HARR 6 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1939 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 1939 CARYL THOMAS, M.D., B.Sc., D.P.H., Barrister-at-Law. 2 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 1939. In accordance with their usual practice, the Ministry of Health issued a circular, though not this time until the February of this year, as to the contents and arrangement of the Annual Report of the Medical Officer of Health, the general form of report following very largely on that for previous years. In July, however, a further circular was issued by the Ministry in which it was suggested that, because of the increased pressure of work in public health departments, and also with a view to economy of paper—the relative importance of these two factors not being intimated—that that issued for 1939 should be an interim report only, being confined to essential and urgent matters which have affected the public health during the year. As, however, for the most of the year, apart from interruptions by all raid precautions preparations, the normal health services were in being, and as the biggest changes in the services to arise from the war will, it is expected, have occurred round about the beginning of the war, it was felt that it would be preferable to record the 1939 occurrences in the more usual form, even though the reports for subsequent years are to be of a different pattern. One of the immediate effects of the outbreak of hostilities was the loss to the department of the services of several members committed to service in His Majesty's Forces. Some left immediately, others later, but by the end of the year the staff involved included one of the assistant medical officers, the superintendent midwife, one of the health visitors, the chief clerk, and three assistants to the sanitary inspectors. Apart from these we had already lost the service of one of the sanitary inspectors seconded for A.R.P. duty, while the Shops Act inspector was seconded for duty in the Food Office. Another of the assistant medical officers resigned shortly after the outbreak of hostilities and could not be replaced until the new year. The section most seriously affected by the withdrawal of service of the personnel is that of the sanitary inspectors. To such an extent is the shortage felt that of course a serious curtailment in service has had to be effected. With the reduced staff it is just simply not possible to help people to the extent that they 3 were formerly assisted, and the activities of the inspectors have to be limited to dealing with those matters of real sanitary significance and with matters with which they have actual powers to deal. Such matters as routine housing inspection have to be left untouched, not only because of the shortage of staff, but because it would not be possible to enforce the carrying out of work necessary to comply with any notices that might be served, because of the owner's difficulty in obtaining materials and labour. Apart from the fact that the Meat Depot takes up practically the whole time of one of the inspectors, their availability for their strict duties as sanitary inspectors is further curtailed by the senior sanitary inspector having been appointed chief billeting officer, so that the time of himself and of his colleagues has been taken up in finding billets, more particularly for the staffs of the hospitals in the district. Apart from the few weeks following the outbreak of hostilities, when the time of the health visitors was almost entirely devoted to A.R.P., more particularly at the first aid posts, they have been enabled to carry on their ordinary duties and, up to the end of the year, it had not been necessary to use them to any great extent for other purposes. No special difficulties arose in the case of the work of the midwives. The transfer of population from one area to another and the closure of some hospitals resulted in their having to attend patients who were newcomers to the district, but as they were, to some extent, relieved of attending some they had already booked because these had left the district, the numbers they actually had to attend were well within their scope and no real difficulties arose. The midwives were of great assistance in the first few weeks of the war, when practically all the ante-natal clinics had to close down, as they arranged for numbers of their patients to attend at their, the midwives', homes, and were there seen by the assistant medical officer. The war has made little difference to the isolation hospitals. So few cases were notified that it was possible to close down the Honeypot Lane hospital and for the rest of the year no patients were admitted here. The diphtheria block at South Harrow cannot be satisfactorily rendered blast or splinter proof. Diphtheria patients were therefore transferred to one of the other blocks and scarlet fever patients were admitted to the old diphtheria block with arrangements for the transport of these patients to the more sound scarlet fever block on the occurrence of an air raid warning. Owing to the transfer of large masses of the population of the country and to the fact that many of the males would be in the Army, the Registrar General devised arrangements for dealing with the statistical treatment of non-civilian deaths and of transferable births and deaths, the purpose being to ensure as far as possible that the rates reflected the different conditions in the areas in which 4 the persons at risk lived. In the case of infant and maternal death rates this would be areas in which the births occurred. Under the prevailing war conditions non-civilian (non-civilian being defined as all males serving in H.M. Armed Forces, but not including women in auxiliary corps, nor any members of A.R.P. auxiliary fire brigade or other similar auxiliary or civil defence service) deaths will not be assigned to local administrative areas. Transferable deaths up to the 30th September were dealt with in accordance with pre-war practice; but those occurring as from the 1st October, in the case of a person temporarily residing away from home on account of the war the death was assigned to the area of temporary residence, a similar arrangement being made where such a person dies in an institution. Similarly, in regard to transferable births, up to the 30th September the previous practice of transference to areas of the mothers' usual residence was maintained. As from October 1st, the primary assignment for the purpose of calculating birth rates was in accordance with pre-war practice; but for the purpose of calculating infant and maternal mortality a secondary arrangement was made corresponding to that adopted for deaths, namely, to the area in which a mother may be temporarily residing as a result of war. The number of live births for purposes of calculation of birth rates was 3,321 (1,710 and 1,611), and for calculation of death rates 3,320 (1,711 and 1,609). The figure of the estimated population for calculation of birth rates is 190,200 and for the calculation of death rates, or of the incidence of notifiable disease, 189,300. Being a neutral area, with consequent relatively slight changes in population—at least during 1939—the differences are not marked. In common with other areas the death rates will not have been affected to any great extent by the calling up of men to the Services. The vital statistics show that the year was a very healthy one for the district, the only factor accounting for any excessive morbidity or mortality being the exceedingly cold spell in the early weeks of the year, which was reflected in a high mortality from respiratory complaints. Both the infant mortality and maternal mortality rates were low, the latter being the lowest recorded in this district since amalgamation. Though the death rate per thousand population for diphtheria is low, having regard to the low incidence of the disease the position is not satisfactory, as the case mortality is very high. This is doubtless in some measure associated with the low incidence, as, while during epidemic times the public is aware of the prevalence of the infection, so that any throat condition is soon followed by inspection by a medical man, the contrary position obtains in the absence of widespread infection, as parents are then the less likely to summon a doctor when diphtheria is not in their minds. The high case mortality is undoubtedly related to the late stage at which the patients obtain specific treatment. There was not this year a repetition of 5 the high mortality amongst infants from gastro-intestinal affections. Statistics relating to tuberculosis are likely to be fallacious during the war because of the transference of population. It is the duty of a medical practitioner, on becoming aware that his patient is suffering from tuberculosis, to notify the fact to the medical officer of health of the district in which the patient is residing, this duty being imposed on him irrespective as to whether or not the patient had previously been notified in some other area. Many of the transferred persons who have already been notified in their own districts will, in due course, be notified in the area in which they have been temporarily transferred. There may, of course, be more than one transfer in respect of any particular person. While such persons are notified and their names added to the registers of the receiving authorities, in very many cases it is unlikely that they will be removed from the registers of their own areas. Tuberculosis statistics, therefore, for many districts, will give erroneous impressions because of the increase in the notifications and the numbers of persons on the register, while, taking the country as a whole, the summation of these notifications for the different areas will give a figure much larger than in former years, and therefore give a fictitious impression of a heavy increase in the incidence of the disease. Reference is made in the body of the Report to the lessening of the incidence of scarlet fever in the last quarter of the year, a time when, of course, a heavier rate of infection is expected. This phenomenon, which, however, was not shared by diphtheria (which, although the numbers are small, did, in fact, show a doubled rate of incidence in the fourth as compared with the third quarter), was in keeping with the experience of the local medical practitioners that, with the onset of hostilities, illness seemed to have disappeared. While the disturbances resulting from the war, with its excitement and concentration of attention on matters other than one's own personal feelings, might have been an explanation in part of the very large reduction made by his patients on the time of the general medical practitioner, a demonstration of the influence of mind over matter, it is difficult to imagine that a reduction in the incidence of scarlet fever could be ascribed to the increased resistance to the haemolytic streptococcus infecting the fauces of the more youthful members of the community brought about by similar influences. Whatever the explanation the future may yield—and probably it will prove necessary to accept the occurrence as being entirely fortuitous—there is no doubt as to the benefit derived through the absence of a heavy incidence of infection at a time when so many demands were being made on the staff in other spheres. This low incidence of scarlet fever was not the only instance of a departure from the expected demonstrated by infectious illness, as measles, which should have made its appearance in the latter months of 1939, heralding in the bi-annual epidemic in the 6 early part of 1940, also failed to put in an appearance. This failure has since proved to be mere postponement, but since the heavy incidence occurred in the summer months rather than in the early months of the year there have been far fewer respiratory complications, and even though ultimately the outbreak proves to have been of the same magnitude as the expected incidence again this mere postponement will prove to have been of advantage. There are those who see in these alterations in the outbreaks of infections which have occurred since the commencement of hostilities an association with action taken because of the war, namely, the effects of evacuation and of school closure. While the fact that these major departures from the expected should occur at the same time as these vast alterations in the living of the susceptible members of the community suggests that the matter is more than a mere coincidence, before too much can be ascribed to these changes following evacuation it should be appreciated that variations in behaviour of epidemic diseases have occurred in other countries not similarly the subject of evacuation; that the changes in behaviour in the epidemic diseases were demonstrated in neutral areas, that is, in