Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1941 CARYL THOMAS, M.D., B.Sc., D.P.H., BARRISTER AT-LAW KING AND HUTCHINGS, LTD., PRINTERS, UXBRIDGE. 1 REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Chairman and Members of the Urban District Counril of Harrow. Mr. Chairman, Mrs. Roberts and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1941. As contrasted with the figures relating to pre-war years the chief differences in the vital statistics for this year are a rise in the death rate, though this is the same figure as for 1940, a further rise in the infant mortality rate, and an increase in the incidence and in the death rate from tuberculosis. Reference is made in the body of the report to each of these points. In line with the rest of the country, this district has experienced an increase in the incidence of the infections caused by foods. There was a sharp rise in the number of notifications of enteric disease, almost all of them being of para B. infection. Some, probably much, of the increased incidence of the illness in the country is considered to have been due to the ingestion of contaminated synthetic cream, much of which is composed of a mixture of flour, sugar and water, a vegetable oil and an egg powder. In many of the local cases no history of the intake of such comestible could be obtained. The great increase in the incidence of such an infection in which, however, there could be found no connecting link, the cases being separated geographically and in time suggests the possibility of the organisms being much more widely distributed than formerly but that only a proportion of those into whose systems they have entered have reacted by a recognisable clinical attack. Such a risk is one to be expected as arising directly out of war conditions where the demands of the Services and air raid precautions lead to the substituting of the skilled staff by those not educated up to sound hygienic standards, to work having to be done in conditions such as of diminished lighting, and to damaged plant not being capable of being replaced. Dysentery notifications also were markedly commoner this year. Most of these, however, related to children who, while in-patients at the orthopaedic hospital contracted an infection with the Sonne organism. Notifications of food poisoning, as such, remained low. Not all the problems to be faced after the war will arise from circumstances brought about by the war. Some will follow on the change in the age distribution of the population which will result from the decline in the birth rate. Until recently the generally accepted indications as to the trend of population suggested that the war years would include those in which the population of the country would have been at a maximum. The recent Memorandum of the Registrars General of England and Wales and of Scotland includes calculations of the future population based on the assumptions that the mortality rates will continue to decline and that the present day fertility rate continues, the resulting calculations showed a maximum population of between 47 and 48 millions may be expected during the decade 1951 to 1961. 2 A decline would follow, but sufficiently gradual at first not to reduce the population figure below its present value of 46 millions until after 1971. As in the last war there will occur progressively increasing shortage of houses resulting from the accumulation of the annual deterioration which is not at the time being balanced, let alone being counterbalanced by replacement by new building. This ordinary rate of lapse will probably still remain, in spite of the result of enemy action, the largest factor causing the increasing demand for housing. The tremendous shortage of houses, based on the standard of one family per house which followed on the last war though is unlikely to be repeated on the same scale this time. The deficiency then was due to the fact that the increase in the number of families had been at a greater rate than the growth of the population. Much of this was attributable to the higher birth rate at the time of the turn of the century leading to a higher proportion of persons reaching marrying age ; part to the large number of post-war marriages, and part to the general decline in the mortality rate leading to survival of families. Irrespective of the trend of population the number of families will continue to increase so long as that section of the population constituted of young adults continues to grow. The ultimate fall in this section, which is inevitable, will in time result in this deficiency out-balancing the increase in the number of families due to the lengthening of the lives of the married persons, at which time the number of families will fall. For the country as a whole this time possibly is only a few years distant. That there will be no vast changes resulting from any change in the average size of the family will perhaps result in an arrest in the continued expansion of large towns by housing development. Because much of the industry and many of the offices which have removed from London will possibly not return, because, too, of the possible industrialization of other units of population distributed throughout the country quite apart from the creation of new industrial units in rural areas future development in an area such as this might be only on the smallest scale. The presence in residential parts of the district of premises occupied as offices or factories in some instances appears to be a contravention of the Town Planning Scheme. It may nevertheless be of real advantage to the residents. Light industry to-day can be carried on with such little interference with the amenities of a locality as to raise a doubt as to whether the zoning of certain parts for industrial purposes to the exclusion of use of residential parts of the area for this purpose is to the advantage of most of the residents who have, because of the localization of industrial premises in certain areas, to travel distances to and from their work. When this necessitates travelling to outside the district, whether to factory or office, with the result that the district is a mere dormitory for such a large portion of the residents, the most powerful factor making for the sense of a town with associated civic consciousness of the residents is removed. The more people not only sleep but work in the district, the more likely there is to develop that sense of stability in the persons ; and this should lead to a diminution in the constant changes of occupancy of the houses. This would help to prevent, to some extent, the rot which is occurring in certain parts of the district 3 which at the present rate of deterioration it seems inevitable will need to be the subject of action under the slum clearance provisions of the Housing Acts. While the principles on which town planning was based are sound enough, it is questionable whether the circumstances of the occupants of many of the smaller types of villa residences are really benefited by the limitation of density imposed. The many uncultivated gardens demonstrate only too forcibly that there needs to be catered for quite a substantial section of the community in habitations without these gardens. It seems quite likely, even if the same total density is retained, that the part of land not covered by the actual buildings might be better apportioned, perhaps restricting the garden while providing nearby allotments for those who wish to cultivate them, and playing fields or playgrounds for the children. Apart from the cost of the land and other building costs which are higher with the semi-detached type of development, there is the real disadvantage that the more the houses are spread the more transport is required, transport in conditions not conducive to health and which subtracts appreciably from the leisure time of the workers. It can probably be said to-day that very few of the social services completely meet the demands. A reduction in the population and especially the differential reduction consequent on the falling birthrate will, in certain cases, so reduce the demand that the existing services will then prove sufficient to meet it. Such certainly would quite soon have been the case in regard to tuberculosis. In time the differential reduction in population will result in the diminution in the population of ages 15 to 34 at which ages tuberculosis causes 35 to 40 per cent, of the total deaths. In the same way the pre-war school medical staff would, with the reduced number of children attending school, be sufficient to enable them to carry out the desirable fourth routine medical inspection ; and the relative increase in the dental staff would go some way to reducing the present inadequacy of the dental service which is common throughout the country. In the field of maternity and child welfare, though, it is quite possible that increasing demands made by existing numbers will outweigh any reduction in the actual numbers ; for instance, the steadily growing proportion of the women who wish to be confined in hospital will probably for long result in the demand for institutional accommodation not being met. The low birth rate with consequent changes in the age distribution of the population will lead to an increased proportion of those of greater ages coincident with a lower proportion of those at younger and in time intermediate ages. Doubt has been expressed as to whether this growing proportion of the aged can continue to be supported by the efforts of the smaller number of workers, and whether there will not need to be a reversal of the movement which was leading to more persons retiring at younger ages. Apart from this aspect, though, there will need to be considered the arrangements for the care of the elderly. In a previous generation when the family unit was larger and there was much less movement of the younger members of the family away from the neighbourhood of the home, although the children one by one left the home it 4 frequently fell to the lot of one to continue to live with the parents who were consequently looked after. To-day's circumstances are very different, each of the smaller number of children of the family going his or her own way, removing to distances from home. While the parents are both alive they manage ; but difficulty arises when, on the death of one, the other is left. They cling to their independence and are opposed to entering an institution. There are many, too, who have some small income but one which is insufficient to enable them to be accepted in suitable homes. Although the position of these old people was before presenting a growing problem which it was appreciated would have to be studied, the war has accentuated the difficulties, more particularly when these elderly persons succumb to some ailments, even though only of a minor character. The situation of many has been made distressing because the shortage of accommodation has prevented their admission to any form of institution, whether hospital or nursing home, while it is proving impossible to obtain the services of anyone to provide attention in the home. It would seem that housing authorities will need to devote more attention to finding the answer to the question of the best way of housing these persons. One suggestion is the creation of small colonies of self-contained units in which the occupants could feel that they were retaining their independence, but colonies of sufficient size to warrant the engagement of a matron-supervisor, and to provide certain communal services so that there would be assurance that each member of the colony was living under hygienic and safe conditions and could easily obtain suitable nourishment. In the Ministry of Health Circular 2604, which deals with the subject of the Report for 1941, it is requested that for reasons of National security population figures be not included. I have the honour to be, Mrs. Roberts and Gentlemen, Your obedient Servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Harrow-on-the-Hill. August 13th, 1942. 