Public Health Dept. REPORTS COLLECTION COPY Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1951 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW KINO AND HUTCHINGS, LTD., PRINTERS, UXBRIDGE Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1951 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 8 General Health Services : Hospitals 16 Nursing Homes 16 Establishments for Massage and Special Treatment 17 Nursing, etc., in the Home 18 Day Nurseries 20 Clinics and Treatment Centres 20 Provision for Special Classes of Person 24 Ambulances 27 Laboratory Facilities 28 Sanitary Circumstances 29 Sanitary Inspection : Housing 34 Inspection and Supervision of Food 48 Infectious and Other Diseases : Prevention and Control 52 Tuberculosis 66 The Medical Officer of Health 72 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 1951. This last year has again been uneventful in that there were no special occurrences or outbreaks of serious import. As in previous years, the vital statistics are satisfactory. Even allowing for the fact that because so much of the district is of recent development the age constitution of the population is not that of the country as a whole, the death rate is appreciably below that for England and Wales. In general, too, the incidence of and the mortality from the various infections are below the average for the country. Although appreciably higher than last year's figure, the infant mortality rate is well below the average. These are the figures accepted as indices of health of a district or country, and on these bases the health of those in this district is better than that of those for the average of the country. These indices have been accepted as the recognised standards ; their validity for this purpose is, however, now being questioned. Although the high incidence of many of the grave infectious diseases which formerly invaded the country is now a thing of the past, there are some diseases which are becoming more common. These seem to have their origin not in bacteriological or other forms of life in polluted water, food or air, but in conditions of living. States such as duodenal ulcers or other psycho-neuroses are becoming more common and point to the state of health of the population declining rather than improving, as suggested by the older yardsticks. Other indices of social health or ill-health may be the fall in the birth-rate, the suicide rate, the incidence of juvenile delinquency, the industrial sickness rate, and the extent of industrial absenteeism. To-day's conditions, perhaps, favour such disturbances. The effects of the recent war in one way or another will last for a very long time, perhaps for the life-time of those who were children in those years ; while the effect of the war, the overcrowding of houses and the economic disturbances, will play their part for a long time, causing emotional disturbances and even bringing about organic diseases. Preventive medicine is faced with a very difficult task ; but yet, perhaps, not so vastly more difficult than the one which faced those concerned with such matters in the later years of the last century. Disturbances such as these which arrest the progress of development and even financial crises may not be wholly disadvantageous if they force those concerned to consider what is essential and what is not. The law of diminishing returns operates in many fields. It is most desirable that every child in every district should be immunised against diphtheria. These days a large response can be obtained by the expenditure of a reasonable amount of time, labour and money, a response sufficient to ensure that there is unlikely to be any serious outbreak in a district. Perhaps just the same sized effort is necessary to obtain the 6 protection of that much smaller additional proportion who need to be treated, to remove any real risk. But to attempt to see that every child was protected would call for an effort of much greater size and one which would be unwarrantable as it could be carried out only at the expense of effort on other lines. It might well be that standards are continually being pushed up to an unprofitable height. It must be very tempting for the orthodontist to aim to get the very best results, but perhaps he achieves the final improvement in some children only at the expense of other children who need his help. Notices under the Housing Acts can be served to call on the owner to do work which, were it not done, it could not be said that the health of the occupants of the house would necessarily suffer. It is times of financial stress that lead to the consideration of such matters as these calling for a reassessment to decide whether the right step is not a lowering of the standard of service provided, retaining what is necessary but eliminating what can be achieved only by the expenditure of disproportionate amounts of money or labour which in present circumstances can be done only at the expense of some other service or help. Whether what is being considered is the physical health of the population, or its mental health, which so often has its repercussions on the physical side of the body, there are certain fundamental standards. Of these, perhaps the most essential is a sufficiency of a sound dietary. Close in importance to this is housing, the securing for each family its own home in a house of sound hygienic standards. Even overcrowding may not matter if the one family is occupying the house. Overcrowding, though, is so often caused by the occupation of a house by more than one family. It is then possibly more damaging in its effects than low hygienic standards. It can only be with satisfactory housing standards that the family unit can again become the real important factor ; one which is necessary to bring about an improvement in to-day's lowered standards of morality or of living. Bad housing must be the cause of so very much of to-day's troubles in the country. It is now going on for four years since the National Health Service Act came into operation—a short enough time, particularly having regard to national and international difficulties and disturbances, for the full benefit of the change to have been achieved, but long enough for there to be a definite indication of whether these benefits really are to be brought about. In regard to Part III Services, especially those which were previously locally provided but are now the responsibility of the County Council, it does not seem that any progress has been made. There are still no signs that the County Council is likely to grant that measure of autonomy to the local Area Committee which alone can ensure that full benefit can be obtained from local knowledge and interest, and to that extent the services provided are likely to be less efficient than they would have been had they continued to be the responsibility of the Local Authority. This is not a fault of the general scheme, but probably it is merely a weakness of the working of the arrangements. It is natural that districts such as this which previously supplied what they were satisfied were adequate services, should have a different standard from those in some other areas where the standard of service just could not 7 be so high. For many of such districts the changes brought about by the Act would have resulted in a raising of the standard and therefore in an improved service. It is one of the weaknesses of the Act, that the position of such authorities as this, of larger population and greater financial resources than many a county borough, was not recognised. Unless something is done to recognise this position, then the populations of many of those larger districts are not likely to have the standard of service which otherwise they might have. The responsibility for providing a satisfactory environmental service remains with the local authority. Many of the personal services can best be administered by those with knowledge of local conditions. These, then, should be provided by local councils who should themselves employ the staff providing them. Those providing these services need to work in such close association that there is every advantage in their being members of the one staff. Since the first Medical Officer of Health was appointed over 100 years ago, the position of the Medical Officer of Health in the administration of the health services of a district has been recognised. Transference of powers from the district councils to the county councils led to a change in the status of the Medical Officer of Health in many districts, a change which might have serious effects on the recruitment of health officers. This subject is dealt with in a separate chapter at the end of the report. As to what might be done to improve what are now County Council services but which are supposed to be managed by local Area Committees, some see no hope of improvement except by legislation which will grant autonomy to the larger of these districts, or legislation which will permit full delegation of authority to be granted to local bodies. But such a conclusion can be arrived at only if it is accepted that the present arrangements cannot succeed. Such conclusions cannot really be reached until everything has been done to give the present arrangement a real opportunity of succeeding. For this to come about, it is not necessary to resort to formal agreements or to written formulae. All that is needed is a recognition by some that others who have had just as much experience as they have and who are, to say the least, not less interested than they are in their districts, can be trusted to administer delegated services. While this is all that is needed, this much at least is essential, because without that the Local Area Committees cannot possibly feel that they are responsible bodies and unless they can feel that, they cannot be expected to have the essential interest in the work of the body, with inevitable consequences. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, " Cottesmore," Uxbridge Road, Stanmore, Middx. May 28th. 1952. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,559 Registrar-General's estimate of resident population, mid-year 1951 220 000 Rateable Value (April 1st] 1951) £2,219,810 Sum represented by a penny rate (April 1st, 1951) £8,978 Total number of occupied houses 53,613 Total number of occupied flats 7,941 Extracts from Vital Statistics for the Year. Live Births :— Total Male Female Legitimate 2,793 1,454 1,339 Birth rate per 1,000 Illegitimate 102 51 51 population, 13-1 Total 2,895 1,505 1,390 Stillbirths :— Legitimate 70 36 34 Rate per 1,000 total Illegitimate 1 1 — births, 2-4 Deaths 2,094 1,022 1,072 Death rate per 1,000 population, 9-5 Rate per 1,000 Deaths total births Deaths from pregnancy, childbirth 3 1.0 Death rate of Infants under one year of age :— All infants per 1,000 live births 22.1 Legitimate infants 21.8 Illegitimate infants 29.4 Deaths from Cancer 389 „ „ Measles 1 „ „ Whooping cough 2 „ „ Tuberculosis 48 Population. The mid-year population of the district was 220,000, a decrease of 2,300 on the mid-year population for 1950. The natural increase in population, i.e., the excess of births over deaths during the year, was 801. Births. The total number of live births registered during the year was 2,895 (1,505 male and 1,390 female). Of these, 102 were illegitimate, being a percentage of total births of 3.5. 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, 2,848, and 2,895. 9 1,279 births occurred in the district (1,258 live- and 21 stillbirths). Of this number 222 were to residents of other districts, 1,786 (1,738 live and 48 still) birth notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in hospitals in Middlesex or in London. Deaths. 1,675 persons died in this district in 1951. Of these 194 were persons who were not resident in the area. 40 deaths took place in the various hospitals, including Roxbourne Hospital ; 58 in private nursing homes and 12 in Oxhey Grove. Of the 785 deaths of the local residents which occurred outside the district, most took place in institutions, 330 being at the Edgware General Hospital and 36 at other hospitals in the County. 14 deaths occurred in institutions for the treatment of those suffering from tuberculosis, and 2 new-born infants died at maternity hospitals. 134 deaths took place in hospitals just outside the district including 7 in nearby isolation hosnitals. and 130 in various London hosDitals. 1 he following is the Kegistrar-Ueneral s abridged list of causes of death in this district :— Male Female Male Female Resp. tuberculosis 25 16 Other heart diseases 116 217 Other tuberculosis 4 3 Influenza 26 14 Syphilitic disease 3 1 Pneumonia 45 51 Diphtheria 0 0 Bronchitis 86 49 Whooping Cough 0 2 Other respiratory dis eases 3 6 Meningococcal infections 1 0 Peptic ulcer 11 9 Acute poliomyelitis 0 0 Gastritis, enteritis 3 4 Measles 0 1 Nephritis 6 8 Other infective diseases 1 4 Hyperplasia of pros tate 24 0 Cancer of stomach 29 20 Pregnancy, etc. 0 3 Cancer of lung 69 12 Congenital malforma tion 12 9 Cancer of breast 0 55 Cancer of uterus 0 17 Other diseases 74 102 Cancer of other sites 92 95 Motor vehicle accidents 13 4 Leukaemia 4 8 Diabetes 5 10 Other accidents 16 12 Vascular diseases of nervous system 86 150 Suicide 10 8 Homicide 1 0 Coronary disease 182 99 Hypertension 35 37 Other circulatory diseases 40 46 Total ,022 1,072 The number of deaths, 2,094, is higher than the 1,999 of 1950, which was the largest number of deaths in this district in any one year. The death rate is 9.5 per thousand population. The rates for the district for the years 1944 onwards were 9.3, 9.0, 8.6, 8.5, and 8.9. 10 The rate for the country as a whole was 12.5. The lower local rate would seem to point to the district's being more healthy than the country as a whole. But because the old are more likely to die than the young and because women survive longer than men, death rates are affected by the age and sex constitution of the population. The effect of these changes can be discounted by allowing for the extent to which the composition of the local population differs from that of the country as a whole. To indicate this, the Registrar-General prepares a comparative mortality index which when used to multiply the death rate gives a figure which would be the death rate for the district were the population of the same age and sex constitution as that of the country. The figure for this district is 1.16. Applied to the local death rate gives an adjusted death rate of 11.0. This again is below the national rate and indicates that the conditions of this district do, in fact, make for longer living of the population, and that therefore the district is healthier than the average of the country. Of the 2,094 deaths, 1,022 were males and 1,072 were of females. 58 per cent, of the males who died had attained the age of 65 and 70 of the females. These are much the same figures as last year, namely, 55 per cent, for males and 70 per cent, for females. Infant Mortality. The infant mortality rate is one of the vital statistics of special interest because it has for long been accepted as an index of the healthiness of the community, being influenced by so many of the factors which affect the health of the population. The dramatic fall in the rate in the present century was mostly in the deaths which previously occurred in infants who had survived one month. The greater the fall in these deaths, the greater the proportion the deaths are now due to factors associated with the pregnancy of the mother or with factors related to the confinement. To that extent, then, once the rate has fallen to low figures (although it cannot do this if environmental factors are bad) it can no longer act in the same way as an indicator of these conditions. The greater the proportion the neo-natal deaths (that is, those among infants who have not reached the age of one month) bear to the rest, the more the rate points to the importance of factors relating to pregnancy or labour than to environmental conditions. Last year 62 infants died under one year of age. In the same year 2,895 infants were born. The infant mortality rate, therefore, was 22.1. In 1950, only 39 infants in this district died before reaching the age of one year, the infant mortality rate being the exceedingly low one of 13.6. Up to this, the previously lowest rate for the district was 20.7 in 1949, which itself was a marked fall on the previous record of 24.0 in 1947. That this last year's figure was not as low as that for the previous year is not a matter for surprise as the rate for 1950 was quite unexpected in that it was so much lower than anything which had been previously experienced locally. Sharp rises can be expected when conditions are exceptionally adverse. For instance, an especially hard winter might lead to many deaths, just as an outbreak of an infection such as influenza 11 might. But 1951 did not bring anything of that sort. For the country as a whole, the infant mortality rate was 29.6, a figure not so very different from that of 29.8 for 1950 when the local rate was 13.6. It may be that in a few years time the low rate of 1950 and the relatively high rate of 1951 can be seen to average out at an annual rate of about 20. The vital statistics for small populations are subject to disturbances of this sort from year to year, when the maternal mortality rate can be markedly affected by the occurrence of one death. It may be that these variations in the numbers of infant deaths and in the infant mortality rates will prove to be due to effects of this nature. Certainly there is nothing known of any changes in local conditions or of those occurring in the country as a whole which can account for this marked difference in the numbers of infant deaths in two consecutive vears. The following table is an analysis of the causes of deaths of infants at different ages for the years 1950 and 1951 :— Number Birth Injury Prematurity Congenital Causes Lung Infection Other Conditions Under 1 day 1950 10 3 4 3 — — 1951 22 4 13 4 1 — 1-7 days 1950 16 1 9 4 2 — 1951 21 1 13 2 4 1 1-4 weeks 1950 1 — _ 1 — — 1951 5 1 1 _ 1 2 1-3 months 1950 6 — 1 1 3 1 1951 2 — _ 1 1 — 3-12 months 1950 6 — — — 5 1 1951 14 — — 5 5 4 Included in the column headed prematurity are those who died from immaturity or from atelectasis. Congenital causes include such conditions as hæmolytic diseases. The group of other conditions includes deaths from infections and from accidents. It will be seen that the large increase in the 1951 figures over those of 1950 was in the deaths of those under 24 hours old and in those who had survived three months. Of the increase in the numbers of those who failed to survive 24 hours, the big increase was in the number of those where death was due to atelectasis. Most of these deaths in 1951 occurred among infants who had been born in hospital, where as far as is known, no change in practice had been made. These figures, then, do not suggest that these deaths could have been prevented by any improvement in the local arrangements for the care of such infants born at home. Of the increase in the numbers of those who died between 3 and 12 months of age, many were due to deaths from congenital causes. The rest were under the heading of other conditions ; of these, two were whooping cough and two were accidents. Stillbirths. Some infants die very soon after they are born. The numbers of these increase the infant mortality rate and the general death rate. 12 Sometimes the death occurs just before and not after delivery ; this is then classed as a stillbirth, not as an infant death. But the loss is the same. So, too, is it if it occurs even earlier ; and these losses of potential members of the population whether occurring in the later months of pregnancy being then known as stillbirths or occurring in the earlier months, being called abortions, are just as important as those occurring in the infants who were born alive. Little is known of the factors which bring about early termination of pregnancy, so that little can be done to prevent this. Some studies suggest that one factor of importance is an adequate diet of the mother. Some stillbirths are, of course, the result of errors in development of the growing foetus which results in its being not viable. Then there are those deaths that occur during a labour which takes place at full term. Here the important factor is the standard of obstetrical practice amongst those attending the mother. In this district the stillbirth rates have been consistently low. 71 stillbirths were registered in this last year, yielding a rate per thousand population of 0.32, a rate higher than previous ones, but still below that of 0.36 for the country as a whole. Deaths of Infants 1 to 5 Years of Age. The child who survives the first year of life enters a period when the probability of dying is very small. Some survive their first birthday in spite of suffering from congenital abnormalities which then become responsible for or contribute to death. Weaker children, especially in the earlier years, might succumb to infections which older children can throw off. Accidents, too, early start to exert their toll. Ten children survived their first but did not reach their fifth birthday. Of these, five died in their second year. Two suffered from congenital abnormalities ; one from a developmental condition ; one from an accident, and one from pneumonia. Of the two children of 3 years of age who died, one suffered from congenital defects ; the death of the other was the result of an accident. Of the three who died having reached their fourth birthdays, two died from infections and one from the result of congenital abnormalities. Maternal Mortality. The total maternal mortality rate includes all deaths of women primarily due to or associated with pregnancy or childbirth expressed as a rate per thousand live- and stillbirths registered in the year. The rate up to comparatively recently used to be about 4 per thousand ; for some years now the figure has been nearer one. There were in this last year three deaths the result of pregnancy or delivery. The maternal mortality rate therefore was 1.0. One death was the result of a self-induced abortion ; another the result of an abortion brought about by someone else. The remaining fatality was that of a woman who had had a normal delivery at home, retention of the placenta resulting in hæmorrhage and shock. She was removed to hospital but died within the hour. 13 Deaths from Accidents. There were 45 deaths (29 male and 16 female) from violent causes during the year. Of these, 22 (17 male and 5 female) were the result of road traffic accidents. 