N 439 Haten 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 1934 together with the ANNUAL REPORT of the Chief Sanitary Inspector Stanley Woodfield, T.U. Printer, 8, 10, 12, Windmill Hill, Enfield. ENF 18 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 1934 together with the ANNUAL REPORT of the Chief Sanitary Inspector PUBLIC OFFICES, ENFIELD. 28th March, 1935. Annual Report of the Medical Officer of Health, 1934. To the Chairman and, Members of the Urban District Council of Enfield. Mr. Chairman and Gentlemen, I beg to place before you my 8th Annual Report on the health of the District. Once again the Department has had to face the difficulties associated with a developing District necessitating the expansion of existing services. In 1933, 1,417 houses were completed by the Council and private enterprise; during 1934, 1,238 houses were completed, all by private enterprise. The Department has, therefore, had to cope with 2,655 more houses than two years ago. In connection with Infectious Disease the year was noteworthy for the fact that no single Enfield resident died of either Scarlet Fever or Diphtheria. This is the first time I have been able to record such an occurrence, and incidentally, during the course of the year I only received 37 notifications of Diphtheria, which is the smallest figure that has occurred within my recollection. Towards the end of the year the Council determined to grant facilities to the residents of the District for obtaining immunisation against Diphtheria. I have detailed the plan that has been adopted within this Report, but so far the scheme has not been in operation sufficiently long to judge as to the demand of the District for protection against Diphtheria. It is a most unfortunate fact that the average person seldom seeks protection against disease until disease is upon him and it is too late. In the case of immunisation against Diphtheria, immunisation cannot be obtained till three to six months after the last 2 injection has been given, and, therefore, is useless to control an epidemic; it can, however, prevent it. Those who desire immunity should seek it now, and not wait for an epidemic to visit Enfield. During the year I became aware of many cases of Whooping Cough, Chicken Pox, Measles and Mumps through exclusions from School on account of these diseases. The number, however, was neither large nor the cases of great severity. During the course of the Summer months I kept under supervision the condition of the water at the Enfield Lock Baths and the Enfield Swimming Pool. The water from both Baths was analysed regularly once a month, whilst I carried out weekly tests, and the Baths Superintendents, daily tests. In my opinion, at no time was the Bath water at either place other than safe for bathing purposes. The bacteriological count was always low and no disease-bearing organisms were isolated. This result was obtained by adding disinfectant to the water in an amount which is usually considered undesirable. No harmful effects were reported, however, to me, nor did I receive complaints at any time. On the other hand, the aim at a Swimming Pool should be to maintain the water in such a condition that it conforms to the standard for drinking water, and is, in fact, fit for drinking. The turn-over period at the Enfield Swimming Pool is being increased from a twelve-hour turn-over to a four-hour turn-over, and I sincerely hope and trust that during 1935 I shall be able to state that the water of our Swimming Pool is fit to drink. Swimming Pools have arisen in large numbers throughout the country, and as a result Medical Officers have had to revise their ideas as to what standards of purity are required and what tests are of the greatest importance. To my mind, the water should always be crystal clear, free from vegetable growth of any description, sparkling, odourless and absolutely free from germs, whilst it should contain the minimum possible quantity of disinfectant. In addition to this, it is usual to take into consideration the amount of chlorides, nitrites and ammonia compounds present. I think that too much importance can be placed on these chemical results. Nearly all these compounds increase during the course of the season; provided that the water is clear, sterile and odourless, I do not think their presence can be considered of great importance. 3 I am pleased to be able to record a steady expansion of the Council's Maternity and Child Welfare services, fuller reference to which will be found in the Report. There is one fact, however, upon which the Council can congratulate itself. The Infantile Mortality for 1934 is 43.27, which compares with an Infantile Mortality rate of 59 for the whole of England and Wales and 63 for the 121 County Boroughs and Great Towns, including London. It is the lowest Infantile Mortality rate that Enfield has ever recorded. It was in 1888 that Annual Reports were first introduced and this figure ascertained. This figure warrants further information on the subject of Infantile Mortality. It represents the number of children who died under the age of one year per 1,000 births, and the figure is corrected to take into consideration children who rightly belong to Enfield, whether they were born or died outside or inside the District. It is considered by some to be a very important indication of the health of the district. I am, therefore, setting out the Infantile Mortality rates since 1888, when the first Annual Report was published. Infantile Year. Mortality Rate. 1888 135.0 1889 105.0 1890 145.0 1891 95.0 1892 114.0 1893 135.0 1894 94.0 Average 1895 109.0 131.30 1896 147.0 1897 153.0 1898 155.0 1899 175.0 1900 145.0 4 1901 89.3 1902 127.1 1903 113.4 1904 158.3 1905 117.17 1906 105.7 1907 116.6 1908 90.14 Average 1909 111.42 >101.76 1910 83.15 1911 140.79 1912 76.30 1913 87.15 1914 80.75 1915 86.85 1916 57.83 1917 88.10 1918 66.94 1919 56.35 1920 45.39 1921 66.77 1922 63.34 1923 54.62 1924 44.22 1925 51.66 Average 1926 65.60 55.94 1927 59.89 1928 58.53 1929 59.21 1930 51.21 1931 53.50 1932 60.11 1933 50.38 1934 43.27 It will be noted that since 1916, when the Infantile Mortality rate was 57.83, there has been a persistent drop, and the figure has remained since then between 50 and 67, with only one exception. It was in 1916 that the Council appointed its first Health Visitor and opened its first Maternity and Child Welfare Clinic ; therefore, 1916 marks the beginning of Maternity and Child Welfare in Enfield. Since that date the services have been increased in every 5 direction and our Infantile Mortality rate has remained consistently low. During the course of the year, in applying scales for the granting of help, the Council determined to take into consideration the unborn child, realising that care of an infant must begin before it is actually born. As a result of this, many mothers were enabled to obtain treatment for their teeth before their children were born, instead of waiting until the additional member of the family brought them within the scale. The demand for Home Helps after a confinement has continued throughout the year, and dental treatment has been sought and appreciated. During the latter months of the year the work of building three new Maternity and Child Welfare Centres was commenced, and before this Report is circulated they will have been opened and be in use. They should ultimately be the nucleus of a Health Service in each part of the District; not a service to cure disease, but one to prevent it. Enfield will probably be the first District to have opened three new Maternity and Child Welfare Clinics on one day, and I am hopeful that the occasion will mark a new era in the prevention of disease within the District and that there will be created throughout Enfield a health-conscientiousness and a determination to prevent disease, or at least control it in its earliest stages. During the course of the year 11 houses were demolished. In 1933 the Council adopted as its 5 year programme the demolition of 63 houses. By the end of 1934, 56 houses had been demolished and arrangements completed for the demolition of 17 more. It will be seen that the Council has not only completed its 5 year programme in two years, but exceeded this programme; furthermore, I represented to the Council three areas comprising 45 houses as Clearance Areas. These areas are at present under consideration by the Council. In order to obtain even further improvement in the condition of the dwelling-houses in the District, the Department commenced using Section 17 of the Housing Act, 1930, instead of dealing with most of the defects found, under the Public Health Acts. Under previous procedure, it was only possible to abate those nuisances that were, more or less, specifically stated in the Act. According to Section 17 of the Housing Act, 1930, it is possible to get remedied any defect which renders a house in any way unfit for human habitation. It has been with the greatest pleasure that I have noted the 6 gradual increase of co-operation and help that has been received from the landlords and their agents. On no occasion during the year have we had to go to Law to enforce the carrying out of works under Section 17 of the Housing Act, 1930. Whilst this is largely due to the fact that the Notices served have been in strict accordance with the Act and included only such work as could rightly be enforced, the willingness of the landlords and their agents to do their best to render property fit to live in has materially helped to get the work done in a smooth and pleasant manner. Thousands of pounds must have been spent during the year in securing improvement in the condition of houses in the District. Of no small importance is the fact that three new refuse collection vehicles of the dustless type were purchased. By the end of 1934 the Council had a fleet of six dustless collection vehicles, leaving only one of the old semi-open type. In addition to this, the Council purchased a combined Cesspool and Gulley Emptier. This cesspool emptier replaces the old horsedrawn van and hand-worked pump which used to take anything up to an hour-and-a-half to empty one cesspool. The new vehicle can achieve the same object in a matter of minutes. Whilst this is an asset to the District, it does not represent the perfect system, which consists in securing main drainage to every house. The best cesspool does not replace main drainage. I once more wish to express my gratitude to the Council for its courtesy, and especially to the Chairmen of the Health and Maternity and Child Welfare Committees, from whom I have received the greatest help and co-operation. My thanks are also due to my colleagues, and above all, to the members of my Staff who have so loyally co-operated with me throughout the year. I am, Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health. 7 URBAN DISTRICT COUNCIL OF ENFIELD. Chairman of the Council G. E. JONES, 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. S. G. ROWLANDSON, Esq. A. E. KINGWELL, Esq., F.R.I.B.A. W. W. CAKEBREAD, Esq. S. G. HILLS, Esq. A. R. KEMP, Esq. H. G. SHORT, Esq. W. T. TAYLOR, Esq. T. H. M. CLARKE, Esq. F. C. O. MINNS, Esq. Members of the Health Committee:— Chairman W. J. CLARKE, Esq. also Messrs. ANDERSON, T. H. M. CLARK, COLLINS, EDWARDS, KEMP, KINGWELL, MINNS and SHORT. Members of the Maternity and Child Welfare Committee Chairman F. C. 0. MINNS, Esq. The whole of the Members of the Council, and Co-optative Members—Mrs. E. ADAMS, Mrs. A. I. BUSHELL, Mrs. I. G. DUFTON, Mrs. B. C. EELES, Mrs. A. E. HEATH, Mrs. G. F. PORTER, Mrs. B. S. RIDER, Mrs. H. ROTHWELL and Miss G. M. FORD. Clerk and Solicitor to the Council KENNETH TANSLEY, Esq. Engineer and Surveyor to the Council H. R. CRABB, Esq., M.lnst.C.E., F.S.I., A.R.I.B.A. Treasurer to the Council S. GIBSON, Esq., A.S.A.A., F.I.M.T.A. Chief Sanitary Inspector FRED WILSON, Esq., M.R.San.I., M.S.I.A. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,400 POPULATION. The population as estimated by the Registrar General in the middle of the year was 74,664, 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. 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 1934 74,664 The number of inhabited houses at the end of 1934, according to the Rate Books, was 17,938. The rateable value of the District is £619,042 The net product (after allowing for cost of collection) of a penny rate is £2,360 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. 9 Year No. of inhabited houses. Rateable value. Sum represented by a penny rate. £ £ s. d. 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 1934 17,938 619,042 2,360 0 0 Although in the last ten years the population has increased by about 11,000 and the number of houses by 5,000; the total increase in the Staff in that period, apart from Maternity and Child Welfare, consists of 1 Sanitary Inspector and 2 Junior Clerks. SOCIAL CONDITIONS. Development in Enfield is still proceeding apace. During 1933, 1,417 houses were erected, and during 1934, 1,238. This makes a total of 2,655 in the course of two years. The houses built during 1934 were all built by private enterprise. I think it is safe to say that at least 80 per cent. of these houses are of a type suitable for occupation by the working classes. Despite this development, however, Enfield still retains its general character of being both a rural and urban district. I cannot help feeling, however, that as time goes by Enfield will lose much of its rural characteristics. Factories continue to be erected. The continuance of Town Planning should prevent the District from being spoilt, and it is to be hoped that eventually Enfield will be a District free from slums and that lack of amenities that is bound to exist without such control. The District is, to a large extent, a dormitory for London, and it is probable that the better facilities for travelling, resulting from the opening of stations on the Piccadilly Tube at Enfield West and Cockfosters, will increase this position. 10 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:— Total Male. Female. Legitimate 1,057 535 522 Illegitimate 29 18 11 Birth-rate—14.54 per 1,000 population. Still Births:— Total. Male. Female. Legitimate 36 17 19 Illegitimate 4 1 3 Rate per 1,000 total births—35.52. Total. Male. Female. Deaths 720 355 365 Death-rate—9.64 per 1,000 population. Number of women dying in, or in consequence of, childbirth:— Rate per 1,000 Deaths. Total Births. From Puerperal Sepsis 2 1.77 From other Puerperal causes 2 1.77 4 3.55 One of these four cases was removed to 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 43.27 Legitimate infants per 1,000 legitimate live births 41.62 Illegitimate infants per 1,000 illegitimate live births 103.44 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) 2 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, 121 County Boroughs and great towns (including London) and 135 smaller towns:— Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Births. Still Births. England and Wales 14.8 0.62 11.8 59.00 London 13.2 0.50 11.9 67.00 121 County Boroughs and Great Towns (including London) 14.7 0.66 11.8 63.00 135 Smaller Towns 15.0 0.67 11.3 53.00 ENFIELD 14.54 0.53 9.64 43.27 11 DEATHS. The deaths registered in the District during the year were 448, of which 203 were males and 245 females, giving a crude death-rate of 6.00. To these must be added 314 deaths of Enfield residents registered outside the District, and from this total must be subtracted 42 deaths of non-residents, occurring in the District, which brings the number of deaths to 720 for the year, giving a net deathrate of 9.64 per 1,000 population. The corresponding figures for Enfield for the five previous years are 1929 1930 1931 1932 1933 Net death-rate 10.56 9.63 10.40 10.64 9.83 Seventy-five deaths registered in the District were persons over 80 years of age, 21 being males and 54 females, one man dying at the age of 97. The more important causes of deaths registered were:— Malignant Disease, 103; Bronchitis, 36; Heart Disease, 176; Old Age, 13; Tuberculosis of Respiratory System, 52; Pneumonia, 52; Other Respiratory Diseases, 11; other Circulatory Diseases, 44; Nephritis, 10; Cerebral Haemorrhage, 29; Deaths from Violence (excluding suicides), 27; Influenza, 5; whilst among the children, Premature Births accounted for 14; Inanition and Marasmus, 7; Congenital Malformations, 4; Pneumonia, 8; and Injury at Birth, 4. . It is to be noted that of the 720 deaths that occurred during the year, 314 took place outside the District of Enfield; most of these were Enfield residents who died at the North Middlesex County Hospital, Edmonton. In past years the weekly death returns that I have received have been those of persons dying in Enfield, including those, who, although they died in the District, are residents elsewhere and must be transferred to their respective Districts. It will be realised, however, that during the year a large number of Enfield residents die in the North Middlesex Hospital. These deaths have been notified to me at the end of each quarter by the County Authority. Through the courtesy of Doctor Harding, the Medical Officer of Health for Edmonton, arrangements have been made whereby I have been supplied by Doctor Harding each week with the names, addresses, ages and causes of deaths of Enfield residents dying in the North Middlesex Hospital. This information has been of value, and is much appreciated. 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. 12 TABLE 1. Causes of Death during Year 1934. Causes of Death. Males. Females. Total. All Causes—Certified 355 365 720 Uncertified — — — Typhoid and Para-Typhoid Fevers — — — Measles — 1 1 Scarlet Fever — — — Whooping Cough — 1 1 Diphtheria — — — Influenza 3 2 5 Encephalitis Lethargica — — — Cerebro-Spinal Fever — — — Tuberculosis of Respiratory System 26 26 52 Other Tuberculous Diseases 4 4 8 Syphilis 1 — 1 General Paralysis of Insane Tabes Dorsalis 2 — 2 Cancer, Malignant Disease 48 55 103 Diabetes 5 3 8 Cerebral Haemorrhage, etc. 16 13 29 Heart Disease 76 100 176 Aneurysm 3 — 3 Other Circulatory Diseases 26 18 44 Bronchitis 20 16 36 Pneumonia (all forms) 25 27 52 Other Respiratory Diseases 4 7 11 Peptic Ulcer 8 2 10 Diarrhoea etc. (under 2 years) 1 1 2 Appendicitis 3 4 7 Cirrhosis of Liver 1 1 2 Other Diseases of Liver, etc. 1 1 2 Other Digestive Diseases 8 9 17 Acute and Chronic Nephritis 5 5 10 Puerperal Sepsis — 2 2 Other Puerperal Causes — 2 2 Congenital Debility, Premature Birth, Malformations, etc. 14 15 29 Senility 2 11 13 Suicide 6 4 10 Other Violence 22 5 27 Other Defined Diseases 24 29 53 Causes ill-defined or unknown 1 1 2 Total 355 365 720 13 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 8 2 3 30 9 5 3 - 47 Uncertified — — — — — — - — — — Smallpox - - - - - - - - - - Chickenpox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping Cough - - — - - - - - - - Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - - - - Convulsions — 2 — — 2 — — — — 2 Laryngitis - - - - - - - - - - Bronchitis - - - - - 1 - - - 1 Pneumonia (all forms) — 1 — 1 2 2 2 2 — 8 Diarrhoea - - - - - - - - - - Enteritis - - - - - 1 - - - 1 Epidemic Diarrhoea - - - - - - - - - - Gastritis - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - — - - Suffocation, overlying - - - - - - - - - - Injury at Birth 3 — — 1 4 — — — — 4 Atelectasis - - - - - - - - - - Congenital Malformation 2 — — 1 3 1 — — - 4 Premature Birth 11 3 — — 14 — — — - 14 Atrophy, Debility and Marasmus 1 1 1 - 3 2 2 - - 7 Other Causes — 1 1 — 2 2 1 1 - 6 Totals 17 8 2 3 30 9 5 3 - 47 Net Births in the year:—Legitimate: Live births, 1,057; Stillbirths, 36. Illegitimate: Live births, 29; Still-births, 4. Net Deaths in the year:—Legitimate Infants, 44; Illegitimate,3. 