439(1) (1) R. china 5 B (2) Library HOR 048 HORNSEY'S HEALTH 1956 THE ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, BOROUGH OF HORNSEY HOR 048 HORNSEY'S HEALTH 1956 THE ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, BOROUGH OF HORNSEY MEMBERS OF THE COUNCIL *Alderman Neil Muldoon, j.p., Mayor Councillor P. F. H. Emery, m.a., Deputy Mayor ALDERMEN G. S. Aitken G. F. N. Norman F. H. Bailey, j.p. H. L. Norman M. W. Burns †*Miss J. Richardson E. C. Castle *T. Tivendale *S. G. Goulding *L. J. Valette Sir William Grimshaw, j.p. COUNCILLORS †*Miss O. R. Anderson J. Newstead {Chairman of Health Committee) p Phillips L. A. Bains J. R. Richardson Miss M. M. Barrie P. P. Rigby D. F. W. Billingsley H. A. L. Rossi, ll.m. *A. R. Bowerley *A. Stanley Mrs. J. M. Carter *P. G. Stapley F. C. Cave, j.p. *C. V. Tipping H. P. Creasy, M.I. .Mech.e. M. H. Waley-Cohen W. J. M. Crosland G. Watson Mrs. K. M. St. Patrick Crump R. I. G. Watt, m.a. *J. F. Ford †*Miss M. E. West *V. P. Gellay, b.sc. G. E. Whitman R. J. Hooker †*J. T. Wilkins A. S. Kent †*C. R. Williams E. M. Larard (Vice-Chairman of Health Committee and Area Health R. G. Leeming Committee) *D. H. P. Levy A. Wilson B. D. Lipson, ll.m. *F. J. Worster * Member of Health Committee at 3 l.st December, 1956. t Member of Area Health Committee at 3 1st December, 1956. 2 STAFF OF THE HEALTH DEPARTMENT Medical Officer of Health G. Hamilton Hogben, m.r.c.s., d.p.h. Deputy Medical Officer of Health A. Yarrow, m.b., ch.b., d.p.h. Veterinary Inspector F G. Buxton, m.r.c.v.s. Chief Public Health Inspec- J. H. Jesse, m.a.p.h.i., tor, Petroleum Inspector Public Health Inspector's Cert. and Shops Inspector Food Inspector's Cert. Chief Clerk D. B. Da vies, d.p.a. (Lond.) Public Health and Shops J. D. Chance, m.a.p.h.i., Inspectors Public Health Inspector's Cert. Food Inspector's Cert. E. Hundy, m.a.p.h.i., Public Health Inspector's Cert. Food Inspector's Cert. Cert. in Sanitary Science. R. Downes, m.a.p.h.i., Public Health Inspector's Cert. S. Swinnerton, m.a.p.h.i., Public Health Inspector's Cert. Food Inspector's Cert. A. K. D. Shuttleworth, m.a.p.h.i., Public Health Inspector's Cert. R. L. Hooper, m.a.p.h.i., Public Health Inspector's Cert. Food Inspector's Cert. Food Inspector and Shops W. J. Wilson, d.p.a. (Lond,), m.a.p.h.i., Inspector .. .. Public Health Inspector's Cert. Food Inspector's Cert. Senior Clerks .. .. D. N. Irvine, d.p.a. (Lond.), H. P. Bradford ClerkMrs. M. M. Berry. Shorthand-typists Mrs. M. S. Wilton Miss A. E. Unite Mrs. D. Newman Rodent Operator .. .. E. J. Mead. Disinfectors and Mortuary P. F. Hall (Foreman) Attendants .. .. W. Hooper S. J. Twinn Drainage Inspection Assistant .. .. H. S. Fagg 3 Public Health Department, Town Hall, Hornsey, N.8. To His Worshipful the Mayor, Aldermen and Councillors of the Borough of Hornsey. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit my Annual Report on health conditions in the Borough for the year ended the 31st December, 1956. The population as estimated by the Registrar General was 97,220, showing a decrease of 380 compared with the previous year. Deaths from all causes totalled 1,115 showing a death rate per thousand of the population of 10.3. Deaths from cancer claimed 217 as compared with 203 in 1955. The number certified as due to lung cancer was 54 compared with 46 in the previous year. The total number of births was 1,459 resulting in a birth rate of 13.95. Infant deaths under one year numbered 34 giving an infantile death rate per thousand live births of 23.3 as compared with a rate of 23.8 for England and Wales. Details of the work of your public health department are set out in appropriate sections of the report. Control of infectious diseases was well maintained and no serious outbreak occurred during the year. Housing efforts were concentrated on repairs, the closing and/or demolition of individual unfit houses, and further progress in slum clearance in the Campsbourne area. Efforts in the clean food campaign were intensified under the consolidating Food and Drugs Act and Food Hygiene Regulations which came into force during the year. Good co-operation was had from food traders in the district following a well attended meeting to discuss with the health department the various provisions of the new legislation. Future prospects of lessening the health risks of atmospheric pollution are assured by the passing of the Clean Air Act; though its implementation in creating "smoke controlled areas" will require much public support and not inconsiderable expenditure of money in order to achieve really worth-while results. The new statutory change in designation of sanitary inspector to that of public health inspector is in keeping with the expansion in recent years of this officer's contribution to the solution of many environmental health problems beyond the limits of sanitary law. After a long and distinguished record of service to Hornsey, the department, at the end of the year, suffered the loss by retirement of Mr. J. H. Jesse, Chief Public Health Inspector, to whom the Council and his colleagues expressed their sincere good wishes. In Mr. J. D. Chance, who has also given long and loyal service in the health department, a worthy successor is assured. The publication of this Report coincides with the Jubilee Year of the school health service introduced by the Education (Administrative Provisions) Act, 1907. The occasion, I feel, should not pass without comment since though Hornsey, in common with other large non-county 5 boroughs in the outer London area, lost its autonomy in this and other personal health services under post-war legislation, it was in fact the Hornsey Education Committee, as the then Local Education Authority, that built up the school health service to its present standards of efficiency. Again I wish to refer to the increasingly close relationship which has developed in recent years between the three arms of the national health service—hospital, general medical practitioner and local government services. By a system of local liaison committees opportunities for mutual understanding and goodwill have been created and much has been done to strengthen the meaning of a truly comprehensive local health service. To Dr. Yarrow my deputy, Mr. Jesse and Mr. Chance chief public health inspectors and Mr. Davies chief clerk; and all other members of the staff of the health department I acknowledge my indebtedness for their loyal support throughout the year. In conclusion I wish to express my sincere appreciation for the combined support and encouragement shown me by the Chairmen and members of the various committees with which I and my department are concerned. I am, Your obedient servant, G. Hamilton Hogben, Medical Officer of Health. 31st July, 1957. 6 CONTENTS Page INFECTIOUS DISEASES Encephalitis 9 Poliomyelitis 9 Food Poisoning 9 Preventive Measures against Tuberculosis 10 Laboratory Services 11 Tables of infectious diseases notified 12 HOUSING AND SANITARY CIRCUMSTANCES Houses Let in Lodgings 17 Re-housing on Health Grounds 18 Closing and Demolition Orders 19 Certificates of Disrepair 20 Inspection of Shops 20 Cleansing of Soiled Articles 20 Inspection of Factories 21 Rodent Control 22 Atmospheric Pollution 23 Inspections by Public Health Inspectors 27 Abatement Notices 28 Work Carried Out by the Council in Default 28 Summary of sanitary improvements effected 29 Water Supply 30 Rivers Pollution 31 Licensing of Pet Shops 32 Flooding in Campsbourne Area 33 Barbers and Hairdressers 33 FOOD Food and Drugs Act 1955 and Food Hygiene Regulations 1955 37 Food Premises inspected 39 Food Premises classified 40 Registration of Hawkers of food 40 Milk Supply 41 Ice Cream 41 Bakehouses 41 Dried Egg Albumen 41 Beer Spillage 42 Legal Proceedings under the Food and Drugs Act 44 Food Sampling 45 GENERAL Perinatal Mortality 47 Welfare of Old People 48 Massage and Special Treatment 49 Medical examination of Staff 50 Diseases of animals 50 Storage of petroleum 50 Burial of the Dead 51 Public Mortuary 51 VITAL STATISTICS 53 APPENDIX—REPORT OF THE AREA MEDICAL OFFICER 59 7 INFECTIOUS DISEASES Hornsey suffered no epidemic of infection during 1956 which can be described as an uneventful year. Again no cases of diphtheria occurred and the general incidence of other infectious diseases was as expected. One case of paratyphoid fever was notified in October. The patient had returned from Jordan about 14 days before admission to hospital, having been ill in Jordan before returning to England. He was discharged from hospital after five weeks, no other case having occurred. ENCEPHALITIS During the past few years improvement in technical methods have aided in the differentiation of a number of clinically similar virus infections of the nervous system. One patient, a man of 33 years, was notified as poliomyelitis but later diagnosed as a case of acute encephalitis. The Ministry of Health is interested in investigating all cases of encephalitis with unusual symptoms, such as were shown by patients in an outbreak at a London Hospital last year. A Medical Officer from the Ministry visited the patient's house in company with my deputy. POLIOMYELITIS In 1956 eight cases of poliomyelitis were notified—five paralytic and three non-paralytic. One was notified in the first quarter of the year, four in the third quarter and three in the last quarter. Two of the paralytic cases have slight residual paralysis but one, a child under school age, has severe paralysis of the left arm and right leg. FOOD POISONING Thirteen cases of food poisoning were notified in 1956, three cases were admitted to hospital, and there were no deaths. All were single cases, 8 being caused by salmonella typhi-murium and 5 arising from unknown causes. Food infections are bowel infections and contaminated hands are the major cause in the spread of food posioning. A high standard of personal cleanliness, together with a rigid observance of the habit of washing the hands immediately after using the toilet, could do much to reduce the incidence of food poisoning. 9 PREVENTIVE MEASURES AGAINST TUBERCULOSIS The Mass X-ray Unit No. 5b from the North West Metropolitan Regional Hospital Board visited the Borough in October. For the first time in Hornsey the Unit was in a true sense mobile and contained its own office accommodation. It was, therefore, able to visit seventeen different sites in the Borough; eight of these were visited in one day in a street-to-street survey in the Finsbury Park Ward. Also for the first time there was no separation of the sexes and it was possible for people to attend in family groups. As appointments were not necessary there was really no excuse for people not attending. Waiting time at the Unit was cut to an absolute minimum by the excellent organisation of the Unit and results were received by first post the next day by people who attended before about 5 p.m. I am indebted to Dr. John R. Mikhail, Medical Director of the Unit for the following figures which I have extracted from his report:— The total number of people x-rayed in Hornsey was 4,096—3,540 at the public sessions and 556 in organised groups from factories and offices. Of the total number 1,934, had not been x-rayed previously and 2,845 i.e. 69.45% of those attending had not been x-rayed within the previous three years. Seven persons were found to be suffering from active pulmonary tuberculosis and in need of immediate treatment (2 men and 5 women) and 3 others were in need of occasional supervision (1 man and 2 women). The numbers attending at each point visited were as follows:— Public Sessions Coldfall Estate . 144 Muswell Hill . 837 High Street Hornsey . 1,263 Upper Tollington Park 591 Highgate, Archway Road . 344 Highgate Village . 188 Street-to-street stops at 8 points in Finsbury Park Ward .. . 173 3,540 Organised Groups Cross Lane . 261 Tottenham Lane . Ill Park Road . 184 556 Improvements in technique have resulted in only 1.2% of persons attending the Unit being recalled for further x-ray on a large film compared with just over 2% previously. The proportion of active cases of 10 pulmonary tuberculosis found has at the same time risen to 1.66 per thousand. This is to be expected as a large proportion of the people attending are x-rayed for the first time. Conditions needing medical advice, other than pulmonary tuberculosis are also discovered, and the persons concerned are therefore able to have treatment at an early stage of the illness thus greatly improving the prognosis—other conditions discovered include carcinoma of the lung, acute inflammatory condition, bronchiectasis, pneumoconiosis and certain cardiac conditions. A report on patch testing and B.C.G. vaccination of school children is given in the Appendix to this report. LABORATORY SERVICES The Public Health Department is the collection centre for specimens submitted for laboratory examination by general practitioners in Hornsey and containers are obtainable from the department during office hours— 9 a.m. to 5.15 p.m. weekdays and 9 a.m. to 12.30 p.m. Saturdays. Specimens received in the department are collected by a messenger from the laboratory at 3 p.m. on weekdays and 10 a.m. on Saturdays but they may be sent direct by doctors to the laboratory at Coppetts Wood Hospital any time before 5 p.m. on Mondays to Fridays and 12 noon on Saturdays. The Central Public Health Laboratory at Colindale maintains a twenty-four hour emergency service. The Public Health Laboratory service is under the direction of the Medical Research Council on behalf of the Ministry of Health and the assistance of the technical staff" is available to the department in connection with outbreaks of infectious diseases in the Borough. Copies of bacteriological reports on Hornsey patients are sent to the Medical Officer of Health and the following is a summary of reports made during 1956:— Faeces 522 Nose and Throat 10 Sputum 14 Per Nasal 4 Rectal swab 1 11 12 TUBERCULOSIS The total number of cases on the Tuberculosis Register at the end of 1956 was 955, viz., pulmonary 852, non-pulmonary 103. Pulmonary Non-Pulmonary Total Male Female Male Female Male Female (a) Number of Cases on Register at commencement of year 489 318 68 47 547 365 (6) Number of Cases notified for first time during year under Regulations 40 27 4 40 31 (c) Cases restored to Register 1 . • 1 (d) Cases added to Register otherwise than by notification under Regulations (1) Transferred from other Districts 59 26 3 1 62 27 (2) From Death Returns 4 1 . 4 1 (e) Number of Cases removed from Register 77 36 8 2 85 38 (/) Number of Cases remaining on Register at end of year 516 336 53 50 569 386 Cases removed from Register shown under (e) are accounted for as follows :— Found not to be T.B. Recovered Removed to another area Died at home Died at Sanatorium or other Institution TOTAL M F M F M F M F M F M F PULMONARY 1 1 12 7 47 24 4 2 13 2 77 36 . . 3 . 5 NON-PULMONRAY . . 2 8 2 13 CASES OF TUBERCULOSIS COMING TO THE KNOWLEDGE OF THE MEDICAL OFFICER OF HEALTH DURING THE YEAR under 1 year 1 year 2 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over TOTALS BY FORMAL NOTIFICATION Pulmonary M . . . 1 , , 5 4 13 9 5 2 1 40 67 F . . 1 . i 5 4 9 6 1 . 27 Non-Pulmonary M . . . . . . . . . . . . . . 4 F . . . . . . . 1 1 1 . 1 • 4 OTHER THAN BY FORMAL NOTIFICATION Death returns from Local Registrar Pulmonary M . . . . . . . . . . . . 1 1 2 F . . . . . . . . . . 1 . . 1 Inward transferable deaths Pulmonary M . , . . . . . 1 . . . 1 1 3 3 Transfers from other Districts Pulmonary M . . . . . 1 5 19 11 10 5 7 1 59 85 F • • 1 • • 3 4 13 3 2 26 Non-Pulmonary M . . . . . . 1 1 . . 1 . . 3 4 F • . . • • . . 1 . • . • • 1 14 NOTIFICATION OF INFECTIOUS DISEASE BY AGE AND SEX AGE IN YEARS Scarlet fever Whooping Cough Acute poliomyelitis Measles Dysentery Meningococcal infection Paralytic Non-paralytic M F M F M F M F M F M F M F Under 1 . . 5 5 . . . . 2 . 3 1 . . 1 2 . 1 4 1 . . . 7 6 . 2 . . 2 . 3 6 10 1 . . . 10 8 3 1 . . 3 6 5 5 8 . . . . 6 7 2 2 . . 4 6 2 7 2 . . . . 11 13 2 3 . . 5-9 30 26 26 24 . 1 1 41 29 9 17 . . 10-14 4 3 3 5 . . 1 . 2 . 3 5 . . 15-24 . . . 2 2 . 1 . . 3 2 2 . 1 25 and over 1 . . 3 . . . . . 1 3 9 . . TOTALS 49 39 53 63 4 1 3 . 79 67 27 42 . 1 88 116 5 3 146 69 1 AGE IN YEARS Acute pneumonia Acute encephalitis Infective Erysipelas Food poisoning Puerperal pyrexia Paratyphoid fevers M F M F M F. M F M F M F Under 5 3 1 . . 1 . 3 1 . . . . 5-14 1 . . . . . 2 1 . . . . 15-44 10 3 1 . . 1 1 4 . 8 1 . 45-64 12 5 . . 2 4 . 1 . . . . 65 and over 10 8 . . 2 2 . . . . . . TOTALS 36 17 1 . 5 7 6 7 . 8 1 . 53 1 12 13 8 1 There were no cases of diphtheria or ophthalmia neonatorum. 15 NOTIFICATION OF INFECTIOUS DISEASE BY WARDS Highgate Muswell Hill Crouch End Central Hornsey North Haringey South Haringey Stroud Green Finsbury Park Totals Scarlet fever 5 1 4 28 9 9 25 7 88 Whooping cough 33 19 2 11 28 13 9 1 116 Acute poliomyelitis Paralytic 2 1 . . . 1 . 1 5 Non -paralytic . . • . . 3 . • 3 Measles 15 19 7 28 12 10 23 32 146 Acute pneumonia 3 2 1 6 24 5 7 5 53 Dysentery 6 33 10 . 6 • 11 4 69 Erysipelas 1 1 2 . 2 1 4 1 12 Food poisoning 2 1 3 1 1 5 . . 13 Puerperal pyrexia 1 4 . 1 . 1 . 1 8 Meningococcal infection 1 . . . . . . . 1 Acute encephalitis Infective 1 . . . . . . . 1 Paratyphoid fevers 1 . . . . . . 1 TOTALS 70 81 29 75 82 48 79 52 516 HOUSING AND SANITARY CIRCUMSTANCES HOUSES LET IN LODGINGS In last year's report the change in the law regarding standards of fitness to be applied to houses let in lodgings or to more than one family was discussed. In March 1956 the Council adopted in principle standards to be applied to such houses under Sections 11 and 12 of the Housing Repairs and Rents Act 1954. The approved standards under Section 11, based on the items specified in paragraphs (d) to (h) of Section 9 of the Act, are as follows:— (d) Natural Lighting. Every habitable room shall be provided with a window or windows opening directly to the external air, and having, where practicable, an area equal to at least 1/10 of the floor area. Every common staircase shall be provided with adequate means of natural lighting wherever practicable. (e) Ventilation. Adequate means of ventilation shall be provided and maintained for every room, passage and staircase, water-closet and bathroom. The windows of habitable rooms must be capable of being opened at the top to at least 1/30 of the floor area. (f) Water Supply. A sufficient supply of water for domestic purposes shall be provided on the storey, or one of the storeys in which the rooms or lodgings in the separate occupation of each family occupying the house are situated. (g) Sanitary Conveniences. The number of water-closets shall be as follows:— (a) One water-closet for every four habitable rooms. (ft) One water-closet for every eight persons (irrespective of age) but this standard shall be deemed to be insufficient if it fails to conform to both these conditions and if, though conforming, it is not readily accessible to the persons for whom it is intended. In the case of conversions to single room lettings, one water-closet shall be provided not more than one floor distant for every four lettings, and for existing single room lettings there shall be, if practicable, one water-closet for every four lettings. (h) Facilities for the storage, preparation and cooking of food and disposal of waste water. Facilities for the storage, preparation and cooking of food and disposal of waste water shall be separately provided for every part of the house which is occupied as a separate 17 dwelling, and such facilities shall include a food store, sink and waste pipe, water supply and utility services. Such facilities shall not be installed on a common landing, and regard shall be had to the number of rooms occupied when determining the size of the food store. Under Section 12 of the Act the local authority may specify the number of persons who may occupy the rooms in this type of house. The approved standard under Section 12 is one person per 50 square feet of bedroom floor area, provided that no account shall be taken of any floor area over which the ceiling height is less than 5 feet. Section 12 also provides that no person shall permit the house to be occupied by such a number of persons that it is not possible to provide for the proper separation of the sexes. RE-HOUSING ON HEALTH GROUNDS This subject was dealt with at some length in my report for 1955. During 1956 a detailed review was carried out of all cases in which a health factor was involved—213 in all. In the course of the review it became evident that the more urgent cases could be divided into the following four groups:— Group 1—Serious medical conditions. (a) Acute pulmonary tuberculosis. (b) Other medical conditions. Group 2—Chronic medical or surgical conditions which have crippled the patient. Group 3—Old persons needing ground floor accommodation because of infirmity possibly with illness. Group 4—Serious overcrowding causing undesirable mixing of sexes with its accompanying moral danger. Thirty cases were then selected to illustrate these groups and a report made to the Housing Management Sub-Committee to draw attention to the need for some improvement in the degree of priority given to such cases. The points scheme was revised in certain respects, giving the Medical Officer of Health power to recommend the award of up to fifteen health points according to the urgency of the case. This was a welcome change since the rigidity of the former scheme (which provided for one award of ten points only) sometimes proved to be embarrassing in its application. Other changes resulted in a slight reduction in the number of points in the majority of cases but this was more than offset by the increased maximum of fifteen health points. As the Housing Management Sub-Committee is still able to award up to fifteen "discretionary" points the Committee is better able to deal with cases of serious medical need. 18 The need for specially designed housing for old people was made evident by discussions on the cases included in group 3 above. It was decided that the Council's housing policy should have due regard to the needs of physically handicapped persons, particularly in connection with redevelopment proposals and the improvement of pre-war Council property. The following facts relate to new cases dealt with in 1956: Applications recommended for the award of medical points 31 Applications in which the award of medical points was not recommended 19 Applications in which no action was required 20 Total number of cases dealt with 70 Number of cases with medical points which were rehoused 12 Four families were rehoused as a matter of urgency, three as a result of this review. CLOSING AND DEMOLITION ORDERS Closing Orders Property Part affected Order made Action taken 1 Albert Road Whole house Sept. 17 th One family rehoused and two families still in occupation at end of year. 5 Eastfield Road One basement room Oct. 17 th Unoccupied room closed. 