AC 439(1) HARROW (Latin Mum B.) HARR 5 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1938 CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law. Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1938 CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law. 3 TABLE OF CONTENTS. page Officers of the Public Health Services 6 General Statistics 7 General Provisions of Health Services for the Area Hospital Provision 10 Ambulance Facilities 11 Clinics and Treatment Centres 12 Professional Nursing in the Home 15 Laboratory Facilities 15 Legislation in Force . 15 Sanitary Circumstances of the Area Water 16 Drainage and Sewerage 17 Public Cleansing 20 Mortuary 21 Swimming Baths 22 Establishments for Massage and Special Treatment 22 Sanitary Inspection of District 22 Smoke Abatement 23 Shops Acts 23 Rats and Mice 24 Places of Public Entertainment 24 Factory and Workshop Act 25 Eradication of Bed Bugs 25 Housing Statistics Statistics of Inspections 26 Action under the Housing Act, 1936 28 Inspection and Supervision of Food Milk Supply 32 Meat and Other Foods 33 Adulteration, etc 35 4 PAGE solation Hospitals Administration 36 Clinical Aspects 39 Prevalence of and Control over Infectious and Other Diseases Control of Infectious Disease 42 Diphtheria 42 Scarlet Fever 44 Other Diseases 48 Tuberculosis 51 Maternity and Child Welfare Registration and notification of Births 55 Stillbirths 55 Infant Mortality 56 Deaths of Older Children 58 Infant Morbidity 58 Maternal Mortality 58 Puerperal Infection 60 Infant Welfare Services 61 Infant Life Protection 63 Maternity Services 64 Midwives Acts 68 Nursing and Maternity Homes 72 School Medical Service 74 Classification of Deaths 76 5 REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Chairman and Members of the Urban District Council of Harrow. Mr. Chairman, Mrs. Leech and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1938. The Report this year is somewhat curtailed as it is felt that any value such a volume possesses steadily diminishes with the lapse of time from the period covered. The vital statistics again are satisfactory. The maternal mortality rate is lower than in previous years, though again is above the rate recorded for the rest of the country. The infant mortality rate, while well below the national rate, is an appreciable rise on the exceedingly low figure recorded in 1937. The clinic services were again extended to cope with the increasing population, though the rate of this increase might be expected to be slower in future as the houses erected during the year were only 2,890 as compared with figures of 4,331, 4,715, 4,173 and 4,222 for the years 1934 to 1937. I have the honour to be, Mrs. Leech and Gentlemen, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Harrow-on-the-Hill. July 1st, 1939. 6 OFFICERS OF THE PUBLIC HEALTH SERVICES. Full-time Staff. Medical Officer of Health : CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law. Assistant Medical Officers of Health : O. C. DOBSON, M.D., B.Hv., D.P.H. MABEL DODDS, M.B., B.S., D.P.H. MARGARET DOUGLAS, M.B., B.S. Sanitary Inspectors : A. B. KRAMM (Senior Inspector) †‡ D. J. ANDERTON (Sanitary S. N. KING, †‡* Inspectors' Assistant). J. E. JOHNSON, †‡ R. S. COOPER, †‡ P. SCHOFIELD, †‡ H. DRABBLE, †‡* B. H. WHITE † (Shops Act Inspector) A. C. GROOM, †‡ †Cert. R.San.I. ‡Meat Inspectors' Cert. *Smoke Inspectors' Cert. Health Visitors: MRS. D. BRACE (Supt. Health Visitor) †‡* MISS M. E. BENNETT, †‡* MISS E. J. LEWIS,†‡* MISS B. COOPER,†‡* MISS D. MARSHALL, †‡* MISS G. COUZENS, †‡* MISS G. M. REED,†‡*' MISS B. EDWARDS, †‡* MISS G. RICHARDSON, †‡* MISS A. W. EVANS, †‡* MISS M. J. SIMPSON. †‡* MISS A. GOVE, †‡* MISS M. J. WALDEGRAVE, ‡* MISS T. M. LEE, † MISS F. H. WALKER, †‡* MISS E. K. WILTON, †‡* Midv-ives : MISS M. CARPENTER (Supt. Midwife) tt§ MRS. M. L. ANGEL, †‡ MRS. F. R. MOONEY,‡ MISS A. W. H. CRAFT,‡ MRS. D. PONTER,†‡ MRS. M. M. FRANCIS, †‡ MISS P. E. RAEBURN, ‡ MRS. S. B. FRASER, †‡ MISS M. R. ROBERTSON, ‡ MRS. A. H. JANES, ‡ MISS R. M. ROUGH,†‡ MISS E. A. LAMB,†‡ MRS. G. THOMPSON,†‡ MRS. B. LUNDY,‡ MISS E. WATT,†‡ MRS. E. A. WHITCHURCH, ‡ Matron of Isolation Hospital : MISS V. R. THOMAS, †‡ District Fever Nurse : MISS V. G. ROBERTSON. †State Registered Nurse. ‡State Cert. Midwife. *Health Visitors' Cert. § Midwife Teachers' Cert. Clerical Staff : W. GOODFELLOW, Chief Clerk. Eleven whole-time Clerks. Part-time Staff. Consultant Qyncecologists : 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. ARNOLD L. WALKER, M.B., F.R.C.S., M.C.O.G. Consultant Orthopedic Surgeon : H. J. SEDDON, F.R.C.S. Consultant Physiotherapist : ELEANOR H. RUSSELL, M.D., B.S. Consultant Surgeon : R. TREVOR JONES, B.Sc., M.B., B.S., F.R.C.S. Maternity and Child Welfare Officers : NORAH BEAUMONT, M.B., B.S., D.P.H. ETHEL M. BRAND, L.M.S.S.A. LUCY PARKER, M.D., M.R.C.P. Birth Control Clinic Medical Officer : ROSALIE BURKE, M.R.C.S., L.R.C.P. 7 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, mid-year, 1938 183,500 Number of inhabited houses including flats (end of 1938) according to Rate Books 54,460 Rateable Value (April 1st, 1939) . £2,044,599 Sum represented by a penny rate (1938-9) £7,866 Social Conditions of Inhabitants. See Annual Report for the year 1934. The Manager of the Local Labour Exchange reports that the figures of unemployment for 1938 do not differ materially from those in previous years. For males the heaviest winter figure, which was during a period of very severe weather, was about 2,500. The previous steady flow of persons from distressed areas into this district is apparently diminishing in volume. Extracts from Vital Statistics for the Year. Live Births :— Total. Male. Female. Legitimate 3,187 1,641 1,546 Birth Rate per 1,000 of the estimated resident population, 17.9 Illegitimate 105 56 49 Stillbirths :— Legitimate 102 60 42 Rate per 1,000 total (live and still) births, 3.1. Illegitimate 4 3 1 Deaths 1,311 674 637 Death rate per 1,000 of the estimated resident population, 7.1. Deaths from puerperal causes:— Rate per 1,000 total (live and still) births. Deaths. Puerperal sepsis 3 0.88 Other puerperal causes 9 2.64 Total 12 3.52 Death rate of Infants under one year of age :— All infants per 1,000 live births 38.3 Legitimate infants per 1,000 legitimate live births 36.6 Illegitimate infants per 1,000 illegitimate live births 87.6 Deaths from Cancer (all ages) 212 „ ,, Measles (all ages) 2 „ Whooping Cough (all ages) 2 „ Diarrhoea (under 2 years of age) 25 8 Population. The mid-year estimate of population is 183,500. This increase of 8,700 over the figure of 174,800 for mid-year 1937 is partly due to the natural increase of population (i.e., the excess of births over deaths, this figure being 1,981 in 1938 and 1,750 in 1937) and partly due to the occupation of the new houses erected (2,890 in 1938 and 4,222 in 1937). Birth Rate. 3,292 births were registered during the year, the birth rate per 1,000 population being, therefore, 17-9. The corresponding figure for England and Wales was 14.9 and the local figures for the four preceding years 1937 to 1934 were 17.7, 17.8, 17.5 and 16.4. A high birth rate can be anticipated for some years as the recently erected properties will, on an average, contain a higher than normal proportion of young adults. Deaths and Death Rates. Total deaths in the district 724 Outward transfers 48 Inward transfers 635 Deaths of residents 1,311 Of the 48 deaths of non-residents occurring in the district, 9 took place at the Orthopaedic Hospital, 3 at the Harrow and Wealdstone Hospital, one at the Stanmore Cottage Hospital, 13 at local nursing or maternity homes and 16 in private houses. Of the 635 deaths of local residents which occurred outside the area most took place in institutions, 322 being at Redhill Hospital, 23 at other county hospitals and 8 at Barnet Hospital. 33 deaths occurred at institutions for the treatment of the tuberculous (18 at county tuberculosis institutions) and 23 at mental hospitals (21 at Shenley). 36 deaths occurred in hospitals just outside the district and 3 at municipal isolation hospitals. 69 deaths took place in various of the London general and maternity hospitals, including 6 deaths of infants of mothers confined in the hospitals. Thirty-six local residents died in the Harrow and Wealdstone Hospital. 1,311 deaths in a population of 183,500 is a death rate of 7.1 compared with local figures of 8.1, 7.7, 7.7 and 7.7 for the years 1934 to 1937, a figure of 11.6 for England and Wales and one of 11.7 for the Great Towns. The corrected death rate obtained by the application of the areal comparability factor of 1.17 is 8.31. The corresponding figures for the years 1934 to 1937 were 9.5, 9.01, 9.01 and 9.01. 9 The fatalities of the infectious diseases expressed as a rate per thousand population compare favourably with figures for the country as a whole. The rates for measles (0.01), scarlet fever (0), whooping cough (0.01), diphtheria (0.04) and influenza (0.05) were all lower than the corresponding national rates of 0.04, 0.01, 0.03, 0.07 and 0.11. Deaths from pulmonary tuberculosis were again fewer than those in the previous year, though there was a slight increase in those due to non-pulmonary tuberculosis. The death rate per 100,000 population of 46.8 was well below the figure of 69.5 recorded for the country as a whole in 1937. The infant mortality rate of 38 3, though an increase on the figure of 355 of the previous year, compares favourably with the figure of 53 for England and Wales and 57 for the Great Towns. The local figures for the years 1934 to 1936 were 47, 42 1 and 44.9. The maternal mortality rate was 3.52 compared with local figures for the years 1934 to 1937 of 5.99, 3.46, 4.02 and 4.07, and a figure of 2.97 for England and Wales. There were 212 deaths recorded from cancer, the recorded death rate per million living being 1,155 compared with a figure of 1,634 for England and Wales for the year 1937. There were 25 suicidal deaths (16 male and 9 female) during the year, giving a rate of 100,000 population per 13.6 compared with a figure of 12.6 for the country as a whole for 1937. The commonest method was the use of coal-gas (6 male and 4 female), other methods including drowning (5) and hanging (3). Of the 37 (20 male and 17 female) other deaths from violence 13 were due to road accidents, of which 8 were of pedestrians. Falls of elderly persons accounted for 8 deaths. The commonest causes of deaths are shown in the following table, in which the local rates for certain causes are compared with those of England and Wales for the year 1937, the figures representing the percentage of deaths from the particular cause of total deaths:— Local, 1938. England and Wales, 1937. 1- Diseases of the heart and circulatory system 278 310 2. Malignant disease 161 131 3. Bronchitis, pneumonia and other respiratory diseases 98 102 4 All forms of tuberculosis 64 56 10 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. HOSPITALS PROVIDED OR SUBSIDISED BY THE LOCAL AUTHORITY OR BY THE COUNTY COUNCIL. (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. (3) 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, particulars of which were given in the 1937 Report. HOSPITAL 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. For particulars of the in-patient accommodation of these institutions see the Annual Report for the year 1935; and of other hospitals used by local residents see the Annual Report for the year 1934. (2) Hospitals for Maternity Cases. Up to this year the Council has arranged for the admission of such maternity cases as were recommended at the ante-natal clinics for hospital treatment and could not be accommodated in the County Council hospitals to various of the London Maternity and General Hospitals. Since the time, however, that the decision of the Minister that the County Council were to be considered the authority in this area for the provision of maternity hospital accommodation was made known, the Council has limited its responsibility for maternity accommodation to accepting liability for the hospital charges only of those patients admitted to the City of London Maternity Hospital under the care of Dr. Christie Brown, most of such patients being referred from the consultant ante-natal clinics. Cases of puerperal infection are admitted either to the London County Council North Western Fever Hospital or to the Isolation Block of Queen Charlotte's Hospital. 11 (3) Hospitals for Children. Apart from the arrangements by which children suffering from ophthalmia or from orthopaedic defects are admitted to special hospitals for the treatment of these conditions, there is no provision for the admission of children to hospital. On application by hospital authorities, financial assistance is granted in respect of children referred from the infant welfare centres and admitted for in-patient treatment. (4) Orthopaedic Hospitals. The Council now accepts liability for the hospital charges of those children under five years of age admitted to the Stanmore Orthopaedic Hospital on the recommendation of the Consultant Orthopaedic Surgeon. 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. There are four ambulances for the removal of non-infectious and accident cases: two 20-h.p. Austin ambulances housed at the Headquarters Station, a similar ambulance at the Harrow-on-theHill Station and a 20-h.p. Talbot ambulance housed at the Wealdstone Station. The following is a summary of the extent to which the ambulances have been used during the year and figures for previous years:— 1938 1937 1936 Accident cases 690 517 480 Maternity cases 295 336 211 Other cases 1,357 1,229 971 With the additional ambulance put into commission early in 1939 the needs of the district are, in the opinion of the Chief Officer of the Fire Brigade, sufficiently met. Reciprocal arrangements are in operation with neighbouring authorities. During the year the rule by which a maternity case being conveyed to hospital for her confinement should be accompanied by a woman was amended so that now such patient must be accompanied by a midwife or recognised maternity nurse. The nurses who accompany patients are mostly those midwives or maternity nurses in independent practice; but if none other is available one of the Council's midwives accompanies the patient. 12 CLINICS AND TREATMENT CENTRES. The following is a summary of the various clinics and treatment centres in the district :—- Infant Welfare Centres. The Broadway Clinic, Wealdstone—Tuesdays, Wednesdays and Thursdays at 1.30 p.m. Elmwood Avenue Clinic, Kenton—Wednesdays, Thursdays and Fridays at 1.30 p.m. Spiritualist Church Hall, Vaughan Road, West Harrow—Wednesdays at 1.30 p.m. Baptist Church Hall, Northolt Road, South Harrow—Tuesdays and Thursdays at 1.30 p.m. St. George's Hall, Headstone—Tuesdays, Wednesdays and Fridays at 1.30 p.m. The Institute, Whitchurch Lane, Stanmore—Mondays, Thursdays and Fridays at 1.30 p.m. Memorial Hall, Harrow Weald—Thursdays at 2 p.m. Baptist Church Hall, Imperial Drive—Mondays, Tuesdays and Thursdays at 1.30 p.m. Methodist Church Hall, Love Lane, Pinner—Fridays at 1.30 p.m. Baptist Church Hall, Streatfield Road, Kenton—Wednesdays, Thursdays and Fridays at 1.30 p.m. Methodist Church Hall, Walton Avenue, South Harrow—Mondays and Fridays at 1.30 p.m. St. Anselm's Hall, Hillview Road, Hatch End—Specific Thursdays at 1.30 p.m. Toddlers' Clinics. The Broadway Clinic, Wealdstone—Alternate Fridays at 1.30 p.m. Elmwood Avenue Clinic, Kenton—Specific Fridays at 9.30 a.m. Baptist Church Hall, Imperial Drive, Ravners Lane—Fridays at 9.30 a.m. Baptist Church Hall, Streatfield Road, Kenton—Specific Fridays at 9.30 a.m. Methodist Church Hall, Walton Avenue, South Harrow—Alternate Wednesdays at 9.30 a.m. Methodist Church Hall, Love Lane, Pinner—Alternate Fridays at 9.30 a.m. Ante-Natal Clinics. The Broadway Clinic, Wealdstone—Mondays at 1.30 p.m. and Wednesdays at 9.30 a.m. 13 Elmwood Avenue Clinic, Kenton—Wednesdays and Thursdays at 9.30 a.m. The Institute, Whitchurch Lane, Stanmore—Mondays at 9.30 a.m. Baptist Church Hall, Imperial Drive, Rayners Lane—Tuesdays at 9.30 a.m. Baptist Church Hall, Northolt Road, South Harrow—Tuesdays at 9.30 a.m. 76, Marlborough Hill, Wealdstone—Mondays at 1.30 p.m. Baptist Church Hall, Streatfield Road, Kenton—Thursdays at 9.30 a.m. Spiritualist Church Hall, Vaughan Road, Harrow—Wednesdays at 9.30 a.m. Methodist Church Hall, Walton Avenue, South Harrow—Mondays at 9.30 a.m. Methodist Church Hall, Love Lane, Pinner—Alternate Fridays at 9.30 a.m. Birth Control Clinic. The Broadway Clinic, Wealdstone—Mornings of the first and third Tuesdays of the month. Consultant Ante-Natal Clinic. The Broadway Clinic, Wealdstone—Mornings of the second and fourth Tuesdays of the month. All these clinics are maintained by the Local Authority. Treatment Centres. Massage and light clinics are held at 76, Marlborough Hill, Wealdstone, on the mornings of Tuesdays, Thursdays and Saturdays (children). In addition the Harrow and Wealdstone Hospital maintain sessions at this address on the mornings and evenings of Mondays, Wednesdays and Fridays (adults), and on Tuesday and Thursday afternoons, tor massage and sunlight (mainly adults). School Treatment Services. Minor Ailments Clinic:— Roxeth Hill School, Harrow—Wednesdays at 9.30 a.m. Broadway Clinic, Wealdstone—Mondays and Thursdays at 9.30 a.m. Whitchurch Institute—Fridays at 9.30 a.m. Elmwood Avenue, Kenton—Mondays at 9.30 a.m. Ophthalmic Clinic 76, Marlborough Hill, Wealdstone—Tuesdays and Fridays at 9.30 a.m. 14 Dental Clinics:— 76, Marlborough Hill, Wealdstone—Thursdays at 1.30 p.m. Elmwood Avenue Clinic, Kenton—daily. Baptist Church Hall, Northolt Road, South Harrow— Mondays and Fridays at 9.30 a.m. and 2.30 p.m. ; Thursdays and Saturdays at 9.30 a.m. Whitchurch Institute, Stanmore—Tuesdays and Wednesdays at 9.30 a.m. and 2.30 p.m. Roxeth Council School—daily except Wednesday mornings. Clinics held outside the District but serving Schools within the District. Minor Ailments Clinic — Northwood Council School, Rickmansworth Road, Northwood—Tuesdays at 9.30 a.m. Ophthalmic Clinics :— Lady Bankes Council School, Dawlish Drive, Ruislip— Monday and Wednesday mornings. Kingsbury Green School, Kenton Lane, N.W.9—Wednesdays at 9.30 a.m. Wembley Hill School, High Road, Wembley—Fridays at 9.30 a.m. Dental Clinic:— Northwood Council School, Rickmansworth Road, Northwood—daily at 9.30 a.m. and 2.30 p.m. By arrangement with the Middlesex County Council, children under school age can receive minor ailment treatment at the school clinics held at Roxeth Hill School and at the Whitchurch Institute. Patients requiring treatment under the Council's maternity and child welfare scheme are referred to the County Council's ophthalmic or dental clinics held at 76, Marlborough Hill, Wealdstone. Tuberculosis Clinic. Sessions are held at the Tuberculosis Dispensary at 53, Greenhill Crescent, on Monday mornings, Thursday afternoons and at 6 p.m. on the second and fourth Wednesdays of the month. At the Chest Clinic, Redhill County Hospital, sessions are held on Wednesday and Friday mornings and at 6 p.m. on the first and third Wednesdays of the month. 