BAR 21 Barking Town Urban District Council. REPORT OF THE MEDICAL OFFICER OF HEALTH For the Year 1927. C. LEONARD WILLIAMS, B.Sc. Hons. (Lond.) M.R.C.S. (Eng.), D.P.H. (Gamb.) 3 TABLE OF CONTENTS SECTION 1—GENERAL. Staff Statistical Summary- Comparative Statistical Table Table of Vital Statistics from 1922 to 1927 Summary of Xursing Arrangements Clinic and Treatment Centres Ambulance Facilities Laboratory Work Local Bye-Laws, Regulations and Adoptive Acts Deaths Inquests Causes of Death (Table) Causes of Death at Various Ages under 1 year Marriages Births PAGE 5 8 9 10 1 12 13 13 13 15 17 18 19 20 20 SECTION 2—SANITARY CIRCUMSTANCES OF THE DISTRICT. Water Supply Rivers and Streams Rainfall Sewerage Scavenging Housing Statistics Sanitary Inspection of the Area Summary of Sanit-.ry Work carried out Notices Served Smoke Abatement Offensive Trades Common Lodging Houses Stables Tents, Vans, Sheds, etc. Piggeries Houses Let in Lodgings Inspection and Supervision of Food :— (a) Milk (b) Meat (c) Unsound Food 21 21 21 21 22 22 24 25 27 28 28 29 29 29 29 29 30 30 32 4 * < SECTION 2—-Continued. PAGE Sale of Food and Drugs Act 32 Improvement of Existing Housing Conditions 32 Overcrowding 33 Schools 33 Factories, Workshops, Workplaces, etc 34 SECTION 3—NOTIFIABLE INFECTIOUS DISEASES. Table of Cases of Infectious Diseases notified and removed to Hospital 38 Cases Classified According to Age Groups and Wards 40 Monthly Summary of Receipt of Notifications 41 Scarlet Fever 42 Smallpox and Vaccination 42 Diphtheria 42 Puerperal Fever 43 Acute Primary and Acute Influenzal Pneumonia 43 Pneumonia Supervening upon Measles 43 Non-notifiable Diseases 43 Table of Admissions and Discharges from Hospital 44 Tuberculosis 44 Tuberculosis After-care 48 SECTION 4—MATERNITY AND CHILD WELFARE. Notification of Births Acts, 1907-1915 50 Ante-Natal Clinic 51 Post-Natal Cases 52 Maternity Ward 53 Puerperal Fever and Puerperal Pyrexia 54 Maternal Mortality 55 Neonatal. Mortality 55 Still Births 56 Ophthalmia Neonatorum 57 Work of Health Visitors and Infant Welfare Centres 58 The Pre-School Child 59 Foster Children 59 Infantile Mortality 59 Dental Clinic 60 Orthopaedic Clinic 61 Artificial Sunlight Clinic 62 Provision of Meals and Fresh and Dried Milk 63 5 STAFF, 1927. Medical Officer of Health, School Medical Officer, Medical Superintendent, Isolation Hospital, and District Tuberculosis Officer. *C. LEONARD WILLIAMS, B.Sc. Hons. (Lond.) M.R.C.S. (Eng.) D.P.H. (Cambs.) Asst. Medical Officer of Health and Asst. School Medical Officer : *MURIEL J. LOUGH, M.B., B.S., B.Sc., M.R.C.S., L.R.C.P., D.P.H. Orthopaedic Surgeon (Part Time) : *B. WHITCHURCH HOWELL, M.B., B.S., F.R.C.S. School Dentist : *H. S. SMYTH, 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). Health Visitors : *MRS. G. STOKES (i). *MRS. M. W. WALTON (a, h, and 1). *MISS G. ELLIOTT (a, h and 1). Matron, Isolation Hospital : MISS M. J. HEDGCOCK (h, i and j). Masseuse, Orthopaedic Clinic (Part Time) : *MISS A. E. FINDLAY, C.S.M.M.G. (k). Clerical Staff. E. W. WINCHESTER (Chief Clerk) (a, c and d). MISS A. SHAW. MISS V. SHEAD. MISS B. INGHAM (Resigned, July 1927). MISS H. NUNN (Commenced, Angnst 1927). , Disinfector and Mortuary Keeper: H. LONG. (a) Sanitary Inspector's certificate of Sanitary Inspectors' Examination Board. (b) Sanitary Inspector's certificate of Royal Sanitary Institute. (c) Meat, etc.. Inspector's certificate of Royal Sanitary Institute. (d) Mc.it, etc., Inspector's certificate of Sanitary Inspectors' Examination Board. (e) Building Inspector's certificate of Worshipful Company of Carpenters. (f) Sanitary Science Certificate of Royal Sanitary Institute. (g) Health Visitor's certificate of Royal Sanitary Institute. (h) Certificate of Central Midwives' Board. (i) General Hospital Training. (j) General Fever Training. (k) Certificate M.E. and S.R.E. (l) Health Visitor's Diploma of Board of Education. *Proportion of salary contributed under Public Health Acts or by Exchequer grants. 7 ANNUAL REPORT OF THE Medical Officer of Health for the Urban District of Barking Town, in the County of Essex, for the Year ended 31st December, 1927. Public Health Offices, Barking, Essex. To the Chairman and Members of the Urban District Council of Barking Town. Mr. Chairman, Mrs. Jackson and Gentlemen, Herewith I beg to submit for your favourable consideration the Annual Report on the Public Health Services of the Urban District of Barking for the year ended 31st December, 1927. It was only late in September that I took up my duty as Medical Officer of .Health, so that I am unable personally to speak for more than a small portion of the year under review, but, for the purpose of complying with the requirements of the Ministry of Health, I have written the report as though I were responsible for its entirety. The report for this year will therefore of necessity follow closely the report for the previous year, and I wish to express my indebtedness for the help I have received from that report, and for the help I have received on every hand from my staff, without whose aid the present report would have been very difficult indeed to have produced. I am, Mr. Chairman, Mrs. Jackson and Gentlemen, Your obedient servant, C. LEONARD WILLIAMS, Medical Officer of Health. 8 SUMMARY OF PARTICULARS REQUIRED BY CIRCULAR 834 OF THE MINISTRY OF HEALTH, DATED 15th DECEMBER, 1927. 1. General Statistics. Area (acres) 4,106 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, 1927) (Registrar General's estimate) 39,900 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 9.7 Rateable Value—Houses, Buildings, etc £297,430 0 0 Lands £2,738 0 0 Sum represented by a penny rate £1,160 0 0 Education rates :— Elementary 3 23/4 Secondary 6 Assessable Value £278,712 17 6 General District Rate 7 8 Poor Rate 9 6 2. Extracts from Vital Statistics for the Year. Births :— Males. Females. Total. Birth Kate. Legitimate 332 357 689 17.26 Illegitimate 13 8 21 0.52 Total 345 365 710 17.78 Deaths:— Male. Female. Total. Death Rate. Standard Death Rate Factor 1.040} 204 202 406 10.1 10.5 Number of deaths of women during, or in consequence of, childbirth :— From Sepsis. From other causes. Total. 2 1 3 Number of deaths of infants under one year of age :— Males. Females. Total. Total Infantile Death Rate. Death Rate. Legitimate 18 24 42 60.9 66.1 Illegitimate 2 3 5 238.0 Number of deaths from Measles (all ages) — „ „ Whooping Cough (all ages) 7 „ „ Diarrhoea (under 2 years of age) 7 9 3. BIRTH RATE, DEATH RATE, AND ANALYSIS OF MORTALITY DURING THE YEAR. Birth Rate per 1,000 Total Population. Annual Death Rate per 1,000 Population. Rate per 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. Certified by Coroner after P.M. No Inquest. Uncertified Causes of Death. England and Wales 16.7 12.3 0.01 0.00 0.09 0.01 0.09 0.07 0.57 0.51 6.3 09 91.7 6.6 0.7 * 1.0 107 County Boroughs and Great Towns including London 17.1 12.2 0.01 0.00 0.12 0.01 0.10 0.08 0.49 0.46 8.3 71 91.9 6.6 0.9* 0.6 155 Smaller Towns (1921 Adjusted Populations 20,00050,000) 16.4 11.3 0.01 0.00 0.07 0.01 0.08 0.05 0.58 0.41 5.0 68 92.7 5.8 0.3* 1.2 London 16.1 11.9 0.01 0.00 0.04 0.01 0.12 0.09 0.39 0.51 7.5 59 90.3 7.9 1.8* 0.0 BARKING 17.7 10.1 0.05 — — — 0.17 0.05 0.55 0.55 9.8 66 88.7 11.1 0.2* — * The Coroners (Amendment) Act 1926, which came into operation on the 1st May, 1027, provided for the registration of deaths on a certificate of the Coroner after P.M. without inquest. These percentages relate therefore to 8 months of the year only. 10 VITAL STATISTICS OF WHOLE DISTRICT FROM 1922 to 1927. Year. Population estimated to Middle of each Year. Births. Total Deaths Registered 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 Hate. 1 2 3 4 5 6 7 8 9 10 11 12 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 — 107 66 80.0 386 10.0 1926 38,920 818 21.0 259 6.6 11 118 49 59.9 366 9.4 1927 39,900 710 17.7 251 6.2 7 162 47 66.1 406 10.1 •Registrar General'S Figures. 11 5. CAUSES OF SICKNESS. There were no special causes of sickness or invalidity. 