LIBRARY ENF 21 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 J937 TOGETHER WITH THE ANNUAL REPORT OF THE Chief Sanitary Inspector (FRED. WILSON, M.R.San.I., M.S.I.A.) 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 1937 TOGETHER WITH THE ANNUAL REPORT OF THE Chief Sanitary Inspector (FRED. WILSON, M.R.San.I., M.S.I.A.) 1 Public Offices, ENFIELD. 17th April, 1938. Annual Report of the Medical Officer of Health, 1937. To the Chairman and Members of the Urban District Council of Enfield. Mr. Chairman and Gentlemen, I beg to place before you my 11th Annual Report on the health of the District. During the course of the year the work of the Department has been considerably increased by the passing of the Midwives Act, whilst the new Public Health and Housing Acts of 1936 have meant alteration in procedure. In addition to this, the Department has been concerned in the study of Air Raid Precautions and the preparation of schemes in connection therewith. Overcrowding has decreased during the year, and in general the health of the District has been well maintained. A mild type of Dysentery due to the Sonne Bacilli broke out during the months of November and December, and in all there were notified 113 cases. This disease was of a mild nature and in most cases resulted in no more than a few days of illness. The factor which calls for the greatest consideration is the general development of the District and the number of houses that are being built. During 1937 over 2,000 houses were erected in Enfield, and the number of houses in the district has increased from 13,469 in 1927 to 24,310 in 1937. That this matter is causing concern is evidenced by such frequently heard remarks as "What is beccming of Enfield ?", " What will be he effcct of all this building on the rates ?" These remarks do not call for comment from me, but there are others which might well 2 be analysed. It is stated that the development is bad, the building hurried, the workmanship not of the best; that the houses will not stand the test of time, and that forty to sixty years hence they will be unfit for human habitation and constitute veritable slums. I am afraid that I do not subscribe to the view-point of these pessimists. The new houses of Enfield have been built at a specified number to the acre and site overcrowding has, therefore, been prevented. The lay-out of the new estates has been far superior to that of 50 years ago, wide streets, small gardens and air space being apparent everywhere. Each house contains a damp-proof course, a concrete covering to the site, sufficient window space, a bathroom, a suitable kitchen and a certain amount of tiling. I am told that a lot of this is window dressing which masks hasty erection, cheap material and faulty construction, defects that although not apparent now will show themselves in the years to come, and that the sound workmanship of pre-war days is no longer seen. One wonders if it is not owing to the sound construction of the houses of 100 years ago that we possess slums to-day. I refer to houses, erected on overcrowded sites, with no bathrooms, small windows and bad construction, whose external walls are so sound to-day that their demolition is impracticable. Although they have outworn their period and do not conform to modern standards of housing they remain, improved and repaired from time to time, yet never reaching modern ideals, and above all, never becoming a home of which the housewife can be proud. I would stress the importance of this particular factor. Whatever may be the faults of these mass production houses with their so-called superficial window dressing, they are, nevertheless, homes of which the housewife can be and is proud. To realise this one need but stroll round new housing estates to see how quickly the gardens are put in order, and how frequently the brass knocker is polished. There is in my opinion a steady improvement in the mental outlook of the family that moves from old dwellings into these new houses, be they built by private enterprise or by the Council, and there is, moreover, a steady gain in health. If in forty to sixty years time these houses have decayed and must of necessity be pulled down, they will be replaced by property which future generations may erect according to their improved outlook on housing; they will not remain as their predecessors, out-of-date, yet unlikely to be demolished. Just as we consider early Victorian houses ugly, inconvenient, dark and damp, so may our 3 children cast similar aspersions on the property we erect to-day. From a health point of view I am satisfied that the mass of new houses arising in Enfield to-day is improving the civic and personal pride of the people who are housed thereby. I would once more thank the Council for the courtesy I have received throughout the year, and would pay a tribute to the help I have received from every member of my staff. I beg to remain, Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health 4 URBAN DISTRICT COUNCIL OF ENFIELD. G. M. Sparrow, Esq., J.P., C.C. Chairman H. Muspratt, Esq., O.B.E. Vice-Chairman also H. R. Neilson, Esq. E. Edwards, Esq. C. Partington, Esq., J.P. W. W. Cakebread, Esq. J. C. Bland, Esq. F. Greenwood, Esq. W. C. Bennett, Esq. H. A. D. Brown, Esq. W. H. Bishop (Jnr.), Esq. S. G. Rowlandson, Esq. L. R. Morris, Esq. H. H. Collier, Esq. A. R. Kemp, Esq. G. S. Thompson, Esq., F.R.C.S. (Edin.). F. G. Fletcher, Esq. A. M. Eeles, Esq. G. E. Jones, Esq. HEALTH COMMITTEE. H. Muspratt, Esq., O.B.E. Chairman also Messrs. Thompson, Greenwood, Kemp, Cakebread, Bennett, Brown and Fletcher. Clerk to the Council S. J. Dabbs, Esq. Engineer and Surveyor to Frank Lee, Esq., A.M.Inst.C.E., the Council P.A.S.I., L.R.I.B.A., M.Inst.M. & Cy.E. 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. Solicitor to the Council K. E. Lauder, Esq., LL.B. 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 87,200, and this figure is being used in connection with the vital statistics as set out in this report. The following table shows how the population of the District has increased during the last ten years. Year. Population. 1928 64,910 1929 65,100 1930 65,504 1931 68,220 1932 69,910 1933 71,790 1934 74,664 1935 76,960 1936 81,920 1937 87,200 The number of inhabited houses at the end of 1937, according to the Rate Books, was 24,310. The rateable value of the District is £755,785 The net product (after allowing for cost of collection) of a penny rate is £2,773 The following table indicates the increase 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. £ £ 1928 13,733 377,644 1,335 1929 14,123 472,199 2,080 1930 14,707 479,466 1,920 1931 15,215 491,451 1,991 1932 15,962 513,225 2,045 1933 16,500 548,461 2,145 1934 17,938 619,042 2,360 1935 19,298 652,693 2,525 1936 22,887 707,617 2,625 1937 24,310 755,785 2,773 SOCIAL CONDITIONS. The number of inhabited houses in the District has increased by 10,577 during the course of ten years. This means that the number of occupied premises which have to be inspected in accordance with the administration of Acts delegated to the Health Department has increased by 77 per cent. The rateable value has doubled itself, whilst the sum represented by a penny rate is more than double that of 1928. During 1936, 1,952 houses were erected, and during 1937, 2,230. This makes a total of 4,182 houses built in the course of two years, all of which were erected by private enterprise. EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:— Total Male. Female. Legitimate 1,481 765 716 Illegitimate 42 22 20 Birth-rate—17.46 per 1,000 population. 7 Still Births:— Total. Male. Female. Legitimate 42 20 22 Illegitimate 2 2 0 Rate per 1,000 total births—28.07. Total. Male. Female. Deaths 913 439 474 Death-rate—10.47 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 0.63 From other Puerperal causes 2 1.21 3 1.91 These three cases were removed to the North Middlesex Hospital, Edmonton, where they died. Death-rate of Infants under one year of age: — All infants per 1,000 live births 43.99 Legitimate infants per 1,000 legitimate live births 42.53 Illegitimate infants per 1,000 illegitimate live births 95.21 Deaths from Measles (all ages) Nil Deaths from Whooping Cough (all ages) 2 Deaths from Diarrhoea (under 2 years of age) 11 The following table gives the birth-rate, recorded death-rate and infantile deaths for Enfield as compared with those for England and Wales, London, 125 County Boroughs and Great Towns (including London) and 148 Smaller Towns Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Still England and Wales 14.9 0.60 12.4 58.00 London 13.3 0.54 12,3 60.00 125 County Boroughs and Great Towns (including London) 14.9 0.67 12.5 62.00 148 Smaller Towns 15.3 0.64 11.9 55.00 ENFIELD 17.46 0.50 10.47 43.99 8 DEATHS. The deaths registered in the District during the year were 568, of which 271 were males and 297 females, giving a crude death-rate of 6.51. To this must be added 415 deaths of Enfield residents registered outside the District, and from this total must be subtracted 70 deaths of non-residents occurring in the District, which brings the number of deaths to 913 for the year, giving a net deathrate of 10.47 per 1,000 population. The corresponding figures for Enfield for the five previous years are:— 1932 1933 1934 1935 1936 Net death-rate 10.64 9.83 9.64 9.81 9.82 One hundred and thirteen deaths registered in the District were persons over 80 years of age, 41 being males and 72 females, one man and one woman dying at the age of 99. The more important causes of deaths registered during the year and the previous four years were:— Cause of Death. 1937 1936 1935 1934 1933 Malignant Disease 130 133 118 103 85 Bronchitis 28 34 27 36 26 Heart Disease 242 185 164 176 169 Old Age 15 18 20 13 11 Tuberculosis of Respiratory System 51 60 46 52 36 Pneumonia 62 57 64 52 61 Other Digestive Diseases 17 10 21 17 13 Other Circulatory Diseases 51 35 59 44 36 Nephritis 17 15 13 10 19 Cerebral Haemorrhage 44 37 40 29 37 Deaths from Violence (excluding Suicides) 37 34 30 27 28 Influenza 28 6 11 5 22 Children:- Premature Birth 10 34 22 14 12 Inanition and Marasmus 5 6 5 7 10 Congenital Malformations 6 4 4 4 3 Pneumonia 21 15 12 8 10 Injury at Birth 3 4 3 4 2 Enteritis 8 5 10 1 6 9 It is to be noted that of the 913 deaths that occurred during the year, 415 took place outside the District of Enfield. Of these, 320 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. The figure of 913 deaths assigned to Enfield represents an increase of 108 on last year. There were 22 more deaths from Influenza, 57 more from Heart Disease, 5 more from Pnemuonia, 7 more from Other Digestive Diseases, 16 more from Other Circulatory Diseases, 2 more from Nephritis, 7 more from Cerebral Haemorrhage and 3 more from Violence, whilst amongst the children, there were 2 more deaths from Congenital Malformations, 6 more from Pneumonia and 3 more from Enteritis. 10 TABLE 1. Causes of Death during Year 1937. Causes of Death. Males. Females. Total. All Causes- Certified 439 474 913 Uncertified — — — Typhoid and Para-Typhoid Fevers - — - Measles — — — Scarlet Fever — — — Whooping Cough 1 1 2 Diphtheria 2 2 4 Influenza 16 12 28 Encephalitis Lethargica 1 1 2 Cerebro-Spinal Fever — — — Tuberculosis of Respiratory System 28 23 51 Other Tuberculous Diseases 5 4 9 Syphilis — 1 1 General Paralysis of Insane, Tabes Dorsalis 1 — 1 Cancer, Malignant Disease 56 74 130 Diabetes 4 13 17 Cerebral Haemorrhage, etc. 11 33 44 Heart Disease 109 133 242 Aneurysm 3 1 4 Other Circulatory Diseases 23 28 51 Bronchitis 18 10 28 Pneumonia (all forms) 24 38 62 Other Respiratory Diseases 5 — 5 Peptic Ulcer 8 1 9 Diarrhoea etc. (under 2 years) 5 6 11 Appendicitis — 1 1 Cirrhosis of Liver 1 1 2 Other Diseases of Liver, etc. 2 4 6 Other Digestive Diseases 8 9 17 Acute and Chronic Nephritis 8 9 17 Puerperal Sepsis - 1 1 Other Puerperal Causes — 2 2 Congenital Debility, Premature Birth, Malformations, etc. 21 7 28 Senility 10 5 15 Suicide 9 4 13 Other Violence 23 14 37 Other Defined Diseases 37 36 73 Causes ill-defined or unknown — — — Total 439 474 913 11 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 18 5 4 1 28 13 8 14 4 67 Uncertified - - — - - - — — — — Smallpox - - - - - - - - - - Chickenpox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - — Whooping Cough - - - - - - 1 1 - 2 Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - — Tuberculous Meningitis - - - - - - - 1 - 1 Abdominal Tuberculosis - - - - - - - - - - Other Tuberculosis Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - — 1 - - 1 Convulsions - - - - - - — 1 - 1 Laryngitis - - - - - - - - - - Bronchitis - - - - - 2 - 1 1 4 Pneumonia (all forms) 3 1 1 1 6 4 4 5 2 21 Diarrhoea - - - - - - — — — — Enteritis - - - - - 3 2 3 - 8 Epidemic Diarrhoea - - - - - - - - - - Gastritis - - - - - - - - - - Syphilis — - — - — — — — — — Rickets - - - - - - — — — — Suffocation, overlying - - - - - - - - - - Injury at Birth 2 1 - - 3 - - - - 3 Atelectasis 3 - — - 3 — - - - 3 Congenital Malformation 2 1 2 - 5 1 - - - 6 Premature Birth 7 2 1 - 10 - - - - 10 Atrophy, Debility and Marasmus 1 - - - 1 3 - 1 - 5 Other Causes — — — - — — — 1 1 2 Total 18 5 4 1 28 13 8 14 4 67 Net Births in the year:—Legitimate: Live births, 1,481; Stillbirths, 42. illegitimate: Live births, 42; Still-births, 2. Net Deaths in the year:—Legitimate Infants, 63; Illegitimate,4. 12 Cancer carried off 130 individuals, and Tuberculosis of the Respiratory System 51, a combined number of 181. This compares with a total of 193 for last year, and the percentage of deaths from these two causes is 19.8, as against 23.9 for 1936. INQUESTS. Twenty-six inquests and forty P.M.s without inquests were held in Enfield during the year, and the verdicts were as follows:— Natural Causes 42 Accidental Causes 13 Suicides 9 Misadventure 1 Open Verdict 1 The above table shows that 9 persons committed suicide during the year under review. In 1936 there were 9, and in 1935, 4. The ages and sexes of the 9 people who committed suicide during the year were as follows:— Males 24, 30, 62, 66, 69 and 70 years. Females 19, 38 and 56 years. The causes of death, sex and ages of Enfield residents who committed suicide in or outside the District were as follows: 6 Coal Gas Poisoning Males: Ages 30, 30 and 66. Females: Ages 19, 38 and 56 1 Cut Throat Male: Age 70 years. 1 Poisoned by drinking Prussic Acid Male: Age 69 years. 1 Poisoned by drinking Lysol Male: Age 24 years. 1 Poisoned by drinking San-Izal Male: Age 65 years. 1 Poisoned by taking massive dose of Aspirin Female: Age 22 years. 1 Drowned in a River Male: Age 62 years. 1 Crushing of Chest and Aorta caused by being run over by a Lorry Male: Age 59 years. 13 BIRTHS. The actual number of births registered in the District was as follows:— Boys. Girls. Total. 523 523 1046 including 23 illegitimate births, i.e., 2.19 per cent. of the total. In addition, 8 male (including illegitimate) and 11 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. 1933 537 520 1,057 14.72 .50 1934 571 555 1,126 15.08 .44 1935 628 639 1,267 16.46 .51 1936 709 694 1,403 17.12 .50 1937 809 758 1,567 17.97 .50 INFANTILE DEATHS. The total number of deaths which occurred amongst infants under one year, including 33 registered outside the District, and deducting 3 of non-residents occurring in the District, was 67, giving a death-rate of 43.99 per 1,000 births, as compared with a death-rate of 58.00 for England and Wales, and 62.00 for the 125 County Boroughs and Great Towns (including London). The corresponding figures for Enfield for the last four years were: 1933,50.38; 1934,43.27; 1935,50.00; and 1936, 62.77. It will be noticed that there were 19 fewer deaths of children under one year of age this year than last. The number of deaths of illegitimate children was 4, which gives a death-rate of 95.21 per 1,000 illegitimate infants. 14 PUBLIC HEALTH STAFF. Medical Officer of Health: *D. H. GEFFEN, M.D., D.P.H. Deputy Medical Officer of Health and Assistant School Medical Officer: *A. G. T. THOMAS, M.D., D.P.H. (Resigned 15th Jan., 1937) *W. D. HYDE, M.B., Ch.B., D.P.H. Chief Sanitary Inspector: *FRED WILSON, M.R.San.I., M.S.I.A., Cert. Sanitary Inspector's Examination Board (London); Faudell-Phillips Medallist, King's College, London University; Silver and Bronze Medallist, Carpenters' Company; Diploma of R.San.Inst, for Inspection of Meat and other Foods; Cert. Practical Sanitary Science. Sanitary Inspectors: *NOEL SMITH, A. R. San.I., M.S.I.A. *HARRY WIGGETT, Cert. R.San.I., Diploma of R.San.Inst, for Inspection of Meat and other Foods, M.S.I.A. *A. RAMSDEN, Cert. R.San.I., M.S.I.A., Diploma of R. San.I. for Inspection of Meat and other Foods. *R. JOHNSON, A.R.San.I., Diploma of R.San.I. for Inspection of Meat and other Foods, Cert. of R.San.I. for Smoke Inspectors, Certificate and Diploma of Institute of Hygiene. *G. R. EVANS, Cert.R.San.I. and Sanitary Inspectors Joint Examination Board. Diploma of Royal San.I. for Inspection of Meat and other Foods. M.S.I.A. Instructor C.A.G.S. 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 of the 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 (Deceased 22nd Dec. 1937). Miss C. WILKINSON, C.M.B., New Health Visitor's Certificate of R.San. Inst., State Registered Nurse, Invalid Cookery. Municipal Midwives: Nurse S. BARNES, S.R.N. Nurse G. DEAR, C.M.B. Nurse D. HARRISON, C.M.B. Nurse M. L. MITCHELL, C.M.B. Nurse E. E. WILLIAMS, C.M.B. 15 Chief Clerk SYDNEY COULTER, Cert.R.San.I. 2nd Clerk Miss E. W. BOWYER. Clerk J. HULME. Clerk Miss V. M. SIMMONS (Resigned 21st August 1937) Clerk C. W. CHAPMAN. Clerk Miss D. HILLER. Clerk Miss A. K. MOTTRAM. Clerk Miss W. PAYNTER. Shorthand-Typist Miss N. L. BROWN. Shorthand-Typist Miss K. M. HALLAM. Maternity and Child Welfare: 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.A. (Part-time Dental Surgeon). Mr. H. MACKAY, L.D.S. (St. Andrew's), (Part-time Dental Surgeon). *Contributions received from the County Council. NURSING IN THE HOME. There are two Associations in Enfield which provide nursing for the sick poor of the District, viz.:— The Eastern Enfield District Nursing Association. The Enfield District Nursing Association. A Grant of £25 per annum is made to each of these Associations on condition that— 1. They are prepared to carry out such home nursing as is required for seeing to the health of expectant or nursing mothers, and children under the age of five years who are not being educated in schools recognised by the Board of Education, on a certificate signed by the Medical Officer of Health or by one of the Medical Officers of the Health Department or School Medical Department. 2. The Associations submit their Annual Reports to the Council. 3. The Associations submit such statistics quarterly to the Health Committee of the Council or the Medical Officer of Health, as may be required, including the number of children under five years of age and the number of expectant and nursing 16 mothers who have been nursed, and the conditions for which they have been nursed. 4. The Health Committee of the Council are allowed to nominate one of its members to serve on the Executive Committee of each Association, and that the Medical Officer of Health or one of the Medical Officers of the Health Department or School Medical Department shall be an ex-officio member of the Executive Committee of each Association. There are no permanent arrangements in the District for the domiciliary nursing of cases of infectious disease. 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: 286 patients were removed from Enfield during the year. Three 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 1937, the Ambulances removed 1,808 patients. NATIONAL HEALTH INSURANCE. None of the work of the Authority is related to or administered by this service. LABORATORY FACILITIES. The following work was carried out in the Council's laboratory during the year. Specimen. No. Positive. Negative. Percentage of Positives. Swabs 2,341 239 2,102 10.20 Sputa 289 27 262 9.30 Totals 2,630 266 2,364 10.11 Reference to the laboratory report shows that 2,341 swabs were 17 examined during the year. This number is 930 more than for last year. It will also be noted that the number of sputa examined increased by 50. In addition to this, regular examinations of the water from the Enfield Swimming Pool and the Enfield Lock Baths were carried out during the time these Baths were open. The laboratory is open every day throughout the year, and by every day is meant Christmas, Easter and every Bank Holiday. An attempt is made to see that every General Practitioner in the District receives a report of specimens he has sent in, at about 10 o'clock the next morning after the specimens are received. I consider the laboratory service of the Council to be of the utmost importance and I am satisfied that it is reasonably well-equipped and maintained. The position with regard to Hospitals has not altered since my Report for 1932, and for information in this respect 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 1937. HOSPITALS. 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 1937. Institution. Accommodation. Type of case. Adults. Children. M. F. County Sanatorium, Harefield 150 150 GO Pulmonary—Sanatorium. 4 4 10 Pulmonary—Observation. County Sanatorium, Clare Hall, South Mimms 132 66 — Pulmonary—late sanatorium and Hospital. Victoria Home, Margate — — 6 Non-pulmonary. 18 Other Institutions at which patients have been maintained by the County Council during 1937 are:— SANATORIA.—Brompton Hospital Sanatorium, Frimley; Cotswold, Gloucester; Daneswood, Wodurn Sands; Douglas House, Bournemouth; Eversfield, St. Leonards; Fairlight, Hastings; Grosvenor, Ashford, Kent; Hawthorndene, Bonchurch, I.O.W.; Holy Cross, Haslemere; Ipswich (County Borough); Kelling, Holt, Norfolk; King Edward VII, Midhurst; King George's, Liphook; Marillac, Warley, Essex; Merivale, Sandon, nr. Chelmsford; Mundesley, Norfolk; National, Beneden; Old Manor House, Broadstairs; Pinewood, Wokingham (L.C.C.);, Prior Place, Camberley, Surrey; Royal National, Bournemouth; Royal National, Ventnor; Tehidy (Cornwall C.C.); Winsley,. nr. Bath. HOSPITALS.