following table :— Entrants. Intermediates. (12 years old.) Leavers. (10 years old.) Boys. Girls. Boys. Girls. Boys. Girls. No. examined... 32 23 2!) 13 20 22 No. referred for Treatment... 4 7 9 3 3 9 No. referred for observation... . 4 - ! 1 1 Re-Inspections. Number re-inspected. Number found to have been treated. Boys 12 9 Girls 31 24 (20) CONTINUATION* SCHOOLS. There are 110 Continuation Schools in the district. (21) EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Milk and newspaper deliveries, general errands, hawking and newspaper selling are the usual forms of employment of children and young persons. In accordance with the Bye-laws of the Education Authority, 10 applicants of school age submitted themselves for examination prior to employment, of which number it was unnecessary to refuse any applicant on medical grounds. Street trading is permissible to boys of 15 years, although licence is refused girls under 16 years, no prior medical examination being required of applicants. Certain conditions, however, such as mental defect, prevent street trading being engaged in. 24 Legal proceedings during the year were instituted in one case for infringement of Bye-laws in respect of the employment of children, and one_ in respect of the employment of young persons in street trading. (22) SPECIAL ENQUIRIES. Owing to the pressure of other work, it was found impossible during the year to devote time to the prosecution of any special enquiries in connection with the School Medical Service. (23) MISCELLANEOUS. Six young persons, who desired to become bursars and student teachers, were medically examined during the year, out of which number no one was rejected on medical grounds. 25 REPORT OF THE ORTHOPAEDIC SURGEON. Orthopaedic Clinic, Faircross School, Barking, Essex. February, 1926. I'o the School Medical Officer. The year 1925 has shown that' the establishment of the Orthopaedic Clinic was a wise step on the part of the authorities. During the period 60 new cases were examined, and 111 reexamined. All types of cripples and potential cripples were seen. The following will give some idea of the greal variety of cases dealt with :— Infantile Paralysis. Spastic Paralysis. Tuberculous Joints. Injuries to Bones and Joints. Lateral Curvature of the Spine. Rickets. Congenital and other deformities. The majority of the patients are under my direct charge, and, when in-patient treatment is necessary, are admitted into my beds at the Queen's Hospital for Children, Hackney—where I am Senior Surgeon—or into the Brookfield Orthopaedic Hospital. If into the latter, education continues during in-patient treatment, as Brookfield is a Hospital School and recognised as such by the Hoard of Education and Ministry of Health. Amongst children so admitted have been cases of congenital clubfoot, rickets, etc. Another, a serious dislocation of the elbow, is still under treatment. The rest of the cases are under the care of various London surgeons, with whom I communicate from time to time over questions of treatment or supervision. 26 It would perhaps be wise to emphasise the importance of the early treatment of rickets, clubfoot, etc., as it is in the Infant Welfare Centres that these cases are first seen. Deformities can be thus prevented or cured, and every facility should be given the medical officers of the centres and general practitioners of the neighbourhood to see this work carried out at the Orthopaedic Clinic. Consultations are held on the morning of the first Wednesday in each month. The equipment of the clinic will be made complete within the next few weeks by the installation of an Ultra-Violet Light Apparatus Cases of Rickets, Anterior Poliomyelitis, Surgical Tuberculosis. etc., will be very carefully selected by myself in close cooperation with Dr. Simpson, Medical Officer of Health, for this line of treatment which is still under trial. It cannot be emphasised too strongly that such treatment cannot take the place of true sun-light and fresh air, and that these two essentials to life must be available more than heretofore during the coming summer months. In my opinion, therefore, Faircross Open-air School is an ideal one for the cripples and physically defective children of the district, in that in winter they will have the benefit of ultra-violet light treatment, and in summer, education in the open air and in direct sun-light. (Signed) B. Whitchurch Howell, F.R.C.S. 27 report of school dental surgeon. To the School Medical Officer. I beg to present my report for the year ended December 31st, 1925. The whole of the schools in the area were visited during the year, and children in the various age groups inspected. It was found that from a total of 6,765 children inspected, 4,700, or 69.17 per