AC 439 (3) AARROW HARR 10 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1943 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 1943 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 1943. The health of the district during the year was again most satisfactory, even though some of the rates were not as low as in the previous year, notably the infant mortality rate which rose from 31.5 to 38.0 (a figure which nevertheless compared very favourably with the national rate of 48.0) and the maternal mortality rate which rose from the exceptionally low level of 1.50 in 1942 to 2.57, a figure which, most unusually, was slightly higher than the rate for the country as a whole. The birth rate figure at 18.2 is the highest recorded for this district, while the death rate at 9.1 remained the same as the average for the war years. The incidence of scarlet fever showed a further increase but as the distribution was fairly even throughout the year with no epidemic prevalence, no difficulty was experienced in arranging admission to hospital of all patients whose removal was requested. The severity of the illness was again of the slightest. Diphtheria incidence remained at its usual low level. There was a further fall in the figures of cerebrospinal fever and of dysentery, two diseases which have been more common during the war than in the pre-war years ; while the number of cases of tuberculosis was a further decline on the figures for the previous years. There was a minor prevalence of influenza in the earlier months of the year, but nothing compared with the epidemic incidence to which this district, in common with the rest of the country, was subjected in the last few weeks of the year. This infection was the outstanding cause of death at that time, particularly amongst the elderly. The maternity and child welfare services have been maintained with little change. The increase in the number of births to an average of seventy per week, or another five babies every week added to those for whose supervision each health visitor is responsible, indicates perhaps the need for a substantial increase in the health visiting staff, more especially as their duties are so steadily embracing so very much more than the advice to the mother on the care of her baby, or even on the care of children up to five years of age. The future of the health visitor as a general family advisor must soon force a decision as to whether her training with its disproportionate amount of time spent in hospital will not have to be radically amended so that, without increasing the total time in training, substantially more can be devoted to the sociological and educative aspects of her work. Public health rests so largely on environmental hygiene and on health education, and health education so very largely is the responsibility of the health visitor. Three more nurseries were opened during the year, and in general 3 it could be felt by the end of the year that except for a part of Kenton the demand was being adequately met. The routine work of the sanitary department continued. In the earlier part of the year we lost the services of Mr. P. Schofield who, prior to amalgamation, had been Sanitary Inspector to the Wealdstone Urban District, and, at the end of the year, Mr. J. E. Johnson, who had occupied a similar post in the Hendon Rural District. In addition to their other qualities both these inspectors possessed an intimate knowledge of the district, a factor of inestimable value to a sanitary inspector and the loss of these officers will be keenly felt. Reference is made in the body of the Report to certain conditions arising out of the war which add to the labours of the sanitary inspectors in their efforts to abate sanitary nuisances to which householders are subjected, and to the transference to this Council of the powers and duties of the County Council under the Rats and Mice (Destruction) Act, a change which will add so substantially to the work undertaken by the sanitary inspectors as will necessitate later a considerable increase in their numbers. While war conditions continue to prevent its being possible to take steps after routine housing inspections so that these remain in abeyance, a preliminary survey has been undertaken to try to ascertain the requirements of new housing to replace that which should be condemned as being unfit for human habitation. The standard on which ultimate judgment is made will of course depend to some extent on the availability of alternative accommodation. The number in the category of houses which will need more urgent consideration is about a hundred, these being properties which it is felt will with some urgency become the subject of Demolition or Clearance Orders ; while there are another 630 which will need to be considered from this aspect. A number of White Papers have been published during the year which, if the proposals are implemented, will affect the local health services. The three most closely affecting these, namely, those on Education, on the Health Services, and on Milk Control all point the same way—to the curtailing of the powers of the smaller local authorities by their transference to County Councils, to bodies larger than County Councils or even to Central Departments. These changes probably make' for ultimate benefit; certainly no local government administration if started entirely afresh would be based on arrangements quite so seemingly haphazard and apparently administratively untidy as those which are in being—but which work—today. Less concern then might be felt for the remote than for the immediate future. It seems that long before its achievement in 1934 much had been heard of the amalgamation of neighbouring districts. With the prospect of extinction or at least of absorption before them, it is inevitable that authorities will be less progressive, and more facilities might have been available for the inhabitants of the three constituent districts by 1934 had the possibility of amalgamation not acted as a curb. In the same way much annoyance was suffered by local residents because before the sewage of the district could be dealt with by the West Middlesex Drainage Scheme, the local facilities for sewage disposal had been taxed to their utmost—and beyond. Will the possibility that the proposals of the White Paper on the Health 4 Services might ultimately be adopted curtail immediate post-war progress ? The district badly needs premises in which the maternity and child welfare clinics can be held ; the unsatisfactoriness for this purpose of the buildings which have to be used in default of our possessing these adds considerably to the difficulties of the staff, and must seriously impair the quality of the work undertaken there. The Health Centres of the White Paper, though at present in a very nebulous state, are probably to be buildings of very different design. Is the fact that sometime or other a number of these buildings may have to be erected in the district, and if erected are conceived to abolish the work done at the infant and ante-natal clinics, to prevent the erection of those other buildings which are so badly needed ? Then there is the case of the Isolation Hospital—the existing institutions are admittedly far from ideal. If the future infectious cases in the district are to be admitted not to a new isolation hospital to be erected by the Council but to some other institution—either because of the desirability of having institutions of a certain minimal size or because of the administration of the isolation hospital service by the Joint Boards—then it is desirable that the decision should be taken early, and even though it might mean the closing of the local hospitals administered by the local council, this step should be taken, rather than indefinitely continue to provide a service which might not be of the best. As to the effect on the local health services of the three White Papers, the proposals most advanced are those relating to education. Whatever the advantages of the administration of education being in the hands of larger authorities, the general effect here in regard to health services is that there is the possibility of the school medical service being administered by the same staff as that dealing with maternity and child welfare, a most desirable arrangement. Much is heard at times about continuity of treatment, but the real advantage of the linking lies not so much in the fact that the same medical officers are dealing with the children in both groups so that they see at school those whom they knew at the clinics, but in that the health visitor will embrace in her activities the school child whose home she already visits for those of under five years of age. As to the existing health activities of the Council, the proposals of the White Paper on the Health Services leave alone the environmental services provided by the Council as the local Sanitary Authority, excepting, of course, the responsibility for the treatment of the infectious sick. The Council will presumably continue to administer the maternity and child welfare services for which it is at present responsible—but as the agent for the County Council. In these circumstances the real test of responsibility and therefore of interest will lie in the degree of delegation. The proposals in regard to the supervision of milk production are again very logical and administratively tidy. In an urban district such as this in which even the years since amalgamation have seen further reductions in the amount of milk produced locally, this duty is only one of those undertaken by the sanitary inspectors ; and the loss of these duties will only very slightly affect the volume of their work, though they as a body perhaps do not view with favour any restricting and curtailing of the very wide field of their activities. In milk producing counties though, the 5 control of milk production might take up a substantial part of the time of the sanitary inspectors, and probably would take up the same proportion of time of many more were they appointed. The case for the transference of powers and duties seems to rest on the fact that veterinary inspectors already by their present duties must visit the farms, undertaking a duty which only they can perform. Less would be feared from the proposals if it could be felt that these activities would be carried out by the veterinary surgeons ; but it is extremely doubtful if there is this staff available, so that the fear is that from the first it will be necessary for much of the work to be undertaken by assistants to the veterinary surgeons, people who, there is no reason to suppose, can carry out the work any more efficiently than the existing service provided by the sanitary inspector. Another ground for concern is that the veterinaryprofession quite rightly will look on the disease of cattle in relation to the animal or the herd ; however desirable this outlook may be, it should not be overlooked that those same animal diseases are capable of transmission to man. The adoption throughout the country of uniform conditions of service for nurses of many grades and of midwives by the application of the Rushcliffe Report, the recommendations of the Hetherington report in regard to domestic staff at institutions and probably similar provisions for other members on the staffs of local authorities will go far to smooth the introduction of arrangements which involve the transfer of staffs from one to another local authority. The general raising of the salaries of midwives is another step towards the creation of a profession in which the general conditions of service will be sufficiently attractive to recruit sufficient of a class and enable the training to be long enough for the midwife of the future to be looked on as the natural attendant of the woman in labour, one whose qualities and qualifications will be such that much for which today she has to summon to her aid a medical practitioner, she will be permitted to undertake. One striking disadvantage of today's arrangements with its time off and week-end break of the midwife is that so frequently a mother is not only not able to have at her confinement the midwife she chooses but that she may altogether during the fourteen days have the services of as many as four midwives. It is not suggested that the service provided by each is not good, but it is to be imagined that many a mother would look back with regret to the day when she could book a midwife, knowing she would have her services during the labour and also have her for the subsequent nursing. Medical service is just as personal as midwifery, even more so, and it is hoped that what is happening in the midwifery service need not be accepted as an augury of what will happen if the proposals of the White Paper are adopted. The war has been responsible for the introduction of a number of changes in administration of the different services, some brought about by the necessity for seeing that in times of shortage of essentials, those who need it most obtain it first ; some introduced to conserve man-power, transport, etc., while others again formulated on premises that the progress of the war would be different from what has actually happened. Some of these arrangements, or something resembling them, have been 6 advocated on other grounds, and the better of these provisions should not be allowed to lapse at the end of the war. Today's arrangements for ensuring that rising prices of essential food stuffs do not put these beyond the reach of the less affluent, the issue of milk free or at 2d. a pint, the distribution of vitamins—all measures to ensure an adequate minimal dietary for all, are instances of what should continue. Centralisation of slaughter-houses, though selected in the future on considerations of hygiene rather than of transport, with the consequent abolition of the many small inconveniently sited slaughter-houses, should be insisted upon. The retention of the laboratory services, though based more on the groupings of epidemiologically similar areas rather than the hospital sectors, with the close association of the medical head of the laboratory with the general medical practitioner and public health staff is most desirable. For the day nurseries—no longer war nurseries, and, .presumably then no longer a matter of such interest to the Ministry of Labour or even perhaps to the Ministry of Health—there will continue to be a demand, at least for a time, though probably not on the present scale. These are matters though for national decision. There are other problems which, at the end of hostilities when presumably there will not be the same hold on people, will face local authorities. Today the public health ambulances are manned by civil defence personnel; the treatment of scabies at the First-Aid Posts—and 2,000 odd patients required treatment last year—is undertaken also by the civil defence personnel; while many of the staff of the war nurseries are there only because, if not there, they would be directed elsewhere. Possibly circumstances will be such that for long those at present undertaking these duties will be willing to continue, though on a different basis ; if not, it is to be hoped that authorities will be enabled to obtain the necessary personnel. The Ministry of Health have requested again that for reasons of national security the population figures should not be included in these annual reports. 