AC 439(1) ENMONTON EDM 15 Middx Edmonton Urban District. (PARLIAMENTARY BOROUGH.) ANNUAL REPORTS on the Public Health and School Medical Services FOR THE YEAR 1920. BY SIDNEY C. LAWRENCE, Medical Officer of Health and School Medical Officer, Supervisor ot the Maternity and Child Welfare Centres, M.B., Ch.B., D.P.H. (Lond ), M.R.C.S. (Eng.), L.R.C.P. (Lond), Fellow of the Society of Medical Officers of Health. R. H. STRONG, L.R.C.P. & S. (Edin.), L.F.P.S. (Glasg.), Assistant and Deputy S.M.O.—S.M.I. Also the Report of RICHARD J. BUTLAND, M.R.San.I. JOLLY THE PRINTER (T.U.) EDMONTON. Edmonton Urban District. (PARLIAMENTARY BOROUGH.) \ ANNUAL REPORTS on the Public Health and School Medical Services FOR THE YEAR 1920. by SIDNEY C. LAWRENCE, Medical Officer of Health and School Medical Officer,: Supervisor of the Maternity and Child Welfare Centres, M.B., Ch.B., D.P.H. (Lond.), M.R.C.S. (Eng.), L.R.C.P. (Lond), Fellow of the Society of Medical Officers of Health. R. H. STRONG, L.R.C.P. & S. (Edin.), L.F.P.S. (Glasg). Assistant and Deputy S.M.O.—S.M.I. Also the Report of RICHARD J. BUTLAND, M.R.San I. JOLIY THE PRINTER (T. U.) E DMONTON. 2 PUBLIC HEALTH DEPARTMENT. December 31st, 1920. 1.—Medical Officer of Health: SIDNEY C. LAWRENCE, M.B., Ch.B., D.P.H.† 2.—Assistant and Deputy Medical Officer of Health: (Vacant since July, 1914.) 3.—First Male Inspector and Inspector of Canal Boats: R. J. B0TLAND.*‡ 4.—Second Male Inspector: J. E. WINTER.*†‡ 5.—Third „ „ G. H. HUCKLE.¶* 6.—Fourth „ ,, W. TILLCOCK.*† (since July 1). 7.—Fifth ,, ,, A. EDE. ¶ (since June 3). 8.—First Woman Inspector: Vacant. 9.—Second „ „ G. M. SHINER.*¶ (C.M.B.). 10.—Third „ „ A. BINTCLIFFE.*¶ (ClM.B.).*** 11.—Fourth ,, ,, Mrs. J. A. HOBBS.(C.M.B.)** (also Sch. Nurse) 12.—Fifth „ „ E. TOOTELL.* (C.M.B.) (since April 12). 13.—Sixth „ „ F.G.K.BRENNAND *(C.M.B.)** (since July5) 14.—Senior Clerk: A. OADES. 15.—School Medical Clerk: JOHN P. FARRAR. 16.—Junior Clerk: DORIS B. HILL. 17.—Disinfector, Sanitary Stores Keeper and Transport Officer: J. MADLE. 18.—Mortuary Attendant, Laboratory, Disinfecting Station: C. HICKFORD. 19.—Caretaker of Emergency Hospital: J. MADLE (temporary). 20.—Driver of Ambulance and Bedding Vans: A. H. ALDRIDGE. 21 Opener-up of Old Drains, Urinal Cleanser and General Sanitary Workman. A. PASHALL. 22 . Opener-up of Old Drains (part-time): A man from Engineer's Department as required. 23-26.—Attendants at Sanitary Convenience at Angel Road: Two male and two female. 27—30.—Attendants at Sanitary Convenience on The Green: Two male and two female. * Officers marked thus hold the certificate of the Royal Sanitary Institute † These officers have the certificate of Meat and Food Inspector. ‡ These officers are appointed as Inspectors under the Shops' Act, 1912. ¶ These officers have the certificate of the Sanitary Inspectors' Board. ** A nurse with three years' training. *** Maternity and Child Welfare Certificate. 3 SUMMARY. Area 3,894 acres, including 31 of water Census Population, April, 1911 64,797 Estimated Nett Population, June 30th, 1920 77,202 Density of Population per acre of land, 1920 20.4 Rateable Value, October, 1920 £249,437 Assessable Value, October, 1920 £235,580 General District Rate, 1920 9s. 6d. in the £ Poor Rate, 1920 1 is. 2d. in the £ A Penny Rate produces (about) £960 VITAL STATISTICS. Birth-rate per 1,000 living 24.88 Gross, or Registered, Death-rate per 1,000 living 13.82 Nett Death-rate per 1,000 living 9.17 Infantile Mortality per 1,000 births registered 67.67 Zymotic Death-rate per 1,000 living 0.58 HOSPITAL ACCOMMODATION. For Infectious Cases—Enfield and Edmonton Joint Isolation Hospital. For Smallpox—South Mimms Smallpox Hospital and Clavering's Farm, Edmonton. Electricity—North Metropolitan Electric Power Supply Company, Limited. Water Supply—New River District, Metropolitan Water Board. Gas Supply—Tottenham District Light, Heat and Power Company. Sewerage—Separate System. Sewage Disposal—Broad Irrigation and Bacterial Filters. 4 Men vobis ultima verba: laus Deo ! Town Hall, Edmonton, N. 9. To the Chairman and Members of the Edmonton Council. Ladies and Gentlemen, I herewith present my 15th (and last) Report on the health and sanitary circumstances of this urban district. It refers to the year 1920. At the end of April, 1921, I had completed 15 years' service as Medical Officer of Health, 9 years as School Medical Officer and 3 years as Supervisor of the Maternity and Child Welfare work in Edmonton, but I reserved my resignation until to-day in order that my friends and employers, the Ratepayers, should not be financially embarrassed, in the absence of my annual reports, by the withholding, or loss, of grants from the Government On an occasion such as this, one is warranted in publishing some reminiscences, but neither time nor space will permit me to tabulate the number of instances in which my advice as to improvements in the public health, maternity and school medical services has been ignored by past and present Councils, although I have advocated some for 15 years. A perusal of my past Annual Reports will bring most of them to my readers' notice. On the other hand, I will quote some vital statistics of years ago in comparison with those recorded in this report, which comparison will justify a claim for myself and staff that, notwithstanding many difficulties and obstructions, our work has had praiseworthy results in saving the lives of thousands of future Edmonton citizens and making their surroundings more endurable. Year Rate Year Rate Year Rate Infant death-rate per 1,000 births 1898 195.84 1905 128.00 1920 67.67 Total death-rateperi,oooinhabitants ,, 16.81 ,, 1334 ,, 9.17 Zymotic „ „ ,, ,, 5.08 „ 2.36 „ 0.58 N.B.—Without going further back than 1905 and comparing the figures with 1920, there are marked decreases, e.g.:— Infant death-rate a decrease of 60.33 = nearly half. Total death-rate a decrease of 4.17 = nearly one-third. Zymotic death-rate a decrease of 1.78 = over three-fourths, 5 My staff and I are to be congratulated on leaving Edmonton with the lowest rates on record as regards the infant, the total and zymotic deaths. The nett population of Edmonton urban district in 1905 was 54,606, and in 1920 was 77,202 that is, an increase of no less than 22,596, or over 41 per cent! This huge increase in population and the enormous output of Acts of Parliament, Orders, Regulations and Circulars from the Government departments have more than trebled the duties and responsibilities of your Principal Medical Officer since 1905. Beginning with only a staff of 9 persons, I now have no less than 40 under my control. I have, therefore, every reason to beg of you to give my successor all the courtesy, consideration and assistance that is his due. He will need proper treatment, if he is to carry out his work efficiently and in a cheerful spirit. Further, I warn you not to make him any promises that you are not prepared to fulfil. I gratefully acknowledge the help received during 1920 from the loyal members of my three staffs and from the Heads of the other departments. I am indebted to our Engineer, Mr. Cuthbert Brown, for his kind help with Sections III, IV and V. Moreover, in compiling this report, I have received very valuable assistance from my School Medical Clerk, Mr. J. P. Farrar, who has recently obtained the certificate of the Sanitary Inspectors' Board, the highest obtainable. I feel sure that you will all endorse fully the sentiment of the Latin sentence heading this Preface. SIDNEY C. LAWRENCE, Jtily 30th, 1921. Principal Medical Officer. 6 EDMONTON URBAN DISTRICT. REPORT OF THE Medical Officer of Health For the YEAR 1920. RECENT HISTORY. The district was divided into three Wards—Church Street, Fore Street and Bury Street—by an Order of the Middlesex County Council in 1903, and is controlled by an Urban District Council of 27 members, nine of whom should retire annually. The elections were suspended during the war, since the last one in 1915, but revived in 1919. After the election of April, 1920, Mrs. Benjafield, Messrs. George Rowe and W. F. Middleton remained as co-opted members for another year. It is represented on the Middlesex County Council by three members: Messrs. Cornish, Cull and Councillor H. Barrass. The population is almost entirely industrial, and a large proportion of the workers travel daily by tram and train to their employment in the City and other parts of London. The County Medical Officer's Report for 1919 was received on February 8th, 1921. Foreword.—I am glad to say that I am now able to dispense with this chapter, which first appeared in my annual report of 1914. Distress Committee.—In April, this Committee was reconstituted for one year (1920-21). Rates.—From April 1st the collection of the Poor and District Rates were combined and shared by Messrs. J. Williams and M. F. Cadman. The Food Control Committee was ended on June 30th, 1920, and the office shut on 31st December, 1920. Postages.—In May I pointed out that an increase in the charges would affect our expenses considerably, as (in the aggregate) an increase of only |d. on the postages to and from the schools, clinic and attendance officers, together 7 with notifications of infectious disease, and births from the midwives and medical men make a considerable total. The Council made representations to the Postmaster General urging that Jd. stamp should suffice for postcards and open envelopes in connection with public health work. Our appeal was successful. THE N.A.L.G.O. On August 31st the Council informed the Edmonton branch that it accepted the principle of a local Whitley council, but that it must be representative of all grades of employees. In October the Central N.A.L.G.O. asked the Council to put into operation from July 1st, 1920, the minimum salaries and grading scheme unanimously adopted by the National Joint Council, but the consideration was adjourned to January, 1921, when a sub-committee of the Finance Committee was appointed to discuss the subject with representatives of the Edmonton branch of the N.A.L.G.O. I make this brief note of N.A.L.G.O. activities here, as the zeal with which I and my staff perform our duties naturally fluctuates with the amount of courtesy and consideration we receive from the Council and to that extent the public health of Edmonton is thereby affected. POOR LAW INSTITUTIONS. The Institution belonging to the Edmonton Board of Guardians, which is in Fore Street, and covers an area of 22J acres, receives a certain proportion of its inmates from this district, and such proportion is treated as part of our population for statistical purposes. The large bulk of the inmates, however, is derived from Tottenham, Southgate, Wood Green, Hornsey, Enfield, Cheshunt (Herts), and Waltham Abbey (Essex), which places make up the large Poor Law Union of Edmonton, and these inmates, of course, do not enter into our vital statistics. Mr. B. Andrews is the master. In March, 1920, the estimated population of Edmonton Union was 493,956; rateable value ^2,595,005. Amongst a total of forty Guardians, Edmonton district proper has only four representatives. Millfield House has been occupied since January, 1917, by the Metro, politan Asylums Board as a male epileptic colony. It accomodates 302 patients from other districts, therefore these people are excluded from our Vital Statistics. Dr. Bebb is the visiting Medical Officer, and Mrs. S. Pallin is the Matron. 8 NORTH MIDDLESEX HOSPITAL. Formerly the Edmonton Mi'itary Hospital and old Infirmary. The dissolution of the Military Hospital.—At the end of October, 1920, the Military Authorities evacuated the buildings, i.e. the new Infirmary and the Nurses' Home which had been a military hospital since April, 1915, the temporary ward, and all others that had been made use of in the interval, which then reverted to civilian use and the title of "North Middlesex Hospital" was assumed. This title now extends to the buildings formerly in use by the military with the addition of what was known as "the old infirmary" with its mental and maternity wards. The workhouse proper with its able-bodied, infirm and casual inmates remains as "The Edmonton Workhouse" under the control of Mr. B, Andrews. All army and naval cases not evacuated became pensioners and demobilised from the services. Of these there were about 100 at the ead of 1920. After discharge, these pensioners, if necessary, can attend as out-patients, or they may be re-admitted on the request of Pension Committees in the neighbourhood. Service men on leave, by the authority of the War Office, can be treated as emergency cases, either as in or out-patients. There is a special orthopaedic visiting surgeon who was appointed by the Guardians and approved by the Ministry of Pensions. These services are paid for by the Government to the Guardians on a capitation basis. The temporary wards have not yet been removed, but are used partly for military stores that have not yet been disposed of and partly for massage and electricity cases. No patients have been housed there since November, 1920. The Strand Workhouse was closed about the end of 1920 and handed back to the Military Authorities. The Special Military Surgical Hospital, Edmonton, ceased to receive military cases on the 31st October, 1920, after having performed this function during the war for a period of 5J years. 44,892 patients were passed through and treated during that time, and it is noteworthy that the late Edmonton Military Hospital was one of the very first to commence work in the military capacity, and certainly the last to cease such duty, as other Units had been ceasing to perform this public service about 12 months beforehand. The special reason at Edmonton was that the Hospital was pre-war, built and adapted for acute surgical cases and operative surgery; the War Office thought it wise to utilise this as a special surgical unit, in view also of the provision which had been made for auxiliary treatment of operative work, namely, Massage, Electricity, Radiography, Curative Workshops, Plaster (of 9 Paris) Department, etc., and all the necessary provision for re-education of the wounded soldier after leaving the surgeon's hands. After closing for the reception of military cases in the Main Hospital, there is still an arrangement with the Admiralty, War Office, and the Air Force for treating Service men in emergency conditions. Additionally, the Ministry of Pensions for a large area in the North of London and even for Districts outside, is utilizing the Hospital for surgical treatment of pensioners, and for the restoration of the broken ex-service civilian to full industrial capacity. The work performed during the war has had a great effect on the psychological question of hospital treatment, that is to say, many thousands of visitors who came to help the soldiers have subsequently returned for treatment in the wards, having seen through the war the effect of hospital treatment, and having thus got rid of the long standing prejudice in most minds as to what is actually done in a hospital. Prior to 1914 the ordinary man in the street had a rooted adversion to hospital treatment, but having learnt from the experience of his relatives the nature of the care which is bestowed on the suffering sick, he has come to appreciate the value in serious illness, and in fact the actual necessity, of being nursed and treated with the help of modern appliances and modern methods, which could not be adapted in a private house, except in slight illness. Apart from the scheme of pensioners, the furnishing of the special departments for physical therapeutics will remain for the treatment of the general population, and it is hoped thus that sick infirm and deformed children and adults may be restored to health by teams of doctors and nurses engaged on a more extended curative treatment than has previously been possible by operative measures. Every encouragement in scientific advance has been given by the Hospital Committee, and in the future the usefulness of such a large Unit with an enormous turnover of patients should daily improve for the benefit of the public. The position of the Hospital is rather unique, inasmuch as emergency and urgent surgical cases which cannot be received in the regular General Hospitals between here and North of the Thames, are being received into the North Middlesex Hospital owing to the small number of beds and shortage in these General Hospitals, and an increasing number of these patients are being dealt with who cannot elsewhere receive treatment. A great advance is being made in the Special Maternity Department for Council cases, and this is recognised as a Training School for maternity work in North London and the Central Midwives Board have requested that all 10 lectures on Midwifery be thrown open to outside students as well as pupils engaged in the wards. The Senior Medical Officers became civilians again; Dr. Mort as Medical Superintendent and Surgical Director and Dr. Gregorson as Deputy Superintendent and Physician. Mentally Deficients. -Mentally deficients both over and under 16 years of age (of whom there are about 55 in residence) are reported to the County M.D. Medical Officer, and they are retained at the North Middlesex Hospital until Dr. Laval can find accommodation at suitable institutions. Tuberculosis.—These cases are handled in the same way as in 1919. The County Council take some at South Mimms, the Northern Hospital at Winchmore Hill or Brentford free of cost to the Guardians. Maternity Cases.—Four Local Authorities (Enfield, Wood Green, Southgate and Tottenham) have contracted agreements with the Guardians. The agreement with Edmonton has not yet been completed. There are 40 beds available with a seperate entrance from Bull Lane. The wards are kept distinct from those used for pauper women. The Deaths that occurred in the Edmonton Military Hospital until dissolved totalled 47 (eight of them residents)—4 from wounds and 43 from disease. These deaths are not included in Table III. CHANGES IN MY PUBLIC HEALTH STAFF. Male Inspectors.— Mr. H. K. Nixon resigned in April and the Public Health Committee recommended that, owing to the great increase of work, not only his vacancy be filled, but that an additional male inspector be appointed. Mr. A. Ede commenced duty on the 3rd June and Mr. W. Tillcock on the 1st July. I placed both on to systematic house-to-house inspection. Women Inspectors.—In February the Public Health Committee recommended the appointment of a permanent officer to fill the vacancy to be made by Miss Simpson leaving and that an additional woman inspector also be appointed owing to the increased duties. On April 12th Miss E. Tootell was appointed to fill the vacancy of Miss Simpson who left on 3rd April. Miss F. G. K. Brennand was appointed as additional woman inspector on July 5th. 11 Miss Tootell ceased work for the year on the 22nd November owing to illness and Miss E. Reddock was taken on as her deputy. ACCOMMODATION FOR WOMEN OFFICERS. In May I reported the great necessity of providing further office accommodation for the women inspectors and thereupon the Works and General Purposes Committee were instructed to arrange, in consultation with the head officers, for extended accommodation for the staff generally. This Committee in May appointed a Sub-Committee to consider the matter. In June the Works Committee recommended that the Engineer should take over the offices formerly used by the Overseers and relegate them to his present small drawing office, but that the Public Health Department's requirements be met by erecting a temporary building, sandwiched in between my general office and the east wall of the south committee room. At the same time the lavatory of the ante-room of the Council Chamber was reserved for the lady councillors and women inspectors. In my report of the 7th July to the Public Health Committee, I pointed out that the arrival of additional inspectors accentuated the overcrowding in the department and I once again emphasised the necessity of providing more accommodation. The Committee requested the Council to expedite the erection of the temporary building referred to. I submitted a report to the Public Health Committee on the 8th September pointing out the urgent need for further office accommodation for the women inspectors and the storage of important records. My colleague the Engineer also wrote requesting increased accommodation for his department. On the 10th September I addressed a letter to the Council on this matter, a copy of which I sent to each member of the Council; it was referred to the Works Committee for consideration. Both items were referred by the Council on the 14th September to the Works Committee. This Committee advised the Council on the 28th September that the Engineer be allowed to make the necessary alterations to his own office and those of the Assistant Superintendent Overseer (which he was taking over), but that the M.O.H. might have the use of the room formerly used by the staff of the late Architect. In October I reported that I had not yet obtained possession of this large room. 12 On January nth, 1921, through the Public Health Committee, I informed the Council again that I was still unable to use the room allotted for the women inspectors So that throughout 1920, notwithstanding all my efforts, my women officers were herded together in a tiny room, whose cubic capacity was only equal to two persons, even on the common lodging house scale. How difficult and unhealthy it was for five persons to attempt to carry on work there, may be imagined. Similar overcrowding amongst female outworkers or in a factory would probably have caused prosecution by my Council and deserved it. ORGANISATION OF PUBLIC HEALTH DEPARTMENT On the 7th January the Public Health Committee considered a special report of the M.O.H., together with a criticism invited from my Senior Inspector. Both documents were referred to the Council in Committee. My report was dated 26th November, 1919, and was published in my previous Annual Report. At the Council of the 27th January it was resolved to summon a special meeting of the Council in Committee at the first convenient date to consider these documents. On the 9th February, owing to my illness, the matter was deferred until my return. On the 29th June the Council again adjourned consideration of the matter until 13th July. On that date a special committee of the Council was appointed to confer with the Clerk, M.O.H., Engineer and Accountant, with a view to consider better co-operation of their departments of the Council and also the position and duties of their staffs and to report to the Council at an early date with their recommendations; such Committee to invite and make representation to the Education Committee; it was further agreed that no ex-member of the Council to be given employment under the Council until a period of 12 months has elapsed from the time when he or she ceased to be a member of the Council. This special reorganisation committee did not meet until the nth November, when the M.O.H. was not present, but nothing arose with reference to his department except that it was advised that the questions of the sewers and control of the public conveniences should be referred to the Public Health Committee. On July 13th the question of reorganisation was again adjourned until 31st August. 13 At the adjourned special meeting of the 31st August the Chairman's suggestion was adopted that the M.O.H. and Inspector of Nuisances should draw up a joint report in co-operation with himself, the Vice-Chairman and the Chairman of the Public Health Committee, and submit such report in the first instance to the Public Health Committee. At the end of the year the important matter of reorganisation of my department was still in a state of suspended animation. These are the chief recommendations of my report:— 1. The appointment of a whole time Assistant M.O.H., who can carry on when I am absent on holiday or through illness, and take over Mrs. Outram's duties as Medical Adviser of the Maternity and Child Welfare Centres, who is drawing a salary as part-time officer at the rate of over £1,000 a year ! 2. The district to be divided into four wards all the men inspectors to be "warded", each one to be responsible for the sanitary conditions of his area (I have now four women ward inspectors, so that there would be a man and woman inspector in each ward). 3. That besides, special men inspectors should be appointed as (1) house- to-house inspector; (2) inspector of food and meat supplies and superintendent of the public abbatoir (when erected), supervisor of the dairies and milkshops and to administer the Shop Hours Acts. 4. That the men engaged in Nos. 2 and 3 should be solely under the supervision of the M.O.H. and report directly to him. 5. That the collection of house and trade refuse and the control of the sanitary conveniences be transferred to the Engineer. 6. That the extravagant supply of disinfectants be stopped; it should be obtained and distributed under the instructions of the M.O.H. only. 7. That sufficient and suitable office accommodation be provided for the women officers. [This has at last been secured.] 8. That a Chief Clerk be appointed and that the sanitary inspectors be divorced from all clerical work and so enable them to spend most of their time in their proper sphere—outside the office. 9. That an office boy be added to the clerical staff who, with the yard men, shall be managed by the Chief Clerk under my supervision. 14 Advice.—I expressed my confidence that reorganised on these up-to-date lines, my department would prove equal to all reasonable demands on its efficiency and energy and would fully justify the change, but unfortunately the discussion of my scheme, although prolonged over a year and a half, has by July, 1921, produced but feeble results. Recommendations 1, 2 and 4 have been ignored and Nos. 3 (2), 5, 6, 8 and 9, have not been carried out. As regards Nos. 2 and 4, Mr. R. J. Butland, the oldest male sanitary inspector who held the ancient office of " Inspector of Nuisances ", is still left unwarded and is responsible for no particular area and is still permitted to attend the Public Health Committee and Council as well as the M.O.H., his superior officer. Yet under the recent Act (The Public Health Officers Act) his old title is abolished and he is now merely senior (by length of service) of the male inspectors. An Inspector of Nuisances was always superfluous in a populous place with a whole-time M.O.H. His annual report should be presented to the Medical Officer of Health, who would incorporate anything of importance in his own. Mr. Butland's annual report is not asked for by the Government as mine is. I find that he was first invited to make one by the Council in 1900. I speak from over 15 years' experience, when I say that harmony and efficiency will be absent from the Public Health Department until my recommendations Nos. 2 and 4 are fully carried out and the M.O.H., both in theory and practice, is maintained as the sole head of the Public Health (Sanitary) Department at the Edmonton Town Hall. This principle was laid down by the Government in a Circular accompanying the Sanitary Officers Order 1910, where it stated that "The Medical Officer of Health must be regarded as the Head of the Public Health Department." MARKETS. In January an order was made requiring stall-holders on the Broadway to remove their stalls on Saturday nights. In March the Council agreed to allow the stalls in Silver Street and the Broadway to continue for another three months, and in July their existence was prolonged for a further three months. In October the stall holders in Silver Street were provided with a proper water supply and a dustbin; this latter convenience was also provided for those on the Broadway. During this month their life was further prolonged for six months. 