districts in which there would have been no major flow of population either in or out and no major departures in the practice of opening schools; that the population that evacuated was still only a portion of the population at risk (i.e. the risk of infection) and not anything like the whole population ; that the evacuation, even on this partial scale, was, to a very great extent, only temporary, and the general effect not on a very much greater scale than occurs ordinarily in the month of August. The third interim report of the Local Government and Publi( Health Consolidation Committee, set up with a view to recommending consolidation in Local Government and Public Health law, dealt with enactments relating to food. The Committee found that one of the most difficult questions to be decided was which local authority should enforce those provisions of the Bill which reproduced the law administered by the food and drugs authorities. This subject had been fully considered by the Royal Commission on Local Government, which reported in 1929, and which recommended that the administration of the Food and Drugs (Adulteration) Act, 1928, and the appointment of public analysts should be assigned to county councils and county borough councils ; that councils of county districts should retain the right to procure samples and take proceedings; and the county council should be empowered if it thought fit to contribute towards the cost incurred by the council of a county district. This recommendation was not acceptable to those members of the Committee representing local government associations. The Committee, however, was in entire agreement that the population of an area in 1881 was out of date as a criterion of fitness to administer these Acts, and that a definition in terms of boroughs having police establishments and 7 courts of Quarter Sessions had become irrelevant in view of the fact that the service in question was now rightly treated as a public health service rather than as a police matter. The Committee expressed the opinion that the main factors determining whether a local authority should be the food and drug authority were the extent to which the routine work of food inspection and sampling in the area would represent something more than occasional duties for the officers engaged in the work; and the standard which the authority had achieved in its public health arrangements. The first of these factors is mainly determined by the size of the population of the area, and in judging the second it is relevant to consider whether the authority employs, on the one hand, a medical officer of health who is engaged exclusively in their work or exclusively in the work of public authorities, or, on the other hand, one who has a part-time private practice. Having regard to these considerations the Committee agreed to compromise by recommending that the functions be entrusted to county councils, county borough councils, and the councils of urban areas (whether borough or urban districts) having a population, according to the last published census, of not less than 40,000, and empowering the Minister by Order to confer them on the council of any other urban area with a population of not less than 20,000. Clause 64 of the Bill gave effect to this recommendation. In its passage through the House, however, it was modified, so that Clause 64 of the Act is the corresponding clause of the Bill with the addition of the proviso that if a county council satisfy the Minister that the area or areas in respect of which they would be the food and drugs authority would be rendered inconvenient in size, shape, or situation for the efficient performance of their duties as the food and drugs authority, the Minister may direct that the county council shall be the food and drugs authority as respects the district or districts of any one or more of the local authorities who, but for such a direction, would be food and drugs authorities under this Act, but were not such authorities under the law in force immediately before the commencement thereof. The Middlesex County Council took advantage of this clause and made representations to the Ministry that the County Council should retain their existing powers as the food and drugs authority, this in spite of the fact that the work is in charge not of the public health but of the public control department. Although, in common with that of some other local authorities, this Council felt that the sampling in this area was not done to the extent it would have been had it been the duty of the local authority, and that the cost per sample taken was considered to be inordinately high, so that they felt that they could provide a better service more economically, the Ministry supported the application of the County Council. Because it was feared that the Order of the Food Controller 8 raising the maximum price of milk might result in a number of expectant and nursing mothers and young children being precluded, through lack of means, from obtaining a supply of milk adequate to their needs, the Milk Order of 1919 of the Food Controller empowered local authorities to provide milk to those whom the person authorised by them certified such provision to be necessary. Two years later this Order was revoked as the Minister had decided that many local authorities were incurring expenditure greatly in excess of what was considered necessary or desirable for the purpose in view, and in place of the powers withdrawn the Minister laid down conditions under which milk should be granted, limiting the class of person entitled to benefit and the amount permitted to be given. Grants of milk at less than cost price could be given only where the medical officer of health or, in certain cases, the medical officer of the centre, was satisfied that a supply was necessary on grounds of health. For years most local authorities granted milk at reduced rates subject to these conditions, though, in point of fact, apart from those cases where a special recommendation was required in order that the recipient could have more than the usual amount, the only criterion on which milk grants have been made has been a financial one, that is, whether or not the income of the family was less than a certain figure which varied, usually, with the number of the family, though the recommendation was actually made by the medical officer of the clinic. This very general practice had the advantage that it resulted in the attendance at the clinics of certain persons who otherwise, perhaps, would not have come, persons whose infants needed the supervision of the health visitor and the medical officer. Local authorities in making grants of milk have had regard to the safety of that supplied. Although not many have given the graded milks, many have been able to arrange for the supply of pasteurised milk and so have been in a position to assure themselves that the milk was safe. In 1934 the Milk in Schools scheme came into operation. This, ostensibly a health measure, as the grant could be made on medical grounds, was a measure designed primarily in the interests of the milk trade. Subsequently, in some quarters, efforts were made to obtain benefits for the child under five similar to those now obtainable for school children, and in August, 1939, the Minister of Health started such a scheme by which local authorities were to obtain milk for maternity and child welfare purposes at a reduced rate. In the application of this scheme, however, there was no assurance of the safety of the milk supply in that the Ministry would not permit the local authority to insist on the milk being pasteurised (a concession, no doubt, to the milk trade, some of whose members seem to deem themselves competent to decide on matters such as the safety of milk and some of whom seem actively opposed to the pasteurising of milk), nor would they, in this district at least, agree to the local authority insisting that the issue should be made only to those attending the 9 clinics. Correspondence on such matters as these delayed the putting into operation of the scheme—fortunately, as it turns out, because, in the summer of 1940, entirely new arrangements were made by which the supply of milk, either free or at low rates to those mothers and children entitled to it, is by the Ministry of Food with their own staff of local officials. Theirs is frankly a distributing scheme in which there is no assurance of the safety of the milk supplied. The application of this scheme does not detract from the powers of the maternity and child welfare authority to grant assistance under its powers and by a continuation of its previous arrangements, but it does, of course, considerably reduce the free issues made by the Council as a maternity and child welfare authority. Owing to the difficulties of the local milk officer in arranging for the supply of dried foodstuffs to those recommended to have dried rather than local milk, the local authority staff at the clinics, acting as the agents of the Food Ministry, have had to come to his assistance. It will be of interest to follow the working of the scheme, more particularly to learn if the milk supplied under the Food Order is to be additional to or a substitution of that formerly purchased for the household. Under the maternity and child welfare arrangements for distribution it was appreciated, of course, that there was little enough assurance that those for whom the milk was intended actually consumed it. Now, it seems, there can be none. Since amalgamation the Public Health Committee has had under constant review the housing conditions in the area, and numbers of individual and of groups of houses have been considered with a view to their capability of being rendered habitable, or, alternatively, to being made the subject of demolition or clearance orders. Starting with those properties in the worst conditions, where there could be no question at all that they were, in their existing state, entirely unfit for human habitation, and were obviously, because ot the unsoundness of the framework, not capable of repair, there is no sharp line of demarcation between these and those properties which admittedly are in need of attention, and where the conditions must be, in some degree, prejudicial to the health of the occupants, but which, because the framework of the house is more or less sound, can be rendered habitable, but again, with some, only at a cost for which there would be no return. Fully to appreciate the way in which the medical officer of health has had to have regard to the cost of repair of houses—a matter on which few medical officers of health will claim to have any knowledge—it is necessary to review the provisions of the enactments dealing with the improvements of housing conditions. Amongst the statutory nuisances included in section 91 of the Public Health Act, 1875, were "any premises in such a state as to be a nuisance or injurious to health." By the Housing of the Working Classes Act, 1885, sanitary authorities had to secure the proper sanitary condition of all premises within their districts. In 10 the 1890 Act, it became the duty of the medical officer of health to report to his authority any dwelling-house that appeared to be in a state so dangerous or injurious to health as to be unfit for human habitation. Local authorities, under the Housing and Town Planning Act, 1909, were required to see that inspections were made in their district for houses so dangerous or injurious to health as to be unfit for human habitation. The implied contract that a house should be kept by the landlord reasonably fit for human habitation during the holding became, under the 1925 Housing Act, an obligation on the owners of properties not exceeding a certain rental to see that the house would be kept in all respects reasonably fit for human habitation. At the same time it was made the duty of the local authority to cause inspections to be made from time to time with a view to ascertaining whether any dwelling-house is in a state so dangerous or injurious to health as to be unfit for human habitation, and a duty of the medical officer of health to report such houses to the local authority. The procedure under this Act for dealing with groups of houses was replaced by the machinery laid down under the 1936 Housing Act. Clearance Areas under this Act were groups of dwelling-houses which, by reason of disrepair or sanitary defect, were unfit for human habitation, or which, by reason of their bad arrangement or the narrowness or bad arrangement of the streets, were dangerous or injurious to the health of the inhabitants, and which were more satisfactorily dealt with by the demolition of all the buildings. Steps could be taken to effect the demolition of any dwelling-house unfit for human habitation which is occupied, or is of a type suitable for occupation, by persons of the