(AC 4390) HORNSEY BOROUGH OF HORNSEY. Annual Report FOR 1924 OR THE Health and Sanitary Circumstances of the Borough BY A. T. Nankivell, M.D. (Lond.), D.P.H. (Camb.), Medical Officer of Health and School Medical Officer. "Hornsey Journal" Printing Works, 36, Crouch Hill, N.4. HOR 016 BOROUGH OF HORNSEY. ANNUAL REPORT FOR THE YEAR 1924. on the HEALTH AND SANITARY CIRCUMSTANCES OF THE BOROUGH together with A RECORD OF THE WORK of THE SCHOOL MEDICAL SERVICE IN THE BOROUGH by A. T. Nankivell, M.D. (Lond.), D.P.H. (Camb.) Gold Medallist in State Medicine of the University of London; Bachelor of Surgery of the University of London; Licentiate of the Royal College of Physicians; Member of the Royal College of Surgeons; Medical Officer of Health and School Medical Officer to the Borough of Hornsey; Fellow of the Royal Society of Medicine and Fellow of the Society of Medical Offictrs of Health, etc. Formerly Temporary Captain, R A.M.C.; Medical Officer of Health, etc., of Poole, and Demonstrator of Public Health and Lecturer in Epidemiology at King's College in the University of London. STAFF OF PUBLIC HEALTH AND SCHOOL MEDICAL SERVICES. Medical Officer of Health A. T. Nankivell, M.D., D.P.H. Assistant Medical Officer of Health J. R. Prior, M.D., D.P.H. Assistant for Maternity and Child Welfare Purposes Flora Shepherd, M.B. Assistant for Ante-natal Clinics Jessie Muir, M.B. Senior Sanitary Inspector Wm. Thorpe Sanitary Inspectors Henry Eastwood James Goodman Joseph H. Jesse John D. Chance Arthur C. Arnold Chief Clerk Wm. Gilroy Assistant Clerks Reginald H. Wigmore George E. Dorrell James Wilson School Nurses L. M. Oliver M. Anscombe E. Paris Clerks at School Clinic Hilda M. Croak V. Powell Health Visitors A. Glover J. I. Macpherson E. Durnford Midwife M. Andrews Mortuary Keeper Charles F. Catlin Motor-Ambulance Driver T. J. Skilbeck Disinfectors Wm. H. Lewis Wm. Rutter PREFACE. To the Mayor, Aldermen and Councillors of the Borough of Hornsey. Gentlemen, In accordance with the Order of the Ministry of Health, I have the honour of presenting to you my fourth Annual Report on the Health of Hornsey. This will be my last Report as your Medical Officer, and by the time it is in your hands I shall be occupied with my new work at Plymouth. To see the results of Public Health activities, and properly to appreciate the great advantages which Preventive Medicine has brought us, it is necessary to take a long view; and in doing so, and comparing modern conditions with those of even a quarter of a century ago, the benefits performed by our Health Services are obvious to us all. Many diseases have been exterminated, others are on the wane, the "Expectation of Life" has been increased, and children born now-a-days have a reasonable chance of healthy survival. That we shall see further increased benefits from our Health Services I have no doubt, if we continue in the future (as we have done in the past) wisely to increase the scope of our services, adding clinics, centres, open-air homes and staff as they may be required. The Town Council may, I believe, be reasonably proud of their Public Health Services; and I cannot leave the Borough without thanking the Members of the Town Council for the support which they have given me in my endeavours during my four years of office. I should like to take this opportunity of expressing my gratitude also to the Heads of the various Borough Departments for their advice and support, and of putting on record my great appreciation of the work of my Staff, who have laboured diligently and loyally with me for the benefit of our Borough. I am, your obedient Servant, A. T. NANKIVELL. January, 1925. 4 HORNSEY STATISTICS, 1924. Population 88,661 Birth-rate 15.0 per 1,000 population Death-rate 104 ,, ,, ,, Infectious diseases death-rate 0.3 ,, ,, ,, Infant mortality rate ... 36 ,, ,, births GENERAL CONSIDERATION. The Borough of Hornsey is 2,874 acres in area, and is situated to the north of the County of London. On the southeast the Borough is bounded by the Metropolitan Borough of Stoke Newington, on the south by that of Islington, on the south-west by that of St. Pancras, and on the west by the Metropolitan Borough of Hampstead and the Urban District of Finchley; on the north the Borough is bounded by the Urban District of Friern Barnet, and on the east by the Urban District of Wood Green and the Urban District of Tottenham. The centre of the Borough is about five miles north of Charing Cross, and there are rail, tube, tram and 'bus services between the Borough and the Metropolis. About 28,000 Hornsey residents spend their days at work in other parts of London and return home in the evenings. Speaking generally, the Borough consists of good house property, which is occupied by the well-to-do classes; there is not much poor house property, and there are no slum areas. There are no large factories in the district, no offensive trades are conducted, and there are no common lodging-houses and no dwellers in tents and vans. The Assessable Value of the Borough is £709,975, and a penny rate produced about £2,958 during the past year. The Borough is fortunate in possessing many lovely open spaces, such as the Highgate Woods and the. Queen's Wood; these undoubtedly add to the amenities and health of the Borough. 5 VITAL STATISTICS. Tables of figures showing the chief features of the vital statistics of the Borough of Hornsey will be found at the end of this Report. These tables of statistical matter, although they are not always interesting in the reading, are to be considered as comparable to an annual balance-sheet. They show the work done by the Health Department during the year, and enable us to contrast the health of to-day with that in previous years. Population.—The population of the Borough, estimated by the Registrar-General's method, was 88,661 in 1924. As I ha e pointed out in previous Reports, the taking of the Census in Midsummer, 1921, decreased our population figure, as many of our inhabitants were away in the country or at the seaside. The estimate of the present-day population, given above, which is worked out from the Census figures, is probably, therefore, an under-estimation. Aye and Sex Distribution.—Death-rates vary considerably according to the age of the population in which they are estimated. If all the persons in Hornsey were under 45 years of age our death-rate would be about 4.3 per 1,000; if, on the other hand, our population was composed of persons over 65 years of age, the death-rate would be as high as 72.5 per 1,000. Neither of these extremes exist in the Borough, but the amount of mortality is increased by the fact that we have a definite excess over the average for England and Wales of elderly persons. This increases the death-rate, and may in part account for the rise in the mortality from Cancer, to which further reference will be made. Birth-rate.—During the past-year 1,331 children were born in the Borough of Hornsey. This corresponds to a birth-rate of 15.0 per 1,000 persons, and is the lowest rate on record with the exception of those which occurred during the war years (Table A). The main reasons for this low birth-rate are that persons marry at a later age than formerly, and that they deliberately wish to avoid adding to the population. Another factor is the practice of taking drugs or using other methods to procure abortion. About a dozen instances of this have been 6 brought to my notice during the year, but that small number certainly does not represent the total prevalence of this unfortunate practice—unfortunate because it brings ill health to the mother, and, in the event of the child surviving, ill health to it after its birth, which is often premature. Death-rate.—The death-rate in Hornsey last year was only 104 per 1,000 population (Table A). This is a low rate, and would not have been possible had the Borough been visited by epidemics of any magnitude. A lower death-rate than this can hardly be expected in this district on account of the excess in our population of elderly persons. The Infant-mortality rate in Hornsey during the past year was by far the lowest oil record, and only 36 per 1,000 births, compared to 69 per 1,000 births for London and 75 per 1,000 births for England and Wales. This is a record of which our town may justly be very proud. The infant mortality rate is a very excellent index for gauging the health of a district, for the delicate organisms of little children are very sensitive indicators of insanitary circumstances. Infants react very readily and quickly to their environments, and in an unhealthy town a low rate of infant mortality is never found. It will be seen from the Chart (Table H) that a considerable proportion—two-thirds—of our infant deaths were due to ante-natal causes, to influences which affected the child before birth. "This ante-natal death-rate has remained fairly constant for a long period of years, and it is to reduce this that the ante-natal work of the Maternity Centres was instituted. In the course of time I have no doubt that the work of our antenatal sessions will succeed in reducing materially this waste of infant life, and already we can see some little improvement, but the results are not yet obvious. Before any marked reduction in this child mortality can take place it will be necessary to educate the mother regarding the need for antenatal supervision. Nature teaches a mother without our education to take a sick or ailing child to a doctor or to a maternity centre, but she does not, so naturally, seek skilled advice during the period of her pregnancy. Although the rate of infant mortality during 1024 is satisfactorily low, compared to rates in former years, yet it could be lower still; and when our ante-natal sessions have b en 7 established long enough for their value to be well-known to all the mothers in the Borough, I anticipate a further decrease in our infant death-rate. Causes of Death.—A tabulated statement showing the principal causes of death is given in the Appendix (Table B). It is desirable, however, to make a few comments on it here. There were no deaths from Small-pox or Enteric (Typhoid) Fever. There was only one death from Scarlet Fever. This disease as a cause of mortality is negligible to-day, and of a very different nature to the Scarlet Fever of twenty-five years ago. There were two deaths from Diphtheria. Delay in the adequate treatment of any disease diminishes the patient's chance of recovery, but in no disease is delay more deadly than in Diphtheria. Diphtheria Anti-toxin is supplied by the Town Council, and for the convenience of doctors it is kept at the Town Hall, the Isolation Hospital, the School Clinic and at the two Maternity Centres. Measles caused 2 deaths. Whooping Cough caused 2 deaths. Summer Diarrhoea caused the death of only 1 infant during the year. This disease is fly-borne, and, in the absence of flies, the summer diarrhoea is non-existent. The cold and wet summer of 1924 was prejudicial to the breeding of flies, and in addition the Public Health Department supervised, as in former years, the places where flies are likely to breed, such as manure heaps and stables. Cancer or Malignant Diseases caused the death of 150 persons. This disease is definitely on the increase, as reference to Table C and the accompanying chart (Table D) in the Appendix will show. In the chart the percentage variations from the average of cancer death-rates in Hornsey is plotted over a series of years, and it is evident when comparing the cancer death-rates from, say, 1902-1907, with those of 1921 and onwards that the mortality-rate from this disease has increased. In part, no doubt, this increase is due to the fact that in this Borough we have an excess of persons living at the "cancer age," for this disease is one of middle-aged and elderly people 8 rather than of the young. A small part of the increase may be due to better diagnosis on the part of medical practitioners; but probably neither of these two factors is sufficient to explain the increasing prevalence of this fatal condition. The cause, the natural history, of cancer has not yet been fully elucidated, although scientists for many years have been examining the nature of this disease. Some few facts about it seem, however, to be clearly established. Chronic irritation or inflammation, a neglected sore, certain trade processes and other conditions leading to excessive stimulation of the cells of the body lead frequently to these cells becoming malignant. It has been suggested also, that auto-intoxication or self-poisoning due to over-eating, chronic constipation and a sedentary life is a predisposing cause of cell malignancy. Again, the theory has been advanced