439 (1) HARROW HARRIS Urban District of Harrow Annual Report of the MEDICAL OFFICER OF HEALTH for the year 1948 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 1948 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW 3 ANNUAL 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 1948. The administration of the personal services has now passed into the hands of the major authorities as local health authorities. Those services then remaining to be administered by the Harrow Council as the health or sanitary authority are largely those of the environmental or impersonal character. This report, however, is not restricted to particulars of these, but an attempt has been made to include information of the many various other activities which are included in the health services of a district. The National Health Service Act which came into force on July 5th, 1948, brought about changes in the administration of the local health services in three main ways. The biggest change followed on the transference of the maternity and child welfare powers of the Harrow Council to the Middlesex County Council. Most of these powers were returned to be locally administered by the arrangement of the County Council by which ten Area Committees, being sub-committees of the Health Committee of the County Council, were set up. All of the Area Committees except for this district which deals only with Harrow's services cover more than one district. By the result of the Children Act, some of the powers previously administered by the Harrow Council as maternity and child welfare authority have passed not to the health department of the County Council, but to the Children's Department, an entirely new organisation. This department will deal with the deprived child, with the foster child, and with the adopted child, and is the department which will be responsible for the administration of the residential nursery provided in the building that was the Honeypot Lane Isolation Hospital. The second big change is the result of the transference to the Minister of the hospitals. Included in these was the South Harrow Isolation Hospital, previously maintained by the Harrow Council, but now forming part of the general hospital service administered by the North-West Metropolitan Regional Hospital Board. The third change is the result of the intention to merge the treatment portion of the authorities' services with the provisions of the National Health Service. At present this is resulting in 4 certain sections of the population not having at their disposal as efficient a service as they had before. Unless some change is to be made, the future of the domiciliary midwifery service can only be viewed with some apprehension. At the time of writing, though, the Act has not been in force for 12 months. Once more it is possible to report that the general standard of the healthiness for the district was high. While the year proved to be a favourable one for the country as a whole, the vital statistics of this area are in general even more favourable than the national rates. One effect of the operation of the National Health Service Act was the transference to other authorities of large numbers of the staff. At the Isolation Hospital, and in the office, were members who had been engaged by the predecessors of the Harrow Council before amalgamation in 1934. Some of those engaged on the maternity and child welfare services were amongst the earliest of the staff appointed by the Harrow Council. Some of the midwives who have now transferred to the County Council had been in private practice in the district many years before they came over to the staff of the Harrow Council as the result of the passing of the Midwives Act, 1936. Fortunately, although these members of the staff have transferred from the Harrow Council to other authorities, most of them are still available to continue their services for the district that they have served so long. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, " Cottesmore," Uxbridge Road, Stanmore. June 25th, 1949. 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1948 218,700 Rateable Value (April 1st, 1948) £2,187,095 Sum represented by a penny rate (April 1st, 1948) £8,775 Total number of occupied houses 52,069 Total number of occupied flats 7,601 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Legitimate 3,108 1,571 1,537 Birth rate per 1,000 of Illegitimate 118 52 66 the estimated resi- Total ... 3,226 1,623 1,603 dent population, 14-7 Stillbirths :— Legitimate 66 40 26 Rate per 1,000 total Illegitimate 3 3 - (live and still) births, Total 69 43 26 2 1 Deaths 1,837 922 915 Death rate per 1,000 of the estimated resident population, 8-4 Rate per 1,000 Deaths from puerperal causes :— total (live and Deaths still) births Puerperal sepsis 0 0 Other puerperal causes 2 0.6 Total 2 0.6 Death rate of Infants under one year of age :— All infants per 1,000 live births 288 Legitimate infants per 1,000 legitimate live births 25.7 Illegitimate infants per 1,000 illegitimate live births 110.0 Deaths from Cancer (all ages) 359 „ ,, Measles (all ages) 1 „ „ Whooping Cough (all ages) 4 „ „ Diarrhoea (under 2 years of age) 9 Population. The mid-year population of the district was 218,700, an increase of 2,770 on the mid-year population for 1947. The estimated population at the end of the year was 219,900. The natural increase in population, i.e., the excess of births over deaths during the year, was 1,409. Part of the rest of the increase would be the result of influx of population into the new houses, particularly the 318 put up by the London County Council; the occupants of the 365 new Council houses would be persons already living in the district. 6 Births. The total number of live births registered during the year was 3,226 (1,623 male and 1,603 female). Of these, 118 were illegitimate, being a percentage of total births of 3.7. The number of live births registered in each of the years from 1944 onwards was 3,473, 3,068, 3,934 and 3,828. 1,882 births occurred in the district (1,861 live and 21 still births). Of this number, 390 (387 live and 3 still births) were to residents of other districts. 1,645 (1,610 live and 35 still) birth notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in Middlesex County Council or in London Hospitals. The birth rate for each of the years from 1914 was 18.7, 16.0, 18.0, 17.7 and 14.7 in 1948. These higher local rates were in accord with what has occurred throughout the country as a whole, when for the first time since 1923 the number of births in 1946 was sufficient to raise the reproduction rate above unity. This rate during the nineteenth century had been well above the standard necessary to maintain the population, being for the years from 1880 to 1890 some 50 per cent, above this. By 1922, however, the rate had fallen below the standard, and it was not until 1946 that it rose above it, being in this year 11 per cent. above, and in 1947 20 per cent, above. 69 (43 male and 26 female) stillbirths were registered, being a rate per 1,000 population of 0 32 compared with a figure of 0.42 for the country as a whole. Deaths. Of the 1,837 deaths which occurred in the district, 107 were of persons who were not residents of this area. Twenty-four of these took place in the various hospitals, 43 in nursing homes and 2 in Oxhey Grove, a home for the elderly. Of the 710 deaths of local residents which occurred outside the district, most took place in institutions, 254 being in Redhill County (later the Edgware General) Hospital, and 78 at other county institutions. Five deaths occurred in institutions for the treatment of the tuberculous, and 4, all of new-born infants, at maternity institutions. Fifty-six deaths took place in hospitals just outside the district, including 9 deaths in near-by isolation hospitals, and 157 in the various London hospitals. The following is the Registrar-General's abridged list of causes of death in this district :—- Male Female Typhoid fever 0 1 Cerebro-spinal fever 0 0 Scarlet fever 0 0 Whooping cough 2 2 Diphtheria 0 0 Resp. tuberculosis 43 33 Other tuberculosis 8 7 Syphilitic diseases 6 4 Male Female Heart disease 254 243 Other circ. diseases 38 53 Bronchitis 59 23 Pneumonia 44 35 Other resp. diseases 12 6 Ulcer of stomach 16 5 Diarrhoea under 2 years 6 3 Appendicitis 4 2 7 Male Female Influenza 1 3 Measles 0 1 Acute poliomyelitis 2 1 Acute encephalitis 0 1 Cancer of mouth and oesophagus (M), and uterus (F) 11 20 Cancer of stomach 28 25 Cancer of breast 0 40 Cancer of other sites 119 116 Diabetes 0 5 Intra-cran. lesions 71 130 Male Female Other digestive diseases 27 15 Nephritis 25 22 Puerperal sepsis 0 0 Other maternal causes 0 2 Premature birth 5 9 Cong. malformations, etc 32 26 Suicide 6 9 Road traffic accidents 9 1 Other violent causes 16 19 All other causes 78 62 All causes 922 915 The number of deaths, 1,837, is a slight increase on the figure of 1,834 for each of the two previous years, though because of the slightly larger population the death rate was no higher, being 8.4 per 1,000 population compared with figures of 9.3, 9 0, 8.6 and 8.5 for the years since 1944, and with a figure of 10.8 for the country as a whole. Infant Mortality. The infant mortality rate is the death rate per 1,000 births of infants under one year of age. It has been accepted as a delicate index not merely of the adequacy or efficiency of those services dealing particularly with the welfare of the child, but of the social or sanitary state of the community. The causes of the deaths in the early days of life are so very different from those which cause the deaths of those even up to the age of 12 months, that those occurring before the infants have attained the age of one month are separately classified as neo-natal deaths, and the number expressed as a rate per 1,000 births is the neo-natal mortality rate. The main causes of death at this time of life are congenital malformations, prematurity, birth injuries, asphyxia and infection. Prevention of the deaths due to causes such as birth injury or asphyxia is very largely an obstetrical problem. Losses due to prematurity are difficult to control as only in half of the cases does there seem to be any cause for the onset of early labour, though there is the possibility that improvement in the general condition of health of the mother might result in a reduction. A number of those born prematurely must almost inevitably die because the infant is functionally incapable of a separate existence. Many of the remainder, however, can be saved by the special attention now being given to such infants. The effects of birth injury and such factors as bring about the deaths in the early days steadily decline as the child survives, and infections appear as the main cause of death, being responsible for most of the losses for the remainder of the year. The dramatic fall in the infant mortality rate which has taken place in this country during this century has been brought about chiefly by a reduction in the deaths of those between the ages of one and 12 months. The death rates amongst those of these ages were high in places where the housing was poor, where premises were overcrowded, where sanitation was defective, and particularly if these factors were associated with maternal ignorance and neglect. 8 The following table sets out the local infant mortality rates and the neo.natal mortality rates, and also the infant mortality rates for the country as a whole : National Infant Mortality Rate Local Neo.natal Mortality Rate Local 1939 50.6 38.5 20.8 1940 56.8 50.0 31.1 1941 60.0 55.6 28.0 1942 50.6 31.5 20.2 1943 49.1 38.0 22.0 1944 48.7 34.8 22.7 1945 46.0 32.2 25.3 1946 43.0 31.0 25.6 1947 41.0 24.0 14.6 1948 34.0 28.8 16.1 The local rates which, for every year, were lower than the national rates can be seen to follow the same general curve, showing the steady improvement in the rates, though with interruptions in the fall in the years 1940 and 1941. In 1948, 93 (80 legitimate and 13 illegitimate) infants died before they attained their first birthday, this being an infant mortality rate of 28.8 compared with the national rate of 34. Fifty.two of the infants failed to survive one month. The neo.natal mortality rate, therefore, was 16.1, being a percentage of the total rate of 55. The following table shows how the factors prominent in causing death in the early part of the first year become of less importance in the later months, at which time the infections are responsible for most of the deaths:— Under 1 day 1.7 days 1 wk. to 1 mth 2.3 mths 4.6 mths 6.9 mths 10.12 mths Congenital defect 4 7 3 7 3 2 —. Atelectasis 3 3 2 1 — — . Birth injury 1 1 . . . . . Prematurity or immaturity 14 10 _ 2 _ — Bronchitis or pneumonia 1 3 2 3 2 1 Whooping cough . . . 1 . 1 1 Gastro.enteritis — — . 2 3 — — Other infections _ — — 2 2 — — Non.infectious diseases . . . 1 2 2 . Total 22 22 8 18 13 7 2 9 Stillbirths. Apart from the loss of lives of young children, there is the further loss of those who die before being born. In a number of these, the foetus was alive up to the time of labour and a reduction in this loss is largely dependent on an improved obstetrical practice, particularly where the loss occurs at term. It would appear that the death of a foetus at some time before term might be due to factors which are determined by the mother's health or her nutritional state. The national food policy during the war years might have been responsible for the reduction in the stillbirth rate for this period. In this district 69 still births were registered, being a rate of 1,000 population of 0-32, compared with the figure of 0-42 for the country as a whole. Deaths of Children of 1 to 5 Years of Age. 18 children survived their first but did not reach their fifth birthday. Of these, 12 died in their second year, one in the third, another in the fourth and four in their fifth year. Infections of various types accounted for more than half of the deaths in the second year, including one from measles and two from tuberculosis. Maternal Mortality. The total maternal mortality rate includes all deaths of women primarily due to or associated with pregnancy or childbirth, expressed as a rate per 1,000 live and still births registered in the year. The rate for the country as a whole for the years 1911 to 1935 was about four. Since 1935 the rate has fallen and is now round about two. The average number of lives lost in Harrow as the result of pregnancy and childbirth for the years 1934 to 1939 was 12. From 1939 to 1945, the average was five, despite the average number of births for this period being higher. In 1948 there were two deaths only, this number giving a maternal mortality rate of 0-6, compared with the figure of 1-0 for the country as a whole. The first death was the result of toxaemia, which developed at about the thirty-second week of pregnancy. The other death was the result of a haemorrhage from a ruptured ectopic pregnancy occurring during the fourth month of pregnancy. Deaths from Accidents. There were 39 (25 male and 14 female) deaths from accidents during the year. Of these 13 were amongst the elderly (3 male and 10 female), many of them the result of a fall or a trip which resulted in a fractured leg, death following then from hypostatic pneumonia. Nine of the deaths, eight of them being amongst males, were the result of road accidents of various kinds. Four men died from poisoning, two being from coal gas. Two deaths were the result of drowning, one of a boy of 16, the other of a woman of 82. None of the fatal accidents occurred amongst small children, the youngest person who died being a boy of 15. According to figures published by the Royal Society for the Prevention of Accidents, 6,000 fatal accidents occur every year in homes in England and Wales. This amounts to almost one-third of the total fatal accidents in this country from all causes including industrial, transport, mines, etc. Not only has there been no diminution in the total number of fatal domestic accidents in the last 10 years, but there has been an actual increase in fatalities amongst young children under five years of age, and 10 amongst those over 65. Falls account for 60 per cent. of the fatalities (for 80 per cent. of those amongst the elderly) while burns and scalds account for 15 per cent. affecting mostly the small children and to a less extent, the elderly. Of children under five, more are killed in the home than are killed on the roads, and more, too, than die from any single infectious disease. Much has been done to reduce the losses from these two causes. Special attention needs to be devoted to reducing fatal domestic accidents. Deaths from Suicide. Six men and nine women committed suicide, four of the men and all but one of the women choosing poisoning by coal gas. One of the men and the other woman took poison, and the remaining man died by hanging. The incidence was even throughout the year, there being one event in most months, but in each of three months, two. Deaths from Cancer. Cancer and other malignant diseases are responsible for about 15 per cent. of the deaths ; of fatalities amongst those dying between the ages of 60 and 70, one-fifth are due to cancer. Out of 1,837 local deaths, 359 (158 male and 201 female) were due to cancer or other malignant disease, a percentage of 19. Diseases of the respiratory organs were commonest amongst males (bronchus 27, and lung 15), the next most frequent site being the stomach (31). Primary growths in the large intestine and in the rectum each accounted for 17 deaths. Amongst females, the commonest site was the breast (42) ; the lesions of the other reproductive organs accounted for 34 deaths, the uterus being the primary site in 20 and the ovary in 14. The large intestine (31 cases) was the second commonestly affected site, accounting for many more deaths among females than among males, whereas lesions of the other parts of the intestinal tract (stomach 19 and rectum 14) were less common, as were also the lesions of the respiratory tract (lungs six and bronchus eight). Eight deaths of males were the result of malignant disease of the prostate ; these are independent of the many deaths which occur amongst elderly males as the result of non-malignant enlargement of this gland. The following table shows how cancer of the respiratory organs affects those at ages younger than those at which sufferers succumb to lesions of other sites. Under 40 40-50 50-60 60-70 Over 70 Stomach M. 2 3 8 7 12 F. — 1 2 4 12 Other intestinal sites M. 1 - 2 9 22 F. 1 4 7 12 21 Lungs and bronchi M. 2 7 12 18 3 F. 1 2 4 2 6 Breast _ 3 7 9 14 9 Uterus -_ _- 4 4 3 9 Ovary -_ _ _ 5 7 2 Other sites M. 2 4 6 14 25 F. 1 4 4 9 17 11 In general, the ages of death of those who succumb to sarcoma are lower than those dying from cancer. Nevertheless, although cancer is typically a disease occurring more in the elderly, the young do not escape entirely. The youngest to die from cancer of the stomach was a man of 32 ; of a lesion of the large intestine a man of 30 ; of the lungs a man of 31 ; while a woman of 32 died from cancer of the breast. Deaths from Infectious Diseases. The number of local deaths from the various infections compared favourably with the rates of the country as a whole, the rates per 1,000 population for whooping cough of under 0.01, for tuberculosis 0.41, and influenza under 0.02, all being lower than the corresponding national rates of 0.02, 0.51 and 0.03. The death rate from enteritis and diarrhoea in those under two years of age at 2.8 per 1,000 total births was lower than the rate of 3.3 for England and Wales. 12 HEALTH SERVICES OF THE AREA HOSPITALS. General Hospital Service. Apart from the teaching hospitals, those hospitals taken over by the Minister have been grouped into 14 regions. For each region a Hospital Board has been appointed. That of the hospitals in or serving those living in Harrow is the North-West Metropolitan Regional Hospital Board (Secretary, A. J. Bennett, M.A., Senior Administrative Medical Officer, H. M. C. Macaulay, M.D., 11a, Portland Place, London, W.l, Tel. No". Museum 9575). The Hospital Board administers the hospital service through Hospital Management Committees. The area covered by the Hospital Board has been divided into 22. The hospital in each of these is under the management of a Hospital Management Committee. That of most interest to those in this district is the No. 11, or Hendon Group Hospital Management Committee ; its headquarters are at Edgware Hospital (Secretary, J. Fielding, F.H.A., Tel. No. Edgware 8181). The hospitals in this group comprise :— Edgware Hospital Edgware 644 beds 60 cots King Edward VII Hospital Hendon, N.W.4 65 beds Hendon Isolation Hospital Goldsmith Avenue N.W.9 110 beds Colindale Hospital The Hyde, Hendon, N.W.4 205 beds Middlesex Maternity Home Heathbourne Road, Bushey Heath, Hertfordshire 50 beds 30 cots Stanmore Cottage Hospital Stanmore 9 beds 1 cot Harrow Isolation Hospital South Harrow 50 beds Oxhey Grove Oxhey Lane, Hatch End... 42 beds In addition the Committee administers the Harrow Chest Clinic, 53, Greenhill Crescent, Harrow, and the Edgware Chest Clinic at the Edgware General Hospital. Included in Group 16, the Harefield and Northwood Group (Headquarters, Mount Vernon Hospital, Northwood. Secretary, F. A. Watson, F.H.A. Tel. No. Northwood 2665) are the Northwood, Pinner and District Hospital (36 beds) ; Mount Vernon Hospital and Radium Institute (427 beds) ; and the Grimsdyke Rehabilitation Unit, Harrow Weald (50 beds). The Harrow Hospital (Secretary, S. Garbutt, F.H.A. Tel. No. Byron 2232) and the Wembley Hospital are not administered by the North-West Regional Hospital Board, but are associated with the Charing Cross Hospital. The Isolation Hospital up to July, 1948, administered by the Harrow Council, passed into the hands of the Minister, to be administered by the North-West Metropolitan Regional Hospital Board, becoming the Roxbourne Hospital. 