Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1946 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW King and Hutchings, Ltd., Printers, Uxbridge. Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1946 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW 3 REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Chairman and Members of the Urban District Council of Harrow. Mr. Chairman, Mrs. Cock and Gentlemen, I beg to submit the Annual Report of the Health and Sanitary Circumstances of the District for the year 1946. In last year's report an account was given of the development of the local health services and each described in detail, so this year's report will contain only the story of occurrences during the year under review and the more detailed consideration of certain of the services. In regard to the health services the local authority acts in its capacity as local sanitary authority dealing with environmental hygiene, supervision of foodstuffs, and the control, prevention and treatment of infectious disease, as a welfare authority administering maternity and child welfare including the midwifery service, and as an excepted district administering as agents of the local education authority certain of the school medical services. The National Health Service Act brings about certain changes in the administration of these services. The personal services—a product of this century—pass to the County Council, the newly designated local health authority, but in turn the County Councils lose to the regional boards—those bodies appointed by the Minister, fourteen of them throughout the country—not only the hospital service but those services which at present or in the future are to be based on these hospitals, such as the tuberculosis service and the arrangements for the treatment of venereal disease. The effect of these changes which date from the 5th July, 1948, will be that Harrow reverts to its duties of the sanitary authority of the latter part of the last century, being directly responsible, of the health services, only for that of the environment, the physical surroundings of the population, the protection of foodstuffs and the control of infectious diseases. It will lose its responsibility for the maintenance of the isolation hospital, as infectious disease hospitals, along with others, become the responsibility of the regional boards. It loses, too, its responsibility for arranging for the immunisation of children against diphtheria, a service which passes into the hands of the County Council, just as does the ambulance service. Presumably no change is intended as yet in regard to the local administration of the education services, so that for the time being, at least, the Council, as an excepted district, will continue to act as agents for the County Council in the administration of certain of the school medical services. The maternity and child welfare services pass from the hands of the Council to those of the County Council. The Act provides for the making of regulations for the making of schemes of divisional administration, delegating certain of the maternity and child welfare functions of local health authorities on the lines of the devolution of duties to excepted districts under the Education Act. The Council then may possibly still retain some measure of responsibility for the day-to-day administration of those services which it provides to-day as the welfare authority. The functions of the County Council (the newly 4 created local health authority) are widened. Just as they are the education authority for the entire County they now become responsible for the administration of the maternity and child welfare services throughout the area. They will maintain the ambulance service transferred from local authorities. They will be responsible for the new home nursing service and also for the domestic help service. The duties of the health visitors are to be broadened, and the County Council becomes responsible for making arrangements for the immunising of the population against diphtheria and its vaccination against smallpox. The County Council is the authority responsible for providing, equipping and maintaining the new health centres which are to figure so largely in the new sickness service and which will in most areas presumably in time replace the surgeries of the general medical practitioners, while at the same time at them will be provided certain health services for which the local health authority is responsible. The County Council though while acquiring much, is losing much. It is losing its hospitals, not only the general, medical and surgical hospitals, institutions for the administration of which they were made responsible by the Local Government Act, 1929, but special hospitals such as those for maternity cases, those for the tuberculous and for the mentally afflicted. They lose, too, services related to clinics and hospitals, including the entire tuberculosis service with its chest clinics and institutions for pulmonary and for non-pulmonary cases and the social services now based on these centres. All these pass into the hands of the regional board. The country is being divided into fourteen regions, each based on a university area, each being administered by a board appointed by the Minister of Health. Each board will operate through hospital management committees—bodies appointed by the board and having on them representatives of local health authorities, executive councils, and medical and dental staffs. The last of the bodies concerned in the administration of this new health scheme is the executive council. These are bodies each representing an area corresponding to a county or a county borough on which will be representatives of the Minister, of the local health authority and of the local medical, dental and pharmaceutical committees. The doctors who will be responsible for the general medical service will contract with the executive council. The direction of activities of a welfare authority is changing. Health visitors have gradually extended their range of duties embracing the entire family and not now merely the small child or the mother. This extension is to be given official recognition in the definition of the functions of the health visitor in the new Health Service Act. Her outlook is more sociological than clinical. Authorities provide day nurseries. The administration of these nurseries falls to the welfare committee in that it is the committee which has to be responsible for the arrangements for ensuring the health and well-being of the children but this is more the concern of the staff, whereas what concerns the committee more is the justification for the nurseries which leads to the discussion of such problems as the employment of married women and the country's drive for export. Again the domestic help service is not so very far removed from a domestic service agency, and while the service 5 deals with conditions closely related to the health or the sickness of the community the trend is the growth of a social welfare rather than a health, and certainly rather than a preventive health, service. The vital statistics for the year were very satisfactory, and as these are the only standards we have for assessing the health of a community we can assume that the health of the district was good. The infant mortality rate, accepted as an index not merely of the welfare services but of the general hygienic and social conditions of the community, was low, as was also the maternal mortality rate. There were no widespread epidemics and even those diseases which did prevail caused few fatalities. In general the sanitation of the country is now on such a firm foundation that spectacular outbreaks of those diseases which are the result of insanitation are largely a thing of the past. Typhoid fever in Aberystwyth, in Croydon and in Bournemouth though shows that the freedom from such diseases can be earned only as the result of unremitting attention, and above all by the education of all sections of the community about hygiene and its standards. Any district though can without notice be subjected to a large scale outbreak of infections of different sorts, so freedom from infection or years of satisfactory vital statistics can give no assurance that trouble might not be met, nor give any grounds for complacency or for relaxation of effort on the part of those who deal with the health services. An outbreak of an infection such as typhoid fever will strain to the limit the capabilities and the time of the available staff. The real solid work is done though not when an outbreak occurs but in the routine, unspectacular day-to-day inspections and visits to premises to discover and remedy unsatisfactory conditions, and to educating those dealing with foodstuffs. Shortages of staff which prevent this work being done are not made obvious at the time, and become so only when the lowered standard has allowed practices which are fraught with danger. Many of the diseases which occur in epidemic form, however, are not related to hygienic conditions, though these might have a secondary effect on the severity of the illness in the patients. Even overcrowding seems to affect the incidence only to a slight degree and it has to be very marked to produce such an effect on the occupants that their standard of health is so lowered that this is reflected in the severity of an attack. To-day scarlet fever is a disease bearing little relation to that which was so feared in the last century. Last year it was not very prevalent, nor has it been for some years, but this is not the result of anything which has been done to protect the community from acquiring it, nor is it the result of any improvement in the hygienic surroundings of the population. It has been a very mild type. Again this is not the result of anything that man has done, unless those are right who hold that hospitalisation of the more severe cases resulted in a general decline in its severity. For an explanation of such occurrences we must turn then not to the human or to the host or the soil, but to the seed or the organism, and presumably what has happened in the case of scarlet fever is a change in the organism. If so it can be assumed that it is capable of reverting again to a virulent strain. Changes of this sort in the organism which cause diphtheria were thought to have taken place some years ago when certain localities were infected 6 by a very severe variety of the germ which caused an illness resistant to the treatment successful in the more usual cases of the disease. To-day's happy position is the result of a decline not necessarily in the incidence of disease, but in the severity of attack of such infections as scarlet fever, diphtheria, measles and whooping cough—the one time killing diseases of childhood. The fact that the decline has occurred in all at the same time suggests that it is the result of a change in the human host which offers greater resistance rather than co-incidence that simultaneous changes in the organisms have occurred. It would be encouraging to feel that this is so because it would lead to the hope that the disadvantages of these diseases could be overcome by enabling in time all the population to benefit from those better conditions which render them resistant to attack. This may be the position, though more probably it is not so, and probably we are to remain at the mercy of variations of the organisms except in the case of those against which we in time can acquire some preventive. As most of the commoner infections are spread by individuals and probably most commonly indoors, it may be that some form of treating the indoor air will be elaborated which may result in a reduction of the incidence of these complaints. To a few diseases we are almost all susceptible and immunity is acquired only on recovery from attack. To others most of us acquire immunity not by attack which results in a frank illness but by our overcoming repeated small sub-lethal doses to which we are subjected. A low incidence of infection deprives us of these stimulating doses and so leads to the development of a susceptible community. General freedom then is likely to be obtained only by the artificial means of active immunisation by inoculation. In these diseases infection spreads mostly from the patient usually more in the developmental or at the most in the early stages of illness and by carriers, including the incubationary, the convalescent and the contact carriers. In some diseases such as poliomyelitis, and cerebro-spinal fever it seems probable that at the time of heavier incidence much of the population is exposed to infection by the organisms, but of those exposed only those who are susceptible at the moment are likely to succumb to a recognised attack of the disease. In some diseases it seems perhaps the immunity of an individual is not a systemic or generalised one, but is possibly more localised and is subject to more variation than the general immunity which occurs in such a disease as diphtheria. Whereas then in diphtheria an immunity sufficient to safeguard against an exposure on one occasion will be sufficient to protect against a similar exposure on other occasions, with these other infections it seems than an individual might be immune on one occasion, but susceptible on another. In such infections then even less than ever can be done to limit the spread of infection or reduce the possibility of anyone acquiring an attack of the disease. Hygiene and sanitation then are limited in the extent to which they can prevent the invasion of a community, and in the light of our present knowledge once to-day's standards have been achieved there is little more to be done to prevent such invasions, though increasing knowledge undoubtedly will result in the preparation of effective preventive substances for an increasing number of diseases. Whether when they have been discovered their general use will be warrantable will depend on the particular disease. 7 The development of the personal services seems to have been almost haphazard as though it suddenly dawned on someone that a particular section of the community or those suffering from special diseases should receive special attention. The favoured sections are those of school age, firstly those attending the then-called elementary schools, then those of the secondary schools, enjoying first the benefits of medical inspection and then the ever-widening treatment services, culminating as a result of the 1944 Act in the almost full health services for those attending maintained schools. The next sections were first the babies, then the children up to five, the nursing mothers and the expectant mothers. To help these groups authorities have very wide powers. Of those sections of the community suffering from diseases or abnormal states the first were those with tuberculosis, then the sufferers from venereal disease, the mentally afflicted and mentally subnormal, and then the blind. Later the Local Government Act, 1929, put the duty on the councils of counties and county boroughs of providing a general hospital service; and just before the war schemes were being made to meet the needs of those suffering from cancer. The very success of some of these endeavours lead to a dimunition in the need of the service, and now they are all to be re-arranged. Some are to be integrated with the national arrangements for the care of the sick and of those suffering from the effects of accidents. Others are to remain at least for the time being as independent services. Some persons are apprehensive for the future, fearing that when these services are based on different foundations there will be less likelihood of progress and improvement because of lack of a driving force. In regard to many of these services possibly this is now of less moment because of the advanced stage many of them have reached. Certain of the personal services would seem to have reached the stage of the environmental services. On the other hand though there is still room for development. The cancer service has barely begun; nothing very definite on a national scale has been done for the sufferers from rheumatism; the care of the elderly certainly looks like replacing as a prominent activity of authorities the attention previously bestowed on the very young, while the developing new social medicine has yet to be fitted into the scheme of things. Under the new arrangements environmental hygiene will remain with the local sanitary authorities, many of the personal services with the new local health authorities and much of the treatment service with the new hospital boards. Out of this development integration may evolve. The fate of the smaller local authorities seems decided. The question is whether movement on these lines might not result in local government itself as it at present exists being put in the melting pot. The trend definitely is towards larger units. Are we seeing the beginnings of changes which are to result in the complete severing of the health services from local government units? So far as Harrow is concerned, apart from the temporary setback in the standard of housing, the general environmental services are good. These are for the time being to remain the responsibility of the local authority. Epidemiology, at one time considered to be the chief responsibility of the medical officer of health, is likely to pass out of his hands because of the development of the laboratory service, coupled with the fact that the isolation hospitals pass 8 to the hospital boards. Unless and until new legislation is introduced the Council will retain its responsibility for much of the local school health services. What is to happen about the present welfare and associated services, whether they for this district are to be administered by the local council in a committee with a majority or a minority of county councillors or whether it is to become part of a county area with these services administered by a combined committee, is yet to be seen. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Harrow-on-the-Hill. July 28th, 1947. 9 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1946 210,890 Rateable Value (April 1st, 1947) £2,146,873 Sum represented by a penny rate (April 1st, 1947) £8,600 Total number of occupied houses 51,016 Total number of occupied flats 7,968 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Legitimate 3,755 1,947 1,808 Birth rate per 1,000 of the estimated resident population, 18.0 Illegitimate 179 93 86 Total 3,934 2,040 1,894 Stillbirths:— Legitimate 114 63 51 Rate per 1,000 total (live and still) births, 3.0 Illegitimate 8 5 3 Total 122 68 54 Deaths 1,816 897 919 Death rate per 1,000 of the estimated resident population, 8.6 Deaths from puerperal causes:— Deaths Rate per 1,000 total (live and still) births Puerperal sepsis — — Other puerperal causes 3 0.75 Total 3 0.75 Death rate of Infants under one year of age:— All infants per 1,000 live births 31.0 Legitimate infants per 1,000 legitimate live birth 30.3 Illegitimate infants per 1,000 illegitimate live births 67.0 Deaths from Cancer (all ages) 350 „ „ Measles (all ages) 2 „ „ Whooping Cough (all ages) — „ „ Diarrhœa (under 2 years of age) 9 Population. The population of the district in the middle of 1945 was 191,710. It rose to 201,070 at the end of the year. A similar increase gave a mid-1946 figure of 210,890. Since then the increases have been more gradual so that the population figure at the end of September was 214,860 and at the end of the year 216,230. Of the mid-year population those of ages 0.4 were estimated at about 16,000, and those of 5-14 years about 29,500. The natural increase in the population, that is the excess of births over deaths, in the year was 2,118. 10 Births. The number of births in the last three-quarters of the year was an appreciable rise on the earlier figures, though less than those of 1947. The number of live births 3,934 is the largest ever recorded for the district, the previous record being 3,500 in 1943. The local rate per thousand population was 18.7 compared with the figure of 19.1 for the country as a whole. Over the last few years the local rates have ranged from 14.7 recorded in 1941 to a figure of 18.7 in 1944. Deaths. 1,816 local residents died during the year, a death rate per thousand population of 8.6. This is a fall on the almost constant rate of 9.1 obtaining since 1940, but is still appreciably higher than the pre-war rates, a factor attributable probably to the influx of a number of the elderly. The fact that the rate is so much lower than that of the country as a whole, the national rate being 11.5, must be ascribed less to the general healthiness of the district than to the age constitution of the population being one favourable to the lower rates. The actual number of deaths is an increase on the 1,732 of the previous year; the fall in the death rate in spite of this being due to the greater population at risk. The actual number is nearly the highest figure ever reached, that of 1,818 in 1942. Of the 1,222 deaths in the district 106 were of non-residents. 22 took place in the various hospitals, 20 in nursing homes (this figure including 6 newborn babies), and 6 in Oxhey Grove, a home for the elderly. Of the 690 deaths of local residents which occurred outside the area most took place in institutions, 266 being in Redhill Hospital, 22 at Redhill House and 76, including 7 newborn infants, at other county institutions. Five deaths occurred in institutions for the treatment of the tuberculous. 81 deaths took place in hospitals just outside the district, including 40 at Mount Vernon and 4 in isolation hospitals. 117 died at various of the London hosDitals. 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 219 226 Cerebro-spinal fever 1 1 Other circ. diseases 34 39 Scarlet fever 0 0 Bronchitis 57 40 Whooping cough 0 0 Pneumonia 45 44 Diphtheria 0 1 Other resp. diseases 11 13 Resp. tuberculosis 55 24 Ulcer of stomach 18 3 Other tuberculosis 4 7 Diarrhoea under 2 years 5 4 Syphilitic diseases 2 4 Appendicitis 1 2 Influenza 9 11 Other digestive diseases 14 25 Measles 0 2 Nephritis 31 20 Acute polio-myelitis 0 1 Puerperal sepsis 0 0 Acute encephalitis 2 0 Other maternal causes 0 3 Cancer of mouth and oesophagus (M), and uterus (F) 6 25 Premature birth 13 22 Cong. malformations etc. 28 22 11 Male Female Male Female Cancer of stomach 34 22 Suicide 7 6 Cancer of breast 0 35 Road traffic accidents 5 4 Cancer of other sites 127 101 Other violent causes 21 15 Diabetes 2 8 All other causes 71 62 Intra.-cran. lesions 75 127 All causes 897 919 Whereas 50 per cent. of the deaths of the males occurred among those of under 65, the corresponding prcentage of the females was only 40. The increased proportion of deaths amongst those who have attained the age of 65 is quite striking. In 1930 the percentage of deaths for the country as a whole which occurred amongst those who had reached this age was 44; in 1945 the prcentage was nearly 57. On the face of it it would seem that the health of the community has markedly improved in this short time. The figures though are only percentages, so that a fall in the number of deaths at other ages would cause a rise in those of the higher ages. This fall could be the result of a smaller number of deaths taking place, not because of a lowering in the death rate, but because of the smaller population at risk. In the same way the higher proportion of deaths of the elderly might be and actually largely is the result of there being more reaching these higher ages, again not from any lowering of the death rate, but because of the survival of the many born at a time of a high birth rate. This altered age distribution of the population is shown by the following series of figures which give for the populations of 1930 and of 1945 for the country as a whole the proportions per thousand population in the various age groups 5-yearly up to 25, then 10-yearly up to 85, those above this age being grouped together : 76, 87, 79, 88, 90, 157, 137, 124, 93, 50, 17 and 2 (1930), the other series 82, 74, 73, 68, 52, 122, 157, 141, 117, 79, 30 and 5 (1945). This higher proportion of the elderly must for some years constitute a problem until satisfactory arrangements can be made for dealing with at least a high proportion of them. While the postponement of death may be an achievement, it is a desirable aim only if the elderly are in possession of their faculties. We are far in outlook from those days not so very far back when those who had reached a certain age, more especially the women seemed to feel that they had had all there was to be had out of life and were merely waiting their end. To-day it is no uncommon sight to see the quite elderly full of vigour and mental and physical energy. It can only be if that standard can become general that there can be any justification for endeavouring to increase the average lifetime. Fatalities from the infectious diseases again compared most favourably with the figures for the country as a whole. This year there were no deaths from typhoid fever, scarlet fever or whooping cough. The fatality rate expressed as a rate per thousand population of measles was under 0.01, influenza 0.10 and diphtheria 0.005, compared with national rates of 0.00, 0.15 and 0.01. The rate for diarrhcea in those under 2 years of age of 2.2 per thousand live births was just half the national rate. 12 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. HOSPITALS. 