ENF 22 Hrban Ditstrict Counctl of Enfield ANNUAL REPORT OF THE Medical Officer of Health and School Medical Officer (D. H. GEFFEN, M.D., D.P.H.) FOR 1938 TOGETHER WITH THE ANNUAL REPORT OF THE Chief Sanitary Inspector (FRED. WILSON, M.R.SAN.I., M.S.I.A.) ' Hrban Disitrict Council of Enfield ANNUAL REPORT of the Medical Officer of Health and School Medical Officer (D H. GEFFEN, M.D., D.P.H.) for 1938 together with the ANNUAL REPORT of the Chief Sanitary Inspector (FRED. WILSON, M.R.San.I., M.S.I.A.) Enfield: Stanley Woodfield Printer 8, 10, 12, Windmill Hill 1 Public Offices, Enfield. 4th May, 1939. Annual Report of the Medical Officer of Health, 1938. To the Chairman and Members of the Urban District Council of Enfield. Mr. Chairman, Ladies and Gentlemen, I beg to place before you my twelfth Annual Report on the health of the district. During the course of 1938 the work of the department continued on normal and progressive lines. The outstanding occurrence of the year was the Crisis of September. Up to that time work on the preparation of an Air Raid Precautions Scheme had progressed and taken its place as one of the major tasks of the Health Department ; for the duration of the Crisis it naturally occluded every other branch of work and since then has been carried out at increasing speed. For the first time I am devoting to it a separate section in my Annual Report, indicating to some extent the work that has been entailed. In dealing with Air Raid Precautions, the department is faced with the difficulty of preparing for an occurrence, the size, magnitude and type of which it cannot estimate. Past experience of air raids in this country, or for that matter in other countries, seems to bear so little relation to what might happen if a European War broke out, that guidance based on such experience varies as the source from which it comes. As a result many Air Raid Precautions Medical Schemes have been suggested, yet altered as new ideas have been conceived. The Council will realise how difficult it is to determine on a procedure for an eventuality, the results cf which tax the gifts of imagination. In helping to secure the training in First Aid and Anti-Gas precautions of the personnel that are required, I have had the 2 close co-operation and help of the Doctors of Enfield and the StJohn Ambulance Brigade. The magnitude of the task that has been before us will be appreciated from the fact that I have been required to train in Anti-Gas and First Aid no less than 1,275 persons ; each of these individuals must undergo a full course of training and should pass a requisite examination, after which Units must be formed and collective training arranged. To direct an organisation containing a volunteer staff of this size is no easy task. It is pleasing to record that during the year 1938 the work of the department was continued and kept up to date, yet all the work associated with Air Raid Precautions was carried out with the existing staff. During 1939 this task has become impossible, and I have had to divert one of the staff on to Air Raid Precautions work, whilst in addition the Council has authorised me to appoint a temporary clerk for a period of 6 months. It would appear that Air Raid Precautions is overshadowing these opening remarks in my Annual Report ; my justification is that it is also overshadowing the work of the department. The outstanding feature of the vital statistics for 1938 is the fact that the death rate was 9.15, the lowest recorded since 1923 when it was 8.73 ; the average death rate between 1921 and 1937 was 9.97 per 1,000 population. The number of cases of Scarlet Fever increased from 161 to 190, Diphtheria cases decreased from 132 to 57. In connection with Diphtheria, immunisation continues to be /carried out at the various Clinics and at the Council Offices on Saturday mornings. The number of children immunised is, however, low, and I would like to see more parents take advantage of this successful method of protecting their children from a dangerous and incapacitating disease. During the course of the year 2 cases of Parrot Disease or Psittacosis occurred. They were both Attendants at the London Zoo and contracted the disease from a consignment of parrots recently received there. I saw these cases in consultation with the Doctor in charge. Both patients fortunately recovered and there was no spread of the infection in the district of Enfield. The cases were subsequently described in detail in the British Medical Journal. Towards the end of the year, acting in accordance with Circular 1705 of the Ministry of Health a Maternal Advisory Committee was established by the Council. I have referred to this in detail 3 in another part of my Report. The Enfield Medico-Ethical Society also appointed an Advisory Committee in connection with Air Raid Precautions, and one in connection with the public health of the district. The function of each of these Committees is to assist the Council or the Health Department by tendering advice or giving co-operation when so requested, on matters affecting the General Practitioners of Enfield and the health of the district. Both these Committees have met regularly every month in my office, and I have been very thankful for the advice and help I have received. The Public Health Advisory Committee consists of Drs. D. R. Chisholm (Chairman), Wade and Adam, and on the occasions when the Committee has met various matters of importance to the public health of the district have been discussed. It will be noticed that the number of Council houses found to be infested with vermin was only 22 last year, as compared with 80 in the previous year. It would appear that the problem in so far as Council houses are concerned is diminishing in Enfield. I would once more tender my thanks to the Council for the courtesy I have received throughout the year, and to the members of the Health Department for their loyal co-operation I beg to remain, Ladies and Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health 4 URBAN DISTRICT COUNCIL OF ENFIELD. H. Muspratt, Esq., O.B.E. Chairman S. G. Rowlandson, Esq., F.C.A. Vice-Chairman also H. R. Neilson, Esq. F. G. Fletcher, Esq. E. Edwards, Esq. A. M. Eeles, Esq. C. Partington, Esq., J.P. G. E. Jones, Esq. W. W. Cakebread, Esq. W. H. Betts, Esq. J. C. Bland, Esq. J. W. Draper, Esq. F. Greenwood, Esq. W. G. Spice, Esq. W. C. Bennett, Esq. E. S. Stephens, Esq. H. A. D. Brown, Esq. C. Evans, Esq. W. H. Bishop (Jnr.), Esq. D. Mason, Esq. L. R. Morris, Esq. G. F. Willgress, Esq. H. H. Collier, Esq. T. H. M. Clarke, Esq. A. R. Kemp, Esq. W. S. Williams, Esq. G. S. Thompson, Esq., F.R.C.S.(Edin.). HEALTH COMMITTEE. H. Muspratt, Esq., O.B.E. Chairman also Messrs. Thompson, Clarke, Kemp, Cakebread, Bennett, Brown, Draper and Morris. 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 91,940, 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. 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 1938 91,940 The number of inhabited houses at the end of 1938, according to the Rate Books, was 25,920. The rateable value of the District is £760,172 The net product (after allowing for cost of collection) of a penny rate is £3,120 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. £ £ 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 1938 25,920 760,172 3,120 SOCIAL CONDITIONS. The number of inhabited houses in the District has increased by 11,797 or 83 per cent, during the course of ten years. The rateable value has increased by £287,973, or 61 per cent., whilst the sum represented by a penny rate has increased by £1,040 or 50 per cent, during the course of ten years. During 1937, 2,230 houses were erected, and during 1938, 2,270. This makes a total of 4,500 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 1,678 827 851 Illegitimate 58 32 26 Birth-rate—18.88 per 1,000 population. 7 Still Births:— Total. Male. Female. Legitimate 50 33 17 Illegitimate 1 0 1 Rate per 1,000 total births—28.07. Total. Male. Female. Deaths 842 412 430 Death-rate—9.15 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 0.55 From other Puerperal causes 1 0.55 2 1.11 One of these two cases was removed to the Enfield, Edmonton and Potters Bar Joint Isolation Hospital, where she died. The other case died at home. Death-rate of Infants under one year of age:— All infants per 1,000 live births 50.69 Legitimate infants per 1,000 legitimate live births 44.10 Illegitimate infants per 1,000 illegitimate live births 241.37 Deaths from Measles (all ages) 3 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) 20 The following table gives the birth-rate, recorded death-rate and infantile deaths for Enfield as compared with those for England and Wales, London, 126 County Boroughs and Great Towns (including London) and 148 Smaller Towns:— Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Still England and Wales 15.1 0.60 11.6 53.00 London 13.4 0.48 11.4 57.00 126 County Boroughs and Great Towns (including London) 15.0 0.65 11.7 57.00 148 Smaller Towns 15.4 0.60 11.0 51.00 ENFIELD 18.88 0.63 9.15 50.69 8 DEATHS. The deaths registered in the District during the year were 521, of which 244 were males and 277 females, giving a crude death-rate of 5.66. To this must be added 389 deaths of Enfield residents registered outside the District, and from this total must be subtracted 68 deaths of non-residents occurring in the District, which brings the number of deaths to 842 for the year, giving a net deathrate of 9.15 per 1,000 population. The corresponding figures for Enfield for the five previous years are:— 1933 1934 1935 1936 1937 Net death-rate 9.83 9.64 9.81 9.82 10.47 Ninety-seven deaths registered in the District were persons over 80 years of age, 36 being males and 71 females, two women dying at the age of 94. The more important causes of deaths registered during the year and the previous four years were:— Cause of Death. 1938 1937 1936 1935 1934 Malignant Disease 116 130 1 33 118 103 Bronchitis 15 28 34 27 36 Heart Disease 232 242 185 164 176 Old Age 19 15 18 20 13 Tuberculosis of Respiratory System 40 51 60 46 52 Pneumonia 67 62 57 64 52 Other Digestive Diseases 23 17 10 21 17 Other Circulatory Diseases 58 51 35 59 44 Nephritis 16 17 15 13 10 Cerebral Haemorrhage 37 44 37 40 29 Deaths from Violence (excluding Suicides) 29 37 34 30 27 Influenza 7 28 6 11 5 Children :— Premature Birth 11 10 34 22 14 Inanition and Marasmus 10 5 6 5 7 Congenital Malformations 7 6 4 4 4 Pneumonia 19 21 15 12 8 Injury at Birth 3 3 4 3 4 Enteritis 17 8 5 10 1 9 It is to be noted that of the 842 deaths that occurred during the year, 389 took place outside the District of Enfield. Of these, 301 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 Borough of Edmonton. The figure of 842 deaths assigned to Enfield represents a decrease of 71 on last year. There were 14 less deaths from Malignant Disease; 13 less from Bronchitis; 10 less from Heart Disease, and 11 less from Tuberculosis than last year. On the other hand the number of deaths of children under 1 year of age increased from 67 to 88. 10 TABLE 1. Causes of Death during Year 1938. Causes of Death. Males. Females. Total. All Causes—Certified 412 430 842 Uncertified — — — Typhoid and Para-Typhoid Fevers — — - Measles 1 2 3 Scarlet Fever — 1 1 Whooping Cough — 1 1 Diphtheria — 1 1 Influenza 3 4 7 Encephalitis Lethargica — 1 1 Cerebro-Spinal Fever — 1 1 Tuberculosis of Respiratory System 20 20 40 Other Tuberculous Diseases 4 4 8 Syphilis. 1 - 1 General Paralysis of Insane, Tabes Dorsalis — - — Cancer, Malignant Disease 52 64 116 Diabetes 7 4 11 Cerebral Haemorrhage, etc. 18 19 37 Heart Disease 111 121 232 Aneurysm 1 1 2 Other Circulatory Diseases 29 29 58 Bronchitis 8 7 15 Pneumonia (all forms) 38 29 67 Other Respiratory Diseases 7 3 10 Peptic Ulcer 7 2 9 Diarrhoea etc. (under 2 years) 12 8 20 Appendicitis 3 3 6 Cirrhosis of Liver - — — Other Diseases of Liver, etc. — 4 4 Other Digestive Diseases 10 13 23 Acute and Chronic Nephritis 9 7 16 Puerperal Sepsis — 1 1 Other Puerperal Causes — 1 1 Congenital Debility, Premature Birth, Malformations, etc . 21 15 36 Senility 4 15 19 Suicide 7 4 11 Other Violence 13 16 29 Other Defined Diseases 25 29 54 Causes ill-defined or unknown 1 — 1 Total 412 430 842 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 23 7 2 4 36 20 19 7 6 88 Uncertified — — — — — — — — - Smallpox - - - - - - - - - - Chickenpox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping Cough - - - - - - - - - - Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - 1 _ 1 Convulsions — 1 — - 1 - — - - 1 Laryngitis - - - - - - - - - - Bronchitis — - — 1 1 - 3 — - 4 Pneumonia (all forms) — 1 — 1 2 7 4 4 2 19 Diarrhoea - - - - - - - - - - Enteritis - - - - - 5 7 1 4 17 Epidemic Diarrhoea - - - - - - - - - - Gastritis - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Suffocation, overlying - - - - - - - - - - Injury at Birth 3 - - - 3 - - - - 3 Atelectasis 7 - - 1 8 - - - - 8 Congenital Malformation 3 1 1 1 6 1 - - - 7 Premature Birth 8 3 - - 11 - - - - 11 Atrophy, Debility and Marasmus 1 1 - - 2 5 3 - - 10 Other Causes 1 — 1 — 2 2 2 1 — 7 Totals 23 7 2 4 36 20 19 7 6 88 Net Births in the year :—Legitimate: Live births, 1,678; Stillbirths, 50. illegitimate: Live births, 58 ; Still-births, 1. Net Deaths in the year: —Legitimate Infants,74; Illegitimate, 14. 12 Cancer carried off 116 individuals, and Tuberculosis of the Respiratory System 40, a combined number of 156. This compares with a total of 181 for last year, and the percentage of deaths from these two causes is 18.5, as against 19.8 for 1937. INQUESTS. Twenty-three inquests and twenty-seven P.M.s without inquests were held in Enfield during the year, and the verdicts were as follows:— Natural Causes 29 Accidental Causes 9 Suicides 10 Open Verdict 2 The above table shows that 10 persons committed suicide during the year under review. In 1937 there were 9, and in 1936, 9. The ages and sexes of the 10 people who committed suicide in Enfield during the year were as follows :— Males 29, 47, 55, 62, 67 and 76 years. Females 26, 26, 36 and 38 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 29, 55 and 67 years. Females Ages 26, 26 and 38 years. 1 Cut Throat Male Age 62 years. 1 Hanging Male Age 39 years. 1 Run over by Locomotive Engine. Female: Age 36 years. 1 Drowned in a River Male Age 47 years. 1 Multiple injuries 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. 526 544 1,070 including 27 illegitimate births, i.e., 2.52 per cent, of the total. In addition, 14 male and 8 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. 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 1938 892 895 1,787 19.43 .64 INFANTILE DEATHS. The total number of deaths which occurred amongst infants under one year, including 53 registered outside the District, was 88, giving a death-rate of 50.69 per 1,000 births, as compared with a death-rate of 53.00 for England and Wales, and 57.00 for the 126 County Boroughs and Great Towns (including London). The corresponding figures for Enfield for the last four years were: 1934,43.27; 1935, 50.00; 1936, 62.77; and 1937,43.99. It will be noticed that there were 21 more deaths of children under one year of age this year than last. This increase is accounted for by the fact that there were 9 more deaths from Enteritis than last year, 5 more from Atelectasis, 1 more from Congenital Malformation, 1 more from Premature Birth, 5 more from Atrophy, Debility and Marasmus, and 5 more from other causes. The number of deaths of illegitimate children was 14, which gives a death-rate of 241.37 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 Heal! hand Assistant School Medical Officer: *W. D. HYDE, M B., Ch.B., D.P.H. Maternity and C hild Welfare: Dr. C. J. THOMSON, M.B., M.D., D.P.H., (Assistant Medical Officer of Health). (Appointed Full-time February 1st, 1938.) 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). C hief 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. (Special). Housing and Shops Inspector: G. PROVEST. * Contributions received from the County Council. 15 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. Miss C. WILKINSON, C.M.B., New Health Visitor's Certificate of R.San. Inst., State Registered Nurse, Invalid Cookery. Miss W. BROWN, S.R.N., C.M.B. Miss M. PITCHER, S.R.N., C.M.B. Municipal Miriwives : Nurse S. BARNES, S.R.N., C.M.B. Nurse G. DEAR, C.M.B. (Resigned November, 1938). Nurse D. HARRISON, C.M.B. Nurse M. L. MITCHELL, C.M.B. Nurse E. E. WILLIAMS, C.M.B. (Deceased 14th April, 1938). Nurse I. MITCHELL, S.R.N., C.M.B. Nurse P. REDLEY, C.M.B. Nurse K. SWEETMAN, S.R.N., C.M.B. Nurse K. WASMUTH, S.R.N., C.M.B. Nurse A. WILKINSON, C.M.B. Nur-e M. M. W ILLIAMS, S.R.N., C.M.B. Chief Clerk SYDNEY COULTER, Cert.R.San.I. 2nd Clerk Miss E. W. BOWYER. Clerk J. HULME. Clerk C. W. CHAPMAN. Clerk Miss D. HILI.ER. Clerk Miss A. K. MOTTRAM. Clerk Miss I. BOOTMAN. Clerk Miss W. PAYNTER. Shorthand-Typist Miss N. L. BROWN. Shorthand-Typist Miss K. M. HALLAM. 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 16 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 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: 261 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 1938, the Ambulances removed 3,257 patients. NATIONAL HEALTH INSURANCE. None of the work of the Authority is related to or administered by this service. 17 LABORATORY FACILITIES. The following work was carried out in the Council's laboratory during the year. Specimen No. Positive. Negative. Percentage of Positives. Swabs 1,650 73 1,577 4.42 Sputa 241 24 217 9.96 Totals 1,891 97 1,794 5.12 Reference to the laboratory report shows that 1,650 swabs were examined during the year. This number is 691 less than for last year. It will also be noted that there was a decrease of 48 in the number of sputa examined. 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 wellequipped and maintained. HOSPITALS. 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 1938. 18 Institution. Accommodation. Type of case. Adults. Children. M. F. County Sanatorium, Harefield 150 150 60 Pulmonary—Sanatorium. 4 4 10 Pulmonary—Observation. County Sanatorium, Clare Hall, South Mimms 132 66 — Pulmonary—late sanatorium and Hospital. White House, Milford - 24 — Pulmonary. Royal Chest Hospital 24 — Pulmonary. Victoria Home, Margate - - 6 Non-pulmonary. Patients are also sent to numerous other Voluntary Hospitals and Sanatoria. 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 157 Diphtheria 50 Erysipelas 14 Typhoid and Paratyphoid 1 Cerebro-Spinal Fever 4 Ophthalmia Neonatorum 1 Puerperal Pyrexia 7 Dysentery 3 ?Diphtheria 4 19 Measles 12 Measles and Pneumonia 5 ? Enteric Fever 1 Whooping Cough and Convulsions 1 Whooping Cough and Bronchitis 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. The wells in Enfield were kept under strict observation during the year. The following is a summary of action taken:— Samples. 15 samples were taken from wells supplying—17 houses. 33 „ ,, ,, ,, ,, „ —26 Industrial and other premises. These figures refer to those wells the water from which was used for drinking and domestic purposes. As a result of action taken in respect of wells where the condition of the water was questionable— 23 wells supplying 27 houses, and 6 wells supplying 6 Industrial premises, were either closed or steps taken whereby the water therefrom was disused for drinking purposes, arrangements having been made for a mains supply to be available. In two other cases suitable and sufficient Chlorination Plants have been installed and are working satisfactorily. At the end of 1938 the following wells were still in existence :— Dwelling-houses . . 11 Industrial premises .. 