6. SUMMARY (FOR REFERENCE) OF NURSING ARRANGEMENTS, HOSPITALS, AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. (a) Nursing in the Home. (i) The Plaistow Maternity Charity provide a staff of nurses, who attend at the homes of the sick once or twice a day, carry out such skilled nursing as is required, and offer instructions where advisable in hygienic home practices in relation to the sick. (ii) For infectious diseases. In the event of an epidemic, the Council can provide nurses for such cases as may require to be nursed in their own homes. Of late years this has not been necessary. No other provision of home nursing is carried out by the Department, but Health Visitors and School Nurses regularly advise parents as to the nursing and general care of children. (b) District 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 ended 31st December, 1927, amounted to £226, leaving a balance due to the charity from the Council of £74, such sum ranking for grant. 12 (c) CLINIC AND TREATMENT CENTRES. Name and Situation. Nature of Accommodation. By Whom Provided. I. Maternity and Child Welfare :- (a) Centres Clinic premises, East Street. Accommodation for consultations, weighing of babies, waiting V Local Authority. Greatfields Centre, Movers Lane. „ „ Alexandra Centre St. Pauls Road „ „ (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) Eve Clinic „ „ One room. „ „ (c) Dental Clinic „ „ Two rooms. „ „ (d) Orthopaedic Clinio Faircross School. One room. „ „ III. Tuberculosis 37, Linton Road. Three rooms. Essex County Council. IV. Venereal Diseases London Hospitals, etc. — By arrangement with Essex County Council. 13 (d) Hospitals provided or subsidised by the Local Authority : (i) Smallpox.—An arrangement exists with the neighbouring County Borough of West Ham whereby an unlimited number of beds are available at Dagenham for the reception and treatment of cases of small pox 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 motor ambulance is now 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, th6 ambulance and fire services being run in conjunction under the Chief Fire Officer. . 7. LABORATORY WORK. The necessary laboratory work of the district is carried out by arrangement with the Essex County Council at the Counties' Laboratory, situated in Queen Victoria Street, London, E.C.4, particulars of the number of specimens submitted for examination being supplied by the following table :— Specimen Numte examined Diphtheria 669 Sputa 222 Typhoid 24 Ringworm 13 Miscellaneous 8 8. List of Adoptive Acts, Bve-laws, and Local Regulations relating to Public Health in force within the district. & (i) Local Acts : Barking Town Wharf Act, 1893, Barking Parish Act, 1888. 14 ' (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, 1923. Baths and Wash-houses 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) Bye-laws with respect to: Nuisances, 1884. Common Lodging Houses, 1884. . Offensive Trades, 1907 (revised 1924). Houses let in lodgings, or occupied by members of more than one family, 1924. Public Baths, 1900. Tents, Vans, Sheds and similar structures, 1909. Paving of Open Spaces, 1901. Nuisances in connection with the removal of offensive matter, 1908. Employment of Children and Young Persons, 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, glue maker, size maker, gut scraper, and oil boiker to be offensive trades, the last being so declared in 1925. 15 9. DEATHS. There were 251 deaths registered in Barking in 1927. Of these 7 were deaths of non-residents. Barking residents to the number of 162 died elsewhere during the year. Including the latter and excluding the deaths of visitors, the net number of deaths were as follows:— Males. Females Total 204 202 406 The death rate for 1927 was 10.1 per 1,000, compared with 9.4 in 1926, calculated on the Registrar-General's estimated population and number of deaths, compared with 12.3 for England and Wales, 12.2 for the hundred and seven Great Towns, 11.3 for the hundred and fifty-five Smaller Towns, and 11.9 for London. Sex Mortality.—The 406 deaths of 1927 were divided as follows:— 204 males, equal to a death rate of 5.1 per 1,000 population. 202 females, equal to a death rate of 5.06 per 1,000 population. Age Mortality.— The deaths in various age groups, according to the figures obtained locally, were as follows:— Age Group. No. of Deaths. Death Rate per 1,000 Population. Under 1 year 47 1.17 1 to 2 years 10 0.25 2 to 5 ycars 11 0.27 5 to 15 years 14 0.35 15 to 25 years 24 0.60 25 to 45 years 46 1.15 45 to 65 years 105 2.63 Over 65 years 149 3.73 Causes of death in 1927.—The table on page 17 shows the principal causes of death at various ages. Those diseases, etc., . 16 causing most deaths or important from a Public Health aspect were as follows :— Disease. No. of Deaths. Percentage of total net deaths registered. Cardio-vascular system 59 14.5 Cancer 51 12.5 Tuberculosis (all forms) 46 11.3 Pulmonary affections, (exclusive of tuberculosis), viz., Bronchitis 19 4.6 Pneumonia 31 7.6 Other respiratory disease 4 0.9 Zymotic Diseases 18 4.4 Of the total deaths, tuberculosis caused one in every 8.8, heart diseases one in every 6.8, bronchitis one in every 21.3, cancer one in every 7.9, pneumonia one in every 13.0, suicide and violence one in every 18.4, other respiratory diseases one in every 101.5, and zymotic diseases one in every 22.5. Deaths from Zymotic Diseases.—These diseases caused 4.4 per cent, of the total deaths, such deaths being caused in the following proportions:— Enteric Fever 0.49 Measles — Whooping Cough 1.72 Scarlet Fever — Diphtheria 0.49 Diarrhoea 1.72 S mallpox — 17 INQUESTS.—Coroner's inquests were held on 45 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. Accident 2 — 1 1 5 1 5 2 17 Suicide — — — — 5 1 1 1 8 Tuberculosis — — — — — 3 1 — 4 Encephalitis Lethargica — — — — — 1 — — 1 Heart Disease — — — l — — 2 2 5 Arterio Sclerosis — — — — — — 1 — 1 Cerebral Haemorrhage — — — — — — 2 — 2 Pneumonia 1 — — — — 1 — — 2 Convulsions — — — — — — — — 1 Enteritis Convulsions 1 — — — — — — — — 1 Pneumonia Convulsions 1 — — — — — — — 1 Influenza Pneumonia 1 — — — — — — — 1 Septicaemia due to Miscarriage — — — — — 1 — — 1 Totals 7 — 1 2 10 8 12 5 45 * This figure includes inquests of non-residents whose deaths occurred in the district. 18 CAUSES OF AND AGES OF DEATH DURING YEAR, 1927. (Nett Deaths.) Causes of Death. Deaths at the subjoined ages of " Residents" whether occurring in or beyond the district. Under one year 1 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 65 65 and upwards Total Encephalitis Lethargica — — — — 1 1 — 2 Influenza 4 1 1 1 2 8 5 22 Scarlet Fever — — — — — — — — Small Pox — — — — — — — — Measles —— — — — — — — — Whooping Cough 3 2 2 — — — — 7 Epidemic Influenza — — — — — — — — Diarrhoea and Enteritis (under 2) 5 2 — — — — — 7 Diphtheria — 2 — — — — — 2 Enteric Fever — — — — — 2 — 2 Puerperal Fever — — — — 2 — — — Phthisis (Pulmonary Tuberculosis) — — 2 6 13 14 — 37 Other Tubercular Diseases 1— 3 2 — 2 1 — 9 Cancer , Malignant — — — — 4 21 26 51 Bronchitis — — — — — 3 16 — Pneumonis 7 8 — 3 5 6 2 31 Other Respiratory Diseases — — — 1 — 3 4 Alcoholism (Cirrhosis of Liver) — — — — 1 1 Premature Birth, Malformation and Debility 21 — — — — — — 21 Accidents 1 1 1 4 1 5 2 15 Suicides — — — 5 1 1 — 7 Rheumatic Fever — — 3 1 — — — 4 Diabetes — — — — 3 3 6 Cerebral Hsemorrhage — — — — — 7 17 24 Heart Disease — — 1 — 5 12 39 59 Arterio-Sclerosis — — — — — 1 5 6 Ulcer of stomach or duodenum — — — — 2 2 1 6 Appendicitis and typhlitis — — — — 1 — — I Acute and Chronic Nephritis — — 1 — — 2 5 8 Other accidents and diseases of pregnancy;_nd parturition — — — — — — — 1 Other defined diseases 5 2 1 2 5 10 22 52 Causes ill-defined or unknown — — — 1 — — — — Totals 47 21 14 24 46 105 149 406 19 INFANT MORTALITY DURING THE YEAR 1927. The following table gives the actual causes of death of children dying under one year of age. Nett 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 G months. 6 months and under 9 months. 