7 Eastfield Road One basement room ,, 99 99 99 9 Eastfield Road One basement room and scullery ,, Tenants still in occupation at end of year. 11 Eastfield Road One basement room and scullery ,, Room closed. 4 Pembroke Road One basement room ,, Unoccupied room closed. 6 Pembroke Road One basement room 99 8 Pembroke Road One basement room 99 99 99 27 Campsbourne Road Two semi-basement rooms and scullery 99 Tenants found other accommodation and rooms closed. 29 Campsbourne Road Two basement rooms ,, Unoccupied rooms closed. 27 Myddelton Road One basement room ,, Unoccupied room closed. 29 Myddelton Road One basement room ,, 99 32 Myddelton Road One basement room and scullery ,, Rooms closed. 34 Myddelton Road One basement room and scullery ,, Tenants still in occupation at end of year. 36 Myddelton Road One basement room and scullery ,, Rooms closed. 42 Mount View Road Lower ground floor back living room and scullery Nov. 12 th Rooms closed. 12 Ennis Road Whole house Dec. 12th Two families still in occupation at end of year. 19 Closing Order determined A Closing Order made on five underground rooms at 2 Bishopswood Road on the 20th October, 1953, was determined on the 14th June, 1956, the work required having been carried out. Demolition Orders A Demolition Order made on 15 Haringey Road on the 14th April, 1955, was revoked on the 17th October, 1956, the work required to render the premises fit for human habitation having been carried out. CERTIFICATES OF DISREPAIR The figures to the end of 1956 were as follows:— Certificates of Disrepair Revocation of Certificates Granted Refused Granted Refused 1954 (from 30th Aug.) 77 24 8 2 1955 55 14 67 3 1956 10 7 17 7 The decline in the number of applications for certificates of disrepair continued to a more marked degree in 1956, only a quarter of the total for 1955 being received. The above figures also show that more applications were received in the first four months of the working of the Act than in the whole of 1955 and 1956 together. INSPECTION OF SHOPS 1,991 visits were paid to shops and, apart from a number of minor infringements, which were dealt with, the provisions of the Shops Act have been well observed. Only four written notices were served during the year as, generally speaking, the proprietors of shops remedied defects as the result of informal notices. The following work was carried out:— Lighting provided 11 Ventilation provided 9 Clothing accommodation provided 11 Sanitary accommodation provided 7 Rooms cleansed and repaired 175 Washing facilities provided 26 CLEANSING OF SOILED ARTICLES During the year 568 articles for cleansing under the terms of Section 84 of the Public Health Act were collected from premises in the Borough; 40 people received assistance and 4 were still receiving the service at the end of the year. The number of cases assisted at any one time has never been more than 12, but the service undoubtedly fills a very great need and is much appreciated not only by the persons themselves but by home nurses, home helps, and others giving them care and attention. 20 FACTORIES ACT, 1937 The following tables show the work carried out by the Public Health Inspectors under this Act:— 1. Inspections ot Factories Premises Total No. of Factories No. Inspected Inspections Made Factories with Mechanical Power 196 140 187 Factories without Mechanical Power 39 35 39 TOTALS 235 175 226 2. Detects Found Particulars No. of defects Referred to H.M. Inspector Found Remedied Want of cleanliness 1 1 . Overcrowding . . . Unreasonable temperature . . . Inadequate ventilation . . . Ineffective drainage of floors Sanitary conveniences— . . . (a) insufficient 1 . . (6) unsuitable or defective 5 3 . (c) not separate for sexes . . . Other offences 2 1 1 TOTALS 9 5 1 There are 290 Outworkers on the register engaged in the following occupations:— Making, altering, etc., of wearing apparel 190 Making or repairing of umbrellas, sunshades, etc. 11 Making of artificial flowers 13 The making of boxes or other receptacles or parts thereof made wholly or partially of paper 22 Making of brushes 8 Feather sorting 1 Carding, boxing, or packeting of buttons, hooks, etc. 1 Making stuffed toys 2 Making or filling of Christmas crackers, Christmas Stockings, etc. 15 The weaving of textile fabric 4 Manufacture of lampshades other than lampshades made wholly of metal or glass or stone 23 210 visits were paid to outworkers' premises during the year. 21 22 RODENT INFESTATION: SEWER MAINTENANCE TREATMENT 1956 Total number of foul manholes — 1,810 Dates of Treatment 1st February—14th March 5th July—29th September Sewer treated Soil Surface water Soil Surface water Bait and poison used Soaked bread and arsenic Sausage rusk and zinc phosphide Sausage rusk and zinc phosphide Sausage rusk and zinc phosphide No. of manholes baited ... 1,152 79 1,112 38 No. of manholes showing complete prebait take 409 7 300 2 No. of manholes showing partial prebait take 83 8 120 3 RODENT CONTROL During the year no notification of the presence of rats or mice in substantial numbers has been received. However, as the result of complaints received, properties were inspected and treatment for the eradication of rats or mice carried out by the rodent operator in 200 properties In many instances, as can be expected, the rat infestations were associated with defects in the drainage system. Following is a summary of the work carried out during 1956:— Properties inspected as a result of notification 376 Other properties investigated 147 Properties found to be infested:— Rats (a) Major infestations 1 (b) Minor infestations 213 Mice (a) Major infestations 2 (b) Minor infestations 104 No. of infested properties treated by Rodent Operator 200 Total No. of treatments 208 No. of written notices served 1 ATMOSPHERIC POLLUTION Apparatus for the measurement of smoke and sulphur dioxide was installed at two sites during 1956, one site being at the Disinfecting Station, High Street, Hornsey, and the other at the Council's Depot in Fortis Green. A third was installed at the Town Hall in January, 1957. The apparatus is designed to measure the concentration of smoke and sulphur dioxide in the atmosphere. A measured quantity of air is drawn through a clean white filter paper and smoke particles are trapped on it. The grey stain thus produced is measured by means of a reflectometer and the reading obtained is used to estimate the weight of smoke per 100 cubic metres of the atmosphere. After passing through the filter paper the air is bubbled through a solution of hydrogen peroxide which dissolves the sulphur dioxide in the air forming sulphuric acid. The sulphuric acid formed can then be measured and the amount of sulphur dioxide calculated. Table (B) gives the figures from August to December, 1956. In addition to the measurement of smoke and sulphur dioxide, sampling of deposits of solid matter from the atmosphere was continued, and the readings given on the three gauges in Hornsey are shown in table (A). The gauge sited at the factory in Frobisher Road was moved to the Council's Depot in Highgate in January, 1956. 23 24 25 (A) ATMOSPHERIC POLLUTION—Summary of Reports for the Year on Solid Deposits (a) Roof of Town Hall. (6) Church of Christ— Wightman Road, (c) Highgate Depot, North Hill. 1956 Deposit in Tons per Square Mile Rainfall in inches Total water-insoluble matter Ash Total water-soluble matter Total solids (a) (b) (c) (a) (b) (c) (a) (b) (c) (a) (b) (c) (a) (b) (c) January 3.54 3.64 3.65 9.73 23.37 6.00 6.40 17.68 3.74 7.66 9.59 7.22 17.39 32.96 13.22 February 0.20 0.17 0.14 6.69 13.97 3.48 4.60 11.29 2.42 2.94 3.47 2.52 9.63 17.44 6.00 March 0.77 0.82 0.92 16.52 12.35 9.00 12.42 8.36 6.03 5.81 6.58 5.12 22.33 18.93 14.12 April 1.22 1.17 1.19 8.62 20.91 6.69 5.68 15.77 4.46 4.78 5.94 4.54 13.40 26.85 11.23 May 0.485 0.52 0.49 8.00 20.22 6.68 5.46 14.27 4.16 2.16 3.47 2.87 10.16 23.69 9.55 June 2.57 2.62 2.56 5.19 18.27 11.62 3.08 5.48 8.92 4.91 7.07 4.90 10.09 25.34 16.52 July 4.36 4.14 5.36 5.76 21.11 3.35 3.63 16.11 1.84 11.14 11.21 7.64 16.90 32.32 10.99 August 5.46 5.83 5.40 3.30 13.87 2.85 2.34 10.38 2.25 7.59 14.36 7.52 10.89 28.23 10.37 September 2.08 2.12 2.08 3.27 11.78 3.11 2.65 7.08 2.15 5.60 7.86 6.22 8.87 19.64 9.33 October 2.47 2.27 2.40 5.06 9.82 4.13 3.23 5.96 2.89 3.66 5.72 4.76 8.72 15.54 8.89 November. 0.33 0.31 0.34 4.41 10.35 5.12 3.27 6.17 2.95 3.96 4.94 4.23 8.37 15.29 9.35 December 2.34 2.67 2.63 5.56 13.78 5.47 3.89 8.55 3.87 8.08 11.45 7.49 13.64 25.23 12.96 26 (B) ATMOSPHERIC POLLUTION—MEASUREMENT OF SMOKE AND SULPHUR DIOXIDE (a) Fortis Green Depot (b) Disinfecting Station *1956 SMOKE (milligrams per 100 cubic metres) SULPHUR DIOXIDE (parts per 100 million parts of air) Monthly average Highest daily average Lowest daily average Monthly average Highest daily average Lowest daily average (a) (b) (a) (b) (a) (b) (a) (b) (a) (b) (a) (b) August 5 6 10 12 2 3 1.8 2.6 3.7 4.7 0.4 1.2 September 6 9 14 17 2 4 2.7 4.2 5.9 8.7 0.9 1.4 October 14 18 37 43 4 7 5.2 6.3 14.1 14.6 1.4 2.0 November 19 22 41 42 6 8 5.8 7.4 13.9 14.4 1.1 1.1 December 20 25 42 55 8 11 6.3 8.7 19.7 22.9 1.5 2.6 * These measurements were first recorded on the 1st August, 1956. INSPECTIONS BY PUBLIC HEALTH INSPECTORS 1st Inspection Re-Inspections Food Food Premises (See table on page 39) 567 1,004 Hawkers 11 1 Milk Sampling 36 - Ice Cream Sampling 6 - Infectious Diseases Notifiable Infectious Diseases 203 33 Food Poisoning 13 - Public Health Inspections Nuisances 1,655 3,975 Drainage 229 453 Drain tests 132 - Rodent Control 197 60 Overcrowding 4 2 Factories 175 51 Outworkers 209 I Renewal of Music and Dancing Licences 17 1 Rivers Pollution 1,231 1,049 Smoke observations 119 6 Verminous conditions 18 4 Pests 57 10 Rag Flock premises 1 - Certificates of Disrepair 20 18 Revocation of Certificates of Disrepair 18 1 Cinemas 4 - Sanitary accommodation in schools 44 9 Campsbourne Flooding 130 - Housing Act Inspections Preliminary Surveys of Clearance Areas 434 - Clearance Areas 113 3 House to House 65 - Individual unfit houses 8 3 Permitted numbers 38 - Shops Inspections 1,097 894 Others Pet Animal Shops 7 1 Petroleum Stores 105 9 Fireguards 5 - Visits to old people 20 13 27 ABATEMENT NOTICES The Notices served during the year were as follows :— Verbal Preliminary Statutory Public Health and Housing Acts 162 555 63 Shops Act 2 4 • Food and Drugs Act 130 45 . Factories Act 2 7 . Prevention of Damage by Pests Act, 1949 2 1 . Middlesex County Council Act, 1950 • 1 . Heating Appliances (Fireguards) Act, 1952 • 2 . 298 615 63 WORK CARRIED OUT BY THE COUNCIL IN DEFAULT UNDER THE PUBLIC HEALTH ACT, 1936, Sec. 39 Premises Cost of Works carried out Nature of work done Date completed 1956 19, Mount Pleasant Villas, N.4 £91 17s. 6d. Reconstruction of drains 15th June 32, Campsbourne Road, N.8 £6 4s. 5d. Renewal of water-closet 12th July 28 SUMMARY OF SANITARY IMPROVEMENTS EFFECTED Drainage Number of houses and premises redrained 40 Repairs or amendments to existing drains 440 Drains or gullies unstopped or cleansed 195 Manholes provided or repaired 87 Intercepting traps fixed 52 Soil and ventilation pipes repaired or renewed 26 Water- Closet and Sanitary Fittings Water-closet buildings provided or repaired 1 Water-closet pans provided or renewed 57 Water-closets unstopped, cleansed or repaired 15 Flushing cisterns provided or repaired 19 New sinks provided 6 New lavatory basins provided 4 Waste pipes trapped, repaired or unstopped 88 Baths provided or made usable 3 General Roofs repaired 204 Rain-water gutters, renewed or repaired 88 Rain-water pipes provided or repaired 30 Dampness remedied 103 Damp-proof courses provided 4 Yard paving provided or repaired 10 Rooms cleansed 139 Floors repaired 50 Sub-floor vent provided 3 Windows, doors, skylights, sashcords and fittings repaired 213 Window-sills repaired 23 Water cisterns repaired, cleansed or covered 12 Water supply pipes repaired 39 Stoves, Ranges, Coppers renewed or repaired 45 Flues and Chimneys repaired 14 Accumulation of Refuse removed 11 Dustbins provided 12 Miscellaneous items 87 29 WATER SUPPLY I am indebted to Dr. E. Windle Taylor, Director of Water Examination of the Metropolitan Water Board, for the following information. The supply for Hornsey area has been satisfactory both in quantity and quality during the year 1956. The supply came from two main sources:— (a) River Thames-derived water stored in Littleton and Walton reservoirs and treated at the Board's filtration works at Kempton Park and Hampton. (b) Water from the New River derived from the River Lea and from wells and treated at the Board's filtration works at Stoke Newington. Samples are collected on five days of every week, or more often if required, at each stage of the purification process as well as samples from the distribution system, and tests include physical, chemical and micro-biological examination. All new and repaired mains are chlorinated before being restored to use and samples of water from them are tested to ensure that its quality is up to that normally supplied. The water supplied to this area is not plumbo-solvent. The water supply is in all cases direct to dwelling houses; none is supplied by means of a stand pipe. Chemical Examination 1,598 samples of filtered water derived from the River Thames and 213 from the New River were taken for chemical examination. All were found to be satisfactory. The natural fluoride content in water supplied to Hornsey is 0.15 parts per million. Bacteriological Results Filtration Works No. of Samples No. of microbes per ml. Colonies counted on agar after 20-24 hrs., at 37°C. Bad. coli test Percentage of samples negative to Bact. coli in 100 ml. Bact. coli per 100 ml. River Thames— derived filtered water 3,736 5.0 99.9 0.002 New River— derived filtered water 260 15.2 100.0 Nil 30 The following further information has been extracted from Dr. Windle Taylor's report on the examination of the London waters. All the water supply of the Borough is river-derived and subjected to filtration and chlorination. The Board's slow sand filters contain a bed of sand some 2 feet thick lying upon a foot or so of graded gravel which in turn is supported by a system of underdrains, and when the filter is working the whole bed is submerged under about 4 feet of water. After filtration, the water is chlorinated by an automatic process controlled by specially designed instruments which record the amount of residual chlorine in the water after treatment and automatically adjust the rate of chlorination. As filtered river-derived water varies appreciably in character, automatic adjustment of the rate of chlorination ensures that there is always sufficient chlorine to disinfect the water. RIVERS POLLUTION Pollution of the surface water drainage system was reported at three points in the Borough during the year, and extensive investigations of house connections were carried out by the district public health inspectors and the drainage inspection assistant. Details of these areas of pollution are as follows: Strawberry Vale Brook Part of the surface water drainage from the extreme north-west area of Muswell Hill ward discharges into this brook at a point on the extreme tip of the northern boundary. This water collection area has been thoroughly investigated and sources of pollution eliminated. Mutton Brook Part of the surface water drainage of the southern part of Muswell Hill ward and part of Highgate ward discharges by means of two main surface water sewers to this brook and eventually to the River Brent. This investigation is still continuing. Stonebridge Brook The surface water drainage from the North Haringey ward discharges to a surface water sewer in Green Lanes and eventually to the Stonebridge Brook in Tottenham. This investigation is still continuing. In addition to the above areas, inspection of the Moselle catchment area was continued by the drainage inspection assistant. The following figures relate to the whole of the work done in connection with rivers pollution during the year: 31 Inspections by drainage inspection assistant 3,741 Re-inspections 2,708 Inspections by district public health inspectors 1,231 Re-inspections 1,049 Number of premises in which defects were found 537 Number of premises in which defects were remedied after service of written or verbal notices 440 Summary of defects found: Intercepting chamber obstructed 4 Intercepting chamber defective 10 Interceptor obstructed 152 Interceptor cap missing or displaced 162 Surface water cap missing or displaced 105 Drain obstructed 10 Wrong connections (soil drain to surface drain) 80 Total No. of defects 523 LICENSING OF PET SHOPS The Pet Animals Act 1951 has undoubtedly led to an improvement in the conditions under which pet animals are kept while awaiting sale. Until the Act was passed, there was no check on these conditions, and only in cases of gross cruelty or neglect could legal proceedings be taken. Now that premises have to be licensed and are subject to inspection the general standard is good. During the year 12 inspections were carried out, 4 by the veterinary inspector and 8 by the Public Health Inspectors. Seven existing licences were renewed at the beginning of the year. Two of these shops later closed down and the remaining five sold pets as follows:— Mammals and birds 1 Tropical fish 1 Birds 1 Birds and fish 1 Birds and small mammals 1 32 FLOODING IN CAMPSBOURNE AREA Two heavy storms occurred in 1956, one on the 9th July and the other on the 6th August. Both caused flooding in parts of the Borough, and this was severe in the Campsbourne Area where 56 basements were flooded on each occasion. Forty-one of these basements were in houses included in Stage III of the Campsbourne Clearance Area, on which a Compulsory Purchase Order had been confirmed and from which families were being rehoused; 15 of the basements were in premises not within this Stage. Re-housing of the families concerned was treated as urgent and by the end of the year only 11 basements were still occupied. When the level of the water in the sewers had fallen sufficiently pumping out of the basements was commenced by the Borough Engineer's Staff. Disinfectants and soap were issued to all families affected and the Disinfecting Station and the Baths and Wash-houses were opened to provide hot water and drying facilities. Members of the W.V.S. provided valuable assistance to supplement the work being done by the Council's staff. Of the 15 flooded basements outside Stage III one had previously been closed by the Council. A report on the others was submitted to the Health Committee and closing orders were made. Only three families required rehousing as a result of this as in all other cases where the basements were used alternative accommodation was available. It was necessary in some cases to qualify the closing orders in order to provide access to the water supply or water closet when these were situated in the basement and there were no alternative facilities in the house. Details of these closins orders will be found in the table on page 19. The following table summarises the figures given above:— 9th July 6th August Basements flooded 56 56 Flooded basements0 occupied 33 31 Basements which were the sole accommodation of the family in occupation 4 3 Basements occupied, end of 1956 11 BARBERS AND HAIRDRESSERS The type of public health risk associated with a lack of hygiene in hairdressing establishments generally relates to transmission of infections of the skin and scalp. It has been generally accepted that such instruments as shaving brushes, razors, combs, hairbrushes, etc. should be disinfected as a routine. The employment of the same instrument, towel, or brush upon successive clients does indeed introduce a risk which is not lessened by chance abrasions or injuries to the skin caused by inattention, lack of skill or faulty implements. 