ACU89(1)AARRow HARRM (Lalit mun B) Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1952 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW KING AND HUTCHINGS, LTD., PRINTERS, UXBRIDGE. Urban District of Harrow Annual Report OF THE MEDICAL . OFFICER OF HEALTH FOR THE YEAR 1952 TABLE OF CONTENTS page General Statistics 10 General Health Services: Hospitals 16 Nursing Homes 17 Establishments for Massage and Special Treatment 17 Nursing, etc., in the Home 18 Day Nurseries ... 19 Clinics and Treatment Centres20 Provision for Special Classes of Person24 Ambulances 27 Laboratory Facilities 27 Sanitary Circumstances 29 Sanitary Inspection: Housing 33 Inspection and Supervision of Food 50 Infectious and Other Diseases: Prevention and Control 53 Tuberculosis 66 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 1952. The health of the population as judged by the vital statistics was very satisfactory. There were no cases of diphtheria, no deaths from measles and only one from whooping cough. Influenza caused just a few deaths at the extremes of the year. There was a welcome fall in the number of cases of tuberculosis notified and in the number of deaths caused by this complaint. The infant mortality rate was low. The maternal mortality rate was slightly above the national figure. The excess of the local over the national rate was due to the inclusion of one case in which pregnancy could have had very little to do with the death. The other fatalities occurred amongst patients who had arranged to be confined in hospitals. Because of the financial difficulty the country continues to be in, and because of the steadily rising costs of different departments of the health services, there are those who feel that the country cannot afford to spend as much as is being spent on these services. (There is too, the view of those who maintain the country cannot afford ill health from a productive apart from a humanitarian angle). With the overlap which is only too possible under the present tripartite administration of Regional Hospital Boards, Executive Councils, and Local Authorities, the question is rightly being asked of whether some tidier arrangement might not be more efficient and more economical. Such thoughts lead to the question of the necessity to-day for at least some of the health services being provided by local authorities. Consideration of such problems leads back to the origins of the activities of local authorities in health matters. The position, of course, is that local authorities stepped in because the need for something to be done was there and no organised attempt was being made to meet those needs. Local authorities themselves might well have had their origins in the necessity of devising some machinery which would make it the obligation of some organisation or authority to see that the basic essential sanitary services were available for those living in every part of the country. The story of the development of the personal services runs on the same lines. The findings of those who examined recruits for the Boer War and the findings of the Royal Commission on Physical Training led to the passing of the Education (Administrative Provisions) Act, under which the only recently created education authorities were obliged to arrange for the examination of every pupil attending the then called elementary schools. It was not intended that anything more should be done than arrange for these examinations, the intention being that those found to be in need of treatment should be referred to existing agencies—the doctors and the 6 hospitals. It is only because these proved to be utterly incapable of meeting the demands that local education authorities were obliged, haltingly at the start, to provide treatment services; a gradual extension led to to-day's widely embracing school health services. In a similar way, the shockingly high infant mortality rate, and the mortality and the morbidity following childbirth led to beginnings which have grown into to-day's maternity and child welfare service. Arrangements for the detection and the treatment of those suffering from tuberculosis were followed during the years of the first world war, because of the sharp rise in the incidence, to similar provisions being made for those suffering from venereal diseases. Up to this time, there had been no organised provision for those suffering from these conditions. A similar development led to a number of to-day's personal health services and ultimately, in 1930, to local authorities becoming responsible for the first time for seeing that there were adequate general hospital services in their districts. To the question of when does a health problem become a public health problem? the answer has been given: When or if a given problem of health and disease can no longer be resolved by the unassisted effort of the citizen and the unco-ordinated resources of the community. Judged by this standard, these were all public health problems. But because the magnitude of a problem was such that it could be dealt with only on a community basis, so necessitating a further public health service to cope with it, must the answer always be the continuation of the local authority activity? When medical inspection of school children was introduced so many were found to be ailing, diseased, or crippled, that they could not be attended to by the existing agencies. The minor ailment clinics which were established were crowded with those attending for treatment of sores, impetigo, and running ears. At to-day's clinics few attend for such treatments: instead, the whole character of the clinic has altered, and they have become essentially consultation clinics. The reduction of the numbers needing treatment has completely changed the position and what treatment is now required can be made available by agencies other than the education authority. But there is still the need for the routine medical inspection of the school children or of something to take its place. The maternity and child welfare service has grown on the basis of home visiting by the health visitors and attendances at clinic sessions. The service was introduced when the infant mortality rate was about 150; to-day this rate is in the 20s. Is this service now necessary? The giving of a correct answer is complicated by to-day's shortages of health visitors. There is no doubt about the desirability of the health visitors continuing to keep in touch with the mothers. When home conditions were bad, this contact had had to be in the home. Under to-day's conditions, at least in an area such as this, this is the less necessary once the health visitor knows of the homes. A health visitor though can keep in touch with more if the mothers come to her at the clinics. Shortage of health visitors then may be a reason for continuing the clinics which otherwise might not have been found necessary. If they are to be closed though, some alternative 7 satisfactory arrangement for group teaching would need to be made. One alternative to the continuation of a local authority clinic is something on the same lines provided by the family doctors who could be helped by the health visitors. Even though the time comes that the family doctor has sufficient time to be able to do this, it is unlikely that all would wish to. In that case it would be necessary for some organisation to arrange the sessions on the lines of to-day's clinics to meet the needs of the mothers who attend those doctors, that is, until there are sufficient health visitors to enable full home visiting once more to be undertaken. It would seem then that just as the school health service can be shorn of many of the treatment arrangements, many of the existing maternity and child welfare arrangements can come to an end; but, just as the periodic observation of school children is essential, so are the services of the health visitors to the mothers. So far then from the position being that once an authority establishes a service it should continue to provide it, it is rather that authorities should constantly have in mind, particularly in times of change, the possibility that the objectives of the service have been achieved, and that so far as the authority is concerned, these services can then be curtailed. If this were done, it would leave the authorities free to undertake fresh responsibilities in other fields, undertakings which they might be able to take on without increased cost and without the necessity of recruiting additional staff because they have reduced their commitments in other fields. The preventive services are being reproached for having done so little against the very important groups of diseases, the cardio-vascular complaints, cancer and peptic ulcer. There is now so very much less need than formerly to concentrate on the teaching of mothercraft and on the control of infectious diseases—but, a steadily growing need to study the conditions leading to psychotic disorders and to helping the unwanted and the neglected. From the time that local authorities were virtually forced into the field of curative medicine, the boundaries between preventive and curative medicine have become blurred. Local authorities are responsible not only for environmental but also for personal services. These cannot tidily be allocated to the various types of authority, environmental to the minor and the personal to the major, if only because of the extent to which the health of a family is bound up with its housing. Perhaps the most urgent step is for an appreciation by those in each of the branches dealing with patients of the services of the others and for an understanding between those of the public health service, general practitioners and hospital staffs. Only by the closest working of those in these various branches can patients be helped to obtain full benefit of the services available to them. The question of what further powers might be delegated to district councils by the County Council was at the end of the year to be discussed by representatives of the County Council and of the district councils. In connection with the arrangements for carrying out those of the Part III services which the County Council could delegate to district councils, the following report was submitted to the Public Health Committee: 8 " It will be remembered that at their last meeting, the Committee agreed to this subject, Delegation of County Health Services, being discussed at their next meeting. As consideration is limited to any changes which can be brought about within the framework of existing legislation, matters such as the administration of the Food and Drugs provisions of the Public Health Act are ruled out, and the issue narrows down to the administration of the Part III Services of the National Health Service Act. The position as seen by the Public Health Committee of the Council is rather different from that of the local Area Committee, as there is for them a wider range of possibilities. Any one of a number of steps can be taken: 1. The Council could of course elect to have nothing to do with the administration of the Part III Services of the County Council. This line has been taken by a few of those authorities which had themselves up to 1948 maintained maternity and child welfare services. This decision prevented that closeness of association between those responsible for the environmental services and those providing the Part 111 Services which is so desirable. 2. The Act does allow for the Council being virtually responsible for the administration of certain of the Part III Services. Under Section 22(4), regulations could have been made giving to those authorities covered by schemes of divisional administration in regard to the education services, similar powers in regard to some of the Part III Services. In point of fact, no regulations were made. If any were made and the powers in this section applied to this district, the range of service which could have been passed over would be very small, and it is far better that other closely related Part III Services which could not have been handed over under these arrangements, should be provided by the same body as the one providing these more restricted ones. There is then, little point in anything being done to try to have regulations framed with a view to the Council's acquiring these limited powers. 3. The County Council has taken advantage of the provisions contained in the Fourth Schedule of the National Health Service Act. Paragraph 6 of Part II of this reads: "The Health Committee of a local health authority may, subject to any restrictions imposed by the local health authority, establish such sub-committees as the Health Committee may determine, and any sub-committee established under this paragraph shall be constituted in such manner as may, subject to any restrictions imposed by the local health authority, be determined by the health committee, and at least a majority of every sub-committee shall be members of the local health authority or of a local authority for any area forming part of the area of the local health authority." The County Council used these powers to set up in each of the 10 areas into which the County was divided an Area Committee, each being a sub-committee of the health committee. 9 (a) It does seem that it is in the power of the County Council to constitute that committee in such a way that it could be much more closely associated with the District Council, because the committee could be so constituted as to have on it even a majority of members of the District Council. If this were done there would be point in exploring the possibility of using officers of the Clerk's Department and the Treasurer's Department of the Council in the administration of the work for which that committee was responsible. (b) The last method of procedure is the one adopted by the County Council in constituting its Area Committees. The method did not lead to there being any close association between the Health Committee of the County Council and the District Council. Circular 118/47 of the Ministry stressed the desirability of using the knowledge and experience of local bodies in the administration of the Part III Services. If the committee is to achieve this, it is essential for the County Council or its Health Committee to give to each local Area Committee greater powers to do the work entrusted to it. The County Council has the necessary powers to do this. Paragraph 7 of the Fourth Schedule reads: ' The Health Committee of a local health authority may, subject to any restrictions imposed by the local health authority, authorise any subcommittee to exercise on their behalf any functions of the Health Committee.' But the County Council or the Health Committee do not seem really to favour authorising the local Area Committee to exercise on their behalf any of the functions of the Health Committee." I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, " Cottesmore," Uxbridge Road, Stanmore, Middx. 13th June, 1953. b 10 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population mid-year 1952 219,000 Rateable Value (1st April, 1952) £2,232,470 Sum represented by a penny rate (1st April, 1952) £9,085 Total number of occupied houses 53,729 Total number of occupied flats 8,382 Extracts from Vital Statistics for the Year. Live Births:— Total Male Female Legitimate 2,736 1,391 1,345 Birth rate per 1,000 population 13 0 Illegitimate 119 62 57 Total 2,855 1,453 1,402 Stillbirths:— Legitimate 49 29 20 Rate per 1,000 total births 18.2 Illegitimate 4 2 2 Total 53 31 22 Deaths 1,920 1,021 899 Rate per 1,000 population 8 7 Deaths of infants under one year of age 62 Infant mortality rate 21 7 Legitimate infant mortality rate 21 5 Illegitimate infant mortality rate 25 1 Deaths from pregnancy and childbirth 4 Rate per 1,000 total births 13 Deaths from Cancer 386 Measles 0 Whooping cough 1 Tuberculosis 38 Population. The mid-year population of the district was 219,000, a decrease of 1,000 on the mid-year population for 1951. The natural increase in population, i.e., the excess of births over deaths during the year, was 935. Births. The total number of live births registered during the year was 2,855 (1,453 male and 1,402 female). Of these 119 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, 2,895, and 2,895. 1,037 births occurred in the district (1,031 live, six stillbirths). Of this number 147 were to residents of other districts. 1,916 (1,873 live and 43 still) birth notifications were transferred from other districts, 11 being mostly of births occurring to Harrow mothers in hospitals in Middlesex or in London. Deaths. 1,358 persons died in this district in 1952. Of these, 228 were persons who were not resident in the area. 42 deaths took place in the various hospitals and 54 in private nursing homes. Of the 761 deaths of the local residents which occurred outside the district, most took place in institutions, 279 being at the Edgware General Hospital. Two mothers and two new-born infants died at maternity hospitals. 230 deaths took place in hospitals just outside the district, including four in nearby isolation hospitals, and 130 in various London hospitals. Vital events in England and Wales are registered in the areas in which they occur, and the addresses in which they occur are recorded in the registers. When the address is not the usual residence the Registrar transfers the event for statistical purposes to that place. Vital events relating to people with no usual residence within England and Wales are not transferable. This means that if anyone dies in this district whose usual place of residence is not in England or Wales, this death is allotted to this district. In this way the number of deaths for last year is swollen by 16, the number of persons not ordinarily resident in England and Wales who were killed in the railway accident at the Harrow and Wealdstone Station in October. X Certain types of institutions are not regarded in ordinary circumstances as the usual residence of those living there. These include general, maternity, and special hospitals, maternity homes, nursing homes, sanatoria, convalescent homes, homes for unmarried mothers, hotels, boarding houses, etc. On the other hand, there are many institutions which are regarded as the usual residence of their inmates. These include accommodation provided under Parts III and IV of the National Assistance Act, 1948, boarding schools, convents, nursing homes for the aged and chronic sick, nursing homes (mental) and residential nurseries. Any deaths occurring then in the following institutions in this district are allotted to this district: — Cottage Hospital, Stanmore; Oxhey Grove Hospital, Hatch End; Little Company of Mary Nursing Home, Harrow; St. Saviours, Harrow View, Harrow; Stanmore Residential Nursery, Honeypot Lane; St. Dominics Convent School, Harrow; Wembley Eventide Homes, Priory Close, Harrow; Springbok House, Stanmore Hill; St. Josephs Convent, High Street, Wealdstone; " Woodcote," Stonegrove, Edgware; Bowden House, Sudbury Hill, Harrow; Roxbourne Hospital, Rayners Lane, South Harrow; Blythwood House, Uxbridge Road, Pinner; Chiswick House, Moss Lane, Pinner; Pinner House. The occurrence of deaths at most of these institutions is not common except such of them as provide accommodation of the type provided at the Roxbourne Hospital. 