AC 439(1) HARROW HARR 9 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1942 CARYL THOMAS, M.D., B.Sc., D.P.H., BARRISTER-AT-LAW King & Hutchings, Ltd., Printers, Uxbridge Urban District of Harrow Annual Report of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 1942 CARYL THOMAS, M.D., B.Sc., D.P.H., BARRISTER-AT-LAW REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Chairman and Members of the Urban District Council 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 1942. The health of the district during the year under review in general remained good. A slight increase in the death rate was recorded over the figure for the previous year, the actual number of deaths being the largest that have occurred in this area. While the infant mortality rate for the years 1940 and 1941 showed a sharp rise on the pre-war figures, an analysis of the causes suggested it was not inevitable that the increase should be sustained during the war period. 1942 showed'a welcome fall for these figures to a rate not very different from the best of the pre-war years. The figure for the country as a whole showed a similar fall from that of 59 for 1941 to 49 for 1942. Only in 1940 was the maternal mortality rate lower than that for last year. Of the infections scarlet fever was much more prevalent than during recent years, a marked increase occurring particularly in the last quarter. Diphtheria incidence remained at the usual low level. Measles was prevalent in the first half of the year, though resulting in few fatalities. There was a further fall in the incidence of cerebro-spinal fever, and there was only one case of paratyphoid infection. A greater than usual number of notifications of dysentery was received. Notifications of tuberculosis were at a lower level than the previous year but still much higher than the pre-war figures. The usual maternity and child welfare services have been maintained with little change, the increase in clinic attendances necessitating the opening of additional sessions. The average weekly attendance at the infant welfare centres remains though very far short of pre-war experience. The very extensive changes in the staff of health visitors which occurred during the year, more changes in a number of months than had occurred in former years, caused their own difficulties in this branch of the service. Competing demands for the labour of women has caused difficulties in finding accommodation for foster children and also in finding home helps to attend the homes of those who are being confined at home. This is the more unfortunate as the need for such assistance is now greater than ever, both because of the demand on hospital accommodation which is so much in excess of that available and because the women are deprived of what assistance they might in other circumstances have obtained because their relatives, friends and neighbours are now otherwise engaged. 4 Four nurseries were opened during the year and steps had been taken with a view to the erection of others. In order that the maximum benefit in the way of freeing mothers to undertake war work might follow on the opening of nurseries, it was decided that in selecting children for admission preference should be given to those where the acceptance of the one child would free the mother for full-time work. All nurseries have, up to this, been filled with children in this category and at most nurseries there is a waiting list of children fulfilling these requirements. This has meant that not more than one child from any family has been accepted ; nor have the children of mothers who find themselves in a position to undertake part-time employment only. When, in the years before the war, consideration was given to the question of establishing nurseries, it was found that then there was not any large demand. Conditions might well be very different after the war. Many more mothers, doubtless, will continue to work, some from necessity, but many from choice, and it is probable that the pre-war demand will not be a measure of that which will occur after the war. On the other hand, because the underlying reason then will be primarily the interests of the child rather than the freeing of the mother to be in a position to accept employment, so far from the position being that two or three children from one family are not accepted, these will in post-war nurseries probably actually be given preference. The nurseries to-day fall short of attaining their object because so frequently the mother is required to remain at home because the child is ailing, not necessarily of an infectious condition. Provision of some residential accommodation possibly based not at each nursery but available to serve a group of nurseries would help to meet this difficulty which will be just as important in the post-war nurseries. This accommodation would be useful, too, for the care of the nursery children when their mothers for any reason were incapacitated. Of the many requests for assistance received, the commonest fall into two groups. To an increasing extent people are finding difficulty in arranging for the care of the elderly. This is a big enough problem when they are well, but the situation is much worse when they are incapacitated by some ailment. Owing to the increasing demands made on their accommodation for acute, including maternity, patients, those nursing homes which formerly accepted the elderly as chronic patients are no longer doing so. The other group, of course, is that of those who wish other housing accommodation. Some of these are living in conditions so cramped as even to be statutorily overcrowded ; some are still in houses which have been condemned as being unfit for human habitation, while others are in houses which, under ordinary conditions, would have been represented for closure or demolition ; some families have to live and sleep in the same room as a patient with open tuberculosis, while some mothers with small children are confined to limited upstairs accommodation. Out of the last war was born to-day's very far-reaching and widely embracing maternity and child welfare service. Out of this may evolve changes of far greater importance and significance. Towards the end of the year the Beveridge Report on social insurance was published. One of the underlying principles recognises that want is only one of the 5 five giants on the road to reconstruction, one of the others being disease : logically, therefore, one of the three assumptions in the report is a comprehensive health and rehabilitation service for prevention and cure of disease and restoration to capacity for work to be available to all members of the community. Earlier in the year it had been announced that it was proposed to establish at Oxford an Institute of Social Medicine, with the object of investigating the influence of social, genetic, environmental, and domestic factors on the incidence of human disease and disability ; and to seek and promote measures other than those usually employed in the practice of remedial medicine for the protection of the individual and of the community against such forces as interfere with the full development and maintenance of man's mental and physical capacity. In this country specific diseases are declining. For this fall the activities of those administering the health services might be held partly responsible. There continues to remain, and, it may be that there is even a growth in the non-specific invalidism or state of sub-normal health, suggesting that there is something wrong in the social structure in which we live—something independent of such factors as nutrition and housing, and other external physical environment. Some diseases have declined in incidence not as a result of measures directed at them specifically, but because of improved sanitation in general. The attention paid to the purification of our water supplies has undoubtedly contributed to the fall in the incidence of typhoid fever, but purity of water is an ideal to be achieved independently of the repercussions on the prevalence of typhoid fever. Tuberculosis incidence was falling. Part of this fall undoubtedly was due to the influence of the anti-tuberculosis measures, but just as undoubtedly some fall would have occurred without these activities. That this is so offers more hope for the future than if the converse had been the position. Immunization against diphtheria achieves no benefit except the protection against that disease ; vaccination in childhood protects only against smallpox. It is possible, of course, that in the case of the infective diseases some direct protective measures of that nature will always need to be taken until the particular organism has reached that stage in its development when it achieves its purpose of adaptation to living in association with humans, in which case infection would not be followed by a violent reaction, toxin production and disease or death. In the aetiology of the infections though, important as may be the question of the virulence of the invading organism, the state of the immunity or resistance of the body to infection or to the influence of the toxin is also of first importance. This immunity is not always at the same level, and-it is often something more than the specific resistance to any organism or group of organisms. Whether a child succumbs to a dosage of infection depends on some factor other than the virulence of the bacillus or the anti-toxic content of the blood. This non-specific resistance to the development of communicable diseases, a factor perhaps common to all and one that may not need to be specifically stimulated for each of a number of infections, may be related to or associated with that which resists the onset or possibly overcomes the development of the non-communicable ailments. During this war millions are being spent on pegging the cost of living, to ensure that financial difficulties 6 shall not deprive a family of the fundamentals of a sound dietary. It is to be hoped that such measures have come to stay and that they will play their part, together with the proposed extensive housing programme, to ensure that each family is suitably housed and fed. To the assurance of an adequate diet and proper dwelling must be added the need for right working conditions. Social medicine it would seem has as its aims the building up of the health of the community. To-day, in our ignorance, this is limited to taking those few steps which can be taken to prevent disease, in detecting disease in those in whom it has not been prevented, and in the treatment of those who have fallen. At some future date, increased knowledge might lead to the conception of positive health, understanding by this not merely a state of absence of ill-health or even one of a feeling of well-being but a state of vital activity which protects us from such influences for ill as surround us. During this year, too, was taken, perhaps, the most important step in the prevention of venereal diseases, namely, the removal of the taboo which had prevented discussion of the subject and therefore dissemination of knowledge. Whatever benefits might follow the operation of the provisions of Regulation 33b they will not assume the importance of those which will follow on venereal diseases in future being considered and referred to merely as one of the many communicable diseases. In the Ministry of Health Circular 2,773, which deals with the subject of the Report for 1942, 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. June 11 th, 1943. 