70 With regard to the dwelling houses, negotiations were in hand at the end of the year for a mains supply to be laid on to 6. The following table shows the position m connection with the 5 remaining:— Arrangements made for a mains water supply to be available 2 House empty and about to be demolished 1 House empty 1 Water satisfactory 1 20 In the case of the 70 wells that supply Industrial premises, in only two cases is the water used for drinking purposes, and in both these cases the water is regularly examined and is subject to chlorination. In one other case there is no drinking supply ; the necessary steps are being taken to remedy this state of affairs. In the case of the wells which were not used for drinking purposes the owners were requested to exhibit a Notice stating that the water was not to be used for drinking purposes, and complied therewith in all cases. Well water used for drinking and domestic purposes is analysed twice a year. 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. Towards the end of the year there was evidence that some of the sewers in Enfield were surcharged in wet weather. Investigation showed that this was partly due to the large increase in the number of houses in Enfield, and the consequent growth of population, and partly to periods of excessive rainfall. This matter has received the very careful consideration of the Council. It would appear that the difficulty will be dealt with adequately when the East Middlesex Sewerage scheme is in operation, and the Council have asked the Middlesex County Council to accelerate the construction of the Trunk sewer between Cheshunt and Edmonton. CESSPOOLS. During 1938 the cesspools of the District were emptied by a combined cesspool and gulley emptier. During the course of the year, of the 2,270 houses the construction of which was completed, 24 were drained by means of cesspools. 21 In my report last year I referred to the unsatisfactory state of affairs in Crews Hill where some 60 houses are drained by means of cesspools. The unsatisfactory condition continued during the year and was a source of nuisance and complaint. Proposals have been submitted to, and have been approved in principle by, the Ministry of Health for the construction of a small sewage works to deal with the sewerage from the houses in this area. 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 earthclosets, or privies with movable receptables. I am not aware of any middens in the District. Every week one man in the employ of the Council 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. 7 " S.D." Freighters. 1 Tuke and Bell Barrier Type Petrol Vehicle. 1 Bedford 2-ton General Purpose 3 way Tipping Lorry. 3 Dennis Refuse Collection Vehicles. 1 Karrier-Kolt 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. In 1936 an agreement was entered into with Messrs. Heath and Sons whereby the Council might dispose of the refuse of the District in Heath's pit, Carterhatch Lane at a fee of Is. Od. per load of refuse or covering material brought therein. During 1938 this arrangement remained in force until 27th August when the new Refuse Disposal Works were opened. The Heenen and Froud Separator and Destructor which the Council determined to erect in 1936 was completed and brought into operation on 8th August, 1938. 22 SANITARY INSPECTION OF DISTRICT. A full repott on this matter is contained in the Report of the Chief Sanitary Inspector, which will be found at the end of this Report. SHOPS AND OFFICES. Many preliminary Notices under the provisions of the Shops Act, 1934, with regard to ventilation and temperature of shops and to sanitary conveniences, were served during the year, but it was not found necessary to take statutory action either under the Shops Act, 1934, or the Public Health Act, 1936. CAMPING SITES. (1) The number of sites in the area which were used for camping purposes during the year None. (2) The number of camping sites in respect of which cences have been issued by the Council under Section 269, of the Public Health Act, 1936 None. (3) The estimated number of campers resident in the area at one time during the summer season None. 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. 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 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 23 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 Pool Bathers Baths Hours of Sunshine 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 1938 85,522 30,551 773.2 The following table shows the extent to which the Slipper Baths both at the Pcol and Enfie'd Lock Baths have been used during the past 5 years. Financial Year Number of Attendances Pool Baths 1934-35 28,472 6,906 1935-36 27,351 7,037 1936-37 26,007 7,255 1937-38 28,186 7,855 1938-39 28,587 8,983 It is pleasing to record the increased use that is being made 01 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 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 24 which is in their opinion a reasonable rent has been, or is to be, received by the tenant in consideration of the assignment, subletting 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-'etting 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. During the course of 1938 I have continued to deal with applications for sub-letting in Council houses. The following work was carried out. Total number of applications dealt with 51 Number granted permission to sublet 47 Number refused permission 4 Numbers of letters sent 167 Number of visits made by Sanitary Inspectors 13 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. Periodical examinations of the conditions of the public elementary schools are made by the Sanitary Inspectors, and any defects 25 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 920 Number of children found to be suffering from Infectious Disease 593 This compares with the following figures for last year:— 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 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) 2,270 (i) By the Local Authority — (ii) By other Local Authorities — (iii) By other bodies or persons 2,270 (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 2,481 12,419 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932, and the number of inspections made 241 3,658 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 17 (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.) 766 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 637 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 25 27 (2) Number of dwelling-houses which were rendered fit after service of formal Notices (a) By owners 23 (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 35 (2) Number of dwelling-houses in which defects were remedied after service of formal Notices :— (a) By Owners 28 (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 16 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 41 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 and 1932 241 Apart from the Do. Nil Total 241 28 During the course of 1938 I represented 19 houses as unfit for human habitation. Demolition Orders were made in respect of all these houses. Since the passing of the Housing Act, 1930, 160 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. Land has been acquired for the erection of further houses, but so far has not been utilised for this purpose. HOUSING ACT, 1936—PART IV.—OVERCROWDING. During the course of the year routine inspection has been made of the houses in Enfield to ascertain what overcrowding there might be, in accordance with the standard set by the Housing Act, 1936, and to remedy such overcrowding as might be discovered. This was rendered difficult, as in most cases the overcrowding could only be overcome by transfer to houses containing 4 and 5 bedrooms. It is not likely, therefore, that the present state of overcrowding will be abolished until such time as larger Council houses are erected. At the end of 1938 the position was as follows:— (a) (i) Number of dwellings overcrowded at the end of the year 97 (ii) Number of families dwelling therein 97 (iii) Number of persons dwelling therein 730½ (b) (i) Number of new cases of overcrowding ported during the year 10 (ii) Number of persons concerned in such cases 11½ (c) (i) Number of cases of overcrowding relieved during the year 52 (ii) Number of persons concerned in such cases 339½ (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 3 (These cases were all abated within a short time by the Owners giving tenants notice to quit, without legal action having to be taken.) (e) Any other particulars with respect to overcrowding conditions upon which the Medical Officer of Health may consider it desirable to report. 29 With regard to clause (e), transfers which resulted in the abatement of overcrowding have continued during 1938 in co-operation with the Treasurer's Department. The abatement of overcrowding was effected as follows:— Council Houses— By removal or transfers 6 By marriage of children, or girls going into domestic service and sons in Armed Forces 4 By death 1 Total 11 No further Council houses have becdme overcrowded through increase in family, increase in ages of children, or other causes. Non- Council Houses— By removal 31 By marriage of children, or girls going into domestic service and sons in Armed Forces 9 By deaths 1 Total 41 On the other hand, 10 fresh cases of overcrowding have arisen due to increase in size of families, children attaining adult age, or other causes. During 1938 in accordance with the authority of the Council your Treasurer and I considered applications for transfer from one Council house to another. These transfers are necessitated, due to increase in age or number of the family, extra bedrooms being required, or alternately due to children getting married when smaller houses would appear to be suitable. I am satisfied that the transfers we have made have resulted in better use of Council property and added convenience to Council tenants. HOUSING CONDITIONS. The standard of housing in EnfieM 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. 30 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. 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. There are approximately only 4 houses in Enfield 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. The veterinary inspection of cows in the County of Middlesex is now carrried out by officials of the Ministry of Agriculture and Fisheries and in that the inspections are carried out uniformly throughout the County, it is not possible to obtain a separate report insofar as Enfield is concerned. 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 32 samples were taken of this 31 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 specified is as follows :— 1914 January. December. 1938 1938 Registered 10 6 4 Licensed 7 4 4 Total 17 10 8 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 952 visits during the year, when they examined 13,219 carcases, securing the surrender of 25 carcases arid 166 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. 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. No new applications for Licences were received during the year, but 20 applications for renewal of Licences were received, and all these were granted. 32 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 S. J. Pugh, Esq., Acting Chief Officer of the Public Control Department. URBAN DISTRICT OF ENFIELD. List of samples purchased during the year ended 31st December, 1938: Article Taken Adulterated Milk 192 6 Milk, sterilized 6 — Cream 2 — Gin 2 1 Whisky 20 4 Hake 1 — Lemon Sole 3 — Sausages 3 — Meat 2 — Minced Beef 3 — 234 11 No. of Prosecutions 1 No. of Convictions 1 33 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. The number of cases of Scarlet Fever was 190, compared with 161 in 1937: of Diphtheria 57, as compared with 132; of Pulmonary Tuberculosis 115, as compared with 99; and of Pneumonia 98, as compared with 50. The same methods of control were used as in pievious years, but it is regretted that the number of immunisations against Diphtheria was considerably less than last year, as is shown on pages 36-37 of this Report. One child died of Diphtheria during the year, as compared with four deaths in 1937. There was one death (a female aged 32 years) from Scarlet Fever. 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 1938 1937 1936 1935 1934 Scarlet Fever 190 161 213 229 252 Diphtheria 57 132 68 77 37 Pulmonary Tuberculosis 115 99 80 83 77 Pneumonia 98 50 58 34 48 PUBLIC HEALTH (SMALLPOX) PREVENTION REGULATIONS, 1917. No primary vaccinations or re-vaccinations were done by me during the year. NOTIFIABLE DISEASES DURING THE YEAR 1938. The following table shows the cases of infectious diseases notified during the year, and the number of deaths that occurred. 34 TABLE III —Cases of Infectious Diseases notified during the year 1938. 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) 57 1 15 34 5 2 — - 50 1 - - - - - - - 1 Diphtheria Carriers 2 - — 2 — — — - - - - - - - - - - - Erysipelas 32 - — 5 4 7 12 4 14 - - - - - - - - - Scarlet Fever 190 1 36 131 12 9 1 - 157 - - - - - - - - - Typhus Fever - - - - - - - - - - - - - - - - - - Typhoid Fever 1 - - - - 1 - 1 - - - - - - - - - Paratyphoid Fever - - - - - - - - - - - - - - - - - - Relapsing Fever - - - - - - - - - - - - - - - - - - Continued Fever Puerperal Pyrexia 10 - — — 1 9 - - 7 - - - - - 1 - - 1 Cerebro-spinal Meningitis 4 1 1 1 — 1 — — 4 1 - - - - - - - 1 Poliomyelitis 1 - - — — 1 - - 1 - - - - - - - - - Ophthalmia Neonatorum 1 1 - — - - - - 1 - - - - - - - - - Pulmonary Tuberculosis 115 1 2 7 24 53 24 4 - - 1 1 - 11 10 15 2 40 Other forms of Tuberculosis 20 - 2 7 4 5 1 1 - - 1 - 2 3 2 - - 8 Encephalitis Lethargica - - — - - - - - - - - - - - 1 - - 1 Malaria - - - - - - - - - - - - - - - - - - Pneumonia 98 6 14 32 4 22 17 3 12 19 7 - 3 1 6 13 18 67 Dysentery 114 7 25 32 3 28 14 5 3 - - - - - - - - - Totals 645 18 95 251 57 138 69 250 250 21 9 1 5 15 21 28 20 120 35 SCARLET FEVER. One-hundred-and-ninety cases of Scarlet Fever occurred during the year in 174 houses, as follows:— Number of houses where 1 case occurred 159 Number of houses where 2 cases occurred 14 Number of houses where 3 cases occurred 1 Total number of houses where cases occurred 174 Total number of cases 190 Deaths 1 DIPHTHERIA. Fifty-seven cases of this disease occurred daring the year in 47 houses, as follows:— N umber of houses where 1 case occurred 39 Number of houses where 2 cases occurred 6 Number of houses where 3 cases occurred 2 Total number of houses where cases occurred 47 Total number of cases 57 Deaths 1 DIPHTHERIA CARRIERS. Two cases of this disease occurred during the year in 2 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 rrje with information as to the children who are immunised. The re-agent used is T.A.F. (Toxoid Antitoxin Floccules). 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 123 individuals were immunised during 1938. 36 Since 1935, 1,080 individuals have been immunised. This is a very 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, ENTERIC AND PARATYPHOID FEVER. One case of Typhoid Fever was notified during the year. There were no deaths during the year. DYSENTERY. One-hundred-and-fourteen cases of this disease were notified during the year. The cases occurred in eighty-six houses, and none of the cases proved fatal. POLIOMYELITIS. One case of this disease was notified during the year. CEREBRO-SPINAL FEVER. Four cases of this disease were notified during the year, and there was one death. ENCEPHALITIS LETHARGICA. No cases of this disease were notified during the year but there was one death of an old outstanding case. 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 Heath. Some idea of the extent of these diseases can be obtained, however, by the fact that 357 cases of Measles and no cases of German Measles were excluded from the schools during the year. These figures compare with 43 cases of Measles and no cases of German Measles for last year. 37 ENTERITIS. Twenty deaths of children under two years of age occurred from this disease during the year. Of this number seventeen 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 seve'n chief zymotic diseases during the past five years:— Disease. 1934 1935 1936 1937 1938 Small Pox - - - - - * Scarlet Fever 1 1 2 1 3 *Diphtheria 2 6 2 8 5 *Measles 7 — 8 — 4 *Enteric Fever — 5 1 1 — *Whooping Cough 1 1 4 3 — Epidemic Enteritis — — — — — Totals 11 13 17 13 12 *The actual Enfield deaths were: Diphtheria, 0; Scarlet Fever, 1; Whooping Cough, 0; Measles, 3; and Enteric Fever, 0. The figures for Scarlet Fever, Diphtheria, Measles and Enteric F. ver 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 eight deaths of persons residing outside the District who died in Institutions in the District, and adding two deaths which occurred outside the District is 0.06 per 1,000 population. 38 Disease. 1937 1938 Deaths. Death-rate Deaths. Death-rate Scarlet Fever - - 1 .01 Diphtheria 4 .04 1 .01 Enteric Fever — — — — Small Pox — — — — Measles — — 3 .03 Whooping Cough 2 .02 1 .01 Epidemic Enteritis — — — — Totals 6 .06 6 .06 PREVENTION OF BLINDNESS. No action was taken during the year under .Section 176 of the Public Health Act, 1936, for the prevention of blindness or for the treatment of persons suffering from any disease or injury to the eyes OPHTHALMIA NEONATORUM. Cases Vision Unimpaired Vision impaired Total Blindness Deaths Notified Treated. At home. In Hospital. 1 — 1 1 — — — Ophthlamia 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, 1937, 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. 39 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. North-East 29 1 24 5 - 1 South-East 31 2 33 6 — 3 Central 32 4 47 5 1 3 West 23 1 32 4 1 4 T otals 115 8 136 20 2 13 First Notifications, including transfer, restoration to Register and Death Return notifications 135 Old Cases re-notified, i.e., some by fresh doctors 10 Duplicate Notifications, i.e., those which report the entering and leaving of Sanatoria 149 Total Notifications 294 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 to 5 — 2 1 1 1 1 — 1 5 to 10 4 2 3 1 — — — 2 10 to 15 - 1 2 1 — — — — 15 to 20 2 5 3 — 1 2 1 1 20 to 25 9 8 — 1 3 5 1 — 25 to 35 22 13 2 1 2 2 1 — 35 to 45 12 6 1 1 3 3 1 — 45 to 55 13 5 — 1 6 5 — — 55 to 65 4 2 — — 2 2 — — 65 and upwaids 2 2 1 — 2 — — — Totals 69 46 13 7 20 20 4 4 40 SEX (1st NOTIFICATIONS). Form. Males. Females. Totals. Pulmonary 69 46 115 Other 13 7 20 Totals 82 53 135 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 North-East 29 11 5 1 South-East 31 9 6 4 Central 32 13 5 2 West 23 7 4 1 Totals 115 40 20 8 Ten 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 135 first notifications received during the year, 76 weie in persons between 20 and 45 years of age, and of the 48 deaths, 21 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. 41 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, 1936, SECTION 172. No action was taken during the year under this Section. SUPPLY OF INSULIN. During the course of the year two children received 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 22 Number of Council houses disinfested 22 Number of other houses found to be infested 65 Number of other houses disinfested 65 (2) The methods employed for freeing Infested houses from bugs, and the name of the fumigant and/or insecticide used. M ethods. During the course of the year 106 Council houses became vacant: all of these were examined by your Sanitary Inspectors for the presence of vermin. In 81 cases it was deemed advisable to carry out a detection test. For this purpose the room is sealed and a sulphur candle used. If bugs are present they tend to come out of their hiding places and die and the fact that the house is infested is thus established. It was found that. 22 houses out of the 106 were infested, i.e., roughly 20 per cent of the total. When it is remembered that last year of 216 houses so vacated and investigated, 80 were found to be infested, i.e., a percentage of 37, it will be realised that there is a tendency for the condition of 42 Council houses to improve in this respect. In general, Council houses were disinfested by means of heavy naphtha which proved consistently satisfactory. The Council may remember that much of the initial work in connection with the method of disinfestation by means of heavy naphtha, was carried out in Enfield, and I have reason to believe that the successful results we have achieved have increased its use throughout the country. The procedure in the use of Heavy Naphtha 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. We have not found it necessary to use the more newly suggested method whereby tennis cloth is hung throughout the premises on frames specially erected for the purpose, nor to intensify the concentration of heavy naphtha by means of a delayed action spray. Heavy Naphtha can be used in houses that contain furniture and/or bedding, but it is essential that the house should remain unoccupied for two days whilst the process is being carried out. For this reason it is not easy to obtain permission for its use in occupied premises, and in these cases resort has had to be made to spray methods, chiefly the use of Pyagra. This has achieved such success as can be expected, under the circumstances, of its employment. Name of Fumigant and/or Insecticide used. Sulphur Dioxide as a detector, followed by the use of Heavy Naphtha. Pyagra. Zaldecide. 