15 In December I received a letter from the Retail Butchers' Association directing my attention to the importance of seeing that the stall-holders engaged in the meat trade had proper provision for storing every night any of their stock unsold. Readers of my previous annual reports will remember that my desire has ever been to have costers removed from all our streets. They obstruct the traffic and pollute the surfaces, especially the fish stalls. To clear up after them costs the ratepayers a large sum annually and shopkeepers who are not favoured (?) with their company may well object to pay this for the benefit of people, some of them non-residents and aliens, who compete with them on unequal terms. VITAL STATISTICS. My statistics refer to 53 weeks ending on January 1st, 1921. I am much indebted to Mr. W. H. Miller, our Registrar of Births and Deaths, for information promptly afforded whenever asked for. The Registrar-General estimates our population at 73,529 for both deathrate and birth-rate, whereas I estimate our nett civil population at 77,202, and the gross civil population (including institutions) at 78,636. My figures are more likely to be in accordance with facts, as there are few, if any, houses vacant in Edmonton, and those occupied are more over crowded than ever. I estimate the nett population at the middle of 1920 as 77,202 persons, including 250 Edmonton people in North Middlesex Hospital and Edmonton Workhouse. The gross total number of births registered in Edmonton was 2,098, i.e , 1075 boys and 1023 girls; of these 129 (64 boys, 65 girls) were illegitimate. The gross total number of deaths registered here was 1087, i.e., 537 males, 550 females. So the births exceded the deaths by ion. You will remember that 1918 presented an unique record for Edmonton, viz., the gross total of deaths exceeded that of the births by nine. The natural increase of the population, that is, the excess of the nett total of births over the nett total of deaths, was 1,921, minus 708, equals 1213. The figure was 536 last year. The area of the district is 3,894 acres (less 31 of water), and the density of the population, or the average number of persons per acre of land, is 20.4. This figure is calculated on the gross population, which includes the average populations of Edmonton Workhouse and North Middlesex Hospital, and the Epileptic Colony, and amounts to 78,636. 16 In the Edmonton Workhouse and North Middlesex Hospital there were estimated to be 1356 persons, of whom 250 were Edmonton residents. In the Epileptic Colony, where the inmates are admitted from Central London areas, mainly the metropolitan boroughs, there was estimated to be a population of 317 persons, including 15 on the resident staff. During 1920 there were six deaths and one birth. There were 302 admissions during the year. STATISTICS OF REGISTRAR-GENERAL. The following rates are provisional: The marriage rate for England and Wales for 1920 was 20.1. The birth-rate, 25.4, compared with 18.5 last year. The death-rate at 12.4 is 1.4 lower than in 1919. The infantile death-rate was 80 per 1000 births, compared with 89 last year. The natural increase in the population of England and Wales, i.e., the excess of births over deaths, is 491,781, or 304,156 more than the average of the preceding five years! The marriage rate was the highest, the total death-rate and infantile mortality rate were the lowest records. The birth-rate was the highest since 1909. COMPARATIVE STATISTICS, 1920. This table of vital statistics for 1920 shows the various rates for the whole country and for the groups of greater and large towns and for London, and is given for the purpose of comparison. Estimated Population middle of 1920. Annual rates per 1,000 of the population. Infantile Mortality per 1,000 births registered. Nett Births. Nett Deaths. Zymotic Deaths. England and Wales 37,609,600 25.4 12.4 — 80 The 96 great towns including London and Edmonton 18,516.804 26.2 12.5 — 85 The 148 smaller towns 4,906,278 24.9 11.3 — 80 London (including City) 4.531.971 26.51 12.4 — 75 Edmonton nett 77,202 24.88 9.17 0.58 67 Note.—Since 1911 the aggregate death rates from the principal epidemic diseases have not been recorded by the Registrar-General the Zymotic death-rate is therefore not obtainable. 17 BIRTHS. The number of births registered by the Edmonton Registrar, Mr. W. H. Miller, was 2,098 (1,075 boys and 1,023 girls), which includes 24 births that took place in the Edmonton Workhouse and 19 in the Maternity Home, born of mothers belonging to Edmonton. The figures for 1919-18-17 were 1,321, 1,248 and 1,376. One hundred and ninety five births born of mothers who are not Edmonton residents are excluded from our statistics, just as foreign deaths are of these, 68 occurred in the Workhouse, besides 110 in the Maternity Home and one in Epileptic Colony. The Registrar-General has again not reported any births which took place when Edmonton mothers were residing temporarily out of their district, but from other Medical Officers of Health I have received notifications of 18 births—eleven boys and seven girls. Thus the nett total of births was 1,921. Of these 1,921 births, 55 (2.9%) were declared illegitimate this rate is 2.3% less than last year. The birth-rate per 1,000 inhabitants is therefore 24.88, compared with 16.33 last year. My lowest record of births in Edmonton for a lunar month was for the four weeks ended 19th April, 1919, and numbered only 71. Notification of Births Acts, 1907 and 1915.—During this year 2,134 births were entered in our register of these, 1,109 were males and 1,034 females and one sex undeclared 123 (5.8%) of the whole number were born out of wedlock. Fifty-two children were declared "still-born." Mr. H. Weston, Superintendent of the Cemetery, informs me that there were 55 children styled "still-born" buried during 1920; for 1919-18-17 the figures were 39, 34 and 35. For work done in visiting infants and their mothers, see section "The Women Inspectors and their Work." In a previous paragraph it is noted that 2,098 births were registered during 1920. The figures of notification and registration will, of course, never coincide, but they show that few, if any, births escape notification in'accordance with the Act. Twenty-one pairs of twins arrived, but no triplets. The birth-rate (24.88) for 1920 is 8.55 more than last year, and is 0.52 lower than 25.4, the birth-rate of England and Wales for 1920. The birth-rate for the preceding ten years will be found in Column 5 of Table 1. DEATHS. The gross total of deaths registered in the district during the year was 1,087—537 males and 550 females; of these, 509 occurred among non-residents at Edmonton Workhouse and North Middlesex Hospital, six at the Guardians' Maternity Home in Bull Lane, and six at the Epileptic Colony, and four 18 temporarily resident, while 106 deaths of Edmonton residents and seven vagrants, taking place in the Edmonton Workhouse and North Middlesex Hospital, are included in our nett deaths. Thus the number of deaths amongst " Edmonton residents" registered in the district amounted to 555, besides seven vagrants, all of whom died at the Infirmary. Of the 47 "war" deaths, all were registered here; they are considered separately, as instructed by the Local Government Board. The gross death-rate is based upon the total number of deaths registered in the district, and is 13.82 per 1,000 living. This rate is calculated on the estimated gross population of 78,636. The nett death-rate is based upon the total number of deaths of Edmonton residents occurring inside or outside the district, and is 9.17. This rate is calculated on the estimated nett population of 77,202. I receive quarterly, from the Registrar-General (through the County Medical Officer), particulars concerning Edmonton residents whose decease has taken place whilst they are away from their usual home. I have accepted 146 deaths returned in this way during the year, making the nett total of deaths at all ages (including seven vagrants) for the district proper, 708. The nett death-rates for the preceding ten years will be found on Table I., Column 13. The nett death-rate for Edmonton is, as I have said, 9.17 per 1,000 living; it was 9.25 last year. It is 1.39 lower than the average of the five previous years, and the lowest on record. The senile deaths (65 years and over) at 195 are 13 less than last year. Death Certification.—All deaths, except one, were certified either by the medical attendant or by the Coroner. Inquests were held on 58 residents, or 10.3 per cent, of the total deaths amongst residents registered in the district; 36 of them during first half of the year and 22 during the second half. This percentage compares favourably with nearly 13 per cent, in 1913. For inquests on infants see next section. The ages at, and causes of, death are set out in detail in Table III. Zymotic death-rate.—This rate is a statement of the number of deaths from the seven principal zymotic diseases per 1,000 of the population. These 19 diseases are small-pox, enteric fever, measles, scarlet fever, whooping cough and diphtheria, at all ages, also diarrhoea (and enteritis) in children under two years of age. There were 45 deaths from these diseases during the year, and the zymotic death-rate is therefore 0.58, as compared with 0.55 for the previous year. This figure is 0.03 more than last year. INFANTILE MORTALITY. The infantile mortality is a special death-rate, referring to the first age period (o to 1 year), and is expressed as the number of deaths that take place amongst children under one year of age per thousand births registered. The number of such deaths occurring amongst Edmonton children and registered within (or without) the district was 130, and the births registered within (or without) the district, born of Edmonton mothers, numbered 1,921; therefore the infantile death rate, based on these figures, is 67.67 per thousand births. This is the lowest on record; the previous lowest was 67.91 in 1919. Eight of the 130 infantile deaths were those of illegitimate infants—that is 6.2 per cent, of the infantile deaths three inquests were held. Inquests were also held on 18 of the other infants, making a total of 21. The infantile mortality rate for the year in England and Wales was 80; in London, 75; in the 96 great towns (which include Edmonton), 85; and in the 148 smaller towns, 80 per thousand births registered. Table IV shows that 50 per cent, of the infantile deaths occurred within the first month of life, and that 46.2 per cent, were due to what are termed "wasting diseases," viz., premature birth, atrophy, debility, congenital defects, and marasmus. Last year the figures were 47.6 and 40.5 per cent. I must also notice that the premature births were 35, compared with 26, 25 and 2i for 1919-18-17. 20 TABLE IV.—Infantile Mortality, 1920. Nett deaths from stated causes at various ages under i year of age. Causes of Death (I uncertified). Classification. Under i 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 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 year. Small-pox 5 .. .. .. .. .. .. .. .. .. .. Chicken-pox 19c .. .. .. .. .. .. .. .. .. .. Measles 6 .. .. .. .. .. .. 1 .. .. 2 Scarlet Fever 7 .. .. .. .. .. .. .. .. .. .. Whooping Cough 8 .. .. .. .. .. .. .. 1 .. 1 Diphtheria and Croup 9 .. .. .. .. .. .. .. .. .. .. Erysipelas 18 .. .. .. .. .. 1 .. .. .. 1 Tuberculous Meningitis 30 .. .. .. .. .. 1 .. .. .. 2 Abdominal Tuberculosis 31 .. .. .. .. .. .. .. 1 .. 1 Other Tuberculous Diseases 28-29b 32-5 .. .. .. .. .. .. .. .. 1 1 Influenza 10 1 .. .. .. 1 .. .. .. .. 1 Meningitis (not tuberculous) 61 .. .. .. .. .. 1 .. 1 .. 2 Convulsions 71 1 2 .. .. 3 .. 2 1 .. 6 Laryngitis 87 .. .. .. .. .. .. .. .. .. .. Bronchitis 89—90 .. .. 2 1 3 4 4 .. 1 12 Pneumonia (all forms) 91—92 .. .. .. 1 1 8 8 4 .. 21 Diarrhœa 104 .. .. .. .. .. 1 2 .. .. 3 Enteritis 105 .. .. .. .. .. .. .. .. .. .. Gastritis 103 .. .. .. .. .. .. .. .. .. .. Syphilis 37 .. .. .. .. .. 1 .. .. .. 1 Rickets 36 .. .. .. .. .. .. .. .. .. .. Suffocation—overlaying 168 .. 1 1 1 .. 1 1 .. .. 5 Injury at Birth 152C—153 3 .. .. .. 3 .. 1 .. .. 4 Atelectasis 152b 3 .. 1 .. 4 .. .. .. .. 4 Congenital malformations 150 2 3 .. .. 1 2 .. 1 .. 8 Premature Birth 151a 21 2 4 5 32 2 1 .. .. 35 Atrophy, Debility, and Marasmus 15Ib. c, d, e. 7 1 2 .. 10 5 2 .. .. 17 Other causes .. .. .. .. .. .. 2 1 .. 3 Totals 38 9 10 8 65 27 24 10 4 130 Nett Births in the year legitimate, 1,866 illegitimate, 55. Nett Deaths in the year. legitimate infants, 122 illegitimate infants, 8. THE WOMEN INSPECTORS (HEALTH VISITORS). I give below an analysis of the number and nature of the visits paid by them during 1920. The hulk of their work falls into four large divisions:— 1. The crusade against preventible infantile mortality. 2. The work done in factories, workshops, etc., where women and girls are employed, and amongst home-workers of their own sex. 21 3. The visitation of consumptives and other tubercular persons. 4. The visitation of scholars at home when suffering from the nonnotifiable infectious diseases. INFANTILE MORTALITY, 1920. Month. After Birth. Revisits. After 6 mths. After Death. Expctnt. Mothers Stillbirths. Nglctd. Children Over 1 year. January 60 38 53 13 34 - 1 30 February 42 31 86 19 22 — — 39 March 51 57 73 29 25 — — 12 April 59 53 — 26 12 — — 17 May 30 31 5 2 17 — — 3 June 61 24 2 7 7 — — 8 July 45 4 2 4 6 — — 9 August 253 32 10 4 7 1 — 5 September 300 68 47 11 11 — — 49 October 110 38 68 7 20 1 — 30 November 106 33 100 8 29 — — 25 December 79 40 138 4 8 1 - 10 Totals 1196 449 584 134 198 3 1 237 INSPECTIONS UNDER FACTORY AND WORKSHOPS ACT. Month. Factories. Workshops. Laundries. Outworkers. Rooms Measured. January - - - - - February — — — 29 — M arch — — — 165 — April — — — 15 — May — — — 38 — June — — — 46 — July — — — 5 — August — — — 8 — September 2 — — 37 - October — 3 1 12 - November — 5 - - - December 1 11 1 - - Totals 3 19 2 355 — 22 NOTIFIABLE DISEASES, 1920. Month. Doubtful. Tubercle (all forms). Erysipelas. Ophthalmia Neonatorum. Puerperal Fever. Totals. January 5 84 29 17 - 135 February — 45 17 10 — 72 March 2 67 18 l6 — 103 April 1 32 7 17 — 57 May — 54 2 10 4 70 June 1 23 8 5 — 37 July — 47 2 21 3 73 August — 52 16 6 1 75 September — 47 20 — 3 70 October 6 26 10 — - 42 November 20 41 13 2 — 76 December 10 - 30 13 - 53 Totals 45 518 172 117 11 863 NON-NOTIFIABLE DISEASES. Month. Measles. Mumps. Whooping Cough. Chickenpox. Doubtful. Total. January 44 1 10 14 5 74 February 14 7 12 3 — 36 March 30 16 13 19 3 81 April 37 4 29 11 2 83 May 63 5 47 18 6 139 June 30 8 107 10 1 156 July 109 23 90 11 — 233 August 37 4 25 2 — 68 September 15 27 30 14 5 91 October 22 45 7 16 8 98 November 23 81 8 47 20 179 December 11 71 21 39 10 152 Totals 435 292 399 204 60 1390 *Schools closed for holidays. SCHOOL NOTIFICATIONS. Visits and revisits concerning measles and the non-notifiable diseases, such as whooping cough, chicken-pox, etc., 1,390 to 2,118 children at 1283 homes. Of this number, 435 visits were for measles. Last year the figures were 2,532, 3,209 and 2,109 respectively. (For further information see Annual Report of School Medical Officer.) 23 GENERAL WORK. Visits to Private Schools o Enquiries re Complaints 29 Miscellaneous Visits 181 Visits re Nuisances 369 Visits re Overcrowding o 579 WOMEN OFFICERS' INDOOR WORK, 1920. Office Work. Statistical Work. Tuberculosis Accounts. Infant Welfare Centre. Ante-Natal Clinic. Miss Shiner 143½ 6½ - 129 45 half days Miss Bintcliffe 104½ 2 — 123 42 half days Mrs. Hobbs 91½ 2 — — — Miss Simpson 48 10 ½ — — Miss Tootell 76 — 1 — — Miss Brennand 55½ — - 2 1 half day Miss Reddock 6½ - - — - Total Days. 525½ 20½ 1½ 254 88 half-days. MUNICIPAL MILK SUPPLY. The first order was issued on the 19th December, 1919, and up to the end of 1919 the Medical Officer had issued orders to five families for 266 pints at a cost of /"6 16s. 6d.: one family was ineligible. The following table shows the number of pints supplied and the cost for the year 1920:— Period. Pints. Cost. Families ineligible. £ s. d. Four weeks ending 24th January, 1920 798 18 18 0 20 Four „ ,, 21st February, 1920 980 20 6 0 8 Five ,, ,, 27th March, 1920 1428 27 15 5 12 Four ,, ,, 24th April, 1920 1624 29 0 10 3 Four ,, ,, 22nd May, 1920 1624 24 5 4 5 Five ,, „ 26th June, 1920 1526 24 0 8 8 Four ,, ,, 24th July, 1920 1498 22 8 0 1 Four ,, ,, 21st August, 1920 1593 24 19 6 0 Five ,, ,, 25th September, 1920 2380 39 11 0 8 Four ,, ,, 23rd October, 1920 2114 42 2 11 2 Four ,, „ 20th November, 1920 1703 41 11 5 5 Five ,, ,, 25th December, 1920 2667 55 3 4¾ 9 One ,, ,, 1st January, 1921 280 6 8 4 1 Total 20215 376 10 9¾ 82 24 As will be seen by the above table the cost of milk only for the year cost £376 10s. 9¾d., without accounting for the cost of administration, stationery and postage. THE MILK SCHEME. The scale of economic circumstances adopted by the Edmonton Council is as follows:— Free Supply. No. in family. Nett income per head of the family per week. Total nett income. 2 11/- or under £1 2 0 3 9/6 „ 1 8 6 4 8/- „ 1 12 0 5 7/6 „ 1 17 6 6 7/6 „ 2 5 0 All necessitous cases, not coming within the free supply, are dealt with on the half-price scale in accordance with the following tariff:— No. in family. Nett income per head of the family per week. Total nett income. 2 12/9 or under £1 5 6 3 11/3 „ 1 13 9 4 9/9 „ 1 18 0 5 9/3 „ 2 6 3 6 9/3 „ 2 15 6 The nett income per head of a family is defined as the income less the outgoings, divided by the number in family. Outgoings. Outgoings include: (a) rent; (b) insurance; (c) fares to and from work; and (d) payments for care of children. Number in Family, The number in family is taken to be the parents or guardians, or older sisters looking after the home and not working, and children under 14 years of age. In other words, children over 14 years earning their living are not counted. 25 Income. Income is calculated under the following heads:— (a) Wages—(1) Parents or guardians weekly wage, the average for four weeks being taken. (2) The earnings of children under 14 years. (b) Lodgers—Children over 14 years of age working are reckoned as Lodgers. Income from lodgers is reckoned on the following basis:— Payments received per week from lodgers. Proportion reckoned as income. Up to 12/- Nil. Over 12/- 50% or surplus over 12/- (c) Letting—The whole amount received is taken as income. Quantities. These are prescribed by the Medical Officer of Health for a period not exceeding one month. The quantities must not exceed:— (a) For children under eighteen months, not more than one and a half pints daily. (b) For children between eighteen months and five years, not more than one pint daily. (c) For expectant and nursing mothers, the quantity specified by the officer above-mentioned. If dried milk or preparations of milk are used, the quantity should be such as would, when properly reconstituted, be approximate to the quantities of fresh milk given above. LATER NOTES ON THE SCHEME. In February it was decided to amend the tariff so as to treat all children over 14 years of age, who are workers, as part of the family instead of lodgers, 26 so that their wages will be pooled with the family income, subject to travelling and insurance expenses being deducted. This amendment I advised was very necessary, as it was found that working children as lodgers contribute most inadequate sums to the mothers for their board and lodgings. In November I drew attention to two cases who were obtaining a free milk supply, although the fathers were fully employed by (1) the Edmonton Guardians and (2) by the Crippled Girls' Institution at "Halliwick," and our Clerk was instructed to draw the attention of the managers of these institutions to the apparently inadequate rate of pay to their employees. In December it was pointed out to these institutions that the Council's minimum wage for their employees was £4 per week, which rate of wages practically excluded all their employees from obtaining milk at the expense of the ratepayers. MATERNITY AND CHILD WELFARE. The working of the Centres:— Address. Session. Average attendance per session. Central Hall twice weekly 56 children St. Michael's Hall once 68 Central Hall „ „ 8 mothers (ante-natal) Note.—The attendance is very poor, considering that 1,921 births occurred in 1920, of whom at least 80 per cent. should attend the Centres. The educative value of the Centres as conducted in 1919 and 1920 has been small. As my junior colleague Dr. (Mrs.) Outram reported, the Centres now keep such a varied stock that the rooms have the appearance of a co-operative store. Instead of listening to health talks, the mothers are busy buying goods at cost price, or less. A recent list of articles requiring renewal from wholesale sources besides drugs, bandages, elastic belts, dried milk, cod-liver oil and malt, malted milk and virol, included sesame oil, Chapman's food, lactagol, slippery elm, syrup of bananas, wool, linen, mado-polam, jean, flannel, etc. REPORTS TO COUNCIL OF THE COMMITTEE The first report of 1920 of the Maternity and Child Welfare Committee was dated the 23rd January and presented to the Council on the 27th. It was agreed that the accounts of the Committee be kept in the department of the Council's Accountant on and after 21st May, 1920. Southgate Council 27 suggested that Edmonton should recompense their expenditure in dealing with mothers attending the Southgate Centre from Solna Road area. It was recommended that the ante-natal clinic be held once a week at the Central Hall, and that Miss Shiner and Miss Bintcliffe assist there. In February the Ministry of Health announced that they would make a grant of £267 toward the expenditure of the Council on the Maternity and Child Welfare account for the year ending 31st March, 1919. The new centre was opened in Bury Street on the 24th March. It provides accommodation for mothers and infants in the northern part of Edmonton. In April a new Committee was constituted for the year ended April, 1921, consisting of 20 councillors, including the two ladies, and eight non-councillors (seven ladies and one gentleman) leaving two vacancies for the medical practitioners, when they should think fit to rejoin. To the Council of the 22nd April a report was submitted dated the 26th March, when it was announced that the Committee had increased the salary of their medical officer in order to cover the increased cost of travelling and living, Mrs. Outram's salary is now at a rate exceeding that of the M.O.H.! This lady presented the Committee with a report for six months in which she emphasised the value of whole fresh unpreserved cows' milk over a sterilised dried full-cream milk. She also stated that both whooping cough and measles had been noticed amongst the children attending the clinic. Cases of impetigo and running ears had been less than formerly. She remarked that some mothers use the clinic solely as "a shop with wholesale terms." My Council, with the acquiescence of the Public Health Committee, lent Misses Shiner and Bintcliffe for services at the Centres. These ladies assist Mrs. Outram very considerably in her duties as Medical Officer. A report, dated the 30th April, was submitted to the Council on the nth May. It stated that the Committee had elected Mrs. Ithell to the chair and Mrs. Barrass to the vice-chair. The Centre Sub-Committee was continued. The report dated the 28th May was presented to the Council on the 8th June. It recommended that all necessitous cases desirous of entering the Maternity Home be dealt with on the scale adopted by the Council for the free supply of milk. The report of the 25th June was presented to the Council on the 13th July. It was announced that the Committee had agreed to pay Southgate Council 2/- 28 per case for each attendance of the mothers and infants at their centre. A very high figure! The advisability of a whole-time clerk had been discussed but not settled. A report, dated 24th September, was submitted to the Council on the 28th September in which the Committee recommended the Council to enter into an agreement with the Guardians for the maintenance and care of patients at 42/per case as from 1st November, 1920. A report, dated 28th October, was submitted to the Council on the 9th November, which stated that difficulties were arising in recovering payment from patients for admission to the Maternity Home. A report, dated 26th November, was submitted to the Council on the 14th December. In a report, dated 17th December, 1920, submitted to the Council on the nth January, 1921, the Committee recommended the Council to obtain as a third centre the rooms in Brookfield House formerly used by the Food Control Officer. A Christmas party was held for mothers on the 4th January, 1921. Ante-Natal Centre.—This is held once a week at the Central Hall in Fore Street. The conditions under which this important work is carried on at present are not favourable to the mothers or the staff. The room is far from clean and is used for other purposes. There is not a constant supply of hot water close at hand, so that the sterilizer provided cannot be used. The number of bowls, etc., is inadequate, and the table used for the examination of expectant mothers is of a purely makeshift character. In short it is not possible to carry out the work under antiseptic conditions. Mrs. Outram was placed in charge here. When the establishment of this Clinic was first mooted in 1918, I advised that it be only initiated under proper conditions, viz., that a special room be provided with proper equipment and that the services of a specialist in women's diseases be secured, to whom both doctors and midwives could with confidence send their patients for purposes of diagnosis only. Then both doctors and midwives would readily co-operate with the gynaecologist-in-charge, when they could secure advice for themselves and their patients superior to that of an ordinary medical practitioner, male or female. On 1st November the Maternity and Child Welfare Committee wrote to 29 the Council stating that the ante-natal clinic session was transferred from Thursday afternoon to Tuesday morning. Clerk.