12 The following is the Registrar-General's abridged list of causes of death in this district: — Male Female Resp. tuberculosis 20 14 Other tuberculosis 1 3 Syphilitic disease 5 0 Diphtheria 0 0 Whooping Cough 1 0 Meningococcal infections 0 0 Acute poliomyelitis 1 0 Measles 0 0 Other infective diseases 2 0 Cancer of stomach 32 24 Cancer of lung 71 20 Cancer of breast 0 42 Cancer of uterus 0 10 Cancer of other sites 96 91 Leukæmia 3 5 Diabetes 3 5 Vascular diseases of nervous system 89 138 Coronary disease 188 83 Hypertension 22 37 Other circulatory diseases 42 48 Male Female Other heart diseases 104 142 Influenza 3 3 Pneumonia 39 33 Bronchitis 70 44 Other respiratory diseases 15 1 Peptic ulcer 17 9 Gastritis, enteritis 4 4 Nephritis 10 9 Hyperplasia of prostate 20 0 Pregnancy, etc. 0 4 Congenital malformation 15 11 Other diseases 64 84 Motor vehicle accidents 13 2 Other accidents 57 23 Suicide 14 10 Homicide 0 0 Total 1,021 899 The number of deaths, 1,890, was a marked fall on the 2,094 of the previous year which was the largest number of deaths recorded for this district. The death rate was 8 7 per thousand population. The rates for the district for the year 1944 onwards were 9 3, 9 0, 8 6, 8.5, 8.9 and 9.5. The rate for the country as a whole was 11.3. To offset the effect of the population of a district having a different age and sex constitution from that of the country as a whole, the Registrar-General calculates a comparative mortality index. When the death rate figure is multiplied by this, a figure is obtained which would be the death rate for the district if the age and sex distribution of the population were that of the country as a whole. The index figure is 1.16. The adjusted death rate therefore is 10.1, a figure well below that for the country as a whole. Of the 1,890 deaths, 1,021 were of males and 899 were of females. 72 per cent. of the males who died had attained the age of 55, and 83 per cent. of the females. The corresponding percentages for the previous year were 58 and 70. Infant Mortality. 62 infants died under one year of age. In the same year 2,855 babies were born. The infant mortality rate therefore was 21.7. The 13 rate for the country as a whole was 27 6, and for the district for 1951 was 221. The rates for the years 1946 and onwards were 31 0, 24 0, 28 8, 20.7, and for the year 1950 the exceedingly low figure of 13.6. Of the 15 deaths which occurred in those who failed to survive 24 hours, six were of those prematurely born; four infants had congenital defects and in three the mothers had had difficult confinements. 23 infants survived 24 hours but failed to survive one week. In the case of eight, delivery had been difficult; six suffered from congenital defects and in five births were premature. All but one of the seven who lived one week but failed to survive one month, suffered from congenital defects. Infections of the lung accounted for three of the six deaths of those who died between the ages of one and three months, of six of the seven who died between three and six months, and of two of the three deaths of those who lived six months but who died before reaching one year of age. Stillbirths. Only 53 stillbirths were registered in this district last year, this giving a rate of 0.24 per thousand population or 18.2 per thousand births, figures well below those of 0 35 and 22.6 for the country as a whole. Mortality of Infants between 1 to 5 Years of Age. Eight children survived their first but did not reach their fifth birthdays, the numbers in each year of age being 2, 4, 0 and 2. Of these deaths, developmental abnormalities caused three and non-infective diseases two; infections caused two of the deaths. Maternal Mortality. There were four deaths primarily due to or associated with pregnancy or childbirth. The maternal mortality rate was therefore 13. The figure for the country as a whole was 0.7. The first death was that of a woman of 41 years who had arranged to be confined in hospital. She was admitted at term, and was medically induced. A precipitate labour was followed by post-partum haemorrhage. The second fatality was that of a woman of 36 who had arranged to be confined in a maternity hospital; delivery was followed by post-partum haemorrhage. The third fatality was that of a woman of 32 who had booked at and was delivered at a maternity hospital, and was due to eclampsia and toxaemia of pregnancy occurring after delivery. The certificate of the remaining death read: 1 (a) uraemia; (b) chronic arteriosclerotic nephritis and hypertension; (c) toxaemia of pregnancy. The pregnancy, however, was some 20 years before the death. Deaths from Accidents. During the year there were 95 deaths (70 male and 25 female) from violent causes. Of these 44 were the result of the railway accident at the Harrow and Wealdstone Station on 8th October, 1952. Of this figure 28 were of those who lived in the district; 16 were of persons whose homes were not in England or Wales, and whose deaths therefore had to be allocated to the district in which they occurred. 14 15 deaths (13 male and two female) were the result of road accidents. Of these 10 occurred elsewhere than in this district. In most of these a motor vehicle was involved. There were five fatal road accidents in the district. Two of those who died were youths on motor-cycles who collided with lorries. Two were pedestrians, one being knocked down by a cyclist, the other by a motor-cyclist; and the other was a cyclist who was knocked down by a motor-car. Falls of the elderly accounted for the deaths of 13 (two male and 11 female). In nearly all instances the fall occurred at home; in only one case was it outside. Poisoning by coal gas was responsible for the death of only one person this year, as contrasted with a figure of seven in 1951. Burns caused the deaths of five persons, three of whom were elderly. Deaths from Suicide. There was a sharp rise this year in the number of persons who committed suicide, the figures being 24 (14 male and 10 female), the corresponding figures for 1951 being 18 (10 and eight). Eight of the men and seven of the women chose poisoning by coal gas. Four of the men chose other forms of poisoning. Two of the women elected death by hanging. In some years the distribution of suicides is fairly even throughout the year. This last year it was most uneven as 11 of the suicides took place in January or in November. The age distribution of the deaths in the two sexes differed markedly. In 1951, all of the females were above 40 years of age but under 70; the only difference this year was the one death in one over 70. As a contrast, two of the males were under 20, and two were in their 20's; the numbers in each of the succeeding decades were 3, 2, 1 and 6. None of the males was over 70. Deaths from Cancer. Of the 1,920 deaths of residents in the district, 386 were due to cancer, this causing 19 per cent. of the deaths of males and 21 per cent of those of females. Of the 199 deaths from this cause amongst males, in 69 the site was the lung (the same figure as in 1951) and in 32 the stomach. Of the 187 deaths amongst females, the site was the breast in 39 and 23 in the stomach, in 22 the lung (as contrasted with 12 in 1951) and the uterus in eight. Although cancer was the cause of death of three males of under 35 years of age, it was not until after this age that it figured as a substantial proportion of the deaths. In the age group 35 to 45, the percentage of deaths from this cause was 11; the percentage in the succeeding decennial periods was 23, 27, 20, and amongst those over 75 years of age only 14. Higher figures are recorded in each group for females, the percentage in the age group 35 to 44 being 33, and in the succeeding decennial periods 50, 35 and 16, and amongst those women who were over 75 when they died, in 20 per cent. the cause was cancer. This distribution is much 15 the same as that for 1951, the age group in which cancer was responsible for the higher percentage of deaths of males again being 55 to 64 and of females being again the group 45 to 54. After these ages, the percentages of deaths due to cancer fell for each sex and although the actual numbers of those dying from this cause over 75 years of age increased, the percentage of deaths from this cause was less, the lowering being because of the larger number of deaths from other causes in the more elderly. Although there was no increase in the numbers of males who died from cancer of the lung (a figure of 69 in 1952 as in 1951) the number of women who died from this complaint rose from 12 in 1951 to 22 in 1952. Death from Infectious Diseases. Infections other than tuberculosis again accounted for very few deaths in this last year, there being one only each from whooping cough and poliomyelitis, none from measles and only six from influenza. Tuberculosis accounted for 38 deaths, disease of the lung accounting for 34. The death rate per thousand population from the various infections again compared very favourably with those of the country as a whole. 16 HEALTH SERVICES OF THE AREA HOSPITALS General Hospital Services. 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.) In addition to the obstetric beds at the hospital, there is accommodation for maternity cases at the associated Bushey Maternity Hospital. 2. Harrow Hospital. This is associated with the Charing Cross Hospital, which, as a teaching hospital, is administered by a Board of Governors. (Secretary: S. Garbutt, F.H.A., Harrow Hospital. Tel. No.: Byron 2232.) The hospital maintains a physical treatment department at the Car Park Building, 227, Station Road, Harrow. (Tel. No.: Harrow 0926.) 3. Annexes. The former South Harrow Isolation Hospital which became the Roxbourne Hospital, provides accommodation for the elderly chronic sick of either sex. admissions being made from the Edgware General Hospital. Similar use is made of the accommodation at the former Stanmore Cottage Hospital. The 40 beds at Oxhey Grove have been allocated to short-stay chronic sick patients who are admitted for periods of 21 days to enable the relatives responsible for their care to take a holiday or, for one month, to give some small relief from nursing. In September, the National Association for the Care of the Aged acquired Warren House, Stanmore (now " Springbok House ") to be used jointly by the West Middlesex and the Hendon Group of hospitals. The accommodation is for elderly chronic sick patients well enough to leave hospital but not well enough to return to their own homes. 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 patients had to be taken to hospitals further, and sometimes much further, afield. 17 Convalescent Homes. Arrangements for the admission to convalescent homes of persons who need nursing care or medical treatment while they are at the homes, are made by the hospital Almoners on behalf of the Regional Hospital Boards. Persons who need only supervision and rest in homes which do not provide nursing care or medical treatment are admitted to homes by arrangements made by the local health authority. The usual length of stay is two weeks, though the time can be extended on the advice of the medical officer of the home. Patients or those responsible for them are expected to contribute towards the payment of the charges of the home. At one time recommendations were accepted from hospital Almoners on behalf of those attending as out-patients of hospitals. To-day, however, such patients are referred to their own doctors from whom most of the recommendations are now received. The applications are submitted to the Area Medical Officer, being passed to the County Medical Officer who decides on the homes the patients are to go to. No charges are made to the parents of children attending maintained schools who are admitted to convalescent homes under these arrangements. NURSING HOMES Any person who carries on a nursing home in this district needs to be registered. The responsibility for registering and supervising the homes rests with the Health Committee of the County Council, as this is not one of the services which has been delegated to the local Area Committee. This year saw a further fall in the number of nursing homes registered, and in the number of beds registered in the homes. At the beginning of the year 17 homes were registered; these provided 196 beds, of which 29 were for maternity cases. At the end of the year there were 16 registered homes which provided 172 beds, of which 22 were for maternity cases. A demand which continues to increase but one which has not been met, is for places which can accept elderly persons who so readily might become patients needing nursing care and medical attention. Before the war there were many homes in the district accepting at low fees elderly persons not needing much attention. Unfortunately, any provision of this sort still available cannot be obtained at the low cost which is essential if use is to be made of the accommodation by persons for long periods. ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT By Section 355 of the Middlesex County Council, Act, 1944, no person shall carry on in this district an establishment for massage or special treatment without a licence from the Council authorising him to do so. There is a saving clause for registered members of the Chartered Society of Physiotherapy and for members of the medical profession. Before approving the licensing of any premises, the Public Health Committee requires to be satisfied about its general suitability for the 18 work to be done in it, and about the equipment. Those in whose names the premises are licensed have to comply with the bye-laws relating to the conduct of these premises. Licences are issued for one year. Further reports are received by the Committee when they are considering the renewal of the licences. It is the premises which are licensed. Anyone who carries on the same treatment not at any premises but at the homes of patients, does not need to be licensed. Although the Council has power to refuse to grant or to renew a licence because the treatment might be administered by any person who does not possess such treatment qualifications as may be reasonably necessary, there is no power to specify minimum standards of the qualifications of the practitioners. At the end of the year there were in the district 25 premises licensed as establishments for massage or special treatment. 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. From August, 1951, when the Bessborough Road Nurses' Home was closed, the local home nursing service has been staffed partly by full-time nurses living at the Nurses' Home in Uppingham Avenue, partly by some whole-time nurses who live in their own homes and also by a number of part-time nurses who work mostly in the mornings and who are based on the home. The service is run under difficulties because of the inability to recruit sufficient nurses. Except to meet the needs of that part of the district served by nurses based on the Nurses' Home, the ideal is to have a number of whole-time nurses living in their homes distributed evenly throughout the area, each working the district immediately around her home, relief being provided by neighbouring nurses. In such circumstances, the medical practitioners would get directly into touch with the nurses about the treatment they wished their patients to receive. 2. Midwifery and Maternity Nursing. The County Council is responsible both for providing the staff of midwives necessary to attend on women being delivered in their own homes, and, as the local supervisory authority, for supervising all midwives practising in the district. The number of mothers confined in their own homes continues to fall. This is partly because there are fewer confinements and partly because a greater proportion of mothers are being delivered in hospitals. Whereas, therefore, at one time a staff of 17 midwives was necessary, there were at the end of last year only 13 Council midwives, a number which nevertheless was sufficient to meet the demands made on them. They attended, as midwives, 567 home confinements, and as maternity nurses, 139. The midwives live in their own homes. Expectant mothers get into touch with them either directly at their own homes or at the ante-natal clinics which the midwives attend. The midwives work under 19 the supervision of the Non-medical Supervisor of Midwives, Mrs. Bromley. 3. Home Helps. The County Council, as local health authority, provides domestic helps to households where such help is required because of illness, or the lying-in of an expectant mother, because of anyone who is mentally defective or is aged or because of children not over compulsory school age. Home Helps are engaged full-time or part-time; they are paid by the Authority. According to the financial circumstances of the household, part or all of this expenditure is recovered from those who are helped. Although in essence an emergency service or at least one which it is intended shall be provided for short periods only, many of those who are assisted need continual help because their difficulty is not so much that they cannot find someone to help them as that they cannot afford to pay for that help. This applies more especially when the help is given to' families where there is a member suffering from tuberculosis or where help is being given to the aged or to the chronically incapacitated. As contrasted with the arrangements for the engagement of nurses and midwives, the allocation of duties of home helps is made by the organiser of the service, Mrs. Chilvers, who works from the Area Health Office at " Kynaston Court" (Tel. No.: Grimsdyke 3131). DAY NURSERIES The County Council as local health authority continues to maintain the four day nurseries for which the Harrow Council was responsible in 1948, these being at Spencer Road, Wealdstone; Walton Avenue, South Harrow; Kenmore Road, Kenton; and Headstone Drive, Wealdstone. Each of these nurseries was well attended until towards the end of the year when the County Council altered the arrangements for the admission of children to these nurseries. This revision, which resulted in the exclusion of many children, partly because the financial circumstances of the parents of some of the children was above the standard set down, partly because many parents withdrew their children as they felt they could not afford to pay the higher charges which they were being assessed to make. From the time that these new charges came into effect, the attendances at the nurseries have been in general something under one half the number of places. The County Council had previously considered the needs of the various areas for day nurseries and had decided that the need in this district could be met by three nurseries The difficulty about this decision is that the two nurseries most closely situated are those which are best attended, so that the case for the retention of each of these is greater than that for the retention of either of the others. On the other hand, the distance of any other nursery from either of the other two is so great that real hardship would be imposed on the mothers of children at either of these nurseries if it 20 were closed, as they would not be able to arrange for their children to attend any other. The argument for and against day nurseries continues, but the fact remains that there will in any locality be a number of mothers who need to be helped to enable them to bring up their small children, and under present arrangements this help can best be given by arranging for their children to be looked after and so free them to go out to earn the family income. Children of over two but under five years of age are also admitted to one of the three nursery schools maintained by the Education Authority, these being at "Tyneholme," at Rayners Lane, and at Buckingham Road. Older children attend the nursery classes attached to some schools. CLINICS AND TREATMENT CENTRES The County Council as the local health authority maintains the following clinics and treatment centres in, or serving, the district: — Infant Welfare Centres. Elmwood Clinic, Elmwood Avenue, Kenton Mon. and Wed. p.m. Baptist Church Hall, Streatfield Road, Kenton Wed. a.m. and p.m. Broadway Clinic, The Broadway, Wealdstone Wed. a.m. and p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. p.m. St. Hilda's Hall, Northolt Road, South Harrow Tue. and Thu. p.m. The Clinic, Alexandra Avenue, South Harrow Mon. and Fri. p.m. Methodist Church Hall, Walton Avenue, South Harrow Thu. p.m. St. George's Hall. Pinner View, Harrow Tue. and Fri. p.m. Memorial Hall, High Road, Harrow Weald Thu. p.m. The Clinic, Honeypot Lane, Stanmore Mon. and Wed. p.m. Methodist Church Hall, Love Lane, Pinner Fri. p.m. St. Anselm's Hall, Hatch End Thu. p.