working classes. In the Act it is stated that in determining whether a house is fit for human habitation regard shall be had to the extent, if any, to which, by reason of disrepair or sanitary defects, the house falls short of the provisions of any bye-laws in operation in the district, or of the general standard of housing accommodation for the working classes in the district. In the earlier days of slum clearance inquiries the evidence of the medical officer of health did deal largely with the vital statistics of the area under consideration. In the case of large areas where there was a stable population, such figures could be procured and might be of value; but because of the low standard of housing accommodation these areas are more often inhabited by floating populations. In any event, any statistics are entirely valueless in the case of small areas. In spite of the fact that legislation insists on the procedure being initiated by the medical officer of health, with an indefinite medical background in his representation, the inquiry, held not by a medical man, follows the line in which more is heard of cost of repair and incapability of repair than of the effect of occupation of the premises on the health of the inhabitants. It is of interest to note that much the same form of words, namely, that the house or building is in any respect unfit for housing 11 modation, and that it is capable of being rendered fit for habitation purposes at reasonable expense, appears in the Housing (Emergency Provision) Act, 1939, being included in the conditions about which the surveyor has to satisfy himself before taking active steps to repair houses which have suffered war damage. For a long time it had been appreciated that the group of properties known to many as Poets' Corner—or Mushroom Square—called for attention. The Sub-Committee paid visits to the area, and the Public Health Committee deliberated as to the best procedure to adopt. Redevelopment was considered—only to be ruled out. In full appreciation of the many difficulties that loomed large, difficulties arising from the fact that such a high proportion of the properties were owner-occupied, that there was a number of shop properties, and that some of the properties had recently been reconditioned, while, scattered amongst buildings most of which were the same age, were some of much more recent erection, it was decided that the only way of suitably dealing with the many properties of low standard was to treat the area as a whole, and proceed by way of clearance. Official representations were made, and in due course the local inquiry was held. Starting as a local attraction of interest, a galaxy of talent appeared before an appreciative audience. At long last the inquiry dragged itself to its close. After many weeks the findings were promulgated—and some five properties were to be demolished ! The outbreak of hostilities has resulted in the shelving of a very difficult problem which the findings of the inquiry left, namely, what line was to be taken in regard to those properties which were certainly not in all respects fit for human habitation but which, equally definitely, it was considered could not at a reasonable expense be rendered fit. A problem which has been increasing in dimensions is that arising from the letting to two families of houses designed for the occupation of one only. It was considered that to register these houses and so be able to insist on alterations, such as the provision of additional sanitary conveniences, which would make the houses much better suited for the occupation of more than the one family, would result in their being permanently so occupied. In view of the class of tenant such letting attracts, it was felt that such a step would stabilise the tone of the neighbourhood at a low level, and such a lowered standard would percolate into the surrounding areas and cause black spots in the district. Other measures, including attempts at obtaining the co-operation of the owners of the properties and of the Building Societies who have made advances in respect of the premises, have, however, proved unavailing, so in June authority was given for the service of notices requesting information for the purposes of registering some of the houses in some of the roads where the practice of letting to two families was most common. In the summer months a rent strike took place among the occupants of a group of houses in the district, the conflict between 12 the owner and tenants being, apparently, because the owner was not prepared to do work at certain houses occupied by persons he did not wish as tenants. In the course of the dispute the question of the standard of the original construction of the premises came forward. A similar issue was raised more particularly on behalf of the owner-occupiers of another estate of more recent construction, from which it appears that the building bye-laws in force in any district give disappointingly little power for the inspectors to insist on a high standard of construction. In one instance it seemed that the building bye-laws were powerless to prevent a form of construction which resulted, before the premises were occupied, in such a degree of dampness in the living room that there would have been no hesitation on the part of the public health department, on the premises becoming inhabited, of serving a notice to abate the nuisance. A depressingly large amount of property erected in this district is of very poor initial construction. Given occupation by careful tenants, these houses might survive; but it seems that there is much that is occupied by careless tenants, and this will, in a few years, have to be considered with a view to demolition. From the earliest days of the newly-constituted Council in 1934 it had been agreed that certain premises were needed for increasing the efficiency of the health services of the district. As yet none has materialised. The Isolation Hospital seemed at last to be well on the way to erection. The fate of the Central Clinic became linked up with that of the Town Hall, Council Offices, or Civic Buildings. The very modest proposal for a small clinic, which was so badly needed near the Kenmore Estate, became lost in more ambitious proposals which it has since been decided were impracticable. Had it not been for the war it seems probable that added clinic facilities would, by this, actually have been made available for the population in certain parts of the district—in premises erected by the County Council. I am taking this opportunity of expressing my appreciation of the work carried out by the staff of the Public Health Department. Not only were additional burdens thrust upon them by A.RP., and, more particularly, by increases in the volume of their own work arising out of the war, but this had to be done by what remained of a curtailed staff. This extra work, which has fallen, not only to each section, but, to a great degree, to almost every member of each section, has been undertaken ungrudgingly and uncomplainingly, even though long additional hours were worked. For their help I accord them my most sincere thanks. I have the honour to be, Mrs. Leech and Gentlemen, Your obedient servant, Council Offices, CARYL THOMAS, Harrow-on-the-Hill. Medical Officer of Health 25th October, 1940. 13 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, mid-year, 1939, for calculation of (a) birth rates 190,200 (b) death rates or the incidence of notifiable diseases 189,300 Number of inhabited houses including flats (end of 1939) according to Rate Books (approximately) 56,500 Rateable Value (April 1st, 1940) £2,093,165 Sum represented by a penny rate (April 1st, 1940) £8,180 Extracts from Vital Statistics for the Year. Live Births:— Total. Male. Female. Legitimate 3,212 1,651 1,561 Birth rate per 1,000 of the estimated resident population, 17.5 Illegitimate 109 59 50 Stillbirths:— Legitimate 98 62 36 Rate per 1,000 total (live and still) births, 3.1 Illegitimate 9 2 7 Deaths 1,408 711 697 Death rate per 1,000 of the estimated resident population, 7.4 Deaths from puerperal causes:— Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis 2 0.58 Other puerperal causes 6 1.75 Total 8 2.33 Death rate of Infants under one year of age:— All infants per 1,000 live births 38.5 Legitimate infants per 1,000 legitimate births live 36.4 Illegitimate infants per 1,000 illegitimate births live 100.0 Deaths from Cancer (all ages) 240 „ „ Measles (all ages) — „ „ Whooping Cough (all ages) 3 „ „ Diarrhoea (under 2 years of age 12 14 Deaths and Death Rates. Total deaths in the district 859 Outward transfers 85 Inward transfers 634 Deaths of residents 1,408 Of the 85 deaths of non-residents occurring in the district, 27 took place at the Orthopaedic Hospital, 10 at the Harrow and Wealdstone Hospital, 3 at the North Middlesex County Hospital, 13 at local nursing or maternity homes and 30 in private houses. Of the 634 deaths of local residents which occurred outside the area most took place in institutions, 199 being at Redhill Hospital, 182 at Redhill House, and 28 at other county hospitals, including 9 newly born infants. 7 deaths occurred at institutions for the treatment of the tuberculous (3 at county tuberculosis institutions) and 24 at mental hospitals (23 at Shenley). 36 deaths occurred in hospitals just outside the district and 5 at municipal isolation hospitals. 112 deaths took place in various of the London general and maternity hospitals, including 5 deaths of infants of mothers confined in the hospitals. Thirty-three local residents died in the Harrow and Wealdstone Hospital. 1,408 deaths in a population of 189,300 is a death rate of 7.4. The corrected death rate obtained by the application of the area comparability factor of 1.17 is 8.6. 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), scarlet fever (0), whooping cough (0.015), diphtheria (0.045) and influenza (0.11) were all lower than the corresponding national rates of 0.01, 0.01, 0.03, 0.05 and 0.21. 15 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. AMBULANCE FACILITIES. The number of accident cases removed by the ambulances provided for the removal of non-infectious and accident cases was 670, the number of maternity cases 176, and of other cases 1,589. The Public Health Committee decided that the Council accept responsibility for the payment of the fee of 10s. for the attendance of a midwife or other qualified person to accompany maternity cases conveyed in the Council's ambulance, and recover from the patient the fee or such proportion thereof as may be appropriate upon application of the Council's income scale for maternity assistance. CLINICS AND TREATMENT CENTRES. From the beginning of the year until the end of August, infant welfare centres were maintained by the Council at the Broadway Clinic, Wealdstone, three times weekly; Elmwood Clinic, Kenton, thrice; Spiritualist Church Hall, Vaughan Road, West Harrow, once; Baptist Church Hall, Northolt Road, twice; St. George's Hall, Headstone, thrice; The Institute, Whitchurch Lane, Stanmore, thrice; Memorial Hall, Harrow Weald, once ; Baptist Church Hall, Imperial Drive, thrice; Baptist Church Hall, Streatfield Avenue, Kenton, thrice; Methodist Church Hall, Walton Avenue, South Harrow, twice; and St. Anselm's Hall, Hatch End, once weekly, being a total of 26 weekly sessions. Toddlers' clinics were held alternate weeks at the Broadway Clinic; two weeks out of three at Elmwood Clinic; every third week at Streatfield Road; weekly at Imperial Drive, and alternate weeks at Walton Avenue and Love Lane, Pinner, being an equivalent of 3½ weekly sessions. Two ante-natal sessions were held weekly at the Broadway Clinic and at the Elmwood Clinic; weekly sessions were held at the Stanmore Institute, Imperial Drive Church Hall, Northolt Road Church Hall, 76, Marlborough Hill, Streatfield Road Hall, Vaughan Road Hall, and Walton Avenue Church Hall; and a fortnightly session at Love Lane, Pinner, being the equivalent of 11½ weekly sessions. In addition, the Birth Control Clinic was held at the Broadway Clinic alternate weeks, and a consultant ante-natal clinic at the same building on alternate weeks. At the outbreak of the war, many of these buildings were lost for this purpose, including the Broadway Clinic; the Stanmore Institute; Memorial Hall, Harrow Weald; Imperial Drive Church Hall; Walton Avenue Church Hall; the Hall in Love Lane, Pinner; and St. Anselm's Hall. Partly because so many of the 16 premises were not available, and partly because the health visiting staff were temporarily so largely engaged on A.R.P. duties, and because for a while, at this time, collections of people were discouraged, infant welfare centres were, for a few weeks, run on very different lines from their usual routine. Ante-natal clinics temporarily ceased to function, ante-natal supervision being exercised by the