that staleness of food and preservatives in food poison the body cells and induce them to be cancerous. Certain foods, such as animal fat, meat, butter, milk and eggs contain a "growth-producing vitamin" which, while it is of essential value to the rapidly growing child, is, or may be, of actual detriment to the adult who has ceased to grow; and it would seem that at the "cancer ages" an excess of this growth-producing vitamin might predispose the tissues to form new growths. Certainly the majority of people over 40 years of age tend to eat more than is necessary to maintain life and activity, and it is interesting to note in this connection that whatever cancer may be, it is not a disease of poverty. No doubt, when the true facts regarding the life history of this disease are known, the prevention of it will become easy; but in the meantime little can be done except to advise the public to live so far as possible healthy and natural lives, to abstain from excesses and to be on the watch for any signs or symptoms of that chronic cell irritation which later may lead to malignant diseases. Tuberculosis was the cause of death in 60 instances. Details are given in Tables B and C. Heart Disease caused 107 deaths and Nephritis or Bright's Disease was given as the cause of death of 34 persons. These two diseases represent in the majority of cases, though not in all, the penalty which is paid to the stress and strain of modern life. Much invalidism and mortality from heart disease and kidney trouble could be avoided if the "beginnings" of the disease 9 could be diagnosed in time, and the sufferer would take the necessary care of his slightly damaged heart or kidneys. To ensure such early diagnosis the six-monthly or annual overhaul by a competent physician is of the greatest preventive value. Many wise men make it their practice to go every six months or so to their dentist, in order that he may treat the beginnings and thereby prevent the spread of dental disease; and we shall see a great improvement in the health of the country when it becomes the custom to apply this principle of preventive medicine to other and perhaps even more perishable organs of the body; for diseases of the arteries, heart and kidneys yield very well to care and to early treatment. Old Age was stated to be the cause of death in 82 cases. Altogether 496 persons over the age of 65 died in the Borough last year. SANITARY CIRCUMSTANCES OF THE BOROUGH. Water Supply.—The water supply of the district is from the mains of the Metropolitan Water Board. There are no wells or private supples of water in the Borough. Closet Accommodation, Drainage and Sewerage.—All houses in the Borough are connected to the public sewers, and 108 tests of drains were made during the year. The majority of the sewage passes into the London sewers; a small part from some of the northern area is treated on the Corporation Sewage Farm in Coppett's Road. The final effluent from this sewage farm is invariably of a very high standard of purity. Scavenging. — Hornsey is a clean town, and its roads and footpaths are regularly scavenged. The importance of tarspraying and of cleanliness is considerable from the point of view of the public health. There are 75 stables in the Borough, and special attention was given to these by the Health Department during the spring and summer in order to prevent the breeding of flies. The Inspectors made altogether 291 visits to these premises. House Refuse.—This is removed once a week from ordinary dwelling-houses and twice a week from flats, and is disposed of by burning in the Corporation Refuse Destructor. 10 ments have been made to deal with trade refuse which is brought to the Refuse Destructor by the shopkeepers. During the year the Town Council served notices on 160 householders to provide proper and sufficient ash-bins. Mortuary.—The Public Mortuary and Coroner's Court are situated in Hortisey. During the year 43 bodies were placed in the mortuary and 43 inquests were held at the Coroner's Court. The condition of the mortuary has been considerably improved during the year: a new porcelain table has been provided and electric light has been installed in place of gas. Cleansing Station.—There is an excellent Cleansing Station at the Hornsey Depot, primarily for cleansing school children. During the year it was used in addition for the cleansing of 6 adults. Disinfection.—A steam disinfector at the Hornsey Depot serves to disinfect bedding, clothes and other articles from infected houses. Disinfection is offered now to householders, and is gratefully accepted, after deaths from cancer and tuberculosis as well as after the ordinary infective and contagious complaints. During the year 7,547 articles were disinfected. Two motor-vans are employed in the collection and returning of such articles. Electric lighting has been installed at the depot during the year. Sanitary Inspection of the District.- Throughout the year inspection of the district was made by the Medical Officer of Health and the six Sanitary Inspectors. As the result of these inspections insanitary conditions were found on 5,176 occasions. Details of these defective and unhealthy conditions are given in Table E, and the work done by the inspectors is shown in Tables E, F and N. In order to have insanitary conditions abated 1,619 preliminary intimations were sent. out from the office drawing the attention of the owner or occupier to the defects. In addition 297 statutory notices were served and were obeyed, except in two instances where it was found necessary to have these orders enforced by the Bench. Ten notices were outstanding at the end of the year. The Borough of Hornsey may well be proud of its Sanitary Inspectors, who perform difficult and sometimes objectionable work with unfailing tact and success. It is not in every district that this service is performed so quietly and so well, and very 11 great credit is due to the Chief Inspector, Mr. Thorpe, for the competent way in which he has regulated the work and advised his junior Inspectors during the last 21 years. PREMISES AND OCCUPATIONS WHICH CAN BE CONTROLLED BY BY-LAWS AND REGULATIONS. (a) Common Lodging-houses, (b) Offensive trades, (c) Under-ground sleeping rooms, (d) Vans, (e) Canal Boats, (f) Houses let in lodgings. None of these are found in the Borough. (g) Outworkers.—There were 132 outworkers on the register at the end of 1924. All their premises were visited, and generally the conditions found were satisfactory. (h) Factories and Workshops.—There are 109 factories and 283 workshops in the Borough. All of them are small establishments. They were visited on 918 occasions, and any unhealthy conditions that were discovered were remedied. (j) Bakehouses.—There are 33 premises on the register which are used as bakehouses. They were visited 96 times. (k) Other Food Premises.—Frequent visits were made to premises where food is prepared or sold, and these were found generally to be of a high sanitary standard. (1) Places of public entertainments were visited and inspected 35 times, and the conditions of cleanliness and ventilation were found to be generally satisfactory. (m) Rag Flock Act.—Twenty-eight inspections were made under this Act, and the conditions found were generally satisfactory. (n) Shops Acts.—The sanitary inspectors act as inspectors under the Shops Acts. They made 1,413 visits during the year, and found that generally the provisions of the Act are observed. In cases of infringement the offender has been cautioned. (o) Schools.—The Medical Officer of Health is also the School Medical Officer, and this ensures co-ordination between the two Health Services. A special report, is issued on the School Medical Service. 12 FOOD. The administration of the Sale of Food and Drugs Acts is in the hands of the Middlesex County Council. Unsound Food.—No unsound meat, fish, fruit or vegetables were found exposed for sale during the year, but in four instances food (80 lbs. fish) that was unfit for human consumption was voluntarily surrendered to us by provision dealers. No instances of food poisoning came to my notice during the year. There are 7 Slaughter-houses in the Borough. They are well kept. Last year they were inspected on 52 occasions. MILK. Under the Milk (Special Designations) Order, 1923, 24 samples of milk which had been pasteurised were taken for analysis. In the majority of instances it was found that the pasteurised milk sold in this Borough was up to the required standard. Pasteurised milk is milk that has been heated to a temperature of 145°-150° F. for at least half-an-hour and immediately cooled to a temperature of not more than 55° F. Practically all the milk (except Grade A) sold in London and other large towns is pasteurised, although it may not be sold as such. The milk supply of London comes from distant places, e.g., Somerset and Derbyshire, and if it were not pasteurised it would rapidly go sour, especially during the warm weather. It is the custom of milk retailers, therefore, to filter and heat their milk on its arrival at their London depots, to cool it and perhaps to bottle it, and later to retail it. It is possible in some instances that milk and cream may remain in cold storage for many days before it is delivered to the purchaser, and it is also possible for surplus milk—that is to say, milk which has travelled around the streets in a barrow and has not been sold—to be re-heated for the purpose of preservation, and again to be placed in cold storage. Some milk firms sell milk which has been pasteurised as "fresh milk" or "new milk" or merely "milk," rather than under its proper title of "pasteurised milk"; and by this practice it. would seem that they evade the obligations which the seller of pasteurised milk 18 has to fulfil. An example came to my notice during the year of a milkman who has a pasteurising plant which he uses, not invariably, I believe, but frequently. He sells the liquid from this plant as milk: on two or three occasions analysis showed that the milk had been insufficiently or improperly pasteurised and that it contained an excessive amount of microbes. The milkman's explanation was that he was selling "milk" and not "pasteurised milk," and that no standard had been laid down for the number of microbes that milk may contain. A milkman, therefore may be licensed to sell pasteurised milk; he may have a suitable pasteurising plant; he may put the milk through the plant, lay it down in cold storage and retail it at his convenience under the engaging title of new or fresh milk. I do not suggest that such is the practice of all milk vendors, but the provisions of the Milk (Special Designations) Order, 1923, make such practices possible. It seems reasonable for the public to demand that if milk is pasteurised it should be sold as such. A most objectionable practice, to which my attention has been frequently drawn, is that of the milkman who fills up from a churn on his barrow dirty and unclean bottles taken from door-steps and forthwith re-distributes these to consumers. If Members of the Town Council or of the public see this filthy process in operation they will do a real service to the Public Health if they will call the attention of the Medical Officer of Health to this fact and will send a postcard giving the name of the milk vendor and the address at which they witnessed this affair. PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. (See Tables G and M.) Small-pox.—There have been no oases of small-pox in the Borough during the year, although the disease occurred in neighbouring areas. The Borough of Hornsey contains no small-pox hospital, but arrangements have been made for the treatment and isolation of its small-pox patients at the small-pox hospital of the Uxbridge Joint Hospital Board. The Borough of Hornsey now has the right to use ten beds in this hospital. — 14 — Typhus Fever, Continued Fever, Cholera, Dysentery, Relapsing Fever, Trench Fever, Cerebro-Spinal Fever.—There were no cases of these diseases notified. Diphtheria.—There were only 40 cases of this disease notified during 1924, compared to 123 cases in the previous year. This is a welcome reduction, and corresponds to an attack-rate of only 4.5 per 10,000 population, which is a record low rate such as the Borough has never had before. None of the cases were related to the milk supply. The disease is spread by personal contact and often by a mild and missed case. Modern science has invented a safe and certain method of immunising people against diphtheria: this method consists in injecting a mixture of the diphtheria poison together with its antidote, and the immunity conferred lasts apparently for many years and perhaps indeed throughout life. The education of the public can alone popularise this method, which in other countries, and notably in the United States, has been employed for several years past with undoubted success. Scarlet Fever.