AC 439(1) HARROW (???) HARR 20 Urban District of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1953 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW KING AND HUTCHINGS, LTD., PRINTERS, HARROW AND UXBRIDGE. ??? 21/6/54 ??? urban district of harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1953 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 9 General Health Services: Hospitals 16 Nursing Homes 17 Establishments for Massage and Special Treatment 17 Nursing, etc., in the Home 17 Day Nurseries 18 Clinics and Treatment Centres 18 Provision for Special Classes of Person 21 Ambulances 23 Laboratory Facilities 24 Sanitary Circumstances 25 Sanitary Inspection: Housing 32 Smoke 43 Inspection and Supervision of Food 49 Infectious and Other Diseases: Prevention and Control 58 Tuberculosis 67 Vital Statistics, 1934-1953 73 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 1953. Once more it is possible to record that as judged by vital statistics the health of the district for the year has been most satisfactory. For yet another year the district has been free from diphtheria, this being the third consecutive year of freedom. In the last six years there have been only two cases. Although measles and whooping cough were both prevalent, there was only the one death from measles. The district was relatively free from influenza which attacked some parts of the country in the earlier weeks of the year until late in February, when it was responsible for a number of deaths. There has been a further fall in the number of deaths from tuberculosis, but an increase in the number of cases notified during the year. The infant mortality rate was again below that of the country as a whole, although this has fallen to such a satisfactory level. The one maternal death resulted in a mortality rate of 0.3. Although there is nothing outstanding in the health of the district in this last year to record, it will be seen that special reference is made to certain matters. Of these housing can once more be expected to take up the time of those in the health department, because of the stimulus given by proposed new legislation to improve the conditions under which many are living. The report, too, contains summaries of the recent reports on smoke and the abatement of atmospheric pollution. That the district is comparatively free from this nuisance is perhaps only a challenge to all concerned to see that what pollution is occurring should be reduced. Reference is again made to the subject of clean food. The campaign has now entered on the phase of educating consumers and future consumers in the hope that these will play their part in raising the standard of care in the handling of food. Reference is made to the extent to which the district was affected by poliomyelitis, and to the incidence of tuberculosis. The number of new cases learned of in the last year was a sharp rise on the figure for the previous year, though fewer than the new cases in the preceding years. The means by which new cases might be discovered are discussed. The last pages of the report contain the vital statistics for the twenty years of the Urban District. Perhaps the most striking figures are those of the steady fall in the infant mortality rate and the freedom of the district from diphtheria for a number of years. This is the last of the Annual Reports about the health of the Urban District as next year's will start the series relating to the health of the Borough. Unfortunately, the advance in civic status does not confer on 6 the authority any additional powers in administering the health services of the district. The new Borough will then have just as little direct responsibility for providing the health services as had the Council of the Urban District. There are no signs of the County Council being any more ready to hand over, to what extent they are able, the administration of these services, services which should be managed locally. For this desirable state to come about it would seem the next stage in the elevation of the civic status of the authority must be attained. At one time the minimum size of a County Borough was fixed because of the needs of such a district to provide institutions of different kinds each with its own optimum minimum size, though even then the disadvantages of some small districts were got over by agreement between bodies to provide and maintain institutions. Now that the hospitals have passed to the Ministry, there are not these objections in connection with the administration of the health services to smaller districts being County Boroughs. On the education side there may be a case for some special schools meeting the needs of districts of even more than 200,000 population ; but that and similar aspects which might be held to be points in favour of the present arrangement of local government administration in the County of Middlesex are far outweighed by the very real disadvantages of the many services which should be administered locally, and by those who have local knowledge and interest in the various districts being managed centrally, being anything but locally administered, and being almost not even local government services. While then the promotion in status does nothing at the moment to improve the health services of the district, it may perhaps be looked on as a necessary step of progress to the next stage when the district becomes wholly and directly responsible for the administration of the personal health services of the Area. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Kynaston Court, Harrow Weald. 23rd April, 1954. 7 COUNCIL COMMITTEES The general reference to the Committees of the Council which are concerned with matters of Public Health read Public Health Committee.—All matters relating to public health, including rehousing, prevention of overcrowding and sanitary conditions (except those specifically mentioned in the order of reference of the Housing Committee) ; and food and drugs. Housing Committee.—All matters relating to housing activities of the Council, including the rehousing of inadequately housed or overcrowded persons, or persons displaced by reason of clearance or compulsory purchase orders. Highways and Cleansing Committee.—All matters relating to streets and roads, whether highways or private streets, cleansing and lighting of streets, refuse collection and disposal, sewerage and sewage disposal, streams and water courses. . . . Open Spaces Committee.—All matters relating to . . . public baths, cemeteries and burial grounds. . . . General Purposes and Finance Committee.— ... all other matters concerning the Council not specifically included in the order of reference of another Committee. Clearance and Re-Development Committee.—To consider, and where necessary to make recommendations to the Council in regard to, the submission to the Minister of Housing and Local Government of proposals as to clearance, and improvement areas, including the preparation of detailed proposals, showing phased programmes for the acquisition and clearance of insanitary dwellings and replacement thereof and the re-housing of their occupants; and for the acquisition and temporary improvement of unfit houses. General Purposes and Finance Sub-Committee of the Education Committee.—All matters relating to finance, supplemental and ancillary services, and to special educational treatment; control of the Education Department, and matters not within the order of reference of another Sub-Committee. 8 SENIOR PUBLIC HEALTH OFFICERS Medical Officer of Health: Caryl Thomas, M.D., B.Sc., D.P.H., Barrister-at-Law—four-tenths time allotted to work as District Medical Officer of Health, remainder as Area Medical Officer of the County Health Area No. 5, which comprises the district of Harrow. Deputy Medical Officer of Health: R. A. Strang, M.B., D.P.H.— one-tenth time allotted to local duties, remainder as Deputy Area Medical Officer of Area No. 5. Senior Sanitary Inspector: S. N. King, M.S.I.A.—with an establishment of 12 Sanitary Inspectors, one Shops Act Inspector and two assistants to Sanitary Inspectors. Chief Clerk: S. Wharton—one-tenth time on district duties, remainder as Chief Clerk of County Health Area No. 5. Senior Clerk: Miss P. Rawlinson—with an establishment of eight assistants. 9 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population mid-year 1953 217,900 Rateable Value (1st April, 1953) £2,257,770 Sum represented by a penny rate (1st April, 1953) £9,235 Total number of occupied houses 54,057 Total number of occupied flats 8,463 Extracts from Vital Statistics for the Year Live Births:— Total Male Female Legitimate 2,614 1,323 1,291 Birth rate per 1,000 population 12.5 Illegitimate 107 58 49 Total 2,721 1,381 1,340 Stillbirths:— Legitimate 68 32 36 Rate per 1,000 total births 25.4 Illegitimate 3 2 1 Total 71 34 37 Deaths 1,925 964 961 Rate per 1,000 population 8.8 Deaths of infants under one year of age 48 Infant mortality rate 16.9 Legitimate infant mortality rate 16.7 Illegitimate infant mortality rate 18.9 Deaths from pregnancy and childbirth Rate per 1,000 total births 0.3 Deaths from Cancer 362 „ „ Measles 1 „ „ Whooping cough 0 „ „ Tuberculosis 30 Population The mid-year population of the district was 217,900, a decrease of 1,100 on the mid-year population for 1952. The natural increase in population, i.e., the excess of births over deaths during the year, was 796. This population figure is the home population and includes members of the Armed Forces stationed in the district. 10 Births The total number of live births registered during the year was 2,721 (1,381 male and 1,340 female). Of these 107 were illegitimate, being a percentage of total births of 3.9. 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, 2,895, and 2,855. 759 births occurred in the district (746 live, 13 stillbirths). Of this number 133 were to residents of other districts. 1,949 (1,901 live and 48 still) birth notifications were transferred from other districts, being mostly of births occurring to Harrow mothers in hospitals in Middlesex or in London. The birth rate was 12.5. The local comparability factor for births is 1.02, the corrected birth rate was therefore 12.7; that for the country as a whole was 15.5. Deaths 1,302 persons died in this district in 1953. This figure includes those of members of the Armed Forces stationed here. Of these, 138 were persons who were not resident in the area. 37 deaths took place in the various hospitals and 35 in private nursing homes. Of the 762 deaths of the local residents which occurred outside the district, most took place in institutions, 326 being at the Edgware General Hospital. 