33 Barbers' and hairdressers' premises are subject to the provisions of the Shops Act, 1950 which ensures that there shall be a sufficient number of sanitary conveniences for the staff employed and the premises shall be properly heated and ventilated. The Act also regulates early closing days, assistants' half-holidays and arrangements for the health and comfort of the shop assistants. To obtain up-to-date information on the hygienic condition of hairdressers' and barbers' premises in the Borough and methods of sterilising equipment, a special survey was carried out. From this survey the following information was obtained. Total number of hairdressers' and barbers' shops in the Borough 62 Number catering for men only 18 Number catering for women only 33 Number catering for both sexes 11 Total number of staff employed— Males 32 Females 74 Young persons 8 114 Number of premises found to comply in all respects with the Shops Act and Model Byelaws in regard to cleanliness of staff, premises and equipment 44 Number of premises failing to comply with the Model Byelaws in the following respects:— (a) General cleanliness of premises, painting and decoration, etc. 8 (b) General cleanliness of floors and receptacles for litter 7 (c) Sanitary conveniences: defective, unsuitable or insufficient 2 (d) Washing facilities: inadequate or defective 2 (e) Lighting and ventilation: inadequate or defective 4 (f) Water supplies: inadequate hot and cold supplies 1 (g) Instruments: hairbrushes, combs, shaving brushes, clippers, etc., inadequate cleansing 4 (h) Disinfection of brushes, scissors, etc. unsatisfactory 3 Arrangements for cleansing, disinfection and sterilisation of overalls, brushes, instruments and other equipment varied considerably. 34 Overalls and towels—overalls were usually shaken after being used and re-used again. In 26 instances these were sent to the laundry once or twice a week. In 36 instances they were washed on the premises. Supply of towels appeared adequate. In 46 cases cotton wool was used which was destroyed and fresh used for each customer. In 8 cases paper tissues were used in place of cotton wool. Hairbrushes, combs, etc.—some form of disinfection or washing of hairbrushes, combs, clippers, scissors, etc. was carried out at all the premises but usually only once a day. Disinfectants and antiseptics—in 44 cases it was the general practice to use some form of disinfectant or antiseptic solution in which equipment was either kept or dipped after use, or washed. The conclusions drawn from this report indicated that the standards of hairdresser's premises in the Borough were, on the whole, good but the varying methods of disinfecting and sterilising equipment left much to be desired. For this reason the Model Byelaws of the Ministry of Housing and Local Government were adopted by the Council and the Bye-Laws came into force on the 1st December, 1956. 35 FOOD THE FOOD AND DRUGS ACT 1955 AND THE FOOD HYGIENE REGULATIONS 1955 The Food and Drugs Act, 1955, which consolidates, with certain amendments, the provisions of the Food and Drugs Acts, 1938 to 1954, and of the Slaughterhouses Act, 1954, came into operation on the 1st January 1956. The Food Hygiene Regulations, 1955, also came into force on that date, except for those Regulations involving alterations to premises or equipment or substantial changes in existing practices; these came into operation on the 1st July 1956. The Regulations take the place of the provisions in the earlier Acts as to rooms where food intended for sale is prepared or stored, and introduce a number of new provisions as to the hygienic handling of food and the construction and maintenance of premises, stalls, vehicles, etc. where food is handled. The main provisions of the Regulations are concerned with the cleanliness of food premises, equipment, wrapping materials and food handlers. Requirements are also laid down as to drainage and sanitary conveniences, adequate lighting and ventilation, and the storage temperatures of certain foods. The Regulations are unique in that they are not merely punitive, and are not mainly concerned with the service of statutory notices requiring the correction of specific faults in the structure or decoration of food premises. They prescribe the conditions which should be satisfied to render premises fit for use as food shops or factories and in addition give in some detail the practices which must be adopted by all food handlers in the interest of food hygiene. Smoking in any room of a food business where open food is stored or displayed or handled is now a punishable offence, proof of food contamination being unnecessary. Food handlers are required to keep themselves clean and to prevent any avoidable contamination of the food. Furthermore these and other requirements to secure the cleanliness of the public food supply are the concern of the food handler as an individual whether he be employer or employee and it is provided that against him personally will action be taken for infringement. Hospital kitchens, private industrial canteens, clubs and boarding houses are now subject to inspection. Many food premises in the Borough were fully equipped and satisfactory before the legal requirements became operative, and there is evidence of a continuing improvement in the practices and conditions in many food premises to a standard well above that now required by the Regulations. Some matters still require attention, however, and among these must be mentioned the need for improving the conditions under which food 37 is transported. Meat which is not otherwise fully protected should be wrapped, at least, in muslin cloths, and should be carried in vehicles equipped with proper hanging rails or metal shelves. The provision of cleansable sides and floor to a meat carrying vehicle is of little significance if the meat is deposited on the floor which has been walked on by the meat porters. It is to be expected that the owners and workers in retail food premises in being made aware of their responsibilities to ensure the protection of food from contamination must sometimes have grave misgivings about the methods still prevalent in wholesale distribution, and must consider that their efforts as retailers are largely defeated by inadequate precautions at other stages. At the retail shop level there has been a growth of a practice which is hygienically undesirable and which may in some cases be an infringement of the Regulations. For want of a better description this may be referred to as the "mixed shop". There are shops within this Borough whose principle business is the sale of hardware, household goods, soaps, paraffin oil and paints. Some of these shops are now including in their stocks such foods as packeted tea, cereals and flour, all commodities which readily absorb odour, a form of contamination specifically mentioned in the Regulations. No less a risk of contamination by odour arises at those shops selling principally groceries and provisions and cooked meats which have extended their range of goods to include soaps, disinfectants, and scented sanitary cleansing powders. Meeting of Food Traders A meeting of Hornsey food traders was held in May 1956 to discuss the implications of the new Regulations with the officers of the Department. This meeting was attended by 168 traders, and the Chairman of the Health Committee in welcoming them invited them to ventilate problems arising from the Regulations with the staff of the Department at any time, as the Council wished to assist in maintaining Hornsey's high standard. Questions were asked on many aspects of the subject which were engaging the attention of the traders, and as full an answer as possible was given to each question. The meeting was undoubtedly of value to those traders who were able to attend. Judging by questions asked, the subjects which were engaging the attention of the traders were: 1. dogs in food premises; 2. supply of wash-hand basins and the need for fitted basins with piped water; 3. washing facilities for stalls and mobile traders such as ice cream vendors; 4. storage and display of foods for sale; 5. hygienic transport of food; 6. "open-food" and the meaning of the expression; 7. the need for the customers to adjust their standards. 38 Washing Facilities—Exemption During inspection of a small lock-up shop which sells tobacco, cigarettes and wrapped confectionery it was seen that there were no washing facilities in the shop, but it was found that the provision of suitable facilities would be difficult and expensive. As no open food was sold and reasonable arrangements for handwashing were made with the occupier of the adjoining premises a certificate was issued under Section 31 to the occupier exempting her from the provisions of Regulations 15 and 16 for so long as no open food is handled. Regulation 31 provides for exemption of premises from certain requirements if the Council is satisfied that by reason of restricted accommodation or other special circumstances affecting the premises it is reasonable that such exemption should be in force. Exemption is granted only in exceptional circumstances to meet special cases. Inspections of Food Premises were made during the year as follows: Bakehouses and Bakers' Shops 188 Grocers' Shops 287 Butchers' Shops 228 Ice Cream Premises 77 Cooked Meat Shops 55 Milkshops 42 Confectioners 113 Public Houses 80 Fish Shops 92 Restaurants, Cafes, etc. 294 Greengrocers' Shops 115 TOTAL INSPECTIONS MADE, 1,571 The following is a list of unsound food surrendered during 1956. Wherever possible this was salvaged for use as animal feeding or industrial purposes. Cwta. lbs. Cwts. lbs. Canned Vegetables . 22 Cheese • 30 Canned Fruit and Fruit Juices 1 40 Meat and Bacon 10 40 Canned Meat 7 9 Fish 1 77 Canned Fish 7 Frozen Whole Egg . 44 Canned Soup 65 Cereals 1 74 Canned Jam & Marmalade 5 Biscuits . 48 Potatoes 5 39 FOOD PREMISES CLASSIFIED ACCORDING TO THEIR PRINCIPAL TRADES No. of Premises Registered under Section 16 of the Food and Drugs Act 1955 (a) For Sale or manufacture of Ice Cream (6) Prepared foods Bakers and flour confectioners 25 4 1 Butchers 51 1 32 Confectionery (sugar) 122 96 1 Fish (wet and dried) 12 3 3 Fish (fried) 9 . 1 Fruit and vegetables 72 10 . Grocery and provisions 138 35 17 Milk 3 1 . Canteens 3 . . Preserved foods 2 1 . Public houses and off licences 74 5 . Restaurants and cafes 67 . . Ice cream 2 2 . Herbalist and health foods 1 . . Confectionery warehouse 1 . . Grocery warehouse 1 . . Preserved food factory 1 . 1 Stalls : . . Fruit and vegetables 3 . . Jellied eels 1 . . Refreshments 1 . . Shellfish 1 . . REGISTRATION OF HAWKERS OF FOOD AND THEIR STORAGE PREMISES During the year one new registration was effected under Section 11 of the Middlesex County Council Act, 1950, and at the end of the year there was in the Borough 1 registered storage premises used by a hawker from another Borough and 29 registered hawkers who are at present selling the following foods:— Confectionery 2 Groceries 1 Eggs 1 Ice Cream 1 Fish 1 Winkles and shrimps 1 Fruit and vegetables 22 40 MILK SUPPLY Four new registrations were effected under Part III of the Milk and Dairies Regulations, 1949. Licences for the sale of special designated milk under the Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949, were granted as follows. New Dealers' Licences Supplementary Renewals Dealers' Supplementary Pasteurised 1 29 10 Tuberculin Tested 1 Nil 24 10 Sterilised 4 45 11 Thirty-six samples of milk were taken in course of delivery or from shops and submitted for bacteriological examination. All proved to be satisfactory. ICE CREAM There is only one manufacturer of ice cream in this borough and most traders sell only pre-packed ice cream. Six samples of ice cream were taken for bacteriological examination with the following results:— Grade 1 Grade 2 Grade 3 Grade 4 2 4 - - BAKEHOUSES There are 14 bakehouses in the Borough, three of them being underground and in respect of which certificates of suitability are in force. Those underground are subject to special inspection every five years under Section 54 of the Factories Act, 1937. All bakehouses are frequently inspected to ensure that hygienic conditions are maintained. DRIED EGG ALBUMEN Some mention should be made of the continuing risk of salmonella food poisoning by infected egg albumen. Evidence of the continued presence of this infection has been collected by the Public Health Laboratory Service from consignments of albumen arriving in this country from abroad. A suitable and practicable method of disinfection has now been evolved which will eventually ensure the complete removal of the risk. In the meantime precautions are being successfully adopted by the food manufacturers within the Borough who must use this type of commodity. 41 Supplementary Arising from questions asked at a meeting of the Health Committee, investigations were made into the question of beer spillage and the following is a report based on a survey of eight public houses in the Borough. The practice of re-using "spillage" arising from overfill of beer glasses or from "first drawing" on new barrels has been followed in nearly all public houses since the introduction of the beer pump. With clean and frequently sterilised pipes, spillage trays and filters there is little objection to this practice on hygienic grounds, but the recharging of used glasses with the consequent "washing" of the glass into the spillage is a practice which cannot be regarded as satisfactory. The following factors are said to influence the methods and practices normally followed in this trade:— 1. Excise duty is paid by the brewers on the volume of beer manufactured from a known quantity of malted grain, and stocks and costings in retail premises are based on the quantity of beer delivered thereto. Duty is not refunded on overspill beer caused when filling customers' glasses, although an arrangement of this kind would be beneficial from a hygienic point of view as it would prevent this beer being returned to the cask for sale. 2. Where beers are returnable to the brewers for re-processing, an allowance of about 10s. for nine gallons is made. This represents less than the initial cost of the liquid to the licensee. 3. All licensees endeavour—for economic reasons and because the filtering of beer is a duty which they wish to keep to a minimum—to keep spillage as low as possible and they claim that an experienced and skilled barman will keep it as low as 2% or even less. However, it has been necessary in this trade, as in many others, to employ persons of lesser skill and sometimes the amount of spillage may rise as high as 20%. 4. The estimated amount of spillage beer passing back into the "fresh" beer is generally between 5% and 10%. 5. Some brewers are stated to recommend the tipping of bottle bottoms into mild beer spillage for filtering and passage back into this type of beer on the grounds that this improves the head on the beer, but most licensees do not follow this practice. 6. Tests have proved that beer, when it reaches the consumer, usually has an extremely low bacterial count and pathogenic organisms are generally absent. Beer being slightly acid (it usually has a pH value of approximately 6) is not a suitable medium for the growth of the types of bacteria which are associated with food poisoning. 42 7. Some time ago many licensees followed the brewers' recommendation of using only clean glasses and refused to refill used beer glasses. This experiment failed partly because of the objections of many customers and also because of delays in busy periods while soiled glasses were being washed and dried. 8. The use of filters, sieves, etc. is general to the trade, but none of these are designed to deal with any bacterial or salivary contamination of the beer. They are purely methods for the removal of fines; i.e. yeasts, vegetable matter and grit which may be found in a beer barrel. Public House Beer Salvaged Treatment Re-used in Soiled Glasses No. 1 Into drip trays from pumps. Collected in pail. Mild Ale. Re-used on request. No. 2 Under each pump special continuous funnels connected direct to pump. None. Apart from daily washout of system. All. Re-used on request. No. 3 Spillage direct through drip sink into utiliser. No special filtering. None. Mild Ale. About 10% Re-used on request. No. 4 Mild spillage collected and returned to brewery at 1s. gallon. Other beers individually salvaged and filtered into main barrels. Filter bags and papers. Bitters only. Best bitter. Re-used on request. Clean glasses routine a failure. No. 5 Mild Beer straight through drip sink into utiliser—non-filtering. Bitters filtered after collection and put in utiliser. Utiliser washed daily. Beers part filtered. Mild Beer only. About 5% Re-used on request. No. 6 Spillage salvaged under each pump and collected and filtered back through papers into individual barrels. Drip sink runs to waste. A11 beers. Re-used on request. No. 7 Spillage collected daily from under pumps. Each separate beer filtered through papers into same barrels. All beers. Re-used on request. No. 8 Spillage into individual drip trays. Collected and filtered daily back into individual barrels Bottoms not used. Drip sink runs to waste. All beers. Re-used on request. 43 44 LEGAL PROCEEDINGS Under the Food and Drugs Act, 195 Date of hearing Offence Section of Act Result of Proceedings 15th February China in loaf of bread 2 Fine £5. Costs £2 2s. 0d. 11th April Beetle in tin of peas 2 Fine £1. Costs £2 2s. 0d. 29th August Baby food not of the quality demanded 2 Fine £10. Costs £10 10s. 0d. 5th September Dirt in bottle of milk 2 Fine £2. Costs £5 5s. 0d. 5th September Aluminium seal inside bottle of milk 2 Fine £2. Costs £1 1s. 0d. 12th December Mould on surface of loaf of bread 2 Fine £5. No order made for costs. FOOD SAMPLING I am indebted to Mr. J. A. O'Keefe, Chief Officer of Public Control of the Middlesex County Council for the following information. Food and Drugs Act, 1955 Samples procured in the Borough of Hornsey during the year 1956. Article Total samples procured Unsatisfactory Milk, new 3 . Milk, various 114 . Cakes 63 . Camphorated oil 6 . Cheese 7 . Cooked meat 21 . Drugs 11 . Cream 10 . Fish and fish products 11 1 Fruit (fresh and canned) 6 . Ice cream 3 . Jelly 4 . Meat and meat products 16 . Sausages, etc. 27 . Sweets 5 . Vinegar 5 . Wine and spirits 25 . Miscellaneous 23 . Totals 360 2 The following comments relate to samples noted as unsatisfactory:— Fish and Fish Products Fried fillet of cod was sold as "fillet of haddock". Proceedings were instituted and the magistrates gave an absolute discharge, no costs being allowed. Meat and Meat Products A sample of pork rissoles contained preservative. Follow-up samples proved to be genuine, and no further action was taken. The Food and Drugs Act, 1955, in Section 47, contains new provisions concerning the descriptions which can be applied to certain substances which resemble cream in appearance but are not cream. This has necessitated the making of many inspection visits and the giving of advice to all traders likely to be concerned to ensure that they were fully aware of these new requirements. 