Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1947 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW King & Hutchings, Ltd., Printers, Uxbridge. Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1947 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW J 3 REPORT OF THE MEDICAL OFFICER OF HEALTH To the Chairman and Members of the Urban District Council of Harrow. Mr. Chairman, Ladies and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1947. Each year since the creation of the Harrow Urban District this report has included a chapter on the maternity and child welfare services presented to the Council first as a maternity and child welfare authority and later as welfare authority. For the last two years a chapter dealing with the local school health services has been included because of the Council's responsibility under the scheme of Divisional Administration. This report for 1947 will be the last for a full year presented to the Council as a welfare authority, because of the changes brought about by the National Health Service Act of 1946. Of the eight pages of the Annual Report of the Medical Officer of Health to the Harrow Urban Sanitary Authority for the year 1880, six were taken up with the question of sewerage disposal plant. The Medical Officer of Health was apparently referring to a recurring item, the serious defects in the house drainage and in the public sewerage of the town, and discussed at length the question of land treatment and of tank treatment with chemical precipitation. The Board was reminded that they had made no provision for the isolation of cases of small pox or other infectious diseases, and reference was made to the many complaints about the water supply. In 1887, the Medical Officer of Health drew attention to the absence of water from a number of water closets. In that year the Board acquired land on which to build an isolation hospital. The sick were removed by a " fly," which was difficult to disinfect. Attention was drawn to the advisability of having a dry impervious area adjoining houses, as it was felt that the sodden state of the ground surface near dwellings was responsible for much illness, especially illness affecting the throat. For the same reason, it was recommended that ponds and other accumulations of stagnant water should be filled in. In 1888 the infant mortality rate was 96. Gratification was expressed at the low death rate of 11.4. The Medical Officer of Health regretted the Board's decision not to proceed with the erection of an isolation hospital, as he felt the district was being deprived of a real defence against the introduction and extension of infectious diseases. In that year a public enquiry by the Local Government Board resulted in a decision that the authority should provide a public mortuary. The conditions of private roads called for adverse comment. The state of slaughter houses left much to be desired and the Medical Officer of Health favoured the provision of a public abattoir. At this time the town was in general well supplied with water, but it was only partially sewered and what sewers there were varied considerably in age and quality. In 1889, the district with a population of 6,006, suffered from an epidemic of scarlet fever with 63 cases. " The disease was, for the most part, of mild description, 4 only two deaths being recorded due to it . . . "Considerable difficulties were met with in dealing with this outbreak owing to the fact that the district is at present without any provision for isolating patients suffering from such diseases or for efficiently disinfecting their clothing." The Infectious Diseases Notification Act was adopted in this district. For the year 1891, the Medical Officer of Health reported " The action of the Board in a recent case where I reported the existence of water closets without a water supply will, if continued, soon remove a virtual source of disease . . . ." "Many householders are careless as to the cleanliness and situation of their drinking water cisterns. All such cisterns should be covered so as to prevent contamination by birds, mice, etc." The Medical Officer of Health, reporting in 1892, returned to the subject of defective drains. "No amount of ventilation of the main sewers will prevent sewer gas being drawn into houses that communicate directly with the drains." These extracts from the reports for the later years of the last century of the Medical Officers of Health of Harrow-on-the-Hill are given as reminders that the activities of the Health Authorities up to the turn of the century were largely in relation to environmental hygiene. Even in a district which for many years, because of its favourable vital statistics, was claimed to be the healthiest in Middlesex, there was a great need up to the end of the century for improvements in the many aspects of environmental hygiene. The extracts show the attention being given during those years in this district, as of course would have been the case in other areas throughout the country, to such matters as the provision of a sufficient and safe water supply, the disposal of sewage, the improvement in drainage and in sewerage, improved highways, protection of food supplies, better housing, freedom from nuisances and various measures to prevent and limit the spread of infection. Although up to the middle of the century, the general sanitary state, particularly of towns of any size, was of a low standard, by the turn of the century matters had so improved that it could be claimed that by then environmental hygiene had been put on a firm basis, the benefits from which were to be seen in the improved general health of the community reflected in the better vital statistics and by the virtual disappearance of the more spectacular outbreaks of such epidemic diseases as cholera, small pox and typhoid fever. Local Authorities played their part in this improvement. Admittedly it would not be claimed that this vast improvement was the result only of their endeavours ; on the contrary, it will be accepted that the energies of the local authorities were but part of the surge which was reflected in such various ways as the activities of voluntary bodies concerned with such varied matters as the provision of housing, cleansing of the poor, etc. ; by the writings of such as Dickens, or the individual efforts of those like Elizabeth Fry and Florence Nightingale. To the extent, however, that the improvement in health was the result of the activities of local authorities, this was from the energies of the local sanitary authorities—to-day's county districts. For the greater part of the time there were, of course, no other authorities who could have been looked to to shoulder the burdens, as it was not until the 1888 Local Government Act that county councils and county borough councils were created. 5 With the turn of the century the health activities of local authorities were deflected to other channels which produced less spectacular results. The major blots had been removed and up and down the country the environmental state of the community was being markedly improved. The main interests in the health services then passed from the general impersonal environmental services to the personal services, namely, those provided for the benefit of individuals of a certain group or section of the community, or those suffering from some specific disease or disability. The first of these was the school medical service which was imposed on those bodies who on the abolition of the school boards were made education authorities. These were boroughs of 10,000 or urban districts of not less than 20,000 population—elsewhere in the county, the county council. The next was the maternity and child welfare service. The authorities made responsible to provide this were the larger of the county districts, including rural districts, but elsewhere in the county the county council. This, though, was almost the limit to which the provision of personal services was made the responsibility of county districts. Thereafter the duty of providing all the new personal services was laid on the county council (and for its area the county borough council) ; so that they were responsible in turn for the tuberculosis service, the schemes for the treatment and control of venereal disease, the care of the mentally afflicted and the mentally defective, the care of the blind and, in due course, on the abolition of the Boards of Guardians, under the Local Government Act, 1929, they were the authorities responsible for the provision of general medical and surgical hospital accommodation. Up to recently then, in a county district of any size, the local council was responsible for the environmental services, as an education authority for much of the school medical service, and as a welfare authority for the maternity and child welfare service, with, in some cases, the domiciliary midwifery service as well. The responsibility for providing the other personal services in the area of the county district rested on the county council. During the recent war, the local government system was put in the melting pot. The first indication of a pattern for the future was given in the Education Act, 1944. This resulted in the withdrawal of powers from the councils of those county districts which had been Part III Education Authorities, with the transference to the county councils, only the major authorities—the county councils and the county borough councils—in future being the education authorities. There was, however, provision for the exercise of delegated powers in regard to the day-to-day functions by the county council to the larger of the county districts as excepted districts. Included in the delegated functions was much of the school health service. The divisional executive, then—that is very largely the local council—is responsible for much of the school health service in the district. The National Health Service Act brings about a similar transfer of powers and responsibilities in connection with the maternity and child welfare service. This is to be lost to the county districts, passing into the hands of the county councils. The Act made provision for the use of the knowledge and experience of the councils of county districts in administering these services. It provided that certain of the services could actually have been delegated to some of the district 6 councils. The Middlesex County Council, however, acted not under this clause, but under another which authorised the Health Committee of the Local Health Authority, i.e., the Middlesex County Council, to authorise any sub-committee to exercise on their behalf any functions of the Health Committee. The county has been divided into ten areas, for each of which has been appointed an area committee, which as a subcommittee of the local health committee of the County Council will be responsible for the day-to-day administration of certain of the health services of the County Council in the area covered by the Area Committee. The Committee consists of local councillors, county councillors and co-opted members. In every part of the county except Harrow the Area Committee serves an area which will include two or more county districts. In the case of Harrow, however, the Area Committee is responsible for the services only of this area. The result of these changes, then, will be that of the health services provided by local government authorities in this district, the environmental services will be the responsibility of the Harrow Council acting through its Public Health Committee ; certain of the school health services will be provided by the local divisional executive (the Harrow Council plus some co-opted members), acting through its General Purposes and Finance Sub-Committee ; and some of the maternity, child welfare and midwifery services by the Local Area Committee (comprising local councillors, county councillors and co-opted members) acting as a sub-committee of the Health Committee of the County Council. Besides these, there will be the health services provided by the County Council themselves throughout the entire county. Over and above all these services will be the wide range of institutional service provided by the Minister of Health through the Regional Hospital Boards ; and the general medical services, the responsibility of the Executive Council. This is the position in Harrow which, as has been seen, is the only district in the county covered by an Area Committee. The position is still more confusing in other parts where for a time there may be in the area covered by an Area Committee two district councils providing the environmental services, two councils acting as divisional executives and providing some of the school health services, but only one Area Committee responsible for the maternity and child welfare and the midwifery services. Where the Area Committee covers more than two districts, the complications are even more marked. Order will in time, however, come out of this chaos. Firstly, the treatment part of the school health service is the responsibility of the Local Area Committee, leaving as a duty of the Divisional Executive not much more than the responsibility for arranging the medical and dental inspection of the school children. These functions must in time pass to the Area Committee, and the school health service become completely integrated with the other aspects of the general health service. Then with the passage of time the officers responsible for the personal services in each of the county areas will probably be those responsible for the administration of the environmental services in each of the county districts comprising the county areas. Even though legislation might be necessary to bring it about, the position can be visualised that all the health services in each of these areas will be provided by the one set of officers for each area under the one committee 7 for that area. It can be seen, then, that to-day's division of the county might be the basis of the creation of a smaller number of enlarged county districts. If this is so, then it must be regretted that the considerations which determined the division of the county were not those more closely related to the operation of the various health services. Although to-day's difficulties lower the standard of the local maternity and child welfare services, the Council can still be proud of the service it has provided. The standard has not been maintained without difficulty. Though buildings do not make a service, yet the necessity for having to continue to use premises not designed for the purpose in which to hold infant welfare centres and ante-natal clinics has added to the labours of the health visitors. Every effort has been made to provide clinic facilities within reasonable reach of all the residents of the district. The Council was able to put up a very strong case of providing its own maternity home. Their repeated efforts in the early days of the Council met with no more success than their recent application. The use of the Honeypot Lane Isolation Hospital as a residential nursery and as a home for mothers should ensure the building being put to best use, even though it now looks as though the Council, having provided and converted the building, is not to be responsible in any way for its future administration. The midwifery service, again at times maintained under great difficulty, has been most efficient and the letters of appreciation so often received must be a source of gratification to the staff. The County Council will be acquiring a staff of midwives, every one of whom is qualified to use the gas and air apparatus. As far as vital statistics are indicative of the efficiency of the services, they are satisfactory. The infant mortality rate of 24.0 is well below the national rate of 41.0. The maternal mortality rate at 1.0 is lower than that of the county as a whole, while the stillbirth rate at 0.42 per 1,000 population compares favourably with the national rate of 0.50. Full use has been made of the services. 