AC.439 (1) HARROW HARR 11 ??? Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1944 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER- AT-LAW King & Hutchings, Ltd., Printers, Uxbridge 68596 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1944 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 1944. The health of the district during the year was again most satisfactory, most of the vital statistics being an improvement even on those of the year 1943. The infant mortality rate was 34 (last year 38.0; national rate 46) and the maternal mortality rate 0.56 (2.57 in 1943; national rate 2.03). The birth rate rose to 18.7, so exceeding last year's figure which was the highest recorded for the district. On the other hand the death rate also showed a slight rise to the figure of 9.3 (9.1 last year; national rate 11.6). None of the notifiable infectious diseases exhibited an epidemic prevalence while the death rates of these infections were mostly smaller than the national figures. In addition to the submission of the report in its usual form, this year in a separate chapter the health of the district throughout the war years has been reviewed. After that follows another chapter in which are considered those changes which have already been brought about, those which might happen, and certain other aspects respecting the local health services. 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. July 7th, 1945. STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Statistics and Social Conditions of the Area Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1944 185,090 Rateable Value (April 1st, 1944) £2,116,516 Sum represented by a penny rate (April 1st, 1944) £8,445 3 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Birth rate per 1,000 of the estimated resident population, 18.7 Legitimate 3,314 1,685 1,629 Illegitimate 159 82 77 Stillbirths:— Legitimate 115 67 48 Rate per 1,000 total (live and still) births, 3.3 Death rate per 1,000 of the estimated resident population, 9.3 Illegitimate 6 4 2 Deaths 1,732 862 870 Deaths from puerperal causes:— Deaths Rate per 1,000 total (live and still) births Puerperal sepsis 1 0.28 Other puerperal causes 1 0.28 Total 2 0.56 Death rate of Infants under one year of age:— All infants per 1,000 live births 34.8 Legitimate infants per 1,000 legitimate live births 34.7 Illegitimate infants per 1,000 illegitimate live births 37.7 Deaths from Cancer (all ages) 320 ,, ,, Measles (all ages) 1 ,, ,, Whooping Cough (all ages) 3 „ „ Diarrhœa (under 2 years of age) 12 Population. The estimate of the Registrar-General of the population of the district has steadily declined in recent years. His figure of 185,090 is a sharp fall on the estimate of 191,660 in 1943. Births. The 3,500 live births in the district in 1943 was the highest recorded figure, resulting in the highest birth rate since amalgamation. There was a slight fall to the figure of 3,473, though, because of the smaller population, the birth rate rose to 18.7 as against the figure of 18.2 for the previous year. Deaths. Of the 1,034 deaths in the district, 92 occurred among non-residents. Of the outward transfer deaths, 16 took place at the Orthopaedic Hospital, 5 at the Harrow Hospital, 20 in Nursing Homes and 30 in private houses. Of the deaths of local residents which occurred outside the area, most took place in institutions, 333 being at Redhill Hospital, 66 at 4 Redhill House and 60 (including 7 new-born infants) at other County Hospitals. Nine deaths occurred in institutions for the treatment of the tuberculous. 57 deaths took place in hospitals just outside the district, and 92 in various London general hospitals. The following is the Registrar-General's abridged list of causes of death in the district:— Male Female Male Female Typhoid fever 0 0 Heart disease 191 185 Cerebro-spinal fever 1 1 Other circ. diseases 30 43 Scarlet fever 0 0 Bronchitis 43 34 Whooping cough 2 1 Pneumonia 53 58 Diphtheria 1 1 Other resp. diseases 11 13 Resp. tuberculosis 44 39 Ulcer of stomach 25 3 Other tuberculosis 9 5 Diarrhoea under 2 years 10 2 Syphilitic diseases 6 3 Appendicitis 2 4 Influenza 3 2 Other digestive diseases 17 24 Measles 0 1 Nephritis 22 16 Acute polio-myelitis 0 0 Puerperal sepsis 0 1 Acute encephalitis 1 0 Other maternal causes 0 1 Cancer of mouth and oesophagus (M), and uterus (F) 14 17 Premature birth 15 11 Cong. malformations, etc. 24 18 Cancer of stomach 28 19 Suicide 10 7 Cancer of breast 0 44 Road traffic accidents 14 2 Cancer of other sites 112 86 Other violent causes 38 49 Diabetes 3 2 All other causes 82 73 Intra.-cran. lesions 51 105 All causes 862 870 1,732 deaths in a population of 185,090 is a death rate of 9.3, a slight rise on the average figure of 9.1 for the last four years. The total deaths, 962 male and 870 female, is a further slight decline on the figures of the previous year. The relative freedom from influenza was reflected in the smaller number of deaths, 5 as against 51. There were fewer deaths from intra-cranial lesions, 156 as against 180. On the other hand there was a substantial increase in each sex of deaths due to cancer, the corresponding figures in each of the groupings being 31 as against 26, 47 as against 32, 44 as against 31 and 198 as against 189. Although the number of deaths from pulmonary tuberculosis amongst males showed a fall from 55 to 44, this is again offset by an identical increase amongst females, deaths being 39 as against 28 in 1943. Fatalities from the infectious diseases expressed as a rate per thousand population again compared favourably with figures for the country as a whole, those of whooping cough 0.015, diphtheria 0.01, and measles 0.005 being about half the national rates (0.03, 0.02 and 0.01), that for influenza being much less, 0.02 as against 0.12, and diarrhoea in those under two years of age being slightly lower at 4.0 per thousand live births as against 4.8. 5 GENERAL PROVISIONS OF HEALTH SERVICES FOR THE AREA. CLINIC AND TREATMENT CENTRES. The only changes in the clinic sessions during the year were the transference in November, on the closing down of First-Aid Post 61, of the infant welfare and ante-natal sessions to the Broadway clinic, and the transferring in August of one infant welfare session from Chandos to the Honeypot Lane clinic building. At the end of the year then, 24 weekly infant welfare centre sessions were being held in 13 premises, 14 antenatal sessions (2 fortnightly, the remainder weekly) at 12 premises, and the equivalent of 5 weekly toddlers' sessions at 8 premises. AMBULANCE FACILITIES. The ambulances continued throughout the year to be stationed at Ruffell's Garage, Wealdstone, being manned by the Civil Defence personnel attached to C.15 ambulance depot. The following figures relate to the service for the past year:— Traffic accidents 146 Other accidents, including street illness 442 Maternity removals 407 Sick removals to and from hospitals 2,845 Calls received, ambulance not required 48 Total calls for the year 4,851 Total mileage for the year 42,012 Carried out for other authorities 123 SANITARY CIRCUMSTANCES OF THE AREA. WATER. Circular 49/45 of the Ministry of Health requires that reference be made to certain aspects of the water supply. Full particulars of the district's supplies were set out in the Annual Report for 1938. Copies are regularly received from the analyst of the Colne Valley Water Company of the results of the analyses carried out on samples of water collected from houses throughout the district. In addition each quarter samples are submitted for full chemical and bacteriological analysis at an independent laboratory. The findings in every case have proved satisfactory. The Water Company are advised of the occurrence of any infection which might be water borne, and they arrange for the water of the house in which the patient is to be analysed and copies of these reports are received. Practically every house in the district is served with water from public water mains direct to the house. 6 SANITARY INSPECTION OF DISTRICT. A. Inspection of Houses:— (a) Public Health Acts. On complaint of defects 616 On complaint of other nuisances 765 Routine inspections 124 Number defective 493 Revisits 4,951 Inspections of foster parents' premises 14 Visits to verminous premises 413 (b) Housing Act. Routine inspections 19 On complaint of defects — Not in all respects fit 1 Unfit for human habitation — Revisits 182 Surveys under S. 157, 1936 Act 64 Number of cases of overcrowding 29 Inspections of houses-let-in-lodgings — B. Inspection, Visits, etc., to Other Premises:— On complaint 92 Number of routine inspections of premises liable to give rise to nuisance 315 Revisits 235 Number of visits to premises kept under periodical inspection 136 Number of complaints of rats investigated (primary visits) 970 Number of revisits 1,256 Number of visits re food poisoning or small pox contacts 107 Number of observations for smoke nuisances 1 Number of inspections of factories (mechanical) 440 do. do. factories (non-mechanical) 117 do. do. workplaces 40 do. do. outworkers' premises 118 do. do. cinemas and places of entertainment 74 do. do. hairdressers' premises 1 Number of visits under Shops, etc., Acts 9 Number of evening observations under Shops Acts 2 Number of visits to premises where rag flock used — C. Inspection of food and premises where food is manufactured or prepared:— Slaughterhouses 25 Butchers (including Meat Depot) 507 Cowsheds 36 Dairies 92 Fish-shops 48 Fried Fish-shops 32 Bakehouses 65 Cafes and Restaurants 108 Ice Cream premises 29 7 D. Inspection of premises where food is retailed:— Greengrocers 76 Provision Merchants 501 Milk shops 4 Bakers and Confectioners 39 Other Food premises 96 HOUSING INSPECTION. 1. Inspection of Dwelling-Houses:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 802 (b) Number of inspections made for the purpose 5,935 (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 494 2. Remedy of Defects without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 365 3. Action under Statutory Powers:— 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 1 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 1 (b) By Local Authority in default of owners — B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 108 (2) Number of dwelling-houses in which defects were remedied after service of formal notices (a) By owners 75 (b) By Local Authority in default of owners — C. Proceedings under Sections 11, 12, and 13 of the Housing Act, 1936 — 8 Complaints. During the year, 1,387 complaints were received. These were:— Accumulations of refuse 61 Animals causing a nuisance 41 Damp condition of premises 39 Decorations 22 Drains and sewers:Blocked 447 Defective 50 Dustbins defective 98 Houses in generally defective condition 98 Houses with only small defect (roofs 31, gutters 9, walls 2, chimneys 8, stoves 12, stairs 3, floors 29, doors 3) 97 Defective waterclosets 45 Dirty premises 27 Factories—insufficient watercloset accommodation 5 Food unfit or in dirty condition 49 Gardens—flooding 11 Insect infestations 22 Overcrowding alleged 59 Plumbing defects 87 Shelters unsatisfactory (shelters dirty 1, W.C.s dirty 9, flooding 1) 11 Smoke nuisances 3 Vermin 63 Watercourses 3 Complaints of smells (chiefly smells from pigs and dead rats or mice under floor boards) 15 Other complaints (pig bins, wasps nests, mis-use of footpaths, defective fences, etc.) 34 Total 1,387 During the year 1,118 informal notices were served; and 108 statutory notices, of which 75 were complied with. Inspection of Houses. Sixty-four surveys were carried out and certificates issued under Section 157 of the 1936 Housing Act. The number of certificates issued is now 10,327. Overcrowding. At the end of the year 65 houses were known to be statutorily overcrowded. Of these one was crowded by 4 units, two by 3½, two by 3, three by 2½, eleven by 2, eight by 1½, sixteen by 1, and twenty-two by ½ unit. These are learned of mostly by the tenants applying to be helped to obtain more commodious premises. Routine inspection of houses is no longer carried out so that the true position as regards crowding is unknown. 9 Housing Act, 1936. Amongst the premises the subject of Clearance or Demolition Orders in 1943 were Nos. 7 to 10, Burns Road, Wealdstone. These were vacated and later demolished during the year. The appeal against the Demolition Order in respect of 38, Shelley Road was withdrawn, but not that in regard to 16, Marlborough Hill. The following is a list of those houses included in the different Orders, Clearance or Demolition, which are still occupied:— Clearance Orders: West End Lane, No. 1 (1) and No. 2 (2); Ferndale Terrace (8); High Street, Stanmore, No. 3 (2) and No. 4 (4); College Hill Road (2); Headstone Place (20); Pleasant Place (3); Brewery Cottages (5), a total of 47. Demolition Orders: 1-11, Peel Road (1); 93, 95 (1) and 99, 101 (1), Greenford Road; Kingsfield Terrace (6), a total of 9. Closing Orders: Canning Place (2). In addition, 4 out of the 5 properties the Minister condemned in the unconfirmed Marlborough Road Clearance Orders are occupied, the total number of condemned properties still being occupied being 62. There are also four houses at present occupied but in regard to which the owner has given an undertaking that they will not be re-let when vacated by the present tenants. In addition, there are many houses which, but for the intervention of hostilities, would have been represented. Apart from those in "Poets Corner," some 220 houses have been listed. Over and above these are a further 550 included in the survey of the Senior Sanitary Inspector which will call for early inspection with a view to representation. Rat Infestation. During the year a third operative took up duties. This enabled work to be done on the larger areas of infestation, including the infested refuse tips at Wealdstone and Cannon Lane. In all 970 complaints were received and the number of re-visits totalled 1,256. Before the end of the year there was an appreciable slacking off in the number of complaints, from which it is hoped it can be deduced that the preventive measures of rat eradication are being really effective. The major surface infestations at the tips having been dealt with, it was possible to start a complete examination and, where necessary, treatment of the brooks and surface waters of the district. When these have been dealt with, work will be started on the sewers. Smoke Abatement. No observations for smoke nuisance were carried out during the year. Verminous Premises. Eighty-five premises were inspected on receipt of complaints of infestation by vermin and other insects such as ants, crickets, beetles, cockroaches and moths. The number of premises found to be infested with the bed bug was 63; the total visits paid to these premises was 413. 10 As to the eradication of bugs in cases of bad infestation, arrangements were made with the owner or occupier to engage specialist firms to fumigate, and in some cases these firms used Cyanide Gas. In other cases where the infestation was not so extensive, advice as to best means to adopt were given to owner or occupier and in a few cases where this advice was not put into effect a notice had to be served to enforce abatement of nuisance. In many instances advantage was taken of the opportunity to purchase insecticide and loan of a spray from this department. As to infestation by any of the other insects mentioned, the Sanitary Inspector gave the necessary advice to the occupier as to best means to adopt. Factory Act. In this district there are 454 factories with mechanical power, 148 without mechanical power, and 113 workplaces. The numbers of visits paid to these three classes of premises were 440, 117, and 40. Of the 67 public health nuisances detected, 9 were due to want of cleanliness. The sanitary accommodation was unsatisfactory in 46 instances, being unsuitable or defective in 16, unclean or insufficient in 29, and not separate for sexes in one. Twelve other nuisances were noted. Particulars of 109 outworkers resident in this area were received. To these 118 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 the general welfare of the shop assistants. Nine visits were paid. Two evening observations were carried out; no contraventions were recorded. 