7 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1942 Rateable Value (April 1st, 1943) £2,110,615 Sum repesented by a penny rate (April 1st, 1943) £8,350 Extracts from Vital Statistics for the Year. Live Births :—- Total Male Female Legitimate 3,134 1,579 1,555 Illegitimate 134 76 58 Stillbirths :— Legitimate 77 37 40 Illegitimate 4 2 2 Deaths ... 1,818 922 896 Birth rate per 1,000 of the estimated resident population— Rate per 1,000 total (live and stillbirths, 2.4 Death rate per 1,000 of the estimated resident population— Deaths from puerperal causes :— Deaths Puerperal sepsis 2 Other puerperal causes 3 Total 5 Rate per 1,000 total (live and still) births 0.60 0.90 1.50 Death rate of Infants under one year of age :— All infants per 1,000 live births 31.5 Legitimate infants per 1,000 legitimate live births 29.7 Illegitimate infants per 1,000 illegitimate live births 74.6 Deaths from Cancer (all ages) 301 ,, ,, Measles (all ages) 2 „ Whooping Cough (all ages) 2 ,, ,, Diarrhoea (under 2 years of age) 8 Population. The Registrar General's estimate of the 1942 mid-year population is a slight decline on the previous year's figure. This is unexpected in view of the increasing extent to which it has been found that subletting of houses is occurring and the occuring at times of gross crowding. The movement of population is apparently less than in the previous year as judged by the information kindly given by the Food Officer of the children under six years of age who move into and out of the district. Deaths. Of the 1,013 deaths in the district, 92 occurred among non-residents. As there were 897 inward transfer deaths, the total number of deaths of 8 residents was 1,818, a figure comparable to that of 1,774 in 1942, the previous highest figure. Of the 92 outward transfer deaths, 30 took place at the Orthopedic Hospital, 8 at the Harrow and Wealdstone Hospital, 16 in Nursing Homes and 31 in private houses. Of the 897 deaths of local residents which occurred outside the area, most took place in institutions, 390 being at Redhill Hospital, 97 at Redhill House and 66 (including 8 new-born infants) at other County Hospitals. Nine deaths occurred at institutions for the treatment of tuberculosis and 27 at Shenley Hospital. 96 deaths took place in hospitals just outside the district and 101 in various London General Hospitals. The following is the Registrar General's abridged list of causes of death in the district:— male female male female Typhoid fever 0 0 Heart disease 228 237 Cerebro-spinal fever 4 0 Other circ. diseases 31 26 Scarlet fever 0 0 Bronchitis 52 38 Whooping cough 1 1 Pneumonia 50 33 Diphtheria 2 4 Other res. diseases 13 8 Resp. tuberculosis 61 40 Ulcer of stomach 14 5 Other tuberculosis 1 7 Diarrhoea under 2 years 3 5 Syphilitic diseases 13 2 Appendicitis 4 3 Influenza 6 8 Other digestive diseases 26 20 Measles 1 1 Nephritis 21 20 Acute polio-myelitis — — Puerperal sepsis — 2 Acute encephalitis — — Other maternal causes — 3 Cancer of mouth and oesophagus (M), and uterus (F) 14 12 Premature birth 22 11 Cong. malformations, etc 22 23 Cancer of stomach 24 18 Suicide 2 8 Cancer of breast — 29 Road traffic accidents 10 4 Cancer of other sites 110 94 Other violent causes 22 31 Diabetes 5 5 All other causes 85 76 Intra.-cran. lesions 75 113 All causes 922 896 1,818 deaths in a population of — is a rate of — . Last year's rate was 9.1, a higher figure than for previous years. The increases which were recorded in certain infections for 1941, were not repeated in 1942, there being falls in the rates for cerebro-spinal fever, whooping cough and respiratory tuberculosis, while the puerperal mortality rate also fell. The 1941 figures for infantile diarrhoea and also for road traffic accidents had exceeded normal rates, but these again by 1942 had fallen to the more usual rates so that in general these figures were more in accord with pre-war standards than the higher figures found in the earlier years of the war. Of the infections and those conditions particularly susceptible to external environmental influences only the tuberculosis rate remained at a figure substantially higher than those usual in pre-war years. Fatalities from the infectious diseases expressed as a rate per thousand population again compared favourably with the figures for the country 9 as a whole, the rates for whooping cough 0.01, diphtheria 0.025 and influenza 0.07 being lower than the corresponding national rates of 0.02, 0.05, 0.09 ; measles being the same figure, 0.01. Last year infantile diarrhoea accounted for many infant deaths, yielding a fatality rate of 10.3 per thousand live births ; in 1942 the figure was only 2.3 as compared with the national rate of 5.2. As has been pointed out already, in spite of this fall in the number of deaths from these conditions, the number of deaths recorded for the inhabitants of the district reached the highest level ever recorded. The increase in the number of deaths again took place amongst those of more advanced years ; in each sex, it was largely limited to those over the age of 65, the males of these ages contributing 46.4 of the total deaths as compared with a figure of 42.1 in 1941 and 40.3 in 1938, and the females 56.8 as compared with figures of 53.0 in 1941 and 46.5 in 1938. GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. CLINICS AND TREATMENT CENTRES. A few changes took place during the year in the clinic sessions. Early in the year one session was transferred from Roxeth to Walton Avenue. In March St. Anselms Hall, which, while it was occupied as a first aid post, had not been used for clinic sessions, again became available, all three classes of session, ante.natal, infant welfare and toddlers, being held. About the same time the increasing attendances at the Stanmore ante.natal clinic necessitated the holding of an additional session. In May, chiefly owing to difficulty in obtaining medical staff, the three weekly infant welfare sessions in Wealdstone were reduced to two. Increasing difficulty has been experienced in obtaining the services of part-time practitioners to staff these clinics and when, for any reason, the usual medical officer cannot attend it is frequently impossible to find a substitute, so that what was formerly a most exceptional experience is now unfortunately becoming not unusual. The question of the appointment of another full-time Assistant Medical Officer was favourably considered by the Council but the suggestion did not meet with the approval of the Local Medical War Committee. Clinic sessions play such an important part in any authority's maternity and child welfare service that it is to be hoped that it will again become the exception if a session at which a medical officer is expected to be present has to be held without one. At the end of the year 23 infant welfare sessions were being held in 12 premises ; 13 ante-natal clinics (two fortnightly, the remainder weekly), at 12 addresses, and the equivalent of 5 weekly toddlers' sessions at 8 premises. The steadily increasing attendances at the Marlborough Hill clinic are resulting in conditions there being most unsatisfactory, both from the point of view of the patients and of the staff who attend them. The question of providing extensions to the premises was considered, but up to the end of the year approval to this had not been obtained owing to the competing demands of labour and materials. Further 10 tion was given by the clinic Committee of the Harrow and Wealdstone Hospital to the question of providing at this address a foot clinic. On representations of the Women's Co-operative Guild urging the need for establishing a gynaecological clinic and a chiropody clinic it was decided, after consultation with the County Council and the Council's consultant gynaecologist that any facilities which could be provided by a gynaecological clinic were available at the Redhill County Hospital; while the question of establishing a chiropody clinic was left in view of the decision of the hospital clinic Committee to establish their foot clinic at 76, Marlborough Hill. Agreement was reached with the County Council that maternity and child welfare cases in the Edgware area could attend the orthopaedic clinic maintained by the County Council at their Stag Lane clinic ; also that school children suffering from orthopaedic defects could benefit from the facilities available at the Marlborough Hill clinic. During the year the Middlesex Education Committee established a Child Guidance clinic at St. John's Road, Harrow. By arrangement children under five attending the local maternity and child welfare clinics can be referred there. ESTABLISHMENT FOR MASSAGE AND SPECIAL TREATMENT. In accordance with the provisions of part 7 of the Middlesex County Council Act, 1934, no person, with certain provisos regarding practice by medical practitioners or members of the Chartered Society of Massage and Medical Gymnastics shall carry on an establishment for massage or special treatment without a licence. In 1938, there were 21 treatment premises while in addition there were four used by members of the C.S.M.M.G. Since the outbreak of the war these figures have been reduced so that in 1942, there were only 17 premises licensed. Consideration was given to the question of restricting in this area the practice of massage and special treatment to those possessing suitable qualifications. A draft bye-law was submitted to the Home Office, who however, expressed the view that it was not advisable at the present time to consider any further bye-law though it was hoped that a less restrictive form of bye-law would be formulated when circumstances are more favourable. AMBULANCE FACILITIES. Up to the end of the year the ambulances continued to be housed at the different fire stations, being manned by the Civil Defence personnel. There were no changes in the fleet of five vehicles. The following figures relate to this service in the past year :— Traffic accidents Accidents (other than traffic) including street illnesses, etc. Maternity removals Sick removals to and from hospitals 2,832 Calls received, ambulance not required upon arrival Total number of calls answered by ambulances during year 3,829 Total mileage covered during the year 38,590.4 Carried out for other Authorities 11 SANITARY CIRCUMSTANCES OF THE AREA. SANITARY INSPECTION OF DISTRICT. A. Inspection of Houses : Number inspected under P.H. Acts: (a) Complaint 1,692 (b) Routine 212 Number found defective 810 Revisits 3,892 Routine inspections under the Housing Act 20 Revisits 66 Surveys under Section 157 of the Housing Act 228 No. of cases of overcrowding 42 Inspection of houses let in lodgings — No. of foster parents' houses inspected 49 Inspections of houses for other reasons 285 Total visits paid 6,444 B. Inspection of other premises ; visits and enquiries ; No. of routine visits to premises liable to give rise to nuisances 581 Further visits paid to these premises 840 No. of visits to premises under periodical inspection 763 No. of inspections of cinemas, etc. 5 No. of complaints investigated (excluding those referred to above under Housing) 335 No. of observations for smoke nuisances 18 No. of inspections of factories (mechanical) 546 do. do. (non-mechanical) 203 do. do. work places 173 do. do. outworkers' premises 167 No. of visits to premises where rag flock is used No of visits under the Shops, etc., Act 166 No. of evening observations under the Shops Act — No. of inspections of hairdressers' premises 20 No. of visits re infectious diseases 14 C. Inspection of premises where food is manufactured or prepared : Slaughterhouses 49 Butchers (including Meat Depot) 875 Cowsheds 49 Dairies 156 Ice Cream premises 11 Fish-shops 140 Fried Fish-shops 66 Bakehouses 94 Cafes and Restaurants 73 D. Inspection of premises where food is retailed : Greengrocers 235 Provision Merchants 634 Milk shops 89 Bakers and Confectioners 49 Other Food premises 163 12 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) 1,293 (b) Number of inspections made for the purpose 5,251 (2) (a) Number of dwelling-houses inspected and recorded under the Housing Consolidated Regulations 20 (b) Number of inspections made for the purpose 86 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 2 (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 810 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 657 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 23 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners 16 (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 60 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 43 (b) By Local Authority in default of owners 11 C. Proceedings under Sections 11, 12, and 13 of the Housing Act, 1936 Complaints. During the year 1,957 complaints were investigated by the Sanitary Inspectors. Of these 521 arose from blocked or defective sewers or drains, 60 from accumulations of rubbish and 46 from nuisances from animals or birds. 