—A clerk is required giving at least half-time service to this Committee. At present Miss D. B. Hill cannot do so, without some of her Public Health work falling into arrears. To prevent this, an office boy should be at once admitted to my general office, who could take over from her a good deal of unimportant routine work, capable of being done by any intelligent school-boy. Baby week.—This was held from Monday, July 19th to July 23rd (both dates inclusive), during which there were two baby shows held, one an open show for ail babies in Edmonton and the other only for babies attending the welfare centres. The prizes were distributed at a pram parade on Wednesday, and on Thursday the past and present mothers of the welfare centres were taken on an excursion to Benfleet and Canvey Island, each mother paying 7s. 6d. for railway fare and tea. On the last day there was an exhibition at the Central Hall of garments made by the mothers. Supervisor.— I cannot yet state that the Committee has regained the confidence and co-operation of the medical practitioners and midwives of the area, although at the end of the year (1920) i.e. about a year after I had issued a writ in the High Court against my Council, an arrangement was arrived at between us on the terms proposed by my solicitor by which my position as Supervisor was restored, as from June 24th, 1919, with payment of arrears of salary and bonus. During 1920 there were no representatives of the doctors or midwives of Edmonton on this Committee. On the 19th February the Edmonton Medical Society reported that no member of that Society was at present willing to act on the Committee. On the 15th May, the Edmonton Medical Society informed the Council that they were unwilling to appoint representatives on the Maternity and Child Welfare Committee until they had reinstated the M.O.H. as Supervisor. On the 26th November, the Medical Officer, having been reinstated as Supervisor of the Centre, attended the meeting of the Maternity and Child Welfare Committee, his first since May, 1919. Rivalry.—During the year a voluntary centre has been carried on in the Church Hall at St. Edmunds, Hertford Road, which is open for the mothers residing in the northern part of Edmonton, whether Roman Catholics or not. A session is held every Monday afternoon and Dr. P. F. Evans is the Medical 3° Officer in attendance there. This institution is decidedly useful, if only to relieve us of overcrowded attendances at the Council's centre in St. Michael's Hall, Bury Street. Voluntary Agencies.—In a circular letter (138) the Ministry of Health advised Local Authorities to co-operate with voluntary agencies in their district and if necessary, to render them financial assistance. The Maternity and Child Welfare Committee advised no action thereon. Voluntary Workers.—My experience confirms that of other Medical Officers of Health. Official workers have the training and knowledge that enable them—when the opportunity occurs—of imparting good advice to the mothers in attendance at the centres, as well as at their homes. Voluntary workers have an enthusiasm that is spasmodic and not well-informed: therefore they cannot be relied on to attend regularly and are only useful in so far as they obey the instructions of the official workers and in carrying out simple tasks, such as weighing the babies and the sale of virol, etc. To take over temporarily their infants from the mothers enables the latter to give their undivided attention to the health-talks of the Lady Superintendent, Miss A. Bintcliffe, who was appointed in April, 1921. These little talks, now resumed, will benefit the loving, but ignorant, mothers immensely. I hope that the horrid spectacle of babies sucking " dumb teats " will never be seen again in our Centres. Married Women's Labour.—Ever since I have had women officers on my staff, they have been instructed to advise all married women to let the care of the home, husband and children, take the first place in their life-work and therefore not to attempt work which necessitates their absence from the home for long periods of each day. Shocking examples of neglect of this advice too frequently come under my notice in connection with dirty homes and verminous and neglected children. This teaching has been continued up-to-date, but it is difficult for myself and officers to enforce in Edmonton, when it is common knowledge that my Council itself employs married women amongst the school teachers. Indeed, the medical officers of the Maternity and Child Welfare Centres and at the Mentally Defective School are both married women. District Maternity Home.—In April the Committee recommended that the Council seal an agreement with the Guardians accepting the responsibility for the admission of pregnant women into the maternity wards which are separate from the pauper wards and have a separate entrance from Bull Lane. Such admission to be authorised by the medical adviser and not, as advised by the Government, by the M.O.H. At the end of the year the agreement on these terms had not yet been settled. 31 On September 7th three Councillors, the Clerk and M.O.H. attended a conference with the Edmonton Guardians and other District Councils included in the Union, when they discussed the increased cost of maintaining patients, it being suggested that the remuneration to the Guardians be increased from 4/to 6/- per day. From the minutes I find that, although the agreement was not signed by the Guardians, in August the sum of £416s., and in September the sum of 12s., was paid to them by the Council. In November the Guardians raised their fees from 28/- to 42/- per case. On the 6th October, the M.O.H. reported to the Public Health Committee on the conference with the Guardians, when it was found that only four (Tottenham, Southgate, Enfield and Wood Green) of the eight districts had accepted the agreement with the Guardians and that Tottenham had ceased sending any cases since receiving notice of the increased charge. Day Nursery.—I believe this institution is still continuing at The Rosery," Fore Street, but I have received no report as to its progress during 1920 from the promoters, Mr. and Mrs. A. E. Beer. The only link between this nursery and our welfare centres is due to the fact that Mrs. Outram, M.B., is medical adviser at both places. 32 SECTION II. A. COMMUNICABLE DISEASES—NOTIFIABLE. The Infectious Diseases Notification and Prevention Acts have been in force in this district since March 31st, 1891. Table II. shows details as to age-distribution and locality of the notified cases, and number of cases removed to hospital. The following table shows the number of cases notified amongst residents, and the number isolated, the percentage of these to the cases notified, and the fatality, i.e., the percentage of cases dying to those notified. Disease. Cases Notified. No. isolated in Hospital. Isolations per cent. Total Deaths. Fatality per cent. Scarlet Fever 348 334 96.0 5 1.4 Diphtheria & Mem. Croup 297 291 98.0 24 8.1 Enteric Fever 2 2 100.0 nil nil Totals 647 627 — 29 — Compared with last year (1919) the table shows 271 less notifications of scarlet fever, and 7 less fatal cases actually, but only 0.5 per cent. less relatively. There were 189 more notifications of diphtheria and 14 more deaths, but the percentage of fatal cases was 1.2 per cent. less; there were two cases of enteric fever notified but no deaths, so the fatality was nil, as last year. Foreigners.—Eight cases of non-residents were notified from the North Middlesex Hospital—2 erysipelas, 3 puerperal fever, 1 ophthalmia neonatorum, and 2 primary pneumonia. Besides these, 1 erysipelas, 1 puerperal fever, 1 cerebro-spinal fever, 2 ophthalmia neonatorum, 2 encephalitis lethargica and 12 primary pneumonia, were former residents in this district. There was one diphtheria notified from the Epileptic Colony, a non-resident. Cases of tubercle are referred to in another part of my report. The Ministry of Health declined my Council's suggestion of a public enquiry with regard to the alleged continued epidemics in Edmonton. 33 the causes of the infectious diseases prevalent in the district. This is a short statement as to conditions in Edmonton at the present time that favour the spread of diseases such as scarlet fever, diphtheria, enteric fever and measles; conditions which it is in your power to remove or to mitigate. I should like to point out that epidemics of infectious disease (like comets) appear and disappear in cycles, that is, for recurring periods. This habit is well exemplified in plague, cholera and small-pox which cannot be said to be dependent on local insanitary conditions, which may be more or less permanent. In Edmonton, during the war years 1915-18, both scarlet fever and diphtheria cases were few, but the children born during that period have provided material for the attacks in 1919, 1920 and 1921. Enteric fever, both during and since the war-period, has not troubled Edmonton much: in 1914-15-16-1718-19-20 there were 17-5-6-2-5-0-2 cases respectively. I might here remark that the prevalence of scarlet fever and measles has not been found to have any relation to the existence of gross insanitary defects in an area. Conditions in Edmonton, present or recent. that favour the spread . of infectious disease are:— 1. Overcrowding.—By increasing personal contact in living and (or) sleeping rooms. This exists in two degrees:— (a) Temporary from war conditions. The establishment of huge munition works created an influx of persons into Edmonton from other areas, far and near. Since the armistice was declared in November, 1918, some of these have moved off to their former homes, but a number still remain. (b) Permanent.—This may be existing in, or both, of two forms— (i) too many persons in a house: (ii) two many houses per acre. The latter is an error of the past which the present Council cannot retrieve, but I trust that in the future my Council will not consent to the erection of houses 30 to the acre, or of houses with only two rooms upstairs. The former can be remedied when new 34 houses are available for the surplus inhabitants. As I have pointed out in recent annual reports, if stringent measures were now taken to abate overcrowding in one street, it would only lead to the persons dispersed producing overcrowding in some other street, or streets, of Edmonton. Bush Hill Park, which is the least overcrowded part of the area, is the least troubled with infectious disease, because the houses are less to the acre and with fewer inhabitants per room than in other parts of the district. 2. The irregular and belated removal of house refuse.— This has been the subject for remarks in my annual reports for years past. Now the Council is dealing with the refuse themselves, we are looking forward to a removal of this insanitary condition. Shall we be disappointed? 3. Rats.—These animals are now well recognised as the carriers of disease and the Act of 1919 (if efficiently carried out) will keep their numbers down. But the Council may set a good example to occupiers by abolishing a great breeding place, viz., the dumps of house refuse at our sewage farm and elsewhere in the area. I have persistently recommended the erection of a Dust Destructor, but it remains a vision of the future. The abolition of private slaughter-houses will remove another favourite breeding ground. Since April my Council supplies poison free, or at reduced cost, to occupiers whose duty it is to deal with them under the Rats and Mice Destruction Act 1919. in June the County ratcatchers spent a week on the dust shoot and farm buildings at the cost of £9. In November a yearly contract was entered into with the County of £50 for their ratcatchers to devote a week every three months. 4. The existence of a sewage farm in our midst.—The diversion of the sewage of Enfield, Southgate and Edmonton into the London County Council's mains: on the eve of the lamented death of Mr. Eachus (your late Engineer) in 1911, this desirable object seemed nearly attained. No doubt those Councils, who then opposed Edmonton's efforts, would be only too glad to co-operate now in having the Lea Valley scheme carried out, if it were possible at the original estimate. 5. Verminous persons and homes.—On January 28th, 1921, I received from our Isolation Hospital a notice that 21 per cent. of the males and 60 per cent. of the females admitted from Edmonton were found to have verminous heads. These figures show that there is great room for improvement in this respect and induces one to again enquire when the Vermin Station will be completed. The Education Committee appointed a cleansing nurse as far back as July, 1920, but Miss Edmonds is still without this base for her work. 35 6. The School Clinic.—The habit of some head teachers, attendance officers and others of sending cases of suspected infectious disease to the School Clinic, instead of referring them to their private medical advisers, is no doubt maintaining a source of contagion at Pymmes Park, more especially of mumps and whooping-cough. I have not been allowed to issue a circular letter to the head teachers drawing their attention to the great danger of this practice. Note.—There are other matters of a minor character to these mentioned above, reference to which can be found in my 15 annual reports to this Council. What will not prevent the spread of infectious disease is the lavish and uncontrolled use of disinfectants. This is a point to which I have drawn your notice since 1906. Smallpox.—A satisfactory feature of the infectious returns for the year is the absence of smallpox from amongst them; since 1904 the district has enjoyed a complete immunity from this disease. An epidemic of this dreadful disease is overdue, and, judging from the returns of the Vaccination Officer, there were many Edmonton children unprotected from infection and sure to die if attacked. There were no deaths from chicken-pox. SCARLET FEVER. Three hundred and forty-eight cases were notified, giving an attack rate of 4.51 per 1,000 of the population; 619, 86 and 51 were notified in 1919-18-17. There were 5 deaths, giving a death-rate of 0.06 per 1,000 of the population. No cases were notified from the North Middlesex Hospital, nor from the Epileptic Colony. No cases were doubly notified. Secondary cases numbered 46 out of 348. One case was re-notified and sent back to hospital. There were 7 cases notified, where subsequent observation did not confirm the diagnosis; they are not included in the above figures. Return Cases.—See section on "Hospitals." DIPHTHERIA AND MEMBRANOUS GROUP. I received notifications of 297 cases during the year, compared with 109, 37 and 20 in 1919-18-17, and they represent an attack rate of 3.85 per thousand of the population. There were 24 deaths, giving a death-rate of 0.31 per thousand of the population. One case was doubly notified. There were 43 3® secondary cases. There were no cases notified from the North Middlesex Hospital, but one from the Epileptic Colony. There were three cases notified where subsequent observation did not confirm the diagnosis; two cases were transferred to the scarlet fever list; they are not included in the above figures. Return Cases.—See section on " Hospitals." Anti-Toxin, in curative doses of 4,000 units, and preventive doses of 1,000 units, is supplied free to the practitioners any time during the day or night, either from the Town Hall, or (when this is closed) the former can be had from our fire-stations. An injection-syringe for the doctors' use lies at each fire-station. Enteric Fever.—Two cases were notified, making an attack rate of 0.03 per thousand of the population. One of these was notified from a London Hospital. There were no deaths. Acute Anterior Poliomyelitis.—No cases were notified. Cerebro-Spinal Fever.—The last previous case was notified on 7th December, 1918. In June two cases were notified in two houses, one of whom died, the other was re-notified in September. A third case was notified in November, and died next month. Two other cases were certified as dying from "meningitis," class 61C, and one from "post basic meningitis," class 61 B. ENFIELD AND EDMONTON JOINT ISOLATION HOSPITAL. This is situated on 27 acres of land in the Enfield district, on its Winchmore Hill border. The contribution of Edmonton towards the Hospital for the year ending 31st March, 1921, was £3,315, compared with £7,768 for the previous year. The Superintendent's report for the year ending March, 1920, reached me on July 13th, 1921; his report for the past year is not yet published! The Accommodation.—The Hospital contains 163 beds, as follows:— Block I.—Beds, 2 Observation. Block II.— Beds, 26 Scarlet Fever. Block III.—Beds, 26 Scarlet Fever. Block IV.—Beds, 26 Scarlet Fever. Block V.—Beds, 18 Scarlet Fever. 37 Block VI.—Beds, 13 Diphtheria. Block VII.—Beds, 26 Diphtheria. Block VIII.—Beds, 14 Enteric Fever. Block IX.—Beds, 12 Cubicles, for doubtful or mixed cases. 163 "As Block I. (two beds) is seldom in use, it has been handed over to a portion of the night staff as sleeping quarters, and being in a quiet spot, answers admirably. At any time it can be used for the purpose for which it was originally intended." During 1919-20 the greatest number of patients resident on one day was 198, that is, 35 above the normal accommodation; the smallest number was sixty-three. The patients admitted from other districts appear to have been two, viz., 1 scarlet fever and 1 diphtheria, or 0.19 per cent. of all admissions; it was 3.9 in 1918-19. No case of cerebro-spinal fever was treated. Officers.—Dr. Haldane Cook is the resident Medical superintendent and sole medical officer. The Clerk and Surveyor of the Enfield Council still act as Clerk and Architect of the Hospital. Miss Janet McFadyen is the matron; there are one assistant matron, four sisters (one for night duty), eight staff nurses, 21 probationers, and six ward-maids. In 1919-20, the resident staff numbered 64 and the outdoor staff six, compared with 38 and four the year before. Five of the staff contracted scarlet fever and two diphtheria. Treatment of Diphtheria.—The Superintendent states that "Antidiphtheritic serum was used in all cases where none, or an insufficient quantity, had been administered previous to admission. In most cases 4,000 units were given, but some received as much as 52,000 units. Drugs were rarely used, and then only for complications." Fourteen inoculations on guinea pigs were carried out for testing swabs from long-standing cases. Enteric Fever.—No cases were treated in 1919-20. Return Cases.—During the year 1920 there have been 27 such of scarlet fever and eight of diphtheria. These figures, especially the latter, are abnormally high. Dr. Cook estimates the percentage of return cases of scarlet fever during 1919-20 as 3.6, compared with 4.76 for the previous period. Cross Infection.—There appear to be ten cases, a regrettable item. 38 Mixed Infection.—This was manifest in at least three families. Return Cases and Cross Infection.—In nearly every monthly report to the Public Health Committee I had to submit cases of this kind and finally in December my Public Health Committee were so dissatisfied that the Council begged the Ministry of Health for a public enquiry into the matter, and I was instructed to personally investigate all cases of patients who have returned from hospital and are renotified shortly after. Supervision.—By order of the Local Government Board, 29th July, 1910, one of the duties of the County Medical Officer of Health is stated to be that " He shall from time to time enquire into and report upon the isolation hospitals in his county." Does he ? Accommodation.—At the end of 1919 patients were still being sent to the Cheshunt Isolation Hospital owing to our own accommodation being filled up, and on the 5th January there were nine cases at Cheshunt (eight cases of scarlet fever and one of diphtheria); for this help at a very difficult time my Council expressed their indebtedness to the Cheshunt Authority. On February 4th there was one case of scarlet fever. On March 3rd there were 18 cases of scarlet fever and five cases of diphtheria at Cheshunt. In March, arrangements were made with the hospital for the blankets used in the ambulance to be washed at the hospital instead of at Deepham's Farm. Vermin.—On the 27th April, the Council's attention was drawn to a report from our Isolation Hospital with reference to the number of persons admitted from Edmonton District who at that time had verminous heads. I now receive regularly the names and addresfes of such cases, which enables enquiries to be made by the following-up nurse at the homes of the children. This report furnishes another powerful argument for the immediate completion of our vermin station. Transport.—This continues on the old-fashioned lines by the Council's horse-drawn vehicle. As I have been saying for the past 15 years, the proper and prompt method is by motor transport from our hospital with a trained nurse in attendance. That is the method of the Metropolitan Asylums Board and of our own Smallpox Hospital Board. 39 Motor Vehicles.—In December, it was decided to obtain three motor vehicles for my department:— 1—for infected bedding at £231 10 0 2—for bedding after disinfection at 231 10 0 3—for bringing home patients discharged from our isolation hospital 301 10 0 Total cost 764 10 0 SMALLPOX HOSPITAL ACCOMMODATION. Since January 31st, 1907, the Middlesex Districts Joint Smallpox Hospital has been in existence at South Mimms. We must rejoice that although precepts have been made from time to time on the Edmonton treasury, no patients from the district have been sent there yet with smallpox. The money (£489 for 1920-21—it was £242 the year before) is a premium for an advantageous insurance. Dr. Ta'Bois, the resident medical superintendent, informs me that there are 70 beds in the permanent buildings, and 143 more can be put in the buildings of wood and corrugated iron. During 1920, no cases of smallpox were admitted. In April, the Borough of Hornsey and the Urban District of Sunbury-onThames were added to the Smallpox Hospital Board, so that 24 districts are now shareholders in the Institution. During this month, H. Barrass was appointed as representative for Edmonton, instead of W. A. Cull, for a period of three years. During the year I had under observation many contacts with cases which had occurred on board ship, or in London and suburbs, etc., but no developments arose. The number of tuberculosis cases in the institution on January 2nd, 1921, was 185, 19 of whom were resident in Edmonton Urban District. Beds at Uxbridge and Picketts Lock, Edmonton, are available for sporadic cases of smallpox. If there should appear a prospect of a larger number, the tuberculous patients at Clare Hall would be cleared out at once. 40 DISINFECTION. Our methods of disinfection are stated in my report for 1914. Disinfectants continue to be supplied without charge to callers, mostly children, on the same lavish scale as heretofore. Their unlimited use does not prevent outbreaks of infectious disease, as this report shows; it discourages cleanliness. In my own home, during 15 years residence in Edmonton, I have used none and yet kept it clean and free from infectious disease. Besides, its distribution wastes an enormous amount of time for my inspectors, clerks and others of my staff. A visit to our stores on Saturday morning would be instructive to the ignorant. BACTERIOLOGICAL LABORATORY. During the year the following specimens were examined and reported upon:— Disease. Result Positive. Result Negative. Doubtful. Total. Diphtheria 108 204 - 312 Enteric Fever 1 — — 1 Tubercle (sputum) 7 14 — 21 Cerebrospinal Fever - 1 - 1 Totals 116 219 — 335 The total number last year was 118. You will notice the very large increase in 1920. PUERPERAL FEVER. Three residents were notified, including one from the North Middlesex Hospital. There were two deaths. Our death-rate is therefore 1.04 per 1,000 births; it was 1.62 last year. Moreover, three women, two of Tottenham and one of Waltham Cross, were notified as inmates of the North Middlesex Hospital. During 1919 there were 257 midwives practising privately in Middlesex and 420 not practising; besides, there were nine engaged in poor-law infirmaries, who are exempt from the provisions of the Act. In Edmonton there were 17 practising at the beginning of 1919, but only nine at the end of the year. 41 One midwife, reported to the Central Midwives Board, was struck off the roll in 1919, and ten were cautioned verbally. During that year no uncertified women were prosecuted by the County Council for acting as midwives, but 16 were verbally cautioned by the Inspector of Midwives, Miss Pollard, who now has an assistant. There were in December, 1920, only seven midwives residing and practising in Edmonton, of whom two are untrained. OPHTHALMIA NEONATORUM. There were 16 cases, all residents, notified during 1920 by 21 notifications; also one, a Hornsey infant, was notified to me from the Edmonton Infirmary. Of the 16, six were in Bury Street, five in Fore Street and five in Church Street Ward. Two cases were triply notified by three doctors. One case was doubly notified by two doctors and one by a doctor and a midwife. Of the single notifications, all were from doctors, except one from a midwife. Miss Shiner paid 117 visits in connection with these cases; last year she paid 87 visits to 14 cases. ERYSIPELAS. Fifty-four cases were notified, compared with 55 in the previous year; one occurred amongst residents in the North Middlesex Hospital. There were three deaths (one an infant) from this cause. No cases were doubly notified. There were two cases amongst the foreigners in the above hospital, one from Tottenham and one from Hornsey. Sixteen cases occurred amongst people who were living in our district outside the Union Infirmary, and yet unable to provide proper attention for themselves. Under agreement with the Guardians, my Council received remuneration for the nurses and dressings provided for those unfortunate persons. The cases were most numerous in the last quarter of 1920. PHTHISIS AND OTHER TUBERCULOUS DISEASES. The deaths from phthisis numbered 68, as compared with 59, 69, and 86 during 1919-18-17. The death-rate from the disease is therefore 0.88 per 1,000, compared with 0.78 last year. Of these deaths, six occurred among residents 42 of the district in the North Middlesex Hospital. The total deaths from phthisis there numbered 39. The other tubercular diseases together accounted for 20 deaths, giving a death-rate of 0.26 per 1,000. It was 0.23 last year. Of these deaths, four were residents of the district in the North Middlesex Hospital. The total deaths from these diseases there numbered nine. In this way, tuberculosis contributed a total death-rate of 1.14 per 1,000 of our own population, or 12.4 per cent. of all the deaths, excluding strangers; it was 1.02 last year. The Women Inspectors paid to tubercular persons 518 visits and re-visits during the year, compared with 237 the year before. The disinfection of the room lately occupied by the patient, and of his clothes and bedding, is carried out. There was, as before, some overlapping of visits with those of the County official. Tuberculosis Meat and Milk.