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 2nd, 1944. 7 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1943 - Rateable Value (April 1st, 1913) £2,110,615 Sum represented by a penny rate (April 1st, 1943) £8,399 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Legitimate 3,350 1,731 1,619 Birth rate per 1,000 of the estimated resident population, Illegitimate 150 84 66 J Stillbirths:— Legitimate 95 52 43 Rate per 1,000 total (live and still) births, Illegitimate 6 4 2 2.4 Deaths 1,749 823 926 Death rate per 1,000 of the estimated resident population, Rate per 1,000 Deaths from puerperal causes :— total (live and still) births Deaths Puerperal sepsis 4 1.14 Other puerperal causes 5 1.43 Total 9 2.57 Death rate of Infants under one year of age:— All infants per 1,000 live births 38.0 Legitimate infants per 1,000 legitimate live births 36.4 Illegitimate infants per 1,000 illegitimate live births 70.3 Deaths from Cancer (all ages) 278 ,, ,, Measles (all ages) 1 „ „ Whooping Cough (all ages) 3 ,, ,, Diarrhœa (under 2 years of age) 20 Population. The Registrar General's estimate of the 1943 mid-year population is a still further decline on the previous year's figure, which itself was smaller than that for 1941. The occupation of premises by more than one family is much more general than ever it was before the war, so it is to be assumed that the increase in population brought about by the entry into the district of these new families is not sufficient to outweigh the losses by so many families contributing one or more of their members to the Services. The movement of population, as indicated by the number of children under six years of age who move into and out of the district each week is still quite considerable, though an appreciable decline on what occurred 8 in the previous year, the average weekly number coming in 1943 being 40 as compared with 50 in 1942, and going out 34 as contrasted with 42 for the previous year. Births. 3,500 live births is the greatest number which have occurred to women in this district, being a rate per thousand of the estimated population of —, a rate appreciably higher than any previously recorded for this district. The average rate in the five years 1935 to 1939 was 17.7, the range varying from 17.5 to 17.9. In 1940 there was a fall, followed by a still sharper decline in 1941, but a return in the next year to the 1940 level, the average for these three years being 15.6. Deaths. Of the 996 deaths in the district, 88 occurred among non-residents. As there were 841 inward transfer deaths, the total number of deaths of residents was 1,749, a figure comparable to that of 1,818 in 1943. Of the 88 outward transfer deaths, 16 took place at the Orthopaedic Hospital, 12 at the Harrow and Wealdstone Hospital, 17 in Nursing Homes and 24 in private houses. Of the 841 deaths of local residents which occurred outside the area, most took place in institutions, 382 being at Redhill Hospital, 75 at Redhill House and 70 (including 5 new-born infants) at other County Hospitals. Eleven deaths occurred at institutions for the treatment of tuberculosis and 27 at Shenley Hospital. 88 deaths took place in hospitals just outside the district and 94 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 1 Heart disease 195 203 Cerebro-spinal fever 2 0 Other circ. diseases 28 33 Scarlet fever 0 0 Bronchitis 45 45 Whooping cough 2 1 Pneumonia 58 68 Diphtheria 0 1 Other res. diseases 13 17 Resp. tuberculosis 55 28 Ulcer of stomach 20 6 Other tuberculosis 8 5 Diarrhoea under 2 years 9 11 Syphilitic diseases 11 9 Appendicitis 3 6 Influenza 16 35 Other digestive diseases 19 22 Measles 0 1 Nephritis 17 12 Acute polio-myelitis 0 0 Puerperal sepsis — 4 Acute encephalitis 0 0 Other maternal causes — 5 Cancer of mouth and oesophagus (M), and uterus (F) 10 16 Premature birth 13 18 Cong. malformations, etc 31 18 Cancer of stomach 18 14 Suicide 6 6 Cancer of breast — 31 Road traffic accidents 9 1 Cancer of other sites 91 98 Other violent causes 18 17 Diabetes 4 4 All other causes 64 66 Intra.-cran. lesions 60 120 All causes 823 926 9 1,749 deaths in a population of — is a death rate of —. The rate for the six pre-war years was a fairly steady average of 7.6; there was a sharp rise in 1940 to 9.1 which remained the average of the three years 1940 to 1942. The total deaths, 823 male and 926 female, is a decline on the previous year's figure, the deaths amongst males being 99 fewer, though those amongst females 30 more. This increase in the number of female deaths is almost entirely accounted for by the greater number amongst women from influenza, 35 as against 8 in the previous year. Associated with these were the increases due to respiratory diseases, 130 as against 79, which outweighed the saving of 34 in deaths due to heart disease, 203 as against 237. Amongst males influenza was not responsible for so great a rise, only 16 as against 6, while there was no increase in the number of deaths from respiratory diseases. The decline of 99 was made up by a saving of 19 in deaths due to cancer, and 51 to intracranial lesions, heart and other circulatory diseases. The 51 deaths from influenza as contrasted with only 14 in the previous year was due to a number of fatalities occurring, more particularly amongst the aged, from the outbreak of influenza which affected this district as it did the whole country towards the end of the year. Infantile diarrhoea after falling in 1942 was responsible for a greater number of deaths again, 20 as against 8. It was pointed out last year that 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. The position was the same in 1943, and it can even be recorded that there is a further improvement in the case of tuberculosis, as although the number of deaths from non-pulmonary tuberculosis rose from 8 to 13 the number from pulmonary tuberculosis showed a decline from 101 to 83. Fatalities from the infectious diseases expressed as a rate per thousand population again compared favourably with figures for the country as a whole, the rates for whooping cough — , diphtheria —, measles , and influenza — , being lower than the corresponding national rates of 0.03, 0.03, 0.02 and 0.37. The death-rate from infantile diarrhoea of — per thousand live births is slightly higher than the national rate. Of the deaths of males 50 per cent occurred in those of over 65 years of age. In 1938 the corresponding figure was 40.3, in 1941, 42.1 and in 1942, 46.4. The greater expectation of life amongst females is shown by the fact that 56.3 of the total deaths amongst women occurred amongst those of over 65, the corresponding figures for the years 1938, 1941, and 1942 being 46.5, 53.0 and 56.8. GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. CLINICS AND TREATMENT CENTRES. The only changes in the clinic sessions during the year were the holding from January 21st of an additional ante-natal session in North Harrow, and from April of an additional monthly attendance of the 10 consultant gynaecologist at the consultant ante-natal clinic. At the end of the year then, 24 infant welfare clinics were being held in 12 premises, 14 ante-natal clinics (two fortnightly, the remainder weekly) at 12 addresses, and the equivalent of five weekly toddlers' sessions at 8 premises. Consideration was given to the programme for the erection of clinic buildings and, where necessary, approaches were made to other interested parties. AMBULANCE FACILITIES. From early in the year the ambulances which, up to this, had been accommodated at the Fire Stations of the district, have been housed at Ruffles Garage, Wealdstone, which became the ambulance station for the public health ambulances, the vehicles being manned by the civil defence personnel attached to C.15 ambulance depot. Of the five vehicles in the fleet, one was worn out and a decision was taken in September to purchase a new ambulance. Owing to difficulty in obtaining the help of midwives or maternity nurses to accompany maternity cases removed, it was decided that the rule by which such cases should be accompanied by midwives be relaxed for the time being, it being understood that it should be adhered to where possible, and that where the rule is departed from, a female attendant will accompany the patient. The following figures relate to the service for the past year:— Traffic accidents 117 Other accidents, including street illnesses Maternity removals 370 Sick removals to and from hospitals 3,180 Calls received, ambulance not required 61 Total calls for the year 4,239 Total mileage for year 46,109 Carried out for other authorities PROVISION OF INSULIN. Local Authorities were empowered by Section 133 of the Public Health Act, 1875, with the approval of the Minister of Health, to arrange for the supply of insulin in necessitous cases. By Circular 2734 of the 4th January, 1943, approval was given for insulin to be provided either free of cost or at a reduced price to persons suffering from diabetes. Under the National Health Insurance Acts an insured person, while entitled to medical benefit, may obtain insulin free of charge if it is prescribed or dispensed for him by his insurance practitioner. Under the Poor Law Acts insulin may be provided as a part of medical relief for any destitute person whose condition requires it. The sanction authorised in Section 80 (1) of the Education Act, 1921, was extended so as to enable all local Education Authorities, until the end of the war, to supply insulin free or at reduced rates to all children and young persons attending certain specified types of schools or educational institutions. Not covered by these arrangements are some classes of person for whom no public provision is made apart from Poor Relief, and who find the 11 cost of insulin a substantial burden. Approval was, therefore, given for this class of case to be helped, under Section 177 of the Public "Health Act, 1936, by Local Authorities. The Council decided that insulin should be provided free of cost to those of incomes of under £420 per annum who could not obtain it from other sources. Seven persons were helped in this way during the year. SANITARY CIRCUMSTANCES OF THE AREA. SANITARY INSPECTION OF DISTRICT. A. Inspection of Houses: (a) Public Health Acts. On complaint of defects 1,059 On complaint of other nuisances 1,003 Routine inspections 222 No. defective 593 Revisits 7,437 Inspections of foster parents' premises 37 Visits to verminous premises 716 (b) Housing Act. Routine inspections — On complaint of defects 1 Not in all respects fit 1 Unfit for human habitation — Revisits 208 Surveys under Section 157, 1936 Act 210 No. of cases of overcrowding 74 Inspections of houses let in lodgings — B. Inspection of other premises ; visits and enquiries: No. of routine visits to premises liable to give rise to nuisances 857 Further visits paid to these premises 531 No. of visits to premises under periodical inspection 531 No. of inspections of cinemas, etc. 39 No. of complaints investigated (excluding those referred to above under Housing) 179 No. of observations for smoke nuisances 13 No. of inspections of factories (mechanical) 672 do. do. (non-mechanical) 186 do. do. work places 152 do. do. outworkers' premises 61 No. of visits to premises where rag flock is used — No. of visits under the Shops, etc., Act 80 No. of evening observations under the Shops Act — No. of inspections of hairdressers' premises 63 No. of visits re infectious diseases 8 No. of complaints of rats investigated 534 12 C. Inspection of premises where food is manufactured or prepared : Slaughterhouses 35 Butchers (including Meat Depot) 805 Cowsheds 45 Dairies. 