AC 439(1) HARROW HARR 17 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1950 CARYL THOMAS, M.D., B.Sc., D.P.H. barrister-at-law King & Hutchings, Printers, Uxbridge Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1950 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 7 General Health Services: Hospitals 13 Nursing Homes 14 Establishments for Massage and Special Treatment 14 Nursing, etc., in the Home 14 Day Nurseries 16 Clinics and Treatment Centres 16 Provision for Special Classes of Person 19 Ambulances 20 Laboratory Facilities 20 Sanitary Circumstances 21 Sanitary Inspection: Statistical Summary 23 Inspection and Supervision of Food 30 Infectious and Other Diseases: Prevalence of and Control 34 Tuberculosis 42 5 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 1950. There was no occurrence in 1950 which affected the health of the district to which special attention need be drawn. The sanitary inspectors each year get through their very large volume of unspectacular work and there was, fortunately, no breakdown to cause any of those events which alone seem to figure as health news. The campiagn for clean food made steady and quite satisfactory progress. That the vital statistics of the district are that much better than those of the country as a whole is now commonplace, as this happens year after year. To be able to record that in a whole year only one member of the population of over 220,000 succumbed to diphtheria stirs no one; memories are so short that already it seems to be forgotten that only just before the war a district of this size could be expected to have anything between 200 and 400 cases in a year, of which between 10 and 40 could be expected to have proved fatal. The infant mortality rate was 13.6. At the beginning of the century the national rate was 150. The fall of this rate is one of the achievements of the modern public health service—a service guided by those who today are dubbed "administrative officers with some medical knowledge." About 30 years ago the figure of 40 was thought to be the irreducible minimum; since that time figures of 20 have been recorded. The previous lowest figure for this district was 20.7 in 1949. It is pleasant to be able to draw attention to the fact that in this last year there was a substantial fall in the number of new cases of tuberculosis brought to notice. In 1950 the country was once more subjected to invasion by poliomyelitis and this district had its due proportion of sufferers. The National Health Service Act has now been in operation for nearly three years—a short enough time, no doubt, for the new arrangements to take shape, especially in view of post.war difficulties and world disturbances, but long enough to give some indication of whether the upheavals which have been brought about are to result in conditions more satisfactory than those which they replaced. As to the Part III services, there is nothing today to suggest that their administration is likely to have been improved as the result of the new arrangement. This does not mean that the design was necessarily wrong. It might well be that in parts of the country the inhabitants of some districts are enjoying better services than they were before or better than they possibly would have had the change not been made. But in such areas as this where the Authority previously responsible for the administration of these services was one controlling an area of sufficient population, possessing sufficient wealth, and where the Authority 6 took a pride in the efficiency of the services it administered, the previous standard was sufficiently high that it would have needed to be something very good to improve on it. However, even in such a district as this, as long as the powers and duties given to the body administering the services, a body that must needs be local if it is fully to be aware of and be anxious to meet local needs, were sufficient to arouse and maintain the interest of sufficiently experienced councillors to encourage them to remain on the the committee controlling these services, then the arrangements might have worked—but they are not doing so at present. The local committee is just not being given that very necessary encouragement. Added to this are the interminable delays which occur even in dealing with matters of quite minor importance. The result is a sapping of interest which cannot bring about any raising of the standard of service. In one sphere there has been a marked improvement in this last year. The position of many elderly chronics is one of great difficulty. A number of these elderly persons find themselves not eligible for admission to the Old People's Homes provided by the local authorities because they are bedridden, but, on the other hand, cannot be accepted in ordinary general hospitals because of the claims for admission of the acute cases. Many who should be in an institution of some sort have to remain at home. A medical officer who has now been appointed at the Edgware General Hospital has reviewed the circumstances of everyone of those chronic patients waiting for admission to the hospital and visits the home of every chronic sick person to assess the urgency of each case from both medical and social aspects. This, of course, does not add to the available accommodation, but it does ensure that what accommodation there is for this class of patient is put to the best use; and it does mean that there is someone with whom a medical practitioner can get into touch to press for the admission of those who he feels are especially urgent cases. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, " Cottesmore," Uxbridge Road. July 2nd, 1951. 7 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,558 Registrar-General's estimate of resident population, mid-year 1950 222,300 Rateable Value (April 1st, 1950) £2,203,047 Sum represented by a penny rate (April 1st, 1950) £8,736 Total number of occupied houses 53,391 Total number of occupied flats 7,782 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Birth rate per 1,000 population, 12.8 Legitimate 2,756 1,429 1,327 Illegitimate 92 50 42 Total 2,848 1,479 1,369 Stillbirths:— Legitimate 62 30 32 Rate per 1,000 total births, 2.1. Illegitimate 1 1 — Total 63 31 32 Deaths 1,999 982 1,017 Death rate per 1,000 population, 8.9 Rate per 1,000 Deaths from pregnancy, childbirth Deaths 4 total births 1.3 Death rate of Infants under one year of age:— All infants per 1,000 live births 13.6 Legitimate infants per 1,000 legitimate live births 13.4 Illegitimate infants per 1,000 illegitimate live births 21.7 Deaths from Cancer 422 „ ,, Measles 3 „ Whooping cough 0 ,, ,, Tuberculosis 40 Population. The mid-year population of the district was 222,300, an increase of 1,900 on the mid-year population for 1949. The natural increase in population, i.e., the excess of births over deaths during the year, was 849. Some indication of the extent to which movements of the population are taking place is obtained from the information of the length of residence of those who were notified as suffering from scarlet fever. Of 192 persons who were notified in 1950 as suffering from this complaint, 6 had lived in their then homes for less than one year, 5 for over 1 but under 2, 16 between 2 and 3 years, 13 between 3 and 4, 13 between 4 and 5, 8 for 5 years, and 12 for over 5, a total of 73. The remaining 119 had lived in the houses they were in all their lives. Of this portion of the population then, roughly one-third had changed their homes in recent years, the 8 vast majority within the preceding six years. It cannot, of course, be assumed from this that about one-third of the local population changes its home in five years. The population studied was not a normal one; it was largely composed of children and it is possible that families with children move more than those without. Again, it is not to be concluded that this movement is necessarily one into this district from outside. To what extent this has occurred, as the population figure of the district has increased only roughly proportionately to the new housing accommodation being made available, such movement must be balanced by corresponding movement of people from this district to outside. Some of it will be the result of movement within the district; what proportion this forms of the total is not known. Whatever might be the exact extent of movement, however, these figures certainly suggest that it is one on a large scale. Births. The total number of live births registered during the year was 2,848 (1,479 male and 1,369 female). Of these, 92 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, 3,226, 3,083 and 2,848. 1,480 births occurred in the district (1,457 live and 23 stillbirths). Of this number 345 were to residents of other districts. 1,641 (1,605 live and 36 still) birth notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in hospitals in Middlesex or in London. 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 1950 it was 12.8: the national rate was 15.8. 63 (31 male and 32 female) stillbirths were registered, being a rate per 1,000 population of 0.28 compared with a figure of 0.37 for the country as a whole. The birth rate for many years has been falling, not merely in this, but in most European countries, in the United States and in the Colonies. In this country the fall has not, up to this, been reflected in a fall in the population figure, because over the same period the death rate too has fallen. Nevertheless, the nation is not reproducing itself and unless the birth rate rises the population must fall. The fall, once having started, again unless the birth rate rises, the population will decline, possibly to a very small figure. The fact that the nation is not reproducing itself is best shown by the use of the net reproduction rate, which is the ratio of the number of future mothers who will be born to the present mothers. A figure of 1.00 means that at the prevailing birth and death rates 100 women will be replaced by 100 of their daughters surviving to child. bearing age in the next generation. As long as the figure is less than unity replacement is not occurring. The rate before the war was well below unity. In 1939 it was 0.808. After figures of 0.772 and 0.761 in 1940 and 1941, a rise to 0.996 in 1944, it fell to 0.909 in the next year, but rose then to 1.103 and then to 1.205 in 1947. Since then the figures have been 1.070, 1.023, and for 1950, 0.980. This last figure means that the births were 2 per cent, below the number required for the population to be replaced. 9 Deaths. Of the 1,999 deaths which occurred in the district, 137 were of persons who were not residents of this area. Thirty-one of these took place in the various hospitals, 36 in nursing homes, and 3 in Oxhey Grove, a home for the elderly. Of the 760 deaths of local residents which occurred outside the district, most took place in institutions, 259 being in the Edgware General Hospital, and 55 at other hospitals in the county. Six deaths occurred in institutions for the treatment of tuberculosis, and three new.born infants at a maternity institution. 