TOT 18 Borough of Tottenham Annual Report ON THE HEALTH OF THE BOROUGH FOR THE YEAR 1943 G. Hamilton Hogben Medical Officer of Health and School Medical Officer 2 Public Health Department, Town Hall, Tottenham, N. 15. 31st December, 1944. To the Mayor, Aldermen and Councillors of the Borough of Tottenham. Mr. Mayor, Ladies and Gentlemen, T have the honour to submit my Annual Report on the health of the Borough for the year ending 31st December, 1943, which, owing to war-time conditions is again considerably curtailed. Vital Statistics. The population which in 1939 was 144,400, and fell in 1941 to 105,620, .continued, as in 1942, to show a rise, now estimated to be 110,350. The birth rate, the highest since 1924, was 17.85, and the number of registered births 1,970, as compared with 1,819 in the previous year; the proportion of male to female births being 1,018 boys to 952 girls. The infantile death rate was 43.65 per 1,000 live births. It is interesting to compare this rate with that of the year 1918, the fourth year of the last war, when it was 84.7. The deaths in the first four weeks of life caused a neo-natal mortality of 24.8 per 1,000 live births, a figure which compares favourably with that of 30.2 in 1942, and 35.0 in 1918. The maternal death rate was 2.94 as compared with 2.6 in 1942. The general death rate of the whole population showed a rise to 13.7 as compared with 12.2 in 1942. Deaths from Cancer showed an increase, as also diseases of the heart and lungs. In spite of a further decline in housing conditions due to enemy action, disrepair and overcrowding, the general standard of health has remained high. But as emphasised in previous years, housing must continue to be regarded as priority number one in the task both of combating disease and in promoting positive health. Infectious Diseases. Notifiable infeotious diseases showed an increase over the previous year, mainly clue to Measles and Whooping Cough, though the figures generally were lower than in pre-war years. The 3 incidence of pulmonary tuberculosis, as measured by notifications, showed only a slight increase in Tottenham over previous war years. The number of deaths due to this disease was 83, as compared with 80 in 1942. The campaign for immunisation against diphtheria continued with vigour throughout the year with particular concentration on the pre-school age group. By a special resolution of the Borough Council, and with the approval of the Ministry of Health, Scabies became a compulsorily notifiable disease as from 1st December, 1943. War-time Services in the Public Health Department. The statistical picture of the effect of enemy action on the lives and working conditions of the citizens of Tottenham cannot yet be given. The Public Health Department, charged with the added duties of organisation of the civil defence casualty services', the repair of war damaged residential property, the care of persons rendered homeless by enemy action and their rehousing or billeting, including also the finding of accommodation for essential war workers, has tackled many problems of social interest, the experience of which should be of inestimable value in the furtherence of public health in the days of peace. In the solution of these problems the department recognises their great indebtedness to the good will of the general public, to their patience and endurance in times of great personal stress and difficulty. A warm tribute must also be paid to the work of the Womens Voluntary Services and the joint war organisation of the British Red Cross and St. John's, whose voluntary services to the homeless and injured have contributed so much to the smooth running of the services. The Sanitary Inspectors, the rehousing and clerical staffs, have all rendered loyal and efficient service, and in their difficult and exacting work have, 1 believe, enjoyed the full confidence of the Town Council and general public alike. School Medical Service. A pre-war standard of completeness in the provision of medical and dental services for children attending elementary and secondary schools has been maintained. A notable increase in attendances at all clinics in the Municipal Health Centres has been observed, as compared with the previous year. The extension of the Government's scheme for the supply of cod liver oil and orange juice to all children under five years of age attending school was a noteworthy addition to the functions of the school medical service. The small 1 epidemic of measles occurring in children of school age was unaccompanied by serious complications, as is shown by the report of the "following-up" of cases by the school nurses. Maternity and Child Welfare. The war-time nurseries for children of mothers engaged in wartime industry, of which there are eight non-residential and one residential, under the control of the Maternity and Child Welfare Committee, continued to function smoothly throughout the year. No serious outbreak of infection occurred in any nursery, and the universally high standard of health and happiness of the children was evidence of the efficiency of the work of the supervisor, matrons and their staff. With the increasing birth rate, the midwifery service, operating under difficult conditions of war-time, proved adequate for all the calls made upon it. The availability of transport for midwives during "black-out" hours proved to be of great value to the efficiency of the service. Mrs. J. Kent Parsons, M.B.E., Superintendent, who was due to retire two years ago, has continued another year to give most energetic and untiring services for the welfare of the mothers and children of the district. The Health Visitor's work in the homes and at the Health Centres has contributed much to the maintenance of health among the expectant and nursing mothers and children under five. In conclusion I wish to acknowledge the support and encouragement given to myself and the departments for which 1 am responsible to you, Mr. Mayor, the Aldermen and Councillors of the Borough Council. I have the honour to be, Your obedient Servant, G. Hamilton Hogben, Medical Officer of Health and School Medical Officer. THE HEALTH AND HOUSING COMMITTEE (as at 31st December, 1943). Chairman: Alderman R. H. Warren, J. P. Members: (Ex-Officio) His Worshipful the Mayor (Councillor F. A. F. Keay, J.P.). (Ex-Officio) The Deputy Mayor (Alderman E. J. Field). Alderman Mrs. W. A. Kent. Councillor G. A. Armfield. ,, Mrs. A. Kitchener. ,, Mrs. M. Berry. ,, J. H. Morrell, J. P. ,, Miss R. F. Cox. ,, A. Reed, A.C.I.I.,J.P. ,, R. W. H. Ford. ,, A. R. Turner. ,, Mrs. A. E. Lyons. Councillor Mrs. G. E. Morrison. ,, H. W. Pearce. ,, J. Wallace. Council's Representative on the Metropolitan Water Board under the Metropolis Water Act, 1902: Alderman R. C. Morrison, M.P., J.P. Town Clerk: Eric Townson, LL. B. 6 STATISTICAL SUMMARY. Year ended 31st December, 1943. Area of the District in acres 3,014 Registrar-General's estimate of the Civilian Population Mid-year 1943 110,350 Rateable Value £976,917 Sum represented by a penny rate £3,805 Births and Deaths. Registered live births:— Total. Males. Females. Legitimate 1,873 968 905 Illegitimate 97 50 47 1,970 1,018 952 Birth Rate (per 1,000 estimated population) 17.85 Stillbirths Total. Males. Females. Legitimate 69 36 33 Illegitimate 1 1 — 70 37 33 Stillbirth Rate per 1,000 total (live and still) births 34.31 Deaths Males 761 Females 752 Total 1,513 Death Rate (per 1,000 estimated population) 13.71 Deaths from Cancer—Males 115: Females 117 232 Deaths from Diphtheria 4 Deaths from Measles 4 Deaths from Whooping Cough 3 Deaths from Diarrhoea (under 2 years) 5 7 Maternal Deaths:— Puerperal Sepsis Nil Other Puerperal Causes 6 Total 6 Maternal Death Rate (per 1,000 total live and still births) 2.94 Deaths of Infants under 1 year of Age: Total. Males. Females Legitimate 80 41 39 I llegitimate 6 4 2 86 45 41 Infantile Death Rate (all infants per 1,000 live births) 43.65 Legitimate Infants per 1,000 legitimate live births 42.71 Illegitimate Infants per 1,000 illegitimate live births 61.85 8 STATISTICS OF TOTTENHAM FOR THE LAST TWENTY YEARS. Year Population Deaths Death Rate Births Birth Rate Infantile Deaths Infant Death Rate Number of Cases. Puerperal Fever and Puerperal Pyrexia Scarlet Fever Diphtheria Typhoid Fever SmallPox 1923 154,300 1,408 9.1 3,093 20.0 180 58.1 3 385 194 2 - 1924 156,000 1,559 9.9 2,853 18.2 176 61.6 5 367 227 6 - 1925 156,700 1,596 10.1 2,756 17.6 150 54.4 6 427 252 2 - 1926 159,500 1,545 9.6 2,601 16.3 147 56.5 4 481 495 7 - 1927 162,000 1,664 10.2 2,388 14.7 154 64.4 2 466 398 3 - 1928 165,000 1,540 9.3 2,478 15.0 133 53.7 19 594 328 1 - 1929 168,000 1,839 10.9 2,561 15.2 162 63.2 19 536 562 5 6 1930 170,000 1,569 9.2 2,510 14.8 137 54.6 22 574 541 6 131 1931 159,300 1,621 10.2 2,345 14.7 124 52.9 19 571 220 6 7 1932 156,800 1,591 10.1 2,214 14.2 114 51.4 37 452 149 4 5 1933 154,700 1,618 10.5 2,138 13.8 118 55.2 35 551 194 5 4 1934 152,694 1,572 10.3 2,091 13.7 108 51.6 34 628 300 1 - 1935 150,310 1,456 9.7 1,969 13.1 108 54.8 41 577 286 3 - 1936 148,600 1,600 10.8 1,931 13.0 100 51.8 37 430 227 5 - 1937 146,200 1,617 11.1 1,973 13.5 126 63.9 36 306 236 7 - 1938 144,400 1,512 10.5 1,893 13.1 89 47.0 23 186 221 - - 1939 142,400* 1,406 10.3 1,776* 12.5 66 37.95 15 335 60 — - 136,000 1,739 1940 119,400 1,703 14.26 1,666* 13.95 64 41.05 20 103 28 5 — 1,559 1941 105,620 1,418 13.43 1,560* 14.77 61 46.35 13 103 73 4 — 1,316 1942 110,100 1,349 12.25 1,819 16.52 79 43.43 12 295 75 1 - *For the years 1939—1941 alternative birth figures were given by the Registrar-General:— (a) for calculation of birth rates; and (b) for calculation of death rates or the incidence of notifiable diseases. Likewise for the year 1939 only, two population figures were given:— (a) for calculation of birth rates; and (b) for calculation of death rates, etc. 9 Table of Deaths during the year 1943 in the Borough of Tottenham, classified according to Diseases. Cause of Death Males Females Totals Typhoid and Paratyphoid Fevers — — — Measles 1 3 4 Scarlet Fever — — — Whooping Cough 2 1 3 Diphtheria 2 2 4 Influenza 19 27 46 Encephalitis Lethargica 1 1 2 Cerebro-Spinal Fever 3 1 4 Tuberculosis of Respiratory System 45 38 83 Other Tuberculous Diseases 6 7 13 Syphilis 6 4 10 General Paralysis of the Insane Tabes Dorsalis - - - Cancer, Malignant Disease 115 117 232 Diabetes 5 9 14 Cerebral Haemorrhage, etc. 54 78 132 Heart Disease 170 157 327 Other Circulatory Diseases 36 31 67 Bronchitis 84 59 143 Pneumonia (all forms) 48 48 96 Other Respiratory Diseases 10 9 19 Peptio Ulcer 18 2 20 Diarrhoea (under 2 years) 3 2 5 Appendicitis 4 3 7 Other Digestive Diseases 10 23 33 Acute and Chronic Nephritis 15 14 29 Puerperal Sepsis — — — Other Puerperal Causes — 6 6 Congenital Debility, Premature Birth, Malformations 26 31 57 Road Traffic Accidents 7 — 7 Other Violent Causes 11 9 20 Suicide 6 9 15 All other Causes 54 61 115 761 752 1,513 10 Infantile Deaths in Ages and Sexes during the year 1943. Cause of Death. Under 1 week. 1—2 weeks. 2—3 weeks. 3—4 weeks. Total under 4 weeks. 1—3 months. 3—6 months. 6—9 months. 9—12 months. Total deaths under 1 year. Males. Females. Bronchitis — — — — — 1 4 1 1 7 6 1 Diarrhoea and Enteritis — — — — — 3 3 — — 6 3 3 Measles — — — — — — — 1 — 1 — 1 Pneumonia — — — — — — 4 3 2 9 6 3 Premature Births, Congenital Malformations, etc. 42 4 - 2 48 7 1 - 1 57 26 31 Miliary Tuberculosis — — — — — — — — 1 1 — 1 T.B. Meningitis — — — — — — — — 1 1 — 1 Whooping Cough — — — — — — — 2 — 2 2 — Other Causes 1 — — — 1 1 — — — 2 2 — Totals 43 4 — 2 49 12 12 7 6 86 45 41 11 Table of Cases of Infectious Disease coming to the knowledge of the Medical officer of Health during the year 1943 in the Borough of Tottenham, classified according to Diseases and Ages. Notifiable Disease. Males. Females Under one. 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 45—65 65 & over. Total Cases Removed to Isolation Hospital by Council Scarlet Fever 172 168 2 7 13 30 38 167 56 11 12 3 1 - 147 Diphtheria 49 58 1 1 2 5 6 49 26 7 7 1 1 1 105 Pneumonia 52 60 5 3 4 3 2 11 4 6 10 17 28 19 — Erysipelas. 25 16 — — — — — — — — 5 6 21 9 16 Puerperal Pyrexia — 9 - - - - - - - - 6 3 - - 1 Dysentery 10 8 1 1 2 2 4 4 1 — — 1 1 l 11 Ophthalmia Neonatorum 1 - 1 — — — — — — — — - - - 1 Meningitis 3 6 — — — 1 1 1 — — 2 - 4 4 Malaria 1 - — — — — — — — — 1 - - - - Scabies 22 36 — 2 1 3 — 6 7 10 15 6 5 3 - Enteritis — — — — — — — — — — — — — - - Food Poisoning 1 3 — — — — 1 — — — 2 — 1 - - Whooping Cough 120 125 29 33 29 32 40 77 3 1 1 — — - 18 Measles 525 512 61 108 124 122 181 395 30 9 4 2 1 — 51 Pulmonary Tuberculosis 87 87 — 1 1 — 1 3 6 23 89 22 24 4 — Other forms of Tuberculosis 12 12 - 1 - 3 - 4 3 2 9 1 1 - - Totals 1,079 1,101 100 157 176 201 274 717 136 69 163 62 88 37 354 12 INFECTIOUS AND OTHER DISEASES. Scarlet Fever. 340 cases of Scarlet Fever were notified during the year, compared with 295 in 1942, 103 in 1941, 103 in 1940 and 335 in 1939. Less than 50 per cent., namely 147 of these cases, were removed to Isolation Hospital. Diphtheria. The number of cases notified was 107, compared with 75 in 1942, 73 in 1941, 28 in 1940, 60 in 1939 and 221 in 1938. There were 4 deaths from this disease. Immunisation has been intensified during the year, and the method used has been two doses of alum precipitated toxoid; 0.2 c. c., followed 3 weeks later by 0.5 c.c. Total attendances at Immunisation Clinics .. 