EDM 18 Urban District Council of Edmonton. REPORT Medical Officer of Health for the Year 1925. Urban District Council of Edmonton. REPORT of the Medical Officer of Health for the Year l © 2 5. 3 Edmonton Urban District Council 1925. Chairman T. J. HARINGTON, J.P. Vice-Chairman G. W. PERRY. PUBLIC HEALTH COMMITTEE. Chairman H. BARRASS. Mrs. BARRASS. P. W. DASHWOOD. Mrs. HEARN. A. R. HONE. H. J. KEEN. Mrs. SANDERS. A. E. TUGHAN. W. W. VENABLES. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman - Mrs. A. C. TABRAHAM. Vice-Chairman - Mrs. JENNER [co-opted). Mrs. BARRASS, A. H. BOWEN, P. W. DASHWOOD, Mrs. HEARN, A. R. HONE, Mrs. ITHELL, H. J. KEEN, Mrs. KEY, T. J. McMANIS, Mrs. SANDERS, A. E. TUGHAN, W. W. VENABLES, Mrs. YOUNG. Co-opted Members (Not being Councillors)— Mesdames BRADLEY, COE, ODY, LONG, ELMS, BEER. STAFF OF THE PUBLIC HEALTH DEPARTMENT. * H. W. Harding, M.D. (Lond.), D.P.H., M.R.C.S. and L.R.C.P., Medical Officer of Health, School Medical Officer and Supervisor for the Maternity and Child Welfare Committee. * R. J. Butland, M.R.S.I., Senior Sanitary Inspector, Inspector of Canal Boats and Inspector under the Shops Act, 1912. ab J. E. Winter, Sanitary Inspector. Inspector under the Shops Act. ab G. H. Huckle ,, „ „ „ „ ab W. Tillcock ,, „ „ „ „ a J. P. Farrar „ „ for the Housing (Inspection of District) Regulations, 1910 (February, 1925). S. Clayton, Shops Act Inspector (from December 1st). A. Oades, Clerk. F. Nash, „ (half-time from February). F. Padley, Junior Clerk. 4 MATERNITY AND CHILD WELFARE. * Mrs. G. F. Fleetwood-Outram, M.B., Ch.B., (Glas.) (part-time), in charge of the Ante-Natal Clinic and Child Welfare Centres. * W. H. Willis, L.D.S., R.C.S., B.Sc., Dentist (part-time). +*aeMiss A. Bintcliffe, C.M.B., Superintendent. *a Miss A. Naylor, C.M.B., Health Visitor. * Mrs. C. Boothby, C.M.B. ,, „ *e Miss J. Anderson, C.M.B. „ „ (from May 1st). * Miss Warburton, Clerk. * Moiety paid under Public Health Act, or by Exchequer Grants a Certificated Sanitary Inspector. b Certificate of Meat and Food Inspector. e Maternity and Child Welfare Certificate, † Certificate as prescribed by the Board of Education. To the Chairman and Members of the Edmonton District Council. Ladies and Gentlemen, I beg to present you my Report for the year 1925 on the sanitary conditions of the District of Edmonton and its vital statistics. This report is directed by the Ministry of Health in their Circular 648, dated December 10th, 1925, to be treated as a survey report, and for this purpose should include:— (1) The measure of progress made in the area during the preceding five years in the improvement of the public health ; (2) The extent and character of the changes made during that period in the public health services of the area (e.g., housing, water-supply, sewerage, scavenging, food inspection or other circumstances affecting the environment; maternity and child welfare schemes, provision of isolation hospitals or other services directed to the prevention or cure of disease in individuals). (3) Any further action of importance in the organisation or development of public health services contemplated by the Local Authority or considered desirable by the Medical Officer of Health. The above will be dealt with under the various subjects. 5 Very few years pass without changes on the staff, and 1925 was no exception. Mr. Farrar was appointed Inspector under the Housing Regulations, 1910, commencing his duties in February; his previous position as Public Health and School Clerk was taken by Mr. Nash. In the Maternity and Child Welfare Department, an additional Health Visitor was appointed, Miss Anderson commencing duties on May 1st. Mr. Butland, the chief Sanitary Inspector for so many years, terminated his duties on December 31st, 1925, with the good wishes of all. I take this opportunity of thanking the Public Health and the Maternity and Child Welfare Committees for their courteous consideration and also all members on each staff for their willling and loyal co-operation. I am, Your obedient servant, H. W. HARDING, Medical Officer of Health. 6 NATURAL AND SOCIAL CONDITIONS OF THE AREA. Area (including 31 acres of water) 3,894 acres. Population, census of 1921 66,807 ,, as estimated by the Registrar-General for the mid-year 1925 71,210 Number of inhabited houses, 1921 11,891 Number of families or separate occupiers, 1921 14,654 The Overseer has kindly furnished the following figures relating to 1925:— Number of inhabited houses 12,134 ,, ,, ,, tenements 835 Total 12,969 Rateable Value, for purposes of Poor Rate £245,752 „ „ District Rate £237,459 Sum represented by a Penny Rate. For Poor Rate £1,010 For District Rate £970 Rates in the £. April. October. For Poor Rate 5/5 5/5 For District Rate 4/- 4/- PHYSICAL FEATURES OF THE DISTRICT. The Urban District of Edmonton has an area of 3894 acres, including 31 of water. It is situated in the County of Middlesex, on the west bank of the River Lea. The chief watercourses are Salmon's Brook, which takes a southeasterly course across the northern part of the district to the sewage farm, but there turns due south and joins Pymmes Brook on the extreme south-east corner of the district. Pymmes Brook flows through the southern part of Edmonton and Pymmes Park in an easterly direction as far as Angel Road Station, but a little further on it takes a southern course and is joined by Salmon's Brook ; the combined waters ultimately fall into the River Lea below Tottenham Lock. The New River lies on the western boundary. 7 The soil is loam, and the subsoil consists of brick-earth and gravel, of varying depth, overlying the London clay. The urban district is bounded by Enfield urban district on the north and the urban districts of Southgate and Tottenham on the west and south respectively. Chingford urban district of the County of Essex lies on the east, on the opposite bank of the River Lea. The district is for the most part flat, rising slightly from the river marshes on the east to the higher ground to the westward. CHIEF OCCUPATIONS OF THE INHABITANTS. (Over 12). The following details are abstracted from the Census of 1921 and give the proportions per 1,000, male and female separately, for those engaged in the respective occupations; for purpose of comparision, similar figures are given for the County of Middlesex as a whole. Occupations. Males. Females County. Edm. County. Edm. Agricultural 32 25 10 17 Metal Workers 87 121 ?4 65 Electrical Apparatus and Electricians 19 21 16 59 Textile Workers 16 16 6 9 Makers of Foods, etc. 11 10 18 44 Workers in Wood, etc. 42 57 6 12 Printers and Bookbinders 20 30 23 54 Builders and Contractors 39 59 – Painters and Decorators 24 29 — Railway Transport Workers 26 12 17 14 Road ,, ,, 44 48 Other ,, ,, 34 35 Commerce (not Clerks) 116 75 96 87 Public Administration 34 18 35 11 Defence 14 6 Professional (not Clerks) 36 14 87 52 Entertainments or Sport 6 3 7 3 Personal Service (Hotels, etc.) 25 23 346 190 Clerks (not Civil Service) 91 45 168 115 Warehouses, Packers 18 29 21 49 Undefined, mostly Labourers 65 97 9 10 Chemical Works, Paints, Oils – – 7 39 Unoccupied and Retired .. 142 140 – – 8 The following table gives the locally important single occupations or groups of related occupations:— Occupation. Males. Females. County. Edm. County. Edm. Gardeners Florists, etc. 16 12 — — Agricultural and Gardeners Labourers 13 12 8 14 Boot and Shoe Makers 5 — 3 12 Proprietors in business 39 25 17 18 Salesmen and Shop Assistants 33 26 72 59 Civil Service Officials and Clerks 21 — 31 9 Teachers 9 — 47 24 Laundry Workers 2 — 46 17 Machine Tool Workers 7 13 — — Fitters, Millwrights, etc. 13 17 — — Carpenters 18 20 — — Horse Drivers 11 15 — — Messengers 14 16 — — Porters 7 11 — — Undefined Labourers 52 87 — — Retired 28 19 — — Workers in Chemical Process — — 4 38 Press Workers and Stampers (Metal) — — 3 24 Tailoresses — — 9 15 Dress and Blouse Makers — — 36 33 Embroiderers — 4 9 Sewers, Stitchers (not elsewhere enumerated) .. — — 18 38 Sugar Confectionery Makers — — 4 17 Envelope and Paper Bag Makers — — 2 7 Cardboard Box Makers — — 3 12 Sick Nurses — — 21. 19 Domestic Servants (indoor) — — 242 113 Charwomen — — 17 23 Packers, Labellers, Ticketers — — 17 44 9 The actual numbers employed in the various occupations are given in the same Census figures as follows:— Male. Female. Total population over 12 years 24,119 26,131 Total occupied 20,748 8,698 Unoccupied and retired 3,371 17,433 Occupation. Males. Females. Agricultural Occupations 614 151 Makers of Bricks, Pottery and Glass .. 361 36 Workers in Chemical Processes 102 329 Makers of Paints and Oils 45 7 Metalworkers 2916 565 Workers in Precious Metals 108 18 Electrical Apparatus Makers 511 514 Watch and Clock Makers 82 4 Workers in Skin and Leather (not boots) 136 72 Textile Workers 55 76 Makers of Textile Goods and Dress 393 IIIQ Makers of Food, Drink and Tobacco .. .. .. .. 362 385 Workers in Wood and Furniture 1446 IO5 Printers, Bookbinders, etc. 797 467 Builders. Bricklayers, etc. 1417 3 Painters and Decorators .. 692 9 Workers in Other Materials (Rubber, Vulcanite, Brush) .. 167 132 Other Workers (undefined materials) .. 205 131 Gas, Water and Electricity Undertakings 197 7 Transport and Communication .. 2456 120 Commercial (not Clerks) 1805 714 Public Administration 583 99 Professional Occupations 339 449 Entertainment and Sport 79 29 Hotels, Clubs, etc. (personal service) 543 1653 Clerical 1081 998 Warehousemen and Packers 698 427 Stationary Engine Drivers 194 – Other and Undefined Workers (General Labourers, Rag and Bone Merchants,Watchmen) 2329 73 Not Retired and not Gainfully Occupied 2834 17360 As regards the effect of the occupation upon health, it cannot be said that this has been noticed in any of the Edmonton works; brick-works give off fumes, whilst deleterious gases are generated in some chemical processes and smelting, etc., but no ill effects from these are known. In comparision with Middlesex as a whole, the following are the outstanding industries and occupations Chemical and metal workers, Makers of clothing and foods (largely sugar confectionery), Cardboard box makers, Packers Agricultural and general labourers. 10 This comparison, with the comparative figures already given relating to Edmonton and Middlesex, will indicate very largely what one would expect to find from a social point of view. The district is essentially a working-class one as well as a dormitory for London. VITAL STATISTICS. Population, mid-year 1925, as estimated by the RegistrarGeneral 71,210 Deducting 1,477, being the non-Edmonton residents in three large institutions: the North Middlesex Hospital, Edmonton House, and Epileptic Colony and it is upon these latter figures that the birth and death rates are based. 