14 Cancer carried off 103 individuals, and Tuberculosis of the Respiratory System 52, a combined number of 155. This compares with a total of 121 for last year, and the percentage of deaths from these two causes is 21.5 as against 17.1 for 1933. INQUESTS. Seventeen inquests and twenty-five P.M.s without inquests were held in Enfield during the year, and the verdicts were as follows:— Natural Causes 26 Accidental Causes 6 Suicides 7 Open Verdict 2 Misadventure 1 The above table shows that 7 persons committed suicide during the year under review. In 1933 there were 8, and in 1932, 8. The ages and sexes of the 7 people who committed suicide during the year were as follows:— Males, 33, 42, 56 and 60 years. Females, 22, 32 and 68 years. SUICIDES. I would call attention to the continued fact that the number of suicides is greater among males than amongst females. This tendency exists through the Country. The causes of death were as follows — 4 Coal Gas Poisoning. 1 Hanging. 1 Cut Throat. 1 Drowned in a river. In 1933 of 7 suicides either in the District or of Enfield residents outside, 3 were older than 45 years. In 1932, of 12 suicides in the District or of Enfield residents outside, 10 were older than 45 years. 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. BIRTHS. The actual number of births registered in the District was as follows:— Boys. Girls. Total. 424 409 833 15 including 16 illegitimate births, i.e., 1.92 per cent. of the total. In addition, 12 male and 14 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. 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 1934 571 555 1,126 15.08 .44 INFANTILE DEATHS. The total number of deaths which occurred amongst infants under one year, including 24 registered outside the District, and deducting 3 of non-residents occurring in the District, was 47, giving a death-rate of 43.27 per 1,000 births, as compared with a death-rate of 59.00 for England and Wales, and 63.00 for the 121 County Boroughs and Great Towns (including London). The corresponding figures for Enfield for the last four years were: 1930, 51.21; 1931, 53.50; 1932, 60.11; and 1933, 50.38. The causes of death remain much the same as last year, Pneumonia accounting for 8 deaths, Enteritis for 1, Congenital Malformations, Premature Birth, Atrophy, Debility and Marasmus, etc., accounting for 29. The number of deaths of illegitimate children was 3, which gives a death-rate of 103.44 per 1,000 illegitimate infants. This is the lowest infantile death rate that Enfield has been able to record since 1888 when Annual Reports were first published. The mildness of the Winter may be partly responsible for this, but on the other hand it must be remembered that in past years a 16 hot summer usually accounted for a large number of deaths from Summer Diarrhoea. It has always been assumed that Summer Diarrhoea is an infectious disease spread through germs carried on dust. It is obvious that hot weather and lack of rainfall must mean increase of dust. This factor, however, seems to have been overcome, for despite the fact that the last two summers have not only enjoyed hot spells, but, in addition, have been marked by lack of rainfall, the infantile mortality rate has dropped. One would like to feel that the Maternity and Child Welfare services which the Council provide have contributed towards this drop in the infantile mortality rate. The low figure recorded is doubly important, for it may be assumed that with a low infantile mortality rate there has been a low sickness rate, and not only has much grief been prevented, but, in addition, a considerable amount of suffering avoided. 17 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 Medallist, 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 : *NOEL SMITH, A.R.San.I., M.S.I.A. *HARRY WIGGETT, Cert.R.San.I., Diploma of R. San. Inst., for Inspection of Meat and other Foods, M.S.I.A. *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. *L. ROWLEY, Cert. R. San. I., M.S.I.A., Diploma of R. San. 1. for Inspection of Meat and other Foods. *A. RAMSDEN, Cert. R. San. I., M.S.I.A., Diploma of R. San I. for Inspection of Meat and other Foods. 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. I. 2nd Clerk—Miss E. W. BOWYER. 3rd Clerk—Miss L. GOSFORD. (Resigned 30th June, 1934.) 4th Clerk—S. H. BEYER., Cert. R. San. I. 5th Clerk—L. R. GODFREY., Cert. R. San. 1. 6th Clerk—R. JOHNSON. 7th Clerk—Miss V. M. SIMMONS. 8th Clerk—C. W. CHAPMAN. 9th Clerk—Miss D. HILLER. Maternity and Child Welfare: Dr. H. DEAN, M.R.C.S., L.R.C.P., D.P.H. (Part-time Assistant Medical Officer of Health). (Resigned 28th February, 1934). Dr. K. McKEOWN, M.D., D.P.H. (Part-time Assistant Medical Officer of Health). Dr. C. J. THOMSON, M.B., M.D., (Part-time Assistant Medical Officer of Health). Mr. C. E. JAMES, L.D.S., Eng., R.C.S. (Part-time Dental Surgeon). Mr. R. BRADBURY, L.D.S. (Manchester) (Part-time Dental Surgeon). *Contributions received from the County Council. 18 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 1,008 56 952 5.55 Sputum 222 31 191 13.96 Totals 1,230 87 1,143 7.07 Reference to the laboratory report shows that 1,008 swabs were examined during the year. This number is 332 less than that for 1933. This diminution is due to the fact that there were only 37 cases of Diphtheria notified during the year as compared with 45 in 1933. The year is marked by an absence of one single death from Diphtheria. The mortality rate is, therefore, zero. It is not, however, sufficient that there should be no mortality from Diphtheria. This disease to-day is preventable by means of Schick testing and inocculation. Towards the end of the year I placed before the Council a scheme for the testing and inocculation of Enfield residents. 19 According to this scheme it has been decided to provide the material necessary for immunisation free to the poorer residents of the District who may desire it. Immunisation will be carried out at the Council's School Clinics and Maternity and Child Welfare Clinics by the Medical Officers of the Council. There is provision in the scheme, however, for the supply of materials to Practitioners treating Enfield residents. The scheme was only adopted at the end of the year and has not been put into practice completely at the time of writing this Report. The small number of cases of Diphtheria and the absence of mortality render it unlikely that much demand will be made for immunisation. I sincerely hope, however, that the residents of the District will not wait for a serious epidemic to provide the propaganda and impetus to the obtaining of protection against this serious disease. 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 1932, and for information in respect to these reference thereto is advised. TUBERCULOSIS (COUNTY OF MIDDLESEX SCHEME). The following statement shows the total number of beds belonging to, or reserved for the sole use of, the County Council during 1934. 20 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 Non-pulmonary. Victoria Home, Margate - - 6 Non-pulmonary. Other Institutions at which patients have been maintained by the County Council during 1934 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; Royal Sea-bathing, Margate ; St. Anthony's, Cheam; All Saints, Royal National Orthopaedic, St. Mary's, St. Thomas's, 21 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, Tottenham; St. Michael's Orthopaedic, 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 Hospital from the Enfield District during the year:— Scarlet Fever 201 Diphtheria 36 Diphtheria Carriers 5 Erysipelas 1 Measles 12 Puerperal Pyrexia 2 Puerperal Fever 1 Poliomyelitis 1 Whooping Cough 1 Chicken Pox 1 Pemphigus Neonatorum 1 Anthrax 1 Other 20 22 MATERNAL MORTALITY. During the year 1 case of Puerperal Fever and 4 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 Isolation Hospital. 2. Pulmonary Embolism At Home. Post Partum. 3. Septic Abortion In North Middlesex County Hospital, Edmonton. 4. Eclampsia and Cardiac Do. Failure. The average age of these four women was 31 years. In November, 1934, the Maternity and Child Welfare Committee considered Circular No. 1433 of the Ministry of Health concerning maternal mortality. In this Circular the Minister reviewed the steps that had been taken to reduce maternal mortality, and suggested that local authorities should call for a special report on this subject from their Medical Officer of Health, shewing to what extent effect had already been given to the recommendations of the Maternal Mortality Committee in their final report for 1932 in respect of the following:— 1. Improving the Ante-natal services. 2. Ensuring that the services of a trained midwife are available for all confinements. 3. Securing the provision of maternity beds for complicated cases and for patients with unsuitable home conditions, such beds to be associated where practicable with general hospitals, preferably in small units readily supervised, and for which prompt specialist services for serious cases may be made available. 4. Providing facilities for the adequate isolation and separate nursing of cases of Puerperal Sepsis, and 5. Obtaining the services of a consultant for doctors needing assistance in difficult and complicated cases. The Minister stated that there was a clear case for development of maternity services on urgent grounds of public health, and he considered that it would be true economy for each Authority to do what is needed to provide a service for their area which is both effective and comprehensive. 23 The Maternity and Child Welfare Committee considered each one of the aforementioned headings. It was considered that for the moment the nine sessions held monthly for the examination of ante-natal cases was sufficient, but that, in view of the fact that the numbers were increasing, it would be wise to consider the possibility of increasing the number of clinics when the new Clinics in course of erection were completed, as the cost then would be considerably less than holding them in hired premises. The Committee noted that arrangements had already been made for the treatment of dental defects and the provison of dentures, but arranged with the Education Committee for treatment of ante-natal and nursing mothers at the School Ophthalmic Clinic if they were suffering from defects of the eyes or bad eyesight. This scheme has been put into operation and is proving successful. Arrangements already existed whereby individual application for the services of a midwife could be considered by the Maternity and Child Welfare Committee, and a midwife provided free where the Committee considered this to be necessary. Following upon the Circular of the Ministry of Health, the Committee determined to pay for the service of a midwife in every case where the income of the family was below a certain scale, and this, whether a doctor was in attendance or not. The midwives and doctors of the District have been circulated and informed of this scheme. It was not until the end of the year that the effect of the scheme was felt, but applications for the services of a midwife have increased in number during the first few months of 1935. Complicated maternity cases have been regularly admitted to the North Middlesex County Hospital and a few to the Enfield War Memorial Hospital. The Maternity and Child Welfare Committee was not aware of any case where admission had been refused. The Council, however, have under consideration the possibility of erecting a Maternity Home, either under the direct control of the Council, or in conjunction with other districts or voluntary associations, and meetings are being held to consider alternative suggestions. In the meanwhile the Council has been given to understand that the number of maternity beds at the North Middlesex County Hospital has been increased, and that there is a possibility of an even larger increase in the future should this be found to be necessary. Cases of puerperal sepsis and other cases needing isolation and special nursing have been admitted in the past to the Enfield and Edmonton Joint Isolation Hospital. This procedure has worked satisfactorily, and the Committee did not propose to take any 24 further steps at the moment in this direction. The Maternity and Child Welfare Committee gave very careful consideration to the question of obtaining consultants for doctors needing assistance in difficult and complicated confinement cases. The distance of Enfield from London makes it extremely difficult, if not impossible, for local practitioners to call an Obstetric Specialist from London during the course of a confinement unless his patient is at least well-to-do. The alternative has been to obtain admission to the North Middlesex County Hospital or the Enfield War Memorial Hospital. This must have meant the admission to hospital of some cases that could have been adequately treated with Specialist advice at home. Moreover, the Committee had the fear that in view of the difficulties of obtaining a second opinion there was a tendency for doctors to deal with difficult cases themselves, when they would have been far happier had they been able to obtain a second opinion. I accordingly was instructed to confer with Doctor Tate, the County Medical Officer, and see if steps could be taken to obtain the services of the Obstetric Specialists at the North Middlesex County Hospital for complicated midwifery cases. Doctor Tate gave me a most kind and sympathetic hearing, and the County have now agreed to make the services of their Obstetric Specialists at the North Middlesex County Hospital available for complicated midwifery cases in the district. The scheme will work very simply. Any practitioner attending an Enfield resident during her confinement and desiring a second opinion can telephone the Medical Superintendent at the North Middlesex County Hospital and consult him concerning the case. If it appears that immediate admission to hospital is necessary in the interest of the patient, arrangements will be made at once for such admission. In other cases, however, where the danger is not so urgent, one of the Obstetric Specialists at the Hospital will visit the case, together with the general practitioner in charge, and will advise and help him. Each time a consultant attends on an Enfield resident the Enfield Council will pay the Middlesex County Council a sum of £2 2s., and the Enfield Council will recover from the patient as much of that sum as the patient can reasonably afford to pay. I look upon this as one of the most important steps the Council has made in connection with maternity and child welfare, and I feel that I shall have the whole-hearted support of every practitioner in Enfield in making this scheme a success. 25 Perhaps at this juncture I should do well to pay tribute to the practitioners of the District. It behoves me to remember that the prevention of disease is essentially in their hands, and that it is their help and co-operation that enables the Council to protect the health of the district and prevent disease. I can imagine no more loyal body of colleagues than the practitioners of the district ; their help has been forthcoming on any and every occasion when it has been required, and has been truly given on every and any occasion. I do believe that the practitioners will welcome this scheme. I hope that they will take full advantage of it and not hesitate to telephone the Medical Superintendent of the North Middlesex County Hospital in any midwifery case that causes them the slightest concern. I would also like to record my thanks to Doctor Tate and Doctor Ivor Lewis, Medical Superintentent of the North Middlesex County Hospital, for helping me in facilitating these arrangements. 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 ; 283 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 3,432. St. John's Ambulance Brigade also deals with some cases. No charge is made for the use of the Council's Accident Ambulances. 26 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 R:v.d 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, & 2nd Tuesday 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 Tuesdays 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. 27 Owing to the large number of mothers who were attending at the Ante-Natal Clinic at the Southbury Road Centre, Ponders End, in July, 1934, the Maternity and Child Welfare Committee determined to hold three sessions each month instead of two. This extra session has relieved the congestion at this Clinic, and has enabled the Medical Officers to give more individual attention to each case. 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. Ponders End 6,699 3,145 336 1,422 66.3 Bush Hill Park 7,215 3,215 251 1,838 71.4 Town and Chase 6,857 3,127 246 1,984 69.9 Ordnance 8,819 3,878 325 1,350 89.9 Totals 29,590 13,365 1,158 6.594 74.3 ANTE-NATAL CLINICS. Centre. New Attendances. ReAttend ances. Total Attendances Average Attendance per Meeting. Southbury Rd. Council School 174 329 503 17.9 St. Mark's Institute 112 219 331 13.7 Armfield Road Institute Totteiidge Road Baptist 79 168 247 10.2 Sunday School 111 249 360 15.0 Totals 476 965 1,441 14.4 The following table gives particulars of the work done by the Health Visitors during the year. 28 Visits. Town, Chase and Hadley. Bush Hill Park. Ordnance. Ponders End. Totals. Birth Notification Visits 238 230 263 242 973 Ditto Re-visits 464 667 519 791 2,441 Children, 1-5 years. Visits 1,367 1,516 1,540 1,543 5,966 Visits re Insanitary Conditions 14 2 - 1 17 General Visits 324 69 59 98 550 Ante-Natal Visits 143 150 109 195 597 Post-Natal Visits — 158 29 21 208 Blank Visits 300 153 65 140 658 Infectious Disease Visits 34 134 93 76 337 Ophthalmia Neonatorum Visits - 1 - 1 Puerperal Fever Visits - 1 — — 1 Puerperal Pyrexia Visits 1 1 1 1 4 Visits re Foster Children 18 22 28 28 96 Totals 2,903 3,103 2,707 3,136 11,849 Feeding, etc. Feeding. Town, Chase and Hadley % Bush Hill Park % Ordnance % Ponders End! % Totals % Natural 208 87 205 89 240 91 210 86 863 88 Artificial 30 12 25 10 22 8 32 13 109 11 Mixed — — — — 1 .4 - — 1 .1 Separate Cot 223 93 208 90 207 78 224 92 862 88 Number of Births notified 1,126, which includes 263 born outside the district, 86.4 per cent of which were visited. 29 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 16,414⅜ galls., costing £1,481 4s. 3d. Dried milk 4,201 lbs., costing £311 3s. 4d. These figures demonstrate that a smaller quantity of free milk was supplied during this year, and a considerable saving of expenditure thereby obtained. At first sight it would appear that the Maternity and Child Welfare Committee has attempted to economise in the amount of free milk supplied to ante-natal and nursing mothers and children under five years of age. This is not the case, for the Scale for the supply of free milk has been so amended as to take into consideration the unborn child, thus raising the number to be considered as members of the family and bringing an even larger number of families within the Scale. The fact that despite this the milk supplied has decreased in quantity must, therefore, be due to the lessening of unemployment in the district, or, alternatively, to the obtaining of more continuous employment. I am inclined to think that the increasing prosperity of the country has made it possible to make the Scale even more generous and yet grant a smaller supply of milk. Every care and attention has been taken to see that applicants come within the Scale, whilst the Health Visitors have co-operated in seeing that all those mothers and children entitled and in need of milk obtain it. This decrease in the quantity supplied can, therefore, be looked upon with satisfaction in that it is a sign of increased prosperity and diminution of unemployment within the district. ROUTINE MEDICAL INSPECTION OF CHILDREN UNDER FIVE YEARS OF AGE. This scheme, which was inaugurated in April, 1933, was continued throughout the whole of 1934. The following table shews the result of this work Total number of appointments made 6,780 Total number kept 2,231 Total number of additional examinations 960 It will be seen that roughly one-third of the appointments are kept. This table compares with the following table for the last nine months of 1933:— Total number of appointments made 4,102 Total number kept 1,769 Total number of additional examinations 562 30 The following table is an analysis of the children sent for tor routine examination, shewing the number of appointments made at each birthday. Appointments. 