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1941 — Rateable Value (April 1st, 1942) £2,109,510 Sum represented by a penny rate (April 1st, 1942) 8,250 Extracts from Vital Statistics for the Year Live Births :— Total. Male. Female. Legitimate 2,625 1,364 1,2611 Illegitimate 126 63 63 Birth rate per 1,000 of the estimated resident population, — Stillbirths:— Legitimate 75 41 34 Illegitimate 4 1 3 Rate per 1,000 total (live and still) births, 42 Deaths 1,774 885 889 Death rate per 1,000 of the estimated resident population, — Rate per 1,000 Deaths from puerperal causes :— total (live and Deaths. still) births. Puerperal sepsis 3 1.06 Other puerperal causes 6 2.12 Total 9 3.18 Death rate of Infants under one year of age:— All infants per 1,000 live births 55.6 Legitimate infants per 1,000 legitimate live births 50.5 Illegitimate infants per 1,000 illegitimate live births 103.2 Deaths from Cancer (all ages) 288 Measles (all ages) 2 „ „ Whooping Cough (all ages) 8 „ „ Diarrhoea (under 2 years of age) 28 Population. — , the Registrar-General's estimate of the civilian population, is a rise on the figure of — in the previous year. Reference was made in last year's report to the constant changes in the population even though the totals remained much the same, hat this process is continuing is indicated by the fact that the weekly average number of children under six years of age admitted to the district during the last months of the year was 65, while for the same Period a weekly average of 52 left. 6 Deaths. Of the 909 total deaths in the district, 148 occurred among nonresidents. As there were 813 inward transfer deaths, the total number of deaths of residents was 1,774, a figure comparable to that of 1,725 in 1941, whereas the previous highest figure before that was 1,408 in 1939. Of the 148 outward transfer deaths, 62 took place at the Orthopaedic Hospital, 10 at the Harrow and Wealdstone Hospital, 20 in Nursing Homes and 53 in private houses. Of the 813 deaths of local residents which occurred outside the area, most took place in institutions, 326 being at Redhill Hospital, 98 at Redhill House and 86 (including 11 new-born infants) at other County Hospitals. Three deaths occurred at institutions for the treatment of tuberculosis and 22 at Shenley Hospital. 80 deaths took place in hospitals iust outside the district and 56 in various of the London General Hospitals. The following is the Registrar-General's abridged list of cases of death in the district :— Male Female Male Female Typhoid fever 0 I Heart disease 172 219 Cerebro-spinal fever 5 2 Other circ. diseases 22 25 Scarlet fever 0 0 Bronchitis 56 44 Whooping cough 3 5 Pneumonia 68 60 Diphtheria 0 0 Other res. diseases 14 12 Resp. tuberculosis 72 39 Ulcer of stomach 26 3 Other tuberculosis 3 6 Diarrhoea under 2 years 18 10 Syphilitic diseases 6 3 Appendicitis 6 2 Influenza 17 12 Other digestive diseases 16 28 Measles 1 1 Nephritis 30 22 Acute polio-myelitis 0 0 Puerperal sepsis 0 3 Acute encephalitis 2 1 Other maternal causes 0 6 Cancer of mouth and œsophagus (M), and uterus (F) 13 22 Premature birth 19 13 Cong. malformations, etc. 22 12 Cancer of stomach 20 16 Suicide 6 b Cancer of breast 2 29 Road traffic accident 19 3 Cancer of other sites 92 94 Other violent causes 26 31 Diabetes 6 12 All other causes 67 77 Intra-cran. lesions 56 70 All causes 885 889 1,774 deaths in a population of — is a death rate of , the same figure as last year as contrasted with figures ranging from 71, to 8-1 in the years 1934 to 1939. Compared with last year, fatalities from some infections were higher, the figure for cerebro-spinal fever being 7 instead of 3, whooping cough 8 instead of one, and respiratory tuberculosis 110 as compared with 77. Puerperal deaths were 9 this year as against 2 last year. The number of infant deaths was almost identical with that in the previous year, though with the smaller number of births the infant mortality rate is raised. There was an increase o 7 7 in the number of deaths from diarrhoea amongst those under two years of age in spite of last year's figure being a substantial rise on the rate for any previous year. Road traffic accidents resulted in nearly the doubling of the number, 22 against 12, but deaths due to other forms of violence were exactly half those of 1941 (57 instead of 114) the reduction being the result of lessened enemy activity. Fatalities from the infectious diseases expressed as a rate per thousand population again compared favourably with the figures for the country as a whole, the rates for whooping cough 0-04, diphtheria 0, influenza 014, measles 0 01, being lower than the corresponding national rates of 0 06, 0-07, 0 19, and 0-03. The figure of 10-3 deaths per thousand live births for diarrhoea and enteritis in infants under two years of age is over double the national figure of 5-1. In the following table are analysed into the different age groups the deaths for each sex for the year 1941 and for 1938 for purposes of comparison, this year being typical of the pre-war years when the local death rate was 71. Under 5 5/14 15/24 25/44 45/64 Over 65 Male, 1941 13.0 2.1 1.5 13.0 30.2 42.1 1938 14.1 2.7 3.3 10.6 29.6 40.3 Female, 1941 8.4 0.8 2.3 11.1 24.1 53.0 1938 10.0 1.9 2.3 17.1 21.9 46.5 The distribution of the deaths of the males in the age groups for each year is remarkably similar, the proportion in each of the lower age groups being lower in the year 1941 but each group over 25 showing an increase as compared with 1938. In the case of the females though, the increase is limited to those over 45 and is particularly marked in the case of those over 65. Of the difference of 219 between the number of deaths of males in 1941 and those in 1938, 104 occurred amongst those over 65 years of age and 85 amongst those in the 45 to 64 age group. The 259 increase of female deaths, too, is practically all included amongst those of the higher ages, 170 being amongst those of over 65, and 74 in the 45-64 age groups. Of the increase in the deaths amongst the males 58 were due to respiratory complaints, 40 to intra-cranial lesions, and 15 to cancer (most of these increases being amongst the elderly) and 45 to respiratory tuberculosis (mostly amongst those of ages 15-54); and amongst the females, 48 to cancer, 37 to intra-cranial lesions, 49 to heart lesions and 58 to respiratory complaints, most of these increases being amongst those of advanced ages. GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. CLINICS AND TREATMENT CENTRES. A few additional sessions were opened during the year so that at the end of 1941 24 weekly infant welfare clinics were being held in 11 Premises, the equivalent of 4i weekly toddlers' sessions in 7 premises 8 and 11½ ante-natal clinics in 11 premises0. The corresponding figures at the beginning of the year were 21, 2½ and 9½, and in August 1939, 26, 3½ and 12½. The clinic sessions held in North Harrow were changed during the year to different premises. LABORATORY FACILITIES. This service provided as part of the organisation set up by the Medical Research Council continued to be most satisfactory. AMBULANCE FACILITIES. Since the merging of the local Fire Brigade in the National Service, the public health ambulances have been manned by the personnel of the Civil Defence Ambulance Service. Approval was given to arrangements being made for the transport of Harrow residents suffering from infectious diseases from addresses outside the district to their homes within the district, the charges to be those that would have been made had removal been effected by the Council's accident ambulance. SANITARY CIRCUMSTANCES OF THE AREA. SANITARY INSPECTION OF DISTRICT. A. Inspection of Houses : Number inspected under P.H. Acts : (a) Complaint 1,178 (b) Routine 329 Number found defective 671 Revisits 3,105 Routine inspections under the Housing Act Revisits 142 Surveys under Section 157 of the Housing Act No. of cases of overcrowding 17 Inspection of houses let in lodgings No. of foster parents'houses inspected Inspections of houses for other reasons 63 Total visits paid 4,848 B. Inspection of other premises ; visits and enquiries: No. of routine visits to premises liable to give rise to nuisances 648 Further visits paid to these premises 1,050 No. of visits to premises under periodical inspection 585 No. of inspections of cinemas, etc. 12 No. of complaints investigated (excluding those referred to above under Housing) 554 No. of observations for smoke nuisances 9 No. of inspections of factories (mechanical) 622 do. do. (non-mechanical) 215 do. do. work places 122 do. do. outworkers' premises 214 No. of visits to premises where rag flock is used — No. of visits under the Shops, etc., Act 638 No. of evening observations under the Shops Act 9 No. of inspections of hairdressers' premises 17 No. of visits re infectious diseases 11 C. Inspection of premises where food is manufactured or prepared: Slaughterhouses 48 Butchers (including Meat Depot) 1,046 Cowsheds 57 Dairies 162 Ice Cream Premises 21 Fish-Shops 192 Fried Fish Shops 70 Bakehouses 110 Cafes and Restaurants 75 D. Inspection of premises where food is retailed: Greengrocers 334 Provision Merchants 460 Milk Shops 158 Bakers and Confectioners 49 Other Food Premises 69 HOUSING INSPECTION. 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) 1,507 (b) Number of inspections made for the purpose 4,754 (2) (a) Number of dwelling-houses inspected and recorded under the Housing Consolidated Regulations — (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 671 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 548 10 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 10 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 8 (b) By Local Authority in default of owners B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 54 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 27 (b) By Local Authority in default of owners 18 C. Proceedings under Sections 11, 12 and 13 of the Housing Act, 1936 - Complaints. During the year 1,597 complaints were investigated by the Sanitary Inspectors. Of these 538 arose from blocked or defective sewers or drains, 83 from accumulations of rubbish and 51 from nuisances from animals or birds. 330 related to housing defects of which 102 were defects of plumbing, 49 from dampness and 46 from defective waterclosets. Complaints as to rats and mice numbered 69, and as to insect and vermin infestation 48. Householders were experiencing increasing difficulty in obtaining dustbins and 188 complaints were from this cause. This problem has now been largely got over by the Council's having obtained bins to supply to the owners of premises. Many complaints continue to be received in regard to matters over which, as the public health authority, the Council has no control, e.g., flooded air raid shelters, accumulations of milk bottles, the overgrowing of gardens with weeds, broken garden fences and the burning of rubbish in gardens. Informal action in 1,238 instances was followed by the abatement of the nuisance in 1,143 cases. During the year 114 statutory notices under the Public Health Acts were served, 105 being complied with, though in 18 instances the work was executed in default by the local authority. Under the Housing Acts 10 statutory notices were served, 8 being complied with. Inspection of Houses. 96 surveys were carried out under the Housing Acts, mostly following receipt of an application from the owner or agent for a certificate of 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 10,076, this figure being made up of 2,122 11 issued in 1936 and 5,473, 749, 1,402, and 96 in the succeeding years. No houses this year were inspected under the Housing Consolidated Regulations. The housing situation in the district remains acute. Subletting, though very prevalent does not meet the demand for accommodation. Apart from the inconvenience which arises to the ordinary householders in cramped surroundings, the cases of some in special circumstances are particularly distressing. One type is the expectant mother whose accommodation is severely restricted, more particularly as it is proving increasingly difficult for those whose claim for admission to hospital for confinement is based not on medical grounds but more on domestic circumstances, to find any hospital which can accept them. Then there is the case of the mother of a young child or children who, because she can obtain accommodation only in an upstairs flat cannot see that her children get the fresh air they need. The tuberculous patient, too, might be a source of infection not only to the members of his family living in cramped conditions with him but may be a risk to members, especially young members, of any family occupying part of the same house. In some instances deplorable conditions have arisen because his family has followed to an address a man who was in lodgings. Verminous Premises. Sixty-three premises were inspected on receipt of complaint of infestation by insects or vermin, chiefly ants, crickets, beetles, cockroaches, etc. The number of premises found to be bug infested was 48. In most instances where infestation was heavy, fumigation was carried out by firms using cyanide gas. Inspection of Other Premises. These premises include