AC.439 (B) ENF MDDY ENF 17 (Latu Man .B.) URBAN DISTRICT COUNCIL OF ENFIELD. ANNUAL REPORT OF THE Medical Officer of Health and :: School Medical Officer :: (D. H. Geffen, M.D., D.P.H.) FOR 1933 together with the ANNUAL REPORT of the Chief Sanitary Inspector Stanley Woodfield, T.U. Printer, 8, 10, 12, Windmill Hill, Enfield. Middix. PUBLIC OFFICES, ENFIELD. 28th March, 1934. Annual Report of the Medical Officer of Health, 1933. To the Chairman and Members of the Urban District Council of Enfield. Mr. Chairman and Gentlemen, 1 beg to place before you my Annual Report for the year 1933. This is a year during which the work of the Department has grown in accordance with the increasing population and necessities of the District. The year was one relatively free from serious Infectious Disease, but on the other hand an epidemic of Mumps and Whooping Cough which started early in the year still remains unabated. There were 45 cases of Diphtheria during the year which despite the increase in population, is less than we have had since 1924 when there were 15 cases and the population was 62,992. The Department suffered a very grievous loss during the year due to the death of Mr. T. M. Boswell who had worked in the Department for 37 years. During the last 25 years of his life he was Sanitary Inspector to the south-eastern portion of the District, and many of the improvements in this area are due to his careful and painstaking work. Mr. Boswell was a man of outstanding merit and kindliness and he will be much missed both as an Official and colleague. 2 During the year the Staff has been increased by the advent of Miss Simmons who was appointed Junior Clerk in April last for the purpose of carrying out work in connection with the routine inspection of children under 5 years of age. Further reference to this work will be found under the heading of Maternity and Child Welfare. In April last Dr. Dunbar retired from the position of Assistant Medical Officer for Maternity and Child Welfare after working at the Council's Centres since 1916. She had created a feeling of great confidence and friendship between herself and the Mothers and children of the District who will greatly miss her. Her work has been carried out during the year by Doctors McKeown and Dean, who have been appointed Part-time Assistant Medical Officers of Health for Maternity and Child Welfare purposes. At each of the four Maternity and Child Welfare Centres two Clinics are now held weekly for children under 5 years of age, and two clinics each month for Ante-Natal purposes. At all of these clinics one of the Assistant Medical Officers is in attendance, viz., Dr. McKeown—At the Bush Hill Park and Armfiad Road Centres. Dr. Dean—At the Ponders End and Totteridge Road Centres. The Council has adopted as its 5 years programme the demolition of 63 houses. By the time this report is before the Council it is probable that over 45 of these houses will have been already demolished, whilst proceedings have been taken in connection with another 18. I sincerely hope that the programme will have been completed long before the 5 years have passed and that I shall be able to augment the number of houses to be demolished. The growth of the District has made it impossible to carry out as much House-to-House inspection as is necessary and I sincerely trust that the appointment of an extra Sanitary Inspector to which the Council have agreed will make it possible to increase this work during 1934. Houses continue to be erected in Enfield in large numbers. It will be noticed that 1,417 houses have been completed by the 3 Council and private enterprise during the year. This means additional work for my Department and additional plant to deal with the collection and disposal of refuse, and the Council have agreed to the purchase of a new dust vehicle and the replacement of two of an older pattern. The purchase of a Cesspool and Gulley Emptier will be a material improvement of the amenities of the District. I beg to take this opportunity of recording my thanks to the Council for its courtesy, my colleagues for their constant co-operation, and my Staff for its continued loyalty throughout the year. I am, Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health. 4 URBAN DISTRICT COUNCIL OF ENFIELD Chairman of the Council H. H. COLLIER, Esq., J.P. Vice Chairman of the Council A. B. WHARTON, Esq. Members of the Council:— P. DAINES, Esq., E. EDWARDS, Esq., G. M. SPARROW, Esq., G. J. COLLINS, Esq., W. B. ANDERSON, Esq., W. J. CLARKE, Esq., H. A. D. BROWN, Esq., W. H. BISHOP (Jnr.) Esq., A. C. FINCKEN, Esq., A. E. KINGWELL, Esq., F.R.I.B.A., W. W. CAKEBREAD, Esq., S. G. HILLS, Esq., H. G. SHORT, Esq., W. T. TAYLOR, Esq., T. H. M. CLARKE, Esq., G. E. JONES, Esq., O. M. PROUDLOCK-DUNBAR, Esq., Clerk and Solicitor to the Council KENNETH TANSLEY, Esq. Engineer and Surveyor to the Council H. R. CRABB, Esq., M.Inst.C.E., F.S.I., A.R.I.B.A. Treasurer to the Council W. BENTLEY, Esq., A.S.A.A., A.I.M.T.A. Chief Sanitary Inspector FRED WILSON, Esq., M.R.San.I., M.S.I.A. 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,575 POPULATION. The population as estimated by the Registrar General in the middle of the year was 71,790, and this figure is being used in connection with the vital statistics as set out in this report. The following table shews how the population of the District has increased during the last ten years. Year. Population. 1924 62,992 1925 63,740 1926 63,640 1927 64,160 1928 64,910 1929 65,100 1930 65,504 1931 68,220 1932 69,910 1933 71,790 The number of inhabited houses at the end of 1933, according to the Rate Books, was 16,500. The rateable value of the District is £548,461 The net pruduct (after allowing for cost of collection) of a penny rate is £2,145 6 Although in the last ten years the population has increased by about 10,000 and the number of houses by 4,000, the total increase in the Staff in that period, apart from Maternity and Child Welfare, consists of 1 Sanitary Inspector and 1 Junior Clerk. SOCIAL CONDITIONS. Although Enfield still remains essentially a District both rural and urban in which all types of inhabitants dwell, it is of importance that during the last year 1,417 houses were erected, and nearly all of these were built for occupation by persons of the working classes. From a Public Health point of view this means an increase of the social services which is bound to represent a cost upon the rates. The erection of houses with a rateable value of less than £30 is not a paying proposition from the point of view of the ratepayers. The following table indicates the growth in the number, of inhabited houses, the rateable value and the sum represented by a penny rate during the last ten years. Year No. of inhabited houses. Rateable value. Sum represented by a penny rate. £ £ s. d. 1924 12,418 350,060 1,190 5 0 1925 12,643 353,820 1,229 0 0 1926 12,982 361,565 1,265 12 10 1927 13,469 369,284 1,304 18 3 1928 13,733 377,644 1,335 0 0 1929 14,123 472,199 2,080 0 0 1930 14,707 479,466 1,920 0 0 1931 15,215 491,451 1,991 0 0 1932 15,962 513,225 2,045 0 0 1933 16,500 548,461 2,145 0 0 7 It is possible, however, that the opening of the Tube to Enfield. West and Cockfosters may result in increased building in the Western portion of Enfield of houses of a higher rateable value. EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:— Total. Male. Female. Legitimate 997 505 492 Illegitimate 35 20 15 Birth-rate—13.88 per 1,000 population. Still Births. Total. Male. Female Legitimate 24 11 13 Illegitimate 1 1 — Rate per 1,000 total births—23.74. Total. Male. Female. Deaths 706 353 353 Death Rate—9.83 per 1,000 population. Number of women dying in, or in consequence of, childbirth:— Deaths. Rate per 1,000 Total Births From Puerperal Sepsis 2 1.87 From other Puerperal causes 2 1.87 4 3.78 Two of these four Cases were removed too the Edmonton and Enfield Joint Isolation Hospital, and two to the North Middlesex Hospital, Edmonton, where they died. Death rate of Infants under one year of age:- All infants per 1,000 live births 50.38 Legitimate infants per 1,000 legitimate live births 47.14 Illegitimate infants per 1,000 illegitimate live births 142.85 Deaths from Measles (all ages) Nil Deaths from Whooping Cough(all ages) 4 Deaths from Diarrhoea (under 2 years of age) 6 8 The following table gives the birth-rate, recorded death-rate and infantile death-rate for Enfield as compared with those for England and Wales, London, 118 County Boroughs and great towns (including London) and 132 smaller towns:— Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Births. Still Births. England and Wales 14.4 0.62 12.3 64.00 London 13.2 0.45 12.2 59.00 118 County Boroughs and Great Towns (including London) 14.4 0.67 12.2 67.00 132 Smaller Towns 14.5 0.63 11.0 56.00 ENFIELD 14.99 0.34 9.83 50.38 DEATHS. The deaths registered in the district during the year were 457, of which 210 were males and 247 females, giving a crude deathrate of 6.36. To these must be added 317 deaths of Enfield residents registered outside the District, and from this total must be subtracted 68 deaths of non-residents occurring in the District, which brings the number of deaths to 706 for the year, giving a net death-rate of 9.83 per 1,000 population. The corresponding figures for Enfield for the five previous years are — 1928 1929 1930 1931 1932 Net death-rate 9.92 10.56 9.63 10.40 10.64 Eighty-nine deaths registered in the District were persons over 80 years of age, 29 being males and 60 females, three women dying at the age of 94. The more important causes of deaths registered were Malignant Disease, 85; Bronchitis, 26; Heart Disease, 169; Old Age, 11; Tuberculosis of Respiratory System, 36; Pneumonia, 61; Other Respiratory Diseases, 4; other Circulatory Diseases, 36; Nephritis, 19; Cerebral Haemorrhage, 37; Deaths from Violence (excluding suicides), 28; Influenza, 22; whilst among the children, Premature Births accounted for 12; Inanition and Marasmus, 10; Congenital Malformations, 3; Pneumonia, 10; and Enteritis 6. It is to be noted that of the 706 deaths that occurred during the year, 317 took place outside the District of Enfield; most of 9 these were Enfield residents who died at the North Middlesex County Hospital, Edmonton. The following table shows the causes of death at all ages during the year, and Table II gives an analysis of the causes of death in infants under one year of age. TABLE I. Causes of Death during Year 1933. Causes of Death. Males. Females. Total. All Causes—Certified 353 353 706 Uncertified — — — Typhoid and Para-Typhoid Fevers — — — Measles — - — Scarlet Fever 2 — 2 Whooping Cough 1 3 4 Diphtheria 1 1 2 Influenza 9 13 22 Encephalitis Lethargica — — — Cerebro-Spinal Fever - — — Tuberculosis of Respiratory System 19 17 36 Other Tuberculous Diseases 6 7 13 Syphilis — — — General Paralysis of Insane Tabes Dorsalis 1 — 1 Cancer, Malignant Disease 33 52 85 Diabetes 2 6 8 Cerebral Haemorrhage, etc. 10 27 37 Heart Disease 95 74 169 Aneurysm 3 1 4 Other Circulatory Diseases 12 24 36 Bronchitis 15 11 26 Pneumonia (all forms) 26 35 61 Other Respiratory Diseases 3 1 4 Peptic Ulcer 4 2 6 Diarrhoea etc. (under 2 years) 6 — 6 Appendicitis 3 — 3 Cirrhosis of Liver — — — Other Diseases of Liver, etc. 1 1 2 Other Digestive Diseases 4 9 13 Acute and Chronic Nephritis 8 11 19 Puerperal Sepsis — 2 2 Other Puerperal Causes — 2 2 Congenital Debility, Premature Birth, Malformations, etc. 16 13 29 Senility 7 4 11 Suicide 6 1 7 Other Violence 22 6 28 Other Defined Diseases 38 30 68 Causes ill-defined or unknown — — — Total 353 353 706 10 TABLE II. Infant Mortality Net Deaths from stated causes at various Ages under One Year of Age. Causes of Death Under 1 week. 1 to 2 weeks. 2 to 3 weeks. 3 to 4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under One Year. All Causes—Certified 17 5 7 4 33 5 8 4 2 52 Uncertified - — — — — — — - - - Smallpox - - - - - - - - - - Chickenpox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping Cough — — — 1 1 — — 1 - 2 Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - 1 1 Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - - - - Convulsions — — . — — — — - 1 - 1 Laryngitis - - - - - - - - - - Bronchitis - - - - - - - - - - Pneumonia (all forms) — 1 — — 1 9 5 1 1 10 Diarrhoea - - - - - - - - - - Enteritis 2 - 1 1 4 1 1 - - 6 Epidemic Diarrhoea - - - - - - - - - - Gastritis - - - - - - - - - - Syplilis - - - - - - - - - - Rickets — — — — — - - - - - Suffocation, overlying - - - - - - - - - - Injury at Birth 1 — 1 — 2 - — — — 2 Atelectasis 2 — — — 2 - — — — 2 Congenital Malformation 2 - - - 2 - 1 - - 3 Premature Birth 10 1 - 1 12 - - - - 12 Atrophy, Debility and Marasmus - 3 4 1 8 1 - 1 - 10 Other Causes — - 1 - 1 1 1 - - 3 Totals 17 5 7 4 33 5 8 4 2 52 Net Births in the year Legitimate: Live births, 997; Stillbirths, 24. Illegitimate: Live births, 35; Still-births, 1. Net Deaths in the year Legitimate Infants, 47; Illegitimate,5.. 02++ 11 Cancer carried off 85 individuals, and Tuberculosis of the Respiratory System 36, a combined number of 121. This compares with a total of 130 for last year, and the percentage of deaths from these two causes is 17.1 as against 18.5 for 1932. INQUESTS. Twenty-two inquests and twenty-four P.M.s without inquests were held in Enfield during the year, and the verdicts were as follows:— Natural Causes 26 Accidental Causes 9 Suicides 8 Open Verdict 2 Murder 1 The above table shows that 8 persons committed suicide during the year under review. In 1932 there were 8, and in 1931, 8. The ages and sexes of the 8 people who committed suicide during the year were as follows:— Males, 18, 28, 32, 40, 41 and 58 years. Females, 27 and 48 years. SUICIDES. 1 would draw attention to the younger age at which suicides are taking place. Most cases of suicide have tended, in the past, to occur during the latter years of life. The causes of death were as follows 2 to Multiple injuries due to being run over by a Railway train. 3 to Coal gas poisoning. 1 to Cut throat. 1 to shock due to sudden immersion in a river. 1 to Acute oxalic acid poisoning. In 1932 of 12 suicides either in the District or of Enfield residents outside, 10 were older than 45 years. 12 In 1931 of 8 suicides of Enfield residents, 3 were over 35 and 4 over 45 years. In 1930 of 6 suicides either in the District or of Enfield residents outside, 3 were over 20, 1 over 35 and 2 over 45 years. In 1929 of 5 suicides of Enfield residents, 1 was over 15, 1 over 20, 1 over 35, 1 over 45 and 1 over 65 years. BIRTHS. The actual number of births registered in the District was as follows:— Boys Girls Total. 401 383 784 including 18 illegitimate births, i.e., 2.29 per cent. of the total. In addition 6 male and 11 female still-births were registered. The corrected birth-rates for both sexes, live and still-births, which takes into consideration those born outside the District and those in the District not rightly recorded to the District, and also the corrected birth-rates for the last 5 years, are:- Year. Boys. Girls. Total. Birth-rate per 1,000 Population. Illegitimate Birth-rate per 1,000 Population. 1929 561 512 1,073 16.48 .58 1930 537 541 1,078 16.45 .53 1931 550 483 1,033 15.12 .64 1932 571 527 1,098 15.69 .62 1933 537 520 1,057 14.72 .50 INFANTILE DEATHS. The total number of deaths which occurred amongst infants under one year, including 32 registered outside the District, and deducting 3 of non-residents occurring in the District, was 52, giving a death-rate of 50.38 per 1,000 births, as compared with a 13 death-rate of 64.00 for England and Wales, and 67.00 for the 118 County Boroughs and Great Towns (including London). The corresponding figures for Enfield for the last four years were: 1929, 59.21; 1930, 51.21; 1931, 53.50; and 1932, 60.11. The causes of death remain much the same as last year, Pneumonia accounting for 10 deaths, Enteritis for 6, Congenital Malformations, Premature Birth, Atrophy, Debility and Marasmus, etc., accounting for 29. The number of deaths of illegitimate children was 5, which gives a death-rate of 142.85 per 1,000 illegitimate infants. 14 PUBLIC HEALTH STAFF. Medical Officer of Health. *D. H. GEFFEN, M.D., D.P.H. Chief Sanitary Inspector. "FRED WILSON, M.R.San.I., M.S.I,A., Cert. Sanitary inspector's Examination Board (London), Faudell-Phillips Medalist, King's College, London University, Silver and Bronze Medallist, Carpenters' Company, Diploma of R. San. Inst. for Inspection of Meat and other Foods. Cert. Practical Sanitary Science. Sanitary Inspectors: *T. M. BOSWELL, A.R.San.I., M.S.I.A., Diploma of R. San. Inst., for Inspection of Meat and other Foods. (Died on 27th August, 1933). *NOEL SMITH, A.R.San.I. *HARRY WIGGETT, Cert.R.San.I., Diploma of R. San Inst., for Inspection of Meat and other Foods. *A. J. WILLIAMS, Cert. R. San. I., M.S.I.A., Diploma of R San. Inst., for Inspection of Meat and other Foods. Certificate of R. San. Inst., for Smoke Inspectors. Health Visitors : Miss M. E. NEWBEGIN, General Trained Nurses Certificate, C.M.B., Member of the Royal College of Nursing, State Registered Nurse, Certificate of Queen's Nurses. Miss M. GARLICK, C.M.B., Medical and Surgical Nursing, Invalid Cookery. State Registered Nurse. Member Royal College of Nursing. Mrs. C. D. HERBERT, C.M.B., State and General Trained Nurse. Certificate of R. San. Inst., for Health Visitors. Invalid Cookery. Ranyard District Nursing. Miss C. WILKINSON, C.M.B., New Health Visitor's Certificate of R. San. Inst. State Registered Nurse. Invalid Cookery. Chief Clerk—SYDNEY COULTER, Cert. R San, 1 2nd Clerk—Miss E. W. BOWYER. 3rd Clerk—Miss L. GOSFORD 4th Clerk—S. H BEYER. 5th Clerk—L. R. GODFREY 6th Clerk—R. JOHNSON. 7th Clerk—Miss V. M. SIMMONS. Maternity and Child. Welfare. Dr. MARGARET PROUDLOCK DUNBAR, M.D., B.S. (Part-time Medical Officer). (Retired March 31st. 1933). Dr H. DEAN, M.R.C.S., L.R.C.P., D.P.H,, (Part-time Assistant Medical Officer of Health). Dr. K. McKEOWN, M.D , D.P.H., (Part-time Assistant Medical Officer of Health). Mr, C. E, JAMES, L.D.S., Eng. (Part-time Dental Surgeon). Mr. W. McWALTER, L.D.S., Eng., (Part-time Dental Surgeon). *Contribution received from the County Council. 15 NURSING IN THE HOME. The Ponders End and District Nursing Society provides two Nurses for the assistance of the sick poor. No financial contribution is paid to the Society by the Local Authority, there being no co-ordination between the Society and the Sanitary Authority. No arrangements are in force in the District for nursing cases of Infectious Disease in the home. MIDWIVES. The Middlesex County Council is the supervising authority under the Midwives' Act. There are 11 Midwives practising in the District. NATIONAL HEALTH INSURANCE. None of the work of the Authority is related to or administered by this service. LABORATORY FACILITIES. The following work was carried out in the Council's laboratory during the year. Specimen. No. Positive. Negative. Percentage of Positives. Swabs 1,340 77 1,263 5.74 Sputum 196 24 172 12.24 Totals 1,536 101 1,435 6.57 Reference to the laboratory report shows that 1,340 swabs were examined during the year. This number is 326 less than that for 1932. 16 Two children died from Diphtheria, giving a mortality rate of 0.02 per 1,000 population; this compares with that of 0.06 for the country. In my Report for the year 1932 I called attention to the fact that it was possible by means of Schick testing and inoculation to determine what children were liable to catch Diphtheria if exposed to infection, and that by means of inoculation such persons could be rendered immune from Diphtheria. So far no steps have been taken in the District to make facilities available for the inhabitants to obtain this testing and immunisation. The latter consists of a course of injections and I hope during 1934 to submit a scheme to the Council whereby such service might be made available for the District through the General Practitioners of the area. LEGISLATION IN FORCE IN THE DISTRICT. Sanitary Administration. Adoptive Acts. The position has not been altered since my Annual Report for 1932, and for information in this respect reference thereto is advised. BYE-LAWS AND REGULATIONS. The position with regard to these has not altered since my Annual Report for 1932, and for information in this respect reference thereto is advised. HOSPITALS. The position with regard to Hospitals has not altered since my Report for last year, and for information in respect to these reference thereto is advised. 17 TUBERCULOSIS (COUNTY OF MIDDLESEX SCHEM). The following statement shows the total number of beds belonging to, or reserved for the sole use of, the County Council during 1933. Institution. Accommodation. Type of case. Adults. Children. M. F. County Sanatorium, Harefield 129 129 56 Pulmonary—Sanatorium. 