160 deaths took place in hospitals just outside the district, including four in nearby isolation hospitals, and 177 in various London hospitals. The Registrar General arranges that the information about those who have died outside the district in which they normally reside is transferred to the Health Office of those districts, and these numbers are added to the deaths of those districts, corresponding reductions being made from the deaths allocated to any districts in respect of those who died in those districts, but normally reside elsewhere. According to this practice, whereas the death of a person, say in the Harrow Hospital, which is classed as a hospital for acute illness, is passed to the district in which the person normally lived, deaths occurring amongst those at Roxbourne Hospital are counted locally. So far as concerns those who have lived in Harrow before their admission, this makes no difference ; but many of the inmates of Roxbourne Hospital were resident in some other district and their deaths swell the local figures. Of the 56 who died in 1952 at Roxbourne Hospital, nearly one-half had been ordinarily resident not in this district. It seems that the question has been looked into and the criterion for determining the amount of acute cases which could cause an otherwise chronic hospital to be treated as a general hospital as regards transferability of deaths has been selected as being the ratio of the numbers of deaths and discharges to the average daily bed occupation being two or more in each of the two most recent years for which figures are available. The following is the Registrar-General's abridged list of causes of death in this district:— 11  Male Female Male Female Resp. tuberculosis 16 10 Other heart diseases 93 141 Other tuberculosis 3 1 Influenza 14 21 Syphilitic disease 3 0 Pneumonia 47 57 Diphtheria 0 0 Bronchitis 79 43 Whooping Cough 0 0 Other respiratory diseases 9 5 Meningococcal infections 0 1 Peptic ulcer 11 9 Acute poliomyelitis 1 0 Gastritis, Enteritis 6 3 Measles 1 0 Nephritis 8 9 Other infective diseases 1 2 Hyperplasia of prostate 21 0 Cancer of stomach 15 24 Pregnancy, etc. 0 1 Cancer of lung 63 12 Congenital malformation 6 6 Cancer of breast 0 26 Cancer of uterus 0 17 Other diseases 66 92 Cancer of other sites 98 107 Motor vehicle accidents 10 5 Leukæmia 8 6 Diabetes 6 5 Other accidents 10 14 Vascular diseases of nervous system 112 134 Suicide 8 6 Homicide 0 0 Coronary disease 189 108 Hypertension 21 30 Other circulatory diseases 39 63 Total 964 961 The total number of deaths was 1,925. The figure for 1952 was 1,890, a marked fall on that of 2,094 in 1951 which was the largest number of deaths recorded for this district. The death rate was 8.8 per thousand population. The rates for the the years 1944 and onwards were 9.3, 9.0, 8.6, 8.5, 8.9, 9.5 and 8.7. The liability to death varies at different ages. Any changes in the age distribution of a population then affects the death rate; similarly the death rates of the sexes are not the same. To offset the effects of these variations and so produce a rate which can be compared with that of other districts, or that of the same district at other times, the Registrar General calculates a comparative mortality index derived from the 1947 local civilian population estimates by age and sex, or recalculated on the basis of the final 1951 census population. When the death rate figure is multiplied by this, a figure is obtained which would have been the death rate for the district had the age and sex distribution of the population been that of the country as a whole in an agreed year. The index figure is 114; the adjusted death rate is 10.3, a figure well below that of 11.4, for the country as a whole. 1,292 deaths were due to diseases of the circulatory system, vascular diseases of the central nervous system and to cancer, a percentage of 66 of the total deaths. In 1952 over two-thirds of the deaths in the country as a whole were due to these groups of causes. The growth of this fraction is due partly to the increased control over certain of the communicable diseases which in other days accounted for deaths, and the extending longevity of the population. 12 Of the 964 males who died, 56% had attained the age of 65. Of the females the corresponding numbers were 961 and 71. While these days much is being written and spoken about the ageing of the population and the sociological problems this is leading to, less is heard about the fact that to-day's improved conditions mean that many fewer years are lost during the active working period of life. Compared with the position of a hundred years ago, in general mortality has been halved. The effect on different age groups has not been the same. The mortality in early life is only one-sixth of what it was and in childhood one-twentieth, whereas for those over 65 the average mortality rate for men is still five-sixths and for women two-thirds of what it was a hundred years ago. A point of importance to the community is the reduction in the loss of productive capacity or the loss in working years caused by premature death. In 1952 mortality represented a loss of 72 working years for every thousand of the working population (i.e., aged 15 to 64). A hundred years ago the corresponding figure was 497 so that the loss of working capacity caused by early death is to-day only one-seventh of what it used to be. The figures for tuberculosis in males are one-twentieth and for females one-twentyfifth. Loss from violence, excluding suicide but including road accidents is only one-third of what it was. There has been little change in the loss of working life for men on account of heart disease, but a greater loss is now being attributed to cancer. Deaths in the young are due to tuberculosis, intestinal disorders, and injury. In the interests of the productive capacity of the community these are the conditions where improvement can save working time. Infant Mortality 46 infants died under one year of age in 1953. In the same year 2,721 babies were born alive. The infant mortality rate was therefore 16.9. The rate for the country as a whole was 26.8. The rate for this district for the years 1946 and onwards was 31.0, 24.0, 28.8, 20.7, 13.6, 22.1 and 21.7. Of the 12 deaths that occurred in those that failed to survive twentyfour hours, six were of those prematurely born, four deaths were due to atelectasis, or developmental abnormalities, or disease, one to birth injury, and one to accident. All but one of these deaths occurred in infants whose mothers were confined in hospital. Twelve infants survived twenty-four hours, but failed to survive one week. In three the deaths were due to prematurity, in another three atelectasis. Birth injury was responsible for the death of two, congenital malformations another two, and two died from bronchial pneumonia. The mothers of all these infants had been delivered in hospitals or similar institutions. Four of the seven infants who lived one week, but failed to survive one month, died because of congenital developmental defects and two from bronchial pneumonia. The mothers of all but one of these infants had been delivered in hospital. Infections accounted for most of the deaths of those that survived one month, but died before reaching the age of one year. Of those who reached the age of one, but failed to reach the age of three months, two 13 died from congenital developmental defects and from bronchial pneumonia. Of the four who died between three and six months bronchial pneumonia killed two, gastro-enteritis the other two. Pneumonia accounted for five of the eight deaths of those who reached six months of age, but died before reaching one year of age. The difference between the 62 infant deaths of 1952 and the 46 deaths of 1953 is accounted for by a reduction of three in the number of those who died within twenty-four hours of birth, and of nine of those who survived one day, but failed to survive one week. Most deaths at these ages occurred amongst those whose mothers were confined in hospital. What was very striking was the small number of transfer deaths of infants in the last months of the year, there being in fact none in December and only two in November. The weather at this time was, of course, particularly mild and that may be the real explanation for the infant mortality rate for 1953 being such a marked improvement on that of 1952. Because deaths which occur before the infant has reached one month of age are due to causes so different from the causes of fatalities of those who survive one month, but fail to reach the age of one year the rate of deaths of those of under one month is commonly recorded separately as neo-natal mortality rate. In this district in this last year it was 31, comprising 67% of the infant mortality rate. The great fall in the infant mortality rate which was such a feature of the vital statistics of this country for this century occurred principally in the deaths which were due to environmental causes and which occurred largely in those infants who had survived one month. The infant mortality rate of the country as a whole continues to fall, but now at a slower rate. Nevertheless, this neo-mortality rate which for the country as a whole for 1952 was 18.-2, had hardly changed at all since 1950. Whereas at one time it formed a relatively small proportion of the infant mortality rate, it is now becoming responsible for most of the infant deaths. As a contrast to those deaths occurring in infants which have survived the first few weeks and which are largely due to environmental factors, these infant deaths are due to factors associated with delivery, prematurity, congenital diseases or abnormalities, or to atelectasis, which in some cases is a failure of adaptation of the infant in its new environment. Stillbirths Stillbirths represent a loss of infants just as do the infant deaths, and many probably are the result of factors similar to those which bring about some of the earlier infant deaths. The stillbirth rate for the country as a whole has not changed much for some years. In 1952 it was 27.2 per 1,000 live births, much the same figure as that for 1949. 