cent., were found to require treatment, and of these 2,I6I, or 52.36 per cent., made 3,211 attendances for treatment. The latter figure compares favourably with that of 38.69 per cent. for 1924, and is due among other reasons to the " following up " of cases by the Denial Nurse who, since her appointment in April, 1 925, made 1,291 primary and 298 secondary home visits. There is, however, still a considerable amount of prejudice to be broken down before ideal conditions can be established, a fact now recognised by the Dental Board of the United Kingdom who propose a widespread campaign of Dental Health propaganda during 1926, in order to impress the importance of the care of the teeth upon the population generally, and especially upon parents of children attending elementary schools, only 55 per cent of whom accepted treatment for their children throughout the British Isles in 1924. An encouraging feature of the year was the sale of 1,152 tooth-brushes at cost price, and the free distribution of samples of tooth-paste and literature. This indicates an enlightenment of many parents on the need of the prevention of dental disease, and should result in effects even more encouraging than those of actual treatment. It will be noticed with regard to treatment at the Dental Clinic, that an increase of permanent as opposed to temporary fillings has been undertaken. This has been done with the object of saving as many of the all-important permanent teeth as Possible rather than patching up temporary teeth, a process now regarded as unsatisfactory by many of the best authorities. A decrease in the number of general anaesthetics and a consequent increase in the number of local anæsthetics given will be noted 28 by reference to Table IV., page 37. This is more satisfactory, and is besides more favoured by parents and children, leaving little or no effect and being less of an ordeal to younger children. Unfortunately, the dental clinic premises leave much to be desired as a treatment centre. It is especially inconvenient for the administration of general anaesthetics for both mothers and children, being too restricted, far from sound-proof and possessing only one common waiting-recovery room. The Ante- and Post-Natal side of the work is very encouraging, attendances on the part of mothers having steadily increased throughout the year. This result may be accounted for by the provision of dentures at cost price subsequent to extraction, and the resulting benefit to the general health of mothers accepting treatment. Unfortunately, the neglect of the care of the mouth and teeth in the majority of cases renders the conservation of teeth by filling, etc., impossible, and the extraction of large numbers of teeth has had to be undertaken in the best interests of the patient's health. Particulars of the work done on behalf of expectant and nursing mothers and children of pre-school age are furnished by the subjoined table :— New cases (children) 39 Old cases (do.) — New cases (mothers) 118 Old cases (do.) 400 Extractions 971 Fillings 22 Scaling 23 No. of sessions 60 No. of dentures supplied 18 W. W. F. Dawe, L.D.S., R.C.S.(Eng.), Dental Surgeon. 29 ABLE 1.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections: Entrants 1,015 Intermediates 437 Leavers 640 Total 2,092 Number of other Routine Inspections 205 B.—Other Inspections. Number of Special Inspections 49 Number of Re-inspections 1,162 Total 1,211 30 TABLE II.—A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31ST DECEMBER, 1925. Defect or Disease. Routine Inspections. Special Inspection . 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 20 23 1 — Uncleanliness — — — — Skin Ringworm—Scalp 1 — — — Body — — — — Scabies 4 — — — Impetigo 10 — — — Other Diseases (NonTuberculosis) 1 — 1 — Eye Blepheritis 12 — — — Conjunctivitis 1 — — — Keratitis — — — — Corneal Opacities — — — — Defective Vision (excluding Squint) 82 6 15 1 Squint 10 — — — Other Conditions 1 — — — Ear Defective Hearing 7 — 3 — Otitis Media 31 — 3 — Other Ear Disease — — — — Nose and Throat Enlarged Tonsils only 78 30 — — Adenoids only 21 7 — 1 Enlarged Tonsils and Adenoids 104 3 2 — Other Conditions 40 5 4 — Enlarged Cervical Glands (NonT.B.) 3 11 — — Defective Speech — — — — Teeth—Denial Diseases (See Table IV., Group IV.) Heart and Circulation. Heart Disease : Organic — 21 — 2 Functional — 7 — — Anæmia 22 3 — — Lungs Bronchitis 48 12 — — Other Non-Tuberculous Diseases 4 4 — — 31 TABLE II.—Continued. Defect or Disease. Routine Inspections. Special Inspection. 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) Tu berculosis Pulmonary : Definite 2 2 — — Suspected 5 7 — — Non-Pulmonary : Glands 2 6 — 1 Spine — — — — Hip — — — — Other Bones and Joints — — — Skin — — — — Other Forms — — — — Nervous System Epilepsy 1 — — — Chorea 1 1 2 — Other Conditions 2 — — — mities- Rickets 1 — — — Spinal 24 2 — — Other Forms 38 6 — 2 Other Defects and Diseases 28 8 3 4 32 B.