1. For Infectious Cases. In general the same arrangements for the hospital treatment of those suffering from infectious diseases were continued. The proposal that the needs of the three districts—the Boroughs of Hendon and Wembley and this district—should be met by enlarging the Hendon Isolation Hospital to be maintained by a Joint Hospital Board was acceptable to all three authorities. In the light of the provisions of the National Health Service Act the Minister saw little point in any development on these lines, so the proposal was abandoned. The position, then, is that the local Council continues to be responsible, probably until July 4th, 1948, for the hospital treatment of the infectious sick. From July 5th, 1948, this responsibility devolves on the Regional Board, which is responsible for the administration of all the hospitals in its area brought under its control. The Board is not obliged to take over every hospital functioning as such at the time of the change, so that the local Isolation Hospitals might not be taken over, though presumably if they are not there can be no question of their continuing to accept infectious patients. In the meantime, because for so very long, over three years now, the Stanmore Hospital has been closed owing to there being no demand on its beds for scarlet fever patients, consideration is being given to the question of its being adapted for use for other purposes. 2. Tuberculosis. No marked changes have been made in the arrangements made by the County Council for the institutional treatment of those suffering from pulmonary or from non-pulmonary tuberculosis. The County Council, along with most other hospital authorities, has been faced with the problem of the shortage of nursing staff, and hospital accommodation in existence cannot be used for the benefit of those requiring treatment because of the lack of nursing staff. In March, 1945, the County Council opened a new institution for men suffering from pulmonary tuberculosis at Grimsdyke. The primary object here is to fit men who have been through the stages of active treatment in a sanatorium for a return to full working life. At the beginning of the year there were 452 beds at Harefield County Hospital (including 18 for observation), 506 and a further 54 in the hospital block at Clare Hall County Hospital, 60 beds for convalescent female cases at Danesbury Manor, Welwyn, 50 at Grimsdyke and 248 in other institutions. Of these 1,370, 254 were not available owing to shortage of staff. A further 386 beds were reserved for patients suffering from pulmonary tuberculosis, mostly advanced cases, at the County Council's general hospitals. Of these 106 were temporarily not available because of staffing difficulties. 13 3. General Hospitals. The chief change which has been made in the matter of general hospital accommodation in this last year is that no part of the country branch of the Orthopaedic Hospital at Stanmore is now a general hospital. Redhill County Hospital, the County Council Hospital which serves this area, too, has been affected by the shortage of nurses to such an extent that the work of certain special departments has been disorganised. NURSING HOMES. The demand on the accommodation of nursing homes continues, particularly for maternity beds. During the year then changes have been made in the numbers of beds for which certain homes are registered and also the type of patient to be received. Some of the homes have changed hands, and the following is a summary of the changes which have occurred during the year:— Additional Registration. Beds. Heywood Nursing Home, Stanmore Mrs. M. Guyatt 7 medical or convalescent or maternity. Beverley Maternity Home, 170, Whitchurch Lane, Edgware. Miss C. Dear 3 maternity. Elmside Nursing Home, Sheepcote Road, Harrow Mrs. F. M. Smith 6 maternity. Changes in Registration. Beds. St. Vincent's Nursing Home, Headstone Lane, N. Harrow. Mrs. P. B. Thomas s 9 maternity and others. Maitlands Nursing Home, 54, Marsh Road, Pinner Mrs. H. Payne 9 maternity and others. Oakdene Nursing Home, 11, Hindes Road, Harrow. Mrs. A. Gee 10 maternity and convalescent. College Hill Nursing Home, 123, College Hill Road, Harrow Weald Mrs. F. Ellis 10 maternity, medical, or surgical. Bowden House, London Road, Harrow-on-theHill Bowden House N.H. Association. 14 mental. Three Homes were first registered during the year, having a total of 12 maternity and four other beds, in all 16. At the end of the year there were 20 registered Homes with 170 beds, half maternity and half for other patients. NURSING IN THE HOME. 1. General. No changes occurred in the year in the arrangements for nursing in the home. The Greater Harrow District Nursing Association, which provides this service for most of the district, accepted 3,579 new cases during the year, 2,005 being dealt with by the staff at Warneford, and 1,579 by that at Belmont. In all, 35,130 visits were paid. There are 14 eleven nurses in addition to the Superintendent, the Deputy Superintendent and the senior nurse at Belmont. Although at times private bills have been introduced in the House to empower authorities to provide a nursing service in the home, in most areas this service continues to be provided by staffs of district nursing associations. From July 5th, 1948, it becomes the responsibility of the local health authority—in this area the County Council, Section 25 of the National Health Service Act, 1946, which deals with the subject reading: "It shall be the duty of every local health authority to make provision in their area whether by making arrangements with voluntary organisations for the employment by those organisations of nurses or by themselves employing nurses for securing the attendance of nurses on persons who require nursing in their own homes." 2. Midwifery and Maternity Nursing. The following are the names and addresses of the Council midwives : Nurse Raeburn, 16, Worcester Court, Headstone Drive, Wealdstone. Nurse Tennant, 49, Cannons Lane, Pinner. Nurse Eagle, 168, Whittington Way, Pinner. Nurse Lundy, 2, Church Avenue, Pinner. Nurse Angel, 9, Thistlecroft Gardens, Stanmore. Nurse Craft, 134, Brampton Grove, Kenton. Nurse Swann, 38, College Hill Road, Harrow Weald. Nurse Shaw, 113, Locket Road, Wealdstone. Nurse Ponter, 36, Corbins Lane, South Harrow. Nurse Walsh, 65, Shaftesbury Avenue, South Harrow. Nurse Janes, 14, Crown Street, Harrow. Nurse Rough, 213, Exeter Road, South Harrow. Nurse Mooney, 39, Malvern Gardens, Kenton. Nurse Francis, 68, St. Paul's Avenue, Kenton. Nurse Robertson, 83, Merlin Crescent, Edgware. Nurse Speaight, 470, Honeypot Lane, Stanmore. In addition there were at the end of the year eight midwives living in the area whose work is almost entirely restricted to domiciliary practice here, while as well there were six midwives living out of the area, but whose domiciliary practice extends into this district. The responsibility for the supervision of midwives and the administration of the midwifery service passes to the County Council next July, under Section 23 of the National Health Service Act. "The local health authority shall be the responsible authority for the purposes of the Midwives Acts, 1902-1936... It shall be the duty of every local health authority to secure that the number of certified midwives who are available in the authority's area for attendance on women in their homes as midwives or as maternity nurses during childbirth and from time to time thereafter during a period not less than the lying-in period is adequate for the needs of the area." 15 CLINICS AND TREATMENT CENTRES. The following is a summary of the various clinics and treatment centres in or serving the district as at December 31st, 1946. Infant Welfare Centres. The Clinic, Broadway, Wealdstone Wednesday a.m. and p.m. The Clinic, Elmwood Avenue, Kenton Monday p.m., Wednesday p.m. The Clinic, Honeypot Lane, Stanmore Monday p.m., Wednesday p.m. The Clinic, Alexandra Avenue, South Harrow Monday p.m., Friday p.m. St. Hilda's Hall, South Harrow Tuesday p.m., Thursday p.m. St. George's Hall, Headstone Tuesday p.m., Friday p.m. Memorial Hall, Harrow Weald Thursday p.m. Spiritualist Hall, Vaughan Road Wednesday p.m. Methodist Church Hall, Love Lane, Pinner Friday p.m. St. Anselm's Hall, Hatch End Thursday p.m. Baptist Church Hall, Streatfield Road Wednesday a.m. and p.m. Methodist Church Hall, Walton Avenue South Harrow Thursday p.m. The Pavilion, Chandos Recreation Ground Thursday p.m., Friday p.m. All these sessions are held weekly. Ante-Natal Clinics. The Clinic, Broadway, Wealdstone Tuesday a.m., Thursday p.m. The Clinic, Elmwood Avenue, Kenton Monday a.m. St. Hilda's Hall, South Harrow Tuesday a.m. Spiritualist Hall, Vaughan Road Wednesday a.m. Memorial Hall, Harrow Weald Tuesday p.m. The Clinic, Honeypot Lane, Stanmore Tuesday p.m. Methodist Church Hall, Pinner Monday p.m. St. Anselm's Hall, Hatch End Thursday p.m. Baptist Church Hall, Streatfield Road Thursday p.m., Friday p.m. 76, Marlborough Hill Monday, p.m. Methodist Church Hall, Walton Avenue Thursday a.m. The Pavilion, Chandos Recreation Ground Monday a.m., Friday a.m. The Clinic, Alexandra Avenue, South Harrow Wednesday p.m. The sessions were held at these clinics weekly, except at Pinner and at Hatch End, where they are held fortnightly. A consultant antenatal clinic was held on the second, third and fourth Tuesday mornings at the Clinic, Elmwood Avenue. Toddlers' Clinics. The Clinic, Elmwood Avenue, Kenton Thursday a.m. The Clinic, Alexandra Avenue, South Harrow Wednesday a.m. Honeypot Lane Clinic Monday a.m. Methodist Church Hall, Love Lane Pinner Monday a.m. 16 Baptist Church Hall, Streatfield Road Thursday a.m. The Pavilion, Chandos Recreation Ground Thursday a.m. Spiritualist Church Hall, Vaughan Road First Monday a.m. of month. St. George's Hall, Headstone First and Second Tuesday a.m. of month. Birth Control Clinic. The Clinic, Broadway, Wealdstone First and Third Friday a.m. of month. School Minor Ailment Clinics. The Clinic, Broadway, Wealdstone Thursday a.m. The Clinic, Elmwood Avenue, Kenton Friday a.m. The Clinic, Alexandra Avenue, South Harrow Friday a.m. The Clinic, Honeypot Lane, Stanmore Tuesday a.m. Methodist Church Hall, Love Lane, Pinner Monday a.m. The Pavilion, Chandos Recreation Ground Tuesday a.m. Ophthalmic Clinic. 76, Marlborough Hill Tuesday a.m., Friday a.m. The Clinic, Alexandra Avenue, South Harrow Thursday a.m. Dental Clinics. The Clinic, Elmwood Avenue, Kenton. 76, Marlborough Hill. The Clinic, Alexandra Avenue, South Harrow. The Clinic, Roxeth Hill. Stanburn School. The sessions are held most week-day mornings and afternoons. Physio-Therapeutic Treatment. Treatment sessions are held throughout the week, cases being seen by a consultant physio-therapist on the mornings of Wednesday and Friday; Monday and Tuesday afternoons or Thursday evenings ; or the orthopaedic surgeon attending on the morning of the first Wednesday of the month. Tuberculosis Clinic. The part of the district roughly that to the west and south of the main L.M.S. line, is served by the Chest Clinic at 25, Greenhill Crescent, where the medical officer attends on Monday morning, Thursday afternoon and some evenings. Persons from the area north and east of the railway line attend the Chest Clinic at Redhill County Hospital, where sessions are held on the mornings of Tuesday, Wednesday and Thursday and some evenings. 17 The reduction in the number of beds available for the institutional care of patients threw further work on those staffing the chest clinics. The functions with which these clinics are concerned have been classed as (i) the diagnosis and supervision of the tuberculous case; (ii) the prevention of tuberculosis or the diagnosis of disease in an early stage in a household contact of a known case; (iii) continuing the treatment of cases that have been in an institution; (iv) keeping under supervision all cases on the register whether receiving active treatment or not; (v) carrying out such welfare work as is possible. The institution of the Government scheme of financial allowance to many patients led to the appointment of welfare officers at these clinics. Apart from these grants under Ministry of Health Memorandum 266/T considerable assistance is now given in the way of extra nourishment, clothing, bedding, home helps and boarding allowances for patients and their families. Venereal Diseases. In addition to the hospitals at which treatment is available under the London and Home Counties scheme, facilities are available at the following County Hospitals:—Central Middlesex Hospital, Acton Lane, Willesden; Hillingdon Hospital, Royal Lane, Hillingdon; West Middlesex Hospital, Twickenham Road, Isleworth. The most convenient of the London Hospitals at which treatment is provided, are St. Mary's Hospital, Cambridge Place, Paddington, and University College Hospital, Gower Street. ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT. At the beginning of the year 19 premises were licensed, while in addition there were 3 used by members of the Chartered Society of Physio-Therapy. During the year a further 3 were licensed, the number occupied at the end of the year being 18. PUBLIC HEALTH AMBULANCE SERVICE. The following is a summary of the extent to which the ambulances and the sitting case cars have been used during the year, with last year's figures for purposes of comparison: 1945. 1946. Traffic accidents 162 297 Other accidents (including street illness) 517 483 Maternity removals 413 463 Sick removals to and from Hospitals 2,977 5,920 Total 4,069 7,163 Up to 1939 the public health ambulances were stationed at the various fire stations, being manned by members of the Fire Brigade. On the establishment of the National Fire Service the ambulance service was maintained by personnel of the Civil Defence Ambulance Service. On this being disbanded the ambulances reverted to the control of the local council, being stationed at the Central Fire Station, though manned B 18 by full-time Council personnel who devote their entire time to these duties. From next July the public health ambulance service and, too, the arrangements for the removal of infectious patients pass into the hands of the County Council. LABORATORY FACILITIES. The public health laboratory work of the district is now undertaken at the Public Health Laboratories at Colindale, the change being made in May. The arrangements are working smoothly. The laboratory sends a van to a number of collecting points about mid-day, these being the South Harrow Isolation Hospital, the Public Health Offices on the Hill, and the Central Fire Station, Pinner. The van also collects from the Harrow Hospital. Its last collection from the neighbourhood is at the Hendon Isolation Hospital, at which specimens from this district can be left. The following is a summary of the work done by the laboratory in regard to the examination of clinical material from persons from this area in the last six months of the year: 241 nose and throat swabs for K.L.B., hæmolytic streptococci or the organisms of Vincent's angina; 20 specimens of faeces for organisms of dysentery or food poisoning; 11 samples of sputum for the tubercle bacillus; three specimens for the presence of the whooping cough organism, and 18 samples of milk. In addition 105 nose and throat swabs from patients in the Isolation Hospitals were sent for examination, This laboratory service is a great improvement on that available to the general practitioner before the war, the then arrangements necessitating postal transport of the specimens, a practice which had the disadvantage not only of lapse of time before the results were known, but also in certain cases deterioration of the specimens with resulting wrong results. Another weakness of the previous practice was the detachment of the doctors from the laboratory. The present service gets over these difficulties and it is anticipated that growing use will be made of the laboratory service by general practitioners not only in their submission of specimens, but in their direct approach and contact with the workers in the laboratory for discussion as to what help might be available in certain cases, what tests might with advantage be carried out, and details on the submission of clinical material. Visits by the doctors to the laboratory are encouraged by the director, Dr. Robert Cruickshank. The laboratory staff have in many areas been of great help to the local authority in undertaking investigations into the cause of outbreaks of infection. 19 SANITARY CIRCUMSTANCES OF THE AREA. WATER. Particulars of the water supply to the district and the procedure of sampling by the local authority to satisfy itself as to the suitability and safety were set out in the Annual Report for 1945. The laboratory findings of the samples submitted for detailed analysis gave the same satisfactory results. SEWERAGE AND SEWAGE DISPOSAL. There has been no change in the arrangements detailed in the Annual Report for 1945. PUBLIC CLEANSING. Refuse Disposal. Up to the end of the year it had not been found practicable to arrange for a weekly instead of a fortnightly collection of house refuse, a change which was not introduced until the early months of 1947. Never have so many complaints been received of the deposits of accumulations on a number of parcels of land throughout the district. These deposits are more unsightly than a real injury to health, though any site on which any sort of accumulation has been deposited is an invitation to the dumping of other forms of matter. Sometimes the main component is builders' rubbish, at others old tins and hardware. From the public health standpoint some might be brought in because the deposit offers a harbourage for rats, or in the warmer months receptacles for collecting water facilitating the breeding of mosquitos, or decaying vegetable refuse, causing offensive smells or encouraging the multiplication of flies. So often though, they are more potential than actual nuisances from the public health standpoint, but all the time are an eyesore and an encouragement to further deposits—factors lowering the tone of the neighbourhood. So much of this matter comes from the house, and it would seem at times that the householder is driven to depositing this matter in this way because of the difficulties of otherwise dealing with it. Particularly at times of such household activities as spring cleaning there must be much to be removed from a house other than that which ordinarily finds its way into the household's dustbin. A generous interpretation of what is house refuse would remove the necessity for people to dispose of their accumulations in ways which might cause offence to others. It is much better for the householder to have the mattress he wishes to dispose of removed as house refuse than for him to dump it on a parcel of land, there to encourage others to dump their cardboard boxes and worn-out furniture. It might be suggested that steps be taken to insist on the owners of these parcels of land taking such measures as would prevent the sites being used for dumping and for tidying up those which have already been abused in this way. One difficulty, of course, is that compulsory measures can be taken only if there was a sanitary nuisance. Again, these days it is not easy for the owners to obtain the materials necessary to prevent the intrusion of people on these sites. 20 The pig bins remain, so often an eyesore and an offence, an encouragement to rats and to flies, but at last the street shelters, with their nuisances, have gone. It can only be hoped that things will so improve that the country will not need to require the collection in this way of a supplementary pig ration. Street Cleansing. It had not been possible by the end of the year to move any nearer towards restoring the pre-war practice of street cleansing. In some localities especially, greater attention to cleansing of the streets would be an encouragement to the occupants of the houses fronting to make their own contributions to arrest the lowering of the general standard of the locality. Ill-swept streets are no encouragement to those who, perhaps, need stimulating to keep the fronts of their houses, their gardens and their fences in good condition. Secondary access roads are a frequent source of complaint. They only too readily become dumping grounds for the locality, their drains are readily blocked, while those not surfaced become unfit in wet weather for use by pedestrians. Where these passages are the only means of access for the occupants of flats over the adjacent shops, very real inconvenience is suffered. Again, so often these passages cannot be held to be public health nuisances. So frequently they are potential nuisances, while in any event their state must frequently result in a very real inconvenience to many. Even in those cases where action can be taken under the provisions of the Public Health Acts, the machinery is so very cumbersome that the cost of postage alone for the communications sent to those who might have to contribute to the cost of whatever is required may be greater than the cost of the work or of the article. On the other hand, such unsatisfactory states should not be permitted to remain, again tending to lower the tone of a locality, quite apart from the real inconvenience to a number. The only satisfactory solution would seem to be the taking over of such passages or secondary access roads by the Council so that they would then be maintained in a satisfactory state. MORTUARY. During 1946, 295 bodies were received, post mortems were carried out on 210, and 62 inquests held. 85 bodies were admitted for storage. 27 bodies were sent into the mortuary from the Borough of Wembley, a post mortem examination being carried out, and an inquest held on each. 21 SANITARY INSPECTION OF THE DISTRICT and THE INSPECTION AND SUPERVISION OF FOOD. When the legislation passed in the last quarter of the last century gave the newly-created authorities powers to take action to improve the hygienic surroundings of the community, conditions, in even the better parts of the country, were far from ideal, while the circumstances in which many were living could only be described by to-day's standards as truly appalling. There were major problems to be tackled becaused the surroundings of so many, whether in their homes or their places of work, were positively detrimental to their health. The accent of the public health legislation in these days was on the removal of those conditions which were injurious to health, and that was the standard of the inspector visiting a house or a factory. Even as recently as the time when a group of houses was represented for slum clearance the case rested on the vital statistics which would be that much worse for the occupants of such property. To-day, and particularly in an area such as this, which does not carry the heavy legacy still borne by many towns of the effect of the industrialisation of the country, we are getting far away from these standards. Under the Housing Act, when a house is being judged for repair or demolition, regard must be had to the presence of sanitary defects, to whether the house reaches the standards of the bye-laws and to the standard of the house compared with other houses in the area occupied by members of the working classes. In such a district as this, then, the standard is not whether the conditions would be actively detrimental to the health of the occupants of the house, but whether the house is in all respects in a decent state of repair. The legacy of the war years cannot be removed for some time yet. Shortage of labour and of materials will necessitate attention being concentrated on those houses suffering from grosser defects, conditions on which the authorities can take further action if need be in the event of non-compliance on the part of the owner. It is hoped though that the day will not be long deferred when all these major defects have been removed and that it will be possible once again to obtain by the co-operation of the owners, the desirable standard of maintenance. This altered outlook is seen in other ways. When infections were attributed to faults in drains and drainage, to accumulations or deposits, the Sanitary Inspectors visited the homes on the receipt of a notification. Because of the importance attached to the infectiousness of inanimate objects they arranged the details of the formidable ritual of fumigation of the premises and the removal of bedding, etc., for steam disinfection. To-day, and particularly when so many of the patients suffering from milder attacks are retained at home instead of being admitted to hospital, the Health Visitor calls to discuss with the mother measures such as isolation and concurrent disinfection which are necessary to prevent spread. In yet another phase of the Sanitary Inspector's activities is there a marked change. The Inspectors spend a considerable proportion of their time supervising foodstuffs at different premises. Emphasis in such a district as this, though, is less now on the conditions of milk 22 production because so little milk is now produced in this area, but rather on the treatment of the milk, and still more so on its state as delivered to the houses. While it is generally accepted that heat-treated milk is the only certainly-safe milk, and while, too, it is understandable that to warrant the expenditure of installing and maintaining a pasteurizing plant necessitates large-scale handling, the price is being paid with to-day's staffing difficulties. Most of the complaints received about milk relate not to the milk itself but to the bottles in which it is delivered, the fault being the presence of dirt or glass or other foreign matter. On paper the precautions to prevent such occurrences ought to be sufficient. The bottles are subjected to examination before being passed into the washing machines where they are subjected to a process ample to cleanse the ordinary bottle; they are again examined after bottling, while on top of this is the fact that they are again handled when any unsatisfactory conditions might be noted. In spite of all this, though, milk is delivered in unsatisfactory bottles. The explanation of the presence of glass is that sometimes a bottle is broken in the process of capping, and again the precautions taken should ensure that the bottles, which might contain a fragment, are withdrawn. As to the heavy pollution of the bottles, while, of course, the milk retailers have their own responsibilities, it must be accepted that there would not be the complaints of this contamination if those to whom the milk was delivered would only treat the bottles in a reasonable manner. Accepting that it is the responsibility of the milk retailer to reject the heavily-soiled bottle, the fact remains that it is not the milk retailer, but usually some householder who has, by irregular use, allowed a bottle to become soiled. So long as milk has to be delivered in returnable containers, the co-operation of the general public will be required if the householders are not occasionally to have delivered to them milk in containers in unsatisfactory condition. This co-operation of the housewife is wanted in other ways. While it can only be the Inspector who can see that the conditions under which food is prepared are wholesome, it is surely a matter for the housewife as much as for the Inspector to see that the conditions under which it is sold are satisfactory, whether what is objectionable is the handling by the shop assistants or the very common contamination by other possible purchasers. The following report is submitted by the Chief Sanitary Inspector, Mr. S. N. King. Introduction. The year under review has been remarkable for the small return in almost every phase of the Inspectors' work, judged by the tasks completed as compared with the efforts made and energy expended. In pre-war years between 60 and 70 per cent. of the requests made to owners or agents to improve or repair premises were acted on by them without question. Of the remainder, possibly 50 per cent. demanded more forceful methods, making it necessary in only a comparatively small number of cases to serve statutory notices or take other extreme methods. During 1946, owners and agents however, found themselves faced with such a multiplicity of difficulties before any work could be put in hand, that only a few endeavoured at an early date to take serious action. 