HARR 16 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1949 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 1949 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 1949. The Sanitary Officers (Outside London) Regulations, 1935, which revoked previous similar provisions, set out the duties of certain officers. Paragraph 17 of these regulations reads: A medical officer of health in respect of the district for which he is appointed shall (1) inform himself as far as practicable respecting all matters affecting or likely to affect the public health in the district, and be prepared to advise the local authority on any such matter. . . .; (5) as soon as practicable after the 31st day of December in each year make an annual report to the local authority for the year ending on that date on the sanitary circumstances, the sanitary administration, and the vital statistics of the district, containing, in addition to other matters on which he may consider it desirable to report, such information as may, from time to time, be required by the Minister. The Minister usually sends out a circular indicating the form the report should take. On the 25th January, 1950, he issued Circular 2/50 asking that the Council should direct that the report for 1949 should be prepared on the lines of that for 1948. " Besides dealing generally with matters within the medical officer of health's responsibility regarding public health and preventive medicine, the report should, as appropriate, deal specifically with the National Health Service Act, 1946, the review of the working of the arrangements made for providing the local health services under Part III and the mental health services, the operation of Section 47 of the National Assistance Act, 1948, water supply, sewerage, food and the administration of matters under Parts 1 and 8 of the Factories Act, 1937." In the Memorandum of the duties of medical officers of health, it is stated that the chief function of the medical officer of health is to safeguard the health of the area for which he acts by such means as are at his disposal. He should endeavour to acquire an accurate knowledge of the influences, social, environmental and industrial, which might operate prejudicially to health in the area and of the agencies, official or unofficial, whose help can be invoked in amelioration of such influences. While he has special duties for the prevention of infectious diseases, all morbid conditions contributing to a high sickness rate or morbidity in the area from these or other causes should be studied with a view to their prevention and control. The health services of a district now comprise the activities of a number of authorities. The district council, in many areas, provides many of the essential environmental services including drainage and sewerage, water supply, housing, roads, and the collection and disposal of house refuse. Others of their activities, such as the provision of parks and open spaces, green belt schemes, town planning, etc., are 4 closely related to the health services. Again, as the health authority, the district council concerns itself with environmental conditions such as circumstances which might become sanitary nuisances and cause injury to the health of the public. In this way the Council is concerned with the condition of the houses in which people are living; the freedom from pollution of the atmosphere; the freedom from pollution of rivers; the safe state of food and drink, and to a limited extent with the conditions under which some people work. The local health authorities, the major authorities, in this case the Middlesex County Council, provide the personal services including the school medical services and the Part III Services of the National Health Service Act, many of which were, before July, 1948, provided by the maternity and child welfare authorities. These Part III Services include home nursing and a wide range of activities of the domestic or home helps. Hospitals of all sorts have passed to the Minister to be administered by him through the Regional Hospital Boards and, in turn, by the Hospital Management Committees. Without very efficient basic sanitary circumstances, such as a pure water supply and efficient drainage, an urban community of this size could not for long remain in a sound sanitary state, no matter at how high a degree of efficiency the Part III Services and the hospital and associated clinical services might be maintained. Given sound basic sanitary services, it would not be held that the health of the district was dependent on the Part III or the hospital services. A district such as this starts at a great advantage in that it is in the south and more than that, in the south-eastern part of the country where it would seem the easier climatic conditions put this and other districts here in a position more favourable than that of some towns in the north. It is not an industrial area; although by no means free from smoke pollution, if only because of the great number of domestic chimneys belching their smoke into the atmosphere, the air is that much more free from contamination than that of many industrial towns. Much of the district grew when development was subject to some building density restrictions and the height of the buildings in relation to the width of roads and gardens helps to ensure freedom from darkness and from courts and alleys to which the sun has no access. Most of the houses in the district have been built comparatively recently and are better laid out than the houses in many of the towns which developed before the first world war. Although conditions under which many are living leave much to be desired, the actual degree of overcrowding, even to-day, is relatively slight. To these factors must be added that of the comparative affluence of the general run of the population, a state which enables a sound and nutritional state to be maintained. These are the factors which contribute to the satisfactory state of the public health of the district. This is not to decry the importance of the personal and of the hospital services. These, however badly they may be needed by any individual person, and when required at all, are wanted very badly, are required by the individual. Admittedly, there may be some 1,000 mothers who need the services of midwives in the course of the year, and another 1,000 who need to be admitted to hospital for their confinements; some hundreds who need the services of a home help and further hundreds 5 who need to be admitted to the surgical or a medical ward of a hospital, or to have the services of a home nurse. These persons, although in their tens, hundreds or even in some cases thousands, do not add up to the 220 odd thousand of all those living in Harrow. The public health services—the health, not the sickness, services—deal with those conditions designed to keep in health that 220,000. The activities under the National Health Service Act are designed to deal with the treatment of those who have become ill, or who need treatment. So much has been heard of the introduction of the National Health Service Act and especially of the transfer of powers under the Act from the minor to the major authorities, that it is liable to be overlooked that the essential health services of a district are still the concern of the county district council and that what these authorities have lost are their responsibilities for arranging to deal with those who, for any reason, need treatment, those who in a way may be evidence of the breakdown of the fundamental health services. For obtaining a knowledge of the operation of the Part III Services of the National Health Service Act, the Medical Officer of Health for this area is fortunately placed. The scheme of delegation was designed to allow of the day-to-day administration being in the hands of a local committee and local staff, It seems to be general that the workings of the local committees and the local staffs are hedged in by restrictions imposed by the county councils. For the arrangements to work smoothly and efficiently, it is essential that the Area Committee be given a real job; only if this is so, can it be hoped that the interest of members can be retained and a strong committee assured. The committee should be given full responsibility for the administration of the local services and full regard should be paid to any recommendations it makes. The other main weakness in the administration of these services is the inordinate delay. Part of this is possibly due to the cumbersome machinery, but it is one of the powerful factors contributing to the feeling of frustration felt by so many of these who are concerned in any way with the local administration of the Part III Services. The Health Service Act will bring about material improvements in the health services to be made available to those who need them. Many of these benefits are now being made available at a much earlier date than they would have been had progress been on the lines of the development of personal services since the beginning of this century. It is, perhaps, inevitable that the gain in this way should be offset to some degree by the position of some being worsened. Advantage was taken in the passing of the Act to further a movement which started with the Education Act, 1944, of handing over powers from the minor to major authorities. There were many local authorities with quite small populations which were responsible for the provision of personal services. There must be some limiting figure below which a district of that population could not be a satisfactory functional unit for such purposes, and the Act will probably result in an improvement in the services in such localities up and down the country, now that they are provided by the county councils. It is unfortunate though that this district, and so many others which for years provided really satisfactory services, 6 could not have retained autonomy. At the time they were first designated, it was appreciated that there should be some minimum figure for a district to be a county borough. Later legislation imposed a limit which was, in its turn, raised. One of the main reasons making this desirable was that, to provide an economical and efficient institution such as a hospital, it was necessary that it should have a minimum number of beds; that in turn, meant that the hospital should serve a minimum sized population. With the erection of institutions to serve more than one area such a point carried less weight; still less is that the case to-day, when such institutions are not provided even by county boroughs. If then it should appear that areas such as this have, in fact, lost something tangible because they are classed as minor authorities, this might be all the greater argument for their being upgraded and being made major authorities. Of the administration of the hospital services, the medical officer of health learns little. In some districts, he has been appointed on the Hospital Management Committee. His knowledge of local conditions and all that might be arranged through the local services is probably of real benefit to the other members of the committee. This district is served by hospitals in two groups; the Edgware General Hospital in the Hendon group is just outside the district; on the other hand the Harrow Hospital is administered by the Charing Cross Hospital Board of Governors. It happens then, that there is no member of the District Council on either of the local Hospital Committees providing services in this area. When the local Council made grants to some of the voluntary hospitals, it was customary for the authority to receive reports on the workings of the hospitals. Nothing of that sort is now being presented to the Council. However small a case can be made out for the importance of the hospital services in the general scheme of the health services of an area, it would seem that there should still, with advantage, be room for close association between those on the local Council providing the health services, and those administering the hospitals. These health authorities were the natural bodies on which were imposed the earlier of the personal health services. The same interest which made them the natural repositors of those trusts at that time, would seem to make them again the bodies from whom should be drawn some, at least, of those who are responsible for the local administration of the hospital and clinic services. All these bodies surely would gain if there were some members who were on the Public Health Committee of the District Council, on the Sub-Committee of the County Council responsible for the Part III Services, and on the committees responsible for the management of the hospitals and clinics in those areas. 1949 was the first complete year of the working of the services provided under the National Health Service Act. It is understandable that those in health departments learn more of the difficulties arising from the operation of the Act because they are approached for help, help which so often cannot be given. Whether this is a matter which has arisen out of the changes brought about by the Act or whether, if no change had been made, matters would have been much the same, there does seem to be a very real difficulty in finding accommodation 7 in hospitals. This applies more particularly to the elderly, chronics, some of whom have to remain at home in very difficult circumstances and at great hardship to those looking after them, because of an inability to arrange their admission to hospital. The elderly and infirm, as such, though not suffering from any added ailment which renders medical or nursing attention necessary, form another group for whom more adequate provision is necessary. Section 47 of the National Assistance Act gives powers to the medical officer of health to arrange for the removal, to suitable premises, of persons in need of care and attention. The powers of this section though should be invoked more particularly where it is necessary that the person should be removed either in his own interests, or perhaps more often, in the interests of others. The section does not provide any additional accommodation for those many who would be only too willing to take advantage of suitable provision if it were available. The transference of the isolation hospitals from the local authorities to Regional Hospital Boards has resulted in the medical officer of health (except where he continues to be associated with the hospital) being less closely alive to the problems of the infections in his district, and has resulted perhaps, in the medical practitioners being more casual in sending in their notifications. In this district, the buildings previously used for the reception of those suffering from infectious diseases have been put to other purposes. This is a change which would have come about even though the National Health Service Act had not been passed. In the light of their experience since 1934, as to the needs for the district of isolation accommodation, the Council had decided that 100 beds would be sufficient, and had approached the Borough of Hendon to see if the Hendon Isolation Hospital could not be extended to cater for those to be admitted from Harrow. In many other parts of the country, it seems that the smaller isolation hospitals are now being closed. It is to be hoped that, whatever is being done on these lines, is being carried out with a full appreciation of the reason for the practice of former years. To-day, scarlet fever is a mild disease; even in the years when it becomes prevalent, there are not many cases needing, on clinical grounds, to be admitted to hospital. In most districts the practice had been adopted of admitting to the isolation hospital those suffering from the complications of measles and of whooping cough. Both these diseases too, are very much milder clinically than they were some years ago. Why this change should have taken place in these three diseases almost concurrently, is not known. It would be gratifying to feel that it is because of some improvement in the state of the human hosts, something which is the result of some improvement in the national way of living, such as improved feeding. But there is little assurance that this is the explanation, and there must always be the risk of these organisms reverting to a more serious type. Not so many years ago, a type of the organism of diphtheria caused a variety of the disease which did not respond to the serum which was quite effective in treating the illness caused by other strains. If the haemolytic streptococcus sported a variant of that nature which resulted in a severe clinical variety of scarlet fever, would there be sufficient isolation hospital accommodation, and would those in charge of the hospitals be so anxious to have patients 8 suffering from such infections in wards so close to patients suffering from other diseases? It happened that at the time of the change of administrative arrangements, the prevailing type of most of the infectious diseases was of a mild clinical standard. It is to be hoped that those into whose hands the responsibility of looking after them while they are ill has passed, will not be too sanguine and will not adopt an outlook that an infectious patient is merely a patient suffering from an illness which, because it is communicable, has to be nursed under special conditions. Those who have to be admitted to hospital are merely some of those who are part, outside the hospital, of a greater or smaller epidemic and while, to-day, most people are admitted to an isolation hospital because of the need for them as individuals to receive treatment for their illness, which is one of the infective variety, the position still remains that some, at least, of the sufferers need to be admitted to hospital because that step is necessary to avoid the spread of infection to others; and if that accommodation should not be there, there might be the spread with yet further need for accommodation. The rush by the general public to take advantage of services now available for the first time without charge, has had its repercussions on the treatment services provided by the local authorities. The