11 INSPECTION AND SUPERVISION OF FOOD. (A) MILK SUPPLY. Production. During the year there was a change in the occupation of one farm, and at another the removal of cows was reported. The total number of cowkeepers in the district is 12, occupying 12 separate cowsheds. Of these, 5 hold licences for the production of accredited milk and one for tuberculin tested milk. Five local producers sell milk in the district. Distribution. Including three company distributors, the number of retailers of milk in the district is 30. 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 five local producers who distribute in this area, 6 by the five single retailers, while at five premises milk is sold in unopened receptacles only; in addition there are 12 retailers selling milk here though not occupying premises in the district. Licensing. Two additional licences to retail tuberculin tested milk, and one more supplementary licence to outside producers to retail tuberculin tested milk were issued; also one additional licence to retail pasteurised milk and four more supplementary licences to outside producers to retail pasteurised milk. At one farm pasteurising was discontinued. Of the 17 premises licensed to retail tuberculin tested milk, 8 belong to one firm and two to each of three other firms. Two premises are licensed for the bottling of tuberculin tested milk; supplementary licences were issued to three producers outside the district to retail tuberculin tested milk here, and six supplementary licences were issued to outside producers to retail pasteurised milk in the district. Two establishments were licensed for pasteurised milk, 17 belong to one firm, 13 to one, and 5 to one and 2 to another. Sampling. Eleven samples of pasteurised milk were submitted to bacteriological examination and the phosphatase test. All except two which contained bacillus coli were satisfactory. Three samples of tuberculin tested milk, three of tuberculin tested (Pasteurised) and six of raw milk were taken and all found satisfactory. (B) MEAT. Inspection. Sixty-four pigs owned by pig clubs or institutions were killed and inspected. In all cases the carcases were sound, it being necessary to condemn only one pig's head for tuberculosis. 12 Meat Depot. Carcases of six sheep of total weight 213 lbs. were condemned, three on account of black mould, and three owing to putrefaction; 86 lbs. of beef were condemned because of bone taint; 615 lbs. due to putrefaction, 31 lbs. owing to black mould, 40 lbs. for bruising; 209 lbs. of mutton because of black mould, 24 lbs. due to putrefaction and 10 lbs. owing to abscess; 554 lbs. of pork due to putrefaction, and 31 lbs. for other reasons; 16 lbs. of veal for putrefaction and 8 lbs. for bruising. About 676 lbs. of offal were condemned on account of putrefaction, 122 lbs. for parasitic disease, 172 lbs. for mould, 13 lbs. for tuberculosis and 6 lbs. for bruising. (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 decrease in the number of tinned foods condemned, the 3,494 tins being: fish 1,063, milk 856, vegetables 803, meat 548, soup 117 and fruit 107. Other condemned foodstuffs included 212 stone fish, 340 cwts. 17 lbs. fruit and vegetables, 498 lbs. flour, 263 lbs. and 264 packets of cereals, 122 lbs. tea, 47 lbs. sugar, 100 lbs. cheese, 2,442 lbs. meat, 256 lbs. bacon, 3,085 lbs. sausage, 461 lbs. chickens, 180 lbs. rabbits, 7 lbs. pepper, 2 lbs. lard, 143 lbs. sweets, 120 beef cubes, 19 packets dried eggs and 1,920 eggs; in addition, 703 jars of jam, pickles, meat paste and coffee. ISOLATION HOSPITALS. ADEQUACY OF ACCOMMODATION. 1944 was a year of low incidence of scarlet fever and of diphtheria. The demand on accommodation was so light that the Honeypot Lane Hospital was closed on the 12th March, remaining so for the rest of the year. The greatest number of scarlet fever patients under treatment in the hospital on any one day was 26 and of diphtheria 9. In all 70 patients were removed to outside hospitals, including 8 cases of puerperal infection. PROVISION OF NEW HOSPITAL. Further consideration was given to the question of the provision of new hospital accommodation in view of the proposals in the White Paper on the Health Services, and of the views now held as to a 200-bed hospital being the minimum-sized administrative unit. Scarlet Fever. CLINICAL ASPECTS. Admissions: Number admitted with a diagnosis of scarlet fever 219 Number suffering from scarlet fever 177 Number in whom the diagnosis was not confirmed 42 Of these cases in which the diagnosis was not confirmed, 22 suffered from tonsillitis, 11 from erythema, 4 from rubella and 2 from pharyngitis. 13 Deaths: Number of deaths in patients suffering from scarlet fever, 2. In neither case was scarlet fever the real cause of death. The first fatal case was an adult male who after the first stage operation for prostatectomy developed surgical scarlet fever; death was due to uraemia. The other case was a child who had had a cyst of the neck removed. This suppurated and the child developed a scarlatiniform rash. Purulent rhinitis led to a fatal bronchial pneumonia. Treatment: Of the 165 patients admitted who were considered to be suffering from scarlet fever, 42 were given serum treatment, mostly 3,000 units. Prontosil was given to 94 patients. Complications: 17 per cent. of the patients admitted suffered from some complication. The number who suffered from otorrhœa was 14 (including 3 who developed mastoid involvement), from adenitis 6, from rheumatism 3, and from secondary sore throat 2. A mastoid operation was performed on three patients, one of whom was admitted while suffering from a mastoid involvement. The consultant surgeon visited a patient suffering from an obscure abdominal condition. Cross Infection: Eight patients developed other infections during their stay in hospital, in each case the infection having been contracted before admission. Rubella developed in 3, whooping cough and mumps in 2 each and chickenpox in one. Return Cases: Return cases were notified from six households to which patients treated in hospital for scarlet fever returned during the year. Period of Stay: 68 per cent. of patients returned home on or before the 21st day from admission. 16 per cent. were in until the 28th day or longer, most of them being detained by some minor abnormality. Diphtheria. Admissions: Number of cases admitted on a diagnosis of diphtheria (including 3 Service cases) 54 Number of cases clinically diphtheria 15 Number of positive swab contacts 5 Of the 34 cases in which the diagnosis was not confirmed, 27 were suffering from tonsillitis or quinsy, 2 each from laryngitis or pharyngitis. Deaths: Number of deaths from diphtheria, 2. One child aged 20 months admitted on the sixth day of illness died 28 minutes after admission. The other fatal case, a boy of 5, was admitted with naso-pharyngeal diphtheria on the third day of illness, dying four days later. Other members of the family were infected in each of these instances, these being the only cases of secondary infection of diphtheria in the district during the year. 14 Complications: Three patients suffered from palatal paralysis, one from paralysis of the extrinsic eye muscles, while the heart musculature was involved in one case. 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 1 58 195 73 ??? 9 7 10 3 2 — 387 Diphtheria 1 12 18 9 9 4 3 — 1 — — 57 Pneumonia 6 15 13 5 3 2 9 24 23 9 15 124 Erysipelas — 1 1 — 3 2 7 12 7 4 10 47 Puerperal Pyrexia — — — — 1 3 10 4 — — — 18 Dysentery 1 5 4 — 2 — 1 — — — — 13 Cerebro-spinal Fever — 2 — — 1 1 1 1 1 — — 7 Enteric Fever — — — — — — 1 1 2 — — 4 Malaria — — — — — 2 5 3 — — — 10 Pemphigus neonatorum 3 — — — — — — — — — — 3 Food Poisoning — — — — 1 — — 1 2 — 1 5 Ophthalmia Neonatorum 1 — — — — — — — — — — 1 Acute poliomyelitis — — — 1 — — — — — — — 1 Measles 12 185 30 26 12 8 9 8 2 1 — 573 Whooping Cough 59 330 267 7 3 4 4 6 1 1 — 682 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 387 219 1 — — Diphtheria 57 55 1 — 2 Pneumonia 124 — — — 111 Erysipelas 47 — 11 — 1 Puerperal Pyrexia 18 — 8 — 1 Dysentery 13 — 4 4 — Cerebro-spinal Fever 7 — — 7 2 Enteric Fever 4 — 3 — — Malaria 10 — — — — Pemphigus neonatorum 3 — — — — Food Poisoning 5 — — — — Ophthalmia Neonatorum 1 — — — — Acute poliomyelitis 1 — — — — Measles 573 — 13 — 1 Whooping Cough 682 — 15 — 3 15 DIPHTHERIA. Incidence. Fifty-seven notifications were received during the year of cases occurring amongst the civilian population. In the vast majority of these though the patient was in fact suffering from some other condition, mostly tonsillitis. The corrected figure of 16 is a rate per thousand population of 0.08 compared with the national rate of 0.58. The corresponding figures for the years 1934 to 1943 ranged from 0.20 to 0.60. Four cases occurred in one family, one proving fatal, the infection probably originating in a missed case. Two cases occurred in another family, again one proving fatal. One patient was suffering from laryngeal diphtheria. Of the cases proved to be diphtheria, 20 per cent. were under 5 years of age and 80 per cent. were of school age, none being over 15. Place of Treatment. All but one child who was treated at home were admitted to the Harrow Isolation Hospital. Deaths. Two cases proved fatal, one a child of 20 months, not being treated till the sixth day of illness, the other a boy of 5 years who was not treated until the eighth day. Immunisation. There was a marked falling off in the number of children immunised in 1944, only 2,359 being treated as compared with 5,427 in 1943, 7,366 in 1942, and 6,858 in 1941. Of these, 1,327 were treated at infant welfare centres, 149 at the local war nurseries, 795 by general practitioners and only 28 this year at the local elementary schools. The fall in numbers is less serious perhaps than might appear because it occurred mostly amongst those of school age. As a contrast, the figures of those treated at the infant welfare centres are well maintained, being 1,327 in 1944, against figures of 1,532, 1,977 and 1,184 for the years 1943, 1942 and 1941. Practically all these will be children of under five years of age, the vast majority being done at about the ideal age of near the twelve-month. It is now expected that sufficient children of school age have been immunised to make it most unlikely that there can be any extensive outbreak of diphtheria. In many areas though the percentage of underfives immunised is greater than the proportion amongst school children. This means that for a number of years the position in regard to school children even though no further immunisation were to be carried out would improve. Efforts then should be directed to maintaining a high standard of immunity in the under-fives. The position in this district in this regard is not unsatisfactory, and it is for this reason that it is felt that although there has been this falling off in the total number treated, there is no cause for disquiet in that the position of the under-fives is not deteriorating. 16 Of the 4,633 children invited for Schick-testing, 2,047 attended, of whom 47 were found to be positive. This figure of 3.7 is a distinct increase on that of 2.5 for each of the two previous years. Two children who were considered to be clinical cases of diphtheria had been inoculated against diphtheria. One child had 0.2 and 0.5 c.cs A.P.T. a twelve-month before; she was not subsequently Schick-tested. The other child was supposed to have been immunised some years before in another district; no record of this could be traced though and the child had not been Schick-tested. Provision of Antitoxin. Sixty-four lots were issued, totalling 512,000 units. Schools and the Spread of Infection. There were no cases this year in which there was any suggestion that infection had been contracted in school. SCARLET FEVER. Incidence. Out of 44 of the 390 patients notified as suffering from scarlet fever, the diagnosis was amended to tonsillitis in the case of 15, to German measles 12, and to erythema 8. A net figure of 346 is an incidence rate per 1,000 population of 1.87 compared with the rate of 2.40 for the country as a whole. In this district the incidence had increased from a figure of 1.06 in 1940 to 1.66 in 1941 followed by a sharp rise to 3.16 in 1942 and a further increase to 3.52 in 1943. The rate during the years 1934 to 1943 had ranged from 1.06 to 4.70. The incidence was heaviest in the first quarter, with a weekly average of 14, a range of 8 to 23. This was the same rate which had been almost uniform throughout 1943 and which in that year had given the greatest number of cases notified in this district in any one year. There was a marked fall to a weekly average of 8 in the second quarter, and a further decline to 3.5 in the third quarter. This was followed by a slight increase in incidence in the last quarter with an average weekly rate of 6, a figure though which rose to 9 in the month of December. Deaths. No deaths occurred in this district due to scarlet fever. Place of Treatment. Of the 390 cases 168 or 43 per cent. were treated at home at the election of the parents. Of those removed it seemed another 21 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 10 per cent. the patient was an adult, in 8 per cent. there was more than one patient, in 6 per cent. of the cases there was no-one to nurse the patient, and in 5 per cent. there was a baby in the home. In only one case was removal requested on account of the clinical condition of the patient. 17 Secondary Infection. More than one case occurred in 19 households. In one there were 4 cases, in two 3, while in the remainder only the two patients, the secondary and the presumed infecting case, though in one household, the two children apparently succumbed simultaneously. In 9 of these households the primary 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 another case the onset was on the date of removal. The interval between the onset of the primary to the onset of the secondary case was two days in 4 instances, three days in 2, and four days in 5, i.e. in more than one-half it was four days or less. The longest such interval was 16 days. Return Cases. Return cases occurred in only 6 households, one patient being affected in each case. In only two instances was the interval between the return home of the primary and the onset of illness of the return case under one week; in both of these instances the primary patient was apparently normal. In one of the remaining four the onset of illness was in the third week after return home of the primary case who developed a nasal discharge, while, in the other three it was the fourth week. The primary case was apparently perfectly well in three instances, but the other had developed an otorrhœa 7 days after his return home. Schools and Infection. There was very little suggestion this year that school attendance was responsible for the spread of this infection. In the spring term there were suggestive groupings such as 8 cases over seven weeks in the Stag Lane School, 7 over five weeks at Kenmore, 2 in each of two successive weeks at Priestmead and 3 cases over a fortnight at Stanburn. In the summer term the only occasions were 3 cases in a fortnight at Belmont, and 4 in a fortnight at Headstone. In the Christmas term, Stag Lane again had 3 cases in one week, while Vaughan Road had 2 in a week followed by a fortnight's interval and then 4 cases in a fortnight. The instance where it was felt that school attendance was really operative in the spread was at Cannon Lane School. Over a period of 13 weeks there were 7 cases amongst children attending this school and living in this district, 3 occurring in one week, while children attending the school but living in an adjoining district also succumbed. A child thought possibly to be a missed case was excluded. This step was followed by a temporary freedom, with a later recurrence. SMALLPOX. A service patient while in a hospital in an adjoining district in February was