C.I. Mddx M AC 439(1) ENFIELD (Later 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 1935 together with the ANNUAL REPORT of the Chief Sanitary Inspector (Fred Wilson, M.R.San.I., M.S.LA.) ENF 19 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 1935 together with the ANNUAL REPORT of the Chief Sanitary Inspector (Fred Wilson, M.R.San.I., M.S.I.A.) Printed by Stanley Woodfield, 8, 10, 12, Windmill Hill, Enfield. PUBLIC OFFICES, ENFIELD. 28th March, 1936. Annual Report of the Medical Officer of Health, 1935. To the Chairman and Members of the Urban District Council of Enfield. Mr. Chairman and Gentlemen, I beg to place before you my 9th Annual Report on the health of the District. It will be noticed that the Birth-rate is 15.85, the highest recorded since 1929, whilst the Death-rate, which is 9.55, is the lowest since 1930. The Infantile Death-rate, which is the number of deaths in children under one year of age, per 1,000 recorded births, is 50.00, which is the lowest on record except for 1934 when it was 43.27, and 1924 when it was 44.22. It would therefore appear that generally the health of the District has been well maintained throughout the year. I have referred to each health activity of the Council under a separate heading in this Report, and there is, therefore, little need for general comment in these introductory remarks. The most notable event of the year was the opening of three Maternity and Child Welfare Clinics, and the beginning of the Housing Survey. I would like to stress the importance of this Survey. No 2 matter how vast the Maternity and Child Welfare, the School Medical and prevention of Infectious Disease services in any District may be, it most be realised that as a health measure none of these services can be fully efficacious unless the residents of the District are properly and healthily housed. It is extraordinary to realise how little the evils of overcrowding are realised, not only by those who live in satisfactory conditions, but even by those who are overcrowded. It has been my experience to find in the District families in receipt of as much as £10 and £13 per week who were living under conditions of severe overcrowding. One would have thought that such families with an income so high would have looked for better accommodation. On the other hand there are many families in the District too poor to pay adequate rent for the accommodation they need. Housing must be looked upon as a health measure of the utmost importance, and I sincerely trust that now that a standard of overcrowding has been officially laid down, conditions will improve throughout the Country. One most important point is that from 1st July, 1936, every rent book will have to contain a statement as to the maximum number of persons who may inhabit a house, and it will be impossible for the landlord or tenant to claim ignorance of this standard as an excuse for overcrowding. The standard is admittedly low, but at least it is a step in the right direction, and it is to be hoped that when overcrowding has been abated on this standard, a higher one will be adopted. Recent years have shewn that Diphtheria is a preventable disease, and you will be pleased to hear that the propaganda that has been carried out is resulting in an increased demand for immunisation against this disease, in Enfield. There is no reason why Diphtheria should not be practically wiped out in the District. It is true that in recent years the number of cases notified has been low. I would take this opportunity of warning the public that it must not be assumed from this that Diphtheria is disappearing from Enfield. I have but little doubt that unless the public is protected by immunisation, an epidemic of this disease will once more arise and the fact that the number of notified cases has been low for the past few years will tend to make this epidemic more widespread and more severe. 3 Might I refer to the fact that during the year Diphtheria broke out in an Institution in Enfield. It shewed a tendency to be serious and I have no doubt whatsoever but that it would have been serious and cost loss of life had the Public Health Department, the Medical Officers of the Institution, and the Ministry of Health not combined to take active and immediate steps. Yet Diphtheria should never occur in a residential Institution for healthy children. This Report would be incomplete were I not to express my thanks to the Chairmen of the various Committees and the Members of the Council for their courtesy throughout the year. I would also record my thanks to every Member of my Staff for the help and co-operation I have received. I beg to remain, Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health. 4 URBAN DISTRICT COUNCIL OF ENFIELD. Chairman of the Council T. H. M. CLARKE, Esq., J.P. Vice Chairman of the Council W. W. CAKEBREAD, Esq. Members of the Council:— P. DAINES, Esq. E. EDWARDS, Esq. C. PARTINGTON, Esq. W. B. ANDERSON, Esq. W. J. CLARKE, Esq. F. GREENWOOD, Esq. H. MUSPRATT, Esq., O.B.E. H. A. D. BROWN, Esq. W. H. BISHOP, (Jnr.), Esq. S. G. ROWLANDSON, Esq. A. E. KINGWELL, Esq., F.R.I.B.A. H. H. COLLIER, Esq. A. R. KEMP, Esq. H. G. SHORT, Esq. W. T. TAYLOR, Esq. A. M. EELES, Esq. G. E. JONES, Esq. Members of the Health Committee:— Chairman W.J.CLARKE, Esq. also Messrs. ANDERSON, BISHOP, EDWARDS, GREENWOOD, JONES, KEMP, ROWLANDSON and TAYLOR. Members of the Maternity and Child Welfare Committee:— Chairman W. J. CLARKE, Esq. Councillors ANDERSON, BISHOP, EDWARDS, GREENWOOD, JONES, KEMP, ROWLANDSON, and TAYLOR. Also Co-optative MembersMrs. B. C. EELES, Mrs. A. E. HEATH, Mrs. G. F. PORTER 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.Inst.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. 5 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 76,960, and this figure is being used in connection with the vital statistics as set out in this Report. From information that has been collected subsequent to December 31st, 1935, it would appear that the population at the end of the year was probably 79,000. The following table shews how the population of the District has increased during the last ten years. Year. Population. 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 1935 76,960 The number of inhabited houses at the end of 1935, according to the Rate Books, was 19,298. The rateable value of the District is £652,693, The net product (after allowing for cost of collection) of a penny rate is £2,525 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. 6 Year No. of inhabited houses. Rateable value. Sum represented by a penny rate. £ £ s. d. 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 1935 19,298 652,693 2,525 0 0 SOCIAL CONDITIONS. It is interesting to note that in ten years the number of inhabited houses in the District has increased by nearly 50 per cent., that the rateable value has almost doubled itself, whilst the sum represented by a penny rate is double that which it was in 1926. During 1934, 1,238 houses were erected, and during 1935, 1,953. This makes a total of 3,191 houses built in the course of two years, all of which were erected by private enterprise. Building of this nature still continues, is principally of the three bedroomed and two sitting-room type of house, erected for sale to the occupier. I am of the impression that very few, if any, houses are being let on a yearly tenancy or lease. 7 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:- Total Male. Female. Legitimate 1,183 584 599 Illegitimate 37 23 14 Birth-rate—15.85 per 1,000 population. Still Births:— Total. Male. Female. Legitimate 44 20 24 Illegitimate 3 1 2 Rate per 1,000 total births—37.09. Total. Male. Female. Deaths 755 385 370 Death-rate—9.55 per 1,000 population. Number of women dying in, or in consequence of, childbirth:— Deaths. Rate per 1,000 Total Births. From Puerperal Sepsis .. 1 0.78 From other Puerperal causes 3 2.36 4 3.15 One of these four cases was removed to the Prince of Wales Hospital, and three to the North Middlesex Hospital, Edmonton, where they died. Death-rate of Infants under one year of age:— All infants per 1,000 live births 50.00 Legitimate infants per 1,000 legitimate live births 48.18 Illegitimate infants per 1,000 illegitimate live births 108.10 Deaths from Measles (all ages) 0 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) 12 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 140 smaller towns:— Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Births. Still Births. England and Wales 14.7 0.62 11.7 57.00 London 13.3 0.52 11.4 58.00 121 County Boroughs and Great Towns (including London) 14.8 0.68 11.8 62.00 140 Smaller Towns 14.8 0.64 11.2 55.00 ENFIELD 15.85 0.61 9.55 50.00 8 DEATHS. The deaths registered in the District during the year were 438, of which 223 were males and 215 females, giving a crude death-rate of 5.68. To this must be added 365 deaths of Enfield residents registered outside the District, and from this total must be subtracted 48 deaths of non-residents, occurring in the District, which brings the number of deaths to 755 for the year, giving a net deathrate of 9.55 per 1,000 population. The corresponding figures for Enfield for the five previous years are :— 1930 1931 1932 1933 1934 Net death-rate 9.63 10.40 10.64 9.83 9.64 Eighty-six deaths registered in the District were persons over 80 years of age, 38 being males and 48 females, one woman dying at the aee of 98. The more important causes of deaths registered during the year and the previous four years were:— Cause of Death. 1935 1934 1933 1932 1931 Malignant Disease 118 103 85 90 91 Bronchitis 27 36 26 30 19 Heart Disease 164 176 169 180 160 Old Age 20 13 11 25 24 Tuberculosis of Respiratory System 46 52 36 40 39 Pneumonia 64 52 61 54 57 Other Digestive Diseases 21 17 13 15 14 Other Circulatory Diseases 59 44 36 43 44 Nephritis 13 10 19 25 22 Cerebral Haemorrhage 40 29 37 39 35 Deaths from Violence (excluding Suicides) 30 27 28 28 22 Influenza 11 5 22 14 20 Children :— Premature Birth 22 14 12 12 12 Inanition and Marasmus 5 7 10 8 6 Congenital Malformations 4 4 3 7 9 Pneumonia 12 8 10 14 6 Injury at Birth 3 4 2 1 4 Enteritis 10 1 6 1 7 It is to be noted that of the 755 deaths that occurred during the year, 365 took place outside the District of Enfield. Of these, 256 were Enfield residents who died in the North Middlesex Hospital, Edmonton, and information as to these deaths and the causes thereof is supplied to me regularly each week by the courtesy of the Medical Officer of Health of the Urban District Council of Edmonton. 9 TABLE 1. Causes of Death during Year 1935. Causes of Death. Males. Females. Total. All Causes—Certified 385 370 755 Uncertified - - - Typhoid and Para-Typhoid Fevers 1 1 2 Measles - - - Scarlet Fever - 1 1 Whooping Cough - 1 1 Diphtheria - 2 2 Influenza 3 8 11 Encephalitis Lethargica - - - Cerebro-Spinal Fever - 1 1 Tuberculosis of Respiratory System 26 20 46 Other Tuberculous Diseases 4 - 4 Syphilis - - - General Paralysis of Insane Tabes Dorsalis 2 - 2 Cancer, Malignant Disease 54 64 118 Diabetes 3 1 4 Cerebral Haemorrhage, etc. 13 27 40 Heart Disease 77 87 164 Aneurysm 1 - 1 Other Circulatory Diseases 28 31 59 Bronchitis 18 9 27 Pneumonia (all forms) 35 29 64 Other Respiratory Diseases 1 - 1 Peptic Ulcer 5 - 5 Diarrhoea etc. (under 2 years) 4 8 12 Appendicitis 4 2 6 Cirrhosis of Liver 2 1 3 Other Diseases of Liver, etc. 1 - 1 Other Digestive Diseases 12 9 21 Acute and Chronic Nephritis 6 7 13 Puerperal Sepsis - 1 1 Other Puerperal Causes - 3 3 Congenital Debility, Premature Birth, Malformations, etc. 15 19 34 Senility 10 10 20 Suicide 6 - 6 Other Violence 20 10 30 Other Defined Diseases 34 18 52 Causes ill-defined or unknown - - - Total 385 370 755 10 TABLE II. Infant Mortality Net Deaths from stated causes at various Ages under One Year of Age. Causes of Death Under 1 week. 1 to 2 weeks. 2 to 3 weeks. 3 to 4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under One Year. All Causes- —Certified 24 7 7 1 39 9 5 4 4 61 Uncertified - - - - - - - - - - Smallpox - - - - - - - - - - Chickenpox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping Cough - - - - - - - - - - Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - Abdominal Tuberculosis . . - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - 1 - - 1 2 Convulsions - - - - - - - - - - Laryngitis - - - - - - - - - - Bronchitis - 1 - - 1 - - - - 1 Pneumonia (all forms) 1 2 - - 3 2 2 2 3 12 Diarrhoea - - - - - - - - - - Enteritis - - 4 1 5 3 1 1 - 10 Epidemic Diarrhoea - - - - - - - - - - Gastritis - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Suffocation, overlying - - - - - - - - - - Injury at Birth 2 1 - - 3 - - - - 3 Atelectasis 2 - - - 2 - - - - 2 Congenital Malformation 1 - 1 - 2 1 1 - - 4 Premature Birth 17 3 2 22 - - - - 22 Atrophy, Debility and Marasmus 1 - - - 1 2 1 1 - 5 Other Causes - - - - - - - - - - Totals 24 7 7 1 39 9 5 4 4 61 Net Births in the year:—Legitimate: Live births, 1,183; Stillbirths, 47. illegitimate: Live births, 37; Still-births, 3. Net Deaths in the year:—Legitimate Infants, 57; Illegitimate,4. 11 Cancer carried off 118 individuals, and Tuberculosis of the Respiratory System 46, a combined number of 164. This compares with a total of 155 for last year, and the percentage of deaths from these two causes is 21.7, as against 21.5 for 1934. INQUESTS. Nineteen inquests and twenty-seven P.M.s without inquests were held in Enfield during the year, and the verdicts were as follows:— Natural Causes 28 Accidental Causes 11 Suicides 4 Open Verdict 1 Misadventure 2 The above table shows that 4 persons committed suicide during the year under review. In 1934 there were 7, and in 1933, 8. The ages and sexes of the 4 people who committed suicide during the year were as follows:— Males, 22, 26, 54 and 59 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, sex and ages of Enfield residents who committed suicide in or outside the District, were as follows:— 4 Coal Gas Poisoning. Males: Ages 22, 26, 54 and 59 years. 1 Pistol shot wound of head. Fracture of skull and laceration of brain. Male: Aged 52 years. 1 Incised wound of wrist. Male: Aged 63 years. In 1934, of 10 suicides either in the District or of Enfield residents outside, 1 was over 20, 4 were over 30, 2 over 40, 1 over 50, and 2 over 60 years. 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. 12 BIRTHS. The actual number of births registered in the District was as follows:— Boys. Girls. Total. 435 461 896 including 22 illegitimate births, i.e., 2.45 per cent. of the total. In addition, 15 male (including 1 illegitimate) and 17 female stillbirths 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. 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 1935 628 639 1,267 16.46 .51 INFANTILE DEATHS. The total number of deaths which occurred amongst infants under one year, including 39 registered outside the District, and deducting 5 of non-residents occurring in the District, was 61, giving a death-rate of 50.00 per 1,000 births, as compared with a death-rate of 57.00 for England and Wales, and 62.00 for the 121 County Boroughs and Great Towns (including London). The corresponding figures for Enfield for the last four years were: 1931, 53.50; 1932,60.11; 1933,50.38; and 1934, 43.27. It will be noticed that there were 14 more deaths of children under one year of age this year than last. This is accounted for by the fact that there were 10 deaths from Enteritis compared with 1 for last year, and 22 deaths from Premature Birth as compared with 14 for last year. The number of deaths of illegitimate children was 4, which gives a death-rate of 108.10 per 1,000 illegitimate infants. 13 PUBLIC HEALTH STAFF. Medical Officer of Health. *D. H. GEFFEN, M.D., D.P.H. Assistant Medical Officer of Health and Assistant School Medical Officer : *A. G. T. THOMAS, 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.LA. *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. (Resigned 16th March, 1935.) *L. ROWLEY, Cert. R. San. I., M.S.I.A., Diploma of R. San. I. 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. *G. S. SAFFIN, A.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—S. H. BEYER, Cert. R. San. I. (Resigned 22nd July, 1935.) Clerk—L. R. GODFREY, Cert. R. San. I. (Resigned 29th May, 1935.) Clerk—R. JOHNSON, Cert. R. San. I. (Resigned 8th December, 1935.) Clerk—Miss V. M. SIMMONS. Clerk—C. W. CHAPMAN. Clerk—Miss D. HILLER. Clerk—V. F. KERRY. Clerk—Miss N. L. BROWN. Clerk—Miss K. M. HALLAM. Maternity and Child Welfare: Dr. K. McKEOWN, M.D., D.P.H. (Part-time Assistant Medical Officer of Health.) (Resigned 21st June, 1935.) 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. 14 NURSING IN THE HOME. There are two Associations in Enfield which provide nursing for the sick poor of the District, namely:— The Ponders End, Enfield Highway and District Nurse Fund. The Enfield District Nursing Association. No financial provision has been paid to either Association by the Local Authority. Application was received for a grant in the early part of 1936 and the matter is now under consideration. There are no permanent arrangements in the District for nursing cases of infectious disease. In the past during times of epidemics of Measles the Council has employed a temporary Nurse. Owing to the fact that Measles is no longer notifiable, I have not had as complete information as to the number of cases of Measles in the District as heretofore, and no Nurse has been employed for the nursing of these cases in recent years. On the other hand, it must be remembered that the Isolation Hospital now admits bad cases of Measles, or cases complicated by other disease, or children suffering from this disease who cannot be nursed satisfactorily at home. 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: 308 patients were removed from Enfield during the year. Two Ambulances are maintained by the Urban District Council of Enfield, and are available for the removal of accident cases and acute or urgent medical and surgical conditions requiring removal to Hospital. Such cases are taken free of charge either to the North Middlesex Hospital, Edmonton, the Prince of Wales' Hospital, Tottenham, or the Enfield War Memorial Hospital. During 1935, the Ambulances removed 3,953 patients. St. John's Ambulance Brigade also maintained an Ambulance during the early part of the year. NATIONAL HEALTH INSURANCE. None of the work of the Authority is related to or administered by this service. 15 LABORATORY FACILITIES. The following work was carried out in the Council's laboratory during the year. Spicimen. No. Positive. Negative. Percentage of Positives. Swab 1,580 133 1,447 8.41 Sputum 163 17 146 10.42 Total 1,743 150 1,593 8.60 Reference to the laboratory report shows that 1,580 swabs were examined during the year. This number exceeds that for 1934 by 572. This increase is due to the fact that there were 77 cases of Diphtheria notified during the year as compared with 37 in 1934, and to an outbreak of Diphtheria in a residential Institution in the District. A report on this outbreak will be found under the heading "Infectious Disease," together with a reference to Diphtheria immunisation. 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 alteration in the boundaries of Enfield consequent upon the ceding of Cockfosters to the Borough of Southgate, gave the Council an opportunity of revising the Bye-laws and Regulations that have been made for the District of Enfield. In this connection new Bye-laws and Regulations have been framed in accordance with the models of the Ministry of Health in respect of the following:— Nuisances. Common Lodging-houses. Slaughterhouses. Houses Let in Lodgings. Tents, Vans, Sheds and Similar Structures. Offensive Trades. Cleansing of Earth-closets, Privies, Ashpits, etc. Consent to these new Bye-laws and Regulations from the Minister of Health is now being awaited. 