4 8 Pulmonary—Observation. County Sanatorium, Clare Hall, South Mimms 120 66 — Pulmonary—late sanatorium and Hospital. Heatherwood Hospital Ascot — — 25 N on-pulmonary. Victoria Home, Margate - - 6 Non-pulmonary. Other Institutions at which Patients have been maintained by the County Council during 1933 are:— Sanatoria.—Brompton Hospital Sanatorium, Frimley; Daneswood; Eversfield, Sussex; Fairlight, Hastings; Grosvenor, Ashford, Kent; Holy Cross, Haslemere; King Edward VII Midhurst; King George's, Bramshot; National Sanatorium, Benenden; Royal National, Bournemouth; Royal National, Ventnor; Mount, Bishopstoke; Hawley, Devon; Cotswold, Gloucester; Ipswich Borough; St. Michael's, Axbridge. Hospitals.—City of London, Victoria Park; St. Mary's; University College, London; St. Anthony's, Cheam; St. Barnabas', Torquay; Colindale, Hendon; Brompton; Seamen's Hospital, London. Colonies.—British Legion Village, Preston Hall, Kent; Papworth Village Settlement, Papworth Hall, Cambridge: Burrow Hill, Frimley. Homes for very advanced cases.—St. Joseph's Hospice, Hackney; St. Peter's, Kilburn. All the above are for pulmonary cases of various types. The following hospitals are for Non-pulmonary adult cases:— Hendon Cottage; Prince of Wales's, Tottenham; Roysl 18 Sea-bathing, Margate; St. Anthony's, Cheam; All Saints, Royal National Orthopaedic, St. Mary's, St. Thomas's, and University College, London; All Saints, Eastbourne; Atkinson Morley, Wimbledon; Holy Cross, Broadstairs; St. Vincent's Orthopaedic, Pinner; Shropshire Orthopaedic, Oswestry; Wingfield Orthopaedic, Oxford. The following hospitals are for Non-pulmonary child cases:— Alexandra Hospital for Hip Disease, Swanley, Kent; Hendon Cottage; Lord Mayor Treloar Cripples, Alton; Royal National Orthopaedic, Country Branch, Stanmore; Royal Sea-bathing, Margate; St. Nicholas' and St. Martin's Orthopaedic Hospital, Pyrford; St. Vincent's, Pinner; Wingfield Orthopaedic, Oxford; Cheyne Hospital, Chelsea; Holy Cross, Broadstairs; Holy Cross, Ramsgate; Prince of Wales's, Tottenham; St. Michael'sOrthopaedic.Clacton; University College Hospital, London. Tuberculosis Dispensary (Middlesex County Council):— 279, Fore Street, Edmonton, N. Maternity (Maternity Hospital, North Middlesex County Hospital, Edmonton). Children. Fever. Small Pox. Unmarried Mothers. Illegitimate Infants and Homeless Children. The position with regard to these has not altered since my Report for 1932, and for information in respect to these reference thereto is advised. The following cases of notifiable and other infectious disease were taken to the Edmonton and Enfield Joint Isolation Ho pital from the Enfield District during the year:— Scarlet Fever 202 Diphtheria 40 Diphtheria Carriers 9 Erysipelas 10 Measles and German Measles 1 Puerperal Pyrexia 3 Puerperal Fever 3 Cerebro-Spinal Fever 1 Whooping Cough 4 Pneumonia 1 Other 13 19 MATERNAL MORTALITY. During the year 3 cases of Puerperal Fever and 5 cases of Puerperal Pyrexia have been notified. In each case the Doctor in charge of the case reported that full facilities for the nursing and treatment of the case in question were available. There were, however, 4 maternal deaths during the year, and the causes of death were as follows:— 1. Puerperal Septicaemia In Edmonton and Enfield Joint (Streptococcal). Isolation Hospital. 2. Streptococcal Septicaemia Do. (Puerperal). 3. Mitral Stenosis, Chorea, In North Middlesex Hospital, Pregnancy 6 months Edmonton. 4. Post Partum Haemor- Do. hage. Adherent Placenta. Confinement. The average age of these four women was 28. AMBULANCE FACILITIES. For Infectious Cases.—Two Motor Ambulances are stationed at the Isolation Hospital for the removal of cases from the Enfield and Edmonton Districts ; 287 patients were removed from Enfield during the year. For Non-Infectious cases the Urban District Council of Enfield has a Motor Ambulance at each of the Fire Stations, viz., Enfield Town and Ponders End. Number of patients removed 2,149 St. John's Ambulance Brigade also deals with some cases. No charge is made for the use of the Council's Accident Ambulances. 20 CLINICS AND TREATMENT CENTRES UNDER THE CONTROL OF THE LOCAL AUTHORITY. MATERNITY AND CHILD WELFARE. District. Situation of Centre. Day and times open. Infant Welfare Centres:— Ponders End Southbury Road Council Schools Tuesday and Thursday afternoons, 2 to 5 p.m. Bush Hill Park St. Mark's Institute, St. Mark's Road. Tuesday and Thursday afternoons, 2 to 5 p.m. Town and Chase Armfield Road Institute, Armfield Road Monday and Wednesday afternoons, 2 to 5 p.m. Ordnance Totteridge Road Baptist Sunday School Monday and Wednesday afternoons, 2 to 5 p.m. Ante-Natal Clinics:— Ponders End Southbury Road Council Schools 1st and 3rd Thursdays in each month. 9.30 to 11.30 a.m. Bush Hill Park St. Mark's Institute, St. Mark's Road 1st and 3rd Wednesdays in each month 9.30 a.m. to 12 noon. Town and Chase. Armfield Road Institute, Armfield Road 2nd & 4th Tuesday in each month. 9.30 to 11.30 a.m. Ordnance Totteridge Road Baptist Sunday School 2nd and 4th Thursdays in each month. 9.30 to 11.30 a.m. Dental Clinic:— Whole District Southbury Road Council Schools Saturday mornings, 9.30 to 11.30 a.m. Wednesday afternoons, 2 to 4 p.m Each of the above Centres is provided and maintained by the Council. 21 MATERNITY AND CHILD WELFARE WORK. The following tables show the attendances at the Infant Welfare and Ante-Natal Clinics during the year. INFANT WELFARE CENTRES. Centre. Total Attendances. Individual Attendances. New Attendances. No. seen by Dr. Average Attendance per Meeting. Town and Chase 8,680 3,398 239 1,781 88.5 Bush Hill Park 8,361 3,584 247 1,770 82.7 Ordnance 10,517 4,009 284 1,310 107.3 Ponders End 6,764 2,930 269 1,328 66.9 Totals 34,322 13,921 1,039 6,189 86.2 ANTE-NATAL CLINICS. Centre. New Attendances. ReAttend ances. Total Attendances Average Attendance per Meeting. Southbury Rd. Council School 154 274 428 17.8 St. Mark's Institute 88 235 323 13.4 Armfield Road Institute 96 177 273 11.8 Totteridge Road Baptist Sunday School 116 264 380 15.8 Totals 454 950 1,404 14.7 22 The following table gives particulars of the work done by the Health Visitors during the year. Visits. Town, Chase and Hadley. Bush Hill Park. Ordnance. Ponders End. Totals. Birth Notification Visits 242 189 256 256 943 Ditto lie-visits 333 501 468 728 2,030 Children, 1-5 years. Visits 1,018 1,075 1,289 1,441 4,823 Visits re Insanitary Conditions 52 2 1 2 57 General Visits 313 63 70 65 511 Ante-Natal Visits 210 94 113 122 539 Post-Natal Visits — 94 50 37 181 Blank Visits 284 141 88 224 737 Infectious Disease Visits 101 100 154 77 432 Ophthalmia Neonatorum Visits 1 - 3 - 4 Puerperal Fever Visits 1 1 1 — 3 Puerperal Pyrexia Visits 1 2 1 1 5 Visits re Foster Children 25 15 14 29 83 Totals 2,581 2,277 2,508 2,982 10,348 Feeding, etc. Feeding. Town, Chase and Hadley % Bush Hill Park % Ordnance % Ponders End % Totals % Natural 208 85 176 93 238 92 217 84 839 89 Artificial 34 14 13 6 16 6 39 15 102 10 Mixed — — — 2 1 — — 2 2 Separate Cot 222 91 167 88 197 76 224 87 810 85 Number of Births notified 1,034, which includes 247 born outside the district, 91.1 per cent of which were visited. 23 The quantity of Fresh and Dried Milk supplied to necessitous cases under the assisted Milk Supply Scheme during the year was as follows:— Fresh Milk 19,860⅝ Galls, costing £1,825 11s. 2½d. Dried Milk 3,683 lbs. costing £273 19s. 0⅜d. During the course of the year the Council determined to consider the erection of three Maternity and Child Welfare Clinics where Maternity and Child Welfare work could be carried out instead of at the present premises. Whilst the premises which we have occupied in the past have been satisfactory to a point, they have lacked many of those advantages which can only be expected from premises built specially for the purpose. In no case are the present premises built for semi-medical work ; they can only be occupied at special times and on special days, and there is no hot and cold water laid on in the rooms. The rooms, moreover, are not as free from dust as such Clinics should be. An examination of the figures shewed that it would be possible to build and maintain three new Clinics at an annual cost of little more than is being paid at the present moment for the hire of the premises that we now occupy. The Council therefore determined to erect three new Centres on the following sites:— On a piece of ground at the junction of Baker Street and Rosemary Avenue. On a piece of ground adjoining the Bush Hill Park Council Schools. On a piece of ground situate in St. Stephen's Road, Enfield Wash. Plans have been drawn out and approved by the Council and sanction has been obtained from the Minister of Health to the scheme generally. It is to be hoped that these Clinics will be completed during the course of 1934. Early in the year with the consent of the Education Committee it was determined to hold the Clinics previously conducted at the Hut, Alma Road Council Schools, in the new School Clinic in Glyn Road. 24 The transfer was accordingly made on the 20th March, 1933, and these premises have been used for Maternity and Child Welfare purposes as well as for School Medical work since then. The transfer has proved a very great advantage both to the Department and the Mothers and children of the Ponders End area. As from April, 1933, a scheme for the routine examination of children under 5 years of age was put into practice. A register was made shewing the date of birth of every child in the District under 5 years of age. Those children who need the help of the Council's Maternity and Child Welfare Service have been sent for periodically for routine examination. Each child under the age of 5 years now receives an invitation on its birthday and six months later to attend at one of the Clinics for a routine examination, and the following are the types of cards that are sent URBAN DISTRICT COUNCIL OF ENFIELD. To Miss/Master The Maternity and Child Welfare Committee wishes you many happy returns of the Day and invites you to come to Centre on at p.m. for the purpose of being examined by the Doctor to see that you are keeping well. D H. CEFFEN, Medical Officer of Health. URBAN DISTRICT COUNCIL OF ENFIELD. Maternity and Child Welfare Committee. To Miss/Master You are invited to come to Centre on at p.m. for the purpose of being examined by the Doctor to see that you are keeping well. D. H. GEFFEN, Medical Officer of Health. 25 At each session twenty children are invited to attend for this special examination, but as not all of these attend it has been possible to arrange for the Medical Officer present to see special cases referred to her by one of the Nurses. The following table shews the result of this work:— Total number of appointments made 4,102 Total number kept 1,769 Total number of additional examinations 562 Number of Children sent for and Appointments kept at various Birthdays. Appointments. 1st. Birthday. 2nd Birthday. 3rd. Birthday. 4 th. Birthday. Total. No. sent for 295 299 210 161 965 No. kept 134 121 96 82 433 Total number of appointments made, not including birthdays, 3,137. Total number kept, 1,336. It will be seen that 43.1 per cent, of the appointments made were kept, but this figure should really read as higher for although some appointments were not kept on the specified date they were kept a week or two later and are recorded as appointments kept. This percentage is very satisfactory for the first year of the scheme. The scheme has resulted in bringing to the Clinics for routine examination a large number of children who would not otherwise have attended. It must be remembered that routine examination is the basis of the prevention of disease. By this means a large number of ailments, some serious and some of a minor character, have been referred for treatment to their own Doctor or to a Hospital. Many children have thus been cured of serious diseases, whilst others have received treatment for an ailment that would have become .serious had it not been dealt with in its early stages. 26 The scheme represents a great improvement upon the previous methods whereby children were examined by the Medical Officer only when they were suffering from an ailment of which the parent or the Nurse had become aware. It has, moreover, another very great advantage. In the past our Clinics have tended to cater for children under 2 years of age, whilst children between the ages of 2 and 5 years have only attended in small numbers. The present scheme assures that each child in the District should have an opportunity of being examined twice during the year if it be under 5 years of age. I trust that as this scheme continues the parents of the District will realise its importance, and that the response that will be obtained will be much greater than it has been in the year of its inception. Another scheme to which I would draw attention was that provided by the Council and Education Committee during the year 1932. Under this scheme arrangements were made for the examination and treatment of children under 5 years of age attending the Council's Maternity and Child Welfare Clinics who were found to be suffering from disease of the ear. By this arrangement such children are referred to the School Medical Clinic where they can receive the expert advice of the School Aural Specialist and daily treatment by one of the School Nurses. Twenty-four cases were referred to the School Ear, Nose and Throat Clinic during the year, and of these twenty-one attended and were treated and cured. Of the three who failed to attend one case was admitted to Hospital for operation for middle ear disease. It is the daily treatment of Aural trouble that is the essential part of its cure, and it is very difficult for the poorer inhabitants of the District to obtain this treatment except through the School Clinic. The scheme has probably resulted in the prevention of chronic discharge from the ear, and possibly deafness. 27 BIRTH CONTROL. Memorandum 153/M.C.W. and Circular 1208, dated 14th July, 1931, of the Ministry of Health, gave permission to Maternity authorities to teach Birth Control to married women attending Maternity and Child Welfare Centres who are either pregnant or nursing mothers, and to whom further pregnancy would be detrimental to health. No advice was given during the year. During the course of the year a request was made at a Meeting of Fathers that I should lecture in the District on Birth Control and Vaccination. This request was conveyed to the Council, and the Council determined that two such Lectures should be given, one in the Eastern portion of the District and one in the Western. Arrangements for these two Lectures are now being made. It is my considered opinion that no method of birth control suitable for the use of women of the working class has yet been discovered, and by suitable I mean easy in application, certain in effect and harmless. The advice should be given to husbands, who are the right persons to be taught birth control where such teaching is wise and necessary. CHILDREN ACT, 1908-1932. During the year 12 notifications of intention to accept foster children were received, and in no case was the home found unsuitable. 83 visits were paid by the Infant Life Protection Visitors during the year in connection with their duties under this Act. ADMINISTRATION OF PART I OF THE ACT DURING THE YEAR, 1933. (a) Number of persons receiving children for reward on the Register at the end of the year 41 28 (b) Number of children on the Register:— (i) at the end of the year 46 (ii) who died during the year Nil (iii) on whom inquests were held during the year Nil (c) Number of Infant Protection Visitors holding appointment under Section 2 (2) at the end of the year who were:— (i) Health Visitors 4 (ii) Female, other than Health Visitors Nil (iii) Male Nil (d) Number of persons (in addition to or in lieu of Visitors under (c) above) or societies authorised to visit under the proviso to Section 2 (2) Nil (e) Proceeding taken during the year:— No : of cases. Section of Act under which taken. Nil. (f) Number of cases in which the local authority has given sanction during the year:— (i) Under (a) of Section 3 of the Act of 1908 Nil (ii) Under (b) do. do. Nil (iii) Under (c) do. do. Nil (g) Number of Orders obtained during the year under Section 67 of the Act of 1932:— (i) From a Court of Summary Jurisdiction Nil. (ii) From a single Justice Nil DENTAL TREATMENT. 29 The following particulars show the work which has been carried out during the year, also the totals for the four previous years. Mothers. Children Totals. 1933 1932. 1931. 1930. 1929 Attendances 931 326 1,257 1,111 592 468 545 Treated 190 150 340 340 172 132 145 Administrations : Local Anaesthetics 44 71 115 100 85 98 111 Extractions with Local Anaesthetics 91 120 211 181 160 127 257 Administrations : N20 196 56 252 308 155 132 150 Extractions under N20 918 153 1,071 1,501 600 456 528 Total Extractions 1,080 230 1,310 1,682 760 583 785 N20 Sessions 36 — 36 40 26 19 20 Ordinary Sessions 44 — 44 41 27 22 22 Total Sessions 80 — 80 81 53 41 42 Dentures fitted 131 - 131 120 54 50 61 Patients receiving Dentures 78 - 78 63 29 28 35 Number of Patients having repairs 20 - 20 3 - - - Number of repairs fitted 20 - 20 3 - - - Number of fillings 68 150 218 217 41 40 — Other Operations 664 139 803 593 250 253 261 Number of patients having extractions under N20 76 51 127 159 68 63 73 Do. do. under Local Anaesthetics 54 80 134 81 53 54 68 The growth of this work shews steady increase since its beginning in 1928. It will be noted that the numbers of dentures fitted and being fitted have substantially increased over the figures shewn for last year. At the same time I can only repeat that I still feel that there is far too little dental work being carried out for children under 5 years of age ; only 326 attendances were made. I consider that a satisfactory figure would be somewhere in the neighbourhood of 1,000 to 1,500. Unless children receive dental treatment before they enter school one cannot expect much improvement in the dental condition of school entrants, and this condition is, at present, very unsatisfactory. 30 BABY WEEK. This was celebrated on June 12th, 13th, 14th, and 15th. Garden parties and meetings were held at the Red Triangle Club and St. George's Hall. The weather on all occasions was satisfactory. The total attendance of mothers and children at the four meetings was 1,548. The numbers were higher than on any previous occasion, and the parties much appreciated by those who attended. Many members of the Maternity and Child Welfare Committee were present, and the distribution of spoons to those who had made a 50 or 75 per cent, attendance during the previous year, was made by Miss D. E. Collier, Mrs. Desborough-Brown, Dr. G. M. ProudlockDunbar and Miss R. Nickolds. Two lectures were given for fathers only. The first was held on Monday, the 12th June, at St. George's Hall, Freezywater, and the speakers were Dr. E. H. T. Nash, Medical Officer of Health for the Borough of Heston and Isleworth, and the Medical Officer of Health. The second Lecture was given on Thursday, the 15th June, at the Red Triangle Club, Church Street, the speakers on this occasion being Dr. H. C. Macaulay, Deputy County Medical Officer for Middlesex, and the Medical Officer of Health. The total number of fathers present at these two Lectures was 320, an increase of 120 on last year's attendances. These Lectures were very successful, and the audience highly appreciative. CO-OPERATION WITH THE EDUCATION COMMITTEE. The Co-operation with the Head Teachers has been continued as in previous years, and the Health Visitors have attended at Senior Girls' Departments in order to demonstrate to the older girls the bathing of a baby. The following work was carried out:— 31 Miss Newbegin 3 demonstrations at Bush Hill Park Schools. Miss Garlick 4 demonstrations at Chesterfield Road and Eastfield Road Schools. Mrs Herbert 2 demonstrations at Lavender Road, and 2 at Chase Side Schools. Miss Wilkinson 1 demonstration at Alma Road Schools. SANITARY CIRCUMSTANCES OF THE AREA. Water Supply. With the exception of Hadley Wood and Cockfosters Ward which derive their water from the mains of the Barnet Gas and Water Company, the District is almost entirely supplied by the Metropolitan Water Board. The supply of water, with the possible exception of some few private wells in the rural portions of the District, is ample, the quality good, and the supply practically constant. Streams and Water-Courses. Turkey Street Brook and other streams in the District are under the control of the Middlesex County Council, and observation is also kept on them by your Sanitary Staff, but no sources of contamination were detected. Drainage and Sewerage. The populous parts of the District are all provided with sewers, with outfall to Cuckoo Hall Farm, where sewage is dealt with by septic tanks, filters, and partly by irrigation. Two men are employed daily, who devote their whole time to the work of examining and flushing the sewers, and any defect or obstruction found is immediately dealt with. Cesspools. The cesspools of the District are emptied on the application of householders by means of horse-drawn vans and handmanipulated pumps, and a small charge is made by the Council for this service. This method is far from satisfactory and arrangements are being made for the purchase of an up-to-date mechanical cesspool emptier during 1934. 