recognised as suffering from smallpox. Other cases occurred amongst the staff and visitors. There were over 80 persons resident here who were contacts either of the original case or of one of those secondarily infected. These were visited for the usual period; none developed the infection. B 18 ENTERIC FEVER. Four patients were notified as suffering from typhoid fever, though in one the notification was withdrawn, the diagnosis being changed to malignant endocarditis. Of the two cases of typhoid fever, one was apparently contracted on board ship. The remaining case was a para-B. infection where watercress was the suspected source. Three of the patients were admitted to isolation hospitals. DYSENTERY. The 13 cases of dysentery included four of Sonne infection which occurred amongst the patients in a hospital in this district, and a further two in which infection occurred amongst patients already in hospitals in London. This leaves seven cases occurring amongst those living at home in this district. One case occurred in a girl of 8 in January, the organism being unknown. Of three cases notified in March, a boy of 8 suffered from a Flexner infection, a girl of 9 from Sonne, but in the case of a baby of 8 months the organism was unknown. An adult male suffered from a Gaertner infection in July. In October an infant of 15 months succumbed and next month a boy of 5 years, from Sonne infection. Of these seven patients one was treated at home, four in a general hospital and two in an isolation hospital. FOOD POISONING. Five patients were notified as suffering from food poisoning. Three were members of one family who succumbed at much the same time to an attack of diarrhœa, vomiting and abdominal pain. Pork was suspected, though no complaints were received from consumers of other parts of the consignment. The other two patients were again members of the same family, who succumbed to the same symptoms on the same day. The food-stuff suspected in this case was spam. ERYSIPELAS. Forty-seven cases of erysipelas were notified in 1944 (in each of the two previous years the number was 46). Of these 27 were females. The face was affected in 28 cases and the leg in 11. Twelve patients were treated in isolation hospitals, the remainder at home. A child of one month died from erysipelas following a suppurating cervical adenitis. CEREBRO-SPINAL FEVER. Seven notifications were received of patients suffering from cerebrospinal fever, six of them occurring in the period from the beginning of the year to the beginning of April, the remaining case in December. The cases were independent of one another, occurring in different parts of the district; one seemed to have been contracted outside the area. Two cases proved fatal. Six of the patients were removed. to general hospitals for treatment. 19 ACUTE ANTERIOR POLIOMYELITIS. In September a child of 12 was notified as suffering from acute anterior poliomyelitis. The infection seemed to have been contracted while she was out of the district on holiday in August. MEASLES. 1944 was an inter-epidemic year for measles in this district, only 573 cases being notified. The incidence was most erratic throughout the year. The 1943 outbreak faded before the last quarter, and the first quarter of 1944 was quiet with only 72 cases or a weekly average of 5. A sharp rise took place in the second quarter with a total of 260 cases, a weekly average of 20, the average of 10 in the first month being balanced by a rate of 28 in the third. The figures steadily fell throughout the third quarter to 102, a weekly average of 8, though this was only 3 for the month of September. A slight rise occurred in the last quarter with a total of 138 cases or a weekly average of 11, this increase presaging the extensive outbreak which occurred in the earlier months of 1945. Most schools escaped entirely. Those attacked were mostly affected during one term only. In the spring term notifications were received in any numbers only from Greenhill, Vaughan Road and Grimsdyke. In the summer term Priestmead and Longfield were mostly affected, Eastcote Lane and Kenmore to a lesser extent. The autumn infection was limited almost entirely to the Harrow Weald School. One death was recorded as due to measles. The total number of visits paid to the homes by health visitors was 371 while 13 children were removed to hospital. WHOOPING COUGH. 683 cases were notified during the year. One-half of these occurred in the first quarter, a weekly average rate of 25. There was a falling off in the second quarter, 245 cases being notified, a weekly average of 19. From the second week in July there was a marked decline, only 66 cases in all being notified in the third quarter and only 37 in the last. Only a small number of schools were affected to any extent. Abercorn was attacked in the first term; Roxbourne, Belmont and Stag Lane were affected to some extent in the spring, and again in the summer term. Priestmead was attacked in this term. There were three deaths from whooping cough. The number of patients suffering from whooping cough who were removed to hospital for treatment was 15 and the number of visits paid by the health visitors 306. NON-NOTIFIABLE INFECTIONS. Chickenpox. Intimations were received from the head teachers of the public elementary schools of 714 cases amongst school children. The incidence was limited almost entirely to the spring term, the schools most affected being Belmont, with altogether 82 cases, Welldon Park, Bridge (97), Priestmead (72), Pinner Park (72) and Stanburn (49). Lighter infections 20 occurred at Vaughan Road (28), Camrose (17) and Kenmore (16). Some of these schools were lightly affected in the summer. Welldon Park which had had 32 cases in the previous term now had 111. In the second half of the year there were very few cases. Mumps. Mumps was about as prevalent as during the previous year, 439 intimations being received. Again one school, Cannon Lane, was heavily attacked with 158 cases, others more mildly affected being Abercorn (66), Priestmead (48), Longfield (40), Greenhill (31), and Kenmore (23) cages. Apart from 31 cases at Priestmead in the spring term the infection was confined to the summer term, the disease being practically non-existent throughout the district in the second half of the year. German Measles. As contrasted with the previous year when the district was practically free from infection, there was a very sharp attack throughout the entire district in the four months February to May, a total of 1,598 cases being learned of. The following eight schools had over 100 cases each: Roxbourne, Belmont, Stag Lane, Welldon Park, Eastcote Lane Infants, and Priestmead, Cannon Lane and Stanburn. The following four had between 50 and 100: Kenmore, Harrow Weald, Pinner Park and Longfield. At most of these schools when German measles was present, measles was absent. The only ones where both infections were present together were Greenhill and Eastcote Lane. Priestmead, which had German measles in the spring term, had measles in the summer; while Harrow Weald which had a sharp attack of German measles in the spring was attacked by measles in the autumn. At the height of the outbreak a number of patients were sent to the isolation hospital on a diagnosis of scarlet fever but were found to be suffering from German measles. Influenza. The district suffered in the earlier weeks of the year from a continuation of the influenza outbreak which had attacked this district in common with the rest of the country in the later months of 1943. Three deaths in January were followed by one in each of the next two months. These occurred principally amongst the elderly. 124 notifications of pneumonia were received during the year. VERMIN INFESTATION. Scabies. 1,815 cases of scabies attended the treatment centres during the year, a slight fall in the figure of 2,178 in 1943. One reason for the smaller number though will be that only 93 attended in August, a decline probably due to the numbers of local residents who evacuated. Another reason may be the withdrawal of facilities for treatment from some parts of the district. For most of the year treatment was available at five 21 first aid posts. Of these, No. 61, at the Broadway Clinic, Wealdstone, treated the most, whereas, throughout the year only 34 attended Post 63 at Pinner. Towards the end of the year the curtailment in the Civil Defence Services led to the closing of Posts 59 (Priestmead School), 61 and 63. For the month of December, then, treatment was available only at Posts 56 (Alexandra Avenue Clinic) and Post 58 (The Car Park, Harrow). In December, although Post 58 would be treating those who would previously have attended here and at Posts 61 and 59, the attendance for the month, though much greater than the average there in previous months, was very much less than the sums of the average attendances of the three posts. The reduction in the total numbers attending for treatment throughout the year then cannot be accepted as indicating a decline in the incidence of infection, but more probably is a measure of the deficiency of the services provided as compared with previous arrangements. The difficulties in the way of providing the service arise from lack of premises and shortage of staff. Head Infestation. Of the male patients admitted to the Isolation Hospital during the year, the heads of 4 per cent, of those under 5 years of age, 6 per cent, of those of 5 to 9 years, and 8 per cent, of those of 10 to 14 years were infested, though the heads of all of those over the age of 14 were clean. The corresponding figures amongst females were 0, 12, 15 and 0. TUBERCULOSIS. Notifications. New Cases Deaths Primary Notification Brought to notice other than by Form A Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F M F M F Under 1 — — — — — — — — — — — — 1-4 3 4 1 1 — — — — — 1 1 1 5-9 7 5 1 6 — — — — — — 1 — 10-14 4 3 3 1 1 — — — — — 1 — 15-19 15 16 1 1 — 1 — — 1 4 1 1 20-24 24 23 1 4 1 3 — — 2 3 — — 25-34 39 39 3 9 1 3 1 2 8 12 — 2 35-44 40 18 6 1 2 — — 12 8 3 1 45-54 17 9 2 1 1 — — — 8 6 2 — 55-64 13 5 — — 1 — — — 7 5 — — 65 & up 5 — — — — — — — 6 — — — Total 167 122 18 24 7 9 1 2 44 39 9 5 The notifications of pulmonary tuberculosis which reached their highest figure of 349 in 1941, fell to 318 in the next year, then to 261 in 1943. Last year saw a slight rise again to 289. Of all those first learned 22 of during the year, 75 (63 male and 12 female) occurred amongst persons in the Services; 49 (33 and 16) had been notified before transferring to the district, while two persons notified had never lived here; 184 (93 and 91) though, were notified first in this district. In the case of the remainder information had not been obtained as to whether they were original cases or transfers. The figure of 42 of non-pulmonary notifications was smaller than that of last year. In 8 the patients transferred here had previously been notified elsewhere as suffering from the condition. Five notifications were of persons in the Services. Of 29 cases who presumably contracted the infection locally, 8 suffered from joint or bone disease, 7 from lesions of the cervical lymph glands, 5 from lesions of the skin, 3 from abdominal tuberculosis and two each from salpingitis, renal disease and meningitis. In only three of these was there a family history of tuberculosis. Register. Pulmonary Non-pulmonary Male Female Male Female No. on register January 1st, 1944 556 505 104 97 No. of New Cases added 167 122 18 24 No. of cases added—other than on Form A 13 18 4 3 No. of cases restored to register 6 6 1 1 No. of cases removed 158 138 25 30 No. on Register December 31st, 1944 584 513 102 95 The following table is a summary of the cases removed from the register with the reasons for removal : Reasons for Removal Pulmonary N on-pulmonary Male Female Male Female Left the district 54 62 7 11 Died 67 53 6 4 Cured 31 21 12 13 Diagnosis not confirmed or withdrawn 6 2 — 2 Total 158 138 25 30 Deaths. 83 persons (44 and 39) died from pulmonary tuberculosis during the year, and 14 (9 and 5) from non-pulmonary tuberculosis. This infection therefore accounted for 5.6 per cent, of the total deaths in the district. The corresponding figures last year were 92 deaths from pulmonary and 15 from non-pulmonary tuberculosis, the disease accounting for 5.2 per cent, of the total deaths. 59 per cent, of the deaths of those who succumbed to pulmonary tuberculosis took place outside the district, mostly in institutions, the 23 corresponding figure of those suffering from non-pulmonary tuberculosis being 75. Eighteen deaths occurred amongst those who had not been notified, though in only one case was a posthumous diagnosis made. Of the 8 deaths which occurred locally one was due to meningitis ; the remaining 7 cases were of pulmonary tuberculosis which had not been notified apparently as a result of a misunderstanding. Of the 6 deaths caused by pulmonary disease which occurred outside the district, two were in sanatoria, one in a London Hospital, and three in hospitals in other districts. Of the 4 non-pulmonary cases, two were meningitis, and one was miliary tuberculosis, diagnosed post-mortem. MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,473; 1,767 male and 1,706 female. Of these 159 were illegitimate, being a percentage of total births of 4.6. 2,332 births occurred in the district (2,296 live and 36 still births). Of this number 458 (447 live and 11 still births) were to residents of other districts. Of the local confinements 2,215 were notified by midwives and 117 by doctors or parents. 1,477 (1,434 live and 43 still births) notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in, Middlesex County Council or in London Hospitals. STILL BIRTHS. 40 male and 37 female still births were registered, being a rate per thousand population of 0.41 compared with the figure of 0.50 for the country as a whole. Of the 51 cases about which any particulars have been obtained 4 were dead before the onset of a premature labour. In 16 others the baby was apparently alive at the onset of a premature labour. In 6 of these the infant was deformed, in 4 the pregnancy was multiple, in 3 labour followed an ante-partum haemorrhage, in 2 there had been some degree of toxaemia of pregnancy while in one case labour was surgically induced. In 4 instances death had occurred some time before the onset of labour at full term. In 2 of these there was malformation and in one hydramnios. In most cases the infant was alive at the onset of labour at term. In 11 cases there was definite difficulty in delivery arising from some such condition as impacted shoulders, transverse presentation, small pelvis, etc. Toxaemia was present in 5 cases, while in 3 there was abnormal development. Prolapse of the cord or the cord round the neck was the ascribed cause of death in 3 cases, and haemorrhage in one. In 9 cases, though, no explanation for the occurrence of the death could be obtained. 24 INFANT MORTALITY. 121 (71 male and 50 female) infants died under one year of age, constituting an infant mortality rate of 34.8. 79 failed to survive one month. The neo-natal mortality rate was therefore 22.7 constituting 65 per cent. of the total infant mortality rate. Of these 79, 30 failed to survive the 24 hours, the cause of death in 13 being prematurity, in 5 birth injury, and in 4 each atelectasis or developmental abnormality. 