1,166 confinements were attended by the Council's midwives last year. 63,000 visits were made by children to the infant welfare centres, while 3,135 mothers, or 80 per cent. of those confined made use of the Council's ante-natal services. The other vital statistics, too, were satisfactory. The death rate was only 8.5, and the district was only lightly attacked by most of the infections, though having its share of the nation-wide outbreak of poliomyelitis ; and having an outbreak of typhoid fever in a children's home. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Cottesmore, August 30th, 1948. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1947 215,930 Rateable Value (April 1st, 1948) £2,134,540 Sum represented by a penny rate (April 1st, 1948) £8,600 Total number of occupied houses 51,263 Total number of occupied flats 7,397 Extracts from Vital Statistics for the Year. Live Births :— Total Male Female Legitimate 3,695 1,874 1,821 Birth rate per 1,000 of the estimated resident population, 17.7 Illegitimate 133 61 72 Total 3,828 1,935 1,893 Stillbirths :— Legitimate 88 44 44 Rate per 1,000 total (live and still) births, Illegitimate 3 2 1 Total 91 46 45 2.4 Deaths 1,834 896 938 Death rate per 1,000 of the estimated resident population, 8.5 Deaths from puerperal causes:— Deaths Rate per 1,000 total (live and still) births Puerperal sepsis 1 0.25 Other puerperal causes 3 0.75 Total 4 1.00 Death rate of Infants under one year of age :— All infants per 1,000 live births 24.0 Legitimate infants per 1,000 legitimate live births 23.5 Illegitimate infants per 1,000 illegitimate live births 37.5 Deaths from Cancer (all ages) 333 „ „ Measles (all ages) 1 ,, ,, Whooping Cough (all ages) 4 „ „ Diarrhoea (under 2 years of age) 6 Population. The mid-year population of the district was 215,930 compared with the figure of 210,890 in the middle of 1946. The natural increase in population, that is the excess of births over deaths during the year, was 1,994. 9 Births. The number of live births was 3,828, a slight fall on the figure of the previous year, but very many more than the figure recorded for any earlier year. The birth rate per 1,000 population was 17.7 as contrasted with the figure of 20.5 for the country as a whole. Deaths. Of the 1,224 deaths which 'occurred in this district 109 were of persons not resident in the area. Thirty-five of these took place in the various hospitals, 19 in nursing homes and 6 in Oxhey Grove, a home for the elderly. Of the 719 deaths of local residents which occurred outside the district most took place in institutions, 242 being in Redhill Hospital, 23 in Redhill House and 88 including 4 new born infants at other county institutions. Many of these deaths were of the elderly who probably spent the last years of their lives in these institutions. Seven deaths occurred in institutions for the treatment of the tuberculous. Forty-nine deaths took place in hospitals just outside the district, including 9 in the isolation hospitals of other authorities. A hundred and fifty-one died at various of the London hospitals. This figure does not necessarily bear any relationship to the deficiency of local hospital beds, as from a district so near to London as this, many patients are referred for admission to special hospitals or to special departments of the general hospitals. Deducting from the 1,224 deaths which occurred in the area, the 109 which were of non-residents and adding the 719 inward transferred deaths, namely those of local residents which occurred outside the district, results in a total of 1,834 deaths, a figure slightly above the 1,816 of last year and the highest figure ever recorded for this district. This is a death rate per 1,000 population of 8.5. Before the war the rate was almost constant at 7.7. This low rate was largely due to the abnormal age constitution of the population, a factor common to developing districts and resulting from the undue proportion amongst the population of those of low risk of death. During the war years the figure rose to 9.1. This it was thought was due to the influx into the district of a number of the elderly. With the return of those from the services the rate fell in 1946 to 8.6. As most of what new houses are built are occupied by families already living in the district, there will be no repetition of the pre-war large influx of young families. The age constitution of the population then will tend to become more normal. It is improbable then that the death rate will ever fall to the pre-war figure. It will, after a period of ranging between 8.0 and 9.0, rise because of the general ageing of the population. Even when the time arrives that the age constitution of the population is much that of the country as a whole, the rate will probably remain something below the national rate which last year was 12.0. This will be because the district is healthier than the average for the country as a whole. The following is the Registrar-General's abridged list of the causes of the deaths of those in the district : 10  Male Female Male Female Typhoid fever 0 0 Heart disease 235 241 Cerebro-spinal fever 0 1 Other circ. diseases 36 44 Scarlet fever 0 0 Bronchitis 58 41 Whooping cough 1 3 Pneumonia 46 40 Diphtheria 0 0 Other resp. diseases 18 15 Resp. tuberculosis 40 29 Ulcer of stomach 12 3 Other tuberculosis 3 4 Diarrhoea under 2 years 0 6 Syphilitic diseases 8 10 Appendicitis 2 2 Influenza 4 4 Other digestive diseases 15 18 Measles 1 0 Nephritis 26 24 Acute poliomyelitis 1 1 Puerperal sepsis 0 1 Acute encephalitis 1 0 Other maternal causes 0 3 Cancer of mouth and oesophagus (M), and uterus (F) 12 12 Premature birth 15 3 Cong. malformations, etc. 22 22 Cancer of stomach 26 24 Suicide 13 6 Cancer of breast 0 45 Road traffic accidents 15 4 Cancer of other sites 109 105 Other violent causes 14 20 Diabetes 2 8 All other causes 76 75 Intra-cran. lesions 85 124 All causes 896 938 Fifty per cent. of the deaths of the males were amongst those over 65 years of age. The corresponding figure amongst the females was 66. Put another way round, this means that while only half of the males attained the age of 65, the proportion of females reaching this age was two-thirds. Fatalities from the infectious diseases again compared favourably with the figures for the country as a whole. This year there were no deaths from typhoid fever, scarlet fever or diphtheria. The death rate of 0.02 per 1,000 population from whooping cough was the same as the national rate. The rates of 0.05 for measles and 0.04 for influenza were about half the rates for the country as a whole. The rate for diarrhoea in those under two years of age of 1.5 per 1,000 live births compared favourably with the national rate of 5.8. 11 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA HOSPITALS. 1. For Infectious Cases. The same arrangements continued by which patients suffering from scarlet fever were admitted to the South Harrow Isolation Hospital, but those suffering from other infections who needed hospital treatment were admitted to the isolation hospitals of other authorities. There was no difficulty for the most of the year in arranging the admission of patients to these hospitals. Once more the accommodation at the South Harrow hospital was sufficient to enable all the scarlet fever patients requiring hospital treatment to be accepted there, so that it was not necessary to open the Stanmore Isolation Hospital for this purpose. The sanction of the Minister of Health has since the end of the year been received for the conversion of this hospital into a residential nursery. The South Harrow Hospital has been taken over by the Regional Hospital Board, but it will not continue to be used for the reception of infectious cases. Most of those from this area then needing to be admitted to an isolation hospital will be accepted at the Hendon Hospital. 2. Tuberculosis. There have been no marked changes in the arrangements made by the County Council for the institutional treatment of those suffering from pulmonary or from non-pulmonary tuberculosis. The responsibility for providing this accommodation for those in this area needing it after July 5th is that of the Regional Hospital Board. 3. General Hospitals. There have during the year been no changes in the general hospital accommodation for the district. NURSING HOMES. A number of new nursing homes have been registered during the year and there have been changes in the registration of many of those in being. The following is a summary of the various homes, their ownership and their accommodation at the end of the year :— Beds Type of Case Bermuda House, Mount Park, Harrow Mrs. A. M. Elphick Mr. A. E. Elphick 6 Maternity and chronic. Beverley Maternity Home, 170, Whitchurch Lane, Edgware Miss C. Dear 3 Maternity. 12  Beds Type of Case Bowden House, London Road, Harrowon-the-Hill Bowden House Nursing Home Association Ltd. 14 Mental or borderline. Brockenhurst Nursing Home, 84, Hindes Road, Harrow Mrs. T. M. Bell 6 Chronic. College Hill Nursing Home, 123, College Hill Road, Harrow Weald Mrs. F. M. Ellis 7 Maternity, medical or surgical Culverlands Nursing Home, Green Lane, Stanmore Dr. P. Vosper 11 Chronic. Grosvenor House Nursing Home, 100, High Street, Harrow-on-the-Hill Mrs. N. Chaplin 20 Medical or surgical. Heywood Nursing Home, London Road, Stanmore Mrs. M. Guyatt 11 Maternity and surgical. Hillside Nursing Home, 49, Harrow View, Harrow Mrs. M. Cusack 5 Senile and convalescent. Lincoln House Nursing Home, London Road, Harrow-onthe-Hill Mrs. N. Chaplin 10 Chronic. Maitlands Nursing Home, 54, Marsh Road, Pinner Mrs. H. Payne 9 Maternity. Oakdene Nursing Home, 11, Hindes Road, Harrow Mrs. A. Gee 10 Maternity and others. Roxborough Nursing Home, 25, Roxborough Avenue, Har- row Miss Calland Miss Burrows 13 Maternity and others. St. Anne's Nursing Home, 34, West End Avenue, Pinner Mrs. D. Hickman 4 Maternity. St. Vincent's Nursing Home, Headstone Lane, North Harrow Mrs. P. Thomas 10 Maternity and others. Suffolk House Nursing Home, Marsh Lane, Stanmore Miss M. C. Ping 8 Maternity and others. The Avenue Nursing Home, 28, The Avenue, Hatch End Mrs. A. Carter 4 Maternity and chronic. 13  Beds Type of Case The Firs Nursing Home, 13, Roxborough Park, Harrow Hillingdon Surgical Instrument Co. 22 Maternity. The Hall, Harrow Weald Dr. Lincoln Williams 10 Mental (borderline) In all, at the end of the year, there were 19 registered homes, with 183 beds, about half of these being for maternity and the other half for other patients. NURSING IN THE HOME. 1. General. No change occurred in the arrangements for nursing in the home. The staff of the Greater Harrow District Nursing Association working from two homes, Warnford, in Bessborough Road, and one in Uppingham Avenue, covered most of the district with a general nursing but not a midwifery service. The staff of the Pinner and Hatch End Nursing Association provided a maternity and a nursing service for Pinner, and a nursing service for Hatch End. The Edgware and Little Stanmore Nursing Association maintained a general-trained nurse in that area, and the Watling District Nursing Association operating from Hendon provided a midwifery and a nursing service for part of the eastern area of the district. Under the new arrangements the administration of the home nursing service for the district will be the responsibility of the Area Committee. 2. Midwifery and Maternity Nursing. The following are the names and addresses of the Council midwives engaged in July, 1948:— 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, Rayners Lane, Pinner. Nurse Ponter, 36, Corbins Lane, South Harrow. Nurse Rough, 213, Exeter Road, South Harrow. Nurse Walsh, 2, Goldsmith Close, South Harrow. Nurse Hinton, 4, The Lawns, Lower Road, Harrow. Nurse Angel, 9, Thistlecroft Gardens, Edgware. Nurse Shaw, 113, Locket Road, Wealdstone. Nurse Swann, 38, College Hill Road, Harrow Weald. Nurse Mooney, 39, Malvern Gardens, Kenton. Nurse Robertson, 83, Merlin Crescent, Edgware. Nurse Speaight, 470, Honeypot Lane, Stanmore. Nurse Francis, 68, St. Pauls Avenue, Kenton. The same arrangements continued by which the domiciliary midwifery service maintained by the Council was carried out by a staff of 14 16 midwives working in four groups of four. Because of the increasing work expected from the residents of the London County Council Headstone Estate it was hoped to be able to house an additional midwife on the Estate. In addition to the Council's midwives there were, at the end of the year, 13 midwives living in the area whose work was almost entirely restricted to domiciliary practice here ; while as well there were 7 midwives living out of the area but whose domiciliary practice extends into this district. The midwifery service is another of those which passes into the hands of the County Council on July 5th to be, in turn, administered by the Area Committee. CLINICS AND TREATMENT CENTRES. The following is a summary of the various clinics and treatment centres in, or serving the district, at the 31st December, 1947 :— Infant Welfare Centres. Elmwood Clinic, Elmwood Avenue, Kenton Monday and Wednesday p.m. Baptist Church Hall, Streatfield Road, Kenton Wednesday a.m. and p.m. Broadway Clinic, The Broadway, Wealdstone Wednesday a.m. and p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wednesday p.m. St. Hilda's Hall, Northolt Road, South Harrow Tuesday and Thursday p.m. The Clinic, Alexandra Avenue, South Harrow Monday and Friday p.m. Methodist Church Hall, Walton Avenue, South Harrow Thursday p.m. St. George's Hall, Pinner View, Harrow Tuesday and Friday p.m. Memorial Hall, High Road, Harrow Weald Thursday p.m. Clinic, Honeypot Lane, Stanmore Monday and Wednesday p.m. Methodist Church Hall, Love Lane, Pinner Friday p.m. St. Anselm's Hall, Hatch End Thursday p.