Medical Officer visiting the homes of the midwives at times at which they had collected together some patients. With the release of the staff to their ordinary duties, however, and the finding of alternative premises, within the month 19 weekly infant welfare sessions were being held and a fortnight later 9 weekly ante-natal clinics. Partly, no doubt, because there has been some exodus of the population from this area, which has resulted in smaller numbers coming to the clinics, and to a certain extent because in some parts of the district it has proved impossible to find alternative accommodation to replace that which was formerly used but is now not available, the needs of the district are being met by a smaller number of sessions than were found necessary in August. At the end of the year, 21 weekly infant welfare sessions were being held, these being three at the Baptist Church Hall, Wolseley Road, Wealdstone; two at the Elmwood Clinic; three at St. Alban's Church Hall, North Harrow; three at St. Hilda's Hall, Northolt Road, South Harrow; one at Vaughan Road Spiritualist Church Hall; one at Pinner Council School; two at St. George's Hall, Headstone; two at the Chandos Pavilion, Stanmore; three at the Streatfield Road Baptist Church Hall; and one at the Memorial Hall, Harrow Weald. Ante-natal clinic sessions were held weekly at Wealdstone, Elmwood Clinic, St. Alban's Church Hall, Roxeth, Vaughan Road, Harrow Weald, Stanmore, Marlborough Hill, Streatfield Road, and Pinner; in all, ten weekly sessions. Toddlers' sessions were held weekly at Elmwood Clinic and Roxeth, and fortnightly at Pinner. In addition the birth control clinic and the consultant ante-natal clinic were continued. The same arrangements in regard to treatment continue in force. LABORATORY FACILITIES. As in previous years, the examination of clinical material was undertaken at the laboratories of the Clinical Research Association. The Medical Research Council, in consultation with the Ministry of Health, organised an Emergency Laboratory Service to augment the existing facilities for bacteriological diagnostic work required for public health purposes. An emergency laboratory was attached to each of the several hospital sectors, that serving this area being stationed at the Merchant Taylors' School under the control of Dr. C. J. C. Britton. In a communication, the Chief Medical Officer 17 of the Ministry of Health indicated that while the general function which the Emergency Laboratory Services would perform would be the rapid diagnosis of outbreaks of infective disease and the distribution of vaccines and sera to prevent their spread, it was not intended that the scheme should interfere in any way with the operation of normal services where these could be maintained, nor was it proposed that the service should undertake pathological work of other kinds. As the Clinical Research Association were in a position to continue their laboratory work, there was no occasion to arrange for any of the work previously sent to them to be sent to the Emergency Laboratory. On the other hand, the service has proved particularly useful in regard to the examination of outside bacteriological swabs. Ordinarily, these swabs, having been taken by the doctors, are sent by them to the Isolation Hospital, where they were examined. Owing to the depletion of the medical staff it was not possible to ensure that a medical officer could be at the Isolation Hospital each morning to examine swabs. Ordinarily, the alternative arrangement would have been the despatch of these swabs by post, an arrangement which would have entailed an additional delay of at least 24 hours. The services afforded by the emergency laboratory got over this difficulty as they have undertaken the examination of those swabs which are transmitted each day to their laboratory by van. The necessity of having a bacteriological laboratory closely associated with the work of a district, or, preferably, of a region, is one which has long been felt. Such a region would, of course, be based not on the existing hospital sectors, which were determined on very different considerations, but should be regions having a common epidemiological background. The close contact which such an arrangement would provide between the bacteriologist and a group of field workers should prove a factor of immense value in early recognition of outbreaks. It is to be hoped that some such development will prove to be one of the lesser blessings conferred by the present war. LEGISLATION. The following bye-laws came into force during the year :— the bye-laws for the regulation of offensive trades and the trade or business of fish frying; building bye-laws; and bye-laws as to pleasure fairs. The Motor Vehicle and Supplies and Accessories (Harrow) Exemption Order, relative to the provisions of section 4 of the Shops Act, 1912, in regard to the closing for the weekly halfholiday, became operative during the year. B 18 SANITARY CIRCUMSTANCES OF THE AREA. WATER. Weekly bacteriological reports received on samples of water taken in different parts of the district and analysed at their laboratories by the Colne Valley Water Company have all proved satisfactory, as have also the quarterly samples submitted by the Council for detailed chemical and bacteriological analyses. The supply of the Rickmansworth and Uxbridge Valley Water Company again failed on one occasion. Since that time it is understood that, at least as a temporary measure, the premises in this district previously served by this Company are to be supplied by the Colne Valley Company. WELLS. The possibility of pollution of the London underground water from disused wells and borings of water obtained from the chalk over London has increased because of the constantly increasing number of borings through the protective clay stratum and because of the lowering of the water level in the chalk. Such borings pierce the impermeable clay cover after penetrating the superficial covering of sands and gravel which often contain foul water. So long as the bore hole is in use, care is taken to exclude surface water ; but many such borings are abandoned and their lack of maintenance causes a risk of polluted surface water reaching the chalk. The following are particulars of wells in this district:— Sinclair's Joinery Works, Greenhill Crescent.—An artesian well over 100 feet deep; not now used. Brazier's Farm, Kenton Lane.—A metal barrel sunk 250 feet deep; the usual supply about 15,000 gallons per hour. Pattison Cole, Stanmore Hill.—Two disused brick-built wells, one (open) situated in the factory grounds, the other (sealed over) to the rear of the property to the north-west of the factory. The City Cottages, Harrow Weald.—A well covered with stone slabs; a pump is connected. The Fountain, Church Road, Stanmore.—A well in the forecourt of a public house; now disused, being covered with stone slab. Kodak Ltd., Wealdstone.—Four disused wells, approximately 100 feet deep, lined to 70 feet. Now sealed. Two artesian wells in use. Garage, West Hill, Byron Hill.—A shallow brick well; water used for car washing. Greenhill Laundry.—One artesian well in use. Water-works, Bessborough Road.—Recently acquired by the Colne Valley Water Company from the Harrow Urban District Council. 19 PUBLIC CLEANSING. The following particulars have kindly been supplied by the Surveyor:— Refuse Collection. Lighting restrictions during the winter months so curtailed the period during which refuse could be disposed of that it was possible to provide only fortnightly instead of weekly collections of house refuse. Such a departure from the normal practice causes a stir amongst some householders. Whilst it is undesirable that refuse should be permitted to accumulate near houses, the fear that infections will prevail because the collection is made less frequently is unfounded. The likelihood of any nuisance can be lessened by intelligent action by the householder in reducing to a minimum the amount of putrescible matter in the bin, by wrapping in paper those containers whose surface may be smeared with such material, and by keeping the contents of the bin as dry as possible. Refuse Disposal. The difficulties in the disposal were aggravated by the necessity, because of lighting restrictions, of damping down the fires at dusk. Street Cleansing. The normal peace-time standard of service cannot be maintained because of the extra duties falling on the staff. MORTUARY. 155 bodies were received during the year. Post-mortem examinations were carried out on 98 and 30 inquests were held. 46 bodies were admitted for storage and 11 bodies of persons dying from accident or suicide on whom no post-mortem examination was carried out in the mortuary. CAMPING GROUNDS. Section 55 of the Middlesex County Council Act, 1934, prohibits the placing or keeping on any land in the district of movable dwellings without the consent of the Council. During the year consent under this section was given to the use of land forming part of the Grimm's Dyke Estate, and also a camping ground for the Church Lads' Brigade on a site in South Harrow. SANITARY INSPECTION OF DISTRICT. [a) Number of:— Houses inspected under the Housing Act, 1936 190 Houses found unfit 32 Houses not in all respects fit 155 Revisits 2,257 Surveys under Housing Act, 1936 481 20 Houses inspected under Public Health Acts 2,057 Houses found defective 958 Revisits 2,274 Other premises visited for nuisances 838 Revisits 463 Complaints investigated 1,619 Complaints re rats investigated 58 Visits re infectious disease 3 Inspections of:— Foster parents' premises 84 Factories 807 Workplaces, including offices 188 Outworkers' premises 137 Cinemas and places of entertainment 54 Houses-let-in-lodgings 7 Visits to:— Slaughterhouses 737 Greengrocers 416 Butchers 1,028 Provision Merchants 424 Cowsheds 50 Dairies 349 Ice Cream Premises 358 Fish Shops 177 Fried Fish Shops 117 Bakehouses 100 Other Food Premises 250 Hairdressers 82 Premises where rag flock used Inspections of premises under periodical inspection 643 Observations for smoke nuisances 21 Visits under Shops Acts 2,056 Evening observations under Shops Acts 72 (b) Notices served:— Statutory:— No. complied with. Public Health Act 54 53 Housing Act 37 28 Informal 1,983 1,903 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 21 observations were carried out. During the 642 minutes observation dense smoke was seen for 20 minutes, and moderate smoke for 136 minutes. 21 SHOPS ACTS, 1912-1936. At the end of the year the total number of shops on the register was 2,119. 2,056 visits were paid to shops under the above Acts and 72 evening observations made. 68 contraventions were recorded, these being classified as:— Serving customers after closing hours, 28; intervals for meals not given to assistants, 4; assistants not having a half-holiday, 3; young persons employed in excess of 48 hours per week, 13; assistants employed after 1.30 p.m. on early closing day, 13. 232 letters were sent to traders regarding the absence of appropriate notices, in 7 instances the traders receiving a final warning. In two cases it was necessary to take legal proceedings, fines amounting in total to £2 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, 11; insufficient sanitary accommodation, 8; absence of or insufficient means of heating, 35; and absence of suitable and sufficient facilities for taking meals, 1. Defects of sanitation noted included :—Dirty or defective water-closet accommodation, 35; absence of properly constructed intervening ventilated lobbies between water-closets and shop, 2; walls of shops dirty, 8 ; and water-closets choked, 1. Six certificates of exemption from the provisions requiring sanitary accommodation were granted and two refused. During the year 78 contraventions of the provisions of the Shops (Sunday Trading Restriction) Act, 1936, were noted, these being classified as:— Serving customers with non-exempted goods, 4; assistants not receiving compensatory holiday, 4; records of compensatory holidays not kept, 35; notices not exhibited, 32; assistants employed on more Sundays in month than allowed, 3. In each case a warning was given. FACTORY ACT, 1937. In this district there are 389 factories with mechanical power, 145 without mechanical power, and 140 workplaces, to which the following numbers of visits were paid during the year:— Mechanical factories, 571; non-mechanical factories, 236; and workplaces, 188. Of the 72 public health nuisances detected, 15 were due to want of cleanliness and 2 to absence of ventilation. There were 41 instances of unsatisfactory sanitary accommodation, these being unsuitable or defective in 39 cases and insufficient in 2. 14 other nuisances were detected. 59 notices from other Councils and 3 from employers were received containing the addresses of 131 outworkers. 137 visits of inspection were made to outworkers' premises, in none of which were unwholesome conditions found to exist. 