154 deaths took place in hospitals just outside the district, including 7 deaths in nearby isolation hospitals, and 131 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 Resp. tuberculosis 23 15 Other heart diseases 128 197 Other tuberculosis 1 1 Influenza 2 5 Syphilitic disease 4 4 Pneumonia 35 39 Diphtheria 0 0 Bronchitis 66 40 Whooping Cough 0 0 Other respiratory diseases 7 4 Meningococcal infections 0 0 Peptic ulcer 10 3 Acute poliomyelitis 2 2 Gastritis, enteritis 8 4 Measles 1 2 Nephritis 13 17 Other infective diseases 3 3 Hyperplasia of prostate 17 0 Cancer of stomach 35 29 Pregnancy, etc. 0 4 Cancer of lung 59 21 Congenital malformation 5 8 Cancer of breast 0 48 Cancer of uterus 0 19 Other diseases 67 86 Cancer of other sites 108 103 Motor vehicle accidents 14 4 Leukaemia 4 1 Diabetes 5 15 Other accidents 13 14 Vascular diseases of nervous system 85 127 Suicide 9 12 Homicide 2 1 Coronary disease Hypertension 185 31 83 45 Other circulatory diseases 40 61 Total 982 1,017 The number of deaths, 1,999, is a marked increase on the figure of 1,890 for the previous year and is the largest number of deaths experienced in this district. The death rate was 8.9 per thousand population, compared with figures of 9.3, 9.0, 8.6, 8.5 and 8.5 for the years since 1944 and with the figure of 11.6 for the country as a whole. In general, the death rate amongst the older is higher than amongst the younger members of the population. Also, in general, the rate amongst women is lower than that for men. If for any reason, then, the age constitution of a population is abnormal, containing, for instance, more women or a higher proportion of those age groups with lower death rates, 10 then the death rate will be lower than it would have been had the population been of normal age and sex distribution. In order to allow for variations in such age and sex distribution and so enable death rates to be more accurate indicators of the healthiness or otherwise of a district, the Registrar.General now issues a figure known as the comparative mortality index, which, applied to the local death rate, allows for these variations. The population of this district is of a different age group distribution than that of the country as a whole, because it would be the younger adults who came out to this area to live in the many new houses, which were put up before the war. The index for this district is 1.17. The adjusted death rate then is 10.4, a figure below the national rate of 11.6. Of the 1,999 deaths 982 were of males and 1,017 of females. The corresponding figures for 1949 were 1,890, 928 and 962. Of the 982 males who died 547 were over the age of 65; of the 1,017 females, 719; that is to say, 55 per cent. of the males who died had attained the age of 65 and 70 per cent. of the females. Most of the extra deaths which occurred in 1950 as compared with 1949, were amongst those of ages over 65. The nation is at last waking up to the importance of the effect of the falling birthrate and of the age distribution of the population, because this is now giving rise to the problem of the aged. It seems to be assumed that the larger number of the aged now living and the still larger numbers there are to be in the future, are the result of people living longer now; and the assumption is that this is because of the improved living conditions brought about partly by the activities of the Public Health Service. But the true position is not that people are living so very much longer, as that so many more are living to these advanced ages. The main reason that there are these many more living to these ages is that there were so very many infants born in this country in the last decades of the last century. For some years to come there will be this relative preponderance of the aged, a preponderance which is to be more marked in the coming years because for so many years of this century the number of births each year has been so much lower than the number in each of the latter years of the last century. A rise in the birth rate now will only add for some years to the disproportion between the consumers and the producers and would result in the needs of that many more dependants having to be met by the relatively smaller working population. This problem of the aged which is to face administrators for a number of years to come is, however, not necessarily a permanent one. When the population, which is the result of the large number of births in the latter part of the last century, has died, the population will become stabilized at one of more normal age distribution, but, of course, of smaller numbers, if the stability results from a persistently low birth rate. The plans for the care of the aged then for the more distant future should not be based on the assumption that the disproportion of the aged in the population of the coming years will be a permanent feature. 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 11 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. These neo.natal deaths result from developmental abnormalities, prematurity and defects in labour as contrasted with those which occur in infants in the rest of the first year of life which are largely related to those conditions which affect the healthiness of the general population. A few years ago it was suggested that the most that could be hoped for was that the neo.natal rate might be stabilized about 20, and that it ought to be possible to reduce the infant death rate of those of ages 1 to 12 months to 10. In this last year 39 infants in this district died in their first year of life. This is an infant mortality of 13.6. Of these 39 deaths, 27 occurred in infants before they had reached the age of one month. The neo.natal mortality rate was therefore 10, being 69 per cent. of the total infant mortality rate. The rates for this district have consistently been below those of the country as a whole. Never before, though, in this district, and probably in no other district of this size in the country, has a rate as low as this been reached. The lowest rate hitherto recorded here was 20.7, in 1949, which was itself a marked fall on the previous record of 24.0 for 1947. The national rate for last year was 29.8. 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 63 stillbirths were registered, being a rate per 1,000 population of 0.26 compared with the figure of 0.37 for the country as a whole. Deaths of Children of 1 to 5 Years of Age. Eight children survived their first, but did not reach their fifth birthday. Of these 3 died in their second year, 1 in the fourth and 4 in their fifth year. Maternal Mortality. The total maternal mortality rates 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. There were 4 deaths during the year associated with pregnancy, the maternal mortality rate therefore being 1.3. The first was a death during labour, the result of myocardial degeneration associated with uterine haemorrhage and toxaemia of pregnancy. The patient had had full ante.natal supervision and the labour took place under good conditions. The second death, which occurred after delivery, was the result of a suprarenal haemorrhage due to infective hepatitis. The third 12 fatality again followed a normal labour, the patient developing puerperal toxaemia. The remaining fatality was due to post-partum eclampsia, developing in a patient who had normal ante-natal findings and who had a normal delivery. Deaths from Accidents. There were 45 deaths (27 male and 18 female) from violent causes during the year. Of these 18 (14 male and 4 female) were the result of road traffic accidents. Falls of the elderly accounted for 8 (2 male and 6 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. Deaths from Suicide. Nine men and twelve women committed suicide. Four of the men and six of the women chose poisoning by coal gas. One man and six women took other poisons. The incidence was fairly even throughout the year. Deaths from Cancer. Out of 1,999 local deaths, 422 (202 male and 220 female) were due to cancer or other malignant disease, a percentage of 21. Diseases of the respiratory organs were commonest amongst males (59); the next most frequent site being the stomach (35). Amongst females the commonest site was the breast (48). Death from Infectious Diseases. The number of deaths in the district from the various infections compared favourably with the rates for the country as a whole; the rate per 1,000 population for tuberculosis was 0.18 and influenza 0.03, being below the corresponding national rates of 0.36 and 0.10. 13 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, and 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 has been modernised and as the Roxbourne Hospital provides 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 Hendon 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 Hendon 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. Application for the admission of patients is made by the general medical practitioners or by hospital almoners to the Area Medical Officer. 14 NURSING HOMES The responsibility for the registration and supervision of nursing homes lies with the Health Committee of the County Council. At the beginning of the year there were 19 registered homes with 210 beds, of which 73 were for maternity patients. There has been a continuing fall in the demand for admission to these homes, more particularly by maternity patients. This has been reflected in the change in the type of accommodation for which the homes have been registered. At the end of the year 20 homes were registered. These provided 226 beds, of which 71 were for maternity cases. ESTABLISHMENT 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 their general suitability for the work and about 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. At the end of the year 30 premises were licensed. In addition, certificates were lodged by registered members of the Chartered Society of Physiotherapy in respect of five premises. 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. Miss Dutson, who was on the staff of the former Pinner and Hatch End Nursing Association, works from 254, Uxbridge Road, Hatch End (Tel. No. Hatch End 213). The arrangement by which members of the staff of the Edgware and Little Stanmore Nursing Association and of the Watling District Nursing Association worked in this district came to an end during the year. 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 15 number agreed as the establishment, even though there is accommodation at the nurses' homes and even though, too, non-resident staff are engaged, so that the services could not meet all 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 fifteen midwives living in their homes in various parts of the district, who work under the supervision of the non.medical supervisor of mid. wives, Miss Webster, and the senior midwife, Miss Rough, of 213, Exeter Road, South Harrow (Tel. No. Pinner 5752). 