—During the year 215 cases of Scarlet Fever were notified. The disease is now-a-days of a mild type, and only one death occurred. Some of the private schools in the Borough were infected, and the arrangements were made by me for the Heads of all the Private Schools to notify me of such cases in the future and to give me an opportunity, if they so desired, of visiting the school and of inspecting the scholars. Several visits were made under this arrangement during the year, and resulted on more than one occasion in a prompt cessation of these cases of infection. Erysipelas was notified on 26 occasions. Enteric Fever.—During the year 3 cases were notified, of which only 2 proved to be enteric fever. In both instances the infection appears to have been acquired outside the Borough. Pneumonia.—Sixty-one notifications of Pneumonia were received. This infectious disease is one of the common causes of death in children and old people. As in former years, a mixed vaccine for use in the prevention of pneumonia and similar catarrhal conditions was isued by the Health Department to those doctors practising in Hornsey who wished to use it. The general opinion of those practising and of their patients 15 is that the vaccine is of value in preventing or ameliorating those catarrhal conditions which are prevalent in this country during the colder months of the year. Puerperal Fever.—There was one notification of this infection during 19.24. Ophthalmia Neonatorum is an inflammation of the eyes of newly-born children which, if untreated, leads to blindness. During the year only one notification of this condition was received. Arrangements have now been made by the Hornsey Town Council with the Metropolitan Asylums Board whereby cases of this acute and serious inflammation may be admitted immediately into St. Margaret's Hospital, Kentish Town. This Hospital is solely for the purpose of treating these little children, and they receive there, probably, the beet attention in the world. The result is that a child's sight is saved, it is prevented from becoming permanently blind and being a misery to its friends and a cost to the State. Tuberculosis.—During the year 124 cases of Tuberculosis were notified. Although the administrative control of this disease is in the hands of the Middlesex County Council, we take every opportunity of disinfecting those houses from which a case of tuberculosis has gone, and offer disinfection also from time to time during the illness. During the year 133 rooms which had been occupied by tuberculous people were disinfected and 703 articles were sterilised by steam. Disinfection.—During the year 734 rooms were disinfected by sulphur or formalin, and 7,547 articles were passed through the Council's steam disinfector. In addition to these, 243 articles were destroyed after infectious and other diseases. Note.—The attack-rates of the population of Hornsey from certain infectious diseases have been worked out. for the last twenty years, and are given in Table M in the Appendix. ISOLATION HOSPITAL. The Hornsey, Finchley and Wood Green Joint Hospital Committee provides accommodation for Hornsey patients at the Hospital in Coppett's Road. The Hospital is under the able administration of Dr. .J. R. Prior, the Resident Medical 16 Superintendent. During the year 209 patients from Hornsey were admitted to the Hospital. Of these, 33 were suffering from Diphtheria, 159 from Scarlet Fever and 17 from other diseases. The Isolation Hospital is in need of extension, and a scheme is being prepared for the accomplishment of this. Laboratory Work. — During the year 892 specimens were examined in the laboratory of the Hospital for the Borough of Hornsey. MATERNITY AND CHILD WELFARE. (See Tables H, J, K and L.) It is difficult to exaggerate the importance of Maternity and Child Welfare work both to the individual and the community. A large amount of suffering, wretchedness and poverty has its origin in small beginnings—in the neglect of the health of the child. The seeds of disease sown in childhood have, often enough, their crop of sorrow and pauperism in after years, and it is to increase the health, efficiency and happiness of the next generation that our Maternity and Child Welfare Work and School Medical Services have been established, and already the growing children are reaping the benefit of these. It is never too early to begin to take an interest in the wellbeing even of the unborn child, and it is interesting to observe that the public is beginning to recognise in the science of Eugenics a way of escape from some of the problems that appal us to-day. A mother with one mentally defective daughter and another who was very backward deplored to me that she had ever had children, and stated her determination to do all in her power to prevent her daughter from passing on this family taint. Insanity, epilepsy, certain forms of blindness and of nervous diseases, and possibly some other conditions are definite contra-indications to the propagation of children, and it is gratifying to see that the people are beginning to appreciate this. Ante-natal Work.—Given healthy parents, a child has a better chance of being born well and strong; but much depends upon the condition of the mother before the birth of the child. 17 Under-nourishment, lack of sleep and exercise, insanitary surroundings, these and other factors influence profoundly the health of the unborn child, and it is to remedy adverse conditions and to give the mother and baby every possible chance that our ante-natal sessions, conducted by Dr. Jessie Muir, have been established. Four of these sessions are held every month at Brook Road Centre and two every month at Wightman Road Centre, and last year Dr. Muir gave advice to mothers, who made 738 attendances at these sessions. I have pointed out earlier in this Report that the majority of the deaths of little children are due, not to disease contracted after birth, but to adverse conditions before the child was born. Extension of these antenatal sessions is wanted so that more and more mothers may be able to receive advice during their pregnancy. It is pleasant to note that both doctors and midwives practising in the Borough have sent their ante-natal cases to our Centres for advice. Natal Work.—The Town Council employs a Midwife, who works mainly in the Campsbourne area of the Borough. Her work is greatly appreciated and her services are eagerly sought. The Borough Midwife was appointed in 1921, and, starting work in October, she attended 2 confinements to the end of the year. In 1922 she attended 41 cases; in 1923, 60 cases, and in 1924, 79 cases, these figures alone speaking for the increasing popularity of this valuable service. In addition, during 1924 the Midwife attended 60 ante-natal Clinic sessions, and paid 212 ante-natal visits and 197 post-natal visits. Post-natal.—Sessions are held at Brook Road Centre every Wednesday and Friday and at Wightman Road Centre every Tuesday for the purpose of giving advice to mothers regarding the health of their young children. Dr. Flora Shepherd conducts these infant consultations and is "snowed under" with work. Indeed, during the year she has herself paid lady medical colleagues to come and help her so that the work should not accumulate too greatly. An additional session a week is therefore urgently required, and the Ministry of Health was asked to sanction this. The approval of the Ministry was given in December. Regarding the value and popularity of this work, I do not believe that there is anything undertaken by the Hornsey Town Council, with the possible exception of elementary education, 18 which is so gratefully welcomed and appreciated by the public The fathers and mothers of babies who attend the Centres are enthusiastic over the work done there. I have asked Dr. Flora Shepherd to give me a few notes on her work at the Centres, and she writes as follows:— "The aim of the Maternity and Child Welfare Work of the Borough of Hornsey is prevention of disease and improvement in the standard of health of the children under five years of age. The channels through which this is brought about are:— (1) Education of mothers in feeding, hygiene and clothing and training of their children. (2) Ante-natal care of the mothers. (3) Detection of deviation from the normal of health at the earliest possible stages and the insistence upon having these corrected by the most suitable existing agency, e.g.:— (a) Medical Officer at the Maternity and Child Welfare Centre. (b) General Practitioners. (c) General Hospitals. (d) Cottage Hospital. (e) Infirmaries. (f) School Clinic, to which all eye cases are sent. (g) Dentists, of whom two are connected with the Centres. (h) Tuberculosis Dispensary. It is to be noticed that the Maternity and Child Welfare Department recognise the fact that many curative agencies exist in their immediate neighbourhood and that the most suitable of these should always be used, the Maternity and Child Welfare Department acting, whenever possible, as a clearing station, and only doing that curative work which would be left undone if not undertaken by itself. Personnel. The Maternity and Child Welfare Department consists of:- The Medical Officer of Health. An Assistant Medical Officer of Health in charge of the Maternity and Child Welfare Clinical Work. 19 A Medical Officer for ante-natal work. Three Health Visitors. Municipal Midwife. A Staff of Voluntary Workers, of which the nucleus is the women appointed to the Town Council's Statutory Committee for Maternity and Child Welfare. Areas. For the purpose of this work the Borough of Hornsey is mapped out into three distinct areas, and for the visiting in each area one Health Visitor is responsible. The notifications of births in each area are sent from the Town Hall direct to the Health Visitor responsible for that area. Visits are made to the mother within ten days of the birth of the child. Advice is given if asked for, and the parents are told of the available assistance at their disposal at any time in the future and of the method of obtaining at any time that assistance. Method of Work. There are two Centres in the Borough to which the mothers may bring their children for advice. At No. 1 Centre, which includes two visiting areas, the Medical Officer for Maternity and Child Welfare holds, during the week, four consultations, and at No. 2 Centre two consultations, at each of which she sees on an average 24 infants and children. The object at these consultations is not to treat minor ailments, but to prevent them and to improve the standard of health. The cases dealt with fall mainly under the following headings:— 1. Education, in tne normal feeding of the normal child. 2. Difficulties in breast feeding and failing lactation. 3. Abnormalities in nutrition and metabolic deviations. 4. Incorrect feeding. 5. Detection of congenital abnormalities. 6. Diagnosis in their earliest stages of systemic infection, e.g., tuberculosis, rheumatism. A certain amount of time is given to each case to the education of the mother in. the recognition of the normal, and in feeding and hygiene; her own child being used as the clinical material and the point upon which she is anxious is used as 20 the subject of education. In this way no time is wasted, for the mother being anxious, is receptive, and the practical elucidation of her difficulty becomes her future theory. Ante-natal Clinic. The Ante-natal Clinics are growing rapidly. All cases who have not engaged a doctor for the confinement are examined, measurements taken and urine tested on the first visit. If there is any abnormality or if there has been previous difficulty in labour the patient is referred to a doctor or a lying-in hospital. Arrangements are made, if desired, for the attendance of the patients at the North Middlesex Hospital or at a nursing home or lying-in hospital. The Municipal Midwife attends Ante-natal Clinics and undertakes confinements where a full fee is impossible and the mother unable to have her confinement away from her home. Advice is given at this Clinic in ante-natal hygiene, clothing, feeding, care of the breasts and the management of the infant in the first few weeks of life. Health Visiting. This falls under four headings: — (1) Notified birth visits. (2) Re-visits to children up to the age of five. (3) Special visits under the instruction of the Medical Officer of the Centre to difficult cases of breast feeding, to delicate or marasmic infants, to mothers who require special and intense teaching about their children. (4) In cases where special information is required as to home conditions which may be affecting the health of the mother or child. It is felt that the foundation of preventive work in the Borough is laid by careful sympathetic visiting in the home. Excellent work is being done, but much more ground could be covered with one or two additional visitors. This is particularly the case with regard to breast feeding. Where there is difficulty in lactation or failing lactation action must be taken instantly and advice and assistance given daily, otherwise within two, or at the most three, days, the infant is weaned and artificial feeding, usually unsatisfactory, is substituted. 