13 The hospital service is running under great difficulties. The following information obtained from a report of the medical director of Edgware General Hospital, the hospital which deals with most of the patients from this area, for last year touches on the difficulties experienced at the hospital. " During 1948, 10,579 in-patients were treated in the hospital, but nevertheless, at the end of the year there were 860 cases awaiting admission. Although the bed complement is 704, four wards containing 62 beds and children's cots were closed throughout the year, primarily owing to shortage of nurses. This resulted in a 25 per cent. reduction in the number of general surgical beds, and a 66 per cent. in the case of ear, nose and throat accommodation. The medical side is much handicapped by the blocking of acute beds by chronic cases. During the year, chronic cases and cases of advanced pulmonary tuberculosis ranged daily from 110 to 125, and blocked a daily average of not less than 20 per cent. of the occupied complement. These beds not being available for acute cases prevented the admission of at least 2,000 cases, necessitating waiting lists and the refusal to admit acute cases. The waiting periods are as long as six months for surgical cases and 30 months for varicose veins. Nevertheless, the number of patients treated during the year showed an increase of 826, the improvement resulting from an increased use of available beds and a reduction in the average length of stay from 20-3 to 19-4 days. The average daily percentage of occupied beds was 87. Waiting periods are four to five weeks at the skin and gynaecological clinics, but are shorter periods at the other clinics, except the newly instituted deaf aid clinic where the delay is four months." To arrange for the admission of a patient a general practitioner first approaches the nearest hospital direct. If he is unable to obtain admission for his patient there, the emergency bed service is requested to arrange for the patient's admission to any hospital in which suitable accommodation is available. Isolation Hospital Accommodation. These hospitals were established up and down the country towards the latter part of the 19th century, the object being the provision of accommodation for the reception of infectious patients and so by removing the infective focus, limit the spread of infection. They were therefore provided by the local sanitary authorities, the bodies concerned with the health of the district. Because so many who succumbed to the infectious diseases are infectious, and in some cases most infectious, in the very early stages of the disease, the damage is often done before the disease has been recognised. The subsequent removal of the patient to hospital then does not limit the spread. The provision of these hospitals then failed in their purpose. Nevertheless the hospitals continued to be used and new ones were provided, while at the same time the list of diseases from which sufferers were admitted to the hospitals was extended. This followed on a reorientation of the purpose of the infectious hospital away from the idea of it being an institution for the incarceration of infectious persons and towards the conception of a hospital for the reception of a patient who was suffering from some condition which necessitated skilled medical or nursing attention, but because 14 the patient was himself infective or possibly was a contact of another who was infectious and therefore might be a spreader of infection could not be admitted to the general ward of a general hospital. Many general hospitals have provided isolation accommodation very often in the same block as other wards. Such accommodation could be used only for the reception of infectious cases of low infectivity. It is very necessary that those attending the patients should have a sound knowledge of aseptic and antiseptic technique. To a growing extent, then, those suffering from any infective condition have been admitted to isolation hospitals, and to a correspondingly less degree to the general hospitals. The isolation hospital of to-day, then, is staffed and equipped much as a general hospital, because it might have to admit for treatment those suffering from conditions which need these resources. In some countries the tendency has been to deal with infectious cases not in a separate institution, but in an isolation block of a general hospital. This development is gradually gaining favour in this country, and it might be that any new large hospital to be erected will contain the necessary proportion of isolation accommodation. Under the National Health Service Act, virtually all hospitals were transferred to the Minister, their administration to be in the hands of the Regional Hospital Boards. Amongst the hospitals transferred are the isolation hospitals provided and maintained by the local sanitary authorities. Of the two institutions in this district for the reception of those suffering from infectious diseases, the Minister had already agreed to the conversion of the Honeypot Lane Isolation Hospital into a residential nursery. As such, then, it has passed into the hands not of the Regional Hospital Board, but of the County Council to be administered by their Children's Department. The other, the South Harrow Isolation Hospital, was transferred to the Regional Hospital Board. It had for years been apparent that the fall in the prevalence of many of the infections meant that the needs of the district would at most times be met by accommodation of some 100 beds. This is below the optimum size for an independent isolation hospital unit. Approach had therefore been made to the Borough of Hendon with a view to considering whether an extended Hendon Isolation Hospital could not meet the needs of this district. This proposal was favourably considered by the Councils of both districts, and as a later development it was agreed that the Hendon Hospital could be extended to provide accommodation sufficient to meet the needs of the three districts, Hendon, Wembley and Harrow. No further development took place though, in view of the changes which were to be brought about by the operation of the National Health Service Act. The Regional Board, however, felt that Harrow's needs of isolation could be met by Hendon. In July then the South Harrow Isolation Hospital was closed as an Isolation Hospital, and is being used as an Institution run in association with the Edgware General Hospital for the further nursing of patients transferred from that Hospital. Infectious cases from Harrow therefore, are now admitted to the Hendon Isolation Hospital. As in the case of demand for other hospital accommodation, the assistance of the Emergency Bed Service can be sought by general practitioners if their patients cannot be admitted to the Hendon Hospital. 15 Convalescent Homes. Such of these homes as accept patients needing nursing care and medical treatment are administered by the Regional Hospital Boards. Arrangements for the admission of patients are made by the hospital almoners. Persons needing only supervision and rest in homes not providing nursing care or medical treatment are admitted to homes administered by the local health authority. Arrangements for admission are made by the County Medical Officer, 10, Great George Street, London (Tel. No. Whitehall 4400). NURSING HOMES. The responsibility for the registration of nursing homes which had been delegated to the Harrow Council as maternity and child welfare authority, returned in July, 1948, to the County Council. This was not one of the matters referred to be administered by the Area Committee, and remains then to be dealt with by the Health Committee of the County Council. The last year has seen a falling off in the demands for admission to the nursing homes, more particularly for maternity beds, part of this fall being the result of the smaller number of births. Doubtless, however, the main cause of the decline is that no charge is made for admission to those hospitals administered on behalf of the Minister. The following table sets out the particulars of the various homes registered at the end of the year, with details of their ownership and their accommodation. Bermuda House, Mount Park, Harrow Beverley Maternity Home, 170, Whitchurch Lane, Edgware Bowden House, London Road, Harrowon-the-Hill Brockenhurst Nursing Home, 84, Hindes Road, Harrow College Hill Nursing Home, 123, College Hill Road, Harrow Weald Culverlands Nursing Home, Green Lane, Stanmore Grosvenor House Nursing Home, 100, High Street, Harrow-on-the-Hill Mrs. A. M. Elphick Mr. A. E. Elphick Miss C. Dear Bowden House Nursing Home Associa tion, Ltd. Mrs. T. M. Bell Mrs. F. M. Ellis ... Dr. P. Vosper Mrs. N. Chaplin Beds Type of Case 11 Maternity and chronic 4 Maternity 14 Mental or borderline 6 Chronic 7 Maternity, medical or surgical 11 Chronic 20 Medical or chronic 16 Heywood Nursing Home, London Road, Stanmore Hillside Nursing Home, 49, Harrow View, Harrow Maitlands Nursing Home, 54, Marsh Road, Pinner Oakdene Nursing Home, 11, Hindes Road, Harrow Roxborough Nursing Home, 25, Roxborough Avenue, Harrow St. Anne's Nursing Home, 34, West End Avenue, Pinner St. Vincent's Nursing Home, Headstone Lane, North Harrow Suffolk House Nursing Home, Marsh Lane, Stanmore The Avenue Nursing Home, 28, The Avenue, Hatch End The Firs Nursing Home, 13, Roxborough Park, Harrow The Hall, Harrow Weald Mrs. M. Guyatt Mrs. M. Cusack Mrs. H. Payne Mrs. A. Gee ... Miss Calland Miss Burrows Mrs. D. Hickman ... Mrs. P. Thomas Mrs. D. M. Williamson Mrs. A. Carter Hillingdon Surgical Instrument Co. Dr. Lincoln Williams Beds Type of Case 11 Maternity and others 5 Senile and convalescent 10 Maternity 10 Maternity and others 13 Maternity and others 7 Maternity and chronic 10 Maternity and medical 8 Maternity and others 4 Maternity and chronic 22 Maternity 10 Mental (borderline) In all, at the end of the year, there were 18 registered homes, with 183 beds, about half of these being for maternity and the other half for other patients. ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT. By Section 355 of the Middlesex County Council Act, 1944, no person shall carry on in this district an establishment for massage or special treatment without a licence from the Council authorising him to do so. There is a saving clause in respect of a registered member of the Chartered Society of Physiotherapy practising in an establishment with respect to which there has been lodged with the Authority a certificate in approved form, signed by two registered medical practitioners ; and a similar saving clause in respect of establishments carried on by medical practitioners. 17 Although there is provision in the Act for the making of bye-laws prescribing the technical qualifications to be possessed by any person who administers massage or special treatment in any licensed establishment, permission to make a bye-law calling for certain standards of training of the practitioners has not yet been received. The following are particulars of the premises licensed at the end of the year:— Mr. Cecil Sidney Arnold, 27, Exeter Road, South Harrow. Mr. Arthur Arndt, 54, Methuen Road, Edgware. Mr. Sidney Barnard, 70, Sherwood Road, Harrow. Mr. Wm. Allan Bradley, 128, Headstone Road, Harrow. Mr. A. Blum-Chassereau, 5, Amersham Road, Harrow. Mr. Jn. Arthur Darnton, 213a, Station Road, Harrow. Mr. Archibald Wm. Dunlop, 41, Station Road, Nth. Harrow. Mr. David Jn. Fox 196, Kenton Lane, Kentone Mr. Sidney Stewart Houslop, 2, Manor Parade, Harrow. Mr. Ronald Wm. Jull, 77, Marlborough Hill, Harrow. Mr. Simon Sidney Knight, 73, Station Road, Harrow. Mr. P. R. Lewis, 55, Lowlands Road, Harrow. Mr. James Porter Mason, 1, High Worple, Rayners Lane. Mr. Benjamin Robinson Stocks, 62, Hunters Grove, Kenton. Messrs. Lilley & Skinner, Station Road, Harrow. Mr. L. Cameron-James, 67, Coledale Drive, Stanmore. Mr. Arthur Charles Back, 27, Shaftesbury Avenue, Roxeth. Miss G. N. Burgess, 106, Marsh Road, Pinner. Mr. H. G. Gillett, 72, Gayton Road, Harrow. Miss M. A. Goulding, 5, College Road, Harrow. Mr. Jack Frederick Ingrey, 32, St. Ann's Road, Harrow. Mrs. D. E. Praeger, 54, Sheepcote Road, Harrow. Miss F. Sabin, 40, College Road, Harrow. Mrs. L. Schneid, 100, Streatfield Road, Kenton. Mrs. A. D. Wilson, 53, Elgin Avenue, Harrow. The following are particulars of premises in respect of which certificates have been lodged by registered members of the Chartered Society of Physiotherapy :— Miss A. M. Churchill, 50, Wychwood Avenue, Edgware. Mrs. B. A. Elsmore, 23, Devonshire Road, Hatch End. Miss Bessie Teasdale, 118, Headstone Lane, Harrow. GENERAL MEDICAL SERVICES. According to Section 31 of the National Health Service Act there shall be constituted for the area of each local health authority, an Executive Council for the purpose of exercising functions with respect to the provision of general medical (including maternity and medical) services for all persons in the area who wish to take advantage of the arrangements, proper and sufficient drugs and medicines and prescribed appliances for all persons receiving general medical service, a general dental service, and a supplementary ophthalmic service, i.e., supplementary to that provided as part of the hospital and specialists' service. B 18 The Executive Council comprises a chairman appointed by the Minister of Health and 24 members, of whom eight are appointed by the Local Health Authority, four by the Minister of Health, seven by the Local Medical Committee, three by the Local Dental Committee, and two by the Local Pharmaceutical Committee. The office of the Middlesex Executive Council is at North-West House, 119, Marylebone Road, N.W.3 (Clerk, Mr. F. J. Ashford. Tel. No. Paddington 3223). Included in the duties of the Local Health Authority is one to provide, equip and maintain to the satisfaction of the Minister, premises (health centres) at which facilities shall be available for all or any of the following purposes : general medical services, general dental services, pharmaceutical services, any of the services which the Local Health Authority are required or are empowered to provide, and the services of specialists or other services provided for outpatients. NURSING, MIDWIFERY, ETC., IN THE HOME. 1. General Nursing. The needs of those requiring nursing in the home were for most of the district met by the staff of the Greater Harrow & District Nursing Association, working from two homes, " Warneford," 79, Bessborough Road, Harrow, and 93, Uppingham Avenue, Harrow Weald. The Pinner and Hatch End Nursing Association provided a maternity and nursing service for Pinner and a nursing service for Hatch End. The Edgware and Little Stanmore Nursing Association maintained a general trained nurse in Whitchurch Lane, while the Watling District Nursing Association operating from Hendon provided a midwifery and a nursing service for some of the eastern part of the district. Since July, 1948, the County Council has assumed responsibility for the home nursing service as required to under Section 25 of the National Health Service Act : " It shall be the duty of every local health authority to make provision in their area whether making arrangements with voluntary organisations for the employment by those organisations of nurses, or by themselves supplying nurses, for securing the attendance of nurses on persons who require nursing in their own homes." The County Council decided to maintain the service by themselves employing the nurses, although for some time some of the nursing associations have assisted the County Council by continuing to administer the service. The service will be under the supervision of the superintendent of the Home Nursing Service working at the Area Office, her duties being combined with those of non-medical supervisor of midwives. For the time being those needing the services of a home nurse should approach Miss Dodds at " Warneford," 79, Bessborough Road, Harrow (Tel. No. Byron 2647) ; Miss Allan, 93, Uppingham Avenue, Harrow Weald (Tel. No. Wordsworth 2538) ; Miss Dutson, 254, Uxbridge Road, Hatch End (Tel. No. Hatch End 213) ; Miss Swift, 135, Pinner Hill Road, Pinner (Tel. No. Pinner 2607) ; Miss F. M. Sennitt, 138, Whitchurch Lane, Edgware, of the Edgware and Little Stanmore Association, and the matron, Miss Perkins, of 1, Gervase Road, Edgware (Tel. No. Mill Hill 1836), the superintendent of the Watling District Nursing Association. 19 2. Midwifery and Maternity Nursing. The Harrow Council engaged a staff of 16 midwives to provide its domiciliary midwifery and maternity nursing service. Midwives worked in four groups of four each. The services transferred in July, 1948, to the Middlesex County Council. Owing to the volume of work in the London County Council Headstone Lane Estate, an additional midwife to live on the estate has been appointed. The following are the particulars of the members of the staff:— Nurse Raeburn, 16, Worcester Court, Headstone Drive, Wealdstone. (Harrow 1669). Nurse James, 75, Pinner Hill Road, Harrow. (Pinner 5558.) Nurse Eagle, 168, Whittington Way, Pinner. (Pinner 7864.) Nurse Lundy, 2, Church Avenue, Pinner. (Pinner 3378) Nurse Ponter, 36, Corbins Lane, South Harrow. (Byron 2851.) Nurse Rough, 213, Exeter Road, South Harrow. (Pinner 5752.) Nurse Walsh, 2, Goldsmith Close, South Harrow. (Field End 9090.) Nurse Hinton, Flat 4, The Lawns, Lower Road, Harrow. (Byron 0340.) Nurse , 37, Queens Court, Kenton Lane, Kenton. (Wordsworth 2052.) Nurse Shaw, 113, Locket Road, Wealdstone. (Harrow 1601.) Nurse Rees, 1, Masefield Avenue, Uxbridge Road, Stanmore. Nurse Speaight, 585, Honeypot Lane, Stanmore. (Wordsworth 5564.) Nurse Mooney, 39, Malvern Gardens, Kenton. (Wordsworth 2153.) Nurse Robertson, 83, Merlin Crescent, Edgware. (Edgware 1181.) Nurse Francis, 68, St. Pauls Avenue, Kenton. (Wordsworth 1433.) Nurse Hutnell, 14, Tiverton Road, Edgware. (Edgware 1378.) Nurse Swann, 161, Courtenay Avenue, Headstone Lane, Wealdstone. The work of the midwives is co-ordinated by the non-medical supervisor of midwives. For the last two years this duty has been undertaken by Mrs. Brace, the superintendent health visitor, until such time as the non-medical supervisor of midwives will be appointed. In addition to the Authority's staff, there were at the end of the year five midwives living in the area whose work was almost entirely restricted to domiciliary practice here, while as well there were seven midwives living out of the area but whose domiciliary practice extends into this district. 3. Home Helps. For many years most maternity and child welfare authorities provided a service of home helps to assist in those households where the mothers were being confined. During the war years the service was extended to provide help as well in the homes where the need arose because the housewife fell ill or had to undergo an operation, where she 20 was suddenly called away to see her husband in hospital and arrangements had to be made to look after the children, where there were elderly people who were infirm or one of them suddenly fell ill, or where several members of the family all fell ill about the same time as might occur in an influenza outbreak. Although the number of helpers is growing, the demand cannot be met, and it is necessary to select those to be helped. Apart from the confinement cases, first consideration is given to the households where the need arises urgently, particularly where it is because of some acute illness likely to be of short duration. To a growing extent, though, it is now proving possible to provide assistance to those families where there are elderly persons to be looked after, particularly if they are disabled in such ways as by rheumatism or blindness. Help, too, is given to many of those suffering from pulmonary tuberculosis, and who have to spend long periods resting; very often the families themselves find those who are willing to help, the Authority then remunerating them. Helps are paid by the Local Health Authority and according to the financial circumstances of the household, some or all of this is recovered from those who are helped. Applications for help should be made to the organiser of domestic helps, Mrs. McLeod, at the Area Office, " Cottesmore," Uxbridge Road, Stanmore (Tel. No. Grimsdyke 741). DAY NURSERIES. The Local Health Authority maintains four day nurseries, to which children up to the age of five years are admitted. They are intended primarily for the children of mothers engaged whole-time on work classed as of national importance. They are open for longer hours than are the schools, so as to meet the needs of the working mothers. A charge of Is. Od. per head per day is made. Forms of application can be obtained from the matrons of the nurseries or from the Area Office. Below are set out the particulars of the nurseries :— No. of Address Children Matrons Telephone No. Kenmore Nursery, Ken- more Road, Kenton 60 Mrs. Brocklebank Wordsworth 5578 Spencer Road Nursery, Wealdstone 50 Mrs. Walmsley Harrow 4580 Headstone Drive Nursery, Wealdstone 50 Miss Tompkins Harrow 0134 Walton Avenue Nursery, South Harrow 60 Miss Sainsbury ... Byron 4692 Children under five years of age are admitted to one of the three nursery schools maintained by the Education Authority, "Tyneholme," Rayners Lane, and Buckingham Road; or to the nursery classes attached to some schools. 21 CLINICS AND TREATMENT CENTRES. The following is a summary of the various clinics and treatment centres in, or serving, the district:— 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 a.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Thursday and Friday p.m. Home Guard Building, Station Road, North Harrow Monday a.m. Any mother can bring her child up to five years of age to these clinics, though it is an advantage that where there is more than one session, if those coming from different parts of the area attend on different days, as this makes it more probable that the health visitor who visits the homes in that locality will be present on the days those mothers attend. Ante-Natal Clinics. Elmwood Clinic, Elmwood Avenue, Kenton Tuesday p.m. Baptist Church Hall, Streatfield Road, Kenton Thursday p.m. and Friday a.m. Broadway Clinic, The Broadway, Wealdstone Tuesday a.m. and Thursday p.m. 76, Marlborough Hill, Wealdstone ... Monday p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wednesday a.m. 22 St. Hilda's Hall, Northolt Road, South Harrow The Clinic, Alexandra Avenue, South Harrow Methodist Church Hall, Walton Avenue, South Harrow Home Guard Hut, Station Road, North Harrow Memorial Hall, High Road, Harrow Weald Clinic, Honeypot Lane, Stanmore Methodist Church Hall, Love Lane, Pinner St. Anselm's Hall, Hatch End Chandos Pavilion, Chandos Recreation Ground, Edgware Tuesday a.m. Wednesday p.m. Thursday a.m. Monday p.m. Tuesday p.m. Tuesday p.m. Monday p.m. Thursday p.m. Friday a.m. Where there is more than one session in any one building, it is preferable for those mothers who are to be confined in hospital to attend in the morning, so as to free the afternoon session for those mothers who are to be confined in their own homes, when it is more likely that the midwives who will be attending them will be present. A consultant ante-natal clinic is held at Elmwood Avenue clinic on the mornings of the 2nd, 3rd and 4th Mondays of the month. Those attending these sessions are referred either by the medical officers of the ante-natal clinics or by their own medical practitioners, whose attendance with their patients is welcome. Toddlers' Clinic. Elmwood Clinic, Elmwood Avenue, Kenton ... ... ... ,.. Baptist Church Hall, Streatfield Road, | Kenton ... Spiritualist Church Hall, Vaughan Road Harrow ... Clinic, Alexandra Avenue, South Harrow St. George's Hall, Pinner View, Harrow Clinic, Honeypot Lane, Stanmore Methodist Church Hall, Love Lane, Pinner The Pavilion, Chandos Recreation Ground Edgware Alternate Thursday a.m. 1st Monday a.m. in month Wednesday a.m. 1st and 2nd Tuesday a.m. Monday a.m. Monday p.m. Thursday, a.m. These clinics are to enable children who are too old to be brought regularly to the infant welfare sessions to be kept under medical supervision and, as contrasted with the infant welfare clinics, only those who have been given an appointment can attend at a session. Birth Control Clinic. A birth control clinic is held on Friday mornings at the Broadway clinic. Advice can be given only to those in whose case it is considered further pregnancy would be detrimental to their health. It is advisable 23 that anyone intending to obtain advice should bring a note from her medical attendant indicating the grounds on which advice is necessary. The aim of the Harrow Marriage Guidance Council (Secretary, Mr. J. W. A. Chorley, 110, Marlborough Hill, Harrow. Tel. No. Harrow 3981) is to promote happy marriage and parenthood. The service offered includes personal consultations both to help engaged couples adequately to prepare themselves for marriage and to assist married couples with problems and difficulties of married life. School Minor Ailment Clinic. Sessions are held at a number of premises in the district. The Clinic, Broadway, Wealdstone Monday a.m., Thursday a.m., Saturday a.m. The Clinic, Elmwood Avenue, Kenton Friday a.m. The Clinic, Alexandra Avenue, South Harrow Monday a.m., Friday a.m., Saturday 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. Children attend at the request of the parents or of the teachers, or they are referred by school medical officers. Not only are those who need treatment for minor ailments seen at the clinics, but children are kept under observation for such conditions as cervical glands, cardiac murmurs, etc. Any children needing special examination, especially if these are likely to be prolonged, are referred to be seen at these clinics. Ophthalmic Clinics. School children selected by the school medical officer as the result of an examination at the school or at the minor ailment clinic, can be referred to be seen by the ophthalmic surgeon at the ophthalmic clinic at 76, Marlborough Hill on the mornings of Tuesdays and Fridays, or at the Alexandra Avenue clinic on Thursday mornings. Only those who have an appointment can be seen, any new cases being referred in the first instance to be seen by the school medical officer at one of the minor ailment clinics. Child Guidance Clinic. A child guidance clinic with its team of psychologists and psychiatric social workers under the administration of the psychiatrist. Dr. Margaret Saul, is held at No. 2, St. John's Road, Harrow. The clinic, which is not sufficient to meet the needs of this district, nevertheless is serving a much larger part of the County with the result that there is a very long waiting list. The children considered to be in need of the help of this clinic should be referred in the first instance to be seen by a school medical officer at one of the minor ailment clinics, except that cases can be referred direct to Dr. Saul by general medical practitioners, who when they do so should forward her a report. The child guidance clinic is part of the education service, and therefore is available only for children attending maintained schools. The only exception to this is that a child who might 24 prove to be a maladjusted child, and as such be a handicapped pupil, might be referred there for examination, though not for treatment. A speech therapy clinic for school children is held in the same building. Dental Treatment. Dental treatment apart from that provided under the National Health Service Act is available for certain priority sections of the public, namely, school children, children under five and expectant and nursing mothers. The service is under the administration of the area dental officer, Mr. A. G. Brown. There are dental surgeries at five premises, namely, 76, Marlborough Hill, Elmwood Avenue clinic, Alexandra Avenue clinic, Roxeth clinic and Honeypot Lane clinic. Apart from the sessions when the dental officers are examining children in the schools, treatment sessions are held every week-day morning and afternoon. The school children treated there are those found as the result of routine dental inspection of children at the schools to need treatment. The only ones who can attend without a previous appointment are those who are referred by the head teachers of the schools, the children attending under the arrangements made for the urgent or emergency treatment of those needing such attention for some cause such as toothache. Most of the children under five and the expectant and the nursing mothers are referred by the medical officers at the clinics which they have attended. The Health Authority dental service is, however, available to ante-natal mothers who do not attend the local clinics, but who are referred for treatment by the medical practitioners under whose care they are, appointments being made through the Area Office. Physio-Therapy Treatment. The Harrow Hospital maintains a physical treatment centre at the Car Park Building, Station Road, Harrow, Tel. No. Harrow 0926. The medical director, Dr. G. G. Farrington, attends at fixed sessions to see all new cases. A wide range of treatment is carried out by the staff under supervision of Miss M. Lock. The orthopaedic surgeon, Mr. K. I. Nissen, attends 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 the Edgware General Hospital. Treatment of Venereal Diseases. In addition to the hospitals at which treatment is available under the London and Home Counties Scheme, facilities are available at the following Hospitals: Central Middlesex Hospital, Acton Lane, Willesden; Hillingdon Hospital, Royal Lane, Hillingdon; West Middlesex Hospital, Twickenham Road, Isleworth. 