9,826 Schick Tests 2,743 Cases completed during the year:— Over 5 years of age, 1,038. Under 5 years of age, 1,400—Total 2,438. Estimated percentage of child population immunised at the 31st December, 1943:— Aged under 5 years, 68 per cent. Between 5 and 15 years, 55 per cent. Diabetes. With the approval of the Ministry of Health, Insulin has been supplied to necessitous persons suffering from Diabetes since 1925, but with the more recent publicity given to this matter as a result of the general authority given in Circular 2734, dated January, 1943, there has been an increase in the number of cases taking advantage of this facility during the year 1943. During this period 17 cases were supplied with Insulin, at a cost of £93 2s. 7d. 13 Scabies. By a special resolution of the Council, and with the subsequent approval of the Ministry of Health, Scabies became a notifiable infectious disease in the Borough as from the 1st December, 1943. It will be seen, from the following comparative table, that the larger number of cases notified occurred in adult females. Period Cases Notified. Males Females Total 1st December, 1943, to 31st December, 1943:— Under 15 years of age 9 8 17 Over 15 years of age 13 28 41 Totals 22 36 58 1st January, 1944, to 30th June. 1944:— Under 15 years of age 47 49 96 Over 15 years of age 82 177 259 Totals 129 226 355 Adequate cleansing facilities are available in the Borough, under the supervision of a whole-time Infectious Diseases Nurse. The Ministry of Information sound film 'Scabies: Diagnosis and Treatment" was shown during the year to a professional audience, with the result that there has been good co-operation in securing treatment of this disease. Laboratory Facilities. The following examinations were made during the year in the Council's laboratory:— Swabs (Throat and Nasal). Negative. Positive. Total. Referred by the Health Department:— Diphtheria Contacts, Discharged Cases, Convalescent Home Cases, etc. 847 27 874 Medical Practitioners 547 60 607 Totals 1,394 87 1,481 14 Specimens of Sputa examined for Tuberculosis :— Negative 101 Positive 7 Total 108 Stools examined for Typhoid 2 (Negative). Faeces examined for Dysentery 1 (Positive). Tuberculosis. The County Council are responsible for the treatment of Tuberculosis. 198 notifications were received under regulations during 1943. Pulmonary, 174; other than Pulmonary, 24. Cases remaining on the register at the end of the year were— Pulmonary, 529; Non-Pulmonary, 147. The Tottenham Tuberculosis Officer has his premises at 140, West Green Road. The days and hours of attendance at the dispensary are:— Monday to Saturday—10 a.m 12 noon. (also from May to September, first and third Thursdays 6—7 p.m.). Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. Males Females Males Females Males Females Males Females Under 1 year - - - - - - - 2 1 to 5 years 2 1 1 3 — — 1 2 5 to 15 ,, 6 3 3 4 — — 2 1 15 to 25 ,, 27 38 5 1 6 8 — — 25 to 35 „ 17 30 1 4 10 17 — — 35 to 45 ,, 14 8 1 — 9 8 1 2 45 to 55 ,, 7 2 — — 9 1 — — 55 to 65 ,, 12 3 1 — 7 3 1 — 65 years and upwards 2 2 — — 4 1 1 — Totals 87 87 12 12 45 38 6 7 15 Organs affected (New Cases):— Males. Females. Lung 87 87 Glands 4 8 Neck — 1 Rib — 1 Hip 2 Peritoneum — 1 Meninges 4 — Skin 1 — Genito urinary system 1 1 The deaths represent a death rate of 0.87 per 1,000 population, and in 18.18 per cent, of the fatal cases no previous notification had been received. There was, however, no suggestion of wilful neglect or refusal to notify, and accordingly no proceedings were taken. SANITARY CIRCUMSTANCES OF THE AREA. Water Supply. The Borough water supply is obtained from the Metropolitan Water Board, and has been satisfactory in all respects. Certain warnings were received, however, from time to time, urging the conservation of supplies. Adequate arrangements have been made for maintaining the supply and the purifying thereof in the event of an emergency due to enemy action. Drainage and Sewerage. Soil sewerage is taken into the L. C. C. system, and the surface water drainage passes into the River Lee. Members of the Borough Council will have had an opportunity of studying the report prepared by the Borough Engineer and Surveyor, and the proposals contained therein, regarding the surface water drainage of the Borough, by which it is hoped to alleviate flooding which occurs from time to time in certain parts of the district. Closet Accommodation. There has been no variation in the form of closet accommodation, but arrangements exist for the provision of emergency sanitation should the need arise. 16 Housing. The pre-occupation of the department in relation to Housing may be divided into two spheres:— (a) the immediate housing needs: and (b) post-war housing, including the clearance of unhealthy areas. The general standard of houses occupied by the working classes in this the fifth year of war, has deteriorated; and the reasons for this are many and varied. Ministry of Health Circulars provided evidence that the central authority was aware of the critical and serious position that had developed during the war years, and within certain limits they were prepared to assist local authorities in the urgent task of ameliorating the unsatisfactory housing conditions now existing. Ministry of Health Circulars 2828 and 2828a sought to initiate a scheme of priority for the repair and maintenance of houses, but no great advance was made until the issue of Circulars 2845 and 2871. Circular 2845 gave local authorities the power to requisition houses for families inadequately housed, and Circular 2871 made provision for securing protection for the labour employed on repairs, at the same time imposing conditions whereby certain types of work were regarded as essential. Financial limitations were imposed, but these were subsequently improved by Circular 9/44. The department has made every effort to use the new powers to provide additional accommodation, and at the time of writing 50 premises had been requisitioned and repaired. Every effort has also been made to keep in reasonably habitable condition the many occupied houses. Reference to statistics will show that there has been no diminution in housing repairs, but the details given of work carried out by the Council in owners' default will indicate the difficulties experienced in operating the Housing Act. Post-War Housing. Plans for post-war housing are proceeding, and the necessary building sites are being acquired. But a major problem confronts the Council here in deciding for what purposes the limited number of acquired sites are to be made available. 17 The needs of the public may be summarised as follows:— (a) accommodation for persons displaced as a result of the redevelopment of unhealthy areas; (b) accommodation for the inadequately housed and the overcrowded; and (c) accommodation for returning service men and their families—families created since the war and who have never yet occupied a "home". These questions have been discussed at successive meetings of the Housing Committee, but no final decision has yet been reached. It is well to recall, at this stage, that on the successful solution of this problem depends the arrangements for Tottenham's future development and planning. During the year under review, and indeed during most of the war years, provision of housing accommodation for those urgently needing better conditions, has been at a standstill. In fact, the only accommodation available has been the few "re-lets" on existing Municipal Housing Estates, and this has been negligible. The effect of this has been the building up of a waiting list of applicants amounting to over 2,000 families; a list which, when returning service men begin to declare their needs, will no doubt double itself. Inspections Carried out by the Sanitary Inspectors, and Defects, etc., Remedied. House to House Inspections Nil Infectious Disease 619 Complaints 3,953 Drains Tested 540 Drains Defective 207 Re-Inspections 8,077 Factories 281 Workplaces 53 Dairies, etc. 114 Slaughter-houses 35 Bakehouses 104 Public House Urinals 84 Stables and Mews 41 Food Premises 627 Appointments and Interviews 1,251 Other Visits 1,838 18 Visits in connection with the supervision of repairs to war-damaged residential property 5,408 Visits to requisitioned houses (for homeless persons) in connection with the general maintenance of these properties 2,583 Drains reconstructed 45 Drains repaired 130 Drains cleared 194 W. C. Cisterns repaired or renewed 168 W. C. Pans renewed 99 W. C. Pans cleansed 194 Waste Pipes repaired or renewed 304 Pain-water Pipes repaired or renewed 146 Roofs repaired or renewed 742 Eaves Gutters repaired or renewed 512 Drinking Water Cisterns renewed 21 Drinking Water Cisterns covered 58 Water Service Pipes repaired 481 Water Supply reinstated 48 Yards repaired or reconstructed 94 Sinks renewed or provided 68 Floors repaired or renewed 357 Floors ventilated 94 Dampness remedied— by insertion of damp-proof courses 38 by pointing of brickwork 94 by internal rendering 201 by miscellaneous remedies 84 Window Frames and Sashes repaired or renewed, or painted 241 Coppers repaired or renewed, or provided 41 Fireplaces, Stoves and Ovens repaired or renewed 411 Flues and Chimney Stacks repaired 54 Brickwork of Walls repaired and Walls rebuilt 21 Ventilated Food Stores provided 10 Rooms cleansed 1,742 Staircases, Passages and Landings cleansed 620 Staircases, Balconies and Steps repaired or renewed 120 Noxious Accumulations removed 38 Nuisances arising from Animals abated 14 Miscellaneous Defects remedied 421 19 Notices Served. Informal 2,498 Statutory- Housing Act, 1936, Section 9 623 Public Health Act, 1936:— Section 24 28 Section 39 64 Section 83 43 Section 94 8 Section 45 5 Section 44 1 Total 772 Repair of Houses by the Council. £ s. d. Work carried out in default:— Section 9, Housing Act, 1936. 114premises: 2,559:7:3 Public Health Act, 1936:— Section 39, 18 premises 474:6:2 Section 83, 1 property 11:0:4 Section 44, 1 property 15:7:1 Section 79, 1 property 0:3:6 Work carried out for maintenance of public sewers, 35 premises 688:5:11 Housing Act, 1936, Section 11. Demolition Orders with respect to two houses, namely, No. 10, Railway Terrace and No. 4, Stanley Grove, were made under this Section. Housing Act, 1936, Section 12. A Closing Order under this Section was made with respect to part of the premises (left hand—North Side) No. 11, Railway Terrace. Disinfection Work. Private firms in the Borough continued to use the Health Department's Disinfection Service to a considerable extent, as also the Civil Defence Services." 20 Rooms disinfected after Diphtheria, Scarlet Fever, Tuberculosis, etc. 701 Number of houses where bedding was disinfected after the occurrence of infectious disease 633 Wards or School Rooms disinfected 12 Verminous Rooms (including disinfestation process) 440 Miscellaneous rooms 54 Bedding and Blankets:— Blankets. Pillows. Overlays. Other Articles. Private Firms 5,566 856 829 105 Civil Defence, Fire Watchers, etc 2,784 200 308 1,437 Houses disinfested on the Council's Estates—53 houses (128 rooms). Milk (Special Designations) Orders, 1936 and 1938. These designations may only be used under licence from the local authority. In 1943 the following licences were granted:— Pasteurised Milk:— Pasteurisers' Licences 4 Dealers' Licences 15 Supplementary Licences 4 Tuberculin Tested Milk Bottlers' Licences 1 Dealers' Licences 8 Supplementary Licences 3 Accredited Milk Licence 1 War Damage. The criterion by which the success or otherwise of the department's efforts in dealing with the repair of war-damaged bouses must be judged, is the contribution which such repairs have made towards the maintenance or provision of houses for the general needs of the community. Defence of the Realm Regulations do not permit the setting out in precise detail the progress made, but it is significant that at the end of the year 1943, there were only 8 seriously damaged houses which had not been repaired or were not in the process of being repaired. 21 Repair work to the value of over £250,000 has been carried out and supervised by the Public Health Department, and it is fitting here to pay tribute to the excellent co-operation given by local building contractors and builders' merchants. Food and Food Premises. The quantity of foodstuffs condemned continued to be high. The Ministry of Food salvage organisation was set in motion by various circulars, notably 2640 and 2468; and more recently 2886, which advised local authorities on the appropriate steps to be taken and also stipulated the minimum quantities which would justify removal by that department. The removal of condemned foodstuffs for salvage raises the objection that the authority ordering the condemnation are prevented from supervising the disposal of the condemned articles. Milk. During the year the Government published a White Paper (Cmd. 6454) on Measures to Improve the Quality of the Nation's Milk Supply. The aim of the White Paper is one which cannot fail to commend itself to all interested in Public Health. It is interesting to note, however, that Ministry of Health Circular 2879, referring to Special Designations, contains the following reservation:— ". . . . it is not possible to maintain the quarterly inspection "of herds and carry out the White Paper proposals". Further provisions contained in the White Paper relative to the heat treatment of milk, are now included in Statutory Rules & Orders No. 65, by which the Ministry of Food are to define certain areas as "specified" areas, and all milk sold therein shall be "heat treated". This Order is enforced by the Food and Drugs Act, the Middlesex County Council being the responsible authority; thus dual control may occur—the local authority being responsible for pasteurised milk and the County Council for heat treated milk other than pasteurised. Reference should also be made to the service which, happily up to the present time, has not been required—namely, the poison gas food decontamination service. The personnel of this service 22 is composed of voluntary members of local food traders, all of whom have been trained to deal with foodstuffs which may become contaminated by gas attack from enemy action. Much spare time has been given by the