21 There is no form of preventive work either by the doctor or the health visitor which takes up so much time as re-establishing failing lactation, and if we are to see a diminution in the number of artificially fed infants in the Borough of Hornsey, it is necessary that this question shall be specifically considered and more time spent upon it. Additional Duties. The Health Visitors attend at the Centre on the days when consultations are held in their area, and thereby maintain an unbroken fine of contact between the child, the mother, the doctor and themselves. It is realised that if the greatest result in education of the mother is to be obtained in the shortest possible time it is urgent that all forces working shall work in unison, that there shall be no deviation in the smallest particular in advice given. Lectures and Health Talks. Classes are held by the Health Visitors at each Centre once a week for a more theoretical education of the mothers. A syllabus of lectures and discussions is made out each term and a very wide field is covered. Though the course is carefully graded the subjects may be as diverse as physiology and housing, psychology and dentition. It is interesting to note that at these health talks quite a number of older parents attend, and this is encouraged, for it is often those women whose children are growing up who are the most useful as propagandists either of wise or unwise doctrines that eSect preventive medicine. The Staff of Voluntary Workers. The Voluntary Workers attend the Centre with the same regularity as the professional staff, and work is planned by their Committee with reference to the Medical Officer of the Centre. Each has her allocated duty to which she is trained and which she has done once or twice weekly for a period of from 6 to 8 years. This work consists of secretarial work and keeping oE a day book of records, correspondence for the doctor to hospitals, etc., and the weighing of infants and children. The work is done thoroughly and accurately, and makes for speed and efficiency in the conduct of the Clinics. 22 Convalescence. The Voluntary Committees arrange for all convalescents, either themselves maintaining convalescent beds or acting as almoners in finding convalescent vacancies and arranging for methods of payment for these. As this work is done in close co-ordination with the professional staff, there is no overlapping of assistance. Massage. Three Massage Clinics are arranged at the Centres by the Voluntary Committee, and conducted by two trained masseuses. This fills a long-felt want, and since it has been arranged has been of the greatest assistance in remedial and preventive work. Clothing. Model sets of clothing are arranged by the Voluntary Committee, and are always on view at the Centre. These may be bought by the mothers, and instructions are given and classes held for those who wish to make them. The result has been a tremendous advance in the clothing of children in the Borough as the fashion of loose, warm, useful clothing has been set, and has become popular even amongst those children who are not directly in contact with the Centres. Flora Shepherd." Health Visitors.—The function of the Health Visitors is to visit the houses of newly-born babies as often as may be requisite, and to give such advice regarding infant care and management as the mother may need. They attend also at the Centres and help at the Medical Consultations. Their work is of great value in bringing the principles of health into the homes of the people, and in preventing, by their advice, the onset of much infant illhealth. They should be able to visit regularly every child from birth up to the age of five years, when it enters school and comes under the control of the School Medical Service; but unfortunately we have only three Health Visitors, and much of their working time is spent at the Centres and in visiting difficult cases at the special request of Dr. Shepherd: so necessarily their other visits have to be curtailed- In spite of this, however, they visited during the year 4,036 children under one year of age and 3,524 between one and five years old. The Ministry of Health has recently sanctioned the engagement by us of an additional Health Visitor. 23 Convalescent Home.-—In my last Annual Report I drew the attention of the Town Council to the need which existed for some convalescent home to which we could send mothers and babies after illness. At the present time money is subscribed voluntarily for the purpose of retaining a cot in some convalescent home, and babies are sent to this, as accommodation becomes available. Such an arrangement is better than nothing; but we might do far more. I hope that in future schemes for extending Maternity and Child Welfare Work, the need for a convalescent home will not be disregarded. Various.—During the year the Borough has obtained a new Motor Ambulance, which is used, among other purposes, for the transport of mothers who reside in Highgate to Brook Road Maternity Centre. During l924 I have visited Brook "Road Centre on special occasions for the purpose of taking blood from mothers and babies for whom a Wassermann Blood Test appears to be desirable. This arrangement has proved of considerable value, and has saved the patients a journey to some London Hospital. Voluntary Workers.—A number of ladies give devoted service at both our Centres, and if it were not for their help the work at the Centres would greatly suffer. They assist in the weighing of babies, in record keeping, in the various classes for mothers and in other matters; and it is largely owing to their unselfish work and untiring activity that our Centres continue to be so successful and so deservedly popular. Milk (Mothers and Children) Orders.—After careful investigation of cases, milk is allowed free or at half-price to pregnant women and nursing mothers and to children under one year of age. During the year 344 applications for milk were received, and of these 303 were granted, the remainder being refused. Milk from a dairy, or dried milk, is given according to the needs of the case. Home for Unmarried Mothers.—There is a small but admirable home situated in Upper Tollington Park where unmarried mothers are received and cared for until and after their confinements. This home receives a grant from the Town Council, and the mothers and babies attend the Maternity Centre in Wightman Road. 24 Retrospect.—It is interesting to observe how our Maternity and Child Welfare Work has grown from small beginnings into what it is to-day. Every indication points to further increase in the future. The following summary gives a short history of our progress from 1916 to the present time: — The first Maternity and Child Welfare Centre was opened at Brook Boad in October, 1916, with one Health Visitor and Dr. Flora Shepherd as part-time Lady Doctor. Two afternoon Sessions were held per week by the Doctor with a weekly HealthTalk by the Health Visitor. During the first full year of working (1917) the attendance of babies was 3,751, with an average per session of 37.9, the number of babies seen by the Doctor was 2,207, the average being 23.3 per session. 106 Mothers were seen by the Doctor, and 1,720 Visits were paid by the Nurse to Mothers and Babies. In June, 1918, a second Centre was opened at Wightman Boad with one Health Visitor and Dr. Flora Shepherd as parttime Lady Doctor. In 1918 the Sessions were increased to three per week on the opening of the second Centre. The attendances increased at Brook Boad to 4,120, with an average of 59.7; the number of babies seen by the Doctor being 2,002, with an average per session of 29.0, and the number of Mothers seen by the Doctor was 429, with an average of 6.2 per session. The number of Babies attending Wightman Boad Centre during the half-year in which it was opened was 1,119, the average per session being 38.7; the number of Babies seen by the Doctor was 706, and the average was 243 per session. 252 Mothers were seen by the Doctor, the average per session being 5.2. The total number of Visits paid to Mothers and Babies attending both Centres was 2,537. In May, 1919, a second Health Visitor was appointed for Brook Boad Centre, and the number of sessions was increased for part of the year to three at Brook Boad and two at Wightman Boad. — 25 — In 1919, 5,139 Babies attended Brook Boad Centre, with an average of 42.1 per session. 2,659 babies were seen by the Doctor, with an average of 21.7 per session. 805 Mothers were seen by the Doctor, with an average of 6.5 per session. At Wightman Road Centre 3,034 Babies attended, with an average of 42.1 per session. 2,032 babies were seen by the Doctor, with an average of 28.2 per session. 436 Mothers were seen by the Doctor, the average being 6 per session. The number of Visits paid by Nurses to Mothers and Babies attending both Centres was 3,496. In 1920, during the first full year of the further increased sessions 5,483 Babies attended Brook Road Centre, with an average of 421 per session. 2,710 babies were seen by the Doctor, with an average of 20.8 per session. 742 Mothers were seen by the Doctor, an average of 5.7 per session. At Wightman Road Centre 3,097 Babies attended, with an average of 38"2 per session. 1,798 babies were seen by the Doctors, with an average of 22.1 per session. 417 Mothers were seen by the Doctor, the average being 6 per session. 3,359 Visits were paid by the Nurses to Mothers and Babies attending both Centres. In 1921, 4 Sessions were held weekly at Brook Road and 2 Sessions at Wightman Road. There were 137 Sessions at Brook Road and 90 at Wightman Road, making 227 in all. In 1921, 6,862 Babies attended Brook Road Centre, with an average of 50.0 per session. 3,480 babies were seen by Doctor, with an average of 25.4 per session. 1,178 Mothers were seen by the Doctor, the average being 8.5 per session, and 4,366 Visits to Mothers and Babies were paid by the Nurses. At Wightman Road Centre 3,602 Babies attended, with an average of 400 per session. 2,065 Babies were seen by Doctor, with all average of 22 8 per session. 363 Mothers were seen by the Doctor, an average of 4.0 per session, and 2,604 Visits were paid by the Nurses to Mothers and Babies. In 1922 an Ante-natal Session as such was started at each Centre in the latter part of the year, the Doctors attending the Ante-Natal Sessions being paid by Voluntary Subscriptions, thus increasing the Sessions to 4 and 1 Ante-natal Session weekly at Brook Road and 2 weekly sessions and 1 Ante-natal Session — 26 — monthly at Wightman Road. 199 Sessions were hold at Brook Road Centre and 100 at Wightman Road; in addition there were 39 Ante-natal Sessions at Brook Road and 7 at Wightman Road, making a total number of 345 Sessions. During the year 7,737 Babies attended Brook Road Centre, with an average of 38.8 per session. 4,877 babies were seen by Doctor, with an average of 24.5 per session. Mothers were seen by the Doctors as follows:—361 Ante-natal and 604 Postnatal, the average being 4.8 per session. 4,861 Visits were paid by the Nurses to Mothers and Babies. At Wightman Road Centre 3,562 Babies attended, with an average of 35.6 per session. 2,372 babies were seen by Doctor, with an average of 23.7 per session. 85 Mothers were seen by the Doctor at the Ante-natal and 338 Post-natal Sessions, the average being 4.2 per session. 3,023 Visits were paid by the Nurse. In 1923 the Ante-natal Sessions at Wightman Road were increased from one to two per month. 206 Sessions were held at Brook Road Centre and 98 at Wightman Road Centre; in addition there were 40 Ante-natal Sessions at Brook Road and 15 at Wightman Road, making a total number of 359 Sessions. 9,270 Babies attended Brook Road Centre, with an average of 45.0 per session. 5,181 babies were seen by Doctor, with an average of 25.1 per session. 469 Mothers were seen by the Doctor at the Ante-natal and 771 at the Post-natal Sessions, the average being 6 0 per session. 