—See Section VI., "Unsound Food." Institutional Accommodation.—I have received the following information with reference to this:— 1.—The North Middlesex Hospital.—A few chronic cases are retained here, but all cases likely to benefit are transferred by the County Council to Clare Hall, the Northern (M.A.B.) Hospital at Winchmore Hill, or Brentford. 2.—Epileptic Colony.—When found to be tubercular, a man is sent back to his own area. tuberculosis regulations, 1912. The total number of patients notified under these regulations was 253. The number of notifications was 470. Lungs— Patients notified once 109 „ „ twice 57 „ „ thrice 31 „ „ four times 20 ,, ,, five times 3 ,, ,, six times 2 ,, ., ten times 1 223 43 Other forms- Patients notified once 24 „ „ twice 5 ,, ,, thrice 1 30 The notifications are thus analysed: — Received from— Pulmonary. Other forms. M. F. M. F. Private Practitioners (A) 40 37 - — S.M.I. (B) 2 2 2 I Sanatoria (C and D) 157 54 7 3 Infirmary (A, C and D) 7 8 2 4 District Medical Officer — — — — Hospitals (A, C and D) — 1 3 2 Other Institutions (A, C and D) 3 2 — — Dispensary (No. 1 and other areas) 72 47 8 5 Voluntary — 1 — — 281 152 22 15 433 37 Scholars.—Seven children—four boys and three girls—were notified by the School Medical Inspector during the year as suffering from tuberculosis, two boys and two girls from pulmonary tuberculosis, and two boys and a girl from other forms of tubercle. measles. There were six deaths, compared with 10, 7 and 17, in 1919-18-17. This number is equal to a death-rate of 0.08 per 1,000 living, compared with 0.13 last year. The rate was 0.19 in England and Wales, 0.22 in London, and 0.22 in the 96 Great Towns (including London). Two occurred in the first age-period (under one year), two in the second period (one and under two years), one in the third (two and under five years)' and one between five and fifteen years of age. There was none in the Infirmary. I received notifications about 93 cases—80 being defined as English and 13 as Rubella (formerly "German measles"). No cases were notified amongst residents or strangers at the North Middlesex Hospital. 44 In December (five weeks ending 27th December), 1919, there were 339 cases in 270 houses. In January, there were 37 cases in 31 houses. During February, 17 cases in 15 houses and in March 31 cases in 28 houses. The drop was probably due to notices in the press of the withdrawal of notification. Measles Regulations, 1915.—On the 27th November, 1919, an Order of the Ministry of Health was issued, withdrawing at the end of 1919 these Regulations. On my advice, the Council decided to obtain an Order continuing the Regulations up to March 31st, 1920. An Order of the Ministry of Health, dated 31st December, 1919, continued the Regulations as desired. In January, 1920, I advised that compulsory notification be continued permanently, or at least until the end of 1920, but no action was taken thereon. I distributed to the Councillors copies of a leaflet on the subject (which are distributed by the Health Visitors amongst affected families) in the forlorn hope that the perusal would give them (judging from the respective death-rates) an idea of the really serious nature of measles, compared with scarlet fever or diphtheria. On May 5th, I again urged the Council to renew compulsory notification and on July 13th the Education Committee also appealed to the Council; in September the Public Health Committee recommended it, but on October 27th the Ministry of Health replied that they would be prepared to entertain the idea when the Council's arrangements for treatment and supervision were complete; so further action was postponed until domiciliary nursing was established in our district. PUBLIC HEALTH (AeUTE ENCEPHALITIS LETHAR GICA and acute polio-encephalitis REGULATIONS, 1918, which were originally only in force for 1919, were, by circular of the Ministry of Health, dated 31st December, 1919, continued until further notice. Two cases of encephalitis lethargica were notified in 1920. 45 PNEUMONIA, ETC., REGULATIONS, 1919. The following notifications under this Order were received by the end of 1920:— Pneumonia, 118 cases—primary, 96; after influenza, 22. Malaria, nine cases, all contracted abroad in the first instance. Dysentery, no cases. Trench Fever, no cases. In a letter of the 28th March, 1919, from the Joint Hospital Board, it was announced:— "That the Board, at their meeting yesterday, decided to set apart one of the blocks at their hospital for the reception of cases of malaria, dysentery, trench fever, and such cases of pneumonia as are contemplated on page 5 of the memorandum of the Local Government Board, dated January, 1919, on the understanding that each case is recommended by the Medical Officer of Health of one of the constituent districts," of Enfield and Edmonton. DISTRICT NURSING This was again considered, but not settled in January. In July, the Public Health Committee appointed a sub-committee to consider the matter with a view of selecting one of two offers from the Queen Victoria Jubilee Nurses Institute and Bury House Nursing Institute. In October, I mentioned that the nine following diseases could be dealt with by the District Nurse, when the Council had secured her services:— Measles Pneumonia Diarrhoea Whooping Cough Ophthalmia Neonatorum Erysipelas Influenza Puerperal Fever Polio-myelitis. I again brought up the subject in November, when the Public Health Committee recommended that negotiations be entered into with the Bury House Nursing Institution for the services of one fully trained nurse to cases selected by the Medical Officer of Health upon the following terms:—retaining fee of £20 with the payment of is. for each of the first three visits and 6d. for each 46 subsequent visit, and that any dressings required and supplied be paid for at cost price. At the end of November, the Cottage Benefit Nursing Association suggested that the Council might loan £1,000 for extension of the "association's buildings, and to assist the establishment at the maternity branch of lying-in wards." On the advice of the Maternity and Child Welfare Committee no action was taken. In January, 1921, Bury House were allowed to have pupil nurses accompanying the trained nurse, but it was laid down that they must not be left in charge of a case themselves. However, the Council did not finally complete the agreement with the Bury House Nursing Institute for sometime, which did not take effect till April, 1921. 47 SECTION II. B. COMMUNICABLE DISEASES—NON-NOTIFIABLE. We can partly judge from the prevalence of these diseases by the death returns. The deaths from whooping cough have been three more; the deaths from diarrhoea have been six less than last year; from influenza 36 less than last year, when they numbered 58. A prompter and better knowledge of the prevalence of these diseases is gained from the notifications received from the head teachers, when they are sent in fully and regularly to the Medical Officer of Health, as they should be, in accordance with Section 7 of "Instructions to Teachers," issued by the Education Committee. Some head teachers rely too much on their attendance officers, and so delay arises in my becoming aware of the suspected cases. diarrhoea. Five deaths occurred from diarrhœa and epidemic enteritis, as compared with 11, 17 and 22 for 1919-18-17. The death-rate from the disease is 0.06 per 1,000 of the population, as compared with 0.15 last year. Of these deaths, three occurred in children under one year of age, giving an infantile mortality rate for the year from this cause of just over 1.5 per thousand nett births; the numbers in 1919-18-17 were 6, 12 and 9. Three deaths were in children under two years; these contribute to the zymotic death-rate. In July, 100 posters were exhibited on the hoardings, drawing the attention of the public to the fly pest. The local weather during 1920.—The year cannot be in any respect regarded as a good one. The sunshine recorded was the lowest since 1913, and also the rainfall. July and September were the wettest months; this accounts for our low death-rate from diarrhœal diseases. WHOOPING COUGH. There were seven deaths from this cause, as compared with 4, 14 and 13 in 1919-18-17. This is equal to a death-rate from the disease of 0.09 per 1,000 living, compared with 0.05 last year. All the deaths occurred amongst children under five years of age—one in the first age-period, one in the second and five in the third. Two in February and August and one in March, July and December. 48 INFLUENZA. Twenty-two deaths amongst residents were due to this cause, compared with 58, 218 and 6 in 1919-18-17. The 22 deaths were divided into the following age-periods:—one under one year, one between one and two, one between two and five, none between five and fifteen, one between fifteen and twenty-five, nine between twenty-five and forty-five, six between forty-five and sixty-five, three sixty-five and upwards. Total, 22. As last year, the greatest mortality occurred in the very prime of life! The death-rate was 0.28 per 1,000 inhabitants, compared with 0.77 in 1919. Besides, there were three deaths among non-residents in the North Middlesex Hospital, none in the Epileptic Colony, but one amongst the military. In January, at the suggestion of the Ministry of Health, 10,000 leaflets were distributed throughout the boys' and girls' departments of the elementary schools. ANTHRAX. In December, at the suggestion of the Ministry of Health, this disease in humans was made compulsory notifiable. In the early part of the year, a local hairdresser surrendered a consignment of three dozen shaving brushes (minus one) which were believed to be recently imported from Japan. The one which had been sold could not be traced, but no evil results were traced to it. On instructions from the Government I carefully packed up these brushes and returned them to the wholesalers in London and notified the M.O.H. of the area of the transmission. In February, 1920, by order of Privy Council, the importation of hair from Japan was forbidden. MUMPS. The Clerk at the Minor Ailments Section of the Clinic was off duty in December, 1920, suffering from the above disease, no doubt contracted from children sent there. VENEREAL DISEASES. Two deaths were recorded as due to these diseases in their primary forms, one from acquired syphilis, one from congenital syphilis, but deaths due to their 49 later effects are recorded, e.g., general paralysis of insane, locomotor ataxy, stricture, etc. In July, the Council declined to support a resolution of East Ham, urging the Government to provide for compulsory notification, but 100 posters on the subject were obtained from the County Council and exhibited on the hoardings. I drew up a leaflet, modelled on Portsmouth, of which 5,000 were printed in September and distributed to the adult males of Edmonton with the help of the clergy and secretaries of the local trade unions. OTHER DISEASES. Alcoholism,—No deaths from this cause were recorded. The death returns of this disease, as in the instance of venereal diseases, are most deceptive. Respiratory Diseases, including bronchitis, pneumonia, pleurisy, and other non-tuberculous diseases of the respiratory system, gave rise to 26 more deaths than in 1919. The number was 130, giving a death-rate of 1.74 per 1,000, compared with 114 and a death-rate of 1.51 for the latter year. Cancer.—Sixty-two deaths of Edmonton residents were certified as being due to cancer, and this is equivalent to a death-rate of 0.80, compared with 0.86 last year. The deaths during 1919-18-17 were 65, 52 and 49. 50 SECTION III. SEWERAGE AND DRAINAGE. The district is sewered on the separate system. The surface water is conveyed into the Pymmes and Salmon's Brooks. The sewage proper, together with that of the neighbouring district of Southgate, passes to the Council's Sewage Farm of 233 acres. Mr. Frank Rackham is the farm bailiff. Urinals.—In April the Council invited the co-operation of the police and Licensed Victuallers' Association in keeping clean and free from nuisances the urinals attached to public houses. There is certainly room for improvement in this direction—the publicans should keep these places open for 20 minutes after closing time. Everyone should be compelled to provide sanitary conveniences for their customers of both sexes. THE SEWAGE FARM. The conditions under which the Council would take the effluent from the gas works on to our sewage farm were stated in a letter from Mr. Eedes Eachus, the late Engineer of the Council, to the Engineer of the gas works in 1903. In January, as trouble had again arisen owing to the bad effluent, the Gas Company were served with notice by the Council under Section 68 of the Edmonton Urban District Council Act 1898, and the Public Health Act Amendment Act 1890, Section 17. In February, the County Council reported that a sample of the effluent was bad, although the Council's chemist stated it was fairly good. In March, our Engineer reported that the effluent was still far from satisfactory, although the Gas Company stated that they were laying down plant to improve the effluent. In April, it was reported that the effluent from the Gas works was improving. In May, it was declared to be much improved in quality. The engine and boiler houses and the wheelwright's shop have been fitted with electric light. A new garage and charging station has been built at the sewage farm for the electric dust vans. The building is of concrete cavity-blocks, with steel roof trusses, covered with boarding and ruberoid, while the front is fitted with revolving shutters. The charging station, forming part of the garage building, is equipped with converter, charging board, etc., for recharging the batteries of the vehicles, 51 Enfield.—The sewage farm of the Enfield Urban District extends over 109 acres, and is entirely situate in Edmonton, lying to the north of our own farm. There are six bacteriological filters. HOUSE REFUSE DISPOSAL. I regret to say that Edmonton is still without a destructor. In January, there were 32 complaints, and seven letters were written to the contractor. The Inspector of Nuisances was instructed to collect house refuse where grossly neglected, the cost to be debited against the contractor. In February, the Engineer reported that, owing to the moulders' strike, he could not get delivery of the electric dust carts, although Knifton's contract was expiring on 31st March. He advised the purchase of three steam wagons from the Westminster City Council at £1050 for the three, also three tipping vans at £25 each, three horses at £300 and £100 for their harness. There were 10 complaints during February. In March, another horse and harness were added to the estimate at £120. The Engineer presented an estimate for the ensuing 12 months which included a sum of £4,393 for collection of house refuse, and in this month the Council agreed that the work of house refuse collection be transferred to the Engineer's department. In March, there were 14 complaints and in 11 other cases the non-removal of refuse was discovered by the Sanitary Inspectors. On the 6th April, the removal of the refuse by direct labour was begun. Iron bins are now used for removing the refuse instead of baskets as formerly. In April there were 25 complaints. In July, four complaints and in August 10 complaints. In October, the Engineer reported that a concrete road was to be constructed up to and over the dust shoot at our Deepham's Farm at a cost of £729. This road would save the horses and wear and tear of the vans. In November, the Engineer reported that the electric dust vehicles had been delivered and that the charging plant for the four was ready for use. These vehicles commenced work on the 13th December. During December, a number of complaints of non-removal was received. 52 WATER SUPPLY. The Metropolitan Water Board took over, in 1904, the control of the public water supplies provided by eight independent water companies and two urban district councils in London and certain of the surrounding areas. The Water Board is responsible for the public water supply of an area of 558 square miles extending from Hertford in the north to Westerham in the south, and from Northfleet in the east to Hounslow in the west; it includes a few urban and many rural districts in the outer ring of Greater London. Samples of the water from a deep tube well sunk on the Vegetable Oil Works ground were analysed by Professor Kenwood and found very good. 53 SECTION IV. ROADS. No private streets have been made up during the year under the 1892 Act. The usual tar-spraying of main and other roads was carried out during the summer months, and the systematic repair of roadways and footpaths has been carried on throughout the year, when material has been available. The main road widenings consequent upon the installation of electric tramcars have made progress, but even at the end of the year some few had not been completed. In January, it was decided to raise a loan of £1,000 for resurfacing Angel Road Bridge with granite setts. A conference was held at the Guildhall, Westminster, of the Middlesex Local Authorities and the County Council on the 30th April, to consider suggestions of the Ministry of Transport with regard to the classification of roads. In April, the Ministry of Transport informed us that £5,000 grant was available for works to improve various roads in the district and our Engineer forwarded plans for the making up of the following roads:—Cross Street, Dysons Road, Bridge Road; Montague Road (Angel Road to Cart Overthrown), Park Avenue and St. Mark's Road. On the 12th October, the Engineer reported that a complete scheme had been forwarded to the Ministry of Transport on the 22nd September for the extension of the North Circular Road through Edmonton with a width cf 60 feet, together with estimates and full particulars. This scheme would provide work for many unemployed. It would continue work which had been done shortly before the outbreak of the Great War by widening Silver Street and culverting Pymmes Brook. It was proposed to extend the North Circular Road eastward across Fore Street and down Angel Road as far as the River Lea by culverting in Pymmes Brook for that distance and throwing the additional width into the roadway. For the work done in 1914, contributions had been received from the Road Board, the Government Unemployed Fund and the Middlesex County Council, and the Edmonton Council found the balance of the total expenditure which was estimated at about £12,000. In October, the Council decided that the Ministry of Transport, the Ministry of Health and the Middlesex County Council be approached with a view to 54 ascertaining what proportion of the cost they would be prepared to bear with reference to the formation of the North Circular Road. In November, permission was given to the British Vegetable Oil Co. to lay a railway siding from the Great Eastern Railway at Pickett's Lock, crossing Angel Road at Cook's Ferry. On the 2nd December, it was reported to the Council that the County Council had resolved to co-operate with the Government on the construction of arterial roads in the County, providing that the Ministry of Transport supplied not less than 50 per cent. of the cost and the Government, if required, floated a loan for the amount of the County Council's contribution. The County Council stated they would be prepared to undertake construction of the roads by their own Engineer. This resolution, as far as it affects Edmonton, refers to a portion of the North Circular Road estimated to cost £260,000 and a portion of the Cambridge Road which is estimated to cost £160,000. On receipt of this information my Council requested the County Council to instruct our Engineer, under the supervision of the County Engineer, to proceed with the Silver Street section of the North Circular Road, and a special committee of five councillors was appointed to co-operate with the Unemployment Committee to select the men to be employed. On 15th December, the Works Committee reported that the widening of Silver Street had been commenced and the unemployed had been taken on through the Labour Exchange. It was also reported that the County Council had written approving that the arterial roads be constructed by the District Council as the agents of the County Council acting under the supervision of the County Engineer, and that this work was commenced on December 6th, the building lines to be not less than 20 feet apart. Further, in order to provide work for the large number of ex-service and other men now out of employment, the Council decided, in conjunction with the Middlesex County Council and the Ministry of Transport, to proceed with the construction of the new 100 feet arterial road towards Cambridge (coming north from Tottenham, and passing through Weir Hall, the Council's housing estate, across Bury Street and through the brickfields of Mr. Cornish in a north-eastern direction, involving the erection of a new bridge over the Great Eastern line to Enfield. 55 SECTION V. HOUSING AND TOWN-PLANNING. Buildings.—Even including the Council's estate, very few dwellings have been erected, because of the scarcity of labour and the high prices of wood, glass and other materials. Overcrowding —Conditions are still bad here. If stringent measures were taken to abate this, as no small houses are to be had, it would only lead to those dispersed producing overcrowding elsewhere. Bungalows.—A certain amount of building has taken place (especially in the Bush Hill Park area) which has been in the form of direct«contracts taken up by builders on behalf of private owners for their own occupation. In fact, it has almost become an epidemic and one which I do not at all appreciate; it is a tendency of the times which I fail to understand. The total cost, compared with the amount of accommodation provided, must be out of all proportion, owing to the large amount of roof and foundations. One recalls that this style of architecture is only in its proper place in tropical climates, where the bungalow with its huge overhanging eaves is greatly appreciated, because it every ray of direct sunlight out of all the rooms. Again, the placing of a bungalow on a plot in a road containing the usual stylish suburban villas, gives passers-by a shock to their sense of the appropriate. I think such buildings (if erected at all) are best grouped together in an area by themselves under the name of "Bungle Low Town." Lastly, as far as I am personally concerned, I am still old-fashioned enough to like to go upstairs to bed without the knowledge that an enterprising burglar has easy access to every room in my humble dwelling. By-Laws.—In November, 1919, an Order (65569) of the Ministry of Health was received whereby the Council's Building By laws are relaxed for three years from July 31st, 1919. No prosecution for contraventions of building by-law 113 has taken place since 1907. However, Mr. H. W. Dobb, our late Architect, earned the gratitude of the ratepayers for his keen supervision of the builders in the district, the knowledge of which did not enable them to appreciate the arbitrary dismissal in 1920 of that gentleman by the Council, after 23 years faithful service. 56 No notices were served under the Housing and Town Planning Act, 1909, from my Department. In May, 1919, Mr. Butland expressed his opinion that the row of ten houses, called Crescent Cottages, off Hertford Road, should be demolished, but these wretched dwellings are still occupied. In September, the Council decided to give all owners and agents the extended time of one month to carry out repairs and remedying of nuisances in their properties. Dilapidated Premises.—Nos. 11 to 29 (odd numbers) Bridport Road, and Nos. 59 to 87 (odd) St. Mary's Road, referred to in my last report, are still inhabited. On 4th June, the Ministry of Health informed us that their Inspector after visiting the premises in Bridport Road had come to the conclusion that the houses are not capable, without reconstruction, of being made fit for human habitation under the provision of Section 28 of the Housing and Town Planning Act 1909. Closing Orders should therefore become operative with regard to these houses. The Ministry's letter, however, concluded with this observation:— " The Council will, however, doubtless bear in mind the exceptional shortage of house accommodation when serving notices under Section 17 (4) of the Act of 1909, specifying the period in which the occupiers must cease to inhabit the houses." HOUSE-TO-HOUSE INSPECTION. Inspector Huckle ceased work on this section on June 1st, 1920, but it was continued by Inspector A. Ede on June 3rd, in which he was joined by Inspector W. Tillcock on July 1st, so that during the last half of the year two inspectors were engaged in this important work. I submit a table below giving the reader a slight idea of the considerable amount of useful work that has been carried out by these officers:— 57 Road. Inspections Re-inspections Preliminary Notices. Statutory Notices. Statutory Dust-bin Notices. Sec. 28 H .&T.P. Act 1919 Notices. Bridport Road 17 404 71 - - 17 St. Mary's Road (1919) 463 31 6 12 10 St. Mary's Gardens (19I9) 194 2 24 17 — Bounces Road 178 314 162 1 1 — Graham Road 54 133 50 — — — Cumberland Road 21 47 22 — — — Goodwin Road 48 112 43 1 — — Warley Road 6 10 6 — — — Walbrook Road 6 12 7 — — — Little Bury Street 32 (1921) 18 — — — Second Avenue 16 33 16 — — — West Street 11 - — — — 2 Brettenham Road 10 57 11 — — — Dysons Road 55 l6 14 — — — Ladysmith Road 20 21 18 18 — — Kimberley Road 127 269 100 100 — — Crescent Cottages (1919) 30 — — — — Anns Place — — — — — 2 601 2115 571 150 30 31 Defects found 1748 Defects remedied 2366 Sundry visits (other than inspections) 246 HOUSING AFTER THE WAR. In August, the Minister of Health (Dr. Addison) stated in the House of Commons that the capital sum required to make good the shortage of houses in the United Kingdom will amount to approximately £120,000,000 a year. He also stated that housing in Scotland and Ireland does not come within the purview of his department, but in England and Wales the total estimated need, as disclosed by surveys made by Local Authorities in pursuance of Section I. of the Housing Act, 1919, amounted in round figures to 800,000 houses, taking account of replacements of existing unsatisfactory houses. At the time of writing (July) no one can help reading this paragraph with a sad smile in view of a recent statement by his successor, Sir A. Mond, from which it appears that England and Wales will be lucky if more than 176,000 houses are erected and inhabited before 1923. He stated that the loss to the State on each house erected by Local Authorities would be about £60 a year and in terms of 300,000 houses this meant a loss to the State and a burden on the tax-payer of something approaching 18 million sterling a year. In addition, a grant of 15 millions had been voted for a subsidy to private builders. 