25 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. PROVISION FOR SPECIAL CLASSES OF PERSON. The Deprived Child. The Children Act, 1948, put into effect the main recommendations of the Curtis Committee, providing a comprehensive service for the deprived child, that is, the child who has neither parents nor guardian, or has been and remains abandoned by its parents or guardian, or is lost; or whose parents or guardian are for the time being or permanently prevented by reason of mental or bodily disease or infirmity or other incapacity, or other circumstances, from providing for its proper accommodation, maintenance and upbringing. Administered centrally by the Home Office, locally the duty falls on the Children's Committee of the County Council and the Children's Officer (Miss J. Rowell, of 10, Great George Street, S.W.I. Tel. No. Whitehall 4400). In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at the County Council's Children's Care Office, 48, Station Road, Harrow (Tel. No. Harrow 2963). The Authority has to assume the responsibility for receiving him into its care when it appears their intervention is necessary in the interests of the welfare of the child, any deprived child in their area under the age of 17. In certain circumstances the Authority are able to assume parental powers and rights. Another group for whom the Authority are directly responsible are children committed to their care by a Juvenile Court under the Children and Young Persons Act, 1933. In regard to those children for whom the Authority is responsible, it is their duty to further their best interests. The children can be maintained by being boarded out or being placed in residential homes provided under the Act, or in voluntary homes. The child life provisions of the Public Health Act which hitherto applied to children taken for reward while under nine years of age, are now extended to all children taken for reward while under school-leaving age. A child placed for reward will continue under supervision after it reaches school-leaving age as long as it remains with the foster parents with whom it was living when it reached school-leaving age, and is under 18. There is a similar extension of Section 7 of the Adoption of Children (Regulation) Act, 1939, which provides for the supervision of children placed through third parties in the care and possession of a person who is not the child's parent or guardian or near relative. The Handicapped Adult. The former Poor Law officers under the Public Health Acts had a wide range of duties, including arranging for the care of the needy or destitute and the mentally afflicted. The latter service is now in the hands of the Mental Health Section, the authorised officers being Mr. W. J. Pedel and Mr. W. Bullwinkle, of 48, Station Road, Harrow. Tel. No. Harrow 1252. 26 The National Assistance Board assists persons who are without resources to meet their requirements, or whose resources must be supplemented in order to meet their requirements. It is the duty of the Local Authority (the County Council) to provide (a) residential accommodation for persons who by reason of age, infirmity or other circumstances, are in need of care and attention which is not otherwise available to them; and (b) temporary accommodation for persons who are in urgent need thereof, being need arising in circumstances which could not reasonably have been foreseen, or any other circumstances as the Authority may in any particular case determine. Persons for whom accommodation is provided are to pay for it. The Local Authority has power also to make arrangements for promoting the welfare of persons who are blind, deaf or dumb, or of other persons who are substantially and permanently handicapped by illness, injury, or congenital deformity, or such other disability as may be described by the Minister. The service is administered locally by the Welfare Department (Area Welfare Officer Mr. H. G. Plummer, 48, Station Road, Harrow. Tel. No. Harrow 1252). The County Council maintains some persons in the home of the Harrow Housing Society, Pinner Hall, Church Lane, Pinner. The London Council of Social Service provides a welfare service for elderly people, and has helped in the setting up of local Old People's Welfare Committees throughout the Metropolitan Police Area. The activities of these Committees include the appointment of visitors, securing better housing facilities for the elderly, the organisation of clubs and the provision of a meals service. The secretary of the Harrow Committee is Mrs. Gilbert, of 41, Barrow Point Avenue, Pinner. Tel. No. Pinner 5206. AMBULANCE SERVICE. Before the war, the Harrow Council's accident and sick removal ambulance service was provided in association with the fire service, the ambulances being stationed at the fire station and manned by the fire service personnel. During the war, the ambulance service for the civilian population was provided as part of the Civil Defence Ambulance Service. After the war it continued as an independent organisation. Those suffering from infectious diseases who needed to be removed to hospital whether in or outside the district were removed by ambulances stationed at the Isolation Hospitals. One of the effects of the National Health Service Act was the transfer of responsibility for providing an ambulance service from the minor to the major authorities. The County Council decided to revert to what was the pre-war position in this district, and run it in association with the fire service. Ambulances for the removal of accident cases will be housed in or adjacent to the Fire Station, Tel. Nos. Harrow, Pinner, Byron, Wordsworth, Grimsdyke, Underhill 2222; those for sick persons will be placed as close as possible to main hospitals, including the Isolation Hospitals. 27 LABORATORY SERVICE. The examination of clinical material of public health significance is carried out free of cost to the patient and to the doctor at the Central Public Health Laboratory, Colindale Avenue, London, N.W.9. Tel. No. Colindale 6041 and 4081. Most samples submitted are throat swabs for the presence of organisms of diphtheria or of the hæmolytic streptococcus. Another group of samples is of dejecta for the presence of organisms of the typhoid or dysentery group. Specimens of sputa are submitted for examination for the presence of tubercle bacillus. Blood serum is sent for examination of the reaction indicating the infection of the body by the typhoid group. Cough plates are examined for the presence of the organisms of whooping cough. In general the examination is carried out of material which will be of aid in the early diagnosis of infectious conditions, one purpose of the laboratory being to carry out investigations of public health significance. It is not intended that other clinical material shall be sent, this work being carried out at the laboratories of certain hospitals. The laboratory does not deal in the ordinary way with the examination of specimens of those suspected to be suffering from venereal disease, which are sent to hospitals which provide clinics for the treatment of those suffering from these diseases. Apart from the examination of this clinical material, the laboratory also carries out the routine bacteriological examination of such foods as milk or ice-cream, and examines other food stuffs considered possibly to have been the source of a food poisoning. The staff of the laboratory also carry out investigations in the field in the case of various forms of outbreak, however spread. Another service provided by the laboratory is the issue of certain preparations such as lymph for vaccination against smallpox, and antigens for the immunisation of the population against diphtheria. The clinical material is collected each day by a van sent from the laboratory calling about mid-day at the Harrow Hospital, the Public Health Office, "Cottesmore," and the Central Fire Station, Pinner. The following is a summary of the examinations of material from this district, carried out during the year: nose and throat swabs, 567; fæces, 40; sputum, 21; pertussis, 11; milk, 32; ice-cream, 44, and water, 3. Miscellaneous, 70. 28 SANITARY CIRCUMSTANCES OF THE AREA WATER. Apart from a small part of the south-west portion of the district served by the Rickmansworth & Uxbridge Valley Water Company (supplied from stations at Ickenham, West Drayton and Mill End) the area is supplied with water by the Colne Valley Water Company. The water originates in gathering grounds in the Chilterns, the area of supply being some 80 square miles. It is pumped at a number of stations from wells about 200 feet deep in the chalk, the main pumping stations being at Aldenham Road, Bushey, Berry Grove, near Aldenham, and Eastbury Road, between Bushey and Rickmansworth. The water is softened, part by Clark's lime process, part by the method of base-exchange, and is then chlorinated. The service reservoirs are at Windmill Lane, Bushey Heath. A boosting station at Grove Hill Road ensures adequate pressure on Harrow Hill. The purity of the water is ensured by the supervision carried out by a staff of chemists and bacteriologists. Water undertakers who derive their powers by special statutory enactments are required to ensure the water supplied by them to consumers is at all times wholesome. Section 111 of the Public Health Act, 1936, imposes a duty on every local authority to take from time to time such steps as may be necessary for ascertaining the sufficiency and wholesomeness of the supplies within the district. As a routine practice, then, samples are submitted quarterly for both chemical and bacteriological analysis. Below is set out one of these analyses of a sample taken which is typical of all those which have been submitted:— "Appearance: bright with a very slight flocculent deposit consisting of chalk particles. Colour Nil Iron 0.03 Odour Nil Turbidity less than 5 pH 7.3 Taste Nil Electric conductivity 600 Free carbon-dioxide 14 Chlorine 50 Total solids 400 Hardness total 215; Alkalinity 205 temporary 205; permanent 10 N in nitrites under 0.01 N in nitrates 5.0 Oxygen absorbed 0.20 Free ammonia 0.014 Residual chlorine absent Albuminoid ammonia 0.014 Other metals absent "This sample is practically clear and bright in appearance since it carries only a trace of matter in suspension. The water is neutral in reaction, hard in character, but not unduly so, contains no excess of salinity or mineral constituents in solution, and it is free from metals, apart from a negligible trace of iron. It is of a high standard of organic quality." In addition, copies are received regularly from the analyst of the Colne Valley Water Company of the results of analyses carried out on samples of water collected from houses throughout the district. These have been uniformly good. 29 Some diseases are water-borne. In order that the water company shall be aware of the occurrence of these, particulars are sent to them of those households at which there are patients suffering from diseases which might have been contracted by the consumption of infected water, even though there was nothing to suggest that in those particular cases infection had been contracted in that way. There have been no complaints of inadequacy of supply in the areas served by the Colne Valley Water Company, though before the war from the small part of the district served by the Rickmansworth & Uxbridge Valley Water Company complaints of shortage were not infrequent. Towards the end of 1948 it was necessary to communicate with the Colne Valley Water Company about the inadequacy of supplies to a terrace of houses fed by the stand pipe; the lumen of the pipe had been narrowed through scaling. Occasionally complaints are received about the hardness of the water, and sometimes, too, about the taste of chlorine. The water is usually about 20° hardness, a figure which might compare well with that of water of other deep-well supplies, but it is very noticeable to those used to an upland water supply. Hardness is only indirectly related to health. In that it is a protection against the risk of plumbo-solvency to which soft waters are subject, a certain degree of hardness is advantageous. Hardness can be indirectly related to health through increasing the difficulties in attaining cleanliness. Whatever might be the difficulties of the water company in ensuring a softer supply, whether it be shortage of labour or of materials, these must be but a fraction of those resulting from failure to soften when regard is had to the total volume of labour of the housewife and of her meagre soap allowance. The taste of chlorine in the water, about which no complaints have been received in this last year, is apparently due to a deliberate overdosing of the water when work has been done on some mains. On these occasions there are sometimes complaints of the turbidity of the water. The water company notifies the authority of their intention to cut off the supply of water to an inhabited house. Wells. There are eight groups of wells in this district only a few of which are now in use. These are:— (1) That at Braziers Farm, a well of about 250 feet deep, the water from which is used for cooling purposes in connection with the dairy business. The results of the analyses of samples have been satisfactory. (2) The six at Kodak Works. Of these, four are sealed and have not been opened for many years. The other two are deep wells, the water being used in connection with the work of the factory. (3) A shallow well in the yard of the Harrow Motors, Limited, West Hill, Harrow. The water is used for car washing purposes only. This well is superficial and does not draw its water from the depth of the other functioning wells in the district; nor is it likely that its water can find its way to the deeper underground supplies. The other wells are not in use. They are:— (4) Two at Messrs. Patterson and Company, Stanmore Hill. These are two disused brick wells which have not been used for years, both 30 being sealed off with planks. The tops of the wells are above the level of the ground, so surface water or surface washings are unlikely to find their way into the wells. (5) A shallow well at the City Cottages which has for years been sealed off with stone slabs. No pollution is likely to occur, nor is it probable that the well water communicates with the deeper underground water. (6) A shallow well in the forecourt of the Fountain Public House, Church Road, Stanmore. This has not been used for years, and is now surfaced over. (7) There is a deep well at Messrs. Hivæ, Limited, Greenhill Crescent. The well opening is concreted over. (8) The deep well at the Greenhill Laundry is no longer in use, and is sealed over with a stone slab. The position, then, is that the use of the superficial wells has been largely discontinued and no pollution is likely to occur of the deep wells. Those not in use are adequately sealed, so that their pollution is unlikely. On the other hand, there is little risk of pollution of these deep wells which are in use. DRAINAGE AND SEWAGE DISPOSAL. The district is served by the separate system of drainage. Early in 1936, the last of the five sewage disposal works, which had up to this treated the sewage of the district, ceased to be used for this purpose. Since then, virtually all the sewage from this area has been treated under the West Middlesex Drainage Scheme at the disposal works at Mogden, where it is treated by the activated sludge process. The capacity of the trunk sewers and main outfall sewers is such that it is estimated on a dry weather flow at 40 gallons per person per day, they can serve an ultimate population of 330,000. At South Vale, Sudbury, a pumping station lifts sewage some 80 feet from the South Vale area to the high-level sewer in South Hill Avenue. There are still a few houses on the northern fringe of the district from which the sewage is treated mostly in small plants in the grounds of the houses, the effluent finding its way to a water course. Open water courses generally are under the jurisdiction of the County Council or of the Thames Conservancy, but long lengths running through developed land have been culverted and so have become the responsibility of the district council. In some cases, the Council has acquired land along the banks. There are five main water courses in the district. The River Pinn (under the control of the Thames Conservancy) rises in the Royston Park Estate; running in a southerly direction to High Street, Pinner, during which part is open and part culverted, it then turns in a westerly direction, passing out of the district between Cuckoo Hill and Eastcote Road. The Yeading Brook rises in two sources, one near the Pinner Road recreation ground, the other near Headstone Manor. The two streams, which are culverted in part, join at Hooking Green Bridge, and then run in a south-westerly direction through North Harrow and Harrow Garden Village, leaving the district near Yeading Avenue. The Wealdstone Brook, rising in Harrow Weald, runs in an 31 easterly direction through Wealdstone, crossing out of the district at the Kenton Road, near Kenton Grange Farm. The Kenton Brook, rising out of the district, passes near the site of the Little Stanmore Sewage Farm to flow in a southerly direction through the Glebe Estate, crossing out of the district near Kenton Lane, later to join the Kenton Brook. The Edgware Brook, which rises in two sources south of the Stanmore Village, flows in a southerly direction through Stanmore Marsh, then easterly to Edgware, later to run into the Silk stream. The largest of the lakes are those at Canons Park (8.7 acres and 10 mil. gals.); Bentley Priory (4.3 acres and 5 mil. gals.); Harrow Weald Park (3.1 acres and 2 mil. gals.); Temple Ponds, Stanmore Park (2.9 acres and 2 mil. gals.). PUBLIC CLEANSING. Refuse Collection. Refuse is collected once a week from some 70,000 premises. A separate collection is made of waste paper from shops, etc. Collection of trade refuse is undertaken at a charge. Kitchen waste, deposited in about 1,500 communal bins, is collected in some parts by the Local Authority, in others by contractors. Now that it has been possible to restore the weekly collection of house refuse, fewer complaints are being received. The greater ease with which new bins can be now obtained also has reduced the number of nuisances and of complaints. The kitchen waste bins are still a source of nuisance, though this is very much less where the bin has been provided with a surround which makes it that much less liable to be knocked over. This surround provides, however, its own nuisance if care is not taken thoroughly to cleanse it when the bin is being emptied. The recent decision of the Courts as to whether the landlord or the tenant is responsible for replacing a dustbin at a house has caused much additional work. In general, the Committee decided that unless there was an agreement or there were any special circumstances which imposed the burden on the tenant, then it was the responsibility of the landlord. There have been many appeals to the Courts against this ruling, but in general the Council's line has been upheld. Refuse Disposal. Before the war, the refuse of this district was dealt with by three of the recognised methods of disposal, namely, by direct incineration at the South Harrow destructor, by separation at the Wealdstone separation plant, and by controlled tipping, mostly at the Cannon Lane tip. It had been decided that when the plant was ready, all refuse should be treated at the hyganic plant at Wealdstone, on which work had already begun. For a number of reasons, including the low calorific value of the refuse, the destructor and the separation plant were not used from early on in the war, so that for many years all refuse was disposed of by controlled tipping. The sites available for this purpose were diminishing, and tipping was started at Old Redding. Complaints were received in the summer months from those living near the sites at which refuse 32 is being tipped about the absence of cover and the height to which the tip was being raised. Lack of available sites will necessitate alternative arrangements being made for the disposal of the refuse, which amounts to over 1,000 tons a week. Street Cleansing. The lengths of highways repairable by the public are the nine miles of roads directly maintained by the Middlesex County Council, the 36 miles of main roads maintained by the district council under agreement with the Middlesex County Council, and the 163 miles of district roads. The pre-war practice was for the main roads and shopping centres to be cleaned twice daily, the main district roads once daily, the general district roads three times a week, cul-de-sacs twice weekly and private streets once a week. Unfortunately shortage of labour has prevented the service being restored to this level, the present practice being a daily cleaning of the roads of all shopping areas (about 50 miles); the sweeping two or three times a week of some 50 to 60 miles of roads of the Council housing estates, where schools are sited and the approaches to recreation grounds; and once weekly sweeping of the other 120 miles of roads. Some 15 miles of the County Council main roads and roads to shopping centres are swept daily; the remaining 200 miles of roads can be done only weekly. The sweepings are collected in orderly barrows and are deposited on the tips. During the summer months the channels of the roads of all shopping areas and congested thoroughfares and the roads used as playgrounds are sprayed twice daily. PUBLIC CONVENIENCES. Apart from those in the Recreation Grounds, there are public conveniences at Havelock Place, the Car Park at Station Road, Pinner Road, at North Harrow and Peel Road, and there is a urinal in Northolt Road. Because of the use made by the public of the urinal at the Red Lion Public House, Pinner, the Council agreed to be responsible for its cleansing. In consideration of a lump sum payment by the Council, the convenience provided and maintained by the London Transport Executive at South Harrow Station is available to the public. Arrangements were in train for conveniences to be provided in many more of the Recreation Grounds, but the onset of the war interfered with this programme and with the erection of a new convenience in Whitchurch Lane. Conveniences are required in many parts of the district, but none perhaps more urgently than to serve the Kenton shopping area or Pinner Village. SWIMMING BATHS. There are two open-air swimming baths in the district, one at Charles Crescent, Honeybun Estate, Harrow, and the other at Christchurch Avenue, Wealdstone. The former, constructed in 1923, measures 165 feet by 75 feet, with a depth of 7 feet to 3 feet 6 inches. The water, after being filtered, is treated by chlorination. Dressing accommodation, shower and foot baths and sanitary conveniences are provided. The 33 Wealdstone bath, constructed in time for the 1934 season, measures 165 feet by 75 feet, with a depth of 8 feet 6 inches to 2 feet 6 inches; in addition, there is a shallow semi-circular beginners' pool. Suitable dressing accommodation, with shower and foot baths, and sanitary conveniences are provided. The water is treated by passing through filters and is then chlorinated. The duration of the turn-over period varies according to the amount the baths are used, but it is at least once a day, and at busy times is every eight hours. Daily tests are carried out for the presence of free chlorine and to determine the pH value. DISPOSAL OF THE DEAD. Burial Grounds. The Council, under the provisions of Section 46 of the Middlesex Review Order, 1934, became the burial authority for the district and has control of the following burial grounds or cemeteries: Paines Lane and Roxeth Hill (both full except for re-openings), Pinner Road, Byron Road, Eastcote Lane, Pinner Cemetery, and Harrow Weald. The acreage unused is about 24, sufficient to last at the present rate for about forty years. There is, apart from re-openings, little available at the grounds under the control of the Church authorities, namely Harrow, Roxeth, Pinner, Harrow Weald, Great Stanmore and Whitchurch. Cremation. At their meeting on the 4th November, 1944, the Council agreed in principle to the provision and erection at the appropriate time of a crematorium on land forming part of the Harrow Weald cemetery reservation. A meeting of representatives of a number of the West Middlesex Authorities discussed the possibility of the joint use by such Authorities of the crematorium to be provided by the Council. The outcome was that the Council agreed in principle that the early provision of a crematorium to serve Harrow and Wembley was desirable. It was later suggested the joint crematorium should be built in Wembley on the Northwick Golf Course site. This proposal had later to be abandoned. The present position is that discussions are now taking place about the erection of the crematorium at the Harrow Weald site. Burial. Under S. 50 of the National Assistance Act, 1948, the powers which the County Council had under the Poor Law Act are replaced by a duty placed on the District Council to arrange for the burial or cremation of any person who has died or been found dead in their area, this duty being exercisable only where it appears to the Council that no other suitable arrangements have been or are being made. The Council decided at their meeting in October that in such circumstances the body should be transferred to the mortuary, that enquiries be made as to the person or persons legally responsible for the burial of the body, and where such cannot be found, arrangements should be made for the burial. For this purpose arrangements were made with a number of undertakers in the district. c 34 The County Council decided to exercise its powers in regard to the burial or cremation of the body of any deceased person who was living in accommodation provided under Part III of the Act, or was living in a hostel provided by the County Council. The only establishment of this nature in which are persons for whose cost of maintenance the County Council is responsible is the Home of the Harrow Housing Society, Ltd., at Pinner House, Church Lane, Pinner. Mortuary. The district is served by the one mortuary at Peel Road which is under the care of a full-time mortuary attendant, Mr. C. Russell, of 30, Lome Road, Wealdstone. The room for the post-mortem examinations is separate from that for the reception of bodies and has a separate pathological room with sanitary annexe. It is fitted with a revolving slab, centrally drained to the sewer. A refrigerating chamber has been fitted. The reception room has a separate viewing room. During the year, 271 bodies were received. Post-mortem examinations were carried out on 188, and 30 inquests were held. Eighty-three bodies were admitted for storage. The Coroner for this district is Dr. Alan Cogswell, 14, Airedale Road, Ealing, W.5. (Tel. No. Ealing 8544.) 