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Thu. and Fri. p.m. St. Alban's Church Hall, North Harrow Thu. a.m. The Rectory, Elstree Mon. p.m. 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. 21 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 Alternte Thu. a.m. Baptist Church Hall, Streatfield Road, Kenton Spiritualist Church Hall. Vaughan Road, Harrow 1st Mon. a.m. in month The Clinic, Alexandra Avenue, South Harrow Wed. a.m. St. George's Hall, Pinner View, Harrow 1st and 2ndTue.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. 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, The 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. 22 Ophthalmic Clinics. School children selected by the school medical officers when seen either at the school inspection or at the minor ailment clinic can be referred to the surgeon at the ophthalmic clinic who holds sessions at Marlborough Hill on the mornings of Tuesdays and Fridays and 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. One of the changes brought about by the National Health Service was that it is no longer permissible for children under school age to be treated by the ophthalmic surgeon. Instead, these children have now to be advised to attend their own doctors, just as are any other members of the public who need attention for their eyes, being referred by them to ophthalmic surgeons or to opticians. During the year, the Regional Hospital Board took over its responsibility for the medical staffing of these clinics, which means that they now find the ophthalmic surgeons and the necessary locums to replace them. During the year, a whole-time orthoptist was appointed to work at the Marlborough Hill clinic; her work is by exercises to straighten squinting eyes. Child Guidance Centre. The same arrangements at the Child Guidance Centre (formerly the Child Guidance Clinic) at 2, St. John's Road, Harrow, have continued, though the Regional Hospital Board has now accepted responsibility for the medical staffing of the Centre. 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. 23 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. The changes brought about by the coming into operation of the National Health Service Act in July, 1948, very seriously affected the dental services provided by local authorities. The situation has somewhat eased, though probably no authority has the dental staff necessary for providing a full service to those in the priority groups. This district has been more fortunate than many, and in fact the complement of dental officers is now what it was before the war when each child attending school could be examined every year. This very desirable state of affairs does not now exist because of the larger number of children attending the maintained schools (partly because of the raising of the school age, partly because of the larger population of the district), because of the increased proportion of time devoted to the teeth of expectant and nursing mothers and of children under school age, and also because as a result of the years when there were fewer dental officers available, the average standard of a child's mouth is worse and each child therefore needs that much more treatment. At present, there are dental officers occupying almost to the full each dental surgery. In addition, a number of evening sessions are held by some of the dental officers. Although then it must be a long time before the pre-war standard of an annual examination can be reached, the position to-day is a marked improvement on the time when at some of the schools, at least, the interval between inspections was two years. The orthodontic surgeon is working full-time at the Marlborough Hill Clinic. Phvsio-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. 24 Care of the Feet. From the early days of the new Harrow Council, the principle was accepted that the Council, while providing advisory and educational services, would try to assist those bodies responsible for providing treatment services to put these at the disposal of selected groups of the population rather than the Council itself should provide such services. In this way it was understood that a foot treatment service would be made available by the Harrow Hospital for those in the district needing such attention. The matter was re-opened after the war when the possibility of the hospital's being able to make use of the First-Aid Post in the Car Park was being discussed, and at one time hopes ran high. Later, the hospital found itself unable to make arrangements on these lines. A limited chiropody service is provided in some areas of the county for children attending maintained schools, for nursing and expectant mothers and for children under school age. The County Council authorised the Area Committee to make similar provision in this district. To-day, then, these sections of the population in this district can take advantage of this service. While these perhaps are not the sections of the population who suffer most from conditions of the feet needing this form of treatment, there is room for much useful work to be done in dealing with them. Apart from this aspect, it is hoped that the activities of the chiropodist will result in more attention being given to this matter and that steadily more will appreciate what scope there is for preventing the development of disabling and painful conditions. 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 County was divided for these functions into the same 10 areas as for the administration of the delegated health services. In November a re-organisation was made. Harrow with Acton. Wembley and Willesden form the central division which is served by Shenley Hospital. The Mental Welfare Officer. Mr. W. J. Pedel, and other officers now work at Winkworth Hall, Chevening Road, Kilburn, N.W.6 (Tel. No.: Ladbroke 2411). 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 10 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 boundary dividing the persons falling into the one group from those in the other is very indefinite, more particularly in the case of the aged. The Ministry now distinguish the sick and infirm as: "Sick—and therefore proper to the board—patients requiring continued medical attention or supervision and nursing care. This would include very old people who, though not suffering from any particular disease, are confined to bed oil account of extreme weakness." "Infirm—and therefore proper to the local authority—persons who are normally able to get up and who could attend meals either in the dining-room or in a nearby dayroom. This class would include those who need a certain amount of help from the staff in dressing, in toilet, or in moving from room to room, and also those who, from time to time—e.g., in bad weather—may need to spend a few days in bed." c 26 The Aged. In 1901 there were in the country about half a million persons over the age of 65; they formed about 5 per cent. of the population. In 1947 there were some 41/2 million, constituting 10 per cent. of the population. It is anticipated that in 1967 there will be 51/2 million. The problem of the aged has come to the fore both because of the actual increase in their numbers (this is the factor of importance when there is competition for available services such as hospital beds which have not increased in the same proportion as the population) and because of the relative increase, a factor of importance when the ratio of consumers to producers is under consideration. Assuming the age and sex distribution of Harrow's population to be the same as that of the country as a whole, there are some 10,000 men and 14,000 women over the age of 65. Most of them of course need no special help, but on such large figures even a small percentage gives a number large enough to be a formidable challenge. The needs of those who require help vary. There is the hospital group, the group of those needing permanent medical and nursing attention; these are the responsibility of the Regional Hospital Boards. In some hospitals much encouraging work has been done which has shown that there is no need to allow many of these elderly chronics to remain bedridden. By treatment, rehabilitation, mobilisation and occupational therapy, many of those previously bedridden can be got up and many can reach the stage of no longer being hospital patients, being capable of transfer to welfare hostels. A number of hospitals, including the local Edgware General Hospital, have set up special geriatric departments with their specialist officers with their primary responsibility of seeing to the interests of those aged who are ailing. There are in this district hospital annexes such as the Roxbourne Hospital and the Stanmore Cottage Hospital which are the permanent homes of some of those transferred from the Edgware General Hospital. Another group is of those needing not the special nursing or medical care of the first group, but nevertheless requiring care and attention which is not otherwise available to them. These are helped by the Welfare Department of the County Council. The third group is that of those old people who are living as ordinary members of the community but who, nevertheless, are not really ordinary members because many have their own special needs. There is no official authority responsible for them, though many agencies, especially voluntary, help in different ways. The homes of the aged need special consideration from the point of view of the location of the accommodation, its design and its furnishing and equipping. As a housing authority, the Council has built a number of houses specially designed for the aged. The Harrow Housing Society, Limited (the Secretary, Miss D. Walding, 2, Manor Road, Harrow; Tel. No.; Harrow 1418), provides accommodation for a number of elderly persons at Pinner House, Church Lane, Pinner. A number of aged are helped to obtain meals. There is a luncheon club at the Assembly Hall, North Harrow, where old people are 27 served with meals at a charge of 1s. a meal. In addition, the Women's Voluntary Service maintains a "Meals on Wheels "service, taking meals to some old people confined to their homes. There are a number of old people's clubs in this area, including six "Evergreen" Clubs run by the British Red Cross Society and four "Darby and Joan" Clubs run by the Women's Voluntary Service. The Harrow Old People's Welfare Committee, on which are representatives of the many agencies in the district helping the aged in any way, helps to link up the work of these organisations. The Committee, last year, appointed Mrs. Maxwell as the Co-ordinating Officer. A home visiting service has been set up under which arrangements are made to recruit visitors who will keep in touch more specially with lonely old people. Although then, there is no official agency responsible for seeing to the needs of these old people who are not ill enough to need the services of the Regional Hospital Board or of the Welfare Committee, much is being done in various ways, mostly by voluntary effort. These activities of the voluntary agencies, tentative and experimental as some of them must be, are sufficiently flexible to be freely adaptable. It is from such beginnings that, in time no doubt, a comprehensive service will develop just in the same way as to-day's extensive maternity and child welfare service, which became in time the responsibility of local authorities, grew from the small beginnings started by the enthusiasm of those giving voluntary service. AMBULANCE SERVICE The County Ambulance Service now operates in two distinct branches, namely, the accident branch and the sick removal branch. The accident branch is operated from the Fire Stations, the emergency telephone facilities being used for the making of calls. The sick removal service is to be based on 10 depots throughout the County; the local station which is in course of erection is at Imperial Drive. Calls, whether made by doctors, those at nursing homes, or others in the Edgware, Arnold, Wordsworth, and Grimsdyke telephone exchange areas, are made to the Fire Station at The Mall, Kenton (Wordsworth 7721); and in the Harrow, Byron, Pinner. Hatch End, and Northwood areas, to the Harrow Fire Station (Pinner 8900). Ambulance transport is intended to be provided only when the person for whom it is asked is suffering from illness, is proceeding for medical treatment and nursing and is unfit to travel by ordinary means. 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). 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 28 shall be sent, this work being carried out at the laboratories of certain hospitals. The clinical material is collected each day by a van sent from the laboratory calling about mid-day at the Harrow Hospital, Kynaston Court, 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, 487; faeces, 253; sputum, 25; pertussis, 7; milk, 39; ice-cream, 109; and water, 4; miscellaneous, 80. 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 analysis of samples taken throughout the year were all satisfactory. The residents living on Stanmore Common at times suffer from an inadequate water pressure. It is understood that the Colne Valley Water Company have received permission to carry out works which involve the laying of 2,000 yards of 12 in. and 9 in. mains and the installation of a temporary booster. It is not expected though that the pipes will be available until the summer of 1954, so that the new mains will not be effective until 1955. The temporary booster, however, is expected to get over the difficulties arising from high loading of the distribution system. DRAINAGE AND SEWAGE DISPOSAL Particulars of the local arrangements were set out in the Annual Report for 1948. The following is an extract from the report of the meeting of the Highways and Cleansing Committee held on 10th September, 1952: — " The Surveyor reported that, on the evening of Wednesday, 6th August, 1952, exceptionally heavy rain occurred in north-west London, causing widespread flooding of roads and houses; that in Harrow, heavy rain began to fall at 7.30 p.m. and continued without abatement until 8.15 p.m.; that during that period, 2.62 inches of rain were recorded on the rainfall gauge at the Council Offices at 'Cottesmore,' Uxbridge Road, Stanmore; and that this was equivalent to a storm of 3.49 inches per hour. Further, that the appropriate Government Department recommendation for design of sewers for a 45minute storm is 0.61 inches per hour. Thus, the storm in question was about five-and-a-half times greater than that for which sewers are normally designed. Under these circumstances, all sewers, both foul and storm water, were running full and were unable to deal with the excess water falling on the area. The Surveyor also reported that, in addition, all brooks and watercourses were overloaded and storm water outlets were submerged; that these conditions gave rise to flooding in many parts of the District; and that members of the Council staff and workmen had been called out at 8 p.m. on 6th August and had commenced at once with relief works. " The Surveyor submitted a list, showing the areas and properties in the District, which had suffered flooding; and stated that the storm was the severest ever recorded in Harrow; that a fall of 2.62 inches of rain in the short period of three-quarters of an hour was bound to cause considerable flooding and inconvenience which could not be avoided; that everything had been done to restore sanitary conditions and to render assistance where required; and that in each case brought to the Council's notice where property was flooded by water from a foul sewer, cleansing operations had been carried out as soon as possible, and were completed by 11th August, 1952. " The Clerk submitted a list of properties which had sustained flooding and reported as to the action taken by the appropriate departments of the 30 Council in regard thereto, including visits to premises by representatives of the Surveyor or Medical Officer of Health or both. Further, visits had been made by the Chairman of the Council and the Chairmen of the Highways and Cleansing and Public Health Committees to certain affected properties and areas. Also that, resulting from the approach by the Chairman of the Council to the Local Food and Fuel Offices, satisfactory assurances had been received that all legitimate steps would be taken to help the unfortunate sufferers." The following is an extract from a report submitted to the Public Health Committee at their meeting on 9th September, 1952: — "At times of heavy rain, the surface water sewers in a number of parts of the district are liable to be surcharged, some parts being especially vulnerable. Although some years ago at such times, complaints about sewerage pollution were not uncommon, more recently these have been fewer. "The phenomenal rainfall in this district on the evening of 6th August overloaded the surface water sewers causing in parts flooding of premises and gardens. The especial concern of this department was the extent to which the contents of the foul sewers might have found their way to premises and on land. Complaints were received from residents of certain parts of the district. All these were followed up and visits were paid to the vulnerable areas, even if no complaints had been received from them. "Where contamination with solid matter had taken place, arrangements were made for the removal and cleansing. "In some houses, furnishing and bedding had been soiled. Some households were helped by these being dried and sometimes disinfected, free of charge, at the Council's disinfecting plant. "Although many households were subjected to extreme inconvenience from which some are still suffering, it is not felt that there was at the time, any risk of the spread of infection among those in the affected areas: nor any since." The following is a copy of an extract from the report of the Highways and Cleansing Committee of 31st December: — "The Surveyor reported that, by resolution 1976 (27th July, 1939) the Council decided to apply to the Ministry of Health for approval to a scheme for relieving the the sewers in the Pinner area, but, in view of the outbreak of war, no subsequent action was taken; that the scheme had been examined in the light of development since 1939 and was now submitted for consideration; that the work involved the construction of a new relief sewer which would intercept the existing sewers at various points and convey to the Middlesex Main Drainage Sewer near Cannon Lane; that the sewers comprising the present system were laid many years ago and were inadequate to deal with the discharge from the area affected, with the result that flooding and surcharging of sewers occurred during times of rain; that the total length of the proposed new sewer would be 3,635 yards, with 44 manholes; and that the pipe sizes proposed are 27 in., 33 in. 39 in. and 42 in. diameter. Further, that the new sewer would start at Barrow Point Avenue and proceed along Avenue Road (27 in. dia.) to Love Lane, where the diameter would be increased to 33 in.; that the route would continue along Love Lane, Bridge Street, Marsh Road and Eastcote Road to the junction with Whittington Way, where the pipe would increase in size to 39 in., and would continue at this size along Cannon Lane to the junction with Village Way, at which point it would increase to 42 in. diameter, continuing to the junction with the Middlesex Main Drainage manhole. The Surveyor also reported that, owing 31 to the need for picking up the existing sewers along the route, most of the sewer would be too deep to construct in open trench, and the greater part of the work would therefore be carried out in tunnel; and that the estimated cost (mid-1952) of the scheme was £112,299 12s. 3d. "Resolved: That the report and the Pinner Relief Foul Water Sewer scheme be received; and that the Clerk be hereby instructed to submit the scheme to the Minister of Housing and Local Government for his approval thereto in principle; and to inform the Minister that this scheme will be followed, in the near future, by the submission of other schemes of drainage relating to various parts of the District." 