15 of these occurred elsewhere than in this district. In most of these a motor vehicle was involved. The victim was in the vehicle in 2 instances, was a cyclist in 9, and a pedestrian in one. There were seven fatal road accidents in the district. Three of those killed were non-residents. In every case a motor vehicle was involved in the accident. Four of the victims were pedestrians, one was the rider of a pedal-cycle, and two were in the vehicles. Falls of the elderly accounted for 10 (4 male and 6 female) deaths. Many of these were the result of a fall or a trip which resulted in a broken leg, death resulting from the subsequent hypostatic pneumonia. In many cases the tall occurred at home. Poisoning by coal gas was responsible for the deaths of 7 (4 male and 3 female). In at least some of the cases it would appear that the death was accidental. All but one of these persons was over 79 years of age. Many elderly persons are living at home with only limited attention, so that accidents of this sort are very liable to occur, as are also those which caused the death of two persons of over 70 years of age by burns. Deaths from Suicide. Ten men and eight women committed suicide. Five of the men and four of the women chose poisoning by coal gas. In most years the incidence has been fairly even throughout the year. In this year, however, ten of the events occurred in the four months May to August. All but one of the remainder occurred in the first three months of the year. The age distribution was unusual. Whereas all the females were between 40 and 70, only one of the males was of this age, five of the males being under 40 and three over 70. Deaths from Cancer. Of the 2,094 deaths of residents in this district, 389 were due to cancer, this causing 18 per cent, of the deaths of males and 18 per cent, of females. Of the 190 deaths from this cause amongst males, in 69 the site was the lung, and in 29 the stomach. Of the 199 deaths amongst females, the site was the breast in 55, in 20 the stomach, in 12 the lung, and the uterus in 17. Although one type of malignant disease attacks the young, in general cancer attacks most heavily those of more advanced years, but not the very old. There is a period when a very large proportion of the deaths is due to cancer ; but once that stage has passed, cancer as a cause of death is overshadowed by other factors. Of the males resident in the district who died last year, malignant disease caused the death of only one under the age of 35. In the successive ten-year periods, cancer caused the death of eight out of 38 who died between the ages of 35 to 44 (percentage 21), and 29 out of 102 who died between 45 and 54 (percentage 28). In the next age group 55 to 64, there was a further rise namely, 61 deaths out of 186 (percentage 33). This was followed by a fall, 51 out of 244 14 (percentage 21) in the age group 65 to 74 ; then to a much lower figure, 27 out of 306 (percentage of 9) in those over 75. The picture of the distribution of the deaths of females is rather different. In the first place, cancer caused 13 of the 33 deaths of those between the ages of 35 and 44 (a percentage of 39). In the next group 45 to 54, out of 95 deaths, 35 were due to cancer (a percentage of 37). Of those aged 55 to 64, 47 out of the 134 deaths were the result of cancer (percentage 35). Then there was a fall to a percentage of 18, as only 47 of the 248 deaths in the group 65 to 74 were due to it, and a further fall in those over 75 in whom malignant disease accounted for only 50 out of the 460 deaths (a percentage of 11). In this district in this last year, then, the percentage of deaths in males due to cancer was highest in the age group 55 to 64, there being a fall in the later age groups. In females, the proportion was highest in the age group 35 to 44, almost as high in the next two groups 45 to 54, and 55 to 64, and it then fell as in the case of males. The question of what might be done to reduce the fatalities from cancer has been much discussed. On the one hand there is the problem of ensuring that patients suffering from the complaint receive treatment early, sufficiently early for the treatment to be effective. Two factors are important. One is the education of the public as to the signs and symptoms which may be indicative of this complaint in the early stages. The other is the allaying of the fear that so many have about the inevitability of a fatal issue and of the hopelessness of anything being done. On the other hand, it is desirable that whatever is done should not result in the creation of a general feeling of apprehension amongst the population. It is this second factor which makes it so important that care should be taken about the approach to the public on this subject. When consideration is being given to the question of what might be done there are many factors to be taken into account. When malignant disease attacks some sites, there may be no early typical signs or symptoms, nothing being noticed sufficiently early to lead to the recognition of the disease in a curable state of development. Then, too, so little can be done when certain organs are attacked. In any approach to the public, it is probably best if emphasis were laid on the disease in those organs which give rise to typical signs or symptoms and in those in which treatment at an early stage offers real hope of recovery. Possibly the organs which most adequately fulfil both these requirements are the breast and the uterus. Last year, 52 women in this district died from cancer of the breast ; 8 of these were under 45 years of age. In many of them, it is certain that some abnormality of the breast was recognised long enough before they consulted their doctors. Many fear to go to their doctors just because they fear the diagnosis. The numbers of these could be reduced if they could be reassured by learning of the success of surgery when treatment is carried out in the early stages. Cancer of the lung, either of the lung itself or of the bronchus again accounted for many deaths, 81 in all (69 male and 12 female). While deaths from cancer of most sites are no longer increasing, the incidence of cancer of the lung mounts steadily. As yet, it is not known what factor is responsible for this. 15 Deaths from Infectious Diseases. Infections other than tuberculosis accounted for few deaths in this last year, there being two from pertussis, one from meningitis, one from measles, and 40 from influenza. Tuberculosis accounted for 48 deaths, disease from the lung being responsible for 41. The death rates per thousand population from the various infections compared favourably with those of the country as a whole. 16 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. At these hospitals and Oxhey Grove the Regional Hospital Board provides accommodation for the chronic sick. 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 now being removed to hospital for treatment. 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 by arrangement made by the local health authority. Applications for the admission of patients are made by the general medical practitioners or by hospital almoners to the Area Medical Officer. NURSING HOMES Any person who carries on a Nursing Home in this district needs to be registered. The responsibility for the registration and supervision 17 of these homes rests with the Health Committee of the County Council. This is not one of the services managed by the local Area Committee. There have over the years been many nursing homes of different sorts in this district, some for the reception of as many as 20 patients, others receiving only the one patient. Some accept only maternity patients, others only mental patients. Before the recent war, there were here many homes which accepted two or three elderly persons. The war brought about many changes and the National Health Service Act many more. There is now a much smaller demand for beds in such institutions, especially maternity beds. On the other hand, the need for suitable places which can accept the elderly person who so readily becomes a patient has markedly increased. These alterations in demand have had their effect in bringing about a change in the number of homes and in the allocation of the beds available. At the beginning of the year there were 20 homes, with 226 beds, of which 71 were for maternity cases. At the end of the year, 17 homes were registered ; these provided 196 beds, of which 29 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 and 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. The licence is issued in regard to the premises. Before approving the registration of any premises, then, the committee requires to be satisfied about its general suitability for the work done in it, and about the equipment. Those in whose names the premises are licensed have to comply with the terms of the bye-laws relating to the exhibition of the certificate of registration, the scale of charges, etc. The Authority may refuse to grant or renew a licence, or may revoke a licence granted to any person because the person is under the age of 21 years, because the person is considered unsuitable to hold the licence or in respect of any establishment in which massage or special treatment is or may be administered by any person who does not possess such treatment qualifications as may be reasonably necessary. Power is also given to the local authority to make bye-laws prescribing the technical qualifications to be possessed by any person who administers massage or special treatment at any licensed establishment. The Council applied to be allowed to make a bye-law prescribing minimum standards of qualification of the practitioners at licensed premises. The request, however, was not granted. The question of what qualification or standard of training those practising at licensed establishments should possess, therefore, remains unsettled. That members of the Chartered Society of Physiotherapy are exempted from certain provisions suggests that membership of that Society as a minimum qualification cannot be insisted on ; and yet it would be most invidious for an authority to have to determine that some qualifications or periods of training are acceptable, B 18 but others not, while again there are many practitioners whose previous experience in other fields enables them to give most helpful services, although they possess no academic qualifications. A committee set up to consider the supply and demand, training and qualifications of certain medical auxiliaries in the National Health Service reported last year. The Committee considered the training of medical auxiliaries who were defined as persons who assist medical practitioners in the investigation and treatment of disease by virtue of some special skill acquired through a recognised course of training. The committee was concerned about what training or qualifications should be possessed by those medical auxiliaries who were to be employed in the National Health Service, that is to say they were concerned about persons who would be working under the direct or indirect supervision of a doctor. For these the Committee recommended certain minimum periods of training at recognised places and the obtaining of the appropriate qualification after training. That these recommendations should be made in respect of such persons working under these conditions points to the desirability of the training and qualifications of those working on their own and not under medical supervision at licensed premises being no less. The committee, of course, was considering the matter from the point of view of the employers of these auxiliaries. The Council is not in the same position as it does not employ those in whose names the establishments are licensed, nor are they responsible for the work carried out. Nevertheless, that those licensed can, and of course do, make a point of drawing attention to the fact that the premises are licensed by the local authority, will suggest to prospective patients that the Council is satisfied about all that is done there. To that extent the present position of inability of the authority to lay down specified training or possession of certain qualifications is unsatisfactory. As anyone aggrieved has a right of appeal to the Court of Summary Jurisdiction an authority which decides that certain standards of qualification or training must be possessed by those treating persons at these premises, must have regard to the views on the matter of those who would be hearing the appeal. At the end of the year 24 premises were licensed. In addition, certificates were lodged by registered members of the Chartered Society of Physiotherapy in respect of six premises. NURSING, MIDWIFERY, ETC., IN THE HOME 1. General Nursing. Nursing of patients in their homes was formerly carried out by the staff of a number of voluntary nursing associations. Of these, the largest in this district was the Greater Harrow District Nursing Association. The staff lived at and worked from two Homes in the district and met the needs of most of the area. The Home Nursing Service as provided by the County Council which assumed responsibility for it in July, 1948, continued on much the same lines in the earlier days. Later, one of the local associations was disbanded, and the staff of those associations housed outside the district but some of whom had worked in this area withdrew that help. For some time, then, the service was provided by the staff 19 of the former Harrow Nursing Association, supplemented by the work of new staff recruited either part-time or whole-time, most of them living in their own homes. In addition, there was one of the two remaining nurses of the former Pinner and Hatch End Nursing Association. For some time after resuming responsibility for this service, the County Council was not able to recruit additional staff who wished to live in. Neither of the two Nurses' Homes then was full. The County Council then decided that the Bessborough Road Nurses' Home should be closed ; this step was taken on 31st August, 1951. Since that time, the service has been mainained by staff, some living at the home at 93, Uppingham Avenue, Stanmore (Superintendent, Miss J. L. Dodds. Tel. No. Wordsworth 2538) ; some part-time nurses who work mostly in the mornings, and who are based on the Home, and some whole-time nurses who live in their own homes and who work their own areas. In addition there are two whole-time male nurses whose work is selective. It has not up to this been possible to recruit to establishment. Even if it were, the service could meet only part of the demand, as it would need many more nurses to enable a 24-hour service to be provided. As it is, there are many persons who are being looked after at home who cannot be adequately helped. Some are suffering from chronic conditions from which some are not to recover. Their great need is for some attention at a particular time ; but no nursing service can guarantee that. The help that is needed by so many of these is something which can be given by someone less skilled than a trained nurse. The only other member of the staff of the Health Department who might be able to help is a Home Help. But just as what is required falls short of what a nurse is needed for, so it is something which is beyond the range of what a Home Help could be expected or be permitted to do. Members of the voluntary associations with their training and experience could do this work, but with to-day's changed conditions they are not available for such work in the way they used to be. 2. Midwifery and Maternity Nursing. The County Council as the local authority is responsible for the domiciliary midwifery service of the district. At one time, there were 17 midwives on the health staff. The fall in the number of births and the higher proportion of confinements which take place in hospitals have reduced the number of home confinements to be attended by these midwives, so that now not so many are necessary. At the end of the year, the staff was 16 midwives living in various parts of the district, who work under the supervision of the Non-medical Supervisor of Midwives and the Senior Midwife, Mrs. Bromley, of 213, Exeter Road, South Harrow (Tel. No. Pinner 5752). 3. Home Helps. The County Council, as local health authority, provides domestic helps 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. Helps are engaged full-time or part-time. They are paid by the 20 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. 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). 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 are admitted. They are 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 over two but under five years of age are also admitted to one of the three nursery schools maintained by the Education Authority, " Tyneholme," Rayners Lane, and Buckingham Road ; and older children 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. 21 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. Greenwood Hall, Rickmansworth Road, Pinner Wed. p.m. Ante-Natal Clinics. Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. Baptist Church Hall, Streatfield Road, Kenton Fri. p.m. 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. a.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 1 ,,, , Baptist Church Hall, Streatfield Road, Kenton J Alternate Thu. a.m. 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, Edgware Thu. a.m. 22 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 be seen. 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. 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. For many years the County Council has maintained a Child Guidance Clinic at No. 2, St. John's Road, under the administrative control of the full-time psychiatrist, Dr. Margaret Saul, who is aided by such other members of the team as psychologists and psychiatric social workers. Those working at the clinic were a balanced team, the time of the members being largely taken up with dealing with the patients under the care of Dr. Saul. The psychologist has an important role in the education service. Not only can he be of help in such purely educational fields as ensuring that the child is put into the way of obtaining the type of education for 23 which he is best suited, but he can help those children who without such assistance might reach the stage of needing treatment which only the psychiatrist can give. In this range of activities, the psychiatrist who is dealing with only the maladjusted child or with the child who without help would become maladjusted, deals with a relatively small part of the school population. In many places, then, it might well be that the attendance of the psychiatrist is necessary only two or three sessions a week as contrasted with the full-time service of certain members of the staff including the psychologist. In such an organisation, then, the educational side might far outweigh the clinical side as conducted by the psychiatrist. In such circumstances, there is every justification for the name of the service being changed to indicate the altered emphasis and for it to be known as a child guidance centre rather than a child guidance clinic. This, however, is not the position here. The service that was being provided was essentially a medical one, given by the psychiatrist and the team working with her. Quite apart from any educational work, which could be carried out by the psychologist at the clinic or by any others who might be appointed there, there has been more than sufficient medical work being carried out at No. 2, St. John's Road, to have warranted the organisation being continued as a child guidance clinic under the psychiatrist. There is, of course, room for the extra range of activities of the psychologists in the schools and there is every advantage in the closest co-operation between them and other workers in this field. But there is not the physical room at the building for it to be the headquarters of the larger number of workers who would need to be appointed if so much of this other work were to be done there that the psychiatric work would be swamped to such an extent as to warrant the organisation being known as a child guidance centre. In spite, then, of the altered title, No. 2, St. John's Road, is essentially still a child guidance clinic, and as such should be under the administrative control of the whole-time psychiatrist. Speech Clinic. The Speech Clinic formerly maintained at No. 2, St. John's Road, was transferred during the year to the Marlborough Hill Clinic. Those attending are nearly all school children referred to Miss Clayton, the Speech Therapist, either by the school medical officers or by the head teachers. 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. 24 Apart from the sessions when the dental officers are examining children in the schools, treatment sessions are held every week-day, morning and afternoon. The school children treated there are those found as the result of routine dental inspection of children at the schools to need treatment. The only ones who can attend without a previous appointment are those who are referred by the head teachers of the schools, the children attending under the arrangements made for the urgent or emergency treatment of those needing such attention for some cause such as toothache. Most of the children under five and the expectant and the nursing mothers are referred by the medical officers at the clinics which they have attended. The Health Authority dental service is, however, available to ante-natal mothers who do not attend the local clinics, but who are referred for treatment by the medical practitioners under whose care they are, appointments being made through the Area Office. Physio-Therapy Treatment. The Harrow Hospital maintains a physical treatment centre at the Car Park Building, Station Road, Harrow (Tel. No. Harrow 0926). The medical director, Dr. G. 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 199, Station Road, Harrow, the 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.I. (Tel. No. Trafalgar 7799). In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at the County Council's Children's Care Office, 48, Station Road, Harrow (Tel. No. Harrow 2963). 25 Mental Health Service. 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, Mr. W. Bullwinkle and Mr. E. M. Jayne, of 48, Station Road, Harrow (Tel. No. Harrow 5600). Persons in need of Care and Attention. It is the responsibility of the Hospital Boards to provide residential accommodation for those persons needing the special medical or nursing care which can be provided only in hospitals or similar institutions. On the other hand, the National Assistance Act makes it the duty of the County Council to provide 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. For administrative purposes, the County is divided into the same ten areas as for the County Council functions under Part III of the National Health Service Act. Acting under the supervision of the Chief Welfare Officer for the County there is a Welfare Officer in each area ; the one for this district is Mr. H. G. Plummer, 48, Station Road, Harrow (Tel. No. Harrow 1252). To provide the necessary accommodation the County Council has taken over a number of large houses such as Oxhey Grove in this district. In addition, persons are accepted at such places as Redhill House. The accommodation, however, falls very short of what is needed. The boundary dividing the person falling into the one group from those in the other is very indefinite, more particularly in the case of the aged and some persons might well at one stage fall to be dealt with by the County Council Service, temporarily to need the services provided by the Hospital Board and then later again to need only the services of the Welfare Authority. Neither Authority has anything like the accommodation necessary to meet the demands, so that many persons are in their homes to their own disadvantage and in many cases with real inconvenience and even hardship to the relatives of those who need the services which can adequately be provided for them only in an institution. A very real problem faces the hospital administrator. The shortage of hospital beds is forcing consideration to be given to the question of whether the best use is being made of what beds are available. This can be determined only when agreement has been reached on what are the main uses to which these beds should be put. In the past, patients were freely admitted to hospitals for investigation and for observation, and were retained there without regard to the fact that, while admission to the hospital was necessary to enable certain investigations to be carried out, many of the tests and examinations could have been carried out on those attending as out-patients. Convalescence after an operation was extended, the patient remaining in hospital. To-day, arrangements exist by which 26 persons recovering from an acute illness or operation can be admitted to a convalescent home, so shortening the average length of stay of patients in hospitals and so leading to a greater turnover of hospital beds. Many were admitted to hospital not because it would be only in a hospital that such a person could obtain the necessary medical or nursing attention! but because that patient could not in his own home receive the attention he needed. In these days it is less likely than previously to be because he cannot receive the services of a doctor or of a nurse, but might well be because of the unsatisfactoriness of the home conditions. The extent to which hospitals can be relieved of demands on their beds, occasioned by difficulties which would follow from the patient being nursed at home, depends partly on the efficiency of some of the Part III services provided by the County Council. Unfortunately, in this district it is proving impossible to recruit up to full establishment Home Nurses or Home