most striking instance is the effect on the school dental services, where already so much harm has been done, that if staffing could be restored even to the early 1948 position, it would be many years before the school dental service could be restored to what it was. Not only have the teeth of the school children not been treated up to the standard of the pre-war arrangements so that, in general, the mouths of these children are less fit dentally and therefore, on an average, much more work is necessary on each individual child, but there is the risk that all the efforts of years towards educating the public to the state that there was a high acceptance rate, is being lost. There were many in the public health services who were apprehensive that the provisions of an Act designed to deal with those needing treatment, would lessen the desirable emphasis on the preventive aspects of disease. There were probably few enough who could claim to have been sufficiently far-sighted as to have anticipated that the operation of the Act would have such an unfortunate effect on one of the preventive services. As yet, the solution to the problem cannot be seen and, in the meantime, the priority dental service for school children and for expectant and for nursing mothers, and for children under five, is crumbling. This district is particularly fortunate in that the strength of the dental staff has not been weakened, although it is most disappointing, after the long wait to obtain premises that, at the time when they are now available, there should be this further obstacle to progress and to the development of a really satisfactory dental service for the priority sections of the population. The delays in supplying spectacles for school children, which was another effect of the operation of the Act, were very long; but already seem to be shortening and it looks as though this difficulty ought soon to pass. When glasses are provided soon after prescription, it should be possible for more satisfactory arrangements for the following-up of children to be made than can be when the delay is long. Midwives were 9 hensive about their status, as they feared that the arrangements by which mothers could obtain the services of medical practitioners might result in their becoming, to an increasing extent, maternity nurses. Again, too, they feared an extension of the practice by which mothers were admitted to hospital for their confinements and, because of limited accommodation, were discharged home early, to be nursed at home by the midwives. It was intended that only those medical practitioners with special experience in midwifery should be recognised as General Practitioner Obstetricians, although later, the only distinction to be made between those recognised and those not, was to be a difference in the fee payable by the Executive Council for their services. It was anticipated that only those recognised as General Practitioner Obstetricians would be allowed to answer the midwives' medical aid notices. There seems to have been difficulty, however, in deciding on those entitled to be recognised and, as far as is known, no special list for this district has been compiled. Included in the Part III Services provided by the County Council, as the local health authority, are the arrangements for vaccinating members of the public against smallpox, and immunising them against diphtheria. The very much greater extent to which infants were being immunised against diphtheria under a voluntary arrangement as compared with the numbers of infants vaccinated against smallpox, although the law required these to be done unless the necessary steps to obtain exemption had been carried out, led some to suppose that vaccination would be carried out on a greater scale if the compulsory element were removed. So far from this being the case, throughout the country it seems that, small as was the proportion of the vaccinated in the years before 1948, the numbers are now only about half what they were. There is, of course, now no person whose special responsibility it is to see that infants are vaccinated. In this district, the new arrangements by which immunisation against diphtheria is carried out largely by the general medical practitioners, as required under the Act, brought about no great change as many of those in this district who had been treated, were dealt with under similar arrangements. Information as to the extent to which children are vaccinated or immunized is obtained only on receipt, by the Area Medical Officer, of the records completed by the medical practitioners doing the work. As there was such a delay in an agreement being reached as to the basis of payment for this work, it is quite possible that many records were not and possibly never will be sent, so that to some extent, the official returns will be an understatement of the actual position. As to the workings of the ambulance service, little is known, as it seems it is not possible to separate local figures from those of the County as a whole. Although the report follows on much the usual lines of its predecessors there are certain features to which special attention might be drawn. During the year under review, the district, in common with the rest of the country, suffered another invasion by acute anterior poliomyelitis. This was not on the scale of the outbreak of 1947, but apart from that year, is the highest incidence to which the district had been subjected. These two outbreaks and the fact that the incidence in the 10 intervening year did not fall to the former low level, suggests that the country might never again be as free from this infection as it was before the 1947 invasion. Under the heading of food, further information is given of the development of the campaign for raising the standard of the cleanliness of food. A lot of spade work has been done and although there was nothing, even by the end of 1949, to show that progress had been made, it was felt by those intimately concerned with the campaign that everything by then was set for the real launching of the campaign in 1950. In the chapter relating to infectious diseases, reference is made to the rising numbers of notifications of those suffering from tuberculosis and to the increasing numbers of those on the register. Possible explanations for this are discussed and the conclusion reached was that these larger figures do not indicate that there is a worsening of the situation in regard to the prevalence of tuberculosis in this district. The position in regard to the housing of those sections of the population which are the special concern of those in this department, are analysed. It will be seen that most of those living in condemned property have been rehoused and that the families in which there is a member suffering from tuberculosis, whose needs to be rehoused were greatest, have been given this other accommodation. In regard to this special group of families, those now most needing to be helped are not those in which the family containing the tuberculosis patient needs to be rehoused, but other families living in that house and causing the overcrowding. It is possible once more to record that the general standard of healthiness of the district was high. The only serious outbreak was that of poliomyelitis, the invasion being part of the attack to which the whole country was subjected. The state of health of the country, in general, was good and the vital statistics satisfactory, but the figures for this district were mostly an improvement on those of the country as a whole. The infant mortality rate of 20.7 is particularly gratifying. It is not so many years ago that a figure of 40 was suggested as an irreducible minimum. Further reduction on such a low rate must, of course, be slow but undoubtedly will take place. The local infectious rates were lower than the corresponding rates for the country as a whole. After a period of nearly two years' freedom from this infection a local resident suffered from diphtheria, although the attack was only of the nasal type. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, "Cottesmore," Uxbridge Road, June 29th, 1950. 11 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,558 Registrar-General's estimate of resident population, midyear, 1949 Civilian 220,400 Total 222,300 Rateable Value (April 1st, 1949) £2,164,502 Sum represented by a penny rate (April 1st, 1949) £8,750 Total number of occupied houses 53,160 Total number of occupied flats 7,699 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Birth rate per 1,000 of the estimated resident population, 13-9 Legitimate 2,983 1,530 1,453 Illegitimate 100 58 12 Total 3,083 1,588 1,495 Stillbirths:— Legitimate 64 38 26 Rate per 1,000 total (live and still) births, 2.1 Illegitimate 2 1 1 Total 66 39 27 Deaths 1,890 928 962 Death rate per 1,000 of the estimated resident population, 8.5 Deaths from puerperal causes:— Deaths Rate per 1,000 total (live and still) births Puerperal sepsis 0 0 Other puerperal causes 5 1.6 Total 5 1.6 Death rate of Infants under one year of age:— All infants per 1,000 live births 20.7 Legitimate infants per 1,000 legitimate live births 20.0 Illegitimate infants per 1,000 illegitimate live births 50.0 Deaths from Cancer (all ages) 344 „ „ Measles (all ages) 0 ,, ,, Whooping Cough (all ages) 2 „ „ Diarrhoea (under 2 years of age) 2 Population. The mid-year population of the district was 220,400, an increase of 1,700 on the mid-year population for 1948. The natural increase in population, i.e., the excess of births over deaths during the year, was 1,193. Part of the rest of the increase could be the result of influx of population into the new houses, particularly those put up by the London County Council. 12 Births. The total number of live births registered during the year was 3,083 (1,588 male and 1,495 female). Of these, 100 were illegitimate, being a percentage of total births of 3.2. The number of live births registered in each of the years from 1944 onwards was 3,473, 3,068, 3,934, 3,828, 3226 and 3,083. 1,283 births occurred in the district (1,269 live and 14 still births). Of this number, 370 were to residents of other districts. 1,750 (1,711 live and 39 still) birth notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in Edgware General Hospital, Bushey Maternity Hospital or in London Hospitals. The birth rate for each of the years from 1944 was 18.7, 16.0, 18.0, 17.7, 14.7, and 13.9 in 1949. 66 (39 male and 27 female) stillbirths were registered, being a rate per 1,000 population of 0.30 compared with a figure of 0.39 for the country as a whole. Deaths. Of the 1,890 deaths which occurred in the district, 108 were of persons who were not residents of this area. Twenty-six of these took place in the various hospitals, 35 in nursing homes and 3 in Oxhey Grove, a home for the elderly. Of the 697 deaths of local residents which occurred outside the district, most took place in institutions, 230 being in the Edgware General Hospital, and 78 at other hospitals in the county. Three deaths occurred in institutions for the treatment of the tuberculous, and one, a new-born infant, at a maternity institution. 132 deaths took place in hospitals just outside the district, including 8 deaths in near-by isolation hospitals, and 127 in the various London hospitals. The following is the Registrar-General's abridged list of causes of death in this district:— Male Female Male Female Typhoid fever 0 0 Heart disease 287 278 Cerebro-spinal fever 1 1 Other circ. diseases 40 73 Scarlet fever 0 0 Bronchitis 71 46 Whooping cough 2 0 Pneumonia 33 42 Diphtheria 0 0 Other resp. diseases 8 12 Resp. tuberculosis 34 21 Ulcer of stomach 10 3 Other tuberculosis 2 0 Diarrhoea under 2 years 1 1 Syphilitic diseases 6 4 Appendicitis 6 4 Influenza 5 8 Other digestive diseases 17 11 Measles 0 0 Nephritis 21 26 Acute poliomyelitis 1 2 Puerperal sepsis 0 0 Acute encephalitis 0 2 Other maternal causes 0 5 Cancer of mouth and oesophagus (M), and uterus (F) 8 22 Premature birth 5 4 Cong. malformations etc. 24 17 Cancer of stomach 26 21 Suicide 6 8 13  Male Female Male Female Cancer of breast 0 31 Road Traffic accidents 5 8 Cancer of other sites 132 104 Other violent causes 21 19 Diabetes 3 7 All other causes 69 61 Inter-cran. lesions 84 121 All causes 928 962 The number of deaths, 1,890, is a slight increase on the figure of 1,837 for the previous year. The death rate was 8.5 per 1,000 population compared with figures of 9.3, 9.0, 8.6, 8.5 and 8.4 for the years since 1944, and with a figure of 11.7 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. 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. The local rates each year have been lower than the national rates, and have declined with the fall of the rates of the country as a whole. In 1949, 64 (58 legitimate and 6 illegitimate) infants died before they attained their first birthday, this being an infant mortality rate of 20.7 compared with the national rate of 32. This is the lowest rate for this district, the previous lowest being the rate of 24.0 in 1947. Forty-four of the infants failed to survive one month. The neonatal mortality rate, therefore, was 14.2, being a percentage of the total rate of 68. Stillbirths. Apart from the loss of lives of young children, there is the further loss of those who die before being born. In this district 66 stillbirths were registered, being a rate of 1,000 population of 0.30, compared with the figure of 0.39 for the country as a whole. Deaths of Children of One to Five Years of Age. Ten children survived their first but did not reach their fifth birthday. Of these, 3 died in their second year, 4 in the third, 2 in the fourth and another in his fifth year. 14 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 stillbirths registered in the year. In 1949 there were 5 deaths, this giving a maternal mortality rate of 1.6. The first fatality of the year was haemorrhage following a ruptured ectopic gestation. Two deaths were the result of haemorrhage due to placenta prævia, caesarean section being carried out in both. The other two deaths were the result of eclampsia which in each case set in some time after delivery. Deaths from Accidents. There were 53 deaths (26 male and 27 female) from violent causes during the year. Of these, 13 (5 male and 8 female) were the result of road traffic accidents. Falls of the elderly accounted for 15 (3 male and 12 female). Many of these were the result of a fall or a trip which caused a broken leg, death resulting from the subsequent hypostatic pneumonia. Seven males and 2 females were drowned and 3 men died on the railway. Coal-gas poisoning caused the death of 6 (3 of each sex) and other poisoning 5. Two deaths were of children, a boy of three being burned and a girl of five being killed on the road. Deaths from Suicide. Six men and eight women committed suicide, one of the men and three of the women chose poisoning by coal gas. Two men and two women hanged themselves. The incidence was fairly even throughout the year. 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 1,890 local deaths, 344 (166 male and 178 female) were due to cancer or other malignant disease, a percentage of 18. Diseases of the respiratory organs were commonest amongst males (bronchus 26, and lung 16), the next most frequent site being the stomach (28). Primary growths in the large intestine accounted for 17, and in the rectum for 15 deaths. Amongst females, the commonest site was the breast (29); the lesions of the other reproductive organs accounted for 37 deaths, the uterus being the primary site in 23 and the ovary in 14. The large intestine (28 cases) was the second most commonly affected site, accounting for many more deaths among females than among males, whereas lesions of the other parts of the intestinal tract (stomach 21 and rectum 14) were less common, as were also the lesions of the respiratory tract (lungs 3 and bronchus 8). Twelve 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. 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 0.26, and influenza under 0.06, all being lower than the corresponding national rates of 0.01, 0.45, and 0.15. The death rate from enteritis and diarrhoea in those under two years of age at 0.6 per 1,000 total births was lower than the rate of 3.0 for England and Wales. 15 HEALTH SERVICES OF THE AREA HOSPITALS General Hospital Service. Details of the hospitals in and serving this district were set out in the Annual Report for 1948. Those most used by the local inhabitants are:— 1. Edgware General Hospital. This is included in the institutions allotted to 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 is managed by the No. 11, or Hendon Group Hospital Management Committee. (Secretary: J. Fielding, F.H.A., Edgware General Hospital. Tel. No. Edgware 8181.) 2. Harrow Hospital. This is associated with the Charing Cross Hospital which, as a teaching hospital, is administered by a Board of Governors. The hospital maintains a physical treatment department at the Car Park Building, Station Road, Harrow. 3. Roxbourne Hospital. The Regional Hospital Board took over the South Harrow Isolation Hospital which the Harrow Council had in their earliest days decided to replace by a modern infectious diseases hospital. The premises have been modernised and as the Roxbourne Hospital provide accommodation for a number of elderly patients. Isolation Hospital Accommodation. Most of the patients suffering from an infectious disease who have needed to be admitted to hospital have been accepted at the Edgware Isolation Hospital which admits a far wider range of patients than used ordinarily to be accepted at the isolation hospitals. A much smaller proportion of patients suffering from scarlet fever is being removed to hospital for treatment as many can satisfactorily be cared for at home. On the other hand, no case is known in the last year of a patient suffering from an infectious condition and needing to be admitted to hospital not having been accepted at some hospital. Because of staffing difficulties accommodation could not always be found at the Edgware Isolation Hospital; in these cases the patient had to be taken to hospitals further, and sometimes much further, afield. 