149 Ice Cream premises 2 Fish-shops 85 Fried Fish-shops 81 Bakehouses 107 Cafes and Restaurants 115 D. Inspection of premises where food is retailed : Greengrocers 100 Provision Merchants 601 Milk shops 40 Bakers and Confectioners 30 Other Food premises 68 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) 1,640 (b) Number of inspections made for the purpose 9,285 (2) (a) Number of dwelling-houses inspected and recorded under the Housing Consolidated Regulations (b) Number of inspections made for the purpose — (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 595 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 477 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 ... 5 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 2 (b) By Local Authority in default of owners — 13 B. Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 85 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 65 (b) By Local Authority in default of owners 4 C. Proceedings under Sections 11, 12, and 13 of the Housing Act, 1936 — Complaints. During the year 1,800 complaints were investigated by the Sanitary Inspectors. Of these 507 arose from blocked or defective sewers or drains, 35 from accumulations of rubbish, 20 from dirty pig bins and 46 from nuisances from animals or birds. 414 related to housing defects of which 123 were defects in plumbing, 85 from dampness and 37 from defective water-closets. Complaints as to rats and mice numbered 208, and as to insect and vermin infestation 97; 235 complaints were of defects in or absence of dustbins; 50 were regarding dirty premises and 84 alleged overcrowding; 34 complaints were received regarding such matters as flooded gardens and air raid shelters, burning of garden refuse, dangerous trees, fouling of footpaths by dogs, defective fences and noise from wireless sets. Informal action in 1,575 instances was followed by the abatement of the nuisances in 1,443 cases. During the year 85 statutory notices under the Public Health Acts were served, 65 being complied with, though in 4 instances the work was executed in default by the local authority. Under the Housing Acts 5 statutory notices were served, 3 being complied with. The continuance of the war indirectly adds to the annoyance to which the householder is subject. Although a properly cared for house refuse-bin should not become a nuisance even though it is emptied only fortnightly, this extended interval permits of the hatching of maggots which otherwise would not have reached the adult stage in the proximity of the house. To increase the number of pigs reared, local authorities are exhorted by the Ministry of Food to arrange for the collection of waste food. These pig-bins have been the cause of many complaints. The wind or animals dislodge the covers or upset the bins, resulting in the strewing of the contents on the ground. Little care seems to be taken in the cleaning of the bins so that they constitute a prolific breeding ground for maggots. These bins must of necessity be placed near houses so that householders have to put up with something which may be very unsightly, is a breeding ground for flies and is an encouragement for rats. Other enthusiasts during salvage drives collect heaps of light metals at their dumps and ignore, in selecting these positions, the fact that their proximity to habitations will subject the tenants to annoyance from flies and smells. 14 Inspection of Houses. 210 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 10,319. One house was inspected under the Housing Regulations. Overcrowding. The following tabular statement sets out the position as regards overcrowding for the last few years:— No. of houses o/c 31st December Abated New Cases 1935 187 66 — 1937 121 113 53 1938 61 81 51 1939 31 32 20 1940 19 12 10 1941 17 11 18 1942 24 35 45 1943 34 37 72 This shows that of the 34 cases known at the beginning of the year and the 72 new cases learned of, 39 were abated, leaving the number of premises overcrowded on December 31st, 1943 as 69. Of the 27 cases re-housed 6 were provided with accommodation by the Council. Little advantage was taken by these overcrowded families of the accommodation made available for the release of requisitioned properties, only three, in fact, actually availing themselves of the facilities. Housing Act, 1936. The houses included in the Broadway (Stanmore) Clearance Order, 1937, and the High Street, Stanmore, No. 2 Clearance Order, were demolished during the year. Of the Demolition Orders made in 1943 relating to nine properties, appeals were lodged against the two relating to 16 Marlborough Hill and 38, Shelley Road, appeals which had not been heard by the end of the year. Three of the seven other houses, namely, 21 and 37, Milton Road, and 35, Shelley Road, have already been demolished, while 9 and 10 of the four houses 7, 8, 9, and 10, Burns Road, the subject of the remaining Demolition Orders, are empty. Circular 2845 of the Ministry of Health, issued in August, authorised the release of houses requisitioned for the housing of bombed-out persons for the use of families inadequately housed, the guiding principles in the allocation being those considerations governing the selection of tenants for houses on municipal housing estates. Section 85 of the Housing Act, 1936, was quoted. " In the selection of tenants, reasonable preference is given to persons who are occupying insanitary or overcrowded houses, 15 for large families, or those who are living in insanitary housing conditions." In the light of this circular, a list of families whose needs were considered to be the most urgent was prepared, the families mostly being those living in overcrowded conditions, but some being included because of the unsatisfactory state of their dwellings. The accommodation offered though, failed to attract some of those living in houses which had been condemned as unfit for human habitation. Verminous Premises. 97 premises were inspected on receipt of complaint of infestation by insects or vermin, ants, crickets, beetles, cockroaches, etc. The number of premises found to be bug infested was 66; to these 716 revisits were made. As in previous years, several houses and flats requisitioned by the Council lor rehousing of bombed-out London families were, during the year, found to be in a verminous condition, necessitating fumigation. Rat Infestation. The subject of rat infestation received particular attention during the year from the Infestation Branch of the Ministry of Food. By the Infestation Order of 1943, any local authority might be directed (a) to make a report as to the prevalence of rats; (b) to remedy infestation on the land of the authority, or (c) to enforce control of infestation, these duties being in addition to and not in derogation of any obligations under the Rats and Mice (Destruction) Act. In June a direction was received to carry out a survey of major infestations. The two areas considered to fall in this category were the controlled tip at Elmgrove Road, Wealdstone, and the tip at Cannon Lane, Pinner. In September, the Ministry of Food undertook a publicity campaign, inviting residents to report the occurrence of rats to the Public Health Office, either by telephone or by completing and posting coupons cut out of newspapers. The information received was passed on to the Ministry of Food in detail, though later they requested to be informed only of the number of notices received, without particulars. There were 326 intimations from this source. In November, as the result of representations by the Ministry of Food, the County Council approached local authorities with a view to their assuming the powers and duties under the Rats and Mice (Destruction) Act. The Council had, on a previous occasion, applied for these powers to be transferred to them, an application which the County Council at that time declined to accede to. In spite of an appreciation of the difficulties that would be experienced in obtaining staff for the purpose it was decided that these new duties should be assumed. April 1st, 1944, was later accepted as the date of transfer, but as from February 1st the Local Authority was requested to take over the work as the agents of the County Council. The Council delegated to the Public Health Committee their powers and duties under the Rats and Mice (Destruction) Act and the Infestation Order. The control of rat infestation, particularly in houses and small business premises is closely linked with the routine work of the sanitary inspector. Accumulations and deposits which might give rise to sanitary 16 nuisances, might also become rat harbourages. On the other hand, some accumulations, unsightly though they may be and of which removal on general grounds may be so desirable, frequently cannot be dealt with under the nuisance sections of the Public Health Act, but as rat breeding grounds they can be removed. Similarly, the keeping of poultry or collection of food waste for pigs may give rise to such nuisances as need to be dealt with by the sanitary inspector, while, in addition, these conditions encourage rats. Again, one of the first lines of investigation of rodent-infested premises is ar, inspection of the drainage system. Because then of the closeness of this association, it was decided that the administration of this work should be brought into line with the routine duties of the sanitary inspectors. On receipt of a complaint of rat infestation then, the first enquiries are made by the inspector who refers the case if need be to the rodent officer if any work of extermination needs to be undertaken. It is impossible at this stage to judge what number of operatives ultimately will be required. These additional duties on the sanitary inspectors undoubtedly will necessitate an increase in their numbers. Apart from difficulties in staffing, the assumption of these duties is made more onerous today for reasons arising out of war conditions, There are far more people keeping poultry in their back gardens. Of these, even those who know what is necessary in the way of rat-proofing the runs find difficulty in undertaking this because of shortage of material. Another factor increasing rat infestation in the area is the keeping of pigs by numbers of clubs, and the salvaging of waste food for pig feeding. Apart from domestic infestations though, there are collections of rats in other sites. Reference has already been made to the classification of the two tipping grounds as major infestations, understanding by this that here rats breed and multiply so that these areas act as sources of infestation for other parts. A partial inspection of the sewers showed that while those in the more recently developed parts of the district are apparently free, the sewers in the older established part of the area are infested. Again, water courses are infested, even those where the source need not be assumed to be the surface water sewers. The present teaching is that the line of approach is first to destroy those sources of major infestation, and then continue to the individual instances. The reverse procedure, while it might result in the freeing of premises from infestation, effects this only temporarily as, as long as the reservoirs are alive, infestation must shortly recur. Inspection of other premises. These premises include those at which nuisances might be anticipated and to which 857 visits were paid. Another group of premises which are the subject of periodical inspection and to which 531 visits were paid consisted mainly of public and private conveniences and air raid shelters. Smoke Abatement. Thirteen observations for smoke nuisances have been carried out, but on only four occasions was smoke observed. During the 130 minutes observations, no dense smoke was recorded, but 40 minutes of moderate smoke. 17 Factory Act. In this district there are 423 factories with mechanical power, 158 without mechanical power and 119 workplaces. The numbers of visits paid to these three classes of premises were 672, 186 and 152. Of the 98 public health nuisances detected, 15 were due to want of cleanliness. The sanitary accommodation was unsatisfactory in 71 instances, being unsuitable or defective in 25 ; unclean or insufficient in 44 and not separate for sexes in 2. Twelve other nuisances were noted. Particulars of 113 outworkers resident in this area were received. To these 61 visits were paid. SHOPS ACTS. As last year, the work under the above Acts was confined to investigating complaints as to hours worked by young persons, giving advice as to notices and other matters connected with sanitary accommodation and general welfare of the shop assistants. Eighty visits were paid. No evening observations were carried out and no other contraventions recorded. The Home Office advised that Regulations as regards the closing of shops for the winter period should cease to have effect on the 6th March and the General Closing Hours on and after the 7th March 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 for the winter period, 7th November, 1943 to 4th March, 1944 inclusive, in accordance with Defence Regulation 60A (b). INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY. Production. Another cowkeeper was registered during the year, bringing the total number of cowkeepers in the district to 12, occupying 14 separate cowsheds. Of these, five hold licences for the production of accredited milk and one for tuberculin tested milk. Six local producers sell milk in the district. Distribution. Including three company distributors, the number of retailers of milk in the district remains as in previous year, at 27. 