71 stillbirths were registered in this district last year, this being a rate of 0.32 per thousand population, or 25.4 per thousand total births; the corresponding figures for the country as a whole were 0.35 and 22.4. Mortality of Infants between One and Five Years of Age Five children survived their first but did not reach their fifth birthday, the numbers who died in each year being 1, 1, 1, and 2. Infections accounted for three of these deaths, accident for one. 14 Maternal Mortality There was in 1953 only one death primarily due to or associated with pregnancy or childbirth. The maternal mortality rate was therefore 0.3. The figure of the country as a whole was 0.76. The fatality occurred in a woman who had full ante-natal supervision. Because of adherence of the placenta, following normal delivery at home, the patient was removed to hospital. The placenta was removed and the puerperium was uneventful until on the eighth day the patient had a pulmonary embolism which proved fatal in a short time. Deaths from Accidents During the year there were 40 deaths (19 male and 21 female), from violent causes. Ten deaths (eight male and two female) were the result of road accidents. Of these six occurred other than in this district ; in all of these a motor vehicle was involved. There were five fatal road accidents in this district, a motor vehicle being involved in each one. In three, the victim was a pedestrian, two of these being elderly persons who were knocked down by cars. The other was a young person knocked down by a motor cycle. Two deaths occurred amongst the riders of motor cycles and two cyclists were fatally injured when knocked down by cars. Falls of the elderly accounted for eleven deaths, ten of these being of women. In all but one of these cases the fall occurred at home. Poisoning caused the deaths of three, burns of another three. Coal gas poisoning resulted in one death. There was only one death from accident amongst children, this being the result of a burn of a child of four years of age. According to the Home Office Report of the Standing Inter-departmental Committee on Accidents in the Home, the commonest kinds of fatal accidents in the home in 1951 were falls 58%, burns and scalds 13%, suffocation 12%, and coal gas poisoning 8 %. About nine-tenths of the falls, over half the burns and scalds and nearly two-thirds of the coal gas poisonings happened to old people over 65 ; while at least eight out of every ten suffocations and one out of five of the burns and scalds happened to children under five years of age. The Heating Appliances (Fireguard) Act, 1952, will help to ensure that domestic heating appliances are adequately guarded. Deaths from Suicide The 24 cases of suicide in 1952 were a sharp rise over the number of 18 in 1951. In 1953 the figure fell to 14 (eight men and six women). Five of the men and all of the women chose poisoning by coal gas; two of the other men took poison. The distribution of the deaths was fairly even over the year. Once again there is the variation in the ages of those of the two sexes. As in previous years, nearly all the women were between 40 and 60, whereas the men were mostly outside this range. 15 Deaths from Cancer Of the 1,925 deaths of residents in this district, 362 were due to cancer, which caused 18% of the deaths of males and 19% of those of females. Of the deaths from this cause amongst males, in 63 the site was the lung (69 in 1951 and 71 in 1952) and 15 (32 in 1952) in the stomach. Of the deaths amongst females the site was the breast in 26 (42 in 1952), 24 the stomach, 12 the lung (20 in 1952) and the uterus in 17. Deaths from Infectious Diseases Infections other than tuberculosis again caused very few deaths, there being only one each from measles, meningococcal infection and poliomyelitis, and none from diphtheria, scarlet fever, or whooping cough. Influenza in the earlier months of the year caused a number of deaths, more especially in the aged. 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. 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. 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. Patients for whom accommodation cannot be found at the Hendon Isolation Hospital are admitted to hospitals further, and sometimes much further, afield. 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 applications are submitted by the patients' doctors to the Area Medical Officer, being passed to the County Medical Officer who decides on the homes the patients are to go to. 17 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. During the year Hillside Nursing Home closed; and Heywood re-opened, being registered for the reception of one maternity and four other patients. At the beginning of the year 17 homes were registered; these provided 193 beds, of which 22 were for maternity cases. At the end of the year there were 17 registered homes which provided 194 beds, of which 20 were for maternity cases. 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. At the end of the year there were in the district 27 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 The District Nursing Service maintained by the Harrow District Nursing Association was run from two homes, one at Bessborough Road, the other at Uppingham Avenue. Because of the inability to recruit sufficient staff who wanted to live in to warrant both homes being retained, in 1951 the Bessborough Road home was closed. For the same reason the Uppingham Avenue home was closed this last year. The Home Nursing Service now then is provided by nurses, some whole-time and some part-time, working from their own homes. As far as possible, each whole-time nurse serves the district near her home. Medical practitioners get into touch direct with the nurses who serve those parts of the districts where the patients live. 2. Midwifery and Maternity Nursing With the fall in the numbers of births which take place in the homes of the mothers, a fall largely due to the wishes of mothers to be confined in hospitals or other institutions, the 13 County Council midwives were more than sufficient to meet the needs of the Area. During the year the district lost one of its midwives to an adjoining area. The County Council midwives during the year attended as midwives 494 home confinements and 108 as maternity nurses. 3. Home Helps The County Council, as local health authority, provides domestic helps to households where such help is required because of illness or B 18 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. DAY NURSERIES The County Council as local health authority continued to maintain the four day nurseries they took over in 1948. Towards the end of 1952 they amended the arrangements for admission of children to the nurseries. Many children who had up to then attended were withdrawn. In some at least of these cases it is understood that the reason for the withdrawal was the high charge being made for the child who was admitted. When the question of the number of nursery places required to accommodate those who " needed " to be admitted was raised, the analysis was based on the findings of that smaller number still attending the nurseries and, therefore, did not assess the true need. The findings arrived at in this way were that the needs of the district were not much more than the number of places at one of the nurseries. The County Council then decided only two nurseries, that at Headstone Drive and that at South Harrow, should be retained. The Spencer Road nursery and the Kenmore Road nursery were, therefore, closed to children at the end of the year. 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 British Legion Hall, Headstone Lane Wed. p.m. 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. Stanmore Park Thu. p.m. 19 Ante-Natal Clinics Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. Baptist Church Hall, Streatfield Road, Kenton Fri. p.m. The Clinic, The Broadway, Wealdstone Tue. a.m. and Thu. p.m. 76, Marlborough Hill, Wealdstone Mon. p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. a.m. St. Hilda's Hall, Northolt Road, South Harrow Tue. a.m. The Clinic, Alexandra Avenue, South Harrow Wed. p.m. Methodist Church Hall, Walton Avenue, South Harrow Thu. a.m. St. Alban's Church Hall, North Harrow Tue. a.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. The Clinic, Honeypot Lane, Stanmore Tue. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. St. Anselm's Hall, Hatch End Thu. a.m. Chandos Pavilion, Chandos Recreation Ground, Edgware Fri. a.m. The Rectory, Elstree Mon. p.m. Toddlers' Clinic Elmwood Clinic, Elmwood Avenue, Kenton Baptist Church Hall, Streatfield Road, Kenton Alternate Thu. a.m. Spiritualist Church Hall, Vaughan Road, Harrow 1st Mon. a.m. in month The Clinic, Alexandra Avenue, South Harrow Wed. a.m. St. George's Hall, Pinner View, Harrow lst and2ndTue. 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. 20 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 treatment for such conditions as cervical glands, cardiac murmurs, etc. Any children needing special examination, especially if these are likely to be prolonged, are referred to be seen at these clinics. Ophthalmic Clinics School children selected by the school medical 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 Tuesday afternoons and Friday mornings 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. A whole-time orthoptist works 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 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. An orthodontic surgeon works full-time at the Marlborough Hill Clinic. 21 Physio-Therapy Treatment The Harrow Hospital maintains a physical treatment centre at the Car Park Building, Station Road, Harrow. (Tel. No.: Harrow 0926.) The medical director, Dr. G. C. Farrington, attends at fixed sessions to see all new cases. A wide range of treatment is carried out by the staff under the supervision of Miss M. Lock. The orthopaedic surgeon, Mr. K. I. Nissen, attends once a month. Care of the Feet A limited chiropody service is provided for children attending maintained schools, for nursing and expectant mothers, and for children under school age. 