478 related to housing defects of which 141 were 13 defects in plumbing, 90 from dampness and 51 from defective waterclosets. Complaints as to rats and mice numbered 70, and as to insect and vermin infestation 14 ; 235 complaints were from defects in or absence of dustbins. 47 complaints were received regarding such matters as flooded gardens and air raid shelters, accumulations of milk bottles, overgrowing of gardens with weeds, defective fences and burning of garden rubbish. Informal action in 1,333 instances was followed by the abatement of the nuisances in 1,205 cases. During the year 73 statutory notices under the Public Health Acts were served, 67 being complied with, though in 24 instances the work was executed in default by the local authority. Under the Housing Acts 23 statutory notices were served, 16 being complied with. Inspection of Houses. 228 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 10,304. 20 houses were inspected under the Housing Regulations. Overcrowding. In a report submitted October, 1942, the then position in regard to overcrowding was summarised. On January 1st, only 17 cases of statutory overcrowding were known. This figure increased to 36, of which nine were single family occupants, 23 were of families occupying part of a house or rooms, and in two cases the overcrowding was of one room. These figures, of course, do not represent the true state of the overcrowding of the district. Only a complete survey would bring to light this information which again would relate only to the statutory overcrowding. Families living in conditions in which crowding is short of that standard though are found to be existing in distressing conditions, more particularly those families where one is suffering from active tuberculosis or where there are small children. Consideration was given to the means by which the Council could have available accommodation to meet some of these difficult cases. Housing Act, 1936. A closing order was made in respect of the rooms over the stables 1 to 4, Canning Place, Canning Road, Wealdstone, prohibiting their use for human habitation. The Committee being satisfied that exceptional circumstances existed necessitating the demolition of the houses included in the confirmed Broadway, Stanmore, Clearance Order, 1937, and the High Street, Stanmore, No. 2, Order of 1937, authority was given for the necessary steps to be taken to secure their demolition. Verminous Premises. ' 8 premises were inspected on receipt of complaint of infestation by insects or vermin, ants, crickets, beetles, cockroaches, etc. The number °f premises found to be bug infested was 64. 14 Several houses and flats requisitioned by the Council for rehousing of bombed-out London families were, during the year, found to be in a verminous condition, necessitating fumigation, generally by firms using cyanide gas, and complete redecoration throughout. In most other cases fumigation was carried out either by firms using the cyanide gas process or owners or builders using a spray. Inspection of other premises. These premises include those at which nuisances might be anticipated and to which 581 visits were paid. Another group of premises which are the subject of periodical inspection and to which 763 visits were paid consisted mainly of public and private conveniences and air raid shelters. Smoke Abatement. Seven observations for smoke nuisances have been carried out. During the 155 minutes' observations, no dense smoke was recorded, but 119 minutes of moderate smoke. Factory Act. In this district there are 413 factories with mechanical power, 147 without mechanical power and 119 workplaces. The numbers of visits paid to these three classes of premises were 546, 203 and 173. Of the 54 public health nuisances detected, 17 were due to want of cleanliness and one to insufficient ventilation. The sanitary accommodation was unsatisfactory in 26 instances, being unsuitable or defective in 21 ; unclean or insufficient in 4, and not separate for sexes in 1. Ten other nuisances were noted. Particulars of 142 outworkers resident in this area were received. To these 167 visits were paid. SHOPS ACTS. 166 visits were paid to shops primarily to investigate complaints and to give advice as to hours young persons could be employed. The reduction in the volume of the work carried out under these Acts was due to the Inspector who normally carries out these duties having to give full time to his work in the Food Office, leaving to the sanitary inspectors, already depleted in number, the work under these Acts. No evening observations were carried out as practically all traders were closing well before the appointed hour for closing. No other contraventions were recorded. The Home Office advised that regulations as regards the closing of shops for the winter period should cease to have effect on the 28th of February and the general closing hours on and after the 1st March, 1942 became those as fixed by Section 1, 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. The closing hours for shops were again altered as from the 1st November. No alteration was made in the general closing hours during the days preceding Christmas. 15 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. Six local producers sell milk in the district. Distribution. Including three Company Distributors there are 27 retailers of milk in the district. Apart from an increase of three in the number of premises from which the three multiple firms distribute, the only changes in the register have been that two local producers have ceased to retail locally, and two other retailers have ceased to carry on business. In all, milk is retailed from 53 premises in the district, 34 of these belonging to the three multiple firms which distribute milk, 8 are used by the six local producers who distribute in this area, six by the six single retailers, while at 5 premises milk is sold in unopened receptacles only ; in addition there are 9 retailers selling milk here and not occupying premises in the district. Licensing. The only changes in the numbers of the licences issued are a reduction of one in the licences of pasteurizers, a reduction of one supplementary licence to producers outside the district to retail T.T. milk in the area, and a reduction of one supplementary licence to producers outside the district to retail pasteurized milk. Of the 15 premises licensed to retail tuberculin-tested milk, 8 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 two producers outside the district to retail tuberculin-tested milk in the district and 2 supplementary licences were issued to outside producers to retail pasteurised milk in the district. Two establishments were licensed for pasteurizing milk. Of the 41 premises licensed for the selling of pasteurised milk, 17 belonged to one firm, 13 to one, and 4 to one and 2 to another. Sampling. 16 samples of pasteurised milk were submitted to bacteriological examination and the phosphatase test. All except one, which contained B.Coli, were satisfactory. All but one of the eight samples of tuberculintested milk weie satisfactory. The two samples of tuberculin-tested (pasteurized) milk and the 2 samples of accredited milk produced locally were satisfactory. Of 12 samples of raw milk, two gave too high a count of B.Coli. 16 (B) MEAT. Inspection. As in the previous year very little slaughtering of animals took place in the district, the occasional pigs or sheep killed belonging to an institution or private pig club. 47 pigs and 33 sheep were killed and inspected. In all cases the carcases of pigs were sound, it being necessary to condemn only four mesenteric fats and a pluck due to tuberculosis and three plucks owing to parasitic disease and pneumonia. Most of the sheep killed at a slaughterhouse in this district were for consumption by special troops stationed just outside the district. Slaughter of three privately owned sheep was necessary because of accident ; the carcase in each case was fevered and so condemned for destruction. Meat Depot. During the year daily visits continued to be made by one of the sanitary inspectors. The amount of meat and offal condemned was less than in the previous year, though the volume of meat passing through remained much as before. Carcases of three sheep were condemned, two on account of black mould and one owing to being fevered ; 843 lbs. of beef because of putrefaction, 318 lbs. due to black mould and 148 lbs. owing to bruising and abscess ; 46 lbs. of mutton because of putrefaction, 117 lbs. due to black mould and 34 lbs. owing to bruising and abscess ; 64 lbs. of pork because of putrefaction, 8 lbs. due to black mould and 3 lbs. owing to bruising; 31 lbs. of veal because of putrefaction, and about 147 lbs. of offal on account of putrefaction or parasitic disease. During the year more tinned meats, such as corned beef, pork and mutton were distributed from the Depot than in previous years. The percentage of this class of food which had to be condemned was also higher, about 5,235 lbs. being unsound, mainly because the tins were blown or leaking. (C) OTHER FOODS. Food Shops. Food shops received the same attention as in previous years and in addition to the routine inspection 51 complaints regarding bad food were investigated. The foodstuffs condemned and voluntarily surrendered included 2,450 lbs. meat, 1,583 eggs, 520 lbs. cereals, 17J cwt. potatoes, 6 cwt. nuts, 103 lbs. of fruit and vegetables, 169 lbs. bacon, 462 lbs. cheese, and 153 lbs. jams and jellies. 