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, 6 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. 18 Licensing. The only change in the number of the licences issued was one additional licence to pasteurise. 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 licenses were issued to two producers outside the district to retail tuberculin tested milk here and 2 supplementary licences were issued to outside producers to retail pasteurised milk in the district. Three establishments were licensed for pasteurising milk. Of the 41 premises licensed for the sale of pasteurised milk, 17 belong to one firm, 13 to one, and 4 to one and 2 to another. Sampling. 12 samples of pasteurised milk were submitted to bacteriological examination and the phosphatase test. All except one, which contained bacillus coli were satisfactory. All four samples of tuberculin tested milk were satisfactory. Of the five samples of tuberculin tested (pasteurised) milk, three failed to pass the prescribed tests; and two of the eight samples of raw were unsatisfactory, yielding too high a B.Coli count. Sterilising of Utensils. Owing to difficulties in arranging steam sterilisation of dairy equipment, Article 21 of the Milk and Dairies Order, 1926, was amended to permit the use of sodium hypochlorite of certain strength. (B) MEAT. Inspection. Still less slaughtering of animals took place, only 44 pigs owned by pig clubs or an institution being killed and inspected. In all cases the carcases were sound, it being necessary to condemn only two mesenteric fats for tuberculosis and five plucks for parasitic disease or pneumonia, and two livers on account of abscesses and fluke. Meat Depot. This depot has, during the year, been under constant supervision, receiving daily visits by one of the sanitary inspectors. Carcases of five sheep, of total weight 158 lbs. were condemned, four on account of black mould and one owing to putrefaction; 1,238 lbs. of beef because of bone taint, 993 lbs. due to putrefaction, 106 lbs. owing to black mould, 51 lbs. for bruising, 17 lbs. because of tuberculosis; 6 lbs. of mutton because of bruising and 5 lbs. due to black mould and brine stain; 127 lbs. of pork due to putrefaction, 123 lbs. of veal owing to bone taint and about 98 lbs. of offal on account of putrefaction or parasitic disease; and of tripe 2,062 lbs. There was a further increase in the tinned meats, such as corned beef and mutton, distributed from the depot, and the percentage of this class of food which had to be condemned was higher, about 9,493 lbs. being unsound, mainly because the tins were blown or leaky. 19 (C) OTHER FOODS. Food Shops. Food shops were visited regularly as a routine apart from special visits following complaint. Large quantities of foodstuffs were condemned and voluntarily surrendered. There was a further increase in the number of tins of tinned food condemned, the 4,500 tins being : 979 meat, 877 milk, 860 vegetable, 637 fruit, 568 soup, and 530 fish. Other condemned foodstuffs included 186 stone of fish, 3,189 lbs. of fruit, 528 lbs. flour, 530 lbs. sugar, 445 lbs. cheese, 430 lbs. bacon; and 950 eggs. ISOLATION HOSPITALS ADEQUACY OF ACCOMMODATION. Although the total number of cases of scarlet fever notified throughout the year was still above the average of the previous years, because the distribution was so even with the absence of anything in the nature of an epidemic prevalence, the accommodation at the two local hospitals met the demands of patients suffering from this infection. During the months of lighter prevalence, June to November, it was possible to close down the Honeypot Lane Hospital. The greatest number of cases of scarlet fever under treatment on any one day was 52, and of diphtheria 12. Cases of infections other than scarlet fever and diphtheria have, as in former years, been admitted to the hospitals of other authorities. In all 80 patients were removed, including 9 cases of puerperal infection. Arrangements were made with other districts for the admission in case of need of local patients to their isolation hospitals. In future then, patients may be admitted to the South Middlesex and Richmond Hospital, the Enfield, Edmonton and Potters Bar Hospital, the Finchley, Hornsey. Wood Green and Friern Barnet Hospital, and the Acton Isolation Hospital. PROVISION OF NEW HOSPITAL. This year's figure of 682 notifications of scarlet fever is the greatest number received, though the incidence rate per thousand population did not reach the figure of 4.7 of the year 1934 which was the highest rate for any of the ten years 1934 to 1943. In this year, too, the percentage of notified cases who were removed to hospital for treatment was the highest for any year, a figure of 80. Assuming then, the association of that high incidence and high removal rate, 750 cases of scarlet fever might require admission from a post-war Harrow population of some 200,000. Were this distribution even throughout the year, the weekly average of admissions would be only 15. Sero- and chemo-therapy in the treatment of scarlet fever, coupled with the general mildness of the complaint today, enables most patients to be detained even less than three weeks from the day of admission, so that some 50 beds would be adequate for the reception of scarlet fever patients. This calculation is, of course, invalidated though, because of the uneven incidence of infection. On the other hand the figure relates to an incidence nearly double the average of 2.7 over the past ten years. 20 Diphtheria incidence in any urban locality might be about 50 per cent of that of scarlet fever. In this district the rate for the last ten years has been markedly low, even before the immunisation of children had protected any appreciable number, and in not any of these years have as many as 100 cases been notified, while the true incidence has been about one-half the notification rate. For this reason then, in this district the accommodation provided for diphtheria patients does not need to be on the same basis as was at one time common practice, i.e., about one-half of that of scarlet fever. In regard to other infections, arrangements have been made for those patients who need hospital treatment because of some infectious condition to be accepted at the hospitals of other local authorities. Apart from groupings of cases suffering from complications of measles, whooping cough or influenza, when these ailments are prevalent, most of these patients are sporadic cases of such conditions as erysipelas, cerebrospinal fever, enteric fever, puerperal infection, etc., most of whom would require to be admitted to cubicle wards. The greatest number of such cases for whom admission to outside isolation hospitals has been arranged in any one year was 80. In most years it has been possible to find the accommodation, only rarely it proving necessary for patients, whom it was desirable to be treated in hospital, because of lack of accommodation, to be nursed at home. In general then, the position for the past ten years has been that the needs of the district have been met by most of the cases of scarlet fever and diphtheria being accepted in the local hospitals, and cases of other infections being admitted outside. It is not suggested that the conditions are ideal. Quite apart from the fact that what accommodation is available locally is provided in two detached institutions which are run as one unit is that both hospitals are admitting more than the desirable numbers of patients to the wards. On the basis of 144 square feet per patient the Honeypot Lane Hospital accommodation is 17 and South Harrow 25, whereas the limiting figures for these institutions are 26 and 46. Nevertheless the needs of the district have over these years been met by some 60 beds for scarlet fever patients and some 12 for diphtheria, together with the admitting of cases of other infections to outside hospitals. At one time it was accepted as a rough guide that an urban area would require isolation hospital accommodation on the basis of one bed per thousand population. Changing factors have modified this. Although scarlet fever and, to a less extent, diphtheria, provided most of the patients admitted to an isolation hospital, most hospitals have, to an increasing extent, accepted cases of other infections. In all, these would not amount to a very high proportion of admissions, but has necessitated the provision of some accommodation in small wards and cubicles. The main factor curtailing admissions though, is the mildness of scarlet fever today, as has been the case now for some years. This results in a larger proportion of patients being treated at home, and also shortens the stay of those admitted. More recently still the use of scarlet fever serum and of the chemical drugs enables patients to be discharged earlier than was the previous practice. When consideration was given to the question of the size of the new 21 hospital to be erected, a standard of something less than one bed per thousand population was agreed upon, the initial accommodation proposed being 120 beds. The experience of the last ten years indicates that this figure is possibly too high. It has been agreed for many years that the small isolation hospital is not a very satisfactory institution, and it had been accepted that 100 beds was the minimum sized unit, this being the size of an institution which would justify the appointment of a resident medical officer. More recent views are in favour of a 200 bed hospital as the minimum administrative unit, a hospital which would have a resident medical officer and an assistant. This would then mean that a 100 or 120 bed unit which would probably adequately meet Harrow's needs is less than the optimum sized hospital. Consideration will, therefore, later have to be given to the question of whether or not to continue with the proposal of the construction of a new isolation hospital, or whether to revert to the plans of the County Council in their review by which the needs of this district would be served by the Hendon Isolation Hospital. According to the proposals in the White Paper on the National Health Service, the local sanitary authorities are in any event to lose their isolation hospitals. ADMINISTRATION. The recommendations of the Report of the Nurses Salaries Committee (Rushcliffe Report) were accepted, and later the recommendations of the Hetherington Committee on the salaries and emoluments of female domestic staffs in hospitals. CLINICAL ASPECTS. Scarlet Fever. Admissions : Number admitted with a diagnosis of scarlet fever 481 Number suffering from scarlet fever 443 Number in whom diagnosis not confirmed 38 Of these cases in which the diagnosis was not confirmed, 6 suffered from pharyngitis and the same number from influenza, 5 from tonsillitis, 4 from erythema, and 3 each from urticaria and from measles. Deaths: Number of deaths from scarlet fever : Nil. One child died in the hospital who had been discharged after a mild uncomplicated attack of scarlet fever on the 13th January. Ear-ache and otorrhœa started on the 20th and she was re-admitted on the 30th owing to a possible mastoid involvement. Bilateral mastoid operation was performed, but she died from meningitis. Treatment: Of the 443 patients admitted who were considered to be suffering from scarlet fever, 230 received serum, most of them 3,000 units, only 16 receiving 6,000. Serum reactions occurred in only 5. Prontosil was given to 194 patients. 22 Complications : A slightly greater proportion suffered from complications this year as compared with the previous year, 18 per cent. as against 13 per cent. The number of patients who suffered from adenitis was 22, from otorrhoea 24 (including one who needed to have a mastoid operation), from rhinorrhoea and abscess 6 each, whitlows 9, albuminuria 5, secondary sore throat 4 ; in 3 a heart condition caused some anxiety, while one child suffered from rheumatism and another suffered from a secondary attack. These figures refer to those patients admitted to hospital during the year, even though they had not been discharged by the end of the year. Cross Infection : 13 patients suffered from chicken pox while in the scarlet fever ward, 9 of them apparently being in the incubation stage at the time of their admission, as were the 3 patients who suffered from German measles, measles and mumps. Return Cases: Return cases were notified from 14 households to which patients treated in hospital for scarlet fever returned during the year. Period of Stay : 60 per cent, of patients returned home on or before the 21st day from admission, the commonest interval being the 19th day, the next the 18th. Nearly 20 per cent, were in until the 28th day or longer, most of these being held up because of some minor abnormality. Diphtheria. Admissions : Number of cases admitted on a diagnosis of diphtheria (including 8 Services cases) 68 Number of cases clinically diphtheria 26 Number of positive swab contacts 10 Of the 24 cases in which the diagnosis was not confirmed 16 were suffering from tonsillitis or quinsy. Of those suffering from clinical diphtheria one was nasal. Most of the contact swab cases were patients from a ward in a hospital in which a case had occurred. Deaths: Number of deaths from diphtheria: Nil. One patient admitted as diphtheria who suffered from pneumonia, a baby of 11 months, died within 24 hours of admission. Complications : Three patients suffered from albuminuria not present at the onset of illness and one each from paresis of the palate, tonsillitis and involvement of heart muscle. A rash occurred in 5 per cent. of those to whom serum was administered. 