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.1. (Tel. No.: Trafalgar 7799.) In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at Kynaston Court. 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 Treatment Acts, and for the ascertainment and community care of mental defectives. 22 For administrative purposes 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, 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, Kynaston Court. The Aged Although the numbers of the aged are increasing, it is, of course, only a small proportion of those numbers who need any form of assistance. These will fall into one of three groups :— (1) Those needing medical or nursing care. These are the responsibility of the hospital services. Many from this district pass to the care of the Geriatric Department of the Edgware General Hospital. (2) Those needing care and attention but not medical or nursing care. These are the responsibility of the Welfare Department of the County Council. (3) The third group are those who are not ill and are not needing any special medical or nursing care or even care and attention. But many still have their own special needs, whether in the provision of meals, company or companionship. The Harrow Old People's Welfare Committee on which are representatives of the many agencies in the district that help the aged in any way, helps to link up the work of the many organisations which help in different ways to meet the needs of these people. One of the problems arising from those whose admission to hospital or institution is desirable but cannot be arranged, is the soiling of the bedding and the clothing of the incontinent. This problem arises more particularly in the aged. There seem to be administrative difficulties in arranging for something to be done to help. Although in many cases the problem arises from the inability of the hospital service to accommodate patients, it would seem, and quite understandably so, that the hospital authorities cannot assist those who have not been admitted to the hospital. The Local Health Authority would seem to have the necessary powers under Section 28 of the National Health Service Act—"A Local 23 Health Authority may, with the approval of the Minister, and to such extent as the Minister may direct make arrangements for the purposes of the prevention of illness, the care of persons suffering from illness or mental defectiveness and the after care of such persons." But there would appear to be difficulties about these arrangements being made under these powers. Local Sanitary Authorities have certain restricted powers under Section 84 of the Public Health Act, 1936: "Where it appears to a local authority upon a certificate of a Medical Officer of Health or the Sanitary Inspector that any article in any premises (a) is in so filthy a condition as to warrant its cleansing purification or destruction in order to prevent injury or damage to the health of any persons in the premises, or (b) is verminous ... the local authority shall cause that article to be cleansed, purified, disinfected or destroyed as the case may require at their expense." Anything done under these powers is limited in scope and cannot be of general application. Some local authorities have made use of their powers ; some provide a form of laundry service. The Hendon Group Hospital Management Committee have for long had this problem under consideration, and they were prepared to consider arranging for the actual work of the treating of the articles and clothing to be done if the Local Sanitary Authorities would meet the expense. The Council agreed to this within the limit of their powers, as to the type of case to be helped. At the end of the year it was learned that it was likely that arrangements on these lines would be made. They would be restricted to rather small numbers because of the restricted powers of the Council. Nevertheless, for those who can be helped in this way, the help would be of real benefit to the patients and to those who were looking after them. During the year a change was made in the arrangements by which some elderly persons are supplied with meals by the Meals on Wheels Service. Up to July these meals had been obtained from the kitchens at Kodak Limited. Under the new arrangements they have been provided from the Old People's Restaurant at the North Harrow Assembly Hall. AMBULANCE SERVICE Although the County Council decided that the Fire and Ambulance Service should be run as one combined service, the combination of the two services is limited to organisation and administration. Fire appliances are manned by firemen specially enrolled and trained for that purpose, and ambulances are manned by ambulance driver/attendants and attendants. "Ambulances specially equipped to deal with accidents and similar emergencies are kept at 28 fire stations throughout the county. These ambulances and their crews, who are trained in first-aid, are always ready to respond immediately to accident and emergency calls. A call which is received at a station when the ambulances are away attending other calls is instantly transmitted to a control centre from which the nearest available ambulance is ordered to answer the call. "Sick removal cases far outnumber accident cases. Many vehicles carry out the day to day task of transporting sick persons to and from 24 hospitals, clinics, maternity homes and other treatment centres. No matter where the destination may be, the County Council is responsible for the transport if the need arises within the county on medical grounds, always provided the patient is not capable of travelling by public transport." The County Council development plan provided for the building of ten ambulance depots at various places throughout the county. All ambulances and sitting case vehicles were to be used in these depots which would cater for the needs of the surrounding districts. They would also assist in the accident work if this became necessary in an emergency, e.g., in the event of a train accident or aircraft crash. Of the three of these buildings which have been erected one is in this district at Imperial Drive. (Tel. No. : Pinner 7351.) The hospital car service, operated jointly by the British Red Cross Society, the St. John Ambulance Association and the Women's Voluntary Services, provides cars and drivers, who give their services voluntarily, and by arrangement with the County Council takes many patients to and from hospitals and clinics. 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 7041.) In general, the examination is carried out of material which will be of aid in the early diagnosis of infectious conditions, one purpose of the laboratory being to carry out investigations of public health significance. It is not intended that other clinical material shall be sent, this work being carried out at the laboratories of certain hospitals. The 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, 268; fasces, 71; sputum, 25; pertussis, 6; milk, 48; ice-cream, 94; and water, 3; miscellaneous, 163. 25 SANITARY CIRCUMSTANCES OF THE AREA WATER Details of the water supply for the district and of the steps taken to ensure that the water supplied is pure were set out in the Annual Report for the year 1938. The Colne Valley Water Company is at present "carrying out a major programme of new capital works in order to be in a position to meet the increasing demands for water throughout the 81 square miles supplied by the Company. The new works include a very large treatment and softening plant. It has since the inception of the Company been the policy to soften the water supplied and that policy remains unchanged. Until the new works are completed, which will be in some two to three years, it is impossible to express an opinion as to the amount of softening which will be carried out." The results of the analyses of samples taken throughout the year were all satisfactory. The water supplied in this district is classed as hard. A typical analysis, for instance that of the 2nd October, 1953, was that the total hardness was 236, made up of temporary or carbonate hardness of 183 and permanent or non-carbonate hardness of 53. The accepted classification of water according to hardness is that those under 50 degrees hardness are soft, those of 50 to 100 p.p.m. moderately soft, of 100 to 150 slightly hard, 150 to 200 moderately hard, 200 to 300 hard and over 300 very hard. According to the Ministry of Health report on water softening (reprinted 1950) the percentage of population of the country supplied by these different types of water are 20.5, 14, 12, 8.5, 40 and 5. The local population is therefore being supplied with water which is harder than that supplied to most of the population of the country. Although the relationship of hardness of water to the health of consumers has been the subject of debate it is probably now generally agreed that there is little direct relationship; that it cannot be maintained that soft waters are responsible for the poor teeth or the defects in the bones which led to the deformities shown by rickety children ; nor on the other hand is the consumption of hard water related to any incidence of stone in the kidney, gout or arterio-sclerosis. Soft waters may be indirectly harmful because they are more likely to be plumbo-solvent and unless care is taken, their consumption could lead to lead poisoning; so also possibly the process of reducing hardness by adding soda might lead to a loss of vitamins in the food-stuffs on cooking. Again the fact that washing, whether of the person or of the clothing, in soft waters is so much more easy and more pleasurable than when hard waters are used might result in those living in areas supplied by hard waters being more susceptible to skin lesions and infections than those in districts where the water is soft; but there is probably no direct relationship between the hardness of water supplied to any district on the health of the consumers of that water. 