45 Merchandise Marks Acts, 1887-1926 One hundred and forty-five inspections of shops were undertaken to ensure that the Marking Orders relating to certain imported foodstuffs made under the Merchandise Marks Act, 1926 were complied with. 1,263 separate displays of meat, apples, tomatoes, poultry, dried fruit, bacon and butter were examined. Verbal cautions were given in respect of minor infringements not being found so serious as to warrant more stringent action. A firm of butchers exposed for sale Argentine beef not marked with the country of origin. They were fined £2 and ordered to pay £2 2s. costs. The manager of that particular branch was also prosecuted for selling Argentine beef not marked with the country of origin. He was fined £2 and ordered to pay £2 2s. costs. The Labelling of Food Order, 1953 This Order prescribed that, subject to certain exceptions, pre-packed foods shall be marked with legible and conspicuous statements of the designation of the food, of the ingredients of which compounded foods are composed, and of the name and address (or registered trademark) of the packer or labeller. It also prescribes special labelling requirements in respect of certain specified food and in respect of foods concerning which there is a claim as to their vitamin or mineral content. At 169 premises 818 articles of pre-packed food were examined. No proceedings were taken in respect of any of the infringements detected and manufacturers took immediate steps to correct unsatisfactory labels as soon as their attention was drawn to them. False or Misleading Descriptions A considerable amount of work is carried out each year in scrutinising advertisements and the labelling of pre-packed food and taking such action as is possible to secure satisfactory amendments in those cases where a label or advertisement contains a false or misleading description of the food to which it relates. This work is of benefit to all districts of Middlesex, irrespective of where the offending advertisement or label is discovered, and during the year under review corrective action has been taken in respect of cherry wine, biscuits, chocolate Easter Eggs, flour and sugar confectionery, imitation caviare, blackcurrant punch, fruit juice drinks and creme de menthe. 46 GENERAL PERINATAL MORTALITY At the turn of the century something like one in every seven babies born died before they reached the end of the first year of life. The great advances in public health and in medicine during this century have reduced this appalling mortality enormously but the position has now been reached where no further advance is being made. The majority of these deaths occur in the first month of life, the neonatal deaths so-called; and most of these occur in the first week. The causes of death at this time are by and large the same as the causes of still-birth and the two are often grouped together for purposes of study as perinatal deaths. These so-called causes are really little more than descriptive titles e.g. congenital debility, congenital deformity, prematurity. Indeed they are more aptly described as effects rather than causes and the latter often remain unknown. Progress is being made however as for example the elucidation of the rhesus blood-group incompatibility as a cause of death and injury and the effects of viruses on the foetus. During 1956 a survey of the position in Hornsey showed that while the perinatal mortality was appreciably below the national average nevertheless this hard core of deaths remained on which no impression was being made. Discussions were held with representatives of the two large hospitals in which most of the Hornsey births take place and it was decided as from January 1st 1957 to keep detailed records of perinatal deaths on a form adapted from that used for maternal deaths. Further meetings are to be held from time to time to discuss these records. It is hoped by these means to ascertain whether any of the deaths are avoidable. The following table gives the relevant statistics for the past six years and for 1938. Year 1. Stillbirths 2. Deaths under 1 week 3. Deaths between 1 week and 1 month 4. Deaths between 1 month and 1 year 5. Total infant deaths 6. Perinatal mortality (Total of columns 1 and 2) 1938 45 19 8 12 39 64 1951 31 22 6 7 35 53 1952 27 20 1 4 25 47 1953 26 18 1 12 31 44 1954 21 20 1 5 26 41 1955 26 13 5 7 25 39 1956 28 19 4 11 34 47 47 WELFARE OF OLD PEOPLE The number of cases reported to the Department of old people in need of care and attention has again increased, the figure for 1956 being 38. It has been said that a study of national statistics reveals not that we are an elderly nation, but that Victorian society was youthful. The fact remains that the proportion of aged persons in the population is increasing yearly, and the increase in numbers referred to the Department for investigation would seem to be a natural consequence of this increase. It is important to remember that those referred to the Department constitute only a very small proportion of the old people. There are, in Hornsey approximately 12,500 people over the age of 65 years and the majority of them are well able to care for themselves or are cared for by relations without any need for assistance from official or voluntary sources. Most of the remainder receive help of various kinds such as attendance by home helps, and home nursing care as required; the Old People's Welfare Committee ensures as far as is possible that these old people receive the services they need. It appears that the position has not worsened and may well be a little better owing to the increased use of available services. The main difficulty in the winter months is that old people feel the cold so much more than others and the cost of heating is a great worry. Unfortunately too many old people occupy top floor or attic rooms and must carry coal from the ground floor or cellar which presents a real problem; in fact some home help assistance is given mainly with this difficulty in mind. Living at the top of many stairs also causes some old people to be more or less confined to their rooms. The service of home helps under the National Health Service Act is provided in over 360 instances to old people and, as in many cases more than one person is involved, this represents direct help to probably over 500 persons. In addition there are a number who receive regular visits from a home nurse. The health visitors visit old people known to them to be in need of help or on request from hospital or general practitioners but owing to shortage of staff it is not possible to extend these visits as much as is desirable. Malnutrition due to poverty, ignorance or apathy is a major factor in the cases investigated. Trained visitors can do much to overcome ignorance, once they have become aware of the existance of a case, but poverty is a problem outside their scope. It has been suggested that regular medical examinations would be useful in detecting malnutrition and other untreated disease. It might be possible to arrange this through the general practitioner service, as each general practitioner has records available from which he can select those over 65 years of age. Any old person who appears to be living in especially bad conditions is reported to the Medical Officer of Health and the case investigated. In addition all reports received in the Health Department are quickly and carefully investigated and the necessary assistance arranged so as 48 to improve the circumstances of the person concerned. It is only in rare instances, that action is taken to compel admission to an old persons' home. Indeed, a comparatively small number of the old people reported to the Department are recommended for admission to a Home as by proper use of the voluntary and official services it is usually possible to help them to continue to live in their own homes in reasonable conditions. The following are brief notes relating to the only case in which compulsory action was taken during 1956. Mrs. W., an old lady over 90 years of age, had been receiving home help assistance for some time. A report was received from the home help attending her that her condition was deteriorating, and that she had taken to defaecating in the back garden. Mrs. W. was becoming senile, eccentric and forgetful, and her general practitioner reported that he had found the gas taps left on with the gas not lighted. Attempts were made to persuade her to go into a home but without success, and it became necessary for her own safety to ask the Health Committee for authority to apply to the Court for a removal order. The Order was granted and Mrs. W. was removed to a County Council Welfare Home, where she died ten days later. MASSAGE AND SPECIAL TREATMENT Any premises in the Borough used or represented as being used or intended to be used for the reception or treatment of persons requiring massage or special treatment must be licensed. The treatments are defined as:— (a) massage, manicure or chiropody; or (b) electric treatment or radiant heat light electric vapour or other baths for therapeutic treatment; or (c) other similar treatment; Following is a summary of the 20 premises which are licensed under the Act:— Massage 6 Chiropody 18 Electrical treatment 5 Other similar treatment 4 Four members of the Chartered Society of Physiotherapy also practise in the Borough. 49 MEDICAL EXAMINATION OF STAFF Thirty persons were medically examined to determine their fitness for acceptance on the permanent staff. Twenty-five were found to be fit. One of the conditions of the scheme for sickness pay for all employees who come within the scope of the National and Provincial Councils for Non-Trading Services (Manual Workers) is that all new employees be required to submit to a medical examination before the completion of six months' service with the Council in order to determine their fitness for admission to the scheme. Sixty-one persons were examined, fifty-seven of whom were accepted for the scheme. Three other examinations were carried out. DISEASES OF ANIMALS The Borough Council is the Local Authority for Hornsey under the Diseases of Animals Acts and the Council's Veterinary Inspector is responsible for the investigation of outbreaks of fowl pest or other contagious diseases affecting animals, routine inspections of piggeries and similar establishments, and any action which may be necessary under the Foot and Mouth Disease Orders. Mr. F. G. Buxton, M.R.C.V.S., the Veterinary Inspector, has kindly supplied me with the following information:— No licences were issued under the Contagious Diseases of Animals Acts. Four inspections were made under the Pet Animals Act, 1951. 2 at Pet Shop—St. James's Lane. 2 at Pet Shop—1 Clissold Cottages, Fortis Green. There were no outbreaks of Fowl Pest. No action was necessary under the Tuberculosis Order of 1925. STORAGE OF PETROLEUM Under the Petroleum (Regulation) Acts, 1928 and 1936, the Council is responsible for the licensing of all establishments at which petrol is stored, whether for sale to the public or not. The Acts also apply to the storage of certain india-rubber solutions, varnishes, quick-dry paints and spraying liquid. 50 The number of establishments licensed for storage is 74 and the number of licences issued is as follows:— Storage of Petroleum 63 Cellulose 18 Napthaline 1 Hydro-carbon 2 Benzole 1 Petroleum mixtures 1 Total 86 (Note.—Ten establishments are licensed for more than one product.) BURIAL OF THE DEAD Under Section 50 of the National Assistance Act, 1948, it is the responsibility of the Borough Council to arrange the burial or cremation of all persons who die in the Borough for whom no suitable arrangements would otherwise be made. Arrangements were made for the burial of five bodies, men aged 71 and 72 years, women aged 79 and 92 years and one stillborn child. PUBLIC MORTUARY The Hornsey mortuary and post-mortem room are situated at the Central Depot, Hornsey High Street. During the year 111 bodies were admitted for post-mortem examination. Inquests were held on 12 bodies. 51 VITAL STATISTICS Area (acres) 2,872 Area of Parks and Open Spaces (acres) 576 Population: Registrar General's estimate at 30 June, 1956 97,220 Number of separately assessed habitable premises according to Rate Books 24,546 Rateable value (General Rate) £1,540,469 Product of a penny rate £6,175 LIVE BIRTHS M F Total Legitimate 678 685 1,363 Illegitimate 53 43 96 731 728 1,459 Birth Rate (live births per 1,000 population) Hornsey 15.0 Area Comparability Factor 0.93 Adjusted Rate for Hornsey 13.95 England and Wales (provisional) 15.7 Middlesex County (adjusted rate) 13.2 STILL-BIRTHS M F Total Legitimate 16 11 27 Illegitimate 1 1 Still-birth Rate (per 1,000 total live and still-births) Hornsey 18.8 England and Wales (provisional) 23.0 INFANT DEATHS (under 1 year of age) M F Total Legitimate 18 14 32 Illegitimate 2 2 Comparable Infant Death Rates (per 1,000 live births) Hornsey 23.3 England and Wales (provisional) 23.8 Middlesex County 19.1 53 Neo-Natal Deaths (under 4 weeks of age) M F Total Legitimate 14 7 21 Illegitimate 2 - 2 Neo-Natal Death Rates Hornsey 15.8 England and Wales (provisional) 16.9 Middlesex County 14.6 MATERNAL DEATH RATES (per 1,000 total live and still-births) Hornsey (two deaths) 1.34 Middlesex County (eighteen deaths) 0.58 DEATHS FROM ALL CAUSES Males • • • • 501 1,115 Females 614 Death Rate (per 1,000 population) Hornsey 11.5 Area Comparability Factor 0.90 Adjusted Rate for Hornsey 10.3 England and Wales (provisional) 11.7 Middlesex County (adjusted rate) 10.8 54 55 DEATHS OF HORNSEY RESIDENTS—Classified according to age groups and sexes Under 1 year 1 to 4 5 to 14 15 to 24 25 to 44 45 to 64 65 to 74 75 and over Totals 1 Tuberculosis, respiratory M . . . . 2 4 3 1 10 12 F . . . . . 2 . . 2 3 Syphilitic disease M . . . . . . 1 . 1 3 F . . . . . . 1 1 2 10 Malignant neoplasm, stomach M . . . . . 3 5 4 12 29 F . . . . . 4 4 9 17 11 Malignant neoplasm, lung, bronchus M . . . . 2 18 14 7 41 54 F . . . . 1 4 4 4 13 12 Malignant neoplasm, breast M . . . . . . . . . 20 F . . . . 3 10 4 3 20 13 Malignant neoplasm, uterus M . . . . . . . . . 8 F . . . . . 3 3 2 8 14 Other malignant and lymphatic neoplasms M . . 1 . 3 15 16 12 47 106 F . . . . 4 10 17 28 59 15 Leukaemia, aleukaemia M . 1 . . 2 1 . . 4 8 F . . . . . • 3 1 4 16 Diabetes M . . . . 1 1 . . 2 9 F . . . . 1 1 1 4 7 N.B.—No deaths occurred from the following causes :— 2 Tuberculosis, other ; 4 Diphtheria; 5 Whooping Cough ; 6 Meningococcal infections; 7 Acute poliomyelitis ; 8 Measles 9 Other infective and parasitic diseases. 56 Deaths of Hornsey Residents—continued Under 1 year 1 to 4 5 to 14 15 to 24 25 to 44 45 to 64 65 to 74 75 and over Totals 17 Vascular lesions of nervous system M . . . . . 2 10 20 32 117 F . . . . 2 10 19 54 85 18 Coronary disease, angina M . . . . 2 31 44 39 116 208 F . . . . 1 6 23 62 92 19 Hypertension with heart disease M . . . . . 2 5 5 12 25 F . . . . . 1 2 10 13 20 Other heart disease M . . . . . 5 7 23 35 113 F . . . . . 2 15 61 78 21 Other circulatory disease M . . . . 1 4 4 7 16 58 F . . . . . 2 9 30 42 22 Influenza M . . . . . . . . . 1 F . . . . . . . 1 1 23 Pneumonia M 1 . . . . 1 5 18 25 66 F 2 . . . . 1 7 31 41 24 Bronchitis M . . . . 1 5 22 21 49 89 F . . . . . 2 9 29 40 25 Other diseases of respiratory system M . . . . . 2 1 . 3 9 F . . . . . 2 1 3 6 26 Ulcer of stomach and duodenum M . . . . 1 2 5 3 11 21 F . . . . . 2 1 7 10 57 Deaths of Hornsey Residents—continued Under 1 year 1 to 4 5 to 14 15 to 24 25 to 44 45 to 64 65 to 74 75 and over Totals 27 Gastritis, enteritis and diarrhoea M . . . . . 2 1 . 3 5 F . . . . . 1 • 1 2 28 Nephritis and nephrosis M . . . . . 2 . 2 4 9 F . . . . 1 2 . 2 5 29 Hyperplasia of prostate M . . . . . . 2 6 8 8 F . . . . . • . • . 30 Pregnancy, childbirth, abortion M . . . . . . . . . 2 F . . . . 2 • . . 2 31 Congenital malformations M 6 . . . . . . . 6 10 F 3 . . . . 1 . . 4 32 Other defined and ill-defined diseases M 12 . . 1 4 3 5 8 34 79 F 8 . 1 1 5 5 8 17 45 33 Motor vehicle accidents M . . . . 3 2 1 . 6 7 F . . . 1 • . • • 1 34 All other accidents M 1 . . 1 1 5 3 4 15 27 F 1 . . . 1 1 1 8 12 35 Suicide M . . . . 2 2 4 . 8 11 F • . . • 1 2 . . 3 36 Homicide and operations of war M . 1 . . . . . . 1 1 F . . . . . . . • . TOTALS M 20 3 1 2 25 112 158 180 501 F 14 . 1 3 22 74 132 368 614 34 3 2 5 47 186 290 548 1,115 58 INFANT DEATHS CLASSIFIED ACCORDING TO AGE GROUPS AND SEXES Age at Death Under 1 Day 1-6 Days 7-13 Days 14-20 Days 21-27 Days Total Under 4 Weeks 1-2 Months 3-5 Months 6-8 Months 9-11 Months Total Under 1 Year Inflammatory diseases of central nervous system M . . . . . . . 1 . . 1 2 F . . . . . . 1 . . . 1 Pneumonia M . 1 . . . 1 . . . . 1 3 F . . . . . . 2 . . . 2 Spina bifida & meningocele M . . . . . 1 . 1 . . 2 2 F . . . . . . . . . . . Congenital malformations of heart M . 1 1 . . 2 1 . . . 3 4 F . . . . . . 1 . . . 1 Other congenital malformations M 1 . . . . 1 . . . . 1 3 F . . . . . . 1 1 . . 2 Injury at birth M 3 1 1 . . 5 . . . . 5 6 F 1 . . . . 1 . . . . 1 Postnatal asphyxia and atelectasis M 2 1 . . . 3 . . . . 3 5 F . 2 . . . 2 . . . . 2 Haemolytic disease of newborn M . . . . . . . . . . . 1 F 1 . . . . 1 . . . . 1 Immaturity M 2 . . 1 . 3 . . . . 3 5 F 2 . . . . 2 . . . . 2 Obstruction by inhalation or ingestion M . . . . . . . 1 . . 1 2 F . . . . . . 1 . . . 1 All other causes M . . . . . . . . . . . 1 F 1 . . . . 1 . . . . 1 TOTALS M 8 4 3 1 . 16 1 3 . . 20 34 F 5 2 . . . 7 6 1 . . 14 13 6 3 1 . 23 7 4 . . 34 APPENDIX AREA HEALTH COMMITTEE HORNSEY AND TOTTENHAM (Population 217,920) The tables are for the Area as a whole except where stated for Hornsey only. 59 MEMBERS of the LOCAL AREA COMMITTEE AS AT 31st DECEMBER, 1956 Members of Middlesex County Council County Alderman Mr. R. A. Clarke County Alderman Mr. M. W. Burns, j.p. County Councillor Mr. V. Butler County Councillor Mr. H. H. Godwin-Monck County Councillor Mrs. H. C. Norman, j.p. County Councillor Mrs. M. E. Soall Members of Hornsey Borough Council Alderman Miss J. Richardson Councillor Miss O. R. Anderson Councillor Miss M. E. West Councillor Mr. J. T. Wilkjns Councillor Mr. C. R. Williams (Vice-Chairman) Members of Tottenham Borough Council Alderman Mr. A. Reed, a.c.i.i., j.p. Alderman Mrs. A. F. Remington Councillor Mr. H. Langer Councillor Mr. M. T. Morris Councillor Mrs. M. E. Protheroe (Chairman) Councillor Mr. J. R. Ramshaw Member nominated by appropriate Hospital Management Committee Mrs. R. M. Fry Persons who may attend in an advisory capacity Dr. L. Hornung (Middlesex Local Medical Committee) Mr. R. W. D. Brownlie (Middlesex Local Dental Committee) Mr. L. Hayward (Middlesex Local Pharmaceutical Committee) Mrs. E. A. Lee (Royal College of Nursing) Miss V. Edey (Royal College of Midwives) G. Hamilton Hogben, m.r.c.s., d.p.h. (Medical Officer of Health and Area Medical Officer) 60 AREA HEALTH STAFF 1956 Deputy Area Medical A. Yarrow, m.b., ch.b., d.p.h. Officer Senior Assistant Medical Mrs. J. H. Garrow, m.b., ch.b., d.p.h. Officer Area Dental Officer .. V. Sainty, l.d.s., r.c.s. Superintendent Health Miss H. Townsend, s.r.n., s.c.m., h.v. Visitor Non-Medical Supervisor Miss F. E. Curtis, s.r.n., s.c.m., h.v., of Midwives and Home m.t.d. Nursing Superintendent Home Help Organiser .. Mrs. D. Edwards, s.r.n., dip.soc.sc. Assistant Home Help Mrs. W. E. Pickard, s.r.n. Organisers Mrs. F. G. Wills Area Chief Clerk .. W. L. N. Relleen, t.d., d.p.a. Deputy Area Chief Clerk T. W. Hadley, ll.b. Sectional Heads .. A. Balls N. P. Child H. J. Dunham, b.a. Classification of Staff Full-time Part-time Medical Officers 8 7 Dental Officers 7 3 Supervisory Nursing Staff 2 Administrative and Clerical Staff 36 8 Health Visitors/School Nurses 27 1 Clinic Nurses 8 1 Sponsored Student Health Visitor 1 Midwives 8 Home Nurses 22 8 Speech Therapists 2 2 Physiotherapists 1 3 Occupational Therapist 1 Chiropodists 2 Gramophone Audiometrician 1 Orthoptists 2 Dental Attendants 8 1 Day Nursery Staff 30 1 Home Help Service 6 186 Manual workers, domestic grades, etc. 9 25 175 252 61 CARE OF MOTHERS AND YOUNG CHILDREN Section 22 Notification of Births The following table shows the births notified during the year compared with previous years. The number notified last year was the highest for four years and as most of the additional births took place at home, the percentage of hospital confinements fell to 83.1% as compared with 88.9% in the previous year. 1956 1955 1954 Live Births (a) Domiciliary 534 429 553 (b) Hospital or Nursing Home 2,589 2,509 2,387 Still Births (a) Domiciliary 4 4 5 (b) Hospital or Nursing Home 56 53 51 Totals 3,183 2,995 2,996 Ante-natal Clinics The percentage of expectant mothers making at least one attendance at an ante-natal clinic was 69% during 1956 compared with 66% the previous year. This has halted the steady decline noted in previous years but it is too early as yet to draw any conclusion from it. As a matter of interest the percentages for the years 1949 to 1956 were 74%, 79%, 77% 75%, 72%, 74%, 66% and 69% respectively. The following table gives details of attendances at all clinics in the. Area:— No. of sessions held No. of new cases Total attendances Average attendance per session A.N. P.N. A.N. P.N. Burgoyne Road 49 162 91 1,054 94 23.4 Church Road 76 155 78 1,213 89 17.1 Fortis Green 97 219 131 1,687 138 18.8 Hornsey Town Hall 153 342 146 2,300 150 16.0 Mildura Court 63 183 81 1,365 82 23.0 Stroud Green 51 151 65 700 65 15.0 The Chestnuts 