69,733 Births registered during the year. Male. Female. Total. Legitimate 684 654 1,338 Illegitimate 33 20 53 Total 717 674 1,391 The birth-rate for the year is thus 19 9 That for London is 18 0, and for England and Wales 18 3. The number of stillbirths notified during the year was 62, of which 30 had Edmonton addresses; the remainder came from the other districts of the Edmonton Union and the confinements took place in the Maternity Wards of the North Middlesex Hospital. It must be remembered that the Poor Law Union of Edmonton is very extensive, with a population at the time of the 1921 census of 472,219 folk. The Maternity Wards of the North Middlesex Hospital have 700 to 800 patients passing through them annually, and all births taking place there are not of Edmonton residents. It is unfortunate that the figures given by the Registrar-General in the quarterly return, No. 308, are misleading. The births for the year are given as 1,971, evidently including those of non-Edmonton residents ; this gives an exaggerated birth-rate of 28, whilst the infantile mortality is quoted at 39. II Deaths of Infants under One Year. Male. Female. Total. Deaths of legitimate infants 43 30 73 „ illegitimate „ 2 3 5 Total 45 33 78 The Infantile Mortality Rate, that is the deaths of children under one year per 1,000 births is, for legitimate children, 546, and for illegitimate, 94.3; for the total, 561; that for London is 67, and for England and Wales, 75. The following table gives comparative figures for the past five years:— Total Births. Birth Rate per 1,000 living. Infantile Mortality Rate. London Rate. 1921 1665 24.5 69.6 80 1922 1520 22.7 69.0 74 1923 1520 22.4 55.0 69 1924 1363 19.7 56.5 69 1925 1391 19.9 56.1 67 Deaths. The total number of all deaths for the year were: males, 358; females 318; these figures, based on a net population of 69,733, give a death-rate per 1,000 of the population of 9'7. The following table of the causes of death is furnished by the RegistrarGeneral:— M. F. Total. Whooping Cough 4 5 9 Diphtheria 10 17 27 Influenza 2 9 11 Encephalitis Lethargica — 2 2 12  M. F. Total. Meningococcal Meningitis 1 — 1 Tuberculosis of the Respiratory System 42 22 64 Other Tuberculous Diseases 8 5 13 Cancer, malignant disease 40 38 78 Rheumatic Fever 1 1 2 Diabetes 1 2 3 Cerebral Haemorrhage, etc. 19 16 35 Heart Disease 59 67 126 Arterio-sclerosis 15 10 25 Bronchitis 14 21 35 Pneumonia (all forms) 30 23 53 Other Respiratory Diseases 6 4 10 Ulcer of Stomach or Duodenum 2 — 2 Diarrhoea, etc. (under 2 years) 6 5 11 Appendicitis and Typhlitis 6 3 9 Cirrhosis of Liver — 1 1 Acute and Chronic Nephritis 8 4 12 Puerperal Sepsis — — — Other accidents and diseases of Pregnancy and Parturition — 1 1 Congenital Debility and Malformation, and Premature Birth 18 10 28 Suicide 3 5 8 Other Deaths from Violence 12 5 17 Other defined Diseases 51 42 93 It is not possible to deduce anything from the death returns relating to a small population like that of Edmonton, but the following, which relate to the five years under survey, may be interesting. Deaths from 1921 1922 1923 1924 1925 Respiratory Tuberculosis 65 58 77 60 64 Other Forms of Tuberculosis 21 9 12 14 13 Cancer (malignant disease) 65 84 77 79 78 Circulatory Disease 134 149 129 152 186 Respiratory Affections 94 126 79 139 98 13 Comparative Statistics. The Registrar-General has forwarded provisional figures relating to England and Wales, and I am thus enabled to shew the following comparative tables. ANNUAL DEATH RATE PER 1,000 POPULATION. All Causes. Enteric Fever. Small Pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria Influenza. England and Wales 12.2 •01 00 .13 •03 •15 •07 •32 105 Great Towns .. 12.2 •01 •00 •17 •03 •18 •09 •30 London 11.7 .01 •00 .08 .02 •19 .11 •23 Edmonton .. 9.7 •00 00 •00 .00 •13 .39 •16 Unfortunately, the deaths this year from diphtheria are out of all proportion when compared with the deaths from this disease occurring in London or in the rest of England. The subject is more fully discussed under the infectious illnesses. Causes of Sickness or Invalidity. In February and March of this year, influenza was widespread in the district; it was associated with gastric and respiratory symptoms, and a large proportion of the population suffered. In the early part of the year, both measles and whooping cough were fairly prevelant; these diseases abated during April, and, during the remainder of the year, only isolated cases occurred. German measles appeared in the middle of March and soon spread over the whole area; the outbreak subsided in July. Diphtheria occurred in sporadic fashion during the year until the autumn months, when the number and the severity of the cases increased ; the worst month was November. Chicken pox appeared during the autumn months and gradually increased in numbers towards the close of the year. Isolated cases of mumps occurred late in the year. 14 Nasal and other forms of respiratory catarrh were prevalent during the autumn months. Edmonton is low-lying and has a heavy soil; this, in rainy weather, makes for undue dampness and chill and probably exaggerates the tendency to catarrhal affections. The habit of wearing rubber over-shoes in such weather is an excellent one and which, in my opinion, would prove efficacious in saving many colds and similar affections. The Amount of Poor Law Relief. Unemployment is still a serious problem in the district, though the various works undertaken by the District Council has meant employment for many men. Mr. E. Ridley, the Clerk to the Guardians, has furnished me with figures for the year 1925, shewing the amount of Poor Law relief and the extent of gratuitous medical relief. Out-Door Relief. Number. Amount. Unemployed cases 1,179 £14,535 Ordinary Cases 1,527 £42,210 2,706 £56,745 North Middlesex Hospital. 1925. 1924. No. of day's maintenance 90,208 95,512 Number of cases 2,102 2,006 The Education Authority supply free dinners to necessitous school children; during 1925 the total number of children thus fed was 311. At St. Michael's Hall, in Lower Edmonton, there were 24,014 dinners, whilst at the centre in Pymmes Park the number was 28,452. For 1924, the corresponding figures were : 487 children—31,698 and 35,285 dinners respectively, in addition to 64 breakfasts. 15 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA Hospitals provided or subsidised by the Local Authority or by the County Council. 1. Tuberculosis.—The County of Middlesex makes provision tor the treatment of Tuberculosis, and the majority of the cases of pulmonary disease are treated at:— (а) County Council Sanatorium, Harefield. Accommodation : 129 males, 129 females, 64 children. (б) County Council Dispensary, Hounslow. Accommodation : 9 males, 7 females. (c) County Council Hospital, Isleworth. Accommodation, 40 males. (d) Clare Hall Hospital, South Mimms. Accommodation : 120 males, 66 females. During 1924 the Council equipped the County Sanatorium with a set of X-ray apparatus, in order to enable treatment by the induction of artificial pneumothorax to be undertaken in suitable cases, and, towards the close of the year, arrangements were made for the provision of dental treatment for patients in the Sanatorium. The Council has not provided any institution of its own for the treatment of "surgical" Tuberculosis, but has six cots reserved at the Victoria Home, Margate, for children suffering from this form. Advantage is taken of beds at existing institutions, and patients have been maintained by the Council at various hospitals, among which are Mount Vernon Hospital; Royal Sea Bathing Hospital, Margate; St. Anthony's Hospital, Cheam; Alexandra Hospital, Swanley; Headington Orthopaedic Hospital); Lord Mayor Treloar's Cripples' Hospital, Alton, and various London Hospitals. 2. Maternity.—No hospital accommodation is provided by the Local Authority for maternity cases, but an arrangement is made with the Guardians for the admittance of such to the Maternity Wards of the North Middlesex 16 Hospital. The Council is responsible for the fee, at the rate of 6/- per day, and the total amount is collected from the patient prior to the order of admittance being given. The Order is signed by Dr. Outram, who is in charge of the Ante-natal Clinic, and who sees each case before admission. Some cases are partly or wholly assisted by the Maternity and Child Welfare Committee. Cases dealt with during 1925:— (a) Whole cost borne by patient 7 (b) Partly assisted by the Committee 6 (c) Wholly „ 3 The total sum incurred by the Committee in connection with the above was £10 1s. Od. 3. Children.—Children are received into the North Middlesex Hospital, but there are no special children's hospitals. 4. Fever Hospital.—This Authority has combined with the Enfield Council to form a Joint Hospital Board ; the Hospital is situated in Enfield, on itsWinchmore Hill border, and has 161 beds. The precept payable by each Council is based on the estimated population, calculated on the number of inhabited houses ; in addition, a contribution of 30s. Od. per case admitted is made by the district from which the patient is sent in. The Hospital is primarily for the reception of cases of scarlet fever, diphtheria and enteric fever, but the Joint Board have sanctioned the admittance of cases of measles, erysipelas and puerperal fever, provided it is convenient. The Hospital is in charge of a Resident Medical Superintendent. 5. Small Pox.—Edmonton is one of the contributors to the Middlesex District Joint Hospital Board, the precept payable being a farthing rate for half a year; the Hospital is at South Mimms and is at present used as a Sanatorium for phthisical patients. The administrative block of the Small Pox Hospital at Clavering's Farm, Edmonton, erected in 1902, is kept in order and would be available for the reception of urgent cases ; it has 14 beds. 17 6. Other Hospitals.—Edmonton is on the outskirts of London, and many of its residents seek advice and treatment at the various London Hospitals. In Edmonton itself there is the North Middlesex Hospital, under the jurisdiction of the Guardians. During recent years it has enlarged its scope of activity by the appointment on the staff of visiting specialists. The local Education Authority has made arrangements whereby children suffering from enlarged tonsils and adenoids can have the operation for their removal carried out in the out-patient department of the Hospital, also the X-ray treatment of ringworm. It is hoped that, at some near future date, children suffering from discharging ears will obtain the benefit of modern treatment at this Hospital, namely, ionisation and, where necesary, a mastoid operation. The Prince of Wales' Hospital is within short reach of Edmonton, and provides facilities for the treatment of special, including venereal, diseases. It has a specialist visiting staff and is also a teaching hospital for post-graduates. 7. Institutional Provision for unmarried mothers, illegitimate infants and homeless children in the area is provided by the Guardians in the North Middlesex Hospital, Edmonton House, and the Chase Farm Schools at Enfield. AMBULANCE FACILITIES. (a) For Infectious Disease The Council maintain a motor ambulance for the conveyance of patients to the Isolation Hospital. There is no attendant nurse, so a relative—usually the mother—has to accompany the patient. A small bus is also used for two purposes:— (1) To bring the patients home from the Isolation Hospital; (2) To take relatives to visit the patient when the latter is on the dangerously ill list. After office hours on week-days and on Sundays, the Fire Brigade undertake this latter duty with their Ambulance. (ib) For Non-infectious and Accident Cases.—A motor ambulance is housed at the Fire Station and run by the Brigade ; the following figures given by the Superintendent show the extent to which it has been used during 1925. 18 Surgical and private cases 1,072 Illness in Street and Accident 219 Maternity Cases 106 Adenoids and Clinic cases 322 Parents' urgent visits to Isolation Hospital 71 Total cases removed 1,790 The school clinic cases are children brought home from the North Middlesex Hospital after the operation for the removal of tonsils and adenoids. A school nurse accompanies the patients home. CLINICS AND TREATMENT CENTRES. Situation. Accommodation. Authority. Maternity and Child Welfare Brookfield House, adjoining the Town Hall Five sessions weekly, including one antenatal session Edmonton Council. Maternity and Child Welfare At the School Clinic, Pymmes Park One dental session weekly Edmonton Council. Day Nursery Fore Street 30 children Private. School Clinic Pymmes Park Minor Ailments; Dental, Ophthalmic Edmonton Education Committee. School Clinic Houndsfield Road School Minor Ailments Edmonton Education Committee. Tuberculosis Silver Street, Edmonton Dispensary Middlesex County Council. Venereal Disease Prince of Wales' Hospital, Tottenham, and many London Hospitals — Middlesex County Council. 