32 Closet Accommodation. All the houses in the Urban portion of the District are supplied with W.C.'s of various types, the majority being those of " washdown " pattern. In the Rural parts of the District the accommodation consists of water-closets connected with cesspools, or earthclosets or privies with movable receptables. I am not aware of any middens in the District. Every week one man in the employ of the Council att nds some few earth-closets in a rural part of he District. REMOVAL AND DISPOSAL OF HOUSE AND TRADE REFUSE. At the beginning of the year the Council possessed the following vehicles for the collection and disposal of refuse : 3 " S.D." Freighters. 3 Electric Vehicles. 1 Tuke and Bell Barrier Type Petrol Vehicle. The three electric vehicles are not of the " dustless " type. Towards the end of the year one electric vehicle had to be taken out of service as being no longer capable of repair and the Council determined to purchase two " S.D." Dustless Freighters, one to replace the disused electric vehicle, and one as an extra vehicle to cope with the increased work of the District. This means that the Council still possesses two unsatisfactory vehicles. At the time of writing this report one of these is already out of commission, and in the estimates for 1934 is included an item for the purchase of a vehicle for this one. The last remaining electric vehicle will probably have to be taken out of service at the end of 1934, and the Council will be, by then, rid of the old type of refuse collection vehicles, and will possess a complement of vehicles of a satisfactory nature. The whole of the refuse of Enfield was deposited on Brown's brickfields during 1933, and no complaint in connection with the disposal of refuse there was received during the course of the year. Part of Brown's brickfield has now been raised to a satisfactory level, and covered with a suitable quantity of earth and is being used for allotments. 33 It is probable that there will be sufficient space to continue dumping on Brown's brickfield until the middle of 1935. SANITARY INSPECTION OF DISTRICT. A full report on this matter is contained in the statement and report of the Chief Sanitary Inspector, which will be found at the end of this Report. SMOKE ABATEMENT. No legal action was taken during the year under the Smoke Abatement Act. SUB-LETTING IN COUNCIL HOUSES. The terms of the agreement under which the Council's house are let does not allow the tenant to sublet without obtaining permission. During the year I have continued to consider and determine the cases in which sub-letting was to be allowed in Council houses, in accordance with the Resolution passed by the Council on December 13th, 1927. The following work was carried out:— Total number of applications dealt with 100 Number granted permission to sub-let 84 Number refused permission 16 Number of letters sent 275 Number of visits made by Sanitary Inspectors 153 As a result 153 visits wore made by the Sanitary Inspectors during 1933, as compared with 240 in 1932, and 275 letters were written as compared with 398 in 1932. I have tried on every occasion to deal sympathetically with these applications to sub-let, and whenever it has been possible to grant such permission without detriment to the health of the tenants, or the property of the Council, I have done so. 34 SCHOOLS. There are 21 Public Elementary Schools in Enfield, comprising 47 departments. The Secondary Schools include the Boys' Grammar School, the County School for Girls and the Junior Technical School. In addition there are a number of private establishments. There are also the Chase Farm Schools belonging to the Middlesex County Council, and a Roman Catholic Institution known as St. Joseph's Home for Destitute Boys. Periodical examinations of the conditions of the public elementary schools are made by the Sanitary Inspector, and anv defects found are brought to the notice of the Education Committee and Managers, with the result that they are remedied without delay. Infectious Diseases and Schools. Following a suggestion of the Ministry of Heath, an arrangement is in force between the Council and Education Committee, under which the Head Teachers of the various schools notify the Medical Officer of Health of all absentees suspected to be suffering from any infectious disease. These absentees are then visited, and the cause of absence ascertained. This means of becoming aware of cases of infectious disease is now most important in view of the fact that Measles is no longer notifiable in the District. The Public Health Department relies upon the list of absentees from schools, possibly on account of infectious disease, to discover the extent of an outbreak of non-notifiable infectious disease. No. of children notified to be absent from School due to suspected Infectious Disease 1,576 No. of children found to be suffering from Infectious Disease 1,390 RAG FLOCK ACTS, 1911 AND 1928. There are 6 premises in the District where Rag Flock is manufactured, used or sold, and these are kept under observation by the Sanitary Inspectors. Four samples were taken during the year, and as one was found not to comply with the standard laid down in the Acts, a letter of warning was sent from the Council. 35 HOUSING Number of New Houses erected during the year:— (a) Total (including numbers given separately under (b) 1,417 (i) By the Local Authority 366 and 25 Flats (ii) By other Local Authorities 0 (iii) By other bodies and persons 1,026 (b) With State Assistance under the Housing Act : (i) By the Local Authority 366 aud 25 Flats (ii) By other bodies or persons 0 1. Inspection of Dwelling houses:— No. of No. of houses inspections (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) and number of inspections made 2,669 8,288 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925, and the number of inspections made 139 571 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habi tation 44 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subheading) found not to be in all respects reasonably fit. for human habitation 1,439 (The number here given is of houses where any insanitary conditions were found.) 2. Remedy of Defects without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 1,279 36 3. A ction under Statutory Powers. A.—Proceedings under Sections 17,18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Notices were served requiring repairs None. (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners None. (b) By Local Authority in default of owners None. B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which Notices were served requiring defects to be remedied 133 (2) Number of dwelling-houses in which defects were remedied after service of formal Notices:— (a) By Owners 118 (b)By Local Authority in default of Owners 0 C.—Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 2 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 16 D.—Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made None. 37 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit None. The number of house-to-house inspections made was:— Under Housing Regulations, 1925 139 Apart from the Do. 581 Total 720 HOUSING CONDITIONS. The standard of housing in Enfield varies within the District, the Eastern Portion containing houses for the working classes, and the Western for more wealthy residents. There are very few houses in Enfield which are not built of brick. Fitness of Houses. (a) No action was taken under Section 3 of the Housing Act, 1925. (b) No special measures were taken or suggested for the gradual carrying out of programmes of repair. (c) I should estimate that about 20 houses in Enfield are not supplied with water by the Water Company. (d) There are about 20 houses in the District which are not supplied with a water-closet. All these have earth-closet accommodation. Bye-laws relating to Houses, to Houses let in Lodgings, and to Tents, Vans, Sheds, etc. The existing bye-laws are adequate, but increase in the Staff of the Department would be necessary if the bye-laws with respect to houses let in lodgings were to be enforced. 38 General Observations. The Council now possesses 1,740 houses. During the course of the year much difficulty has arisen not only within Enfield, but throughout the Country, in connection with the condition of Council houses. Large numbers of them have been found to become infested with vermin within a short time of their occupation, whilst generally there are many houses which are not being kept by their tenants in the condition that the Council has a right to expect. The question of verminous houses is one which needs very careful consideration. During the course of the year my Department was asked to examine 151 houses which had become vacant, and to report how many of them were infested with vermin ; 59 such houses were found to be verminous. It must te realised at the outset that the ordinary methods that have been taken so far to disinfest houses are unsatisfactory. The full appreciation of the life history of the bug is essential if this problem is to be tackled on proper lines. The bug is an extremely active and knowledgeable individual. It is capable of judging the time it will take to leave its hiding place, attack an individual and return to its home during the hours of darkness, and to plan its route accordingly. Investigation has proved, moreover, that the bug is capable of living for many months without food. It thus becomes obvious that leaving a house vacant does not in itself starve out bugs, unless the term of vacancy is for a very considerable length of time. The present methods of disinfestation, whilst succeeding in killing live bugs, have little effect upon the eggs. The result is that though the house may be apparently free from vermin due to disinfestation after the vacation of the previous tenant, when the house becomes once more occupied and fires are lit and the house becomes warm, the eggs hatch out and the new occupant gets attacked by bugs and finds his house verminous. This is one way in which new tenants sometimes find themselves in infested houses despite the fact that it has been disinfested prior to their entry. On the other hand there seems to be but little doubt that some tenants bring bugs with them to a brand-new Council house. 39 It is probable that the trouble arises in this way ; a tenant having been granted a Council house departs from his two rooms to occupy a house containing five rooms. Accordingly he sets out to purchase additional furniture for his new home. He usually proceeds to a secondhand store and buys secondhand beds and bedding. In many cases he is buying a hot-bed of bugs and bringing them along to his new house. Bugs can and do travel from house to house, and it is possible for one house to infest a whole row if the houses are adjacent. How is this problem to be tackled ? In the first place houses must be erected of such a nature that they do not tend to become infested with bugs, and in the second place that should they become infested they can easily be disinfested. This is a matter of construction ; wall-papers, wooden picture rails, and wood panelling on ceilings should be forbidden. Wooden skirting boards should be replaced with cement. Prior to going into a new Council house some Authorities have adopted a complete scheme of disinfestation of each family, and housing in temporary accommodation whilst this disinfestation is being carried out. I think these are measures which the Council will do well to consider. There is a further suggestion which I think worthy of consideration . Council tenants tend to buy too much furniture and the wrong type of furniture. I would like to see new houses constructed in which the furniture was built into the house and in many cases made of metal. In the living room a metal flap table might well replace the large wooden table at present so often seen, and could be let down against the wall giving more room for the occupants. Wardrobes, chests of drawers, dressing-tables could easily be constructed with the houses and I should even like to see metal beds erected in a similar manner. If this were done I believe that our Council houses would be cleaner, less liable to infestation, lighter, more roomy and generally healthier. The granting of a Council house is one of the great events in the life of the recipient. After years of living under deplorable conditions in two rooms a family at last finds itself granted a five-roomed house with a bathroom and a sink, and in addition, a garden to itself. 40 It cannot be expected that the average tenant knows how to obtain the fullest benefits from his altered conditions. Together with Housing must go Education. The tenant, moreover, discovers something else, that he has to pay a higher rent than he has previously paid, and is often hard put to it to find this extra rent. There are two ways of getting rent from tenants ; one is to threaten eviction unless the rent be paid, and the other is to educate the tenant and shew him how to budget his income in such a way that he will be able to pay his rent without undue difficulty. I submit that the second method is the method of choice. Many Authorities have already realised this and have appointed Housing Managers to visit the homes and educate the parents in Housecraft. In some cases these Managers are ladies and they are given the duty not only of advising the tenants on the management of the house but in addition the collecting of rents. Whether it is advisable for women to be rent collectors or not I do not know, nor am I sure that the collection of rents and education in Housecraft can march satisfactorily hand-in-hand, but I am certainly convinced that where families are failing to pay their rents or paying irregularly, or where the home is getting into an unsatisfactory condition, that a visit from an individual trained in Estate Management might well precede action to recover unpaid rent. I think much might be done to encourage communal life and pride by the tenants of our Council Estates. One would like to see the tenants organise themselves into Committees for the purpose of improving the Estate, by seeing that gardens are kept in order, by arranging football and cricket teams, facilities for lectures and methods of improving the Estate and tenants generally. If this spirit were properly fostered I see no reason why our Estates should not each become small Garden Cities. INSPECTION AND SUPERVISION OF FOOD. Milk. Dr. Tate, the Medical Officer of Health for the County, has supplied me with the following report on the inspection of cows in the Enfield district during the year under the Milk and Dairies (Consolidation )Act, 1915, and the Tuberculosis Order, 1925 41 MILK AND DAIRIES (CONSOLIDATION) ACT 1915. TUBERCULOSIS ORDER 1925. During the year 1933 thirty-seven samples of milk were taken from a retailer in the district. These samples were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. Seven samples were found to contain living tubercle bacilli. Two of these samples were traced to farms in Hertfordshire; at one the offending cow was discovered and slaughtered, at the other no offending animal was found, but sixcows had recently been sold by the owner. The remaining live samples were from Middlesex producers, and in one casethe offending cow was discovered and slaughtered, in the remaining four cases could not be traced. Eight cows were reported by owners as suspected to be suffering from tuberculosis and six of these cows were slaughtered. One further cow was discovered and slaughtered whilst an examination of the herd under the Tuberculosis Order 1925 was being carried out. THE MILK (SPECIAL DESIGNATIONS) ORDER, 1923. The inspection of premises where Graded Milk is sold has been carried out as heretofore. No request was received during the year from the Ministry of Health for samples of Certified Milk to be taken for analysis to see that they fulfilled the requirements of the Act, and if they came up to the standard necessary for Certified Milk. Meat. There are no public abattoirs in the District. Quite a large quantity of meat slaughtered at the Caledonian Market is brought into the District. The number of slaughter-houses in the District at the date specified is as follows:— 1914 January, 1933 December, 1933 Registered 10 8 6 Licensed 7 4 4 Total 17 12 10 Mr. Fred Wilson, Chief Sanitary Inspector, Mr. T. M. Boswell Mr. H. Wiggett and Mr. A. J. Williams, Sanitary Inspectors, who, 42 hold the Certificate of the Royal Sanitary Institute as Inspectors of Meat and Foods, visit the slaughter-houses at very frequent intervals, and, as will be seen by a reference to the Sanitary Inspector's Report, they paid 2,536 such visits during the year, when they examined 19,757 carcases, and secured the surrender of 183 carcases and 344 parcels of diseased organs. SLAUGHTERHOUSES. The inspection of slaughterhouses and of animals slaughtered therein takes up a large amount of the time of the Sanitary Inspectors, and causes considerable difficulty in view of the fact that much of the slaughtering takes place between the hours of 5 and 9 at nights. Public Health (Meat) Regulations, 1925. Systematic inspection of all butchers' shops and other premises for the sale of meat and offal was carried out during the year. With few exceptions it was found that the Regulations were satisfactorily obeyed BAKEHOUSES. All bakehouses in the District are inspected regularly. OTHER FOODS. Every shop selling provisions is inspected frequently. ADULTERATION, ETC. The Sale of Foods and Drugs Act is under the control of the Middlesex County Council. A report thereon, kindly supplied by R. Robinson Esq., Chief Officer of the Public Control Department follows 43 URBAN DISTRICT OF ENFIELD. List of Samples purchased during the year ended 31st December, 1933. Article Taken. Adulterated Milk 166 5 Butter 4 — Gin 1 — Whisky 3 1 Hake 13 3 Sausages 2 — Apples 1 — Total 190 9 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. Diphtheria was less prevalent than during the previous year, and only two children aged 2 and 3 years of age, died. There were altogether 45 cases, which gives us a mortality rate of a little over 2 per cent. During 1932 there were 96 cases; and 1 died. Scarlet Fever also accounted for 2 deaths during the year. One of these cases was complicated by Acute Haemorrhagic Nephritis and Acute pleuro-pneumonia, and the other by Empyema and Pulmonary Abscess and Acute Pneumonia. PUBLIC HEALTH (SMALLPOX) PREVENTION REGULATIONS, 1917. No primary vaccinations or revaccinations were done by me during the year. NOTIFIABLE DISEASES DURING THE YEAR 1933. The following table shows the cases of infectious diseases notified during the year, and the number of deaths that occurred. n TABLE III.—Cases of Infectious Diseases notified during the year 1933. Notifiable Disease. Number of Cases Notified. Deaths. At Ages—Years. At Ages—Years. At all ages. Under 1. 1 and under 5. 5 and under 15 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Total cases removec to Hospital. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Totals. Smallpox 2 - - - 1 — 1 — 2 — — — — — — — — — Cholera—Plague — — — — — — — — — — — — — — — — — — Diphtheria (inc. Membranous Croup) 45 2 15 23 3 2 — — 40 — — 2 — — — — — 2 Diphtheria Carriers 12 1 — 6 3 2 — — 9 — — — — — — — — — Erysipelas 19 — 1 1 2 3 9 3 10 — — — — — — 1 — 1 Scarlet Fever 249 — 40 156 30 20 3 — 202 — 1 — 1 — — — — 2 Typhus Fever — — — — — — — — — — — — — — — — — — Typhoid Fever 1 — — 1 — — — — — — — — — — — — — — Paratyphoid Fever 2 — — — — — — — 2 — — — — — — — Relapsing Fever — — — — — — — — — — — — — — — — — — Continued Fever Puerperal Fever 3 — — — 1 2 — — 3 — — — — — 2 — — 2 Puerperal Pyrexia 5 — — — 1 4 — — 3 — — — — — — — — — Cerebro-spinal Meningitis 1 — 1 — — — — — 1 — — — — — — — — — Poliomyelitis 1 — — — — — — — — — — — — — — — — — Ophthalmia Neonatorum 3 3 — — — — — — — — — — — — — — — — Pulmonary Tuberculosis 67 — — 3 16 32 13 3 — — — — — 7 14 12 3 36 Other forms of Tuberculosis 13 1 4 2 3 3 —. — — 1 — 4 3 2 3 — — 13 Encephalitis Lethargica — — — — — — — — — — — — — — — — — — Malaria — — — — — — — — — — — — — — — — — — Pneumonia 80 2 10 11 12 18 16 11 — 10 1 1 2 3 5 13 26 61 Dysentery — — — — — — — — — — — — — — — — — — Totals 503 9 71 203 73 87 43 17 272 11 2 7 6 12 24 26 29 117 45 SCARLET FEVER. Two-hundred-and-forty-nine cases of Scarlet Fever occurred during the year in 211 houses, as follows:— Number of houses where 1 case occurred 188 Number of houses where 2 cases occurred 16 Number of houses where 3 cases occurred 5 Number of houses where 4 cases occurred 1 Number of houses (Chase Farm Schools) where 10 cases occurred 1 Total number of houses where cases occurred. 211 Total number of cases 249 Deaths 2 DIPHTHERIA. Forty-five cases of this disease occurred during the year in 27 houses, as follows:— Number of houses where 1 case occurred 21 Number of houses where 2 cases occurred 1 Number of houses where 3 cases occurred 3 Number of houses where 4 cases occurred 1 Number of houses (Chase Farm Schools) where 9 cases occurred 1 Total number of houses where cases occurred 27 Total number of cases 45 Deaths 2 DIPHTHERIA CARRIERS. Twelve cases of this disease occurred during the year in 11 houses as follows:— Number of houses where 1 case occurred 10 Number of houses (Chase Farm Schools) where 2 cases occurred 1 Total number of houses where cases occurred 11 Total number of cases 12 46 ENTERIC AND PARATYPHOID FEVER. One case of Enteric Fever, and two cases of Paratyphoid Fever were notified during the year. No cases of these diseases were notified in the previous year. POLIOMYELITIS. One case of this disease was notified during the year. CEREBRO-SPINAL FEVER. One case of this disease was notified during the year. ENCEPHALITIS LETHARGICA No cases of this disease were notified during the year. MEASLES AND GERMAN MEASLES. As from the beginning of 1032 Measles and German Measles were made non-notifiable in Enfield with the consent of the Minister of Health. It is, therefore, impossible to give definite figures as to the extent of these diseases within the District. Some idea of the extent of these diseases can be obtained, however, by the fact that 4 cases of Measles and 5 cases of German Measles were excluded from the Schools during the year. ENTERITIS. Six deaths occurred from this disease during the year, and were of infants under one year of age. ZYMOTIC DISEASES. The following table shows the deaths registered in the District from the seven chief zymotic diseases during the past five years:— 47 The following table shows the deaths registered in the District from the seven chief zymotic diseases during the past five years:— Disease. 1929 1930 1931 1932 1933 Small Pox - - - - - *Scarlet Fever 1 6 9 11 3 *Diphtheria 12 7 10 7 6 *Measles — 2 — 10 — *Enteric Fever - 3 2 — - *Whooping Cough 9 — 1 6 4 Epidemic Enteritis - - - - - Totals 22 18 22 34 13 *The actual Enfield deaths were:—Diphtheria, 2 ; Scarlet Fever, 2 ; and Whooping Cough, 3. The figures for Scarlet Fever, Diphtheria, Measles, and Enteric Fever include all the deaths that occurred in the Enfield and Edmonton Joint Isolation Hospital, which is situated in the Enfield District. Patients belonging to other districts are also received, so that the Enfield figures are therefore smaller than those given. ENFIELD ZYMOTIC DEATH-RATE. The zymotic death-rate, after deducting six deaths of persons residing outside the District who died in Institutions in the District, and adding one death of an Enfield resident who died outside the District, is 0.11 per 1,000 population. Disease. 1932 1933 Deaths. Death-rate Deaths. Death-rate Scarlet Fever 2 .02 2 .02 Diphtheria 1 .01 2 .02 Enteric Fever — — — — Small Pox — — — — Measles 12 17 — — Whooping Cough 5 .07 4 .05 Epidemic Enteritis — — — — Totals 20 .28 8 .11 The same routine as previously reported has been carried out in the control of Infectious Disease in Enfield. 48 PREVENTION OF BLINDNESS. No action was taken during the year under Section 66 of the Public Health Amendment Act, 1925, for the prevention of blindness' or for the treatment of persons suffering from any disease or injury to the eyes. OPHTHALMIA NEONATORUM. Cases. Vision Unimpaired Vision impaired Total blindness Deaths Notified Treated. At home. In Hospital. 3 2 1 3 — — — It is the duty of the midwife who discovers that a child is suffering from discharge from the eyes, to notify the County Medical Officer immediately. A local practitioner is then called in to see the ease, whose duty it is to notify me forthwith. The child is visited by one of the Maternity and Child Welfare Nurses who reports thereon to me, and the information is passed on to the County Medical Officer of Health. TUBERCULOSIS. The following table shows the number of notifications of Pulmonary and Other Forms of Tuberculosis received during the year :— Ward. Pulmonary. Other. Fresh Cases. Old Cases re-notified. Duplicates. Fresh Cases. Old Cases re-notified. Duplicates. Town 6 - 16 2 - - Chase 13 - 25 4 — 10 Ordnance 13 1 22 1 - 2 Green Street and Ponders End 18 1 41 4 - 1 Bush Hill Park 17 1 25 2 - 8 Hadley and Cockfosters -— - 1 — - - Totals 67 3 130 13 - 21 49 First Notifications, including transfer notifications 80 Old Cases re-notified, i.e., some by fresh doctors, or under old Regulations 3 Duplicate Notifications, i.e., those which report the entering and leaving of Sanatoria 151 Total Notifications 234 The following table gives particulars of the ages of the new cases notified, and deaths from this disease during the year:— Age Periods. New Cases. Deaths. Respiratory. NonRespiratory Respiratory. NonRespiratory. M. F. M. F. M. F. M. F. Under 1 — — — 1 — — — 1 1 to 5 — — 1 3 — — 2 2 5 to 10 2 1 1 1 — — 1 2 10 to 15 — — — — — — 15 to 20 3 — 1 2 1 1 1 1 20 to 25 6 7 — — 2 3 — — 25 to 35 7 11 1 1 4 4 2 1 35 to 45 6 8 1 — 2 4 — — 45 to 55 5 2 — — 7 2 — — 55 to 65 3 3 — — 1 2 — — 65 and upwards 3 — — — 2 1 — — Totals 35 32 5 8 19 17 6 7 Sex (1st Notifications). Form. Males. Females. Pulmonary 35 32 Other 5 8 Totals 40 40 Cases and Deaths. The number of cases, also deaths from this disease, in the different Wards during the year is shown in the following table, viz.:— 50 Ward. Pulmonary. Other. Cases Deaths Cases Deaths Town 6 1 2 2 Chase 13 7 4 3 Ordnance 13 7 1 — Green Street and Ponders End 18 13 4 6 Bush Hill Park 17 8 2 1 Hadley and Cockfosters — — — 1 Totals 67 36 13 13 20.4 per cent. of the cases dying of tuberculosis had not previously been notified. It will be noticed that the highest mortality occurs between the ages of 20 and 55 years. Public Health (Prevention of Tuberculosis) Regulations, 1925. It was not found necessary to take any action, under the above Regulations, with regard to tuberculous persons employed in the milk trade. Public Health Act, 1925, Section 62. / No action was taken during the year under this Section. DISINFECTION OF VERMINOUS PERSONS AND THEIR BELONGINGS. Four dwellings and twenty-nine articles of clothing, etc., were disinfected and cleansed during the year at the request of the Education Committee. Meteorology. The following instruments are installed at the Public Offices:— Standard Fortin Barometer. Maximum Thermometer Minimum Thermometer Standard Hygrometer In a Stevenson's screen in grounds of the Public Offices. Terrestrial Radiation Thermometer Earth Thermometer In the grounds of the Offices. Campbell-Stokes Sunshine Recorder Rain Gauge On the roof of the Public Offices. Daily records have been taken, and monthly returns sent to the Meteorological Office. The accompanying table gives the result of our operations for the year in a condensed form. METEOROLOGICAL STATISTICS, 1933. Month. Barometer. Temperatures. Rainfall. Millimetres. Sunshine hours. Thunderstorms Fogs on days. Frosts on days. Snowfalls. Prevailing. Winds. Highest Lowest Earth. Means. Lowest Grass. Min. Highest Maximum. Lowest Minimum. Means of latter. Jan. 30.760 on 23rd 29.410 on 17th. 43.4° 18° on 23rd. 53° on 2nd. 20° on 23rd. 36° 40.2 1.59 inches. 44.9 — 5 21 2 S.W. Feb. 30.606 on 12th. 29.482 on 7th. 41.6° 19° on 24 th. 55° on 8th & 9th. 22 ° on 24th 40° 32.5 1.28 inches. 80.0 — 2 10 7 S.W. Mar. 30.458 on 21st 28.864 on 17th. 43.2° 24° on 26th 68° on 28th 28° on 21st 46° 62.2 2.45 inches. 175.5 1 1 14 — S.W. April 30.540 on 14th. 29.704 on 29 th 47.0° 27° on 23rd. 73° on 8th 30 °on 19th 49.5° 23.0 0.94 inches. 146.9 1 — 5 — S.W. May 30.246 on 18 th. 29.486 on 7th. 51.6° 35° on 15th. 80 ° on 23rd 38° on 15th 55° 53.5 2.48 inches. 155.4 4 — — — N.N.W. June 30.234 on 10th. 29.330 on 19th 56.8° 41° on 18th 87° on 5th 44° on 22nd 62° 46.0 1.92 inches. 248.2 5 — — — S.E.&N. July 30.544 on 4th. 29.588 on 14th. 60.2° 46° on 1st. 93° on 27th. 50° on 1st 67° 27.0 1.07 inches. 215.7 — — — — S.W. Aug. 30.374 on 2nd. 29.670 on 23rd. 62.1° 42° on 24th 92° on 6th. 48°on 22nd & 24th 67° 14.8 0.54 inches. 237.7 — — — — S.W. Sept. 30.353 on 15th 29.449 on 23rd. 60.3° 36° on 15 th 81° on 3rd. 40° on 15th& 16th 61° 67.5 2.8 inches. 171.0 1 1 — — S.W. Oct. 30.346 on 3rd. 29.182 on 28th. 56.4° 29° on 28th 69° on 5th. 31° on 18th & 28th 51° 37.5 1.49 inches. 90.3 — 4 2 — S.W. & N.E. Nov 30.265 on 8th 29.259 on 15th. 49.9° 29° on 13 th. 55° on 7th. 32° on 16th. 42.5° 24.1 0.95 inches. 42.5 — 3 4 — N.W. Dec 30.702 on 22nd. 29.050 on 28th. 44.1° 20° on 6 th & 10 th 44° on 6th. 23° on 6th. 34° 9.4 0.41 inches. 27.8 — 11 15 — N.E. Totals 437.7 17.92 inches. 1635.9 hrs. 12 27 71 9 THE ANNUAL REPORT OF THE School Medical Officer For the Year ending 31st December, 1933 52 MEMBERS OF THE ENFIELD EDUCATION COMMITTEE. 1933-1934. Chairman Mr. H. A. DESHBOROUGH BROWN Vice-Chairman Mr. H. G. SHORT Representative Members— Mr. W. H. BISHOP, Junr. Mr. H. A. DESHBOROUGH BROWN Mr. W. W. CAKEBREAD Mr. W. J. CLARKE Mr. H. H. COLLIER Mr. G. E. JONES Mr. H. G. SHORT Mr. G. M. SPARROW Mr. W. T. TAYLOR Mr. A. B, WHARTON Co-optative Members,— Miss E. M. CRESSEE. Mrs. E. A. DAVIES, Mrs. H. ROTHWELL, Miss G. M. FORD, Mr. A. BURRAGE, Mr. D. MASON, Mr. C. F. WATTS. Director of Education— F. G. APTHORPE, Esq., M.A. 53 STAFF OF THE SCHOOL MEDICAL DEPARTMENT. School Medical Officer— DENNIS H. GEFFEN, M.D., B.S., D.P.H., M.R.C.S., L.R.C.P. Assistant School Medical Officer— GERTRUDE FORRESTER, M.B., B.S., (Lond.) School Dentist— C. E. JAMES, L.D.S., R.C.S. (Eng.) R. BRADBURY, L.D.S., R.C.S. (Eng.) School Ophthalmic Surgeon— S. MACKY, M.B., B.S., D.O.M.S. School Aural Surgeon— J. C. HOGG, F.R.C.S. School Nurses— E. SANDERS, M.R.C.N., S.R.N. I. FOWLER, S.R.N. V. MURPHY, S.R.N., C.M.B. Dental Nurse— F. ANDERSON, R.S.C.N. Clerks— H. OGILVIE. I. GROVES. 54 Annual Report of the School Medical Officer Dr. DENNIS H. GEFFEN, M.D., B.S., D.P.H., M.R.C.S., L.R.C.P. For the Year ending 31st December, 1933. To the Chairman and the Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to place before you my report on the health of the school children of Enfield. There has only been one change in the staff of my department during the year, namely the retirement of Mr. McWalter, one of our school dentists, in order to engage in private practice, and the appointment of Mr. Bradbury to fill the vacancy caused thereby. Mr. Bradbury commenced work in Enfield on 1st October, 1933, and I am pleased to report that he is carrying out his duties satisfactorily and has already made friends with the mothers and children with whom he comes in contact. At the end of this report follows a report from Mr. James, the senior school dental surgeon, on the dental work carried out at the school dental clinic. I would draw your attention to one or two matters therein. In the first place, Mr. James shows the increase of conservative dental work that has taken place during the past few years. The final success of a dental department should be shown by the number of children who, by means of preventive measures, have never had dental decay and have got sound teeth. Such measures should be of an educational character and include instruction on diet and the hygiene of oral cleanliness. Unfortunately we are unable to lay down golden rules that will 55 prevent dental caries and one must assume that many factors play an important part in the cause of the present large amount of this disease. On the other hand, it is a fact that children of the wealthier classes and children brought up in institutions suffer less from dental caries than children attending elementary schools. Apart from this it is gratifying to note that as each year goes by we are able to record a larger proportion of fillings to extractions. This means that more children are accepting treatment before the teeth are so bad that extractions are inevitable. In the latter part of his report, Mr. James points out the necessity for the treatment of children over the age of fourteen. The County Council are arranging for dental treatment to be provided for the children of Middlesex attending secondary schools and in this way part of the need for dental treatment of children over the age of fourteen will be met. I am glad to report the success of the session which is now held regularly once a fortnight for the extraction of teeth under nitrous oxide gas. I consider this to be a welcome addition to our school dental service. In a special examination Mr. James carried out of 898 children, only eleven were found whose teeth had never been attacked by dental caries. Mr. James has attempted to show some of the factors responsible for this condition in these eleven children. His report does not show that breast feeding is essential in the prevention of dental caries, for some of these children were bottle-fed in infancy; nor does it show that incidence of infectious disease causes dental caries. One factor is of importance, namely, that there was evidence to show that other members of the family were equally free from dental defect. This may be due to hereditary influences; on the other hand it may be due to the fact that other members of the family have been brought up by similar methods and on a similar diet. The report of the School Ophthalmic Surgeon shows keen interest in the care of children who are suffering from squint and myopia (short sight). During 1933 children requiring treatment that could not be obtained at the Eye Clinic were sent to the Western Ophthalmic Hospital. The hospital admitted ten children for operative treatment and in addition to this 68 attendances in the out-patient department were made by Enfield children. This service has been carried out in the past as purely voluntary work by the hospital. In view of the satisfactory results that had been obtained and the increasing number of cases that are being referred to the Western Ophthalmic Hospital especially for squint, arrangements have been entered into with this hospital in the early part of 1934 whereby 56 for a fixed sum of money the hospital will undertake to admit or treat as out-patients such cases as are sent from the school ophthalmic clinic. I would like to make special reference to one case. A child was found by the Assistant School Medical Officer, to be suffering from defective vision and was referred to the School Ophthalmic Specialist. After examining the child Mr. Macky referred the case to the Western Ophthalmic Hospital for further opinion. This further examination demonstrated that the child was suffering from a septic focus and that this focus was probably the teeth. It is interesting to note that the mother of the child had previously been told that the child was suffering from dental caries and had been advised to obtain treatment for it and that the parent had refused. This child's teeth have now been treated, the septic focus removed, and the child's vision is steadily improving. In drawing attention to the report of the School Aural Surgeon, it will be noted that children are now attending for treatment from the Council's Maternity and Child Welfare Centres, and it is to be hoped that the treatment of these children at an early age may result in the avoidance of the permanent ear trouble that is apt to arise if these children are neglected until they enter our elementary schools. Much has been written during the year concerning malnutrition in school children, and I think there has been a tendency to assume that malnutrition is confined to those whose means are so limited that their children are unable to obtain a sufficient quantity of the right kind of food, or who are so ignorant that they are unaware of the right type of food that should be given to children of school age. Dr. Forrester and I realise this possibility and are aware of the statement that removal of children to council houses has not always resulted in their better nutrition, due to the increase in rent that has to be paid, and the consequent diminution of the money available for food. We, nevertheless, feel that there is much malnutrition among the better class children of the district, and that certain factors of an entirely different nature are responsible for this. The children that we are classifying as suffering from malnutrition are those who are to the lay observer, listless, anaemic, debilitated, or underweight. We admit that we are adopting no scientific standard for we know of none that can be safely applied to denote malnutrition. On the other hand it is a fact that there are a large number of children who obviously are not in that state of health which normal children should possess; so obviously so that the untrained observer can detect them. It is to this class of children that the following remarks refer. Investigations were carried out at the following schools:— 57 St. Andrew's. Chase Side. George Spicer Central. George Spicer Junior. S. Mark's. S. Matthew's. Alma Road. We are assuming that the children attending S. Andrew's, Chase Side, and George Spicer schools come from wealthier homes than those attending St. Mark's, S. Matthew's and Alma Road. In the first four schools 549 children were examined, and in the second three schools 332 children were examined. Of the 549 children examined at S. Andrew's, Chase Side, George Spicer Central, and George Spicer Jnr., and Infts.' about 50 per cent. of the children were found to be below par; whilst of the 332 children examined at S. Mark's, S. Matthew's, and Alma Road this figure was about 25 per cent. In short we found the children in the wealthier schools less healthy. We admit, without hesitation, that our methods were unscientific, but they nevertheless represent our joint opinion that the children selected were below the standard which may be reasonably expected of healthy children. We failed to see a sufficient number bright-eyed, rosy cheeked, and sturdily built. We would like to be able to give you reasons for the tiredness and pallor of so many of our school children, for whilst we would make it clear that we do not consider the Enfield children unhealthier than those in corresponding districts, we nevertheless would like to see an improvement in their condition. Our general impression is that parents do not realise that elementary school life provides a child with sufficient to occupy its mind. Many parents seem to think it necessary to augment their children's scope of thought by taking them or allowing them to go too frequently to cinematograph performances. Apart from the fact that the atmosphere of a cinematograph cannot replace the atmosphere of our parks, there lies the fact that the average film causes a child to attempt to unravel psychological problems that are beyond its understanding and can only worry it. School children should spend more of their leisure in the open spaces of the district playing at healthy exercises, and this is far better than motoring, sometimes till late hours at night. It is rather interesting to note that 21 per cent. of the children examined at S. Andrew's School, 16 per cent. of those at Chase Side, and 22 per cent. of those at George Spicer Jnr. and Infts. came from homes where parents possessed motor cars. We are convinced that Enfield children go to bed far too late at night. Summer time and the exceptional weather that the country 58 experienced last year may be partly responsible for this, but parents should realise that children need a large amount of rest and sleep, and that both should be obtained in bed in quiet surroundings. There is, moreover, too much coddling and too much talk of illhealth amongst a certain section of our community. During the year one child came to the clinic and informed the doctor that she had lung trouble, and another boy that he thought he had heart disease. On other occasions mothers have complained that their children were suffering 1. from enteritis, bronchitis, and tonsillitis. 