15 Venereal Diseases. Provision for the treatment of venereal disease is made under the London and Home Counties Scheme. All treatment, whether in-patient or out-patient, is provided free of charge. Travelling expenses are paid by the County Council to out-patients in necessitous circumstances who otherwise might be unable to make the numerous attendances over long periods which are usually necessary if a cure is to be obtained. PROFESSIONAL NURSING IN THE HOME. (a) General. The Greater Harrow Nursing Association covers the entire district except for a portion served by the Pinner Nursing Association and a small portion on the eastern border of the area. Altogether 2,476 patients were nursed, 32,003 visits being paid. (b) Nursing of Cases of Infectious Disease. Apart from the 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 45 swabs were examined for the diphtheria bacillus, or for the haemolytic streptococcus, 124 samples of sputum for the tubercle bacillus, 23 samples of faeces and 4 of blood and 3 samples for other purposes. At the same laboratory 41 samples of milk were examined. Most diphtheria swabs are now examined at the Isolation Hospital. LEGISLATION IN FORCE. See page 21 of the Annual Report, 1935, and page 19 of the Report for 1936. Most of the provisions of the Middlesex County Council (General Powers) Act, 1938, amongst which are many of sanitary significance, came into force during the year. CAMPAIGN ADVERTISING THE HEALTH SERVICES. The arrangements reported in last year's report in regard to action taken up to the end of 1937 were continued in the earlier months of 1938. 16 SANITARY CIRCUMSTANCES OF THE AREA. WATER. Particulars of the sources of the water supplied by the Colne Valley Water Company which serves practically the whole area were contained in the Annual Report for 1937. The Rickmansworth and Uxbridge Valley Water Company obtain their water from ten wells of depths of 200 feet to 360 feet, the water supplying this district coming from one of the pumping stations at Ickenham, West Drayton and Mill End. Towards the end of 1937 a chlorination plant was installed and since early in 1938 all the water supplied by this undertaking for public use is first subjected to sterilisation by the chloramine process, in doses of chlorine 0.15 and ammonia 0.3 parts per million. Section 111 of the Public Health Act, 1936, lays it as a duty on every Local Authority " to take, from time to time, such steps as may be necessary for ascertaining the sufficiency and wholesomeness of the water supplies within their district." On consideration of a circular letter issued by the Ministry of Health relating to the purity of public water supplies controlled by Local Authorities and Statutory Water Companies, it was resolved "that the Medical Officer of Health be instructed to obtain from the Colne Valley Water Company and the Rickmansworth and Uxbridge Valley Water Company, respectively, weekly analyses of the water supplied by them, and periodically, himself, to take samples of the water supplied for the purpose of comparison with the analyses submitted by the Companies." The former Company have supplied, each week, the result of an analysis undertaken at their laboratories of samples collected at different premises within the district. It is, however, the practice of the latter Company to carry out an analysis only once monthly, but even of this no copies have been received. Samples of the supply of both companies have been submitted quarterly for examination, all of which have proved satisfactory. The following is a copy of the results of analyses of one sample from each Company :— Results in parts per 100,000. Sample A. Sample B. Appearance Clear and bright Clear and bright Colour Normal Normal Odour Nil Nil Reaction pH 7.0 7.5 Free Carbonic Acid 3.3 1.0 Electric conductivity 515 485 17  Results in parts per 100,000 Sample A. Sample B Total Solids dried at 180oC. 34.5 32.5 Chlorine in Chlorides 1.9 5.2 Alkalinity as Calcium Carbonate 24.0 13.5 Nitrogen in Nitrates 0.28 0.40 Nitrogen in Nitrates Absent Absent Hardness—Total 28.0 13.0 Permanent 6.0 1.5 Temporary 22.0 11.5 Metals Absent Absent Free Ammonia 0.0000 0.0000 Albuminoid Ammonia 0.0000 0.0000 Oxygen absorbed in 4 hrs. at 80°F 0.005 0.010 Bacteriological Results. No. of organisms per c.c. on agar in 24 hours at 37°C 1 2 B.Coli (absent in) 100 c.c. 100 c.c. B.Welchii (absent in) 100 c.c. 100 c.c. A summary of the analysis of Sample A is:—" This is a clear and bright water of normal colour. It is neutral in reaction, hard in character, although not to an excessive degree; contains no excess of salinity and no metals. The water is of a high degree of organic and bacterial purity, and is considered pure and wholesome in character and suitable for drinking and domestic purposes." A summary of the analysis of Sample B is:—"This sample is clear and bright, of normal colour, neutral in reaction and free from metals. The water is neutral in reaction, of moderate hardness, contains no excess of salinity and is of a high standard of organic and bacterial purity. It is therefore considered pure and wholesome in character and suitable for drinking and domestic purposes." On occasion the premises served by the Rickmansworth and Uxbridge Valley Water Company are without a supply. This happened once during the year. DRAINAGE AND SEWERAGE. The following particulars relating to the drainage and sewerage of the district have been kindly supplied by the Surveyor. Main Sewerage. The County Council's Main Drainage Scheme has now operated for two full years and is proving itself eminently satisfactory. The existence of this scheme with its nine infalls in this district B 18 provides under all conditions a free outfall to the various sectional sewerage zones into which the local system is divided. This fact has allowed a thorough investigation to be made of the older sections of the system and adjustments designed that will reduce the load in various sections to that for which they were originally intended before the development of the Greater Harrow took place. The construction of a 30-inch outfall main measuring 1,250 yards from the Edgware Road to Honeypot Lane where it connects to the County Council's trunk sewer has now been completed and is in operation. This sewer now takes all the load of the zones north of Whitchurch Lane and affords a positive relief to all sewers south of that lane, which were previously severely overloaded. During the course of the construction of this sewer it was decided to extend its service by the provision of a deep level sewer in the Edgware Road which, in addition to affording relief to the existing sewer, would serve the new development of the Cannon's Park Golf Course. This sewer is now completed and in operation. It is 15 inches in diameter and measures 1,260 yards and is laid at an average depth of 30 feet approximately. The electrically operated pumping station at South Vale Avenue, Sudbury, which replaced the ejectors operated by the Bessborough Road Air Compressor Station, is now well into its second year of service and its operating costs are showing a very considerable economy over the previous system. Considering the height to which the sewage is pumped (80 feet) the estimated cost of 23s. Od. per house per annum, which has not been exceeded, is very low. Work is well advanced on the preparation of a new main sewerage scheme for the Pinner-Hatch End area. This scheme will be on similar lines to the Moat Farm scheme except that it will deal entirely with sewage. A preliminary estimate of the cost of this scheme amounts to £36,000. Main Surface Water Drainage. The County Council are responsible for the maintenance of main watercourses in the district and as these become culverted the culverts vest in the Council as surface water sewers. The Thames Conservancy Board have now assumed responsibility for the maintenance of the River Pinn and its watershed from where it enters the district to the Royal Commercial Travellers' Schools at Hatch End and to its northern tributary as far as Nugent s Park off the Uxbridge Road. Both the authorities concerned are engaged upon improvement works which will eventually reach this district when the lower reaches of the watercourses have been dealt with. These works will especially affect the well-being of the River Pinn and the Yeading Brook. 19 During the summer months of 1938 considerable trouble was experienced with the pollution of the watercourses in the district and a special organisation was formed by the Department to deal with this problem. The work entailed an investigation and examination in detail of the whole main drainage and sewerage system of the district. The investigation was commenced in June of last year and the first inspection has now been completed, with the result that 750 sanitary defects were disclosed and in all instances these have now been put in order. Section No. 4 of the Moat Farm scheme is well in hand and should be completed by the autumn of this year. This section, in conjunction with Section No. 1, is the most important of the scheme. The section in hand will extend the culvert from the Moat Farm to Weald Lane where it will intercept the flow from the Harrow Weald area sewers and prevent the overloading of the old Wealdstone surface water system. It should, when complete, obviate the flooding that has been experienced in the Wealdstone area from time to time. Rainfall. During the year 1938-39 rain fell on 151 days against 138 days during 1937-38. April-March. Year 1937-38. Year 1938-39. Total Rainfall 22.77 ins. 22.98 ins. Average per month 1.90 ins. 1.915 ins. Wettest month (May & Dec.) 3.18 ins. (June) 4.58 ins. Driest month (Feb.) 0.36 ins. (April) 0.23 ins. General. In accordance with the requirements of the Public Health (Consolidation) Act of 1936 a complete survey of the sewers has been made and plans completed showing the whole of the main drainage of the district. WATERCOURSES. During the summer months complaints were received regarding sewage pollution of the watercourses. Investigation showed that there were three main causes of pollution:—Blocking of the interceptor traps leading to foul water entering the surface water sewers; wrong connections, the soil drains being connected to the surface water sewers; and connection of bath and sink wastes to the surface water drains. The first cause, namely, the blocking of the interceptor traps, was a frequent occurrence in the Wealdstone area where the surface water drains run through the soil manholes, intercepting traps being inserted on both surface water and soil drains. On 20 the sewers becoming surcharged the caps of the interceptors have blown off, causing choking of the soil interceptor leading later to an overflow of the foul drainage into the surface water connections. The reversal of this position was found in many instances where, because the rain water drains were blocked, surface water entered the soil sewers. Pollution from this cause is likely to recur until every surface water drain is sealed against the influx of foul water. This work of fixing in the stoppers is now in hand. Apart from this, however, the risk of pollution of the water courses in this manner could be reduced by systematic inspection of the sewers. The second cause of pollution of the watercourses mentioned, namely, wrong connections, has arisen because it has become the practice of developers, before constructing the roads which will later be taken over by the Council, to lay the sewers and bring up separate connections from the soil and surface water sewers to different points at the side of the road to which the house drains are connected. In spite of the precautions taken to reduce the possibility of wrong connections being made, these have occurred on occasion and are followed by heavy pollution of the watercourses when a number of premises drain into a single channel which is connected to the wrong sewer. Trouble arising from the third cause, namely, bath and sink wastes being connected to the surface drains, occurred in properties where these fittings have been added later than the original building of the house, frequently on the occasion of a house being converted into flats. Much of this work has been done without prior intimation having been given to the Local Authority. All builders in the district have had their attention drawn to the provisions of Section 34 (3) of the Public Health Act, 1936, which reads:— "A person desirous of availing himself of the foregoing provisions of this Section (right of owners and occupiers within the district to drain into public sewers) shall give to the Local Authority notice of his proposals." PUBLIC CLEANSING. Refuse Collection. No changes were made during the year in the service provided to the householders. The charges for the collection and disposal of shop refuse were modified somewhat and are now:— (i) One bin of refuse per week to be regarded as house refuse and collected and disposed of free of charge. (ii) If required, additional collections to be made weekly at a charge of £3 3s. 0d. per annum for each such additional weekly collection, provided not more than two bins shall be collected at each collection for such charge. 21 (iii) Fish offal not to be included in collections under paragraph (i) or (ii) above but to be collected separately at a charge of £3 3s. Od. per annum for each weekly collection, provided not more than two bins shall be collected at each collection for such charge. (iv) A quarterly charge (payable in advance) of 6s. Od. per bin for the first and 4s. Od. per bin for each subsequent bin, to be made for bins in excess of one bin collected at the normal weekly collection under paragraph (i) above. (v) A charge of 6d. per bin to be made for each bin in excess of two bins collected at any additional collection under paragraph (ii) above or at any collection of fish offal under paragraph (iii) above. (vi) Refuse to be delivered direct to the destructors, with the consent of the Surveyor, for disposal by the Council at a charge at the rate of 6s. 8d. per ton of refuse so delivered. Refuse Disposal. The Annual Report for 1937 contained an account of the particulars of the treatment of house refuse by the hyganic process and it was reported that at their meeting on January 1st, 1938, the Council approved of this method of treating house refuse. During the year the consent of the Minister of Health was obtained to the lease by the Council of approximately 3.5 acres of the former Greenbill Sewage Farm lor this purpose. The weekly average amounts of refuse disposed of in December were:—At the Harrow destructor, 232 tons; at the Wealdstone destructor, 142 tons; at the Pinner controlled tip, 251 tons; and at the Stanmore controlled tip, 265 tons. The net cost of collection for the nine months ending December 31st was 10s. 7½d. per ton and for disposal 2s. 11d. per ton. Towards the end of August the Stanmore controlled tip was subjected to localised infestation with crickets. Street Cleansing. No changes were made during the year in the arrangements for the cleansing of the streets in the district. PUBLIC CONVENIENCES. See Annual Reports for 1935 and 1937. MORTUARY. Particulars of the mortuary were contained in the Annual Report for 1934. 154 bodies were received during the year. Post-mortem examinations were carried out to 113, and 46 inquests were held. 32 bodies were admitted for storage and 9 bodies of persons dying from accident or suicide on whom no post-mortem examination was carried out in the mortuary. 