26 Quite apart from the health aspect, there are many disadvantages in the use of hard water. There is the wastage of soap and the additional labour in washing. Hard water harms fabrics washed with soap, and hard waters cause considerable trouble by the disposition of scale when heated, the scale in its turn causing inefficiency in heating. According to the report referred to, " A hard water of 250 parts per million of hardness of which 50 parts are permanent cannot conveniently be softened by the lime process (not lime soda) to less than 80 to 100 p.p.m. hardness ; neither can water softened by the base exchange process be distributed to the consumers at a hardness of less than 80 to 100 p.p.m. without running the risk of severe corrosive troubles in the mains and service pipes." Amongst the conclusions of the Committee are:— 1. As soon as economic conditions allow, the Minister of Health should approve schemes already prepared by undertakers to soften their supplies, after being satisfied, of course, that the proposals are sound and unobjectionable in other ways. 2. As it is known that several undertakers are desirous of adopting softening, but have not prepared plans to do so, they should be informed that such proposals would receive favourable consideration, the actual time of carrying them out being dependent upon the materials and labour situation. 3. All other undertakers supplying water of hardness greater than 200 p.p.m. should be informed of our conclusions and asked to consider the matter. A number of them would doubtless find it possible to convince the Minister that softening schemes were out of the question for them for a number of years, but the remainder could be urged to take action. The General Purposes Committee at their meeting on the 26th November agreed that the Council would join with the authorities of certain other districts mainly served by the Colne Valley Water Company in their submission of a protest to the Company about the hardness of the water supply. DRAINAGE AND SEWAGE DISPOSAL Particulars of the local arrangements were set out in the Annual Report for 1948. In April an Inspector of the Ministry of Housing and Local Government visited in connection with the Council's proposals for the construction of a relief soil sewer in Pinner. In June the Council was informed that the proposals were approved in principle, but that because of the many pressing claims of other urgent and essential projects, agreement could not then be given to the work proceeding. At their meeting on the 2nd September the Highways and Cleansing Committee agreed to submit to the Minister of Housing and Local Government the Wealdstone foul sewer relief scheme. This is necessary to relieve conditions in certain low-lying parts of Wealdstone which are subject to flood by soil water because of the inadequate size of the existing 27 old sewer. The first stage would be the construction of a 21-inch sewer in High Street along Palmerston Road to Byron Road, thence to Masons Avenue and discharging into the new 21-inch at the rear of Cullington Close. The second stage will involve the picking up of the existing sewer in Headstone Drive by a 12-inch pipe near Cecil Road and then by an 18-inch pipe to discharge into the new 21-inch sewer. PUBLIC CLEANSING Refuse Collection The same arrangements continued in force for the collection of house refuse. Although many fewer than at one time, complaints were still being received of nuisances arising from the bins used for the collection of waste food. In October the Council decided, because of the financial losses suffered, to reduce to one-half the tonnage of waste food collected in the district. In view of the Government's decision that salvage of waste food by local authorities would in future be on a voluntary basis, the Highways and Cleansing Committee at their meeting on the 16th December decided to discontinue entirely the operation of the waste food salvage scheme in the district. Refuse Disposal All refuse collected in this district is taken outside to be tipped. Street Cleansing The same general arrangements are made for the cleansing of the streets of the district. PUBLIC CONVENIENCES The Highways and Cleansing Committee at their meeting on the 16th December agreed with the Cannon Brewery Company about the decoration and maintenance of the conveniences at the "Red Lion," "Queen's Head" and "The George" public houses at Pinner on the understanding that these should be available for use by the general public. DISPOSAL OF THE DEAD Burial Grounds Particulars of these were included in the Annual Report of 1948. Of the burial grounds and cemeteries under the control of the Council there are no new grave spaces available for interments at the burial grounds at Roxeth Hill, Eastcote Lane or Pinner Road, nor at the cemetery at Paines Lane, Pinner. The only interments which can take place here can be by the re-opening of existing graves. There is at the present rate of interments provision for burials at the Pinner Road, Pinner cemetery for 27 years and for 4i years at the Byron Road, Wealdstone cemetery. 28 At their meeting on the 24th November the Open Spaces Committee agreed to the consecration of 1.55 acres at the eastern corner of the recently extended part of the Harrow Weald cemetery (providing 1,400 grave spaces) instead of the 2 acres at the northern end of the extended area formerly proposed. In 1949 the Council agreed in principle to acquire by arrangement with the Borough of Wembley land forming part of the Carpenders Park site, Oxhey Lane, Herts., for cemetery purposes. At their meeting on the 24th November the Open Spaces Committee decided, subject to the consent of the Minister of Housing and Local Government to purchase 7.63 acres of this land. 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 five 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, 309 bodies were received in the mortuary. Postmortem examinations were carried out on 309 and inquests were held on 44. 29 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 complaints of dampness or other housing defects 907 (ii) On complaint of other nuisances 569 (iii) Routine inspections 484 (iv) Revisits arising from defects found 6,651 (v) Surveys under s. 157, Housing Act, 1936 219 Conditions Found (i) Number of dwellings or other premises where defects were found 1,764 (ii) Number of cases of overcrowding revealed 96 PUBLIC HEALTH Inspection of Other Premises (i) On complaint or request 152 (ii) Routine inspections of premises 583 (iii) Revisits arising from defects found 1,059 (iv) Surveys arising from Rat and Mice complaints 1,796 (v) Inspection of Factories 700 (vi) Inspection of Workplaces 104 (vii) Inspections of Outworkers' Premises 314 (viii) Inspection of Cinemas and Places of Entertainment 54 (ix) Inspection of Licensed Premises 69 (x) Visits under Shops Acts 1,593 (xi) Evening observations under Shops Acts 23 (xii) Sunday observations—Shops Acts 14 (xiii) Observations made for Smoke Nuisances 56 Conditions Found (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 188 (ii) Number of premises where action taken by Council's Rodent Operatives to deal with rats or mice 1,264 30 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 71 (iv) Number of Cinemas and/or Licensed Premises where defects were found 30 (v) Contravention of Shops Acts— (a) Failure to observe closing hours 2 (b) Other contraventions (failure to exhibit notices, etc.) 530 FOOD HYGIENE Inspection of Food : Food Shops and Food Preparing Places Visits (i) Slaughterhouses 29 (ii) Butchers' Shops 395 (iii) Cowsheds 9 (iv) Dairies 79 (v) Fish Shops 222 (vi) Bakehouses 124 (vii) Cafes and Restaurants 351 (viii) Ice Cream Premises 231 (ix) Provision Merchants 591 (x) Greengrocers 342 (xi) Other Food Premises 182 PART II COMPLAINTS RECEIVED Summary Accumulations of refuse 94 Animals causing a nuisance 25 Dampness and Housing defects 582 Drains and Sewers—choked 90 defective 95 Dustbins defective 68 Flooding—Gardens 17 Vermin 52 Insect infestations 88 Overcrowding, alleged 102 Smoke nuisances 26 Water course 7 Other complaints (pig bins, wasps' nests, defective fences) 184 Food unfit (excluding requests received from shops to visit and inspect unfit food) 38 31 PART III NOTICES SERVED Under Housing Act, 1936 (i) Statutory notices served under s. 9 requiring execution of repair work 32 (ii) Dwellings reported under s. 11 as being unfit for human habitation 14 (iii) Dwellings reported under s. 12 7 (iv) Informal notices swrved under s. 9 77 Under Public Health Act, 1936 Statutory Notices under:— (i) s. 24—Work to a public sewer 181 (ii) s. 39—Repair or renewal of drains 39 (iii) s. 45—Repair or renewal of defective water closets 13 (iv) s. 56—Undrained or badly drained yard area – (v) s. 75—Renewal of a dustbin 37 (vi) s. 93—Abatement of a nuisance 49 (viii) Informal notices served 1,917 ACTION TAKEN Following Housing Act Notices (i) s. 9—Dwelling rendered fit:— (a) By owners 22 (b) By local authority in default of owners 3 (ii) s. 11—Demolition order made 19 (Three of these orders relate to properties reported for action under s. 11 during 1952) (iii) s. 12—Closing order made 5 (iv) Dwellings rendered fit by owners after receipt of informal notice 66 Following Public Health Act Notices (i) s. 24—Public sewers repaired 34 (ii) s. 39— (a) By owners 10 (b) By local authority in default of owners 22 (iii) s. 45— (a) By owners 10 (b) By local authority in default of owners 2 32 (iv) s. 56— (a) By owners – (b) By local authority in default of owners 1 (Notice outstanding from 1952) (v) s. 75— (a) By owners 19 (b) By local authority in default of owners 9 (c) By occupier 4 (vi) s. 93—Nuisances abated (17 outstanding from 1952) 51 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,607 SUMMARY PROCEEDINGS On 13 occasions application was made to the Courts for Abatement Orders. In the case of three an order was granted; in the case of six others the Court granted an adjournment to enable the work necessary to abate the nuisance to be carried out and in each of the other four cases the work required was executed before the date fixed for the Magistrates to hear the case. A fine was imposed in one case and costs were allowed in six others. Appeals were lodged against two notices under Section 45 of the Public Health Act, 1936 requesting the owners to carry out repairs to water closets. Both were dismissed. An appeal was also lodged by the owner against a notice asking him to provide a dustbin. This was dismissed. For some time now it has been a matter of debate as to whether a notice calling for a new dustbin to be provided should be served on the owner of the house or on the occupier. Section 15 of the Middlesex County Council Act, 1950, enabled