16 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 1935. 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. For a number of years past the Middlesex County Council had reserved 25 beds at Heatherwood Hospital, Ascot, for the treatment of cases of non-pulmonary tuberculosis in children. This excellently equipped hospital, which was established by, and belonged to, the United Service Fund, was acquired in 1934 by the London County Council. Arrangements were made with the London County Council whereby the Middlesex County Council should continue to have the use of 25 beds at Heatherwood for a period of two years from October 1st, 1934, the date on which the London County Council took over the hospital. The convalescent home, Melton Lodge, Great Yarmouth, which formerly served for the after-treatment of children discharged from Heatherwood, and was a very valuable institution, is no longer available for that purpose, having been acquired by another Local Authority. 17 Other Institutions at which patients have been maintained by the County Council during 1935 are:— Sanatoria.—Brompton Hospital Sanatorium, Frimley; Cotswold, Gloucester; Daneswood, Woburn Sands; Eversfield, St. Leonards; Fairlight, Hastings; Grosvenor, Ashford, Kent; Holy Cross, Haslemere; Kelling, Holt, Norfolk; King Edward VII., Midhurst; King George V., Godalming (L.C.C.); Maltings Farm, Nayland, near Colchester; Marillac, Warley, Essex; Merivale, Sandon, near Chelmsford; National, Benenden; Old Manor House, Broadstairs; Prior Place, Camberley, Surrey; Royal National, Bournemouth; Royal National, Ventnor; Tehidy (CornwallC.C.). Hospitals.—St. Anthony's, Cheam; St. Barnabas', Torquay; Colindale, Hendon (L.C.C.); Creaton, Northampton; Pontsarn, Merthyr Tydhl; Prince of Wales's, Tottenham; All Saints,' Southwark; City of London, Victoria Park; National Temperance, Royal Northern, Holloway; Brompton; Royal Chest; St. Mary's; St. Thomas's; University College Hospital; and the London County Council's general hospitals, Archway; Hackney; Mile End; New End; Paddington; St. Charles; St. Mary Abbots. Colonies.—British Legion Village, Preston Hall, Aylesford; Burrow Hill, Frimley; Papworth Village Settlement, Papworth Hall, Cambridge. Homes for very advanced Cases.—St. Joseph's Hospice, Hackney. All the above are for Pulmonary cases of various types. The following hospitals are for Non-pulmonary adult cases:— Atkinson Morley, Wimbledon; Hendon Cottage; Holy Cross, Broadstairs; Royal National Orthopaedic, London, and Country Branch, Stanmore; Royal Sea-Bathing, Margate; St. Anthony's, Cheam; St. Nicholas-at-Wade; St. Vincent's Orthopaedic, Pinner; Tait Home, Broadstairs; Wingfield Orthopaedic, Oxford; and Prince of Wales's, Tottenham; The London, St. Mary's, St. Peters for Stone, St. Thomas's, and University College Hospitals, London. 18 The following hospitals are for Non-pulmonary child cases:— Alfred Yarrow Home, Broadstairs; Heritage Craft Schools, Chailey; Holy Cross, Broadstairs; Holy Cross, Ramsgate; Lord Mayor Treloar Cripples', Alton; Melton Lodge, Great Yarmouth; Royal, Richmond; Royal National Orthopaedic, Country Branch, Stanmore; Royal Sea-Bathing, Margate; St. Michael's Orthopaedic, Clacton; St. Nicholas and St. Martin's Orthopaedic, Pyrford; St. Vincent's, Pinner; Wingfield Orthopaedic, Oxford; Hendon Cottage; Prince of Wales's, Tottenham; Cheyne, Chelsea, 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 the above has not altered since my Report for 1932, and for information in respect to these reference thereto is advised. INFECTIOUS DISEASE. 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 193 Diphtheria 74 Diphtheria Carriers 11 Erysipelas 10 Paratyphoid 1 Cerebro Spinal Fever 1 Ophthalmia Neonatorum 1 Measles 1 Puerperal Pyrexia 2 Whooping Cough 8 Other 6 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 19 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 8 wells supplying water to 8 houses and premises. The water was found to be satisfactory in 4 cases and unsatisfactory in 4 cases. In those cases where the water was found to be unsatisfactory steps were taken to have the wells 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. 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. Four men are employed daily, who devote their whole time to the work of examining and flushing the sewers ; any defect or obstruction is dealt with immediately. Cesspools. During 1935 the cesspools of the District were emptied by a combined cesspool and gulley emptier. During the course of the year, of the 1,953 houses the construction of which was completed, 7 were drained by means of cesspools. It is hoped that further development in Enfield will be restricted to houses that can be placed on main drainage. 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 ome few earth closets in a rural part of the district. 20 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:— 8 "S.D." Freighters. 1 Tuke and Bell Barrier Type Petrol Vehicle. A weekly collection of household refuse was made throughout the District, and market refuse was collected every Saturday evening from the Market in Enfield Town. During the course of the year it became apparent that only a limited time remained during which refuse could be disposed of at Brown's brickfields, and the Council considered how refuse was to be disposed of in the future. A Sub-Committee was set up to consider the matter. The purchase of alternative sites within the District for controlled tipping, the conveying of refuse out of the District for controlled tipping, its removal from the District by rail and barge, or alternatively the erection of a Destructor were considered. The Committee determined that the problem of disposal of refuse should best be met by the erection of a Destructor, and Destructors at the following places were visited and inspected by various Members of the Committee, together with the Medical Officer of Health and the Chief Sanitary Inspector. Croydon. Wood Green. Brighton. Walthamstow. Clacton. Dagenham. Southgate. Huddersfield. The Committee also considered a report on the disposal of refuse in certain towns in Denmark. After due consideration the Council determined, subject to the consent of the Minister of Health to the borrowing of the requisite sum of money, to instal a Woodhall-Duckham Inclined Rotary Refuse Destructor (Volund Patents), and came to an agreement subject to the above, whereby the North Metropolitan Electric Power Supply Company would accept such steam as was generated from the Destructor for a period of years to be mutually arranged. During 1935 the Council continued to dispose of refuse at their gravel pit in Carterhatch Lane. No complaint was received during the year in connection with the disposal of refuse. SANITARY INSPECTION OF DISTRICT. A full report on this matter is contained in the Report of the Chief Sanitary Inspector, which will be found at the end of this Report. 21 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 these have resulted in the abatement of the nuisance. SWIMMING BATHS AND POOLS. The Enfield Swimming Pool is situated in Southbury Road, Enfield. It is an open air Bath which measures 200 feet by 80 feet. The water is purified by means of two filtration plants and aerated by an external fountain and an internal aerator. The water is chlorinated and the plant is capable of passing all the water in the Pool through the filter in the course of four hours. Samples of the water were taken and tested repeatedly throughout the Season and were found to be satisfactory. The Enfield Lock Baths are situated in Bradley Road, Enfield Lock, and are indoor Baths. There is no filtration plant, but the water is changed at least once a week, and during hot weather twice a week, whilst Chlorine is sprayed into the water in the form of Voxsan. Repeated tests were taken of the water throughout the Season, and were found to be satisfactory. 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 77 Number granted permission to sub-let 67 Number refused permission 10 Number of letters sent 331 Number of visits made by Sanitary Inspectors 28 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. 22 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 670 Number of children found to be suffering from Infectious Disease 378 This compares with the following figures for last year:— 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 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. Four samples were taken during the year, and these were all found to comply with the standard laid down in the Acts. 23 HOUSING. Number of New Houses erected during the year:— (a) Total (including numbers given separately under (b)) 1,953 (i) By the Local Authority — (ii) By other Local Authorities — (iii) By other bodies orpersons 1,953 (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 houses. No. of inspections. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) and number of inspections made 2,761 12,395 (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 498 4,742 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 7 (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 1,409 (The number here given is of houses where any insanitary conditions were found.) 2. Remedy of Defects without service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 1,109 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 repairs 108 24 (2) Number of dwelling-houses which were rendered fit after service of formal Notices:— (a) By owners 54 (b) By Local Authority in default of owners None. B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which Notices were served requiring defects to be remedied 53 (2) Number of dwelling-houses in which defects were remedied after service of formal Notices:— (a) By Owners 51 (b) By Local Authority in default of Owners 0 C.—Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 2 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 12 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 498 Apart from the Do. 70 Total 568 During the course of the year Demolition Orders were made in respect of 2 houses which were unfit for human habitation, and 25 these 2 houses are now in course of demolition. In addition to this, I entered into arrangements with owners concerning property which was unfit for human habitation, and as a result thereof, 20 houses were demolished without official action being taken. Since the passing of the Housing Act, 1930, 92 houses have been demolished either by official action under Section 19 of the Housing Act, 1930, or by arrangements with owners. The task of ridding the District of unsuitable houses is continuing. It is held back to some extent, however, by the shortage of housing accommodation and the time that is required for dealing with each individual house. Procedure under the Act is lengthy, and in addition to this, much work must be done before such information can be obtained as is required before representation can be made by the Council. The work, however, is proceeding steadily. GENERAL OBSERVATIONS. The Council now possesses 1,740 houses, a figure which has remained stationary for the last two years. Land has been acquired for the erection of further houses, the erection of which will be proceeded with in due course. At the end of the year the Housing Survey required by the Housing Act, 1935, was commenced, and the results of this survey will be available to help in deciding what type of house is required for the purpose of housing those families found to be living in overcrowded conditions. During the course of the year the Health Department examined 110 houses which had been vacated, and of these, 29, or 26 per cent., were found to be verminous and had to be disinfested. In 1934, 38 per cent. of the vacated houses were found to be verminous, and it is to be hoped that the decrease in this percentage will be continued. Disinfestation has been carried out during the year by means of sulphur, various spray preparations, and stripping down of all woodwork in the rooms. 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. 26 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. 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 1935, thirty-five 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. Two of these samples, produced in Enfield, were found to contain living tubercle bacilli. In one instance the offending animal was discovered and slaughtered, but in the other instance it was not found possible to trace the animals responsible. Nine cows were reported by Owners as suspected to be suffering from tuberculosis. On examination, seven of this number were found to be so suffering and were 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; 3,151 inspections of bovine animals were made in Enfield; ten cows were found to be suffering from tuberculosis as defined in the Tuberculosis Order, 1925, and were slaughtered. 27 THE MILK (SPECIAL DESIGNATIONS) ORDER, 1923. The inspection of premises where Graded Milk is sold has been carried out as heretofore. There are 15 Purveyors of Milk who sell or distribute Pasteurised Milk in the District. During the course of the year 27 samples were taken of this milk, either at the place of pasteurisation or in the course of delivery. Of these, 22 were found to comply with the Regulations prescribed in connection with Pasteurised Milk, and 5 were not in accordance with the standard. Investigations were made in these cases, and the Purveyors advised as to what steps should be taken to come within the standard. In all cases the necessary steps were taken and further samples showed the milk to be in order. 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. 1935 1935 Registered 10 6 6 Licensed 7 4 4 Total 17 10 10 Mr. Fred Wilson, Chief Sanitary Inspector; Mr. H. Wiggett, Mr. A. J. Williams, Mr. L. Rowley, Mr. A. Ramsden and Mr. G. Saffin, 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 1,071 such visits during the year, when they examined 13,271 carcases, and secured the surrender of 130 carcases and 223 parcels of diseased organs. 28 SLAUGHTERHOUSES. The inspection of slaughterhouses and of animals slaughtered therein takes up a large amount of the time of the Sanitary Inspectors, and causes considerable difficulty, in view of the fact that much of the slaughtering takes place between the hours of 5 and 9 at nights. 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. Two new applications for Licences were received during the year, both of which were granted. In addition, 14 applications for renewal of Licences were received, and all these were granted. The total number of persons who held a Licence during 1935 was 25. 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 Food and Drugs Act is under the control of the Middlesex County Council. 29 A report thereon, kindly supplied by R. Robinson, Esq., Chief Officer of the Public Control Department, follows:— URBAN DISTRICT OF ENFIELD. List of samples purchased during the year ended 31st December, 1935: Article. Taken. Adulterated. Milk 216 2 Milk, Sterilized 6 — Arrowroot 2 — Butter 3 — Chocolate 1 — Cinnamon 1 — Gin 1 — Ground Rice 1 — Hake 5 1 Lemon Sole 1 1 Meat 2 — Minced Beef 1 — Mustard 2 — Sausages 9 — Whisky 7 1 Total 258 5 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. Diphtheria was more prevalent than during the previous year, and two deaths occurred. There were altogether 77 cases. During 1934 there were 37 cases, with no mortality. PUBLIC HEALTH (SMALLPOX) PREVENTION REGULATIONS, 1917. No primary vaccinations or revaccinations were done by me during the year. NOTIFIABLE DISEASES DURING THE YEAR 1935. The following table shows the cases of infectious diseases notified during the year, and the number of deaths that occurred. 30 TABLE III.—Cases of Infectious Diseases notified during the year 1935. Notifiable Disease. Number ot 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) 77 2 14 53 6 2 - - 74 - 1 - 1 - — - - 2 Diphtheria Carriers 21 — 1 20 — — - - 11 - - - - - - - - - Erysipelas 17 — — — 3 9 3 2 10 - - - - - 1 1 1 3 Scarlet Fever 229 — 49 144 24 12 - — 193 - - - 1 - - - - 1 Typhus Fever - - - - - - - - - - - - - - - - - - Typhoid Fever 1 - - - - 1 - - - - - - - - 2 - - 2 Paratyphoid Fever 1 — — 1 — — - — 1 - - - - - — - - - Relapsing Fever - - - - - - - - - - - - - - - - - - Continued Fever Puerperal Fever 1 - - - - 1 - - - - - - - - - - - - Puerperal Pyrexia 4 - - - 1 3 - - 2 - - - - - - - - - Cerebro-spinal Meningitis 1 1 - - - - - - 1 1 - - - - - - 1 Poliomyelitis 2 - 2 - - - - - - - - 1 - - - - - 1 Ophthalmia Neonatorum 2 2 — - - - - - 1 - - - - - - - - - Pulmonary Tuberculosis 83 - — 7 24 34 15 3 - - - - - 12 19 13 2 46 Other forms of Tuberculosis 23 - 4 13 3 2. 1 - - - 1 1 - 1 1 - - 4 Encephalitis Lethargica - - - - - - - - - - - - - - - - - - Malaria - - - - - - - - - - - - - - - - - - Pneumonia 34 2 4 8 1 8 7 4 - 9 3 3 4 1 4 12 28 64 Dysentery — — — - - - - - - - - - - - - - - - Totals 496 7 74 246 62 72 26 9 293 10 5 5 6 | 14 27 26 31 124 31 SCARLET FEVER Two hundred and twenty nine cases of Scarlet Fever occurred during the year in 201 houses, as follows:— Number of houses where 1 case occurred 176 Number of houses where 2 cases occurred 23 Number of houses where 3 cases occurred 1 Number of houses where 4 cases occurred 1 Total number of houses where cases occurred 201 Total number of cases 229 Deaths 1 DIPHTHERIA. Seventy-seven cases of this disease occurred during the year in 50 houses, as follows:— Number of houses where 1 case occurred 43 Number of houses where 2 cases occurred 5 Number of houses where 3 cases occurred 1 Number of houses (St. Joseph's Home) where 21 cases occurred 1 Total number of houses where cases occurred 50 Total number of cases 77 Deaths 2 DIPHTHERIA CARRIERS. Twenty-one cases of this disease occurred during the year in 3 houses, as follows:— Number of houses where 1 case occurred 2 Number of houses (St. Joseph's Home) where 19 cases occurred 1 Total number of houses where cases occurred 3 Total number of cases 21 It will be seen that the number of cases of Diphtheria was comparatively low during the year. Of the cases, 21 occurred in St. Joseph's Home, and of the Carriers, 19. This is accounted for by the fact that this Institution had a sharp outbreak of Diphtheria during the months of January and February. 