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 still hoped that the Council will decide to provide and maintain a crematorium. Burial. Under Section 50 of the National Assistance Act, 1948, the Council can arrange for the burial or cremation of any person who has died or who has been found dead in their area, if no other suitable arrangements have been or are being made. 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. Mortuary. The mortuary, enlarged in 1951, now has four slabs and is provided with two refrigerator chambers capable of receiving six bodies. During the year, 323 bodies were received in the mortuary. Postmortem examinations were carried out on 322 and inquests were held on 54. This year only one body was admitted for storage. 32 Many of those killed at the railway accident which occurred at the Harrow and Wealdstone Station on the morning of 8th October were removed to one of the hospitals serving the area. From about 10.30 though, the bodies were admitted to the local mortuary, 16 being accepted by mid-day. After that until the evening of the 10th, bodies were admitted at intervals in small numbers, in all, 32 being admitted. The greatest credit is due to Mr. C. J. Russell, the Mortuary Attendant, for the way he faced the difficulties confronting him and for the efficient way he managed. 33 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 1,006 (ii) On complaint of other nuisances 652 (iii) Routine inspections 431 (iv) Revisits arising from defects found 7,150 (v) Surveys under S. 157, Housing Act, 1936 168 Conditions Found. (i) Number of dwellings or other premises where defects were found 1,882 (ii) Number of cases of overcrowding revealed 90 PUBLIC HEALTH Inspection of Other Premises. (i) On complaint or request 152 (ii) Routine inspections of premises 571 (iii) Revisits arising from defects found 1,163 (iv) Surveys arising from Rat and Mice complaints 1,498 (v) Inspection of Factories 718 (vi) Inspection of Workplaces 176 (vii) Inspection of Outworkers' Premises 316 (viii) Inspection of Cinemas and Places of Entertainment 62 (ix) Inspection of Licensed Premises 73 (x) Visits under Shops Acts 1,574 (xi) Evening observations under Shops Acts 42 (xii) Sunday observations—Shops Acts 16 (xiii) Observations made for Smoke Nuisances 18 Conditions Found. (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 217 (ii) Number of premises where action taken by Council's Rodent Operatives to deal with rats 1,328 34 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 108 (iv) Number of Cinemas and/or Licensed Premises where defects were found 32 (v) Contravention of Shops Acts— (a) Failure to observe closing hours 17 (b) Other contraventions (failure to exhibit notices, etc.) 570 FOOD HYGIENE Inspection of Food, Food Shops, and Food Preparing Places. Visits. (i) Slaughterhouses 48 (ii) Butchers' Shops 488 (iii) Cowsheds 8 (iv) Dairies 101 (v) Fish Shops 284 (vi) Bakehouses 146 (vii) Cafes and Restaurants 395 (viii) Ice Cream Premises 328 (ix) Provision Merchants 799 (x) Greengrocers 358 (xi) Other Food Premises 201 PART II. COMPLAINTS RECEIVED Summary. Accumulations of refuse 84 Animals causing a nuisance 23 Dampness and Housing Defects 656 Drains and Sewers—choked 73 defective 97 Dustbins defective 130 Flooding—Gardens 42 Vermin 89 Insect infestations 166 Overcrowding, alleged 116 Smoke nuisances 11 Water courses 4 Other complaints (pig bins, wasps' nests, defective fences) 245 Food unfit (excluding requests received from shops to visit and inspect unfit food) 37 35 PARI 111. NOTICES SERVED Under Housing Act, 1936. (i) Statutory notices served under S. 9 requiring execution of repair work 38 (ii) Dwellings reported under S. 11 as being unfit for human habitation 6 (iii) Dwellings reported under S. 12 and closing order made 6 (iv) Informal notices served under S. 9 84 Under Public Health Act, 1936. Statutory Notices under: — (i) S. 24—work to a public sewer 60 (ii) S. 39—repair or renewal of drains 34 (iii) S. 45—repair or renewal of defective water closets 3 (iv) S. 56—undrained or badly-drained yard area 2 (v) S. 75—renewal of a dustbin 27 (vi) S. 93—abatement of a nuisance 50 (vii) Informal notices served 2,099 ACTION TAKEN Following Housing Act Notices. (i) S. 9—dwellings rendered fit: — (a) By owners 11 (b) By local authority in default of owners 12 (In six of these properties the notices were served during 1951.) (ii) S. 11—demolition order made 4 (iii) S. 12—closing order made 6 (iv) Dwellings rendered fit by owners after receipt of informal notice 91 Following Public Health Act Notices. (i) S. 24—public sewers repaired 16 (ii) S. 39— (a) By owners 14 (b) By local authority in default of owners 6 (iii) S. 45— (a) By owners 1 (b) By local authority in default of owners 2 36 (iv) S. 56— (a) By owners 1 (b) By local authority in default of owners 0 (v) S. 75— (a) By owners 13 (b) By local authority in default of owners 8 (c) By occupier 8 (vi) S. 93—Nuisances abated 35 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,904 SUMMARY PROCEEDINGS It was necessary to apply to the Courts for Abatement Orders in respect of four properties. In the case of three, an order was granted; in the other, the work was completed before the date of the Hearing. During August a quantity of diseased meat was seized at a butcher's shop and laid before the Magistrates who ordered it to be condemned and destroyed. Action under S. 9 of the Food and Drugs Act was taken later. Action under the same section was taken because of glass found in a milk bottle. Fines totalling £26 were imposed. One case was taken under S. 7 of the Factory Act, 1937, because the occupier of a factory failed to maintain the sanitary accommodation in a proper state. HOUSING Repair of Houses. As labour and materials are now easier than before, more houses are being dealt with under S. 9 of the Housing Act rather than by the nuisance section of the Public Health Act. The powers of S. 9 though can be invoked only if the house is considered to be capable of being made fit for human habitation at a reasonable cost. The reasonableness of an expenditure is determined by the returns from that expenditure. If the rents are small and if they are controlled, then the landlord cannot see any immediate prospect of his obtaining a return on a heavy expenditure on his property. In these circumstances it is becoming not uncommon for owners to suggest, rather than that they should spend the money on doing the work which is required, the Council should acquire the house from them and carry out the repairs. If the Council does not do so, then housing units are lost which otherwise might have been retained for a number of years. In the meantime, while negotiations are proceeding, the occupants of the houses are living under conditions prejudicial to their health. During 1952 84 informal notices were served under S. 9 of the Housing Act. In most of these cases, the work was carried out. In 38 instances, however, a statutory notice had to be served. Where work is still not carried out, the authority has power under S. 10 of the Housing 37 Act to carry out the work at the cost of the owner. In 12 instances this had to be done. A number of houses were considered to be unfit for habitation and to be not capable of repair at a reasonable cost. Demolition Orders were made in respect of six and Closing Orders in respect of six. During the year two houses were demolished, both being in the Poets' Corner area. At the end of the year 39 houses were still being occupied which were the subject of Demolition or Clearance Orders. Of these, five are in the "Brewery Cottage Order four in the "Stanmore (High Street) (No. 4) Order 20 in the "Headstone Drive Clearance Order and 10 were the subject of Demolition Orders made before the war. The following is a copy of a statement prepared early this year which sets out the position about Poets' Corner at the end of 1952: — "In 1938, the Public Health Committee recommended that as so many of the 126 houses in Shelley Road, Wordsworth Road, Burns Road, Marlborough Road and Milton Road, were unfit for human habitation the most satisfactory way of dealing with them was by clearing the site. The Minister, after an inquiry held in April, 1939, was not satisfied except in regard to five properties that the most satisfactory method of dealing with the conditions in the area was by the demolition of the buildings. "During the war years a number of these houses were demolished, some as a result of enemy action, some at the election of the owners and a number following the making of Demolition Orders. "It has not since the end of the war been possible nor has there been much point in trying to arrange for the systematic routine inspection of houses. Instead, the time of the inspectors has been taken up with trying to see to the repair of those houses about whose unsatisfactory state the tenants have drawn attention. It is in this way that attention has been called to the defects of certain houses in these roads. "Some of these houses have been found to be incapable of repair at any reasonable cost; these have been brought to the notice of the Public Health Committee. The Inspection Sub-Committee after their visit on the 29th October, 1949, recommended that in the first stage Nos. 20-36 (even) Shelley Road and Nos. 23-33 (odd) Milton Road should be dealt with and at a later stage Nos. 4-10 (even) Shelley Road, the odd numbers in Shelley Road and certain even numbered houses in Milton Road should be dealt with. Since that date a number of Demolition Orders have been made. "The position at the end of March, 1953, was that of the 126 houses, 33 had been demolished. In addition one was the subject of confirmed Demolition Order, and action pursuant to Section 11, Housing Act, 1936, had been commenced in respect of eleven others. It is anticipated that it will be necessary to bring to the notice of the committee, in stages, a further 40/45 houses in these roads with a view to the committee considering whether steps should be taken to have these demolished. "It will be appreciated that this statement about what is anticipated will be done, is based very largely on information obtained at the detailed surveys carried out in 1938 supplemented by knowledge gained by visits paid more recently following receipt of complaints from the tenants of certain of these houses. It may be that houses included in these lists have had sufficient work 38 done to them to warrant their exclusion from these lists. On the other hand, there may be some in which deterioration has been that much more rapid than in others that although they were relatively that much better in 1938, they are that much worse now and might be calling for early attention. "Most of these houses were put up about the same time and were, it seems, of much the same standard of initial construction. That suggests that as some of them have already been found to be incapable of repair none can now have a very long life. But the standards at which the different houses have been maintained have varied enormously. Some being owneroccupied have had quite careful attention; others have had very extensive repairs and renovations carried out. There may be up to 40 of these houses whose condition to-day is sufficiently satisfactory that they can be expected to be suitable for habitation for many years." Overcrowding. At the beginning of the year, 275 families were known to be living in overcrowded conditions. During the year 90 new cases were learned of; but in 140 instances, the overcrowding ceased. The number of families known to be living in accommodation which by the standards of the Housing Act was overcrowded at the end of the year was 229. In 68 instances the overcrowding was abated by the rehousing of the family in Council Houses, and in a further eight by families being rehoused by the Council in requisitioned property. Of the new cases of overcrowding learned of during the year, 43 occurred because married children had continued to live with their parents, and 33 were brought about by the natural increase in the size of the family. In eight households the overcrowding was brought about by the acceptance of lodgers who were related to the principal tenants and in a further two by the acceptance of lodgers who were not related. Four houses were let so as to be overcrowded. At the end of the year there was one family living in accommodation which was overcrowded by 4 units, two families were overcrowded by 31/2 units, nine by 3 units, five by 21/2 units, 16 by 2 units, 28 by 11/2 units, 78 by one unit, and 89 families were living in accommodation which was overcrowded by one half unit. Provision of new Houses. By the end of 1952 the total number of new permanent and temporary dwellings completed and handed over for occupation since the end of the war was 1,907. There is now so little land left in this district available as sites for houses to be erected whether by the Council or by private enterprise that particular interest attaches to any housing development which might be available to those now living in this district. The New Towns Act, 1946, made provision for the erection of 14 new towns. Eight of these are in the Greater London Area. Each provides for an expansion ranging from the 13,000 at Hatfield to the 39 50,000 at Stevenage. Hemel Hempstead, which is to expand by 37,000, has already accepted 100 families from this district. For each of these towns, a development corporation has been set up which is responsible for the planning of the building. The local authority for each area, however, exercises its ordinary powers. A different type of development is provided for under the Town Development Act, 1952, under which smaller towns are to be expanded, some of them to two or three times their present population. This development is in the interests not so much of those in the existing towns as of those in other towns which cannot meet the housing needs of their populations. In the earlier stages then, the development will be financed by the Government. Authorities whose families are accepted by these towns may be looked to to contribute towards the rates a sum in respect of each house for a number of years. The two towns under which development is taking place on these lines which are most likely to be of interest to those in this district, are Bletchley, to which some families have already gone, and Aylesbury. Allocation of new Houses. As there is not sufficient land available in the district to provide sites for all the houses needed to meet the various demands for new houses made by those in the district, the Housing Management SubCommittee asked the Public Health Committee to give an indication of the numbers of houses needed for its different purposes. A summary of the findings, as presented in the report in November, 1951, was that 386 houses were needed to rehouse those families at present living in houses which ought, within the next few years, to be considered for demolition; 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; and to house those known to-day to be living in overcrowded conditions, 293 houses are needed. The Housing Management "Sub-Committee considered reports indicating what sites might become available on which the Council might build new houses and what the demands would be for those houses which become available. The following is an extract from a report of the decision of the meeting of the Housing Committee on the matter as set out in a report presented to the Public Health Committee at their meeting on 14th October, 1952: — " The Demand. (i) Number of applicants on the main waiting list, who at 1st July, 1952, had been given an official promise to be rehoused 65 (ii) Number of applicants on main waiting list who qualified at 1st July, 1952, to be rehoused, but to whom no promise has been given 93 (iii) One-sixth allocation for tuberculosis cases at present outstanding 13 40 (iv) Number of units of accommodation for the occupants of (a) Merrion Avenue hutments; Newton Buildings, Rayners Lane, and Belmont Lodge, London Road, whose rehousing has already been agreed; (b) families from insanitary houses the subject of operative demolition or closing orders whom it has also agreed to rehouse; (c) special hardship cases outstanding; and (d) licensees from requisitioned properties now to be released 84 (v) Number of families occupying the remainder of requisitioned properties to date 764 (vi) Number of overcrowded cases to the exent of more than one unit (after deducting such proportion as might reasonably be expected to be settled by the normal operation of the points scheme) 56 (vii) Number of applicants who, but for the fact that they are included on the supplemental waiting list, would qualify for rehousing on the basis of the existing points scheme 186 (viii) The number of accommodation units required for families living in houses of the following categories: — (a) Clearance Order cases 41 (b) Demolition Order cases not yet accepted for rehousing by the Council 14 (c) "Poets' Corner" cases 50 (d) 305 houses expected to become unfit for human habitation during the next three years which would require family accommodation for 381 1,747 "Proposed Disposal. Estimated total number of new units of Council dwellings to be provided during 1952, 1953, and 1954 from all sources 1,075 Less (a) units to meet items (i), (ii), (iii) and (iv) 255 (b) one-sixth of the remainder for tuberculosis cases 137 (c) a marginal allowance to meet new cases of special hardship; licensees from properties to be de-requisitioned from time to time; and newly - qualified applications 100 (d) units already provided for rehousing families from properties the subject of (a) clearance orders (41), and (b) demolition orders (14) 55 547 Estimated number of units remaining to be allocated 528 Your Sub-Committee is satisfied that the 528 housing units above referred to or such other number as may become available, should be allocated as to one-half for families to be rehoused from (a) further insanitary dwellings and (b) from premises which are statutorily 41 crowded to the extent of more than one unit as may, in each case, be represented by the Medical Officer of Health during the three-year period; and as to the remaining one-half to applicants qualifying on the basis of the points scheme." In regard to the houses needed on public health grounds, an allocation has been given for the housing of those families with a member suffering from tuberculosis already referred to the Housing Officer and a further allocation for the housing of those families living in houses which are already the subject of confirmed Clearance or Demolition Orders. The needs of those families with a member suffering from tuberculosis are dealt with separately and the allocation continues to be a proportion of the new houses which become available. The houses for all other families whose claims for rehousing are on public health grounds come out of the half of the otherwise unallotted houses; these will be the families living in condemned houses and those living in overcrowded conditions. It will be seen that the needs of those families to be rehoused on public health grounds cannot be met to the full any more than can the claims of those based on other than public health grounds. In regard to the houses which will need to be