22 HOUSING. HOUSING STATISTICS FOR THE YEAR, 1939. Number of New Houses erected during the Year:— Total 1,375 (1) By the Local Authority 3 (2) By other Local Authorities - (3) By other bodies and persons 1,372 1. Inspection of Dwelling-Houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,257 (b) Number of inspections made for the purpose 6,788 (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 190 (b) Number of inspections made for the purpose 2,447 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 32 (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 , 1,113 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 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 3 / (2) Number of dwelling-houses which were dered fit after service of formal notices:— (a) By owners 28 (ib) By Local Authority in default of owners 23 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 54 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 53 (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 8 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders — 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) Number of separate tenements or ground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit ACTION UNDER THE HOUSING ACT, 1936. Section 1. In January Clearance Orders were confirmed in respect of six groups of properties which were represented in 1938, namely :— 1-5, Brewery Cottages; 1—4, Pleasant Place; 2-40 (even numbers), Headstone Drive; 61, 63 and 65, College Hill Road ; the two cottages in No. 3, High Street, Stanmore, Order; and the four cottages in No. 4, High Street, Stanmore, Order. Of the 112 properties included in the area covered by Nos. 1, 2, 3 and 4 Marlborough Road Areas, only four in Shelley Road and one in Marlborough Road were approved by the Minister. Up to the end of the year, then, a total of 21 Clearance Areas had been confirmed, the total number of properties affected being 156. Of the houses the subject of previously confirmed Clearance Orders which were still standing at the beginning of the year, the two Marsh Road Cottages ; Nos. 81, 83 and 85, Greenford Road ; Nos. 54, 56 and 58, Middle Road ; Stalford House ; Kirby and I 24 Ivy Cottages, Stanmore; and Nos. 1-3, Ivy Cottages, High Street, Stanmore, were demolished during the year. Other properties which were the subject of Clearance Orders but which had not been demolished were West End Lane Cottages; Nos. 3-15 (odd numbers), High Street, Edgware (all vacant but not all down); East End Cottages, Pinner; Broadway and Holland Square, Stanmore (all but one vacant); 1-12, Ferndale Terrace, Wealdstone; and four shop properties in High Street, Stanmore. During the year, official representations were made in respect of the following properties: 96-102, Canning Road, and Spring Villa and the adjoining properties. Preliminary steps were also taken in regard to Nos. 1-61 (odd numbers) and Nos. 2-50 (even numbers), Mead Road, Edgware; Nos. 137-147 (odd numbers), Northolt Road, and Nos. 1-11, Green Lane, Stanmore. Sections 11 and 12. Demolition Orders were made in respect of Boxtree Cottage, West End Lane, and 1-7, Kingsfield Terrace. Action under Section 11 was being taken in respect of Hilltop Cottage, Elstree; the wooden dwelling at the rear of Littlecote, Uxbridge Road ; No. 17, High Street, Edgware ; and Nos. 2-12, Palmerston Road, Wealdstone ; and under Section 12, in regard to Nos. 1-4, Canning Place. Properties which had been the subject of Demolition Orders before the beginning of the year included No. 23, High Street, Edgware, which, though vacant, had not been demolished ; Nos. 99 and 101, Greenford Road (one vacant); Nos. 93 and 95, Greenford Road (one vacant) ; and Nos. 1-11, Peel Road (vacant). A number of properties had, at different times, been the subject of consideration from the point of view of demolition. Mostly because the houses were occupied by elderly persons who were very loath to leave their homes, undertakings were accepted from the owners that, on the lapse of the existing tenancy, the properties would not be re-let. Of such premises dealt with in this manner, Belvedere Cottages, Stanmore, and Nos. 1-6, Felton's Cottages, were still occupied at the end of the year, but Nos. 41, 43 and 45, High Street, Edgware, and Nos. 1, 2 and 3, French's Cottages, were vacant. In December, 1937, the owner of Nos. 112 and 114, Greenford Road, agreed to demolish them within 18 months. Nos. 59-65 (odd numbers), West Street, Harrow, and Nos. 57-65a, lhe Broadway, Stanmore, were to be reconditioned, as were also Nos. 1-7, Rectory Cottages, Stanmore. In none of these premises had the necessary work been completed by the end of the year. Of Nos. 1-4, Wooden Cottages, Paines Lane, two had been demolished, but two were still occupied. No. 95, East cote Lane, was pulled down before an actual demolition order had been made respecting it, though the preliminary steps had been taken. 25 Procedure during the War. Action under the Housing Acts hinges on the initial steps of routine housing inspection being undertaken by the Sanitary Inspectors. Owing to the depletion of the staff, such routine inspection, of course, cannot be carried out. There are, too, the other important factors of shortage of labour, and, still more so, of shortage of materials. It would serve little purpose, then, even though it were practicable, for the sanitary inspectors to draw up schedules of work required to bring properties up to a certain state of repair if, as proves so often to be the case, such work could not be undertaken. Routine housing inspection as such, therefore, must temporarily be abandoned, and the attention of the inspectors in regard to housing be devoted to obtaining rectification of those defects of such a magnitude as to possess real sanitary significance. Policy in regard to slum clearance was outlined in Circular 1866 of the Ministry of Health, dated the 8th September, 1939. At that date it was decided that, for the time being, no further enquiries into Slum Clearance Orders would be held and that, therefore, local authorities should take no further steps in connection with Orders which had not reached the stage of local enquiry. Where an Order had been confirmed by the Minister, the opinion was expressed that, save in exceptional circumstances, steps taken should stop short of actual demolition because it was desirable, in view of the possible destruction of housing accommodation by air attack, that the existing supply of accommodation should not be diminished. In view of their appreciation of the need of retaining properties to meet such contingencies, it is regrettable they did not obtain powers to restrain owners from demolishing much more sound premises merely to obtain immediate personal gain. The same Circular indicated that, generally speaking, the Ministry would not be prepared, for the time being, to approve of the erection of further houses, and in regard to houses in the course of construction he asked local authorities to concentrate on those houses in an advanced state of construction, and not to continue work on houses in an early stage. 26 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 88 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 10 Number of shops from which milk is sold in unopened receptacles only 66 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 16 (Of these, 7 belong to one firm, 2 to one, and 2 to another.) Bottling of T.T. milk at premises other than at place of production 2 Supplementary licences issued to producers outside the district to retail T.T. milk in the district 4 Pasteurizing establishments 4 Selling of pasteurized milk at premises other than establishments where pasteurization is carried on 39 (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 ^ Two applications for the licensing of pasteurizing establishments were received in respect of premises at which it was considered that application should be refused on the grounds that the apparatus used did not pasteurize all the milk. The plant provided an ingenious arrangement for automatic operation, but suffered from the defect that each holder was served by a pipe, a very small length of which acted as the inflow and outlet passage for the milk, with the result that a small volume of the milk escaped admission to the holder each time and was therefore not pasteurized. One of 27 the applicants appealed to the Minister of Health against the refusal of the Council to grant the licence. After the holding of a local inquiry, however, the Council's decision was upheld and the licence refused. Milk Sampling. Of the 44 samples of pasteurized milk submitted to the phosphatase test, only one sample, that of a milk treated outside this district, proved to be unsatisfactory. Of 44 samples of tuberculin-tested milk, 14 were unsatisfactory, in each case the milk being produced outside the district. 22 samples of ordinary milk produced on farms in this area were analysed. Of 10 which proved unsatisfactory, 8 had B. Coli present in 1 /100th of a c.c. and 7 had more than 100,000 organisms per c.c. Of two samples of accredited milk one failed to satisfy the methylene blue test. (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, 737 visits being paid during the year and 5,360 carcases examined. 'Of the 413 beasts slaughtered, 121 were unsound in some respect, the liver or lungs being affected in 49 instances of which 39 were by parasitic disease. Tuberculous lesions were found in the lungs of 58, the mesenteric fat of 16, the liver of 18, the head of 24, and the tongue of 10 (commonly more than one site being affected in the same animal). Of the 160 cattle (excluding cows) slaughtered, 24, or 15 per cent., were unsound in some respect other than tuberculosis. The percentage affected with tuberculosis was 1T2. Of the 253 cows slaughtered, 26, or 10*3 per cent., were unsound by reason of some condition other than tuberculosis. Tuberculosis was found in 53, or 21 per cent. Two entire carcases were condemned on account of this disease. Some part of 133 of the 2,043 pigs slaughtered was diseased, more than one organ of the same animal frequently being affected. The entire carcase in 12 cases was condemned on account of emaciation or immaturity, in 4 instances on account of pneumonia and in 3 because of swine fever. Pneumonia was present in 22 cases, pleurisy in 7, pericarditis in 6, lesions of the liver 17 (parasitic disease 8, cirrhosis 9), and other lesions in 3. Tuberculosis was found in the entire carcase of 3, in the mesenteric fat of 26, in the head of 44, in the lungs of 14, and in the liver of 20. Of the 2,508 sheep slaughtered only 21 were found unsound in any respect. The commonest abnormal states were parasitic diseases affecting the liver of 18 and the lungs of 19. The following table gives particulars of the numbers of animals slaughtered and the incidence of disease:— 28  Cattle excluding Cows. Cows. Calves. Sheep & Lambs. Pigs. Number killed 160 253 396 2,508 2,043 Number inspected 160 253 396 2,508 2,043 ALL DISEASES EXCEPT TUBERCULOSIS. Whole carcases condemned - - - - 19 No. of carcases of which some part of organ was condemned 24 26 - 21 35 Percentage of the number inspected affected with disease other than tuberculosis 15 103 - 0.8 2.6 TUBERCULOSIS ONLY. Whole carcases condemned - 2 - — 3 Carcases of which some part or organ was condemned 18 51 - - 76 Percentage affected with tuberculosis 112 21 — — 39 Meat Depot. Soon after the outbreak of the war a distributing meat depot was established in Canterbury Road. From the first the manager invited the assistance of the sanitary inspectors in regard to the condemnation of unsound meat. Because of the volume of business, this has necessitated almost the entire time of one of the sanitary inspectors being spent at the depot. The premises were not originally intended and were therefore not designed for the purposes of a meat depot, so the conditions in which the meat was stored were conducive neither to improving the keeping qualities of the meat, nor to facilitating the work of the officers in carrying out their inspections. More recently improvements have been effected. Up to the end of the year 51 carcases of sheep and the carcase of one calf were condemned, chiefly because of emaciation, dropsy or bruising, and some 55 lbs. of bruised beef. About 3,000 lbs. of offal were condemned, mainly on account of parasitic disease or of putrefaction. Registration of Hawkers. Section 71 of the Middlesex County Council (General Powers) Act, 1938, obliges a hawker of meat, fish, fruit and vegetables himself to be registered with the local authority, and obliges the owner of any premises used to see that they are registered. In the course of the year a large number of persons had been registered. 