32 In connection with this outbreak, my advice and help was called in by the Medical Officers of the Home, and furthermore, I had the advice and help of one of the Officers of the Ministry of Health. We were not able to trace the source of the disease. In view of the fact that children are being admitted to the Home throughout the year, the liability of conveying Infectious Disease to the Home is considerable. The Home attempts to cater for the largest number possible, and although this may be ideal from a philanthropic point of view, it has meant that to some extent the Home is rendered overcrowded. As soon as it became apparent that the disease was not limited to one or two children, and that the type would tend to be severe if not treated immediately, special arrangements were made for the employment of a full-time Nurse trained in fever work who should be a resident of the Home. Following upon her appointment, suspicious cases were seen and given treatment immediately, and no serious case arose after that date. It was impossible, however, to control the spread of the disease, although the 200 children there were swabbed on an average five times each. The epidemic abated when those children who were not immune had contracted the disease, as was shewn by the fact that Schick testing of those children who had not had the disease, and for whom permission for the test to be carried out had been obtained, were all found to be immune. The Authorities in charge of the Home have been strongly advised to refuse admission to children until they have been found to be, or rendered, immune to this disease, and were also advised to reduce the number of children maintained in the Home. DIPHTHERIA IMMUNISATION. Sanction was received from the Minister of Health on the 31st January, 1935, for the carrying out of the Schick test and immunisation against Diphtheria for the poorer inhabitants of the District. Arrangements were accordingly made whereby the Health Department was authorised either to carry out the work itself or supply the necessary material to the general Practitioners of the District, subject to their giving me information as to the children who had been immunised. During the year 15 children were tested and 20 immunised. 33 All tests subsequent to immunisation proved to be negative. In addition to this, 35 children at an Institution in Enfield were tested and found to be negative. It will be realised that very little work on immunisation was carried out during the year. New schemes take some time to receive appreciation from the public, and in view of the fact that the number of cases of Diphtheria was low, it was difficult to create much enthusiasm for immunisation. Towards the end of the year lectures on Diphtheria Immunisation were given, and I am pleased to report that in the early part of 1936 large numbers of children have been immunised. The scheme is now gaining ground in Enfield. TYPHOID AND PARATYPHOID FEVER. One case of Typhoid Fever and one case of Paratyphoid Fever were notified during the year. There were two deaths during the year, one from Typhoid and one from Enteric Fever. POLIOMYELITIS. Two cases of this disease were notified during the year. CEREBRO-SPINAL FEVER. One case of this disease was notified during the year, which proved fatal. 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 15 cases of Measles and two cases of German Measles were excluded from the Schools during the year. These figures compare favourably with 430 cases of Measles and 160 cases of German Measles for last year. 34 ENTERITIS. Ten deaths of children under one year of age occurred from this disease during the year. In view of the fact that this figure is considerably higher than the figure for 1934 and previous years, I have analysed the cases. Of the 10 deaths 3 occurred in March, 1 „ May, 3 „ June, 2 „ July, and 1 „ August. It has always been assumed that Enteritis in babies is a disease of the Summer months, associated with dust-born germs and conveyed by milk. Under these circumstances the greatest mortality should be during the months of July, August and September, and although all the deaths were between March and August, it can hardly be held that this conforms with our present conception of the disease. Another fact of some importance is that five of the children were under three weeks old, and I rather feel that causes other than Enteritis account for the deaths. ZYMOTIC DISEASES. The following table shows the deaths registered in the District from the seven chief zymotic diseases during the past five years:— Disease. 1931 1932 1933 1934 1935 Small Pox - - - - - *Scarlet Fever 9 11 3 1 1 *Diphtheria 10 7 6 2 6 *Measles — 10 — 7 — *Enteric Fever 2 - — — 5 *Whooping Cough 1 6 4 1 1 Epidemic Enteritis — — — — — Totals 22 34 13 11 13 *The actual Enfield deaths were: Diphtheria, 2; Scarlet Fever, 1; Whooping Cough, 1; Measles, 0; and Enteric Fever, 2; the latter two deaths occurring outside the District. 35 The figures for Scarlet Fever, Diphtheria, Measles, and Enteric Fever include all the deaths that occurred in the Enfield and Edmonton Joint Isolation Hospital, which is situated in the Enfield District. Patients belonging to other districts are also received, so that the figures for Enfield residents only are therefore smaller than those given above. ENFIELD ZYMOTIC DEATH-RATE. The zymotic death-rate, after deducting seven deaths of persons residing outside the District who died in Institutions in the District, and adding two deaths of persons who died outside the District, is 0.07 per 1,000 population. Disease. 1934 1935 Deaths. Death-rate Deaths. Death-rate Scarlet Fever - - 1 .01 Diphtheria — — 2 .02 Enteric Fever — — 2 .02 Small Pox — — — - Measles 1 .01 — - Whooping Cough 1 .01 1 .01 Epidemic Enteritis — — — — Totals 2 .02 6 .07 The same routine as previously reported has been carried out in the control of Infectious Disease in Enfield, except that during the year two disinfecting vans were purchased. These are vans on Commer 20/35 cwt. chassis, with zinc lined bodies so constructed as to be easily disinfected and cleansed; they are painted cream and cost £215 each. They replace the old horse and van previously used for disinfection purposes. 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 36 OPHTHALMIA NEONATORUM. Cases. Vision Unimpaired Vision impaired Total blindness Deaths Notified Treated. At home. In Hospital. 2 1 1 — — — — 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 - 11 2 - 1 Chase 17 3 33 7 — 4 Ordnance 22 — 40 6 1 4 Green Street and Ponders End 28 2 70 3 - 2 Bush Hill Park 8 2 30 4 — - Hadley and Cockfosters — — — 1 — 2 Totals 83 7 184 23 1 13 37 First Notifications, including transfer notifications 106 Old Cases re-notified, i.e., some by fresh doctors, or under old Regulations 8 Duplicate Notifications, i.e., those which report the entering and leaving of Sanatoria 197 Total Notifications 311 The following table gives particulars of the ages of the new cases notified, and deaths from this disease during the year:— Age Periods. New Cases. Deaths. Respiratory. NonRespiratory Respiratory. NonRespiratory. M. F. M. F. M. F. M. F. Under 1 - - - - - - - - 1 to 5 — — 3 1 — — 2 — 5 to 10 2 1 3 3 — — — — 10 to 15 2 2 4 3 — — — - 15 to 20 3 1 1 - 1 3 1 — 20 to 25 7 13 2 — 4 4 — — 25 to 35 9 10 1 — 7 6 1 — 35 to 45 10 5 — 1 3 3 — — 45 to 55 7 4 — 1 5 1 — — 55 to 65 3 1 — — 5 2 — — 65 and upwards 2 1 — — 1 1 — — Totals 45 38 14 9 26 20 4 — Sex (1st Notifications). Form. Males. Females. Pulmonary 45 38 Other 14 9 Totals 59 47 38 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 1 2 - Chase 17 5 7 1 Ordnance 22 12 6 - Green Street and Ponders End 28 21 3 2 Bush Hill Park 8 7 4 1 Hadley and Cockfosters — — 1 — Totals 83 46 23 4 Eight per cent. of the cases dying of Tuberculosis had not previously been notified. As reported previously, the mortality from Tuberculosis is most severe during what should be the healthiest and most active period of life. Of the 106 first notifications received during the year, 58 were in persons between 20 and 45 years of age, and of the 50 deaths, 28 were in the same age period. Cancer and Consumption are still the present scourges of our generation and account for a large proportion of ill-health and premature death. If these two diseases could be prevented, the expectation of life would be materially lengthened. 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. METEOROLOGICAL STATISTICS, 1935. . 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. 30.698 on 20th 29.190 on 25th 45.7° 22° on 28th & 29th 53° on 1st, 2nd & 14th 24° on 29th 40° 25.8 1.35 inches. 49.2 — 2 9 2 N. & N.W. Feb. 30.634 on 17th 28.752 on 25th 44.0° 23° on 9th 57° on 2nd 26°on 9th 43° 60.1 2.45 inches. 53.6 — — 7 1 s.w. Mar. 30.676 on 8th 29.263 on 1st 44.0° 27° on 5 th & 16th 67° on 28° on 9th 44° 13.6 0.58 inches. 106.6 — — 7 — N.E. & S.W. April 30.324 on 28th 29.306 on 17th 46.9° 28° on 5 th & 13th 66° on 23rd 32° on 5th & 13th 48° 68.8 2.98 inches. 119.1 — — 3 3 S.W. May 30.492 on 8th 29.760 on 17th 50.3° 26° on 17th 78° on 6th 29° on 17th 52° 29.5 1.31 inches. 175.6 1 — 3 — N.N.E. June 30.398 on 28th 29.472 on 5th 54.5° 36° on 9th 86° on 24th 41 ° on 9th 62° 81.3 3.46 inches. 189.4 5 1 — — S.W. July 30.309 on 23rd 29.571 on 20th 60.5° 40° on 31st 86° on 13th & 14 th 44° on 31st 66° 17.4 0.67 inches. 258.9 1 — — — w. Aug. 30.439 on 6th 29.461 on 28th 50.5° 39° on 29th 88° on 22nd 43° on 28th 64° 45.6 1.9 inches. 187.2 1 — — — S.W. & N.W. Sept. 30.260 8th & 10 th 29.155 on 17th 59.2 34° on 26th 73° on 12th & 14 th 38° on 26th 58° 81.3 3.33 inches. 149.9 1 — — — S.W. Oct. 30.376 on 17th 29.084 on 3rd 54.4° 22° on 21st 62° on 16 th 28° on 21st & 26th 50° 78.8 3.16 inches. 101.0 2 3 3 — S.W. Nov. 30.218 on 25th 28.985 on 17th 50.2° 25° on 25th 62° on 3rd 27° on 25th 44° 85.1 3.77 inches. 43.0 1 3 3 — S.W. Dec. 30.465 on 10th 28.839 on 26th 44.4° 18° on 23rd 51° on 27th & 28th 19° on 23rd 38° 64.6 2.82 inches. 33.2 1 7 15 2 S.W. Totals 651.9 27.78 inches. 1466.7 hrs. 13 16 50 8 39 SUPPLY OF INSULIN. In November, 1935, permission was received from the Minister of Health to supply Insulin to the poorer inhabitants of the District. It is a drug used in the treatment of Diabetes, and is costly, in that it has to be repeatedly used, sometimes daily. One application was received from the parents of a boy aged 14 years who was suffering from Diabetes. After enquiries had been made, it was determined to pay for the cost of a supply. The child is being treated at the Hospital for Sick Children, Great Ormond Street, from whom I receive reports concerning the progress of the case, and I am pleased to report that such information as I have assures me that the child's health is being maintained. DISINFECTION OF VERMINOUS PERSONS AND THEIR BELONGINGS. No requests were received during the year from the Education Committee for the disinfection and cleansing of verminous dwellings and clothing. METEOROLOGY. The following instruments are installed at the Public Offices:— Standard Fortin Barometer. Maximum Thermometer Minimum Thermometer Standard Hygrometer In a Stevenson's screen in grounds of the Public Offices. Terrestrial Radiation Thermometer Earth Thermometer In the grounds of the Offices. Campbell-Stokes Sunshine Recorder Rain Gauge On the roof of the Public Offices. Daily records have been taken, and monthly returns sent to the Meteorological Office. The accompanying table gives the result of our operations for the year in a condensed form. MATERNITY and CHILD WELFARE SECTION. 41 MEMBERS OF THE MATERNITY AND CHILD WELFARE COMMITTEE, 1935-1936. Chairman W. J. CLARKE, Esq. Councillors ANDERSON, BISHOP, EDWARDS, GREENWOOD, JONES, KEMP, ROWLANDSON and TAYLOR, also Co-optative Members:—Mrs. B. C. EELES, Miss G. M. FORD, Mrs. A. E. HEATH and Mrs. R. G. PORTER. MATERNITY AND CHILD WELFARE STAFF. Medical Officer of Health and Maternity and Child Welfare Officer— DENNIS H. GEFFEN, M.D., D.P.H. Assistant Part-time Medical Officers and Specialists— Dr. K. McKEOWN, M.D., D.P.H. (Resigned 21st June, 1935). Dr. C. J. THOMSON, M.B., M.D. *Dr. T. THOMAS, M.D., D.P.H. (Commenced November, 1935). †Mr. C. E. JAMES, L.D.S. Eng., R.C.S. (Dental Surgeon). †Mr. R. BRADBURY, L.D.S. (Manchester). (Dental Surgeon). ††Mr. S. MACKY, M.B., B.S., D.O.M.S. (Ophthalmic Surgeon). ‡Mr. J..C. HOGG, F.R.C.S. (Aural Surgeon). Health Visitors— Miss M. E. NEWBEGIN, S.R.N., C.M.B., M.R.C.N. Miss M. GARLICK, S.R.N., C.M.B., M.R.C.N. Mrs. C. D. HERBERT, S.R.N., C.M.B., Cert. R. San. Inst. for Health Visitors. Miss C. WILKINSON, S.R.N., C.M.B., New H.Vs. Cert. * Half-time M. and C.W. and half-time School. † School Dental Surgeons. †† Part-time Ophthalmic Officer to the Education Committee. ‡ Part-time Aural Surgeon to the Education Committee. 42 I have no hesitation in looking upon 1935 as one of Enfield's most important years in respect of maternity and child welfare, for it was in this year that three new maternity and child welfare clinics were opened. In the past the Maternity and Child Welfare Committee had to rely upon the hiring of halls for three centres and for co-operation with the Education Committee for the use of one. Co-operation with this Committee remains in respect of the Ponders End Clinic, and is satisfactory. Before turning to a description of the new centres I think it only right to record an appreciation of those bodies who, since maternity and child welfare commenced in Enfield, were the owners of the halls which we hired. Whilst it is perfectly true that the Council paid for the hire of these premises, I think I am right in saying that the owners did a great deal more than just to rent their premises to us, and their friendly co-operation was much appreciated. The three new clinics were erected on land which already belonged to the Council or Education Committee. This land was not suitable for the erection of houses or for other schemes upon which a local authority might embark, and, therefore, was not an additional expense to the ratepayers of the District. The actual cost of building the three new centres was £6,572 8s. 9d. All three centres are similar in design and consist of:— Entrance Lobby 8 ft. by 6 ft. Assembly Hall 32 ft. by 25 ft. Kitchen 8 ft. 3 in. by 9 ft. Store Room 4 ft. by 9 ft. Store Room 4 ft. by 9 ft. Weighing Room 17 ft. by 16 ft. Waiting Room 8 ft. 6 in. by 17 ft. Doctor's Room 13 ft. by 12 ft. They are constructed of brick pillars and breeze partitions. Windows are plentiful and the centres are well illuminated, not only by natural, but by artificial light as well. They are heated by a low-pressure boiler of the Ideal type. Every room has white tiles 43 to shoulder height. Above this the plaster has been left undecorated in order to give it ample time to dry out. During the course of 1936 it will be decorated with a cream glossy paint, for which money is available out of the original estimate for the building of the centres. A feature of the hall is the inclusion of coloured panels, in one case of nursery rhymes, in another of animals, and in the third of pastoral scenes. The lighting is of modern type; all the corners are rounded and the floors are of ebnerite. There is hot and cold water in the kitchen, weighing room and the doctors' rooms. The centres have undoubtedly proved highly satisfactory. It will be remembered that the Council anticipated that the cost of running these new centres would be but a fraction of a penny rate more than the cost of renting and administering the hired premises. The Council will be pleased to hear that the estimates for 1935-36 shew that this has actually been achieved. The centres were opened on the 10th April, 1935, by Doctor G. F. Buchan, Medical Officer of Health for Willesden; past President of the Society of Medical Officers of Health and The Royal Sanitary Institute. The Chair was taken on all occasions by the past Chairman of the Maternity and Child Welfare Committee, Councillor F. C. O. Minns, and a key was presented to Doctor Buchan to mark the occasion. Doctor Buchan congratulated Enfield on its foresight in building the centres, and stated that he believed this was the only occasion on which a maternity and child welfare authority had opened three centres on one day. He commented, with appreciation, on the design and the furnishing and the satisfactory yet economic way in which the whole scheme had been carried out. He referred to Enfield's foresight in providing so complete a maternity and child welfare service, and assured the District that money spent in that service was in truth money saved. The Chairman, during the course of his addresses, expressed his gratification of the achievement the Council had attained. 44 Whilst he would have been prepared to support the scheme, even if it had been at great cost to the District, the truth was that, despite the loan charges on the buildings and the cost of running them, there would be little, if any, call on the ratepayers. In the future, when the loan charges had been paid off and the centres were used even more than they were at the present time, the cost would be less than the previous method of hiring local halls. With all the help received from the bodies who had rented us our previous premises one could not compare the facilities there with these we now had, for the new centres were designed and built for the very purpose for which they were going to be used. The centres have now been in use for nearly a year, and like all those who have to build, certain faults have been realised in connection with them, and, good as they are, I feel that no harm can arise from stating such faults as have been discovered. In the first place, the echo is somewhat severe and makes lecturing very difficult. In the second place, the weighing room is small. On the other hand, these three centres are not built without a view to the future. They are so designed and constructed that a second floor can be placed upon them should it be necessary to meet future demands, whilst in the case of St. Stephen's Road and Lincoln Road there is sufficient space on the site to build an extension for such purpose as may be found to be necessary. In each case a satisfactory perambulator shed has been provided, and in 1936 the surrounding ground will be laid out with shrubs and bushes. I am glad to think that I was Enfield's Medical Officer of Health during the period when these centres were planned and built, and I know that this is the thought of every Member of the Maternity and Child Welfare Committee and the Council, in that something has been achieved of lasting value, and because it is a step which should go far to improve the health and wellbeing of the mothers and children of the District. 45 MATERNITY AND CHILD WELFARE CLINICS UNDER THE CONTROL OF THE LOCAL AUTHORITY. District. Situaticn of Centre. Day and times open. Infant Welfare Centres:— Ponders End School Clinic, Southbury Road, Ponders End. Tuesday and Thursday afternoons, 2 to 5 p.m. Bush Hill Park Lincoln Road, Bush Hill Park Tuesday and Thursday afternoons, 2 to 5 p.m. Town and Chase Rosemary Avenue, Enfield Monday and Wednesday afternoons, 2 to 5 p.m. Ordnance St. Stepehns' Road, Enfield Wash Monday and Wednesday afternoons, 2 to 5p.m. Ante-Natal Clinics:— Ponders End School Clinic, Southbury Road, Ponders End 1st and 3rd Thursdays, & 2nd Tuesday in each month. 9.30 to 11.30 a.m. Bush Hill Park Lincoln Road, Bush Hill Park 1st and 3rd Wednesdays in each month 9.30 a.m. to 12 noon. Town and Chase. Rosemary Avenue, Enfield 2nd & 4th Tuesdays in each month. 9.30 to 11.30 a.m. Ordnance St. Stephen's Road, Enfield Wash 2nd and 4th Thursdays in each month. 9.30 to 11.30 a.m. Dental Clinic:— Whole District School Dental Clinic, Southbury Road, Ponders End 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. 