9 months and under 12 months. Total under one year. Small Pox — — — — — — — — — — Chicken Pox — — — — — — — — — — Measles — — — — — — — — — — Scarlet Fever — — — — — — — — — — —Whooping —Cough— — — — — — 1 1 1 — 3 Diphtheria and Croup — — — — — — — — — — Erysipelas — — — — — — — — — — Tubercular Meningitis — — — — — — — — 1 1 Other Tubercular diseases — — — — — — — — — — Meningitis (non tubercular) — — — — — — — — — — Convulsions — — — — — — — — — o Laryngitis — — — — — — — — — — Bronchitis — — — — — — — — — — Pneumonia (all forms) — — 1 — 1 — 2 3 1 7 Diarrhoea — — — — — 2 — 1 — 5 Gastritis — — — — — — — — — — Syphilis — — — — — — Rickets — — — — — — — — — — Suffocation, overlaying — — — — — — — — — — Injury at birth — — — — — — — — — — Atelectasis 1 — — — 1 — — — 1 — Congenital malformation — — — — — 3 — — — 3 Premcture Birth 11 — — — 11 11 Atrophy, debility and Marasmus 3 2 — — 5 1 1 — — 7 Other causes — — — — — 2 2 1 2 7 Totals 15 2 1 — 18 9 10 6 4 47 Nett Births in the year:— Legitimate 689 Illegitimate 21 Nett Deaths in the year:— Legitimate 42 Illegitimate 5 20 10. MARRIAGES. There were 304 marriages registered in the district in 1927. This is equal to a marriage rate of 7.6 per 1,000 population. In 1922, there were 208 marriages, equal to a rate of 5.6; in 1923, 219 marriages, equal to a rate of 5.9 per 1,000; in 1924, 208 marriages, equal to a rate of 5.4 ; in 1925, 258 marriages equal to a rate of 6.7, and in 1926, 249 marriages equal to a rate of 6.3. 11. BIRTHS. The net number of births registered in 1927 was 710, affording an annual birth rate of 17.7 per 1,000 population, compared with 21.01 in 1926 and 21.4 in 1925. Of all births, 21 were illegitimate, or a proportion to total births of 2.9 per cent. Notification of Births Act, 1907-1915.—Of the total births recorded in the district during 1927, all except 38 or 5.3 per cent. of the total, were notified to the Medical Officer of Health, 461 being notified by midwives and 213 by parents and doctors. 18 still-births were notified, 4 being notified by midwives and 14 by doctors and others. 2 still-births, which took place in the district, were not notified. 20 SECTION 2. SANITARY CIRCUMSTANCES OF THE DISTRICT. 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 the Report for 1923. 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. . RAINFALL. The rainfall for the year ended December 31st was 26.53 inches. Rain fell on 30S days throughout the period in question. SEWAGE. A water-carriage system is general, except at Rippleside. Over the greater part of the area there is a separate sewage and storm water system. 22 Sewage is treated within the district by precipitation and sedimentation, the resulting effluent being discharged into the River Roding. SCAVENGING. The question of scavenging (which is closely linked with that of sewage disposal in several respects) comes under the control of the Engineer. Domestic and trade refuse is collected weekly in horsedrawn two-wheeled vehicles, and deposited on low-lying land. The question of replacing these methods has received consideration and a new type of vehicle is shortly to be introduced. CESSPOOLS, PRIVYMIDDENS AND PAIL-CLOSETS. In the unsewered portion of the district there remains 54 premises with cesspools, 35 with pail-closets and 13 houses with privies. For cesspool emptying, a tank vehicle is employed, the contents being pumped out and afterwards discharged into the sewers. Privymiddens are emptied into tumbrils and the contents buried; the same remark being applicable to pail-closets. Housing Statistics for the year 1927. 1. GENERAL. Number of new houses erected during the year:— (i) Total 358 (ii) As part of a municipal housing scheme 30 (iii) Others (including private enterprise and subsidy houses) 328 2. UNFIT DWELLING HOUSES. I.—Inspection. (i) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 3,976 23 (ii) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) .Regulations, 1910 1,311 (iii) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 5 (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 2,196 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.1,680 III.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925. (i) Number of dwelling houses in respect of which notices were served requiring repairs 135 (ii) Number of dwelling houses which were rendered fit— (a) by owners 129 (b) by Local Authority in default of owners 6 (iii) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations of owners of intention Nil B.—Proceedings under Public Health Act. (i) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 339 24 (ii) Number of dwelling houses in which defects were remedied:— (a) by owners 339 (b) by local Authority in default of owners Nil 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 5 (ii) Number of dwelling houses in respect of which Closing Orders were made 5 (iii) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 2 (iv) Number of dwelling houses in respect of which Demolition Orders were made Nil (v) Number of dwelling houses demolished in pursuance of Demolition Orders Nil SANITARY INSPECTION OF THE AREA. (Work of Sanitary Inspectors.) 1. Inspection of Dwelling Houses. Total under Public Health or Housing Acts 3,976 Housing (Inspection of District) Regulations 1,311 After Infectious Disease 565 Defects Found 6,975 Notices Served (Preliminary) 2,196 Re-inspections re Notices Served 2,521 25 2. Premises Controlled by Bye-Laws and Regulations. Houses Let in Lodgings 70 Common Lodging Houses SO Offensive Trades 385 Tents, Vans and Sheds 76 Dairies, Cowsheds and Milkshops 307 Slaughterhouses 180 3. Factories, Workshops and Workplaces. Factories 139 Laundries 10 Bakehouses 56 Other Workshops 138 Other Workplaces 127 Outworkers' Rooms 42 Butchers' Premises 613 Fishmongers 64 Restaurants and Dining Rooms 105 Markets 64 Stables and Stable Yards 186 Piggeries 132 4. Miscellaneous. Smoke Observations 127 Rats and Mice (Destruction) Act, 1919 130 Vacant Land and Refuse Dumps 82 Public Lavatories 94 Schools 78 General Shops 242 Ice-Cream Vendors 126 Petroleum Stores 130 SUMMARY OF SANITARY WORK CARRIED OUT. (a) Drainage. Choked drains, opened,, repaired, and cleansed 282 Drains reconstructed 30 New Drains # 3 Ventilation Shafts repaired or new fixed 18 New Inspection Covers 11 26 (b) Closet Accommodation., Roofs Walls Floors W.C. structures repaired 200 Doors Seats Fixed 48 New Pans Fixed or Cleansed 135 Flushing Apparatus Repaired or Renewed 326 Privies to Pail Closets 2 (c) Sinks. New Fixed 96 New Sink Wastepipes 111 New Gullies 33 (d) Dampness. Roofs 556 Eavesgutters 441 Rainwater Pipes 165 Damp Walls Remedied 224 (e) Water Supply. Storage Cisterns Abolished 20 Defective Water Fittings Repaired and Supply Reinstated 105 Supply provided inside houses 19 (f) Yard Paving. Yard paving repaired ot; relaid 191 (g) Dustbins. New ones provided 250 27 (h) General Repairs. House floors repaired 329 Windows repaired or renewed 238 Window sills repaired or renewed 110 Sashcords renewed 304 Stoves or coppers repaired or renewed 365 House doors repaired or renewed 162 Stairs repaired 64 Chimney pots renewed and stacks rebuilt 72 Dirty or defective rooms repaired, cleansed and redecorated .. .. .. .. • .. 1,659 External walls repaired 111 Insufficient floor ventilation 46 (i) Miscellaneous. Offensive accumulations removed 88 Animals so kept as to be a nuisance 24 Verminous rooms and persons disinfected 15 Stables cleansed 7 NOTICES SERVED. Informal Notices 2,196 Statutory Notices 516 Section 36, Public Health Act, 1875 35 516 Section 94, Public Health Act, 1875 295 Section 41, Public Health Act, 1875 7 Section 5, Infectious Disease (Prevention) Act, 1890 42 Section 3, Housing Act, 1925 135 Section 22, Public Health Act (A) Act 1890 2 28 SMOKE ABATEMENT. The Public Health (Smoke Abatement) Act, 1926, came into orce on 1st July, 1927. Previous to this date, all observations upon chim::.ey shafts, were for periods of one hour,, but following the commencement of this Act, it was decided to'introduce 30 minute observations and to limit the permissible period of black smoke emission to 2 minutes in the aggregate ; excluding bursts of less than 30 seconds. Whilst there has been considerable improvement in smoke emission, there are still 3 offenders who as yet, do not regularly conform to this standard. These offenders, however, are giving their serious attention to the technical difficulties connected with their boiler installation and are keeping smoke emission to a minimum. One hundred and twenty-seven observations were carried out. In 37 instances, offences occurred ; in which cases appropriate action was taken. In respect of one factory, it was necessary to serve formal notice. This authority is a member of the Greater London Smoke Abatement Regional Committee. OFFENSIVE TRADES. The following shows the nature of trades carried on and the number of premises registered :— Fish Fryers 20 Fish-skin Scrapers 1 Dealers in Rags and Bones 10 Fat Melters and Extractors ■> Gut Scrapers 1 Oil Boilers 1 These premises received 3S5 visits. Forty-two breaches of the Bye-laws were discovered and dealt with. One additional premises was licensed for fish frying, and at four other premises there was a change of occupier. One application to commence the business of a fish fryer was refused. During the year, the occupier of premises situated on the marshes discontinued the business of fish-skin scraper. 