23 Most returned with queries regarding either War Damage, licences, permits and not infrequently with requests for the names of builders who might be prepared to carry out the work. It is not possible to give details, but the additional time and energy involved in dealing with these points was considerable, and, unfortunately these difficulties and queries were not confined to housing matters alone, but to a greater or lesser degree involved every phase of the work of the Inspectorate. It is felt that of all the sections of the report that dealing with overcrowding is the most distressing. The misery and mental anguish suffered by those unfortunate enough to be living under crowded conditions is appreciated by all, but only to those whose duty it is to visit is the real tragedy revealed. One often feels the position of many of these families is hopeless, in that the likelihood of the family unit being broken up by discord arising from the conditions far outweighs the chances of a reasonable home being established. To reflect upon these cases and the solution, namely, the rapid provision of more and yet more housing units, in no way helps; on the contrary, it brings to mind the families still occupying properties which by reason of dampness and other sanitary defects, were prior to the war officially recognised as being unfit for human habitation. As may be realised from the foregoing, this report will contain little that makes pleasing or satisfying reading, but this cannot be otherwise, for little real progress is possible when the order of the day is allied to strict economy and shortage of essential materials. Statistical Summary. PART I. Inspections Made and Conditions Found. HOUSING. Inspection of Houses. Visits. (i) On complaint of dampness or other housing defects 1,418 (ii) On complaint of other nuisances 947 (iii) Routine Inspections 421 (iv) Re-visits arising from defects found 5,958 (v) Inspections of Foster Parents' premises 10 (vi) Surveys under Section 157, Housing Act, 1936 Conditions Found. 616 (i) Number of dwellings or other premises visited as a result of (i), (ii), (iii) and (v), where defects were found 1,282 (ii) Number of cases of overcrowding revealed 486 PUBLIC HEALTH. Inspection of Other Premises. (i) On complaint or request 72 (ii) Routine inspections of premises 194 (iii) Re-visits arising from defects found 142 24 (iv) Surveys arising from rat complaints 718 (v) Re-visits (rats) 346 (vi) Inspection of Factories 165 (vii) Inspection of Workplaces 52 (viii) Inspection of Out-workers' Premises 142 (ix) Inspection of Cinemas and places of Entertainment 38 (x) Inspection of Licensed Premises 69 (xi) Visits under Shops Acts 2,136 (xii) Evening observations under Shops Ats 16 (xiii) Sunday observations under Shops Acts 6 (xiv) Observations made for Smoke Nuisances 5 Conditions Found (i) Premises visited as result of (i) and (ii), where defects or unsatisfactory conditions were found 66 (ii) Number of premises where action taken by Council's Rodent Operatives to deal with rats—see (iv) above 636 (iii) Number of Factories, Workplaces and/or Out-workers' premises where defects or contraventions were found —see (vi), (vii), and (viii) above 37 (iv) Number of Cinemas and/or Licensed Premises where defects were found—(ix) and (x) refer 12 (v) Contraventions of Shops Acts— (a) Failure to observe closing hour 6 (b) Other contraventions (failure to exhibit notices, etc.) 793 FOOD HYGIENE. Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 25 (ii) Butchers' Shops 457 (iii) Cowsheds 26 (iv) Dairies 87 (v) Fish Shops 177 (vi) Fried Fish Shops 37 (vii) Bakehouses 106 (viii) Cafes and Restaurants 166 (ix) Ice Cream Premises 232 (x) Provision Merchants 417 (xi) Bakers' and Confectioners' Premises 82 (xii) Other Food Premises 78 Conditions Found. See Section dealing with Food, Food Shops and Food Preparing Places. PART II. COMPLAINTS RECEIVED. Summary of Complaints Received. Accumulations of refuse 105 Animals causing a nuisance 45 Dampness 138 25 Drains and Sewers—Choked 359 Defective 90 Dustbins defective 264 Houses with defects 516 Plumbing defects 138 Flooding—gardens 34 Vermin 33 Insect infestations 68 Overcrowding, alleged 616 Shelters and Static Tanks unsatisfactory 39 Smoke nuisances 14 Water Courses 6 Defective Water-closets 67 Other complaints (pig bins, wasps' nests, defective fences) 139 Food unfit (excluding requests received from shops to visit and inspect unfit food) 29 PART III. Notices served and/or action taken under Housing or Public Health Acts as a result of inspections made:— Housing Act, 1936. (i) Statutory notices served under Section 9 requiring execution of repair work 38 (ii) Dwellings reported to Public Health Committee and approved for action under Section 11, i.e. as being in a state so dangerous or injurious to health as to be unfit for human habitation 3 (iii) Number of cases reported and approved for action under Section 12, i.e. for the making of a Closing Order on a building or part thereof 1 (iv) Informal notices served with view to subsequent action under Section 9 134 Public Health Act. Statutory Notices under:— (i) Section 24—i.e. Notice requiring work to a public sewer 16 (ii) Section 39—i.e. Notice requiring repair or renewal of drains 32 (iii) Section 45—i.e. Notice requiring repair or renewal of defective water-closets 6 (iv) Section 56—i.e. Notice requiring work on undrained or badly drained yard areas 2 (v) Section 75—i.e. Notice requiring renewal of a dustbin 83 (vi) Section 83—i.e. Notice requiring cleansing of minous premises 2 (vii) Section 93—i.e. Notice requiring abatement of a nuisance 42 (viii) Informal Notices served (all sections) 1,397 26 Action Taken by Local Authority or Owner as result of the Service of Statutory or Informal Notices. Housing Act. (i) Section 9—Dwellings rendered fit after service of Statutory Notices: (a) By Owners 23 (b) By Local Authority in default of Owners 2 (ii) Section 11 and 12 (action to date not completed) 3 (iii) Dwellings rendered fit by Owners after receipt of Informal Notice (Section 9) 97 Public Health Act. (i) Section 24—Public Sewers repaired 14 Note: Work to Public Sewer must be undertaken by the Local Authority or a Contractor instructed by them. (ii) Section 39—Drains repaired or renewed: (a) By Owners 13 (b) By Local Authority in default of Owners 16 (iii) Section 45—Water-closets repaired or renewed: (a) By Owners 5 (b) By Local Authority in default of Owners Nil (iv) Section 56—Yards repaired: (a) By Owners 2 (b) By Local Authority in default of Owners Nil (v) Section 75—Dustbins provided: (a) By Owners 18 (b) By Local Authority in default of Owners 55 (vi) Section 83—Verminous Premises cleansed 2 (vii) Section93—Nuisances Abated 33 Note : Only in one case was it necessary to apply to the Court for an Abatement Order. (viii) Nuisances abated and/or other work carried out by Owners on receipt of Informal Notice 1,274 Housing. As will be appreciated from the figures contained in the statistical summary a considerable amount of the time of the Inspectorate was devoted to dealing with matters affecting housing and housing conditions, and it is perhaps true to say that no section of any department of the Council has greater knowledge of the condition of occupied dwellings 27 in the district or the effects of time upon the various private housing estates in Harrow. One of the many changes wrought by the war in the matter of housing is the source of requests to visit. In pre-war days it was unusual for such requests to come from property owners; to-day it is a common occurrence, the reason being that it is hoped support will be given to applications for Building Licences or permits. As owners of all types of property take this step it does, if nothing else, extend the information available regarding the nature and existence of housing defects. It is not, of course, every owner who considers the maintenance of property a matter of importance and in consequence appeals to the department for assistance. Unfortunately there are a number who use the fact that licences and permits are necessary as a means of delaying the carrying out of work. It is the owner in this category who, whenever possible, brings up outstanding War Damage claims or the difficulty of obtaining a builder to carry out the work as an excuse for repairs not being executed and. whilst War Damage claims, Building Licences and the shortage of labour have, in the case of owners anxious to carry out repairs, added to the routine work of the department, in the case of unwilling owners, they have increased considerably the difficulties experienced in securing the early completion of repair work. There are dwellings in Harrow which, by reason of disrepair, sanitary defects and bad arrangement, are suitable only for demolition. There are others where, because of lack of maintenance, reconditioning or repair work is required. As to the number of properties in the first group, no figure or estimate based upon a recent survey can be given. Seven years during which-but little maintenance work has been carried out have passed since action was possible under the clearance provisions of the Housing Acts whilst Section 11 (i.e. for dealing with dwellings that cannot be repaired at a reasonable cost) has been used in isolated cases only to deal with properties where no alternative to demolition was possible. There is to date no indication as to when the machinery of the Housing Acts can again be operated to the full, and it may well be that before this day arrives the pre-war standards to which the dwellings the subject of confirmed Orders failed to reach may be changed. Even an estimate of the number of properties likely to be considered for clearance or demolition is therefore of little value, and prior to any figure being given a survey will be necessary. Of the cottage property throughout the district in need of reconditioning there is little to be said—the demand that new work is making on the material and labour available prevents serious action being taken to effect reconditioning, though it is becoming abundantly clear that the present-day policy of "patching" is resulting in a steady deterioration of many properties. It is, however, the properties built since 1930 and falling in the second category that are going to be the "problem children" of future years. There are estates in the Pinner, Hatch End, Harrow and Stanmore Districts, built since this date, from which complaints concerning 28 housing defects are seldom received; on the other hand, there are others in the Kenton, Edgware and Harrow Weald areas that provide a steady flow of letters complaining of either dampness, decayed woodwork or general housing defects. Poor initial construction is the cause of the conditions that give rise to the majority of the defects found, plus the heavy use to which many of the properties on the estates concerned are subjected. To avoid misunderstanding the words "poor initial construction" need to be amplified and in the first instance it must be remembered that the average price of these dwellings was between £575 and £850, inclusive of road and other charges. Further, they were built in the days when competition was keen and to sell, attractive fitments were essential. In consequence the structures themselves suffered, the material used in quantity and quality being no more than the minimum required by the Building Bye-Laws. As regards the effect of occupation it is of interest to note that on one of the estates concerned and probably from the angle of construction it is the poorest of all, the majority of the dwellings are owner occupiedmaintenance and careful use is in consequence of quite a high order, and taking the estate as a whole the adverse conditions existing are not to be compared with those on the Glebe Estate. Here the majority of the dwellings are held by non-resident owners who spend as little as possible on maintenance and repair work. Additionally, quite a number of the properties are let to two families which again increases the wear and tear to which the dwellings involved are subjected. That those who developed the Glebe and such-like estates should have elected to provide dwellings of the cheap type is to be regretted, but the fact remains they exist, and there is no doubt that for years to come the service of notices calling for extensive repair work will be necessary. Overcrowding. During the year it was necessary to add to the register of persons occupying overcrowded accommodation details of 486 families, thus bringing the total number known to be living under crowded conditions in Harrow on the 31st December, 1946, to 496. It is of interest to note that on the 31st December, 1939, the register reveals that there were only five families who were living under conditions where statutory overcrowding existed. The term "overcrowding" is in frequent use to-day and is often used by individuals who have little or no idea of what it means when used in relation to the Housing Acts. They are amazed when told that the dwelling with two bedrooms and a box-room on the first floor and two living rooms and kitchenette on the ground has a permitted number of either 7½ or 8½ units, or, in other words, that it can be occupied by 7 adults and 1 child under 10 years of age, or 4 adults and 7 children under 10 years, without the residence being statutorily overcrowded. The majority of cases of overcrowding, however, occur not where one family is occupying a whole house but where families are occupying rooms. In these cases for the purpose of determining the permitted 29 number only the rooms occupied are taken into account. For example, two rooms (each having a floor area of 110 sq. ft. or over), with a family having part use of the kitchen, the permitted number is 3 units. One room (floor area of 110 sq. ft.) with part use of kitchen, the permitted number is 2 units. The first-mentioned can be occupied by man, wife, and 2 children under 10 years of age without being statutorily overcrowded. The second by 2 adults and a child under 12 months. A unit is a person over 10 years of age, whilst children between the ages of 1 year and 10 years count as ½-units; below the age of 12 months, for purpose of determining the actual number of units in the household, children are not counted. The above examples serve to indicate that the standard laid down by the Housing Acts is not high, but when it is realised that even on this standard in Harrow 496 families are occupying accommodation recognised as being overcrowded some idea can be gained of the appalling conditions under which many families resident in Harrow are living. The marked increase in the number of cases brought to notice during the year was due to (a) the return home from the Forces of sons and daughters who had married during war years ; and to (b) families outgrowing accommodation either as a result of births or the return home of single sons and daughters. It was during July that the number of cases investigated in any one month reached the peak, cases being added to the register at this time at the rate of two per day. The rate of decrease in the number of cases from group (a) will probably continue during 1947 to reach a level which may remain more or less constant, so long as there is a housing shortage and conscription continues. It is anticipated, however, that those in group (b) will increase. The reason is that many families who left the London areas during the early years of the war to occupy rooms in Harrow appear to have little chance of being rehoused by the Authority in whose area they were living, whilst others wish to remain there. Secondly many who have married during the last seven years have rented one or two rooms. These room lettings are in many cases occupied to the equivalent of the permitted number and may well become crowded by an increase of one child in the family. Rehousing. The Council's policy of referring to the Public Health Department for grading all housing applicants living in crowded accommodation has proved to be fully justified. Many families living under intolerable conditions have by this arrangement been rehoused much sooner than would have been the case had they been considered only on the general Points Scheme for the selection of tenants. The applicants are graded in order of need, which though related to is not entirely controlled by the degree of crowding. Such factors as a child under one year, or an expectant mother (which are not reflected in the equivalent number of persons) are taken into account; also those living in the smallest unit of accommodation, are given preference over other cases where the degree of crowding is equal. 30 The following is a summary of cases added to the register and/or rehoused during the year:— Overcrowded 1st January, 1946 141 New cases 486 Rehoused in Council Houses 74 Rehoused in requisitioned property 37 Found own accommodation 24 Adjustment where two cases of overcrowding abated by the movement of one family 4 Adjustment where crowding has been reduced, but not abated 8 139 635 Number of cases outstanding, 31st December, 1946 496 In addition, there are 45 families totalling 212 persons occupying properties the subject of confirmed Clearance Orders, and 11 families totalling 42 persons in dwellings the subject of Demolition or Closing Orders. PUBLIC HEALTH. Nuisances. Reference to the summary will reveal the nature and range of the complaints received during the year. A few by reason of the action taken call for special comment, whilst mention is made of others in order to draw attention either to the cause, the remedy or the difficulties experienced in dealing with particular problems. Accumulations. Reference is made to these in view of the difficulties to which they give rise. The complaints received referred mainly to rubbish and other waste matter deposited on undeveloped and unfenced land or on accommodation roads. Such complaints are seldom easy to deal with, for in the first instance, before action is possible, the rubbish must be creating a nuisance capable of being dealt with under the Public Health Act. Secondly, even if a nuisance exists, it is often impossible to ascertain who is responsible for the actual "dumping"—this is invariably the case when accommodation roads are involved. Thirdly, though no nuisance may exist at the time of the initial visit, accumulations of rubbish are always a potential harbourage for rats, whilst further " dumping " may add material of a putrescible nature, and thus give rise to a Public Health nuisance. It is not possible, therefore, to ignore the existence of accumulations of rubbish, and generally they are removed by the Cleansing Department, the cost involved being borne either by the owners of the land or persons with properties abutting the roadway concerned. In the case of accommodation roads, to which the public have access, it is often necessary to have the rubbish cleared and for the cost to be borne by the Local Authority. 31 These methods of dealing with the problems of rubbish are not altogether satisfactory. Whilst there is probably no alternative so far as unfenced land is concerned there is no doubt regular sweeping of the accommodation roads would reduce if not eliminate the trouble experienced with these roadways. It is frequently the result of debris accumulating over a period owing to non-sweeping that gives rise to dumping. Small untidy heaps of waste form, rubbish is added, and once this commences, like most undesirable practices, it grows until action has to be taken. With these roadways vested in so many individuals, with no one in particular responsible, complaints regarding their untidy and neglected appearance are inevitable. One solution to the problem, of course, is for the Local Authority to take them over, and thereby the responsibility for cleansing and maintenance. Animals. The one case where it became necessary to obtain from the Court an order to abate a nuisance concerned the keeping of animals. The case heard by the Magistrates on the 13th December, 1946, arose from the keeping of over a hundred pigs in close proximity to dwelling houses. The action resulted in an order being made for the practice of keeping swine on the premises concerned to be discontinued. Vermin. Compared with previous years the number of complaints received regarding vermin was low. An unusual incident for this district occurred, however, during July, 1946, when an application was made by an individual to be cleansed. It is obligatory upon the Local Authority to take action if such an application is received and the person concerned is verminous and in need of cleansing. The latter point in the case in question was not in doubt and the action required was taken. Dustbins. Mention is made of dustbins in view of a decision taken by the Public Health Committee at their October meeting, resulting in the practice of supplying dustbins in default of owners being discontinued. Prior to this meeting, if an owner failed to comply with a Notice requesting the provision of a dustbin, a bin was supplied by the Council and the cost recovered. In all, 55 dustbins were supplied during 1946 by the Local Authority in default of owners as against 18 by owners themselves. The principal reason for property owners leaving the Local Authority to supply was that they obtained a good quality bin at a cost lower than that which they would have paid if ordered by them through an ironmonger or merchant. The time taken up in dealing with dustbins is considerable, and there is without doubt much to be said for the Council taking advantage of the provisions of the Public Health Acts whereby they can accept the responsibility for providing at a charge dustbins for all properties within the district. 