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, 3, 5, 7, Old Queen Street, London (Tel. No. Trafalgar 7799). 16 NURSING HOMES The responsibility for the registration and supervision of nursing homes lies with the Health Committee of the County Council. One large new home was registered during the year. There have been changes in ownership, and in the number and type of patient accommodated in a number of homes. The trend is a reduction in the number of maternity beds. 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. Beds Type of Case Bermuda House, Mount Park, Harrow Mrs. A. M. Elphick Mr. A. E. Elphick 11 Chronic Beverley Maternity Home, 170, Whitchurch Lane, Edgware Miss C. Dear 4 Chronic Bowden House, London Road, Harrowon-the-Hill Bowden House Nursing Home Association, Ltd. 14 Mental or borderline Brockenhurst Nursing Home, 84, Hindes Road, Harrow Mrs. T. M. Bell 6 Chronic College Hill Nursing Home, 123, College Hill Road, Harrow Weald Mrs. F. M. Ellis 7 Maternity, medical or surgical Convent of the Little Company of Mary Sudbury Hill Mother Superior 34 Medical or chronic Culverlands Nursing Home, Green Lane, Stanmore Dr. P. Vosper 11 Chronic Grosvenor House Nursing Home, 100, High Street, Harrow-on-the-Hill Mrs. N. Chaplin 20 Medical or chronic Heywood Nursing Home, London Road, Stanmore Mrs. M. Guyatt 11 Maternity and others Hillside Nursing Home, 49, Harrow View, Harrow Mrs. M. Cusack 5 Senile and convalescent Maitlands Nursing Home, 54, Marsh Road, Pinner Mrs. H. Payne 10 Maternity 17  Beds Type of Case Oakdene Nursing Home, 11, Hindes Road, Harrow Mrs. A. Gee 10 Maternity and others Roxborough Nursing Home, 25, Roxborough Avenue, Harrow Miss Calland Miss Burrows 13 Maternity and others St. Anne's Nursing Home, 34, West End Avenue, Pinner Mrs. D. Hickman 7 Chronic St. Vincent's Nursing Home, Headstone Lane, North Harrow Mrs. P. Thomas 4 Maternity and medical Suffolk House Nursing Home, Marsh Lane, Stanmore Mrs. D. M. Williamson 8 Maternity and others The Avenue Nursing Home, 28, The Avenue, Hatch End Mrs. A. Carter 4 Medical The Firs Nursing Home, 13, Roxborough Park, Harrow Hillingdon Surgical Instrument Co. 22 Maternity The Hall, Harrow Weald Dr. Lincoln Williams 10 Mental (borderline) At the beginning 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. At the end of the year there were 19 registered homes, with a total of 210 beds; of these 73 were for maternity 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 and a member of the medical profession. Before approving the registration of any premises the Committee requires to be satisfied about the general suitability of the premises for the work and of the equipment. Those registered are required to comply with the bye-laws as to the exhibition of the certificates of registration, the scale of charges, etc. As yet there is no bye-law in force in this district which enables the authority to determine the standard of training of the practitioner. The following are particulars of the premises licensed at the end of the year:— B 18 Mr. Arthur Arndt, 54, Methuen Road, Edgware. Mr. Cecil Sidney Arnold, 27, Exeter Road, South Harrow. Mr. Augustyn Buczek, 326, Rayners Lane, Harrow. Mr. Arthur Charles Back, 27, Shaftesbury Avenue, Harrow. Mr. William Bradley, 128, Headstone Road, Harrow. Mr. Sidney Barnard, 70, Sherwood Road, South Harrow. Mrs. E. C. Blackburn, 40, Wimborne Drive, Pinner. Miss G. N. Burgess, 31, Love Lane, Pinner. Mr. A. Blum-Chassereau, 5, Amersham Road, Harrow. Mr. John Darnton, 213a, Station Road, Harrow. Mr. Arthur W. Dunlop, 41, Station Road, Harrow. Mr. David Jn. Fox Mrs. Margaret Fox. 196, Kenton Lane, Kenton. Miss M. A. Goulding, 5, College Road, Harrow. Mr. H. G. Gillett, 72, Gayton Road, Harrow. Mr. Sidney Houslop, 2, Manor Parade, Harrow. Mr. Jack Ingrey, 32, St. Ann's Road, Harrow. Mr. L. F. Cameron-James, 67, Coledale Drive, Stanmore. Mr. Simon Sidney Knight, 73, Station Road, Harrow. Messrs. Lilley & Skinner, Ltd., Station Road, Harrow. Mr. James P. Mason, 1, High Worple, Harrow. Mrs. D. Praeger, 50, Sheepcote Road, Harrow. Miss F. Sabin, 40, College Road, Harrow. Mrs. L. Schneid, 100, Streatfield Road, Kenton. Mr. H. E. Smith, 26, Borrowdale Avenue, Harrow Weald. Mr. B. R. Stock, 62, Hunters Grove, Kenton. Mr. R. J. Turvey, 87, Streatfield Road, Kenton. Mrs. Upton, 36, High Street, Harrow-on-the-Hill. Miss Nesta Wimbush, 432, Pinner Road, Harrow. 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:— Mr. Douglas C. Lelean, 18, Imperial Drive, North Harrow. Mr. Walter M. Millard, 21, Cuckoo Hill Road, Pinner. Miss B. Teasdale, 118, Headstone Lane, Harrow. Miss A. M. Churchill, 50, Wychwood Avenue, Edgware. Mrs. B. A. Elsmore, 23, Devonshire Road, Hatch End. GENERAL MEDICAL SERVICES At the end of September, 1949, 129 medical practitioners practising from or at addresses in this district were taking part in the general medical services of the district under the National Health Service Act. 83 of these were taking part in the maternity services provided under the Act. 19 NURSING, MIDWIFERY, ETC., IN THE HOME 1. General Nursing. The home nursing service maintained by the County Council is provided for most of the area by the staff based at, and most of them living in, the two homes maintained by the former Greater Harrow District Nursing Association. The service is supervised by Miss Webster at "Cottesmore." The Bessborough Road Nursing Home (Tel. No. Byron 2647) is in charge of the Superintendent, Miss Dodds; and the Home at 93, Uppingham Avenue (Tel. No. Wordsworth 2538) is under Miss Allan. The two nurses of the former Pinner and Hatch End Nursing Association are still working from their own homes: Miss Dutson at 254, Uxbridge Road, Hatch End (Tel. No. Hatch End 213) and Miss Swift at 135, Pinner Hill Road (Tel. No. Pinner 2607). Up to the end of the year, Miss Sennitt, a member of the staff of the Edgware and Little Stanmore Nursing Association, continued to work in this district from her home at 138, Whitchurch Lane, Edgware. Another part of the district was served by the staff of the Watling District Nursing Association, Superintendent Miss Perkins, 1, Gervase Road, Edgware (Tel. No. Mill Hill 1836). The home nursing service is continued on much the same lines as when it was provided over most of the district by the District Nursing Association, the nurses carrying out the treatment ordered by the patients' medical attendants. The number of nurses is far below the number agreed as the establishment, even though there is accommodation at the nurses' homes and even though, too, non-resident staff are engaged. That the salaries of the home nurses were not brought into line with those of the staff engaged at hospitals did not make it any easier to recruit staff, so that the services could not meet the demands made on it even for nursing in the daytime and evening ; still less could a 24-hour service be maintained. 2. Midwifery and Maternity Nursing. The County Council, as local health authority, is responsible for the domiciliary midwifery service of the district. There are sixteen midwives living in their homes in various parts of the district, who work under the supervision of the non-medical supervisor of midwives, Miss Webster, and the senior midwife, Miss Rough, of 213, Exeter Road, South Harrow (Tel. No. Pinner 5752). 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 Walsh, 168, Whittington Way, Pinner. (Pinner 7864.) Nurse Lundy, 2, Church Avenue, Pinner. (Pinner 3378.) Nurse Ponter, 36, Corbins Lane, South Harrow. (Byron 2851.) Nurse Eagle, 2, Goldsmith Close, South Harrow. (Field End 9090.) Nurse Hinton, Flat 4, The Lawns, Lower Road, Harrow. (Byron 0340.) 20 Nurse Sutton, 37, Queens Court, Kenton Lane, Kenton. (Wordsworth 2052.) Nurse Shaw, 29, Dryden Road, Harrow Weald. (Harrow 1601.) Nurse Rees, 1, Masefield Avenue, Uxbridge Road, Stanmore. (GRI 2610.) 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. (Hatch End 2360.) Midwives are required by the rules of the Central Midwives' Board to carry out the ante-natal supervision of their patients. Some of these are seen at the homes of the midwives ; others are seen at those maternity and child welfare clinic buildings at which special sessions are held by the midwives for this purpose. In addition, midwives attend the ordinary ante-natal clinics attended by the County Council medical officers, particularly when their own patients attend them. In addition to the County Council's staff there were at the end of the year 3 midwives living in the area whose work was almost entirely restricted to domiciliary practice here, while as well there were 6 midwives living out of the area but whose domiciliary practice extends into this district. 3. Home Helps. The County Council provides this service under Section 29 of the National Health Service Act, under which a local health authority may make such arrangements as the Minister may approve, for providing domestic help for households where such help is required owing to the presence of any person who is ill, lying-in, an expectant mother, mentally defective, aged, or a child not over compulsory school age within the meaning of the Education Act, 1944. Helps are engaged full-time or part-time. They are paid by the authority according to the financial circumstances of the household; some, or all, of this sum is recovered from those who are helped. The main demand for help is from those who are suffering from pulmonary tuberculosis. Although the hours of help required might vary, the patient, once assisted, needs that help for a very long time. Owing to the difficulty in finding accommodation in institutions for those suffering from tuberculosis, largely because of the shortage of nursing and domestic staff, this demand remains high and, in many households, the help is required for long hours. Another constant demand is for home helps at houses at which women are being confined. In such cases, however, for most of them, the help is provided only for two weeks. There is a constant demand from the elderly who may, or may not be suffering from some disability. To many, a very limited amount of help makes a considerable difference to the person's comfort. There is as well a continuous demand from 21 those suffering from some acute condition. Many of these would have come on suddenly without warning, so that no preparation could have been made. From the nature of the case the demand is often of limited duration. The demand for such help can rise very rapidly, on such occasions as the prevalence of an outbreak of influenza. Applications for home helps should be made to the organiser of the domestic help service, Mrs. McLeod, at the Area Office, " Cottesmore," Uxbridge Road, Stanmore (Tel. No. Grimsdyke 711). DAY NURSERIES The County Council, as local health authority, maintains in this district, four day nurseries to which children up to the age of five years can be admitted. The nurseries are intended primarily for the children of mothers engaged whole-time on work classed as of national importance. In their Development plan, the County Council's proposals regarding day nurseries were:—"It is considered that the provision of day nurseries is required to meet social, rather than health needs. In the circumstances, the demand is likely to be somewhat fluctuating and the County Council accordingly does not propose to embark upon a policy of progressive expansion of this service. It will be guided both as to the numbers of nurseries provided, and their siting, by local demands for women in industry. In any case, it does not propose to encourage the reception of infants under the age of two years in day nurseries." Below are set out the particulars of the nurseries:— Address No. of Children Matrons Telephone No. Kenmore Nursery, Kenmore Road, Kenton 60 Mrs. Brocklebank Wordsworth 5578 Spencer Road Nursery, Wealdstone 50 Miss Poynton Harrow 1580 Headstone Drive Nursery, Wealdstone 50 Miss Tompkins Harrow 0131 Walton Avenue Nursery, South Harrow 60 Mrs. Walmsley 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. CLINICS AND TREATMENT CENTRES The County Council as the local health authority has taken over and continues to maintain the various sessions up to this provided by the Harrow Council. The only change made during the year was the opening of a combined session in the Rectory at Elstree to meet the needs of the mothers on the Harrow Council's Housing Estate at Elstree. The part of the district most in need of new clinic services is the London County Council Headstone Estate. It has not been possible up to this, to provide 22 sessions in any premises nearer than the infant welfare and ante-natal sessions in Harrow Weald and Hatch End, and the school clinic at the Broadway, Wealdstone. 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 Mon. and Wed. p.m. Baptist Church Hall, Streatfield Road, Kenton Wed. a.m. and p.m. Broadway Clinic, The Broadway, Wealdstone Wed. a.m. and p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. p.m. St. Hilda's Hall, Northolt Road, South Harrow Tue and Thu. p.m. The Clinic, Alexandra Avenue, South Harrow Mon. and Fri p.m. Methodist Church Hall, Walton Avenue, South Harrow Thu. p.m. St. George's Hall, Pinner View, Harrow Tue. and Fri. p.m. Memorial Hall, High Road, Harrow Weald Thu. p.m. Clinic, Honeypot Lane, Stanmore Mon. and Wed. p.m. Methodist Church Hall, Love Lane, Pinner Fri. p.m. St. Anselm's Hall, Hatch End Thu. a.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Thu. and Fri. p.m. Home Guard Building, Station Road, North Harrow Mon. a.m. The Rectory, Elstree Mon. p.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 Tue. p.m. Baptist Church Hall, Streatfield Road, Kenton Thu. and Fri. p.m. Broadway Clinic, The Broadway, Wealdstone Tue. a.m. and Thu. p.m. 76, Marlborough Hill, Wealdstone Mon. p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. a.m. St. Hilda's Hall, Northolt Road, South Harrow Tue. a.m. The Clinic, Alexandra Avenue, South Harrow Wed. p.m. Methodist Church Hall, Walton Avenue, South Harrow Thu. a.m. Home Guard Hut, Station Road, North Harrow Mon. p.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. Clinic, Honeypot Lane, Stanmore Tue. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. St. Anselm's Hall, Hatch End Thu. p.m. Chandos Pavilion, Chandos Recreation Ground, Fri. a.m. Edgware Fri. a.m. The Rectory, Elstree Mon. p.m. 23 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 Alternate Thu. a.m. Spiritualist Church Hall, Vaughan Road, Harrow 1st Mon. a.m. in month Clinic, Alexandra Avenue, South Harrow Wed. a.m. St. George's Hall, Pinner View, Harrow 1st and 2nd Tue. a.m. Clinic, Honeypot Lane, Stanmore Mon. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Pavilion, Chandos Recreation Ground, Edgware Thu. 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 that anyone intending to obtain advice should bring a note from her medical attendant indicating the grounds on which advice is necessary. School Minor Ailment Clinic. Sessions are held at a number of premises in the district:— The Clinic, Broadway, Wealdstone Mon. a.m., Thu. a.m., Sat, a.m. The Clinic, Elmwood Avenue, Kenton Fri. a.m. The Clinic, Alexandra Avenue, South Harrow Mon. a.m., Fri. a.m., Sat. a.m. The Clinic, Honeypot Lane, Stanmore Tue. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Pavilion, Chandos Recreation Ground Tue. 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. 24 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 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 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. 25 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. C. 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. Sufferers can be treated at certain London Hospitals and at the Central Middlesex Hospital, Acton Lane, Willesden; Hillingdon Hospital, Royal Lane, Hillingdon; and West Middlesex Hospital, Twickenham Road, Isleworth. The most convenient of the London Hospitals at which treatment is provided are St. Mary's Hospital, Cambridge Place, Paddington, and University College Hospital, Gower Street. PROVISION FOR SPECIAL CLASSES OF PERSON. The Deprived Child. The duty of providing for the deprived child 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.1 (Tel. No. Trafalgar 7799). 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 Handicapped Adult. The mental health services are integrated with the other health services established under the National Health Service Act. The duties of the local health authority include responsibility for the initial care and conveyance to hospital of patients who fall to be dealt with under the Lunacy and Mental Treatments Acts, and for the ascertainment and community care of mental defectives. The Health Committee of the County Council is responsible for the mental health functions of the Authority. The local authorised officers are Mr. W. J. Pedel and Mr. W. Bullwinkle, of 48, Station Road, Harrow (Tel. No. Harrow 5600). 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 26 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, 18, Station Road, Harrow. Tel. No. Harrow 1252). AMBULANCE SERVICE The ambulance service maintained by the County Council is run in association with the fire service. Ambulances for the removal of accident cases are housed in or adjacent to Fire Stations (Tel. Nos. Harrow, Pinner, Byron, Wordsworth, Grimsdyke, Underhill 2222); those for sick persons are to be placed as close as possible to main hospitals, including the isolation hospitals. LABORATORY SERVICE. The examination of clinical material of public health significance is carried of 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 hemolytic 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. 27 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, 488 ; faeces, 26 ; sputum, 11 ; pertussis, 2 ; milk, 54 ; ice-cream, 84 ; and water, 28 ; miscellaneous, 34. 