202 392 210 2,789 222 14.9 Lordship Lane 204 286 173 2,167 177 11.5 Park Lane 102 302 157 1,533 176 16.7 Totals 1956 997 2,192 1,132 14,808 1,193 16.0 1955 1,016 2,003 1,187 14,652 1,261 15.7 1954 1,057 2,210 1,177 15,504 1,257 15.4 62 Investigation of Anaemia at the Ante-natal Clinic, Church Road, Highgate About 140 new cases are registered every year at this clinic; they are drawn from a wide cross-section of the population and the five social classes of the Registrar General are represented more or less equally. They also include women of many nationalities i.e., Irish, Jamaican, African, Swedish, German, French, Italian, Greek, Polish and American. A medical officer of the Department, Dr. H. Gunn, reports that the estimation of haemoglobin levels in expectant mothers has been carried out at this clinic since 1953. For the first few months the Tallquist Haemoglobin Scale was used but this was later abandoned for the Sahli Haemoglobinometer which was found to be more accurate and easier to read in artificial light. At their first visit to the ante-natal clinic, all patients who are to be confined at home or in the Alexandra Maternity Home have samples of blood taken for determination of Blood Group, Rh Factor and Haemoglobin. Approximately 86% of these women make their first visit at or before the 18th week of pregnancy. Of the remaining 14% the majority are seen before the 28th week but there are a few who make their first visit much later either because they have recently moved into the district or because they have neglected to make any arrangements for their confinement or ante-natal care. In almost all of these cases, the Hb has not been determined previously and their figures are included with the "first visit" estimations given overleaf. Although some authorities are concerned that the so-called "physio" logical anaemia of pregnancy" is a true hypochromic anaemia and that the Hb's of pregnant women can be maintained at or above 90%, with adequate iron therapy, 80% has been taken as the dividing line in this clinic. To all women with Hb levels below 80% is given a month's supply of Fersolate Tablets (1 T.D.S.) and they are asked to collect further supplies at each visit until they are told to discontinue. If they report severe constipation, abdominal pains or vomiting as a result of taking the tablets an alternative iron preparation is offered. A second Hb estimation is made at the 34th week and treatment is stopped if the Hb has reached 80%. It is not possible, however, to follow up all the original cases as a number are lost owing to miscarriage, moving out of the district or transfer to hospital clinics. Some of the results obtained, after what should be adequate dosage with iron, are disappointing; but on close questioning of these it has been found that the tablets have been taken erratically or in very inadequate doses. Some women give them up for weeks at a time or reduce the dose to one a day because of various unpleasant symptoms said to have resulted from them. Others admit that they often forget them "because they have to be kept out of reach of the children and are put out of sight." The results obtainable for the last three years are set out overleaf. These readings were all obtained at the first visit and although several of the 63 women had been given iron tablets during a previous pregnancy, only one was actually having them at the time. Total 100% 90%-99% 80%-89% 70%-79% 60%-69% 50%-59% 1954 93 1.1 4.3 46.2 30.1 17.2 1.0 1955 99 . 6.0 37.0 42.0 11.0 2.0 1956 86 2.3 19.7 48.8 24.4 2.3 These figures suggest that there may have been a gradual improvement in Hb levels over the last few years. Thus in 1956 70.8% of those attending for the first time did not require iron therapy as against 43% in 1955 and 51% in 1954. There has also been a marked reduction in the number of readings below 70% 1954 18.2% 1955 13.0% 1956 2.3% and there is an increase in the number of readings over 90% 1954 5.4% 1955 6.0% 1956 22.0% If there has been a real improvement in the Hb levels of this section of the population it is no doubt due to a general improvement in their nutritional state. It is probable that people have become used to the high prices of foodstuffs and it is also worth noting that eggs have been cheaper and more stable in price during the past eighteen months. Mid wives Ante-natal Clinics Owing to the shortage of midwives it has not been possible to hold clinics at Burgoyne Road and Mildura Court, and clinics elsewhere have been on a somewhat reduced scale. The following table shows the attendances made during the year:— Midwives' Clinics No. of sessions held Total No. of attendances Average attendance per session Fortis Green 26 159 6.1 Hornsey Town Hall 13 59 4.5 Stroud Green 26 94 3.6 Park Lane 139 758 5.5 Totals 204 1,070 5.2 The Alexandra Maternity Home, Hornsey The Alexandra Maternity Home was opened in 1944 and in 1948 it was transferred from the Hornsey Borough Council to the Regional 64 Hospital Board in accordance with the National Health Service Act. The number of beds is now 30. The Home— 1. Gives ante-natal care for those women who require rest or treatment. 2. Cares for them during confinement. 3. Co-operates with the domiciliary midwives who take nurses from the Home as pupils to confinements on the district. 4. Trains nurses in midwifery so that they can get the midwives* certificate. Women wishing to be confined at the Alexandra Maternity Home attend one of the Council's ante-natal clinics, and a card with the patient's history, blood group etc. is sent to the Home. Visiting staff:—Mr. J. M. Scott, O.B.E., T.D., Whittington Hospital, Archway Group. Dr. G. D. S. Briggs. Dr. D. M. Wilkins. Matron:— Miss G. M. Howell 1956 1955 1954 Admissions 702 640 640 Live Births 659 599 611 Delivered by Doctors 8 11 11 Emergencies during Labour 19 Transferred to St. Mary's 10 Still Births 2 4 6 Infant Deaths . 3 Infants completely breast fed 581 509 545 Health Education and Parentcraft The teaching of positive health is the full-time occupation of every health visitor wherever her duties take her, particularly in homes, clinics, schools and to a smaller extent in a voluntary capacity in giving evening talks and lectures to organisations outside the health service. Her work is more than the teaching of the prevention of disease such as the popularising of prophylactic measures to combat ill-health. It is the day to day help and advice given to promote mental and bodily health, the prevention of deterioration of families and the working out of family management and difficulties. Education for health is one of the most important of the personal health services and is concerned with individuals of all ages and types. It commences with advice and guidance to the expectant mother and the mother of a new baby. It continues through childhood until the child enters school and comes within the purview of the school health services with routine examinations and follow-up home visits for defects and general care. The continuity of the pattern of her work with these groups, 65 and with discharges from hospital, the elderly and others, does much to extend education by practical assistance to individuals and families when they are most in need of it and gives them support which undoubtedly contributes to the establishment of individual and community health. Social factors cannot be separated in the work of the health visitor where family difficulties, social problems and health are so interlaced, but the health visitor, as the general purpose family visitor, calls on the advice and help of other services when these can be of assistance to members of the public. Account is taken of the different interests of mother and other groups to satisfy inclination and desires to acquire knowledge of health and practical methods connected with parentcraft. Relaxation and Mothercraft Classes are given weekly at eight Maternity and Child Welfare Clinics. This is an increase of one weekly session over those reported for the previous year. The following table shows attendances at Mothercraft Clinics during the year:— Clinic No. of sessions hold No. of new cases Total No. of attendances Average attendance per session Burgoyne Road 41 33 241 5.9 Church Road 45 24 224 5.0 Fortis Green 42 81 465 11.1 Hornsey Town Hall 51 102 487 9.5 Mildura Court 32 18 116 3.6 The Chestnuts 61 101 585 11.5 Lordship Lane 51 98 723 14.2 Park Lane 52 62 453 8.7 Totals 365 519 3,294 9.0 Home-making and Parentcraft talks in schools Health visitors and one school nurse have given talks, demonstrations and films to secondary modern girls in the area. In all, 378 talks and discussions were given in schools. The lively interest of the pupils makes this part of the work very well worth while. Child Welfare Clinics The percentage of children under one year of age who attended for the first time during the year continued the improvement noted in 1955. During the past four years this figure has risen from 89.1% to 94.3%. The total attendances made by children under five years were slightly up on the figure for the previous year, due to the opening of the Somerset Road Centre, Tottenham, which increased the number of sessions held during the year in the Area as a whole by 73 as compared with 1955. To some extent, attendances at the other three centres in Tottenham have fallen since the opening of the Somerset Road Centre, but it has not yet been considered necessary to recommend any adjustment in sessions as a result. 66 The following table shows details of attendances made at all centres during the year:— Name of Centre No. of sessions held No. of first attendances under 1 year No. of attendances Total attendances No. of cases seen by M.O. Average attendance per session Under 1 year Over 1 but under 2 years Over 2 but under 5 years Burgoyne Rd. 151 218 4,051 509 235 4,795 1,407 31.8 Church Rd. 145 228 2,980 566 120 3,666 1,526 25.3 Fortis Green 151 257 3,393 601 237 4,231 1,397 28.0 Hornsey Town Hall 203 421 5,411 786 391 6,588 2,805 32.4 Mildura Court 102 215 3,152 572 88 3,812 1,401 37.4 Stroud Green 101 192 2,866 475 133 3,474 844 34.4 The Chestnuts 256 547 6,716 913 288 7,917 1,958 30.9 Lordship Lane 255 374 5,489 1,158 272 6,919 1,720 27.1 Park Lane 205 293 4,826 793 300 5,919 1,803 28.9 Somerset Road 91 200 2,932 343 144 3,419 897 37.6 Totals 1956 1,660 2,945 41,816 6,716 2,208 50,740 15,758 30.6 1955 1,587 2,709 40,354 7,176 2,659 50,189 15,645 31.6 1954 1,604 2,675 40,891 7,963 3,059 51,913 16,024 32.4 Use of clinics for B.C.G. Vaccination During the year the Mildura Court, Burgoyne Road and Stroud Green Road Welfare Centres have been used on a number of occasions by the Chest Physician for Hornsey for the purpose of carrying out tuberculin testing and B.C.G. vaccination of contact cases. It is hoped that eventually a chest clinic will be established in Hornsey and in the meantime this temporary arrangement saves many patients the long journey to the chest clinic in Finchley. Toddlers Clinics In the Annual Report for 1954 it was stated that more effort was to be made to widen the knowledge of medical officers on the mental health aspect in the care of young children. The psychiatrist (Dr. Cyril Phillips), who attends both Child Guidance clinics in Hornsey and Tottenham, devotes one session per week to "sit in with" a medical officer and discuss some of the problems of these children, with the mother present. This has proved both interesting and rewarding. Gravely disturbed children are not included but the common problems of the physically healthy child who, for instance, refuses food, has disturbed sleep or resents toilet training are considered. This psychological approach yields satisfactory and in some cases quite rapid results in young children attending the Toddler and welfare clinics. As each medical officer spends three months with the psychiatrist for one session per week, confidence in this new approach is assured. 67 A major problem is to get the mothers to attend for such advice. It is a curious fact that a woman will bring her healthy baby regularly to the clinic to be weighed, and to get advice on minor matters, but as soon as the baby can walk, talk and eat ordinary food, the anxiety about him eases off, and small deviations from normality are either not noticed or neglected. An unruly toddler can cause much unhappiness in a family. So often the story of his bad behaviour is the first thing that is told to father on his return from work, which causes annoyance in the father, and in consequence more aggression in the child. The following table, showing referrals to special clinics, gives some indication of the scope of inspection of the child on the physical side, but no idea of the amount of discussion between parent and doctor, which actually takes place. E.N.T. Ophthalmic Orthopaedic Child Guidance Dental Chiropody Artificial Sunlight Speech Therapy 14 50 109 7 185 6 6 23 The work of this clinic is unhurried and gives adequate time for the mother to talk about her child—to ask questions about various injections to protect the child from infection, operations, treatments, feeding, should he be sent to a nursery school or not, what shoes should he wear and so on. In fact the mother has a sympathetic atmosphere in which to discuss the child's and her own problems. The following table gives details of attendances at the individual clinics:— Name of Centre No. of sessions held Total Attendances No. of cases seen by M.O. Average Attendance per session Burgoyne Road 28 470 467 16.8 Church Road 49 468 423 9.6 Fortis Green 36 422 422 11.7 Hornsey Town Hall 61 671 671 11.0 Mildura Court 51 698 659 13.7 Stroud Green 23 326 326 14.2 The Chestnuts 51 617 617 12.1 Lorship Lane 52 647 647 12.4 Park Lane 51 474 472 9.3 Somerset Road 47 503 503 10.7 Totals 1956 449 5,296 5,207 11.8 1955 392 4,904 4,769 12.5 1954 389 5,196 5,040 13.4 68 Anxiety of Mothers about Young Children Parental anxiety is clearly shown in the following summary of the experiences of a medical officer who also attended sessions for two years at a children's out-patient department. Here the medical officer met the same mothers who attended the local clinics, asking all the time the same questions and getting the same answers. Not being convinced that the answers were true, these mothers go from hospital to clinic and vice versa in an attempt to get further advice, or change the child into one they can accept. In their view it is the child that must be changed but not themselves. Liaison between the Hospitals and the Welfare Services A medical officer of the Department (Dr. V. Tracey) reports that at the end of two years as Clinical Assistant in a busy children's out-patient department, an impression remains of great similarity between the types of cases making frequent attendances at hospitals and those commonly seen at the various Welfare Centre sessions. When those children attending hospital because of serious illness are eliminated, one is left with a large, familiar group of conditions common to both— children suffering from recurrent respiratory infections, particularly school entrants, the child who won't eat, or sleep, and children of all ages who show physical symptoms in response to the stresses and strains of growing up and adjusting to school life. Not only are the conditions familiar, often the individuals have been met before at clinics and routine medical inspections. The co-operation of the personal health services seems most often to be sought by the hospital doctor in the case of children of school age. One is often called upon to answer questions about the types of special schooling available and then to pass on the necessary case details to the office so that places in the special schools can be applied for with the least loss of time. Sometimes, having someone immediately available to answer a mother's questions about what is entailed in sending a child to a special school, for example, will help her to agree promptly and without anxiety to the course recommended. Occasionally questions arise about the types of courses followed and the standards likely to be expected in the various categories of day schools, and here, someone who has visited the schools and so can give a clearer picture of what is meant by the newer and relatively unfamiliar terms, such as "secondary modern", "central" or grammar school. There seems at present to be a less close link between hospitals and clinics in the case of infants and pre-school children. Babies fortunately form a relatively small part of the hospital attenders, but their difficulties frequently centre round diet and feeding, either as a sequel to other illness or as an initial complaint. Even while attending an out-patient department every one or two weeks, many mothers continue to attend regularly at their usual welfare centre. Could this, perhaps, be a point at which a closer liaison could be established, with the hospitals making a more deliberate use of the clinics to steer mothers through their difficulties 69 between hospital attendances? The health visitors in such cases could follow a recommended line of management, reinforced, if necessary, by home visits. It would probably be appreciated by many mothers who find it difficult to travel quite long distances to hospital with a baby, and possibly a toddler too, while the clinic is just round the corner. The Toddler Clinics might also be made use of, when longer and more leisurely discussion of developmental or behaviour problems is needed. The busy, bustling atmosphere of an out-patient department is not necessarily the best setting for such discussion, with little to divert the child's attention, and too much to divert the adults' minds. Investigation into the probable cause of Leukaemia The Department of Social Medicine, Oxford, has undertaken to investigate all deaths in England and Wales from malignant disease or leukaemia of children under the age of ten years, which took place from 1953 to 1955. In this Area there were four deaths. During the last 25 years, the leukaemia death rate in this country has nearly trebled. There is an abrupt increase in the risk of death from leukaemia between one and three years of age. The Senior Medical Officer for Maternal and Child Welfare, Dr. Helen Garrow, took part in finding out the environmental factors surrounding each child who died of malignant disease in this Area, and also of another set of children of the same age and social circumstances who were alive and well. As great interest is already aroused on the subject of irradiation from atomic power plants and waste material, and it is also known that radiologists have a death rate nine times greater than other physicians, special attention was paid in the investigation to rays of all kinds. Luminous clocks, watches, television and pedescopes in shoe shops; therapeutic and diagnostic x-rays of all kinds were carefully noted. A preliminary report has been given, that x-rays of the baby before birth may have a harmful effect. This finding has given all doctors caring for the expectant mother, a warning to be careful of having her x-rayed, and has also made radiologists extremely careful of the number and times of exposure of the films. Daily Guardian Scheme Under the general supervision of the Superintendent Health Visitor, Miss Townsend, this scheme is operated to assist working mothers who are unable to obtain day nursery accommodation for their children under five years of age. The scheme is administered from the Area Health Office and payment of Is. Od. per day is made by the local health authority to approved guardians for each child minded for the day. All daily guardians must first be approved by the health visitor for every child cared for under the scheme and thereafter kept under her observation. No daily guardian is approved to mind more than two children and in the majority of cases approval is given for one child only; and a statement of the conditions of the scheme is given to approved 70 daily guardians and to mothers using the scheme. The number of guardians and children involved in the scheme increased very slightly during the year. Though the Daily Guardian Scheme is outside the sphere of the Nurseries and Child Minders Act 1948, it is our opinion that the Act should apply to all persons receiving children under the age of five years for the purpose of daily minding. There is no doubt that there is a proportion of daily minders who operate outside the purview of the Act and the Daily Guardian Scheme, who because they are aged or for other reasons are incapable of providing proper care for young children. The number of guardians on the register at the end of the year was 119 of whom 63 were minding 71 children. The number of individual children minded during the year was 131 and they were in the guardians' care for 15,246 days. Day