23 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 2 172 382 85 22 11 15 13 3 2 707 Diphtheria 2 12 22 5 11 9 4 6 1 1 — 73 Pneumonia 11 26 36 10 6 2 29 38 30 21 27 236 Dysentery — 3 2 — 3 — 3 2 1 — 1 15 Erysipelas — — 2 1 — 1 3 11 16 12 6 52 Cerebro-spinal Fever — 2 6 1 3 1 2 1 — 1 — 17 Puerperal Pyrexia — — — — — 3 13 2 — — — 18 Ophthalmia Neonatorum 2 — — — — — — — — — — 2 Typhoid Fever — — 1 — — — 2 — 1 — — 4 Food Poisoning I — 1 Malaria — — — 1 — 1 — — — 2 Measles 30 590 785 46 27 15 10 11 2 — — 1516 Whooping Cough 39 174 162 7 3 — 1 3 1 2 1 393 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 707 481 5 — — Diphtheria 73 63 5 — 1 Pneumonia 236 — — — 126 Dysentery 15 — 3 4 — Erysipelas 52 — 12 7 — Cerebro-spinal Fever 17 — 9 7 2 Puerperal Pyrexia 18 — 10 2 4 Ophthalmia Neonatorum 2 — 1 — — Typhoid Fever 4 — 3 — 1 Food Poisoning 1 — — 1 — Malaria 2 1 — Measles 1516 28 — 1 Whooping Cough 393 — 11 — 3 DIPHTHERIA. Incidence. 68 notifications were received during the year of cases occurring amongst the civilian population. Of these though, 15 were cases of tonsillitis and in 13 other instances the patient was suffering from some condition other than diphtheria, leaving a corrected figure of 40, this being a rate per thousand population of — (the figures for the years 1934 to 1942 were 0.6, 0.58, 0.22, 0.54, 0.28, 0.41, 0.20 and 0.26). 24 Nine of the notified cases were bacteriological cases only, being children who were found to give positive swabs when examined on the occurrence of a case of diphtheria in the ward. One patient was suffering from laryngeal diphtheria. Two cases occurred in one household. Of those proved to be diphtheria, 22 per cent. were under five years of age, 41 per cent. were of school age and 37 per cent. were over 15. Place of Treatment. All but seven of the patients were admitted to the Harrow Isolation Hospital; two were treated at home. Deaths. One death occurred from diphtheria during the year. The patient was a woman of 33 who, being thought to be suffering from tonsillitis, was admitted to a general hospital. She died on the ninth day of illness. Immunisation. 5,427 children were immunised during the year, 1,532 being treated at the infant welfare centres, 2,220 at the public elementary schools and 1,675 by general medical practitioners. Of all the children under five years of age, 46.1 had been immunised by the end of the year and 69.0 of the children of school age, the corresponding figures at the end of the previous year being 41.8 and 63.5, and at the end of 1941, 15.6 and 31.5. The upper income limit which previously excluded those above it from being treated under the Council's scheme, was removed in February. From the same date the A.P.T. was issued free of charge to medical practitioners. 8,747 children were invited to attend for Schick-testing. Of the 4,363 who attended both the test and the reading, 108 were positive, a percentage of 2.5, the same figure as recorded for the previous year. Of those who were admitted to hospital from what was considered to be diphtheria were two who had received the full protective inoculation. A boy of 7 admitted in February had received 0.1 and 0.3 c.cs A.P.T. at one month's interval in November, 1941, and was found to be Schicknegative in February, 1942. The other case was a child of 15 months admitted in June who in January received 0.2 c.cs and in February 0'5 c.cs A.P.T. He had not been Schick-tested. Both were very mild cases, one being discharged on the 29th, the other on the 30th day from admission. A child of three admitted in February had received one dose of A.P.T. in October, 1942. A boy of eight admitted with a sharp attack was supposed to have been immunised when he was two years of age. Provision of Antitoxin. 36 lots were issued, totalling 288,000 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. 25 SCARLET FEVER. Incidence. In 44 of the 716 patients notified as suffering from scarlet fever, the diagnosis was withdrawn. The net figure of 672 is an incidence rate per thousand population of —, a still further rise on the figure for 1942, which was itself a sharp increase over the rate for the previous years though lower than the average for the country. Local rates for the years 1934 to 1942 were 4.70, 3.47, 2.64, 2.31, 2.72, 1.60, 1.06, 1.66, and 3.16. The incidence for three of the quarters of the year were almost identical at a weekly average of 14, the rate for the third quarter being somewhat lower at a figure of 10. The distribution throughout the year was markedly uniform, in very few of the weeks were there fewer than 10 or more than 20 cases. Deaths. No deaths occurred in this district due to scarlet fever. Place of Treatment. Of the 672 cases notified, 211 or 31 per cent. were treated at home at the election of the parents. Of those removed, it seemed another 37 per cent. might have been so dealt with. In 20 per cent. the reason for removal was the presence of other children at home; in 3 cases there was no room for the patient to be nursed in; in 7 per cent. the patient was an adult, and in a further 6 the homes were crowded. In two instances only was the reason for admission the clinical condition of the patient. Secondary Infection. Secondary infections occurred in 31 households, in three of these there being 2 cases, in one 3, but in the remainder only one. In 10 instances the original patient was treated at home. On 7 occasions the onset of illness of the secondary case preceded the removal of the first patient to hospital, while in a further case the onset was on the day of removal. Where there was an interval between the removal of the first case and the onset of the second, this most frequently was two days; the longest such period was six days. Return Cases. Return cases occurred in 14 households, only the one patient being affected in each home in most instances, but two on two occasions. In eight cases the interval between the return home of the presumed infecting case and onset of the return case was under one week; in five the onset was in the second week, while in one the interval was 26 days. Most of the return cases were quite normal in appearance, only three showing any abnormalities; in two of these a nasal discharge had developed, and in the third a sore nose. 26 Schools and Infection. In the first term of the year there were no groupings of cases amongst children attending the public elementary schools to suggest that attendance was responsible for the spread of infection, though the general incidence of infection throughout the term was heavier at two schools. One of these was Grimsdyke School which in the next term had further cases, in all 11 throughout the term, but not more than three in any one week. The other, Stanburn School, which in the first term had 11 cases over eight weeks had a further 9 cases over nine weeks in the summer term. Belmont School in this term had 7 cases over three weeks. The heaviest grouping was at Stag Lane School where there were 15 cases over nine weeks, in one of which there were 5 cases. The only suggestive grouping in the winter term was at Kenmore School where there were 7 cases over three weeks, though these cases were distributed throughout five classes. ENTERIC FEVER. Five patients were notified as suffering from typhoid fever, though in one the notification was withdrawn, the diagnosis being changed to one of enteritis. All four cases were of para.-B. infection. There was no apparent connection between the cases, one occurring in February, two in different parts of the district in April (one being apparently a recurrence of an old-standing infection) and the other, which proved fatal, occurring in May. Two of the patients were admitted to isolation hospitals for treatment, one to a general hospital, while the other was treated at home. DYSENTERY. For the last few years the incidence of dysentery has been irregular, ranging from the one case notified in 1940 to as many as 24 in 1937. This year's 15 notifications include those relating to two members of the staff of a local hospital who fell ill in July, and four cases amongst the patients and staff at another hospital in September, and a member of the staff of a hospital outside this district at which the infection had apparently been contracted. The Sonne organism was found in most cases, the only patient in whom some other organism was found being an adult female who had only recently come to reside here ; the Flexner organism found in this case was probably the cause of the colitis from which she had suffered for years. Of the remaining cases of infection amongst the members of the general community, three occurred in August, one being an adult male, another an adult female and the third a boy of 16. In September there was the one case of a boy of 7, in October an adult male and in December another boy of 7. Of those patients living at home most were treated at home, three being admitted to a general hospital and one to isolation hospital. FOOD POISONING. Only one patient was notified as suffering from food poisoning, this being an adult female who succumbed in August to infection by B. Aetrycke. 27 ERYSIPELAS. The number of cases of erysipelas notified this year was the same as in 1942. Of these 46 cases, 35 were female. The face was the affected site in 29 and the leg in 7. Nine patients were treated in isolation hospitals, 5 in general hospitals and the remainder at home. The incidence was markedly higher in the second than in the first half of the year, this being due to the 7 cases in August and the 9 in December. CEREBRO-SPINAL FEVER. Of the 16 notifications of patients suffering from cerebro-spinal fever, the diagnosis was subsequently amended in 9, in four instances to pneumonia and in two each to influenza and tuberculosis. The 7 cases then is a further fall in incidence, the rate now approaching the pre-war level which was disturbed by the occurrence of 38 cases in 1940, though from this height the level fell to 25 in 1941 and 13 in 1942. The cases occurred one each month from February to July with an extra case in March. One of these two cases, a boy of 2, proved fatal. Apart from this case information was received in the transfer death returns of the death of a baby of 7 months in January from chronic meningococcal meningitis. 3 patients were treated in general hospitals, 2 in isolation hospitals and 2 at home. MEASLES. The district was subjected in the earlier half of 1942 to a heavy wave of measles incidence which had started in the latter weeks of 1941. The disease had practically completely died out in the first half of 1942, and there had been no rise in the latter part of this year to suggest that the incidence would mount from early 1943 to reach epidemic proportions in the month of March with a weekly incidence of some 110, and April with a weekly average of nearly 100. The fall to an average of 40 in May and a further drop to 24 in June, led to the further decline to a weekly average of 4 in the third quarter and a virtual extinction in the last quarter. In all 1,516 notifications were received. 15 school departments were affected in the spring term, only two of these, however, having as many as 50 cases. In the summer term only two schools had any appreciable numbers. Only one death was recorded as due to measles. The total number of visits paid to the homes by the health visitors was 214, while 27 children were removed to hospital. WHOOPING COUGH. In 1942, the 468 notifications were spread throughout the whole year, the weekly incidence for each of the four quarters being 13, 10, 8 and 5. This last year the disease was again prevalent throughout the year, but the distribution of the 393 cases was markedly different, the weekly average of each of the quarters being 4, 5, 11, and 9. 28 No schools had more than an occasional case in the spring term. In the summer term three school departments had about 20 cases each. Although the infection was more prevalent in the winter term only two departments had as many as 30 cases, a further five having about 20. As was the case in the previous year, about half the schools escaped entirely. 