those at which nuisances might be anticipated, and to which 648 visits were paid. Another group of premises which are the subject of periodical inspection and to which 585 visits were paid consisted mainly of public and private conveniences and air raid shelters. smoke abatement. Nineteen observations for smoke nuisances have been carried out. During the 175 minutes' observations dense smoke was seen for 8 minutes, and moderate smoke for 111 minutes. factory act. In this district there are 465 factories with mechanical power, 145 without mechanical power and 123 workplaces. The numbers of visits paid to these three classes of premises were 622, 215 and 122. Of the 97 public health nuisances detected, 26 were due to want of cleanliness and one to defective heating. The sanitary accommodation was unsatisfactory in 53 instances, being unsuitable or defective in H, unclean in 35, and insufficient in 7. Seventeen other nuisances were noted. Particulars of 122 outworkers resident in this area were received. To these 214 visits were paid. 12 SHOPS ACTS. 586 visits were paid to shops and 9 evening observations were made, a still greater reduction in the volume of this type of work having been carried out during this year due to the fact that the Inspector who normally carried out these duties has been called on to give practically full time to his duties as Enforcement Officer. Seven contraventions of the Acts were recorded, four being the employment of young persons in excess of 48 hours per week ; and three the serving of customers after closing hours. The attention of 59 traders was called to their failure to exhibit the appropriate notices. Five contraventions of Section 10 of the 1934 Shops Act which deals with the arrangement for health and comfort of shopworkers, were noted, all being due to deficient heating arrangements. Eleven contraventions of the provisions of the Shops (Sunday Trading) Restriction Act, 1936 were noted, 4 being due to failure to exhibit notices, 1 to failure to keep records of compensatory holidays and 6 from the serving of customers with non-exempted goods. Orders made on the 31st October, 1940, respecting closing of shops were revoked and the general closing hours on and after the 3rd March, 1941, became those as fixed by Section I Shops (Hours of Closing) Act, 1928, or such earlier hours as may have been determined by the Council under Section 5 of the Shops Act, 1912. INSPECTION AND SUPERVISION OF FOOD. (A) MILK SUPPLY. Production. There was no change in the number of cowkeepers in the district, these being 11 occupying 13 separate cowsheds. Of these, four hold licences for the production of accredited milk. Eight local producers sell milk in the district. Distribution. Including three Company Distributors there are 31 retailers of milk in the district. Apart from the reduction of one in the number of premises from which the three multiple firms distribute the only changes in the register have been the temporary removal of 58 persons retailing milk in unopened receptacles. This reduction is the result of the retailers, mostly provision merchants, being unable to obtain milk and now only five of this category remain. In all milk is retailed from 44 premises in the district, 31 of these belonging to the three multiple firms which distribute milk, 8 are used by the 8 local producers who distribute in this area, while at 5 premises m lk is sold in unopened receptacles only, in addition there are 9 retailers selling milk here and not occupying premises in the district. 13 Licensing. The only changes in the numbers of the licences issued are a reduction of one in the licences of pasteurizers, and one of the licences to sell pasteurized milk. Of the 15 premises licensed to retail tuberculin-tested milk 7 belong to one firm, 2 to one and 2 to another. Two premises are licensed for the bottling of tuberculin-tested milk; supplementary licences were issued to three producers outside the district to retail tuberculin-tested milk in the district and 3 supplementary licences were issued to outside producers to retail pasteurized milk in the district. Three establishments were licensed for pasteurizing milk. Of the 41 premises licensed for the selling of pasteurized milk, 17 belonged to one firm, 12 to one, 4 to one and 2 to another. Sampling. 29 samples of pasteurized milk were submitted to bacteriological examination and the phosphatase test. The counts of four were unsatisfactory and one sample contained B.Coli. All but one of the eight samples of tuberculin-tested milk were satisfactory. The two samples of tuberculin-tested (pasteurized) milk were satisfactory. Of the 9 samples of accredited milk produced locally, one had too high a count and two contained B.Coli. The condition of the milk in general is deteriorating. Producers are experiencing their own difficulties in maintaining a satisfactory level of hygienic standard of production, though, of course, when because the demand exceeds the supply there is an assured market for the article whatever its quality, a very powerful incentive to cleanly methods of production is removed. In times of shortage milk must be of very low quality to suffer rejection. When milk is bulked the presence of a small proportion of milk of inferior quality can adversely affect the standard of the remainder. Transport difficulties have increased the time from the milking to the treatment plant or to the consumer in the case of all but the milk locally produced and locally retailed. Before the war, doubtless much milk was saved to be retailed by its being treated by pasteurization either up to the official standard or not. Nowadays, however, those operating pasteurising plants are experiencing difficulties of their own as great as those of the others who are dealing with the milk in its different stages, one of these being that of the maintenance of the plant, especially the obtaining of spare parts. For this reason, and also because the plant can be effectively manned by less skilled staff the Milk (Special Designations) Regulations, 1941, permitted local authorities to grant pasteurising licences in respect of the plants which carry out high-temperature short-time pasteurisation, whereas, up to this, the only plant recognised for the purposes of licensing was the holder process. For part of the unsatisfactory state of the milk bottles in which the milk is distributed, consumers must accept their share of responsibility. The bottle-washing machinery at the best of times is designed to remove only the normal or expected degree of contamination. In these days, with the restrictions °n the issue of detergents even this has proved difficult. No machinery, however, can be expected to cope with the contamination to which some of the bottles have been subjected. Those soiled by having been out 14 in the garden or rescued from the accumulation in a factory seem to be passed back without any attempt to clean them. More vigilance on the part of the employees of the milk retailers would serve as a check to their being passed on to be subjected merely to the routine cleansing, but to-day it would seem many of these employees do not assist in this way. Normally such bottles which have been not satisfactorily cleansed would be detected by the routine supervision exercised by the staff operating the plant. Less skilled and possibly more indifferent staff and difficult conditions of work, especially arising from the black-out, result in their not being detected, while again, they are deprived of the further check which ordinarily would be given them by the roundsman himself. Fortunately, the cleansing process, although it might fail to remove gross contamination, does result in the sterilization of the foreign matter, so that while unsightly, the pollution is not dangerous from the point of view of health. This is not to imply that such conditions need to be condoned, but it would be helpful if the consumers could be made to realise that many of these instances of heavy contamination are the result of gross misuse of the bottles by themselves. Broken milk bottles are the cause of much annoyance which can be eliminated only by concerted action. The milk distributors are in difficulties owing to their depleted and in many cases unskilled staffs, difficulties which, it seems, in some ways have been added to be a reduction in the number of delivery rounds. These factors lead to accumulations of bottles. The employers have been approached and these accumulations are to-day found less on the highway where they were the subject of abuse, being more commonly now placed by agreement with the owners on private property. It is hoped that the help of the road sweepers can be made use of so that they will salvage unbroken bottles instead of having to remove the remains of those which have been broken. (B) MEAT. Inspection. Of the very limited amount of slaughtering that took place in this district that which did occur was at an institution or was of an occasional pig belonging to a private pig club or individual. Of the 39 pigs killed and examined three entire carcases were condemned on account of emaciation, which the head of one and the mesenteric fats of two others were affected by tuberculosis. Meat Depot. The premises at Canterbury Road continued to be used as a meat depot. The amount of meat or offal condemned formed only a very small percentage of the quantity passing through the depot, not in excess of pre-war experience. (C) OTHER FOOD. Food Shops. Food shops were frequently visited throughout the year, particular attention being paid to their general cleanliness, to freedom from 15 lations in the yards and to the condition of the sanitary arrangements. The food stuffs condemned and voluntarily surrendered included 4,286 lbs. of fruit and vegetables, 410 lbs. of cooked meat, 144 lbs. bacon, 63 stone of fish, 40 lbs. cheese, 55 lbs. jams and jellies. Some 307 tins of tinned foods were also condemned, the contents of half being fruit and vegetables, and of the bulk of the remainder, milk. During one period much tinned food-stuff was detected in the hands of different retailers which were parts of salvaged consignments, the containers evidently having been subjected to the action of water or fire or both. Because of the stresses to which these tins had been subjected, a different standard had to be adopted when considering whether or not they should be passed for human consumption than that generally accepted in determining the fate of tins affected by the less severe stresses in peace-time. Insufficient control seemed to have been exercised in the supervision of the goods from the time they were recovered from the premises in which they had sustained damage to when they were exposed for sale to the householder. Difficulties were experienced in determining whether consignments should be released for sale because while it might be felt that a particular batch which had been exposed to water, and where the containers were rusting, might be wholesome if consumed at an early date, there would be no such assurance as to the innocuousness of the food stuffs if, for any reason, a long time elapsed before consumption, a period which might occur because the unsightly containers did not command a ready sale of the products if others were available or it might occur because the housewife retained the article a long time in her own domestic store. Later in the year control improved as it became more common for notices to be received of the entry of such food-stuffs of doubtful quality into the district. Food Damaged by Enemy Action. In the earlier part of the year further incidents resulted in damage to food shops and necessitated the destruction of a limited amount of food stuffs. ISOLATION HOSPITALS. ADEQUACY OF ACCOMMODATION. Owing to the general low incidence rate of scarlet fever and of diphtheria the present accommodation proved more than sufficient to meet the demands; in fact, the Honeypot Lane Isolation Hospital had been closed from June to the end of the year. Connecting the old diphtheria block to the scarlet fever ward has proved a very great boon, easing the administration at the hospital and enabling a number of patients to be treated there who otherwise would have required removal to some other Isolation hospital. 