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. 43 (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. 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, 1938. Month. Barometer. Temperatures. Rainfall. Millimetres. Sunshine hours. Thunderstorms. Fogs on days. Frosts on days. Snowfalls. Prevailing. Winds. Highest. Lowest. Earth. Means. Lowest Grass. Min. Highest Maximum. Lowest Minimum. Means of Latter. Jan. 30.553 on 23rd 28.857 on 9th 43.5° 28° on 11th 54° on 24th 31° on 11th 42° 73.0 3.13 inches. 40.2 — 2 8 3 S.W. Feb. 30.561 on 20th 29.505 on 1st 40.3° 24° on 25 th 56° on 26th & 27th 26° on 25th 40° 11.8 0.61 inches. 63.0 — 5 9 4 N.E. Mar. 30.728 on 4th 29.628 on 25th 44.6° 29° on 13th 68° on 30th 30 ° on 4th 50° 9.3 0.32 inches. 162.6 — 4 10 — S.W. April 30.808 on 11th 29.990 on 30th 47.8° 26° on 11th 67 ° on 1 st 28° on 11th 46° 4.4 0.17 inches. 138.4 -- — 8 — N.E. May 30.314 on 22nd 29.525 on 30th 50.3° 27° on 8th 75° on 14th 30° on 8th 52° 54.1 2.32 inches. 153.7 1 1 1 — S.W. June 30.347 on 16th 29.591 on 29th 55.7° 41° on 13th 80° on 14th & 21st 44 ° on 3rd & 11th 62° 10.8 0.41 inches. 212.2 — — — — S.W. July 30.219 on 18th 29.546 on 5th 58.6° 42° on 2nd 84 ° on 31st 45° on 2nd 62° 41.8 1.80 inches. 145.2 2 — — - S.W. Aug. 30.302 on 2nd 29.496 on 19th 61.3° 41 ° on 21 st, 30 th & 31st 86° on 1st 44 ° on 30th & 31st 63° 42.3 1.39 inches. 141.0 3 1 — — S.W. Sept. 30.272 on 11th 29.628 on 20th 58.6° 37° on 1st 81° on 13th 39° on 1st 59° 71.0 2.91 inches. 121.1 1 3 — — S.W. Oct. 30.350 on 20th 29.174 on 4th 55.0° 29° on 24th 64 ° on 9th 30° on 25th 50° 72.6 3.02 inches. 119.1 — 6 2 — S.W. Nov. 30.442 on 15th 28.979 on 23rd 51.4° 27° on 27th 68° on 5th 30° on 27th & 30th 49° 83.4 3.32 inches. 51.8 — 8 5 — S.W. Dec. 30.524 on 25th 29.325 on 10th 46.3° 18° on 21st 55 ° on 4th & 5th 19° on 21st 39° 80.8 3.52 inches. 34.8 — 7 12 8 S.W. Note :—EcLipse of Moon on night of November 7th. Totals 555.3 22.92 inches. 1383.1 hrs. 7 37 55 15 AIR RAID PRECAUTIONS SECTION 46 AIR RAID PRECAUTIONS COMMITTEE. F. Greenwood, Esq. Chairman Messrs. Edwards, Eeles, Fletcher, Kemp, Morris, Muspratt, Rowlandson and G. S. Thompson. Air Raid Precautions Officer .. .. S. C. Chedzoy, Esq. Air Raid Precautions Advisory Committee of the Enfield MedicoEthical Society. Dr. D. R. Chisholm Chairman Doctors Johnston, Ridge, Toop, Warren. 47 Public Offices, Enfield. 4th May, 1939. To the Cha irman and Members of the Urban District Council of Enfield. Mr. Chairman, Ladies and Gentlemen, Air Raid Precautions has now formed part of the routine work of the department for over 3 years. Originally the Council was required to provide a scheme that would increase the number of hospital beds in Enfield by about 100 and which would provide Fiist Aid Posts and Cleansing Stations throughout the district. At a later date it was determined that the provision of hospital beds should be left entriely in the hands of the Ministry of Health. The part of the scheme appertaining to the provision of hospital beds was therefore deleted. The effect of gas warfare has been the subject of so much speculation that it has been difficult to determine the extent to which provision should be made for the decontamination of A.R.P. personnel and of the public. Until early September it was considered that medical buildings, such as clinics, could be used satisfactorily. At a later date it was thought that so much space for decontamination should be provided that use of school buildings would be essential. Now finally it would appear that semi-medical buildings are to be utilised with the addition of and aided by Mobile Units. These Mobile Units consist of cars containing equipment for dealing with a large number of casualties. In time of war they would move to such area as had been bombed and open up a First Aid Post in suitable premises as near to the site of disaster as possible. Arrangements have also had to be made for providing adequate ambulances and stretcher party personnel. It has fallen to the lot of the Health Department to train the personnel required in First Aid and Anti-Gas, to assist in the preparation of schemes and to help in the preparation of plans and alterations for the use of the various premises required as First Aid Posts and First Aid Depots, and in the protection thereof. Insofar as the scheme for Enfield is part of the County scheme, 48 and has not at the time of writing this report been officially submitted to the Ministry of Health for approval, I am unable to place details before the members of the Council. I think it would not be premature, however, to state that the present scheme includes the provision of two Stationary Posts and 4 Mobile Units, each of which will be manned by a doctor, a nurse and a detachment of volunteers, the provision of 60 stretcher parties and 75 ambulances. It is hoped that this will be sufficient to cover the whole district. The personnel required amounts to 1,275 persons, all of whom must be trained in Anti-Gas and First Aid measures. Many in addition will require special training in the driving of heavy vehicles. During 1938, 10 First Aid Classes were held as a result of which 235 persons obtained the requisite certificate. The classes were held in co-operation with the St. John Ambulance Brigade, who appointed Mrs. Peabody as the Liaison Officer between the Brigade and the Health Department. I cannot pay too high a tribute to the co-operation I have received from Mrs. Peabody and the members of the Brigade who helped her throughout the duration of the crisis and subsequently. Hurried as the preparations were, I am satisfied that they would have formed the very satisfactory nucleus of a scheme which would have rendered very valuable service. I would also wish to acknowledge the help I received from the Rev. Elmes and from Mrs. Phypers, whose advice and counsel and whose ready work, made possible such results as we were able to achieve. The Council will realise that the training of a large number of volunteers is no mean task. The task is most difficult in its initial stage when it is growing apace. At the time of writing this report there have attended at lcctures no less than 1,309 people, of whom 527 have already obtained Certificates of Proficiency in Anti-Gas measures, First Aid, or both. Ambulances are being obtained or earmarked and shortly drivers will be in training. Until the end of April 1939 the work was carried out without additional staff, but authority has now been given for the employment of one additional clerk for a period of 6 months during the year 1939-40. All new schemes are subject to criticism. It is easy to find fault with them and to better them once they have been tried out and their defects discovered. 49 I cannot persuade myself, however, that I should achieve much in this report were I to offer to the Council a resume of the alterations that have been required from time to time. I think it will suffice if I say that I am satisfied that in due course we shall possess a scheme capable of dealing with Air Raid casualties in Enfield, insofar as we can imagine the destruction that might result from aerial bombardment in a town of the size and character of Enfield. A.R.P. has meant a tremendous amount of work, and a tremendous amount of worry and anxiety. Every member of my staff has been prepared to help in every way. The Doctors of Enfield have assisted me at all the First Aid classes, whilst many of the Head Teachers have acted as Class Secretaries. The Council may not realise the amount of work entailed in acting as a Class Secretary. I would assure them that it has been very considerable and I know that they would wish me to acknowledge the services of Miss Foster, Miss Holland, Miss Oakley, Miss Pateman, Mr. Evans, Mr. Leech, Mr. Sanderson and Mr. Spurgeon and their assistants, without whose co-operation it would not have been possible to train the numbers referred to above. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, D. H. GEFFEN, Medical Officer of Health. MATERNITY and CHILD WELFARE SECTION 52 MATERNITY AND CHILD WELFARE COMMITTEE. 1938—1939. Chairman : H. A. Deshborough Brown, Esq. Councillors Bennett, Cakebread, Clarke, Draper, Kemp, Morris, Muspratt and Thompson. Also Co-optative Members : Miss G. M. Ford, Mrs. H. Hammerton, Mrs. M. M. Howard and Mrs. M. Martin. MATERNITY AND CHILD WELFARE SUB-COMMITTEE. Chairman : Mrs. H. Hammerton. Mesdames Howard and Martin, and Miss Ford. MATERNAL MORTALITY ADVISORY COMMITTEE. Chairman : D. H. Geffen, Esq., M.D., D.P.H. Hon. Secretary : R. Adam, Esq., M.B., Ch.B. A. Goodwin, Esq., O.B.E., F.R.C.S., W. N. Searle, Esq., F.R.C.S., M.C.O.G., R. H. Wade, Esq., M.D., M.R.C.P. 53 MATERNITY AND CHILD WELFARE STAFF. Medical Officer of Health and Maternity and Child Welfare Officer: Dennis H. Geffen, M.D., D.P.H. Assistant Part time Medical Officer and Specia'ists: Dr. C. J. Thomson, M.B., M.D., D.P.H. *Dr. W. D. Hyde, M.D., D.P.H. †Mr. C. E. James, M.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., M.R.C.N. Miss M. Garlick, S.R.N., C.M.B., M.R.C.N. Miss C. Wilkinson, S.R.N., C.M.B., New H.V.'s Cert. Miss M. Pitcher, S.R.N., C.M.B. Miss W. Brown, S.R.N., C.M.B. Municipal Midlives: Nurse S. Barnes, S.R.N., C.M.B. Appointed 15.11.37 Nurse E. G. Dear, C.M.B. Appointed 15.11.37, Resigned November, 1938 Nurse D. Harrison, C.M.B. Appointed 15.11.37 Nurse I. Mitchell, S.R.N., C.M.B. do. 1. 5.38 Nurse M. L. Mitchell, C.M.B. do. 15.11.37 Nurse P. Redley, C.M.B do. 1.10.38 Nurse K. Sweetman, S.R.N., C.M.B. do. 1.10.38 Nurse k. Wasmuth, S.R.N., C.M.B. .. do. 1. 2.39 Nurse A. Wilkinson, C.M.B. do. 1. 6.38 Nurse E. E. Williams, C.M.B. Appointed 15.11.37, Deceased 14. 4. 38 Nurse M. M. Williams, S.R.N., C.M.B. Appointed 1. 2.38 * Half-time M. & 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. 54 Public Offices, Enfield. 4th May, 1939. 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 1938. During the course of the year it was found necessary to increase both the amount and scope of work that was being undertaken in order to maintain the health of the ante-natal and nursing mothers, and the children under five years of age. In the first place there were 200 more births recorded in Enfield than in 1937. This alone gives some indication of the need for increase in the amount of work that had to be done. This increase, however, is only a continuation of that of the last few years. In 1934 there were 1,126 births recorded; in 1938 the number had risen by no less than 661 to 1,787. It has been somewhat difficult to keep the services maintained at such strength as to meet the extra work that has resulted therefrom. Apart from this there has been an increasing tendency for ante-natal mothers to attend at our clinics, till to-day such attendance is made by almost every mother in the district who is not going to be attended at her confinement by a doctor, whilst the ante-natal work for the 500 mothers who are entering each year the North Middlesex County Hospital for their confinements is also carried out at our Clinics, in order to save long journeys to the Hospital during pregnancy. It has, therefore, been found essential to increase the number of ante-natal clinics held during the month. Nineteen hundred and thirty-eight was the first complete year of Enfield's midwifery scheme, and I am pleased to record that it operated simply and satisfactorily. The number of mothers who are seeking the services of the Council's midwives is increasing. A petition was received from residents of Grange Park complaining of the long distances which mothers, living in the area, had to travel in order to attend at one of the Council's Child Welfare Clinics, and requesting that a clinic more conveniently placed be opened. This petition was given very careful consideration by the Maternity and Child Welfare Committee, and as a result such a 55 clinic has been opened and is held regularly once a week at the Church in the Orchard, Grange Park. This clinic has met with immediate and increasing success, and is much appreciated by the residents of the area it serves. On 8th and 9th March, Dr. D. M. Taylor, of the Staff of the Minister of Health, visited Enfield and carried out a comprehensive inspection of the Maternity and Child Welfare services. Following upon her report, the Minister of Health expressed his appreciation of the work which continues to be done in Enfield for the welfare of mothers and children. He was glad to note that a full-time Maternity and Child Welfare Officer and an additional Health Visitor had recently been appointed, and that arrangements for post-natal clinics were under consideration. With a view to developing still further the Enfield scheme, the Minister suggested the desirability of extending facilities for the treatment of minor ailments to children under five years of age, and the provision of sterilised maternity outfits to pregnant women. Following upon the Minister's suggestion, arrangements were made whereby children under five years of age, attending the Maternity and Child Welfare Clinics, could receive treatment at the School Minor Ailment Clinics. Arrangements have also been made whereby every mother who has the services of a Municipal midwife or maternity nurse is provided with a sterilised maternity outfit. These outfits are appreciated by the mothers, the midwives and the doctors. During the year post-natal clinics were commenced but increase in ante-natal work, was so heavy that it was found necessary to use the clinics allocated to post-natal work for ante-natal purposes, and as a result I am only able to record very few post-natal attendances. The re-arrangements which were made at the end of the year, however, made it possible to undertake post-natal work on sound lines. It is now the practice to invite every woman at whose confinement a doctor was not in attendance, and every woman who was confined in the North Middlesex County Hospital, to attend for a post-natal examination six weeks after her confinement. The idea is a new one to most women in Enfield, but despite this fact quite a large percentage of the invitations are being accepted, and I think that during 1939 the public of Enfield will have been educated to look upon this procedure as natural and wise. I am satisfied that I shall be able to record a very successful attendance for the coming year. It has been considered right and proper that the Council's Midwives should attend regularly at the ante-natal clinics with 56 their patients. To achieve this, it has been necessary to hold these clinics in the afternoons instead of in the mornings. It is now the practice for our midwives to attend regularly and to help in the running of the clinic. I am satisfied that this is a most wise and proper procedure, and that it is having most satisfactory and beneficial results. During the course of the year, in accordance with Circular 1705 received from the Minister of Health, the Council determined to set up a Maternal Mortality Advisory Committee under the chairmanship of myself as Medical Officer of Health. The Enfield Medico Ethical Society were asked to nominate two General Practitioners to serve upon this committee, and furthermore, to suggest the names of two Obstetric Specialists to serve thereon. In this the Society co-operated, and on page 52 will be seen the constitution of this committee. The committee has met regularly since its appointment. It has drawn up a list of general practitioners resident in the area who are prepared to act in a midwifery emergency. It has also considered and advised concerning many matters which should help to make motherhood happier and safer. I am much indebted to the members of the committee for the help and advice they have so readily tendered during the year. Before closing these opening remarks, I would call your attention to the fact that the live birth-rate for Enfield for 1938 was 18.88 per 1,000 population. It is most interesting to note this increase in the birth-rate in Enfield, at a time when politicians are very worried as to the decrease in the birth-rate throughout the country. This figure for Enfield is the highest recorded since 1923, and is recorded for a year when the general death-rate is lower than it has been since 1923. These two figures speak very well for the health of Enfield, and augur an increased local population. This live birth-rate of 18.88 compares with 15.1 for England and Wales, 13.4 for London, 15.0 for 126 County Boroughs and Great Towns (including London) and 15.4 for the Smaller Towns. I feel sure that you will wish me to express my thanks, and that of every member of the Council, to the voluntary helpers who have attended regularly at our centres throughout the year. Lastly 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. 57 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 4 p.m. Bush Hill Paik Lincoln Road, Bush Hill Park Tuesday and Thursday afternoons, 2 to 4 p.m. Town and Chase Rosemary Avenue, Enfield Monday afternoons, 2 to 4 p.m. Wednesday mornings, 9.30 to 11.30 a.m. Ordnance Grange Park St. Stephen's Road. Enfield Wash The Church in the Orchard, Grange Park Monday and Wednesday afternoons, 2 to 4 p.m. Thursday mornings, 9.30 to 11.30 a.m. Monday afternoons, 2 to 4 p.m. ANTE-NATAL CLINICS. Ponders End School Clinic, Southbury Road, Ponders End Every Friday afternoon, 2 to 4 p.m. Bush Hill Park Lincoln Road, Bush Hill Park Every Friday morning, 9.30 to 11.30 a.m. Town and Chase. Rosemary Avenue, Enfield Every Wednesday afternoon, 2 to 4 p.m. Ordnance St. Stephen s Road. Enfield Wash Every Tuesday and Thursday afternoon, 2 to 4 p.m. 58 POST-NATAL CLINICS. Ponders End School Clinic, Southbury Road, Ponders End. Every third Thursday morning in the month, 9.30 to 11.30 a.m. Bush Hill Park Lincoln Road, Bush Hill Park. Every first Thursday morning in the month, 9.30 to 11.30 a.m. Town and Chase Rosemary Avenue, Enfield. Every second Thursday morning in the month, 9.30 to 11.30 a.m. Ordnance St. Stephens Road, Enfield Wash. Every 2nd & 4th Tuesday morning in the month, 9.30 to 11.30 a.m. DENTAL CLINICS. Ponders End School Dental Clinic, Southbury Road. Saturday mornings, 9.30 to 11.30 a.m.; Wednesday afternoons, 2 to 4 p.m. Enfield Wash Albany Clinic Alternate Saturday mornings, 9.30 to 11.30 a.m. ; Wednesday afternoons, 2 to 4 p.m. Each of the above Centres is provided and maintained by the Council. 