29 The fat melting premises in Clapgates Lane was burnt out and new buildings erected. They are of a much better character than those previously used, but do not reach the standard we should prefer. PIGGERIES. There are 17 piggeries in the district, at five of which pigs are kept on an extensive scale. These are at considerable distance from any houses ; are situated on low lying land, and require constant supervision to secure any approach to sanitary conditions. Serious attention has been given to the question of drainage, and the general position is still under discussion. STABLES. One prosecution in connection with a stable in North Street was necessary. The occupier was fined 10/- and costs, and ordered to abate the nuisance from absence of sufficient drainage, and* manure accommodation. COMMON LODGING HOUSES. Eighty visits were paid to the two common lodging houses. It was necessary to secure the rebuilding of the wash-house in one instance ; apart from the general repairs in other parts of the premises. At the other lodging house, a systematic renewal of beds took place. With respect to this house, which is of the old type, I am glad to report considerable improvement, which is being maintained, in the standard of conditions. TENTS, VANS, SHEDS. There are still ten of these undesirable dwellings. With respect to a concerted barn at Rippleside which was occupied, a Closing Order was made. To control the usq of this type of dwelling necessitates frequent visits by the sanitary inspectors. With two exceptions, the van dwellers are all anxious, given the opportunity of housing accommodation, to vacate these unsatisfactory habitations. HOUSES LET IN LODGINGS. There is nothing further to add to the report on such,houses contained in the report for the year 1926. 30 INSPECTION AND SUPERVISION OF FOOD. MILK SUPPLY. g. Of the total the bulk is pasteurised, being received from large wholesale factories and distributed by retail dairymen. Including four whose premises are situated outside the district, there are 33 registered retail purveyors. These are frequently inspected, particular attention being paid to facilities for the clcansing of utensils. There continues an improvement in the methods of distribution, unsatisfactory metal cans previously used by householders being gradually withdrawn, and the glass bottle fitted with cap, proving more satisfactory both for service and storage. The following table shows the number of licences granted for the sale of graded milk under the Milk (Special Designations) Order, 1923, during the year :— (a) " Certified " Milk 1 (b) " Grade A (Tuberculin Tested) " Milk 4 (c) " Grade A " Milk 1 (d) "Pasteurised" Milk 1 A licence was granted to a local firm for the bottling of " Grade A" milk. During the year 4 samples of " Grade A " milk were submitted for examination, all of which were satisfactory. MEAT INSPECTION. In the early part of the year, slaughtering was taking place the registered slaughter-house and also the one subject to an annual licence. The occupier of the registered slaughter-house was slaughtering, for the short period of his occupation, indifferent quality cow b^f, which was consigned to the wholesale market. 31 Such carcases received the strictest examination, and a considerable quantity of diseased meat was condemned. It was ascertained that the animals were purchased at certain cattle markets, and a communication on the matter was addressed to the County Medical Officer. The registration of this slaughter-house has since lapsed. The occupier of the licensed premises continues to carry out his business in a satisfactory manner. During the year, 150 notifications to slaughter were received, and 97 beasts, 204 pigs, 78G sheep, and 137 calves were examined. Diseased meat weighing 2 tons, 11 cwts., 1 quarter, and 20 pounds, was destroyed. Particulars are set out in the following table :— DISEASED MEAT. Descripticm. Disease. Weight. 7 Beasts' Carcases Tuberculosis 3.155 pounds. 1 Longside of Beef ,, 200 5 Forequarters of Beef ,, 660 2 Top-pieces of Beef ,, 220 ] Pig Carcase ,, 96 2 Sheep Carcases Dropsical and Emaciated 84 7 Beasts' Heads Tuberculosis 196 8 „ Plucks ,,, 160 5 „ Livers ,, 70 28 „ Lungs ,, 224 8 „ Mesenteries ,, 80 2 „ Plucks Fluke 40 5 „ Livers ,, 70 3 „ Livers Angioma 42 2 Pigs' Heads Tuberculosis 28 4 „ Plucks ,, 40 1 „ Lung ,, 4 1 „ Mesentery ,, 21 4 „ Lungs Pneumonia 16 1 „ Lung Congestion 4 3 „ Livers Cirrhosis 21 10 Sheep Plucks Parasites 70 12 „ Livers ,, 48 75 „ Lungs ,, 225 TOTAL 5,760 32 ADMINISTRATION OF THE PUBLIC HEALTH (MEAT) REGULATIONS, 1924, AS REGARDS STALLS, SHOPS, STORES AND VEHICLES. No contraventions of special importance occurred during the year. Such breach of the regulations as were discovered by the inspectors during their routine visits, were dealt with informally, and successfully. Fortunately, there are no " gutter stalls " used in the district. 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. 55 64 44 163 — — No occasion for prosecution arose during the year. IMPROVEMENT OF EXISTING HOUSING CONDITIONS. During the year, the Minister of Heaith approved the Barking Town (Parson's Row) Improvement Scheme, 1926, and a commencement was made on the erection of flats in Gascoigne Road, in which a number of the tenants are to be rehoused. Sufficient progress had not been made in December, 1927, however, for any rehousing to take place. The sanitary inspectors continue the policy, wherever possible, of raising the standard of fitness, and in this connection, blocks of houses in Trafalgar Street and Grove Place, were provided with water supply and sinks inside the premises. UNSOUND FOOD. The following is a list of unsound food destroyed during the year:— Commodity Quantity. Condition Action taken Pigs Kidneys 12 pounds Decomposed Surrendered Fish—Skate 6 stones ,, ,,, Plaice 6 ,, ,, 33 The house-to-house inspection of the district is being continued, but much of the sanitary inspectors' time is occupied in maintaining satisfactory conditions in the older properties in which repairs are never carried out except as the result of notices. Proceedings were instituted in connection with three houses situated in Kennedy Road. OVERCROWDING. This continues to be a matter of grave anxiety. Thirty houses were erected by the Local Authority during the year, and these are to be followed by 200 more. I am hopeful that such accommodation will relieve our worst cases of overcrowding, which is the cause of considerable discontent and subsequent ill-health. SCHOOLS. All the schools in the district are regularly inspected, when any defect in the sanitary arrangements or water supply are dealt with. With one exception, the whole of the schools are connected with the sewer. Castle School, Rippleside, is cesspool drained. Six of the eight elementary schools have spring-bib fountains with metal cups attached, fixed in the playgrounds, for drinking purposes. The remaining two schools are without fountains of any sort, the children having recourse to taps above the wash-basins. o A distinct improvement from the hygienic standpoint would be the abolition of existing arrangements and the provision of spring Dib fountain jets in every school. 34 FACTORY AND WORKSHOP ACT, 1901. Factories, Workshops, Laundries, Workplaces and Homework. 