16 CLINICAL ASPECTS. Scarlet Fever. Admissions : Number admitted with a diagnosis of scarlet fever 253 Number suffering from scarlet fever 244 Number in whom diagnosis not confirmed 9 Of these 9 cases, 6 suffered from tonsillitis, one from measles and two from urticaria. Deaths : Nil. Complications: 175 patients, or 71 per cent, of those admitted suffering from scarlet fever made an uninterrupted recovery. Of those who suffered from complications 24 suffered from cervical adenitis, 12 from rhinorrhcea, 10 from otorrhcea, 6 from relapse, 4 from albuminuria, 4 from rheumatism, 8 from whitlows, two from endocarditis and two from abscesses which required incising. Four out of the 177 patients' treated with serum developed a serum rash. One developed a protonsil rash. Cross infection : Whooping cough was introduced on three occasions and chicken pox once. One in-patient was considered to have contracted whooping cough. Return Cases : Return cases were notified from seven households to which patients treated in hospital from scarlet fever returned on discharge. Period of Stay : The 22nd day after admission was the date on which most patients were discharged, 26 of the 174 uncomplicated cases going home on this day. 50 were in under 21 days, while 16 went in on the 21st day, 13 on the 22nd, 19, 14, and 12 on the 24th, 25th, and 26th days. Diphtheria. Number admitted on a diagnosis of diphtheria 48 Number of cases clinically diphtheria 31 Number of carriers 5 In 12 cases in which the diagnosis was not confirmed the revised diagnosis was tonsillitis in 6 cases and scarlet fever in two. Of the cases clinically diphtheria 28 were faucal, 2 nasal and one laryngeal. Of the carriers 5 were faucal, and one nasal. Deaths : Number of deaths amongst those admitted during the year 2 Case mortality of diphtheria cases, 64 per cent. The particulars of the fatal cases are (1) a boy of six, not a resident of this district, was admitted on the third day of illness suffering from laryngeal diphtheria. Tracheotomy was performed but did not avert a fatal issue. (2) A girl of 16 was admitted on the sixth day of an attack of faucial diphtheria. She developed paralysis and died on January 1st, 1942, the tenth day after admission. 17 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease. Und. lyr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & yrs. Total Scarlet Fever 1 66 179 33 13 14 12 11 1 1 - 331 Diphtheria — 12 15 3 6 5 9 1 - - - 51 Enceph. Leth — — — - - - - - - - 1 1 Pneumonia 5 14 11 2 10 2 14 19 18 19 29 143 Erysipelas 1 — — — 1 3 9 9 9 5 3 40 Poliomyelitis — 1 1 1 - - - - - 1 — 4 C.S. Fever 2 5 2 2 1 3 4 3 1 —. 1 24 Dysentery — 7 2 — — - 1 1 — — — 11 Measles 21 473 635 73 25 18 17 11 1 1 — 1275 Whooping Cough 70 605 528 14 5 3 17 10 4 — 3 1259 Pemphigus Neon 3 - - - - - - - - - - 3 Puerp. Pyrexia - - - - - 3 4 2 - - - 9 Ophth. Neon. 7 - - - - - - - - - - 7 Food Poisoning — — — - - - - 4 — - — 4 Typhoid Fever 1 1 3 4 2 3 1 — 3 — — 18 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 331 253 - - - Diphtheria 51 48 2 - - Encephalitis Lethargica 1 - - - 3 Pneumonia 143 - - - 148 Erysipelas 40 - 19 - 1 Poliomyelitis 4 - - 2 — Cerebro-spinal Fever 24 - 4 17 7 Dysentery 11 - 1 - - Measles 1275 1 18 - 2 Whooping Cough 1259 - 19 - 8 Pemphigus Neon. 3 - 1 - - Puerperal Pyrexia 9 - 3 - 3 Opthalmia Neon. 7 - 2 1 - Pood Poisoning 4 - - - - Typhoid Fever 18 - 9 4 1 DIPHTHERIA. Incidence. 51 notifications were received during the year, though in a number the diagnosis was subsequently amended, mostly to tonsillitis. The corrected figure of 39 in a population of — gives a rate per 1,000 population of-. (The figures for the years 1934 to 1940 were 0.60, 0.58, 0.22, 0.54, 0.28 and 0.41.) Nearly one-half of the cases occurred in the first quarter, while the third was the quarter of lightest incidence. 18 Secondary infection occurred in two households, in each case the infecting patient being a London child and the case proving fatal. There was one return case, that of a girl of three in a household where there had been two cases, the onset of illness in the case being some six days after the return home of the infecting case. Five were bacterial cases only, three of these giving positive nasal swabs. The age distribution of the cases is of interest. Of those proved to be diphtheria 25 per cent, were under five years of age, 35 were of school age, and 40 per cent, were over fifteen. Place of Treatment. All but three of the patients were admitted to the Harrow Isolation Hospital, these three being removed from general hospitals outside the district. Deaths. Three of the patients notified as suffering from diphtheria succumbed to the infection ; in one case, however, death occurred on the first day of the following year. The other two cases were of children ordinarily resident in London and whose deaths are therefore not included in the mortality returns for this district. The first of these fatal cases was a boy of five who was admitted on the fourth day's illness of laryngeal diphtheria. The second was a boy who, on the fourth day of illness was taken to a general hospital from which he was removed to an isolation hospital not in this district. The third fatal case was that of a girl of 17 who was admitted on the eighth day of illness. Immunization. Although the number of children immunized against diphtheria in the later months of 1940 had been rising, the effects of the national publicity campaign are shown markedly by the number of cards received in the different months. It should be appreciated that any case is recorded in the month the card is received, that there is not less than one month's interval between the two doses, and that frequently there is a lapse between the date of the final dose and the date the card is sent in. Early in the year arrangements were made for treating the children attending the infant welfare centres, while the county school medical staff kindly undertook the work at the schools and school clinics. Cards from these two sources were received first in March. Those from the infant welfare centres have been maintained up to the end of the year at a fairly even rate of some 100 per month, the total number of children treated being 1,184. The arrangements at the schools proved quite popular in the summer months but very little was done in the Christmas term. Altogether, 1,094 were treated at the schools or school clinics. March showed a sharp rise in the monthly rate of 150 to over 400 in the cards received from general practitioners. The figure rose through the summer to 600, falling in September to 500 and then declining each month to a figure of about 250 in December. The total number of 19 children treated by the general practitioners was 4,580, the grand total of children treated under the three arrangements being 6,858. The effect of national propaganda is shown by the fact that, whereas for each of the first two months of the year the average number of children treated was only 150, the figure rose for each of the next seven months to over 700. The falling away in the number of consents was to be expected. An encouraging feature is that the number treated each month at the infant welfare centres has maintained a uniform level. Ideally the number of children treated each year should be the number of births for that year. Those dealt with at the infant welfare centres are treated at the correct age in that they are protected before they have reached the age at which their natural immunity passes off and before they are exposed to greater risks of contracting infection. In surroundings such as these, in these days when, because there is so little diphtheria, there are reduced opportunities for the children to receive their sub-infective doses which will help to raise the waning immunity, it is probably desirable that those children treated round about their first birthday should, just before their admission to school, receive a further boosting dose. At the end of the year it was estimated that some 31-5 per cent, of the children under fifteen in this district had been immunized against diphtheria and 25-6 per cent, of those under five. 7,094 children were invited to be Schick-tested. Of the 3,216 who attended both the test and the reading 97 were positive, a percentage of 3. As the Schick-test state of the children before inoculation was not known, this cannot be accepted as indicating a 97 per cent, conversion rate. In December a child was admitted to hospital with a mild attack of diphtheria. She had been immunized earlier in the year, receiving 0-1 c.c. A.P.T. on the 13th May and 0-3 c.c. on the 13th June. There is no record that she was Schick-tested. Provision of antitoxin. 45 lots were issued totalling 356,000 units. Almost invariably when serum is given in private practice the dosage is 8,000 units. Very few patients had been given serum before admission to hospital. Schools and Diphtheria. There were no cases this year in which there was any suggestion that infection had been contracted in school. SCARLET FEVER. Incidence. 331 cases were notified during the year, amongst which were a few which were errors of diagnosis. 326 cases is an incidence of — per 1,000 population, a rise on last year's rate but still lower than the average for recent years (the local rates for the years 1934 to 1940 were 4.70, 3.47, 2.64, 2.31, 2.72, 1.60, 1.08) and lower than the average for the country. 20 The incidence was fairly uniform for the first half year when there was an average weekly rate of 6-7. In the third quarter the rate was rather less but rose to a weekly average of 9 in the last three months of the year. Place of Treatment. Of the 334 cases notified, 73 or just over 21 per cent, were treated at home at the election of the parents, a slightly lower proportion than usual. It seemed that 30 per cent, of the cases removed might well have been treated at home. The figures of 15 per cent, where the reason for removal was the presence of other young children at home, 13 per cent, because there was no bedroom for the patient to be nursed in, 12 per cent, where the patient was an adult and 10 per cent, where there was crowding, are much the same as previous years. The increasing extent to which mothers are out working is reflected in the larger number of cases in which it was the fact that there was no one at home to nurse the patient that determined the request for removal. In five instances, in two of which the cases were actually diphtheria, the reason for admission was the clinical condition of the patient. Secondary Infection. Secondary infections occurred in 23 households, in 18 there being only the one secondary case, in three 2, in one 3, while in one home there were altogether 5 cases. In seven instances the original patient was treated at home. In five of the instances in which the original case was removed to hospital, the onset of illness of the secondary preceded the date of the removal. Return Cases. Return cases occurred in seven households, in most only one patient being infected but in each of two homes two patients. Apart from these there were three households in which the onset of illness in another member of the family preceded the return home of the original case. Schools and Scarlet Fever. In the Christmas term there was a grouping of cases at four separate schools, in each the infants' department where it seemed in some way that the infection was related to school attendance, though in no instance was the distribution of cases in time or amongst the different classes more than to lead to a fear of association. In one school in September there were nine cases but only two of these were members of the same class. During the rest of the term there were four more cases, again amongst different classes, though two of them were those which had had single cases earlier in the term. Another small infants' department had six cases over three weeks, three of the cases being children attending the one class. From the middle of October to the first week in December 14 cases occurred in another school, four in one class and two each in two other classes. In the last school in which there was any suggestive grouping, in the three months September to November there were altogether 21 cases, but of the 12 classes involved only one had as many as three cases, and these were spread over many weeks. 