the one who was served with the notice to appeal, the Court being empowered to make such order as it thought fit. The Magistrates though were not obliged to make any order against either the owner or the occupier. Section 8 of the Local Government (Administrative Provisions) Act, 1953, may remove some of the difficulties as both the owner and the occupier of a building may be brought before the court where a notice has been served on one of them to provide a dustbin. HOUSING Houses Incapable of Repair A local authority being satisfied that any house is in any respect unfit for human habitation, unless they are satisfied it is not capable at reasonable expense of being rendered so fit, serve a notice under Section 9 of the Housing Act calling for the carrying out of works to render the house fit for human habitation. However, when the authority are satisfied that the house is not capable at reasonable expense of being rendered so fit, steps are taken under Section 11 of the Housing Act with view to a Demolition Order being made. If there are groups of houses, 33 proceedings might be by Clearance Areas, with the demolition of each of the houses in the area. It has for some time been felt that the time was coming when in spite of the acute housing shortage consideration should be given to the continued use of a number of houses which were felt to be unfit for human habitation, but which were not considered capable of repair at a reasonable expense. At their meeting on the 18th November, 1952, the Committee approved of the preparation of lists of houses which should be considered with a view to steps being taken for their demolition. Five groups of properties were therefore submitted to the Committee and at their meeting in November the Committee received the official representations in respect of numbers 1, 3, 5, 7, Pinner Hill Road, Pinner ; 2, 4, 6, 8, 10, 12, Palmerston Road, Wealdstone; and 29, 30, 31, 32, 33 and 34, Little Common, Stanmore. At the same time, it was pointed out that there were other groups of properties in the district which were the subject of Clearance Orders or Demolition Orders made before the War, most of these still being occupied. At their meeting in November, the Committee asked the Housing Committee to provide alternative accommodation for the occupants of all the houses in the district which were the subject of confirmed Clearance Orders and Demolition Orders. These comprise:— Clearance Orders : 2-40, Headstone Drive; 1-5, Brewery Cottages, Stanmore; and Albany, Appleton, Park View, and Northumberland House, High Street, Stanmore. Demolition Orders: 277-285, Pinner Road; 4, 6, 8, 10, Shelley Road; 23, 25, 27, Milton Road; 29, Milton Road; 40, 42, 44, 46, Marlborough Road; 1, 3, 5, Peel Road; 99-101, Greenford Road; and 1-7 Kingsfield Terrace. Demolition Orders have been made in the last year in respect of the following houses:—4, 6, 8, 10, Shelley Road; 23, 25, 27, Milton Road; 40, 42, 44, 46, Marlborough Road ; 44, 46, 48, College Road, and 277, 279, 281, 283, & 285 Pinner Road. In some premises only part of the house is considered to be unfit for human habitation. These can be dealt with by the making of Closing Orders. Recent legislation has permitted the same procedure to be followed in dealing with a house which should be the subject of a Demolition Order, but which cannot be demolished because of its attachment to its neighbours. Through the year Closing Orders were made in respect of part of Waldron Cottage and in respect of 58, Milton Road, 40, Milton Road, 48 and 50, High Street, Harrow-on-the-Hill. Certain provisions of the Local Government (Miscellaneous Provisions) Act, 1953, affect the procedure to be followed in dealing with houses incapable of repair. Under the Housing Act, 1936, a Closing Order could be made in respect of only part of a building, not of the whole. The result was that to deal with a house which was one of a terrace, a Demolition Order had to be made, even though it might be so very difficult, if not impossible, to demolish the house. Section 10 of the new Act enables local authorities, if they consider it expedient, to make Closing Orders instead of Demolition Orders. A local authority, too, may revoke a Demolition Order if it is expedient, having regard to the effect of the Demolition c 34 Order upon any other house or building. The other provision relates to outstanding Demolition Orders. Section 2 of the Housing Act, 1949, empowered a local authority to apply to the Court to quash a Demolition Order if it were satisfied that the house had been made fit for human habitation. Under the 1949 Act, though, the last date on which the owner could apply to the Court was the 31st July, 1950. Section 11 of the new Act extends the period within which owners of houses on which there are outstanding Demolition Orders may apply to the Council for the quashing of the Demolition Orders to the 14th August, 1954. Standard of Fitness A Standard of Fitness was set out in the report of the Standards of Fitness for Habitation Sub-Committee of the Central Housing Advisory Committee. This is that a dwelling must:— (i) be in all respects dry (ii) be in a good state of repair (iii) have each room properly lighted and ventilated; (iv) have an adequate supply of wholesome water laid on for all purposes inside the dwelling; (v) be provided with efficient and adequate means of supplying hot water for domestic purposes; (vi) have an internal or otherwise readily accessible water-closet; (vii) have a fixed bath, preferably in a separate room; (viii) be provided with a sink or sinks with suitable arrangements for the disposal of waste water; (ix) be provided with facilities for domestic washing, including a copper, preferably in a separate room ; (x) have a proper drainage system; (xi) be provided with adequate points for artificial lighting in each room; (xii) be provided with adequate facilities for heating each habitable room; (xiii) have satisfactory facilities for preparing and cooking food; (xiv) have a well-ventilated larder or food store; (xv) have a proper provision for the storage of fuel; (xvi) have a satisfactory surfaced path to outbuildings and convenient access from a street to the back door. Overcrowding At the beginning of the year the number of known cases of overcrowding in the district was 229. In March there were 55 houses known to be overcrowded by more than one unit. Of these the home of one family was overcrowded by 4 units, two families were living in accommodation overcrowded by 3½ units, seven families by 3 units, six families by 2½ units, 14 families by 2 units and 25 families were living in accommodation overcrowded by 1½ or more units. Some of these families already qualified 35 for rehousing under the points scheme. The cases of these families, then, were not considered by the Public Health Committee. The Committee at their meeting on the 31st March recommended that 14 of the overcrowded families be rehoused. At their October meeting a further four were recommended, while the circumstances of three other families, all living in Council houses, was brought to the notice of the Housing Committee. The position at the end of the year, then, of these 55 families, was that the vast majority had either been or were to be rehoused by the Council either by the operation of the points scheme or on the recommendation of the Public Health Committee because of the overcrowded condition of the homes in which they were living. Only three families were living in houses overcrowded by more than 2½ units ; one family living in a house overcrowded by 3½ units and two families living in houses overcrowded by 3 units. There were special reasons in these cases for no recommendation having been made by the end of the year for their rehousing. Apart from these cases, of all the families living in houses overcrowded by more than 1 unit there remained at the end of the year waiting to be considered ten families living in houses overcrowded by 2 units and 11 families living in houses overcrowded by li units. The following table shows the various changes:— Units of Overcrowding 4 3½ 3 2½ 2 1½ Cases known March, 1953 1 2 7 6 14 25 Rehoused in Council Houses 1 1 2 4 7 5 Otherwise abated – – – 1 1 5 Overcrowding reduced to below 1½ units – – 1 1 – 3 Adjustment (subtraction) for variation in the degree of overcrowding – – 2 – – 4 Adjustment (addition) for variation in the degree of overcrowding – – – – 4 3 Balance of outstanding cases – 1 2 – 10 11 Of the twenty-seven cases housed in Council houses, four were rehoused out of the quota of houses for the overcrowded, and two out of the quota for the tuberculous. Twenty-one families were rehoused by the operation of the points scheme. Since March, 30 new cases have become known. Of these seven have been rehoused in Council houses and three have been abated by other means. The total number of cases known to be overcrowded by more than 1 unit at the end of the year is 44. Of these, one is overcrowded by 4 units, two by 3½ units, two by 3 units, two by 2½ units, 14 by 2 units, and 23 by 1½ units. In 1949 publicity was given to the fact that in regard to newly permitted overcrowding which was not the result of the natural increase in 36 the size of the family, consideration would be given to the question of whether the penal provisions of the Housing Act should be used. The Committee instructed that each such case learned of should be reported to them. During this last year there have been six such cases. In one the son of the family and his wife went outside the district to live in a caravan, but on the wife developing tuberculosis, the family returned to their former home ; this family was recommended for rehousing essentially because of the tuberculosis. Another of the cases concerned a family of a man, wife and nine children who came to this country from Canada, where they had been for a number of years and went to the home of the husband's mother ; as there was no other means of abating the overcrowding, the family was offered accommodation in one of the half-way houses. The Chief Medical Officer of the Ministry of Health in his Annual Report for 1952 refers to some national housing statistics:— In 1951, 7% of structurally separate dwellings in England and Wales were shared by more than one household; the corresponding figure in 1931, was 9.2%. In terms of families, 15% of private householders were sharing accommodation in a dwelling in 1951 compared with 19% in 1931. Other comparative figures are:— 1931 1951 Persons per household 3.72 3.19 Number of dwellings 9,123,000 11,934,000 Persons per room 0.83 0.73 Percentage of persons living in overcrowded accommodation 6.94 2.16 New Houses The total number of new permanent and temporary Council dwellings completed and handed over by the end of the year since the end of the war was 2,165. 