28 deaths occurred in infants who survived 24 hours but failed to survive 7 days. Prematurity was the cause in 9 of these, abnormality, birth injury and pneumonia 4 each, and atelectasis and icterus 2 each. Of the 21 who survived one week but succumbed before the end of one month, in 6 the cause was prematurity, in 2 developmental abnormality and in another 2 birth diseases. Infections accounted for 9 deaths. Of the 22 deaths amongst those of 1 to 3 months, 2 were due to developmental abnormalities, respiratory complaints accounted for 10, gastro-enteritis for 6, and other infections 2. Infections again accounted for most of the 20 deaths of those between 3 and 12 months, of which respiratory complaints were the cause of 9, and whooping cough and gastro-enteritis 2 each. MORTALITY AMONGST CHILDREN of 1-5 years of age. Infections caused most of the deaths of children of the ages 1 to 5. Pneumonia was responsible for 4 of the 5 deaths of those aged one year; tuberculosis was responsible for one of the 3 deaths amongst those aged two, and for 2 of the 5 deaths of those aged four. Blood diseases accounted for the deaths of one of the 3 who died aged two, one of the 3 of those aged three, and one aged four. Whooping cough and measles were responsible for one death each of children under 5. INFANT MORBIDITY. Ophthalmia Neonatorum. Only one notification of ophthalmia neonatorum was received, a mild case, treated at home. Pemphigus. Three notifications were received of pemphigus amongst the newborn, two of infants born at home in March, and one born in a local nursing home in May. All were mild cases who recovered. MATERNAL MORTALITY. Two deaths occurred which were classed as being from or associated with pregnancy, giving a maternal mortality rate per 1,000 births of 0.56, comprised of a rate of 0.28 for puerperal sepsis and 0.28 for other puerperal causes. In one case the death was due to causes arising from the pregnancy. This patient had refused to follow advice given her during pregnancy, on one occasion discharging herself from hospital. She was delivered at home, but died 3 hours later from toxaemia. 25 Two cases followed abortion. The first was due to sepsis following a self-induced abortion; the other resulted from a pulmonary embolism following thrombosis of the uterine veins due to an incomplete abortion due to a uterine polyp. The death of another patient was due to the failure of a heart damaged by rheumatism occurring about one hour after delivery in hospital. In another case the patient died from peritonitis following intestinal obstruction due to impaction of a sigmoid polypus during childbirth. One other death took place from failure of an oldstanding damage to a heart 8 weeks after childbirth. PUERPERAL INFECTION. 18 notifications of puerperal pyrexia were received, 3 relating to women who had been confined in London hospitals. 4 of the others related to women who were confined in local nursing homes. Two cases of sepsis followed abortion, and two, in which the raised temperature was not considered to be uterine in origin followed a Caesarian section. In two the raised temperature was due to mastitis, in one to influenza and in another to pyelitis. In four cases operative interference had been necessary, one being followed by a white-leg. Of those delivered in this district 8 were removed to isolation hospital. 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 764 Total visits 1,119 (b) To children under one year of age First visits 3,212 Total visits 9,071 (c) To children between the ages of one and five years Total visits 15,627 In addition visits were paid to 371 cases of measles and 306 cases of whooping cough in children under five 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 41,960 (2) By children between the ages of one and five years 15,263 26 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 2,904 (2) Between the ages of one and five years 210 Total number of children under 5 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 2,446 (2) Over one year of age 5,141 Attendances: The average weekly attendances at the Infant Welfare Centres in 1944 was 1,093. This fall in the figures against those of previous years was due to the lower averages in the late summer and early autumn months when so many had evacuated from the district. The highest average attendance was the period 3 months up to the 20th May, a rate of 1,221. In the previous year the highest average was in the summer months with 1,324 for the ten weeks up to the middle of September and 1,425 up to the middle of October; corresponding figures for this last year for these periods being 897 and 983. TREATMENT. The following particulars show the extent to which the facilities for treatment are used: Dental treatment: 141 children under five years of age and 178 expectant or nursing mothers were treated. 85 mothers were supplied with dentures. Physio-therapeutic clinic: 124 new cases were referred to the clinic (123 children, 1 mother). The total number of attendances by patients was 844 (136 massage, 748 electrotherapeutic). 80 patients were seen by consultant orthopaedic surgeon and 245 were seen by the consultant physiotherapist. Correction of visual defects: 103 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 retested periodically. Operative treatment of tonsils and adenoids: 11 children were treated at the Harrow Hospital for this condition under the provisions of the agreement. Convalescent homes: No children were sent to a convalescent home. Home nursing: Responsibility was accepted for the payment of he fees for the treatment of 4 mothers and 2 children. 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. 27 Number of persons on the register who were receiving infants for reward at the beginning of the year 157 (Of these 91 had children; 66 not) Number of persons registered during the year 11 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.) 53 Number of persons on the register who were receiving children for reward at the end of the year 115 (Of these No. with children 56; without 59) Number of children on the register at the beginning of the year 97 Number of children received during the year 99 Number of children removed from the register during the year — Removed to care of parents 38 Removed to care of another foster mother 15 Legally adopted by foster parent 1 Removed to charitable organisation, etc. 5 Removed to hospital — At exempted premises 24 Foster parent left the district taking the child with her 3 Foster mother no longer receiving payment — Child attained the age of nine years 13 Died — Number of children on the register at the end of the year 77 ADOPTION OF CHILDREN REGULATION ACT. Welfare authorities are concerned more especially with the child notified under the provisions of Section 7 of the Act. During the year 7 notices were received. In most cases though the children were otherwise learned of and the requisite form of notice was received only on request. The provisions of the Act do not seem to be very well known or where known not too well understood, which is not altogether surprising. It is regrettable that welfare authorities are not more completely brought into association with the arrangements. It seems little would have been lost if all cases and not merely those of a restricted class had been compulsorily notifiable to welfare authorities. ILLEGITIMATE CHILDREN. Following consideration of the Ministry of Health Circular 2866 it was agreed that the Council participate in a joint scheme with the County Council by which suitable local cases might be admitted to a hostel in Hendon which could receive mothers and babies. In addition the Council will avail itself of the service of the Special Services Almoner appointed by the County Council. Up to the end of the year it had not been found necessary to take advantage of either of these facilities. Illegitimate births comprised a percentage of 4-6 of total births during the year. 28 SUPERVISION OF CHILDREN. War Nurseries. The opening of the nurseries at Rayners Lane in November, and Vancouver Road in December so reduced the numbers at the South Harrow and Buckingham Road nurseries that for a while it was possible to admit to all four nurseries more than one child from a family and also the children of mothers engaged only on part-time employment. By March though increasing applications necessitated a reversion to the previous practice at all nurseries but that at Vancouver Road. In February there were still vacancies here while there was a waiting list of applicants at Kenmore Nursery so for a number of weeks some of the over-twos awaiting admission at Kenmore were conveyed by Civil Defence vehicles to Vancouver Road. The extensions at Kenmore begun in March were not completed for some three months, the opening being on the 12th June from which date the accommodation was 59. Evacuation from the district reduced the numbers at most nurseries in the summer. In August, owing to staffing difficulties Spencer Road and Headstone Drive nurseries were merged, but for a short time only because of the outbreak of measles. By September staffing difficulties were sufficiently acute that it was decided to close Vancouver Road nursery as there were in any event only small numbers attending there. It was not reopened until November 6th, a curtailed staff coping with a slowly growing number of attenders. This nursery, though, has never justified its opening. The designation of the senior staff of the nurseries had been that Miss James was Matron and those in charge of each nursery, Deputy Matron. In the summer a change was made, Miss James being designated Matron Superintendent and each of the nurseries was then in charge of a matron assisted by a deputy. In February the recommendations of the Rushcliffe Committee as to the salaries of the staff was adopted. The average attendances of the nurseries over the year was lowered by the reduced numbers of children present during the summer months, more especially August and September. Apart from this period though and excepting Vancouver Road nursery, the average attendance at each section at each of the nurseries was well-maintained. Perhaps the fact that the attendances were uniformly best in the babies sections was a reflection only of the need of the mothers of these children to go out to work to supplement their incomes. Infections during the year had little effect on attendances. Daily Minder Scheme. Even less use was made of this scheme during 1944 than in the previous year, only 3 names were on the register at the end of the year. The greatest number of guardians in any month who were looking after children was only 6, the number of children cared for being 6. 29 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. During the year the health visitors paid a total of 1,119 visits to expectant mothers, 764 being first visits. Ante-natal Clinics. The following summarises the work done at the clinics during the year: Total number of expectant mothers attending the clinics 2,604 Total number of attendances by expectant mothers at all clinics 12,719 Percentage of total notified births (live and still) represented by the number of mothers attending the clinics 73 Consultant Ante-natal Clinic. The attendances at the consultant ante-natal clinic necessitated the continuance of the arrangements by which the consultant attended three weeks out of four. During the year 320 women made 424 attendances. General Practitioner Ante-natal Scheme. The same arrangements by which pregnant women referred by midwives could receive ante-natal supervision by their own medical attendants was continued last year. Again only a very limited use was made of the scheme, 17 patients being seen. Three 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 practise was 1,801, in 781 cases the attendant being present as a midwife and in 1,020 as a maternity nurse. Of the confinements occurring in patients' homes in the district 1,066 were attended by local midwives whose practice is limited to domiciliary work (735 as midwives and 331 as maternity nurses), and 20 by midwives from adjoining areas (13 as midwives and 7 as maternity nurses). Number of Midwives: The number of midwives who during the year notified their intention to practise in the district was 42. Of these 4 removed from the District, leaving in practice at the end of the year 38. Of the total number 11 were engaged in local maternity homes, most of them restricting their activities to this. 28 were resident in the district and carried on a domiciliary practice, while 7, though resident 30 in adjoining areas, attended cases in this district. At the end of the year there were in practice 11 independent midwives carrying on a domiciliary service, these between them attending 107 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 256 Still birth 9 Death of infant 4 Death of Mother — Laying out the Dead 1 Artificial Feeding 18 Liability to be a Source of Infection 11 Of the 256 summonses to medical practitioners 37 were on account of some condition during pregnancy, 58 during labour, 108 in the lying-in period and 53 some abnormality of the infant. Of the 37 summonses to a patient during pregnancy, 22 were because of albuminuria, oedema or toxaemia and 9 because of haemorrhage. Of the 58 summonses to a patient during labour, the reason given in 45 instances was delayed labour with cause unspecified and in a further 3 there was some abnormal presentation. 10 summonses were to patients suffering from abortion, actual or threatened. 78 of the 108 summonses to patients in the puerperium were on account of the rupture of the perineum. Post-partum haemorrhage with or without adherence of the placenta was the reason in 7, raised temperature in 6, phlebitis 10, and inflamed breast one. Of the 53 summonses to infants, 9 were on account of some discharge from the eye, 15 because of feebleness or asphyxia, 7 because of deformity and 12 some other abnormal state or condition. 256 out of 781 midwifery cases attended gives a percentage of 32.8. The corresponding figure in 1943 was 32.3 and in 1942, 33.1. Local Authority's Midwifery Service: The number of patients attended by the Council midwives was 697 in which they acted as midwives and 282 in which they acted as maternity nurses, a total of 979, being a percentage of 27.1 of the total number of confinements of local mothers in this year. Of the patients attended by midwives acting as such 362 were assessed to pay the full cost, in 73 cases no charge was made, while 262 were assisted. The corresponding figures in regard to patients attended by midwives acting as maternity nurses were 226, 18 and 38. The average number of cases attended by each midwife was 61. Where a Council midwife acting as maternity nurse rendered service in cases of circumcision, an additional standard charge of 10s. 6d. was made. It has now been decided that this same charge be made where 31 the midwife is acting as such, though not where the operation was found necessary for a condition for which the midwife was required under the rules of the Central Midwives Board to summon a doctor. Home Helps: Owing to the number of home helps on the Council's panel being insufficient to meet the demand, it was agreed that assistance would be given towards payment of those helps not on the panel but who had been engaged by the patient, subject to the receipt of a satisfactory' report on her services by the midwife. During the year 162 cases were attended by home helps under the Council's scheme. During the financial year 155 cases were attended by 45 helps. Of these 21 attended only one patient, 7 two, 4 three and 3 four. Two attended 5 cases each, and another two 12 each. The other helps attended 6, 8, 11, 13, 14 and 15 cases. The Ministry of Health Circular 58/44 authorised the engagement of home helps on a part-time basis, where the need arose not from a confinement but because of the presence of small children in the home. This authorisation will be of use when there is a sufficiency of available help, but little use can be made while such difficulty is being experienced in finding help in confinement cases. Consultant Services: During the year consultants were summoned to 13 patients, 6 in labour, one ante-natal and 6 post-natal. Of those in labour 5 were due to delay or obstruction. Operative interference proved necessary in two; the remaining patient was one suffering from eclampsia. The single- ante-natal patient was suffering from antepartum haemorrhage. Transfusion was carried out in each of the three cases of post-partum haemorrhage; two of the post-natal patients were suffering from puerperal pyrexia. 7 of the patients had been delivered in their own homes and 6 in local maternity homes. Institutional Confinements. Number of Confinements: 1,105 births occurred in registered nursing home in this district. 