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Thursday and Friday p.m. Home Guard Building, Station Road, North Harrow Monday a.m. Ante-Natal Clinics. Elmwood Clinic, Elmwood Avenue, Kenton Tuesday p.m. Baptist Church Hall, Streatfield Road, Kenton Thursday p.m. Broadway Clinic, The Broadway, Weald- stone Tuesday and Thursday a.m. and p.m. 15 76, Marlborough Hill, Wealdstone Monday p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wednesday a.m. St. Hilda's Hall, Northolt Road, South Harrow Tuesday a.m. The Clinic, Alexandra Avenue, South Harrow Wednesday p.m. Methodist Church Hall, Walton Avenue, South Harrow Thursday a.m. Home Guard Hut, Station Road, North Harrow Monday p.m. Memorial Hall, High Road, Harrow Weald Tuesday p.m. Clinic, Honeypot Lane, Stanmore Tuesday p.m. Methodist Church Hall, Love Lane, Pinner Monday p.m. St. Anselm's Hall, Hatch End Alternate Thursday p.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Friday a.m. A consultant ante-natal clinic on the mornings of the 2nd, 3rd and 4th Mondays at Elmwood Avenue clinic. Toddlers' Clinics. Elmwood Clinic, Elmwood Avenue, Kenton Alternating Streatfield Thursday a.m. Baptist Church Hall, Streatfield Road, Kenton Alternating Elmwood Thursday a.m. Spiritualist Church Hall, Vaughan Road, Harrow 1st in month Monday a.m. Clinic, Alexandra Avenue, South Harrow Wednesday a.m. St. George's Hall, Pinner View, Harrow 1st and 2nd Tuesday a.m. Clinic, Honeypot Lane, Stanmore Monday a.m. Methodist Church Hall, Love Lane, Pinner Monday p.m. The Pavilion, Chandos Recreation Ground, Edgware Thursday a.m. Birth Control. A birth control clinic on the mornings of the 1st and 3rd Fridays of the month at The Broadway clinic. 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. 16 Ophthalmic Clinics. 76, Marlborough Hill Tuesday and Friday a.m. The Clinic, Alexandra Avenue Thursday a.m. Dental Clinics. The Clinic, Elmwood Avenue, Kenton. 76, Marlborough Hill, Wealdstone. The Clinic, Alexandra Avenue, South Harrow. The Clinic, Roxeth Hill. Stanburn School. The sessions are held almost every week-day morning and afternoon. Physio-Therapeutic Treatment. Treatment sessions are held throughout the week at the Harrow Hospital Clinic, at 76, Marlborough Hill, the Medical Director attending at fixed sessions to see all new cases. The Orthopaedic Surgeon visits once a month. Tuberculosis Clinic. Most of the area is served by the Chest Clinic at 53, Greenhill Crescent, part of the district to the north and east being served by the Chest Clinic at Redhill County Hospital. Venereal Diseases. In addition to the hospitals at which treatment is available under the London and Homes Counties' Scheme, facilities are available at the following County Council 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 18 premises were licensed. In addition 3 were used by members of the Chartered Society of Physio-Therapy. During the year a further 4 were licensed, the number occupied at the end of the year being 21. Although the Council uses the powers of the Middlesex County Council Act in requiring the licensing of premises used for massage or special treatment, these are not as strong as is desirable. The first consideration on receipt of an application is whether the use of the premises would be an infringement of the Town Planning Scheme. The premises themselves are required to be suitable for the purpose, providing sufficient accommodation for the patients, and being kept in a satisfactory state. The equipment is inspected and note is taken of whether the byelaws in regard to exhibiting lists of charges, etc., are complied with. The unsatisfactory feature, though, is the limited powers of the Council to determine the qualifications or experience of the operators. Application had previously been made for the 17 duction of a byelaw which would have required those working in licensed premises to have attained a certain standard of training. Permission to make such a byelaw, however, was withheld. Those best qualified, namely, the members of the Charterd Society of Physio-Therapy, are excluded from the provisions of the sections, so presumably even if power is given to the making of a byelaw it will not be possible to insist on this standard of qualification. 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 comparison : 1947. 1946. Traffic accidents 306 297 Other accidents, including street illness 499 483 Maternity removals 429 463 Sick removals, to and from Hospitals 9,689 5,920 Total 10,923 7,163 The ambulance service under the provisions of the National Health Service Act passes to the County Council as Local Health Authority. It is proposed it shall be run in association with the Fire Service and its administration will not be delegated to the Area Committee. LABORATORY FACILITIES. The very satisfactory arrangements by which the public health laboratory work of this district is undertaken at the Central Laboratory, Colindale, continued to work smoothly. During the year 603 nose and throat swabs from this district were examined for K.L.B., hsemolytic streptococci, and the organisms of Vincent's angina ; 128 specimens of faeces for organisms of dysentery or food poisoning ; 32 specimens of sputum for the tubercle bacillus ; 5 specimens for the presence of the whooping-cough organism. In addition 39 samples of milk were examined. The service of the laboratory was of inestimable help in the investigation of the origin and the control of the outbreak of intestinal infection in a children's home in the autumn. 18 SANITARY CIRCUMSTANCES OF THE AREA WATER. Particulars of the water supply to the district and the arrangements made by the authority for the examination of samples to satisfy itself about the suitability and the safety were set out in the annual report for 1945. The laboratory findings of the samples submitted for detailed anaylsis gave uniformly satisfactory results. SEWERAGE AND SEWAGE DISPOSAL. There have been no changes in the arrangements set out in the annual report for 1945. PUBLIC CLEANSING. Refuse Collection. The introduction of the weekly instead of fortnightly collection of house refuse early in the year reduced the number of complaints about the service. The Public Health Committee, bearing in mind the nuisances arising from dumping of deposits on waste land, recommended that a more generous interpretation be put on the term " house refuse." The Highways and Cleansing Committee, however, found themselves unable to agree to take the course suggested. Fewer complaints were received about the state of the pig-bins. This was partly because of the introduction of the provision of a support for the bins, which reduced the likelihood of their being knocked over, with consequent scattering of the contents. The nuisances from pigbins, however, were very far from being eliminated, and it is hoped that the time is not too distant when the collection of waste food in this way can be abandoned. Refuse Disposal. The disposal of the house refuse by controlled tipping at Wealdstone and at Harrow Weald can continue for a limited period only, so arrangements are being made to prepare for the disposal by other means when these sites are no longer available for this purpose. Street Cleansing. The Public Health Committee were concerned at the state of a number of secondary access roads, some of these, running at the back of shops, being the only route open to the tenants of the flats over the shops. The Committee referred the matter to the Highways and Cleansing Committee, with the suggestion that such passages and secondary access roads should be taken over and maintained by the Council. The Highways Committee deferred consideration of the question until September, 1948. MORTUARY. During 1947, 322 bodies were received, post mortem examinations being carried out on 232, and inquests being held on 76. 90 bodies were admitted for storage. 37 bodies were sent into the mortuary from the Borough of Wembley. 19 SANITARY INSPECTION OF THE DISTRICT AND , THE INSPECTION AND SUPERVISION OF FOOD Statistical Summary PART I. Inspections Made and Conditions Found. HOUSING. Inspection of Houses. Visits. (i) On complaint of dampness or other housing defects 1,843 (ii) On complaint of other nuisances 754 (iii) Routine inspections 436 (iv) Revisits arising from defects found 6,581 (v) Inspections of Foster Parents' premises 14 (vi) Surveys under Section 157, Housing Act, 1936 405 Conditions Found. (i) Number of dwellings or other premises visited as a result of (i), (ii), (iii) and (v) where defects were found 1,402 (ii) Number of cases of overcrowding revealed 313 PUBLIC HEALTH. Inspection of Other Premises. (i) On complaint or request 96 (ii) Routine inspections of premises 208 (iii) Revisits arising from defects found 227 (iv) Surveys arising from Rat complaints 734 (v) Revisits (rats) 129 (vi) Inspection of Factories 104 (vii) Inspection of Workplaces 88 (viii) Inspection of Outworkers' Premises 99 (ix) Inspection of Cinemas and Places of Entertainment 42 (x) Inspection of Licenced Premises 87 (xi) Visits under Shops Acts 2,902 (xii) Evening observations under Shops Acts 36 (xiii) Sunday observations—Shops Acts 14 (xiv) Observations made for Smoke Nuisances 9 Conditions Found. (i) Premises visited as result of (i) and (ii), where defects or unsatisfactory conditions were found 84 (ii) Number of premises where action was taken by Council's Rodent Operatives to deal with rats—see (iv) above 734 (iii) Number of Factories, Workplaces and/or Outworkers' premises where defects or contraventions were found —see (vi), (vii) and (viii) above 14 20 (iv) Number of Cinemas and/or Licenced premises where defects were found—see (ix) and (x) page 19 26 (v) Contraventions of Shops Acts— (a) Failure to observe closing house 29 (b) Other contraventions (failure to exhibit notices, etc.) 563 FOOD HYGIENE. Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 33 (ii) Butchers' Shops 555 (iii) Cowsheds 31 (iv) Dairies 92 (v) Fish Shops 168 (vi) Fried Fish Shops 42 (vii) Bakehouses 97 (viii) Cafes and Restaurants 226 (ix) Ice Cream Premises 316 (x) Provision Merchants 523 (xi) Bakers and Confectioners 117 (xii) Other Food Premises 141 Conditions Found. See Section dealing with Food, Food Shops and Food Preparing Places. PART II. COMPLAINTS RECEIVED. Summary of Complaints Received. Accumulations of refuse 114 Animals causing a nuisance 65 Dampness 127 Drains and Sewers—Choked 269 Defective 160 Dustbins defective 270 Houses with defects 525 Plumbing defects 240 Flooding—gardens 16 Vermin 59 Insect infestations 69 Overcrowding, alleged 402 Shelters and Static tanks unsatisfactory 43 Smoke nuisances 9 Water Courses 3 Defective Water-closets 79 Other complaints (pig bins, wasps' nests, defective fences) 191 Food unfit (excluding requests received from shops to visit and inspect unfit food) 36 21 PART III. NOTICES SERVED. Under Housing Act, 1936. (i) Statutory notices served under Section 9 requiring execution of repair work 68 (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 2 (iii) Informal notices served with view to subsequent action under Section 9 187 Under Public Health Act, 1936. Statutory Notices under:— (i) S. 24—Notice requiring work to a public sewer 12 (ii) S. 39—Notice requiring repair or renewal of drains 22 (iii) S. 45—Notice requiring repair or renewal of defective water-closets 12 (iv) S. 56—Notice requiring work on undrained or badly drained yard area 7 (v) S. 75—Notice requiring renewal of a dustbin 99 (vi) S. 93—Notice requiring abatement of a nuisance 75 (vii) Informal Notices served (all sections) 1,965 ACTION TAKEN. Following Housing Act Notices. (i) S. 9—Dwellings rendered fit after service of Statutory Notices : (a) By Owners 55 (b) By Local Authority in default of Owners 1 (ii) S. 11—Demolition Orders made in respect of 3 ties referred to in Annual Report for 1946 — (iii) Dwellings rendered fit by Owners after receipt of Informal Notice (Section 9) 119 Following Public Health Act Notices. (i) S. 24—Public Sewers repaired 10 Note : Work to Public Sewer must be undertaken by the Local Authority or a Contractor instructed by them. (ii) S. 39—Drains repaired or renewed : (a) By Owners 13 (b) By Local Authority in default of Owners 9 (iii) S. 45—Water-closets repaired or renewed : (a) By Owners 12 (b) By Local Authority in default of Owners Nil (iv) S. 56—Yards repaired : (a) By Owners 7 (b) By Local Authority in default of Owners Nil 22 (v) S. 75—Dustbins provided : (a) By Owners 78 (b) By Local Authority in default of Owners 16 (vi) S. 93—Nuisances Abated 69 (vii) Nuisances abated and/or other work carried out by Owners on receipt of Informal Notice 1,783 SUMMARY PROCEEDINGS. On two occasions it was necessary to apply to the Courts for an Abatement Order. In one case, as the nuisance was abated before the date fixed for the hearing, it was not necessary to proceed; costs were, however, allowed. In the second case an Abatement Order was made and costs allowed. It was also necessary to attend Court in respect of eight notices served under Section 75 of the Public Health Act, 1936, requiring the provision of dustbins, appeals having been lodged by the owners on receipt of the notices. In two of these cases the tenants had signed agreements undertaking to provide dustbins ; in these the appeals were allowed. Of the six other cases, one was withdrawn after the tenant provided a bin ; the other five were dismissed, fines being imposed in three. Summary proceedings under Section 9 of the Food & Drugs Act followed complaints of glass and other foreign matter being found in milk. Of the five cases, one was dismissed ; of the others one, after a plea of guilty had been recorded, was dismissed under the probation of offenders Act. In the other three, fines were imposed. HOUSING. Repair of Houses. The figures in the summary show that it was possible to deal with a certain number of properties under the provisions of the Housing Act, 1936. Sixty-eight Section 9 notices were served. In two properties action was taken under Section 11. During the year demolition orders were made on the properties referred to in the report for 1946. Overcrowding. On the 1st January, 1947, 496 families were known to be occupying accommodation in the district where overcrowding based on the standard laid down by the Housing Act, 1936, existed. 313 new cases were added to the register during the year, and 232 cases of overcrowding were abated. Of these 100 were rehoused in Council Houses, and 22 in requisitioned property. The overcrowding in 108 was abated by other means. The number of families living in overcrowded conditions at the end of the year was 587. New Houses. 597 new dwelling houses were erected during the year, 138 by private enterprise, 214 by the Council and 245 by the London County Council. In addition 119 war-damaged premises were rebuilt. 