3,735 tins of tinned food were condemned, the contents of most being meat or milk. These figures are much greater than those recorded in this district in any previous year. ISOLATION HOSPITALS. ADEQUACY OF ACCOMMODATION. Because of the low incidence of the two diseases treated in the local isolation hospitals, the accommodation at the South Harrow Hospital was sufficient until towards the end of the year when the increased 17 prevalence of scarlet fever resulted in the demand on the accommodation necessitating the opening of the Honeypot Lane Hospital. The greatest number of cases of scarlet fever under treatment on any one day was 65, and of diphtheria 13. As in previous years, cases of other infections had to be admitted to the hospitals of other authorities. In all, during the year, 77 patients were removed to other hospitals, this figure including 16 cases of puerperal infection. Towards the end of the year on a number of occasions difficulty was experienced in finding room for some of these patients in outside hospitals and on two occasions a patient suffering from erysipelas had to be treated at home because accommodation in hospitals could not be found for them. CLINICAL ASPECTS. Scarlet Fever. Admissions : Number admitted with a diagnosis of scarlet fever 434 Number suffering from scarlet fever 422 Number in whom diagnosis not confirmed 12 Of these 12 cases, two each suffered from chicken pox, erythema, and urticaria. Deaths : Nil. Treatment : Patients were given serum and prontosil as a routine, 289 receiving serum (mostly 3,000 but a few 6,000 units), and 407 receiving prontosil. The difference in the two figures is because serum was not given to those who did not come under treatment before the fourth day. As there were no controls it is impossible to say that the small number of complications and the general mildness of the attack was due to the routine treatment adopted, but the administration of serum certainly has the effect of reducing the temperature, while desquamation of any degree was limited to those not receiving serum. 5 per cent. of the serumtreated patients developed a rash, and about 2 per cent. of those treated with prontosil developed a rash which was thought to be due to the drug, while one patient also suffered from jaundice. Complications : The incidence of complications this year was smaller than usual, only 13 per cent. of patients admitted suffering (this figure does not include those suffering from serum or prontosil rashes or from those minor conditions such as cracks at the angle of the ear which might retard discharge). The number of patients who suffered from adenitis was 17, from rhinorrhcea 8, secondary attacks, whitlows or albuminuria 5 each ; four each from secondary sore throat and otorrhoea (one of these proceeding to mastoiditis which required operative treatment) ; rheumatism, nephritis, and cervical abscess one each. Some patients suffered from more than one complication. In addition two patients suffered from a second attack after their return home ; the one who had been in •26 days developed it on the 7th day after return, and the other who had been in 27 days had the onset 17 days after his return. These numbers refer to those patients admitted to hospital during the year even though they had not been discharged by the end of the year. 18 Cross Infection : 26 patients suffered from chicken pox while in-patients in the scarlet fever wards, three of these apparently being in the incubation stage at the time of their admission. In addition, there was one case each of measles, German measles and whooping cough. In the absence of cubicle accommodation the introduction of any cross infection cases creates administrative difficulties. Return Cases : Return cases were notified from 12 households to which patients treated in hospital after scarlet fever returned during the year. Period of Stay : 60 per cent. of the patients were discharged within 24 days from the onset of their illness, the commonest interval from onset to discharge being 20 days; 4 per cent. went home on the 18th day and the following percentages on the succeeding days, 8, 16, 12.5, 11.5, and 9. Just over 20 per cent. were in until the 30th day or longer. Most of these were held up because of some minor condition which might be infective, e.g., moisture of the nose or a crack at the angle of the mouth, the nose or the ear, some because of some associated minor condition such as pustular eruption, while some were retained in hospital for longer than the usual period because of some cardiac condition from which they were suffering when admitted. Diphtheria. Number admitted on a diagnosis of diphtheria 63 Number of cases clinically diphtheria 45 Number of carriers 2 Of the 16 cases in which the diagnosis was not confirmed the revised diagnosis was tonsillitis, including quinsy, in 10 cases ; laryngitis or croup in 4 ; and scarlet fever and influenza one each. Of the 45 cases clinically diphtheria, 43 were faucial, one nasal and one laryngeal. Both the carriers were nasal. Deaths: Number of deaths from diphtheria amongst those admitted during the year, one. Case mortality : 2.5 per cent. This fatal case was that of a boy of 4 admitted on the 3rd day of illness with an attack of faucial and nasal diphtheria, who died on the 7th day after admission. Another child admitted in 1941 died on January 1st; this case was mentioned in last year's report. Another fatality occurred in a child admitted suffering from croup with oedema of the larynx, tracheotomy being performed very shortly after admission. Complications : Apart from evidence of involvement of the heart muscle in a number of patients, the only complications occurred in one patient who developed slight paresis of the palate, and three who had albuminuria of varying degrees. 7 per cent. of those to whom serum was administered reacted by the production of a serum rash. 19 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 & up Total Scarlet Fever... 130 396 62 14 6 10 10 1 1 630 Diphtheria — 17 16 11 7 4 8 3 1 — — 67 Pneumonia ... 1 12 13 7 2 5 8 21 15 16 17 117 Erysipelas — 1 2 — 3 — 13 7 11 6 5 48 Poliomyelitis — — 3 — 1 — — — — — — 4 C.S. Fever — 4 6 — 1 — 1 2 — — 1 15 Dysentery — 5 1 1 3 2 2 2 3 2 21 Measles 50 897 1433 81 20 12 12 4 — — 2509 Whooping Cough 38 235 170 8 2 2 6 5 — 1 1 468 Pemphigus Neon 2 — — — — — — — — — — 2 Puerp. Pyrexia — — — — — 6 11 5 1 — — 23 Ophth. Neon. 5 — — — — — — — — — — 5 Food Poisoning — — — — — — — — — 1 — 1 Typhoid Fever — — — — — — 1 — 1 — — 2 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 630 434 1 — — Diphtheria 67 63 1 — 6 Pneumonia 117 — — 83 Erysipelas 48 — 13 2 1 Acute Poliomyelitis 4 — 2 — — Cerebro-spinal Fever 15 — 8 7 4 Dysentery 21 3 3 9 — Measles 2509 — 21 — 2 Whooping Cough 468 — 7 — 2 Pemphigus Neon 2 — 1 — — Puerperal Pyrexia 23 — 17 — 2 Opthalmia Neon 5 2 Food Poisoning 1 — — — — Typhoid Fever 2 1 1 — CONTROL OF INFECTIOUS DISEASE. Exclusion. The stringency of the practice of excluding contacts of patients suffering from infectious diseases has been gradually relaxed until to-day many authorities exclude only those whose occupation brings them into contact with those of susceptible ages or renders them possible instruments of widespread outbreaks through their handling milk or some °ther medium ; though even here the restriction is imposed only in the 20 case of the more severe of the infectious diseases. For many years now the procedure in regard to the exclusion of school-child patients suffering from infectious diseases and from school contacts has been governed by the recommendations contained in the " Memorandum on Closure and Exclusion from School " issued jointly by the Ministry of Health and the Board of Education. For a long time there has been doubt as to whether the practice of excluding school-child contacts has been a factor of importance in limiting the spread of infection, and it was certainly felt that the sacrifice of education involved did not bring about any corresponding advantage to the public health. An addendum of the memorandum was issued last year, which recommends a modified procedure. The provisions were adopted by the Middlesex Education Committee and so apply to the public elementary schools in this area. The general effect will be that patients who have suffered from scarlet fever or diphtheria can now be admitted to school one week after being freed after home treatment or being discharged from hospital instead of after a period of two weeks as formerly. In regard to contacts the main change is that contacts of patients suffering from these two diseases can be'admitted to school seven days from the beginning of isolation ; previous practice was to exclude the contact of a home treated case until one week in the case of scarlet fever and ten days in the case of diphtheria after the patient had been released from isolation. Typhus Fever. Owing to the increased risk to-day of the introduction of typhus fever into this country, special attention has been given to the steps which would be taken in the event of an occurrence of a case in this area. Patients detected in Middlesex would be removed to the Hornsey, Finchley, Wood Green and Friern Barnet Hospital or to the Uxbridge Isolation Hospital, by conveyances provided by these institutions. Disinfection of the premises would be necessary, surveillance of the contacts and special precautionary measures would need to be taken by any staff dealing with such infectious cases. DIPHTHERIA. Incidence. 67 notifications were received during the year, though in a number the diagnosis was subsequently amended, mostly to tonsillitis. The corrected figure of 51 in a population of — gives a rate per thousand population of — (the figures for the years 1934 to 1941 were 0.6, 0.58, 0.22, 0.54, 0.28, 0.41 and 0.20). Three were bacteriological cases only, the patients giving positive nasal swabs. Secondary infections occurred in two households. Of those proved to be diphtheria, 26 per cent, were under five years of age, 36 were of school age, and 38 per cent. were over 15. Place of Treatment. All but four of the patients were admitted to the Harrow Isolation Hospital, two of these four being removed from general hospitals outside the district and two being treated at home. 21 Deaths. Three deaths occurred from diphtheria during the year, one being that of a child admitted in 1941. One of the other deaths occurred amongst those treated in the local hospital, and the other amongst those treated in an outside hospital. Immunisation. The last quarter of the year saw a big increase in the number of children immunised, so that by the end of the year 7,366 in all had been treated, this figure including the 1,977 dealt with at the local infant welfare centres, 713 at the public elementary schools, and 4,676 by the local medical practitioners. It was calculated that by the end of the year, of the children under five years of age 42.5 per cent were immunised and of the children of school age 52.1, the corresponding figures at the end of the previous year being 25.6 and 31.5. 6,819 children were invited to attend for Schick-testing. Of the 3,913 who attended both the test and the reading, 96 were positive, a percentage of 2.5. This percentage is the same both for those inoculated with 0.1 and 0.3 c.c. A.P. T. and those who, in the latter months, would be receiving 0.2 and 0.5 c.cs. Of those who were admitted suffering from what was considered to be diphtheria were six who had received some protective inoculation. Two of these had received only the one dose of antigen, the one having received it two weeks before the onset of illness, the other some four months previously. One boy of nine had been immunised at about one year of age ; a girl of 12 had been inoculated in 1939 and another of 13 in 1936, none, apparently, having been subsequently Schick-tested. A boy of 5 who had been immunised was alleged to have been found Schick-negative in 1939. All these cases were clinically of very mild character. Provision of Antitoxin. 