Nurseries There are three day nurseries in the Area with a total of 168 places. The average attendance during the year was 111.4 per day and the number of children on the register at the end of the year totalled 143. The number of applications for day nursery admission during the year was 239 of which 42 were refused. All appeals against the decisions made in accordance with the County Council's regulations are heard by the Day Nurseries Panel appointed by the Area Health Committee for this purpose. Appeals against financial assessment of the charges made for admission are also considered by a similar panel. The health and general care of day nursery children is very good indeed. Four student nursery nurses entered for examination of the Nursery Nurses' Examination Board and were successful in obtaining the Board's Certificate. Two of the day nurseries are recognised by the Ministry of Health as training nurseries for the 0-5 age group and one for the 0-2 age group. The latter will be passed for the whole age range as soon as a warden is appointed for the toddlers group. We anticipate that we shall be able to send a member of the present staff for the special course of training early next year which will qualify her for the post. All children admitted to the nurseries are received from families where there are special difficulties, some of a temporary and others of a more permanent nature. Generally speaking mothers regard the local authority's day nurseries as a safer place for daily minding than any other method of minding outside their own homes and the standard of care and the improvement in the conditions of the children admitted to nurseries does much to endorse this view. Day nursery matrons are to be commended not only on the standard of the nurseries in their charge but also for their interest and handling of the mother's problems which are unfolded to them. 71 B.O.A.C. Stewardesses Eight stewardesses attended Park Lane Day Nursery for one day each to receive practical instruction in the care of healthy children. British Red Cross Cadets were also accepted in day nurseries during August for practical experience. The following table shows the attendances at individual nurseries during the year:— Name of Day Nursery No. of approved places at end of year No. of children on register at end of year Total No. of attendances Average daily attendance Under 2 2-5 Under 2 2-5 Under 2 2-5 Total Stonecroft 15 53 14 33 2,719 8,504 11,223 44.2 Park Lane 20 30 12 33 1,392 5,357 6,749 26.6 Plevna 20 30 11 40 2,829 7,506 10,335 40.7 Totals 1956 55 113 37 106 6,940 21,367 28,307 111.4 Totals 1955 55 113 39 111 9,969 20,963 30,932 121.8 Totals 1954 55 113 52 106 11,392 24,278 35,670 139.3 Distribution of Welfare Foods This work has continued throughout the year with the valuable cooperation of the Women's Voluntary Services in both Boroughs. Issues of the various nutrients, which varied little from the previous year, are shown in the following table:— National Dried Milk (tins) Orange Juice (bottles) Cod Liver Oil (bottles) Vit. A & D Tablets (packets) 59,472 158,725 21,571 11,132 Priority Dental Service for Mothers and Young Children The dental service as a whole is discussed later by the Area Dental Officer, Mr. V. Sainty, under the work of the school health service. Reference was made in last year's report to a visit made to this Area by Miss E. M. Knowles, O.B.E., F.D.S., H.D.D., a Senior Dental Officer of the Ministry of Health. Her report on her visit to the County as a whole has caused the Minister to comment particularly favourably on the average number of 2.7 teeth conserved per child treated in Middlesex which, in 1954, was stated to be the best performance in the country. In this connection it is interesting to compare the figures for this Area with those for the County as a whole, bearing in mind that as this Area's 72 figures are included in the County's, some of the latter appear more favourable than they should be for the purpose of this comparison:— Treatment for 100 patients in 1954 Expectant and Nursing Mothers Scalings Fillings Extractions Dentures County Area County Area County Area County Area 58 63 218 237 167 167 30 17 Pre-school Children Fillings and Conservations Extractions County Area County Area 270 337 102 90 The following table gives details of attendances made and treatment given at all clinics during the past three years:— 1956 1955 1954 Expectant and Nursing Mothers Children under 5 Expectant and Nursing Mothers Children under 5 Expectant and Nursing Mothers Children under 5 No. examined by dental officer 234 670 271 657 253 590 No. referred for treatment 226 618 260 624 241 534 New cases commenced treatment 218 551 240 573 233 603 Cases made dentally fit 76 321 67 317 50 246 Forms of dental treatment provided:— Teeth extracted 235 506 352 479 389 541 Anaesthetics: (a) Local 84 72 142 77 132 115 (b) General. 39 213 48 203 42 206 No. of fillings 380 1,169 414 1,247 553 1,278 No. of root fillings. . . 3 . . . No. of inlays 1 . . . 1 . Scalings and gum treatment 128 . 136 . 148 . Silver nitrate treatment . 565 . 512 . 758 Dressings 163 674 144 519 133 560 Other operations 48 138 70 194 40 159 No. of Radiographs: (a) at County Council clinics 28 . 14 1 10 6 (b) at hospital 2 1 1 . . . Denture dressings 179 . 226 . 100 . Dentures fitted: (a) full 18 . 46 . 17 . (b) partial 39 . 59 . 22 . No. of attendances 873 1,583 984 1,606 930 1,732 No. of appointments not kept 193 247 218 370 258 349 No. of ½ days devoted to treatment 296 338 343 73 MIDWIFERY SERVICE Section 23 The Supervisor of Midwives, Miss Curtis, reports that there has been a slight increase in the number of domiciliary confinements during 1956, as was anticipated in 1955. The number of midwives employed has remained at eight. The number of deliveries conducted by the Area midwives was 509, an average of 63.6 per midwife. In spite of the low number of home confinements four pupil midwives were constantly in training throughout the year. These pupils are directed from the Alexandra Maternity Home with which the domiciliary midwifery service works in close co-operation. Analgesia of all available types is now in common use and it is the exception for a mother not to receive this type of relief. Three midwives were sent for one week's residential refresher course during the year. Transport for midwives has improved and five midwives now use cars with very great benefit to the service. The following table shows an analysis of the midwives' work:— No. of deliveries attended 509 No. of visits made 8,846 No. of hospital confinements discharged before 14th day 38 No. of visits made 354 No. of cases in which medical aid was summoned 143 No. of cases in which gas and air analgesia was administered 400 No. of cases in which pethidine was administered 265 No. of cases in which trichloroethylene was administered 33 74 HEALTH VISITING SERVICE Section 24 The Report of the working party on the field of work, training and recruitment of health visitors published during the year gives Local Health Authorities a clear guide as to the requirements of the service and the position of the health visitor as "truly a medico-social worker playing a full part in both preventive medicine and social action." The recommended average case load of one health visitor to 4,300 population is one of a number of important recommendations and conclusions reached by the working party which have so far not been attained in this Area. Case loads in this Area are approximately 1-6,000 of the population. This heavy case load makes a considerable demand on the time of health visitors who deal with emergency home visits, visits for hospital reports, visits to the aged and other special groups, the follow-up of premature infants, special investigations as well as routine visits, and routine clinic work; resulting in more selective visiting than was the case in previous years. Inevitably therefore the number of actual home visits must fall although the quality of each visit is likely to be more valuable to the individual visited. Home visits are not infrequently undertaken during the evening, that is, where it is necessary in order to see working parents and others who are not accessible at other times. Scheme for the Health Visiting of Problem Families In this Area a detailed scheme was prepared as an attempt to assist in the prevention of the break-up of families or their rehabilitation in their own homes. Two Special Services Health Visitors were appointed for this purpose as from March 1957; one for Hornsey and one for Tottenham. In taking over this specialised work they call on other services and voluntary organisations available in the area to assist them when necessary. The Superintendent Health Visitor, Miss Townsend, reports as follows: Home Visiting of families in the flooded areas of Tottenham and Hornsey was undertaken during August. In all 737 houses were visited to ensure that the health of children in these areas was not impaired by the unexpected and unfortunate occurrences. Sponsored Health Visitor Training The Local Health Authority's scheme for the training of health visitor students has proved valuable in providing a source of qualified health visitors to supplement wastage through retirement and other reasons. At present one sponsored student is receiving practical training in this Area under the scheme. 75 Training of Health Visitor Students Practical training was arranged in the Area for six student health visitors for varying periods during the year and in addition one Public Health Administration student. The students attended from the Royal College of Nursing, Battersea and Chiswick Polytechnical Colleges. Student Nurses Lectures Eleven lectures on Social Aspects of Disease were given, at the Prince of Wales's General Hospital, Tottenham, Preliminary Training School, by the Superintendent Health Visitor during the year. The Superintendent and other members of the health visiting staff also gave lectures on first aid, home nursing and the local health services to various organisations in their own time; and in some cases acted as examiners for the British Red Cross Society, Church groups, etc. The Superintendent and another health visitor acted as consultants at careers evenings arranged by the Youth Employment Officer of the Tottenham Youth Employment Bureau. Student Nurses from the Prince of Wales's General Hospital and from the Middlesex Hospital, W.l. were given a variety of public health visits accompanied by health visitors during the year. Other Visitors interested in health visitor and clinic services were also received from interested bodies and from overseas. Health Visitors, Hospitals, Family Doctors and Voluntary Organisations A number of voluntary workers in Hornsey give valuable and regular assistance in infant welfare clinics by weighing young children and undertaking some clerical work as well as the sale and distribution of welfare foods. We wish to acknowledge their voluntary services to the Area and would welcome others who are willing to undertake similar work. Liaison between hospital almoners and health visitors has been very good indeed. 457 health visitor reports have been sent during the year to almoners and other bodies connected with the health and welfare of families. In addition 348 reports were sent to the Medical Research Council in following up children and young persons in connection with B.C.G. vaccination in the prevention of tuberculosis. Co-operation and assistance from family doctors, voluntary organisations and statutory services have done much to assist health visitors in the course of their work. We are pleased to express our recognition of the cordial team-work of the Children's, Social Welfare, School Welfare Departments, the Borough Health Departments and officers of the National Assistance Board, the N.S.P.C.C., W.V.S., Public Health Inspectors, Old People's Welfare Organiser and Diocesan Moral Welfare. 76 Family Planning Association Hornsey Two sessions were held in the Clinic at the Hornsey Town Hall each week during the year, on Monday and Tuesday evenings. Tottenham On Wednesday evening, 4th January 1956, the first weekly session was held at Lordship Lane Medical Centre, Tottenham. National Blood Transfusion Service The North London Blood Transfusion Service were allowed the use of the School Clinic, rear of Hornsey Town Hall for six sessions during the year for the purpose of holding blood donor sessions. Statistics The following table shows the number of visits paid by health visitors during the past two years:— No. of visits paid by Health Visitors working in the Area 1956 1955 Expectant Mothers First Visits 1,851 1,858 Total Visits 2,886 2,955 Children under 1 year of age First Visits 3,412 3,149 Total Visits 13,941 15,392 Children age 1-2 Total Visits 6,828 7,025 Children age 2-5 Total Visits 12,125 13,953 Other cases Total Visits as Health Visitor 4,310 4,686 Total Visits as School Nurse 1,027 1,144 77 HOME NURSING SERVICE Section 25 The Superintendent of the Home Nursing Service, Miss Curtis, reports that notwithstanding the closure of the District Nurses' Homes in Hornsey and Tottenham, the volume of work is unimpaired. The year's working has shown that this service can be efficiently run from an office and use of the telephone service. It took, however, some time for the public to get used to the idea of the nurses living in their own homes, though in fact the majority had been doing so for years, and only a few lived in the Nurses' Homes. It would appear from this year's numbers that some stability has been reached in requests for the nurses' help. The same relationship exists in calls for general nursing, other treatments and injections. The slight drop in the number of injections given by the nurses is due to the fact that penicillin is now more often administered orally. Twenty-two full time and eight part-time nurses are at present employed in the Home Nursing Service. Apart from four nurses who are kept for relief duties, each nurse has a localised district where she works permanently. This has proved to be the most satisfactory method of using the staff. During the year five home nurses attended refresher courses, each of one week's duration. The work has varied little from that of 1955, injections of various drugs and the care of the aged sick still forming a preponderance. With the increasing demand for nursing the helpless patients at home, a need has become obvious in that some type of lifting apparatus is required to enable a nurse to move heavy patients without injury to herself. It is hoped to provide a simple type of hoist for this work in the near future. Also in connection with nursing these patients, the Hornsey Nursing Association has kindly made a gift of two Dunlopillo mattresses for use in Hornsey. These mattresses were sent out to patients a few days after delivery and have been in constant use ever since. They have afforded great relief and comfort to the long term bed patients. Surgical cases discharged home for care of post-operative wounds has continued in an effort to release hospital beds earlier than would otherwise be possible. As reported in previous years lack of adequate motor transport affects efficiency. During the cold and wet winter of 1955 much discomfort for the nurse and much delay was encountered in carrying out visits. 78 No. of No. of new cases No. of cases revisits attended by home maining on register paid nurses during year at end of year by home Type of Case nurses M F Total M F Total during year Medical 861 1,837 2,398 195 458 653 70,315 Surgical 95 121 216 23 17 40 6,814 Infectious diseases 2 3 5 2 1 3 40 Tuberculosis 55 62 117 9 8 17 4,832 Maternal complications 42 42 4 4 696 Totals 1956 1,013 1,765 2,778 229 488 717 82,698 1955 1,063 1,884 2,947 197 479 676 87,774 1954 ... 1,093 1,830 2,923 211 401 612 75,923 Analysis of treatment given to new cases during 1956 General Nursing 667 Other treatments 805 Injections 1,306 Total 2,778 79 VACCINATION AND IMMUNISATION Section 26 Vacination against Smallpox There was a slight falling off in the percentage of children under one year of age vaccinated against smallpox in 1956 compared with the previous year. Nevertheless, the figure of 49.3% is fairly satisfactory and with a variable birth-rate minor fluctuations from year to year are to be expected. The following table records the number of persons in Hornsey known to have been vaccinated or re-vaccinated during the year, by general practitioners and clinic medical officers:— Under 1 year 1 year 2-4 years 5-14 years 15 years and over Total No. of primary vaccinations 876 38 15 7 39 975 No. of revaccinations . . 2 20 160 182 Immunisation against Diphtheria and Whooping Cough Owing to an outbreak of poliomyelitis in Tottenham during the summer, the diphtheria immunisation campaign was suspended during July and August. Efforts to make up the arrears were intensified during the latter part of the year and the results achieved over the whole year compared not unfavourably with the previous year. The following table shows the total number of immunisations of all age groups carried out during 1956 in Hornsey:— Age at date of immunisation No. of children immunised No. of children given re-inforcing injections Diphtheria only Combined Diphtheria and Whooping Cough Whooping Cough only Diphtheria only Combined Diphtheria and Whooping Cough Under one 24 803 . . 2 One 26 169 6 . . Two to Four 19 46 4 244 14 Five to Fourteen 35 3 3 263 16 Fifteen and over 1 . . . . Totals 105 1,021 13 507 32 80 Vaccination against Poliomyelitis In accordance with Ministry of Health Circular No. 2/56 the County Council decided to take part in a limited scheme to provide vaccination against poliomyelitis during May and June for children born between 1947 and 1954. In the early part of the year leaflets and consent cards were distributed through the schools to children to take home to their parents. Publicity in respect of vaccination for children born before 1955 and not attending school was arranged through the welfare centres and by the distribution of leaflets locally in addition to the publicity given in the National Press. The number of consents received was 5,983 equivalent to 23% of children in the eligible age groups. Vaccination of children in Nationally selected age groups was carried out at local clinics during May and June and a few children who received only one injection then were given their second injection in December when a further small supply of vaccine was received. The following table shows the number of children, by years of birth, who received a complete course of two injections during 1956:— Year of Birth No. of Children vaccinated 1947 108 1948 101 1949 77 1950 69 1951 74 1952 39 1953 28 1954 21 Total 517 81 PREVENTION OF ILLNESS, CARE AND AFTER CARE Section 28 Recuperative Holidays The Area health staff continued to be responsible for dealing with applications for recuperative holidays and during 1956 210 applications were received compared with 235 the previous year. Of these, 178 were approved. DOMESTIC HELP SERVICE Section 29 The total number of cases provided with home help during the year was 1,781. This figure shows no sign of declining and has in fact risen by over 500 in the past four years. As stated last year the bulk of the cases comprise the chronic sick, including aged and infirm, who need more or less permanent help, and the demands on the organisation can be readily appreciated when it is realised that nearly 1,000 patients now require help week by week. The following table shows details of the cases served during the year:— Cases provided with help No. of new cases provided with help No. of old cases for which help was continued from 1965 Total No. of cases provided with help during year Total No. of cases still being provided with help at end of year Maternity (including expectant mothers) 128 8 136 14 Tuberculosis 36 38 74 40 Chronio Sick (including aged and infirm) 585 828 1,413 910 Others 138 20 158 14 Totals 887 894 1,781 978 Night Service The service was extended during the year by the introduction of a night service scheme intended to provide help for patients who are very ill or dying and who need night attention, and so enable relatives or others who normally provide this assistance to get a certain amount of relief. The scheme came into operation in June 1956 and details were 82 forwarded to the local representatives of the British Medical Association and to hospital almoners. The scheme, although not widely publicised in its early stages, has shown that it meets a need, and is to be continued on a gradually developing basis. Training Scheme During the year, by arrangment with the Eastern Electricity Board, a number of home helps attended at the local showrooms for instruction in the use of electrical appliances. In