—Creaton, Northampton; Prince of Wales's, Tottenham; St. Barnabas', Torquay; City of London, Victoria Park, Northern, Winchmore Hill (L.C.C.); Norwood Children's (L.C.C.); St. Peter's, Covent Garden; Brompton; Royal Chest; St. Mary's; St. Thomas's; University College; and the London County Council's general hospitals, Archway; Lambeth, St. George's. 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 All Saints', Eastbourne; 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. Vincent's Orthopaedic, Pinner; St. Luke's, Lowestoft (L.C.C.); Tait Home, Broadstairs; Wingfield Orthopaedic, Oxford; and All Saints', Southwark; Prince of Wales's, Tottenham; St. Mary's and St. Thomas's University College, London. The following Hospitals are for Non-pulmonary child eases Atkinson, Morley, Wimbledon; Heatherwood, Ascot (L.C.C.); Holy Cross, Broadstairs; Holy Cross, Ramsgate; Lord Mivor Treloar Cripples', Alton; Royal, Richmond; Royal National 19 Orthopaedic, London and 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, Tottenham; and All Saints', Southwark, Cheyne, St. Mary's and University College, 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 137 Diphtheria 132 Erysipelas 10 Typhoid and Paratyphoid 1 Cerebro—Spinal Fever 1 Ophthalmia Neonatorum 1 Puerperal Fever 1 Puerperal Pyrexia 2 Dysentery 1 WATER SUPPLY. The District of Enfield is supplied with water by the Metropolitan Water Board, except for part of the Hadley Wood and Cockfosters area, which is supplied by the Barnet District Gas and Water Company. Copies of analyses have been received from both these Authorities, and an assurance that the water is regularly tested. In addition to this, however, there have been discovered in Enfield 99 wells. Of these 58 are used exclusively for agricultural 20 or manufacturing purposes, and 41 in part or wholly for domestic use. Where water is used exclusively for business purposes, manufacturers or owners of nurseries have been asked to exhibit a notice to the effect that the water is not to be used for drinking or domestic purposes. During the course of the year samples of water were taken from 60 wells supplying 71 houses and premises. The water was found to be unsatisfactory in 41 cases; in 15 of these cases the water was being used for drinking purposes. Steps are being taken to close the unsatisfactory wells that are used for drinking purposes, and to obtain a supply of water from the Main. In addition to this an attempt is being made to persuade owners of property whose sole supply of water is derived from wells, to replace that supply, where possible, by a Main Supply even though the well water be satisfactory. Wells in a populous District like Enfield are liable to contamination, for many of them are of the shallow variety. Five important business concerns in the District derive their water for drinking purposes for their staff, as well as for commercial use, from wells; in some cases an attempt is being made to replace these wells by a Mains water supply, and in others to arrange for a continuous chlorination of the supply. STREAMS AND WATER COURSES. Turkey Street Brook and other streams in the District are under the control of the Lee Catchment Board, 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 1937 the cesspools of the District were emptied by a 21 combined cesspool and gulley emptier. During the course of the year, of the 2,230 houses the construction of which was completed, 10 were drained by means of cesspools. There has grown up in the Crews Hill Area a residential district of some 60 houses, all drained by means of cesspools. In some cases the owners empty the cesspools themselves; in others, the cesspools are emptied at somewhat irregular periods by the Health Department on the request of the owners. Generally the position is unsatisfactory, for the cesspools tend to overflow, the ground has become sodden as a result of this overflow, and artificial streams consisting of the effluent from the cesspools have existed in the District. Repeated complaints have been received concerning these conditions, and the Council has now determined to erect a small sewage plant locally to deal with the drainage from the houses in this area. 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 the "washdown" pattern. In the Rural parts of the District the accommodation consists of water-closets connected with cesspools, or earth-closets, or privies with movable receptacles. I am not aware of any middens in the District. Every week one man in the employ of the Council attends some few earth closets in a Rural part of the District. REMOVAL AND DISPOSAL OF HOUSE AND TRADE REFUSE. At the end of the year the Council possessed the following vehicles for the collection and disposal of refuse. 9 "S.D." Freighters. 1 Tuke and Bell Barrier Type Petrol Vehicle. 1 Bedford 2-ton General Purpose 3 way Tipping Lorry. 1 Dennis Refuse Collection 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. 22 In 1936 an agreement was entered into with Messrs. Heath & Sons whereby the Council might dispose of the refuse of the District in Heath's pit, Carterhatch Lane at a fee of 1s. 0d. per load of refuse or covering material brought therein. During 1937 this arrangement remained in force and all the refuse of Enfield was disposed of accordingly at this Pit. In the earlier part of the year some difficulty was experienced owing to the continuous presence of water in the lower levels of the Pit, arising in all probability from local springs. As the lower parts of the field were raised in height this nuisance disappeared and towards the end of the year no refuse was being tipped into water. The Heenen & Froud Separator and Destructor which the Council determined to erect in 1936 was under construction at the end of 1937. It is anticipated that it will commence to operate as from the middle of 1938. 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. SMOKE ABATEMENT. During the course of the year observation has been kept on the chimneys of the District for nuisances 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. The Enfield Lock Baths are situated in Bradley Road, and are enclosed. There is no filtration plant, but the water is changed at least 23 once a week, and during hot weather twice a week, whilst Chlorine is sprayed into the water in the form of Voxsan. The water at each of the Baths in Enfield is tested twice daily by the Superintendents to ascertain the concentration of Chlorine in the water. In addition, samples are taken each week by my Department and examined in the Laboratory for Chlorine content and Alkalinity. During the season samples of the water are sent to the Home Counties Public Health Laboratories where a full chemical and bacteriological examination is carried out. The number of such tests depends on the number of bathers attending the Pool and Baths. I was satisfied that throughout the season the water was pure, wholesome and free from bacterial pollution. In the following table is set out the attendances for the past 5 years, and against these the number of hours of sunshine from the 1st May to the 30th September. Year Number of Bathers Hours of Sunshine Pool Baths 1933 263,284 26,638 1,028.0 1934 162,226 32,215 984.3 1935 149,640 31,129 956.0 1936 97,924 26,007 764.6 1937 97,533 30,617 817.3 The following table shows the extent to which the Slipper Baths both at the Pool and Enfield Lock Baths have been used during the past 5 years. Financial Year Number of Attendances Pool Baths 1933-34 28,967 7,338 1934-35 28,472 6,906 1935-36 27,351 7,037 1936-37 26,007 7.255 1937-38 28,186 7,855 It is pleasing to record the increased use that is being made of the slipper baths both at the Pool and at Enfield Lock Baths. It is indicative of appreciation on the part of the public of the facilities provided, and an increased desire for physical cleanliness. SUBLETTING IN COUNCIL HOUSES. Section 85, sub-section 7 of the Housing Act 1936 lays down that a Housing Authority shall make it a term of every letting that the 24 tenant shall not assign, sublet or otherwise part with the possession of the premises, or any part thereof, except with the consent in writing of the Authority, and shall not give such consent unless it is shewn to their satisfaction that no payment other than a rent which is in their opinion a reasonable rent has been, or is to be, received by the tenant in consideration of the assignment, sub-letting or other transaction. The Housing Committee recommended on the 9th December, 1935— (a) That the Medical Officer of Health be authorised to continue to give consent for sub-letting to tenants of Council houses, where in his opinion it is desirable to do so. (b) That the Council express their opinion that the reasonable rent per room to be received by the tenant in consideration of the sub-letting shall not exceed the amount of the rent and rates divided by the number of rooms in the house (excluding the bathroom) and in the case of the sub-tenant being allowed the part use of a room, e.g., the living room, kitchen or scullery, such use shall be considered as equivalent to half a room for the purpose of calculating the reasonable rent. (c) That, in the case of a lodger boarding with the tenant's family at an inclusive payment for board and lodging, the amount in respect of rent be taken at one-fifth of the total amount paid. The following work was carried out. Total number of applications dealt with 50 Number granted permission to sublet 46 Number refused permission 4 Number of letters sent 198 Number of visits made by Sanitary Inspectors 6 SCHOOLS. There are 21 Public Elementary Schools in Enfield, comprising 43 departments. The Secondary Schools include the Boys' Grammar School, the County School for Girls and the Junior Technical School. In addition there are a number of private establishments. There is also a Roman Catholic Institution known as St. Joseph's Home for Destitute Boys. 25 Periodical examinations of the conditions of the public elementary schools are made by the Sanitary Inspectors, and any defects found are brought to the notice of the Education Committee and Managers. 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 method of discovering cases of infectious disease is important, in that Measles, Whooping Cough, Chicken Pox and Mumps are not notifiable, and the Public Health Department relies upon the list of absentees to discover the extent of an outbreak of such diseases. Number of children notified to be absent from School due to suspected Infectious Disease 683 Number of children found to be suffering from Infectious Disease 410 This compares with the following figures for last year:— Number of children notified to be absent from School due to suspected Infectious Disease 1,304 Number of children found to be suffering from Infectious Disease 848 RAG FLOCK ACTS, 1911 AND 1928. There are three 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. 26 HOUSING. Number of New Houses erected during the year:— (a) Total (including numbers given separately under (b)) 2,230 (i) By the Local Authority — (ii) By other Local Authorities - (iii) By other bodies or persons 2,230 (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 2,229 12,665 (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 285 3,214 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 5 (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 (The number here given is of houses where any insanitary conditions were found.) 808 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 547 3. Action under Statutory Powers. A.—Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling-houses in respect of which Notices were served requiring repairs 7 27 (2) Number of dwelling-houses which were rendered fit after service of formal Notices:— (a) By owners 25 (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 27 (2) Number of dwelling-houses in which defects were remedied after service of formal Notices:— (a) By Owners 19 (b) By Local Authority in default of Owners None. C.—Proceedings under Sections 11 and 13 of the Housing Act, 1936:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 41 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 15 D.—Proceedings under Section 12 of the Housing Act, 1936:— (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 285 Apart from the Do. 7 Total 292 28 During the course of 1937 I represented 39 houses as unfit for human habitation. Demolition Orders were made in respect of all these houses. In addition 3 houses were demolished as a result of informal action by the Health Department. Since the passing of the Housing Act, 1930, 119 houses have been demolished either by official action under the appropriate sections of the Housing Acts, or by arrangements with owners. GENERAL OBSERVATIONS. The Council now possesses 1,746 houses, a figure which has increased by 6 in the last three years. Land has been acquired for the erection of further houses, but so far has not been utilised for this purpose. HOUSING SURVEY HOUSING ACT, 1935. In accordance with the Housing Act, 1935, a survey of the District was made to ascertain the extent of overcrowding in the District. As a result thereof it was found that the overcrowding in Enfield was as follows:— Houses Overcrowded to the extent of Total ½ 1 1½ 2 2½ 3 3½ 4 4½ 5 5½ Units Council 36 36 23 9 3 1 2 - - - - 110 Non-Council 83 57 38 28 11 7 3 1 2 — 1 231 Totals 119 93 61 37 14 8 5 1 2 - 1 341 During the course of 1936 attempts were made to abate overcrowding by means of the granting of Council houses and transfers' At the end of 1936 the conditions had improved so that there were overcrowded in Enfield:— 120 Council Houses 179 Non-Council Houses At the end of 1937, the extent of overcrowding was as follows:— Council Houses—50 Non-Council Houses—89. It will be seen, therefore, that the number of over-crowded 29 houses in Enfield has decreased, to the best of our knowledge, by 202 in two years. It must be remembered that on January 1st, 1937, over-crowding became a statutory offence, and by that time it had become compulsory for every landlord to insert in his rent book or similar document the number of persons allowed to occupy any particular premises. At the end of 1937 some 16,000 to 17,000 houses had been measured in order that landlords might place this information in their rent books. The total effect of this is that overcrowding is being lessened by children marrying and leaving home, by families moving from overcrowded premises and by the general increase in the number of houses in the District and new overcrowding only occurs on account of increase in the size of the family and age of children; property becoming vacant can not be let so as to cause immediate overcrowding. The amount of overcrowding in Enfield is therefore falling, and should ultimately disappear. The cases that cause the biggest difficulties are those where the tenants have limited means and a large number of children. During the course of the year the services of an Inspector were employed to measure rooms for the purpose of ascertaining the permitted number of persons in premises in the District, and to make a general survey to see that all rent books contained the information which is enforced by the Housing Act, 1936. Throughout 1937 an attempt was made by means of transfers to abate overcrowding, and at the end of the year the position was as follows:— (a) (i) Number of dwellings overcrowded at the end of the year 139 (ii) Number of families dwelling therein 139 (iii) Number of persons dwelling therein 1,011 (b) (i) Number of new cases of overcrowding reported during the year 54 (ii) Number of persons concerned in such cases 293½ (c) (i) Number of cases of overcrowding relieved during the year 214 (ii) Number of persons concerned in such cases 1,358 30 (d) Particulars of any cases in which dwelling-houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding 1 (This overcrowding was immediately abated) (e) Any other particulars with respect to overcrowding conditions upon which the Medical Officer of Health may consider it desirable to report. The abatement of overcrowding was effected as follows:— Council Houses— By removal 47 By marriage of children, or girls going into domestic service and sons in Armed Forces 28 By death 1 Total 76 On the other hand, 6 Council houses have become overcrowded through increase in family, increase in ages of children, or other causes. Non-Council Houses— By removal 72 By marriage of children, or girls going into domestic service and sons in Armed Forces 62 By deaths 4 Total 138 On the other hand, 48 fresh cases of overcrowding have arisen due to increase in size of families, children attaining adult age, or other causes. HOUSING CONDITIONS. The standard of housing in Enfield tends to improve year by year. As a result of action by the Council houses that are unfit for human habitation are either demolished, or rendered fit. In addition there has been a tendency for landlords to pull down poor class property and erect more modern premises in their places. This is due in part to the fact that they have realised that where land values are high it is uneconomical to possess slum property. 31 In addition, there have been built in Enfield in the last year over 2,000 houses subject to the restrictions of modern building bye-laws. FITNESS OF HOUSES. No special measures were taken or suggested for the gradual carrying out of programmes of repair. 1 should estimate that about 44 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. A considerable amount of work was carried out in connection with moveable dwellings in order to put into force the provisions of the Middlesex County Council Act, 1934. 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 1937, thirty-nine 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 animal responsible. Eight cows were reported by owners as suspected to be 32 ing from tuberculosis. On examination, three 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; 2,598 inspections of bovine animals were made in Enfield; eight cows were found to be suffering from tuberculosis as defined in the Tuberculosis Order, 1925, and were slaughtered. THE MILK (SPECIAL DESIGNATIONS) ORDER, 1936. The inspection of premises where Graded Milk is sold has been carried out as heretofore. There are 27 Purveyors of Milk who sell or distribute Pasteurised Milk in the District. During the course of the year 18 samples were taken of this milk, either at the place of pasteurisation or in the course of delivery. These samples all complied with the Regulations prescribed in connection with Pasteurised 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 The number of slaughter-houses in the District at the date Specified is as follows:— 1914 January. 1937 December. 1937 Registered 10 6 6 Licensed 7 4 4 Total 17 10 10 Mr. Fred Wilson, Chief Sanitary Inspector; Mr. H. Wiggett, Mr. A. Ramsden, Mr. R. Johnson and Mr. G. R. Evans, 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. They paid 989 visits during the year, when they examined 9,555 carcases, securing the surrender of 10 carcases and 171 parcels of diseased organs. SLAUGHTER-HOUSES. The inspection of slaughter-houses 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. 33 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 slaughter-house. 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, which were granted. In addition, 20 applications for renewal of Licences were received, and all these were granted. PUBLIC HEALTH (MEAT) REGULATIONS, 1925. Systematic inspection of all butchers' shops and other premises for the sale of meat and offal was carried out during the year. With few exceptions, it was found that the Regulations were obeyed. BAKEHOUSES. There are 31 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 administered by the Middlesex County Council. The following report thereon has been supplied by R. Robinson, Esq., Chief Officer of the Public Control Department. URBAN DISTRICT OF ENFIELD. List of samples purchased during the year ended 31st December. 1937: Article Taken Adulterated Milk 264 9 Milk, new 20 5 Cream 1 - Butter 2 - Gin 5 2 Whisky 29 3 Cakes 1 — Sheep's Liver 8 3 Sausages 2 — Vinegar 5 3 337 25 No. of Prosecutions 9 No. of Convictions 7 34 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. The number of cases of Scarlet Fever was 161, compared with 213 in 1936 : of Diphtheria 132, as compared with 68; of Pulmonary Tuberculosis 99, as compared with 80; and of Pneumonia 50, as compared with 58. The same methods of control were used as in previous years, except that the number of immunisations against Diphtheria was considerably increased, as is shown on pages 36-37 of this Report. Four children died of Diphtheria during the year, as compared with no deaths in 1936. The following table shows the number of cases of Scarlet Fever, Diphtheria, Pulmonary Tuberculosis and Pneumonia notified during each of the past 5 years :— The following table shows the number of cases of Scarlet Fever, Diphtheria, Pulmonary Tuberculosis and Pneumonia notified during each of the past 5 years:— Disease 1937 1936 1935 1934 1933 Scarlet Fever 161 213 229 252 249 Diphtheria 132 68 77 37 45 Pulmonary Tuberculosis 99 80 83 77 67 Pneumonia 50 58 34 48 80 PUBLIC HEALTH (SMALLPOX) PREVENTION REGULATIONS, 1917. No primary vaccinations or re-vaccinations were done by me during the year. NOTIFIABLE DISEASES DURING THE YEAR 1937. The following table shows the cases of infectious diseases notified during the year, and the number of deaths that occurred. 35 TABLE III.—Cases of Infectious Diseases notified during the year 1937. Notifiable Disease. Number of Cases Notified. Total cases removed to Hospital. Deaths. At Ages—Years. At Ages—Years. At all ages. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Totals. Smallpox - - - - - - - - - - - - - - - - - - Cholera—Plague - - - - - - - - - - - - - - - - - - Diphtheria (inc. Membranous Croup) 132 2 31 88 5 5 - 1 132 - 1 1 2 - - - - 4 Diphtheria Carriers 4 - - - - - - - - - - - - - - - - - Erysipelas 26 - 1 - - 10 11 4 10 - - - - - - - - - Scarlet Fever 161 - 29 107 15 9 1 - 137 - - - - - - - - - Typhus Fever - - - - - - - - - - - - - - - - - - Typhoid Fever 2 - 1 - - 1 - - 1 - - - - - - - - - Paratyphoid Fever 1 - 1 - - - - - - - - - - - - - - - Relapsing Fever - - - - - - - - - - - - - - - - - - Continued Fever Puerperal Fever 3 - - - 1 2 - - 1 - - - - - 1 - - 1 Puerperal Pyrexia 7 - - - 3 4 - - 2 - - - - - - - - - Cerebro-spinal Meningitis 1 - - - 1 - - - 1 - - - - - - - - - Poliomyelitis - - - - - - - - - - - - - - - - - - Ophthalmia Neonatorum 5 5 - - - - - - 1 - - - - - - - - - Pulmonary Tuberculosis 99 - 1 4 23 45 21 5 - - - - 1 8 23 18 1 51 Other forms of Tuberculosis 30 1 4 13 4 5 2 1 - 1 - - 5 - 2 - 1 9 Encephalitis Lethargica 2 — — — — 1 1 — - - - - — — — 2 - 2 Malaria - - - - - - - - - - - - - - - - - - Pneumonia 50 1 6 16 3 16 6 2 - 17 3 3 1 2 3 13 20 62 Dysentery 113 6 23 44 11 9 12 8 1 - - - - - - - - - Totals 636 15 97 275 66 108 54 21 286 18 4 4 9 10 29 33 22 129 36 SCARLET FEVER One-hundred-and-sixty-one cases of Scarlet Fever occurred during the year in 139 houses, as follows:— Number of houses where 1 case occurred 124 Number of houses where 2 cases occurred 9 Number of houses where 3 cases occurred 5 Number of houses (War Memorial Hospital) where 4 cases occurred 1 Total number of houses where cases occurred 139 Total number of cases 161 Deaths Nil DIPHTHERIA. One-hundred-and-thirty-two cases of this disease occurred during the year in 104 houses, as follows:— Number of houses where 1 case occurred 85 Number of houses where 2 cases occurred 15 Number of houses where 3 cases occurred 2 Number of houses where 4 cases occurred 1 Number of houses (War Memorial Hospital) where 7 cases occurred 1 Total number of houses where cases occurred 104 Total number of cases 132 Deaths 4 DIPHTHERIA CARRIERS. Four cases of this disease occurred during the year in 4 houses. 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. Immunisation is carried out either by the Medical Officers of the Health Department, or the General Practitioners of the district, to whom the necessary materials for immunisation are issued subject to their providing me with information as to the children who are immunised. The re-agent used is T.A.F. (Toxoid Antitoxin Floccules). 37 This is considered to give the least re-action and the best results. It can be used for adults and children alike. Through the services of the Council 369 individuals were immunised during 1937. Since 1935, 957 individuals have been immunised. This is a ery small number as compared to the population of Enfield. It is roughly about one per cent. In the event of an epidemic those who have been immunised would be protected, but the number is insufficient to stay an epidemic or minimise the result of one. In addition to the number quoted above it is probable that many Enfield residents have been immunised by their General Practitioner without recourse to the services of the Enfield Council for the provision of T.A.F. and these persons are not included in the numbers quoted above. TYPHOID AND PARATYPHOID FEVER. Two cases of Typhoid Fever and one case of Paratyphoid Fever were notified during the year. There were no deaths during the year. DYSENTERY. One-hundred-and-thirteen cases of this disease were notified during the year. The cases occurred in ninety-seven houses, and none of the cases proved fatal. POLIOMYELITIS. No cases ot this disease were notified during the year. CEREBRO-SPINAL FEVER. One case of this disease was notified during the year. ENCEPHALITIS LETHARGICA. Two cases of this disease were notified during the year and there were two deaths. 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. 38 Some idea of the extent of these diseases can be obtained, however, by the fact that 43 cases of Measles and no cases of German Measles were excluded from the schools during the year. These figures compare with 369 cases of Measles and 9 cases of German -Measles for last year. ENTERITIS. Eleven deaths of children under two years of age occurred from this disease during the year. Of this number eight were of children under one year of age. None of these deaths occurred in children under the age of one month. ZYMOTIC DISEASES. The following table shows the deaths registered in the District from the seven chief zymotic diseases during the past five years :—• Disease. 1933 1934 1935 1936 1937 Small Pox - - - - - *Scarlet Fever 3 1 1 2 1 *Diphtheria 6 2 6 2 8 *Measles — 7 — 8 — *Enteric Fever — — 5 1 1 *Whooping Cough 4 1 1 4 3 Epidemic Enteritis - - - - - Totals 13 1 1 13 17 13 *The actual Enfield deaths were: Diphtheria, 4; Scarlet Fever, 0; Whooping Cough, 2; Measles, 0; and Enteric Fever, 0. 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, is 0.06 per 1,000 population. 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, is 0.06 per 1,000 population. 39 Disease. 1936 1937 Deaths. Death-rate Deaths. Death-rate Scarlet Fever 1 .01 - - Diphtheria — — 4 .04 Enteric Fever 1 .01 — — Small Pox — — — — Measles 5 .05 — — Whooping Cough 3 .03 2 .02 Epidemic Enteritis — — — — Totals 10 .10 6 .06 PREVENTION OF BLINDNESS. No action was taken during the year under Section 66 of the Public Health Amendment Act, 1925, for the prevention of blindness or for the treatment of persons suffering from any disease or injury to the eyes OPHTHALMIA NEONATORUM. Cases. Vision Unimpaired Vision impaired Total Blindness Deaths Notified Treated. At home. In Hospital. 5 4 1 5 — — — Ophthalmia Neonatorum is notifiable by a General Practitioner to the Medical Officer of Health. Where the case is attended by a midwife it is her duty to notify the Local Supervising Authority and to call in a Doctor. Since the 1st April of this year Enfield has been the Local Supervising Authority and has therefore received double notification as to these conditions which may be very serious. The home is visited and steps taken to see that the child receives adequate treatment, if necessary in an institution. By arrangement with the Enfield and Edmonton Joint Hospital Board babies suffering from Ophthalmia Neonatorum may be admitted, if necessary with their mothers to the Isolation Hospital for treatment. 40 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 10 1 20 2 — 1 Chase 18 2 46 8 — 2 Ordnance 38 3 47 12 1 — Green Street and Ponders End 23 2 33 5 - 1 Bush Hill Park 9 1 18 1 — 1 Hadley and Cockfosters 1 - 1 2 — — Totals 99 9 165 30 1 5 First Notifications, including transfer restoration to Register and Death Return notifications 129 Old Cases re-notified, i.e., some by fresh doctors 10 Duplicate Notifications, i.e., those which report the entering and leaving of Sanatoria 170 Total Notifications 309 The following table gives particulars of the ages of the new cases notified, and deaths from this disease during the year:— Age Periods. New Cases. Deaths. Respiratory. NonRespiratory Respiratory. NonRespiratory. M. F. M. F. M. F. M. F. Under 1 - - - 1 - - - 1 1 to 5 1 — 2 2 — — — — 5 to 10 — 3 4 4 — — 3 — 10 to 15 1 — 3 2 — 1 1 1 15 to 20 — 5 — — 1 — — — 20 to 25 8 10 3 1 3 4 — — 25 to 35 15 15 2 2 5 9 — 1 35 to 45 10 5 1 — 7 2 1 — 45 to 55 6 3 2 — 5 3 — — 55 to 65 6 4 — — 7 3 — — 65 and upwards 2 3 — 1 — 1 — 1 Totals 49 50 17 13 28 23 5 4 4! SEX (1st NOTIFICATIONS). Form. Males. Females. Pulmonary 49 50 Other 17 13 Totals 66 63 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 10 7 2 1 Chase 18 13 8 2 Ordnance 38 10 12 5 Green Street and Ponders End 23 12 5 1 Bush Hill Park 9 9 1 — Hadley and Cockfosters 1 — 2 — Totals 99 51 30 9 Eleven 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 129 first notifications received during the year, 72 were in persons between 20 and 45 years of age, and of the 60 deaths, 32 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. 42 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. SUPPLY OF INSULIN. In November, 1935, permission was received from the Minister of Health to supply Insulin to the poorer inhabitants of the District. During the course of the year the child who was under treatment in 1935 continued to receive Insulin at the expense of the Council. 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. ERADICATION OF BED BUGS. (1) Number of Council houses found to be infested 80 Number of Council houses disinfested 80 Number of other houses found to be infested 64 Number of other houses disinfested 64 (2) The methods employed for freeing infested houses from bed bugs. Only one substance was used extensively during the course of 1937, viz., Heavy Naphtha: it was found to be adequate and put into routine use by the Health Department. Pyagra was used on some occasions in dealing with occupied premises where signs of localised infestation only were present. The Council will be aware that a sum of £100 was allowed me in March in order that I should carry out experiments with Heavy Naptha. This sum was expended (i) in the modification of one of the disinfecting vans for use in the disinfestation of furniture, etc., and (ii) in experiments in Council houses for the eradication of bed bugs. I am satisfied that our experiments have been successful. Until Heavy Naphtha was used it was essential to strip many 43 houses of woodwork before disinfestation could be carried out. It is possible that a sum of between £5 and £8 was expended per house, apart from disinfestation as such, in removing this woodwork, replacing it, and making good the damage caused thereby. In that Heavy Naphtha was used throughout 1937, no such expenditure was incurred, with a saving of some hundreds of pounds. The van has been demonstrated before the Society of Medical Officers of Health, and Deputations from several Local Authorities have been received in order that the Enfield method of disinfestation could be examined and adopted elsewhere. Enfield has specialised on a simplified, but nevertheless thorough, technique. The procedure in respect of empty Council houses is as follows. Every Council house, on becoming empty, is inspected by my Department to see if vermin are present, or the evidence thereof. In some cases sulphur is used as a detector for it tends to bring the bed bug from its hiding place into the open. Of the 216 houses thus inspected during the year, suspicions that infestation might be present warranted the disinfestation of 80 houses, a percentage of 37. Of these 80 houses, 78 were treated with Heavy Naphtha. I would not like to argue that as a result thereof one could assume that this percentage represents a fair idea of infestation of Council houses throughout the District. In the first place it is possible that some houses were disinfested although they were not verminous; this figure, however, is extremely low as in practically every case dead bugs were found in the house after the use of Heavy Naphtha. On the other hand it must be remembered that some of the houses are empty because their occupants have failed to pay rent, and these may be considered the more feckless tenants of the Council, and those more likely to allow their houses to become infested. It was the practice during the year to use Heavy Naphtha and if dead bugs were found, to use it a second time or a third time until no dead bugs were found. In this way we could be reasonably certain that a house had been completely disinfested. It may be assumed, therefore, that houses in which Heavy Naphtha was used once or twice were really successfully disinfested in one process, and those disinfested three times in two processes. The following table shews the position in this respect. Council Houses Non-Council Houses Treated once 31 3 Treated twics 37 - Treated three times 9 — Treated four times 1 — During 1936, four houses were disinfested by means of Heavy 44 Naphtha. In 1937 we did not receive a complaint from these houses that evidence of infestation was present. The procedure in the use of Heavy Naptha is easy. The rooms, having been draped with tennis cloth, are brought up to as high a temperature as possible by the use of Primus stoves and partially sealed; the Primus stoves are removed, and the rooms sprayed. A similar procedure, except that blankets instead of tennis cloth are used, is adopted for the loft. The rooms and house are sealed and left for twenty-four hours. In badly infested houses I have seen the floors of bedrooms so fully covered by dead bugs on opening next morning, that it has been practically impossible to walk in the room without treading on them. Whilst I am not prepared to say that this method is 100 per cent satisfactory, I would state that in my opinion it is the best and safest method that has so far been discovered. The van has been used on a few occasions during the year and has always proved satisfactory. The Council owes a debt of gratitude to Mr. A. E. McKenny Hughes, D.I.C., F.R.E.S., of the British Museum (Natural History) and Mr. S. A. Ashmore, B.Sc., A.I.C., of the Government Laboratory for their help throughout the year in perfecting the technique adopted in Enfield, and for their skilled and technical advice. I would add that there are one or two refinements in the technique which have been considered by my Department. The results we have achieved have not warranted the adoption of these refinements so far. A small charge is made by the Council where disinfestation of empty Non-Council houses is carried out for the owners. (3) The methods employed for ensuring that the belongings of tenants are free from vermin before removal to Council houses. No routine has yet been adopted in this connection. In a few cases the belongings have been disinfested in the Heavy Naphtha van. (4) Whether the work of disinfestation is carried out by the Local Authority or by a contractor. The work of disinfestation is carried out by the Local Authority. (5) The measures taken by way of supervision or education of tenants to prevent infestation or re-infestation after cleansing. Nil except for such educational work in this respect as is carried out by the District Sanitary Inspectors and Health Visitors. 45 METEOROLOGY. The following instruments are installed at the Public Offices :Standard Fortin Barometer. Maximum Thermometer In a Stevenson's screen in Minimum Thermometer grounds of the Public Offices. Standard Hygrometer Terrestrial Radiation Thermometer In the grounds of Earth Thermometer the Offices. Campbell-Stokes Sunshine Recorder On the roof of the Rain Gauge Public Offices. Daily records have been taken, and monthly returns sent to the Meteorological Office. The accompanying table gives the result of our operations for the year in a condensed form. METEOROLOGICAL STATISTICS, 1937. Month. Barometer. Temperatures. Rainfall. Millimetres. Sunshine hours. Thunderstorms. Fogs on days. Frosts on days. Snowfalls. Prevailing. Winds. Highest. Lowest. Earth. Means. Lowest Grass. Min. Highest Maximum. Lowest Means of Minimum. Latter. Jan. 30.600 on 8th 28.930 on 18th 44.1° 26° on 30th 54 ° on 6th 28° on 41° 29th & 30th 89.6 3.53 inches. 28.2 — 4 9 2 S.W. Feb. 30.112 on 15 th 28.787 on 28th 44.3° 26° on 12 th 56° on 15 th 31° on 38° 12th & 28th 98.2 4.02 inches. 62.2 — 2 10 3 S.W. & w.s.w. Mar. 30.402 on 30th 28.891 on 14th 42.2° 21 ° on 10th 56° on 20th 25° on 10 th 40° 55.5 2.41 inches. 99.4 1 3 16 8 N.E. April 30.476 on 29th & 30 th 29.324 on 20th 46.2° 27° on 1st 62° on 27th 31° on 1st 48° 68.9 2.72 inches. 87.4 2 3 1 — N. & N.E. May 30.370 on 1st 29.553 on 21st 51.1° 31° on 9th 82° on 25th & 29th 40° on 58° 6th 75.6 3.25 inches. 160.4 3 — — — W. & S.W. June 30.286 on 16th 29.795 on 29th 57.1° 40° on 3rd . 82° on 6th, 7th & 11th 44° on 3rd 60° 46.9 1.92 inches. 200.8 4 — —' — N.W. July 30.239 on 17th 29.594 on 15th 53.5° 45° on 8th & 11 th 85 ° on 3rd 49° on 64° 11th & 30th 17.0 0.76 inches. 123.5 2 — — — S.W. Aug. 30.350 on 27th 29.696 on 17th 53.5° 42° on 13 th Broken 49° on 16th Broken & 23rd 47.4 2.03 inches. 180.7 3 — — — N.W. Sept. 30.266 on 8th 29.183 on 17th 46.3° 37° on 21st Broken 40° on Broken 21st 42.5 1.72 inches. 151.9 1 2 — — S.W. Oct. 30.546 on 17th 28.781 on 23rd 44.0° 35° on 16th & 18th 66° on 1st & 2nd 37° on 51° 18th & 19th 52.2 2.12 inches. 70.8 1 5 — — N. Nov. 30.560 on 28th 29.284 on 19 th 49.7° 22° on 21st 54 0 on 2nd 23° on 41° 21st 36.8 1.42 inches. 57.7 — 10 10 — N.E. Dec. 30.714 on 27th 29.020 on 13th 43.8° 23° on 19th & 20th 53° on 22nd & 23rd 24° on 37° 20th 83.3 3.33 inches. 14.8 — 8 11 5 N.W. Totals 713.9 29.23 inches. 1237.8 hrs. 17 37 57 18 MATERNITY and CHILD WELFARE SECTION 48 MEMBERS OF THE MATERNITY AND CHILD WELFARE COMMITTEE, 1937-1938. Chairman . . H. A. DESHBOROUGH BROWN, Esq. Councillors BENNETT, GREENWOOD, MORRIS, KEMP, MUSPRATT, ROWLANDSON, CAKEBREAD and THOMPSON ; also Co-optative Members :-Miss G. M. FORD, Mrs. H. HAMMERTON, Mrs. A. E. HEATH and Mrs. M. HOWARD. MATERNITY AND CHILD WELFARE STAFF. Medical Officer of Health and Maternity and Child Welfare OfficerDENNIS H. GEFFEN, M.D., D.P.H. Assistant Part-time Medical Officers and Specialists- Dr. C. J. THOMSON, M.B., M.D., D.P.H. *Dr. T. THOMAS, M.D., D.P.H., (Resigned 15.1.37). *Dr. W. D. HYDE, M.D., D.P.H. †Mr. C. E. JAMES, L.D.S. (Eng.), R.C.S. (Dental Surgeon). †Mr. H. MACKAY, L.D.S. (St. Andrews). ††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. (Deceased 22nd December, 1937). Miss C. WILKINSON, S.R.N., C.M.B., New H.V's. Cert. Municipal Midwives— Nurse S. BARNES, S.R.N., C.M.B. Nurse G. DEAR, C.M.B. Nurse D. HARRISON, C.M.P. Nurse M. L. MITCHELL, C.M.B. Nurse E. E. WILLIAMS, C.M.B. * 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. 49 Public Offices, Enfield. 17th April, 1938. To the Chairman and Members of the Urban District Council of Enfield. Mr. Chairman and Gentlemen, I beg to place before you my report on the Maternity and Child Welfare services of Enfield for the year 1937. That these services are appreciated by the public is evidenced by the fact that over 3,000 more attendances were made this year than last, whilst looking back over a period of 10 years, I find that in 1928 the total attendances at all our Clinics amounted to 22,531, and in 1937 they were 36,828. At our Ante-natal Clinics alone 200 more mothers received advice this year than in 1936. There are in Enfield approximately 7,000 children under the age of five years and nearly half of them attend at our Clinics. These figures shew the extent to which the Council's Maternity and Child Welfare service caters for the population. It cannot be held that the popularity of the Council's Clinics is in proportion to the gifts in kind that can be obtained there, for in actual fact the amount of milk and dried food given free by the Council last year diminished by 1,000 gallons and 50 lbs. respectively. Ninteen thirty-seven was an important year from the point of view of Maternity and Child Welfare. In the first place the Council applied to the Minister of Health to be made the Local Supervising Authority under the Midwives Acts and consent was obtained from the Minister as from the 1st April, 1937. This was important in that it meant not only the supervision of the midwives of the district by the Enfield Council but also that the duty devolved on the Council of preparing and putting into force a municipal midwifery scheme for the district. In the second place application was made to the Middlesex County Council that the Enfield District Council have transferred to it the County's powers in connection with the registration of nursing homes in Enfield. Such transfer also took place as from April 1st, J937- There are only 7 Local Supervising Authorities in Middlesex of which Enfield is one ; there are only 6 Authorities that are both Supervising Authorities and Local Education Authorities, and again Enfield is one. The preparation of a scheme in connection with the Midwives 50 Act 1936 was referred to a special Sub-Committee. After consulting the Enfield Medico-Ethical Society, as representing medical opinion in Enfield, and meeting all the Midwives who had intimated their intention to practice within the district, the Sub-Committee made the following resolutions. 1. That nine midwives be employed of whom five shall be appointed at the commencement of the application of the scheme to the district, and four as and when required; that these appointments be made by the Chairman of the Maternity and Child Welfare Committee and the Medical Officer of Health. 2. That the Medical. Officer of Health be empowered in an emergency to obtain the services of a private midwife for any specific cases at such a fee as he may find necessary, or obtain temporary help by employing a midwife for such time as may be required at a salary not exceeding £6 6s. od. per week inclusive. 3. That Midwives who are also State Registered Nurses be paid a salary of £215 per annum rising by annual increments of j£io to a maximum of £305 per annum, and midwives who are not State Registered £180 per annum rising by annual increments of £10 to a maximum of £250 per annum. 4. That future appointments shall, as far as possible, be given to State Registered Nurses only. 5. That the Medical Officer of Health be empowered to appoint one of the municipal midwives as a senior midwife and another as a deputy senior midwife, the scale of salary to be increased by the sum of £20 and £10 per annum respectively. Their duties shall include the responsibility for arranging that midwives are always available to attend any case during the day or night. 6. That each midwife be required to be connected to the Telephone system and that in addition to the salaries allowances shall be made as follows :- Telephone Rental plus 200 calls Uniform and laundry £15 per annum Provision and maintenance of cycle or travelling £3 10s. od. per annum Drugs to be provided through the Health Department. 