members to training and preparation, and they are to be congratulated on their enthusiasm and willingness to co-operate. Inspection of food premises reveals that either as a result of overwork, or shortage of staff, a degree of laxity has been noticeable in the general standard of cleanliness. In certain cases it has been found necessary to institute legal proceedings. Rodent Control. For the first time in my Annual Report reference is made to departmental activity in connection with rat and mice destruction— "rodent control". Annual wastage and spoilage of foodstuffs due to rodents is estimated in millions of pounds, and being aware of this, the Ministry of Food, in May, 1943, took the first steps in a drastic national drive to deal with the rodent problem, by issuing (under the Defence Regulations) the Infestation Order, 1943. Under this Order the Minister has power to direct owners and occupiers of land to take such steps as may be necessary to deal with any infestations, or to report that such infestations exist. The first intimation received was a "direction", issued in July, 1943, requiring the local authority to make a survey and report any major infestations in the area. Failure to comply with this "direction" constituted an offence. This was followed by a further "direction" to take such steps as were necessary to disinfest all sewers in the area. This work was carried out by the Public Health Department, with the co-operation of the sewers section of the Borough Engineer's Department, and over a period of two months, two complete treatments were affected throughout the sewerage system of the Borough. The Ministry of Food were apparently aware of the ambiguous position created, whereby local authorities who were not the statutory authority under the Rats & Mice (Destruction) Act, 1919, might receive directions to carry out certain work which was in conflict with the duties of the Rats & Mice (Destruction) Act 23 authority, and this has now been overcome in Tottenham by arrangements having been made for the County Council to delegate their powers under this Act to the local authority. The following is a report made by the Chief Sanitary Inspector to the Public Health Committee, regarding the first stages of rodent control in relation to sewers. INTRODUCTION. The rat population in sewers, drains and the adjacent ground is admitted to be the cause of a high proportion of the many infestations above ground in heavily built up areas. The type of rat which so infests these places is the Brown rat, or common rat, often called a sewer rat. Movement to and from the sewers is probably made through defects in the sewers themselves or, perhaps, more frequently through fractures in the drains. This movement can occur in two directions; along the sewers and drains themselves, where there is normally a large amount of foodstuffs available, or up into the surrounding buildings, which may or may not contain food. When the rats which gain access to the surface find a source of food supply, more and more are drawn up, and thus infestation of the premises takes place. OBJECT AND PLANNING OF THE TREATMENT. The object of the treatment is obviously then, destruction or extermination of the greatest number of the rat population which exists in and/or can be attracted to the sewers, over as large an area as possible in the minimum of time. This object has been achieved by placing at given points in the sewers, foodstuffs which will provide food for those rats which might normally feed there, and to keep in the sewers those rats which may normally come up to the surface. This is termed baiting. This baiting can only be carried out at the manholes, and therefore the number of baiting points cannot be increased or decreased according to the degree of infestation, even if this were known. The scheme provides for baiting with unpoisoned food to be carried out for four days, known as the pre-baiting period. Some criticism may be made that four days is too long, and 24 an unnecessary waste of food. Research work, however, proves that rats take some time to travel, and therefore ample time must be given to ensure that all the baited points are visited. Again, in dealing with a surface infestation it is possible to lay the bait between the point where the rats emerge and the point where they feed. This is not the case in the sewers, as food may be found at any point before the bait is reached. The food, mixed or treated with poison, is laid on the fifth day. A preliminary survey of all soil manholes in the Borough was made and details regarding position, depth and suitability for baiting, were recorded on survey sheets, regard being paid to the possibility of flooding. The Borough was then divided into a number of workable areas, each containing approximately 70 to 80 manholes. From the survey sheets, lists were prepared of manholes where direct baiting could not be carried out, and those manholes, where possible, were fitted with iron traps to which were attached a piece of stout rope. The positions of the manholes were next plotted on a large scale map, and a route worked out which permitted of each area being baited in one day, i.e., every manhole in the area was baited on the same day. Bait is placed in position by a special "bait depositer" devised and supplied by the Ministry of Food. During the preliminary survey all manholes which it was intended to bait, were identified, covers loosened, and greased where necessary, and any accumulation of sludge or deposit swept off the benching. APPLICATION AND TREATMENT. The treatment was carried out by gangs of men, each gang consisting of two men from the Borough Engineer's Department, and one volunteer from the Civil Defence Services. The latter were trained by the staff to act as baiters and recorders. The bait base used was damp sausage rusk, the poison used on the final day being Zinc Phosphide mixed in the 25 proportion of 95 per cent, sausage rusk and 5 per cent. Zinc Phosphide. Treatment of the first areas commenced on December 6th, 1943, and continued during the subsequent weeks until the whole Borough was completed on January 16th, 1944. Each area was begun on a Monday, and on that and the three following days unpoisoned bait was laid. Poison bait was laid on Friday, and the results checked on Saturday; thus the complete treatment of any area took one week. The amount of bait eaten is divided into four categories; viz.:—(1) No take, (2) small take, (3) good take, (4) complete take, and the estimate is based on the amount remaining. These takes are recorded for the previous day, i.e., Monday's take is recorded on Tuesday, before placing Tuesday's bait, and so on. The weight of bait placed in each manhole was 6 ozs. of unpoisoned pre-bait, and 12 ozs. of poisoned bait. RESULTS AND CONCLUSIONS. Before setting out the results of the campaign, it is advisable to indicate how the estimated number of rats killed is obtained. From experiments carried out by the Ministry of Food, it is calculated that two-fifths of an ounce of the poison bait is a lethal dose. This is a conservative estimate and has been determined by weighing the contents of the stomachs of dead rats. Thus, if the total weight of poisoned bait taken is known, it is possible to estimate the number of rats killed. Appended below is a summary of the results, from which it will be seen that the number of manholes baited was 1,109, and the estimated number of rats killed 10,898. One can only conclude from these results that the careful and thorough preparation was worth while. It is not, however, anticipated that any sudden falling off in the complaints of rats will be felt; rather will this be a gradual process. The second treatment was commenced on the 17th January, 1944, and the results of this treatment show that there is a substantial reduction in the rat population in the sewers, bearing testimony to the efficacy of the methods used. 26 BOROUGH OF TOTTENHAM. Sewer Rodent Control. Summary of First Treatment. Bait Base Damp Sausage Rusk. Poison Bait 5% Zinc Phosphide. Area Ward Boundaries (approx. only) Number of Manholes baited Estimated Kill A.l. Town Hall Ward .. 53 248 A.2. Stamford Hill Ward 58 413 A.3. Seven Sisters Ward 73 825 A.4. Green Lanes Ward South 73 1,335 A.5. Green Lanes Ward North 58 727 A.6. West Green and St. Ann's North 56 345 A.7. West Green Ward 72 990 A.8. West Green Ward East and Town Hall Ward West 75 862 A.9. St. Ann's 63 592 B.l. White Hart Lane Ward West 44 225 B.2. White Hart Lane Ward East 69 855 B.3 .Bruce Grove and Central 73 773 B.4. West Green Ward North West 56 352 B.5. High Cross and Stoneleigh Ward 66 398 B.6. White Hart Lane Ward Centre 64 345 C. Park Ward South 47 870 D. Park Ward North 62 383 High Road 47 360 Totals 1,109 10,898 Second Treatment of Sewers. The second treatment of sewers was commenced on the 17th January, 1944, and was completed on the 12th February, 1944. A total of 1,111 manholes were baited, resulting in the destruction of 4,483 rats. As a comparison, it will be noticed that with the first treatment for approximately the same number of manholes, 10,898 rats were killed. Shops Acts, 1912—1938. In the administration of the Shops Acts, 4,387 inspections were made by the Shops Inspectors. Most contraventions reported have been minor defaults, such as non-exhibition of statutory notices, in respect of which 261 verbal warnings and notices were issued. 27 By means of systematic visitation of shops throughout the Borough, effective administration is secured, and the necessary information obtained for the purpose of keeping up-to-date a register of all shops in the Borough. Regular visits and investigations are made on the days on the weekly half holiday, and in the evening, to ensure that the provisions of the Acts and the various early closing orders made thereunder are duly complied with. Shops in the Tottenham (Remainder) Area are closed for the weekly half holiday at 1 p.m. on Thursday, and in the Harringay area on Wednesday at 1 p.m. In connection with half holiday closing, 215 visits were made. Shops Act, 1934, and Young Persons Employment Act, 1936. Regular investigations and inspections were made in connection with these Acts, and it has been ascertained that the conditions of employment have improved, both as to hours of employment of young persons and the arrangements made for the health and comfort of shop workers generally. 349 special visits were made in connection with the enforcement of these Acts. The number of young persons employed at present is still above the normal, owing to wartime conditions. Shopkeepers are desirous of taking reasonable measures to comply with all the requirements of the Shops Acts, and are ready to obtain and act upon the advice and instructions given by the Shops Inspectors. Shops (Sunday Trading Restriction) Act, 1936. The provisions of this Act are effectively carried out by means of systematic investigations and observations. It is satisfactory to note that shopkeepers appreciate the opportunity of having a day's rest each week, and very few shops open on Sundays in Tottenham. 28 ELEMENTARY SCHOOLS. Table I.—Medical Inspections of Children attending Public Elementary Schools—Year ended 31st December, 1943. A.—Routine Medical Inspections. (1) No. of Inspections in the prescribed Groups Entrants 1,659 Second Age Group 1,196 Third Age Group 1,424 Total 4,279 (2) No. of other Routine Inspections 337 Grand Total 4,616 B.—Other Inspections. No. of Special Inspections and Re-Inspections 22,422. Table II.—Classification of the Nutrition of Children Inspected during the year in the routine AgE groups. No. of Children Inspected. A. (Excellent). B. (Normal). C. (Slightly Sub-Normal). D. (Bad). No. % No. % No. % No. % 4,616 403 8.7 3702 80.2 492 10.7 19 4 Table III. Group I.—Treatment of Minor Ailments (excluding uncleanliness.) Total number of defects treated or under treatment during the year under the Authority's Scheme 5,634 Group II.—Treatment of Defective Vision and Squint. Under the Authority's Scheme. Errors of Refraction (including Squint) 563 Other defects or diseases of the eyes (excluding those recorded in Group I) 5 Total 568 Under the Authority' s Scheme. No. of Children for whom spectacles were: (a) Prescribed 544 (b) Obtained 543 29 Group III.—Treatment of Defects of Nose and Throat. Under the Authority's Scheme. Received Operative Treatment 180 Received other forms of treatment 340 Total number treated 520 Table IV.—Dental Inspection and Treatment. (1) No. of children inspected by Dentist:— (a) Routine Age Groups 0,120 (b) Specials 1,056 (c) Total (Routine and Specials) 10,176 (2) No. found to require treatment 6,712 (3) No. actually treated 3,673 (4) Attendances made by Children for treatment 6,480 (5) Half days devoted to:— Inspection 54 Treatment 900 Total 954 (6) Fillings:— Permanent Teeth 1,802 Temporary Teeth 832 Total 2,634 (7) Extractions:— Permanent Teeth 850 Temporary Teeth 4,828 Total 5,678 (8) Administrations of general Anaesthetics for Extractions . 578 (9) Other Operations:— Permanent Teeth 494 Temporary Teeth 1,226 Total 1,720 (10) Attendances for Orthodontic Treatment 746 Table V.—Verminous Conditions. (1) Average No. of visits per school made during the year by the School Nurses or other authorised persons 18.3 (2) Total number of examinations of children in the Schools by School Nurses or other authorised persons 93,454 (3) No. of individual children found unclean 1,516 (4) No. of individual children cleansed under Section 87 (2) and (3) of the Education Act, 1921 36 (5) No. of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 38 (b) Under School Attendance Byelaws — 30 SECONDARY SCHOOLS. Number of Pupils Inspected 1st January, 1943, to 31st December, 1943. Routine Medical Inspection. Total. Age 9 10 11 12 13 14 15 16 17 Boys 8 13 94 169 155 59 92 11 — 601 Girls — — 95 128 96 64 67 1 1 448 Totals 8 13 189 297 247 123 159 12 1 1,049 TECHNICAL SCHOOLS. Number of Pupils Inspected 1st January, 1943, to 31st December, 1943. Routine Medical Inspection. Total. Age 12 13 14 15 16 17 Boys — 16 74 30 23 1 144 Girls — 7 55 38 11 — 111 Totals — 23 129 68 34 1 255 Table II. Classification of the Nutrition of Children Inspected during the Year in the Routine Age Groups—Secondary and Technical Schools. Number of Children Inspected. A B C D No. % No. % No. % No. % 1,304 320 16.8 1,004 77.0 78 5.9 2 .15 31 Table III.