AC 439(1) HARROW HARR 7 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1940 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 1940 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 1940. By the provisions of the Sanitary Officers Regulations, 1935, the medical officer of health of a county district is required as soon as practicable after the 31st day of December in each year to make an annual report to the local authority for the year ending on that date on the sanitary circumstances, the sanitary administration and the vital statistics of the district. Towards the end of each calendar year a circular is received from the Ministry of Health outlining the form the report shall take. This circular usually states that the statistics to be provided by the Registrar General will be available early in the year and urges medical officers of health, particularly in view of the fact that the report is the less in value the more distant the time it is presented from the period to which it relates, to make every effort to publish it early. In point of fact it had become customary not even to expect the Registrar General's statistics, let alone to be in a position to publish the report by the time the Ministry hoped to see it issued. Last year, after receiving this guidance early in 1940, a subsequent circular was received from the Ministry suggesting that any issued should be an interim report only, being confined to essential and urgent matters which had affected the public health during the year. A report on the usual lines was submitted, but because of the very late receipt of the Registrar General's statistics only very belatedly. Whatever value the report possesses it would seem that as an article of record it is the more rather than the less advisable that it should appear during a period when changes which are of public health significance are, or might be, at their maximum. The records of the public health activities of a stable community will show from year to year a steady progress effected; those of a rapidly growing community may present more spectacular features, but no changes in peace-time can be of the magnitude of some of the social upheavals which have taken place in so very many districts this last year, and yet this is the time when it is suggested, with a view to economy of paper, that the annual reports should be curtailed. Issued on the 26th March, Circular 2314 of the Ministry of Health requested the Council to direct that the Annual Report of the Medical Officer of Health for 1940 be prepared on the lines indicated the previous year. Again it was felt that the economies of time and of paper which might 3 have been effected by acceding to this request might possibly be more than off-set by the receipt of a report in the more usual form. On considering the question as to whether the non-inclusion of the Registrar General's official statistics would be outweighed by the advantages of the report being presented at an earlier date and therefore closer in time to the period to which it related, it was decided to delay the presentation of the report until such date as would permit of the inclusion of these statistics. With the object of attaining uniformity and so ensuring that statistics of different countries shall be comparable, conferences internationally represented are held periodically. Consequent on recommendations made at these meetings some alteration in the procedure of completing death certificates or of classifying the various causes of death enumerated in the certificates are sometimes made. Such a change was made in this country, being effective as from the beginning of 1940. There are certain rules intended to be followed by medical practitioners in completing death certificates. It is unfortunate that more attention is not paid to that in which it is suggested that the practitioner should for each case first consider whether the essential facts of the case cannot be epitomized by a statement of a single cause. The prescribed form of certificate is now divided into two sections. In the first should be included the immediate cause of death and any morbid conditions which led up to it, if such there were, the latter being stated in order backwards from the immediate to the remoter causes. In the second should be indicated conditions which are not in the chain of pathological events which have led to the immediate cause of death but which have none the less contributed seriously to the fatal issue. Where more than one cause of death appears on the certificate the Registrar General allocates the death into the appropriate category according to his rules, causes entered in the first section of the certificate being, as a rule, preferred to causes entered in the second section. Under the new arrangement, allocation will be based more than formerly on the order of statement of the diseases by the certifying practitioner rather than by the application of any rules, for which reason correct certification is now more than ever necessary. Many certificates appear to be completed with little regard to the suggestions made by the Registrar General respecting the completion of certificates of death. Had the district registrars in the change following the coming into force of the provisions of the Local Government Act, 1929, been attached to the local sanitary authorities, or at least to the larger of them, improvement in this respect in time might have been attained. The Registrar General classifies the deaths into one of some 200 categories for the purpose of compiling a detailed international list of causes of death. In addition he compiles an abridged list of some 36 headings. Alterations in the headings of these categories have 4 been made in the case of both lists. In the case of the abridged list while there are still the 36 divisions, separate headings for post-syphilitic disease (now embodied under syphilitic disease), liver diseases, senility and ill-defined or unknown causes have been withdrawn, acute poliomyelitis and encephalitis, cancer of different sites, prematurity and road traffic accidents now being distinguished. The altered basis of classification is reflected in the distribution of the causes to which the deaths are ascribed. While the figure for heart diseases for 1940 is much the same as that for 1939, the figure for intracranial vascular diseases rose from 69 to 163. In the case of the respiratory complaints, while the increase in the bronchitis figure from 29 to 96 and pneumonia from 91 to 111 may be partially attributable to an increased number of fatalities from those complaints, to some extent probably it is statistical. There was a sharp increase in the total number of deaths, the death-rate per thousand population jumping to over 9, each sex recording about 150 more than in the previous year. Most of this increase was amongst those over 55 years of age. While the maternal mortality rate was low, the infant mortality rate reached a disappointingly high figure. As for each of the last three years the figure has been below 40, the rise to 50 is very marked, and little consolation is to be found in the fact that the national rate had increased to 55. The notification rates of most of the infections, e.g., enteric fever, scarlet fever, diphtheria, erysipelas and cerebro-spinal fever, were lower than those of the country as a whole, though the rates of 12.16 for measles and 1.53 for whooping cough were slightly in excess of the corresponding national rates of 10.24 and 1.34. Further losses to the staff were sustained during the year, another of the health visitors and another sanitary inspector being called up. Additional duties came the way of the staff because of the effect of the war. At the time when it was anticipated that there would be an influx of people into the district, referred to later, the health visitors visited a total of some 2,500 houses listed by the wardens to ascertain the willingness of the occupants and their suitability to take in persons or families. The sanitary inspectors assisted in the same search for accommodation, visiting some 70 houses which would, had the need actually arisen, have afforded accommodation for between 300 and 100 persons. Arrangements had been made for the systematic visiting of premises at which persons had been billeted by workers under the supervision of the members of the Women's Voluntary Service. The main object was to ensure that there should be no missed cases of persons falling ill of some of those infections with a long incubation period. The services of the health visitors were used in this connection too as they further investigated any doubtful cases met by the Visitors provided by the W.V.S. Once raiding had actually started additional duties were imposed on 5 the sanitary inspectors as they had to carry out the inspection of food stuff damaged or possibly damaged to determine whether its condition was such that it should be withdrawn from sale to the public. In the course of their more ordinary duties, particular attention has been devoted by the health visitors to the subject of feeding and purchasing, regard being had, in the case of the latter, to the availability of suitable products. As reported last year, the health visitors, who at the outbreak of the war, for a few weeks, devoted practically the whole of their time to A.R.P. services, were, as soon as possible, released from this occupation, though in most cases remaining available as part-time volunteers to the A.R.P. services, and returned to their usual duties which, as contrasted with the work at the first aid posts, could be carried out only by persons of their experience and training. This line of action has since received the approval of the Ministry of Health who in their circular No. 2280 pointed out that while appreciating that the health visitors have done most valuable work at first aid posts, emphasize that their routine maternity and child welfare work is so important that the Minister trusted that authorities would make every effort to free them from regular duties at the posts in order that they may attend to the health and well-being of mothers and young children. In a later communication, circular No. 2376, the Minister pointed out the inadvisability of sanitary inspectors being wholely or mainly employed as air raid wardens or in the first aid services, etc. In this district, owing to the reduction of the sanitary inspectorate because of the demand of the Services, it had never been possible to consider the use of the few inspectors available for any duties other than those in which their particular training and experience would be put to full use. During the year there have been many phenomena arising directly or indirectly from enemy action which might have had their repercussions on the health of the district. Of these, the one which possibly came nearest to having any effect was the danger arising from the use as dormitories of public air raid shelters by large numbers of persons. As this district was a neutral area, no official evacuation took place from it, nor were there admissions to it on any great scale from evacuated areas. It was, however, designated a reception area for other purposes, and has had from one source or another fresh additions to its population. A more direct effect of enemy action is that risk of the spread of water-borne infection following on damage to water mains and pollution of the supply. Then, to be also considered are those risks to health which might arise from the enforced acceptance of lower hygienic standards because of the shortage of man-power or the inexperience of the newcomers. Although, in point of fact, the account which follows is one of occurrences which might have, rather than had, taken place, it is felt desirable to make 6 reference to these circumstances even though they did not, during the year, actually have any effect one way or the other on the health of the district. In this as in other districts it was at one time feared that the frequenting of air raid shelters by large volumes of individuals would give rise to major public health problems. The trenches and basements were, of course, designed for use in certain definite circumstances, namely, as places of temporary harbourage for those caught out in the streets. It was never anticipated that they would be used for long periods, and still less for such long periods at night-time. Designed for the one purpose they have been found seriously wanting in many respects in the light of the demands later made on them. They were damp, if not definitely wet, cold and ill-ventilated, while the nuisances from the sanitary arrangements were soon intolerable. Fortunately, the use made of them here fell very short of their capacity. The 66 shelters in this district provided sitting accommodation in public trenches for 17,000, school trenches 11,000, and in basements for 3,000, in all some 31,000. The Chief Warden reported on October 25th that he estimated that not more than 5,000 persons were using the shelters regularly each night. During November the district was less subject to air attack. This factor, coupled, no doubt, with the discomfort associated with occupying the shelters, led to a large reduction in occupation, so large that the number of occupants on the night of December 2nd was only some 2,200; some 5,263 were occupying Anderson shelters and 171 others including surface shelters, the total number of persons occupying public and other shelters on this night being 7,651. In the meantime energetic steps had been taken to lessen some of the unsatisfactory features. The problem of combating dampness in underground structures in the soil of this district proves very difficult of solution. Satisfactory lighting was a real contribution towards improving conditions. In that regard those trenches in which the walls were colour-washed in some light tint struck a much more pleasing tone which helped to dissipate gloom. Heating of the shelters presented another problem. Apart from the necessity of avoiding pollution of the atmosphere by products of combustion care was necessary to prevent over-heating. While the sparsely occupied surface shelter might be given some form of heating in the latter part of the day, it is probably safer to avoid at any time heating those which are liable to crowding. Though steps can be taken to minimise discomfort and reduce the more flagrant offences to the senses, and while the provision of water and the improvement in the sanitary conveniences might lead to a reduction in the risk of spread of the alimentary infections, the real risk of the spread of air-borne infections remains. Of such palliative measures as the wearing of masks, the spraying of the atmosphere with disinfectants, or even the destruction ot 7 the organisms by ultra-violet light, each has its adherents, but no method of control of the spread of these diseases can be as effective as proper spacing of the individuals, combined with adequate ventilation. The standard beyond which crowding must not be allowed to occur has been laid down as 50 cubic feet per occupant, a standard, of course, infinitely removed from any at any other time laid down for human-beings. Crowding to this extent will necessitate the provision of other means for preventing the spread of nasopharyngeal flora from one individual to another if epidemics are not to take place. Adequate spacing implies much more room space than this standard. The crux of the problem is undoubtedly this question of crowding, in regard to which lateral spacing is probably of more importance than cubic content. The policy of dispersal, whether by evacuation of the inhabitants of towns to reduce the demand on shelters, by distributing the population in small bodies in a large number of shelters rather than in large crowds in a small number of shelters, or by reducing crowding and so to ensure adequate spacing in the shelters is not less important as an epidemiological factor than as a method of minimising casualties from air attack. The dangers resulting from shelter existence arise not only from the degree of proximity of the individuals with presumably at least a proportional increased risk of the spread of infection as compared with that obtaining when the more usual standards of accommodation are adopted, but also from the added factor, the length of exposure to any possible infection. Some diseases spread to the susceptible members of the population on what would seem to be momentary exposure, while others appear to require more lengthy exposure, and it is to be imagined that a susceptible person who has been partially salted might well successfully resist a certain dosage to which he is exposed for a short time but succumbs to the same dosage if he is exposed to it for many hours. The physical discomforts and the psychological reactions of those at the shelters would also tend to lessen whatever powers of immunity were possessed by the shelterers, while the humid and stagnant atmosphere must materially increase the opportunities for the spread of droplet infections. These are the risks, which in some cases might be considered to outweigh in importance the dangers against which shelter existence was adopted. If congregation of large numbers in shelters is to continue, adequate ventilation must be provided. For this to be tolerated and so be permitted to function at all, will necessitate an effective system such as the provision of fans coupled with some method of heating the incoming air. Better than the congregation of large numbers in shelters, however, is the return to the family unit. Street surface