—Number of Individual Children FOUND AT Routine MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEAN LINESS AND DENTAL DISEASES). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment CODE GROUPS: Entrants 1015 265 26.108 Intermediates 437 124 28.37 Leavers 640 141 22.03 Total (Code Groups) 2,002 530 25.33 Other Routine Inspections 205 27 1317 33 TABLE III-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 — — — (II.) 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 – 1 1 At other Institutions — – — At no School or Institution – — Deaf (including deaf and dumb 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 6 8 Attending Public Elementary Schools – – – At other Institutions — – — At no School or Institution... — – – (II.) Suitable for training in a School or Class for partially deaf. Attending Certified Schools or Classes for the Deaf – – – Attending Public Elementary Schools – – – At other 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 16 19 35 Attending Public Elementary Schools – – – At other Institutions — — — At no School or Institution — — — Notified to the Local Control Authority during the year. Feebleminded – 1 1 Imbeciles 2 1 3 Idiots 2 – 2 Epilepsy. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics — – – In Institutions other than Certified Special Schools 1 – 1 Attending Public Elementary Schools – – At no School or Institution — 1 1 Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 1 5 6 At no School or Institution – – – 34 TABLE III.—continued. Boys. Girls. Total Infectious pulmonary and glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board – 1 1 At other Institutions — — At no School or Institution — — — Non-infectious, 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, auæmia, etc.) At Certified Residential Open Air Schools – – – At Certified Day Open Air Schools 07 52 119 At Public Elementary Schools 1 – 1 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 1 1 2 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 including those with severe heart disease. At Certified Hospital Schools, – 1 I At Certified Residential Cripple Schools – – – At Certified Day CrippleSchools 21 19 40 At Public Elementary Schools – – – At other Institutions – — – At no School or Institution 2 – 2 35 TABLE IV.—TREATMENT TABLE. (Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V). Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin Ringworm—Scalp 10 — 10 Body 20 — 20 Scabies 34 1 35 Impetigo 347 1 348 Other Skin Diseases 123 — 123 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 137 7 144 Minor Ear Defects 193 22 215 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc. 1001 1 1002 Total 1,865 32 1,897 36 Group II.—Defective Vision and Squint (excluding Minor Eve Defects Treated as Minor Ailments—Group I.—.) Defect or Disease. Under Authority s Scheme. Xumber of defects dealt with. Submitted to refraction by private practitioner or at hospital apart from the Authority's Scheme. Otherwise Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) 131 36 – 167 Other Defects or Diseases of the eyes (excluding those recorded in Group I.) — — – — Total 131 36 – 167 Total number of children for whom spectacles were prescribed :— (a) Under the Authority's Scheme 113 (b) Otherwise 30 Total number of children who obtained or received spectacles :— (a) Under the Authority's Scheme 113 (b) Otherwise 30 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Under the Authority's Scheme 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) 154 47 201 28 220 37 Group IV Dental Defects. (1) Number of Children who were :— (a) Inspected by the Dentist Routine Age Groups. Age 3 — 4 12 5 636 6 665 7 621 8 691 9 686 10 841 11 829 12 811 13 773 14 192 15 8 Total 6,765 (b) Found to require treatment 4,700 (c) Actually treated 2,461 (2) Half-days devoted to Inspection 41 Treatment 340 Total 381 (3) Attendances made by children for Treatment 3,211 (4) Fillings—Permanent Teeth 1,515 Temporary Teeth 36 Total 1,551 (5) Extractions—Permanent Teeth 462 Temporary Teeth 3,137 Total 3,599 (6) Administrations of general anæsthetics for extractions 579 (7) Other operations—Permanent Teeth Total 119 Temporary Teeth 38 GROUP V.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurse 3 (ii) Total number of examinations of children in the schools by School Nurses 17,501 (iii) Number of individual children found unclean (iv) Number of children cleansed under ments made by the Local Education Authority 169 (v) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 (b) Under School Attendance Bye - laws