—(Group II.) Under the Authority's. Scheme. Treatment of Defective Vision and Squint:— Errors of Refraction (including Squint) 166 Other defects or disease of the eyes 1 Total 167 No. of Children for whom Spectacles were:— la) Prescribed 166 (6) Obtained 166 Table IV.—Dental Inspection and Treatment. (1) No. of Children Inspected by the Dentist— (a) Routine Age Groups— Age 9 10 11 12 13 14 15 16 17 18 Total Number 12 13 139 271 333 391 453 321 100 29 2,062 (6) Specials 1 (c) Total (Routine and Specials) 2,063 (2) Number found to require treatment 1,186 (3) Number actually treated 423 (4) Attendances made by children for treatment 1,100 (5) Half-days devoted to:— Inspection 17 Treatment 140 Total 157 (6) Fillings:— Permanent Teeth 710 Temporary Teeth — Total 710 (7) Extractions:— Permanent Teeth 224 Temporary Teeth 53 Total 277 (8) Administrations of general anaesthetics for extractions 30 (9) Other Operations:— Permanent Teeth 217 Temporary Teeth — Total 217 (10) Attendance for Orthodontic treatment 96 32 SCHOOL MEDICAL AND DENTAL STAFF. Table VII.—School Medical and, Dental Staff. Name of Officer. Proportion of whole time devoted to School Medical Service. Public Health. School Medical Officer:— Dr. G. Hamilton Hogben Administrative — Deputy School Medical Officer:— Dr. B.Broadbent (On Military Service) l/6th 5/6th Senior Assistant Medical Officer— Dr. Joyce E. Marshall (Temporary) l/3rd 2/3rds Assistant School Medical Officers:—- Dr. R. H. Smythe Whole time — Dr. Nora A. M. Webster (Temporary) 2/3rds. l/3rd Senior Dentist:—V. Sainty, L.D.S. Dentists:— A. E. Fisher, B.D.S., joined dental branch R.A.F.V.R. (November, 1940). Misa C. M. Dixon, L.D.S. Miss E. M. McRaith, L.D.S. (Temporary appointment.) Note.—2/3rds of the services of one Dental Unit is apportioned to the Maternity and Child Welfare Committee. The whole of the school medical and dental inspection and treatment of secondary school children is undertaken for the Higher Education Authority. School Nursing Staff. (Excluding Specialist Nurses such as Orthopaedic Nurses). Number of Officers Aggregate of time given to S .M.S. work in terms of whole time Officers. School Nurses 8 Whole time. District Nurses — — Nursing Assistants* — — Dental Attendants 3 See Note above under Dentists. *This term refers to untrained assistants described in paragraph 3 of Circular 1604. 33 SCHOOL MEDICAL SERVICE. Staff. Table VII gives particulars of the medical dental and nursing staff. There have been two changes in the staff during the year. In February Dr. B. Broadbent, Deputy School Medical Officer was called for service with H. M. Forces. Dr. Joyce E. Marshall, was appointed temporarily. A new appointment was made to fill the vacancy caused by the retirement of one of the school nurses. The number of nurses on the staff at the end of the year remained at eight, five of these have the Health Visitors Certificate. Co-ordination. Close co-operation continues between the Maternity and Child Welfare and School Medical Departments. Two of the three Municipal Health Centres contain both services, this emphasises the continuity of the preventive health service for children. The Juvenile Employment Bureau received recommendations with regard to the suitability or otherwise of school leavers for certain types of employment, and is in close touch with the work of the school medical service. The Invalid Children's Aid Association has given valuable help, as in past years. The National Society for the Prevention of Cruelty to Children is always ready to give assistance with difficult cases, and their co-operation is much appreciated. The parents of the children for whom the service exists have shown by their interest that they value the facilities provided for them. It is their co-operation which enables the work to be effective. PHYSICAL WELFARE IN WAR-TIME. Nutrition. Medical inspections have shown that there is no deterioration in the nutritional standard of school children. The provision of meals and milk in school is undoubtedly an important factor. 34 The Director of Education has kindly supplied the following figures and notes on the provision of solid meals. "During the year the scheme for the provision of School Meals on a sliding scale of payment continued with even greater success than that which was noted in this Report last year, as proved by the following table in which the daily average is shown month by month:— Month. Free. On Payment. January 456 2,998 February 467 3,169 March 504 3,206 April 597 3,265 May 515 3,411 June 566 3,559 July 560 3,629 August 488 3,553 September 526 3,503 October 601 3,827 November 572 3,727 December 549 3,513 "According to figures issued by the Board of Education, Tottenham remains among those areas in the country with the highest proportion of children receiving a daily hot meal in school". Throughout the year meals were also provided for all school children whose parents so desired on Saturdays and during school holidays, through the British Restaurant Service which is organised jointly with the School Meals Scheme. The number of children having school meals has increased since last year. The daily average, as shown by the preceding table being 533 (439 in 1942) for free meals, and 3,480 (2,761 in 1942) for paid meals. Provision of Milk. Number of children in receipt of milk in school:— Free 296 Paid 4,188 35 The teaching staff voluntarily helped in the provision of milk during school holidays. Nutrition Clinic. All children found below normal standard of nutrition are referred to nutrition clinics for further examination and observation. Children whose nutrition is normal but whose home circumstances necessitate the giving of free milk and meals are also kept under observation, and steps taken to prevent, if possible, any deterioration in their physical welfare. Nutrition Clinics have been held regularly throughout the year. Vitamin Supplements for Children under Five. Arrangements for the administration to children under five, in public elementary schools and nursery schools, of orange juice and cod liver oil, were provided for in a joint Circular issued during the year, and later put into operation. Rest. All children under five years of age in Infants' Departments have midday rest of 40 minutes to 1 hour. Arrangements are made for children over five years of age to have extra rest, when this is considered necessary by the Medical Officer. Clothing. The standard of clothes and shoes remains satisfactory in the majority of children, in spite of rationing, but there is some deterioration in those families where the standard is already low, especially with regard to footwear. Necessitous cases are referred to the Education Department for their consideration. Owing to the shortage of supply, it has been found necessary to pass on plimsolls, which have already been used for P. T. lessons, to other children. Precautions are taken to minimise the risk of contagion by careful attention to cleanliness of feet, and by use of a disinfecting powder. There has been no apparent increase in plantar warts or other contagious conditions of feet. 36 CLEANLINESS. See Table V. There has been a rise in the number of individual children found to have verminous heads—(1942, 1,157; 1943, 1,516). The school nurses are of the opinion that this may be due to the fashion of longer hair for girls, and the fact that many mothers are now out at work. In most cases the condition has been quickly remedied when the mother has been informed. Lethane has been given a thorough trial by all school nurses, but they are generally agreed that this is no more effective than paraffin or carbolic oil, i.e., it kills live vermin, but has no effect on nits, and does not make their removal any easier. SUNLIGHT. In June, 1943, lamps were installed at the Lordship Lane Health Centre, and school children were transferred from Park Lane. The treatment is given by school nurses. 271 children attended on 4,539 occasions. The attendance was good, and nearly all cases benefitted by treatment, the mothers reported increased appetite, energy and sleep. IMMUNISATION. Total number of children over five immunised .. .. 1,038 Between the ages of 5 and 15, 55 per cent, of the child population was immunised at 31st December, 1943. PLAY CENTRES. Play Centres are of great value in ensuring the welfare and safety of those children, especially the younger ones, whose mothers are still at work after school hours. There are six of these centres and an average of 250 children attend daily. They are essentially "play" centres, and there are toys and other apparatus for the children's use. In good weather the children play out-of-doors as much as possible, and there is suitable accommodation for indoor amusements when it is unfavourable. A teacher is in charge of each centre, and tea is provided. 37 NURSERY CLASSES. At the Lancasterian Nursery Classes, there is an average number on the register of 120 children between the ages of two and four and a half years. These children are accommodated in modern nursery rooms which open into their own playground, so that during the time spent away from home (9.30 a.m.—3.30 p.m.), they are in the best possible surroundings. The physical needs of the children are well provided for; there is a daily rest period; milk is taken twice a day, and a good midday dinner is provided for all. There is a daily visit by the school nurse, when every child is inspected. The School Medical Officer visits regularly, the children receiving a medical examination three times during the year. All the children receive a midday meal, with the exception of two or three who go home. The percentage of children suffering from infectious disease was very low. Number on register 120 (average) Attendance 90% ,, Immunised 75% (30 immunised in school during the year). DENTAL SERVICE. Mr. Sainty, Senior Dental Surgeon, reports as follows:— "There have been three clinics in operation during the year 1943, with a consequent increase in the volume of treatment carried out. "In addition to the more routine dental work it has been possible to give treatment to a much greater extent to those children suffering irregularity of dentition. This is of great importance, not only aesthetically but by increasing the masticatory function of the jaws, and reducing the habit of mouth breathing, and so aiding the growth and health of the child. Many cases of malformation of the jaws and teeth, e.g., narrow arch, high palate, protrusion of upper front teeth, are caused by adenoids and consequent nasal obstruction and mouth breathing. Where in these cases adenoidectomy is carried out very early in life nothing like so much abnormality occurs, but persistent enlarged tonsils and adenoidal growth over some years will do a great deal of damage, and treatment 38 entails long wearing of orthodontic appliances, and often removal of some teeth crowded out of the arches. "Unfortunately, in many cases, mouth breathing still continues after adenoid removal, as the habit has been set up, causing gingivitis in the anterior part of the gums and consequent likelihood of periodontal trouble early in life. "Breathing exercises often help to break the mouth breathing habit, and are a useful complement to dental treatment. Radiography. "Expansion of the dental service will be necessary after the coming into force of the new Education Act, and it is to be hoped that an X-ray unit will be installed in any new Centre which may be built. X-ray diagnosis is very necessary in dealing with orthodontic cases, and also in verifying clinical examination of periodontal and apical conditions of the teeth, when such come under suspicion. In cases of fractured incisors, a common accident with children, it is necessary to find out whether the root growth is complete, or whether the apices are still wide open, and treat accordingly. Also cases are referred for questions as to (1) presence or absence of unerupted teeth. (2) The position of partly erupted teeth, particularly upper canines and pre-molars. (3) Cases of impacted and unerupted mandibular third molars. "Usually small intra-oral films are sufficient, but occasionally as in cases of misplaced lower wisdom teeth, a larger plate may be necessary. "At the present time, cases are referred by arrangement with a radiographer—17 cases were X-rayed during the year". OPHTHALMIC CLINIC. The Ophthalmic Surgeon has again held three sessions weekly at Lordship Lane Centre, where children are examined and treatment given to those who do not receive their treatment at the Minor Ailment Clinics. Particular efforts are made to provide early treatment for squint, children under school age being referred from the Infant Welfare and Toddler Clinics. 