shelters, even though they are accepted as safe, are not popular, very largely, it seems, because of the noise. The absence of noise appears to be one of the contributory factors to the feeling of 8 security given by the deeper shelters. In this district the Anderson shelter is difficult to make satisfactory. Even if acceptable in summer its disadvantages will probably always in winter outweigh the advantages, being as they are, damp and cold and difficult to ventilate. There remains the question of strengthening a room or part of a room in every house. This would go a long way to removing many difficulties which arise under arrangements in which there is herding of people, e.g., those present because of patients suffering from temporary acute illness, whether infectious or not, who cannot be removed to hospital and also the case of the tuberculous patient who should not be in a public shelter. Of course for that matter for the open case of tuberculosis to be in any shelter with his family is contrary to the teachings of all tuberculosis authorities who have for these years continued to stress the necessity for such patients having separate sleeping accommodation. The congregation of large numbers, even though the sanitation of the shelters were satisfactory would still afford a risk of the spread of infection greater than that to which the community is ordinarily exposed. Not unnaturally the medical profession would be looked to to minimise this risk. In the latter part of the year the Metropolitan Boroughs were authorised to engage medical men, in the case of the largest shelters, as full-time medical officers of the shelters, but, in the case of other shelters holding 500 persons, to pay a regular nightly visit and be on call, or, in the case of the smallest shelters to be on call only. In the last weeks of the year these provisions were extended to this district, though in point of fact, because of the limited use made of the shelters it was necessary to take advantage only of the provision by which a medical man could be summoned at the cost of the authority to attend to a patient in any of the public shelters. While such authority is undoubtedly of advantage to those in charge of the shelters, although the doctors summoned will have an opportunity of advising the shelterers on matters of hygiene, too much, if anything at all, must not be expected that by this means the risk of infection can materially be lessened. Many infections are spread by carriers, healthy persons who harbour the organism unknown to themselves or to others. Many others are most infectious in the very often unrecognised, and, for all practical purposes, unrecognisable, stage. Few enough are the occasions when an infection is brought home to any offending individual. From the point of view of reducing the spread of infection all that can be done is to appeal to the shelterers to present themselves for medical examination at the onset of any symptoms which might be precursors to any infection. For such a step to be of any real advantage, however, it would be necessary to have some place in which such persons can be housed where they will not be a risk to others. In the case of declared diseases for which hospital provision is ordinarily made, if the patients 9 are willing, removal to hospital is arranged. If, however, the patient is not willing, nor content to stay at home if removed there, the powers of the local authority are rather weak, though perhaps now strengthened by the Rules of Conduct for Shelterers. Where an infectious disease is only suspected, however, or is one of those infections for which ordinarily there is no hospital accommodation, the situation can be met only by the provision of isolation facilities in the shelter, either by restricting some shelters or certain portions of shelters to the admission of selected persons, coupling with an insistence on the removal of the possibly infectious to these portions, the prohibition of admission there of other persons. Apart from air-borne infections, the use of the shelters as dormitories provides a very real risk of louse infestation with the attendant risks of the spread of louse-borne diseases. All the conditions exist for heavy louse infestation which is substantially increased when the same clothing is worn by day and by night. Once introduced this is going to be a real problem to eradicate, more particularly as bedding is left in the shelter during the day-time and the bunk frames are of a continuous pattern providing no intervening space either horizontally or vertically between those portions of the frame used as separate bunks. In some districts cleansing stations have proved a necessity. Up to this in this area the magnitude of the problem has never justified any separate provision. This means that this and similarly circumstanced areas might be faced with the necessity of improvising. Lesser degrees of the problem can be dealt with by the facilities available at the isolation hospital for the steam disinfection of any clothing with possibly the use of the cleansing sections of the first aid posts as a means of dealing with persons. If the problem should assume formidable proportions, however, it might be necessary to commandeer premises at which can be provided such arrangements for dealing with persons and articles. The third of the plagues which might arise is the spread of contact diseases such as impetigo and scabies. In the autumn it seemed as though both were becoming more prevalent at least in some parts of the district, but more recently they have both been less in evidence. As yet, however, while at no time have more than a few trenches been occupied to anything like full capacity, before the end of the year very little use was being made at all, the shelters being occupied to about two per cent, capacity. On the occurrence of the siren during the evening some few more would be added to the number of regular users, and heavy gunfire occurring locally would result in still more. While the events of the future remain unknown, at the time of writing (January) it can be said that in this district the shelters do not provide a public health problem. One hopes that even should raiding have more 10 nounced effects in this district again the population, having once adapted themselves to spending their nights in their own homes, will continue to feel secure there and not feel the need for that additional sense of security that must, it seems, be one, if not the chief of the benefits derived from occupancy of these shelters, and which seems to be derived, in the main, from the companionship obtained there. Mere massing together of people by itself does nothing to reduce the risk to which as individuals they are subjected. If the shelters were so much less liable to damage than are their houses there would be some justification in householders running the risks inherent of such herding in such conditions. As things are, however, they would seem to be running greater, if unappreciated risks in order to minimise though probably only slightly an obvious hazard. The district not being one of those designated a reception area under the national scheme for evacuation of certain sections of the population from evacuation areas, the local authority was not called upon to make arrangements for billeting. In the spring, the threat of the over-running of some of the smaller countries across the Channel necessitated provision being made for the reception of foreign refugees. The Middlesex County Council were the responsible authority, though the District Council were, of course, to co-operate. The proposals envisaged those refugees allocated to the county being received at two large reception stations where they would be medically examined. Any hospital or infectious cases were to be sent to hospital, and unaccompanied children or other persons who, not being suitable for billeting in private or empty houses, would be sent to special institutions. The remainder after being fed, having their personal clothing made good, their registration numbers taken and identity cards issued, would then be distributed throughout the county. The county's proposals envisaged the temporary housing of large numbers of persons in suitable halls and other buildings, possibly for some three or four weeks, pending the arrangements for their being placed in private billets or empty houses. Such an arrangement, while it is appreciated might in certain circumstances not be avoidable, was, it was considered, fraught with too much risk of the spread of communicable infections. Having regard to the hardships and exposures to which the refugees would have been subjected for some days before they actually arrived in the district, it seemed urgently necessary that herding should be avoided and dispersal practised as far as possible. For this reason it was decided, if at all possible, to avoid congregating the refugees received from the reception centres for longer than was necessary and to endeavour to pass them straight on to their billets. Had it been necessary to billet any numbers temporarily in halls the County Council had made arrangements for the medical attention of any sick persons through their public assistance machinery. 11 Once billeted in households the refugees would have become ordinary members of the population who, if they needed medical attention which they could not otherwise obtain, would receive it under the County Council's District Medical Officer service. As events turned out, we were asked to receive only relatively small numbers of refugees, numbers small enough to be dealt with by arranging for them to be passed direct to their billets. Very shortly after the reception of these this area was declared a protected area so that aliens were no longer permitted here, and all the arrangements fell through. Apart from the small numbers of persons who found their way as individuals or as families into this district when those living within the vicinity of certain possible targets were advised to leave their homes and find other accommodation, the next occasion on which it was considered likely that any large numbers of persons would have to be received here was in the early summer when it seemed that mass migration of the population from certain coastal areas was imminent. On this occasion, as contrasted with the arrangements for the billeting of the refugees it seemed that any necessary action was the responsibility of the local authority and not this time of the County Council. Guidance on the steps to be taken was contained in a memorandum from a government department but this did not really help to clear up points of difficulty which it was anticipated might arise, particularly in the matter of disposal of selected persons such as pregnant mothers, the verminous, patients needing hospital treatment, or patients ill of some infectious condition for which hospital accommodation is not ordinarily available. With their hospital services the County Council were in a better position to deal with such patients. As the people were to be admitted to private houses and particularly as billeting was to be compulsory it was desirable that the householders should be as far as practicable protected from the risk of having to receive anyone suffering from an infectious or contagious condition. Medical examination was the obvious suggestion of ensuring this and as it was not possible to arrange for the medical inspection at the entraining end, the memorandum suggested such examination as may be possible at the receiving centres in order to segregate any persons suffering from infectious diseases or those in a verminous condition. It was not considered that the public health problems involved in the entry to the district of a few thousands of persons who had only a few hours before left their own homes would be of any magnitude. It was also felt unreasonable to subject these persons to any thorough medical examination, even though it had been considered that any advantage would follow such a practice. The arrangements actually to be put into force then included the provision of nurses (the Council's health visitors) and a doctor (one of the general medical practitioners living in the vicinity) at the station at which detraining was taking place. The persons would file 12 past the medical officer who would arrange for the more thorough examination of those who looked ill or were dirty. Infectious patients were to be removed to the Isolation Hospital. In regard to those women in an advanced stage of pregnancy or who seemed to be in premature labour, if there was no accommodation in the hospitals of the County Council approval was given to arrangements being made at the cost of the local authority for their admission to local maternity homes. The formulation of proposals for dealing with those infested with vermin caused some anxiety. It was anticipated that any lightly infested would be admitted to billets, while those more severely affected might be treated at the cleansing sections of the first aid posts, but in regard to those heavily infested or those suffering from contagious conditions such as scabies or extensive impetigo it was thought it might have been necessary to arrange for their admission to the Stanmore Isolation Hospital which at that time was vacant. By means of pamphlets issued on their arrival the evacuees were to be informed of the local health and social services, and once they had been admitted to their billets they would become members of the local population, obtaining any medical attention privately by the local medical practitioners if possible but if not then through the public assistance machinery of the County Council. As in the case of the other preparations made these also proved unnecessary. Although some persons came here from the coast towns, they came as units and not in official train-loads. Even of these, before the end of the year, large numbers had returned to their homes, having decided in September or October that they would be subject to less inconvenience there than they would if they remained here. In September the district began to receive numbers of persons who had been rendered homeless as a result of enemy action, while from time to time there was the need to provide accommodation for those of our own residents whose homes have been temporarily or permanently damaged. In regard to those from London it will probably prove that they are fleeting, as it seems that this district is too far removed from the district from which they come for it to be convenient for the wage-earner to go to his work from here, whereas, on the other hand, it is not sufficiently far out to provide that degree of safety which an evacuee can reasonably look for. The following is a summary of the extent to which the district is housing residents from this and other areas : The 2,071 persons on October 1st comprised 22 local inhabitants billeted, 1,322 from London and 610 from coast towns. A month later the corresponding figures were 165, 3,131 and 576, a total of 3,946. An increase to a total of 4,971 next month was followed by a fall to a total of 4,971 at the end of the year of whom 421 were local, 3,253 from London and 389 from coast towns. One of the direct deleterious effects of enemy action envisaged 13 is the pollution of public water supplies with attendant risks of water-borne infection. Apart from gross obvious damage to mains, with possibly similar damage to near-by sewers, it was considered possible that less obvious damage could be done to a main which, coupled with reduction in pressure in the mains through damage at some other point, could allow of contamination of the contents. The routine practice of the Water Company, however, affords protection against this possibility as the steps taken are those which follow on the assumption that fracture has occurred until it is proved that the mains are undamaged. When a main has been joined up at a crater, precautions are taken before the main is allowed to transmit water into supply to ensure that no further point of leakage exists. Special attention is being paid to the proper sterilization of those mains to be rejoined and watch is kept for the presence of contamination at the sites. A further precaution which is taken by the Company is the submission for analysis at their laboratories of samples of water taken from premises supplied by the affected mains. Apart from these, samples are taken by the sanitary inspectors and transmitted for analysis to the Emergency Laboratories. As a further precaution, if, at any time, there is reason to suppose that the supply may have become unsafe, consumers will be warned to treat water for drinking or culinary use either by boiling or, where this is not practicable, by chemicals. As yet the district has been fortunate in the limited extent to which damage has been done either to its water mains or sewers. On one occasion damage to a sewer resulted in a damming back of the drainage from a school playground so that it was considered advisable to close school for a few days. The last reference to the possible effects of the war on local health is merely touching a subject which may have important indirect bearings. With the demands of H.M. Forces on labour there is the likelihood of the recruits to certain fields of industry being less skilled than those whom they are replacing. In the industrial sphere this would lead possibly to merely a temporary lowering of output or might result in a lowered standard of quality. Such a factor might have important bearings on health if the men skilled in the operation of large