1st. Birthday. 2nd Birthday. 3rd. Birthday. 4th. Birthday. Total. No. sent for 720 682 645 538 2585 No. kept 279 190 180 141 790 The total number of appointments made, not including birthdays, was 4,195. The total number kept was 1,441. It will be seen that there is a very big falling-off in the percentage of appointments kept when the child reaches its third and fourth birthday. This is indeed regrettable, for the aim of this scheme of routine examination is to treat children for those ailments which otherwise would have to be treated when the child attends school. The earlier this treatment can be obtained the more the child can be saved unnecessary suffering. This especially applies to dental caries; if treatment can be commenced when only a small defect is present, that defect can be remedied without pain to the child, but if the teeth be neglected until they are bad, the child has to suffer pain during a large filling, or alternatively, the tooth has to be extracted. Although I would like to see a bigger percentage of appointments kept, I am, nevertheless, satisfied that the scheme is successful. 2,231 full examinations have been made of children under five years of age and a large amount of treatment obtained before disease became serious. The routine carried out in 1934 was the same as that carried out in 1933, children being invited to attend for examination on their birthday, and in certain cases, during the year as well. The work of routine examination was augmented by the examination of all children who, in the opinion of the Health Visitors or in their parents' opinion, were not doing well, and for whom medical advice was considered necessary. AURAL TREATMENT. The scheme whereby children under five years of age found 31 to be suffering from defects of the ear could be referred to the School Aural Clinic was continued, and during the course of the year 23 children were so treated under the scheme. Most of these children were found to be suffering from acute middle ear disease, and were cured as a result of appropriate treatment. This scheme also applies not only to children under 5 years of age, but to ante-natal and nursing mothers as well. OPHTHALMIC TREATMENT. Following upon the success of the scheme whereby the services of the School Aural Specialist were made available for those children attending the Maternity and Child Welfare Centres, a similar scheme was approved in September, 1934, for mothers and children attending the Centres who were in need of ophthalmic treatment for disease of the eyes, bad eyesight or squint. This scheme has been put into practice, and already seven individuals have been treated by the School Ophthalmic Surgeon through the Maternity and Child Welfare Centres. The scheme is proving a success and will be of undoubted benefit to the residents of the district. BIRTH CONTROL. Arrangements have been made whereby advice on Birth Control is given to mothers attending the Council's Maternity and Child Welfare Centres, in whose case further pregnancy would be detrimental to health. This work follows upon Memorandum 153/M. and C.W. and Circular 1208, dated the 14th July, 1931, of the Ministry of Health, also Circular 1408. The Committee determined, however, that, where possible, advice should be given to the husband, rather than, or as well as, to the wife, and in this resepct I have interviewed three men during the year. Whilst my report for 1933 was being printed arrangements were being made for two lectures to be given on Birth Control, one in western Enfield and one in eastern Enfield, and the Council determined that I should give these lectures myself. One lecture was, therefore, given under the Chairmanship of Councillor W. J. Clarke, on the 21st March, at the Red Triangle Club, and there was an attendance of 160, and the other on the 30th April, under the Chairmanship of Councillor Hills, when there were present 50 persons, at the Co-operative Hall, Enfield Highway. I have no hesitation in saying that it has never been my pleasure to lecture to a more satisfactory audience than on these occasions. During the whole while I was speaking the audience was perfectly quiet and dignified. The information I gave was as 32 complete as I could make it and technical as far as detail was concerned. For those who feared that a meeting of this description might be unpleasant, I can faithfully say that their fears were in no way justified. The questions that followed upon the lectures were clearcut and to the point. In order that no religious body in the district should have the right to fear that the Council was attempting to teach a doctrine to which it might be opposed, each meeting was opened with an appeal to all those whose religious doctrine advised against Birth Control to leave the hall. This is not the first occasion on which I have lectured on Birth Control, but there is one remarkable feature which I have found on all occasions: that among the many questions that one gets asked it is a routine for some husbands to demand information concerning sterility. To my mind, these questions are rather enlightening. During the past few years there has been so much talk and propaganda about birth control, and so much about poverty and injury to health resulting through large families, that one has rather tended to forget what is also a very serious problem, namely, the problem of the childless marriage. Combined with the lectures on birth control, I also dealt with the subject of vaccination, and placed the present position concerning this matter before the audience. CHILDREN ACT, 1908-1932. During the year 20 notifications of intention to accept foster children were received, and in no case was the home found unsuitable. Ninety-six 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, 1934. (a) Number of persons receiving children for reward on the Register at the end of the year 44 (b) N umber of children on the Register:— (i) at the end of the year 54 (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 33 (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) Proceedings taken during the year:— Number of cases. Section of Act under which taken. Nil. — (/) 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. 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. 1934. 1933. 1932. 1931. 1930. Attendances 778 293 1,071 1,257 1,111 592 468 Treated 150 169 319 340 340 172 132 Administrations: Local Anaesthetics 47 37 84 115 100 85 98 Extractions with Local Anaesthetics 97 69 166 211 181 160 127 Administrations: N20 181 91 272 252 308 155 132 Extractions under N20 894 293 1,187 1,071 1,501 600 456 Total Extractions 991 362 1,353 1,310 1,682 760 583 N20 Sessions 39 — 39 36 40 26 19 Ordinary Sessions 41 — 41 44 41 27 22 Total Sessions 80 — 80 80 81 53 41 Dentures fitted 129 — 129 131 120 54 50 Patients receiving Dentures 70 - 70 78 63 29 28 Number of Patients having repairs 11 11 20 3 - - Number of repairs fitted 11 11 20 3 - - Number of fillings 22 170 192 218 217 41 40 Other Operations 540 121 661 803 593 250 253 Number of patients having extractions under N20 78 79 157 127 159 68 63 Do. do. under Local Anaesthetics 24 36 60 134 81 53 54 34 BABY WEEK. This was celebrated on June 18th, 19th, 20th and 21st, Garden Parties being held at the Red Triangle Club and St. George's Hall, Freezywater. The weather on all occasions was satisfactory. The total attendance of mothers and children at the four meetings was 1,330. Many members of the Maternity and Child Welfare Committee were present, and the distribution of prizes was made by Councillor G. E. Jones, J.P., Miss G. M. Ford, Mrs. E. M. Thirkettle and Doctor C. Thomson. In previous years it has been the practice to award silver or silver gilt spoons for 50 or 75 per cent. attendance at the Maternity and Child Welfare Centres. The Maternity and Child Welfare Committee determined that in 1934, instead of giving prizes for regularity of attendance, it would be better to organise competitions, and award prizes for the best entries. The following competitions were therefore organised : 1. Write a letter to a friend, telling her that your child under 5 years of age had had measles ; tell her the child's symptoms and how you treated the child. 2. The best made knitted new garment. 3. The best garment made from new material. 4. The best garment made from old knitted material. 5. The best garment made from old material. Some 151 entries were sent in. The garments were judged by Doctor Agnes Nicol, Assistant Medical Officer of Health for the Borough of Willesden; whilst the essays were referred to me for marking. The standard of the entries was satisfactory, and served as an indication as to how much attention had been paid to the instructions given to the mothers at the Maternity and Child Welfare Centres and during home visitation by the Health Visitors. Moreover, the entries formed a basis for demonstration, and we were able to point out where the garments failed to be hygienically satisfactory. I am quite satisfied that it is far better to organise these competitions than to give away prizes for regularity of attendance. It is very pleasant to think that during our Baby Week the mothers of Enfield were turning their minds to the care of the health of young children and to the consideration of the most hygienic form of clothing for them. When prizes were given for regularity of attendance one always had a feeling that many children were brought out in inclement weather to make an attendance at one of the Centres, when the child would have been far better off if it had been kept at home. 35 CIRCULATION OF BOOKLET ON REARING OF CHILDREN. The Maternity and Child Welfare services of the district have been improved in certain respects. At its meeting in May, 1934, the Maternity and Child Welfare Committee determined that on every occasion when a notification of a birth was received, a letter of congratulations to the parents should be sent and a booklet enclosed, called " To Mothers and Fathers." This booklet, which consists of some 90 pages, is a complete guide to the rearing of a child as regards its clothing, its health and its mental well-being. It contains a chapter for fathers, a chapter for mothers, and advice concerning diet. The book is excellent and up to date in every respect, in that it is being completely revised and kept modern year by year. It is issued under the auspices of the National Council for Maternity and Child Welfare Centres, and every page of it has been prepared by experts in maternity and child welfare. I am informed that this book has been much appreciated by the recipients, and has served, not only as a useful guide at the time, but as a stock book of reference concerning the rearing of children in the right and proper manner. I am at present preparing a leaflet which will be enclosed with this book pointing out the services which the Council is willing to render to mothers and children whose circumstances are such that they cannot obtain these services except through the help of the Council. HOME HELPS. The scheme for the provision of Home Helps set out a scale shewing the charges to be made according to the incomes of those who desired the benefit of this service. The scale did not include the provision of a Home Help free of charge, and on every occasion where it was thought that no charge could rightly be made the case came up for consideration before the Committee. In December, 1934, the Maternity and Child Welfare Committee determined that where the income of the family was 6s. per head or less, after making various allowances for rent, etc., that a Home Help should be provided free of charge. This new arrangement has proved satisfactory. THE UNBORN CHILD. In October, 1934, the Maternity and Child Welfare Committee considered the question of altering the Council's Scales for the granting of help in order to take into consideration the unborn child. It was found that certain ante-natal mothers applying for help 36 as regards dental treatment, or the provision of dentures, were unable to obtain such help until the child was born, owing to the fact that the newborn child increased the number in the family and brought the family within the scale for the provision of dental treatment. The Committee felt that a scheme that delayed such treatment until the birth of the child was wrong in principle, inasmuch as such treatment should certainly be provided before childbirth. Under the circumstances the Committee determined that the unborn child should be considered as a member of the family for the purpose of applying all scales for the granting of help under the Maternity and Child Welfare Acts. This determination of the Committee has been of the greatest help to some of the poorer residents of Enfield, is far-seeing and wise. MILK IN SCHOOLS. During the course of the year a scheme was arranged by the Milk Marketing Board in conjunction with the Board of Education, whereby school children might be provided daily with one-third of a pint of milk at the cost of one halfpenny per day. This scheme recommended that the milk should be supplied in one-third of a pint bottles and that the supply should be approved by the Medical Officer of Health of the district. It further recommended that where available only pasteurised milk should be approved for the scheme. When the scheme came into force in Enfield, only one firm in the district held a licence to pasteurise or sell pasteurised milk. On the other hand, many purveyors were pasteurising their milk, in some cases unofficially, but did not hold a licence, and were, therefore, not selling milk as pasteurised. Following upon the recommendations of the Board of Education, I informed all the teachers of the district that I would only be prepared to approve pasteurised milk. As a result 5 other purveyors of milk applied for a licence to sell pasteurised milk, and at the moment of writing, 6 purveyors in the district possess such a licence. In many cases the plant had to be improved, or new plant bought in order to obtain adequate pasteurisation. It will be remembered that pasteurised milk must not contain more than 100,000 germs per c.c. before delivery. Some of the samples taken fell very short of this standard, but in all cases the purveyors took steps to improve their plant in order to obtain the requisite purity of their supplies. This scheme, therefore, has had a two-fold advantage. Not only has it resulted in many hundreds of school children obtaining a third of a pint of milk per day, but in addition, it has improved the quality of the milk supply of the district. 37 Milk sold as pasteurised milk will be examined in future regularly throughout the course of the year to see that the requisite standard is not only obtained, but persistently held. I received applications for approval of the milk supply from 43 Head Teachers. The scheme has caused a tremendous amount of work for the teachers. This work is all of a voluntary nature, and as a health authority the thanks of the Council must proceed to those who have helped to make the scheme the success that it is. I have no doubt that the knowledge that milk is the best form of food, and that by drinking this milk the children's health is being improved, will bring to the teachers a satisfaction that will far outweigh the work which they have so kindly undertaken. My only fear is that the propaganda and publicity given to the scheme at the time of its inception caused many parents to take advantage of it, and as time goes by they may forget its benefits and discontinue the milk allowance to their children. I sincerely hope that my fears will not be fulfilled, and that the decrease in the number of children receiving milk, which I note at present, may not be continued. I should like to think that every child in the district was receiving milk of a good and pure quality regularly every day in the year, with the exception of those few children who are unable to take milk with advantage. It must be acknowledged that some children have an idiosyncrasy to milk and cannot digest and obtain advantage from it. These children, however, are rare. I would add that the Education Committee have made arrangements for the provision of milk in schools free to children where the income of the family is such that they cannot afford to pay for it. The scale adopted for this purpose by the Education Committee is similar to that adopted by the Maternity and Child Welfare Committee in granting milk to children under five years of age. One of the essentials of the scheme is that the milk should be drunk on the school premises. 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:— Miss Newbegin 3 demonstrations at Bush Hill Park Schools. Miss Garlick 5 demonstrations at Chesterfield Road. Mrs. Herbert 2 demonstrations at Lavender Road, and 2 at Chase Side Schools. 38 Miss Wilkinson 1 demonstration at Alma Road Schools. In completing my report on the maternity and child welfare services of the district, I am able to say that the services provided are adequate for the needs of the district. They are not complete and cannot be expected to be so in a district which is growing as rapidly as is Enfield. On the other hand, the care of the mother and child has always received the most sympathetic consideration of every member of the Council, irrespective of political creed, and I have no doubt new problems will always be adequately dealt with. 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. There are, however, about 80 houses in the District which derive their water from wells. During the course of the year samples of water were taken from 15 wells supplying water to 29 houses and premises. The water was found to be satisfactory in 4 cases and unsatisfactory in 11 cases. In those cases where the water was found to be unsatisfactory the wells were closed and the houses provided with a main water supply. 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. Whilst the populous parts of the District are all provided with sewers, development commenced in one portion of the District where no means of drainage were available, and 3 houses have already been erected on this site. 39 I am glad to report that development in this area has ceased, and I sincerely trust that it will not be continued until main drainage has been supplied. The best cesspool is a very poor substitute for main drainage. If a house drained to a cesspool is to be adequately drained, it is essential either that the cesspool should be emptied weekly or alternatively that the residents should cut down the amount of water used, especially for bathing. The first alternative is costly and the second not be to advised. Whilst I can imagine rural districts where it is impossible for every house to be supplied with main drainage, I am of the opinion that there is no need to attempt development on a large scale within the District until such time as that area has been properly sewered. Cesspools. During 1934 the cesspools of the District were emptied by horsedrawn vans and hand-manipulated pumps. In December a combined cesspool and gulley emptier was purchased at a cost, including all necessary hose, of £950. This machine was very badly needed and is already doing good service. 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 receptacles. I am not aware of any middens in the District. Every week one man in the employ of the Council attends some few earth closets in a rural part of the district. REMOVAL AND DISPOSAL OF HOUSE AND TRADE REFUSE. At the end of the year the Council possessed the following vehicles for the collection and disposal of refuse:— 6 " S.D." Freighters. 