21 ENTERIC FEVER. During the year 17 persons were notified as suffering from enteric fever, one proving to be typhoid fever and the remainder cases of paratyphoid B infection. In addition to these there was the case of a patient who died in October of bronchial pneumonia and on whose certificate reference was made to paratyphoid B infection but about whom no particulars could be obtained. The single case of typhoid infection was that of a man of 33 whose illness dated from August 9th. The remaining cases were all of para B infection. In the case of two, namely, a girl of eleven, who came to this district on April 7th anc' who fell ill on the 13th of that month, and a boy of nine who came to the district on the 4th September and who fell ill on the 8th, the infection was almost certainly contracted in another area. The following are the particulars of the remaining cases : (1) Two adult women living in the same house fell ill, one on May 23rd, the other two days later. One of these patients died on July 3rd. (2) A girl of five, onset of illness, June 6th. (3) A boy of ten who fell ill on June 9th, but whose illness was not diagnosed until July 3rd. (4) A girl of eleven, onset of illness June 23rd, and diagnosed as paratyphoid infection on July 3rd. (5) Female adult of 49, onset of illness June 22nd, diagnosis made July 19th. (6) A girl of 21 fell ill on June 28th, being diagnosed on July 27th. A number of cases had occurred amongst her colleagues at work in London. (7) A boy of 17, onset of illness July 8th, case diagnosed July 19th. (8) A male of 20 who fell ill on August 30th and was notified on September 8th. He worked in and took many meals in London. (9) An infant of seven months, though notified as a case, was, at the time of notification, really a carrier. There had been, some weeks previously, in the institution in which the baby had been for some time, acase of paratyphoid infection. (10) A female of 20, onset 7th September, notified 14th October. She had several meals at the canteen at her factory, which was not in this area. (11) A boy of 2, and his mother, whose illness dated some ten days after that of the infant, fell ill in October. (12) A girl of 8, onset of illness October 2nd, notified October 18th. No connecting links could be found in these cases except, of course, those which occurred in the same household, in one instance it appearing probable that there was a simultaneous infection, in the other familial infection. In some instances the patient was in the habit of having meals out. In one case it seems probable, in view of the occurrence of cases amongst co-workers, that the infection was contracted by food consumed there. In most instances, however, there could be obtained no history of food having been consumed elsewhere than at home. There was no common milk supply. Some patients had partaken of preparations which presumably contained synthetic cream, a product which has been thought to have been responsible for some outbreaks, but the remainder gave no such history. Investigations, of course, are not easy in a disease with such a long incubation period and one, moreover, in which the clinical condition of the patient is such that a 22 diagnosis was frequently made only very belatedly after the onset of the first signs or symptoms. Although, in point of fact, the illness in one of the patients was sufficiently serious to cause a fatal issue, in the majority the attacks, clinically, were of the mildest. It seems most probable, therefore, that there must have been many other cases in which the clinical condition was just that much milder to prevent the condition being recognised at all as a paratyphoid infection. There are many factors which would tend to lead to an increase in food infections. The mere fact that paratyphoid fever has, of recent years, been on the increase is of itself one factor making for further increase as a certain proportion of patients may continue to act as carriers. With the absorption of unskilled labour, particularly of persons not hygienically educated, into factories dealing immediately or remotely with food products, the risk is increased. Deficient lighting, arising from the imposition of black-out conditions favours contamination. Shortage of skilled labour operating plants to process food stuffs, or inability to obtain or repair or replace damaged parts of plants, may increase the output of potentially infective food. At ordinary times the sanitary conditions at some premises where food is handled are not of the best. To-day many who have had little previous experience are handling food, so adding to the risks of dissemination of food-borne infections. The matter is of sufficient importance to justify in at least the larger food factories the appointment of a welfare supervisor. The salvage of products exposed to the heat of a fire in a burning warehouse or to the rusting effects of the water with consequential sale possibly at reduced prices of these goods, with the small amount of supervision which it seemed at one time it was proving possible to devote to it, must have led to a substantial increase in the consumption of food stuffs not entirely sound. Rationing of food stuffs too must undoubtedly lead to a consumption of articles which at other times the discriminating housewife would reject. Difficulties of purchase, coupled with the rationing will tend, too, to result in much in the household larder being kept for longer periods than usual. The course of the illness in most patients was not severe. It is of interest that two patients presented symptoms of an acute abdomen for which they were admitted to hospital and operated on. Four of the patients were treated at home, six were removed to isolation hospitals, while the remainder were treated at general hospitals, in many cases the diagnosis having been made at the hospital. DYSENTERY. Twelve cases of dysentery were notified during the year, the diagnosis being subsequently withdrawn in two. With the single exception of an adult male, a sailor home on leave, in whom the infection was due to the Flexner organism, the illness was due to Sonne infection. Six of those so affected were child in-patients at one of the local hospitals, in whose cases it seemed the infection was contracted in the hospital. One patient was a nurse in an institution outside this area whose illness was diagnosed while she was home here on leave and who was thought to have contracted the illness at her place of work. The other two cases 23 were members of the same family in which the onset of the father's attack was some six days after that of the child. In all those patients at home the illness was so mild in character that there was no necessity to remove any of them to hospital. FOOD POISONING. Only four cases of food poisoning were notified during the year, two of them being adult members of the same family. In each case the symptoms were of short duration. ERYSIPELAS. 39 cases of erysipelas were notified during the year, of whom 26 were females. The face was the affected site in 28, the leg in 7. 17 patients were treated in isolation hospitals, the remainder at home. The incidence of the cases was somewhat higher in the first half of the year, March being the month with most cases when 8 were notified. The incidence in the second half of the year was more irregular, 7 of the 15 cases occurring in the month of November. CEREBRO-SPINAL FEVER. In 1940, this district with its 38 cases suffered in common with the rest of the country from a higher than normal incidence. This last year, the 25 notifications, while a marked decrease on the figure in 1940, was still appreciably higher than the average notification rate for previous years. One notification was withdrawn but one fatal case was first known of from the transfer death returns. Apart from one case in September and two in November, the cases occurred in the first half of the year, being more or less evenly distributed over this period. All ages were affected, the youngest case being a female infant of one month and the oldest a man of 62. Five cases proved fatal. Three patients were treated at home, four in isolation hospitals and the remainder in general hospitals, in most cases it seems, the diagnosis having been made after the admission of the patients. MEASLES. As reported last year, this infection behaved irregularly by not appearing at the expected time in what was anticipated to have been an epidemic year, there being little enough until the outbreak rising from the onset in September to its peak in November. In 1941, a non-epidemic year, there were, nevertheless, 1,275 notifications. The distribution, however, was most irregular. The average weekly notifications tor the first quarter was 57; there was a marked fall at the beginning of the second quarter and the incidence in the next thirteen weeks remained fairly uniform, resulting in an average notification rate of 25. The disease virtually died out early in the third quarter when there were Only 57 cases in all, to rise again in December, this increase being the Prelude to the epidemic proportions reached in the early months of this year. The children of 21 schools were affected, though at most the 24 cidence was very light. In two schools some 100 children were affected in the first few months of the year, at another some fifty and at a fourth about thirty in the first term. In the last few weeks of the year one school had nearly 100 children affected and another about 30. In spite of the number of cases which occurred, there were no deaths recorded as due to measles. The total number of visits paid to the homes was 414, while 19 children were removed to hospital. WHOOPING COUGH. While the number of notifications of whooping cough is almost identical with that of measles the distribution of the two diseases showed a marked divergence. The weekly incidence figure of 20 for the first two months rose in March to an average of 40, this rate being maintained for five months ; in August there was an appreciable decline and in the rest of the year the weekly average was only nine. Few schools escaped entirely, though there were many in which throughout the year there were fewer than 20 cases. On the other hand, even those most heavily attacked had not more than 70 cases. Four children died from whooping cough. The number of patients suffering from this disease who were removed to hospital for treatment was 19, and the number of visits paid by the health visitors was 531. NON-NOTIFIABLE INFECTIONS. Chicken Pox. In the months March to June two schools each had about 100 children away suffering from chicken pox, while three others had about half of this number. In the winter term another school had some 40 cases spread over the three months, while another had some 70 cases in the month of December. At many other schools the incidence was very light. In all, intimations were received of 624 absences from school on account of this infection. Mumps. Mumps also was much more prevalent than in the previous year, intimations being received of 1,175 children being absent from school on this account. One school in the months March to May had 257 cases, another in the first three months 139 ; 133 cases occurred in one school in the first half-year, and 146 cases in another school in the same period. In the autumn, some schools previously unattacked were affected, one having 130 cases, another 74, while two others at this time had 39 cases each. German Measles. The incidence of this infection this year was very light, intimations being received of only ten cases. Influenza. Influenza was prevalent in the months of February and March during which time 25 out of the total of 30 deaths due to this ailment occurred. 143 cases of influenzal pneumonia were notified. 