19 DAY NURSERY. This is situated in Fore Street; the charge is 9d. per day or 3s. 6d. per week. The Hon. Secretary, Mr. A. E. Beer, in his report for the year 1925, states:— "The work of the Day Nursery continues, and further appreciation of its usefulness has been shown by the increased attendances, which numbered 6,649, an increases of 1,101 over the previous year. "It is gratifying to note that, in spite of the large amount of sickness in the district, the health of the children attending the Nursery has been excellent, and the Institution has remained open for the whole of the year, with the exception of the usual holiday periods. "The instruction in Mothercraft to girls from the Council schools has been continued by the Matron, and a larger number than last year, namely, 180 girls, have attended. The girls show great interest in the work, which appeals to them, and they are very keen to learn. "The extension of the Day Nursery, foreshadowed in the last report, has been completed, and in addition to the two extra bedrooms, a large recreation room at the farther end of the grounds has been provided, which enables the children to be grouped according to age, and the work of the Nursery more efficiently carried on. In this new room a piano (lent by a lady interested in the Nursery) has been installed, making it possible for the nurse to give the children Musical Drill, which adds considerably to the cheerfulness both of the children and the probationers. "The scheme for taking resident children has proved a boon in several cases. Forty-three weekly payments of 10s. Od. have been made for various children, amongst whom were four sent and paid for by the Maternity and Child Welfare Committee of the Council, the children staying on an average three weeks each. "It is felt that, as it gradually becomes more widely known, mothers who are incapacitated by illness and have to go away to hospital for treatment, or for confinement, or for convalescence, can place their younger children at the Day Nursery for the small fee of 10s. Od. per week and have no anxiety about 20 their health and well-being, they will, in increasing numbers, take advantage of this scheme. "The Nursery was open to visitors during Health Week in October, and . many took advantage of the opportunity to become better acquainted with the work carried on. "The management of the Nursery is still in the capable hands of Miss Biggs, who, together with the staff of nurses and probationers, has performed the duties to the entire satisfaction of the Committee. "At the request of the Clerk to the Council, the Treasurer furnished a statement of expenditure at the Edmonton Day Nursery for comparison with that of other institutions of the same nature, which showed that Edmonton has by far the largest attendance, and while charging the mothers a lower rate than any other, had very nearly the lowest expenditure per child, which shows that the Institution is being efficiently and economically managed. "The total expenditure at the Edmonton Day Nursery for the year ending March 31st, 1926, was £930, towards which the mothers subscribed £220; the Ministry of Health, £330 ; the Edmonton Education Committee, £50; and the remainder, about £330, was subscribed by voluntary contributors." Professional Nursing in the Home. In 1921, the Council made an agreement with the Cottage Benefit Nursing Association, of Dennison House, Vauxhall Bridge Road, S.E., whereby the latter supplies, through its local branch at Bury House, the services of a fullytrained nurse for general illnesses and those infectious illnesses, measles, etc., which are not usually received into an infectious fever Hospital. The Council pay a retaining fee of £20 per annum, paid quarterly, and, in addition, a fee for each visit by the nurse at the following rate: 1s. 0d. for each of the first three visits and 6d. for each subsequent visit. The school nurses pay visits to school children suffering from the nonnotifiable infectious illnesses, provided early notice be given and that no doctor is in attendance; their duties are threefold: to confirm the diagnosis, to insist on isolation of the patient, and to suggest useful home remedies and those measures which may prevent complications. 21 Midwives. The Middlesex County is the Registration Authority, and Dr. Tate, the County Medical Officer of Health, has furnished me with the following particulars:— At the beginning of 1925 there were 19 midwives practising in the district, two at the North Middlesex Hospital, seven in connection with the Cottage Nursing Association, and ten in private work. At the beginning of 1926 the total number was 12 ; as above, 0, 5 and 7 respectively. The number of applications received during the year from doctors called in to Edmonton patients was 124, and the fees for these cases totalled £120 18s. Od. The Local Authority does not employ nor subsidise midwives. An arrangement is made with the Maternity Department of the North Middlesex Hospital for the reception of paying patients—details of the scheme are given in the last section of this report under Maternity and Child Welfare. Chemical Work. The County is the Local Authority under the Sale of Food and Drugs Acts, and a summary of the work undertaken in the district is given under the section dealing with the Inspection of Food. An occasional chemical examination of a sample of water is required, but there are no definite arrangements for such. LEGISLATION IN FORCE. List of Adoptive Acts, Bye-Laws, Local Regulations, etc., in force in the District. ACTS. Date of Adoption. Infectious Disease Notification Act, 1899 13-1-1891 Infectious Disease Prevention Act, 1890 13-1-1891 Baths and Wash-houses Acts of 1847-78-82 26-2-1901 Public Health Acts (Amendment) Act, 1890— Parts 2 and 3 9-12-1890 Part 5 23-4-1895 22 Public Health Acts (Amendment) Act, 1907 Sections 35, 36, 37, 38, 39, 40, 41, 42, 43, 46 to 51 inclusive, comprising Part 3 relating to Sanitary Provisions, the whole of Part 4 relating to Infectious Diseases, and the whole of Part 5 relating to Common Lodging Houses. The Order of the L.G.B., made Dec. 24th, 1909, declaring these Sections to be in force in Edmonton, came into operation Feb. 11th. 1910. Edmonton Urban District Council Act 1898 BYE-LAWS. Date when confirmed by the Board (L.G.B.). Bye-laws with regard to removal of house refuse and with respect to nuisances 31-8-1903 Bye-laws with respect to slaughter-houses 21-4-1904 Bye-laws with respect to pleasure-grounds 13-9-1904 Bye-laws with respect to houses-let-in-lodgings 19-10-1906 Bye-laws with respect to the management of sanitary conveniences and lavatories 23-1-1909 Bye-laws for the regulation of the offensive trade of a gut-scraper 15-9-1913 Bye-laws with regard to new streets and buildings 5-6-1904 Bye-laws with regard to common lodging-houses 21-4-1904 SANITARY CIRCUMSTANCES OF THE AREA. Water. The district comes in the Metropolitan Water Board area, there being a constant supply for all houses. Rivers and Streams. The Enfield sewage farm is in Edmonton; this and our own sewage farm discharge their effluents into the River Lea. There is no pollution of the Salmon's Brook or of Pymmes Brook by any commercial process, etc. Drainage and Sewerage. The drainage is the dual system in nearly all parts of the district, there being a separate sewer for surface water. 23 During the past two years, extensive alterations have been taking place on the Edmonton sewage farm, which is on the border of the River Lea. From the public health point of view, the most important alteration is the building of a huge reservoir—this will facilitate the emptying of sewers in the lower part of the town. In the past, a potential blockage has been caused by heavy rains and high tides; manholes have been forced in the lower-lying districts and sewage has been distributed over the adjacent ground. Closet Accommodation. This is wholly of the water-closet type. Scavenging. The removal of house refuse is carried out by the Council with the aid of electric vehicles ; that this is efficient is shewn by the extremely few complaints received as to non-collection. In spite of this, one not infrequently sees the gardens of some houses littered with garbage—ashes, vegetable refuse, old cans and irons, etc.—and the same can be said of neighbouring gutters and waste pieces of land. There is no difficulty in obtaining suitable dustbins : if the landlord fails to comply with Sec. 36 of the 1875 Act, the Council supply the article and recover the cost. The Council do not possess a destructor, but all house refuse is dumped in the neighbourhood of the sewage farm. This dump is of considerable size, and furnishes an excellent breeding place for rats, for the destruction of which the Council pay £50 annually. There are some half-dozen cesspools in the district, these due to the fact that entry into a sewer is a difficulty, or that it is too far away. These are attended to by the Engineer's department. Sanitary Inspection of the Area. The district is divided into three areas, one Sanitary Inspector being warded for each area. A fourth inspector carries out house-to-house inspection under the Housing Regulations, 1910. The work is supervised by the Senior Sanitary Inspector, who is also Inspector under the Canal Boats Acts. 24 The following tabular statement gives the number and the nature of a the inspections made by the Inspectors during the year:— Complaints 911 Infectious Disease 299 House-to-House 325 Factories 142 Workshops 58 Outworkers 28 Schools 147 Dairies, Cowsheds and Milkshops 116 Offensive Trades 71 Shops and Stalls 177 Common Lodging House 47 Sanitary Conveniences, Urinals, etc. 308 Stables 33 Piggeries 38 Gipsies 225 Petroleum 135 General Inspections 536 Re-inspections 7222 Sundry visits 1537 Inspections of places where Food is prepared:— Butchers 288 Fish Shops 25 Coffee Shops 7 Ice Cream Shops 32 Dairies, Cowsheds and Milkshops 116 Slaughterhouses 268 Bakehouses 84 The number of notices served were:— Preliminary or informal Notices 1478 Statutory Notices 717 The work carried out as the result of these notices:— Houses or parts of Houses repaired or cleansed 731 Drinking water cisterns covered, cleansed or repaired 35 25 Water fittings repaired 120 Water taken from main 5 Drains examined, tested or exposed 417 Drains cleared, trapped or repaired 532 Drains reconstructed 12 Chambers inserted 12 Chambers sealed down 21 Soil and ventilation pipes renewed or repaired 27 Water closets repaired, cleansed or improved 253 Flushing cisterns repaired 201 Waste pipes renewed or repaired 109 Sinks repaired 37 Roofs repaired 441 Gutters and rainwater pipes repaired 384 Yards paved or repaired 124 Scullery floors repaired 105 Spaces under floors ventilated 32 Dampness remedied 96 Ventilation improved 2 Floors repaired 132 Coppers and stoves repaired 379 New dustbins supplied 251 Accumulation of refuse removed 21 Nuisances from animals abated 4 Gipsies removed 271 Other nuisances abated 534 Rooms cleansed after infectious disease 101 Proceedings were instituted in 2 cases: against an owner-tenant, on account of filthy rooms and an accumulation of rubbish, and against a gipsy. The fines imposed were, respectively, two guineas and costs and five pounds and costs. Smoke Abatement. No action has been taken this year with regard to smoke nuisance. The only complaints received referred to one chimney stack emitting smuts— usually on washing day!—and this has been much improved by the use of a better coal and more careful stoking. 