4,747 dwellings have been provided since the war, these comprising 2,165 in new permanent and temporary Council houses, 657 in requisitioned premises, 331 by the re-building of war destroyed houses, 1,281 permanent houses erected by private enterprise and 333 by the conversion of existing houses. Circular No. 29/53 of the Ministry of Housing and Local Government dealt with the arrangements which should be made for securing the transfer of families to new and large towns. It is proposed that Harrow with 12 other Middlesex and two Hertfordshire Authorities in an exporting sector be linked with (1) Harlow, Hatfield, Hemel Hempstead, Stevenage, and Welwyn New Towns; and (2) Aylesbury, Bletchley, Harpenden, Hertford, Letchworth, St. Albans, and Swindon Expanding Towns; being towns to which the exporting authorities would naturally seek to 37 decentralise their populations. The Council is already operating schemes with Bletchley and Aylesbury, paying the annual rate fund contribution for ten years in the one case and for 20 years in the other in respect of each family nominated by the Council for a house in those towns. Apart from movements under these arrangements, some families had already moved from Harrow to Hemel Hempstead. It is now proposed that exporting towns should make a contribution to the New Town Corporations on the same lines as they were making to the Expanded Towns in respect of families nominated by the Council, the annual rate fund contribution being paid for ten years. Arrangements have been made for 100 houses in Aylesbury to be allotted to families whose names are on the Harrow waiting list. For each house Harrow will pay Aylesbury an annual rate fund contribution of £8 18s. Od. per house for 20 years. Provision is made for the position to be reviewed after 20 years. By the end of the year 409 Harrow families had been housed in new or in expanded towns, 277 being at Hemel Hempstead, 44 at Stevenage and 60 at Bletchley. Of these, 284 families had been on the ordinary housing waiting list. Allocation of New Housing The following table sets out the position regarding the rehousing of families recommended by the Public Health Committee as reported on the 8th September. Families Recommended Families Rehoused Clearance Orders 29 – Demolition Orders 31 5 Closing Orders 3 2 Overcrowding 22 *5 Tuberculosis 50 38 To enable property to be renovated 2 – *A further five cases recommended by the Public Health Committee have qualified for housing on their pointing. The following table gives for the different years: (a) The number of Council houses built. (b) The number houses allocated to registered cases of overcrowding either by the operation of the points scheme, or on the special recommendation of the Public Health Committee. (c) The number of houses allocated to families with a member suffering from tuberculosis. (d) The number of houses included in operative Clearance Orders. (e) The number of individual unfit houses condemned. (f) The number of Closing Orders made. 38 (a) (b) (c) (d) (e) (/) 1935/39 135 82 – 149 73 5 1942 – – – – – 4 1943 – – – – 10 – 1945 * – – – – – 1946 215 74 19 – – – 1947 255 100 22 – 2 – 1948 365 131 20 – 3 – 1949 286 87 27 – 1 1 1950 181 71 20 – 19 3 1951 366 51 10 – 2 – 1952 239 68 31 – 4 6 1953 258 69 27 – 19 5 Total 2,300 733 176 149 133 24 Pre-War 135 82 – 149 83 9 Post-War 2,165 651 176 – 50 15 * Start on 50 prefabricated bungalows. Rehousing The revised housing list on the 31st March contained 4,725 applications. Of these, 4,073 were of families living in the district, 554 of families living outside the district and 98 were separated families. Because of the very small numbers of houses likely to become available to rehouse those who would be allocated houses under the points scheme, the Housing Committee at their meeting on the 2nd July agreed to remove from the housing waiting list applications from (a) Childless couples; (b) Applicants at present adequately housed ; (c) Persons residing outside the Urban District; on the understanding, however, that applicants in these categories could apply on special or hardship grounds to be reinstated to the list in the event of a worsening of their present housing circumstances. "Houses: The next step" In common with many other districts, though probably not on the same scale as in many districts of comparable size, this authority has been faced with difficulties of getting houses which are in need of attention repaired because the owners cannot or will not carry out the work. This has come about partly because of the deterioration in the state of the houses over the war years and partly because the controlled rents do not enable the owners to recoup themselves for any additional expenditure on the houses. Some houses, therefore, are being lost as housing units. In some cases it has appeared that the houses could, with expenditure of some money on them, be saved for many years and in the past years a number of such houses have been brought to the notice of the Public Health Committee with the suggestion that the Council should consider acquiring them and carrying out the work necessary to save them as housing units until the housing situation is easier. 39 Harrow's problem is probably relatively small because so much of the district was developed in recent years. The Ministry of Housing and Local Government refers in the Publication— "Houses : the next step"— to the problem as it affects the country as a whole. For the purpose of a comprehensive plan of repair, maintenance, improvement and demolition which covers all types and conditions of houses, houses are divided into four categories:— (i) The best—the great mass of essentially sound houses, many of which are in good condition and all of which the landlords could be expected to keep in good condition given a reasonable rent. This in many cases must mean some increase in rent. (ii) The worst—the slum houses which ought to be demolished as soon as circumstances permit. Only a proportion can be pulled down and replaced in the next five years. Since the rest must, of necessity, remain in use they should at least be patched up in order to make life more tolerable for their occupants. (iii) An intermediate class—the "dilapidated" houses—some of which may be brought into the first class by their owners, others of which local authorities may have to get repaired in all essentials by greater use of their statutory powers. (iv) Houses which could give years of good service if they were improved—that is to say provided with bathrooms, hot water, up-to-date cooking arrangements and other necessary amenities; also houses too big for present-day needs which could be converted into good, comfortable flats. To give the landlord sufficient to enable him to carry out repairs to the essentially sound houses, it is proposed that the repairs increase shall be an amount equal to twice the statutory deduction, i.e., the difference between the gross value for rating purposes and its rateable value, with a proviso that no rent shall rise above twice the existing gross value of the house. The landlord will be able to claim the repairs increase only if the house is in good general repair as respects both structure and decoration. If the tenant considers at any time that the house is not maintained in this state of repair, he can apply to the local authority for a "certificate of disrepair." This certificate will enable him to withhold payment of the repairs increase. The repairs increase is not allowed unless the landlord can show that he has actually spent money on repairs. Slum houses are defined as those which are unfit for human habitation and cannot be made fit at a reasonable expense, or which by reason of their bad arrangement or the narrowness or bad arrangement of the streets are dangerous or injurious to the health of the inhabitants. Some of these houses were already scheduled for demolition before the war. The lack of attention to property during the war years accelerated the decay of others. There are so many of these houses that they cannot all be demolished over a short period of time, so that many must continue to be lived in for some time to come. For this time they must be made 40 better. What is to be done is to become the responsibility of the local authorities. Where these houses are in groups which if it were possible to do without the houses now would be the subject of the clearance procedure, the authority will acquire the houses even though the houses cannot be demolished for some years ; and until demolition and replacement becomes possible, the authority will improve the condition of the houses. The authority will follow in respect of these houses the same procedure as that for the demolition of houses; but demolition in fact will be deferred. The third group are the "dilapidated houses." If a local Authority considers that a house is unfit for human habitation and can be made fit at reasonable expense, they may require the owner to carry out the repairs needed to make it fit. If he does not comply, the local authority may do the necessary repairs themselves, recovering the necessary cost from him. Proceedings under these provisions were complicated because there was no accepted standard of unfitness for human habitation. It is intended that such a standard shall now be defined, and local authorities will be expected to do on behalf of the owner such work as will enable the house to reach that standard if the owner fails to do so. The landlord will not be entitled to any increase in rent where all that he does, or the local authority does for him, is merely to make the house fit for human habitation. To qualify for the repairs increase, the house must be put in good repair as respects both structure and decoration. The last group of houses are those which would give good service