Ac 439 (1) Harrow Mddy M Lata Mum.B Harrz The Urban District Council of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 19 3 5 E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law The Urban District Council of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 19 3 5 E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law 3 TABLE OF CONTENTS. page Officers of the Public Health Services 8 General Statistics 9 General Provisions of Health Services for the Area Hospital Provision 14 Ambulance 17 Clinics and Treatment Centres 19 Nursing in the Home 20 Laboratory Facilities 21 Legislation in Force 21 Sanitary Circumstances of the Area 24 Sanitary Inspection 29 Housing Statistics Statistics of Inspections 34 Inspection and Supervision of Food 37 Isolation Hospitals 41 Infectious and Other Diseases Prevalence and Control 47 Diphtheria 51 Scarlet Fever 54 Other Diseases 63 Tuberculosis 66 Maternity and Child Welfare 72 Infant Mortality 72 Maternal Mortality 76 Infant Welfare Services 79 Maternity Services 86 5 REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Chairman and Members of the Urban District Council of Harrow. Mr. Chairman, Ladies and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1935. In the body of the Report are particulars which indicate the volume of work performed, not only in providing facilities for the rapidly increasing population of the district, but in augmenting the existing services. This is particularly marked in connection with the maternity and child welfare work. Up to January 31st the Middlesex County Council continued to provide, on behalf of the local Council, these services in the former Hendon Rural District. From that date, however, the work has been carried out by the Council's own staff, as also has been the work in the Harrow-onthe-Hill area, which, up to December 31st, 1934, had been performed by other agencies. The health visiting staff has been increased to enable the necessary home visiting and clinic sessions to be provided to meet the increasing demand. New infant welfare centres have been opened up, but a rearrangement of the districts serving the centres consequent on taking over the work in the Hendon Rural District enabled some sessions to be closed with the result that the net increase is only three, there being sixteen weekly sessions at the end of the year compared with fourteen at the beginning. A comparison of figures of the work done during the two years 1934 and 1935 is set out:— 1934. 1935. Attendances at Infant Welfare Centres: By children under 1 year 19,290 28,138 By children aged 1 to 5 years 12,494 15,067 Number of mothers attending Ante- Natal Clinics 465 823 Number of attendances at Ante-Natal Clinics 1,354 2,370 Visits to expectant mothers 229 852 Visits to children under 1 year 3,580 4,603 Visits to children aged 1 to 5 years 2,018 4,084 Added facilities made available for nursing mothers include the Consultant Ante-Natal Clinic, Birth Control Clinic, General Practitioners' Ante-Natal Scheme, provision of maternity outfits, arrangements for home nursing and the provision of ambulance facilities for the conveyance of maternity cases to hospitals. For the children, arrangements have been made for operative treatment of adenoids and enlarged tonsils, for ophthalmic treatment, for home nursing and for convalescent home treatment. The first 6 steps towards the erection of two clinics in the district have been taken, and a site has been purchased on which will be erected the main clinic central to the district. In view of the urgent need for added maternity accommodation the Council is seeking authority to provide, with the Wembley Urban District Council, a joint maternity institution. Although the scheme submitted by the County Council as a result of the survey of Isolation Hospital accommodation as required by the Local Government Act, 1929, excluded Harrow from possessing its own Isolation Hospital, sanction was obtained during the year to proceed with the erection of a new hospital for the reception of cases of infectious disease. In the meantime, improvements have been carried out at the two existing hospitals to enable more efficient services to be provided pending the erection of the new hospital. In the early part of the year the Council sanctioned a scheme for diphtheria immunization of which quite fair advantage was taken. In connection with infection, one of the major steps taken was the abolition of fumigation as a routine after infectious diseases, this being now carried out only at the request and cost of the householder. The Sanitary Inspectors have had a very active year in connection with the improvement of the condition of houses. The previous proposals submitted in regard to slum clearance by the former three councils were modified, representations for clearance being made with regard to three groups of properties. In addition to these, a number of houses have been scheduled for action under Section 19 of the 1930 Housing Act. In connection with these, the Council decided that the occupiers of properties which are being demolished under Section 19 rather than under Section 1 shall, if their circumstances warrant, be entitled to the same benefits as if the properties had been dealt with by the procedure followed in clearance areas. Complaints have been received regarding nuisances and flooding arising by reason of the overloading of the sewage disposal works, a state of affairs partly due to the late date at which the connections were made under the West Middlesex Sewage Scheme. Complaints of rats have been very common from all parts of the district. To judge by the complaints of the local residents, the service provided by the Middlesex County Council as the authority administering the Rats and Mice (Destruction) Act, appears most meagre. Application was made to the County Council for transfer of the powers and duties under this Act to the District Council, but was met by a refusal. There are some services which are more efficiently administered by large authorities, particularly those requiring institutions. There are others, however, where local knowledge outweighs other advantages, and of these the powers under the Rats and Mice (Destruction) Act is one. Another is the supervision of midwives, a service for which the Council had previously 7 made application to be permitted to become the local supervising authority. In Middlesex, the districts which have been granted these powers are the Boroughs of Ealing, Tottenham, Willesden and the Urban District of Edmonton. With regard to elementaryeducation the district must be the largest which is not a local education authority, the reason for this being that the population of not one of the three constituent districts was a certain minimum at the 1901 census. Out of the twenty-nine sanitary districts in Middlesex, the County Council is the local education authority in sixteen, namely:—Feltham, Friern Barnet, Hampton, Hampton Wick, Harrow, Hayes and Harlington, Potters Bar, RuislipNorthwood, Southall-Norwood, Southgate, Staines, Sunbury, Teddington, Uxbridge, Wembley and Yiewsley and West Drayton. In ten of these, the County Council is also the Maternity and Child Welfare Authority. If only with a view to effecting unification of the health services of the district, it is regrettable that a district of this size should not be its own education authority, a position, however, which could not be altered except by legislation apart from the district becoming autonomous for all services. The complete severance of the maternity and child welfare services from the school medical services, however, is, from certain points of view, still more regrettable, and for the removal of this, means as cumbersome as legislation are not required. The vital statistics for the district are very satisfactory. The general death rate is low; the mortality from the various infectious diseases, including tuberculosis, is low; the infant mortality rate is well below that of the country as a whole, and the maternal mortality rate, while being slightly lower than the national rate, is appreciably less than that of the preceding year. The incidence of scarlet fever was heavy at the beginning of the year, but from May onwards was light, while diphtheria has continued at its exceedingly low rate. During the year the Council took steps to promote the General Powers Bill which contained many very useful public health clauses. Although the desirability of the Council possessing these very necessary additional powers was never at any time questioned, these clauses went the way of the rest of the Bill. I desire to thank the members of the Council and the Administrative Staff for the help they have given me in the past year. I have the honour to be, Ladies and Gentlemen, Your obedient servant, E. W. CARYL THOMAS, Medical Officer of Health. Council Offices, Harrow-on-the-Hill. May 25th, 1936. 8 OFFICERS OF THE PUBLIC HEALTH SERVICES. Full-time Staff. Medical Officer of Health: E. W. CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law Assistant Medical Officers of Health : KATHARINE R. BROWN, M.B., Ch.B., D.P.H. O. C. DOBSON, M.D., B.Hy., D.P.H. Sanitary Inspectors: A. B. KRAMM, Cert. R.S.I., Meat Inspector's Cert., Cert. Sanitary Inspector's Examination Board. (Senior Inspector.) H. DRABBLE, Cert. R.S.I., Meat Inspector's Cert. R. B. GIRLING, Cert. R.S.I., Meat Inspector's Cert. A. C. GROOM, Cert. R.S.I., Meat Inspector's Cert. J. E. JOHNSON, Cert. R.S.I., Meat Inspector's Cert. S. N. KING, Cert. R.S.I., Meat Inspector's and Smoke Inspector's Cert. P. SCHOFIELD, Cert. R.S.I., Meat Inspector's Cert. E. A. SMITH, Cert. R.S.I. Health Visitors: MRS. D. BRACE, S.R.N., S.C.M., H.V.'s Cert. (Senior Health Visitor.) MISS COUZENS, S.R.N., S.C.M., H.V.'s Cert. MISS LEE, S.R.N., S.C.M., H.V.'s Cert. MISS MARSHALL, S.R.N., S.C.M., H.V.'s Cert. MISS MATTHEWS, S.R.N., S.C.M., H.V.'s Cert. MISS REED, S.R.N., S.C.M., H.V.'s Cert. MISS SIMPSON, S.R.N., S.C.M., H.V.'s Cert. Matron of Isolation Hospitals: MISS V. R. THOMAS, S.R.N., S.C.M. District Fever Nurse: MISS V. G. ROBERTSON. Clerical Staff: W. GOODFELLOW, Chief Clerk. Six wholetime clerks. Part-time Staff. Consultant Gynaecologists: MARGARET BASDEN, M.D., F.R.C.S., F.C.O.G. R. CHRISTIE BROWN, M.S., F.R.C.S., M.C.O.G. Consultant Surgeon: R. TREVOR JONES, B.Sc., M.B., B.S., F.R.C.S. Maternity and Child Welfare Medical Officers: NORAH BEAUMONT, M.B., B.S., D.P.H. ETHEL M. BRAND, L.M.S.S.A. ELIZABETH GOURLAY, M.D. LUCY PARKER, M.D., M.R.C.P. 9 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, mid-year, 1935 144,280 Number of inhabited houses (end of 1935) according to Rate Books 41,265 Rateable Value (April 1st, 1936) £1,654,372 Sum represented by a penny rate (1935/36) £6,140 Social Conditions of Inhabitants. See Annual Report for the year 1934. There is little unemployment in the district, exceedingly little amongst Harrow residents who have been in the district for some time. The ordinary winter register for unemployed males of the district is about 1,800, a figure which falls to 750 or 1,000 in the summer, the reduction being due to the engagement of employees in the building trade. During weather in the winter unfavourable for building operations there might be a rise to an additional one-third or even one-half the winter standard. There are no skilled men unemployed in the building, engineering or allied trades, practically all the unemployed being unskilled men who have come to friends or who have of their own accord come from distressed areas. The figures for unemployed women vary from 250 in winter to 160 in summer. These are chiefly young married women who are "in and out," not being on the register long. There is practically no juvenile unemployment in the district. None of the local forms of employment prejudicially affects the health of the workers. Extracts from Vital Statistics for the Year. Live Births:— Total. Male. e. Legitimate 2,441 1,301 1,140 Birth Rate per 1,000 of the estimated resident population, 17.5 Illegitimate 82 38 44 Stillbirths:— Legitimate 77 43 34 Rate per 1,000 total (live and still) births, 30 Illegitimate 2 - 2 Deaths 1,108 547 561 Death rate per 1,000 of the estimated resident population, 7.7 Rate per 1,000 total [live and still) births. Deaths. Deaths from puerperal causes:— Puerperal sepsis 5 1.92 Other puerperal causes 4 1.54 Total 9 3.46 10 Death rate of Infants under one year of age:— All infants per 1,000 live births 42.1 Legitimate infants per 1,000 legitimate live births 39.7 Illegitimate infants per 1,000 illegitimate live births 109.8 Deaths from Measles (all ages) Nil „ Whooping Cough (all ages) 5 „ Diarrhoea (under 2 years of age) 12 There was no noteworthy cause of sickness or invalidity during the year excepting a rather high incidence of scarlet fever in the earlier part of the year. The incidence of diphtheria continues to remain light. Population. The mid-year estimate of population for the year 1934 was 132,049 and for 1935 144,280. This increase is partly due to the natural increase of population (i.e. the excess of births over deaths, this figure being 1,091 in 1934 and 1,415 in 1935) and partly due to the occupation of the new houses erected (4,331 in 1934 and 4,715 in 1935). The number of houses inhabited at the mid-year was 39,025, the average number of persons per house being therefore 3.69, compared with the figure of 3.68 which obtained in 1934. Applying this figure to the number of houses occupied at the end of the year gives a population figure at that date of 152,000. Birth Rate. 2,523 births were registered during the year, the birth rate per thousand population being therefore 17.5, compared with the figure of 16.4 for the district in 1934 and one of 14.7 for England and Wales. This high birth rate is due to the high proportion of young adult population in the district, and will probably be repeated as long as the district continues to grow at its present rate. Deaths and Death Rate. Total deaths in the district 674 Outward transfers 54 Inward transfers 488 Deaths of residents 1,108 Of the 54 deaths of non-residents occurring in the district, eight took place at the Orthopaedic Hospital, seven at the Harrow and Wealdstone Hospital and 16 in various local nursing and maternity homes (of which a number were new-born infants), 14 in private houses and five were due to road accidents. Of the 488 deaths of local residents which occurred outside the area, most took place in institutions, 190 being at Redhill Hospital and 65 at other County general hospitals. 22 deaths occurred at institutions for the treatment of tuberculosis (16 in County institutions) and 20 at mental hospitals (19 at Shenley). 11 22 deaths occurred in hospitals just outside the district, eight being at the Northwood and Pinner Hospital and five at Wembley Hospital. 106 deaths took place at various of the London general and maternity hospitals (Middlesex Hospital 21, St. Bartholomew's Hospital 13) and 14 at other hospitals. Five fatalities occurred in municipal isolation hospitals. 1,108 deaths in a population of 144,280 represents the death rate per thousand population of 7.7, compared with the figure of 11.7 for England and Wales, 11.8 for the Great Towns, and a local rate of 8.1 for the district in 1934. Death rates of districts are not comparable as the age and sex distribution of populations are an important factor in determining the rates. To eliminate variations in the death rates arising by reason of different age distributions of population, the Registrar-General now issues a comparability factor which when applied to the crude death rate gives a corrected rate which is a figure indicating the death rate that would have occurred in the standard population, which standard population is taken as the present age distribution of the population of the country as a whole. These corrected death rates can then be used as indicators of the comparative healthiness of districts. Those districts that have a population of higher than average age will have a comparability figure of less than unity, whereas those whose populations contain a relative excess of young adult population will have a figure greater than unity. The factor for this district is T17. Applying this to the crude death rate gives a corrected death rate of 9.0l, a figure to be compared with the national figure of 11.7. The fatalities expressed as a rate per thousand population of the infectious diseases compare favourably with the figures for the country as a whole. There were no deaths from measles, and the figures for whooping cough and influenza, namely 0.03 and 0.10 were lower than the national rates of 0.04 and 0.18. The diphtheria rate of 0.01 is strikingly lower than the rate for the country as a whole, namely 0.08, but that for scarlet fever, 0.02, is higher than the national rate of 0.01. Deaths from tuberculosis, both pulmonary and non-pulmonary forms, were fewer than occurred in 1934, and the rate per hundred thousand population, viz., 49.9, was well below that of 71.8 recorded for the country as a whole. The infant mortality rate was only 42.1 compared with the figure of 47 in 1934. The rate for England and Wales was 57, and in the Great Towns 62. The maternal mortality rate of 3.46 is appreciably lower than that of the previous year, and well below that for England and Wales, namely 4.10. There were 145 deaths from cancer this year, compared with 156 in 1934—but whereas last year the rate amongst females 12 only slightly exceeded that of males, this year the number of female deaths doubled that of male deaths. The age groupings of the males were five in group 35/44; 10, 10 and 14 in the next three decennial periods, and nine over 75. Of the females three were in the age group 25/34, five, 18, 24, and 29 in the next four decennial periods, and 17 over 75. The commonest affected sites amongst females were the breast 20; colon 14; stomach 13; uterus 10; lung 6; and oesophagus five. Amongst the males the stomach was the site of the lesion in eight; rectum and prostate six each; and the lung five. The recorded death rate from cancer per million living in England and Wales was 1,587; the corresponding rate for the district was 1,000. There were twenty suicides during the year (13 male and seven female), giving a rate per hundred thousand population of 14, being the same as that for the country as a whole in 1934 and a local rate that year of 16. Coal gas poisoning was the method chosen by four, three of whom were females, and cut-throat by four, all males. Of the remaining males three used the railway track; two lysol and two gun-shot; and one each drowning and hanging. Thirty-five deaths were due to violence (24 males and 11 females). Of this latter group six were due to falls of elderly females and a further three to their being knocked down on the road. Falls amongst elderly males accounted for four deaths and motor-cycle accidents a further five. Five children of five years and under had accidental deaths. When the deaths are grouped together in age groups it is noticeable that after the first year when the factors concerned in infant mortality have ceased to operate, the death rates are low up to 15 years. In the decennium 15/24 the most potent factor as a cause of death is tuberculosis, which is still more powerful in the next two decennial periods, but thereafter declines. In the group 35/44, however, it no longer stands alone as a single factor, but is associated with two other causes of death, viz., malignant disease and heart disease—but, as contrasted with tuberculosis, the influence of these two becomes more powerful in the succeeding age groups. By the period 45/54 another factor is added, viz., cerebral haemorrhage, which exerts its influence to the end—and deaths from bronchitis and pneumonia are more commonly found. Degenerative changes in the kidneys appear after 55, as do also circulatory changes other than heart disease. No deductions can be drawn on the frequency of the distribution of the deaths amongst the various age groups, particularly as affecting the deaths of the aged. This for a number of reasons, amongst them being the inaccuracy of the diagnosis and of more importance, the manner in which the death certificate is completed. Where more than one cause of death appears on the certificate, the Registrar-General allocates the deaths according to certain 13 rules, but unfortunately there is laxity in the completion of the certificates and the various causes are entered in the wrong order, with resulting misleading allocation. Then so much depends on the whim of the certifying practitioner. An aged person dies after being bedridden for a short time; there is some hypostatic congestion of the lungs and the heart has the usual degenerative changes. One doctor would be content with "senility" as a cause of death, another will blame the "bronchitis" as the cause, while a third will attribute it to the "myocardial degeneration," and, according to the words used, the death would be classified to groups 32, 20 or 16 of the short list of causes of death. Another reason that deductions will be fallacious is that such vastly different conditions are grouped under the one heading. The significance of a death from heart disease varies greatly according to the age of the patient. Excluding those in the early days of life which are alleged congenital abnormalities of the heart, heart disease in early life is mostly due to acute rheumatism. Later on are manifest the effects of a specific disease, viz., syphilis, and certain secondary changes consequent on degenerative changes in the arterial system, and lastly in the aged there is the myocardial degeneration, part and parcel of the wearing out of the body. These are the main aetiological factors—a disease associated probably in some way with nutrition and surroundings and calling for action by Local Authorities for early diagnosis and treatment ; a disease preventable and curable; changes taking place largely through faulty personal hygiene, apart from those causes due to hereditary influence; and what might almost be termed physiological wearing out. Another instance is group 15, referred to as cerebral haemorrhage, apoplexy, etc.—but including conditions which cause similar signs but are of so very different origin as cerebral haemorrhage, cerebral embolism, cerebral thrombosis and cerebral softening. For tabulated list of causes of death, see end. 14 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Hospitals provided or subsidised by the Local Authority or by the County Council. a. (1) Fever. The two Isolation Hospitals in the District were described in the Annual Report for 1934. (2) Smallpox. The Middlesex County Council is the Authority for the provision of smallpox hospital accommodation for the whole of the administrative county. By agreement with the London County Council cases of smallpox occurring in the County of Middlesex are removed to the River Hospitals. b. Tuberculosis. The Middlesex County Council is the Authority by whom arrangements are made for the treatment of those in the county suffering from tuberculosis. The County Council possesses two sanatoria, that at Harefield, which is reserved for sanatorium pulmonary cases, possessing 129 male and 129 female beds, 64 for children and eight observation beds. The Clare Hall sanatorium, for late sanatorium and hospital pulmonary cases, has 120 male and 66 female beds. Cases of non-pulmonary disease in children are treated at one of the 25 beds reserved for the County Council at Heatherwood Hospital, or at one of the six beds reserved at Victoria Home, Margate. The number of beds available for the treatment of tuberculosis in various of the County institutions is 91. At the North Middlesex Hospital there are 35 beds, 30 for pulmonary cases (28 adult and two children) and five for non-pulmonary cases (four for adults and one for children). At the Central Middlesex Hospital are 13 beds for adult pulmonary cases and two for non-pulmonary disease in children. At Redhill County Hospital are two beds for adult pulmonary disease and one for non-pulmonary disease in children; and at the Redhill Institution are a further five beds for adult patients, four being for pulmonary and one for non-pulmonary disease. Hillingdon County Hospital has eight beds for pulmonary disease in adults and one for non-pulmonary disease in children; while the Institution has one bed for pulmonary disease in adults. Of the 33 beds at the West Middlesex Hospital, 26 are for pulmonary disease amongst adults and seven for non-pulmonary disease, of which six are reserved for children. 