7. That each midwife shall be required to reside in such area as may be approved by the Medical Officer of Health. 8. That each midwife shall be required to attend an average of 70 cases (midwifery or maternity) per annum. 9. That each midwife shall be allowed three weeks annual 51 holiday, to be taken at such time as may be determined by the Medical Officer of Health, and in addition one week-end off duty every month and one day every fortnight, and such other off-duty time as shall be authorised by the Medical Officer of Health, the period of week-end off duty to be from 6 p.m. Friday night until 10 p.m. on Sunday night. 10. That each midwife shall be required to carry out such maternity and child welfare work as shall be required by the Medical Officer of Health. 11. That no municipal midwife shall accept a gratuity from the patient or relative thereof. 12. That each midwife shall be required to enter into an agreement not to practice in the district for a period of five years after retirement. 13. That marriage shall not be a bar to appointment nor shall there be a fixed age limit at the commencement of the scheme . 14. That the post of midwife be designated as an established post under the Local Government and Other Officers' Superannuation Act, 1922. 15. That appointments shall be made as far as possible from those midwives practising in the area and preference given to those who have the largest practice. 16. That as free a choice of midwife as possible shall be given to applicants who desire to engage a municipal midwife. 17. That the charge for the services of a midwife shall be £2 os. od. for a primipara and £1 10s. od. for a multipara. The Committee determined that in cases of necessity midwives should be supplied at a reduced cost to the applicant, and adopted a scale in connection therewith. These proposals were approved and adopted by the Council and submitted to the Minister of Health. Enfield commenced its Municipal Midwifery Scheme as from the 15th November, 1937. The Council now provides a reasonably complete service for the ante-natal and nursing mothers of Enfield. Through this service it provides a midwife ; pays for a doctor should medical help be required during or after the confinement ; arranges for a Specialist to attend if in the opinion of the general practitioner this be necessary, and an emergency service for the treatment in their homes of those women who may be unfit to be removed to hospital. In addition to this, the ante-natal clinics provide continuous advice and such treatment as should tend to avoid complicated confinements. There is provision for the supply of milk and other 52 nutritive substances calculated to secure that the diet of the ante-natal and nursing mother contains adequate protective elements, also dental treatment, ophthalmic treatment and aural treatment. All this should tend to improve, not only the health of the expectant and nursing mother, but the chances of the physical and mental well-being of the expected child. There is as yet no maternity hospital in Enfield and women who require institutional confinements are admitted in-so-far as beds are available, to the North Middlesex County Hospital. By co-operation with the County Medical Department arrangements have been made whereby expectant mothers attend regularly at the Enfield ante-natal clinics, and are thus saved the journey to the North Middlesex County Hospital until such time as they are ready to be admitted. By co-operation between the Health Department and the Superintendent of the North Middlesex County Hospital information concerning the condition of patients is passed from the one body to the other. This scheme is working satisfactorily. It is impossible at this stage to say what will be the effect of the Council's scheme for the provision of municipal midwives to those who require them, for the scheme had only been in operation about six weeks when the year closed. It would appear, however, that the scheme is likely to be popular and work satisfactorily. I feel sure that the Maternity and Child Welfare Committee would wish me to express thanks to the Voluntary Helpers who have attended regularly throughout the year at our clinics and rendered such excellent help. Many of them have served the Council in a voluntary capacity for very many years and must now be seeing the babies of mothers whom they put on the scales and weighed some years ago. I know that the success of the work is the truest thanks our Voluntary Helpers can expect, and that these words of appreciation are little compared to the happiness of the mothers and children who are attending our centres. I regret to have to record the death during the year of Mrs. Herbert who had been a Health Visitor in Enfield for the past seven years. Mrs. Herbert will be kindly remembered for many years to come by the numerous mothers and children whom she helped and to whom she was a friend. During the years she served the Council she displayed the enthusiasm and zeal that can only come from those who look upon their service to a local authority as a mission. In ending this report I would express my thanks to the Maternity and Child Welfare Committee for its courtesy throughout the year and to the professional and clerical members of my staff for their loyal co-operation. I am, Mr. Chairman and Gentlemen, Your obedient servant, DENNIS H. GEFFEN, Medical Officer of Health. 53 MATERNITY AND CHILD WELFARE CLINICS UNDER THE CONTROL OF THE LOCAL AUTHORITY. District. Situation 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. Stephen's Road, Enfield Wash Monday and Wednesday afternoons, 2 to 5 p.m. Ante-Natal Clinics :— Ponders End School Clinic, Southbury Road, Ponders End 1st, 2nd and 4th Friday in each month, 9 30 to 11.30 a.m. Bush Hill Park Lincoln Road, Bush Hill Park 1st, 2nd and 4th Wednesday in each month 9.30 a.m. to 12 noon. Town and Chase. Rosemary Avenue, Enfield 1st, 2nd & 4th Tuesday in each month, 9.30 to 11.30 a.m. Ordnance Dental Clinic :- St. Stephen's Road, Enfield Wash 1st, 2nd and 4th Thursday in each month. 9.30 to 11.30 a.m. 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 bv the Council. 54 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:- Total Male. Female. Legitimate 1,481 765 716 Illegitimate 42 22 20 Birth-rate-17.46 per 1,000 population. Still Births:-Total. Male. Female. Legitimate 42 20 22 Illegitimate 2 2 0 Rate per 1,000 total births-28.07. Total. Male. Female. Deaths 913 439 474 Death-rate-10.47 per 1,000 population. Number of women dying in, or in consequence of, childbirth :- Rate per 1,000 Deaths. Total Births. From Puerperal Sepsis 1 0.63 From other Puerperal causes 2 1.21 3 1.91 These three cases were removed to the North Middlesex Hospital, Edmonton, where they died. Death-rate of Infants under one year of age : — All infants per 1,000 live births 43.99 Legitimate infants per 1,000 legitimate live births 42.53 Illegitimate infants per 1,000 illegitimate live births 95.21 Deaths from Measles (all ages) Nil Deaths from Whooping Cough (all ages) 2 Deaths from Diarrhoea (under 2 years of age) 11 The following table gives the birth-rate, recorded death-rate and infantile deaths for Enfield as compared with those for England and Wales, London, 125 County Boroughs and Great Towns (including London) and 148 Smaller Towns :- Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Still England and Wales 14.9 0.60 12 4 58.00 London 13.3 0.54 12.3 60.00 125 County Boroughs and Great Towns (including London) 14.9 0.67 12.5 62.00 148 Smaller Towns 15.3 0.64 11.9 55.00 ENFIELD 17.46 0.50 10.47 43.99 55 INFANT MORTALITY. On pages 11 & 13 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 Deathrate on pages 38 and 39. BIRTHS. The actual number of births registered in the District was as follows :- Boys. Girls. Total. 523 523 1046 including 23 illegitimate births, i.e., 2.19 per cent, of the total. In addition, 8 male (including illegitimate) and 11 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. 1933 537 520 1,057 14.72 .50 1934 571 555 1,126 15.08 .44 1935 628 639 1,267 16.46 .51 1936 709 694 1,403 17.12 .50 1937 809 758 1,567 17.97 .50 INFANTILE DEATHS. Reference to Table 2 on page 11 shews that of the 67 deaths of children who died under one year of age, 18 occurred during the first week of life, 5 during the 2nd week, 4 during the 3rd week, and one during the 4th week; 28 in the first four weeks of life. During 1936, when 86 children died under the age of one year, the number who died during the first 4 weeks of life was 47. The biggest reduction, however, is that during the first week of life, for in 1936, 34 children died, whereas in 1937, the figure was 18. It will be seen, therefore, that the reduction in the number of deaths, and therefore in the infant mortality rate from 62.77 in 1936 to 43.99 in 56 1937 is chiefly due to a reduction in deaths under one week. The cause of these early deaths is largely ante-natal. An investigation was made concerning 9 of them. In 2 cases only did the mother attend at an ante-natal clinic. In 4 cases delivery was instrumental, five of the children died in hospital, five of the mothers were primiparae and four multiparae. It must be admitted that ante-natal care would not have saved 2 children, for in one case death followed an operation for harelip and in another the child was suffering from spina bifida. If there is any moral to be drawn from these figures small as they are, it is that ante-natal treatment in its widest sense can do much to lessen infantile mortality. In the opening remarks of this report I have referred to the increase of ante-natal work carried out at our Clinics, and the cooperation with the North Middlesex County Hospital in connection therewith. Fifty-four per cent of the mothers of Enfield are now receiving their ante-natal care at the Council's own Clinics. I use the phrase “ ante-natal care in its widest sense ” to denote that I mean something more than adequate medical attention. I refer to such things as the proper preparation of the home ; the obtaining of a suitable layette ; adequate help in the home during the confinement and puerperium; the provision of suitable nourishment for the mother during pregnancy, and the addition to her diet of essential food stuffs in special cases. I include, moreover, the care of the ears, the eyes and the teeth. All these advantages can be obtained for those who need them through the ante-natal clinics, but these advantages are not limited to the mothers who are under the care of a municipal midwife or whose pregnancy is supervised by one of the Council's Medical Officers. These services, which promote healthy mother-hood and the birth of a normal child, are available to all those women in Enfield whose circumstances warrant it, and the Enfield patients of the private practitioner can be and are provided with these services at the request of the patient and her doctor. I am inclined to admit that they are more often obtained by those who are under the care of the Council's staff. This is chiefly due to the fact that the clinics tend to deal with the poorer mothers of Enfield, but I do not think this is the only reason. At the Clinic the mother is at the very place where municipal services are discussed and thought of. The object of these remarks is that the General Practitioners of Enfield and the public may be made aware that the Council and its Officials desire to co-operate with them in providing all such services as will make mother-hood safer and promote healthier children. 57 PUERPERAL PYREXIA. During the year three cases of Puerperal Fever and seven Puerperal Pyrexia were notified. The Minister of Health issued a Circular dated the 30.9.37, in which it was suggested that after that date all cases of temperature arising during the puerperium should be notified as Puerperal Pyrexia, the figures quoted, therefore, in this connection for Puerperal Fever relate to the first nine months of the year alone. Cases of Puerperal Pyrexia arising in Enfield are sent to the Enfield and Edmonton Joint Isolation Hospital. The Council, however, has arranged that in special circumstances they should be admitted to Queen Charlotte's Hospital, Ravenscourt Square, Hammersmith. MATERNAL MORTALITY. There were six maternal deaths during the year and the cause of death was as follows :- Ante Partum Eclampsia (32 weeks) . . In North Middlesex County Hospital. Pulmonary Embolism. Therapeutic Abortion after 5 previous pregnancies. Diabetes Mellitis. Accident. P.M. Inquest Do. Puerperal Septicaemia Do. Pulmonary Embolism following Oopherectomy for ovarian cyst and curettage for removal of an incomplete abortion of a single foetus (three previous confinements). Do. Atonic postpartum Haemorrhage Uterine inertia Do. Acute Yellow Atrophy of liver. Pregnancy. Retained Placenta. P.M. . . Chase Bank Nursing Home, Southgate. The average age of these six women was 36 years. Cases of death arising in connection with pregnancy and childbirth are investigated by me and a report thereon transmitted to the Minister of Health. These reports are private and confidential. MIDWIVES. The Middlesex County Council was the Supervising Authority under the Midwives Acts until the 31st March, 1937. As from this date the Enfield Urban District Council became the Supervising 58 Authority and undertook the duties in connection therewith. During 1937 there were 22 midwives practising in Enfield, of whom 7 lived outside the district but practised therein. The midwives living in Enfield were visited regularly by the Medical Officers of the Council and their records and equipment inspected. They were regularly advised on such points in connection with their practice as appeared desirable. According to a resolution of the Council I was appointed, together with Doctors Thomson and Hyde, as Supervising Officers. The duties of a Supervising Officer are not entirely those of an inspector who is looking for trouble or searching to see if the midwives in his area are committing a dereliction of duty. He is rather an advisor and counsellor of the midwife; a friend with whom she can discuss her problems and from whom she can receive counsel and information as to the most modern ideas in midwifery. The object is to maintain and improve the standard of midwifery of each individual midwife and to prevent trouble rather than look for it. I am satisfied that your Medical Officers are so regarded by the midwives practising in Enfield, for it is a routine for them to seek our advice and help in any difficulty. In November 1937 the Council appointed five Municipal Midwives and commenced to put into operation a midwifery scheme for the district. The midwives act not only on their own as midwives, but also together with Doctors, in the capacity of a maternity nurse. The following table shews the work carried out by the midwives of Enfield during 1937. Number of cases in the area of the Local Supervising Authority attended during the year by midwives :- Domiciliary Cases Cases in Nursing Homes T otals (a) Employed by the Council- As Midwives 26 — 26 As Maternity Nurses 12 - 12 (b) In private practice- As Midwives 532 29 561 As Maternity Nurses 226 55 281 Totals: As Midwives 558 29 587 As Maternity Nurses 238 55 293 The number of cases in which Medical Aid was summoned from the 1st April, 1937 by a Midwife engaged in domiciliary cases was 117. 59 It will be seen from this table that out of the 1,036 births which took place in the district, a midwife was present alone or with a doctor in 880 cases, and in 156 cases the patient was attended by a doctor without the assistance of a midwife. This is a matter of importance in that it is the intention of the Minister of Health that in course of time there shall be a midwife in attendance at every confinement. When such time arises the Minister will be able to exercise his powers under the Midwives Act 1936 and prohibit the attendance of unqualified persons to assist any woman in labour except in an emergency. In 117 cases medical aid was sought by midwives. In these cases the doctor's fee is paid by the Council according to a scale laid down in the Act. The Council then has the right to recover from the person responsible for the maintenance of the patient such sum as it may deem wise. The fees paid to doctors during the nine months for which the Council has been the Local Supervising Authority amount to £86 and of this £27 17s. od. was recovered. SUPERVISION OF MIDWIVES AND NURSING HOMES. The functions of the Middlesex County Council in this respect were handed over to the Urban District Council of Enfield as from the 1st April, 1937. There are in Enfield the following Nursing Homes. Proprietor. Address. Total No. of beds No. of maternity beds Barker, Mrs. 238 and 240, Baker Street, Enfield 11 - Christmas, Mrs. 3, Chalkwell Park Avenue, Enfield 3 2 Hoy, Mrs. 66, Main Avenue, Enfield 2 2 Mitchell, Mrs. 346, High Street, Ponders End 2 2 Spray, Miss 74, Graeme Road, Enfield 6 Tughan, Dr. and Mrs. 29, Derby Road, Ponders End 4 4 These homes have been inspected regularly by your Medical Officers. 60 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 8,247 788 423 1,506 80.85 Bush Hill Park 8,336 725 307 2,421 81.72 Town and Chase 7,439 770 384 1,972 76.69 Ordnance 10,102 983 519 1,750 104.14 Totals 34,124 3,266 1,633 7,649 85.74 ANTE-NATAL CLINICS. Centre. New Attendances. Re ances. Total Attendances. Average Attendance per Meeting. Ponders End 237 495 732 20.9 Bush Hill Park 166 420 586 25.4 Town and Chase 173 449 622 23.9 Ordnance 243 521 764 29.3 Totals 819 1,885 2,704 24.6 61 VISITS. Town, Chase and Hadley. Bush Hill Park. Ordnance. Ponders End. Totals. Birth Notification Visits 305 318 411 293 1,327 Ditto Re-visits 324 705 467 624 2,120 Children, 1-5 years Visits 1,040 1,330 1,331 1,206 4,907 Visits re Insanitary Conditions 36 2 - - 38 General Visits 224 43 78 111 456 Ante-Natal Visits 162 205 138 252 757 Post-Natal Visits 16 156 27 37 236 Blank Visits 256 151 125 96 628 Infectious Disease Visits 111 165 93 48 417 Ophthalmia Neonatorum Visits - 3 - 3 Puerperal Fever Visits - 2 — — 2 Puerperal Pyrexia Visits - 4 — — 4 Visits re Foster Children 24 29 58 42 153 Totals 2,498 3,113 2,728 2,709 11,048 BIRTHS NOTIFIED. The number of children born to Enfield mothers during 1937 was 1498. This includes 462 who were born outside the district. The Health Visitors visited 88.5 per cent, of the Enfield babies born during the year. ASSISTED MILK SUPPLY. The quantity of fresh and dried milk supplied to necessitous cases under the Assisted Milk Supply Scheme during the year was as follows :- Fresh Milk 10,287½ galls. Cost . . £1,164 8 7¾ Dried Milk 2,745 lbs. Cost £206 11 11 The corresponding figures for 1933, 1934, 1935 and 1936 are :- 1933 1934 1935 1936 Fresh Milk 19,860 galls. 16,414 galls. 13,377 galls. £1,825 11 2½ £1,481 4 3 £1.395 15 6½ £1,269 12 6 Dried Milk 3.683 lbs. 4,201 lbs. 3.389 lbs. 2,803 lbs £273 19 0¾ of £311 3 4 £243 13 11¾ £204 0 10 62 The reduction in the amount of milk, wet and dried, supplied free since 1933 must be noted. This has been due to the better conditions of the working classes in Enfield for I am satisfied that the public are aware of the benefits that can be obtained. Furthermore there has been no alteration in the scale that could have effected this reduction; if anything, the Committee has tended to deal with cases more generously as each year has gone by. There has been recently a tendency for the demand for assistance to rise and I am of the opinion that the cost for 1938 will be higher than that for 1937. As in previous years consideration is given to the rent of the family, fares, and the season of the year, whilst the expected child is considered as a member of the family in the application of the milk scale. 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 for 1934, 1935, 1936 and 1937. 1934 1935 1936 1937 Total number of appointments made 6,780 7,570 7,340 8,487 Total number kept 2,231 2,714 2,309 2,432 Total number of additional examinations 960 1,222 1,280 1,599 The following table is an analysis of the children sent 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 1,093 926 865 708 3,592 No. kept 337 205 155 135 £32 The total number of appointments made, not including birthdays, was 4,895. The total number kept was 1,600. The procedure whereby invitation cards are sent to children 63 on their birthdays inviting them to attend the Maternity and Child Welfare Clinics to be medically examined, has been continued throughout the year. This scheme commenced in April 1933 and during the nine months of that year the total number of appointments kept was 1,769. The scheme has been successful in that the total number of appointments kept in 1937 had risen to 2,432. I feel constrained to repeat the remarks I have made in previous years, that the proportion of children whose appointments are kept is too low, especially those made for children of between 4 and 5 years of age. AURAL TREATMENT. The scheme whereby children under five years of age and antenatal and nursing mothers could be referred to the School Aural Clinic was continued, and during the course of the year 92 children and 8 mothers were so referred. This compares with 45 children during the previous year. Of the 92 children and 8 mothers, 45 were found to have enlarged tonsils and adenoids needing removal. OPHTHALMIC TREATMENT. The scheme whereby mothers and children attending the Centres who are in need of ophthalmic treatment could be referred to the School Ophthalmic Surgeon. was continued throughout the vear. From the following figures it will be seen to what extent such services have been utilised. Mothers Children Total Number of individual cases seen 45 64 109 Number of attendances made 52 110 162 Number of glasses prescribed 37 17 54 Number not requiring glasses 4 15 19 Number of cases referred for conditions other than refractions 2 3 5 Number referred to Hospital 2 3 5 Number referred to Hospital for meibomian cyst 1 1 2 BIRTH CONTROL. Arrangements exist whereby advice on Birth Control is given to those mothers attending the Council's Maternity and Child Welfare Centres for whom further pregnancy would be detrimental to health. This is in accordance with Memorandum 153 M. and CW. and 64 Circulars 1208 and 1408 of the Ministry of Health. The Committee determined that, where possible, advice should be given to the husband rather than, or as well as, to the wife. CHILD LIFE PROTECTION. PUBLIC HEALTH ACT, 1936. 