59 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR. Live Births:— Total Male. Female. Legitimate 1,678 827 851 Illegitimate 58 32 26 Birth-rate— 18.88 per 1,000 population. Still Births:— Total. Male. Female. Legitimate 50 33 17 Illegitimate 1 0 1 Rate per 1,000 total births—28.53. Total. Male. Female. Deaths 842 412 430 Death-rate—9.15 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 0.55 From other Puerperal causes 1 0.55 2 1.11 One of these two cases was removed to the Enfield, Edmonton and Potters Bar Joint Isolation Hospital, where she died. The other case died at home. Death-rate of Infants nnder one year of age :— All infants per 1,000 live births 50.69 Legitimate infants per 1,000 legitimate live births 44.10 Illegitimate infants per 1,000 illegitimate live births 241.37 Deaths from Measles (all ages) 3 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) 20 The following table gives the birth-rate, recorded death-rate and infantile deaths for Enfield as compared with those for England and Wales, London, 126 County Boroughs and Great Towns (including London) and 148 Smaller Towns:- Birth-rate. Recorded Death-rate. Infantile Death-rate. Live Still England and Wales 15.1 0.60 11.6 53.00 London 13.4 0.48 11.4 57.00 126 County Boroughs and Great Towns (including London) 15.0 0.65 11.7 57.00 148 Smaller Towns 15.4 0.60 11.0 51.00 ENFIELD 18.88 0.63 9.15 50.69 60 INFANT MORTALITY. On pages 11 and 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 Death Rate " on page 37. BIRTHS. The actual number of births registered in the District was as follows:— Boys. Girls. Total. 526 544 1,070 including 27 illegitimate births, i.e., 2.52 per cent. of the total. In addition, 4 male and 8 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-rate for the last 5 years, are:— Year. Boys. Girls. Total. Birth-rate per 1,000 Population. Illegitimate Birth-rate per 1,000 Population. 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 1938 892 895 1,787 19.43 .64 INFANTILE DEATHS. Reference to Table 2 on page 11, shows that of the 88 deaths of children who died under one year of age, 23 occurred during the first week of life, 7 during the second week, 2 during the third week, and 4 during the fourth week; i.e. 36 in the first four weeks of life. During the year 1937 this figure was only 28. In so far as it is possible, investigations are made to ascertain the cause of a still birth or infantile death. Evidence of causation in the case of still birth was surprisingly negative in those cases investigated, for ante-natal treatment appears to have been obtained. The homes were satisfactory and there was no evidence to show that industrial employment was a causal factor, for in no case was the mother employed except in household duties. In a large 61 centage of the cases investigated, however, there was evidence to show that thehealth of the mother was unsatisfactory and in nearly 50 per cent, of the cases the child was premature. Of the 36 children who died during the first four weeks of life, it was found possible to investigate 22. In all cases the home was satisfactory and in 21 cases there appeared to be sufficient ante-natal care. The health of the mother was recorded as unsatisfactory in nine cases, and labour was premature in a similar number. Generally it was found impossible to come to any definite conclusion as to the general cause of death, but it is to be noted that seven of these 22 children died of Broncho-Pneumonia. Twenty-two cases of children dying between the ages of one month and one year were also investigated. It is interesting to note that only nine of these children were breast-fed. GastroEnteritis accounted for eight deaths. The majority of the cases attended at one of the Council's Welfare Clinics. Congenital malformation, a non-preventable cause, accounted for four deaths, whilst two of the children who died of BronchoPneumonia, were imbeciles. Investigations were carried out in the case of six children who died between the ages of one and five years. It is interesting to note that none of them was completely breast-fed for the first nine months of life, and only two partially breast-fed. It is difficult to form a conclusion from the small numbers quoted above, but generally it would appear that lack of breastfeeding, prematurity and congenital malformation, diseases of the lespiratory system and Gastro-Enteritis, account for a large number of deaths in young children. During the year there were recorded in Enfield 59 illegitimate births, and 14 deaths of illegitimate children. This gave an infantile mortality rate of 241.37 per 1,000. This figure is so inordinately high as to call for some investigation. I find that five of the 14 children who died were resident at Chase Farm Homes. It must be remembered that this Institution serves not only Enfield but the whole of Middlesex, and accepts children who are in a weakly state. It is possible that in many cases their condition is the cause of their admittance to the Institution. One of these children was premature and another was marasmic. Children of this description stand very little chance when they are exposed to infection. Of the remaining nine, bronchc-pneumonia is recorded as 62 the cause of death in five cases; in two cases the babies were premature, in one case the baby was marasmic and in the other the child died due to inattention at birth. There seems to be no doubt that illegitimate children stand a far-lessened chance of survival, and the cause is probably generally attributable to the social and mental environment of the ante-natal and post-natal periods of the child's life. As far as Enfield is concerned, the very high illegitimate infantile mortality rate must be read with the fact that a large number of illegitimate children enter Enfield after their birth in order to reside in Chase Farm Homes. Therefore the comparison between the number of births of illegitimate children in the district and the number of illegitimate children who died in the district is not comparable with the figures supplied for other districts, or for the general rate throughout the country. PUERPERAL PYREXIA. During the year 10 cases of Puerperal Pyrexia were notified. Cases of Puerperal Pyrexia arising in Enfield can be admitted to the Enfield, Edmonton and Potters Bar 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 two maternal deaths during the year and the cause was as follows:— Obstetric Shock following Labour At home. Pulmonary Embolus—Puerperal Pyrexia and Child Birth In Isolation Hospital. The average age of these two mothers was 35 years. Cases of death arising in connection with pregnancy and child birth are investigated by me, and a report thereon transmitted to the Ministry of Health. These reports are private and confidential. 63 SUPERVISION OF NURSING HOMES. The functions of the Middlesex County Council in this respect were handed over to the Urban District Council of Enfield as from 1st April, 1937. There are, in Enfield, the following Nursing Homes:- Proprietor. Address. Total No. of Beds. No. of Maternity Beds. Barker, Mrs. 238 & 240, Baker Street, Enfield. 11 - Christmas, Mrs. 3, Chalkwell Park Avenue, Enfield. 3 2 Spray, Miss 74, Graeme Road, Enfield. 6 —- Tughan, Dr. & Mrs. 29. Derby Road, Ponders End. 4 4 These homes have been regularly inspected by your Medical Officers. ADMINISTRATION OF MIDWIVES ACT, 1902-1936. During the year 1938 there were 19 Midwives practising in Enfield, of whom four lived outside the district but practised therein. The Midwives resident in the district were visited regularly by the Medical Officers of the Council and their records and equipment inspected. Of the 19 practising, 11 were employed by the Council as wholetime salaried Midwives. The following table shows the cases attended during 1938 and the corresponding figures for 1937. 1938. 1937. MUNICIPAL MIDWIVES. Cases attended as Midwives 482 26 Cases attended as Maternity Nurses 197 12 PRIVATE MIDWIVES. Cases attended as Midwives 97 561 Cases attended as Maternity Nurses 60 281 It will be seen from this table that out of the 1,080 births which took place in the district, a Midwife was present alone or with a doctor in 836 cases. 64 NOTIFICATIONS. In accordance with the Rules of the Central Midwives Board, the following notifications were received from midwives:— Sending for Medical Aid 150 Still Births 3 Laying-out of the Dead 6 Artificial Feeding 5 Liability to be a source of Infection 10 The notifications in connection with Medical Aid can be classified as follows:— During Pregnancy 13 During Labour 103 During Lying-in Period 9 Infant 25 Where a doctor is called on a Medical Aid Form, his 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. During the year it was determined not to make such collection in any case. RETIREMENT OF MIDWIVES ON COMPENSATION. The Midwives Act, 1936, provides that any midwife who, within three years of the passing of the Act, desires to cease practice, may surrender her Certificate to the Local Supervising Authority and claim compensation. Alternatively, the Local Supervising Authority may, within the same period, require a midwife to cease practice, if it is of the opinion that she is incapable, by reason of age or infirmity, of discharging her duties efficiently, and pay her compensation. At the end of 1938 four midwives had voluntarily surrendered their Certificates. One midwife had been requested by the Local Supervising Authority to surrender her Certificate. The total amount paid out by the Authority in compensation amounted to £2,497. HELP WITH COST OF MIDWIVES' FEE. In 21 cases help was granted in respect of the cost of a Midwife This compares as follows with previous years:— 1935 36 1936 41 1937 38 1938 21 65 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 six cases during the year. On each occasion when the Specialist is called in a fee of £2 2s. 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 1938 £7 19s. was recovered out of a cost to the Council of £12 12s. 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. HOME HELPS. The number of Home Helps supplied during 1938 was 105. This compares as follows with previous years:— 1935 52 1936 88 1937 146 1938 105 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. & C.W. and 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. CIRCULATION OF BOOKLET ON REARING CHILDREN. It has been the practice in recent years to circulate a book on child welfare called "To Mothers and Fathers," to all mothers concerning whom a birth has been notified to my office. It is obvious, however, that since much of this book deals with ante-natal care and the provision for the coming child, the value of the book would be increased if it reached the mothers 66 during their pregnancies. In the past this has not been possible, for there was no notification of pregnancy and the Health Department has not been officially aware of the names and addresses of expectant mothers. Now, however, some 800 mothers have asked the Department to provide a nurse to attend them at their confinements, either as a midwife or a maternity nurse. In addition, the ante-natal care of mothers who are entering the North Middlesex County Hospital for their confinements, is carried out in Enfield. In this way we become aware of some further 500 ante-natal mothers. It has therefore been possible to circularise this book to some 1,300 expectant mothers. During the course of the year 2,141 books were circulated. ATTENDANCES AT INFANT WELFARE AND ANTE-NATAL CLINICS. The following tables shew the attendances at the Infant Welfare and Ante Natal Clinics during the year. INFANT WELFARE CENTRES. Centre. Total Attendances. New Attendances. No. seen by Dr. Average Attendance per Meeting. Ponders End 9,128 409 1,576 90 Bush Hill Park 8,329 358 1,912 83 Town and Chase 8,016 427 1,812 82 Ordnance 12,012 618 1,996 110 Grange Park 98 45 62 16 Totals 37,583 1,857 7,358 90 ANTE-NATAL CLINICS, Centre. New Attendances. ReAttend ances. Total Attendances. Average Attendance per Meeting. Ponders End 261 705 966 26 Bush Hill Park 210 667 877 21 Town and Chase 212 610 822 21 Ordnance 366 975 1341 30 Totals 1049 2,957 4,006 24 67 VISITS. Town, Chase and Hadley. Bush Hill Park. Ordnance. Ponders End. Totals. Birth Notification Visits 412 301 600 243 1,556 Ditto Re-visits 330 653 564 546 2,093 Children, 1-5 years Visits 919 967 1,528 1,155 4,569 Visits re Insanitary Conditions 2 9 3 14 General Visits 95 46 23 118 282 Ante-Natal Visits 122 249 214 234 819 Post-Natal Visits 36 140 12 23 211 Blank Visits 309 136 600 85 1130 Infectious Disease Visits 32 151 77 29 289 Ophthalmia Neonatorum Visits - 1 1 Puerperal Fever Visits - - - - - Puerperal Pyrexia Visits - - - - - Visits re Foster Children 23 28 69 16 136 Totals 2,280 2,680 3,691 2,449 11,100 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: 12,391-3/8 galls. ; cost, £1,344 Os. 4d. Dried Milk: 2,404 lb.; cost, £182 12s. 8d. The corresponding figures for 1934, 1935, 1936 and 1937 were: 1934- 1935- 1936- 1937- Fresh Milk: 16,414 galls. 13,377 galls. 11,414 galls. 10,287½ galls. £1,481 4s. 3d. £1,395 15s. 6½d. £1,269 12s. 6d. £1,164 8s. 7¾d. Dried Milk : 4,201 lbs. 3389 lbs. 2,803 lbs. 2,745 lbs. £311 3s. 4d. £243 13s. l1¾d. £204 0s. l0d. £206 l1s. lid. The grant of free milk and food and the cost thereof has dropped from 1934 to 1937 due to increased employment throughout the district. On page 62 of my report last year I referred to a tendency for the demand for assistance to rise. This tendency continued throughout 1938, and the cost increased for the year. 68 ROUTINE MEDICAL INSPECTION OF CHILDREN UNDER FIVE YEARS OF AGE. The following table shows the result of the work carried out under the above scheme for 1934, 1935, 1936, 1937 and 1938. Total number of 1934. 1935. 1936. 1937. 1938. ments made 6,780 7,570 7,340 8,487 7,919 Total number kept 2,231 2,714 2,309 2,432 2,145 Total number of additional examinations 960 1,222 1,280 1,599 1,740 The following table is an analysis of the children sent for routine examination, showing the number of appointments made at each birthday. Appointments. 1st. Birthday. 2nd Birthday. 3rd. Birthday. 4 th. Birthday. Total. No. sent for 1,354 1,095 955 858 4,262 No. kept 423 243 192 1 142 1,000 The total number of appointments made, not including birthdays, was 3,657. The total number kept was 1,145. The procedure whereby invitation cards are sent to children 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 1938 had risen to 2,145. I feel constrained to repeat the remarks I have made in previous years, that the proportion of children whose appointments arekept is too low, especially those made for children of between four and five years of age. AURAL TREATMENT. The scheme whereby children under five years of age and ante-natal and nursing mothers could be referred to the School Aural Clinic was continued, and during the course of the year 69 52 children and 7 mothers were so referred. This compares with 92 children during the previous year. 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 year. From the following figures it will be seen to what extent such services have been utilised. Mothers. Children. Total. Number of individual cases seen 47 90 137 Number of attendances made 56 149 205 Number of glasses prescribed 31 25 56 Number not requiring glasses 9 23 32 Number of cases referred for conditions other than refractions 2 17 19 Number referred to Hospital 1 1 2 Number referred to Hospital for Meobomian Cyst 1 3 4 CHILD LIFE PROTECTION. PUBLIC HEALTH ACT, 1936. One hundred and thirty-six visits were paid by the Infant Life Protection Visitors during the year in connection with their duties under this Act. In addition, visits have been paid by the Medical Officers and Sanitary Inspectors. (a) Number of persons receiving children for reward on the Register at the end of the year 24 (b) Number of children on the Register:— (i) at the end of the year 29 (ii) who died during the year 1 (iii) on whom inquests were held during the year .. Nil 70 (c) Number of Infant Protection Visitors holding appointment under Section 2 (2) at the end of the year who were:— (i) Health Visitors 5 (ii) Female, other than Health Visitors Nil (iii) Male Nil (d) Number of persons (in addition to or in lieu of Visitors under (c) above) or societies authorised to visit under the proviso to Section 2 (2) Nil (e) Proceedings taken during the year:— Number of cases. Section of Act under which taken. Nil. — (/) 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 71 DENTAL TREATMENT. The following particulars show the work which has been carried out during 1938 and the previous four years. Mothers. Children Total. Totals. 1937. 1936. 1935. 1934. Attendances 727 262 989 1,047 1,027 991 1,071 Treated 177 187 364 353 390 468 319 Administrations: Local Anaesthetics 75 50 125 163 98 96 84 Extractions with Local Anaesthetics 229 115 344 378 230 207 166 Administrations: N2O 140 134 274 280 326 302 272 Extractions under N2O 773 453 1226 1,285 1,425 1350 1,187 Total Extractions 1002 568 1570 1,663 1,655 1557 1,353 N2O Sessions 37 - 37 39 41 39 39 Ordinary Sessions 43 - 43 43 45 43 41 Total Sessions 80 - 80 82 86 82 80 Dentures fitted 120 - 120 133 121 82 129 Patients receiving Dentures 70 - 70 71 64 44 70 Number of Patients having repairs 14 - 14 9 9 13 11 Number of repairs fitted 15 - 15 11 9 14 11 Number of fillings 27 50 77 96 135 187 192 Other Operations 460 54 514 489 491 394 661 Number of patients having extractions under N2O 72 123 195 169 210 203 157 Do. do. under Local Anaesthetics 52 47 99 133 86 69 60 BABY WEEK. Baby Week was held in Enfield from 27th to 30th June. Earlier in the year competitions had been set and advertised. These were on similar lines to those of last year, and included:— (1) The best made garment out of new material. (2) The best made garment out of old material. (3) The best made knitted garment. (4) The best darn or patch. In addition to this, two essay competitions were held. The first was for mothers, who were asked to write a letter to a friend describing how they would prepare their home for a confinement. 72 The second was for fathers, who were asked to write to the Medical Officer of Health stating why they liked their wives and children to attend at the Maternity and Child Welfare Clinics, and for suggestions of improvement there. For these competitions there were 216 entries. It is pleasing to record that there was considerable difficulty in determining who should be the prize winners, for even those entries which did not obtain a prize showed, in most cases, hygienic outlook and care. I have no hesitation in saying that since these competitions have been commenced in Enfield, there has been a steady improvement in the knowledge shown by the competitors as to the hygienic clothing of children. The letters received were extremely gratifying, especially those from the fathers. They showed keen appreciation of the benefits of the Maternity and Child Welfare Clinics and most of the suggestions that were made were that additional clinics should be held. Except on the last day, that is, the 30th, the weather was satisfactory and the distribution of the prizes took place in the open. The prizes consisted of table cloths, pillow cases and spoons engraved with a design similar to that of the seal of the Council. The prizes were distributed by the following ladies:— Mrs. Howard, member of the Maternity and Child Welfare Committee. Mrs. S. J. Dabbs, wife of the Clerk of the Council. Mrs. Porter, formerly Chairman of the Maternity and Child Welfare Committee. Miss Ford, member of the Maternity and Child Welfare Committee. The mothers appreciated Baby Week and showed keen interest in the entries that received prizes. A short time was devoted on each afternoon to a brief explanation as to why certain garments were awarded prizes and why others failed to be hygienically sound. 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 six children under the age of five years, and 73 four mothers and their babies were sent to Convalescent Homes. During recent years there has been an increasing demand for Convalescent Home treatment for mothers and their babies. In addition to this there has been an increasing demand for similar treatment for school children. It is extremely difficult to meet this demand, for there are few Homes in the country that are prepared to take mothers with young babies, and nearly all the Convalescent Homes are fully booked during the summer months. I anticipate that the time will shortly arise when the Council will deem it wise to consider the question of having its own Convalescent Home. 