29 ISOLATION HOSPITALS. ADEQUACY OF ACCOMMODATION. The accommodation proved sufficient for the demands made on it this year by the straightforward cases of scarlet fever and diphtheria, 253 patients being admitted with a diagnosis of scarlet fever, and 78 with a diagnosis of diphtheria. A few patients suffering from these diseases were admitted to other hospitals, these mostly being removed as in- or out-patients from general hospitals in London. Patients suffering from other infections had, of necessity, to be admitted elsewhere, these including 14 sufferers from whooping cough and 7 from puerperal infection. PROVISION OF NEW HOSPITAL. By midsummer all obstacles impeding the erection of the newhospital appeared to have been removed, and everything seemed to be plain-sailing. The final draft of the conditions for the architectural competition had been agreed upon, the assessor for the competition had been appointed, as had also the consulting engineer, and an agreement had been reached with the County Council on the question of the access roads, drainage and provision of other services. CLINICAL ASPECTS. Diphtheria. Admissions:— Number admitted on a diagnosis of diphtheria 78 Number of cases clinically diphtheria 43 Number of carriers 4 In 31 cases the diagnosis of diphtheria was not confirmed, the revised diagnosis in 23 being acute tonsillitis, and in 4, respiratory complaints. Of those cases clinically diphtheria, 41 were faucial and 2 nasal. Of the carriers, one was faucial and 4 nasal. Deaths.—Number of deaths, 8. Case mortality of diphtheria cases, 19 per cent. The days of disease on which the fatal cases were admitted were the 4th in two, the 5th in three, the 6th in two, and the 8th in one. Cross Infection.—Two patients contracted scarlet fever and one whooping cough. 30 Scarlet Fever. Admissions:— Number admitted with diagnosis of scarlet fever 253 Number suffering from scarlet fever 245 Number in whom diagnosis not confirmed 8 Of these 8 cases, four suffered from tonsillitis, three from rashes, and one from an abscess. Deaths.—Nil. Complications.—31 patients suffered from cervical adenitis; 22 from otorrhoea; 15 from rhinorrhoea; 8 from a relapse; 7 from albuminuria and 1 from nephritis; 7 from whitlows; 2 from abscesses; and 1 from a sty. Four suffered from secondary sore throats and one from rheumatism. Return Cases.—Return cases occurred in 18 households. 31 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASE (other than Tuberculosis) Disease. Under 1 yr. 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 - 70 166 38 15 6 15 6 1 - - 317 Diphtheria - 10 24 5 3 1 4 1 - - 54 Pneumonia 2 13 7 6 7 3 24 12 21 10 12 117 Erysipelas 1 — 2 1 1 4 6 8 11 4 8 46 Puerperal Pyrexia - - - - - 2 17 - - - - 19 Enteric Fever - 1 1 2 1 - 3 3 1 - - 12 Ophthalmia Neonatorum 4 - - - - - - - - - - 4 Cerebro-spinal Fever 2 - - - - - 1 - I - - 4 Dysentery - 1 1 - - - - 1 1 - - 4 Acute Poliomyelitis Encephalitis - 1 3 - 2 - - - - - - 6 Lethargica - - - - - - 2 - - 1 - 3 encephalitis - 1 2 2 - - - — - - - 5 Food Poisoning - 2 1 - 1 1 4 1 - 1 - 11 Measles — 2 - 1 - - - - - - - 3 Whooping Cough 2 5 1 - - - - - - - - 8 • Disease. Cases to Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitte to othe Hospitals Deaths Registered Scarlet Fever 325 249 - - - Diphtheria 86 78 1 - 9 Pneumonia 117 - - - 71 Erysipelas 46 — 16 - 1 Puerperal Pyrexia 19 - 8 5 2 Enteric Fever 12 - 7 2 - Ophthalmia Neonatorum . 4 - - 4 - Urebro-spinal Fever 4 - 1 3 4 Dysentery 4 - 1 Acute poliomyelitis 6 - - 6 - Eephalitis Lethargica 3 — 1 2 2 uu-encepnalitis 5 — — 5 - Food Poisoning 11 — - - - Measles 3 — - - - Whooping Cough 8 — 14 — 3 32 DIPHTHERIA. Incidence. 85 notifications were received during the year, the diagnosis, however, being revised in 31 instances, most commonly to acute tonsillitis. 54 cases in a population of 189,300 is a rate per thousand of 0-3, as compared with that of 1-14 for the country as a whole. This is the tenth consecutive year in which a low incidence has prevailed. In the first quarter there were 22 cases ; in the second, 10; in the third, 8 ; while the incidence rose in the last quarter, when 19 cases were notified. Secondary infections occurred in three households. One patient was a return case from a patient treated in the hospital of another authority ; two patients were bacteriological cases, while three were suffering from nasal diphtheria. Place of Treatment. All but seven of the cases notified were admitted to the South Harrow Isolation Hospital. Deaths. Nine deaths were recorded as due to diphtheria. Immunization. Although the two-dose A.P.T. method was approved, most practitioners treating children in the district continued to favour the use of T.A.M. as an antigen, though this involved three inoculations. 1129 children completed treatment during the year. Of the 665 offered facilities, 355 attended for post-Schick testing, of whom 6 reacted positively. Provision of Anti-toxin. In order to facilitate the early administration of diphtheria anti-toxin in cases, or suspected cases, arrangements were made for the serum to be distributed not only from the two isolation hospitals, but also from the different fire stations. The medical practitioners were circularised to the effect that they could obtain serum in this way, and that by virtue of Section 113 of the Middlesex County Council (General Powers) Act, 1938, the serum could be used for any patients and not be limited, as under the Diphtheria Anti-toxin Order, to the poorer inhabitants of the district. 69 lots were issued during the year, totalling 552,000 units. SCARLET FEVER. Incidence. 325 cases were notified during the year, of which 9 were errors of diagnosis—4 of these suffering from tonsillitis, 4 from rashes, and one from an axillary abscess. 316 cases represent an incidence 33 of 1.66 per thousand population, as compared with a figure of 1-89 for the country as a whole. The distribution of cases throughout the year was most uneven. The 90 cases occurring in the first quarter were evenly distributed, as were also the 142 cases of the second quarter, most weeks in this period having some 10 to 15 cases. The third quarter started with a rather lighter incidence for the first five weeks, but during the remaining eight weeks in no instances were more than 4 cases notified, the total number of notifications for the quarter being 56. Contrary to expectations, instead of a rise in the last quarter there was a further lightening of incidence, only 29 cases being notified in the whole quarter. Place of Treatment. Of 319 patients notified, including those in whom the notification was later withdrawn, 68 were treated at home at the election of the parents, 248 were admitted to the local isolation hospital and 4 to the isolation hospitals of other local authorities. Of those admitted to the local hospitals in 35 per cent, of cases there appeared to be no real reason that the child should not have been treated at home. In 17 per cent, of the cases the reason for admission was the fact that there were in the house other children of tender years ; in 15 per cent, of cases the patient could not have been isolated in a room to himself, while in 10 per cent, of cases the patient was an adult, and in a similar number of cases there was crowding in the home. Secondary Infections. Secondary infections occurred in 19 households, in 17 of which there was onlv one secondary case and in two households two cases each. Return Cases. Return cases occurred in 19 households, in most only the one patient being infected, but in three homes two patients each. In one of the latter instances the presumably infecting case was treated in the hospital of another authority. In nearly one-half of the cases the discharged patient appeared perfectly well at the time of the onset of the illness of the other member of the family. In two of the other instances the child developed a tonsillitis some time after his return home, while in the other instances the patient had developed a nasal discharge. Schools and Scarlet Fever. On two occasions only was there any suggested grouping of cases of scarlet fever in the school, both occurring in the summer term. At Priestmead School over three weeks there were five cases, four of them in the same class. At Stanburn School over a period of 8 weeks there were 18 cases distributed altogether amongst 8 classes. 34 ENTERIC FEVER. 12 notifications of enteric fever were received during the year, though in 5 the diagnosis was not confirmed. though in 5 the diagnosis was not confirmed. The following are the particulars of those in which the diagnosis was confirmed :— No. Sex Age Onset Notified Infection 1 Female 16 29/ 8/39 4/ 9/39 Para-B 2 Female 11 17/ 9/39 19/ 9/39 Para-B 3 Female 30 7/10/39 13/10/39 ? 4 Female 49 22/ 9/39 11/10/39 Para-B 5 Female 45 8/10/39 15/10/39 Typhoid 6 Female 39 6/10/39 16/10/39 Para-B 7 Female 8 20/11/39 11/12/39 Para-B Three of the patients were treated at home, two at isolation hospitals and two in general hospitals. All recovered. No association could be traced between the different cases, nor between these and any in other districts. Case No. 4 had been an in-patient at a general hospital for long before the onset, but no other notifications were received from there. In Case No. 3 blood tests gave negative results. DYSENTERY, Five cases of dysentery were notified, all being bacteriologically proven to be Sonne infection. Three were treated at home ; one was removed from a London hospital out-patient department to a London County Council isolation hospital, while the other was admitted to one of the Middlesex County Council general hospitals. One case proved fatal, this being an adult female of 49 who fell ill on the 18th November and died in hospital on December 3rd. FOOD POISONING. Amongst the provisions of the Food and Drugs Act, 1938, which came into operation on October 1st, 1939, was one which required a medical practitioner, on becoming aware or suspecting that a patient whom he is attending is suffering from food poisoning, forthwith to send to the medical officer of health of the district a certificate stating the name, age, sex and address of the patient and particulars of the food poisoning from which he is, or is suspected to be, suffering. This clause is one which, by having been included in a number of private Acts, has been in operation in many districts. The experience of the medical officers of health of these districts had already been that, for want of any sort of definition as to what was to be understood by food poisoning, a large number of cases were notified which had no public health interest. While a foodstuff to which an individual has an idiosyncrasy which results in his suffering from some constitutional 35 turbance might legitimately be looked on as a poison to that person, the fact that it is only the exceptional person who reacts in this way removes this reaction from the sphere of public health interest. The purpose underlying the notification is for the public health department to get to know of those substances which cause reactions not in the susceptible individual alone but in a high proportion of those partaking of them. Eleven notifications of food poisoning were received in the last three months of the year. In three instances the person notified who suffered from some gastro-intestinal disturbance was the only member of the household affected. Three members of one family —a mother and her two children—were suddenly ill with vomiting and diarrhoea and raised temperature, but no incriminating foodstuff could be traced. In another family four members, all of whom partook of tinned salmon, succumbed about the same time to a gastro-intestinal disturbance, while the remaining two members of the family who abstained from the dish remained unaffected. The last case notified was that of a child ; in this case liver was the suspected foodstuff, other members of the family who ate this foodstuff being similarly affected. ERYSIPELAS. 