15 During the year 1934 between 900 and 975 tuberculous persons were being maintained by the County Council in hospitals or sanatoria. Those for whom institutional accommodation is required and who cannot be accommodated at the County Institutions are admitted to sanatoria or hospitals belonging to other Local Authorities or to voluntary organizations, where the cost of their maintenance is met by the County Council. Hospitals for General Cases. (1) Hospitals for Medical and Surgical Cases. The two hospitals most used by the local inhabitants are the Harrow and Wealdstone Hospital and the Redhill County Hospital. The Harrow and Wealdstone Hospital, a voluntary institution, has a complement of 77 beds, comprised of 20 male and 27 female beds and 18 children's cots in the public wards, and 12 private beds. The total number of in-patients admitted during the year was 1,418. Consultative out-patient clinics are held at the Hospital for the following branches:—medical; surgical; diseases of children; diseases of women; ear, nose and throat; and radiological examinations, patients being seen by appointment. The total number of out-patients seen at the Hospital last year was 3,127, of whom 325 were accident cases, and 2,802 consultations, treatment or X-ray examinations. Massage, electrical and sunlight treatment are provided at "Tyneholme" on Mondays, Wednesdays and Fridays at 5 p.m. 732 patients were treated, 513 by massage and 219 received sunlight treatment. Of the County Hospitals the nearest and most used by local inhabitants is the Redhill County Hospital which contains 61 medical beds (32 male and 29 female), 61 surgical (32 male and 29 female), 18 ear, nose and throat (seven male, five female and six children), 26 maternity beds, 20 cradles and six isolation beds, 22 beds for children and two beds for sick nurses. At the Redhill Institution are 34 male beds and 77 female beds for the chronically sick. Of the 3,972 patients admitted in the year 1934, 1,867 came from the borough of Hendon, 1,241 from the urban district of Harrow, 807 from the urban district of Wembley and 57 from other districts of Middlesex. The Hospital is too small to meet the demands made on its accommodation, so that in 1934 741 patients from Harrow and Hendon had to be admitted to the Central Middlesex County Hospital, and others to even more distant of the County Hospitals. The proposals of the County Council for extending the Hospital include provision for a total of 313 beds for acute, including maternity, cases, and 294 chronic beds, the main work in the scheme including a new maternity block to accommodate 61 patients, a 16 new block to accommodate 294 chronic patients, alterations to the existing hospital which will increase the hospital by 74 beds, and the erection of a new treatment, casualty, X-ray and out-patients block. The District Council were concerned with the inadequacy of the general hospital services in the district and in July a deputation from the Public Health Department attended before the Middlesex County Council and the Voluntary Hospitals Joint Advisory Committee. The following is a list of the out-patient services held at the Redhill Hospital:— Ante-Natal Clinic Tuesday and Thursday, 10.30 a.m. Post-Natal Clinic Monday, 2 p.m. Dental Monday and Thursday, 2 p.m. Orthopaedic Wednesday and Friday, 2 p.m. X-Ray Monday and Wednesday, 2 p.m. Medical Tuesday, 2 p.m. Surgical Follow-up Thursday, 3 p.m. Head Injury Clinic Tuesday, 2 p.m. Ear, Nose and Throat Consultative Clinic Wednesday, 1.30 p.m. Varicose Veins Clinic Tuesday, 2 p.m. General out-patients are seen daily from 9.30 a.m. by the Medical Officer on duty; and ear, nose and throat out-patients are dressed daily by the Aural Sister. The other hospitals used by local inhabitants were referred to in the Annual Report for 1934. (2) Hospitals for Maternity Cases. Arrangements are made for the admission of maternity cases to various of the London Maternity and General Hospitals. The Council pays the fees of necessitous cases for whom such arrangements have been made. Cases of puerperal infection are admitted either to the London County Council North-Western Fever Hospital or to Queen Charlotte's Isolation Hospital. (3) Hospitals for Children. Apart from the arrangements by which cases of ophthalmia neonatorum are admitted to St. Margaret's Hospital, Hampstead, there is no provision for admission of children to hospital. (4) Orthopaedic Hospitals. The Council has no agreement with any particular orthopaedic hospital for the admission of patients though responsibility for the payment of fees of necessitous cases admitted to the various orthopaedic hospitals is accepted. 17 Ambulance Facilities. (a) For Infectious Cases. Infectious cases are removed by the Austin ambulance, which is housed alternately at the two isolation hospitals. (b) For Non-infectious Cases and Accidents. A 20-h.p. Austin ambulance is housed at the Fire Station, Harrow-on-the-Hill, and a 20-h.p. Talbot ambulance at the Wealdstone Fire Station. At the latter station a 14-h.p. Morris ambulance is also housed, being used as a stand-by. The following is a copy of the rules and conditions governing the use of the ambulance, as adopted by the Council in July, but including modification of charges made in the early part of 1936:— 1. Nature of Cases dealt with. At present the ambulances are housed at Harrow-on-the-Hill, Wealdstone and Stanmore Fire Stations and are available at all times of the day and night, for accident and urgent removal cases occurring within the district necessitating their use. 2. How to Obtain the Ambulances. Applications for the use of an ambulance should be made to any of the undermentioned Fire Stations:— Fire Station, High Street, Harrow-on-the-Hill (Telephone Nos., Harrow 2222 or Byron 2222). Fire Station, Palmerston Road, Wealdstone (Telephone No., Harrow 0273). Fire Station, 13, Handel Parade, Whitchurch Lane, Stanmore (Telephone No., Edgware 2224). Fire Station, Bridge Street, Pinner (Telephone No., Pinner 2222). 3. Charges. (a) No charge shall be made for cases of accident, seizures or fits, happening at home, in the street, at work or elsewhere, within the district, if removed within 24 hours of the accident, seizure or fit occurring. After such period the case shall be treated as a sick removal and the charges mentioned hereafter shall apply. (b) A fixed charge of 7s. 6d. shall be made for sick removals (other than cases referred to in (a) above) necessitating the use of the ambulances to hospitals, nursing homes and similar institutions within the district, and also to Redhill and Pinner and Northwood Hospitals. Where the ambulances are required to proceed to destinations outside the district, the following scale of charges shall apply:— B 18 To hospitals, nursing homes and similar institutions:— £ s. d. (i) Not more than four miles distant from the boundary of the district 10 0 (ii) Beyond four miles but not more than eight miles distant from the boundary of the district 15 0 (iii) Beyond eight miles but not more than fifteen miles distant from the boundary of the district, and to East End Maternity Hospital and the Mothers' Hospitals, Salvation Army, at Lower Clapton 1 0 0 (c) The same charge as set out in paragraph (b) shall be payable in all cases where the ambulances are used for removing from hospital any person residing within the district. (d) The ambulance shall be limited to proceed to places situated within 15 road miles from the boundary of the district. (e) The drivers of the ambulances are authorised to accept payment at the time the ambulances are used and to issue official receipts; in other cases payment must be made to the Treasurer, at the Council Offices, Stanmore, within one calendar month. (f) These charges shall not in any way affect the reciprocal arrangements entered into with neighbouring authorities. 4. General. (a) The ambulances shall return to their stations immediately on discharging their patients and shall not be kept waiting under any circumstances at hospitals, nursing homes, or other institutions. (b) Patients who are not local residents having been conveyed to any hospital, nursing home, institution, etc., requiring to be conveyed to their home, must make arrangements with the Ambulance Authority of their own district for their removal. (c) The Council will not hold themselves responsible for any delay, or non-removal of private cases, or for loss or injury suffered by patients. (d) Not more than two persons shall be allowed to travel in an ambulance with patients, but the Council will not be liable for any accident occurring to passengers in the ambulances. 19 (e) These Rules and Conditions are subject to amendment or alteration as the Council may deem necessary from time to time. (f) Where an ambulance is required in connection with a maternity case, the person calling the ambulance must arrange for a midwife, or a woman friend or relative to accompany the patient in the ambulance. The following list gives a summary of the extent to which the ambulances have been used during the year:— Accident cases 400 Maternity cases 142 Other cases 897 Clinics and Treatment Centres. The following is a summary of the various clinics and treatment centres in the district at 31st December, 1935:— Infant Welfare Centres. The Broadway Clinic, Wealdstone—Tuesday, Wednesday and Thursday. Elmwood Avenue Clinic, Kenton—Wednesday, Thursday and Friday. Conservative Club, Lowlands Road, Harrow—Tuesday. Baptist Church Hall, Northolt Road, South Harrow—Thursday and Friday. St. George's Hall, Headstone—Tuesday and Wednesday. Free Church Hall, Paines Lane, Pinner—Friday. The Institute, Whitchurch Lane, Stanmore—Monday and Friday. Memorial Hall, Harrow Weald—Thursday. Baptist Church Hall, Imperial Drive—Tuesday. These clinics, all sessions of which are held weekly in the afternoons, are maintained by the Local Authority. Ante-Natal Clinics. The Broadway Clinic, Wealdstone—Monday afternoon and Friday morning. Elmwood Avenue Clinic, Kenton—Wednesday morning. The Institute, Whitchurch Lane, Stanmore—Monday morning. Baptist Church Hall, Imperial Drive—Tuesday morning. " Tyneholme," Headstone Drive, Wealdstone—Tuesday at 2 and 5 p.m. These clinics are maintained by the Local Authority with the exception of those at "Tyneholme," which are maintained by the Council of Child Welfare. 20 Treatment Centres. The following treatment centres are provided by the Council of Child Welfare at "Tyneholme," Headstone Drive, Wealdstone:— Dental Clinic Saturday, 10 a.m. and 2 p.m. Massage Clinic Monday, Wednesday and Friday, 1.30 p.m. Sunlight Clinic Tuesday and Thursday, 9 a.m. In addition the following clinics are held on behalf of the Harrow and Wealdstone Hospital:— Massage Clinic Monday, Wednesday and Friday, 5 p.m. Sunlight Clinic Monday, Wednesday and Friday, 5 p.m. School Treatment Services. Minor Ailments Clinic:— Roxeth Hill Council School, Harrow—Wednesday, 9.30 a.m. Broadway Clinic, Wealdstone—Monday and Thursday, 9.30 a.m. Whitchurch Institute—Friday, 9.30 a.m. Ophthalmic Clinic:— Broadway Clinic, Wealdstone—Wednesday, 9.30 a.m. Dental Clinic:— "Tyneholme"—By appointment. Baptist Church Hall, Northolt Road, Harrow—Monday, Tuesday and Wednesday, 9.30 a.m. and 2 p.m. Whitchurch Institute, Stanmore—Wednesday, 9.30 a.m. and 2 p.m. Tuberculosis Clinic. The local Tuberculosis Dispensary is maintained at 25, Greenhill Crescent, Harrow, on Thursday afternoons. This is a branch dispensary, the main one which serves an area which includes Harrow, Wembley, Willesden and Ruislip-Northwood, being situated at Pound Lane, Willesden. The work carried out at the tuberculosis dispensary is mainly consultative and advisory in character, active treatment not being undertaken to any considerable extent. Venereal Diseases. There is no treatment provided locally for persons suffering from venereal disease. Provision is made under the London and Home Counties Scheme, the only centre in the county providing this treatment being the Prince of Wales' Hospital, Tottenham. Professional Nursing in the Home. (a) General. There are three Nursing Associations in the district. 1. Pinner Nursing Association. Hon. Secretary, Mrs. Lascelies, Manor House, Waxwell Lane, Pinner; Staff, Nurse-Midwife Swift, Northview, Rickmansworth Road, Pinner Green. 21 The work of this Association is almost limited to the Pinner North Ward. 2. Stanmore Nursing Association. Secretary, Miss F. Enthoven, The Links House, Stanmore; Staff, Nurse-Midwife Worsfold, S. Francis, Elm Park, Stanmore. The work of this Association is limited to Stanmore Village and the immediately surrounding area. 3. Harrow, Wealdstone and Harrow Weald District Nursing Association. Secretary, Mrs. D. H. Tupper; Staff, nine nurses working under a Superintendent housed at 17, Hindes Road, Wealdstone. This Association is affiliated to the Queen's Institute of District Nursing and is a recognised training school for Queen's nurses. During the year the nurses paid 22,475 visits to 1,597 patients. The Association has a Provident Scheme which entitles families to free nursing for the husband and wife and children under 16, open to all those whose incomes are within the National Health Insurance limit, for 5s. 0d. a year. (b) Nursing of Cases of Infectious Diseases. Apart from arrangements made under the maternity and child welfare scheme, there is no provision for home nursing of cases of infectious disease. Regular visits are paid to the homes of those suffering from notifiable diseases, but on these occasions advice only is given and no treatment carried out. Laboratory Facilities. Examination of clinical material is undertaken at the Laboratories of the Clinical Research Association. During the year 630 swabs were examined for the diphtheria bacillus, 135 samples of sputum for the tubercle bacillus, and 21 other samples for various purposes. The same laboratory also undertakes the bacteriological examination of milk, of which 14 samples were examined during the year. Most diphtheria swabs are now examined at the Isolation Hospital. Legislation in Force. The following adoptive provisions and orders are in force in the district:— Baths and Washhouses Acts, 1846-1899. Infectious Disease (Prevention) Act, 1890. Public Health Act Amendment Act, 1890: Parts II and III. Public Health Acts Amendment Act, 1907: Parts II and III; sections 52-65, 67 and 68 of Part IV; Parts V and VI; sections 81 (modified), 84 and 86 of Part VII; Parts VIII and IX; and section 95 of Part X. 22 Local Government and Other Officers Superannuation Act, 1922 Public Health Act, 1925. Orders under section 33 Local Government Act, 1894. Orders of Local Government Board of 23rd April, 1896; 1st August, 1896; 30th April, 1897; and 19th April, 1903. Order under the Infectious Disease (Notification) Act, 1889. Order to include disease of Pemphigus as a notifiable disease: confirmed by the Ministry of Health 31st July, 1935, and effective as from 17th August, 1935. Order under the Public Health Act Amendment Act, 1907. Order of Local Government Board, 6th April, 1910, under section 51, declaring the trade of fish-fryer to be an offensive trade The Sunday Entertainments Act, 1933, is in force in the district, by virtue of an Order dated 21st February, 1935. The Private Street Works Act, 1892, has been adopted by the Council. Bye-laws.—All bye-laws in force in the constituent areas of the district continued in force in those districts, but if made prior to the 1st June, 1934, they continued for a period of one year only. In consequence of this there are comparatively few bye-laws in force. The following were approved early in 1936:— Removal of house refuse. Slaughterhouses. Regulation of Offensive Trades. Smoke abatement. Nuisance in connection with the removal of offensive or noxious matter. Underground rooms. Prevention of nuisance arising from snow, filth, dust, ashes and rubbish, and for prevention of keeping of animals in premises so as to be injurious to health. Houses let in lodgings. Sanitary conveniences. Provisions of some of the Middlesex County Council Acts apply in this district. The 1930 Act contains provisions dealing with street trading, combined drains and noise nuisances; and the 1934 Act provisions regarding movable dwellings, establishments for massage, etc., and hairdressers, etc., premises. Bye-laws made by the County Council for the Good Rule and Government deal with the following matters:—Indecent language; 23 threatening language; waste paper, refuse, etc.; broken glass, etc., on highways or public places; destruction of wild plants; deposit of litter to the detriment of public amenities; deposit of tree or hedge chippings; indecent bathing; noisy animals; orange peel, etc., on footways; posting bills without permission; shooting galleries; roundabouts, etc.; spitting; music near churches and places of public assembly; music near hospitals; music near houses; defacing pavements or carriageways; gypsy encampments; loading of vehicles; shouting in streets; stink bombs, etc.; violent behaviour, etc., on school premises; wireless loudspeakers, etc.; carrying soot; carrying carcases; touting; dangerous games near streets; contents of ashbins; bulls; fouling by dogs on footways; fighting; perambulators on footways; wilful jostling; projecting signs ; loitering at church doors. 24 SANITARY CIRCUMSTANCES OF THE AREA. Water. Most of the district is served by the Colne Valley Water Company, a small portion only of the southern part of the Roxeth Ward being served by the Rickmansworth and Uxbridge Valley Water Company. This latter supply is most unsatisfactory as it completely fails at times. It appears that the mains of both companies are laid in those roads which suffer from the shortage, but that the companies will not agree to their respective mains being connected, though, apparently the Colne Valley Water Company would, if requested by the Rickmansworth and Uxbridge Valley Water Company, be prepared to supply the houses in these roads. Drainage and Sewage. An account of the arrangements for sewage disposal appeared in the Annual Report for 1935. Under the West Middlesex Sewerage and Sewage Disposal Scheme, authorised by the Middlesex County Council in 1931, all the sewage from this district is to be treated at the Central Purification Works at Mogden. The main items of work in connection with surface drainage have been the construction of a main out-fall culvert from Belmont to Kenton Lane with a total length of 2,500 yards, and sections of culvert near the Parish Church in Wealdstone and at Queensbury Station. In addition, much culverting has been done by the estate owners in the course of development of their lands. Rivers and Streams. See Annual Report, 1935. Public Cleansing. Refuse Collection. Domestic Refuse.—Up to March, 1935, the collection of domestic refuse in the former Hendon Rural District was done by contractors, but since that date the refuse collection of the entire district has been carried out by direct labour, collections being made regularly each week on the same day. The fleet engaged at the end of the year for collection of refuse comprised 15 mechanical vehicles of which 10 were S. and D. Freighters (six of 15 cu. yards capacity, and four of 10 cu. yards) and five Karriers (two of 15 cu. yards capacity, and three of 10 cu. yards). The average weekly amount collected during the nine months ending 25th December was 551 tons. The cost of collection has fallen during the year. For the six months ending 30th September it was 12s. 8¾d. per ton, while for the nine months ending 25th December it was 11s. 8¾d. For the financial year 1935-36 the estimated cost of collection per thousand population is £111. 25 Trade Refuse.—The arrangements with regard to the collection of trade refuse were mentioned in the Report for 1934. Garden Refuse.—In October it was agreed that garden refuse be collected at the following cost:—6d. per large skip (approximately two barrow loads) or 6s. Od. per load (approximately two cubic yards). Refuse Disposal. Refuse is disposed of by direct incineration at the destructor, South Harrow, by separation followed by incineration at the separation plant, Wealdstone, and by tipping at Cannons Lane, Pinner. The destructor, which serves an area corresponding roughly to the former Harrow-on-the-Hill district, deals with 170 tons weekly. The separation plant, serving an area roughly corresponding to the former Wealdstone district, deals with 130 tons weekly, while 250 tons are deposited weekly at the Cannons Lane tip, being collected largely from the former Hendon Rural District. With the continued growth of the former Harrow and Wealdstone districts, the plants are incapable of disposing of all the refuse from these areas, so that an increasing amount has to be transported to the Cannons Lane tip. Complaints have been received from neighbouring inhabitants of the presence of rats and flies, and of smells. The average cost of disposal per ton for the nine months ending 25th December for disposal by destruction was 5s. 10d., compared with a figure of 2s. 7d. as the cost of disposal by controlled tipping. Gully Emptying. Street gullies are regularly cleared and sealed mechanically by a street gully emptier. Cesspool Emptying. The few cesspools in the district are emptied by the owners. Street Cleansing. All highways are swept at least once daily, in shopping areas more frequently. The sweepings are collected in orderly barrows and are disposed of at the tip. In May the Council resolved to undertake scavenging of private streets Public Conveniences. In addition to those in the recreation grounds, open spaces and cemeteries, there are conveniences at the following places:— Northolt Road, South Harrow Three-stall urinal only. Roxborough Bridge An underground 3-stall urinal and 1 W.C. Havelock Place For women 4 W.C.s and for men 4 W.C.s, and 10 urinal stalls. Lavatory basins with hot and cold water in each department. 26 Car Park, Station For women 2 W.C.s, for men 2 W.C.s and Road, Harrow 2 urinal stalls. Lavatory basins with hot and cold water in each department. Pinner Road, North For women 3 W.C.s, for men 3 W.C.s and Harrow 6 urinal stalls. Lavatory basins with hot and cold water in each department. Peel Road For women 2 W.C.s and for men 2 W.C.s and 5 urinal stalls. The convenience at the car park is attended to by the car park attendant. At the Havelock Place and at the Pinner Road conveniences there are four attendants, two of each sex. The remaining conveniences receive daily casual attention by the road sweepers. In July the Council agreed that in view of the use made by the public of the urinal at the Red Lion Public House that the Cleansing Superintendent arrange for its cleansing and disinfection. In October it was agreed that the convenience at Peel Road, Wealdstone, be modernised and upon completion of the work, for four attendants, two male and two female, to be appointed. The London Passenger Transport Board have erected a convenience at the new station at South Harrow. This will be open to the public in consideration of a payment of £2,000 by the Council, the Company maintaining the convenience and providing the necessary attendants. With the development of the district further provision of sanitary conveniences will be necessary, particularly in the neighbourhood of shopping centres. The two districts most urgently calling for attention are Kenton, near the Station, and Pinner. Mortuary. Since the early part of the year only the Wealdstone Mortuary has been used. Particulars of the building were given in last year's Report. 122 bodies were received during the year. On 90 post-mortem examinations were held, and on a further 13 inquests without post-mortems. 19 bodies were admitted for storage. Swimming Baths. Particulars of the two swimming baths were given in the Annual Report for 1934. A pressure filtration plant is installed at both baths and alumina-ferric is used as a coagulant. Free chlorine is injected into the filtered water, and daily tests are carried out for the presence of free chlorine in the water and for the pH value. The duration of the turnover period varies according to the amount the baths are used, but it is at least once a day and at busy times once every eight hours. During the summer the attendances at the Harrow Baths were 102,837, and at the Wealdstone Baths 84,259. 27 SCHOOLS. The following is a list of the public elementary schools in the district with their division into departments and the number of children on roll at the end of January, 1936:— School. Dept. Accommoda tion. Temp. Accom. at end of Jan., 1936. Greenhill S.M. 250 — 268 J.M. & I. 328 — 315 Vaughan Road M. 540 40 536 I. 400 — 392 Roxeth Hill J.M. & I. 415 — 329 Welldon Park J.M. & I. 576 — 521 Eastcote Lane S.B. 480 — 367 S.G. 440 — 369 J.M. 434 192 665 I. 434 192 628 St. Anselm's R.C. M. & I. 200 50 256 Bridge J.B. 350 — 275 J.G. 350 — 293 I. 342 — 326 High Street J.M. 420 100 513 I. 300 — 265 Whitefriars S.M. 280 120 341 J.M. & I. 300 150 436 Belmont S.B. 400 — 399 S.G. 400 — 413 Glebe Avenue J.M. 386 100 576 I. 340 100 412 Harrow Weald J.M. 190 48 240 I. 246 100 340 Priestmead J.M. 582 40 599 I. 480 96 589 Headstone S.M. 320 — 243 Pinner Park J.M. 628 — 579 I. 250 — 253 Pinner Council J.M. & I. 190 48 215 Longfield J.M. 386 — 332 I. 338 — 316 Cannon Lane J.M. & I. 392 48 422 Stanmore M. & I. 261 — 235 Camrose S.M. 560 30 670 J.M. & I. 500 180 782 Stag Lane J.M. & I. 450 — 424 Grand Total: 21 37 14,238 1,634 15,154 28 There were 21 schools and 37 departments. Owing to the rapid increase in population overcrowding occurs in some of the schools. In a number, temporary accommodation has been provided to meet the deficiency. School attendance has played little part in the dissemination of infection. None of these schools has been closed or disinfected during the year on account of infectious diseases. Other educational institutions under the control of the Middlesex Education Committee are the County School for Boys at Gayton Road, Harrow, the County School for Girls, at Lowlands Road, Harrow, the Harrow Weald County School (for boys and girls), Brookshill, Harrow Weald, and the Harrow Technical School and School of Arts and Crafts, Station Road, Harrow. Apart from the Harrow School and the Royal Commercial Travellers School Hatch End, there are some 63 private schools in the district, mostly for day scholars, the numbers on roll varying from small numbers up to nearly 300. COUNCIL HOUSING. The Annual Report for the year 1934 contains a summary of the various houses maintained by the Council, being a total of about 1,800. Between July, 1934, and September, 1935, 1,191 applications for Council houses were received. About 250 of these were from residents in each of the three districts, Edgware and Little Stanmore, Harrow and South Harrow, and Wealdstone. A further 150 were from residents of Harrow Weald, 75 from Pinner and North Harrow, and 60 from Kenton. In May the Housing Committee recommended the development of two portions of land in the possession of the Council acquired for housing purposes, viz., the Glebe Housing Estate (Stanmore North) and the Berridge Estate (Stanmore South). In December it was resolved to invite tenders for the erection of 50 three-bedroomed and 20 two-bedroomed houses on the Berridge Estate. As, apart from these two portions of land, which would hold 40 and 70 houses, there is no land in the possession of the Council suitable for the erection of houses for the working classes, at their October meeting the Council resolved to acquire compulsorily some 40 acres of land on the east side of Rayners Lane, South Harrow. BURIAL GROUNDS. By Section 46 of the Middlesex Review Order, 1934, the Council became the Burial Authority for the district, the Burial Acts 1856 to 1906 being declared to be in force. The following is a list of the burial grounds under the control of the Council, with particulars of the undeveloped portion, and the number of interments which have taken place in the grounds 29 since the amalgamation of the three districts on 1st April, 1934, to 31st December, 1935:— Paines Lane, Pinner Full except for reopenings 37 Roxeth Cemetery Full except for reopenings 12 Harrow Cemetery, Pinner Road 1.5 acres 419 Eastcote Lane Cemetery 2.46 acres 166 Wealdstone Cemetery 2.0 acres 282 Pinner Cemetery 20.0 acres 157 The following is a list of the burial grounds under the control of the Church Authorities:— Harrow Churchyard Closed. Roxeth Churchyard Full except for reopenings. Pinner Churchyard Full except for reopenings. Harrow Weald Churchyard Full except for reopenings. Harrow Weald Cemetery Practically full. Great Stanmore Churchyard Practically full. Whitchurch, Little Stanmore Small area available. In July the Council resolved on the purchase of 10.87 acres of land at the rear of Uxbridge Road for cemetery purposes. Towards the end of the year consideration was given