2. from a lump in the chest which might become consumptive. 3. from nerves and catarrh. 4. from blood pressure and tonsillitis. In all these six cases the children were free from disease. We consider that these complaints illustrate a state of mind amongst certain members of the community which is directed towards disease rather than health. There should be less discussion about sickness and disease and more concerning good health and robustness ; in other words our attitude should be directed towards the obtaining of good health as much as it should be towards the prevention of sickness. I wish to take this opportunity of expressing to the Committee my thanks for the courtesy that has been extended to me during the year, to my colleagues for their constant co-operation, and the staff for their loyal help at all times. I am Mr. Chairman, Ladies and Gentlemen, Your obedient servant, DENNIS H. GEFFEN 59 REPORT OF THE SCHOOL MEDICAL OFFICER. Area (acres) 12,575 Population (Registrar General's figure—mid 1933) 71,790 Number of Schools 20 1929 1930 1931 1932 1933 Average number on Books of Elementary Schools 9024 9104 9172 9453 9725 Average Weekly Attendance 7928 8049 8205 8495 8685 ROUTINE MEDICAL INSPECTION. Three age-groups are examined as required by the Board of Education Grant Regulations No. 19 (1925). These groups are:— 1. Entrants. 2. Intermediates (children having attained their eighth birthday). 3. Leavers (children having attained their twelfth birthday). The total number of children examined during the year was 2869. In 1932, 3087 were examined. Routine Medical Inspection is carried out on the school premises except in those cases where there is a school, or maternity and child welfare clinic conveniently placed. During the year the arrangements were continued whereby notices were handed to children stating in lay terms, the defect from which they were suffering with the request that they should hand these notices to their parents. In addition to this a visit is made subsequently by the school nurse, who urges upon the parent the necessity of getting the defect remedied. Seventy-seven per cent. of the children examined during the year in the course of routine examination were accompanied by their parents. The comparative figures for the last five years are as follows:— 1929 1930 1931 1932 1933 Percentage of children accompanied by parents 78 78 79 78 77 37 per cent. of the children examined were vaccinated. The comparative figures for the last five years are as follow:— 1929 1930 1931 1932 1933 Percentage of children vaccinated 40 40 42 42 37 DEFECTS FOUND AT ROUTINE MEDICAL INSPECTION. Uncleanliness.—Of 2869 children examined 21 were found to have vermin in their heads and 224 had nits. One child was excluded for body vermin. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 Number of children examined 3258 2514 2790 3087 2869 No of children verminous 112 82 64 54 21 Percentage of children verminous 3.4 3.3 2.3 1.7 0.7 No. of children found to have nits.. 457 335 328 281 224 Percentage of children found to have nits 14.0 13.4 11.7 9.1 7.8 These figures show a steady improvement in the cleanliness of our school children. Were it not for a few bad families these numbers would be considerably better. Malnutrition.—No cases of malnutrition due to insufficient feeding were seen in the course of routine inspection, but many cases of pallor, listlessness, and debility were seen and special reference is made to them in my opening remarks. Skin Diseases.—Eight cases were seen, six required treatment and two were kept under observation. Ear Disease.—Twenty-three cases of middle ear disease were found; also 53 cases of defective hearing. All these cases were referred to the Aural Clinic for treatment. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 No. of Children examined 3258 2514 2790 3087 2869 No. of cases of Middle Ear Disease found 18 24 11 18 23 Percentage of cases of Middle Ear Disease found 0.6 0.9 0.4 0.6 0.8 No of cases of Defective Hearing found 63 40 42 56 53 Percentage of cases of Defective Hearing found 1.9 1.6 1.5 1.8 1.8 61 It is probable that the increased number of children who were found to be suffering from middle ear disease represents previous cases who have attended for routine examination and in whom the condition is still present or has recurred. It is also possible that increased facilities for bathing due to the open-air baths and sea bathing during the course of the hot summer of 1933 may be a slight contributory cause. If this be so, the increase of five children over the number for last year is small, when one considers the opinions frequently expressed that bathing in the sea and in the swimming baths is a frequent cause of infection of the middle ear. Tonsils and Adenoids.—One thousand, one hundred and twenty-one children had already had operation for removal of tonsils and/or adenoids; 388 were found to have enlarged tonsils, adenoids, or both. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 No. of children examined 3258 2514 2790 3087 2869 No. of children already operated upon 842 684 914 1049 1121 Percentage of children already operated upon 25.9 27.2 32.8 33.9 39.1 No. of children with enlarged tonsils, adenoids, or both 1149 810 961 787 388 Percentage of children with enlarged tonsils, adenoids, or both 35.3 32.2 34.4 25.5 13.5 I would call attention to the fact that the percentage of children who have had their tonsils and adenoids removed is steadily increasing and has now reached the figure of 39.1, whilst correspondingly the number found to have enlarged tonsils and adenoids or both has dropped to the figure of 13.5, which is little more than one third of what it was in 1929. If one adds these two percentages together it will be seen that the percentage of children who have had or need this operation has remained fairly steady in the district, the difference being that there is now a bigger percentage of children who have had the requisite treatment. To those who consider that this figure of 39.1 is high, I would again remark that it compares with a figure of about 65 per cent, of children in wealthy public schools who have had their tonsils and adenoids removed before they enter school. The procedure for removal of tonsils and adenoids was the same as in previous years. 62 Eye Diseases and Defects.—Nineteen children were found to be suffering from external eye disease. All were referred for treatment to the minor ailment clinic. 296 cases of defective vision were referred for treatment to the Ophthalmic Clinic or hospital; 21 of these had squint. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 No. of children examined 3258 2514 2790 3087 2869 No. of children with defective vision 308 222 240 237 296 Percentage of children with defective vision 9.5 8.9 8.6 7.7 10.3 No. of children with squint 121 102 96 48 21 Percentage of children with squint 3.7 4.1 3.4 1.6 0.7 For some time past I had been anxious to arrange for special treatment for children suffering from squint. During the course of the year many of the children were referred for treatment to the Western Ophthalmic Hospital and all these children were admitted and operated upon. For these services no fee was charged to the Education Committee by the hospital. Early in 1934 arrangements have been made whereby for a sum of ten guineas per annum the hospital will accept all patients referred by the School Ophthalmic Surgeon either for admission or out-patient treatment; arrangements have also been made for the payment of fares to and from the hospital. Tuberculosis.—One case of active tuberculous glands was found. Crippling Defects.—The following defects were found during Routine Medical Inspection 2 cases of cleft palate and hare lip. 2 cases of infantile paralysis. 2 cases of hemiplegia. 1 case of club foot. 1 case of congenital absence of fingers. 1 case of old tuberculous elbow. 1 case of old spina bifida. 1 case of traumatic shortening of leg. 3 cases of wry neck. 1 case of severe knock knee. 1 case of deformity of toes. 63 INFECTIOUS DISEASE. The following table is a comparative table for the last five years : 1929 1930 1931 1932 1933 Measles 40 833 65 460 4 German Measles 340 6 1 5 6 Mumps 54 149 86 43 667 Whooping Cough 204 59 43 180 78 Chickenpox 41 187 169 131 235 Scarlet Fever 81 136 159 124 134 Diphtheria 46 141 178 77 28 Diphtheria Carriers 1 1 3 1 — Smallpox — 7 — 1 — Typhoid Fever — 3 — — — Erysipelas 1 — — — — Poliomyelitis — — 1 1 — During the course of the year much absence from school was caused by a prolonged outbreak of mumps, whooping cough, and chickenpox. Scarlet Fever of a mild type also occurred. On the other hand we had less Diphtheria than we have had for many years past. DETECTION AND PREVENTION OF SPREAD OF INFECTIOUS DISEASE. Close co-operation exists between the School Medical Department and the Public Health Department, whereby when either becomes aware of infectious disease in any school, house, or district, the other department is informed. Joint action is, therefore, possible in preventing the spread of infectious disease. VERMIN. Of 2869 children examined at Routine Inspection 21 were found to have vermin in their hair, and 224 had nits—i.e., 8.5 per cent. had unclean heads. One child was reported as having body vermin. THE WORK OF THE SCHOOL NURSES. There are four school nurses. One is attached to each of the three Treatment Clinics, which she attends daily for the 64 treatment of minor ailments; one of them is also in charge of the Aural Clinic. Each nurse is responsible for the followingup of children attending her clinic, for the cleanliness of the scholars attending the schools which feed her clinic, and for any visits to those schools besides those for head inspections. In addition to these duties, two of the school nurses attend in turn at the Routine Medical Inspection to assist the Medical Officer. The fourth nurse is employed mainly on dental work, assisted by a clerk. The following is a summary of the work of the school nurses during 1933 and for the past five years:— 1929 1930 1931 1932 1933 No. of home visits 3109 3062 2603 2298 2943 No. of school visits 384 390 387 377 621 No. of school visits for routine examination of heads 223 212 216 220 220 Total number of heads examined 35401 36255 38228 37469 • 39154 TREATMENT CLINICS. Minor Ailment Clinics are held at the three centres. The Assistant School Medical Officer attends one clinic each week at each centre. In addition, the school nurses hold a daily clinic at each of the three centres. Every new case attending the nurses' clinics during the week is seen by the Assistant School Medical Officer at her next visit. The number of children that attended the minor ailment clinics during 1933 was 3335 and the total number of attendances was 22171. The average attendance at the nurses' clinics was 38 (i.e., 114 per day for the three clinics). At the School Medical Officer's Clinic the average attendance was 44. All children leaving school are given a medical examination early during their last term, so that defects may be remedied before they leave. The result of this examination is entered upon a special card which is sent to the Juvenile Employment Committee. Table IV. gives in detail the diseases dealt with at the Minor Ailment Clinics. Tonsils and Adenoids.—During the year 467 cases were seen at the clinics and referred for treatment, and 233 cases were kept under observation. Of these 224 were operated on under the 65 Authority 's scheme and 53 were operated on by private arrangement. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 No. of cases referred for treatment 1446 1037 780 709 467 No. of cases operated under Authority's scheme 435 496 450 295 224 No. of cases operated by private arrangement 109 91 84 62 53 Tuberculosis—Twenty-one cases of suspected or definite tuberculosis were seen at the clinic during the year. Four children were offered sanatorium treatment and two accepted. Three children who were recommended in 1932 were still away in sanatoria in 1933. All cases notified in previous years were kept under observation, and some were given convalescent treatment. Ringworm.—Nine children were found to be suffering from ringworm. Two were scalp lesions and seven were skin lesions. The following is a comparative table for the last five years:— 1929 1930 1931 1932 1933 No. of children found to be suffering from Ringworm 18 7 2 3 9 Impetigo.—During the year 14 cases were seen, all were treated at the clinic. The following is a comparative table for the last five years:- 1929 1930 1931 1932 1933 No. of children found to be suffering from Impetigo 44 10 30 13 14 Scabies.—Eleven cases were seen. All of these were treated at the clinics. The following is a comparative table for the last five years:- 1929 1930 1931 1932 1933 No. of children found to be suffering from Scabies 5 3 7 13 11 Other Skin Diseases.—117 cases were seen. These consisted chiefly of seborrhoea, eczema and psoriasis. Eye Diseases.—220 cases were treated at the clinics. These 66 Avere chiefly conjunctivitis, blepharitis and styes. All cases of defective vision were referred to the Ophthalmic Clinic for treatment. Ear Diseases.—Seventy cases of otitis media were found. All were referred for treatment to the Aural Clinic. Heart Disease.—Seventy-eight children were found to be suffering from organic heart disease; fourteen of these were referred for treatment and the rest were kept under observation. In addition to these, five cases were seen at Routine Inspection only—making a total of 83 cases seen during the year. Of these cases, 21 were congenital, and seven followed acute infectious diseases. The remaining 55 cases may be classified as follows:— Definite Rheumatic History 21 Vague Pains 5 No history of Illness 29 Chorea.—Seven children were found to be suffering from Chorea; one of these was recovering and was kept under observation. All the rest were referred for treatment to a doctor or hospital. Crippling Defects.—The following defects were seen at the clinics:— 2 cases of old tubercular elbow. 1 case of hemiplegia. 3 cases of congenital multiple exostosis. 1 case of congenital absence of fore-arm. 9 cases of spinal curvature. 2 cases of hammer toe. 5 cases of club foot. 1 case of old tubercular hip. 10 cases of infantile paralysis. 5 cases of cleft palate and hare lip. 1 case of cleft palate. I case of congenital shortening of leg. 1 case of wry neck. 2 cases of cerebral diplegia. 1 case of traumatic ankylosis of hip. 1 case of severe knock knee. 1 case of congenital dislocation of hip. 2 cases of birth palsy. 2 cases of old tuberculous knee. 1 case of old spina bifida. 1 case of traumatic shortening of leg. 2 cases of facial paralysis. 67 All of these children who required treatment were either attending hospital or obtaining treatment locally. Other Conditions.— 1 girl was found to be suffering from enlargement of the thyroid gland and is being kept under observation. 1 case of severe nephritis was attending hospital. 9 cases of obesity were referred to hospital for treatment. 1 case of hydrocephalus was attending hospital. 1 case of mongolism was attending hospital. 1 girl suffering from exophthalmic goitre was attending hospital. Three children were referred to hospital requiring operations for hernia. The total number of children examined during the year, excluding those attending the Dental Department, was 8385. This number was made up as follows:— Examined at Routine Inspection 2869 Examined at Minor Ailment Clinics 3335 Examined at Ophthalmic Clinic Only 512 Examined at Aural Clinic only 80 Examined at School Leaving Age for Juvenile Employment Committee 593 Examined under Juvenile Employment Byelaws 50 Examined under Mental Deficiency Act 17 Examined as Contacts with Infectious Disease 929 Payments at the clinics were continued on the same lines as in former years—i.e., a charge of twopence per week was made for treatment at the Minor Ailment Clinic, and threepence per attendance at the Dental Clinic (sixpence if gas is given). For spectacles and for nose and throat operations parents are asked to sign a form of consent and willingness to pay at least part of the cost before the child is referred for treatment. In really necessitous cases the Local Authority bears the whole cost. During the year the sum of £273 19s. 3d., was collected as follows:— Minor Ailment Clinics £3 14s. 6d. For cost of Spectacles £45 18s. 3d. For Convalescent Treatment £61 18s. 6d. For Operations for Tonsils and Adenoids £98 9s. 0d. For Dental Treatment £63 15s. 0d. For X-ray Treatment of Ringworm £00 4s. i 0d. 68 The Local Authority still reserves four beds (two for boys and two for girls) at the Russell-Cotes School of Recovery, Parkstone, Dorset. The children are sent for a period of six weeks or longer. Sixteen girls and sixteen boys were sent during 1933. During 1933 two beds were also reserved for a period of six months at Collington Manor, Bexhill, and three girls and two boys were sent during this period. Wherever possible the Local Authority recovers part of the cost of maintenance from the parent, but as most of the children are drawn from really necessitous homes, the amount recovered is comparatively small. There was a total of 14 deaths among school children during the year. In 1932 there were 23. The causes of death during 1933 were as follows:— 5 Pneumonia. 2 Osteomyelitis. 1 Tuberculous Meningitis. 1 Meningitis. 1 acute Nephritis. 1 Epilepsy. 2 Accidents. 1 Murdered. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC HEALTH. On the whole the hygienic conditions of the schools in Enfield may be considered satisfactory. Most of them are in good surroundings and well ventilated. With three exceptions the schools are lit by gas ; in the cases of Botany Bay Council, Chesterfield Road Council, and St. Matthew's C.E., Ponders End, electric light has been installed. The schools are warmed with hot-water pipes and open fires. Most of the desks are of the dual type, except for children in the Infants' Departments where small chairs and tables are used. Five Senior Departments have single locker desks. The rooms are cleaned regularly and the floors swept with a suitable preparation. The water supply is sufficient. The sanitary conveniences at the non-provided schools are cleansed regularly every day by one of the employees of the Public Health Department ; whilst, in addition to this, every quarter the Sanitary Inspectors visit all the schools in the district and report on any defective condition that may be found. The water carriage system of sanitation is present in all the schools except St. John's, Clay Hill, where middens are provided and supervised weekly by the Public Health Department. 69 THE TEACHING OF HYGIENE. The teaching of hygiene is part of the routine of the school syllabus, which includes a special course in such training for junior and senior children. In connection with Housecraft and Mothercraft teaching, arrangements have been made for the Health Visitors to visit Senior Girls' Departments to give a demonstration of the bathing of a baby, with the Housecraft teacher assisting. This is part of the educational course laid down for all girls from aged 12 to 14. The following demonstrations have taken place:— By Miss Newbegin at Bush Hill Park School 3 demonstrations. By Miss Garlick at Chesterfield Road School 4 demonstrations. By Mrs. Herbert at Lavender Road School 2 demonstrations. By Mrs. Herbert at Chase Side School 2 demonstrations. By Miss Wilkinson at Alma Road School 1 demonstration. Thus twelve demonstrations were given during the year as compared with fourteen last year. OPEN-AIR EDUCATION. There are at present, no open-air schools or classes in Enfield. PHYSICAL TRAINING. Enfield does not possess an organiser for physical training, but exercises and games are carried out under the supervision of the teachers. PROVISION OF MEALS. Meals are provided for the necessitous children, the arrangements being undertaken by the Children's Care Committee. The names of the children requiring free meals are submitted by the Head Teachers and School Medical Officers. During 1933, 24,015 dinners were provided. During the course of the year a visit was paid to each of the following feeding centres:— Chase Feeding Centre. Ponders End Feeding Centre—Alma Road. Enfield Wash Feeding Centre. 