26 Premises, etc., controlled by Bye-laws. These are common lodging-houses, houses let-in-lodgings, slaughterhouses the offensive trade of gut-scraper. There is one common lodging-house for men and, though an antiquated building, it serves a useful purpose and is kept sanitary. There are five slaughterhouses—one registered and four licensed—and are kept under supervision. There is one business of gut-scraper and fat extractor; the premises are modern and modern machinery and ventilating apparatus are installed. The bye-laws relating to houses-let-in-lodgings are practically a deadletter, as they refer only to lodgings let for 8s. Od. per week or under if unfurnished, and 10s. Od. if furnished. Other sanitary conditions are mentioned under Housing and Supervision of Food. SCHOOLS. The sanitary conditions of the schools are, on the whole, favourable. The majority of the schools are of recent date, standing in good, ashphalted playgrounds, well-lit and well-ventilated. In some of the older ones, the buildings are cramped and the cloak-room accommodation is not perfect. All schools have proper lavatory accommodation and a seperate tap off the main for drinking purposes. The equipment is satisfactory. During recent years the whole of the schools have had the old long desks replaced by modern dual desks. The majority of the sanitary conveniences are of the trough form, with automatic flushing. Many children are living under much better hygienic conditions whilst at school than when living at home—there is more air space, freer circulation of air, a better chance of obtaining sunshine, and movements, such as drill, etc., are in a better atmosphere. An enquiry last year into the ventilation of the schools showed that all possible means were taken to provide the class-rooms with fresh air; there 27 were a few exceptions where, on very cold days, owing to the exposed position of the class-room, it was found impossible to ventilate as thoroughly as was desired, it being difficult to maintain the warmth of the room to a proper degree. I think if medical men realised the difference between school and home life, they would not be so ready to keep children away from school for the sake of fresh air. My opinion is that, during the winter months, a large number of children are in a better environment at school than when staying at home. Action taken as to Health of Scholars. I can only tabulate the various activities of the Education Committee in this respect:— Routine Medical Inspection of the three age groups. Two minor ailment clinics, open daily. Dental and Ophthalmic clinics. Arrangements for removal of tonsils and adenoids and the treatment of ringworm by X-rays. Reservation of two beds at Stanmore Orthopaedic Hospital. Reservation of three beds for boys at the Russell Cotes Home, Parkstone, and four beds for girls at the Ogilvie School, Clacton— both open-air schools. The giving of cod-liver oil to children needing it, and free meals and milk to necessitous cases. Cleansing baths for scabies and verminous cases. Slipper and swimming baths at cheap rates. Voluntary boot fund. Employment of Children Bye-laws. These are administered by the local Education Committee, and children have to be medically examined by the Assistant School Medical Officer. Infectious Disease in the Schools. The suggestions conveyed in the Memorandum of 1925 regarding these diseases have been followed. 28 The contacts of the notifiable diseases, mostly diphtheria and scarlet fever, are seen by me at the Town Hall, the former being swabbed. Notices are sent to the day and Sunday Schools, excluding for a week. Children, on returning from the fever hospital, are seen by me and returned to school when fit. Instructions have been given that school children supposed to be suffering from an infectious complaint can be sent by the Head Teacher to see me at the Town Hall, and these have been taken advantage of. Many cases of mumps and chicken pox and a few of measles and German measles have thus been seen. Other cases are visited at their homes by the school nurses, provided there is no doctor in attendance and that early information is given; advice is given and exclusion notices are sent to the schools by the nurses. It has not been necessary to close any school or department of a school on account of infectious disease during the year. HOUSING STATISTICS FOR THE YEAR 1925. I.—NUMBER OF NEW HOUSES ERECTED DURING THE YEAR. (a) Total 167 (b) With State assistance under the Housing Acts:— (1) By Local Authority 70 (2) By other bodies or persons 11 II—UNFIT DWELLING-HOUSES. I. Inspection (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) ... 1168 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or Consolidated Regulations, 1925 325 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — 29 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1188 II. Remedy of Defects without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 819 III. Action under Statutory Powers:— A. Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 191 (2) Nnmber of dwelling-houses which were rendered fit:— (a) By Owners 111 (b) By Local Authority in default of Owners 9 (3) Number of dwelling-houses in repect of which Closing Orders became operative in pursuance of declarations by Owners of intention to close — B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 63 (2) Number of dwelling-houses in which defects were remedied:— (a) By Owners 61 (b) By Local Authority in default of Owners — C. Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925 (1) Number of representations made with a view to making Closing Orders — (2) Number of dwelling-houses in respect of which Closing Orders were made — 30 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling- houses have been rendered fit — (4) Number of dwelling-houses in respect of which Demolition Orders were made — (5) Number of dwelling-houses demolished in pursuance of Demolition Orders — HOUSING. The large majority of the houses in the district consist of working-class dwellings; the exception occurs in the Bush Hill Park area, on the Enfield border, where there is a better class of property. There is undoubtedly a marked shortage of houses, and there are, at present, two types of dwellings being erected. One type is that of workingclass dwellings, put up by the Council on their housing estate ; the other is the small villa, put up by private enterprise for selling. The increase in the number of assessed houses during the past year is 167, of which the Council houses (No. 2 Scheme) are 70. A third scheme for the building of 98 houses is being pushed forward by the Council. It is difficult to estimate the extent of overcrowding in the district, but the following may help to form some idea of its prevalence:— (1) One not infrequently comes across cases where families of 6, 7 or 8 are living and sleeping in one room. (2) The population of 100 houses in St. Mary's Road and Gardens gave an average of 9 per house. (3) Of the houses infected with scarlet fever or diphtheria, 213 were 5 or 6 roomed honses. The total population of these were 1,629, or an average of 7 6 per house. This figure is a little higher than that found in 1921 in 749 houses, namely seven. As mentioned above, the District Council are pushing forward their third Housing Scheme. The first provided 232 houses, completed in 1922, the second provided 82 houses, completed early in 1926, and the third scheme makes provision for 98 houses. There were over 800 applicants for the 82 houses! 31 There is a good deal of undeveloped land in the district, and it is possible that in a few years time the population may be appreciably greater than at the present. During the last few years there has been a marked reduction in the proportion of elementary school children to the rest of the population: in 1921 the percentage was 18'2, whilst for 1925 the percentage had fallen to 14 6. Two factors are responsible for this—the declining birth rate and increased longevity. The main cause of overcrowding is undoubtedly the dearth of suitable houses. In some cases a small family has taken rooms six or seven years ago, and find that now, with a larger family, it is impossible to obtain proper accommodation; in other cases, relatives have married or come up from the country and have been accommodated. The overcrowding has led to squabbles and bickering, and must have a bad effect not only on the health, but on the morale of the inhabitants. The services of the Sanitary Inspectors are not infrequently invoked when the climax is reached by the tenant locking up sanitary accommodation or the water supply, or the lodgers needlessly making themselves offensive as regards the disposal of slop waters, etc. The worst cases of overcrowding have been abated without resorting to statutory interference; milder cases have been left alone for the simplest of reasons—there is no remedy. The problem of housing is a very serious one—it is a national and not a local one. Fitness of Houses. Taken as a whole, the general standard of housing in the area is fair. There are a few blocks of buildings which, owing to structural defects, can never be made wholly sanitary, but, in the majority of cases, the defects are of a temporary nature—defective window-frames and sashes, leaking roofs and gutters, burnt-out stoves, dirty and dilapidated walls and ceiling, etc. There are two causes of the above: in the first place, very little repair was done to property during the war, and hence dilapidations have accumulated ; secondly, many rooms are now put to uses not originally intended. 32 To use a bedroom for a living-room and a bedroom stove for cooking purposes is to rapidly dirty and deteriorate the one and to burn out the other; increased traffic along passages increases dilapidations. Landlords are not anxious to carry out repairs due to this increased wear and tear, especially if the tenant, owing to the number of lodgers, is living rent free. Unfortunately, it is sometimes the neglectful tenant who has the most complaints to make. The Sanitary Inspector has to exercise great discretion when asking the landlord to undertake repairs or make good dilapidations. A useful guide is to ascertain when the landlord put the room or premises into order last; it is then possible to form some idea of the manner in which the tenant has used the house. The majority of defects have been remedied either under Section 94 of the 1875 Act or Section 36 of the same Act (as regards dustbins), or Section 28 of the 1919 Housing Act and its successor, Section 3 of the 1925 Housing Act. Details are given in the preceeding paragraph dealing with Housing statistics, which also give the number of cases in which the Council carried out the work in default of the owner, as provided for under the Housing Acts. The only difficulty found in remedying unfitness was under the Housing Acts. The owner appealed to the Ministry, who asked for a deposit of £5 from the owner before hearing the appeal; this has not been done, consequently the appeal has not been heard, and the local Authority are apparently helpless. At the time of writing, it is just on 12 months since the inspection of the property was first made. If all property owners adopted the same procedure, the Housing Act of 1925 would be a dead letter. During the past year, special attention has been paid to the water supply. In many cases it is off the rising main, but if direct from a cistern, then special regard is paid to its accessibility for cleansing and as to whether it is properly covered. The Amendment Act of 1907 adds to the Statutory Nuisances any cistern so placed, constructed or kept as to render the water therein liable to contamination likely to cause risk to health. During the year there were five cases in which the cistern was regarded as so "placed," and the drinking water has been taken off the main. Accommodation. All premises in the district are supplied with water furnished by the Metropolitan Water Board. Closet accommodation in the district is, on the whole, satisfactory. Defects, of course, are frequent, but these do not influence the accomodation. The forms met with are of the hopper type, either long or short. The latter, with the straight back, is the more sanitary, and is the type preferred when replacement is necessary. The collection of houshold refuse is undertaken by the Council direct, electric vehicles calling weekly; judging by the paucity of complaints, the work is done thoroughly. In some of the poorer quarters, proper regard to the disposal of ashes, etc., is not paid by the tenants. It is not uncommon to find the gardens at the rear of these houses littered with ashes, vegetable refuse, old tins, etc.—a most uncongenial playing-place for children. This is entirely a matter for the tenants, who, unfortunately, fail to realise their responsibility. No complaints have been received or representations made as to the existence of nnhealthy areas. There are a few blocks of buildings which, as stated previously, owing to structural defects, cannot be made wholly sanitary, but there is no area which could be termed unhealthy. The Council possess bye-laws relating to houses-let-in-lodgings, but, as they refer only to lodgings let under the sum of 8s. Od. weekly, they are practically useless—it is very difficult to get accommodation to-day at so small a figure. The bye-laws with respect to common lodging-houses adequately meet the needs of the district—there is one such house, for males only, and is referred to previously. The bye-laws dealing with new houses date from 1904, and though relaxation of these might allow houses to be erected more cheaply, it is very doubtful whether such would be a wise measure. Posterity will find plenty to do without having to look after property put up to-day the chief merit of which is cheapness. 