39 Total number of cases of refraction errors including cases suffering from squint 563 Total No. of cases provided with glasses 543 AURAL CLINIC. I am indebted to Mr. F. P. M. Clarke (Aural Surgeon) for the following report:— "The two sessions a week at the Aural Clinic, Municipal Health Centre, Park Lane, were fully occupied during the year 1943. Most of the children evacuated at the beginning of hostilities had returned and the regular school medical inspection which provides the majority of cases seen at the clinic, was able to carry on its normal routine examinations without interruption, thus keeping the clinic fully occupied. The total number of new cases seen actually exceeded that of the immediate pre-war years. "It is gratifying to note here the very good attendance of those referred for courses of special treatment, as under existing circumstances it must be fairly difficult and inconvenient for many of the parents to fit in the requisite number of attendances. To meet this difficulty, to some extent, one of the two weekly clinics was arranged for the afternoon and the other for the morning, instead of, as previously, the two in the mornings. This arrangement considerably convenienced many of the parents. "There has been a marked rise in the number of pre-school children referred to the clinic for examination and subsequent treatment. This is a progressive step the importance of which cannot be too strongly impressed. The earlier an ear, nose or throat defect is treated, the easier and more certain it is to effect a permanent cure. And it is by the careful examination of these young children and infants by experienced school medical officers that most of these early affections are discovered. In the majority of cases they are not at all noticeable to the parents, at least as of any serious importance—just regarded as a passing 'ailment'—and allowed to drift into a chronic intractable form of permanent disability. It was a regular practice at all the leading Welfare Clinics in Paris before the war, to give each child a course of intranasal massage or Diastolisation 40 so as to ensure in every child a free, normal nasal airway and inculcate into him the only normal way of healthy respiration—through the nose. Obstruction in the nasal airway is very easily set up in the infant or young child by plugs of retained mucus secretion, leading to infection and congestive rhinitis—perhaps sinus involvement and then from here—by extension through the lymphatic chain to the tonsils and glands on the neck. The adenoid tissue becomes hypertrophied and infected and extension here has easy access to the middle ear, setting up otitis and discharging ear. This is the chain of events. We dilate on this "subject to explain our reasons for stressing the importance of the early recognition and correction of what might seem just a 'minor ailment'. All those infants and young'pre-school children now found with any nasal insufficiency or obstruction are given a course of diastolisation, and in certain cases the parents are given 'nasal drops' and instructed to instill three drops into the child's nostrils every night, while lying on its back. This ensures the passage of the medicament into the post nasal space. The drops consist of mercury, menthol and olive oil. They are strongly recommended by Mr. E. A. Peters, F. R. C.S. "The number of children attending the clinic for 'nose and throat conditions' has greatly increased during the year, and now outnumbers those treated for purely ear defects. We advocate this, because in the early detection and correction of these nose and throat ailments, we can, in the main, eliminate the chief potential factors and exciting causes of later ear involvement, otitis, discharging ear, deafness, etc. We use the Proetz method of 'displacement' very largely in sinus-nasal treatment, and we can confirm our previous account of this valuable method. It is both diagnostic and theropeutic, and the percentage of sinus disease present in children, showing no very obvious physical signs, will surprise anyone who has not hitherto given this matter its deserved, detailed investigation, particularly in respect of cases referred as 'diseased tonsils and adenoids'. In all the cases of 'unhealthy' tonsils which we now treat by Tonsil Suction (Peter's Method), we invariably do a 'displacement' test, first to satisfy ourselves as to the condition of the sinuses. We have found, on an average, that about 20 per cent, have infected, unhealthy sinuses. Sinusnasal treatment is given concurrently with the Tonsil Suction 41 or in severe cases, a course of nasal treatment is carried out before the Tonsil Suction is begun. This is all important, for we must say emphatically that the removal of tonsils or Suction, without the adequate treatment of co-existent sinus disease is of no benefit. In fact, we have seen cases where tonsils were removed in unhealthy, diseased sinus-nasal fields which were left untreated and expected to be cured by the tonsillectomy, but whose condition, on the contrary, was aggravated and extended. "Throughout the year Tonsil Suction has been used with satisfactory results. A certain discretion has to be used in the selection of suitable cases. There is a certain number, but a small number of 'diseased tonsils' which is best treated by operation. To go into the clinical details of this would properly be the subject of a Clinical Paper rather than a general Annual Report, but we can say that the greater majority of school children can be treated and cured much more satisfactorily and effectively by the combined methods (where necessary) of Tonsil Suction and 'displacement', etc., than by operation alone. It has many advantages over operation. There is no operation risk, haemorrhage, etc., hospitalisation or danger of secondary otitis media. The immunological value of the tonsil tissue is retained and this is especially important in young children. We stress here that mere hypertrophy of a tonsil (unless it is so great as to become obstructive) is not in itself, an indication for removal. "There has been an increase in the amount of acute otitis met with during the year, mostly arising from the mild epidemic of measles and scarlet fever in the early part of the year, the results of the early treatment of these cases has been most satisfactory. Last year we referred to the regular employment of suction in the treatment of acute otitis. It is a rational, effective, rapid method of treatment. We use a Smith (U. S. A.) Glass Suction Tube. The suction keeps the perforation potent, allowing free drainage, empties the middle ear of the irritating discharge and therefore considerably assists the delicate tissues to recover and heal. If the discharge is excessive or there is much pain, the suction is followed by a long (one or two pints) warm douche of a mild antiseptic lotion through a Fowler (U.S.A.) Suction cup. This is carried out daily, and the majority of cases heal up rapidly. 42 "There have been very few cases of chronic otorrhoea. This is largely due to the early, effective treatment of otitis in its acute stage. Chronic otorrhoea is, in the main, the result of neglected or improperly treated acute otorrhoea, and it is for this reason that we now insist, as far as it is possible, that all patients with acute otorrhoea attend the clinics daily where the treatment is carried out by nurses specially trained in this work, with all the necessary facilities at hand, rather than giving the parents a bottle of 'ear drops' with directions for use, which in very few instances can be satisfactorily carried out. The most important point—the thorough cleansing of the ear, swab or by suction, is quite impossible for the parents to do. There has been a remarkable improvement in the rapidity with which these acute otitis cases have healed up since having efficient clinic treatment. The rapid cure of acute otitis is important in the prevention of deafness. "Zinc ionisation has been employed for all cases of chronic otorrhoea, and it still remains the most effective and rapid method of curing this condition, but the technique must be correct in all its details. "Diastolisation has been used successfully in the majority of nasal cases, rhinitis, catarrh, deafness, etc. "During the early summer three cas.es of hay fever were cured of any further 'attacks' by one or two applications of nasal ionisation. "It was not possible to carry out routine Audiometric testing for hearing in all school children as in pre-war time, but it has been regularly employed for all those with ear defects attending the aural clinic, and the special cases referred from school examinations and the Deaf School". SUMMARY. Total number of new cases examined and prescribed for during 1943 799 As follows:— Acute otitis—school children 251 Acute otitis—pre-school children 28 Chronic otorrhoea, without complications—school children 27 43 Chronic otorrhoea, with complications—school children 27 Chronic otorrhoea—pre-school children 4 Nose and throat conditions—school children 318 Nose and throat conditions—pre-school children 62 Nose and throat conditions associated with otitis media—school children 59 Nose and throat conditions associated with otitis media—pre-school children 11 Miscellaneous—school and pre-school children 118 Ear cases treated by zinc ionisation 63 Nasal cases treated by diastolisation 187 Nasal cases treated by Proetz Displacement 50 Tonsil cases treated by conservative methods, Tonsil Suction, etc. 107 Ear cases referred to Hospital 8 Tonsils and adenoids referred for operation 24 Children examined at the Aural Clinic and treatment arranged, but who failed to attend for same 66 Total number of pre-school children seen at the clinic 94 ORTHOPAEDIC CLINIC. I am indebted to Mr. J. A. Cholmeley, M.B., F. R.C.S., for the following report on the work of the Orthopaedic Clinic during the year ending December, 1943. "There has been a further increase in the number of new cases seen at the Orthopaedic Clinic, a number which is approaching the figure for 1938. In 1940, when the London air-raids were at their maximum, there was the smallest attendance of new cases, and in 1943, this figure has almost been doubled, although it has not been possible to increase the number of surgeon's sessions held on account of the shortage of staff at the hospital; on the other Land the number of children attending for treatment, and the number of treatments given, has fallen slightly since 1942, partly due to requests by parents for examination of their children at the clinic when the 'defect' is only a variation of the normal, this is shown by the considerable number of cases diagnosed as 'nothing abnormal discovered' and always tends to occur when special clinics become well established. 44 "Even though there has been some reduction in the number of treatments given during 1943, the amount of work done by Mrs. Yorke, the masseuse, is very large, particularly as much of it is individual and cannot be carried out in classes, and it is only by her careful organisation of the work and her efficiency that such good results are obtained at the clinic. It is interesting to note that the number of-treatments compared with 1940 is more than doubled. "Analysis of the cases during the past few years shows a remarkable reduction of rachitic deformities, a steady flow of congenital deformities and of postural spinal defects (the latter never large) and an increase during the past two years of cases of foot defects on which I commented last year, and almost certainly due to the inclusion of secondary school children. It is noticeable that few cases of bone and joint tuberculosis are ever seen at the orthopaedic clinic; this is due to their attendance at the County Tuberculosis Dispensaries which is rather an unfortunate division of crippled children between two authorities when housed and educated in one borough. "Education at school is, of course, an essential part of the training of every child, and more so of the physically defective on account of his handicap and on account of gaps in his education due to illness and periods spent in hospitals where education is not provided. For education purposes physically defective children can be sub-divided into four groups 1. Severely crippled children whose homes are unsatisfactory. 2. Severely crippled children whose homes are satisfactory. 3. Moderately crippled children who can get to school without special transport, and who benefit adequately at a school for normal children. 4. Moderately or temporarily severely crippled children who have recently been discharged from hospital and who are not fit enough to attend a school for normal children for the time being. "Those in the first group are much better taken away from their homes and educated in residential schools for 45 physically defective children; these include some of those incapacitated by infantile paralysis. "Those in the second group should be educated at a day school for physically defective children such as exists in Tottenham. "The third group is much the largest, it includes many of the cases of infantile paralysis, e.g., a child wearing a surgical boot or a single walking instrument, it also includes all cases of amputation where there has been the loss of one limb, either upper or lower, who should be provided with an artificial limb at as early an age as possible, sometimes even before school age, this limb being as much like a normal one as obtainable; thus in a lower limb amputation a peg leg should not be provided as this not only encourages an ungainly gait but it also labels the child as an obvious cripple which should be avoided whenever possible. "The fourth group has in the past, been either overlooked, ignored, or sent to a school for physically defective children. This could be dealt with very adequately by sending to a residential school for one or two terms; at such a school there would be children convalescing from many conditions, e.g., severe attacks of infectious fevers, severe fractures, long periods of hospitalisation for medical or surgical reasons, some cases of surgical tuberculosis. The majority of these children would, after a term or two at such a school, be able to attend a school for normal children on return home. Such provision was made before the war at the Authority's Residential School at Hayling Island. "I am afraid I may have rather overstressed thedesirability of children attending schools for the normal, but I do consider that it is bad psychologically for anyone to be always with the abnormal, if avoidable, and the majority of physically defective people have to compete on the open labour market when they leave, so that the sooner they become adjusted to this the better and easier. "With regard to vocational training, this should be postponed until the child has reached the age of sixteen years, and should be reserved for those cases who are unable to receive adequate training or apprenticeship amongst normal people. 