46 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:— Total Male. Female. Legitimate 1,183 584 599 Illegitimate 37 23 14 Birth-rate—15.85 per 1,000 population. Still Births:— Total. Male. Female. Legitimate 44 20 24 Illegitimate 3 1 2 Rate per 1,000 total births—37.09. Total. Male. Female. Deaths 755 385 370 Death-rate—9.55 per 1,000 population. Number of women dying in, or in consequence of, childbirth:— Deaths. Rate per 1,000 Total Births. From Puerperal Sepsis 1 0.78 From other Puerperal causes 3 2.36 4 3.15 One of these four cases was removed to the Prince of Wales Hospital, and three to the North Middlesex Hospital, Edmonton, where they died. Death-rate of Infants under one year of age:— All infants per 1,000 live births 50.00 Legitimate infants per 1,000 legitimate live births 48.18 Illegitimate infants per 1,000 illegitimate live births 108.10 Deaths from Measles (all ages) 0 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) 12 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 140 smaller towns:— Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Births. Still Births. England and Wales 14.7 0.62 11.7 57.00 London 13.3 0.52 11.4 58.00 121 County Boroughs and Great Towns (including London) 14.8 0.68 11.8 62.00 140 Smaller Towns 14.8 0.64 11.2 55.00 ENFIELD 15.85 0.61 9.55 50.00 47 INFANT MORTALITY. On page 10 of this report full details of deaths of infants under the age of one year will be found, and a further reference on the subject will be found under the heading Zymotic Death-rate on page 34. BIRTHS. The actual number of births registered in the District was as follows:— Boys. Girls. Total. 435 461 896 including 22 illegitimate births, i.e., 2.45 per cent. of the total. In addition, 15 male (including 1 illegitimate) and 17 female stillbirths 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. 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 1935 628 639 1,267 16.46 .51 INFANTILE DEATHS. Reference to Table 2 on page 10 of this Report shews that of the 61 deaths of children under 1 year of age 24 occurred during the first week of life, 7 during the second week, 7 during the third week and 1 during the fourth week. In other words, 39 of the 61 deaths occurred before the children were one month old. This is a very serious percentage, and needs careful consideration. 48 In 22 of the 39 cases the cause was prematurity, in 3 injury at birth, in 2 atelectasis (failure of the lungs to expand), in 2 congenital malformation, and in 1 marasmus. How far are these deaths preventable, and if preventable, what steps should be taken towards this end ? I believe that most of these deaths are preventable, but it is obvious that little can be done to prevent them by means of postnatal care. Prematurity should be avoidable by more care on the part of the mother and further supervision as to her mode of living and health during the time she is carrying; whilst injury at birth is usually the result of a difficult confinement. It is possible that the provision of specialist care during child-birth and increased antenatal work would reduce this type of infant mortality. MATERNAL MORTALITY. During the year one case of Puerperal Fever and four cases of Puerperal Pyrexia were notified. Two of the cases of Puerperal Pyrexia were removed to Hospital, and in the other cases the Doctor in charge reported that full facilities for the nursing and treatment of the cases in question were available at the place of confinement. There were five maternal deaths during the year, and the causes of death were as follows:- Septicaemia. Incomplete Abortion In North Middlesex County Hospital. Haemorrhage due to Ruptured Ectopic Gestation In Prince of Wales' Hospital, Tottenham. Eclampsia North Middlesex County Hospital. Placenta Praevia do. Acute Oedema of Lungs. do. Mitral Stenosis; 24 weeks pregnant. The average age of these five women was 36 years. Following upon Circular 1433 of the Ministry of Health concerning maternal mortality, the Council agreed to pay for the service of a Midwife where the family income was below a certain scale, whether a Doctor was in attendance or not. It is interesting to note the during 1935 the Council helped in 36 cases. This compares with 5 for the previous year. Of these 36 a Doctor also attended in 4 cases. This large increase in the number of Midwives is understandable when one realises that the scheme was put into operation in December, 1934, and some time was bound to elapse before the 49 service became known to the public. I regret that in only 4 cases a Doctor was also in attendance. I should like to feel that every poor mother in Enfield had the service, not only of a Midwife, but also a Doctor, and that in addition, a Home Help was present to look after the family and relieve the mother of all household responsibility during the lying-in period. It is pleasing to record that 52 cases were supplied with a Home Help during 1935, as compared with 30 in 1934. This number will be exceeded in 1936, for this new scheme, like others, is becoming very popular as the public realises the benefits of it. Each case is investigated by the Committee in order that steps should be taken to ensure that help is only granted in those cases where it is necessary. During 1935 dental treatment and/or dentures were provided for 224 ante natal or nursing mothers as compared with 150 in 1934. There is also a scheme whereby ante-natal or nursing mothers may obtain treatment for ear or eye defects through the School Medical Service. There is one important direction in which our maternity service has been improved. The Council will realise that in a district like Enfield, 12 miles or more from London, it is difficult to obtain a Specialist, possibly in the middle of the night, to help in a difficult confinement case. When help is required it is wanted immediately. During the year it was possible to arrange with the Middlesex County Council for a Gynecologist and Obstetrician from the North Middlesex County Hospital to be available to the Practitioners of Enfield when attending confinements of Enfield women in the District. All that the Practitioners have to do is to telephone to the Hospital when they will be able to consult immediately with the Specialist who is resident at the Hospital. In cases where it appears to be necessary, the patient is admitted to the Hospital; in other cases the Specialist visits the home in consultation with the Practitioner in charge of the case. Each time the Specialist visits a case the Council pays to the Middlesex County Council a fee of £2 2s., and of this a reasonable amount is obtained from the patient. Although the scheme has only just commenced it has been made use of in 4 cases. In one case the sum of £1 1s. was paid by the patient, and in the other three cases no charge was made. I have received letters of appreciation and thanks from patients where this help has been given. It is very gratifying to think that any Doctor in Enfield can obtain this help almost immediately, and I consider this to be one of the wisest steps the Council has taken in connection with the abating of maternal mortality in the District. 50 MIDWIVES. The Middlesex County Council is the supervising authority under the Midwives Act. There are 23 Midwives practising in the District. ATTENDANCES AT INFANT WELFARE AND ANTE-NATAL CLINICS. 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 7,371 3,435 344 1,534 72.2 Bush Hill Park 7,522 3,639 335 1,917 73.7 Town and Chase 7,086 3,152 324 1,895 69.4 Ordnance 8,635 3,705 386 1,470 84.6 Totals 30,614 13,931 1,389 6,816 72.6 ANTE-NATAL CLINICS. Centre. New Attendances. ReAttend ances. Total Attendances. Average Attendance per Meeting. Ponders End 178 330 508 14.5 Bush Hill Park 135 284 419 17.5 Town and Chase 116 174 290 13.0 Ordnance 157 263 420 18.3 Totals 586 1,051 1,637 15.6 51 The following table gives particulars of the work done by the Health Visitors during the year. Visits. Town, Chase and Hadley. Bush Hill Park. Ordnance. Ponders End. Totals. Birth Notification Visits 255 246 334 239 1,074 Ditto Re-visits 304 645 423 571 1,943 Children, 1-5 years Visits 1,119 1,325 1,459 1,293 5,196 Visits re Insanitary Conditions 27 2 2 - 31 General Visits 299 65 40 131 535 Ante-Natal Visits 184 133 108 172 597 Post-Natal Visits — 161 37 32 230 Blank Visits 221 132 40 65 458 Infectious Disease Visits 40 86 69 87 282 Ophthalmia Neonatorum Visits 1 6 - - 7 Puerperal Fever Visits — 1 — — 1 Puerperal Pyrexia Visits 3 — 1 — 4 Visits re Foster Children 23 50 55 25 153 Totals 2,476 2,852 2,568 2,615 10,511 Feeding, etc. Feeding. Town, Chase and Hadley % Bush Hill Park % Ordnance % Ponders End % Totals % Natural 229 89 223 90 314 94 221 92 987 91 Artificial 26 10 23 9 20 6 18 7 87 8 Mixed — - — — - - — — - — Separate Cot 254 91 217 88 274 82 231 96 976 90 Number of Births notified 1,223, which includes 320 born outside the district, 87.8 per cent of which were visited. 52 ASSISTED MILK SUPPLY. The quantity of fresh and dried milk supplied in necessitous cases under the Assisted Milk Supply Scheme during the year was as follows:— Fresh milk 13,377 galls. Cost £1,395 15s. 6½d. Dried milk 3,389 lbs. Cost £243 13s. 11¾d. The corresponding figures for 1933 and 1934 were as follows:— 1933. Fresh milk 19,860 galls. Cost £1,825 11s. 2½d. Dried milk 3,683 lbs. Cost £273 19s. 0¾d. 1934. Fresh milk 16,414 galls. Cost £1,481 4s. 3d. Dried milk 4,201 lbs. Cost £311 3s. 4d. It will be noted that the amount of fresh and dried milk is less than in the two previous years, despite the fact that the scale has remained practically constant. It may be assumed that it is due to a higher standard of living in the District and the lessening of unemployment. Owing to the fact that the Public Assistance Committee was increasing the payment to unemployed persons by 2s. 6d. weekly during the winter months, the Maternity and Child Welfare Committee agreed that from the beginning of November until the end of April each year the Scale for the supply of free milk should be raised by one shilling and six pence. ROUTINE MEDICAL INSPECTION OF CHILDREN UNDER FIVE YEARS OF AGE. The following table shews the result of the work carried out under the above scheme during the year:- Total number of appointments made 7,570 Total number kept 2,714 Total number of additional examinations 1,222 This table compares with the following for the year 1934:— Total number of appointments made 6,780 Total number kept 2,231 Total number of additional examinations 960 53 The following table is an analysis of the children sent for for routine examination, shewing the number of appointments made at each birthday. Appointments. 1st. Birthday. 2nd Birthday. 3rd. Birthday. 4th. Birthday. Total. No. sent for 852 783 723 691 3,049 No. kept 371 282 210 190 1,053 The total number of appointments made, not including birthdays, was 4,521. The total number kept was 1,661. The procedure whereby invitation cards are sent to children on their birthdays inviting them to attend the Maternity and Child Welfare Clinic to be medically examined has been continued throughout the year and has proved reasonably satisfactory. I would like, however, to see a larger percentage of these invitations accepted. AURAL TREATMENT. The scheme whereby children under five years of age found 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 33 children were so treated under the scheme. This compares with 23 during the previous year. 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. During the year 18 expectant or nursing mothers and 34 children under the age of 5 years attended at the School Ophthalmic Clinic, making a total of 85 attendances. Twenty-nine prescriptions for glasses were given and 3 cases were referred to the Western Ophthalmic Hospital. BIRTH CONTROL. Arrangements have been made whereby advice on Birth 54 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 respect I have interviewed four men during the year. CHILDREN ACT, 1908-1932. During the year 36 notifications of intention to accept foster children were received, and in one case the home was found to be unsuitable. One hundred and fifty-three 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, 1935. (a) Number of persons receiving children for reward on the Register at the end of the year 28 (b) Number of children on the Register:- (i) at the end of the year 32 (ii) who died during the year Nil (iii) on whom inquests were held during the year Nil (c) Number of Infant Protection Visitors holding appointment under Section 2 (2) at the end of the year who were:— (i) Health Visitors 4 (ii) Female, other than Health Visitors Nil (iii) Male Nil (d) Number of persons (in addition to or in lieu of Visitors under (c) above) or societies authorised to visit under the proviso to Section 2 (2) Nil (e) Proceedings taken during the year:— Number of cases. Section of Act under which taken. Nil. — (f) Number of cases in which the Local Authority has given sanction during the year:— (i) Under (a) of Section 3 of the Act of 1908 Nil (ii) Under (b) do. do. Nil (iii) Under (c) do. do. Nil (g) Number of Orders obtained during the year under Section 67 of the Act of 1932:— (i) From a Court of Summary Jurisdiction Nil (ii) From a single Justice Nil 55 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. 1935. 1934. 1933. 1932. 1931. Attendances 628 363 991 1,071 1,257 1,111 592 Treated 224 244 468 319 340 340 172 Administrations: Local Anaesthetics 49 47 96 84 115 100 85 Extractions with Local Anaesthetics 107 100 207 166 211 181 160 Administrations: N20 172 130 302 272 252 308 155 Extractions under N20 919 431 1350 1,187 1,071 1,501 600 Total Extractions 1026 531 1557 1,353 1,310 1,682 760 N20 Sessions 39 — 39 39 36 40 26 Ordinary Sessions 43 — 43 41 44 41 27 Total Sessions 82 — 82 80 80 81 53 Dentures fitted 82 — 82 129 131 120 54 Patients receiving Dentures 44 - 44 70 78 63 29 Number of Patients having repairs 13 - 13 11 20 3 - Number of repairs fitted 14 - 14 11 20 3 - Number of fillings 12 175 187 192 218 217 41 Other Operations 286 108 394 661 803 593 250 Number of patients having extractions under N20 83 120 203 157 127 159 68 Do. do. under Local Anaesthetics 35 34 69 60 134 81 53 BABY WEEK. This was celebrated on the 1st, 2nd, 3rd and 4th July, 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 1,564. Many members of the Maternity and Child Welfare Committee were present, and the distribution of prizes was made by Mrs. Vanderpump, Mrs. T. Clarke, Mrs. W. J. Clarke and Mrs. Cakebread. 56 The practice commenced in 1934 of providing prizes for competitions was continued in 1935, the following competitions being held:— 1. Write a letter to a friend, telling her that your child under 5 years of age had had Whooping Cough; 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. The garments were judged by Doctor McGregor, Assistant Medical Officer of Health for Shoreditch, whilst the essays were referred to me. There were altogether 97 entries for the competitions. Although this number is low compared with the number of mothers attending at our clinics, it need not be read as a failure. The fact is, that during the period of the competitions those mothers who entered, and most of those who did not, had to consider the garments they had to make, and whether to enter them for the competition. This meant they had to turn their minds to whether the garments were hygienically satisfactory and made in a clean and workmanlike fashion. The psychological effect of this, spread throughout the District, is of great importance. It means that during Baby Week the mothers of Enfield turned their minds towards the proper clothing of their children. In addition to this, others went through in their minds the symptoms of Whooping Cough and the care of the disease. Whooping Cough is a disease that takes its toll of child life practically every year in Enfield. It is to be hoped that the thoughts turned towards this disease in 1935 were helpful during the early part of 1936 when Whooping Cough was prevalent. The previous year the subject was Measles, and I believe that the lectures given at the Centres on this subject and the consideration of the subject resulting from competition, have meant that mothers had a better conception of the disease and how to treat it during the epidemic in 1936. CIRCULATION OF BOOKLET ON REARING OF CHILDREN. The circulation of the booklet called "To Mothers and Fathers" was continued during 1935, being sent to all mothers giving birth to a child during the year. Approximately 1,250 books were distributed. On the cover of this book is printed the times and days on which the Maternity and Child Welfare Centres are open. I and the Maternity and Child Welfare Staff have received 57 repeated expressions of appreciation and thanks for this booklet. It sets out in a simple form, in the course of some 90 pages, practically all that a mother need know concerning the care, clothing, feeding and hygiene of her children until the age of five years. There is, in addition, a chapter for the ante-natal mother, telling her how to care for herself in order to avoid such difficulties as are associated with the carrying and bearing of a child, and a chapter as well for the expectant father, setting out for him his duties as a husband and a prospective father. 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 number of Home Helps supplied during 1935 was 52, as compared with 30 in 1934. CONVALESCENT TREATMENT. The Maternity and Child Welfare Committee has no Convalescent Homes nor Homes for Mothers and Babies under its control, nor have any beds been reserved. Should it be found by the Medical Officers at the Centres that a mother or baby needs convalescent treatment a report is made by them. The family circumstances are then investigated and the matter reported to the Maternity and Child Welfare Committee, with a recommendation from me that the patient be sent away for a period of convalescence. During the year two children under the age of five years and two mothers and their babies were sent to Convalescent Homes under the control of private bodies. 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. 58 Miss Garlick 2 demonstrations at Chesterfield Road. Mrs. Herbert 2 demonstrations at Lavender Road, and 2 at Chase Side Schools. Miss Wilkinson 1 demonstration at Alma Road Schools. STUDENT HEALTH VISITORS. For some years now it has been the practice of the Royal College of Nursing to send a Nurse, who is studying for the Health Visitor's Certificate, to gain her practical experience in Enfield. The student spends a period of six weeks with us, during which time she is given the opportunity of seeing how the various clinics are run and how Health Visiting is carried out. One such student was received during last year, and I am pleased to say that she was successful in passing her Health Visitor's examination. CONCLUSION. Enfield's Maternity and Child Welfare Scheme includes the provision of:— 1. Health visiting. 2. Eight clinics weekly for children under 5 years of age. 3. Nine clinics monthly for expectant mothers. 4. Milk and other foods to children under 5 years of age, and to expectant and nursing mothers. 5. Dental treatment. Dentures. 6. Home Helps. 7. Payment of Midwives' fees. 8. Ophthalmic treatment. 9. Aural treatment. 10. Convalescent treatment. 11. Obstetric Specialist in difficult confinements. 12. Routine examination of children under 5 years. 13. Diphtheria immunisation. In concluding my remarks on Maternity and Child Welfare, I have no hesitation in saying that 1935 was a thoroughly successful year. Not only were three new clinics of modern type and design opened and put into use, but in addition, a scheme was commenced which should ensure that help is available during every difficult confinement in the District. Moreover, the figures shew that each service in connection with Maternity and Child Welfare has increased; a sure sign that it is appreciated by the public for whom it has been provided. This section of my Report would be incomplete without an expression of appreciation of the excellent help that has been afforded by the Voluntary Helpers who have attended regularly at each of our Centres. 