1. Inspections (including inspections made by Sanitary Inspectors.) Premises. Number of Inspections. Written Notices. Prosecutions. Intimations. Statutory. Factories 155 10 - - Workshops 194 9 1 - Workplaces 274 3 — - Total 623 22 1 - * Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act as remediable under the Public Health Acts. £5 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 14 14 — — Want of ventilation — — — — Overcrowding 1 1 — — Want of drainage of floors - — — — Other nuisances 16 16 — — Sanitary accommodation :— Insufficient 3 3 — — Unsuitable or Defective 18 18 — — Not separate for sexes - - — - Unscreened for Sexes 1 1 — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (S.101) - — Breach of special sanitary requirements for bakehouses (SS. 07 to 100 3 3 - Other offences (excluding offences relating to outwork which are included in Part 3 of this Report) Total 56 56 — 36 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 (Sees. 109, 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Lists. Outworkers. Lists. Outworkers. Contrac tors. Workmen. Contrac tors. Workmen. Wearing Apparel:— Making, etc. 2 6 27 — — — 4 — — — — — — — — Total 2 6 27 — — — 4 — — — — — — — 37 REGISTERED WORKSHOPS. Workshops on the Register (Sec. 131) at the end of the year. (1) Number. (2) Bakehouses (including seven factory bakehouses) 14 Other Workshops 47 Total number of Workshops on Register 61 OTHER MATTERS. Class. (1) Number. (2) Matters notified to H.M. Inspector of Factories :— Failure to affix Abstract of the Factory and Workshop Act (Sec. 133) 2 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) 2 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 26 out-workers :— Wearing apparel 11 Ties " 4 Umbrella makers 2 Life belt covering 8 Tennis ball sewers 1 During the year 19 lists of out-workers were received from other Authorities in respect of addresses in Barking. 4 lists were received from employers within the district. In all instances the premises of oat-workers were kept in a satisfactory state. 38 SECTION 3. NOTIFIABLE INFECTIOUS DISEASES. The following table shows the number of notifications of infectious disease received during 1926 :— TABLE I. Males. Females. Total Total cases rem'd to Hos. Deaths Scarlet Fever 83 101 184 158* — Diphtheria 34 43 77 77** 2 Puerperal Septicaemia — 8 8 3+ 2 Pneumonia (Acute primary and influenzal & following Measles) 61 50 111 6 31 (All Forms) Erysipelas 14 16 30 4 1 Ophthalmia Neonatorum 12 12 24 1+ — Puerperal Pyrexia — 7 7 — — Enteric 11 4 15 13 2 Encephalitis Lethargica 1 1 2 1 2 Anterio Poliomyelitis 2 1 3 — — Totals 218 243 461 263 40 * Includes io cases removed to Ilford Isolation Hospital. ** Includes 3 cases removed to M.A.B. Hospitals and 2 cases to Shad well Children's Hospital. + Includes case of woman confined in Maternity Ward of Hospital. + Includes case transferred from Maternity Ward. 39 The following diseases were notifiable in 1927 under the original Infectious Disease (Notification) Act, 1889, and 1899 :— Smallpox, diphtheria, relapsing fever, xholera, erysipelas, typhus, plague, puerperal fever, enteric fever, scarlet fever and continued fever. and by Orders or Regulations framed under Section 180, Public Health Act, 1875 :— Tubeiculosis (all forms), ophthalmia neonatorum, cerebro-spinal fever, acute poliomyelitis, encephalitis lethargica, influenzal pneumonia, acute primary pneumonia, malaria, dysentery, trench fever, and puerperal pyrexia. The Barking Town (Pneumonia) Regulations, 1924, provides for the notification of Pneumonia supervening upon Measles. The total notifications of infectious disease numbered 461, exclusive of tuberculosis compared with 32S the previous year. During 1927 the number of notifications of tuberculosis (alL forms) was 108 compared with 133 in 1926. 40 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 65 years. Over 65 years. Abbey. Gascoigne. Central. Ripple. Longbridge, Westbury. Scarlet Fever 1 2 6 9 19 97 31 12 4 3 28 30 31 22 36 37 Diphtheria – 5 5 8 11 32 6 3 6 1 12 9 11 18 15 12 Puerperal Septicemia Pneumonia (primary, influenzal and ing Measles) – – – – – – – – 3 2 – – 2 2 1 1 2 Erysipelas 8 8 8 5 1 16 5 6 17 12 16 9 30 19 15 12 16 19 Ophthalmia 1 l 2 1 – 1 2 16 6 4 3 5 6 8 4 Neonatorum 24 – – – – – – – – 6 6 1 3 6 2 Puerperal Pyrexia – – – – – – – – 5 2 3 0 1 — — 1 Enteric Fever – – 1 1 1 4 __ 3 1 2 2 – 1 2 — 2 8 2 Cerebro Spinal Fever – – – – – – – – – — — — — — Anterio Poliomyelitis — — 2 — – 1 — — — — — – — 1 1 1 — — Totals 34 16 22 23 32 152 43 24 40 24 34 15 86 74 65 65 90 79 41 TABLE 111 Monthly summary of notifications of infectious disease :— Month. Scarlet Fever. Diphtheria. Puerperal Fever. Pneumonia. Erysipelas. Ophthalmia Neonatorum. Enteric Fever. Anterio Poliomyelitis Puerperal Pyrexia Encephalitis Lethargica. Totals. January 10 2 1 31 2 — — — 1 — 53 February 22 6 2 11 3 2 — — — — 40 March 17 0 — 14 1 3 6 1 2 — 50 April 10 0 1 9 1 3 2 — 1 1 43 May 15 4 — 9 2 2 — — — 32 June 13 8 — 4 4 3 1 — — — 33 July 5 5 — 2 3 1 1 — — — 17 August 19 0 1 2 3 2 2 — — — 35 September 9 1 1 6 2 4 1 2 2 — 28 October 10 11 1 7 3 1 — — — 39 November 10 6 1 6 2 — 1 — — 1 27 December 23 16 — 10 4 3 1 — 1 — 58 Totals 184 77 8 111 30 24 15 3 7 2 461 42 (a) Scarlet Fever.—The number of cases notified was 184, compared with 135 the previous year. No fatal cases occurred. 148 cases were isolated at the local Infectious Hospital, and 10 at the Ilford Isolation Hospital. The average stay of scarlet fever cases in the Municipal Hospital was 36.5 days, compared with 34.4 days in 1926. The longest period of detention was. 106 days and the shortest 22 days. One patient was discharged after a stay of 14 days, but the diagnosis of Scarlet Fever in this case was doubtful. Of cases treated in hospital, the age incidence was as follows:— Under one year 1 5—10 years 85 1—2 years 2 10—15 years 28 2—3 years 5 15—20 years 10 3—4 years 7 4— 5 years 15 20—35 years 3 35—45 years 2 Sex.—83 cases were male and 101 female. (b) Small Pox.—No case of Small Pox occurred in 1927. (c) Diphtheria.—77 cases were notified, compared with 55 the preceding year. Of cases notified, 72 were removed and treated in the local isolation hospital. Two deaths from diphtheria occurred, one in hospital and the other in an outside institution. The average stay of clinical diphtheria in hospital was 39.8 days, the longest stay being 123 and the shortest 16 days. Six cases of laryngeal diphtheria were admitted to the local hospital, in two instances tracheotomy being necessary. One patient died five days after admission, while the others made a satisfactory recovery. Of diphtheria patients treated in hospital the age incidence was as follows:— 1—2 years 5 10—15 years 6 2—3 years 5 15—20 years 3 3—4 years 8 20—35 years 6 4—5 years 11 35—45 years 1 5—10 years 32 Sex.—34 cases were male and 43 female. 43 (d) Enteric Fever.—Fifteen cases of enteric fever were notified during the year, 13 of which were removed to hospital. The diagnosis of enteric fever was, however, confirmed in 9 instances only, two patients dying after stays of 7 and 10 days respectively. Four cases removed to hospital proved to be mistaken diagnosis as follows :— Pneumonia 1 Stomatitis & Enteritis 1 Rheumatic Fever 1 Tubercular Meningitis 1 (Died) (e) Puerperal Fever.-—Eight cases were notified during the year, three of which were admitted to hospital, one being transferred from the Maternity Ward. All of the cases recovered. (f) Puerperal Pyrexia.—Seven cases were notified during the year. All of the cases recovered. (g) Erysipelas.—30 cases were notified during the year compared with 37 during 1920. Four patients were removed to hospital, one patient dying five days after admission. (h) Malaria and Trench Fever.—Xo cases were notified during the year. (i) Acute Primary and Acute Influenzal Pneumonia.—111 cases were notified during 1927, compared with 62 for the preceding year. Six patients were admitted to hospital, two of whom died nine and twenty-three days respectively after admission. (j) Pneumonia Supervening upon Measles.—No cases were notified under the Barking Town (Pneumonia) Regulation, 1924. (k) Encephalitis Lethargica.