47 lots were issued, totalling 372,000 units. Schools and Spread of Infection. There were no cases this year in which there was any suggestion that infection had been contracted in school. SCARLET FEVER. Incidence. 630 cases were notified during the year, amongst which were a few which were errors of diagnosis. 618 cases is an incidence of — per thousand population, a marked rise on the rate for the last few years (the local rates for the years 1934-1941 were 4.70, 3.47, 2.64, 2.31, 2.72, 1.60, 1.06, and 1.66) but lower than the average for the country. In the first quarter of the year the degree of infection was much the same as in the previous year, a year of relatively low incidence, and the average weekly incidence was only 5. This figure rose to one of 8 in the second quarter, rising again in the third to 11. A sharp increase occurred in the last quarter when over twice as many cases were notified as in the third quarter, the average weekly incidence rising to over 22. 22 Deaths. No deaths occurred in this district due to scarlet fever. Place of Treatment. Of the 618 cases notified, 195 or 30 per cent. were treated at home at the election of the parents. Of those removed, it seemed another 44 per cent. might have been so treated. In 22 per cent. the reason for removal was the presence of other children at home; in 4.5 cases there was no room for the patient to be nursed in; in 6 per cent. the patient was an adult, and in a further 6 the homes were crowded. In one instance only was the reason for admission the clinical condition of the patient. Secondary Infection. Secondary infections occurred in 32 households, in four of them there being two cases but in the remainder only one. In twelve instances the original patient was treated at home. On 8 occasions the onset of illness of the secondary case preceded the removal of the first patient to hospital, while in a further 5 the onset was on the day of removal. There were two instances of simultaneous onset in two children. Return Cases. Return cases occurred in 14 households, only the one patient being affected in each home. In one instance the onset of the illness in the presumed infected child was on the second day from the return home of the primary patient, in another the sixth, and in another the eighth day. The onsets in the case of two were in the first half of the second week and of five were in the latter part; of one in the third, and of five in the fourth week. The condition of all but four patients who returned home was normal; of these four, three developed a nasal discharge and one epistaxis. In addition there was one household in which the onset of illness in another member of the family preceded the return home of the original case. Schools and Infection. In the Easter term there were no groupings of cases in the schools to suggest that school attendance played any part in the spread of infection. In the summer term many cases occurred in one department in the six weeks June to mid-July, the 23 cases notified being distributed through 8 classes, in one of which there were 9 cases spread over six weeks, not more than two cases occurring in any one week. At another school in the early part of this term one case in each of three consecutive weeks was followed by four in one week, while later in the term at another school two cases occurred in each of three successive weeks. In the last term of the year, particularly when the infection was more prevalent, many schools had groupings of cases not at any time reaching large dimensions, but smouldering with sufficient activity to suggest that school attendance influenced the onset. Some such grouping on a greater or smaller scale was found during this term in ten schools. Of those with limited groupings are included : (1) a school where 5 cases were distributed in 4 weeks—1, 2, 1 and 1 cases ; (2) one with an incidence of 3, 1 and 1 ; (3) one with a 2, 0, 1 and 2 distribution ; (4) a school where 23 three cases in each of two consecutive weeks were followed by a single case in each of three weeks ; (5) a school from which one case only was notified for each of 13 consecutive weeks except two when there were no cases and one when there were three. In one school over a period of 17 weeks there were 28 cases, 5 occurring in one week, 4 in two and 3 in another two. In another school there were 16 cases over 7 consecutive weeks, 4 cases occurring in one week and 3 in another. Later in the year 19 cases occurred in 7 consecutive weeks in one department, 5 cases appearing in one week and 4 in another. Another school had cases almost every week for 15 weeks, the greatest number in any one week being 5, there being 4 cases on two occasions and 3 on two, in all during that time there being 24 cases. 10 cases occurred over a period of 11 weeks at a junior school, the greatest number of cases notified in any one week being three. ENTERIC FEVER. As contrasted with last year when there were many infections in the district, this year only two cases were notified and in one of these the diagnosis was revised to that of enteritis. The only case was that of a paratyphoid B. infection in an adult female whose onset was late July and who was removed for treatment to a general hospital. DYSENTERY. More notifications than usual of dysentery were received, the number being 22, but the diagnosis in 3 who were admitted to Isolation Hospitals was, as a result of bacteriological findings, amended to enteritis. Seven were either in-patients or members of the staff of a hospital in this district, the organism in each case being Sonne. Three patients were admitted to Redhill Hospital from different parts of the district during February, the illness in each case being due to the Sonne organism, as was that of another patient admitted to the same hospital in May. In July two patients admitted to Redhill Hospital were suffering from infection, the one with a Flexner organism, the other, a small girl, infected with Morgan's bacillus which was responsible for the illness of a boy admitted there in October and a man admitted in the same month. The Flexner organism was also found in a Service patient admitted to another hospital in December. Two patients were treated at home, one in June, the other in October, and no bacteriological examinations were carried out. It seems very certain that much of this type of infection has been prevalent as many general medical practitioners experienced it amongst their patients some time during the year. It would be only the severer cases in respect of whom bacteriological examinations would have been carried out and they would be notified only if specific organisms had been found. The number of notifications cannot be accepted as being any real indication of the prevalence of this ailment. FOOD POISONING. One case was notified as suffering from this condition, a patient aged 59 who died from a ruptured aneurysm a few days after she had been admitted to hospital on account of food poisoning. 24 ERYSIPELAS. 48 cases of erysipelas were notified during the year, of whom 30 were females. The face was the affected site in 30 and the leg in 8. 14 patients were treated in isolation hospitals, 2 in general hospitals and the remainder at home. Of these, removal of two had been requested but was not possible as accommodation was not available. The incidence of the cases was fairly even throughout the year, the only month showing an undue prevalence being November. One death was recorded from erysipelas, a transfer death in March relating to a female of 64. CEREBRO-SPINAL FEVER. This year saw a further drop in the number of notifications received from the figure of 25 in 1941 and 38 in 1940. Of the 17 notifications the diagnosis was subsequently amended in 4 instances. The 13 cases were uniformly distributed throughout the year. 10 of the cases were amongst boys, the heaviest incidence occurring amongst those of six and under. Most patients were notified from and treated in general hospitals, only 3 being removed to isolation hospitals. Two patients died, one a boy of 3, the other a girl of 5. In addition, the transfer death returns contained particulars of a man of 35 who died from this disease in another part of the country in February. ACUTE ANTERIOR POLIOMYELITIS. Four cases of acute anterior poliomyelitis were notified during the year, a boy of 15 in March, a boy of 9 in June, a boy of 5 in August and a girl of 5 in September. Two cases were treated at home, the others being removed to isolation hospitals. MEASLES. The greater prevalence of measles in December, 1941, was the beginning of a wave of infection affecting the district for the first half of 1942. A weekly incidence of 26 in January was followed by one of 60, 108, and 118 in the succeeding months, reaching a peak of 144 in May. A sharp fall to 60 in June was followed by another drop to 26 in July, after which for this year the disease was almost non-existent in this area. In all 2,509 notifications were received. 22 School Departments were affected, six having over 100 cases and another six having between 70 and 100 cases. Two deaths were recorded as due to measles. The total number of visits paid to the homes by the health visitors was 284, while 21 children were removed to hospital. WHOOPING COUGH. The 468 notifications this year were spread over the whole of the year. The average weekly notification rate in the first quarter was 13, and for the remaining quarters, 10, 8 and 5. About half the public elementary schools escaped completely, and none suffered to any 25 great extent, the heaviest incidence being the occurrence of 22 cases spread over two months in one school. Only two other schools totalled as many as 20 cases throughout the year. Two children died from whooping cough. The number of patients suffering from this disease who were removed to hospital for treatment was 7 and the number of visits paid by the health visitors 112. NON-NOTIFIABLE INFECTIONS. Chickenpox. Intimations were received from the head teachers of absences of 924 children from public elementary schools on account of chickenpox. Most of these were from three schools where the infection started in March and lasted until June or July, the numbers of affected children in the schools being 160, 155, and 138. About the same time another school had altogether 73 cases. Most schools were involved to some extent, though most only slightly, and in general the incidence was concentrated in the months March to July, though one school had some 40 cases in the first two months of the year. Mumps. This complaint was, in all, about as prevalent as chickenpox, intimations being received of absences on account of it of 984 children. Considering the district as a whole the distribution was more evenly spread throughout the year though the occurrence in January and in the latter months of the year was due to cases at two separate schools, most of the others at these periods being relatively free. The range of infection was not so marked as in the case of chickenpox because while two schools had each of them just over 100 cases a further four had between 80 and 100 and another just over 40. German Measles. Again the incidence of this infection was very light, intimations being received in all of some 38 cases, these being reported from schools which were, at the time, being attacked by measles. Influenza. Influenza was again prevalent in the earlier months of the year, 10 of the 13 deaths from this complaint occurring some time in the first quarter of the year. 15 cases of influenzal pneumonia were notified. Scabies. VERMIN INFESTATION. The same arrangements continued in operation by which persons suffering from scabies were treated at the cleansing sections of five of the first aid posts in the district. The total number of cases, 1,701, treated, is a large increase on the number of 299 who attended for treatment in the previous year. While of those under five years of age the numbers for each sex approximated (95 male and 120 female) there was a marked difference in those of school age (285 and 472) and still greater difference in adults of whom the number of females was three times that of the males (180 and 549). 