58 THE HOUSING AND TOWN*PLANNING COMMITTEE. Amalgamation.— The fusion of the Public Health Committee with the Housing Committee from April, 1920, proved a huge mistake. I had earnestly advocated this in the early years, when the business connected with new houses and town-planning was comparatively insignificant. Now, when this had become enormous owing to the Council fostering a Housing estate of their own, was decidedly the wrong time. My experience has been that this change has led to very late meetings—or adjournments again and again with business unfinished—chaos, confusion and despair! No one, not even the Labour party, can compress a quart into a pint pot. Besides, this Committee was thereby placed under the dual direction of myself and the Engineer. One officer c,in combine in himself the control of two or more sections of work, but two captains only put the one ship on the rocks ! OUR HOUSING SCHEME. The question of housing has been further considered during the year, and the Council have approved a lay-out plan showing some 1700 to 1800 houses, with new roads and sewers on a site extending from Victoria Road to Firs Lane, on the eastern edge of Southgate. Levels have been taken all over the estate, and plans prepared of roads and sewers. The approval of the Ministry of Health has been obtained to proceed with the erection of 126 houses of "A" type, containing three bedrooms, parlour, living room, scullery and bathroom, and 70 of "B4" type, which contain four bedrooms, parlour, living room, scullery and bathroom. The contract for the erection of these has been placed with Messrs. Baldry, Yerburgh and Hutchinson, of Westminster, and the work has been commenced in Church Street adjoining the Recreation Ground. A depot has been formed in Victoria Road on the site of the allotments north of Park Road, adjoining the railway. A siding has been put in from the G.E.Rly. line to Enfield on a specially formed embankment; an office and store huts erected. Steam plant has been installed for hauling and lifting stores, excavating ballast, etc. At the end of 1918 the Local Government Board asked for the opinion of every Local Authority as to the number of houses necessary for the working classes in every district. I think the number was in many cases exaggerated, because allowance was not made for the number of prospective householders who had been killed in the war, and for the large diminishing of the birthrate during war years. As to the desirability of Edmonton developing a housing 59 estate at all, I think the opinion expressed in December, 1918, by my Council on the advice of their officers was perfectly sound, and I regret that within twelve months the policy of my Council underwent a radical change. The opinion expressed at the end of 1918 was:— "That the Council was not prepared to build any houses, unless it was decided to form a single housing authority to undertake the whole work for Greater London." Further, my Council stated that it was not prepared to build a number of small houses which would become a very heavy burden to the district, already heavily rated, and that therefore Edmonton hesitated to launch upon a huge scheme before the incidence of rates had been equalised for Greater London. But if Edmonton must be in the fashion, the ratepayers cannot refrain from wonder that the Brookfield Estate, behind the Town Hall, was not used for the purpose. They have been paying for 20 years or thereabouts to the interest and sinking fund, with the object of repaying the loan obtained for the special purpose of acquiring this land for the erection of houses for the working classes of Edmonton. It was then fully equipped with fencing, roads, sewers and water-mains at a large further expense. Towards the cost of putting in these mains, poor Edmonton is still paying an annual sum to the Metropolitan Water Board, although even yet there are no houses requiring a water supply ! 6o SECTION VI. LEGISLATION OF 1920. ACTS, CIRCULARS, ORDERS, REGULATIONS, etc. I.— Board of Education. During 1920, the Board of Education, amongst other Orders and Regulations, issued the following:— (1) The Order dated 3rd January, 1920, directed that the 1st April, 1920, should be the appointed day referred to in Section 18 of the Education Act, 1918, for the purpose of that Section being carried out so far as it was not in operation already. The Board thereby enlarged the duties of Local Education Authorities with reference to medical inspection. Their powers with reference to medical inspection and treatment were extended to all schools and educational institutions (not being elementary schools) provided by that Authority. Those duties laid down under Section 13 of the Education (Administrative and Provisions) Act, 1907, have been thus extended beyond the children of the elementary schools, and the powers therein accorded to make arrangements for treatment have been made compulsory in public elementary schools, and extended to secondary, continuation schools, and other educational institutions provided by them, or to any educational institutions if so requested by the managers. (2) Regulations relating to special branches of education (other than nursery schools) for promoting the mental and physical development of the scholars. II.—Unhealthy areas. In March an interim report was issued from the Committee appointed by the Ministry of Health to consider and advise on the procedure to be followed in dealing with unhealthy areas. On the 12th April, Dr. Addison, then Minister of Health, issued Statutory Order "No. 560," laying down rules under which appeals under Section 6 (2) of the Housing (Additional Powers) Act, 1919, might be made to the Ministry of Health against a refusal by a Local Authority to give permission to demolish a house, in whole or in part. This document had a special interest to us with reference to our dealings with houses in Bridport Road, referred to in my " Housing " section in this Report. 61 III.— Maternity and 6hild Welfare. Milk.— A circular letter from the Ministry of Health, dated 7th January, was received"on the 13th, conveying the Local Authorities Milk (mothers and children) Order, 1919, dated 19th December, 1919, and the Milk (mothers and children) Order, 1919, dated 22nd December, 1919, made by the Food Controller under the Defence of the Realm Regulations. These orders revoke the Milk (mothers and children) Order made by the Local Government Board in 1918, and a simultaneous order of the Food Controller. The above Orders relate to milk only and not to food. The power of the Local Government Board to require Local Authorities to make arrangements for the supply of milk has been omitted and the Local Authorities are empowered to supply milk free, or at less than cost price not merely in necessitous cases, but also where such supply is necessary, because of the high retail price of milk in any area. The quantity of milk to be supplied is prescribed by the new Order. In October I received from the Ministry of Health a circular letter stating conditions under which licenses are issued, permitting the use of the description Grade A (Certified) and Grade A milk. Under the terms of the Milk Order, 1920, the Food Controller required that no person should describe or refer to any milk offered for sale under the above description, except under license from the Ministry of Food. Together with this, I received a pamphlet from the Ministry of Health with regard to the proper use of milk, which they enclosed with a circular letter addressed to Local Authorities on October 20th, suggesting that the specimen pamphlet might be useful information to M.O.'s and their staffs, in disseminating useful knowledge on the special value of milk as a food and showing the proper method of guarding against comtamination of milk when taken into the home. The Ministry also desired that producers and distributors should be encouraged to undertake the supply of higher grade milk. In May the Ministry of Health published an interesting memorandum with regard to Maternity Hospitals and Homes, together with plans. In July, through our Local Food Control Officer, I received from the Ministry of Food, form "R. 29." This was an application which required recommendation from a medical practitioner or midwife to be used by expectant mothers for extra rations of sugar during the last three months of pregnancy. IV.—Dangerous and Unhealthy Industries. An Order of the Home Office, dated November 28th, 1919, came into force on the 1st January, 1920. It required notification in cases of " Epitheliomatous 62 Ulceration" due to contact with tar and "Chrome Ulceration" due to contact with chromic acid or bi-chromates. This Order enforces the provisions of Section 73 (4) of the Factory and Workshops Act 1901, with reference to these diseases. I sent a copy of this Order (as stated later) to Messrs. T. Glover & Co., Ltd., of the Gothic Works, in August. Y.—Theatres and Music Halls. 1 received a circular dated the 20th August from the Ministry of Health which advised local authorities to cause these places to be periodically visited by my staff and report any insanitary conditions found therein to the Council and County Council who issues the licenses. VI.—Shops Early Closing Act, 1920. The duty of enforcing the previous Acts is thereby transferred from the Police to the Inspectors of the Council. VII.—Water Supply. The River Lea Water-shed (Flooding) Act, 1920, empowers the Conservancy Board to prepare a scheme for the effective prevention of the flooding of lands and for carrying off the overflow. The Act further authorises the Board to make enquiries and surveys and prepare the necessary plans and systems. In conjunction with the Lea Conservancy Board, an Engineering Advisory Committee has been appointed, on which the engineers of the districts in this watershed are members. 63 SECTION VII. PLACES OVER WHICH THE COUNCIL EXERCISE SUPERVISION. 1.—Factories and Workshops. The premises coming under the Acts have been inspected periodically and at irregular intervals. A record of the work done has not been asked for this year by the Home Office. Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the District Council. The standards of sufficiency and suitability of sanitary accommodation for persons employed in factories and workshops have been enforced, and are those advised by the Home Office. Gothic Works. On the 17th January I received a complaint of the lack of washing accommodation for the sheet metal workers at the above works where gas meters are constructed, regulated and repaired. I visited these premises on several occasions and ultimately was able to report in June that the firm were constructing a series of lavatories both for males and females. In September 1 was able to report that the firm had not only provided extra sanitary conveniences for their male and female clerks, but also washing basins for the male workers. At one of my early visits six or seven employees were shown me, amongst whom there was one with a severe case of tar eczema of both wrists and forearms, alleged to be due to the irritating effect of the tar liquid found on opening old gas meters for repair. I sent the firm a copy of the Government's recent views upon this condition. 2.—Common Lodging House. There is only one in the district, It has accommodation for men only. Mr. A. Denning was registered as keeper in April and was given a licence for 12 months. It is a very old structure in Eaton Place, a cul-de sac off Upper Fore Street, and its demolition should not be long deferred. 3.—Houses Let in Lodgings.—The bye-laws were revised and sealed by the Council in September, 1906. A large number of houses come within their scope. With the addition to the male inspectors more attention can be paid to this work in future. It is quite necessary. 64 4.- Slaughterhouses.—In April licenses were granted to E. Beeton, 19, The Green, and T. H. Chester, 3, The Green, valid for twelve months. In May the Public Health Committee refused to renew the license of E. Knifton of Langhedge Lane, but (strange to say!) next month it was granted for twelve months. I must regret this remarkable change of mind. In January, 1921, N. A. Barrett had his license at 188, Fore Street, renewed for three years; beforetime I have vainly protested against anyone, however good, being favoured with more than one year's license. The license is not a personal one, but attached to the premises, where a good butcher of to-day may be supplanted by a bad one on the morrow. In March, 1919, my Council passed a resolution "that there should be a public abattoir in every district, and that in every such district power should be granted to the Local Authority to compulsorily close private slaughterhouses." As I stated in my annual report for 1919— "I heartily endorse this resolution and trust that the day is not far distant when there will be a public slaughterhouse in Edmonton." 5.—Pigs. —It seems strange that no less than three Committees deal with pigftyes, and it is my opinion that the whole subject should be dealt with by one Committee, namely, the Public Health Committee, whether new styes or old ones are being considered. 6. —Dairies, Cowsheds and Milkshops.—There are only two cowkeepers now in the district, the same as the last three years; and about 25 cows are owned by these keepers. Veterinary inspection of the cows is not undertaken in this district, either by my Council or the County Council. There were 61 purveyors of milk in our register at the end of the year. 7.—Unsound Food.—In January, 119 boxes of ham were surrendered, and in the same month, 27 boxes of bacon arrived at Angel Road Station from Southampton for Brown's fat melting factory at Chingford. In April, rotten tomatoes were seized from a stall on the Green. In November the Retail Butchers' Association wrote me with reference to proper storage of meat left over nightly by stall holders and hawkers. 8.—Bakehouses.—Nothing to report thereon for this year. 9.—Offensive Trades.—In the early part of the year one person was fined 25/- and costs for carrying on the trade of a rag dealer in Fore Street without the permission of the Council. 65 In March an application for permission to carry on the business of a fish frier at 135, Bulwer Road, and another to establish the business of a rag and bone dealer, were refused. In April it was decided to take proceedings against a man in Bridport Road and one in Hertford Road for carrying on the trade of rag, bone and skin dealers. The former was ultimately fined 5/-, which was followed up by his disappearance from the district. In July the fried fish shop at 121, Fore Street was reported by the Inspector of Nuisances to have become a nuisance, and a notice was served upon the occupier. In October, the Public Health Committee recommended that permission be given to establish two fried fish shops, one at the market place in Silver Street, and one in Argyle Road; each applicant to sign an undertaking to cease carrying on the business, should it become a nuisance. I am aware that three outward and visible signs of a poor district in London are an abundance of public houses, pawn-shops and fried fish shops; but they are a class of necessary evils which I am not prepared to encourage. A fried fish shop, unless carried on under most cleanly conditions and with the most modern apparatus, can easily become a centre for distributing most offensive odours throughout the neighbourhood; therefore, I think that my Council should decline to allow the establishment of fried fish shops, until they have issued stringent bye-laws on the trade, and are prepared to insist upon their observance. It is equally necessary to take similar steps with reference to rag, bone and skin dealers. On May 8th, 1912, the Local Government Board confirmed the resolution of the Council of February 27th, declaring the following to be offensive trades, which could not in future be established in Edmonton without the consent in writing of the Council, viz., blood drier, fat melter or fat extractor, tanner, leather dresser, glue maker, size maker, fish skin dresser, fish curer, manufacturer of manure from any putrescible animal or vegetable matter, fish frier and gut scraper. (See my annual reports for 1912 and 1913.) This should have been followed by the enacting of bye-laws with reference to all the above offensive trades, but owing to the utter lack of encouragement from the Local Government Board, only those for gutscrapers were completed. 66 10.—Gipsies. The return of peace conditions seems to have brought the vagaries of these wanderers to the front again—at least in Edmonton, where for years van-dwellers have worried myself and inspectors, who have a consciousness of lack of power in dealing with them. At present it is perhaps farcical to report on this subject under the heading "Places over which the Council exercise supervision," until local authorities have more stringent powers and a willingness to use them. 11. Marine Stores. Nothing of importance with reference to 12.—Knackers. these transpired during the year. 67 SUMMARY OF MALE INSPECTORS' W0RK. Mr. R. J. Butland reports to me as follows :— Work done in factories— W.C.'s repaired or improved 5 New pedestal W.C.'s. put in 5 One two-bay urinal 1 Lavatory basins 7 Water fittings repaired 1 Branch drains reconstructed and watertested 9 Inspection chambers put in 3 Lavatories ventilated 2 Work done in workshops— Lime-washings after notice 22 W.C.'s cleansed 1 Drain repaired 1 Slaughterhouses. No. in district, 5. No. of visits 335 Dairies, Cowsheds and Milkshops. No. in district, 61. No. of inspections 172 Common Lodging House 1 in district. Visits 78 Offensive Trades. 31 in district. No. of visits 103 Prosecutions 2 Rooms disinfected after ordinary infectious disease 674 „ ,, ,, phthisis 95 Rooms stripped and cleansed 575 Articles disinfected or destroyed 3826 „ phthisis 378 No. of intimation notices served 4240 No. of statutory notices served 1663 No. of defects remedied after notices served 5548 No. of reinspections 12506 Total number of inspections and reinspections 15047 68 TABLE I. Vital Statistics of Whole District during 1920 and ten previous Years. Year Nett Population estimated to Middle of each Year. Births. Total Deaths Registered in the District Transferable Deaths Nett Deaths belonging to the District. No. registered here. Nett. *Number Rate. Of Non-Residents Registered in the District. Of Residents not Registered in the District. Under 1 Year of age. At all Ages. Number Rate Number. Rate per 1,000 Nett Births. Number. Rates. Out In 1 2 3 4 5 6 7 8 9 10 11 12 13 1910 61,741 1,961 1,878 30.42 872 I3.56 376 94 140 74.55 587 9.51 1911 63,146 1,921 1,847 29.25 1,219 18.68 489 100 265 143.48 830 13.14 1912 65,084 1,844 1.765 27.12 1,126 16.76 563 103 149 84.42 666 10.23 1913 66,552 1,912 1,862 27.98 1,184 17.31 501 111 196 105.26 794 11.93 1914 68,203 1,922 1,859 27.25 1,233 17.67 591 94 159 85.53 736 10.79 1915 69,774 1,694 1,666 23.88 1,227 17.45 543 136 186 111.64 817 11.71 1916 71,396 1,689 1,633 22.87 1,009 14.04 405 122 142 86.96 726 10.17 1917 72,974 1,376 1,328 18.20 947 12.86 390 136 115 86.59 693 9.50 1918 74,330 1,248 1,196 16.09 1,141 15.23 406 I70 96 80.27 905 12.18 1919 75,744 1,321 1,237 16.33 980 12.75 407 128 84 67.91 701 9.25 1920 77,202 2,098 1,921 24.88 1,087 13.82 525 146 130 67.67 708 9.17 Notes.—This table is arranged to show both the gross births and deaths in the district, and the births and deaths properly belonging to it with the corresponding rates. The rates in column 7 are calculated per 1,000 of the gross population. In this district, in which large Public Institutions for the sick and infirm seriously affect the statistics, the rates in columns 5 and 13 are calculated on a nett population, obtained by deducting from the gross population the average number of inmates not belonging to the district in such institutions. The rate in columnn is calculated on the nett births. •In column 6 are included the whole of the deaths registered during the year as having actually occurred within the district, but excluding the deaths of soldiers and sailors that have occurred in our hospital. Area of District in acres (including 31 acres of inland water) 3,894 Total population at all ages 64,797 At Number of inhabited houses or tenements 12,491 Census Average number of persons per house or tenement 5.00 of Including Institutions 5.19 1911. 69 TABLE II. All Cases of Infectious Disease Notified during the year 1920 (excluding Military). Notifiable Diseases. Number of Cases Notified. Total cases notified in each Ward or Institution. Total Cases Removed to Hospitals. At all Ages. At Ages—Years. Bury Street Ward Church Street Ward Fore Street Ward Residents Edmonton Infirmary Total Residents Others in Edmonton Infirmary Epileptic Colony Under 1 1 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 65 65 and upwards. 1 2 3 4 5 6 7 Enteric Fever 2 - - - 2 - - - 1 - 1 - 2 - - 2 Scarlet Fever 348 3 66 237 35 7 - - 116 151 81 - 348 — — 334 Diphtheria (including Membranous Croup) 298 6 58 193 25 14 2 - 81 115 101 1 297 - 1 291 Erysipelas 56 2 2 5 4 17 15 11 26 15 13 1 54 2 — — Puerperal Fever 6 — — — 3 3 — — 2 1 — 1* 3 3* — — Cerebro-spinal Fever 3 — — 1 1 - 1 — — — 3 1 3 — — — Poliomyelitis None - - - - - - - - - - - - - - - Ophthalmia Neonatorum 17 17 - - - - - - 6 5 5 2 16 1 — — Pulmonary Tuberculosis See Women Inspector's Report. Other Forms Measles, English 80 4 44 28 3 1 — — 29 24 27 — 80 — — — „ German 13 — 7 6 — — — — 10 3 — — 13 — — — Influenza-Pneumonia 22 — 1 1 — 14 4 2 12 4 6 2 22 — — — Acute Primary 96 11 15 18 14 22 15 1 26 32 35 12 73 2 — — Malaria 9 — - — 1 8 - — — 3 6 — 9 — — — Encephalitis Lethargica 2 — — — 1 — 1 — 1 1 — 2 2 — — — * Treated at Infirmary. The figures take account of any corrections made as a result of error in notification, or revision of diagnosis as a result of the further course of the disease. Isolation Hospitals and Sanatoria, etc. :— 1. Enfield and Edmonton joint isolation hospital at World's End, Winchmore Hill, is in the urban district of Enfield. 2. Clare Hall small-pox hospital and sanatorium for consumptive persons. This is situate in the South Mimms rural district of Middlesex and belongs to the 24 Middlesex districts. 3. There is a building on Clavering's Farm, Edmonton, capable of taking 10 male and 6 female small-pox cases; is now attached to No. 2. TABLE III. Causes of, and Ages at, Death during the Year 1920. (Classified by age and cause; excluding military.) Cause of Death. (One uncertified by Doctor or Coroner.) Class. Nett deaths at the subjoined ages of "Residents" whether occurring within or without the district. Total deaths of ''Non-residents" in institutions in the district. All Ages. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Foreign. Infy. M.A.B. Total. Enteric Fever 1 - - - - - - - - - - - - Smallpox 5 - - - - - - - - - - - - Measles 6 6 2 2 1 1 - - - - - - - Scarlet Fever 7 5 - - 2 2 1 - - - - - - Whooping Cough 8 7 1 1 5 — - — — — 1 - 1 Diphtheria and Croup 9a 24 — 1 9 13 1 — - (IV) — 1 - 1 Influenza 10 22 1 1 1 — 1 9 6 3 3 - 3 Erysipelas 18 3 1 - — — — 1 - 1 — - — Dysentery 14 1 - - - - 1 - - - - - - Malaria 4 - - - - - - - - - - - - Cerebro-Spinal Fever 61a 2 — — — 1 1 — - — — - — Encephalitis Lethargica 60 1 — — — — 1 — - — 2 - 2 Phthisis (Pulm. Tub.) 28a b 29a 68 1 — — 2 12 37 14 2 33 - 33 Tub. Meningitis 30 9 2 1 1 4 1 — - — — - — Other Tuberculous disease 29b 31-35 11 (IV) 1 1 1 3 2 3 - - 5 - 5 Cancer, malignant disease 39-45 62 - - 1 1 2 4 (IV) 31 23 81 - 81 Rheumatic Fever 47 1 - - - - - 1 - - - - - Meningitis 61 3 2 — — 1 — — — — — - — Organic Heart Disease 79 86 — — — 1 5 11 22 (IV) 47 (IV) 79 - 79 Bronchitis 89-90 50 12 2 1 1 — 1 5 (IV) 28 35 2 37 Pneumonia (all forms) 91-92 64 21 8 6 — 1 13 10 5 15 — 15 Other diseases of respiratory organs 93-98 20 - 1 - - - 1 6 12 7 - 7 Diarrhœa and Enteritis 104-5 5 3 — — — — 1 1 — 9 — 9 Appendicitis and Typhlitis 108 5 - - - 4 - - 1 - 2 - 2 Cirrhosis of Liver 113 3 - - - - - - 2 1 3 — 3 Alcoholism 56 - - - - - - - - - - - - Nephritis and Bright's Disease 119-20 15 - - - - - 3 8 4 26 - 26 Accidents and Diseases of Pregnancy 134-6 4 - - - - - 4 - - 2 - 2 Puerperal fever 137 2 - - - - 1 1 - - 2 - 2 Ditto Parturition 138-141 1 — — — — — 1 — — 2 — 2 Infantile Diseases 151-3 26 25 1 - - - - - - 3 — 3 Congenital Diseases 150 10 8 — 1 1 — — — — 2 — 2 Premature Birth 151a 35 35 - - - - - - - 8 — 8 Violent Deaths— excluding Suicide 164-86 20 5 - 2 3 - 2 (IV) 3 5 9 - 9 Suicide 155-63 7 - — — - — 1 4 2 2 — 2 Other defined diseases — 128 10 1 1 5 6 9 34 62 177 4 l8l Diseases ill-defined or unknown 187-89 2 - - - 1 - - 1 - - - - Total — 708 130 20 32 44 36 103 148 195 509 6 515 Ten deaths of non-residents, not in institutions of Edmonton, are not included in this table. Seven vagrants are in table marked V. Cerebro-spinal Fever, 61 A Two. SUB-ENTRIES included in Acute Poliomyelitis None. above table Encephalitis Lethargica One. 71 EDMONTON URBAN DISTRICT. REPORT OF THE Chief Sanitary Inspector For the YEAR 1920. Public Health Department, Town Hall, Edmonton. To the Chairman and Members of the Edmonton Urban District Council. Ladies and Gentlemen. I have the honour to present to you my Report on the work done in the Public Health Department for the year 1920 by your Inspectors and Staff. The unsatisfactory position in which Local Authorities are placed with reference to that ever-vexed question as to what is, or what is not, a sewer, is still retarding the work of reconstruction of certain drainage. It seems monstrous that Local Authorities should be made responsible for drainage work on private property. I sincerely hope that the Joint Isolation Hospital Board will, as speedily as possible, undertake the removal of patients to hospital in their own ambulances, properly equipped with nurse and attendants. This would, no doubt, enable patients to be removed more expeditiously, although every endeavour is made to remove all cases as quickly as possible; advantages would be gained if the Hospital Board undertook the removal of all patients. REMOVAL OF PATIENTS TO HOSPITAL AND DISINFECTIONS. No. of journeys of motor ambulance to remove patients to Winchmore Hill Hospital 365 No. of journeys of horse ambulance to hospital 88 No. of journeys of bedding van to remove infected bedding 307 No. of journeys of bedding van to return bedding 300 72 No. of journeys of brougham to fetch patients from hospital 198 No. of patients returned to their homes from hospital by brougham 604 No. of rooms disinfected after infectious diseases 674 No. of articles of bedding disinfected 3805 No. of articles of bedding destroyed 21 No. of books disinfected 45 No. of rooms disinfected after phthisis 95 No. of articles of bedding, etc., disinfected after phthisis 378 No. of articles of bedding, etc., destroyed after phthisis 12 No. of rooms and bedding disinfected for vermin 72 The Library, all day schools and Sunday schools were disinfected. MOTOR VEHICLES. I regret the motor bedding vans and the motor brougham for conveying the patients to their homes after recovery are not yet in evidence. However, I hope early in the new year these will be running, and enable me to do away with much of the horse hire. ERYSIPELAS. Having no hospital for the treatment of erysipelas it was found necessary to send (in 15 cases) a nurse into the home of the patient. Two cases were exceedingly bad. I am pleased to say that many expressed their gratitude for the careful attention they had received. The cost of nursing was £70 10s. 3d. I hope the proposed agreement with the Nursing Institutions, now under consideration, will soon be settled. This will relieve me of a responsibility, and should facilitate matters considerably. DISINFECTANTS. The number of applicants during the year for fluid and powder was 43,750, an increase of nearly 10,000 on the previous year. It appears that the public continue to appreciate the Council's generosity. Instructions are given to the applicants as to the method of using the disinfectants in a proper manner. MORTUARY. During the year 82 bodies were received into the mortuary. Of these 12 were deposited by undertakers to await burial. 