1 Tuke and Bell Barrier Type Petrol Vehicle. One of the "S.D." Freighters is 8 years old and of the Old Semi-open type. Reference to page 33 of my Annual Report for 1933 will show that I estimated that there would be sufficient space to continue depositing refuse on Brown's brickfield until the middle of 1935. In actual fact this field will be completed at the end of May, 1935, and it is intended that refuse shall be disposed of by controlled 40 tipping in the Council's gravel pit in Carterhatch Lane. Some dissatisfaction has been expressed at the method of disposing of refuse by means of controlled tipping, and the Council has given very careful consideration to the problem of refuse disposal. It might be well, therefore, in this Report, to consider some of the advantages and disadvantages of the methods that have been and might be adopted in Enfield. It is interesting to remember that eight years ago refuse was disposed of in Enfield by dumping it on a field abutting on Hoe Lane. One man was employed to take care of this refuse, but he was only paid a part-time salary, as he was expected to eke out a living by means of collecting saleable materials from the refuse, or, in other words, by "totting." The total cost to the Council was, therefore, about thirty shillings per week. The Council realised, however, that this economy was purchased at a very high cost. Complaints were continuous, the refuse was on fire and had been so for many years. The Council determined to deal with the matter seriously. The fire was put out and Enfield's "flaming disgrace," as it was commonly known, ceased to exist. Controlled tipping was instituted and carried on not only there but in various parts of the District. The cost of refuse disposal rose to about two shillings per ton, or between £1,500 and £2,000 per annum. This two shillings per ton which is the cost to-day is low compared with the cost elsewhere of refuse disposal by a similar method, but the fact remains that, except for complaints arising from an outbreak of crickets, there have been few complaints during the last eight years concerning nuisance from refuse disposal in Enfield. I do not think I have had one serious complaint during the last two years. There is another side of the question, however. Refuse can be disposed of satisfactorily by controlled tipping, provided suitable land, and preferably excavated land, can be purchased at a cheap price, where the haul will not be far, and yet where the site will not be surrounded by many houses. In addition to that, covering material must be available in plenty and ample labour supplied. It is becoming increasingly difficult to obtain suitable sites in Enfield, and it has always been difficult to find a satisfactory, continuous and sufficient amount of covering material. Under these circumstances, one necessarily turns one's mind to the provision of a Destructor. The advantages of a Destructor are that refuse is either completely destroyed or brought to such a temperature that it becomes inoccuous, that once erected, unlike a pit, it does not get used up, 41 but is a permanency, and that it can be placed in a site of choice, where it should not become a buisance. The disadvantages are that the cost is twice that of disposal by controlled tipping and that provision has to be made for a certain amount of sorting, which is objectionable, and clinker has still to be disposed of by some method of controlled tipping. During the course of the year the Council proposes to consider the whole question of refuse disposal. 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. During the course of the year observation has been kept on the chimneys of the District for nuisance due to the issue of excess amount of smoke. Many warning letters have been sent, and in all cases, with one exception, these have resulted in the abatement of the nuisance. In this case a summons was taken out, but before further legal action was necessary, the nuisance was abated by the installation of effective plant. SUB-LETTING IN COUNCIL HOUSES. The terms of the agreement under which the Council's houses are let does not allow the tenant to sub-let 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 87 Number granted permission to sub-let 75 Number refused permission 12 Number of letters sent 138 Number of visits made by Sanitary Inspectors 33 In every case permission to sub-let has been given where such permission can be granted without detriment to the health of the tenants or the property of the Council. 42 SCHOOLS. There are 21 Public Elementary Schools in Enfield, comprising 43 departments. The Secondary Schools include the Boy's 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 any 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 Health, 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. Number of children notified to be absent from School due to suspected Infectious Disease 1,257 Number of children found to be suffering from Infectious Disease 944 This compares with the following figures for last year:— Number of children notified to be absent from School due to suspected Infectious Disease 1,576 Number of children found to be suffering from Infectious Disease 1,390 RAG FLOCK ACTS, 1911 AND 1928. There are six premises in the District where Rag Flock is manufactured, used or sold, and these are kept under observation by the Sanitary Inspectors. Seven samples were taken during the year, and these were all found to comply with the standard laid down in the Acts. 43 HOUSING. Number of New Houses erected during the year:— (a) Total (including numbers given separately under (b)) 1,238 (i) By the Local Authority — (ii) By other Local Authorities — (iii) By other bodies and persons 1,238 (b) With State Assistance under the Housing Act: (i) By the Local Authority — (ii) By other bodies or persons — 1. Inspection of Dwelling Houses :— No. of No. of inhouses. spections. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) and number of inspections made 2,778 8,376 (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 586 1,015 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 30 (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 1,517 (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 1079 3. Action 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 rcvairs ,„ None 44 (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 requring defects to be remedied 66 (2) Number of dwelling-houses in which defects were remedied after service of formal Notices:— (a) By Owners 59 (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 24 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 11 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. (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 586 Apart from the Do. 207 Total 793 The work of demolition of unsatisfactory property has been enthusiastically pursued during the course of the year. It will be 45 noted that demolition orders were made in respect of 24 houses represented to the Council as unfit for human habitation, and that 11 houses were demolished during the course of the year. In addition to this, by private arrangement with the owners, 23 undertakings were accepted to the effect that houses would be demolished provided the Council found alternative accommodation for the tenants thereof. Following upon such undertakings, 21 houses were demolished. Demolition work can only be carried out where alternative accommodation can be offered to tenants, and in view of the fact that the Council did not build houses during the year, it was only possible to rehouse tenants when vacancies of existing houses occurred. Nevertheless, it is very satisfactory to record that in all 32 houses were demolished during the course of the year. As this work proceeds, a time will arrive when there will be no houses in the district occupied yet unfit for human habitation. In 1933 the Council adopted as its five year programme the demolition of 63 houses. At the time of writing this Report, 73 houses have already been demolished. It will therefore be seen that, not only has the programme been carried out in less than the five years anticipated, but the number of houses demolished has exceeded the original estimate. The demolition of individual houses is still proceeding, whilst, in addition, three areas have been represented as Clearance Areas. The demolition of these Areas must necessarily take time and await the erection of further Council houses. The Council is at present exploring every avenue towards the obtaining of further land for the erection of houses. A new feature during the year has been the formation of associations of Council house tenants. From the point of view of public health, I sincerely hope that these associations will devote themselves, not only to the righting of such grievances as they may consider that they have, but, in addition, to the improvement of the health of the Council's tenants. These associations can be a great power for good in the district. I should like to see them organising lectures; arranging inter-estate sports matches; arranging competitions for the best-kept house and the most beautiful garden; creating the spirit of pride in the homes of the Council's tenants, and generally improving the health of the mothers and the children and the physique of the fathers. I am convinced that these associations, if they proceed on the right lines, can be a strong bulwark in the fortress protecting the tenants against ill-health and disease. 46 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. No special measures were taken or suggested for the gradual carrying out of programmes of repair. I should estimate that about 80 houses in Enfield are not supplied with water by the Water Company. There are about 20 houses in the District which are not supplied with a water-closet. All these have earth-closets 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. GENERAL OBSERVATIONS. The Council now possesses 1,740 houses and are taking steps to erect more. It is thus to be hoped that overcrowding may ultimately cease in the District and that the general standard of accommodation be improved. Once again the Council has been faced with the problem of freeing houses from vermin. There are many methods of disinfestation, but unless some form of hydrocyanic gas is used, it is difficult to ensure that, even after disinfestation, the house is free from vermin. Hydrocyanic gas, however, is extremely poisonous, and the Council have, therefore, not thought it wise to use it. Various preparations have been employed throughout the year, most of them being sulphur compounds. In many cases repeated disinfestations have had to be carried out at fortnightly intervals, and the removal of nearly all the woodwork of the house, and subsequent re-decoration has been necessary. It is difficult to estimate the size of the problem, and I can only quote the actual facts. During the course of the year the Health Department examined 47 86 houses which had been vacated, and of these 33, or 38 per cent., were found to be verminous and had to be disinfested. This proportion, viz., 38 per cent., has been constant for the past three years, but I am unable to say whether this figure could be applied to the Council estates generally ; it is possible that the figure for the occupied houses is not so high as that for those that have been vacated. It has been suggested that whereas figures are obtained concerning verminous conditions of Council houses, such figures are not shewn for other property situated within the District, and in this respect Council tenants have tended to feel that some slight has been cast upon them. The fact is, that short of a general inspection of all the property of the District, it is impossible to give comparative figures, and it is only in the case of vacated Council houses that these figures are available. No slight is intended upon the Council tenants, and it is the object of the Department to help the tenants to rid their houses of vermin and to give such aid and scientific advice as is available. I am sincerely hoping that some new preparation may soon be discovered that will enable disinfestation to be carried our very easily and without considerable removal of the woodwork of the premises. 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. MILK AND DAIRIES (CONSOLIDATION) ACT, 1915. TUBERCULOSIS ORDER, 1925. During the year 1934 fifty-four samples of milk were taken from retailers in the District. These samples were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. One of these samples was found to contain living tubercle bacilli, was traced to a farm in Enfield, and the offending animal was discovered and slaughtered. Four cows were reported by owners as suspected to be suffering from tuberculosis. On examination one of this number was found 48 to be so suffering, and was slaughtered. Routine examination of milch cattle was carried out during the year by Mr. Reginald Wooff, M.R.C.V.S., the County Council's whole-time Veterinary Inspector; 1,904 inspections of cows were carried out in Enfield, seven cows were found to be suffering from tuberculosis and were slaughtered. 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. December. 1934 1934 Registered . . 10 8 6 Licensed 7 4 4 Total 17 12 10 Mr. Fred Wilson, Chief Sanitary Inspector, Mr. H. Wiggett, Mr. A. J. Williams, Mr. L. Rowley, and Mr. A. Ramsden, Sanitary Inspectors, who 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 1,415 such visits during the year, when they examined 18,005 carcases, and secured the surrender of 238 carcases and 379 parcels of diseased organs. SLAUGHTERHOUSES. The inspection of slaughterhouses and of animals slaughtered 49 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. SLAUGHTER OF ANIMALS ACT, 1933. The Slaughter of Animals Act, 1933, provides that no animal shall be slaughtered except by means of a mechanically operated instrument. Certain exceptions to this rule, however, are set forth. This Act has been put into force in the District, and the methods recommended are in operation in every slaughterhouse in the District. In addition, the Act provides that no person, unless holding a Licence from the local Authority, shall slaughter animals. Thirtythree applications for Licences were received during 1934, and in 32 cases such Licences were granted. 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. There are 32 bakehouses in use in the District, all of which have been regularly inspected. 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:— 50 URBAN DISTRICT OF ENFIELD. List of samples purchased during the year ended 31st December, 1934: Article. Taken. Adulterated. Milk 178 6 Milk, Sterilised 19 — Vinegar 1 — Gin 2 — Whisky 9 — Hake 2 — Sausages 4 — Lemon Sole 1 — Meat Pies 5 — Minced Beef 2 — Total 223 6 With regard to the 6 adulterated samples of milk, 3 were informal samples in respect of which no action could be taken. Subsequent "follow-up" samples were found to be genuine. Of the other three cases, two vendors received letters of caution, and in the third case no action was taken, as the deficiency reported was quite small. PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. Diphtheria was less prevalent than during the previous year, and no deaths occurred. There were altogether 37 cases, with no mortality rate. During 1933 there were 45 cases, and 2 died. PUBLIC HEALTH (SMALLPOX) PREVENTION REGULATIONS, 1917. No primary vaccinations or revaccinations were done by me during the year. NOTIFIABLE DISEASES DURING THE YEAR 1934. The following table shows the cases of infectious diseases notified during the year, and the number of deaths that occurred. 51 TABLE III.—Cases of Infectious Diseases notified during the year 1934. Notifiable Disease. Number of Cases Notified. Total cases removed to Hospital. 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. 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 - - - - - - - - - - - - - - - - - - Cholera—Plague - - - - - - - - - - - - - - - - - - Diphtheria (inc. Membranous Croup) 37 - 11 23 - 3 - - 36 - - - - - - - - - Diphtheria Carriers 17 - 8 5 4 - - - 5 - - - - - - - - - Erysipelas 15 - - 1 3 2 7 2 3 - - - - - - - - - Scarlet Fever 252 - 60 149 17 25 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Typhoid Fever - - - - - - - - - - - - - - - - - - Paratyphoid Fever - - - - - - - - - - - - - - - - - - Relapsing Fever - - - - - - - - - - - - - - - - - - Continued Fever Puerperal Fever 1 - - - - 1 - - l - - - - - 2 - - 2 Puerperal Pyrexia 4 - - - 3 1 — — 4 - - - - - - - — — Cerebro-spinal Meningitis - - - - - - - - - - - - - - - - - - Poliomyelitis 3 - 1 1 1 - - - 3 - - - -—- - - - - - Ophthalmia Neonatorum 1 1 - - - - - - - - - - - - - - - Pulmonary Tuberculosis 77 - - 4 21 34 17 1 - - - - - 10 25 15 2 52 Other forms of Tuberculosis 12 - 1 4 1 5 1 - - - - 1 1 2. 3 1 - 8 Encephalitis Lethargica - - - - - - - - - - - - - - - - - Malaria Pneumonia 48 2 5 7 2 16 12 4 - 5 3 2 2 - 14 13 13 52 Dysentery - - - - - - - - - - - - - - - - - - Totals 468 3 86 194 52 88 38 7 253 5 3 3 3 12 44 29 15 114 52 SCARLET FEVER Two hundred and fifty two cases of Scarlet Fever occurred during the year in 223 houses, as follows:— Number of houses where 1 case occurred 199 Number of houses where 2 cases occurred 20 Number of houses where 3 cases occurred 2 Number of houses where 4 cases occurred 1 Number of houses (Chase Farm Schools) where 3 cases occurred 1 Total number of houses where cases occurred 223 Total number of cases 252 Deaths 0 DIPHTHERIA. Thirty-seven cases of this disease occurred during the year in 22 houses, as follows:— Number of houses where 1 case occurred 17 Number of houses where 2 cases occurred 3 Number of houses (Chase Farm Schools) where 4 cases occurred 1 Number of houses (St. Joseph's Home) where 10 cases occurred 1 Total number of houses where cases occurred 22 Total number of cases 37 Deaths 0 DIPHTHERIA CARRIERS. Seventeen cases of this disease occurred during the year in 6 houses, as follows:— Number of houses where 1 case occurred 5 Number of houses (Chase Farm Schools) where 12 cases occurred 1 Total number of houses where cases occurred 6 Total number of cases 17 53 TYPHOID AND PARATYPHOID FEVER. One case of Typhoid Fever was notified during the year. Three cases of Typhoid and Paratyphoid Fever were notified in the previous year. POLIOMYELITIS. Three cases of this disease were notified during the year. CEREBRO-SPINAL FEVER. No cases of this disease were 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 1932 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 430 cases of Measles and 160 cases of German Measles were excluded from the Schools during the year. ENTERITIS. One death occurred from this disease during the year, and was of an infant 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:— Disease. 1930 1931 1932 1933 1934 Small Pox - - - - - *Scarlet Fever 6 9 11 3 1 *Diphtheria 7 10 7 6 2 *Measles 2 - 10 - 7 *Enteric Fever 3 2 - - - *Whooping Cough - 1 6 4 1 Epidemic Enteritis - - - - - Totals 18 22 34 13 11 54 *The actual Enfield deaths were:—Diphtheria 0; Scarlet Fever, 0; Whooping Cough, 1; and Measles, 1. The figures for Scarlet Fever, Diphtheria, Measles, and Enteric Fever include all the deaths that occurred n 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 nine deaths of persons residing outside the District who died in Institutions in the District, is 0.02 per 1,000 population. Disease. 1933 1934 Deaths. Death-rate Deaths. Death-rate Scarlet Fever 2 .02 - Diphtheria 2 .02 - Enteric Fever - - Small Pox - - - Measles - - 1 .01 Whooping Cough .. 4 .05 1 .01 Epidemic Enteritis - - - - Totals 8 .11 2 .02 The same routine as previously reported has been carried out in the control of Infectious Disease in Enfield. 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. 