22 SWIMMING BATHS. Particulars of the two swimming baths were given in the Annual Report for 1934. In last year's Report reference was made to the failure of the plant at the Charles Crescent bath effectively to purify the water, and to the proposed improvements which had been agreed upon. This work was carried out during the winter months. Satisfactory reports were received on the samples submitted for analysis from both baths, the conclusion of the analyst on each report being to the effect that the water was of satisfactory organic and bacterial purity and considered suitable and safe for swimming bath purposes. ESTABLISHMENTS FOR MASSAGE OR SPECIAL TREATMENT. The Council adopted Part VII of the Middlesex County Council Act, 1934, regarding establishments for massage and special treatment which are defined as premises for the reception or treatment of persons requiring (a) massage, manicure or chiropody, (b) electric treatment or radiant heat, light, electric, vapour or other baths for therapeutic treatment, or (c) other similar treatment. By the provisions of the Act, and subject to certain provisos regarding practice by medical practitioners or members of the Chartered Society of Massage and Medical Gymnastics and certain premises, such as hospitals, no person shall carry on an establishment for massage or special treatment without a licence from the Local Authority authorising him so to do. Under Section 68 of the Act bye-laws were made regarding the conduct of the business. Twenty-one premises were licensed during the year. In addition there are four premises used by members of the C.S.M.M.G., making a total at the end of the year of 28 premises. Licensed premises are visited twice a year. SANITARY INSPECTION OF DISTRICT. (a) Number of Houses inspected under the Housing Act, 1936 353 Houses found unfit 73 Houses not in all respects fit 234 Revisits 3,343 Surveys under Housing Act, 1936 508 Houses inspected under Public Health Acts 2,625 Houses found defective 797 Revisits 3,824 Other premises visited for nuisances 985 Revisits 783 23 Complaints investigated 1,647 Complaints re rats investigated 104 Visits re infectious disease 21 Inspections of:— Foster parents' premises 90 Factories 687 Workplaces, including offices 176 Outworkers' premises 105 Cinemas and places of entertainments 88 Houses-let-in-lodgings 17 Visits to :— Slaughterhouses 732 Greengrocers 303 Butchers 688 Provision Merchants 342 Cowsheds 81 Dairies 199 Ice Cream Premises 2 Fish Shops 198 Fried Fish Shops 108 Bakehouses 125 Other Food Premises 266 Hairdressers 133 Premises where rag flock used 10 Inspections of premises under periodical inspection 810 Observations for smoke nuisances 31 Visits under Shops Acts 2,997 Evening observations under Shops Acts 157 (6) Notices served:— No. complied with. Statutory:— Public Health Act 30 27 Housing Act . 26 23 Informal 1,984. 1,922 SMOKE ABATEMENT. This district is very free from atmospheric pollution, the chief offender being the gas works, about which complaints are at times received regarding nuisances from dust and soot. During the year 31 observations were carried out. During the 642 minutes' observation dense smoke was seen for only half-a-minute, and moderate smoke for 203 minutes. SHOPS ACTS, 1912-1936. At the end of the year the total number of shops on the register was 2,108. 2,997 visits were paid to shops under the above Acts and 157 evening observations made. 24 161 contraventions were recorded, these being classified as:— Serving customers after closing hours, 73; intervals for meals not given to assistants, 6; assistants not having a half-holiday, 20; young persons employed in excess of 48 hours per week, 59; young persons not allowed interval of 11 consecutive hours, 3. 657 letters were sent to traders regarding the absence of appropriate notices, in 14 instances the traders receiving a final warning. In five cases it was necessary to take legal proceedings, fines amounting in total to £9 being inflicted. The following contraventions of the provisions of Section 10 of the Shops Act, 1934, were noted:—Absence of suitable and sufficient sanitary and washing accommodation, 20; insufficient sanitary accommodation, 33; absence of or insufficient means of heating, 112; and absence of suitable and sufficient facilities for taking meals, 15. Defects of sanitation noted included Dirty or defective water-closet accommodation, 54; absence of properly constructed intervening ventilated lobbies between water-closets and shop, 12; walls of shops dirty, 5 ; and water-closets choked, 2. Five certificates of exemption from the provisions requiring sanitary accommodation were granted and two refused. During the year 172 contraventions of the provisions of the Shops (Sunday Trading Restriction) Act, 1936, were noted, these being classified as:—Serving customers with non-exempted goods, 12; assistants not receiving compensatory holiday, 8; records of compensatory holidays not kept, 66; notices not exhibited, 80; assistants employed on more Sundays in month than allowed, 6. In each case a warning was given. During the latter part of the year the fixing of a definite day as the weekly half-holiday for shops was considered and preliminary steps were taken with the object of obtaining a decision. Application was also made by the Motor Agents' Association for an Exemption Order from the provisions as to weekly halfholiday for the sale of motors. This matter is still under consideration. RATS AND MICE (DESTRUCTION) ACT, 1919. 104 complaints were received during the year regarding the presence of rats. On receipt of a complaint, an inspection is made by a sanitary inspector ; where any sanitary defects or nuisances remediable under the Public Health Acts likely to be predisposing causes of the presence of rats are found the necessary action is taken, and the complaint is forwarded to the County's Inspector. PLACES OF PUBLIC ENTERTAINMENT. 88 visits were paid to places of public entertainment for inspection of their sanitary condition. In all instances the sanitary arrangements were found to be satisfactory. 25 FACTORY ACT, 1937. In this district there are 290 factories with mechanical power, 179 without mechanical power, and 183 workplaces, to which the following numbers of visits were paid during the year:—Mechanical factories, 471; non-mechanical factories, 216 ; and workplaces, 176. Of the 69 public health nuisances detected, 17 were due to want of cleanliness and 3 to absence of ventilation. There were 26 instances of unsatisfactory sanitary accommodation, these being unsuitable or defective in 20 cases, insufficient in 3, while in 3 instances there was no separate provision for each sex. 23 other nuisances were detected. 48 notices from other Councils and one from an employer were received containing the addresses of 108 outworkers. Of the local outworkers, 95 were engaged in the making of wearing apparel, 13 in leatherwork, one in brushmaking, one in the making of artificial flowers and one in box-making. 105 visits of inspection were made to outworkers' premises, in none of which were unwholesome conditions found to exist. ERADICATION OF BED BUGS. During the year 17 Council houses and 62 other dwellings were found to be infested with vermin; while of the 37 houses included in Clearance Areas, in regard of which orders have been confirmed or Demolition Orders have become operative, 27 were verminous. The Council houses were treated by being sprayed with Keritox or other insecticides, or fumigated with a heavy naphtha. 17 houses, slightly affected, were treated by fumigation or spraying. Houses seriously infested were treated by outside contractors, the cost of this work being borne by the owner or occupiers. Before removal of tenants from infested houses to Council houses, the houses and the household effects are fumigated and the bedding steam-disinfested. Success in the method of bug eradication has not been maintained and consideration is being given to the question of treating the household effects by cyanide in a van constructed for this purpose en route to the new house. Periodical visits are paid to the tenants whose furniture has been treated and if recurrence is found fumigation or spraying is again done, which has had successful results, particularly where the tenants have adopted the recommendations as to scrupulous cleanliness. CAMPING SITES. Only one site was used as a camping ground, being one which a party of about 60 of the Church Lads' Brigade have used for a number of years for two weeks. 26 HOUSING. HOUSING STATISTICS FOR THE YEAR, 1938. Number of New Houses erected during the Year:— Total 2,890 (1) By the Local Authority 114 (2) By other Local Authorities - (3) By other bodies and persons 2,776 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) 3,016 (b) Number of inspections made for the purpose 10,183 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 353 (b) Number of inspections made for the purpose 3,696 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 73 (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 1,031 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 918 3. Action under Statutory Powers during the Year:— A. Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 26 (2) Number of dwelling-houses which were dered fit after service of formal notices :— (a) By owners 32 (b) By Local Authority in default of owners 2 27 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 30 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 27 (b) By Local Authority in default of owners — C. Proceedings under Sections 11 and 13 of the Housing Act, 1936 — (1) Number of dwelling-houses in respect of which Demolition Orders were made 14 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 26 D. Proceedings under Section 12 of the Housing Act, 1936 (1) Number of separate tenements or ground rooms in respect of which Closing Orders were made 2 (2) Number of separate tenements or ground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — 4. Housing Act, 1936. Part IV. Overcrowding :— (a) (i) Number of dwellings overcrowded at the end of the year 31 (ii) Number of families dwelling therein 31 (iii) Number of persons dwelling therein 280 (b) (i) Number of new cases of overcrowding reported during the year 51 (c) (i) Number of cases of overcrowding relieved during the year 82 (ii) Number of persons concerned in such cases 577 (d) Particulars of any cases in which dwelling- houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding — 28 ACTION UNDER THE HOUSING ACT, 1936. Section 1. In January Clearance Orders were confirmed in respect of three groups of properties which were represented in 1937, namely, High Street, Stanmore, No. 1 Order (3 houses); High Street, Stanmore, No. 2 Order (4 houses); and Ferndale Terrace Order (12 houses). Those properties dealt with during the year, with the position regarding them at the end of the year, are shown in the following table :— Title of Order. No. of Houses. Position at end of Year. High Street, Stanmore, No. 3 2 Application opposed— Public Inquiry. High Street, Stanmore, No. 4 4 Do. Brewery Cottages 5 Do. Headstone Drive 20 Do. College Hill Road 3 Application not opposed. Pleasant Place 4 Do. Marlborough Road Area No. 1 83 Clearance Order declared. Marlborough Road Area No. 2 10 Do. Marlborough Road Area No. 3 13 Do. Marlborough Road Area No. 4 6 Do. Northolt Road 4 Premises demolished. Up to the end of the year 15 Clearance Orders in respect of 118 premises had been confirmed. Of these the 59 premises included in five Orders have been demolished, 27 families being re-housed in Council houses and 22 finding accommodation elsewhere. The premises included in two Orders have not been demolished within the time limit specified owing to the difficulty in finding accommodation for the tenants in a neighbourhood suitable to their requirements. One of these Orders concerned two properties, of which one is still inhabited; and the other, eight, of which three are still occupied. Of the families previously occupying the other houses included in these two Orders, four were re-housed in Council houses and four found alternative accommodation. Sections 11 and 12. Notices to appear were served on the owners of 25 properties, 23 under Section 11 and 2 under Section 12. Of those dealt with under Section 11 Demolition Orders were made in respect of 14 and undertakings to re-condition accepted in respect of 9. Of those dealt with under Section 12 approval was given to the premises being used as stores. 29 The following statement extracted from the returns on Form H. 256 shows the position at the beginning and at the end of the year:— Position at December 31st. 1937. 1938. Number of houses demolished under Section 11 65 91 *Parts of buildings closed under Section 12 7 8 Number of persons displaced from these houses 196 345 Number of dwelling-houses made fit under Sections 9-12 80 109 Insanitary houses demolished in anticipation of formal procedure under Section 11 19 25 Insanitary houses closed (but not demolished) on an undertaking (which has not been cancelled) by the owner under Section 11 26 15 Houses made fit as a result of informal notice preliminary to formal notice under Section 9 884 989 Overcrowding. In the Report of 1937 it was shown how the number of houses which were overcrowded at the time of the Survey had been reduced from 152 to 32. By December, 1938, this figure had been reduced to seven by granting Council houses in the case of five families, by granting larger Council houses in the case of nine families, whilst the remaining 12 cases were abated by the movement of occupants. By December 31st, 1937, the number of review cases had been reduced from 35 to 11. During 1938 this figure had been reduced to one, as the overcrowding of the premises occupied by the ten other families had been abated by the movement of occupants. By December 31st, 1937, 53 cases of overcrowding, which occurred during that year, were reduced to 18. Of these 18 cases, nine were rehoused in Council houses and seven others became decrowded by the movement of occupants. During 1938 a further 51 families have been found to be overcrowded. By the end of the year this figure had been reduced to 21. This reduction was achieved by granting Council houses in 21 cases, transferring to larger Council house in one case and the remaining eight cases became decrowded by movement of the occupants. 30 The following table sets out the progress of overcrowding abatement since the official survey :— No. of premises overcrowded on Jan. 1st. Council houses granted. Transferred to larger Council house. Overcrowding otherwise abated. No. of premises overcrowded on Dec.31st Overcrowded houses :— 1936 152 11 - 47 94 1937 94 9 4 49 32 1938 32 5 9 12 7 Review cases :— 1936 35 4 — 4 27 1937 27 5 — 11 11 1938 11 — — 10 1 Additional 1937:— 1937 53 14 — 21 18 1938 18 9 — 7 2 Additional 1938:— 1938 51 21 1 8 21 Total overcrowding at end of 1938 31 It will be seen from the above table that the 31 cases of overcrowding at the end of the year are made up of seven from the original survey, of one review case and of 23 cases of overcrowding found during 1937 and 1938. Of these 31 premises, two houses are included in Clearance Areas, three are owner-occupied, the occupants of six will be granted Council houses, and of one a larger Council house, and one family will be transferred into a house of another Authority. One of the cases previously overcrowded in a Council house moved to another address where he is also overcrowded. In one other case the family were requested to make formal application for a Council house and failed to do so. In other cases where overcrowding has been discovered to have occurred since the appointed day, either by reason of the taking in of lodgers or a house being let so as to be overcrowded, notices have been served on the persons causing the overcrowding. Council Housing. By September the 46 new houses erected on the Glebe Estate were occupied, 30 by families displaced by slum clearance procedure, nine by families which were overcrowded in their previous homes and seven by ordinary applicants. Of the 68 houses on the Berridge Estate, 40 were used to accommodate ordinary applicants, nine families from slum clearance areas and 19 families formerly in overcrowded premises. 31 In March the Council authorised the Housing Committee to proceed with the erection of 16 one-bedroomed flats for the aged on 0.76 acres of land forming part of the disused Little Stanmore Sewage Farm. In June authority was given for the Committee to proceed with the development of the first half of the proposals for the erection of 488 houses on land comprised in the Harrow Urban (Rayners Lane) Housing Confirmation Order, 1935, entailing the erection of 276 houses comprising 17 four-bedroomed; 31 large three-bedroomed; 113 small three-bedroomed; 14 angle three-bedroomed and 53 two-bedroomed houses, and 48 onebedroomed maisonnettes. At the same meeting authority was given to the Committee to proceed with the scheme for the erection of eight bungalows for aged persons on land adjacent to George V Avenue. 32 INSPECTION AND SUPERVISION OF FOOD. (A) MILK SUPPLY. Producers. There are now 11 cowkeepers occupying 13 separate registered cowsheds in the district, the same number as in the previous year. Of these five hold licences for the production of accredited milk. Eight only of these producers sell milk in the district by retail. Retailers. Including the three company distributors, there are 90 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 32 Number of premises from which the single retailers distribute milk 8 Number of retailers not occupying premises in the district 13 Number of shops from which milk is sold in unopened receptacles only 63 Licences. The following licences were in force in respect of premises in the district :— Retailing of T.T. milk at premises other than at place of production 18 (Of these, 8 belong to one firm, 2 to one, and 2 to another.) Bottling of T.T. milk at premises other than at place of production 1 Supplementary licences issued to producers outside the district to retail T.T. milk in the district 3 Pasteurizing establishments 5 Selling of pasteurized milk at premises other than establishments where pasteurization is carried on (Of these, 18 premises belong to one firm, 12 to one, 3 to one and 2 to another.) Supplementary licences issued to producers outside the district to retail pasteurized milk in the district Milk Sampling. 