49 inquests were held and 42 post mortem examinations were made. 20 were deposited owing to being of an infectious nature, and I had one deposited owing to there not being sufficient accommodation at the house. 73 SANITARY CONVENIENCES. There are, in the District, six watertroughs (two with drinking fountains attached) and four drinking fountains, exclusive of those in the Park. I regret to again report that much wilful damage has been done to the water taps, etc. of the fountains. The whole of the public urinals connected with public houses require much attention to keep them in a cleanly condition. The amount collected from Angel Road lavatories during 1920 was £460 19s. 1d. a decrease of £11 14s. 1d. on the previous year. The amount collected from the Green Conveniences was £574 18s. 2d., an increase on the previous year of £12 12s. 5d. GIPSIES. During the year 159 visits were made to these people and 62 were removed. The complaints from the occupiers and others in the vicinity of their camping ground warrants some drastic action. Why they are still allowed to roam the country without having to pay rates or taxes passes my comprehension. Some of these people are clean, but the majority live under the most filthy conditions, destitute of the very elements of cleanliness and morality. The children are taught to prevaricate. However, much of the land is still under cultivation, which to some extent enables us to keep them more on the move. DAIRIES, COWSHEDS AND MILKSHOPS. The number of cowkeepers on the Register remains the same as last year, viz., 2. The number of cows kept varies, but the cubic space of the cowsheds will not admit of more than 25 being kept. During the greater part of the year the cows are out to graze. The periodical lime-washing has been carried out. There were 61 purveyors of milk at the end of the year. Ten gave up the sale of milk; three businesses changed hands; 23 devote their business practically to dairy produce. Two persons were found to be selling milk without being registered, and although cautioned, continued the sale of milk. They are now under consideration for contravening the order. 74 All milk-dealers should be licensed from year to year, and unless the conditions of the business are satisfactory the licence should be revoked. Unless this method becomes law, we cannot expect to make much progress. OFFENSIVE TRADES. There has been a considerable decrease in the Rag and Bone and Skin dealers during the year. We are needing Bye-laws urgently to deal with these trades. It was necessary to prosecute in two cases ; both were convicted, one was fined 5/- and the other 25/-. I am pleased to say that no nuisance has been observed from the fried fish shop which the Council gave permission to be established. SLAUGHTERHOUSES AND FOOD INSPECTION. During the year one slaughterhouse has been done away with, leaving only five on the register, four of these being licensed annually, and having been registered a great number of years. The periodical limewashing has been carried out. An improvement has been effected in one case by providing an improved cold store. 335 inspections have been carried out and the following number of carcases have been examined either during, or shortly after slaughter:— oxen 146, cows 23, heifers 25, sheep or lambs 284, pigs 755, calves 254, and one bull, making a total of 1488, During the year the following were examined, surrendered and destroyed : — January—1 case of rabbits, 1 tin of corned beef, 1 case of rabbits (68 lbs.), 30 rabbits, 24 rabbits. February—1 pig's head (28 lb.) 1 pig's head (10 lb.). March—14 lbs. cheese, 1 trunk of herrings. April—28 lbs. veal and a quantity of tomatoes. May—1 carcase of cow-beef (n cwt. 3 qr. 14 lb ), 1 box of apples. June—1 tin of corned beef, 20 cwts. currants, 64 tins of milk, 6 tins of corned beef, 2 trunks of haddocks, 1 trunk of skate, 2 boxes of peaches. July—1 box of herrings, 12 tins of condensed milk, 38 lbs. cheese. August—6 stone of hake, 40 lb. skate, 84 lb. conger, 96 lb. hake. September—30 imported wild rabbits, tons potatoes, 12 wild rabbits, 13 rabbits, 15 tins condensed milk, 1 tin of beef 75 October-5 boxes of kippers, 2 cases of imported rabbits, 4 boxes of kippers, 1 bag of walnuts. November-38 tins condensed milk, 10 stone ling, 2 boxes of coal fish, 78 imported rabbits, 1 box coal fish, 1 box of megrims, 8 imported rabbits. December-1 box of dates, 1 lamb (4 st. 4 lbs.), 25 imported rabbits. In the early part of the year six trucks of decomposed bacon were brought to Angel Road Station, which was most offensive. However, it was unloaded as expeditiously as possible and taken into Chingford to be boiled down. I hope this will be the last consignment brought into this District. Herewith I append a statement of work done under the Sale of Food and Drugs Act by the Middlesex County Council Inspector for this District, kindly supplied by the Chief Officer of the Public Control Department. Article. Taken. Adulterated. Milk 123 20 Butter 9 - Sugar substitute 1 - Lemonade powder 2 - Custard powder 1 - Salmon and Shrimp paste 1 - Total 137 20 No. of prosecutions 4 No. of convictions 3 Fines £i us. 6d. The figures for adulterated samples given above include a number of samples slightly below the standard. OUST COLLECTION. The dust collection during the first three months of the year was carried out by contract, and the succeeding nine months it was carried out by the Council by direct labour. The complaints of non-collection during the first three months exceeded the whole of the complaints during the nine months done by the Council, so this showed an improvement. I hope to see a regular weekly collection throughout the district. Overcrowding.-Unfortunately, much of the overcrowding exists amongst very respectable people, who themselves are most anxious to get other accommodation. I sincerely hope much of this overcrowding will be relieved when the houses now in course of erection are ready for occupation. 76 The Common Lodging House.—These premises still afford shelter for a number of inmates who would drift into poor lodgings if not accommodated here. Although the premises are very old, they are kept clean, and subjected to regular inspection. But the time is not far distant when these houses, together with some adjoining, should be demolished, as they are practically beyond repair and unsuitable for dwelling houses. The Rats and Mice Destruction Order is, no doubt, doing very much good. During the year much has been done in exterminating rats, especially on the Council's sewage farm. I have seen hundreds of rats dead after one gassing operation, and no doubt there were a large number killed in their holes. We have examined a number of premises where rats have been reported, and in many cases have found defects in the covers of the Inspection Chambers, especially where they have been kept below ground level, thus allowing the rats to find their way on the premises. We have also in many cases laid down a number of rat baits with good effect. To keep these pests down it requires systematic operations, as they increase and multiply very quickly. Pig-keeping in the district is again increasing, and owing to the relaxation of the Bye Laws during the past few years, will require much attention during the coming year. Canal Boats.—There were 17 registered boats inspected during the year, and only one contravention found, i.e., 1 dirty cabin. Very little is seen of the " narrow boat," or those who carry women and children. The usual boats seen are those that are registered at Ware, and are, generally speaking, well kept. The Canal Boats work could be more efficiently performed by an officer having control of the whole of the water way, as the Canal is situated on the outskirts of the district, and practically away from any dwelling houses and much time is wasted waiting for boats. The particulars of the work in connection with Factory and Workshops, Housing and Town Planning Act, etc., I have handed to your Medical Officer of Health, who will include it in his Report. During the year Mr. Nixon, one of the Inspectors, obtained an appointment in the Borough of St. Pancras. Mr. W. Tillcock was appointed to fill the position, and is very tactful in carrying out his duties. 77 Mr. Ede received his practical training in the district, and after passing the necessary examinations, the Council appointed him to carry out the House-to-House Inspection. He is most anxious to give satisfaction. The following is a summary of the most important work done in connection with house-to-house inspections, infectious diseases and the abatement of nuisances:— No. of complaints received and investigated 759 No. of visits in connection with infectious disease 632 House to house inspections 637 Common lodging house 78 Bakehouses 44 Factories and workshops 143 Slaughterhouses and butchers' shops 536 Public and private sanitary conveniences 307 Petroleum 46 Schools 75 Drains re-constructed 18 Ventilation under floors provided 50 Offensive trades 103 Total inspections and re-inspections to see various works carried out 15047 Houses or parts cleansed or repaired 650 Drinking water cisterns covered, cleansed or repaired 27 W.C.'s repaired or improved 311 Drains tested or examined 394 Drains repaired, cleansed or trapped 381 Sink waste pipes repaired 103 New soil or ventilation pipes repaired 40 Inspection chambers inserted 20 Chambers sealed down 16 Rooms stripped or cleansed after infectious disease 575 New dustbins supplied 549 Water closets and flushing cisterns repaired 181 Accumulations of refuse, stagnant water, etc. 26 Water fittings repaired 112 Water restored to premises 5 Water supply put on main direct 19 Scullery floors repaired 84 Coppers and stoves repaired 148 Roofs, gutters and rainwater pipes repaired 772 Yards paved or repaired 111 78 Nuisances from animals abated 17 Other nuisances abated 877 The year has been a most trying one, caused by the unnecessary friction which has taken place. The work of the Public Health Department is necessarily of such a varied nature that it is essential for all its members to work amicably together for the good of the district, but f regret to say that this spirit has been insidiously suppressed to a great extent. I sincerely hope, in the coming year, all this friction will cease, so that the arduous work of the Department may not be hampered in any way. My hearty thanks are due to all those in the Department who have worked harmoniously with me during the past year. I desire to express my grateful thanks for the continued support I have received from my Committee and Council in the discharge of the multifarious duties. I have the honour to be, Ladies and Gentlemen, Your obedient servant, RICHARD JOHN BUTLAND, Chief Sanitary Inspector. 79 ANNUAL REPORT for 1920 On the Health of the Scholars in the Urban District of Edmonton. SIDNEY C. LAWRENCE, School Medical Officer. R. H. STRONG, Deputy and Assistant School Medical Officer : School Medical Inspector. J. P. FARRAR, School Medical Clerk (half-time) (Mrs.) J. A. HOBBS, 1st School Nurse, Following-up (half-time) (Miss) R. EDMONDS, Cleansing Nurse (Miss) M. FAIRBARNS, School Nurse (Routine inspection) At Clinic. Minor Ailments Section— (Mrs.) S. A. G. WILKIN, Nurse (Miss) V. E. GARRETT, Clerk Dental Section— L. S. PILBEAM, Dentist (Miss) R. HEMBRY, Nurse (Miss) G. BANKS, Clerk Ophthalmic Section— (Miss) MARY JOLL, Oculist 80 Edmonton Education Committee. REPORT of the School Medical Officer for the Year ended December 31st, 1920. Town Hall, Edmonton, N. 9. To the Chairman and Members. Ladies and Gentlemen, I herewith submit my ninth (and last) Annual Report. The establishment of the Clinic has led, of course, to a large increase of my staff in your school medical service and correspondingly to my responsibilities. Whereas in 1919 there were four persons associated with me, there are now twelve. On relinquishing my office as School Medical Officer, I am still left wondering on a few subjects :— (1) When the cleansing station will be finished and in use ? (2) When the absurd restriction will be withdrawn that prevents the S.M.O. addressing the head teachers or attendance officers directly on any important subject concerning the welfare of the scholars ? (3) When the clinic will cease to be an exchange-station for distributing infectious disease throughout Edmonton ? SIDNEY C. LAWRENCE, July 30, 1921. School Medical Officer. 81 SOME LIABILITIES. In taking my farewell of the Education Committee, it is well to remind you that Local Education Authorities are under obligation to provide for the education of all children belonging to their area whose age exceeds seven years and who are ascertained to be mentally defective—but eaucable in a public school, backward class, or special school. The responsibility of providing for ineducable children rests upon the Middlesex County Council. This is provided by the Elementary Education (defective and epileptic children) Act 1914, Sec. 1 (1). Sec. 20 of the Education Act 1918 imposes a similar obligation in respect to physically defective and epileptic children within the meaning of the Elementary Education (Defective and Epileptic Children) Act 1899. The Elementary Education (Blind and Deaf Children) Act 1893 imposes on you the obligation for the education of all blind children over five years of age and of all deaf children over seven years. Please note that a grant is payable from the Board for the education of all children from two years of age and upwards sent to special schools by Local Education Authorities. I cannot understand the age limit of seven. Indeed I think at a much lower age, say three years, it would be well for these children and their future that they should come under the care of experienced teachers. This especially applies to educable mentally defective and deaf children. THE EDUCATION ACT, 1918. Sec. 39 empowers a Local Authority to undertake prosecution of parents or guardians for neglect and cruelty to a child under Section 12 of the Children's Act, 1908. This enables local authorities to dispense with any other effort to punish neglectful parents for not cleansing verminous children, as Section 122 of the Act was found to be of no use, unless the authority had established a cleansing station. The Act extends medical inspection and treatment to schools other than elementary. One would have imagined that the control of the one in our district would have been left to the S.M.O. of the area, but the Middlesex County Council thought fit to bring in a Medical Officer from outside. It seemed logical and consistent to me that the same medical officer should continue his medical supervision of a child during the whole of its school career. 82 Under the Act the provision of medical treatment by the Local Authority has been made compulsory, instead of optional. No child may leave an elementary school before the end of the term during which it reaches the age of 14 years, and the Local Authority may require it to attend until 15 years of age, and (with the consent of the Board of Education) may require it to remain even longer. Part-time continuation schools are provided for children (who enter the labour market) till they reach the age of 16 years and possibly until 18 years of of age. Thus most children between two and 18 years of age and all those between 5 and 16 years have now been brought within the purview of the School Medical Service. The administration of the Employment of Children Act, 1903, is transferred from the Public Health to Educational Authorities. This Act also compels Local Authorities to deal more effectively with physically defective and epileptic children. It is interesting to notice that Mr. Fisher, President of the Board of Education, in one of his speeches at the House of Commons whilst passing the Act through the Legislature, expressed the opinion that the medical functions of the Board should be ultimately transferred to the Ministry of Health. In December, both my Education Committee and Council passed resolutions deprecating suggestions from other Local Authorities that further expenditure in connection with this Act be suspended, until the finances of the country are in a more satisfactory condition. ATTENDANCE OFFICERS. In my last report I strongly advised tbat the Attendance Officers should be placed on the staff of the School Medical Officer and in cases of vacancies arising that they should be filled by school nurses, whose training enables them to investigate and appreciate the causes of absence which are mostly due, or alleged to be due, to ill-health. If the suggestion had been carried out years ago, I venture to say that the year 1921 would not have arrived and found the Education Committee still without a complete and up-to-date census of the mentally defective and physically defective children in this area. I again advise you in the same direction and to place yourself in this matter amongst the number of really progressive authorities. 83 On this point I quite agree with the views of the leading article of "The Medical Officer," of the 20th November: "In school attendance as such the medical officer is not interested. This is a function of the local school attendance committee laid upon it by statute. He is, however, very much concerned to know what children are away from school on account of illness, in order to secure that such children shall, so far as lies in his power, receive proper attention, and in order to safeguard the health of the children still in school. All this information can only be collected by those who have had adequate training in the recognition of illness and disease. It is not too much to say that a large proportion of the enormous sum now expended on the school-attendance-officer system could be better devoted to an extension of the school nurse-health-visitor-service, which would have a still wider scope for useful work than is possible with the overlapping and duplication at present in vogue." CENTRAL SCHOOLS. Towards the end of 1918 the Education Committee decided to establish these for domestic and more advanced education of the older boys and girls, and in 1919 classes for boys were started at Croyland Road and for girls at Brettenham Road. In 1920 that for the girls was transferred to Raynham Road. There was supposed to be provision for 80 boys and 80 girls. Admission was reserved to scholars between the ages of 11 and 12 who have passed through Standard V; also subject to an entrance examination and satisfactory school records. The course extends for four years, so that the pupils could remain to at least the age of 15 years. There are no fees for books or stationery. According to the Education Act, 1918, young persons who attend a course of instruction at school up to the age of 16 years are not compelled to attend part-time continuation schools up to the age of 18 years. Towards the end of 1920 my Education Committee were desirous of transferring the Central Schools (which were described as "blind alleys") into Secondary schools in association with the Middlesex County Council, but one practical difficulty was the provision of buildings, which the County Council are unable to provide within a definite time—it may be three years, five years or even longer. Meanwhile the County Council were asked to take over the central as secondary schools temporarily. However, in January, 1921, the County Council referred back the proposal for further consideration. 84 NURSERY SCH00LS. Section 19 of the Education Act, 1918, gives power to Local Education Authorities to provide nursery schools for children between the ages of two and six years. My advice on this subject was given to my Education Committee as long ago as 1916, and is published in my annual report for that year. ETCETERA. In March the Council approved of the Education Committee arranging for groups of children to visit Pymmes Park and the Recreation Ground during school hours under the supervision of their teachers for the purpose of taking part in organised games, as recommended by the Board of Education. In April the Clerk reported to the Council that he had received the sanction of the Ministry of Health to a loan of ,£2,100 to purchase a school site and playing fields in the Bush Hill Park area. This was completed in October. At the Council meeting of the 14th September, a request was received from the Edmonton Teachers' Association that the National Union of Teachers' Local Branch should have direct representation upon the Education Committee. Later, the Council endorsed the resolution of the Education Committee of the 5th October that the Teachers'Association were at liberty to forward the names of nominees to the Council when the appointment of co-opted members on the Education Committee comes up for consideration at the annual meeting in April. 85 THE SCH00LSO OF EOM0NT0N. (17 in Number.) Public Elementary Schools 11 Secondary School 1 Private Schools 5 TECHNICAL INSTITUTE. The Technical Institute was opened on Saturday, September 28th, 1912; it was erected on the site of the old Latymer School in Church Street. Provision for extension of the building, when necessary, has been made. Mr. H. Farrands, M.A., is the Secretary. THE SECONDARY SCH00L. The Headmaster is Mr. R. A. Ashworth, B.A., Lond. Its remarkable success will necessitate considerable extension of its accommodation at an early date. PUBLIC ELEMENTARY SCH00LS. I.—Non-provided 4 schools, 8 departments. II.—Provided 7 schools, 26 departments. The management of these schools has been delegated by my Council to an Education Committee, which consists of 15 members of their own body and two ladies as co-opted members, one of whom, Miss Seward, is a Headmistress. Since July, 1908, no children under five years of age have been admitted. Bush Hill Park. The rapid development of this northern part of the district necessitated an agreement, in October, 1906, with the Enfield Council, to provide accommodation for 81 scholars from this neighbourhood at the nearest Enfield School, but there was an average attendance of 219 this year. No Edmonton scholars under five years of age are now admitted. Baths. The elder children are taken from the schools to learn swimming once a week in the summer months. During the past winter, 1920-21, this wholesome practice has been continued as far as the boys are concerned. A woman instructress has been appointed for the girls, but the boys are taught by their class teachers. Building Operations. Since 1914 nothing has been done beyond the ordinary repairs necessary to keep the buildings in good order. 86 ACCOMMODATION AND ATTENDANCE. I have extracted the following interesting information from the Committee's Year Book for 1920-21. I should have liked to have brought this information up-to-date, but I have not been able to obtain the information from the Secretary of the Education Committee or from the Year Book for 1921-22, which the Education Committee decided on the 5th July, 1921, not to publish ! Council Provided schools. TOtals. Accommodation-March, 1920 12122 2183 14305 1917-18 No. of scholars on rolls 10485 2225 12710 Average attendance 9339 1936 11275 1918-19 No. of scholars on rolls 10217 2233 12450 Average attendance 8909 1941 10850 1919-20 No. of scholars on rolls 10318 2267 12585 Average attendance 9126 1992 11118 DETAILS OF EACH SCHOOL FOR YEAR ENDING 31st MARCH, 1920. Council Schools. Accommodation. Average Attendance. Boys. Girls. Junr. Mixed Infts. Boys. Girls. Junr. Mixed Infts. Raynham Road 660 540 600 576 475 360 401 398 Brettenham Road 459 398 - 437 369 365 - 270 Silver Street 592 562 - 562 433 438 - 376 Montague Road 300 300 300 460 239 228 244 312 Croyland Road 537 369 420 369 392 292 335 282 Eldon Road 660 540 521 600 500 417 437 475 Houndsfield Road 300 300 300 460 259 250 288 291 Total 3508 3009 2141 3464 2667 235° 1705 2404 Non-Provided Schools. Accommodation. Average Attendance. Boys. Girls. Senr. Mixed Infts. Boys. Girls. Senr. Mixed Infts. St, James's 218 207 220 216 201 197 All Saints' - 455 - 447 - 433 - 374 Latymer Elementary 300 - - - 285 - - St. Edmund's, R.C. - - 248 88 - - 215 71 Total 518 662 248 755 501 634 215 642 Grand Total 4026 3671 2389 4219 3168 2984 1920 3046 87 There were 12,585 children on the books for the year ending 31st March, 1920, besides the children attending Enfield schools; the average number of children of the Edmonton district attending Enfield schools during the year was 219, so that there is in Edmonton one child in the public elementary schools for 6.1 inhabitants (reckoned on the nett population); it was 6.0 last year. There were 135 more children attending school than last year, and 547 less than in 1915. The number of children who obtained labour certificates enabling them if they wish, to leave school at an earlier age than 14, was 20; 75 last year. Expenses. Six precepts in March for £24,000 for elementary, and in October for £38,153 for elementary education, in all for £62,153, were served on the overseers to meet the requirements of public education for the year ending March 31st, 1921; the amount last year was £46,417. Besides, a very large necessitous grant had been received from a sympathetic Government. MY STAFF IN THE SCHOOL MEDICAL SERVICE My junior colleague (Dr. R. H. Strong) continues his strenuous career and his work, like my own, continues yearly to increase. Indeed, he has only been able to contend with the most recent accession to his duties, i.e., the examination of children seeking work under the Juvenile Employment Bye-Laws, by making considerable over-time. I am very sorry to say that his salary is not so progressive as his work. Such an officer is worthy of appreciation and encouragement, and he should receive a basic salary of at least £500, rising £50 yearly to a maximum of £750. During the year there have been some changes in my staff which I herewith record:—Mrs. S. A. G. Wilkin, the first nurse at the Minor Ailments Section of the clinic was appointed on February 1st, 1920, and began work in her section on the 16th March, but after the nth September a severe illness brought her association with the work to an end, much to the regret of both Dr. Strong and myself. Her place was filled in January, 1921, by Mrs. K. Christain as Nurse Matron, and shortly after, Miss M. Innes-Brown was appointed as junior nurse in the Minor Ailments Section. To replace Miss Williams as school nurse, dealing mainly with routine medical inspection, Miss M. Fairbarns was appointed and commenced duty on the 12th April. 