35 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 1,438 (ii) On complaint of other nuisances 502 (iii) Routine Inspections 473 (iv) Revisits arising from defects found 8,446 (v) Inspections of Foster Parents' premises 13 (vi) Surveys under Section 157, Housing Act, 1936 499 Conditions Found. (i) Number of dwellings or other premises visited as a result of (i), (ii), (iii), and (v), where defects were found 1,324 (ii) Number of cases of overcrowding 275 PUBLIC HEALTH. Inspection of Other Premises. (i) On complaint or request 94 (ii) Routine inspections of premises 232 (iii) Revisits arising from defects found 313 (iv) Surveys arising from Rat complaints 766 (v) Inspection of Factories 804 (vi) Inspection of Workplaces 130 (vii) Inspection of Outworkers' Premises 399 (viii) Inspection of Cinemas and Places of Entertainment 52 (ix) Inspection of Licensed Premises 53 (x) Visits under Shops Acts 1,808 (xi) Evening observations under Shops Act 37 (xii) Sunday observations—Shops Acts 6 (xiii) Observations made for Smoke Nuisances 8 Conditions Found. (i) Premises visited as result of (i) and (ii) where defects or unsatisfactory conditions were found 89 (ii) Number of premises where action taken by Council's Rodent Operatives to deal with rats—see (iv) above 728 (iii) Number of Factories, Workplaces and/or Outworkers' premises where defects or contraventions were found—see (vi), (vii) and (viii) above 98 36 (iv) Number of Cinemas and or Licensed Premises where defects were found—(ix) and (x) refer 18 (v) Contraventions of Shops Acts— (a) Failure to observe closing hours 16 (b) Other contraventions (failure to exhibit notices etc.) 220 FOOD HYGIENE. Inspection of Food, Food Shops and Food Preparing Places. Visits (i) Slaughterhouses 25 (ii) Butchers' Shops 481 (iii) Cowsheds 30 (iv) Dairies 137 (v) Fish Shops 137 (vi) Bakehouses 42 (vii) Cafes and Restaurants 292 (viii) Ice-cream Premises 227 (ix) Provision Merchants 549 (x) Other food Premises 221 PART II. COMPLAINTS RECEIVED. Summary of Complaints Received. Accumulation of refuse 121 Animals causing a nuisance 48 Dampness 126 Drains and Sewers—Choked 229 Defective 158 Dustbins defective 251 Houses with defects 509 Plumbing defects 198 Flooding—Gardens 12 Vermin 28 Insect infestations 47 Overcrowding, alleged 499 Shelters and Static Tanks unsatisfactory 7 Smoke Nuisances 10 Water Courses 5 Defective Waterclosets 49 Other complaints (pig bins, wasps' nests, defective fences) 182 Food unfit (excluding requests received from shops to visit and inspect unfit food) 32 37 PART III. NOTICES SERVED. Under Housing Act, 1936. (i) Statutory notices served under S. 9 requiring execution of repair work 69 (ii) Dwellings reported to Public Health Committee and approved for action under S. 11, i.e., as being in a state so dangerous or injurious to health as to be unfit for human habitation 8 (iii) Number of cases reported and approved for action under S. 12, i.e., for the making of a Closing Order on a building or part thereof Nil (iv) Informal notices served with a view to subsequent action under S. 9 175 (v) No. of properties demolished as a result of action taken under the Housing Acts during previous years:— (a) Individual unfit dwellings 4 (b) Dwellings the subject of Clearance Orders 15 Under Public Health Act, 1936. Statutory Notices under:— (i) S. 24, i.e., Notice requiring work to a public sewer 126 (ii) S. 39, i.e. Notice requiring repair or renewal of drains 38 (iii) S. 45, i.e. Notice requiring repair or renewal of defective water-closets 9 (iv) S. 56, i.e. Notice requiring work on undrained or badly drained yard area 1 (v) S. 75, i.e. Notice requiring renewal of a dustbin 57 (vi) S. 83, i.e. Notice requiring cleansing or verminous premises 2 (vii) S. 93, i.e. Notice requiring abatement of a nuisance 106 (viii) Informal Notices served (all sections) 1,629 ACTION TAKEN. Following Housing Act Notices. (i) S. 9—Dwellings rendered fit after service of Statutory Notices:— (a) By Owners 46 (b) By Local Authority 4 (ii) S. 11—Dwellings not capable of being rendered fit at reasonable cost 8 (iii) Dwellings rendered fit by Owners after receipt of Informal Notice (S. 9) 126 Following Public Health Act Notices. (i) S. 24—Public Sewers repaired 30 Note: Work to public sewer must be undertaken by the Local Authority or a Contractor instructed by them. 38 (ii) S. 39—Drains repaired or renewed:— (a) By Owners 16 (b) By Local Authority in default of Owners 14 (iii) S. 45—Water-closets repaired or nenewed:— (a) By Owners 7 (b) By Local Authority in default of Owners Nil (iv) S. 56—Yards repaired:— (a) By Owners 1 (b) By Local Authority in default of Owners Nil (v) S. 75—Dustbins provided:— (a) By Owners 18 (b) By Local Authority in default of Owners 32 (vi) S. 83—Verminous Premises cleansed 1 (vii) S. 93—No. of applications to Magistrates for an Abatement Order 6 (viii) Nuisances abated and/or other work carried out by Owners on receipt of Informal Notice 1,534 SUMMARY PROCEEDINGS. On six occasions it was necessary to apply to the Courts for an abatement order. In five cases, orders were made by the Magistrates and costs allowed. In two cases fines were also imposed. The sixth case is still before the Courts, an appeal having been lodged by the owners against the decision of the local Magistrates. Summary proceedings, under Section 9 of the Food & Drugs Act, were also taken following three complaints of glass being found in milk delivered to schools. Fines totalling £20 and costs were imposed by the Magistrates in respect of two of these cases. The third case was dismissed. HOUSING. Repair of Houses. Public Health Act, 1936—S. 93: One of the chief duties of a sanitary inspector is the investigation of complaints. Included amongst these are those relating to housing conditions. Many of these refer to defects such as of roofs, gutters, windows and defective yard paving. Most of the defective conditions giving rise to complaints are remedied by the owners on their having their attention drawn to them. In a few instances formal action under the Public Health Acts is necessary. If the nuisance continues after the service of a statutory notice, application is made to the Court for an order to be made that the nuisance shall be abated. During 1948, authority was given for the service of 318 notices; 106 were served. In respect of six of these, application was made for an abatement order; in five of these the order was granted. Public Health Act, 1936—SS. 24 and 39. A similar procedure follows in regard to drainage trouble, a notice being served under S. 39 when the defect involves the drainage system of individual properties, or under S. 34 if the defect is in a sewer for which persons other than the local authority are responsible. 39 In the event of the owner failing to comply with any notice served, the local authority can enter and themselves carry out the work and recover the cost. During 1948, 89 notices were authorised to be served under S. 39. Of the 38 served, 16 were complied with; in 14 the work was carried out by the Council. 126 notices were served under S. 24 involving 30 sewers. The work was carried out by contractors instructed by the Council and the cost recovered. Public Health Act, 1936—S. 45. The Council authorised the service of 14 notices under this section, which empowers action to be taken for the repair of defective water closets. Nine were actually served, all being complied with. Housing Act, 1936. In ordinary circumstances when an inspector visits a house, especially if it is because of some complaint, he has to consider whether action should be taken under the relevant provisions of the Housing Act, Before the war, then, a thorough inspection would be made and an assessment made of the cost of the work required to put the house in a habitable condition. If the estimated cost was not out of all proportion to the value of the house, the Committee's sanction would be sought to the serving of a notice under S. 9 of the Housing Act. One advantage of proceeding under this section rather than under the nuisance section of the Public Health Act, is that more work can be demanded. Further, in default of the owner carrying out the work, the Authority can do it and recover the cost. During the war years, shortage of labour and materials necessitated action being limited to the more urgent needs of the standards of the Public Health Acts. The situation is getting easier and more use is again being made of the power of the section. During 1948, the Committee authorised the service of 175 notices; 69 were actually served, and of these 46 were complied with by the owners within the time stipulated in the notice. In four cases the Council arranged for the carrying out of the work at the cost of the owner. If the cost of repair is very high in relation to the value of the house, then the question of the making of a demolition order under S. 11 is considered, the owner of the property being invited to discuss the matter with the Committee. Present-day demands on accommodation have so added to the value of the property, while those living in unsatisfactory conditions are only too glad to obtain accommodation of any sort, that the standard now is very different from that of before the war, so many houses are now being retained for use that on pre-war standards would have been the subject of S. 11 procedure. In spite of the desirability of continuing to keep in use if at all possible any property which can meet the needs of a family, during the year eight houses were dealt with by demolition orders being made. Three of these houses were demolished before the end of the year, the families being rehoused by the Council. In some instances, the owners of the houses not being in a position to meet the expenditure necessary to put the houses in a fit state have offered them for purchase by the Council. While at ordinary times there could be no question of the authority continuing to own property of such standard, to-day's shortage of accommodation and difficulty in 40 viding new houses warrants such a step being taken so as to prevent the loss of yet another house to add to the difficulties of the housing situation. If the condition of a number of adjacent properties is unsatisfactory and it is felt that the houses cannot be repaired at a reasonable cost, the procedure is not the making of individual demolition orders but of a clearance order. No use has been made of these powers of the Housing Act since the end of the war. Overcrowding. 1. The survey carried out as required by the Housing Act, 1936, showed that of the 12,943 houses visited, 152 were overcrowded as judged by the standards of the Housing Act. By 1941, the number of overcrowded premises had been reduced to 17. The figure remained low for the next three years. Towards the end of 1945, however, there was a marked increase, which was followed by a still greater rise in 1946, when 486 new cases were added to the register. Since then there has been an increase each year, though a diminishing one. On the other hand, the number of houses in which the overcrowding has been abated has increased, so that the stage had been reached in 1948 when the number of cases abated (234) approximated to the 275 new cases. The number of overcrowded houses reached its hitherto highest level of 628 at the end of 1948. 2. The Housing Act provides for a statutory permitted number for a house let as a whole and a separate permitted number for each portion let separately. In many cases the overcrowding, then, may be in one room only, where that is let separately, while the number of occupants in the house as a whole might not exceed the permitted number. Even though the sub-tenant family were related to the principal tenants, if the sub-tenant family was restricted to the use of certain rooms, the permitted number for these was assessed and if this was exceeded by the equivalent number of occupants, that letting was ranked as being overcrowded. Of the 628 cases of overcrowded houses, 237 were instances of overcrowding in rooms though the house as a whole was not overcrowded. 3. The following table analyses the other 391 cases in the varying types of accommodation, the cause of the overcrowding (houses let overcrowded; normal increase; married children; three generations; lodgers related or not related) and the number of cases where the degree of overcrowding is 50 per cent. or more than the permitted number. Accommodation Let O/C Normal Increase Married Children 3 Gen. Lodgers 50 per cent.O/C Total Rel. Non-rel. 1 Room 10 12 — — 1 — 6 23 2 Rooms 17 105 10 3 21 5 49 158 Flat 5 15 25 16 10 6 8 61 House 2 12 107 78 19 11 6 149 Total 34 144 142 97 51 22 69 391 41 The table shows that most of the cases of overcrowding are due to normal increases in families in rooms or to married children continuing to live with their parents. 4. The degree of overcrowding, of course, varies. In many cases it will be of the slightest, but nevertheless sufficient to necessitate the house being classified as being overcrowded. At the other end of the scale are many very badly crowded and the table shows that there are 69 families living in accommodation which is crowded by 50 per cent. more than the permitted number. Apart from the deleterious effects of living in overcrowded conditions on the physical state of the inmates, regard must be had to the psychological manifestations which appear in many. Some of these families are lowly pointed and, therefore, are unlikely to be rehoused by the Council. Nevertheless, the living conditions of families are seriously undermining their health and causing conditions which can be remedied only by the rehousing of some of the occupants. The following is a summary of the cases added to the register and/or rehoused during the year:— Overcrowded, January 1st, 1948 587 New cases 275 Rehoused: Council houses 131 Requisitioned property 29 Other means 78 Adjustment for two cases abated by movement of one family Nil Overcrowding reduced but not abated 4 238 866 Cases outstanding 31.12.48 628 Provision of Houses. Although the first of the Acts which enabled local authorities to build houses to be occupied by those living in their districts was passed as far back as 1890, it was not until after the first world war that local authorities took advantage on any scale of their powers. The housing situation in many districts had been becoming difficult before 1914. The position was made more severe for a number of reasons. During the war years no houses had been erected; the lack of maintenance during these years resulted in a speedier obsolescence of houses, whilst in addition building costs rose markedly. In the 1920's a number of Housing Acts were passed to encourage the building of new houses, some of these by means of the subsidies favouring construction by local authorities, others by private enterprise. The flow of new houses was sufficiently satisfactory that the Housing Acts of the 1930's aimed not so much at the construction of new houses as at the prohibition of occupation of those which had had their day and 42 at the abatement of overcrowding. Nevertheless, it was becoming apparent that the provision of houses for quite a substantial section of the community would have to be the responsibility of local authorities rather than private enterprise. The second world war added to housing difficulties in just the same way as had the first war, with the added factor of the large number of houses which were destroyed by enemy action. The post-war period, then, found almost every section of the community looking to the local housing authority to find them accommodation, a very changed outlook from the time when it was only a limited section which would consider living in Council houses. The number of houses in the ownership of the Harrow Council at the outbreak of the war was some 2,000. Most of these had been erected by one of the three constituent authorities before amalgamation. The housing programme of the Harrow Council was of quite modest dimensions designed to meet the needs of a limited section of the community. The needs of the rest, private enterprise was meeting, especially at the time of the construction of much new property which had been such a feature in this district. Shortage of materials, especially of certain items, and shortage of labour make the number of houses being built fall short of requirements both nationally and locally. The building programme has, therefore, had to be curtailed, while there are, too, the regulations controlling the proportion of building by private enterprise and by municipal authorities. Last year 882 houses were built in Harrow. Of these 365 were erected by the Council and 87 by private enterprise, and 112 replaced houses demolished as the result of enemy action. In addition there were 318 houses put up by the London County Council in their Headstone Lane estate. Since the end of the war, the total number of new houses built in the district is 2,541. Of these, 835 are Council houses (635 permanent and 200 temporary), 330 were put up by independent builders, and 1,098 (1,026 permanent and 72 temporary) are part of the London County Council Headstone estate. It was calculated that the land available in this district would be sufficient to enable the Council to build after the war only 2,175 houses; of these the number available after October 1st, 1948, would be 1,438. On the other hand the number of housing applications received by September 30th, 1948, was 6,327. The allocation of the 2,175 houses was decided as: one-bedroomed, available for man and wife, 196, a percentage of nine; two-bedroomed, available for man, wife and one child, 676, or 31 per cent; three-bedroomed, available for man, wife and two or three children, 1,205, or 55 per cent.; and four-bedroomed, available for man, wife, and four or more children, 98, or 5 per cent. Allocation of Houses. Local Authorities have available for letting their pre-war accommodation, houses or flats in requisitioned properties, and the post-war accommodation, temporary and permanent. With the number of applicants for Council houses being out of all proportion to the accommodation available, most local authorities determined the selection of those to whom houses were to be allocated by some system of points. In this 43 district such a scheme was prepared. In regard to some of those applicants whose needs rested primarily on health grounds, however, other arrangements were made. Particulars of these could be submitted by the Medical Officer of Health to the Selection Sub-Committee. The three groups were those living in overcrowded conditions, those families of whom a member was suffering from open tuberculosis, and those families living in condemned properties, whether the result of a demolition order or of a clearance order. Last year the points scheme was altered, and at the same time special provision was made for those living in overcrowded conditions; the revised pointing made allowance for this. It was also decided that one in six of the new houses built should be allotted to those whose needs rested primarily on the grounds of one of the family suffering from tuberculosis. The case of those living in condemned properties was met by their particulars being brought to the notice of the Public Health Committee and suitable recommendations being made to the Housing Committee. By this procedure the case of those living in the houses in the College Hill Road clearance order and the Ferndale Terrace clearance order were referred to the Housing Committee in 1947, and all the families were rehoused during 1948. At the end of the year the following properties which had been the subject of a demolition order or of a clearance order of the Council made before the war were still occupied (the number in brackets is the number of houses occupied). Clearance Orders: High Street, Stanmore, No. 3 (2); High Street, Stanmore, No. 4 (4); Headstone Drive (20); Pleasant Place (3); and Brewery Cottages (5). Demolition Orders: 1-11, Peel Road (3); 99-101, Greenfield Road (1); Kingsfield Terrace (6). In addition, demolition orders have been made since the war in respect of 35, Milton Road and 11, Burns Road. There are the names of 1,400 persons on the register of those who have been notified as suffering from tuberculosis. Of these 200 are suffering from non-pulmonary tuberculosis; most of these will be noninfectious. Of the 1,200 notified pulmonary cases, many are not infectious and are not a danger to those with whom they are living. Unsatisfactory housing conditions might well be one of the factors that lead to the development of an attack; in the same way they may cause the breakdown of a lesion which has healed. For these reasons it is most desirable that all who have had or have tuberculosis and the family contacts of sufferers should be adequately housed. In determining, however, which families in which a member is suffering from the disease should be given the special claims to housing over and above all those thousands of persons who for one reason or another so badly needed rehousing, it was felt that the test should be the danger to others arising from the presence of the patient suffering from open tuberculosis. Such a person should have a room to himself. If this could be managed only by the rest of the family being overcrowded, then the family is put on the list of those considered for rehousing. 