59 61 Public Offices, Enfield. 1st March, 1936. Report of the Chief Sanitary Inspector for the year, 1935. 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, 1935. 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 498 From House-to-House apart from this Act 70 On Account of Infectious Disease 279 On Account of Phthisis 83 On Account of Complaint by occupant or otherwise 1,467 On Account of Vermin 364 195 Factories 186 101 Workshops and Workplaces 72 Outworkers' premises inspected 158 42 Bakehouses, of which 31 are in use 71 3,248 62 Inspections—(continued). Inspections. Brought forward 3,248 10 Slaughterhouses, of which 7 are in use 1,071 21 Cowkeepers' premises 438 83 Dairies and Milkshops inspected frequently 201 21 Schools 40 Public Conveniences inspected 443 Conveniences at Railway Stations inspected 9 Fish shops; Total number of visits 79 Coffee and Eating Houses: Total number of visits 14 Coffee-stalls: Total number of visits 16 Shops where Ice-cream is made: Total number of inspections 18 Meat Shops: Total number of inspections 154 Food Stalls in Markets: Total number of inspections 1,052 3,535 Visits to absentees excluded from Elementary Schools 554 Visits in connection with cases of Infectious Disease 1,174 Visits in connection with Phthisis 258 Visits re Verminous Premises, etc. 585 Offensive Trades (excluding Fish Shops) 6 Smoke observations 72 Other inspections, including works in progress 9,080 Petroleum Stores Inspected 275 Visits re Shops Act 361 Cinemas, etc., inspected 37 Visits and inspections re Rats 240 Visits re Sub-letting in Council Houses 28 Visits re Gypsy Vans, etc. 107 Visits re Overcrowding 14 Visits re Rag Flock Act 11 Visits and Inspections at Mortuary 41 Inspections of Stables 5 Visits re Noises 34 Visits re Water Supply 13 Visits re Pig-styes 4 Visits re Fair Grounds 2 Other Visits 1,107 14,008 20,791 63 Notices Issued. Statutory:— Provision of dustbins 4 For repairs to houses, drains and abatement of nuisances 90 Providing sufficient water-closets 10 Paving of yards - Provision of Sinks or Drains 2 Abatement of Smoke — 106 Informal:— Notices 1,065 1,065 1,171 Other Notices issued under Infectious Diseases Acts:— To occupiers 434 To Education Committee and Head Teachers at Schools 1,216 To Librarian 27 1,677 2,848 Other letters sent 7,401 Number of Certificates issued in connection with plans 260 Result of Service of Statutory and Informal Notices:— Statutory. Informal. Number complied with 102 738 Number outstanding 4 327 106 1,065 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 sines and waste pipes; leaking roofs; defective gutters; absence of, or broken, paving around houses; defective plaster of ceilings and walls; damp walls; want 64 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. 813 Roofs repaired 370 Gutters and down pipes repaired 224 Downpipes disconnected from drains 98 Houses underpinned and settlement remedied 1 Dampness remedied 205 Concrete site provided under floors 2 Cesspools emptied 245 Cesspools abolished 0 New Cesspools provided 0 Closet Pails Emptied 987 House drains cleared, repaired, etc. 194 House drains tested, examined, etc. 284 House drains reconstructed 37 Soil-pipes and drains ventilated, including repairs to ventilators 206 New vents provided 5 New manhole covers provided 5 New Manholes provided 1 Sink-wastes disconnected or repaired 55 New sinks provided 85 Closets provided with proper flushing cisterns or water supply 16 New closets provided 24 Closets repaired, covered, cleansed, etc. 262 Water-closets substituted for earth-closets 2 Elsan or Chemical Closets provided 1 Urinals repaired 1 Privy substituted for earth-closet 0 Storage cisterns repaired, covered, cleansed, etc. 42 Storage cisterns provided 3 Water laid on or restored 15 Water laid on in houses 0 Taps provided over sinks 1 Taps repaired 2 New wells provided 0 Wells closed 0 Wells cleansed and repaired etc, 0 Samples of Water taken from Wells 8 Do. do. Main 0 Do. do. Swimming Pool and Baths 41 Samples of Rag-Flock taken under Rag-Flock Act 4 65 Samples of Milk taken 29 Yards paved, or existing paving made good 156 Yards drained 1 Ventilation provided under ground floors 35 Floors repaired 163 Handrails provided to Stairs 14 Stairs repaired 5 Dustbins repaired, or new ones provided 342 Forecourts paved 0 Food Stores provided 16 Ventilation provided to food stores 18 Chimney stacks rebuilt or repaired 8 External paintwork renewed 17 Houses re-pointed 9 Doors repaired or replaced with new 19 Fences repaired 8 Manure heaps removed 15 Fowls and other animals removed 5 Coppers repaired, etc. 56 Stoves repaired, etc. 160 Windows repaired, etc. 476 Other nuisances abated 274 Cases of overcrowding abated 1 Ditches cleaned out 3 Gipsy vans removed 27 Pig-styes removed 1 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. 554 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 20,791. Disinfection. Houses Disinfected:— After infectious disease 310 After Phthisis 76 386 66 Brought forward 386 After verminous cases 148 Vacated Council houses 110 258 644 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 16 Ditto, ditto, by cases of Phthisis 2 Articles of clothing, bedding, etc., disinfected 1,675 Ditto, ditto, destroyed 92 Library Books disinfected 38 No. of Certificates issued re disinfection of clothing and premises 7 Number of Schools disinfected 1 Private Patients removed to Hospital or Infirmary 3,953 Gipsy Vans removed from District 27 Articles or parcels of unsound food destroyed or otherwise disposed of 390 110 vacated Council houses were disinfected during the year. Of these, 29 showed signs of vermin—26 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. I am sorry to say that we have still 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 of 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 we 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 themse ves regarded as unclean, and secondly there is the fear that they will not be granted the tenancy of a Council house. 67 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 Disinfect or 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 1935 there were 72 workshops, 29 workplaces and 42 bakehouses registered. The following tables give details of the work done in connection with these places:— Inspections. Premises. Nnmber of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 186 - - Workshops (including Workshop Laundries) and Workplaces 230 - - Bakehouses 71 — — Total 487 - - 68 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 2 2 - - Want of Ventilation — — - — Overcrowding — — — — Want of Drainage of Floors — — — — Other Nuisances 5 5 — — Sanitary Accommodation:— Insufficient 7 7 - - Unsuitable or Defective 12 12 — - Not separate for sexes — — — - Offences under the Factory and Workshops Acts:— Illegal occupation of underground bakehouse - - - - Breach of special sanitary requirements for bakehouses - - - - Other Offences 2 2 — - Total 28 28 — - 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 9 19 18 28 8 Boot-making 4 4 2 2 — Brushes 1 1 — — — Cardboard Boxes 1 1 — — — Totals 15 25 20 30 8 Five addresses of outworkers have been forwarded to other districts. 69 PLACES OF PUBLIC ENTERTAINMENT. Thirty-seven 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 and in connection with these, 85 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. No doubt the Council will have noted that we are now endeavouring to obtain a higher standard of Fish Fryers by asking for the most up-to-date apparatus to be installed in Fish Saloons rather than the old type of open Fish Fryers' shops. 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 70 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. 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 "12 Dealer's Licence to use the Designation " Grade A (Tuberculin Tested)" 2 Dealer's Licence to use the Designation "Certified" 1 Dealer's Licence to use the Designation " Grade A (Pasteurised)" 1 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 Supplementary Licence to use the Designation " Pasteurised" 2 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 in lorries, to the various slaughter houses in Enfield by road, 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 71 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 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 308 Organs or parts of carcases found diseased 35 Cows 17 5 Calves 93 5 Sheep 6,538 197 Pigs 6,315 111 Totals 13,271 353 The organs or parts of carcases found to be diseased were surrendered and destroyed. The weight of the meat destroyed was 4 tons 15 cwt. 3 qrs. 14 lbs. The carcases generally were in good condition, and there was no case which necessitated the obtaining of a Magistrates Order. I am satisfied that matters are still on the improvement with regard to meat inspection in Enfield. 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 1,071 Shops 144 Stalls in Markets 1,052 Food Preparing Shops 10 2,277 72 As in previous years, foodstuffs purchased in the various London Markets were submitted for inspection, and 37 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. Fifteen 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. 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. All duties in regard to the storage of Petroleum are now carried out under the Fire Brigade Superintendent, Mr. A. H. fohnstone. SHOPS ACTS. The duties of the Inspectors under the Shops Acts are carried out by this Department. The arrangement made last year with regard to the inspection of plans for all new shops by this Department is now being carried out, and this naturally has meant an increase in the work, both in respect of the inspection of the plans and the inspection of the premises by the Inspectors under the Shops Acts. No legal action was taken during the year under the provisions of the Shops Act, 1934, relating to ventilation and temperature of shops and to sanitary conveniences. 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. 73 Thirty-eight Dustmen and the following vehicles are in use for the removal of house refuse:— 1—6 cubic yards "S.D." Freighter (petrol) dust-van. 2—10 cubic yards dustless-loading "S.D." Freighters. 5—15 cubic yards "S.D." Moveable Floor Rear-loading Freighters. 1—Tuke and Bell 10 cubic yards " Barrier " Type end-loading vehicle. 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. Arrangements exist whereby trade refuse is removed from shopkeepers' premises on payment of a prearranged charge. The income from this source was £75 10s. during the year. During the year, 17,569 tons of refuse were collected and disposed of at a cost of £14,388. This equals 16s. 4.5d. per ton for collection and disposal, as against 12s. 0.2d. in 1934. The cost per head of the population is 3s. 8.8d. per annum, or 0.8d. per week. The average for each house is 14s. 10.9d. per year, or 3.4d. per week. DISPOSAL OF REFUSE. The dumping site at Brown's field, Enfield Highway, was completed in May and a fresh site was opened on the old Gravel Pit in Carterhatch Lane. I am sorry to say that this will not give many months' life for the disposal of refuse, and we shall accordingly have to look for another site shortly. Covering material from road works in progress has again been available. 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. A second gang of sewer flushers has been put into operation and the whole of the sewers throughout the District, both new and old, are now being flushed. CESSPOOLS. The various cesspools in the District are examined and emptied by special members of the Staff, a proportion of the cost of the work entailed being charged to the owner or occupier of the property. The machine purchased in the latter part of last year from 74 Messrs. Shelvoke and Drewry has proved a decided acquisition to the District. The work of emptying cesspools has been much expedited and carried out in a far more sanitary manner. SCHOOLS AND HOSPITALS. The arrangement with the Education Committee is still carried out as regards the conveniences at all non-provided Schools, and these receive daily attention as regards cleansing by one of the employees of this Department. The drainage systems of all elementary and secondary schools in the District are examined by the Sanitary Inspectors. At both the Isolation Hospital and the Enfield War Memorial Hospital the sanitary arrangements are under the supervision of this Department, and those at the Isolation Hospital are attended to regularly in accordance with arrangements made by the Joint Hospital Board, while those at the War Memorial Hospital are attended to weekly as a voluntary service on the part of the Council. In addition, a large amount of disinfection has been carried out at the latter Hospital free of charge. PUBLIC CONVENIENCES. The public conveniences at the parks and pleasure grounds, and also five attached to public-houses, making eighteen in all, are under the supervision of this Department. Those attached to the public-houses receive daily attention by a man specially detailed from this Department for that purpose, and are kept in a satisfactory condition. Arrangements are being made by which during the coming year a system of full-time attendance to all conveniences throughout the District will be commenced. This, I hope, will lead to considerable improvements with regard to the condition of public conveniences in the District. HORSE TROUGHS AND DRINKING FOUNTAINS. Drinking fountains, and also four horse troughs in the District, receive daily attention as regards cleansing. 75 PUBLIC MORTUARY. One Public Mortuary in the District, established at the Enfield Highway Cemetery, is constantly under supervision. RATS. It has been found necessary during the year to pay an increased number of visits with regard to the destruction of rats. One harbouring place for rats has been found to be tool-sheds, etc., placed adjacent to the rear of dwelling-houses, and I am hoping that the householders will realise the danger of having such out-houses attached to their premises. While there are improvements in some parts of the District, possibly due to the fact that the householders have begun to realise their duties with regard to the carrying out of matters for the prevention of rat infestation, there are still cases where the people are either ignorant of their responsibility or anxious to place the onus upon the Local Authority. 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 work to be dealt with. I have endeavoured to impress the ratepayers 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. I am pleased to say that some slight notice has been taken of my suggestion, although I had hoped that it would be more generally adopted. 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 76 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. THE ANNUAL REPORT of the School Medical Officer for the Year ending 31st December, 1935 78 MEMBERS OF THE ENFIELD EDUCATION COMMITTEE, 1935-1936. Chairman Mr. D. MASON. Vice-chairman Mr. W. T. TAYLOR. Representative Members— Mr. H. A. DESHBOROUH BROWN. Mr. W. W. CAKEBREAD. Mr. T. H. M. CLARKE. Mr. H. H. COLLIER. Mr. G. E. JONES, J. P. Mr. A. R. KEMP. Mr. H. MUSPRATT, O.B.E. Mr. C. PARTINGTON. Mr. H. G. SHORT. Mr. W. T. TAYLOR. Co-optative Members— Miss E. M. CRESSEE. Mrs. N. DAVIES. Mrs. J. G. DUFTON. Mrs. H. ROTHWELL. Mr. D. MASON. Mr. G. M. SPARROW. Mr. C. F. WATTS. Director of Education— F. G. APTHORPE, Esq., M. A. 79 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 Officers— GERTRUDE FORRESTER, M. B., B. S. (Lond.). A. G. T. THOMAS, M. D., B. S., D.P.H. 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. Clerks— H. OGILVIE. I. GROVES. M. STIFF. 80 Annual Report of the School Medical Officer, DENNIS H. GEFFEN, M.D., B.S., D.P.H., M.R.C.S., L.R.C.P. For the Year ending 31st December, 1935. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to place before you my ninth annual report on the health of the school children of Enfield. On reading the subsequent pages of this report I feel certain you will be satisfied with the scope of the work that is being carried out, and amazed at the various types of disease which have passed through the hands of the department, and the help that it has been possible to provide. You will note that in one instance a child has been provided with an artificial eye, whilst one child received insulin for the treatment of diabetes. Three cases of hemiplegia were seen, one case of birth palsy, one case of cerebral diplegia, and one case of congenital absence of fingers. The duties of the School Medical Officer are multifarious; he must be prepared to diagnose the most obstruse form of disease and advise as to the best means of obtaining treatment. It will be noted that the school population and average attendance have increased by about 1,000 in the last five years. In addition, the members of the Committee will realise that the department has undertaken the examination and treatment of about 1,000 secondary school children, whilst a large amount of work is now involved in connection with the provision of milk for school children and the examination of children who are being sent to camp. On the medical side the increase of work has been met by the appointment of Dr. Thomas, who, as Assistant School Medical Officer and Assistant Medical Officer of Health, devotes half his time to school medical work. I will deal with the adequacy of our dental staff later. I am satisfied, however, that the general condition of the children of Enfield is being well maintained, and I 81 look with great pleasure upon the fact that the percentage of children found to be suffering from untreated defects of the eyes and ear, and of children found to be suffering from uncleanly conditions and disease of the skin is diminishing year by year. Dr. Forrester has given me certain information concerning obesity in children within the district, and, at my request, she has presented a report on this condition which I have much pleasure in including in this survey of the health of Enfield children. I have no doubt that every member of the Committee will read this report with the greatest interest. It is extraordinary that the number of cases of fatness or obesity that came before Dr. Forrester during the past three years has shown such an enormous increase. Dr. Forrester sets out in her report the actual weight, height, and age of these children, and in certain cases their mental condition. Neither Dr. Forrester nor I can account for this sudden increase and we shall be interested to know whether it is common throughout the country. We do not think the condition can be endemic in Enfield, for in many cases the children have come from other areas or passed through the district, only remaining here for a period of a few months. I believe this report to be of great importance at the present moment when so much is being said throughout the country on the subject of malnutrition. In the minds of the public the expression "malnourished child" conjures up a thin, frail, anaemic subject. This may be classified as a branch of malnutrition and named subnutrition, but there is no doubt that these 41 children seen by Dr. Forrester are suffering from a form of malnutrition, and a form of a very serious nature ; serious because in most cases a cure