26 TUBERCULOSIS. Notifications. New Cases Deaths Primary Notification Brought to notice other than by Form A Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 — — — — — — — — — — — — 1-4 — 4 2 — — — — — — — — — 5-9 3 4 6 5 — — — — 1 1 — 1 10-14 3 4 3 2 — — — — 1 — 1 15-19 15 31 4 1 — — — — 2 8 — 1 20-24 26 35 — 3 — — — — 2 6 — — 25-34 37 42 7 6 — — — — 11 13 — 3 35-44 37 19 3 1 — — — — 16 5 — 1 45-54 21 12 — 2 — — — — 11 4 1 55-64 13 3 1 4 — — — — 14 1 — — 65 & up 8 1 1 — — — — — 3 1 — — Total 163 155 27 24 — — — — 61 40 1 7 During the year 318 (163 male and 155 female) pulmonary cases were notified, a slight fall on the figure of 349 for the previous year, but still much higher than that of 226 in 1940. The number of cases, 81 (40 and 41) of persons who transferred here suffering from the complaint is somewhat smaller than in previous years. Those cases about whom information is unobtainable or about whose position there is doubt in view of their short period of residence here numbered 73 (37 and 36). There remains the 150 (76 and 74) cases notified for the first time this 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, a figure much the same as that of 159 for last year. Of these 13 per cent, of the males, but 23 per cent, of the females, gave a close family history of tuberculous infection. The percentage age distribution of the males was : under 14, 4 ; 15-19, 11 ; 2024, 15 ; 25-29, 8 ; 30-34, 12 ; 35-39, 12 ; 40-44, 13 ; and over 45, 24. The proportion in those over 25 was not unlike those of last year, but the percentages in ages 15-19 of 11 and 20-24 of 15 differed markedly from last year's figures of 18 and 3. The percentage distribution amongst the same age-groups of the females was 12, 24, 25, 12, 15, 4, 0 and 8. 51 notifications (27 and 24) of non-pulmonary tuberculosis were received. Of these nine patients transferred here suffering from the complaint; of 10 the history is unknown, leaving 32 (16 male and 16 female) who contracted the disease while resident here. Only 2 of these gave a family history of tuberculosis. Nearly one-half suffered from bone or joint disease and in one-third the affection was in lymph glands, mostly cervical. 27 11, being about 10 per cent of the deaths of patients suffering from pulmonary disease and 3, or 60 per cent. of the deaths of patients suffering from non-pulmonary disease occurred among patients who had not been notified in this area as suffering from tuberculosis. Almost all these deaths had taken place in institutions ; in the case of some the diagnosis was made only as the result of post-mortem examination. Register. Pulmonary Non-pulmonary Male Female Male Female No. on register January 1st, 1942 459 392 79 91 No. of New Cases added 164 155 27 24 No. of cases added—other than on Form A — — — — No. of cases restored to register 2 7 1 — No. of cases removed 129 102 18 24 No. on Register December 31st, 1942 496 452 89 91 The following table is a summary of the cases removed from the register with the reasons for removal: Reasons for Removal Pulmonary Non-pulmonary Male Female Male Female Left the district 33 36 7 7 Died 74 47 1 5 Cured 15 10 6 8 Diagnosis not confirmed or withdrawn 7 9 4 4 Total 129 102 18 24 Deaths. 101 persons (61 male and 40 female) died from pulmonary tuberculosis during the year and 8 (1 male and 7 female) from non-pulmonary tuberculosis. Tuberculosis disease therefore accounted for 6.0 per cent. of the total deaths in the district. The corresponding figures for last year were 111 deaths from pulmonary and 9 deaths from non-pulmonary tuberculosis, the disease accounting for 6.7 per cent. of total deaths. 46 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 75 per cent. The numbers of deaths in each of the five years 1938 to 1942 from pulmonary tuberculosis were 68, 60, 77, 111, and 104. The corresponding, figures for non-pulmonary tuberculosis were 28, 18, 16, 9 and 5, while the proportion of total deaths caused by tuberculosis in this area in each of the years was 7.2, 5.5, 5.4, 6.7 and —. The total population at risk was not so very different in each of those years. 28 No acceptable explanation of the manner in which changes brought about by war conditions so soon affected the incidence of and death rate from tuberculosis has been offered. The most interesting attempt to account for these changes suggests that such stress of the war as overwork, food shortage and crowding, coupled with prevalence of the influenza outbreak and the hard winter exerted a selective influence on those already affected, resulting in an increased number of deaths. This increase should therefore be followed by a diminished number of deaths, partly because of the anticipation of time of death of those who succumbed and also because the death of these removed a number of spreaders of infection. On the other hand, those same conditions which hastened the disease of the declared cases would also be responsible for tipping the scale of the cases of those persons who in better surroundings and under better conditions might have successfully overcome their infection. This influence would manifest itself soonest in those who are most susceptible such as children and would be patent soonest where infection most readily gives rise to manifestations such as the meninges and the nervous system. If this is the position, then any lessening in the incidence of pulmonary infection may prove to be ephemeral as the infection is there and is merely taking that much longer to show itself. While the local figures of new infections of pulmonary disease might fit in with this hypothesis, the non-pulmonary figures do not do so. On the other hand, considering the country as a whole, it might be assumed that the country has, during this war, already experienced an initial wave of anticipated deaths in the already tuberculous and a wave of fresh meningitis infections. A secondary wave of pulmonary infections can be anticipated both because of the continuance of the conditions of stress and secondarily because any increase in the number of pulmonary infections increases the number of spreaders of infection. MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,268 ; 1,655 male and 1,613 female. Of these 134 were illegitimate, being a percentage of total births of 4.1. 2,317 births occurred in the district (2,288 live and 29 still births). Of this number 403 (399 live and four still births) were to residents of other districts. Of the local confinements, 2,204 were notified by midwives and 113 by doctors or parents. 1,229 (1,189 live and 40 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. 39 male and 42 female still births were registered, being a rate per 1,000 population of — compared with a figure of 0.54 for the country as a whole. 29 Of the 29 cases of whom particulars are known, in 18 delivery was premature, the reason in 12 being toxaemia and in 3 ante-partum haemorrhage. In 9 instances the infant was alive up to the onset of delivery at term, the death of seven being due to difficulties in labour. 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, 1939 to 1942. Table I. 1939 1940 1941 1942 No. of Live Births 3320 2999 2712 3268 No of Deaths of Infants— Under 24 hours 19 18 16 27 1 to 7 days 36 35 28 25 1 to 4 weeks 14 41 31 14 2 to 3 months 28 23 28 19 3 to 6 months 12 14 20 6 6 to 9 months 10 12 17 9 9 to 12 months 4 6 11 3 Total 128 150 151 103 Infant Mortality Rate 38.5 50.0 55.6 31.5 Neonatal Rate 20.8 31.1 28.0 20.2 No. of Deaths of Children aged One year 8 7 14 13 Two years 6 8 8 1 Three years 4 6 3 5 Four years 4 1 2 3 INFANT MORTALITY. 103 (59 male and 44 female) infants died under one year of age, constituting an infant mortality rate of 31.5. 66 failed to survive one month. The neonatal mortality rate was therefore 20.2 constituting 66 per cent. of the total infant mortality rate. Of these 66, 27 failed to survive the 24 hours, the cause of death in 16 being prematurity, in 3 abnormality and in 7 atelectasis. 25 deaths occurred in infants who survived 24 hours, but failed to survive 7 days. Prematurity was responsible for 14 of these, birth injury for 5, and developmental abnormalities 4. Of the 14 infants who survived one week but succumbed before the end of the first month, in 4 the cause was prematurity, in 1 birth injury, in 6 developmental abnormalities or atelectasis. Infections accounted for only one death. Of the 19 deaths amongst those of 1 to 3 months, 4 were due to developmental abnormalities and 4 to prematurity; respiratory complaints accounted for 7 and gastro-enteritis 2. 30 Infections accounted for most of the 18 deaths of those between 3 and 12 months, of which respiratory complaints were the cause in 6, gastro-enteritis in 4, and meningitis in 1. Deaths in infants over one month old are largely due to the infections. Much of the reduction in the infant mortality rate which has occurred in this century is due to the improvement in hygiene, either outside or more particularly inside the home. On the other hand, those deaths occurring under one month are due to a variety of causes, some arising from some failure of intra-uterine development, some due to difficulties arising from the birth itself and others due to a failure of adaptation to the new surroundings. The underlying causes for the first group are probably related to and associated with those unknown factors which are responsible for premature delivery, or, in still earlier stages for miscarriages, and may be found to be due to such influences as endocrine imbalance or vitamin deficiency. The reduction in the next group can be achieved by better midwifery, including in this not only the standard of midwifery and nursing care but sound ante-natal hygiene and the conduct of the confinement in good surroundings. Many deaths, though, occur amongst those who have survived the shock of birth itself but fail to live for one week, and a similar number fail to survive the rest of the month. Under existing practice the mother confined at home has the attention of the midwife for some 14 days which is a comparatively recent extension on the previous period of ten days. If a home help is available she attends for the same period, after which time these helps are withdrawn and the mother so soon after her ordeal is expected to manage, as before, her household together with the added burden of affording the extra care and attention to the very young baby. It is just at this time that difficulties in the feeding of the baby arise. There is much to be said for provision being made for the services of the home help to be available for one month after the birth of the baby so as to smooth the difficulties with which the mother has to contend, probably with beneficial results in the matter of breast feeding of the infant, and to enable her to devote more of her time to the child in those most critical days. In the same way it would probably be of advantage if a change in attendants