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. (a) Number of persons receiving children for reward on the Register at the end of the year 23 (b) Number of children on the Register :- (i) at the end of the year 27 (ii) who died during the year 1 (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 (i i) 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 153 visits were paid in connection with child life protection by the Infant Life Protection Visitors. In addition visits have been paid by the Medical Officers and Sanitary Inspectors. 65 DENTAL TREATMENT. The following particulars show the work which has been carried out during 1937 and the previous four years. Mothers. Children. Total. Totals. 1936. 1935. 1934. 1933. Attendances 774 273 1047 1,027 991 1,071 1,257 Treated 167 186 353 390 468 319 340 Administrations : Local Anaesthetics 82 81 163 98 96 84 115 Extractions with Local Anaesthetics 189 189 378 230 207 166 211 Administrations : N20 180 100 280 326 302 272 252 Extractions under N20 977 308 1285 1,425 1350 1,187 1,071 Total Extractions 1166 497 1663 1,655 1557 1,353 1,310 N20 Sessions 39 - 39 41 39 39 36 Ordinary Sessions 43 - 43 45 43 41 44 Total Sessions 82 - 82 86 82 80 80 Dentures fitted 133 - 133 121 82 129 131 Patients receiving Dentures 71 - 71 64 44 70 78 Number of Patients having repairs 9 - 9 9 13 11 20 Number of repairs fitted 11 - 11 9 14 11 20 Number of fillings 19 77 96 135 187 192 218 Other Operations 444 45 489 491 394 661 803 Number of patients having extractions under N20 78 91 169 210 203 157 127 Do. do. under Local Anaesthetics 60 73 133 86 69 60 134 BABY WEEK. This took place on the 5th, 6th, 7th and 8th of July, Garden Parties being held at St. George's Hall, Freezywater and The Red Triangle Club, Church Street, Enfield. Baby Week in Enfield has grown in popularity. In 1928 the total attendances during the week were 1,006; in 1937 they had risen to 1,922. This is not due to the fact that the mothers are treated any better at these functions than they were in 1928; in fact there is less entertainment now than then. I think it represents the keenness of the mothers and their interest in their local Maternity and Child Welfare Centre. 66 Prizes are given to the successful entrants of the competitions which are set. These competitions last year were judged by the medical officers of the Health Department. The following competitions were held :- 1. A letter to a friend telling her what you would do to prevent your child catching colds. 2. The best made new knitted garment. 3. The best garment made from new material. 4. The best garment made from old material. 5. The best darn in a sock or stocking, or a patch in a pair of boy's trousers. CIRCULATION OF BOOKLET ON REARING OF CHILDREN. During the course of the year approximately 1,513 booklets called “ To Mothers and Fathers ” were sent to mothers giving birth to a child. HOME HELPS. The number of Home Helps supplied during 1937 was 146 as compared with 88 in 1936, 52 in 1935 and 30 in 1934. MIDWIVES. In 38 cases help was granted in respect of the cost of a midwife. This compares with 5 in 1934, 36 in 1935 and 41 in 1936. OBSTETRIC SPECIALIST. The scheme whereby the General Practitioners of Enfield are enabled to call in the help of the obstetrician at the North Middlesex County Hospital in cases of doubt or difficulty during the ante-natal period or at the confinement, has been continued. The Obstetrician was called to four cases during the year. In one case three visits were necessary. On each occasion when the Specialist is called in a fee of £2 2s. od. is paid to the Middlesex County Council and is recovered from the patient or her husband to the extent to which the family circumstances make this possible. During 1937 £8 18s. od. was recovered out of a cost to the Council of £14 14s. od. This service represents co-operation between the General Practitioners, the Maternity and Child Welfare Committee and the County Council. It has worked throughout the year without any difficulty. It is a service of the greatest value to the district and one which is much appreciated by all concerned. 67 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 they submit a report thereon to me. The family circumstances are investigated and the matter reported to the Maternity and Child Welfare Committee. During the year 5 children under the age of five years, and 3 mothers and their babies, were sent to Convalescent Homes. 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 . . 2 demonstrations at Bush Hill Park School 4 Central Girls' School 6 Suffolks Girls' School Miss Garlick 4 Chesterfield Girls' School Miss Wilkinson 2 Alma Road Girls' School Mrs. Herbert 2 Lavender Road Girls' School. In addition, two parties of girls from the Central School were shewn over the Bush Hill Park Infant Welfare Centre. SUMMARY. 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. Twelve clinics monthly for expectant mothers. 4. Four clinics monthly for post-natal mothers. 5. The supply of milk and other foods to children under 5 years of age, and to expectant and nursing mothers. 6. Dental treatment for children under 5 years of age. 7. Dental treatment and the provision of dentures to Ante-Natal and Nursing Mothers. 8. Home Helps. 68 9. Provision of midwives. 10. Medical Assistance Aid in cases attended by midwives. 11. Obstetric Specialist in difficult confinements. 12. Domiciliary Emergency Service. 13. Ophthalmic treatment. 14. Aural treatment. 15. Convalescent treatment. 16. Routine examination of children under 5 years of age. 17. Diphtheria immunisation. 18. Supervision of midwives. 19. Supervision of Maternity Homes. CONCLUSION. The scope of maternity and child welfare work has been increased during the year by the preparation of a scheme of municipal midwives. The Council has also undertaken the duties of supervision of midwives and maternity homes. There has been an increase in the number of persons who have received medical advice and treatment, and a decrease in the demand for free milk and food. 69 Public Offices, Enfield. 17th April, 1938. Report of the Chief Sanitary Inspector For the year 1937. To the Chairman and Members of the Urban District Council of Enfield. GentlemEn, In submitting my Annual Report for the year ended 31st December, 1937, there are some points to which I would direct your attention. I regret to say that certain food premises, e.g., milkshops and bakehouses, are not receiving the attention I consider necessary. This indicates the desirability of appointing an additional Sanitary Inspector for the District. The number of vacated Council houses inspected during the year was much larger than in previous years. It is pleasing to record that the percentage found verminous was much lower. During the year the fifteen vehicles owned by the department travelled 71,961 miles. The refuse collection lorries alone covered 57,090 miles to collect 19,000 tons of refuse. Thus each vehicle travelled 3 miles to collect a ton of refuse or 61 miles per load. The dustman's weekly call costs less than 3½d. per week per house. 70 During 1937, the survey of the district with regard to overcrowding was completed and owners are being informed of the number of persons allowed per house. A further work added to the Department is the inspection of Hairdressers' premises carried out to enforce the provision of the new Bye-laws in connection therewith. The passing of the Public Health Act, 1936, has needed some reorganisation in the work of the Department. STATEMENT PREPARED BY SANITARY INSPECTOR UNDER ARTICLE XIX (12) MINISTRY OF HEALTH ORDER, No. 276, 1922. Number of Houses Inspected. Inspections. House-to-house under the Housing Consolidated Regulations, 1925 285 House-to-House apart from this Act 7 On Account of Infectious Disease 206 On Account of Phthisis 61 On Account of Complaint by occupant or otherwise 1,269 On Account of Vermin 401 197 Factories 231 111 Workshops and Workplaces 80 Outworkers' premises inspected 90 42 Bakehouses, of which 31 are in use 117 10 Slaughterhouses, of which 7 are in use 989 21 Cowkeepers' premises 410 101 Dairies and Milkshops inspected frequently 230 21 Schools 84 Public Conveniences inspected 559 Conveniences at Railway Stations inspected 9 Fish shops ; Total number of visits 80 Coffee and Eating Houses : Total number of visits 16 Coffee-stalls : Total number of visits 16 Shops where Ice-cream is made : Total number of visits 40 5,180 71 Inspections-(continued). Inspections. Brought forward 5,180 Meat Shops : Total number of inspections 171 Food Preparing Premises : Total number of inspections 38 Food Stalls in Markets : Total number of inspections 1,084 Visits to absentees excluded from Elementary Schools 722 Visits in connection with cases of Infectious Disease 1,364 Visits in connection with Phthisis 266 Visits re Verminous Premises, etc. 846 Offensive Trades (excluding Fish Shops) 20 Smoke observations 71 Other inspections, including works in progress 9,590 Visits re Shops Act 415 Cinemas, etc., inspected 45 Visits and inspections re Rats 309 Visits re Sub-letting in Council Houses 6 Visits re Caravans, etc. 151 Visits re Overcrowding and Housing Survey 9,091 Visits re Rag Flock Act 13 Visits and Inspections at Mortuary 47 Inspections of Stables 41 Visits re Noises 22 Visits re Pig-styes 51 Visits re Exhumations 2 Other Visits 1,251 Visits re Fair Grounds 3 Visits re Hairdressers' Premises 26 Visits re House let in Lodgings 3 25,648 30,828 72 NOTICES ISSUED. Statutory :- Public Health Acts. Provision of dustbins — For repairs to houses, drains and abatement of nuisances 10 Providing sufficient water-closets — Paving of yards — Provision of Sinks or Drains 30 Offensive accumulation 1 Housing Acts, 1930 and 1936 14 Shops Act, 1934 11 66 Informal:- Notices-Public Health Acts 435 Housing Acts 226 661 727 Other Notices issued under Infectious Diseases Acts:- To occupiers 387 To Education Committee and Head Teachers at Schools 2,832 To Librarian 6 3,225 3,952 Other letters sent 11,182 Number of Certificates issued in connection with plans 133 Number of Certificates issued in connection with disinfection 18 Result of Service of Statutory and Informal Notices:- Statutory. Informal. Number complied with 49 485 Number outstanding 17 176 66 661 73 As will be seen by the list of items given below, the inspection of premises has revealed defects varied and general in character. Houses or parts of houses cleansed, repaired, etc. 433 Roofs repaired 165 Gutters and down pipes repaired 136 Downpipes disconnected from drains 3 Houses underpinned and settlement remedied 0 Dampness remedied 191 Concrete site provided under floors 0 Cesspools emptied 296 Cesspools abolished 1 Cesspools re -constructed or NewCesspools provided 1 Closet Pails Emptied 2,802 House drains cleared, repaired, etc. 139 House drains tested, examined, etc. 282 House drains reconstructed 44 Soil-pipes and drains ventilated, including repairs to ventilators 58 New vents provided 1 New manhole covers provided 1 Sink-wastes disconnected or repaired 35 New sinks provided 67 Obsolete Gulleys replaced 5 Closets provided with proper flushing cisterns or water supply 4 New closets provided 20 Closets repaired, covered, cleansed, etc 141 Water-closets substituted for earth-closets 0 Elsan or Chemical Closets provided 0 Urinals repaired or provided with flushing tank and water supply 1 Privy substituted for earth-closet 0 Intervening ventilated space provided 1 Water-closets provided with ventilation 19 Water-closets provided with light and ventilation 9 Storage cisterns repaired, covered, cleansed, etc. 12 Storage cisterns provided 4 Water laid on or restored 8 Taps provided over sinks 0 New wells provided 0 Wells closed 2 Wells cleansed and repaired etc 0 Samples of Water taken from Wells 64 Do. do. Main 0 Do. do. Swimming Pool and Baths 46 74 Samples of Rag-Flock taken under Rag-Flock Act 4 Samples of Milk taken 19 Yards paved, or existing paving made good 85 Yards drained 0 Ventilation provided under ground floors 11 Floors repaired 65 Handrails provided to Stairs 31 Lighting provided to staircases 13 Ventilation provided to bedrooms 5 Dustbins repaired, or new ones provided 322 Ashpits abolished and dustbins provided 1 Forecourts paved 0 Food Stores provided 20 Ventilation provided to food stores 3 External paintwork renewed 26 Doors repaired or replaced with new 4 Manure heaps removed 10 Fowls and other animals removed 1 Coppers repaired, etc 16 Stoves repaired, etc 90 Windows repaired, etc 215 Other nuisances abated 179 Dairies demolished and rebuilt to requirements 1 Ditches cleaned out 7 Gipsy vans removed 17 Pig-styes removed 0 Drainage provided to piggeries 1 Quarries fenced 1 Proper rent books provided 1 Heating provided to shops 0 Coffee stalls abolished 0 While everything possible is done by the District Sanitary Inspectors to secure the speedy execution of the varied classes of work, I have been able to expedite the progress of repairs considerably by interviewing the owners and agents of property. Where there has been no reasonable excuse for delay, a suitable warning from the Council has been of much assistance in securing the completion of works without having recourse to legal proceedings. Some inconvenience was experienced during part of the year owing to the fact that we were short of one Sanitary Inspector for some months. 722 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 30,828. 75 DISINFECTION. Houses Disinfected:- After infectious disease 310 After Phthisis 43 353 After verminous cases (Non-Council) 64 Vacated Council houses 80 144 497 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 5 Ditto, ditto, by cases of Phthisis 1 Articles of clothing, bedding, etc., disinfected 2,124 Ditto, ditto, destroyed 59 Library Books disinfected 96 No. of Certificates issued re disinfection of clothing and premises 18 Number of Schools disinfected 4 Private Patients removed to Hospital 1,808 Gipsy Vans removed from District 17 Articles or parcels of unsound food destroyed or otherwise disposed of 24 216 vacated Council houses were examined for the presence of vermin during the year, and in 142 of these houses it was deemed advisable to carry out a detection test. 80 houses shewed definite evidence of vermin-37 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 is the practice of the Health Department to inspect every Council house as soon as it becomes vacant, in order to ascertain if the house be verminous ; where vermin are found the house is disinfested before being re-let. The use of Heavy Naphtha was continued through the year and the results were most encouraging. It is pleasing to know that at last we see in sight a harmless substitute for Hydrocyanic Acid Gas. In spite of continued advice to the contrary there is still a tendency to buy second-hand furniture not only from shops but also from neighbours living in infested houses. It is hoped that in the near future by the use of a specially equipped van and of Heavy Naphtha some of the infestation carried by second-hand furniture will be avoided. The disinfection of verminous clothing and bedding is carried 76 out by means of a Washington-Lyon's Steam Disinfector situated at the Council's Sewage Farm. FACTORY AND WORKSHOPS ACTS, 1901 AND 1907. A register is kept of all the workshops in the District, and at the end of 1937 there were 106 workshops, 5 workplaces and 31 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) 231 - - Workshops (including Workshop Laundries) and Workplaces 170 — — Bakehouses 117 3 — Total 518 3 — Defects Found. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts :— Want of Cleanliness 1 1 — — Want of Ventilation — — — — Overcrowding — — — — Want of Drainage of Floors — — — — Other Nuisances 2 2 — — Sanitary Accommodation :- Insufficient — — — — Unsuitable or Defective 7 7 — — Not separate for sexes — — — — . Offences under the Factory and Workshops Acts :- - Illegal occupation of underground bakehouses - - - - Breach of special sanitary requirements for bakehouses 2 2 - - Other Offences — — — — Total 12 12 — — 77 Homework. Nature of Work. Lists received from Employers Sending once in the year. Sending twice in the year. Notices served on Occupiers as to keeping or sending Lists. Lists. Workmen. Lists. men Embroidery 1 1 4 6 - Umbrellas 1 1 — — — Fancy Leather Goods 1 1 — — — Badges 1 1 — — — Making Wearing Apparel 15 28 8 20 8 Boot-making 4 5 2 2 — Toys 1 1 — — — Cardboard Boxes 1 3 2 2 — Artificial Flowers 1 1 — — — Hairnets and Combs 1 1 — - — Crackers 1 1 — - — Millinery 1 1 2 2 — Totals 29 45 18 32 8 Three addresses of outworkers have been forwarded to other districts. 78 During the year, 3 new Fish-frying shops have been opened in Enfield with the consent of the Council and I am happy to say that these are of a much improved design. The closed saloon type is becoming popular with the traders. 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. Practically the whole of the farms retailing milk are now fitted with sterilisation plant, and the farmers have realised their responsibility with regard to limewashing and complied with the requirements of the Act. Licences as follows were in force on the 31st December under the Milk (Special Designations) Order, 1936 Dealer's Licence to use the Designation “ Accredited ” 1 Dealer's Licence to use the Designation “ Pasteurised ” 24 Dealer's Licence to use the Designation “ Tuberculin Tested ” 7 Pasteuriser's Licence to sell milk as “ Pasteurised ” 1 Supplementary Licence to use the Designation “ Accredited ” 1 Supplementary Licence to use the Designation “ Tuberculin Tested ” 2 Supplementary Licence to use the Designation “ Pasteurised ” 3 PUBLIC HEALTH (MEAT) REGULATIONS, 1924. Meat inspection is carried out according to the Regulations ; as stated in previous years, every possible endeavour is made to see that foodstuffs are dealt with under the most modern hygienic conditions. The various tradesmen in the District are realising the importance of this matter and are endeavouring to deal with it in a progressive manner. The following table shews the results of inspections of the carcases and organs of animals killed in the slaughterhouses of the District. 79 Cattle, excluding Cows Cows. Calves Sheep and Lambs Pigs Totals Number killed 307 22 37 3,683 5,506 9,555 Number inspected 307 22 37 3,683 5,506 9,555 All Diseases except Tuberculosis. Whole carcases condemned - - - 4 3 7 Carcases of which some part or organ was condemned 20 5 - 19 65 109 Percentage of the number inspected affected with disease other than tuberculosis 6.5 22.7 - 0.6 1.2 1.2 Tuberculosis Only. Whole carcases condemned 1 - - — 2 3 Carcases of which some part or organ was condemned 2 5 - - 55 62 Percentage of the number inspected affected wit'h tuberculosis 0.9 22.7 - - 1.0 0.6 The organs or parts of carcases found to be diseased were surrendered and destroyed. The weight of the meat destroyed was 1 ton 16 cwt. 2 qrs. 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 improving in regard to meat inspection in Enfield. The slaughtering is spread out over the whole week, Sundaysand holidays included and till late hours at night. It absorbs a large portion of the Sanitary Inspectors' time. 80 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 989 Shops 171 Stalls in Markets 1,084 Food Preparing Shops 38 2,282 Foodstuffs of various kinds purchased in London Markets and outside the District were submitted for inspection by the Health Department ; 34 parcels consisting of fish, meat, poultry, etc. were found to be unfit for human consumption. Certificates were given in all cases, so that the owner might obtain replacement of the goods or return of the money from the wholesale dealer. Renewal of old Licences and plans for new Coffee Stalls are available at the Surveyor's Office for inspection by this Department. The best sanitary provisions available are enforced as to the removal of refuse, water supply and drainage. MOTOR AMBULANCES. There are three Motor Ambulances for use in the District. They are under the charge of Mr. A. H. Johnstone, the Fire Brigade Superintendent. SHOPS ACT. While the duties of inspection under the Shops Acts are carried out by this Department, we have now the assistance of Mr. Provest who was appointed this year as Shops Inspector. This has helped in bringing this work more up to date. It is somewhat unfortunate that we have to face a drawback in another direction. The Court inflicts such small penalties for infringement of the Shops Act, even in regard to continued offences, that there is little to deter the wrong doer from repeating the offence. It was found necessary to take action during the year against one shopkeeper for contraventions of the Act and fines were imposed. The arrangements made 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 Act. 81 The provisions of the Shops Act, 1934, relating to ventilation and temperature of shops and to sanitary conveniences are being dealt with as speedily as possible. It was not found necessary to take legal action under the Act during the year. 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. Forty-seven Dustmen are employed 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. 