44 There are, of course, degrees of urgency dependent mostly on the degree of overcrowding. Other factors have to be considered, however, including the infectivity of the patient. In regard to this, great help has been received from the physicians at the chest clinics. At the beginning of the year there were 79 families on the list for consideration for rehousing because a member was suffering from open tuberculosis. A further 63 cases became known in the course of the year. During this period, the names of 39 were removed from the list, 21 being rehoused by the Council. The number at the end of the year needing to be rehoused was therefore 103. SUPERVISION OF OTHER PREMISES. Factories. The following is a copy of the return made to the Ministry of Labour and National Service giving information about the number of factories in the district, the inspections made and the defects found:— Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4, and 6 are to be enforced by Local Authorities 98 268 23 — (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 361 804 72 — (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 72 130 3 — Total 531 1,202 98 — Particulars Number of cases in which defects were found Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 67 42 — — Overcrowding (S. 2) 1 — 1 — Unreasonable temperature (S. 3) 1 — — — Inadequate ventilation (S. 4) 1 1 — — Ineffective drainage of floors (S. 6) — — — — Sanitary Conveniences (S. 7)— (a) Insufficient 3 2 — — (b) Unsuitable or defective 16 13 — — (c) Not separate for sexes 1 — — — Other offences against the Act (not including offences relating to Outwork) 8 6 1 1 Total 98 64 2 1 45 In addition to the inspections recorded above, 399 visits were made to premises of outworkers, i.e., persons undertaking at home, work sent out from factories or business premises. Shops. During the year 1,803 visits were made to shops in the district by the Shops Acts Inspector. As a result, 114 contraventions of the Acts in respect of the exhibiting of notices and the keeping of records were noted and dealt with. Sixty-one food shops were cleansed and redecorated, and 143 requests for other repairs and improvements were made and complied with. Sixteen contraventions about the hours of closing were noted. Fourteen of these were first offences and warning letters were sent to the persons concerned; and on the instructions of the Public Health Committee final warning letters were sent to the other two offenders. In addition, two cases were found where assistants were being employed on their weekly half-holiday and in one instance a shopkeeper had to be warned for failing to close his shop on the day of the weekly holiday. The Shops Acts on the 31st December applied to 2,230 shops in the district, an increase of 23 over the number appearing on the register at the 31st December, 1947. Rat Infestation. During the year two surveys were made of the sewers in the district to ascertain whether they were rat infested. Though 820 manholes were baited, no serious infestation was found. Regular treatment of the Council's refuse tips was also carried out and the watercourses in the district dealt with. No serious infestations were encountered during the course of this work though rats were found present along considerable stretches of the River Pinn. The nature of the land through which this watercourse flows makes complete eradication difficult and it is now receiving periodical attention at frequent intervals. Most of the 766 surveys made during the year as a result of observations or complaints dealt with overgrown gardens, chickens or accumulations of waste matter. Householders who keep pountry would render a real service to the community if, when erecting chicken runs, they would ensure that the buildings are kept well above ground level and the run itself is ratproofed. Householders can also help to prevent infestations occurring by not retaining on premises any unnecessary debris or allowing gardens to become overgrown. From the administrative side the most important event of the year was the introduction by the Council during August of a free rat-destruction service for private dwellings. A charge is still made for any work carried out on factory, business or commercial premises. Smoke. Combustion of bituminous coal, the common domestic industrial fuel of Great Britain, results in three million tons of solid matter (tar, oil particles, soot) and five million tons of sulphur dioxide and various other products of partial combustion, including methane and carbon monoxide 46 being thrown into the air each year. It is estimated that smoke costs annually one hundred million pounds because of the need to clean buildings and repair masonry, the laundering entailed, the replacing of plants in parks and open spaces, the waste of fuel by imperfect combustion and the need for extra lighting, etc. Half of the smoke emitted is produced by the domestic grate. Even in non-industrial districts such as this one in which the smoke problem is light compared with many other localities, improvement could be brought about by the conversion of domestic grates into types which produce little or no smoke, or by the greater use of smokeless fuels. Ten complaints were received during the year of nuisances arising from smoke. In one of the two factories where wood chippings are being used as part of the fuel, a grit arresting plant has been installed. 47 INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY. Production. The number of farms in the district remains as for the year 1947 at nine. Of these, four are producing T.T. milk, one accredited and remainder ungraded milk. From only four of the farms is the milk produced sold locally. From the others, which include three of those producing a designated milk, it is sold wholesale. Distribution. The following is a summary of the premises licensed under the Milk (Special Designations) Orders:— (i) No. of premises licensed to pasteurise milk 2 (ii) No of premises licensed to bottle T.T. milk 2 (iii) No. of premises from which pasteurised milk may be sold Of these, 30 are controlled by the United Dairies, Ltd., or Express Dairy Company. 44 (iv) No. of premises outside the Harrow district from which pasteurised milk may be retailed in Harrow 9 (v) No. of premises from which T.T. milk may be retailed Of these, 10 are controlled by the United Dairies (London) Ltd., or the Express Dairy Company. 22 (vi) No. of premises outside the Harrow district from which T.T. milk may be retailed in Harrow 10 In addition, there are three establishments from which raw milk is retailed; and three from which milk is sold in sealed containers. Inspection and Supervision. During the year, 167 visits were made to cowsheds and dairies and where necessary those responsible were requested to execute work of repair or improvement. At one farm a modern type of milking parlour was provided. The layout allows cows to enter the parlour only for the purpose of being milked; whilst this is in progress, a regulated quantity of food is provided to each animal, supplied from a store in a room above, the food passing to the feeding pan and down an enclosed duct. The milking is by means of a mechanised milker, and the yield of each cow is automatically recorded. The milk is conveyed by pipe lines from a glass reservoir in the parlour to the dairy without being handled or exposed to the air. A similar plant is to be installed at another farm in the district. Of only one of the fifty-one samples or milk taken during the year was an adverse report received. In this case a follow-up sample and those subsequently taken showed the cause of the trouble had been removed. In addition to samples taken locally, samples were taken every month from producers in the district by the Middlesex War Agricultural Executive Committee; the results indicate the high standard of previous years is being maintained. 48 The following is an extract from the Annual Report of the County Medical Officer for the year 1946: In regard to milk production, samples are being taken by inspectors of the Public Control Department either in the course of retail or at the farms of origin which are in Middlesex. These are submitted to examination for the presence of tubercle bacilli. In 1946, out of 391 samples, 17 or 4.3 per cent. contained living tubercle bacilli. Ten of the infected samples were produced in Middlesex. Diseased animals were traced at ten of the farms concerned, six of these being in Middlesex, and 12 cows were slaughtered. The routine veterinary inspection of Middlesex herds is carried out by officials of the Ministry of Agriculture. In 1946, 4,589 clinical examinations of bovine animals were carried out. Tuberculosis was suspected in 19, and 19 animals were slaughtered. The County Council is responsible under the Milk (Special Designations) Orders, 1936 to 1938 for the granting of licences for the production of tuberculin tested and for accredited milk. Before the issue of such a licence, the farm is inspected by a member of the County Council staff and the Milk Production Officer on the staff of the War Agricultural Executive Committee. Enquiries are made into the condition of the premises and of the herd and the suitability of the technique adopted. After the issue of licences regular routine samples of milk in the course of production are taken at the farms and submitted to biochemical and bacteriological investigation with a view to ascertaining that a satisfactory standard of cleanliness is being maintained. Complaints. During the year, 12 complaints were received regarding foreign matter in milk delivered to consumers in the district. Summary proceedings were instituted in respect of three of these, the foreign matter in one being a piece of coke and the other two glass. Complaints regarding the presence of foreign matter in milk bottles would be reduced, if not eliminated, if householders and the occupiers of other establishments receiving milk would rinse out bottles after use and place them in a position where they can be collected and not allowed to accumulate. (B) MEAT. There are seven slaughterhouses in the district. Even in ordinary circumstances, very little killing took place there. From the early days of the war, the use of these was prohibited by the Live Stock (Regulation of Slaughtering) Order, 1940, though a limited amount of killing at one was permitted. S. 3 of the Slaughter of Animals Act, 1933, prohibits the slaughter or stunning of animals in slaughterhouses except by persons licensed by the local authority. No regular slaughtering took place in the district during the year, the only animals slaughtered being pigs kept by either private individuals or pig clubs. Eighteen pigs were inspected, and all were found fit for human consumption. 49 (C) OTHER FOODS. Inspection and Supervision. During the year, 2,187 visits were made to premises at which food was prepared or sold. As a result much work resulting in improvement of the premises was carried out. During the year, much of the preliminary work of the cleaner food handling campaign was carried out. The following is a summary of the food found to be unfit for human consumption during the year, and either destroyed locally or disposed of by the salvage division of the Ministry of Food:— lbs. tins Fresh meat (home killed and imported) 1,188 Tinned Meat (including bacon and sausages) 2,805 901 Other meat products (including poultry) 880 Fresh fish 4,995 Tinned fish 743 2,032 Fresh vegetables 3,948 Tinned vegetables 1,759 1,329 Fresh fruit 231 Tinned fruit ... 1,356 723 Groceries (including jam, cereals, cake mixture, cooking fats, dried egg, etc.) 3,076 Tinned milk 1,043 1,114 Shell eggs 3,994 The total weight of food found unfit during the year was a little under 10 tons. This represents an increase of approximately 8 per cent. over the quantity involved during the year 1946. Ice-cream. On the 31st December, 22 premises were registered for the manufacturing of ice-cream, and 185 others for the retailing of this commodity. Most of the premises registered for retailing deal only in pre-packed cream ; they give rise to little trouble. During the year, 227 visits were made to the premises of manufacturers or persons dealing in loose cream. In a number of cases, as a result of advice given, structural improvements were carried out, or new and improved equipment installed. Registration of Hawkers. S. 279 of the Middlesex County Council Act obliges a hawker of meat, fish, fruit and vegetables himself to be registered with the local authorities, and obliges the owner of any premises used to see they are registered. (D) ADULTERATION OF FOOD. In spite of the lead given by the Local Government and Public Health Consolidation Committee set up with a view to recommending the consolidation of Local Government and Public Health law, that authorities with a population of not less than 40,000 should become Food and Drugs Authorities, the Minister of Health on the representation of the Middlesex County Council declined to make an order endowing the D 50 Harrow Council with such powers. Sampling of food stuffs with a view to their being analysed, therefore, in this district is undertaken by the staff of the Public Control Department of the Middlesex County Council (Public Control Officer, Mr. S. J. Pugh, of County Offices, Great West Road, Brentford). The public analyst is Mr. E. Voelsker, Stuart House, 1, Tudor Street, E.C.4. (Tel. No. Central 9026). During 1946, 1,500 samples were submitted for examination by the County Analyst ; 85 were found to be adulterated or to be not up to standard. In addition, 4,422 samples were examined by officers of the Public Control Department. (E) HYGIENE OF FOOD. Apart from an occasional outbreak of an infection such as typhoid fever, which receives a certain measure of publicity, or the rarer instances of food poisoning due to chemicals, relatively little is heard of the relationship of food and infection. Yet it is felt that much of the gastrointestinal upsets to which so many are subject must have their origin in contaminated food, and the possibility or even the probability is that infection of food or drink is responsible for a much greater proportion of the upsets to which all are subject than it is ordinarily credited with. Just as infection of water was not a serious public health problem until water was distributed on a large scale, so infection of food stuffs has assumed greater seriousness as the result of the increased extent to which people are taking meals out rather than limiting their consumption to that which has been prepared in their own homes. There is a higher consumption of prepared foods. Shortage of hot water, soap, towels and crockery increases the risks of infection, especially if associated with an insufficiently trained kitchen staff. The contamination of the food which may be the cause of trouble might be chemical or bacterial. Where bacterial, it might be infection by living organisms or only by their released toxins, in which case the food acts as a chemical irritant. Chemicals which have been responsible for poisoning have been added deliberately as preservatives or as colouring agents ; they have gained entry at some stage of the preparation of food and they have been absorbed from the food containers. Such outbreaks, however spectacular, are not usually a serious public health problem. There is a variety of organisms responsible for food poisoning, but the most common can be divided into two groups, namely, the typical food poisoning salmonella group, and that group of staphylococci which produce a resistant toxin. These two groups gain entry from different sources, typically infect different kinds of foods and result in different clinical manifestations. The salmonella infection is mostly the result of contamination of foodstuffs such as meat pies, etc., in which preparations are used which are both liable to contamination and are themselves favourable media for the multiplication of the organisms. Infection may be by the hands of the humans, by inanimate objects such as contaminated kitchen utensils, by flies and by rats. The staphylococci are usually of human origin and may have their source in an infected finger or nose. Control of the spread of infection by food and drink, therefore, involves an attack being made at many points and on a very broad front. 51 Although food poisoning is notifiable under the Food & Drugs Act, every medical practitioner being required to send a certificate to the Medical Officer of Health of the district if he becomes aware or suspects that a patient whom he is attending is suffering from food poisoning, it is very certain that the number of notifications received is but a small fraction of the cases that should be notified. In this last year only one case was notified. In no year have there been as many notifications as the 11 in 1939 when food poisoning was first made generally notifiable. The 1875 Public Health Act gave authorities power to deal with food which was diseased, unsound or unwholesome. Later legislation enabled improvements to be made in the state of the premises in which food was prepared or sold or stored or handled. Other legislation has dealt with the transport of certain foodstuffs. If all the provisions of the statutory enactments, bye-laws and regulations relating to food and its handling were enforced to their utmost, however, this would necessarily lead to the abolition of food infections. This is not to be achieved by the application of penal provisions of the legislation, but rather by the education of all those concerned. This relates not only to those who deal with the preparing and the handling of the food, including the housewife, but with all those who deal at any stage with the foods or the containers or the machines which are used. With this in mind the Council accepted the recommendation of the Public Health Committee that a campaign should be opened with a view to raising the standard of food hygiene throughout the district. To deal with this the Public Health Committee appointed the Food Hygiene sub-committee. In this district there are 904 trades or businesses concerned with the handling of food at which two or more assistants are employed. Those concerned with the preparation of food for consumption on the premises number 120, including 45 restaurants, 21 tea shops and cafes attached to shops, and 54 dining rooms or snack bars. This figure does not include the 16 public houses at which meals are served, the factory canteens, the school canteens and the civic restaurants. There are 123 butchers' shops, 217 grocers, 122 fruiterers and greengrocers, 61 fish shops (wet and dry, 34; fried fish, 15; wet, dry and fried, 12), 166 sweet shops, 59 confectioners (20 with bakeries attached) and 36 dairies. There are 21 manufacturers and 162 retailers of ice-cream. Foodstuffs are sold at 9 multiple stores. In addition to all those concerned at these very many premises, there are the street vendors and delivery hands. Because of the very large numbers involved, the widespread nature of the district and the many separate shopping centres, it was decided not to attempt to deal at the one time with all those concerned in the handling of food. Because of the large numbers and because, too they were dealing with the food in its final state before consumption, the catering industry were first approached. There was a gratifying response to the invitation sent to them to attend a meeting at which the Chairman of the Council presided and at which the aims of the Food Hygiene sub-committee were submitted by the Chairman of the Public Health Committee. A subcommittee of those interested was set up in which those actually handling the food were well represented. The Food Hygiene sub-committee of the Council is kept in touch with this sub-committee by one of their 52 members attending. The committee favoured the setting up of a Guild of Hygiene of the food handlers, with separate sections for the various interests, and for each of which a code of practice was to be prepared. Membership of the Guild would be conditional on the premises attaining certain standards and subject to the conforming by all employees of a satisfactory technique. By the end of the year, the Catering sub-committee were preparing their code of practice which would be applicable to those in this section of the trade. The intention, then, was that other sections were to be approached in a similar manner so that ultimately all those dealing with the preparation or handling of food in this district would be included. While much work falls to the traders' sub-committee in the early stage, particularly in preparing the code of practice which, being of a standard high enough to achieve the objects of the campaign, would nevertheless be practicable, it is anticipated that afterwards each sub-committee would need to meet only infrequently, the main labours then falling on the Advisory Council, which would comprise the members of the Council's Food Hygiene sub-committee and members representing all the various trades and interests. Essentially the campaign is one of education to make all those concerned in the handling of food at any stage aware of the dangers of contamination of foodstuffs, but more than that to endeavour to raise the levels of aesthetic standards, so that precautions are taken or things are not done not because of the risk that the consumers of the food might develop some illness, but because the action is an offence to decent standards. The campaign might result in an improvement in the structural state of some premises; the Council might be able to help the traders to obtain those items which will make it easier to attain a state of cleanliness but at the back of it all is the object of developing first an awareness of the problem in the minds of all those who are dealing with food and then encouragement and stimulation so that all will naturally in their practice attain these high standards. 53 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. 20-25 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over Total Scarlet Fever 2 40 97 18 10 2 4 8 181 Diphtheria 1 2 2 1 — — 5 2 — — — 13 Pneumonia 3 5 5 1 — 1 7 8 16 9 8 63 Dysentery 2 2 — — — 1 1 2 1 1 — 10 Erysipelas — — 1 1 — — 2 4 6 12 3 29 Cerebro-spinal Fever — — — — 2 1 — — — — — 3 Puerperal Pyrexia — — — — — 1 2 3 — — — 6 Poliomyelitis 1 2 3 — 3 1 1 1 1 — 1 14 Polioencephalitis — — — — 1 — — — — — — 1 Measles 25 540 585 13 5 2 6 3 2 — — 1,181 WhoopingCough 64 305 237 4 1 4 5 2 3 — 1 626 Typhoid Fever — — — — — — — — — 2 — 2 Encephalitis Lethargica — — — — — — — 1 — — — 1 Disease Cases Notified Admitted to Harrow Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Scarlet Fever 181 57 48 — Diphtheria 13 — 13 — Pneumonia 63 — — — Dysentery 10 — 3 2 Erysipelas 29 1 13 — Cerebro-spinal Fever 3 — 3 — Puerperal Pyrexia 6 — 4 — Poliomyelitis 14 — 9 3 Polioencephalitis 1 — 1 — Measles 1,181 — 12 — Whooping Cough 626 — 8 — Typhoid Fever 2 — 2 — Encephalitis Lethargica 1 — 1 — CONTROL OF INFECTIOUS DISEASES. The communicable diseases are spread in many ways. In most of them, the organisms are probably conveyed more or less directly through the air from the infectious person who may be suffering from a frank attack of the disease, or he might be one of a variety of carrier. A much smaller group of infections are those most commonly conveyed through the medium of food or drink. Some contagious diseases are spread only when there is actual physical contact. For a small number 54 of infections, a very small group now in this country, the infection is introduced by inoculation, the infective agents getting into the body tissues through a breach in the surface of the skin, or sometimes of the mucous membrane. Occasionally, transmission is by mediate infection, which may be remote or recent. With such a variety of means of spread, the methods adopted to control transmissions must vary. Then diseases differ very much in their severity and in their public health significance. To some, virtually all of us in this country succumb some time or other. There might be, then, little point in endeavouring to avert an attack. On the other hand, an attack of, say, measles in the very young might be so serious that every effort should be made at least to postpone the onset. Then there are very common complaints which in childhood cause so little disturbance, but which in the adult may have more serious consequences. While it would not be suggested that there should be deliberate exposure of a child to such a disease as mumps or german measles, yet in view of the possible complications of an attack of mumps in an adult or the effect on her child of an attack of german measles by a mother in the early stages of pregnancy attacks of these two complaints in childhood in general cannot be looked upon as disasters. Whether anything should be attempted, then, to limit the spread of infection depends partly on the clinical seriousness of the disease. Another point that must arise in the case of the less serious of the complaints is whether anything really effective can be done to control the spread. These are some of the points which have determined the policy governing the steps to be taken in regard to the various diseases. Notification. The first step in the control of any infection is to obtain a knowledge of the incidence and, more especially, to learn of the early cases. This is done by notification. In 1889, a number of communicable diseases was set out in the Infectious Diseases (Notification) Act, which was adoptive, that is, it was not of general application, but could be operative in any district at the election of the local authority. Ten years later the Act became generally applicable throughout the country, though London had its own Acts. In the consolidating Public Health Act, 1936, some small amendments were made to the list which now includes smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fevers. These are the " notifiable diseases." A local authority can, with the sanction of the Minister, add to the list of diseases which are notifiable. In this way, pemphigus of the new-born has been made notifiable in this district. The Minister of Health is empowered to take steps to control the spread of various infections. Under these he has made regulations which call for the notification of the following conditions:—plague, cerebro-spinal meningitis, acute poliomyelitis, acute polioencephalitis, encephalitis lethargica, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles and whooping cough. 