is not known. It has been suggested that certain glands of the body, namely the thyroid or the pituitary glands, are at fault; but after all, there must be a reason why they are at fault, and this must be due to some form of malnutrition. The matter is serious, moreover, as it causes so much mental unhappiness, especially so in the case of the older girls. This will be obvious from Dr. Forrester's opening remarks, where she explains the reluctance of the parents and the children with regard to examination and weighing. Once again, Mr. James, the Senior School Dental Surgeon, has placed before you a report which is full of interesting facts and deductions. His report brings before us clearly the necessity that existed for the treatment of secondary school children. The proportion of children at these schools who were suffering from dental caries was not only higher than amongst the children in our elementary schools, but the dental condition of the individual child was worse. It had been thought that the children attending secondary schools were obtaining treatment privately, in view of the fact that it was suggested that they came from wealthier homes and that the higher form of education they were receiving had led 82 them to appreciate the value of sound teeth. It is now obvious that this was not so, and the dental condition of the children in our secondary schools was deplorable. As a result of the work undertaken for these children it was not possible to do as much for the elementary school children, and the number of elementary school children treated during the year was 1,000 less than in 1934. This brings us to consider the question as to whether it is possible for two dentists to deal adequately with the number of children attending Enfield schools. In our elementary schools there are about 10,500 children and the secondary schools about 1,000. The response to dental treatment in Enfield is excellent; a response which, in my opinion, should be encouraged. Moreover, the school population of Enfield is now increasing rapidly, and I do not believe it is possible for two dentists to deal adequately with a school population of which will shortly be 12,000. The time has come when the Education Committee should consider the appointment of a third dentist. At the present moment both our dentists carry out their work in a small dental clinic attached to Southbury Road School, at which there is no adequate waiting room, nor electric lighting nor power provided. Children have to go long distances from every school in the area to attend this clinic, with consequent waste of school time. It is to be hoped that a second dental clinic will be provided when new schools are erected, in the forthcoming year. I am pleased to see that our dentists are carrying out regulation work ; this not only secures a better biting surface, and consequently better condition of the teeth, but, in the case of girls, greatly enhances their appearance. It is probably true that to be healthy one must look healthy, for health depends, not only on a physical condition of the body, but a phsycological state of the mind. Regulation work is difficult to carry out without proper X-ray equipment, and I am hoping that this may be provided when a new dental clinic is erected. There is little I can say concerning the reports of either the Ophthalmic or Aural Specialists, except to comment most favourably on the work that is being done at the Western Ophthalmic Hospital, for the children who squint. Regularly every Thursday morning a party of between six and ten children are conducted to the Western Ophthalmic Hospital by one of the clerks of the School Medical Department, where they undergo orthoptic treatment. By this method some children have been actually cured, whilst others have needed an operation as well. Both our Specialists are conducting their work with enthusiasm and foresight, and their help is much 83 appreciated by the mothers and children of the district. My report would not be complete without an expression of thanks to the Chairman and Members of the Committee for their co-operation during the year; to Mr. Apthorpe and Mr. Pascal, who have directed education in Enfield during 1935 and have given me their constant and valuable help ; and to every member of my Staff, whose loyal help I much appreciate, and whose enthusiasm in improving and maintaining the health of the children of Enfield receives its greatest reward in the happiness it is able to create. I am, Mr. Chairman, Ladies, and Gentlemen, Your obedient servant, D. H. GEFFEN, School M edical Officer. 84 REPORT OF THE SCHOOL MEDICAL OFFICER. Area 12,400 Population 76,960 Number of Schools 20 1931 1932 1933 1934 1935 Average number on Books of Elementary Schools 9,172 9,453 9,725 9,970 10,155 Average weekly attendance 8,205 8,495 8,685 8,857 9,200 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 3,436. In 1934, 3,378 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 percent. 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:— 1931 1932 1933 1934 1935 Percentage of children accompanied by parents 79 78 77 76 76 Thirty-seven percent. of the children examined were vaccinated. The comparative figure's for the last five years are as follows :— 85  1931 1932 1933 1934 1935 Percentage of children vaccinated 42 42 37 37 37 DEFECTS FOUND AT ROUTINE MEDICAL INSPECTION. Uncleanliness.—Of 3,436 children examined, 7 were found to have vermin in their heads and 182 had nits. The following is a comparative table for the last five years :— 1931 1932 1933 1934 1935 Number of children examined 2,790 3,087 2,869 3,378 3,436 Number of children with verminous heads 64 54 21 15 7 Percentage of children with verminous heads 2.3 1.7 0.7 0.4 0.2 Number of children found to have nits 328 281 224 279 182 Percentage of children found to have nits 11.7 9.1 7.8 8.2 5.0 These figures indicate that the improvement in cleanliness apparent since 1931 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. Nutrition.—At the end of 1934 the Chief Medical Officer of the Board of Education requested that nutrition in children should be classified under the four headings:— A Excellent. B Normal. C Slightly sub-normal. D Bad. The number of children examined in routine inspection in 1935 was 3,436 and these were classified as follows :— A 1.1 percent. B 66.6 C 30.6 D 1.7 The estimation of the degree of nutrition or malnutrition varies with the standard adopted by the examining doctor, and also to some extent with the condition of the child upon the day of examination. It is very difficult therefore to make an accurate report on this subject. Skin Diseases.—Eighteen cases were seen; seventeen required treatment and one was kept under observation. Ear Disease.—Nineteen cases of middle ear disease were found; 86 also thirty-three 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:— 1931 1932 1933 1934 1935 Number of children examined 2,790 3,087 2,869 3,378 3,436 Number of cases of Middle Ear Disease found 11 18 23 18 19 Percentage of cases of Middle Ear Disease found 0.4 0.6 0.8 0.5 0.6 Number of cases of Defective Hearing found 42 56 53 53 33 Percentage of cases of Defective Hearing found 1.5 1.8 1.8 1.6 0.98 Tonsils and Adenoids.—One thousand two hundred and five children had already had operation for removal of tonsils and/or adenoids; 663 were found to have enlarged tonsils, adenoids, or both. The following is a comparative table for the last five years:— 1931 1932 1933 1934 1935 Number of children examined 2,790 3,087 2,869 3,378 3,436 Number of children already operated upon 914 1,049 1,121 1,202 1,205 Percentage of children already operated upon 32.8 33.9 39.1 35.6 35.0 Number of children with enlarged tonsils, adenoids, or both 961 787 388 512 663 Percentage of children with enlarged tonsils, adenoids, or both 34.4 25.5 13.5 15.3 19.3 Eye Diseases and Defects.—Twenty-nine children were found to be suffering from external eye disease. Twenty-eight were referred for treatment to the minor ailment clinic and one was kept under observation. Two hundred and forty-three cases of defective vision were referred for treatment to the Ophthalmic Clinic or Hospital; forty-three of these had squint. The following is a comparative table for the last five years:— 1931 1932 1933 1934 1935 Number of children examined 2,790 3,087 2,869 3,378 3,436 Number of children with defective vision 240 237 296 234 200 87 Percentage of children with defective vision 8.6 7.7 10.3 6.9 5.9 Number of children with squint 96 48 21 40 43 Percentage of children with squint 3.4 1.6 0.7 1.1 1.2 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:— 3 for removal of meibomian cysts. 6 for operation for squint. 5 for other conditions. In addition to these, 21 children attended the hospital during the year for treatment for squint, making a total of 153 attendances during the year. Tuberculosis.—No cases of pulmonary tuberculosis were found. Crippling Defects.—The following defects were found during Routine Medical Inspection:— 1 case of birth palsy. 1 case of hemiplegia. 1 case of rheumatoid arthritis. 3 cases of infantile paralysis. 3 cases of spinal curvature. 1 case of cleft palate. 1 case of spastic diplegia. 1 case of multiple exostosis. 2 cases of hammer toe. 1 case of congenital shortening of leg. 1 case of congenital dislocation of hip. INFECTIOUS DISEASE. The following table is a comparative table for the last five years : 1931 1932 1933 1934 1935 Measles 65 460 4 430 15 German Measles 1 5 6 160 1 Mumps 86 43 667 277 53 Whooping Cough 43 180 78 72 79 Chicken-pox 169 131 235 100 243 Scarlet Fever 159 124 134 135 136 Diphtheria 178 77 28 11 32 Diphtheria Carriers 3 1 — 3 — Small-pox — 1 — — — Poliomyelitis 1 1 — — — 88 These figures show that the schools were comparatively free from infectious disease during the year. The parents, however, should not imagine that the small number of Diphtheria cases that has occurred during the past years is likely to be maintained. It is quite possible that the figures of previous years may recur, and I would strongly urge parents to obtain immunisation against this disease. Such immunisation can be obtained through the general Practitioners of the District or the Medical Officers employed by the Council. DETECTION AND PREVENTION OF SPREAD OF INFECTIOUS DISEASE. Close co-operation exists between the School Medical Department and the Public Health Department, whereby when either becomes aware of infectious disease in any school, house, or district, the other department is informed. Joint action is therefore possible in preventing the spread of infectious disease. VERMIN. Of 3,436 children examined at Routine Inspection, 7 were found to have vermin in their hair, and 182 had nits—i.e., 5.5 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 oi 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 1935 and for the past five years:— 1931 1932 1933 1934 1935 Number of home visits 2,603 2,298 2,943 2,697 2,830 Number of school visits 387 377 621 559 573 Number of school vists for routine examination of heads 216 220 220 195 184 Total number of heads examined 38,228 37,469 39,154 37,303 36,616 89 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 1935 was 3,315 and the total number of attendances was 20,113. 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 42. All children leaving school are given a medical examination early during their last term, so that defects may be remedied before they leave. The result of this examination is entered upon a special card which is sent to the Juvenile Employment Committee. Table IV. gives in detail the diseases dealt with at the Minor Ailment Clinics. Tonsils and Adenoids.—During the year 501 cases were seen at the clinics and referred for treatment, and 203 cases were kept under observation. Of these, 331 were operated on under the Authority's scheme and 76 were operated on by private arrangement. The following is a comparative table for the last five years:— 1931 1932 1933 1934 1935 Number of cases referred for treatment 780 709 467 320 501 Number of cases operated under Authority's scheme 450 295 224 224 331 Number of cases operated by private arrangement 84 62 53 29 76 Tuberculosis.—Eighteen cases of suspected or definite tuberculosis were seen at the clinic during the year. Five children were offered sanatorium treatment and four accepted. Two children who were recommended in 1934 were still away in sanatoria in 1935. All cases notified in previous years were kept under observation, and some were given convalescent treatment. Ringworm.—One child was found to be suffering from ringworm. This was a scalp lesion. The following is a comparative table for the last five years:— 1931 1932 1933 1931 1935 Number of children found to be suffering from ringworm 2 3 9 11 1 90 Impetigo.—During the year fourteen cases were seen; all were treated at the clinic. The following is a comparative table for the last five years:— 1931 1932 1933 1934 1935 Number of children found to be suffering from impetigo 30 13 14 12 14 Scabies.—No cases were seen. The following is a comparative table for the last five years:— 1931 1932 1933 1934 1935 Number of children found to be suffering from scabies 7 13 11 16 - Other Skin Diseases.—One hundred and thirty-three cases were seen. These consisted chiefly of seborrhea, eczema and psoriasis. Eve Diseases.—Two hundred and thirteen 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-three cases of otitis media were found. Sixty-one were referred for treatment to the Aural Clinic. Heart Disease.—Fifty-five children were found to be suffering from organic heart disease; ten 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 sixty cases seen during the year. Of these cases, fourteen were congenital, and eight followed acute infectious diseases. The remaining thirty-eight cases may be classified as follows:— Definite rheumatic history 18 Vague pains 5 No history of illness 15 Chorea.—Nine children were found to be suffering from chorea; one of these was recovering and was kept under observation. All the rest were referred for treatment to a doctor or hospital. Crippling Defects.—The following defects were seen at the clinic I 1 case of old tubercular elbow. 3 cases of hemiplegia. 2 cases of congenital multiple exostosis. 6 cases of spinal curvature. 1 case of hammer toe. 5 cases of club foot. 3 cases of old tubercular hip. 7 cases of infantile paralysis. 5 cases of cleft palate and hare lip. 1 case of cleft palate. 91 2 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 tubercular knee. 1 case of traumatic ankylosis of hip. 2 cases of severe flatfoot. 1 case of cerebral diplegia. 1 case of rheumatoid arthritis. 1 case of congenital absence of fingers. All of these children who required treatment were either attending hospital or obtaining treatment locally. Othet Conditions:— 5 girls were found to be suffering from enlargement of the thyroid gland; 4 are being kept under observation, and 1 was referred for treatment. 2 cases of chronic nephritis were attending hospital. 41 cases of obesity; 13 were referred for treatment and 28 were kept under observation. 1 case of hydrocephalus was attending hospital. 2 cases of diabetes, both of which are being treated at hospital. 1 case of severe rheumatoid arthritis is now at a Heart Home. 1 boy suffering from dwarfism is attending hospital. 1 girl was found to be suffering from thyroglossal cyst and was referred to hospital. 8 children were found to be suffering from hernia; all were referred to doctors or hospitals; 2 were operated upon. 2 cretins were referred to hospital. 1 boy was found to be suffering from haemophilia. The total number of children examined during the year,, excluding those attending the Dental Department, was 9,370. This number was made up as follows :— Examined at Routine Inspection 3,436 Examined at Minor Ailment Clinics 3,315 Examined at Ophthalmic Clinic only 686 Examined at Aural Clinic only 77 Examined at school leaving age for Juvenile Employment Committee 821 Examined under Juvenile Employment Bye- laws 87 Examined under Mental Deficiency Act 21 Examined as contacts with infectious disease 927 92 Payments at the clinics were continued on the same lines as in former years —i.e., a charge of twopence per week was made for treatment at the Minor Ailment Clinic, and threepence per attendance at the Dental Clinic (sixpence if gas is given). For spectacles and for nose and throat operations parents are asked to sign a form of consent and willingness to pay at least part of the cost before the child is referred for treatment. In really necessitous cases the Local Authoritv bears the whole cost. During the year the sum of £306 17s. l0d. was collected, as follows:— £ s. d. Minor Ailment Clinics 2 11 10 For cost of Spectacles 51 18 3 For Convalescent treatment 66 6 6 For Operations for Tonsils and Adenoids 133 18 0 For Dental treatment 52 3 3 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 17 boys were sent during 1935. During 1935 two beds were also reserved for a period of six months at Collington Manor, Bexhill, and two girls and two boys were sent during this period. Wherever possible, the Local Authority recovers part of the cost of maintenance from the parent, but as most of the children are drawn from really necessitous homes, the amount recovered is comparatively small. During the course of the year, in addition to the help set out above, five children were supplied with surgical instruments, one child suffering from diabetes was provided with insulin, one child was provided with an artificial eye, and 13 children were sent to convalescent homes other than the Russell-Cotes School or Collington Manor. There was a total of ten deaths among school children during the year. In 1934 there were twelve. The causes of death during 1935 were as follows:— 1 Malignant endocarditis. 4 Pneumonia. 1 Meningitis. 2 Abscess of lung. 1 Pulmonary embolism. 1 Diphtheria. 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 surround- 93 ings and well ventilated. With six exceptions, the schools are lit by gas ; in the cases of Botany Bay Council, Chesterfield Road Council, Chase Side Council, Suffolks Council, Lavender Road Council and St. Matthew's C.E., Ponders End, electric light has been installed. The schools are warmed with hot-water pipes and open fires. Most of the desks are of the usual 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 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:— By Miss Newbegin, at Bush Hill Park School 3 demonstrations By Miss Garlick at Chesterfield Road School 2 demonstrations By Mrs. Herbert at Chase Side School 2 demonstrations By Mrs. Herbert at Lavender Road School 2 demonstrations By Miss Wilkinson at Alma Road School 1 demonstration Thus 10 demonstrations were given during the year, as compared with 13 last year. OPEN-AIR EDUCATION. There are no open-air schools or classes in Enfield. 