1 1 — 1 — — — 55 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 case, 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 8 - 9 1 - Chase 7 1 20 2 - 3 Ordnance 22 2 32 1 1 1 Green Street and Ponders End 28 4 49 4 1 1 Bush Hill Park 12 - 40 4 - 2 Hadley and Cockfosters - - - - - - Totals 77 7 150 12 2 7 First Notifications, including transfer notifications 89 Old Cases re-notified, i.e., some by fresh doctors, or under old Regulations 9 Duplicate Notifications, i.e., those which report the entering and leaving of Sanatoria 157 Total Notifications 255 The following table gives particulars of the ages of the new cases notified, and deaths from this disease during the year:— 56 Age Periods. New Cases. Deaths. Respiratory. NonRespiratory Respiratory. NonRespiratory. M. F. M. F. M. F. M. F. Under 1 - - - - - - - - 1 to 5 - - - 1 - - - 1 5 to 10 2 - 1 1 - - - 1 10 to 15 1 1 2 - - - - - 15 to 20 5 4 - - 1 2 - 1 20 to 25 4 8 1 - 2 5 1 25 to 35 8 16 - - 3 10 1 1 35 to 45 5 5 4 1 6 6 1 - 45 to 55 8 2 - - 5 2 - 55 to 65 6 1 - 1 7 1 1 - 65 and upwards. - 1 - - 2 - - - Totals 39 38 8 4 26 26 4 4 Sex (1st Notifications). Form. Males. Females. Pulmonary 39 38 Other 8 4 Totals 47 42 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.:— Ward. Pulmonary. Other. Cases Deaths Cases Deaths Town 8 7 1 - Chase 7 10 2 3 Ordnance 22 10 1 - Green Street and Ponders End 28 15 4 4 Bush Hill Park 12 10 4 1 Hadley and Cockfosters - - - - Totals 77 52 12 8 57 16.6 per cent. of the cases dying of Tuberculosis had not previously been notified. It will be noted that 60 deaths occurred from Tuberculosis during the year, and that 40 of them occurred in persons between the ages of 15 and 45 years. Tuberculosis, therefore, remains a very serious cause of mortality at a period of life when people should be enjoying their fullest activities and the pride of their strength. It is disappointing that all the steps taken to lower the incidence of Tuberculosis and reduce its mortality rate have yet failed to deal adequately with these age groups. In many cases a family history of the disease is found. The problem is not entirely one of either poverty or housing, for cases have arisen where the sufferers have been well-to-do and satisfactorily housed; nor can it be said that the cause is due to continued malnutrition. 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. Ten dwellings and 75 articles of clothing, etc., were disinfected and cleansed during the year at the request of the Educaton Committee. Meteorology. The following instruments are installed at the Public Offices :— Standard Fortin Barometer. Maximum ThermometerIn a Stevenson's screen in Minimum Thermometer > grounds of the Public Offices. Standard Hygrometer J Terrestrial Radiation Thermometer \ In the grounds of Earth Thermometer J the Offices. Campbell -Stokes Sunshine Recorder \ On the roof of the Rain Gauge f 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, 1934. 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. 30.752 on 21st 28.960 on 14th. 42.8° 17° on 23rd. 55° on 17th & 18th 19° on 23rd. 38° 39.8 1.57 inches. 28.9 — 11 13 — S.W. Feb. 30.920 on 15th. 29.653 on 28th. 40.7 * 17° on 3rd. 53° on 22nd 24 ° on 3rd 38° 4.6 0.18 inches. 83.2 — 6 20 2 W. Mar. 30.384 on 25th 28.820 on 17th. 41.7° 23° on 2nd. 60° on 25th 27 ° on 2nd 42° 50.6 2.04 inches. 101.5 1 3 16 — S.W. April 30.141 on 30th. 29.096 on 24 th 45.3° 24° on 10th. 76° on 15th 28° on 8th & 10th 48° 56.3 2.16 inches. 109.1 2 2 4 — S. May 30.484 on 10th. 29.420 on 16th. 50.8° 30° on 17th. 80 ° on 12th 35° on 17th 55° 13.1 0.52 inches. 189.7 1 — 1 — N.E. June 30.299 on 15 th. 29.663 on 19th 55.5° 33° on 5th 88° on 17th 43°on 13th 61° 33.7 1.35 inches. 208.4 2 — — — N.&S.W. July 30.316 on 3rd. 29.677 on 31 st. 57.0° 44° on 4th & 25th 85° on 8 th. 49° on 1st & 25th 67° 16.7 0.67 inches. 261.1 2 — — — W. Aug. 30.233 on 26th. 29.452 on 2nd. 60.1° 36° on 31st 80° on 18th. 39° on 31st 62° 58.1 1.9 inches. 162.5 2 — — — S.W. Sept. 30.388 on 12th 29.540 on 24th. 58.8° 37° on 1st 2nd & 22nd 81° on 7th. 40° on 1st 60° 47.4 1.83 inches. 162.3 1 — — — S.W. Oct. 30.432 on 13th. 29.093 on 4 th. 55.8° 25° on 31st. 67° on 11th. 27° on 31st 52° 28.7 1.23 inches. 79.5 — — 2 1 w. & S.W. Nov. 30.674 on 25th 29.172 on 9th. 49.3° 25° on 1st 55° on 27th. 28° on 1st. 42° 45.5 1.93 inches. 34.8 — 5 6 — N. & W. Dec. 30.327 on 1st. 28.745 on 15th. 48.9° 31° on 21st 56° on 8th. 34° on 22nd 46° 121.1 5.00 inches. 13.8 1 5 — — s.s.w. Totals 515.6 20.38 inches. 1434.8 hrs. 12 32 62 3 THE ANNUAL REPORT of the School Medical Officer for the Year ending 31st December, 1934 60 MEMBERS OF THE ENFIELD EDUCATION COMMITTEE, 1934-1935. Chairman Mr. D. MASON. . Vice-Chairman Mr. W. T. TAYLOR. Representative Members— Mr. W. B. ANDERSON. Mr. H. A. DESHBOROUH BROWN. Mr. W. W. CAKEBREAD. Mr. T. H. M. CLARKE. Mr. S. G. HILLS. Mr. G. E. JONES, J.P. Mr. A. R. KEMP. Mr. H. G. SHORT. Mr. A. B. WHARTON. Mr. W. T. TAYLOR. Co-optative Members— Miss E. M. CRESSEE. Mrs. E. A. DA VIES. Mrs. H. ROTHWELL. Mr. H. H. COLLIER. Mr. A. M. EELES. Mr. D. MASON. Mr. C. F. WATTS. Director of Education— F. G. APTHORPE, Esq., M.A. 61 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 Dentists— 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. H. OGILVIE. Clerks— I. GROVES. M.STIFF. 62 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, 1934. To the Chairman and the Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to place before you my eighth report on the health of the school children of Enfield. In my report last year I referred to the fact that many children were being referred from the School Ophthalmic Clinic for inpatient and out-patient treatment at the Western Ophthalmic Hospital, which institution had carried out the work gratuitously. During the course of the year the Committee determined to make a grant of £10 10s. per year to the Western Ophthalmic Hospital, on condition that this work was continued and either in-patient or out-patient treatment given to all children referred there from the School Ophthalmic Clinic. It will be seen from the report of the School Ophthalmic Surgeon that seven children were admitted to the hospital for operation for squint. Following upon the operation some of these children attended regularly for orthoptic exercises to restore sight in the squinting eye. In addition, it will be noted that two other cases were referred to the hospital for operative treatment, as well as twelve other cases of complicated eye conditions. This arrangement with the Western Ophthalmic Hospital is working extremely well and has been of great advantage to those school children of the district who are suffering from eye disease of such a nature that it cannot be dealt with satisfactorily at a school clinic. The report of the School Ophthalmic Surgeon is full of interest, and the Committee may rest assured that Enfield children are receiving every attention concerning the conditon of their eyes. 63 During the course of the year a report was published by the Board of Education concerning the question of the treatment of children suffering from defective eyesight. The Committee will be aware that it is the practice to send children whose sight is so bad that they cannot be taught with normal children, to a special school known as a myope school, or a school for blind children. Both these names are bad. In the first case many of the children attending the myope schools are not suffering from myopia or short sight, whilst none of the children are actually blind. A better name would be " school for partially sighted children." Careful consideration has to be given as to what children should be sent to this type of school. In the first case there is the child whose sight is so bad that it cannot gain education by being taught with sighted children; for these children special educational methods are obviously necessary. There is a second type, however, consisting chiefly of children suffering from myopia where, although the child can see quite well either with or without glasses, the strain of normal school life is derogatory to the child's eyes and likely to cause further injury. With these children it is essential to determine whether the condition is stationary or progressive. If the condition is stationary and the sight good, there is no reason why the child should not be left in an ordinary school. Where, however, the condition is progressive, it is essential that the child's sight should be safeguarded by special methods of education, even if the sight be good. These facts are well borne in mind when consideration is given as to the question whether in any specific case a child should be sent to a special school or allowed to remain in an ordinary school. I would stress here that not only in the case of eye defects, but that in all cases it is preferable for abnormal children or children suffering from physical defects to be retained in elementary schools if they can be taught there without harm to themselves or the other children. The abnormal child or the child with a physical defect will have to live and earn its living with normal children when it leaves school, and it is wrong to segregate such children during school life if it can be avoided. The ideal is for these children to remain in elementary schools participating in that part of the school programme from which their physical defect does not bar them, but receiving care and education in special classes in those subjects for which special methods of education are necessitated by their defect. The acreage of Enfield and its small population as compared with its extent makes it difficult to have special classes in our elementary schools for children suffering from defects of vision and hearing, but I consider this is an aim which the Education Committee should have in mind when the population has increased to such an extent that its achievement becomes possible. 64 The report of the School Aural Surgeon shows a steady continuation of the work carried out in previous years. A slight increase in the number of children referred from the Council's Maternity and Child Welfare Clinics will be noted. It is to be hoped that the early treatment now obtainable for the children in the district may lessen the number who have to be treated for aural defects when they enter school. I would draw attention to the fact that out of 60 children found to be suffering from acute disease of the middle ear, 50 were treated and discharged cured. This is a condition that unless promptly and efficiently treated is apt to lead to chronic discharge from the ear and even deafness. The report of the Senior Dental Surgeon is once again full of interest. Good as is the dental treatment offered to the children of Enfield, I cannot persuade myself that it is as yet complete. According to Sir George Newman, Chief Medical Officer to the Ministry of Health and the Board of Education, one dentist can have under his care about 4,000 children, provided that of these 4,000 children 75 per cent. actually require treatment and about 60 per cent .accept it. In Enfield 71 per cent. of our children were found to need dental treatment in 1934, and about 65 per cent. accepted it; therefore we should need one dentist for each 4,000 school children annually inspected. There are two dentists for roughly 10,000 elementary school children, whilst, in view of the fact that dental treatment will be provided in 1935 for secondary school children, another 1,000 must be added to this number, making two dentists for 11,000 children. The school population has increased by nearly 1,000 in the last five years, apart from secondary school children. It cannot be expected, therefore, that the same dental treatment can be given to the number of children we now have to deal with as could be before this increase in number. It is not yet possible to see that each child is dentally examined once a year, nor to treat promptly all those children who would accept treatment if they were examined during the course of the year. During the latter part of 1934 special arrangements were made by the Milk Marketing Board and the Board of Education to make milk available at cheap prices for children attending elementary schools. Certain conditions were laid down, however: (1) that the supply of milk should be such as was approved by the Medical Officer of Health; and (2) that the milk should be drunk on the school premises. It was further recommended that where available the milk supplied should be pasteurised and delivered in one-third pint bottles. My approval was sought as to the supply of milk, and I specified, according to the recommendation of the Board of Education, that I would only approve pasteurised milk. Several 65 dairymen in the district have improved their plant in order that their milk should conform to the standard set up for pasteurised milk and that they should be allowed to supply the schools. The scheme has been a success and large numbers of children are now being supplied with one-third pint of milk daily. Arrangements are also in operation for the supply of milk free of charge to those children whose parents are unable to pay the reduced cost thereof. As for the previous two years arrangements were made for sending children to camp. During July, 1934 , 281 children were sent to camp at Dovercourt, and all these children were examined by the School Medical Department before they were allowed to go, in order to see that they were in a clean condition, free from infectious disease, and not suffering from any ailment which might make it unwise to send them to camp. In general, I am satisfied that the health of the children attending our schools has been maintained during the course of 1934, and that the school medical service is safeguarding the health of the children satisfactorily. I am indebted to my staff and colleagues for the co-operation and loyalty that I have received from them during the year, and to the members of the Committee for their courtesy at all times. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, DENNIS H. GEFFEN. 66 REPORT OF THE SCHOOL MEDICAL OFFICER. Area (acres) 12,400 Population (mid 1934) 74,664 Number of Schools 20 1930 1931 1932 1933 1934 Average number on Books of Elementary Schools 9,104 9,172 9,453 9,725 9,970 Average weekly attendance 8,049 8,205 8,495 8,685 8,857 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 3,378. In 1933, 2,869 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-six 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:— Percentage of children accom- 1930 1931 1932 1933 1934 panied by parents 78 79 78 77 76 Thirty-seven per cent. of the children examined were vaccinated. The comparative figures for the last five years are as follows:— 67 1930 1931 1932 1933 1934 Percentage of children vaccinated 40 42 42 37 37 DEFECTS FOUND AT ROUTINE MEDICAL INSPECTION. Uncleanliness.—Of 3,378 children examined, 15 were found to have vermin in their heads and 279 had nits. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 Number of children examined 2,514 2,790 3,087 2,869 3,378 Number of children with verminous heads 82 64 54 21 15 Percentage of children with verminous heads 3.3 2.3 1.7 0.7 0.4 Number of children found to have nits 335 328 281 224 279 Percentage of children found to have nits 13.4 11.7 9.1 7.8 8.2 These figures indicate that the improvement in cleanliness apparent since 1930 has been maintained. The conditions found consisted of nits and vermin in the head; in no case during the year was a child found to have body vermin. Malnutrition.—Three cases of malnutrition were seen during the course of routine inspection. Skin Diseases.—Fifteen cases were seen; fourteen required treatment and one was kept under observation. Ear Disease.—Eighteen 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:— 1930 1931 1932 1933 1934 Number of children examined 2,514 2,790 3,087 2,869 3,378 Number of cases of Middle Ear Disease found 24 11 18 23 18 Percentage of cases of Middle Ear Disease found 0.9 0.4 0.6 0.8 0.5 Number of cases of Defective Hearing found 40 42 56 53 53 Percentage of cases of Defective Hearing found 1.6 1.5 1.8 1.8 1.6 Tonsils and Adenoids.—One thousand and two children had already had operation for removal of tonsils and/or adenoids; 512 were found to have enlarged tonsils, adenoids, or both. 68 The following is a comparative table for the last five years 1930 1931 1932 1933 1934 Number of children examined 2,514 2,790 3,087 2,869 3,378 Number of children already operated upon 684 914 1,049 1,121 1,202 Percentage of children already operated upon 27.2 32.8 33.9 39.1 35.6 Number of children with enlarged tonsils, adenoids, or both Percentage of children with 810 961 787 388 512 enlarged tonsils, adenoids, or both 32.2 34.4 25.5 13.5 15.3 Eye Diseases and Defects.—Thirty children were found to be suffering from external eye disease. Twenty-eight were referred for treatment to the minor ailment clinic and two were kept under observation. Two hundred and seventy-four cases of defective vision were referred for treatment to the Ophthalmic Clinic or hospital; 40 of these had squint. The following is a comparative table tor the Jast hve years:— 1930 1931 1932 1933 1934 Number of children examined 2,514 2,790 3,087 2,869 3,378 Number of children with defective vision 222 240 237 296 234 Percentage of children with defective vision Number of children with squint 8.9 102 8.6 96 7.7 48 10.3 21 6.9 40 Percentage of children with squint 4.1 3.4 1.6 0.7 1.1 During 1934 arrangements were made with the Western Ophthalmic Hospital that for a fee of 10 guineas per annum the hospital should accept for in-patient or our-patient treatment all children referred there by the School Ophthalmic Surgeon. During the course of the year the following cases were referred to the Western Ophthalmic Hospital:— 2 for removal of meibomian cysts. 7 for operation for squint. 12 for other conditions. Of these children, 12 received out-patient, 4 were given inpatient treatment, and 5 were given both in-patient and out-patient treatment. These figures show how satisfactory this scheme has been. 69 Tuberculosis.—One case of pulmonary tuberculosis was found. Crippling Defects.—The following defects were found during Routine Medical Inspection:— 1 case of cleft palate and hare lip. 1 case of infantile paralysis. 1 case of club foot. 1 case of wry neck. 3 cases of spinal curvature. 1 case of leontiasis ossia. 1 case of cleft palate. 1 case of severe flat foot. 1 case of wasting of lower limbs. 1 case of spastic diplegia. 1 case of multiple exostosis. INFECTIOUS DISEASE. The following table is a comparative table for the last five years : 1930 1931 1932 1933 1934 Measles 833 65 460 4 430 German measles 6 1 5 6 160 Mumps 149 86 43 667 277 Whooping cough 59 43 180 78 72 Chicken-pox 187 169 131 235 100 Scarlet fever 136 159 124 134 135 Diphtheria 141 178 77 28 11 Diphtheria carriers .. 1 3 1 — 3 Small-pox 7 — 1 — — Typhoid fever Poliomyelitis 3 1 1 The figure for Diphtheria is the lowest I have yet been able to record in my annual reports; not a single school child died of either Scarlet Fever or Diphtheria during the course of the year, and I believe that this is a record. It will be seen that, apart from Measles, the district has been very free from infectious disease. 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. 70 VERMIN. Of 3,378 children examined at Routine Inspection, 15 were found to have vermin in their hair, and 279 had nits—i.e., 8.7 per cent. had unclean heads. No child was found to have 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 treatment of minor ailments; one or them is also in charge of the Aural Clinic. Each nurse is responsible for the following up 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 1934 and for the past five years 1930 1931 1932 1933 1934 Number of home visits 3,062 2,603 2,298 2,943 2,697 Number of school visits 390 387 377 621 559 Number of school visits for routine examination of heads 212 216 220 220 195 Total number of heads examined 36,255 38,228 37,469 39,154 37,303 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 1934 was 3,188 and the total number of attendances was 19,886. The average attendance at the nurses' clinics was 34 (i.e., 102 per day for the three clinics). At the School Medical Officer's Clinic the average attendance was 41. 