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 4 demonstrations at Central Girls' School Miss Newbegin 5 demonstrations at Suffolks Girls' School Miss Newbegin 2 demonstrations at Bush Hill Park Girls' School Miss Garlick 3 demonstrations at Lavender Road Girls' School Miss Wilkinson 2 demonstrations at Alma Road Girls' School Miss Pitcher 2 demonstrations at Chesterfield Road Girls' School STUDENT HEALTH VISITOR. It has been the practice for the Health Department, in conjunction with the College of Nursing, to give practical training in Maternity and Child Welfare and School work to students studying for the Health Visitors' Certificate. During the year two students were so trained. WINTER SCHOOL FOR HEALTH VISITORS. As in previous years one of the Health Visitors attended the Winter School at Bedford College. 74 DOMICILIARY NURSING. A grant of £25 per annum is made by the Council to :— (a) The Eastern Enfield District Nursing Association, and (b) The Enfield District Nursing Association ; on condition that they are prepared to carry out such domiciliary nursing as may be required in connection with expectant and nursing mothers and children under five years of age. During the year 1938 a large number of such nursings were carried out by these Associations. SUMMARY. Enfield's Maternity and Child Welfare Scheme includes the provision of :— 1. Health Visiting. 2. Nine clinics weekly for children under 5 years of age. 3. Five clinics per week 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 AnteNatal and Nursing Mothers. 8. Home Helps. 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. 20. Minor Ailment treatment. 21. Supply of sterilized maternity outfits. 22. Consultative Ante-Natal Clinic fortnightly. 75 Report of the Chief Sanitary Inspector For the year 1938. Public Offices, Enfield. 4th May, 1939. To the Chairman and Members of the Urban District Council of Enfield. Ladies and Gentlemen, In submitting my Annual Report for the year ended 31st December, 1938, there are certain matters to which I would direct your attention. Food premises, milk-shops, bake-houses, coffee shops and eating houses are not receiving the amount of supervision that is desirable. This indicates the necessity for the appointment of an additional Sanitary Inspector, and I am hoping that the matter will be remedied when such an appointment is made in 1939. The number of Council houses vacated during the year was smaller than in previous years. I have pleasure in stating that the number of verminous houses was again much lower. The purchase of three new vehicles accounts, to some extent, for the increased cost of refuse collection, for the dustman's weekly call accounts for less than 4d. per week per house. In common with other districts in the country other type of work has arisen during the year and more than fully occupied the time of the various members of the Staff. 76 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 and 1932 241 House-to-House apart from this Act On Account of Infectious Disease 152 On Account of Phthisis 79 On Account of Complaint by occupant or otherwise 1,726 On Account of Vermin 283 292 Factories 286 13 Workplaces 214 Outworkers' premises inspected 119 42 Bakehouses, of which 31 are in use 96 10 Slaughterhouses, of which 7 are in use 952 15 Cowkeepers' premises 405 90 Dairies and Milkshops inspected frequently 271 21 Schools 48 Public Conveniences inspected 569 Conveniences at Railway Stations inspected 16 Fish shops ; Total number of visits 92 -Coffee and Eating Houses: Total number of visits 17 Coffee-stalls: Total number of visits 16 Shops where Ice-cream is made: Total number of visits. 50 Meat Shops : Total number of inspections .. 265 Food Preparing Premises: Total number of inspections 92 Food Stalls in Markets: Total number of inspections 1,067 Visits to absentees excluded from Elementary Schools 1,021 Visits in connection with cases of Infectious Disease 1,303 Visits in connection with Phthisis 238 Visits re Verminous Premises, etc. 449 Offensive Trades (excluding Fish Shops) 14 Smoke observations 102 Other inspections, including works in progress 9,489 Visits re Shops Act 2,678 22,350 77 Inspections—(continued,). Inspections. Brought forward. 22,350 Cinemas, etc., inspected 47 Visits and inspections re Rats 293 Visits re Sub-letting in Council Houses 13 Visits re Caravans, etc. 309 Visits re Overcrowding and Housing Survey 3,923 Visits re Rag Flock Act 12 Visits and Inspections at Mortuary 37 Inspections of Stables 66 Visits re Noises Visits re Pig-styes 29 Visits re Exhumations 1 Other Visits 536 Visits re Fair Grounds 1 Visits re Hairdressers' Premises 62 Visits re House let in Lodgings 1 5,330 27,680 NOTICES ISSUED. Statutory:— Public Health Act. Provision of dustbins 2 For repairs to houses, drains and abatement of nuisances 21 Providing sufficient water-closets 5 Paving of yards — Provision of Sinks or Drains 3 Offensive accumulation Emptying Cesspools 4 Housing Act, 1936 50 Shops Act, 1934 50 135 Informal:— Notices—Public Health Act 485 Housing Act 275 760 895 78 Brought forward 895 Other Notices issued:— To occupiers 565 To Education Committee and Head Teachers at Schools 2,094 To Librarian 3 2,662 3,557 Letters re Air Raid Precautions 1,033 Other letters sent 11,693 Number of Certificates issued in connection with plans 99 Number of Certificates issued in connection with disinfection 31 Result of Service of Statutory and Informal Notices:— Statutory. Informal. Number complied with 128 517 Number outstanding 7 243 135 760 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 225 Gutters and down pipes repaired 131 Downpipes disconnected from drains 4 Houses underpinned and settlement remedied 0 Dampness remedied 201 Damp-proof Courses inserted in walls 7 Natural lighting of houses improved 2 Concrete site provided under floors 0 Cesspools emptied 348 Cesspools abolished 5 Cesspools re -constructed or NewCesspools provided 0 Closet Pails Emptied 1,560 House drains cleared, repaired, etc. 165 House drains tested, examined, etc. 262 House drains reconstructed 29 Soil-pipes and drains ventilated, including repairs to ventilators 81 New vents provided 8 79 New manhole covers provided 0 Sink-wastes disconnected or repaired 46 New sinks provided 62 Obsolete Gulleys replaced 0 Closets provided with proper flushing cisterns or water supply 5 New closets provided 17 Closets repaired, covered, cleansed, etc. 126 Water-closets substituted for earth-closets 4 Water-closets provided with doors 1 Elsan or Chemical Closets provided 0 Urinals repaired or provided with flushing tank and water supply 0 Privy substituted for earth-closet 0 Intervening ventilated space provided 0 Water-closets provided with ventilation 0 Water-closets provided with light and ventilation 2 Water-closets substituted for trough-closets 4 Storage cisterns repaired, covered, cleansed, etc. 10 Storage cisterns provided 2 Water laid on or restored 37 Taps provided over sinks 6 New wells provided 0 Wells closed 10 Wells cleansed and repaired etc. 0 Samples of Water taken from Wells 48 Do. do. Main 0 Do. do. Swimming Pool and Baths, also Paddling Pool 69 Samples of Rag-Flock taken under Rag-Flock Act 5 Samples of Milk taken 32 Yards paved, or existing paving made good 83 Yards drained 0 Ventilation provided under ground floors 7 Floors repaired 73 Handrails provided to Stairs 55 Lighting provided to staircases 0 Ventilation provided to bedrooms 0 Dustbins repaired, or new ones provided 318 Ashpits abolished and dustbins provided 0 Forecourts paved 0 Food Stores provided 16 Ventilation provided or improved to food stores 20 External paintwork renewed 20 Doors repaired or replaced with new 18 Manure heaps removed 13 Fowls and other animals removed 6 80 Coppers repaired, etc. 19 Stoves repaired, etc. 68 Windows repaired, etc. 294 Other nuisances abated 218 Dairies demolished and rebuilt to requirements 0 Ditches cleaned out 3 Caravans and Gypsy vans removed 120 Pig-styes removed 0 Drainage provided to piggeries 0 Quarries fenced 0 Proper rent books provided 0 Heating provided to shops 13 W.C.s provided to shops 2 Washing facilities provided to shops 5 Facilities for meals provided to shops 1 Rest rooms to shops improved 1 Coffee stalls abolished 0 Every possible effort is made by the District Sanitary Inspectors to expedite the work following requests to property owners and agents, and we have been able to speed up the progress of repairs considerably. Where there has been any undue delay a suitable warning letter from the Council has helped considerably in having the works completed without recourse to legal proceedings. 1,021 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 27,680. 81 DISINFECTION. Houses Disinfected:— After infectious disease 275 After Phthisis 59 334 After verminous cases (Non-Council) 65 Vacated Council houses 22 87 421 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 8 Ditto, ditto, by cases of Phthisis 3 Articles of clothing, bedding, etc., disinfected 1,503 Ditto, ditto, destroyed 158 Library Books disinfected 91 No. of Certificates issued re disinfection of clothing and premises 31 Number of Schools disinfected 8 Private Patients removed to Hospital 3,257 Caravans and Gipsy Vans removed from District 120 Articles or parcels of unsound food destroyed or otherwise disposed of 22 106 vacated Council houses were examined for the presence of vermin during the year, and in 81 of these houses it was deemed advisable to carry out a detection test. 22 houses shewed definite -evidence of vermin—20 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, be found to be occupying a house free from vermin. DISINFESTATION OF VERMINOUS HOUSES. The rule of the Health Department, as in the past, has been to see that every house becoming vacant is inspected for the purpose of deciding whether it is verminous. Where evidence of infestation has been found the house has been disinfested before being relet. Our experience with Heavy Naphtha has proved so satisfactory that it has been considered highly desirable that its use should be continued in the case of empty houses. The Department has now a specially equipped van in which verminous articles, particularly furniture, can be efficiently fumigated. The disinfection of verminous clothing and bedding is carried out by means of a Washington-Lyons Steam Disinfector situated at the Council's Sewage Farm. 82 FACTORY AND WORKSHOP ACT, 1901, AND FACTORIES ACT, 1937. A register is kept of all the factories, etc. in the District, and at the end of 1938 there were 292 factories and 13 workplaces registered. The following tables give details of the work done in connection with these places:— Inspections. Premises. Number of Inspections. Written Notices. Prosecutions. Factories with mechanical power 286 23 — Factories without mechanical power 70 — — Other Premises under the Act (including Works of building and engineering construction but not including outworkers premises) 240 — — Total 596 23 — Defects Found. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Want of cleanliness 10 10 — — Overcrowding 1 1 1 — Unreasonable temperature — — — — Inadequate ventilation 1 1 1 — Ineffective drainage of floors — — — — Sanitary Conveniences:— Insufficient 1 — — — Unsuitable or defective 12 12 — — Not separate for sexes — — — — Other offences 6 6 9 — Total 31 30 11 — 83 Homework. Nature of Work. Lists received from Employers Notices served on Occupiers as to keeping or sending Lists. Sending once in the year. Sending twice in the year. Lists. Workmen. Lists. Workmen. Brushes 1 1 — — — Cleaning 3 3 — — — Embroidery — — 2 2 — Umbrellas — — 2 2 — Fancy Goods 1 2 — — — Electrical Equipment — — 2 2 — Making Wearing Apparel 17 50 12 28 8 Boot-making 1 1 2 2 — Toys 3 17 — — — Cardboard Boxes — — 2 2 — Artificial Flowers 1 1 — — — Trimmings 1 1 2 2 — Handbags — — 2 2 — Millinery 1 1 — — — Gloves 1 1 — — — Totals 30 78 26 42 8 Nine addresses of outworkers have been forwarded to other districts. PLACES OF PUBLIC ENTERTAINMENT. Forty-seven inspections of cinemas and other places of entertainment were made in accordance with the recommendation contained in the Circular of the Ministry of Health, dated August 25th, 1920. The sanitary accommodation at each place was found to be satisfactory and sufficient. OFFENSIVE TRADES. The following offensive trades are established in the District:- Fish Fryers 30 Rag Sorters 3 Glue Maker 1 Soap Boiler and in connection with these, 106 inspections were made during the year. 84 During the year 2 new fish-frying shops have been opened with the consent of the Council, and I am pleased to say that these have been of an improved type. The closed saloon type is still very much in favour 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. It will be noted that the number of Cow-keepers in the district has fallen. The reason for this is somewhat difficult to ascertain, but is probably correlated to the increased urbanisation of Enfield. Licences as follows were in force on the 31st December under the Milk (Special Designations) Orders, 1936 and 1938 :— Dealer's Licence to use the Designation "Accredited" 1 Dealer's Licence to use the Designation "Pasteurised" 21 Dealer's Licence to use the Designation "Tuberculin Tested" 5 Pasteuriser's Licence to sell milk as "Pasteurised" 2 Supplementary Licence to use the Designation "Accredited" 1 Supplementary Licence to use the Designation "Tuberculin Tested" 2 Supplementary Licence to use the Designation "Pasteurised" 4 PUBLIC HEALTH (MEAT) REGULATIONS, 1924. The inspection of meat as in previous years has been carried out according to the Regulations, and all possible efforts are made to see that the various foodstuffs are prepared under the most modern hygienic conditions. I think the desirability of obtaining these conditions is fully appreciated by the various tradesmen in the district and they are all doing their best to work in cooperation with us in this matter. The following table shews the results of inspections of the carcases and organs of animals killed in the slaughterhouses of the District. 85  Cattle, excluding Cows Cows. Calves Sheep and Lambs Pigs Totals Number killed 389 31 38 5,475 7,286 13,219 Number inspected 389 31 38 5,475 7,286 13,219 All Diseases except Tuberculosis. Whole carcases condemned - - - 0 1 21 Carcases of which some part or organ was condemned 13 2 1 4 83 103 Percentage of the number inspected affected with disease other than tuberculosis 3.3 6.4 2.6 0.4 1.1 0.9 Tuberculosis Only. Whole carcases condemned - 1 - - 3 4 Carcases of which some part or organ was condemned 6 6 - - 51 63 Percentage of the number inspected affected with tuberculosis 1.5 22.5 - - 0.7 0.5 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. 22 lbs. The various carcases were found to be in very satisfactory condition and there was, therefore, no necessity to obtain a Magistrates Order with regard to the condemnation of any carcase. With regard to the inspection of meat in Enfield the standard has been well maintained. Meat inspection takes up a great deal of the Inspectors' time and the slaughtering is spread out over the whole week, Sundays and holidays included and till late hours at night. 86 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 952 Shops 265 Stalls in Markets 1,067 Food Preparing Shops 92 2,376 The traders submitted various articles of food purchased in the London markets and other districts and on inspection 22 were found to be unfit for human consumption. As in previous years Certificates were given in all cases so that the purchaser might obtain either alternate goods or a refund of his money from the wholesaler. The plans for new Coffee Stalls are inspected at this Office and the best sanitary provisions as to the removal of refuse, water supply and drainage are insisted upon. 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 ACTS. The appointment of a Shops Inspector has been of considerable assistance in carrying out the duties required by the various Acts. Again I must say that inflicting small fines for infringements of the Shops Acts has very little effect in preventing repetition of the offence. It was found necessary to take action during the year against two shopkeepers for contraventions of the Act of 1912 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. The provisions of the Shops Act, 1934, have been pressed forward during the year and I am pleased to say that it was not found 87 necessary to take any legal action. Following upon the receipt of a petition from a number of Bakers and Confectioners in the District, the Council made and brought into operation on the 23rd December an Order, known as the Bakers and Confectioners Order, 1938, requiring the earlier closing of shops where bread and confectionery were sold. CARAVANS. The Council have powers under the Middlesex County Council Act, 1934, to deal with caravans or moveable dwellings. The main provisions of the Act include:— The power of the Court, upon application by a local authority, to prohibit moveable dwellings in certain areas. The prohibition of moveable dwellings without previous consent of the local authority, and unless the site is properly paved and the land provided with sufficient roads, sanitary conveniences, drains and sewers, and is furnished with a separate supply of water to the satisfaction of the Council. 8 applications were made to the Council during the year for permission to camp in various parts of the District. 5 received permission for a limited time subject to the requirements of the Act being complied with, and 3 applications were refused. Various travelling "gypsy" vans have attempted to camp in the District but on the threat of being hauled off the ground into the roadway, have removed their vans elsewhere. There were no true gypsy vans to deal with. 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. Fifty-seven Dustmen are employed and the following vehicles are in use for the removal of house refuse:— 2—10 cubic yards dustless-loading "S.D." Freighters. 6—15 cubic yards Moveable Floor Rear-loading "S.D." Freighters. 2—15 cubic yards Moveable Floor Rear-loading "Dennis" Vehicles. 1—22 cubic yards Moveable Floor Rear-loading "Dennis " Vehicle. 1—Tuke and Bell 10 cubic yards "Barrier" Type end-loading vehicle. 1—8 cubic yards Moveable Floor Rear-loading Karrier "Colt " three-wheeled Vehicle. 1—Bedford 2 ton General Purpose 3-Way Tipping Lorry. 