17 samples of pasteurized milk were examined, of which two gave unsatisfactory counts; 15 were submitted to and passed the phosphatase test, two being unsatisfactory. Of seven samples of tuberculin-tested milk submitted to bacteriological analysis, one proved unsatisfactory. All the six samples of ordinary milk proved satisfactory, as did the one sample submitted to the phosphatase test. 33 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:— "During the year 1938, 36 samples of milk were taken from retailers in the district, and were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. "One of these samples, produced in Buckinghamshire, was found to contain living tubercle bacilli, and investigation was not completed by the close of the year regarding the cows concerned. "In two other instances, the guinea-pig inoculated with the sample of milk succumbed to an acute infection by some organisms other than tubercle contained in the milk. It was, therefore, impossible to say whether these samples did or did not contain tubercle bacilli." (B) MEAT AND OTHER FOOD. Meat Inspection. There are eight licensed but no registered slaughter-houses in the district. These premises are kept under observation, 732 visits being paid during the year and 3,681 carcases examined. Of the 205 beasts slaughtered, 71 were unsound in some respect, the liver being affected in 35 instances of which 34 were by parasitic disease and the other by abscess. One forequarter of beef was destroyed on account of fevered condition, 64 lbs. for necrosis, and 79 lbs. on account of decomposition. Tuberculous lesions were found in the lungs of 26, the mesenteric fat of 11, the liver of 9, the head of 10, the tongue of 2, and in other sites in 4 (commonly more than one site being affected in the same animal). Of the 146 cattle (excluding cows) slaughtered, 25, or 17 per cent., were unsound in some respect other than tuberculosis. The percentage affected with tuberculosis was 9.5. The forequarters of two carcases were condemned on this account. Of the 59 cows slaughtered, 11, or 18.5 per cent., were unsound by reason of some condition other than tuberculosis, one entire carcase being condemned on account of Johnes disease. Tuberculosis was found in 21, or 35.5 per cent. One entire carcase was condemned on account of this disease. Some part of 209 of the 1,561 pigs slaughtered was diseased, more than one organ of the same animal frequently being affected. The entire carcase in one case was condemned on account of pneumonia and the forequarters of another because of abscesses. Pneumonia was present in 8 cases, pleurisy in 25 and other lesions of the lung in 1, pericarditis in 13, peritonitis in 5, lesions of the liver 29 (parasitic disease 10, cirrhosis 18), and other lesions in 22. Tuberculosis was found in the entire carcase of 10, in the mesenteric fat of 73, in the head of 70, in the lungs of 19, and in the liver of 20. c 34 Of the 1,601 sheep slaughtered only 32 were found unsound in any respect. The commonest abnormal states were parasitic diseases affecting the liver of 29 and the lungs of 8. Only 2 of the 314 calves were unsound, the entire carcase of one being condemned on account of immaturity, the lungs of another being affected with abscesses. The following table gives particulars of the numbers of animals slaughtered and the incidence of disease:— Cattle excluding Cows. Cows. Calves. Sheep 6Lambs. Pigs. Number killed 146 59 314 1,601 1,561 Number inspected 146 59 314 1,601 1,561 ALL DISEASES EXCEPT TUBERCULOSIS. Whole carcases condemned — 1 1 — 1 No. of carcases of which some part of organ was condemned 25 10 1 32 71 Percentage of the number inspected affected with disease other than tuberculosis 17 18.5 .5 2 4.5 TUBERCULOSIS ONLY. Whole carcases condemned — 1 — — 10 Carcases of which some part or organ was condemned 14 20 — 127 Percentage affected with tuberculosis 9-5 35-5 — — 9 Bakehouses. There are 6 factory and 41 retail bakehouses in the district, to which 125 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. Food Shops. 688 visits were paid to butchers' shops, 198 to fish shops, 342 to provision shops, 199 to dairies and milk shops and 303 to greengrocers' shops. The following amounts of foodstuffs were condemned and voluntarily surrendered:—Fish, 81 stones; corned beef, 8 lbs.; meat-pies, 403; chickens, 53 lbs.; fresh fruit of various descriptions, 28 lbs.; and dried fruit f lb. 35 Fried Fish Shops. Fish frying is one of the scheduled offensive trades in the district. At the beginning of the year there were 28 such premises in the area. During the year one business was sanctioned, and another sanctioned in 1937 commenced business, making a total at the end of the year of 30. Three applications for fresh establishments were refused. To these 108 visits were paid. Most of the 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. Food and Drugs. During the year 206 samples were analysed. Of these 161 were of milk, of which four were adulterated. Seven out of the 45 samples of other commodities proved to be adulterated. Two cases were prosecuted, one conviction being obtained. (D) CHEMICAL AND BACTERIOLOGICAL EXAMINATION OF FOOD. These examinations are carried out at the Laboratories of the Clinical Research Association Limited, Watergate House, Adelphi, London, W.C.2. 36 ISOLATION HOSPITALS. PREMISES. Particulars of the hospitals were given in the Annual Report for 1934. ADMINISTRATION. In last year's Report reference was made to the fact that the question of nurses' hours and service conditions was considered particularly with a view to the possibility of establishing a 96-hours' fortnight for the nurses and for the domestic staff. At their meeting on February 1st the Council adopted a recommendation that:—(a) The working hours of the nursing and domestic staffs in the Council Isolation Hospitals be reduced to 96 per fortnight; and (b) that in order to render effective the policy the following additional staff be appointed:—Six general trained staff nurses; three ward maids ; and one kitchen maid. The improved conditions of service of the staff, including increased rates of pay, still failed to attract applicants for the vacancies so that difficulties were found in implementing the resolution of the Council with regard to the 96-hour fortnight. Temporary appointments had to be made both of nurses and of domestic workers at higher rates of pay than those payable to the permanent staff. The Council then, at its meeting on May 31st, approved the recommendation of the General Purposes Committee increasing the rates of pay both of the nursing and of the domestic staffs. Advertisements at the higher rates brought in greater numbers of applicants than formerly, but the position even yet cannot be considered satisfactory, and at no time has it been possible to engage on the permanent staff the approved complement. ADEQUACY OF ACCOMMODATION. For most of the year the accommodation at the hospital proved sufficient to meet the demands for beds for cases of scarlet fever and diphtheria, though in early January, as had been the case in the December of the previous year, it was found necessary to send cases of diphtheria to other hospitals. On two occasions the scarlet fever accommodation was over-strained and in March 10 cases had to be sent to outside hospitals and in May a further 16 patients. The following table shows the extent to which use was made of the hospital during the year:— Admitted as In Hospital 1/1/1938 A dmitted during year. Discharged. Died. In Hospital 31/12/1938 Scarlet Fever 48 339 355 32 Diphtheria 13 70 77 7 6 37 In addition to these cases there were 79 others who were admitted to the isolation hospitals of other authorities who, had suitable accommodation been available, would have been admitted to the local hospitals. The highest number of local patients under treatment during the year in isolation hospitals (either local or those of other authorities) was 69. The highest number of patients suffering from scarlet fever only was 61, from diphtheria only was 14; the corresponding minimal figures were 17, 13 and 3. The average duration of stay of all patients was 42.5 days; for scarlet fever patients, 40.8; and for diphtheria cases 50.3 days. 38 The following table indicates the extent to which hospital provision has been required in the last five years:— Scarlet Fever. Diphtheria. Other infectious cases removed to hospital. Mid-year population. No. of notifications. Rate per 1,000 population. No. removed to isolation hospitals. Rates per 1,000 population. Percentage removed. No. of notifications. No. removed to hospitals. 1934 621 4.7 495 3.7 80 80 80 34 132,049 1935 501 3.5 391 2.7 78 85 81 41 144,280 1936 433 2.7 235 1.5 54 30 27 41 160,300 1937 416 2.4 304 1.7 73 95 102 59 174,800 1938 500 2.7 360 1.9 72 63 61 79 183,500 This table shows (1) that the incidence of scarlet fever of 4.7 per thousand population can occur. This, admittedly, was a higher incidence than that prevailing over the rest of the country at this time. (2) That, in regard to scarlet fever, the percentage of requests for removal to hospital might range from 54-80. (3) That a high request rate might be associated with a high incidence rate. (4) That in the case of scarlet fever, requests for removal to hospital might reach a figure of 3.7 per thousand population. (5) That the incidence of diphtheria which, taken for the country as a whole, might be 40-60 per cent. to that of scarlet fever has been of recent years very low in this area. There is nothing peculiar to this district to account for this low incidence and certainly diphtheria immunization amongst the young is not carried out to a degree sufficient to result in the raising of the herd immunity, and so prevent in this way widespread infection. 39 PROVISION OF NEW HOSPITAL. At their meeting on May 31st the Council agreed that the accommodation to be provided at the hospital should comprise:— Patients' Blocks:— 2 Ward Multiple Blocks 44 beds 2 Geographical Blocks 52 „ 2 Cubicle Blocks 24 „ 120 beds Future Extension:— 2 Geographical Blocks 52 „ 2 Cubicle Blocks 24 „ 76 „ 196 beds Small operating theatre unit; House for resident medical officer ; Administrative building, comprising quarters for matron and resident assistant medical officer, lecture room, office for matron, clerk's office, medical officer's office, dispensary, kitchen and its offices, dining rooms for nurses and domestics, bedrooms for 25 domestics; Staff home, including nurses' and sisters' recreation room and a study, bedrooms for 40 sisters and nurses; provision to be made for eventual extension of administrative building and staff home to accommodate a 50 per cent. increase in staff ; Four three-bedroom non-parlour cottages, including porter's cottage; Laundry; disinfector; boiler-house; garage : and mortuary. CLINICAL ASPECTS. Diphtheria. Admissions:— Number admitted on a diagnosis of diphtheria 70 Number of cases clinically diphtheria 52 Number of carriers 5 In 13 cases the diagnosis of diphtheria was not confirmed, the revised diagnosis in seven being acute tonsillitis, in two acute bronchitis, and in one each broncho-pneumonia, laryngitis stridula and rhinitis. 40 Of those cases clinically diphtheria 49 were taucial and 3 nasal. Of the carriers 2 were faucial, 2 nasal, and 1 aural. Period of stay.—The average length of stay in hospital of all cases discharged during the year was 50.3 days; of clinically diphtheria cases 60.2; of carriers 19.8; and of the non-diphtheritic cases 9.3 days. Deaths.—Number of deaths, 7 (one due to broncho-pneumonia). Case mortality of diphtheria cases, 11.5 per cent. The days of disease on which the six fatal cases were admitted were the 3rd in three, the 4th in two, and the 5th in one. Complications.—Amongst those discharged during the year the following complications occurred:—Paralyses, 10, comprising palatal 9 and 1 of the extrinsic eye muscles ; albuminuria 15 ; otorrhœa 4; and myocarditis 2. Cross Infection.—One case contracted scarlet fever. Double Infection.—One patient was incubating chicken-pox on admission. Day of Disease on Admission.—The following summarizes the information with regard to the duration of illness at the time of admission of the 49 cases of faucial diphtheria:— Over Day. 1st 2nd 3rd 4th 5th 6th 7th 7 Number of cases 1 9 14 10 10 3 2 - Serum Administration.—The average amount of serum used on faucial cases was 34,171 units. In 45 per cent. some form of serum sickness occurred. Operations.—No operations were performed. Bacteriological Examination.—2,315 swabs were examined for the Klebs-Loeffler bacillus. Of the 746 sent in by general medical practitioners, 45 were positive. Of the 470 swabs from patients in the diphtheria wards, 33 were positive. Of the 699 swabs from patients admitted to hospital suffering from other diseases, 8 were positive. Immunization.—Of the 70 patients admitted to the diphtheria wards, 5 gave a history of having been immunized against diphtheria. Two of these were carriers, 1 proved to be laryngitis stridula, and of the remaining 2 cases of clinical diphtheria, 1 had received the final injection three days before admission, while the other made a good recovery from a severe attack. This latter case had never been Schick tested after completion of immunization. 41 Scarlet Fever. Admissions:— Number admitted with diagnosis of scarlet fever 339 Number suffering from scarlet fever 327 Number in whom diagnosis not confirmed 12 Of these 12 cases, 6 suffered from an erythema, 3 from food or drug rashes, and 1 each from german measles, otitis media, and an abscess of the arm. Period of stay.—The average length of stay of all cases discharged during the year was 40.8 days. The average stay of scarlet fever cases was 41.2, the duration in uncomplicated cases being 25.5 and of complicated cases 58.2. Non-scarlet fever cases were detained on an average of 15.3 days. Deaths.—Nil. Complications.—85 cases (or 49.7 per cent.) suffered from some complication, 25 of these having more than one complication during the course of the illness. Adenitis occurred in 17.5 per cent., otorrhœa in 16.1, rhinorrhœa in 15.5, abscess in 6.4, albuminuria in 4.9, rheumatism in 1.8, secondary sore throat in 1.5, relapse in 2.9, erythema nodosum in 1.2, nephritis in 0.6, and bronchitis in 0.3 per cent. Operations.—The mastoid operation was performed on two cases, one of whom had developed measles during the stay in hospital. Cervical glands were incised in the case of two patients. Cross Infection.—Six cases developed measles. Double Infection.—Two cases were incubating measles on admission. Serum treatment.—Serum was given in 62 cases (20 c.c.s in 23 and 10 c.c.s in 39). Reactions followed in 24 cases, nine being after 20 c.c.s and 15 after 10 c.c.s. Six cases who reacted to serum had been previously immunized against diphtheria. Only 37 out of the 355 cases discharged during the year gave a history of having been immunized against diphtheria. Prontosil Treatment.—Prontosil was used in 40 cases of the more severe type, and in most cases appeared to be of considerable value in hastening recovery, especially when given early and in conjunction with serum. Return Cases.—Return cases occurred in 23 households, to which the patient had returned home during the year after treatment in hospital for scarlet fever. 42 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASE (other than Tuberculosis) Disease. Under lyr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over. Total Scarlet Fever 2 105 245 69 20 13 28 9 7 - 2 500 Diphtheria - 11 28 17 3 1 2 1 - - - 63 Pneumonia 4 11 18 9 2 4 11 14 14 3 8 98 Erysipelas 1 _ 1 _ 4 2 7 4 15 10 3 47 Puerperal Pyrexia - - - - - 5 28 1 - - - 34 Enteric Fever - _ 1 . 1 - - - - - - 2 Ophthalmia Neonatorum 9 - - - - - - - - - - 9 Cerebro-spinal Fever 1 2 - - - - - - - 1 - 4 Dysentery 1 3 4 1 - 1 2 — - - - 12 Acute Poliomyelitis - - 1 1 2 2 - - - __ 6 Encephalitis Lethargica - - - - - - - - - - - - Pemphigus Neonatorum 1 - - - - - - - - - - 1 Disease. Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 500 327 33 — Diphtheria ... 63 57 6 — 8 Pneumonia ... 98 — — — 92 Erysipelas ... 47 — 22 4 — Puerperal Pyrexia 34 — 11 12 3 Enteric Fever 2 — — — — Ophthalmia Neonatorum ... 9 — — 6 — Cerebro-spinal Fever 4 — 2 2 2 Dysentery ... 12 — 1 — — Acute poliomyelitis 6 — 4 — — Encephalitis Lethargica ... — — — — Pemphigus Neonatorum ... 1 Incidence. DIPHTHERIA. 79 notifications of diphtheria were received during the year, the diagnosis, however, being revised in 16 instances, most commonly to acute tonsillitis. 63 cases in a population of 183,500 is a rate per 1,000 of 0-34, as compared with that of 1-58 for the country as a whole. This is the ninth consecutive year in which a low incidence has prevailed. Secondary infections occurred in five households, on one occasion there being two secondary cases apparently due to an infective ear discharge. 