45 cases of erysipelas were notified during the year. The sexes were almost equally affected. The face was the region in about two-thirds of the cases, the leg being the only other commonly affected site. One-half of the cases were treated at home, most of of the remainder being admitted to isolation hospitals, only a few being treated in general hospitals. One case proved fatal, that of a man of 72 whose arm was affected. EPIDEMIC DISEASES OF THE CENTRAL NERVOUS SYSTEM. Cerebro-spinal Fever. Five patients were notified as suffering from cerebro-spinal fever, though one diagnosis was withdrawn in favour of tubercular meningitis. Two infants of 3 and 4 months fell ill in January, both cases proving fatal. In June a man of 47 succumbed to a fatal attack. In April an infant of 4 months died of the disease, though the case had never been notified. A further notified case was that of a child non-resident in this district transferred from a London hospital to the Orthopaedic Hospital and notified from there. Acute Anterior Poliomyelitis. Eleven cases were notified during the year, of which, however, five were patients transferred at the outbreak of the war from one °f the London hospitals to the Orthopaedic Hospital, Stanmore. fhe first notified was a girl of 17, the onset of whose illness was early April. There were no further cases till the onset of the disease 36 in a girl of 5 in October. In the same month a boy of 9 was notified from a hospital outside this district. He had suffered from a complaint diagnosed as influenza in July, but the history of the onset of the paralysis of the leg from which he was suffering when admitted to hospital on September 29th, dated only about a week previously. Ten days later a sister of seven years of age was admitted to the same hospital suffering from paralysis of the leg, the onset of illness in her case being a week before removal. Another girl of three years of age fell ill in late October and a girl of 17 early in November. All these patients were treated in general hospitals. Encephalitis Lethargica. Three notifications of encephalitis lethargica were received, though one was withdrawn in favour of cerebral thrombosis. On 29th March a man of 31 was admitted to hospital, where he died the next day, the illness dating from some eight weeks prior to admission. In July the diagnosis was made in the case of a man of 27. NON-NOTIFIABLE INFECTIONS. Measles. Before this disease became notifiable, knowledge of its prevalence came from the returns of the head teachers of the local elementary schools. For the first seven months of the year for which period these returns relate, there were only some 21 cases of measles and 13 of German measles throughout the whole district. Whooping Cough. As contrasted with measles, whooping cough was more prevalent than in the previous years, 458 intimations being received in the spring and summer terms. Thirteen school departments were affected, three each with over 50 cases and three with between 40 and 50. Chickenpox. The district was relatively free from this infection. While the 153 cases were distributed amongst 17 school departments, in only one school was there any heavy incidence, in this some 40 cases occurring in the month of January. Mumps. 36 of the 85 cases of mumps occurred in the one school. Influenza. This infection was not specially prevalent. Most of the 20 deaths ascribed to it occurred in the first four months of the year. 37 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—4 1 3 2 2 - - - - - - 4 1 5—9 4 — 3 1 - - - - - 3 1 1 10—14 5 1 - 2 - - - - - - — - 15—19 9 10 2 6 — — - — 3 - 2 3 20—24 13 15 2 1 - — — - - 4 - 1 25—34 35 43 4 5 3 1 - - 9 7 1 1 35—44 18 15 4 3 - — — — 8 3 - - 45—54 13 7 2 - - - — - 11 5 1 - 55—64 6 4 - 1 - _ - — 4 1 1 - 65 & upwards. 2 2 - - - - - - 1 1 - - Total 106 100 19 21 3 1 - - 36 24 10 7 During the year 210 pulmonary cases (109 male and 101 female) were added to the register. Of this number 38 males and 41 females had previously been notified in other districts as suffering from this disease before they removed here. In addition there were 6 unnotified pulmonary cases (3 male and 3 female), who died unnotified in hospitals outside this district. 40 cases (19 male and 21 female) of non-pulmonary disease were made known during the year. Of these, 12 (7 male and 5 female) were known to have been notified as suffering from the disease before they moved into this district. Of those who contracted infection while resident here, 9 suffered from disease of bones and joints, 5 from tuberculosis of cervical glands, 4 from abdominal and 3 from genito-urinary tuberculosis. In addition, there were 7 cases, 5 of whom were male, who were not notified during life as having suffered from this disease but in whom tuberculosis appeared on the register as the cause of death, six being due to meningitis. 38 Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register Jan. 1st, 1939 326 267 64 75 No. of New Cases added 106 100 19 21 No. of cases added—other than on Form A 3 1 - - No. of cases restored to register 4 3 - 1 No. of cases removed 108 91 18 17 No. on register Dec. 31st, 1939 331 280 65 80 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 49 48 6 8 Died 34 22 3 - Cured 18 17 7 7 Diagnosis not confirmed or withdrawn 7 4 2 2 Deaths. 60 persons (36 male and 24 female) died from pulmonary tuberculosis during the year, and 18 (11 male and 7 female) from non-pulmonary tuberculosis. Tuberculous disease, therefore, accounted for 5-5 per cent, of the total deaths in the district. 23 of the deaths of pulmonary cases and 5 of the non-pulmonary took place in this district, mostly in the patients' own homes, while 37 of the pulmonary and 13 of the non-pulmonary occurred outside the district, mostly in institutions. 39 MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,320, 1,711 male and 1,609 female. Of these 110 were illegitimate, being a percentage of total births of 3.3. 2,096 births occurred in the district (2,039 live and 57 still births). Of this number 201 (194 live and seven still births) were to residents of other districts. Of the local confinements 1,393 were notified by midwives and 501 by doctors or parents. 1,368 (1,329 live and 39 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. 64 male and 43 female still births were registered, being a rate per 1,000 population of 0.56 compared with a figure of 0.59 for the country as a whole. Of the 47 cases of which particulars are known, in 14 there was no definite cause, in 15 the reason was acute disease in or accident to the mother (including 12 toxaemias), and in two others the cause was maternal. Anomalies of the foetus, placenta or cord accounted for 9 (3 due to congenital malformations and 6 to vicious insertion of the placenta). Nine were due to death of the foetus, three because of prolonged labour, and two because of prolapse of the cord. INFANT MORTALITY. 128 (69 male and 59 female) infants died under one year of age, constituting an infant mortality rate of 38.5. 69 failed to survive one month. The neonatal mortality rate was therefore 20.8, constituting 54 per cent. of the total infant mortality rate. Of these 69, 19 failed to survive the 24 hours, the cause of death in 13 being prematurity, in 3 birth injury and in another 3 abnormality or atelectasis. 36 deaths occurred in infants who survived 24 hours but failed to survive 7 days. Prematurity was responsible for 12 of these, birth injury for 8, developmental abnormalities 10, and atelectasis 6. Of the 14 infants who survived one week but succumbed before the end of the first month, in 2 the cause was prematurity, in 3 birth injury, in 4 developmental abnormalities or atelectasis. Infections accounted for 5 deaths, 2 being due to gastro-enteritis and 3 to respiratory complaints. Of the 28 deaths amongst those of 1-3 months, 4 were due to developmental abnormalities, 4 to deficient inherent vitality and only one to birth injuries. Respiratory complaints accounted for 10 and gastro-enteritis 6. 40 Infections accounted for most of the 12 deaths of those between 3 and 6 months, of which respiratory complaints were the cause in 4, gastro-enteritis in 2, whooping cough in 2, and meningococcal meningitis in 3. Respiratory infections accounted for 6 of the 10 deaths of those between 6 and 9 months and 3 of the 4 deaths amongst those aged 9 to 12 months. DEATHS OF OLDER CHILDREN. Of the 8 fatalities amongst those aged one year most were due to communicable complaints, influenza, tuberculous meningitis and whooping cough accounting for one each and lung affections 3. Four of the 6 children who died in the second year died from pneumonia and one each from diphtheria and tuberculous meningitis. Diphtheria accounted for 2 of the 4 deaths of those aged 3, and tuberculous meningitis 2 of the 4 deaths of those aged 4. INFANT MORBIDITY. Ophthalmia Neonatorum. Four cases of ophthalmia neonatorum were notified, 2 of them in respect of infants born in hospitals in London. All cases made complete recovery. MATERNAL MORTALITY. Eight deaths were registered as due to or associated with pregnancy, giving a maternal mortality rate of 2.40 per thousand live births. Of these 2 were due to sepsis, this being a mortality rate from this cause of 0.60 and those to other accidents and diseases of pregnancy a rate of 1.80. The corresponding rates for England and Wales were 0.77, 2.16 and 2.93 and for this district in 1938 0.91, 2.73 and 3.64. The rates per thousand total births were 0.58, 1.75 and 2.33, compared with figures of 0.74, 2.08 and 2.82 for the country as a whole. One of the deaths from sepsis occurred in a patient who had received systematic ante-natal supervision followed by a normal confinement in hospital, but who, from vaginal laceration, developed a genital tract infection. The other was a married woman of 27 who died from a septic abortion in respect of whom an open verdict was returned. The particulars of the deaths from other causes are:—(1) A patient of 33, on the 13th day from a normal confinement, died of pulmonary embolism. (2) A patient of 31, who was under the supervision of her own doctor, suddenly developed eclamptic fits. She was immediately removed to hospital but in spite of all treatment died within 24 hours of admission. (3) A patient whose ante-natal findings were normal suddenly developed eclamptic fits. Although immediately admitted to hospital she died the same day 41 without recovering consciousness. (4) This patient died from pulmonary embolism on the 9th day of the puerperium following a normal confinement in hospital. (5) This patient, who had twice during her pregnancy suffered from minor degrees of haemorrhage, at the 36th week of pregnancy had severe ante-partum haemorrhage due to placenta praevia. She was immediately admitted to hospital in a severe state of shock from which she did not rally. (6) The death certificate read: Eclampsia; necrosis of liver. Acute influenza; pneumonia. PUERPERAL INFECTION. 19 notifications of puerperal pyrexia were received, being a rate per thousand total births of 5.5, compared with a figure of 14.35 for the country as a whole. Three notifications were in respect of women confined in institutions in London. Of the patients who were confined in this district, in 9 the raised temperature was due to genital tract infection. Of these, in 3 the infection followed a miscarriage, in 4 there was some operative interference at the confinement, but in 2 the delivery was normal. Of these patients, 9 were removed under the Council's arrangements to hospital for treatment, two were treated in nursing homes, while three were mild cases who remained at home. Of the cases notified, only the one proved fatal, being that of a septicaemia following an abortion. 42 INFANT WELFARE SERVICES. HOME VISITING BY THE HEALTH VISITORS. The following table shows the number of visits paid by the health visitors during the year:— (a) To expectant mothers First visits 920 Total visits 1,347 (b) To children under one year of age First visits 3,350 Total visits 8,517 (c) To children between the ages of one and five years Total visits 13,706 In addition visits were paid to 14 cases of measles and 355 cases of whooping cough in children under 5 years of age. INFANT WELFARE CENTRES. 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 49,229 (2) By children between the ages of one and five years 32,330 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 2,824 (2) Between the ages of one and five years 1,243 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 2,385 (2) Over one year of age 6,359 TREATMENT. The following particulars show the extent to which the facilities for treatment are used. Dental treatment:—295 children under five years of age, 378 expectant or nursing mothers made 1,105 attendances for treatment. 101 mothers were fitted with dentures. Physio-therapeutic clinic:—242 new cases were referred to the clinic. 76 patients were seen at the consultant orthopaedic clinic, and 114 patients were seen by the consultant physiotherapist. Correction of visual defects:—79 children and 4 mothers 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. 43 Operative treatment of tonsils and adenoids:—12 children were treated at the Harrow and Wealdstone Hospital for this condition under the provisions of the agreement. Convalescent homes:—10 children and two mothers were admitted to convalescent homes. Home nursing:—Responsibility was accepted for the payment of the fees for the treatment of 8 patients. 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 99 Number of persons registered during the year 54 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.) 