55 Another condition which is notifiable to the Medical Officer of Health is food poisoning; this is under the provisions of the Food & Drugs Act, 1938. In general, notification is required by the medical attendant and by the head of the household. In practice it is most exceptional for the parent to send in a notification. The medical practitioner is required to notify forthwith on becoming aware that his patient is suffering from the notifiable condition. This is necessary not so much in the interests of his patient, because so often no action by the local authority as regards the patient might be necessary, but so that other steps might be taken to limit the spread. Enquiries. Following receipt of the notification a visit is made to the home. Up to recent years, this was carried out by the sanitary inspector, because so many of the infections were considered to have their origin in some defect in the drainage or in the structure or ventilation of the house. To-day, with an appreciation of the individual as the source of infection, in most cases the visit is made by the health visitor. It is felt, too that she might be the more suitable person to give advice about isolation and concurrent disinfection, which is considered to-day to be in most cases of more importance than terminal disinfection. Nevertheless, in certain conditions, such as food poisoning or the enteric or the dysenteric infections, or smallpox, the sanitary inspector visits. The enquiries are directed to two ends. The first is to determine, if possible, the source of the infection, with the object of taking whatever steps might be practicable to avoid others being infected from that source. It is for this reason that enquiries are made as to the source of the water or milk, or about the school or other buildings, at which the child has been. The second line of enquiry is to enable such steps to be taken as will minimise the spread of infection by the infected person. It is for this reason questions are asked about his place of occupation and lists obtained of the contacts and their places of work. Aid to Diagnosis. The earlier the diagnosis, the greater the likelihood that preventive measures will limit the spread of infection. In some diseases, the laboratory is of help. (See Laboratory Service, page 27.) Where a patient is suffering from some clinical condition which is suspected as being infectious, and in which the help of the laboratory is sought, it is usually advisable, pending the confirmatory diagnosis, for the same precautionary steps to be taken as if the patient were known to be suffering from the infectious condition. The other assistance a practitioner can obtain in the making of a diagnosis is having the second opinion. Because of his training and because, too, he was so often associated with an isolation hospital, the Medical Officer of Health usually had more experience in infectious diseases than his colleagues in general practice. It was quite usual then for him to see cases about which the general practitioner was in doubt. In future, the Medical Officer of Health will not be any more 56 closely associated with infectious cases than the medical practitioners, who will now obtain the second opinion from the medical superintendent of the Isolation Hospital. To obtain a consultant's opinion in doubtful cases of smallpox or typhus fever advantage is taken of the arrangements made by the Regional Hospital Board, approach being made to the Officer of the Emergency Bed Service. Isolation. Whether the isolation of a patient suffering from a communicable disease is necessary depends on the usual mode of spread of the complaint. The stringency of the isolation is partly dependent on the severity of the disease; its value is largely determined by the infectiousness of the patient before the nature of the disease is first recognised. Isolation hospitals were established as places to which infectious patients might be admitted with the object of preventing the spread of infection to others. The diseases from which those who were accepted were suffering were scarlet fever, diphtheria and enteric fever. In this object, isolation hospitals failed largely because of the infectiousness of the patient before the disease is diagnosed, so that secondary infection would already have occurred. Nevertheless, isolation hospitals have continued to be erected and have continued to be used, but to-day's conception of their purpose is that they are institutions to which are admitted patients suffering from conditions needing hospital treatment, but who, because of their infectiousness, cannot be admitted to the ordinary ward of a general hospital. At the same time the range of usefulness of the hospital has been widened and most of those suffering from communicable conditions who need to be treated in hospital are now admitted to the isolation hospitals. Not all those suffering from the communicable diseases, then, have to be admitted to hospital. It is not usual to admit those suffering from the commoner non-notifiable children's complaints, such as mumps, chickenpox and german measles. It would not be practicable, nor is it necessary to admit all those suffering from measles and whooping cough, though it is most desirable that those suffering from these complaints who are very young or are badly housed, or are suffering from the more serious of the complications, should be admitted. Diphtheria and enteric fever are two diseases which need skilled nursing, and all sufferers should be treated in hospital. Although infection is considered to have only rarely been spread by actual cases of poliomyelitis and cerebro-spinai fever, sufferers from these diseases are treated more often in isolation than in general hospitals. Particularly during an epidemic of influenza those suffering from the complications of this complaint are if possible admitted to hospital. With the very mild clinical type prevailing to-day, it is unnecessary for those suffering from scarlet fever to be admitted to hospital. Many beds could be better used if parents and medical practitioners would realise that not only is it unnecessary for many of the children to be removed to hospital, but that there are actual disadvantages in this being done, because, having to be admitted to a general ward, as so many of them are, they are exposed to more dangerous strains of the organisms than that which caused their complaint. Most of the patients admitted to an isolation hospital are 57 accepted at the Edgware Isolation Hospital, which was the Hendon Isolation Hospital, Goldsmith Avenue, Hendon—Medical Superintendent, Dr. Livingstone. Tel. No. Colindale 8182. For those patients who cannot be accepted here, but who are considered to be in need of admission to hospital, application for their admission elsewhere is made to the Emergency Bed Service. Smallpox is one of the notifiable diseases which is treated in a hospital quite apart from those taking in other infections. Before such patients are removed to hospital, it is now customary for the diagnosis to be confirmed by a consultant attached to one of the larger isolation hospitals. This is arranged through the Emergency Bed Service, which also decides which hospital the patient is to be admitted to. A similar arrangement obtains in the case of those suspected to be suffering from typhus fever. There are special institutions too, for the treatment of those suffering from tuberculosis, many of the pulmonary cases being admitted to sanatoria, while those suffering from the non-pulmonary disease who are mostly children are, in general, admitted to separate institutions. The arrangements for the admission to hospital of those suffering from tuberculosis are made by the physicians at the chest clinics. The school child who has suffered from scarlet fever is usually excluded from school for seven days after his discharge from hospital or from home isolation. This period is extended should he develop a cold in the head, a discharge from the nose or ear, a sore throat or septic spots. The period of exclusion of those who have suffered from diphtheria is determined usually by the child's clinical condition. After recovery, it is usual to obtain negative nose and throat swabs. A sufferer from measles is excluded for 14 days from the appearance of the rash; from german measles for seven days from the appearance of the rash; from whooping cough for 28 days from the beginning of the characteristic cough; from mumps for 14 days from the onset of the disease, or seven days from the subsidence of the swelling; and from chicken pox for 14 days from the date of the appearance of the rash. Exclusion of Contacts. Because a contact of a sufferer from an infectious disease might be a carrier either contact or incubationary, it was at one time customary to insist on the exclusion of contacts from work. The stringency of this practice has been greatly relaxed so that to-day most authorities exclude only those contacts whose work brings them into association with those of susceptible ages or which renders them possible instruments of widespread outbreaks through their handling of milk or some other medium. Even where exclusion is required, it is imposed only in the case of the more severe of the infectious diseases. In regard to children attending day schools the practice in this district is that recommended in the addendum issued in 1942 to the memorandum on the Closure of and Exclusion from Schools which had at an earlier date been issued by the Ministry of Health and The Board of Education. The period of exclusion of contacts of patients suffering from scarlet fever is seven days after the removal of the patient to hospital or the beginning of his isolation at home. Contacts of diphtheria are excluded for seven days after the removal of the patient to 58 hospital, or the beginning of his isolation at home; if there are any suspicious signs the child is excluded further until pronounced by a medical practitioner to be free from infection. Infant contacts of measles who have not had the disease are excluded for 14 days from the appearance of the rash in the last case in the house; other contacts are allowed to attend school. Infant contacts of whooping cough who have not had the disease are excluded for 21 days from the onset of the disease in the last case in the house. It is not now the practice to exclude for any time contacts of those suffering from a number of infections, e.g., german measles, mumps or chicken pox. Disinfection. The surroundings of the infectious person may be contaminated the extent to which this will take place depending very largely on the way in which the organisms leave the body of the patient. In most of the infections, the organisms leave the naso-pharynx, passing out to the air. Many of the heavier particles will fall immediately and so will infect the floor coverings, the bed clothes or the patient's clothing and hands. Some of the smaller particles remain buoyed in the air, being carried long distances, but ultimately falling on horizontal surfaces such as floors or shelves, or infecting curtains. The air then probably does not remain infective for any very long period. Naso-pharyngeal infections might also be transmitted by the soiling of the patients' hands or fingers, with the subsequent contamination of articles including furniture, books or door handles. Hands are also liable to contamination with the organisms which cause gastro-intestinal complaints originating in the infected dejecta. The procedure to be followed, then, to effect sterilisation of the premises and their contents will depend partly on the degree to which these are liable to contamination. Another factor is the viability of the organism away from the human host. Some organisms are so very delicate that it is only with the greatest difficulty that they can be kept alive away from the human. In the case of the infections due to these organisms there is little point in carrying out any practice of which the object is to destroy the organisms. Yet another factor to be taken into account is the susceptibility to infection of those who might be exposed to infection in the premises. While a room in which there had been a case of scarlet fever might not need to receive any special treatment if it is to be occupied after the child's recovery only by the mother who had nursed the child throughout his illness, the position would be very different if it was to be occupied by an expectant mother nearing the time of her confinement. With the background of these various considerations, rules of practice have been evolved upon which is based the Council's policy in regard to the practice of disinfection following the occurrence of a case of infectious disease. Departure from the practice might be necessary in special circumstances. As these when required are necessary primarily on medical grounds, any application for a modification of the general practice is usually supported by a medical certificate. The Council decided that except in cases of smallpox and typhoid fever, and in any exceptional cases approved by the Medical Officer of Health, where disinfection cannot be carried out in the home, terminal 59 fumigation and removal of bedding and other articles for stoving after the commoner notifiable infections shall be abandoned, the householder being instructed as to the precautionary measures to be taken. Where householders still request that fumigation or stoving be carried out, a charge is made, 7s. 6d. for fumigating the room, and 10s. Od. for the stoving of the first load, 5s. Od. for any subsequent load. It was later decided that terminal fumigation and stoving of articles should be carried out free of cost in the case of open tuberculosis and of scabies. Experience during the war showed that the risk of transmission of infection in scabies by clothing is very much less than it had been thought to be. Although, then, when the incidence of scabies rose so markedly in the earlier of the war years, arrangements were made for the stoving of the clothing, the practice was later modified, as ordinary laundering of under-garments was considered sufficient in most cases. In regard to the treatment of premises which have been occupied by those suffering from open tuberculosis, it is felt that in this even more than in the other infections, it is essential that the premises should be thoroughly cleansed beforehand, otherwise the organisms are too likely to be protected against the action of the disinfectant. The practice has been adopted, then, through the kindness of the staff of the chest clinics, of a report being obtained from them that the other steps have been taken and the premises cleansed. On receipt of this report, but not until then, arrangements are made for the treatment of the rooms and their contents. DIPHTHERIA. Incidence. Not a single person in Harrow suffered from diphtheria in 1948; 11 patients were notified to be suffering from the infection and admitted to hospital, but in not one of these cases was the diagnosis confirmed, each one of them suffering from streptococcal infection of the throat. Although in some years only a few persons succumbed to the disease, this is the first time it has been possible to record the absence of the infection for an entire year. Only a few years ago, a district with Harrow's population would be expected to have anything between 200 and 400 cases in a year. Of these, between 10 and 40 could have been expected to have died. It is common knowledge that throughout the country the incidence of and the fatality from diphtheria have fallen markedly in recent years, a decline which has coincided with the increasing extent to which children have been immunised against diphtheria. Although in some districts facilities for protecting the children have been available since the late 1920's, it was not until the national campaign started during the war that the practice became general throughout the country. The fall in the number of notifications in the whole country during the past few years, although quite dramatic, had not been here on the same scale as happened in parts of America where for a time the disease was virtually obliterated. While other factors such as a decline in the invasiveness of the organism may have played some part in the fall of incidence, it is generally accepted that the main factor is the extent to which the children have been immunised. 60 This district is without doubt very fortunate in that no cases occurred here in this last year. In spite of the general fall throughout the country, there were still very many cases, the incidence for England and Wales being 0.08 per 1,000. At that rate Harrow's population of about 220,000 would have had 18 cases. The difference is not that immunisation in Harrow has been any more successful than in the country as a whole. It has not been carried out on a great scale here, nor has it been less, but has been very much the same as the national rate. Harrow's percentage of children under 5 who were immunised was, at the end of 1948, 53; of those over 5 but under 15, was 67. In point of fact, even before immunisation was practised in this district to any large extent, in some years the local incidence was very slight. The actual numbers of cases in which the diagnosis was confirmed in each of the years from 1934 to 1947 were 80, 85, 30, 98, 63, 54, 78, 39, 51, 40, 16, 29,17 and 6, giving rates ot incidence per 1,000 population of 0.60, 0.58, 0.22, 0.54, 0.34, 0.30, 0.41, 0.20, 0.26, 0.21, 0 08, 0.15, 0.08 and 0.03. Place of Treatment. All those notified as suffering from diphtheria were admitted for treatment, almost all to the Hendon Isolation (the Edgware Isolation) Hospital. Immunisation. When the Harrow Council first agreed in 1934 to arrangements being made for children to be immunised against diphtheria, this was to be done by the general practitioners rather than by the usual arrangements by which children attended special immunisation sessions. When the national campaign started, facilities were offered to those mothers who brought their children to the infant welfare centres to have them treated there, while for a short time school children were treated at some of the schools. All children attending the day nurseries are required to be immunised against diphtheria. During the last few years the numbers of those who have been treated at the clinics have exceeded those treated by the general medical practitioners. Under the provisions of the National Health Service Act, the responsibility for offering facilities to the public of the district to be immunised against diphtheria has passed from the District Council to the County Council. Under these arrangements the general medical practitioners will play a big part in the diphtheria immunisation campaign. It is a service which is quite independent of the general medical service and can be undertaken by doctors who do not participate in the general services providing they have entered into the arrangement with the County Council. On the other hand, it is only those who have entered into this arrangement that can treat the children under the County Council's scheme. The treatment is free of cost to the parents, the medical practitioner being paid a capitation fee by the County Council. He is also supplied free of cost with the necessary antigens; these can be obtained from the Public Health Office or from the Central Laboratory, Colindale. For the immunising of children A.P.T. is the accepted antigen, 0.5 c.c. being given, followed by another dose in a month's time. It is now recommended that reinforcing doses should be given when a child 61 attains the age of two, and again at three, and then again just before he is admitted to school. For those who are susceptible, and they will include most adults who need to be treated, T.A.F. is recommended as an antigen less likely to cause reactions. This is supplied free of cost to the doctor wishing to use it. Immunisation of the infant is now advocated at six to nine months, so that the full effect of the inoculation, which takes some three months to develop, will come into play by the time the infant is losing his natural immunity and is reaching the stage when he is more likely to come into contact with infection. Provision of Anti-toxin. Diphtheria anti-toxin was first made available for issue under the 1910 Anti-toxin Order, under which it could be issued to medical practitioners for the treatment of the poorer inhabitants of the district. These powers were extended by the provisions of the Middlesex County Council Act, by which a local authority could provide with or without charge to any registered medical practitioner antidotes and remedies against notifiable diseases. Advantage was taken of these powers to supply diphtheria anti-toxin for medical practitioners to administer to any of their patients suspected of suffering from diphtheria. Supplies for issue were kept at the Isolation Hospital, at the Public Health Office and also at the Fire Stations. Under the National Health Service Act, the Regional Hospital Boards are providing anti-toxin for general medical practitioners, supplies being obtainable at the Edgware Isolation Hospital or at the Public Health Office. SCARLET FEVER. Incidence. Scarlet fever is a disease which is always present to some extent in a district of any size and which has a seasonal prevalence, being more common in the autumn, about 20 per cent. of the population suffering at some time or other from the illness. In the years between the two wars, the national incidence ranged from about 2.0 to 3.5 per 1,000 population. Local rates have ranged from 1.06 to 4.70 per 1,000, the number of cases each year from 1934 being 621, 501, 423, 415, 500, 316, 207, 326, 618, 672, 346, 270, 248 and 180, these being rates per 1,000 population of 4.70, 3.47, 2.64, 2.31, 2.72, 1.60, 1.60, 1.06, 1.66, 3.52, 1.87, 1.41, 1.38 and 0.83. 