23 PUBLIC HEALTH. Rats. It was not until the early part of the year that it was possible to start the treatment of the soil and surface water sewers of the district. The number of " takes " (i.e. bait removed by rats) showed, however, that the sewers are practically free of vermin and in consequence treatment over the entire area was not carried out. Test baiting to the satisfaction of the Rodent Division of the Ministry concerned was completed, and periodical baiting in various districts will be undertaken from time to time. The regular treatment of watercourses, refuse tips and sites known to be likely breeding areas was continued throughout the year, and 734 complaints of rats were investigated and dealt with. Most of these were from premises where poultry or ducks are kept, some from factories and business premises. No major infestation was found and the complaints received give no indication of any one part of the district being more especially affected. Factories Act, 1947. The local authority has a duty to see to the cleanliness, crowding, temperature, and ventilation and drainage of floors of certain factories. There are 114 of these in this district, to which 88 visits of inspection were made. There are 422 factories in which the local authority has to see that there are sufficient and suitable sanitary conveniences properly maintained. To these factories, 104 visits were paid. In 14 instances, defects were found. In six cases these were want of cleanliness of the premises. The other eight related to the sanitary conveniences, which were insufficient in one case, unsuitable and defective in six and not separate for the sexes in one. Written notices were served in 14 instances ; in 13 the unsatisfactory state had been remedied by the end of the year. Notice had been received of 124 outworkers in the district. 84 of these were engaged in the making of wearing apparel, 16 of artificial flowers. FOOD. Inspection and Supervision. During the year 2,341 visits were made to food shops, cafes and other establishments concerned with the preparation, retailing or distribution of food. Many of them were at the request of traders to inspect food considered by them to be unfit for human consumption. As a result large quantities were collected and disposed of by the Cleansing Department or the Salvage Division of the Ministry of Food. The procedure of disposal varies with the quantity and nature of the commodity involved, but whenever possible, such food is used for animal feeding. The inspections made of food shops and other establishments at which food is prepared or stored showed many to be in need of renovation. Difficulties in obtaining the necessary building licences have prevented many of these premises being satisfactorily dealt with. Applications submitted, even if supported by this department, and in spite of work being required to bring the premises to a standard necessary to comply with the Food & Drugs Act, have unfortunately been considerably delayed. The position now, however, is improving. 24 Milk. Production.—The number of farms in the district was reduced by one during the year, and the total is now nine. On the 31st December, 1947, two of these were producing. Tuberculin Tested milk, three Accredited and the remainder ungraded milk. The number of producers of Tuberculin Tested milk for the year 1947 is one less than the number in the year 1946, the result of changes in the tenancy of one of the farms. Distribution.—The number of premises licensed under the Milk (Special Designations) Regulations to pasteurise is two; and to bottle T.T. milk is two. The number of premises from which pasteurised milk may be sold is 42, 30 of which are controlled by United Dairies Limited or Express Dairy Company. The number of premises outside the Harrow district from which pasteurised milk may be retailed in Harrow is eight. The number of premises from which T.T. may be retailed is 17, of which 10 are controlled by the United Dairies Limited or the Express Dairy Company ; and the number of premises outside the Harrow district from which T.T. milk may be retailed in Harrow is six. In addition, there are three establishments from which raw milk is retailed, and three from which milk is sold in sealed containers. Sampling.—Fifty-three samples were taken during the year, 44 were satisfactory, but nine failed to reach the standard required. Subsequent samples taken from the dealers returning these unsatisfactory samples showed the cause of the trouble had been removed. From August to December not one adverse report was received. The standard of milk production in the district is high. One producer of Tuberculin Tested milk (Mr. S. K. Hedges, of Pinner Wood Farm) has not had an unsatisfactory sample report for over five years. Complaints.—During the year 24 complaints were received about milk delivered to householders in the district. Most of these were about dirty bottles or bottles containing foreign matter. Summary proceedings were instituted in five cases ; in four convictions were obtained. Most of the Dairy Companies take all steps possible to prevent bottles which are not in all respects satisfactory leaving their depots. If householders would only see that bottles are rinsed after use, complaints of dirty bottles would be much less common. Ice Cream. In the district there are one hundred and sixty-one premises registered for the manufacture, storage or retailing of ice cream. Manufacturing is carried on at eighteen ; sixteen are registered for the retailing of ice cream received from manufacturers in sealed containers ; and the remainder for the retailing of the commodity in wrapped packages. Three hundred and sixteen visits were made during the year to premises where ice cream is manufactured or retailed. Advice was given in many cases about improving both the premises and the methods used in the manufacture and handling of this commodity. 25 No serious difficulties were experienced in dealing with those trading in this commodity and occupying premises in the district; but this cannot be said of itinerant vendors. There are many difficulties in obtaining the proper control and ensuring a high standard of cleanliness of the itinerant vendor. SHOPS ACTS. During the year 2,902 visits were made to shops in the area by the Shops Acts Inspector. Most of the contraventions found were about notices required by the Acts to be exhibited. Thirty-six evening observations were made to see that the provisions of the Shops (Hours of Closing) Act, 1928, were being observed. As a result it was necessary to issue twenty-nine warnings about the failure of shopkeepers to observe the closing hours. Four contraventions of the Shops (Sunday Trading Restrictions) Act, 1936, were noted during the course of fourteen Sunday observations. In each case the attention of the persons concerned was drawn to the requirements of this Act. Following the inspections, cleansing and redecorating at two hundred and twenty-seven shops and cafes or rooms used in connection with the retailing and distribution of food were asked for. At eighty-six general repairs were necessary, whilst at forty-nine others action was taken to deal with inadequate heating or the absence of sufficient sanitary accommodation and rest rooms for members of the staff. On the 31st December, 1947, the number of shops on the register totalled 2,203, an increase of 78 over the 1946 figure. 26 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease. Und. 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over Total Scarlet Fever – 51 71 30 13 4 4 3 3 – – 179 Diphtheria — 8 5 2 3 3 5 2 1 — — 29 Pneumonia 4 15 10 3 7 — 5 12 11 8 11 86 Dysentery — 2 1 2 — — 1 — — — 1 7 Erysipelas — 2 — — 3 — 4 4 13 6 6 38 Cerebro-spinal Fever – 3 2 3 2 – – 2 – 1 – 13 Puerperal Pyrexia – – – – 1 4 8 4 – – – 17 Ophthalmia Neonatorum 3 – – – – – – – – – – 3 Poliomyelitis 2 11 17 5 5 6 8 2 1 — — 57 Measles 35 620 509 38 19 10 10 8 2 1 — 1252 Whooping Cough 53 245 206 7 1 — 5 2 1 — 1 521 Typhoid Fever 4 10 — 1 3 — 2 — 1 — — 21 Encephalitis Lethargica — — — 1 — — — — — — — 1 Disease. Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Scarlet Fever 179 92 13 — Diphtheria 29 — — — Pneumonia 86 — — — Dysentery 7 — 2 — Erysipelas 38 — 12 — Cerebro-spinal Fever 13 — 7 6 Puerperal Pyrexia . 17 — 13 1 Ophthalmia Neonatorum 3 — 2 Poliomyelitis 57 — 50 5 Measles 1,252 — 30 — Whooping Cough 521 — 15 — Typhoid Fever 21 — 21 — Encephalitis Lethargica 1 — — 1 27 The outstanding circumstances of 1947 in relation to infectious diseases were the invasion of the district of poliomyelitis—part of the outbreak throughout the country—and the outbreak of typhoid fever in a children's home. The incidence of scarlet fever was exceptionally light, while the number of cases of diphtheria, too, was very small. Cerebro-spinal fever and erysipelas had their usual incidence. Measles which had been increasing in the last months of 1946 was prevalent in the district in the spring term, invading other schools in the summer term so that it was not until September that no notifications were received in any one week. Whooping cough smouldered throughout the year, being commonest in the summer months. Mumps attacked some schools in the summer term and chickenpox in the autumn, but in not one of these infections was the incidence very high. A number of contacts of cases of smallpox and in the later months of the year of cholera—the result of the outbreak in Egypt—were kept under supervision. DIPHTHERIA. Incidence. Of the 30 cases notified as suffering from diphtheria in only six was the diagnosis confirmed, the condition from which most of the others were suffering being streptococcal tonsillitis. The corrected figure of 6 gives a rate of 0.03 per thousand population. The national rate was 0.13. The local rate for the years 1934-1946 ranged from 0.08 to 0.60. Those attacked had not been immunised against diphtheria. Place of Treatment. All cases notified were admitted to isolation hospitals, in all instances those of other authorities. Deaths. None of the cases proved fatal. Immunisation. Of the 2,807 children immunised against diphtheria during the year, 1,973 were treated at infant welfare centres, 49 at the nurseries and 787 by the general medical practitioners. It is estimated that at the end of the year 53.7 per cent. of children under five in the district were protected against diphtheria, and 63.6 per cent. of those of ages 5.15. These figures compare with 54.7 and 61.1 at the end of the previous year. 1,349 children were invited for Schick testing; 531 attended. Of these 2 were positive, a percentage of 0.4. Provision of Antitoxin. Diphtheria antitoxin is available at a number of points in the district for issue to general practitioners for those suffering or suspected to be suffering from diphtheria. Schools and Spread of Infection. In no case this year was there any suggestion that infection had been contracted in a school. 28 SCARLET FEVER. Incidence. Four of the 184 patients notified as suffering from scarlet fever were subsequently found to be suffering from some other condition—in most cases tonsillitis, and the nett figure of 180 is an incidence rate per thousand population of 0.83. The rate for the country as a whole was 1.37, the local rates for the years 1934-1946 ranged from 1.06 to 4.70. Throughout the first quarter of the year the average weekly notification rate was 5, in the second quarter 4, in the third 1.5, and in the fourth 4.0. Deaths. There were no deaths in the district from scarlet fever. Place of Treatment. 46 per cent. of the cases were treated at the home at the election of the parents. In a further 15 per cent. there seemed no reason the patient should not have remained at home. In 15 per cent, the reason for removal was the presence of other children in the house, in 11 per cent, that the patient was an adult, and in another 11 per cent, the infectious patient was an inmate of a hospital. Secondary Infection. Secondary infections occurred in eight households. In most only the single secondary patient was infected. In two households there were two patients in addition to the primary case. In four cases the primary patient had not been removed to hospital. Most of the secondary infections occurred in the month of December, about the same time as the occurrence of a relapse in two patients discharged together. In one instance the secondary case was the mother who was nursing the original patient at home. Return Cases. Return cases occurred in two households, both within a week of the return home of the primary case who in one instance presented no abnormal signs, but in the other had developed a sore nose. Schools and Infection. In only two instances this year was there any suggestion of infection having been contracted at school. In the one—an infants' department —over a period of three weeks in December six cases occurred, mostly in children in the one class. The other instance was of three children of the same class—an infants' department—falling ill in the same week. ENTERIC FEVER. Four cases of enteric fever were notified amongst the general population during the year. One patient proved to be suffering from rubella, another from sinusitis. One, an adult who was ill with typhoid fever the day she arrived at the address in this district, had only recently 29 arrived in this country from Egypt. The remaining case was an infant of fourteen months who in March was diagnosed as suffering from para B. infection. The following is an account of infection in a Children's Home in this district: On the 10th September a child of four at a children's nursery fell ill, being admitted on the 20th September to Redhill County Hospital suffering from bronchitis. The eruption suggesting a typhoid infection, laboratory investigations were carried out with the result that on the 24th September a typhoid organism was recovered from the stools, on which the child was transferred to the isolation hospital. The same evening two other children at the home who were ailing—one from gastro-intestinal symptoms—were removed to the isolation hospital. All further admissions to the home were prohibited and precautionary steps taken at the home. The home was a large house which had been opened in August, 1946, for the admission of up to 30 refugee children of ages of up to five years, many of whom had only recently come to this country. Unfortunately the necessary adaptation of the house such as the installation of lavatory pans, sluices, etc., to make it suitable for the number of children had not been carried out. The house was under the supervision of a trained nurse as matron, assisted largely by a staff of aliens possessing some nursing or teaching qualifications or experience. From the 24th September numbers of children ailing in some way, usually with a raised temperature, but sometimes with gastro-intestinal trouble, were removed to the isolation hospital; also two members