33 The Council posssss no bye-laws relating to tents and vans; these would furnish a more ready method of dealing with nuisances than the present one of obtaining a summons against the offender, but what is required for an urban district is not regulating bye-laws, but a prohibitive Act. Canal boats, with their accommodation, etc., have been supervised by Mr. Butland, who gives the following report:— "There were 17 registered boats inspected during the year, and the following contraventions of the Acts and Regulations were dealt with:—One dirty cabin ; one cabin required painting; one cabin top defective and cabin required painting ; one no certificate produced. '' The first three contraventions have been remedied, but in the fourth case the steersman is working two boats, and had left the certificates locked up in the cabin of the other boat. On his return to this district he has promised to leave the certificate in charge of the lock-keeper for inspection. " Several boats are worked by one steersman, as while the unloading and loading is taking place, he is able to return with an empty boat. "Two boats changed ownership during the year; these have been thoroughly overhauled and put into excellent condition." GENERAL MEASURES, ETC. The first Health Week in Edmonton was held in October, and included the following:—lectures and lantern demonstrations, a school essay on " Cleanliness," with suitable awards, and an exhibition of various foods and sanitary appliances. The lectures were poorly attended, but about 1,000 visited the exhibition, and the school essays provoked great enthusiasm. The following was the programme :— Sunday, October 4th. Special Addresses at Churches, Chapels and Sunday Schools. 11.0 a.m., Service will be held at Parish Church. 6.30 p.m., Service will be held at Independent Congregational Church. Monday, October 5th. 2.0—4.0.—School Clinic, Pymmes Park, will be open. 8.0.—An Address will be given at the New Hall (opposite Town Hall), by Dr. Elizabeth Sloan Chesser, on "Psychology, Health and Happiness." Chairman : Mr. Councillor T. J. Harington, J.P. 34 Tuesday, October 6th. 3.0—4.30.—A Gas Cookery Demonstration will be given by Miss Moss, M.C.A., 1st Class Diplomee, N.T.S. of Cookery, in the New Hall. Kindly arranged by the Tottenham District Light, Heat and Power Company. 3.0—4.30.—Oakthorpe Dairy will be open, by kind permission of the London Co-operative Society, Ltd. (this Dairy is situated on the Palmers Green border, via Silver Street). 7.30.— Presentation of Prizes to school children for Health Essay, at the Town Hall, by Mrs E. Broad, followed, at 8.0, by an Address by Dr. Eric Pritchard, Medical Director of Infants Hospital, Westminster: " Some Common Errors in Diet." Chairman: Mr. Councillor H. Barrass. Wednesday, October 7th. 2.0—4.0.—Child Welfare Centre (Brookfield House) and Baths, etc., Cleansing Station, both of which adjoin the Town Hall, will be open. 2.30—4.30.—Edmonton Day Nursery, 311, Fore Street, will also be open, by kind permission of A. E. Beer, Esq. 4.0—10.0.—Exhibition of Foodstuffs, Disinfectants, Sanitary Appliances and other health measures, etc., will be held in the New Hall. Cookery Demonstration will be given by Mrs. Walker during the evening, kindly arranged by the North Metropolitan Electric Power Supply Company. Orchestral selections will be rendered by the County Secondary School during the evening. Thursday, October 8th. 3.0—4.0.—Another Gas Cookery Demonstration by Miss Moss in the New Hall. 8.0.—A Lantern Lecture will be given in the New Hall by Dr. H. W. Harding on "Flies and Disease," followed, at 8.45, by an Address by Cuthbert Brown, Esq., M.Inst.C.E., on "Health Measures adopted by the Council," including Housing, Roads, Recreation, Sewage Disposal, etc. Chairman : Mrs. Councillor M. L. Key. Friday, October 9th. 3.0—4.30.—A further Gas Cookery Demonstration by Miss Moss in the New Hall. 8.0.—Dr. Stenhouse Williams, National Institute for Research in Dairying, Reading, will give a Lantern Lecture in the New Hall, on "The Production and Distribution of Clean Milk." Chairman : Mrs. Councillor L. R. Ithell. 35 Saturday, October 10th. 4.0.—A Conducted Tour round the Wards, etc., of the North Middlesex Hospital has been arranged. Tea provided. Use of Disinfectants. The Council distribute disinfectants—liquid and powder—for general use to residents who apply for same. Every afternoon except Saturday, these are given away between 4 and 5, and in the summertime the number of applicants is very numerous. It is difficult to prove that they have any influence on health—on the other hand, it is possible that harm is done, inasmuch as the users may depend on them and neglect cleanliness. If a drain or sink gully becomes offensive, it is not a remedy to pour down a liquid disinfectant, however strong it may be; the correct remedy is to find the reason of the smell and get the cause removed. A good deal of the disinfectant must get into the drains and from thence to the sewage farm; as the reduction of the organic matter depends on bacterial action, it is possible that this action is retarded by the presence of such an antiseptic. The number of applicants during the year was 52,614—an increase of 5108 on the previous year—an average of a little over 200 each afternoon. The disinfectant powder is also supplied to the dustmen for use after emptying dustbins. Rat Destruction. The Council make arrangements with the County for the latter to supply its official rat-catcher for the purpose of keeping down rats on the dust dump. In addition, help is given by the Sanitary Staff in rat-infested premises by testing drains, giving rat-poison, etc. As far as possible, isolated action is avoided, as it only means driving the pests from one premises to another. Offensive Trades. There is one gut-scraping business in Lower Edmonton which is regularly supervised. 36 The premises now are vastly different to what they were in 1920—they were then most unsatisfactory, with defective flooring and discharging all its refuse into a ditch ; now they are modern premises, properly constructed, with proper ventilation and proper disposal of refuse. This is one of the marks of progress during the last five years, and it was a pity that the Council should have had to invoke the aid of the Law to carry out such a badly-needed change. Rag and bone dealers give very little trouble; there are not many in the district, and it is possible that it is not such a lucrative business as it has been in the past, or perhaps out-door relief and unemployment assurance is respon for the few numbers. Flies are unpleasantly numerous each summer. There are two possible main breeding grounds : one is our own refuse dump, a huge mound situated on the eastern boundary, near the River Lea; the others are the many allotments in the area, with their numerous dumps of manure, not necessarily matured. Knowing that flies are carriers of germs of all sorts, it is remarkable that we do not get more summer diarrhoea in our midst; I am unable to explain our freedom in this respect. Gipsies and van-dwellers frequently cause a nuisance by settling on vacant plots of land. They worry residents for water and their camping ground gathers an assortment of organic material—horse manure, potato peelings and other vegetable refuse, old rags, bones, tins, etc. Towards the end of the year, a Special Council Meeting was convened for the purpose of obtaining summons against a number who had encamped in the vicinity of a large school. Work carried out in connection with Infectious Disease. The following gives an idea of the work done:— Number of journeys of motor ambulance to remove patients to Hospital 306 Number of journeys of bedding van to remove infected bedding 310 Number of journeys of bedding van to return bedding 300 Number of journeys of motor bus to fetch patients from Hospital 178 37 Number of patients returned to their homes 360 Special journeys for visitors to Hospital, etc. 475 Number of rooms disinfected for vermin 32 Number of articles disinfected in connection with infectious disease 3064 Number of articles disinfected in connection with Phthisis 360 Number of rooms disinfected in connection with infectious disease 423 Number of rooms disinfected in connection with Phthisis 144 Number of rooms disinfected in connection with Cancer 9 Number of articles disinfected in connection with other cases 25 Number of books disinfected 150 Articles of bedding destroyed 35 Mortuary. The Mortuary is situated in the Town Hall yard. The total number of bodies received during the year was 75; 40 of these were for inquest or post-mortem examinations, the remaining 35 for sanitary reasons. SHOPS ACTS. The part-time Inspector continued his work under the above Acts until the end of 1925, when the Council determined to appoint a whole-time Inspector. That part of the Acts with which he was mostly concerned was in respect of the hours of closing, but it was felt that other parts of the Acts dealing with the employment of young persons, the number of hours employed, mealtime, sitting accommodation, etc., also required careful attention. Proceedings were undertaken in one case for contravention, and a fine of £1 and costs was imposed. First offenders were always warned by letter. The full-time Shops' Act Inspector commenced his duties on December 1st, 1925. 38 INSPECTION AND SUPERVISION OF FOOD. The Middlesex County Council is responsible for the carrying-out of the Sale of Food and Drugs Acts, and I am indebted to the County Medical Officer of Health for the following information, which relates to Edmonton. of Health for the following information, which relates to Edmonton. The figures include some adulterated informal samples, in respect of which no proceedings could be taken. Article. No. taken. Adulterated. Milk 309 14 Butter 12 0 Arrowroot 1 0 Cinnamon 2 0 Cocoa 1 0 Coffee 4 0 Egg Powder 1 0 Jam 6 2 Mustard 4 1 Pepper 3 0 Prescription 3 1 Sausage 1 0 Whisky 6 4 353 22 Number of prosecutions 3 Number of convictions 3 Fines and costs imposed £33 5s. 0d. DAIRIES, COWSHEDS AND MILKSHOPS. There are 78 purveyors of milk on the register. There is only one registered cowkeeper in the district, the number of cows at the present time being ten; these are stall-fed summer and winter. The sale of sterilised milk in the district is increasing; one large firm and two private individuals are thus catering for the neighbourhood and surrounding districts. Edmonton is badly off for retailers of designated milks; the number of milk-sellers who have licenses to sell these are:— For certified milk 1 For "Grade A" (Tuberculin tested) milk 0 For " Grade A " milk 1 For "Grade A" milk (pasteurised) 0 For pasteurised milk 0 39 In addition, there are four supplementary licenses, two for "certified" milk, one for " Grade A " (T.T.), and one for Pasteurised. The tes t for these designated milks is the bacterial count and character— in other words, the cleanliness of production. It is a curious anomaly that a milk-seller can sell milk containing as many organisms as he pleases, provided the milk is not altered in taste or smell by these, but if he wants to sell a clean milk and at the same time impress his customers with the fact that he is trying all he can to provide a clean milk continually, he has to obtain a license! The benefit he obtains from this license is that he can label each bottle of milk so sold as " Grade A," etc. Certified milk is produced from a healthy herd of cows, and is bottled on the farm premises. "Grade A" milk can be bought in bulk and bottled at the retailers' premises. The term "tuberculin tested" means that any cow that reacts to this test is eliminated from the herd. There has been no refusal to register retailers of milk, nor to grant licenses for designated milks, neither has there been any revocation, but one retailer was advised not to apply for a license on account of the condition of his premises. The bacteriological findings of three samples of "Grade A" milk, obtained from the retailer, gave an average of:— 355,000 organisms per c.c., and Bacillus coli (dung organism) in c.c. There has been no application for a renewal of the license for 1926. Meat. There are five slaughterhouses in the district, but, with the exception of pigs, there is not much slaughtering done at present. Due notice, however, is given