88 It will be noted that 3 new vehicles of the roller-floored type were purchased during the year. One of these was of the same capacity as older vehicles, namely, 15 cubic yards; another was exceptionally large being of 22 cubic yards capacity with a special compartment for carrying waste paper and/or loaders. The third vehicle, although of the roller-floored type was of only 8 cubic yards capacity. This vehicle, after considerable experiment, was evolved to negotiate narrow, winding roadways at the rear of premises. It was found that the only vehicle which could negotiate these special roadways was a three wheel type. Arrangements exist whereby trade refuse is removed from shopkeepers' premises on payment of a prearranged charge. The income from this source was £264 14s. Od. during the year. The total refuse collected and disposed of amounted to 20,300 tons. The cost was £21,807 or 21s. 5.8d. per ton for collection and disposal, as against a figure of 17s. 8.9d. for 1937. The cost per head of the population was 4s. 8.9d. per annum or 1.09d. per week. The average for each house is 16s.9.9d. per year, or 3.8d. per week. DISPOSAL OF REFUSE. The depositing of refuse in the old Gravel Pit in Carterhatch Lane was continued until August. The tip in the Gravel Pit when left was approximately 99 per cent. covered. There is no doubt that the filling of the old Gravel Pit has removed an eyesore and added to the amenities of the District. Refuse is now taken to the new Refuse Disposal Works in Carterhatch Lane, which are under the supervision of the Council's Engineer and Surveyor. SEWER FLUSHING. This work was carried out by the Department, and all sewers were regularly examined and flushed until nearly the end of the year when, unfortunately, owing to the considerable rainfall experienced it was found inexpedient to carry out any further flushing, as the sewers were becoming surcharged. The clearing and repair of sewers, and the regular examination of all main drains has been carried out as in previous years. CESSPOOLS. The dual-purpose cesspool-gulley emptying machine purchased in 1934 has been in constant use during the year, primarily for the emptying of cesspools. When not so employed the machine has been of use to assist in the emptying of street gullies for which purpose the Surveyor's Department have now a special machine of their own. 89 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 improvement in cleanliness at all the public conveniences in the district, including those at the Parks and Pleasure Grounds and also 5 attached to Public Houses (making 18 in all) has been maintained since the appointment of full-time attendants. HORSE TROUGHS AND DRINKING FOUNTAINS. The cleansing of the drinking fountains and 4 horse troughs in the District has again received daily attention throughout the year. PUBLIC MORTUARY. One Public Mortuary in the District, established at the Enfield Highway Cemetery has received close supervision from this Department. There is a whole-time attendant at the Mortuary who attended to 50 cases during the year. 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 and the Department is well equipped with apparatus to deal effectively with the problem. 90 The Officer appointed by the Middlesex County Council under the Rats and Mice (Destruction) Act, 1919, has afforded us assistance in many cases when called upon to do so. There still remains the serious question as to whether the Health Department has sufficient Staff to carry out the work that it is now called upon to do and, as I have previously stated in my Annual Report, I hope this will be remedied during the coming year. 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 Ladies and 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, 1938 92 MEMBERS OF THE ENFIELD EDUCATION COMMITTEE, 1938-1939. Chairman Mr. H. A. Deshborough Brown Vice-Chairman Mr. H. G. Short. Representative Members. Mr. W. C. Bennett Mr. W. H. Betts Mr. H. A. Deshborough Brown Mr. T. H. M. Clarke Mr. H. H. Collier Mr. J. W. Draper Mr. D. Mason Mr. H. Muspratt, O.B.E. Mr. C. Partington, J.P., M.R.S.T. Mr. S. G. Rowlandson Co-optative Members. Mrs. I. G. Dufton Mrs. H. Rothwell Mr. F. Acres Mr. F. G. Cobbin Mr. H. G. Short Mr. E. S. Stock Mr. C. F. Watts Director of Education. E. Pascal, Esq., M.A. 93 STAFF OF THE SCHOOL MEDICAL DEPARTMENT. School Medical Officer— Dennis H. Geffen, M.D., B.S., D.P.H., M.R.C.S., L.R.C.P. Assistant School Medical Officers— Gertrude Forrester, M.B., B.S. (Lond.). 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. E. Davif.s, S.R.N., C.M.B., New H.V's Certificate. Dental Nurse— F. Anderson, R.S.C.N. Dental Attendant— I. Groves Clerks— H. Ogilvie. M. Stiff. 94 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, 1939. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies, and Gentlemen, I beg to submit my Annual Report on the school children of Enfield for the year ending 31st December, 1938. The work of the department has been carried on steadily throughout the year, and I am satisfied that the health of the children has been well maintained. Figures as to the state of nutrition of children in Enfield must be read with caution. Your medical officers take a very high standard as to the state of nutrition that should be expected in a district such as Enfield, and comparisons with other districts cannot, therefore, rightly be made. There has been some comment as to the number of children who are operated upon for the removal of tonsils and adenoids through the aegis of the School Medical Department. It is a fact that the number dealt with by the Enfield Education Committee is considerably higher than the numbers dealt with by the Education Committees of some of the neighbouring, or other districts in the country. This does not mean that the number of children in Enfield who have their tonsils and adenoids removed is higher than in those areas with which the comparison has been made. It merely shows that in Enfield the public turn to the Education Committee in greater proportion, to arrange the operation. The operations performed under the aegis of your Committee are only performed after a child has been examined, kept under observation, possibly after consultation with your Ear, Nose and Throat Specialist, and as often as not at the request and on the advice, or with the co-operation, of the family practitioner. It must be remembered 95 that the children upon whom we operate are sent to the War Memorial Hospital—a hospital which is under the medical control of the general practitioners of the district, and where the children are operated upon by doctors who have the confidence not only of the School Medical Department, but of the public, and of the doctors in the district. If comparisons are to be made with other districts all these factors should be taken into consideration. In actual fact the number of children in Enfield schools who have had their tonsils and adenoids removed is less than in the Public Schools of England, where it is fair to assume that the operation is carried out only after expert advice has been obtained. In September the school routine was disturbed by the crisis, and I have attempted to assay the mental effect upon the children of Enfield. In this connection I have had the co-operation of all our head teachers. I wrote to them asking for such information as they could give me as to whether the crisis caused any signs of fear in the children, what effect, if any, it had on their work, and how they reacted to the excitement of the period. Mr. Pascal and I were fully aware of the outstanding calm and efficiency with which the teachers dealt with the exigencies of the time, and the sense of strength and steadiness which they imparted not only to the children but also to the neighbourhood. There was a concensus of opinion that no signs of fear were apparent in the children attending our schools, that there was little effect on their work, that there was a sense of excitement largely on account of the fact that some of the children thought they might go away, or alternatively that the schools might be closed. One teacher remarked that there was that same sense of excitement as might be caused by preparation for a school concert, or national holiday. Certain children had showed signs of fear, but on going to school where an atmosphere of calm prevailed had soon settled down. The children did not realise the meaning of a war, and generally the crisis caused no nerve strain upon them. Whilst this was the general impression we all had I was glad to have it confirmed by those whose duty it was to look after the children of our district during the major portion of the day. The effect upon the teachers was not quite so happy, and many reports state that the staff showed signs of nerve strain and that there was excessive illness following upon the crisis. A typical remark is as follows:— "The members of the staff understanding the implications of the crisis, and realising their responsibility with regard to the children, were subjected to a certain amount of strain which may, or may not, have been responsible for a considerable amount of illness in the Spring Term." I would like to take this opportunity of thanking the teachers for their reports. I know that the Committee feel with me that the 96 value of the confidence children have in their teachers is, and will be, in time of crisis a most important factor in preventing panic. The crisis in September was significant in the complete absence of any signs of panic in our schools or amongst our children, and this was largely due to our teachers. The number of children who have been found to be suffering from skin disease or defects associated with lack of cleanliness tends to decrease, and where lack of cleanliness is discovered the tendency is for the condition to be less severe than in previous years. I include a report from the Senior School Dentist, Mr. James. This shows clearly the impossibility of dealing adequately with the dental condition of the children of Enfield with the existing staff. I sincerely hope that the appointment of a third dentist will ameliorate in part the present position. Mr. Hogg, the School Aural Specialist, and Mr. Macky, the School Ophthalmic Surgeon, in their reports give indication of the work that has been carried out in their particular departments during the year. I am satisfied that the extension of the services of the Aural and Ophthalmic Clinics to children under five years of age will prevent much of the incapacitating disease which so far has only been discovered when children enter school. The completion of new schools with their vast improvement in design, the erection of houses, the appointment of more teachers, and the growth of the School Medical Services are in my opinion factors which are improving the physique of the children of the district year by year. The healthy child is created by a variety of circumstances, one of the most important of which is the social environment in which it can be brought up. Children spend almost one third of their lives within the precincts of their schools. It is difficult to exaggerate the good that can be achieved by securing that these hours shall be healthy both from the mental atmosphere with which the child is surrounded, and the physical freedom it is given to improve its actual health and strength. I beg to take this opportunity of thanking the Committee for the courtesy it has always extended to me, and to pay tribute to my colleague, Mr. Pascal, and to every member of the School Medical Department who has helped me during the year. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, Dennis H. Geffen. School Medical Officer 97 REPORT OF THE SCHOOL MEDICAL OFFICER. Area (in acres) 12,400 Population 91,940 Number of Schools 19 1934 1935 1936 1937 1938 Average number on books of elementary schools 9,970 10,155 10,570 11,038 11,564 Average weekly attendance 8,857 9,200 9,342 9,756 10,278 SCHOOL. Number on roll 31.12.38 Alma Road Boys' 241 Alma Road Girls' 218 Alma Road Infants' 212 Bush Hill Park Senior Mixed 258 Bush Hill Park Junior Boys' 240 Bush Hill Park Junior Girls' 229 Bush Hill Park Infants' 280 Botany Bay 26 Chase Side Boys' 323 Chase Side Girls' 260 Chase Side Infants' 224 Chesterfield Road Boys' 452 Chesterfield Road Girls' 464 Chesterfield Road Junior Mixed 490 Chesterfield Road Infants' 406 Eastfield Road Mixed 693 Eastfield Road Infants' 480 Forty Hill 134 George Spicer Central Boys' 229 George Spicer Central Girls' 238 George Spicer Junior 405 Lavender Road Boys' 370 Lavender Road Girls' 372 Lavender Road Infants' 318 Southbury Road Boys' 315 Southbury Road Girls' 264 Southbury Road Infants' 258 Suffolks Senior Mixed 464 Suffolks Junior 525 Suffolks Infants' 596 98 St. Andrew's Boys' 94 St. Andrew's Girls' 132 St. Andrew's Infants' 74 St. George's C.E. Infants' 140 St. George's R.C. Mixed 100 St. James' Boys' 224 St. James' Girls' and Infants' 357 St. John's Mixed 54 St. Mary's R.C. Mixed 194 St. Matthew's Girls' and Infants' 199 St. Michael's Boys' 58 St. Michael's Girls' and Infants' 143 SECONDARY SCHOOLS. County School for Girls 464 Grammar School for Boys 496 Junior Technical School for Boys 168 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 4,112. In 1937, 3,967 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. 79 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:— 1934 1935 1936 1937 1938 Percentage of children accompanied by parents 76 76 79 73 79 36 per cent of the children examined were vaccinated. The comparative figures for the last five years are as follows:— 1934 1935 1936 1937 1938 Percentage of children vaccinated 37 37 39 30 36 99 DEFECTS FOUND AT ROUTINE MEDICAL INSPECTION. Uncleanliness.—Of 4,112 children examined 8 were found to have vermin in their heads and 201 had nits. The comparative figures for the last five years are as follows:— 1934 1935 1936 1937 1938 Number of children examined 3,378 3,436 3,819 3,967 4,112 Number of children with verminous heads 15 7 11 5 8 Percentage of children with verminous heads 0.4 0.2 0.3 0.1 0.2 Number of children found to have nits 279 182 220 202 201 Percentage of children found to have nits 8.2 5.0 5.8 5.1 4.9 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 1938 was 4,112 and the following table shows how they were classified, with comparative figures for 1935, 1936 and 1937. 1935 1936 1937 1938 Number of children examined 3,436 3,819 3,967 4,112 Number of children classified "A" 38 295 270 295 Percentage of children classified "A" 1.1 7.7 6.8 7.1 Number of children classified "B" 2,286 1,953 2,708 2,809 Percentage of children classified "B" 66.6 51.1 68.1 68.3 Number of children classified "C" 1,056 1,116 843 884 Percentage of children classified "C" 30.6 29.3 21.3 21.5 Number of children classified "D" 56 455 146 124 Percentage of children classified "D" 1.7 11.9 3.7 3.0 100 I have given considerable attention to the figures for 1938 and previous years. As I have already stated the classification is carried out at the request of the Board of Education, but I am afraid that I cannot ask the Committee to come to any conclusion based on these figures as to the nutrition of the children of Enfield. It has been my experience that they differ very widely as between doctor and doctor. Nutrition is something which it is impossible to define. It depends, admittedly, to a large extent on food. On the other hand it is possible to find children whom one cannot classify as either " A " or " B " yet whose standard of living and whose supply of food is both adequate and satisfactory. Apart from the fact that exercise, home environment, sleep, rest, and freedom from noise and worry are factors of importance, there must be considered, furthermore, the question of heredity. I mention these facts lest the Committee should consider that since there were 884 children classified as slightly sub-normal and 24 as nutritionally bad, there is an immediate need to supply all these children with extra milk and/or meals. It is quite possible that many of them are being adequately fed at home, and that the cause of their nutritional deficiency lies other than in inadequacy of food in quality or quantity. During 1939, should time permit, I hope to correlate more closely the question of nutrition with that of the provision of milk and/or meals, for at the present moment the latter is carried out largely on a family income basis. This may be criticisable, but looked at from a preventive point of view there is much to be said for feeding and giving milk to children from homes where the family income is low, even though nutritionally these children appear to be well-nourished. Unless these preventive measures are taken, malnutrition will arise in due course. Rightly or wrongly it has been, in most cases, on the suggestion of the head teachers, confirmed by the School Medical Department, that free milk and meals have been provided, and I rather feel that the recommendations from the teachers have been based verv largely on their own knowledge of family hardship. It is hoped to institute nutrition surveys very shortlv, but these cannot be carried out with the existing medical staff. Skin Diseases.—Twenty-two cases were seen; all required treatment. Ear Disease.—Thirteen cases of middle ear disease were found; also twenty-nine cases of defective hearing. All these cases were referred to the Aural Clinic for treatment. 101 1934 1935 1936 1937 1938 Number of children examined 3,378 3,436 3,819 3,967 4,112 Number of cases of Middle Ear Disease found 18 19 22 25 13 Percentage of cases of Middle Ear Disease found 0.5 0.6 0.6 0.6 0.3 Number of cases of Defective Hearing found 53 33 26 59 29 Percentage of cases of Defective Hearing found 1.6 0.98 0.7 1.5 0.7 Tonsils and Adenoids.—1,210 children had already had operation for removal of tonsils and/or adenoids; 310 were found to have enlarged tonsils, adenoids, or both. The following is a comparative table for the last five years:— 1934 1935 1936 1937 1938 Number of children examined 3,378 3,436 3,819 3,967 4,112 Number of children already operated upon 1,202 1,205 1,143 1,123 1,210 Percentage of children already operated upon 35.6 35.0 29.9 28.3 29.2 Number of children with enlarged tonsils, adenoids, or both 512 663 597 494 310 Percentage of children with enlarged tonsils, adenoids, or both 15.3 19.3 15.6 12.5 7.5 Eye Diseases and Defects.—Thirty children were found to be suffering from external eye disease. All were referred for treatment to the minor ailment clinic. 270 cases of defective vision were referred for treatment to the Ophthalmic Clinic or hospital; 37 of these had squint. The following is a comparative table for the last five years:— 1934 1935 1936 1937 1938 Number of children examined Number of children with defective vision 3,378 234 3,436 200 3,819 220 3,967 237 4,112 233 Percentage of children with defective vision 6.9 5.9 5.8 5.9 5.4 Number of children with squint 40 43 46 40 37 Percentage of children with squint 1.1 1.2 1.2 1.1 0.9 102 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. 8 for other conditions. In addition to these, 21 children attended the hospital during the year for treatment for squint, making a total of 196 attendances. Tuberculosis.—One case of pulmonary tuberculosis was found. Crippling Defects.—The following defects were seen during the course of Routine Medical Inspection:— 1 case of hemiplegia. 2 cases of spinal curvature. 1 case of cleft palate. 1 case of cleft palate and hare lip. 1 case of congenital shortening of leg. 3 cases of club foot. 1 case of severe knock-knee. 1 case of amputation of leg due to tuberculosis. 1 case of web fingers. 1 case of infantile palsy. INFECTIOUS DISEASE 1934 1935 1936 1937 1938 Measles 430 15 404 37 386 German Measles 160 1 9 — — Mumps 277 53 197 264 47 Whooping cough 72 79 154 61 43 Chickenpox 100 243 149 87 159 Scarlet Fever 135 136 128 93 130 Diphtheria 11 32 53 87 35 Diphtheria Carriers 3 — 1 2 3 Cerebro-Spinal Fever — — — — 1 The Enfield school children were reasonably free from infectious disease during the year. It will be noted that the number of children suffering from diphtheria was much less than that for 1937, whilst the figure for Scarlet Fever increased. Children are brought in small numbers to our clinics requesting immunisation against diphtheria, and some attend at the Public Offices on Saturday mornings, to be immunised there. The number, however, is small. It seems that propaganda and advice which are given during periods when the incidence of diphtheria is low are 103 not heeded, and it is fortunately some years since diphtheria existed in Enfield in serious, or in epidemic form. I feel that the public have been lulled into a false sense of security, and I would again urge parents to take advantage of this safe and successful method of obtaining protection from a disease so serious as diphtheria. DETECTION AND PREVENTION OF SPREAD OF INFECTIOUS DISEASE. Close co-operation exists between the School Medical Department and the Public Health Department, whereby when either becomes aware of infectious disease in any school, house or district, the other department is informed. Joint action is therefore possible in preventing the spread of infectious disease. VERMIN. Of 4,112 children examined at Routine Inspection 8 were found to have vermin in their hair, and 201 had nits—i.e., 5.8 per cent had unclean heads. No child was found to have body vermin. THE WORK OF THE SCHOOL NURSES. There are five 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, three of the school nurses attend in turn at the Routine Medical Inspection to assist the Medical Officers. The fifth nurse is employed mainly on dental work assisted by a dental attendant. The following is a summary of the work of the school nurses during 1938 and for the past five years :— 1934 1935 1936 1937 1938 Number of home visits 2,697 2,830 2,710 2,752 3,809 Number of school visits 559 573 535 610 706 Number of school visits for routine examination of heads 195 184 166 153 198 Total number of heads examined 37,303 36,616 33,806 33,227 45,229 104 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 Clinics by the Deputy Medical Officer of Health and Assistant School Medical Officer. The number of children that attended the minor ailment clinics during 1938 was 4,098 and the total number of attendances was 28,043. The average attendance at the nurses' clinics was 36 (i.e., 109 per day for the three clinics). At the School Medical Officers' Clinics the average attendance was 43. 