3 children died from whooping cough. The number of patients suffering from whooping cough who were removed to hospital for treatment was 11, and the number of visits paid by the health visitors 98. NON-NOTIFIABLE INFECTIONS. Chickenpox. Chickenpox was the most prevalent of the infections in the schools, intimation being received from the head teachers of the absence of 1,234 children from the public elementary schools. It was most prevalent in the spring term when 10 schools were affected to some degree, though only six to any great extent. Of these one had 152 cases, the others 145, 125, 101, 63 and 53. Of these, two were slightly affected in the summer term, while two other schools had the one 102 and the other 41 cases. In the winter term those previously affected largely escaped though two other schools were attacked, one having 143 and the other 93 cases. Mumps. Mumps was much less prevalent than in the previous year, only 413 intimations being received. One school was heavily (121 cases) and another two lightly (31 and 22 cases) attacked in the spring term, sporadic cases occurring in a few other departments. One department which had 21 cases in this term was the only one seriously affected in the summer, having a further 61 cases. The incidence was even lighter in the winter term, only one school having as many as 25 cases. German Measles. The district was practically free from this infection in 1942, a very different state from that of the earlier months of 1943. Influenza. Influenza was prevalent in the earlier months of the year, nine out of the total number of deaths from this complaint occurring in February and March. The disease returned in the last six weeks of the year, this district being affected by the epidemic of the respiratory type from which the country as a whole suffered. The deaths recorded in the succeeding weeks, after one in each of the three consecutive weeks in the latter part of November, were 6, 8, 11, 7, and 3. The fatalities occurred mostly amongst the elderly, especially females, 30 out of the 50 deaths being amongst those over 65 years of age. 29 VERMIN INFESTATION. Scabies. This year saw a still greater increase in the number of persons who attended the treatment centres on account of this complaint, 2,178 attending as compared with 1,701 last year and 299 the year before. The months in which the attendances were appreciably above the average were September, October and November. As was found the case last year, while the numbers for each sex of those under five years of age were almost equal, far greater numbers of girls of school age attended than of boys, while the figures of attendances of adult females were about three times those of adult males. The same routine of treatment was continued, namely, two applications of benzyl benzoate following a bath, and steam disinfection of clothing. At one time it was assumed that the spread of scabies was largely the result of infestation by clothing, bedding, etc. For this reason disinfesting was considered an essential part of the procedure for the eradication of this infestation. In February the Ministry issued a circular pointing out that recent investigations had shown that while articles of clothing and bedding may play some part of the spread of scabies, the importance of this as a means of dissemination has been much overestimated, so much so in fact that it was considered routine disinfesting of clothing to be unnecessary after the standard methods of treatment. Accepting that re-infestation might occur if disinfestation is not carried out, the circular pointed out that repetition of treatment in an occasional case is simpler than continuing the expenditure of man power and material required for routine disinfesting in all cases. When this circular was considered by the Public Health Committee it was decided to continue to offer facilities for the disinfestation of clothing of those treated under the Council's arrangements. Head Infestation. The analysis carried out in 1941, of the extent of head infestation occurring amongst patients who had been admitted to the local Isolation Hospital in the previous few years disclosed a disturbingly high incidence. Amongst males of under five, the figure was 10 per cent.; of ages 5 to 9, 7 per cent.; of ages 10 to 14, 2 per cent., with no infestation of those of over 14. The corresponding figures amongst females were much higher, being respectively 25, 16 and 15, while 8 per cent. of adolescent females were found to have dirty heads. A similar analysis of patients admitted in the years 1942 and 1943 showed a marked improvement. The corresponding figures for boys were 6, 3, and 2, while again no vermin were found in the heads of males of over 14. Amongst girls of under ten there was a welcome fall, the incidence in those under five and in those of ages 5 to 10 being just under 8 per cent. The figure of 13 per cent. though for those of 10 to 14 was much the same as that found in the previous analysis, as was the figure of 8 per cent. found amongst adolescents. A sample investigation carried out by the health visitors in 1941 of children under five disclosed an average incidence of 7.5 per cent., this figure being an average of a range from 0 to 30 per cent. Five of the 14 health visitors recorded nil returns. In a similar investigation this year 30 again five found no infestation. The general average was 4 per cent. the nil returns or light infestations being off-set by those districts where percentages were 20, 13, and 11. The incidence rose with the increasing age of the child from a percentage of 2 amongst babies of under one year to that of 7 amongst children of 4 years of age. The Ministry of Health Circular 2831 contained recommendations aimed at the eradication of head lice. Amongst these was one that health visitors should pay special attention to this subject and include examination of children's heads, though not the cleansing, as part of their work, both in the houses and at the clinics; also that suitable combs be provided for sale or on loan at the clinics; and reference was made to the efficacy of the preparations containing lethane. These particular recommendations had been in operation in this district since consideration had been given to the previous circular in March 1941. 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 — 2 — — — — — — 2 2 1 — 1-4 4 1 5 2 — 1 — — — — 1 2 5-9 2 3 7 — — — — 1 — — 1 1 10-14 3 3 4 2 — — — — — — 1 1 15-19 11 19 3 5 — — — — 2 3 1 2 20-24 20 25 1 4 — — 1 — 3 3 2 2 25-34 31 46 6 2 1 1 — — 10 9 — 1 35-44 37 13 2 4 — — — — 14 3 — — 45-54 23 8 — — 1 — — — 14 2 — — 55-64 7 — 1 — 3 1 — — 6 5 — — 65 & up 2 2 — — 1 — — — 4 1 1 — Total 140 122 29 19 6 3 1 1 55 28 8 9 Notifications of tuberculous cases differ in one important respect from those relating to most of the other notifiable diseases, because whereas in the case of most diseases the notification is received within a short period of the onset of infection, in tuberculosis this may not be so. For this reason, then, whereas the origin of most infections lies in some influence exerted on the patient about the time of receipt of notification, in tuberculous patients the onset of recognised illness may be some years after, while the causative factors leading to that onset may be still more remote. It follows then that a patient notified might owe his illness to factors not related to his place of work, his environment or conditions of living at that date. When a person moves from one sanitary district to another, particulars of his notification are required by the Tuberculosis 31 Regulations to be sent to the Medical Officer of Health of the new district. It is also the duty of a medical attendant to notify to the Medical Officer of Health of the district in which the patient is living unless the case has already been notified to that Medical Officer of Health. The result of these provisions is that the name of a tuberculous patient who has moved from one district to another might for a long time be on the register of two or, in the case of more frequent removals, more than two authorities. The actual number of notifications received then by an authority is not necessarily indicative or a measure of the factors in that district which cause tuberculosis in the population. In any district in which any substantial numbers of people have moved in, the number of notifications received will be higher than the number which would have occurred in those same surroundings in a stable population of that size and age-constitution. This will be so because notifications may be received of cases in the transferred population which have been first detected not in that one year but over many years. On the other hand, when people remove from a district there will be a lapse of time before the authority they are leaving and on whose register the names appear, has been made aware of the transfer and so can remove the name. A district subjected to changes in population then, even though the total population remains roughly the same, will have an unusually high rate of tuberculosis notifications, while the register too will contain a greater than average number of names per thousand population. In 1934 when the mid-year population of the district was 132,000, the number of new cases of pulmonary disease brought to light was 121. The bigger numbers in the succeeding years of 1938, namely, 152, 190, 212, and 231, were roughly in proportion to the larger population. The 1939 population was slightly greater but the notification figure fell slightly to 210, rising again to 226 in 1940. The very sharp rise to 349 in 1941 was out of all proportion to the changes in population, changes which nevertheless were quite material, but which left the total population largely undisturbed. The fall to 318 in 1912 has been succeeded by another drop, the number of pulmonary cases notified in 1943 being 261. Of these, 56 transferred here suffering from the disease, a further fall as compared with the figures for the previous year. Of the others about whom information has been obtained, 168 were notified first to this district. Of these though, some 9 males and 5 females were in the Services at the time the diagnosis was made, 3 persons had never lived here, 2 were chronic patients in hospitals outside the district, while 2 were cases of recrudescence or relapse. A family history amongst those who presumably contracted infection while living here was obtained in 18 per cent. of cases. 50 notifications (30 male and 20 female) of non-pulmonary tuberculosis were received. Of 30 patients who presumably contracted the infection while living here, 10 suffered from joint or bone disease, 6 from lesions of the cervical glands, 4 from meningitis and 3 from abdominal tuberculosis. A family history was obtained in 4 out of these cases. In 9 out of the 12 patients who transferred here suffering from the disease, the lesion was in bone or joint. 32 There was a sharp rise in the proportion of deaths which occurred amongst those who had not been notified, the percentage figure for pulmonary cases being 19 (16 out of 56 deaths) as compared with 10 last year. Of those who died from non-pulmonary disease, only 3 out of the 15 had been notified. Most of the deaths took place in institutions. In 8 of the cases (6 of them pulmonary) the diagnosis was arrived at only as a result of post-mortem examination. Register. Pulmonary Non-pulmonary Male Female Male Female No. on register January 1st, 1943 495 452 89 91 No. of New Cases added 140 122 29 19 No. of cases added—other than on Form A 6 3 1 1 No. of cases restored to register 4 1 — — No. of cases removed 90 76 16 17 No. on Register December 31st, 1943 554 502 103 94 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 17 29 3 3 Died 56 30 6 6 Cured 13 15 4 8 Diagnosis not confirmed or withdrawn 4 2 3 — Total 90 76 16 17 Deaths. 92 persons (66 male and 26 female) died from pulmonary tuberculosis during the year and 15 (7 male and 8 female) from non-pulmonary tuberculosis. Tuberculosis therefore accounted for 5.2 per cent. of the total deaths in the district. The corresponding figures for last year were 101 deaths from pulmonary and 8 deaths from non-pulmonary tuberculosis, the disease accounting for 6.0 per cent. of total deaths. 60 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 56 per cent. The numbers of deaths in each of the six years 1938 to 1943 from pulmonary tuberculosis were 68, 60, 77, 111, 104, and 101. The corresponding figures for non-pulmonary tuberculosis were 28, 18, 16, 9, 5, and 8, 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, 6.0 and 5.2. The total population at risk was not so very different in each of those years. 