in accordance with the Meat Regulations, and the carcases are inspected soon after slaughter ; no marking is done. The animals thus inspected were:— Cows 3 Sheep 11 Calves 1 Pigs 329 Total 644 40 The Meat Regulations which came into force last year promised great things as regards cleanliness and contamination from flies, dust, etc. The Medical Officer of Health and the Senior Sanitary Inspector visited all butchers' shops and shops where ham, bacon, lard, cooked meats, etc., were exposed for sale, on the instruction of the Public Health Committee. The result was that practically all the butchers in the district agreed to put in glass fronts to their shops to protect their meat from dust blowing on to it, and other provision merchants were to reserve a portion of a counter for ham, cooked meats, etc., and this special portion was to be protected by a glass front and glass sides. It was felt by the shopkeepers themselves that such a provision, though entailing expense, was a wise one, and the result would have been satisfactory in the extreme if it were not for another circular from the Ministry of Health saying that glass fronts were not intended and that cooked meats were exempted. The number of slaughterhouses in the district for the following dates were:— In 1920. Jan., 1925 Dec., 1925. Registered 1 1 1 Licensed 4 4 4 Total 5 5 5 These premises are regularly inspected, and are kept in satisfactory order. Bakehouses. These are regularly inspected by the District Inspectors to see that the premises are kept in a cleanly state and that the usual limewashing, etc., is carried out. Some of the premises are antiquated and only suitable for a limited output. They all have facilities for the employees to wash their hands, but it cannot be said that these facilities are in every case ideal. There are very few dining-rooms or eating-houses in the district, and these are kept under supervision as to the storage of the food and the actual place where it is prepared. Ice-cream manufacturers are carefully supervised during the season; it is not uncommon for an individual to start in a small way, and a living-room or rarely an old shed in a garden is utilised for that purpose. The Middlessex 41 County has an Act, part V of which regulates the manufacture and sale of icecream. It is the habit of retailers in the district to bring unwholesome or diseased articles of food to the Town Hall for condemnation, and this is a practice beneficial to all. A condemned note is given to the retailer, and there is usually little trouble with the wholesaler who supplied the goods. The following list gives an idea of the kind and the quantity of food so condemned:— 2 lbs. tomatoes and 1 bag of winkles. 1 barrel of hake and 1 box of herrings. 1 box of herrings and four pigs' livers. 1 box of herrings, 3 bundles of tomatoes. 1 61b. tin of Libby's Beef. 2 boxes of skate and 4 boxes of tomatoes. 1 sieve of blackcurrants. 4 bags of brussel sprouts. 1 box of fresh haddock. It was hoped that the 1924 Meat Regulations were the first of a series dealing with the exposure of articles of food to contamination, and that subsequent Regulations would embrace many articles found on stalls or outside shops, namely: cheap chocolates, broken biscuits, dates and other articles which are eaten uncooked. PREVALANCE OF AND CONTROL OVER INFECTIOUS DISEASE. The year 1921 was characterised by a large number of notifiable infectious diseases; excluding the various forms of tuberculosis, the actual number notified was 956. The figure fell during the next three years to 570, 363 and 365 respectively, but went up to 441 for the year 1925. The high figure in 1921 was due to the prevalence of scarlet fever and diphtheria, two complaints which had been raging for some time previously and which, apparently, had burnt themselves out. Unfortunately, the same characteristics which were noted during these earlier years with regard to diphtheria have appeared in Edmonton during the latter months of 1925 and the early months of 1926; these were:— 42 (1) An increased virulence of the disease; (2) Persistent carriers; (3) Nasal form of the disease; (4) Greater variety in the morphology of the organism. An increase in the number of cases or the virulence of the disease in scarlet fever has not been noted, but in the last outbreak it was not uncommon to find that scarlet fever cases were carriers of the bacillus of diphtheria, and that the unhealthy condition of the throat, so often associated with the presence of the germ, was a potent cause in the spread of scarlet fever. The following table gives, for the last five years, the number of notified cases of diphtheria, the case fatality, and the fatality per 1,000 of population compared with London and the whole of England and Wales. Cases Notified. Deaths. Case Fatality. Death Rate per 1,000 Population. Edmonton. London. England and Wales. 1921 404 32 8% .48 .25 .12 1922 153 20 13% .30 .25 .11 1923 81 6 7.4% .09 .13 .07 1924 78 9 11.5% .11 .12 .06 1925 208 27 13% .38 .11 .07 During November, 1925, the incidence and the severity of the cases which occurred in Enfield, as well as Edmonton, so increased that Dr. Cook, the Medical Superintendent of the Joint Isolation Hospital, communicated with the Ministry of Health, the result being visits of investigation by Dr. Sturdee, of the Ministry; his report is of great importance to the community, and I give it in toto. 30th January, 1926. Sir, I am directed by the Minister of Health to inform the Edmonton Urban District Council that he had received a report by Dr. E. L. Sturdee, one of the Medical Officers of the Department, on Diphtheria, with special reference to the high rate of mortality from the disease in the Enfield and Edmonton Joint Hospital. 43 Dr. Sturdee reports that the disease, prevalent during the year 1925 in the Joint Hospital district, was of a comparatively severe type, which demanded prompt and adequate treatment from the outset. Of 198 cases admitted to the Isolation Hospital during the seven months from April to October last, 31 died, and it is significant that whereas there was only one death among 26 patients from the Chase Farm Residential School, of the Guardians of the Edmonton Union, there were 30 deaths among the 172 patients from private houses. Dr. Sturdee adduces evidence to show that the infection of both these classes was of the same origin and the only essential difference between them appeared to be that, of the 26 school cases, 19 who presented clinical symptons were given antitoxin approximately one day after onset of the illness and before admission to Hospital, whereas to 21 cases only from private houses was antitoxin given before admission, and the delay in giving it varied from 1 to 6 or more days. After admission to Hospital, the patients had every care and consideration. The Report again seems to emphasise the need for prompt and adequate treatment of diphtheria with antitoxin, and the Minister appreciates the fact that provision is made by the Edmonton Urban District Council for the gratuitous supply to medical practitioners of antitoxin in necessitous cases, and that steps are being taken by the Joint Hospital Board to improve the ambulance service and so expedite the removal of patients to Hospital. He can but regret that the efforts of the Council in this direction appear to have been to some extent neutralised by the frequency of delay on the part of parents in calling in medical aid, and that more use is not made by medical practitioners in the district of the facilities already referred to. I am to add that the Minister concurs entirely in the action taken by the Medical Officer of Health of the Urban District on the 19th October last, and it is suggested that the observations set out herein should be brought to the notice of medical practitioners in the Urban District as opportunity offers. I am, Sir, Your obedient Servant, F. F. Marchbank. 44 A copy of the above was sent to all medical men practising in the district, whilst leaflets on the subject were distributed at the schools for children to take home. Local medical practitioners had been previously circularised as to the virulence of the disease and were asked to give adequate doses of diphtheritic anti-toxic serum to suspected cases whilst awaiting the result of the swab. This has been done and many cases have received an early dose, but unfortunately in a fair proportion of cases, medical men are called in after the patient has been ill several days, and the diagnosis is only too apparent. That diphtheria in its early stages or in a mild form is difficult of diagnosis is perhaps shewn by the fact that a fair proportion of cases have received antitoxin and from whom a negative swab has been obtained and conversely no antitoxin is given and the swab proves positive. On the other hand, swab results are not always reliable. If taken from a case several days old and coming in contact with the superficial surface of the false membrane only, the swab may be negative, and it may be positive in a carrier suffering from follicular tonsillitis, etc. The subject is interesting from a technical point of view, but it must be borne in mind that the attending doctor must make his diagnosis upon clinical evidence and must not rely wholly upon laboratory results. The Council supply antitoxic serum in doses of 4000 units and 8000 units free to medical men applying for it, and pay 3/6 for its injection. Both serum and sterilised syringes are kept at the Town Hall and at the Fire Station. The Council supply swab outfits and the M.O.H. carries out the necessary examinations in the Council's laboratory at the Town Hall. Special arrangements are made in order that swabs arriving at the Town Hall on Saturday afternoon or on Sunday are attended to. The mother and all child contacts in the house infected are swabbed by the M.O.H. at the Town Hall. Adults who are engaged in handling food, etc., and textile materials are also swabbed. 45 The number of swabs examined for diphtheria during the year was 1,229, whilst the findings were as follows: — Positive. Negative. Suspects 74 473 Contacts 34 584 Old cases and carriers 15 49 123 1106 Other bacteriological examinations carried out were 47 for the tubercle bacillus in sputa, of which 12 shewed its presence; 2 examinations of hairs for ringworm, the organism being present in both; and 6 examinations of pus from the eyes of the new-born for the prescence of gonococci. "Carriers" of diphtheria germs were usually sent to the Isolation Hospital; this was necessary in all cases sent, on account of the presence of numerous other children in the house. For instance, in one street where eight cases of diphtheria had occurred, I found that the average population of the infected houses was 13. In the same street the average population of 100 houses where the sanitary inspector had recently been, was 9. In only a few cases was it possible to keep carriers at home. In two cases where the nose was affected and where adenoids were present, the surgeon in charge of the Throat Department at the Prince of Wales' Hospital kindly made the necessary arrangements for their removal. Return cases of diphtheria have given no trouble during the year; as far as I know, there has only been one such case. There is, however, one difficulty in regard to nasal cases, and that is, that whilst in Hospital local treatment apparently gives negative results when swabs are taken, but that, on being home for a week or so, the organisms get the upper hand and the child is easily recognised as a nasal carrier. The Schick test has not been used for any cases, but the question of artificial immunisation against diphtheria is worthy of consideration. In my report to the Public Health Committee in December, 1925, with reference to the appointment of a Deputy Medical Officer of Health, there is this passage: "The treatment of diphtheria is altering considerably by the method of active immunisation ; this is bound to come sooner or later, and it is probable that scarlet fever may rapidly follow." 