6-15 cubic yards Moveable Floor Rear-loading “ S.D.” Freighters. 1-15 cubic yards Moveable Floor Rear-loading “ Dennis ” Vehicle. 1-Tuke and Bell 10 cubic yards “ Barrier ” Type end-loading vehicle. 1-Bedford 2 ton General Purpose 3-Way Tipping Lorry. 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 controlled tip. Arrangements exist whereby trade refuse is removed from shopkeepers’ premises on payment of a prearranged charge. The income from this source was £138 17s. 6d. during the year. In this report it has been stated that the Council’s vehicles collected about 19,000 tons of refuse. In addition hired vehicles were employed at times and the total refuse collected and disposed of amounted to 20,250 tons. The cost was £17,970 or 17s. 8.9d. per ton for collection and disposal, as against a figure of 18s. 2.6d. for 1936. The cost per head of the population was 4s. 1.4d. per annum or 0.9d. per week. The average for each house is 14s.9.4d. per year, or 3.3d. per week. DISPOSAL OF REFUSE. The depositing of refuse in the old Gravel Pit in Carte hatch Lane was continued through the year. As was stated last year it has been a difficult task to prevent nuisance, for, owing to the presence of several springs, refuse has had to be deposited in waterlogged cavities. We were able to overcome the trouble by having at our disposal some fair amount of covering material. 82 SEWER FLUSHING. This work is carried out by the Department, and all sewersare 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. CESSPOOLS. The dual-purpose cesspool-gully emptying machine purchased in 1934 has been in constant use during the year, primarily for the emptying of cesspools. When not so employed it has been available for the emptying of street gulleys (by the Surveyor's Department). The Council has ordered a gulley-emptying machine for use by the Surveyor's Department and this will greatly facilitate the efficient emptying of the gulleys in the District. 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. The conveniences provided for men are now cleansed by whole-time attendants, and there has been a considerable improvement in the cleanliness of these places since the Attendants commenced work. The Council have under consideration at the present time the alteration of the conveniences in the Town. This will be a great improvement to the District, as the present conveniences in the Market Place are now practically obsolete. 83 HORSE TROUGHS AND DRINKING FOUNTAINS. Drinking fountains, and also four horse troughs in the District, receive daily attention as regards cleansing. PUBLIC MORTUARY. One Public Mortuary in the District, established at the Enfield Highway Cemetery, is constantly under supervision. There is a whole-time Attendant at the Mortuary. RATS. It is the responsibility of the householder to carry out such measures as will prevent rat infestation. The Council have been, and are, at all times willing to supplement efforts made by the occupier to effect an improvement. There still remains the serious question as to whether the Health Department contains sufficient Staff to carry out the work that now falls upon it. Housing and other Acts are increasing the work of the Sanitary Inspectors, whilst at the same time the population and number of houses in the District show rapid increase year by year. I am of the opinion that increase in Staff is now required. This Report would not be complete unless I again state how much I appreciate the kindly manner in which Dr. Geffen, your Medical Officer of Health, has always treated me 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, 1937. 86 MEMBERS OF THE ENFIELD EDUCATION COMMITTEE, 1937-1938. Chairman Mr. H. A. Deshborough Brown Vice-Chairman Mr. H. G. Short. Representative Members. Mr. J. C. Bland Mr. H. A. Deshborough Brown Mr. H. H. Collier Mr. A. M. Eeles Mr. G. E. Jones Mr. H. Muspratt, O.B.E. Mr. C. Partington, J.P., M.R.S.T. Mr. S. G. Rowlandson Mr. G. M. Sparrow, J.P., C.C. Mr. G. S. Thompson, F.R.C.S.Ed. Co-optative Members. Mrs. N. Davies Mrs. I. G. Dufton Mrs. H. Rothwell Mr. T. H. M. Clarke Mr, F. G. Cobbin Mr. H. G. Short Mr. C. F. Watts Director of Education. E. Pascal, Esq., M.A. 87 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 OfficersGertrude Forrester, M.B., B.S. (Lond.). W. D. Hyde, M.B., ChB., D.P.H. School Dentists- C. E. James, L.D.S., R.C.S. (Eng.). H. Mackay, L.D.S. 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. 83 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, 1937. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my Annual Report on the health of the school children of Enfield during the year ended 31st December, 1937. The number of children on the School roll shows an increase of 468. In the last five years the elementary school population has increased by 1,313. During this period, moreover, the Education Committee has under-taken the inspection and treatment of secondary school children, amounting to over 1,100 in number. The extent to which the work entailed in the care of Enfield school children has increased will, therefore, be realised. Of great interest will be found Mr. Macky's report on the work carried out at our Ophthalmic Clinic. Many of the children he has treated have been referred to him by the Medical Officers of your staff, their ophthalmic defects having been discovered during the course of routine examination, or attendance at one of the Council's Maternity and Child Welfare Clinics. The results that have been achieved are highly satisfactory and demonstrate the value of that co-operation between the medical services of the Council which it has been the policy to foster during the past years. The same remarks apply to Mr. Hogg's report on the School Aural Clinic. The Committee will be interested to see the diversity of cases that have been treated at both clinics. At the time of writing this report a clinic is being erected in connection with the new Bell Lane School. This clinic includes accommodation for a dental surgery. It is hoped that the appointment of a third dentist when the new clinic is opened, a policy upon which the Committee has already determined, will do much to make it 89 possible to deal somewhat more adequately with the dental condition of Enfield children. Reviewing generally the health of the children attending our schools, I think one must feel satisfied that there is an improvement in the physique of the pupils. Throughout the country children weigh more and are taller than were their predecessors some years back. I think, too, that the children are generally tidier and cleaner. A question of supreme importance, however, is the mental health of the modern child. I know of no way of assessing mental health, for if one is to compare the children of to-day with those of past years one must also consider the environmental changes that have taken place. In the first place children get less community life at home than formerly, for large families are infrequent. In the second place our cities are noisier and our traffic faster, whilst wireless and the cinematograph have enlarged the field of thought of our pupils. It cannot be surprising then that we are frequently consulted by parents who complain that their children are “nervy,” or difficult, or that they are unable to manage them. Certain of these children we treat ourselves, others have attended at Child Guidance Clinics. It has been almost a routine to receive from these clinics reports to the effect that the home surroundings of the children are unsatisfactory, or that the parents are not wise in the way that they manage their children. We couple this with our own observations that some of the younger children attending our clinics are so spoilt as to make examination and treatment difficult. It has been our aim to advance the treatment of dental caries to as early an age as possible, yet the report of our Senior School Dental Surgeon stresses the difficulty of treating young children. Is one, therefore, right in assuming that parents need more training in the care of children than they are receiving ? I think this must be so, for the improvement in behaviour of a number of children as soon as they go to school is often surprising, whilst the skilled handling of children by members of your staff soon produces a docile patient out of a refractory, spoilt and crying child. The improvement in behaviour of children as soon as their parents are out of the room is most surprising. Admittedly doctors and teachers by their experience and training learn how to deal with such children, but there are certain rudimentary elements in child management which should be appreciated by parents and known to them. Children should not be frightened either of a doctor or dentist because he has been held up to them as a “bogey man.” They should be accustomed to accept orders from their parents or from other adults in whose care they are placed, if not without question at least without crying. Yet 90 we have children brought to us by their parents, who cry from the moment they enter the clinic until they leave, unless their parents can be persuaded to leave them alone in the hands of the doctor or dentist. A doctor-not a member of the Enfield staff-recently said to me that there are many parents he has never seen but whom he would like to slap. Whilst, on the other hand, I recall a physician who, after bringing a child of six through a long and dangerous illness involving four operations, remarked that if that child had been spoilt by foolish parents he could not have saved him. Excepting these difficult cases Enfield abounds in parents who seek the advice of the School Medical Department, appreciate it, and co-operate with the Education Committee in producing the many sturdy children whom it is a delight to see in our schools. The co-operation of my colleague, Mr. Pascal, has been most valuable throughout the year, and in the preparation of this report he has supplied me with much of the information to be found therein. I would once more acknowledge my appreciation of the help I have received from my staff, and from the teachers in our schools, and for the unfailing courtesy of the members of the Education 'Committee throughout the year. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, D. H. GEFFEN, School Medical Officer. 91 REPORT OF THE SCHOOL MEDICAL OFFICER. SCHOOL. Area (in acres) 12,400 Population 87,200 Number of Schools 19 Average number on books of elementary schools 1933 1934 1935 1936 1937 9,725 9,970 10,155 10,570 11,038 Average weekly attendance 8,685 8,857 9,200 9,342 9,756 SCHOOL. Number on roll 31.12.37 Alma Road Boys’ 26l Alma Road Girls’ 229 Alma Road Infants’ 208 Bush Hill Park Senior Mixed 267 Bush Hill Park Junior Boys’ 242 Bush Hill Park Junior Girls’ 209 Bush Hill Park Infants’ 263 Botany Bay 22 Chase Side Boys’ 318 Chase Side Girls’ 254 Chase Side Infants’ 227 Chesterfield Road Boys’ 408 Chesterfield Road Girls’ 441 Chesterfield Road Junior Mixed 475 Chesterfield Road Infants’ 421 Eastfield Road Mixed 615 Eastfield Road Infants’ 376 Forty Hill 130 George Spicer Central Boys’ 266 George Spicer Central Girls’ 268 George Spicer Junior 398 Lavender Road Boys’ 359 Lavender Road Girls’ 349 Lavender Road Infants’ 289 Southbury Road Boys’ 289 Southbury Road Girls’ 281 Southbury Road Infants’ 254 Suffolks Senior Mixed 347 Suffolks Junior 474 92 Suffolks Infants’ 548 St. Andrew’s Boys’ 84 St. Andrew’s Girls’ 128 St. Andrew’s Infants’ 77 St. George’s C.E. Infants’ 124 St. George’s R.C. Mixed 92 St. James’ Boys’ 247 St. James’ Girls' and Infants’ 342 St. John’s Mixed 53 St. Mary’s R.C. Mixed 184 St. Matthew’s Girls’ and Infants’ 211 St. Michael’s Boys’ 56 St. Michael’s Girls’ and Infants’ 141 SECONDARY SCHOOLS. County School for Girls 444 Grammar School for Boys 496 Junior Technical School for Boys 180 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 3,967. In 1936 3,819 were examined. Routine Medical Inspection is carried out on the school premises except in those cases where there is a school clinic conveniently placed. Notices are handed to children stating in lay terms the defect from which they are 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. 73 per cent of the children examined during the year in the course of routine examination were accompanied by their parents. The comparative figures for the last five years are as follows :— 1933 1934 1935 1936 1937 Percentage of children accompanied by parents 77 76 76 79 73 30 per cent of the children examined were vaccinated. The comparative figures for the last five years are as follows :- 93 1933 1934 935 1936 1937 Percentage of children vaccinated 37 37 37 39 30 DEFECTS FOUND AT ROUTINE MEDICAL INSPECTION. Uncleanliness.—Of 3,967 children examined 5 were found to have vermin in their heads and 202 had nits. The comparative figures for the last five years are as follows :— 1933 1934 1935 1936 1937 Number of children examined 2,869 3,378 3,436 3,819 3,967 Number of children with verminous heads 21 15 7 11 5 Percentage of children with verminous heads 0.7 0.4 0.2 0.3 0.1 Number of children found to have nits 224 279 182 220 202 Percentage of children found to have nits 7.8 8.2 5.0 5.8 5.1 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 1937 was 3,967, and the following table shows how they were classified, with comparative figures for 1935 and 1936:- 1935 1936 1937 Number of children examined 3,436 3,819 3,967 Number of children classified "A" 38 295 270 Percentage of children classified " A " 1.1 7.7 6.8 Number of children classified " B " 2,286 1,953 2,708 Percentage of children classified " B " 66.6 51.1 68.1 Number of children classified " C " 1,056 1,116 843 Percentage of children classified " C " 30.6 29.3 21.3 Number of children classified " D " 56 455 146 Percentage of children classified " D " 1.7 11.9 3.7 94 From this table it would appear that the number of children in excellent health is higher than in 1935 and that the number of normal children has considerably increased. I cannot ask the Committee to accept these figures as a real statement of the position in EnfieldThere is no scientific standard of nutrition upon which doctors can work for comparative purposes and the figures obtained vary enormously with the doctor examining the children. I believe this accounts for the variation in the figures shown above. I am satisfied that the state of nutrition of the children in Enfield is reasonably similar to that of the last two years. Skin Diseases.—Thirteen cases were seen; twelve required treatment, and one was kept under observation. Ear Disease.—Twenty-five cases of middle ear disease were found; also 59 cases of defective hearing. All these cases were referred to the Aural Clinic for treatment. 1933 1934 I935 1936 1937 Number of children examined 2,869 3,378 3,436 3,819 3,967 Number of cases of Middle Ear Disease found 23 18 19 22 25 Percentage of cases of Middle Ear Disease found 0.8 0.5 0.6 0.6 0.6 Number of cases of Defective Hearing found 53 53 33 26 59 Percentage of cases of Defective Hearing found 1.8 1.6 0.98 0.7 1.5 Tonsils and Adenoids.—1,123 children had already had operation for removal of tonsils and/or adenoids; 494 were found to have enlarged tonsils, adenoids, or both. The following is a comparative table for the last five years :— 1933 1934 1935 1936 1937 Number of children examined 2,869 3,378 3,436 3,819 3,967 Number of children already operated upon 1,121 1,202 1,205 1,143 1,123. Percentage of children already operated upon 39.1 35.6 35.0 29.9 28.3 Number of children with enlarged tonsils, adenoids, or both 388 512 663 597 494 Percentage of children with enlarged tonsils, adenoids, or both 13.5 15.3 19.3 15.6 12.5. 95 Eye Diseases and Defects.—Thirty-two children were found to be suffering from external eye disease. Thirty-one were referred for treatment to the minor ailment clinic and one was kept under observation. 277 cases of defective vision were referred for treatment to the Ophthalmic Clinic or hospital; 40 of these had squint. The following is a comparative table for the last five years :— 1933 1934 1935 1936 1937 Number of children examined 2,869 3,378 3,436 3,819 3,967 Number of children with defective vision 296 234 200 220 237 Percentage of children with defective vision 10.3 6.9 5.9 5.8 5.9 Number of children with squint 21 40 43 46 40 Percentage of children with squint 0.7 1.1 1.2 1.2 1.1 In 1934 arrangements were made with the Western Ophthalmic Hospital that for a fee of ten guineas per annum the hospital should accept for in-patient or out-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 :— 6 for operation for squint. 10 for other conditions. 1 for operation for detached retina. In addition to these, 28 children attended the hospital during the year for treatment for squint, making a total of 253 attendances. Tuberculosis.— No cases of pulmonary tuberculosis were found. Crippling Defects.— The following defects were seen during the course of Routine Medical Inspection :— 3 cases of infantile palsy. 1 case of hemiplegia. 5 cases of spinal curvature. 1 case of cleft palate. 1 case of spastic diplegia. 1 case of severe flat foot. 1 case of cleft palate and hare lip. 1 case of old tuberculous shoulder. 1 case of dwarfism. 1 case of congenital dislocation of hip. 1 case of hammer toe. 1 case of talipes equinus. 1 case of Perthe's disease. 96 INFECTIOUS DISEASE. 1933 1934 1935 1936 1937 Measles 4 430 15 404 37 German Measles 6 160 1 9 - Mumps 667 277 53 197 264 Whooping cough 78 72 79 154 61 Chickenpox 235 100 243 149 87 Scarlet Fever 134 135 136 128 93 Diphtheria 28 11 32 53 87 Diphtheria Carriers — 3 — 1 2 The above table shows that school children were reasonably free from infectious disease during the year. The figures for measles, german measles, whooping cough and chickenpox are based on the number of children excluded from school for these complaints. These diseases are not notifiable in Enfield. Mumps continued all the year round but it was only in the latter part of the year that measles appeared. There was a reduction in the number of cases of scarlet fever notified, but an increase in those of diphtheria. Most of the cases of diphtheria were spread throughout the year, with the exception of the last three months when there was an increase in the rate of notification. I still continue to immunise a small number of school children against diphtheria and there is a limited call from the medical practitioners of Enfield for material to carry out immunisation. I can only repeat, however, my remarks of previous years, that the number of children immunised against diphtheria in Enfield is insufficient. I am not satisfied myself that the lowered number of cases of diphtheria that has been recorded for the past five years is due to better social conditions, better housing, better environment, purer water supplies, better drainage, nor increased purity of the food. I think that it is purely and simply a matter of chance, and that a time will come when diphtheria will once more be prevalent in Enfield in virulent form. Should such a time arise, the increased urbanisation of the district will favour the spread of the disease. Every parent who desires to give his child protection against disease should take advantage of the increase in medical knowledge which has made diphtheria a preventable disease, and arrange for his children to be immunised either through the services of the medical practitioners or the amenities provided 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 97 department is informed. Joint action is therefore possible in preventing the spread of infectious disease. VERMIN. Of 3,967 children examined at Routine Inspection 5 were found to have vermin in their hair, and 202 had nits—i.e., 5.2 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 of 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 Officers. 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 1937 and for the past five years :— 1933 1934 1935 1936 1937 Number of home visits 2,943 2,697 2,830 2,710 2,752 Number of school visits 621 559 573 535 610 Number of school visits for routine examination of heads 220 195 184 166 153 Total number of heads examined 39,154 37,303 36,616 33,806 33,227 TREATMENT CLINICS. There are three Minor Ailment Clinics in Enfield at which a nurse attends every day. These clinics are held from 2 p.m. to 3.30 p.m. at Eastfield Road School and Lavender Road School, and from 9 a.m. to 10.30 a.m. at Southbury Road School. Every new case attending the Nurse's Clinic during the week is seen by one of the Assistant School Medical Officers at the next Doctor's Clinic. One attendance a week is made by the Assistant School Medical Officer at Eastfield Road, Lavender Road and Southbury Road Clinics, and an additional clinic is held on Wednesday mornings at the Southbury Road Clinic by the Deputy Medical Officer of Health and Assistant School Medical Officer. During the course of the year the Committee resolved to build 98 a new minor ailment clinic to replace the Eastfield Road School Clinic. This clinic will be built in conjunction with the new school that is being erected in Bell Lane. It will also contain accommodation for a dental surgeon. At the time of writing this report the clinic is in the course of erection and I hope in my next annual report to give a description of it. The number of children that attended the minor ailment clinics during 1937 was 4,245, and the total number of attendances was 27,272. The average attendance at the nurses' clinics was 37 (i.e., III per day for the three clinics). At the School Medical Officers' Clinics the average attendance was 44. All children leaving school are given a medical examination early during their last term so that defects may be remedied before they leave. The result of this examination is entered upon a special card which is sent to the Juvenile Employment Committee. Table IV gives in detail the diseases dealt with at the Minor Ailment Clinics. Tonsils and Adenoids.