43 Two patients were bacteriological cases, while five were nasal cases, of which one had recently had his tonsils and adenoids removed. A throat infection followed on a similar operation to another child. Place of Treatment. All but six of the cases notified were admitted to the South Harrow Hospital. Of these six, two who, when diagnosed, were in-patients of London Hospitals, were removed to the London County Council Isolation Hospital, one was admitted to the London Fever Hospital, a carrier was treated at home, one child escaped from the district but was shortly afterwards admitted to the isolation hospital serving the district to which his parents had removed him, while one child died at home before his removal had been requested. Deaths. Eight deaths were recorded as due to diphtheria, a case mortality of the notified cases of nearly 13 per cent., though one fatality was that of a child admitted on the eighth day of illness in December, 1937, and died on January 1st, 1938. Immunization. For most of the year the same arrangements as obtained in previous years were continued. From November, however, approval was given to the two dose A.P.T. method, the rate of the remuneration to the general practitioners was amended and the antigen was provided free. In practice, most of the local practitioners continue to favour the three-shot method, using T.A.M. as the antigen. The number of children inoculated, namely 956, is a welcome increase on the figures for recent years, the response in general, apart from the year the scheme was started having been very poor, only 315 children being done in 1936 and 226 in 1937. The increase this year must, in some degree, be due to the efforts made to concentrate on children of 9 to 12 months of age. The health visitors were asked to make a point of discussing the subject to the mothers of infants of this age, the medical practitioners were asked to co-operate, and a letter is sent to the parents of each child attaining the age of nine months, pointing out the advisability of the child's being immunized, and more particularly at this age. That these efforts are responsible for this increase is suggested by the fact that out of the 956 children inoculated, 225 were about one year of age. It is most probable, also, that when the parent decides to have the baby done, older children are treated at the same time. Actually 555 of the children treated were under five years of age. These numbers, of course, relate only to those dealt with under the Council's scheme, and relate therefore to the children of families in general of income limit of under £250 a year. 44 Provision of Antitoxin. Diphtheria antitoxin is available free of charge for medical practitioners for the treatment of necessitous patients. 22 lots were issued during the year, totalling 176,000 units. Diphtheria in Schools. Over a period of three weeks five cases occurred in two classes in one department of a public elementary school. Two children in the same class of another school within a week of each other succumbed to diphtheria, both cases proving fatal. Apart from these instances, there appeared to be no association of the incidence of the disease and school attendance. SCARLET FEVER. Incidence. 500 cases of scarlet fever were notified during the year, an incidence rate of 2.72 per thousand population as compared with a figure of 2.41 for the country as a whole. The number of cases notified in the first quarter was 162, these being evenly distributed, the weekly notifications ranging from 8 to 16. 165 cases were notified in the second quarter; the distribution was less even, the notifications in two consecutive weeks being 23 and the range for the other weeks being from 6 to 16. The summer quarter was that of lowest incidence, the total notifications being only 67 and only in the first week of the quarter were double figures reached. In the last quarter the incidence, while slightly higher on the average than in the summer quarter, remained each week at single figures until the last month of the year, the 46 cases notified in the last four weeks bringing the total number of cases for the quarter to 106. Of the 514 patients notified (including those in whom the notification was later withdrawn) 144 were treated at home throughout the illness at the election of the parents, 339 were removed to the local isolation hospital and 34 were removed to isolation hospitals of other local authorities. Of this 34, 26 were removed elsewhere because there was no accommodation available for them at the local isolation hospital, this straining of accommodation occurring for two short periods in March and in May. Of the remainder treated in outside hospitals, six were out-patients or in-patients at general hospitals in London at the time of diagnosis, one was removed from Redhill Hospital and one patient, at the wish of his parents, was admitted to the London Fever Hospital. Five patients who began their treatment at home were later admitted to hospital, one because of the development of aural complications, one because of limited accommodation at home, one because of the difficulty in nursing, and the other two at the election of the parents. Of the 339 cases treated in hospital, 230 were removed primarily because of domestic circumstances, of which, in the case of 58, the reason was the absence of a separate bedroom for the 45 patient, in 54 the presence in the house of children under five years of age, 45 were adults, in 11 instances there was no one to nurse the patient, in 19 instances there was more than one patient in the household, and in 42 homes there were many other children. Ten patients were removed to hospital from institutions and in nine instances the retention at home of the patient would have entailed the abstention from work of a wage-earner. In no instance was a child removed primarily because of serious clinical condition, while 91 removals were of patients in whose cases there appeared to be no real reason that the child should not have been treated at home. Secondary Infections. Secondary infections occurred in 29 households, in 25 of which there was only one secondary case, in three there were two, and in one there were three. In 14 of these households the primary case was nursed at home; in 12 of these there was one secondary case and in two of them, two. In six of these instances the secondary infection led to the diagnosis of the illness of the infecting patient. The secondary case occurred in the first week from the onset of illness of the primary case in five instances, in the second week in three, in the third, four, and in the fourth, two. Excluding those cases where the primary case was not diagnosed until the onset of illness in the second case and where, therefore, no precautionary measures in the way of isolation had been taken, the number of infections occurring in the first week from the onset of illness of the primary case were three (of whom one was the mother of the infecting case), in the second week one, in the third week three (of whom, again, one was the mother of the infecting case), and in the fourth week one. Those infections which were secondary to cases removed to hospital occurred within a week of removal in eight instances and early in the second week in three (of whom two were adults). In four instances the secondary case was diagnosed before the removal of the primary case, and in one instance the diagnosis in both was made at the same time. The interval separating the onset of the first of the secondary cases in the household in which the primary case was removed to hospital from the time of removal of the primary case was under a week in 10 instances, and over one week but under two in four. Return Cases. There were 26 households in which return cases occurred; in 23 there being only one return case, in two, two cases, and in one, four cases. Of the discharged patients all but one had been treated in the local isolation hospitals, most for scarlet fever, but two for measles. Of the patients discharged from the local hospitals after treatment for scarlet fever this constitutes a return case rate of 6.8 per cent. 46 11 of the discharged patients showed no abnormal signs at the time of illness of the secondary case. In two instances (including one where the return case was the mother) the interval separating the return home of the primary to the onset of the illness of the return case was four to seven days, in five instances (including one where the mother succumbed) the second week, in three the third week, and in two the fourth week. 12 presumably infecting cases showed some abnormality, this being a nasal discharge in five, a sore nostril in three and ear discharge in one, and tonsillitis or enlarged tonsils in two. In none of these instances was the interval separating the return home of the primary to the onset of illness of the secondary case under one week. In seven the onset was in the second week from the return home, in two in the third week, and in two in the fourth week. Of the 26 patients whose return home was followed by the occurrence of a further case in the house, two were removed to hospital on the first day of illness, three on the second, six on the third, six on the fourth, five on the fifth, one on the sixth, and one on the seventh, while one was not removed before the ninth day, and another not before the fifteenth day. The average period of stay in hospital of the infecting cases was long, only four patients, of whom three were adults, were in less than 28 days, eight were discharged in the fifth week from the onset of illness, two in the sixth, and three in the seventh, while six were in over eight weeks. These long periods of detention were, of course, on account of complications, some, such as a nasal or aural discharge, recurring after the return home of the patient. Recovery Cases. One recovery case occurred, the infective patient being isolated for five weeks and the onset of the illness of the recovery case being 27 days from the release of the primary case from infection. Home Treated Cases. 140 patients suffering from scarlet fever were treated in their own homes. Most cases were uncomplicated and made uninterrupted recoveries. The following is the percentage of incidence of complications, the figures in brackets being the incidence of complication in hospital treated cases:—Rhinorrhcea, 4.5 (15.5) otorrhoea, 3.8 (16.1); albuminuria, 1.5 (6.4); rheumatism, 1.5 (1.8); and adenitis, 0.8 (17.5). Cases following Operation on the Nasopharynx. There were five cases this year in which scarlet fever followed operative treatment of tonsils and adenoids, three at local hospitals and two at London hospitals. All were of children under eight years of age. The interval from the operation to the onset of the illness was three days in two instances, but seven or eight days in three. One of the patients gave rise to a secondary case. 47 Deaths. No deaths were registered as due to scarlet fever. Dick-Test. Apart from those tests carried out in the isolation hospital for diagnostic purposes, no provision was made for Dick-testing. Schools and Scarlet Fever. 221 of those cases notified were children who, prior to succumbing to their illness were in attendance at a public elementary school. In 80 cases the patient was the only person in attendance at school who suffered from scarlet fever at that time, the onset of illness in any child who attended the same department being separated from that of each of these cases by an interval of at least ten days. In many other instances there was little to suggest that school attendance was responsible for the infection. Two cases occurred in the same department of a school during the same week but with the preceding and succeeding weeks both free on nine occasions, and three cases occurred similarly once. Single cases in two consecutive weeks occurred eight times and three cases distributed over two or three weeks on five occasions. Five cases occurred in three consecutive weeks amongst children attending the same departments on three occasions. Two cases in each of two consecutive weeks were of children attending the same department of a school but all were in different classes. A few weeks later four cases occurred in this same school in one week but again the children were in different classes. In a junior mixed and infants' department during the period January 21st to April 16th 16 cases occurred, in only two weeks there being no notification; on two occasions two cases were notified in one week and in one week four cases. Eight different classes were affected but only once did the grouping suggest class infection when two children from the same class succumbed in one week and a third in the next. In another school seven cases occurred over a period of six weeks. In only one instance was there more than one child attending a class affected, two children in this class succumbing in the same week, which was a fortnight after the previous case in the class. After an interval of two weeks three more children attending different classes in the department tell ill in the same week. In a third school infection smouldered from the middle of March until the end of the summer term. Apart from the Easter holidays there were only two weeks in which no infections occurred. In one week three cases were notified (two from one class) and in each of three other weeks two cases (from the same class on two occasions). Five classes were involved, one having, over these weeks, eight cases, one six and the third four. The distribution of cases amongst the classes appeared to be most haphazard at times, an interval of a month separating two consecutive cases from the same class. The usual investigations 48 were made, followed by the exclusion of suspicious cases, but the cases continued to crop up until the end of the summer term. Apart from one case in October, the department remained free from scarlet fever throughout the Christmas term until the last two weeks of the term when six cases were notified. Period of Residence of Patients Notified. Of 474 patients notified as suffering from scarlet fever, eight had lived in the district less than one month ; 14 had been here over one but under three months, 24 over three but under six months, and 42 over six but under 12 months. 45 had been here over 12 but under 18 months, and 23 over 18 months but under two years. 79 were in their third year of residence, 80 in their fourth, 56 in their fifth and 123 had lived here over five years. ENTERIC FEVER. Six notifications of enteric fever were received during the year, in only two of which, however, was the diagnosis confirmed. One was a case of paratyphoid B infection in a girl of nine ; the other patient, an adolescent, had apparently contracted the infection abroad. DYSENTERY. 13 cases of dysentery were notified. Most of these occurred in the first few weeks of the year. They were all mild in character, the infection in the case of those investigated being due to the Sonne organism. These cases which occurred up to early March were a continuance of the infection which had prevailed in the country in the latter part of 1937 and which affected this district from November. In July an adult female fell ill with dysentery due to the Flexner organism, the case subsequently proving fatal. In late September three further mild cases were reported, the only one in which the causative agent was known being due to the Sonne organism. ERYSIPELAS. 47 cases of erysipelas were notified during the year, the sexes being almost equally affected. The face was affected in about two-thirds of the cases, the head and the legs being the other most common sites. One half of the cases were treated at home, most of the remaining patients being admitted to isolation hospitals. SMALLPOX. No cases of smallpox were notified. Visits were paid to the homes of those, who, while on board ship, were contacts of this infection. 49 EPIDEMIC DISEASES OF THE CENTRAL NERVOUS SYSTEM. Cerebro-spinal Fever. Four notifications of cerebro-spinal fever were received, the first was a child of two notified in January; the next was an adult of 55 notified in May. In September a child of 18 months fell ill, the disease proving fatal. The remaining case was one of a child of six months whose onset was in November. Two of the cases were admitted to isolation hospitals and one to a general hospital. Acute Anterior Poliomyelitis. Six cases of acute anterior poliomyelitis were notified during the year. Two of these, both adults, fell ill in July, two (one adult and one a child of 10) in September, and two (one adult and a boy of 16) in December. Four were admitted to isolation hospitals, the other two being treated at home. NON-NOTIFIABLE INFECTIONS. Measles. Measles was prevalent in the first six months of the year when 1,316 intimations were received from head teachers that children attending the public elementary schools were absent on account of this ailment. During the rest of the year the district was practically free. The 148 cases in January were mostly due to the incidence in three schools (48, 48 and 32 cases). Five departments had more than 20 cases in February, when altogether 220 notifications were received. There was a sharp rise to 428 cases in March, the month of heaviest incidence, when seven departments had more than 20 cases each, one having 75 and another 65 cases. In April and May 188 cases were notified each month, two schools having 53 and 45 cases in April and one school previously unaffected having 56 in May. In June only 143 cases were notified, five schools having over 20 cases each, but the greatest number in any one school being only 26. In some schools the infection was limited to two months (one school having 89 cases in the two months, another 95, and a third 91) whereas in others infection was present over longer periods (172 cases over four months, 138 over four months, and 105 over three months). 