represented, the number for which provision is being made is in effect an up-to-date figure which takes the place of the number of 212 referred to in the report of November, 1951. In regard to the number of houses for those families with a member suffering from tuberculosis, the ratio of one-in-six of new houses has been retained. This proportion of the number of new houses which it is anticipated will be built is not far short of the figure referred to in the report of November, 1951. In regard to the overcrowded, the number of houses to be allotted falls far short of the number of families at present living in overcrowded conditions. The claims of those whose overcrowding is by not more than one unit are being ignored. Instead then of 270 cases of overcrowding to be considered, the number was reduced to 84, this being the number of families living in conditions which are overcrowded by more than one unit. There will of course be cases in which a family is well placed on the ordinary points scale and is also one of the families most in need of rehousing, because of overcrowding. Because of this overlap, the committee felt that the figure of 84 could be reduced by one-third to 56. The houses allotted to these overcrowded families will come out of the one pool of houses available to those living in insanitary houses, or in overcrowded houses. The claims of those cases of hardship where the need arises on health grounds other than these three classes of the tuberculous, the overcrowded, and those living in condemned houses, will continue to be considered by the Housing Sub-Committee, and any houses allotted to them will come out of a pool of houses to be made available for those with a variety of claims including hardship on health grounds. The following is a copy of Item 3273 of the Report of the Meeting of the Public Health Committee of 14th October, 1952: — " Allocation of New Houses: With reference to Council resolution 6015 (3rd October, 1952), whereby it was agreed, with regard to the allocation of an estimated number of 528 Council houses (to be provided during 1952, 1953 and 1954) that one-half thereof should be allocated to families to be rehoused from: "(i) further insanitary dwellings; d 42 "(ii) premises statutorily overcrowded to the extent of more than one unit, as may, in each case, be represented by the Medical Officer of Health during the three-year period; the Medical Officer of Health reported that the above-mentioned allocation did not include families with a member suffering from tuberculosis or contact cases—for whom a separate allocation is made—nor families living in houses which are already the subject of confirmed Clearance or Demolition Orders, as to whom provision has been made elsewhere in the scheme of allocation. "The Medical Officer of Health also reported: "Re: Overcrowded Cases: (a) That, out of a minimum figure of 270 cases of overcrowding, there were 84 cases which were overcrowded by more than one unit; but that, in view of the fact that a number of such families were well placed in the housing waiting list (due to their priority under the points allocation scheme), the number of cases to be dealt with in the threeyear period, had been reduced to 56. "Re: Special Hardship Cases: (b) That these cases, where the need arises on public health grounds—other than cases involving tuberculosis, overcrowding, or insanitary housing—would continue to be dealt with by the Housing Management Sub-Committee, from a separate pool of houses to be set apart for those with a variety of claims. "Re: Clearance and Demolition Order Cases: (c) That it has been the practice for the Public Health Committee to submit to the Housing Committee, recommendations as to the rehousing of families living in premises, the subject of Demolition Orders. "Re: Cases of Urgency: (d) That he had, in the past, been authorised to refer to the Committee, cases of overcrowded families on the housing waiting list whose housing need has become urgent, but who had not qualified for immediate rehousing under the points allocation scheme, and suggested that such cases would continue to be reported to the Committee for authority to rehouse. "Generally: (e) That, in view of the allocation of the houses from the pool referred to in the first paragraph above, it would be necessary for the Committee to undertake responsibility for measuring the relative strength of the claims of those whose special consideration is on public health grounds, so that appropriate recommendations for rehousing particular cases could be made; and that he had prepared tables showing the order of priority of appropriate families for rehousing, according to housing needs, availability of the type of houses required, etc.; and "Re: Tuberculosis Cases: (f) That, heretofore, he had decided the order in which tuberculosis cases should be referred to the Housing Officer for rehousing; and recommended that, in future, responsibility for the final selection of those cases for rehousing should be undertaken by the Committee. "Resolved: (1) That the report be received; and that, subject to the approval (where necessary) of the Housing Committee, the following procedure for the allocation of certain housing accommodation be approved:— "(2) That the Medical Officer of Health be instructed to submit to the Committee, as often as may be necessary, lists of families occupying premises statutorily overcrowded to the extent of more than one unit; together with particulars of cases referred to in paragraphs (c) and (d) above, as they arise, to enable recommendations for rehousing to be made; "(3) That the Medical Officer of Health be instructed, in future, to settle and submit to the Committee, lists of priority cases involving tuberculosis 43 (or contact cases), that require to be rehoused, to enable the Committee to undertake the allocation of accommodation available for these cases." SUPERVISION OF OTHER PREMISES Routine work carried out during the year included the inspection of factories, cinemas, licensed premises and many other buildings, water courses and other sites. In the case of vacant parcels of land it was possible to take action to prevent unsatisfactory conditions arising; while in other cases inspections resulted in unsatisfactory conditions being removed or improvements carried out. 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 Ocupiers prosecuted (i) Factories in which S.S. 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 81 105 – – (ii) Factories not included in (i) in which S. 7 is enforced by the Local Authority 416 620 27 1 (iii) Other premises in which S. 7 is enforced by the Local Authority (excluding out-workers' premises) 67 94 10 – Total 564 819 37 1 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 37 39 – – – Overcrowding – – – – – Unreasonable temperature – – – – – Inadequate ventilation 4 4 – – – Ineffective drainage of floors – – – – – Sanitary conveniences— (a) Insufficient 3 3 – – – (b) Unsuitable or defective 25 27 – – 1 (c) Not separate for sexes – – – – – Other offences against the Act (not including offences relating to outwork) 39 39 – – – Total 108 112 – – 1 44 In addition 316 visits were made to premises of outworkers who are persons undertaking at home work sent out from factories or business premises. Industrial Hygiene. "The Council at its meeting on the 3rd October, resolved that the following suggestion be referred to the Public Health Committee for consideration: 'That the County Council should seek amendment of the existing legislation or the promotion of new legislation, with a view to the integration of all forms of welfare in the County districts, with special reference to all factory welfare schemes, by which local Medical Officers would be enabled the better to control in their respective districts any outbreaks of illness or disease, or infringements of the Factory or other Health Acts.' The following was submitted by the Medical Officer of Health to the Public Health Committee: — "Legislation about the health of those working in factories preceded that which led to the development of the public health services, and has all along remained distinct, with the result that even to-day local sanitary authorities have very little direct concern with the conditions of work of those employed in factories. "The first of the Factory Acts of general application, that of 1833, required the appointment of factory inspectors and prohibited the employment of children under nine years of age. The Act of 1844 provided for statutory medical supervision by certifying surgeons. Later legislation was largely incorporated in the Factory Acts of 1937 and 1948. The provisions of all these and the orders and regulations made under them provide for the control of environmental working conditions, dangerous hazards and the employment of juveniles. Quite apart from what has been required by legislation, since the middle of the last century a few progressive employers appointed doctors to care for the health of their workers. But it was not until the first world war that the importance of the human factor in industry began to be recognised. The second world war emphasised this. "In the last few years a number of authoritative bodies have surveyed the needs and the structure of the present industrial services. The most recent is the Dale Committee set up in 1949, with the following terms of reference. 'To examine the relationship between the preventive and curative health services provided for the population at large and the industrial health services which make a call on medical manpower; to consider what measures should be taken by the Government and the other parties concerned to ensure that such medical manpower is used to the best advantage, and to make recommendations.' It will be noticed that the emphasis is on the conservation of manpower. The Committee reported in 1951. "To-day, there are engaged in various aspects of the health, safety and conditions of work of those engaged in factories, a variety of agencies which include the public health service, industrial medical officers, and the general practitioner service under the National Health Service. One of the chief demands seems to be for the general application and extension to industries throughout the country of industrial health services of the kind irregularly distributed among a comparatively few industries. There is no questioning the advantages to employers and employees alike, of an industrial health 45 service. Such a service should be made available as soon as possible for all industries, and should be extended to cover non-industrial employment. Some seem to foresee the picture of a future industrial health service embracing all aspects of health created as a separate entity and controlled by a central department which will not necessarily be that concerned primarily with the administration of the health services. Some bodies such as the British Medical Association and Royal College of Physicians consider that the industrial health service should be an integral part of the National Health Service in its fullest sense. The Dale Committee considered there should be a considerable measure of co-ordination between the various agencies— medical, legislative, and administrative, at present providing health services for industry. It is not clear from the report though, how they intend that this should be done. In any event, the Dale Committee were considering the matter within a restricted framework. "The subject 'Hygiene in Industry' was discussed at the Annual Congress of the Royal Sanitary Institute this year. One of the opening papers was given by the Medical Officer of Health of Leeds. He divided the various types of service which might be needed in varying degrees at different factories into three—(1) treatment and rehabilitation services, including emergency treatment and first-aid, these being services of the kind already provided by the National Health Service; (2) environmental and preventive health services, including replacement and retirement examinations, routine medical examinations for fitness for employment, the medical aspects of job selection, the maintenance of health standards in all places of work, and the routine investigating of known industrial hazards together with the application of methods of prevention; and (3) the research into new and existing health hazards and into the scientific aspect of working conditions; this is essentially a function of special scientific research organisations. "If local authorities are to have a place in industry, it will be essentially in regard to the second type. ' Artificial division between the medical treatment of the man at work and at home is undesirable, but the preventive health aspects of the man at home and at work are distinct and can be dealt with as separate problems.' Dr. Davies suggests the medical officer of health and his staff assisted by the appointed factory doctor, should be responsible, in association with the local factory inspectorate, for detailed enforcement and maintenance of health standards and for medical examinations. "The Dale Committee pointed out 'The maintenance of industrial health and the prevention of industrial diseases and accidents may often be a matter for administrative action in the light of facts established by research.' Others have suggested that if the state of the small factories is bad, are they not to be improved less by direct action by doctors than by stronger enforcement of stricter minimum standards in matters of legislation and inspection, not of medical services." Shops. During the year 1,574 inspections were made by the Shops Act Inspector. The contraventions found and dealt with included eight cases of assistants being employed on the day of their weekly half holiday, one of a young person being employed in excess of the permitted number of hours; two of failing to allow assistants compensatory holidays for Sunday employment; 11 of failing to keep records of Sunday employment; 46 three of failing to close on Sunday for the sale of non-exempted articles, and four of failing to close on the weekly half holiday for the sale of non-exempted articles. Evening observations led to 17 shopkeepers being warned for failing to observe the General Closing Hours; 14 were first offences and two received warnings from the Clerk. The number of warnings about failure to exhibit notices required by the Shops Act was 570. It was found necessary in 26 cases to ask for improved heating in shops, and 115 requests were made for cleansing or repair work to be carried out. During the year two exemption certificates were issued in respect of the provision of sanitary accommodation; and, on application, one retailer was registered as a Jewish trader. Smoke. In 1930, fog in the Meuse valley, near Liege, caused 60 deaths. In 1948, fog in Dorona, Pennsylvania, caused 20 deaths. Far more interest seemed to be aroused by these occurrences than by the fact that the fog which hung over London for four days last December caused some 4,000 deaths. These other occurrences were regarded as national disasters, and were subjected to immediate full public enquiries. As yet, however, no investigation has been made into the London episode, and whatever interest was aroused, this disaster was not regarded in the way anything else of a comparable nature would have been. The 4,000 deaths were the excess of the deaths in Greater London during the two weeks following the fog over the number anticipated from the general trend of the weeks immediately preceding the fog. The weather condition which caused this fog was an anti-cyclonic system of cold air established over the London basin from 5th to 8th December. A temperature inversion at 200 to 500 feet was set up, the mass of cold still air immediately over the ground being overlaid by warmer air. In such conditions the natural water fog forming in the colder air was kept down below the ceiling between the two layers. Smoke was similarly trapped. The virtual absence of lateral air movement prevented any marked diffusion of the fog. Pollution of the atmosphere probably plays little part in the production of a dense water fog. On the other hand, it does add to its density and to its persistence. On this occasion, smoke poured for four days from the chimneys of London and from the exhausts of the vehicles. The usual recorders of pollution do not give information in such a form as to indicate the extent of pollution which occurred. The daily measurements of smoke and of sulphur-dioxide suspended in the atmosphere showed that the highest average smoke concentration was 14 times greater than the lowest in the nine days from 3rd to 11th December, and that there was a nine-fold variation in the sulphur-dioxide figures. The maximum pollution reached was probably considerably higher than the average figures. 47 There was in the London administrative county and in the Greater London area, a marked rise in the number of deaths from a number of causes in the week ending 13th December, a rise which persisted but to a diminishing extent over the next two weeks. In the administrative county of London the number of deaths from all causes rose from 945 in the week ending 6th December to 2,484 in the next week. The corresponding figures for deaths due to bronchitis and pneumonia were 121 and 872, and from diseases of the heart and circulatory system 318 and 801. The corresponding figures of the deaths from all causes in the Greater London area were 2,062 and 4,703. It is common for severe smoke fogs to be followed by an increase in the number of deaths from bronchitis, pneumonia and heart failure following respiratory disease. The especial feature of this occasion was the abnormal extent of the rise. Most of the deaths occurred amongst the older people, though almost all age groups were affected to some extent. Very striking on this occasion was the rapidity with which the deaths started to increase, there being an obvious increase even on the first day, 5th December. One writer who described the fog as a catastrophe of the first magnitude said, "There is reason to believe that the fog incident in December, 1952, caused deaths in London on a scale possibly never experienced before from this cause. It is hoped that such an event will never recur—or be allowed to recur." These increases in the numbers of deaths can give only a slight indication of the amount of illness, pain and distress that must have occurred. A more accurate guide to this is the number of applications made to the emergency bed service for the admission of patients to hospital. As many as 492 applications were made at the height of the fog, a figure to be contrasted with that of 293 at the height of the influenza epidemic on 1st January, 1951. The condensation of moisture on solid or liquid nuclei which results in fog, is a natural phenonomen and, apart from their effect in reducing visibility, fogs are in themselves innocuous. It is when they are contaminated by the impurities produced in cities and industrial areas that they become dangerous. It is only occasionally that these meterological conditions occur under which town fogs of such proportions as those of December are produced. But the emission into the atmosphere of the polluting matter which makes the fogs so destructive goes on continuously. Apart from that occurring in special localised areas, the pollution of the atmosphere is caused by the combustion of coal, the polluting substances comprising on the one hand a group of solids such as coal dust, ash and tarry soot, and on the other gaseous sulphur oxides. The diminution of the solid constituent depends on the efficacy of the combustion and of the velocity of the flue gasses which in its turn is conditioned by the design of the flue system and on the chimney draught. The formation of the oxides of sulphur is inevitable. There has been in recent years a diminution in the pollution by the domestic chimney because of the increased use of gas, of electricity and of central heating, and by the use of improved appliances. On the other hand, the gas and electricity substitutes used in the house are produced at power stations at which dust and grit are discharged, and because, in all, more coal is being burned. 