plants for the pasteurising of milk should now be replaced by those new to the work or similarly if those skilled in food production who have been educated to certain hygienic standards have perforce to be replaced. Against some of these risks which are enlarged in war time it is possible for persons as individuals to take precautions to protect themselves. There are three diseases whose incidence might well be increased as an outcome of enemy action against which prophylactic measures can be taken. Typhoid fever is one of the diseases which may become more prevalent because of the lowered hygienic standards of food production or food control, because of an increase in the number of carriers especially 14 through the return home of troops who have served overseas, or more directly because of pollution of water supplies as a direct result of enemy action. Because of these possibilities the Ministry of Health, while not advocating mass immunization of the population, have recommended that facilities be available for the treatment of those whose work exposes them to this hazard or those individuals who wish to be done. Under these arrangements, local medical practitioners were informed that vaccine obtained from the Emergency Laboratories could be supplied for them to administer to their patients. Up to the end of the year, however, very little advantage had been taken of these facilities beyond the immunizing of the nursing and domestic staff of one of the hospitals in the area. The question of immunizing persons against tetanus has been raised more particularly in regard to those persons who are more especially exposed to infection by reason of their occupation. While there is general acceptance of the degree of protection afforded by the protective inoculation, the process is the less likely to meet with general acceptance in view of the fact that any person injured by enemy action will receive serum prophylactically whether or not he has been immunized, and early administration of anti-tetanus serum is effective. In regard to the practice of subjecting all those who have received injuries which have resulted in a breach of continuity of the skin surface to the routine of two or three prophylactic doses of A.T.S., it would seem that many persons are being unnecessarily put to discomfort and much material wasted. It is difficult to see a reason for the administration of serum to persons whose injuries have been received indoors and whose wounds are therefore most unlikely to be contaminated with tetanus bacillus. It does not seem to be common practice in ordinary circumstances for the practitioner to inject A.T.S. to patients so injured, but as long as the recommendation remains that all the wounded shall receive the A.T.S., medical officers of first aid posts will naturally hesitate to refrain from ordering the injection. The last of the diseases against which prophylactic inoculation has been shown to be effective that remains to be considered is diphtheria. As a public health measure diphtheria immunization is of the first importance and most districts have made arrangements by which those wishing to avail themselves of the facilities can have their children protected against this, one of the most serious of childhood diseases. The local arrangements provide for the actual work being undertaken by the general medical practitioners, the Council providing the reagent free and remunerating the practitioner for the treatment of those persons in receipt of incomes of less than £250 a year. When the scheme started three inoculations with T.A.M. was favoured, but for some time now two doses of A.P.T. were preferred in the case of younger children. Phials containing small quantities of antigen were 15 issued so that the quantity required for any one person could be drawn from the container used for that person alone. Towards the end of the year the Council agreed to raise the income limit to £450. Shortly after this a certain measure of publicity was given to the whole question, the Minister of Health urging authorities to take energetic action. While being duly grateful to the Minister for this propaganda it was felt that any steps taken should as far as possible be in line with those already in operation so that any publicity should act as a fillip to the ordinary measures and should not result in a merely temporary increase in the acceptance rate. In this district at least there have been no major changes arising from the war which have substantially increased the risk of any section of the community or even of any individual contracting diphtheria. From the point of view of the well-being of the community, to-day and of the future, it is far more important that a substantial proportion of the children born in this district should be immunized year after year, than that any, even though large, numbers should be treated to-day or in the next few weeks. For this reason, then, it was not advised that any special clinics should be held, but rather that the parents should continue to avail themselves of the existing machinery. If the only effect locally of any propaganda had been to increase the numbers going to their own doctors to be treated, such stimulus applied to them would have been welcome. Unfortunately, however, whether because of the demands made on the antigen elsewhere because of the larger numbers requesting to be done or whether it was because any reagent available was put up in the more economically sized containers or whether it was because shortage of glass prevented the distribution of the reagent in small sized containers, the fact remains that we were confronted with the situation that we were unable to supply the local doctors with the reagent. The only A.P.T. obtainable was that in the possession of the Emergency Laboratories. This was put up in 25 c.c. bottles and was for use at clinics and not for issue to the local practitioners. I have the honour to be, Mrs. Leech and Gentlemen, Your obedient Servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Harrow-on-the-Hill. June 30th, 1941 16 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, mid-year, 1940 188,710 Rateable Value (April 1st, 1941) £2,108,363 Sum represented by a penny rate (April 1st, 1941) £8,280 Extracts from Vital Statistics for the Year. Live Births:— Total. Male. Female. Birth rate per 1,000 of the estimated resident population, 16.4 Legitimate 2,898 1,521 1,377 Illegitimate 103 50 53 Stillbirths:— Legitimate 82 50 32 Rate per 1,000 total (live and still) births, 2.7 Illegitimate 2 1 1 Deaths 1,725 860 865 Death rate per 1,000 of the estimated resident population, 9.1 Deaths from puerperal causes:— Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis — — Other puerperal causes 2 0.62 Total 2 0.62 Death rate of Infants under one year of age:— All infants per 1,000 live births 500 Legitimate infants per 1,000 legitimate live births 46.6 Illegitimate infants per 1,000 illegitimate live births ... 145.6 Deaths from Cancer (all ages) 254 „ „ Measles (all ages) 4 „ „ Whooping Cough (all ages) 1 „ „ Diarrhœa (under 2 years of age) 21 17 Population. The figure of 188,710 as the Registrar-General's estimate of the civilian population is a drop on the figure for the previous year, even though it includes temporary residents from other areas. Apart from the official evacuees there are large numbers of persons who have made their own arrangements to come here. Though the total figures remain much the same, they are in fact only the balance of quite considerable movements of population. To what extent these changes took place during last year information is not available, but for a period of weeks in the early months of 1941 a net weekly increase in population of 370 was the balance of an average of 880 coming into the area and 510 leaving. These movements in population add materially to the work of the health visitors, whose records show that up to the end of May, 1941, nearly 1,000 children under five years of age had been evacuated from the district, against which were to be off-set some 750 who had moved in. Apart from these there were another 750 children under five years of age who had left the district permanently. The Registrar-General's estimate of the mid-year population is lower than that which was assumed, and lower than the figure of 195,000 given by the Chief Warden in his report in October when he found the distribution of the population in the different districts to be—Pinner North 14,000; Headstone 10,000; Pinner South 25,000; West Harrow 11,000; Roxeth 22,000; Harrow 9,000; Wealdstone South 16,000; Wealdstone North 20,000; Kenton 20,000; Harrow Weald 10,000; Stanmore North 13,000; Stanmore South 25,000. The return in June, compiled from information obtained at the time the Contex containers were being fitted to the gas masks of the population, disclosed that of the figure of 186,459, 4,586 infants of an average age of 21 months were provided with babies' protective helmets and 6,361 children of an average age of 3 years 7 months were furnished with small children's respirators. The population was distributed through 58,831 houses or dwellings, giving an average figure of 3.17 per house, a figure appreciably smaller than that found in recent years, namely, 3.37 in 1938, 3.31 in 1937 and 3.46 in 1936. Deaths. Total deaths in the district 1,231 Outward transfers 211 Inward transfers 705 Deaths of residents 1,725 The figure for the outward transfers is much larger than in previous years, this being in part due to the fact that the Royal National Orthopaedic Hospital has been enlarged and is used for B 18 the treatment of general cases, and use made by the County Council of Grimsdyke. Of the 203 deaths, 67 took place at the Orthopaedic Hospital, 3 at the North Middlesex County Hospital, 8 at Harrow and Wealdstone Hospital, 79 in private houses, 36 in nursing homes (including the deaths of 4 infants whose mothers had been confined in the home), 10 outside and one in the Isolation Hospital. Of the 705 deaths of local residents which occurred outside the area, most took place in institutions, 270 being at Redhill Hospital, 117 at Redhill House and 27 (including 11 new-born infants) at other County Hospitals. 8 deaths occurred at institutions for the treatment of tuberculosis and 28 at Shenley Hospital. 51 deaths took place in hospitals just outside the district and 68 in various of the London general and maternity hospitals, this figure including 5 infants of mothers confined in the hospitals. 16 of the deaths amongst local residents occurring outside the district were due to enemy action. 1,725 deaths in a population of 188,710 is a death rate of 9.1, a sharp rise in the figures for previous years, which for the years 1934-39 ranged between 7.1 and 8.1. The corrected death rate obtained by the application of the area comparability factor of 1.23 is 11.2. The previous highest number of deaths in the district in any one year was 1,408 in 1939. The altered rules which are followed in classifying the deaths into their various categories precludes any detailed examination into the cause of the increase of some 300 deaths. Intracranial cardio-vascular diseases show an increase from 69 to 163 and respiratory complaints from 118 to 236. These increases are equally divided in the sexes and occurred mostly amongst persons over 55 years of age. 36 of the increase were accounted for by there being 150 as compared with 124 deaths amongst infants under one year of age. Deaths from violence rose from 57 to 126, most of this increase being accounted for by the use of an allocation which amongst the civilian population at any rate, is new, namely death through war injuries or enemy action. One classification in which a reduced number of deaths took place this year is that of suicide, there being only 11 cases in 1940 as against 14 in 1939. Fatalities of the infectious diseases expressed as a rate per thousand population compare favourably with the figure for the country as a whole, the rates for whooping cough (0.005), diphtheria (0.01) and influenza (0.13), being lower than the corresponding national rates of 0.02, 0.06 and 0.32, the rate for measles at 0.02 being the same. The figure of 7.0 deaths per thousand live-births for diarrhoea and enteritis in infants under two years of age was much greater than the national figure of 4.6. 19 The following is the Registrar-General's abridged list of the causes of death in the district:— Male Female Male Female Typhoid fever 0 0 Other circ. diseases 26 32 Cerebro-spinal fever 1 2 Bronchitis ... 53 43 Scarlet fever 1 0 Pneumonia 56 55 Whooping cough 0 1 Other res. diseases 18 11 Diphtheria 1 1 Ulcer of stomach 16 3 Resp. tuberculosis 45 32 Diarrhoea under 2 years 14 7 Other tuberculosis 7 9 Syphilitic diseases 5 3 Appendicitis 6 7 Influenza 14 10 Other digestive dis. 26 20 Measles 1 3 Nephritis 27 18 Acute polio-myelitis 0 0 Puerperal sepsis 0 0 Acute encephalitis 0 1 Other maternal causes 0 2 Cancer of mouth and oesophagus (M), and uterus (F) 4 13 Premature birth 16 18 Cong. malformations, etc. 34 20 Cancer of stomach 24 18 Cancer of breast 1 34 Suicide 7 4 Cancer of other sites 81 79 Road traffic accidents 11 1 Diabetes 7 8 Other violent causes 65 49 Intra-cran. lesions 63 100 All other causes 68 71 Heart disease 162 190 All causes 860 865 20 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. CLINICS AND TREATMENT CENTRES. At the beginning of the year 21 weekly infant welfare sessions were being held at ten different premises; nine weekly and one fortnightly ante-natal clinic sessions at separate addresses and two weekly and one fortnightly toddlers' clinic session. In March an additional weekly toddlers' session was opened at Stanmore and arrangements made by which every third of the weekly sessions previously held at the Elmwood Clinic were in future held at the Baptist Church Hall, Streatfield Road, Kenton. At this building, too, a weekly ante-natal clinic session was started. In August fortnightly toddlers' sessions were started at St. Alban's Church Hall, North Harrow. At the end of the year, then, the sessions held were twenty-one weekly infant welfare centres, two weekly, three fortnightly, and the equivalent of another weekly toddlers' session, and ten weekly and one fortnightly ante-natal clinic sessions. The same arrangements in regard to treatment continued in force. In December, the Ministry of Health issued a circular (No. 2226) bringing to the notice of the local authorities certain considerations with regard to the treatment of venereal diseases in war time. They had previously urged the necessity of the provision of treatment facilities within easy reach of new aggregations of population, particularly in rural areas, and now suggested the employment by local authorities of suitably qualified medical practitioners who would give treatment in their own surgeries during normal hours of attendance. It was suggested in the circular that such method was particularly suited to the needs of rural areas and that it was not intended that a practitioner service should in any way replace any existing treatment centres. The Middlesex County Council as the authority responsible for the provision of the treatment of those in the county affected with venereal diseases acts under the London and Home Counties' Scheme by which there is made available to those affected the services provided at a large number of hospitals in and around London, though actually only at one in the County of Middlesex itself. While it is appreciated that affected patients will often be unwilling to attend treatment centres in the immediate neighbourhood to their homes and prefer to go to more distant centres where they are not likely to be recognised, it still remains the position that too many difficulties must not be put in the way of sufferers as even though they might be willing to attend in such circumstances they are more likely to default before full cure has been achieved. It cannot be felt that the present arrangements 21 in the County are satisfactory and it was therefore hoped that advantage would have been taken by the County Council of the authority contained in the circular to make these arrangements with the general practitioners which would so substantially help to bring treatment within the reach of those affected. It seems that the County Council considered that the scheme was for application for rural areas only. Nevertheless it is gratifying to learn that the County's arrangements are to be materially improved in due course by the establishment at three of the County's hospitals of Venereal Diseases Clinics. LABORATORY FACILITIES. As mentioned in last year's report examination of clinical material has been undertaken at the laboratory forming part of the services organized by the Medical Research Council. During the year the laboratory moved into London from the premises at which they had been temporarily housed. Nevertheless, the transmission of samples by the van which covers the sector served by the laboratory ensures the early examination of articles and early receipt of reports, a factor of importance in the case of diphtheria swabs. Because of difficulties of transmission the services of the laboratory are being used to a greater extent than formerly as routine bacteriological examination of milk samples is now undertaken at these laboratories, while advantage is taken, too, of the service for the examination of samples of water from premises served by water mains which have been or may have been damaged as a result of enemy action. In this regard it seems that some change occurs which results in a temporary addition of some, even though relatively small, numbers of organisms to the water for a period extending some two or three weeks and that the lapse of a period of time is required before the restoration of the quality of the water to that ordinarily obtaining. 