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. 71 Table IV. gives in detail the diseases dealt with at the Minor Ailment Clinics. Tonsils and Adenoids.—During the year 320 cases were seen at the clinics and referred for treatment, and 174 cases were kept under observation. Of these, 224 were operated on under the Authority's scheme and 29 were operated on by private arrangement. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 Number of cases referred for treatment 1,037 780 709 467 320 Number of cases operated under Authority's scheme 496 450 295 224 224 Number of cases operated by private arrangement 91 84 62 53 29 Tuberculosis.—Ten cases of suspected or definite tuberculosis were seen at the clinic during the year. Two children were offered sanatorium treatment and two accepted. One child who was recommended in 1933 was still away in sanatoria in 1934. All cases notified in previous years were kept under observation, and some were given convalescent treatment. Ringworm.—Eleven children were found to be suffering from ringworm. Three were scalp lesions and seven were skin lesions, and one was a skin and scalp lesion. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 Number of children found to be suffering from ringworm 7 2 3 9 11 Impetigo.—During the year 12 cases were seen; 10 were treated at the clinic. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 Number of children found to be suffering from impetigo 10 30 13 14 12 Scabies.—Sixteen cases were seen. Fourteen of these were treated at the clinics. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 Number of children found to be suffering from scabies 3 7 13 11 16 Other Skin Diseases.—One hundred and twenty-three cases 72 were seen. These consisted chiefly of seborrhoea, eczema and psoriasis. Eye Diseases.—Two hundred and thirty cases were treated at the clinics. These were chiefly conjunctivitis, blepharitis and styes. All cases of defective vision were referred to the Ophthalmic Clinic for treatment. Ear Diseases.-— Sixty-five cases of otitis media were found. Sixty-four were referred for treatment to the Aural Clinic. Heart Disease.—Seventy-one children were found to be suffering from organic heart disease; nine 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 76 cases seen during the year. Of these cases, 15 were congenital, and five followed acute infectious diseases. The remaining 56 cases may be classified as follows:— Definite rheumatic history 21 Vague pains 8 No history of illness 27 Chorea.—Eight children were found to be suffering from chorea; two of these were recovering and were kept under observation. All the rest were referred for treatment to a doctor or hospital. Crippling Defects.—The following defects were seen at the clinic:— 1 case of old tubercular elbow. 3 cases of hemiplegia. 1 case of congenital multiple exostosis. 5 cases of spinal curvature. 4 cases of hammer toe. 5 cases of club foot. 2 cases of old tubercular hip. 5 cases of infantile paralysis. 5 cases of cleft palate and hare lip. 1 case of cleft palate. 1 case of congenital shortening of leg. 3 cases of wry neck. 1 case of severe knock knee. 1 case of congenital dislocation of hip. 1 case of birth palsy. 1 case of old tuberculous knee. 1 case of old spina bifida. 1 case of traumatic shortening of leg. 1 case of deformity of chest. 73 1 case of congenital absence of fingers. 1 case of spastic paralysis. 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. 22 cases of obesity. 1 case of hydrocephalus was attending hospital. 1 case of diabetes is being treated at hospital. 1 severe case of rheumatoid arthritis is attending hospital. 1 boy suffering from dwarfism is attending hospital. 1 girl was found to be suffering from thyroglossal cyst and was referred to hospital. 1 girl was found to be suffering from appendicitis and was referred to hospital and operated upon. 4 cases of erythema nodosum were referred to doctors for treatment. 5 children were found to be suffering from hernia; 1 was operated upon, 3 are waiting operation, and 1 is wearing a truss. The total number of children examined during the year, excluding those attending the Dental Department, was 8,568. This number was made up as follows:— Examined at Routine Inspection 3,378 Examined at Minor Ailment Clinics 3,188 Examined at Ophthalmic Clinic only 632 Examined at Aural Clinic only 83 Examined at school leaving age for Juvenile Employment Committee 932 Examined under Juvenile Employment Bye- laws 59 Examined under Mental Deficiency Act 17 Examined as Contacts with infectious disease 279 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 74 cases the Local Authority bears the whole cost. During the year the sum of £247 11s. 9d. was collected, as follows:— £ s. d. Minor Ailment Clinics 3 6 6 For cost of Spectacles 52 6 9 For Convalescent treatment 54 1 6 For Operations for Tonsils and Adenoids 78 3 3 For Dental treatment 59 13 9 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; 16 girls and 16 boys were sent during 1934. During 1934 two beds were also reserved for a period of six months at Collington Manor, Bexhill, and four girls and four 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 12 deaths among school children during the year. In 1933 there were 14. The causes of death during 1934 were as follows:— 1 Heart Disease. 2 Pneumonia. 1 Osteomyelitis. 1 Meningitis. 1 Acute Nephritis. 2 Epilepsy. 1 Drowned. 1 Murdered. 1 Abdominal Tuberculosis. 1 Peritonitis. 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 five exceptions, the schools are lit by gas; in the cases of Botany Bay Council, Chesterfield Road Council, Chase Side Council, Suffolks 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 75 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. THE OPENING OF SUFFOLKS SCHOOL. This report would not be complete without reference to the opening of Suffolks School. This school is built on 23 acres of land, and consists of a Senior Mixed and Junior Mixed Department, and has accommodation at present for 800 children. This school is built on the most modern an up-to-date lines; the hall is of large dimensions, capable of division into two and is indeed a beautiful structure; the cloakrooms are built on hygienic lines; the lavatory accommodation is well up to date, and the staircases and passages wide and airy. The whole building represents a new idea in schools for elementary teaching, and sets up a standard of which the Enfield Education Committee may be truly proud. I have no doubt but that schools of this description will contribute largely toward maintaining the health of the scholars that attend there. 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 ages 12 to 14. The following demonstrations have taken place:— 76 By Miss Newbegin, at Bush Hill Park School 3 demonstrations By Miss Garlick at Chesterfield Road School 5 demonstrations By Mrs. Herbert, at Lavender Road School 2 demonstrations By Mrs. Herbert, at Chase Side School0 2 demonstrations By Miss Wilkinson, at Alma Road School 1 demonstration Thus 13 demonstrations were given during the year, as compared with 12 last year. OPEN-AIR EDUCATION. There are 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 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 1934 23,688 dinners were provided. CO-OPERATION OF PARENTS. The parents take an active interest in the work of the School Medical Department. Parents are notified in writing of the Routine Medical Inspection of the children, and 76 per cent. attended in person in 1934. 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. 77 CO-OPERATION OF TEACHERS. In no year more than 1934 have I appreciated the co-operation and help which the school teachers and especially the Head Teachers have afforded the School Medical Department. Much as the School Medical Department can do towards improving the health of the children, it is only through the constant care and vigilance of the Head Teachers that early cases of disease can be brought to our notice. The teacher is the first person to notice that a child is becoming quiet or listless, the first to realise that the child's work is falling below its previous standard. Great as may be the influence the school doctor can wield in urging parents to obtain treatment for their children, it is very often to the Head Teacher that a parent goes to discuss the matter. I have no hesitation in saying that the co-operation I have received could not be better, and the happy conditions under which we work with the school teachers gives me the very greatest pleasure; I have had the feeling throughout the whole year that my work has been backed by the loyal help of the teachers, probably at the expense of much of their leisure time, and I know that the Committee join with me in feeling deeply grateful for the services the teachers have rendered in this respect. Following upon the permission of the Education Committee, arrangements were made during the year for the transference of all the School Medical Cards to my Department, so that I now have in the office a medical record of every child who is attending our schools. The Head Teachers have been most helpful in supplying me with such particulars concerning the health of the children as I have required, and I hope by means of having the cards in my own office to relieve the Head Teachers of a certain amount of clerical work. 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 information 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 1934 23,688 dinners were thus provided. 78 Twenty-one children were given cod-liver oil and malt, Parrish's Food, etc., and nine convalescent treatment; 331 pairs of ordinary boots were also provided. 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. In addition to the services already set out as being rendered to school children, during the course of the year two children were provided with surgical boots, two with surgical instruments, one child suffering from diabetes was provided with insulin, one child was provided with an artificial eye, and one with a spinal jacket. In addition to the children already mentioned who were sent to Parkstone or Bexhill, one child was given convalescent treatment elsewhere. CO-OPERATION OF LOCAL PRACTITIONERS. One of the strongest bulwarks in a school medical sercive is the support of the general practitioner. It is to the family doctor that parents go when they are worried concerning the health of their children. Many practitioners have brought to my notice cases where the school medical service could be helpful, and in every case I have been able to give the help required. On the other hand, it is the routine for children found to be suffering from conditions that should not be treated at our Minor Ailment Clinic to be referred to the family doctor. It is interesting to note that during the course of the Christmas term alone, 130 children were advised to seek advice from their family doctor. 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 11 such children in Enfield, and they are educated as follows:— 3 girls attending residential schools for the blind. 2 boys and one girl attending Edmonton School for the Partially Blind. 79 4 girls attending Wood Green School for the Partially Blind. 1 boy awaiting admission to School for the Partially Blind. Mentally Defective Children.—Seventeen children were examined under the Mental Deficiency Act (1913) during 1934. The following is a comparative table for the last five years:— 1930 1931 1932 1933 1934 A. Dull and backward but capable of instruction in an elementary school 7 3 2 1 4 B. Mentally Defective but capable of instruction in a special school 8 3 6 7 8 C. Mentally Defective but incapable of instruction in a special school 3 – – – – D. Incapable of further instruction in a special school 3 3 1 – 2 E. Imbecile 2 2 4 4 1 Moral Imbecile 1 – – – – F. Mental condition due to physical defect – – – – – G. Not scheduled — 2 — 5 2 EXAMINATION OF SECONDARY SCHOOL CHILDREN. The Enfield Education Committee undertakes the examination of children attending the secondary schools in the district, on behalf of the Middlesex Education Committee. There are three such schools in Enfield, namely the Grammar, County, and Junior Technical Schools. The following tables set out the number of children examined at each school during the course of the year and the defects found to be present:— Junior Technical. Grammar. County. Examinations 68 236 221 Special Examinations 24 — — 80 DEFECTS. Jnr. Technical. Grammar. County. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Dental Caries 25 1 37 34 Defective Vision 9 1 21 3 33 15 Enl.Tonsils, etc. 1 4 12 14 5 1 Other Nose and Throat conditions 1 – – – – – Defective Hearing — — — — 1 — Otorrhoea 1 — 1 —• 3 — Skin Diseases – — 1 — 1 — Spinal Curvature — — 2 — — — Other Deformities 3 — — — — — Other Diseases and defects 5 – 7 3 8 Anaemia 4 – – – – – During the course of the year the Middlesex County Council determined to put into operation a scheme for the treatment of children attending secondary schools who were suffering from either dental defects or defective vision. Arrangements were made whereby such treatment should be carried out through the staff of the school medical service of the district in which the school was situated. This scheme will come into operation during 1935. The figures that I have quoted in the above table show how very necessary it was that such treatment should be provided. Twenty-five per cent. of the children examined were found to be suffering from dental caries, whilst 12 per cent. required treatment for defective vision. I welcome the decision of the County Education Committee, and look forward to a considerable improvement in the health of the Enfield children attending secondary schools as a result thereof. My only regret is that the scheme was not made comprehensive to include treatment for conditions of the throat and nose and minor ailments. 81 Annual Report of the Senior School Dental Surgeon Mr. C. E. JAMES, L.D.S., R.C.S. (Eng.) for the year ending 31st December, 1934. Mr. Chairman, Ladies and Gentlemen, I beg to submit the annual report for the year ending 31st December, 1934. Fillings inserted during the year totalled 4,446, the number in permanent teeth being 3,903, and in temporary teeth 543. An additional 691 temporary teeth received conservative treatment by the application of Silver Nitrate and Formalin. With regard to the use of Silver Nitrate as a means of preserving carious temporary teeth, Mr. Bradbury and I are of the opinion that considerable care is necessary in the selection of teeth for this treatment and in the preparation of the cavities. Unless the cavities will permit the removal of soft caries without the pulps becoming exposed, and unless they are rendered as self cleansing as possible by the removal of overhanging edges, the results are not satisfactory. The total number of teeth extracted was 5,116, 4,465 being temporary and 651 permanent teeth. The number of children inspected as routines was 6,211; as specials, 658; a total of 6,869. Of this total, 5,077 were found to require treatment, and 3,552 were actually treated at the school clinic. Of the routines inspected, 71 per cent. were found to require treatment, and 65 per cent. of those requiring treatment actually received it at the school clinic. When a child attends as a " special," generally in order to have a tooth extracted for the relief of pain, all the teeth are examined in order to ascertain if conservative treatment is also required. If the child should be one whose parents have on previous occasions refused their consent to treatment, it is almost invariably found that one or more teeth are in need of fillings, and an immediate extraction is only performed on the understanding that the parent will bring the child to the clinic the following week for the necessary conservative treatment. This procedure has been the means of introducing conservative treatment to many children, and of 82 ersuading their parents, previously classified as "Refusals" to consent to dental treatment at subsequent routine inspections. It has been found that if a parent definitely promises to bring a child for completion of treatment, the promise is generally kept, provided always that the interval between the immediate extraction and the next appointment does not exceed one week. It is very desirable that the Dental Inspection of school children should be carried out at least once each year so that dental disease may be detected and treated while still in its initial stage. That this is still impossible in Enfield is due to the large number of children referred for conservative treatment, and the high proportion of fillings to extractions. In the year under review 599 permanent fillings were inserted for every 100 permanent teeth extracted. A number of the permanent teeth extracted were sound teeth removed for regulation purposes, and if these were deducted from the total number extracted, the ratio of fillings to extractions would be a little higher than the figure given. The following table gives the number of fillings inserted in temporary and permanent teeth and the number of extractions of temporary and permanent teeth during recent years. Year Fillings in temp. and perm. teeth Extractions of temp. and perm. teeth No. of fillings in temporary and permanent teeth 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 1934 4446 5116 86.9 The number of children referred for treatment at Routine Inspection depends very largely on the standard of dental fitness required before exempting a child from treatment. In Enfield 83 every child is referred for treatment whose permanent teeth show defects, however slight, as indicated by the "catch" of a sharp probe during inspection. So far as the temporary dentition is concerned, the standard of inspection is necessarily not so high. Of the permanent teeth those that most frequently require attention in the order of their liability to dental caries, are: (1) the first lower molars; (2) the first upper molars; (3) the second lower molars; (4) the second upper molars. It has been estimated that more than 90 per cent. of the permanent molar teeth are eventually attacked by caries, and that in the case of children more than 70 per cent. permanent molar teeth have structural defects on their occlusal surfaces that will permit the entry of a sharp find probe. Recognition of these facts has led to the operative technique termed Prophylactic Odontotomy, i.e., " The removal by cutting of a defective part of a tooth in order that the area so treated may be protected from a threatened onset of caries, the operation being confined to pre-carious pits and fissures." Time would not permit the adoption by the School Dentist of all the measures advocated by the Prophylactic Odontotomists, but there are obvious advantages in treating dental defects at the earliest possible moment. Among these may be mentioned:— (a) The painlessness of the operation—an important point, especially in the case of nervous children. (b) The avoidance of pulp infection from deep seated caries. (c) The smallness of the fillings—being small, they are rapidly inserted, permanent, and unlikely to cause pulp irritation. One frequently notes with satisfaction that the insertion of small fillings in the pits and fissures of molar teeth confers immunity for several years. A child who has had all the four first permanent molar teeth treated in this way at the age of seven, frequently requires no further treatment so far as the permanent teeth are concerned for a period of five years until the eruption of the second permanent molars. It is found that the latter teeth quickly become carious in those cases where the first permanent molars required fillings at an early age. In such cases, indeed, the second permanent molars not infrequently require conservative treatment before their complete eruption. A further point noticed is that caries is markedly bilateral. If a molar on one side of the mouth becomes carious, not only is it almost invariably found that the corresponding tooth on the other side of the mouth is also attacked, but the situation of the caries in each case is frequently identical. 