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 was one midwife 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 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 741). 16 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, these being at Spencer Road, Wealdstone; Walton Avenue, South Harrow; Kenmore Road, Kenton; and Headstone Drive, Wealdstone. 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." 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 maintains the following 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. The 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. p.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Thu. and Fri. p.m. St. Alban's Church Hall, North Harrow Thu. a.m. The Rectory, Elstree Mon. p.m. Ante-Natal Clinics. Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. Baptist Church Hall, Streatfield Road, Kenton Thu. and Fri. p.m. 17 The 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. St. Alban's Church Hall, North Harrow Tue. p.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. The Clinic, Honeypot Lane, Stanmore Tue. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. St. Anselm's Hall, Hatch End Thu. a.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Fri. a.m. The Rectory, Elstree Mon. p.m. Toddlers' Clinic. Elmwood Clinic, Elmwood Avenue, Kenton Alternate Thu. a.m. Baptist Church Hall, Streatfield Road, Kenton Spiritualist Church Hall, Vaughan Road, Harrow 1st Mon. a.m. in month. The Clinic, Alexandra Avenue, South Harrow Wed. a.m St. George's Hall, Pinner View, Harrow 1st and 2nd Tue.a.m. The Clinic, Honeypot Lane, Stanmore Mon. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Pavilion, Chandos Recreation Ground, Edg- ware 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., Sat. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Pavilion, Chandos Recreation Ground Tue. a.m. b 18 Children attend at the request of the parents or of the teachers, or they are referred by school medical officers. Not only are those who need treatment for minor ailments seen at the clinics, but children are kept under observation for such conditions as cervical glands, cardiac murmurs. etc. Any children needing special examination, especially if these are likely to be prolonged, are referred to be seen at these clinics. Ophthalmic Clinics. School children selected by the school medical officer as the result of an examination at the school or at the minor ailment clinic, can be referred to be seen by the ophthalmic surgeon at the ophthalmic clinic at 76, Marlborough Hill, on the mornings of Tuesdays and Fridays, or at the Alexandra Avenue clinic on Thursday mornings. Only those who have an appointment can be seen, any new cases being referred in the first instance to be seen by the school medical officer at one of the minor ailment clinics. Child Guidance Clinic. A child guidance clinic with its team of psychologists and psychiatric social workers under the administration of the psychiatrist, Dr. Margaret Saul, is held at No. 2, St. John's Road, Harrow. The 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 schoolchildren 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 19 who are referred by the head teachers of the schools, the children attending under the arrangements made for the urgent or emergency treatment of those needing such attention for some cause such as toothache. Most of the children under five and the expectant and the nursing mothers are referred by the medical officers at the clinics which they have attended. The Health Authority dental service is, however, available to ante-natal mothers who do not attend the local clinics, but who are referred for treatment by the medical practitioners under whose care they are, appointments being made through the Area Office. Physio-Therapy Treatment. The Harrow Hospital maintains a physical treatment centre at the Car Park Building, Station Road, Harrow (Tel. No. Harrow 0926). The medical director, Dr. G. C. Farrington, attends at fixed sessions to see all new cases. A wide range of treatment is carried out by the staff under the 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. Whitehall 4400). In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at the County Council's Children's Care Office, 48, Station Road, Harrow (Tel. No. Harrow 2963). The 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. 20 W. Bullwinkle, of 48, Station Road, Harrow (Tel. No. Harrow 5600). By the provisions of Part III of the National Assistance Act it is the duty of 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 of it. The Authority has also the power and to such an extent as the Minister may direct, the duty to provide specialised welfare services for the blind, deaf, dumb and other handicapped persons. For administrative purposes the County is divided into the same ten areas as for the County Council's functions under the National Health Service Act. Acting under the supervision of the Chief Welfare Officer there is a Welfare Officer in each area, the one for this district being Mr. H. G. Plummer, 48, 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, Underbill 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 out free of cost to the patient and to the doctor at the Central Public Health Laboratory, Colindale Avenue, London, N.W.9 (Tel. No. Colindale 6041 and 4081). Most samples submitted are throat swabs for the presence of organisms of diphtheria or of the haemolytic 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. 21 Another service provided by the laboratory is the issue of certain preparations, such as lymph for vaccination against smallpox, and antigens for the immunisation of the population against diphtheria. The clinical material is collected each day by a van sent from the laboratory calling about mid-day at the Harrow Hospital, the Public Health Office, " Cottesmore," and the Central Fire Station, Pinner. The following is a summary of the examinations of material from this district, carried out during the year: nose and throat swabs, 364; faeces, 27; sputum, 17; pertussis, 12; milk, 36; ice-cream, 87; and water, 3; miscellaneous, 41. 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 analysis 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 1918. PUBLIC CLEANSING Refuse Collection. The same arrangements continued in force for the collection of house refuse. Only a few complaints about the state of the kitchen waste bins were received. Refuse Disposal. 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, refuse is being 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. The proposal for the construction of a crematorium on land forming part of the Harrow Weald cemetery reservation has been abandoned. Burial. Under Section 50 of the National Assistance Act, 1948, the Council 22 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 4 burials. Mortuary. During the year 326 bodies were received in the mortuary. Postmortem examinations were carried out on 267 and inquests were held on 42. 59 bodies were admitted for storage. 23 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 1,418 (ii) On complaint of other nuisances 591 (iii) Routine inspections 456 (iv) Revisits arising from defects found 8,204 (v) Surveys under Section 157, Housing Act, 1936 801 Conditions Found. (i) Number of dwellings or other premises where defects were found 1,989 (ii) Number of cases of overcrowding revealed 141 PUBLIC HEALTH Inspection of Other Premises. (i) On complaint or request 179 (ii) Routine inspections of premises 441 (iii) Revisits arising from defects found 1,049 (iv) Surveys arising from Rat complaints 1,313 (v) Inspection of Factories 995 (vi) Inspection of Workplaces 157 (vii) Inspection of Outworkers' Premises 266 (viii) Inspection of Cinemas and Places of Entertainment 73 (ix) Inspection of Licensed Premises 54 (x) Visits under Shops Acts 1,158 (xi) Evening observations under Shops Acts 46 (xii) Sunday observations—Shops Acts 15 (xill) Observations made for Smoke Nuisances 12 Conditions Found. (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 184 (ii) Number of premises where action taken by Council's Rodent Operative to deal with rats 1,179 (iii) Number of Factories, Workplaces and/or Outworkers' premises where defects or contraventions were found 121 24 (iv) Number of Cinemas and/or Licensed premises where defects were found 21 (v) Contravention of Shops Acts— (a) Failure to observe closing hours 25 (b) Other contraventions (failure to exhibit notices, etc.) 98 FOOD HYGIENE Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 22 (ii) Butchers Shops 562 (iii) Cowsheds 22 (iv) Dairies 142 (v) Fish Shops 265 (vi) Bakehouses 164 (vii) Cafes and Restaurants 597 (viii) Ice Cream Premises 517 (ix) Provision Merchants 901 (x) Other Food Premises 225 PART II. COMPLAINTS RECEIVED Summary. Accumulations of refuse 112 Animals causing a nuisance 34 Dampness 158 Drains and Sewers—choked 106 defective 120 Dustbins defective 107 Houses with defects 548 Flooding—Gardens 36 Vermin 34 Insect infestations 47 Overcrowding, alleged 299 Shelters and Static Tanks unsatisfactory 3 Smoke nuisances 9 Water courses 24 Other complaints (pig bins, wasps' nests, defective fences) 156 Food unfit (excluding requests received from shops to visit and inspect unfit food) 60 PART III. NOTICES SERVED Under Housing Act, 1936. (i) Statutory notices served under S. 9 requiring execution of repair work 46 (ii) Dwellings reported under S. 11 as being unfit for human habitation 2 25 (iii) Dwellings reported under S. 12 and closing order made 1 (iv) Informal notices served under S. 9 140 Under Public Health Act, 1936. Statutory Notices under:— (i) S. 24—work to a public sewer 72 (ii) S. 39—repair or renewal of drains 36 (iii) S. 45—repair or renewal of defective water closets 3 (iv) S. 56—undrained or badly-drained yard area 3 (v) S. 75—renewal of a dustbin 35 (vi) S. 93—abatement of a nuisance 73 (vii) Informal notices served 2,122 ACTION TAKEN Following Housing Act Notices. (i) S. 9—dwellings rendered fit (a) By owners 36 (b) By local authority in default of owners 15 (In five of these properties the notices were served during 1949.) (ii) S. 11—demolition order made (These orders relate to properties where action was started in 1948 or 1949.) 20 (iii) S. 12—closing order made (These orders relate to properties where action was started during 1949.) 