Helps. Even were the recognised numbers of these staffs engaged, there would still be difficulties arising from the fact that the patient needs attention at times the Home Nurse is not available, while many of those at home need the help of someone less skilled than a nurse but help which would be outside the range of activities of a Home Help. There is room for an extension of these services which can be provided in the sufferer's home which would avoid the necessity of admission of the patient to hospital where, if admitted, he would be occupying a bed which would then not be available for the admission of those suffering from acute conditions needing only short-term attention. The chronic patient occupying a bed for twelve months might, by blocking that bed, have caused difficulties in the reception at hospital of twenty other persons, persons too who could be helped only by the services available in hospital as contrasted with the needs of the one chronic patient whose needs so often could be met by help elsewhere than in a general hospital. It is this question of the chronic patient, especially the chronic elderly patient, which is causing such concern to the hospital administrator. They cannot be admitted to hospital on such a scale as would result in the virtual withdrawal of the general hospital's facilities for those in the district suffering from acute conditions. On the other hand, they all cannot be ruled out of consideration, partly because ultimately many will progress to reach the stage that they should not be nursed at home, partly because of the severity of the burden imposed on those running the home in which they are. It might be that a working arrangement will be the allocation of a number of beds for the short-term admission of this type of sufferer which would both enable the condition of the patient to be improved and also give the attendants at home a much-needed rest. If, as seems to be inevitable, many of these persons have to spend their days at home, there is much room for voluntary effort, especially as " sitters-in," to free for some time those running the home. But in many households because those at home cannot attend to the patient either because of their own infirmity, or because they have to leave home to earn their living, it would seem that it will be necessary to recruit someone, a paid worker, not a volunteer who is less trained than the nurse, who could be a " sitter-in " and who could attend to the needs of the patient. Until someone of this sort can be 27 found to supplement the services of the Home Nurses and Home Helps provided by the County Council, it would seem that there will continue to be the demand on hospital beds by those who strictly do not need this provision, and whose admission to hospital can only lead to an impairment of the general hospital services available to those in the district. Apart from the powers possessed by the hospital boards or by the local health authorities to help persons in need of care and attention, the local sanitary authority has been given powers to deal with those persons who, because they cannot look after themselves, are causing injury or nuisance to those living near. These powers are contained in Section 47 of the National Assistance Act, 1948, which sets out the arrangements for the removal to suitable premises of persons who (a) are suffering from grave chronic disease, or being aged, infirm or physically incapacitated, are living in insanitary conditions, and (b) are unable to devote to themselves and are not receiving from other persons proper care and attention. Both conditions must be satisfied before this section is applicable. The procedure to be followed is set out in further clauses of the section, namely, if the Medical Officer of Health certifies in writing to the Authority that he is satisfied that in the interests of such person residing in the area of the Authority, or for preventing injury to the health of or serious nuisance to other persons, it is necessary to remove such person from the premises in which he is residing, the Authority may apply to a Court of Summary Jurisdiction for an Order. The Court if satisfied may order the removal of the person by an officer of the Authority to a suitable hospital or other place in or near the area of the Authority. But before the Order is made, the person managing the premises must be heard, or have been given seven days' notice of the intended application. Any Order made would be applicable for three months and the Court could extend the period. Up to this, no action has been taken in this district under the powers given by this section. In some districts in which these powers have been used it has been found that the machinery is cumbersome. The 1951 Amendment Act aims at dealing more expeditiously with the cases which Section 47 of the 1948 Act were intended to deal. Under the new procedure, if the Medical Officer of Health and another registered medical practitioner certifies that it is necessary that a person shall be removed without delay from the place he is living in, an application for a Removal Order may be made to the Court or to a single justice without the necessity of giving notice to the person whose removal is desired, or to the person in charge of him ; nor is it necessary that notice shall be given to the person in charge of the premises to which it is proposed to removed the person providing that the applicant can show that that person is willing to receive into the establishment the person in need of care and attention. An Order made under this machinery is valid for three weeks only ; any application for the extension of an Order made under this arrangement has to be made under Section 47 of the 1948 Act. AMBULANCE SERVICE The ambulance service maintained by the County Council is run in association with the fire service. 28 Ambulances for the removal of accident cases are housed in or adjacent to Fire Stations (Tel. Nos. Harrow, Pinner, Byron, Wordsworth, Grimsdyke, Underhill 2222) ; those for sick persons are to be placed as close as possible to main hospitals, including the isolation hospitals. LABORATORY SERVICE The examination of clinical material of public health significance is carried out free of cost to the patient and to the doctor at the Central Public Health Laboratory, Colindale Avenue, London, N.W.9 (Tel. No. Colindale 6041 and 4081). Most samples submitted are throat swabs for the presence of organisms of diphtheria or of the hæmolytic streptococcus. Another group of samples is of dejecta for the presence of organisms of the typhoid or dysentery group. Specimens of sputa are submitted for examination for the presence of tubercle bacillus. Blood serum is sent for examination of the reaction indicating the infection of the body by the typhoid group. Cough plates are examined for the presence of the organisms of whooping cough. In general the examination is carried out of material which will be of aid in the early diagnosis of infectious conditions, one purpose of the laboratory being to carry out investigations of public health significance. It is not intended that other clinical material shall be sent, this work being carried out at the laboratories of certain hospitals. The laboratory does not deal in the ordinary way with the examination of specimens of those suspected to be suffering from venereal disease, which are sent to hospitals which provide clinics for the treatment of those suffering from these diseases. Apart from the examination of this clinical material, the laboratory also carries out the routine bacteriological examination of such foods as milk or ice-cream, and examines other food stuffs considered possibly to have been the source of a food poisoning. The staff of the laborarory also carry out investigations in the field in the case of various forms of outbreak, however spread. Another service provided by the laboratory is the issue of certain preparations, such as lymph for vaccination against smallpox, and antigens for the immunisation of the population against diphtheria. The clinical material is collected each day by a van sent from the laboratory calling about mid-day at the Harrow Hospital, the Public Health Office, " Cottesmore," and the Central Fire Station, Pinner. The following is a summary of the examinations of material from this district, carried out during the year : nose and throat swabs, 309 ; faeces, 37 ; sputum, 21 ; pertussis, 9 ; milk, 36 ; ice-cream, 117 ; and water, 4 ; miscellaneous, 53. 29 SANITARY CIRCUMSTANCES OF THE AREA WATER Details of the water supply for the district and of the steps taken to ensure that the water supply is safe were set out in the Annual Report for the year 1948. The results of the analyses of samples taken throughout the year were all satisfactory. No complaints were received during the year about the quality or the quantity of the water supply. DRAINAGE AND SEWAGE DISPOSAL Particulars of the local arrangements were set out in the Annual Report for 1948. PUBLIC CLEANSING Refuse Collection. The same arrangements continued in force for the collection of house refuse. Complaints still come in about the state of some of the kitchen waste bins. It is hoped that the benefits which result from the collection of this material are sufficient to warrant these arrangements being made and to offset the nuisances to which some residents are subjected. Refuse Disposal. These days, none of the house refuse collected in this district is disposed of here, all being taken outside of the district to be tipped. Street Cleansing. The same general arrangements are made for the cleansing of the streets of the district. DISPOSAL OF THE DEAD Burial Grounds. Particulars of these were included in the Annual Report for 1948. Cremation. It is hoped that the Council will decide to provide and maintain a crematorium. The objections to this method of disposing of the dead seem to be diminishing and a steadily increasing number of bodies are disposed of each year by these means. An authority with Harrow's population and financial resources ought to be able to provide this service, not only for those in this district, but for those in neighbouring areas. Districts such as this, with only limited land now free for any purpose, ought to take such steps as they can to ensure that the land required for burial grounds is not obtained out of that which otherwise would be put to health-giving purposes. 30 Burial. Under Section 50 of the National Assistance Act, 1948, the Council can arrange for the burial or cremation of any person who has died or who has been found dead in their area, if no other suitable arrangements have been are are being made. Each year there has been a small number of requests for these arrangements to be made. In this last year arrangements were made for four burials. In some cases, sums of money are recovered from the relatives out of the estates of the deceased. It is probable that in time the requests for these arrangements to be made by local authorities will diminish, as fewer will die for whom contributions to the burial expenses, obtained under the National Insurance Act, will not be available. Mortuary. The number of admissions to the mortuary fluctuates in the course of the year, being heaviest in some of the winter months when deaths are most frequent. The facilities available at the mortuary have at times proved insufficient. The Council therefore agreed to these being increased. During the year, then, the mortuary was enlarged so that it now has four slabs and is now provided with two refrigerator chambers capable of receiving six bodies. During the year, 231 bodies were received in the mortuary. Postmortem examinations were carried out on 229 and inquests were held on 33. This year only two bodies were admitted for storage. This marked fall on the demand on previous years, for instance, 59 in 1950, is because the local undertakers are providing their own Chapels of Rest. 31 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 1,208 (ii) On complaint of other nuisances 560 (iii) Routine inspections 348 (iv) Revisits arising from defects found 7,942 (v) Surveys under S. 157, Housing Act, 1936 213 Conditions Found. (i) Number of dwellings or other premises where defects were found 1,952 (ii) Number of cases of overcrowding revealed 91 PUBLIC HEALTH Inspection of Other Premises. (i) On complaint or request 151 (ii) Routine inspections of premises 517 (iii) Revisits arising from defects found 1,137 (iv) Surveys arising from Rat complaints 1,475 (v) Inspection of Factories 791 (vi) Inspection of Workplaces 240 (vii) Inspection of Outworkers' Premises 324 (viii) Inspection of Cinemas and Places of Entertainment 87 (ix) Inspection of Licensed Premises 75 (x) Visits under Shops Acts 1,307 (xi) Evening observations under Shops Acts 36 (xiii) Sunday observations—Shops Acts 17 (xiii) Observations made for Smoke Nuisances 26 Conditions Found. (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 206 (ii) Number of premises where action taken by Council's Rodent Operatives to deal with rats 1,380 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 147 (iv) Number of Cinemas and/or Licensed Premises where defects were found 24 32 (v) Contravention of Shops Acts— (a) Failure to observe closing hours 19 (b) Other contraventions (failure to exhibit notices, etc.) 382 FOOD HYGIENE Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 45 (ii) Butchers' Shops 493 (iii) Cowsheds 9 (iv) Dairies 99 (v) Fish Shops 255 (vi) Bakehouses 175 (viii) Cafes and Restaurants 421 (viii) Ice Cream Premises 391 (ix) Provision Merchants 718 (x) Greengrocers 399 (xi) Other Food Premises 120 PART II. COMPLAINTS RECEIVED Summary. Accumulations of refuse 98 Animals causing a nuisance 22 Dampness 712 Drains and Sewers—choked 85 defective 129 Dustbins defective 133 Flooding—Gardens 29 Vermin 74 Insect infestations 45 Overcrowding, alleged 131 Shelters and Static Tanks unsatisfactory 1 Smoke nuisances 26 Water courses 14 Other complaints (pig bins, wasps' nests, defective fences) 197 Food unfit (excluding requests received from shops to visit and inspect unfit food) 57 PART III. NOTICES SERVED Under Housing Act, 1936. (i) Statutory notices served under S.9 requiring execution of repair work 36 33 (ii) Dwellings reported under S. 11 as being unfit for human habitation 7 (iii) Dwellings reported under S. 12 and closing order made 2 (iv) Informal notices served under S. 9 100 Under Public Health Act, 1936. Statutory Notices under :— (i) S. 24—work to a public sewer 23 (ii) S. 39—repair or renewal of drains 12 (iii) S. 45—repair or renewal of defective water closets 5 (iv) S. 56—undrained or badly-drained yard area 2 (v) S. 75—renewal of a dustbin 29 (vi) S. 93—abatement of a nuisance 64 (vii) Informal notices served 2,058 ACTION TAKEN Following Housing Act Notices. (i) S. 9—dwellings rendered fit :— (a) By owners 22 (b) By local authorit in default of owners 12 (In ten of these properties the notices were served during 1950.) (ii) S. 11—demolition order made 2 (iii) S. 12—closing order made 0 (iv) Dwellings rendered fit by owners after receipt of informal notice 108 Following Public Health Act Notices. (i) S. 24—public sewers repaired 10 (ii) S. 39— (a) By owners 9 (b) By local authority in default of owners 1 (iii) S. 45— (a) By owners 5 (b) By local authority in default of owners 0 (iv) S. 56— (a) By owners 1 (b) By local authority in default of owners 0 (v) S. 75— (a) By owners 9 (a) By local authority in default of owners 4 (c) By occupier 1 (vi) S. 93—Nuisances abated 42 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,877 SUMMARY PROCEEDINGS It was necessary to apply to the Courts for abatement orders in respect of 12 properties. In the case of seven an order was granted ; in the other five the work was completed before the date of the hearing. 34 HOUSING Repair of Houses. The Sanitary authorities have been given increasingly greater powers to ensure that the health of occupants is not impaired by the structural condition of the homes in which they are living. Premises in such a state as to be a nuisance or injurious to health were made statutory nuisances under the Public Health Act of 1875. A similar provision now appears in Section 92 of the 1936 Public Health Act by which nuisances which may be dealt with summarily include any premises in such a state as to be prejudicial to health or a nuisance. The Housing of the Working Classes Act, 1885, required sanitary authorities to secure the proper sanitary condition of all premises within their districts. In 1890, it became the duty of the Medical Officer of Health to report to his Authority any dwelling house which appeared to be in a state so dangerous or injurious to health as to be unfit for human habitation. The Housing and Town Planning Act, 1890, required local authorities to see that inspections were made in their districts of houses so dangerous or injurious to health as to be unfit for human habitation. The implied contract that a house should be kept by the landlord reasonably fit for human habitation during the holding became under the 1925 Housing Act an obligation on the owners of properties not exceeding a certain rental to see that the houses would be kept in all respects reasonably fit for human habitation. At the same time, it was made the duty of the local authority to cause inspections to be made from time to time with a view to ascertaining whether any dwelling house was in a state so dangerous or injurious to health as to be unfit for human habitation and a duty of the Medical Officer of Health to report such houses to the local authority. It has, then, become the duty of the authority to cause inspection of properties to be made. During the war, the mere shortage of staff would have prevented this being undertaken, quite apart from the futility of doing this work to discover conditions which because of shortage of labour and material could not be put right. During these years, then, any action which was called for was taken under the powers of the Public Health Act, and not under those of the Housing Act. This remained the position for some time after the end of the war, but small beginnings have now been made in using again the powers of the Housing Act to bring about the repair of houses. The work which can be called for under the Public Health Act is that necessary to abate a nuisance. Very much more can be called for under the procedure of the Housing Act. In fact, when the work called for under Section 9 Notices was completed, the house used to be considered to be in all respects fit for human habitation and therefore needing at that time no further attention. On the other hand, when the Section 9 machinery is used the question of the cost of the work to be done has to be considered, because a Section 9 Notice cannot be served unless the authority is satisfied that the unfitness from which the house is suffering can be remedied at a reasonable cost. The procedure in default of the owner complying with the Notice is different in the two Acts. In the case of non-compliance with the work 35 called for under the Public Health Act's Notice, the Court of Summary Jurisdiction could make a Nuisance Order ; non-compliance with this might be followed by the infliction of penalties. The procedure for obtaining the repair of houses is very much more direct when a Section 9 Notice of the Housing Act is served, because in default, the local authority can themselves arrange for the work to be carried out, recovering the expenses from the owner. Since the end of the war, action on these lines has been taken, Notices being served under Section 9 of the Housing Act and if necessary the work being carried out in default. To-day, many owners on whom Section 9 Notices are being served, are saying that they do not wish to carry out the work. Before the war when there was any dispute between the Authority and the owner on whether or not the house was considered to be capable of repair at a reasonable cost, most often it would be the Authority who would maintain that it was not and that they thought a Demolition Order should be made, whereas the owner, in an endeavour to keep his property, would claim that it could be made fit at a reasonable cost. To-day, however, the roles are reversed, the Authority maintaining that the house can be made fit at a reasonable cost and the owner objecting. In many cases this would be because the rise in the cost of the work to be done makes the sum a very large one, particularly having regard to the small receipts, especially in those houses where the rents are controlled. At ordinary times such a decision by the owner would merely have meant that the Authority would have been looked to to rehouse the tenants. With to-day's serious housing position, though, the disturbing aspect is that the decision would result in the loss to the district and to the country of a housing unit. Because of the Authority's interest in this aspect of the problem it does not seem equitable for the Authority to seek to compel an owner to incur expenditure which they themselves could incur if they elected to acquire the property. It does seem that serious consideration should be given to the question of the acquisition of some of these houses which, unless this step were taken, would be lost as housing units. It is not suggested that such a step should be taken in regard to individual houses scattered throughout the district, but that it might be considered where there are groups of houses where the plot, when it ultimately became vacant, which it is hoped would be in a few years' time when the houses are pulled down, will be of some value. If houses were acquired in this way, it could not be expected that they could be put into a really satisfactory state. They could never be properties about which the Council could be proud and it is not expected that all the money spent on them would be recovered. It may even be that the houses will be of such a low standard that it might be decided they shall be occupied by adults only, and not by children. But in default of some such arrangement, the position would seem to be that throughout the district there would be a number of these houses which by to-day's standards are not considered to be in such a state of sanitary disrepair as to call for demolition but, nevertheless, are suffering from sanitary defects to such a degree that living in them must impair the health of the occupants. This problem must be of very much greater dimensions in some districts where, because of its magnitude, the 36 ties probably cannot contemplate taking action on these lines, in which case, the houses, presumably, must be allowed steadily to deteriorate and, in the meantime, those living in the houses are living in insanitary conditions. In this district, the problem is one of relatively small dimensions which perhaps makes it all the more desirable that the situation should be faced and the problem dealt with. Local authorities have had steadily increasing responsibilities in regard to providing houses. The earlier legislation referred to the housing of the working classes. The difficulties arising from the first world war resulted in many persons being glad to accept Council houses who before then would not have been considered for tenancies. Although the situation eased between the wars, it seemed that in many towns, more especially the industrial districts, the local authorities would have to assume the burden of providing houses for many and in some areas perhaps for most of their residents. The second world war appears to have made this more certain so that in many towns a high proportion of the inhabitants can be provided with suitable houses only by the local authority. Where it was necessary to take action following receipt of complaints about the state of houses, in most the powers of the Public Health Act were used. To a greater extent than previously since the war, the machinery of the Housing Acts is being used and 100 informal notices were served under Section 9. The work requested was carried out in most cases but in 36 statutory notices had to be served; in 12 cases, the work had to be done in default. A number of houses were considered to be unfit for human habitation and to be not capable of repair at a reasonable cost. Demolition Orders were made in respect of four, and Closing Orders on parts of two. The undertaking of the owner to recondition and convert three into one housing unit was accepted. During the year 17 houses were demolished, 14 of which were in the Poets' Corner area. At the end of the year 39 houses were still being occupied which were the subject of Closing or Demolition Orders. Overcrowding. At the beginning of the year, 338 families were known to be living in overcrowded conditions, during the year 91 new cases were learned of, but in 155 the overcrowding ceased. The number of families known to be living in accommodation which, by the standard of the Housing Act, were overcrowded at the end of the year was 275. The abatement of the overcrowding in 59 was by the family's being rehoused by the Council. Of the new cases, in all but five the overcrowding was the result either of children passing from one age group to the next, of the natural increase in the size of the family, or because of the marriage of older children. Provision of New Houses. 