22 SANITARY CIRCUMSTANCES OF THE AREA SANITARY INSPECTION OF DISTRICT. A. Inspection of Houses. Number visited on complaint 1,036 Routine inspections under the Housing Act - Surveys under Section 157 of the Housing Act 232 Inspection of houses let in lodgings Number of foster parents' houses inspected 63 Inspections of houses for other reasons 119 Total visits paid 5,206 B. Inspection of other premises; visits and enquiries: Number of routine visits to premises liable to give rise to nuisances 571 Further visits paid to these premises 351 Number of visits to premises kept under periodical inspection 519 Number of inspections of cinemas and places of entertainments 4 Number of complaints investigated (excluding those referred to above under Housing) 389 Number of observations for smoke nuisances 22 Number of inspections of factories (mechanical) 459 do. do. (non-mechanical) 229 do. do. work places 162 do. do. outworkers' premises 180 Number of visits to premises where rag flock is used Number of visits under the Shops, etc., Act 939 Number of evening observations under the Shops Act 29 Number of inspections of hairdressers' premises 27 Number of visits re infectious diseases 3 C. Inspection of premises where food is manufactured or prepared: Slaughterhouses 53 Butchers (including Meat Depot) 1,309 Cowshed 35 Dairies 55 Ice Cream Premises 82 Fish-Shops 139 Fried Fish Shops 76 Bakehouses 152 Cafes and Restaurants 465 D. Inspection of premises where food is retailed: Greengrocers 353 Provision Merchants 519 Milk Shops 167 Bakers and Confectioners 263 23 Complaints. As a result of the visits paid on receipt of the 1,036 complaints included above under "Inspection of Houses," it was found that 669 houses exhibited some defect, commonly of roofs and gutters or windows, some faults affecting drainage whether defective sinks, waterclosets, drains, or choking of the drains; and defective yard paving. Most of the defective conditions giving rise to complaint would be remedied on drawing the attention of the owners to the conditions, but in some few formal action under the Public Health Acts was required. In some few instances the premises are found to be in such an advanced state of disrepair that ordinarily they would have called for action under the appropriate section of the Housing Acts. Choking of drains— which is cleared by the Council free of cost—arises mainly from one of two causes, misuse by the occupants of the house, and poor initial construction. From misuse, a variety of articles such as scrubbing brushes, rat traps, toys, newspapers, tea-leaves, etc., find their way to and lodge in the interceptor trap of the drain. In the case of a terrace of houses such carelessness may result in the blocking of a combined drain with consequent very real nuisance to a number of persons. In regard to the second cause, the trouble in many instances is the result of cement protruding through the joints of pipes or of pieces of cement having fallen away from the walls and benching of the manhole of the drains. Much of this trouble could therefore have been obviated if, at the time of their construction, the drains had been "badgered" and if the manholes had been rendered with better material and with greater care. The other complaints received cover a very wide field: 33 were in regard to the presence of rats. The procedure in such cases is for the Sanitary Inspector to visit and inspect. When there are conditions such as defective drains, accumulations of rubbish, dirty chicken-houses or accumulations of foodstuffs which, if not causative, are contributory to the nuisance, action is taken under the Public Health Acts, apart from particulars of the complaints being forwarded to the County Council's Rat Destruction Officer. Many complaints are received in regard to matters over which as the public health authority the Council has no control, many the result of the behaviour by some without any consideration for their neighbours. Complaints about such matters as the lighting of bonfires in the gardens, the shaking of carpets or rugs from the window, etc., have apparently increased since the beginning of the war, a fact which may be attributed to the influx into the district of persons who at their ordinary places of residence, are more in the habit of invoking the aid of the inspectors. It is particularly to this type of complaint that, because of the small staff available, it has been found impossible to devote much attention. In regard to the remedying of conditions, many of 24 which were brought to light on complaint, informal action in 1,270 instances obtained abatement before the end of the year in 1,195 cases. 27 Statutory Notices under the Public Health Acts were required, 25 being complied with. In four cases formal notices under the Housing Acts were served, three being complied with. In regard to compliance with notices served under the Public Health Acts it was necessary in eight cases for the Council to carry out the work in default. Similar action was resorted to in one of the cases where notice served under the Housing Act had not been complied with. Action was required in regard to three cases of overcrowding. Inspection of Houses. 234 surveys were carried out under the Housing Act, in most cases these measurements following on the receipt of an application from the owner or agent for a certificate giving particulars of the number of persons permitted to occupy the premises. The total number of certificates issued since the coming into force of these sections of the Act is 9,980 being made up of the figures of 2,122 issued in 1936 and 5,473, 749, and 1,402 in the succeeding years. These figures represent almost the number of separate premises measured up; almost though not entirely because a different number of persons is permitted to occupy a house according as to whether it is let to one or to more than one family so that requests may be received for the permitted number following a change of tenancy. No houses this year were inspected and recorded under the Housing Consolidated Regulations. The inspection of foster parents' houses follows on the intimation of any person that she proposes to undertake the care of foster children, attention in these cases being paid particularly to the hygienic conditions of the premises and also the question of possible overcrowding is gone into. Inspection of other Premises. The premises included in the category of those at which nuisances might be anticipated, to which 571 visits were paid, include such places as stables, farms, pig-styes, allotments and yards at which a nuisance might arise from accumulations of manure or of rubbish or from general dirty conditions. Apart from the routine visits, further visits would be necessary where nuisance is being caused, these being repeated until the nuisance has been abated. The other group of premises which are the subject of periodic inspection and to which 519 visits were paid consisted mainly of public and private conveniences, and this year include air raid shelters. Hairdressers' premises are visited periodically to see that the Council's bye-laws as to the cleanliness of the premises and the 25 cleanliness and sterilization of the utensils are complied with. The visits to cinemas and places of amusement are directed more particularly to the sanitary arrangements of the hall, especially their cleanliness and adequacy. Most of these are modern buildings so little trouble is experienced, nor were any complaints received regarding ventilation. SMOKE ABATEMENT. During the year 22 observations were carried out. During the 369 minutes' observation, dense smoke was seen for 16½ minutes and moderate smoke for 211½ minutes. FACTORY ACT. In this district there are 379 factories with mechanical power, 132 without mechanical power and 159 work places. The numbers of visits paid to these three classes of premises were 459, 229 and 162. In regard to mechanical factories the chief function of the local sanitary authority is in regard to sanitary accommodation, supervision of most other matters of sanitary significance being exercised by the factory inspector. The sanitary authority has greater responsibility in regard to non-mechanical factories and work places as in these their duties include the supervision of cleanliness, ventilation, overcrowding, heating and sanitary accommodation. Of the 52 public health nuisances detected, 18 were due to want of cleanliness and one to defective heating. The sanitary accommodation was unsatisfactory in 28 instances, being unsuitable or defective in 22, unclean in five, and insufficient in one. Five other nuisances were noted. Interchange of information between the factory inspectors and sanitary inspectors is provided for. Under these arrangements notices were received from the factory inspector in six instances relating to want of cleanliness and in one to absence of sanitary accommodation. Notices were received of 154 outworkers' residences in this area. To these premises 180 visits were paid, attention being paid particularly to the avoidance of such nuisances as overcrowding, want of cleanliness, insufficient ventilation and inadequate heating. SHOPS ACTS. 939 visits were paid to shops and 29 evening observations made, a very considerable reduction in the volume of this type of work as compared with previous years. 43 contraventions of the Acts were recorded, these being classified as employment of young persons in excess of 48 hours per week, 35; assistants employed after 1.30 p.m. on early closing day, 3; the serving of customers after closing hours, 2; shops not closed on weekly half-holiday, 2; failure to keep records of hours worked by young persons, 1. 26 The attention of 92 traders was called to their failure to exhibit the appropriate notices, in two instances a final warning being given. 26 contraventions of section 10 of the 1934 Shops Act which deals with the arrangements for health and comfort of shop workers were noted, 18 arising from the dirty or defective water closet accommodation, four cases of dirty walls; three were due to absence of suitable and sufficient sanitary or washing accommodation and one due to deficient heating arrangements. One certificate of exemption from the provision requiring sanitary accommodation was granted. 13 contraventions of the provisions of the Shops (Sunday Trading) Act, 1936, were noted, five being due to failure to exhibit notices, five due to failure to keep records of compensatory holidays and one each from serving customers with non-exempted goods and assistants not receiving compensatory holidays, and assistants employed on more than the permitted number of Sundays in the month. During the year the Secretary of State issued instructions for closing of shops during the winter months to become operative from 17th November to 2nd March, 1941. For general purposes shops were required to be closed not later than 7.30 p.m. on Saturday and 6 p.m. other days. The sale of tobacco, smokers' requisites, newspapers and periodicals is not affected by the Order nor the sale of articles mentioned in the first Schedule of the 1938 Act. The closing hours for barbers' and hairdressers' shops is 8 p.m. on Saturday and 7 p.m. other days, the closing of shops on the weekly half-holiday remaining unchanged. The Harrow Chamber of Trade decided not to apply for an Order to vary the hours. 27 HOUSING. HOUSING STATISTICS FOR THE YEAR, 1940. 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) 1,544 (b) Number of inspections made for the purpose 4,974 (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 (b) Number of inspections made for the purpose (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation (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 669 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 595 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 4 (2) Number of dwelling-houses which were dered fit after service of formal notices:— (a) By owners 2 (b) By Local Authority in default of owners 1 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 27 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 17 (b) By Local Authority in default of owners 8 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 2 28 (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— VERMINOUS PREMISES. Of the forty-four houses found infested with bugs and one house with fleas, seventeen were reported by the owner or occupier, seven by firms undertaking fumigation on behalf of the owner and the remaining twenty were found either by routine inspection or when investigating other complaints. Of the forty-four bug-infested houses, forty were treated by the owners and/or occupiers (eight by cyanide gas process). Two more were disinfested by cyanide gas at the Council's expense, the bedding in another case was fumigated by steam and the remaining case outstanding at the end of the year was subject to a legal notice. A house to house inspection was carried out during the year in Avondale Road and out of a total of forty-four houses, fifteen were found verminous. This high percentage is due to the apathy on the part of some of the tenants (many of whom alleged that they had never seen bugs, though examination proved the infestation to be one of long standing) but more particularly to the gross neglect on the part of some of the owners who failed to take the necessary action to disinfest the houses before reletting them to new tenants. The efficiency of the treatments carried out by the owners and occupiers varied considerably. In most cases the procedure followed consisted of stripping the wall papers from infested rooms and spraying with proprietary vermicides. In many cases this has done little more than control the infestation and unless every precaution is taken by the occupier, further trouble can be expected. It has been found that where the owner has sprayed the house and supplied the occupier with vermicide and spray for secondary and periodical applications, the treatment has proved successful. While the local authority may carry out work of disinfesting in default of the person on whom the notice is served to carry out the work doing so, and may recover the expenses incurred by them, if they elect to use gas for the purpose of destroying the vermin, they must bear the cost of their operations. This is an unfortunate provision which acts to the advantage of the owners of those houses which, just because they are the more seriously infested, call for more stringent treatment. 29 INSPECTION AND SUPERVISION OF FOOD. (A) MILK SUPPLY. Distribution. There was no change in the number of producers of milk as compared with the previous year, and in regard to the retailers the only changes were the reduction of one in the number of those not occupying premises in the district and a reduction of three in-the number of shops from which milk is sold in unopened receptacles only. The only change in the licences issued was one less supplementary licence issued to a producer outside the district to retail T.T. milk here, and a similar reduction regarding the supplementary licences to retail pasteurized milk here. On the other hand, there were three more premises other than those in which pasteurization took place from which pasteurized milk is sold. Sampling. Eighteen samples of pasteurized milk were submitted to bacteriological examination and the phosphatase test. A sample from one firm who pasteurize in this district proved unsatisfactory; after inspection of the premises a further sample showed a vast improvement but was not altogether satisfactory; two further samples taken a little later passed the phosphatase test and had low bacterial counts. Four samples of T.T. milk and four of the five samples of ungraded milk produced locally gave satisfactory counts. (B) MEAT. Inspection. In the early days of the year slaughtering of animals at the eight licensed slaughter-houses in the district ceased to be carried out. At one institution a limited amount of killing has taken place regularly throughout the year so that 53 visits were necessary, a total of 326 carcases being examined. Of the 51 beasts slaughtered 22 were unsound in some respect, in 14 (or 28 per cent.) the lesion being tuberculosis, and in five parasitic disease. Of the 167 pigs killed eight (or 5 per cent.) showed tuberculous lesions, one-half in the lungs, the other half in the liver. One entire carcase was condemned on account of fevered condition. Only two of the 76 sheep were unsound in any respect, the lungs and livers of both carcases being affected with parasitic disease. None of the 32 calves killed exhibited any signs of disease. The Live-Stock (Restriction on Slaughtering) Order, 1940, of the Ministry of Food came into operation on January 15th, 1940. While for many years the continuance of the use of the large number of private slaughter-houses in this country has been accepted as a reproach on the public health service in that so many 30 premises left much to be desired while their multiplicity rendered impossible the post-mortem examination of all the animals killed and resulted in the ante-mortem examination representing only a small proportion of that desired, none of the Public Health Acts or acts of public health significance passed between the years of 1875 and the outbreak of the war permitted much to be achieved in reducing the number of slaughter-houses (the relevant positions of the Food and Drugs Act, 1938, did not come into force until after the outbreak of the war). This Order, by which the work formerly carried out in some 16,000 premises has now been concentrated in some 500 slaughter-houses succeeds to that extent, though because those selected for use were taken more because they fitted in with the rationing scheme of the Ministry of Food than from public health considerations it is probable that not the most hygienic will in fact be in use. Perhaps post-war economic conditions necessitating the economies which would arise from centralized slaughtering will effect as a public health benefit what measures promoted on public health grounds have failed to achieve. Meat Depot. The Meat Depot at Canterbury Road is used as a distributing house for Harrow and other districts. As was the case last year the inspection of the meat here demands practically the whole time of. one of the inspectors. While not ideal for their purpose no real exception can be taken to the premises. Both home-killed and imported meat are received at the depot, the home-killed mostly in entire carcases, but the imported quartered or the offal in barrels. Some home-killed meat bore evidence of previous inspection, but much appears to have missed this. The following is a statement of the extent to which the meat has had to be condemned:—Carcases of 144 sheep, of 2 calves, and of 3 pigs on account of emaciation, dropsy, putrefaction or immaturity; 10 carcases of sheep because of black mould: 1,769 lbs. of beef because of putrefaction or bruising; 3,655 lbs. of mutton because of putrefaction or of black mould; 89 lbs. of veal because of putrefaction; 43 lbs. of pork because of tuberculosis. About 38,000 lbs. of offal were condemned on account of parasitic disease, putrefaction or pneumonia. Much of the meat is condemned because of putrefaction. Part of this arises, probably, from delay in transporting the meat to the depot; on the other hand, some of the meat could possibly have been saved if some system of refrigeration were installed at the depot. While it is appreciated that difficulties arise from war conditions, the handling and transporting of the meat leaves much to be desired, some of the carcases on arrival being in a very dirty condition. In a Memorandum on the Control of Slaughtering issued by the Ministry of Health and the Ministry of Food it is stated that 31 the provisions of the Food and Drugs Act, 1938, in relation to the seizure of unsound food are not applicable in relation to the meat, etc., in possession of the Crown and it is requested that if it appears to an authorised officer of a local authority that such meat is unfit for human consumption the facts should be brought as soon as possible to the notice of the Government Slaughter-house Manager. This raises the question as to the powers of the sanitary inspectors examining the meat at the depots. In this district there has not been the slightest suggestion of friction between the officials and, of course, even if the inspector could not obtain the concurrence of the manager as to the unsoundness of any meat he has his remedy as soon as the meat passes into the possession of the retailers. (C) OTHER FOOD. Food Shops. Food shops in the district are visited frequently. The following amounts of food stuffs were condemned and voluntarily surrendered: Fruit and vegetables, 300 lbs.; fish, 19 stone; meat, 167 lbs.; bacon, 32 cwt.; tinned ham, 253 lbs.; chicken, 42 lbs.; and 290 eggs. A measure aiming at the elimination of the spread of alimentary infections by means of contaminated food stuffs is the power given by Section 13 of the 1938 Food and Drugs Act, requiring the provision of washing facilities in rooms in which food intended for human consumption is prepared or stored. At bakeries, and at those shops dealing with dairy products satisfactory arrangements had almost always previously been made. At butchers' shops and provision merchants' premises, however, little had previously been done and on the coming into force of this portion of the Act much of the time of the sanitary inspectors had been devoted to this work, their aim being to secure the provision of a constant supply of hot water. Before the end of the year their requests had been complied with in most premises, though, more particularly in some small shops where the owners have their own household arrangements conveniently at hand, a separate supply in connection with the shop only has not been insisted upon. It is hoped later to be able to reach the same standard at fruiterers' and greengrocery shops. Food Damaged by Enemy Action. In the latter months of the year many of the incidents resulted in damage to food shops. These premises are visited by the inspectors who inspect all the food and see that any damaged, which is most commonly by impregnation by glass splinters, is withdrawn from sale, but that all that is capable of salvage is referred to the local food officer. 32 ISOLATION HOSPITALS. ADEQUACY OF ACCOMMODATION. Owing to the low incidence of scarlet fever, the Honeypot Lane Hospital was closed for the earlier part of the year. When raiding started it was considered unwise to use the so-called diphtheria pavilion which had since the beginning of the war been used for housing scarlet fever patients because its relatively unprotected condition made it advisable that it should be possible to evacuate it completely and if necessary hurriedly, a step which could with less risk be taken in the case of scarlet fever patients than in the case of those suffering from diphtheria, amongst whom there are usually some which it is undesirable to move. This reduction of available accommodation, together with the rise in the incidence of infection, soon made it necessary to admit patients to the Stanmore Hospital. Accommodation for scarlet fever patients proved sufficient but a slight increase in incidence of diphtheria cases in November necessitated some patients having to be found accommodation in the hospitals of other authorities. In order to restore to use the accommodation afforded at the diphtheria ward it was decided to provide both lateral and overhead protection. This work was in hand at the end of the year. Owing to the difficulty of providing overhead protection in the wards and the need that there might be of refraining, because of the serious condition of the patient, from subjecting him to the strain of moving him, it was decided to construct an annexe to the diphtheria ward of sufficient size to accommodate at least two patients, which afforded satisfactory lateral and overhead protection. On a previous occasion the question of the limited accommodation in the Nurses' Home at the South Harrow Hospital had been considered, but in view of the then likelihood of the further need of the hospital and of the home being of short duration, it was decided that no action should be taken. With a view to improving conditions, however, this year a building has been erected, one portion of which will afford accommodation for Matron's office and improve the conditions under which visitors to the hospital can be interviewed, and the remainder will provide an additional recreation room for the nurses. The remaining structural changes made at the hospital are the construction of overground shelters provided with bunks for the protection of the staff during raids. No such provision had previously been made as it had been assumed that raiding would be intensive for short intervals and that for those periods the staff would be in the wards. Pending the erection of the new Isolation Hospital reliance has had to be placed on the goodwill of other authorities to accept 33 infectious cases which could not be accommodated in the local institutions. On the whole the district has been particularly fortunate in the limited number of occasions on which these authorities have been unable to meet the demands of this area. It can be anticipated, however, for a variety of reasons that greater difficulties will be met with in future. One reason is that some of the isolation hospitals have had at least part of their accommodation allocated for E.M.S. purposes. It is understood in such circumstances provided the demand by E.M.S. needs permits, that available accommodation might, if required, be used for the original purpose. Even though there are no E.M.S. demands, however, this does not result in quite as fluid a reserve of beds as ordinarily obtains. Having regard to the possible needs it is an urgent necessity that as much as possible of the isolation facilities at the different hospitals should be released for their intended purpose. Not only is the available accommodation reduced in this way, and also by the isolation hospital premises being no more exempt from being damaged in raids than are other buildings, but the demands on available accommodation are increased even though the incidence of the infections for which isolation hospital beds are intended does not increase, the greater pressure arising from increasing demands made for the admission of patients suffering from infectious conditions which are not ordinarily admitted to the infectious diseases hospitals. These difficulties arise on the one hand because of the congregation of persons in circumstances which must cause a real risk of the spread of infection if the infectious patient is not restrained from being admitted. While the uncomplicated case of mumps can well be treated at home and almost invariably is, difficulties arise if the family of which the patient is a member goes to a public air raid shelter with the patient, or where it is discovered that a child amongst the many received in a rest centre proves to be suffering from some similar minor infectious state, or where a child billeted in a household develops one of these conditions. Then circumstances arise of a patient ill of one of these conditions who, because of the raiding, is removed to the best protected room in the house, there to mix intimately with the rest of the family. It is appreciated the anxiety that is caused amongst the parents of other children even though they may be free from anxiety on their own account, that the presence of an infective person gives rise to, but in spite of the impression gathered from different documents that in certain circumstances hospital accommodation is available for the admission of patients thereby removing them from the congregation where they might spread disease, the fact remains that the accommodation just is not there, at least in this district, which is dependent on there being in some other area beds surplus to the needs of that area, needs which these authorities must themselves find hard to meet. c 34 Demands for arrangements to be made for the admission to hospital of patients suffering from milder infectious diseases which are not ordinarily removed to hospital are also received from the military authorities. While it is appreciated that in certain circumstances real difficulties will arise if such a patient cannot be removed, yet in other circumstances it does seem that the military authorities might adopt a less helpless attitude. It would seem, too, that more regard might be had to such matters when it is being decided that a number of troops are to be stationed in any area, and that when any place seems likely to be used for an indefinite period that they should take the necessary steps to provide their own accommodation to meet such contingencies. No very elaborate provision need be made for the reception of adult males slightly ill of a mild infectious complaint provided, as would always be the case, that hospital accommodation would be found for those whose clinical condition necessitated hospital care and nursing. One of the lesser difficulties now being encountered arises from the fact that parents of patients who cannot be admitted to the local hospitals are proving very reluctant—quite understandably so—to agreeing to their children being admitted to a hospital which is nearer to London than is this district. Partly because this was anticipated, and partly, too, to endeavour to have further accommodation of which to avail ourselves if it should prove impossible for those hospitals which ordinarily accept patients from here to continue to do so, enquiries were made, but with very little success, as to the possibility of local patients being, if necessary, admitted to the hospitals of those authorities in the areas to the north and west of this. CLINICAL ASPECTS. Diphtheria. Admissions:— Number admitted on a diagnosis of diphtheria Number of cases clinically diphtheria 56 Number of carriers 12 In 10 cases in which the diagnosis was not confirmed the revised diagnosis was laryngitis in 5 cases, quinsy in 3, and bronchial pneumonia and scarlet fever in one case each. Of the cases clinically diphtheria, 48 were faucial, 5 nasal, one laryngeal and 2 aural. Of the carriers 8 were faucial, and 4 nasal. Seven of these were admitted from the Orthopaedic Hospital. Deaths.—Number of deaths, 3. Case mortality of diphtheria cases, 5.3 per cent. The particulars of these fatal cases are:—(1) A girl of 8 admitted on the eighth day of disease suffering from laryngeal diphtheria died within a few hours of admission. (2) A boy of 35 4 admitted on the third day suffering from haemorrhagic diphtheria. He had a bull neck and haemorrhages from the throat and subcutaneously. He died on the seventh day from admission. (3) A boy of 12 admitted on the alleged second day of nasal and faucial involvement died on the fourth day after admission. Concentrated serum is now used in treatment, most patients receiving it intra-muscularly but the more serious being given at least some intra-venously. No serum reactions occurred this year. Scarlet Fever. Admissions:— Number admitted with a diagnosis of scarlet fever 163 Number suffering from scarlet fever 155 Number in whom diagnosis not confirmed 9 Of these 9 cases 4 suffered from German measles, 2 each from measles and from tonsillitis, and one from septic rash. Deaths.—Nil. Complications.—12 patients suffered from cervical adenitis, 11 from rhinorrhœa, 9 from otorrhcea, 9 from relapse, 7 from albuminuria, 4 from rheumatism and one from a stye. Seven out of the 56 patients treated with serum developed a serum rash. One developed a prontosil rash. Cross Infection.—One patient admitted incubating whooping cough was removed to the hospital of another authority. Measles was introduced into a ward on one occasion; prophylactic injections of the contacts who had not previously suffered from the disease failed to prevent the development of the attack in those exposed, though it may have had some influence in ameliorating the severity of the attack; while it certainly seemed to be instrumental in prolonging the incubation period of the disease by some two days, an achievement of course which is not to be desired from an administrative point of view as it only prolongs the period for which the ward has to remain in quarantine. Return Cases.—Return cases were notified from 9 households to which patients treated in the hospital from scarlet fever returned on discharge. Other Diseases. One case of erysipelas was admitted to the Stanmore Isolation Hospital, at a time when it proved impossible to find accommodation elsewhere. 36 PREVALENCE OF, AND CONTROL OYER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis) Disease. Under 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65 & Total 1 yr. yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs. over. Scarlet Fever 1 43 104 25 12 6 12 11 2 1 - 217 Diphtheria - 26 23 14 6 4 7 5 - 1 - 86 Pneumonia 7 4 12 5 1 3 13 23 11 17 16 112 Erysipelas 1 1 2 1 - - 4 7 10 6 5 37 Puerperal Pyrexia - - - - - 1 6 2 - - - 9 Ophthalmia Neonatorum 5 - - - - - - - - - - 5 Cerebro-spinal Fever 3 8 7 - 3 5 5 6 - - - 37 Dysentery - 1 - - - - - - 1 - - 2 Food Poisoning - 1 — - — — 2 - - 1 - 4 Measles 28 760 1383 53 30 11 14 5 1 - - 2285 Whooping Cough 21 129 130 3 1 1 - 11 - - - 296 Typhoid Fever - 1 - - - - 1 — — — — 2 Disease. Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 217 163 - - 1 Diphtheria 87 77 7 — 2 Pneumonia 112 — — 111 Erysipelas 37 — 6 — 1 Puerperal Pyrexia 9 — — — — Ophthalmia Neonatorum 5 — 1 — — Cerebro-spinal Fever 37 — 9 — 3 Dysentery 1 — — — — Food Poisoning 4 — — — — Measles 2285 — 22 — 4 Whooping Cough 296 — 9 — 1 Typhoid Fever 2 — 1 — — 37 DIPHTHERIA. Incidence. Eighty-seven notifications were received during the year, though in a number the diagnosis was subsequently amended. Seventy-eight cases in a population of 188,710 gives a rate per thousand of 0.41 a rate which although a slight rise on that for last year is only in conformity with the rates experienced by the district of recent years. (For the years 1934 to 1939 the figures were:—0.60, 0.58, 0.22, 0.54, 0.34, 0.28.) The incidence throughout the year was fairly even, the number of cases notified each quarter being 13, 21, 19 and 28. The number for the last quarter was swollen because of the occurrence of 9 cases in one family. An unusual proportion of households were affected by secondary infection: (1) A girl of 2 who fell ill on May 29th was removed to hospital on June 1st, on which day her sister, aged 6, fell ill. (2) A girl of 8 fell ill on April 28th, and her sister on May 1st, both being removed to hospital on May 3rd. Some weeks later two members of the same family were admitted to hospital, both suffering from aural diphtheria, but neither giving a history of any affection of the throat. (3) A girl of 16 whose illness dated from October 9th, but who was not removed to hospital until the 14th, apparently infected her brother whose onset was the 10th, and another girl of 3 in the house who fell ill on the 14th. (4) On the same day five members of the same family whose illness was alleged to have started only on the day before were admitted to hospital. One, a girl of 10 who suffered from rhinorrhoea had nothing on her throat and gave no history beyond that of a cold. Her subsequent progress, however, only confirmed the suspicion that she had been a missed case, and was probably the source of origin of the illness in the others. Within the next two or three days a further four members of the household were affected. There were two return cases, being the parents of a boy of three years of age, who had been admitted to hospital on February 7th, being discharged on May 8th and who developed a nasal discharge. Two patients were bacteriological cases only; two suffered from laryngeal, two from nasal and one from aural diphtheria. In the course of the year 18 patients were admitted from the Orthopaedic Hospital. Though many of them came from the same ward investigations of the ward staff failed to show that anyone was acting as a carrier. Some of those admitted were only bacteriological cases. The distribution of the cases in time was most erratic. Three cases in the week ending February 10th were separated from four in the fortnight ending June 22nd, by one case in the week ending April 20th; single cases in the weeks ending July 27th, September 14th, September 28th and October 5th and 12th were followed by four in the three weeks ending December 28th, 38 Place of Treatment. All but two patients were admitted to hospital, most to the South Harrow Isolation Hospital, but nine to the hospitals of other authorities. Of those removed elsewhere one was not admitted to the local hospital because he was suffering as well from measles. The other eight cases had to be refused admission locally because there was no accommodation at the time for them. Deaths. Three deaths were recorded as due to diphtheria. Immunization. During the year T.A.M. as the antigen was largely replaced by A.P.T., the change being practically complete towards the end of the year owing to the difficulties experienced in obtaining as an antigen anything else but A.P.T. 705 cards of children immunized were received during the year. The practice was more prevalent in the last quarter but the increased numbers who came forward in the last weeks of the year following special propaganda are not included in the 1940 figures as the second dose in the vast majority of cases would not fall due until 1941. It was not possible to carry out Schick-testing on any children during the year. As it was felt that the mothers of some infants brought to the infant welfare centres might agree to their children being immunized if the facilities were available then and there, in the latter part of the year approval was given to the necessary arrangements being made. Provision of Antitoxin. 44 lots were issued, totalling 392,000 units. Schools and Diphtheria. Apart from the occurrence of two cases in the same department with onsets in the same week on one occasion, and two cases in consecutive weeks on three occasions, the only grouping in relation to schools was that in which the onset of illness of three members of the same family attending a school in one week was followed the next week by two cases in the class attended by one of these children. SCARLET FEVER. Incidence. 217 cases were notified during the year, of which, however, 10 were errors of diagnosis, the illness in most of these being German measles or measles, though two were tonsillitis and one a septic rash. 207 cases is an incidence of 1.08 per thousand population, a figure even lighter than that of 1.60 for the previous year which was, in itself, the lowest incidence in the previous six years, the rate per thousand population for the years 1934 to 1938 being 4.70, 3.47, 2.64, 2.31 and 2.72. 39 The low incidence of the first quarter of the year, when only 31 cases were notified, was followed by a still lighter rate in the second quarter, the number of cases notified being only 21. Though in no week of the third quarter were more than seven cases notified, the general prevalence throughout this period resulted in the total notifications for the quarter being 46. A heavier average weekly incidence, in the last quarter, though again with no week having recorded more than 14 cases, made a total of 106 notifications received for this period. Place of Treatment. Of the 217 cases notified, including those in whom the notifications were later withdrawn, 54 were treated at home at the election of the parents. 160 were admitted to the local isolation hospital, and three to the isolation hospitals of other local authorities. Of those admitted to hospitals, in 27 per cent. of cases there appeared to be no real reason that the child should not have been treated at home, a figure within the range of 25 to 35 per cent. for the years 1936 to 1940. Air raids have apparently had little influence on the question as to whether removal to hospital would be requested or not. Probably there are those who, though ordinarily they would nurse the child patients at home, are influenced to send them to hospital because of the particular difficulties in providing isolation of the patient and protection of other members of the family, or because they feel that more adequate protection can be afforded to the patient in hospital. There was more than one patient whose parents began to treat them at home but whose admission to hospital was actually requested because of the air raids. On the other hand, there will be those parents who would wish at all costs to avoid parting with their children, so that the possibility of raiding will have the result of keeping some at home who ordinarily would have been sent to hospital. The fact that there is little change on previous practice is probably to be accounted as a final result of two opposing factors. In point of fact, the ratio of the number kept at home to those admitted to hospital in the first quarter was 1 to 4, and in the second quarter, 1 to 3. The slight fall of 1 to 2.5 in the third quarter was followed by a return in the last quarter to a ratio 1 to 3. In rather more cases this year was the reason for admission the fact that the patient was an adult, the percentage being 18 as against 10 for last year. The figure of 15 per cent. where the reason was the presence of younger children at home and a similar figure where it was because there was no bedroom in which the patient could be nursed by himself are much the same as the figures for last year. Only in 5 cases was a request for admission on the grounds that there was no one to nurse the patient, and in only one case was admission requested because of the clinical condition of the patient, this sole instance being a patient suffering from mastoid involvement. 40 Secondary Infections. Secondary infections occurred in seven households, in four of which there was only one secondary case, in two, two cases, and in one, three cases. Return Cases. Return cases occurred in nine households, in most only the one patient being infected but in two homes two patients each. At the time of the onset of the illness in the infected patient the patient discharged home in six cases seemed apparently fit and exhibited no abnormal signs. In only one case secondary to these infecting patients was the onset of the illness of the return case within a week of the return home; in three instances it was in the second week and in two it was in the fourth. The onset of illness of those patients who were presumably infected by the returned patients who exhibited abnormalities at the time that the infected patients succumbed was appreciably shorter on the average, in two cases the onset being within the first week from the return home of the presumably infecting cases and in the other instance in the second week. Two of the three patients exhibiting abnormal signs were suffering from a nasal discharge, and a third from a sore in the nose. There was one recovery case, the affected patient falling ill on the sixth day after the infecting case had been freed from isolation. Deaths. Amongst the transfer death returns for the last quarter of the year was one recording the death from scarlet fever of a baby boy of eleven months in November. The child had shortly before been evacuated from this district, apparently being quite well when he left here. Schools and Scarlet Fever. Schools appeared again to play a very small part in the spread of scarlet fever. In two departments there was possibly some relation between the incidence and attendance at school as in one department 8 cases occurred over a period of 7 weeks, and in another 17 cases over a period of 14 weeks. Apart from these instances the only other groupings were: on one occasion two cases occurred in the same department in one week; on two occasions three cases occurred in the one week; once two cases one week were followed by one case the next week; and on six occasions one case was followed by another in the following week. ENTERIC FEVER. Three persons were notified as suffering from paratyphoid fever, one a female of 34 who fell ill in June, and the other a boy 41 of 2 who succumbed early in September to what proved to be a fatal attack. In the third case the diagnosis was not confirmed. Both patients were treated in general hospitals. DYSENTERY. Only one patient was this year notified as suffering from dysentery, a girl of 3 whose onset was in December, 1939, but whose complaint was not diagnosed until February when she was admitted to a near-by general hospital. FOOD POISONING. Four patients were notified as suffering from food poisoning, of whom two were members of the same family, and one was sufficiently ill to require hospital treatment. Abdominal pain, vomiting and diarrhoea were the symptoms usually encountered. All patients made early recovery. ERYSIPELAS. 37 cases of erysipelas were notified during the year, of which 22 were in females. The face was the affected site in 25, the head and the ear 3 each, and the leg in 4. 10 patients were treated in hospital, 7 being admitted to isolation and 3 to general hospitals. At one period it proved impossible to obtain accommodation anywhere and one patient who later died of the illness had to be refused admission. The onset of the illness in 24 of the patients was in the four months September to December. CEREBRO-SPINAL FEVER. In common with most of the country the district had a heavier than usual incidence of cerebro-spinal fever, 38 cases being notified, but the notification being withdrawn in the case of two. The distribution of the cases throughout the year was most irregular. After 2, 4 and 3 cases with onsets in the first three months of the year 9 and 7 cases were notified in April and May; the next three months were free, then one case in September was followed by 2 in October and by 4 each in November and in December. All patients were removed to hospital for treatment, 23 to Redhill County Hospital, 5 to other general hospitals and 8 to isolation hospitals. Of the 36 patients, 16 were adults, of whom 13 were males; 3 were babies under one year of age; 8 were children of ages 1 to 5; while 7, of whom 6 were girls, were aged 5 to 15. Three cases proved fatal. MEASLES. Measles and whooping-cough were made notifiable towards the end of 1939. Measles was for a time added to the list of the diseases required to be notified during the last war, together with 42 German measles, but in general the requirement was later withdrawn and it was understood that only those authorities who were in a position to demonstrate that they were undertaking special measures which were dependent on the disease remaining notifiable should retain the provision. The inclusion of this disease amongst those to be made statutorily notifiable was considered at the time the clauses in the now Public Health Act, 1936, relating to the notification of infectious diseases were under consideration, but it was decided not to include it. While many reasons can be adduced for making this or that disease notifiable, in general it can be said that to justify its requiring such action the disease should be one of public health importance, either from the standpoint of the number of deaths caused, or because of the disability suffered by the patients; or it should be one which can be effectively combated by public health measures, or one for which prophylactic or therapeutic agents exist. The fact that the disease is notifiable may heighten the respect with which the complaint is held by the public, and to that extent assist in the educative efforts of the staff of health departments to instil into the minds of the public a full appreciation of the seriousness of the ailment, more particularly in those of tender years. The disease, however, is notifiable only by the attending medical practitioners and not by the parent—not that many notifications would in fact be received if the obligation were actually laid on the parent. Whatever advantage to the patient might accrue from the notification as a result of any measures taken by the staff of the public health department, these are the less likely to be required by those patients whose illness has been notified, as the mere fact of notification connotes that there is a medical practitioner already in attendance, whereas, on the other hand, it is just those patients who might be considered to be most in need of whatever help can be given by the public health department, who are not brought to the notice of the department, just because a medical man is not called in to them. For this reason, then, it is questionable whether the benefits derived from making the disease notifiable are any the greater than those which follow on the position which obtains by which the head teachers of the public elementary schools send to the medical officer of health the names of those children who are absent from school, being either sufferers or contacts of cases of infection, including measles. Where the numbers from the two sources of information, namely the doctors' notifications and the head teachers' lists, do not overlap, the information which is the more valuable to the public health department as measured by the help that the department can give, is that contained in the head teachers' lists, these being the affected children who are not under the care of the medical practitioners, though, of course, to be of real advantage, the information must be received promptly. On occasion, particulars 43 are received weeks, and, it has even been months, after the absence of the children referred to. As it happens, the actual figures for the year are not dissimilar, namely, 1,710 from the head teachers and 2,285 notifications from medical practitioners. Of course, the head teachers' returns relate only to children of school age, whereas those of the medical practitioners relate to persons of all ages. The weekly number of notifications received in the first four months of the year were only 2, 3 or 4, figures which rose to 15 and 13 in May and June. The absences from school, however, over these months showed that whereas in January the incidence of measles was low, there was a steady rise in the succeeding months and the disease had become quite widespread by the second quarter. In many large towns measles exhibits a characteristic bi-annual beat. This is particularly marked in London, and the extra-metropolitan areas in general behave similarly, the high incidence occurring in the first months of the even years, though the incidence will have started to rise in the last months of the odd years. The 1940 epidemic, however, failed to put in an appearance, and the number of cases which did occur in this district in the earlier months of the year bore no relation to what might have been anticipated. The weekly notification rate of 30 in July was followed by a lighter incidence in August and this, in turn, by a progressive increase in the next three months when the weekly notification figures for September, October, and November were 72, 119, and 152. This increased incidence at what must be accepted as an unusual time of the year, was not general. Although not being heavily attacked in July, the district was, at that time, receiving over one-third of the notification of all cases of measles which were being made in the County of Middlesex. This, broadly, remained the position for the next three months, though, by November, because of the increased prevalence elsewhere in the County, in spite of the larger number of notifications received in Harrow, the proportion had fallen to one quarter and by December the proportion was only one-fifth. Measles in itself is not a disease of high fatality, but the high rate of respiratory complications makes it a dread ailment. The large number of patients who succumbed to the infection in the milde; months of the year removed this number from those who might have succumbed in the more severe weather when respiratory complaints are the more likely to occur, and also lessened the likelihood of an epidemic outbreak. To this extent the district has been the favourite of fortune, even more so than its neighbours. The number of fatal cases was only four. In the case of measles and whooping-cough where notifications have been received visits are not paid to the homes by the health visitors as a routine practice. The medical practitioners 44 have been advised that at their request, visits will be paid and similarly arrangements will be made for home nursing by the staff of the district Nursing Association. In the case of those patients of whom knowledge is gained by intimation of the absence of a sick child from one of the public elementary schools, the health visitors visit the homes whether or not there are there children under five years of age. The total number of visits paid by the health visitors was 1,152, and 22 children were removed to hospital. WHOOPING COUGH. For the first three quarters of the year the incidence of whooping-cough remained slight, the weekly average notifications received for the first five months, being only one; two in each of the next two months; three and four for August and September, followed by a rise to 7 in October, and figures of 21 and 20 in November and December. No intimations were received of absences from school on account of this complaint for the first four months of the year. As in the case of the notifications from medical practitioners, the rise in the summer months was followed by an increase in September and a still heavier incidence in the last months of the year. While the numbers considered week by week or month by month vary, the total number of notifications received from the medical practitioners, namely, 299, closely approximated, as happened in the case of measles, to that of the figure of 282 received from the head teachers of the public elementary schools. Only one case proved fatal. The number of patients suffering from whooping-cough who were removed to hospital for treatment was 9, and the number of visits paid by the health visitors was 168. NON-NOTIFIABLE INFECTIONS. Chickenpox. Of the 261 children who were absent from the public elementary schools during the year because they were suffering from chickenpox 63 attended one school. Four other schools had between 20 and 40 sufferers, most of these being during the summer term. Mumps. 