25 VERMIN INFESTATION. Scabies. Although even in the years preceding the war this complaint had been increasing in incidence in different parts of the country, war conditions have apparently caused it to become still more prevalent. In a district such as this where the extent of infestation in normal times did not warrant the setting up of any special machinery to deal with those cases which came to light, the degree of infestation could be judged only by the extent to which requests were received from the almoners of London hospitals that the disinfection of the patients clothing might be carried out after the treatment of the condition in the patient. The increase in these requests suggested that there was a volume of population of such size requiring treatment as to justify arrangements being made. Accordingly, in August, with the approval of the County Medical Officer, provision was made for the treatment of scabies patients at a number of first aid posts in the district, the treatment being carried out under the supervision of the trained nurse attached to the posts. Patients are accepted for treatment only if referred by a medical practitioner. A number of cases are referred by the school medical officers but most are sent by the patient's family doctor. The routine practised was the application of benzyl benzoate following a hot bath, sulphur ointment being little used, particularly as many persons before attending have already applied it. The patient's clothing was removed for steam disinfection and returned to the post to be collected by the patient. It is hoped that the facilities for investigation afforded by the present prevalence of the infection will enable a definite answer to be given to the question of whether or not it is essential to treat the clothing in this way and whether the soaking in a hot bath and lathering which is the accepted prelude to all forms of treatment is essential either. If these two practices could be omitted no elaborate machinery would then be necessary to deal with this complaint. In the later part of the year the Scabies Order, 1941, came into force. This gives power to the medical officer of health to arrange for the inspection of premises occupied or recently occupied by a verminous person, to arrange for the examination by a registered medical practitioner of a person suspected of being verminous and to arrange for the cleansing or treatment of verminous persons and the cleansing, treatment or destruction of any article which is or is likely to be verminous by reason of having been used by or in contact with that person. The question of making scabies notifiable has more than once been raised. In the absence of suitable provision for the treatment of those affected, there would be little enough justification for the practice. On the other hand, notification alone would achieve little in the way of enforcing treatment of those affected. The Scabies Order itself, which is designed to this end, may prove of little value. In all some 299 patients attended for treatment, this number be'ng comprised of 100 adults, 166 children of school age, and 33 children under five years of age. Few patients failed to attend for the full treatment. 26 The relief from itching obtained as a result of one application it seems in some cases was most striking. Very few patients returned for subsequent treatment and those who did were considered to be cases of re-infection rather than of relapse. Lice Infestation. Early in the year because attention had been drawn to the high rate of infestation of heads of children and adolescents the records of the patients admitted to the local isolation hospital were analysed, yielding most disquieting results. Of children under five years of age 25 per cent of the heads of the girls and 10 per cent of those of the boys were infested, the year of heaviest incidence being the fourth. These rates were higher than those relating to children of school age ; of the girls of five to nine years, 16 per cent being affected and of boys of the same ages, 7 per cent, while the corresponding figures of those from 10 to 14 years of age were 15 and 2. All male adolescents of 15 to 19 were free, but 8 per cent of the females of these ages were infested. These figures were very much higher than had been expected by those whose work brought them into contact with children. Apart from the high rate of infestation, the most striking finding is that the incidence rate is higher amongst those of pre-school age and not amongst those of school ages. Even amongst these though the incidence of infestation is considerably higher than that disclosed by the findings of tho school nurses who recorded in 1940 an average incidence of not more than 3 per cent. A sample investigation carried out by the health visitors subsequent to the study of the hospital records, an enquiry in the conduct of which every attempt was made to make the population examined as representative a cross section of the population as possible, disclosed an average incidence of infestation of 7.5 per cent of those children of over one but under five years of age. This figure was an average of ranges from 0 to 30 per cent., five of the fourteen health visitors recording nil returns, while one recorded a percentage infestation of 26 and another of 30. The incidence amongst the different age groups was fairly uniform, being 6 per cent, in the groups 1 to 2 and 3 to 4, and 8 per cent in the others Apart from the special attention it was decided should be devoted to the specially affected areas, added facilities were put in the way of those wishing to obtain instruction while, in addition, arrangements were made at the different clinics and first aid posts for the cleansing of the heads of those infested. 27 TUBERCULOSIS. Notifications. New Cases Deaths Primary Notification Brought to notice other than by Form A Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 - 1 - - - - - - - 1 - - 1-4 5 2 4 3 — — — — 1 2 — 2 5-9 4 1 1 1 — — — — 1 — 1 1 10-14 3 1 3 3 — — — — 15-19 24 15 3 6 — — — — 3 6 — 2 20-24 18 37 2 1 — — — — 25-34 46 39 3 7 — — — — 14 17 — 1 35-44 53 21 2 3 — — — — 22 11 - — 45-54 35 11 2 - - - - - 15 4 — 1 55-64 15 10 4 — — — — - 8 — 1 — 65 & up 10 3 — 1 — — — — 9 — — — Total 213 141 24 25 — — — — 74 41 2 7 During the year 349 (211 male and 138 female) pulmonary cases were added to the register, this being more than a 50 per cent, increase on the figure of 226 for 1940, which was itself a rise on the number of notifications in the previous year. Many of these notifications relate to persons who had suffered from the disease before transferring to this district, though in point of fact this figure is not markedly different from that for 1940, namely 109 (62 male and 47 female) as contrasted with 106 (49 male and 57 female). Those cases about whom information is unobtainable or about whose position there is doubt in view of the short period of their residence here before being notified numbered 81 (54 male and 27 female) as contrasted with the figure of 56 in 1940. Apart from these, though, there remain the 159 (95 male and 64 female) cases notified for the first time this last year, and who having regard to the period of residence here before the disease manifested itself can be assumed to have succumbed while living here. It is this increase which is so disturbing. Of these cases, 15 per cent, of the male and 20 per cent, of the female give a close family history of tuberculous infection. The age distribution of the males was: Under 14, 6; 15-19, 18; 20-24, 3; 25-29, 5; 30-34,12; 35-39,11; 40-15, 10; and over 45, 27. The corresponding figures amongst the females were : 5, 9, 15, 5, 7, 5, 8, 10. The heaviest incidence amongst the males was the group 15 to 19, and amongst these the family history was most pronounced, being recorded in five out of the 18 cases. Nine of the patients were engaged in some indoor work (clerk, photographer or laboratory assistant), four were engaged in engineering or factory work, while two were in the services. The 28 heaviest incidence amongst the females was recorded at the ages 15 to 24, 9 in the group 15 to 19, and 15 in the group 20 to 24. A family history of infection was obtained in one-third of these. Five of these girls worked in a factory, nine were engaged in offices as clerks or typists, four were married women and two were shop assistants. The 42 notifications (16 male and 26 female) of non-pulmonary disease is a decline on the figure of 53 for last year. Of these patients 22 came here suffering from the disease. This year only six, 2 male and 4 female, had previously been notified before removal here, so that the number of new notifications is much the same as last year. Of the cases which contracted the infection locally, one-third suffered from infections of glands, mostly cervical; in most of the other cases the affected site was bone or joint, meninges, genito-urinary tract or abdomen in equal numbers. Of the transferred cases one-half suffered from lesions of bones or joints. 16, or 14 per cent, of the deaths of patients suffering from pulmonary disease and 4, or 44 per cent, of the deaths of patients suffering from nonpulmonary disease occurred among patients who had not been notified in this area as suffering from tuberculosis. Register. Pulmonary Non-pulmonary Male Female Male Female No. on register January 1st, 1941 356 318 77 89 No. of New Cases added 213 141 19 25 No. of cases added—other than on Form A - - - - No. of cases restored to register 5 7 1 2 No. of cases removed 115 74 18 25 No. on Register December 31st, 1941 459 392 79 91 The following table is a summary of the cases removed from the register with the reason for their removal. Reasons for Removal Pulmonary Non-pulmonary Male Female Male Female Left the district 37 37 9 8 Died 61 30 2 7 Cured 16 6 7 9 Diagnosis not confirmed or withdrawn 1 1 — 1 115 74 18 25 Deaths. Ill persons (72 male and 39 female) died from pulmonary tuberculosis during the year and 9 (3 male and 6 female) from non-pulmonary tuberculosis. Tuberculous disease therefore accounted for 6.7 per cent. 29 of the total deaths in the district. The corresponding figures lor last year were 77 deaths from pulmonary and 16 deaths from non-pulmonary tuberculosis, the disease accounting for 5.4 per cent, of total deaths. 42 per cent, of the total deaths of those who succumbed to pulmonary tuberculosis took place outside the district, mostly in institutions, the corresponding figure of those suffering from non-pulmonary tuberculosis being 72 per cent. Viewed from the angle of those concerned particularly with the health of the community, the deleterious effects of the war may be most pronounced through its influence on the incidence of tuberculosis. There has been an increase in the notifications. As previously pointed out, much of this may represent only a statistical increase arising from the obligation of a medical practitioner to notify to the medical officer of health of the area in which the patient is resident any case of tuberculosis which he knows has not been notified in that area. With the large movements of population which have occurred, many such persons will have been notified in the area of their new temporary place of residence though they will already have been notified in their home areas. Another suggested explanation of the increase is that it is not so much an actual rise in the incidence of the disease as the result of an advance in a disease already present but up to then dormant. As most cases, at least of the pulmonary disease, in humans have their origin in an organism which at one time resided in another human who acted as a spreadei any increase in the number of open cases results in a much larger rise in the number of those infected. It is for this reason that the repercussions of the war are to be so tragic. Without it, although the rate of decline was slowing up there was a continuing reduction in the incidence of the infection with the consequent lessening in the number of spreaders. It would therefore have been possible to imagine that the time would not have been far distant in which the existing tuberculosis service, including bed accommodation, even without any marked extensions, would have been amply adequate to deal with any demands made on it. Whatever may be the real position of the incidence of infection there is no escaping the fact of the increase in the number of deaths from tuberculosis. The national figures showed an increase of about 10 per cent, in the mortality figures for pulmonary tuberculosis in 1940 as compared with 1939, the percentage increase being greatest amongst women between the ages of 15 and 25. The slight fall which occurred in the early part of 1941 was unfortunately not maintained in all areas. One possible explanation of an increase in the number of deaths from those suffering from tuberculosis may be that it is due not to any factors arising from or associated with war conditions but to circumstances which adversely affect those suffering from this disease more than the general population. Inclement weather might be such a factor. This, it might be anticipated, would also affect the death rates of other groups such as the elderly, though not necessarily leading to an increased fatality in such other sections of the population at exactly the same time. Against this as an explanation though is the fact that the rise took place in each quarter of the year and not merely in that when the weather was most severe though this again might well have been the late result of such adverse influences in the 30 previous quarter. From the fact that war conditions are associated with an increase in tuberculosis incidence it does not follow that any increase is necessarily due to the war. Epidemics of cerebro-spinal fever are considered to be associated with wars, but the epidemic of this infection which occurred in the first two of the war years was preceded by a growing prevalence in the years which preceded the war. The parallel course followed by the tuberculosis rate in this war and that in the last, however, suggests the association of cause and effect; but if so, in what manner does it occur ? Important as is the part nutrition is considered to play in the setiology of this infection the reaction must surely have been too rapid in its onset for it to be affected by any lowering in the nutritional standards of the community, even though it is suggested that there has been any. Ignorance of the causes of the increased incidence precludes the taking of direct measures. That the greatest increase should occur amongst those women of 15 to 25 and possibly brought about by their working conditions, whether these are considered to be the long hours or the hard work or the irregularity of living, is in itself a justification for the steps taken, amongst other places, in factories in this area to attempt to discover by routine examination of the employees those with abnormal chest signs. Not only may the early cases be discovered before their symptoms would otherwise have led to their discovery with the resultant advantage to those actually affected, but the removal of infectious persons will help to reduce the infection of others. Mass radiography is being increasingly urged though not universally so, the objection of some being due to the restricted examination from the point of view of the one disease but of others that any large-scale action to attempt to effect a diagnosis in an earlier stage is premature until there is adequate bed accommodation, which, in its turn, is dependent on an increase in the supply of nurses. MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 2,712 ; 1,415 male and 1,297 female. Of these 126 were illigitimate, being a percentage of total births of 4.6 1,930 births occurred in the district (1,885 live and 45 still births). Of this number 289 (284 live and five still births) were to residents of other districts. Of the local confinements 1,653 were notified by midwives and 275 by doctors or parents. 