1948 was a year of low incidence. Four of the 185 patients notified as suffering from scarlet fever were subsequently found to be suffering from some other condition. The net figure of 181 was an incidence rate per 1,000 population of 0.82. The rate for the country as a whole was 1.73. There was this year no autumnal increase in prevalence. For the first two quarters of the year the average weekly number of notifications was four ; in each of the last two quarters the figure was three. Deaths. There were no deaths in the district from scarlet fever. This infection for part of the last century was a dread disease with a case mortality of up to 16 per cent. To-day in this country the case mortality 62 is a fraction of one per cent. This decline in severity must be due to some change in the organism responsible for the disease and is not due to any interference by man unless, as has been suggested, the practice of admitting to hospital the more serious cases which was carried out on a large scale towards the end of the last century had any effect in this way. That a decline in virulence of this sort has taken place suggests there is no reason a reversal of the process should not occur, with resulting increased severity of the disease. Place of Treatment. Sixty-six out of the 185 cases notified were nursed at home at the election of the parents. In the case of many of those patients who were removed to hospital, there seemed no reason that they should not have remained at home. There are these days very few cases where admission is necessary on clinical grounds. In a small number of cases, removal is advisable with the object of limiting the spread of infection, or because of some special situation at the home. So often the patient even when removed has been at home in an infectious condition for some days, so that it is probable that he has by then done what harm he is likely to do in the way of transmitting infection. Too many cases are being admitted to hospital not because the step is necessary, but because it is convenient to the household, or because of what in many cases is an unreasonable apprehension. Admitting such patients results in the hospitals not being able to accept those suffering from other diseases, patients who are so much more in need of hospital attention. Secondary Infection. Secondary infection occurred in six households. In four of them only the one secondary case occurred ; in two of these the primary patient was removed to hospital. In the first of these, removal was on the fourth day, in the other on the fifth. The interval between the onsets of the illness of the primary cases who were nursed at home and the secondary cases were eight days and four days. In each of the other two households, there were two secondary cases. In the first house, the primary case was the mother, whose illness had been unrecognised until a week from the onset of illness of her two children. In the other household a child of six fell ill on the 11th December, and was removed to hospital on the 13th ; the following day his two sisters succumbed. Return Cases. There was only one household in which a return case occurred. The primary case was a girl of six who had fallen ill on the 18th June and was removed to hospital on the 22nd. She was apparently normal when discharged on the 10th July, and remained apparently healthy. Her sister, aged four, developed scarlet fever on the 19th July. Schools and Infection. Although so many of the patients who succumb to scarlet fever are children of school age, it is very rarely in this district that the onset of illness is associated with another recognised case at the school. Of course, scarlet fever is but one manifestation of the reaction of an 63 individual to infection by the hæmolytic streptococcus which might in various persons set up other reactions such as sore throats. Although, then, a child at school cannot be found to be a contact of another school child suffering from scarlet fever, it could well be possible for him to have contracted the infection by the streptococcus at school from a child who might be a symptomless carrier, or may be reacting in one of the other ways to his infection by the streptococcus. Whether that actually is the case is unknown. What is known, however, is that contrary to what at one time seemed common experience, namely, that a child of school age suffering from scarlet fever was often found to have been associated with the previous case in the same school, in this district for yet another year it has to be reported that school attendance seemed to have played little if any part in the transmission of this infection. There have certainly been groupings of cases in departments, and it may be that infection might have spread from one child to another in a different class, though associated in the school, even though in that event the original patient did not seem to have infected his classmates. Had this occurred at all, though, it must have been on a very small scale. In each of six weeks, there were two cases in one school. On one occasion there were three cases in the one school. Apart from these groupings, there was usually only the one case from a department in any one week, and no case in that department in the preceding or in the following week. SMALLPOX. It is only exceptionally these days that there are any patients in this country suffering from smallpox. Occasionally cases occur secondary to the landing in this country from abroad of a patient. In such cases, the contacts are listed, the health authorities of the areas to which they are proceeding are advised, and the contacts are visited up to the limit of the incubation period of the disease. Air transport has added to the risks of importation of this infection, and has considerably swollen the numbers of persons who have to be kept under observation. The National Health Service Act removed the compulsory element of the Vaccination Acts. Instead of the practice being obligatory, except to those exempted under the conscientious objection clauses, it is now left to the parents to decide about having their children vaccinated. If they wish this done, they can have it carried out free of cost by any of the doctors who have entered into the arrangements of the County Council to do this work, but it cannot be done by the family doctor under the County Council's arrangements if this doctor has not agreed to take part in the scheme. In recent years only about one child in three has been vaccinated. It may be that the removal of the compulsory element will result in this proportion being increased. On the other hand, smallpox to-day in this country is not the real risk to a child that diphtheria was until a few years ago, so it is improbable that as many will have their babies vaccinated against smallpox as are having them protected against diphtheria. 64 Patients suffering from smallpox are admitted to special hospitals, and for many years those from Middlesex have been admitted to one of the London County Council special hospitals. Before admission to a hospital can be arranged, it is now necessary that the opinion of a consultant shall have been given confirming the diagnosis. The Regional Hospital Board has arranged that consultants might be available through the machinery of the Emergency Bed Service. The actual arrangements for removal of the patient and his admission to hospital are made by the same body. TYPHUS FEVER. Typhus fever, a louse-borne infection, is not ordinarily present in this country, but is liable to be imported, particularly during wars. Air travel increases the risk of importation, so many visits have to be paid to the homes of those about whom information is received that they have recently arrived by air from a suspected area. If a case is suspected the opinion of a consultant can be obtained just as in the case of smallpox. Patients suffering from typhus fever are not admitted to the ordinary isolation hospitals. Because of the manner in which it is conveyed, special precautions have to be taken by all those who come into contact with what may prove to be a case of this infection, every member wearing special garments which will reduce the risk of louse infestation. For this reason the suspect is removed to hospital not by the ambulance which is used for the removal of those suffering from the commoner infections, the arrangements for the removal of the patient are made by the authorities of the hospitals to which these patients are admitted. MALARIA. Although at one time endemic in large areas of this country, to-day malaria is endemic only in limited localities, and in general the greatest risk of infection is the return home of those large numbers of members of the services who have been in malarial-infested countries. Notifications are occasionally received, though in fact not one was in 1948. All of those in this area have referred to persons who had contracted the infection abroad and were suffering from relapses. ENTERIC FEVER. Each year a small number of notifications is received amongst those living in this district. Very rarely the disease is typhoid fever, the vast majority of the cases being of paratyphoid fever, the organism nearly always being the para B type. Although clinically similar—though again the paratyphoid illness is in general more mild in character than the typhoid infection—epidemologically the diseases are very different in that typhoid fever is almost always related in its incidence to water, while paratyphoid infections are more commonly food borne. The ultimate origin of the organism is human. 65 In 1934, seven cases were notified; in the succeeding six years, the numbers were 5, 5, 2, 2, 7 and 2. In 1941, there were 17 cases. This prevalence, which was due to a paratyphoid infection, was part of a heavy incidence throughout the country, which was probably the result of lower hygienic standards of food preparation, distribution and handling. In the next years 1, 4 and 3 cases were notified. In 1945, no cases were confirmed. There were three para B notifications in 1946. In 1947, there were two confirmed cases among the general population; the other cases of infection which were notified in that year being those occurring in a residential nursery in the district. The cases which have occurred each year in this district have never been found to be associated with each other. It is hoped that in future the services of the Public Health Laboratory, particularly with the phage typing, will enable even the apparently single sporadic case to be traced and the cause detected. Of the eight cases notified in 1948, in only four was the diagnosis confirmed; of these a patient suffering from typhoid fever died. The other three were all cases of the para B infection. The first was a man of 61, who fell ill in December, 1947, but the attack was not diagnosed until January 7th, 1948. The next was a girl of five who was admitted to hospital on January 19th. The remaining case was a man of 34 who succumbed in August. The cases had no association one with another, and lived in different parts of the district. DYSENTERY. This is an infectious complaint manifested typically by gastrointestinal symptoms which may follow infection a variety of organisms. Those which cause such widespread infection in some parts abroad do not occur in this country except amongst those who contract their infection overseas. Some of the organisms present in this country can cause severe attacks; on the other hand, some of them cause so little disturbance that the infection is attributed merely to a gastro-intestinal upset. Dysenteric infection is probably very widespread. Attack by one variety of organism is responsible for the very marked invasions of the populations of mental institutions. A different organism, however, is responsible for the infections which occur so frequently in children's hospital wards. How common the infection is amongst the general population is not known. If the dejecta of those suffering from alimentary disturbances were submitted more frequently to bacteriological examination, it is probable that it would be demonstrated that infection is very widespread. In the absence of full use being made of the services of the laboratory it is probable that the number of infections bears little relation to the actual number of persons infected. Probably in most years the numbers of those throughout the country who are notified are mostly the result of infection of those in institutions. Even if all cases in which a doctor were summoned were correctly diagnosed and notified, it is probable that these figures would still reflect only a fraction of those who have suffered infection, as in so very many the severity of illness would be too slight for the doctor to be summoned. However E 66 mild though the attack might be, it is important that all cases should be recognised because of their infectiousness, the unsuspected patient infecting in most cases only a member of the same household, but if she handles food, she might infect very many, all of whom might not escape with a similar mild attack. In the seven years, 1934 to 1940, the numbers of cases notified were 1, 3, 3, 24, 13, 5 and 1. Since that time, the numbers of cases notified have been higher, the actual numbers being 10, 19, 15, 13, 25 and 28. In 1948, nine cases were notified, but in two the diagnosis was not confirmed. Three cases occurred in the one household, a child of three succumbing first to a Sonne infection, to be followed within a few days by the illness of his brother and his mother. One patient was suffering from amoebic dysentery contracted in the previous year when he was in India. Control of dysentery in this country calls for the same measures as the control of food poisoning. ERYSIPELAS. Erysipelas is a disease which, although notifiable, has now little public health significance. It no longer causes the dreaded outbreaks in institutions especially amongst patients in the surgical wards, while to-day's methods of treatment have reduced the mortality rates of those attacked. Sufferers may be admitted to hospital, but if so, this is usually to enable them to obtain nursing and medical attention not available at home, and it is not now carried out with a view to limiting the spread of infection. There are, however, still some circumstances in which the disease may be dangerous, and so although for most little needs to be done, enquiries are still made at the homes of the notified cases. The most important of these conditions, perhaps, is that of an expectant mother nearing the time of her confinement being in the same house as a patient suffering from erysipelas. Each year, from 1934, the number of cases of erysipelas notified has ranged from 31 to 48. In 1948, 31 cases were notified, but in one patient the diagnosis was subsequently amended. Females outnumbered males by nearly 2 to 1, only 11 of the 30 cases being amongst males. In more than half the cases the face was the affected site, the leg being the only other commonly affected area. Half the patients were admitted to hospital for treatment, all of these being to isolation hospitals. CEREBRO-SPINAL FEVER. Each year a number of sporadic cases of cerebro-spinal fever is notified, the numbers from 1934 onwards being 1, 2, 2, 7, 4 and 4. The 36 cases in 1940 were part of the national outbreak. In the succeeding years, notifications numbered 25, 13, 7, 7, 11, 9 and 13. In 1948, four cases were notified, but in only one was the diagnosis confirmed; this was a girl of four who in March succumbed to meningococcal septicaemia. 67 ACUTE ANTERIOR POLIOMYELITIS. Small numbers of cases of anterior poliomyelitis were notified in most years, the actual number of cases in each year from 1934 being 0, 1, 5, 4, 6, 6, 0, 0, 4, 0, 1, 3 and 4. This district was attacked in 1947, when the rest of the country was subjected to the epidemic, the diagnosis being confirmed in 31 cases, It is only in recent years that the disease has taken on an epidemic phase, so not very much is known of its epidemiology. What is known suggests that once a community has been heavily attacked, the incidence afterwards remains at a higher level than before the attack. In 1948, 16 patients were notified as suffering from poliomyelitis; in the case of four, however, the diagnosis was not confirmed, leaving then, 12 cases of this infection. Of these patients, two died. In two of the patients the onset was in December, 1947, but the diagnosis was not made until January, 1948. A further patient fell ill in this month, and another in February. There was then a lull until two cases were notified in July and two in August. A further lull was followed by two cases amongst the boys of a residential school in November, and an adult female, a case which proved fatal. The last case in this year was that of a child of nine months who fell ill in December. Of the cases, four were under five years of age, two were between five and 14, three were between 15 and 21, while three were adults. The sexes were equally affected. ENCEPHALITIS LETHARGICA. This is a disease which was first epidemic in this country towards the end of the first world war, many cases occurring in the next few years. Since that time only sporadic cases have occurred. While occasional cases continue to be notified, in most the diagnosis is not confirmed. This was the position in the one case notified this year. MEASLES. Measles is a disease which had a marked biennial incidence, an outbreak starting in the last months of the year to reach a peak in the spring of the next year, fading to extinction by the late summer or autumn, after which the district would be free until the development of the next outbreak. This periodicity was disturbed in 1940, as in many areas the expected rise did not occur. In this area the epidemic was postponed to the summer. Instead of the years of heavy incidence alternating with almost complete freedom from the disease, the intermediate years are not now nearly as free. This district was attacked in 1947, the incidence having risen from October, 1946, to a peak in the early part of 1947, when there were 100 cases a week, but it was not until September that no notifications were received in any week. 1948 was a year with a minor outbreak. A weekly incidence of 12 in January rose to 26 in February, 56 in March, and 64 in April. A fall to an average weekly notification rate of 37 in May and June was followed by a steady fall to extinction in September, since when the disease has smouldered in the district with a weekly average of three notifications. 68 In the spring term, Stag Lane Infants' School was the department most heavily attacked. Stanburn School was affected towards the end of the term and suffered much in the summer term, when Priestmead Infants' School also was attacked. There was one death from measles this year. Although the disease is now notifiable, the health visitors do not call at all houses in which there are patients, but only at those at which there are young children or at which the notifying practitioner has asked that a visit might be made. Apart from the notifications, the other source of knowledge of the occurrence of measles patients is the intimation received from the head teacher of the absence of children from schools. These lists are studied and visits paid by the health visitors to those homes in which there are younger contacts. In epidemic times, over 200 cases may be notified in a week. No hospital system could cater for admissions on this scale, nor, of course, is it necessary that all those suffering from measles should be admitted to hospital for treatment. Admissions are limited to those requiring hospital treatment because of their clinical condition, usually some complication such a pneumonia or ear infection, the very young, those suffering as well from some other complaint, those who cannot be satisfactorily nursed at home, or those living in poor housing conditions. During the year, 12 patients were admitted to hospital, while the health visitors paid 191 visits to homes at which there were patients suffering from measles. There is no preparation which can produce an active immunity in humans. On the other hand, passive immunity can be induced by the injection of various preparations of human blood including convalescent serum, adult serum and placental extract. Such immunity, however, is of very short duration, and a few weeks after the administration of the serum the child is again susceptible to attack. Conferring a passive immunity then, does nothing to reduce the almost 100 per cent, of attack of the population at some time or other. There is, then, little advantage in the general administration of serum to the susceptible. On the other hand, there is a real advantage in its administration in certain circumstances. The fatality from measles is so very high in the very young that every effort should be made to prevent the very young from being attacked. Then, too, it may be advisable to protect temporarily those who are suffering from some other condition. For administrative convenience it is advisable to cut short an outbreak which might follow the introduction of a case of measles to a general ward of a hospital; in all these cases the aim is to prevent the development of the attack. In some circumstances, however, it is sufficient to ensure that the child suffers only a mild attack. This can be done by reducing that dose necessary to bring about protection or by giving the full dose at a later date. A child receiving this treatment will not be protected from an attack, but if he succumbs it will be to a modified attack, but one which nevertheless will be followed by a life-long immunity to the disease. The serum for administration can be obtained from the Colindale Public Health Laboratory. 69 WHOOPING COUGH. While not exhibiting the marked periodicity of measles, whooping cough is a disease which attacks districts in large outbreaks and then completely disappears. It has been notifiable since the latter part of 1939. The number of notifications received in 1940 was 296, and in the succeeding years 1,259, 468, 468, 683, 220, 441 and 521. In 1948, the disease smouldered throughout the whole year, the average weekly notifications in the first quarter numbering 15, in the second 20, in the third 7, and in the last 2. Many schools were attacked in the first months of the year, but none of them especially heavily. There were four deaths from whooping cough, all of them of infants under 12 months of age. The same practice in regard to visiting is carried out as in the case of measles, the health visitors paying 36 visits to the homes of those affected. Again, while it is not necessary that all sufferers shall be admitted to hospital, it is essential that these facilities should be available for those suffering from some of the complications of the disease or those in homes where nursing is difficult or the home conditions are not good. Eight patients were admitted to the isolation hospitals. The Local Health Authority is empowered under the provisions of the National Health Service Act to arrange for the immunisation of people against certain diseases. The County Council has decided not to use these powers to offer facilities for protecting children from whooping cough throughout the county. On the other hand, in certain areas before July 5th, 1948, the local authorities had already made these arrangements. Then, again, some areas are taking part in the investigations carried out by the Medical Research Council as to the efficiency of certain preparations. In these ways, then, the parents in some parts of Middlesex can have their children inoculated against whooping cough free of cost under the arrangements of the County Council, but in others, including this, these facilities are not available. It is hoped that the investigations will be sufficiently encouraging to justify the authority offering these facilities throughout the county, as although the number of deaths attributed to whooping cough might be small, the probability is that the disease in fact causes the death of many more, while in addition it results in much acute illness and in much invalidity amongst those who have recovered. PUERPERAL INFECTION. As defined by the regulations which call for the notification of this condition, puerperal pyrexia is any febrile condition occurring in a woman within 21 days of childbirth or miscarriage, in which a temperature of 100.4° F. has been sustained for 24 hours or has recurred within that period. While the raised temperature might be the result of an infection of the birth canal, or might be due to some other condition associated with the pregnancy, such as an inflamed breast or inflamed varicose veins, it might also be due to some condition, such as influenza, entirely unrelated to the pregnancy. Many of the notified patients are removed to isolation hospitals for treatment. This is especially necessary if the febrile patient is in a nursing home and some innocent 70 cause of the pyrexia has not been found. Because of the risk of transmission of infection to other patients, the midwife who attends other confinements is relieved of her duties of attending the febrile patient who is at home and who is thereafter attended by the home nurses who do not nurse women at their confinements. If a patient in a London hospital develops puerperal pyrexia, the notification is forwarded to the office of the authority of the district in which she lives. In this way each year a number of notifications are received of patients who were not delivered in this district. In 1948, six cases were notified as suffering from puerperal pyrexia ; of these, one was a notification transferred from London. Two patients were suffering from infection of the genital tract, both of them patients who had been delivered in a small maternity home in this district. OPHTHALMIA NEONATORUM. Ophthalmia neonatorum is an inflammation of the eyes of the new-born. At one time it was responsible for much blindness. To-day, probably mainly the result of preventive treatment carried out at the time of the birth of the infant, the position is much more satisfactory. Infection of the eye, however, can so readily lead to blindness that for many years local authorities have made special arrangements for the treatment in hospital of the more severe cases or the treatment by skilled nurses of those infants remaining at home. If the infant has to be admitted to hospital, it is as well for the mother to be admitted, too. If ophthalmia neonatorum occurs in an infant born in a London hospital, the notification is sent to the health office of the authority of the district in which the mother lives. In 1948, no cases of ophthalmia neonatorum were notified in this area. PEMPHIGUS NEONATORUM. This is a disease of the skin which in the new-born can cause extreme illness, or even death. Outbreaks have occurred in which the spread seemed to be associated with the practice of a particular midwife, though the exact mode of transmission is unknown. Although it is rarely met with, because of its seriousness when it does