215 houses were completed in 1946, 255, 365 and 286 in the next three years, and 181 in 1950. By the end of 1951, the total number of new permanent and temporary dwellings completed and handed over for occupation since the end of the war was 1,668. 37 Allocation of New Houses. When new housing units first became available, the Council decided to allocate them on a points system, the points being allotted for a variety of reasons. Three groups of persons remained outside the scheme whose applications were dealt with independently because their claims for rehousing rested essentially on health grounds. Of these three groups, the overcrowded family was later brought into the points scheme by additional points being given because of the overcrowding. This left two groups outside the scheme. One was the family living in the condemned house. This family was helped by the Public Health Committee making an appropriate recommendation to the Housing Committee. The other group was the family with a member suffering from tuberculosis. To meet the needs of those in this group, one-sixth of the housing accommodation which became available was allotted to them. There is not very much land available for use as housing sites left in this district so there is a limit, probably to be reached in a few years, to the number of houses the Council will be able to build and to have available to meet the needs of those who apply for them. To obtain a picture of the various demands which will or might be made on what houses become available, the Housing Management Sub-Committee asked the Public Health Committee to give an indication of (1) the number of new houses which the Medical Officer of Health anticipates having to report for action under Section 11 of the Housing Act, 1936 ; (2) the number of tubercular families to be rehoused ; and (3) the number of overcrowded families requiring to be rehoused. The following is a copy of the report presented :— A. Families in Condemned Houses. 1. Section 11 reads : " Where a Local Authority upon consideration of an official representation or a report from any of their officers or other information in their possession are satisfied that any house is unfit for human habitation and is not capable at a reasonable expense of being rendered fit they shall ..." According to Section 188 (4) in determining whether a house is fit for human habitation regard shall be had to the extent, if any, to which by reason of disrepair or sanitary defects the house falls short of the provision of any bye-laws in operation in the district. 2. There is no one standard of the unfitness of a house for human habitation. It varies from place to place and changes in the one place from time to time. There are a number of reasons for this. One is that the standard is determined partly by the general standard in the district. Then, too, in considering whether a house shall be represented with a view to demolition not only is the unfitness considered but whether the house can be repaired at a reasonable expense. The assessment of reasonableness depends not only on the cost of the work that needs to be done, a variable factor, but also on the value of the house when this work is completed. To-day it is worth while keeping in use houses which cannot be considered really fit for human habitation ; some of these houses were, in fact, considered for demolition before the recent war. 38 3. This means that the number of houses to be considered for representation is determined not only by the condition of these houses but by the availability of others, as there is no point in making a Demolition Order for a house which, because the occupants cannot be housed elsewhere, cannot in fact be demolished. Because of the competing demands of other families on houses which may become available, there have been some other factors in addition to the mere opinion of a house being unfit for human habitation which has been present in the case of those houses which have been brought to the notice of the committee. 4. The Housing Regulations required local authorities to arrange for the systematic examination of all houses in their district with a view to steps being taken in regard to those houses which were unfit, either to render them fit or to demolish them. It was such routine housing inspections which brought to light these unfit houses. For years these inspections have not been carried out, so that to-day's knowledge of the numbers of such houses rests largely on information yielded by surveys carried out before 1939. 5. By that year, Clearance Orders had been made in respect of a number of groups of houses. Some of these houses, however, had not been demolished by September, 1939 ; a number have been demolished since the end of the war. There are still standing 5 of those included in the Brewery Cottage Order; 4 of those included in one of the Stanmore High Street Orders, and the 20 in the Headstone Drive Clearance Order. In addition, there are still being occupied 10 houses which were before the war the subject of Demolition Orders. The houses in Poets' Corner were, in 1939, the subject of an enquiry with a view to making a number of Clearance Orders. All the houses were included in the representations, not because they were all considered to be unfit, but because it was considered that the best way of dealing with all the houses on the site was by clearance. The Ministry agreed to the demolition of five houses only. At various times since 1939, a number of houses have been pulled down : the Council recently made Orders in respect of 22 properties. There are other houses which are in almost as bad a condition, and which must soon be represented, these including 4, 6, 8 and 10 Shelley Road ; 23, 25, 27 and 29 Milton Road, together with a number of properties on the odd-numbered side of Shelley Road and the even-numbered side of Milton Road. There are yet further houses which should be represented, but whose condition is very much that of some other houses in the district and which can be considered only against the background of the need to deal with these others. Then there are the remainder which will not for a long time need to be considered. 6. Besides all these, there were 222 houses which were listed as being those which would first have to be considered with a view to demolition. Of these, a small number already have had to be dealt with, leaving 212 in this list. That some of them have in this way had to be dealt with, confirms the soundness of the original selection. Furthermore, although it has been necessary to make Demolition Orders in recent years on some other houses which were not included in that list, this was necessary because of such conditions as settlements—conditions which could not have been foreseen some years before—and not because of the presence of the usual type of sanitary defect or dilapidation found in an ageing house. It is felt, then, that it can be accepted that the list of 222, comprised the houses which, in 1939, more urgently called for examination with a view to the possibility 39 of their being the subject of Demolition Orders. They probably still head the list and being nearly ripe for demolition in 1939, are that much more unfit to-day. But to-day they are possibly closely followed by other houses which in ordinary circumstances would have survived longer, but which are in that much worse condition because of the limited attention they have had in the last twelve years. A list of these has not been prepared, and these are being referred to now only to remove any impression that, were it possible to deal with the 212 houses, that would be the end of the list of houses which are likely to wear out in the next few years. It must be appreciated, too, that just as for such reasons as settlements, some houses, including some built as recently as the 1930's, have had to be demolished, so others might need to be for similar reasons. 7. The minimum requirement of housing, then, in the coming few years is 41 to house those living in houses which are already the subject of confirmed Clearance Orders ; 13 for those living in houses the subject of confirmed Demolition Orders ; at least 50 to house those living in Poets' Corner in houses which should not be occupied ; 282 to house the families now living in those 212 houses which in 1939 were about to be considered for demolition. To this total of 386 must be added an unknown figure to provide houses for those living in houses which will become unfit for human habitation, either because of dilapidation due to ageing or because of such factors as settlements. 8. The information about the condition of the 200-odd houses, is that of 1939. It would not take too long to obtain particulars of the families living in them. It would, however, take a very long time to decide which should be the first 20, 50 or 100 to be brought to the attention of the Committee with a view to Demolition Orders being made. For the time being, then, no information is being obtained about the composition of the families at present occupying these houses. 9. If a house is considered to be capable of being put into a proper state at a reasonable cost, the procedure is the serving of a Notice under Section 9. When a Section 11 Notice is served, the owner must be given an opportunity of appearing before the committee to show cause that a Demolition Order should not be made. There is no similar provision when a Section 9 Notice is served. If the owner objects to the Notice, he may exercise his right to appeal to the Court, or he may just not do the work, in which case the Authority might do it and then proceed to recover the cost from the owner. To-day some owners who on being served with a Section 9 Notice maintain they are not in a financial position to undertake repairs and rather than have to do this, would be prepared to see the house demolished. In some such cases, the owners have offered to sell the houses to the Council. These houses have sanitary defects in them which, in the interests of those living in them, must be remedied. The houses are classed as being unfit for human habitation, and the Housing Act imposes on the Authority an obligation to see either they are rendered fit or they are not used for human habitation. Many of these, however, are not houses which to-day can be considered as not being capable of repair at a reasonable expense. But the owners decline to do the necessary work. The Authority can insist on the work being done by carrying it out themselves, but if they later have to use the Courts to recover the cost, they would appear as a body which insists on the private owner undertaking work which they themselves are not prepared to do. If they do not carry out the work, then as long as the houses are occupied, the tenants continue to live in houses unfit for human 40 habitation and the Authority is not carrying out its obligations as a sanitary authority. On the other hand, if nothing is done and the houses should become unoccupied, they are lost as housing units—and yet these are houses which it is not felt can be said to-day cannot be repaired at a reasonable expense. If they are allowed to go, they only add to the other list of those for whom the Council would be looked to to provide housing. It is felt that, just as to-day there are houses which, although suffering from real defects, cannot be demolished because the district cannot afford to lose them as housing units, so every consideration should be given to the means by which these other houses can remain available. It might well be that it will cost the Council an expenditure which it can never recover. Such expenditure, however, would by delaying the time before such families have to be housed by the Council, enable some others who so badly need it, to be satisfactorily housed. B. Families with a Member Suffering from Tuberculosis. 1. For some years the Council has continued its policy of allotting for the rehousing of families having a member suffering from open tuberculosis one-sixth of the new houses which become available. 2. This means that the rate at which such families have been rehoused has depended not on the needs of the individual families, but on the rate at which new houses have been erected. For this reason, then, the figures about the numbers of families rehoused in the past years cannot in themselves be accepted as a guide to future needs. 3. The cases which are added to the department's list of such families are but a fraction of those families in the district which have a member suffering from tuberculosis (at the end of 1950 there were on the tuberculosis register the names of 2,876 persons suffering from pulmonary tuberculosis and 269 suffering from non-pulmonary tuberculosis). The vast majority come to notice on representations made by the staff of the tuberculosis service. The two chief factors which lead to these families being considered for rehousing are the infectiousness of the patient and the degree of overcrowding of the accommodation the family occupies. 4. The following table shows the position of these families in recent years:— 1946 1947 1948 1949 1950 1951 No. of cases, 1st January 16 69 81 103 114 80 No. of new cases each year 77 41 64 49 26 22 No. of cases housed by Council 19 22 20 27 20 10 No. of cases removed from register for other reasons 5 7 22 11 40 8 It will be seen that the number of new cases in each year has in most years been greater than the number of cases lost in that year, so that numerically there has not been much improvement in the position. In point of fact, though, the situation is to-day very much more satisfactory than it was in the earlier of these years as those families most urgently needing to be rehoused have been found other accommodation. 41 5. It will be seen that over the last five years, the average excess of new cases over those abated otherwise than being rehoused by the Council is 23. It is felt that there are no reasons for these averages being very different in the coming years and that there will therefore be a continuing demand of this order. In addition, the present number of 80 cases has to be dealt with. For these families to be rehoused in, say, 5 years will need 39 houses for each of the next five years (a total of 195), and then a lower requirement of 23 houses for each year afterwards. C. Families Living in Overcrowded Conditions. 1. Although overcrowding of houses has for long been classed as one of the sanitary nuisances, it was not until the Housing Act of 1935 that the great drive to abate overcrowding was taken. 2. There were two standards of crowding. The first was if two persons of 10 years of age or more of opposite sexes and not being persons living together as husband and wife had to sleep in the same room. The other was the number of units permitted in certain rooms, the adult being classed as one unit, the child of 1 to 10 years as a half-unit, and the child of under one year not at all. Rooms under 50 sq. ft., bathrooms and sculleries, were not included in the available accommodation. The number permitted to occupy two rooms is 3 units ; three rooms 5 units ; four rooms 7½ units, and five rooms 10 units. 3. It was an offence if, after the appointed day, the occupier or landlord of a dwelling house allowed it to become overcrowded. There was, however, no offence if the overcrowding had arisen amongst persons living in the house at the appointed day unless suitable alternative accommodation had been offered and had been refused. 4. The standard of the Housing Act was fixed because of the serious position of crowding in many parts of the country. For such an area as this, therefore, it was low and more especially when many of the units of the family are made up of a number of half-units, because of children in the house, very many could occupy accommodation without that being statutorily overcrowded. 5. The first survey to determine the extent of overcrowding carried out in 1936 showed that 187 families were occupying overcrowded accommodation. By 1940 the figure had fallen to 19 ; it rose to 65 by 1945. In 1946 486 new cases were added to the register, and in each of the next two years the numbers added were greater than the numbers in which overcrowding was abated. 1949 saw a marked improvement in the position as the numbers of new cases were far exceeded by the numbers which had been abated, 178 cases being brought to light but overcrowding having been abated in 423. The number of known cases at the end of 1949 was 383. There was a fall again in 1950, the number at the end of the year being 338, because although 141 new cases became known, overcrowding was abated in 186. The position up to the end of October of this year shows a further improvement as against the 80 new cases, 125 have been lost, so that the number of families known to be in overcrowded accommodation is 293. Although no survey has taken place since 1937, it is felt that most of the overcrowded families in this district are known as so many families have stressed this factor in support of their application for a Council house. 6. New overcrowding is brought about in a number of ways. Often it is by the natural growth of the family, or it may be by the ageing of children who, on reaching the age of 10, rank as whole instead of half-units. Many cases result from the marriage of a son or daughter of the tenant and then 42 children are born to the couple. Sometimes, cases of overcrowding, though, are the result of the occupants of houses accepting as lodgers or sub-tenants individuals or families. To try to restrict new cases of overcrowding the owners and tenants of houses from which families had been rehoused had their attention drawn to their statutory obligations not to permit the overcrowding of the accommodation over which they had control. Then, towards the end of 1949, publicity was given to the fact that in regard to newly permitted overcrowding which was not the result of the natural increase in the size of the family, consideration would be given to the question of whether the penal provisions of the Housing Act should not be used. Of the outstanding new cases brought to light this year, in 34 the overcrowding was the result of the natural increase in the family, and in 28 it was through married children coming to live with parents. There were only 10 other cases in which the overcrowding in 5 was brought about by relatives coming to the home, one by lodgers being accepted, and four were let so as to be overcrowded. These figures which are similar to those of previous years show that most new cases of overcrowding can be dealt with only by the provision of alternative accommodation. 7. The following table shows the changes which have taken place in recent years in regard to overcrowding :— 1946 1947 1948 1949 1950 1951 No of cases, 1st January 141 496 587 628 383 338 No. of new cases each year 486 313 275 178 141 80 No. of cases housed by the Council 111 122 160 107 75 39 Otherwise abated 20 10 74 316 111 86 This table brings out the facts (1) that there has been a continuous fall in the number of new cases each year since 1946 ; (2) that the number of cases of overcrowding known to the Public Health Department abated by rehousing in Council property has fallen each year since 1948, and (3) that the rate at which cases are being abated by other means is also rapidly falling. 8. A house can be occupied by many persons without its being statutorily overcrowded ; overcrowding by even as little as a half-unit can mean families living in very difficult circumstances. Unfortunately, the relief of overcrowding has not been most marked in those houses most crowded (as contrasted with the position of the families with a member sufiering from tuberculosis where the greatest relative improvement has been amongst those worse placed). This is brought out by a comparison of the numbers of families with the varying degrees of overcrowding of the houses in 1946 and in 1951. In 1946 the numbers of families living in accommodation overcrowded by a half-unit, one unit, etc., were 185, 145, 80, 36, 22, 13, 9, 3, 0, 3, 0. The corresponding figures in 1951 were 114, 92, 37, 29, 8, 10, 1, 0, 1. 0, 1. 9. The post-war increase in the birth rate will result in an enlarged age grouping which will pass as a wave for a number of years ; each child will in some years result in crowded or in near crowded houses in the increase of overcrowding by a half-unit when he becomes 10 years of age. Some years later there will be all those extra numbers of young men and women to marry and bring their wives or husbands to live with their parents. It 43 must be many years before the effect of the lowered birth rate will bring any relief to these overcrowded conditions. 10. The table in paragraph 7 showed the fall in the number of cases of overcrowding and showed too that in 1951 the number of new cases was more than offset by the number of cases in which overcrowding was abated otherwise than by rehousing of families by the Council. If this state should continue in future, the problem facing the Council is the abatement of the known cases of overcrowding, a figure to-day of 293. D. Summary To rehouse families at present living in houses which ought to be considered within the next few years a minimum of 386 houses are needed (paragraph A.7). To house those families with an open case of tuberculosis at present known to be living under unsatisfactory conditions and to house those other families expected to become known in the next five years, 195 houses will be needed (paragraph B.5). To house those known to-day to be living in overcrowded conditions, 293 houses are needed (paragraph C.10). 