70 The premises with the possible exception of the hut at Alma Road can hardly be considered satisfactory, nor was I satisfied that the children were provided with proper and sufficient cutlery. The menu, whilst supplying ample, appeared to me to be neither appetising, well-balanced, nor to contain the essentials of a good diet. I submitted to the Care Committee a suggested dietary and whilst the Committee has not been able to adopt this diet in its entirety, the meal has been altered so that it conforms more to hygienic standards. Every child now receives a certain quantity of milk and fresh butter with its meal, and fresh vegetables play a larger part than hitherto in the diet. It is to be hoped that better premises will be obtained in the future where the children can receive their meals in more hygienic surroundings. The provision of meals for school children should not have as its only object provision of food, it should have an educative effect as well. By this I mean that the children should be taught by example not only what to eat, but how to eat, and I cannot persuade myself that the arrangements I saw when I visited the feeding centres were entirely satisfactory. I am glad to report that steps have been taken subsequent to my report to improve both the diet and the conditions. CO-OPERATION OF PARENTS. The parents take an active interest in the work of the Schoo Medical Department. Parents are notified in writing of the Routine Medical Inspection of the children, and 77 per cent, attended in person in 1933. When a child is required at the clinic for examination, the parent is informed, either by the School Nurse or by letter of the date and time of examination. Parents are personally instructed by the School Medical Officer in regard to the treatment required for various defects, and also as to the carrying out of breathing and other remedial exercises at home. CO-OPERATION OF TEACHERS. I would take this opportunity of paying tribute to the cooperation of the teachers in the work of the School Medical Department. By drawing attention to minor defects it has been possible to prevent the occurrence of many conditions which, though trivial at the moment might have resulted in serious illness. 71 CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. Arrangements are in force by which the School Attendance Officers, on becoming aware of absence from school due to infectious disease or contact therewith, notify the School Medical Officer. On the other hand, the School Medical Department notifies the Director of Education of similar cases in order that he may pass on the informaton to the Attendance Officers. CO-OPERATION OF VOLUNTARY BODIES. The Children's Care Committee provides help for necessitous children. Through its agency free meals are granted to children who are suffering from insufficient feeding, and during 1933 24015 dinners were thus provided. Nineteen children were given cod-liver oil and malt, Parrish's Food, etc., and eleven convalescent treatment. 500 pairs of ordinary boots were also provided; one child was given fares to hospital. Through the medium of the Children's Care Committee massage is provided for the children requiring it. A fee of two shillings per visit is charged, and this is paid by the parent whenever possible. In really necessitous cases the Care Committee bears the cost. The National Society for Prevention of Cruelty to Children assists in dealing with parents who are guilty of continued neglect. BLIND, DEAF, EPILEPTIC AND MENTALLY DEFECTIVE CHILDREN. There is no special school for the blind in this area and children suffering from vision so defective that they are unable to be taught in an ordinary elementary school are educated either at a special school in Edmonton or Wood Green or at a residential school for the blind. There are 13 such children in Enfield and they are educated as follows:— Three girls attending residential schools for the blind. One boy and one girl attending Edmonton School for the Partially Blind. Five girls attending Wood Green School for the Partially Blind. Three boys awaiting admission to Schools for the Partially Blind. During the course of the year I visited the Myope School, 72 Wood Green. This school consists of two rooms, each of which is adequately lighted by large windows, both on the right and left of the scholars. About 35 children were present and the accommodation is for 50 children. The children do a certain amount of reading from boards, using various sizes of type. According to the teachers the standard of education is about one year behind that of an ordinary elementary school. The children are inspected regularly by Dr. Manson and their eyes are looked after by the Specialist of the District from which they come. I also visited the Myope School, Montagu Road, Edmonton. This school really consists of one classroom, and including two Enfield children, there are altogether nine children under one mistress. The children's ages vary from seven to sixteen years and the sexes are mixed. During the course of the year I visited the Tottenham School for the deaf, Philip Lane. The following is a copy of the report I submitted to the Education Committee in connection with my visit to the school:— On Tuesday, 14th November, 1933, a visit was made by Dr. Forrester and myself to the Philip Lane School for the Deaf. At this school there are thirteen Enfield children in attendance. Twelve of these were seen by Dr. Forrester and me; one child we were unable to see as she was absent due to illness. The thirteen Enfield children attending this school may be classified as follows:— Totally deaf 4 Partially deaf 5 Motor aphasia 4 Some explanation may be useful concerning these three categories. The totally deaf are those children who have been deaf from birth and would therefore be deaf and dumb except for the teaching they receive at a special school. The four deaf and dumb children at this school are all learning to lip read and to speak. The partially deaf children are those who have become deaf due to disease. Of the five such children attending this school two are practically totally deaf. The question as to whether these children are dumb or not depends on the age at which they acquired their deafness. It will be obvious that if they became deaf before they learnt to speak they are deaf and dumb from the point of view of their education. The five children were doing well and learning 73 to lip read satisfactorily and to speak where the teaching of speech was found to be necessary. The four children classified as Motor Aphasia arc suffering from disease due to lack of development of a certain part of the brain known as the Speech centre. These children hear perfectly but are unable to speak until subject to special training. The four children in question were all learning to speak satisfactorily. Dr. Forrester and 1 were very satisfied with the care and attention that Enfield children were receiving at this school and especially so with the admirable efforts made by the Head Teacher, Miss Beckingsale, to find work for all the children as they leave her school. I am given to understand that she succeeds in placing practically every child that leaves the school. We feel satisfied that the Education Committee is caring for the deaf and dumb children of the district satisfactorily by placing them in Philip Lane School. Mentally Defective Children.—Seventeen children were examined under the Mental Deficiency Act (1913) during 1933. The following is a comparative table for the last five vears:— 1929 1930 1931 1932 1933 A. Dull and backward but capable of instruction in an elementary school 1 7 3 2 1 B. Mentally Defective but capable of instruction in a special school 6 8 3 6 7 C. Mentally Defective but incapable of instruction in a special school 1 3 D. Incapable of further ininstruction in a special school - 3 3 1 - E. Imbecile 2 2 2 4 4 Moral Imbecile - 1 - - - F. Mental condition due to physical defect - — - - - G. Not scheduled 2 - 2 - 5 74 Annual Report of the Senior School Dental Surgeon Mr. C. E. JAMES, L.D.S., R.C.S. for the year ending 31st December, 1933. Mr. Chairman, Ladies and Gentlemen, I beg to submit my annual report for the year ending 31st December, 1933. Fillings inserted during the year under review amounted to 5349, the number in permanent teeth being 4858, and 491 in temporary teeth. Extractions totalled 4112, 586 being permanent and 3526 temporary teeth. It will bo. noted that the number of fillings remains high and exceeds the number of extractions by 1237. These figures are in striking contrast with the corresponding figures prior to the appointment of an additional dentist, when the number of extractions was always more than double the number of fillings. The following table shows comparative figures since 1926 during which period the number of fillings per hundred extractions has risen from 36.7 to 130. Year Fillings temp, and perm. Extractions temp, and perm. No. of fillings per 100 extractions of Temporary and Permanent Teeth 1926 1981 5390 36.7 1927 2001 5583 38.8 1928 1957 5753 34.0 1929 2425 5591 43.3 1930 2115 5850 36.1 1931 3301 4149 79.5 1932 5674 5178 109.5 1933 5349 4112 130.0 75 During 1933 the number of sessions devoted to inspection was 18, an average of 127 children being examined at each session. The practice in Enfield is to devote sufficient time to the routine examinations to permit an accurate record being made of the number of unsaveable teeth, both temporary and permanent, and also a rough estimate of the number of teeth requiring fillings. It is true that more children can be inspected per session if a cursory examination only is made, simply with the object of recording which children should be notified to attend the clinic for treatment. This procedure, however, makes it impossible to obtain a record of the dental condition of the children whose parents subsequently refuse their consent to treatment, as the only opportunity the dentist has of seeing these children is during inspection at the schools. Immediately before inspection, short talks are given to the children on the importance of dental health, and the prevention and treatment of dental disease. These talks are given in the classrooms to each class separately, and the time spent in this manner is about ten minutes for each class. It is felt that although time could be saved if the talk were given to larger numbers of a children at time possibly to a whole department—it is easier to maintain the interest of children when the number addressed is small and when the information and advice is given in the familiar surroundings of their own classrooms. The total number of children examined during the year was 6812, of whom 4748 were found to require treatment and 3328 actually received it. In 1926, 4015 children were found to require treatment of whom 2532 or 63 percent, received it. As pointed out in a recent report of the Chief Medical Officer of the Board of Education, the number of children each dentist can treat in the course of a year depends on the nature of the treatment given. When much time is given to the conservation of teeth as in Enfield, the number treated is necessarily much less than would be the case if the treatment consisted in large measure of extractions. An example of the amount of conservative work necessary even when the general condition of the teeth is good and the number accepting treatment is always high, may be found in the figures relating to the Central School. In this school 67.4 percent, of those examined were referred for treatment and of those referred 87.7 percent, actually received treatment. Of 251 children receiving treatment 208 required conservative treatment, and for these children 550 fillings were inserted, being an average of 2.19 fillings for each child treated or 1.29 fillings for each child examined. The School Dental Service has been compared to the purchase of furniture on the hire purchase system in which the ultimate 76 session of the furniture is contingent on the regular payments of the instalments. To illustrate the correctness of this comparison and the importance of providing facilities for the dental treatment of children who have passed the usual school leaving age of 14 years, figures have been obtained during the past year of the dental treatment required by certain children attending the Central School whose ages ranged from 14—16 years at the time of inspection. For the purpose of this examination only those children were included who had in former years always accepted treatment when notified that it was necessary. It was found that even when the teeth of children undergo regular conservative treatment, as required, up to the age of 14 years, more than 61 percent, of such children are in need of further treatment before they have attained the age of 16 years. During the past year arrangements were made for the administration of nitrous oxide gas anaesthesia for the extraction of teeth. Extractions had previously been carried out under local anaesthesia only. Local anaesthestics, however, are frequently not suitable, especially in the case of nervous children or when septic conditions are present. Many parents had expressed a wish that their children should be given a general, in preference to a local anaesthetic and there can be no doubt that the institution of regular gas sessions will render the school dental scheme more popular and more efficient. The Chief Medical Officer of the Board of Education in a recent annual report requested that school dentists should note the number of children aged 12—13 years at the time of inspection, who had always been free from dental caries, and that certain information should be sought respecting their diet, habits of life and other factors that might tend to explain their immunity to dental disease. An endeavour has been made during the past year to comply with this request, but of 898 children examined aged 12—13 years only eleven were found whose teeth, both temporary and permanent, had never been attacked by dental caries. Particulars respecting nine of these children are submitted. Of the two remaining children it was not found possible to obtain information on which reliance could be placed. Girl. No. 1. Breast fed for 8½ months. Girl. No. 2. Bottle fed on Allenbury's Food for 10 months. Girl. No. 3. Breast fed for 9½ months. Boy. No. 4. Bottle fed on Allenbury's for 9½ months. Boy. No. 5. Breast fed for 8½months. Boy. No. 6. Breast fed for 4½ months, then on cow's milk. Orange juice taken daily. 77 Girl. No. 7. Breast fed for 9 months. Girl. No. 8. Breast fed for 9 months. Children aged 12—13 years whose teeth have always been free from dental caries. Sex. Diet etc. Medical History Condition of teeth of Mother, Brothers and Sisters. 1. Girl. Breast fed for 8 J mths. Good appetite. Eats regularly raw fruit and raw vegetables. Cod liver oil in winter. Brushes teeth daily. Has sweets daily. Raw milk daily. General health good. Chickenpox at age 6 Measles at age 7. Mother's teeth bad. Teeth of brother age 14 always free from caries. Had measles at age 8. Other particulars same as for sister. 2. Girl. 3. Girl. (twins) Bottle fed in infancy. Good appetite. Eats regularly raw fruit and raw vegetables. Raw milk daily in summer, hot milk in winter. Brushes teeth occasionally. Has sweets daily. (Girl 3 as above.) General health good. Whooping Cough age 5 Measles at age 6. Mumps at age 11. (Same as above) Mother's teeth fair. Sister aged 9 has had caries in two teeth only— one temporary molar lost and one permanent molar filled. 4. Boy. Bottle fed in infancy. Good appetite. Eats regularly raw fruit and raw vegetables. Very few sweets. Brushes teeth daily. General health good. Diphtheria at age 7. Chicken pox at age 8. Mother's teeth good. 5. Boy. Breast fed in infancy. Appetite good. Eats regularly raw fruit and raw vegetables. Cod liver oil in winter. Has sweets daily. Brushes teeth occasionally. General health good. Measles at age 5. Mother's teeth fair. Teeth of brother aged 11 always free from caries. Diet same as brother. 78 6. Boy. Breast fed in infancy. Good appetite. Eats regularly raw fruit and raw vegetables. Cod liver oil in winter. Few sweets. Brushes teeth occasionally. General health good. Measles at age 4. Mother's teeth good. Teeth of sister age 15 always free from caries. Diet similar to brother's. 7. Girl. Breast fed in infancy. Appetite good. Eats regularly raw fruit and raw vegetables. Cod liver oil in winter. Few sweets. Brushes teeth daily. General health good. Measles at age 4. Mother's teeth good. Teeth of sister aged 6 years always free from caries. Bottle fed —other particulars same as sister. 8. Girl. Breast fed in infancy. Appetite good. Eats regularly raw fruit and raw vegetables. Has sweets occasionally. Brushes teeth regularly- General health good. Measles at age 6. Mother's teeth fair. Teeth of sister aged 15 always free from caries, excepting one permanent molar filled. 9. Boy. Bottle fed in infancy. Appetite good. Eats regularly raw fruit and raw vegetables. Large quantity of milk taken since age of 18 months cold in summer hot in winter. Brushes teeth rarely. General health good. Scarlet fever at age 5. Measles at age 10. Mother's teeth fair. A considerable number of children of other ages were also found to have teeth naturally free from dental caries, and particulars obtained respecting them were similar to those given relating to children in the 12—13 years age group. A typical example was a family of five children aged 5—10 years whose teeth had always been free from caries, with the exception of two children who had each had superficial caries in two teeth. There is strong evidence that if the diet of children is so controlled that carbo-hydrate stasis is avoided as far as possible the incidence of dental caries is much reduced. Complete freedom 79 from dental caries, however, requires some farther explanation than the cleansing effect on the teeth of certain foods, however beneficial these are known to be. The explanation may, it is felt, be found in the superior structure of some teeth. It has been observed that some children are more liable to dental caries than others, even when the diet and environment are similar, and this may be held to support the view that enamel varies considerably in its susceptibility to dental caries. In the case of children naturally free from dental caries in all age groups, there was a noticeable absence of pits on the coronal surfaces of the molar teeth, so generally noted as the starting points of decay, the enamel presenting a smooth polished surface and appearing to be highly calcified. This characteristic, combined with the regular arrangement of the teeth in well developed arches, rendered the teeth self cleansing in a marked degree. It was observed that brothers and sisters of these children frequently had equally good teeth, or if not equally good the incidence of dental caries was unusually low. This is what one would expect, as the factors responsible for good teeth in one member of a family are generally common to all. In the rare instances found where one child had naturally sound teeth and a brother or sister had a high incidence of dental caries, ill health and a different diet usually afforded an explanation. Children with naturally sound dentitions did not appear to brush their teeth more regularly than other children. It was particularly observed that the diet of caries free children had at no time presented difficulty to their parents, and that they partook regularly of food requiring vigorous mastication. There were instances of children being given raw vegetables from a very early age. The diet of children with a high incidence of dental caries was usually in striking contrast. Many parents complained that the appetites of these children were poor and that they had difficulty in persuading them to eat food of a fibrous nature. In general, their diet was ill balanced, being deficient in elements necessary for the formation of well calcified teeth, and in detergent properties that would tend to maintain them in health after eruption. The sum taken in fees for dental treatment amounted to £63 14s. Od. In conclusion, I would like once more to thank Head Teachers 80 for their co-operation at all times, and to acknowledge the valuable assistance rendered by Nurse Anderson and Miss Groves. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. E. JAMES, Senior School Dental Surgeon. 81 Report of the School Ophthalmic Surgeon Mr. S. MACKY, M.B., B.S., D.O.M.S., for the year ending 31st December, 1933. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my report on the Ophthalmic Department for the year ending 31st December, 1933. Total number of attendances at the clinic 2475 New Cases 1055 Prescriptions for glasses 446 Number not requiring glasses 91 The cases requiring glasses consisted of:— Hypermetropia 79 Hypermetropia with Astigmatism 353 Hypermetropic Astigmatism 175 Myopia 79 Myopia with Astigmatism 104 Myopic Astigmatism 13 Mixed Astigmatism 53 Anisometropia 18 During the year nineteen children were referred for operation for squint. Nine were operated upon and five refused operation and five are awaiting admission to hospital. One child who was awaiting operation in 1932 was operated upon in 1933. As I surmised last year, the total number of attendances has increased by 320 while the number of new cases has only increased by 125, and actually fewer glasses have been prescribed. Obviously this is due to the more frequent examination of the children with squints. As there are 146 of these, naturally the total number of attendances has increased. For the same reason the number of operations shows an increase. Of the cases requiring glasses it is pleasing to note (though perhaps quite insignificant) that the 82 proportion of Hypermetropia to Myopia has still further increased. In regard to early Myopia we carried out a little research at the Routine Medical Inspection. 108 children who read 6/6 with each eye unaided were asked to read again with a + 1.0 dioptre spherical lens. 41 failed to read 6/9. Of this number, after examination under atropine at a later date, seven were found to need glasses. Most of these were low grades of mixed astigmatism and belonged to the 12—13 age group. Only one was aged 8. As the extra time taken for the preliminary examination with the + 1.0 dioptre spherical lens interfered with the routine inspection considerably it was not considered worth while continuing the experiment. More especially as all children with less than 6/9 are sent for examination under atropine as a routine. The details of this investigation are as follows :— No. of children examined 26 Aged 8-9 7 Aged 12-13 19 Hypermetropia Hypermetropic Astigmatism 8 Myopia Myopia Astigmatism 5 Aged8 1. Aged 12. .4. Mixed Astigmatism (4 of the 5 above). Emmetropes (Normal) 10 Emmetropes who may be developing myopia and need watching 3 Given glasses (one case already had glasses) 7 All the errors were less than one Dioptre—except one of hypermetropia with astigmatism. In thinking over the year's work, it occurs to me that the course of action in the case of myopia and high and moderate hypermetropia is clear. But with low hypermetropia and low astigmatism "vertical" much is yet in doubt. Children often present themselves with a history of vague headaches, occasional styes, perhaps red eyes while reading, very often these symptoms have disappeared in the interval between school inspection and attendance at the clinic. On examination many of them prove to be practically emmetropic; perhaps a dioptre or half a dioptre of hypermetropia. Considering the large reserve of accommodation these children possess it seems quite unreasonable to attribute their symptoms to this low degree of hypermetropia, and I think I follow general practice in not giving these children glasses unless symptoms persist or recur. Of course, many of these cases are suffering from disease or defects elsewhere, but after allowing for these there still remain a great number whose symptoms recur, and I 83 think, if a routine examination of the fusion function could be made, we would find many deficiencies. When we consider what an active sense sight is; how perceptions are built up out of myriads of tiny oscillatory movements (even when the eye is "fixed"), how the mind has to build its clear pictures out of this confusing succession of images and after-images; when we remember the vast number of nerve endings in the retina subjected to this continual bombardment, and the unique ocular muscles so highly sensitive and for ever in action; and moreover, when we recollect what great violence we do to nature by setting children to converge and accommodate all day—to look down their noses with organs that only are "at rest" when gazing on far horizons (i.e. more than 20ft ! ); then we can only marvel at the adaptability of man and wonder if some of its failures are not due as much to lack of fusion as to lack of psychological balance. The static part of vision is well cared for, but the active has to take care of itself. We have no eye drills nor gymnastics. But to test the accuracy of this notion would take more research work than can well be undertaken by the Local Authority. Again I have great pleasure in recording my thanks to our very efficient medical and secretarial staff. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, STEWART MACKY. School Ophthalmic Surgeon. 84 Annual Report of the School Aural Surgeon Mr. J. S. HOGG, F.R.C.S. For the Year ending 31st December, 1933. To the Chairman and the Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my report on the work done in the Aural Department tor the year ended 31st December, 1933. During the year we have dealt with 266 cases, of which 186 were new, an increase of 71 over the year 1932. The total number of attendances was 821. Of these 148 have been discharged cured, and there are 18 cases of a recurrent nature who require occasional attention. Forty-two children are still under treatment, ten have refused treatment and in two cases treatment was sought elsewhere either privately or in hospital. Eight cases have been recommended for the removal of tonsils and adenoids, of which one has refused the operation. Seven cases have been referred to hospital for Myringotomy; five of these did well and are cured. In two cases Mastoid operations were performed resulting in a dry ear with good hearing in one case, and great improvement in the other. One case of chronic aural suppuration was admitted to the Throat Hospital, Golden Square, under my care for a practical mastoid operation. He has subsequently been discharged and is now attending the clinic again for after-treatment. Furthermore, during the past year 20 infants, totalling 49 attendances have been referred to the Aural Clinic from the Welfare Centre. Of these only one remains under treatment. I should once more like to express my thanks to the nursing staff of the Southbury Road and other clinics for their help and co-operation during the past year. A detailed list of cases is appended. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, J. C. HOGG. School A ural Surgeon. CLASSIFICATION. Statistical Tables fur the Annual Report of the School Medical Officer, for the Year 1933. TABLE l. RETURN OF MEDICAL INSPECTIONS. A.—ROUTINE MEDICAL INSPECTION. Number of inspections in the prescribed Groups Entrants 561 Second Age Group 944 Third Age Group 832 Total 2337 Number of other Routine Inspections 532 B.—OTHER INSPECTIONS. Number of Special Inspections 5466 Number of Re-inspections 2906 Total 8372 Total Left School or District Refused treatment. Recurrent, but again discharged. Discharged cured. Improved. Still under treatment. I.S.Q. 1. Acute or subacute suppurative otitis media .. 2 , — 50 — 3 5 60 2. Chronic suppurative otitis media 11 12 27 7 4 2 63 3. Chronic catarrhal deafness, Eustachian obstruction and otosclerosis 4 8 21 4 2 1 I 40 4. Wax, otitis externa, eczema, boils, etc. .— 31 7 — 1 39 5. Chronic Rhinitis, nasal obstruction, etc. 1 15 19 — 1 1 37 6. Non-aural — — — — — |— 27 Total 266 86 TABLE II. (A) Return of defects found by Medical Inspection in the year ending 31st December, 1933. DISEASE OR DEFECT. Routine Inspection Special Inspection No. of Defects No. of Defects Requiring Treatment Requiring to be kept under observation, but not requiring treatment Requiring T reatment Requiring to be kept under observation , but not requiring treatment (1) (2) (3) (4) (5) Malnutrition - - - - SKIN. Ringworm. Scalp 1 - 2 - Body 1 - 7 - Scabies - - 11 - Impetigo 1 — 14 - Other Diseases (Non-Tuberculous) 6 2 106 11 EYE. Blepharitis 7 — 33 — Conjunctivitis 8 — 115 — Keratitis — — - — Corneal Opacities 1 — - 6 Defective Vision 275 187 231 12 (Excluding Squint) 8 Squint 21 31 16 Other Conditions 3 — 83 1 EAR. Defective Hearing 53 1 31 4 Otitis Media 23 — 70 — Other Ear Diseases 7 1 64 1 NOSE AND THROAT. Chronic Tonsillitis only 14 51 57 62 Adenoids only 4 4 7 6 Chronic Tonsillitis and Adenoids 220 95 403 165 Other Conditions 23 3 150 145 ENLARGED CERVICAL GLANDS (Non-T uberculous) - 1 28 25 DEFECTIVE SPEECH — 6 2 8 87 TABLE II (continued) HEART AND CIRCULATION. Heart Disease Organic 2 22 14 65 Functional — 1 — — Anaemia — - — — LUNGS Bronchitis 2 — 3 4 Other Non-Tuberculous Diseases — — 6 1 TUBERCULOSIS. Pulmonary Definite 1 4 1 Suspected 1 — 8 2 Non-Pulmonary Glands 1 — 3 4 Bones and Joints Skin - — - — Other Forms - — 1 — NERVOUS SYSTEM. Epilepsy 3 — 5 5 Chorea 2 - 6 1 Other Conditions 3 — 4 8 DEFORMITIES. Rickets — — — — Spinal Curvature — — 8 1 Other Forms 12 8 23 25 OTHER DEFECTS AND DISEASES (excluding Uncleanliness and Dental Diseases) 37 6 1299 237 88 (B) Number of individual children found at Routine Medical Inspection to require treatment (excluding uncleanliness and dental diseases). GROUP. (1) Number of Children Percentage of Children Inspected (2) Found to require treatment (3) require treatment. (4) PRESCRIBED GROUPS Entrants 561 108 19.3 Second Age Group 944 242 25.4 Third Age Group 832 167 20.1 Total (Prescribed Groups) 2337 517 22.1 Other Routine Inspections 532 125 23.5 TABLE III. Children suffering from Multiple Defects, i.e., blindness, deafness, mental defect, epilepsy, active tuberculosis, crippling or heart disease Nil BLIND CHILDREN. At Certified School for the Blind. At Public Elementary Schools. At other Instutions. At no school or Institution Total 3 — — 3 PARTIALLY BLIND CHILDREN. At Certified Schools the Blind. j At Certified At Schools for Elemetary the Partially Schools. Blind. At other Institutions At no School or Instituttion. Total. - | 8 3 - 11 89 DEAF CHILDREN. At Certified schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total 4 - - 1 4 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf At Certified Schools for the Partially Deaf. At Public Elementary Schools At other Institutions At no School or Institution Total - 5 - - - 5 MENTALLY DEFECTIVE CHILDREN. FEEBLE-MINDED CHILDREN. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions At no School or Institution Total 37 - - - 37 EPILEPTIC CHILDREN. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools. At other Institutions At no School or Institution Total - - - - - 90 PHYSICALLY DEFECTIVE CHILDREN. A. Tuberculous Children. I.—CHILDREN SUFFERING FROM PULMONARY TUBERCULOSIS. (Including pleura and intra-thoracic glands.) At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 - - - 2 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools At other Institutions At no School or Institution Total 1 6 1 2 10 B.—DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions. At no School or Institution Total 8 - - - 8 C.—CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total - 30 - 3 33 91 D.—CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions. At no School or Institution. Total 1 - 1 1 3 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1933. TREATMENT TABLE. GROUP I. MINOR AILMENTS (excluding Uncleanliness, for which see Group VI.) Number of Defects treated, or under treatment during the year DISEASE OR DEFECT. (1) Under the Authority's Scheme, (2) Otherwise. (3) Total. (4) SKIN Ringworm—Scalp 2 - 2 Ringworm—Body 7 - 7 Scabies 11 - 11 Impetigo 14 — 14 Other Skin Diseases 95 13 108 MINOR EYE DEFECTS (E.xternal and other, excluding cases falling in Group II.) 220 10 230 MINOR EAR DEFECTS 288 12 300 MISCELLANEOUS (e.g., minor injuries, bruises, sores, chilblains, etc.) 1131 83 1214 Total 1768 118 1886 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.) No. of Dcfects dealt with. Under The Authority's Scheme. By Private Practitioner or at Hospital apart from Scheme Otherwise Total Errors of Refraction (including squint) 964 18 - 982 Other Defects or Disease of the Eyes 12 - - 12 Total 976 18 - 994 No. of children for whom spectacles were Prescribed. (1) Obtained. (2) Under the Authority's Scheme Otherwise. Under the Authority's Scheme Otherwise. 446 18 437 18 93 GROUP III—TREATMENT OF DEFECTS OF NOSE AND THROAT No. of Defects. Received Operative Treatment. Received other forms of Treatment (4) Total number treated. Under the Authority's Scheme, in Clinic or Hospital. (1) By Private Practitioner or Hospital, apart from the Authority's Scheme (2) Total (3) I. 11. Ill IV I. II. IlijlV. I. II. III IV 22! — 202 — 6 2 45 — 28 2 247 143 420 GROUP IV— ORTHOPAEDIC AND POSTURAL DEFECT S. Under the Authority's Scheme. Otherwise. Residential treatment with education Residential treatment without education Nonresiden tial treatment at an Orthopaedic Clinic Residential treatment with education. Residential treatment without education. Nonresiden tial treatment at an Orthopaedic Clinic Total number treated Number of Children treat ed . 1. Tonsils only. II. Adenoids only. Ill Tonsils and Adenoids. IV. Other defects of nose and thoat. 94 GROUP V.—DENTAL DEFECTS. 1. Number of Children who were:— I. Inspected by the Dentist: Aged: 5 328 6 406 7 502 8 522 Routine Age Groups 9 724 Total 5998 1 10 779 11 819 12 697 13 774 14 447 Specials 814. Grand Total 6812 II. Found to require treatment 4848 III. Actually treated 3328 2. Half-days devoted to:— Inspection 48 Treatment 734 Total 782 3. Attendances made by children for treatment 6030. 4. Fillings:— Permanent teeth 4858 Temporary teeth 491 Total 5349 5. Extractions:— Permanent teeth 586 Temporary teeth 3526/ Total 4112 6. Administrations of general anaesthetics for extractions:— 207. 7. Other Operations:— Permanent teeth 588 Temporary teeth 443 Total1031 95 GROUP VI.—UN CLEANLINESS AND VERMINOUS CONDITIONS. I. Average number of visits per school made during the year by the School Nurses 11 II. Total number of examinations of children in the Schools by School Nurses 39,154 III. Number of individual children found unclean 977 IV. Number of children cleansed under arrangements made by the Local Education Authority 7 V. Number of cases in which legal proceedings were taken: a. Under the Education Act, 1921 b. Under School Attendance Byelaws 9 96 Public Offices, Enfield. 1st March, 1934. Report of the Chief Sanitary Inspector for the Year, 1933. To the Chairman and Members of The Urban District Council of Enfield. Gentlemen, I beg to submit my report for the year ending 31st December. 1933. STATEMENT PREPARED BY SANITARY INSPECTOR UNDER ARTICLE XIX (12), MINISTRY OF HEALTH ORDER, No. 276, 1922. Number of Houses Inspected. Inspections. Under the Housing Consolidated Regulations, 1925 139 From House-to-House apart from this Act 581 On Account of Infectious Disease 357 On Account of Phthisis 67 On Account of Complaint by occupant or otherwise 1,525 177 Factories 130 135Workshops and Workplaces 43 Outworkers' premises inspected 21 42 Bakehouses, of which 32 are in use 84 2,947 97 Inspections— (continued). Inspections. Brought forward 2,947 14 Slaughterhouses, of which 10 are in use 2,536 21 Cowkeepers' premises 447 87 Dairies and Milkshops inspected frequently 182 23 Schools 27 Public Conveniences inspected 482 Conveniences at Railway Stations inspected 5 Fish shops ; Total number of visits 58 Coffee and Eating Houses: Total number of visits 6 Coffee-stalls; Total number of visits 42 Shops where ice-cream is made : Total number of inspections 35 Meat Shops: Total number of inspections 121 Food Stalls in Markets: Total number of inspections 966 Fair Grounds: Number of inspections 4 4,911 Visits to absentees excluded from Elementary Schools 1,358 Visits in connection with cases of Infectious Disease 2,020 Visits in connection with Phthisis 297 Visits re Housing Act 66 Visits re verminous premises, etc. 961 Offensive Trades (excluding Fish Shops) 1 Smoke observations 41 Other inspections, including works in progress 8,288 Petroleum Stores Inspected 254 Visits re Shops Act 83 Cinemas, etc., inspected 28 Visits and inspections re Rats 137 Visits re Sub-letting in Council Houses 153 Visits re Gypsy Vans, etc. 21 Visits re overcrowding 3 Visits re Rag Flock Act 4 13,715 21,573 98 Notices Issued. Statutory:— Provision of dustbins 26 For repairs to houses, drains and abatement of nuisances 188 Providing sufficient water-closets 38 Paving of yards Provision of Sinks or Drains 18 270 Informal:— Notices 1,345 1,345 1,615 Other Notices issued under Infectious Diseases Acts:— To occupiers 553 To Education Committee and Head Teachers at Schools 6,798 To Librarian. 129 7,480 9,095 Other letters sent 4,593 Number of Certificates issued in connection with plans 294 Result of Service of Statutory and Informal Notices:— Statutory. Informal. Number complied with 240 1,126 Number outstanding 30 219 270 1,345 As to these outstanding notices, the work required was delayed on account of the weather or other reasonable cause. The general character of the defects found in the dwellinghouses inspected is as follows:— Defective drains and ventilating pipes, etc.,; W.C. flushing cisterns and pipes out of order; cracked and broken W.C. pans; broken, cracked and porous scullery sinks and waste pipes; leaking 99 roofs; defective gutters; absence of, or broken, paving around houses; defective plaster of ceilings and walls; damp walls; want of ventilation under ground floors and general uncleanly conditions. The following are the works carried out as the result of the noticcs or letters Houses or parts of houses cleansed, repaired, etc. 550 Roofs repaired 231 Gutters and down pipes repaired 152 Cesspools emptied 373 Cesspools abolished 0 New Cesspools provided 2 Closet Pails Emptied 1196 House drains cleared, repaired, etc. 224 House drains tested, examined, etc. 593 House drains reconstructed 27 Soil-pipes and drains ventilated, including repairs to ventilators 24 New vents provided 1 Sink-wastes disconnected or repaired 57 New sinks provided 48 Closets provided with proper flushing cisterns or water supply 94 New closets provided 2 Closets repaired, covered, cleansed, etc. 313 Water-closets substituted for earth-closets 0 Privy substituted for earth-closet 0 Storage cisterns repaired, covered, cleansed, etc. 27 Storage cisterns provided 5 Water laid on or restored 23 New wells provided 1 Wells closed 0 Wells cleansed and repaired, etc. 0 Samples of Water taken from Wells 5 Do. do. Main 0 Do. do. Swimming Pool and Baths 4 Samples of Rag-Flock taken under Rag-Flock Act 3 Yards paved, or existing paving made good 109 Ventilation provided under ground floors and causes of dampness removed, etc. 196 Dustbins repaired, or new ones provided 208 Forecourts paved 0 Manure heaps removed 8 Fowls and other animals removed 1 Coppers repaired, etc. 63 100 Stuves repaired, etc. 71 Windows repaired, etc. 120 Other nuisances abated 101 Cases of overcrowding abated 3 Ditches cleaned out 1 Gipsy vans removed 4 Every possible endeavour is made to ensure the carrying out of work with as little delay as possible, and in order to secure this I have interviewed many owners and agents and thus expedited the work. In some cases, when there seemed to be no reason for the delay, a warning from the Council that further proceedings would have to be taken, has secured the final carrying out of the work required. 1,358 visits were paid in respect of children excluded from elementary schools during the year, and the total number of inspections and visits for all purposes made by the Staff of the Public Health Department was 21,573. Disinfection. Houses disinfected After infectious disease 329 After Phthisis 73 After verminous cases 115 Vacated Council houses 157 674 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 27 Ditto, ditto, by cases of Phthisis 11 Articles of clothing, bedding, etc. disinfected 1,150 Ditto, ditto, destroyed 146 Library Books disinfected 154 No. of Certificates issued re disinfection of clothing and premises 20 Number of Schools disinfected 1 Private Patients removed to Hospital or Infirmary 2,149 Gipsy Vans removed from District 4 Articles or parcels of unsound food destroyed or otherwise disposed of 614 From the above table it will be noted that the disinfection of verminous houses, which had to be carried out, meant increased work for the Department. 