of the staff. There was nothing specific about these ailments, and had they occurred in those living in ordinary households probably little enough notice would have been taken of them. Full laboratory investigations were made of the blood and excreta of these patients with negative results. It was not until the 4th October that a typhoid organism was found in one of the adult patients. This gave a lead to the investigations of the remainder of the children and of the staff at the nursery, examinations being made of the blood and of the stools. By the 9th October the laboratory reported positive results from two more of the children in hospital, the date of admission of the last positive case being the 2nd October. Further admissions to hospital had brought the total to 19 by the 17th October, being 15 children and 4 adults. There was then a lull until the last known case, a child admitted on the 27th October. All the typhoid organisms were found to be of the same phage type. A number of children admitted to hospital and also some of those, who because they showed no abnormal signs remained at the home, were found to have a Giardia infection. This might have been responsible for the symptoms in some of the cases. There remained, however, a number suffering from gastro-intestinal symptoms in whom no pathogenic organisms could be found. At the home then there were probably three separate infections : the limited number of typhoid cases probably all of whom were detected, the Giardia infection which was present, whether or not it was the cause of disturbances in any, and an undetected 30 organism responsible for much of the illness. From the history which could be obtained—not an easy matter and perhaps not too reliable in view of the very extensive changes which had taken place in the staffing of the nursery—it seems that the nursery had probably for a long time had a smouldering infection or infections as numbers of children had suffered over a period of months from minor alimentary and febrile disturbances. The source of the typhoid organisms is considered to be the mother of one of the children in the nursery. She was on the staff of a convalescent home outside the district. On investigation she was found to be excreting typhoid organisms of the same phage type as those found in the sufferers at the nursery. Her child was admitted to the nursery on the 19th August. She was alleged to have arrived in this country from Germany the previous day. The opportunity was there for spreading infection as she visited the nursery each week, bringing food which was consumed not only by her own child. She gave no history of recent illness, so it is improbable that she was herself infected at the nursery. The laboratory results of examinations of blood specimens were described as being compatible with temporary or chronic excretion of typhoid organisms. It is strange if she was the origin of the trouble that she neither infected her own child nor, it appears, anyone at the convalescent home at which she was working. Another member of the staff came under suspicion, more especially as she with her child came to the nursery on the 16th August, having only a short time before arrived in this country. Both she and her infant, however, were considered to be recent infections both because of the clinical signs of their illness and because of the altered titre of their blood serum. Complications in the investigation arose because of the difficulty in obtaining the organisms for purposes of identification. In some cases positive results of the examination of the stools were obtained only after a series of four or five negative findings. The same thing happened when the time came for the patients to be freed from isolation, a positive result coming up after a series of as many as six negative findings. The interval between the penultimate and the last case is of interest. The penultimate positive case was removed to hospital on the 2nd October. The last case found to be positive after admission to hospital was admitted on the 27th October. This long period suggested the possibility of there being some inanimate undiscovered infection still present in the home, a long period of incubation dating from infection by one of the patients previously removed to hospital or the presence of an intermittent carrier state amongst one or more of those at the nursery. No further cases occurred to give a clue to the reason. The home was closed, any children there who had not been admitted to hospital being allowed to proceed to other places on the many laboratory investigations failing to show that any of those at the nursery were excreters of the infectious organism. As far as possible those admitted to the hospital were discharged to their new homes without returning to the nursery. This was the first experience in this district of the facilities available by the staff of the Public Health Laboratory at Colindale, and it is a pleasure to acknowledge appreciation of the services so freely given. 31 DYSENTERY. Eight patients were notified during the year as suffering from dysentery. The first two were children from the same address who fell ill in January. In April the mother, father and three children of a family succumbed to a Sonne infection. The remaining case was an adult, a male of 69, who fell ill in June. FOOD POISONING. Only one patient was notified as suffering from food poisoning, an adult whose illness was apparently caused by food consumed out of the district. ERYSIPELAS. Forty notifications were received during the year, but in two the diagnosis was amended to cellulitis. Sixteen of those suffering were males. The face was affected in twenty-six patients, a leg in three. The one case in which the scalp was involved proved fatal. Eleven of the patients were admitted to an isolation hospital for treatment. CEREBRO-SPINAL FEVER. In two of the fifteen cases notified as cerebro-spinal fever the diagnosis was withdrawn. Four cases fell ill in January, one in February, then five in March. Two cases occurred in April and one in July. No case seemed to be associated with any of the others. Two cases proved fatal. All but one of the cases were treated in hospital, six in isolation and the others in general hospitals. ACUTE ANTERIOR POLIOMYELITIS. Two cases were notified as suffering from acute anterior poliomyelitis before the occurrence of those cases which were part of the generalised outbreak to which the country was subjected. In one of these, however, the diagnosis was later amended to septic arthritis of the hip. The other was a girl of five who in early April was considered to be suffering from a mild attack of the infection. The following is a report of the local incidence of the outbreak which affected the country: Poliomyelitis is a disease which only comparatively recently has developed an epidemic phase. Though sporadic cases are known to have occurred for many years the greater of the epidemics have occurred only in this century, more especially in America, Scandinavia and Australia. The first serious invasion of this country was in 1926. The incidence was again heavy in 1938. The fact that the country was likely to be subjected to a severe invasion this summer was suggested in the early months of the summer by the fact that the number of notifications even then was much larger than usual and that the rise had started that much earlier in the year than the time of the usual seasonal prevalence. Reaching nearly its peak figure of notifications in the week ending 16th August and remaining 32 at about that level for a month, the outbreak declined sharply to virtual extinction by the end of the year. This is the greatest invasion to which this country has been subjected. The question now is whether the general incidence will not be at a consistently higher level than it has been hitherto and whether the country will not from now on be subject to periodical invasion. The first case in the district which occurred in the period covered by the general attack of the country was a female of thirty who succumbed on the 30th June, dying a few days later. The next case was a child of five whose onset was the 10th July, and who suffered from a severe attack. Three more patients were notified in July, but in two of these the illness proved not to be poliomyelitis. A three weeks' interval of freedom was followed by seven cases with onsets between the 6th and 14th August. After a further interval of a week two cases were notified in the last week of August. In the same month another eight cases who were notified were found later not to be suffering from poliomyelitis. Ten confirmed cases occurred evenly distributed throughout September during which time another eight notifications were received of patients in whom the diagnosis was not confirmed. Quite a number of those diagnosed at this time as sufferers were abortive cases, in whom the diagnosis could be confirmed only as the result of laboratory findings. There was in many nothing clinically to differentiate them from those other cases who were later considered not to be affected. Of the eight cases notified in October four proved to be poliomyelitis. After an interval of freedom of three weeks the last two cases were notified in the second week of November. Over the period of nineteen weeks in all fifty-five notifications were received ; in twenty-five of these the diagnosis was not confirmed, leaving thirty actual cases. The first few patients were admitted to general hospitals, but when the disease became more prevalent virtually all cases were removed to isolation hospitals. No difficulty was experienced in arranging these admissions. The more severe cases were not discharged to their homes, but were transferred to an orthopaedic hospital. Towards the end of the outbreak difficulty was experienced in finding this accommodation with the result that there was delay in the transfer of some of the patients. The clinical type of illness varied from the one sufficiently severe to terminate fatally to those abortive cases which did not pass from the stage of the early acute illness and at no stage developed any paralysis. Males were more commonly affected than females, 18 to 12 cases. The age and sex group most affected was the male, 5 to 10 with seven cases. Though the disease is known as infantile paralysis, those of higher ages are so far from being exempt that the next most commonly affected group was that of males of 30 to 35 with five cases. In fact of the thirty cases fourteen were amongst those over 15 years of age. The commonest illnesses of those notified but not suffering from poliomyelitis were streptococcal tonsillitis 4 cases, pneumonia 4 cases and influenza 2 cases. There was no apparent connection between the cases which occurred in different parts of the district amongst those of different ages. At least two cases probably contracted the infection outside the district. 33 There was no suggestion of infection having been spread by any congregation of susceptibles. While precautions were taken to avoid any gross overcrowding of the swimming pools no schools, nurseries or swimming pools were closed because of the outbreak. ENCEPHALITIS LETHARGICA. A boy of twelve was in June notified as suffering from encephalitis lethargica. The illness proved fatal. MEASLES. The incidence of measles had been rising from October, 1946, to reach its peak in the early weeks of January, 1947, with an average weekly notification rate of just over 100. It maintained a high level up to the middle of March at an average of 70 cases, but fell markedly from then. For the next three months the weekly average was about 20. In July a further sharp decline occurred, but it was not until the middle of September that no notifications were received in any week. In all 1,252 cases were notified, a rate of 5.8 per thousand population. The rate for the country as a whole was 9.41 and for the administrative County of London 5.29. Although many schools were involved in the spring term the heaviest incidence occurred in Glebe Avenue Infants' School, the only school to be heavily attacked at this time. Again, although many were affected in the summer term the brunt was borne by Camrose and by Cannon Lane Infants' School. Thirty children were removed to the isolation hospital. One death was recorded as due to measles. WHOOPING COUGH. Whooping cough which prevailed to only a slight degree in the spring term became much more common in the summer term, though no school was very heavily affected. There was virtually none in the autumn. Altogether 521 cases were notified, being a rate per thousand population of 2.41 compared with that of 2.22 for the country as a whole, and 2.80 for the administrative County of London. Fifteen patients suffering from complications of whooping cough were admitted to the isolation hospital for treatment. There were four deaths this year from this complaint. NON-NOTIFIABLE INFECTIONS. Chickenpox. Intimations were received from the head teachers of the local schools of 789 cases of chickenpox amongst school children. Most of these were the result of a heavy invasion of Cannon Lane and Glebe Avenue schools, and to a less extent Greenhill and Stag Lane schools in the autumn term. Mumps. A few schools were lightly affected in the spring term, but most of the 332 intimations from the head teachers were from Cannon Lane and the Bridge schools in the summer term. 34 VERMIN INFESTATION. Scabies. There was a further marked falling off in the number of patients who attended for treatment, only 457 this year as compared with 801 in 1946, and 1,714 in 1945. Thirty-five were children under five, 152 children of school age, and 260 adults of whom 157 were women. The attendances varied most erratically throughout the year. From the 60 in January the numbers fell to 14 in April, to rise to 54 in July. Smaller attendances in the next two months were followed by a rise to 68 cases in November, but only 22 attended in December. TUBERCULOSIS. Notifications. New Cases Deaths Primary Notifications 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 – – – – – – – – – 2 1 1-4 6 3 1 3 — — 1 — 1 — — — 5-9 5 6 — – 1 1 — — — — — 1 10-14 3 1 — — 1 1 1 – — — — — 15-19 24 21 1 4 1 2 1 – 1 2 1 — 20-24 20 27 2 3 3 4 — 1 1 2 — 1 25-34 30 32 5 3 14 19 2 2 1 6 — 1 35-44 24 16 6 6 12 5 1 1 13 7 — — 45-54 19 7 1 1 2 4 — — 11 7 — — 55-64 14 1 1 1 2 — — — 7 3 — — 65 & up 9 1 — 1 — — — — 5 2 — — Total 155 115 17 22 36 36 6 4 40 29 3 4 There was a further rise in the number of pulmonary cases first learned of during the year, 342 against 308 in 1946, which figure was itself a rise on the 261 of 1945. Of this year's figures 18 were of persons in whom the disease was first diagnosed while they were in the Services. Of those of whom particulars are known 116 were notified in other districts before they came here, having already contracted the infection before transfer. This leaves 208 who presumably contracted the infection while living here. In 40 cases there was a family history of tuberculosis. The 49 notifications of non-pulmonary disease is a marked increase on the figure for the previous year. In 10 instances the onset of the disease preceded the transfer of the patient to the district. In only 3 of the cases that presumably contracted the infection while living here was there a family history of tuberculosis. 