—Two cases of encephalitis lethargica occurred in 1927. One patient was removed to the local Municipal Hospital and died after a stay of six days. The other patient died in the Authority's ambulance en route to London Hospital. (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 — Whooping Cough 7 Summer Diarrhoea 7 44 Measles and 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. ISOLATION HOSPITAL. The following is the table of admissions, etc., in respect of infectious diseases during 1927 :— Disease. In Hospital January, 1st, 1927. Admitted during the year. Died. Dis charged In Hospital Dec. 31st. 1927. Scarlet Fever 10 148 — 136 20 Diphtheria 5 72 2* 58 18 Pneumonia I 6 4 2 1 Puerperal Fever — 1 — 1 — Whooping Cough — 2 — 2 — Chicken Pox — — — — — Mumps — — — — — Epidemic Diarrhoea — — — — — Enteric Fever — 13 3 8 2 Ophthalmia Neonatorum — 1 1 — Erysipelas — 4 1 — — Encephalitis Lethargica — 1 1 — Tuberculosis — 1 — — — * i death certified due to Ulcerated Tonsillitis. +I case transferred from Maternity Ward. +I death certified due to Tubercular Meningitis. TUBERCULOSIS. Administrative Arrangements.—Under the Essex County Council (the responsible authority for the treatment of tuberculosis), the Medical Officer of Health of Barking continued as 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, and Liverpool Road Hospital, Islington. 45 The number of notified cases on the register on December 31st„ 1927, was 946, compared with 896 for the corresponding period of the preceding year. During the year, 108 notifications were received of all forms of tuberculosis—pulmonary 87, and non-pulmonary 21— representing a notification rate of 2.7 compared with 3.41 foi 1926. Information was received of the removal into the district of six tuberculous persons. Thirty-seven deaths of notified cases occurred. 12 cases left the district or could not otherwise be traced, 15 cases were discharged "cured," leaving 946 on the register on December 31st, 1927, 471 being male and 475 female. Particulars of new cases of tuberculosis notified and of deaths from the disease during 1927 is afforded by the following table :— New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. Male. Female. Male. Female. Male. Female. Male. Female. Under 1 year _ — — 2 — — — 1 1 to 5 years 1 3 3 I — — 1 2 5 to 10 years 6 7 4 1 — 1 1 — 10 to 15 years 1 1 — 2 — 1 1 — 15 to 20 years 3 2 1 — — 1 — — 20 to 25 years 6 3 — — 2 3 — — 25 to 35 years 11 10 1 — 5 2 2 — 35 to 45 years 8 6 1 — 3 3 — — 45 to 55 years 7 i 2 1 5 2 — 1 55 to 65 years 5 2 — — 3 4 — — 65 yrs. & upwards 1 — — — — — — — Totals 49 38 12 9 20 17 5 4 PUBLIC HEALTH (PREVENTION OF TUBERCULOSIS) REGULATIONS, 1925. These regulations, which came into force on July 31st, 1925, give power to a local authority to prevent any person suffering from tuberculosis of the respiratory tract entering upon any employment or occupation in connection with a dairy which would involve the milking of cows, the treatment of milk, or the handling of vessels used for containing milk. Any person who deems himself aggrieved by a requirement under these regulations 46 may appeal to a Court of Summary Jurisdiction, and may, under certain circumstances, be compensated for ail}' damage sustained. In no instance was it found necessary to take action under these regulations. PUBLIC HEALTH ACT. 1925, SECTION 62. In no instance was it found necessary to take action under this section to secure the compulsory removal to hospital of a tuberculous person in an infective state. As regards the occupations of notified and inward transfer cases during the year, the following table is of interest:— Boot Salesman 1 Fur Cutter 1 Bookbinder 1 Seaman 1 Motorman 1 Asbestos Factory Worker 1 Butcher's Assistant 1 Gas Worker 1 Housewives 26 Clerks 6 Machinist 1 Electricians 3 Glass Blower 1 Advertising Agent 1 Greengrocer 1 Police Constable 1 Factory Workers 3 Dressmaker 1 Printer 1 Cable Jointer 1 Storekeeper 1 Insurance Agent 1 Labourers 9 School 25 Tramway Cleaner 1 No occupation 13 Coal Trimmer 1 Not elicited 9 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 under the County Council:— Attendances at Dispensary. Admission to Sanatoria. No. Rate per 10,000 population. No. Rate per 10,000 population. 1st Quarter 322 80.7 9 2.2 2nd Quarter 339 84.9 14 3.5 3rd Quarter 232 58.1 16 4.01 4th Quarter 283 70.9 14 3.5 47 The average for the year was 73.6 and 3.3 compared with S6.1 and 4.5 for the preceding year, and 92.6 and 4.3 respectively for 1925. The proportion of sanatoria admissions to cases notified was 46.4 per cent., and the incidence of tuberculosis per 10,000 population in respect of notified cases 28.5. 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. 36 19 9 8 33 18 7 7 Forty-six deaths occurred from tuberculosis (all forms), 37 of these being pulmonary cases. The number of deaths in institutions was 21. The death rate for tuberculosis (all forms) during 1927 was 1.1, compared with 0.8 for the previous year. During 1927 nine deaths from tuberculosis were registered of persons not previously notified as suffering from the disease. The importance of notification is that the necessary steps can be taken 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 9 Number notified less than 3 months before death 16 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 4 Number notified 12 to 18 months before death 5 Number notified 18 to 24 months before death 2 Number notified more than 24 months before death 5 48 591 patients made 1,176 attendances at the dispensary during the year for the purpose of medical examination, 138 being new cases. Of new cases attending during the year, 55 were notified as suffering from tuberculosis. The following table gives in tabular form the number of patients removed from the Dispensary Register during the year:— No. on Dispensary Register during 1927. Numbers removed from the Dispensary Register. Number on Dispensary Register 31-12-27. Died. Left District. Discharged (Non Tb.) Discharged Cured" Transferred to another Dispensarv. etc. Total 591 20 20 51 4 2 97 494 At the end of the year, 419 cases on the Dispensary Register were definitely diagnosed as suffering from tuberculosis, whilst in 75 cases the diagnosis still remained in abeyance. 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 After-care 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 17 new cases were so assisted, whilst 25 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. 49 (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 not 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 his or her dependents to secure such patient's removal compulsorily or otherwise to a suitable institution and to there detain 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 the report for 1924. 50 SECTION 4. MATERNITY AND CHILD WELFARE. The Council's Scheme under the Maternity and Child Welfare Act, 1918, has been extended during the year. The use of the Artificial Sunlight Clinic, working in co-operation with the Infant Welfare Clinics, is already being attended with good results. During the latter part of last year an attempt was made to reorganise this section of the department by putting into operation a number of reforms long overdue, although certain existing difficulties had continued to prevent their adoption. An improvement in the position generally was obvious by the end of the year. REGISTRATION AND NOTIFICATION OF BIRTHS. By the Registration Act, 1836, all live births must be registered within a period of six weeks. The actual number of live births within the district during the year was 712, the net total of 710 being obtained by adjustment of inward and outward transfers, etc. The births registered included 345 males and 365 females. There were 21 illegitimate births, or 2.9 per cent. of the total. In comparison with 1926, 108 fewer births were registered during the year, a fall equivalent to 13.2 per cent. By the Notification of Births Act, all live births and still-births of seven months and over are required to be notified to the Medical Officer of Health within 36 hours. Of the toal live births all except 38 or 5.3 per cent. were notified. In addition 2 still births were not notified. 