32 Rats. No evidence of any major infestation of rats was found during the year, though a steady flow of complaints was received. These related mainly to “back-yard” poultry keeping. The sites of the disused sewage farms and many of the watercourses where trouble had been experienced in the past, were inspected regularly and where found necessary appropriate action was taken. These sites and watercourses are, as a result of being visited regularly, remarkably free from rats. It was hoped that it would be possible during 1946 to commence the treatment of sewers throughout the district, but labour and other difficulties prevented this materialising. A certain amount of preliminary work was, however, undertaken and it is possible that the sewer treatment will be completed during 1947. Smoke Abatement. There are few factories in the district with steam raising plant which, during the year, did not experience trouble as a result of poor quality fuel allocated to them, and the fact that engineers managed to maintain steam pressure without the undue emission of smoke is surprising. In one instance it was necessary to contact the Ministry of Fuel and Power with a view to the fuel allocated to a factory being changed, and this was done. The definition of smoke is such that it includes ash, grit, and gritty particles, and the incident referred to above was connected with the emission of grit. The boilers concerned had been worked to capacity during the war years with little or no maintenance, and in consequence the stage was reached when it was practically impossible to fire them with the fuel available without giving rise to a nuisance. After the fuel was changed and the boilers overhauled no further trouble was experienced. Factories. There are 774 factories in the district, and during the year 307 visits were made to these premises. In addition visits were made to the premises of 142 Out-workers, i.e. persons undertaking at home work sent out from factories or business premises elsewhere. The majority of these out-workers undertake work for firms outside the district, in fact from as far afield as Scotland. It is of interest to note that during 1946, 37 new factories were added to the register; 24 were deleted whilst 22 changed hands. Arising from the inspections made it was necessary to request the provision of additional sanitary accommodation in 8 factories and the repair of conveniences in 5 others. In addition, cleansing and action to secure the abatement of minor nuisances was found necessary in a further 24. FOOD. Inspection and Supervision of Food. During the year, 1,890 visits were made to premises concerned with the production, preparing or retailing of food. The majority of these 33 visits resulted from requests by traders to inspect food considered by them to be unfit, a practice seldom resorted to in pre-war years. This action on the part of traders arises from the fact that in order to obtain replacements it is necessary for them to produce a certificate confirming that the goods in question had been surrendered. The actual disposal of goods found unfit depends on their nature and quantity—if possible they are used for animal feeding or manufacturing purposes, though seldom have the quantities involved in this district justified movement in this direction by the Ministry of Food. The majority of the articles were therefore disposed of by the Cleansing Department. The following is a summary of the food that was surrendered during the year:—Tinned Food: meat, 4,998 lbs., 1,268 tins; vegetables, 846 lbs., 738 tins; fish, 449 lbs., 611 tins; fruit, 462 lbs., 212 tins; milk, 1,907 lbs., 2,116 tins. Fresh Meat: home killed, 1,130 lbs; imported, 925 lbs. Game, Poultry, Bacon and Meat Products: bacon, 143 lbs; sausages, 145 lbs.; poultry, 141 lbs.; game, 224 lbs.; meat pies, 109 lbs.; brawn, 14 lbs. Fresh Fish, 193 stone. Groceries: shell eggs, 1,786; cheese, 213 lbs.; butter, 31 lbs.; bread, 1,446 lbs.; flour, 262 lbs.; biscuits, 320 lbs.; cake mixtures, 281 lbs.; sugar, 49 lbs.; jam, 550 lbs.; cereals, 42 lbs.; cocoa, 672 lbs.; dates, 135 lbs; puddings, 8 lbs.; dried peas, 139 lbs.; prunes, 106 lbs.; coffee, 25 lbs. Miscellaneous Foods, 30 lbs. Other Food: sweets, 73 lbs; chocolate, 50 lbs.; celery, 15 cwt.; pickles, 93 lbs. MILK. Milk Production. The number of farms in the district was reduced by one during the year and the total is now 10. Of these 3 are producing Tuberculin Tested milk, 3 Accredited and the remainder ungraded milk. From only 3 of the farms is the milk produced retailed locally— from the remainder, which includes the 6 producing designated milk, it is sold wholesale. Distribution. Details of the premises licensed under the Milk (Special Designations) Regulations are as follows:— (i) To pasteurise 2 ii) To bottle T.T. Milk 2 (iii) No. of premises from which pasteurised milk may be sold 45 Note: Of this total 30 are controlled by United Dairies Limited or Express Dairy Company. (iv) No. of premises outside the Harrow district from which pasteurised milk may be retailed in Harrow 9 (v) No. of premises from which T.T. milk may be retailed 17 Note: Of this total, 10 are controlled by the United Dairies Limited or by the Express Dairy Company. (vi) No. of premises outside the Harrow district from which T.T. milk may be retailed in Harrow 6 In addition, there are 3 establishments from which raw milk is retailed and 5 from which milk is sold in sealed containers. c 34 Supervision. Cowsheds, dairies, pasteurising and bottling establishments were visited frequently during the year and where necessary essential improvements or repairs were carried out. Sampling. Thirty-nine samples were taken, 6 of which were reported as being unsatisfactory. In these cases enquiries were made and appropriate action taken—in one case a new sterilising plant was installed ; in another dairy a new cooler was fitted. In addition, samples were taken every month from producers by the Ministry of Agriculture & Fisheries, and 36 were taken by the Middlesex War Agricultural Executive Committee. One local producer had not returned an adverse sample over a period of 4 years, and another for 3 years. Complaints. During the year 17 complaints were received regarding milk delivered to householders in the district. Seven related to dirty bottles and 10 to bottled milk containing foreign matter. In these cases investigations were made and action taken with the retailers concerned. ICE CREAM. In the district there are 101 premises registered for the manufacture, storage or retailing of ice cream. Of these, manufacturing is carried on at 16, whilst 7 are registered for the retailing of ice cream received in bulk from manufacturers, and 78 for the retailing of the commodity in wrapped packages. In addition, during 1946 details were obtained of 5 persons found retailing from vehicles. 232 visits were made to the premises of persons engaged in the manufacture or retailing of this commodity. MEAT. Thirty-six pigs, owned by pig clubs, were slaughtered in the district during the year. All were inspected and found fit for human consumption. SHOPS ACTS. With the return to the Public Health Department of the Shops Acts Inspector (this Officer acted during the war years as the Local Food Enforcement Officer) it was possible for more attention to be given to the various requirements of the Shops Acts, and the position to-day is by no means unsatisfactory. As will be appreciated during the war years the difficulties experienced by shopkeepers not only in respect of labour but also in other directions made it necessary for many sections of the Acts affecting shops to fall into the background though the number of defects and contraventions regarding Notices that have been noted are by no means as numerous as might have been expected. It appears the majority of shopkeepers are anxious to avoid a return to the pre-war hours of evening closing and more is likely to be heard on this subject in the future. 35 For those interested in figures the following summary regarding the shops in the district is included:— Antiques 11 Builders' Merchants 22 Butchers 123 Boot Accessories 67 Boot & Shoe Dealer 50 Corn Chandlers 7 Chemists 77 Cycle & Motor Accs. 75 Cafes & Confectioners 158 Coal Officers 31 Dairies 34 Departmental & Mixed Drapers 52 Shops 25 Fruiterers & Greengrocers 110 Florists 20 Fish Shops (Wet, Dried Furnishers 36 & Fried) 60 Grocers & Provisions 212 Hairdressers 135 Glass & China Ware 7 Hardware Stores 59 Hosiers 3 Leather Goods 6 Jewellers 24 Newsagents, etc. 127 Lending Libraries 10 Outfitters—Ladies' 60 Opticians 11 ,, Gent's 67 Public Houses 51 Radio & Electrical 61 Photographers 8 Tobacconists & Sweets 151 Secondhand Wardrobes 8 Wool Shops 24 Wines & Off Licence 33 Unclassified 110 Total 2,125. 36 housing. New Building. During the year 416 new houses were erected. Of these, 146 prefabricated bungalows, 69 houses and 8 flats were put up by the Council. 72 temporary pre-fabricated houses were erected by the London County Council on their Headstone Estate and 121 other houses were erected by private enterprise. Other accommodation is available to the Council by the requisitioning of private houses, the larger of these being converted for the use of five or more families. Allocation of Houses. Any bouses the Council has available for letting are allocated by the Housing Committee on a points system. To meet the case of special families whose needs cannot be assessed on such a basis the Council agreed to give special consideration to the following classes of applicant recommended by the medical officer of health—families one or more of whose members is or are suffering from tuberculosis, families living in overcrowded conditions, families requiring to be rehoused as a result of operative Clearance Orders and families living in houses subject to operative Demolition Orders. In regard to those living in condemned properties, the Council has a legal obligation to rehouse those living in the house at the time of the Order, in fact the Council's intention and power to rehouse has to appear in the application. This legal obligation of course does not extend to those who might go into the house after the making of the Order. In regard to the occupants of houses the subject of a Demolition Order there is not the same legal obligation on the Council to rehouse. Actually the Council has accepted this liability. The Council agreed to the Housing Committee taking on the duties of the Public Health Committee in regard to the construction of new houses for the occupancy of those dispossessed by the making of these Orders. Of the Orders made before the war a number had not been enforced by the outbreak of the war. A number of houses on the South Harrow Estate were intended for the occupants of these houses. As their occupants had not been rehoused nothing could be done towards effecting the demolition of the properties. Once the war had started the Minister requested that no houses should be demolished, so that even those which became vacant were not as a rule demolished though an application for permission to demolish made in respect of some of them was granted. The position then is that there are many houses in the district the subject of Demolition or Clearance Orders which are still occupied. In the case of some of these the Council owes a duty to the occupants to rehouse. The following is a list of these houses (with the numbers of houses still occupied in parenthesis): 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). 37 The next group is that where a member of the family is suffering from tuberculosis. This has been accepted as an open case of infection. Those figuring on the list of applicants are those who have themselves made application for rehousing, or on behalf of whom someone such as the almoner at the Chest Clinic has pressed the case. There are, of course, very many more cases on the register of the tuberculous than appear in this list. Again those who are favourably housed at the moment are not considered. In general then the names of those on the rehousing list are those who have applied and where there is some measure of crowding in addition to the presence of an open case of tuberculosis. The degree of crowding taken note of is, of course, very much less than that needed by an ordinary family to qualify for admission to the overcrowded list. At the end of December the number of cases on the tuberculosis list for rehousing was 80. The remaining list is those who are statutorily overcrowded. The official standard was laid down in the Housing Act, 1936, which was the first great attempt to abate the vast amount of overcrowding known to prevail. The same standard was fixed for the whole country so because of the appalling conditions in some of the black spots of the country it had to be a low one. According to it there were in this district just before the war only 31 overcrowded houses. The position to-day is very different, the numbers running up to 500. Few outside those who are intimately brought into contact with many cases realise what a degree of crowding can occur in a house without there being statutory overcrowding. In assessing the degree individuals are classed as units, any person over ten years of age counting as one, a child from 1 to 10 years as a half unit, but the baby under one year not at all. All habitable rooms are counted, the standard not reserving any room for sleeping purposes alone. As an indication then two rooms of average size of 110 square feet each might without overcrowding contain three units which can comprise a man, his wife, two children under ten and a small baby. Something more is needed to cause overcrowding and yet there are 150 houses with a half unit of crowding and another 150 of one unit. Worse still is the fact that having regard to the demands for housing by those in the other two groups, and those in the overcrowded group who are crowded to a greater degree even with the most generous allocation of houses by the Housing Selection Sub-Committee to Public Health Committee cases there is little enough prospect of those of a half and of one unit overcrowding being rehoused. Some houses are crowded by only half a unit. In others the overcrowding may be by as many as four and a half units. The inconvenience caused by this crowding is to be measured not so much by the one-half or the unit, but is obviously related to the total accommodation available. Other factors have to be taken into account. When two families occupy the one house circumstances will be different if they are virtually living as one family or if the sub-tenants are restricted to their own part. Although for the standards of the Housing Act a child does not rank even as half a unit until it attains the age of a twelve-month, in selecting for special consideration the cases out of those of the same degree of crowding regard is had to the presence not merely of the small baby, but even of the unborn child, as it is hoped if anything is to be 38 done for a family that the removal might be effected before the date of confinement. In selecting those to be submitted on the grounds of crowding for the consideration of the Sub-Committee a room standard is adopted. Obviously a half-unit of crowding where the family is limited to the occupation of one room may well represent worse living conditions than one-and-a-half or more units of crowding where a family has control over the whole house. These are the only groups of cases which have been taken out of the ordinary run of allocation on the basis of points. There are, of course, innumerable other conditions which make it highly desirable the family should be better housed. When these are primarily medical conditions, it is natural that this department is approached to support the application. It would be impossible to devise any formula or scale by which the merits of such cases could be assessed, but in default of any such device every case would have to be considered on its own merits and the claims judged against the most urgent of those based on other considerations, an arrangement which because of the magnitude of the problem would be unworkable. The families then where there are these special factors cannot be moved from a lower to a higher group, and all that can be done is to have regard to these factors when the time comes for those in any particular group to be considered. As between those of equal pointing the existence of such factors may determine which family shall be selected to head the list. Overcrowding. The attached chart shows at a glance the extent of overcrowding in the district and how it is comprised. The permitted number for any accommodation is indicated by the figure running horizontally at the top. Dropping down vertically to the datum line gives the reading in the left vertical column of the same number. All the figures in the vertical column below the datum line relate to numbers of families which occupy that accommodation and are overcrowded, giving the numbers of different degrees of crowding. For instance, starting with accommodation for which the permitted number is 2. Dropping vertically to the datum line, below it is a figure 72. The reading in the left-hand vertical column is 2½. This means that there are 72 families living in accommodation which is a half-unit (2½ minus 2) overcrowded. The figure of 46 below on the horizontal line of three persons in the house means that there are 46 families occupying accommodation of a permitted number of 2 of 3 units, being therefore 1 unit overcrowded. Towards the other end of the scale of families occupying a house with a permitted number of 7½ units, 10 are crowded to the extent of a halfunit, 8 by one unit and so on. In all 52 families with this accommodation are overcrowded. A summary of the overcrowded position at the end of the year is that 185 families were overcrowded bv a half-unit, 145 bv 1, 80 by 36 by 2, 22 by 2½, 13 by 3, 9 by 3½, 3 by 4, and 3 by 5. The chart also shows that of families living in one room, 148 were overcrowded, of families in two rooms 162, of those in three 53, and of those in a house of four or more rooms 133. 39 ISOLATION HOSPITALS PROVISION OF ACCOMMODATION. The proposal that the Hendon Isolation Hospital should be extended to meet the needs of the Boroughs of Hendon and Wembley, and of Harrow, the institution being managed by a Joint Committee, had to be abandoned in view of the Government's proposals regarding the administration of all hospitals under the provisions of the National Health Service Act. During the year, staffing difficulties became very acute, it proving almost impossible to obtain sufficient nursing or domestic staff. It was agreed then that the local hospitals should be used for the reception only of scarlet fever patients, all other infectious patients requiring hospital treatment being admitted to the hospitals of other authorities. It was agreed too that of the scarlet fever patients those suffering from complications should be admitted elsewhere. The incidence of all infections remained low so that the accommodation at the South Harrow Hospital was sufficient to enable all the scarlet fever patients requiring admission to be accepted there. For another year, then, the Honeypot Lane Hospital was not opened. It has now been closed since the early part of 1944. The South Harrow Hospital was closed in August, this being the easiest way of arranging for the staff to take their annual leave. Because of the difficulties under which the hospital was run to provide even the very restricted service which was all it could manage, towards the end of the year the question of closing the hospital was discussed. It was, however, decided that it should remain open to provide only the restricted service as long as it was possible to obtain sufficient staff. It was felt that such an arrangement would make it more probable that it would be possible to meet the greater demands for accommodation should the incidence of any of the infections rise sharply. It was decided, too, that having regard to the staffing difficulties and to the small number of such cases, that arrangements be made for those suffering from diphtheria to be admitted to outside hospitals. The 121 admitted to outside hospitals was a sharp rise on the number removed in previous years. Only 28, 2 of scarlet fever and 26 cases notified as diphtheria, though, would under former arrangements have been admitted to the local hospital. Measles and whooping cough were both prevalent during part of the year, and 24 of the outside admissions were sufferers from complications of measles, 13 of whooping cough. The diseases from which the others removed to hospital were notified as suffering from were erysipelas 14, cerebro-spinal fever 8, puerperal pyrexia 13, poliomyelitis 5, typhoid fever 3, pemphigus and gastroenteritis 1 each. CLINICAL ASPECTS. Scarlet Fever. Admissions: Number admitted with a diagnosis of scarlet fever, 127. Number suffering from scarlet fever, 110. Number in whom the diagnosis was not confirmed, 17. 40 Of these cases in which the diagnosis was not confirmed, 6 suffered from tonsillitis and 5 from food or drug rashes. Deaths: There were no deaths. Treatment: Of the 110 patients admitted who were considered to be suffering from scarlet fever, serum alone was given in 23 cases, prontosil alone in 21 cases and both serum and prontosil in 37 cases. 29 cases were given neither. Complications : 22 per cent, of the scarlet fever patients suffered from some complication. The number who suffered from otorrhoea was 4, from septic sores 7, from adenitis 7, from rhinorrhoea 2 and from rheumatism, secondary sore throat, relapse, abscess and endocarditis, 1 each. Cross Infection : No patients developed other infections during their stay in hospital. Return Cases : There were no return cases this year. Period of Stay : 61 per cent, of patients returned home on or before the twenty-first day from admission. 24 per cent, were in until the twenty-eighth day or longer, most of them being detained for some minor abnormality. Diphtheria. Admissions : Number of cases admitted on a diagnosis of diphtheria, 12. Number of cases clinically diphtheria, 5. Number of positive swab carriers, 1. Of the 6 cases in which the diagnosis was not confirmed, all were suffering from tonsillitis. Deaths: There were no deaths from diphtheria. Complications: The heart musculature was involved in 1 case, while all the 5 cases had albuminuria on admission. 41 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease Und. 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65 & Total 1 yr. yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs. yrs. over Scarlet Fever 3 42 152 34 9 10 7 5 2 1 265 Diphtheria 1 5 9 7 2 6 4 2 — 2 — 38 Pneumonia 2 6 9 4 5 2 12 23 21 15 20 119 Dysentery — 6 6 — 1 3 4 6 3 2 1 32 Erysipelas 1 1 1 1 — — 3 9 11 2 6 35 Cerebro-spinal Fever — 4 2 1 1 — 1 2 - - - 11 Puerperal Pyrexia — — — — — 5 14 1 - — - 20 Pemphigus - Neonatorum 1 - - - - - - - - - - 1 Malaria — 2 2 - - 4 Ophthalmia Neonatorum 2 - - - - - - - - - - 2 Poliomyelitis 1 2 1 1 - - - 5 Typhoid Fever — — — — — 1 — 2 - - 1 4 Gastro- Enteritis — 1 — — — - - - - - 1 Measles 37 701 809 28 10 11 5 4 - - - 1605 Whooping Cough 34 247 147 5 3 3 1 1 — — — 441 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Deaths Registered Scarlet Fever 265 132 2 - - Diphtheria 38 12 26 — 1 Pneumonia 119 — — - 89 Dysentery 32 — 11 4 - Erysipelas 35 — 14 — — Cerebro-spinal Fever 11 — 8 3 2 Puerperal Pyrexia 20 — 13 - - Pemphigus Neonatorum 1 — 1 - - Malaria 4 - - - - Ophthalmia Neonatorum 2 — — 1 - Poliomyelitis 5 — 5 - 1 Measles 1605 — 24 - 2 Whooping Cough 441 — 13 - - Typhoid Fever 4 — 3 — — 42 DIPHTHERIA. Incidence. Thirty-eight notifications were received during the year. In 21 instances the patient was suffering from some other condition, most frequently tonsillitis. The corrected figure of 17 is a rate of 0.08 per thousand population, compared with the national rate of 0.28. The local rates for the years 1934-1945 ranged from 008 to 060. A substantial proportion of the population has been immunised against diphtheria, and the very low incidence of this infection could be attributed to these endeavours. On the other hand, though the district had had a similar freedom even before many of the children had been treated. The steady fall in the incidence of diphtheria throughout the country, a fall which has coincided with the successful national efforts to see that most children are treated, must be held to be related to this treatment. Of the 13 cases, 2 were under five years of age, both being infants suffering from laryngeal diphtheria, 6 were between 5 and 15, while the others were over 15, all but one being adults. Five children were members of one family, all being ill together. Of these, two had been inoculated in 1942 with 0.2 and 0.5 c.c. A.P.T., but neither was subsequently Schick tested. Places of Treatment. All notified patients were admitted to the isolation hospital for treatment, 12 cases up to the end of February to the Harrow Isolation Hospital, the remainder to the hospitals of other authorities. Deaths. None of the cases notified locally proved fatal. There was a transferred death in which diphtheria was the cause. This child of six, a pupil at a boarding school, who had not been immunised, succumbed to what is reported to have been a very toxic fulminating attack. Immunisation. The same facilities were available for the immunising of children against diphtheria. The numbers of children treated had fallen from 7,366 in 1942 to 2,359 in 1944. In 1945, 3,111 were treated and last year, 2,889. When the scheme was first introduced the only arrangement was for the inoculation by the general medical practitioners. With the introduction of the national campaign in 1941, arrangements were made for the treatment at the clinics of those children who were regularly brought to the clinics. Since 1943, slightly more are treated in this way now than by the local doctors—this last year very many more. This is due less to an increase in the number of those done at the clinics (1,885 cases in 1946, as compared with 1,934 in 1945) than to a falling-off in the numbers treated by the doctors (the 1946 figure of 928 as against 1,023 in the previous year). Seventy-six were treated at the nurseries. Concentrating on those attending the clinics undoubtedly involves the least expenditure of time. They are brought very frequently and are in contact with others, most of whom have been treated. 43 It is estimated that at the end of the year 51.7 per cent. of children under five had been immunised, and 61.1 per cent. of those of ages 5-15, an improvement on the figures of 45.3 and 54.7 per cent at the end of the previous year. For Schick testing, 3,602 were invited and 42 per cent. attended. Of these, 61 were positive, a percentage of 2.5. Provision of Anti-Toxin. The same arrangements exist for the distribution of anti-toxin. During the year, 56 lots were issued, totalling 448,000 units. Schools and Spread of Infection. In no case this year was there any suggestion that infection had been contracted in school. SCARLET FEVER. Incidence. Seventeen of the 265 patients notified as suffering from scarlet fever were subsequently found to be suffering from other conditions, mostly tonsillitis. The net figure of 248 is an incidence rate per thousand population of 1.18, compared with the rate of 1.38 for the country as a whole. The local rates during the years 1934 to 1945 ranged from 1.06 to 4.70. The incidence was very uniform for the first, third and fourth quarters, with an average of just over 4 cases a week. The period of greatest prevalence was the second quarter with an average of 7 cases a week. Deaths. No deaths occurred in this district from scarlet fever. Places of Treatment. Of the 265 cases, 131, or 49 per cent., were treated at home at the election of the parents. In the case of a further 27 per cent. of those removed there seemed no reason the patient should not have remained at home. In 13 per cent. the reason for removal was that there were other children in the house, in 12 per cent. that the patient was an adult, and in 7 per cent. of the cases there was a small baby in the house. Secondary Infection. There were 10 households in which secondary infections occurred. Included in these were two in which two members succumbed with simultaneous onset, being later followed by a secondary case. Apart from these there was only the one household in which there was more than one secondary case, two patients falling ill together, and having presumably been infected by the original case. In three instances the secondary case was the mother who, in the case of two, was nursing the original patient at home. Only 10 per cent. of the removal to hospitals were made on the first day of illness, 24 per cent. on the second, 30 per cent on the third and 20 per cent. on the fourth. In 16 per cent. of cases the patient was not removed until after the fourth day of illness. In many of these cases, then, it is improbable that secondary cases would have occurred had the patient been treated at home the entire course of the illness. 