46 This must, of course, depend on the facilities available in the child's home district. "A difficult problem is the child with a mental and physical defect. Here the mental defect is, from the point of view of education, the more important." Attendances. No. of new cases dealt with during the year 153 Total number of children treated during the year 196 Total number of treatments during the year 2,811 Schedule of New Defects. 1. Congenital defects 24 2. Birth injuries 3 3. Rickety deformities — 4. Knock-knees (non rickety) 12 5. Postural defects of the spine 23 6. Structural curvature of the spine 2 7. Flat feet, footstrain, etc. 53 8. Infantile paralysis 2 9. Sequalae of acute fevers — 10. Fractures and other injuries 3 11. T. B. joints — 12. Other bone or joint diseases (Non T. B.) 3 13. Osteomyelitis 5 14. Other conditions including postural in- toeing 2 15. Non-Orthopaedic — 16. N.A.D 21 Provision of Surgical Instruments. Surgical appliances were supplied, and repairs and replacements effected in 31 instances. Provision of Artificial Limbs. A Joint Circular issued by the Ministries of Health and Education was issued in April with the object of ensuring that there should be adequate provision of artificial limbs for children. Local Authorities are given sanction (where this was not previously 47 possessed) to make all necessary arrangements, and the facilities of Queen Mary's Hospital, Roehampton, were made available. The importance of early treatment, and fitting of a good artificial limb were emphasised. NERVOUS DISORDERS. Cases requiring treatment were referred for psychological treatment to the following clinics:— Tavistock Clinic. The London Child Guidance Clinic. Guy's Hospital. The London Child Guidance Clinic returned from Cambridge this year, and thus provided a welcome increase of treatment facilities for these children. HOSPITAL TREATMENT. The North Middlesex Hospital has again undertaken the operative treatment for enlarged tonsils and adenoids. CONVALESCENT HOME TREATMENT. Number of children sent away during the year by the Invalid Children's Aid Association:— Bronchitis, pneumonia and asthma 18 Ears 6 Debility 13 Tonsils and adenoids 4 Nervous troubles, chorea, etc. 19 Inanition, malnutrition, anaemia 8 Post operations 7 Infections 6 Jaundice 4 Nose 2 Skin 6 Bones 5 Rheumatism and heart 6 Glands 4 108 48 The Annual Report of the Tottenham branch of the Invalid Children's Aid Association was received. Their valuable help and co-operation are much appreciated. Convalescent treatment was arranged through the local Education Authority for 127 children recommended by the School Medical Service. These children were placed in suitable recognised homes, as in previous years. During the year, visits of inspection were paid to the following homes, by one of the assistant medical officers, and the children from this Borough were medically examined, and reports made to the parents concerned:- St. Catherine's Home, Ventnor. St. Vincent's Home, Liphook. The conditions were found to be very satisfactory, and the opportunity afforded of meeting the staffs and discussing the progress of the children were of considerable value. INFECTIOUS DISEASES. (a) Non-Notifiable. The following table gives the monthly numbers of cases of nonnotifiable infections occurring in the schools compiled from weekly returns of Head Teachers—all these cases are visited in their homes by School Nurses. 49 Month Jaundice Sore Throats German Measles Chicken Pox Mumps Whooping. Cough Scabies Impetigo Tinea A. B. A. B. A B. A. B. A. B. A. B. A. B. A. B. A. B. Jan - - - - - 1 26 43 48 43 5 2 3 7 5 6 2 1 Feb - - - - - - 51 14 45 32 13 — 6 9 3 - - - Mar. - - - - - - 40 40 36 61 14 14 2 10 1 - - — Apr. 3 3 - - 1 1 51 20 71 61 8 2 6 5 2 4 1 — May. 3 3 1 - 2 1 48 30 21 30 26 1 4 2 3 1 - - June - 2 - - 4 10 29 20 13 10 12 1 4 2 — 1 2 — July 2 3 - - 3 4 19 10 8 3 14 4 5 2 2 — 1 1 Aug. - - - 1 - - 2 1 -. 1 7 3 1 - - - - - Sept. 3 4 1 - 3 - 7 6 - 3 15 6 8 4 8 — 2 — Oct. 3 - - - 3 2 48 4 4 2 12 — 5 3 2 — — 1 Nov. - 4 - 1 1 - 5 2 3 6 15 3 3 1 2 5 — — Dec - - - - - - 2 1 3 3 11 — 1 1 - - - - Totals 15 22 2 2 17 19 528 191 352 255 152 36 48 46 28 21 12 3 A represents—children in Infants' Department. B represents—children in Junior and Senior Departments. 50 Scabies. There has been a slight fall in the number of cases attending for treatment at the clinics, and the number of cases with secondary infections is less, as parents recognise the defect, and are prepared to have immediate treatment, and to co-operate in the arrangements made for the whole family to be treated simultaneously. Number of Cases of Scabies Treated by the School Medical Service. Lordship Lane Health Centre 217 Park Lane Health Centre 173 Markfield Road Baths for Downhills School Clinic 193 Total 581 (b) Notifiable. Scarlet Fever 231 Diphtheria 72 Measles 386 Severity of Measles. Total number of cases of measles visited by school nurses from January—June, 1943 886 No. of cases reported with complications 28 Pneumonia 15 Severe bronchitis 4 Pleurisy 1 Otorrhoea 4 Removed to Hospital—cause probably home conditions 4 28 The above figures show the relatively small incidence of complications occurring in cases of measles in school children. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. School for the Deaf. In February, 1943, the evacuated portion of the School for the Deaf, and those who were still in Tottenham were re-united, and later in the year the school was transferred from West Green School 51 to its own premises in Philip Lane, although the whole of the latter accommodation is not available. At the end of the year, there were 42 deaf and partially deaf children on the roll. In addition there were 21 children with severe speech defects who were continuing their ordinary education, while receiving remedial instruction. The twice weekly classes for stammerers were resumed—10 cases receiving treatment. The three boys and two girls who left school during the year were successfully placed in industry as follows:— Boys. Girls. Woodwork 1 Printing trade 1 Surgical instrument making 1 Sweet factory 1 Commercial Art 1 School for Physically Defectives. This school was still occupying temporary premises, namely three rooms in West Green School during 1943. There were fortyseven children in the school at the end of the year. Some of the children were still evacuated to various residential schools. The school was visited periodically by the school medical officer. All the children were examined every six months. A school nurse visited daily. The staff of the Orthopaedic Clinic supervise and treat the children, where the need arises, at the School Medical Centre. Analysis of Cases. Infantile Paralysis 5 Paralysis 3 Osteomyelitis 1 Fragilitas ossians 1 T. B. Joints.. 6 Perthes disease 3 Muscular Dystrophy 1 Heart disease 27 Oak Lodge Special School. The progress of the children has been satisfactory and there has been a good standard of health throughout the year. Regular visits have been made by the school medical officer. The number of children attending at the end of 1943 was 56. 52 School for Blind and Partially Sighted Children. Nine children from this Borough (all suffering from myopia) attended during the year. This school is still accommodated at Hale End Open Air School, and is in the charge of the Borough of Walthamstow. By December, 1943, the school numbered 46 children. A satisfactory standard of health was maintained during the year, and good progress was made by all the children. EXAMINATIONS BY MEDICAL OFFICERS. Number of adult staff, including teachers examined during the year 16 HEALTH EDUCATION. Dental Exhibition. The Dental Staff arranged an exhibition at Park Lane Municipal Medical Centre, some of the exhibits were also shown at the Chestnuts and Lordship Lane Medical Centres. Some of the parents still fail to appreciate the value of early and regular dental care, and it has been found that there is still a great deal of ignorance about this matter. The exhibition served a useful purpose by bringing the facts of the importance of dental work to the notice of parents and senior school children. Schoolgirls attended Park Lane Centre for instructions by the health visitors in infant care and management. The children attending the two Medical Centres where Maternity and Child Welfare work is also carried out in the same building, and where there are nurseries, see the principles and practice of hygiene presented in a most attractive way, this visual education being a most valuable means of arousing their interest in the importance of healthy living. MATERNITY AND CHILD WELFARE (December 31st, 1943). Committee: Chairman: Alderman Mrs. A. Kitchener. Vice-Chairman: Councillor Mrs. A. E. Lyons. Members: His Worshipful the Mayor (Councillor F. A. F. Keay, J.P.). Alderman Mrs. W. A. Kent. Councillor G. A. Armfield. „ J. H. Morrell, J. P. „ Mrs. M. Berry. „ A. Read, A.C.I.I., J.P. „ Miss R. F. Cox. „ A. R. Turner. „ T. J. Dickinson. „ R. H. Warren, J.P. „ R. W. H. Ford. Councillor Mrs. E. M. A. Morrell. Clerk to the Committee .. Miss M. F. Davidson. Superintendent Mrs. J. Kent Parsons, M. B.E. Executive Officer Dr. G. Hamilton Hogben. 54 STATISTICAL INFORMATION. The population of the Borough as estimated by the RegistrarGeneral is 110,350 as compared with the pre-war estimated population of 144,400. Number of Births:—Male 1,018 Female 952 1,970 Birth Rate (per 1,000 population) 17.85 Number of deaths under one year of age 86 Number of still births registered 70 Infantile Death Rate (per 1,000 live births) 43.65 Number of maternal deaths 6 Maternal Death Rate (per 1,000 total births) 2.94 CO-ORDINATION. The wide field covered by the work of a large Maternity and Child Welfare Department involves contact with many other organisations whose work is related to some aspect of the welfare of mothers and young children. The various departments of the Health Service are within the same administration and good co-operation is a valuable part of this organisation. Frequent contacts occur with the services of other Committees, especially that of Education. The effectiveness of the work owes much to the ready co-operation which has been obtained throughout the year. In regard to bodies outside this Authority, most valuable help and co-operation have been given by the Almoner Services of the Prince of Wales's and North Middlesex Hospitals, the Invalid Children's Aid Association and the Women's Voluntary Service. The National Society for the Prevention of Cruelty to Children has, as in former years, proved most helpful; and the co-operation of the Tuberculosis and Venereal Diseases' Services of the County Council has been appreciated. Maternity Hospital Service. The following table shows the various institutions in which the confinements of this area took place:— 55 The Mothers' Hospital, Clapton:— Under the Council's scheme 53 Own arrangements 10 North Middlesex County Hospital 208 Other outside institutions 205 Evacuated under the L.C.C. scheme 421 Work of the Health Visitors. The work of the Health Visitors maintained its usual high level. The staff comprised eighteen health visitors. During the year three of the staff left; one to take up special work, and two who married and moved to another district. Newlyqualified health visitors were engaged through the Ministry of Labour to replace them. The health visiting service suffered by the temporary loss of two experienced members who were loaned to the Tottenham Residential Nursery at Hertford, in turn, from the 19th of February to the 23rd of July during the illness of the matron. Three health visitors attended the first year of the Lecture Course for the Social Science Diploma, held at the Westminster Commercial Institute. Thirteen health visitor students from the National Health Society and Battersea Polytechnic Institute received their practical training in the department. Each student attended two days a week for three months. This training was followed by a similar but shorter course in the School Medical Department, and a final visit, through the courtesy of Alderman A. J. Lynch, J. P., to the Juvenile Court. Two groups of health visitor students from the Royal College of Nursing attended practical demonstrations in the department during the year. The Superintendent of the war-time nurseries (a seconded member of the health visitors' staff) attended the Summer School organised by the Women Public Health Officers' Association at Newnham College, Cambridge, from the 26th June to the 5th July. The health visitors have maintained a friendly contact with the eight war-time nurseries and their assistance in following up absentees from the nurseries proved most helpful. Members of the staff have given lectures on the Public Health Services to the students training for the Nursery Nurses' Diploma of the National Society of Children's Nurseries. 56 Rushcliffe Report on the Scale of Salaries. The Reports of the Nurses Salaries Committee (Rushcliffe) were received at the end of the year and conditions recommended therein were adopted in full and became operative from the 1st of April, 1944. The home visitations of the health visitors included 1. Routine and special visits to expectant and nursing mothers, and to children under five years. 