84 of the 142 cases of mumps occurred in one school during the summer term. In the following term three other schools were lightly affected. Influenza. Influenza was prevalent in the earlier part of the year, 11 out of the 24 deaths ascribed to it occurring in the latter half of February and the first half of March. 45 German Measles. This infection was particularly prevalent in the first half of the year, 22 school departments being affected. Starting with 42 cases in February the incidence rose to 109 in March, reaching a maximum of 285 in April, and continuing at almost the same level in May when there were 269 cases. The incidence fell then, only 135 cases being known of in June and 28 in July. Practically no cases were intimated during the Christmas term. 46 TUBERCULOSIS. Notifications. New Cases. Deaths. Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F Under 1 - - - - 1 - 1 - 1—4 — — 3 1 - - - - 5—9 1 2 5 3 — - - - 10—14 3 1 6 1 1 - - 5 15—19 6 7 4 — 4 1 1 - 20—24 8 21 — 4 4 5 1 1 25—34 36 53 5 5 10 15 1 - 35—44 32 13 5 4 7 2 1 2 45—54 16 6 2 2 10 5 1 — 55—64 11 2 1 1 7 2 1 65 & upwards 6 2 — 1 2 2 1 - Total 119 107 31 22 45 32 7 9 During the year 226 pulmonary cases (119 male and 107 female) were added to the register, a slight increase on the figure for the previous year. This increase was to be expected because of the admission to the district of persons from other areas, this transfer of population accounting for the fact that of the persons notified, 106 (49 male and 57 female) were known to have been notified in some other district before coming to live here, a figure which compares with one of 79 for the year 1939. This figure of 106 is probably an under-statement of the position as there were a further 56 persons of whom the particulars are not known of which quite a substantial proportion will probably ultimately prove to have transferred here suffering from the disease. It should be appreciated that the temporary transfer of population seriously disturbs the figures relating to tuberculosis. There will be a time lag between a notification being received in an area to which a person is transferred (the date on which that name appears on the register of the new authority) and the date on which that person's name is removed from the area in which he formerly resided, and for this period of time his name will figure in the returns of two areas and, maybe, in more than two if further removals occur. Then again a further cause for an apparently high notification rate occurs when populations are transferred as the persons suffering from tuberculosis who are received in any area may all be notified within a short time after transfer. If they are, then their names are added to the register of the receiving area at the rate of five per thousand population (this being the 47 average proportion of pulmonary cases of tuberculosis on the register of local authorities) whereas, in point of fact, the actual incidence of tuberculosis in that population will have been only at the rate of, say, one per thousand of its members (this being the average rate at which persons are formally notified as suffering from pulmonary tuberculosis). The admission of a few thousand persons, then, to any area might in this way in a short time be followed by quite a sharp rise in the notification rate, an increase which might give rise to illfounded apprehension. The 53 notifications (31 male and 22 female) of non-pulmonary cases is also an increase in the number of cases notified last year, an increase due largely to the greater number of persons, 22 as compared with 12, who came here already suffering from the disease. Of the 21 (10 male and 11 female) who contracted infection while resident here, the affected site in the case of 7 was either bone or joint, cervical glands of 8, abdominal tuberculosis 4, and genito-urinary 2. Those who transferred here with the disease showed a much higher rate of cases where the affected site was bone or joint, namely, 14 out of 22. In their circular 2362 issued on the 19th May, 1941, the Ministry of Health deal with the question of the transfer of notificafications of evacuated persons. The Public Health (Tuberculosis) Regulations, 1930, require the transfer from the old to the new area of residence of notifications in respect of tuberculous persons who have changed their place of residence permanently. In the Minister's view, evacuation or any other temporary change of residence as a consequence of the war does not constitute a permanent change of residence within the meaning of the Regulations, and notifications in respect of evacuated persons should therefore not be transferred to the new area of residence. While this line may be taken with regard to transfers of notifications, an analogous line as regards to notifications received in the area would not seem to be practicable. If a patient evacuated to this area is first diagnosed while living more or less temporarily here, there could, it seems, be no question as to the obligation on the attendant practitioner to notify the case to the medical officer of health of the area, and as long as that patient resided in that area the notification would not be transferred to the area of the patient's original home. The attendant physician will not be expected differentiate between patients who had or who had not been notified in other areas as suffering from the disease. He will always be encouraged to notify to the medical officer of health of the area in which the patient was then resident whether or not the transfer of the kind referred to in the circular had taken place. Merely to exclude all notifications relating to evacuees will not get over the difficulties as in many cases, no doubt, it will turn out that the evacuees will become permanent residents, and can it be suggested that a person is still a resident for statistical 48 purposes in the district in which he formerly resided if his house is no longer and cannot be rendered fit for occupation ? To enable the tuberculosis notification statistics more accurately to represent the true state of affairs, instructions should be given that only those forms A are to be accepted and included in the returns as such as relate to persons who have not been notified elsewhere. Such a departure from existing practice would have resulted in the notification figures for any rapidly-growing district being more in conformity with the actual facts because in such cases, too, the transferring person in time figures or may figure as a case notified for the first time in two separate areas. 12, or 15 per cent., of the deaths of patients suffering from pulmonary disease, and 7, or 30 per cent, of the deaths of patients suffering from non-pulmonary disease, occurred amongst patients who had not been notified in this area as suffering from the disease. Register. Pulmonary. Non-Pulmonary. Male. Female. Male. Female. No. on register Jan. 1st, 1940 331 280 65 80 No. of New Cases added 120 108 31 23 No. of cases added—other than on Form A - - - - No. of cases restored to register 4 1 — 1 No. of cases removed 99 71 19 15 No. on register Dec. 31st, 1940 356 318 77 89 The following table is a summary of the cases removed from the register, with the reason for their removal:— Pulmonary. N on-Pulmonary. Male Female. Male. Female. Left the District 44 32 7 8 Died 43 27 3 3 Cured 10 12 9 3 Diagnosis not confirmed or withdrawn - 1 3 Deaths. 77 persons (45 male and 32 female) died from pulmonary tuberculosis during the year, and 16 (7 male and 9 female) from non-pulmonary tuberculosis. Tuberculous disease, therefore, accounted for 5.4 per cent. of the total deaths in the district. 36 per cent. of the deaths of those who succumbed to pulmonary tuberculosis took place outside the district, mostly in institutions, as against the corresponding figure of 70 per cent. of those suffering from non-pulmonary tuberculosis. 49 MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 2,999, 1,571 male and 1,428 female. Of these 103 were illegitimate, being a percentage of total births of 3.4. 2,005 births occurred in the district (1,958 live and 47 still births). Of this number 249 (241 live and eight still births) were to residents of other districts. Of the local confinements 1,568 were notified by midwives, and 437 by doctors or parents. 1,092 (1,055 live and 37 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. 51 male and 33 female still births were registered, being a rate per 1,000 population of 0.44 compared with a figure of 0.55 for the country as a whole. Of the 41 cases of which particulars are known, in 7 there was no definite cause, in 15 the reason was acute disease in or accident to the mother (including 8 toxaemias), and in two others the cause was maternal. Anomalies of the foetus, placenta or cord accounted for 10 (5 due to congenital malformations and 2 to vicious insertion of the placenta). Eight were due to death of the foetus, seven because of prolonged labour, and one because of prolapse of the cord. INFANT MORTALITY. 150 (91 male and 59 female) infants died under one year of age, constituting an infant mortality rate of 50.0. 94 failed to survive one month. The neonatal mortality rate was therefore 31.1, constituting 62 per cent. of the total infant mortality rate. Of these 94, 18 failed to survive the 24 hours, the cause of death in 9 being prematurity, in 1 birth injury and in another 6 abnormality or atelectasis. 35 deaths occurred in infants who survived 24 hours but failed to survive 7 days. Prematurity was responsible for 16 of these, birth injury for 3, developmental abnormalities 3, and atelectasis 2. Of the 41 infants who survived one week but succumbed before the end of the first month, in 13 the cause was prematurity, in 1 birth injury, in 8 developmental abnormalities or atelectasis. Infections accounted for 17 deaths, 7 being due to gastro-enteritis and 10 to respiratory complaints. Of the 23 deaths amongst those of 1-3 months, 2 were due to developmental abnormalities, 1 to deficient inherent vitality and 2 to birth injuries. Respiratory complaints accounted for 5, gastro-enteritis 5, and pyloric stenosis 3. Infections accounted for most of the 34 deaths of those between 3 and 12 months, of which respiratory complaints were the cause 50 in 10, gastro-enteritis in 3, and meningococcal meningitis, measles, scarlet fever and tubercular meningitis 1 each. In 1939, when the infant mortality rate was 38.5 the 128 deaths of infants under one year of age were comprised of 69 males and 59 females. Of the 150 children who died this year, 59 were females and 91 males. The increased rate was therefore entirely due to the increase of deaths amongst male infants. In 1939 the number who failed to survive the first month was 69. In 1940 it was 94. This increase occurred amongst those who survived one week but failed to survive one month, the figure of these, of 41 in 1940 contrasting with one of 14 for 1939. Of this addition of 27, 11 were accounted for by an increase in the number of deaths ascribed to prematurity, a further four to developmental abnormalities, while infections accounted for an additional 7 deaths. The number of deaths amongst those of ages one to three months was actually slightly smaller than those of the previous year ; tut those occurring amongst infants of ages 3 to 12 months were 34 as compared with 12, respiratory affections accounting for most of this increase. DEATHS OF OLDER CHILDREN. Of the seven fatalities amongst those aged one year, three were due to respiratory affections and one to meningococcal meningitis. Two of the eight children who died in their second year succumbed to pneumonia and one each to measles, cerebro-spinal fever and influenzal meningitis. Whooping-cough was the cause of death of one of the six children who died in their third year. The sole death amongst children of four years of age was the result of an accident. There were five deaths from war injury amongst those under five years of age. INFANT MORTALITY. Ophthalmia Neonatorum. Five cases of ophthalmia neonatorum were notified, two of them infants born in hospitals outside the district. Two infants were admitted to a special hospital for treatment. All made complete recovery. MATERNAL MORTALITY. Five deaths were known as having having occurred from or had been associated with pregnancy. In two of the cases, however, the pregnancy was associated and not causative : (1) a patient whose confinement was due in April, in the week ending February 17th contracted influenza; premature labour commenced on the 18th, and the infant was born on the 19th, but the mother died 51 from heart failure the next day; (2) the other patient who was admitted to a nursing home on the 11th May had a normal labour, being delivered on the 13th, but died on the 15th from diabetic coma. Pregnancy was the causative factor in the other cases:— (1) after exhibiting no abnormal signs or symptoms during her pregnancy this patient while giving birth to a full-time child at her first pregnancy in a nursing home developed eclampsia to which she succumbed; (2) this patient, a midwife's case, was referred by the practitioner summoned on account of albuminuria, to hospital when she was about 34 to 36 weeks pregnant. As she failed to respond to treatment the membranes were ruptured and soon after she developed a concealed retroplacental haemorrhage which caused collapse. Spontaneous delivery of a stillbirth later occurred but anuria developed and the patient died the next day ; (3) the remaining fatal case was that of an evacuee from a coast town who, during labour in a nursing home developed uterine inertia. Delivery was followed by adherence of the placenta which resulted in severe post-partum haemorrhage and death. It was suggested that the atonic condition of the uterus was associated with the air raid in progress during delivery. PUERPERAL INFECTION. Nine notifications of puerperal pyrexia were received, of which two related to women who were in-patients at London hospitals, and one to a patient who had been admitted to a hospital outside the area because of an abortion. The raised temperature in three of the remaining cases was probably due to infection of a perineal suture and in one to a breast abscess. Of the remaining two cases, one in which there was a normal delivery was considered by the consultant to be a true puerperal infection; the other case was one in which a forceps delivery was followed by retention of the placenta, which because of haemorrhage needed manual removal. Four of the patients were admitted under the Council's arrangements to hospital for treatment. 52 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 884 Total visits 1,415 (b) To children under one year of age... First visits 2,852 Total visits 7,983 (c) To children between the ages of one and five years Total visits 15,455 In addition visits were paid to 231 cases of measles and 81 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 42,536 (2) By children between the ages of one and five years 25,856 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 2,732 (2) Between the ages of one and five years 745 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 2,535 (2) Over one year of age 6,331 TREATMENT. The following particulars show the extent to which the facilities for treatment are used. Dental treatment:—315 children under five years of age and 381 expectant or nursing mothers made 1,012 attendances for treatment. 102 mothers were fitted with dentures. Physio-therapeutic clinic:—289 new cases were referred to the clinic. The total number of attendances by patients was 5,244 (1,695 massage, 2,778 electrotherapeutic, 346 ante-natal treatment). 