—During the year 482 cases were seen at the clinics and referred for treatment, and 240 cases were kept under observation. Of these, 324 were operated on under the Authority's scheme and 61 were operated on by private arrangement. The following is a comparative table for the last five years 1933 1934 1935 1936 1937 Number of cases referred for treatment 467 320 501 400 482 Number of cases operated under the Authority's scheme 224 224 331 290 324 Number of cases operated by private arrangement 53 29 76 76 61 Tuberculosis.—Seven cases of suspected or definite pulmonary tuberculosis were seen at the clinic during the year. One child was offered sanatorium treatment and refused. All cases notified in previous years were kept under observation, and some were given convalescent treatment. Ringworm.—Two children were found to be suffering from ringworm. The following is a comparative table for the last five years :— 1933 1934 1935 1936 1937 Number of children found to be suffering from ringworm 9 n 1 6 2 Impetigo.— During the year thirty-three cases were seen; all were treated at the clinic. 99 The following is a comparative table for the last five years :— 1933 1934 1935 1936 1937 Number of children found to be suffering from Impetigo 14 12 14 33 33 Scabies.—Fifteen cases were seen. The following is a comparative table for the last five years. 1933 1934 1935 1936 1937 Number of children found to be suffering from scabies 11 16 — 15 15 Other Skin Diseases.—203 cases were seen. These consisted chiefly of seborrhoea, eczema and psoriasis. Eye Diseases.—364 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.— Eighty cases of otitis media were found and were referred for treatment to the Aural Clinic. Heart Disease.—Sixty-five children were found to be suffering from organic heart disease; nine of these were referred for treatment and the rest were kept under observation. In addition to these, 8 cases were seen at Routine Inspection only, making a total of seventy-three cases seen during the year. Of these cases, twelve were congenital and four followed acute infectious diseases. The remaining fifty-seven cases may be classified as follows :— Definite rheumatic history 16 Vague pains 9 No history of illness 32 Chorea.—Fifteen children were found to be suffering from chorea; eight of these were recovering and were kept under observation. All the rest were referred for treatment to a doctor or hospital. Crippling Defects.—The following defects were seen at the clinic 3 cases of hemiplegia. 1 case of congenital multiple exostosis. 6 cases of spinal curvature. 3 cases of hammer toe. 4 cases of club foot. 2 cases of old tubercular hip. 6 cases of infantile paralysis. 2 cases of cleft palate and hare lip. 1 case of cleft palate. 1 case of dwarfism. 1 case of crippling following osteomyelitis. 1 case of congenital dislocation of hip. 100 1 case of birth palsy. 1 case of old tubercular knee. 1 case of severe flat foot. 3 cases of cerebral diplegia. 1 case of Perthe's disease. 1 case of old ricketty chest. 1 case of wasting of right shoulder and arm muscles. 1 case of old tubercular shoulder. 1 case of ankylosis of hip. All of these children who required treatment were either attending hospital or obtaining treatment locally. Other Conditions. i case of intermittent glycosuria. 1 case of fibro-cystic disease of humerus. 5 girls were found to be suffering from enlargement of the thyroid gland. Four are being kept under observation, and one is attending hospital. 2 cases of chronic nephritis were seen, one was attending hospital for treatment, and the other was kept under observation. 62 cases of obesity were seen. 20 were referred for treatment and 42 were kept under observation and advised re diet. 4 cases of potential obesity in young children were seen and kept under observation. 1 case of diabetes is being treated at hospital. 11 children were found to be suffering from hernia; all were referred to doctors or hospitals. Five were operated upon, and 4 refused treatment. 1 case of hydrocoele was referred to hospital and operated upon. 3 cretins were referred to hospital. 1 child was found to be suffering from erythema nodosum. 2 cases of haemophilia. 1 child was found to be suffering from a post orbital growth. The total number of children examined during the year, excluding those attending the Dental Department, was 12,138. This number was made up as follows :— Examined at Routine Inspection 3.967 Examined at Minor Ailment Clinics 4.245 Examined at Ophthalmic Clinic only 520 Examined at Aural Clinic only 106 Examined at school leaving age for Juvenile Employment Committee 908 Examined under Juvenile Employment Bye-laws 83 Examined under Mental Deficiency Act 29 Examined as contacts with infectious disease. . 2,280 Payments at the clinics were continued on the same lines as in 101 former years— i.e., a charge of twopence per week was made for treatment at the Minor Ailment Clinic, and three pence per attendance at the Dental Clinic (sixpence if gas is given). For spectacles and for nose and throat operations parents are asked to sign a form of consent and willingness to pay at least part of the cost before the child is referred for treatment. In really necessitous cases the Local Authority bears the whole cost. During the year the sum of £ 320 17s. 6d. was collected as follows :— £ .s. d. Minor Ailment Clinics 2132 For cost of spectacles 40 14 6 For convalescent treatment 80 3 6 For operations for tonsils and adenoids 146 19 11 For dental treatment 49 14 5 For provision of instruments 120 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; 15 girls and 14 boys were sent during 1937. During 1937 two beds were also reserved for a period of six months at Collington Manor, Bexhill, and three girls and three 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, one child was supplied with a surgical instrument, and ten children were sent to residential schools other than the Russell-Cotes School or Collington Manor. There was a total of 14 deaths among the school children during the year. In 1936 there were five. The causes of death during 1937 were as follows :— 1 Miliary Tuberculosis. 3 Pneumonia. 1 Cerebral Abscess. 2 Heart Disease. 1 Laryngeal Diphtheria. 4 Meningitis. 1 Neuroblastoma (Malignant). 1 Accident (Fractured Skull). THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC HEALTH. The hygienic conditions of the schools in Enfield are the same as in my report for the year 1935. 102 THE TEACHING OF HYGIENE. For the greater part, hygiene is taught as a class room subject, hut is correlated with Domestic Subjects and with Natural Science. The Authority has included in its film library cyclic films (diagrammatic) on "The Heart" and "Circulation of the Blood." These are proving the most popular numbers in the Film Library. Considerable advance in Science (including Biology) teaching in Girls' Schools has been made in the last two years. There are seven full time teachers of Domestic Subjects. Until the reorganisation programme is completed some of the Senior Girls will continue to take Domestic Subjects at schools other than their own. At present all the Senior Girls receive Domestic Subjects instruction for one whole day per week for the last academic year of the school life. In some cases the instruction is continued beyond this period till the leaving date. It is the Authority's aim to make sufficient provision to give at least two years' instruction. The scheme includes :— 1. General elementary principles of Housewifery. 2. The fundamentals of kitchen management and cookery. 3. The fundamentals of laundry. 4. The elements of Mothercraft. (This is directly linked with the Council's Maternity and Child Welfare service). Items 1 and 2 constitute about two-thirds of the course. The following demonstrations of the bathing of a baby were given by the Health Visitors during 1937 :— By Miss Newbegin at the Central School 2 demonstrations By Miss Newbegin at SufFolks School 6 demonstrations By Miss Newbegin at Bush Hill Park School 4 demonstrations By Miss Garlick at Chesterfield Road School 2 demonstrations By Miss Wilkinson at Alma Road School 2 demonstrations By Mrs. Herbert at Lavender Road School 2 demonstrations Thus 18 demonstrations were given during the year, as compared with seventeen last year. OPEN-AIR EDUCATION. There are no open-air schools or classes in Enfield. PHYSICAL TRAINING. Up to January, 1938, the Authority had the services of Mr. M. Dixon as Physical Training Organiser. From that time they have shared with Middlesex County Council in the services of Mr. Dixon and Miss D. Oldham, M.A., as joint organisers of Physical Training for all purposes throughout Enfield and adjacent parts of Middlesex. 103 This has resulted in a marked improvement in the official connection between all forms of Physical Training throughout the area. Particularly, advance had been made, by Mr. Dixon, in preparation for this extension of function, in organising throughout 1937 Leaders Classes so that a full and well developed programme is operative now, and much help is being afforded to Juvenile Organisations, who have also been granted use of the Authority's schools and playgrounds for approved activities at the nominal rate of 1/- per use. The development of Physical Training in the schools of the Authority has reached an advanced standard. PROVISION OF MEALS. Meals are provided for necessitous children. They are provided at the following centres :— St. Luke's Institute, Enfield. Feeding Centre, Alma Road, Ponders End. Bellside Dining Rooms, Enfield Wash. Dining Rooms, St. Mark's Road, Bush Hill Park. During the course of 1937 41,954 meals were provided free to 396 children. The number of dinners provided in 1936 was 42,657. The arrangements commenced during 1935 for the provision of milk to children free, and at id. for 1/3 pint, were continued. During 1937 982,047 bottles of milk were provided and paid for, and 88,288 bottles of milk were provided free to those children whose circumstances were such that their parents could not afford to pay. This compares with 892,743 bottles and 96,974 bottles respectively during 1936. The milk was pasteurised and delivered in one-third pint bottles, and drunk through a straw. Children receiving free milk are examined twice a year by one of the School Medical Officers. The average gain in weight amongst children having milk was about six pounds during the year. CO-OPERATION OF PARENTS. It is very disappointing to note that this year the percentage of parents who attended when their children were examined fell to 73. This is between three and six per cent lower than it has been for the past five years. The Education Committee provides for the school children of Enfield facilities to improve the health of the children. These facilities include routine medical inspection, dental treatment, ophthalmic treatment, convalescent treatment, special examinations, and medical advice. If the children are to benefit fully from the advantages which are placed before them by the Education Committee the co-operation of the parents must be obtained. It is extraordinary that parents should realise the necessity for the general education 104 of their children yet fail to appreciate the fact that it is essential in the first place to secure for them perfect health. During the year the Medical Department receives frequent requests for special treatment at the school clinics, be they for the provision of glasses, the treatment of squint or defects of the ear; these requests frequently come from parents who have refused toallow their children to be examined at routine inspection, or failed to come when their children were examined. It is a routine to refuse this specialised treatment until the children have been presented for a full examination. To provide treatment without examination would be unscientific and unwise. The fact remains, however, that 27% of the parents of Enfield who knew their children were being medically examined did not think it essential to be present themselves nor to be represented by a relative or friend. I am not arguing that the percentage of parents who do attend in Enfield is lower than elsewhere—it is probably as high or even higher than the average. There are districts, however, where almost 100% of the parents attend and this is what should pertain in Enfield, and something which the Education Committee have a right to expect. It is extremely difficult to help parents who are unwilling to help themselves. If, however, this paragraph is a criticism of the 27% of absentee parents, it is alsoan acknowledgement of the co-operation received from the remaining 73% who did attend. CO-OPERATION OF TEACHERS. It has been stated, and rightly so, that the first line of defence in the prevention of disease among school children is manned by the school teachers, and that the success of a school medical department depends on their whole-hearted co-operation. The teachers are in daily contact with the children ; it is they who become aware of dullness, listlessness, pallor, and general debility amongst their scholars. It is they who often diagnose the first signs of infectious disease and exclude children before they spread infection. Bearing this in mind I cannot pay too high a tribute to the school teachers of Enfield for their friendship and co-operation. Throughout the year at every clinic children are seen who have been sent there on the advice of the teacher. Many of these children have been found to be suffering from defects, which except for the care and concern of the teachers might have passed unnoticed. CO-OPERATION OF SCHOOL ENQUIRY OFFICERS. Arrangements are in force by which the School Enquiry 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 Enquiry Officers. 105 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 :— Twelve children were given cod-liver oil and malt, Parrish's Food, etc., and ten convalescent treatment; 409 pairs of ordinary boots were also provided. One child was provided with fares to hospital. Through the medium of the Children's Care Committee, massage is provided for the children requiring it. A fee of two shillings per visit is charged, and this is paid by the parents 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. CO-OPERATION OF LOCAL PRACTITIONERS. The co-operation of the general practitioners of Enfield has been sought and maintained throughout the year. In 396 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 cooperation 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 six such children in Enfield, and they are educated as follows :— 2 girls attending residential schools for the blind. (1 at Swiss Cottage and 1 at Court Grange Special School.) 4 girls attending Lordship Lane School for the Partially Sighted, Wood Green. Deaf and Deaf-mutes.—These children attend the Philip Lane School for the Deaf, Tottenham. At the end of 1937, 11 children were attending : 3 deaf-mutes, 3 suffering from acquired deafness, and 5 suffering from motor aphasia. Mentally Defective Children.—Thirty children were examined under the Mental Deficiency Act (1913) during 1937. 106 The following is a comparative table for the last five years :— 1933 1934 1935 1936 1937 A. Dull and backward, but capable of instruction in an elementary school 1 4 5 4 12 B. Mentally Defective, but capable of instruction in a special school 7 8 9 8 7 C. Incapable of further instruction in a special school 2 1 1 D. Imbecile 4 1 4 6 10 . Moral Imbecile 2 E. Not scheduled 5 2 1 1 EXAMINATION AND TREATMENT OF SECONDARY SCHOOL CHILDREN. The Enfield Education Committee undertakes the examination of children attending the secondary schools in the district, on behalf o 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 :— Jnr. Technical. Grammar. County. Number of children examined 101 239 217 DEFECTS. Jnr. Technical. Grammar. County. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Dental Caries 6 15 2 Defective Vision 4 1 16 — 32 25 Enlarged Tonsils, etc. — — — — 4 — Blepharitis — — — — 1 — Other Diseases and Defects 1 2 11 4 Anaemia — — 1 — — — Other Skin Diseases — — — — 1 — Enlarged glands — — 1 — — 408 children were treated at the Dental Clinic during 1937. 86 children were treated at the Ophthalmic Clinic during 1937. 107 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, 1937. 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, 1937. The elementary school population of Enfield was 10,844 in March, 1937. There were in addition 1,140 secondary school children, and at Nassau House Special School a further 36 children who reside in Enfield and are entitled to treatment under the Enfield dental scheme—a total of 12,020 children. It was suggested by Sir George Newman, late chief Medical Officer of the Board of Education, in his annual report for 1929, that in a complete dental scheme one dentist could undertake the dental care of 2,300 children and that in a partially complete scheme one dentist should have under his care not more than 4,000 children. If these figures are accepted, the inadequacy of the present dental staff in Enfield of two dentists for 12,000 children is apparent. The total number of elementary school children examined during the year under review was 4,936 and the number treated 2,659. Fillings and extractions for elementary school children amounted to 3,068 and 5,998 respectively. The following table shows how these figures compare with the corresponding figures of the two previous years :— TABLE A. INSPECTION AND TREATMENT OF ELEMENTARY SCHOOL CHILDREN. Year. Number Inspected. Number Treated. Number of Fillings. Number of Extractions. 1935 4139 2577 3268 4339 1936 5597 3554 4871 6498 1937 4936 2659 3068 5998 108 During 1937 much treatment was carried out for children attending the secondary schools. This treatment was given as a result of the Dental Inspection held towards the end of 1936. These children were not re-inspected during 1937, no time being available. The following table shows how the treatment of secondary school children was distributed between the three schools :— TABLE B. TREATMENT OF SECONDARY SCHOOL CHILDREN IN 1937. School No. treated No. of Attendances No. of fillings in perm, teeth No. of fillings per child insptd. No. of Extractions of Total no. of extractions No. of administra tions of Gen. Anaes. No. of other operations Temp, teeth Perm, teeth Girls' County School 186 439 399 2.14 3 102 105 9 61 Boys' Grammar School 169 367 727 4.3 23 95 118 5 78 Boys' Technical School 53 165 277 5.2 3 34 37 - 36 Totals 408 971 1,403 3.43 29 231 260 14 175. 109 groups. Consequently more time is required for the treatment of secondary school children than for children attending the elementary schools. During 1937 the number of secondary school children treated was 408, while in 1936 only 86 received treatment. The larger number of secondary school children treated during the year under review explains the reduction in the total number inspected and treated—elementary and secondary school children combined—as compared with 1936. It is submitted, however, that the figures to which most importance should be attached are those referring to treatment. To inspect a large number of children without being able to offer treatment to those requiring it does not serve much purpose, and it is less desirable to give incomplete treatment to many than complete treatment to a smaller number. At the present time the interval between routine inspections is approximately two years. In order to reduce this interval a restrictive scheme has been suggested in which priority is given to those children likely to derive most benefit from the treatment offered. This can be regarded only as a temporary expedient until such time as the Dental Staff is increased. Out of every 100 children inspected as routines 69.1 were referred for treatment and written consents to treatment were received from parents in the case of 75 per cent, of those referred. This does not mean that the remaining 30.9 per cent, were dentally perfect. Many cases were not offered treatment owing to repeated previous refusals to accept treatment, and for other reasons. Fillings in permanent teeth numbered 4324, in temporary teeth 147, a total of 4471 fillings. Of the total number of 6258 extractions, 5141 were temporary and 1117 permanent teeth. Of the permanent teeth extracted 116 were sound teeth extracted for regulation purposes, the remainder being extracted for advanced dental caries. The number of administrations of general anaesthetics was 236 and of local anaesthetics 2485. "Other operations" totalled 1218, and under this heading are included 293 polishings of permanent teeth, root dressings, root fillings, silver nitrate dressings, temporary fillings, polishings of fillings, and adjustments to regulation plates. The number of regulation plates fitted was 17. The average amount of work done by each dentist per treatment session was :— Fillings 5.9 Extractions 8.3 Other operations 1.6 The high incidence of dental caries during adolescence, referred to earlier in this report, is well illustrated in the following table of the higher age groups of Grammar School boys. 110 TABLE D. Grammar School Boys. Higher age groups. Age. Number treated. Number of Fillings inserted. Number of Fillings per child treated. 