261 visits were paid by the health visitors to homes where there were cases of measles, and 29 patients were removed to isolation hospitals for treatment. d 50 Whooping Cough. Whooping cough was less prevalent in 1938 than in the previous year, notifications having been received of only 302 cases as compared with 427 in 1937. The incidence was more or less uniform throughout the year, rather more cases occurring in March that at any other time. 19 departments were affected in all but none to any heavy degree, one having 30 cases over three months in the spring term, another 40 cases over five months. Apart from this latter school, in no instance did any department suffer to any appreciable extent more than one term. 154 homes were visited by the health visitors and seven patients were removed to isolation hospitals for treatment. Chickenpox. Chickenpox was again very prevalent, 964 intimations being received, most of them occurring in the first six months of the year, the number of cases in each of the months January to June being 83, 127, 216, 67, 187 and 175. One school suffered for the whole period, the total number of cases over six months being 258. No other school suffered to this degree, the other heavy incidences being 91 cases over two months, 63 over three months, 56 over two months, 58 over two months, and 61 over three months. Apart from the one school mentioned where the infection attacked the school over a period of six months, the only other instance of a school being affected more than the one term was where one department had 31 cases in February and March and a further 58 cases in the summer term. Mumps. The district was very free from mumps during 1938, only 66 cases being intimated, of which 22 occurred in one department, most of them in the same term. Influenza. There was no heavy incidence of influenza during the year under review and only eight deaths were ascribed to this disease. 51 TUBERCULOSIS. Notifications. 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— 4 - 2 6 - - - - - - 6 4 5— 4 4 8 1 - - — - - — - 1 10— 3 3 2 2 - - - 1 - - 15— 7 13 5 2 - - 1 - 4 5 2 - 20— 14 24 4 2 2 — — 1 25— 33 49 4 8 - - - - 7 17 1 1 35— 21 12 2 2 - - - - 4 10 - - 45— 17 8 - 1 - — - - 5 5 1 1 55— 8 3 1 - - — - - 7 - - - 65 & upwards. - 2 - - - - - - 1 - - - Total 111 118 28 24 2 - 1 2 29 37 10 7 During the year 231 pulmonary cases (113 male and 118 female) were added to the register as compared with 212 for the year 1937. Of this number 102 had previously been notified in other districts as suffering from this disease before they removed here. In view of the short period which elapsed between their coming to reside here and the date the disease was notified, it is probable that many other patients had been infected before transfer. Assuming, however, that all those 129 cases who had not been previously notified contracted the infection here, the rate per 1,000 population of new cases would be 0.70, compared with the national rate in 1937 of 0.9. Of those cases locally contracted, one in five gave a family history of infection. Amongst the males there was no especial preponderance amongst workers at any particular employment ; one-half of the females were engaged on housework, most of them being married. Of 98 cases who transferred here while suffering from tuberculosis, 50 were known of within six months of transfer and a further 25 within the twelvemonth. 13 were learned of in their second year of residence, five in the third, but five had been here for three or more years. 55 cases (29 male and 26 female) of non-pulmonary disease were learned of during the year, being a rate of 0.30 per 1,000 52 population compared with the figure of 0.31 for England and Wales for the year 1937. Of these, 20 were known to have been notified as suffering from the disease before they moved into this district. In almost one-half of the cases bones or joints were affected, the remaining cases being almost equally divided into lesions of the cervical glands and abdominal tuberculosis. Roughly the same proportions hold for those who contracted the disease locally, though these included five cases of genito-urinary tuberculosis and five cases of meningitis. In only three of the non-pulmonary cases was a family history of tuberculosis obtained, and almost invariably the milk supply was pasteurized. Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register Jan. 1st, 1938 285 243 57 62 No. of New Cases added 111 118 28 21 No. of cases added—other than on Form A 2 - 1 2 No. of cases restored to register 2 1 - 1 No. of cases removed 73 95 22 14 No. on register Dec. 31st, 1938 327 267 64 75 Per 100,000 total population the numbers of pulmonary cases on the register at the end of the year were 178 male and 145 female, the comparable figures for the country as a whole at the end of 1935 being 290 and 249. The corresponding local figures for nonpulmonary tuberculosis were 3.5 and 4.1, and for England and Wales 12 and 11.5. The following table is a summary of the cases removed from the register with the reason for their removal:— Pulmonary. Non-Pulmonary. Male. Female. Male. Female. Left the District 29 44 2 1 Died 29 37 10 7 Cured 8 7 6 1 Diagnosis not confirmed or withdrawn 7 7 4 5 Deaths. 68 persons (30 male and 38 female) died from pulmonary tuberculosis during the year and 28 (10 male and 18 female) from non-pulmonary tuberculosis. The death rate per million population was therefore 359 for the pulmonary disease compared with the figure of 584 for England and Wales for the year 1937, the comparable local figure for non-pulmonary tuberculosis being 98 and the corresponding national figure 111. 53 Tubercular disease resulted in 94 deaths, accounting for 7.2 per cent. of the total deaths in the district, the corresponding figure for England and Wales being 5.6. 18 deaths, or 19 per cent. of those who died from tuberculosis, occurred amongst patients who had not been notified in this district as suffering from tuberculosis, though two posthumous notifications were received of cases who had succumbed to meningitis. In three of these cases the diagnosis was made only as a result of post-mortem examination, and another five of the deaths were due to meningitis, and one to miliary tuberculosis. Almost all the remaining deaths occurred in institutions outside the district. In the case of two of the patients who died in this district there was an old-standing history of tuberculosis. 17 of the deaths of the pulmonary cases and six of the non-pulmonary cases occurred in the district, mostly in the patients' own homes; while 41 of the pulmonary and 10 of the nonpulmonary occurred outside the district, mostly in institutions. Treatment. The following figures relating to the treatment of local tuberculous patients have been kindly provided by the County Medical Officer Dispensary. New cases examined during 1938:— Pulmonary 198 Non-pulmonary 25 Non-tuberculous 223 446 New contacts examined during 1938 347 No. of old cases on Dispensary Register, December 31st, 1938 447 Total number of cases on Dispensary Register, December 31st, 1938 635 No. of attendances at Harrow Dispensary 3,175 54 Institutional Treatment. In Institutions on Dec.31st, 1937. Admitted during 1938. Discharged during 1938. Died in Institutions during 1938. In Institutions on Dec.31st 1938. Number of cases admitted for observation:— Adults:— Males - 2 2 — — Females 1 2 3 — - Children — 2 2 — — Total 1 6 7 — — Number of patients suffering from pulmonary tuberculosis:— Adults:— Males 36 95 74 9 48 Females 37 83 72 5 43 Children 3 12 8 - 7 Total 76 190 154 14 98 Number of patients suffering from non-pulmonary tuberculosis:— Adults:— Males 4 8 6 — 6 Females 8 8 9 - 7 Children 7 12 10 — 9 Total 19 28 25 — 22 GRAND TOTAL 96 224 186 14 120 Preventive Measures. Home visiting of tuberculous patients is now carried out by the staff of the Middlesex County Council. Bacteriological examination of sputa is carried out at the laboratories of the Clinical Research Association, 124 samples having been examined during the year. No action was taken during the year under Section 172 of the Public Health Act, 1936, for the compulsory removal to hospital of any infectious tuberculous person. 55 MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,292, 1,697 male and 1,595 female. Of these 105 were illegitimate, being a percentage of total births of 3.2. 2,243 births occurred in the district (2,190 live and 53 still births). Of this number 289 (282 live and seven still births) were to residents of other districts. Of the local confinements 1,489 were notified by midwives and 881 by doctors or parents. 1,367 (1,332 live and 35 still birth) notifications were transferred from other districts, being mostly in respect of births occurring to Harrow mothers in Middlesex County Council or London hospitals. STILL BIRTHS. 63 male and 43 female still births were registered, being a rate per 1,000 population of 0.57 compared with a figure of 0.60 for the country as a whole. The following is a classified list of the causes of those stillbirths of which particulars are know:— 1. Caused by disease in or accident to the mother:— (1) Chronic disease of the mother:— (а) Syphilis 1 (b) Other 1 (2) Acute disease in or accident to mother (a) Toxaemia during pregnancy 9 (b) Other 4 (3) Over-exertion:— (a) As result of over-work — (b) Other — (4) External violence — (5) Others 3 2. Anomalies of fœtus, placenta or cord:— (6) Congenital malformation incompatible with life 7 (7) Vicious insertion of placenta 2 (8) Other anomalies of placenta or cord — 3. Death of foetus by injury or other causes (9) Abnormal presentation 4 (10) Malformations of pelvis — (11) Prolapse of cord — (12) Prolonged labour or uterine inertia 8 (13) Obstetrical operations:— (a) Operation causing mutilation — (b) Other obstetrical operation 4 (14) Other causes — 56 4. Stillbirths due to other causes:— (15) Other or unsuspected causes 20 Included in this last group are five cases where the still-birth was one of twins. INFANT MORTALITY. 126 (74 male and 52 female) infants died under one year of age. The infant mortality rate, by which is expressed the number of deaths among infants under one year of age per 1,000 born was therefore 38.3, compared with the figure of 53 for the country as a whole, 57 for the Great Towns, 57 for London, and local rates of 42.1, 44.9 and 35.5 for the years 1935, 1936 and 1937. The following table indicates the ages at which these deaths occurred, with the corresponding figures for England and Wales for the year 1937 for comparison:— Local. England & Wales. 1938. 1937. M. F. M. F. Under 4 weeks 22.9 18.1 32.79 26.55 4 weeks—3 months 5.9 4.4 11.05 7.60 3—6 months 3.0 1.9 9.43 7.03 6—9 months 8.2 2.5 6.59 5.16 9—12 months 4.7 4.4 4.81 3.82 Total under 1 Year 44.7 31.3 64.67 50.16 Below is set out an analysis of the causes of these deaths under 12 months with the corresponding figures for the country as a whole for the year 1937:— Local 1938. England & Wales. 1937. M. F. M. F. Measles - - 0.39 0.38 Whooping cough — — 1.31 1.51 Influenza — — 0.69 0.53 Diarrhœa and enteritis 6.4 5.6 5.94 4.12 Premature birth 8.8 7.5 18.44 15.46 Congenital defects 2.9 6.2 8.92 7.30 Congenital debility and icterus 4.1 0.6 3.25 2.29 Developmental and wasting diseases 2.4 3.7 30.61 25.05 Birth injury 5.9 0.6 — — Tuberculous diseases 0.6 — 0.69 0.58 Convulsions — — 1.53 1.04 Bronchitis and pneumonia 10.0 5.6 13.02 9.23 Violence 1.2 0.6 10.49 7.72 Other causes 1.7 1.2 Total 44 31 64.67 50.16 57 68 infants failed to survive one month. The neonatal mortality or the death rate per 1,000 births occurring in infants at under one month was therefore 21, constituting 54 per cent. of the total infant mortality rate. The distribution of these deaths per 1,000 births amongst infants of different ages is set out below, with the corresponding figures for the country as a whole for the year 1937:— Local. 1938. England & Wales. 1937. Under 1 Day 8.5 10.82 1—7 Days 8.2 11.20 1—4 Weeks 3.9 7.73 Total 20.6 29.75 28 of the neonatal fatalities occurred in premature infants. In one of these the onset of the premature labour was due to antepartum haemorrhage and in another four to some abnormal state of the mother (nephritis, toxæmia, etc.). In one instance labour had been induced; in two cases there was a twin pregnancy. In 13 cases the infant suffered from congenital abnormality (congenital heart, 4). In 11 instances there was a history of difficulty in labour. In seven death was ascribed to atelectasis (twins, 2; maternal toxæmia, 1; and icterus, 2). In most of these cases the death occurred very shortly after delivery. Of the remaining infants who survived the first week but died within the first month, the cause of death in one was bronchitis, and in another leukaemia. The following table is an analysis of the causes of death of those infants of ages between one and twelve months :— 1-3 Mths. 3-6 Mths. 6-9 Mths. 9-12 Mths. Infectious Disease - - - - Pneumonia & Bronchitis 6 3 10 6 Tuberculosis - - 1 - Diarrhœal Diseases 6 2 5 6 Deficient Inherent Vitality 4 - - - Violence - 1 1 - Other Causes 1 2 1 3 Total 17 8 18 15 58 DEATHS OF OLDER CHILDREN. The following table classifies the deaths of children between the ages of 1 and 5 years:— 1-2 Yrs. 2-3 Yrs. 3-4 Yrs. 4-5 Yrs. Infectious Disease 1 2 1 1 Pneumonia & Bronchitis 5 2 1 1 Tuberculosis 1 3 1 3 Violence 1 — 3 — Other Causes 4 - - 1 Total 12 7 6 6 The death rates per 1,000 living at these ages in England and Wales for the year 1937 were 9.7, 4.5, 3.3 and 2.8. The local figures of actual deaths cannot be translated into corresponding rates as the actual numbers of those living in this district at these ages is not known, though some indication is obtained from the knowledge that in 1937 the number of births in the district was 3,098, in 1936 2,873, in 1935 2,523 and in 1934 2,167. INFANT MORBIDITY. Ophthalmia Neonatorum. Number of cases notified:—9. Number treated at home:—9. In hospital:—2. Vision unimpaired 9. Impaired:—nil. Blindness:—nil. Deaths:—nil. Of the nine cases notified four were infants who were born in and had been notified from London hospitals. All cases were mild in character and made complete recovery. Pemphigus. Pemphigus of the new-born has since July 31st, 1935, been notifiable in this district. One case was notified during the year. MATERNAL MORTALITY. Twelve deaths were registered as due to or associated with pregnancy, giving a maternal mortality rate of 3.64 per 1,000 live births. Of these three were due to sepsis, being a mortality rate from this cause of 0.91 and nine to other accidents and diseases of pregnancy, a rate of 2.73. The corresponding rates for England and Wales were 3.08, 0.89 and 2.19, and for this district in 1937: 4.19, 2.26 and 1.93. The rates per 1,000 total births were 3.52, 0.88 and 2.64, compared with figures of 2.97, 0.86 and 2.11 for the country as a whole. 59 Of the three deaths from sepsis, one was that of a patient who was advised at the consultant clinic because of suspected moderate disproportion to be attended at her confinement by a doctor. At labour the shoulders were impacted, and the patient was removed to hospital where embryotomy was performed. Signs of general infection appeared on the following day, the patient dying on the fourth day from "toxic myocarditis, puerperal fever, childbirth." The second patient, because of toxaemia, was treated as an in-patient for a period during the ante-natal stage and was admitted shortly before term because of raised blood pressure and oedema. Labour was complicated by uterine inertia, and forceps delivery was followed by post-partum hæmorrhage for which blood transfusion was given. The patient did well for three weeks when pyrexia developed, and death occurred from pyaemia following parametritis. The third patient was one who died six weeks after confinement from sub-acute bacterial endocarditis which was associated with some degree of puerperal infection. Nine deaths were due to conditions other than sepsis. (1) A normal confinement attended by one of the Council's midwives was followed by post-partum haemorrhage. The patient was removed to hospital but died 15 minutes after admission. It was her seventh pregnancy and she had refused ante-natal supervision. (2) A normal confinement was, except for a slight rise of temperature on the eighth day, followed by a normal puerperium. On getting up on the fourteenth day the patient died suddenly from pulmonary embolism. (3) A normal delivery of a patient who had systematic ante-natal supervision at the hospital at which she was confined was followed by acute uterine inversion with a partially adherent placenta. (4) A patient whose condition was normal on the eight occasions she attended the hospital for ante-natal supervision (including the day before confinement) died of post-partum eclampsia. (5) A large baby was delivered by forceps. Subsequent haemorrhage was controlled, but because of the shocked condition of the patient the placenta was left in. Six hours later the patient suddenly collapsed. (6) This patient was advised at the clinic to be attended at her confinement by a doctor. After some hours of labour she was admitted to hospital for observation. Trial of labour was permitted, but because the head remained high a lower segment Caesarian Section was performed. The patient collapsed and died just after the baby was delivered. (7) This patient was admitted to hospital at 36 weeks because of pregnancy toxaemia. Drug induction was performed at term. Because of ante-partum haemorrhage an anaesthetic was given and the child delivered by forceps. Haemorrhage and collapse followed manual removal of the placenta. (8) This patient died from post-partum eclampsia after a Caesarian section followed by moderate hæmorrhage. (9) This patient was recommended at the ante-natal clinic to have her confinement in hospital because she suffered from some degree of contraction of the pelvis. After forceps 60 delivery at term the placenta was adherent. There was no hæmorrhage, but one hour later the patient became restless and cyanosed. Post-mortem examination showed toxic degenerative changes in the liver and the kidney in an advanced state of autolysis. PUERPERAL INFECTION. 