94 PHYSICAL TRAINING. In September, 1935, the Education Committee appointed an organiser of physical training, whose duty it will be to supervise the physical training of the children throughout the elementary schools, and instruct the teachers in the latest methods of physical training. PROVISION OF MEALS. Meals are provided for necessitous children. Until July, 1935, the arrangements were made by the Care Committee, but subsequent to that date the arrangements were taken over by the Education Committee itself and are now in the hands of the " Provision of Meals Sub-Committee." During the year 33,949 dinners were provided. During 1935 arrangements were made for the provision of milk to children at ½d. for one-third pint. The children took advantage of the arrangement to such an extent that 917,234 bottles of milk were provided and paid for ; in addition to which 76,265 bottles of milk were provided free to those children whose circumstances were such that their parents could not afford to pay. The milk supplied was in every case pasteurised, regularly tested by the Public Health Department to see that it conformed to the prescribed standard for pasteurised milk, and was delivered in one-third pint bottles and drunk through a straw. Those children who are receiving milk free of charge will be examined by one of the Medical Officers of the Staff in order that the necessity may be ascertained and the condition of the children observed. CO-OPERATION OF PARENTS. Once again 76 per cent, of the children examined at Routine Inspection were accompanied by their parents. This figure has shown but little variation during past years, and although it may be considered as satisfactory, it might well be improved. Whilst I realise that home duties prevent some parents from attending when their children are examined, I do not think it can be considered to account for the 24 per cent, who failed to attend. Parents should realise the importance of this routine examination and take full advantage of it. The Medical Officer present is always prepared to explain to parents the significance of such defects as may be found to be present and to answer such questions concerning the wellbeing and hygienic care of their children as they may care to ask. The value to public health of routine inspection cannot be exaggerated. It would be far better if we could interview personally every parent rather than send a short note to the 24 per cent, who are absent, explaining what defects have been found. I would take 95 this opportunity of assuring the parents of Enfield that they will be welcome whenever they come with their children to routine inspection, and I trust that this figure may be materially increased during the coming year. CO-OPERATION OF TEACHERS. Once more it is a pleasure for me to be able to pay tribute to the co-operation I have received from school teachers during the course of the year. The friendly relationship between the teachers and the medical department does much to improve the health of the children and promote the smooth running of my department. A large amount of work has fallen on teachers in connection with the provision of milk at a cheap price to school children. Milk is probably the most important substance in the diet of a child of school age, and the increased consumption that should result from this scheme is bound to improve the health of the children. I am sure that this remark alone will be more than sufficient compensation to the teachers for the work they have done in this direction. 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 in those cases that cannot be helped within the scope of the Education Acts. Through its agency the following help was given during the course of the year:— Sixteen children were given cod-liver oil and malt, Parrish's Food, etc., and two convalescent treatment ; 470 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. 96 CO-OPERATION OF LOCAL PRACTITIONERS. The co-operation of the general practitioners of Enfield has been sought and maintained throughout the year. In 263 instances parents were advised to obtain advice from their own doctors ; only those cases which are too trivial to need the advice of the general practitioner are treated at the minor ailment clinic. The thanks of the school medical service are due to the doctors of Enfield for their whole-hearted co-operation throughout the year. 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 Wood Green or at a residential school for the blind. There are seven such children in Enfield, and they are educated as follows: 3 girls attending residential schools for the blind. 4 girls attending Wood Green School for the Partially Blind. Deaf and Deaf-mutes.— These children attend the Tottenham (Philip Lane) School for the Deaf. At the end of 1935, 12 children were attending; 3 deaf-mutes, 7 suffering from acquired deafness, and 2 suffering from motor aphasia. Mentally Defective Children.— Twenty-one children were examined under the Mental Deficiency Act (1913) during 1935. The following is a comparative table for the last five years — 1931 1932 1933 1934 1935. A. Dull and backward but capable of instruction in an elementary school 3 2 1 4 5 B. Mentally Defective but capable of instruction in a special school 3 6 7 8 9 C. Mentally Defective but incapable of instruction in a special school D. Incapable of further instruction in a special school 3 1 2 1 E. Imbecile 2 4 4 1 4 Moral Defective — — — — 2 F. Mental condition due to physical defect G. Not scheduled 2 — 5 2 — 97 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:— J unior Technical. Grammar. County. Examinations 139 275 206 DEFECTS. Jnr. Technical. Grammar. County. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Dental Caries 19 1 13 1 Defective Vision 6 3 30 4 46 13 Enl. Tonsils, etc. 1 1 4 2 6 2 Other Nose and Throat conditions 1 3 1 1 - Defective Hearing — —• — — 1 — Otorrhoea - — 1 — 1 — Other Deformities - - 2 — — — Other Diseases and defects 2 2 12 - 4 - Anaemia 1 - - - — — Conjunctivitis, Styes, - - 1 - 1 - Stammer — — 2 — — — In April, 1935, the scheme for the dental and ophthalmic examination and treatment of secondary school children commenced. From a reference to the report of the Senior School Dentist, Mr. James, the result of the dental inspection will be seen. Other than to report that 77.7 per cent, of the 963 children examined were found to need treatment is unnecessary, for it shows how essential was this scheme. Still more important is the fact that the 98 dental condition of these children was worse than the condition of elementary school children, due to the fact that since they had left elementary schools their teeth had been neglected. The number of fillings that was required for each child was higher than that found necessary for elementary school children. The initial year of this scheme was bound to be a difficult one. I am hopeful, however, that within a short time we shall have so improved the teeth of secondary school children as to make the work in connection therewith considerably less. Twenty-two children were found at secondary schools to need the advice of the Ophthalmic Specialist. Fourteen of these needed glasses and the remainder either had glasses which were satisfactory or did not need them. Report on Obesity in School Children. By Mrs. G. FORRESTER, M.B., B.S. On comparing the School Medical Officer's reports for the past ten years, one is struck by the sudden increase in the number of obese children attending the elementary schools, who have been presented for examination. 1935 1934 1933 1932 1931 1930 1929 41 22 9 3 2 3 3 1928 1927 1926 1925 1924 1923 1922 4 2 0 2 2 3 1 99 It is difficult to carry out any conclusive work on this subject in school children. Parents and children are very sensitive about the condition, and will even resent questions regarding family history and the child's personal habits. In many cases the parents refuse to allow the child to attend the clinic for periodic weighing. Of the forty-one cases seen in 1935, fifteen refused to attend for weighing, and of fifteen children referred to doctor or hospital only four sought further advice, and three of these were irregular in attendance at hospital. Parents dislike having the children undressed for a general examination ; and investigation into the condition of the genital organs is out of the question. A few points have, however, been noted in regard to the condition:— 1. Well-to-do and poor children are about equally affected. 2. Males are more frequently affected than females. 1935 Boys 24 1934 Boys 16 1933 Boys 7 Girls 17 Girls 6 Girls 2 3. Eleven cases gave a very definite history of obesity in other members of the family; but accurate information is difficult to obtain in all cases. Among the forty-one cases in 1935 were three pairs of brothers, and all these were very obese. 4. All the children except one were well over the average height. In three cases the height was 8, 9 and 11½ ins. above the normal for the age. 5. Mentality.— Most (60.9 per cent.) of the children were of average intelligence, but twelve (29 per cent.) were dull. Three (two girls and one boy) were brilliant at school work. 6. Age of Onset.— It would appear that most of the cases start in early life. Under 5 years 13 Under 6 years (when first examined) 3 Between 5 and 8 years 11 Between 8 and 12 year: 5 (One case doubtful) No history obtainable 9 100 7. Associated Ocular Defects.— Nine children had ocular defects or defects of vision :— Double optic atrophy 1 Ptosis and contraction of right pupil 1 (Refused treatment) Myopia 2 Other errors of refraction 5 Causation.— What causes the disorder of metabolism resulting in the excessive deposition of fat in these children ? Is it due simply to disproportion between the food intake and bodily activity or is it due in every case to under-activity of the thyroid or pituitary (posterior lobe) glands ? I am inclined to think that many of the cases are the result of errors of diet and modern methods of living but cannot confirm this without more reliable information as to the children's habits. According to the parents' history— for what it is worth— many of these children are not large feeders, but some of them are large eaters of sweets and farinaceous foods. Children get less bodily exercise year by year. They spend long hours in school and in the majority of cases have no walk to get there, or if they have, are conveyed, and moreover, apart from school more children make use of omnibuses or private cars than formerly. On the other hand, this will not account for the general overgrowth of tissues in most of thecases. Presuming that there is dysfunction of the thyroid or pituitary glands, what factor in our method of living during the past ten years is responsible for the upset of the endocrine balance ? Symptoms.— The chief complaint is breathlessness on exertion, but as most of the children are slow in moving, even this is seldom complained of. Treatment.— Four children were treated by dietary and glandular extracts, either by the family doctor or at a hospital. Two of these cases attended irregularly and increased greatly in weight during the year. My experience in former years suggests that these cases can be much improved if the treatment is regularly and conscientiously carried out. In 1935 only three showed a marked improvement. In one of these cases the obesity was definitely of pituitary origin. At 12½ years this boy weighed 11 st. 12 lbs., and he had associated genital changes and marked enlargement of breasts, probably due to dysfunction of anterior lobe. He was very dull and was unable to read at all. His mentality improved rapidly under treatment, and after five months he could read well. 101 Case No. Sex. Age. Weight. Height. Remarks. St. lbs. Ft. Ins. 1 F. 5 5 8 3 11½ 2 F. 7 5 3½ 3 8½ Attending hospital and diagnosed as probable tumour of pituitary gland. Double optic atrophy. 3 F. 7 5 6 4 F. 8 8 3½ 4 6½ 5 F. 8 6 7 4 6 6 F. 8 5 3½ 4 0 7 Twins M. 8 6 4 4 5 8/ M. 8 6 2 4 5½ 9 M. 8 7 11 4 7 10 F. 9 6 13 4 74 11 M. 9 12 F. 9 6 3½ 4 5 13 M. 9 6 13 14 M. 10 6 13 4 74 Brother suffering from hypopituitarism. 15 F. 10 6 7 4 61 Brilliant mentality. 16 F. 11 9 7 4 10½ High degree of myopia— corrected. 17 F. 11 9 3½ 5 1 18 M. 11 8 7½ 4 8½ 19 M. 11 9 10½ 5 2 20 M. 11 7 7 4 7i High degree of myopia— corrected. 21 M. 12 7 8 4 9 22 M. 12 7 5 4 9½ Error of refraction— corrected. 23 M. 12 9 1 5 1½ Defective vision—refused treatment. 24 M. 12 11 12 5 3 Hypopituitarism. 25 M. 12 9 5 5 1 Error of refraction— corrected. 26 M. 12 8 5½ 4 11 27 M. 12 8 4 5 0 28 F. 12 7 12½ 4 10 29 F. 12 13 7 5 7 30 F. 13 11 6½ 31 M. 12 10 9 5 1 32 M. 13 8 5½ 4 11½ 33 M. 13 10 3 5 2 34 M. 13 9 3i 5 1½ 35 M. 14 12 74 5 5½ Contraction of right pupil —Right ptosis. Refused examination. 36 M. 14 16 134 5 8½ Brilliant mentality. High error of refraction— Refused examination. 37 M. 14 9 11 5 2½ Error of refraction. Refused examination. 38 M. 14 10 4 5 5 39 F. 14 11 4 5 5 40 F. 14 11 0 5 4 41 F. 15 16 0 5 8 Brilliant mentality—good at all games. 102 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, 1935. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit the annual Dental Report for the year ending 31st December, 1935. The outstanding event in the Enfield School Dental Service during 1935 has been the initiation of dental inspection and treatment for children attending the secondary schools. Tables and figures given later in this report show the urgent necessity for the inclusion of these children in the dental scheme. As a result of the large amount of work carried out for secondary school children, figures relating to elementary school children were considerably reduced during the year under review, as compared with previous years. The following figures show the reduction in the number of elementary school children inspected and treated. 1934 1935 Total number of elementary school children inspected 6,869 4,139 Total number of elementary school children treated 3,552 2,577 There was a corresponding reduction in the number of fillings and extractions for elementary school children. It is anticipated, however, that more of the latter children will be inspected and treated in the coming year, since the secondary school children who have now been rendered dentally fit will require little or no further treatment. With regard to the total amount of work done during the year, for elementary and secondary school children combined, there was a slight increase in the number of fillings inserted in permanent teeth,. as shown by the following figures:— 103 1934 1935 Total number of fillings inserted in permanent teeth 3,903 3,998 Of this total of permanent fillings, the most important part of school dental work, 2,913 were for elementary and 1,085 for secondary school children. The number of fillings in temporary teeth was 355, making the total number of fillings 4,353. The number of permanent teeth extracted also shows an increase, as follows:— 1934 1935 Number of permanent teeth extracted 651 950 This total is represented by 674 extractions for elementary and 276 for secondary school children. The number of temporary teeth extracted for elementary school children was 3,665, being 800 less than the number extracted in 1934. Under the heading of " other operations " 955 teeth of elementary school children received treatment, the total figure for both elementary and secondary school children being 1,305, an increase of 69 over the corresponding figure for 1934. This total figure comprises 201 applications of silver nitrate for the conservation of temporary teeth, 520 scalings and brushing of permanent teeth, the remaining 584 operations being temporary fillings in permanent teeth, root fillings and adjustments to regulation appliances. During the year under review 18 elementary school children received treatment for irregular teeth, involving the wearing of regulation appliances. Of this number, the treatment was completed for 12 children, the remaining 6 being still under treatment at the end of the year. Parents are very appreciative of the improvement in the appearance of their children as a result of orthodontic treatment, several cases of marked superior protrusion being treated by means of removable appliances, with good results. The total number of parents of elementary school children who gave their written consent to the treatment offered was 71 per cent. A certain number of children, however, failed to keep their appointments, so that the number actually treated of those referred during the year was 66.8 per cent., the George Spicer and Central Schools being the best in this respect with 87 per cent, treated. It has been suggested that free dental treatment would result in a higher percentage of acceptances, but it is not considered that the small fee of 3d. per visit required in Enfield before treatment is given, acts to any appreciable extent as a limiting condition so far as the number of acceptances is concerned. Particulars respecting the dental inspection and treatment of secondary school children are given in the following tables 4* INSPECTION OF SECONDARY SCHOOL CHILDREN. School. Number Inspected. Found to Require Treatment. Percentage of those Inspected. Requiring. Treatment. Halfdays Devoted to Inspection. Number of Permanent Teeth. Total No. of Decayed Permanent Teeth Savable and UnSavable. Number Per Child Inspected. Decayed Saveable. Number Per Child Inspected . Decayed Unsaveable. Number Per Child Inspected. Girls— County School 362 247 68.2 4 368 1.01 104 .28 472 1.30 Boys— Grammar School 434 365 84.1 5 963 2.21 135 .31 1,098 2.52 Boys— Technical School 167 137 82.0 2 356 2.13 49 .29 405 2.42 Total 963 749 77.7 11 1,687 1.75 288 .29 1,975 2.05 © C/i TREATMENT OF SECONDARY SCHOOL CHILDREN. School. Number Inspected. Found to Require Treatment. Percentage of those Inspected Requiring Treatment. Number Actually Treated. Percentage T reated of those Requiring Treatment. Attendances made by Children for T reatment. No. of Fillings in Permanent Teeth. Number of Extractions of Administra tion of General Anaesthetics for Extrac tions. No. of other Operations on Permanent Teeth. Temporary Teeth. Permanent Teeth. Total No. of Extrac tions. Girls— County School 362 247 68.2 167 67.6 406 336 24 103 127 8 155 Boys— Grammar School 434 365 84.1 202 55.3 576 671 28 160 188 17 165 Boys— Technical School 167 137 82.0 59 43.0 104 78 - 13 13 - 30 Total 963 749 77.7 428 57.1 1,086 1,085 52 276 328 25 350 106 It will be noted that each child had on an average 2.05 decayed permanent teeth. For every 100 secondary school children examined more than 29 permanent teeth were unsaveable. These figures compare unfavourably with those obtained as a result of the dental inspection of children having the benefit of regular examination. In the Central School, for instance, each child had an average of 1.13 decayed permanent teeth, and for every 100 children examined only 17 teeth were unsaveable. This greater incidence of dental caries in secondary school children was to be expected, as many of them had received no dental attention for three to six years. Moreover a study of the bare figures does not reveal the real difference in the dental condition of these groups of children. In the case of the Central School children most of the fillings required were small and could be inserted quickly, whereas the cavities in the teeth of the secondary school children were generally large and treatment necessitated the expenditure of much more time. This is shewn in the case of the Grammar School boys by the fact that 77 per cent, of the 671 fillings required linings to protect the pulps of the teeth from thermal shock. The better condition of the secondary school girls as compared with the boys will further be noted, 68 per cent, of the girls requiring treatment, 84 per cent, of the Grammar School boys, and 82 per cent, of the boys attending the Technical School. Each boy examined had on an average nearly twice as many carious permanent teeth as each girl. The greater interest taken by the girls in the cleanliness of their