were deferred. It is customary for the health visitor to call as soon as possible after the midwife has ceased her visits to the mother. Even where her visit can be paid at the earliest date it is rarely possible for the health visitor as a routine to pay many more early calls, having to limit such visits to such special cases as need her attention. It would be of advantage for the midwife to undertake these earlier duties of the health visitor, at least in regard to her own patients, continuing to attend them for a month, by which time their supervision would pass into the hands of the health visitor. Such practice probably would not seriously reduce the number of cases which the midwife would be enabled to attend. Not so many years ago when the infant mortality rate was in the region of 120, the irreducible minimum was assumed to be a figure of about 40. To-day, when figures of under 30 have been reached it is not accepted that there is any limit and what remains is referred to rather as the hard core of resistance. Undoubtedly though the law of diminishing returns will operate and any future successes will be far more difficult 31 to achieve and will be that much the less spectacular. Success, too, will probably follow only the results of efforts aimed specifically at the object. While no doubt much of the reduction of the infant mortality rate already achieved in this century is due to the efforts of local authorities and their staffs in the operation of the extensive maternity and child welfare services, part of the decline is undoubtedly part and parcel of the general improvement in the health standards of the community. It is an interesting speculation as to what extent these improvements would have occurred without the operation of specific measures. In the case of what is now left of infant mortality, though, anything from one-half to three-quarters of the loss of infants is due to prematurity. Premature expulsion of the foetus may be brought about by a variety of causes, some accidental, others purposive in that the uterus is expelling a waste product. That, no doubt, is what occurs in a number of instances when the infant is deformed. Feeding experiments indicate that nutrition may be a factor of importance, though probably, because of the parasitic state of the foetus, not one of major importance, and probably whatever influence there is is due to a shortage of some specific factor or factors rather than to a general shortage of calorie value. If all these lives could be saved, though, it would effect in itself nothing like the reduction in mortality or, conversely, the saving of life as remains possible in another field. The average figure of the incidence of stillbirths is one of 3 per cent of the viable births. It has been calculated that there are four abortions for every stillbirth, this giving a figure of 12 abortions per 100 viable births or a total ante-natal mortality of 150 per 1,000 live births. The factors causing these losses may prove to be those which account later on for premature births and there is a vast field here for exploration as to the causative factors. To-day at last the nation is waking up to an appreciation of the significance of the declining birth rate. Many are the reasons proffered as the explanation of the falling rate and widely differing remedies have been suggested for improving the condition. There are, however, many instances where pregnancy has already been achieved but has not resulted in a viable infant. Possibly related in some cases is the subject of sterility, more particularly where the reason for the failure to produce an infant is not the failure to achieve pregnancy but is the result of a very early expulsion of the developing foetus. Absence or shortage of Vitamin E. appears to have some relation to the sterility of rats. It may be that some such factor might be found to be one of importance in the expulsion from the uterus of the products of conception at any stage of development. MORTALITY AMONGST CHILDREN of 1 to 5 years of age. Infections caused 10 of the 13 deaths amongst children of one year of age, pneumonia being responsible for six and specific infections the other four. Two deaths were accidental, as was also the single death amongst children of two years of age, and two of the 5 deaths of those of three years of age. Specific infections were responsible for two of the other deaths of this age, and for two of the 3 fatalities amongst those of four years of age. Diphtheria was the cause of death of one child aged one, one aged 3 and one aged 4. Tuberculosis this year was responsible for none. 32 INFANT MORBIDITY. Ophthalmia Neonatorum. Five cases of ophthalmia neonatorum were notified, three occurring amongst infants born in nursing homes. Two of these children were removed to hospital for treatment. All made complete recovery. Pemphigus. Two cases of pemphigus were notified, one being sufficiently severe to require admission to hospital for treatment. MATERNAL MORTALITY. Five deaths occurred from or were associated with pregnancy, giving a maternal mortality rate per thousand live births of 1.50 comprised of a rate of 0.60 for puerperal sepsis and 0.90 for other puerperal causes. The first patient was admitted to hospital in labour with severe pregnancy toxaemia and distocia due to irregular uterine action with an associated contraction ring. Intra-uterine death of the foetus occurred and caesarean section was necessary because of the deteriorating condition of the patient, but death took place soon afterwards. The second patient who had received full ante-natal supervision, was surgically induced about term because of a slight contraction of the pelvis; later, forceps delivery of a macerated foetus was followed by uterine sepsis which led to a generalised infection which proved fatal a month later. The third patient who had been admitted to hospital for trial of labour proved to need caesarean section; recovery was uneventful for 48 hours when she developed paralytic ileus. The fourth fatality occurred in a patient whose premature labour at the 30th week was probably caused by a ruptured pyosalpinx. The remaining death was due to an embolism in a patient while being subjected to surgical induction of labour. PUERPERAL INFECTION. 24 notifications of puerperal pyrexia were received, two relating to women who had been confined in London hospitals. The remaining cases were divided equally between those who were confined in their own homes and those delivered in local maternity homes. One quarter were probably cases of uterine infection, operative interference for adherent placenta having been necessary in one half; while one case was of an abortion. In a further quarter the raised temperature was probably due to infection of the perineal tear and two to phlegmasia alba dolens. In three the cause of the pyrexia was considered to be pyelitis, while in a further three the raised temperature was thought to be other non-uterine causes. 17 patients were admitted to hospital for treatment, the remainder of the local cases being nursed at home. 12 cases were passed to the District Nursing Association for treatment. 33 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 1,160 Total visits 1,648 (b) To children under one year of age First visits 2,921 Total visits 7,725 (c) To children between the ages of one and five years Total visits 14,815 In addition visits were paid to 284 cases of measles and 112 cases of whooping cough in children under 5 years of age. INFANT WELFARE CENTRES. The following table shows the work done at the Infant Welfare Centres during the year: Total attendances at all Centres: (1) By children under one year of age 43,818 (2) By children between the ages of one and five years 20,161 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 2,807 (2) Between the ages of one and five years 481 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 2,489 (2) Over one year of age 6,516 Attendances: The average weekly attendances at the infant welfare centres for 1912 was 1,296, a figure almost identical with that of 1,295 in the previous year. This was the average of a range from the figure of 983 in January to one of 1,479 in September and is well below the pre-war attendances which, in the summer of 1939 reached an average of nearly 1,900. Vitamin Preparations: From January, 1942, arrangements had been made for the issue from most of the clinics of the free supply of vitamin preparations to children under two years of age. In February the age for free issue of Cod Liver Oil was raised to five years. From April 1st, while the ages of the children entitled to the issues remained the same, a charge was made to those above a certain income limit. In July the age of children entitled to fruit juices was raised to three years. In December expectant mothers were entitled to the issue so that from that date children under five and expectant mothers in the last six months of pregnancy were entitled to the issue free or at a charge of Cod Liver Oil and of fruit juices. 34 TREATMENT. The following particulars show the extent to which the facilities for treatment are used. Dental treatment: 251 children under five years of age and 686 expectant or nursing mothers made 937 attendances for treatment. Physio-therapeutic clinic: 357 new cases were referred to the clinic. The total number of attendances by patients was 3,704 (986 massage, 2,718 electrotherapeutic), 54 patients were seen by consultant orthopaedic surgeon and 540 were seen by the consultant physiotherapist. Correction of visual defects: 109 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: 15 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 13 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 91 Number of persons registered during the year 45 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.) 40 Number of persons on the register who were receiving children for reward at the end of the year 82 Number of children on the register at the beginning of the year 149 Number of children received during the year 127 Number of children removed from the register during the year 150 Removed to care of parents 84 Removed to care of another foster-mother 17 Legally adopted by foster-parent 4 Removed to charitable organisation, etc. 8 Removed to hospital 2 Foster-parent left the district taking the child with her 1 Child attained the age of nine years 8 Died 1 126 Number of children on the register at the end of the year 35 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,648 visits to expectant mothers, 1,160 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 2,765 Total number of attendances by expectant mothers at all clinics 12,720 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 82 Consultant Ante-natal Clinic. The consultant ante-natal clinic was held fortnightly throughout the year. During the year 324 women made 524 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, 14 patients being seen. Of this number, only one was an insured patient. Two women attended for post-natal examination. ARRANGEMENTS MADE FOR CONFINEMENTS. At Home. 1,188 confinements took place in the patients' own homes. Of these 894 were attended by midwives acting in their capacity as midwives, and 294 by local midwives who had given notice of their intention to practice, acting as maternity nurses. Consultant Service. During the year the consultant was summoned to five patients, three of whom were in labour, one being subsequently admitted to hospital under the care of the consultant. The other two patients were suffering from puerperal pyrexia. Arrangements were made during the year by which local practitioners could obtain the assistance not only of the Council's Consultant but also of the obstetric staff attached to the Redhill County Hospital. Daily Minder Scheme. Though publicity had been given at the end of 1941 to the daily minder scheme no real advantage was taken of it. Towards the end of last year the full scheme under which a guardian was to be subsidised to the extent of 4s. per week was introduced. Up to the end of the year very little action had been taken under it though it had been felt 36 that possibly it would prove of advantage in areas where the demand for the care of children did not warrant opening a nursery and it had been hoped that it would have provided evidence of the extent of the demand for nursery accommodation in different parts of the district. In an Institution. 