28 SANITARY CIRCUMSTANCES OF THE AREA WATER Details of the water supply for the district and of the steps taken to ensure that the water supply is safe were set out in the Annual Report for the year 1948. The results of the analyses of samples taken throughout the year were all satisfactory. No complaints were received during the year about the quality or the quantity of the water supply. DRAINAGE AND SEWAGE DISPOSAL Particulars of the local arrangements were set out in the Annual Report for 1948. The only complaints received were at times of heavy rainfall when flooding by surface water occurred in some parts of the district. PUBLIC CLEANSING Refuse Collection. The same arrangements continued in force for the collection of house refuse. Although some continued to be received, complaints about the state of the kitchen waste bins were far fewer than in previous years. Refuse Disposal. Most of the refuse of the district was disposed of by controlled tipping at the Old Redding site. It will not be possible to continue to use this site for very long now. Pending the erection of one or more separation plants which the Council has decided on as the method of disposal of the refuse of the district, arrangements are being made for the refuse to be disposed of by tipping outside the district. Street Cleansing. The same general arrangements for the sweeping of the streets, as set out in the Annual Report for 1948, were continued, although greater use is now being made of mechanical sweepers. DISPOSAL OF THE DEAD Burial Grounds. Particulars of these were included in the Annual Report for 1948. Cremation. No further progress has been made in regard to the proposal for the construction of a crematorium on land forming part of the Harrow Weald cemetery reservation. 29 Burial. Under Section 50 of the National Assistance Act, 1948, the Council can arrange for the burial or cremation of any person who has died or who has been found dead in their area, if no other suitable arrangements have been or are being made. During the year arrangements were made for 5 burials. Mortuary. During the year, 307 bodies were received in the mortuary. Postmortem examinations were carried out on 236 and inquests were held on 48. 71 bodies were admitted for storage. 30 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 1,485 (ii) On complaint of other nuisances 413 (iii) Routine inspections 406 (iv) Revisits arising from defects found 8,669 (v) Surveys under S. 157, Housing Act, 1936 819 Conditions Found. (i) Number of dwellings or other premises visited as a result of (i), (ii) and (iii) where defects were found 1,798 (ii) Number of cases of overcrowding revealed 178 PUBLIC HEALTH. Inspection of Other Premises. (i) On complaint or request 158 (ii) Routine inspections of premises 396 (iii) Revisits arising from defects found 724 (iv) Surveys arising from Rat complaints 1,023 (v) Inspection of Factories 663 (vi) Inspection of Workplaces 75 (vii) Inspection of Outworkers' Premises 319 (viii) Inspection of Cinemas and Places of Entertainment 41 (ix) Inspection of Licensed Premises 53 (x) Visits under Shops Acts 1,286 (xi) Evening observations under Shops Acts 37 (xii) Sunday observations—Shops Acts 16 (xiii) Observations made for Smoke Nuisances 15 Conditions Found. (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 148 (ii) Number of premises where action taken by Council's Rodent Operative to deal with rats—see (iv) above 926 (iii) Number of Factories, Workplaces and/or Outworkers' premises where defects or contraventions were found —see (v), (vi) and (vii) above 124 31 (iv) Number of Cinemas and/or Licensed premises where defects were found—(viii) and (ix) refer 14 (v) Contraventions of Shops Acts— (a) Failure to observe closing hours 34 (b) Other contraventions (failure to exhibit notices, etc.) 190 FOOD HYGIENE. Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 18 (ii) Butchers' Shops 532 (iii) Cowsheds 18 (iv) Dairies 139 (v) Fish Shops 211 (vi) Bakehouses 55 (vii) Cafes and Restaurants 594 (viii) Ice-cream Premises 354 (ix) Provision Merchants 514 (x) Other Food Premises 185 PART II. COMPLAINTS RECEIVED. Summary of Complaints Received Accumulations of refuse 132 Animals causing a nuisance 51 Dampness 134 Drains and sewers—choked 212 defective 161 Dustbins defective 208 Houses with defects 607 Plumbing defects 189 Flooding—gardens 6 Vermin 21 Insect infestations 33 Overcrowding, alleged 406 Shelters and static tanks unsatisfactory 7 Smoke nuisances 4 Water courses 11 Defective waterclosets 28 Other complaints (pig bins, wasps' nests, defective fences) 164 Food unfit (excluding requests received from shops to visit and inspect unfit food) 51 32 PART III. NOTICES SERVED. Under Housing Act, 1936. (i) Statutory notices served under S. 9 requiring execution of repair work 64 (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 15 (iii) Dwellings reported to Public Health Committee and approved for action under S. 12, Housing Act, 1936, i.e., closing order on part of the dwelling 3 (iv) Informal notices served with view to subsequent action under S. 9 167 Under Public Health Act, 1936. Statutory Notices under:— (i) S. 24, i.e. Notice requiring work to a public sewer 65 (ii) S. 39, i.e. Notice requiring repair or renewal of drains 45 (iii) S. 45, i.e. Notice requiring repair or renewal of defective water closets 4 (iv) S. 56, i.e. Notice requiring work on undrained or badly drained yard area 5 (v) S. 75, i.e. Notice requiring renewal of a dustbin 42 (vi) S. 93, i.e. Notice requiring abatement of a nuisance 78 (vii) S. 138, i.e. Notice requiring a sufficient water supply 5 Informal notices served (all sections) 2,154 ACTION TAKEN. Following Housing Act Notices. (i) S. 9—dwellings rendered fit after service of Statutory Notices :— (a) By owners 48 (b) By local authority in default of owners (In the case of six of the properties referred to in (b) the notices were served during 1948) 10 (ii) S. 11—demolition order made (These orders related to properties where action was started during 1948) 7 (iii) S. 12—closing order made in respect of parts of dwellings 3 (iv) Dwellings rendered fit by owners after receipt of informal notice (S. 9) 103 (v) Number of houses demolished as a result of action taken under the Housing Act in previous years 2 33 Following Public Health Act Notices. (i) S. 24 16 (ii) S. 39 : (a) By owners 18 (b) By local authority in default of owners... (In eight the notices were outstanding from 1948) 35 (iii) S. 45 : (a) By owners 4 (b) By local authority in default of owners Nil (iv) S. 56 : (a) By owners 7 (b) By local authority in default of owners 1 (v) S. 75 : (a) By owners 16 (b) By local authority in default of owners (Four dustbins were supplied in default on the notices outstanding from 1948) 26 (vi) S. 93 (Of the 76 nuisances abated, seven were outstanding from 1948) 76 (vii) S. 138—water supply improved 5 (viii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,909 SUMMARY PROCEEDINGS. On two occasions it was necessary to apply to the Courts for an abatement order. In both cases orders were made by the magistrates and costs allowed. In one case a fine was also imposed. During the year the appeal against an abatement order made by the local magistrates and referred to in the Annual Report for 1948 came before the Court of Quarter Sessions at Middlesex Guildhall. The Court dismissed the appeal. Five cases about dustbins were also heard by the local magistrates, in each case an appeal having been lodged by the owner against the service of a notice under S. 75 of the Public Health Act, 1936. In one case the appeal was dismissed. In the others the appeals were allowed, in two costs being awarded against the Council. One of these cases was later the subject of an appeal by the Council to the King's Bench Division. This appeal was dismissed with costs. The local magistrates also heard two summonses involving a hawker. One summons referred to trading in the district without being registered pursuant to S. 279 of the Middlesex County Council Act, 1944, and the second for failing to have his name and address inscribed on his vehicle. Fines were imposed in respect of each of these summonses. HOUSING. Repair of Houses. 1,485 complaints of dampness or other housing defects were received during the year, a small increase over the number received during 1948. c 34 Action to deal with the conditions found was taken under either the Public Health Act or the Housing Act, the latter being used to a slightly greater extent than in the previous year. In the case of ten properties dealt with under the Housing Act, it was necessary to carry out repair work in default of the owner. Fifteen properties were found in such a state of disrepair as to necessitate action being taken with a view to demolition orders being made. The provision of other accommodation for the occupants of dwellings which are the subject of demolition orders gives rise to many difficulties, for though there is no statutory obligation on a local authority to provide alternative accommodation, the present housing shortage makes it almost impossible for either owners or tenants to do this. The question of the rehousing of the occupants of such properties is, therefore, referred to the Housing Committee. Six families were rehoused by the Council during 1949 from properties which were the subject of demolition orders of previous years, leaving 41 condemned properties occupied at the end of the year. No appeals were lodged against the notices served under the provisions of the Housing Acts for securing the execution of works of repair on the grounds that the property concerned could not be repaired at a reasonable cost. Where an owner failed to execute the work within the period allowed by the notice, it was carried out by the Council in default. Overcrowding. At the end of 1948 there were 628 known cases of overcrowding in the district. During the year 178 new cases were brought to light. On the other hand, overcrowding was abated in 424 instances. The number of cases by the end of 1949, therefore, was 383. 107 cases were abated by families being rehoused by the Council, 87 in Council houses and 20 in requisitioned property. In assessing crowding, according to the standards of the Housing Act, an adult ranks as 1 unit; a child of 1 to 10 years as half a unit, but a child under one year, not at all. A family which is not overcrowded when it first occupies certain premises might well become so by the natural increase in the size of the family, or by the ageing of the child members. This will happen only in those cases in which the accommodation, before the change in circumstances, was already near the limit of crowding. Another closely associated method by which overcrowding can occur is by one of the older children getting married, the spouse coming to live with the family and then perhaps, in due course, a child being born. Crowding by these two methods can be expected to occur year after year, as long as accommodation is being occupied near to the limits of crowding. In 32 of the 383 houses which were overcrowded at the end of the year, the houses or some rooms in the houses had been let so as to be overcrowded. In 144 cases, the overcrowding was brought about by the married children going to live with their parents; in 51 by relatives other than married children going to live with the tenants; and in 24 was 35 due to the presence of lodgers who were not related to the original householders. In 132 instances, the overcrowding was the result of the natural increase in the size of the family or of the ageing of children. In 219 cases, the overcrowding was not of the house, but only of rooms separately let. However great might be the injury to the health of those living in overcrowded rooms, the restriction of the sub-tenants to part of the house perhaps is no more damaging to the health of the inmates than the arrangement by which two families try to live in communal accommodation. The first survey to determine the extent of overcrowding carried out in 1937 showed that 187 families were occupying overcrowded accommodation. By 1940, this figure had been reduced to 19, but rose to 65 by 1945. In the next twelve months, 486 new cases were added to the register, and in each of the next two years the numbers added were greater than the numbers in which overcrowding was abated. This last year saw a marked improvement in the situation in that the number abated considerably exceeded the number of new cases. This is unlikely to happen again on this scale. Of course, there should not be again the large number of additional new cases which occurred in 1946 and the following years, the result of the return of those from the forces. On the other hand, it is known that many are already occupying accommodation near the limit of crowding and it is inevitable that, with the ageing of the child members of these families, the child, on attaining the age of 12 months, ranking as ½ unit instead of as 0, and the child on attaining the age of 10 ranking as 1 unit instead of i, there must be a steady addition of new cases of crowding. To try to restrict new cases of crowding, the owners and tenants of houses from which families have been removed to be rehoused have had their attention drawn to their statutory obligations not to permit the overcrowding of accommodation over which they have control. Then, towards the end of the year, publicity was given to the fact that in regard to newly permitted overcrowding which was not the result of the natural increase in the size of the family, consideration would be given to the question of whether the penal provisions of the Housing Act should not be used. Provision of Houses. The Council's Housing Programme for the years 1946/52 provided for the erection of 2,176 housing units, comprising 1,192 houses, 694 flats and 200 temporary houses. The actual number completed in 1946 was 215; 255 and 365 were built in the next two years, and 286 in 1949. Allocation of Houses. When the points scheme for the selection of those to whom Council houses were to be offered was decided upon, those whose needs rested primarily on health grounds were dealt with separately, particulars of these being submitted by the Medical Officer of Health to the Selection Sub-Committee. These three groups were those living in overcrowded conditions ; those families with a member suffering from open tuberculosis, and those families living in condemned property. 36 In 1948, the points scheme was revised and special provision was made by which those living in overcrowded accommodation were dealt with under the general points scheme qualifying for additional points because of the crowding. The same arrangements have continued by which particulars of those needing to be rehoused because of the presence of a member suffering from open tuberculosis, are referred direct by the Medical Officer of Health. The generous allocation for those in this group has resulted in all those families whose claims on these grounds were greatest having been rehoused, and there are few such families now living in accommodation in this district which is overcrowded to any great degree. There were numbers of houses which, although condemned before the war, were still occupied. The worst of these have now been demolished, the Council rehousing the tenants. Unfortunately, there are many houses now being occupied which are utterly unfit for human habitation and which must very shortly be represented for demolition. The families in these houses stand no chance of obtaining other accommodation, unless given it by the Council. On the other hand, rehousing of these families will make great inroads on the limited numbers of houses which the Council have, or are to have, for letting. Many of these houses were in poor condition before the war. For many years now they have had little attention and there must be many which cannot be allowed to be occupied in their present state, and yet they cannot at a reasonable cost be made fit. Many of the families which were overcrowded have been rehoused under the points scheme. On the other hand, there are quite a number of families which, because of short residence here, have only a few points and who therefore stand little chance, under present arrangements, of reaching the position that they can hope to be rehoused by the Council; and yet the overcrowding in some of these cases is of such a degree that it is felt that living in such conditions cannot be other than injurious to the health of the occupants. SUPERVISION OF OTHER PREMISES In addition to the work undertaken in securing the execution of repair and improvement work in dwellings, routine inspections were made of factories, cinemas, licensed premises and many other buildings and sites. As a result it was possible, particularly in the case of watercourses and vacant parcels of land, to take action that prevented unsatisfactory conditions arising, whilst in other cases the inspections resulted in improved methods or facilities being introduced. 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 :— 37 Inspections. Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (i) Factories in which S.S. 1, 2, 3, 4, and 6 are to be enforced by Local Authorities 104 79 19 - (ii) Factories not included in (i) in which S. 7 is enforced by the Local Authority 362 305 25 - (iii) Other Premises in which S. 7 is enforced by the Local Authority (excluding out-workers' premises) 72 45 7 - Total 538 429 51 — Defects Found. Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 44 64 Overcrowding (S. 2) — 1 - — — Unreasonable temperature (S. 3) - 1 - - - Inadequate ventilation (S. 4) 2 2 - — — Sanitary Conveniences (S.7)— (a) Insufficient 3 4 - — — (b) Unsuitable or defective 36 35 - 1 (c) Not separate for sexes 2 1 - — — Other offences against the Act (not including offences relating to outwork) 37 28 1 — — Total 124 136* 1 1 — *The number of defects remedied exceeds the defects found because of work outstanding on the 31st December, 1948 being completed during 1949. In addition, 319 visits were made to premises of outworkers who are persons who undertake at home work sent out from factories or business premises. Shops. During the year 1,286 visits were made to shops in the district by the Shops Acts Inspector. 