35 Register. Pulmonary Non-pulmonary Male Female Male e No. on register January 1st, 1947 652 563 97 101 No. of new cases added 155 125 17 22 No. of cases added—other than on Form A 36 34 6 4 No. of cases restored to register . 5 2 1 — No. of cases removed 82 83 12 9 No. on register December 31st, 1947 766 641 109 118 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 30 46 5 3 Died 41 31 5 3 Recovered 10 5 1 1 Diagnosis not confirmed or withdrawn... 1 1 2 2 Total 82 83 13 9 Deaths. During the year 69 persons (40 male and 29 female) died from pulmonary tuberculosis and 7 (3 male and 4 female) from non-pulmonary tuberculosis. This infection then accounted for 4.1 per cent. of the total deaths in this area, a proportion slightly less than last year, and appreciably lower than the proportion for the country as a whole. Diagnosis. The Middlesex County Council Mass X-Ray Unit had visited the district for the examination of those working in a local factory. Outside groups were not allowed to attend, so arrangements were made for the Unit to be established at Bridge Schools, Wealdstone, a site convenient to those working in a number of the smaller factories, and also for the general public. Two days were allocated to the factory groups. and three to the general public. In all 2,348 persons attended (934 men, and 1,414 women). 36 MATERNITY AND CHILD WELFARE REGISTRATION AND NOTIFICATION OF BIRTHS. The total number of live births registered during the year was 3,828, 1,935 male and 1,893 female. Of these 133 were illegitimate, being a percentage of total births of 3.4. 2,742 births occurred in the district (2,708 live and 34 stillbirths). Of this number 625 (617 live and 8 stillbirths) were to residents of other districts. Of the local confinements 2,678 were notified by midwives and 64 by doctors or parents. 1,613 (1,567 live and 46 stillbirths) notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in Middlesex County Council or in London hospitals. STILLBIRTHS. Ninety one (46 male and 45 female) stillbirths were registered, being a rate per 1,000 population of 0.42 compared with the figure of 0.50 for the country as a whole. INFANT MORTALITY. During the year 92 infants (52 male and 40 female) died under one year of age, this being an infant mortality rate of 24.3, compared with 41.0 of the country as a whole. The legitimate rate was 23.6 and the illegitimate rate 37.6. Fifty-six failed to survive one month. The neo-natal mortality rate was therefore 14.6, constituting 61 per cent. of the total infant mortality rate. Of these 56, 24 failed to survive the first 24 hours. The cause of death of 11 was prematurity, of one immaturity ; 5 suffered from congenital developmental abnormalities and 3 from want of attention at birth ; another 3 from atelecasis and 1 from birth injury. Deaths of infants who survived 24 hours but failed to live 7 days numbered 15, the fatalities being the result of prematurity or immaturity in 7, developmental abnormalities 4, and in birth injuries 2. Of the 17 who survived one week but succumbed before the end of one month, in 8 the cause was prematurity or immaturity, in 3 respiratory diseases, and 2 each birth injury or congenital or developmental abnormalities. Infections accounted for a much higher proportion of the deaths of those over one month, by which time prematurity, birth injury and congenital abnormality are less important factors in producing fatalities. Of the 11 deaths of those of 1 to 3 months of age at the time of death, 3 were due to respiratory and 2 to gastro-intestinal infections, and 3 to congenital defects. Twenty-five infants survived 3 months but died before they attained the age of 12 months. Twelve died from respiratory and 2 from gastro-intestinal complaints ; developmental abnormalities resulted in 2 deaths and accidents in another 2. MORTALITY AMONGST CHILDREN OF 1-5 YEARS OF AGE. Infections account for most of the deaths of the children in this period of life of lowest fatality though accidents are a growing factor. Five of the 9 deaths amongst those who had reached the age of one but not two years of age were due to these causes. Two children of two years of age died; there were 3 deaths in those of three years of age and another 3 amongst those of four years. 37 INFANT MORBIDITY. Ophthalmia Neonatorum. Three notifications of ophthalmia neonatorum were received amongst infants born in this district. Two of the patients were admitted to hospital for treatment. All recovered with vision unimpaired. Pemphigus. No notifications of pemphigus amongst the new born were received this year. MATERNAL MORTALITY. Four deaths occurred in which pregnancy or childbirth was the primary cause, one from sepsis and three from other causes. The maternal mortality rate was therefore 1.02 per 1,000 births compared with the rate of 1.17 for the country as a whole. The first fatality was the result of a pulmonary infarction in a patient who developed an infection after a normal delivery at home, death occurring nearly a month after the date of confinement. The second fatality occurred in a patient who had a full ante-natal supervision. Because of a small pelvis accommodation was reserved for her at a hospital to which she was admitted before labour because of a raised blood pressure. As progress in labour was slow delivery was carried out by Caesarian section. Her condition, however, deteriorated after operation and she died from eclampsia. The third fatality was only indirectly related to pregnancy. Haemorrhage from a six weeks' ectopic pregnancy was followed by peritonitis, probably related to a previous appendicitis. The last death was the result of pneumonia and nephritis following a natural abortion of a two months' pregnancy. The total maternal mortality rate for the country as a whole for the years 1911 to 1935 ranged from 3.79 to 4.60. The findings of the Departmental Committee on Maternal Mortality and Morbidity reported in 1930 and 1932 their findings on an analysis of some 5,000 cases. These were that 46 per cent. of the deaths showed some primary avoidable factor. In 15.3 per cent. this was absence or inadequacy of antenatal supervision ; in 19.1 an error of judgment in the management of the case ; lack of reasonable facilities in 3.7 ; and negligence on the part of patients or her friends 7.7. The rate for the country has fallen since and is now usually well under two per thousand births. Part of the decline is due to the reduction in the sepsis rate brought about by the success of the chemotherapy. Analysis of the local deaths each year shows that most of them are not preventable ; that they are of the nature of accidents. To-day in a district such as this very full advantage is taken of the ante-natal services available. Those delivered at home have the benefit of the help of skilled midwives who can summon practitioners, who in turn can summon consultants or the " flying squad " from Redhill hospital. Although many more would prefer to be admitted to hospital or other institutions for the confinement, it does not seem that those whose needs to be admitted rest primarily on medical grounds are not being 38 accepted, while those whose home conditions are totally unsuited for a confinement are usually accepted at hospital even though they might have to wait until they are in labour before this can be arranged. The co-operation of the patients with those providing these services is probably an important factor in the local maternal mortality rate being so consistently on the low side. PUERPERAL INFECTION. Of the 17 notifications received 5 were in respect of patients delivered in local maternity homes, one was of a patient delivered in a London hospital and the remainder of those delivered at home. Three cases followed an abortion. In only three instances was the raised temperature the result of an infection of the birth canal, the cause in others being such conditions as mastitis, phlebitis and pyelitis. Fourteen of the patients were removed to an isolation hospital for treatment, while for the other three home nursing was arranged. 39 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 areas of 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 4,450 Total visits 10,208 (b) To children between the ages of one and five years Total visits 11,211 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, 22 weekly infant welfare sessions were being held in 14 separate premises. 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 51,914 (2) By children between the ages of one and five years 11,148 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 3,186 (2) Between the ages of one and five years 439 Total number of children under 5 years of age who attended at the centres during the year and who, at the end of the year, were : (1) Under one year of age 2,990 (2) Over one year of age 6,094 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 five years of age referred for treatment during 1947 was 368. 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. The forms of physiotherapy available include exposure to rays of mercury Vapour 40 and carbon arc lamps, short-wave therapy, massage and active exercises. Class exercises are held for the correction of postural conditions. During the year 171 new cases were referred. The consultant orthopaedic surgeon saw 82 patients, and 259 were seen by the consultant physio-therapist. Orthopaedic patients requiring in-patient treatment are admitted to the Stanmore Orthopaedic Hospital or to the Harrow 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 retested periodically. 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 3 children were treated under this arrangement. Child Guidance Treatment: 11 children were referred during the year to the Child Guidance Clinic maintained at 2, St. Johns Road, Harrow, by the Middlesex Education Committee. Speech Therapy: 11 children were referred during the year to the Speech Therapy Centre maintained at 2, St. Johns Road, Harrow, by the Middlesex Education Committee. 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. 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 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 130 (Of these 55 had children ; 75 not) Number of persons registered during the year 14 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.) 26 41 Number of persons on the register who were receiving children for reward at the end of the year 118 (Of these 38 with children ; 80 without) Number of children on the register at the beginning of the year 78 Number of children received during the year 61 Number of children removed from the register during the year 90 Removed to care of parents 43 Removed to care of another foster mother 16 Removed to charitable organisation, etc. 6 Removed to hospital 19 At exempted premises 10 Child attained the age of nine years 3 Child died 1 Number of children on the register at the end of the year 49 One residential school receives children under nine years of age. In addition, there are two schools exempted. Under the new arrangements the supervision of foster children will be in the hands of the Children's Committee of the Health Authority, so will not be a function delegated to the Local Area Committee. In the same way the supervision of the adopted child will be dealt with by the Children's Committee. During the year 10 notices were received under Section 7 of the Adoption of Children's Act. At the end of the year 20 children were under supervision. SUPERVISION OF CHILDREN. Day Nurseries. The four day nurseries maintained by the Council as part of its child welfare service continued to be in demand throughout the year, most of the places in each section of each nursery being occupied even though the admissions of children were restricted to those of mothers engaged whole time on work classed as of being of national importance, and in general only one child from any family being accepted. Up to this year the Council had continued the Ministry's practice of making a uniform charge of one shilling per head per day. During the year it was decided instead to make the standard charge the cost to the authority, reducing this sum in accordance with the financial circumstances of the applicants. As it seemed that the application of the scale suggested would operate harshly on those of small families and especially on the mother who was the sole support of her family, the scale of recovery was amended so that the first 30s. of the mother's earnings were not brought into account. The standard charge was fixed at five shillings and a smaller percentage was to be recovered in each case. Coinciding with the bringing into operation of this new scale a number of mothers withdrew their children from the nurseries. In some cases it is probable that the higher charge made was the real cause for the withdrawal; in others it might well have been merely the D 42 precipitating cause, the mother already haying contemplated withdrawing the child on other grounds, such as her decision to give up work. All those on the waiting list were advised of the revised scale of payment. The result of the withdrawal of some children from the nursery and many of those on the waiting list was the virtual elimination of this waiting list. Although for some time in some sections of some nurseries there were vacancies not taken up, this reduced demand for admission enabled arrangements to be made for the first time since the nurseries had been opened for some children to be admitted on health grounds, that is in the interests of the family rather than in the interests of the country's productive effort. Residential Nursery. The Ministry of Health agreed to the Honeypot Lane Isolation hospital which had not had patients in it since early 1944 being converted into a residential nursery. The work is now in hand. The premises as part of the Council's maternity and child welfare service were on July 5th transferred to the County Council. It is probable that the nursery will be administered not by the health department of the County Council but by the newly created children's department with the result that its administration will not be delegated to the local area. 43 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 1,771 visits to expectant mothers, 1,382 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. An ante-natal clinic session conducted by midwives only and not by medical officers has been opened at one of the clinic buildings, staffed by those midwives working in that neighbourhood. It was felt that holding such a regular session would not be such a tie on each midwife as her having to be at home some specified time to see her patients ; while if for any reason such as the midwife being on a case she could not be present there would be some other midwife available who could see the patient. The advantages of the arrangement are sufficient to warrant an extension of the experiment, though to enable it to work satisfactorily there needs to be a clinic building near to and centrally situated for a group of midwives. The following is a summary of the work done at the clinics during the year: Total number of expectant mothers attending the clinics 3,135 Total number of attendances by expectant mothers at all clinics 15,001 Percentage of total number of births (live and still) represented by the number of mothers attending the clinics 80.0 44 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 14 ante-natally examined and 3 post-natally. Consultant Ante-natal Clinic. The Council's consultant obstetrician attends the clinic three weeks out of four. In 1947 the consultant paid 34 visits to the clinic, seeing 256 patients, who made altogether 331 attendances. 