452 births to mothers from outside districts which occured here took place in nursing homes, 6 in private houses. Of these 1,105 confinements 390 were conducted by private practitioners. Notifications were received of 1,477 births to Harrow mothers, which took place outside the district. Of these 1,262 were from hospitals and 181 from nursing homes. Of the patients confined in hospitals outside the district 586 were delivered at Redhill County Hospital, and 424 at Bushey Maternity Hospital. Of a total of 3,351 births, 1,221 occurred in the patients' own homes, 653 in local nursing homes and 1,477 in hospitals or homes outside the district. Some 2,130 or 63 per cent, therefore, of the confinements took place in institutions either inside or outside the district. During the year 13 patients were admitted to a London Hospital under the Council's arrangements. 32 POST-NATAL SERVICES. Post-natal Examination. 259 women attended the clinic for post-natal examination and 3 attended their own doctors under the General Practitioner Ante-natal scheme. Puerperal Infection. (a) Consultant Services: The consultant was summoned to two patients suffering from puerperal pyrexia. (b) Hospital Services: Eight patients were removed to the London County Council North-Western Isolation Hospital. (c) Home Nursing: Four 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 11 cases attended by the Council's midwives who developed pyrexia or were for other reasons suspected of being infectious. BIRTH CONTROL CLINIC. The clinic throughout the year was held at monthly intervals. Increasing attendance though will necessitate its being held more frequently. 213 women, of whom 119 attended for the first time made a total of 328 attendances. Advice is given only where medical grounds render the pregnancy undesirable. No cases attended in which there was no justification for advice being given. 33 THE WAR YEARS. Introduction. The vital statistics of this district compare very favourably with those of the rest of the country. Part of the explanation for the lowered death rate is to be found in the age constitution of the population, a factor associated with the growing community. Apart from this aspect, though, the district possesses many natural advantages which help to promote healthy conditions. The general standard of housing is good ; atmospheric pollution is not marked, while of course the district shares with the rest of the southern counties the milder climatic conditions not enjoyed by some parts of the country. In the same way the district has been fortunate during the war in that it has been spared, where it has not escaped entirely, the vicissitudes to which other districts have been exposed. In the early days it was not an evacuation area and in fact it even became a reception area, but there was neither the outpouring nor at any time an overwhelming influx of population. Although provision was made for the reception of refugees at the time of the overrunning of the low countries, and for the reception of persons from the coastal towns, in point of fact'few came and of those who did most were here only a short time. Larger numbers arrived later, following enemy action on different parts of the country. Not until the August of 1944 was evacuation encouraged, and then most of it was of a few weeks' duration only. Admittedly the district did not escape the results of enemy activity and can point to the effects of bombing, of the attention of flying bombs and of rockets, but in each case only on a small scale. Perhaps because of the lightness of the attack here comparatively few crowded into the shelters. At no time were these used by more than 5,000 while they had the accommodation for over 30,000, and only for a period of a few weeks was there any question at all of the occupancy of these shelters and the herding of large numbers in unhygienic surroundings becoming a public health problem. The very general fears of epidemics which might be started by the herding of vast numbers of people in shelters which were damp, cold, ill-ventilated and with deficient sanitation and never designed for persons to sleep in proved entirely unfounded. Even the slight increase in the incidence of impetigo and scabies which were apparently more prevalent in the autumn of 1940 was short-lived. The district then suffered nothing peculiar to itself, was affected by that which was common to the whole country, and escaped rather lightly from those troubles to which it was, together with most of the rest of the country, exposed. c 34 vital Statistics. The following table sets out certain vital statistics for the area for the war years and for comparison as a standard year those for 1938. 1938. 1939. 1940. 1941. 1942. 1943. 1944. Population 83,500 190,200 188,710 195,480 195,100 191,660 185,090 Births: Legitimate 3,187 3,211 2,898 2,625 3,134 3,350 3,314 Illegitimate 105 109 103 126 134 150 159 Birth Rate 17.9 17.5 16.4 14.7 16.6 18.2 18.7 Stillbirths (per 1,000 total births) 3.1 3.1 4.2 2.7 2.4 2.4 3.3 Deaths: No. 1,311 1,408 1,725 1,774 1,818 1,749 1,732 Death Rate 7.1 7.4 9.1 9.1 9.3 9.1 9.3 Infant Mortality Rate 38.3 38.5 50.0 55.6 31.5 38.0 34.8 Tuberculosis 86 78 93 120 109 96 97 Influenza 8 21 24 29 14 51 5 Population. The fluctuations in the population figures are less marked than the changes which occurred. The variations in numbers give no indication of the vast changes in the position. In 1941 (the district was not then an evacuation area) the weekly average number of children under six years of age admitted to the district was 65, the weekly average of those leaving being 52. Movement of population on this scale with all the disturbances of family life involved must have had its own effect on health conditions. It resulted, too, in other changes more statistical than actual, e.g., increases in the number of notifications of those suffering from tuberculosis in that sufferers would be notified in the new district while their names might not be off the register of the districts in which they previously resided. Apart from changes in the position due to movements of population though, there would follow other effects; the age distribution would be altered by the recruitment of the various combatant forces. Those withdrawn from the local civilian population would be of two decades of low fatality; this accounts for some at least of the increase in the death rates. Births. The number of births has fluctuated markedly, so the birth rate has ranged from 14.7 to 18.2. The increase in the national rate from the year 1941 when the effective reproduction rate was 0.76 to reach that of 0.99 for 1944 suggests that there is little in many of the explanations offered to account for the decline in the birth rate which affected this country as well as many others, and which had been such a marked feature this century. 35 The number of local illegitimate births has increased to a figure nearly 50 per cent, above that pre-war. Part at least of this increase is to be accounted for, not by any lowering of moral standards, but by the difficulties experienced because of war conditions of the couples being able to arrange a marriage. The low stillbirth rate (expressed as a rate per thousand births) is of interest. There is general agreement not only that the nutritional standards of the country have been well maintained but that that of some sections of the community has actually improved. The findings of certain experiments have suggested that an improvement in the stillbirth rate might follow improved nutrition of the mother. It may be then that these low rates are the result of the better feeding. Deaths. General: The raising of the death rate is what can be expected when large sections with a favourable mortality rate are withdrawn from the population. The increase which has occurred, though, is not merelv one of rate but of actual deaths. The following table which shows the distribution of the deaths for each sex in various age groups for three of the years shows how this increase is mostly due to extra deaths occurring amongst the more elderly of the population. Under 5 5/14 15/24 25/44 45/64 Over 65 Male: 1938 674 14.1 2.7 3.3 10.6 29.6 40.3 1941 885 13.0 2.1 1.5 13.0 30.2 42.1 1944 905 8.9 1.1 1.3 8.4 30.1 50.2 Female: 1938 637 10.0 1.9 2.3 17.1 21.9 46.5 1941 889 8.4 0.8 2.3 11.1 24.1 53.0 1944 876 7.0 0.7 2.3 11.4 23.9 54.6 Analysis of the 1941 figures compared with those of 1938 showed that "The increase of 219 in the deaths of males in the year 1941 over those for 1938 was contributed to by 104 amongst those of over 65 years of age and 85 amongst those in the 45 to 64 age group. The 259 increase of female deaths too was almost entirely to be found in those of the higher ages, 170 being amongst those of over 65, and 74 in the 45 to 64 age groups. Of the increase in the deaths amongst males, 58 were due to respiratory complaints, 40 to intracranial lesions and 15 to cancer (most of these increases being amongst the elderly), and 45 to respiratory tuberculosis (mostly amongst those of ages 15 to 54); and amongst the females 48 to cancer, 37 to intracranial lesions, 49 to heart lesions, and 58 to respiratory complaints, most of these increases being amongst those of advanced years." Infant Mortality Rate: The following table sets out details of the deaths of infants for each of the years, and also the number of deaths amongst those of 1 to 4 years of age. 36  1938. 1939. 1940. 1941. 1942. 1943. 1944. No. of live births 3,292 3,320 2,999 2,712 3,268 3,500 3,473 Deaths of infants Under 24 hrs 28 19 18 16 27 21 30 1-7 days 27 36 35 28 25 36 28 1-4 weeks 13 14 41 31 14 20 21 2-3 months 17 28 23 28 19 20 22 9-12 months 41 28 34 49 18 36 20 Total 126 128 150 151 103 133 121 Infant Mortality Rate 38.3 38.5 50.0 55.6 31.5 38.0 34.8 Neonatal Mortality Rate 21.0 20.8 31.1 28.0 20.2 22.0 22.7 Deaths of children aged 1 to 4 years 31 22 22 27 22 17 16 The infant mortality rate used to be accepted as a guide to the social or sanitary state of a community. With the marked decline in deaths associated with unsatisfactory environmental factors, its reliability in this respect is now less. What association remains, though, led one to assume that the disturbances resulting from total war would be reflected in a rise in the rate. The quite marked rise in 1940, then and even a further increase in 1941 were not unexpected. An analysis of the causes of the deaths though, more particularly when it was found that the increases in deaths over those of a standard year occurred in different age groups in the two years, and were also the result of different abnormal conditions, suggested that such rise as had occurred was not necessarily to be expected for the rest of the war years. The following is a summary of the analysis of the deaths in these two years which appeared in the report for 1941: "it can be seen that the increase in the deaths amongst children under one month of age arises not in the earlier period but is due to a heavier mortality due to respiratory affections and abdominal disturbances in those who had survived their seventh day. There was little enough change in the mortality of those dying before this time, suggesting then that the increase in the infant mortality did not arise from a lower standard of the ante-natal or midwifery services or from an impairment in the condition of the expectant mother. "What was saved in the neonatal deaths in 1941 as compared with 1940 though was lost in the later months, the increase being equally apportioned between respiratory and abdominal disturbances. Having regard to the severe weather experienced in the earlier part of the year the following analysis of the distribution of death amongst infants of different ages is of interest: The number of deaths amongst those under the age of 7 days occurring in the months of January to April was 17; in the months May to August, 16, and the period September to 37 December, 10. The effect of the harsher weather is, as might be expected, not markedly reflected in this distribution. By contrast, the corresponding figures relating to the deaths of children aged one week to one month were 25, 4 and 4; and of infants from 3 to 12 months, 40, 21 and 15. "These figures therefore suggest that in spite of the fact that the infant mortality rate has risen sharply from 1939 to 1940 and less sharply from 1940 to 1941, that it need not be accepted that this is an inevitable consequence of the war, or that there must of necessity be a steady deterioration." In point of fact in the following years the rate fell below that ever previously recorded for the district since amalgamation. The rise to 38-0 in 1943 brought the figure only to the very satisfactory pre-war rate. Tuberculosis: Another of the diseases responsible for additional fatalities in times of physical stress and unsatisfactory environmental conditions is tuberculosis. Owing to the usually long course of illness deaths occur perhaps many years after the declared onset and because this too may be insidious and protracted, very long after the patient has been exposed to those influences which resulted in his succumbing. Where deaths, then, follow a disease in which the onset is ascribable to such disturbances as have been experienced during the war they will take place later than would, say, those infant deaths ascribed to the same causes. Whereas then the peaks of the infant mortality rates were reached in the years 1940 and 1941 deaths from tuberculosis reached their heights in 1941 and 1942, the figures for the years 1938 to 1944 being 86, 98, 93, 120, 109, 96 and 104. The following table sets out the number of deaths amongst each sex divided into pulmonary and nonpulmonary. Male Female. Total. Pulm. NonPulm. Pulm. NonPulm. 1938 30 10 38 8 86 1939 36 11 24 7 78 1940 45 7 32 9 93 1941 72 3 39 6 120 1942 61 1 40 7 109 1943 55 8 28 5 96 1944 44 9 39 5 97 It will be noted that in any one year the numbers of deaths from non-pulmonary disease in males and from pulmonary and non-pulmonary disease in females barely exceeded those for the year 1938. The rise occurred almost entirely amongst the males with figures of 72 and 61 in the peak years 1941 and 1942 as against that of 30 in 1938. (This figure of 30 while low was not a freak figure as the corresponding one in 1937 was 35 and in 1935, 36.) 