addition, ten home helps attended a departmental course of five lecture demonstrations designed to make the personnel more able to deal with emergencies, teaching them elementary precautions which they can take to avoid infection and advising them how their services may be of most use in families where financial or material resources are limited. Further courses have been arranged for 1957. NURSING HOMES The Senior Medical Officer, Dr. Helen Garrow, reports there were, up to November 1956, five Nursing Homes in Hornsey. Since then one has changed to an Old People's Home, leaving four registered Nursing Homes. The position of the private Nursing Home has grown steadily more difficult, mainly but not entirely due to the rising cost of commodities. Heating of the large houses has been one of the greatest expenses, as well as increased cost of linen, mattresses, dressings, etc. Difficulty of getting adequate nursing staff of the right type, and the cost of staff has also been great. Few nursing homes can compete with the "Private Wings" of the big general hospitals, and the four remaining Homes in Hornsey do not attempt to do so. They cater for the aged sick and chronic cases. They supply all the comforts and care necessary for the treatment of these old people, whether they are in for a short rest, or for many months. Strathlene, Creighton Avenue 16 beds Claremont, Colney Hatch Lane 9 beds Kenwood Annexe, Princes Avenue 14 beds Kenwood Nursing Home, transferred to Old People's Home, November 1956 St. Mary's, North Hill 6 beds 83 SCHOOL HEALTH SERVICE The work of the school health service was maintained and expanded during 1956. Routine medical inspections continue to prove of real value and much appreciated by parents who attend in such large numbers. It is important to bear in mind that the health-assessment and healthpromoting functions of these examinations are at least as important as the discovery of defects. This year was the first full year of the B.C.G. (anti-tuberculosis campaign) and the good response of parents seen in 1955 was well maintained. The orthoptic clinic, opened at Lordship Lane in June 1956, has filled a great need for the people of Tottenham saving much time and expense for parents who formerly took the children to hospital. The clinic was inaugurated with six sessions weekly and has expanded to nine sessions. Extension of the work of the Cerebral Palsy Unit at Vale Road School for the Physically Handicapped is mentioned later in the report. During the previous year the Minister of Health gave approval to the diagnostic and advisory functions of this unit being extended to pre-school children under Section 22 of the National Health Service Act. General Health and Infectious Diseases The health of the school population was in general well maintained during 1956 as is shown in the following table. The general condition of pupils is now classified as "satisfactory" and "unsatisfactory" and not as "A", "B" or "C", the classification used heretofore. This new assessment must be regarded as an improvement; the noting of a child as unsatisfactory is an immediate stimulus to action by the doctor and health visitor concerned to take steps to see that the child is restored to optimum health. PERIODIC MEDICAL INSPECTION IN HORNSEY Periodic Medical Inspections Additional periodio inspections Other Inspections Entrants Second age gronp Third age group Total Special Inspections Reinspections 990 525 854 2,369 2,158 1,414 923 84 CLASSIFICATION OF THE GENERAL CONDITION OF PUPILS IN HORNSEY Age Groups No. of pupils inspected Satisfactory Unsatifactory No. % No. % Entrants 990 984 99.4 6 0.6 Second Age Group 525 523 99.6 2 0.4 Third Age Group 854 849 99.4 5 0.6 Additional period inspections 2,158 2,153 99.8 5 0.2 Total 4,527 4,509 99.6 18 0.4 As far as the notifiable infectious diseases in school children are concerned, 1956 was, with the exception of poliomyelitis, an uneventful year. The outbreak of poliomyelitis in Tottenham is referred to elsewhere but it should be noted here that 15 cases occurred in school children of whom six were at Lancasterian School and the Nursery Classes at this school were in fact closed from the 3rd July until the summer vacation. One of the children concerned was left with a paralysed arm and has been admitted since to Vale Road School for Physically Handicapped Children. Two others were not yet fit to return to school at the end of the year and may require to attend at a special school when discharged. One case of diphtheria, rather unusually, of the ear, occurred in an immunised school child, but this case was extremely mild and made an entirely satisfactory recovery. There were no outbreaks of food poisoning or of dysentery in the schools of either borough during 1956. Tuberculosis in Schools Notifications of tuberculosis (all forms) in school children during 1956 were seven in number compared with 14 in 1955. These cases were discussed with the appropriate chest physicians and where the child was infectious, or where no source of infection was found in the home, epidemiological investigation was carried out at the school. In 1956 this was necessary in only one case, when a boy at South Grove Secondary Modern School was discovered to have tuberculous pleurisy. As no contact could be found in the home, epidemiological investigations were carried out at the school. One boy was found to have tuberculosis of the right lung and has been admitted to Highwood Hospital. The School Meals staff have been x-rayed and all x-rays were found to be negative. Nine of the teaching staff were x-rayed and found to be negative. Tuberculin testing undoubtedly proved its value in this case bringing to light an adolescent with active tuberculosis. 85 Mantoux testing at another school as part of the B.C.G. vaccination programme revealed an unusually high number of strong positives. An epidemiological investigation had been carried out during the previous year at this school as the result of the discovery of a case of tuberculosis in a school child. Nevertheless, after consultation with the chest physician it was thought desirable to recommend that all the teachers be x-rayed and this was done. Fortunately all were found to be healthy. Patch Testing in Schools District Patches applied and read Results Positive Negative Hornsey 701 15 % 2.1 686 Tottenham 542 19 3.5 523 Totals 1,243 34 2.7 1,209 During 1956 patch testing of school entrants was carried out on all children whose parents gave consent and the results are given above. The percentage positive is very small, a fact in line with the findings at Mantoux testing of 13 year olds. The Tottenham percentage of positives is higher than in Hornsey but the number is small. All of these children were referred to the chest clinic for further investigation and follow-up of family contacts but no case of active tuberculosis was discovered in this way. It may well be that the routine annual patch testing of children attending at toddler clinics may prove to be a more fruitful source of primary cases and this has indeed begun at one clinic. B.C.G. Vaccination The B.C.G. vaccination campaign has continued in our schools in 1956 and followed the scheme outlined in last year's Annual Report. The service has been extended to include schools other than those of the Local Education Authority and the B.C.G. vaccination team visited Highgate School in December. Vaccination against tuberculosis, by means of the avirulent B.C.G. vaccine, was carried out on all tuberculin negative children in the 13-14 age group whose parents gave consent. The accompanying table shows that the successful start made in 1955 has been continued in 1956. 86 HORNSEY 1 956 1955 % % Parents approached 1,025 343 95.3 Parents accepting 741 72.3 327 95.3 Mantoux positive 67 9.8 17 5.9 % Strong positives, Reaction greater than 20 mms in diameter 44.8 5.9 % Weak positives 55.2 94.1 Mantoux negative 587 85.9 266 92.4 Total vaccinated 586 57.2 of children in group approached 264 76.9 of children in group approached Within the whole of the Area 70% of the parents accepted in 1956, which was the same percentage as in 1955. 12% of those tested were tuberculin positive compared with 8.6%: the mean figures for the two years being 10% tuberculin positive. There appears to be an increased reaction to the Mantoux test in 1956 compared with 1955. For 1955 there were 25.7% "strong" Mantoux positive reactions, while in 1956 there were 40.2%. The B.C.G. vaccination reactions again showed no excessive ulceration or abscess formation. (2,278 children have now been B.C.G. vaccinated in this Area under the present scheme). The Mantoux positive children referred to the chest clinic during the year were all found to be free from tuberculosis. The general medical practitioners in the Area have been notified of the results of Mantoux testing and informed when each child has been vaccinated. The staff of the schools visited and the chest physicians have throughout the year shown the utmost consideration and co-operation. M.R.C. Clinical Trials with B.C.G. In 1956 the Medical Research Council published the first progress report of their Tuberculosis Vaccines Clinical Trials undertaken by Dr. T. M. Pollock. It has been previously reported that school leavers in this Area in 1951 volunteered to take part and that they have been followed up by the health visitors since. The investigation consisted of a controlled clinical trial of B.C.G. and Vole bacillus vaccines in the prevention of tuberculosis in adolescent boys and girls. The results in the test areas appeared satisfactory in so far as the trials indicated that each vaccine conferred a substantial and similar degree of protection against tuberculosis over the period of the trial. 87 In the above trials the participants were investigated towards the end of their 15th year by which time 40% were tuberculin positive using old tuberculin for the Mantoux test. In 1955 and 1956 in this Area the 13-14 age group were Mantoux tested using Purified Protein Derivative and only 10% found to be tuberculin positive. This figure is therefore far below that of the Medical Research Council trials, but other information available has shown that other neighbouring areas vaccinating the same age group and using P.P.D. for the Mantoux test have a percentage of tuberculin positive children which is similar to ours. The Medical Research Council's report stated that in the light of present results the vaccination of tuberculin negative school children in the 13-14 age group, as carried out in the present B.C.G. vaccination scheme, is a valuable measure. 88 89 THE HANDICAPPED CHILD—DISTRIBUTION AS AT 31st DECEMBER, 1956 IN HORNSEY CATEGORY In Special Day Schools In Special Residential Schools In Maintained Primary and Secondary Schools In Independent Schools Not at School TOTAL B G B G B G B G B G B G Blind Pupils . . 3 2 . . . . . . 3 2 Partially Sighted Pupils 2 3 . . . . . . . . 2 3 Deaf Pupils 1 1 . . . . . . . . 1 1 Partially Deaf Pupils 2 2 2 2 . . . . . . 4 4 Educationally Sub-Normal Pupils 26 20 5 3 . . . 1 . . 31 26 Epileptic Pupils . . 1 1 . . . . . . 1 1 Maladjusted Pupils . . 15 3 2 . . . . . 17 3 Physically Handicapped Pupils 8 2 . . . . 1 . . 1 9 3 Pupils with Speech Defects 1 1 . . 88 26 2 2 2 1 93 30 Delicate Pupils 2 1 4 4 1 . . . . . 7 5 Pupils with Multiple Defects 1 . . . . . . . 1 . 2 . TOTALS 43 30 30 15 91 28 3 3 3 2 170 78 GRAND TOTALS 73 45 119 6 5 248 Dr. Yarrow, Deputy Area Medical Officer, reports as follows on the local provisions for the care of the physically handicapped child. This year has been one of consolidation of the work done in previous years in this field of the School Health Service. The opening of special schools for physically handicapped and deaf children elsewhere in the County has entailed some alteration in placement of children at Vale Road School for Physically Handicapped Children and at the Blanche Nevile School for Deaf Children in Tottenham although no child was moved where this was thought undesirable on medical or educational grounds. The provision of further school places elsewhere for E.S.N children meant a considerable easing of the position at Oak Lodge (Finchley) and this has had the result of virtually eliminating the Hornsey waiting list for such children. During 1956 consent was obtained from the Ministry of Education to the opening of an Audiology Unit in Tottenham for the ascertainment and supervision of young deaf children. Unfortunately its opening was followed shortly after by the prolonged absence through illness of the Visiting Aurist, Dr. F. P. M. Clarke, so that a real start could only be made with this on his return to health. The separation of partially deaf children from the deaf has been of great value in the younger age group and it is hoped that a unit for senior partially deaf pupils will, during 1957, be opened at the new Markfield (Secondary Modern) School in Tottenham. The degree of integration with normal hearing children would be much greater with these older children than is at present the case at the Devonshire Hill class for junior partially deaf children. With so much work accomplished in the field of provision of new facilities for handicapped children in the past few years, it is useful now to have a period in which we can take stock. As is well known, there has been a revolution in medicine over the past few years and this has had far-reaching effects on the type of child needing special educational treatment, and less apparent effect on the numbers. An attempt has been made here to consider these changes as they affect the problem of the deaf and physically handicapped categories of school children. The use of prophylactic technique (e.g. B.C.G. vaccination of infants) and chemotherapeutic drugs and antibiotics has wrought far reaching changes in the types of children reaching the Blanche Nevile School for the Deaf. These drugs, the sulphonamides, penicillin and streptomycin at first succeeded in saving the lives of a great many children who would otherwise have died of meningitis but unfortunately many of the survivors were afflicted with deafness, some as a result of streptomycin therapy. This phase has been succeeded by another in which therapeutic techniques seem to have greatly improved so that the survivors are not being deafened. Tables A and B illustrate these phases admirably. Table A shows the causes of deafness in the various age groups among deaf and partially deaf children at special schools (both day and residential) in the Autumn term of 1956. Table B was prepared from the register of the Blanche Nevile School as at September 1951 and the two together illustrate the changes that have taken place in five years. 90 Table A Ascertained Deaf or Partially Deaf Children in Tottenham and Hornsey at special schools in Autumn Term 1956 Age Cause 2- 4 Congenital 5 5-10 Congenital 7 T.B. Meningitis 2 (1950-52)(1953) Suppurative Otitis Media 2 (1949-50)(1953) 11-16 Congenital 13 Pneumonia 1 (1946) Meningitis 3 (1943)(1945)(1947) T.B. Meningitis 2 (1951-52)(1950) Suppurative Otitis Media 1 (1948-51) Dates in brackets show date of causative illness. Table B Tottenham and Hornsey Children at Blanche Nevile School in September, 1951 Present Age Cause 10-15 Congenital Deafness 11 T.B. Meningitis 1 (1950) Purulent Meningitis 2 (1945)(1947) 16-20 Congenital 1 T.B. Meningitis 1 (1950) Purulent Meningitis 3 (1937) (1941) (infancy) Suppurative Otitis Media 2 (1938) (Not known) Dates in brackets show dates of causative illness. It will be seen that the cases of purulent meningitis occured soon after the discovery of the clinical uses of the sulphonamides circa 1935 and cover the years 1937 to 1947; but no child has been admitted to the school roll who has had meningitis since that date. Similarly cases of tuberculous meningitis first began to recover soon after the initiation of streptomycin therapy circa 1948, but many of these children were deafened. Once the dangers of excessive streptomycin therapy became apparent these cases too have appeared to lessen and no child has so far been admitted who was treated with streptomycin later than 1953. As far as suppurative otitis media is concerned, the picture is not very clear, but it does appear to be a continuing cause of deafness. Clinical impressions lead one to believe that the disease, at least in its chronic form, is less common and more efficiently treated and it is to be hoped that fewer cases will require to attend special schools in the future. 91 Admissions then are likely to be more and more confined to the group of congenital defects. It is of interest to note that in no case of the group of congenitally deaf children (Table A) did the mother give a history of rubella in pregnancy, and in only one case (in the nursery group) was there a history of erythroblastosis foetalis, a much more easily diagnosed and remembered condition. Of course, congenital deafness of hereditary origin is often a diagnosis of exclusion but it is of interest to note that of the 25 cases of congenital deafness (Table A) ten gave a family history and of the remainder four were Jewish children. As far as absolute numbers are concerned, the above considerations would lead one to expect a drop in the total number of deaf children, but the national figures (Health of the School Child 1954-5) do not yet support this and perhaps it is too soon to expect it. It may be, too, that fuller ascertainment partially accounts for this. The Physically Handicapped Child A review of the children ascertained as physically handicapped in Tottenham and Hornsey as at December, 1956 reveals a similar picture:— 1. Congenital deformities and disorders 14 2. Congenital heart disease 7 3. Infantile cerebral palsies 13 4. Tuberculosis 2 5. Post rheumatic fever 2 6. Post paralytic poliomyelitis 3 7. Perthe's disease 1 8. Still's disease 1 9. Bronchiectasis (infective origin) 1 10. Cerebral accidents 2 46 Only in groups 4, 6, 9 and probably in 5 and 8 can there be said to be an infective origin, a total of only 9 out of 46 children. All of these groups show a declining incidence, apart from poliomyelitis which will probably give way soon to prophylactic technique. Improved obstetrics and operative techniques will, however, increase the number of children with congenital deformities who are likely to survive and require special educational treatment. Improved obstetrics may, however, reduce the number of cases of cerebral palsy (and perhaps of deafness). It would appear that in this field at least only further research into the causes of congenital defects and the elimination of harmful ante-natal influences can further reduce the number of handicapped children. Change of Name of the Tottenham School for the Deaf In a letter to the Borough Education Officer, Mr. J. Power, M.A., Miss Nevile, the first headmistress to the School, writes:— "In giving my permission for the Tottenham School for the Deaf to be renamed ' The Blanche Nevile School', I wish to say how greatly I appreciate the honour done me by such a suggestion. 