to the question of the erection of a crematorium in the district, but by the end of the year no decision had been arrived at. Sanitary Inspection of the District. (a) Number of Inspections of:— Houses—First visits 2,641 Revisits 5,014 Bakehouses 143 Slaughterhouses 936 Milkshops and Dairies 342 Cowsheds 114 Foodshops 1,816 Fostermothers' premises 132 Outworkers' premises 63 Ice-Cream premises 24 Caravans 78 Infectious Disease Enquiries 653 Smoke Observations 31 Number of nuisances investigated 1,187 Periodical visits 634 (b) Notices served. No. Complied with. Statutory 35 34 Informal 1,313 1,278 30 Smoke Abatement. As in the previous year, comparatively little nuisance from smoke has occurred in the district. In the few instances where nuisances were apparent or where advice had been sought, the trouble was rectified following advice being given to the stoker of the furnace. Thirty-one observations were carried out, the summary of the results being that during 465 minutes there were only 22i minutes of dense smoke and 111 minutes of moderate smoke. Shops Acts, 1912 to 1934. The Shops Act, 1934, which came into operation on 30th December, 1934, contains provisions to protect young people and to prevent employment putting an undue stress on their health. It includes provision for regulating the hours of employment of young persons between 14 and 18 years engaged in the distributing trades, and is now applied not only to shop assistants but also to those engaged indoors in retail and wholesale shops and warehouses and to those employed out-of-doors about the business of these establishments. The term "shop assistant" is extended to those engaged about the business of a shop. The other main provisions are to improve the conditions affecting the health and comfort of all those employed about the businesses of wholesale and retail shops and warehouses, including consideration of such matters as heating, lighting, ventilation, sanitary conveniences, washing facilities and facilities for the taking of meals. The question of the appointment of Shop Acts Inspectors was considered during the year, but it was decided to continue the practice of sanitary inspectors acting in this capacity. The following orders are in force in the different parts of the district, having been made by the former councils under the Shops Acts, 1912 to 1928, and therefore by Article 36 of the 1934 Order remain operative in the same districts:— Area. Effect of Order. Shops Affected. (i) General Half-holiday Orders:— Little Stanmore Fixes Thursday as All non-exempted early closing day shops except barbers, hairdressers, furniture dealers, cabinet makers and motor engineers and agents. Wealdstone Fixes Wednesday Barbers and hairas early closing dressers. day 31 (ii) Extensions of Half-holiday Orders to exempted orders:— Wealdstone Fixes Wednesday Fruiterers and as early closing Greengrocers. day Wealdstone do. Butchers and pork butchers (uncooked meat including pork but excluding bacon and and ham). Wealdstone do. Fishmongers. (Kenton area only) Wealdstone (except Kenton Fixes Monday as do. area) early closing day (iii) Exemptions from half-holiday obligations:— Harrow-on-the- Total exemption Wardrobe dealers Hill from half-holiday and retailers of toys and fancy articles. Wealdstone do. do. (iv) Closing Orders:— Harrow-on-the- Fixes closing hours Butchers and pork Hill butchers. Wealdstone do. Wardrobe dealers and retailers of toys and fancy articles. (v) Orders under Shops (Hours of Closing) Act, 1928:— Harrow-on-the- Fixes later closing Tobacco and smokHill hours ers' requisites. Consideration was given to the question of amending the Closing Order respecting tobacconists in order to effect the closing at the same hour throughout the district, but as the only way in which this could be done would be by extending the hours of opening in part of the district, it was decided that no action should be taken. Inspections under the Shops Acts are undertaken by the Sanitary Inspectors. During the year 824 new shops were registered so that by the end of the year the total number of shops on the register was 1,505. 2,886 visits were paid to shops under the above Acts and 129 evening observations made. 101 contraventions were recorded, these being classified as:—Serving customers after closing hours, 60; intervals for meals not given to assistants, 17; assistants not 32 having a half-holiday, five; young persons employed over the statutory limit, 11; shops not closed for one half-day, one; absence of suitable and sufficient sanitary or washing accommodation, five; temperature of the shop not maintained, two. 699 letters were sent to traders regarding the absence of the appropriate notices. No legal proceedings were taken but in seven instances the traders concerned received a final warning. Two certificates of exemption from the provisions requiring sanitary accommodation were granted. Rats and Mice (Destruction) Act, 1919. The duties under this Act are carried out by the Middlesex County Council. During the year 99 complaints were received regarding the numbers of rats. On receipts of complaints, inspections are made by the Sanitary Inspectors and where any sanitary defects or nuisances remediable under the Public Health Acts, likely to be pre-disposing causes to the presence of the rats, are found, the necessary action is taken and the complaint is forwarded to the County's Inspector. Places of Public Entertainment. In Circular 120 issued on the 25th August, 1920, the Minister of Health suggested that arrangements should be made by the Sanitary Authority for all theatres, music-halls, and other places of public entertainment to be visited periodically with regard to their sanitary condition. The Secretary of State also suggested that when considering an application for the grant or renewal of a licence of any theatre or other place of public entertainment the licensing authority should require a certificate from the Sanitary Inspector that the condition of the building is satisfactory in sanitary and other respects. During the year 56 visits were paid to such premises, in all cases the sanitary arrangements being found satisfactory. Rag Flock Acts, 1911 to 1928. No rag flock is manufactured in the district, although there are two premises where rag flock is occasionally used. No samples have been taken for analysis, but during the year the premises have been kept under constant observation and at all times found in a clean condition. Administration of the Factory and Workshop Act, 1901. In this district there are 159 factories, 169 workshops and 29 workplaces, to which the following numbers of visits were paid during the year:—Factories, 256; workshops, 410; workplaces, 134. Of the total 56 Public Health Acts nuisances detected, 13 were due to want of cleanliness and one to deficient ventilation. There 33 were 30 instances of unsatisfactory sanitary accommodation, these being unsuitable or defective in 23 cases, insufficient in six, while in one there was no separate provision made for the sexes. 12 other nuisances were detected. By section 107 of the Factory and Workshop Act, 1901, in the case of persons employed in such classes of work as may be specified by special order of the Secretary of State, the occupier of every factory and workshop and every contractor employed by such occupier in the business of the factory or workshop shall keep a list of the persons directly employed by him outside the factory or workshop and the places where they are occupied; and shall send on or before the first day of February and the first day of August in each year copies of those lists to the district council of the district in which the factory or workshop is situate. Every district council shall furnish the name and place of employment of every outworker whose employment is outside this district to the council of the district in which the place of employment is. Further sections of the Act prohibit the employment of outworkers in unwholesome premises, and prohibit homework being given out to the occupant of a house where there is a case of infectious disease. A notice of 74 addresses was received from other councils and 11 addresses were forwarded to other councils. 60 of the local outworkers were engaged in the making of wearing apparel, while a further 12 were leather dressers. 65 visits of inspection were made to outworkers' premises, in none of which were unwholesome conditions found to exist. c 34 HOUSING. HOUSING STATISTICS FOR THE YEAR, 1935. Number of New Houses erected during the Year:— Total 4,715 (1) By the Local Authority — (2) By other Local Authorities (3) By other bodies and persons 4,715 1. Inspection of Dwelling-Houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,517 (b) Number of inspections made for the purpose 7,531 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 590 (b) Number of inspections made for the purpose 2,430 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 48 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 623 2. Remedy of Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 589 3. Action under Statutory Powers during the Year:— A. Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 12 (2) Number of dwelling-houses which were dered fit after service of formal notices:— (a) By owners 12 (b) By local authority in default of owners - 35 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 23 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 22 (b) By local authority in default of owners — C. Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 17 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 7 D. Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or ground rooms in respect of which Closing Orders were made — (2) Number of separate tenements or ground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — ACTION UNDER THE 1930 HOUSING ACT. Particulars of the returns made by the three former councils of the properties which it was anticipated would be considered for demolition were included in the Annual Report for the year 1934, there being no proposals for Clearance Areas or Improvement Areas but a number of properties to be dealt with under Section 19. The following properties were, during the year, the subject of action under Section 19, demolition orders being made in respect of most and an undertaking being received in respect of one that the house would not be used for human habitation:- Peel Cottage, Peel Road; Nos. 1 to 6, Barters Cottages, Rickmansworth Road; Forge Cottage, Kenton Lane; No. 9, Greenford Road; Nos. 1 to 8, Waldron's Yard. In December the Council agreed to the principle of rehousing persons displaced as a result of demolition orders made under the Housing Acts in cases where economic hardship exists. The following is a summary of action taken during the year 36 under Part II of the Housing Act, 1930, other than direct action taken under Sections 19 or 20:— Insanitary properties demolished in anticipation of action under Section 19 5 Insanitary houses closed but not demolished on an undertaking which has not been cancelled ... 4 Number of houses rendered fit as a result of informal action under Section 17 111 In June the Council approved of the following properties being dealt with as Clearance Areas:— Nos. 8, 10, 12, 14, 16, Peel Road, Wealdstone. Nos. 3-21 (both inclusive), Alma Row, Harrow Weald. Nos. 1-11 (both inclusive), Whitchurch Lane, Stanmore. HOUSING DEVELOPMENT. During the year 4,715 houses were erected. The following is a classification of the houses of different rateable values giving the position at March 31st, 1935 and 1936, with the percentage each group of houses represents of the total of the rateable properties :— 1935. 1936. No. of hereditaments. percentage. No. of hereditaments. percentage. Rateable value not exceeding £10 353 0.86 343 0.8 £11-£12 5,029 12.29 6,181 14.5 £21-£30 17,863 43.64 21,892 52.1 £31-£40 7,749 18.93 8,451 19.9 £41-£50 2,784 6.80 3,131 7.3 £51-£60 1,026 251 1,070 2.5 Over £60 1,333 3.25 1,360 3.2 During the year the Minister of Health intimated his decision to confirm the County of London (Harrow—Middlesex) Housing Order, 1935, for the compulsory purchase of land at Headstone Lane for housing purposes. Proposals were also submitted by the London County Council for the development of 58 acres at Kenmore Park Estate as a housing site. Some 3.5 acres of this is set aside as a school site, and a further three acres as an open space. The number of houses to be built on the estate will be about 600. OVERCROWDING. During the year 31 cases of overcrowding were reported. Of these 28 were abated, in some cases the occupants being rehoused in Council houses, in others, which were due to the sub-letting or to the presence of lodgers, by the vacation of the premises by surh sub-tenants or lodgers. Towards the end of the year was begun the survey to determine the extent of overcrowding of the working-class houses in the district as required by the 1935 Housing Act. 37 INSPECTION & SUPERVISION OF FOOD. (a) Milk Supply. Producers. There are 18 cow keepers in the district, all except one of whom produce only ungraded milk. The exception was a producer of Grade A milk, but he discontinued this at the end of the year. Nine only of these sell milk in the district by retail. Retailers. Including the three Company Distributors, there are 72 retailers of milk in this district. The following is a summary of the various classes of retailer:— Number of local producers who sell milk locally 8 Number of premises from which the three multiple firms distribute milk 31 Number of premises from which the single retailers distribute milk 9 Number of retailers not occupying premises in the district 10 Number of shops from which milk is sold in unopened receptacles only 46 Licences. The following licences are in force in respect of premises in the district:— Bottling of Grade A (T.T.) Milk at premises other than place of production 1 Bottling of Grade A Milk at premises other than place of production 1 Pasteurizing establishments 2 Selling of pasteurized milk at premises other than establishments where pasteurizing is carried on 36 (Of these, 16 premises belong to one firm, 12 to another and three to a third.) Selling of certified milk at premises not including establishments where the milk is produced 14 (Of these nine premises belong to one firm and two to another.) Selling of Grade A (T.T.) Milk at premises other than establishments where the milk is produced 17 (Of these nine belong to one firm and two to another.) Selling of Grade A Pasteurized Milk at premises other than establishments where the milk is produced 2 (Both of these belong to one firm.) Selling of Grade A Milk on premises other than establishments where the milk is produced 2 38 Milk Sampling. The Ministry of Health, acting as licensing authority for producers, arrange for the sampling of Certified milk and of Grade A (T.T.) Milk in the areas where the milk is sold, this being carried out by the sanitary authority at the cost of the Ministry. Under this arrangement 44 samples of certified milk were examined during the year, of which four gave unsatisfactory counts. Nine samples of other milks were taken. Of these the single sample of Grade A milk was satisfactory ; one of the four samples of pasteurized milk was unsatisfactory, and two of the four samples of ordinary milk were not up to standard. Milk and Dairies Act and Tuberculosis Order. The following is a copy of a report on the working of the Milk and Dairies Act, 1915, and the Tuberculosis Order, 1925, in this district:— "During the year 1935 22 samples of milk were taken from retailers in the district. These samples were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. Two of these samples, one produced in Buckinghamshire and one in Harrow Urban District, were found to contain living tubercle bacilli. In the first instance two offending animals were discovered and slaughtered, and in the second instance one animal was found to be suffering from tuberculosis and slaughtered. During 1935 no cows were reported by owners as suspected to be suffering from tuberculosis. "Routine examination of milch cattle was carried out during the year by Mr. Reginald Wooff, M.R.C.V.S., the County Council's whole-time Veterinary Inspector; 1,495 inspections of bovine animals were made in Harrow. Two cows, in addition to the one mentioned above, were found to be suffering from tuberculosis, as defined in the Tuberculosis Order, 1925, and were slaughtered." (b) Meat and Other Foods. Meat Inspection. There are nine licensed but no registered slaughterhouses in the district. All these premises have been used for this purpose for a number of years and are kept under observation, 936 visits being paid by the Sanitary Inspectors, the number of carcases examined being 3,818. During the year slaughtering took place only on one occasion at 94, High Street, Wealdstone, while the premises at Stanmore Hill, Stanmore and Warren House Farm, Stanmore, were not used for this purpose. The average weekly killing which takes place at the remaining slaughterhouses is:—7, Northolt Road—pigs 7, calves 2, sheep 2 ; High Street, Pinner—beasts 2, pigs 2, sheep 4; rear of 25, High Street, Wealdstone—beasts 2, pigs 6, calves 2, sheep 13 ; Green Man, Stanmore—pigs 16; Stanmore Hall Farm— 39 pigs 9, calves 3; rear of 63, High Street, Edgware—sheep 4. The total average weekly killing amounts only to:—Beasts 4, pigs 40, calves 7 and sheep 23. For this very limited amount, the provision of an abattoir by the Council is not warranted. Of the 193 beasts slaughtered 49 were unsound in some respect. Parasitic disease of the liver was found 32 times. The only other common disease present was tuberculosis, being found in the head of nine, tongue of nine, lungs of 12, liver of one and mesenteric fat of six (more than one organ of the same animal being frequently affected). In addition to these diseased organs, 124-lbs. of beef were condemned on account of decomposition. 112 of the 2,109 pigs slaughtered were diseased, cirrhosis of the liver occurring in 13, pericarditis in seven, pleurisy in three, pneumonia in 17, parasitic disease of liver in one, abscesses in two, nephritis in three, swine erysipelas in one, and bruising in one. Tuberculosis was found in the entire carcass of five, in the head of 27, in the lungs of four, and the mesenteric fat of 29. 1,195 sheep were slaughtered, of which only 11 were found unsound in any respect, parasitic disease of the liver occurring in three, parasitic disease of lungs in five, abscesses in carcass of one, extensive bruising in carcass of one, and another carcass was in a fevered condition. Carcases of sheep of total weight of 276-lbs. were condemned on account of decomposition. 321 calves were slaughtered, of which only three were found unsound in any respect, the lesion being tuberculosis of the lungs, malnutrition and oedema, and neoplasms. All the diseased meat was surrendered and destroyed. The three former constituent Councils of the present district passed a resolution under Section 2 (1) of the Slaughter of Animals Act, 1933, that Section 1 under which "every animal shall be instantaneously slaughtered or shall, by stunning, be instantaneously rendered insensible to pain until death supervenes, and such slaughtering or stunning shall be effected by means of a mechanically operated instrument " shall apply to sheep, ewes, wethers, rams and lambs. The Council has since passed the resolution necessary under Section 4 (6) by which these conditions apply in the present constituted district. Section 3 of the same Act prohibits the slaughter or stunning of animals in slaughterhouses except by persons licensed by the local authority. 22 slaughtermen have been granted annual licences. Bakehouses. There are 30 factory and 10 retail bakehouses in the district, to which a total of 143 visits were paid during the year. In some instances it was found the premises needed cleansing which was carried out on receipt of notice from this department. 40 Food Shops. 838 visits were paid to butchers' shops, 181 to fish shops, 279 to provision shops, 342 to dairies and milk shops and 261 to greengrocers' shops. The following amounts of food stuffs were condemned and voluntarily surrendered:—Fish 28 stone; bananas 7-lbs.; brussels sprouts 108-lbs.; chestnuts 2-lbs.; cherries 74 tins; and tomatoes 36 tins. Fried Fish Shops. Fish frying is one of the scheduled offensive trades in the district. At the beginning of the year there were 25 such premises in the area. During the year another was sanctioned but business was discontinued at one address. To these a total of 112 visits were paid. Most of these businesses are carried on in up-to-date premises with modern appliances. The premises are kept clean and the few complaints received were promptly attended to. (c) Adulteration, Etc. The Food and Drugs (Adulteration) Act is administered by the Public Control Department of the Middlesex County Council. During the year 180 samples were analysed. Of these 159 were of milk, of which only one was adulterated. None of the samples of the other commodities examined, which included cream pastries, spirits, butter, meat and condiments, proved to be adulterated. (d) Chemical and Bacteriological Examination of Food. These examinations are carried out at the laboratories of the Clinical Research Association, Ltd., Watergate House, Adelphi, London, W.C.2. 41 ISOLATION HOSPITALS. DESCRIPTION OF PREMISES. Particulars of the hospital are contained in the Annual Report of 1934. ADMINISTRATION. During the year the necessary changes were made by which the two isolation hospitals, viz., the Harrow-on-the-Hill Hospital at Rayners Lane and the Hendon Rural Hospital at Honeypot Lane, which had previously been run separately, became parts of a single unit, Rayners Lane Hospital admitting cases of scarlet fever and diphtheria and later transferring convalescent scarlet fever patients to Honeypot Lane. On 1st January the Medical Officer of Health took over the superintendence of the Honeypot Lane Hospital in place of the late Dr. Leslie Romer, and on 1st July, when the Assistant Medical Officer took up his duties, the previous practice under which the local medical practitioners attended their own patients at the Rayners Lane Hospital was discontinued. In the earlier part of the year the Honeypot Lane Hospital admitted acute cases of scarlet fever but since 31st May, on the resignation of the Matron, Miss Streeter, only the convalescent cases from Rayners Lane Hospital have been admitted. All the laundering for both hospitals has, since the early part of the year, been carried out at the Honeypot Lane Hospital, at which a water softener and a press were installed. The ambulance is stationed at the hospitals alternate weeks, the disinfecting van being at the other hospital. Owing to the altered practice with regard to disinfection much less outside fumigation is now being done. Diphtheria swabs are now examined at the Rayners Lane Hospital. All patients admitted to the scarlet fever wards are now swabbed for the presence of Klebs Loeffler bacillus. The following is a summary of the various recommendations adopted during the year concerning the two institutions, with the month of their adoption by the Council:— That the visiting of patients at the Harrow Isolation Hospital be discontinued, and that the Matron be on duty to interview relatives for an hour on two days each week. (1st January.) The staffing of the hospitals was fixed: At Rayners Lane Hospital—Matron (to be in charge also of the Honeypot Lane Hospital); Assistant Matron; one senior and two other Staff Nurses and eight Nurses. At Honeypot Lane Hospital—one Staff Nurse and two Nurses. 42 The following scale of salaries was recommended:—Matron, £175 X £10—£225; Assistant Matron, £100 X £5—£120; Senior Staff Nurse, £75 X £5—£90; Staff Nurse, £65 X £5—75; Nurse, £55 x £5—65. (5th February.) That the holiday for the nursing staff at each hospital be three weeks annually, except that nurses now entitled to a month's holiday continue under these conditions. (7th May.) That ambulance attendants be supplied with overalls for use when removing patients. (30th July.) The following daily holiday allowances were agreed:—Matron, 3s. 6d. ; Assistant Matron, 3s. Od.; Nurses, 2s. 6d.; Wardmaids, 2s. (5th November.) That uniform be supplied to the Matron, nursing staff and female domestic staff, the uniforms to remain the property of the Council. (5th November.) (At their meeting on the 4th February, 1936, the Council approved of recommendations with regard to the grading of the hospital porters and laundry staff.) The following is a copy of the hospital's rules for the information of the relatives of patients, adopted by the Council at their meeting on the 5th February:— The Hospital to which the patient is being removed is at Rayners Lane, Harrow (Telephone Number:—Byron 1450). Certain convalescent cases of scarlet fever are transferred later to the Hospital at Honeypot Lane, Stanmore (Telephone Number:—WORdsworth 2088). Any garments or articles for personal use, such as hairbrushes taken into the hospital by the patients, will not in ordinary circumstances be returned on the discharge of the patient. Relatives or friends are not allowed to visit a patient unless such patient becomes dangerously ill, in which case notice will be sent to the nearest relative or friend granting permission to visit him. It is, therefore, important that notice of any change of address should at once be sent to the Matron. Parents or near relatives of those dangerously ill will be admitted to the wards at the discretion of the Medical Superintendent or Matron. Only two visitors will be allowed at one time. Ordinarily no interview shall last more than 15 minutes. Visitors are to put on the special dress provided before entering the ward, and are to wash their hands before leaving the Hospital. Visitors must not touch the patients or their beds, etc., or sit, except on a chair so placed that no part of the visitor's dress shall touch any bed. Parents or near relatives wishing to see the Matron in order to make enquiries about the patient should attend the Hospital on Mondays or Thursdays between 2 p.m. and 2.30 p.m. 43 Letters may be sent to patients as often as desired and should be addressed to the patients direct. Letters from patients will be collected twice weekly and after the necessary disinfection will be despatched. Matron will always convey messages of urgency. All letters making enquiries should state the full name of the patient and should be addressed to the Matron. Enquiries may also be made by telephoning the Hospital between the hours of 9 and 10 a.m. It is particularly requested that frequent telephone inquiries be not made except in the case of those who are seriously ill. as such enquiries interfere considerably with the work of the staff. Flowers, plants, books, and toys may be sent to the patients, but cannot afterwards be returned. No eatables may be sent except fresh fruit, plain chocolate, plain biscuits and fresh eggs. Any of these articles will not necessarily be for the sole use of the patient for whom they are sent. Patients are discharged as soon as the Medical Superintendent thinks safe. The Matron will notify the parents of the day and time a patient is ready to leave, when a fresh supply of clothes must be brought. The following are the major expenditures incurred at the two institutions during the year:—At the Rayners Lane Hospital: External decoration of the hospital wards; internal and external decoration of the administrative block; decoration of the porter's lodge; the repair of fence; conversion of the laundry block into nurses' quarters. At Honeypot Lane Hospital: External decoration of the hospital wards; external and some internal decoration of the administrative block; the equipment of the laundry; the installation of a water softening plant. ADEQUACY OF ACCOMMODATION. In the early months of the year the demand on scarlet fever beds could not be met by admission to the local institutions, so cases were sent to the hospitals of other authorities and for a short time, owing to the simultaneous occurrence of a number of cases of diphtheria, similar arrangements were made for admission of patients suffering from this disease. Owing to the absence of cubicle accommodation it is necessary that all cases of double infection be treated elsewhere. For such reasons, arrangements were made for the admission to outside hospitals of some 100 cases suffering from infectious disease. PROVISION OF NEW ISOLATION HOSPITAL. Following the proposals of the County Council as a result of the survey required to be made under Section 63 of the Local Government Act, 1929, the Minister of Health suggested that the Harrow Urban District and the Hendon Borough form one area 44 for the purpose of hospital accommodation for infectious diseases, Hendon to be the Local Authority to provide the accommodation and to receive into their hospital patients from Harrow Urban District by agreement. In January a deputation was received by the Ministry of members of the Public Health Committee who submitted the views of the Local Authority in regard to the proposed scheme for the provision of hospital accommodation for infectious disease cases. The proposals of the County Council were amended, and a modified scheme for the provision of adequate hospital accommodation for the treatment of infectious disease received approval on the 4th March, 1936. The portions of the scheme applicable to the district are:— 1.