38 Incidence of Disease. Exact information is not available to measure the standard of fitness or of invalidity of a community. The few statistics at hand are those of communicable diseases. Records such as those of a hospital show what illnesses or abnormalities take the patients attending that particular hospital either as in-patients or out-patients, and, especially where such a hospital serves a limited community so that the population in general can attend only there, the figures are useful for comparing one year with another. Even those figures though serve only a comparative purpose, and are not a measure of the illness of the community. Even were records compiled from all the agencies dealing with invalids, including hospital in-patients and out-patients and all the general medical practitioners, all that would be listed would be the number of people who attended for treatment for different conditions. The records would not indicate, for instance, the total number of persons whose stomachs were ulcerated but only those who attended for treatment for the condition ; the person suffering from a gastric ulcer though is burdened with something other than and in addition to the ulcer. This aspect possibly had something to do with the disappearance of illness at the outbreak of the war, perhaps the most striking occurrence in regard to health during the war years, unless pride of place in this respect goes to that astounding freedom from all those pestilences spread by droplet infection which by all the laws of probability and of hygiene should have decimated the population living in the shocking conditions in the shelters during the earlier periods of enemy raiding. Our freedom from plagues has coincided with the period when perhaps the general community has benefited most from and enjoyed the soundest physiological nutritional standards. While some factors, e.g., vitamin A have attributed to them anti-infective powers, and while malnutrition is accepted as an aetiological factor in the onset of tuberculous disease, in general a patient's sound nutritional state has been thought to be of greater help in aiding him to overcome rather than to resist an infection, so that these benefits were not expected to follow good feeding. The cause may of course be assumed to be a fortuitous and most fortunate waning of the virulence of organisms, the opposite state of the enhanced virulence of the organism responsible for the influenzal pandemics which were the sequel to the last world war. If, on the other hand, as an explanation recourse must be had to metaphysical conditions, particularly the mental state of the population who were the prospective sufferers from the invasions of the organisms, it will be of interest to note whether, quite apart from the introduction of some exotics, the health of the population as determined by the prevalence of communicable diseases is to deteriorate. Notifiable Diseases: The incidence of those diseases considered to be spread by droplet infection has been most variable. The 500 cases of scarlet fever in 1938 were followed by much the same incidence for the earlier part of 1939 when there were 90 cases in the first quarter and 142 in the second. The third quarter started with a somewhat lighter incidence, but during its last eight weeks on no occasion were 39 more than four cases notified. Contrary to expectations, instead of the rise in the last quarter there was a further fall, only the 29 cases being notified in the whole quarter. This extraordinarily low rate continued into the next year when, in the first quarter there were only 31 cases and 21 in the second. The third quarter's incidence was light, but there was a marked increase at the end of the year when there were 106 cases in this quarter out of the 217 for the whole year. From that time the disease became more prevalent, the number of cases being 331 for 1941, 630 in 1942 and 707, the highest incidence ever recorded for this district, in 1943. Fortunately the distribution of these cases throughout this year was remarkably uniform so that no difficulty was experienced in finding hospital accommodation for those seeking it. The number of notifications fell sharply in 1944 to 387' The following are the number of notifications of diphtheria from 1938 to 1944:—63, 54, 51, 86, 67, 73 and 57. The corrected figures are substantially lower, these in some years being only about half the notification figures. Diphtheria in this locality has for years been of low incidence. At one time the continued low rate was a cause for anxiety in that it resulted in a lowering of the herd immunity of the population, with consequent risk of a substantial explosive outbreak. Because of the low incidence which this district has enjoyed, it cannot be claimed that the present low figures are the result of the arrangements by which large numbers of children have been immunized. On the other hand, though, the success of the campaign, a success which is all the more creditable in that its results have been achieved without the undoubted stimulating effect of the occurrence of cases of diphtheria in the area, with the production of immunity in so large a proportion of the population who otherwise would have been susceptible, allays the anxiety about possible outbreaks. Cerebro-spinal fever is one of those diseases which are expected to increase in prevalence during war-time. The very considerable outbreak which swept through the country though was the peak of a rise in incidence which had started before the war. In this district there was a sharp rise to 37 cases in 1940 as compared with the figure 4 in each of the two previous years. The figures in the following years were 24, 15, 17 and 7. The distribution of poliomyelitis was irregular, though in no year was the figure greater than the 6 of 1938 and of 1939. Possibly this freedom is related to the reduced facilities for children spending their holidays at the seaside. Measles and whooping-cough were made notifiable only during the war years so that there is no pre-war standard for comparison. Measles behaved entirely contrary to expectations. In ordinary circumstances this district, as is common to those in and around London, is subjected to a measles outbreak each even year, the rise which marks the beginning of the epidemic being apparent in the latter weeks of the odd year. The 1940 outbreak though failed to put in its appearance to time. It was not until May that the increase started, to reach epidemic figures in September, October and November. Fatalities from measles are mostly due to respiratory complications which are more common in 40 inclement weather. The delay in onset then was of real advantage to the sufferers. Except for the rise in the latter weeks of the odd years which is the prelude to the epidemic of the even year, the disease is practically absent after an epidemic with very few cases in the odd years. Again what occurred was not the expected. The epidemic years of 1940 and 1942 with figures of 2,285 and 2,509 were separated by a figure of 1,275 in 1941 and followed by 1,516 in 1943 but in the even year of 1944 only 562 cases were notified. This strange behaviour of a disease which for the time at least had exhibited stability has been accounted for in many ways, most of the explanations offered being related to war conditions and more particularly to distribution of population, especially by evacuation. Against these explanations though are the facts that in such a district as this where extensive fluctuations of population did not occur, the course of incidence was disturbed, while places far removed from this country which were not subjected to war changes experienced the same occurrence. It may be that the disease is passing through a phase in which the cycle of incidence is about to alter. Only 299 notifications of whooping cough were received in 1940, the first full notification year. In 1941 though the district was heavily attacked by 1,259 cases. Relatively low figures of 468 and 393 in the next two years were followed by a rise to 701 in 1944. Notifications of the pneumonias relate to diseases of quite different aetiology, the notifiable conditions being acute primary pneumonia and acute influenzal pneumonia. Any increases then might be associated with an epidemic of influenza or of a spell of inclement weather. It is not felt though that notifications are correct, in that many cases which should be notified are not, whereas notifications are received of some conditions not strictly notifiable. The actual number of notifications received each year from 1938 were 98, 117, 112, 143, 117, 236 and 124. Of the behaviour of those notifiable diseases spread by droplet infection then the most striking occurrences have been (a) the almost complete disappearance of scarlet fever following the outbreak of the war, the low incidence during the time the health of the district must have been most subjected to baneful influences, and its later rise to a peak never before experienced; (b) the erratic behaviour of measles with its delayed appearance in the first of what should have been its epidemic war years, the failure to disappear in inter-epidemic years and its failure to appear as an epidemic in 1944; and (c) the rise which occurred in the incidence of cerebro-spinal fever taking place at the same time as the increased prevalence throughout the country but which had been only a continuation of an increase which started before the war. A different group amongst the notifiable infections are the alimentary complaints which are mostly contracted by the ingestion of infected foodstuffs. This district, in common with the rest of the country, suffered from an increase in the incidence of paratyphoid infections in 1941, but in later years had very few cases. The lowering of hygienic standards of food production, more especially in some new preparations replacing those withdrawn during the war, together with the introduction of labour not educated to the desirable hygienic standards 41 was probably the reason for this increase. The same year too saw an increase in the dysenteric infections. Notification of this disease or condition though is so erratic that little can be gained by a study of the notification figures. The same remarks apply to the notification of food poisoning which seems to be so little practised. For what it is worth it is recorded that in none of the war years did the number of notifications of food poisoning reach the figure of 1939, the first year of notification of this condition under the Food and Drugs Act, 1938. While then it is obvious that war conditions materially increased the risk of the spread of alimentary infections, apart from the increase in paratyphoid infection in 1941, they do not appear to have been responsible for any actual increase. Tuberculosis: Tuberculosis is one of the diseases closely associated with poor sanitation, malnutrition and mental and physical stress. It is consequently one to be expected to be more prevalent in war conditions. The actual number of notifications received though cannot be accepted as a true index of the prevalence of the disease, more especially as the position regarding the notification of temporary residents was for lone not clear. The following table which sets out the numbers of new cases added each year to the register, classified according to sex and character of the disease, show that the notifications have increased, most being received in the years 1941 and 1942. 1938. 1939. 1940. 1941. 1942. 1943. 1944. Pulmonary: Male 1ll 109 120 213 164 146 167 Female 118 101 108 141 155 125 122 Non-Pulm.: Male 28 19 31 19 27 30 18 Female 24 21 23 25 24 20 24 It will be noted that the increased incidence was primarily amongst sufferers from the pulmonary disease, and affected both sexes, though more especially males. Part at least of the substantial rise in 1944 was due to an increase in the number of persons in whom the disease manifested itself while they were in the Services. Scabies is one of the conditions which has apparently markedly increased during the war. While in many districts its incidence was on the increase in the years before 1939 there had been no increase in the number of cases brought to the notice of the Public Health Department in this area. Apart from the occasional approach by a local medical practitioner all that was learned of this complaint would be the request from hospital almoners to assist persons attending as out-patients. By 1941 though it was patent that there was a substantial volume of sufferers in this area. The civilian section apparently attributed the infection to the return home on leave of Service personnel; on the other hand it is understood that the infection in the Services was attributed to infestation at the home of a person who had been on leave. In August 1941 then arrangements were made by which facilities for treatment were offered at the first aid posts in the district, the work being undertaken by the civil defence personnel. 299 persons attended for treatment from then until the end of the year. Probably more 42 because the facilities became better known or were more taken advantage of than any actual increase of incidence, 1,701 persons attended in 1942 and 2,178 in 1943. In the latter part of 1944 most of the first aid posts were closed, leaving only the two. The reduction in facilities may have accounted at least in part for the slightly smaller number of attendances, namely 1,915 in 1944. The return of persons from abroad, particularly from those districts subject to the full blast of war provides a means of introduction of infections to which we in this country are not ordinarily subject. One of these diseases is smallpox. Up to the present the nearest the district has been to this infection was in 1944 when numbers of its residents became contacts of a Service patient at Mount Vernon Hospital or contacts of those who contracted infection from this patient. An increasing number of notifications is received in respect of Service- or Ex-Servicemen suffering from a relapse of malaria contracted abroad. Typhus fever is one of the diseases liable to be introduced, and some cases have in fact developed amongst those who have returned to this country, though this district has as yet escaped. Summarizing the position then, as far as can be ascertained from the notification rates : tuberculosis has increased ; there was a short period increase of paratyphoid infection, while it is understood that general experience is that the incidence of venereal diseases is rising. Beyond these, those infections which might have increased in war conditions have not done so. Some might conclude perhaps with justification that the public health organisation is on sufficiently sound lines that it has been able to withstand and overcome these tests and trials to which it has been subjected. But while this may be accepted as the position, it must not be inferred that it is maintained that the health of the community has not suffered. It is just that there is no means of knowing of or estimating the prevalence of those such very common conditions, whether rheumatic, digestive, dermatological or nervous which cause the sufferers to be far short of fit, and, while not in any sense real invalids, nevertheless so very far removed from the class enjoying perfect health. It is feared that such disabilities might now be much more prevalent. General Environmental Conditions. Drainage: The district has been fortunate in that enemy action resulted in so little damage to drains or sewers, and only for a short period was any inconvenience suffered, while there was never any risk to health. Water Supplies: Damage to mains with consequent risk of pollution was one of the hazards feared from enemy action. Precautionary measures taken would probably have ensured safety even in the event of far greater damage than the district sustained. Scavenging and Cleansing: Labour difficulties resulted in less attention being paid to street cleansing and also necessitated less frequent collections of house refuse. The lengthened intervals probably contributed to the prevalence of flies of which complaints were received. 