48 the total pollution is not lessened. While it needed an unusual combination of circumstances to bring about the conditions that gave rise to the December fogs for this contamination to cause the appalling damage which resulted, the position is that this pollution is continuous, and this noxious matter in polluted air must have a detrimental effect on human and animal health and comfort, an effect not violent but persistent. Improvement can be brought about, but of course only at a price. The economists can decide whether the cost of removing these impurities is less than the cost of remedying the damage done to buildings, to fabrics, to crops, to agricultural land and to cattle—quite apart from the injury to humans. Some measures can be applied to reduce the pollution by solid particles, but these may have no affect on the gaseous oxides of sulphur. The solid constituents from the combustion of coal can be reduced by improving fuel utilisation as this would result in a reduction in the coal consumed, by thorough cleansing of the coal, which would prevent potentially polluting matter reaching the furnaces, and by house coal being replaced by smokeless fuel, or by its being burned in efficient modern grates or stoves. Such measures, while reducing the solid contents of the polluting smoke would do nothing to reduce the pollution by sulphur gasses: probably it is only the power stations or larger factories with their larger coal consumption concentrated in a few combustion units which can bring about any significant reduction of this constituent. Infestation of Premises. 1,498 complaints of infestation by rats or mice were received during the year. No infestation was found in 170 cases. 1,175 complaints were of infestations of private houses (rats 1,048; mice 127). Of the 153 infestations of other premises, rats were the trouble in 99 and mice 54. The Hydrogen Cyanide (Fumigation of Buildings) Regulations, 1951, came into force on 1st February, 1952. Any person undertaking the fumigation of premises with cyanide is required to notify the Medical Officer of Health. Anyone attending on his behalf is allowed to remain in the risk area only if he is an authorised person and carries the appropriate certificate of authority. Licensed Premises. 73 visits were made to licensed premises in the district during the year; and a report on the conditions found was submitted to the Licensing Justices. At two of the premises major works of improvements were carried out to the kitchens, and at others improved sanitary accommodation was provided. At 18 other houses, work of cleansing and redecorating the bars and other public rooms was carried out. Cinemas and premises licensed by the Middlesex County Council for music and dancing were visited and a report on the conditions found was submitted to the Middlesex County Council. 49 Rag Flock. During the year 16 visits were made to the five premises registered under this Act. Visits were also made to other upholstery workshops to ensure that no work covered by this Act was being carried out on unregistered premises. All registered premises within the district used only filling materials delivered under warranty and carrying the mark of the British Standards Institution. Stocks of filling materials and the statutory records were inspected; in no case was to be any contravention of the Act found. Keeping of Pet Animals. The Pet Animals Act, 1951. regulates the conditions under which livestock are kept in shops selling pets, ornamental fish, cage birds, etc. The provisions of the licences issued are designed to ensure that the animals are kept in accommodation which is suitable as regards size, temperature, lighting, ventilation, and cleanliness; that they are supplied with adequate and suitable food and drink, that mammals shall not be sold at too early an age, and that reasonable precautions shall be taken against the spread of infectious diseases. The R.S.P.C.A. offered the assistance of one of the inspectors should this be needed. Up to the end of the year it was not necessary to take advantage of this offer. Applications for licences were received in respect of 14 premises in the area. These premises were inspected, were found to be satisfactory and licences were issued. Since then one shop has been closed and one has changed hands. During the year 44 visits were made to the licensed premises to ensure that the conditions of the licence were observed. Leaflets explaining the provisions of the Act were issued to all licensees. All traders have proved to be most co-operative and it has not been found necessary to take any statutory action under this Act. 50 INSPECTION AND SUPERVISION OF FOOD (A) MILK SUPPLY 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. During the year the work of erecting a new dairy complete with new bottle washing, churn sterilising, bottle filling and milk pasteurising equipment, was completed. At the same establishment work to a new milking parlour was completed, and the cooling and sterilising equipment necessary for the production of farm bottled tuberculin tested milk installed. 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 50 (3) Number of premises outside Harrow from which pasteurised milk was retailed in the district 17 (4) Number of premises from which T.T. milk was sold 47 (5) Number of premises outside Harrow from which T.T. milk was retailed in the district 17 (6) Number of premises from which sterilised milk was sold 46 (7) Number of premises outside Harrow from which sterilised milk was retailed in the district 14 Inspection and Supervision. During the year 109 visits were made to cow sheds and dairies. Sampling. Thirty-eight samples of milk were taken during the year. All were satisfactory. Complaints. During the year 12 complaints were received about foreign matter in milk, this being about one half of the number received during 1951. Five of the complaints were about glass fragments, one was in respect of cement, four about pieces of debris, one about a snail and another about the presence of a safety pin. (B) MEAT Only two of the six slaughter houses in the district were used for the slaughtering of animals; at neither was regular slaughtering carried out. In all 104 pigs and two calves were slaughtered; very little disease was found and only one set of lungs and four heads had to be condemned. Five slaughtermen renewed their licences to slaughter. 51 The P.H. (Meat) (Amendment) Regulations 1952 amend the 1924 Regulations by extending the definition of 'animals' to include 'horses, asses and mules.' Persons intending to slaughter animals for sale for human consumption must give the local authority three hours' notice of the time and place of slaughter. (C) OTHER FOODS Food Condemned. The following is a summary of all foods found to be unsound or unfit for human consumption:— Groceries, Miscellaneous 7,543 lbs. Fish and Fish Products 1,475½ lbs. Vegetables, Soups and Pickles 4,579 lbs. Fruit 3,131½ lbs. Meat and Meat Products 8,338 lbs. With the exception of one case, when a quantity of beef was formally seized and taken before the magistrates for condemnation prior to a successful prosecution, all food was voluntarily surrendered by traders who freely seek advice about food of doubtful fitness. The total of 25,067 lbs. is an increase of nearly 50 per cent. on the amount condemned in 1951, and is, in fact, the highest quantity condemned in post-war years. With the exception of tinned ham, wet fish and shell eggs, the increase was general, though the increase in groceries is partly because of the need to condemn perishable goods, including 3,071 lbs. of sugar, which were contaminated by flood water. The bulk of the sugar was salvaged for refining. In spite of representations to the Ministry of Food about transport arrangements, the amount of home killed carcase meat condemned (3,270 lbs.) because of spoiling in storage and transit as distinct from organic disease is the highest figure yet recorded here. The factors causing the spoilage occur outside and not in the Harrow District. The fall in the number of bad eggs condemned (8,532 in 1950 to 449 in 1952), suggests that improvements can be brought about by more careful and speedier handling at docks and distribution centres. The amount of unsound tinned fruit is greater because more is available. Most of the damage was the result of chemical action, not due to the effect of bacteria. Ice Cream. During the year 104 samples of ice cream were taken; 83 were Grades 1 or 2 and the remainder Grades 3 or 4. In the case of these latter, investigations were made and follow-up samples were taken. Nineteen premises were registered during the year for the sale of ice cream, 17 for the prepacked product, two for the sale of loose ice cream. The number on the register at the end of the year was 334. No new premises were registered during the year for the manufacture of ice cream, the number of manufacturers registered being 13. 52 The 1947 (Heat Treatment) Regulations called for the heat treatment of the ingredients of ice cream, either by heating to 150°F. for 30 minutes or 160°F. for 10 minutes. The 1952 Amendment Regulations permit of heating to 175°F. for 15 seconds. Registration of Hawkers. During the year two hawkers were registered under the Middlesex County Council Act, both applicants trading in greengrocery. In October, 1952, the Council made an Order under the Town Police Clauses Act, 1847, prohibiting street trading in those roads likely to be congested and where as a result obstruction might occur. (D) HYGIENE OF FOOD By the end of the year certificates had been issued in respect of 256 out of the 970 food shops in the district. Steady progress was made during the year in interesting the public in the subject of clean food. Every opportunity is taken of exhibiting features bearing on this subject as are afforded by the gathering together of people on such occasions as the Council's Delegate Conference. More film strips have been purchased, and talks are given at which these are shown at meetings of women's organisations and also to mothers attending the local infant welfare clinic sessions. Another means of stimulating interest is by arranging for parties to visit food preparing premises in the district. At the end of the year consideration was being given to undertaking a more active campaign in the financial year 1953/54. As part of this, a booklet on food hygiene was to be prepared for free distribution. 53 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis) Disease Und. 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over Age unknown Total Scarlet fever – 45 163 24 5 4 3 – 1 1 – – 246 Diphtheria – – – – – – – – – – – – – Pneumonia 2 6 5 1 2 3 9 23 19 9 17 – 96 Dysentery – 2 – – – 1 3 1 3 2 – – 12 Erysipelas – 1 – 1 1 2 3 4 6 6 5 – 29 Cerebro-spinal fever 1 3 1 – – – – – – – – – 5 Puerperal pyrexia – – – – – 1 5 2 – – – – 8 Ophthalmia neonatorum – – – – – – – – – – – – – Poliomyelitis— paralytic 1 – 3 – – – 3 1 – – – – 8 non-paralytic – 1 2 1 1 2 2 1 – – – – 10 Polioencephalitis – – – – – – – – – – – – – Measles 13 502 862 27 4 2 5 2 – – – – 1417 Whooping cough 23 189 201 3 1 1 2 2 1 1 – – 424 Paratyphoid fever – 2 1 1 – – 1 – – – – – 5 Food poisoning – – 1 – – – 1 – 1 1 – – 4 Typhoid fever – – – – – – – – – – – – – Malaria – – – – – 1 – – – – – – 1 CONTROL OF INFECTIOUS DISEASES Notification. Although some measures to control the spread of certain infectious diseases had been practised in this country for a long time and, although much later, authorities were given powers to provide isolation hospitals for the reception and treatment of some of the infectious sick, it was not until 1889 that some of the infectious diseases were made notifiable and then only in certain parts of the country. It was not until the Infectious Disease Notification (Extension) Act of 1899 that a number of diseases became notifiable throughout the country. This list of diseases included smallpox, cholera, diphtheria, erysipelas, scarlet fever, typhus fever, typhoid fever, puerperal fever. These diseases were all communicable in some way and they could all be serious. It is this latter character perhaps that differentiated them from a number of the communicable complaints which children more especially suffer from, such as chickenpox and mumps. In the case of some of the notifiable diseases it was possible to take steps to limit the spread of infection; it may be that it was the apparent inability to take any such action which led to such diseases as whooping cough and measles, which are so very damaging to small children, being omitted from the list. During this century, a number of other diseases have been made notifiable by regulation. Some of these have been brought in perhaps because later it was appreciated that something could be done either for the sufferer or with a view to limiting the spread of infection. Others have been brought in possibly because a temporary increase in incidence has led to more attention being given to an infection which up to then had not been very prevalent. The result is that to-day. 54 the list of conditions notifiable by one regulation or another is as long as the original list of diseases set out in the Notification Act, most of which now appear in the Public Health Act, 1936, as the notifiable diseases. Each of the earlier of the notifiable diseases was a clinical entity, caused by closely related if not the same organisms. But some of the conditions which are now notifiable, although they may be communicable, are not so. Ophthalmia neonatorum is the reaction of an infant's eye to one of a variety of organisms; while the fever which occurs in a recently confined woman and is notifiable as puerperal pyrexia, might be due to a very wide range of causes, some having nothing to do with pregnancy, delivery or the puerperium. In the case of most of these conditions that are notifiable, there are certain common factors. The condition is usually sufficiently serious for it to be desirable that steps should be taken to control it; and in most cases some steps can be taken that might enable some control to be exercised. Most but not all of the notifiable diseases possess these features, though some diseases which are notifiable to-day are notifiable not because of the severity of the disease to-day as that it was a danger in past years. Where the clinical type has changed and the general condition is so very different to-day from what it was before, there is the question of whether any good purpose is now served by such a disease remaining in the list of those to be notified. At one time, a patient had to be considered to be suffering from one of the notifiable diseases before he could be admitted to an isolation hospital; but to-day that is not the case to the same extent so that is not a point in favour of the retention of a disease on the list. What might be done to limit the spread of infection varies with the disease and is not the same, even in different cases of the one disease. Notification is the means by which the health department gets to know of the case of infection and is the starting point of certain enquiries which are made in all cases. These enquiries are directed to two ends. On the one hand, they aim at obtaining information which will indicate the source from which the patient contracted his infection; if this is established, steps can be taken to prevent others contracting infection from the same source. The other line of enquiry is to determine those with whom the patient might have been in contact and who therefore might be carriers of the infection. The activities of some of these might have to be controlled for a period until they can be felt to be no longer a risk of spread of infection. As to the detection of the source of infection, difficulties arise in either extreme. If there is, as is so often the case, only the single case of enteric infection, it is virtually impossible to trace the origin, though laboratory investigations may now result, at a later stage, in the case being linked with others. On the other hand, when during a measles outbreak one to two per thousand of the population might be falling ill each week for a number of weeks, there is little need to spend time in tracing the origin. In point of fact, measles which is now generally notifiable, has been made so not because of any steps which can be taken to control it, but primarily for statistical purposes. 55 The disease about which most discussion has taken place about the desirability of its continuing to be notifiable, is scarlet fever. The reason is that the rash from which the condition takes its name, is only one of the reactions of the body to the invasion by the organism and, many persons attacked by the organism do not develop the rash, though they may be just as infective as the person suffering from a typical attack of scarlet fever and can, in just the same way, hand on that organism which may cause a typical attack of scarlet fever in the recipient. When so many patients suffering from scarlet fever were admitted to the fever hospitals almost automatically because they had scarlet fever, not to treat seriously the other infectious person just because he had not developed a rash, seemed illogical. To-day however, when, largely because of the mild character of to-day's scarlet fever, it is becoming more common for scarlet fever patients to be nursed at home, the position is more rational, and would be still more so if the test of the need for the patient to be admitted to hospital was not so much his possible infectiousness as the severity of his illness and his need for skilled medical and nursing attention. The other notifiable condition which is discussed, is erysipelas, at one time the dread of hospital wards. To-day, this condition is usually mild and in any event, responds well to treatment. The organism responsible for this can cause trouble to specially susceptible persons such as recently confined mothers. To-day, this is about the limit of the public health significance of erysipelas. Aids to Diagnosis. (1) Laboratory service (see page 27). (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, arangements being made either by the staff of the Hendon Isolation Hospital or by the patient's doctor applying to the Emergency Bed Service. (b) Smallpox or Typhus Fever: Patients suffering or suspected to be suffering from these complaints are admitted to special hospitals. (c) Tuberculosis: Arrangements for admission are made by the staff of the Tuberculosis Service, mostly to special but sometimes to general hospitals. 