2. Foster mothers and "daily minders" received regular visits. 3. Mothers who failed their appointments at the pre-natal and post-natal clinics were visited immediately, the cause found and new appointments made for them. 4. Mothers who were being evacuated for their confinement were visited and given full instructions before their departure. 5. Where defects were discovered during visits to the Welfare clinics, the health visitors were responsible for ensuring that the medical recommendations were carried out. In addition to home visiting, the health visitors were in regular attendance at the Maternity and Child Welfare Department in the Town Hall, and at the three Municipal Health Centres, where they arranged demonstrations in Mothercraft and assisted at the following clinics:— 1. Pre-natal and post-natal clinics. 2. Infant and toddlers' clinics. 3. Sunlight treatment sessions. 4. Dental anaesthetic sessions for attendance on expectant mothers. Care of the Unmarried Mother and Illegitimate Children. The urgency of this problem, aggravated by war conditions, was outlined in a Ministry of Health circular received in October, 1943. In this area there already existed good co-operation between the Department and the local voluntary organisations who deal with 57 this work. The local branch of the Moral Welfare Association has, in particular given most valuable help to the Welfare Authority in dealing with these cases. DETAILS OF HOME VISITING BY HEALTH VISITORS. Expectant Mothers. Children under 1 year. Over 1 yr. Totals. First Visits. Re-visits. First Visits. Re-visits. Re-visits. 1,544 2,171 1,869 6,874 13,156 25,614 Other visits:—Infantile Deaths 35 Still Births 85 Ophthalmia Neonatorum 1 Pneumonia 3 Infectious Diseases 976 Special visits: Mothers 1,123 Children 392 Total 28,229 Breast Feeding. The report on breast feeding of the Advisory Committee of the Ministry of Health was received. It has been read by the appropriate officers of the department and the recommendations implemented so far as war-time conditions permit. BREAST FEEDING. The following table shows the types of infant feeding and their incidence in the total infant population of the Borough. The information is obtained by the Health Visitors when the child has reached six months, and is based on the total notified births for the year, i.e., 1,982:— Breast fed 1,134 Part Breast fed, plus milk, dried milk or condensed milk 526 Bottle feeding—Cow's milk 44 Dried milk 114 Other Artificial Feeding 3 Feedings unknown: i.e., removals, evacuations and deaths 161 Total 1,982 58 ANTE-NATAL CLINICS. Centre. Sessions. Attendances. Cases. PostNatal. The Chestnuts 200 3,720 1,022 238 Lordship Lane 155 3,021 811 183 Park Lane 104 1,980 489 164 Total—1943 459 8,721 2,322 585 Total—1942 429 8,377 2,220 518 Again the amount of work has increased, partly due to the rising birth rate (17.85 as against 16.52 in 1942), and partly to the fact that the clinics are being used increasingly in this area. The clinics have worked to their maximum capacity and the co-operation and conscientious work of the health visitors and midwives has been most valuable. In order to facilitate the regular supervision of ante-natal cases, provision has been made for patients to be conveyed to the ante-natal clinics and home again where necessary, by the Corporation ambulance service. Despite war-time difficulties, the standard of health of the mothers attending the clinics has been good. The special war-time provisions for additional rations have been fully used and much appreciated. As in previous years the Mothers' Hospital, Clapton, and the North Middlesex Hospital have continued to work closely with the ante-natal clincis. Prevention of Rickets. The popularity of the ante-natal clinics and the health visitors' and midwives' visits, have assisted in encouraging expectant and nursing mothers to take a balanced and adequate diet, and to avail themselves of the vitamins and extra milk, oranges and eggs provided under the Ministry of Health schemes. The Report of the British Paediatric Association published during the year on behalf of the Ministry of Health, emphasised again, the high incidence of minor degrees of rickets among young children, even breast-fed 59 babies, thus showing the necessity for intelligent planning and the best use of foodstuffs for the production of healthy children. INFANT WELFARE CENTRES. The following table shows the attendances of infants and Children under five at the Municipal Health Centres:— Centre. Sessions. Weighings . Infant Attendances . New Cases. Weighings. Over 1 year Attendances . New Cases. Examined by Doctor. Lordship Lane Municipal Health Centre 256 6,517 508 2,265 75 1,575 The Chestnuts, St. Ann's Road 259 7,876 640 2,394 75 2,170 Park Lane Municipal Health Centre 103 3,839 326 1,059 31 888 Town Hall 52 1,015 94 248 4 — Totals—1943 670 19.247 1,568 5,966 185 4,633 Totals—1942 .. 675 16,396 1,440 6,251 163 4,709 I am indebted to Miss Alice King, M.D., M.R. C.P., for the following report on the Infant Welfare Centres:— "War-time conditions have affected the attendances at the Welfare Centres to some extent during the past year, but the increase in the number of first babies, consequent upon war marriages has rendered the total attendances comparable with those of the previous year. "The absence from home of so many fathers has increased the sense of responsibility of the mothers of families, many of whom have sought advice upon various problems connected with the family and home life. TODDLERS CLINIC. Clinics for children between 2 and 5 years were held regularly throughout the year, attendance being by appointment at six monthly intervals. Their object was to secure routine medical inspection of children under five not regularly attending the Infant Welfare Centres, Nurseries, or nursery classes. The attendances 60 were well maintained and an average of between 15 and 16 children were seen at each session. Over two-thirds of the children attended twice or more during the year, where further supervision had been advised. It is very satisfactory to know that 80 per cent. of the children who attended had been immunised against diphtheria. Parents who had previously refused to have the children immunised, were persuaded to change their minds about this important prophylactic measure, in 28 cases. The defects found during medical examination were of a minor degree in the majority of cases, for example, slight dental caries. Signs of emotional disturbance, such as feeding difficulties, slight stammering, excessive fears, were slight and generally cleared up spontaneously. Therefore the fact that as many as 60 per cent. of all the children seen, had some minor defect at the time of examinations, only indicates the importance of medical supervision and advice during this age period. The standard of nourishment and development of the children was good in the majority of the cases. The parents were co-operative and appreciative of the facilities which they were afforded. The following table shows the attendances at the Toddlers Clinics held weekly at the Municipal Health Centres:— Centre. Sessions. Number Notified. New Cases. Reexams . Total. Lordship Lane 44 1,090 336 259 595 The Chestnuts 25 654 192 152 344 Park Lane 28 840 202 232 434 Total 97 2,584 730 643 1,373 Nature of defects found. Infections of the Ear, Nose, Throat. Signs of emotional disturbances Dental. Vision. Nutrition C. Debility after Infectious Disease. T.B. Family History. 20% 20% 16% 5% 5% 4% 2% 61 The number of children under five who attended the special clinics by arrangements with the School Medical Service are as follows:— Clinics. No. of Consultations. Treatments. Minor Ailments 134 73 Dental 191 329 Orthopaedic 109 514 Ophthalmic 218 8 Ear, Nose and Throat 125 125 Artificial Sunlight 676 Treatments 2,934 Immunisations:— Final Schick Tests 1,357 Immunised 1,398 By arrangements with the Maternity and Child Welfare Committee, 425 individual children of school age attended the Committee's Artificial Sunlight Clinic and 2,224 treatments given. CHILD LIFE PROTECTION. The Health Visitors, as Infant Life Protection Officers have, during the year paid 84 visits to the 21 foster mothers in the area in respect of 22 foster children. The Adoption of Children (Regulation) Act, 1939, came into force on 1st June, 1943, and certain provisions of this Act (Section 7) resulted in an important extension of Maternity and Child Welfare work. Two duties were imposed on Welfare Authorities, (1) in relations to the adoption arrangements made in their area, (2) regarding the supervision of certain children who are to be adopted in all cases where the parents do not directly make their own arrangements for adoption. Subsection 3 of Section 7 makes it the duty of any person (not parent, relative, or guardian or adopter), who participates in the arrangements for the adoption of a child under 9 years, to notify the Welfare Authority of the area in which the child is to be placed. Change of residence of the adopter must also be notified. Subsection 7 gives the Infant Life Protection Officer the following statutory duties:— 1. To visit and examine adopted children under 9 years of age, in the care and possession of adopters in their area. 2. To seek out any children in respect of whom a notice should have been given. 3. To supervise, without compulsory powers, those children placed by their own parents. 62 Further provisions of the Act, such as the further regulation of Adoption Societies, the prohibition of advertisements re adoption, and the increased facility afforded for the adoption of an illegitimate child by his own parent under certain conditions, are the concern of the Education and not the Welfare Authority. HOSPITAL TREATMENT FOR CHILDREN UNDER FIVE YEARS. Thirty-nine children have been referred to the North Middlesex Hospital for consultation and treatment of tonsils and adenoids, where operation was probably required. Orthopaedic surgical appliances have been supplied to two children. CONVALESCENT HOME TREATMENT. The Invalid Children's Aid Association have co-operated with the Department in placing children in convalescent homes, and have sent away 38 children under five years of age. In six cases mothers have been sent away through the Church Army Fresh Air Fund. Invalid Children's Aid Association. Number of children who stayed for 1—10 weeks 16 „ 11-20 „18 „ „ „ „ 21—30 „ 3 „ „ „ „ 31—40 „ 1 Of the 38 children, one case was free: the other 37 paid varying amounts weekly towards the cost. The following is a table of the defects for which they were sent away:— Otorrhoea 5 Post Mastoid 1 Debility 20 Bronchitis 4 Post Pneumonia 5 Rickets 2 Pink's disease 1 63 Three mothers went to convalescent homes with their children (under 5) during 1943. These mothers did not contribute towards the cost, being below the income level scale. Five orthopaedic appliances were provided, and of these, one parent paid part cost. The central office of the Invalid Children's Aid Association set up a committee during the year, to consider the need for additional post-war provision of convalescent home treatment for children under five years of age. WAR-TIME NURSERIES. New Nurseries. Three additional war-time nurseries were opened, two on the 15th November, 1943, and the other on 1st December, 1943. Each of these new nurseries is for 50 children from 0—5 years. The nurseries are pre-fabricated temporary structures, the material being hollow clay blocks, and the roof asbestos. Three rooms are provided for the children, so that a division into three age groups can be made. This is a most valuable measure both in the prevention of spread of infection and in facilitating the provision of daily routine suited to each of the age groups. These nurseries are a marked improvement on the type of nursery provided earlier in the war, both in material and design. The spaciousness of the nursery rooms is appreciated, and is only lacking in the size of kitchen provided. Staff. At the end of the year there were eight nurseries in the Borough, and one residential nursery at Hertford. The staff comprised 89 members. Thirty-four were students training for the National Society of Children's Nurses Diploma and 55 were trained staff. The standard of work was maintained at high level. The interest and co-operation of the staff has been outstanding, and the success of the three new nurseries has been due in a large measure to the enthusiasm and hard work of the matrons and nursery teachers. The nurseries were all affiliated to the National Society of Children's Nurseries, and recognised for training purposes. Four 64 students obtained the N.S.C.N. Diploma, and one student passed with distinction. The Cambridge Region of the Ministry of Health, issued a circular (2675) on 2.3.43, authorising the issue of badges to persons engaged in residential nursery work to indicate the importance of this national service. Badges were consequently issued to members of the staff of the Tottenham Residential Nursery, Hertford. The Matron of this nursery met with a serious accident on the 22nd February, 1943, whilst on vacation. Fortunately she made a good recovery and returned to work on the 17th November, 1943, but she was much missed during her long illness. Health visitors in rota from Tottenham took charge of the nursery during her absence, so that satisfactory running was maintained. The nursery continues to be a most useful part of the Maternity and Child Welfare provisions of the Borough, making provision for many short-stayed children during temporary domestic alteration in family life. The neighbouring secondary schools were informed of the particulars of the training course in the War-time Nursery Service in accordance with a Ministry