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 503, of whom 74 were supplied with dentures. The staff of the District Nursing Association treated 24 nursing mothers. 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 1,210, in 889 cases the attendant being present as a midwife, and in 321 as a maternity nurse. Of these 1,179 were attended by local midwives, whose practice is limited to domiciliary work (868 as midwives and 311 as maternity nurses) and 31 as midwives from adjoining areas (21 as midwives and 10 as maternity nurses). Number of Midwives: The number of midwives who during the year notified their intention to practise in the district, was 52. Of these, 20 removed, leaving in practice at the end of the year 32. Of the total number 22 were engaged in local maternity homes, most of these restricting their activities to these duties. Resident in the district were 23 who carried on a domiciliary practice, while 7, though resident in adjoining areas, attended cases in this district. At the end of the year there were in practice 13 independent midwives carrying on a domiciliary service, these between them attending 44 cases during the year, 30 as midwives and 14 as maternity nurses. 45 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 337 Stillbirth 7 Death of infant 13 Death of mother — Laying out the dead 2 Artificial feeding 15 Liable to be a source of infection 5 Of the 337 summonses to medical practitioners, 26 were on account of some condition during pregnancy, 88 during labour, 185 in the lying-in period, and 38 some abnormality of the infant. Of the 26 summonses to a patient during pregnancy, 9 were because of albuminuria, oedema, or toxaemia, and 14 because of haemorrhage. Of the 88 summonses to a patient during labour, the reason in 61 instances was delayed labour, with cause unspecified. In a further 11 there was some abnormal presentation. Summonses to patients suffering from abortion (actual or threatened) numbered 6. Of the 185 summonses to patients in the puerperium, 140 were on account of rupture of the perineum. Post partum haemorrhage, with or without adherence of the placenta, was the reason in 14, a raised temperature in 8, phlebitis 5, and inflamed breast 4. Of the 38 summonses to infants, 6 were on account of some discharge from the eye, 17 because of feebleness or asphyxia, 4 because of deformity, and 11 some other abnormal state or condition. Out of 889 midwifery cases attended, 337 is a percentage rate of 35. The corresponding figures in the years 1942 to 1946 were, 33.1, 32.3, 32.8, 38.0 and 34.0. 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 1,166, being a percentage of 29-7 of the total number of confinements of local mothers. To 861 they attended as midwives, and to 305 as maternity nurses. Of the patients attended by midwives acting as such, 503 were assessed to pay the full cost, in 44 cases no charge was made, while 314 were assisted. The corresponding figures in regard to patients attended by midwives as maternity nurses were 247, 0, and 58. The Council had agreed that pupils who had received their part I training in London should come to this district for their part II domiciliary training. For most of the year three pupils were here each for three months. The demand on accommodation at maternity institutions was so great that many including Redhill County hospital were obliged to discharge well before the end of the usual period of 14 days patients who had been delivered in hospital. On being approached the Council 46 had agreed as far as was practicable to undertake the nursing of these discharged patients. The general situation eased so that the services of the Council's midwives were not required in many cases. By the end of the year all but one of the Council's midwives had obtained their certificates of competence to administer gas and air and algesia. In spite of the availability of this service and despite, too, the fact that it would be provided without any additional cost there was no real increase during the year in the number of requests. 326 patients availed themselves; in 290 the administration was a pronounced success ; in 28 only a partial success, while in 8 instances it was a failure. Home Helps: The arrangements for the provision of home helps in maternity cases continued as on previous lines, the standard charge for the 14 day's attendance being £7 7s. Od. Increased use has been made of the engagement for any particular mother of a help selected by her who does not come on the panel of helps. Altogether 117 cases were attended by helps under the Council's arrangements. During the financial year 122 cases were attended by 22 helps. Of these 3 attended only one confinement, 4 two, 1 attended at three, 3 at four, 4 at five, 6 at six, two at seven. One attended 12, another 14, and one attended 20. The domestic help service which was authorised in 1944 by regulations under which helps could be provided in households where the need arose primarily because of illness, was extended during the year following the taking up of her duties early in the year of the full time organiser of the service. The following is a copy of the report presented to the Committee on the first year's working of the service after the appointment of the organiser: The Ministry's approval was first given for the engagement of domestic helps in households where assistance was needed because the housewife herself was ill, where she was suddenly taken away with no one to look after the children, and where several members of the family were ill at the same time. Few home helps offered their services when the scheme was first started, nor did many more when the remuneration was raised. In November, 1946, the Council appointed Mrs. Clarke as organiser of the service. She took up her duties early last year. Apart from the failure to obtain sufficient helps the chief difficulty all the way through has been balancing supply and demand. If a woman was persuaded to act as a home help it was necessary to be able to offer her employment straight away, otherwise her help would be lost. On the other hand the demand is quite spasmodic. Apart from what might be expected as a seasonal incidence, heavy in the winter months and light in the summer, irregular fluctuations in demand occur. It was felt that the greatest help that could be given by limited numbers of helpers was part-time service in a number of houses on one to six days of the week to a large number of householders rather than something nearer whole-time service at a small number of houses. For this reason, too, assistance was limited to short periods, up to four or so weeks. 47 The household whose need arose from acute illness was the one helped rather than that requiring help because of some long term and even lifelong condition. To those households where the need is likely to be of indefinite but long duration the help would be given only for a short time to enable other arrangements to be made. Not only is this practice one by which more households are enabled to receive some assistance in their difficulties, but it tends to prevent the service becoming one closely allied to a domestic service agency to which application is made for domestic assistance on grounds unrelated to the illness of any member of the family. In regard to publicity, it was felt unwise to invite applications from all who came across families in difficulties until there was some assurance of help being available. Of the first few helps offering their services a number came from one locality, so those in this area were first informed, approach being made to the general medical practitioners, district nurses and hospital almoners. A gradual development on these lines meant that ultimately it was possible to advise those who might come across these difficult cases throughout the entire district that there was now a domestic help scheme in the area. It was soon found that the uncertainty of employment made some of those helps who had offered their services unwilling to remain. The possibility of whole-time or part-time engagement was debated and the Committee authorised the engagement of helps on a guaranteed 20-hour week, it being thought that the availability of the greater number in the mornings would be more welcome than the smaller number of wholetime workers. It turned out though that these conditions were not sufficiently attractive to provide a nucleus. Apart from the rate of pay which is less than women can earn in other ways criticisms were raised about loss of time in travelling, no provision of overalls, etc. By the summer months, too, the volume of work was falling, so there was the greater risk of losing what helps were available. It was felt then that it was necessary to provide at least a firm nucleus of helpers, the additional help being obtained by the engagement of part-time casual helpers. To retain those of this whole-time nucleus they were given a guaranteed minimum of remuneration. Time in travelling was counted for payment and they were provided with overalls. This nucleus enabled the service to continue through the summer months when the demand fell off. It may well be helpful to engage some on the 20-hour week, though the raising of the hourly rate of remuneration of those on less than 30 hours from 1s. 9d. to 2s. an hour may increase the numbers of those willing to help on a casual basis. It is felt that the service can be extended by increasing the number of those engaged whole-time if that part of their time not taken up in households of the more acute cases could be made available in houses where the need is long standing, such as where there are the elderly, the chronic arthritics, the blind, etc., who would so welcome this assistance. Even were the numbers of whole-time helps increased it is felt the services of the casually employed will always be needed to meet times of exacerbation of demand. These casual cases can be retained only if they are fairly regularly offered some work. 48 From February to April, 1947, 81 cases were helped with 14 helps, May to July 62 cases with 14 helps, August to October 36 cases with 10 helps and November to the 17th January 47 cases with 10 helps. Out of the 36 helps recruited 13 were actually working or are prepared to work. Of these 34 engaged 2 were discharged because of unreliability. The others left because they considered 1s. 9d. an hour insufficient, because of the loss of time in travelling, and because there was no guaranteed regular work. Consultant Service: A consultant was summoned on 16 occasions; in 12 the help of the Redhill Unit being sought, in four a consultant on the Council's panel. One patient was suffering from a miscarriage; two from puerperal pyrexia; while in one case the help was sought because of the condition of the infant. In all other cases the patient was suffering either from obstetric shock or from haemorrhage due to retention of the placenta. In most cases blood transfusion was carried out in the home and only rarely was it necessary for the patient subsequently to be admitted to hospital. The facilities by which blood transfusions can be carried out in the home by the Redhill Unit are a great advantage, as the alternative in many cases could only be the removal of the patient to hospital for treatment and patients suffering from such conditions do not stand removal well. Institutional Confinements. 1,424 births occurred in registered nursing homes in this district. On the 617 births to mothers from outside districts which occurred in this area, 606 took place in maternity homes, 11 in private houses. Notifications were received of 1,567 births to Harrow mothers, which took place outside the district. Of these 1,341 were from hospitals and 226 from maternity homes. Of the patients confined in hospitals outside the district, 702 were delivered at Redhill County Hospital, and 321 at Bushey Maternity Hospital. Of a total of 3,730 births, 1,355 occured in the patients' own homes, 818 in local nursing homes, and 1,567 in hospitals or homes outside the district. Some 2,385 or 64 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 339 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 15 occasions. 49 Puerperal Infection. (a) Consultant Services: On only two occasions 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, 14 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. Three patients notified as suffering from puerperal pyrexia were nursed by the staff of the Association under these arrangements. In addition, there were further cases of nursing mothers whose nursing the staff of the Association undertook on behalf of the Council. 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 177 new patients attended, and altogether 547 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. 50 SCHOOL HEALTH SERVICES Medical Inspection. Of the children attending the maintained schools 6,678 were examined as routines (3,297 as entrants, 2,277 on leaving the primary schools and 1,104 on leaving secondary schools), 3,503 at other age groups, 2,974 as specials and 1,954 at re-examinations. Treatment. The same arrangements were continued for dealing with those suffering from conditions for which the authority provides treatment arrangements. Minor Ailment Clinics: 2,971 children were seen at the various clinics for the first time; 1,924 made more than one attendance. The attendances at Broadway are the greatest. 