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 67 101 — — (ii) Factories not included in (i) in which S. 7 is enforced by the Local Authority 437 726 42 — (iii) Other premises in which S. 7 is enforced by the Local Authority (excluding out-workers' premises) 55 105 20 — Total 559 932 62 — 44 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 60 65 1 2 — Overcrowding — — — — — Unreasonable temperature 3 3 — 2 — Inadequate ventilation 4 4 1 — — Ineffective drainage of floors 1 1 — — — Sanitary conveniences— (a) Insufficient 3 3 — 3 (b) Unsuitable or defective 46 42 — 1 — (c) Not separate for sexes 4 4 — 4 — Other offences against the Act (not including offences relating to outwork) 26 32 2 1 — Total 147 154 4 13 — In addition 324 visits were made to premises of outworkers who are persons undertaking at home work sent out from factories or business premises. Shops. During the year 1,307 inspections were made by the Shops Act Inspector. The contraventions found and dealt with included six cases where assistants were being employed on the day of their weekly halfholiday ; two cases where a young person (i.e., an employee under 18 years of age) was being employed in excess of the permitted number of hours ; one case where a young person was being employed after 10 p.m. ; four cases where assistants were being employed on Sunday work and not being given compensatory time off during the week, and eight cases where there was a failure to close the shop on the day of the weekly half-holiday. There were also 361 cases where the notices required by the Shops Act were not being exhibited. Evening observations led to 19 shopkeepers being warned for serving customers after closing hours. In those cases where a previous warning had been given, the Public Health Committee were informed and final warnings were sent by the Clerk of the Council. Following visits by the Shops Act Inspector, 29 shops were redecorated and 112 requests for other repairs and improvements were complied with. These included the provision of improved heating facilities, hot water heaters and other matters concerned either with the cleanliness of premises or the welfare of the assistants. The number of shops on the register at the end of the year was 2,307, an increase of 32 on the previous year. 45 Smoke. Before the war, there were in use many hundreds of private slaughterhouses. Some had been used for many years and because of developments around them since they were first put up, they came to be poorly sited both because of the unsatisfactoriness of the approach by which the animals reached them and also because of the proximity of nearby dwellings. There were other disadvantages in that many were far from ideal for the greater use made of them, while their very numbers made it difficult for arrangements to be made for the inspection of the carcases. In spite of all these disadvantages which were fully recognised, the private slaughterhouse continued and it needed the recent war to bring an end to these arrangements. For many years, much interest has been taken in the subject of atmospheric pollution. Legislation has been passed with the object of reducing the emission of factory smoke, and courses of instruction have been held for the training of those especially concerned with the stoking of boilers. In some districts, the pollution by smoke emitted from factories is far exceeded by that from the domestic chimney. Against this, there is no legislation—and yet quite apart from the relative amounts of pollution from these two sources, it may be found that the smoke from the household chimney is far more damaging than that from factories. The question of smoke pollution is important for many reasons. There are those who see in the smoke in the air something which causes damage to animal and vegetable life by interposing a barrier to the passage through the air of certain of the rays of the sun or by causing injurious deposits on vegetables or on the soil. To others, the main concern is the spoiling and the damage to buildings ; to others again, the most important aspect is that the unconsumed or partially consumed carbon which finds its way into the air is a loss of that much fuel. To those whose chief concern is the health of the community, it may be that the most important aspect is the effect of contaminated air in bringing about cancer of the lungs. While much of the increase in the incidence of cancer can be accounted for by the fact that more of the population are reaching the ages at which cancer is more common, this is not the explanation of the increase in the incidence of cancer of the lung and of the bronchus. The reason for this increase is not known. An enquiry is now being undertaken to see if there is any substance in the suggestion that this greater prevalence results from the practice of smoking. If this should be even a partial explanation, further enquiries will be needed to ascertain the particular constituent which causes the harm. Even though it should be found that there is no relationship between the incidence of cancer of the lungs and the smoking habits of the sufferers, it might nevertheless be the case that pollution of the atmosphere might be one of the ætiological factors, pollution possibly by a breakdown product such as benz-pyrene, or possibly by some substance such as arsenic which is volatilised and passes into the air from the fire when coal is consumed. It may be, then, that there is such an additional factor, which makes it desirable that everything should be done to reduce the contamination of the atmosphere, and for not excluding the fire in the house from attention. All too frequently it seems that a fatalistic 46 attitude is adopted because it is repeated so readily that an English household will not do without its open fire. But just as the war was able to bring about an end to the use of the many hundreds of private slaughterhouses, might it not be that the results of the war might bring about an end to an insistence on the open fire ? It is stated at times that the fate of the country hangs on its being possible to export so many tons of coal ; and then discussion passes to a consideration of what might be done to increase the amount of coal won from the mines. Would it not be as well that at lease an equal amount of attention be given to the question of putting to the best use the coal which has been obtained and that not only in the industrial field but in what is consumed in the home. The open hearth is the most wasteful way of heating a room, much of the heat being dissipated and much of the fuel passing up the chimney unconsumed, there causing atmospheric pollution. Some towns arc taking steps to bring about an improvement by scheduling smokeless zones. It is to be regretted that no steps were taken to insist on only really efficient heating units being installed in any new houses being erected. There are open fires which are very much more economical in fuel consumption than the older type of open fire, while providing just as much heat in the room. The replacement of many of the less efficient grates by those of this pattern would be a step towards both a smaller fuel consumption and a reduced pollution of the atmosphere. These grates, however, although such an improvement on the older pattern, are not such efficient heating units as stoves, of which there are very satisfactory patterns. Besides securing that a greater proportion of the heat produced by the fuel consumed in a stove is used in actually warming the air of the room, the stove has the advantage of its being an efficient consumer of smokeless fuels. The economic interests of the country would be served by the greater use of such efficient heating units in the houses, quite apart from the secondary advantages of a reduction in the pollution of the atmosphere. It would seem to be worthwhile then actively encouraging, even possibly by financial assistance being given to householders, the conversion of existing relatively inefficient heating units in the homes to those of the more efficient type. During the year, 26 observations were made of factory chimneys. On six occasions the attention of those responsible was drawn to the quantity of smoke being emitted. In only one of these cases was the nuisance found to be due to causes difficult to remedy, and here action is being taken to instal a grit arresting plant. In four cases the smoke emission was the result of lapses in stoking ; and in the other a breakdown in a mechanical stoker. Rat Infestation. During the year, 1,475 complaints of rats or mice were received. In the case of 95 of these complaints, no infestation was found. Steps to destroy the rats or mice were taken in the remaining 1,380. No major infestations were found and of the complaints received which involved private dwellings, most were associated with poultry keeping. 47 Besides dealing with the complaints received, the rodent operatives treated the sewers twice ; but as in previous years no evidence of any serious infestation was found. The watercourses in the district were also treated and other sites where infestations were considered likely were visited at regular intervals. Licensed Premises. These premises are visited regularly, particular attention being paid to the adequacy and the state of the sanitary accommodation, the arrangements for the cleansing of the glasses, and, where meals are provided, the state of the kitchens. A report on these matters is sent each year to the Licensing Justices. Premises licensed by the Middlesex County Council for music and dancing are kept under observation and a report on their state is sent each year to the County Council. Rag Flock. The Rag Flock and Other Filling Material Act, 1951, came into force on 1st November, 1951. Two classes of premises are recognised. Registered premises are those where filling material of the types listed, e.g., unwoven cotton, unwoven wool, jute, hair, etc., are used in the manufacture of bedding, toys, baby carriages and other articles of upholstery. Licensed premises are those where rag flock is manufactured or stored for distribution to registered premises. It is now unlawful for upholstery, etc., to be done on any other than registered premises, though relivening of upholstery can be done elsewhere. There are a number of premises in the district which will be registered, but there are none to be licensed. 48 INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY Legislation. The Milk (Special Designations) (Specified Areas) Order which came into force on October 1st, 1951, prohibits the sale by retail of milk intended for human consumption not produced or treated as required under the Milk (Special Designations) Regulations. Two producers who previously produced and sold raw milk now sell the milk wholesale. Production. There are nine farms in the district at which milk is produced. Of these, five are producing tuberculin tested milk and one accredited. The milk from the remainder is sold wholesale. Processing and Distribution. The following is a summary of the position :— (1) Number of premises licensed to pasteurise milk 2 (2) Number of premises from which pasteurised milk was sold 48 (3) Number of premises outside Harrow from which ised milk was retailed in the district 16 (4) Number of premises from which T.T. milk was sold 46 (5) Number of premises outside Harrow from which T.T. milk was retailed in the district 16 (6) Number of premises from which sterilised milk was sold 47 (7) Number of premises outside Harrow from which sterilised milk was retailed in the district 13 Inspection and Supervision. During the year 108 visits were made to cow sheds and dairies. Sampling. 36 samples of milk were taken during the year. All were satisfactory. Complaints. During the year 25 complaints were received about foreign matter in milk bottles. In six instances the bottles had cement in them. Although unsightly and indicative of faulty supervision at some stage, the cement could not be said to be injurious to health. Those responsible for the scrutiny of the returned bottles and for inspecting the washed and the filled bottles, must be held to be at fault. The chief blame, though, rests on those who allowed the misuse of the bottle. In many cases, householders do not do what they might to see that bottles are so treated that passage through the ordinary washing and rinsing plant can thoroughly cleanse the bottle. In six instances the substance in the bottle was glass. The only explanation in many of these cases was that the top of the bottle had been broken at the stage of 49 its being filled so that fragments were left so attached that they entered a bottle being filled later. These fragments of glass are potentially dangerous to the consumer, especially to children sucking up the milk through straws. The foreign matter in the other instances was of varied origin ; in most cases, although sometimes unsightly and even revolting, they would not result in the milk being dangerous to the consumer. (B) MEAT At none of the six slaughterhouses in the district is regular slaughtering carried out. At those used occasionally, 93 pigs belonging to pig clubs or to private persons were slaughtered; very little disease was found, only seven lights, one liver and one head having to be condemned. (C) OTHER FOODS During the year 3,646 visits were made to food shops or other premises at which food was stored or prepared. Of these visits 521 were made to examine foodstuffs which the shopkeeper considered unfit. The following is a summary of all food found to be unfit for human consumption:— Groceries 3,478 lbs. Fish 1,327 lbs. Vegetables, Soups, and Pickles 1,479 lbs. Fruits 2,246 lbs. Meat and Meat Products 8,693 lbs. In all cases the food was voluntarily surrendered and either destroyed locally or dealt with by the Salvage Division of the Ministry of Food. The total of 17,223 lbs. is an increase of 4,597 lbs., a percentage of 36 on the previous year, though it is less than the quantity dealt with in each of the three preceding years. The increase in 1951 was attributable largely to the condemnation of a large quantity of imported tinned ham which appeared when import restrictions were lifted (3,279 lbs.) and to an increase in the amount of home killed beef (2,696 lbs.) condemned. Only a small percentage of this beef was diseased, condemnation being necessary because of taint and decomposition due to either poor handling or to unsatisfactory conditions during storage or transit. This matter was taken up with the Ministry of Food and an improvement in the condition of supplies coming into the district was noticeable towards the end of the year. The amount of wet fish condemned has steadily decreased over the past five years. It is not possible to say whether this decrease is the result of improved packing at the ports or speedier distribution from the market. Both are matters that have been receiving attention during recent years. Ice Cream. The number of premises registered for the manufacture of ice cream was increased by one during the year to a total of 13. 28 additional premises were registered for the sale of ice cream, the total registered for this purpose at the end of the year being 315. D 50 122 samples were taken, 85 were Grades 1 or 2, and the remainder Grades 3 or 4. In the case of the Grade 3 or 4 report, investigations were made and follow-up samples were taken. When Grade 3 or 4 samples were obtained of supplies coming into the district the local authorities concerned were advised. In some of these cases by arrangement with the Health Department concerned supplies were sampled at the place of manufacture and locally; in two instances, this proved of real help in tracing the cause of the trouble. Registration of Hawkers. Eleven hawkers were registered under the Middlesex County Council Act, 1944, ten trading in greengrocery, one as a fishmonger. Towards the end of the year the Public Health Committee recommended that, in the interests of food hygiene, the Council should consider adopting Part IX of the Middlesex County Council Act, 1944, which deals with street trading. (D) HYGIENE OF FOOD By the end of 1950 the Council's certificate had been issued to nearly one-quarter of the establishments in the district dealing with the preparation or sale of food. During this last year, further applications were received, and 27 certificates were issued. The Public Health Committee felt that a sufficiently large proportion of those in this district dealing with food had received and were exhibiting the Council's certificate or the Guild's plaque to warrant the next step in the campaign being taken, namely, the approach to the public. They therefore decided to hold a Clean Food Exhibition which was held for a week in September in the Victoria Hall, Station Road, Harrow. Over 3,000 persons attended, including 800 members of organised parties from schools or women's organisations. It was felt that the results justified the expenditure of money and effort. It had been hoped that one result would have been a large increase in the number of applications for the issue of the Council's certificate from those who it was felt would be granted one if they applied. The exhibition did not do much on these lines, though it did play its part in stimulating interest in the subject of food hygiene amongst various organisations which later applied for speakers to address meetings. The rousing of the interest of the consumers is the third phase of the campaign. If this can be achieved it will probably be reflected in the interest of those who deal with foodstuffs who up to this have taken no action. Many authorities up and down the country are taking steps to try to improve the conditions under which food is handled. In Harrow, there is close contact between the traders and the Public Health Committee by means of the Food Hygiene Committee on which both sides are represented. Many helpful suggestions have been made by the Committee which have been forwarded to the Public Health Committee, and following these, representations have been made to different departments on such matters as the conditions under which meat is distributed to the retailers. As a result of the Public Health Committee's 51 tion, the Council decided that in the interest of hygiene, street trading of foodstuffs should be controlled. Any of such activities as these as lead to improvement in any way in the way foodstuffs are handled, are desirable if only on; esthetic grounds. It is not suggested that the unsatisfactory conveyance of meat from wholesaler to retailer necessarily causes illness or disease in the consumers of the meat. But practices as dirty as these should be condemned, even though they cause no ill-effects. Probably much of the activity of the many local authorities in this question of food hygiene is aimed at faults which are not necessarily disease producing. Control of food poisoning as such can be achieved by measures conducted on a much narrower basis. About one-half of all food poisoning outbreaks are due to processed or made-up meat such as pies, stews, rissoles, etc. For control of much of the food poisoning, then, attention should be focused on the preparation and handling of such processed and made-up meat. However desirable it might be that everything should be done to attain decent standards of the handling of food, this work should not be carried out at the expense of those steps necessary to prevent the poisoning of food. 52 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 — 45 119 6 5 5 — — — 1 — — 181 Diphtheria — — — — — — — — — — — — — Pneumonia 2 15 18 18 6 1 11 17 20 21 37 — 166 Dysentery 1 5 28 2 — 1 4 — 1 2 — 1 45 Erysipelas — 1 — — — — 3 2 4 8 7 — 25 C.S. fever 1 1 — — — — — 1 2 — — — 5 Puerperal pyrexia — — — — — 2 9 2 — — — — 13 Oph. neon. 2 — — — — — — — — — — — 2 Poliomyelitis — 2 1 1 2 — 1 1 — — — — 8 Measles 46 1155 1239 46 17 13 12 4 2 1 2 11 2548 Whooping cough 47 404 298 14 2 4 5 2 1 1 — 2 780 Para-typhoid fever — 1 3 — 1 — — — 1 — — — 6 Food poisoning — — — — 1 2 1 — — — — — 4 CONTROL OF INFECTIOUS DISEASES Notification. Puerperal pyrexia as notifiable under the 1938 Regulations was any febrile condition occurring in a woman within 21 days of childbirth or miscarriage in which a temperature of 100.4°F. or more had been sustained during a period of 24 hours or had recurred during that period. This definition had proved to be ambiguous. Moreover, many drugs now in use can reduce temperatures. A patient, then, suffering from a state which would result in her developing a temperature reaching a degree calling for notification could have her temperature reduced by these drugs with the result that the condition would not be notifiable. The 1938 Regulations were therefore replaced by those of 1951 which came into force on 1st August, 1951 under which the definition of puerperal pyrexia is any febrile condition occurring in a woman in whom a temperature of 100.4°F. or more has occurred within 14 days after childbirth or miscarriage. The diseases which are notifiable are a number listed under the Public Health Act, 1936, and others notifiable by regulation. In the case of a number of those infections notifiable by regulation, the regulations themselves have suggested the pattern of the form of notification because in some infections information would be asked for from the notifying practitioner which would not be required in other notifiable conditions. The result is that local authorities have supplied to the medical practitioners a number of books of notification forms. Ministry of Health Circular 33/51 suggests that one composite form should be used for the purpose of notifying all infectious diseases and food poisoning. Arrangements are being made for this to be used in this district. The Public Health (Leprosy) Regulations came into force on 22nd June. These call for the notification by a medical practitioner to the Chief Medical Officer for the Ministry of Health of any case of leprosy he is attending. All other notifications of infections are sent to the Medical Officer of Health of the district in which the patient lives. It is 53 understood that the notification in this case is to be sent to the Chief Medical Officer of the Ministry rather than to the District Medical Officer of Health, so that those concerned can feel that the notification will be handled in strictest secrecy. It seems that when the notification of certain infectious diseases was first required, some opposed the practice, more especially those medical practitioners who felt that by notifying they were being obliged to commit a breach of confidence by their disclosing facts which they learned from their patients. There was further agitation some years later when it was suggested that tuberculosis should be notified, agitation which was sufficiently strong that the full notification, as required at present was introduced only in stages. Periodically, the question of the notification of those suffering from venereal diseases is raised, and some authorities have by means of local Bills tried to have these conditions notifiable in their areas. Up to this, none has been successful so that these conditions are nowhere in this country notifiable, though they are in some places abroad. There were, of course, special provisions during the war by which those who were suspected to be spreaders could be got into touch with. Apart from the controversy of the notification of those suffering from venereal infections, there seems to have been little opposition to the very wide extension by means of regulations of the list of conditions required to be notified. This makes it all the more strange that this most unusual procedure should have been decided upon in regard to the notification of leprosy. Local Authorities have particulars of the most intimate nature of many persons living in their district: the behaviour of those suffering from mental disorders; the pregnancy of unmarried girls; during the war information about some of those suffering from venereal diseases or infested with vermin or by scabies. They know of many of those in their district suffering from tuberculosis and at times they are made aware that there is a smallpox patient ; but they are not to be allowed to know of the perhaps only one case of leprosy in their areas. Aids to Diagnosis. (1) Laboratory service (see page 28). (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. 