44 Return Cases. There was only the one household in which a return case occurred this year. The brother aged three of a boy of seven, who was discharged on the 19th July, sickened on the 15th August. Schools and Infection. There was no suggestion this year that infection was contracted at any of the schools. The only suspicious grouping was that of three cases occurring in the one week at one school, but in the succeeding weeks no further cases occurred. In two other instances, three cases occurred over a period of a fortnight. SMALLPOX. The few persons who came to the district from areas in which the disease was present were kept under surveillance. MALARIA. Notifications were received of four cases in whom the malaria contracted abroad a relapse occurred. ENTERIC FEVER. Four notifications were received this year, but in one case the diagnosis was not confirmed. The other three were all of para. B. infection. All cases were unrelated. The first fell ill in early August, the other two in October. One patient was treated at home, the other two being admitted to isolation hospitals. DYSENTERY. The diagnosis in four of the 32 cases notified was withdrawn. Two patients were suffering from a relapse of amoebic dysentery, contracted abroad. In 10 the illness was the result of a Sonne infection. The laboratory findings of the remaining cases are not known. The infections were irregularly distributed through the year. Apart from the amoebic cases the onset of 1 was in January, 2 in February, 8 in March, 10 in April, 2 in May, 1 in July, 2 in September and 1 each of the last three months of the year. The only associated cases seemed to be 2 in one family in March, and 3 in one family in April. Fourteen patients were admitted to isolation hospitals and 4 to other hospitals. FOOD POISONING. Only one case of food poisoning was notified during the year—a boy of two who, in September, was diagnosed as suffering from a salmonella typhi-murium infection. ERYSIPELAS. Thirty-five notifications were received during the year, but in 3 the diagnosis was amended. Twenty of those suffering were males. The face was affected in 24, the leg in 5. Fourteen of the patients were admitted to an isolation hospital for treatment. 45 CEREBRO-SPINAL FEVER. In 2 of the 11 cases notified as cerebro-spinal fever, the diagnosis was withdrawn. One of the cases occurred in January, 3 in February, 2 in March and 1 each in April, June, September and November. One of the notified cases proved fatal. In addition, another child whose illness had not been notified died in September. All cases were treated in hospital, 8 in isolation hospitals, the others in a general hospital. ACUTE ANTERIOR POLIOMYELITIS. Five notifications of cases of poliomyelitis were received, but in one the notification was withdrawn. The first case, a girl of nine who fell ill in June, had within the incubation period returned from a holiday at the seaside. The other cases occurred in July, September, and November. None seemed to be associated with any of the cases which occurred in some of the nearby districts in the summer months. From the death returns it was learned that a girl of 15 had died in September from an infection, apparently contracted in August in the district in which she had spent her summer holiday. All the notified cases were removed to an isolation hospital for treatment. MEASLES. During the year, 1,605 notifications were received, a rate of 7.6 per 1,000 population. The rate for the country as a whole was 3.92, but for the administrative County of London, 7.35. Apart from the first two months, the district was never entirely free from this infection. The weekly average rose from 4 in March to 6 in April, 25 in May and 40 in June. There was a fall to 32 in July, to 18 in August and to only 4 in September. The incidence rose to a weekly average of 23 In October, 82 in November and 114 in December. The summer outbreak was almost limited to the children at Longfield and Pinner Wood Schools. Three schools were affected in October and three others especially in November and December. Twenty-four children were removed to hospital. The health visitors paid 257 visits to homes in which there were measles patients. Two deaths were recorded as due to measles. WHOOPING COUGH. Children notified as suffering from whooping cough numbered 441, an incidence per 1,000 population of 2.10, which compares with a rate of 2.28 for the country as a whole, and 2.22 for London. The district was never entirely free from the infection, though most cases occurred in the five months April to August. The only school at all heavily attacked was Roxbourne, where there were many cases from April to June. Thirteen patients suffering from complications of whooping cough were admitted to hospital for treatment. The number of visits paid by health visitors was 41. There were no deaths this year from this complaint. 46 NON-NOTIFIABLE INFECTIONS. Chickenpox. Intimations were received from the head teachers of the local schools of 583 cases of chickenpox amongst school children. No schools were really heavily attacked. Many were affected in the spring, but rather more in the summer term. Mumps. Mumps was prevalent particularly in the summer term. In all 689 intimations were received. One school had 112 cases in the one term. VERMIN INFESTATION. Scabies. There was a marked falling-off in the number of persons attending for treatment, only 801 as compared with a figure of 1,714 in the previous year. Seventy-five were children under 5, 220 children of 5-15, the remainder adults. Of these this year again the greater number were women. 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 3 I — — — 1 — — — 1 2 5-9 ... 4 2 4 2 — — — 1 — — — 1 10-14... 9 7 2 1 1 — —. — — — — 1 15-19... 14 17 — — 1 2 2 — 2 5 1 1 20-24... 26 27 1 4 . 6 5 — — 3 2 — 1 25-34... 34 22 — 5 9 14 — 1 10 2 1 1 35-44... 25 21 — 1 3 5 — — 9 6 — — 45-54... 17 7 — 2 3 — — — 19 5 1 — 55-64... 5 3 — 1 1 — — — 10 1 — — 65 & up 6 3 — 1 — 1 1 — 2 3 — — Total 143 112 8 17 24 27 4 2 55 24 4 7 There was a sharp rise in the number of pulmonary cases first learned of during the year, 308 as against 261 in 1945. Of these, 36 were of persons in whom the disease was diagnosed while they were in the Services. Of those of whom particulars are known, 92 were notified in other districts before they came here, having already contracted the infection before transfer. This leaves 170 who, presumably, contracted the infection while living here. In 29 cases there was a family history of tuberculosis. 47 The 33 notifications of non-pulmonary disease is the same as the figure for the previous year. In nine instances the onset of the disease preceded the transference to the district of the patient. In most others it must be presumed that the infection was contracted while they were resident here. In only two of these cases was there a family history of tuberculosis. Register. Pulmonary Non-pulmonary Male Female Male Female No. on register January 1st, 1946 609 543 98 103 No. of New Cases added 143 112 8 17 No. of cases added—other than on Form A ... ... ... 24 27 4 2 No. of cases restored to register 3 6 — — No. of cases removed ... 130 130 14 27 No. on Register December 31st, 1946 649 558 96 98 The following table is a summary of the cases removed from the register with the reasons for removal: Reasons for Removal Pulmonary Non-pulmonary Male Female Male Female Left the district 43 69 4 6 Died 65 28 1 5 Cured 21 26 8 15 Diagnosis not confirmed or withdrawn 1 7 1 1 Total 130 130 14 27 Deaths. Seventy-nine persons (55 male and 24 female) died from pulmonary tuberculosis during the year, and 11 (4 male and 7 female) from nonpulmonary tuberculosis. This infection, therefore, accounted for 4-4 per cent, of the total deaths—much the same figure and much the same proportion as last year. The disease these days accounts for 8-1 per cent, of deaths for the country as a whole. 48 MATERNITY AND CHILD WELFARE. REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,934, 2,040 male and 1,894 female, a marked increase on the 1945 figure of 3,068. Of these, 179 were illegitimate, being a percentage of total births of 4.5, a lower figure than the 5.8 of the previous year. 2,701 births occurred in the district (2,657 live and 44 stillbirths). Of this number 584 (574 live and 10 stillbirths) were to residents of other districts. Of the local confinements, 2,602 were notified by midwives, and 99 by doctors or parents. 1,765 (1,701 live and 64 stillbirths) notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in Middlesex County Council or London hospitals. STILLBIRTHS. Stillbirths registered were 68 male and 54 female, being a rate per thousand population of 0.30, compared with the figure of 0'53 for the country as a whole. Of the 68 cases about which any particulars have been obtained 3 were dead before the onset of a premature labour. In 4 others the baby was apparently alive at the onset of a premature labour. Of the 11 other cases when labour was premature, toxaemia was apparently the cause of death in 3. In 6 instances death had occurred some time before the onset of labour at full term. In most cases the infant was alive at the onset of labour at term. In 8 cases there was definite difficulty in delivery arising from some such condition as impacted shoulders, transverse presentation, small pelvis, etc. Toxaemia was present in 7 cases, while in 3 there was abnormal development (hydrocephalus or spina bifida). Prolapse of the cord or the cord round the neck was the ascribed cause of death in 7 cases, and haemorrhage in three. In 18 cases, though, no explanation for the occurrence of death could be obtained. INFANT MORTALITY. During the year, 129 infants (68 male and 61 female) died under one year of age, this being an infant mortality rate of 31.0 compared with 43.0 for the country as a whole. The legitimate rate was 30.3 and the illegitimate rate 67.0. Ninety-seven failed to survive one month. The neo-natal rate was therefore 25'6, constituting 75 per cent. of the infant mortality rate. Of these 97, 27 failed to survive the 24 hours, the cause of death in 10 being prematurity, in 4 atelectasis, and in 7 birth injury. Deaths occurring of infants who survived 24 hours but failed to live 7 days were 45. Prematurity was the cause in 20, diseases of the new-born 7, abnormality 4, immaturity and atelectasis 3 each, birth injury 5, and pneumonia 2. Of the 25 who survived one week, but succumbed before the end of one month, in 9 the cause was prematurity, in 4 developmental abnormality, 49 in 3 birth diseases. Infections accounted for 8, of which 7 were cases of pneumonia. Of the 14 deaths amongst those of 1 to 3 months, 7 were due to respiratory complaints, and 2 each of gastro-enteritis and pyloric stenosis. Eighteen survived 3 months, but died before the 12 months, infections again accounting for practically all of these deaths, the majority being respiratory complaints, gastro-enteritis accounting for most of the remainder. In 1900, the infant mortality rate for the country was 156. By 1939, it had fallen to 50. Last year's figure for England and Wales was 43—a low record. Harrow's figure was 31—a figure for an area not with a mere handful, but with nearly 4,000 births in the year. An achievement and to what is it attributable ? Firstly it should be pointed out that it is not a mere flash in the pan, because on many occasions the figure has been in the low 30's. In fact, apart from the disastrous years of 1940 and 1941 the rate has been less than 40, often considerably less, since 1937. To be even part of the way to answering the question it must be realised that, although the infant mortality rate has been so often referred to and has been accepted as an index of the sanitary state of a community, yet it is composed of two quite different factors. So different are these that it might be better to discontinue considering the rate for the year as a whole. A child's greatest risk of dying is at or shortly after birth. When the infant mortality rate was 60, which means that 60 out of every 1,000 babies born died before reaching the first birthday, 10 of those deaths would occur before the infants were 24 hours old, another 10 roughly before the end of the first week, another 10 before the end of the first month, yet another 10 before the end of the third month, and the remainder spread out over the rest of the year. The earliest deaths were the result of damage during delivery, of lack of sufficient vitality to survive in the new surroundings (just as many failed to survive long enough to reach the full stage of gestation), and to their suffering from congenital abnormalities or defects inconsistent with their survival. Such deaths are constant in all social groups. There has been relatively little decline in them since the early part of the century. As the child gets older other quite different factors operate to prevent its survival, more especially the infections, whether specific or non-specific, respiratory or gastro-intestinal. It is at these ages that the very marked differences in the mortalities amongst those of the various social classes are seen, and it is deaths from these causes which have been saved during this century, and which account for to-day's rate being so much lower than that in the early 1900's. The difference between a high rate and a low rate was largely the result of an altered standard of maternal care, and as a background to this ignorance, poverty, fecklessness, employment of women, illegitimacy and domestic insanitation. Investigations into the infant mortality rates in different parts of the country showed that it is higher amongst males than females, higher in the summer months, in urban as opposed to rural communities, and higher in the north than in the south. As an explanation of Harrow's favourable rate, then, must be placed first the fact that Harrow is in the south and not the north of the country, and it is not an industrial area producing much smoke to deprive the 50 inhabitants of certain important rays from the sun, while at the same time adding contamination which irritates the lungs. Favourable geographical siting alone, though, is not sufficient to ensure a low rate or the district would not have suffered the high rates of 50.0 and 55.6 in 1940 and 1941. As a second factor can be put Harrow's fortunate financial position. Most of the district is of recent development, which means there are no large insanitary blots, while the general level of living is not low. Many, of course, to-day are living in very distressing and even unhygienic surroundings, but they are not accepting that as a normal state. They react to it, and are only too anxious to better their lot. Even the surroundings, then, of these smaller numbers have not the same significance as when these are accepted by populations as a normal above which there is to be no rising. Probably the harmful effects of unsatisfactory surroundings are not so much direct as indirect. Sanitation is low in such surroundings at ordinary times, not because of the surroundings themselves as because of the attitude of mind and the standard of living of those in them. It is the commonest experience to see widely different standards of cleanliness and tidiness amongst neighbours whose houses structurally are the same. Perhaps, then, the slight effect of any adverse environmental conditions is due to the generally high standards of domestic hygiene in those who ordinarily have been fortunate enough to be living in houses in which such standards have been easily maintained. The high rates of the early part of the century, though, were not limited to the black areas of the country. It would be exceptional for even the most blessed and favourably placed districts at that time to have reached as low as the national rate of to-day. An explanation for this difference is education, not merely the knowledge imparted by the health visitor to the mother, nor the knowledge acquired by the mother as the result of compulsory school attendance for some decades, but probably more important, all that went to the demand for compulsory education and which, in its turn, makes the mother receptive to tuition. The health visitor is perhaps the most important official in the public health service. Partly as the result of the efforts of the sanitary inspector, his work has become that much less important. Environmental hygiene gave way to the personal services. It is to the health visitor that we must look for the next improvements. At the Annual Conference of the Royal Sanitary Institute, the subject of infant mortality was discussed. The causes of the deaths were analysed, and it was pointed out that in some districts lives were lost because the homes of the babies born in hospital were not fit for them to come to. The remedy suggested was the provision of a hostel to which the mother and her baby could be admitted for a while till the baby's hold on life was strengthened, so that it would survive the move to its adverse home surroundings. Possibly in some districts such steps are necessary. It would be most unfortunate, though, if such a policy was to be generally pursued. The correct solution to that problem, surely, is concentrating on the home so that its standard might be raised, and the mother educated and helped to enable the child to return in safety to a safer home. Such work is the responsibility of the health visitor. The National Health Service Act has recognised her importance 51 by extending officially her range of duties—an extension which will bring them into line with to-day's practice in many areas. It is particularly to be regretted that it is becoming increasingly difficult to be able to appoint such important people. MORTALITY AMONGST CHILDREN OF 1-5 YEARS OF AGE. Infections which had started to exert their toll on the older of the infants under one year of age remained the most important cause of death in the next few years. Of the 8 deaths of those of one year of age, 5 were due to infections (pneumonia 1, meningitis 2, tuberculous meningitis 1, and measles 1). The 7 deaths of those of two years of age were mostly due to developmental diseases, or developmental abnormality. Accidents accounted for 2 of the 5 deaths of those ages three and four. INFANT MORBIDITY. Ophthalmia Neonatorum. Two notifications of ophthalmia neonatorum were received, one in an infant born in an institution, one at home. One of the patients was referred to the District Nursing Association for treatment. Both recovered with vision unimpaired. Pemphigus. One notification was received this year of the occurrence of pemphigus among the new born. The infant was treated in hospital and recovered. MATERNAL MORTALITY. Three deaths occurred in which pregnancy or childbirth was the primary cause, all three from conditions other than sepsis. The puerperal mortality rate was therefore 0.74 per 1,000 births, compared with the rate of 1.43 for the country as a whole. The first fatality was a patient pregnant for the fifth time, but whose previous pregnancies had resulted in miscarriages. She was under regular ante-natal supervision and because of toxaemia was referred to hospital. A Caesarean section was performed, but she failed to survive the operation. The second case died from a severe post partum haemorrhage, which was due to hypoplasia of the uterine muscles, cause unascertainable. The third fatality was of a patient who died from haemorrhage due to the rupture of an ectopic gestation. It is difficult in cases such as these to see what could possibly be done to evade fatalities. It would seem that whatever machinery is set up, there will be occurrences of this nature which are almost in the nature of accidents of pregnancy or parturition. PUERPERAL INFECTION. Of the 20 notifications received, 9 were in respect of patients delivered in local nursing homes, the remainder at home. Five followed an abortion. In 4, the cause seemed to be uterine infections ; 3 were infections of a perineal tear, while pyelitis was the cause in 2, inflamed breast 1, phlebitis 1, and other infections such as influenza caused 2. Removal to an isolation hospital was arranged in 13 instances, and home nursing provided in 2. 52 INFANT WELFARE SERVICES. HOME VISITING BY THE HEALTH VISITORS. The foundation of the child welfare services is the work undertaken by the health visitors. Their activity in the first place was the supervision of the child under one year. This was later extended, in the one direction, to embrace the child up to the age of five, and in the other direction, to include the expectant mother. The district is divided into 18 areas, with roughly equal populations, each health visitor undertaking all the maternity and child welfare duties in her section. The following is a summary of the number of visits paid by the health visitors during the year : (a) To children under one year of age... ... First visits 3,695 Total visits 8,362 (b) To children between the ages of one and five years... ... ... ... ... Total visits 12,167 In addition, visits were paid to 257 cases of measles, and 41 cases of whooping cough in children under five years of age. INFANT WELFARE CENTRES. About half the time each health visitor devotes to maternity and child welfare work is spent at the clinics. Those dealing with children under five are either infant welfare centres or toddlers' clinics. At the end of the year, in all, 21 weekly infant welfare sessions were being held in 13 separate premises. The average weekly attendance at all the infant welfare centres was 1,209. The highest rate of attendance was for the five weeks' period ending 2nd November, when the average was 1,408. The following is a summary of the attendances at the infant welfare centres during the year : Total attendances at all centres : (1) By children under one year of age 43,721 (2) By children between the ages of one and five years 14,962 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 3,091 (2) Between the ages of one and five years 427 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 3,863 (2) Over one year of age 5,027 TREATMENT. The following are particulars of the various treatment facilities available :— Dental Treatment: This is undertaken by the staff of the Middlesex Education Committee, who treat patients in five clinics in the district. General anaesthetic sessions are held as required. The number of children under 5 treated during 1946 was 176. 53 Physio-therapeutic Treatment : Children are referred from the local clinics to be seen by the physio-therapist or the orthopaedic surgeon at the Marlborough Hill Clinic. Children under five recommended for treatment by the Council's staff of the Clinic are treated on behalf of the Council, even though they were not in the first instance referred from a Council clinic. The forms of physio-therapy available include exposure to rays or mercury vapour and carbon arc lamps, short-wave therapy, massage and active exercises. Class exercises are held for the correction of postural conditions. During the year 164 new cases were referred. The total number of attendances by patients was 1,433 (140 massage and 1,293 electro-therapeutic). The consultant orthopaedic surgeon saw 41 patients, and 329 were seen by the consultant physio-therapist. Orthopaedic patients requiring in-patient treatment are admitted to the Stanmore Orthopaedic Hospital. Correction of Visual Defects : Children requiring ophthalmic treatment receive this at the hands of the Education Committee staff. Glasses where required are provided free of cost. Provision is made for children wearing glasses to be re-tested periodically. During the year 173 children were referred for treatment. Operative Treatment of Tonsils and Adenoids : Children requiring this treatment are admitted either to the Harrow Hospital or to the Redhill County Hospital, the patients being detained in hospital the night before and the night after operation. During the year 9 children were treated under this arrangement. Child Guidance Treatment : 14 children were referred during the year to the Child Guidance Clinic maintained at 2, St. John's Road, Harrow, by the Middlesex Education Committee. Speech Therapy : 15 children were referred during the year to the Speech Therapy Centre maintained at 2, St. John's Road, Harrow, by the Middlesex Education Committee. Convalescent Homes : Up to 1939 arrangements were made for suitable children to be admitted for a short period stays to convalescent homes. It was getting more difficult to find accommodation and quite impossible when the war started. Some authorities maintain their own homes, others pay for the reservation of a certain number of beds at established homes. Home Nursing: Welfare authorities are empowered to provide home nursing for certain groups of ailments of children under five. In this district such treatment is carried out on behalf of the Council by the staff of the local nursing association. During the year responsibility was accepted for the payment of fees for the treatment of one child. CHILD LIFE PROTECTION. On a prospective foster mother making application, she is visited by the health visitor, each of whom is appointed child protection visitor for her area, and the premises are inspected by the sanitary inspector. In 54 most cases the applicant wishes to foster only the one child. There are in the district a certain number of homes in which a number of children are cared for. In this case the number is determined by the area of the sleeping room, each child being allowed 40 square feet. In addition wherever there are more than three children a separate day nursery is required. The foster mother undertakes to keep the child under the supervision of her own medical attendant or attend the nearest infant welfare centre. The homes are visited by the health visitor once a month, so that the older of these children receive much more attention from the health visitors than the other children in the district. The following table summarises the information regarding the fostering of children in this district : Number of persons on the register who were receiving infants for reward at the beginning of the year 123 (Of these 60 had children ; 63 not.) Number of persons registered during the year 17 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.) 