(V) The Urban District Council of Harrow shall provide hospital accommodation comprising not less than 100 beds which shall be available for patients from the Urban District. 2. Every authority within the County providing or maintaining a hospital pursuant to this scheme shall, if in the opinion of the County Medical Officer of Health, circumstances so require and accommodation is available, admit patients from any part of the county on such terms as may be agreed between the authority concerned or, in default of agreement, on such terms as may be determined by a single arbitrator in accordance with and subject to the provisions of the Arbitration Acts, 1889 to 1934, or any statutory modification thereof for the time being in force. The Public Health Committee at their October meeting as an outcome of the suggestion that the District Council shall erect a hospital of not less than 100 beds were of the opinion that the present population of the district requires immediate provision of a hospital of 130 beds, with facilities for ultimate expansion to 180 beds ; that a site of about ten acres would be necessary ; and that the design for the building should be obtained by the promotion of an open competition under the regulations of the Royal Institute of British Architects. CLINICAL ASPECTS. Diphtheria. Admissions:— Number of patients admitted with the diagnosis of diphtheria 54 Number of cases clinically diphtheria 35 Number of carriers (2 nasal, 6 faucial) 8 Of the other 11 cases, 10 were acute tonsillitis and one acute bronchitis, which died on the second day after admission. The incidence of diphtheria was so light that for a period towards the end of the year the diphtheria block was closed. 45 Period of Stay.—The average length of stay in hospital of all cases was 31.1 days; for clinical diphtheria cases 40.2 days; and for carriers 23.3 days. Deaths.—Number of deaths, 1. Case mortality rate.—2.86. The fatal case was admitted on the eighth day of disease, dying thirteen hours after admission. Complications:—Paralysis, palatal 4, and external ocular 1; nephritis 1; otorrhoea 1; albuminuria 12. Double Infection.—One case on admission was suffering from scarlet fever and diphtheria, while another was incubating scarlet fever when admitted. Cross Infection.—One patient contracted scarlet fever while in hospital. Day of Disease on Admission.—The following summarises the information with regard to the stage of development of the disease at the time of the admission of the patient :— 9th and Day 1st 2nd 3rd 4th 5th 6th 7th 8th over Number of cases 2 6117 3 2 2 1 1 Serum.—The average amount of serum used per case was 17,314 units. Bacteriological Examination.—Since 25th July swabs have been examined for the Klebs Loeffler bacillus at the Rayners Lane Hospital. 567 swabs were examined, 256 being sent in by general medical practitioners, of which 19 were positive; 89 swabs of patients admitted on the diagnosis of diptheria, of which 12 were positive; and 222 swabs of patients admitted with scarlet fever, of which 10 were positive. Scarlet Fever. Admissions:— Number of patients admitted with the diagnosis of scarlet fever 332 (250 to Rayners Lane and 82 to Honeypot Lane) Number of patients in whom diagnosis confirmed 324 Of the remaining eight cases three were suffering from bronchitis, one from asthma and four from erythema. Period of Stay.—The average length of stay of all cases was 33.2 days; for the uncomplicated cases, 26.6. (These averages are based on the 314 cases which completed their treatment during the year.) Deaths.—Number of deaths, 2. Case mortality rate.—0-62. The first of these fatal cases was a girl of four admitted on the seventh day of disease. There were slight signs of a rash on the 46 trunk though none on the legs and arms. The throat was dirty, the glands enlarged, the tongue peeling and the patient very toxic. Over the pubes there was a dark desquamated patch of some twelve square inches where exfoliation had occurred. There were moist sounds in the chest, which by the third day after admission exhibited consolidation. The patient died in another 48 hours. The other death occurred in a girl of seven, admitted on the second day of disease with a moderate attack and who was given 10 c.c.'s serum. The illness ran a very mild uncomplicated course until the eighteenth day from the onset when a subcutaneous haemorrhage was noticed on the legs. In a few hours other similar haemorrhages had occurred and the feet became gangrenous. Within 48 hours of the occurrence of the first haemorrhage the patient was dead. Complications.—Adenitis occurred in 39 (12.7 per cent.), otonhoea 23 (7.5), albuminuria 14 (4.6), nephritis 2 (0.6), rheumatism 3 (1.0), tonsillitis 4 (1.3), abscess 4 (1.3), and rhinorrhea 8 (2.6). Operations.—Mastoid operations were performed on four patients. Two other patients had minor operations, one an incision of a gland and the other an incision of a mastoid abscess. Double Infection.—One patient was incubating whooping cough, one mumps and one incubating whooping cough and mumps on admission. Cross Infection.—Two cases of mumps occurred, following the development of the disease in the patient who was admitted incubating it. Serum Treatment.—Serum, which is given to those exhibiting a sharp reaction providing their admission was within five days from the onset of the illness, was given to 104 patients, 10 c.c.'s to 80 and 20 c.c.'s to 24. Serum reactions occurred in 22.5 per cent. of those patients who received 10 c.c.'s, but in 41.6 per cent. of those who received 20 c.c.'s. Of the eight patients who had previously been inoculated against diphtheria, four suffered from reactions, one of the four having received 20 c.c.'s and the other three 10 c.c.'s. 33 of the 104 who received serum developed complications, a percentage of 31.7, as compared with the figure of 26 or a percentage rate of 27.6 of the 203 who had no serum. Return Cases.—The discharge home from hospital was followed by a case of scarlet fever within 28 days in the case of 33 patients. Relapses.—Two patients suffered from a second attack of scarlet fever within a short period after their being discharged from hospital after the first attack. A girl of eight years whose onset was the 3rd April was removed to hospital on the 6th, discharged on the 4th May and readmitted on the 6th. Another girl of seven years whose onset was the 14th April was admitted to hospital on the 16th, discharged on the 14th May and readmitted on the 19th. 47 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASES. (Other than Tuberculosis.) Disease. Under 1 yr. 1/4 5/9 10/14 15/1 9 20/24 25/34 35/44 45/54 55/64 65 & over Total Scarlet Fever 3 95 226 96 27 15 26 10 1 1 1 501 Diphtheria - 22 33 17 5 2 4 1 1 - - 85 Pneumonia 4 5 10 1 7 4 19 15 14 6 8 93 Erysipelas 1 1 3 1 1 1 6 9 6 4 5 38 Puerperal Fever — - - - - — — 1 - - - 1 Puerperal Pyrexia - - - - - 3 18 1 - - - 22 Enteric Fever - - - 1 1 1 - 1 - - 1 5 Ophthalmia Neonatorum 9 - - - - - - - - - - 9 Cerebro-spinal Fever 1 - - - - - - - - - 1 2 Dysentery - 2 - 1 — - — - — - - 3 Encephalitis Lethargica - - - - - - - 1 - - - 1 Acute Polioencephalitis - 1 - - - - - - - - - 1 Pemphigus - - - - - - - - - - - - Disease. Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospital Deaths Registered Scarlet Fever 501 332 56 3 3 Diphtheria 85 52 26 3 2 Pneumonia 93 - - - 64 Erysipelas 38 - 10 15 2 Puerperal Fever 1 - 1 - 5 Puerperal Pyrexia 22 - 5 - Enteric Fever 5 - 1 3 - Ophthalmia Neonatorum 9 - 1 1 - Cerebro-spinal Fever 2 - - 2 3 Dysentery 2 - - 2 - Encephalitis Lethargica 1 — — — — Acute Polio-encephalitis 1 — — — — CONTROL. Notification. The operation of the adoptive Infectious Diseases (Notification) Act, 1889, was made general by the 1899 Act which called for the notification of the following diseases:—Smallpox, cholera, diphtheria, membranous croup, erysipelas, the disease known as scarlatina or scarlet fever, and the fevers known by any of the following names:—Typhus, typhoid, enteric, relapsing, continued and puerperal. 48 The Local Government Board (now the Ministry of Health) added other diseases to the list which now include the following:— Plague, cerebro-spinal meningitis, acute poliomyelitis, tuberculosis and encephalitis lethargica; and, by special regulations, ophthalmia neonatorum and puerperal pyrexia are also notifiable. By the Infectious Disease (Notification) Act, the Local Authority may extend the definition of infectious diseases under this power. Approval was received in June to add to the list pemphigus of the newborn, the disease being notifiable as from 17th August. Enquiries and Exclusion. On receipt of notification of infectious disease, the premises are visited and enquiries made. Any sanitary defects receive attention. If the case is treated at home, advice is given as to the precautionary measures to be taken to prevent the spread of infection, stress being laid on isolation and concurrent disinfection. If the patient is removed to hospital, advice is given as to the procedure to be followed with regard to possibly infected articles. Contacts are excluded if from the nature of their work this is considered advisable. The following list summarises the information with regard to exclusion of patients and contacts from school:— Scarlet Fever:— Home treated patient. Patient—14 days from date of onset. Contact—Seven days from recovery of patient. Hospital treated patient. Patient—14 days from date of discharge. Contact—Seven days from removal of patient to hospital. Diphtheria:— Home treated patient. Patient—14 days from date of recovery. Contact—10 days from the recovery of patient. Hospital treated patient. Patient—14 days from date of discharge. Contact—14 days from removal of patient. Contacts are visited a few days prior to the date on which, in the absence of suspicious signs, they would be returning to school, and, if showing no abnormal discharges or other signs which might render them possibly infective, the School Authorities are informed that they can be admitted. Similar steps are taken before the return to school of patients. Information regarding non-notifiable infections is mostly obtained from the head-teachers of the public elementary schools who send weekly lists of their scholars absent from school while suffering from, or being contacts of cases of, infectious disease. 49 The following table is an extract from the regulations laid down by the Middlesex Education Committee as to exclusion in the case of infectious disease:— Disease. Exclusion of children attacked by disease. Exclusion of children living in infected houses. Scarlet Fever (1) If treated in hospital, until two weeks after date of discharge from hospital, or longer, if Medical Officer of Health so certifies. (1) Until one complete week after the house has been disinfected subsequent to removal of patient. (2) If treated at home, until two weeks after the date of disinfection of house, or longer if Medical Officer of Health requires. (2) Until one week after disinfection of house. Diphtheria (1) If treated in hospital, until two or three weeks or longer after date of discharge from hospital, at the discretion of the Medical Officer of Health. (1) Until two weeks after disinfection of house, or such other period as the Medical Officer of Health determines. A negative swab should be obtained. (2) If treated at home, until two or three weeks or longer after disinfection of house, at the discretion of the Medical Officer of Health. (2) Until ten days after disinfection of house, or such other period as the Medical Officer of Health determines. A negative swab should be obtained. Smallpox (1) Until after discharge from hospital. (1) Until 16 days after disinfection of the house subsequent to removal of patient or until certified free to attend school. (2) If treated at home, until certified free to attend school. (2) Until certified free to attend school. Enteric Fever Erysipelas (1) Until after discharge from hospital. Children coming from houses in which cases of enteric fever or erysipelas have occurred need not, as a rule, be excluded, (2) If treated at home, until certified free to attend school. Measles, including German measles Three weeks from date of appearance of rash or such longer period as the medical attendant certifies. Infants—All infants to be excluded for three weeks from date of onset of last case in house. If the complaint is definitely known to have been "German measles" exclusion for one week from the date of appearance of rash is usually sufficient. Seniors—Children who have not already had the disease must be excluded as in case of infants. Children who have had the disease need not be excluded unless the Medical Officer of Health or medical attendant requires. Dysentery Until certified free to attend school. Until certified free to attend school. D 50 Disease Exclusion of children attacked, by disease. Exclusion of children living in infected houses. Whooping cough Six weeks, or as long as the cough with whoop continues. Infants—Children in infant schools to be excluded for six weeks from date of onset of last case, or as long as the cough with whoop continues; or three weeks from date of last exposure to infection. Seniors—Children who have not had the disease to be excluded as in case of infants. Children who have had the disease need not be excluded. Chickenpox Three weeks, or until all scabs have disappeared. Infants—Children in infant schools to be excluded for three weeks from date of last exposure to infection. Seniors—Children who have not already had the disease to be excluded as in the case of infants. Children who have had the disease need not be excluded. Mumps One week after the subsidence of the swelling. Owing to the long incubation period of this complaint, exclusion from school involves considerable interference with school work. In view of the fact, and of the absence of danger of life, the exclusion may be confined to the patient. Cerebro-spinal Fever Three months or longer. Three weeks. Acute Poliomyelitis Six weeks or longer. Three weeks or longer. Encephalitis Lethargica Mild or abortive attack— Six weeks or longer. Fully developed attack—Six months or longer. Until three weeks after isolation of patient. Disinfection. In November, 1934, it was agreed that fumigation and stoving be carried out free of charge at premises infected with a notifiable infectious disease. In other cases fumigation shall be undertaken only when demanded, an appropriate charge being made for each case. In March, 1935, it was agreed:— (a) That, except in cases of smallpox and typhoid fever and in any exceptional cases approved by the Medical Officer 51 of Health where disinfection cannot be carried out in the home, when the present practice will be followed, in future all terminal fumigation and removal of bedding and other articles for stoving after the commoner notifiable infection be abandoned, and that the householders be instructed as to the precautionary measures to be taken. (b) That, where householders still require the present routine to be followed, a charge be made on the scale at present in operation for any disinfection carried out after nonnotifiable infections, namely:— s. d. Fumigation of room 7 6 Stoving of Bedding:— First load 10 0 Subsequent loads 5 0 each (c) That disinfectant be supplied free, on application, to householders where infectious disease has occurred. During the year 263 rooms were fumigated, 202 following notifiable infectious diseases, 45 for non-notifiable infectious diseases, and 16 for other reasons. 316 loads were removed for stoving, 204 following infectious diseases, and 112 for other conditions. DIPHTHERIA. Incidence. There were only 85 cases of diphtheria notified during the year, being a rate per thousand population of 0.58 compared with the figure of 1.60 for the country as a whole. This is the sixth consecutive year in which a low incidence has prevailed. Nearly one half of the cases occurred in the first two months of the year. In only one week subsequent to this were as many as three notifications received, while no cases at all were notified for a number of weeks. The relatively high incidence of the earlier weeks was due largely to the occurrence of a number of cases at a residential hoys' school. 59 of the cases were admitted to the Rayners Lane Hospital, four were treated at home and 29 removed to outside hospitals. Some of these removals were due to the fact that a diagnosis of diphtheria had been made on a patient attending as an out-patient at a hospital outside the district. Most, however, were due to a failure to admit them to the local hospital owing to shortage of accommodation in the earlier weeks of the year when most cases occurred. A few were admitted to outside hospitals owing to the patients suffering from a double infection. As there are no detached cubicles at the Rayners Lane Hospital such patients could not be admitted. 52 Four of the cases were secondary to notified cases, though of these one appeared to be only a case of bacteriological diphtheria. There were no return cases this year. A revised diagnosis of tonsillitis was made in five cases, of cellulitis in one, and nasopharyngeal infection in one. Eight cases were notified as suffering from nasal diphtheria. In most of these rhinorrhoea was present, but in some the nose was apparently healthy. Deaths. Two deaths, one of each sex, were certified as being due to diphtheria, being a case mortality of 2.3 per cent. In one the patient was not brought under treatment until the eighth day of illness. Apart from the few cases who were not removed to hospital until after the seventh day of illness, there were few severe attacks. Bacteriological Examinations. 630 diphtheria swabs were examined during the year at the laboratories of the Clinical Research Association. From 1st July most swabs have been examined at the Rayners Lane Hospital. Of 256 swabs sent in by outside practitioners, 19 were positive. In addition 311 swabs of patients in the hospital were examined. Schools and Diphtheria. Attendances at the day schools played no part in the spread of infection, no two cases having occurred in the same department at a shorter interval than a month, except in one instance where the interval was a fortnight. No day schools were closed during the year on account of diphtheria, and no schools or school rooms fumigated. A number of cases occurred at one of the residential schools for boys. One case in the week ending 26th January was followed by two cases in the next week, and these by subsequent cases in the next few weeks, the total number notified by the week ending 2nd March being 17. Immunization. At their meeting on the 1st January the Council adopted the following recommendation of the Public Health Committee:— "That a sum not exceeding £200 be allocated for the period ending 31st March, 1935, to provide facilities for residents in the district whose annual income does not exceed £250 to receive immunization treatment against diphtheria, this sum to provide for payment of a fee of 10s. Od. in each case to medical practitioners carrying out the treatment, and to cover the cost of the necessary propaganda, and that the Medical Officer of Health be authorized to take all necessary 53 steps for circularizing practitioners, informing the public, and generally bringing the scheme into operation as soon as possible." Most of the general practitioners in the district agreed to participate in the scheme. The attention of the public was drawn to the facilities offered by posters, notices in the press, posters in the infant welfare centres and by the distribution of leaflets throughout the schools in the district. In most of the private schools also these leaflets were distributed. It was suggested tentatively that as a general rule Schicktesting should be carried out only in the case of children over ten years of age, though arrangements could be made for any under this age to be done, if desired. The following results of tests carried out on a few children proved a justification for this:— Percentage of Schick positives in those under 11 years of age 100 (14), amongst those of 11 and 12 years of age 76 (30), and of those 13 to 15 years of age 71 (35). (The figures in brackets were the number of children tested.) For the period March to June the number of children immunized was very gratifying, but then it fell to quite small proportions. A few more were done in the late autumn as the result of again drawing attention of the public to the advisability of young children being immunized. Altogether some 1,804 children were immunized in the year under this scheme. To this number, however, must be added quite a large number of those done privately by the medical practitioners of children whose parents' income was outside the scale within which this service was provided. Altogether during the year some 7,548 units of T.A.M. were issued from this department, indicating that some 2,500 children would have been treated. Many practitioners purchased their own supplies direct so that this figure does not represent the total of those treated. It is questionable whether these same numbers would have accepted treatment had arrangements been made in the more usual way, either at clinics or at the schools. Many parents on having their attention drawn to the subject would have consulted their medical practitioners, who would in such circumstances doubtless have advised them to have their children immunized. On the other hand, when the immunizing is carried out at the schools, the fact that the children make little fuss allays the fears on the part of the parents, with the result that large numbers of scholars are treated. If the lack of response in the autumn is an index for the future, then before any further large number are to be treated in this district either a reliable "one-shot" antigen must be produced or an effort must be made to treat the children in the schools. All children who received their three doses of T.A.M.—and apparently there was very little defaulting on the part of those who 54 began treatment—were invited to be post Schick-tested some months after the completion of the course. Of the 675 tested, 18 were still positive, though the majority of these gave a very slight reaction. This does not represent a conversion of 97.3 per cent. from a state of susceptibility to one of immunity, as the large majority were not Schick-tested before being treated. As most of the children, however, were under the age of ten there were probably only a few who were originally Schick negative. Those reacting positively were referred to their medical practitioners for further inoculation. Provision of Anti-Toxin. Diphtheria anti-toxin is available free of charge to medical practitioners for the treatment of necessitous patients. 24 lots were issued, totalling 160,000 units. SCARLET FEVER. Incidence. 501 cases of scarlet fever were notified during the year, a fall on the figure for the previous year, and being an incidence rate of 3.47 per thousand compared with a figure of 2.96 for the country as a whole. In the previous year the average of weekly notifications, which had been eight or nine for the most of the year, from September onwards reached a figure of 20. This figure gradually fell from an average of 18 in January to 13 in May. For the rest of the year the weekly notifications were only single figures, the lowest incidence in September being a rate of four per week, following which there was a gradual rise until in December the average weekly notifications were seven. In the earlier months of the year the accommodation at the isolation hospitals proved insufficient, patients having to be sent to hospitals of other authorities, a total of 61 being treated outside during the year. 115 patients were treated at home at the election of the parents. For the first six months of the year scarlet fever patients were admitted both to the Rayners Lane and the Honeypot Lane Hospitals. From the 1st July, however, the Stanmore Hospital has been used only for the reception of convalescents, all patients in the acute stage being treated at the Rayners Lane Hospital. In the ordinary uncomplicated cases the transfer is made early in the third week of the patient's illness. There were 15 cases missed at the onset, but diagnosed in the later stages. In the case of some the diagnosis was made when the medical attendant was called in for the first time to see the second patient; in other cases the parents would first have sought advice on noticing the peeling. 