966 (941 live and 23 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. 41 male and 37 female still births were registered, being a rate per 1,000 population of — compared with a figure of 0.51 for the country as a whole. 31 Of the 42 cases of which particulars are known, in 6 there was no definite cause, in 7 the reason was acute disease in or accident to the mother (including 4 toxaemias), and in two others the cause was maternal. Anomalies of the fcetus, placenta or cord accounted for 8 (6 due to congenital malformations and 2 to hydramnios). 15 were due to death of the fcetus, 12 because of prolonged labour and one because of prolapse of the cord. CHILD MORTALITY. In the following table is set out an analysis of the ages at which the deaths amongst children under five occurred in each of the four years, 1938 to 1941. Table I. 1938 1939 1940 1941 No. of Live Births 3292 3320 2999 2712 No. of Deaths of Infants— Under 24 hours 28 19 18 16 1 to 7 days 27 36 35 28 1 to 4 weeks 13 14 41 31 2 to 3 months 17 28 23 28 3 to 6 months 8 12 14 20 6 to 9 months 18 10 12 17 9 to 12 months 15 4 6 11 Total 126 128 150 151 Infant Mortality Rate 38.3 38.5 50.0 55.6 Neonatal Rate 21 20.8 31.1 28.0 No. of Deaths of Children aged One year 12 8 7 14 Two years 7 6 8 8 Three years 6 4 6 3 Four years 6 4 1 2 INFANT MORTALITY. 151 (91 male and 60 female) infants died under one year of age, constituting an infant mortality rate of 55.6 76 failed to survive one month. The neonatal mortality rate was therefore 28.0 constituting 50 per cent, of the total infant mortality rate. Of these 76, 16 failed to survive the 24 hours, the cause of death m 9 being prematurity, in 2 birth injury, and in another 5, abnormality or atelectasis. 28 deaths occurred in infants who survived 24 hours, but failed to survive 7 days. Prematurity was responsible for 15 of these, birth injury for 2, and developmental abnormalities 6. Of the 31 infants who survived one week but succumbed before the end of the first month, 111 8 the cause was prematurity, in 2 birth injury, in 8 developmental abnormalities or atelectasis. Infections accounted for 13 deaths, 6 being due to gastro-enteritis and 7 to respiratory complaints. 32 Of the 28 deaths amongst those of 1 to 3 months, 2 were due to developmental abnormalities; respiratory complaints accounted for 11, gastro-enteritis 7, and infections 5, of which 4 were from whooping cough. Infections accounted for most of the 48 deaths of those between 3 and 12 months, of which respiratory complaints were the cause in 21, gastro-enteritis in 13, influenza in 2, and whooping cough, measles and tubercular meningitis one each. The infant mortality rate for 1938 was 38.3 and in 1939, 38.5. The increase to 50.0 in 1940 was brought about by a rise in the number of deaths occurring in children under one month, a figure of 94 was compared with figures of 68 and 69 in the preceding years. The rate of 55.6 for 1941, which is an increase on the figure for 1940, is brought about not by there being a greater number of deaths, because the figure is only 151 as compared with 150, but is due to the fact that these deaths occurred in an appreciably smaller number of infants. As compared with last year the number of deaths amongst those under one month is much less, reducing the neonatal mortality rate to 28-0, one though which is still much higher than that occurring in the years 1938 and 1939. While the neonatal death rate, based on deaths occurring amongst those infants under one month of age is frequently recorded, it is appreciated that a more suitable date of demarcation would be the seventh day rather than the 28th day. Deaths up to the 7th day are very largely due to inherent deficiencies in the organism, to birth injuries arising from difficulty in delivery, to congenital abnormalities which preclude extra uterine survival and failure of adaptation to new surroundings. Many of the deaths, however, which occurred amongst those who have survived the 7th day but failed to reach their 28th day of life are due to the same causes which result in fatalities in the infant for the remainder of the first year. In the following table the causes of death amongst infants are further analysed. Table II. Under 1 day 1 to 7 days 1 to 4 weeks 1 to 3 mths. 3 to 12 mths. 38 39 40 41 38 39 40 41 38 39 40 41 38 39 40 41 38 39 40 41 Prematurity 16 13 10 9 11 12 16 15 3 2 13 8 2 1 Birth Injuries 4 3 2 4 8 3 2 2 3 1 2 1 2 1 Abnormalities 3 3 7 4 6 10 3 6 4 4 6 2 1 4 2 2 1 Atelectasis ... 1 1 1 1 6 2 1 Marasmus, etc. 1 3 6 2 2 3 5 9 4 1 1 Respiratory 3 1 1 3 10 7 5 10 5 11 19 13 10 21 Gastro-enteritis 2 7 6 5 6 5 7 17 2 3 13 Infections 5 1 7 6 6 Other causes 2 2 1 1 2 1 1 1 1 2 4 8 2 4 6 11 8 Total 27 19 18 16 27 37 34 28 13 15 41 31 17 29 23 28 41 27 34 48 From this it can be seen that the increase in the deaths amongst children under one month of age arises not in the earlier period but is due to a heavier mortality due to respiratory affections and abdominal 33 disturbances in those who had survived their seventh day. There was little enough change in the mortality of those dying before this time, suggesting then that the increase in the infant mortality did not arise from a lower standard of the ante-natal or midwifery services or from an impairment in the condition of the expectant mothers. What was saved in the neonatal deaths in 1941 as compared with 1940 though was lost in the later months, the increase being equally apportioned between respiratory and abdominal disturbances. Having regard to the severe weather experienced in the earlier part of the year the following analysis of the distribution of death amongst infants of different ages is of interest. The number of deaths amongst those under the age of 7 days occurring in the months of January to April was 17; in the months May to August, 16 and the period September to December, 10. The effect of the harsher weather is as might be expected not markedly reflected in this distribution. By contrast the corresponding figures relating to the deaths of children aged one week to one month were 25, 4 and 4; and of infants from 3 to 12 months, 40, 21 and 15. These figures therefore suggest that in spite of the fact that the infant mortality rate has risen sharply from 1939 to 1940 and less sharply from 1940 to 1941, that it need not be accepted that this is an inevitable consequence of the war or that there must of necessity be a steady deterioration. MORTALITY AMONGST CHILDREN of 1 to 5 years of age. Table I showed that the deaths amongst the children of ages 1 to 4 were not markedly different in 1941 from those of other years. Respiratory affec' ions accounted for 5, gastro-enteritis 2, and other infections 3 of the deatl.; of those of one year of age. Of those of 2 years of age the corresponding figures were 3, 1 and 3. Tuberculosis accounted for the deaths of 4 children over one but under five years of age. INFANT MORBIDITY. Ophthalmia Neonatorum. Seven cases of ophthalmia neonatorum were notified, one of them being in an infant born in a hospital outside the district. Two infants were admitted to a hospital for treatment while three were passed to the local District Nursing Association. All made complete recovery. Pemphigus. Three cases of pemphigus neonatorum were notified, one being sufficiently severe to require admission to hospital for treatment. MATERNAL MORTALITY. Nine deaths occurred from or associated with pregnancy, giving a maternal mortality rate per 1,000 total births of 3-18 comprised of a rate of 1.06 from puerperal sepsis and 2.12 from other puerperal cases. Two of the patients were attended at their confinement by the Council midwives. The first after a normal confinement developed a raised temperature on the 6th day on account of which she was removed to 34 hospital. Involution appeared normal but the general condition in spite of blood transfusion deteriorated and she died of puerperal sepsis. The second case went into labour about term. As there was no advance a medical practitioner was summoned and delivered a macerated foetus and soon after delivery the patient died from severe retro-placental haemorrhage. One of the other fatalities occurred in a nearby hospital to which the patient had been admitted in a moribund condition caused by a ruptured ectopic pregnancy. Two of the cases were to have been delivered at home, private practitioners being in attendance. The first patient was admitted to hospital after delivery by forceps had been unsuccessfully attempted. Owing to the development of a contraction ring craniotomy and cleidotomy was necessary, sepsis set in and the patient died five days afterwards. The other case too developed a contraction ring and was admitted to hospital after forceps delivery at home had proved unsuccessful. She died undelivered. The other four patients were all booked hospital cases of which the following are particulars. (1). A primipara who had been treated for toxaemia during pregnancy was admitted in labour. She developed an A.P.H., with suppression of urine. Delivery was effected, but the patient succumbed to eclampsia. (2) This patient was delivered by Caesarian section in 1937, but had a normal confinement in 1940. At her confinement in hospital all was normal until ten minutes after the birth of the infant, when she collapsed, having ruptured the caesarian section scar. (3) This patient died from P.P.H., which occurred some time after a forceps delivery. (4) This death occurred from obstetric shock following a P.P.H. due to a retained placenta. PUERPERAL INFECTION. Nine notifications of puerperal pyrexia were received, two relating to women who were in-patients at London Hospitals. In two instances the pyrexia occurred in a patient in whom some operative interference had been required. Two of the local cases were patients in Nursing Homes, and the remainder were delivered at home. Three patients were removed under the Council's arrangements to hospitals for treatment while one was taken over by the staff of the District Nursing Association. 