43 Difficulties in the supply of bins necessitated arrangements being made for these to be sold by the Council to householders. The altered composition of the house refuse was amongst others a reason that the use of the destructor and separation plant was discontinued, the refuse being disposed of by controlled tipping at different sites in the district. One class of nuisance to which the district has been subjected is the bin for pig food which is an offence to sight and smell as well as being a breeding ground for flies and a larder for rats. Housing: Since amalgmation progress had been made in the eradication of the poorer class of habitation in the district. Concurrently repairs were being carried out to quite a high standard. There were areas in the district which it was appreciated would have to be very seriously considered with a view to demolition, the more extensive of these perhaps being groups of houses erected comparatively recently. The overcrowding survey showed that there was relatively little statutory overcrowding in the area. Of course the standard had to start with to be pitched lower than was desirable, but there were comparatively few houses in the area needing attention. On the other hand, concern was being felt at the growing practice of houses not built for that purpose and not modified being used for the occupation of more than one family. It was felt that this practice would lower the general standards of part of the area, and lead to such a deterioration that the premises would be occupied only by the more undesirable tenant and so rapidly lead to patches of slumdom. The war soon altered the relatively satisfactory housing position of the district. Shortage of labour and shortage of materials restricted action under the Housing Acts, quite apart from the shortage of sanitary inspectors to carry out the routine inspections. Repairs of property then had to be limited to that work necessary to comply with the more urgent standards of the Public Health Acts. No further houses were reported with a view to the making of demolition or clearance orders, while the demolition of properties already condemned was suspended, especially so as there was no accommodation to offer to the occupants of these condemned houses. The standard of housing then has fallen. In many of the poorer classes of building this decline has been particularly rapid, and much is being occupied to-day which must have been condemned on the pre-war standards. The position in regard to crowding, too, has become much worse. In many instances it is not merely a question of the members of one family causing overcrowding by one or more units, but to-day entire families are living in parts of houses, in some cases only one room, against all standards of decency let alone of hygiene. It is a sad thought that for a period presumably of years distressing conditions must be tolerated, and that it must be long before the district will recover sufficiently to reach the pre-war standard, and this too, before consideration can be given to those problems present in 1939, and which to-day are so very much worse. Food: One of the earlier effects of the war was the closing of private slaughterhouses, and the establishment in this district of a meat depot for wholesale distribution. For many years abolition of the many private slaughterhouses has been advocated on the grounds of 44 hygiene rather than ease of distribution. It is hoped that the use of well-sited abattoirs will prevent the return to old conditions in towns of any size. The time saved by the inspectors not being required to attend the local slaughterhouses was more than off-set by the demand at the distribution depot. Difficulties in distribution have been the cause of some foodstuffs having to be condemned. At one time this was particularly the case with eggs, and at another with fish. Perhaps the time of greatest activity in this line though was the period when food which had been salvaged from premises which had been the subject of enemy action was released, which, possibly because it was later retained too long, suffered from the perforation of the tins from rust. The occasions when the district was subjected to enemy activity resulted in the inspectors spending much of their time in an endeavour to combine safety to the consumers with the maximum recovery of comestibles. Maternity and Child Welfare Services. Apart from dispossession from some premises at which clinic sessions were held and staff difficulties, these services have continued almost uninterruptedly, and in general home visiting by health visitors, and the number of clinic sessions, infant welfare, ante-natal and toddlers, has been maintained. Movements of the child population added to the difficulties of the health visitors in their home visiting, while much of their time in dealing with mothers has been taken up in discussing matters of real importance to the mothers but calling for less of the skilled knowledge which enables the health visitor to advise the mother on the satisfactory unbringing of her child. Though the number of infant welfare sessions has remained much the same, the weekly attendances have never reached anything like those before the war. The peak figure for this district was some 1,900 per week in the summer of 1939. At times the weekly attendance has not reached the 1,000 figure and has never reached 1,500. The employment of women has probably been partly responsible for these reduced attendances, another factor possibly being the introduction of the national milk distribution scheme for mothers and children. The work of the Council's domiciliary midwifery service continued smoothly, the midwives attending each year about one-third of the confinements of the mothers of the area. For a number of reasons the demand for institutional confinements has increased, two factors making this more desirable during war conditions than previously being housing difficulties and deficiency in domestic help. The lessened accommodation available in London added to these difficulties. In March 1942 the first of the war nurseries was opened. By the end of the next year altogether seven were established, with a total accommodation of about 360. Except for the Vancouver Road nursery which has never been filled there has always, except for a few months of V.l activity, been a sufficient demand for admission that all places have been taken up with children one from the family of the full-time war worker. The other provision by which the children of mothers engaged on war work might be cared for, namely, the daily guardian scheme, never caught on here and was made very little use of. 45 Staffing. Although all departments have suffered from depletion of staffs to some extent throughout the war, the section that suffered most here was the sanitary inspectorate as all the time we were deprived of the help of some of the assistants, apart from those periods when there were reduced numbers of inspectors. The war nurseries in general have never had their full complement of staff and those engaged suffered from a very high absence rate. Apart from the reduction in members of the department though, much time of the health visitors was taken up in trying to help householders whose difficulties arose from shortages of such persons as home helps and foster mothers, two classes of person whose aid was never needed more. The greatest numbers of appeals received over the years by the Public Health Department have probably been on the one hand for housing accommodation, and on the other for help for those, particularly the elderly, who, while not sufficiently ill to need immediate admission to the bed of a general hospital yet could not be left alone but who could turn to no one for assistance. Conclusion. The normal services operated in the district for most of 1939, much time though being spent on the preparation of the A.R.P. Organization. A Ministry of Health scheme of milk for maternity and child welfare cases at reduced rates was at long last about to be introduced. Perhaps the proximity of the war had some effect on the decision on the Council's application for the Marlborough Hill Clearance Area. The Public Health Committee was concerned at the limited control given by the Building Bye-laws to prevent the erection of poor standard houses. With the war came the early loss of many members of the staff. For a short time health visitors were engaged entirely at the first aid posts. Clinic sessions were discontinued to avoid massing of people, and ante-natal supervision was carried out at the homes of the midwives. As a neutral area there were fewer population changes than in most other districts near. The low incidence of illness of any kind and the postponed onset of measles outbreak have already been referred to. Though apparently normal until the beginning of raiding, 1940 was sufficiently disturbing to result in a sharp increase in the number of deaths, especially amongst those over 55, while the infant mortality rate rose considerably, though the incidence of infectious diseases remained light. The second half of that year seemed to be taken up in making arrangements for the reception of numbers of people who never came. 1941 was the year in which judged by the available statistics, the health of the community suffered most, the number of deaths and the death rates being raised, the notifications of and deaths from tuberculosis increased, the higher infant mortality rate and the greater prevalence of those infections spread by food. From that time on conditions steadily improved, the health of the district throughout 1942 being in general good, the infant mortality rate in particular having fallen. Apart from the higher death rate and the tuberculosis figures, the statistics for 1943 were not so very dissimilar from those of a pre-war year. 46 THE FUTURE. 1. During the phase when report after report was published dealing with the future of such very varied subjects, when each interest in its turn seemed to have in mind as local government districts suitable for its purpose something different from any other, local government itself might be thought to have been in the melting pot. For a time at least that question seems to be shelved ; and with the death-knell sounded for any form of regional administration comparable to that in operation for Civil Defence, the stage seems to be set for the aggrandizement of the Councils of Counties and County Boroughs with the consequent belittling of the status of the so-called minor authorities. Time alone will show whether this is the preliminary step towards the later creation of all purpose authorities. In education the change has already been made. The unification of administration of the maternity and child welfare and the school medical services has long been the advocated, legislation already exists to enable it to be effected, while it is contemplated in the White Paper on the Health Services. There is little reason to suppose then that this as a service will not pass to the County Council, though again for a while no doubt the minor authorities will continue to act as agents : step No. 2 in the reduction in the status of the minor authorities. The White Paper contemplates the handing over to the Hospital Authorities the responsibility for the provision and maintenance of the isolation hospitals : step No. 3 ; and how much remains under the direct control of the local sanitary authority ? 2. As to the White Paper on the Health Services, already its submissions, which it has been emphasized were brought out to be discussed, have been substantially amended. The hospital districts of sizes larger than the counties seem to be disappearing, with possibly no other local government area brought into the picture than the counties and county boroughs. Even if introduced in its entirety it would be long before the proposals could be put into effect. In the meantime it is probable that even though no part is introduced in the immediate future that it will be there, having its effect on all new health proposals of any magnitude, so that what changes or developments are made will fit in the pattern laid down, so that the ultimate introduction of the proposals would necessitate changes of far less magnitude than if the corresponding transition were to be made to-day. 3. Turning now from these very theoretical issues—the health of a community as of an individual depends very largely on sound feeding and sound housing. In so far as the first of these concerns any body other than the individual, it is of national solicitude. Feeding through the war has been on a sound basis, and it is hoped that the success of the arrangements in war will ensure the carrying on of similar practice in times of peace, the most important measure perhaps being the provision of "sufficient milk for expectant and nursing mothers and young children. The obligations of the education authorities as to the feeding of school children should go far to ensuring that children of these ages cannot be deprived of the food factors essential to their growth and health. Housing provision is essentially a matter of local arrangement and looms high in the list of essentials, not only to ensure that those living in overcrowded conditions might be rehoused, with benefits to themselves and to the other occupants of the house, but to enable those living in insanitary premises also to be suitably accommodated. It is hoped, too, that there will soon be a sufficiency of labour and materials to permit of the repair and decoration of habitations to bring them back to standards of decency and of hygiene. 4. Though not spectacular, one of the most important of services provided by the Council is the help given by the health visitors. Much of their time is taken up by visiting the mothers in their homes, but more than one half by seeing them at the different clinic sessions. They are working here under difficulties inherent in their having to use buildings not designed for this purpose, and the early construction of suitable clinic buildings is a matter of urgent importance. At the central clinic it was anticipated that the Harrow Hospital would provide out-patient services of every variety, including extensive physiotherapeutic treatment. The activities of the new Charing Cross Hospital to be erected near the district boundary might influence these proposals. 5. But for the war it is probable that the new isolation hospital would by this have been constructed. The original proposal was the erection of a hospital of 120 beds, with possible extension to 180. There is a growing body of opinion that as an efficient unit an isolation hospital should have nearer 200 beds. On the other hand the experience of this district in the last ten years is that 100 beds would more than have met all requirements, so the hospital to be erected should not be much more than this figure. As this is so much smaller than the desirable standard, approach was made to the Borough of Hendon to ascertain whether an extension of their hospital to a size sufficient to accommodate patients from both areas would not be a move in the interests of the inhabitants of both districts, rather than that each authority should continue to provide separate institutions. The original proposal has been extended and the question of a still larger hospital to meet the needs of Hendon, Wembley and Harrow is now under consideration. The proposed management of the Isolation Hospital by the bodies responsible for the provision of general hospital accommodation seems to have just as little to be said for it as the insistence that new maternity hospital accommodation should be provided in association with a general hospital. It is agreed that full treatment facilities should be available at the isolation hospital, in that to-day patients are admitted to these hospitals for conditions just as urgent as those demanding their admission to a general hospital. That is why the hospital should be a proper sized unit, fully equipped for all purposes, in charge of a clinician experienced in the treatment of infectious diseases and backed by all the necessary surgeons and physicians. None of this though is an argument in favour of the hospital being part of or attached to or 48 associated with a general hospital. It is because the treatment of the acute infectious diseases is so important that control of the institutions to which the patients are admitted should be under a clinician specialising in them, otherwise they as diseases will run the risk of their not being studied. 