55 Secondary Infection. There were 20 households in which a secondary infection followed on the first case. In 15 instances only one further case occurred; in three households two further cases followed, and three and four cases occurred on one occasion, making a total of 28 secondary infections. In no instance did a secondary infection occur in a household in which the original patient was treated at home after the diagnosis had been made in the first case, though there were four instances in which secondary infections had occurred in a home treated case. In two instances the diagnosis of infection was made in the second case at the same time as it was made in the case of the original patient. In one the recognition of the disease in the secondary case led to the detection of the disease which had been missed in the first case. In the other instances two members of the same family succumbed the day after the diagnosis had been made in the primary patient. 111 patients were treated at home without the occurrence of secondary cases. In most cases where secondary infection had occurred the onset followed soon after the onset in the primary case. Of the 20 cases (where more than one was secondarily infected only the first of these cases is being considered) the time separating the onsets was one day in three instances, two days in six, three days in one, four days in three. In one instance in each case, the number of days interval was five, six, seven, nine, thirteen, fourteen and eighteen. These latter cases are all instances of missed cases where the disease was no, recognised in the first patient until at a later stage. Of the 16 cases in which a secondary infection occurred in a home from which the primary patient was removed to hospital, in nine the onset of the disease in the secondary patient preceded the removal of the primary patient, in many instances the diagnosis being made in both at the same time, and the patients being removed to hospital together. In a further three instances the onset of the illness of the secondary case was the same day as the primary patient was removed. The interval separating the onset of illness in the secondary from the time of the removal of the primary case was, in the remaining four instances, two, three, four and ten days. Of the households where there was more than one secondary case, in the instance where there were three such secondary infections, all succumbed the same day, which was the day preceding the removal of the primary patient. In one of the cases where there were two secondaries, these had a simultaneous onset the day following the removal of the first case. In the other households where there were two secondaries, the intervals separating their onsets were two and three days. In the house where there were four secondaries, the onset and removal to hospital of the first preceded the diagnosis of the disease and 56 removal of the primary patient to hospital; the day following his removal, the third case fell ill but the case was not diagnosed, and the patient was not removed for three days during which time he had infected two other members of the household. Apart from these cases of secondary infection there were two instances of two patients in the same house succumbing simultaneously. Return Gases. In 41 instances the return home of a patient from an isolation hospital to which he was removed while suffering from scarlet fever was followed by the onset of a further case of scarlet fever in the same household, the onset of the illness in the second case being more than 24 hours from, but within 28 days of the return home of the child from hospital. 31 of these occurred in the first six months of the year as contrasted with 10 in the latter six months. This heavier incidence at the time of greater prevalence of the disease is what is usually found to occur. The actual number of cases of scarlet fever notified in this district in the first six months was 357 and in the second six months 159. Of the 41 patients, 33 were treated in one of the two local isolation hospitals, and eight in the hospitals of other authorities. This proportion is very nearly that of the ratio of cases admitted to the hospitals, namely, 248 to the local hospitals and 61 to outside hospitals, the ratio of possibly infective patients to the total number admitted to outside hospitals being one to 13.1 compared with the ratio of one to 13.3 in the case of the local hospitals. Where more than one case occurs in a house subsequent to the return home of a discharged patient, unless the onsets of illness in the patients are simultaneous or nearly so, it is impossible to determine whether the third patient has been infected by the patient who returned home or by the first of the return cases. All except one of the return cases succumbed within three weeks of the homecoming of the original patient, 19 of the 41 succumbing in the first week, 16 in the second and five in the third. 28 of the infecting patients were free from any nasal discharge or other complications. 13 however, though fit on their discharge from hospital, developed some trouble, the commonest, that of a nasal discharge, being present in nine cases. Two developed a recurrence of an aural discharge which had been present in hospital and which had postponed their release from isolation, one patient having been detained 67 days and the other 56 days. Of the other complications, one was a septic finger which developed on the return home of the patient. The other was a case of a child who had a discharging sinus following an incision into an abscess from a broken down tonsillar lymph gland. After a stay in hospital of 55 days, the sinus closed, but reopened on the patient's return home; following the occurrence of a return 57 case, the wound was swabbed and haemolytic streptococci found, so the child was readmitted. The time intervals between the return home of the infecting patient and the onset of illness in the return case were the same in the series where the infecting patient showed no abnormality as in the series showing some abnormality. Of the 28 cases in the former series, 13 succumbed in the first week, 11 in the second, three in the third and one in the fourth; and of the 13 in the other series, six in the first week, five in the second and two in the third. The sexes of the infecting patients were almost exactly equally represented. Of the return cases females preponderated in the proportion of three to two. Of the 25 females three were the mothers of the returning patients. This heavier incidence amongst females suggests that isolation of the patients on their return home is not practised. The ordinary uncomplicated case of scarlet fever is discharged from hospital about the twenty-eighth day from the onset of his illness. Although many patients receive serum on admission, the period of stay is not reduced on this account. Adult patients, if uncomplicated, are frequently discharged in the fourth week. The following analysis shows the time of detention of those patients whose return home was followed by the occurrence of a return case:— Number discharged under 28 days, three; number discharged on the 28th day, six; in the fourth week, 11; in the sixth week, seven; in the seventh week, 4. Ten patients had been detained over eight weeks, the time ranging from 59 to 107 days. While the straightforward case is detained until about the 28th day from the onset of his illness, if he is not admitted until late in the disease, he is detained, even though uncomplicated, for a longer period. The detention of any over this period is due to their suffering from some complication. In many cases this is a nasal or aural discharge which is probably infectious, and which it is desired to clear up before the discharge home of the patient. In these cases the detention of the patient is in the interests of the public rather than that of the patient. In other cases, however, the patient is detained for the treatment of some condition, e.g., nephritis, which is not infectious. The following table gives the number of patients discharged after certain periods of stay in hospital, and also the number of return cases following on the discharge of these patients: Time discharged. No. of Patients. No. of return cases. Under 26 days 20 — 26th day 14 2 27th day 22 1 28th day 38 6 29th day 41 — 30th day 38 1 31st day 28 4 58 Time discharged. No. of Patients. No. of return cases. 32nd day 22 3 33rd day 18 1 34th day 11 1 35th day 10 1 36-42 days 48 7 43-48 days 17 4 49-56 days 20 — Over 56 days 16 10 (This analysis is only of the patients admitted and discharged during the year, and includes the findings in respect of patients admitted to outside as well as to local hospitals. The day of discharge is reckoned from the day of the onset of the illness, not from the day of admission to hospital.) The striking features of the table are:- 1. That no return cases followed on the return home of patients discharged after a period of under 26 days' detention in hospital. These patients would mostly be adults, and the figures do not include those of patients admitted to the hospital as suffering from scarlet fever, but discharged after a few days' observation. 2. That, in general, there are more return cases the longer the period of stay in hospital. Grouping those days when most of the uncomplicated cases are discharged, namely, from the 26th—31st day, the discharge of 181 patients was followed by the occurrence of 14 return cases, a ratio of one to 13. In the group discharged in the second half of the fifth week the return home of 61 patients was followed by the occurrence of six cases, a ratio of one to 10. Seven cases followed the return home of 48 patients discharged in the sixth week, a ratio of one to nine, and four cases followed the return home of 17 patients in the seventh week from the onset of the illness, a ratio of one to four. 20 patients were discharged in the eighth week, but caused no return cases; but of the 16 who were in hospital more than eight weeks in 10 instances their return home was followed by the occurrence of a case of scarlet fever. Most of those who were detained for long periods suffered from a nasal or an aural discharge or both. In all such cases whose return home was followed by the occurrence of a return case, these discharges had ceased before the patients were released from hospital. In a number the discharge recurred some days after the patients' return home, but in most cases this did not happen. Four of the patients whose return home from hospital was followed by the occurrence of another case in the house had been removed to hospital on the first day of the disease; 11 on the second; and 15 on the third. Seven, however, were not removed until the fourth day of illness, and one each until the fifth and 13th days. When it is appreciated that the disease was most probably not diagnosed in most cases until the day it was subsequently 59 removed and that, therefore, probably no precautions had been taken to isolate the patient or to prevent the contact of other members of the family with him, the absence of spread to other members of the family who later showed their susceptibilty by succumbing as return cases is striking. More particularly is this so when it is remembered that in most of the secondary infections, infection took place very shortly after the onset of the disease in the first patient. The typing of the organisms found in the throat of the primary patient at the time of the onset of his illness, and of the return case would be interesting. The following cases show that not all infections occurring in the households following the return home of a patient discharged from hospital should necessarily be considered to have been infected by the returning patient: An adult woman who fell ill with scarlet fever on the 8th January was removed to hospital on the 10th and discharged on the 5th February—on the 4th February her child of three succumbed to the disease. On the 28th September a child was removed to hospital and discharged on the 22nd October—on the morning of the day the child came home the mother complained of a sore throat and was later diagnosed as suffering from scarlet fever A return case has been defined as one occurring within 28 days of the return home of a patient from hospital. In the following cases the interval was more than 28 days:— Onset of primary case 17th January, removed 18th January and discharged 23rd February—onset of disease in the second patient, 27th March; onset of primary case 17th June, removal 18th June and discharged 28th August—onset of disease in other patient, 28th September ; onset of primary case 22nd April, removal 24th April, discharged 21st May—onset of disease in second case, 19th June. In all these instances the illness in the first patient was mild and the disease uncomplicated, and no abnormal discharges developed, either during the stay of the patient in hospital or subsequently. In nine households more than one case occurred subsequent to the return home of a patient discharged from hospital, in six, 2 being affected, in two, 3, and in one, 4. In the last case, on the fifth day after the patient's return home one of the children fell ill, and within another four days three more went down with scarlet fever. In the house where the three members of the household suffered subsequent to the return home of a patient, one child fell ill on the tenth day after the patient's return, but the case was not recognised, and two more were affected before the disease was diagnosed. In the other house where three were affected, the first fell ill on the seventh day after the first patient's return home, was removed on the third day of his illness and two days later another succumbed. He was removed the next day and two days later another fell ill. In such circumstances it is impossible to decide whether the returning patient was responsible for all the 60 infections, or whether the later ones were secondary to the first of the return cases. In two of the cases where two were affected the onsets were simultaneous, occurring on the sixth and tenth day after the patient's discharge from hospital. In such a case the returning patient will have infected both. It is probable also that he will have done so in the home where his return on the 5th day of the month was followed by the onset of illness in another member of the household on the 14th; subsequent to the removal of this patient on the 15th, another succumbed on the 25th. In a similar instance, the patient returned home on the 19th January; on the 2nd February a brother fell ill and was removed on the' 4th; the onset of illness in the other patient was the 21st February. This interval was therefore 17 days from the removal of the first of the return cases, but 34 from the return home of the first patient in the household. Of the remaining cases, the first patient returned home on the 24th January, the onset of illness in the next member was the 29th and his removal to hospital the 31st; the other patient fell ill on 2nd February. The particulars of the last case are that the patient, removed to hospital on the 8th February, was discharged on 10th March, apparently well; on the 11th March another child in the household fell ill with scarlet fever, but was not removed until the 18th ; on the 22nd the third patient fell ill. There were two instances where a return case followed on the return home from hospital of one who had himself been a return case. Home Treated Cases. 111 patients suffering from scarlet fever were treated in their own homes. These cases are visited frequently by the fever nurse where visits are welcome. Most were mild in character, two-thirds being uncomplicated and making an apparently uninterrupted recovery. Adenitis occurred in 11 per cent., being slightly commoner in its onset in the second than in the third week of illness. This figure compares with that of 12.7 per cent. for those patients treated in hospital. Otorrhoea occurred in seven patients, the onset being limited to the first and second weeks. Two of these patients were later admitted to hospital on account of suspected mastoid involvement. Rheumatic pains occurred with far more frequency in the home treated cases, being present some time during the illness of 14 per cent., the onset being mostly in the second week, with a slightly smaller number in the first, and few in the third week of illness. Two patients, brothers, who commenced home treatment were subsequently removed to hospital on account of development of mastoid infection. 61 No cases treated at home who had not caused infection in others of the household before the disease was diagnosed did so afterwards. There were no recovery cases following on the freeing from isolation of the recovered patient. Most uncomplicated cases were freed about the 28th day, though a number were freed in the fourth week, while a few were under the supervision of their medical attendants up to six weeks from the onset of their illnesses. Two patients suffered from concurrent infections, mumps in one case and chicken-pox in the other. These findings suggest that while this mild type of scarlet fever case can quite well in many houses be treated at home so far as the risk of infection to others is concerned, it would not appear that in all cases adequate care is taken in the nursing of the patient. Cases following Operations on Naso-pharynx. Compared with the six cases of last year, there was only one case which followed on the operative treatment of tonsils and adenoids. In this instance the onset of the illness was on the fifth day after the operation. The disease was not recognised until it had given rise to a secondary case. Deaths. There were only two deaths amongst those who contracted scarlet fever locally this year, both of female patients in hospital. One was due to the septic type of the disease. In the other gangrene occurred in the third week of an apparently very mild attack. A third death, that of an adult female, an inmate of an institution outside this area was allocated to this district. Dick-testing and Active Immunization. Apart from those tests carried out for diagnostic purposes in the isolation hospital, no persons were Dick-tested during the year and none immunized. Schools and Scarlet Fever. Of the 501 cases notified, 179 were children who at the time of or immediately prior to, the onset of the illness were in attendance at one of the local public elementary schools. In 69 cases the patient was the only person who suffered from scarlet fever at that time, the onset of illness of any other children who attended the same department being separated from that of each of these cases by more than 10 days. On 11 occasions a single case occurred in the same department in a school in two consecutive weeks, and on one occasion in three consecutive weeks. Two cases occurred in the same department in one week on six occasions. On another two, two cases in one week were preceded by one in the previous week, and on two occasions two cases were followed by one in the 62 next week. On two occasions four cases occurred distributed through three consecutive weeks. Twice three cases occurred in one department in the same week, and on another occasion three cases in one week were followed by one in the next week. On one occasion three cases in one week had been preceded by one in the previous week, and were followed by one in the next week. Such groupings at the time of their occurrence are suggestive of school infection, but this is discounted when no subsequent cases occurred. It will be appreciated that these groupings are of cases occurring in the same department of a school and not in the same class. It is improbable that many of these infections were due to school attendance. The following notifications from children attending the same department were received in successive weeks:—1, 5, 0, 0, 0, 0, 3, 1, 2, 0, 0, 1. In the infants' department of this school during the same weeks the following number of cases occurred:— 1, 1, 2, 1, 1, 0, 0, 0, 0, 0, 1, 1. The five cases occurring in one week suggested a school infection, but no suspects were found on examination. The probability is that the last four were infected from the first patient as the onset of the illness in the case of all four was distributed over only two days. The smouldering in two departments suggests rather an infection due to outside contact. A similar smouldering occurred in an infants' department of a school of the older type of building in which the following numbers occurred in successive weeks:— 3, 0, 1, 0, 2, 2, 0, 1, 2, 0, 0, 1, 1, 1, 1, 0, 0, 1. The cases, while occurring in the same department, were scattered irregularly through the different classes comprising the department. In a new school building on the edge of the district a number of cases occurred in the autumn. Of the 11 children affected 10 lived in the neighbouring district. The cases were spread over some 10 weeks, and five separate classes were affected. In February four cases were notified amongst the children attending a private school. Examination of other pupils showed that five in attendance at the school were missed cases. One of these cases further infected another three patients not at the school. During late October and November a total of seven cases of scarlet fever occurred in a private school of some 76 pupils. The October case was last in attendance on the 25th and his onset was given as the 26th. The onset in the next case was the 6th November. Then followed two more cases and then three with their onsets of either the 15th or 16th November. The school was closed for a week and on reopening another case occurred with the onset of 29th November. A number of classes were affected, none of these apparently mixing inside the school. Apart from one boy who showed some roughness of the skin no other suspects were found. The relatively high incidence of cases amongst pupils attending the 63 school naturally suggests a school infection. These cases proved to be the prelude to a larger series of cases in the Easter Term of this year. Apart from the case of the private school that closed voluntarily, no schools were closed on account of scarlet fever, and no schools or school rooms fumigated. Period of Residence of Patients in District. Of 333 patients who were notified as suffering from scarlet fever, six had lived in the district less than one month; eight had been here over one but under three months; 21 over three but under six; and 23 over six but under 12 months. 48 had been here over 12 but under 18 months, and 26 over 18 months but under two years. 50 were in their third year of residence, 26 in their fourth; 24 in their fifth; and 111 had lived here over five years. ENTERIC FEVER. Five cases of enteric fever were notified during the year, all being cases of para-typhoid B infection. None of the cases appeared to be associated with one another. In January a woman of 35 was notified; in February a girl of 16, and in March a male of 22, the three patients living in different parts of the district. In September a man of 70 attended one of the London hospitals suffering from a retropharyngeal abscess due to erosion of cervical vertebrae. The para-typhoid B organism was found in the pus and his blood agglutinated para-typhoid B in a dilution of 1 /80. On enquiry he gave a history of a long febrile illness in June, 1934. The remaining case was a boy of 10 who was notified in November. One patient was treated in a nursing home, one in an isolation hospital, and the other three in general hospitals. DYSENTERY. Three cases were notified as suffering from dysentery. The first was a child of two who was notified in September, the diagnosis being made on clinical grounds, no bacteriological examination having been made and the patient very shortly made a rapid recovery. The other two cases were patients who apparently contracted the infection in London hospitals. A boy of 11 who was admitted to hospital on the 12th October and operated for appendicitis was diagnosed later as suffering from dysentery, the onset of this illness being the 7th November, the infection being with the Sonne organism. The same type of organism was responsible for the illness of a child admitted on 18th October on account of rickets and who succumbed on 18th November to dysentery. 64 ERYSIPELAS. 38 cases of erysipelas were notified during the year. Apart from eight cases in January and six in February, the cases were very evenly distributed throughout the rest of the year. Females suffered more than males in the proportion of three to two, the age groups most heavily affected being 35 to 44 and 45 to 54. The site affected was the face in rather more than half the cases, the legs being the next most frequently affected and then the head. Two cases proved fatal, both being infants. Ten cases were admitted to isolation hospitals, 15 to general hospitals, and 13 were treated at home. EPIDEMIC DISEASES OF THE CENTRAL NERVOUS SYSTEM. CEREBRO-SPINAL FEVER. In April a child of 10 months was notified as suffering from cerebro-spinal fever and was removed to hospital, the case proving fatal. Information of two other cases was first received from the transfer death certificates, as neither of these cases had been notified locally, being treated in hospitals outside the district. In February a woman of 55 had been removed to hospital with an illness which proved to be cerebro-spinal fever, and in March a boy of 14 was similarly removed. In September a male of 62 was notified as suffering from epidemic meningitis, and was removed for treatment to a nearby general hospital, where a revised diagnosis of subarachnoid haemorrhage was made. POLIO-ENCEPHALITIS. In November a child of 12 months was diagnosed as suffering from polio-encephalitis, having had convulsions followed by temporary paresis and lymphocytosis of the cerebro-spinal fluid, from which he recovered. ENCEPHALITIS LETHARGICA. In June a woman of 36 was notified as suffering from acute epidemic encephalitis lethargica, the onset of illness being the 17th. By the 26th she had made a complete recovery. SMALL-POX. No cases of small-pox were notified during the year, and no vaccinations were performed by the Medical Officer of Health under the Public Health (Small-Pox Prevention) Regulations, 1917. 