16 contraventions of the Shops Acts in respect of the exhibition of notices and the keeping of records were noted and dealt with. Evening observations resulted in 28 38 ventions of the Shops (Hours of Closing) Act, 1928, being observed; of these, 20 were first offences and the remaining 8 were the subject of reports to the Public Health Committee. The Defence Regulations restricting the general closing hours on Saturdays to 7.30 p.m., on other evenings of the week to 6 p.m., came into operation as in previous years on the first Sunday in November. The hours laid down by these Regulations remain the closing hours until March, 1950, when the hours as laid down by the Shops (Hours of Closing) Act, 1928, came into operation. Most of the 28 contraventions as to the hours of closing occurred during the period when the hours as laid down by the Defence Regulations were in operation. Other contraventions reported by the Shops Acts Inspector included six cases of hawkers retailing fruit and vegetables on Wednesday afternoons (after 1 p.m.) in the Wealdstone area in contravention of the Wealdstone Fruit and Vegetables Order; five cases of shop assistants being employed on the afternoon of their weekly half-holiday; and three cases where ladies' hairdressing saloons failed to close for one halfday in each week. In respect of all these contraventions, warnings were given. As a result of visits made by the Shops Acts Inspector, 45 shops were redecorated and 155 requests for other repairs and improvements were made and complied with. At the end of the year there were 2,265 shops on the register, an increase of 35 on the previous year. Smoke. Four complaints were received during the year of nuisances arising from smoke emitted from business or factory premises. In one case a grit arresting plant was installed and in another the factory management agreed to the fuel being changed from coal to coke. In the other two cases lapses in stoking were found to be the cause of the trouble. During the year 15 observations were made of factory chimneys. Rat Infestation. During the year 1,023 complaints of rats or mice were received. Although this number is an increase of 257 over that received for 1948, it is felt that this is due to the introduction during August, 1948, of the free service and not to an increase in the rat population of the district. That the destruction service is free for private dwellings is becoming more widely known and householders now notify generally without any delay, the presence or suspected presence of rats or mice. On two occasions during the year, sections of the sewers were treated, but as in previous years no evidence of any serious infestation was found. 39 The watercourses of the district were also dealt with and regular visits were made to the Council's refuse tips and salvage depot. It was necessary to carry out treatment along the banks of the River Pinn and to several other watercourses, but no treatment was found necessary at the Salvage Depot or the Council's refuse tips. Wasps. An unusually large number of requests for assistance were received from householders and others in the district about wasps. 239 nests, many of which were in recreation grounds or in banks along the highways were dealt with. Others were removed from coal bunkers, roof spaces and several from under floors of living rooms and one from the space between the ceiling of one room and the floor of the room above. 40 INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY Legislation. On the 1st October, 1949, regulations made by the Ministers of Health, Food and Agriculture and Fisheries brought about many changes in the responsibilities of the Council in regard to milk. The broad effect of the new regulations is to make (i) the Minister of Agriculture and Fisheries responsible for the supervision of farms and the production side of the industry, (ii) the Food and Drugs Authorities responsible for the supervision of the processing and treatment of milk, and (iii) local authorities responsible for the supervision of distribution. There are two establishments in the district at which milk is pasteurised. The responsibility for their supervision has now passed to the County Council. This is because the Harrow Council is not a Food and Drugs Authority, though in many areas with a population of 60,000 or less, the local authority is the Food and Drugs authority and therefore remains responsible for such establishments. It is the more unfortunate because now officers of the County Council and the Harrow Council will need to visit the two pasteurising establishments in the district. Production. During the year one farm in the district ceased to be a dairy farm, and the number at which milk is now produced is eight. Of these, four are producing tuberculin tested milk, one accredited and the remainder ungraded milk. Processing and Distribution. The following summarises the position in Harrow up to the 1st October, 1949:— (i) Number of premises licensed to pasteurise milk 2 (ii) Number of premises licensed to bottle T.T. milk 2 (iii) Number of premises from which pasteurised milk was sold 44 Of these, 30 were controlled by the United Dairies (London) Ltd., or the Express Dairy. (iv) Number of premises outside Harrow from which pasteurised milk was retailed in Harrow9 (v) Number of premises from which T.T. milk was retailed 22 Of these 10 were controlled by the United Dairies (London) Ltd. or the Express Dairy (vi) Number of premises outside Harrow from which T.T. milk was retailed in Harrow 10 In addition there were two establishments from which raw milk was retailed. 41 Inspection and Supervision. During the year 157 visits were made to cowsheds and dairies and where necessary, those responsible were asked to execute work of repair or improvement. Action was taken early in the year to secure the modernising of one of the pasteurising establishments and plans for the erection of a new dairy in which the latest type of equipment will be installed were approved. Sampling. Of the 52 samples of milk taken, 46 were satisfactory. Of the 6 samples in respect of which adverse reports were received, investigations were made and follow-up samples showed the cause of the trouble had been removed. Complaints. During the year 17 complaints were received about the dirty condition of milk bottles or of foreign matter being present in the milk. These complaints were investigated and action was taken with the companies concerned. The milk distributing companies are alive to the problem and would seem to take all possible precautions to prevent such occurrences. To an increasing extent, milk is distributed in narrow-necked bottles sealed with overlapping caps. There is no doubt many of the complaints are because householders and others fail to rinse the bottles after use. To remove a possible source of contamination, in May, 1949, all dairymen in the district were asked to issue instructions to employees to refrain from placing crated milk bottles on the public highway. The trade has co-operated in this matter and it hoped that eventually the practice will cease. (B) MEAT There are seven slaughterhouses in the district, but at none was regular slaughtering carried out. Only 15 pigs were slaughtered, being pigs kept by private individuals or pig clubs. All the carcasses were inspected and found fit for human consumption. (C) OTHER FOODS Inspection and Supervision. During the year 2,620 visits were made to food shops and other premises at which food was stored or prepared. Many of the visits were in connection with unsound food and others were routine inspections. As a result of these visits work of improvement was carried out at a considerable number of premises. The following is a summary of the food examined and found to be unfit for human consumption, being destroyed locally or disposed of by the Ministry of Food:— 42  lbs. Meat and meat products 7,536 Vegetables, soups and pickles 1,641 Groceries and miscellaneous 3,735 Fish 5,301 Fruit 713 Total 18,926 The total weight of food found unfit during the year was a little under 8½ tons. Ice-cream. During the year the manufacture of ice-cream was discontinued at 11 premises which at the end of 1948 were registered for this purpose, so that the number of registered manufacturers in the district at the end of 1949 was only 11. This reduction is due partly to the improved supply position resulting in smaller traders receiving larger quantities of icecream from the better known manufacturers, and partly to the cost of installing and maintaining equipment for manufacturing purposes. In contrast with the smaller number of premises at which ice-cream is manufactured, the number of premises registered for retailing it increased from 185 to 244. During the year 354 visits were made to premises retailing or manufacturing ice-cream and as a result of advice taken many improvements were carried out. Eighty-four samples were taken and of these 52 were reported as being either Grades 1 (the highest standard) or 2, and the remainder Grades 3 and 4. The establishments supplying the latter were investigated and in the case of supplies coming into the district, the local authorities concerned were advised. In all of these cases follow-up samples were taken. Registration of Hawkers. Pursuant to S. 279 of the Middlesex County Council Act, 1914, 36 hawkers were registered during the year. Of these, 32 were registered as hawkers of greengrocery and 4 as hawkers of fish. Action was taken against one hawker for trading in the district without being registered and also for failing to have his name and address inscribed on his vehicle. Fines were imposed in respect of each summons. (D) HYGIENE OF FOOD The local campaign for the improvement of the conditions under which food is prepared and handled dates back to the summer of 1948, when the Public Health Committee having considered a report of the local conditions, appointed a Food Hygiene Sub-Committee. Because of the very large numbers engaged in the handling of food and the many shopping centres here, the Committee decided not to attempt to deal at one time with all those concerned in the handling of food. The catering industry was the one selected to be approached first. From a meeting to which all in that trade were invited, a sub-committee was 43 formed with which the Council's Food Hygiene Sub-Committee kept in contact. The sub-committee favoured the setting up of a guild of food handlers, with separate sections for the various interests, and for each of which a code of practice was to be prepared. By the end of the year the Catering Sub-Committee had prepared a code of practice which could only apply to that section of the trade. That is as far as the campaign had progressed by the end of 1948. Sufficient had been learned from the contact with representatives of the catering trade to warrant the next step being taken, namely, approach being made to those engaged in the other branches of handling of food. The Food Hygiene Committee, too, decided that the time had arrived that steps should be taken to constitute an Advisory Committee. At their meeting on July 1st, the Council accepted the recommendation of the Public Health Committee "That the Council hereby approve of the setting-up of the Harrow Food Hygiene Advisory Committee, to comprise eight tradesmen representatives and the members of the Food Hygiene Sub-Committee." All representatives of the various sections engaged in the handling of food apart from the caterers, were invited to a general meeting. This was very well attended, and from it sub-committees were appointed for each of the other seven sections of the food trade, namely, bakers, butchers, confectioners, fishmongers, greengrocers, grocers, and retailers of ice-cream. Each of these sub-committees met on various occasions and agreed on a code of practice appropriate for each section. At their meeting on the 12th July, the Food Hygiene Advisory Council considered its constitution, standing orders and rules of procedure. At their meeting on the 11th October, they recommended (1) that steps be taken to set up an organisation in the district to be known as The Harrow Guild of Food Hygiene; (2) that a letter together with a copy of the relevant code of practice be addressed to all food traders in the district, inviting application for membership of the guild, the conditions of membership being that the premises were of a satisfactory standard, and those engaged in them would comply with the relevant codes of practice; (3) the issue of a suitable certificate to establishments, as members of the guild be approved. At their meeting on December 20th, the Advisory Council had approved the form of certificate the members of the guild are entitled to exhibit, and it is hoped that the public will look for this when entering any establishment in which food is sold or handled. By the end of the year 174 applications had been received, and a beginning made of the inspection of the premises. It is felt that an important part of this campaign is the stimulation of interest and the education of those actually dealing with food. A trial series of five lectures was, therefore, arranged, in collaboration with the Education Authority, to which were invited members of the catering trade. The lectures were held in the evening. This perhaps accounted in part for the poor attendances, which were sufficiently low as to raise doubts as to the advisability of running any more on the same lines. Another line to be followed with, it is hoped, greater success, is the instruction of 44 the food handler at his place of work, and in his employer's time. It had not been possible by the end of the year to obtain the film strips which were felt to be so important if this venture were to succeed. By the end of the year then it could be felt that real progress had been made in this campaign. Contact with those concerned in the various sections of the food industry demonstrated that many felt that a very real interest in the subject. The Food Hygiene Advisory Council with its representatives of the trade and of the Council, had been constituted and was the focus of activity. All trades had agreed to a code of practice, and by the end of the year the first applications for membership of the guild had been received. Lastly the first steps to interest and educate those immediately concerned with the handling of food had been taken. 45 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease Und. 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over Total Scarlet fever 1 75 238 28 4 3 1 1 - - - 351 Diphtheria — — 1 — - - - - - - - 1 Pneumonia 1 — 9 5 2 3 7 7 14 12 17 77 Dysentery — 2 1 1 1 1 — 1 3 -_ 1 11 Erysipelas — — — 1 1 — 2 4 7 9 2 26 1 5 Cerebro-spinal fever 1 - - - - - - - - - - Puerperal pyrexia - - - - - - 4 1 - - - Ophthalmia neonatorum 1 - - - - - - - - - - 1 Poliomyelitis — 4 8 1 — 2 1 4 - - 1 21 Polioencephalitis — — — — — — 1 1 2 Measles 45 999 930 37 6 3 8 9 1 - - 2.038 Whooping cough 11 109 62 6 1 — - 1 1 191 Paratyphoid fever - - - - 1 - 1 - - 2 Food poisoning 1 - — — — — 2 1 — 4 Disease Cases Notified Admitted to Hendon Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Scarlet fever 360 106 37 1 Diphtheria 17 11 6 - Pneumonia 77 5 3 9 Dysentery 13 3 - - Erysipelas 30 11 - 1 Cerebro-spinal fever 1 - - 1 Puerperal pyrexia 5 2 - - Ophthalmia neonatorum 1 - - - Poliomyelitis 27 19 5 3 Polioencephalitis 2 1 1 - Measles 2,038 4 8 - Whooping cough 191 9 8 - Paratyphoid fever 5 3 1 - Food poisoning 4 — — - CONTROL OF INFECTIOUS DISEASES. Notification. The diseases notifiable under the Public Health Act, 1936 are smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fevers. 46 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, acute poliomyelitis, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles, whooping cough, and, since January 1st, 1950, acute encephalitis and meningococcal infection. Food poisoning is notifiable under the provisions of the Food & Drugs Act. Enquiries. Following receipt of the notification a visit is made to the home, usually by the health visitor, but in certain conditions, such as food poisoning or the enteric or the dysenteric infections, or smallpox, by the sanitary inspector. 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. The second line of enquiry is to enable such steps to be taken as will minimise the spread of infection by the infected person. Aid to Diagnosis. The earlier diagnosis, the greater the likelihood that preventive measures will limit the spread of infection. In some diseases, the laboratory is of help. 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 from the medical superintendent of the Isolation Hospital. To obtain a consultant's opinion in doubtful cases of smallpox or typhus fever the medical practitioner gets into touch with those at the Public Health Office, who arrange for the attendance of one of the consultants on the list of the Ministry of Health. 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. Not all those suffering from the communicable diseases 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, chicken- 47 pox, 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-spinal 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. Most of the patients admitted to an isolation hospital are accepted at the Edgware Isolation Hoapital, 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. Patients suffering from smallpox are 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. A similar arrangement obtains in the case of those suspected to be suffering from typhus fever. 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. 