51 The following table gives details of the notifications received:— By whom notified. Live Births. Still Births Medical Practitioners 79 7 Certified Midwives 461 4 Parents and Others 134 7 The percentage of still-births was 2.7 Of the total live births during the year 343, or 48.1 per cent. were attended by midwives, the remainder being attended by medical practitioners. BIRTH RATE. The birth rate for the year was 17.7, compared with. 16.7 for England and Wales. MATERNITY AND INFANT WELFARE. The Ante-Natal Clinic. The work of the Clinic was carried on as in previous years. The attendances during the year were well maintained. The number of primary attendances was 340, compared with 346 for 1926. Reattendances numbered 872 in 1927, and 659 during 1926. One hundred and three sessions were held during the year, making an average attendance of 11 mothers per session. Of the mothers attending, 152 were pregnant for the first time. Expectant mothers attending the Ante-natal Clinic are drawn from the following classes:— (a) Patients intending to enter the Upney Maternity Ward for confinement. (b) Those engaging with the midwives of the Plaistow Maternity Charity. (c) Patients engaging with private midwives. 52 From the figures given at the beginning of this section of the report it will be seen that 343 of the live births were attended by midwives, and of these 294 mothers availed themselves of the facilities provided by the Clinic, that is, four-fifths of the cases attended by midwives are under supervision duripg pregnancy. But in spite of this growing recognition on the part of some of the mothers of the value of ante-natal supervision, there still remains a great deal of prejudice which will only be broken down by unremitting efforts of the health visitors, together with the active co-operation of the midwives. The following table gives particulars of cases referred from the Ante-natal Clinic for hospital or other treatment:— Diseases of Lungs 4 Tolaemias of Pregnancy 3 Heart Disease 2 Epilepsy 2 Small Pelvis 2 Grave's Disease 1 Syphilis 1 Threatened Abortion 1 Premature onset of Labour (Twins) 1 Abnormal Presentation 1 A new development towards the end of the year at the Antenatal Clinic was the attendance of one of the health visitors at one session weekly for the purpose of giving advice and instruction in ante-natal hygiene and other appropriate subjects. The number of mothers attending this class at any time is not large, so that it is possible for the health visitor in many cases to give individual instruction. These talksare of especialvalue to the younger mothers. Post Natal Cases. Twenty-six cases attended by midwives were referred by them or by the health visitors for examination at the Ante-natal Clinic owing to the presence of defects following childbirth. Seven of these cases were found to be in need of special medical treatment, for which they were referred to hospital or elsewhere, according to the defect found. 53 MATERNITY WARD. The admission to the Maternity Ward of the Municipal Hospital numbered 221, compared with 206 in 1926. Of these 45 cases were admitted for ante-natal treatment, and 176 for confinement. Corresponding figures for 1926 were 37 cases for ante-natal treatment, and 169 for confinement. The number of cases confined in the Ward represents 24.7 per cent. or approximately 1 in 4 of the total births of the district, a proportion which it is hoped will increase still further. (1) Number of cases admitted 221 (45 of which Ante-natal) (2) Average duration of stay Confinement cases 13.9days Ante-natal cases 11.2 days (3) Number of cases delivered by:— (a) Midwives 168 (b) Doctors 8 (4) Number of cases in which medical assistance was sought by the midwife with reason for requiring assistance:— (a) Ante-natal 1 1 High Presentation 1 Miscarriage 1 Transverse Extended Breed 2 Uterine Inertia l Collapse after 3rd Stage (b) During Labour 7 (c) After Labour 2 1 Collapse after 3rd Stage 1 Sub-involution (d) For Infant — (5) Number of cases notified as puerperal sepsis with result of treatment in each case None (6) Number of cases notified as puerperal pyrexia with result of treatment in each case None (7) Number of cases of pemphigus neonatorum None (8) Number of cases notified as ophthalmia neonatorum with result of treatment in each case 1 (Cured) (9) Number of cases of "inflammation of the eyes," however slight None 54 (10) Number of infants not entirely breast fed while in the Institution, with reasons why they were hot breast fed 4 (a) Weakness of mother 2 (b) Cleft Palate 1 (c) Feeble Twin (mother anaemic) 1 (11) Number of maternal deaths None (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) Still-born 2 (b) Within 10 days of birth 5 PUERPERAL FEVER AND PUERPERAL PYREXIA. On October 1st, 1926, the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926, came into force. These regulations require the notification of puerperal pyrexia (according to the definition given in the regulations), in addition to those cases previously notifiable as puerperal fever under the Infectious Diseases Notification Act, 1899. In a circular accompanying the Regulations, the Minister of Health urges local authorities to exercise the powers conferred on them under the Maternity and Child Welfare Act for provision of facilities for diagnosis, skilled nursing at home, or institutional treatment, if in the opinion of the medical practitioner in charge of the case any one of these is necessary. In accordance with this direction, arrangements have been made by the Council for nursing of the patient at home, or in the isolation hospital as desired. In addition, Dr. A. Kennedy has been engaged as consultant for those cases in which a second opinion is required by the medical attendant. Eight cases of puerperal fever were notified as compared with 3 in 1926, 3 of which were admitted to the Isolation Hospital, 2 of the cases were attended by midwives. Once case occurred in the Municipal Maternity Ward. The patient was isolated immediately on the onset of pyrexia, and no further cases occurred. 55 In addition to the cases of puerperal sepsis, 7 cases of puerperal pyrexia were notified, the confinements in 3 cases being attended by midwives. All the patients recovered. No definite cause of infection was found in any of the cases, although it was noted by the health visitors in the routine investigation, that in three out of four patients foci of infection were present before labour MATERNAL MORTALITY. Three maternal deaths occurred during 1927, the deaths being certified as follows:— (a) Post mortem haemorrhage—transverse presentation 1 (b) Septicaemia due to miscarriage 1 (c) Septicaemia—incomplete abortion 1 NEO-NATAL MORTALITY. The number of deaths of infants under four weeks of age was 18, giving a rate of 25.3 per thousand, compared with 18.3 for the previous year in Barking. It is hoped that, with the extension of nate-natal care, this low rate will be maintained. Deaths Under Four Weeks. Under seven days. Under fourteen days. Under twentyone days. Under twenty light days. Total. Atelectasis 1 — — - 1 Premature Birth 11 — - - 11 Debility 3 1 - - 4 Marasmus — 1 — — 1 Pneumonia - - 1 - 1 56 STILL-BIRTHS. Of the total notifications received under the Notification of Births Act, 20 related to stillborn children, giving a percentage of 2.7 compared with 2.6 in 1926. In addition, 5 Barking women were delivered of stillborn infants in institutions outside the district, so that the total number for the year was 25. Two cases were of twin pregnancy—both infants being stillborn in one instance and one infant only in the other. Investigation of the health visitors elicited the following information:— (1) Duration of pregnancy:— (a) Less than seven months 1 (b) More than seven months 21 (c) Not elicited 3 (2) Presentation:— (a) Vertex 11 (b) Breech 2 (c) Transverse 5 (d) Not elicited 7 (3) Supposed cause of stillbirth:— (a) Abnormal presentation 1 (b) Overwork — (c) Accident, etc. 4 (d) Not known 19 (e) Ill health — (f) Strain 1 4) Occupation of mother:— All the mothers were engaged in household duties at home. In addition, one woman did an occasional day's cleaning elsewhere, whilst one was engaged in dressmaking at home. 57 OPHTHALMIA NEONATORUM. There was again an increase in the number of cases of ophthalmia neonatorum, notifications being 24, compared with 16 in 1926. 