4,837 Visits were paid by the Nurses. At Wightman Road Centre 3,659 Babies attended with an average of 36.4 per session. 2,247 babies were seen by the Doctor, with an average of 22.9 per session. 156 Mothers were seen by the Doctor at the Ante-natal and 260 at the Post-natal Sessions, the average being 4.1 per session. 4,099 Visits were paid by the Nurse. In 192-1, 200 Sessions were held at Brook Road Centre and 102 at Wightman Road Centre; in addition there were 45 Antenatal Sessions at Brook Road and 22 at Wightman Road, making a total number of 369 Sessions. 9,925 Babies attended Brook Road Centre, with an average of 40.9 per session. 5,913 babies were seen by the Doctor, with an average of 24.1 per session. 520 Mothers were seen by the Doctor at the Ante-natal Session and 754 at the Post-natal, the average being 5.2 per session. — 27 — At Wightman Road Centre 3,947 Babies attended, with an average of 31.8 per session. 2,821 Babies were seen by Doctor, with an average of 22.7 per session. 218 Mothers were seen by the Doctor at the Ante-natal Session and 297 at the Post-natal, the average being 4.2 per session. 7,985 Visits were paid by the Nurses. HOUSING. Hornsey is mainly a residential tow n of good-class houses, but there are here and there some collections of inferior house property. There is no slum area such as would be suited to a reconstruction scheme. Frequent house-to-house inspection, and the visits of inspectors on other occasions, serve to bring to my notice houses which are insanitary and are not in all respects reasonably fit for human habitation. These defects, when discovered, are promptly remedied, and the houses in the Borough can generally be described as reasonably sanitary, so far as their structure is concerned. (Tables E and N.) But. as I have pointed out in previous reports, the practice of subletting and of taking in lodgers prevails to a considerable extent in Hornsey, and in consequence two or more families may be obliged to share a water-closet, a sink and a kitchen range; the staircase may also be common property. What is everyone's duty is nobody's, and the house and its fittings rapidly become unclean, because each sub-tenant thinks that another ought to do the cleaning. This congestion of several families under one roof is economic in origin, and is not likely, to any great extent, to be remedied by the Council's new Houses, although these undeniably are eagerly sought by the more fortunate citizen who is able to afford to pay a reasonable rent for a good building HEALTH PROPAGANDA. During the year the Medical Officer of Health delivered lectures to the members of the Hornsey Burgesses' Association and the Mothers and Fathers at both the Maternity and Child Welfare Centres. Courses of Health Talks to pupils at the Secondary Schools in the Borough were also arranged, and these lectures were given during the opening term of 1925. — 28 — In addition a small book was prepared which gave health hints to school children; and this book, of which twelve thousand copies were printed, was circulated to the Elementary, Secondary and Private Schools early in the current year. A copy of these Health Hints for School Children is sent with each copy of this Annual Report. LIST OF TABLES. TABLE A.—Vital Statistics, 1904-24. TABLE B.—Causes of, and ages at, death during the year 1924. TABLE C.—Death-rates per 10,000 population from Cancer and Consumption, 1901-24. TABLE D.—Chart showing the Increase of Cancer, 1902-24. TABLE E.—Nuisances and other defects discovered. TABLE F.-—Work of the Inspectors during the year. TABLE G.—Cases of Infectious Disease notified in 1924. TABLE H.—Chart showing Ante natal and Post-natal Infant Mortality Rates, 1883-1924. TABLE J.—Work- done at the Maternity and Child Welfare Centres during the year. TABLE K.—Maternity and Child Welfare Work, 1916 24. TABLE L.—Infant Mortality during the year 1924. TABLE M.—Attack-rates per 10,000 population from Scarlet Fever, Diphtheria and Enteric Fever, 1904-24 TABLE N.—House-to-house Inspection in 1924. TABLE O.—Inspection of Factories, etc., 1924. TABLE A BOROUGH OF HORNSEY VITAL STATISTICS, 1904-1924. Year. Estimated Mid-Year Population. Birth Kate per 1,000 Population. Death Kate per 1,000 Population. Infant Mortality per 1,000 Births. Zymotio Death Rate per 1,000 Population. 1904 76,861 21.6 8.9 86 0.9 1905 77,945 20.0 8.7 67 0.5 1906 79,069 20.1 9.8 84 0.9 1907 80,173 19.0 9.5 76 0.5 1908 81,264 18.2 9.2 63 0.5 1909 82,378 18.3 9.5 57 0.4 1910 83,401 16.7 8.8 69 0.3 1911 84,592 17.5 9.6 78 0.9 1912 84,840 16.3 9.9 75 0 .4 1913 85,122 16.7 9.7 56 0.5 1914 85,456 17.8 9.2 57 0.5 1915 85,800 15.5 12.2 80 1.0 1916 86,147 16.0 11.5 46 0.3 1917 86,450 11.3 10.9 70 0.3 1918 86,942 11.7 13.8 61 0.5 1919 87,100 13.6 11.4 64 0.2 1920 87,410 19.3 10.3 54 0.5 1921 87,691 15.9 11.0 51 0.6 1922 88,007 15.5 11.2 52 0.3 1923 88,325 15.3 10.5 52 0.3 1924 88,661 15.0 10.4 36 0.3 105 Great Towns (Rates in 1924) 19.3 12.3 80 — 157 Smaller Towns (Rates in 1924) 18.9 11.2 71 London (Rates in 1924) 18.6 12.0 69 — ENGLAND and WALES (Rates in 1924) 18.8 12.2 75 — TABLE B. CAUSES OF, AND AGES AT, DEATH DURING THE YEAR 1924. CAUSES OF DEATH All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and over. 1 Enteric Fever 0 ... ... ... ... ... ... ... ... 2 Small.pox 0 ... ... ... ... ... ... ... ... 3 Measles 2 1 ... 1 ... ... ... ... ... 4 Scarlet Fever 1 ... ... ... 1 ... ... ... ... 5 Whooping Cough 2 2 ... ... ... ... ... ... ... 6 Diphtheria and Croup 2 ... ... ... 2 ... ... ... ... 7 Influenza 19 ... ... ... ... 1 1 5 12 8 Encephalitis Lethargica 2 ... ... ... ... ... l ... 1 9 Meningococcal Meningitis 1 ... 1 ... ... ... ... ... ... 10 Tuberoulosis of Respiratory System 54 ... ... ... 1 7 29 16 1 11 Other Tuberculous Diseases 6 ... ... 1 ... 1 1 1 2 12 Cancer, Malignant Disease 150 1 ... ... ... 1 15 59 74 13 Rheumatic Fever 5 ... ... ... ... ... ... 3 2 14 Diabetes 7 ... ... ... ... ... ... 3 4 15 Cerebral Hemorrhage, etc 65 ... ... ... ... ... 2 11 52 16 Heart Disease 107 ... ... ... 1 1 6 31 68 17 Arterio.Sclerosis 45 ... ... ... ... ... ... 7 38 18 Bronohitis 93 2 ... ... 1 ... 1 19 70 19 Pneumonia (all forms) 65 2 ... ... 1 3 9 21 24 20 Other Respiratory Diseases 3 ... ... ... ... ... 1 2 ... 21 Ulcer of Stomach or Duodenum ... ... ... ... ... ... ... ... ... 22 Diarrhcea, etc 1 1 ... ... ... ... ... ... ... 23 Appendioitis and Typhlitis 8 ... ... ... ... 3 2 ... 3 24 Cirrhosis of Liver 5 ... ... ... ... ... ... 5 ... 25 Aoute and Chronic Nephritis 34 ... ... ... 3 2 2 10 19 26 Puerperal Sepsis 1 ... ... ... ... ... 1 ... ... 27 Other accidents and diseases of Pregnanoy and Parturition 1 ... ... ... ... ... 1 ... ... 28 Congenital Debility and Malformation, Premature Birth 36 33 1 ... 1 1 ... ... ... 29 Suicide 10 ... ... ... ... 1 3 6 30 Other Deaths from Violence 21 3 ... ... ... 4 5 1 8 31 Other Defined Diseases 182 3 4 3 5 13 34 118 32 Causes Ill-defined or Unknown ... ... ... ... ... ... ... ... ... Total 928 48 9 6 12 30 93 234 496 TABLE C. DEATH-RATES PER 10,000 POPULATION from GANGER AND TUBERCULOSIS Year. Cancer. Tuberculosis 1901 6.3 8.0 1902 6.8 9.1 1903 8.2 8.7 1904 6.3 10.0 1905 8.6 9.4 1906 8.2 7.6 1907 9.5 8.6 1908 10.3 8.5 1909 9.1 10.1 1910 10.5 7.2 1911 12.1 9.2 1912 13.4 7.0 1913 10.3 8.1 1914 9.1 6.0 1915 11.5 8.9 1916 12.3 12.2 1917 13.1 9.5 1918 14.8 10.2 1919 13.7 8.8 1920 13.6 8.4 1921 16.1 10.0 1922 16.5 7.9 1923 15.7 6.6 1924 16.9 6.7 TABLE E. NUISANCES AND DEFECTS DISCOVERED, 1924. No. of Premises requiring structural repairs 1,233 ,, ,, ,, ,, cleansing and limewashing 440 Drains choked 77 ,, otherwise defective 109 Defective W.C. fittings 278 ,, Yard surfaces 198 ,, Eaves and downspouts 435 ,, Manure receptacles and ashbins 160 ,, Sinks and waste-pipes 138 ,, Urinals 56 Offensive accumulations 51 Animals improperly kept 1 Other nuisances and defects 2,000 Total number of nuisances and defects 5,176 Total number of all visits to all premises for all purposes 16,808 TABLE F. WORK DONE DURING THE YEAR 1924. No. of visits re Infectious Diseases 524 ,, ,, houses visited re Infectious Diseases 243 ,, ,, ,, disinfected after Infectious Diseases 263 ,, ,, ,, ,, ,, other ,, 286 ,, ,, drains (smoke) tested 100 ,, ,, ,, (water) ,, 8 ,, ,, visits to Outworkers 348 ,, ,, ,, ,, Factories and Workshops 918 ,, ,, ,, ,, Slaughter-houses 52 ,, ,, ,, Bakehouses 96 ,, ,, ,, ,, Rag-Flock 28 ,, ,, ,, ,, Places of Public Entertainment 35 ,, ,, ,, ,, Dairies 75 ,, ,, ,, ,, Other food shops or provision stores 2,061 ,, ,, ,, ,, Premises under Shops Act 1,413 ,, ,, ,, ,, Stables 291 ,, ,, ,, ,, Houses under Rent Act 26 ,, ,, ,, ,, Other premises 1,403 TABLE G.—INFECTIOUS DISEASES NOTIFIED DURING 1924. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Ophth. Neon. Pneumonia. Encephalitis Lethargica. Polioenceph. Poliomyelitis Tuberculosis. Total. Admitted to Hospital Ex. T.B. P hthisis. Other forms. Highgate 19 8 0 0 4 0 5 1 0 0 10 1 11 35 Muswell Hill 11 7 0 0 3 0 9 1 0 0 15 1 16 31 Crouch End 15 1 0 0 1 0 6 1 0 0 5 3 8 24 West Hornsey 37 6 1 0 3 1 23 0 0 0 26 3 29 71 East Hornsey 49 8 0 1 8 0 7 5 0 1 14 0 14 79 Nth. Haringey 15 2 0 0 2 0 5 0 0 0 10 2 12 24 Sth. Haringey 9 4 1 0 1 0 2 1 0 0 13 1 14 18 Stroud Green 38 3 0 0 2 0 1 0 0 0 5 1 6 44 Finsbury Park 22 3 1 0 2 0 3 1 1 0 10 4 14 33 Total 215 40 3 1 26 1 61 10 1 1 108 16 124 359 Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas Ophth. Neon. Pneumonia. Encephalitis Lethargies. Polioenceph. Polimyelitis. Tuberculosis. Total. Admitted to Hospital Ex. T.B. Phthisis. Other forms 1st quarter 62 8 0 0 7 0 36 1 0 0 25 3 28 55 2nd quarter 43 13 0 0 7 0 11 6 0 0 34 8 42 48 3rd quarter 53 10 2 0 5 1 5 1 1 0 17 1 18 53 4th quarter 57 9 1 1 7 0 9 2 0 1 32 4 36 47 Total 215 40 3 1 26 1 61 10 1 1 108 16 124 203 A dmitted to Isolation Hosp. 159 33 0 0 6 0 0 4 1 0 0 0 0 203 Admitted to other Hospitals 4 2 2 1 0 1 3 3 0 1 0 0 0 17 NOTE :—The following non-notifiable infectious diseases were also admitted to the Isolation Hospital—Measles 4, German Measles, Appendicitis 1—making a total of 209. NOTE.—The Infant Mortality Rate is shown as columns in which the post-natal causes of mortality are represented by the unshaded part, and the ante-natal causes by the shaded part. It will readily be seen that although the Infant Mortality due to post natal causes has declined considerably, yet that due to ante-natal causes has shown no diminution TABLE J. MATERNITY AND CHILD WELFARE WORK DONE DURING THE YEAR 1924. Nature of Work. Centres. Totals. No. 1. No. 2. Number of Sessions held 200 102 302 Number of Ante-natal Sessions held 45 22 67 Number of Mothers seen by Doctor: Antenatal 520 218 738 Post-natal 754 297 1,051 Number of Babies entered on Register :— During Year 743 268 1,011 Maximum Number of Babies on Register:— During any one month 1,098 454 1,552 Number of BabieB seen by Doctor 5,913 2,821 8,734 Number of Babies weighed 9,925 3,947 13,872 Children Normal — general advice given 2,088 998 3,086 Suffering from incorrect feeding 298 259 557 Difficult Nutrition 398 242 640 Suffering from Rickets 113 56 169 Suffering from Wasting 26 53 79 Suffering from other Diseases 718 539 1,257 Referred to own private Doctors 44 51 95 Referred to Hospitals 191 111 302 Health Talks given by Nurses 28 37 65 First Visits Total Visits First Visits Total Visits First Visits Total Visits Visits paid by Nurses : — To expectant Mothers 140 264 49 161 189 425 To Infants under one year 707 2,128 356 1,908 1,063 4,036 To Children aged 1-5 years 46 1,691 44 1,833 90 3,524 Total Visits paid by Nurses 4,083 3,902 7,985 TABLE K.—HORNSEY MATERNITY AND CHILD WELFARE WORK SINCE INCEPTION. Year. Centre Brook Rd. (1) Wight.Rd. (2) No. of H.V’S. No. of Sessions per week. No. of Sessions per year. No. of Babies attending Centres. Average attend, per Session. No. of Babies seen by Dr. per year. Av. No. of Babies seen by Dr. per Session. No. of .Mothers seen by Doctor. Av. No. of Mothers seen byDr per Session, Visits paid by Nurses. Ante Natal. Post Natal 1916 (part year) (1) 1 2 20 666 33.3 309 15.5 7 - 0.35 204 1917 (first full year) (1) 1 2 99 3,751 37.9 2,207 23.3 106 - 1.07 1.726 1918 (1) 1 2 69 4,120 59.7 2,002 29.0 69 360 6.2 2,537 (12) 1 part year 7 months 1 29 1,119 38.7 706 24.3 24 128 5.2 1919 (1) 2 pt. yr. 3 pt. yr. 122 5,139 42.1 2,6.59 21.7 194 611 6.5 (2) 1 2 pt. yr. 72 3,034 42.1 2,032 28.2 101 335 6.0 3,496 1920 (1) 2 3 130 5,483 42.1 2,710 20.8 169 573 5.7 (2) 1 2 81 3,097 38.2 1 798 22.1 123 294 5.1 3,359 1921 (1) 2 4 137 6,862 50.0 3,48U 25.4 323 855 8.5 4,366 (2) 1 2 90 3,602 40.0 2,065 22.8 71 292 4.0 2 604 6.970 1922 (1) 2 4 & 1 Ante Natal part year. A.N. P.N. 7,737 38.8 4,877 24.5 361 604 4.8 4,861 199 39 pt. yr. (2) 1 2 & 1 Ante Natal month (part yearl 100 7 pt. yr. 3,562 35.6 2,372 23.7 85 338 4.2 3,023 7,884 1923 (1) 2 4 & 1 Aote Natal 206 40 9,270 45.0 5,181 25.1 469 771 6.0 4 837 (2) 1 2 & 1 Ante Natal month 98 15 3,659 36.4 2,247 22.9 156 260 4.1 4,099 8,936 1924 (1) 2 4 & 1 Ante Natal 200 45 9,925 40.9 5,913 24.1 520 754 5.2 4,083 (2) 1 2 & 2 Ante Natal month 102 22 3.947 31.8 2,821 22.7 218 *97 4.2 3.902 7,985 TABLE L— INFANT MORTALITY DURING 1924. CAUSES OF DEATH. Deaths from stated causes at various Ages under One Year of Age. Total Deaths under One Year. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 4 Weeks. 1-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Whooping Cough — — — — 0 — — 1 1 2 Tuberculous Meningitis — — — — 0 — — — — 0 Other Tuberculous Diseases — — — — 0 — — — — 0 Convulsions 1 — — — 1 — — — — 1 Bronchitis — — 1 — 1 — — — — 1 Pneumonia — — — — 0 1 — 2 2 6 Diarrhœa — — — — 0 1 — — — 1 Rickets — — — — 0 — — — — 0 Injury at Birth 4 — — — 4 — — — — 4 Premature Birth 13 2 2 — 17 1 — — — 18 Atrophy, Debility and Marasmus 5 — 1 1 7 1 — — — 8 Other Causes 2 1 — 1 4 1 — 1 2 8 Total 25 3 4 2 34 5 0 4 5 48 TABLE M. ATTACK-RATES PER 10,000 POPULATION FROM SCARLET FEVER, DIPHTHERIA AND ENTERIC FEVER. Year. Scarlet Fever. Diphtheria. Enteric Fever. 1904 25.6 13.1 1.9 1905 33.4 19.8 2.6 1906 52.0 19.9 3.1 1907 35.3 12.2 1.4 1908 29.5 11.5 1.0 1909 26.9 18.3 0.5 1910 20.7 12.6 1.1 1911 21.2 15.7 0.7 1912 16. 2 10.3 1.0 1913 24.2 13.5 1.2 1914 40.7 11.8 1.1 1915 21.1 12.2 2.9 1916 11.9 8.8 0.9 1917 15.3 7.7 0.4 1918 10.1 7.6 0.9 1919 23.3 10.0 0.6 1920 27.9 17.0 0.6 1921 67.4 21.5 0.2 1922 32.5 13.9 0.1 1923 14.3 15.0 0.1 1924 26.5 4.5 0.2 TABLE N.—HOUSE-TO-HOUSE INSPECTIONS, 1924. Premises. Houses or Tenements. Defective Drains. Obstructed Drains. Defective Sanitary Fittings. Defective Water-closets. Rainwater Pipes, Gutters, etc. Defective Pavings. Dampness. No Damp Course. Dirty Premises. Overcrowding. Dustbins. Drinking-water Cisterns dirty. Do. without covers. Other Defects. Satisfactory. Archway Road 39 — — 3 — — 3 2 — 2 1 — — — 7 23 Beechwood Road 16 — — — 1 6 8 — — 11 — — — — 8 1 Campsbourne, The 25 — — — 1 16 4 14 — 13 — 4 17 12 1 Canon Road 34 — 2 7 — 54 6 6 — 16 — 3 1 2 55 5 Denmark Road 45 6 — 3 3 24 3 — — 22 — 9 — — 37 6 Grove House Road 27 2 — 1 1 17 4 7 — 6 1 6 — 1 10 13 Hawthorn Road 24 — — 1 — 3 9 3 — 14 — 1 — 1 14 5 Hornsey Park Road 52 — — 4 3 20 5 17 3 20 — 8 4 4 15 18 Myddelton Road 103 — — 6 3 75 23 49 — 53 2 15 13 12 98 15 North View Road 46 — 1 — 1 6 5 2 — 23 — 1 — — 15 12 North Hill 23 — — — — 2 1 3 — 1 — — — — — 16 Northwood Road 48 1 1 — 1 12 3 2 — 9 — — 4 2 20 — Orchard Road 51 1 4 1 1 22 1 17 — 2 1 5 2 — 4 4 Osborne Grove 26 — — 1 — 12 5 — — 6 — — — — 24 3 South View Road 33 — — 7 — 6 16 3 — 16 — 5 — — 9 10 St. Mary's Road 152 1 2 9 4 49 12 9 9 20 — 8 2 3 62 28 Spencer Road 48 — 2 5 — 13 7 1 — 6 5 5 1 1 10 18 Total 792 11 12 48 19 337 115 135 12 239 10 70 44 26 400 178 During the year 116 visits were made to houses which had previously been inspected. TABLE 0. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors Premises. Number of Inspections. Written Notices. cutions. Factories (Including Factory Laundries) 316 22 0 Workshops (Including Workshop Laundries) 485 38 0 Workplaces (Other than Outworkers' premises) 57 8 0 Total 858 68 0 DEFECTS FOUND IN FACTORIES, WORKSHOPS <Sr WORKPLACES Pai ticulars. Number ol Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:—* Want of cleanliness 11 11 0 0 Want of ventilation — — — — Overcrowding 2 2 0 0 Want of Drainage of floors 3 3 0 0 Other nuisances 15 16 0 0 Sanitary accommodation insufficient 3 3 0 0 unsuitable or defective 25 25 0 0 uot separate for sexes 3 3 0 0 Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) Other offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921). 6 6 0 0 Total 68 68 0 0 Annual Report FOR 1924 ON THE SCHOOL MEDICAL SERVICE OF THE BOROUGH OF HORNSEY BY A. T. Nankivell, M.D. (Lond.), D.P.H. (Camb.), Medical Officer of Health and School Medical Officer. PREFACE. To the Chairman and Members of the Education Committee. Ladies and Gentlemen, I have the honour of presenting to you my fourth and final Annual Report as your School Medical Officer. During my term of office the work of the School Medical Service has shown considerable development, and you have now in Hornsey an organisation of which the Borough may justly be proud. No doubt in future years this valuable work will undergo still further increase, and will be finally made complete by the provision of a residential open-air school: an institution or convalescent home of this nature would be of unimagined benefit to many children. May I take this opportunity of thanking the Education Committee for the consideration and kindness which they have shown to me during the past four years, and in expressing my gratitude for the help given to me by the Education Secretary and his staff? The Teachers and School Nurses have always done everything in their power to make easy and pleasant the work in which I have been engaged. To the various Doctors who have assisted in conducting our School Medical Service, and especially to Dr. J. K. Prior, I owe a debt of gratitude. I have the honour to be, Your obedient Servant, 6th January, 1925. A. T. NANKIVELL. 4 GENERAL. The object of a School Medical Service is to prevent illness or to cure disease in its beginning; so that the child while it is at school may remain healthy and able to profit by its instruction. The result of a successful school medical service is that the young adult population of the country is healthy and strong and not handicapped by the disastrous effects of neglected disease. Hornsey school children are inspected on entering school at the age of 5 years, again at the age of 8-9 years, and yet again when they are 12-14 years old. Those who remain on at certain of the schools in the advanced courses are also inspected medically before the conclusion of their advanced studies. In addition to these "Routine Groups" a medical examination is given to "Special" children who in the opinion of their parents or teachers seem to require it. This frequent inspection at the schools or in the school clinic secures that no child shall pass through its school life without being given many opportunities for the remedy of defects. To see the results of a slowly operating system is difficult; but th« older teachers and those who, like myself, have been observing school children over a number of years are unanimous in appreciating the difference between the school child of to-day and the child of fifteen years ago. As our school medical service increases the scope of its activities, providing the children with open-air schools and convalescent homes, we may expect in the future to see a corresponding improvement in the health and physique of the school children. SANITARY CONDITION OF THE SCHOOLS. On the whole this is excellent, especially in the newer schools. ORGANISATION OF THE SCHOOL MEDICAL SERVICE. The Medical Officer of Health is also the School Medical Officer, and he is assisted by Dr. J. R. Prior and several part-time medical officers chosen from a panel of local 5 titioners. Dr. Prior performs much of the medical inspection and also the Ophthahnic work. The part-time assistants conduct the work at the minor ailments clinics, give anaesthetics for the dentists and operate for enlarged tonsils and adenoids. Three dental surgeons (and, towards the end of the year, four) undertook the examination and treatment of dental defects. There are three school nurses, one of whom spends all her time at work in the School Clinic. One clerk keeps the considerable records of the service, and last December some temporary help was provided, since it is more than one person can reasonably perform. EXTENT AND SCOPE OF THE WORK. During the year the school nurses made 861 visits to the schools, and 883 visits to the homes of children. At these visits to the schools the nurses made a cursory examination of no lesi. than 29,251 children, inspecting them for obvious defects, such as skin disease, sore eyes, discharging ears or verminous conditions. These inspections, though rapid and superficial, are of the greatest value, since they usually result in securing treatment for the condition before it becomes chronic and difficult to be cured. These "class-to-class" inspections are also of definite educative value to the children, to their parents and to the teachers. A summary of the work of the school nurses will be found in Table 8. The Routine Examination of children has been carried out as usual during the year, and does not call for special comment. The number of children examined in each school will be seen on reference to Table 6. The defects that were discovered at the routine inspection are shown in Table 2. GENERAL REVIEW OF FACTS DISCLOSED BY MEDICAL INSPECTION. Malnutrition.— Out of 2,506 children examined at the routine inspection during the year, 45 were found to be suffering from malnutrition. The chief causes of malnutrition are (1) lack of sufficient food; (2) improper and indigestible food; (3) unsuitable home conditions; (4) excessive employment out of school hours; (5) illness and disease. 6 In Hornsey I do not think that there is much malnutrition caused by lack of food. No doubt there are some children who would benefit by school meals, but they would benefit from these not so much because of the quantity as because of the quality. Bread and jam, cakes and sweets toooften fonn the bull; of the diet of the growing child; and the entire absence of fresh foods from many dietaries is deplorable. Even if a man has an allotment and grows his own green vegetables his family does not seem to eat lettuces, mustard and cress or cabbages; tinned milk is often used instead of fresh milk and canned fruits and fish instead of the fresh articles. With gross errors in diet of this nature it is not surprising that among the children is found a certain amount of malnutrition or sub-health. The remedy lies in the education of the parents, and especially of the children themselves; and girls at cooking classes should learn not only how to cook but also what to cook. Clothing and Footwear.—Out of 2,506 children examined at the routine inspection during the year 60 were found to have defective clothing and 69 to have defective footgear. Uncleanliness.— Out of 2,506 children examined 170 were found to be unclean at the time of the routine inspection. One child had live lice in its head, and 133 others had nits (or eggs of lice), and 35 were found to be flea-bitten. During the year, as the result of class-to-class inspection, the school nurses have discovered 800 children who were unclean. Enlarged Tonsils and Adenoids.—Out of 2,506 children examined at the routine inspection 164 were found to have enlarged tonsils or adenoids or both of these conditions. Defective Hearing.—Sixteen deaf or partially deaf children were discovered during the year. Deafness is due in many cases to the presence of adenoids; in others, to middle ear disease, secondary to measles or to scarlet fever. Defective Vision.—Out of 2,506 children examined at the routine inspection 196 were found to have defects of vision which required treatment. Details of these children are given in Table IV. (Group B). Other Eye Diseases.—Out of 2,506 children examined at the routine inspection 4 were found to be suffering from other diseases of the eyes or eyelids. 7 Dental Diseases.—At the routine inspection out of 2,506 children examined 2,329 were found to have good teeth, 136 tc have less than four bad teeth, and 41 to have more than four bad teeth. The School Dental Surgeons in their careful examination of children in the schools found that out of 6,091 children examined no less than 4,095 needed treatment. Rheumatism and Heart Disease.— Out of the 2,506 children examined 4 were found to be suffering from organic lesions of the heart, the sequel in the majority of cases to a previous attack of rheumatism or rheumatic fever. In addition to the above 27 children were found who had some functional heart condition, and 9 were ansemic.. Bronchitis and Pre-tuberculous conditions of the Lungs.— At the routine inspection, out of 2,506 children examined 17 were found to be suffering from bronchitis or from pre-tuberculous lung conditions. Chronic; bronchitis in children is of grave significance, and the most satisfactory method of treatment is that of sending the child to an open-air school or to a convalescent home. Tuberculosis.-—Out of 2,506 children examined none were found to be suffering from definite pulmonary tuberculosis, but 14 others showed signs pointing to early stages of this disease Ringworm.