2 (iv) Dwellings rendered fit by owners after receipt of informal notice 98 Following Public Health Act Notices. (i) S. 24—public sewers repaired 13 (ii) S. 39— (a) By owners 18 (b) By local authority in default of owners 24 (iii) S. 45— (a) By owners 2 (b) By local authority in default of owners 3 (iv) S. 56— (a) By owners 3 (b) By local authority in default of owners Nil (v) S. 75— (a) By owners 19 (b) By local authority in default of owners 13 (vi) S. 93—Nuisances abated 68 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,956 26 SUMMARY PROCEEDINGS It was necessary to apply to the Courts for abatement orders in respect of six properties. In the case of five an order was granted; in the sixth the work was completed before the date of the hearing. Action under S. 9 of the Food and Drugs Act was taken in respect of a nail in a loaf, glass in milk and soil in milk. Fines totalling £25 were imposed. Two cases were taken under S. 13 of the Food and Drugs Act, 1938— viz., a dirty bakehouse and a dirty kitchen of a cafe. Fines totalling £42 were imposed. Four street traders were prosecuted for trading in the district without being registered or for trading after the hours permitted by the Shops Hours of Closing Act. Fines totalling £11 were imposed. Two cases were taken where toys and day-old chicks were being given to school children in exchange for rags. Five persons were involved in these cases. Fines totalling £9 were imposed. HOUSING Repair of Houses. During the year 46 statutory notices were served under S. 9 of the Housing Act, 1936. In the case of 15 properties it was necessary to carry out work in default of the owner; in five of these the notices had been outstanding from 1949. Two dwellings were reported for action under S. 11 of the Housing Act, 1936, with a view to demolition orders being made. In another property a closing order was made on some rooms. Overcrowding. On the 1st January, 1950, there were 383 cases of overcrowding. During the year 141 new cases became known, but the overcrowding of 187 other houses was abated. The number of cases outstanding at the end of the year was therefore 338. The abatement of crowding of 75 houses was brought about by families being rehoused by the Council, 71 in Council houses and 4 in requisitioned property. 39 per cent. of the houses built by the Council in 1950 were allotted to overcrowded families. This proportion is much the same as that for the preceding years when the percentage ranged from 30.4 to 39.2. In most of the houses which were overcrowded at the end of the year the crowding had been brought about by the natural increase of the family (140 instances). In 110 the crowding was the result of married children living in the same house as their parents; in 36 it was because relatives had been taken in; in 20 it was due to the presence of lodgers who were not relatives. In 32 houses the overcrowding was brought about by accommodation being let so as to be overcrowded. Of the 52 houses in these last two categories in only 6 had the overcrowding occurred since January, 1950, when the Council gave publicity to the offences relating to overcrowding as set out under the Housing Act, 1936. The most disturbing aspect of the overcrowding in the district is that it is being caused by the natural increase in the size of the family and by 27 the ageing of existing members of the family, because this cause is likely to continue; closely related to it is the crowding which results from the marriage of older children who are unable to break away from their parents' homes. It is unlikely that in such cases the overcrowding can be abated other than by rehousing, and that will probably have to be by the local authority. Provision of New Houses. The Council's Housing Programme for the years 1946 to 1952 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. In 1950 the number built was 181. 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 water-courses and vacant parcels of land, to take action that prevented unsatisfactory conditions arising, while 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;— 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 79 169 13 — (ii) Factories not included in (i) in which S. 7 is enforced by the Local Authority 364 686 48 — (iii) Other premises in which S. 7 is enforced by the Local Authority (excluding out-workers' premises) 67 140 16 — Total 510 995 77 — 28 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 48 50 1 Overcrowding — — — — — Unreasonable temperature 1 1 — — — Inadequate ventilation 2 2 — — — Ineffective drainage of floors — — — — — Sanitary conveniences— (a) Insufficient 2 3 — 1 — (b) Unsuitable or defective 47 42 1 4 — (c) Not separate for sexes 1 1 — — — Other offences against the Act (not including offences relating to outwork) 20 16 1 — — Total 121 115 3 5 — In addition 266 visits were made to premises of outworkers who are persons undertaking at home work sent out from factories or business premises. Shops. The Shops Act, 1950, came into force on the 1st October, 1950. This Act repealed eight others, which up to the 1st October contained much of the legislation relating to the hours of closing of shops and such matters as concern the welfare of shop assistants. It is essentially a consolidating Act and does not introduce changes in procedure or practice. During the year 1,158 visits were made to shops in the district by the Shops Acts Inspector. The contraventions found and dealt with included 10 instances of assistants being employed on their weekly halfholiday; 1 of a trader contravening a local closing order by keeping open on the day when the shop should have been closed on the weekly halfholiday; 2 cases where young persons were being employed after 10 p.m. contrary to the provisions of the Shops Act, 1934; 5 instances where records in respect of young persons were not being kept; and 19 cases where notices required by the Acts were not being exhibited. 27 shopkeepers were warned for serving customers after the hour upon which the shop should have been closed. 25 were first offences; in two cases the shopkeepers had been warned previously. As a result of the visits made by the Shops Acts Inspector, 65 shops were redecorated and 111 requests for other repairs and improvements were made and were complied with. At the end of the year there were 2,275 shops on the register, an increase of 10 on the previous year. Smoke Nuisance. Of the 443 factory premises in Harrow comparatively few have large 29 steam-raising plant, and from these no complaint of a serious nuisance was received. Over the year 9 complaints were dealt with; 3 of these involved the disposal by burning of waste matter from the factory workshops, the remainder being associated with poor quality fuel. At two laundries where smoke was giving rise to complaints the smoke was the result of poor fuel. The abatement of smoke nuisance due to a low grade or poor quality fuel is an extremely difficult matter. Rat Infestation. During the year 1,313 complaints of rats or mice were investigated, an increase of 290 on the figure for 1949. In the case of 134 no infestation was found; steps to destroy the rats or mice were taken in the remaining 1,179 cases. The complaints received were scattered throughout the district and gave no indication of one area being more heavily infested than another. No premises or site in the district was found where there was anything in the nature of a major infestation. Three sewer treatments were carried out, but as in past years no evidence of serious infestation was found. Wasps Nests. An unusually large number (239) of requests for assistance in dealing with wasps nests was received in 1949. Last year the number fell to 118, a more average figure. 30 INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY Production. The number of farms in the district remains at eight. Of these, four are producing tuberculin tested milk, one accredited, and the remainder ungraded milk. Processing and Distribution. The following is a summary of the position:— (1) Number of premises licensed to pasteurise milk 2 (2) Number of premises licensed to bottle T.T. milk 2 (3) Number of premises from which pasteurised milk was sold 48 (4) Number of premises from which T.T. milk was sold 44 (5) Number of premises from which sterilised milk was sold 44 (6) Number of premises outside Harrow from which pasteurised milk was retailed in Harrow 16 (7)Number of premises outside Harrow from which T.T. milk was retailed in Harrow 16 (8)Number of premises outside Harrow from which sterilised milk was retailed in Harrow 14 In addition there are two establishments from which raw milk was retailed. Inspection and Supervision. During the year 157 visits were made to cow sheds and dairies and, where necessary, those responsible carried out work of repair or improvement. Work is now proceeding on the erection of a modern dairy at one of the farms; when completed equipment of the most up-to-date design will be in use. Sampling. 34 samples of milk were taken during the year. Of these 33 were satisfactory. Follow-up samples of the milk which gave an unsatisfactory report were satisfactory. Complaints. During the year 15 complaints were received about the dirty condition of milk bottles or of foreign matter being present in the milk. In respect of two of these cases action was taken under S. 9 of the Food and Drugs Act, 1938, one being because of glass, the other soil in the milk. The fines imposed totalled £15. During 1949 dairy companies were asked to discontinue the practice of depositing crated milk bottles on the public highway. As a result milk bottles today are seldom seen on the highway. (B) MEAT During the year one of the seven slaughter houses in the district was converted into a garage and will not again be used as a slaughter house. Two of the remaining slaughter houses were used occasionally, 62 pigs belonging to pig clubs or private persons being slaughtered. All the pigs 31 were inspected and with the exception of three sets of lungs and one liver were found fit for human consumption. (C) OTHER FOODS During the year 3,373 visits were made to food shops and other premises at which food was prepared or stored. They showed that shopkeepers and their employees are becoming more aware of the public demand for cleanliness in the handling of food and in most of the food premises very satisfactory conditions were found. Only in comparatively few cases was it necessary to use the powers given to the Council by the Food and Drugs Act, 1938, and much of the improvement work carried out during the year followed suggestions put forward by the Sanitary Inspector. There were only two cases where failure to maintain a satisfactory standard of cleanliness necessitated Court action being taken; in respect of these fines totalling £42 were imposed. One of the premises involved was a bakehouse; the business was later trar sferred to other premises. The following is a summary of the food examined and found to be unfit for human consumption. It was either destroyed locally or dealt with by the Salvage Section of the Ministry of Food. lbs. Meat and Meat Products 3,127 Vegetables, Soups and Pickles 2,289 Groceries and Miscellaneous 3,346 Fish 2,078 Fruit 1,786 Total 12,626 The total weight of food found unfit during the year was a little over 5½ tons, a reduction of three tons on the quantity found unfit during 1949. Ice Cream. During the year the number of persons manufacturing ice cream increased from 11 to 12. Over the same period 43 additional premises were registered for the retailing of ice cream, making a total of 287. Most of these new registrations were of grocery shops where, as at greengrocers and many other shops, frosted foods in wrapped cartons are sold. During the year 517 visits were made to premises where ice cream was manufactured or retailed, and the premises of the manufacturers received special attention. Without exception these traders co-operated with the Department in the efforts made to ensure ice cream being manufactured under satisfactory conditions. 