10 Number of persons on the register who were receiving children for reward at the end of the year 130 (Of these : 55 with children ; 75 without.) Number of children on the register at the beginning of the year 68 Number of children received during the year 69 Number of children removed from the register during the year 59 Removed to care of parents 38 Removed to care of another foster mother 6 Legally adopted 2 Removed to charitable organisation, etc. 6 Removed to hospital 3 At exempted premises 10 Foster parent left the district taking the child with her — Foster mother no longer receiving payment 1 Child attained the age of nine years 2 Died 1 Number of children on the register at the end of the year 78 There are 38 homes where only one child is received. In addition, there are 16 homes where more than one child is accepted, the number of children in all these being 74. One residential school receives children under nine years of age. In addition, there are two schools exempted. There are many objections to the present arrangements for the supervision of foster parents. On the other hand, the war led to a large increase in the demand for such persons, a demand which has not abated. The health visitors come across cases in which they feel the only satisfactory solution to the problem is the temporary placing of a child with a foster parent. Some persons, though, who might be eminently suitable decline to assume the care of children any more because the 55 parents of children whom they have looked after have defaulted in their payments. Then, too, there is the case of the parent, probably the mother of an illegitimate child, who cannot afford to pay the usual charges of a foster mother. The uncertainty of the background in such cases must give rise in the child to a regrettable absence of feeling of security. In May, the Public Health Committee sought and obtained the sanction of the Ministry to their accepting the responsibility for the payment of one guinea per week to a foster parent caring for a child whose parents have resided in the district for a minimum period of 12 months, the payment being recoverable from the parent in whole or in part in accordance with the Council's scale of recovery. ADOPTION OF CHILDREN. Welfare authorities are interested in the child under nine years of age who is in the care of a person not the parent or guardian, in respect of the placing of whom arrangements have been made by any person not the parent or guardian, unless these were made by a registered adoption society or local authority. As regards such children, any person taking part in the arrangements, is required to give at least seven days' notice to the welfare authority of the area in which the adopter resides. The Harrow and Willesden Ruridecanal Association for Moral Welfare work whose offices are at No. 4, Peterborough Road, Harrow, are a registered adoption society. During the year, only 25 notices were received under section 7. At the end of the year 17 children were under supervision. ILLEGITIMATE CHILDREN. In October, 1943, the Ministry of Health, in circular 2866, urged welfare authorities to consider the problem. The Council participate in a joint scheme with the County Council, by which suitable local cases are admitted to a hostel (" Marylands," Hendon), for mothers and babies, and to another home (16, The Park, Golders Green) for the expectant mother. During the year 4 expectant mothers were admitted to the one hostel, and 10 mothers with their children to the other. SUPERVISION OF CHILDREN. Day Nurseries. The decision of the Council as to the future of the war nurseries was (1) that the Vancouver Road Nursery should be closed on the 31st March, 1946 ; (2) that the Buckingham Road and Rayners Lane Nurseries would, as from the 1st April, be administered by the Education Authority as nursery schools ; (3) that the remaining four nurseries should continue as day nurseries until the time came when the demand at any nursery for the care of the under two's had so fallen off that consideration should be given to the question of its being closed as a nursery, and the Education Committee taking it over as a nursery school. These changes took place, so that whereas for most of the first quarter there were seven war nurseries, for the remaining nine months of the year there were only the four, namely, those at Spencer Road, South Harrow, Kenmore Road and Headstone Drive, with respectively 49, 60, 60 and 50 places. 56 It was decided that the admissions should be on the same basis as during the war, namely, that in selecting children for admission, preference should be given to the child of the mother engaged whole-time on work classed as of national importance, and to the child whose acceptance would free his mother for work. It was only to be if there were vacancies not taken up by children in these categories that children in other groups could be admitted. That meant that children of mothers working only part-time were not accepted, and that only one child from a family could be admitted. Although then the nurseries were being maintained by a welfare authority, the basis of selection of children for admission was that adopted when the nurseries were established with the prime object of freeing mothers to engage in war work. A welfare authority as such would encourage part-time rather than whole-time employment of the mothers, to give them that much more time to look after their children at home. It would tend to accept more than one child from a family so that the mother could be freed to look after the others, or the better to manage her home. It would certainly accept the child of the mother who, because of illness, could not go to work and who, for that reason, too, should be freed from the need of looking after her child, while again accepting the child or children of the widower who had been left with small children to look after. Admittedly these cases can be accepted, but only if vacancies had not been taken up by children of mothers electing to go to work. At times the waiting list, first of one and then of another nursery, has shortened, and it has seemed possible it would disappear, but in every case the list has grown again, so that now every nursery has its list. In general, the application list is very much shorter than during the war, that at Headstone Drive being the only one of comparable size. While the Ministry urge that the places at the nurseries should be given to the children of mothers engaged in work of national importance, in practice little consideration can be given to the particular work on which the mothers are engaged, though every effort is made to see that they do undertake whole-time employment. Certainly no question is raised as to the need to themselves for those mothers to go out to work. It is generally accepted that it is desirable that a mother should look after her child at least until the child attains the age of two years. The question was debated as to whether no infants under twelve months of age should be admitted, but it was decided to continue to accept those of all ages. The difficulty of course is that however desirable it might be, on general grounds, that the mother should look after her child, the fact remains that, in present circumstances, many mothers do not receive sufficient to enable them to maintain a home for themselves and a family. Whatever may be the solution when it is found, until that time there is the need for some such provision to enable the mothers to go out to earn, and nurseries are not cheap establishments to run. It would seem that it ought to be possible to enable the mother to receive the 25/- she is subsidised by her child being at the nursery (the cost per week of 30/-, minus her 5/- contribution), which would help her to arrange other than by the need for her small child to be admitted to the artificial atmosphere of the nursery. Whatever may be the case of the need of those over two years of age, there seems to be general agreement both as 57 to the desirability of the mother's looking after her child up to this age, and more than that, the undesirability on health grounds of congregating children up to this age in nurseries. While it is accepted as a generalisation that the child's place is with its mother at home, this must be subject to the qualification of that being a good home. At one time the limitation was primarily because of the inefficiency of the mother. To-day, though, it is more the result of difficulty of accommodation. So frequently applications are received from mothers for their children to be admitted to the nurseries because of the unsatisfactoriness of the home conditions. Most often the story is that the family are sub-tenants, and quite apart from the limited accommodation available to them, coupled with an inaccessibility to the garden, there is the added necessity for the child to be quiet. Such mothers have said that they are willing to go out to work, not because they need to, but merely to enable them to qualify for the admission of the child where it can lead a normal life, free from the curbs imposed by the family's living in overcrowded conditions. For a large number of such children, of course, admission to the nursery school is as satisfactory a solution as admission to a nursery. The failure of a nursery school to meet the needs of the mother going out to work as much as does a day nursery is partly because the nursery school does not admit children under the age of two years, but also because of its more limited hours of opening. The deficiency is not merely a matter of the reduced number of hours that the school is open each day, but also that it closes during the times of ordinary school holidays. If though, it is accepted that for the child of over two the nursery school is a preferable establishment to the day nursery, it should not be a matter of great difficulty to arrange for the hours it is open, not necessarily by any means to be fully staffed all the time as it is not all mothers who need their children in the longer periods, to be such as would meet the needs of the mothers. It is an anomaly that the mothers who need to work pay more for their children to be cared for at the nurseries than those who do not have to work, but who elect to have their children cared for at the nursery schools. If the difficulty of the hours of opening could be got over, then it might be hoped that the child of under two, whose mother was obliged to go out to work, could be accepted at a residential nursery. The nurseries were erected and equipped during the war, so neither premises nor equipment are up to what before the war would have been considered a desirable standard. When it was decided that the day nurseries should continue as part of the Council's welfare services for as long as there was the demand for the admission of children under two years of age who could not be accepted at a nursery school, it was decided to improve the premises, more especially to try to remedy the cold, damp conditions of some of the rooms, to provide each nursery with some of the larger items so desirable, but not obtainable during the war, and to provide more in the way of toys. The approval of the Ministry was sought, but at the end of the year the sanction to proceed had not been obtained. 58 Residential Nursery. The Council had previously agreed on the desirability of a residential nursery, to which could be admitted for short stay children whose mothers were temporarily unable to look after them. It was anticipated that admission would mostly be of children of mothers admitted to hospital for confinement, or for some other reason. It was accepted that at such a nursery, mothers with illegitimate children might be admitted for some weeks until they could look round and make some more permanent arrangement. The Honeypot Lane Isolation Hospital had had no patients in since early 1944. The Council had already approached the Ministry with a view to its being used for the reception of maternity cases. This proposal was not approved because of the heavy expenditure of material and labour necessary suitably to adapt the building for this purpose. The next step, then, was to consider whether the hospital might not be got ready for adaptation as a residential short-stay nursery. The position at the end of the year was that the prospect of such an arrangement being made was encouraging. 59 MATERNITY SERVICES. ANTE-NATAL SUPERVISION. Home Visiting. About one-third of the mothers confined are attended by the Council's midwives. Health visitors are brought in touch with many of the remaining two-thirds. The vast majority come to the ante-natal clinics and on failure to attend are visited. Again, the almoners of hospitals welcome the health visitor's reports on the home conditions of patients, to help them to decide whether the home circumstances are sufficiently serious to necessitate the confinement taking place elsewhere than at home. During the year the health visitors paid a total of 1,760 visits to expectant mothers, 1,238 being first visits. Ante-natal Clinics. The vast majority of mothers now attend the welfare authority's ante-natal clinics. Here they are seen by the health visitors, their problems discussed, and certain clinical examinations made. Periodically the expectant mother is seen by the medical officer, and in cases of detection of any abnormality, seen frequently until she is better. Midwives attend with their own patients, and when circumstances permit, examine them. Where more than one session is held in any building, where possible one is held in the afternoon for the midwives' cases as they are the more likely to be able to attend at that time. In such circumstances the attendances at the morning sessions are largely made by the mothers who are to be admitted to a hospital or other institution for confinement. The following is a summary of the work done at the clinics during the year: Total number of expectant mothers attending the clinics 3,083 Total number of attendances by expectant mothers at all clinics 15,251 Percentage of total number of births (live and still) represented by the number of mothers attending the clinics 76.0 General Practitioner Ante-natal Scheme. For many years the Council has had a scheme in force by which an expectant mother, to be attended at home by a midwife, can obtain her ante-natal supervision by her own doctor instead of attending the clinic, the Council paying the medical attendant an agreed fee. Most of the local medical practitioners agreed to participate in the scheme. Insured patients are entitled, as part of the service, to ante-natal supervision, but in such cases, the authority is empowered to pay for the report received from the medical attendant. The scheme also extends to the post-natal examination. In no year has any large number of patients been dealt with under these arrangements. Last year the number was only 12 ante-natally examined and 3 post-natally. 60 Consultant Ante-natal Clinic. The Council's consultant obstetrician attends the clinic three weeks out of four. In 1946 the consultant paid 36 visits to the clinic, seeing 370 patients, who made altogether 488 attendances. General practitioners referred 71 patients. There were 4 gynaecological and 3 post-natal cases. Treatment. Welfare authorities are empowered to arrange for expectant and nursing mothers to receive treatment of a limited class of conditions. The arrangements made for them to receive this are the same as for children under five years of age. In May, 1945, the Committee decided that the following treatment services should be provided free of charge to expectant and nursing mothers : dental treatment, excluding the supply of dentures; eye treatment; sunlight treatment and home nursing. Mothers receiving dental treatment totalled 563 and 109 were supplied with dentures. The staff of the District Nursing Association treated 59 nursing mothers. One mother was treated at the physiotherapeutic Clinic at 76, Marlborough Hill. ARRANGEMENTS FOR CONFINEMENT. Domiciliary Confinements. Number of Confinements: The number of births attended in private houses in the district by midwives who gave notice of their intention to practise was 1,095, in 778 cases the attendant being present as a midwife, and in 317 as a maternity nurse. Of these 1,055 were attended by local midwives, whose practice is limited to domiciliary work (749 as midwives and 306 as maternity nurses) and 40 as midwives from adjoining areas (29 as midwives and 11 as maternity nurses). Number of Midwives : The number of midwives who, during the year notified their intention to practise in the district, was 49. Of these, 12 removed, leaving in practice at the end of the year 37. Of the total number 19 were engaged in local maternity homes, most of these restricting their activities to these duties. Resident in the district were 24 who carried on a domiciliary practice, while 6, though resident in adjoining areas, attended cases in this district. At the end of the year there were in practice 12 independent midwives carrying on a domiciliary service, these between them attending 18 cases during the year, 13 as midwives and 5 as maternity nurses. Midwives' Notifications to Local Supervising Authority : During the year the following numbers of notifications were received from all midwives, including those engaged in local maternity homes :— Sending for medical assistance 279 Stillbirth 16 Death of infant 12 Death of mother 1 Laying out the dead 3 Artificial feeding 13 Liable to be a source of infection 6 61 Of the 279 summonses to medical practitioners, 44 were on account of some condition during pregnancy, 64 during labour, 125 in the lying-in period, and 41 some abnormality of the infant. Of the 44 summonses to a patient during pregnancy, 22 were because of albuminuria, oedema, or toxaemia, and 13 because of haemorrhage. Of the 64 summonses to a patient during labour, the reason in 49 instances was delayed labour, with cause unspecified. In a further 9 there was some abnormal presentation. Summonses to patients suffering from abortion (actual or threatened) numbered 5. Of the 125 summonses to patients in the puerperium, 91 were on account of rupture of the perineum. Post-partum haemorrhage, with or without adherence of the placenta, was the reason in 8, a raised temperature in 10, phlebitis 3, and inflamed breast 6. Of the 41 summonses to infants, 11 were on account of some discharge from the eye, 18 because of feebleness or asphyxia, 4 because of deformity, and 8 some other abnormal state or condition. Out of 817 midwifery cases attended, 279 is a percentage rate of 34. The corresponding figures in the years 1942 to 1945 were, 33.1, 32.3, 32.8, and 38.0. Local Authority's Midwifery Service : The sixteen midwives work in four teams of four, this arrangement proving the most convenient to enable each to obtain the off-duty time to which she is entitled. Last year the number of patients attended by the Council's midwives was 1,071, being a percentage of 26.1 of the total number of confinements of local mothers. To 762 they attended as midwives, and to 309 as maternity nurses. Of the patients attended by midwives acting as such, 512 were assessed to pay the full cost, in 56 cases no charge was made, while 194 were assisted. The corresponding figures in regard to patients attended by midwives as maternity nurses were 266, 14, and 29. When the domiciliary midwifery service started, the Ministry anticipated that each midwife in such a district as this would be able to attend about 100 cases, midwifery or maternity, per annum. Insufficient allowance, though, had been made for the effect of the improved off-duty periods of the midwives ; and that it is desirable the midwives should attend the ante-natal clinics, particularly those sessions at which any of their patients are present. The figure then has been reduced. In practice over the years, the local average of 68 cases per midwife was found to be one which could be adequately coped with. This, though, allows little enough in reserve to meet the times of a smaller number of midwives being available because of the long-continued absence of any member of the staff, nor of course does it allow for any substantial increase in the total number of patients to be attended by the existing staff. Absence on account of sickness has during the year been higher than average, while further difficulties arose through the endeavours to secure that each midwife should attend a course of instruction of a fortnight to qualify her to obtain her certificate as to her competency to administer gas and air analgesia. There is a general shortage of midwives ; this district apparently being comparatively well off, no 62 attempt was made to appoint any additional staff. In May, though, the Committee authorised the engagement of part-time midwives at a remuneration of 3/- a visit. It was also agreed that pupils who had received their Part I training in London should come to this district to receive their Part II domiciliary training. Actually no pupils came until early in 1947. The demand on the maternity hospital accommodation at Redhill County Hospital was becoming so great that the authorities found it necessary to discharge far earlier than the accepted period of 14 days many of the patients admitted to the hospital for confinement. This early discharge meant that the services of the trained staff were available for the assistance of a greater number of mothers at their deliveries. The Council, on being approached, agreed to try to help the hospital authorities by undertaking the nursing of these discharged patients. No assurance, of course, could be given that the help could be made available in all cases because the Council, particularly in the second half of the year, was experiencing difficulty in maintaining its midwifery service, and in providing the midwives to attend at the confinements of those patients who had already booked. That a period of further difficulty was to be entered upon was apparent from the fact that, whereas the average number of cases delivered by the midwives each month for the last half of the year was 88, the average bookings per month were 120. For many years, enquiries have been instituted to discover whether there was any anaesthetic which the midwives could be permitted to use, one which would be free from all risk, one which would not interfere with the uterine contractions, and yet one which would provide relief to the mother. Various anaesthetics were suggested, but for some years there has been general agreement that the only one which could be officially approved was gas and air. Accordingly, before the war, midwives who had received the necessary instruction were authorised to administer gas and air provided the patients on being medically examined had been found fit for the administration and on each occasion there was present at the confinement another trained person in addition to the midwife herself. It was probably the latter condition which held up the general introduction of the arrangements. During the war years, at one time there was particularly clamant agitation that all authorities should put these facilities at the disposal of the parturient mother. This perhaps led to a modification of this rule which has been subsequently amended so that there is now no difficulty in providing this person. The war, too, contributed to the difficulties, because of the impossibility of obtaining the necessary apparatus, while in addition there were no courses of training. Since the war, though, these difficulties have been largely overcome, and since February midwives have been released one at a time to attend the course of instruction. By the end of the year, 11 had obtained their certificates. As far as possible, midwives were released so that the number qualified in each of the four groups in which the midwives work should be the same. No publicity was given to the fact that any of the midwives was competent to administer the anaesthetic until a reasonable number altogether were proficient. It was not, then, until September that the first patient received this 63 relief. In this month it was administered to 4, to 11 in each of the next two months, and to 16 in December. No additional charge is made for the service. In most cases the administration was highly successful, in 4 only partly so, but in one was quite a failure. Apparently there always will be some of these cases of failure because of the complete inability of the patient to co-operate. Even if the failures were higher, there would remain the justification for this practice in the comfort which the mothers may derive throughout their pregnancy, from the knowledge that they are to be helped, and their labour pains eased. Even with the facilities available, though, only a proportion of mothers elect to take advantage of them. Home Helps. The arrangements for the provision of home helps in maternity cases continued as on previous lines, though the remuneration was again raised, this time to £7 7s. Od. for the 14 days' attendance. During the year, 145 cases were attended by home helps, under the Council's scheme. During the financial year 98 cases were attended by 20 helps. Of these, 3 attended only one confinement, 6 two, 2 four, 2 five, 2 six, 3 seven, 1 twelve and 1 attended twenty persons. The provision of home helps to assist in the running of a home when the mother is being confined at home has for long been part of the Council's welfare service. In 1944, the Minister authorised the provision of home helps in households where the need arose, not from the mother's having a baby, but because of the presence of a number of children in the home. The principle was later extended to enable authorities to provide a service of domestic helps who would assist in the running of the household where difficulties arose primarily because of illness. The publicity given to the arrangements and the invitation to applicants for such appointments did not meet with much success. The Minister authorised the appointment of a supervisor to run the service. It was felt by some, though, that the rate of remuneration offered was the real obstacle to the engagement. Before proceeding any further with the appointment of an organiser, then, it was decided to raise the hourly rate of remuneration from 1/3 to 1/9. No more success followed this step. In November, therefore, it was decided to appoint an organiser of the service. The appointment was made, and there is now a domestic help service which is proving most valuable, and is enabling aid to be given to households which would be in real difficulty were it not for this assistance. Consultant Service. A consultant was summoned on 13 occasions. The only ante-natal case was a patient suffering from haemorrhage. One patient was in labour and was removed to hospital. Nearly all the remainder (post-natal cases) were suffering from haemorrhage or shock. Transfusion was performed in many cases, and some patients removed to hospital. One was a case of uterine infection, and was removed to hospital; one suffered from a severe perineal laceration, and was operated on at home ; and the remaining case was a patient suffering from what proved to be haemorrhage from a ruptured uterus for the treatment of which she was removed to hospital. 