14 33 105 3.15 15 28 100 3.57 16 25 165 6.6 17 24 145 6 18 1 11 11 Totals 111 526 4.72 It may be of interest to compare the average number of fillings required by secondary school boys with figures recently given respecting dental treatment required by army and air force recruits. It was found that each army recruit required 5.5 fillings. This compares with an average of 4.72 fillings for each Grammar School boy as shown in the above table (higher age groups). In the air force each accepted recruit required an average of 5.1 fillings, and dental conditions were responsible for the rejection of 310 men out of every 1,000 men rejected. The dental condition of recruits shows the urgent necessity of providing dental treatment for adolescents. A boy may leave school dentally fit having received regular dental treatment during his school life. In most cases he will receive no further conservative treatment whatever and much of the benefit he has derived from the School Dental service will eventually be lost. Much has been written lately respecting the importance of improving the condition of the teeth of preschool children. It is noticeable, however, that generally the emphasis is laid on treatment rather than prevention, in spite of the fact that unless prevention occupies the foremost place in the fight against dental disease there can be little hope of any great improvement in the dental health of very young children. The Chief Medical Officer of the Board of Education in his annual report for 1936, writes of the difficulty of carrying out successful conservative work on the temporary teeth of school children, especially when the caries is on the approximal surfaces of the molar teeth. He expresses the view that probably 10% or more, of fillings in these positions are not successful and draws the conclusion that ; " A conservative operation with a failure rate of 10% is likely to do more harm than good to the school dental service." If this view is correct with regard to the treatment of children attending school, 111 it must apply with added force to the treatment of children who have not yet reached school age. In attempting to treat conservatively the teeth of pre-school children the dentist has to contend not only with the technical difficulties referred to by the Chief Medical Officer but with additional difficulties associated with the extreme youth of the patients. Large numbers of these children, entitled to treatment under Maternity and Child Welfare dental schemes, are mere babies between the ages of 2½ and 3½ years, and any treatment of their teeth requiring the use of the dental engine is attended with obvious difficulties. Difficulties of treatment are additional reasons for emphasising the importance of prevention, and while our present knowledge does not permit us to say that dental disease can be entirely prevented, it does permit us to say that it can be controlled. The good teeth of children brought up in institutions illustrate how the incidence of dental caries can be reduced when errors of diet are avoided. Mr. F. Breese, L.D.S., Eng., in a paper given before the Dental Officers group of the British Dental Association a few years ago, gave particulars illustrating the comparative freedom from dental caries of 600 children in a large Poor Law Institution. These children had been under his care for 24 years, and during the whole of this time he had kept a record of their dental condition. Many other dentists holding appointments with Institutions have given similar evidence of the superior dental health enjoyed by these children. It cannot be said that the law of heredity favours Poor Law children, nor that before entering the institution their environment is better than that of the average child—the contrary may, in fact be presumed. There is no doubt that the main factor responsible for the good teeth of children living in institutions is the avoidance of those dietetic errors that Dr. A. Jefferis Turner, M.D., D.P.H., had in mind when he said in the course of a lecture: "It would almost seem that we feed our children expressly with the object of destroying their teeth. Not content with three meals a day, many mothers give biscuits and bread and butter between meals, at irregular intervals, so that the teeth are never free from their debris. Fruit is not looked upon as a regular article of diet to be given at meal times and especially at the end of a meal, but as a luxury to be given between meals and often in excessive quantities. And to make things sure, we give them large quantities of concentrated sugar in the form chiefly of soft sweets." With regard to changing habits of diet, it has been truly said that parents will do for their children what they will not do for themselves —and, it may be added, many parents will do for babies and young children of pre-school age what they will not do for older children. If the simple rules of prevention, which inflict no hardship on the child and can be applied by rich and poor alike, were advocated with persistence, conviction and enthusiasm by all interested in dental 112 health, an enormous decrease in the incidence of dental caries would result—particularly in young children of pre-school age. The sum received in fees from elementary school children during 1937 amounted to £49 14s. 5d. In conclusion, Mr. Mackay and I wish to express our thanks to all Head Teachers for their assistance in obtaining consent to treatment and in persuading children to keep their dental appointments—also to acknowledge our appreciation of the invaluable help rendered by Nurse Anderson and Miss Groves. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. E. JAMES, Senior School Dental Surgeon. 113 Annual Report of the School Ophthalmic Surgeon Mr. S. MACKY, M.B., B.S., D.O.M.S. For the Year Ending 31st December, 1937. 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, 1937. Elementary Schools. 1936 1937 Total attendances 2,072 1,910 New cases 1,028 1,015 Prescriptions for glasses 336 332 Number not requiring glasses 112 95 The cases requiring glasses consisted of :— Hypermetropia 84 74 Hypermetropia with astigmatism 314 312 Hypermetropic astigmatism 154 158 Myopia 96 89 Myopia with astigmatism 99 108 Myopic astigmatism 11 10 Mixed astigmatism 64 62 Anisometropia !5 12 Secondary Schools. Total attendances 96 123 New cases 49 86 Prescriptions for glasses 25 38 Number not requiring glasses 5 9 114 The cases requiring glasses consisted of:— Hypermetropia 2 4 Hypermetropia with astigmatism 10 10 Hypermetropic astigmatism 1 9 Myopia 12 23 Myopia with astigmatism 14 17 Myopic astigmatism — 1 Mixed astigmatism 1 6 Anisometropia 3 3 Six children were referred for operation for squint. Two were operated upon and four are awaiting operation. In addition two children who were referred for operation in 1936 were operated in 1937. One child was operated upon for detached retina. During the year 28 children attended the Western Ophthalmic Hospital for orthoptic exercises making a total of 253 attendances during the year. 1 have taken many interesting cases up to the Western Ophthalmic Hospital for further investigation. These include two cases of suspected optic atrophy, a marked pseudo-neuritis, two cases of retinochoroiditis, one of detached retina, one interstitial keratitis, one of episcleritis, and two of foreign bodies in the eye. The case of detached retina was a very unusual one. We have had a great many more cases from the Welfare Clinics and these are naturally more difficult than the school children, and so we have had to have more extra sessions. It is a great advantage to get some of these children (especially the squints) at a tender age, and in some cases it is vital. For instance, in the current year we have had a case of glioma of the retina and I anticipate that the child's life will be saved by our intervention. That could have been done elsewhere, of course, but the advantages of the full co-ordination of the services should be apparent. I am glad again to give thanks and praise for the kindness and competence of the clerical and nursing staff who help me so much in the work at the clinic. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, STEWART MACKY, School Ophthalmic Servant. 115 Annual Report of the School Aural Surgeon Mr. J. C. HOGG, F.R.C.S. For the Year Ending 31st December, 1937. 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, 1937. 1936 1937 Number of cases dealt with 303 433 Number of new cases 198 327 Total number of attendances 683 851 Number of cases discharged cured 182 214 Number of cases of a recurrent nature requiring occasional treatment 17 15 Number of cases still under treatment 35 112 Number of cases which have refused treatment or sought treatment elsewhere 30 25 Sixty-nine children were recommended for removal of tonsils and adenoids, of which forty-five have had the operation, eight have refused treatment, eleven are awaiting operation and five have been operated on privately. Of the Welfare Department children, forty-five have been referred for removal of tonsils and adenoids, and one case for removal of adenoids only. Three cases have been admitted, under my care, to the Throat Hospital, Golden Square. The first case was operated on for chronic mastoiditis and has since made a complete recovery; the second, a case of cleft palate was admitted for removal of the tonsils by dissection, and the third was admitted for the removal of an aural polypus. The latter was much improved and has since left school. 116 During the year under review, ninety-two infants and eight mothers have been examined in connection with the Infant Welfare Centres and these figures have been included in the list of cases tabled above. The total number of attendances amongst Welfare Infants and Mothers, during the year was one hundred and forty-one. Once again I should like to express my gratitude to the Nursing Staff in the Southbury Road and other Clinics for their whole-hearted support and co-operation in 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. 117 LIST OF CASES. CLASSIFICATION. Still under treatment. I.S.Q. Improved. Discharged cured. Recurrent, but again discharged. Refused treatment. Left School, District, or treated elsewhere. Total 1. Acute or subacute suppurative otitis media 3 1 70 1 1 2 78 2. Chronic suppurative otitis media 20 13 31 14 1 7 86 3. Chronic catarrhal deafness, Eustachian obstruction and otosclerosis 10 6 20 — 4 — 40 4. Wax, otitis externa, eczema, boils, etc. — 2 46 — 1 — 49 5. Chronic Rhinitis, nasal obstruction,T's and A's, etc. 48 9 68 — 5 4 134 6. Non-aural — — — — — — 46 Total 433 118 Statistical Tables for the Annual Report of the School Medical Officer, for the Year 1937. TABLE I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed groups:— Entrants 936 Second Age Group 1154 Third Age Group 998 Total 3,088 Number of other Routine Inspections 879 Grand Total 3,967 B.—OTHER INSPECTIONS. Number of Special Inspections 8,088 Number of Re-Inspections 4,062 Total 12,150 C. CHILDREN FOUND TO REQUIRE TREATMENT. Number of Individual Children found at Routine Medical Inspection to require treatment (excluding defects of Nutrition, Uncleanliness and Dental Diseases). Group. For Defective Vision (excluding squint). For all other conditions recorded in Table IIA. Total. Entrants 6 165 171 Second Age Group 102 163 265 Third Age Group 70 63 133 Total (Prescribed Groups) 178 391 569 Other Routine Inspections 59 170 229 Grand Total 237 561 798 119 TABLE II. (A) Return of defects found by Medical Inspection in the year ended 31st December, 1937. DISEASE OR DEFECT. Routine Inspections Special Inspections 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 — — — — Body — — 2 — Scabies 1 — 15 — Impetigo 1 — 33 — Other Diseases (Non-Tuberculous) 10 1 142 11 Total 12 1 192 11 EYE. Blepharitis 18 1 49 — Conjunctivitis 7 — 91 — Keratitis — — 1 — Corneal Opacities — — — 2 Other Conditions (Excluding Defective Vision and Squint 6 - 96 5 Total 31 1 237 7 Defective Vision (Excluding Squint) 237 172 193 14 Squint 40 21 23 4 EAR. Defective Hearing 59 4 35 2 Otitis Media 25 — 80 — Other Ear Diseases 18 — 63 4 NOSE AND THROAT. Chronic Tonsillitis only 14 43 64 75 Adenoids only 2 3 2 5 Chronic Tonsillitis and Adenoids 251 181 416 160 Other Conditions 27 7 62 302 120 TABLE II (continued) ENLARGED CERVICAL GLANDS (Non-Tuberculous) 1 - 26 35 DEFECTIVE SPEECH 1 11 - 17 HEART AND CIRCULATION. Heart Disease Organic 2 20 9 56 Functional - 4 - 5 Anaemia — 1 7 9 LUNGS Bronchitis 1 4 6 17 Other Non-Tuberculous Diseases 2 4 11 6 TUBERCULOSIS. Pulmonary Definite - - 2 2 Suspected — - 3 — Non-Pulmonary Glands 1 — 8 — Bones and Joints — — — — Skin — — — — Other Forms — 1 — — Total 1 1 8 — NERVOUS SYSTEM. Epilepsy 2 3 10 5 Chorea 1 2 10 3 Other Conditions 1 — 6 11 DEFORMITIES. Rickets — - - — Spinal Curvature 3 2 8 - Other Forms 6 11 28 30 OTHER DEFECTS AND DISEASES (excluding defects of Nutrition, Uncleanliness and Dental Diseases) 93 24 1799 470 Total Number of Defects 830 520 3300 1250 121 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 936 65 6.9 626 66.9 196 20.9 49 5.2 Second Agegroup 1154 73 6.3 733 63.5 294 25.5 54 4.7 Third Agegroup 998 60 5.1 766 76.8 156 15.6 16 1.6 Other Routine Inspections 879 72 8.2 583 66.4 197 22.4 27 3.2 Total 3,967 270 6.8 2,708 68.1 843 21.3 146 3.7 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no school or Institution Total 2 - — 1 3 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions At no School or Institution. Total. — 4 - — — 4 122 TABLE III.—continued. DEAF CHILDREN. At Certified schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total 3 — — — 3 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 — 3 - — - 3 MENTALLY DEFECTIVE CHILDREN. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions At no School or Institution Total 38 — — — 38 EPILEPTIC CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions At no School or Institution Total - — - - - 123 TABLE III.—continued. PHYSICALLY DEFECTIVE CHILDREN. A. TUBERCULOUS CHILDREN. I—CHILDREN SUFFERING FROM PULMONARY TUBERCULOSIS. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 5 - 1 8 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 4 — 1 7 B.—DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions. At no School or Institution Total 6 15 - 1 22 C.—CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 3 22 — 1 26 124 TABLE III—continued. D.—CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions. At no School or Institution. Total 3 - - — 3 CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institutions Total. Crippled and Heart. - 1 - - 1 125 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1937. TREATMENT TABLES. GROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Table VI.) DISEASE OR DEFECT Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) SKIN. Ringworm—Scalp (i) X-Ray Treatment — — — (ii) Other ,, — — — Ringworm—Body 2 — 2 Scabies 15 — 15 Impetigo 34 — 34 Other Skin Diseases 133 15 148 MINOR EYE DEFECTS (External and other, excluding cases falling in Group II.) 246 4 250 MINOR EAR DEFECTS 364 12 376 MISCELLANEOUS (e.g.. minor injuries, bruises, sores, chilblains, etc.) 1696 84 1780 Total 2490 115 2605 126 TABLE IV.—continued. 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) 825 3 828 Other Defects or Disease of the Eyes (excluding those recorded in Group I.) 18 — 18 Total 843 3 846 Under the Authority's Scheme Otherwise. Total Number of Children for whom Spectacles were: (a) Prescribed 332 3 335 (b) Obtained 331 3 334 127 TABLE IV.—continued. GROUP III.—TREATMENT OF DEFECTS OF NOSE AND THROAT No. of Defects. Received Operative Treatment. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme Total Received other forms of Treatment Total number treated. (1) (2) (3 (4) (5) I. II. III IV I. II. Ill IV. I. II. III IV 25 3 296 — 7 — 54 — 32 3 350 - 69 454 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. Residential treatment with education Residential treatment without education Nonresiden tial treatment at an Orthopaedic Clinic Residential treatment with education. Residential treatment without education. Nonresiden tial treatment at an Orthopaedic Clinic Total number treated Number of Children treat ed 5 - - - - 18 23 128 TABLE V. DENTAL INSPECTION AND . TREATMENT. 1. Number of children inspected by the Dentist:— (a) Routine Age Groups. Age 5 6 7 8 9 10 11 12 13 14 Total. Number 298 352 430 428 401 389 356 311 292 165 3422 (b) Specials 1,514 (c) Total (Routine and Specials) 4,936 2. Number found to require treatment 3,879 3. Number actually treated 2,659 4. Attendances made by children for treatment 4,868 5. Half-days devoted to:— Inspection 30 Total 776 Treatment 746 6. Fillings:— Permanent Teeth 2,921 Total 3,068 Temporary Teeth 147 7. Extractions:— Permanent Teeth 886 Total 5,998 Temporary Teeth 112 8. Administrations of general anaesthetics for extractions 222 9. Other onerations:— Permanent Teeth 942 Total 1043 Temporary Teeth 101 TABLE VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. I. Average number of visits per school made during the year by the School Nurses 8 II. Total number of examinations of children in the Schools by School Nurses 33,227 III. Number of individual children found unclean 871 IV. Number of individual children cleansed under Section 87(2) and (3) of the Education Act, 1921 - V. Number of cases in which legal proceedings were taken: (a) Under the Education Act, 1921 - (b) Under School Attendance Bye-laws 30 INDEX A. PAGE Adulteration 33 Ambulance facilities 16 Area of District 5 Aural Surgeon's Report 115 Aural Treatment 63 B. Baby Week 65 Bakehouses 33 Births 13,55 Birth Control 88 Blind, Deaf, Epileptic and Mentally Defective Children 105 Blind and Partially Blind Children 121 Bye-laws and Regulations 31 C. Causes of death at all ages 10 Causes of death under 1 year of age 11 Cerebro-spinal Fever 37 Cesspools 20, 82 Chief Sanitary Inspector's Report 69 Children Act 64 Children Suffering from Multiple Defects 124 Children suffering from Pulmonary and Non-Pulmonary Tuberculosis 123 Children with Heart Disease 124 Circulation of Booklet on Rearing of Children 66 Clinics and Treatment Centres 53 Closet Accommodation 21 Convalescent Treatment 67 Co-operation of Local Practitioners 105 Co-operation of Parents 103 Co-operation of Teachers 104 Co-operation of School Enquiry Officers 104 Co-operation of Voluntary Bodies 105 Co-operation with Education Committee 67 Councillors 4 Crippled Children 123 D. Deaf and Partially Deaf Children 122 Deaths 8 Defective Vision and Squint 126 Defects found at Routine Medical Inspection 93 Delicate Children 123 Dental Inspection and Treatment 128 Dental Surgeon's Report 107 Dental Treatment 65 Detection and Spread of Infectious Disease 96 Diphtheria 36 Diphtheria Carriers 36 Diphtheria Immunisation 36, 37 Disinfection 75 Disinfection of verminous persons and their belongings 42 Disinfestation of Verminous Houses 42,75 D. PAGE Disposal of house refuse 21 Drainage and sewerage 20 Drinking fountains 83 Dysentery 37 E. Encephalitis Lethargica 37 Enteric and Paratyphoid Fever 37 Enteritis 38 Epileptic Children 122 Eradication of Bed Bugs 42, 43, 44 Examination of Secondary School Children 106 F. Factory and Workshops Act 76 Fitness of houses 31 G. General Observations 28 H. Home Helps 66 Horse troughs 83 Hospitals 17 Housing 26 Housing conditions 30 Housing Survey 28 I. Infantile Mortality 11, 13, 55, 56 Infectious Disease 19, 96 Infectious Diseases and Schools 25 Infectious Diseases table 35 Inquests 12 Inspection and supervision of food 31 Insulin, Supply of 42 Isolation Hospital 19 L. Laboratory facilities 16 M. Maternal Mortality 57 Maternity and Child Welfare Statistics 60, 61 Maternity and Child Welfare Staff 48 Maternity Centres 53 Maternity Hospital 19 Measles and German Measles 37, 38 Meat 32 Members of Education Committee 86 Members of Health Committee 4 Members of Maternity and Child Welfare Committee 48 Mentally Defective Children 122 Meteorology 45 Midwives 57, 58, 66 Milk 31, 78 Milk (Special Designations) Order 32 Minor Ailments 125 Mortuary 83 Motor Ambulances 80 N. PAGE National Health Insurance 16 Notices issued 72 Notifiable diseases 34, 35 Number of Elementary School Children 91 Number of Individual school children found at Medical Inspection to require treatment 118 Nursing in the Home 15 Nursing Homes 59 0. Obstetric Specialist 66 Offensive Trades 77 Officials of Council 4 Open Air Education 102 Ophthalmia Neonatorum 39 Ophthalmic Surgeon's Report 113 Ophthalmic Treatment 63 Orthopaedic and Postural Defects 127 Other foods 33 P. Paratyphoid and Enteric Fevers 37 Physical Training 102 Physically Defective Children 123 Places of Public Entertainment 77 Poliomyelitis 32 Population 5 Prevalence of, and control over. Infectious and other Diseases 34 Prevention of Blindness 39 Provision of Meals 103 Public Conveniences 82 Public Health (Meat) Regulations 33, 78 Public Health (Prevention of Tuberculosis) Regulations 42 Public Health (Smallpox Prevention) Regulations 34 Public Health Staff 14 Puerperal Pyrexia 57 R. Rag Flock Acts 25 Rats 83 Regulations and Byelaws 31 Removal and disposal of house refuse 21,81 Return of Defects found by Medical Inspection 119 Return of Defects Treated 125 Return of Medical Inspections (Aural) 117 Routine Medical Inspection 92 Routine Medical Inspection of Children under 5 years 62 S. Sale of Foods and Drugs Act 33 Sanitary circumstances of District 19 Sanitary Inspection of District 22 Scarlet Fever 36 School Medical Officer's Report 88 School Medical Service in Relation to Public Health 101 Schools 24,82 s. PAGE Sewerage and drainage 20 Sewer flushing 82 Shops Act 80 Slaughter of Animals Act 33 Slaughterhouses 32 Smoke abatement 22 Social conditions 6 Staff of Public Health Department 14 Staff of School Medical Department 87 Statistical Tables of School Medical Officer 118 Statistics 6 Streams and Water-courses 20 Sub-letting in Council houses 23 Suicides 12 Supply of Insulin 42 Swimming Baths and Pools 22 T. Teaching of Hygiene 102 Tuberculosis 40,41 Tuberculosis (County of Middlesex) Scheme 17 Treatment Clinics (Schools) 97 Treatment of Defects of Nose and Throat 127 Typhoid and Paratyphoid Fever 37 U. Uncleanliness and Verminous Conditions 128 Unsound Meat and foods 80 V. Vermin 97 Verminous houses 42, 43, 44 Veterinary inspection of cows 31 Vital Statistics 6, 54 W. Water-courses and streams 20 Water supply 19 Work of School Nurses 97 Z. Zymotic death-rate 38, 39 Zymotic diseases 38