56 Exclusion of Contacts. Those who have been in contact with infectious patients may have picked up organisms and may develop the disease. In some diseases these contacts may be infectious before the onset of the clinical manifestations of the illness so that they might, in their turn, spread the infection. Even though they are not to develop the illness, some of these contacts may be harbouring the organisms and they may be spreaders. With a view to reducing the risk of spread of infection by such contacts, it was at one time the practice to restrict the movements of contacts for a period long enough to determine whether they were likely to be developing the disease. This practice has been relaxed by stages, and it is now only exceptionally that adult contacts are excluded from their work. There are two main classes of workers who may be required to abstain from their ordinary work. The one is of those persons whose work brings them into close contact with those such as young children who are especially susceptible to attack, or hospital nurses who might cause infection in a ward. The other group is of those whose work brings them into contact with such foods as milk which, if infected, might result in widespread infection. Even in the case of persons so employed, it is not always necessary that they should stay away from work, but only from that work at which there is the risk of spread. Many employers are able to put the contact employees temporarily on to some alternative work where there is no greater risk of the spread of infection than in the case of ordinary members of the public. If a person has to remain away from work with a view to reducing the risk of spread of infection, he is entitled to draw sickness benefit at the rate he would receive were he ill. This payment can be made, however, only if the Medical Officer of Health for the district can issue a certificate that the exclusion of the contact is necessary with a view to reducing the risk of spread of infection. The Ministry of Health Circular 115/48 reads: "As Medical Officers of Health are aware, it is only exceptionally that it is necessary to require a contact or carrier of infectious disease to stay away from work, and then only as regards the more serious infections. But a Medical Officer of Health, in his responsibility for preventive action, may on occasion consider it necessary, where there is special risk, that such a person should absent himself from his employment for a time: and it is in such circumstances that the right to draw sickness benefit will arise. Benefit will only be paid on the strength of a certificate by a Medical Officer of Health that the person concerned is under medical observation by reason of being a carrier of infectious disease, or of having been in contact with a case of infectious disease, (as the case may be), in circumstances which make it advisable to exclude him from work. The Medical Officer of Health should accordingly be prepared to issue such a certificate where he thinks it proper to do so in order that the person concerned may send it to the local office of the Ministry of National Insurance in support of his claim for sickness benefit. The certificate should be given in writing, preferably on official notepaper." The practice of excluding from school child contacts of infection has been markedly relaxed in recent years. Not only is exclusion required 57 of the contacts of a much smaller number of diseases but the period of exclusion asked for at all is shorter. It was once usual where exclusion was thought to be necessary, to require the child to remain away from school for a few days longer than the longest limit of the period of incubation of that disease. To-day, on the other hand, the time is a day or two longer than the common period of incubation. Another relaxation is that when a patient is nursed at home, the period of exclusion of the contact is for a period from the time the patient is satisfactorily isolated, whereas before that the period ran from the date the patient was declared to be free from infection. It is not felt that these relaxations have resulted in infections having spread any more than they would have under the more rigid restrictions previously imposed. The period of exclusion of day-school contacts of those suffering from scarlet fever is seven days after the removal of the patient to hospital or to the beginning of his isolation at home. Contacts of diphtheria are excluded for seven days after the removal of the patient to hospital, or the beginning of his isolation at home; if there are any suspicious signs, the child is excluded further until pronounced by a medical practitioner to be free from infection. Infant contacts of measles who have not had the disease are excluded for 14 days from the appearance of the rash in the last case in the house; other contacts are allowed to attend school. Infant contacts of whooping cough who have not had the disease are excluded for 21 days from the onset of the disease in the last case in the house. It is not now the practice to exclude for any time contacts of those suffering from a number of infections, e.g. german measles, mumps or chickenpox. The County Council has recently revised their regulations as to the exclusion of contacts of infectious diseases which are a guide to head teachers where no intimation has been received from the Medical Officer of Health or no certificate has been received from a private medical practitioner. Under these regulations, contacts of those suffering from enteric fever, erysipelas, german measles, dysentery, whooping cough, chickenpox, mumps or cerebro-spinal fever, need not be excluded; nor need the contact of a patient suffering from measles unless that contact suffers from a cold, chill, or red eyes. It is quite probable that it will ultimately be found that even further relaxation can be permitted in the rules as to exclusion of contacts of infection without this practice being found to result in the spread of infection. 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. for the stoving of the first load, and 5s. for any subsequent load. e 58 Aircraft Regulations. The P.H. (Aircraft) Regulations 1952 replace those of 1950 following the adoption by the Fourth World Health Assembly in 1951 of the International Sanitary Regulations (World Health Organisation Regulations No. 2) which replace the International Sanitary Conventions. DIPHTHERIA In none of the 12 patients admitted to hospital suspected to be suffering from diphtheria was the diagnosis confirmed. This is the second consecutive year the district has been completely free from this disease. During the five years since the end of 1947 there have been two cases only, one suffering from a nasal infection, the other from a faucial infection. The very fortunate position in which the district finds itself is due not to any one cause. Even before any substantial proportion of the population had been protected by immunisation of the children against the risk of contracting infection, the incidence here for many years had been well below the average for the country. It is quite probable had there been no widescale immunisation throughout the country that there would have been a fall in incidence, though not to the extent that has occurred since the campaign was started. On top of these factors is the effect of immunising a substantial proportion of the vulnerable section of the population. A highly immunised population will not suffer from an outbreak of diphtheria. To repel invasion though, the ratio of the numbers of susceptibles to those immune must be kept low. Only by immunising a high proportion of the new susceptibles—that is the new babies of the district—can this state be maintained. The longer the district remains free from attack, the less necessary it would seem to many that anything should be done. This makes it the more necessary for the need to be constantly emphasised. Many children are immunised by their own doctors; many too are treated at the local clinics. The health visitors when they see mothers either in their own homes or at the clinics, aim at having all the children on their districts treated. In addition to this constant and steady campaign, for a few weeks each year, special attention is given to the matter. During the year 2,167 children were treated for the first time, 1,078 by general medical practitioners, 1,079 at infant welfare centres, and 10 at day nurseries. It is estimated that at the end of the vear 47 per cent. of children under five years of age were protected, and 76 per cent. of children aged five to 15 years, figures much the same as those for 1951. SCARLET FEVER 252 cases of scarlet fever were notified in this district last year. In six the diagnosis was changed. The corrected figure of 246 was an incidence rate of 1.12 per thousand population, a figure to be compared with 1.53 for the country as a whole, and 0.82 for this district last year, the lowest experienced here. 59 The distribution was a weekly average of six for the first quarter, six for the second, two for the third, and five for the last. 51 patients were removed to isolation hospitals; most to the Hendon Isolation Hospital, but five to others. Scarlet fever was, even towards the end of the last century, a very serious disease with a high death rate. Sufferers needed the medical and nursing care which most could obtain only in the infectious diseases hospital. For many years now though scarlet fever has typically been a mild complaint, the sufferers needing little more than being kept to their beds. Nevertheless, many children suffering from scarlet fever seemed to be removed to the isolation hospital although they could quite well have been nursed at home with very little risk of spread of infection. Even up to 1948 in this district about one half of the patients notified each year were removed to hospital: in very few of these was the need for removal the clinical condition of the patient. In 1947, out of 180 cases notified, 105 were admitted to hospital, 13 of them having to be admitted elsewhere than to the local hospital. In 1946, 132 out of the 265 notified cases were removed to hospital. To-day, the proportion admitted is much lower. In 1951, out of 181 cases only 53 were admitted, and out of 262 notified in 1950 only 69 (of whom 25 were admitted to hospitals other than the Hendon Isolation Hospital). There was no marked increase in the number of secondary cases occurring in the households where the patients were nursed at home. Last year, of the 250 cases notified, 51 were admitted to isolation hospitals, 46 of these being to the Hendon Isolation Hospital. There were 12 households in which secondary cases occurred, only one in each of 11, two in the other. In four instances, the primary case was missed. In four others the interval separating the onset of illness of the primary and of the secondary cases was six days or less, so that removal of the primary case probably would not have averted the illness in the other case. In the remaining five cases the interval was 10 days or more; in these, removal to hospital of the primary case probably would have saved the other patients in the houses contracting the infection. There was only one return case this year. The onset of illness in a child in the house occurred nine days after the return home of a child who had been in the isolation hospital suffering from scarlet fever. The child returning home was well on return, but developed a sore throat and discharge from the nose. In one instance a child developed scarlet fever shortly after having his tonsils removed. Some groupings of cases amongst pupils of schools suggested that school attendance might have been a factor in spread, though on each occasion there were only a few cases and these, though in the same school department, were mostly in different classes. In the Spring term, there were six cases spread over three weeks amongst the pupils of Greenhill School; and five cases spread over two weeks in the Infants' Department 60 of Roxbourne School. There were 11 cases in the two departments of Stag Lane School spread over the Summer term; and six over four weeks amongst those at Welldon Park School. There were further cases at this school in the last term, including three cases in one week. A number of cases occurred in this term at the Roxeth Manor School, particularly in the Infants' Department. In spite of these suggestive groupings, there was no occasion on which any child suspected to be a spreader of infection was found attending school. SMALLPOX None of the introductions of smallpox into this country in 1952 concerned this district, though a number of visits were paid to those who came here from infected areas. The practice up to this has been that when a ship on which there is a person suffering from smallpox lands at a port in this country, particulars of all passengers and crew are taken and the health authorities of the districts to which these persons are proceeding are advised. The same procedure was adopted in regard to those who arrive in this country by air. The 1950 Public Health (Aircraft) Regulations have now been amended and a different procedure has been in force from 1st October. This is to enable this country to comply with the provisions of the International Sanitary Regulations adopted by the Fourth World Health Assembly in May, 1951, by which countries accepting these provisions will no longer require a personal declaration of origin and health from passengers arriving by air. There is therefore now no record of the address in this country to which passengers arriving by air from abroad have proceeded. If therefore such person shortly after arrival is found or is suspected to be suffering from a dangerous infectious disease such as smallpox, it might be difficult for the medical officer of health to trace contacts who were on the same aircraft. In such circumstances then, he will now get into touch with the Ministry who will, if necessary, arrange for a message to be put out by the B.BC. and through the Press, requesting any person who travelled on the aircraft to report immediately to his doctor or to the Medical Officer of Health of the area in which he is. So many parents took advantage of the means by which they could avoid having their children vaccinated although the law called for the vaccination of all children, that in the years just before the war, only about one-third were done. With the removal by the National Health Service Act of even what compulsory element there was up to then, there has been a further falling off in the proportion of young children vaccinated. The present arrangements are that children are treated by the family doctors. Encouragement for this to be done is given by the doctors themselves and by the health visitors, clinic doctors, and other members of the local health authority staff. In this district last year 1,385 persons were vaccinated for the first time, but only 883 were under one year of age, and only 162 were under two years of age. 530 were re- 61 vaccinated. In the same year 2,855 babies were born. In the hope that if facilities for the vaccination of children against smallpox were offered to those attending infant welfare centres in the same way as they can be immunised against diphtheria, a greater proportion might be treated, the Middlesex County Council sought the approval of the Minister of Health to such arrangements being made. The approval was given towards the end of the year. ENTERIC FEVER In January, a child of five fell ill with para. B. infection of unknown origin. In April a child of 12, an in-patient of a local hospital, was recognised to be suffering from paratyphoid fever which she must have contracted before being admitted to the hospital. In June a boy of five was admitted to the isolation hospital with an indefinite illness; paratyphoid B organisms were later recovered from the stools. In October a mother and her boy of two who for some weeks had an intestinal disturbance, were admitted to hospital and were diagnosed to be suffering from a para. B infection. Apart from the last two cases there was no connection between these patients. They fell ill at different times and they lived in different parts of the district. This is the usual history of the infection as seen in this district, namely, some half dozen cases almost invariably para. B infection, spread over the year, occurring in different parts of the district and having apparently no connection one with another. In an attempt to discover whether the small number of cases recognised each year is the entire infection of the district, or whether they represent merely that proportion of those infected in whom the illness is recognised, in 1950 some Moore's swabs were put down at four points in the sewer system. It had been intended, had the organisms been found, that further swabs should be inserted further up the system in the hope of tracing back to the origin. In point of fact, none was found to be positive. It was decided to continue the investigation for some months, putting swabs down at intervals of a month if the findings were negative, but tracing back immediately if organisms were found. Unfortunately, the trials were not successful. Organisms were recovered from swabs in the main sewer, but could not then be found in any of the branch lines. On the other hand, on another occasion, organisms were recovered from the swab in a branch line, but none were recovered from the swab put down in the main sewer at the same time. It would seem then that there can be no assurance that a Moore's swab placed in the sewer system dealing with such volumes of sewage as flow in the sewers in this district will pick up organisms which are possibly being excreted intermittently. The position might be different if a patient nursed at home were excreting large number of organisms regularly. This trial then did nothing to give an answer to the question of whether these few cases which are detected each year, are the whole or only part of the infection in the district. 62 DYSENTERY 13 patients were notified to be suffering from dysentery. In four of the cases, diagnosis was not confirmed. In all instances where an organism was recovered, it proved to be of the Sonne type. Two of the patients were children of six years of age; all others were adults. The sexes were equally affected. One half of the patients fell ill in the first three months of the year. In one instance, two members of the same family were affected. FOOD POISONING Only four persons were notified last year as suffering from food poisoning: two were members of the same family. The egg of a duck was suspected to be the source of infection in these cases. One patient had contracted the infection when out of the district on holiday. All four cases fell ill in August. MALARIA One case of malaria was notified, the patient suffering from a benign tertian infection. Although he had recently returned from Korea, he gave no history of a definite attack while out there. ERYSIPELAS 29 notifications of persons suffering from erysipelas were received during the year. As contrasted with last year when the sexes were almost equally affected, this year 22 of the sufferers were females. In all but five the face was the site affected. 