101 151 vacated Council houses were disinfected during the year, and in 6 cases a second disinfection was found necessary. Out of the total of 151 vacated Council houses no less than 59 showed signs of vermin. The Council has decided that no transfer from one Council house to another is to be granted unless the transferee be found to be in a non-verminous house. DISINFESTATION OF VERMINOUS HOUSES. This matter, as in previous years, has been one of extreme difficulty for the department to deal with. It will be noted that the Medical Officer of Health has dealt with this question in his Report. It has also been a very difficult question for other Authorities throughout the Country to deal with, and I have never yet heard of a satisfactory and effective manner of dealing with bugs. The only thing that can be said in the matter is that nothing but cleanliness on the part of the individual will really lead to a solution of the matter. If all tenants were clean and free from bugs, both as regards their person and furniture when entering Council houses there should be no reason to expect further trouble. This, unfortunately, does not occur. The bug, having once found its livelihood in the house, either by itself or for generations following him, is almost impossible to remove. The perfect tenant suffers at the hand of the imperfect one, and there will be no solution of the matter probably until every individual is taught that cleanliness is an extremely close second to Godliness. The disinfection of verminous clothing and bedding is carried out by means of a Washington-Lyon's Steam Disinfector situated at the Council's Sewage Farm. FACTORY AND WORKSHOPS ACTS, 1901 AND 1907. A register is kept of all the workshops in the District, and at the end of 1933 there were 78 workshops, 57 workplaces and 42 bakehouses registered. The following tables give details of the work done in connection with these places:— 102 Inspections. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 130 - - Workshops (including Workshop Laundries) and Workplaces 43 - — Bakehouses 84 - — Total 257 — — Defects Found. Particulars Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:— Want of Cleanliness 1 1 — — Want of Ventilation — — — — Overcrowding — — — — Want of Drainage of Floors — — — — Other Nuisances 1 1 — — Sanitary Accommodation:— Insufficient — — — — Unsuitable or Defective 6 6 — — Not separate for sexes 2 2 — — Offences under the Factory and Workshops Acts:— Illegal occupation of underground bakehouse - - - — Breach of special sanitary requirements for bakehouses 6 6 - — Other Offences 1 1 — - Total 17 17 — — 103 Homework. Nature of Work. Lists received from Employers Notices served on Occupiers as to keeping or sending Lists. Sending once in the year. Sending twice in the year. Lists. Workmen. Lists. Workmen. Making Wearing Apparel 3 10 6 6 47 Brushes 2 4 — Boot-making 2 2 - - — Umbrellas 1 1 - - - Totals 6 13 8 10 47 Two addresses of outworkers have been forwarded to other districts. PLACES OF PUBLIC ENTERTAINMENT. Twenty-eight inspections of cinemas and other places of entertainment were made in accordance with the recommendation contained in the Circular of the Ministry of Health, dated August 25th, 1920. The sanitary accommodation at each place was found to be satisfactory and sufficient. OFFENSIVE TRADES. The following offensive trades are established in the District:— Fish Fryers 28 Rag and Bone Dealers 3 Glue Maker 1 Soap Boiler and in connection with these, 59 inspections were made during the year. With regard to the Fish-fryers, 15 have been established with the consent in writing of the Council, and the majority of the oldestablished businesses have now been fitted with up-to-date frying stoves. Milk. During the year the routine inspection of cowsheds, dairies and milkshops has been carried out under the Milk and Dairies (Consolidation) Order, 1926. It was found t hat the standard of cleanliness has been fairly well maintained. 104 Further sterilisation plants have been fixed on various farms in the District during the year, and as previously reported another farmer has taken up the parctice of milking cows by mechanical apparatus. So far it appears to be, in this case, a success. Though the period of limewashing has been altered a few years to two months instead of one, there still remains, at times, a little difficulty in getting the limewashing done at the proper period. Licences as follows were in force on the 31st December under the Milk (Special Designations) Order, 1923:— Dealer's Licence to use the Designation " Grade A" 1 Dealer's Licence to use the Designation "Pasteurised" 4 Dealer's Licence to use the Designation "Grade A Pasteurised " 1 Dealer's Licence to use the Designation " Grade A (Tuberculin Tested") 1 Dealer's Licence to use the Designation "Certified" 1 Supplementary Licence to use the Designation " Pasteurised " 1 Supplementary Licence to use the Designation " Grade A " (Pasteurised) 1 Supplementary Licence to use the Designation " Certified " 1 Supplementary Licence to use the Designation " Grade A (Tuberculin Tested) " 1 Supplementary Licence to use the Designation " Grade A" 1 PUBLIC HEALTH (MEAT) REGULATIONS, 1924. The method of the past nine years with regard to the inspection of meat under the above Regulations has been carried out as heretofore, and every attention has been paid to see that all food stuffs are dealt with by the best possible hygienic methods. The tradesmen themselves are paying attention to this matter and various machines and methods are being tested by the shopkeepers to improve the present system. As in the past two or three years, pigs are conveyed from the Yorkshire markets to Enfield by road in lorries, thus avoiding the delay of travel from the railway stations. 105 There has been a difficulty during the past year in obtaining as large a supply of pigs from the country markets as there has been in previous years. Slaughtering during late hours, Saturday afternoons, Sundays and Bank Holidays still continues, and a considerable amount of time is spent by the Sanitary Inspectors in examination of carcases and organs of slaughtered animals. The old back and forward movement of meat from the slaughterhouses in Enfield to the Central Meat Markets, London, and meat from the latter being sent to and sold in Enfield, still continues. It will be noticed in the table given below that the number of animals slaughtered in Enfield has considerably increased, and it may be a question for the Council to consider in the coming years whether there shall be a public abattoir provided in Enfield. The number of carcases examined during the year under these Regulations is as follows:— Oxen 336 Organs or parts of carcases found diseased 34 Cows 1 „ „ „ „ 0 Calves 128 ,, „ ,, ,, 0 Sheep 11,962 ,, ,, ,, „ 350 Pigs 7,329 ,, ,, ,, ,, 143 Goats 1 ,, ,, ,, ,, 0 Totals 19,757 „ ,, „ „ 527 The number of carcases examined exceeded by 2,128 that of 1932. The organs or parts of carcases found to be diseased were surrendered and destroyed. The weight of the meat destroyed was 4 tons 10 cwt. 0 qrs. 4 lbs. The carcases generally were in good condition, and there was no case which necessitated the obtaining of a Magistrate's Order. UNSOUND MEAT AND FOODS. In this connection frequent visits were paid to the slaughterhouses, shops and markets, the number of inspections for this purpose being :— Slaughterhouses 2,536 Shops 121 Stalls in Markets 966 3,623 106 As in previous years, foodstuffs purchased in the various London Markets were submitted for inspection, and 87 parcels were found to be unfit for human consumption ; these consisted of fish, fruit, meat, vegetables, etc. Certificates were given in all cases, as it was found that the articles were unfit for the food of man, so that the owner might obtain replacement of the goods or return of the money from the wholesale dealer. Fourteen certificates in ail were granted. COFFEE STALLS. The question of renewal of licences for old Coffee stalls, and also the plans for new ones, are now passed through this Department, and more up-to-date conditions are required than have been in previous years, that is, with regard to the removal of refuse, water supply and drainage. MOTOR AMBULANCES. There are now two Motor Ambulances for use in the District and both are under the charge of Mr. A. H. Johnstone, the Fire Brigade Superintendent. PETROLEUM. The work in connection with the storage of Petroleum is still on the increase, and, as previously stated, all new petroleum stores, including pumps and tanks, are, at the time of installation, under inspection by one of the Sanitary Inspectors. In every case the proper air test is applied to the tanks before permisssion is given for them to be covered over. One of the duties of this Department is the examination of all plans of proposed garages sent to the Engineer and Surveyor's Department, and reports are made on them to the Plans and Byelaws Committee for submission to the Council for approval. With regard to applications for the storage of petroleum, this duty has been further extended by the fact that Bye-laws have been made by the Middlesex County Council, and more extended consideration has to be given to the whole matter. SHOPS ACT. The duties of inspectors under the Shops Acts are carried out by this Department. There has been no need for serious action during the year. 107 REMOVAL OF HOUSE REFUSE. There is a weekly collection of refuse throughout the District, but we are being asked in some quarters for a bi-weekly collection. The following vehicles are in use for the removal of house refuse : 3—"Electricar" Electric Vehicles. 1—6 cubic yards "S.D." Freighter (petrol) dust-van. 2—10 cubic yards dustless-loading " S.D." Freighters. 1—Tuke and Bell 10 cubic yards " Barrier " Type end-loading vehicle. 29 Dustmen. The electric vehicles are kept at the garage adjoining the North Metropolitan Electric Power Company's sub-station at Ladysmith Road, where the batteries are charged under the supervision of the Company's attendants. The satisfactory performance of these vehicles is in no small measure due to the expert advice and assistance so readily given by Mr. A. H. Bennett, the Resident Engineer, and his staff. It was found necessary at the end of the year to discard a second electric vehicle after ten years service, as its period of economic usefulness was over. It is hoped in the early part of the coming year that this will be replaced by a " S.D." 15 cubic yard rear-loading movable floor vehicle. The Tuke and Bell barrier type end-loading vehicle referred to in my last report, which was brought into use in February, 1932, was completely overhauled and brought up-to-date during the year. I find from frequent personal observation that in the time taken to empty this vehicle by hand tipping, three or four mechanically tipping vehicles can be emptied. This is due partly to the fact that the hand-operated tipping gear needs three and sometimes four men to work it, and partly to the angle of tip, which is insufficient to discharge the refuse from the body without a certain amount of raking out. It will be realised that the reduction of effective load, combined with the loss of time at the disposal point, reduces the efficiency of the vehicle very considerably. With regard to the Garage at Lincoln Road Depot consideration will have to be given to the question of providing additional accommodation for the additional vehicles which will be required. 108 Arrangements exist whereby trade refuse is removed from shopkeepers' premises on payment of a prearranged charge. The income from this source was £60 2s. Od. during the year. During the year, 16,939 tons of refuse were collected and disposed of at a cost of £9,805. This equals 11s. 6.9d. per ton for collection and disposal, as against 10s. 7.6d. in 1932. The cost per head of the population is 2s. 8.7d. per annum, or 0.6d. per week. The average for each house is 10s. 10.6d. per year, or 2.9d. per week. DISPOSAL OF REFUSE. During the year the refuse of Enfield was disposed of on Brown's brickfields, Enfield Highway, by the method of controlled tipping. There are two factors of the greatest importance if this method of house refuse disposal is to be a success. The first is that sufficient labour should be employed, and the second that there should be a sufficiency of covering material. The second factor has always been a great difficulty in Enfield, but we have been somewhat more fortunate during the past year owing to the roadmaking being in progress on one or two of the Council's housing estates. During the past year we have again received visits from other Districts with regard both to our vehicles for the removal of house refuse, and our method of disposal of house refuse, and the various Authorities visiting Enfield have stated that they have benefited by their visit to Enfield, and the various points raised they suggest will be for the improvement of their own District. SEWER FLUSHING. This work is carried out by the Department, and all sewers are regularly examined and flushed by men whose special duty it is. A further duty is the clearing and repair of sewers, and the regular examination of all main drains has been maintained. Systematic sewer flushing enables us to keep in constant touch with the various sewers in the District, and it was found necessary to have the main in Saville Row, Green Street, relaid, and this has proved to be a great benefit to those in that part of the District, and also the main at rear of Hanby Terrace, Ordnance Road, is in hand and will be completed in the early part of the coming year. 109 CESSPOOLS. The various cesspools in the District are examined and emptied by special members of the staff, a proportion of the cost of the work entailed being charged to the owner or occupier of the property. The emptying of cesspools was carried out during nights in the Cockfosters district from January 16th to the end of the year, and was done to the entire satisfaction of everyone concerned. SCHOOLS AND HOSPITALS. The arrangement with the Education Committee is still carried out as regards the conveniences at all non-provided Schools, and these receive daily attention as regards cleansing by one of the employees of this Department. The drainage systems of all elementary and secondary schools in the District are examined by the Sanitary Inspectors. At both the Isolation Hospital and the Enfield War Memorial Hospital the sanitary arrangements are under the supervision of this Department, and those at the Isolation Hospital are attended to regularly in accordance with arrangements made by the Joint Hospital Board, while those at the War Memorial Hospital are attended to weekly as a voluntary service on the part of the Council. In addition a large amount of disinfection has been carried out at the latter Hospital free of charge. PUBLIC CONVENIENCES. The public conveniences at the parks and pleasure grounds, and also five attached to public-houses, making eighteen in all, are under the supervision of this Department. Those attached to the public houses receive daily attention by a man specially detailed from this Department for that purpose, and are kept in a satisfactory condition. The others attached to the Parks and Pleasure Grounds while under the supervision of this Department, are attended to by Park Attendants, etc. as part time employment, and this method is not proving satisfactory and the time is approaching when the question of more full-time attendance being given to these conveniences should be gone into. HORSE TROUGHS AND DRINKING FOUNTAINS. Drinking fountains, and also four horse troughs in the District, receive daily attention as regards cleansing. 110 PUBLIC MORTUARY. One public mortuary in the District, established at the Enfield Highway Cemetery, is constantly under supervision. RATS. Though the duty of the destruction of these pests is, under the Rats and Mice (Destruction) Act, one for the occupier of the premises, we are constantly asked to assist various householders, and this help has always readily been given. In many cases it entails a considerable amount of time and work to obtain an effectual clearance of rats. The staff of the Department remains as in the previous year, but it is not really large enough to meet with the full requirementsof the District. This Report would not be complete unless I again state how much I appreciate the kindly manner in which Dr. Geffen, your Medical Officer of Health, has always treated both myself and the staff and the happy conditions under which we work. I also wish to thank the Council for their continued courtesy and support, and all the members of the Public Health Staff for the very competent manner in which they have carried out their duties, and for their help during the past year. I am, Gentlemen, Your obedient Servant, FRED. WILSON, M.R.San.I., M.S.I.A., Chief Sanitary Inspector. INDEX A. PAGE Adulteration 42 Ambulance facilities 19 Area of District 5 Aural Surgeon's Report 84 B. Baby Week 30 Bakehouses 2 Births 12 Birth Control 27 Blind, Deaf, Epileptic and Mentally Defective Children 71 Blind and Partially Blind Children 88 Bye-laws and Regulations 16 C. Causes of death at all ages 9 Causes of death under 1 year of age 10 Cerebro-spinal Fever 46 Cesspools 31, 109 Chief Sanitary Inspector's Report 96 Children Act 27 Children Suffering from Mutiple Defects 88 Children suffering from Pulmonary and Non-Pulmonary Tuberculosis 90 Children with Heart Disease 91 Clinics and Treatment Centres 20, 64 Closet Accommodation 32 Coffee Stalls 106 Co-operation of Parents 70 Co-operation of Teachers 70 Co-operation of School Attendance Officers 71 Co-operation of Voluntary Bodies 71 Co-operation with Education Committee 30 Councillors 4 Crippled Children 90 D. Deaths 8 Dental Defects 92 Defective Vision and Squint 90 Delicate Children 90 Defects found at Routine Medical Inspection 60 Dental Surgeon's Report 74 Deaf and Partially Deaf Children 89 Dental Treatment 28 Detection and Spread of Infectious Disease 63 Diphtheria 45 Diphtheria Carriers 45 Disinfection 100 Disinfection of verminous persons and their belongings 50 Disinfestation of Verminous Houses101 Disposal of house refuse 32,108 Drainage and sewerage 31 Drinking fountains 109 E. Page Encephalitis Lethargica 46 Enteric and Paratyphoid Fever 46 Enteritis 46 Epileptic Children 89 F. Factory and Workshops Act 101 Fitness of houses 37 G. General Observations 38 H. Horse troughs 109 Hospitals 16,109 Housing 35 Housing conditions 37 I. Infantile Mortality 12 Infectious Diseases and Schools 34, 63 Infectious Diseases table 44 Inquests 11 Inspection and supervision of food. 40 Isolation Hospital 18 L. Laboratory facilities 15 Legislation 16 M. Maternal Mortality 19 Maternity and Child Welfare Statistics 21 Maternity Hospital 18 Measles and German Measles 46 Meat 41 Members of Education Committee 52 Mentally Defective Children 89 Meteorology 50 Mid wives 15 Milk 40, 103 Milk (Special Designations) Order 41 Minor Ailments 91 Mortuary 110 Motor Ambulance 106 N. National Health Insurance 15 Notices issued 98 Notifiable diseases 43 Number of Elementary School Children 59 Number of Individual school children found at Medical Inspection to require treatment 88 Nursing in the Home 15 O. Page Offensive Trades 103 Officials of Council 4 Open Air Education 69 Ophthalmia Neonatorum 48 Ophthalmic Surgeon's Report 81 Other foods 42 Orthopaedic and Postural Defects 91 P. Paratyphoid and Enteric Fevers 46 Petroleum 106 Places of Public Entertainment 103 Poliomyelitis 46 Population 5 Prevalence of, and control over, Infectious and other Diseases 43 Prevention of Blindness 48 Provision of Meals 69 Public Conveniences 109 Public Health (Meat) Regulations 42,104 Public Health (Prevention of Tuberculosis) Regulations 50 Public Health (Smallpox) Prevention Regulations 43 Public Health Staff 14 Physically Defective Children 90 R. Rag Flock Acts 34 Rats 110 Regulations and Byelaws 16 Removal and disposal of house refuse 32, 107 Return of Defects found by Medical Inspection 86 Return of Defects Treated 91 Return of Medical Inspections (Aural) 85 Routine Medical Inspection 59 S. Sale of Foods and Drugs Act 42 Sanitary Administration 16 Sanitary circumstances of District 31 Sanitary Inspection of District 33 Scarlet Fever 45 School Medical Officer's Report 51 School Medical Service in Relation to Public Health 68 Schools 34, 109 Sewerage and drainage 31 Sewer flushing 108 Shops Act 106 Slaughterhouses 42 Smoke abatement 33 Social conditions 6 Staff of Public Health Department 14 Staff of School Medical Department 53 Statistics 7 Streams and Water-courses 31 Sub-letting in Council houses 33 Suicides 11 T. Page Teaching of Hygiene 69 Tuberculosis (County of Middlesex) Scheme 16 Tuberculosis 48 Treatment Clinics (Schools) 64 Treatment of Defects of Nose and Throat 93 U. Uncleanliness and Verminous Conditions 95 Unsound Meat and foods 105 V. Vermin 63 Verminous houses 38, 101 Veterinary inspection of cows 41 Vital Statistics 7 w. Water-courses and streams 31 Water supply 31 Work of School Nurses 63 Z. Zymotic death-rate 47 Zymotic diseases 46