65 NON-NOTIFIABLE INFECTIONS. MEASLES. The incidence of measles was low throughout the year. For the two years 1934 and 1935 the incidence followed that of London which is a biennial beat, the years of heavy incidence being the even ones. In February a number of cases occurred in one school and a smaller number in March in the same school. Otherwise there were throughout the year only sporadic cases occurring in a few schools and not spreading. Information of these is obtained from the heads of the elementary schools. As their information is only second hand from the diagnosis by a parent, the probability is that many of these cases thought to be measles actually were not so. German measles appeared in five separate schools in the Christmas term but did not spread. WHOOPING COUGH. Whooping cough was prevalent in the earlier part of the year. In January cases had occurred in eight schools, two being heavily affected. The infection continued in most of these schools throughout February and in March flared up in two previously lightly infected schools, while a further five formerly free were attacked, three heavily. One of those which was first affected in March continued to suffer each month until July. By the end of May most of those attacked in March were free, but two, which started in April and one in May, suffered quite heavily in June. A few scattered cases were then reported for the rest of the year. Whooping cough, which was responsible for three deaths in the year 1934, accounted for five in 1935, three males of under two years, one female of four years and one of six months. Seven cases, all of children under five, were removed to hospital for treatment. CHICKEN-POX. Chicken-pox was prevalent in the first quarter of the year, but after April occurred only rarely except in one school which had cases each month from February to October. MUMPS. Mumps was prevalent throughout the district in the months of February to June, after which there was a marked reduction in incidence, very few cases occurring from August to the end of the year. INFLUENZA. Influenza appeared on the death certificates of 15 fatal cases. Of these, 12 were evenly distributed throughout the first six months of the year. The sexes were equally affected, and the ages of the fatal cases ranged from 18 to 69. E 66 TUBERCULOSIS. Notification. New Cases. Deaths. Primary Notification. Brought to notice other than by Form A. Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 - 1 - 1 - - - - - - - 1 1— - - 2 2 - - 1 - 1 1 1 - 5— 5 2 3 2 - - 2 - 1 - - 4 10— 2 3 1 1 - 1 - 3 15— 5 4 2 1 1 2 1 - 4 3 2 - 20— 11 10 3 2 - 1 1 - 25— 22 28 1 2 4 5 - - 9 7 1 - 35— 17 13 - - 1 8 - - 7 10 1 - 45— 9 7 - 2 2 - - 1 8 1 - - 55— 6 1 1 - - - - — 4 2 2 - 65 & upwards 1 1 - - - - - - 2 - - - 78 70 13 13 8 17 5 4 36 24 7 5 By the Public Health (Tuberculosis) Regulations, 1930, every medical practitioner called in to visit any person and any School Medical Inspector inspecting children attending public elementary schools shall, within 48 hours after his becoming aware that such person or one of such children is suffering from tuberculosis, notify the disease to the Medical Officer of Health of the district in which the place of residence of the person is situate at the date of notification, provided that a medical practitioner or School Medical Inspector shall not notify a case if he has reasonable grounds for believing that the case has, in fact, already been notified to the Medical Officer of Health of the district within which the place of residence of the person is at the time situate. In addition, the Medical Officer of a Poor Law Institution or a Sanatorium shall, as soon as practicable after the end of each week, notify on a specified form all persons suffering from tuberculosis and admitted during the week, to the Medical Officer of Health of the district within which the place of residence of the persons notified are situate, and all cases discharged during the week, other than those transferred to a Poor Law Institution or Sanatorium, to the Medical Officer of Health of the district within which the place of destination of the persons notified are situated. Every Medical Officer of Health on becoming aware that a person who has resided in his district and who is suffering from tuberculosis has permanently changed his place of residence into 67 some other district shall forthwith notify the Medical Officer of Health of that district of the case. During the year 152 cases (81 male and 71 female) were notified as suffering from pulmonary tuberculosis. In addition 28 cases (11 male and 17 female) were brought to notice other than by formal notification. Most of this latter group will be of persons who had recently removed into the district having previously suffered from the disease and having been notified in some other district. These 180 cases added to the register of one year represents a rate of 1.25 per thousand population, a figure to be compared with a rate of 1.20 per thousand for the country as a whole. These figures, however, are not strictly comparable because while the national figure represents the number of new cases brought to notice during the year, the local figures represent those fresh cases discovered and notified in the existing population, plus roughly the total number of tuberculous patients in the transferred population, these having been notified not in any one year but over a number of years. The average notification rate is one per thousand population, whereas the register of notifications will contain eight per thousand. Where a volume of population is transferred to any district, the names will be added to the register of that district not in the proportion of one per thousand transferred population but at the rate of eight. Where the transferred population is small as compared with that of the parent district, this factor is relatively unimportant, but it is obviously significant if the volume transferred in one year represents up to 10 per cent. of the original population. As far as information is available the notifications have been divided into those amongst persons who contracted the disease here and those who transferred here while suffering from it. With regard to the latter point consideration has been given not only to the time of notification in relation to the time of taking up residence locally but rather the time of onset of the disease. Furthermore, tuberculosis in most is a chronic disease, which, although in some it appears as a bolt from the blue or as a sequel to some acute disease, most commonly pursues a smouldering course until some sign or symptom leads to its detection. For this reason an arbitrary period of six months has been selected as representing the average of that time between the onset of infection and the diagnosis of the disease. Patients whose onsets were within six months of their taking up residence here are assumed to have transferred here suffering from the disease, whereas if the onset is over six months from the date of transfer the disease is assumed to have been contracted locally. As it happens there were very few patients notified in which the period was round about the six months, though a large number whose period of residence is a much shorter period. Of 84 males, the disease had already been notified in 26 before 68 their transfer to the district. In another 13 cases the disease was diagnosed within six months of their removal, in all except one of these cases the period being within three months. These are assumed to have contracted the disease before transfer, making a total of 39 out of 84 who came to the district already suffering from pulmonary tuberculosis. Similarly of 83 females 27 definitely had it before transfer and 16 were notified within six months (14 within three months) of transfer, making a total of 43 out of 83. Even if it was assumed that those patients about whom no information is obtainable had contracted the disease locally, the notifications are reduced from 180 to 98, giving a rate per thousand of 0.7 compared with a national rate of 1.2. The following table summarises the position with regard to the period of residence of those who contracted the disease locally:— Period of residence 6-12 months 1-2 years 2-3 years 3-4 years 4-5 years 5-10 years 10-15 years 15-20 years Over 20 years Males 4 3 7 7 6 10 3 — 5 Females 6 3 8 4 1 11 2 2 2 The following table gives the grouping of the ages of the patients at the time of notification in the case of those who contracted the disease locally, there being none under 5 years of age or over 65. 5-14 years 15-24 years 25-34 years 35-4 years 45-54 years 55-64 years Males 4 11 9 11 4 3 Females 5 7 11 7 5 - A family history of tubercular disease was very rarely obtained in the case of the males, in fact only in three cases, one of which was in the 5 to 14 age group. It was found more frequently amongst the females, being obtained in 13 out of 35 cases. The group giving the largest incidence was the 5 to 14 group, in which four out of the five cases gave this history. Of 35 males who at the time of onset of illness were over 15 years of age, 16 were clerks and three printers. Of 22 females of over 25, practically all were married women who were engaged in no outside employment. Of those between the ages of 15 to 24, three were shop assistants. 28 cases (15 male and 13 female) were notified as suffering from non-pulmonary disease. In addition nine cases (six male and three female) were brought to notice other than by formal notification. Of the 36 cases in respect of which information is available, 18 transferred here while suffering from the disease while another three were notified within three months of their coming to reside in the district. In England and Wales for 1934 the rate of notifications for non-pulmonary tuberculosis was 0.4 per thousand. The 37 cases learned of during the year give a rate of 0.26 per thousand 69 tion, but the 16 cases assumed to have contracted the disease locally is a rate of only 0.11. Of the 15 cases who are assumed to have contracted the infection while living here, five suffered from meningitis, three being males of eight, 21 and 34, and two females of four months and 34. In respect of these a family history of tubercular infection was obtained only in the case of the infant. The affected site in the case of four was bone or joint. Three of these cases were males of four, five and 21 years of age, one was a female of 50, this being the only case where there was a family history of infection. The abdomen was the site affected in two, a male of five and a female 16 ; the neck glands of two males of five and 10, and the urogenital tract of two, a male of 56 and a female of five. In practically all these cases of non-pulmonary tuberculosis, the patient had used a pasteurized milk since living here. The period of residence here in the case of six was between 10 and 15 months. Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register Jan. 1st, 1935 245 205 42 55 No. of New Cases added 78 70 13 13 No. of cases added—other than on Form A 8 17 5 4 No. of cases removed 82 79 10 10 No. on register Dec. 31st, 1935 249 213 50 62 Under the Public Health (Tuberculosis) Regulations, 1930, it is laid as a duty on the Medical Officer of Health to keep a register of particulars of all notifications received by him under these regulations. In addition particulars are to be entered of persons notified as suffering from tuberculosis who have removed into the district and of whose removal he is notified by the Medical Officer of Health of the district from which the patients came, and of persons who normally resided in the district and whose death from tuberculosis has come to his knowledge but who have not been notified to him as suffering from tuberculosis. The register shall be revised not less frequently than once in every quarter by the removal of entries which have been withdrawn, of entries relating to persons who have recovered, of entries relating to persons who have died, have ceased to reside permanently in the district or who, after adequate research, cannot be found resident in the district. 70 Per 100,000 population, the numbers of pulmonary cases on the register at the end of the year were 173 males and 147 females. The corresponding figures for the country as a whole at the end of 1933 were 306 and 263. The large number of erasures from the register on account of persons having removed from the district, or having died, is due to the fact that during the year the register was revised by a visit being paid to every house at which a case was supposed to be living. In this way it was discovered that the names of many persons were erroneously still retained, many having removed from the district, some having died and a few having been cured. The following table is a summary of cases removed from the register with the reasons for their removal:— Pulmonary. N on-Pulmonary. Male. Female. Male. Female. Left the District 42 47 6 6 Died 36 26 4 3 Cured 4 6 — - Diagnosis not confirmed or withdrawn - - - - Deaths. 60 persons died from pulmonary tuberculosis during the year and 12 from non-pulmonary tuberculosis. Nearly one-third of the pulmonary cases had not been notified in this district and more than one-half of the non-pulmonary. To a limited extent the failure to notify is due to a diagnosis being made only after the admission of the patient to a hospital outside the district. Many failures, however, are accounted for by a lack of appreciation on the part of the patient's medical attendant that he is required to notify locally a patient who transfers into the district, even though that patient had previously been notified elsewhere. Of the 60 deaths from pulmonary tuberculosis, 36 were males and 24 females. Of the males eight were in the age group 25—34 and a similar number in 45—54; six each were in groups 35—44 and 55—64 and five in the age group 15—24. Of the 24 females, 11 were in the age group 35—44 and six in the group 25—34. Of the 12 non-pulmonary deaths seven were of males and five females. Meningitis accounted for seven of these deaths, of which two were of children under five, and four of children age 5—14. The death rate per 100,000 population for males from pulmonary tuberculosis was 25, and for females 17, compared with the figures of 39 and 30 for the country as a whole in 1933. The corresponding local figures for non-pulmonary tuberculosis were 5 and 3.5, compared with the figures of 7 and 6 for England and Wales in 1933. Of the 60 deaths from pulmonary disease 35 took place in an institution outside the district. The removal of patients in the 71 last very infective stages of the disease from surroundings in which these could cause a mass infection is a valuable preventive measure. Preventive Measures. Paragraph 11 (1) of the Public Health (Tuberculosis) Regulations, 1930, reads "Upon receipt of a notification under these regulations the Medical Officer of Health, or an officer of the Local Authority acting on the instructions of the Medical Officer of Health, shall make such enquiries and take such steps as are necessary or desirable for investigating the source of infection, for preventing the spread of infection and for removing the conditions favourable to infection." Quarterly visits are paid to the homes of persons on the register, additional visits being paid at the time a patient is admitted to or discharged from an institution, advice being given as to the precautionary measures to be taken to avoid the spread of infection. Bacteriological examination of sputa is carried out at the laboratories of the Clinical Research Association. During the year 135 samples were submitted for analysis. No action was taken during the year under Section 62 of the Public Health Act, 1925, for the compulsory removal to hospital of any infectious tuberculous person. 72 MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of births registered during the year was 2,523, 1,339 males and 1,184 females. Of these 82 were illegitimate, being a percentage of total births of 3.2. 2,044 births occurred in the district, 1,900 being live and 144 stillbirths. Of this number, 144, comprised of 138 live and six stillbirths, were to residents of other districts. 539 births (507 live and 32 still) were transferred from other districts, being mostly births occurring to Harrow mothers confined in London or the Middlesex County Council's hospitals. There were 39 twin pregnancies (out of all live and still births). STILLBIRTHS. 43 male and 36 female stillbirths were registered, being a rate per thousand population of 0.54 compared with a figure of 0.62 for the country as a whole. In one-third the infant was alive at the onset of labour at full term, the death occurring from injury or shock during delivery. In some the difficulty arose because of a contracted pelvis; in others it was due to breech delivery, and four were due to twins. It is in this group that the greatest reduction in the stillbirth rate is to be hoped for, many of these difficulties being anticipated by ante-natal supervision of the mother. In a further four the knotting or strangulation of the cord during labour resulted in the death of the foetus. In six cases the cause of death of the foetus was due to ante-partum haemorrhage. In a further nine cases there was premature onset of labour, in the case of most no cause being determined. In about one-quarter of the cases the foetus died in utero. In four of these there was gross developmental abnormality. In the same number the death was apparently due to toxaemia or albuminuria. INFANT MORTALITY. The infant mortality rate, which is expressed as the number of deaths amongst infants under one year of age per thousand born, is one of the most sensitive indices of the health of the district. The local rate in 1935 was 42.1, compared with the figure of 57 for the country as a whole, and 62 for the Great Towns (i.e., the towns in the country with a population exceeding 50,000), 58 for London, and a local figure of 47.5 for the year 1934. Most of the mortality in the days following birth is due partly to damage to the infant during its passage, and partly to a failure 73 of adaptation on the part of the infant to its new surroundings and mode of life. The effect of these two influences is most marked shortly after birth, with the result that there is a very high mortality amongst infants within the first 24 hours, and a still very high rate for the remainder of the first week. After this, these influences become less powerful, but are replaced by environmental conditions, particularly due to the infections. The neo-natal death rate, therefore, which is the rate of mortality of infants under one month of age expressed as a ratio to the total number of births, is an index of the extent of ante-natal and natal influences. Deaths after this time, however, are part and parcel of the mortalities of early childhood. The rate of the earlier deaths is common to all classes of the community, and can be influenced to any extent only by ante-natal care and hygiene, apart from the secondary effects of nourishment on the development of the growing female affecting the pelvic measurements. The deaths in the later months, however, are very susceptible to surroundings. It is amongst these age groups that the tremendous reduction has taken place which has resulted in a halving of the infant mortality rate in a generation. It is in this group that the most striking differences are found in good surroundings as compared with poor ones, in the children subject to good as compared with feckless mothering. The chief causes of death of those infants dying shortly after birth are either congenital malformations such as hydrocephalus, spina bifida or malformations of the heart; congenital debility; premature birth and injury at birth. Some of these are distinct entities, and are diagnosable as such, as instance congenital spina bifida. The cause of death of many infants alleged to have died of congenital heart, however, in all probability should more more correctly be allocated to the other groups, some being due to difficulty in delivery, and others to the infant not having reached a state of development, or not possessing that minimum of vitality, to enable it to survive. Atelectasis or a failure on the part of the infant to expand its lungs fully is a commonly ascribed cause. This and other causes of death might well be described, as many are, as being due to deficient inherent vitality. These are nature's failures—in some cases the developing foetus dies in utero and subsequent labour results in a stillbirth; in other cases the infant has survived to term but has not the stamina to adapt itself. Another large group includes the premature infants. While in some instances the suspected cause of the premature onset of labour can be conjectured, in most there appears to be no reason. Twenty (12 male and eight female) infants died within 24 hours of birth. Prematurity was the cause in 13, of whom two were twins born after 6A months' gestation, and a third was one of twins born at the thirty-sixth week. Premature onset of labour 74 at the seventh month was due to shock in one case, to albuminuria in another; to ante-partum haemorrhage in two cases; to hydramnios and to toxæmia of pregnancy in one each, but no ascribable cause in the other four. Difficult or prolonged labour resulting in intracranial haemorrhage accounted for the death of three. One infant died of asphyxia due to a prolapse of the cord during delivery, and the other in this category from white asphyxia or shock following a precipitate labour. One infant was undeveloped, suffering from anencephaly, and one infant of twins died of congenital debility. Fourteen (10 male and four female) infants survived 24 but failed to survive 48 hours. Premature birth appeared on the death certificates of 10, coupled with congenital heart in one. Two of these deaths were of twins; in two premature onset of labour was due to placenta praevia. One premature onset at the sevenand-a-halfth month was the third such confinement. In another case premature birth was the eighth pregnancy occurring in a woman of 44. In the case of the other three, the cause of onset of labour was not determinable, though one was an illegitimate pregnancy. Of the remaining four deaths in this category, two were ascribed to congenital heart, another to asphyxia due to the winding of the cord round the infant's neck in delivery, and the other to asphyxia in a post-mature infant. Seventeen (12 male and five female) infants survived the first two days but failed to survive the week. Prematurity accounted for the death of seven of these, albuminuria or toxaemia being the cause of the premature onset of labour of two. Congenital malformations accounted for four deaths (one pyloric stenosis, one spina bifida and two congenital heart). Marasmus was the cause of one death, gastro-intestinal haemorrhage another, and icterus gravis a third. Birth injury due to difficult labour and causing cerebral haemorrhage accounted for the death of three. Of the seven who died in their second week (four male and three female) two were infants whose births were premature by 12 and six weeks respectively; one suffered from a congenital defect of the large bowel and the other from a congenital disease. The deaths of the remaining three were due to respiratory infections. Of the six dying in the third and fourth weeks of life, five were males. Apart from one case of premature birth who had survived to this time and one of birth injury, the cause of death was one of the infections, namely bronchitis, pneumonia following whooping cough, contracted from others in the house, erysipelas of the face and gastro-enteritis. Of the 12 infants who died between one and three months of age, nine were males and three females. Congenital malformations accounted for three of these, and three others had had little hold 75 on life, all being premature and one not having left the hospital in which it had been born. The infections accounted for most of the remaining deaths, viz., bronchitis and broncho-pneumonia, gastro-enteritis, whooping cough and mastoiditis. Eight babies (five male and three female) survived three months but died before six months, and a further 22 (15 male and seven female) survived six months but died before the twelfth month. Congenital conditions and birth injuries are by this time a cause of little importance, one child of 11 months dying after an operation for spina bifida, and one child dying at four months of inanition and dyspepsia. Infections of the respiratory tract, occurring largely during, but not limited to, the winter months, figured most prominently amongst the causes of death at these ages. Bronchitis, bronchiolitis or broncho-pneumonia accounted for 11 deaths, in two appearing as a terminal condition in infants who had all along had little vitality, and in one being the cause of death in a mongol with congenital heart lesions. Three other infants had infections of the upper respiratory passages, one leading to mastoiditis and meningitis. Gastro-enteritis was the next most common cause of death, accounting for seven, the illness of most of these occurring during the winter and not the summer months. The infants were all artificially fed but the onset of the illness was not found to occur at the time of weaning. Of the other infections whooping cough accounted for two deaths, tuberculous meningitis, meningococcal meningitis, and erysipelas one each. One child died from acute appendicitis, and one, a child of nine months, died in October from convulsions due to rickets. DEATHS OF OLDER CHILDREN. Twenty-five children (16 male and nine female) died between their first and fifth birthdays. Personally transmissible diseases accounted for the majority of these deaths, there being three from whooping cough, one each from diphtheria, scarlet fever, tuberculous meningitis and streptococcal infection of the nasopharynx, and seven from bronchitis or pneumonia. Gastro-enteritis as a cause of death was less common than in the first year, accounting for the loss of only one child in this group, a boy in his second year. Accidents, one at home and two in the street, accounted for the deaths of three children. Two deaths were the result of congenital abnormalities, viz., spina bifida and congenital aneurism which resulted in a cerebral hæmorrhage; and a boy of three died of sarcoma of the kidney. INFANT MORBIDITY. Ophthalmia Neonatorum. Number of cases notified : 9. Number treated at home : 9. In hospital: nil. Vision unimpaired : 9. Impaired : nil. Total blindness : nil. Deaths : nil. 76 Of the nine cases notified, three were infants who, at the time of notification, were in-patients of London hospitals. All cases were mild in character and made complete recoveries. Cases of ophthalmia neonatorum are investigated by the Health Visitors on receipt of notification and are visited regularly until the eyes are clear. A similar procedure is followed in respect of those cases of which intimation is received from the County Medical Officer that a midwife has summoned a practitioner by a medical aid notice on account of some abnormality of the infant's eyes. Pemphigus. In June the Council approved of application being made for the approval of an Order under the Infectious Diseases (Notification) Act, 1889, by which pemphigus of the new-born would become notifiable in the district. The Order was confirmed by the Minister of Health on the 31st July, being effective as from the 17th August. MATERNAL MORTALITY. There were nine deaths registered as due to or associated with pregnancy, of which five were due to sepsis, giving a maternal mortality rate from this cause of 1.92, and for other accidents and diseases of pregnancy and parturition a rate of 1.54, being a total rate of 3.46 per thousand live births. The corresponding rates for England and Wales were 1.68, 2.42 and 4.10, and for this district for the year 1934, 2.30, 3.69 and 5.99. In addition there were two other deaths in which pregnancy was a causal or a closely associated factor. The death certificate of a married woman of 37 years of age read:— "Shock. Scalds of vagina. Felonious injection of hot water to procure a miscarriage. Felo de se." This is classified for statistical purposes as a suicide. A woman of 37 years of age died on 1st February from:— 1 (a) valvular disease of the heart, (b) rheumatic fever in youth; 2, Childbirth, 5th December, 1934—the pregnancy and confinement probably overtaxing the heart. This death is classified as due to heart failure, but probably had she not become pregnant she would have been alive to-day. Of the five cases of sepsis only one had been notified as suffering from puerperal fever. This patient, a married woman of 40, at her fourth pregnancy went into labour at full term. After 8½ hours in labour a low forceps delivery was effected under light chloroform anaesthesia. On the fifth day the temperature was raised and the lochia became offensive. On the tenth day she was removed to hospital and died 16 days later from haemolytic streptococcal septicaemia. 