92 My mind goes back to a certain day in 1895 when, in pursuance of the Deaf Education Act of 1893, the then Tottenham School Board appointed me to open the school. I did so—in one room—where I found 7 deaf mute children—boys and girls—ranging in age from 5 to 15 years. I was fresh from a special training college and this was a stiff problem in classification! I could only solve it by dividing each session into 5 periods of speech and language training and devising suitable and varied occupation for the restless pupils not under special instruction. The strain was severe and it naturally became my ambition to interest the neighbouring authorities and so to increase numbers, thereby making possible proper classification, so that every child could receive full-time instruction. This took years and as my mind goes back, I realise how much I owed in those difficult times to the sympathetic understanding from the Inspectorate of the Board of Education, the help of the local Education Authority, the wonderful co-operation of my staff and the great courtesy of other schools in England, Germany and America. In these schools I was welcome to gather anything I could to assist me in solving my own problem. In 1925 I left the school to take up other work for the deaf, but I still think of what Tottenham taught me. To educate the deaf—what is it? To give to the deaf, who are deprived of the only natural means of learning it, the power to understand and use that huge complicated system of symbols (spoken and written) we term language, in which the mind of Man lives and moves and has its being. Surely there cannot be any job in the world more intellectually and spiritually rewarding than the Education of the Deaf". Vale Road School for Physically Handicapped Children Cerebral Palsy Unit I am indebted to Dr. William Dunham for the following report:— "Twenty-seven of the 94 children now at this Special School have cerebral palsy, and parents of all but four of these are now participating in a programme of comprehensive management in which parents, teachers and medical staff collaborate to provide for the child the help he needs in attaining to the best of his ability normal activity. Parents attend from time to time for advice at the school and, where necessary, the therapist visits the parents in their homes during the holidays. Only two of the children have left school during the year, both being transferred to another school and their places taken by other children with cerebral palsy. My work as Consultant has included giving advice on 11 children with cerebral palsy other than those attending the school including two who attend Occupation Centres. It is hoped that in the future more of the babies and children of pre-school age who have cerebral palsy will be 93 referred so that, through early treatment, they may be given the best chance of winning for themselves a place in normal society." The Vale Road Day Special School continues to provide mainly for other forms of physical handicap, references to the type of cases and change in pattern being referred to on page 92. The demand for ancillary medical workers at the school has increased and during the autumn term two physiotherapists were engaged to devote seven sessions in all to children other than those suffering from cerebral palsy, the work of the physiotherapists being under the general direction of Mr. E. Hambly F.R.C.S. of the Prince of Wales's General Hospital and of Mr. E. T. Bailey, F.R.C.S. at Highlands Hospital. Formerly many of these children had lost two or three half-days a week travelling to hospital for physiotherapy. The speech therapists, too, have continued their work with several difficult and interesting cases referred to in Miss Came's report. Speech Therapy Miss Came, Senior Speech Therapist, reports as follows:— "The accompanying table shows that the majority of children suffering from dyslalia were referred before six years of age. This satisfactory result is largely due to teachers' recognition that speech therapy frequently assists educational progress. In stammering, early treatment has also proved the most effective. The speech therapists aim to prevent (a) the fixing of early speech nonfluency through the parents' well-intentioned but ill-informed interference, and then labelling the child "a stammerer"; (b) the formation of abnormal secondary symptoms, due to anxiety and increasing awareness of speech difference, causing the disorder to become self-perpetuating. It is therefore most important that all concerned with small children should refer those with any speech defect or delayed speech to the speech therapist as early as possible. During 1956, treatment was carried out in the various groups on the following lines:— 1. Pre-school children. Treatment was mainly indirect, through talks with the mother. This preventive work has proved of particular value in cases of primary stammering. Improvement is more rapid, and final recovery more complete. 2. Infant school children. These formed the largest group treated. Many were discharged as normal speakers, before entry to the junior school. 3. Older children. These were fewer in number, but their difficulties slower in responding to treatment. Work with the older stammerer aims to reduce anxiety and increase insight. 4. Children with severe speech abnormality, sometimes associated with such disabilities as cerebral palsy. These are treated at Vale Road School for the Physically Handicapped. In all cases the improvement resulting from speech therapy has been measurable, although it is inevitably achieved far more slowly." 94 95 HORNSEY CHILDREN SUFFERING FROM SPEECH DEFECTS as at 31st DECEMBER, 1956 Individual Defects Boys Girls Under 6 6-10 11-15 + Total Under 6 6-10 11-15 + Total Dyslalia 26 20 1 47 12 3 . 15 Stammer 5 13 3 21 1 2 1 4 Stammer with defective articulation 1 2 . 3 2 1 . 3 Interdental Sigmatism 6 7 . 13 1 2 2 5 Lateral Sigmatism 1 3 . 5 1 1 • 2 Cleft Palate Speech . . . . . . . . Delayed Speech Development 2 . . 2 . • . . Excessive Nasality . . . . . . • . Insufficient Nasality . 2 . 2 . 1 . 1 Dysarthria . . . . . . . . Inco-ordinated Speech . . . . . • . . Slightly Deaf . . . . . . . . Totals 41 47 5 93 17 10 3 30 One Hornsey boy under 6 years old with multiple defects was receiving speech therapy School Dental Service The Area Dental Officer, Mr. V. Sainty, L.D.S., reports there have been several staff changes during 1956. One full-time dental officer resigned in June, a part-time one, becoming full-time from July 1st, took over the post. Another dental officer resigned his full-time appointment, but remained on a part-time sessional basis. Also there have been other part-time changes in personnel. The net result has been one less full-time staff than in 1955, viz. seven including the Area Dental Officer, as compared with eight, plus approximately the same amount of part-time assistance. This decrease in full-time dental officers emphasises the general trend of a growing difficulty in replacing resignations in the service other than by part-time appointments, and these are sometimes of short duration. In spite of the somewhat less favourable staff situation, compared with the previous year, the amount of treatment carried out has shown little change; in fact as regards fillings inserted in permanent teeth there was a small increase, 15,992, as against 15,537 in 1955. The ratio of fillings to permanent teeth extractions was also better, viz. 12.2:1 as compared with 11.4:1. During the year 19,134 children were inspected at the schools by the dental officers. All age-groups in many of the schools have had an annual inspection during the last two years. Orthodontic Clinic It has not yet been possible to extend this work beyond the six-seven session a week basis and consequently there is still the same long waiting list for treatment, in spite of the quite considerable number of cases treated by some of the dental officers. At the moment the orthodontic situation seems to be the most urgent problem requiring solution. 96 The following tables show the work carried out during the year in Hornsey:— DENTAL INSPECTIONS AND TREATMENT IN HORNSEY Age Groups No. inspected No. found to require treatment No. referred for treatment at the County Council's Dental Clinics Under 5 26 22 16 5-16 and over 2,342 1,767 1,638 Specials 1,717 1,571 1,559 Totals 4,085 3,360 3,213 Number of pupils treatment commenced 2,545 Number of pupils treatment completed 1,895 Number of attendances made by pupils for treatment 7,125 Number of appointments not kept 1,226 Number of half days devoted to (a) Inspection 27½ (b) Treatment 1,047½ Fillings—Permanent Teeth 4,701 Temporary Teeth 1,817 Number of teeth filled.—Permanent Teeth 4,119 Temporary Teeth 1,693 Extractions—Permanent Teeth 256 Permanent Teeth for Orthodontia 91 Temporary Teeth 1,707 Anaesthetics (a) General 772 (b) Local 498 (c) Regional 119 Other operations (a) Permanent Teeth 964 (b) Temporary Teeth 1,536 SPECIAL DENTAL TREATMENT UNDERTAKEN BY DENTAL OFFICERS Number of impressions, etc. 19 Number of Dentures fitted 11 Number of crowns and bridges 1 Number of inlays Number of radiographs (a) at Dental Clinics 80 (b) at Hospital 2 97 ORTHODONTIC EXAMINATION AND TREATMENT AGE GROUPS Totals 5 6 7 8 9 10 11 12 13 14 Number of pupils examined . 5 3 12 11 9 5 5 3 7 60 Number of pupils selected for treatment . 3 2 11 11 6 4 1 3 6 47 Number of pupils commenced treatment (first attendance) 109 Number of attendances made for treatment 596 Number of consultations 1 Number of impressions, etc. 277 Number of fixed appliances fitted . Number of removable appliances fitted 48 Number of radiographs (a) at Dental Clinics 10 (b) at Hospitals Number of pupils treatment complete 19 Number of orthodontic sessions (½ days) 58 Tottenham Eye Clinic I am indebted to Mr. T. G. Kletz, M.B., Ch.B., D.O.M.S., Visiting Ophthalmologist, for the following report:— "The total number of cases seen was 1,790. Orthoptic Department. During the first year of having an orthoptist at the Clinic, this department has been very busy. No. of cases (for investigations and reports) 283 No. of cases having treatment (including 48 cases of occlusion for amblyopia) 170 Orthoptic treatment—successful 44 partially successful and still being treated 66 unsuccessful 12 Occlusion cases—successful 20 improved 10 unsuccessful 18 No. of cases referred for surgery 8 In addition, 37 cases have not been treated due to failure to attend or refusal of treatment. Blind certification. One case only was certified as blind and no cases as partially-sighted during the year. Glasses. The concern, which I have previously mentioned, about the high rate of loss and breakages is fully justified. A total of 1,367 prescriptions for glasses (Form H.E.S.l.B.), were dispensed by the Clinic optician. The number of repairs and complete replacements during the same period totalled 429 (Form H.E.S.l.A.) or nearly 32%. 98 "E" Testing. From March to December the number of cases referred following "E" Test was 61 of whom 34 were given glasses, 55.7%." Orthopaedic Service Mr. E. Palser, M.R.C.S., reports that there has been considerable activity in the orthopaedic services in Hornsey. In addition to the clinics and treatment necessary, the Hornsey orthopaedic service has the advantage of being in close liaison with Highlands General Hospital, N.21, where Mr. Palser and the Orthopaedic Unit directed by Mr. E. T. Bailey, F.R.C.S., can carry out operative treatment, or specialised treatment and further investigations which may be required. The following table gives figures for the above activities:— Under 5 Over 5 Clinic attendances 206 620 Treatment session attendances 72 1,112 Operative treatment at Highlands General Hospital . 5 Further investigations and specialised treatment at Highlands General Hospital . 3 One case of rickets was seen this year, the first for many years. Rheumatism Supervisory Centre This clinic has continued to hold specially allocated fortnightly sessions at the Prince of Wales's Hospital in association with the Children's Outpatient Department under the control of Dr. I. M. Anderson, Consultant Paediatrician. The review of the register commenced during 1954/55 has now been completed, and some lapsed cases have been reclaimed, whilst others have been removed from the register. In spite of this review, the number of new cases exceeds the cases removed, indicating that the field of supervision is enlarging. Distribution of new cases:— Male Female Tottenham area 7 8 Outside area 6 6 Medically these cases were allocated as follows:— Tottenham Area Outside Area Rheumatic Fever 1 Rheumatic Carditis 1 5 Chorea 2 . Rheumatic Limb Pains 1 . Congenital Cardiac Lesions . 6 5 Other cases 4 2 Totals 15 12 99 A review of all cases on the Rheumatic Register shows the following present distribution:— Cases under supervision 69 Discharged 33 Males 125 Transferred on removal 15 Females 119 Lapsed 16 Deaths (total) 11 244 244 Of the children under supervision, 111 children made 266 attendances at the clinic during the year. In addition a number of children were seen in other children's outpatient clinics under the supervision of Dr. I. M. Anderson. The present classification of cases under supervision is:— Tottenham Area Outside Area Total Rheumatic Fever 32 17 49 Rheumatic Carditis 23 13 36 Rheumatic Fever with Chorea 1 • 1 Chorea (uncomplicated) 4 . 4 Chorea with carditis 3 . 3 Rheumatic Arthritis 2 3 5 Congenital Cardiac Lesions 35 22 57 Other cases 11 3 14 111 58 169 Male 81 Female 88 It will be seen that congenital cardiac lesions now form a larger group than other cases of true rheumatic heart disease in childhood. The supervision of these congenital cases is regarded as an important additional aspect of the work of this clinic. Many of these children need no restrictions and are able to lead an active normal life. In other cases, full exercise is not possible, and periodic review is necessary; the increasing possibilities of cardiac surgery may make it possible to advise the parents that the child's condition can be improved in certain carefully selected cases. Another group of children are approaching the school-leaving age; the problems of future careers and occupations are discussed with their parents and it is often possible to supervise the early school leavers for one or two years subsequently, to ensure that they have become firmly established in a suitable occupation. 100 Child Guidance Service I am indebted to Dr. R. E. Brettle, M.A., D.Phil., Borough Education Officer, Hornsey, for the following report on the work of the Child Guidance Service in Hornsey. At the beginning of the year, the staff of the Child Guidance Centre had been increased by the addition of two remedial teachers (one fulltime and one part-time) and, later in the year, a third teacher (full-time) was employed. Against this, must be set the loss of Miss Stewart, the psychotherapist, who, in six sessions per week, had carried out most of the treatment recommended after psychiatric examination. Although the post has been advertised twice, there have been no applications from persons with the qualifications looked for. The lack of qualified psychotherapists is being felt in areas other than Hornsey. Whilst the present need is to use the limited psychiatric time we have to best advantage, it is hoped that the present shortage will be only a temporary one. The additions to the staff have made still more clear the inadequacy of the accommodation. The Educational Psychologist, Psychiatric Social Worker, and Clerical Assistant have rooms at the Town Hall, whilst the psychiatric interviews and treatment take place in rooms at the Social Centre which are hired for certain sessions. The remedial teachers have no satisfactory base for their work. The efficiency of the Centre is reduced by this geographical division; the hired accommodation is not suitable for its purpose, and the accommodation at the Town Hall is extremely cramped. Some thought is being given to this problem of accommodation. The services provided by the Centre range from a more general advisory service to the schools, to the investigation and treatment of children, individually or in small groups. 1. More General Service As will appear later, the facilities for individual work are limited— and will always be so in relation to the needs. Great stress is therefore laid on this more general service since it enables the Child Guidance Centre to influence indirectly a larger number of children. (a) Discussion with Head Teachers and staff of individual children and of the psychological aspects of particular educational problems, e.g., school organisation, the use of pupils' cumulative Records; provision for retarded and backward pupils, behaviour difficulties. (b) A course of lectures was held which was attended by teachers from Hornsey and from the neighbouring boroughs. (c) Surveys were continued of the "backward" readers at three age levels—the first year junior group, the fourth year junior group, and the school-leavers (15+) group. The results, shown in the following table, indicate the good work which schools are doing for the backward children. The results of earlier surveys are added for comparison. 101 SUMMARY OF READING SURVEY RESULTS (% of backward children at each age level) School Year 1st Year Junior 4th Year Junior Leavers Boys Girls Total Boys Girls Total Illiterate SemiIllit erate Backward 1955-56 7.1 3.1 5.1 7.4 5.1 6.4 .1 .2 7.8 1954-55 8.5 4.2 6.4 8.8 7.0 7.9 . . . 1952-53 . . . . • . .1 .2 15.2 1948 19.7 12.2 16.2 15.0 10.4 12.8 . . . 1946 21.7 13.6 17.8 . . . . . • Apart from their value as indicating general levels, these surveys provide schools with lists of their children for whom provision will need to be made; and encourage follow-up inquiries. They are also used when children are selected for help in small groups by a peripatetic remedial teacher. (d) In consultation with the Head Teachers concerned, small groups of children in their first or second year at the junior schools were selected for help by the specially appointed remedial teachers. The intention was to take backward, but intelligent, pupils in the first year of the junior schools, in the hope of dealing with the reading difficulty before it became fixed. The results so far, despite difficulties of accommodation and equipment, have been encouraging. 64 children were included in these groups. Of these, 7 left the area before the end of the year, but of the remainder, 40 improved sufficiently to dispense with this special help; 17 failed to do so and were included in special groups the following year (some of these have now improved enough to dispense with the special help). The following table gives the improvement in Reading Ages of the 57 children for whom details were available. Gain in R.A. No. of Pupils 0- .4 years 4 .5- .9 „ 13 1.0-1.4 „ 15 1.5-1.9 „ 13 2.0-2.4 „ 7 2.5-2.9 „ 2 3.0-3.4 „ 1 3.5-3.9 „ 2 This improvement was, of course, a joint result of the work of the specialist teachers and the class-teachers, whose co-operation will be 102 increasingly fruitful. Nor was the improvement limited to an improved skill in reading; in some cases, the attitudes of the pupils to school itself were changed. (e) Allocation to Secondary Schools The use of school records and Primary School Head Teachers' opinions for the "border-zone" candidates was again used, and ways were discussed of making more use of the Head Teachers' reports on pupils in independent schools. The immigration of children from overseas provided a problem in allocation which may well be larger next year. 2. Examination of Individual Children It is here that statistical analyses are most arbitrary. The following figures do, however, illustrate certain general trends. The referrals to the Chi'd Guidance Centre came mainly from the Schools. Sources of Referral Schools 71 A.M.O. 26 Hospitals 5 G.P.'s 3 Parents 7 Children's Officer 1 113 (excluding children referred for educational guidance). Many of these children or their parents could be dealt with fairly quickly, as when it was a question of educational guidance, examination as possibly E.S.N., selection for special groups; or minor difficulties. Some 57, however, were referred to the visiting psychiatrist for examination. (Dr. Phillins attends the Centre on two mornings each week) The following table shows the "wastage" which occurs. With our present facilities, there is a lengthening of the waiting list for diagnostic examination, and especially for treatment. Children Referred in 1956. 57. Withdrawn before diagnosis 8 (49) Still awaiting diagnosis 16 (33) Referred elsewhere 6 (27) Treatment waiting list 7 (20) Placement away from home 10 (10) Referred to Psychiatric Social Worker 4 (6) Advice only 3 (3) Others 3 (-) The importance of the fairly high proportion of placements away from home which are recommended is that we get extremely severe cases from homes with severe emotional disorders in the parents. "Placement", with its attendant annual review, tends to take an increasing proportion 103 of the psychiatrist's time and, whilst the child is away, work continues with the family and occupies an increasing proportion of the time of the Psychiatric Social Worker and the Educational Psychologist. Psychiatric Interviews Diagnostic Interviews 40 (of these, 10 were referred in 1955). Annual Reviews 15 Case reviews in connection with treatment waiting list 4 59 Children treated by psychiatrist 4 Children treated by psychotherapist 18 22 (Both psychiatrist and psychotherapist had a number of occasional interviews with parents and others). The work of the Psychiatric Social Worker has expanded beyond the taking of social histories and dealing with parents while the child is having treatment. It reflects the wider preliminary work which goes into the selection of cases; the more continuous work which is done while the child is awaiting treatment, or after he has been placed away from home; and the follow-on work which is done after the child's treatment has ceased. In these respects, the work with particular families is becoming more comprehensive, but it will also indicate the relatively small numbers with which a Centre such as ours can deal. Psychiatric Social Worker's Interviews Cases Interviews Social Histories 45 49 Follow-up of diagnostic interviews 20 25 In conjunction with treatment 24 385 Interviews with parents of "placed" children 16 65 Interviews with parents where this is the only recommendation of the psychiatrist 12 56 Interviews with parents of children who are awaiting treatment 12 54 Interviews with parents after treatment has ceased 5 28 104