54 (6) Smallpox or Typhus Fever: Patients suffering or suspected to be suffering from these complaints are admitted to special hospitals. (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 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 fumigation or stoving be carried out, a charge is made, 7s. 6d. for fumigating the room, and 10s. Od. for the stoving of the first load, and 5s. Od. for any subsequent load. DIPHTHERIA Although 15 persons were admitted to the Isolation Hospital suspected to be suffering from diphtheria, in not one was the diagnosis confirmed. In 1946 there were 17 cases; in 1947 six; in 1948 none; in 1949 one, a nasal infection; in 1950 one, the first faucial infection for over three years; and in 1951 none. To-day, more children are immunised against diphtheria than are vaccinated against smallpox. Up to 1948, it was a statutory obligation on a parent to have his child vaccinated. There was, however, provision by which those parents who had a conscientious objection to the practice being excused. Such use was made of this provision that as many children were not vaccinated as were done. Some felt that the compulsory element, so far from increasing the numbers treated, might have the opposite effect. Such persons hoped that the removal of that element under the National Health Service Act might be followed by an increase in the numbers vaccinated. They will have been disappointed in their hope as the numbers vaccinated, so far from increasing, have in fact fallen. That so many mothers have their children immunised against diphtheria, although they do not have them vaccinated against smallpox, is probably because to many diphtheria is still a very real fear, whereas smallpox is to them a more indefinite risk. If this is the explanation for the different extent to which these protective measures are carried out, then it is all the more necessary that every effort should be taken to see that substantial numbers of children are protected against the risk of contracting diphtheria, because with the passage of years, diphtheria in its turn may cease to be the real fear that it is to so many parents. Diphtheria has 55 not caused the death of a single child living in this district since 1945, and since 1946 not more than eight children living here have suffered from an attack. Memories are short, and this freedom of the district from infection carries its own risk. Even without active immunisation, or without their having succumbed to an attack, most adults used to become relatively immune from attack. This state of immunity was reached by the individual being exposed to and overcoming doses which were not sufficiently large to overcome the body defences. The presence of organisms in the district, then, helped to build up the resistance and accounted for those in towns being more resistant than those brought up in rural surroundings. In default of having the stimulus of such sub-infective doses, an individual unless protected by other means does not acquire an immunity. Again, whatever protection the population as a whole might have against wide spread of infection if a substantial proportion have been immunised, the individual child who is unprotected is still subject to the risk of infection, a risk which is the greater in such a district as this with its proximity to the London population. Although it is not maintained that the freedom of the district from diphtheria is entirely due to the immunisation of any of the child population, it is felt that any individual child can be made safe from the risk of attack only by that child himself being adequately inoculated. The Local Authority can make available satisfactory arrangements for children to be immunised. Only the parents of a child can see that that child is given the benefit of those arrangements. It is probable that the occasional case of a disease is often missed. Before poliomyelitis became as common in this country as it has been since 1947, it is quite possible that the non-paralytic infections were missed except those which occurred in the few weeks of the year when the disease was more common. In the same way, there must be a growing risk that any cases of diphtheria which do occur might not be recognised as such until a comparatively late stage of development of the disease, so that freedom from infection of the general population of the district might add materially to the risks of the few who are attacked. This makes it all the more urgent that the numbers of these should be reduced to the minimum. During the year 2,224 children were treated for the first time, 1,273 by general medical practitioners, 936 at infant welfare centres, and 15 at Day Nurseries. It is estimated that at the end of the year, 47.1 per cent. of children under 5 years of age were protected, and 77.9 of children aged 5 to 15 years. The figure relating to the under-fives is rather less, and that relating to the 5-15 age-group rather more than the corresponding figures of last year, the fall being because fewer under-five children were immunised last year than were five years ago. SCARLET FEVER Scarlet fever is a disease which varies much in incidence. It is one of the infections which was considered to have a short cycle of incidence of four to six years superadded on longer cycles of 15 to 30 years. In such a district as this which developed so rapidly in the years before the 56 war and in which, in common with many other districts, there was during the war years such marked movement of the population, it must be a very long time before any such regular periodicity of any of the infections will show itself. For many years, the severity of this infection has waxed and waned. For a number of years now the type prevailing in Northern Europe and in America has been mild, a marked contrast to that common in this country in the XVIIIth century and in the early part and in the third quarter of the XlXth and which prevailed in parts of Europe just before the war. Some saw in the removal to isolation hospitals of the more severe cases the reason for this change in the character of the illness ; but this suggestion ignored the previous history of the disease. What has happened in scarlet fever is probably entirely the result of a change in the organism, and no credit for it can be claimed by those in the Public Health Service. Some diseases have a marked seasonal incidence. Unfortunately, so little is known as to what the factors are that bring about the increased prevalence at certain times or a lowered incidence at others. In the same way, little is known of the reason that a disease takes on an epidemic prevalence in some years, or for parts of years, and is comparatively light in incidence at other times. The organism seems to vary both in toxicity, with resulting change in the clinical severity of the disease produced, and in dispersibility so that one variety of the germ will cause the disease to spread freely while the illness caused by another variety passes from one person to another only with difficulty. Because a sufferer who is severely ill is usually confined to bed and so is unlikely to spread infection to others than his immediate contacts, unless the dispersibility of the organism changes or unless other factors such as meteorological changes or changes in the nutritional state of the population are present, then the disease is less likely to spread. Conversely, it is more likely to do so if the type of illness resulting from infection is mild. This was the case some 20 years ago when the mild variant of smallpox spread so widely throughout the country, as contrasted with the very limited spread of the classical type of smallpox. But mildness of attack does not invariably result in a higher incidence. This was the position last year, when there were in this district only 181 confirmed cases of this infection, an incidence rate per thousand population of 0.82. The only year with a corresponding freedom was 1947, when there were 180 cases, an incidence per thousand population of 0.83. The incidence last year in the country as a whole was 1.11 per thousand population. Characteristically, the incidence of scarlet fever in this country increases throughout the summer to reach a maximum in October or November, after which there is a fall to a minimum in March or April. In this district, cases were most common in 1951 in March to May with a weekly average of five cases; for the rest of the year the incidence was particularly low, there being no cases at all notified in two weeks in the middle of September and only one case in each of ten weeks from the beginning of August to the end of October. 53 patients were removed to isolation hospitals, most to the Hendon Isolation Hospital, but seven to others. There were ten households in which secondary cases occurred. In nine there was only the one secondary case; but in one house three 57 children fell ill, all about the same time, 12 days after the onset of the illness in the primary case who was nursed at home. In three instances the primary patient was removed to hospital; in one the onset of the secondary case was the day before the removal of the primary; in another it was the day after, but in the third there was an interval of 10 days. The intervals between the dates of onset of illness in the primary and in the secondary cases where the primary case was nursed at home, was two days in one case, three days in two, six days in two, and twelve days in two instances. In all but one of these cases, then, it can be presumed that infection of the secondary case would not have occurred had the primary case been removed to hospital. There were no return cases this year, that is, cases of infection occurring within a few weeks in a house to which a person who had been nursed in an isolation hospital had returned. In three instances, scarlet fever developed very shortly after children had had their tonsils and adenoids removed. It is possible that at Stanburn School attendance at school might have had some effect in the development of scarlet fever amongst some pupils, though no source of infection was detected and the occurrence of cases ceased without any specific action being taken. In the second half of February and in March, a case occurred in either the Junior or the Infants' Section of the school for each of six consecutive weeks, two cases occurring in one week. After a period of complete freedom, eight cases occurred in two consecutive weeks in May; after a further interval, six cases occurred in the Junior Department in a period of four consecutive weeks. The only other suggestive groupings were four cases in one week in Vaughan Road School; four in one week in Greenhill School; and three in two weeks in Kenmore Infants' School. SMALLPOX Throughout most of each year, the only concern of the Health Department with smallpox is to keep in touch with those who have come to the district from some place abroad where they might have been infected. Occasionally, there is a more urgent contact as when persons come to the district having arrived in this country by a boat on which there has been a person suffering from smallpox. In the early weeks of the year there were some repercussions from the occurrence of the cases in Brighton, leading to a number of requests for consultation by general practitioners in respect of persons suffering from suspicious rashes. When a ship on which there is a patient suffering from smallpox lands at any port in this country, particulars of all passengers and crew are taken and the health authorities of the district to which they are proceeding are advised. These contacts are visited in their homes, informed that they are smallpox contacts and are advised to inform their doctors and particularly to let their doctors know that they are smallpox contacts, if for any reason they have to call them in. When possible, too, the patient's doctors are informed that these particular patients are smallpox contacts. These contacts are visited for something longer than the incubation period of the disease. Amongst the passengers of a boat which arrived at the Port of London in the middle of February was a girl 58 who was thought to be suffering from chickenpox. by the time the diagnosis was changed to smallpox the passengers had dispersed and no particulars of where they had gone to had been kept. A broadcast appeal was made and in this district the doctors were written to telling them of the position. Against the risks of any particular person contracting infection in these circumstances, there is only one protection—vaccination, with re-vaccination if the individual is to be subject to special risk. The position as to the vaccination of the population is anything but satisfactory. In this district last year, 1,788 persons were vaccinated for the first time, but only 895 were under one year of age and only 1,229 were under two years of age, and 812 re-vaccinated. In the same year, 2,895 babies were born. These figures, poor as they are, are possibly better than those for the country as a whole. It must mean much hard work before the position can be made satisfactory. Even before 1918, as many parents took advantage of the powers available to them to avoid having their children vaccinated as had them done. The mere fact, too, that the compulsory element of the laws about vaccination was removed by the National Health Service Act, must have led many quite genuinely to assume that there was not much to be said for the practice. Another factor of importance which is likely to lead to fewer vaccinations being done is that there are now no officers, corresponding to the Public Vaccinators and the Vaccination Officers, charged with a duty to see that babies are vaccinated. On top of that, is the confusion, because of the different views expressed, about the place of mass vaccination of the general public in the face of an outbreak. At such a time the public is not only willing, but demands to be vaccinated, even though so many of them will not have been contacts of infected persons or of infected articles and therefore they are not really subjects of risk. But because they feel that they possibly may have been exposed, they clamour to be vaccinated, to the great difficulty of those who have to deal with those who have been infected and with their immediate contacts who definitely are at risk. An individual can be protected against the risks of contracting smallpox by being vaccinated or re-vaccinated. An outbreak of smallpox can be limited by the vaccination of the immediate contacts of patients, if it is possible to do this early enough; if it is not and the disease develops in some of the immediate contacts, then by the early vaccination of their immediate contacts (and this is something which can usually be done in time) spread is restricted. These are the measures which the authorities carry out to prevent the spread of smallpox. Authorities should not at such times be burdened with the demands by the masses for their vaccination, more especially of those who would not need to be anxious if they had only taken advantage at the ordinary times of the facilities available for them and their children to be vaccinated. ENTERIC FEVER Of the 13 patients notified to be suffering from enteric infection, the diagnosis was altered to some other condition in six. The first of the cases in which the diagnosis was confirmed was a man who was removed to hospital the day he came to this district from another part 59 of the country where presumably he had contracted the infection. The first of the locally contracted cases was a woman of 50 who fell ill with paratyphoid B fever in the middle of February, and who died a month later. The source of the infection was not detected in this case nor in the next, a girl of 18 who lived in another part of the district and who fell ill also with para. B infection early in May. There were, though, no more notifications until July when within a few days of each other three notifications were received. All three patients were children Living in different parts of the district who had apparently no contact with each other, nor was any food consumed by them of the type which might convey infection obtained from the same source. As these three cases coming together might have been part of a larger number, all general medical practitioners in the district were written to. In the next few days a number of patients were removed to hospital suffering from signs or symptoms suggestive of enteric infection, but in none was the diagnosis confirmed. At the end of the month another child was admitted to hospital, the onset of her illness being at the beginning of the month. In most years, about half-a-dozen cases of enteric infection are recognised amongst those living in the district. Diagnosis in many cases is not easy, and it might be that there are some milder cases unrecognised, more especially if the illness is not sufficiently severe for the patient's medical attendant to be summoned. When these three cases were recognised early in July, the question was whether they were the only cases in the district or whether they were the only ones recognised out of a larger number. In an attempt to discover whether or not there was any hidden infection in the district, Moore's swabs were put down at four points in the sewer system, being sited so that they lay in the course of the drainage from all parts of the districts. After being down for 48 hours the swabs were taken to the Colindale Laboratory for examination. It had been intended if typhoid organisms had been found on any of the swabs, that other swabs would have been put down further up the sewers with a view to tracing back as far as possible the source of the infection. As it happened, no typhoid organism was recovered from any of the swabs. It is proposed to repeat the trial once a month for six months. The only other person in the district who it was known was infected with typhoid organisms was a boy who went in the summer with a number of fellow pupils to France. Some days after their return to their homes in different parts of the country, some were found to be suffering from paratyphoid fever. Information was received from the Ministry of Health that four members of the party lived in this district. Enquiries brought to light the fact that two of these had, after returning home, developed gastro-intestinal symptoms, the other two remaining free from symptoms. One of those who had this upset had gone as a member of a party of Scouts to a camp in the Isle of Wight, being due to return home on the day after the information was obtained. Examination of clinical material from these four pupils showed that one was excreting paratyphoid organisms; he was the one who had had gastro-intestinal symptoms and can be presumed to have suffered from a mild attack of paratyphoid 60 fever. He was also the one who went to the Isle of Wight camp. It does not seem that he caused any infection while at that camp. DYSENTERY Dysentery is a complaint which is the result of an infection of the bowel by bacteria or other forms of organisms in which the patient usually becomes febrile and suffers from diarrhoea with the passage of blood or mucus in the stools. There are many types of bacteria which cause the infection in its characteristic form. On the other hand, there are many dysenteric organisms which can infect the bowel and if they cause any reaction at all, it is of the mildest. Infection, then, may result in an illness of the severest clinical variety, as the disease is seen in some parts abroad, or, on the other hand, may cause so slight a disturbance that the patient treats the matter lightly and does not even summon a doctor. There is probably much infection in this country, though on nothing like the scale of the invasion of a few years ago when the whole country seemed to be attacked by a Sonne infection. The organism is probably introduced into the body by food or drink, including water. Anyone excreting the organisms in the stools can readily pass on infection to others, either by directly infecting food or by the passage of the organisms from an infected hand to some inanimate object such as a door-knob or tap which in turn infects the hand of the new host. As the clinical manifestation might be so very slight, the disease often enough is not recognised by the patient and sometimes not by the doctor summoned to attend the patient. Very often it is only by a bacteriological examination of the stools that it can be recognised what the patient is suffering from. For these reasons, then, the prevalence of the infection throughout the country is probably much greater than is indicated by the number of notifications received. The infection is very common amongst many of the inmates of such institutions as those which accept the mentally subnormal. In this last year there was a big rise in the number of notifications received, namely, 45 as compared with 7 of 1950. 26 of these, however, were of persons either pupils or staff at the local residential school. In many of those notified though, the diagnosis was made as the result of the examination of the specimens of stools submitted for analysis on the occurrence of a few clinical cases amongst the pupils. In only a few cases was the source of the infection even suspected. The persons notified lived in different parts of the district and there seemed to be no common factor in their food supply. The cases were spaced throughout the year, no time being more especially heavily involved and at no time was the district entirely free. Only in two instances was there more than one sufferer in any house. In general, the illness caused was mild. Nine of those notified were admitted to isolation hospitals for treatment. FOOD POISONING Only four persons were notified last year as suffering from food poisoning. Two of these were members of one family where the onset 61 of illness in the one led to recognition of the fact that the other had for some time been suffering, having originally been infected by consuming an inadequately-cooked duck's egg. In one of the other cases, the illness had been preceded by the consumption of a duck's egg. ERYSIPELAS 25 notifications of persons suffering from erysipelas were received during the year, the rate of attack being slightly higher for the earlier months. The sexes were almost equally affected. In all but six, the face was the site attacked. Three patients were admitted to the isolation hospital for treatment. At one time, erysipelas was something of a scourge, being especially damaging to patients in hospital. To-day it is, in general, a milder complaint, and that and to-day's range of highly effective treatments has resulted in the complaint being shorn of its terrors. Although it is still a notifiable disease, it is not now one of any special public health significance. The usual enquiries are made following receipt of notification but almost the only point of interest is whether or not there is likely to be a confinement in the house in which the patient is, or whether the sufferer might have been in contact with an expectant mother. The reason for this interest is that the organism causing erysipelas can result in infection of the puerperal woman. MENINGOCOCCAL INFECTION Although during the year, 13 persons were notified as suffering from cerebro-spinal meningitis, in only five instances was the diagnosis confirmed. Two of these cases were a man and his wife who fell ill within 5 days of each other. Three of those attacked were adults ; two were babies, one aged 4 months and the other 12 months. The cases were scattered throughout the district and occurred at different times throughout the year. All were admitted to hospital, three to general hospitals, the others to isolation hospitals. ACUTE ANTERIOR POLIOMYELITIS Although six persons had previously been admitted to hospital suspected to be suffering from poliomyelitis, but in whom the diagnosis was not confirmed, it was not until September that the first case was recognised, this being a girl of 17 suffering from an abortive attack. A few days later, another girl of 15 was admitted to hospital with what was considered to have been an abortive attack. In October, a girl of 6 fell ill with a non-paralytic attack, and towards the end of the month a boy of 12 was admitted to hospital with what proved to be a paralytic attack, the shoulder muscles being slightly affected. In November there were two cases, a child of 11 months suffering from a paralytic attack 62 and an adult woman from a non-paralytic attack. The last cases were an adult female who in December succumbed to a non-paralytic attack, and an adult male who had a paralytic attack. In all, then, of the 8 cases, two suffered from abortive attacks, two from non-paralytic attacks, and four from paralytic attacks. Six of the 8 patients were females, One of the patients was a baby of 11 months, one a boy of under 5. one a girl between 5 and 10, two were girls between 15 and 20, and three were adults. In view of reports which suggested that recent operations on the throat, or the removal of many teeth, or recent inoculations might have some bearing on the onset of an attack, enquiries on these points are made in each case. The only instance of any of these events preceding an attack was in the case of the baby of 11 months, who fell ill on November 1st and who had had on September 12th received an inoculation against diphtheria in the left arm and on October 10th a similar inoculation in the right arm; paralysis appeared in the right thigh on the 2nd November. As at no time was there any marked prevalence of this infection in the district, no steps were taken this year to discourage the immunisation of children against diphtheria, or to defer operative treatment of tonsils and adenoids. The story of the progress of this infection in this country was not very different in the early parts of 1951 from what it had been in 1950, the outbreak of the preceding year diminishing in each case to a minimum of much the same size in each year in March. As contrasted with 1950, though, when the number of weekly notifications rose rapidly from the beginning of June to as many as 589 in one week in August, in 1951 the rise was very much smaller, the highest figure in this year being 134 in a week in July from which time there was a decline until the end of September. Prevalence was then a little higher for a while, but in the second half of October the fall was resumed, though at a slower rate. This slow rate of fall was in contrast to the rapid decline in the previous year. Nevertheless, by the end of the year the weekly notifications were still appreciably below those for the corresponding periods of the previous year. Before the high incidence in 1947, poliomyelitis in this country attained a marked prevalence only in the later summer months. That there is some factor affecting incidence related to the atmospheric conditions is further suggested by the fact that the first large scale invasion of this country occurred in a summer of such special weather conditions. That the wet conditions of last August and September might have had some action in curtailing any further rise in the prevalence of this disease may be some consolation to those whose enjoyment of their summer holidays was somewhat marred by the weather conditions. MEASLES The district was never entirely free from measles in 1950 when in all there were 1,005 cases. The curve of incidence in that year was symmetrical, rising from a weekly average of one in January to nearly 60 in May and June, falling to two in November. In the last weeks of December there was a sharp rise which was continued into 1951 to a 63 maximum in late February and early March with a weekly average of 180, the highest number of cases notified in any one week being 215. In the first quarter, 1,671 notifications were received. The fall in the next quarter was steady from a weekly average of nearly 100 in April to one of 25 in June, there being 802 notifications in this period of three months. For the rest of the year incidence was light, there being only 71 cases in the third quarter and only 4 in the last. In all, throughout the year, 2,548 cases were notified. In the main the disease was mild in character, there being only one death. 