33 Special Measures. The special feature of pulmonary tuberculosis which makes its control and eradication so difficult is the insidiousness of its onset. When the disease is recognised the patient on looking back can then realise the significance of those ignored symptoms present probably for many months. In the meantime the unrecognised patient may be a source of infection to others, while the advancing state of the lesion necessitates long period treatment to effect cure even in those cases where the time for cure has not, as it so often has by this time, actually passed. Though not invariably so, diagnosis can usually be made earlier by X-rays than by physical examination. The introduction then of arrangements by which large bodies of normal population can be examined by mass radiography gives hope for the early recognition of the disease. Mass radiography is not sufficient by itself, but it can separate from the apparently normal population those requiring further individual diagnosis by established methods. It will be a long time before these facilities can be offered to the entire community, but it is desirable that at least those who are special risks, either because of their age or because of the nature of their occupation, should be offered these benefits, though again their usefulness may be limited because the disease is so rapidly established in adolescents and in young adults. Early recognition of the disease is of advantage to the patient by enabling him to obtain treatment while the disease is in the curable stage; no less advantageous is it to the community if it results in the removal from its midst of open infectious cases. The poor suffer from tuberculosis and the tuberculous become poor. Much of the work in treating tuberculous patients is very soon nullified because the wage-earner cannot afford to remain in the sanatorium sufficiently long for his lesion to be fully arrested, or because on leaving he must return to those conditions at home or at work which led to the breakdown in his resistance and so to the onset of the declared disease. Under the new arrangements a person who can be cured—and as these arrangements made under the Defence of the Realm Regulations are primarily in the interests of the manpower situation of the country, the scheme applies only to those who are likely to become fit—whether in an institution or not, can receive a maintenance allowance while he is unfit for any work, and also assistance during the period of restoration to full working capacity. Perhaps some similar measure can be introduced for the benefit of all affected, regardless of their working capacity. The incidence of tuberculosis has for years been steadily declining though the fall was interrupted by the 1914-18 war and again by this. It can be expected that early diagnosis and removal from the community by speedy admission of diagnosed cases to sanatoria will lead to a fall to still lower levels. It is, perhaps, too much to hope for the complete eradication of the disease, so there will occur in most a reaction of the individual to invasion by the organism, a reaction though which, as in the case of most of us today, does not result in disease. Not so very long ago typhoid fever was not uncommon in this country, outbreaks occurring particularly in the autumn. When a disease is very prevalent it may be difficult to trace the source of infection. Today typhoid fever is relatively 34 rare, and it is now this rarity which creates difficulties in finding the source, because this can usually be conjectured only by finding one source as common to a number of cases. Today, tuberculosis is so common that, apart from those cases where there is a family infection or where there is some equally obvious possible source such as of nurses in sanatoria, there is no knowing where the patient picked up the infection. Is it too much to hope that the fall in incidence might be to such low levels that the diagnosis of disease in any person will be followed with the same object by enquiries similar to those now made on the occurrence of a case of typhoid fever ? MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,500; 1,815 male and 1,685 female. Of these 150 were illegitimate, being a percentage of total births of 4.3. 2,488 births occurred in the district (2,437 live and 51 still births). Of this number 416 (407 live and nine still births) were to residents of other districts. Of the local confinements, 2,383 were notified by midwives and 105 by doctors or parents. 1,437 (1,390 live and 47 still birth) notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in Middlesex County Council or London hospitals. STILL BIRTHS. 56 male and 45 female still births were registered, being a rate per 1,000 population of — compared with a figure of 0.51 for the country as a whole. For all but two of the years 1934 to 1939 this figure was near 0.55, being slightly below the average national rate of 0.61. Both locally and nationally the average figures for the years 1940 to 1942 showed a decline, the local figure to 0.42, and the figure for the country to 0.53. Of the 50 cases about which any particulars have been obtained, four were dead before the onset of a premature labour (in one, shock was thought to be the cause, in another multiple pregnancy) while in 12 other cases the confinement was premature (toxaemia 3, ante-partum haemorrhage 2, a fall 1, severe developmental abnormality 1, long labour 1). In 3 the foetus was dead before the onset of labour at term (a fall being the assumed cause in one and shock in another), while in 34 the foetus was considered to be alive at the onset of labour at term. In 9 labour was difficult; caesarian section was performed in 2 cases; the cord was round the neck in 2, and prolapsed in another 2; the mother was suffering from some degree of toxaemia in 5 instances, while 1 infant was suffering from developmental abnormality. 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, 1940 to 1943. 35 Table I. 1940 1941 1942 1943 No. of Live Births 2999 2712 3268 3500 No. of Deaths of Infants— Under 24 hours 18 16 27 21 1 to 7 days 35 28 25 36 1 to 4 weeks 41 31 14 20 2 to 3 months 23 28 19 20 3 to 6 months 14 20 6 19 6 to 9 months 12 17 9 13 9 to 12 months 6 11 3 4 Total 150 151 103 133 Infant Mortality Rate 50.0 55.6 31.5 38.0 Neonatal Rate 31.1 28.0 20.2 22.0 No. of Deaths of Children aged One year 7 14 13 5 Two years 8 8 1 7 Three years 6 3 5 2 Four years 1 2 3 3 INFANT MORTALITY. 133 (74 male and 59 female) infants died under one year of age, constituting an infant mortality rate of 38.0. 77 failed to survive one month. The neonatal mortality rate was therefore 22 constituting 57 per cent. of the total infant mortality rate. Of these 77, 21 failed to survive the 24 hours, the cause of death in 16 being prematurity, in one abnormality, in one atelectasis, and in two birth injury. 36 deaths occurred in infants who survived 24 hours, but failed to survive 7 days. Prematurity was responsible for 13 of these, atelectasis 3 and developmental abnormalities 17. Of the 20 infants who survived one week but succumbed before the end of the first month, in 5 the cause was prematurity, in 4 developmental abnormalities or atelectasis. Infections accounted for 7 deaths. Of the 20 deaths amongst those of 1 to 3 months, 3 were due to developmental abnormalities and one to prematurity; respiratory complaints accounted for 4 and gastro-enteritis 9. Infections accounted for most of the 36 deaths of those between 3 and 12 months, of which respiratory complaints were the cause in 13, gastro-enteritis in 7, tuberculosis in 5, meningitis, measles and whooping cough in one each. MORTALITY AMONGST CHILDREN of 1 to 5 years of age. Infections caused most of the deaths of children of the ages one to five, pneumonia being responsible for 2, and whooping cough for one of the deaths of those aged one. Pneumonia caused the death of 3 of those 36 of two years of age, influenza, meningococcal meningitis and tuberculosis being responsible for one death each. Tuberculosis was responsible for one of the two fatalities of those aged 3, and for one of those of 4 years of age. INFANT MORBIDITY. Ophthalmia Neonatorum. Two infants were notified as suffering from ophthalmia neonatorum, one, a mild case, having been born in a London hospital. The other child, born locally, was removed to hospital for treatment. Pemphigus Neonatorum. No notifications were received during 1943. MATERNAL MORTALITY. Nine deaths occurred from or were associated with pregnancy, giving a maternal mortality rate per thousand live births of 2.57 comprised of a rate of 1.14 for puerperal sepsis and 1.43 for other puerperal causes. The maternal mortality rates for each of the years from 1934 were 5.99, 3.46, 4.02, 4.19, 3.64, 2.40, 0.62, 3.18 and 1.50. The average for the first four war years, 1.92, is about half the average figure of 3.95 of the six pre-war years. Only part of the fall can be put to the credit of chemo-therapy because although the sepsis rate has fallen from 1.4 to 0.6, there has been a similar fall from 2.5 to 1.2 in those causes of maternal mortality other than sepsis. In the case of some of these deaths, the pregnancy was only remotely related, though perhaps the patient would have survived for longer if she had not become pregnant. One such case was a woman whose history of phlebitis preceded her pregnancy; some time after her confinement she developed thrombo-phlebitis of the veins of the leg which led to gangrene. Even more remote is the case of a woman whose heart had for long caused anxiety and who died five days after her delivery. One patient died in the early stages of pregnancy from a ruptured ectopic gestation, while another died of pyaemia following a self-induced miscarriage. One fatality was due to pulmonary embolism a week after a normal confinement. In two cases operative interference was followed by paralytic ileus. One patient who had had previous deliveries by caesarian section died four days after her delivery this time by the same means. The other, after a prolonged first stage of labour succumbed to obstetric shock and paralytic ileus after delivery. Two deaths were due to puerperal infection. In the one, a normal confinement was followed in a very short time by the onset of acute peritonitis due to the hæmolytic streptococcus. In the other, death finally occurred from broncho-pneumonia due to staphylococcal septicaemia following surgical induction necessitated by toxaemia of pregnancy. Of the patients who were delivered at term, three were confined in their own homes and five in hospitals or nursing homes. 37 PUERPERAL INFECTION. 18 notifications of puerperal pyrexia were received, two relating to women who had been confined in London hospitals. 10 of the others related to women who were confined in local nursing homes. Of these, 11 were removed to hospital of which two were general hospitals and the remainder isolation hospitals. One of the cases was a fulminating hsemolytic streptococcal infection which proved fatal after laparotomy for peritonitis. Two of the 7 patients in whom puerperal pyrexia followed on confinement of patients in their own homes were removed to isolation hospitals for treatment. Four of the notified cases were passed to the District Nursing Association for treatment. 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 836 Total visits 1,099 (b) To children under one year of age First visits 3,174 Total visits 7,353 (c) To children between the ages of one and five years Total visits 13,865 In addition visits were paid to 214 cases of measles and 98 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 47,164 (2) By children between the ages of one and five years 19,056 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 2,858 (2) Between the ages of one and five years 293 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 2,450 (2) Over one year of age 5,567 Attendances: The average weekly attendances at the infant welfare centres for 1943 was 1,250, a figure slightly less than that of 1,296 in the previous year. This was the average of a range from the figure of 1,150 in December to one of 1,425 in September. d 38 Vitamin, etc., Issues. A mother with a child under five years of age is entitled to one pint of milk daily, either free or at 2d. a pint (for children under two years of age the milk could be either liquid or dried). A mother with a child under 12 months is entitled to a priority issue of one pint of milk daily at full cost. All babies aged 6 to 18 months are entitled to 3 eggs per week. In addition children are eligible for their allowances of cod liver oil and orange juice. TREATMENT. The following particulars show the extent to which the facilities for treatment are used: Dental treatment: 157 children under five years of age and 345 expectant or nursing mothers made 952 attendances for treatment. Physio-therapeutic clinic: 178 new cases were referred to the clinic. The total number of attendances by patients was 1,963 (631 massage, 1,332 electrotherapeutic), 30 patients were seen by consultant orthopaedic surgeon and 264 were seen by the consultant physiotherapist. Correction of visual defects: 81 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: 14 children were treated at the Harrow and Wealdstone Hospital for this condition under the provisions of the agreement. Convalescent homes: One child was admitted to a convalescent home. Home nursing: Responsibility was accepted for the payment of the fees for the treatment of 11 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 161 (Of these 79 had children; 82 not) Number of persons registered during the year 29 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.) 33 Number of persons on the register who were receiving children for reward at the end of the year 157 (Of these No. with children 91; without 66) Number of children on the register at the beginning of the year 126 39 Number of children received during the year 76 Number of children removed from the register during the year 105 Removed to care of parents 58 Removed to care of another foster-mother 15 Legally adopted by foster-parent 6 Removed to charitable organisation, etc. 6 Removed to hospital 2 At exempted premises 11 Foster-parent left the district taking the child with her 1 Foster-mother no longer receiving payment 2 Child attained the age of nine years 4 Died Number of children on the register at the end of the year 97 ADOPTION OF CHILDREN (REGULATION) ACT, 1939. The operation of this Act designed to regulate arrangements made by adoption societies and other persons for the adoption of children, to provide for the supervision of adopted children by welfare authorities in certain cases and to restrict the making and receipt of payments in connection with the adoption of children was deferred to June 1st, 1943. Welfare authorities are interested in a child under nine years of age (until he attains that age or is adopted) in the care of a person not the parent or guardian, in respect of the placing of whom arrangements have been made by any person not the parent or guardian unless these were made by a Registered Adoption Society or Local Authority. As regards such children any person taking part in the arrangements should give at least 7 days' notice to the welfare authority of the area in which the adopter resides. During the year 2 notices were received. ILLEGITIMATE CHILDREN. Probably because greater difficulties are encountered which prevent the marriage of the parents under war conditions than in peace time, the illegitimate birth rate has increased. The percentage of total births for this district in the six years 1934 to 1939 was an average of 3.0. The slight rise to 3.4 in 1940 was only a continuation of the increase in each of the three previous years. 