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, 572 cases of enlarged or diseased tonsils and adenoids were seen at the clinics and referred for treatment, and 282 cases were kept under observation. 393 children were operated on under the Authority's scheme and 65 were operated on by private arrangement. The following is a comparative table for the last five years:— 1934 1935 1936 1937 1938 Number of cases referred for treatment 320 501 400 482 572 Number of cases operated under the Authority's scheme 224 331 290 324 393 Number of cases operated by private arrangement 29 76 76 61 65 Tuberculosis.—Four cases of suspected or definite pulmonary tuberculosis were seen at the clinic during the year. Two children were offered sanatorium treatment and accepted. All cases notified in previous years were kept under observation, and some were given convalescent treatment. 105 Ringworm. -One child was found to be suffering from ringworm. The following is a comparative table for the last five years :— 1934 1935 1936 1937 1938 Number of children found to be suffering from ringworm.. 11 1 6 2 1 Impetigo.—During the year sixty-one cases were seen; all were treated at the clinic. The following is a comparative table for the last five vears:— 1934 1935 1936 1937 1938 Number of children found to be suffering from impetigo 12 14 33 33 61 Scabies.—Six cases were seen. The following is a comparative table for the last five years:— 1934 1935 1936 1937 1938 Number of children found to be suffering from scabies 16 — 15 15 6 Other Skin Diseases.—166 cases were seen. These consisted chiefly of seborrhoea, eczema and psoriasis. Eye Diseases.—308 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.—Seventy-nine cases of otitis media were found and were referred for treatment to the Aural Clinic. Heart Disease.—Sixty-nine children were found to be suffering from organic heart disease; fourteen of these were referred for treatment and the rest were kept under observation. In addition to these, seven cases were seen at Routine Inspection only, making a total of seventy-six cases seen during the year. Of these cases, sixteen were congenital and five followed acute infectious diseases. The remaining fifty-five cases may be classified as follows:— Definite rheumatic history 20 Vague pains 6 No history of illness 29 Chorea.—Thirteen children were found to be suffering from chorea ; five 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:— 106 1 case of hemiplegia. 1 case of congenital multiple exostosis. 5 cases of spinal curvature. 1 case of hammer toe. 5 cases of club foot. 1 case of old tubercular hip. 5 cases of infantile paralysis. 4 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. 1 case of shortening of leg. 1 case of birth palsy. 1 case of old tubercular knee. 4 cases of severe flat foot. 4 cases of cerebral diplegia. 1 case of Perthe's disease. 1 case of deformity of chest. 1 case of old tubercular spine. 1 case of ankylosis of hip. All of these children who required treatment were either attending hospital or obtaining treatment locally. Other Conditions. 1 case of osteomyelitis of tibia. 1 case of intermittent glycosuria. 6 girls were found to be suffering from enlargement of the thyroid gland. All are being kept under observation. 2 cases of chronic nephritis were seen, one was attending hospital for treatment, and the other was kept under observation. 74 cases of obesity were seen. 14 were referred for treatment and 60 were kept under observation and advised re diet. 6 cases of potential obesity in young children were seen and kept under observation. 11 children were found to be suffering from hernia ; all were referred to doctors or hospitals. Three were operated upon, and 6 refused treatment. 1 cretin was referred to hospital. 3 cases of haemophilia. 1 child was found to be suffering from a post orbital growth. 1 case of enchondroma was attending hospital. The total number of children examined during the year, excluding those attending the Dental Department, was 10,538. This number was made up as follows:— 107 Examined at Routine Inspection 4,112 Examined at Minor Ailment Clinics 4,098 Examined at Ophthalmic Clinic Only 228 Examined at Aural Clinic only 104 Examined at school leaving age for Juvenile Employment Committee 871 Examined under Juvenile Employment Bye-laws 101 Examined under Mental Deficiency Act 38 Examined as contacts with infectious disease 986 Payments at the clinics were continued on the same lines as in former years—i.e., a charge of twopence per week was made for treatment at the Minor Ailment Clinic, and threepence per attendance at the Dental Clinic (sixpence if gas is given). For spectacles and for nose and throat operations parents are asked to sign a form of consent and willingness to pay at least part of the cost before the child is referred for treatment. In really necessitous cases the Local Authority bears the whole cost. During the year the sum of £372 17s. Od. was collected as follows:— £ s. d. Minor Ailment Clinics 4 6 0 For cost of spectacles 47 16 6 For convalescent treatment 90 2 6 For operations for tonsils and adenoids 172 2 0 For dental treatment 58 4 0 For provision of instruments 6 0 The Local Authority 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; 14 girls and 14 boys were sent during 1938. During 1938 two beds were also reserved for a period of 6 months at Collington Manor, Bexhill, and 4 girls and 3 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, three children were supplied with surgical instruments, one with an artificial eye, and seven children were sent to residential schools other than the Russell-Cotes School or Collington Manor. There was a total of 13 deaths among the school children during the year. In 1937 there were 14. The causes of death during. 1938 were as follows:— 3 Pneumonia. 2 Cerebral Abscess. 1 Meningitis. 108 2 Accident (Fractured Skull). 1 Accident (Drowned). 1 Peritonitis. 1 Aplastic Anaemia. 1 Hydrocephalus. 1 Uraemia. 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. THE TEACHING OF HYGIENE. For the greater part, hygiene is taught as a class room subject, but is correlated with Domestic Subjects and with Natural Science. 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 1938:— By Miss Newbegin at the Central School 4 demonstrations By Miss Newbegin at Suffolks School 5 demonstrations By Miss Newbegin at Bush Hill Park School 2 demonstrations ByjMiss Pitcher at Chesterfield Road School 2 demonstrations By Miss Wilkinson at Alma Road School 2 demonstrations By Miss Garlick at Tavender Road School 3 demonstrations Thus 18 demonstrations were given during the year. OPEN-AIR EDUCATION. There are no open-air schools or classes in Enfield. 109 PHYSICAL TRAINING. The Authority shares with Middlesex County Council in the services of a man and woman as joint organisers of Physical Training for all purposes throughout Enfield and adjacent parts of Middlesex. 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 s. 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 1938 61,571 dinners were provided free to 479 children. The number of dinners provided in 1937 was 41,954. The arrangements commenced during 1935 for the provision of milk to children free, and at ½d. for 1/3 pint, were continued. During 1938 1,133,705 bottles of milk were provided and paid for, and 103,898 bottles of milk were provided free to those children whose circumstances were such that their parents could not afford to pay. This compares with 982,047 bottles and 88,288 bottles respectively during 1937. The milk was pasteurised and delivered in one-third pint bottles, and drunk through a straw. Children receiving free milk are examined by one of the School Medical Officers. CO-OPERATION OF PARENTS. The percentage of parents who attended with their children when they were examined at Routine Inspection was 79. At the School Clinics there are a number of children who come with messages from their parents. Careful note and attention is given to these messages, and an attempt made to answer and deal with them. On the other hand I would suggest that parents would be well advised to attend with their children rather than to send them with messages. In the first place messages, if not in writing, are very often forgotten or distorted by young children, and in the second place, no opportunity is provided for that personal contact between school doctor and parents which is most essential. There are few parents who would send their children to private 110 doctors with a message. It is equally essential that parents should attend with their children at the School Clinics for, in most cases, it is largely advice that is sought. CO-OPERATION OF TEACHERS. The co-operation between the teachers and the staff of the School Medical Service and the Health Department is now so much a matter of routine as to require no note from me. As each year goes by the co-operation gets closer. I find myself in increasing contact with the Head Teachers concerning mental deficiency, and children suffering from defective eyesight and hearing. The work of the School Medical Department is very closely bound up with the work of the teachers, and the mutual assistance which the two bodies are able to give one another is essential in determining the right course of action to take in each specific case. I am very happy in the co-operation which I am able to receive and to give and I cannot thank the teachers too sincerely. 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. 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:— Eight children were given cod-liver oil and malt, Parrish's Food, etc., and 12 convalescent treatment; 519 pairs of ordinary boots were also provided. 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 354 instances parents were advised to obtain advice from their own doctors ; only those cases which are too trivial to need the advice of the general practitioner are treated at the minor ailment clinic. The thanks of the school medical service are due to the doctors of Enfield for their whole-hearted co-operation throughout the year. 1ll 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 two such children in Enfield, and they are educated as follows:— Two girls attending residential schools for the blind. (One at Swiss Cottage and one at Court Grange Special School). Deaf and Deaf-mutes.—These children attend the Philip Lane School for the Deaf, Tottenham. At the end of 1938, 11 children were attending: three deaf-mutes, three suffering from acquired deafness, and five suffering from motor aphasia. Mentally Defective Children.—Thirty-eight children were examined under the Mental Deficiency Act (1913) during 1938. The following is a comparative table for the last five years :— 1934 1935 1936 1937 s A. Dull and backward, but capable of instructior in an elementary school 4 5 4 12 11 B. Mentally Defective, but capable of instruction in a special school 8 9 8 7 14 C. Incapable of further instruction in a special school 2 1 1 1 D. Imbecile 1 4 6 10 8 Moral Imbecile — 2 — — — E. Not scheduled 2 — 1 1 4 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 of the Middlesex Education Committee. There are three such schools in Enfield, namely, the Grammar, County, and Junior Technical Schools. The following tables set out the number of children examined at each school during the course of the year, and the defects found to be present:— Jnr. Technical. Grammar. County. Number of children examined 117 225 230 112 DEFECTS. Jnr. Technical. Grammar. County. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Requiring Treatment. Requiring Observation. Defective Hearing 1 - - - 1 - Dental Caries 3 - - - 2 - Defective Vision 9 - 20 - 31 31 Enl.Tonsils, etc. - - - - 8 - Nerve Conditions - - - - 1 - Skin Disease - - 1 - 1 - Functional Heart Disease - - 1 - - - Organic Heart Disease - - - - - 1 Other Diseases and defects . . - - - - 18 - CLASSIFICATION OF NUTRITION. Junior Technical Grammar. County. Number of Children examined 117 225 230 Classified "A" 6 12 11 Classified "B" 100 185 197 Classified "C" 11 28 20 Classified "D" — — 2 207 children were treated at the Dental Clinic during 1938. 93 children were treated at the Ophthalmic Clinic during 1938. 113 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, 1938. To the Chairman and Members of the Enfield Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit the Dental Report for the year ending 31st December, 1938. Reference to figures given under Table V shows that the total number of elementary school children inspected during the year under review was 4,079, and the number treated, 3,273. These figures represent a decrease of 857 in the number inspected, and an increase of 614 in the number treated as compared with the year 1937. The following table is submitted so that comparison may be made with previous years. INSPECTION AND TREATMENT OF ELEMENTARY SCHOOL CHILDREN. Year. Number Inspected. Number Treated. Number of Fillings. Number of Extractions. 1935 4,139 2,577 3,268 4,339 1936 5,597 3,554 4,871 6,498 1937 4,936 2,659 3,068 5,998 1938 4,079 .3,273 3,705 7,717 Only part of the children attending the secondary schools were inspected and treated during 1938, the number inspected being 606, the number treated 207. The remaining children will be inspected, and treatment carried out for those requiring it, early in 1939. The following table shows the total amount of work done during the year for both elementary and secondary school children:— INSPECTION AND TREATMENT OF ELEMENTARY AND SECONDARY SCHOOL CHILDREN COMBINED. Year. N umber Inspected. Number Treated. Number of Fillings. Number of Extractions. 1935 5,102 3,005 4,353 4,667 1936 6,679 3,640 5,049 6,558 1937 4,943 3,067 4,471 6,258 1938 4,685 3,480 4,231 7,893 114 I wish to draw particular attention to the figures relating to fillings inserted and extractions carried out. It will be noted that the number of teeth extracted reached the large total of 7,893 —the highest yet recorded in the Enfield School Dental Service— while the number of fillings, although it remains high, is less than the corresponding number for any of the three previous years. Children attending the clinic as "specials" on account of pain or sepsis have tended to increase during recent years, and there can be no doubt that the time necessary for the treatment of these children is responsible for the reduction in the amount of conservative work carried out during the year under review. The aim of the school dental service is "to secure that as many children as possible leave school without the loss of permanent teeth, free from dental disease, and trained in the care of the teeth." Large numbers of children attending the clinic as "specials" have, in previous years, been offered conservative treatment which has been refused, and it is obvious that the main purpose of school dentistry will not be advanced if an increasing amount of time is devoted to extracting teeth for children whose parents only value the school dental service as a means of relief from pain. In order to cope with the problem presented by large numbers of "casuals" it has been suggested that when parents apply for treatment for their children after first refusing it, such treatment should not be given until after the next routine inspection, and then only if a promise is made that treatment will in future be regularly accepted as offered by the dentist. It would be incorrect to assume that this procedure would result in children being left in pain, as many dentists in Enfield will perform extractions for a fee well within the means of most parents. Occasional sessions for emergency work are unavoidable, but when the time devoted to such work is found seriously to affect the general educational scheme of conservative dentistry a policy of restriction is necessary. On account of the steady increase of " specials " treated during recent years, as shown in the following table, it is submitted that some such procedure as the one indicated should now be adopted in Enfield. Number of Year. Specials treated. 1935 616 1936 1,054 1937 1,514 1938 1,638 In all Public Health work great emphasis is rightly laid on prevention, and the enormous amount of dental disease that prevails makes this emphasis particularly important in school dentistry. There are three rnain avenues of approach to the ideal of prevention. 115 namely:— 1. Diet. 2. Oral hygiene. 