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 wide-spread 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. The period of exclusion of day-school contacts of those suffering from scarlet fever is seven days after the removal of the patient to hospital or to the beginning of his isolation at home. Contacts of diphtheria are excluded for seven days after the removal of the patient to hospital, or the beginning of his isolation at home; if there are any suspicious 48 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. Except after cases of smallpox, typhoid fever, tuberculosis and scabies, and in any exceptional cases approved by the Medical Officer of Health, where disinfection cannot be carried out in the home, terminal fumigation and removal of bedding and other articles for stoving after the commoner notifiable infections is not carried out by the Council, 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. DIPHTHERIA Incidence. Although on a number of occasions it was possible to record that very small numbers of cases of diphtheria had occurred in the district during the year, 1918 was the first year that it could be reported that there was not a single case. This year, although 17 persons were admitted to hospital suffering from what was suspected to be diphtheria, the diagnosis was confirmed in only one case and that was a case of nasal not faucial infection. This was a boy of seven who had been immunised in 1943, and was subsequently found to be Schick negative. While the dramatic fall in the incidence of diphtheria throughout the country in recent years must be related to the success of the immunisation campaign which has been carried out, and to the facilities put at the disposal of the public especially since 1940, whether or not any individual succumbs depends partly on that person's state of immunity or susceptibility. Anyone who has not been protected may succumb on exposure. Moreover, any who have been protected do not necessarily maintain their immunity unless they receive subsequent treatment. If they do not receive any boosting doses, their immunity might wane sufficiently to reduce them to a susceptible state. Nevertheless, should they succumb, it is probable that the infection will be of a mild degree only. The position, then, is that even though the protection might wane sufficiently to leave the child exposed to an attack, there is very little risk of its waning to such an extent as to leave the child liable to a severe attack, still less liable to a fatal attack. Place of Treatment. No difficulty was experienced in arranging for the admission to hospital of those who were thought to be suffering from the disease. 49 Immunisation. Under the provisions of the National Health Service Act the responsibility for making available facilities for the public of the district to be immunised is now that of the Middlesex County Council, as the local health authority. The arrangements of the County Council by which local medical practitioners carry out the work, were understood to be independent of the general medical service. Immunisation was undertaken by those doctors who entered into an agreement with the County Council to do the work, whether or not they were taking part in the general medical service. Up to the end of the year there were still no signs of agreement on the question of the rate of remuneration of the practitioners for this work. That was a factor, perhaps, which prevented the numbers of those immunised rising to what is desirable. Ideally, the number of children immunised against diphtheria for the first time in any one year should be the same number as the number of births in the preceding year. Apart from the children who are treated by their own doctors, are those who, attending the infant welfare centres, are treated there, and those who are protected while they are at the day nurseries. Of the 2,538 children who were treated for the first time during the year 1,144 were treated by their own doctors, 1,380 at the infant welfare centres, and 14 at the day nurseries. It was estimated at the end of the year that 51 per cent, of the local children under the age of five years were protected, and of these between five and fifteen years 69 per cent. For immunising children A.P.T. is the accepted antigen, 0-5 c.c. being given, followed by a similar dose in not less than one month's time. Immunisation of infants is advocated at six to nine months of age. Reinforcing doses should be given when the child attains the age of two, again at the age of three and yet again before he is admitted to school. For those who are likely to be sensitive, including adults, T.A.F. is recommended as the most favourable antigen. These preparations can be obtained by the medical practitioners free of cost from the Colindale Laboratory or from the Public Health Office. Provision of Anti-toxin. The Regional Hospital Boards provide anti-toxin for issue to and use by general practitioners. Supplies can be obtained free of cost from Edgware Isolation Hospital or from the Public Health Office. SCARLET FEVER Incidence. The incidence of the various infectious diseases varies. Some have waves of epidemic prevalence. These might be of different natures. Some diseases have shown secular, or long period changes of prevalence, the wave lengths extending over many years. Some might show in addition, and others show only, a periodic cycle with a periodicity of months or years. Most infectious diseases again demonstrate a seasonal prevalence, waves occurring on the longer waves at intervals of months. The incidence of most, though not all of them, rises in autumn to fall again in the spring. D 50 Scarlet fever is one of the diseases which has seemed to have a long cycle of 20 to 30 years. Superimposed on this is a short cycle of 4 to 6 years, while, typically the seasonal incidence is shown as an increase throughout the summer to a maximum to October or November, falling from December to a minimum in March or April. For the country as a whole from 1919 to 1933, the incidence ranged from 2.05 to 3.65 per 1,000 population. The typical periodicity is more likely to be found in stable communities, and less likely in such a district as this, where for the pre.war years there was a steady importation of a new population, and during the war, apart from evacuation, a movement of the population occurred on a very large scale. Local rates then have ranged from 1 .06 to as much as 4.70 per 1,000 population. Such fluctuations in the incidence of the infection in a community in which other factors do not change much from year to year, except the degree of immunity which quite possibly will be dependent on the preceding incidence of infection, are probably, then, the result of changes in the organism responsible for the disease. If the organism can change in its power of invasiveness in this way, there must always be the risk that it can change its virulence. Scarlet fever has in a few decades changed from being a dread disease with a high case mortality to one which is so mild that there is a danger of its being treated too lightly. A few hold that admission to hospital of the more serious cases resulted in the organism at large becoming less virulent. Others see in the reduction of the severity at the same time of scarlet fever, measles and whooping cough, the result of some common factor which might be one such as the better nutritional state of the general population. On the other hand, it could easily be pure coincidence that the virulence of the causative organisms of these three infections should about the same time have diminished. If so, then presumably there is always the possibility of a reverse change with increasing seriousness of the infection of those affected. Since the high incidence of 1943 when there were 672 cases, an attack rate of 3.52 per 1,000 population, this district has not been severely attacked, and in general has escaped more lightly than the rest of the country. For instance in 1948 there were under 200 cases, an incidence rate per 1,000 population of 0.82, which was something less than half the figure of 1.72, the rate for the country as a whole. For much of 1949 it seemed that the district was again to be only lightly affected, but the rise in the late months was quite marked ; this was in keeping with the national rate. Another change in the behaviour of scarlet fever locally is that this year as a marked contrast with what has occurred in previous years, there appears to have been more grouping of cases amongst the children attending the same school. During the year, 360 cases were notified as suffering from scarlet fever. In nine of these the diagnosis was subsequently amended, the corrected number of cases being, therefore, 351, or an incidence per 1,000 population of 1.60. The figure of incidence in the country as a whole was 1.63. 51 The cases were unequally distributed throughout the year. In the 13 weeks ended April 2nd, there were only 39, a weekly rate of 3. The weekly rate for the next quarter was 8. This rise was largely due to an increased incidence in June, the result probably of school infection. Undue prevalence amongst those in other schools resulted in a heavier incidence in July, the weekly notification rate for the third quarter being 6.5. In the last quarter of the year the incidence rose to a level not reached for a long time in this district, the cases being generally distributed and not being the result of any special focus of infection. This was in keeping with the general rise in the incidence of this infection throughout the country. The average weekly infections for this quarter were 10.5. Deaths. There were no deaths in this district from scarlet fever in 1949. The last death of a local resident from this disease was in 1940. This was the case of a baby of 11 months who had been evacuated from here and who had contracted the infection in his new temporary home. It is necessary to go back to 1937 to obtain the records of a patient who died as the result of scarlet fever contracted in this area. Up to that time, however, these fatalities were not rarities, and in the year 1934, as many as nine persons living in this area died from this disease. Place of Treatment. For many years now many patients suffering from scarlet fever who have been admitted to the isolation hospitals could quite well have been nursed at home. In times of unusual prevalence it has on occasion been necessary to limit admissions, accepting only those for whom there was some special reason that made it necessary. The most urgent of these cases were those where admission was necessary because of the clinical condition of the patient. At one time this might be the severity of the attack itself, but for many years now the reason would be the development of complications. Sometimes it was necessary to remove a patient because the home circumstances were such that the retention of an infectious patient in the home would cause real risk of other members of the household contracting the disease. This might arise where there are many children in the house, or because the house itself was overcrowded so that isolation could not be practised. Very occasionally removal to hospital is necessary because if the child remained at home a wage earner in contact with the infectious patient would be barred from continuing his employment. Other reasons necessitating admission are the difficulty of nursing the patient. This might be because he is an adult, or because the mother has to look after a baby or other small children. Quite apart from these cases, though, in which removal is desirable, patients have been admitted to hospital from households in which it seemed there was little objection to their remaining at home. In some, of course, removal was asked for because of the apprehension that if the infectious patient remained at home, some other members would contract the disease. In most of the cases there was little substance in this, as so very often the patient is removed to hospital some Dl 52 two or three days from the onset, so that he will already have been home in his most infectious period. The North-West Metropolitan Regional Hospital Board on taking over the administration of the hospitals, including the isolation hospitals, decided that cases of scarlet fever would not be accepted as a routine, but only if there were special circumstances making this step necessary. This decision perhaps accounted for the higher proportion of scarlet fever patients being nursed at home, the number being 212, as against 144 removed to hospital. Of these removed to hospital, most were admitted t.o the Edgware Isolation Hospital, though limitation of accommodation, the result very largely of shortage of staff, prevented the admission of some patients there who were, therefore, accommodated in hospitals much further afield. Secondary Infection. As scarlet fever is an infectious disease, it can be expected that there will be some cases of secondary infection, that is, other cases occurring in the household in which there is already one patient from whom the infection was presumably contracted. There is no general average frequency with which secondary infections occur, as in some years of light incidence the proportion of these cases might be quite heavy. In general it might be expected that in the years of heavy incidence the proportion would be higher because the higher incidence in itself suggests a greater invasiveness of the organism, while, too, the greater number of cases would strain hospital accommodation and so result in a greater proportion of patients remaining at home during the infectious period. In 1945 when there were 270 cases of scarlet fever, secondary infections occurred in 10 households ; the same number occurred the next year, when there were 248 cases. In 1947 there were 4 secondary infections, the number of notified cases being 180, and in 1948 6 households had secondary cases in a year, when there were 181 cases of scarlet fever. This year there were secondary cases in 16 households ; the number of cases of scarlet fever in the district was 351. In a year, then, when a greater proportion of those who suffered from scarlet fever remained at home the entire period of their infectiousness, there was an appreciably higher incidence of secondary cases. To try to determine whether the higher incidence was, in fact, related to the greater extent of home nursing of the scarlet fever patients, it is necessary to ascertain firstly to what extent the primary patients were removed to hospital, and secondly to what extent the primary case which was nursed at home might have been a smaller risk if he had been removed to hospital on the same day of disease as the average patient was removed. The primary case was removed to hospital in 7 out of the 16 households in which there were secondary cases. In another house, both patients succumbed to the. attack of scarlet fever simultaneously. There were then 8 instances in which a secondary case occurred in a household in which the primary case was not removed to hospital. As the time of the onset of the secondary case was, in each of these instances, 4 days or longer from the onset of illness in the primary case, it is possible that, had the primary case been removed to hospital, the second patient might 53 not have contracted the infection. On the other hand, it is most exceptional for any child suffering from scarlet fever to be removed to hospital on the day of onset of illness. Last year, the third day was the commonest, slightly fewer being rerroved on the second day, and the same number again on the fourth or later day. As of the eight cases, the onset in half was the fifth day from the onset in the primary case, it is quite likely that had it been decided that the primary case should be nursed in hospital, removal would not have been carried out sufficiently early in a number of these cases to have prevented the development of the infection in the secondary case. Return Cases. Sometimes an inmate of the household to which has returned a patient who has been nursed in a hospital while suffering from scarlet fever develops the disease. If the onset is within the arbitrary period of 28 days from the return home of the patient, this is classed as a return case. Such cases might occur in about 5 per cent. of the households to which patients return, though the incidence is quite variable. Most of these cases are thought to be associated with the return home of the primary case who, though most often apparently clinically well, does in many cases exhibit abnormal signs such as a running of the nose, an abnormality not present at the time the patient leaves hospital, but developing on his return home. Not all these cases are the result of an infection contracted from the returning patient. In a number of instances the second patient has fallen ill even before the first has returned. It is presumed in these instances that infection has been spread by some inanimate object, or it might be due to the presence of a persistent carrier of the causative organism. When the influence of removal of a patient to hospital in limiting the spread of infection in the household is being considered, it is necessary to take account of the extent to which these return cases occur. Although persons in the same household have been known to develop scarlet fever after freeing from isolation of a child nursed at home throughout the course of the illness, these occurrences are quite exceptional as contrasted with the not unusual development of the return case. The incidence of the return cases is probably related in some degree to the general invasiveness of the organism. Insofar as the occurrence of secondary infection may be due to the same cause, their frequency might be related. In 1949, however, by contrast with the higher incidence of secondary infection there were no return cases. Schools and Infection. Although so many of the patients who succumb to an attack of scarlet fever are children of school age, in this district it has rarelv been found in recent years that an attack of scarlet fever in a child is the result of his contact with another recognised case at his school. This year, mostly during the summer term, there was a markedly higher incidence of infection amongst those attending some schools. These schools were infected at the same time by a throat infection which was quite probably the result of infection by the same organism which caused a reaction 54 manifested in some only by a throat involvement, but in others with, in addition, a rash, a rash which was so often evanescent. The children with the rash were notified as cases of scarlet fever. The first of the schools to be affected in this way was the infants' department of Priestmead. One case was notified in the week ending May 13th : in the following week it was later found that nine children succumbed. Not all of these were known of at the time, as some were not notified until later. This delay in notification was sometimes the result of the medical practitioner having to wait some days, possibly until desquamation started, to confirm his earlier suspicion that the child was suffering from scarlet fever. In other cases the rash could be so fleeting as not to be seen at all by the medical attendant, who could then feel satisfied that the case was one of scarlet fever only when desquamation started. The delay in notification in some cases would be for these reasons. In others, however, it seems that the delay was the result of a failure on the part of a medical attendant to comply with his statutory obligation to notify a case on his first becoming aware that the patient was suffering from a notifiable condition. At this school in the following week, two further cases were notified, and in the next week another 8. In the succeeding weeks the numbers of children notified as suffering from scarlet fever were 0, 3, 0, 3 and 0 ; the school being free by the week ending July 9th. Apart from these cases of scarlet fever were the very large number of children who suffered from a sore throat but with no rash, while in addition many members of the teaching staff were similarly affected. No children who were suspected of being carriers were detected, nor did examination of the feeding arrangements, or of the kitchen staff lead to the conclusion that the outbreak was food-borne. In June many of the pupils at Grimsdyke School suffered from sore throats, but only four, spread over four weeks, were notified as suffering from scarlet fever. In the latter half of June and the first half of July, many of the pupils at Cannon Lane School were notified as suffering from scarlet fever. Over a period of five weeks, 8 children attending the infants' department were notified ; a large number of these were members of the same class. Over the same period 5 of the pupils attending the junior department were also notified. Then in the last three weeks of the summer term, 6 cases were notified amongst the children attending the infants' department of Roxbourne School. In the winter term the most prominent groupings occurred in the infants' department of the Pinner Park School. Here 10 cases occurred in the space of three weeks, the pupils being members of five different classes. These are the instances in which the number of cases and the groupings are sufficiently closely associated as to suggest that school attendance was the causative factor in the infection of many. On the other hand no definite carriers were found and the outbreaks died out without it being possible to take any specific steps such as the exclusion of carriers which might have contributed to the abatement. There were during the year smaller groupings suggestive of school infections. While they might have been the result of infection at school these groupings might also have been merely coincidental. 