of Health letter. Several groups of the girls visited the nurseries. The Juvenile Employment Bureau has given most useful help, in assisting in the provision of probationers and by making the work known to school leavers. The help provided regularly throughout the year by the Civil Nursing Reserve members, and from the First Aid Mobile Unit of the Civil Defence, has been much appreciated. The salaries and conditions of work of the nursery staff were the subject of circular 2893, Ministry of Health, dated 18th December 1943, which set out the changes recommended by the second report of the Rushcliffe Nurses Salaries Committee, to bring the conditions into line with improvements suggested for the other branches of the nursing services. Early in 1944 these recommendations were considered by the Committee and adopted in full, to operate retrospectively from April, 1943, except in the case of probationers, whose conditions of service remained unaltered until 1st April, 1944. Health of Children in the Nurseries. Except during the influenza epidemic of November and December, 1943, and outbreaks of Measles and Whooping Cough WAR-TIME NURSERIES. Nurseries. Children; Places. Opened Attendances, 1943. Total. Days Open. Av. Daily Attendance Saturdays & Other ½-Days January to March. April to June. July to September. October to December. Total. Attendances. ½ -days. Average. Under 2 Over 2 Municipal Day Nursery ParkLane equipped for: Under 2 yrs. of age 20 Over 2 yrs. of age 30 50 1940 April 10 1,024 1,47 0 1,084 1,647 1,011 1,698 1,765 1,378 4,894 6,193 11,087 261 42.5 1,057 51 20.7 War-time Day Nurseries: Vale Road School for: Under 2 yrs. of age 30 Over 2 yrs. of age 30 60 1941 April 28 1,284 1,575 1,076 1,424 1,213 1,861 1,140 1,843 4,713 6,703 11,416 261 43.7 803 48 16.7 Lordship Lane for: Under 2 yrs. of age 15 Over 2 yrs. of age 25 40 1942 Sept. 28 646 997 802 1,445 802 1,139 825 1,438 3,075 5,019 8,094 261 31.0 650 51 12.7 Downhills School for: Over 2 yrs. of age 40 1942 Aug. 10 — 2,125 — 2,242 — 1,624 — 2,404 — 8,395 8,395 261 32.1 521 50 10.4 Parkhurst School for: Over 2 yrs. of age 40 1942 Aug. 10 — 1,636 — 2,123 — 2,015 — 2,296 — 8,070 8,070 261 31.0 434 51 8.9 Plevna Crescent for: Under 2 yrs. of age 25 Over 2 yrs. of age 25 50 1943 Dec. 1 - - - - - - 261 192 261 192 453 22 20.6 43 4 10.7 Pembury House for: Under 2 yrs. of age 25 Over 2 yrs. of age 25 50 1943 Nov. 15 - - - - - - 386 351 386 351 737 34 21.6 56 6 9.3 Rowland Hill for: Under 2 yrs. of age 25 Over 2 yrs. of age 25 50 1943 Nov. 15 - - - - - - 228 371 228 371 599 30 20.0 26 6 4.3 Total under 2, 140 Over 2, 240 380 Total=418 — 2,954 7,80 3 2,972 8,881 3,026 8,337 4,605 10,273 13,557 35,294 48,851 - - - - - Evacuated Nursery, Bengeo, Hertford for: 38 In residence 31.12.42 36 Discharged during 1943 34=2 + 26 admitted = 28 in residence 31.12.43. Age of Children on Admission. Under 1 yr. Over 1 and Under 2. Over 2 and Under 3. Over 3 and Under 4. Over 4 and Under 5 Total. Bengeo House 4 9 7 6 2 28 Park Lane 16 21 30 13 11 97 Vale Road 22 50 36 24 5 137 Lordship Lane 18 21 18 19 5 81 Downhills — — 34 35 16 85 Parkhurst — — 31 32 16 79 Plevna Crescent 7 14 9 9 3 42 Pemburv House 7 14 13 7 1 42 Rowland Hill 1 11 13 5 — 30 Total 75 146 191 150 59 621 65 in two of the nurseries in January, 1943, the health of the staff and of the children has been remarkably good. There were eight cases of mild Dysentery in one nursery; no other gastro intestinal infections occurred. Catarrhal Jaundice affected fourteen members of the staff. Eight children developed this complaint during the year. The Influenza epidemic affected a large number of the nursery staff, the maximum being twenty-two absent in one week. Children who had not been previously immunised against Diphtheria were immunised on admission. Ninety immunisations were thus completed in the nurseries during the year. All these children received the final Schick test. All nurseries were visited fortnightly by a medical officer. Every child was medically examined at three-monthly intervals or more frequently where necessary. Sunlight treatment was provided for all the children in the four nurseries which are situated near Municipal Health Centres. Children from the other nurseries were taken for sunlight treatment where their condition indicated a special need. Circular 90, Region 5, Ministry of Health, set out certain conditions under which children of non-war workers could be admitted to war nurseries. This increased the usefulness of the war nurseries in the Maternity and Child Welfare work of the Borough by assisting cases wheie these conditions were fulfilled. MIDWIFERY SERVICE. In spite of the difficulties of the "black out" and enemy action, the midwifery service has maintained a high standard. The mothers confined in their own homes showed an increase of 58 over those of last year. Ambulance conveyance was provided 20 times during the year for midwives called to urgent cases during the black-out. The Rushcliffe report relating to the hours of duty, conditions of work, holidays, sick pay and salaries was issued by the Ministry 66 of Health, and adopted by the Maternity and Child Welfare Committee. In order to conform with its recommendations a complete revision of the service was undertaken, and it was found necessary to increase the number of midwives employed, from 8 to 12. At the end of 1943, 11 midwives were employed and a twelfth was engaged, to commence duty early in 1944. The midwives have had their premises and equipment examined at frequent intervals. Post Certificate Lectures to Midwives. The Council again had the benefit of courses of lectures arranged by the L. C. C. During the year attendance of the municipal midwives, free or at part cost in necessitous cases was as follows:— Cases attended free 55 Cases attended for part cost.. 86 Total 141 The demand for sterile packages for confinements increased from 632 in 1942, to 726 in 1943. This may be said to show that mothers are increasingly aware of the value of a high standard of hygiene during childbirth. The midwives attended the ante-natal clinics whenever possible and good co-operation existed with the health visitors. The Middlesex County Council's arrangements for an Obstetric "Flying Squad" attached to the North Middlesex Hospital is called out by medical practitioners who desire assistance in the treatment of obstetric emergencies occurring in the district. The terms are £2 2s. for each visit. It was agreed that the benefits of this service should be available in Tottenham Borough, in addition to the approved panel of consultants available in the home. The assistance and co-operation of the District Nursing Association have been most valuable. During March, 1943, when the Department was suffering from pressure of work, five cases were transferred to the District Nursing Association, and 47 nursing visits were paid by them. 67 RECORD OF WORK. (Excluding Work in Reception Areas). Cases. Attended by Total. Municipal Midwives. District Nursing Association. Number of Deliveries 960 11 971 Number of Cases Attended as Maternity Nurse 28 12 40 Primipara Cases 315 10 325 Multipara 673 13 686 Ante-natal Visits 1,699 82 1,781 Nursing Visits 14,601 439 15,040 Deaths of Mothers at Home None - - Mothers Admitted to Hospital:— (a) During Pregnancy 35 — — (b) „ Labour— 3 — — (c) „ Puerperium 5 — — Ante-natal Clinic Attendances included in Ante-natal Clinic table. — — — PUERPERAL PYREXIA. The following table shows the final result in each of the six cases of Puerperal Pyrexia notified during the year:— Doctors' Cases. Midwives' Cases. Occurred in Hospitals outside District. Total. Final Results. Recovered Died. 6 - - 6 6 - MATERNAL MORTALITY. A special report has been forwarded to the Ministry of Health for the six maternal deaths recorded. The Registrar-General's records show that the maternal death rate was as follows:— 68 Deaths from Puerperal Sepsis Nil From other Puerperal Causes 6 Total 6 Maternal death rate (per 1,000 live and still births) 2.94 The rate has been maintained below 3 since 1934, except for a rise to 4. 2 in 1937. The figures for the three years before this were 1932—4.5; 1933—5.9; 1934—5.1. MATERNITY AND NURSING HOMES. The number of Nursing Homes on the register at the beginning of the year was one. No applications for registration were received. Hospitals exempt for registration 1 (The Prince of Wales's General Hospital). Number on register at the end of the year 1 HOME HELPS. The increase in birth rate and number of home deliveries has meant a great demand on the services of all the available Home Helps. Financial aid was allowed in 214 necessitous cases, of which 117 received free help. OPHTHALMIA NEONATORUM. Only one case was notified. Three cases of discharging eye were also reported. All these cases made a satisfactory recovery. EVACUATION OF EXPECTANT MOTHERS. The number of expectant mothers who availed themselves of the Government short-stay evacuation scheme showed a slight decrease, being 421, as against 484 in 1942. This was probably due to the fewer air raids experienced during the year and the natural desire of the mothers to remain with their families. Those mothers 69 who availed themselves of the scheme appreciated the arrangements made for them. The scheme is still very popular. In many cases, where there were children under five, these were evacuated by the W.V.S., to various residential nurseries or were sent to the Tottenham Residential Nursery for approximately eight weeks. This proved to be a most valuable war-time measure. The mothers went away knowing that their children were safe from raids and well cared for, and returned after their confinement rested and refreshed after their stay in the country and lest from household cares. DENTAL TREATMENT FOR MOTHERS AND CHILDREN. The number of expectant and nursing mothers who have received dental treatment was 662. Of these 590 were ante-natal and 72 post-natal, all of whom were rendered dentally fit by fillings where preservation was possible ; and otherwise, by extraction under local or general anaesthesia. 108 mothers wers supplied with artificial dentures, 36 of whom were in the scale for free dentures, and 72 contributed part of the cost. Treatment of children under five continued as in previous years and led to 191 consultations with 329 treatments. ASSISTED MILK SUPPLY AND DISTRIBUTION OF FRUIT JUICE, COD LIVER OIL AND VITAMINS. Further provisions were made by the Ministry of Health for the nutrition of mothers and young children during the year: The period for which the daily pint of milk was provided for young children was extended. The methods of obtaining the vitamins, milk and extra rations during pregnancy and lactation were simplified and a leaflet explaining and advocating their use was issued for circulation to the public. Distribution of fruit juices and cod liver oil was undertaken at the Municipal Health Centres. Iron was also distributed. 70 Centre. Cod Liver Oil. Fruit Juices. To Children. To Mothers. Bottles. Bottles. The Chestnuts 3,589 198 20,322 Lordship Lane 2,505 196 13,867 Park Lane 1,954 208 10,086 Town Hall 1,104 — 5,260 Total 9,152 602 49,535 EXTRA CLOTHING COUPONS. The Food Office took over the provision of clothing coupons during the year, in accordance with the recommendation of the Ministry of Health circular. The issue of one composite medical certificate replaced the previous method of entitling mothers to obtain all maternity benefits. (Circular 2836, Ministry of Health.) 1,066 coupons for expectant mothers were distributed under the Board of Trade scheme up to the 26th July, when the distribution was ceded to the Ministry of Food and so to the local Food Office. HEALTH EDUCATION. As in previous years, health talks and demonstrations have been given to mothers at all the Municipal Health Centres. The. mothers' sewing class and social club has met regularly at the Chestnuts and Lordship Lane Centres. In co-operation with the Education Committee, the Mothercraft course of the National Association for the Prevention of Infant Mortality was given by the health visitor, to school leavers on Saturday mornings. Thirty-nine girls who took this course were able to sit the final examination, passed and were awarded certificates. Senior school girls from elementary schools have attended the Municipal Health Centres during school hours, for lessons in the care of babies and young children. Parties of school girls from 71 secondary, and elementary schools have been brought to see the Municipal Day Nursery and Health Centre in Park Lane. Voluntary help in the war nurseries has proved to be very popular among school girls', and throughout the year they have been permitted to help in the nurseries, out of school hours and during holidays. Girl Guides have come to the nurseries to gain the experience for the Child Care badge. It has been necessary to keep a waiting list of would-be assistants. Visitors, both from this country and overseas, have visited the Health Centres and War Nurseries and learnt how the health service is planned and carried out. The educational value of this part of the work well repays the time it demands. A valuable source of education is the demonstration of the provision of healthy surroundings and a good daily routine for "under fives," which is seen by all who pass, or call at the new Municipal Health Centre in Park Lane. The educational value of seeing fifty children of all ages having their midday sleep in the fresh air, day by day, is especially valuable at present when overfatigue is, for various reasons, all too common among the young children. The lay-out of all the war-time nurseries and the way in which they are conducted is a valuable piece of propaganda for the mothers and fathers and older brothers and sisters who bring and fetch the "under fives" daily.