126 samples were taken; 74 were Grades 1 or 2 and the remainder Grades 3 or 4. In the case of Grade 3 or 1 reports, investigations were made and, if possible, the cause found. In the event of the sample involving supplies coming into the district from outside, the local authorities concerned were advised. In all such cases follow-up samples were taken. Registration of Hawkers. The number of street traders registered under the Middlesex County 32 Council Act, 1944, was 16. Of these one was registered as a hawker of fish, the rest in respect of greengrocery. Four street traders were fined for trading in the district without being registered or for trading after the hours permitted by the Shops Hours of Closing Act. The fines imposed totalled £11. (D) HYGIENE OF FOOD In the Annual Report for 1949 it was reported: "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 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." Steady progress has been made through the last year. Gratifying numbers of applications for membership of the guild had been received, and by the end of the year to nearly one-quarter of the establishments in the district dealing with the preparation or sale of food the Council's certificate had been issued and was being exhibited. At the same time the interest of the housewife was being aroused, more especially by means of talks at meetings of the members of the various organisations. The film strip which had been obtained was found to be of real help at such gatherings. During the year byelaws made under S. 15 of the Food and Drugs Act came into force. Their purpose is the securing of the observance of sanitary and cleanly conditions and practices in connection with the handling, wrapping and delivery of food sold or intended for sale for human consumption, and in connection with the sale or exposure for sale in the open air of food intended for human consumption. Under the Food and Drugs Act, 1938, an urban district with a population of 40,000 could be the Food and Drugs Authority, but: " If a county council satisfies the Minister that the area or areas in respect of which they would be the Food and Drugs Authority would be rendered inconvenient in size, shape or situation for the efficient performance of their duties as the Food and Drugs Authority, the Minister may direct that the county council shall be the Food and Drugs Authority as respects the district or districts of any one or more of the local authorities who, but for such a direction, would be Food and Drugs Authorities under this Act, but were not such authorities under the law in force immediately before the commencement thereof." A number of authorities in Middlesex opposed the County Council's representation to the Minister of Health for a direction that the County Council should be the authority for such county districts. The Minister issued the direction and the County Council remained, as it had been before, the Food and Drugs Authority for the whole of the county, carrying out its functions through the Public Control Department. One result of the coming into operation of the Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulation, 1949, was to transfer from the District Council to the County Council the 33 licensing of milk pasteurisers and the periodic inspection of plant, although the District Council remains responsible for the inspection, etc., of the structural condition of the premises. This was felt to be a further argument in favour of the District Council's being made the Food and Drugs Authority. On being approached, however, the County Council saw no reason at the present time that any alteration should be made in the County Council's position as Food and Drugs Authority for the whole of the county. 34 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 Age unknown Total Scarlet fever 1 64 157 18 9 3 1 2 255 Diphtheria — 1 — — — — — — — — — — 1 Pneumonia 1 5 8 4 1 2 4 8 11 15 12 — 71 Dysentery — 1 — — 1 — 1 — — 1 1 — 5 Erysipelas — 1 1 1 1 — 1 3 6 7 1 — 22 Cerebro-spinal fever 1 2 2 1 1 — 1 — 1 — — — 9 Puerperal pyrexia — — — — 1 — 3 1 — — — 1 6 Ophthalmia neonatorum — — — — — — — — — — — — — Poliomyelitis 2 8 7 2 5 1 2 3 — — — — 30 Measles 23 467 493 5 2 4 4 3 — 2 — 2 1,005 Whooping cough 39 357 356 10 1 — 3 4 — — — 2 772 Enteric fever — — 1 2 — — 1 — — 1 — — 5 Food poisoning 2 2 — — — — — — — 1 — — 5 Disease Cases Notified Admitted to Hendon Isolation Hospital Admitted to other Isolation Hospitals Admitted to other Hospitals Scarlet fever 259 44 25 Diphtheria 24 13 11 — Pneumonia 71 2 — — Dysentery 7 — 1 — Erysipelas 22 6 — 1 Cerebro-spinal fever 9 6 1 2 Puerperal pyrexia 6 2 — 3 Ophthalmia neonatorum — — — — Poliomyelitis 36 19 8 7 Measles 1,005 3 9 — Whooping cough 772 1 8 — Enteric fever 7 7 — — Food poisoning 4 — 3 1 CONTROL OF INFECTIOUS DISEASES For an authority to be put in a position to take steps to control the spread of an infectious disease it must first be made aware of the infectious patients. This information is received when the patient's doctor notifies the Public Health Office. Particulars at the household are learnt of by the visits paid to the homes by the health visitors or sanitary inspectors. The efficacy of preventive steps is limited if the disease in the patient is not recognised at an early stage. Facilities for assisting the making of an early diagnosis, then, are an important step in the control of spread. The spread of infection by the patient is limited by his being isolated either in a hospital to which he has been removed or at home. Those who have been in contact with the patient might be spreaders of infection, so their activities might have to be restricted. The surroundings of the patient, too, might be infective, and so might need treatment. 35 Notification. (1) Notifiable diseases, as defined by S. 343 of the Public Health Act, 1936: Smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fevers. (2) Diseases declared by the Local Authority under S. 147 of the Public Health Act, 1936, to be notifiable: Pemphigus of the new-born. (3) Diseases notifiable by regulation: Plague, acute poliomyelitis, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles, whooping cough, acute encephalitis, meningococcal infection. Aids to Diagnosis. (1) Laboratory service (see page 20). (2) Services of a consultant— (a) Ordinary infections: Dr. Livingstone, of the Hendon Isolation Hospital (Tel. No. Colindale 8182). (b) Smallpox and typhus fever: The patient's doctor can be put into touch with one of the Ministry of Health's panel of consultants by means of the Public Health Office, or the Hendon Isolation Hospital. (c) Tuberculosis: Physicians at the Chest Clinics. Isolation in Hospital. (a) The usual infectious diseases: Most patients removed to hospital are admitted to the Hendon Isolation Hospital, Goldsmith Avenue, Hendon. When there is no accommodation here patients may be admitted to one of a number of isolation hospitals around London, arrangements being made either by the staff of the Hendon Isolation Hospital or by the patient's doctor applying to the Emergency Bed Service. (b) Smallpox or Typhus Fever: Patients suffering or suspected to be suffering from these complaints are admitted to special hospitals. The removal to hospital can be arranged only if the patient has been seen by one of the consultants on the Ministry's list. (c) Tuberculosis: Arrangements for admission are made by the staff of the Tuberculosis Service, mostly to special but sometimes to general hospitals. Exclusion of Contacts. Except for the exclusion from school of child contacts of those suffering from one of a number of infectious complaints, exclusion of contacts is practised only in those rare instances where, because of the nature of his work, there is risk of the contact spreading infection to others. 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 36 the commoner notifiable infections is not carried out by the Council, the household being instructed as to the precautionary measures to be taken. Where householders still request that fumingation 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, and 5s. Od. for any subsequent load. The change in practice in regard to the routine fumigation of premises after the occurrence of a case of infection followed on the altered emphasis of the importance of the human spreader as opposed to the inanimate object. Nothing that has happened, following the virtual abandoning of the practice, has led to the need for any reconsideration of the decision. There has been no increase in the incidence of the secondary cases which might be accounted for by infection by inanimate objects. Today, more importance is being attached to the risk of spread, not directly from the nose and throat of spreaders, but indirectly, either by means of contaminated hands or by the stirring up of the dust of bedclothes or on floors. It may be that some of the invasions, the spread of which are unaccountable, will be found to be the result of the passage of organisms in this way. As yet, though, it does not seem to have been demonstrated that the dust-borne spread of haemolytic streptococcus infections is a very important factor. If it should be shown to be, then possibly ideas about the treatment of premises occupied by infective persons might have to be revised again. DIPHTHERIA Of the twenty-six persons who were thought to be suffering from diphtheria during the year in only one was the diagnosis confirmed; this was a boy of three years of age who had not been immunised. This was the first case of faucial diphtheria in the district for over three years. In 1948 there were no cases, and in 1949 the only sufferer was a child, who had a nasal infection. Eleven of the suspects were suffering from tonsillitis, eight from glandular fever and three from laryngitis. Immunisation of the child population against diphtheria must have contributed largely to the virtual elimination of the disease. Anyone who has reached a state of relative immunity, so that he no longer succumbs to a dose which in the susceptible would result in infection, can, in general, maintain that immune state