88 As mentioned in a later paragraph, Miss B. Cony's post as Cleansing Nurse is now occupied by Miss R. Edmonds. ARRANGEMENTS FOR AND SCOPE OF ROUTINE MEDICAL INSPECTION. Three age-groups have been inspected, the entrants (the majority of whom were 5 or 6 years of age), the 8-year-old group, and the leavers. Five thousand three hundred and eighteen children were passed through the routine inspection ; the number last year was 5,077. TABLE I. • Of the Board of Education. "A"—Code Groups. The ages and numbers of children inspected were as follows:— Ages Entrants. 8 year Leavers. Grand Total. 5 6 7 Totals old group. 12 13 and over. Central Sch'l. Totals Boys 609 98 23 730 674 649 667 62 1378 2782 Girls 552 112 25 689 662 579 57° 36 1185 2536 Totals 1161 210 48 1419 1336 1128 1237 98 2563 5318 "B"— Groups other than Code. Special cases. Re-examinations. Boys 1214 588 Girls 1282 480 Totals 2496 1068 89 "©"—Total number of individual children inspected by the Medical Officer, whether as routine or special cases (no child being counted more than once in the year). No. of individual children: Routine 5318 Special 24961 7814 Re-inspection at the schools, immediately following the routine, 34 boys and 37 girls. The parents were present with 1121, or 40.3 per cent., of the boys inspected, and 1159, or 45.7 per cent., of the girls. There were four objections to medical inspection of the boys, but only regarding two girls on the part of the parents. Visits were made to the schools for routine inspection in the case of Infants' Departments twice a year, and in the case of other groups once a year. The number re-examined at the schools during the year was 1068—588 boys and 480 girls, compared with 4,485—2,248 and 2,237 in 1919. RETURN SHOWING PHYSICAL, CONDITION OF CHILDREN INSPECTED AT ROUTINE MEDICRL INSPECTION. Total inspected, 5318. Boys, 2782; Girls, 2536. Ages. Boys. Girls. Entrants 8-9 Leavers Entrants 8-9 Leavers Clothing: Satisfactory Unsatisfactory 728 2 672 2 1374 4 689 662 11S3 2 Footgear: Satisfactory 729 671 1376 689 661 1183 Unsatisfactory 1 3 2 - 1 2 Total for either 730 674 1378 689 662 1185 90 NUTRITION. Ages. Boys. Girls. Entrants 8-9 Leavers Entrants 8-9 Leavers Good 660 622 1227 618 606 1068 Fair 70 52 151 71 56 117 Bad - - - - - - Totals 730 674 1378 689 662 1185 TEETH. Of the boys, 1189, and 1097 girls, had one to three teeth decayed, and as many as 497 boys and 340 girls had four teeth or more decayed. NOSE AND THROAT. Among the boys, 224, and 265 girls, had either enlarged tonsils or adenoids, or both. EYE DISEASE. Thirty-eight boys and 82 girls were wearing spectacles. Slight errors of vision were found in 87 boys and 120 girls, and marked errors in 65 boys and 87 girls. Thirty-nine boys and 46 girls had squint. TUBERCULOSIS. The number of boys with a family history of consumption was 369, or 12.9 per cent., and 358 girls, or 14.1 per cent. During 1920 Dr. Strong sent seven "B" notifications to the M.O.H. Of these, the repoits on two boys and two girls referred to pulmonary tuberculosis, and two boys and one girl to other forms of tubercle. VERMIN Found during Routine Inspection. Boys. Girls. Cleanliness of Head:- Clean 2606 1699 Nits 170 826 Pediculi 6 11 Cleanliness of Body:— Clean 2780 2530 Pediculi 2 6 Totals for either 2782 2536 91 CLEANSING NURSE. The Cleansing Nurse was first appointed on the 24th March, 1920, but Miss Conry, after a week or two's work was unfortunately smitten with a severe illness and died on April 25th. Miss R. Edmonds succeeded her on July 19th, 1920. She visits a school at short notice and makes an examination for head and body nits and vermin. A record is kept of all children fonud verminous at the routine medical inspection or by the teachers. The following is a summary of the work carried out by Miss Edmonds during the year:— No. of schools examined 3 ,, „ scholars examined 2693 „ „ ,, found with head vermin 188 ,, ,, ,, ,, ,, nits 635 ,, ,, „ ,, „ body vermin 7 ,, ,, ,, excluded 10 Last year the school nurse examined 6,008 children. From September 14th to the end of the year, Miss Edmonds assisted at the Minor Ailments Section of the Clinic owing to the absence of the Clinic Nurse (Mrs. Wilkin) through illness. Special attention is given to the children found verminous by the Cleansing Nurse, who are, if necessary, excluded under Article 53 (b) of the code. Cards giving advice as to prevention and treatment are sent to the parents of such children. They are examined again in a week or two, and to those still found verminous, warning cards are given again. The homes of persistently verminous children are visited by Mrs. Hobbs, 1st schoo nurse. S6ABIES. On this loathsome disease, Dr. Strong reported to me as follows:- "Owing to the unaccountable delay on the part of the Council to equip the Cleansing Station, we have had to deal with a large number of cases of scabies at the clinic. I maintain that a clinic is not a suitable place f0r such cases, but in the absence of the Cleansing Station I have endeavoured to treat such cases with a certain amount of success; but in spite of constant and daily supervision the protracted absence of these children has resulted in a serious loss of grant to the Education Authority. In order to minimise any risk to other children, all these cases are asked to attend at 9 a.m. punctually, the earliest time for other cases being 9.30 a.m." 92 VERMIN STATION To the Council of the 24th February the Engineer submitted plans for the completion of the station at a cost of £2,000, when it was resolved that application be made to the Ministry of Health for sanction to a loan of £2,000 for this extension to the public baths, and as the matter was urgent, the Council instructed the Engineer to proceed at once with the completion of the station; this action followed a communication of the Board of Education dated 8th January. On the 28th August, Dr. F. Higgs, on behalf of the Ministry of Health, interviewed myself and the Clerk, and was shown as much of the station as had been erected. On the 12th October the Council was informed that the Ministry of Health were only prepared to sanction the loan on condition that the proposed building was entirely separated from the building of the disinfector, that it had a separate entrance from the public street, and such arrangements made as will ensure that persons attending to be cleansed do not enter, and are unable to leave, by way of the yard where infected articles are transferred from a vehicle to the disinfector building. On this letter I reported to the Public Health Committee that the conditions laid down appeared incomprehensible in view of the fact that the plans and site of the buildings as now partly erected were accepted by the Local Government Board as far back as 1914 and that the attitude of the Ministry involved still further delay .in obtaining this urgent need for the benefit of the scholars of Edmonton. However, the Council felt they had no other course to pursue but to remove this objection by ordering the removal of the disinfector back to its original position at Claverings Farm at an estimated cost of £125. In October, on giving sanction to the loan of £2,000, the Ministry of Health required an undertaking from the Council that (subsequent to the opening of the cleansing station) no disinfection shall be carried out in the vicinity. In December, the Works Committee were informed that the cost of removing the disinfecting apparatus back to Claverings Farm had been tendered for at £137, excluding the cost of cartage and of cutting away and making good; it was therefore recommended to have this done by direct labour. So the Cleansing Station still remains unfinished, notwithstanding repeated requests from the School Medical Officer and the Education Committee. It is quite time that it was completed and in proper use. 93 arrangements for following-up Children with Defects. The following visits were paid by Mrs Hobbs in "following-up" cases reported to me by the School Medical Inspector, or Head Teachers, or Attendance Officers:- January February March April May June July August September October November December Total P. Corp. 6 2 37 12 7 11 10 6 18 10 10 129 P. Cap 2 3 3 .. 8 1 11 5 7 9 6 55 P, Corp. and Cap. .. .. .. .. 6 2 .. .. 3 .. .. 11 Neglect 1 3 2 8 5 2 9 2 11 2 3 48 P. Cap. and Impetigo 6 .. .. .. .. .. .. .. .. .. .. 6 Impetigo 3 5 6 1 .. 2 1 .. .. .. .. Sick Leave. 18 Scabies 2 1 5 2 1 .. .. .. .. .. 11 Ringworm .. .. 3 1 1 3 1 .. 1 .. .. 10 Tonsillitis .. .. .. .. .. 4 .. .. 3 .. .. 7 HipT.B. .. .. .. .. .. .. .. 1 1 .. .. 2 Mentally Deficients.. .. .. .. .. .. .. 6 3 .. .. .. 9 Glasses .. .. 1 .. .. .. 21 3 4 2 3 34 Doubtful Cases .. .. 3 .. .. .. .. .. .. .. .. 3 Pyorrhoea .. 2 .. .. .. .. .. .. .. .. .. 2 Enquiries .. 10 28 10 13 16 12 5 16 2 .. 112 Dental .. .. .. .. 9 12 61 14 89 29 42 256 Clinic .. .. .. .. 6 6 .. .. .. .. .. 12 Totals 20 26 88 34 56 59 132 39 153 54 64 .. 725 Following-up Nurse. Mrs. Hobbs commenced her useful and important work on September 2nd', 1918. In cases where the necessity for treatment is urgent, the half time services of Mrs. Hobbs (1st school nurse) are available to visit the homes of the scholars and urge treatment by medical practitioners in serious cases, or to teach the mothers how to deal with simple ailments themselves, Where it is found by Mrs. Hobbs that the child is suffering from neglect or cruelty by the parents, or owing to the condition of the home, further steps are taken by the Public Health Department under the direction of the Medical Officer of Health. Useful help is often given in such cases by the Inspector of the N.S.P.C.C., especially in conducting the prosecution of contumacious parents. The work of Mrs. Hobbs in this connection has increased greatly since the establishment of the Clinic, as she has to deal with long lists of cases which are not attending regularly, more especially the Dental Section. Her work also has much increased in connection with applications for financial assistance 94 towards the provision of surgical appliances for physically defective scholars. Her original work amongst cases of contagious disease (especially of the skin) and also amongst neglected and dirty scholars continues to be considerable. I would therefore suggest that the Education Committee approach the Council with a view of releasing Mrs. Hobbs from her public health duties, in order that she may devote her whole time to the services of your Committee. CENTRAL GftRE COMMITTEE. Commencing 1st October, 1920, the Edmonton Education Committee assumed direct control of the working arrangements for the provision of meals to school children, and the old voluntary Canteen Committee was dissolved after a long and honourable career of many years. A standing sub-committee known as the Central Care Committee meet at least once a month and consists of eight members of the Education Committee, eight teachers, the School Medical Officers, the Superintendent of the School Attendance Officers, and other persons interested in child welfare. A special officer has been appointed who attends meetings of the Central Care Committee and School Care Committees; he also supervises the arrangements made for cooking and serving meals at the Feeding Centres and carries out all necessary investigations. A Committee, consisting of Head Teachers, parents and other interested persons, has been appointed for each block of schools. These Committees, known as the School Care Committees, in conjunction with the Special Officer and School Attendance Officer, interview all parents applying for meals. There are two small sub-committees of the Central Care Committee (i.e., the Executive Sub-Committee and the Menu Sub-Committee). Information and advice is sometimes obtained from the Relieving Officer for the District in regard to difficult cases of application for meals. At present there are three Feeding Centres at convenient centres in the town. One of these is situated at a private establishment, the other two are at the Parish Rooms of St. Michael's and All Saints' Churches respectively. The present arrangements make provision only for the feeding of necessitous cases; but if a case of underfeeding were reported by the School Medical Officers, and the income of the parent were above the scale adopted by the Committee, the child would be fed and the cost of the meals recovered from the parents. 95 The schedule of family income adopted by the Committee is as follows, after rent and fares have been deducted:— £ s. d. 4 persons 1 13 0 5 „ 1 19 0 6 „ 2 4 9 7 „ 2 9 9 8 „ 2 13 11 9 „ 2 17 9 10 „ 3 0 9 With reference to the above scale, if it were shown that hardship would be caused by adherence to the regulations of the Committee, special consideration would be given. The following are comparative figures per week of the meals supplied to school children during the months of October and December, 1920 Breakfasts. Dinners. October 30 554 December 151 2074 The great increase in the number of meals supplied was due to the growth of unemployment in the District. MENTALLY DEFECTIVE CHILDREN. The County Council is "the Local Authority" under the Mental Deficiency Act of 1913, which came into force on 1st April, 1914. The "local education authority " is the Edmonton Education Committee, in so far as my Council may have transferred their powers under the Act to that Committee. Your certifying officers, Dr. Strong and myself, on receipt of information from the head teachers, summon the child and mother for prolonged examination and enquiry, lasting for an hour, or over, in each case. We are thus enabled to answer, more or less, the 68 questions in Schedule "F." It concludes with the treatment recommended, and the child is placed as fit for one of four classes:- 1. An ordinary public elementary school. 2. A special class for dull or backward children. 3. A special school (day or residential). 4. Unsuitable for a special school; ineducable. 96 It is only those cases allotted to the last class which are dealt with by the County Council. During the year, four cases,—viz.: D.W., 7 years; I.L., 6 years; H.A., 8 years ; A.L. 15 years—were reported to the Middlesex Council. During 1920, Dr. Strong examined 28 cases, which were classified as follows:— Class I. no case Class II. 1 case Class III. 2 cases (residential) 21 ,, (day schools) Class IV. 4 cases M. D. SCHOOL. In April, the Council agreed to raise a loan of £1,000 to pay half the cost of alterations to Nassau House and the purchase of furniture. On the 26th August, 1920, I attended, by invitation of the Managers, at Nassau House, Enfield Highway. In my address to them, I stated that I, myself, undertook to examine all Edmonton children before signing the special form for their admission to the school; I advocated the appointment of one Medical Officer to the school and that in accordance with the instructions of the Board of Education, the officer be the S.M.O. of Edmonton or Enfield, or if neither were able to undertake this additional duty, that the services of a London specialist in mental diseases should be secured, whose experience would enable him to give the Managers trust, worthy advice. I pointed out that the duties of the Medical Officer of the institution were very onerous and responsible, as all the scholars must be examined every year and twice a year if the parents ask for it. There would also be frequent re-grading of the scholars, either in an upward or downward direction. I regret to say, however, that the Managers gave no heed to my advice and appointed to this responsible post a married woman, who is an ordinary medical practitioner in Enfield. Mrs. Ivereigh commenced her duties as Headmistress on September 1st. The admission of scholars commenced from 15th November, 1920. It was proposed to find room for 36 scholars from each district, but ultimately only half that number were provided for, so that there is a list of Edmonton children waiting to be admitted when there is room. 97 EPILEPSY. There is insuperable difficulty in finding institutions willing to take in sane epileptic children. Their presence in the public elementary schools, as with mentally deficients, is a trial to the teachers, and, when fits occur, disturbing to the scholars. The number of institutions in England is small and the cost beyond the means of poor parents. 98 INFECTIOUS AND (or) CONTAGIOUS DISEASES. The number of children excluded at the routine inspection was 24—7 boys and 17 girls, the reasons for exclusion being:- Vermin— Boys Girls Contagious Skin Dis.— Boys Girls Head .. 5 Ringworm 1 2 Body 1 5 Impetigo 3 .. Head and Body 1 1 Other Conditions .. 1 Scabies 1 2 Totals 7 17 Infectious Disease— Mumps .. 1 N.B.—None were excluded for nits only. Exclusion Certificates. I.—For Contagious and other Diseases. The total number of exclusion certificates (including the above) issued by the School Medical Officers during the year was 1027, compared with 728 the year before. The reasons for the exclusions were:— No. of Cert. No. of Cert. Impetigo 187 Influenza 7 Ringworm 147 Whooping Cough 6 Other causes 146 Diphtheria 6 Scabies 131 Mental Defective 6 Skin Diseases 72 Chicken-pox 5 Vermin 58 Broncho-pneumonia 3 Bronchial Catarrh 61 Anaemia 3 Eye Trouble 40 Scarlet Fever 3 Tonsillitis 34 Pleurisy 2 Pulmonary Tuberculosis 24 Measles 1 Ear Disease 16 Jaundice 1 Mumps 15 Nephritis 1 Febricula !5 Total 1027 Chorea 13 Other T.B. Diseases 7 Epilepsy 7 The number, 1027, is 299 more than last year. Scabies numbered 99 last year. 99 II.—For Infectious Diseases (Notifiable and Non-Notifiable). Without measles, in connection with the notifiable infectious diseases, 2,331 notices were issued by the Medical Officer of Health excluding 2493 children, as patients or contacts, from attending day or Sunday schools for definite periods. The numbers last year were—1,369 notices excluding 1,510 children. On account of measles and the non-notifiable infectious diseases, notices excluding 2,118 children as patients or contacts were issued by me, after enquiries had been made as to the real nature of the illness. The numbers excluded in 1919-18-17 were 3,209, 2,779 and 2,044 respectively, It is interesting to note the great variation in the number of children excluded from the schools during 1920:— 1.—Croyland Road 389 2.—Eldon Road 340 3.—National 277 4.—Brettenham Road 196 5.—Montagu Road 174 6.—Raynham Road 163 7.—Houndsfield Road 153 8.—Silver Street 131 9.—St. Edmund's 97 1O.—St. James' 85 11.—Upper Latymer 15 12.—Lower Latymer 12 13.— Raynham Central 6 14.—Croyland Central 2 Total 2040 Besides the following:—Enfield Council Schools, 5; our private schools, 49; 12 children at various schools in Tottenham, etc. There were 12 children not attending (at the time) any school. Exclusion of Contacts.—The rules adopted for the exclusion of contacts are as before. Disinfection. Numerous disinfections were carried out during the year, either of whole schools, departments or classrooms, by the M.O.H. and staff. A special opportunity was taken during the school holidays. Drainage of Schools. In July, the Council authorised an inspection of the W.C.'s and drinking water supply at Croyland Road Schools. In September a report was submitted 100 to the Council through the Public Health Committee, when it was recommended that a man should be continually employed to visit all schools periodically to attend to any defects in the drainage. Is that being done? The water for drinking purposes at Croyland Road School has now been laid on direct from the main. Many years ago I recommended that the water supply for drinking purposes at all schools should be laid on direct from the main, but that advice has not even yet been carried out. In October, the drainage at St. James' School was inspected and found in good order. I might say that the whole of the sewers and surface-water drains of the public elementary schools are flushed during the holidays. 101 TABLE II (Board of Education) RETURN OF DEFECTS FOUND IN THE COURSE OF MEDICAL INSPECTION, 1920. Defect or Disease. Routine. Special (1) (2) (3) (4) (5) Malnutrition - 419 - 43 Uncleanliness— Head 2 182 63 4 Body — 115 21 - Skin— Ringworm Head 4 — 99 — Body - — 80 1 Scabies 3 - 162 - Impetigo 16 — 463 11 Other diseases (non-tubercular) — — 204 49 Eye— Blepharitis 35 - 46 - Conjunctivitis - — 38 — Keratitis - - 2 - Corneal Ulcer 2 - 15 - Corneal Opacities - - 1 - Defective Vision 146 140 130 20 Squint 50 62 15 1 Other conditions - - 32 4 Ear— Defective hearing 92 55 31 5 Otitis Media 108 - 111 - Other Ear diseases 17 - 29 2 Nose and Throat— Enlarged Tonsils 103 303 55 4 Adenoids 1 1 1 - Enlarged Tonsils and adenoids 53 22 4 - Other conditions 9 10 117 - Enlarged Cervical Glands (non-tubercle) 5 20 17 — Defective speech - 19 - — Heart and Circdlation— Organic Heart disease 19 39 18 9 Functional - - 6 1 Anæmia 5 - 16 4 Lungs— Bronchitis 4 40 65 26 Other non-tubercular diseases - - 20 20 Tdbercolosis— Pulmonary- Definite - - 2 3 Suspected — 8 2 19 Non-pulmonary— Glands — — 3 1 Spine — — - — Hip — — 2 1 Other bones and joints — — — 1 Skin - - - - Other forms 1 - - - Nervocs System— Epilepsy — 4 5 5 Chorea - 3 15 5 Other conditions - - 6 37 Deformities— Rickets - 3 - - Spinal Curvature 12 18 1 - Other forms - - 8 9 Other defects and diseases 6 12 243 350 Number of individual children having defects which required treatment, or to be kept under observation 4544 102 TABLE III. (Board of Education) NUMERICAL RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA IN 1920. Boys. Girls. Total Blind (including partially blind) within the meaning of the Elementary Education (Blind and Deaf Children) Act 1893. Attending public elementary schools 20 7 27 Attending certified schls. for the blind 1 3 4 Not at school 1 - 1 Deaf and Dumb (including partially deaf) within the meaning of the Elementary Education (Blind and Deaf Children) Act 1893. Attending public elementary schools 25 19 44 Attending certified schools for the deaf 9 8 17 Not at school - - - Mentally Deficient— Attending public elementary schools 31 32 63 Feeble-minded Attending certified schools for mentally defective children. 14 5 19 Notified to the Local Control Authority by Local Education Authority during year. - - - Not at school — — — Imbeciles Attending public elementary schools 1 1 2 Notified to the Local Control Authority by Local Education Authority during year 1 - 1 Not at school — — — Idiots Notified to Local Control Authority 2 1 3 Epileptics Attending public elementary schools 8 7 15 Attending certified schools for Epileptics. — — In institutions other than certified schools. - — — Not at school - 1 1 Physically Defect;ve— Attending public elementary schools 14 14 28 Pulmonary Tuberculosis Attending certified schools for physically defective children. - - — In institutions other than certified schools. - — — Not at school 3 1 4 Crippling due to Tubercuculosis. Attending public elementary schools 4 5 9 Attending certified schools for physically defective children. - - - In institutions other than certified schools. - - - Not at school 2 4 6 Crippling due to causes other than Tuberculosis i.e.. Paralysis, Rickets, Rheumatism. Attending public elementary schools 31 19 50 Attending certified schools for physically defective children. — — — In institutions other than certified schools. — — — Not at school 12 13 25 Other Physical Defectives, e.g., delicate and other children suitable for admission to open-air schools, children suffering from severe heart disease Attending public elementary schools 34 59 93 Attending open-air schools — — — Attending certified schools for physically defective children, other than open-air schools. — — — Not at school — — — Doll or Backward Retarded two years 339 99 438 Retarded three years 146 49 195 103 TABLE IV. (Board of Education) TREATMENT OF DEFECTS OF CHILDREN DURING 1920. A.—Treatment of Minor Ailments. From 16th March, 1920. Disease or defect Number of Children Referred for treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Total. Not treated. Skin— Ringworm—head 103 90 12 102 1 Ringworm—body 80 60 20 80 — Scabies 165 99 63 162 3 Impetigo 479 354 80 434 45 Minor Injuries 126 113 13 126 - Other skin diseases 204 105 29 134 70 Ear Disease 388 298 10 308 80 Eye Disease (external) 177 124 16 140 37 Miscellaneous 381 109 263 372 9 B.—Treatment of Visual Defect from May 13th, 1920. Number of children Referred for re-fraction. Submitted for refraction. For whom glasses were prescribed. For whom glasses were provided. Recommended for treatment other than by glasses. Received other forms of treatment. For whom no treatment was considered necessary. Under Local Education Authority's Scheme Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 341 192 8 — 200 Clinic— 156 Practitioners— 8 164 Public— 156 Private- 8 164 236 59 28 104 C.—Treatment of Defects of Nose and Throat. Number of children Referred for treatment Received operative treatment. Received other forms of treatment. Not treated. 129 orders for operations given out. Under Local Education Authority's Scheme-Clinic or Hospital. By private Practitioner or Hospital. Total operations. 343 100 (all at hospital) 6 106 45 Hospital 68 Clinic 113 124 D.—Treatment of Dental Defects. 1. Number of children dealt with From April 21st, 1920. Age Groups. "Specials." Total. 5 6 7 8 9 10 11 12 13 14 (a) Inspected by Dentist. — 616 673 669 - - - - - - 476 2434 (b) Referred for treatment. 1557 476 2033 (c) Actually treated. 866 476 I342 (d) Re-treated (result of periodical inspection). Nil Nil Nil 2. Particulars of time given and of operations undertaken. Number of half days devoted to inspection. Number of half days devoted to treatment. Total number of attendances made by the children at the Clinic. Number of permanent teeth. Number of temporary teeth. Total number of fillings. Number of administrations of General Anaesthetics included in (4) and (6). Number of other operations. Extracted Filled. Extracted. Filled. Permanent teeth. Temporary teeth. 