3. Certain operative procedures. The influence of correct diet on the promotion of dental health is well known, and has been referred to by me in many annual reports, including that for the year 1937. With regard to oral hygiene, there is some divergence of opinion as to the preventive value of brushing the teeth, but if one accepts the generally held view that carbo-hydrate stasis is injurious to the teeth and surrounding structures, it would seem that considerable benefit must be derived from the regular and correct use of the tooth brush. It is at any rate a habit universally adopted by all who value their teeth, and for psychological reasons, quite apart from any good that may fol'ow its practice, should occupy a prominent place in dental propaganda. Probably only a few children on leaving school pay regular visits to the dentist in order that necessary conservative treatment may be carried out, but of those who do so, one feels that practically all will have formed the habit of brushing the teeth regularly, while still at school. An increasing number of children in Enfield take a pride in the appearance of their teeth—an improvement which is naturally more noticeable in children whose parents are in good financial circumstances. In the case of children who come from homes where the family budget is strictly limited, the purchase and periodic replacement of a tooth brush for each child is not possible. Children attending the clinic are shown, while in the chair, the correct method of brushing the teeth, and on the conclusion of treatment are handed a printed form dealing with this preventive measure, together with tooth paste or powder, samples of which are regularly received from the manufacturers for ftee distribution. In addition to correct diet and oral hygiene as important factors in the prevention of dental disease, there are certain operative procedures of preventive value to which reference may be made. In a recent report of the Chief Medical Officer of the Board of Education, it was pointed out that teeth should be treated during the earliest stage of the carious process, in order that the fillings inserted might be small. Dr. Hyatt of America, well-known for his work on preventive dentistry, goes a step further and recommends the treatment of certain teeth by means of fillings before dental caries has begun. This treatment is restricted to teeth which, although not actually attacked by dental caries, are found on inspection to present certain structural defects. Dr. Hyatt states "A study of the liability of these enamel defects to decay 116 gives one the information that only one out of every 2,500 will not decay within five years! "The technique involves the cutting out and filling of pre-carious pits and fissures in teeth, and is a preventive measure that has been shown to yield results not otherwise obtainable. In a well-staffed dental scheme with bi-annual inspections, it would be possible, by the adoption of this technique, to eliminate almost entirely the large restorations so frequently found necessary when the intervals between inspections are unduly long. A further operative procedure of preventive value may be mentioned. The immediate cause of dental caries is carbohydrate stasis, and it is generally recognised that the normal close relationship of each tooth with its neighbour is responsible for the difficulty in preventing the lodgments of finely ground sticky food between the teeth. If, however, the first permanent molars are extracted at the age of 14 to 16 years, a movement of the remaining teeth takes place with eventual fixation. Certain teeth become spaced, others take up positions which cause them to be more self-cleansing than is normally the case, and the whole dentition is in consequence rendered less liable to disease. It is not suggested that the extraction of these teeth should be carried out for all children. In selected cases, however, where there is a marked tendency to dental disease as evidenced, for example, by dental caries in the permanent incisor teeth during school life, or early interstitial caries of the molar teeth, there is a sound case for this procedure. It is important that the extractions be carried out neither too soon nor too late—between the ages of 14 and 16 years being the best time. The total number of attendances made for treatment was 5,590 —an average of 7.5 attendances per treatment session. The average amount of work carried out by each dentist on a session devoted to treatment was:— Fillings 5.7. Extractions 10.6 Other operations 1.3 Of the 4,231 fillings inserted, 152 were in temporary teeth and 4,079 in permanent teeth, while of the 7,893 extraction, 6,417 were temporary and 1,476 permanent teeth. In the total of permanent teeth extracted are included 128 sound teeth extracted for regulation purposes. The number of regulation plates fitted was 16. There were 203 administrations of general anaesthetics for extractions and 3,091 administrations of local anaesthetics. "Other operations" totalled 1,000, included in this figure being polishings of permanent teeth, applications of silver nitrate to temporary teeth, dressings, root fillings, etc. 117 During 1938 the sum received in fees from elementary school children amounted to £58 3s., an increase of £8 8s. 7d. as compared with the previous year. In conclusion, Mr. Mackay and I wish to acknowledge once more the valued co-operation of Head Teachers in the work of the Dental Clinic, and to express our appreciation of the great assistance rendered by Nurse Anderson and Miss Groves. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, C. E. JAMES, Senior School Dental Surgeon. 118 Annual Report of the School Ophthalmic Surgeon Mr. S. MACKY, M.B., B.S., D.O.M.S. For the year ending 31st December, 1938. To the Chairman and Members of the Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my report on the work of the School Ophthalmic Clinic for the year ending 31st December, 1938. ELEMENTARY SCHOOLS. 1936. 1937. 1938. Total attendance 2,072 1,910 1,923 New cases 1,028 1,015 1,007 Prescriptions for glasses 336 332 348 Number not requiring glasses 112 95 144 The cases requiring glasses consisted of:— Hypermetropia 84 74 71 Hypermetropia with astigmatism 314 312 256 Hypermetropic astigmatism Myopia 154 96 158 89 134 76 Myopia with astigmatism 99 108 111 Myopic astigmatism 11 10 12 Mixed astigmatism 64 62 42 Anisometropia 15 12 9 SECONDARY SCHOOLS. Total Attendances 96 123 135 New cases 49 86 101 Prescriptions for glasses 25 38 35 Number not requiring glasses 5 9 4 119 The cases requiring glasses consisted of:— Hypermetropia 2 4 9 Hypermetropia with astigmatism 10 10 13 Hypermetropic astigmatism 1 9 14 Myopia 12 23 22 Myopia with astigmatism 14 17 24 Myopic astigmatism — 1 — Mixed astigmatism 1 6 8 Anisometropia 3 3 3 Eight children were referred for operation for squint. Three were operated upon and five are awaiting operation. In addition four children who were refeired for operation in 1937 were operated upon in 1938. One child was referred to the Western Ophthalmic Hospital for removal of meibomian cyst. During the year 21 children attended the Western Ophthalmic Hospital for orthoptic exercises making a total of 196 attendances The year has been one of steadily increasing work. More and more cases have continued to come from the Welfare Clinics as the value of proper attention to eyes becomes more appreciated. This year, for instance, patients who previously were advised to have glasses but never bothered to get them have been coming back to ask if they may have them now. We have seen more children under school age too. An extra clinic each week has now been found necessary in order to cope with this extra work. Cases of scientific interest continue to occur. Two such cases were shown recently at the Royal Society of Medicine meeting. My gratitude to the staff of the Clinic grows with the years, and I am always glad of the opportunity of recording it. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, STEWART MACKY, School Ophthalmic Surgeon. 120 Annual Report of the School Aural Surgeon Mr. J. C. HOGG, F.R.C.S. For the year ending 31st December, 1938. To the Chairman and Members of the 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, 1938. Number of cases dealt with 343 Number of new cases 239 Total number of attendances 713 Number of cases discharged cured 187 Number of cases of a recurrent nature requiring occasional treatment 15 Number of cases still under treatment 80 Number of cases who have refused treatment or sought treatment elsewhere 24 Twenty-three school children were referred for removal of tonsils and adenoids, of whom 16 have had the operation, four are awaiting operation, and three have refused treatment. Four children were referred for removal of adenoids only. One case of acute mastoiditis was referred to the North Middlesex Hospital, and another to the Prince of Wales's Hospital. Five cases were admitted under my care to the Throat Hospital, Golden Square, W.l. Three cases were operated on for chronic mastoiditis and have made satisfactory subsequent progress. One case was operated on for a deflected septum and another for intra-nasal drainage of the maxillary antra. They have both been discharged from further treatment. During the year under review, 52 infants and seven mothers have been examined in connection with the Infant Welfare Centres —a considerable drop in figures over the preceding year. As the majority of infants have been referred because of acute otitis media, this represents a satisfactory decline in the incidence of this disease. Once again I would like to express my gratitude to the Nursing 121 Staff at the Southbury Road and other clinics for their wholehearted 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. 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 72 1 2 1 80 2. Chronic suppurative otitis media 19 14 34 14 3 4 88 3. Chronic catarrhal deafness, Eustachian obstruction and otosclerosis 7 6 13 — — 5 31 4. Wax, otitis externa, eczema, boils, etc. 1 — 22 — 1 — 24 5. Chronic Rhinitis, nasal obstruction, Tonsils and Adenoids, etc. 19 10 46 — 6 2 83 6. Non-aural — — — — — — 37 Total 343 122 Statistical Tables for the Annual Report of the School Medical Officer, for the Year 1938. TABLE I. MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A.—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed groups:— Entrants 1068 Second Age Group 1186 Third Age Group 914 Total 3,168 Number of other Routine Inspections 944 Grand Total 4,112 B.—OTHER INSPECTIONS. Number of Special Inspections 5,454 Number of Re-Inspections 3,225 Total 8,679 C. CHILDREN FOUND TO REQUIRE TREATMENT. Number of Individual Children found at Routine Medical Inspection to require treatment (excluding defects of Nutrition, Uncleanlinessand Dental Diseases). Group. For Defective Vision (excluding squint). For all other conditions recorded in Table IIA. Total. Entrants 2 219 221 Second Age Group 101 153 242 Third Age Group 61 58 111 Total (Prescribed Groups) 164 430 574 Other Routine Inspections 69 140 187 Grand Total 233 570 761 123 TABLE II. (A) Return of defects found by Medical Inspection in the year ended 31st December, 1938. Routine Inspections Special Inspections No. of Defects No. of Defects DISEASE OR DEFECT. 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 — - 1 — Scabies 1 - 6 — Impetigo 3 - 61 — Other Diseases 18 - 156 10 (Non-Tuberculous) Total 22 - 224 10 EYE. Blepharitis 20 - 66 — Conjunctivitis 7 - 158 1 Keratitis - - 1 — Corneal Opacities — - 1 — Other Conditions (Excluding Defective Vision and Squint 3 - 82 1 Total 30 1 308 2 Defective Vision (Excluding Squint) 233 194 182 16 Squint 37 33 31 3 EAR. Defective Hearing 29 1 23 3 Otitis Media 11 2 79 — Other Ear Diseases 13 — 70 2 NOSE AND THROAT. Chronic Tonsillitis only 16 33 57 72 Adenoids only 3 — 9 2 Chronic Tonsillitis and Adenoids 291 194 506 208 Other Conditions 38 6 160 336 124 TABLE II (continued) ENLARGED CERVICAL GLANDS (Non-Tuberculous) - 2 14 22 DEFECTIVE SPEECH 1 8 — 29 HEART AND CIRCULATION. Heart Disease Organic 2 17 6 53 Functional — 2 — 8 Anaemia — 1 3 4 LUNGS Bronchitis — 3 11 26 Other Non-Tuberculous Diseases 1 3 11 18 TUBERCULOSIS. Pulmonary Definite 1 - 3 - Suspected — — 1 2 Non-Pulmonary Glands — — 5 2 Bones and Joints 1 — 1 — Skin 1 — 2 — Other Forms — — 1 — Total 2 — 9 2 NERVOUS SYSTEM. Epilepsy 1 - 6 5 Chorea 1 2 8 5 Other Conditions — — 6 7 DEFORMITIES. Rickets — — —' — Spinal Curvature 1 — 5 3 Other Forms 12 4 29 25 OTHER DEFECTS AND DISEASES 100 42 1453 414 (excluding defects of Nutrition, Uncleanliness and Dental Diseases) Total Number of Defects.. 845 547 3224 1277 125 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 1068 40 3.7 704 65.9 269 25.4 56 5.2 Second Agegroup 1186 96 8.1 793 66.9 258 21.8 38 3.2 Third Agegroup 914 66 7.2 672 73.5 164 17.9 12 1.3 Other Routine Inspections 944 93 9.8 640 67.8 193 20.4 18 1.9 Total 4,112 295 7.1 2,809 68.3 884 21.5 124 3.1 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 — — — 2 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions At no School or Instituttion. Total. - — 2 — — 2 126 TABLE III.—continued. DEAF CHILDREN. At Certified schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total 4 — — — 4 PARTIALLY DEAF CHILDREN. At Certified Schools for the Partially Deaf. At Public Elementary Schools At other Institutions At no School or Institution Total 2 1 — 3 MENTALLY DEFECTIVE CHILDREN. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions At no School or Institution Total 42 — — — 42 EPILEPTIC CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions At no School or Institution Total — - — — - 127 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 1 — - 3 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 — 4 10 B.—DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools. At other Institutions. At no School or Institution Total 4 21 1 - 26 C—CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools | 1 At other Institutions At no School or Institution Total 1 25 — 2 28 128 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 1 2 — — 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. Mentally Defective and Epileptic — - - 1 1 129 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1938. TREATMENT TABLES. GROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Table VI.) DISEASE OR DEFECT. (1) Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) SKIN. Ringworm—Scalp (i) X-Ray Treatment — — — (ii) Other - — - Ringworm—Body - 1 1 Scabies 3 3 6 Impetigo 56 6 62 Other Skin Diseases 145 16 161 MINOR EYE DEFECTS (External and other, excluding cases falling in Group II.) 300 9 309 MINOR EAR DEFECTS 399 10 409 MISCELLANEOUS (e.g., minor injuries, bruises, sores, chilblains, etc.) 1258 99 1357 Total 2161 144 2305 130 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) 711 6 717 Other Defects or Disease of the Eyes (excluding those recorded in Group I.) 3 - 3 Total 714 6 720 Under the Authority's Scheme Otherwise. Total Number of Children for whom Spectacles were: (a) Prescribed 348 6 354 (b) Obtained 345 6 351 131 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. III. IV. I. II. III IV 34 7 351 1 14 - 50 1 48 7 401 2 104 562 I. Tonsils only. II. Adenoids only. III. Tonsils and Adenoids. IV. Other defects of nose and thoat. GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. Under the Authority's Scheme. Otherwise. Total number treated Residential treatment with education Residential treatment without education Nonresiden tial treatment at an Orthopaedic Clinic Residential treatment with education. Residential treatment without education. Nonresiden tial treatment at an Orthopaedic Clinic Number of Children treat ed 2 - 1 - - 14 17 132 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 437 346 173 99 99 87 110 209 414 467 2441 (b) Specials 1,638 (c) Total (Routine and Specials) 4,079 2. Number found to require treatment 3,393 3. Number actually treated 3,273 4. Attendances made by children for treatment 5,174 5. Half-days devoted to:— Inspection 23 Treatment 739 Total 762 6. Fillings:— Permanent Teeth 3,553 Temporary Teeth 152 Total 3,705 7. Extractions:— Permanent Teeth 1,324 Temporary Teeth 6,393 Total 7,717 8. Administrations of general anaesthetics for extractions 198 9. Other operations:— Permanent Teeth 753 Temporary Teeth 130 Total 883 TABLE VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. I. Average number of visits per school made during the year by the School Nurses 11 II. Total number of examinations of children in the Schools by School Nurses 45,229 III. Number of individual children found unclean 1,028 IV. Number of individual children cleansed under tion 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 4 INDEX A. PAGE Administration of Midwives Act 63 Adulteration 32 Air Raid Precautions 1,4.6 Air Raid Precautions Committee 46 Ambulance facilities 16 Area of District 5 Aural Surgeon's Report 120 Aural Treatment 68 B. Baby Week 71 Bakehouses 32 Births 13,60 Birth Control 65 Blind, Deaf, Epileptic and Mentally Defective Children 111 Blind and Partially Blind Children 125 Bye-laws and Regulations 30 C. Camping Sites 22 Caravans 87 Causes of death at all ages 10 Causes of death under 1 year of age 11 Cerebro-spinal Fever 36 Cesspools 20, 88 Chief Sanitary Inspector's Report 75 Child Life Protection 69 Children Suffering from Multiple Defects 128 Children suffering from Pulmonary and Non-Pulmonary Tuberculosis 127 Children with Heart Disease 128 Circulation of Booklet on Rearing of Children 65 Clinics and Treatment Centres 57 Closet Accommodation 21 Convalescent Treatment 72 Co-operation of Local Practitioners 110 Co-operation of Parents 109 Co-operation of Teachers 110 Co-operation of School Enquiry Officers 110 Co-operation of Voluntary Bodies 110 Co-operation with Education Committee 73 Councillors 4 Crippled Children 127 Crisis, The 1 D. Deaf and Partially Deaf Children 126 Deaths 8 Defective Vision and Squint 130 Defects found at Routine Medical Inspection 99 Delicate Children 127 Dental Inspection and Treatment. 132 Dental Surgeon's Report 113 Dental Treatment 71 Detection and Spread of Infectious Disease 103 Diphtheria 35 D. PAGE Diphtheria Carriers 35 Diphtheria Immunisation 35 Disinfection 81 Disinfection of verminous persons and their belongings 41 Disinfestation of Verminous Houses 41, 81 Disposal of house refuse 21 Domiciliary Nursing 74 Drainage and sewerage 20 rinking fountains 89 ysentery 36 e. Encephalitis Lethargica 36 Enteric and Paratyphoid Fever 36 Enteritis 37 Epileptic Children 126 Eradication of Bed Bugs 41 Examination of Secondary School Children 111 f. Factory and Workshop Act, and Factories Act 82 Fitness of houses 30 G. General Observations 28 h. Help with cost of Midwives' Fee 64 Home Helps 65 Horse troughs 89 Hospitals 17 Housing 26 Housing conditions 29 i. Infantile Mortality 11, 13,60 Infectious Disease 18, 102 Infectious Diseases and Schools 25 Infectious Diseases table 34 Inquests 12 Inspection and supervision of food 30 Insulin, Supply of 41 Isolation Hospital 18 L. Laboratory facilities 17 M. Maternal Mortality 62 Maternity and Child Welfare Statistics 66 Maternity and Child Welfare Staff 53 Maternity Centres 57 Maternity Hospital 18 Maternal Mortality Advisory Committee 52 Measles and German Measles 36 Meat 31 Members of Education Committee 92 Members of Health Committee 4 Members of Maternity and Child Welfare Committee 52 Mentally Defective Children 126 N. PAGE Meteorology 43 Midwives 53 Milk 30, 84 Milk (Special Designations) Order 30 Minor Ailments 129 Mortuary 89 Motor Ambulances 86 National Health Insurance 16 Notices issued 77 Notifiable diseases 33, 34 Notifications 64 Number of Elementary School Children 97 Number of Individual school children found at Medical Inspection to require treatment 122 Nursing in the Home 15 Nursing Homes 63 O. Obstetric Specialist 65 Offensive Trades 83 Officials of Council 4 Open Air Education 108 Ophthalmia Neonatorum 38 Ophthalmic Surgeon's Report 118 Ophthalmic Treatment 69 Orthopaedic and Postural Defects 131 Other foods 32 Overcrowding 28 P. Paratyphoid and Enteric Fevers 36 Physical Training 109 Physically Defective Children 127 Places of Public Entertainment 83 Poliomyelitis 36 Population 5 Prevalence of, and control over, Infectious and other Diseases 33 Prevention of Blindness 38 Provision of Meals 109 Public Conveniences 89 Public Health (Meat) Regulations 32, 84 Public Health (Prevention of Tuberculosis) Regulations 41 Public Health (Smallpox Prevention) Regulations 33 Public Health Staff 14 Puerperal Pyrexia 62 R. Rag Flock Acts 25 Rats 89 Regulations and Byelaws 30 Removal and disposal of house refuse 21,87 Retirement of Midwives 64 Return of Defects found by Medical Inspection 123 Return of Defects Treated 129 Return of Medical Inspections (Aural) 121 Routine Medical Inspection 98 Routine Medical Inspection of Children under 5 years 68 s. PAGE Sale of Foods and Drugs Act 32 Sanitary circumstances of District 19 Sanitary Inspection of District 22 Scarlet Fever 35 School Medical Officer's Report 94 School Medical Service in Relation to Public Health 108 Schools 24, 89,97 Sewerage and drainage 20 Sewer flushing 88 Shops Act 86 Shops and Offices 22 Slaughter of Animals Act 31 Slaughterhouses 31 Smoke abatement 22 Social conditions 6 Staff of Public Health Department 14 Staff of School Medical Department 93 Statistical Tables of School Medical Officer 122 Statistics 6 Streams and Water-courses 20 Student Health Visitor 73 Sub-letting in Council houses 23 Suicides 12 Summary of M. & C. W. Scheme 74 Supply of Insulin 41 Swimming Baths and Pools 22 T. Teaching of Hygiene 108 Tuberculosis 39 Tuberculosis (County of Middlesex) Scheme 17 Treatment Clinics (Schools) 104 Treatment of Defects of Nose and Throat 131 Typhoid and Paratyphoid Fever 26 U. Uncleanliness and Verminous Conditions 132 Unsound Meat and foods 86 V. Vermin 103 Verminous houses 41 Veterinary inspection of cows 30 Vital Statistics 6, 59 W. Water-courses and streams 20 Water supply 19 Winter School for Health Visitors 73 Work of School Nurses 103 Z. Zymotic death-rate 37 Zymotic diseases 37