55 SMALLPOX To the risks of importation of persons in the incubationary and therefore undetectable stage of smallpox, must now be added the possibility of the admission to the country of persons by air. Particulars of those who come from countries where the disease is present, and who might, therefore, later become infectious are received by the medical officers of health of the areas to which these people proceed. Such persons are warned of their risks and are visited until the expiration of the incubation period. Although notifications of a number of such persons were received during the year 1949, there were no cases of smallpox in this district. Patients suffering from smallpox are admitted not to the ordinary isolation hospitals which accept patients suffering from the commoner infectious diseases, but to special hospitals which deal only with those suffering from that disease. Any patient from this area will be admitted probably to one of the hospitals previously maintained by the London County Council, being removed to hospital in an ambulance provided by the hospital. Before patients are removed to hospital the diagnosis must be confirmed by a consultant. The Ministry of Health has issued an approved list of those who might be summoned to patients in this district. Smallpox of all diseases is the one against which protective measures can effectively be carried out. Vaccination can be performed free of charge by any of the medical practitioners who have entered into the arrangements of the County Council to do this work for them, irrespective of whether or not they are taking part in the general medical service under the National Health Service Act. Since the removal of the compulsory element of the Vaccination Acts and since, too, it is no longer the responsibility of one single person to try to see that any particular child has been vaccinated as it was under the former arrangements, it is likely that even fewer than were done before will in future be vaccinated against smallpox. It might need the stimulation of an outbreak to induce mothers to obtain this protection for their babies. Those who are opposed to the practice point to the fact that vaccination is sometimes followed by an illness which in itself is sometimes fatal. That is admitted and in any one year it might well be that the number of these deaths exceeds the number of deaths in the country from smallpox. The risks of these occurrence though are very much less when vaccination is carried out in infancy than when it is left until later. While presentday practice can control the wide spread of true smallpox, it is too much to hope that unless the entire population is adequately vaccinated, the disease can indefinitely be kept out of the country. When the disease is introduced into the country there is the rush for vaccination. Many will be treated then who had not been protected in infancy and the complications will be much more common than if the same person had been treated in infancy. That is the case for the practice of routine vaccination of infants. 56 ENTERIC FEVER There were only two cases of enteric fever in this district in 1949. The first was an adult male of 47 who succumbed in January from an attack of paratyphoid fever, the organism being para A. Paratyphoid fever is now more common in this country than typhoid fever. Of the organisms causing this infection the para B is the commonest, para A being rare. Where this patient picked up his infection could not be ascertained. He is a foreigner who might possibly then have contracted the infection outside this country. The organism was not found in the other members of the household. The patient had many of his meals away from home. The other case was an adult male of 37 who fell ill in December suffering from para B infection. The origin of the infection could not be discovered. DYSENTERY Thirteen cases of dysentery were notified during the year. The diagnosis was amended in two, leaving the number of notified cases as 11. In all instances where the causative organism was isolated it proved, to be Sh. Sonnei. Apart from three occurring in one house, all children, the cases were unrelated to one another. The first half of the year was free, the cases being spread over the six months, May to November. Most of the patients were treated at home, and all apparently made a complete recovery from a relatively mild illness. FOOD POISONING Four persons were notified during the year as suffering from food poisoning, two occurring in the one household. The S. typhi-murium was isolated in two instances. The source of infection was suspected of being a duck's egg in one case. ERYSIPELAS Thirty patients were notified as suffering from erysipelas ; in four, however, the diagnosis was amended. Females again outnumbered males by nearly two to one. In only three cases was the affected site other than the face. One half of the patients were admitted to hospital, mostly to isolation hospitals. One case, a lady of 81 suffering from a lesion of the face, proved fatal. The cases were distributed throughout the whole year, though the incidence was lightest from March to October, only 13 cases occurring in these eight months as contrasted with 14 cases in the remaining four months. CEREBRO SPINAL FEVER One child was notified as suffering from cerebro spinal fever, a girl of four months who died in a few hours from this infection in March. In January a child died from the infection ; the case had not been notified as the diagnosis of the case was made only as the result of a post mortem examination. 57 ACUTE ANTERIOR POLIOMYELITIS In 1947 this country suffered its greatest invasion from poliomyelitis. Two indications of what was to come had been given in July : the incidence started to rise much earlier than usual, and the increase in the numbers of weekly notifications was unusually rapid. The rise was remarkably steady once it had set in, reaching a peak in the week ending September 6th. In 1918 the incidence was only slightly higher than normal. 1949 saw much the same beginning as the outbreak of 1947. There was, however, an early arrest in the rise of the curve of incidence early in July and again later in the same month. Apart from these declines, the curve in general was flatter than the 1947 curve. This resulted in the general incidence being something less than half that of 1947. On the other hand the rise in incidence continued much later, and the peak was not reached until the week ending October 15th. The fall, slow to start with, became more rapid towards the end of the year, but the incidence still remained higher than normal, 61 cases being notified in the last week of the year. Locally the outbreak was erratic in distribution. Although in the earlier weeks of the outbreak many patients were admitted to the isolation hospitals suspected of suffering from this infection, the number of confirmed cases in July was only three, and in August only two. There were, however, eight in September, five in October, four in November and then one in December, the total number of cases in the local outbreak being 13. This figure includes four, the number of abortive attacks in which the patients suffered from no paralysis, but who had nevertheless been attacked by the virus. There was one instance of two brothers being attacked. Apart from this occurrence there was no association of any of the patients with known cases. Once more a striking feature was the slight degree to which infants were attacked, only three of the patients being under five years of age. Nine (five boys and four girls) were children between the ages of five and ten, and nine (six males and three females) were over 21 years of age. The oldest patient was a man of 65, the youngest a boy of one. Only seven of the 23 patients were females. Apart from the four abortive cases, a further four patients recovered completely with no paralysis. Three patients were still in hospital at the end of the year. Two cases proved fatal, a man of 36, and a girl of five, who each suffered from polioencephalitis. The remaining ten cases were suffering from some degree of paralysis, for which at the end of the year they were still attending for treatment. MEASLES The district suffered from a minor outbreak of measles which was at its peak in the latter part of the first quarter of the year. Notifications rose steadily from the figure of eleven in the first week of the year to the peak figure of 207 in the week ending February 26th. Remaining high through most of March, the figures then fell until single figures only were 58 notified from the week ending June 4th, for most of the rest of the year there being only one or two cases each week. The total number of notifications received was 2,038. Intimations were received from the head teachers of the primary schools of 975 cases. No school was especially severely attacked, though eleven departments had about 50 cases each. Twelve children were removed to hospital for treatment. No cases proved fatal. WHOOPING COUGH Only 191 cases of whooping cough were notified in this district in 1949. The weekly average for the first quarter was six, for the second and third quarters four, but it was only one for the last quarter of the year. Intimations were received from the head teachers of the schools of only 59 cases, no school at any time being severely attacked. In spite of the relatively small number of cases in this year, there were two deaths from the disease. Seventeen children were admitted to hospital for treatment. PUERPERAL INFECTION The state which is now notifiable under the regulations is any febrile condition occurring in a woman within 21 days of child-birth or of miscarriage, in which a temperature of 100-4° F. has been sustained for 24 hours, or has recurred within that period. Some of the patients notified then might be suffering from conditions entirely unrelated to their delivery. That seemed to be the case in at least three of the five notified this year. The other two patients suffered from a low grade infection, possibly the result of retained products. OPHTHALMIA NEONATORUM Ophthalmia neonatorum is an inflammation of the eyes occurring in the new born. At one time it was responsible for much blindness, but to-day not only are there fewer cases, the result of preventive measures but for those that occur, arrangements for treatment are more satisfactory. Only one case was notified during the year, the disease occurring in a baby born in a nursing home. Recovery was complete. NON-NOTIFIABLE INFECTIONS These infections are not notifiable, and knowledge of the prevalence of most of them is obtained from the intimations received from the head teachers about children absent from school, as sufferers or as contacts. Chickenpox. In all, 377 intimations were received of the occurrence of chickenpox amongst pupils in the primary schools. Stanmore Church of England School was the most heavily attacked in the spring term, Welldon Park and Harrow Weald Infants in the summer term. 59 Mumps. This complaint was more prevalent in 1949 than in the previous year, 621 intimations being received from the head teachers as compared with the figure of 317 in 1948. Schools were attacked mostly in the spring term, in most of them the attack being limited to this term. This was the case at the Grange, Harrow Weald Junior, Stanburn Junior and Infants, Vaughan Road Infants and Welldon Park. Cannon Lane School was the only one which was attacked in the spring and again in the summer term, this being the only school attacked to any extent in the summer. There was virtually no mumps from then until minor attacks at two schools in November. German Measles. During 1949 only 21 intimations of the occurrence of this infection were received from the head teacher of the schools. Influenza. This condition is not notifiable and indication of its prevalence is obtained either from the number of deaths ascribed to it or from the the number of notifications received of acute influenzal pneumonia. Neither of these is a very reliable index. In the first three months of the year thirteen deaths were ascribed to this infection, most of these occurring amongst the elderly. Scabies. No intimations are now received of the incidence of those infected with scabies, as the condition is not notifiable and the local authority no longer provides facilities for treatment. Before the war from time to time requests were received from the almoners of hospitals asking for advice to be given sufferers. No similar requests seem to be received these days. This is more likely to be because modern methods of treatment are much more efficacious, and more easily applied than that the disease has so completely disappeared. As far as it is known its incidence in this district before the was was never very high. Having regard to the trend throughout the country before the war and the marked incidence during the war years, it is unlikely that to-day's incidence here will be any lower than it was pre-war. 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 those 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 another, the particulars of that patient are sent from the one to the other 60 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. The following table sets out the age and sex distribution of the patients who were notified in this district for the first time in 1949, 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- 4 4 2 — 1 — 2 1 1 5-9 7 3 3 1 1 — — — 10-14 6 4 2 — — — — — 15-19 23 19 1 — 3 3 — 1 20-24 21 32 1 2 11 12 — 1 25-34 37 31 1 3 27 24 — 1 35-44 25 15 3 2 9 6 1 — 45-54 23 8 — — 8 1 — — 55-64 18 3 — — 4 — — 1 65 and over 8 3 — — 4 2 1 1 Total 172 120 11 9 67 50 3 7 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. 61 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, 1949 844 698 116 131 No. of new cases added ... 172 120 11 9 No. of cases other than on Form A 67 50 3 7 No. of cases restored to the register 2 2 — — No. of cases removed 117 105 13 12 No. on register, December 31st, 1949 ... 968 765 117 135 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 district 56 62 8 3 Died 52 33 2 5 Recovered 7 9 2 4 Diagnosis not confirmed or withdrawn 2 1 1 — Total 117 105 13 12 Deaths. Fifty.five persons (34 male and 21 female) died from pulmonary tuberculosis during the year and 2 (both male), from non.pulmonary tuberculosis. This infection, therefore, accounted for only 3.0 per cent. of the total deaths in this district. The corresponding figures for 1948 were 76 deaths from pulmonary and 15 deaths from non.pulmonary tuberculosis, the disease accounting for 4.9 per cent. of the total deaths. 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. Another aid is mass radiography which as yet can be carried out only on selected parts of the population. 