34 notifications of puerperal pyrexia were received, being a rate per thousand total births of 10.6 compared with a figure of 14.4 for the country as a whole. 10 of these notifications were in respect of women confined in institutions in London. Of 21 patients confined in this district the cause of pyrexia in 11 was apparently genital tract infection. In seven of these labour was normal but in the case of the other four there was some operative interference. In another three the raised temperature was due to pyelitis, in one to femoral thrombosis, in another to a localised peritonitis, while in the remainder it was apparently not due to infection of the genitary tract. None of these notified cases proved fatal, though two death certificates were received of patients who died in institutions outside this district in whom the cause of death was puerperal infection. The Council's provisions for the treatment of those suffering from puerperal infection are to arrange for their admission either to the isolation block of Queen Charlotte's Hospital or to the London County Council North-Western Isolation Hospital, or to arrange for home nursing by the staff of the local Nursing Association. Apart from those who were notified while already in-patients in London institutions, eight of the notified cases were removed to hospital for treatment, while home nursing was provided for two patients. In addition seven cases of suspected infection were taken over from the Council's midwives. 61 INFANT WELFARE SERVICES. HOME VISITING BY THE HEALTH VISITORS. Routine visits are paid to infants as soon as possible after the fourteenth day, and special visits are paid to cases of ophthalmia neonatorum, puerperal infection, still births, infant 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 717 Total visits 1,221 (b) To children under one year of age First visits 3,293 Total visits 8,750 (c) To children between the ages of one and five years Total visits 13,283 INFANT WELFARE CENTRES. At the beginning of the year, 23 infant welfare sessions were held at 11 separate premises. In June an additional session was opened at the Methodist Church Hall, Walton Avenue; in November another session at St. George's Hall, Headstone; and in the same month a session was opened at St. Anselm's Hall, Hatch End. At the end of the year 26 weekly sessions were being held at 12 separate premises. At these there was an average weekly attendance in December of 1,340 compared with a figure of 1,166 in the corresponding month of the previous year. At most of the sessions two health visitors attend, the health visitor in charge at any clinic being, as far as possible, the one who visits the district which the clinic serves. In addition a number of voluntary workers kindly assist at the clinics. A large proportion of the time of each health visitor, therefore, is taken up by her attendances at the clinics and restricts the extent of her home visiting. On the other hand, as, at the clinics, each mother is personally interviewed by the health visitor, there is, in the case of the more regular attenders, less need for frequent home visits. 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 52,905 (2) By children between the ages of one and five years 33,425 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 2,889 (2) Between the ages of one and five years 1,497 62 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 2,445 (2) Over one year of age 6,133 The percentage of total notified births represented by the number of children under one year of age who attended for the first time was 94. The percentage of total registered births was 88. TODDLERS. Fortnightly sessions were first started during the year at the Baptist Church Hall, Streatfield Road, Kenton, and at the Methodist Church Hall, Walton Avenue, South Harrow. Toddlers' clinics are proving very popular. There is no difficulty in compiling lists of those anxious to use the clinics, and in general they attend very regularly. TREATMENT. The treatment services include the following:—Dental treatment, operative treatment of tonsils and adenoids, ultra-violet ray therapy, correction of visual defects, orthopædic treatment and the treatment of minor ailments. In addition, arrangements are made for the admission of suitable cases to convalescent homes and for home nursing. The following particulars show the extent to which the facilities for treatment are used. Dental treatment:—321 children under five years of age, 353 expectant and 61 nursing mothers made 996 attendances for treatment; 40 mothers were fitted with dentures, and eight dentures were repaired. Physio-therapeutic clinic:—181 new cases were referred to the clinic. The attendances at the consultant orthopaedic clinic numbered 105, and 405 patients were seen by the consultant physiotherapist. 1,050 attendances were made for massage and exercises, and 2,860 for electro-therapy. Correction of visual defects:—87 children were treated by arrangement with the Middlesex County Council, most of these being recommended to obtain glasses. Provision is made by which children wearing glasses are re-tested periodically. Operative treatment of tonsils and adenoids:—11 children were treated at the Harrow and Wealdstone Hospital for this condition under the provisions of the agreement. Convalescent homes:—15 children and two mothers were admitted to convalescent homes. Home nursing:—Responsibility was accepted for the payment of the fees for the treatment of 18 patients. 63 Up to this year, only those within the limits of the Council's financial scale could obtain these forms of treatment under the provisions made by the Council, the patients' contributions being assessed according to their means. Early in the year this policy was amended, so as to enable those who wished to obtain treatment in this way to do so subject to their contributing an amount equal to the cost price to the Council for the treatment. No upper income limit was established outside of which treatment could not be obtained. Consideration might have to be given to this question. INFANT LIFE PROTECTION. The same arrangements continued in force with regard to the supervision of foster-children, each home being visited every month. 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 89 Number of persons registered during the year 69 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.) 14 Number of persons on the register who were receiving children for reward at the end of the year 99 Number of children on the register at the beginning of the year 155 Number of children received during the year 246 Number of children removed from the register during the year 234 Removed to care of parents 121 Removed to care of another foster-mother 45 Legally adopted by foster-parent 6 Removed to charitable organisation, etc. 31 Removal to hospital 23 Of this number seven died. Foster parent left the district taking the child with her - Child attained the age of nine years 5 Died 3 Number of children on the register at the end of the year 167 Most of the foster-mothers in this district are registered for the care of one child only though some have up to four, and there are two children's homes suitably staffed which are registered for the reception of 22 and 20 children. Monthly visits are made by the health visitors to all homes. One boarding school which occasionally had children under nine years of age was in accordance with Section 219 (1) (b) of the Public Health Act, 1936, exempted from these provisions of the Act. 64 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; consultation at the home in exceptional cases; provision of milk; dental treatment, including provision of dentures; ophthalmic treatment; and artificial sunlight treatment. At confinement:—Assistance in payment of midwife's fees; home helps; maternity sets; consultation in cases of difficult labour; emergency maternity outfit; institutional accommodation ; and ambulance for removal of women in labour. Post-Natal:—Post-natal examination at the clinics, 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 a total of 1,221 visits to 717 expectant mothers. One of the repercussions of the operation of the Midwives Act will be the subtraction of ante-natal care from the duties of health visitors. Ante-natal Clinics. At the beginning of the year ten weekly and one fortnightly ante-natal sessions were held at eight separate premises. One session at the Church Hall, Imperial Drive, was transferred to the Spiritualist Hall, Vaughan Road, and a weekly session was opened at the Baptist Church Hall, Streatfield Road, Kenton, so that at the end of the year there were, in the district, 11 weekly and one fortnightly ante-natal clinics held at ten separate addresses. Since the inception of the midwifery service, ante-natal clinics have been staffed by one midwife and one health visitor, instead of as formerly by two health visitors. The following summarises the work done at the clinics during the year:— Total number of expectant mothers attending the clinics 1,789 Total number of attendances by expectant mothers at all clinics 8,585 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 57 65 Compensation for Midwives. The same arrangements continued in force by which compensation is paid to a midwife whose case is 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. During the year compensation was paid in respect of two cases. Consultant Ante-natal Clinic. The consultant ante-natal clinic was held fortnightly at the Broadway Clinic throughout the year. The patients are mostly referred from the local ante-natal clinics, at least one visit of even the apparently normal primipara being encouraged. Patients are also referred direct by the general medical practitioners in the area and post-natal cases are also seen. During the year 322 women made 416 attendances. Of this number 68 were referred by local medical practitioners, five were post-natal and five gynaecological cases. General Practitioner Ante-natal Scheme. The same arrangements by which pregnant women can receive ante-natal supervision by their own medical attendants was continued last year. Again only a very limited use was made of the scheme, 41 patients being seen by eight practitioners. Of this number, nine were insured patients. Only six women attended for post-natal examination. ARRANGEMENTS MADE FOR CONFINEMENTS. At Home. 1,433 confinements took place in the patients' own homes. Of these 766 were attended by midwives acting in their capacity as midwives, and 445 by local midwives who had given notice of their intention to practice, acting as maternity nurses. In 559 cases the Council paid or contributed to the fees of the midwife, and in 82 cases a home help was provided. Consultant services:—During the year a consultant was summoned to 13 cases. Two were ante-natal cases, in one of which induction was advised, the other being a case of hyperthyroidism. Two patients were suffering from puerperal pyrexia, one due to pulmonary infarct, the other to a mild infection of the cellular tissue of the pelvis. The remaining patients to which the consultants were summoned were in labour:—(1) long labour—patient admitted to hospital for Cæsarean section; (2) uterine inertia— patient removed to hospital where normal delivery took place; (3) retained placenta—placenta removed and intravenous gum saline given; (4) persistent occipito-posterior presentation and uterine inertia—double episiotomy performed, followed by normal delivery; (5) placenta praevia—patient removed to hospital where, E 66 because of the complication of a small pelvis, Cæsarean section was performed, followed by blood transfusion; (6) post partum haemorrhage—uterus emptied, bleeding vessels tied and blood transfusion given; (7) uterine inertia and failed forceps—normal delivery; (8) disproportion—normal delivery; (9) persistent occipito-posterior presentation and disproportion—rotation, incision of cervix and episiotomy, followed by normal delivery. In an Institution. 806 births occurred in registered nursing homes in this district. 285 births to mothers from outside districts which occurred here took place in nursing homes, four in private houses. Of these 806 confinements 716 were conducted by local practitioners, 84 by midwives and 358 by midwives acting as maternity nurses. Notification of 1,367 births were received in respect of Harrow mothers having taken place outside the district. Of these 1,170 were from hospitals, 77 from nursing homes, and 120 from private houses. Of the patients confined in hospital outside the district 339 were delivered at Redhill County Hospital and 192 at Bushey Maternity Hospital. Of a total of 3,132 births, 1,433 occurred in the patients' own homes, 521 in local nursing homes and 1,247 in hospitals or homes outside the district. Some 1,768, or 56 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year 35 patients were admitted to London hospitals under the Council's arrangements. Owing to the increase in maternity accommodation at the Redhill County Hospital and its annexe at Bushey Heath, many more confinements occurred in this institution than formerly. 450 women attending the local ante-natal clinics were referred to the Redhill Hospital during the year with a view of their being admitted there for their confinements. Of this number 125 were referred on account of some medical condition, 93 because of domestic circumstances, 191 because the applicants were primigravidæ and 41 merely because of the personal preference of the applicant. Owing, no doubt, to the fact that, during the year, new beds, which had not previously been booked, became available, most of these women were accommodated, only seven being refused; though a further 42 decided to make other arrangements, most of these deciding to be confined at home, though a few arranged to be admitted to other hospitals or nursing homes. The single refusal of those who were recommended because of domestic circumstances arranged to enter another hospital; four of those whose applications for admission were based merely on personal inclination were refused, all of them subsequently being confined in their own homes. Of the two of those recommended for admission on medical grounds who were refused, one was confined at home, while the other was confined in another hospital. 67 The arrangements by which the local clinics exercise ante-natal supervision over the normal patients to be admitted in the County hospitals are working very smoothly, and undoubtedly by saving them the tedious journey to the hospital the arrangements afford great relief to the patients. This practice has now been extended to benefit those patients who attended the County hospital in the first place and had arranged to be confined there. 145 such were referred by the hospital to the local clinics for their ante-natal supervision. Any cases who apply to the hospital but who cannot be accommodated are also referred to the local clinics. While additional beds becoming available during the year resulted in the hospital being in a position to accommodate a high percentage of applicants, even of those whose only reason for being confined in a hospital was their own personal wish, it is to be expected that in future the same conditions will not obtain, and that selection, possibly even stringent selection, will be carried out in determining those to be admitted; and that the number of beds available will not prove sufficient to meet the demands of the mothers who, to an increasing extent throughout the country, are expressing their desire to be confined in a hospital rather than at home. Even the most popular domiciliary midwifery service cannot compete against this wish, and it is probable that the availability of accommodation this year at the Redhill Hospital and its annexe has had some effect in reducing the number of domiciliary confinements in the district, including those that would have been attended by the Council's midwifery staff, and the number of confinements in the local maternity homes. POST-NATAL SERVICES. Post-natal Examination. 