only if his tissues have to react to attack. When diphtheria was not the uncommon disease that it has become in many parts of the country today, the state of immunity of many was maintained at an adequate level by the individual being subjected to sub-infective doses of the organisms by his coming into contact with spreaders of the germs. Today, however, that is not the position, and many a child who has been satisfactorily immunised, because he is deprived of the opportunity of being exposed to these organisms, runs the risk of losing his immune state. That is why it is so necessary that those immunised in infancy should receive boosting doses at certain intervals. A population which contains a high proportion of immune members will have few or no cases of disease. The result of this is that the many who have been protected reduce the risks of those not immunised from 37 contracting infection. The risk is merely reduced though, and is not completely removed; and the fact that, in any district, a large proportion of children are successfully immunised, and the fact that there is little diphtheria in the district ought not to lull mothers into a sense of false security. Because many other children are protected any individual child is less likely to contact infection, but the risk is still there and cannot be removed unless that child is treated and immunised. From a public health point of view it is sufficient to have a high proportion of the child population immunised. That is an almost certain guarantee against any widespread outbreak. But while in this way the risks to any given child are lessened, they can be removed only if he is himself protected. During the year, 2,118 children were treated for the first time, 1,251 by general medical practitioners, 855 at infant welfare centres, and 12 at day nurseries. It is estimated that at the end of the year 50.2 per cent. of children under 5 years of age were immunised and 75 per cent. of children aged 5 to 15 years. SCARLET FEVER In common with that of the rest of the country the population of this district in 1950 suffered only slightly from invasion by scarlet fever. During the year only 262 persons were notified as suffering from this complaint. In a number of these patients the diagnosis was not confirmed, the corrected figure being 255 cases, an incidence rate per thousand population of 1.1, a very low figure. The incidence was heaviest in the early months of the year. The average number of notifications each week in the first quarter of the year was 9, in the second 5, and in the third 3.5. The incidence continued to fall in the last quarter when the weekly average was only 2.5. The disease was mild in character, and there were no fatalities. The 69 patients who were admitted to hospital were not removed because their clinical condition necessitated special medical or nursing care. Most admitted to hospital were accepted at the Hendon Isolation Hospital, but 25, or about one-third, had to be found accommodation in some other infectious diseases hospital. There were nine households in which secondary cases of infection occurred; in most only the one, but in one home two other children succumbed. In all cases the primary patient had been nursed at home. In four instances the secondary case had probably already been infected before the disease was recognised in the first patient. In the others, however, there was an appreciable interval between the dates of onset of illness in the patients: in one case, up to four weeks; and in these households it is possible that had the original case been removed to hospital the other patient in the house, who succumbed, would not have contracted the infection. There was this year only one return case, the patient falling ill four days after the return home from hospital of her sister, who in that time had developed a sore nose. In one house a child fell ill seven days after her brother, who had been nursed at home for three weeks, had been freed from infection. 38 At only one school this year did it seem that any children who succumbed to an attack of scarlet fever might have contracted the infection as result of attendance at school. In the first five weeks of the spring term at Welldon Park School there were 14 cases of scarlet fever amongst the pupils. In each of the first two weeks there were two cases in the one class; in the following week there were three cases of members of one family, but pupils of different classes; in the next week two more pupils of the first class were again affected; in the last week of multiple infection two of the sufferers were members of the first class affected and two attended other classes. A small number of children suffering from slight abnormalities and who gave suspicious histories were excluded in the early stages. SMALLPOX Although there were no patients in this district suffering from smallpox during the year the inspectors had many visits to pay to the homes of those who, in other areas, had possibly been contacts of patients. The number of children vaccinated for the first time against smallpox during the year was only 1,193, as against the figure of 2,848 babies born. 535 persons were re-vaccinated. It is submitted by some—and quite correctly—that the vaccination of only some of the population increases the risk of the spread of an infection, once it is introduced, because the effect of previous vaccination, if not sufficient to avert an attack, results in a modified form of illness which, being atypical, might not be recognised as an attack of smallpox, so that infection is spread from this person. For this reason some do not favour the practice of wholesale vaccination of infants. But quite apart from the vaccination of babies, there is the vaccination of those going abroad and the vaccination of large numbers of the population when it is known that smallpox has been introduced in any locality, such as Glasgow or Brighton. In these circumstances consideration of what might be the position if the entire population were unvaccinated, so that the disease when introduced would run true to form, must be ignored, and because, in any event, some of the population is vaccinated, the only sound procedure to avoid spread is to see that the entire population is protected. The best age for any member of the public to be protected is in infancy. ENTERIC FEVER The exact number of cases of typhoid infection in the district in this last year is not known. There were two definite cases of paratyphoid B infection. The first was a boy of eight, an inmate of a children's home; no others in the home, either staff or pupils, were infected and the source of this boy's infection could not be discovered. The other definite case was a child who was a visitor to the district and who had probably been infected before she came here. Of the other cases one, a girl of 11, died in hospital. Although the clinical illness was one of typhoid infection laboratory findings failed to confirm the diagnosis. The next case came to light because of an infection in a neighbouring district, due to infected food. The man was one of the 39 employees at the factory at which the infected food was made, and it was considered that he was probably one of the victims. The last of the doubtful cases was that of a man in whom the laboratory findings again were inconclusive. The refinements of today's laboratory examinations increase the likelihood of the source of the infection in any patient being discovered, but that will be only when the laboratory findings are quite definite. DYSENTERY Seven patients were notified as suffering from dysentery, two of them being members of the same family. It is probable that the actual incidence of dysenteric infection is far greater than the number of patients notified as suffering from the complaint. FOOD POISONING Only five patients were notified as suffering from food poisoning; from each of these S. typhi-murium was recovered. One case, that of a man, proved fatal. Two patients were small children in the one family; the other two notifications were children of three and four months of age. ERYSIPELAS Only 22 notifications of persons suffering from erysipelas were received this year. Half the cases occurred in the first quarter of the year; most of the rest occurred in October. This year the sexes were nearly equally affected. As has been the case in recent years, again in the vast majority the site of lesion was the face. Six patients were removed to hospital. CEREBRO SPINAL FEVER Six persons suffered from meningococcal infection during the year. The first case was a boy of 18 months who fell ill in March ; the next boy of three who succumbed in April; and the third was an adult notified in June.. After a lull of some months the next infection was a girl of 17, in September, and then a baby of 11 months, in December. All recovered. ACUTE ANTERIOR POLIOMYELITIS The infection in the country of the summer and autumn, 1949, declined in incidence towards the end of the year, but did not disappear. In the early weeks of 1950 the average number of notifications each week was over 50, and the lowest incidence, an average weekly notification of 20, was not reached until April. The 1950 outbreak started at the end of May. The position in the country as a whole was reflected locally. There was a case early in January, another fatal case late in January, and then another, also a fatal case, in March. Then followed a lull until the disease was diagnosed in June in a person who had probably contracted infection outside the district. Later in the same month the first locally contracted case was diagnosed, an abortive infection. The first case in which paralysis occurred was at the end of July. August yielded seven cases, one being fatal. Then followed the heavy invasion of 16 cases, in September, 40 with one death. There was then another lull until the one case occurred in the middle of November. In all, then, there were 30 cases, of whom four died; 10 suffered from a non-paralytic attack, of whom two suffered from polioencephalitis. The sexes were equally affected. Ten of those attacked were under five years of age, eight were between the ages of 5 and 15, while twelve were over 15. The youngest attacked was a child of four months; the oldest a man of 46. There was one instance of a family grouping. On the 16th September a child of seven was admitted to hospital suffering from a paralytic attack, his paralysis having appeared on the 15th. In the same house was a child of 11 who fell ill on the 11th September with a non-paralytic attack and on the 16th September a brother, aged four, fell ill, also with a non-paralytic attack. ' It has for long been accepted that it is advisable not to carry out any but the most urgent operations on the throat during periods of poliomyelitis prevalence. The attention of those at the local hospitals which provide this treatment for the local population