46 The idea when writing that was to offer to immunise all children as soon as they reached the age of 18 months, and not to bother about the Schick test. Considering, however, the response made at the present day towards vaccination against small-pox, which is a more loathsome disease, I am afraid that few parents would take advantage of the offer; the result would be added danger from a greater number of immune carriers. In 1859 the Medical Department of the Privy Council undertook a lengthy enquiry as regards the incidence of diphtheria, as the result of which it appeared that the disease prevailed for the most part, although not entirely, in damp and marshy situations and on cold, wet clay soils, and it seems to me that, in this respect, that part of Edmonton situated between the main road and the river Lea agrees. A boring made some years ago in this part went first through 7ft. of made ground, then 12 ft. of ballast, into 23 ft. of blue clay; various layers of sand came next and the boring reached chalk at 122 ft. The ground rises on the other side of the main road and the London clay is covered by a loam soil and a subsoil of brick-earth and gravel. Though only 45% of the houses are on the east side of the main road, about two-thirds of the cases of diphtheria occur in these houses; other factors, however, contribute, namely: more overcrowding and a greater proportion of careless and negligent tenants. Scarlet fever has been with us all the year. I think the disease is becoming more difficult to diagnose on account of the incidence of mild cases. A rash not well marked, slight faucial symptoms, a tongue and general symptoms not characteristic—these add difficulties in the way of diagnosis. At the beginning of the outbreak of German measles, several cases were notified as scarlet fever and removed into the Isolation Hospital. I therefore made a practice of seeing certain notified cases before removal and prevented several more such cases going into the Hospital. All the cases of German measles seen by me were characterisiic of the complaint. "Return" cases of scarlet fever gave no trouble—there were possibly two such cases during the year. The Dick test for scarlet fever has not been used, neither has active immunisation been adopted. 47 There were received seven notifications of encephalitis lethargica; one referred to a soldier who was suffering from the effects of the complaint which he had at least four years ago. A short summary of the other cases is as follows:— Female, age 22.—Headache for 2 months, " vacant" for one week, delirium, death in 3 months. Male, 9 months.—Sickness, stupor, squint. Male, 15 years.—Influenza, followed by diplopia. Male, 37 years.— „ „ „ Male, 19 years.—Headache, weakness, stupor. Notified 9 months after onset. Female, 26 years.—Head pains, weary and sleepy. Notified 3 months after onset. There is no doubt that the onset, in some cases, is extremely insidious, and the real nature of the disease is not recognised for some time—in one of the above cases it was nine months! At the end of that time he presented the typical Parkinsonian syndrome—-physical weakness, fixed attitude and immobile features. There were no cases of small-pox notified during the year. A few contacts of cases occuring in other districts resided in Edmonton, and these were personally kept under observation until the incubation period had elapsed. No vaccinations were performed by the Medical Officer of Health under the Public Health (Small-pox Prevention) Regulations, 1917. 48 NOTIFIABLE DISEASES (excluding Tuberculosis). The following table gives details regarding these diseases Disease. Total No. of Cases. Number Removed. Under 1 year. 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 45—65 65 & over. Small Pox Scarlet Fever— Cases 112 104 1 4 5 8 13 44 18 10 8 1 Deaths .. — — — — — — — — — — — — — — Diphtheria— Cases 208 203 2 8 11 17 23 99 28 11 7 — 2 — Deaths 27 27 — 2 3 1 5 13 2 1 — — — — Enteric Fever— Cases 2 1 — — — — — — — — — — — — Deaths — — — — — — — — — — — — — — Puerperal Fever— Cases 3 3 — — — — — — — 1 2—— — — — Deaths Pneumonia— Casmes 44 — 4 1 4 — 1 4 — 6 4 4 11 1 Deaths 19 8 1 — 1 — — — — 1 2 5 2 7 Erysipelas— Cases 26 3 1 — — — — 1 5 7 3 8 1 Deaths Ophthalmia Neonatorum— Cases 3 — 3 — — — — — — — — — — — Deaths — — — — — — — — — — — — — — Encephalitis Lethargica— Cases 7 1 1 — — — — — — — — 2 — — Deaths 3 3 — — — — — — — — — — — — —Cerebro-Spinal —Meningitis— —Cases— 1 1 1 — — — — — — — — — — — Deaths 1 1 1 — — — — — — — — — — — Malaria— Cases 1 — — — — — — — — — — — — — The non-notifiable acute infectious fevers have been mentioned previously under causes of sickness. These are ascertained in two ways: through the 49 Health Visitors and through the School Reports. Through these two sources it is easy to gauge the amount of sickness in the district. Influenza, as previously mentioned, was rife in the district during February and March; though widespread, affecting young and old, the outbreak was not associated with a severe mortality. Four cases of influenzal pneumonia were notified. There were three deaths from encephalitis lethargica, but only one of these had been notified previously. The one case of malaria had contracted the complaint abroad. Disinfection of premises is carried out by formalin spraying, whilst bedding, etc., are disinfected by steam under pressure. Verminous rooms are disinfected by sulphurous acid—the burning of sulphur in the contaminated room. The cleansing station at the Town Hall yard is used solely by the Education Committee for the treatment of verminous school children and the treatment of scabies. A current steam disinfector is used for the clothing. 50 TUBERCULOSIS. Details as to the form and age of patients affected, etc., are given in the subjoined table. Age Periods. New Cases. Deaths. Pulm. Non-Pulm. Pulm. Non-Pulm. M F M F M F M F Under 1 year — — — — — — — — 1— 5 years — — 1 1 — — — — 5—10 „ 7 2 3 2 — — — 1 10—15 .. 3 3 2 2 — 1 1 1 15—20 „ 7 9 — 1 2 1 1 — 20—25 ,, 13 14 3 — 6 8 — — 25—35 ,, 13 9 3 2 11 4 r — 35—45 ,, 4 4 1 — 7 1 2 — 45—55 ,, 8 4 — — 7 1 — — 55—65 ,, 4 — — — 5 — — — 65 and upwds. — — — — — — — — Totals 59 45 13 8 38 16 5 2 The Public Health (Prevention of Tuberculosis) Regulations, 1925, relate to tuberculous employees in the milk trade. In order to obtain the necessary information, the occupation of all tuberculous persons are carefully enquired into and transmitted to the Medical Officer of Health by the doctor in charge of the local tuberculosis dispensary. There is no onus on the employee himself unless he knows that he is suffering from tubercle, the result will be that such employee will carefully refrain from seeing his own doctor or going to the Dispensary, as it will almost certainly mean his losing his occupation if he is found to be so suffering. Up to the present no such individual has voluntarily given the information, nor has any person concerned in the milk trade been notified as suffering from respiratory tuberculosis. 51 The following deaths from tuberculosis occurred without prior notification. Male. Female. Total. Pulmonary 5 7 12 Non-Pulmonary 3 3 6 Four notified cases, 3 males and 1 female, died from other causes. The non-pulmonary forms of tuberculosis were:— Male. Female. Total Meningeal 1 1 2 Bones and Joints 5 2 7 Glandular 3 2 5 Other forms 4 3 7 The notifications of the pulmonary form were received from the following:— General Practitioners 44 Tuberculosis Medical Officers 32 Various hospitals 15 Asylum Medical Officers 2 Removals into district 3 Sanatoria 6 Military Authorities 2 The number of cases on the register at the end of the year was 980, comprising 510 males and 470 females; the corresponding figures for 1923 were 520 males and 445 females; for 1924, 519 males and 463 females ; totalling respectively 965 and 982. During the year 51 names have been removed from the Register by the Tuberculosis Officer, and 15 cases have left the district. It must be noted that the names of persons dying of tuberculosis outside the district during the last quarter of the year do not reach us till 7 or 8 weeks after the end of that quarter, hence the register at the end of the year is actually in excess by that number of deaths, for the last quarter it was ten. Dr. Tate, the County Medical Officer of Health has kindly furnished me with the following particulars which relate to Edmonton patients. The dispensary is in Silver Street, under the charge of Dr. Evans. 5 2 No. of new cases seen at the Dispensary during 1925 260 No. diagnosed as suffering from tuberculosis 70 Total number of persons suffering from tuberculosi sand treated or supervised at or in connection with the dispensary, during 1925 554 Number of cases sent to Sanitoria 77 „ „ Hospital 19 „ „ Surgical Hospital 8 No. of cases sent to Observation Hospital 24 Number of sputa examined 235 ,, „ found positive 52 The Public Health Act, 1925, Section 62, deals with the compulsory removal to Hospital of persons suffering from pulmonary tuberculosis in an infectious state and who are living under such conditions as to accommodation that proper precautions to prevent the spread of infection cannot be taken, and that serious risk of infection is thereby caused to other persons. No action has been taken under this Section so far, for no such case has been brought to my notice, but it is a useful provision and cases have occurred in the past where similar powers would have been welcomed. The section might have been extended to cover other forms of tuberculosis with a discharging sinus. MATERNITY AND CHILD WELFARE. The work carried out by the Maternity and Child Welfare Committee continues to grow, not only as regards the amount of work done, but as to its importance. The growth during the past five years is shown in the following ways:— (1) Municipal milk supply, initiated in the latter part of 1921. (2) Dental treatment, including the provision of dentures, for nursing mothers and children under five, initiated November, 1924. (3) Passing of an Orthpædic Scheme. (4) The appointment of an additional Health Visitor in April, 1925. (5) Four afternoons a week devoted to Child Welfare, instead of three. 53 (6) The provision of a whole-time clerk instead of half-time. (7) The change to Brookfield House for clinic centres, instead of those previously used at St. Michael's Hall and the Central Hall. The ante-natal clinic is held one morning weekly, and the following gives some idea of the work carried out there during the past five years:— New Cases. Total Attendances. 1921 96 310 1922 111 462 1923 114 570 1924 104 597 1925 104 566 The Welfare Centres, during 1925, were held four afternoons a week and the following figures relate to these:— New Cases. Total Attendances. 1921 417 9,492 1922 586 10,393 1923 641 11,286 1924 562 13,968 1925 637 14,563 In addition, there is a sewing and cutting-out class, held weekly. The number of sessions held was 43, and the total attendances were 642. The Council supply milk to expectant mothers during the last three months of pregnancy, to nursing mothers, to children under the age of three, and exceptionally to children between the ages of 3 and 5. Milk is given free only in those cases where the supply is essential on grounds of health, whilst the proportion paid by the parents and the income scale is as follows:— Number of persons in family. Net income per family after deducting rent. Free Supply. 25% cost. 5°% cost s. d. s. d. s. d. 2 25 0 26 0 27 0 3 30 0 31 6 33 0 4 34 0 36 0 38 0 5 37 6 40 0 42 6 6 42 0 45 0 48 0 7 49 0 52 6 56 0 8 56 0 60 0 64 0 9 63 0 67 6 72 0 10 70 0 75 0 80 0 11 77 0 82 6 88 0 12 84 0 90 0 96 0 54 Details regarding the milk supplied during 1925 are:— Number of applicants 862 „ „ „ granted milk 839 Number of pints granted free 3,108 „ „ „ at ½ cost 32,044 at ½ cost 252 In addition to attendances at the various clinics and centres, the Health Visitors paid the following visits to the homes:— Visits to expectant mothers: (1) First 105 (2) Total 156 Visits to children under 1 year: (1) First 1,408 (2) Total 3,985 Visits to children 1—5 years 3,527 Visits re milk enquiries 31 Other visits 1,059 Grand Total 8,758 Included in the above are eight visits to notified cases of ophthalmia neonatorum and three visits to three cases of puerperal fever. Births notified during the year were:— Live births: by doctors 487 „ by midwives or parents 1,493 Still-births: by midwives 44 „ by doctors 18 Total births notified 2,042 (This total includes births at the North Middlesex Hospital, many of which are of non-Edmonton residents). Still-births as well as live-births are visited by the Health Visitors, and due enquiries are made. During 1925 there were 19 midwives practising in the district. The dental clinic, opened in November, 1924, has found plenty of work in the mothers and children attending the centres. 