93 patients were seen by consultant orthopaedic surgeon and 332 were seen by the consultant physiotherapist. Correction of visual defects:—55 children and 3 mothers were treated by arrangement with the Middlesex County Council, most of these being recommended to obtain glasses. 53 Provision is made by which children wearing glasses are re-tested periodically. Operative treatment of tonsils and adenoids:—18 children were treated at the Harrow and Wealdstone Hospital for this condition under the provisions of the agreement. Convalescent homes:—No children or mothers were admitted to convalescent homes. Home nursing:—Responsibility was accepted for the payment of the fees for the treatment of 9 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 93 Number of persons registered during the year 52 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.) 73 Number of persons on the register who were receiving children for reward at the end of the year 152 Number of children on the register at the beginning of the year 131 Number of children received during the year 218 Number of children removed from the register during the year 229 Removed to care of parents 120 Removed to care of another foster-mother 58 Legally adopted by foster-parent 3 Removed to charitable organisation, etc 18 Removed to hospital 3 Foster-parent left the district taking the child with her 17 Child attained the age of nine years 7 Died 3 Number of children on the register at the end of the year 120 54 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,415 visits to expectant mothers, 884 being first visits. Ante-natal Clinics. The following summarises the work done at the clinics during the year:— Total number of expectant mothers attending the clinics 2,441 Total number of attendances by expectant mothers at all clinics 8,833 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 79 Consultant Ante-natal Clinic. The consultant ante-natal clinic was held fortnightly throughout the year. During the year 237 women made 338 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, 15 patients being seen by four practitioners. Of this number, three were insured patients. Only two women attended for post-natal examination. ARRANGEMENTS MADE FOR CONFINEMENTS. At Home. 1,155 confinements took place in the patients' own homes. Of these 886 were attended by midwives acting in their capacity as midwives, and 269 by local midwives who had given notice of their intention to practise, acting as maternity nurses. Consultant Services. During the year a consultant was summoned to 9 cases. Three were ante-natal cases at term, one of whom was admitted to hospital for trial of labour. In all four cases to which the consultant was summoned when the patient was in labour operative interference was necessary. The other two cases were both puerperal women suffering from some febrile condition. In an Institution. 666 births occurred in registered nursing homes in this district. 239 births to mothers from outside districts which occurred here 55 took place in nursing homes, 10 in private houses. Of these 666 confinements 427 were conducted by local practitioners. Notification of 1,092 births were received in respect of Harrow mothers having taken place outside the district. Of these 1,014 were from hospitals and 62 from nursing homes. Of the patients confined in hospital outside the district 521 were delivered at Redhill County Hospital and 298 at Bushey Maternity Hospital. Of a total of 2,818 births, 1,329 occurred in the patients' own homes, 427 in local nursing homes and 1,092 in hospitals or homes outside the district. Some 1,519 or 53 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year 9 patients were admitted to London hospitals under the Council's arrangements. POST-NATAL SERVICES. Post-natal Examination. 109 women attended the clinic for post-natal examination, making altogether 126 attendances, while a further two were examined under the general practitioner ante-natal scheme. Puerperal Infection. (a) Consultant services The consultant was summoned to two patients suffering from puerperal pyrexia. (b) Hospital services:—Any cases of puerperal infection requiring hospital treatment are removed to the London County Council North-Western Hospital. During the year 4 patients were removed. (c) Home nursing:—No patients suffering from puerperal infection were this year nursed under the Council's arrangements by the staff of the local District Nursing Association. BIRTH CONTROL CLINIC. Fortnightly sessions of this clinic were held throughout the year. 136 women, of whom 83 attended for the first time, made a total of 249 attendances. In addition there were two 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 41. Of these. 12 removed from the district or discontinued practice, leaving 29 in practice at the end of the year. Of the total number 24 were resident in the district and carried on a domiciliary practice almost entirely limited to this area; 10 were engaged in local maternity homes, most of them entirely, though a few also carrying on a very limited domiciliary practice; and 7 were resident in adjoining areas but attended some cases in this district. 56 The number of births attended in the district by midwives who gave notice of their intention to practise was 1,494. In 933 cases the midwife was in attendance as a midwife and in the remaining 561 as a maternity nurse. Of the confinements occurring in private houses in the district 1,088 were attended by local midwives whose practice is limited to domiciliary work (848 as midwives and 240 as maternity nurses) and 41 by midwives from adjoining areas (30 as midwives and 11 as maternity nurses). At the end of the year there were in practice 3 independent midwives carrying on a domiciliary service, these between them attending 13 cases during the vear. 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 255 Still birth 16 Death of Infant 8 Death of Mother — Laying out the Dead 6 Artificial Feeding 13 Liability to be a Source of Infection 23 Of the 255 summonses to medical practitioners, 37 were on account of some condition during pregnancy, 65 during labour, 111 in the lying-in period, and 42 some abnormality of the infant. Of the 37 summonses to a patient during pregnancy 16 were because of albuminuria, oedema, or toxaemia, and 12 because of haemorrhage. Of the 65 summonses to a patient during labour the reason given in 40 instances was delayed labour with cause unspecified. In a further 15 there was some abnormal presentation, and 3 were on account of foetal distress. Four summonses were to patients suffering from abortion (actual or threatened). 81 of the 111 summonses to patients in the puerperium were on account of rupture of the perineum. Post-partum haemorrhage, with or without adherence of the placenta, was the reason in 13, a raised temperature in 7, and phlebitis a further 7 cases. Of the 42 summonses to infants 12 were on account of some discharge from the eye, 19 because of feebleness or asphyxia, and some other abnormal state or condition in 11. MIDWIFERY SERVICE. The number of patients attended by the Council's midwives was 835 in which they acted as midwives, and 237 in which they acted as maternity nurses. This figure of 1,072 is an increase on that of 922 in the previous year. 57 Of the patients attended by midwives acting as midwives, 242 were charged the full amount, in 116 cases no charge was made, while 477 were assisted. The corresponding figures in regard to the patients attended by the midwives acting as maternity nurses were 179, 9 and 49. Towards the end of 1939 owing to the heavier bookings of the midwives an additional midwife was appointed, who took up her duties early in the new year. Whereas previously the 15 midwives had worked in five groups of three the 16 were divided into four groups of four, this allocation causing less inconvenience in the arrangements for off-duty time. The off-duty time was also rearranged so that instead of the times being as formerly, a week-end (12 noon Friday to 2 p.m. Monday) every third week, and a day off (8 a.m. to 11 p.m.) in each intervening week, they are now a week-end (12 noon Friday to 9 a.m. Monday) every fourth week, and a day off (12 midnight to 12 midnight) in each intervening week. The time off under the new arrangements is 141 hours every four weeks as contrasted with the old figure of 104 hours every three weeks. SCALE OF CHARGES. Towards the end of the year the scale of assistance was amended with the object of endeavouring to accord to applicants the same measure of assistance as they would have received had it not been for the effect of variation in the cost of living. Apart from the fact that the increased rise in the cost of living reduced the effective income of applicants, the position of a number was worsened by reason of their receiving a cost of living bonus which increased to them out of all proportion the ratio of the standard charge for some of the Council's services. At the same time it was decided that in future no account should be taken of the amount received for maternity benefit which hitherto had entered into the calculation of the contribution to be made by the applicant for the services of the Council in connection with a confinement, whether the service granted was that of a midwife, a home help, or was a bed in a maternity hospital. Hitherto, except in the case of accounts arising from the summons by a midwife of a doctor to her patient because of some abnormal condition of the infant's eyes, in which case no contribution towards the charge was asked for from the parents, in all other circumstances in which the Council was obliged to meet the account of a medical practitioner summoned under the rules of the C.M.B. to the assistance of a midwife a charge was made except in those cases where because of the limited financial circumstances no contribution under the Council's scale was to be sought. While the midwives had been instructed to acquaint the patient, or those responsible for her that the Council were empowered in these circumstances to look to them to pay the practitioner's account, the rendering of the account 58 in many cases was unpopular, the persons protesting that it was the midwife and not they who had summoned the practitioner and in some cases they pointed out that, being an unforeseen expenditure, they had not made any preparations towards meeting it. The Council, therefore, decided that after a date later in the year no further contributions should be sought from the patients or from those responsible for their maintenance to meet the accounts submitted by the practitioners for their services rendered in response to a medical aid notice issued by the midwives in accordance with the rules of the Central Midwives' Board. At their meeting in March, the Committee agreed that all the appropriate treatment services, including the supply of milk, be available to foster children living in the district in the same manner as in the case of other children. PROVISION OF MILK. The milk issued by the Council as maternity and child welfare authority for the later months of the year was but a fraction of that granted in the earlier months, being almost limited to supplementary issues of liquid or dried milk to those infants who needed more than they were being granted under the National Milk Scheme. The total amount of liquid milk issued during the year to young children, to expectant or to nursing mothers, was 31,917 gallons and of dried milk 41,578 lbs. The cost of the liquid milk was £3,414 and of the dried £3,119, a total of £6,533, against which is to be credited the receipts of £2,629 from the sales of dried milk, making the net charge of dried milk £490 and the net cost of liquid and of dried milk £3,904. The following is a statement of the free milk issues in the different areas as compared with the attendances, and might be acccpted, though subject to obvious fallacies, as a very rough guide of the relative affluence of the different parts of the district. The figures are for June, 1940, the last month for which the milk grant was not affected by distribution under the National Scheme. The figures represent the total attendances at the clinics in that area (infant welfare centres and ante-natal clinics) figures which are given in brackets, divided by the number of milk grants, this number being the number of recipients whether receiving one or more than one pint of milk. The figures are:—Broadway, 3.8 (263) ; West Harrow, 3.8 (113) ; Roxeth, 4.5 (277) ; Chandos, 5.8 (153) ; Headstone, 6.2 (90) ; Streatfield, 6.2 (181) ; Elmwood, 6.7 (116); Pinner, 7.9 (47) ; St. Albans, 11.7 (69) ; Harrow Weald, 15.5 (29). Under the National Milk Scheme milk is provided free or at the cost of 2d. a pint to nursing or expectant mothers and to children under five years of age. The arrangements came into force in July when there were 569 beneficiaries obtaining the milk free of cost and 4,066 obtaining it at a cost of 2d. a pint. The 59 greater publicity added corresponding figures of 966 and 7,134 in August and a few more in September. The total for the partquarter was 1,619 free and 11,490 at 2d. a pint. More took advantage of the free issue in October and further applications in the two succeeding months brought the total to 2,022 obtaining milk free. Not all those obtaining it at 2d. a pint in September renewed their applications so that although there were 651 and 453 applicants in November and December, the actual number of beneficiaries for the quarter was only 11,757, a very slight increase only on that for the previous quarter. It is of interest that the free permit is in respect of an average of 1-4 persons as contrasted with that of a permit for issue at 2d. a pint which is in respect of 1.2 persons. Although arrangements were to be made by which those children who, on medical grounds, required dried rather than fresh milk, were to be enabled to obtain it under the National Milk Scheme, it was not until well on into August that provision could, in fact, be made. Most of the dried milk is actually issued at the local infant welfare centres. In August and September the number of permits of dried milk issued free was 51, and the number at the reduced rate of Is. 2d. a packet 66. The corresponding figures for the next quarter were 48 and 51. For those children who require more than the one pint of fresh milk per day or its equivalent in dried milk, a supplementary issue is made not under the National Milk Scheme but by the Council as maternity and child welfare authority. For ease of administration the Council's scale which had hitherto been used in determining whether assistance was to be granted to any applicant was replaced in respect of the issue of milk by that used under the National Milk Scheme. Apprehension has been voiced regarding the provisions of the National Milk Scheme on a number of points, the chief, possibly, being that under it there is no certainty that a safe milk is being distributed, a point on which local authorities issuing milk under their maternity and child welfare schemes could satisfy themselves by prescribing specified grades in their orders. Fortunately, in this district, any fears on these grounds have been proved to be ill-founded. A return has been obtained from the milk purveyors in this district which discloses that practically all the milk distributed in this area under this scheme is pasteurised. The dried milk issued, which, of course, is a very small volume compared with the fresh milk distributed, is only a dried milk, that is, as contrasted with many of the proprietary dried foods it is not a modified dried milk and is not fortified in any way by the addition of vitamins or any preparations such as iron, nor is it available in half-cream preparations. Against this it can be maintained that any children needing the modified milks can obtain them from the maternity and child welfare authorities whose powers to grant such milk were not withdrawn on the coming into force of the National Milk Scheme. How far the scheme is 60 affecting clinic attendances is very difficult to ascertain. The average weekly attendances are certainly appreciably lower than before the war. Some probably small part of this is due to the fact that the buildings now available are not as accessible to as large volumes of parents as those used formerly. The most important factor, however, probably was the occurrence of periods of "alert" in the day time. The fact that the attendances continued to be rather lower in the succeeding weeks might possibly be ascribed to the weather. It has, however, never been felt that in this district many attended the infant welfare centres for that material benefit they could derive, and for that reason, while it is to be expected that some few who previously came primarily to obtain their milk grants now no longer attend, it is not considered that this factor influenced many. The issue of National Milk has not materially affected the sales of dried milks at the clinics. An analysis of the sales for a period in December, 1940, compared with the corresponding period in the previous year showed that there was an 18 per cent. reduction, of which practically one-half was accounted for at the Wealdstone clinic. This, as a percentage reduction, is less than the proportionate fall in the average number of persons attending the clinics for these periods. These figures confirm the impression gathered that to some extent at least the National Milk Scheme has resulted in the Government paying for part of the ordinary milk supply of the household, that actually consumed by the infants for whom the National milk was intended being purchased as before the initiation of the scheme.