was drawn at the appropriate time when it seemed the district was entering its period of poliomyelitis prevalence. Operations on the throats of children were largely discontinued at these hospitals for a period of some weeks. Reports from abroad and from this country seemed to point to there being an association between the onset of poliomyelitis in some children and their recent inoculation. At first this association appeared to be only when a child had been inoculated with pertussis vaccine. Later reports suggested that there was a risk, though a reduced one, when a child was inoculated with APT to protect him against diphtheria. No reports of any such cases had been received in this district. Nevertheless, it seemed that there was a risk, though of unknown magnitude, so for a time the inoculation of children against whooping cough and diphtheria was discouraged. ENCEPHALITIS Two cases of encephalitis were notified. One patient who was thought to be suffering from an encephalitis secondary to mumps was later recognised to have suffered from cavernous sinus thrombosis. MEASLES Although 1950 was not an epidemic year for measles, the district was not entirely free from the disease for any part of the year. The curve of incidence was a shallow symmetrical one, rising from an average weekly incidence of one, in January, to nearly 60 for each of the last two weeks in May and the first two weeks in June, falling then slowly to an average of two in November. In the last weeks of December there was a sharp rise, the prelude to the outbreak of 1951. In all, 1,005 notifications were received. The disease, in the main, was mild in character. That the heavy incidence occurred in the warmer months would naturally result in a lessened incidence of some of the complications of measles; three patients died, but two of these were children resident in an institution outside the district. 41 It is assumed that the biennial character of the wave of incidence of measles is the result of the accumulation of a number of susceptibles. If this is the case, then the fact that over a thousand children suffered from measles in 1950 ought to be followed by the lighter incidence in the district in the attack of the epidemic year. After the virtual freedom from attack in all schools in the spring term, a number were afflicted in the summer term; those most heavily attacked being Stanburn Infants, with 100 cases; Stag Lane Infants, with 85; and Longfield Infants, with 50. WHOOPING COUGH The weekly average of three notifications in the first four months of the year rose to 24 in the summer months. There was a sharp fall in the autumn. This was followed by an even sharper rise in December, the prelude to a heavy invasion in the early part of 1951; 772 cases were notified. There were no deaths from this infection during the year. As was the case with measles, most schools were free from pertussis during the spring term, and it was not until the summer term that most were attacked. In that term virtually every one had some sufferers, though no school was heavily attacked, none having as many as 30 cases. The break of the summer holidays did not see the freeing of schools from this infection, as it did in the case of measles, as most of these schools which were attacked in the summer term continued to have small numbers of cases in the autumn term. PUERPERAL PYREXIA Six patients were notified as suffering from puerperal pyrexia. Two of these were in respect of women who had been delivered in hospitals in London. In two the raised temperature was probably the result of an upper respiratory infection or of influenza. In one patient it was considered to be the result of retained uterine products. The remaining patient developed pelvic cellulitis. OPHTHALMIA NEONATORUM No notifications were received during the year of infants suffering from the inflammation of the eyes. PEMPHIGUS One infant was diagnosed as suffering from pemphigus neonatorum. The attendant was not present at the delivery, which took place in an unsatisfactory home, no arrangements having been made for the confinement. 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. Intimations were received from the head teachers of the local schools 42 of 309 pupils suffering from chickenpox. Some schools were affected each term, the heaviest incidence being in the summer term when the Chantry School was that most heavily involved. Mumps. The 268 pupils who suffered from mumps were mostly those in three schools: Glebe, Priestmead and Roxbourne, in each about 50 cases occurring, mostly in the summer term. German Measles. Only 12 intimations were received of pupils suffering from German measles. These were scattered throughout the district. In most instances there were no cases of ordinary measles in the schools at the time. Influenza. 1950 was not a year in which there was much influenza in the district. Eight persons died in the first quarter of the year from this complaint. TUBERCULOSIS Notification. The following table sets out the age and sex distribution of the patients who were notified in this district for the first time in 1950:— Primary Notification Brought to notice other than on Form A Pulmonary Nonpulmonary Pulmonary Nonpulmonary M F M F M F M F Under 1 — — — — — — — — 1-4 8 7 3 — — — 1 — 5-9 6 3 3 — — — — — 10-14 2 5 2 1 — — — — 15-19 26 19 1 2 2 4 — — 20-24 22 24 2 — 3 8 — 3 25-34 15 34 2 2 12 23 2 1 35-44 27 20 1 2 4 4 — — 45-54 19 5 3 1 2 — — — 55-64 17 4 — — — 3 — — 65 and over 3 5 — 1 1 — — — Totals 145 126 17 9 24 42 3 4 In last year's report attention was drawn to the very marked increase since the war in the number of notifications of those suffering from tuberculosis, an average figure of 374 for the three years, 1945 to 1947, when the average population was 215,000, as contrasted with an average number of 198 for the three years, 1934 to 1936, when the average population was 145,000. As contrasted with the figure of 439 cases learned of for the first time in 1949, the number in 1950 was only 370, a very welcome fall to a figure lower than that of the preceding three years. Of the 337 pulmonary cases, 94 were already suffering from the disease before they moved into this district. Of these, 18 were persons 43 who came to live in the new London County Council Headstone Estate; this is a smaller number than in previous years. Although the estate is now built up there probably will always be a certain number of such transfers because of the filling of houses which fall vacant by the families living in London whose claims for rehousing rest especially on the grounds that they contain members suffering from tuberculosis. It is probably in this way that three persons who had previously contracted the infection were notified when they came to live in the London County Council Kenmore Estate. A comparison of the age distribution of the cases brought to notice by primary notification in the years 1949 and 1950 shows that the greatest divergence is in the numbers notified in those of ages one to four. There were 15 such cases in 1950, as compared with only six in the previous year. Of these, three removed to the district, having already contracted the infection; two of them gave a family history of the disease. Of the 12 who contracted the infection in this area nine gave a close family history of contact. It is probable that many of these were brought to light by the examination of the family contacts of those in which the disease had been detected. Of the 235 patients notified during the year as suffering from pulmonary tuberculosis, 78 or almost exactly onethird, gave a family history of the disease. Of the 29 patients notified as suffering from non-pulmonary tuberculosis at least ten had contracted the infection before coming to live here. Register. The names of all persons notified or otherwise brought to notice are entered on the register. These entries lead to an increase to the numbers on the register. On the other hand, deductions are made by names being removed. Many names are taken off because of persons moving from the district; some die and some recover. Quite apart from the quarterly corrections made in the register, periodically a check is made to ensure that everv nerson whose name is on the register is still in the district The following table is a summary of the changes which have taken place in the register during the year:— Pulmonary Non-pulmonary Male Female Male Female No. on register, January 1st, 1950 968 765 117 135 No. of new cases added 145 126 17 9 No. of cases other than on Form A 24 42 3 4 No. of cases restored to the register 2 1 — — No. of cases removed 110 87 9 7 No. on register, December 31st, 1950 ... 1029 847 128 141 Of the deductions, 110 (102 pulmonary) were of persons who had left the district, 45 (44 pulmonary) were of persons who died, 50 (44 pulmonary) were of persons who recovered, while 8 (7 pulmonary) were of persons in respect of whom the diagnosis was withdrawn. 44 The total net increase to the register, including pulmonary and nonpulmonary cases, was 160, a figure to be compared with that of 196 for the previous year. Deaths. Thirty-eight persons (23 male and 15 female) died from pulmonary tuberculosis during the year and two (one male and one female) from non-pulmonary tuberculosis. This infection therefore accounted for a death rate per thousand population of 018 and for 2.0 per cent. of the total deaths. The corresponding figures for 1949 were 0.26 and 3.0; and for 1948, 0.42 and 4.9. Preventive Measures. Although much of the improvement in the vital statistics relating to tuberculosis occurred during the period that specific efforts of many kinds were being directed to this disease, to what extent the improvement can be said to be the result of this particular attention is debatable. What is quite certain is that however important these factors may be the real need of a community is sound nutrition and good housing, and even good housing ought not to be purchased at the expenditure of adequate nutrition. Chest clinics, hospital accommodation, facilities for early diagnosis, such as mass X-ray units and immunisation schemes, all have their part to play in the control of and ultimate virtual eradication of this disease. But ample provision of all these is helpless unless the basic essentials of feeding and housing are present. During and since the war, and arising out of it, there were and are far fewer people than before who, because of an inability to make the necessary purchases, have been deprived of the essential food factors. On the other hand, housing conditions for very many, and especially in such a district as this, are very much worse than they were before the war. In this district the Council has been generous in its allocation of new houses to those suffering from tuberculosis, giving as many as one in six of their new houses to this group. Before any new houses were built after the war there were many