1941 showed a sharp rise to 4.6 followed by a decline to a figure of 4.1 in 1942. While these increased numbers enlarge the problem, the existing demand for labour eases the making of suitable arrangements for the mother and her child. The Ministry of Health in Circular 2866 (1st October, 1943) urged welfare authorities to consider the problem, suggesting they should reinforce the work of existing voluntary moral welfare associations and appoint a trained worker experienced in the special problems. Consideration of the circular was deferred pending the receipt of proposals from the County Council as, in addition to the appointment of the social work, extra accommodation for the reception of the expectant mother and later of the mother and her child would be required. 40 War Nurseries. SUPERVISION OF CHILDREN. At the beginning of the year there were the following nurseries (with their accommodation): Spencer Road, Wealdstone (49), Walton Avenue, South Harrow (40), Buckingham Road, Edgware (40) and Kenmore Road, Kenton (40). The pressure of demand came from South Harrow and Wealdstone, so the South Harrow nursery was extended by another 19 places (ready in April), while a new nursery for 50 places was opened in August in Headstone Drive, this eliminating the waiting list for the Spencer Road nursery. The Ministry approved the principle of the erection of nurseries to accommodate children of women war workers who applied for the admission of two children, or to accommodate children of part-time workers. On this understanding nurseries were opened in Rayners Lane, in November, and Vancouver Road, Edgware, in December, each being for 50 children. The increasing difficulty in obtaining staff deferred the opening of the Vancouver Road nursery. When local authorities were permitted to advertise, staffing difficulties, though never far off, at no time assumed the serious proportions experienced when this facility was withdrawn. The very high absentee rate amongst the nursing staff makes it essential that most of the staff are ready to take up their duties before risking the opening of a new nursery. The reason for this very high absence rate on account of sickness is not very clear. That it is as high in summer as in winter suggests that the structural conditions of the nurseries themselves are not the cause, and it may be chiefly because many of the staff today would not be working outside their own homes were it not for the war. Towards the end of the year the only part of the district in which the demand for nursery accommodation was not being met was in Kenton, so application, which was belatedly received, was made for approval to extend the Kenmore Road nursery. The average attendances at each of the nurseries was, for Spencer Road 45.2, South Harrow (after extension) 48.0, Buckingham Road 34.0 and Kenmore Road 34.2. The Ministry of Health Circular S.R.O. 78, by which applications from persons outside the district were to be treated the same as those of local residents caused no change here as this practice had been followed for some time. For a period after the new nurseries at Rayners Lane and Vancouver Road were opened, because vacancies were only slowly taken up, it was possible to take advantage of the approval contained in Circular S.R.O. 90 which authorised, subject to certain provisos, the admission to the nurseries of children in cases of domestic hardship. From the time of the opening of the nurseries it was found impossible to attach to each nursery or even to pairs of nurseries a nursery school trained teacher. Towards the end of the year the appointment of such a teacher was made, her duties, in addition to acting as warden at one of the nurseries, being to supervise the work of the wardens attached to the other nurseries. Towards the end of the year one probationer obtained her diploma. Arrangements had been made for certain of the probationers to put in a month at a residential nursery. 41 Daily Minder Scheme. Very little advantage was taken of this scheme. During the year 34 mothers registered, being prepared between them to take care of 61 children. Probably partly because of the delay in their being requested to look after any children, on many occasions when a mother finally called it was only to find out that the proposed guardian had reconsidered the matter. Five withdrew, leaving 29 names on the register at the end of the year; of these, 13 are registered for one child, 11 for two and 5 for three. The greatest number of minders looking after children though, at any one time was only 10; 19 have at some time received children, though 10 have had none. The scheme does not seem to be popular with mothers who wish their children looked after, as few whose application for admission of their children to the nurseries had for any reason to be declined made arrangements for the same children to be looked after by minders. MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,099 visits to expectant mothers, 836 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 3,128 Total number of attendances by expectant mothers at all clinics 14,874 Percentage of total notified births (live and still) represented by the number of expectant mothers attending the clinics 86 Vitamin, etc., Preparations. The expectant mother is entitled to a pint of milk either free or for 2d., to a priority issue of 3 eggs per week; and to a capsule containing vitamins A & D, or to cod liver oil and concentrated orange juice. Clothing Coupons. The extra clothing coupons to which expectant mothers were entitled had been distributed from the Public Health Office, an arrangement which worked quite smoothly and which enabled health visitors to get in touch with some few mothers of whom otherwise they would not have learned until the baby was born. Because such a high proportion of the expectant mothers here attend the ante-natal clinics this number was comparatively small, and amongst them were those who did not in any event wish to avail themselves of the services of the health visitor. While districts with a low percentage attending the ante-natal clinics might therefore have regretted the change made in July by which the issue of the extra clothing coupons was henceforth to be made from the Food Office, in this area it could not be held that the change did really result in the disadvantages that some areas expected to experience. 42 Consultant Ante-natal Clinic. The attendances necessitated the opening of an additional monthly session, so from mid-year the consultant ante-natal clinic has been held three weeks out of every four. During the year 316 women made 433 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, 22 patients being seen. Five women attended for post-natal examination. ARRANGEMENTS FOR THE CONFINEMENT. Domiciliary Confinements. Number of Confinements: The number of births attended in the district by midwives who gave notice of their intention to practice was 1,955, in 883 cases the attendant being present as a midwife and in 1,072 as a maternity nurse. Of the confinements occurring in patients' homes in the district, 1,181 were attended by local midwives whose practice is limited to domiciliary work (805 as midwives and 282 as maternitv nurses) and 24 by midwives from adjoining areas (17 as midwives and 7 as maternity nurses). N umber of Midwives: The number of midwives who during the year notified their intention to practice in the district was 43. Of these 4 removed from the district, leaving 39 in practice at the end of the year. Of the total number, 22 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 few also carrying on a very limited domiciliary practice; and 8 though resident in adjoining areas attended some cases in this district. At the end of the year there were in practice 5 independent midwives carrying on a domiciliary service, these between them attending 68 cases during the year. Midwives Notifications to Local Supervising Authority: 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 288 Still birth 10 Death of Infant 9 Death of Mother — Laying out the Dead — Artificial Feeding 14 Liability to be a Source of Infection 12 Of the 288 summonses to medical practitioners, 59 were on account of some condition during pregnancy, 70 during labour, 120 in the lying-in period, and 39 some abnormality of the infant. 43 Of the 59 summonses to a patient during pregnancy 28 were because of albuminuria, œdema, or toxaemia, and 18 because of haemorrhage. Of the 70 summonses to a patient during labour the reason given in 41 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). 81 of the 120 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 7, a raised temperature in 12, phlebitis 6, and inflamed breast one. Of the 39 summonses to infants, 9 were on account of some discharge from the eye, 17 because of feebleness or asphyxia, 8 because of deformity (including 2 of phimosis) and 4 some other abnormal state or condition. 288 out of 883 midwifery cases attended is a percentage rate of 32.3. The corresponding figure in 1942 was 33.1. Local Authority's Midwifery Service: The same arrangements continued in force, the 16 midwives working in four teams of four. The adoption of the recommendations of the Rushcliffe Committee in regard to off-duty time entailed only a modification of these times to provide for the longer week-end break. The number of patients attended by the Council's midwives was 787 in which they acted as midwives, and 302 in which they acted as maternity nurses, a total of 1,089. Of the patients attended by midwives acting as such, 373 were assisted to pay the full amount, in 149 cases no charge was made, while 265 were assisted. The corresponding figures in regard to patients attended by midwives acting as maternity nurses were 232, 38, and 32. The average number of cases attended by each midwife was 68. Home Helps: There was no easing of the difficulties in providing home helps to attend the homes of mothers being confined, the increased remuneration not proving sufficient attraction. During the year 195 cases were attended by home helps under the Council's scheme. Consultant Services: During the year consultants were summoned to nine patients, two of whom were in labour, two were ante-natal cases and five post-natal. Of the cases in labour, in the one of extended breech delivery was assisted; but the other, a case of slight disproportion, was allowed to deliver herself by natural forces. Both the ante-natal patients, the one suffering from disproportion and the other from post-maturity, were admitted to hospital. Of the five post-natal patients, four were suffering from post-partum haemorrhage, two being due to retention of the placenta; in two of these blood transfusion was given and the patient removed to hospital; in one the placenta was removed under general anaesthesia, while the other patient was immediately admitted to hospital. The fifth was a case of pulmonary embolism who was subsequently admitted to hospital. Institutional Confinements. Number of Confinements: 1,139 births occurred in registered nursing homes in this district. 408 births to mothers from outside districts which 44 occurred here took place in nursing homes, 8 in private houses. Of these 1,139 confinements, 365 were conducted by local practitioners. Notifications were received of 1,437 births to Harrow mothers which took place outside the district. Of these, 1,227 were from hospitals and 179 from nursing homes. Of the patients confined in hospitals outside the district, 604 were delivered at Redhill County Hospital and 374 at Bushey Maternity Hospital. Of a total of 3,509 births, 1,341 occurred in the patient's own homes, 731 in local nursing homes and 1,437 in hospitals or homes outside the district. Some 2,168 or 60 per cent., therefore, of the confinements took place in institutions either inside or outside the district. During the year 17 patients were admitted to a London hospital under the Council's arrangements. POST-NATAL SERVICES. Post-natal Examination. 215 women attended the clinic for post-natal examination, making altogether 264 attendances. Puerperal Infection. (a) Consultant services: The consultant was not summoned to any 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 9 patients were removed. (c) Home nursing: 4 patients notified as suffering from puerperal pyrexia were nursed under the Council's arrangements by the staff of the local District Nursing Association; in addition there were the 15 cases attended by the Council's midwives who developed pyrexia or were for other reasons suspected of being infectious. BIRTH CONTROL CLINIC. Sessions of this clinic were held fortnightly up to July and thereafter monthly. 175 women, of whom 69 attended for the first time, made a total of 258 attendances. In addition there were four cases to whom no advice was given as there were no medical grounds justifying such action. 28