64 Institutional Confinements. In registered nursing homes in this district 1,456 births occurred. Of the 584 births to mothers from outside districts which occurred in this area, 577 took place in maternity homes, 7 in private houses. In 1,123 of the 1,164 confinements attended by midwives, they were present as maternity nurses. Notifications were received of 1,765 births to Harrow mothers, which took place outside the district. Of these, 1,530 were from hospitals and 195 from maternity homes. Of the patients confined in hospitals outside the district, 817 were delivered at Redhill County Hospital, 372 at Bushey Maternity Hospital. Of a total of 3,882 births, 1,238 occurred in the patients' own homes, 879 in local nursing homes, and 1,765 in hospitals or homes outside the district. Some 2,644, or 68 per cent, then, of the confinements took place in institutions inside or outside the district. POST-NATAL SERVICES. Post-natal Examination. Mothers recently confined are recommended to be examined some six weeks after delivery. During the year 255 mothers attended. Consultant Services. Any of the consultants on the Council's panel, and the obstetricians at Redhill Hospital are available to assist general medical practitioners in difficulties at the confinement or in the post-natal period. This year use was made of this service on ten occasions. Puerperal Infection. (a) Consultant Services : On only one occasion this year was the consultant summoned on account of puerperal infection. (b) Hospital Services : The admission to hospital of patients suffering from puerperal infection, who need institutional treatment is arranged by the Council at no cost to the patient, the patients being admitted to the isolation hospitals of some of those authorities with whom the Council has an arrangement for the acceptance of infectious patients. During the year, 13 patients were admitted to hospital, including five who had been confined in local nursing homes. (c) Home Nursing : As some of the conditions causing puerperal pyrexia are communicable, it is undesirable for a midwife, attending such a patient, to attend to other maternity cases. By arrangement with the District Nursing Association the nursing of such patients is passed to suitably qualified nurses of the Association. The Association also, on behalf of the Authority, undertakes the nursing of patients suffering from such conditions as breast abscess, white leg, etc., occurring in the nursing mother. Two patients notified as suffering from puerperal pyrexia were nursed by the staff of the Association under these arrangements. In addition, there were a further two cases of nursing mothers whose nursing the staff of the Association undertook on behalf of the Council. 65 BIRTH CONTROL CLINIC. At a Birth Control Clinic established at a maternity centre, contraceptive advice may be given only to those in whose case further pregnancy would be detrimental to health. Last year 143 new patients attended, and altogether 436 visits were paid. Each year a small number who attend have to be denied any advice on contraceptive methods, as in their cases there are no medical grounds rendering a pregnancy undesirable. 66 SCHOOL HEALTH SERVICES. Staff. All the full-time medical officers devote part of their time to work in the school health services, the total being equivalent to that of twoand-a-half full-time officers. Similarly, all the health visitors act as school nurses, the total time they give being the equivalent of six fulltime officers. During the year there were two health assistants engaged on the work of head inspection and cleansing. Medical Inspection. When the school medical service was first instituted, it was appreciated that those who were suffering from any abnormality or disability requiring treatment could be found only by examining all, so the foundation of the service is the routine medical inspection carried out for many years on three age groups—the entrant, the intermediate and the leaver. Children are examined about 25 to a session, the parents being invited to be present. An important part of the procedure is the consultation of the medical officer with the school staff and the advice given to the parents. Children suffering from some disability requiring treatment are put in the way of obtaining it. Some are found suffering from conditions not needing treatment at the time, but possibly would later. Such children are kept under observation, as are those suffering from such conditions as defects of the heart where periodic examination is advisable to ensure the disease is not progressing. These children will be kept under observation, arrangements being made for them to be seen at the school when the medical officer attends there a term or two or three terms later. In other cases it is necessary the child should be seen at an earlier date or it might be necessary he should be seen more frequently, or it might be a case where a more detailed and time-consuming examination is advisable. Such children will be given an appointment at the minor ailment clinic, which they will continue to attend as long as this periodic observation is considered necessary. This constitutes the second group of children examined, the re-inspection. The third group is that of the specials. These are children who are submitted to the doctor at the request either of the parents or the teachers or the school nurses. These many examinations are carried out throughout the year, about one th'ird of the school population being examined each year as routines and frequently more than half the school population altogether in one category or another. The average of 25 per session examined allows only six minutes a child—time enough for the brief examination of the normal child, but no time for the child suspected of an abnormality and little enough time for discussing the many problems raised by the parents. There has been much criticism of the basis of the observation of the school child, more particularly as so much of the time of the examining medical officer is taken up in dealing with the normal child. No agreement, though, has been reached on the basis of a satisfactory alternative. Many authorities before the recent war favoured the carrying out of four routine inspections. Middlesex was one, and the aim has been continued of examining on this basis. With the raising of the school age, it will be possible to arrange the four inspections at equal intervals. At present the last group is 67 being examined as leavers, this particularly with the object of completing the medical record for the employment exchange. Deferring the examination as late as this deprives the child of the opportunity of having carried out any treatment considered advisable. It is hoped, then, it will be possible to arrange for the examination of this oldest group as an age group, examining the children throughout the year, and re-examining nearer the time of their leaving those about whom there is any question of their requiring on health grounds to avoid certain occupations. Whatever views might be held about the value of the routine inspection carried out of children in a number of age groups, it will be generally conceded that at least the entrants should be thoroughly examined as soon as possible after their admission. There is, too, advantage in the leavers being examined particularly having regard to their future employment. In such cases, though, the examination ought to be carried out sufficiently early in the school year for those found to be in need of treatment to be able to have it. At least one other routine examination should be carried out. Although the regulations require that this should be in the last year of the attendance of the pupil at the primary school, it is understood that there is advantage in this being held on the child's admission to the secondary school as the school staff will know more about the child's capacity for taking part in the more strenuous physical activities. The question, then, is whether further routine examinations should be arranged, which really comes down to the question of whether the time of the medical and nursing staff might be better employed in any other way than examining as a routine one or two further age groups. In this district, particularly because of absences on account of sickness, it has been difficult to adhere to the full programme of four routine inspections. This has meant that those in need of following-up have not all been able to receive this extra attention. Naturally, too, in such circumstances children will not be presented as freely as "specials." It is felt, then, that it would be more useful if the routine inspections were limited to the three groups, and that the extra time can be given to the re-inspections and the specials. The children are under the close observation of their teachers. If full facilities are available for the presentation of children for examination, it is felt to be most unlikely that any child could be attending school and be suffering from any marked deviation from the normal and not be recognised and therefore presented. Then it might be made clear to the parents that these facilities would be available for their children if the parents wished an examination for any reason. As the inspection would be more localised than the general examination, more children could be seen than at the session for the examination of the routine age groups. It is felt that the time of the school staff spent in this way on the examination of " specials " and of those to be re-examined would be much more profitable than if it were devoted to the examination of a fourth and even more of a fifth age group. The Board of Education, when it became the duty of a local education authority to arrange for the examination of those attending what were then known as the secondary schools, required the detailed examination of those of 12 and of 15, and the more cursory examination of those of other ages. There have been no revised instructions as to any changed practice 68 to follow the radical alteration of the classification of schools brought about by the most recent Education Act, nor as yet has any change been suggested since the school-leaving age was raised. In some of the larger schools, there are so many children to be examined that the attendance of the medical officer at many sessions is necessary, but at some of the smaller schools the doctor need come only a few times. It is felt, though, to be a real advantage that it shall be accepted that the medical officer will be present at every department of each school some time during every term, so that even in the smaller schools no attempt is made to complete the inspections in the one term, but rather to spread the attendances. In this way the head teacher has more opportunity of bringing to the notice of the school doctor any child he wishes examined. Such an arrangement, too, enables those who are to be kept under observation to be seen at frequent intervals. It was not possible this year to carry out the full programme of examinations, largely because of the absence of staff on account of sickness. The establishment provides for the appointment of an additional medical officer, but there is no advantage to be gained by making such an appointment until the staff of health visitors and school nurses can be increased, and this is proving impossible. Of the children attending the maintained schools, 6,086 were examined as a routine (1,408 as entrants, 1,298 at age 7, 2,201 at age 10, 1,179 as leavers), 2,972 as specials and 1,976 as re-examinations. Section 78 of the Education Act, 1944, enables the children of nonmaintained schools to obtain the same benefits of the school health services including school inspections as those at maintained schools, the procedure being initiated by the principal applying to the education authority. As far as is known, none of the many private schools in the district has elected to take advantage of the facilities. TREATMENT. Minor Ailments. Weekly sessions are held of minor ailment clinics in six premises in the district, namely, the clinics at The Broadway, Elmwood Avenue, Honeypot Lane, Chandos Sports Pavilion, Alexandra Avenue and the Methodist Church Hall, Love Lane, Pinner. The medical officer is present as well as the school nurse. He prescribes the treatment of those attending suffering from minor ailments. At the clinic, too, he will keep under supervision those children referred for observation, while in addition at this clinic he will see those who need a more detailed examination than can be carried out on the occasion of the routine school medical inspection. At some of the clinic buildings, the nurse attends on one or more other occasions in the week so as to give intermediate treatment to those attending. While children because of the comparative infrequency with which they need to attend the minor ailment clinic can reasonably be expected to travel greater distances than those of the mothers bringing their children regularly to the infant welfare centres, there is undoubtedly a limit to distances and it is probable that many children at school are not attending the present clinics who possibly would avail themselves 69 of the services if the facilities were made more con.ven.ient. It is very striking that although the Honeypot Lane clinic building, being built for the purpose, lends itself much more conveniently for holding clinic sessions than the Sports Pavilion in the Chandos Recreation Ground, those attending the Chandos Clinic would not go the longer way to Honeypot Lane, and that attendances are now greater at Chandos than at the other clinic. The difficulty of providing additional facilities is, of course, that of lack of premises. The medical officer of the clinic refers many cases for consultation to the staff of the Redhill County Hospital, and it is a pleasure to acknowledge the help received. Very full reports are sent of the hospital's findings, while of course the mothers find it far more convenient to attend there than travelling to one of the London hospitals. It is at the clinics that some of the children are examined shortly before leaving school in regard to their fitness for certain employment, and where those who are engaged in part-time employment are seen. Ophthalmic Clinic. The children at all the maintained schools in the district except Stag Lane, for which the Wembley Clinic is so much more convenient, are now seen at three ophthalmic clinic sessions held in the district, two at the Marlborough Hill Clinic and a third opened during the year at the Alexandra Avenue Clinic. Children are referred in the first instance by the medical officer either at the school medical inspection or from one of the minor ailment clinics. They are then examined by the ophthalmic surgeon under a mydriatic and glasses prescribed where necessary. At the Marlborough Hill Clinic a representative of a firm of opticians attends and provides the glasses. If the parents elect to have something more than the standard frame which is provided free of cost, they pay the difference in price. At the Alexandra Avenue Clinic the school nurse decides on the size of frames and the glasses are dispensed by a London firm. All children ordered glasses and those to be kept under observation are called for re-examination after an interval of time determined by the surgeon. Glasses are provided free ; also, if the surgeon considers it necessary, a second pair is provided free. Repairs, too, are carried out free of charge. At each session, a set number of new cases, those referred for refraction and a number of children to be re-examined, are seen. The three weekly sessions are sufficient to enable the children to be seen within a short time of their being referred for examination. The reexaminations, though, tend to accumulate, so every now and again an additional session is held to which many are summoned. The present difficulty is not that of arranging for the children to be seen by the ophthalmic surgeon, but rather the delay in their obtaining the glasses which have been ordered. These difficulties met with by the opticians, though, are somewhat less now, and the period of waiting is diminishing. Some children suffering from squint need operative treatment. Arrangements are made for these to be admitted to hospital. In some districts, encouraging results in the treatment of squint, if loss of vision has not occurred, have followed the practice of orthoptic exercises. 70 The following are the details of the work carried out at the two clinics: Marlborough Hill. Alexandra Avenue. No. of sessions 102 34 No. of children inspected : For first time 364 136 Re-tests 440 121 No. of children examined for other conditions 21 30 Provision of spectacles : No. prescribed 270 115 No supplied 251 108 No. repaired 109 66 No. of cases referred to hospital: For operation for squint — — For other conditions 7 1 Physio-Therapeutic Treatment. The Harrow Hospital maintains at the clinic at 76, Marlborough Hill a staff of physio-therapists for treating those suffering from such conditions as will benefit from treatment, such as massage, electrical treatment, ultra-violet and infra-red irradiation, class exercises, etc. Children under five and those of school age may be referred for the treatment of general or local conditions. Amongst the general are debility, anaemia, muscle flabbiness, asthma, etc. In the other group will be those suffering from localised lesions such as flat feet, knockknees, hammer toes, etc. All are examined by the director of the clinic who attends most days, and the course of treatment will be prescribed, patients being examined at the end again. In some cases a series of courses of exposure to rays or attendance for a series of exercises is necessary. By the extended powers of the 1944 Education Act the authority can provide a wide range of treatment, so may assume financial responsibility for the charges of those who attend the clinics for treatment to correct defects following accidents. Those referred to the clinic, where suffering from grosser orthopaedic abnormalities, are passed by the director to the consultant orthopaedic surgeon who attends once a month. He might order treatment or exercises which can be provided by the clinic staff. He may order special appliances which are provided free of cost, most being made by the Stanmore Cripples' College, or it may be a case necessitating operative treatment. A short-stay case may be admitted to the Harrow Hospital, but the child needing to be in hospital for a long time is admitted to the Stanmore Orthopaedic Hospital, which is recognised by the Ministry of Education as a special school. Certain of the children are recommended for admission to the special schools for the physically handicapped. Many parents take their children to one of the London hospitals. In such circumstances the local education authority assumes responsibility for the payment of the hospital charges and also meets the cost of any appliances needed. 71 Dental Services. With the re-arrangement which took place in the early part of the year, no children attending schools outside this district are now treated by the dental officers who work in this area. On the other hand, though, there are a number of schools whose pupils are still treated by the dental officer working at the Northwood Clinic, while the pupils of Stag Lane School are attended to by the dental surgeon attached to the Wembley Stag Lane Clinic. There are five dental officers working in Harrow, four full-time and one almost full-time. They work at the Alexandra Avenue, Elmwood Avenue and Marlborough Hill Clinics, at the Roxeth Dental Clinic and at Stanburn School. Each dental officer has the assistance of a lay dental attendant, who does the clerical work and assists in the running of the dental clinics. The plan on which the work is carried out is that each dental officer attends each school on a rota. The parents are advised that the dental officer proposes attending the school to examine a number of children. A high proportion of them need treatment. Sufficient are examined then to provide work for the dental officers for the succeeding two or three weeks. Before these have all been treated another lot are examined. The aim is to examine each school child once a year. The number of dental officers, though one time sufficient for this area, is no longer so. At the best of times the schedule could be adhered to only if there were no absences for sickness or other reasons. Most dental officers are treating maternity and child welfare cases as well, which means that they have that much less time for the school children, while the raising of the school-leaving age will add further to the numbers to be seen to. The difficulty in adding to the staff is one arising from failure to obtain accommodation in which to house the extra dental surgery. The district requires probably not an additional one but two more dental officers. This perhaps would enable a start to be made on examining the teeth of all the children, not once in the twelve months, but once in six months. It might be thought that such an arrangement would be extravagant on the time of the dentists. This is not so, though, because if children are examined at intervals as short as this any caries discovered would be in the earliest stages and far less time would be required in the actual treatment. Most extractions are done under a local anaesthetic. In some cases, though, a general anaesthetic is necessary. Periodically, then, each dental officer has a general anaesthetic session, the anaesthetic (usually gas) being administered by a medical practitioner. At these sessions a trained nurse is present, usually one of the school nurses. Some children who grow up with ill-fitting teeth are embarrassed for life. Most authorities for years, then, have made arrangements for at least the worst of these cases to be treated by regulation. Up to this any such children referred to the dental officers have attended the Orthodontic Clinic at Sudbury. In the early part of 1917, arrangements were made for an orthodontic surgeon to work in the district. In spite of the very full dental facilities available some children suffer from toothache or there develop other reasons that they need urgent 72 treatment. At each clinic a time is set aside on one or more days a week to which the head teachers can refer children whose pain can be alleviated. The following table shows the work done by the staff of the dental service in Harrow. In addition, there is the work done by the dental officer of Northwood who attends to children from Cannon Lane, Grimsdyke, Headstone, Pinner Park, Pinner Wood and Pinner County Schools, a school population of nearly 3,000. South Harrow Elmwood Avenue Roxeth Hill Marlboro' Hill Stanburn School No. of Sessions: Inspection 23 27 26 38 45 Treatment 395 416 443 273 445 Total Attendance at Clinics 3,421 2,290 3,455 2,254 3,016 No. of Fillings: Permanent Teeth 2,000 2,003 1,971 1,405 2,191 Temporary Teeth 1,472 625 720 92 189 No. of Extractions 1,576 1,915 1,507 3,105 756 Ear, Nose and Throat Defects. Those found at the school inspections or at the school clinics to be suffering from abnormal states of the ear, nose or throat are referred to the very excellent Ear, Nose and Throat Department of Redhill County Hospital. In ordinary circumstances any referred were given an early appointment and any to be operated on were admitted without undue delay. The shortage of nursing staff which so seriously affected this special department of the hospital completely altered the picture. Matters had come to such a pass that it was pointed out it was useless to refer such cases to the hospital as there was so little prospect of the patients receiving treatment. On the other hand, though, it was impossible to make other arrangements. The London hospitals had their own problems and in their difficulty they asked if arrangements could not be made for those children who attended there and were found to need treatment to obtain it locally. There has, therefore, been no alternative but to continue to refer all cases thought to need treatment to Redhill Hospital. If they were not referred, they certainly could not obtain treatment. If they were referred any easing of the situation might enable some at least to be treated. Most of the cases referred are those considered to need operative treatment of tonsils and adenoids, though other types of case have been referred. Child Guidance. The following is a report by Dr. Margaret Saul, the psychiatrist, on the work of the Harrow Child Guidance Clinic. The present century has seen the recognition of the fact that not only are some of the symptoms from which children suffer not due to organic illness, but also that behaviour difficulties are usually a symptom of mental ill-health, and that they are frequently amenable to treatment and 73 resolution. The behaviour of a child is not conditioned by its innate endowment only; the experiences which befall it, more especially the emotional experiences, have a very marked influence on conduct and attitude. Whilst those qualities which are inborn may be very difficult to modify, the effects of experience are more readily influenced. The problems of personality are largely the result of emotional experience in very early childhood, so that the task of helping the child to make a satisfactory adjustment cannot be undertaken too early. This adjustment may involve treatment of the child or modification of the environment which has served to cause, and if unaltered perpetuate, the ill-health from which the child suffers. The diagnosis involves much patient investigation by a skilled child guidance team, the work of each individual being welded into a whole at a conference held on each child. Whilst all the members of the team take a part in the conduct of the case, the direction of treatment properly falls to the psychiatrist. The form of treatment is not stereotyped, but varies with the type of case, so that there is opportunity for all members of the child guidance team to undertake treatment. The team at this clinic consists of a full-time psychiatrist, two fulltime psychiatric social workers, two part-time psychologists, who together give five sessions (2½ days) per week, and two part-time play therapists, who together give ten sessions per week. New Cases in 1946. Two hundred were seen in 1946. Of these, 126 including 57 from Harrow, were investigated for diagnosis, and 74, including 37 from Harrow, were also selected for treatment. The sources of referral were as in previous years, i.e. over half by school medical officers, including cases ascertained by head teachers, who bring them to the notice of school medical officers for the exclusion of organic disease in the first instance ; the remaining cases are referred by hospitals and welfare centres, private doctors, juvenile courts, and some by the education or public health departments from various indirect sources. The total number referred between January 1st and December 31st, 1946, was 277. 