77 A week before the confinement was expected a woman of 25 went into the labour of her first pregnancy. After 15 hours, with low forceps, she was delivered of her first baby. The second twin lay transverse and after unsuccessful attempts at delivery the patient was taken to hospital where the baby was removed after a difficult embryotomy. The patient was in poor condition, and four days later a blood culture gave a growth of staphylococcus aureus, the patient dying some three weeks later. Incidentally this organism was cultured from a swab of the cervix taken on the patient's admission to hospital. The third case was one of septicaemia following an abortion at 14 weeks which was neglected for three weeks. The other two patients were both hospital cases, booked for admission before labour. The first died of 1 (a) acute suppurative nephritis; (b) septicaemia following full term delivery. The other, an unmarried girl of 20, had been treated ante-natally for venereal disease, but, after her confinement in hospital, died of 1 (a) peritonitis; (b) parturition ; (c) gonococcal cervicitis. The first of the non-septic fatal cases was due to eclampsia. A woman of 32 was pregnant for the second time, the first being a miscarriage. She was under the care of her doctor ante-natally and was seen on the 26th November and 14th February, on both occasions being quite well and her urine containing no albumen. On the 18th February, at the 26th week of pregnancy, she had headache all day and there was a heavy load of albumen in her urine. Within half-an-hour of being seen she had an eclamptic seizure and was removed to hospital. The blood pressure, which had not been previously taken, was 204/118 on admission. Active treatment was carried out but she died 3½ hours after admission. There were degenerative changes in the kidneys, and still more so in the liver. The second case, a woman of 32, who had had one previous normal confinement and had received ante-natal supervision from her medical attendant, at term sent for her doctor because of severe haemorrhage which had occurred without preceding labour pains. After plugging she was immediately removed to hospital. A leg was brought down which controlled the haemorrhage but the condition of the patient was very low and she died undelivered. The third patient, a woman of 28, died of "Severe reactionary haemorrhage following pregnancy." She was recognised antenatally to have some degree of contraction of the pelvis. After 12 hours' labour, low forceps were applied. There was a severe perineal tear and post-partum haemorrhage which was successfully controlled. Six hours later she was apparently comfortable, but after the lapse of another three hours the practitioner was summoned on account of symptoms which were attributable to a very severe haemorrhage from which the patient died in a few minutes. 78 The last case was that of a woman of 36 who had had two normal confinements. She miscarried at the 26th week. The puerperium was normal for a week when signs of cardiac failure were manifested. The blood pressure rose to 220 and the patient died suddenly of:— "1 (a) acute dilatation of the heart; (b) high blood pressure ; (c) recent pregnancy, ten days ago." Of these nine cases which proved fatal, or 11 when the other two are included, not one attended the local ante-natal clinics, nor were the Consultants summoned to any of these difficult cases of labour. Patients who are shocked or who have severe haemorrhage do not stand removal well. Enquiries into local maternal deaths are now carried out by the Medical Officer of Health. PUERPERAL INFECTION. One notification of puerperal fever was received during the year and 22 of puerperal pyrexia, the rate per thousand total births (i.e., live and stillbirths) being therefore 0.38 and 8.45, compared with figures of 3.60 and 9.44 for the country as a whole. The case of puerperal fever proved fatal. After the patient had been 8½ hours in labour, forceps were applied and the child delivered easily. On the fifth day there was some pyrexia and the lochia became offensive. On the tenth day the patient was removed to hospital, but died 16 days later from hæmolytic streptococcal septicæmia. Sepsis accounted for the deaths in outside hospitals of a further four women, not one of whom, however, had been notified as suffering from puerperal infection. Of the 22 notifications of puerperal pyrexia, five were in respect of patients who were confined in London hospitals; a further two patients were confined in local nursing homes, but the remainder were delivered in their own homes. Of the 18 cases in respect of which particulars are available seven appear to have been cases of uterine infection. In two normal labour was followed by uterine infection with hæmolytic streptococci. In another two retained clots caused the infection, the first patient being a case of precipitate labour with a resulting B.B.A., the other, a twin delivery extending over many hours. One case followed the birth of a large baby, the first, labour taking 32 hours and causing vaginal damage. The other two cases followed abortions, one self-induced at the 20th week and the other a three months miscarriage. In three cases the infection was apparently localised to the perineum. In four cases the raised temperature was due to pyelitis, in two to mastitis, in one to phlebitis in a patient who 79 had, during pregnancy, suffered very severely from varicose veins, while in one the rise of temperature was unaccounted for. Of the 18 patients whose confinements occurred in this district, five were removed to hospital for treatment. All cases made complete recoveries. INFANT WELFARE SERVICES. HOME VISITING BY THE HEALTH VISITORS. Routine visits are paid to infants as soon as possible after the 14th day, and special visits are paid to cases of ophthalmia neonatorum, puerperal infection, stillbirths, infants' deaths, etc. Each Health Visitor is appointed Infant Protection Visitor for her own area. The following table shows the number of visits paid by the Health Visitors during the year:— (a) To expectant mothers First visits 489 Total visits 852 (b) To children under one year of age First visits 3,297 Total visits 4,603 (c) To children between the ages of one and five years Total visits 4,084 It will be noticed that the number of first visits to children under one year of age exceeds the number of births which occurred during the year. This apparent discrepancy is accounted for partly by the arrears of visits and largely by the transfer of population to the growing district. This latter factor also causes a large amount of additional work for the Health Visitors. When a district grows by some 12,000 inhabitants in one year, the transferred population contains not only a large number of new babies but also of toddlers who are new to the health visiting staff. INFANT WELFARE CENTRES. At the beginning of the year there were 14 weekly sessions held at eight separate premises. Six of these, held at four separate premises, were conducted by the staff of the Middlesex County Council. From the end of January, when the Middlesex County Council discontinued the maternity and child welfare services which they had provided in the former Hendon Rural District, all clinics were maintained by the Harrow Council. The areas which served the various clinics were rearranged so that mothers were enabled, in many cases, to attend clinics nearer their homes. This led to the closing of one of the sessions at Lowlands Road Hall and the closing of a session at the Harrow Weald Memorial Hall, but a balancing additional session being opened at the Broadway Clinic. By June the attendance at the Stanmore Clinic necessitated 80 the holding of an additional weekly session there, and in October the number of sessions at the Elmwood Clinic was increased from two to three. Difficulty had been experienced in obtaining premises in the Pinner South Ward suitable for the purpose of holding clinic sessions to meet the very great needs of that area, but towards the end of the year the Baptist Church Hall at Imperial Drive was available. At the end of the year there were 16 weekly sessions held at nine premises in the district. All these clinics are maintained by the Local Authority. At most of them two Health Visitors are in attendance, but at some there is only one Health Visitor assisted by a District Nurse. At one time the weighing of the infants was performed by voluntary workers, but the Council decided that only trained nurses should do this work. Owing to the increasing number of sessions, the existing staff was insufficient to permit of the attendance of two Health Visitors at each clinic so that, in June, authority was given for the engaging of District Nurses as and when necessary for this purpose. The Health Visitor in charge of any clinic is, as far as possible, the one who visits the district which the clinic serves. A number of voluntary workers kindly assist at each clinic. The following table shows the work done at the Infant Welfare Centres during the year:— Total attendances at all Centres:— (1) By children under one year of age 28,133 (2) By children between the ages of one and five years 15,067 Total number of children who first attended at the Centres during the year and who, on the date of their first attendance, were:— (1) Under one year of age 1,973 (2) Between the ages of one and five years 921 Total number of children under five years of age who attended at the Centres during the year and who, at the end of the year, were:— (1) Under one year of age 1,605 (2) Over one year of age 2,797 Percentage of notified live births represented by the number of children under one year of age who attended for the first time, 84.3. This last very high figure is partly to be accounted for by the transferred population. Mothers new to the district will bring their children to the clinics so that the numerator of the fraction, namely the number of infants attending the first time, will be 81 increased without any alteration in the denominator, namely the number of notified live births. TREATMENT. The treatment services include the following: Dental treatment, ultra-violet therapy, correction of visual defects and orthopaedic treatment. In addition arrangements are made for the admission of suitable cases to convalescent homes, and for home nursing. Most of the treatment services were provided by the Council of Child Welfare at "Tyneholme," and the District Council made a grant in respect of those treated who fell within the scope of the maternity and child welfare services. In the early part of the year an agreement was entered into which came into operation as from 1st April, by which the District Council would pay the Council of Child Welfare a per capita grant, being a different amount for each of the various forms of treatment, in respect of these cases which the Local Authority referred to "Tyneholme" for treatment. The following are the agreed charges for cases treated: Ante-natal: First 600 attendances in any year, 7s. 6d. per attendance. Any attendances in excess of 600, 6s. per attendance. Sunlight Treatment: First 800 attendances in any year, 2s. 6d. per attendance. Excess over 800 attendances per year 2s. per attendance. Dental: 4s. 6d. per attendance. Massage : 2s. 6d. per attendance. Treatment services for the expectant mother are not limited to those who attend the ante-natal clinic but are available, subject to the financial assessment, to all those who are receiving adequate ante-natal supervision. A scale of assistance was adopted to determine what, if any, contribution should be demanded on behalf of the patient for the different forms of treatment, the amount bearing relation to the cost of the treatment and to the net income per head of family after the deduction of rent and compulsory insurance from the gross income. In the case of dental treatment a single payment is asked for, irrespective of the number of attendances the patient has to make to complete her treatment (excluding, of course, those cases who are provided with dentures). In the case of ultra-violet light treatment or massage, on the other hand, a contribution is expected in respect of each attendance. The following is a tabular statement of the contributions to be made by applicants for various forms of assistance under the maternal and child welfare scheme: F 82 Contributions by Applicants. Nett income per head of family per week after deduction of rent, rates and compulsory insurance. s. d. s. d. s. d. s. d. s. d. s. d. s. d. 2 10 6 12 6 14 6 16 6 18 6 21 0 22 6 3 8 6 10 6 12 6 14 0 16 0 17 6 19 0 4 7 6 9 0 11 0 12 0 14 0 15 0 17 0 5 7 0 8 0 9 6 10 6 12 6 14 0 15 6 6 6 6 7 6 8 6 9 6 11 0 12 6 14 0 7 6 0 7 0 8 0 9 0 10 0 11 0 12 0 Milk free half cost Maternity Hospital up to 10% 20% 30% 40% 50% 66% 80% plus half maternity benefit. Home help free half cost Midwife free half cost quarter maternity benefit per week in assessing income. Dental Treatment free free 2 6 2 6 2 6 Dentures up to 10% 20% 30% 40% 50% 66% 80% Eyes free free free free free Spectacles free 25% 25% 50% 50% Massage free free 1 6 1 6 1 6 Sunlight free free 1 6 1 6 1 6 Maternity Sets free Ts. & As. free 25% 25% 50% 50% 66% Convalescent Home free 25% 25% 50% 50% 66% Splints, etc. free 25% 25% 50% 50% 66% Home Nursing free free All blank spaces—no assistance. In the case of Milk Grants and Maternity Assistance, the unborn child is counted as a member of the family. 83 The cases referred to below include only those in which the Local Authority made some contribution to the cost of the treatment, and do not include all those cases who made their own arrangements or paid the cost in full. Dental Treatment. Children under five and expectant and nursing mothers are referred to "Tyneholme" from the clinics. In the case of children treatment is limited to fillings or extractions which are mostly under gas. Women, in addition, may have their teeth scaled, and in particular cases are assisted in the provision of dentures. During the last nine months of the year 24 children under five made 45 attendances, and 76 mothers made 153 attendances. Five were fitted with dentures. Ultra-Violet Therapy. Five children made a total of 129 attendances during the last nine months of the year. No nursing or expectant mothers were refeired for treatment. Orthopædic Treatment. The orthopaedic arrangements now include: (a) supervision by an orthopaedic surgeon, (b) massage, (c) admission of suitable cases to hospital, (d) provision of splints to necessitous cases. The Consultant Orthopaedic Surgeon now attends "Tyneholme" periodically to review suitable cases attending there for treatment. At the time of his attendance a representative of a firm of surgical instrument makers also attends and measures for appliances those cases which require them. The Local Authority makes a contribution towards the cost of these instruments. Any cases needing hospital treatment can be admitted under the care of the surgeon. Massage is provided by the staff of the Council of Child Welfare. During the year one child made 37 attendances at "Tyneholme" for massage. The Council was responsible for the payment of the hospital charges for one orthopaedic case in hospital. Correction of Visual Defects. Up to the early part of 1935 an ophthalmic clinic was maintained at "Tyneholme." This closed down, however, when the Middlesex County Council arranged as part of the school medical service for the weekly attendance of an ophthalmic surgeon at the Broadway Clinic. By an agreement between the two authorities, children under five are attended to at this clinic at the cost of the Harrow Council. During the year 13 children attended for this purpose, most of them being recommended to obtain glasses. 84 Operative Treatment of Tonsils and Adenoids. Arrangements have been made by which cases can be treated at the Harrow and Wealdstone Hospital at a cost of two guineas, the patient being admitted the night before the operation and detained for 48 hours after it. Only one child was treated under this scheme during the year. Convalescent Homes. Three children and one mother were admitted to convalescent homes. Home Nursing. Arrangements were made with the Harrow, Wealdstone and Harrow Weald District Nursing Association by which the local authority undertook to be responsible for the payment of the nursing fees of those of limited means who came within the scope of the maternity and child welfare scheme, the infants' diseases including ophthalmia neonatorum, pemphigus, measles, etc., and in mothers, conditions such as puerperal infection. The charges agreed were 2s. 6d. per visit to cases of ophthalmia neonatorum and puerperal sepsis, but if more than one visit was paid in a day 1s. 6d. for subsequent visits ; and for other diseases, such as measles or whooping cough, etc., 1s. 6d. per visit. During the year the local authority was responsible, under this arrangement, for the payment of the fees of two patients. INFANT LIFE PROTECTION. Each Health Visitor acts as Infant Protection Visitor for her area and is responsible for the supervision of foster children. On receipt of a notice of intention to undertake the care of foster children, the premises are visited by the Sanitary Inspector. If there are no sanitary defects and the addition of another occupant would not result in overcrowding a report is called for from the Health Visitor. Thereafter quarterly routine visits are paid by the Health Visitor in addition to any special visits that may be required. Foster mothers give an undertaking to keep the children under periodical medical supervision, either at one of the infant welfare centres or by their own medical attendants. In May the Council adopted the following recommendation of the Public Health Committee:— That in future no application to receive more than three infants be granted unless bedroom accommodation of at least 40 superficial feet floor space per infant, and separate playroom accommodation, is provided. In addition to the more usual cases of foster mothers caring for one or more infants, there are two infants' homes in the district, registered for the care of 18 and 20 babies. 85 The following table summarises the information with regard to foster children and foster parents in the district:— Number of persons on the register who were receiving infants for reward at the beginning of the year 54 Number of persons registered during the year 30 Number of persons removed from the register during the year (either by reason of removal from the district; no longer undertaking the care of the child, etc.) 16 Number of persons on the register who were receiving children for reward at the end of the year 68 Number of children on the register at the beginning of the year 117 Number of children received during the year 134 Number of children removed from the register during the year 132 Removed to care of parents 78 Removed to care of another foster mother 22 Legally adopted by foster parent 2 Removed to charitable organization, etc. 17 Removed to hospital 12 Of this number 5 died. Foster parent left the district, taking the child with her - Child attained the age of nine years 1 Number of children on the register at the end of the year 119 About half the children removed to hospital were from one of the homes to which infants who are not thriving are admitted. One of the deaths occurred in this group. Three of the other deaths were due to gastro-enteritis amongst infants in a home registered for the reception of nine. 86 MATERNITY SERVICES. The facilities offered to mothers, expectant or parturient, include:— Ante-Natal:— Ante-natal supervision by home visiting; antenatal clinics; general practitioners' ante-natal scheme; consultant ante-natal clinic; milk in the last three months of pregnancy; dental treatment, including provision of dentures; artificial sunlight treatment; home helps. At Confinement Institutional accommodation; payment of midwives' fees in necessitous cases; home helps; provision of maternity sets; consultation for cases of difficult labour; ambulance for removal of women in labour. Post-Natal:— Post-natal examination at the clinic, including consultant clinic; provision of milk to nursing mothers; dental treatment; artificial sunlight treatment; convalescent homes; home nursing; provision of consultations for cases of puerperal infection, and institutional treatment for such cases. ANTE-NATAL SUPERVISION. Home Visiting. During the year the Health Visitors paid the total of 852 visits to 489 expectant mothers. Some of these visits are paid so that the Health Visitors can advise the mothers in those cases where the confinement is to take place at home; a number of visits are paid as a result of the non-attendance of the mother at the ante-natal clinic; and a number follow on the request of hospitals at which the expectant mothers have attended, for a report on the home circumstances. Ante-natal Clinics. At the beginning of the year ante-natal clinics were held twice weekly by the Council of Child Welfare at "Tyneholme," and the District Council held weekly sessions at the Elmwood and Broadway Clinics. The Middlesex County Council continued up to the end of January the monthly clinic at St. George's Hall, Headstone. A number of sessions were opened at various premises in the district during the course of the year, so that at the end of the year facilities were available at the Council of Child Welfare Clinics at "Tyneholme" (twice weekly) and at the following clinics maintained by the District Council:—Broadway Clinic, Wealdstone (twice weekly), Elmwood Clinic, Kenton (weekly), The Institute, Whitchurch Lane, Stanmore (weekly), and the Baptist Church Hall, Imperial Drive (weekly). The following summarises the work done at the clinics during the year Total number of expectant mothers attending the clinics 823 87 Total number of attendances by expectant mothers at all clinics 2,370 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 36.5 Nearly 50 per cent. of the women attended the clinic on the recommendation of a Health Visitor that they should obtain ante-natal supervision, and some 25 per cent. on the recommendation of a midwife. One-third of the women who attended were pregnant for the first time, and a similar number for the second time. One-sixth were pregnant for the third time, 8 per cent. for the fourth and in the case of 10 per cent. it was the fifth or more than the fifth pregnancy. Thirty-five women were not pregnant, and 73 attended for post-natal examination. The third, fifth, sixth and seventh months of pregnancy were the times when most attended the clinic for the first time, about one-sixth attending at each of those months. The first attendances of most of the remainder being equally distributed in the second, fourth and eighth months. One-third of the mothers attended more than five times and one-fifth attended only the once. The most common reason for the single attendance would be that arrangements had been made for the patient to be admitted to a hospital for her confinement, and her remaining ante-natal supervision would be conducted by the hospital staff. In arriving at these proportions the returns in respect of those women who removed from the district before the confinement or whose pregnancy terminated short of term, have been deducted. Fifteen per cent. attended four times and 12 per cent. attended twice and three times. As these figures relate only to those cases who attended during 1935 and would, because of the birth of the baby, not be attending in 1936, and particularly because the great increase in the attendances occurred in the latter part of the year, the number of cases in respect of whom the nature of the confinement is being referred to is not nearly the number, namely, 823, who attended the clinics for the first time during the year. Out of the pregnancies of 369 women, 11 resulted in an abortion or miscarriage, and eight in a stillbirth, many of which were not at term. 296 normal confinements took place at term at which the birth of a live child occurred and was followed by the uneventful recovery