teeth was noticeable. The number of girls who stated they never failed to brush their teeth each day was 75 per cent., and the number of boys 53 per cent. The condition of the children's teeth was carefully noted during inspection, and these percentages are probably fairly accurate. Considerably more girls than boys accepted the treatment offered them, the figures being 67.6 per cent, acceptances in the case of the girls as compared with 51.9 per cent, for the boys. Probably the simplest and surest method of increasing the number of acceptances is to persuade children to brush their teeth regularly. If a boy does not take sufficient interest in his teeth to keep them clean and free from stain by this means, it is unlikely that he will present himself regularly for conservative dental treatment. The dental condition of elementary school entrants remains unsatisfactory, only 17 per cent, of those inspected during the year being naturally fit with all teeth present. There is a mass of evidence which supports the view that dental caries is mainly due to causes external to the tooth, namely the eating to excess of starchy and sugary foods requiring little or no mastication. Until this view is generally accepted, and the necessary alterations made in the diet 107 of young children, the prospects of an advance on preventive lines would appear to be small. For the maintenance in health of any part of the body exercise is essential, and the teeth can be no exception to this rule. That large numbers of young children between the ages of 2½ and 5 years are brought up almost exclusively on soft pappy foods cannot be doubted. Since with such a diet the teeth receive no exercise, and are in fact not necessary, Nature, in accordance with a universal law, will not permit them to be retained in health. It is not submitted that the whole problem of dental caries is explained by a diet largely deficient in elements requiring the proper use of the teeth. The view is advanced, however, that no further explanation need be sought when a child is seen at the age of 3 or 4 years with all temporary molars so far decayed that extraction is the only remedy. The problem of complete immunity to dental caries may remain unsolved for many years. While awaiting its solution, it is advocated that all who are concerned in the promotion of dental health in young children should concentrate on known facts, and teach parents the importance of the simple dietary rules laid down in the leaflet on the prevention of dental caries which is approved by the Society of Medical Officers of Health. A report has recently been issued by Dr. Arthur Collett, of Oslo, on an investigation he undertook into the dental condition of children living in an institution, where the diet was regulated, and of children living under ordinary home conditions. The ages of the children ranged between 3 and 7 years. The diet of the institution children consisted of home-baked whole meal bread, plenty of vegetables, some fruit, margarine in place of butter, and milk, but very few sweets, with a desert spoonful of cod liver oil daily. Uncooked fruits or carrots at the end of each meal were relied upon as natural tooth cleaners, and tooth brushes were not used ! As a result of this investigation, it was found that each institution child had on an average 1.7 carious cavities, while the children living at home with an unregulated diet had 14.6 cavities per child. These figures are interesting and instructive for those not yet convinced of the part played by a faulty diet in the production of dental caries. For dentists who have been familiar over a long period of years with the results of many similar investigations, they are unnecessary as further proof of facts already known. The sum received in fees from elementary school children amounted to £50 8s. 3d. In conclusion, Mr. Bradbury and I wish once again to thank all 108 Head Teachers for their co-operation in obtaining consents to treatment and in persuading children to keep their appointments ; also to acknowledge our indebtedness to Nurse Anderson and Miss Groves for their invaluable help in the running of the dental clinic. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. E. JAMES, Senior School Dental Surgeon. 109 Report of the School Ophthalmic Surgeon, Mr. S. MACKY, M.B., B.S., D.O.M.S. for the year ending 31st December, 1935. 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, 1935. Elementary Schools. Secondary Schools. Total attendances at clinic 2,095 40 New cases 1,144 22 Prescriptions for glasses 369 14 Number not requiring glasses 94 1 The cases requiring glasses consisted of Hypermetropia 91 1 Hypermetropia with astigmatism 352 5 Hypermetropic astigmatism 172 — Myopia 90 5 Myopia with astigmatism 92 4 Myopic astigmatism 9 1 Mixed astigmatism 73 1 Anisometropia 20 2 During the year six children were referred for operation for squint. Two refused treatment, one was operated upon, and three are awaiting admission to hospital. In addition to these, one child who was referred for operation in 1934 was operated in 1935. Three children were referred to the Western Ophthalmic Hospital for removal of meibomian cysts. The additional work arising from the secondary schools and Maternity and Child Welfare Clinics has not put too great a strain on the clinic, although extra sessions have been needed. Many 110 interesting and some urgent cases have come from these new clinics. The high percentage of myopia in the secondary school children is perhaps only due to the influence of age, but it does suggest at first sight a bad effect of close study. However, the numbers are too few to be reliable. Another new departure is the orthoptic treatment of the squinting children. Arrangements have been made with the Western Ophthalmic Hospital to have our children treated there. The children are escorted by one of the staff, and the arrangement seems admirable. So far 24 children have received treatment and 21 have been put on the waiting list. There are still others, of course, but not every case of squint is suitable for orthoptic training. I am glad to have again an opportunity of expressing my thanks and appreciation to my fellow workers in the clinic. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, STEWART MACKY, School Ophthalmic Surgeon. Ill Annual Report of the School Aural Surgeon. Mr. J. C. HOGG, F.R.C.S. For the year ending 31st December, 1935. 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 ending 31st December, 1935. During the year we have dealt with 227 cases, of which 150 were new attendances. The total number of attendances was 621. Of these 150 have been discharged cured, and there are 14 cases of a recurrent nature which require occasional attendance, but which have again been discharged. There are 46 children under treatment ; 13 have refused treatment, and in three cases treatment was sought elsewhere, either privately or in hospital. Thirty-five cases have been recommended for the removal of tonsils and adenoids, of which 18 have had the operation, 7 are awaiting operation, and 9 have refused treatment. Two cases of long-standing aural suppuration were admitted, under my care, to the Ear, Nose and Throat Hospital, Golden Square, for mastoid operation. They both attend the clinic now, for occasional inspection or treatment. During the year under review, 33 infants, totalling 65 attendances, have been seen in the Aural Clinic, referred from the Welfare Centre. One of these remains under treatment. Once again I would like to express my thanks to the nursing staff of Southbury Road, and other clinics, for their enthusiastic help and co-operation in the work of this department, 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. 112 LIST OF CASES. CLASSIFICATION. Still under treatment. I.S.Q. Improved. ^Discharged cured. Recurrent, but again |discharged. Refused treatment. ILeft School or [District . 1. Acute or subacute suppurative otitis media 3 2 43 5 2 — 55 2. Chronic suppurative otitis media 6 16 13 5 2 5 47 3. Chronic catarrhal deafness, Eustachian obstruction and otosclerosis 3 2 25 5 3 38 4. Wax, otitis externa, eczema, boils, etc. 1 2 24 4 — 1 32 5. Chronic Rhinitis, nasal obstruction, etc. 7 4 45 4 — 60 6. Non-aural 26 Total 258 113 Statistical Tables for the Annual Report of the School Medical Officer, for the Year 1935. TABLE I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A.— ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed groups :— Entrants 886 Second Age Group 952 Third Age Group 855 Total 2,693 Number of other Routine Inspections 743 Grand Total 3,436 B.— OTHER INSPECTIONS. Number of Special Inspections 5,847 Number of Re-Inspections 2,987 Total 8,834 C.— CHILDREN FOUND TO REQUIRE TREATMENT. Number of individual children found at Routine Medical Inspection to require treatment (excluding Uncleanliness and Dental Diseases)— Prescribed Groups :— Entrants 224 Second Age Group 241 Third Age Group 152 Total (Prescribed Groups) 617 Other Routine Inspections 180 Grand Total 797 114 TABLE II. (A) Return of defects found by Medical Inspection in the year ended 31st December, 1935. 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) SKIN. Ringworm. Scalp - - 1 - Body 1 — — — Scabies — — — — Impetigo — — 14 — Other Diseases (Non-Tuberculous) 16 1 118 6 Total 17 1 133 6 EYE. Blepharitis 18 — 49 — Conjunctivitis 5 1 100 2 Keratitis — - — — Corneal Opacities — — — 4 Other Conditions (Excluding Defective Vision and Squint 5 - 64 - Total 28 1 213 6 Defective Vision ing Squint) 200 156 181 10 Squint 43 37 34 2 EAR. Defective Hearing 33 3 16 9 Otitis Media 19 — 61 2 Other Ear Diseases 11 — 56 1 NOSE AND THROAT. Chronic Tonsillitis only 30 80 79 67 Adenoids only 4 5 2 4 Chronic Tonsillitis and Adenoids 346 198 420 132 Other Conditions 28 3 66 352 115 TABLE II (continued.) ENLARGED CERVICAL GLANDS (Non-Tuberculous) 2 3 22 15 DEFECTIVE SPEECH 1 5 1 7 HEART AND CIRCULATION. Heart Disease Organic - 12 10 42 ~ Functional 1 4 1 8 Anaemia — — — — LUNGS Bronchitis 2 2 5 5 Other Non-Tuberculous Diseases 1 2 7 5 TUBERCULOSIS Pulmonary Definite - - 4 - Suspected 3 2 2 2 Non-Pulmonarv Glands - - 5 1 Bones and Joints - - 2 - Skin 1 - Other Forms — — - — Total — — 8 1 NERVOUS SYSTEM Epilepsy 2 3 10 5 Chorea 1 8 1 Other Conditions 1 1 8 8 DEFORMITIES. Rickets 1 2 Spinal Curvature 3 6 1 Other Forms 4 10 25 23 OTHER DEFECTS AND DISEASES 57 28 1371 243 (excluding Uncleanliness and Dental Diseases) Total 838 556 2751 957 116 B.— CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN THE ROUTINE AGE GROUPS. Age Groups. Number of Children Inspected. A (Excellent) B (Normal) c (Slightly subnormal) D (Bad) No. % No. % No. % No. % Entrants 886 13 1.5 549 61.96 311 35.1 13 1.5 Second Agegroup 952 3 .3 598 62.8 339 35.6 12 1.3 Third Agegroup 855 13 1.5 649 75.9 182 21.3 11 1.3 Other Routine Inspections 743 9 1.2 490 65.9 224 30.2 20 2.7 Total 3,436 38 1.1 2,286 66.6 1.056 30.6 56 1.7 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. 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 Instituttion. Total. — 4 — — — 4 117 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 — 6 1 — — 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 35 — — — 35 EPILEPTIC CHILDREN. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools. At other Institutions At no School or Institution  — - - 1 1 118 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 5 — - — 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 - — 1 3 B.—DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions. At no School or Institution Total 9 23 — 1 33 C.—CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 30 — 4 36 119 D.—CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions. At no School or Institution. Total 1 2 - - 3 Children suffering from Multiple Defects .. Nil TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1935. TREATMENT TABLE. GROUP I—MINOR AILMENTS (excluding Uncleanliness, for which see Table VI.) DISEASE OR DEFECT. (1) Number of Defects treated, or under treatment during the year Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) SKIN. Ringworm—Scalp - - - (i) X-Ray Treatment — — — (ii) Other ,, 1 — 1 Ringworm—Body 1 — 1 Scabies — — — Impetigo 14 - 14 Other Skin Diseases 107 18 125 MINOR EYE DEFECTS (External and other, excluding cases falling in Group II.) 213 7 220 . MINOR EAR DEFECTS 256 18 274 MISCELLANEOUS (e.g., minor injuries, bruises, sores, chilblains, etc.) 1213 82 1295 Total 1805 125 1930 120 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.) No. of Defects dealt with. Under The Authority's Scheme. Otherwise Total Errors of Refraction (including squint) 899 — 899 Other Defects or Disease of the Eyes 15 15 Total 914 — 914 Under the Authority's Scheme Otherwise. Total Number of Children for whom Spectacles were: (a) Prescribed 369 - 369 (b) Obtained 365 - 365 121 TABLE IV.— Continued. GROUP III.— TREATMENT OF DEFECTS OF NOSE AND THROAT No. of Defects. Received Operative Treatment. Received other forms of Treatment (4) Total number treated. (5) Under the Authority's Scheme, in Clinic or Hospital. (1) By Private Practitioner or Hospital, apart from the Authority's Scheme (2) Total (3) I. II. III IV I. II. III IV. I. II. III IV 36 4 291 - 11 - 65 — 47 4 356 - 78 485 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 2 1 5 16 24 122 TABLE V. DENTAL INSPECTION AND TREATMENT. 1. Number of children inspected by the Dentist:— Aged (a) Routine Age Groups 5 1311 Total 3,523 6 357 7 532 8 277 9 383 10 375 11 349 12 390 13 360 14 228 15 106 16 35 (b) Specials 616 (c) Total (Routine and Specials) 4,139 2. Number found to require treatment 3,251 3. Number actually treated 2,577 4. Attendances made by children for treatmen 4,460 5. Half-days devoted to:— Inspection 31 Total 732 Treatment 701 6. Fillings :— Permanent Teeth 2,913 Total 3,268 Temporary Teeth 355 7. Extractions :— Permanent Teeth 674 Total 4,339 Temporary Teeth 3,665 8. Administrations of general anaesthetics for extractions 199 9. Other operations :— Permanent Teeth 754 Total 955 Temporary Teeth 201 123 TABLE VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. I. Average number of visits per school made during the year by the School Nurses 9 II. Total number of examinations of children in the Schools by School Nurses 36,616 III. Number of individual children found unclean 966 IV. Number of children cleansed under arrangements made by the Local Education Authority — V. Number of cases in which legal proceedings were taken: (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws 3 INDEX A. PAGE Adulteration 28 Ambulance facilities 14 Area of District 5 Aural Surgeon's Report . 111 Aural Treatment 53 B. Baby Week 55 Bakehouses 28 Births 12 Birth Control 53 Blind, Deaf, Epileptic and Mentally Defective Children 96 Blind and Partially Blind Children 116 Bye-laws and Regulations. 15 C. Causes of death at all ages 9 Causes of death under 1 year of age 10 Cerebro-spinal Fever 33 Cesspools 19, 73 Chief Sanitary Inspector's Report 61 Children Act 54 Children Suffering from Multiple Defects 116 Children suffering from Pulmonary and Non-Pulmonary Tuberculosis 118 Children with Heart Disease 119 Circulation of Booklet on Rearing of Children 56 Clinics and Treatment Centres 45 Closet Accommodation 19 Coffee Stalls 72 Convalescent Treatment.. 57 Co-operation of Parents. 94 Co-operation of Teachers . 95 Co-operation of School Attendance Officers 95 Co-operation of Voluntary Bodies . 95 Co-operation of Local Practitioners 96 Co-operation with Education Committee 57 Councillors 4 Crippled Children 118 D. Deaf and Partially Deaf Children 117 Deaths 8 Defective Vision and Squint 120 Defects found at Routine Medical Inspection 85 Delicate Children 118 Dental Inspection and Treatment 122 Dental Surgeon's Report 102 Dental Treatment 55 Detection and Spread of Infectious Disease 88 Diphtheria 31 Diphtheria Carriers 31 Diphtheria Immunisation 32 Disinfection 65 Disinfection of verminous persons and their belongings 39 Disinfestation of Verminous Houses 66 D. PAGE Disposal of house refuse 20, 73 Drainage and sewerage 19 Drinking fountains 74 E. Encephalitis Lethargica 33 Enteric and Paratyphoid Fever . 33 Enteritis . 34 Epileptic Children 117 Examination of Secondary School Children 97 F. Factory and Workshops Act 67 Fitness of houses 26 G. General Observations 25 H. Home Helps 57 Horse troughs 74 Hospitals . 16, 74 Housing 23 Housing conditions 25 I. Infantile Mortality 12 Infectious Diseases and Schools 22, 87 Infectious Diseases table 30 Inquests 11 Inspection and supervision of food 26 Insulin, Supply of . 39 Isolation Hospital 18 L. Laboratory facilities 15 Legislation 15 M. Maternal Mortality 48 Maternity and Child Welfare Statistics 50 Maternity and Child Welfare Staff 41 Maternity Centres 42 Maternity Hospital 18 Measles and German Measles 33 Meat 27 Members of Education Committee 78 Members of Health Committee 4 Members of Maternity and Child Welfare Committee 4, 41 Mentally Defective Children . 117 Meteorology 39 Midwives 50 Milk 26, 69 Milk (Special Designations) Order 27 Minor Ailments . 119 Mortuary 75 Motor Ambulances 72 N. PAGE National Health Insurance 14 Notices issued 63 Notifiable diseases 29 Number of Elementary School Children . 84 Number of Individual school children found at Medical Inspection to require treatment 113 Nursing in the Home 14 0. Obesity in School Children 98 Offensive Trades 69 Officials of Council 4 Open Air Education 93 Ophthalmia Neonatorum 36 Ophthalmic Surgeon's Report 109 Other foods 28 Orthopaedic and Postural Defects 121 Ophthalmic Treatment 53 P. Paratyphoid and Enteric Fevers 33 Petroleum 72 Photo and Plan of Maternity Centre 59 Physical Training 94 Physically Defective Children 118 Places of Public Entertainment 69 Poliomyelitis 33 Population 5 Prevalence of, and control over, Infectious and other Diseases 29 Prevention of Blindness 35 Provision of Meals 94 Public Conveniences 74 Public Health (Meat) Regulations 28, 70 Public Health (Prevention of Tuberculosis) Regulations 38 Public Health (Smallpox) Prevention Regulations . 29 Public Health Staff 13 R. Rag Flock Acts 22 Rats . 75 Regulations and Byelaws 15 Removal and disposal of house refuse 20, 72 Return of Defects found by Medical Inspection 114 Return of Defects Treated 119 Return of Medical Inspections (Aural)112 Routine Medical Inspection 84 Routine Medical Inspection of Children under 5 years 52 S. Sale of Foods and Drugs Act 29 Sanitary Administration 15 Sanitary circumstances of District 18 Sanitary Inspection of District 20 Scarlet Fever 31 School Medical Officer's Report 80, 84 School Medical Service in Relation to Public Health 92 Schools 22, 74 s. PAGE Sewerage and drainage 19 Sewer flushing 73 Shops Act 72 Slaughter of Animals Act 28 Slaughterhouses 28 Smoke abatement 21 Social conditions 6 Staff of Public Health Department 12 Staff of School Medical Department 79 Statistical Tables of School Medical Officer 113 Statistics 7 Streams and Water-courses 19 Student Health Visitors 58 Sub-letting in Council houses 21 Suicides 11 Supply of Insulin 39 Swimming Baths and Pools 21 T. Teaching of Hygiene 93 Tuberculosis (County of Middlesex) Scheme 16 Tuberculosis 36 Treatment Clinics (Schools) 89 Treatment of Defects of Nose and Throat 121 U. Uncleanliness and Verminous Conditions 123 Unsound Meat and foods 71 V. Vermin 88 Verminous houses 25, 66 Veterinary inspection of cows 26 Vital Statistics 7 W. Water-courses and streams 19 Water supply 18 Work of School Nurses. 88 Z. Zymotic death-rate 35 Zymotic diseases 34