1,007 births occurred in registered nursing homes in this district. 399 births to mothers from outside districts, which occurred here took place in nursing homes, 4 in private houses. Of these 1,007 confinements 113 were conducted by local practitioners. Notifications were received of 1,229 births to Harrow mothers having taken place outside the district. Of these 1,068 were from hospitals and 121 from nursing homes. Of the patients confined in hospital outside the district 603 were delivered at Redhill County Hospital and 315 at Bushey Maternity Hospital. Of a total of 3,143 births, 1,306 occurred in the patient's own homes, 608 in local nursing homes and 1,229 in hospitals or homes outside the district. Some 1,837 or 58 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year 16 patients were admitted to a London hospital under the Council's arrangements. POST-NATAL SERVICES. Post-natal Examination. 137 women attended the clinic for post-natal examination, making altogether 155 attendances. Puerperal Infection. (a) Consultant services: The consultant was summoned to two patients suffering from puerperal pyrexia. (b) Hospital services: Any cases of puerperal infection requiring hospital treatment are removed to the London County Council Northwestern Hospital. During the year 17 patients were removed. (c) Home nursing: 12 patients were 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. 177 women, of whom 93 attended for the first time, made a total of 319 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 42. Of these 6 removed from the district and discontinued practice, leaving 36 in practice at the end of the year. Of the total number 23 were resident in the district and carried on a domiciliary practice almost entirely limited to this area, 11 were engaged in local maternity homes, most of them entirely, though a 37 few also carrying on a very limited domiciliary practice; and 8 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 1,541. In 988 cases the midwife was in attendance as a midwife and in the remaining 553 as a maternity nurse. Of the confinements occurring in private houses in the district, 1,152 were attended by local midwives whose practice is limited to domiciliary work (866 as midwives and 286 maternity nurses) and 36 by midwives from adjoining areas (28 as midwives and 8 as maternity nurses). At the end of the year there were in practice 5 independent midwives carrying on a domiciliary service, these between them attending 69 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 327 Still birth 7 Death of Infant 10 Death of Mother — Laying out the Dead 1 Artificial Feeding 8 Liability to be a Source of Infection 33 Of the 327 summonses to medical practitioners, 43 were on account of some condition during pregnancy, 61 during labour, 159 in the lying-in period, and 56 some abnormality of the infant. Of the 43 summonses to a patient during pregnancy 21 were because of albuminuria, oedema, or toxaemia, and 12 because of haemorrhage. Of the 69 summonses to a patient during labour the reason given in 43 instances was delayed labour with cause unspecified. In a further 9 there was some abnormal presentation. Eight summonses were to patients suffering from abortion (actual or threatened). 122 of the 159 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 11, a raised temperature in 14, phlebitis 7, and inflamed breast 2. Of the 56 summonses to infants, 19 were on account of some discharge from the eye, 19 because of feebleness or asphyxia and 18 some other abnormal state or condition. 327 out of 988 midwifery cases attended is a percentage rate of 33-1; the corresponding figure in 1941 was 35.5. MIDWIFERY SERVICES. The number of patients attended by Council's midwives was 850 in which they acted as midwives and 232 in which they acted as maternity nurses, a total of 1,082. 38 Of the patients attended by midwives acting as midwives, 323 were assessed to pay the full amount, in 162 cases no charge was made, while 365 were assisted. The corresponding figures in regard to patients attended by midwives acting as maternity nurses were 178, 29 and 25. The average number of cases attended by each midwife was 67.5. Analgesia by Midwives. Consideration was again given to this subject, with the object of more especially arranging that facilities might be put at the disposal of those mothers attended by the Council's midwives. Towards the end of the year the Central Midwives Board amended their rules with regard to the qualifications of the second person who was required to be present when the analgesic was being administered. In spite, though, of the broadened basis of qualification it did not appear that there could be available during war-time a supply of suitably qualified persons. Because of the difficulties of putting into force such arrangements it was decided that " in view of circumstances of the war consideration of this matter be deferred until after the cessation of hostilities." Home Helps. The attraction of the greater financial rewards of industry, recruitment to the Services, and the competing demand of those requiring assistance and who offer larger wages have resulted in its being increasingly difficult to maintain on the Council's panel of helps sufficient to meet all demands. Consideration was given to the question of the methods by which more persons might be made available. It was felt that the suggestion in the Ministry of Health Circular 2729 of the appointment of full-time home helps so far from alleviating might even aggravate the position in that the knowledge that a number had been appointed to undertake full-time work might result in those who are engaged actually removing their names from the panel and so reducing the available pool. Difficulties in administration without there being any obvious advantages in the payment of the retaining fee, left, as a means of retaining those on the existing list, and even the hope of adding the names of others, only the method of an increase in the remuneration of those actually engaged. It was therefore decided to increase the rate from the previous 5s. to 7s. 6d. a day. (P.H. Committee, 22/4/43.) It was formerly the practice of the Council not to accept as a home help who would be paid by them one who was a near relative of the patient. Owing to the greater extent to which women are now gainfully occupied such a condition would result in the relative suffering pecuniary loss if she acted as home help. In such circumstances their payment is now approved. WAR NURSERIES. Spencer Road nursery opened in February, and in July nurseries were opened at Walton Avenue, South Harrow, Buckingham Road, Edgware, and Kenmore Road, Kenton. It was decided that in selecting children for admission preference should be given to those of mothers 39 in full-time employment and to such children where the admission of the one released the mother to undertake war work. All four nurseries have been filled with children in these categories. There has been all the time a substantial waiting list of children with such qualifications for admission to the Wealdstone nursery. Negotiations were entered into with the authorities maintaining the nursery school on the Tyneholme site with the object of agreeing to some combined arrangement, but these fell through. In July representations were made for approval of the erection of a war nursery on the Tyneholme site separate and distinct from the nursery school. This proposal was agreed to. At this time the only substantial waiting list at any of the other nurseries was that at South Harrow. Here it seemed that the situation might be met by extending the nursery to take in some twenty more children. Such an arrangement too, would provide a third section at this nursery which, from an administrative point of view is so much more convenient than the two-section nursery. This proposal also was agreed to. Representations had been made that there was an urgent demand in the Edgware district and the possibility of erecting a nursery at Vancouver Road was considered. As the demand for admission to the Buckingham Road nursery, however, was little more than the accommodation no further steps were taken. In the same way though there were advocates for a nursery in North Harrow no one could produce any definite evidence of the need. The position at the end of the year then was that while the Kenmore Road nursery and the Buckingham Road nursery were meeting the demand of the one child per family of the whole-time worker, it was felt that the demand for admission to Spencer Road nursery would be relieved by the erection of a new nursery in Headstone Drive, while the waiting list of admission to the South Harrow nursery would be reduced to negligible proportions by the extra accommodation offered by the extension at that nursery. At one period measles attacked practically all those attending the Kenmore nursery and for a time reduced the attendances to very small numbers. South' Harrow nursery was affected less intensely though over a longer period, so that by the end a very large number of children had succumbed. The average week-day attendances at the nurseries excluding Saturdays are set out, with the available accommodation in brackets: Spencer Road Nursery, 44 (49); South Harrow Nursery, 32.5 (40); Buckingham Road Nursery, 28 (40); and Kenmore Road Nursery, 33 (40). With the object of reducing some of the possible causes of absence of children from the nurseries it was agreed that admission to them of any children should be conditional on the parent agreeing to the child being inoculated against diphtheria and against whooping cough. With the general increase in the provision of these nurseries throughout the country, it can be anticipated difficulties will be met in obtaining the necessary staff. Already in this area the standard has had to be lowered as it proved impossible to find teachers. It would seem, then, that consideration might well be given to the question of limiting the ages of the children to be cared for to the years 2 to 5. The under-twos demand more attention from the staff so that any staff available could 40 look after the larger number of children if the younger ones were not admitted. From an administrative point of view there would be an advantage in such an arrangement as less interference would be caused on the occurrence of infections amongst the children. There would not be the same necessity to bar the admission of a child over two to a nursery in which measles had appeared as there would be in the case of those of under two years of age.