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 997 Total visits 1,588 (b) To children under one year of age First visits 2,649 Total visits 8,057 (c) To children between the ages of one and five years Total visits 17,81— In addition visits were paid to 237 cases of measles and 301 cases of whooping cough in children under 5 years of age. 35 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 38,665 (2) By children between the ages of one and five years 24,501 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 2,426 (2) Between the ages of one and five years 754 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 2,064 (2) Over one year of age 6,015 Attendances: In May a report was submitted dealing with the subject of the attendances at the infant welfare centres. Summarized, it is that whereas just before the outbreak of the war the average weekly attendance was just short of 1,900, soon after the re-opening of the clinic sessions in September the average was 1,346. By April, 1940, the figure had increased to 1,595, and by August to 1,664. The average for the last few months of the year was 1,110, a figure which rose to 1,271 by April, 1941. Rising to a maximum of 1,544 in September the figure fell by the end of the year to 1,372. Many reasons account for the very different figures now as compared with those preceding the war, one being that mothers now go out to work. The fact that premises where sessions are held had to be changed, together with other discomforts, including the black-out in the winter months diminishes attendances. The evacuation of some of the mothers with their children or some of the children without their parents accounts for part of the difference, while, particularly in one or two parts of the district, it is felt that the institution of the arrangement for the issue of free milk without the necessity of the applicants attending the clinics has had some effect in reducing the numbers of those attending. Vitamin preparations: In December arrangements were made by the Ministry of Food for the free supply of vitamin preparations to children under five years of age. In this district the distribution of most of these preparations has been from the infant welfare centres. TREATMENT. The following particulars show the extent to which the facilities for treatment are used. Dental treatment : 280 children under five years of age and 389 expectant or nursing mothers made 1,009 attendances for treatment. 36 Physio-therapeutic clinic: 224 new cases were referred to the clinic. The total number of attendances by patients was 3,406 (832 massage, 2,574 electrotherapeutic, 65 ante-natal treatment) 102 patients were seen by consultant orthopaedic surgeon and 444 were seen by the consultant physiotherapist. Correction of visual defects : 90 children were treated by arrangement with the Middlesex County Council, most of these being recommended to obtain glasses. Provision is made by which children wearing glasses are re-tested periodically. Operative treatment of tonsils and adenoids: 24 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 6 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 152 Number of persons registered during the year 49 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.) 45 Number of persons on the register who were receiving children for reward at the end of the year 156 Number of children on the register at the beginning of the year 120 Number of children received during the year 162 Number of children removed from the register during the year 133 Removed to care of parents 81 Removed to care of another foster-mother 19 Legally adopted by foster-parent 6 Removed to charitable organisation, etc. 14 Removed to hospital 5 Foster-parent left the district taking the child with her 4 Child attained the age of nine years 2 Died Number of children on the register at the end of the year 149 37 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,548 visits to expectant mothers, 997 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 2,321 Total number of attendances by expectant mothers at all clinics 9,660 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 85 Clothing Coupons : The machinery for the distribution of the extra clothing coupons to which expectant mothers were entitled under the scheme which came into force in August, was based on the maternity and child welfare services. As so many of the expectant mothers are attended by the Council's midwives and receive their ante-natal supervision at the local clinics, most coupons were issued at these clinics. In the case of other applicants advantage was taken of this means of becoming aware of the fact that the applicant was pregnant for the health visitor to establish early contact with her, so, when circumstances were favourable the health visitors took the coupons to the expectant mothers. Consultant Ante-natal Clinic. The consultant ante-natal clinic was held fortnightly throughout the year. During the year 229 women made 376 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 two practitioners. Of this number, three were insured patients. No women attended for post-natal examination. ARRANGEMENTS MADE FOR CONFINEMENTS. At Home. 1,164 confinements took place in the patients' own homes. Of these 914 were attended by midwives acting in their capacity as midwives, and 250 by local midwives who had given notice of their intention to practice, acting as maternity nurses. Consultant Services. During the year a consultant was summoned to five patients. Two were ante-natal cases ; two patients were in labour; while the other was suffering from post partum haemorrhage due to retention of the placenta. 38 In an Institution. 661 births occurred in registered nursing homes in this district. 284 births to mothers from outside districts, which occurred here took place in nursing homes, 5 in private houses. Of these 661 confinements 275 were conducted by local practitioners. Notifications were received of 966 births to Harrow mothers having taken place outside the district. Of these 861 were from hospitals and 83 from nursing homes. Of the patients confined in hospital outside the district 474 were delivered at Redhill County Hospital and 293 at Bushey Maternity Hospital. Of a total of 2,607 births, 1,288 occurred in the patient's own homes, 460 in local nursing homes and 885 in hospitals or homes outside the district. Some 1,345 or 51 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year one patient was admitted to London hospital under the Council's arrangements. POST-NATAL SERVICES. Post-natal Examination. 93 women attended the clinic for post-natal examination, making altogether 128 attendances. Puerperal Infection, (a) Consultant services: The consultant was not summoned to any patients suffering from puerperal pyrexia. (£>) Hospital services: Any cases of puerperal infection requiring hospital treatment are removed to the London County Council Northwestern Hospital. During the year 3 patients were removed. (c) Home nursing: One patient suffering from puerperal infection was 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. 133 women, of whom 65 attended for the first time, made a total of 269 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 practice in this district was 36. Of these 3 removed from the district and discontinued practice, leaving 33 in practice at the end of the year. Of the total number 21 were resident in the district and carried on a domiciliary practice almost entirely limited to this area; 10 were engaged in local maternity homes, most of them entirely, though a few also carrying on a very limited domiciliary practice; and 5 were resident in adjoining areas but attended some cases in this district. The number of births attended in the district by midwives who gave notice of their intention to practice was 1,464. In 963 cases the 39 midwife was in attendance as a midwife and in the remaining 501 as a maternity nurse. Of the confinements occurring in private houses in the district, 1,138 were attended by local midwives whose practice is limited to domiciliary work (894 as midwives and 244 maternity nurses) and 26 by midwives from adjoining areas (20 as midwives and 6 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 19 cases during the year. 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 311 Still birth 11 Death of Infant 13 Death of Mother — Laying out the Dead 7 Artificial Feeding 8 Liability to be a Source of Infection 19 Of the 311 summonses to medical practitioners, 39 were on account of some condition during pregnancy, 80 during labour, 130 in the lying-in period, and 62 some abnormality of the infant. Of the 39 summonses to a patient during pregnancy 9 were because of albuminuria, oedema, or toxaemia, and 17 because of haemorrhage. Of the 80 summonses to a patient during labour the reason given in 57 instances was delayed labour with cause unspecified. In a further 12 there was some abnormal presentation. Nine summonses were to patients suffering from abortion (actual or threatened). 90 of the 130 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 16, a raised temperature in 10, phlebitis 7, and inflamed breast 13. Of the 62 summonses to infants, 26 were on account of some discharge from the eye, 14 because of feebleness or asphyxia and 15 some other abnormal state or condition. 311 out of 875 midwifery cases attended is a percentage rate of 35-5 The corresponding figure in 1940 was 30-5. MIDWIFERY SERVICES. 1 he number of patients attended by Council's midwives was 875 in which they acted as midwives and 197 in which they acted as maternity nurses, a total of 1,072. Although this figure is the same as last year, because of the smaller number of confinements that have occurred amongst mothers in the district, a higher proportion of the total number °f births which have taken place have been attended by the Council's midwives. Of the patients to be attended by midwives acting as midwives, 303 were assessed to pay the full amount, in 190 cases no charge was made, 40 while 391 were assisted. The corresponding figures in regard to patients attended by midwives acting as maternity nurses were 177, 31 and 46. The average number of cases attended by each midwife was 67. DAY NURSERIES. Some few years ago, when the question of the provision of one or more day nurseries in the district was considered, because of the small demand there appeared to be for such an institution, no steps were taken to establish one. Instead, encouragement was given to arrangements by which mothers who wished to go to work could have their children looked after in other homes. In February favourable consideration was given to the question of using the maternity and child welfare powers of the Council to establish nurseries specifically with the object of releasing to undertake war work mothers who, because ol the necessity to care for their children, could not otherwise do so. An enquiry instituted by the health visitors to determine the extent to which mothers would go out to work if arrangements could be made for the care of their small children seemed to show that at that time there was a demand for a nursery to serve the Harrow Weald and Wealdstone North areas and for one or more nurseries in the Edgware district. At the same time it was felt that there would be sufficient demand from mothers scattered throughout the rest of the area to necessitate some provision being made, even though requests were not on a scale sufficient to justify establishing nurseries. The Committee therefore agreed that approval be sought of the Ministry for the establishment of full-time nurseries in the Chandos and the Wealdstone Recreation Grounds, and for approval to arrangements for the organisation of a scheme for supplying persons to take charge of infants at their homes during the absence of their mothers on war work. A subsequent circular of the Ministry laid down that provision of nurseries for children of mothers in employment shall be regarded as a war provision, the net approved expenditure of the authority being repayable by the Ministry. Particulars were also given of the arrangements by which in approved districts the payments of mothers to daily minders for looking after their children could be supplemented by a sum payable by the local authority. Local publicity was given to the scheme but very limited use was made of it. In all there were received nine offers from mothers who would be prepared to look after the children of others, and only eleven applications from those wishing their children placed, and even these small numbers were so scattered that only to the most limited extent was the supply present in the same district as the demand. By the late summer it seemed there was an increasing demand for the provision of nurseries arising largely from the necessity, because of straitened financial circumstances, for a large number of women whose husbands were in the Services to go out to work. Representations were therefore made to the Ministry seeking approval for the establishment of war-time nurseries at five sites in the district. The position at the end of the year was that a nursery was to be established at 129, Spencer Road, Wealdstone ; that negotiations were still being carried out with the management at the Tyneholme nursery school, while decisions were being awaited as to the exact siting of the other three proposed nurseries.