48 278 2085 153 408 1790 1174 1582 Nil 92 50 105 TABLE V. (Board of Education). SUMMARY OF TREATMENT OF DEFECTS AS SHOWN IN TABLE IV. Disease or Defect. Number ot Children. Treated. Referred for Treatment. Under Local Education Authority's Scheme. Otherwise. Total. Not Treated. Minor Ailments 1722 1243 243 1486 236 Visual Defects 341 192 8 200 141 Defects of nose and throat 343 168 51 219 134 Dental Defects 2033 1342 nil 1342 691 Other Defects 381 109 263 372 9 Total 4820 3054 565 3619 1211 TABLE VI. (Board of Education). SUMMARY RELATING TO CHILDREN MEDICALLY INSPECTED AT THE ROUTINE INSPECTIONS DURING THE YEAR 1920. (1) The total number of children medically inspected at the routine inspections 5318 (2) The number of children in (i) suffering from— Malnutrition 419 Skin Disease 23 Defective Vision (including squint) 398 Eye Disease 37 Defective Hearing 147 Ear Disease 125 Nose and Throat Disease 502 Enlarged Cervical Glands (non-tubercular) 25 Defective Speech 19 Dental Disease 3123 Heart Disease—Organic 58 ditto Functional - Anæmia 5 Lung Disease (non-tubercular) 44 Tuberculosis— Pulmonary Definite - Suspected 8 Non-pulmonary 1 Disease of the Nervous System 7 Deformities 33 Other Defects and Diseases 18 (3) The number of children in (i) suffering from defects (other than uncleanliness or defective clothing or footgear) who require to be kept under observation (but not referred for treatment) 1,178 (4) The number of children in (i) who were referred for treatment (excluding uncleanliness, &c.) 691 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, etc.) 490 106 THE SGH00L CLINIC. This useful institution has at last materialised, after our long endeavours to establish it, which began as far back as 1912. In July, 1914, the Education Committee had agreed on a scheme, but on the sudden advent of the Great War in the next month, the Board of Education stopped any further progress and the subject was not revived until 1919. The Council agreed to find the necessary rooms at the large mansion in Pymmes Park and the Education Committee took them over on the 21st January, 1920. The Clinic was opened on the 16th March, when the minor ailments section commenced work, with the Assistant School Medical Officer (Dr. R. H. Strong) in charge. The dental section (under Mr. L. S. Pilbeam) commenced work on 12th April, 1920, and finally, the Oculist, Dr. (Miss) Mary Joll, commenced on May 13th, 1920. Accommodation.—At the Town Hall, office room is provided in the Public Health Department for the S.M.O., who is also M.O.H., the School Medical Clerk and Following-up Nurse (all three are part-time officers). This enables the M.O.H. to keep in close touch with them. This co-operation is especially useful, when the home conditions of the scholars require attention. The office of the Cleansing Nurse will be at the cleansing station when it is completed. The girl clerks of the Clinic work at Pymmes Park House. On the ground floor of Pymmes Park House, an office is provided for the Minor Ailments Clerk, sanitary accommodation for the staff and a waiting room. The sanitary accommodation for the mothers and children is provided outside, but just adjoining. On the same floor there is also a staff room, where confidential interviews with the parents can be conducted. On the first floor is the dental surgery, minor ailments treatment room and the Oculist's room. This latter is so large that a portion of it is devoted to extra waiting-room accommodation. Limitations of Treatment.—It should be remembered that the scheme under which this Clinic is established only provides treatment at the expense of the rates on certain defined conditions within which treatment must be limited. For instance, the Minor Ailments Section is for the treatment of xommon skin diseases (other than scabies) external eye diseases, ear discharges and sores. It must not be used as an out-patient department and children must not be sent there in the hopes of sparing the parents the expense of consulting a general practitioner. 107 Arrangements have been made between the Education Committee and the Prince of Wales' General Hospital, Tottenham, for the treatment of ringworm by X rays at the inclusive fee of 25/- per case treated until cure is effected. Adenoids and enlarged tonsils are treated at the same hospital at 10s. per case in the out-patient department. The Education Committee have not yet decided whether payment shall be made, towards indoor treatment for other ear troubles, such as operations on the mastoid, etc. To enable the attendance officers to deal effectively with absentees alleged to be suffering from any illness treatable at the Clinic, they are provided with books of forms in duplicate, instructing the parent or guardian to attend with the child at the Clinic. Visits of other cases to the Clinic are for purposes of diagnosis and certification only, the parents being recommended to secure treatment from private practitioners, the poor law or some hospital. Fees.—In the early stages, no difficulty was experienced in obtaining fees varying from is. to 2s. 6d. from the parents at the commencement of dental treatment of their children, but in June, in accordance with instructions, I drew up a scale of fees to be contributed towards the cost of treatment as follows:— Minor ailments No charge. For spectacles Half contract price. For extraction of teeth 3d. per case (with or without anaesthetic). For filling of teeth 3d. per case. However many extractions or fillings are required no extra fee is charged, and credit is given where parents raise any difficulties about paying at the time. Where necessitous circumstances are stated to exist, such cases are reported to me for enquiry. Parents are invited to contribute something towards the heavy cost of treatment of throat cases and ringworm. So far as I know, no such contributions have been received ever since the credit system was established. I have presented on several occasions to the Education Committee long lists of people who have not attempted to pay even the small contribution 3d. for the teeth, or for the spectacles. Equipment.—My enforced long absence from the district through illness during February, March and April prevented me taking my due share in the establishment and equipping of the Clinic, but after my return I endeavoured to obtain further equipment on economical lines in the interests of the ratepayers. I therefore attended several sales of Government surplus stores and was able to obtain at small cost a large number of useful articles. When, however, I found that the Education Committee did not appreciate my efforts, but preferred to 108 furnish the Clinic with new furniture regardless of cost, I naturally ceased my efforts, although, in my opinion, second-hand articles, provided they are sound, would have served equally as well and at much less expense. The action of the Committee on this point, as well as with reference to the fees at the Clinic, was in my opinion unbusinesslike and reckless. In August the Council resolved to pay the whole cost of installing and maintaining the hot-water apparatus at Pymmes Park House and charge the Education Committee for their share in this convenience. Infectious Disease.—Head teachers and attendance officers are making a practice of sending cases suspected to be suffering from infectious disease to the Clinic, where they sit for some time amongst children who are there for a lawful purpose, thereby creating a great source of infection, not only for the children, but for members of my staff. Indeed, during the year, two members of my staff have contracted mumps there or carried it home to their family. This dangerous practice still continues, notwithstanding the number of protests on the subject made by me to the Education Committee ! I should have liked to have sent a circular letter to the head teachers and attendance officers, asking them to cease using the Clinic for such a purpose and pointing out to them that the proper course to take with regard to a child suffering from infectious disease is to give the mother instructions to send for a doctor to see the child at home and to make a diagnosis. The Clinic must not be used as a cheap substitute for a private practitioner; treatment there is limited by the terms of the scheme to certain minor ailments, dental and ocular defects. Reports.—Every week I receive reports on the work done in each section, which are incorporated with my monthly reports to the Education Committee. From each officer also I have received reports on the work of each section since its establishment, and I have embodied them in this report, with any suggestions they have made as to possible improvements in connection with each section. SCHOOL CLINIC.-A.-MINOR AILMENTS SECTION. This section commenced work on the 16th March, 1920. The staff employed here is as follows:—The Assistant School Medical Officer, one nurse and one clerk. The nurse (Miss Fairbarns) engaged in routine medical inspection, assists here also, when notjsngaged at the schools. The section is open from Mondays to Fridays, both morning and afternoon, and on Saturdays up to mid-day, but during the holidays it meets all require- 109 ments by opening in the mornings only. The Assistant S.M.O. attends from 9 to 9.30 and from 4.30 to 5 every day (Saturdays from 9 till i), i.e., before and after his routine medical inspection, when he sees any children under treatment on which the nurses require advice. The work of the specially-referred centre is now completely absorbed into this section. I have received the following report thereon from Dr. Strong, my Assistant S.M.O., who is in charge of this section:— Method of Work.—Each child has an admission card, stamped on arrival with date of attendance and (if not excluded) time of departure. Each new case on arrival at the Clinic is entered on a record card by the Clerk, giving its name, address, school and department. The cards used are of four colours:— 1. White. For cases of minor ailments found at routine medical inspection. 2. Light Green. For cases with minor ailments specially referred by head teachers, attendance officers, &c. 3. Pink. Cases found at routine inspection or specially referred, which are suffering from defects of nose and throat (these are marked either routine or special). 4. Yellow. Cases found at routine inspection or specially referred, which are suffering from visual defects (also marked routine or special). When seen by the Medical Officer, the diagnosis is noted in one column of the card, treatment to be carried out by nurses (if any) in the next, in the next + or - signifying that the child can attend school or is excluded, and the date of the next visit in the last column. Each visit is recorded on the back of the card. At the end of each week, irregular attendances are listed and sent to the S.M.O. to be handed to the following-up nurse for enquiries. Children from nearer schools (Upper Edmonton) are requested to attend during mornings and those from further schools (Lower Edmonton) in the afternoon. The chief defects requiring treatment are ringworm (head and body), scabies, impetigo, discharging ears and external eye diseases. The children with these defects are seen and treated daily, or as often as necessary to produce successful and rapid results. 110 Having ascertained the method of many other clinics, our scheme was evolved by collating the best points of each one, whereby we could get the quickest possible cure with the minimum loss of attendance at school. Of course, the work of the first year was more or less experimental as to method, but the response of the parents to the opportunities given them, as shown by the total number of attendances has been very encouraging. As the year went on it soon became evident that one nurse was not sufficient to cope with the work of this department. (A second nurse was appointed in January 1921.) The first nurse at the Minor Ailments Section (Mrs. Wilkin), I much regret to say, had to cease work suddenly through illness in September, 1920. Prior to the opening of the Clinic, the services of a half-time officer as following-up nurse were considered sufficient, but the time has now arrived when Mrs. Hobbs should be made a full-time officer. School cases of all kinds, special cases from the S.M.O. and the three sections of the Clinic, are more than sufficient to occupy the whole of her time. This is a record of the number of attendances for the following defects:— Ringworm (head and body) 4176 Scabies 1448 Impetigo 3151 Discharging ears 3227 External eye diseases 1932 The dental surgeon reserves for me Saturday mornings, when he attends to children who, at all ages, have come under my notice during the week's routine inspection. The selection of cases for treatment by the ophthalmic surgeon is left to me. This officer attends one half-session per week, and you have a special report from that officer. R. H. STRONG. 111 SCHOOL CLINIC—B. DENTAL SECTION. The first Dental Clinic was established at Cambridge in 1907. The Dental Clinic is at work at Pymmes Park House every day except Sunday, and for a week after the schools close for the long vacation. The hours are from 9 to 1 and 2 to 5 daily, except Saturdays, when it is open from 9 to 1. At suitable intervals, Mr. Pilbeam and his staff arrange for a dental inspection at the schools, which provides him with a number of cases for treatment lasting several weeks. The following report reached me from the Dentist:— Establishment. The Dental Officer, Mr. L. S. Pilbeam, L.D.S., Eng., was appointed on 12th January, 1920. A nurse, Miss R. Hembry, and a Dental Clerk, Miss G. V. Banks, were appointed to the Dental Clinic on 12th April, 1920, and forthwith inspections and treatment commenced. Prior to this month, considerable time was lost owing to the difficulty of obtaining the necessary dental equipment for the treatment of children, this difficulty being caused by unexpected labour troubles throughout the country. The systemisation of the work was evolved by the School Medical Officer and the Dental Officer, taking advantage ot the experience and knowledge of other Dental Clinics which had been in operation for a considerable period. By utilising the most useful portions of these systems, a simple and effective method of detailed record keeping was adopted and put into operation. We have been pleased to find that this has been entirely successful. Equipment. An operating room and waiting room have been provided. The former has good north light and is well equipped. It includes a pump-chair, which is adaptable for the smallest patient, or for the adult, a fountain spittoon, a cabinet for instruments, drugs and sundries, a foot engine, gas apparatus, bracket table, and aseptic table; whilst hot and cold water is in constant supply with adequate arrangements for sterilisation of instruments. The surgery is lit by gas and heated by coal fire. The waiting room, provided with two forms for parents and children is warmed by a gas fire, and the walls have been utilised for the hanging of instructive posters for the edification of parents and their children (who are able to read) on matters of dental hygiene, of which children and parents should be cognisant. 112 The Rontine. Concisely, it is as follows:— A report is obtained from the head teacher of the number of children (both boys and girls) of ages 6, 7 and 8; then days and times ate arranged with the head teacher for the inspection of these children at the school. The respective parents or guardians of these children are notified of the day and time at which it is proposed to inspect the children, and they are invited to attend at the school, when the Dentist points out to them the dental treatment which should be given and the reasons for the same. These inspections are carried out with the assistance of the N urse and Dental Clerk, and a detailed chart of the mouth is made at the time, showing the number of filling and extractions required, and also the number of sound teeth, both temporary and permanent, each child possesses. A "form of consent" enumerating the number of fillings and extractions which is recommended (and mentioning the fee for same) is handed to the parent or to the child (if the parent is not present). The parents signify their acceptance of the treatment recommended by signing the form of consent and returning same to the Head Teacher. Appointments are then sent to the parents asking them to bring or send the child to the clinic for treatment. The treatment is (if possible) concluded at the first visit, but in cases where there is much to be done, often as many as four or five visits are necessary. Further appointments thus entailed are given in writing to the parent at the Clinic or handed to the child (if parent is not present). On the conclusion of treatment the fee stated on the "form of consent" is requested. If forthcoming a receipt is given; if not, the name, address, and amount of fee due are forwarded to the School Medical Officer, who deals with these through Mrs. Hobbs, the following-up nurse. Head teachers are notified of all appointments. Names and addresses of children not keeping appointments are sent to the S.M.O., who causes enquiry to be made by Mrs. Hobbs, whose visits are productive of very good results. A daily ledger is kept of all treatment given, with date of next appointment (if any) and amount of fee paid, and such treatment is also recorded on the individual charts. A return of all such work is forwarded, weekly, to the School Medical Officer. WORK OF THE DENTAL SECTION DURING 1920. As far as possible, the work has been confined to children of ages 6, 7 and 8, but necessarily there are many children who have attended as casual patients because of pain, who are not of this age. Casuals numbering 476 made 752 attendances. The number of casual patients has, in fact, consumed 113 a very considerable portion of my time, and has resulted in consequent delay in my progress with the age-groups, to which chief attention has been given. The general condition of the childrens' teeth has been found bad; little or no effort being made at cleanliness. There is, as usual, during the first year of a Dental Clinic, a marked apathy and disinterestedness on the part of the parents to take advantage of the exceptional opportunities which are being offered them for the benefit of their children. These observations are confirmed by the tables given below, showing that 80 per cent, of the children inspected require treatment, and of the number recommended for treatment, only 55 per cent accept it. Although 55 per cent. seems a very low percentage, it is pleasing to note that it is higher than is usually found for the opening period of a Clinic. April to December, 1920. No. inspected 1958 No. recommended for treatment 1557 No. accepting treatment 866 No. of attendances of those accepting treatment 1333 Work done- Fillings—Temporary Teeth 1174 Permanent Teeth 408 1582 Extractions—Temporary Teeth 1790 Permanent Teeth 153 1943 Dressing and other treatment 142 Anaesthetic—Local 1153 General nil 1153 The grand total of attendances, routine and casual, was 2085. The attendance of children is good whilst the schools are open, but the attendance during the holidays has been very disappointing, and much difficulty has been experienced in obtaining their attendance during these periods. With the majority, the matter of punctuality in keeping an appointment seems of little importance. Children coming late cause loss of time at the Clinic and often a curtailment of treatment to others. 114 Recommendations of Mr. Pilbeam. 1. Another Dentist.—In view of the large number attending at the schools—over twelve thousand—and now that the initial step has been taken in regard to dental treatment, I would strongly urge that a more serious attempt be made to adequately cope with the dental requirements of this large number of children. Of the 12,585 children attending the schools, it is safe to assert that at least 10,068 require dental attention, It is computed that a whole time Dentist cannot efficiently treat more than three thousand children per annum. It is therefore readily seen that if any serious effort is to be made to cope with the appalling conditions which at present exist in the schools, that a second fulltime dentist is required. It might even be better to appoint two part-time dentists, with a whole-time one, as it is generally acknowledged that the majority of dentists, by reason of the trying nature of the work, give better value in part-time work than in whole-time work. 2. Punctuality.—Although notification of the exact time of appointment is sent to the parents and also to the Head Teacher, considerable difficulty is experienced in obtaining the attendance of the children at the time stated. As previously mentioned, this lack of punctuality causes much inconvenience and loss of time. It would appear that this difficulty chiefly arises from the insistence of Head Teachers on the attendance of the children at school previous to attendance at the Clinic, for the purpose of obtaining the "mark." To obviate this difficulty, I would suggest that the mark for attendance be given provided that the appointment at the Clinic is kept. The names of children failing to keep appointments could be notified to the respective Head Teachers. 3. Casuals.—Attention, as far as possible, has been confined to children of from 6 to 8 years of age, but naturally there are children outside these ages who require dental attention. It has been a practice of Head Teachers to send these children to the Clinic for treatment at all hours of the day, sometimes there being as many as six or seven in the day, and sometimes less. The inclusion of immediate treatment for these children during the day necessarily causes a curtailment of treatment for those for whom appointments have been arranged. I would therefore suggest, that in cases of real urgency, Head Teachers should communicate with the Dental Section by use of the telephone, so that an early convenient time may be given for the treatment of these "casuals." Cases of less urgency can be reported by letter for which appointments can be given by return of post. 115 4. General Anaesthetics.—An apparatus for the administration of General Anaesthetic was provided in the initial equipment, but the part-time services of a Medical Practitioner for the administration of the anaesthetic have not been granted. As it is inadvisable for a Dentist to make a general practice of giving an anaesthetic and performing the operative work single-handed and strongly contraindicated when dealing with children, I have to report that on no occasion, so far, has a general anaesthetic been administered, although in numerous cases it would have been a great assistance, and would have rendered more efficient the practice of the Clinic. In fact, many cases have had to be refused, because the work entailed made the use of a general anaesthetic imperative. For these reasons, I would urge the necessity of obtaining the services of a medical man for the administration of a general anæsthetic, on at least one morning per week. 5. Fees.— With regard to the subject of fees, I should like to assert that, from the experience of a period, 21st April to 5th July, there would be no more difficulty in obtaining reasonable fees than there is in obtaining the extraordinarily low fee which is now requested, that is, 3d. for extraction or filling, however many. This latter scale so obviously pertains to charity, and is in many cases resented by parents. In other cases, some parents unfortunately are inclined to value the services at the fee requested. It seems incredible that even among the poorest, a minimum fee of one shilling would not be gratefully given towards the benefits which accrue to their own children, and I would therefore suggest that the scale of fees be raised. 6. Light.—It is recommended that some better provision be made with regard to artificial lighting for concentration upon the mouth, for the next Winter months, as the present arrangements have been found inadequate. 7. Electricity.—Electric lighting would be infinitely better, and an electric engine would be, for many reasons, an improvement, both for operator and patients. I am given to understand that an electric supply is not available at present, but should it be made available at any time, these suggestions might be carried out. L. S. PILBEAM. Note.—Mr. Pilbeam's recommendations I cordially endorse, and I trust that the Education Committee will endeavour to carry them out. 116 SCHOOL CLINIC.-C.-OCULIST SECTION. The Ophthalmic Surgeon (Oculist) attends one afternoon per week, except during school holidays, when the Minor Ailment nurses aud clerk help her. An Optician attends at the same time as the Oculist and takes measurements and supplies all spectacles required. The optician is under contract with the Education Committee to provide frames and lenses at fixed rates; the parents are asked to contribute not more than half the contract, and are excused even this in necessitous cases. (Miss) Mary E. Joll, M.D., B.L. Loud., reports to me as follows:— The Clinic was opened on May 13th, 1920. The Ophthalmic Surgeon attended on one half day per week, making 28 occasions in all during 1920. The total number of new cases seen were 251 The average number of new cases per session was 9 Average number of attendances per week was 18 Total attendances were 497 Owing to previous neglect of Ophthalmic treatment, it was only possible to refer for treatment the most urgent cases; hence the large proportion of strabismi and congenital abnormalities seen. It should be possible to examine ten new cases per session, but work was hampered in the early stages through inadequate equipment. This is now fairly complete and satisfactoiy, but the dark room light is still a source of much annoyance and loss of time. Electric light supplied from the cable would be a great convenience. There are quite sufficient cases waiting to be seen to warrant the setting apart of two sessions per week for ophthalmic cases, at least until the waiting list is cleared off. Cases dealt with were as follows:— No visual defects 28 Simple errors of refraction 96 Errors of refraction, with concomitant strabismus 68 Corneal nebulas (marked) 3 Adherent leucoma 7 Congenital amplyopia 9 Blind scholar 1 117 Blepharitis 6 Conjunctivitis 22 Cataracts 2 Phlyctenular keratitis 7 Melanoma of plica semilunaris 1 Discharging socket 1 Total 251 The attendance of the Optician at the Clinic is an advantage, and spectacles supplied by Mr. Ledsham have been satisfactory. A weekly return of my work is sent in to the S.M.O. M. E. JOLL.