19 patients were admitted to hospital. Many schools were affected, especially during the Spring term, but in only three of them, namely, Cannon Lane, Harrow Weald, and Roxbourne were there more than 50 cases. As the organism causing measles has not been cultivated, it has not been possible to prepare a vaccine, or similar preparation against this infection. A temporary artificial immunity can be acquired by the injection of certain preparations obtained from the blood of those who have at one time suffered from an attack and which therefore contains anti-bodies. The immunity induced, though, is very short-lived, so that there is no point in this preparation being given in ordinary circumstances. Its use is reserved for those exposed to attack whom it is especially necessary to protect against the risk of contracting infection at that time. WHOOPING COUGH This district was never entirely free from this infection in 1950, the cases being more common in the summer months with an average weekly notification of 24. A fall in the autumn was followed by a sharp rise in December. 772 cases were notified during the year. The rise in the last weeks of 1950 was followed by a weekly incidence of 40 in January, February, and March, of 1951, there being 521 cases in the first quarter. Throughout the second quarter, the weekly average was only 10, in the third 17, and in the last quarter only 2. In all there were 780 notifications. Whooping cough caused the death of two baby girls of under the age of 12 months. 4 sufferers were removed to isolation hospitals for treatment. While many schools had many pupils suffering from whooping cough, none was especially heavily attacked. Although it seems these days to be a much milder infection than it was some years ago, whooping cough is still a disease of public health significance. Not only is it a most unpleasant complaint to suffer from, but it does result in some deaths, while too many of those who recover suffer permanent damage. For many years much work has been done in an attempt to make a preparation which would protect against the risk of contracting infection. Many encouraging reports were published but the position still remained in doubt. This was the state of affairs when 64 the Medical Research Council in 1946 started a field investigation to try to assess the value of a number of preparations. Their findings reported last year were that each of the preparations used in the trials was of some use, though some were markedly better than others. As the trial was started in 1946 and as much work has been done on these vaccines since, it is probable that to-day's preparations are even more efficacious than those used in the trials. Although in some districts arrangements had been made by which children could be immunised against whooping cough, no general scheme had been practised in Harrow until more was known about the efficacy of the preparations. It was felt that encouraging mothers to have their children immunised against whooping cough by preparations which might prove to be ineffective, might have weakened the confidence of the mothers, and have had an adverse effect on the arrangements for the protection of children against diphtheria. Since 1948, the responsibility for making such facilities available to children in this district has rested with the Middlesex County Council as the local health authority. The County Council had agreed to the facilities continuing to be made available in those districts in which they had been up to 1948. After considering the Medical Research Council's report on the findings of the enquiry, the County Council has agreed to facilities for immunising children against whooping cough being made available in all parts of the county. PUERPERAL PYREXIA The condition which is notifiable is a rise of temperature to a certain point occurring within a specified number of days of childbirth or miscarriage. The raised temperature may not be associated in any way with the patient's pregnancy or labour ; it may be the result merely of condition such as a common cold. It may, on the other hand, be associated with the pregnancy, being due to such causes as engorgement of the breasts. The serious states, though, which may be the cause of the rise in the temperature are infections of the genital tract. Such conditions may be serious not only to the patient but to others, and may be of public health significance, as there may be risk of spread of infection to others who may be other expectant or nursing mothers in the same Nursing Home or hospital ward, or may be other expectant or nursing mothers attended by the medical or nursing attendants who are looking after the infectious patient. In general, the notification of an infectious disease is sent to the Medical Officer of Health of the district in which the patient is at the time the disease is recognised, so that most notifications of puerperal pyrexia are sent to the Medical Officers of Health of the districts in which the mothers are at the time of their confinement. In the case of mothers who have been delivered in hospitals in London, and who develop puerperal pyrexia, the notification is sent to the Medical Officer of Health of the district in which the home of the patient is situate. 13 notifications of puerperal pyrexia were received during the year ; three of them related to mothers who had been delivered in hospitals in London. In only two instances was the rise of the temperature thought to be due to an infection of the uterine tract. 65 OPHTHALMIA NEONATORUM This is an infection of the eyes of an infant occurring within 21 days of birth. At one time the condition was very serious and resulted in blindness or marked impairment of vision of many. The practice of instilling prophylactic preparations in the eyes of the newly born is considered to have brought about the very satisfactory position of to-day. It is now not uncommon for no notification to be received in the course of a year. Last year, two cases were notified. One of the infants was admitted to hospital for treatment. In both the condition cleared up without any impairment of vision. NON-NOTIFIABLE INFECTIONS These infections are not notifiable and information about 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 of such infections. Chickenpox. This infection was markedly prevalent in the Spring term, much less so in the Summer term and attacked only a few schools and those only lightly in the Autumn term. Three schools had over 100 cases, Priestmead School being particularly heavily attacked in the Spring term. In all, 1,184 intimations were received. Mumps. This infection, too, was much more common than in the previous year, 569 intimations being received as against 268 in 1950. Although a few schools were attacked in the Spring term and there was some infection in the Autumn term, the condition was most prevalent in the Summer term. Stag Lane School suffered most both in the Spring and in the Summer terms. German Measles. 19 intimations were received of the occurrence of German measles, all of them being in respect of pupils at schools at which there were at that time no cases of measles. Influenza. Influenza as such is not notifiable, though influenzal pneumonia is. The number of notifications of this condition gives some indication of the prevalence of the disease, as do the later returns of deaths from influenza. Although the district escaped the heavy invasion to which some districts in the northern part of the country were subject in the early weeks of the year, it did not entirely escape and deaths from influenza were recorded for every one of the first 11 weeks of the year, the total number of deaths from this cause recorded in this period being 33. Throughout the rest of the year only an occasional death was certified as being due to influenza, the total number being 40. 66 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 1951:— 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 6 2 — 2 — — — — 5- 9 4 5 2 1 — — — 2 10-14 5 5 3 3 — — — — 15-19 14 18 1 1 — 1 — — 20-24 21 28 1 3 5 4 — — 25-34 37 40 4 4 7 9 1 2 35-44 29 13 — 3 10 1 — — 45-54 28 10 — — 1 1 — — 55-64 13 1 — — 1 — — — 65 and over 6 2 — — — 1 — Age uknown 2 — — — 1 — 1 — 165 124 11 17 25 16 3 4 It was pleasing to be able to report that for the year 1950 the number of new cases learned of was less than the number for the previous year, this being the first time there had been a fall since the disquieting rise in the numbers of notifications which took place during the war years. As contrasted with the figure of 439 in 1949, the number in 1950 was only 370. It is gratifying to be able to record a further fall even though it is not on the same scale, as only 358 cases were brought to notice last year. 30 of these notifications were the result of detection of the disease by the examination of some of the population by the Mass X-ray Unit. Of the 326 pulmonary cases, 80 were already suffering from the disease before they moved into this district. Of these, 12 were persons who came to live in London County Council houses. Five men were recognised to be suffering from the disease while they were serving in the Forces. Of the 116 males who contracted the infection while living in the district, 29 gave a family history of tuberculosis, a percentage of 24. The corresponding figure for females was 28. Of the 32 persons notified as suffering from non-pulmonary tuberculosis, at least nine had contracted the infection before coming to live here. Of those who were living here, where presumably they contracted the infection, five gave a history of contact with a relative at home. Although the number of cases notified each year has been falling, the number is still much more than the pre-war figures. The figures for this last year mean that new cases of pulmonary tuberculosis were brought to light at the rate of one case a day—and this in a district which on 67 other standards is considered healthy. All members of the population are exposed to infection by the tubercle bacillus. Not many years ago, most had been exposed to and had overcome their infection before they had reached school-leaving age. When an adult succumbs to infection, it may be that what is overcoming his resistance is a fresh infection, or it may be that it is the result of a reawakening of his childhood infection which had for many years remained dormant. Probably most frequently the latter has happened. There are many sorts of conditions which might bring about a lessening of the resistance which had been keeping the infection in check or which may have brought about an increase in the powers of invasion. An acute illness such as pneumonia or influenza might be the determining factor. So very often, though, there is no history of any such condition, and in these it can only be assumed that the battle has been lost because of some adverse environmental factor which in one case might be housing, in another nutrition, in yet another the conditions of work. And yet, if these are the important factors causing the breakdown of the resistance of so many, it might have been expected that the high rate of notification would have been paralleled by a lowering of the standards of the health of the population as indicated by the ordinary vital statistics. Then, too, in so many instances there is nothing which suggests that any of these factors have had any bearing on the onset of the disease. If the development of the disease in the adult is the result of a fresh infection rather than the result of a reawakening of an attack in childhood, opportunities for these added infections would be important. In a number of instances there is a family history of infection. Sometimes the greatest opportunity of transmission of bacteria is at the place of work ; but again enquiries bring to light little evidence of these possibilities. The effects of family contact are likely to have been greater in childhood and do not in the new cases of last year seem to have been responsible for many of the adult infections. Some of those afflicted work in trades which have an unenviable reputation in regard to the risks of the employees contracting tuberculosis ; but there were not many so employed. Because so little is known of why each of these 300-odd persons did in fact succumb to the invasion by the tubeicle bacillus, it is not possible to do anything specifically directed to this end to prevent the onset in others. The mere fact that the incidence is diminishing will itself lead to a further reduction as there will be that many fewer sources of heavy invasion in others. That this position is being reached is confirmed by the findings of the tests in children which show that the annual invasion rate of children is very much lower than it was only some few decades ago, with the result that many children now reach school-leaving age without having been exposed to, or having been given an opportunity to overcome, invasion. This suggests that it is all the more necessary to keep under close observation the adolescent who might now at the time of many stresses be meeting the tubercle bacillus for the first time. This is one of the steps that can be taken to try to control the disease, by detecting in these susceptibles the infection in its earliest stage when it is both curable and possibly not infective. For the rest, it would seem that reliance must continue to be placed on improving the environmental conditions of all members of the population, 68 so that they have an ample supply of good food, live in good houses and work contentedly under good conditions. 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 every person whose name is on the register is still in the district. The following table is a summary ot the changes which have taken place in the register during the year:— Pulmonary Non-pulmonary Male Female Male Female No. on register, January 1st, 1951 1029 847 128 141 No. of new cases added 165 124 11 17 No. of cases other than on Form A 25 16 3 4 No. of cases restored to the register 5 7 — — No. of cases removed 109 91 14 10 No. on register, December 31st, 1951 1115 903 128 152 Of the deductions, 106 (96 pulmonary) were of persons who had left the district, 60 (54 pulmonary) were of persons who died, 44 (37 pulmonary) were of persons who recovered, while 14 (13 pulmonary) were of persons in respect of whom the diagnosis was withdrawn. The total net increase to the register, including pulmonary and non. pulmonary cases, was 153, a figure to be compared with that of 160 for the previous year. Deaths. Forty.one persons (25 male and 16 female) died from pulmonary tuberculosis during the year and seven (four male and three female) from non.pulmonary tuberculosis. This infection, therefore, accounted for a death rate per thousand population of 0.18 and for 2.0 per cent. of the total deaths, the same proportions as in 1950. The corresponding figures for 1949 were 0.26 and 3.0; and for 1948, 0.42 and 4.9. Preventive Measures. Early diagnosis is an important factor in limiting the spread of infection. So, too, is the provision of suitable accommodation to which the infective can be admitted and so reduce the risk of spread of infection. For this reason, then, the work of the Regional Hospital Boards which have been made responsible for the provision of hospital beds for the treatment of tuberculous patients and for the diagnostic work in connection with the disease has its preventive character, independent of the 69 preventive and welfare aspects of the services provided by the local health authorities. As environmental factors especially housing are so important in this disease, the contribution which the local sanitary authority can make towards its prevention is the improvement of the housing conditions of those families which have a member suffering from the disease, or who are close contacts of the infection. All three bodies, then, have their part to play in the control of this disease. Diagnosis. 30 notifications were the result of the detection of the disease in persons presumably apparently well who had been examined by the Mass X-ray Unit. This Unit visited the district in April, June and July. Representations had been made by different bodies to the Education Committee that all children at school should be examined in this way. As the number of units is limited, as is also the number of people trained in the use of these machines, even if it were desirable, it would not be possible to arrange for the regular examination of every person. It is most desirable, then, that the units available should be used to examine those in groups which are likely to yield the highest proportion of hitherto unrecognised sufferers. Adolescents and young adults probably fall into this category, especially those employed in certain classes of work, but not very young children. The Education Committee agreed that when the unit should visit the district, if possible, arrangements should be made for the older children at the Secondary Grammar Schools and the leavers at the Secondary Modern Schools, to be offered the opportunity of being examined. This was done, except that an invitation was not extended to the pupils of one of the Secondary Grammar Schools where a detailed examination of the pupils had only recently been carried out. There was quite a satisfactory response to this invitation. The unit while in the district examined the personnel at certain factories and in addition, held a number of open sessions which any member of the public could attend. Unfortunately, the way in which the records of the unit are kept does not lend itself to an analysis which can relate these findings to the local population, and of those persons examined at a factory or even examined at an open session, it is not known how many are local residents. In all 12,598 persons were examined, 5,380 males and 7,218 females. Of these, 3,852 (2,109 and 1,743) were employees of local factories; 1,543 were Civil Servants; 631 were Local Government Officers; 56 were members of H.M. Forces, and 541 were school children. The public sessions were attended by 1,786 men and 3,989 women. Out of 12,598 examined, 494 were recalled for examination by large films. In regard to 379 of these, no further action was necessary. Further investigation was called for in respect of the remaining 125, though in only about one-quarter of them was the disease recognised. The incidence of infection amongst the school children examined was exceedingly low ; in fact, at only one school was any case detected and it is probable had the unit not come to the district that this child would have been detected, because investigations which would in the ordinary way have been carried out following the recognition of the infection in one 70 pupil, were not carried out because it was known that the unit was shortly to visit and that the pupils were to be encouraged to attend for examination. As almost all these older children were found to be free from disease, it seems certain that there is no point in examining large numbers of younger children as a routine measure. It would be a different matter, of course, if for any reason pupils, even young ones, were considered to have been expecially at risk of contracting infection. The 30 cases which were diagnosed as the result of the examination of some 12,000 persons by the unit were persons in whom presumably, if it had not been for that examination, the disease would have progressed. Not only have these persons, as individuals, benefited because they can now have treatment for the disease in an earlier stage of its development than they otherwise would have had it, but the public also has gained in that each patient was an unknown spreader of the disease for a shorter time, while as well it might in some cases be that the disease has been recognised in such an early stage and can be cured without that person ever becoming a spreader. While, then, the activities of the unit in any year might result in the number of notifications for that year being larger than otherwise they would have been, its effects must in future years be a reduction in the number of sufferers. Schools and Tuberculosis. Towards the end of 1950, a girl aged 16 attending one of the Secondary Grammar Schools was found to be suffering from pulmonary tuberculosis : she had positive sputum. Arrangements were made for all pupils and staff of the school to be offered the facilities for being tuberculin tested and being examined by the Mass X-ray Unit. The work was done by Dr. Grenville-Mathers, physician of the Harrow Chest Clinic. No case of tuberculosis was found amongst either the pupils or the staff and the incidence of Mantoux positive children was very low, there being only 57 out of 348 girls, 56 out of 312 boys, and 17 out of 28 members of the staff. In the summer of last year a girl of 15 at a Secondary Grammar School was found to be suffering from pulmonary tuberculosis. No investigations were carried out at the school because all pupils of 16 and over at this and other secondary schools were being invited to attend for examination by the Mass X-ray Unit which was coming to the district in June and July. Of the pupils from this school who attended for examination, two were found to be suffering from pulmonary tuberculosis ; one of these was a member of the same class as the previously detected case, the other was not. By the time the information about these other two girls became known, it was too late to do anything at the school which was about to break up for the summer holidays. In view of the long time which would elapse before any arrangements could be made through the school, the parents of all the pupils and all members of the staff were written to advising them that it would be as well for them as contacts of a case to be examined. This was desirable in the interests of any of the contacts who might have contracted the infection so that the disease could be detected in the earliest stages, and was also desirable with a view to detecting any spreader of the infection, if there 71 was one. When the school re-assembled, it was found that many of the pupils and many of the staff had attended for examination and more did so about the beginning of the term. Ultimately, every member of the staff was examined and all but 73 of the pupils, all with negative results. At any time, such an enquiry can be carried out only as the result of much work. In the particular circumstances obtaining at this time, it was possible to arrange for the examination of such a high proportion of those at the school only by the very generous help given by the headmistress of the school and by those at the Chest Clinic. Early in the Autumn term, it was learned that two pupils, a boy of 13 and a girl of 12 at one of the secondary modern schools had been diagnosed as suffering from pulmonary tuberculosis. Because of the possibility that both had been infected by a spreader at the school, arrangements were made for Mantoux testing all the pupils with the intention of carrying out a further examination of those found to react. 