families living in grossly overcrowded conditions with at least one of the members suffering from open tuberculosis, a state of affairs fraught with danger of spread to other members of the family. The worst of these cases have been rehoused, though there are still some families living in overcrowded conditions. In selecting families for nomination, with a view to their being rehoused, regard has been had to the degree to which the family, continuing to live in these homes, would be in danger of spread of infection. The measure was not the effect of these conditions on the patient except in so far as a sufferer might become more infectious by remaining in those unsatisfactory conditions. The factor to be determined was the risk of spread of infection from the patient to those others who were his immediate contacts. Two factors were important: the one was the infectiousness of the patient; the other was the degree of crowding of the house. For the assessment of the first reliance was placed on the advice of the chest physician under whose care the patient was. To measure the other a standard was adopted giving the degree of crowding there would be, assuming the patient was 45 allotted a bedroom to himself. While in a few cases what was wanted was a larger house for the family living in a house too small for them, in the vast majority of cases where a house was overcrowded there were at least two families, though often enough these were related. In some cases the only way to abate the crowding of a house was by the rehousing of a small family—a family comprising only the man and wife, one of them being a sufferer. Rehousing such a family conflicted with the Council's general ruling which had been in force for some time against the allocation of Council houses to families with no children. Another difficulty arose in cases in which the sufferer was a member of the family who were the original tenants of the house, in which case the most direct way of abating the overcrowding would be by the rehousing of the sub-tenant family, even though that family did not have a sufferer. Another difficult class of case is that in which the family needing to be rehoused is one which, having only recently come to the district, has no real claims on this district for rehousing. As a corollary to this class is that of the family which can look only to this district to rehouse them, but who are living somewhere outside the district. In spite of all these difficulties it is felt that, in general, the housing of most of those families in this district in which there is a member suffering from tuberculosis is not unsatisfactory as assessed by the needs for them to be rehoused on public health grounds. The effect of the slowing down of the rate of building construction is already beginning to be felt, and it might well be that the situation will become less satisfactory than the state which has been reached. One effect, at least, must be the deferring of the time when it might be possible, in determining which families whose claims for rehousing rest on the fact that a member of that family has open tuberculosis shall be selected for nomination, for those other factors of the house itself, apart from overcrowding, such as its general state of maintenance and repair, or the state of its surroundings, to be given due weight. As long as there is any real degree of overcrowding it is felt that this factor must outweigh these others, but it had been hoped that the time was arriving when, the degree of crowding of the members of the families being only slight, these other factors could have been given the weight which is their due. Local sanitary authorities have specific powers and duties in regard to tuberculosis. The Tuberculosis Regulations authorise a local authority to supply all such medical or other assistance and all such facilities and articles as may reasonably be required for the detection of tuberculosis, for preventing the spread of infection, and for removing conditions favourable to infection. Amongst the arrangements for the detection of tuberculosis most local authorities provide for the examination of sputum for the tubercle bacillus. This work is now carried out at the Colindale Laboratory as part of the National Laboratory Services. Although the local authority is concerned with the removal of conditions favourable to infection, and it is for this reason that it had rehoused so many families having a family suffering from tuberculosis, in this area the home visiting is undertaken by the tuberculosis sisters attached to the staff of the local chest clinic. It is she who advises as to the precautionary measures to be taken to prevent the spread of infection; from her, reports are received 46 about the condition of the premises, following which the sanitary inspector visits those houses where housing is unsatisfactory, either because of crowding or because of the structural state of the premises. S. 172 of the Public Health Act, 1936, empowers steps to be taken compulsorily to remove to hospital on a court order an infectious person suffering from pulmonary tuberculosis where precautions to prevent the spread of infection cannot be or are not being taken. As there are so many sufferers anxious to be admitted to hospital for treatment who cannot, without long periods of waiting, be accepted, it would these days have to be a very glaring case in which the person would have to be felt to be really a danger that would justify the use of these powers. In point of fact no application for such a court order has yet been made in this district. Other preventive measures are taken by the County Council as the Local Health Authority under the powers of S. 28 of the National Health Service Act. This work is based on the local chest clinics and is carried out by persons who are on the staff of the County Council either full-time or part-time; those engaged on a part-time basis working for the rest of their time for the Regional Hospital Board. The preventive measures include close supervision of the contacts of declared cases, the boarding out of susceptible infants and children with relatives or other suitable foster parents, health education and propaganda. Supervision of the purity and safety of milk supplies is another preventive measure. Employment schemes and contact between the chest physicians and the local officers of the Ministry of Labour and employers are also of help. The examination of persons by mass miniature radiography plays its part in the early detection of disease. It is especially helpful when normal persons are examined—that is, those who do not suspect that they are otherwise than quite well and so would not in the ordinary way attend their doctors. Examination of such healthy groups leads to the recognition of the disease often in its early and therefore most readily curable stage. Work on these lines is limited by the number of appliances and by the numbers of persons trained in this work. It is necessary, then, to select for examination those groups who are most likely to give results. At present it is not profitable to attempt to undertake the examination of the entire population, and it is very doubtful if the results would ever warrant this procedure. Instead, attention is concentrated on those sections of the population which probably contain the highest proportion of sufferers. For this reason certain age groups and more especially those of these ages working at certain types of work are those whom it is most profitable to examine. Although it might be worth while carrying out the examination of school child contacts of a declared and recognised case, in general there is little point in examining children of school age as a routine practice. When in due course the school-leaving age is raised to 16 it might be worth while examining school-leavers as a routine. Today it is probably sufficient to encourage those of 15 or over attending school to attend the public sessions when the radiography unit visits the district. Although the unit is essentially part of the preventive service in that its purpose is the early detection of the disease, it is provided and administered as part of the hospital or essentially treatment service. 47 A development to which much publicity has recently been given is that of B.C.G. vaccination. For very many years much work has been done to try to make a preparation either of the tubercle bacillus itself, or of some of its products, which would help to increase resistance to infection or help those who have already succumbed to invasion to overcome the attack. In preparing vaccines from living organisms which are virulent, it is necessary to ensure that the preparation, while remaining capable of stimulating the processes involved in raising the resistance of the body does not, at the same time, injure the host. Some virulent organisms can be reduced to a non-virulent state by culturing in various ways. B.C.G. (Bacille Calmette Guerin) is a strain of the tubercle bacillus attenuated by years of artificial cultivation. This preparation has been used abroad for some 20 years. The tubercle bacillus is ubiquitous. Virtually everyone in a country such as this is exposed to infection. Although a small proportion succumb, the vast majority overcome the invasion. Some years afterwards though, stress and strain may lower the individual's resistance and enable the organism again to gain the upper hand. Infection of most members of the population is contracted probably not so much from the declared and recognised case, as from the undetected sufferer, though this, of course, does not apply to the home contacts of the declared case. As the vast majority of those invaded succeed in developing their own resistance, which enables the infection to be overcome, some hold that preparations, such as B.C.G. vaccine, need not be given to the general members of the community, but only to those who are the subject of special risk, such as the infant born in the tuberculous household who, if he remains there, will be exposed to massive infection before he has had an opportunity of building up any resistance. Another group is those attending tuberculous patients, such as nurses and medical students, more especially those who, having been brought up in the country, might not have been given the opportunity of developing a resistance by overcoming sub-infective doses. Although much work has been done on the use of B.C.G. in various paits of the world, work which has shown that it has a value, little has been done in the way of controlled trials. It is, however, only such trials that can demonstrate the exact value of the use of such a preparation and can determine which sections of the population can be expected to benefit from its use. Such trials are now being carried out in this country, the preparation being used for the contacts of open cases in the home and or nurses and medical students.