236 children were seen here in October as against 227 at Alexandra Avenue, 61 at Honeypot Lane, 59 at Elmwood, 41 at Chandos and 26 at Pinner. Ophthalmic Treatment: The same arrangements were made for seeing those suffering from conditions needing the attention of the ophthalmic surgeon. Of the 1,196 children seen by the ophthalmic surgeon 547 were provided with glasses. Physio-Therapy: The same arrangements were continued under which children needing treatment were referred to the Harrow hospital clinic at 76, Marlborough Hill. Here they can receive class or individual treatment such as massage, radiation, etc. Those needing the opinion of the orthopaedic surgeon were seen by the consultant who attends monthly. Those requiring operative treatment were referred mostly under the care of the orthopaedic surgeon at the Stanmore Orthopaedic hospital. Altogether 155 school children were treated at the clinic. Dental Services: There was no change during the year in the arrangements for dental treatment. With the growing number of school children and the increasing number receiving treatment under the maternity and child welfare arrangements, the staff of dental officers is proving more than ever inadequate to cover the ground. The interval between the school dental inspections is becoming longer with the result that the mouths of those examined are found to be in that much the worse condition, necessitating more time of the dental officer for the treatment of each child. It is, too, most desirable that there should be a superintendent dental officer for the area. Expansion of the service, even that necessary to restore it to its former standard of efficiency, is held up not by any difficulty in obtaining staff, but by the failure to obtain the accommodation in which the staff to be appointed can work. 14,078 children were examined in the periodic age groups, a further 1,444 as specials. Of the 10,171 found to require treatment, 7,290 were treated under the Authority's arrangements, these children putting in 14,113 attendances. 148 half-days were devoted to inspection, 1,902 to treatment. Fillings totalled 12,067 and extractions 9,505. 51 In addition there is the work done by the dental officer of Northwood, who attends to some 3,000 children from certain schools in the district, and by the dental officer at Wembley, who attends to the 1,000 children at the Stag Lane School. An orthodontic surgeon now works at Roxeth Hill clinic, devoting practically all his time to this clinic though seeing other children from areas other than Harrow. The following is a report for the period May to December, 1947, by Mr. Frank Jones, the orthodontic surgeon in which he analyses the conditions which lead to those states for which the children attend his clinic and gives his views of the position of the orthodontist in the school dental service. "At Roxeth Hill Clinic 330 children were inspected. For nearly all these children study casts were prepared and radiographic examination carried out, the latter work having been done at Redhill and Hillingdon Hospitals. The number of cases actually treated with appliances was 213, whilst a number of children will have appliances ready to be fitted at the beginning of the new term. Some cases not considered to require immediate appliance treatment were referred for observation and will be reviewed at intervals varying from three to six months. A number of appliance cases and others were referred to dental officers for necessary orthodontic extractions. Excluding repairs, a total of 243 appliances were fitted." Attendances: During the seven months 1,820 attendances were made at the clinic for inspection or treatment. About 256 appointments were unkept, approximately 12 per cent. This figure includes illness, special school arrangements, attendance at the wrong session or on the wrong day and new patients who had been found to have left the school or the district. One or two complaints have been received from children and parents that the teacher will not give an attendance mark unless the child attends school for even a short time on the session in question, in spite of previously being notified that the child was to attend the clinic. This misunderstanding, however, does not appear to be a general one. Cases Referred for Orthodontic Treatment: The number of children, in each age group, who were referred to the clinic for orthodontic inspection is as follows:—Age 5, nil; age 6, 3; age 7, 8 (deciduous dentition stage); age 8, 35; age 9, 49; age 10, 70; age 11, 90 (mixed dentition stage); age 12, 42; age 13, 22; age 14, 7; age 15, 2; age 16, 2 (permanent dentition). Total, 330. It will be seen from the above table that less than eleven children in the true deciduous stage were referred. The majority of cases, about 80 per cent., were referred in the mixed dentition stage (half those aged 7 and 12 being placed in this group). The largest number referred were in the 11 age group. This may be accounted for by the fact that it is the average age when the permanent canine tooth makes it very obvious that there is a lack of space for its eruption into normal alignment. Much can be done in the way of simple "functional" appliances during the deciduous dentition stage, and it is a pity that more cases 52 are not detected and referred during this period of development. Further, from the time when deciduous molars have lost a considerable portion of their roots, due to normal absorption, to the time when the premolars have well erupted, treatment by general expansion, so often needed, is very limited. The routine school dental inspection of about 100 children (with parents) per session, often carried out in poor light, is, I feel, too great a number to permit adequate examination for dental caries, gingival conditions and malocclusion together with its predisposing causes. It may be argued that about 60 per cent, of those inspected will be seen again by the dental officer at treatment visits to the clinic, but this still leaves about 40 per cent, who will not be seen again for another year. Malocclusion: I would venture to state that all types of malocclusion are produced by one or more of the following causes:— 1. Dental caries. 2. Untimely loss of permanent deciduous teeth. 3. Habits. 4. Obstructions. 5. Imperfect nutrition. 6. Genetic factors. 7. Endocrine disfunction or over function. 1. Dental caries: Through loss of tooth substance, deciduous teeth become more closely packed and cause loss of space for their permanent successors. 2. Untimely loss of deciduous and permanent teeth: Premature loss of deciduous teeth causes severe loss of space, especially when it can be least afforded, for the permanent successors. Overretention of deciduous teeth may result in deflection of the permanent successors and/or an upset in the articulation. Premature loss of permanent teeth may slightly or seriously affect the articulation, depending upon which teeth are lost. 3. Habits: Habits which can result in malocclusion are too numerous to detail in this report, but I have met three interesting ones which are worthy of note. (a) Tongue thrusting. This by no means unusual habit, though not always caused by thumb sucking, often follows that habit. The thumb or finger which is sucked may result in an anterior open bite, into which space the tongue finds ready access. It is often said, and it is quite true, that the malposition of the anterior teeth, due to thumb sucking, is easy to rectify, but this is not so if the tongue has found the gap. In such cases we have a child who has developed an abnormal swallow, as far as the tongue is concerned, and probably a decided lisp. (b) Occupational habit. Recently a girl aged 12 presented a slewed mandible, over to the right side, and no cause could at first be found. Later the mother thought of the violin which the child had played for the last four years. Fortunately quite good articulation can be obtained in the normal central position. (c) Position of comfort. At the Potters Bar Clinic, a child aged 5 presented a prenormal occlusion. On enquiry it was found that when aged about 2½ years a plaster collar was fitted on the child's neck to 53 rest a tubercular gland. The mother stated that the child used to thrust the lower jaw forward in an effort to relieve irritation from this collar. 4. Obstructions: These include swellings in the pharynx, naso-pharynx, posterior and anterior nares and in the buccal cavity, e.g., large tongue or fraenum. Although it is felt in some quarters that adenoids are not responsible for malocclusion, I cannot help but take the opposite view. In most cases adenoids cause mouth breathing which in turn produces an open mouth habit. That bone will develop more readily towards areas of least resistance had, I think, been proved beyond doubt. In open mouth cases the pressure exerted laterally by the cheeks on the developing maxilla, with the lack of pressure anteriorly, cannot help but produce a long and narrow palatal aspect of this bone. Open bite may also be produced by this same set of circumstances. 5. Imperfect Nutrition: Probably due to psychological causes, many children have food fads. Unfortunately many seem to dislike good proteins such as meat, fish or cheese. In these days of restricted diet it is extremely important that a growing organism should receive all the first grade proteins and fats available. Regarding bones and teeth, parents often seem to be much more worried about the child's intake of calcium, which I understand is present in sufficient quantities in any reasonable diet. 6. Genetic Factors: Seeing the children with their parents proves beyond doubt that the potential size of the jaws and teeth and their shape is strongly governed by genetic factors. 7. Endocrine disfunction or over-function: Detection of these cases is not easy; the diagnosis and prognosis of malocclusions associated with these conditions is difficult. Where a case is suspected, the advice of an endocrinologist should be sought. The above classification is set out primarily to show what an insignificant role is played by the specialist orthodontist in detecting and preventing malocclusion. 1 and 2 are entirely the responsibility of the dental officer ; 3 the dental officer, medical officer and health visitor, not forgetting the parent and the child, without whose co-operation all efforts are useless ; 4 and 5 should be taken care of by the advice of the medical and dental officers ; 7 is the domain of the endocrinologist, whilst 6 no one can direct. A specialist orthodontist has to take cases selected by another officer who has not necessarily received any special training in orthodontics. A dental surgeon who devotes his time entirely to the treatment of children is surely a specialist officer. A dental surgeon who treats mostly adult patients carries out prosthetic work. In my opinion the dental surgeon who specialises in children's dentistry should practise crthodontics to a certain degree as part of his general dental work, having received some post-graduate instruction in the subject. He should have at hand the advice of an experienced orthodontic specialist when possible to whom cases requiring more complicated appliances could be referred. Preventative orthodontics and treatment with "functional" appliances, e.g., the oral screen and the Andresen appliance, together with removable expansion appliances and those with simple springs and 54 incline planes should be part of the routine work of the children's dental specialist. Such an arrangement would mean more dental officers and smaller areas, but, on the other hand less specialist orthodontists and less malocclusion. The dental officer would see his work in a better perspective. In time there is a very real danger that a children's specialist in dentistry will be nothing more or less than a tooth carpenter, feeling as much monotony in his work as does an orthodontist who has other interests in dental surgery apart from his own speciality. Further the system of orthodontics by the specialist orthodontist only, will lead to preferential treatment of children in urban areas whilst those in rural areas get none." Apart from being able to refer cases to the orthodontist, the local dental officers can also refer suitable cases to the specialist dental officer in the Sudbury Clinic. Ear, Nose and Throat Defects. Most children suffering from defects of the ear, nose or throat are referred to the Ear, Nose and Throat Department of Redhill County Hospital, though some find it more convenient to attend at the Harrow Hospital. The long waiting list which is a feature at all hospitals was aggravated by the poliomyelitis outbreak in the summer during which time few throat operations were performed. 27 children received operative treatment for enlarged tonsils and for adenoids, and 4 for other nose and throat conditions. 16 received other forms of treatment. Child Guidance. The Child Guidance Clinic was, because of the temporary shortage of staff, run under greater difficulties than ever. At present the average time from a child being referred to his being seen is some six weeks, but before being accepted for treatment 6½ months. 81 children were treated at the clinic. Speech Therapy. The following information has been supplied by Miss Barbara Fisher, the speech therapist, on the work of the Harrow Speech Clinic for the year 1947. No. of cases seen in the year 125 No. of cases on register at December 1st, 1947 46 No. of cases discharged through the year 61 Speech normal 29 Speech improved 12 Discharged for lack of co-operation 20 Cases referred elsewhere 10 No. not accepted for treatment 8 No. on waiting list 5 Most of the cases dealt with at the Clinic are children attending the maintained schools, though a small number were referred by Medical Officers of the Infant Welfare Clinics. 55 Following-up. The same arrangements were in force for the follow up of children though shortage of staff prevented this being done thoroughly, either by the Health Visitors at the home or by the Medical Officers at the school. Cleansing. The heads of children attending primary schools and the secondary modern schools were systematically examined by the Health Assistants working under the direction of the Health Visitors. Of the 59,196 children examined 1,215 were found to have infested heads, a percentage of 2. On further examination the heads of most were found clean. A small number of children were treated at the Broadway or the Alexandra Avenue minor ailment clinic. Handicapped Pupils. The following are the particulars of the handicapped pupils in the districts at the end of the year: In Special schools In maintained primary and secondary schools In Independent schools Not at school Total A. Blind 2 — — 2 4 B. Partially Sighted 3 - — — 3 C. Deaf 7 2 — 3 12 D. Partially Deaf — 1 — — 1 E. Delicate 13 54 3 — 70 F. Diabetic 1 2 — — 3 G. Educationally Sub-normal 8 42 2 10 62 H. Epileptic — 2 — 3 5 I. Maladjusted 8 61 1 1 71 J. Physically Handicapped 17 20 2 8 47 K. Suffering from Speech Defect — 45 — 5 50 L. Suffering from Multiple Disabilities — — — 6 6