1,058 pupils and 32 members of the staff were examined, but no cases were found. In some districts, children detected to be suffering from tuberculosis have been thought to have contracted infection at the school, more especially when it has been discovered that a pupil of the school has been suffering from open tuberculosis. The findings of the work done in the schools in this district in this last year do not suggest that the risk of spread from a pupil to his fellows is very great. That no cases at all were found amongst the contacts of a pupil at school does raise the question of whether the work involved in examining all the contacts is necessary. On the other hand, had even one case been found where it was suspected that the infection had been contracted at school and which perhaps would not have been detected for some time unless these examinations had been undertaken, there would be no question but that the finding of that single case would have been ample reward for the expenditure of much work. Until more is known of the magnitude of the risk, it would seem better to continue to carry out such investigations even though the findings continue to be negative. Whatever might be found to be the size of the risk of spread from a pupil to his fellows, it is felt that that from an infective teacher must be very much greater. When therefore it was learned that a female teacher at one of the secondary grammar schools was an open case of pulmonary tuberculosis, arrangements were made to Mantoux test all the girl pupils at the school. 300 pupils were examined but no further cases were discovered. 72 THE MEDICAL OFFICER OF HEALTH It is now over 100 years since the first Medical Officer of Health in this country was appointed, and over 75 years since every district was required to appoint a Medical Officer of Health. For many years, these were mostly part-time officers selected from those who were in general medical practice in the locality. They were, of course, more especially concerned with the problems relating to the environment of those living in the community. They were especially interested in securing a sufficient and satisfactory water supply, efficient drainage, sewerage and sewage disposal, and in securing freedom from nuisances or any other states that might be injurious to health. They were, above all other interests, concerned in the control of the spread of infectious diseases and many, in time, were in charge of the isolation hospitals which were built to admit the infectious sick. Other legislation passed after the Public Health Act of 1875 gave them added responsibilities and powers to deal with such matters as unsatisfactory housing, pollution of rivers, and adulteration and contamination of food supplies. When the provision of the personal services which are the development of this century, was added to the duties of many of the larger local authorities, not only did many of these find it necessary to appoint their medical officers of health as full-time servants, but they also found it necessary to appoint additional medical staff to undertake such duties as the medical inspection of school children and attendance at infant welfare sessions. In the meantime, County Councils which had in effect no responsibility of a public health character until the turn of the century, acquired some by their being the authority responsible for the administration of certain provisions of the Midwives Act of 1902 and the Education Act, 1902, not throughout the County, but only in those parts of the County lying outside of the boundaries of the larger districts. The very big extension of the maternity and child welfare services under the Maternity and Child Welfare Act, 1918, was in effect the limit which the responsibility of the local authorities—as opposed to the County Councils—for the personal services reached, because almost all new services went to the County Councils and County Borough Councils. Apart from County Boroughs, then, in all districts there were services provided, some by the County District Councils, some by the County Councils. In the meantime, the same arrangement of appointment continued, in most of the smaller County Districts, the Medical Officer of Health for the district being only a part-time officer of the authority. In the 1920's the practice grew of the making of combined appointments, the officer engaged whole-time in the public health service being for part of his time, Medical Officer of Health of the district, and for the remainder an Assistant County Medical Officer. This practice was markedly extended by arrangements made under Section 58 of the Local Government Act, 1929, by which " The Council of every County Council shall after consultation with the Councils of districts wholly or partly within the County formulate arrangements for securing whether by a combination of districts or otherwise that every Medical Officer of Health subsequently appointed for a district shall be restricted by the terms of his employment from engaging in 73 private practice as a medical practitioner."Some districts combined in the appointment of a Medical Officer of Health who was then engaged full-time in the duties of a Medical Officer of Health. The more common arrangement was and is for the Medical Officer of Health to be appointed in such a way that he is engaged as medical officer of the one district, being responsible for the supervision of the health services to different authorities—for the impersonal or environmental services to the District Council and for the supervision of the personal services to the County Council. The Education Act of 1944 transferred the responsibility for providing the education services previously maintained by many district councils from those to the County Council ; included in this transfer, of course, was the responsibility for the School Health Services. In the same way, the National Health Service Act transferred to County Councils from even more district councils, the responsibility they had had in providing maternity and child welfare and midwifery services. By these changes, County Councils have become responsible for providing these personal services throughout their administrative areas, and the district councils, shorn of the responsibility of providing these personal services, have returned to their position of the last years of the last century when they were responsible for the maintenance only of the impersonal or environmental services. The Medical Officer of Health of the District Council as such, then, has much less responsibility. In some areas, the local authority has retained its Medical Officer of Health in a full-time capacity, even though he is no longer responsible for the supervision of the personal services previously provided by his authority. In most areas, though, arrangements have been made by which the Medical Officer of Health who had previously been responsible for the supervision of the personal services, continued to be associated with them. This is the arrangement in Middlesex. In general, there is more to be said for such an arrangement than that by which the Medical Officer of Health is dissociated from the personal services, because there are so many points of contact of these services that it is helpful if there is one person whose duties overlap on each side of the dividing line. Probably the Medical Officer of Health, as such, is put in a better position to carry out the many and varied duties of his appointment, if he is given the opportunity of being closely associated with as many as possible of all the activities which comprise the health services of the district. The Middlesex County Council and the various District Councils agreed on such an arrangement and in regard to most, agreed to an allocation of the time of the officer: 40 per cent. as Medical Officer of Health of the district, and 60 per cent. on County Council duties. This arrangement was reached at a time when many changes were about to be made and when no one could be expected to see exactly what would develop. There was in the minds of a number, doubt about the correctness of the allocation of the time; but at that time no information was available which enabled anyone to demonstrate that the suggested allocation was, in fact, wrong. Since that time, experience of the working of the arrangement has been obtained—but even now it is not easy to produce any returns which can show what the correct allocation should be. One line of approach to get the answer is to consider what should be the 74 population of a district which needs the whole time of a Medical Officer of Health engaged solely on county district work—but it is not easy to determine this, as so many factors have to be taken into account. A scattered rural district with a small population might call for more time than a district with a larger population living in a compact urban community. The health problems in old established towns can be so very different from those in even larger dormitory districts; then there are the added difficulties if the work of the Medical Officer of Health is shared by more than one sanitary district. If it is accepted that a town of, say, 80,000 to 100,000 can use the whole-time services of a Medical Officer of Health solely engaged on the environmental services of the County district, then it might well be that in a rural district and more so in a combination of rural districts, there would be sufficient work even though the population were as low as 50,000 or even less. On the other hand, in new dormitory communities with their homogeneous character, the same volume of work might not arise even though the population were 150,000 or even more. As Medical Officer of Health of a district administering no personal services except for his duties in regard to the control of infectious diseases, he is responsible for the work of the Sanitary Inspectors and his special training as a medical man is not used to the full. If he is in charge of a large district maintaining the personal services, then again he will spend his time largely in administrative duties though in this case much time will be spent on work for which the background his training gave him is essential. It is unfortunate that promotion to offices of higher responsibility takes the Medical Officer of Health from those duties for which he elected to train and removes him in many cases entirely from the field of clinical medicine. From this point of view, the position of those in charge of small districts where they would spend the minimum time on administration, and the maximum on contact with persons, was the best, the Medical Officer of Health, with the help of one or more medical assistants, himself being in charge of the isolation hospital and the maternity hospital, and himself seeing mothers at the infant welfare centres and ante-natal clinics, and children in the schools. Such a Medical Officer of Health was in the best position to get to know his district and to learn at first hand of any factors which might adversely affect the health of those living in the district. But to-day, such sized units no longer exist as separate entities, as their personal services have passed into the hands of the County Councils. The time of the Medical Officer of Health of the last quarter of the last century was taken up with his concern about the adequacy and the purity of the water supply, about the satisfactoriness of the drainage and of sewage disposal. To-day's Medical Officer of Health has no direct responsibility in maintaining these services, although he is only too aware of the dangers following pollution of water or of the nuisances or risks which would follow a breakdown in the sewerage system. Recent legislation, too, has removed from those in the Public Health Department responsibilities which they previously had in such matters as the conditions under which milk was produced. What is there in the way of additional work to balance these losses? First of all, perhaps there will be the many complaints which have to be dealt with now, numbers greater 75 than before because of a general raising of the standard of the fitness of things possessed by the community which results in conditions not being endured to-day which presumably before were tolerated without complaint. Then there is the large volume of work to bring about the repair of houses because so many landlords and their agents to-day undertake this work of repair only on receipt of a communication from a Sanitary Inspector. Legislation such as the Shops Acts and the more recent Pets' Shops Act, impose additional duties on the staff of the Public Health Department. Much more attention is being given to the state of licensed premises or places of entertainment. Then, all over the country in the last few years, authorities have given much time in many different ways to the means by which a high standard of the handling of food in all its phases from production to consumption, can be achieved. This is largely an educative measure and is but an instance of the ways in which the members of the Public Health Department play their part in health propaganda. A completely new duty arising from Section 47 of the National Assistance Act which takes the staff of the Public Health Department to the homes of some of the elderly or infirm, and brings this staff closely into association with the Welfare and other officers of the County Council, and with those members of the staff of the Hospital Boards who have to decide on the admission to hospital of those who suffer from infirmity or chronic illness. The growth in the volume of work of this sort far outweighs the losses of some of those duties which were so important in the last years of the last century. When under the National Health Service Act local authorities lost their general hospitals, their isolation hospitals and their maternity homes, there were those who pointed to the additional powers given to them under the new Act more especially under Section 28, and the wider range of duties under Part III. There were some who seemed to see the Medical Officer of Health as a kind of liaison officer, helping to oil the wheels of administration of the services provided under the different parts of the Act including the general practitioner service, the hospital service, and those provided by the local health authorities. Whatever might have been or even now might be the position of the Medical Officer of Health of the local health authority (and it might well be that in those County Boroughs which are not too large, the Medical Officer of Health himseif might have an important part to play on these lines) there seems to be no place at all for the Medical Officer of Health of the minor authority whatever might be the size of that authority. And yet the 1925 memorandum (which even yet has not been revised) says that the chief function of the Medical Officer of Health is to safeguard the health of the area for which he acts by such means as are at his disposal and to advise his authority how knowledge of public health and preventive medicine can be made available and utilised for the benefit of the community. "He should endeavour to acquire an accurate knowledge of the influences, social, environmental and industrial, which may operate prejudicially to health in the area and of the agencies official and unofficial whose help can be invoked in amelioration of such influences." But he can advise only if he is informed. To put him in a really satisfactory position, 76 the information ought to reach him officially and it ought to be understood that he has a right to have it. It is because he can become aware of so much about the conditions of his district by his association with the Part III services that he is that much better a Medical Officer of Health to the district council if he has direct association with the maternity and child welfare, the midwifery and the school health services. It might well be that his knowledge of such services and the local conditions of his district could be of help to those administering the hospital services of his district. Factory legislation had different beginnings from that of the Public Health Service, so that the hygiene of industry has remained distinct from the Public Health services of a district. There were hopes that new legislation would lead to an integration of the factory health services and the general health services. These, however, have not been realised so that it is exceptional for a Medical Officer of Health of a district to be put in a position that he can really know of the effect of the industries in his district on the health of those living in the area. As matters are, then, in many districts, at least those of the minor authorities, the Medical Officer of Health is not placed in the position in which he can obtain that accurate knowledge of influences, social, environmental and industrial, in his area. The National Health Service Act transferred the responsibility for providing the maternity and child welfare service from minor to the major authorities. As there are no county boroughs in Middlesex, the County Council became responsible for providing these services throughout the whole county, in just the same way as they had been made by the Education Act, 1944, the Education Authority for the entire county. County Councils were given power to arrange for certain of these transferred services to be administered locally. The County Council divided the County into ten areas, for each of which an Area Committee was appointed locally to manage these services. In all but one of the areas, namely No. 5, which is coterminous with the Urban District of Harrow, the areas of two or more districts were included in each County area. For each County area an Area Medical Officer was appointed, though where an area comprised two County districts, each Medical Officer of Health was appointed Joint Area Medical Officer. It was agreed that the time of the Area Medical Officer should be allocated 40 per cent. to district and 60 per cent. to County Council work. There was at the time this agreement was reached, little enough information available to decide whether the allocation was correct. Even to-day, probably few enough of those concerned have any very definite information on the subject. This will be for a number of reasons. One is that probably few have analysed over a period, the way in which their time is spent. Then, too, it would often enough be a difficult matter to decide whether any particular problem being considered is being dealt with by the Medical Officer of Health or the Area Medical Officer. Environmental or other factors of a family which has a member suffering from tuberculosis may be considered by either, just as may be the circumstances of the elderly or chronic patient who might have to be dealt with by Section 47 of the National Assistance Act; by the Welfare Officer of the County Council or by the machinery of the Regional Hospital Board. The officer may 77 pay a routine visit to the kitchen in a maintained school in either capacity, just as he may deal with an outbreak of infection in one of the County Council day nurseries. At least one person holding the joint appointment of Medical Officer of Health and Area Medical Officer, feels that he is allowing the time he devotes to County Council work to be taken away from that he ought to be spending as the Medical Officer of Health. To that extent it would seem to point to the allocation being wrong. The County Council have recently indicated that they wish the proportion of time to remain as before. They seem, however, to agree to its not being correct, because they now offer (a thing which previously they were not anxious to do) to the district council part of the time of the Deputy Medical Officer, Assistant Medical Officers and clerical staff. Such an offer could be made only in complete ignorance of the position of the Medical Officer of Health of the district. When such an officer needs technical assistance, he needs the help of one who has had some experience in the administration of the district council's health services. To that extent the offer of the County Council is of little value. The solution surely must be found on other lines, namely, for the holder of the joint appointment to give more time to carrying out his duties as Medical Officer of Health and to strengthen his hands in administering the County Council's Part III Services, by increasing the time available to the more senior County staff in the district to help to maintain the Part III Services. If the ratio of time allotted to the Medical Officer of Health of a smaller district is correct, then it cannot be held that that same ratio can be correct in a larger district. If the smaller district needs 40 per cent. of the time of the holder of a joint appointment, a larger district must need something more, a proportion which in the case of the largest districts in this county, might rise to 75 per cent. or 80 per cent. This would leave something very much less than the present 60 per cent. for county work, but that time available would be spent in supervising the work of other county medical staff administering the county's services in the locahty. The following is an extract from the Annual Report of the Chief Medical Officer of the Ministry of Health for the year 1949:— "The appointment of district medical officers of health to do part time work for the county council has much to recommend it. It enables them to keep touch with the population of their areas at all ages, and forms a valuable link with the county medical officer. Where such joint appointments are made, it should not be forgotten that the primary responsibility of the district medical officer of health is to his local sanitary authority, because there is a statutory obligation on all those authorities to appoint medical officers of health, whose duties to them are laid down by statute. Too much emphasis on county work might lead to delay and confusion in dealing with outbreaks of infectious disease." Here is emphasised the primary responsibility of the district medical officer of health. What needs to be further emphasised is the importance of ensuring that medical officers in the public health service are in carrying out their duties in the posts to which they are appointed put into the way of gaining the experience necessary to enable them to undertake the 78 full range of duties of a medical officer of health. When joint appointments are made the prime consideration is the suitability of the candidate for the post of medical officer of health. He could then be offered to the county council to undertake the less responsible county council duties. The procedure ought not to be the appointment by the county council of a county assistant medical officer who is then offered to the district council as the medical officer of health.