occur, the Council approached the Ministry of Health to add it to the list of diseases notifiable in the area, the request being acceded to. In 1948, no notifications were received of any infants in this district suffering from pemphigus neonatorum. NON-NOTIFIABLE INFECTIONS. These infections are not notifiable in this district and knowledge of their prevalence is obtained from the intimations received from the head teachers about the absence of children from school. Chicken Pox. This condition was quite common in the first term of the year, very many schools having cases, but none being really heavily attacked. Only 71 one school had any substantial numbers of cases in the summer term, while there were very few cases in the district in the second half of the year. In all intimations were received about 422 cases. Contacts of infectious patients are not now excluded from school. Mumps. Most schools were free from cases of mumps in the first and in the third terms of the year, but most of them had some cases in the summer term. Altogether, 317 intimations were received. Only one school was affected to any extent, having 52 cases ; this, too, was almost the only school affected in the third term. Contacts are not now excluded from school. German Measles. At times this appears in widespread epidemics, even when there is no undue prevalence of the commoner type of measles. More usually, however, it appears at the same time but to nothing like the same extent as measles. During 1948, intimation was received of only 18 cases amongst children attending school. For long accounted as of little importance, the disease has in recent years assumed a much more serious aspect because of the possibility of the development of congenital defects in a child born to a mother who has suffered from german measles in the early stages of her pregnancy. Contacts are not now excluded from school. Influenza. This condition is not notifiable. Indications of its prevalence can be obtained from the numbers of the fatalities ascribed to it, or from the numbers of notifications received of acute influenzal pneumonia. Neither of these probably is a very reliable index. Only four deaths were ascribed to influenza, all of these occurring amongst the elderly. Scabies. The arrangements for the treatment of the diminishing number of those infected with scabies at the car park building were continued until towards the end of the year. During the year, there had been a further marked fall in the numbers of those attending, the total of these in the first 10 months of the year being 95. This condition, then, is no longer a public health problem in this district. In order to facilitate the adaptation of the car park building to its new use as a rehabilitation centre, the scabies clinic was closed early in November. TUBERCULOSIS. Notification. As with other diseases, notification is required by the medical practitioner attending the patient. These are the primary notifications or those sent in on Form A. In addition, there are the weekly returns made by the medical superintendents of institutions at which those suffering from tuberculosis are treated, both of those admitted and discharged during the week. Sometimes cases are brought to the notice of the authority in this way about whom notifications on Form A have not been received. Then when a patient transfers from one district to 72 another, the particulars of that patient are sent from the one to the other Medical Officer of Health. Yet another way in which cases are brought to light is by the death returns, quite a number of persons having died from tuberculosis who had not been notified in the area in which they were last living. In many cases this is due to their having removed from one district to another after the disease had been first recognised and without the transfer notification which should have been made having been sent. In the following table are set out particulars of the cases notified or otherwise brought to notice for each of the years from 1934:— Form "A " Other Population P. N.P. P. N.P. M F M F M F M F 1934 70 51 9 9 6 14 2 2 132,049 1935 78 70 13 13 8 17 5 4 144,280 1936 99 75 17 13 9 7 2 2 160,300 1937 114 96 13 27 1 1 1 1 174,800 1938 111 118 28 24 2 — 1 1 183,500 1939 106 100 19 21 3 1 — — 190,200 1940 119 107 31 22 45 32 7 9 188,710 1941 213 141 24 25 — — — — 195,480 1942 163 155 27 24 — — — — 195,100 1943 140 122 28 19 6 3 1 1 191,660 1944 167 122 18 24 7 9 1 2 185,090 1945 117 98 12 19 19 18 3 3 191,710 1946 143 112 8 17 24 27 4 2 210,890 1947 155 115 17 22 36 36 6 4 215,930 1948 159 135 13 18 23 27 5 3 219,090 The following table sets out the age and sex distribution of the patients who were notified in this district for the first time in 1948, dividing them into pulmonary and non-pulmonary groups:— Primary Notification Brought to notice other other than by Form "A" Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F Under 1 1 1 — — — — — — 1- 4 9 5 1 2 1 — — — 5-9 7 7 1 1 1 2 10-14 11 9 3 5 2 1 15-19 14 28 2 3 1 1 2 1 20-24 16 29 2 1 2 2 25-34 32 27 1 3 7 11 — 2 35-44 30 16 1 1 5 6 1 — 45-54 15 9 2 2 — 3 — — 55-64 19 3 — — 5 — — — 65 and over 5 1 — — 1 — 1 — Total 159 135 13 18 23 27 5 3 73 When a person is attacked by one of the more common infectious diseases, it can be assumed that he contracted the infection in his home or at his work or his immediate surroundings in the recent weeks. In the case of tuberculosis, however, this is not so; the patient may have been developing the disease for many months, during which time he may have moved from his place of residence or his place of work at which he was when the disease first started to overcome his resistance. For this reason, then, the notification rate might not be an index of the healthiness of a community, particularly if for any reason there is much movement of population. Another factor is present in the case of a community which is growing by the influx of new population. The patient once notified remains notified for a long time. In any population which moves into a new district, then, there will be not only those who have been notified within the last year, but all those notified over the previous years. All these might, as they should, be notified to the new authority very shortly after their transference into the new district. The number of notifications received in the district, then, will be swollen by a much bigger figure when a population moves into the district. These factors do not arise in stable communities, but they are of much importance in developing districts. If the notification rates are to be accepted as any guide to the healthiness of the community, as they might well be, only those of persons who are considered to have contracted the infection while living there should be counted. In view of the usual slow rate of onset, some arbitrary period such as six months from the date of first residence in the district might be taken, it being assumed that a person in whom the disease was first recognised within six months of his coming to live in any area must have contracted the disease because of the conditions in which he was living or working before he transferred. Register. The names of all patients notified or otherwise brought to notice are entered on the register. While names are constantly being added, some are being removed, and this for one of a number of reasons. The patient might have left the district; he might have died. In some cases a patient is later discovered to have been notified in error and the notification is withdrawn. Some patients recover completely. Before the name of such a patient can be removed, it is necessary that the disease shall seem to have been arrested for a number of years, and the names are not removed until the lapse of an appreciable time after the disease has reached a quiescent stage, one in which the patient has apparently recovered. Most of the names removed are of those who have moved from the district. Most of these are learned of either from the physician at the chest clinic that the patient attended or from the Medical Officer of Health of the district to which the patients have removed. Information is not received about all, and unless special enquiries are made, the number accumulates each year of persons whose names are still on the register of an area although the persons no longer reside there. These inaccuracies result in there being an inflated figure of the number on the register. 74 The following table is a summary of the changes which have taken place during the year:— Pulmonary Non-Pulmonary Male Female Male Female No. on register, January 1st, 1948 764 636 108 116 No. of new cases added 159 135 13 18 No. of cases added other than Form "A" 23 27 5 3 No. of cases restored to the register 6 3 — — No. of cases removed 108 102 10 6 No. on register December 31st, 1948 844 698 116 131 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 54 58 3 2 Died 44 28 4 3 Recovered 6 13 2 — Diagnosis not confirmed or withdrawn 4 3 1 1 Total 108 102 10 6 Deaths. Seventy-six persons (43 male and 33 female) died from pulmonary tuberculosis during the year and 15 (8 male and 7 female) from nonpulmonary tuberculosis. This infection, therefore, accounted for 4.9 per cent. of the total deaths in this district. The corresponding figures for 1947 were 69 deaths from pulmonary and 9 deaths from non-pulmonary tuberculosis, the disease accounting for 4.5 per cent. of the total deaths. Twenty-two deaths occurred amongst those who had not been notified. Preventive Measures. Although the local sanitary authority is responsible for the sanitation of the premises in which a tuberculous patient is living, in this area the home visiting is undertaken by the tuberculosis sister attached to the staff of the local tuberculosis dispensary or chest clinic. Routine reports are received about the home circumstances, and the sanitary inspector visits homes where housing is unsatisfactory, either because of crowding or because of the structural condition of the premises. Amongst the chief of the preventive measures is early diagnosis. To facilitate this, arrangements are available for the bacteriological examination of sputum from suspected patients. 75 Section 172 of the Public Health Act, 1936, repeats the powers previously granted under the 1925 Public Health Act, for the compulsory removal to hospital on a Court Order of infectious persons suffering from pulmonary tuberculosis where precautions to prevent the spread of infection cannot be or are not taken, and when serious risk of infection is thereby caused to other persons. No application for such an Order has as yet been made. The very existence of such powers, though, is helpful in difficult cases. The insidiousness of the onset of tuberculosis, and the indefiniteness or even complete absence of symptoms add to the difficulties in the control and eradication of this disease. While the disease is unrecognised, not only are the sufferers possibly communicating the infection to others, but in themselves the disease is progressing so that at best when recognised the lesions are so advanced that long-term treatment is necessary, while in many even that state has been passed. Although not invariably so, diagnosis can usually be made earlier by X-ray than by physical examination. To result in detection in the earliest stages, though, examination must precede even the onset of symptoms. To be successful, then, facilities must be available for the examination of normal healthy individuals. While this cannot as yet be arranged for the general population, something is being done by the examination of specially selected groups. 76 CARE OF MOTHERS AND YOUNG CHILDREN 1st January, 1948, to 3rd July, 1948. 1. Notification of Births. (a) Live births, 1,624; (b) Stillbirths, 32; (c) Total, 1,656. 2. Care of Mothers. Ante-natal Clinics No. of sessions held No. of new cases Total No. of attendances Average attendance per session A.N. P.N. A.N. P.N. Alexandra Avenue 27 83 8 576 8 22 Broadway 54 123 12 782 12 15 Chandos 39 90 22 493 22 14 Elmwood 27 69 6 593 6 22 Harrow Weald 27 76 16 462 16 18 Hatch End 17 30 2 149 2 8 Honeypot Lane 27 69 21 386 21 5 Marlborough Hill 25 63 9 359 9 14 North Harrow 25 49 19 358 19 14 Pinner 25 46 10 325 10 13 Roxeth 27 79 12 552 12 21 Streatfield 53 152 31 1,206 31 23 Vaughan Road 27 81 15 523 15 19 Walton Avenue 27 77 7 402 7 16 Totals 427 1,087 190 7,166 190 17 Consultant Clinic— Elmwood 17 102 106 6 3. Health Visiting Services. Number of visits paid by Health Visitors to :— First Visits Total Visits (a) Expectant mothers 630 804 (b) Children under 1 wear 1,984 4,363 (c) Children between 1 and 5 years 318 4,655 (d) Other persons 558 1,063 4. Birth Control. Birth Control Clinics No. of sessions held No. of new cases Total No. of attendances No. of cases in which advice given Average attendance per session Broadway 12 110 424 424 35 (Continued on page 78) 77 CARE OF MOTHERS AND YOUNG CHILDREN 5th July, 1948, to 31st December, 1948. 1. Notification of Births. (a) Live births, 1,460; (b) Stillbirths, 21 ; (c) Total, 1,481. 2. Care of Mothers. Ante-natal Clinics No. of sessions held No. of new cases Total No. of attendances Average attendance per session A.N. P.N. A.N. P.N. Alexandra Avenue 27 74 13 511 13 19 Broadway 54 105 7 771 7 15 Chandos 26 73 11 427 11 16 Elmwood 27 79 3 580 3 22 Harrow Weald 27 62 6 413 6 15 Hatch End 27 35 4 253 4 9 Honeypot Lane 27 77 15 382 15 14 Marlborough Hill 25 63 14 329 14 13 North Harrow 25 43 7 275 7 11 Pinner 25 34 6 237 6 10 Roxeth 27 65 9 475 9 18 Streatfield 54 131 29 1,021 29 19 Vaughan Road 27 62 14 414 14 15 Walton Avenue 27 47 2 462 2 17 Totals 425 950 140 6,550 140 16 Consultant Clinic— Elmwood 15 51 56 4 3. Health Visiting Services. Number of visits paid by Health Visitors to:— First Visits Total Visits (a) Expectant Mothers 547 693 (b) Children under 1 year 2,088 4,790 (c) Children between 1 and 5 years 539 5,446 (d) Other persons 373 707 4. Birth Control. Birth Control Clinics No. of Sessions held No. of new cases Total No. of attendances No. of cases in which advice given Average attendance per session Broadway 12 110 490 490 41 (Continued on page 79) 78 (Continued from page 76) 5. Care of Young Children. Infant Welfare Centres No. of sessions held First attendances Other attendances Total No. of cases Total average attendant per session Under 1 year Over 1 year Under 1 year Over 1 year Alexandra Av. 51 127 16 1,782 490 2,415 47 Broadway 54 142 18 2,941 741 3,842 71 Chandos 53 130 6 2,579 498 3,213 60 Elmwood 52 126 12 1,916 545 2,599 49 Harrow Weald 27 104 18 1,471 381 1,974 73 Hatch End 27 55 50 642 143 890 33 Headstone 53 126 9 1,829 562 2,526 47 Honeypot Lane 52 156 13 1,937 666 2,772 53 North Harrow 25 54 21 715 205 995 34 Pinner 26 71 17 1,096 265 1,449 55 Roxeth 54 108 36 2,178 655 2,977 55 Streatfield 54 201 30 2,612 648 3,491 64 Vaughan Road 27 84 28 1,239 306 1,657 61 Walton Avenue 27 56 6 1,071 262 1,395 51 Totals 582 1,540 280 24,008 6,367 32,195 55 Toddlers' Sessions— New Old Total Alexandra Av. 27 115 — 286 — 401 15 Chandos 27 — 474 — 474 17 Elmwood 13 52 — 120 — 172 1 Headstone 12 22 — 147 — 169 14 Honeypot Lane 26 12 — 425 — 437 17 Pinner 23 7 — 128 — 135 6 Streatfield 14 39 — 166 — 205 14 Vaughan Road 6 4 — 88 — 92 15 Totals 148 251 — 1,834 — 2,085 14 6. Midwifery Services. Council Midwives Private Midwives Number of cases attended as midwife 351 47 Number of cases attended as maternity nurse 123 5 Number of cases in which analgesia administered 214 — Number of cases in which medical aid summoned 132 1 79 (Continued from page 77) 5. Care of Young Children. Infant Welfare Centres No. of sessions held First attendances Other attendances. Total No. of Cases Total average attendance per session Under 1 year Over 1 year Under 1 year Over 1 year Alexandra Av. 52 118 15 1,874 510 2,517 48 Broadway 54 134 13 2,557 717 3,421 63 Chandos 54 115 6 2,432 486 3,039 46 Elmwood 52 97 14 1,671 590 2,372 45 Harrow Weald 27 95 27 1,323 492 1,937 72 Hatch End 27 43 42 612 147 844 31 Headstone 54 91 27 1,446 621 2,185 40 Honeypot Lane 52 120 9 1,592 611 2,332 44 North Harrow 26 71 20 981 223 1,295 51 Pinner 27 71 3 1,060 297 1,431 53 Roxeth 54 89 12 1,696 536 2,333 45 Streatfield 54 167 7 2,655 580 3,409 63 Vaughan Road 27 105 9 1,420 318 1,852 68 Walton Avenue 27 65 6 1,011 250 1,332 50 Totals 587 1,381 210 22,330 6,378 29,299 49 Toddlers' Sessions— New Old Alexandra Av. 26 111 — 275 — 386 14 Chandos 27 1 — 483 — 484 28 Elmwood 13 47 — 133 — 180 14 Headstone 12 87 — 113 — 200 15 Honeypot Lane 24 7 — 393 — 400 16 Pinner 25 11 — 137 — 148 5 Streatfield 13 46 — 163 — 209 16 Vaughan Road 6 9 — 78 — 87 14 Totals 146 319 — 1,775 — 2,094 14 6. Midwifery Services. Council Midwives Private Midwives Number of cases attended as midwife 308 3 Number of cases attended as maternity nurse 99 — Number of cases in which analgesia administered 234 — Number of cases in which medical aid summoned 91 — 80 SCHOOL HEALTH SERVICE STATISTICS TABLE I. MEDICAL INSPECTION OF PUPILS ATTENDING MAINTAINED SCHOOLS. (a) Periodic Medical Inspections. Number of Inspections in the prescribed Groups:— Entrants 3,457 Second Age Group 2,984 Third Age Group 1,249 Total 7,690 Number of other Periodic Inspections 617 Grand Total 8,307 (b) Other Inspections Number of Special Inspections 3,025 Number of Re-Inspections 2,298 Total 5,323 (c) Pupils Found to Require Treatment. Group For defective vision (excluding squint) For any of the other conditions recorded in Table 11(a) Total individual pupils Entrants 44 407 451 Second Age Group 130 175 305 Third Age Group 45 30 75 Total (prescribed groups) 219 612 831 Other Periodic Inspections 12 43 55 Grand Total 231 655 886 81 TABLE II. (a) Return of Defects Found by Medical Inspection. Defect or Disease Periodic Inspections Special Inspections No of defects No. of defects Requiring treatment Requiring to be kept under observation, but not requiring treatment Requiring treatment Requiring to be kept under observation, but not requiring treatment Skin 17 11 167 10 Eyes: (a) Vision 231 32 233 5 (b) Squint 14 3 9 — (c) Other 24 7 128 8 Ears: (a) Hearing 18 11 18 5 (b) Otitis Media 5 1 4 — (c) Other 16 14 75 6 Nose or Throat 230 216 256 15 Speech 22 15 15 2 Cervical Glands 56 17 14 1 Heart and Circulation 20 47 20 5 Lungs 47 47 106 25 Developmental: (a) Hernia 8 2 3 — (b) Other 8 3 — — Orthopaedic: (a) Posture 23 18 7 2 (b) Flat Foot 22 9 16 2 (c) Other 28 20 59 3 Nervous system: (a) Epilepsy 1 3 3 1 (b) Other 13 8 52 4 Psychological: (a) Development 7 4 10 3 (b) Stability 29 9 22 6 Other 47 24 1,542 97 (b) Classification of the General Condition of Pupils Inspected. Age Groups Number of Pupils Inspected A (Good) B (Fair) C (Poor) No. % of Col. 2 No. % of Col. 2 No. % of Col.2. Entrants 3,457 1,266 36.6 2,150 62.2 41 1.2 Second Age Group 2,984 968 32.4 1,953 65.5 63 2.1 Third Age Group 1,249 422 33.8 814 65.2 13 1.0 Other Periodic Inspections 617 122 19.8 485 78.6 10 1.6 8,307 2,778 33.5 5,402 65.0 127 1.5 82 TABLE III. TREATMENT TABLES. Group I. Minor Ailments. (Excluding Uncleanliness, for which see Table V.) Number of defects treated or under treatment during the year (a) Skin: Ringworm—Scalp— (i) X-ray treatment. — (ii) Other treatment — Ringworm—Body 2 Scabies 10 Impetigo 24 Other skin diseases 127 Eye Disease: (External and other, but excluding errors of refraction, squint and cases admitted to hospital) 128 Ear Defects 93 Miscellaneous: (e.g., minor injuries, bruises, sores, chilblains, etc.) 495 Total 879 (b) Total number of attendances at Authority's minor ailments clinics 5,969 Group II. Defective Vision and Squint. No. of defects dealt with Errors of refraction (including squint) 693 Other defect or disease of the eyes (excluding those recorded in Group I) — Total 693 No. of pupils for whom spectacles were(a) Prescribed 681 (b) Obtained 375 Group III. Treatment of Defects of Nose and Throat. Total number treated Received operative treatment: (a) for adenoids and chronic tonsillitis 131 (b) for other nose and throat conditions 59 Received other forms of treatment 24 Total 214 83 Group IV. Orthopaedic and Postural Defects. (a) No. treated as in-patients in hospitals or hospital schools 19 (b) No. treated otherwise, e.g. in clinics or out-patient departments 326 Group V. Child Guidance Treatment and Speech Therapy. No. of pupils treated (a) under Child Guidance arrangements 64 (b) under Speech Therapy arrangements 116 TABLE IV. DENTAL INSPECTION AND TREATMENT (l) Number of pupils inspected by the Authority's Dental Officers: (a) Periodic age groups 13,263 (b) Specials 1,289 (c) Total (periodic and specials) 14,552 (2) Number found to require treatment 8,552 (3) Number actually treated 7,295 (4) Attendances made by pupils for treatment 14,728 (5) Half-days devoted to (a) Inspection 133 (6) Treatment 1,986 Total (a) and (b) 2,119 (6) Fillings: Permanent Teeth 10,110 Temporary Teeth 3,300 Total 13,410 (7) Extractions Permanent Teeth 1,055 Temporary Teeth 8,487 Total 9,542 (8) Administration of general anaesthetics for extraction 2,792 (9) Other Operations: (a) Permanent Teeth 2,266 (b) Temporary Teeth 1,031 Total (a) and (b) 3297 TABLE V. INFESTATION WITH VERMIN. (i) Total number of examinations in the schools by the school nurses or other authorised persons 66,755 (ii) Total number of individual pupils found to be infested 1,121 (iii) Number of individual pupils in respect of whom cleansing notices were issued (Section 54 (2) Education Act, 1944) 155 (iv) Number of individual pupils in respect of whom cleansing orders were issued (Section 54 (3) Education Act, 1944) — 84 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. (1) Number of children medically examined in order to ascertain whether they were physically fit to undertake employment of a light nature outside school hours 306 (2) Number of instances in which the state of health was found to be such that certificates were withheld 7 (3) Number of children examined as to fitness to take part in entertainments 25 (4) Number of cases in which certificates to take part in entertainments were withheld — EDUCATION ACT, 1944—SECTIONS 57(3) AND 57(5). Cases notified under Section 57, Education Act, 1944: Sub-section 3 10 Sub-section 5 2 Cases de-notified under Section 8, Education (Miscellaneous Provisions) Act, 1948 1 MEDICAL EXAMINATION OF TEACHERS. (a) Number of Teachers examined as to fitness for appointment 88 (b) Number of Students examined as to fitness for first approintment Nil 85 INDEX. page Accidents—Deaths from 9 Adulteration of Food 49 Allocation of Houses 42 Ambulance Service 26 Ante-natal Clinics 21 Assistance Board 26 Authorised Officers 25 Birth Control Clinic 22 Births 6 Board—Regional Hospital 12 Burial Grounds 33 Burial of the Dead 33 Cancer—Deaths 10 Cerebro-spinal fever 66 Chicken-pox 70 Child Guidance Clinic 23 Children's Department 25 Child Welfare Service 21 Clearance Order 43 Clinics 21 Convalescent Homes 15 Coroner 34 Cremation 33 Day Nurseries 20 Deaths 6 Demolition Orders 43 Dental Treatment 24 Deprived Child 25 Diphtheria 59 Diphtheria Anti-toxin 61 Disinfection 58 Disposal of the Dead 33 District Nursing Association 18 Domestic Helps 19 Drainage 30 Dysentery 65 Edgware General Hospital 12, 13 Emergency Bed Service 13 Encephalitis Lethargica 67 Enteric Fever 64 Erysipelas 66 Establishments for Massage 16 Exclusion from School 57 page Executive Council 18 Factories 44 Food: Adulteration 49 Hygiene 50 Poisoning 51 Fumigation 59 German Measles 7t Handicapped Adult 25 Hawkers—Registration 49 Health Centres 18 Home Helps 19 Hospital: Admission to 13 Edgware General 12, 13 General 12 Isolation 13,56 Management Committee 12 Roxbourne 12 Smallpox 64 Housing: Letting 42 New 42 Repair 38 Ice-cream 49 Immunisation against Diphtheria 60 Infant Mortality 7 Infant Welfare Centre 21 Infectious Diseases: Deaths 11 Notification 54 Influenza 71 Isolation 56 Isolation Hospital 57 Laboratory Service 27 Lakes 31 Letting of Houses 42 Malaria 64 Marriage Guidance 23 Massage 16 Maternal Mortality 9 Maternity Nursing 19 Measles 67 86 page Medical Services 17 Mental Health 25 Midwifery Service 19 Milk 47 Mortuary 34 Mumps 71 National Assistance Board 26 Neo-natal Deaths 7,8 New Houses 42 Notification of Infectious Diseases 54 Nursery Classes 20 Nursery Schools 20 Nursing Homes 15 Nursing in the Home 18 Old People's Welfare Committee 26 Ophthalmia Neonatorum 70 Ophthalmic Clinic 23 Overcrowding 40 Pemphigus Neonatorum 70 Pertussis 69 Physiotherapy 24 Poliomyelitis 67 Population 5 Public Cleansing 31 Public Conveniences 32 Puerperal Infection 69 Rat Infestation 45 Refuse Collection 31 Refuse Disposal 31 Regional Hospital Board 12 page Repair of Houses 38 Roxbourne Hospita 12 Scabies 71 Scarlet Fever 61 School Clinics 23 School Health Service 80 Sewerage 30 Shops 45 Smallpox 63 Smallpox Hospital 57 Smoke 45 Speech Therapy 24 Statistics 5 Stillbirths 9 Street Cleansing 32 Suicide 10 Swimming Baths 32 Toddlers' Clinic 22 Tuberculosis 71 Tuberculosis Clinic 24 Typhoid Fever 64 Typhus Fever 57, 64 Vaccination 63 Venereal Disease 24 Water 38 Water Courses 30 Welfare Department 26 Wells 29 Whooping Cough 69