55 Education regarding the care of the teeth is very badly needed, judging by the cases that apply for treatment. Extensive sepsis in the mother and early caries in the child furnish the majority of these. The clinic is held one session weekly, using the dental clinic in Pymmes Park mansion, fitted up by the Education Committee. The first half of the morning is devoted to conservative work, the latter half to extraction under nitrous oxide gas, the anaesthetic being given by the Medical Officer of Health. The following figures give the number of cases treated, but it must be realised that conservative work may be, and often is, very tedious, and that, on account of the septic gums, it is unwise to extract too many teeth at one sitting. Patients are assisted in the provision of dentures by the Council, according to their income, and the dentures supplied are at contract price. The following is the scale of income, exclusive of rent, adopted by the Committee early in 1925, controlling the proportion of the cost which the mother is asked to pay:— Number in family. Quarter Half Three-quarter cost. cost. cost. s. d. s. d. s. d. 3 30 0 40 0 50 0 4 33 0 43 0 53 0 5 36 0 46 0 56 0 6 39 0 49 0 59 0 7 42 0 52 0 62 0 8 and over 45 0 55 0 65 0 Details of the work carried out are as follows:— Mothers. Children. Total number of cases seen 119 120 Number of cases treated 97 82 Number of attendances 324 172 Number of teeth filled 40 70 scaled 56 1 „ ,, extracted 820 318 (a) Under gas 776 310 (b) Local anaesthetic 44 8 Number of general anaesthetics (nitrous oxide gas) 166 86 56 Thirty mothers were financially assisted in procuring dentures, the total cost to the Committee being £75 3s. 9d. Towards the end of the year, the scheme for Orthopaedic treatment was adopted by the Committee and received the sanction of the Ministry early in 1926. The scheme includes the reservation of one bed at the Stanmore country branch of the Royal National Orthopaedic Hospital, a clinic for massage and re-educational movements at Brookfield House, in conjunction with the Education Committee, and the supply of splints. Maternity Homes. There are a few private maternity homes in the district, whilst provision for poorer mothers is made at the North Middlesex Hospital (details are given in an earlier section of this report). Children are also received in the same Hospital for in-patient treatment. Arrangements have been made by the Council for the reception of young children into the Day Nursery whilst the mother is an in-patient at a Hospital, either for the day or for total residence. The charges are 3s. 6d. and 10s. Od. per week respectively. Five such cases have been sent into residence by the Committee, who were responsible for the whole sum in three cases and for a part in the remaining two; the cost to the Committee was £5. The work at the Child Welfare Centres is facilitated by voluntary workers who assist in various ways, and to them the thanks of the Committee are due. They also form a committee, making suggestions to the Statutory Committee in connection with various matters. Baby week was held in June; the items included a lecture by Dr. Gregorson, of the North Middlesex Hospital, a film and lecture dealing with the subject of teeth, and an exhibition dealing with fruit dishes, garments, cake-making, jams, etc. The social side has not been neglected: there was the usual outing to Southend in the summer, the tea at Christmas, and four dances during the winter 1925-1926, these latter being organised to meet the expenses involved in these social activities. 57 It is difficult to discuss the incidence of puerperal fever, because it is not a defined disease, and hence is notifiable or not, according to the opinion held by the individual doctor. The type of disease that is notified appears usually to be one with very grave septic symptoms. It is probable that milder forms occur and recover before the doctor makes up his mind as to whether he is dealing with a notifiable disease or not. During the year three cases were notified as such, and all were admitted to Hospital. Ophthalmia neonatorum, a purulent inflammation of the lids in new-born children, is usually attributed to infection by the gonococcus—the cause of a venereal infection, but here, again, we are not dealing with a distinct entity. One case notified was found to be due to infection with the diphtheria bacillus, another with the pneumococcus, and of those notified the gonococcus was found in only one. This does not mean that it had not started the trouble—secondary infection takes place readily, and may obscure the microscopical findings. In one case, occurring in a previous year, the pneumococcus was found, and the Health Visitor afterwards reported that the mother had had a "bad attack of asthma, with a high temperature "—evidently an attack of pneumonia. The Health Visitors are asked to take swabs of these cases, at as early a date as possible, for the purpose of microscopical examination. Details regarding these cases are as follows:— Number of cases notified 3 „ „ treated (1) at home 2 „ ,, (2) at Hospital I „ „ vision unimpaired 3 „ „ „ impaired 0 ,, ,, with total blindness 0 „ deaths 0 When cases are treated at home, arrangements are made for the child to have treatment either at the Town Hall or at the Centre; if unable to attend the Health Visitors pay frequent visits to the home for this purpose. Measles occurred in the earlier part of the year, but not to any great extent. The disease is not notifiable in this district, and the Health Visitors do not pay visits to these. 58 It is different with regard to school children who go down with measles. Early information is usually obtained from the school, and the school nurses visit these cases with a definite object—that of giving advice on the various measures necessary. There were no deaths from measles. Though cases of whooping-cough occurred throughout the year, there was no definite outbreak of such and no deaths were recorded from the disease. Epidemic diarrhoea is apparently a disease of the past, for very few cases have come to notice during 1925 or the previous four years. How far education is a factor in its disappearance is difficult to say; personally, I think that education has very little to do with it. Other factors are probably the introduction of dried milks and sterilised milks, both having a very low bacterial count. It is possible that an improved water supply may be a factor that is not recognised. Daily talks are given by the Welfare Superintendent during the course of the afternoon at the Centre, and, during hot weather, the subject of summer diarrhoea is dealt with by her. There were no cases of anterior poliomyelitis notified during the year. FACTORY AND WORKSHOP ACT. The following work has been carried out under the Factory and Workshop Acts:— 1.—Inspection of Factories, Workshops and Workplaces. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 159 2 0 Workshops (including Workshop Laundries) .. 125 1 0 Workplaces (other than Outworkers' Premises) 0 0 0 Total 284 3 0 59 2.—Defects found in the above. Particulars. Number of Defects. No. of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts— — — — — Want of cleanliness 2 2 — — Want of ventilation — — — — Overcrowding — — — — Want of drainage of floors 1 1 — — Other Nuisances 7 6 — — Sanitary Accommodation Insufficient 2 2 — — Unsuitable or defective 6 8 — — Not separate for sexes — — — — Offences under the F. & W. Acts— Illegal occupation of underground bakehouses — — — — Other offences — — — — Total 18 19 — — The details of the nuisances remedied are as follows:— Sanitary accommodation provided 2 Water-closets cleansed or repaired 3 Flushing apparatus repaired 6 Urinals repaired 1 Sink waste pipes fixed 1 Drains cleansed or repaired 1 Workshops lime washed 0 Factories limewashed 0 Floors repaired 1 Roofs repaired 1 Water fittings repaired 1 Other nuisances abated 2 19 Under the Ministry of Health (Factory and Workshops Transfer of powers) Order, 1921, 11 bakehouses were limewashed. 3.—Outwork in Unwholesome Premises, Section 108. Nature of Work. Wearing apparel making, etc. Umbrellas Artificial flowers Brush making Instances. Notices served. Prosecutions. Nil Nil Nil 6o Summary. It is evident that a summary of the changes made during the past five years in the public health services of the area and the resulting measure of progress made in the improvement of public health must necessarily, in the first-named, be of a slight nature, and, in the second-named, be difficult of measurement and, to a large extent, intangible at the present time. We can only record the changes and leave the measurement of progress to the future. In the early days of public health, the environment was regarded as the chief factor, but, in recent years, more attention has been given to the individual, and it is along these lines that most changes have taken place. Taking environment first, one can record some improvement in the atmosphere:—proper premises for a gut-scraper and improvements in a smelting factory have nearly eliminated noxious or offensive gases and vapours from these works. The Metropolitan Water Board are giving careful attention to the provision of a wholesome water. The Council have erected, during this time, 302 houses. A big sewerage scheme has been entered upon for the proper collection and disposal of the sewerage ; though a great and necessary requirement, one does not expect to be able to point definitely to any measure of improvement in the near future. Turning now to the individual, one is able to record more definite changes: The municipal milk scheme came into force at the end of 1921. This enables nursing mothers and young children to obtain milk at reduced prices, provided the income comes within a certain scale. Increased facilities for maternity and child welfare: different and more suitable premises, an additional doctor's session and an additional Health Visitor. Scheme for orthopaedic treatment of children under five years of age. Arrangements with the Day Nursery for the reception of children under five into residence if the mother has to go into Hospital. 61 Arrangements with a local branch of a Nursing Association for a district nurse to visit home patients. On the reverse side one must mention the failure to appoint a woman Sanitary Inspector in the place of one who resigned eighteen months ago. There are over 2,000 women employed in factories, etc., there are women outworkers, and there are also the two public female lavatories requiring supervision. Indirect measures are the development of recreation grounds, tennis courts and bowling greens, the fostering of allotments. The above are the most important changes made during the past five years, but it is difficult to say how far they are associated with any changes in the health of the individual. As regards the future, it may be possible to move on similar lines, and the following are suggestions:— (1) A bi-weekly removal of house refuse. (2) The proper destruction of all house refuse by an incinerator or dust destructor. (3) The tar dressing of all roads. Regarding the individual, it is difficult to say how far a public authority can go without undermining his responsibility. Some of the above benefits enumerated are only available to those whose income is below a certain limit; the benefits of any measures pertaining to "public health" should be free to all. Most of the measures introduced recently is merely a subsidising of the income to benefit the individual, and to introduce such measures under the guise of public health is certainly misleading. The Guardians grant milk and medical treatment, the local authority do the same—one is poor-law relief, the other ostensibly comes under public health measures. The future will see the merging of these two authorities ; in the meantime, the local authority can devote its whole attention to the environment. 62