6. It was the general experience throughout the country before the war that an increasing proportion of women wished to have their confinements in an institution. At one time much was heard of the risk of institutional confinement as contrasted with those in the patients' homes. With the truer appreciation of the factors leading to puerperal infection, the risks have been substantially eliminated. If then there are no medical contra-indications of the confinements taking place in an institution, authorities can do little but to provide the accommodation for those wanting it. It is probable that war experience will only have stimulated this growing demand, and that it will be found necessary for authorities to provide beds to meet the needs of proportions even greater than those before the war. The White Paper sees the maternity services as part of the general health services, the institutional accommodation being provided by those bodies responsible for the general hospital accommodation. There is then to be no comprehensive maternity service with each sphere linked to the other. Under to-day's arrangements, and the future holds hope of nothing brighter, we have (a) the domiciliary midwife as an independent unit who establishes touch with the doctor at the ante-natal clinic, but who summons other doctors to her help by the issue of medical aid notices ; (b) the doctor at the ante-natal clinic who sees any midwife who brings her case to the clinic, but sees no patients in hospital and who never attends a confinement ; (c) the Redhill Hospital or the Bushey Annexe, run as a detached service, though the ante-natal supervision of many normal cases is undertaken at the Council's clinics ; (d) a consultant service provided either by the doctor who attends the consultant ante-natal clinic or by one from Redhill Hospital. Apart from the personal contact of the midwife and the doctor at the ante-natal clinic, all other communications are by writing or possibly by telephone. Another body of persons, the health visitors, also is brought into the picture. Full co-operation and unification of the services could be brought about if a local authority were enabled to provide its maternity home, the medical officers to attend the district ante-natal clinics and also answer midwives' medical aid notices, and the district midwives to be periodically interchanged with those at the home. It is hoped that the midwife of the future will be anxious to and will be enabled to be the mother's adviser as to the care of the young infant for a period longer than that for which she continues to attend the mother. The mother passes through a very trying transitional stage about the time she first gets up, so frequently her milk fails then. It is most important that the midwife on whom she has recently been relying so very much should be there to advise and encourage her. It is felt that the midwives can probably, without its making too great a demand on their time,. fit in regular visits to their mothers at least until the infant is one month old. This practice has been adopted here, the 49 midwives for this period supervising all those babies whose mothers they attended, the health visitor being responsible for the supervision of the others. 7. Before the war an enquiry instituted failed to show that there was any clamant demand for the provision of day nurseries in this district. The only nursery school in the area is that maintained by a voluntary organization at Tyneholme. The first of the war nurseries was opened here in 1942. At the end of the next year the number had increased to seven. Apart from that at Vancouver Road, they have been a success in that all places have been occupied, and this even when admissions were in general restricted to children of whole time workers, and usually only one from a family accepted. The Council as Maternity and Child Welfare Authority could continue to maintain day nurseries, providing this accommodation for the reception of infants aged months up to five years. It is highly probable that in some parts of the district and for some time such nurseries could be filled, particularly as, being not war nurseries but maintained by a child welfare authority, the criterion for admission would not be the question of freeing the mother for industry, but the interest of the child. So far from giving preference to those groups at present favoured for admission to the war nurseries, preference might even be given to the case where there is more than one child needing to be looked after, and possibly too even if the mother engaged only in part-time employment. Quite possibly though in some parts of the area, the nurseries will be required not so much because the mother has to go out to work, but to provide suitable surroundings for the development of an only child. An alternative to a day nursery maintained by a child welfare authority is the nursery school provided by the Education Authority which would cater for children of two to five years of age. It is felt that an institution dealing only with children of this age should be a nursery school rather than a day nursery in that its function is to ensure the full mental development of the child, though at the same time adequate attention is paid to his physical condition. Even though it were known that any particular one of these buildings at present used as a day nursery was to remain available, at the moment, because the demand is so very problematical, no decision could be taken as to the fate of any one building. There are certain facts to be borne in mind when each case comes to being considered. A point in favour of the day nursery is that it caters for children under as well as over two years of age, and is open for longer hours than the nursery school. In these ways it is of greater assistance to the mother obliged to go out to work. They are also training schools for the nursery nurse. On the other hand the acceptance of the very young at the day nursery is a heavy responsibility, while caring for the very young is more costly in staffing and equipment, a point to be borne in mind if there is a shortage. The case for the nursery school is that it provides for the more complete development of the child. 8. The increase in the number of illegitimate births has been D 50 responsible for more attention being paid by local authorities to administrative arrangements for the expectant mother, and for the mother and child. Such work has, up to this, been left largely in the hands of moral welfare organizations. The Council is at present party to a scheme by which accommodation is provided in hostels in the County for such girls. Because so many are able to make suitable arrangements, it is only a small proportion of these girls for whom accommodation has to be found. For this reason then, provision of an institution for the reception of this restricted class of person only would have to be by an authority with a very large population. An alternative procedure is the provision of an institution for the admission of different classes. It often happens that a child has because of some slight ailment to be kept away from the day nursery, the mother having to remain at home to care for him. At other times it is the mother whose own illness should prevent her having to look after the healthy infant if other arrangements could be made for his temporary care. There are again those whose homes are not the best places for them to live in while recovering from some operation or illness. A home for the reception of such classes of child, mostly well or convalescing or in any event not seriously ill, could be the same place in which to accommodate these girls, who could undertake part of the work of the home. The Honeypot Lane Isolation Hospital has, for the last few years, been very little used. When opened at all, it has been for the reception of convalescent scarlet fever patients admitted to the South Harrow hospital. A decision that it should no longer be used for infectious patients might result, should other hospitals not be able to accept Harrow patients, in some scarlet fever patients, during epidemic times not being found accommodation. On the other hand, it seems that advantage would lie in the building being used for reception of such other classes of child. 9. One of the earliest of the issues to be attended to is to arrange that those women who wish to have analgesia during labour should be enabled to have it. The difficulties hitherto have been to provide the necessary personnel to secure the second person who has to be present at the confinement, to arrange the training of the staff, and to obtain the apparatus. 10. While it is hoped that the problem of scabies, even though it might have been on the increase before the war will diminish after it, it is probable that some provision for the treatment of sufferers will need to be made. • Possibly the temporary arrangements provided at the First Aid Post at the Car Park can continue until the erection of the central clinic at which provision will need to be made for the treatment of patients and their clothes. 11. As part of the arrangements for decentralising, the Emergency Public Health Laboratory Service was designed, being based on hospital sectors. The scheme proved a success, one very real advantage being the facility with which the general medical practitioner could consult the pathologist responsible for the work. Although in peace time the 51 grouping of areas might with advantage be based on other considerations, it is hoped that arrangements will be made by which the essence of the scheme remains in being. It is to the advantage of the medical officer of health as well as to the general medical- practitioner that he keep in close contact with the practising pathologist who, desirably, deals with the clinical matter from a number of areas, and who would therefore be in a position to know from a study of what has been sent in what is likely to be developing, not in one, but in a group of areas. 12. Because as far back as 1901 neither of the two urban districts which became constituent authorities of the Harrow created in 1934 were of 20,000 population, in spite of the present population Harrow was not a Local Education Authority ; nor did it seem likely that it would become one except by the successful promotion of a special Act. The revolutionary changes brought about by the 1944. Education Act as regards local administration of its provisions has resulted in this district being granted the same powers as many of the previous Part III authorities. The school medical services then are to be locally administered. The main benefit to follow from this is that the school medical and the maternity and child welfare services will become merged, being undertaken by the same staff. While there will be advantages in this as regards the activities of the medical officer, the main benefit follows in the case of the health visitor. The health visitor started as an official whose chief activity was helping the mother in the upbringing of her baby. From this she extended her interest to the child under five years of age. She is now very far though from restricting her services to this limited section of the family, and the concern of the good health visitor is the entire family. It is for this reason that it is so very much better if she is appointed school nurse as well. In her efforts to bring down the infant mortality rate, the health visitor had to battle against adverse hygienic conditions and to educate the mother in the principles of domestic sanitation. For this reason it was essential that much of her time should be spent in the homes of the mothers. To-day in a district such as this which is fortunate in being in general of a high hygienic level, once the health visitor sees the mother and her home there is not the same necessity for her to continue to see her there, and contact made at the clinic sessions, provided these are not too busy to prevent satisfactory consultations, is adequate in the majority of cases. To be of real advantage though, the interview must take place in an atmosphere quieter and less hurried than that obtaining in the usual infant welfare centre. It might well be then that the most economical use of the health visitor's time will be by her attending even more sessions than she does at present, with smaller attendances at each, and each not necessarily attended by the medical officer. This can be a successful arrangement though only in those districts where the general standard of housing and house management is high. To-day much of the time of the health visitor is taken up by her acting as adviser on such a variety of subjects to individual mothers. Her particular function though is to be an educator, and she might 52 when circumstances are favourable be the better able to achieve this by dealing with groups of mothers at clinic sessions. It is appreciated it will be a long day though before she can feel so satisfied with all the mothers on her district that she can reduce the home visiting, to negligible proportions. 13. The Education Act, 1944, imposes an obligation on Local Education Authorities to make arrangements for securing the provision of free medical treatment for pupils either under this Act or otherwise. Such treatments as have been provided under the arrangements of the school medical services will be provided free of cost, while in addition free treatment of the same class of child will be provided for those admitted to the hospitals of the County Council. It would seem that such facilities as are at present offered at the school minor ailment clinics might be extended, and so in this way the free service to the school child enlarged in scope. On the other hand the provision of medical treatment under the Act does not include treatment in the pupil's home. As far as is practicable children under five taking advantage of the treatment facilities of the Council's maternity and child welfare services will in future also be enabled to obtain these services free of charge to the parents. In the same way, nursing and expectant mothers can obtain free of cost treatment such as dental (though not the provision of dentures) ophthalmic and light treatment. It will be long before the treatment services available for school children can really be classed as " comprehensive facilities for free treatment." Circular 29 requires that the extended provisions must be considered in relation to the Government's declared intention to introduce a comprehensive health service as part of their reconstruction policy, this service to cover school children together with all other members of the household. When introduced in its entirety the scheme for the treatment of children of school age will probably be one capable of embracing children up to school age. By that time very substantial additional sections of the community will be covered by free treatment services. Those who are agreed on the necessity of the provision of a health service for the community divide on the issue of whether the service should be based essentially on the arrangements of the present panel system, the patient having to attend the surgery of the doctor, or alternatively be based on the service provided by a team of doctors working from health centres. At the moment there seems to be no general authority to arrange for treatment by a doctor at his surgery, whereas there does seem to be authority to extend the scope of treatment provided at the minor ailment clinics. 14. Before the war, although many local authorities had made arrangements by which children could be immunized against diphtheria, there was little active encouragement from the Ministry. There has been a radical change though during the war when the Ministry by various forms of propaganda encouraged parents to have their children protected, and even provided the material to local authorities free of charge. The result is that the country is in a very much safer position as regards the 53 risk of attack than ever before in its history. In this district the results obtained, though satisfactory, were not outstanding. Sufficient children are now immune to remove the risk of any substantial outbreak. Probably sufficient school children are immune to render unnecessary any special effort being directed towards any more being done, the time being better devoted to those under five years of age and still more so to the child of one year. Some hope that improved sanitation, greater attention to food, and the other factors which improve environmental hygiene will result in a lowering of infection. Possibly in time factors will be discovered which can modify man's susceptibility to attacks by micro-organisms. Until then, it must be accepted that there will remain the interplay and interaction between the parasite and the human host until such time as the organism has adapted itself to a symbiotic existence, no longer being pathogenic to man. As long as the organism remains pathogenic and also prevalent, an individual will need to be actively protected against attack. If the organism disappears and if the reaction it causes to the human which it attacks is so intense that control of the individual is easy, then immunization as a routine is unnecessary. This is to-day's position in this country in regard to smallpox and vaccination against it.