104 Number of persons on the register who were receiving children for reward at the end of the year 93 Number of children on the register at the beginning of the year 167 Number of children received during the year 254 Number of children removed from the register during the year 290 Removed to care of parents 144 Removed to care of another foster-mother 63 Legally adopted by foster-parent 6 Removed to charitable organisation, etc. 17 Removal to hospital 11 Of this number seven died. Foster parent left the district taking the child with her 43 Child attained the age of nine years 3 Died 3 Number of children on the register at the end of the year 131 44 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,347 visits to 920 expectant mothers. Ante-natal Clinics. The following summarises the work done at the clinics during the year:— Total number of expectant mothers attending the clinics 2,044 Total number of attendances by expectant mothers at all clinics 8,814 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 59 Consultant Ante-natal Clinic. The consultant ante-natal clinic was held fortnightly throughout the year. During the year 214 women made 299 attendances. 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, 19 patients being seen by four practitioners. Of this number, five were insured patients. Only one woman attended for post-natal examination. ARRANGEMENTS MADE FOR CONFINEMENTS. At Home. 1,572 confinements took place in the patients' own homes. Of these 855 were attended by midwives acting in their capacity as midwives, and 717 by local midwives who had given notice of their intention to practise, acting as maternity nurses. In 550 cases the Council paid or contributed to the fees of the midwife, and in 199 cases a home help was provided. Consultant services:—During the year the consultant was summoned to 17 cases. Five were ante-natal patients, one a case of post-maturity, two of toxaemia, and two of haemorrhage. Four of these patients were immediately removed to hospital for treatment. Three consultations were in respect of puerperal febrile patients in nursing homes. One consultation was with the regard to the general condition of the patient after delivery at which there 45 had been extensive haemorrhage. Of the remaining eight cases, seven were consultations held because of difficulty arising during the confinement. In four of these an immediate operation was performed, and in one the patient was admitted to hospital. In the other two no operative interference was required. The remaining case was one of haemorrhage at the time of delivery, to deal with which an operation was necessary. In an Institution. 818 births occurred in registered nursing homes in this district 284 births to mothers from outside districts which occurred here took place in nursing homes, 17 in private houses. Of these 818 confinements 704 were conducted by local practitioners, 56 by midwives and 58 by midwives acting as maternity nurses. Notification of 1,368 births were received in respect of Harrow mothers having taken place outside the district. Of these 1,195 were from hospitals, 157 from nursing homes, and 16 from private houses. Of the patients confined in hospital outside the district 536 were delivered at Redhill County Hospital and 340 at Bushey Maternity Hospital. Of a total of 3,263 births, 1,361 occurred in the patients' own homes, 534 in local nursing homes and 1,368 in hospitals or homes outside the district. Some 1,886, or 58 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year 6 patients were admitted to London hospitals under the Council's arrangements. POST-NATAL SERVICES. Post-natal Examination. 102 women attended the clinic for post-natal examination, making altogether 126 attendances, while a further one was examined under the general practitioner ante-natal scheme. Puerperal Infection. (а) Consultant services:—The consultant was summoned to three patients suffering from puerperal pyrexia and to one patient 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 8 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. 46 BIRTH CONTROL CLINIC. Fortnightly sessions of this clinic were held throughout the year. 245 women, of whom 83 attended for the first time, made a total of 290 attendances. In addition there were four 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 46. Of these 15 removed from the district or discontinued practice, leaving 31 in practice at the end of the year. Of the total number 21 were resident in the district and carried on a domiciliary practice almost entirely limited to this area; 14 were engaged in local maternity homes, most of them entirely, though a few also carrying on a very limited domiciliary practice; and 11 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 1,572. In 855 cases the midwife was in attendance as a midwife and in the remaining 717 as a maternity nurse. Of the confinements occurring in private houses in the district 1,021 were attended by local midwives whose practice is limited to domiciliary work (728 as midwives and 293 as maternity nurses) and 50 by midwives from adjoining areas (36 as midwives and 14 as maternity nurses). At the end of the year there were in practice 6 independent midwives carrying on a domiciliary service. These between them attended 17 cases during the year, four attending under 10 cases, while two 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 227 Still birth 14 Death of Infant 10 Death of Mother — Laying out the Dead 6 Artificial Feeding 21 Liability to be a Source of Infection 7 Of the 227 summonses to medical practitioners, 37 were on account of some condition during pregnancy, 67 during labour, 90 in the lying-in period, and 33 some abnormality of the infant. 47 Of the 37 summonses to a patient during pregnancy 15 were because of albuminuria, oedema, or toxaemia, and 12 because of haemorrhage. Of the 67 summonses to a patient during labour the reason given in 37 instances was delayed labour with cause unspecified. In a further 13 there was some abnormal presentation, and 2 were on account of foetal distress. Eight summonses were to patients suffering from abortion (actual or threatened). 77 of the 90 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 four, and a raised temperature in five cases. Of the 33 summonses to infants 8 were on account of some discharge from the eye, 14 because of feebleness or asphyxia and some other abnormal state or condition in 11. MIDWIVES ACT, 1936. The number of patients attended by the Council midwives was 701 as midwives and 221 as maternity nurses, while, in addition, they attended 16 abortions. Although the number of patients actually attended is less than the figure of 1,010 attended in the previous year, the number of bookings, a figure of 1,195, was an increase of 118 on the number booked in the previous year. In anticipation of the extra work, authority was given for the appointment of an additional midwife. The suggestion as to the training of pupil midwives in connection with the Council's Midwifery Service was approved in principle by the Committee at their meeting in April. By the provisions of the Midwives Act, all midwives are obliged to undergo periodical refresher courses. Two of the Council's midwives were to have attended the course towards the end of the year, but all these arrangements were abandoned on the outbreak of hostilities. By the provisions of the Emergency Powers (Defence) Act, 1939, any local supervising authority, if it appeared to that authority to be necessary in order to secure that the number of women who are available in its area for attendance on women in childbirth is adequate for the needs of the area, to make an Order exempting from the provisions of the Midwives Acts, 1902-1936, for such period, and subject to specified conditions, any such women who have surrendered their certificates under Section 5 (1) of the Midwives Act, 1936. It was not found necessary, to meet the needs of this district, to take any such action. Of the 709 patients attended by the midwives acting as midwives 159 were charged the full amount; in 107 cases no charge was made; while 443 were assisted. The corresponding figures in regard to the 323 patients attended by the midwives acting as maternity nurses were 239; 6; and 78. 48 NURSING AND MATERNITY HOMES. The certificates of four homes were surrendered during the year, these being "Rest-a-Whyle" Nursing Home; "Sunnymede"; "Fair Elms"; and 27, Peterborough Road. One home, No. 365, Torbay Road, was registered with accommodation for one maternity case. At the end of the year, then, there were 21 homes registered in this district with a total of 180 beds, of which 82 could be used for maternity cases. The use. of a number of premises registered as nursing homes has, at least temporarily, been discontinued for this purpose. CLINIC BUILDINGS. The County Council began work on the erection of two of the combined buildings, the one at Honeypot Lane, the other at Alexander Avenue, South Harrow, part of which would be used by the Council for the purpose of holding there maternity and child welfare sessions. The plans of the Kenmore Clinic, which had been drawn up to afford facilities both for maternity and child welfare purposes, and for the holding of public meetings, did not receive favour at the Ministry. As the Middlesex County Council intimated that they did not desire the building to be adapted to provide any services for them, the original plans showing a suggested lay-out of the premises, designed solely for maternity and child welfare purposes, were submitted to the Ministry. A step forward towards the erection of the central maternity and child welfare clinic was taken when the Public Health Committee, at their meeting in May, resolved that provisional approval be given to the revised schedule of accommodation to be provided at this building, and that Mr. Verner Rees be asked to submit the preliminary plans of a building providing such accommodation. CAUSE OF DEATH Under 1 year Over 1 and under 2 Over 2 and under 5 Over 5 and under 15 Over 15 and under 25 Over 25 and under 35 Over 35 and under 45 Over 45 and under 55 Over 55 and under 65 Over 65 and under 75 Over 75 Total RegistrarGeneral's Allocations M F M F M F M F M F M F M F M F M F M F M F M F M F 1. Typhoid fever - - - - - - - - - - - - - - - - - - - - - - - - - - 2. Measles - - - - - - - - - - - - - - - - - - - - - - - - - - 3. Scarlet fever - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Whooping cough - 2 - 1 - - - - - - - - - - - - - - - - - - - 3 — 3 5. Diphtheria — — — — 2 1 3 3 - - - - - - - - - - - - - - 5 4 5 4 6. Influenza 1 — 1 — - — 1 — — — — 1 3 1 2 1 2 — 1 4 1 1 12 8 13 8 7. Encephalitis lethargica - - - - - - - - - - 1 - - - - - - - - - - - 1 — 1 1 8. Cerebro-spinal fever 2 1 - - - - - - - - - - - - 1 - - - - - - - 3 1 3 1 9. Respiratory tuberculosis - - - - - - - 3 3 4 9 7 8 3 11 5 4 1 1 1 — — 36 24 36 24 10. Other tuberculosis - — 1 1 3 — 1 1 2 3 1 1 — 1 1 — 1 — — — — — 10 7 11 7 11. Syphilis — 1 — - - - - - - - - - - - 1 - - - 1 - - - 2 1 2 1 12. General paralysis of the Insane — — — — — — — — — — — — — — — — — — — — — — — — 4 — 13. Cancer - - - - - 2 — 1 - — 5 2 4 11 15 23 24 32 35 44 12 26 95 141 99 141 14. Diabetes - - - - - - - - - - - - - - 1 1 4 1 2 3 3 4 10 9 10 9 15. Cerebral haemorrhage - - - - - - - - - - - - 1 1 4 7 6 6 10 8 14 22 35 44 29 40 16. Heart disease - - - - - - - - - 4 2 1 10 2 13 12 38 22 63 55 44 64 170 160 175 165 17. Aneurysm - - - - - - - - 2 - - - - - - 1 1 — 1 1 — — 4 2 4 3 18. Other circulatory diseases - - - - - - - - - - - - - 1 5 — 5 4 18 20 21 19 49 44 46 54 19. Bronchitis 3 5 — — — 2 - - - - - — — 1 2 — 2 — 2 2 3 9 12 19 12 1/ 20. Pneumonia 4 6 1 2 3 — — 1 1 1 1 — — 4 4 3 4 3 13 2 10 9 41 31 41 30 21. Other respiratory diseases - - - - - - - 1 - - - - 1 1 3 — 3 — 3 1 — 1 10 4 11 7 22. Peptic ulcer — — — — — — — — — — 1 — 4 — 3 — 7 — 1 — 2 — 18 — 17 2 23. Diarrhoea (under 2 years) 6 5 — 1 - - - - - - - - - - - - - - - - - - 6 6 6 6 24. Appendicitis — — — — — — 1 — 1 1 1 — 2 — 1 — — — 2 — — — 8 1 7 1 25. Cirrhosis of liver - - - - - - - - - - - - - - - - 2 - 1 - - - 3 1 4 — 26. Other diseases of liver - - - - - - - - - - - - - - 1 1 — — — 1 1 2 2 4 3 5 27. Other digestive diseases 4 - - - - - - - 2 1 1 2 2 2 1 — — 4 1 3 — 2 11 14 10 14 28. Nephritis — — — 1 — — 1 — 1 3 — — 4 1 1 6 3 4 1 5 2 6 13 26 15 22 29. Puerperal sepsis - - - - - - - - - 1 - 1 - - - - - - - - - - - 2 — 2 30. Other puerperal causes - - - - - - - - - 1 - 4 - 1 - - - - - - - — — 6 — 6 31. Congenital debility 44 32 - - - - - - - - - - - - - - - - - - — — 44 32 44 28 32. Senility — — — — — — — - — — — — - - 1 — — — 1 2 5 7 7 9 7 10 33. Suicide - — — — — — — — — 3 — 1 1 1 3 1 — 1 1 — — 7 5 9 5 34. Other violence - 3 1 2 — 1 — 1 1 7 2 7 2 2 1 6 — 7 2 - 8 33 20 37 20 35. Other defined diseases 4 1 — — — 1 2 2 2 — 4 6 5 6 4 6 13 12 9 7 6 17 49 58 46 58 36. Causes ill-defined — — — — — — — — — — — — — — — — — — - — 1 — 1 — 1 — Total 68 56 3 7 10 6 10 12 15 21 36 27 52 39 78 70 116 89 174 162 125 197 687 686 711 697