—During the year under review 24 children were found who were suffering from ringworm of the scalp and 24 who had ringworm of the skin. Impetigo or Infectious Sores.—During the year 131 children were discovered who were suffering from impetigo. Scabies or the Itch. — During the year 11 children were found to be suffering from this irritating condition. Enlarged Lymphatic Glands. — Out of 2,506 children examined 64 were found to have enlargement of the lymphatic glands. In the majority of instances these enlargements were secondary to decayed teeth or to inflamed tonsils or to some other septic condition. In a few cases the enlargement was tuberculous in nature. 8 Mental Deficiency.— During the year under review 12 children were seen who were mentally defective. The mentally defective children in the school at Finchley were inspected twice during the year by the School Medical Officer. A REVIEW OF THE METHODS EMPLOYED FOR TREATMENT. Treatment can be provided for the ailing child in one of three ways:—(1) From the general practitioner in his capacity as family physician; (2) at the voluntary Hospitals; and (3) at the School Clinic. The School Clinic is situated in Topsfield Parade, Crouch End, and during the year it has been instrumental in providing treatment for 3,865 children, who attended there on 11,830 occasions. The treatment of various conditions will now be described under the same headings and in the same order as those in the previous section of this Report. Malnutrition.—Cod liver oil and malt is provided at the recommendation of the Medical Officer to such children as would appear to need it, and milk is given by the Care Committee in certain instances. It may be said that the proper treatment of malnutrition, of the state of sub-health, is often a matter of the greatest difficulty. The ailing child is paying the penalty of the conditions tinder which it is living—late hours, improper food, overcrowding, lack of sunshine and fresh air—all these take a toll of the health of the little child. The remedy is to take the child away from these adverse surroundings and conditions and to allow the child to live for a time in natural and healthy circumstances. We have at present no open-air school, but it is hoped that before long we may be able to establish one. If so it would be a non-residential school, and although it would be of immense benefit to the health of our children it would not provide a remedy for that class of child who needs to be taken away to the country for three or six months. I wrote in my Report for 1923 of the need which existed for a convalescent home or for a residential open-air school. That need is being met to a small extent by the sending of boys, two at a time, to such a school 9 in Parkstone, Dorset: a few girls also are sent away to holiday homes by the Carp Committees; but these provisions touch only the fringe of our necessities. Unclcanliness.—The Education Committee has provided an excellent cleansing station where verminous and unclean children can be cleansed and their clothes can be sterilised. During the year, 144 children passed through this cleansing station, and made altogether 330 attendances. Adenoids and Enlarged Tonsils.—Three to five children are operated on every Saturday morning at the School Clinic for these conditions. As in former Reports, I wish again to put on record that, although the arrangements made for these operations at the Clinic are as perfect as possible the Clinic itself is no place in which to perform this operation, of which the results are sometimes very serious. It would be better if all children who need this operation could be admitted into hospital and kept there for forty-eight hours in order to recover from the effects. As this does not appear to be at present a practicable arrangement we continue to perform these operations at the School Clinic and take every possible precaution to minimise danger to the children. I am glad to be able to report that during the year under review all the operations were safely performed, although one case gave rise to considerable anxiety and had to be removed to a Nursing Home. Defective Hearing.—Cases of chronic otorrhcea are treated at the School Clinic, and these take up a large part of the time of the school nurse. During the year under review 141 children with ear discharge attended on 1,420 occasions at the Clinic. Defective Vision.—Children who are found to be suffering from defective vision are treated at the School Clinic and examined by the Assistant School Medical Officer, who prescribes for them the necessary glasses and gives what other treatment is necessary. This arrangement has worked satisfactorily during the year, and 564 children attended on 2,303 occasions for examination and treatment. Stammering.—A successful class has been established at which children with defective speech are instructed in proper methods of talking. 10 Dental Diseases.—Four part-time dentists are employed by the Committee to examine and to treat children who have defeotive teeth and oral sepsis. During the year they have done much good work. Details of their examinations and treatments are given in Table IV. D. llheumatixm aiul Heart Disease.—The majority of cases of heart disease discovered during the year did not appear to be in need of treatment. In certain cases directions regarding the child's general health were given to the parents. Bronchitis aiul Pre-tuberculosis.—Apart from general instructions to parents and the administration of ood liver oil and malt it was not possible to do much for this group of ailing children. Some individual cases were referred to the Tuberculosis Officer. Tuberculosis.—Children discovered to be suffering from active tuberculosis were in all instances referred for advice anil treatment to the Tuberculosis Officer. Ringworm.—The skin infection is treated at the School Clinic. Children with ringworm of the scalp are referred for treatment to a local doctor who is an expert at X-Ray work. This has already resulted in a diminution of the number of cases of this condition. During the year 13 children received X-Ray treatment for ringworm of the scalp. Impetigo.—This is treated successfully at the School Clinic, and 131 children suffering from this complaint made 565 attendances during the year. Scabies.—Children with scabies are treated at the cleansing station. During the year 21 children underwent the treatment there, and attended on 50 occasions. In every case the Health Department offered to disinfect free of cost the bedding and bedroom at the house where the child livd. To cure a child of scabies and to send it home to sleep in an infected bed is obviously a waste of time and money. Enlarged Lymphatic Glands.—The conditions, such as septic skin troubles, which give rise to enlargements of the-glands are treated at the Clinic. 11 Mental Deficiency.—Children who can benefit by instruction in a special non-residential school are sent to the school in I'inohley, which is shared by Fincliley, Wood Green and Hornsey. Other Conditions. — Ninety-three children suffering from minor injuries made 304 attendances at the Clinic during the year, and 217 children with other skin diseases came for treatment. Altogether during 1924 there were 1,902 children who came to the Minor Ailment Clinic for treatment by the Doctor and Nurse; these children made 5,981 attendances. The Minor Ailment Clinic is doing very good work, and is providing medical treatment and advice for children who otherwise would be without it. The children who attend the Minor Ailment Clinic come from poor homes where medical treatment by a private doctor would be a luxury that could not be afforded. Many of the ailments treated and cured at the Clinic are of a nature which parents tend to regard as trifling and of no importance; and, if ii were not for the Clinic, no medical treatment would be obtained for the child with the sore eyes, discharging ears and other minor ailments. The following are some remarks made by Dr. G. Dawson Dick, who has been attending school children at our clinic during the past twelve months:— "Elsewhere it will be seen that the Borough has every reason to congratulate itself on a remarkably low infant mortality rate. It will be readily understood that this very fact throws a still greater responsibility on the Borough to safeguard the well-being of the child, both in infancy and school life, so as to secure as far as possible a healthy and efficient adult. In the supervision of the child, linking-up Infant Welfare Centres with the medical inspection of school children, no department is more important than that dealing with minor ailments. Mostly these are conditions for which the mother would not take the child to her private doctor, nor are they suitable conditions for the out-patient department of the hospital, where they necessarily tend to be crowded out by children requiring more urgent and definite surgical or medical treatment. Mostly these children are brought direct by the mother, or are referred to the clinic by the teachers, or the school doctor at the time of medical inspection. 12 The main disabilities dealt with, details of which will be found elsewhere, are:— (1) Debility, anaemia and malnutrition; (2) enlarged tonsils and adenoid growths at the back of the nose; (3) inflammation of the middle ear, frequently with chronic discharge and deafness; (4) bronchial catarrh; (5) impetigo and other skin diseases. The privilege of being able to take to the Clinic a child because it is not thriving or not looking well is greatly appreciated by the mother, and is of great importance to its future welfare. Various factors have to be considered as possible causes of variations in the standard of health in young children. These may be classified under three headings:— (1) Heredity; (2) defective feeding; (3) defective hygienic conditions due notably to bad housing and overcrowding. Without denying the importance of either of the first two factors, defective hygiene conditions, as represented by absence of fresh air and sunlight, the breathing of vitiated air, and the lack of the opportunity of exercise in the open, are the great factors leading to impaired development in the adult. The standard of feeding of the children in Hornsey must be considered as good. The cases where one suspected gross ignorance or negligence in feeding were systematically followed up by the nurse or other viaitors. In a certain numb or of the children where the condition of the child seemed to demand it, milk has been supplied at school frequently with the greatest benefit. When the child is suffering from lack of nourishment the regular supply of milk in this way is much more effective than the administration of cod liver oil, although malt and cod liver oil are often very beneficial. This is also given at the school when recommended by the Medical Officer. It is a mistake to suppose that every delicate child requires cod liver oil. Many have too much greasy and fatty focd in their ordinary diet, and when the child is pale and anaemic and suffering from indigestion and loss of appetite (Parrish's) chemical fowl has been frequently used with great benefit. This also has been given at school to many children during the past year. 13 While there are practically no slum areas in the Borough of Hornsey the housing in many parts leaves much to be desired, and the tendency to sub-let houses suitable for one family so as to accommodate two or three families has increased of late years owing to high rentals and shortage of housing which is prevalent throughout the whole country. Till these condition can be efficiently remedied an extension of the work in three directions is very desirable, viz.: — (1) in the provision of open-air classes and open-air schools for delicate children; (2) further opportunities for treatment at convalescent homes at the seaside or in the country; (3) extension of the holiday movement providing two or three weeks at the seaside or in the country during the summer vacation." GENERAL REVIEW OF HOME CONDITIONS AND EMPLOYMENT. Under this heading I have nothing to add to the remarks which I made in my last Report. ACTION TAKEN TO DETECT AND PREVENT THE SPREAD OF INFECTION IN SCHOOLS. This is, generally speaking, the same as last year. The teachers, school attendance officers, nurses and medical officers are always on the watch for possible cases of infectious disease, and no doubt the good health of the school children during the year was due, in part, to this carefulness. The year under review was a non-epidemic year. We have suffered from no epidemics in the schools, and only a few sporadic cases of infectious diseases have been reported. LEGAL PROCEEDINGS. No legal proceedings were taken during the year under section 122 of the Children's Act, but 115 preliminary and 20 statutory notices were served on parents, and children were compulsorily cleansed in 8 instances. In five cases notices under S. 122 were served with satisfactory results. LIST OF TABLES. TABLE I.