18 of the cases occurred in the practice of midwives, the remainder being attended by medical practitioners. Age Group. Cases. Vision unimpaired. Vision impaired . Total Blindness. Deaths. Treated. Notified At Home. At Hosptl. Under 3 weeks 24 23 1 24 - _ _ The growing appreciation among midwives of the seriousness of the condition and of the value of early treatment makes for a greater readiness on their part to call in medical help to the slighter cases of discharge which previously may have escaped notification altogether. i OPHTHALMIA NEONATORUM REGULATIONS, 1926. These regulations came into force on October 1st, 1926. Under them it is no longer the duty of the midwife to notify cases. In accordance with the rules of the C.M.B. the midwife is under obligation to call in medical aid for any inflammation of the eyes, however slight, and the onus is now with the medical man called in to notify if, in his ophinion, the case is one of opthalmia neonatorum. For the effective supervision and treatment of such cases, close co-operation between the Local Supervising Authority and the Local Sanitary Authority is essential, and suggestions are made in a circular accompanying the Regulations as to how this co-operation may best be secured. 58 INFANT AND CHILD WELFARE. Work of the Health Visitors and the Infant Clinics. An analysis of the attendance at the Infant Welfare Centres is given in the following table :— Infant Welfare Centres. Clinic Premises Alex. Centre Movers Lane Total No. of sessions 97 102 i 93 294 No. of attendances of children under one year :— (a) New cases 155 199 145 499 (b) Old cases 1361 1763 1523 4647 No. of attendances of children 1 to 5 years of age :— (a) New cases 37 125 39 201 (b) Old cases 827 1525 893 3245 Average number of attendances per session 24 35 27 29 No. of sessions attended by medical officers 95 102 90 287 No. of children seen by medical officers (a) Under one year 1027 1146 1115 3288 (b) Over one year 559 810 642 2011 Average number of children seen by medical officer per session 16 19 19 18 The total attendances during the year were 8,592 as compared with 10,125 in 1926. There is no reason to anticipate that this reduction is other than a temporary one. Particulars of the home visits paid by the health visitors is given in the following table :— No. of ante-natal visits 130 No. of first visits to children under one year 691 No. of subsequent visits to children under one year :— (a) Attending a Centre 533 (b) Not Attending a Centre 2,710 No. of visits to children 1 to 5 years of age :— (a) Attending a Centre 342 (b) Not Attending a Centre 2,598 No. of special visits in connection with Ophthalmia Neonatorum 47 Ditto Deaths of children up to 3 years of age 59 Ditto Still-births 24 Ditto Puerperal sepsis and Pueperal Pyrexia 20 Ditto Foster Children 41 Other visits (not specified) 97 59 THE PRE-SCHOOL CHILD. Treatment may be obtained for children attending the infant welfare clinics as follows :— Minor Ailments.—Treatment is given at the School Clinic by arrangement with the Education Committee. Dental and orthopaedic treatment, and treatment of septic tonsils and adenoids are available as in the case of school children. Convalescent Treatment.—This is provided for under the Scheme, and is of value for children suffering from debility following acute illness. FOSTER CHILDREN. All cases of foster children resident in the district are notified by the Guardians to the Medical Officer of Health under the Children Act, Part 1. Forty-one notifications were received during the year, and special visits were made by the health visitors to these children, who are also kept under supervision by the Infant Life Protection Visitor. INFANTILE MORTALITY. The total number of deaths of infants during the year was 47, giving an infant mortality rate of 66.1 per thousand registered births, compared with 59.9 per thousand for 1926. Diseases of the respiratory system, bronchitis and pneumonia were responsible for 10 of the infant deaths. 60 An analysis of the distribution of the deaths of infants under I year of age, according to wards, is of interest, and is given in the table following:— Ward. Notified Births. , Deaths. 1927 death rate per 1,000 notified births. Abbey 145 16 110.3 Gascoigne 120 4 33.3 Central 76 5 65.7 Longbridge 131 6 45.8 Westbury 113 12 106.1 Ripple 100 4 40.0 INFANT MORTALITY AND SEX. An excessive female death rate occurred during the year, the rate being 57.9 per thousand for male, and 73.9 for female children. ILLEGITIMACY. Twenty-one illegitimate children were born during the year, and in the same period 5 deaths of illegitimate infants occurred ; the infantile mortality rate among these children was therefore 238.0; while that for legitimate infants was 60.9. DENTAL CLINIC. A steady expansion in this branch of the work has been taking place, and during 1927 the attendances of expectant and nursing mothers and of children referred from the Maternity and Child Welfare Clinics were as follows :— (1) Number of children treated 101 (2) Number of mothers treated :— (a) New cases 118 (b) Old cases 412 (3) Number of dentures supplied 40 Sixty-four sessions were held. 61 Here it must be observed that the aim of the Maternity and Child Welfare Service is the prevention of the onset of dental caries in the child, and, for this purpose, the improvement of the health of the mother and of her diet during pregnancy, the encouragement of breast feeding and the use of suitable dietaries for the young child, together with the practice of mouth hygiene, are all factors which must be dealt with by the Maternity and Child Welfare staff, in order to bring about an improvement in the structure of the teeth, and delay in the onset of caries. ORTHOPAEDIC CLINIC. Eighteen children under school age were referred from the Infant Welfare Clinics or by the local medical practitioners for examination by the Orthopaedic Surgeon during the course of the year, and, in addition, 29 cases attended for re-exainination. Three of the children received in-patient treatment at Orthopaedic Hospitals, and surgical instruments were provided in three cases. The cases dealt with for the first time during 1927 were referred for the following conditions :— Deformities—Bones and Joints— (a) Congenital: (i) Digit 3 Foot R. and L 1 (ii) Webbed Digits 1 (b) Acquired: (i) Rickets 6 (ii) Genu Valgum 1 9 Muscular Deformities— (а) Congenital: (i) Talipes 3 (ii) Amyotonia 1 (б) Acquired: (i) Pes Planus Valgus .. .. .. .. 1 5 62 Paralysis— (a) Congenital: (i) Tetraplegia 1 (&7 Acquired; (ii) Anterior Poliomyelitis 2 3 Congenital Deformities— (i) Congenital weakness in neck muscles 1 1 Total 18 ARTIFICIAL SUNLIGHT CLINIC. The treatment of infants and children under five years of age at the Artificial Sunlight Clinic was continued during 1927. Cases are referred by the medical officers in charge of the Infant Welfare Clinics, and the children attending are kept under constant medical supervision during their course of treatment. The majority of the children referred for treatment were suffering from early rickets and malnutrition. In addition, cases were referred for the following conditions—chilblains, prematurity, general debility, and anaemia. In all, 73 children received treatment during 1927. One session per week was devoted to these cases, and 594 treatments were given. MEALS TO EXPECTANT AND NURSING MOTHERS. Advantage has been taken during 1927 of this provision under the Act, 8 necessitous mothers having been provided with dinners as compared with 18 during the previous year. The total number of dinners supplied was 155. The nutrition of the mother during pregnancy and in the lying-in period has a very important bearing on the well being of the infant, and it is at these times that necessitous mothers are particularly encouraged to avail themselves of the Council's scheme. 63 PROVISION OF FRESH MILK. Particulars of the amounts of wet milk supplied free and at reduced rates to necessitous mothers and children are given in 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. £ s. d. £ s d. 2,496 7,471 9,967 135 11 9 118 17 10 PROVISION OF DRIED MILK, Etc. Particulars of the amount of Dried Milk, etc., supplied free and at reduced rates, are as follows :— C ost Price, (lbs.) , Reduced Price, (lbs.) Free, (lbs.) Total, (lbs.) Glaxo (Full Cream) 250 / / 116 443 Glaxo (Humanised) 40 1 41 Ambrosia 56 2 27 85 462 965 4,718 Lacta 42 3 3 48 Ostelin * 122 — 4 126 Lactogol 207 — — 207 Virol 423 — r — 423 Parrish's 155 ! — 4 159 Parraftin 165 — 4 169 Malt and Oil 333 i — 21 354 Pure Oil 142 i — • 142 Vitoleum Cream 1,021 ! — 2 1,023 Marmite 23 — 23 Vitmar 61 i — 61