84 In Enfield many children leave school with all eight molars filled on their occlusal (biting) surfaces—frequently also with fillings on the buccal (mouth) surfaces of the lower and lingual (lip) surfaces of the upper molars. Of all teeth and of all surfaces, these are the most liable to dental caries, and one feels that even if regular inspection and treatment is not obtained, as it should be, after leaving school, there is a good prospect of these important teeth being retained in a healthy condition for many years. It is true that the treatment mentioned does not provide against the possibility of caries commencing on the proximal surfaces. The regular examination of many teeth, however, indicates that a considerable proportion of proximal cavities have their origin on the occlusal surfaces. Unfortunately, a number of the fillings inserted are sufficiently large to require a lining. This cannot be avoided when the number of children under the care of the School Dentist is in excess of what it should be, but it is a matter for regret that so much time should be expended on filling large cavities that could be better utilized in filling a much larger number of small ones. Accepting the view that " The enamel defect of to-day is the carious cavity of to-morrow," one hopes that it may eventually be possible to reduce the intervals between inspections and to develop the school dental scheme on lines that will tend to be preventive in character rather than remedial. The sum taken in fees for dental treatment during 1934 amounted to £60 10s. 9d. In conclusion, Mr. Bradbury and I desire to place on record our indebtedness to Head Teachers for the co-operation which is an essential factor in the dental treatment of children under their care, and to express once more our thanks to Nurse Anderson and Miss Groves for their valued services. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. E. JAMES, Senior School Dental Surgeon. 85 Report of the School Ophthalmic Surgeon. Mr. S. MACKY, M.B., B.S., D.O.M.S. for the year ending 31st December, 1934. 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, 1934. The following tables show the figures for the last five years:— 1930 1931 1932 1933 1934 Total number of attendances at Clinic 2,122 1,938 2,151 2,475 2,255 New cases 905 870 930 1,055 1,126 Prescriptions for glasses 395 427 469 446 401 Number not requring glasses 59 59 56 91 85 The cases requiring glasses consisted of:— Hypermetropia 93 78 75 79 80 Hypermetropia with astigmatism 165 183 293 353 349 Hypermetropic astigmatism 298 206 152 175 203 Myopia 105 92 72 79 88 Myopia with astigmatism 52 93 113 104 104 Myopic astigmatism 25 11 11 13 10 Mixed astigmatism 8 23 43 53 62 Anisometropia 8 11 12 18 28 During the year eight children were referred for operation for squint. Three refused treatment, four were operated upon, and one is awaiting admission to hospital. In addition to these, three children who were referred for operation in 1933 were operated upon in 1934. Two children were referred to the Western Ophthalmic Hospital for removal of meibomian cysts. The figures for this year show very little variation when compared with the figures for the past few years. There is for instance, only an increase of 99 in the total number of cases examined since 1928, while the new cases have increased by 294 and the 86 tions of glasses decreased by 30. This means that our standard of routine inspection is very high, and that it is well nigh impossible for a child with any visual defect to escape detection. Many of those whom I have passed as not needing glasses have small errors and may need correction later if symptoms persist, but I try to avoid giving glasses for these minor errors. Symptoms seldom survive the first use of atropine and the ritual of the dark-room. The proportion of myopia to hypermetropia remains more or less the same (nearly 1 to 3). The publishing this year of the report of the Committee investigating the education of partially sighted children is, I think, going to change our treatment of the "high myope." I personally hope this change will follow the lines of the Committee's recommendations—chiefly in allowing much more reading in the curriculum. The abandonment of the whole idea of the " myope school " would, I am sure, be deplorable—at least, until a complete statistical investigation has been made—because one's impression of the small number of cases one sees is that nearly all do very well from a visual point of view while they are at the "myope school." There have been an extraordinary number of interesting and unusual cases this year, as the following list will suggest:— 1 case of tubercular choroiditis. 2 cases of retinitis with disturbance of colour sense. 1 case of optic neuritis. 1 case of papilledema (unilateral). 1 case of retinitis proliferans. 1 case of retino-choroiditis (very atypical appearance). 2 cases of cataract—anterior capsular with unusual features. 1 case of " hole in the disc " with optic atrophy. 3 cases of persistent hyaloid artery. 1 case of optic atrophy (bilateral). 1 case of sympathetic nerve paresis. Most of these cases needed further investigation at the Western Ophthalmic Hospital, some at Maida Vale Hospital for Nervous Diseases, and one was shown at the Royal Society of Medicine. I am indeed glad again to have this opportunity of thanking the members of the medical and secretarial staff for their unfailing kindness and most efficient help. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, STEWART MACKY, School Ophthalmic Surgeon. 87 Annual Report of the School Aural Surgeon. Mr. J. C. HOGG, F.R.C.S. For the year ending 31st December, 1934. To the Chairman and 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 for the year ended 31st December, 1934. During the year we have dealt with 250 cases, of which 167 were new. The total number of attendances was 718. Of these 145 have been discharged cured, and there are 21 cases of a recurrent nature which require occasional attention, but which have again been discharged. There are 30 children under treatment, seven have refused treatment, and in two cases treatment was sought elsewhere, privately or in hospital. Twenty-five cases have been recommended for the removal of tonsils and adenoids, of which four have refused operation. One case of long standing aural suppuration was admitted to the Ear, Nose and Throat Hospital, Golden Square, under my care, for a radical mastoid operation. She has subsequently been discharged, and is attending for occasional after treatment. During the year under review, 23 infants, totalling 51 attendances, have been seen in the Aural Clinic, referred from the Welfare Centre. None of these remain 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 Aural Surgeon. +88 CLASSIFICATION. 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 — 4 50 2 4 — 60 2. Chronic suppurative otitis media 8 12 17 13 2 — 52 3. Chronic catarrhal deafness, Eustachian obstruction and otosclerosis 7 8 25 2 3 — 45 4. Wax, otitis externa, eczema, boils, etc. 2 — 28 4 — — 34 5. Chronic Rhinitis, nasal obstruction, etc. 13 10 25 — — — 48 6. Non-aural — — — — — — 34 Total 273 Statistical Tables for the Annual Report of the School Medical Officer, for the Year 1934. TABLE 1. RETURN OF MEDICAL INSPECTIONS. A.—ROUTINE MEDICAL INSPECTION. Number of inspections in the prescribed Groups:— Entrants 826 Second Age Group 892 Third Age Group 864 Total 2,582 Number of other Routine Inspections 796 B.—OTHER INSPECTIONS. Number of Special Inspections 5,131 Number of Re-Inspections 2,645 Total 7,776 89 TABLE II. (A) Return of defects found by Medical Inspection in the year ending 31st December, 1934. 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 Treatment Requiring to be kept under observation, but not requiring treatment (1) (2) (3) (4) (5) Malnutrition 1 2 — — SKIN. Ringworm. Scalp 1 — 4 — Body — — 7 — Scabies 1 — 16 — Impetigo — —. 12 — Other Diseases (Non-Tuberculous) 12 1 111 12 EYE. Blepharitis 13 1 34 1 Conjunctivitis 15 — 125 1 Keratitis — — 1 — Corneal Opacities — 1 — 3 Defective Vision (Excluding Squint) 234 185 195 10 Squint 40 31 25 — Other Conditions 10 — 93 2 EAR. Defective Hearing 48 5 22 5 Otitis Media 18 — 64 1 Other Ear Diseases 11 — 55 3 NOSE AND THROAT. Chronic Tonsillitis only 26 62 44 62 Adenoids only 9 4 10 3 Chronic Tonsillitis and Adenoids 246 165 266 109 Other Conditions 23 2 58 224 ENLARGED CERVICAL GLANDS (Non-Tuberculous) 5 3 25 15 DEFECTIVE SPEECH — 1 — 10 90 TABLE II (continued) HEART AND CIRCULATION. Heart Disease Organic 1 24 9 62 Functional — 1 — – Anaemia — — 1 – LUNGS Bronchitis 1 – 2 3 Other Non-Tuberculous Diseases 3 1 8 3 TUBERCULOSIS. Pulmonary Definite 1 – 4 — Suspected — – 3 — Non-Pulmonary Glands 1 – 5 — Bones and Joints – – — — Skin — – – – Other Forms — – – — NERVOUS SYSTEM. Epilepsy 2 1 2 4 Chorea — – 4 3 Other Conditions 3 1 9 12 DEFORMITIES. Rickets — – – – Spinal Curvature 4 – 5 — Other Forms 5 5 27 19 OTHER DEFECTS AND DISEASES (excluding Uncleanliness and Dental Diseases) 63 15 1348 203 Total 797 511 i2594 771 91 (B) Number of individual children found at Routine Medical Inspection to require treatment (excluding uncleanliness and dental diseases). GROUP. Number of Children Inspected Found to require treatment (1) (2) (3) PRESCRIBED GROUPS:- Entrants 826 170 Second Age Group 892 242 Third Age Group 864 143 Total (Prescribed Groups) 2582 555 Other Routine Inspections 796 176 Grand Total 3378 731 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 Institutions. At no school or Institution Total 3 — — 3 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions At no School or Institution. Total. — 7 — — — 7 92 DEAF CHILDREN. At Certified schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total 4 — — — 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 – 4 3 — — 7 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 33 — — — 33 EPILEPTIC CHILDREN. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools. At other Institutions At no School or Institution Total — — — — — 93 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 1 4 — — 5 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools At other Institutions At no School or Institution Total 2 5 – 1 8 B.—DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions. At no School or Institution Total 8 — 1 — 9 C.—CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total — 24 — 1 25 94 D.—CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions. At no School or Institution. Total 1 — 2 1 4 This section is confined to children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary schools. TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1934. TREATMENT TABLE. GROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Group VI.) DISEASE OR DEFECT. Number of Defects treated, or under treatment during the year Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) SKIN. Ringworm—Scalp (i) X-Ray Treatment 2 2 4 (ii) Other „ — — – Ringworm—Body 6 1 7 Scabies 14 2 16 Impetigo 10 1 11 Other Skin Diseases 107 10 117 MINOR EYE DEFECTS (External and other, excluding cases falling in Group II.) 230 17 247 MINOR EAR DEFECTS 272 20 292 MISCELLANEOUS (e.g., minor injuries, bruises, sores, chilblains, etc.) 1197 126 1323 Total 1838 179 2017 95 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.) DEFECT OR DISEASE. No. of Defects dealt with. Under The Authority's Scheme. Otherwise Total Errors of Refraction (including squint) 925 8 933 Other Defects or Disease of the Eyes 22 — 22 Total 947 8 955 No. of children for whom spectacles were Prescribed. (1) Obtained. (2) Under the Authority's Scheme Otherwise. Under the Authority's Scheme Otherwise. 401 8 399 8 96 GROUP III—TREATMENT OF DEFECTS OF NOSE AND THROAT No. of Defects. Received Operative Treatment. Received other forms of Treatment Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme Total (1) (2) (3) (4) (5) I. II. III IV I. II. III. IV. I. II. III IV 40 293 26 6 192 — 4 2 23 — 30 8 215 — I. Tonsils only. II. Adenoids only. III. Tonsils and Adenoids. IV. Other defects of nose and thoat. GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. Under the Authority's Scheme. Otherwise. Total number treated 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 Number of Children treated – – – – 1 10 11 97 GROUP V.—DENTAL DEFECTS. 1. Number of children who were:— I. Inspected by the Dentist: Aged Routine Age Groups 5 419 Total 6,211 6 725 7 690 8 632 9 747 10 743 11 689 12 645 13 556 14 365 Specials 658 Grand Total 6,869 II. Found to require treatment 5,077 III.—Actually treated 3,552 2. Half-days devoted to:— Inspection 52 Total 794 Treatment 742 3. Attendances made by children for treatment 5,694 4. Fillings:— Permanent teeth 3903 Total 4,446 Temporary teeth 543 5. Extractions:— Permanent teeth .. 651 Total 5,116 Temporary teeth 4465 6. Administrations of general anaesthetics for extractions 262 7. Other operations:— Permanent teeth 499 Total 1,236 Temporary teeth 737 98 GROUP VI—UNCLEANLINESS AND VERMINOUS CONDITIONS. I. Average number of visits per school made during the year by the School Nurses 10 II. Total number of examinations of children in the Schools by School Nurses 37,303 III. Number of individual children found unclean 1,109 IV. Number of children cleansed under arrangements made by the Local Education Authority 13 This cleansing is of clothes and bedding only. V. Number of cases in which legal proceedings were taken: (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws 8 99 Public Offices, Enfield. 1st March, 1935. Report of the Chief Sanitary Inspector for the year, 1934. 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, 1934. 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 586 From House-to-House apart from this Act 207 On Account of Infectious Disease 289 On Account of Phthisis 64 On Account of Complaint by occupant or otherwise 1,636 184 Factories 189 130 Workshops and Workplaces 137 Outworkerte' premises inspected 41 42 Bakehouses, of which 32 are in use 66 3,215. 100 Inspections—(continued). Inspections. Brought forward 3,215 11 Slaughterhouses, of which 7 are in use 1,415 23 Cowkeepers' premises 438 SI Dairies and Milkshops inspected frequently 255 21 Schools 55 Public Conveniences inspected 448 Conveniences at Railway Stations inspected 9 Fish shops; Total number of visits 78 Coffee and Eating Houses: Total number of visits 15 Coffee-stalls: Total number of visits 36 Shops where Ice-cream is made: Total number of inspections 34 Meat Shops: Total number of inspections 176 Food Stalls in Markets: Total number of inspections 1,058 4,017 Visits to absentees excluded from Elementary Schools 1,334 Visits in connection with cases of Infectious Disease 1,584 Visits in connection with Phthisis 305 Visits re Housing Act 133 Visits re Verminous Premises, etc. 1,418 Offensive Trades (excluding Fish Shops) 9 Smoke observations 106 Other inspections, including works in progress 8,376 Petroleum Stores Inspected 312 Visits re Shops Act 145 Cinemas, etc., inspected 31 Visits and inspections re Rats 138 Visits re Sub-letting in Council Houses 33 Visits re Gypsy Vans, etc. 53 Visits re Overcrowding 0 Visits re Rag Flock Act 9 Visits and Inspections at Mortuary 21 Inspections of Stables 3 Visits re Noises 4 14,014 r >1,246 101 Notices Issued. Statutory:- Provision of dustbins 10 For repairs to houses, drains and abatement of nuisances 108 Providing sufficient water-closets 10 Paving of yards - Provision of Sinks or Drains 2 Abatement of Smoke 1 131 Informal:— Notices 1,061 1,061 1,192 Other Notices issued under Infectious Diseases Acts:— To occupiers 585 To Education Committee and Head Teachers at Schools 5,810 To Librarian 59 6,454 7,646 Other letters sent 5,332 Number of Certificates issued in connection with plans 318 Result of Service of Statutory and Informal Notices:— Statutory. Informal. Number complied with 126 713 Number outstanding 5 358 131 1,061 In only one case was it found necessary to take proceedings against an owner of four houses for non-compliance with Statutory Notices served. Fines were imposed and the Order of the Court secured attention to the works required. Reference to the Medical Officer of Health's Report will show that proceedings were instituted for an offence under the Public Health (Smoke Abatement) Act, 1926, in one case, but before the 102 case was heard, steps were taken to abate the nuisance by the installation of effective plant. The completion of the work required by the outstanding Notices was somewhat delayed for various good and satisfactory reasons, but it will be noticed that the number of Statutory Notices not complied with is considerably less than in the previous year. The defects found during the inspection of dwelling-houses are of a somewhat general character, and include the following:— 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 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 notices or letters:— Houses or parts of houses cleansed, repaired, etc. 651 Roofs repaired 188 Gutters and down pipes repaired 128 Downpipes disconnected from drains 4 Settlement remedied 1 Cesspools emptied 265 Cesspools abolished 0 New Cesspools provided 0 Closet Pails Emptied 1,196 House drains cleared, repaired, etc. 197 House drains tested, examined, etc. 479 House drains reconstructed 35 Soil-pipes and drains ventilated, including repairs to ventilators 29 New vents provided 4 New manhole covers provided 2 Sink-wastes disconnected or repaired 47 New sinks provided 71 Closets provided with proper flushing cisterns or water supply 3 New closets provided 5 Closets repaired, covered, cleansed, etc. 195 Water-closets substituted for earth-closets 1 Privy substituted for earth-closet 0 Storage cisterns repaired, covered, cleansed, etc. 44 Storage cisterns provided 9 Water laid on or restored 20 Water laid on in houses 5 103 New wells provided 7 Wells closed 0 Wells cleansed and repaired etc. 0 Samples of Water taken from Wells 15 Do. do. Main 0 Do. do. Swimming Pool and Baths 7 Samples of Rag-Flock taken under Rag-Flock Act 7 Samples of Milk taken 4 Yards paved, or existing paving made good 116 Ventilation provided under ground floors and causes of dampness removed, etc. 173 Floors repaired 8 Dustbins repaired, or new ones provided 267 Forecourts paved 0 Food Stores provided 2 Ventilation provided to food stores 3 Manure heaps removed 22 Fowls and other animals removed 2 Coppers repaired, etc. 32 Stoves repaired, etc. 92 Windows repaired, etc. 190 Other nuisances abated 147 Cases of overcrowding abated 0 Ditches cleaned out 3 Gipsy vans removed 14 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. By interviewing owners and others having control of property in the District, the work has been speeded up, and in cases where there seemed to be no just cause or reason for delay, a suitable warning from the Council has helped to have the work carried out, and so avoided further proceedings being taken to secure the finish of the repairs necessary. 