62 Section 172 of the Public Health Act, 1936, empowers 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. Incidence of Tuberculosis. Various figures can be used as a guide to the prevalence of tuberculosis. However accurate any of these might be, there is probably not one which can be accepted as an index of the effect living in the locality has on the likelihood of one's contracting the disease. (1) Notification. Tuberculosis is a very insidious disease with often a most indefinite onset. Frequently, then, it will have been developing for long before the attack is recognised. The patient might not have been living in the locality all that time. The interval between the time the infecting organism gains the upper hand and the date the disease is diagnosed is very variable. A case notified in any one year often enough will not have been the result of any influence in that year but in some preceding time, possibly one, two, three and more years before. Then again, a medical practitioner is required to notify the case whether or not the patient had been previously notified in some other district before removing to his present address. On the other hand a transferred patient might not be notified either because the practitioner does not appreciate his obligations in such a case, or perhaps because the patient does not attend a doctor in his new district. Then the number of notifications might be related to the facilities there are for aiding the making of a diagnosis. A striking instance is the result of examination of a section of the population by mass radiography. Previously unsuspected active tuberculosis of the lungs is found on an average in about 4 per 1,000 persons. By the end of 1947 over two million persons in this country had been examined in this way. This led to the detection of 8,000 cases. These possibly would have become manifest in later years but were at the time of examination unsuspected. The detection of these cases, then, helped to swell the numbers of cases notified since mass radiography was introduced though, of course, probably leading to a fall in the numbers in those years in which it might have been expected that the disease would have reached the stage in which it would be recognised in those persons. Another factor arises in a community which is growing by the influx of new populations. 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 the previous year, but those notified in the preceding years. All these might, as they should be, have been notified to the new authority very shortly after their transfer into the new district. Amongst any 2,000 persons who transferred, then, within a short time, the new authority might receive not the 3 notifications of those in whom the disease became manifest in the previous twelve months, but the 10 who had been notified over the earlier years, and 63 whose names were on the register. The number of notifications received in the district then will be swollen by a much bigger figure when a new population moves into the district. These factors do not arise in stable communities, but they are of much importance in developing districts. (2) Register. The names of those who have been notified are entered on a register which it is the duty of the medical officer of health to keep up to date, by arranging for the removal of the names of those who have died, or who have left the district. While the number on an efficiently kept register is an index of the extent to which tuberculosis occurs in the population, it is no true index of the influence of the district in causing such disease, because of the inclusion of the names of those who transferred into the district suffering from the disease. As the register is dependent on the notifications of the disease, as such an index it is subject to the same weaknesses as are the notification rates. (3) Deaths. Most of those who suffer from tuberculosis die from the disease after a longer or shorter interval. The death rate, then, should be a reliable index ; but again it is not for a number of reasons. If it is an index of anything it is of the volume of disease amongst the population and not of the factors causing the disease. The length of time a patient survives from the time the disease is notified depends partly on its stage of development at that time. By mass radiography the disease is detected in some much earlier than it would otherwise have been. Not only are the chances of complete cure in such persons that much greater, but if the disease should progress it will ordinarily be that much longer before causing a fatal issue. On the other hand the absence of facilities for treatment and the length of time patients have to remain at home before they can be admitted to hospital to start their treatment must have an effect on the development of the disease. Such factors as these reduce the value of the death rates from the disease as an index of the influence of living in the district on its development, as must also such factors as the age and sex distribution of the population. In spite of its weakness as an indication of the effect of local conditions in causing the onset of the disease for some of which allowance can be made, the notification rate is probably the most satisfactory of these indices. To determine whether any changes in the rate are the result of local as contrasted with national circumstances, it is helpful to consider first what is happening in the country as a whole. consider first what is happening in the country as a whole. The following table sets out the numbers of notifications for the country as a whole for each year from 1934 ; together with the population figures for the country, the local notifications and the local population figures. National Local Formal Notifications Population Notifications Population 1934 56,728 40,467,000 163 132,049 1935 52,070 208 144,280 1936 51,604 224 160,300 1937 52,291 41,031,000 254 174,800 1938 50,689 285 183,500 64  National Local Formal Notifications Population Notifications ation 1939 46,206 250 190,200 1940 46,572 372 188,710 1941 50,964 403 195,480 1942 52,619 42,143,000 369 195,100 1943 54,342 310 191,660 1944 54,313 350 185,090 1945 52,110 289 191,710 1946 51,289 347 210,890 1947 51,725 391 215,930 1948 52,576 43,502,000 383 219,090 1949 439 220,400 It will be seen that although there was a slight increase in the population figures for the country as a whole, the number of formal notifications received each year declined up to the outbreak of the war. There was then a sharp set-back up to 1944. After that, the situation in general improved though recovery was not sufficient to restore the position to what it was at the outbreak of the war, and more recently there has been a recession. What exactly the factors were that led to this set-back during the war years is not known. Certainly the general conditions of strain, the increased opportunities for conveyance of infection, more especially the result of crowding might be expected to have brought about a deterioration in the circumstances ; nevertheless it is difficult to point with any certainty to any specific causative factor. Among the post-war conditions there are two which contribute to-day more than before the war to an increased incidence of disease. The first is housing, more particularly the results of over-crowding. The other is the shortage of accommodation in hospitals, largely the result of failure to obtain the nurses necessary to staff existing accommodation. This acts in two ways. The first is by increasing the waiting time before a patient can be admitted ; this results in that patient being a longer time at home in an infectious condition ; also he becomes that much worse before the time arrives for him to be admitted. He is, therefore, for that period more infectious to others and because the disease has progressed, he needs a longer time before the disease can be arrested. Secondly, the shortage of accommodation results in many of those who cannot be cured having to be sent home, there to live with other members of the family while infectious. These factors which have brought about changes in the national rates will be operative in this district to a greater or lesser extent than they influence the national rates. On the other hand it can be seen that the increases in the local figures are out of all proportion to the increases in the national figures ; and further that the effect of this increase is to change the local rates from the position that they were before the war when they were lower than the national rates, to their being higher than those rates to-day. The local figures show marked variations from year 65 to year which are difficult to explain. It is apparent, however, that there has been a substantial increase, in fact, a doubling in the number of notifications. The average number received for the three years 1934 to 1936, when the average population was 145,000, was 198, a contrast with the figure of 374, the average for the three years 1945 to 1947, when the average population was 215,000. This is a most disturbing increase and quite unexpected, as it is not felt that there are any circumstances in the district which should lead to the development of tuberculosis in the population here being higher than that of the country as a whole. Of the specific circumstances which might account for the statistical increase, the first that come to mind are the transfer of population to new houses which results in swollen notifications ; the movements of population into other houses ; and the age and sex constitution of the population. (a) Movement of population to new homes. This, of course, applies more particularly to those who have moved into the houses on the new London County Council Headstone Estate. An extra number of notifications might be expected from amongst this population than there would have been in another population of similar size, because doubtless special preference will have been given by the London County Council in selecting their tenants for the new houses to those who need the improved accommodation more particularly because a member of the family is suffering from tuberculosis. In 1948, about 30 persons suffering from tuberculosis were brought to the notice of the Authority amongst those living on this estate ; in 1949 the figure was 51. These are notifications which have been received, not because of the development of any adverse factors operating in the district, but merely by the transfer from London of the occupants of about 1,500 houses built by the London County Council. This is one factor which did not operate before the war and when comparing present-day with pre-war figures these numbers should be deducted. (b) There is a constant change in the population occupying the houses in the district. Included in those who move will be some suffering from tuberculosis. In respect of these, notifications are received. These, then, swell the figures of notifications. As the population remains more or less stationary, apart from the increase which is accounted for by the natural increase in population (which is the excess of births over deaths) the number of newcomers must be balanced by those who leave the district. If the incidence of tuberculosis amongst those who come is the same as of that amongst those leaving, the number of cases on the register would remain the same, although the district would have received that additional number of notifications. Whether this movement of population is occurring on a greater or smaller scale than it was before the war is unknown, so it is not possible to take this factor into account when comparing the pre-war and the post-war notifications. But to whatever degree it might have been or is operative the position is that quite apart from those who moved into the London County Council housing estate who had already been notified as suffering from the disease, a further 43 persons moved into other houses in the district 66 who had been suffering from the disease before they moved there. These are the people in respect of whom notification of transfer had been received from the authority in whose area they previously lived. To this number must be added the 36 who were known to have been suffering from the disease before transfer, but about whom no notice was received. In 1949, then, notifications were received of 130 persons who moved into the district while already suffering from the disease. The actual number of such persons is probably greater than this, because at the time of writing the information about a number of those notified during the year had not been received. (c) Age and Sex Distribution. Because it is mostly the younger parents with small children who move into the houses of a developing district, and because so much of this district was developed only shortly before the war, it is probable that the age and even sex distribution of the population of this district is not the same as that of the country as a whole. The incidence of new cases of tuberculosis falls more heavily on certain sections of the population so that in any population in which these particular groups were more especially represented, it would be expected that the numbers of notifications would be greater than those in a population of the same size, but of normal constitution. This factor might be operating in this district, but if at all, it is not possible to determine to what extent, as the age distribution of the local population is not known. It would seem, then, that an important factor leading to the relatively large numbers of notifications of tuberculosis in this district may be the result of the influx of new populations to the area, some of it additional to that here, some of it replacing that previously here. Those additional should, of course, add to the numbers of those on the register. Those which are replacements ought to be off-set by the removal of the names of those who had left the district. If, then, any substantial number of this increase in notifications is the result of the movement of the people into the district (except for the newcomers on the London County Council Estate) then, although the numbers of notifications increased, this should be offset by the numbers of those whose names were removed from the register because they had left the district. From 1935 onwards those figures were 101, 126, 54, 76, 111, 93, 91, 83, 52, 134, 96, 112, 84, 117 and 129. These figures suggest a larger movement after the war than before it. On the other hand, the figures are not so very different from those of the numbers of patients who moved into the district while suffering from tuberculosis. It would seem, then, that the increased number of notifications received must indicate a definite increase in prevalence, or if not an increase in prevalence, an increase in the number of cases recognised and notified. This suggestion is suDDorted bv the figures of the number of cases on the register. on the register. The following table gives the position at the end of each of a number of years :— End of Pulmonary N on-pulmonary Total M. F. M. F. 1935 249 213 50 62 574 1939 331 280 65 80 756 67 End of Pulmonary Non-pulmonary  M. F. M. F. 1944 584 513 102 95 1,294 1945 609 543 98 103 1,353 1946 649 558 96 98 1,401 1947 766 641 109 118 1,634 1948 844 698 116 131 1,789 1949 968 765 117 135 1,985 From this it will be seen that the actual number of people in the district who have been notified as suffering from tuberculosis, and who have not reached that stage of cure which enables their names to be removed from the register, has grown quite markedly. This total number of cases on the register is relatively higher than that for the country as a whole, in keeping with the notification rate being higher than the national rate, and is a reversal of the satisfactory state which obtained in the earlier years of the life of this Council. By contrast the death rate is lower. For the years 1934-38 the average number of deaths from tuberculosis of those living in Harrow was 81 ; for the years 1940-44 it was 105 ; and for 1945-49 it was 83. For the year 1947, the death rate from tuberculosis per 1,000 population in Harrow was 0-353 ; the corresponding figure for the country as a whole was 0-547. That the position of Harrow in this respect is so much more favourable than that for the country as a whole, is only in keeping with the general vital statistics, and in keeping, too, with the general feeling that the circumstances of the district are probably more favourable than the average of the country. On the other hand there is no gainsaying the marked increase in the number of notifications and the increase in the numbers of names on the register. To some extent these are attributable to the new cases amongst the population moving into the district. This factor, however, accounts for only part of the increase. Is there any explanation which could account for an increase in notifications but, because the death rates are so low, is not dependent on an actual increase in the incidence of disease. A marked improvement in the diagnosis of the disease and in the notifications of those diagnosed would provide such an explanation. It might be well that this is the case. The tuberculosis service for the district was extended markedly since the middle 1930's. This is reflected in many ways. The facilities at the chest clinic have been improved and diagnosis has been made easier. In addition much more is now being done in the way of examining contacts of diagnosed cases. Mass radiography leads to the detection of cases amongst members of the population who did not consider themselves to be suffering from any complaint. Mass radiography, too, has considerably lightened the work of the examination of contacts other than home contacts, such as school children. The chest clinic now means more to the general public. A third way in which the effects are manifest is that the general medical practitioners more freely refer their patients for consultation, a step which results in earlier diagnosis and notification. If this is the explanation then it means not that there are more cases 68 in the district, but that a greater proportion of those that there are are being recognised. This is to the advantage of the patients themselves and of the community. There is a reason for thinking that this may be the explanation. At one time there were many posthumous notifications, and it was not at all uncommon to have to communicate with local medical practitioners about their failure to notify. In 1935 the disease had not been notified in nearly one-third of the persons who died from pulmonary tuberculosis, and in more than half of those who died from non-pulmonary tuberculosis. To-day, most of those who die from tuberculosis but who have not been notified, die in institutions ; in many of these the diagnosis was made post-mortem. This change is in keeping with an improvement in the standards of the notification of the disease.