181 women attended the clinic for post-natal examination, making altogether 273 attendances, while a further six were examined under the general practitioner ante-natal scheme. Puerperal Infection. (a) Consultant services:—The consultant was summoned to two patients suffering from puerperal pyrexia and to two patients shortly after confinement. (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. During the year 19 patients were removed. (c) Home nursing:—Two patients suffering from puerperal infection were nursed under the Council's arrangements by the staff of the local District Nursing Association. 68 BIRTH CONTROL CLINIC. Fortnightly sessions of this clinic were held throughout the year. 311 women, of whom 92 attended for the first time, made a total of 327 attendances. In addition there were six cases to whom no advice was given as there were no medical grounds justifying such action. MIDWIVES ACTS, 1902-1926. The number of midwives who, during the year, notified their intention to practise in this district was 57. Of these eight removed from the district or discontinued practice, leaving 49 in practice at the end of the year. Of the total number 28 were resident in the district and carried on a domiciliary practice almost entirely limited to this area; 16 were engaged in local maternity homes, most of them entirely, though a few also carrying on a very limited domiciliary practice; and 13 were resident in adjoining areas but attended some cases in this district. The number of births attended in the district by midwives who gave notice of their intention to practise was 1,654. In 851 cases the midwife was in attendance as a midwife and in the remaining 803 as a maternity nurse. Of the confinements occurring in private houses in the district 1,211 were attended by local midwives whose practice is limited to domiciliary work (725 as midwives and 410 as maternity nurses) and 76 by midwives from adjoining areas (41 as midwives and 35 as maternity nurses). At the end of the year there were in practice 10 independent midwives carrying on a domiciliary service. These between them attended 70 cases during the year, one attending 29 cases, two between 10 and 20 cases, four under 10 cases, while three did not attend any. By the rules of the Central Midwives' Board it is obligatory on midwives to send a notification to the local supervising authority in certain circumstances. During the year the following numbers of notifications were received:— Sending for medical assistance 277 Still birth 16 Death of Infant 12 Death of Mother — Laying out the Dead 11 Artificial Feeding 27 Liability to be a Source of Infection 26 Of the 277 summonses to medical practitioners, 39 were on account of some condition during pregnancy, 70 during labour, 111 in the lying-in period and 57 abnormality of the infant. 69 Of the 39 summonses to a patient during pregnancy, the most frequent was on account of ante-partum hæmorrhage in 15 instances, and 11 were on account of albuminuria, oedema or toxaemia. Of the 70 summonses to a patient during labour, the reason given in 53 instances was delayed labour. Abnormal presentation (including persistent occipito-posterior and breech) accounted for 12, and foetal distress for three. One summons was on account of abortion. 74 of the 111 summonses to patients in the puerperium were on account of rupture of the perineum. Post-partum haemorrhage, with or without adherence of the placenta, was the reason in nine cases. A raised temperature was the cause in 13 instances, and phlebitis in two. Of the 57 summonses to infants, 17 were on account of some discharge from the eye, feebleness or asphyxia in 31, and some other abnormal state or condition in five. Though the local authority is responsible in the first instance for the payment of the medical practitioners' fees for attendance on cases to which they have been summoned by midwives' medical aid notices, in regard to 42 out of the 277 summonses no claim was made on the authority. Of those made about 33 per cent. were for sums of 1 guinea, 25 per cent. for sums of 2 guineas and about 15 per cent. for sums of 5s. 0d., the average being about 25s. 0d. The authority is entitled to recover all or part of the fee paid out from those responsible for the care of the patient. It has been decided that no claim should be made in respect of attendances on cases of any discharge from an infant's eye, of which there were 13 cases during the year. By the operation of the scale adopted the full charge was claimed from about 75 per cent. of the remaining cases, from about 5 per cent. one-half of the charge was claimed, and in about 20 per cent. of the cases no claim was made. MIDWIVES ACT, 1936. Staff. The 15 midwives in the Council's service are grouped in teams of three. The following table is a summarv of the work done by each individual midwife and also by each team. The fluctuations in the numbers of cases attended by the midwives is not, of course, a true index of the work performed by each midwife, as each would undertake part of the nursing for the rest of the team. 70 Midwife. Maternity. Total. Total of Team. Team 1 A 49 30 79 B 28 37 65 C 18 31 49 193 Team 2 A 32 23 55 B 38 11 49 C 54 21 75 179 Team 3 A 52 34 86 B 30 20 50 C 55 34 89 225 Team 4 A 38 33 71 B 37 24 61 C 41 24 65 197 Team 5 A 57 8 65 B 67 12 79 C 64 8 72 216 Total 660 350 1,010 In the Ministry of Health Circular 1569, addressed to local supervising authorities under the Midwives Act, it was stated that the Minister was advised that for the purpose of their calculation local authorities might assume that in populous districts each midwife should usually be capable of attendance on 70 cases as a midwife and 30 cases as a maternity nurse during the year. Even before the scheme was put into operation in the country it was believed that this figure should not exceed 80. Actually in this area, more particularly because of the attendance of the midwives at the ante-natal clinics, the average figure should probably not exceed 70. Even this will not allow for prolonged absence of any of the staff for illness, nor for the absence of at least two members of the staff each year at post graduate instruction. Surrender of Certificates. In the financial year 1937-38 the sum of £398 was paid to one midwife carrying on a domiciliary practice; £330 to one who ran a nursing home, and £35 was paid to neighbouring authorities who were compensating midwives who carried on a limited practice in this district. In the year 1938-39 sums of £836 and £677 were paid to two midwives who, for a few months, were on the Council s staff, and £24 was paid to other authorities. 71 Finance. Of the 660 patients attended by the midwives acting as midwives, 182 were charged the full amount, to 78 no charge was made, while 400 were assisted. The corresponding figures in regard to the 350 patients attended by the midwives acting as maternity nurses were 269, seven and 74. Midwives Medical Aid Notices. At the meeting of the Public Health Committee on 15th September, 1937, it was reported that Circular 1622 had been considered at a meeting of the local practitioners, when the following resolutions were passed:— "(1) That in order to obtain the best possible local obstetric skill we should support the policy of the local authority in forming a list of local practitioners, open to all practitioners willing to undertake obstetric work on the summons of a midwife under the rules of the Central Midwives' Board. (2) That we should establish a liaison between the profession and the local authority by setting up a consultative committee, consisting of members of the local profession and of the local authority, with a view to the maintenance of a high standard of midwifery." The Public Health Committee were authorised, in conjunction with the local medical practitioners, to prepare and maintain a list of practitioners willing to undertake obstetric work upon receipt of a summons by a midwife under the rules of the Central Midwives' Board, and nominated five of their members as representatives on the proposed Joint Consultative Committee. The Harrow Branch of the British Medical Association nominated as their representative to serve on the Committee, Dr. Christie Brown, the Council's Consultant Gynaecologist, and four local medical practitioners. All practitioners practising in the area were communicated with and invited to intimate whether they would be available to respond to a midwife's summons, and, if so, whether they would be available for any emergency or only for an emergency arising with regard to their own patients. At the same time they were invited to nominate from those included on the list a deputy to act for them if necessary. Of the 150 practitioners written to 74 wished to be included in the list. Of these, 35 were willing to be of service in any part of the district, 22 were willing to respond only to calls from restricted areas, 13 would be available in any part of the district but only in respect of their own patients, while four would be available only for those patients in respect of whom they had undertaken ante-natal supervision. A further communication brought in replies from others, so that by the end of the year the names of 95 practitioners were on the list. 72 Section 6. This section prohibits in the area of any local authority to which it is applied by order of the Minister of Health unqualified persons from acting as maternity nurses for gain, with saving provisions in respect of (a) persons undergoing training with a view to becoming fully qualified medical practitioners or certified midwives, (b) persons attending women in registered nursing homes, etc., and (c) women certified by the authorities of approved hospitals or other institutions to have been trained in obstetric nursing. Early in the year application was made to the Minister for the Order to be put in force in the district, and later intimation was received that the Minister had made the Harrow Urban (Midwifery: Prohibition of Unqualified Persons) Order, 1938, applying Section 6 to the Urban District as from June 1st. NURSING AND MATERNITY HOMES. Particulars of the registered nursing homes in this district were given in the Report for the year 1935. One new nursing home was registered during the year, No. 1, Lyncroft Avenue, for one surgical or maternity case. No. 121-123, College Hill Road was extended and registered for 10 maternity cases, St. Ann's Nursing Home similarly for four maternity cases, while No. 21-23, Albert Road changed hands. Exemption from registration was again granted for a period of one year to two voluntary hospitals in the area. Nursing homes are inspected every six months by an Assistant Medical Officer and the Superintendent Health Visitor, while those registered for the reception of maternity cases are visited every three months. No special steps are tak'en to discover unregistered homes, as it is felt that any premises used for this purpose can hardly escape the knowledge of the health visitors, a study of the local press, and a scrutiny of the local death certificates. At the end of the year there were 24 homes registered in this district, with a total of 187 beds, of which 100 could be used for maternity cases. MILK ISSUES. Owing to the amended scale of income on which the issue of milk is determined, there was during the year a large increase in the numbers assisted, the figure in December, 1938, being 1,051, as compared with 438 for the corresponding month in 1937, and 352 in 1936. Of this number 869 grants were for pasteurised milk and 182 for packet milk. 73 The following is a summary of particulars of the milk issues Total quantity of milk supplied by the Council to expectant and nursing mothers and young (a) Liquid Milk 33,236 gals. children during the period Jan. 1st to Dec. 31st, 1938... (b) Dried Milk 40,073 lbs. Total cost of above... (a) £3,132 0s. 3d. (b) £3,066 10s. 11d. Total £6,198 lis. 2d. Receipts (a) Nil (b) £1,364 10s. 2d. Net Cost £4,834 1s. 0d. CLINIC BUILDINGS. At their meeting on June 28th the Council approved of the revised arrangements for the erection of buildings at Marsh Road, Pinner, Alexandra Avenue, South Harrow, and Honeypot Lane, whereby such buildings would be erected and solely controlled by the Middlesex County Council, the County Council to rent to the District Council those portions of the buildings to be used for maternity and child welfare services, and to give an assurance of security of tenure of the accommodation to be provided, and for reasonable extension of such services from time to time as the need arises. A small parcel of land at the rear of the Broadway, Pinner Road, which was considered suitable for the erection of a maternity and child welfare clinic was purchased. 74 SCHOOL MEDICAL SERVICES. The following information regarding the school medical services in the district has been kindly supplied by the County School Medical Officer. ELEMENTARY SCHOOLS. Medical Inspection. The number of children on the roll at December 31st, 1938, was 19,285. The following are the particulars of children inspected during the year:— Routine Medical Inspections 6,368 Entrants 2,175 Age 7 1,490 Age 10 1,504 Age 13 554 Other ages 645 Treatment of Minor Ailments. The attendances at the clinics established for the treatment of minor ailments were:— Roxeth Hill Council School, South Harrow 1,878 Broadway Clinic, Wealdstone 3,049 Whitchurch Institute, Stanmore 899 Elmwood Avenue, Kenton 136 Pinner Park School 160 Treatment of Visual Defects. 424 children were refracted (including 118 re-tests) at the ophthalmic clinic held at 76, Marlborough Hill, Wealdstone, and 39 other children examined. Spectacles were prescribed for 277 children and changes of lens in a further 12, while repairs to the glasses of 106 children were arranged. Three cases of squint were referred to hospital for operation, and nine children suffering from other diseases of the eye were sent to hospital for treatment. Dental Inspection and Treatment. Particulars of the routine dental inspection of elementary school children are set out below:— 5 6 7 8 9 10 11 12 13 14 15 Total 520 1,055 1,164 949 877 934 1,135 1,208 1,052 371 17 9,282 Of this number 6,234 were found to require treatment. 75 SECONDARY SCHOOLS. Medical Inspection. There are four secondary schools in the district and one Junior Art School. The following are the particulars of the medical inspection carried out:— 10 11 12 13 14 15 16 17 Total 1 245 228 47 80 199 47 6 853 Treatment of Defective Vision. 144 children were refracted at the ophthalmic clinic (including 21 re-tests) of whom 102 were supplied with spectacles. Two changes of lens were also provided and repairs to glasses carried out in 15 instances. One child suffering from a disease of the eye was referred to hospital for treatment. Dental Treatment. Particulars of the routine dental inspection of secondary, etc., school children are set out below:— Ages. 11 12 13 14 15 16 17 18 19 Total — 108 168 136 54 76 34 2 — 578 Of this number 450 were found to require treatment. 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 - - - - 1 - - 1 - - - - - - - - - - - - - - 1 1 1 1 3. Scarlet fever - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Whooping cough — — — 1 1 - - - - - - - - - - - - - - - - - 1 1 1 1 5. Diphtheria — — — — 3 — 3 2 - - - - - - - - - - - - - - 6 2 6 2 6. Influenza - - - - - - - - - - - - 1 1 1 — — — 3 1 — 1 5 3 5 3 7. Encephalitis lethargica - - - - - - - - - - - - - - - - - - - - - - - - - - 8. Cerebro-spinal fever — — 1 - - - - - - - - - - - - - - - - - - - 2 - 2 - 9. Respiratory tuberculosis 1 - - - - - - - 4 5 7 17 4 10 5 5 7 — 1 — — — 29 37 30 38 10. Other tuberculosis — — 1 1 5 3 — 1 2 — 1 1 — — 1 1 — — — — — — 10 7 10 8 11. Syphilis — 1 - - - - - - - - - - - - - - - - - - - - - 1 1 1 12. General paralysis of the Insane - - - - - - - - - - - - 2 - - - - - - - - - 2 - 2 - 13. Cancer — — — — — — 1 1 — — 1 1 7 14 18 18 33 24 27 29 17 22 104 109 103 109 14. Diabetes - - - - - - - - - - - - - - - - - 2 5 4 — 5 6 11 7 11 15. Cerebral hæmorrhage - - - - - - - - - - - - 3 1 4 2 6 10 10 9 6 19 29 41 27 40 16. Heart disease - - - - - - 4 3 — 1 2 5 9 9 10 4 39 25 44 44 38 49 146 140 150 144 17. Aneurysm — — — — — — — — — — — — 1 — 1 1 — 1 1 — — 1 3 3 4 2 18. Other circulatory diseases — — — — — — — — 2 — — — — — 2 3 1 4 10 4 16 20 31 31 32 32 19. Bronchitis 3 2 — 1 — — 1 — 1 — 1 — — 1 — — 4 — 2 4 5 6 17 14 18 13 20. Pneumonia 11 8 2 1 3 1 — — 4 — 1 2 4 2 6 3 6 5 5 12 7 7 49 41 50 42 21. Other respiratory diseases — — — — — — — 1 — — — — 1 1 — — 1 2 — — 1 — 3 4 3 4 22. Peptic ulcer — — — — — — — — — — — — 2 1 2 — — — 3 1 1 — 8 2 8 2 23. Diarrhoea (under 2 years) 13 9 1 1 - - - - - - - - - - - - - - - - - - 14 10 15 10 24. Appendicitis — — — — — — 2 1 2 — 1 1 1 — 3 2 1 — 1 — 1 — 12 4 11 5 25. Cirrhosis of liver — — — — — — — — — — — 1 1 — — 2 1 — — — 1 — 3 3 3 3 26. Other diseases of liver - - - - - - - - 1 - - - 1 1 - - - - - - 1 — 3 1 3 1 27. Other digestive diseases 2 1 — — — — — — — — — — 2 2 1 — 2 2 — 2 — 4 7 11 8 12 28. Nephritis — — — — — — — 1 — — 1 1 1 — 1 2 3 1 6 7 4 3 16 15 18 15 29. Puerperal sepsis - - - - - - - - - - - 3 - - - - - - - - - - - 3 — 3 30. Other puerperal causes - - - - - - - - - 3 - 2 - 4 - - - - - - - - - 9 — 9 31. Congenital debility 38 26 - - - - - - - - - - - - - - - - - - - - 33 26 39 31 32. Senility — — — — — — — — — — — — — — — — — — 2 2 13 22 15 24 15 21 33. Suicide — — — — — — — — 1 3 2 1 2 5 6 — 2 — 3 — — - 16 9 16 9 34. Other violence. 3 1 — — 1 1 3 1 3 1 4 4 1 — 2 2 3 — 2 — 2 7 24 17 20 17 35. Other defined diseases 3 4 1 1 — 1 5 — 2 2 1 7 6 10 8 9 9 7 18 5 13 3 66 49 66 49 36. Causes ill-defined - - - - - - - - - - - - - - - - - 1 - - - - - 1 — 1 Total 74 52 6 6 14 6 19 12 22 15 22 46 49 62 73 54 118 84 143 124 126 169 666 630 674 637