1,334 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 21,246. Disinfection. Houses Disinfected:— After infectious disease 292 After Phthisis 85 104 After verminous cases 128 Vacated Council houses 86 591 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 29 Ditto, ditto, by cases of Phthisis 2 Articles of clothing, bedding, etc., disinfected 1,336 Ditto, ditto, destroyed 153 Library Books disinfected 118 No. of Certificates issued re disinfection of clothing and premises 15 Number of Schools disinfected 2 Private Patients removed to Hospital or Infirmary 3,432 Gipsy Vans removed from District 14 Articles or parcels of unsound food destroyed or otherwise disposed of 657 86 vacated Council houses were disinfected during the year. Of these, 33 showed signs of vermin—38 per cent. of the total. It is a decision of the Council that before an occupier may transfer from one Council house to another, the person wishing to be transferred must, on inspection, be found to be occupying a house free from vermin. DISINFESTATION OF VERMINOUS HOUSES. It has been the experience of the Department during the past year in dealing with the question of verminous houses to find that the problem is still one very difficult of solution. Visits have been paid to other districts to try to ascertain if they have a more effective way of dealing with the problem, but I am sorry to say I have not yet been able to find an effective method of dealing with bugs without some risk to either those using the particular preparation or the occupiers of the house or adjoining houses. The great point still seems to be that cleanliness to the extreme on the part of the occupier is the best solution of the matter. If it could be certain that all furniture and effects, as well as the clothing of the people were absolutely free from vermin when taking a Council house we should be a long way towards a good solution of the problem. It is, however, found that people are not too ready to acknowledge the presence of vermin in rooms or houses occupied by them previous to moving into a Council house. On the one hand, it is because they consider themselves regarded as unclean, and secondly there is the fear that they will not be granted the tenancy of a Council house. 105 As stated in previous reports, the bug once imported into the house, quickly multiplying, is almost impossible to remove. Cleanly people seem still to have to suffer for the sins of the uncleanly, and until people can regard cleanliness as next to Godliness there will be no final solution of the difficulty. Even with a perfectly clean person, the unfortunate habit of the poorer class of buying secondhand beds and furniture persists, and the introduction of the bug into the house by this means adds to the difficulty. It is a question whether we can really visualise a house so built as to be absolutely free of cracks and crevices, and the furniture no longer of a portable character but as part of the house and made of such material as is actually bug-proof. Still, one can always strive for an ideal, though at the time of the attempt it may elude one. 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 1934 there were 74 workshops, 56 workplaces and 42 bakehouses registered. The following tables give details of the work done in connection with these places:— Inspections. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 189 - - Workshops (including Workshop Laundries) and Workplaces 137 - - Bakehouses 66 - — Total 392 - — 106 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 7 7 — — Want of Ventilation 2 2 — — Overcrowding — — — — Want of Drainage of Floors — — — — Other Nuisances 9 9 — — Sanitary Accommodation:— Insufficient 3 3 — — Unsuitable or Defective 28 . 28 — — Not separate for sexes — — — — Offences under the Factory and Workshops Acts:— Illegal occupation of underground bakehouse - - - - Breach of special sanitary requirements for bakehouses 21 21 - - Other Offences 6 6 — — Total 76 76 — — 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 8 11 19 19 47 Boot-making 2 2 4 4 — Totals 10 13 23 23 47 Three addresses of outworkers have been forwarded to other districts. 107 PLACES OF PUBLIC ENTERTAINMENT. Thirty-one 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. There are prospects now of places of entertainment of a more imposing and luxurious character being erected in Enfield. Whether this can be considered a matter calling for consideration from the sanitarian I do not know, but it is evident that this latest craze of the public is going to be very much catered for. Perhaps it might be thought desirable that occasionally a few of the pictures were those that would educate the public in some way as regards sanitation. Unfortunately, the public taste at present is for pictures of a more exciting nature. OFFENSIVE TRADES. The following offensive trades are established in the District:Fish Fryers 28 Rag and Bone Dealers 3 Glue Maker 1 Soap Boiler 1 and in connection with these, 87 inspections were made during the year. It will be noted that the number of offensive trades in Enfield has not increased. Repeated visits are paid to ensure them being kept in a good and sanitary condition. 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. Routine inspection of cowsheds, dairies and milkshops has been carried out during the year under the Milk and Dairies (Consolidation) Order, 1926. The standard of cleanliness has been fairly well maintained. I am pleased to say that the farmers are favouring the use of sterilisation plants, and there is an increase in the number being used in the District. There is also a further extension of the practice of milking cows by mechanical apparatus, and this appears to be a success and has come to stay. It undoubtedly appears to add to the cleanliness of milk production. 108 There has been some laxity on the part of one or two of the farmers with regard to limewashing, though the period is now two months instead of the one month of a few years back, but I cannot say there has been anything of a serious nature in this respect. 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" 7 Pasteuriser's Licence to sell milk as "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. Inspection of meat under the above Regulations has, as a routine matter, been carried out as in previous years. Every endeavour is made to ensure that all foodstuffs 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 previous years, animals have been conveyed to the various slaughterhouses in Enfield by road in lorries, thus avoiding driving the animals by road through the District from a Station in the outlying part of the District. It will be seen that the number of pigs slaughtered during the year has fallen. This, I understand, is owing to the difficulty of getting the proper supply from the various markets in the country. Slaughtering is carried out at almost all hours of all days, holidays or otherwise, and the Sanitary Inspectors have to spend a considerable amount of their time in examining the carcases and organs of slaughtered animals, and although there is an increase of one certified Meat Inspector on the Staff, they are all still fully employed. The old back and forward movement of meat from the slaughterhouses in Enfield to the Central Meat Market, London, and meat from the latter being sent to and sold in Enfield, still continues. A perusal of the table below reveals an increase in the number 109 of sheep and calves killed, but a decrease in the number of pigs, the total number of animals killed being somewhat less than in the previous year, but the amount of meat destroyed has increased. The number of carcases examined during the year under these Regulations is as follows:— Oxen 245 Organs or parts of carcases found diseased 48 Cows 2 „ „ „ „ 0 Calves 174 „ „ „ „ 0 Sheep 12,736 „ „ „ „ 423 Pigs 4,848 „ „ „ „ 146 Totals 18,005 „ „ „ „ 617 The organs or parts of carcases found to be diseased were surrendered and destroyed. The weight of the meat destroyed was 6 tons 14 cwt. 3 qrs. 21 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 1,415 Shops 176 Stalls in Markets 1,058 2,649 As in previous years, foodstuffs purchased in the various London Markets were submitted for inspection, and 40 parcels were found to be unfit for human consumption ; these consisted of fish, poultry, 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. Seventeen certificates in all were granted. COFFEE STALLS. As stated in previous reports, renewal of old Licences and the plans for new Coffee Stalls are passed through this Department, and up-to-date provision is required with regard to the removal of refuse, water supply and drainage. 110 There is the prospect that this work will considerably increase under the provision of the new Shops Act. MOTOR AMBULANCES. There are 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 permission 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 ACTS. The duties of inspectors under the Shops Acts are carried out by this Department. It was found necessary during the year to take action in three cases against shopkeepers for contraventions of the Act, and fines were imposed in each case. In one case it was the first on which we had had to take proceedings. We must look forward to considerable increase of the work in the future under the new Shops Act as regards the sanitation of all shops—old and new. Arrangements have been made that the plans of all new shops shall be sent to this Department for report. 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. Thirty-two Dustmen and the following vehicles are in use for the removal of house refuse:— 1ll 1—6 cubic yards "S.D." Freighter (petrol) dust-van. 2—10 cubic yards dustless-loading "S.D." Freighters. 3—15 cubic yards "S.D." Moveable Floor Rear-loading Freighters. 1—Tuke and Bell 10 cubic yards "Barrier" Type end-loading vehicle. The remaining two electric vehicles were discarded during the year, and the three rear-loading Freighters included in the above list were pucheased. They were of the rear-loading roller-floor type, and experience in the use of them led us to modify the method of loading insofar as the position of the winding handle has been moved farther away from the rear of the body in order to obviate as far as possible the discomfort which the man formerly experienced from dust blowing over him as the refuse was ejected from the lorry. The latest type of this make of roller-floored vehicle is operated both for loading and unloading from the front end of the vehicle, and in the event of any further purchase of similar machines this will undoubtedly be the type used. I am of the opinion that, on the whole, the roller-floored type of refuse collection vehicle gives very satisfactory service, and is undoubtedly the best type at present available for use on a dump. An additional garage for four vehicles has been erected at the Lincoln Road Depot, and all the transport of the Department is now concentrated at this Depot. Arrangements exist whereby trade refuse is removed from shopkeepers' premises on payment of a prearranged charge. The income from this source was £72 17s. during the year. During the year, 17,351 tons of refuse were collected and disposed of at a cost of £10,932. This equals 12s. 0.2d. per ton for collection and disposal, as against 11s. 6.9d. in 1933. The cost per head of the population is 2s. 9.5d. per annum, or 0.6d. per week. The average for each house is 11s. 7.5d. per year, or 2.7d. per week. DISPOSAL OF REFUSE. The dumping site at Brown's field, Enfield Highway, on which the refuse of Enfield has been disposed of during the year has only a short life. The Council is surveying the District as to the possibility of obtaining land for tipping purposes. We have again been rather fortunate in obtaining covering material from road works in progress. Visits have been received from other Districts, and from as far abroad as Palestine, with regard to our method of refuse collection and disposal. 112 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. The main drainage at the rear of Hanby Terrace, Ordnance Road, and at Nos. 61 to 85, Churchbury Road, has been re-constructed. The question will arise during the coming year with regard to having a second gang of sewer flushers, owing to the considerable increase in the District, and of this I hope to speak in the next Report. 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. I have pleasure in reporting that the old manual pump in use for many years in Enfield has been replaced by the latest up-to-date cesspool cum gulley emptying machine. This machine has been purchased from Messrs. Shelvoke and Drewry, and so far as the short experience will allow one to express an opinion, it is a considerable benefit from a sanitary point of view. In emptying the gulleys throughout the District it has been found that the work done is of such a nature that has never before been done in Enfield, that is with regard to emptying the whole of the gulley to the bottom. The vehicle is so designed that the whole capacity of the cylindrical main tank is immediately available for emptying either cesspools or gulleys, clean water for re-sealing gulleys being carried to rectangular side tanks. SCHOOLS AND HOSPITALS. The arrangement with the Education Committee is still carried out as ragards 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 the request of the Education Committee I submitted a report on the cleansing of the drainage arrangements attached to the provided Schools, but that has not at present advanced to any further stage. 113 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. During the coming year I hope to be able to recommend an alteration in regard to the attendance at the Gentlemen's conveniences, and should I be happy enough to receive the support of he Council in this, I shall be reporting further next year. HORSE TROUGHS AND DRINKING FOUNTAINS. Drinking fountains, and also four horse troughs in the District, receive daily attention as regards cleansing. PUBLIC MORTUARY. One Public Mortuary in the District, established at the Enfield Highway Cemetery, is constantly under supervision. RATS. It will be noted that fewer visits have been paid with regard to the destruction of rats, and this may possibly be due to the fact that householders are beginning to realise their duty in this respect. One Inspector has left the Department to take up private work, and the Council greatly assisted by appointing two Inspectors 114 in place of the one. There still remains the question as to whether the Staff is going to be equal to the work in the future. New Acts in the way of Housing Acts and others are increasing the work of the Sanitary Inspectors. In addition to this, Enfield is a rapidly increasing District, and I am very much afraid the provision of one Sanitary Inspector only will not be sufficient to keep pace with the growth of the District with the more enlarged scope of the work to be dealt with. During the year I have had the pleasure of delivering lectures in the evenings to various bodies of ratepayers, and hope the suggestions made there will have some impression on the public. One point I endeavoured to impress the ratepayers with was that by lining the dustbin with old newspapers instead of putting them indiscriminately in the dustbin, would ensure a drier and more sanitary dustbin, and would help in the way of dustless removal of refuse. Unfortunately, the public still rely on disinfectant powder being placed in the dustbin. The public regard the powder as having some germicidal effect, which I am afraid is very much lacking, and the only good done is to dry the moisture from the bottom of the dustbin. 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 49 Ambulance facilities 25 Area of District 8 Aural Surgeon's Report 87 Aural Treatment 30 B. Baby Week 34 Bakehouses 49 Births 14 Birth Control 31 Blind, Deaf, Epileptic and Mentally Defective Children 78 Blind and Partially Blind Children 91 Bye-laws and Regulations 19 C. Causes of death at all ages 12 Causes of death under 1 year of age 13 Cerebro-spinal Fever 53 Cesspools 39, 112 Chief Sanitary Inspector's Report 99 Children Act 32 Children Suffering from Multiple Defects 91 Children suffering from Pulmonary and Non-Pulmonary Tuberculosis 93 Children with Heart Disease 94 Circulation of Booklet on Rearing of Children 35 Clinics and Treatment Centres 26 Closet Accommodation 39 Coffee Stalls 109 Co-operation of Parents 76 Co-operation of Teachers 77 Co-operation of School Attendance Officers 77 Co-operation of Voluntary Bodies 77 Co-operation of Local Practitioners 78 Co-operation with Education Committee 37 Councillors 7 Crippled Children 93 D. Deaf and Partially Deaf Children 92 Deaths 11 Defective Vision and Squint 95 Defects found at Routine Medical Inspection 67 Delicate Children 93 Dental Defects 97 Dental Surgeon's Report 81 Dental Treatment 33 Detection and Spread of Infectious Disease 69 Diphtheria 52 Diphtheria Carriers 52 Disinfection 103 Disinfection of verminous persons and their belongingas 57 Disinfestation of Verminous Houses 104 Disposal of house refuse 39, 111 Drainage and sewerage 38 Drinking fountains 113 E. PAGE Encephalitis Lethargica 53 Enteric and Paratyphoid Fever 53 Enteritis 53 Epileptic Children 92 Examination of Secondary School Children 79 F. Factory and Workshops Act 105 Fitness of houses 46 G. General Observations 46 H. Home Helps 35 Horse troughs 113 Hospitals 19, 112 Housing 43 Housing conditions 46 I. Infantile Mortality 3, 15 Infectious Diseases and Schools 42, 69 Infectious Diseases table 51 Inquests 14 Inspection and supervision of food 47 Isolation Hospital 21 L. Laboratory facilities 18 Legislation 19 M. Maternal Mortality 22 Maternity and Child Welfare Statistics 27 Maternity Hospital 21 Measles and German Measles 53 Meat 48 Members of Education Committee 60 Members of Health Committee 7 Members of Maternity and Child Welfare Committee 7 Mentally Defective Children 92 Meteorology 57 Midwives 18 Milk 47, 107 Milk in Schools 36 Milk (Special Designations) Order 48 Minor Ailments 94 Mortuary 113 Motor Ambulance 110 N. National Health Insurance 18 Notices issued 101 Notifiable diseases 50 Number of Elementary School Children 66 Number of Individual school children found at Medical Inspection to require treatment 91 Nursing in the Home 18 0. PAGE Offensive Trades 107 Officials of Council 7 Open Air Education 76 Ophthalmia Neonatorum 54 Ophthalmic Surgeon's Report 85 Other foods 49 Orthopaedic and Postural Defects 96 Ophthalmic Treatment 31 P. Paratyphoid and Enteric Fevers 53 Petroleum 110 Physical Training 76 Physically Defective Children 93 Places of Public Entertainment 107 Poliomyelitis 53 Population 8 Prevalence of, and contraol over, Infectious and other Diseases 50 Prevention of Blindness 54 Provision of Meals 76 Public Conveniences 113 Public Health (Meat) Regulations 49, 108 Public Health (Prevention of Tuberculosis) Regulations 57 Public Health (Smallpox) Prevention Regulations 50 Public Health Staff 17 R. Rag Flock Acts 42 Rats 113 Regulations and Byelaws 19 Removal and disposal of house refuse 39, 110 Return of Defects found by Medical Inspection 89 Return of Defects Treated 94 Return of Medical Inspections (Aural) 88 Routine Medical Inspection 66 Routine Medical Inspection of Children under 5 years 29 S. Sale of Foods and Drugs Act 49 Sanitary Administration 19 Sanitary circumstances of District 38 Sanitary Inspection of District 41 Scarlet Fever 52 School Medical Officer's Report 62, 66 School Medical Service in Relation to Public Health 74 Schools 42, 112 Sewerage and drainage 38 Sewer flushing 112 Shops Act 110 Slaughter of Animals Act 49 Slaughterhouses 48 Smoke abatement 41 Social conditions 9 Staff of Public Health Department 17 Staff of School Medical Department 61 Statistics 10 Streams and Water-courses 38 Sub-letting in Council houses 41 Suffolks School—Opening of 75 Suicides 14 T. PAGE Teaching of Hygiene 75 Tuberculosis (County of Middlesex) Scheme 19 Tuberculosis 55 Treatment Clinics (Schools) 70 Treatment of Defects of Nose and Throat 96 U. Uncleanliness and Verminous Conditions 98 Unsound Meat and foods 109 Unborn Child 35 V. Vermin 70 Verminous houses 46, 104 Veterinary inspection of cows 48 Vital Statistics 10 W. Water-courses and streams 38 Water supply 38 Work of School Nurses 70 Z. Zymotic death-rate 54 Zymotic diseases 53