126 were from the Harrow area and 151 from all other areas covered by the clinic—the main contributors being North West Middlesex 56, Wembley 40, and Hayes 29. Of the total number referred during the year, after home visit and further investigation, 42 children (16 from Harrow) were gradually removed from the waiting list as their names came up for appointment. 12 of these were found to be unsuitable for child guidance, 8 had left or were about to leave the area, 8 had had only transient symptoms and did not need to attend, 1 had been taken to a private doctor, and in the remaining 13 cases, the parents were unco-operative, and, for one reason or another, unwilling to pursue the matter further. Children Under Treatment Previous to 1946. Total 41 from all areas, including 19 from Harrow. Of these, 33 were discharged during 1946 (25 cured or markedly improved; 1 unimproved; 4 because further improvement was prevented by lack of parental co-operation; 2 were unable to continue attendance; 1 adolescent schizophrenic was transferred to Shenley 74 pital); 2 were old cases, who returned later in 1946 for recurrence of symptoms; these and 6 others were still under treatment at the end of the year. Apart from the above 41, 4 children (2 from Harrow), seen for diagnosis in 1945, commenced treatment in 1946, and were all discharged as satisfactory during the year. Thus the total number of children under treatment during 1946 was 74+41+4=119, the old cases gradually diminishing and the new being added throughout the year. Reasons for Referral. This year disorders of habit preponderated, other symptoms following in the main the pattern of previous years as regards numbers. (1) Disorders of Behaviour: Total. Aggressiveness : difficult to manage, disobedient, untruthful 38 57 Theft, petty pilfering and truancy 13 Tantrums 3 Sex difficulties 3 (2) Disorders of Habit (excluding speech): Enuresis 34 62 Faecal incontinence 4 Thumb-sucking 1 Sleep disorder (night terrors, sleep-walking, insomnia) 7 Masturbation 4 Tics 10 Nail-biting 1 Food habits 1 (3) Disorders of Personality: Sensitiveness, nervousness, apathy, obstinacy, solitariness, fears, anxiety, timidity 32 (4) Physical Symptoms: Asthma, blackouts, pains 8 (5) Backwardness: All degrees 41 200 Of the 41 cases referred for backwardness, 16 proved to be mentally defective (I.Q. between 50 and 70), 11 were primarily dull and backward, 9 were low average or average, and 5 were children of good intelligence suffering from emotional disturbance (2 of these had a specific reading disability). In the other cases, the I.Q. was not especially relevant. The number of intelligence tests is substantially the same as the number of new cases seen (i.e. 200 in 1946) for each child when first seen is tested as part of the diagnosis. In addition, 6 children were re-tested in 1946, for whom a reassessment had been considered necessary. 75 Results of Treatment and Disposal of Children. Of the 74 selected for treatment, 24 had been discharged by the end of the year no longer needing treatment, 33 were still under treatment continuing into 1947, and 4 were awaiting vacancies for treatment. As regards the remaining 13 cases, treatment was suspended in 8, owing to lack of parental co-operation or removal from area; 2 were referred to hospital as physical causes were more salient; 1 child was transferred to a school for physically defective children, and 1 to a boarding school for maladjusted children. In 1 case referred for a variety of symptoms including enuresis, the latter remained obdurate to treatment but the child improved markedly in all other respects. Of the 74 children selected for treatment, 37 were from the Harrow area. Staff. The 206 intelligence tests, the coaching of 14 children and a number of school visits, 17 in all, continued through the year to be carried out by the two part-time educational psychologists, Miss Chaplin and Miss Frankenstein. At the school visits, not only cases from that school in attendance at the clinic may be discussed, but also any other children about whom teachers are anxious for advice. With regard to the work of the psychiatric social worker, she sees each mother for an interview lasting rather over an hour, when the child is first brought to the clinic for diagnosis ; the psychiatric social worker also visits the home in nearly all cases before child and mother are asked to attend the clinic; in fact, she may make more than one visit, for the parent may be out even though an appointment has been made. The psychiatric social worker also sees each mother week by week, when the child is brought for treatment, on these occasions spending approximately three-quarters of an hour with the mother each time. Fathers are also encouraged to pay one visit to the clinic, by appointment, whenever it can be arranged, and there has been a greater response in this respect in 1946. Besides this, there are a number of parents who have been helped in the past, who come for a follow-up visit to report progress, or to ask for further advice. The psychiatric social worker also pays a number of these follow-up visits at the parents' homes, and one must also include a considerable burden of other home visits needed to eliminate unsuitable cases from the waiting list; there were 42 such cases in the year 1946. Play therapy work has importance not only as treatment, but also as a diagnostic measure; it is carried out by psychologists trained in the theory and practice of treating disturbed or maladjusted children by play methods. Play is the natural expression of all children, and for young children, apart from dealing with the environment, it is the best, if not the only therapeutic approach. 76 The play-room contains various simple toys, models of objects used in daily life, and opportunities for making a mess (sand and water trays). Each child attends weekly for a period of 45 minutes, during which time he or she is under constant skilled supervision. The psychiatrist is responsible for the individual examination of all new cases, for the regular treatment of a number of children suitable for psychotherapy, and for the co-ordination of the work of all the other members of the team. As regards children whom the psychiatrist treats personally, it is less necessary to see all the mothers week by week, as the children are older (usually in adolescence). In a number of cases, the parent is seen at regular intervals by the psychiatrist, as it is not so necessary with older children to observe the general rule that children and mother should be handled by separate members of the staff. The home environment of the children is an important factor in causation of symptoms. It is the task of the clinic to modify this environment where possible, just as it is to assist the child to make a better adjustment to life. Success does attend these efforts, but all too often it is clear that not only is the environment the cause of the child's difficulties but also that continuance of that environment will so hamper the child as to prevent any improvement from clinic treatment. Many and varied are the factors in the environment which influence the child. Of these, parental disharmony is a fruitful source of difficulties, whilst lack of real affection never fails to produce problems. Personality disorders in either parent may make the task of treating the child almost insuperable whilst he remains at home. Vacancies are very difficult to obtain at residential schools approval by the Board of Education for maladjusted children. Open air residential schools meet the need occasionally when the children's difficulties are not severe, and a foster-home (also very difficult to find) provides an occasional solution. The establishment by the County Council of a hostel or residential school of its own for maladjusted children will fill a great need. Statistics have been given in this report about numbers seen, types of case, and so forth, but otherwise it is not possible in psychological work to convey a true or satisfactory picture by means of figures of the real work done. The work of the clinic does not materially alter year after year, for the type remains the same and the numbers with which any one clinic can deal are always controlled by the factors of time and space ; in other words, where, as here, a clinic of definite size is working to capacity, further numbers could only be dealt with by increasing accommodation and personnel. Five lectures were given to groups of parents by clinic staff during the year 1946. The aims and methods of child guidance have now become much better known and a lively interest is shown by the public in all aspects of the work. 77 Speech Therapy. The following is a report by Miss Barbara Fisher, the speech therapist, on the work of the Harrow Speech Clinic for the year 1946-47. Total Number of Cases seen throughout the Year 125 Total Number of Cases on Register at the end of March, 1947 52 Cases receiving treatment 46 Stammer 23 Dyslalia 11 Sigmatism 5 Cleft palate 2 Spastic 1 Dysarthria 1 Dyslalia and stammer 1 Alalia 1 Disphonia and sigmatism 1 Cases suspended 6 Awaiting further advice 2 Receiving hospital treatment 2 Allowing three months for development 1 On three months' holiday 1 Total Number of Cases Discharged throughout the Year 51 Speech normal 24 Stammer 9 Dyslalia 8 Sigmatism 6 Stammer and Dyslalia 1 Speech considerably improved (Usual reason for discharge is nonattendance for final stages of treatment.) 10 Stammer 4 Dyslalia 4 Sigmatism 2 Cases discharged for non-attendance or lack of co-operation (Usually some improvement.) 17 Stammer 5 Dyslalia 10 Sigmatism 1 Spastic 1 78 Cases Referred to Other Clinics 11 To Child Guidance Clinic 3 To Wembley Speech Clinic 5 To Uxbridge Speech Clinic 1 To Special School 2 Cases Not Accepted for Treatment 11 No speech defect 10 I.Q. too low 1 Number of Cases on Waiting List 33 Cases are taken at the clinic on Mondays, Tuesdays and Wednesdays all day, and on Friday mornings. Thursdays are reserved for home and school visiting. In all, 71 such visits were paid, 50 school visits and 21 home visits. Evening visits are made to the homes if the parents are working during the day. On Friday afternoon I attend a conference held by the staff of the Child Guidance Clinic. Until last August, three students treated their own cases under my supervision (total 2½ days a week). Since September, 1946, 2 students have been treating cases (total 1½ days a week). Over the year, the attendance of patients has been good. During school holidays, however, very few patients attend. Bad weather and the resultant illness early this year also caused a considerable falloff in attendance. With the opening of the Wembley clinic last autumn, five cases were transferred from here. During November, at the invitation of Stag Lane Parents' and Teachers' Association, I gave a talk on " The Work of the Speech Clinic." The majority of cases are referred to the clinic from the schools, but in 8 cases children under school age were accepted for treatment, having been referred from Welfare Clinics. The equipment which arrived last term is invaluable to the treatment of the majority of cases and the cupboard is much appreciated. Following-up. Some children seen at the routine medical inspection are recommended to obtain treatment. In others, while treatment at the time is not considered necessary, it is felt that it might become so. Such children then have to be seen again well before the date of the next ordinary routine inspection. Others again do not require treatment, but need to be kept under observation. In regard to those referred for treatment which in most cases can be arranged through the machinery of the school health service, the children need to be seen again, in some cases to be satisfied that the treatment carried out is adequate, in others to ensure that the treatment is obtained at all. Where arrangements are made for the treatment to be obtained through the local authority's machinery 79 particulars are obtained of those referred for treatment, but who do not attend to obtain it, or who, having started, do not attend the full course. Such cases are followed up by the health visitor, and where the parents are co-operative, further appointments are made. If there is no co-operation, then arrangements are made for the child to be seen at school as one of the re-examination group. In the same way, those who have obtained treatment are re-examined at the school, and where it is found that adequate treatment for the condition referred has been obtained no further steps are necessary in regard to that child. The children needing to be kept under observation will be those suffering from such conditions as enlarged tonsils, cervical adenitis, minor heart lesions, postural conditions, etc. These will in general be only minor departures from the normal, and in the majority of cases it turns out that no treatment is required. As though at the time they are seen the abnormal condition may really be the early stage of a condition which is deteriorating, the children are seen again in some three or six months, when most frequently they are found normal. These inspections are carried out in the school, these children, too, being presented as the re-examination group. Sometimes this period of waiting would be too long. In such cases the child is referred to the minor ailment clinic where he can, if necessary, be seen frequently at short intervals until a decision about what is advisable is arrived at. Cleansing. The same arrangements were made for the systematic examination of the heads of children attending the former elementary schools by the two health assistants, working under the direction of the health visitors. Of the 58,424 children examined, 1,167 were found to have infested heads, a percentage of just under 2 per cent. The heads of most were found clean on further examination. 163 children were treated at the Broadway or the Alexandra Avenue Clinic. Handicapped Pupils. Under section 34 of the 1944 Education Act, it is the duty of every local education authority to ascertain what children in their area require special educational treatment. For that purpose, the parent of any child who has attained the age of two years can be required to submit the child for examination. The examination must be carried out by a medical officer possessing adequate qualifications or experience in the particular type of disability from which the pupil may be suffering. The only courses of theoretical and practical training which have been approved by the Minister for the special instruction of medical officers to carry out the examination of the educationally submormal pupils are those conducted by the London University Extension and Tutorial Classes Council in conjunction with the National Association for Mental Health. Up to recently a fortnight, the period has since been extended to three weeks. The General Purposes Sub-Committee agreed that arrangements be made for facilities to be granted to all the medical officers engaged in school health work to attend the course. The degree of mental retardation varies. Some children can benefit from continuing to attend the ordinary school, especially if particular 80 attention is given them. Children more retarded need the extra care and attention and surroundings which they can obtain only in a special school. Such children are reported under section 34 to the District Education Officer, who refers them for admission to the appropriate school. From this district this is the day special school at Willesden. It is understood that the waiting list of admissions for this school is so long that twelve months may elapse before a child having been recommended, is admitted. Some children are beyond even this, though, being incapable of being educated either at an ordinary or a special school. These are reported under section 57(3) to the District Education Officer, and the particulars ultimately forwarded to the County Education Committee. Subject to the exercise of his right of appeal by the parent, the case is referred to the local authority for the purposes of the Mental Deficiency Acts, 1913. These children are then removed from the sphere of the educational arrangements. If bad enough, they are admitted to an institution. If at home, they benefit from attendance at an occupation centre. There was one in the district which closed during the war. It is understood that one will shortly be established again in Wealdstone. 45 children were specially examined during the year. Of these, one was assessed as being normal; 2 were dull, but were to continue attending the ordinary school. 16 were recommended for admission to a special day school for the educationally sub-normal. 26 were considered to be ineducable. In respect of these there were 9 appeals. Of the 6 which have been decided, two were confirmed, but in the remaining 4 the Minister's decision was that the child should be admitted to a special school. There is another class of child admitted to a day special school, namely, the physically handicapped, the child who, not being a pupil suffering solely from a defect of sight or hearing, by reason of disease or crippling defect, cannot be satisfactorily educated in an ordinary school without detriment to his health or educational development. Those who can benefit from attendance at a day school are admitted to the special school at Willesden, to which they are taken by a special conveyance. Amongst the various groups of handicapped pupils are numbers who can benefit from admission to an open-air school. Amongst these are those of category "E" of the Handicapped Pupils Regulations, the delicate pupils who are defined as those who by reason of impaired physical condition cannot without risk to their health be educated under the normal regime of an ordinary school. There are also the physically handicapped, while sometimes such a school is helpful to the maladjusted child, the pupil who shows evidence of emotional instability or psychological disturbance, and who requires special education treatment in order to effect his personal, social or educational readjustment. These children are referred to the District Education Officer and arrangements for their admission to appropriate schools are made by the Public Health Department of the County Council. In addition to all these, there are those few for whom special provision has to be made, including amongst these the blind the deaf and the epileptic. 81 The following are the particulars of the handicapped pupils in the district: In Special schools In maintained primary and secondary schools In Independent schools Not at school Total A. Blind — — — — — B. Partially Sighted 1 — — 1 2 C. Deaf 1 1 — 2 4 D. Partially Deaf — — — — — E. Delicate 4 8 — 1 13 F. Diabetic — — — — — G. Educationally Sub-normal 3 14 1 3 21 H. Epileptic 1 — — 1 2 I. Maladjusted 5 30 4 5 44 J. Physically Handicapped 4 2 — 5 11 K. Suffering from Speech Defect — 45 — 5 50 L. Suffering from Multiple Disabilities — — — — — f 82 ANNUAL RETURNS. Primary Schools. A. Routine Medical Inspection. No. of code inspections: Entrants 1,408 Age 7 1,298 Age 10 2,201 Leavers 1,179 Total 6,086 No of routine inspections 1 957 B. Other inspections : Examined at Specials Re-inspections Schools 3 96 Clinics 2,967 1,880 C. No. of individual children found at routine inspections to require treatment (excluding uncleanliness, nutrition and dental disease). For defective vision For other conditions (see table H) Total Entrants 6 75 81 Age 7 46 106 152 Age 10 120 212 332 Leavers 40 60 100 Other ages 126 244 370 Total 338 697 1,035 D. Classification of nutrition of children inspected at routine inspections Age group Number A (Excellent) B (Normal) C (Slightly sub-normal) D (Bad) Entrants 1,408 121 1,210 77 — Age 7 1,298 196 1,004 98 — Age 10 2,201 403 1,635 158 5 Leavers 1,179 290 834 55 — Others 1,957 392 1,388 175 2 Total 8,043 1,402 6,071 563 7 83 E. Routine Medical Inspection. Age 10 11 12 13 14 15 16 17 18 19 Total Boys — 12 35 66 61 198 112 55 31 2 572 Girls 1 64 39 12 65 107 86 7 4 - 385 Total 1 76 74 78 126 305 198 62 35 2 957 F. Other Inspections. Specials Re-Examinations Boys — — Girls - — Total — — G. Classification of Nutrition of Pupils Examined : Age Number A (Excellent) B (Normal) C (Slightly sub-normal) D (Bad) 10 1 — 1 — — 11 83 11 65 7 — 12 68 6 61 1 — 13 78 7 71 — — 14 129 20 108 1 — 15 333 71 257 5 — 16 170 34 136 — — 17 62 8 53 1 — 18 31 6 23 2 — 19 2 2 — — — Total 957 165 775 17 — 84 All Schools. H. Return of Defects found by Medical Inspection. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects A B A B Skin Ringworm—Scalp - - 2 - do. Body 2 — 12 3 Scabies 7 — 55 4 Impetigo 4 — 160 1 Other diseases—Non-Tb 14 8 127 7 Eye Blepharitis 1 - 22 5 Conjunctivitis 4 1 61 — Keratitis — — — — Corneal Opacities — — — — Defective Vision (excluding Squint) 238 104 356 66 Squint 4 — 15 1 Other conditions 10 2 105 18 Ear Defective Hearing 14 18 21 5 Otitis Media 1 — 7 1 Other Ear Diseases 4 8 63 11 Nose and Throat Chronic Tonsillitis 19 61 52 14 Adenoids only 6 2 3 4 Chronic Tonsillitis and Adenoids 138 114 83 45 Other conditions 27 91 79 21 Enlarged Cervical Glands (Non-Tb.) 6 17 18 6 Defective Speech 20 4 18 2 Heart and Circulation Heart Disease—Organic 2 7 4 2 do. Functional 12 39 29 18 Anaemia 9 29 34 34 Lungs Bronchitis 3 2 15 2 Other Non-Tb. Disease 22 37 57 13 Asthma 3 7 17 6 Tuberculosis Pulmonary—Definite - — 1 — do. Suspected 13 2 2 — Non-Pulmonary-Glands — — — — do. Bones and Joints — — — — do. Skin — — — — do. Other Forms - — — — Nervous System Epilepsy — 1 5 — Chorea 1 2 3 1 Enuresis 36 9 30 9 Other conditions 15 11 38 10 85 H. Return of Defects found by Medical Inspection. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects A B A B Deformities Rickets — — 3 — Spinal Curvature 54 33 5 2 Other Forms 123 43 60 12 Maladjusted 3 3 11 3 Other Diseases and Defects 120 134 1,264 142 Total 1,035 789 2,837 468 A=Requiring treatment. B=Not requiring treatment, but requiring to be kept under observation. I. Return of Defects Treated. At Clinic Otherwise Total Skin : Ringworm, scalp — 2 2 „ body 11 1 12 Scabies 6 49 55 Impetigo 160 — 160 Others 120 7 127 Minor Eye Defects 116 22 138 Minor Ear Defects 61 9 70 Miscellaneous 420 46 466 Total 894 136 1,030 Defective Vision or Squint: Errors of Refraction 500 — 500 Other Defects 51 — 51 Total 551 — 551 Spectacles prescribed 385 Spectacles obtained 359 J. Verminous Conditions: Total number of examinations of pupils in the schools by School Nurses or other authorised persons 58,424 No. of individual pupils found unclean 1,167 86 K. Attendances at Minor Ailment Clinics: Clinic Seen by doctor Seen by nurse only New Old New Old Alexandra Avenue 807 594 212 361 Broadway 774 606 211 537 Elmwood 615 325 1 2 Honeypot Lane 299 102 2 4 Pinner 180 49 24 6 Chandos 292 204 3 6 Total 2,967 1,880 453 916 L. Examination of Children for Employment: Number examined 145 Certificates granted 140 M. Children referred for Treatment: 245 children were referred for operation treatment of tonsils and for adenoids. 69 were referred to the child guidance and 37 to the speech clinic. N. Dental Treatment: Children examined: Routine 15,146 Special 1,235 Total 16,381 No requiring treatment 10,870 No. treated 5,968 Fillings 12,174 Extractions 9,164 General anaesthetic 2,457 Other operations 3,017 Attendances made 14,461 O. School Meals: Meals and milk are provided five days per week during term time, and during holidays. In June, the number taking milk was 16,388. In September, by which time it was issued free, it was taken by 20,880. Of the 24,000 on the roll of attendance at school one day in October, 1946, 12,589 took dinner. -