19 of the cases occurred in the first half of the year. Four patients were admitted to an isolation hospital for treatment. MENINGOCOCCAL INFECTION Out of the 19 persons suspected to be suffering from cerebro-spinal fever, the diagnosis was confirmed in only seven. All but one were children, five being boys; two were aged seven years, two were aged 18 months, one 12 months, and the other seven months. Three of the cases occurred in September and October. All were admitted to hospital, four being to isolation hospitals. All recovered. ENCEPHALITIS It is now recognised that encephalitis can occur in those who are suffering from or recovering from any one of a number of infectious states. In this last year, two children who had recently suffered from measles developed signs of encephalitis. ACUTE ANTERIOR POLIOMYELITIS Apart from the few occasions when this infection was more or less prevalent, this country was free from poliomyelitis for most of the year. Cases used to occur in the summer months, building up to a maximum in the late summer or early autumn, this increased prevalence being 63 lowed by a fall passing to extinction. Since the outbreak of 1947, the country has never been free. The curve of incidence for these years has been roughly parallel to those of the pre-1947 years. The wave which reaches its highest in August and September now, however, does not pass away before it merges into the new rise of the next year. The weekly average of notifications in England and Wales for January last year was 30. The lowest incidence was reached in February with a weekly average notification of 16. Then followed averages of 19 for each of the next two months; the real rise started in May with an average of 40 notifications each week. The first two cases notified in this district last year were really part of the dying 1951 wave. The first was a man of 25 who fell ill on January 8th with a non-paralytic attack. Next was a woman of 21 who fell ill in February with a paralytic attack. There was then an interval of three months before the first of the cases of the 1952 wave. This was a man of 32 who fell ill on 7th May with a paralytic attack. On 7th May, a man of 34 fell ill, also with a paralytic attack. There were no notifications in the next week. In the week ending 31st May, however, five succumbed, these being a woman of 34 (with a paralytic attack), a boy of six (non-paralytic), a woman of 37 (abortive), a boy of seven (nonparalytic) and his father (abortive). In the next week there were two more cases: a boy of six (non-paralytic) and a boy of seven months (paralytic). Although in the next few weeks many patients suffered from conditions suspected to have been poliomyelitis, in none was the diagnosis confirmed until a girl of seven fell ill with a paralytic attack on 28th June. There was another free interval before an adult male fell ill on 11th August with a paralytic attack which proved fatal. A similar period of freedom was followed by two non-paralytic attacks in the week ending 20th September, a girl of three and a boy of 14, and a paralytic attack in a boy of six in the following week. The other cases were a paralytic attack in a girl of five whose illness followed a few days after her tonsils had been removed in October, and a woman of 22 who fell ill with a non-paralytic attack in November. The grouping cf cases in May was quite local. The figures for England and Waes for the seven weeks from the week ending 19th April were 23, 29, 24, 21, 37, 37 and 44. The London figures for the same period were 2, 3, 1, 3, 1, 4 and 2. The Middlesex figures were larger than usual only because they included these Harrow figures. Apart from the occurence of illness in father and son, there was no known association of these cases who lived in different parts of the district. Apart from this grouping in May, the only other grouping was the three cases in the weeks ending 20th and 27th September. The district had only these three cases in September and only one in August, the two months when the country as a whole was being most severely attacked. In all, there were 18 cases (11 males and seven females). The youngest was a boy of seven months who suffered from a paralytic attack. Eight were children of 10 years of age or under, nine were aged 21 or over. Nine suffered from paralytic attacks, seven from nonparalytic attacks, and two from abortive attacks. 64 MEASLES This infection is usually most prevalent in the second and third months of the year. Any very heavy incidence at this time will usually have been preceded by an undue prevalence in the last weeks of the preceding year. The 1951 wave had almost passed by the end of the second quarter, and there was no increased prevalence up to the end of the year. The low incidence in January of 1952 when only six cases were notified was followed by the weekly average of 33 cases in February and the peak weekly average of 46 in March; in one week in March 66 notifications were received. The figures fell to a weekly average of 10 in April, and to three in May. Instead of dying out though, the disease continued to smoulder for the next months with weekly average notifications of seven in June, 17 in July, 14 in August, to fall to only 10 cases in the whole of September. The next month saw a marked rise to a weekly average of nine cases, a rise which continued to 26 in November and 58 in December; in one week in this month 181 notifications were received. In all, 1,417 cases were notified. In the main, the disease was mild in character, there being no deaths. 17 patients were admitted to hospital. Many schools had some pupils attacked sometime during the year, though those affected in the Spring term escaped in the last. Camrose, Kenmore Park and Stanburn were the schools most affected in the Spring term. Aylward, Glebe, Greenhill, Roxeth, Roxeth Manor, Stag Lane and Vaughan Road were all attacked in the last term. WHOOPING COUGH The district was never entirely free from this infection in any part of 1952, though the incidence was never high. The weekly average of notifications for the first quarter was nine, the second six, and the third three. Although the weekly average for the last quarter was 10, this was the result of an average of three for the first half of the quarter and 19 in the second half. In all, there were 424 notifications. Seven patients were admitted to hospital. There was one death during the year from this infection. Although few schools escaped entirely and in some the infection persisted throughout the year, none was really heavily attacked. During the year 301 children were immunised against pertussis for the first time, 22 by local medical practitioners and 279 at infant welfare centres. It is probable that the actual number treated by their own doctors was much more than the 22 learned of. PUERPERAL PYREXIA Of the nine notifications of puerperal pyrexia received during the year, six related to women who had been confined in London hospitals. One of those delivered at home had had a miscarriage; the rise in temperature in the other two cases did not appear to be the result of an infection of the uterine tract. 65 OPHTHALMIA NEONATORUM No infants were notified this year as suffering from ophthalmia neonatorum. NON-NOTIFIABLE INFECTIONS Information about most of these conditions is obtained from the head teachers of schools about pupils who are absent either because they are suffering or because they are contacts of those suffering from such conditions. Chickenpox. Some schools, namely, the Bridge, Glebe, Pinner Park and Roxeth Manor which were attacked in the Spring term, were virtually free for the rest of the year. Aylward, Roxbourne and Greenhill which had escaped in the Spring term were attacked in the Summer term. Only Cannon Lane and Stanburn were affected to any extent in both terms. Many schools were lightly attacked in the last term of the year. In all, 1,036 intimations were received. Mumps. This infection was more common this last year than in recent years, 898 intimations being received. The incidence was confined almost entirely to the first two terms, only Glebe School being affected to any extent in the third term. Most schools affected at all were attacked in both terms, though Longfield and Pinner Park were attacked only in the Spring terms, and Aylward only in the Summer term. German Measles. This is a complaint which is sometimes prevalent when the ordinary measles is about. A few years ago, the district was heavily attacked at a time when ordinary measles was not prevalent. The ordinary type of measles as seen amongst school children, died out after the first few weeks of the year and did not reappear until the last weeks. German measles however, although it was present amongst the pupils of four schools in January and February, did not become generally distributed until March. From then on it was present in many schools, dying out in most in June, though there were occasional cases in a few schools in July, and again when the schools re-opened after the summer holidays. Junior schools were more heavily attacked than the Infants' departments. In all, 991 intimations were received. German measles occurring in children is typically a mild complaint. It is now being appreciated that it is a very much more serious matter when affecting an expectant mother, not so much because of its effect on the mother herself as on the child she is carrying. This is more marked if the mother contracts the infection in the earlier stages of her pregnancy. In such cases the infant may exhibit developmental abnormalities such as changes in the eye or in the heart. 66 Influenza. Influenza as such is not notifiable. Some, but not a very reliable, guide to its prevalence is given by the notifications received of those suffering from influenzal pneumonia. The spread of an influenza epidemic is very rapid. When it has appeared in any part of this country, an indication of its affecting any district is obtained from the study of the daily record of absenteeism in one or more industrial plants, or schools, by a rise in the number of new insurance claims, or by an increase in the number of requests for admission to hospital, especially for pneumonia. The district was not affected by any epidemic wave of influenza during the year. The deaths of six persons were ascribed to influenza; most of these occurred in the last few weeks of the year and almost all were amongst those over 75 years of age. Psittacosis The existence of acute illness in humans the result of infection by parrots, has been recognised for many years. Because of the many cases that occurred in the country early in 1930, the Parrots (Prohibition of Import) Regulations were made and came into force that year. These regulations prohibited the importation into the country (except of those required for medical or veterinary research or those to be consigned to any body specially authorised to receive them) of parrots, this term including parrakeets and love birds. As from 8th January, 1952, these regulations were revoked by the Parrots (Prohibition of Import) (Revocation) Regulations, 1951. During this last year a number of cases of psittacosis in humans have been recognised. There was a suspect case in this district. A family in Wealdstone who have a number of cage birds, purchased a parrot on the 20th December; the bird soon sickened and died on the 25th December. An adult female member of the household fell ill on the 24th December, and was removed to hospital where a provisional diagnosis of psittacosis was made. Laboratory investigations, however, failed to confirm the diagnosis. Infection seems to be spread by the patient having had close contact with a bird. Transmission from one human to another has occasionally been suspected. The cases of human illness have apparently been infected by recently imported birds. Apart from any risk by the introduction of new birds, there would seem to be no grounds of apprehending danger from cage birds which have been in a household for many months. The sick birds are infectious to humans and at times to other birds. After a sick bird has been removed, careful scrubbing and disinfection of the cages, perches, and other articles used in attending to the birds is necessary to try to avoid infection of the healthy birds. TUBERCULOSIS Notification. The Tuberculosis Regulations of 1912, 1921 and 1924 were rescinded by the Public Health (Tuberculosis) Regulations, 1930, which came into 67 operation on 1st January, 1931, and which have determined the arrangements for the notification of tuberculosis for the last twenty years. Notification on Form A was called for from the general medical practitioner and from the school medical inspector. In addition, medical officers of Poor Law institutions and sanatoria were required to send each week a Form 1 notification of persons admitted to, and a Form 2 notification of persons discharged from the institutions in the previous week. Each of these notifications was sent to the Medical Officer of Health of the district in which the patient lived. Each Medical Officer of Health too, was required to send to the appropriate Medical Officer of Health, particulars of any patient notified as suffering from tuberculosis who had removed from the one to the other district. When Forms 1 were received about patients who had not formerly been notified as suffering from tuberculosis, it was customary to take steps to try to obtain a Form A from the doctor under whose care the patient was before he was admitted to the institution. The 1930 Regulations have now been revoked by the Public Health Tuberculosis Regulations, 1952, which came into operation on May 1st. Under these, weekly notifications are no longer required of patients admitted to or discharged from hospital on the old forms, though the Minister has asked hospital authorities and committees to ensure that this information is sent by the institution concerned to the Medical Officer of Health of the district to which the patient belongs. Further, it is no longer necessary for a Medical Officer of Health to send to his colleagues information about patients who remove from his district. It may be then, that figures in future will not be strictly comparable with those received in recent years. The following table sets out the age and sex distribution of the patients who were notified in this district for the first time in 1952: 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 – – 1- 4 7 3 1 — – – – – 5-9 — 1 1 1 — — – — 10-14 5 2 – – – – – – 15-19 13 11 1 2 1 4 – 1 20-24 12 20 – 3 – 4 1 – 25-34 22 33 1 2 9 5 1 35-44 12 15 2 2 4 1 – – 45-54 19 6 – 1 1 – – – 55-64 14 4 — — 1 1 – 1 65 and over 9 6 1 — 1 2 – — Totals 113 101 7 11 17 18 1 3 68 The notification figures for the three years from 1949 were 439, 370 and 358. Those for 1952 were 271. Of the pulmonary cases, 50 were already suffering from the disease before they moved into the district. Eight men were recognised to be suffering from the disease while they were serving in the forces. Of the 75 males who contracted pulmonary tuberculosis while living in the district, 15 gave a family history of tuberculosis, this being a percentage of 20. The corresponding figures for females were 32, four and 12 5. Of the 22 persons notified to be suffering from non-pulmonary tuberculosis, at least four contracted the infection before coming to live here. Of those who were living here and presumably contracted the infection here, four gave a history of a pulmonary case living in the home. Register. Under the 1930 Regulations, the Medical Officer of Health was required to keep a register which was to include particulars of every person notified as suffering from tuberculosis, particulars of those who transferred to the district of whom he was advised by the Medical Officer of Health of the district the sufferer lived in before transfer and " of any person who normally resided in the district and whose death from tuberculosis has come to his knowledge but who has not been notified to him as suffering from tuberculosis." The regulations required the Medical Officer of Health, from time to time and not less often than once a quarter, to revise the register by removing from it entries relating to notifications which have been withdrawn, entries relating to persons who have recovered, and entries relating to persons who have died, have ceased to live in the district or who after adequate search cannot be found resident in the district. Possibly the greatest inaccuracy in the register arose because of the removals out of the district of persons whose names were on the register. To try to keep the local register accurate, towards the end of each year, home visits have been paid to those about whom no information up to then in that year had been received. Under the new regulations it is no longer obligatory on the Medical Officer of Health to keep the register. But " In the Minister's view he may naturally be expected to do so, and the Minister would urge that he should, in the same way that he keeps a record for his own purposes and without any legal requirement of notification of other diseases." The register is being kept in the same way as it used to. But according to circular 6/52, the essential Tuberculosis Registers will in future be those kept at the Chest Clinics. It may well be then that the published information of the numbers of those on the registers will be lower than in the past. If so, the smaller number of names on the register will not necessarily be due entirely to there being a smaller number of sufferers in the district. 69 The following table is a summary of the changes which have taken place in the register during the year: — Pulmonary Non-pulmonary Male Female Male Female No. on register, January 1st, 1952 1,115 904 128 152 No. of new cases added ... 113 101 7 11 No. of cases other than on Form A 17 18 1 3 No. of cases restored to the register 6 8 — 1 No. of cases removed 117 104 9 14 No. on register, December 31 st, 1952 1,134 927 127 153 Of the deductions, 129 (121 pulmonary) were of persons who had left the district; 46 (41 pulmonary) were of persons who had died; 49 (41 pulmonary) were of persons who had recovered, while six (five pulmonary) were of persons in respect of whom the diagnosis had been withdrawn and 14 were of persons who had been lost sight of. The net increase in the number of cases on the register is 40, as while there was an increase of 42 in the number of pulmonary cases there was a fall of two in the number of non-pulmonary cases. The net increase is markedly less than that of recent years, as in 1951 the figure was 153 and in 1950 160. Deaths. 34 persons (20 male and 14 female) died from pulmonary tuberculosis during the year and four (one male and three female) from nonpulmonary tuberculosis. These figures are much smaller than the corresponding figures of 41 and seven for the preceding year. This infection accounted for a death rate per thousand population of 017, and for just under 2 per cent. of the total deaths, in each case this being a slight decline on the figures for the previous year. These, however, were a very marked improvement on the figures of .0.26 and 3.0 for 1949 which, in their turn, were such an improvement on the figures of 0.42 and 4.9 for 1948. Preventive Measures. Most people are exposed to infection by the tubercle bacillus. Only a small proportion of those exposed succumb to such an extent that they are said to be suffering from tuberculosis. It is recognised that the development of the disease follows other illnesses. It is appreciated too that those suffering from some diseases are more likely than are members of the general population to suffer from tuberculosis. Close contact with an infection is considered to be the cause of the development of illness amongst some; in others it is felt that the development is precipitated by conditions at work. In the case of many persons who suffer from tuberculosis then, it is felt that those factors which led to the development of the disease in those patients are known. But in many others there is no apparent reason. They seem to be no more exposed to infection than 70 are other members of the public, either at their own homes or at their place of work, they are not members of a family with a bad family history who can be felt to be especially susceptible, they have not suffered from any of the acute illnesses which are sometimes followed by tuberculosis, nor are they suffering from any of the illnesses or diseases in which tuberculosis might develop as a complication. And yet they succumb to the disease. To reduce the likelihood of such members of the public succumbing, no specific remedy or direct action is practicable. All that can be done is the taking of those steps which enable the population to be suitably housed and suitably fed. That is why the control of tuberculosis amongst such persons is one of the rewards of the maintenance of a satisfactory general health service. One direct way in which the risk can be reduced is by minimising the possibility of infection in the home. It is for this reason that the Council has made such generous provision in housing those families which have a member suffering from tuberculosis. Even without there being any overcrowding, good housing is sound prevention, especially the good housing of those who are growing up. It is probably much more important to be born in a good environment than to be transferred to a good environment later in life.