—Number of Children Inspected. ,, II. (a).—Defects found on examination. ,, II. (b).—Number of Individual Children found to Require Treatment. ,, III.—Return of Exceptional Children in Area. ,, IV.—Return of Defects Treated. (a) Treatment of Minor Ailments. (b) Treatment of Visual Defects. (c) Treatment of Defects of Nose and Throat. (d) Treatment of Dental Defects. ,,V.—Accommodation, etc., at Schools in the Borough. ,,VI.—Number of Children Examined at each School. ,, VII.—Work done at Minor Ailments Clinic. ,,VIII.—Summary of Work done by School Nurses. TABLE L.-RETURN OF MEDICAL INSPECTIONS, (a) Routine Medical Inspections. Number of Code Group Inspections- Entrants 631 Intermediates 1,050 Leavers 770 Total 2,451 Number of other Routine Inspections 55 (b) Other Inspections. Number of Special Inspections 1,515 Number of Re-inspections 8,644 Total 5,159 TABLE II. (A)—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER. Defect or Disease Routine Inspections Special Inspections No. of Defects. No of Defects. Requiring Treatment. Requiring to be kept under observation but not requiring T reatment. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. (l) (2) (3) (4) (5) Malnutrition — 45 3 — Uncleanliness (See Table IV, Group V). 170 — — — Skin Ringworm, scalp — — 24 — ,, body — — 24 — Scabies — — 11 — Impetigo — — 131 — Other Diseases (non-Tuberculous) 2 4 217 — Eye Blepharitis 3 — 26 — Conjunctivitis 1 — 31 — Keratitis — — 2 — Corneal Opacities — — 1 — Defective Vision (excluding Squint) 188 — 115 — Squint 8 — 19 — Other Conditions 3 1 26 — Bar Defective Hearing 7 1 15 — Otitis Media 7 — 81 — Other Ear Diseases 1 — 32 8 Nose and Throat Enlarged Tonsils only 37 104 28 17 Adenoids only — 6 9 5 Enlarged Tonsils and Adenoids 11 6 42 6 Other Conditions — 1 67 8 Enlarged Cervical Glands (Non-Tuberculous) — 64 12 5 Defective Speech — 4 — — Teeth—Dental Diseases (See Table IV., Group IV.) 177 — 8 — Heart and Circulation Heart Disease : Organic — 4 — 1 Functional 1 26 — 7 Anæmia — 9 130 9 Lungs Bronchitis — 17 109 1 Other Non-Tuberculous Diseases — — 9 — Tuberculosis Pulmonary: Definite — — — — Suspected 1 13 2 1 Non-Pulmonary: Glands — — — — Spine — — — — Hip — — — — Other Bones and Joints — — — — Skin — — — — Other Forms — — — — Nervous System Epilepsy — — — 3 Chorea — — 1 5 Other Conditions — 3 5 6 Deformities Rickets - — 1 — — Spinal Curvature — 5 — — Other Forms — 2 8 3 Other Defects and Disease 5 9 316 31 TABLE II. (B)—NUMBER OF INDIVIDUAL CHILDREN FOUND AT ROUTINE MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEANLTNESS AND DENTAL DISEASES). Group Number of Children. Percentage of Children found to require treatment. Inspected. Found to require treatment. (1) (2) (3) (14) Code Group:— Entrants 681 77 12% Intermediates 1,050 220 25.5% Leavers 770 155 20% Total (code groups) 2,451 452 20% Other routine inspections 55 11 20% TABLE III.—RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys Girls Total Blind (including partially blind). (i) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind — — — Attending Public Elementary Schools — — — At other Institutions — 4 1 At no School or Institution — — — (ii) Suitable fortraining in a School or class for the partially blind Attending Certified Schools or Classes for the Blind 1 5 6 Attending Public Elementary Schools 1 1 2 At other Institutions — — — At no School or Institution — — — Deaf (including deaf and dumb and partially deaf). (i) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 2 5 7 Attending Public Elementary Schools — — — At other Institutions 2 — 2 At no School or Institution — — — (ii) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf — — — Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority.) Attending Certified Schools for Mentally Defective Children 9 14 23 Attending Public Elementary Schools — — At other Institutions — — — At no School or Institution — — — Notified to the Local Control Authority during the year. Feebleminded 1 1 2 Imbeciles — — — Idiots — — — Epileptic Suffering from severe epilepsy. Attending Certified Specia Schools for Epileptics 1 — 1 In Institutions other than Certified Special School. — — — Attending Public Elemen tary Schools — — — At no School or Institution — — — Suffering from epilepsy which is not seven Attending Public Elementary Schools 3 — 3 At no School or Institution — — —  Boys Girls. Total Infectious pulmonary and glandular tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At other Institutions — — — At no School or Institution — — — Non-infectious but active pulmonary and glandular tuberculosis. AtSanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools — — — At Certified Day Open-air Schools — — — At Public Elementary Schools 11 13 24 At other Institutions — — At no School or Institution — — Physically Defective Delicate children (e g , pre-or latent tuberculosis, malnutrition, debility, anaemia, etc ) At Certified Residential Open air Schools 2 — 2 At Certified Day Open-air Schools — — At Public Elementary Schools 23 10 33 At other Institutions — — — At no School or Institution — — — Active nonpulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board — 4 4 At Public Elementary Schools — — At other Institutions — — — At no School or Institution — — — Crippled Child ren (other than those with active tuberculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease. At Certified Hospital Schools — — — At Certified Residential Cripple Schools — 2 2 At Certified Day Cripple Schools — — — At Public Elementary Schools 22 12 34 At other Institutions 2 1 3 At no School or Institution 1 1 2 TABLE IV. (A)—RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER. TREATMENT TABLE. Minor Ailments (excluding Uncleanliness, for which sec Group V.). DISEASE OR DEFECT. Number of Defects treated or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. 1 (2) (3) (4) Skin— Ringworm-Scalp 24 — 24 Ringworm-Body 24 — 24 Scabies 11 — 11 Impetigo 129 2 131 Other Skin Diseases 215 2 217 Minor Eye Defects (External and other, but excluding cases falling in Group II). 57 1 58 Minor Ear Defects 137 4 141 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 92 1 93 Total 689 10 699 TABLE IV. (B).-Defeotivc Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments). Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) (Operations for squint should be recorded separately in the body of the Report). 429 75 — 504 Other Defect or Disease of the eyes (excluding those recorded in Group 1). 60 — — 60 Total 489 75 — 564 Total Number of children for whom spectacles were prescribed (a) Under the Authority's Scheme 276 (b) Otherwise—0. Total Number of ohildrun who obtained or received spectacles (a) Under the Authority's Scheme 274 (A) Otherwise—0. (C).—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 94 7 101 72 173 TABLE IV.—(Contd.). (D)—Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist:— Aged Routine Age Groups 5 — 6 488 7 685 8 771 9 785 10 814 11 878 12 727 13 670 14 273 Total 6,091 Specials 8 Grand Total 6,099 (b) Found to require treatment 4,095 (c) Actually treated 1,641 (d) Re-treated during the year as the result of periodical examination 751 (2) Half-days devoted to Inspection 81 Treatment 189 Total 220 (3) Attendances made by Children for treatment 8,452 (4) Fillings Permanent teeth 864 Temporary teeth 594 Total 1,458 (5) Extractions Permanent teeth 377 Temporary teeth 2,756 Total 3,188 (6) Administrations of general anæsthetics for extractions 822 (7) Other operations Permanent teeth 90 Temporary teeth 102 Total 192 (E)—Uncleanliness and Verminous conditions. (i) Average number of visits per school made during the year by the School Nurses—16. (ii) Total number of examinations of children in the schools by School Nurses—29,251. (iii) Number of individual children found unclean—800. (iv) Number of children cleansed under arrangements made by the Local cation Authority—144. (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Bye-laws Nil TABLE V. LIST OF SCHOOLS IN THE BOROUGH. School. Department. Authorized Accommodation. No. on the Rolls. Muswell Hill Juniors 220 115 St. Michael's Senr. Mixed 238 174 „ Junr. Mixed 192 114 Highgate Senr. Mixed 444 301 „ Junr. Mixed 354 183 North Harringay Boys 416 413 „ „ Girls 416 428 „ „ Junr. Mixed 462 408 South Harringay Senr. Mixed 570 445 „ „ Junr. Mixed 300 205 Stroud Green Boys 418 410 „ „ Girls 418 400 „ „ Infants 426 239 St. Mary's Boys 237 241 „ Girls 235 254 „ Infants 220 199 Crouch End Boys 456 396 „ „ Girls 450 392 „ „ Infants 411 271 Holy Innocents' Infants 101 100 St. James' Mixed 269 264 Campsbourne Boys 450 411 „ Girls 450 422 „ Infants 473 437 Totals 8,626 7,222 TABLE VI.—ROUTINE MEDICAL INSPECTION. Number of Children examined at each School. YEARS OF AGE. 5 6 7 8 9 10 11 12 13 14 TOTALS. School. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. Total Muswell Hill 11 4 2 3 — 1 7 8 2 2 — — — — — — — — — — 22 18 40 St. Michael's 6 4 1 1 2 — 9 12 2 5 1 1 1 1 16 15 2 — — — 40 39 79 Highgate 3 9 2 5 1 — 18 19 2 3 1 4 — — 33 20 4 — — — 64 60 124 North Harringay 27 23 25 17 8 9 67 35 36 31 5 7 3 4 78 65 25 43 1 — 275 234 509 South Harringay 15 17 9 5 6 10 36 25 7 12 — 1 2 2 28 19 4 2 18 6 125 99 224 Stroud Green 30 16 4 7 3 3 41 31 6 11 4 7 — 1 55 39 4 4 22 15 169 134 303 St. Mary's 16 19 12 16. 4 5 29 29 4 2 1 — — 1 19 27 4 2 — 1 89 102 191 Crouch End 21 23 21 25 7 6 73 46 25 18 5 7 59 66 29 15 1 2 — — 241 208 449 Holy Innocents' 6 7 2 8 1 4 2 7 — — — — — — — — — — — — 11 26 37 St. James' 10 6 2 2 3 1 11 8 2 5 2 3 1 3 17 11 — 2 — 2 48 43 91 Campsbourne 44 41 12 10 5 3 70 59 14 17 5 3 — 1 67 85 14 9 — — 231 228 459 Total 189 169 92 99 40 42 363 279 100 106 24 33 66 79 342 296 58 64 41 24 1,315 1,191 2,506 TABLE VII. WORK DONE AT MINOR AILMENTS CLINIC, 1924. No. of Inspection Clinics Held. Total No. of Attendances at Inspection Clinics. Average Attendance at Inspection Clinic. Total No. of Attendances for Treatment. No. of Cases dealt with. No of Re-Examinations of these Children. No, of Cases cured and returned to School. No. of cases referred to private Doctor or Hospital or not requiring treatment. No. of Cases still on Register, 87 2,920 33.5 3,061 1,578 1,342 1,402 73 187 DETAILS OF THE AILMENTS DEALT WITH. Ringworm, Head 24 Nose and Throat Diseases 219 Do. Body 24 Enlarged Cervical Glands 17 Bronchial Catarrh (Bronchitis) 120 Scabies 11 Tuberculosis (susp. non.-pulm.) 5 Impetigo 131 Infectious Diseases 12 Heart Disease 12 Other Skin Disease 217 Epilepsy 8 Minor Injuries 93 Chorea 6 Other Nervous Diseases 11 Ear Disease 141 Debility, Anaemia and Malnutrition 175 Eye Disease 58 Dental Disease 8 Rheumatism — Deformities 12 Abdominal Complaints and Enuresis 16 Miscellaneous 262 Goitre 1 Total 1,578 TABLE VIII.—SUMMARY OF WORK OF THE SCHOOL NURSES, 1924. Schools. Visits to Schools. No. Examined. No. of Individual Children found Unclean. No. of Visits to Schools re other work. Home Visits re Defective Children. Dept. No. of Visits re Uncleanliness. Unc'ean. Teeth. Defective Vision. Tonsils and Adenoids. Lungs. Heart. Bars. Impetigo. Scabies. Ringworm Miscellaneous. Muswell Hill Mixed 26 789 7 12 2 — 16 8 — — — — — — 6 St. Michael's Senr. 17 730 11 16 5 — 12 7 — — 1 — — — 12 „ Junr. 19 596 12 8 2 — 4 4 — — — — — — 1 Highgate Senr. 14 971 11 21 — — 21 4 — — 1 — — — 6 „ Junr. 16 679 5 16 2 1 6 11 — — 2 — — — 2 North Harringay Boys 12 1,174 29 25 7 1 7 11 1 — 1 2 — — 3 „ „ Girls 21 1,498 91 7 5 — 8 12 1 — — — — 1 3 „ „ Infants 16 1.614 68 21 6 — 6 15 — — — — — — 5 South Harringay Senr. 6 702 15 18 — 1 7 2 — 1 — — — — 4 „ „ Junr. 6 731 11 12 1 — 6 24 — — 2 — 1 2 — Stroud Green Boys 9 1,216 2 25 2 — 23 14 — — 1 — — — 3 „ „ Girls 22 1,337 16 17 6 — 26 13 — — 2 — — — 7 „ „ Infants 22 1,242 8 11 2 2 15 19 — — — — — — 7 St. Mary's Boys 8 1,114 6 24 1 — 2 2 — — — — — — 1 „ „ Girls 10 1,923 11 24 — 1 3 — — — — — — 1 „ „ Infants 9 499 4 14 1 — — 6 — 1 — — — 1 3 Crouch End Boys 14 1,413 20 26 6 2 29 14 — — — — — — — „ „ Girls 29 2,237 76 26 24 — 30 10 3 — 4 — 2 1 19 „ „ Infants 28 1,382 35 27 18 — 18 15 2 — 5 2 — — 10 Holy Innocents' Infants 10 488 9 12 — — 1 2 2 — 1 — — 3 14 St. James' Mixed 20 956 12 11 — — 7 7 — — — — — — 1 Campsbourne Boys 18 1,834 67 28 — — 25 4 1 2 — 1 — 4 3 „ Girls 23 2,384 155 30 27 — 32 16 1 1 2 — — 2 8 „ Infants 21 1,742 119 34 10 2 13 16 — 1 3 1 1 6 2 Totals 396 29 251 800 465 127 9 315 239 11 6 25 6 4 20 121