of the mother. In 52 confinements there was some departure from this standard. Of these, six confinements took place by Caesarean section, mostly on account of disproportion, in all cases with satisfactory results. Nine women were induced before term, five on account of toxaemia or albuminuria, and three on account of disproportion. In one of these cases the infant died soon after birth. In a number of cases the confinement itself was 88 normal, but any abnormality was post-natal. Of these, eight patients suffered from post-partum haemorrhage, some being due to retention of the placenta. Three suffered from puerperal pyrexia, one case being due to phlebitis and one to pyelitis. At two confinements at which twins were born, one of the infants was stillborn, and in the case of one of the others, the infant survived only 13 hours after delivery. Three other infants died soon after an apparently normal confinement, one being anencephalic. There were 16 cases in which some departure from the normal occurred during the confinement. Forceps were applied in 13 cases, in some instances for reasons such as a delayed second stage, and, in two, on account of occipito-posterior presentation. Uterine inertia, long labour and difficult labour followed by post-partum haemorrhage were the abnormalities of the other three cases. One patient had an ante-partum hæmorrhage but was delivered of a living child, while one patient went into labour at the seventh month, her infant surviving. Compensation to Midwives. The Council in January agreed to pay the sum of 10s. to a midwife whose case was lost to her by reason of the Medical Officer exercising ante-natal care of the patient referring her on medical grounds to hospital for her confinement. The conditions attached to the payment of this sum are:— 1. That in each case the patient is required to confirm the statement that she has engaged the midwife to attend her confinement and had been referred by the midwife to the doctor or clinic; 2. That the Medical Officer of the Clinic or ante-natal doctor certifies that he or she advised the patient to be confined in a hospital or home; 3. That no payment will be made to the midwife where the patient has herself applied to be confined in a hospital or home. Consultant Ante-natal Clinic. Since July a monthly consultant ante-natal clinic has been held at the Broadway Clinic on the morning of the second Tuesday of each month. Patients are mostly referred from the local antenatal clinics but a number have been referred direct by the general medical practitioners in the area. Post-natal cases are also seen at these clinics. At the six sessions 31 women, of whom nine were referred by their own medical attendants, made 35 attendances. General Practitioners' Ante-natal Scheme. In January the Council approved of arrangements being made by which the Council would be responsible for the fees for antenatal examinations of uninsured women carried out by the patients' 89 medical attendants on women referred to the practitioners by midwives. These arrangements are limited to uninsured women who engage midwives for their confinements, not extending to those women who book their doctors and engage midwives. Insured women are outside the scheme as, in their cases, ante-natal advice is part of the panel services. In general, examinations are recommended at the sixteenth, thirty-second and thirty-sixth weeks of of pregnancy, and one post-natal examination is advised. The fees recommended to be paid to the practitioners were 10s. for the first examination, 5s. for each subsequent examination and report, and 5s. for a report on the examination of an insured patient. Later, the Minister of Health limited the fees to 5s. for each examination and report. Women who choose to obtain their ante-natal supervision under this scheme are offered the same facilities in the way of obtaining milk, dental treatment, etc., as are those attending the ante-natal clinics, arrangements being initiated by a recommendation being made by the ante-natal doctor. Comparatively little advantage was taken of the scheme during the year, only 35 women being referred. Of these, 15 were insured and 20 not insured. Only three of these women attended for post-natal examination. ARRANGEMENTS FOR THE CONFINEMENT. At Home. The various forms of assistance granted to those mothers having their confinements at home, include:— (a) Payment of the fees of midwife. The average fee charged by midwives in this district is £2 10s. 0d. for the first confinement and £2 2s. 0d. for others.' To encourage attendance by the midwife to the 14th day the Council pays £2 15s. Od. and £2 5s. Od. for 14 days' attendance to midwives attending necessitous cases. This payment is ordinarily conditional on the patient having received satisfactory ante-natal supervision. During the year 52 cases were assisted in this manner. (b) Payment of the fee of a home help. The payment of 3s. Od. per day, usually for 14 days' attendance, is made to suitable home helps. A panel of suitable women is compiled by the Health Visitors and the mother chooses one from the list. Exceptionally, arrangements are made for the home help to enter upon her duties before the confinement and, where circumstances warrant it, to remain after the usual period of 14 days. The payments were made in respect of eight cases during the year. (c) Provision of maternity sets. Maternity sets are issued free to necessitous mothers who are receiving adequate G 90 ante-natal supervision and who are to be confined in their own homes. 12 sets were issued. (d) Consultant Services.— Arrangements are in force by which a consultant is available to assist general medical practitioners in necessitous cases in the event of difficulty occurring during labour. Under the scheme the consultant was summoned on six occasions, once ante-natally, three times owing to difficulties occurring during labour and twice to recently parturient women. The ante-natal case was a woman too ill to attend hospital, the illness being due to pyelitis. Of the cases of difficulty in labour, the first was a case of delayed labour; the patient was removed to hospital and by forceps delivery a living child born. The second, a primipara of 35, had been 48 hours in labour; after incision of the cervix, episiotomy and the application of high forceps, a living child was delivered. The third patient, also a primipara, suffered from an impacted breech in a contracted pelvis. The extended legs were delivered and, following an episiotomy, the head was extracted with forceps, a living child again being born. Both the post-natal cases were due to post-partum haemorrhage. The first patient was given two blood transfusions (the operator incidentally acting as donor); when her condition had improved sufficiently the placenta was removed. In the other case the uterus explored and then plugged. In an Institution. The same arrangements for the admission of expectant mothers to hospitals for their confinements continued in operation, namely, endeavouring to engage a bed at one of the hospitals with which the Council has entered into an agreement, and in default of obtaining a bed, arranging for the admission to one of the local maternity homes. 36 women were assisted towards the payment of their fees for their confinement in an institution under this arrangement. In July the Council agreed that in those cases where the Council accepts liability for the payment of the whole or part of the hospital fees, they would also pay the ambulance charges in the first instance, any such fees to be recovered from the patient in the same proportion as the hospital fees are recovered. The ambulance rules have been amended so that when an ambulance is required in connection with a maternity case the person calling the ambulance must arrange for a midwife or woman friend or relative to accompany the patient in the ambulance. Under this arrangement the fees of 13 women were paid either in part or entirely. 91 Local Maternity Home. Of the 2,437 births to Harrow mothers last year 1,377 occurred in private houses, 521 in local nursing and maternity homes and 539 outside the district. Most of this last category occurred in institutions. Excluding the 141 at Redhill County Hospital, the vast majority occurred in London maternity or general hospitals, the institutions most frequently used being Queen Charlotte's Hospital (136 births), City of London Maternity Hospital (40), Queen Mary's Maternity Hospital (24), University College Hospital (23), and Middlesex Hospital (20). 56 per cent. of the births then took place at the homes of mothers, and 44 per cent. in institutions, of which 21 per cent. of the total were in local maternity institutions and 23 per cent. in outside hospitals and maternity homes. The following analysis indicates the reasons for which the mothers attending the local clinics had their confinements in hospitals:— 1. Medical grounds 31 per cent. 2. Domestic difficulties, such as lack of tion, no attendant, etc. 15 per cent. 3. Economic grounds 5 per cent. 4. First pregnancy 43 per cent. 5. Personal preference 6 per cent. Discussions of the needs for maternity beds in this district had been taking place for years. In 1933 a conference had taken place on the possibility of the Willesden Council being able to provide accommodation for cases referred by Wembley, Kingsbury, Wealdstone, Hendon and Harrow. Nothing further transpired as an outcome of these deliberations. In November, 1934, a report was submitted to the Maternity and Child Welfare Committee on the question of institutional accommodation for maternity cases. It was pointed out that the policy of the Ministry of Health followed one of the recommendations of the Departmental Committee on Maternal Mortality and Morbidity, viz., "that new maternity units should, where practicable, be provided in association with general hospitals rather than as isolated units." With regard to this, the only hospital in the district which could provide maternity accommodation is the Harrow and Wealdstone Hospital, at which it is understood there is no likelihood of provision being made for this service. The only other institution in the locality to be considered was the Redhill County Hospital which contains a maternity block of 25 beds, to be increased to a figure of 60. This institution serves Hendon Borough and the Urban Districts of Wembley and of Harrow, a present population of some 400,000, with some 6,000 births annually. The proposed 60 beds could not meet the needs of the 92 area in making provision for all types of maternity cases needing admission either on medical grounds or on account of unsuitable home circumstances. The Departmental Committee on Maternal Mortality and Morbidity advocated "as likely to give the optimum of safety, hospitals providing from 50 to 60 maternity and five to 10 antenatal beds." It was considered that to meet the needs of those women for whom the Council, as maternity and child welfare authority, had concern, a minimum of 20 beds would be required. In addition it was surmised that full use would be made of a further 20 beds, or a total of 40 for the district. In May a conference was held between representatives of the Wembley and of the Harrow Councils at which was considered the question of providing a joint maternity hospital for the combined districts. After further meetings the Councils of both districts agreed to a report of which the following is a very brief summary :— 1. That shortly 70 maternity beds will be required to meet the needs of Harrow and Wembley. 2. That it would be to the advantage of both Councils to provide a joint hospital to provide such accommodation. 3. That the arrangements and control of the establishment should be delegated to a Joint Committee. These proposals were submitted to the Minister and forwarded to the County Council. The following are extracts from a report of the Public Health Committee of the Middlesex County Council submitted to and confirmed by the County Council in December, 1935:— The County Council has a legal obligation to provide beds for necessitous women in their confinements, and in fact, has maternity wards at each of its general hospitals. These, however, are hardly adequate to satisfactorily deal with its obligations, and extensions to all the maternity departments either have been approved by the Council or are under consideration. When these extensions are complete it is anticipated that the County Council will be in a position to accommodate for their confinements all financially necessitous women and all women who require hospital accommodation for medical reasons. The County Council's proposals should also enable the majority of cases of women living in surroundings unsuitable for confinement to take place therein to be dealt with, but will not be adequate to accommodate the very considerable and increasing number of women not included in the above classes who themselves desire admission to hospital for their confinements. The problem under consideration, therefore, is whether the additional accommodation required should be provided by the County Council 93 as a public health measure by an extension of its hospital service, or be provided by the several local District Councils under their maternity and child welfare schemes, by the creation of a number of relatively small ad hoc maternity hospitals. the provision in public hospitals for between 30 per cent. and 40 per cent., should be considered reasonably adequate for the average social conditions obtaining in Middlesex. the population of the County is increasing very rapidly and it is apparent, therefore, that further beds will be needed in order to provide public accommodation for 30 per cent. to 40 per cent. of all births. The extent of this additional accommodation, however, should not be very great. Probably a further maternity block of some 60 beds would go far to meeting the justifiable needs of the County for some time to come. The question that was discussed with the officers ot the Ministry of Health was whether this additional provision should be met by Local Borough and District Councils or by the County Council. Whilst no absolute ruling was given it was understood that the Ministry of Health's present policy was based upon the final report of the Department Committee on Maternal Mortality and Morbidity, which stressed the advantages of maternity provision being made in conjunction with general hospitals, and therefore the Ministry favoured the undertaking of this work by the County Council. On the other hand the actual existing number of beds in the County was patently inadequate and the time was considered a most important factor; therefore, if prolonged delay was likely to result in awaiting the County Council's development of its schemes, the Ministry might find it hard to resist pressure from any Local Authority who urged the immediate needs of their area and gave proof that they were in a position to provide the accommodation at a much earlier date than the County Council. The position may be summarised by stating that the Ministry of Health deprecated the provision of new maternity accommodation by a Borough or District Council and considered that public interest was best served by the County Council, as the hospital authority of the area, adding such maternity accommodation to its general hospitals as would adequately meet the legitimate needs of the County. On the other hand, where a Borough or District Council has already established a maternity hospital the Ministry considers that it is a matter for every Council's own discretion as to whether this hospital shall continue. In the case of Harrow and 94 Wembley, therefore, the Ministry of Health would prefer the County Council making any necessary provision. that the County Council approves in principle of the provision, as a public health measure, of such maternity hospital accommodation at the County General Hospitals as may be necessary adequately to meet the legitimate needs of the County. POST-NATAL SERVICES. Post-natal Examinations. 108 women attended the clinics for post-natal examination, making altogether 148 attendances. A further three were examined under the General Practitioners' Scheme. As yet no separate session has been held for post-natal cases, the women attending the ordinary sessions of the ante-natal clinics. Puerperal Infection. (a) Consultant services: Arrangements are in operation by which local medical practitioners can obtain the services of the consultant in cases of puerperal infection. During the year the consultant was summoned on two occasions: the first patient was immediately removed to hospital, but the second case was treated at home by intra-uterine glycerine. (b) Hospital services: Any cases of puerperal infection requiring hospital treatment are removed, either to the London County Council North-Western Hospital or to the isolation block of Queen Charlotte's Hospital. The single case notified as puerperal fever was removed to hospital, but died. Of 18 cases notified as puerperal pyrexia amongst the women confined in this district, four were removed to hospital: all made complete recoveries. BIRTH CONTROL CLINIC. In March the Council approved of the establishing of a Birth Control Clinic for those women normally attending existing maternity and child welfare centres and needing advice on birth control on medical grounds. The clinic was opened in June, the Medical Officer attending monthly to start with and the nurse attending fortnightly. Since the end of the year, however, the Medical Officer has attended fortnightly. A number of women were not dealt with owing to there being no medical grounds justifying the giving of the advice, but 62 were advised for such reasons as the presence of severe heart disease, tuberculosis, toxic goitre, kidney disease and, in one case, a history of puerperal insanity. 95 ADMINISTRATION OF THE MIDWIVES ACTS, 1902-1926. The following information relates to the administration of the Midwives Acts :— Notification of Intention to Practise by Midwives, resident in the Urban District of Harrow during 1935. Total numbers of midwives practising during 1935 46 Removed from the District during 1935 5 Practising temporarily during 1935 3 Number in District at end of 1935 38 All the midwives who notified their intention to practise in the Urban District of Harrow during 1935 were in possession of the certificate of the Central Midwives Board. Of the midwives practising here two are residents of adjoining districts and eight practised only in nursing homes, leaving some 28 midwives whose practice was almost confined to the attendance of Harrow mothers in their own homes. Number of births attended by midwives resident in the Urban District of Harrow during 1935:— As Midwife 565 As Maternity Nurse 516 1,081 Of the midwives attending to mothers in their own homes, most have limited practices. Only one notified 50 cases, four notified between 30 and 40, two between 20 and 30, five between 10 and 20, and the rest only single figures. Notifications received from Midwives in accordance with the Rules of the Central Midwives Board :— Sending for medical assistance 141 Stillbirth 3 Death of Infant 5 Death of Mother — Laying out the Dead 4 Artificial Feeding 8 Liability to be a Source of Infection 11 172 Classification of the Notifications of sending for Medical Aid :— Medical assistance required for conditions arising:— During pregnancy 16 During labour 97 During lying-in 10 In Infant 18 741 The supervision of midwives is carried out by the staff of the Middlesex County Council as the Local Supervising Authority. 96 NURSING AND MATERNITY HOMES. The following table is a summary of the nursing homes in the district, giving particulars of the type of case dealt with and the allocation of beds:— Type of Case. Total No. of beds. No. of Maternity beds. 25, Roxborough Avenue, Harrow-on-theHill Maternity, medical, chronic, surgical. 8 8 Bowden House, High Street, Harrow Medical, nerve, chronic. 13 - Children's Convalescent Home, Bushey Heath Convalescent 16 - St. Vincent's Nursing Home, Headstone Lane, North Harrow Maternity, medical, chronic. 12 8 Grosvenor House Nursing Home, 100, High Street, Harrow Maternity, medical. 12 3 21/23, Albert Road, Harrow Maternity, medical. 7 5 32, Kingshill Drive, Kenton Maternity. 1 1 61, Weldon Crescent, Harrow Maternity. 5 5 Oxhey Grove, Hatch End Mental, borderline and nervous disease. 6 — Kenwood Nursing Home, Nower hill, Printer Maternity, medical surgical 3 3 3 3 Fair Elms Nursing Home, Headstone Lane, Hatch End Maternity, medical, surgical. 8 6 Highfield Nursing Home, London Road, Stanmore Maternity, medical, surgical. 10 10 Suffolk House Maternity Home, Marsh Lane, Stanmore Maternity, medical, chronic. 7 7 11, Hindes Road, Wealdstone Maternity, medical, surgical. 7 7 97  Type of Case. Total No. of beds. No. of Maternity beds. Sunnymede Nursing Home, Pinner Hill Road, Pinner Maternity, medical. 3 2 Parkside, Alveston Avenue, Kenton Chronic. 3 - Roxborough Maternity Home, Harrow Maternity. 24 24 The Hall, Harrow Weald Mental (borderline). 7 - 27, Peterborough Road, Harrow Maternity. 6 6 College Hill Nursing Home, College Hill Road, Harrow Weald Maternity, medical, surgical. 7 7 The supervision of these homes is carried out by the staff of the Middlesex County Council. MILK ISSUES. Milk, fresh or dried, is granted free or at half-cost on the recommendation of the Clinic Medical Officer to babies and infants under five years of age, to nursing mothers and to expectant mothers in the last three months of pregnancy. The amount is usually limited to one pint daily of wet milk or its equivalent in dried milk, except where, on the recommendation of the Medical Officer, in the case of older infants, the permitted amount may be 1½ pints. Milk orders are issued for one month only, to expire on the last Saturday of the month. In October it was decided to invite tenders for the milk contract, with the result that one firm now supplies the whole area. By a previous decision of the Council the milk supplied is pasteurized. Apart from fresh or dried milks, no other foods or medicaments are issued at less than cost price. The amount granted by the Council has rapidly increased during the year. In January the number of persons in receipt of an assisted supply was 64. In February, the first month for which the Council provided for the whole area, the number was 91. The increase has been steady month by month, reaching in December a figure of 236. Of this last number 209 grants were for pasteurized milk and 27 for packet milk. CLINIC BUILDINGS. The Council possesses two clinic buildings erected by the former Wealdstone Council at the Broadway and at Elmwood Avenue. During the year, by agreement between the District Council and the Middlesex County Council, the Broadway Clinic is now used for school treatment services, namely, minor ailment clinics and ophthalmic clinics. 98 In the early part of the year it was agreed that further clinics were required for the district, particularly in the Stanmore and the Pinner South or Roxeth Wards. The County Council agreed that, were suitable clinics erected, they would be used for school medical purposes. The Council of Child Welfare carry on their treatment services at "Tvneholme," Headstone Drive, Wealdstone. Following an offer by estate developers for the purchase of "Tyneholme" which, if effected, would have resulted in a serious loss to the district owing to the treatment services performed there, the Council adopted the recommendation of the Public Health Committee that "Tyneholme" be purchased, the completion to be on the 1st April, 1937, with a view to the erection on the site of a central clinic for maternity and child welfare purposes. CAUSE OF DEATH Under 1 year Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 and under 75 Over 75 Total RegistrarGeneral's Allocations M F M F M F M F M F M F M F M F M F M F M F M F M F 1. Typhoid fever — — — — — — — — — — — — — — — — — — — — — — — — — — 2. Measles — — — — — — — — — — — — — — — — — — — — — — — — — — 3. Scarlet fever — — — — — 1 — 1 — — — 1 — — — — — — — — — — — 3 — 3 4. Whooping cough 1 1 — — 2 1 — — — — — — — — — — — — — — — — 3 2 3 2 5. Diphtheria — — — — — 1 1 — — — — — — — — — — — — — — — 1 1 1 1 6. Influenza — — — — — — 1 — 1 1 — 2 1 1 3 — 1 — 1 1 — 2 8 7 8 7 7. Encephalitis lethargica — — — — — — — — — — — — — — — — — — — — — — — — — — 8. Cerebro-spinal fever 1 — — — — — 1 — — — — — — — — — — 1 — — — — 2 1 2 1 9. Respiratory tuberculosis — — 1 — — 1 1 — 4 3 9 7 7 10 8 1 4 2 1 — 1 — 36 24 36 24 10. Other tuberculosis — 1 — — 1 — — 4 2 — 1 — 1 — — — 2 — — — — — 7 5 7 5 11. Syphilis — — — — — — — — — — — — — — 1 — — — 1 — — — 2 — 2 1 12. General paralysis of the Insane — — — — — — — — — — — — — — — — 2 1 1 — — — 4 1 4 1 13. Cancer — — — — 1 — — — — — — 3 5 5 10 18 11 25 16 31 9 17 52 99 53 99 14. Diabetes — — — — — — — — — — — 1 1 — — — 3 3 — 3 — 1 4 8 4 8 15. Cerebral hæmorrhage — — — — — — — — — — — — 1 1 3 2 3 10 10 14 8 17 25 44 24 40 16. Heart disease — — — — — — 1 — 1 1 — 3 6 5 12 8 32 14 44 37 26 57 122 125 120 127 17. Aneurysm — — — — 1 — — — — — — — — — 2 — — 1 — — — — 3 1 4 2 18. Other circulatory diseases — — — — — — — — — — — 1 — — — 2 3 6 13 10 12 9 28 28 27 30 19. Bronchitis 4 1 — — — — — — — — — — — 1 4 1 1 2 4 3 4 5 17 13 15 14 20. Pneumonia 13 3 2 1 3 1 3 2 — 1 1 1 2 4 2 3 3 2 2 7 4 9 35 34 32 32 21. Other respiratory diseases — — — — — — — — — — — — 1 — — — 4 1 2 — 1 — 8 1 7 4 22. Peptic ulcer — — — — — — — — — — — — 1 — 2 1 2 1 2 - 1 1 8 3 8 4 23. Diarrhœa (under 2 years) 7 3 1 — — — — — — — — — — — — — — — — — — — 8 3 9 3 24. Appendicitis — 1 — — 1 — — — 1 — 1 — — — — — — — — — — — 3 1 3 1 25. Cirrhosis of liver — — — — — — — — — — — — — — 1 — 1 1 1 — — — 3 1 3 1 26. Other diseases of liver — — — — — — — — — — 1 — — — — — — — — 1 — 1 1 2 2 2 27. Other digestive diseases 1 — 1 1 — — — — — 1 — 1 — 2 5 5 3 — — 5 3 3 13 18 14 19 28. Nephritis — — — — — — — — 1 — — 1 — 1 — 3 7 4 6 4 3 3 17 16 17 15 29. Puerperal sepsis — — — — — — — — — — — 4 — 1 — — — — — — — — — 5 — 5 30. Other puerperal causes — — — — — — — — — — — 3 — 1 — — — — — — — — — 4 — 4 31. Congenital debility 43 18 — — — — — — — — — — — — — — — — — — — — 43 18 45 19 32. Senility — — — — — — — — — — — — — — — — — 1 1 4 16 28 17 33 11 25 33. Suicide — — — — — — — — — 1 1 1 — 2 3 2 6 — 2 1 1 — 13 7 14 5 34. Other violence — — — — 4 — 2 2 2 — 6 — 1 — 1 1 3 3 3 — 2 5 24 11 25 15 35. Other defined diseases 7 3 — 1 1 2 6 2 4 2 2 5 3 7 4 5 5 5 4 7 6 3 42 42 47 42 36. Causes ill-defined — — — — — — — — — — — — — — — — — — — — — — — — — — Total 77 31 5 3 14 7 16 11 16 10 23 34 30 41 61 52 96 83 114 128 97 161 549 561 547 561 KING & HUTCHINGS, LTD. PRINTERS-UXBRIDGE