if they were improved by the provision of necessary amenities, and also houses too big for present-day needs which could satisfactorily be converted into flats. Exchequer assistance is already available under the 1949 Housing Act to owners who are prepared to improve or convert their property. Little use has been made of these powers though, partly it seems because the facilities are not well known and possibly, too, because it is a requirement for a grant that the house should have an expected life of thirty years. There was, too, a limit of £800 on the cost of conversion. This limit is being raised, and as to the money spent an addition to the rent of 8% is to be allowed as against the present figure of 6%. These changes might do something towards retaining as housing units properties which otherwise would be lost. Clearance and Re-development Committee The Council at their meeting on the 11th December accepted the recommendation of the General Purposes and Finance Committee that a special committee to be named the Clearance and Re-development Committee be appointed with the following order of reference:— To consider, and where necessary to make recommendations to the Council in regard to, the submission to the Minister of Housing and Local Government of proposals as to clearance and improvement areas, including the preparation of detailed proposals, showing phased programmes for the acquisition and clearance of insanitary dwellings and replacement thereof and the rehousing of their occupants ; and for the acquisition and temporary improvement of unfit houses. 41 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 Occupiers prosecuted (i) Factories in which S.S. 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 67 84 35 – (ii) Factories not included in (i) in which S. 7 is enforced by the Local Authority 453 554 9 – (iii) Other premises in which S. 7 is enforced by the Local Authority (excluding out-workers' premises) 61 62 6 – Total 581 700 50 – 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 39 44 – – – Overcrowding – – – – – Unreasonable temperature – – – – – Inadequate ventilation 1 3 – – – Ineffective drainage of floors – – – – – Sanitary conveniences— – – – (a) Insufficient – – – – – (b) Unsuitable or defective 13 13 – 2 – (c) Not separate for sexes 1 1 – 1 – Other offences against the Act (not including offences relating to outwork) 17 27 – – – Total 71 88 – 3 – 42 In addition visits were made to premises of the 222 outworkers who are persons undertaking at home work sent out from factories or business premises. Industrial Hygiene: The Council submitted to the Urban District Councils Association their views that the responsibility for the environmental and preventive health services for industrial premises should be entrusted to County District Councils. The Urban District Councils Association, however, hold the view that responsibility for environmental and preventive health services in factories in the industrial areas is not one for local authorities to undertake and that the matter is already in part catered for in the Factories Acts. Shops Towards the end of 1952 the Defence Regulations which required shops to close during the winter months at 6 p.m. Monday to Friday and 7.30 p.m. on Saturday, the late day, were repealed ; and during 1953 the hours of closing for most trades were 8 p.m. Monday to Friday and 9 p.m. on Saturday. Few traders kept their shops open to these hours and on only two occasions were customers observed being served after hours. Both were associated with the sale of cigarettes. The shopping public seem to be continuing to follow the war-time practice of shopping early and so far there are no indications that late Friday and Saturday night shopping will return. During the year, 1,846 visits to shops were made by the Shops Acts Inspector and arising from the various contraventions found 326 warnings were given to traders. Most of the contraventions were the failure to exhibit notices or to keep the records that are required by the Shops Act. 23 cases were found where shops were inadequately heated and in the case of 72 others cleansing or repair work was necessary. 32 offences against the provisions of the Shops Acts in respect of Sunday trading were observed and warnings or advice were given to those responsible. Two traders who had been warned previously for the same offence, were reported to the Public Health Committee; final warning letters were sent by the Clerk. The total number of shops on the register at the end of the year was 2,343, an increase of 19 on the previous year. The following is a classification of the various types of shops, and their numbers:— Antique Dealers 10 Lending Libraries 6 Builders' Merchants 25 Leather Goods 11 Boot Repairers 63 Mixed Shops 14 Butchers 133 Musical 4 Boot & Shoe Shops 52 Newsagent 124 Chemists 77 Opticians 19 Corn Chandlers 8 Ladies' Wear 93 43 Motor/Cycle Accessories 98 Gentlemen's Wear 79 Confectioners—Cafes 177 Pet Shops 6 Coal Order Offices 36 Photographers 13 Drapers 56 Licensed Premises 54 Dairies 36 Radio, Electrical & T.V. 62 Fruiterers, Greengrocers 143 Second-hand Wardrobes 6 Florists 27 Stationers 6 Furnishers 46 Tobacconists 149 Fish Shops 64 Toys & Sports 13 Glass & China Ware 14 Wines & Spirits 41 Grocers 228 Wallpapers, Paint 13 Hairdressers 134 Wool 23 Hardware, Ironmongers 66 Miscellaneous 86 Jewellers 28 Smoke The tragic effects of the fog in and about London in 1952 aroused or stimulated interest in the question of the pollution of the atmosphere by smoke, and many papers have been read in the last year bearing on this subject and a number of reports published. One of these, the Beaver Report, is the interim report of the Committee on Air Pollution. Accepting that improvement will be a slow matter the Committee set out some measures that might be taken during the winter months to avoid the worst effects of smoke. These include:— 1. The prescribing by doctors of masks for patients suffering from heart or lung diseases living or working in an area where smoke-polluted fog is likely to occur. 2. The issue by the Meteorological Office of warnings when serious fog is expected to prevail at least 24 hours in areas of normally high pollution. 3. Householders during these periods to burn smokeless fuel. When persistent fog is forecast it is suggested that coal fires should not be banked up at night; that those who can use smokeless fuels should confine themselves to these ; that rubbish should not be burned in open fires ; that elderly people and those suffering from chronic heart or lung conditions might be helped by wearing a mask or scarf wrapped round the mouth and nose if they have to go out in the fog ; and the general public should refrain from bringing motor vehicles into densely populated areas. On the position of smokeless zones, the report reads:— "The 'smokeless zone' provisions of some local Acts unlike the smoke provisions of the Public Health Acts, apply to domestic as well as industrial smoke. The effect of the provisions of the Acts where in force, is to prohibit the emission of smoke from any premises in certain areas which are defined either by the Acts themselves or by orders made by the local authorities and confirmed by the Minister of Housing and Local Government or the Secretary of State for Scotland. 44 "Of the 17 local authorities which have obtained special powers for the purpose, only two have so far put statutory smokeless zones into operation—Coventry and Manchester. The zone at Coventry became effective on 1st March, 1951, and covers some 30 acres in the central part of the city which were badly bombed during the war and were due for redevelopment. There were only two dwelling-houses in the area. The Manchester zone was established on 1st May, 1952. It covers about 104 acres in the central area, which again is largely non-residential. In many atmospheric conditions the effect of the Manchester smokeless zone is, we understand, very noticeable. It is an indication of what is possible. "In the United States large smokeless areas have been achieved at St. Louis, Pittsburg and elsewhere and without doubt are effective. The principle of smokeless zones has naturally, therefore, attracted much attention and is widely regarded as a simple and easy solution of the 'smog' problem. Its rapid extension in this country is, however, subject to practical limitations. To have any material effect the zones must be large; if they are small they will not, in fact, be 'smokeless' since they will receive smoke from surrounding areas. The prohibition of smoke in an area pre-supposes that all the fuel that is burnt, whether in industrial or domestic premises, can be burnt without smoke, that is to say, that every building will be equipped with the right kinds of appliances and that sufficient smokeless fuels will be available. While supplies of the latter are limited, their allocation only to smokeless zones would be at the expense of other areas. This suggests that any extension of smokeless zones, if they are to have the best results, should be carefully planned according to the needs of different areas. A smokeless zone may be achieved with less difficulty in an area of new development, but in the case of existing property it is likely to entail extensive conversions of plant and equipment and a radical change in traditional methods of heating. The establishment of smokeless zones must, under present conditions, involve increased expenditure and restrictions on the use of fuels whether in regard to industrial or domestic fires. "The practicability and the economics involved in the extensive development of smokeless zones are matters which we are investigating." The report ends:— "This preliminary report has outlined the main features of the problem of air pollution as it exists to-day. The causes and remedies of pollution by smoke are known; the problem is one of practicability and economics, and of the education of the whole community. Complete cure of both solid and gaseous pollution, if indeed it be ever attainable, is bound to take many years, but means of averting at least the worst evils of air pollution by smoke and grit are within practicable reach. It is simply a question of balancing the cost and inconvenience of enforcing a more efficient and scientific use of our fuels against all the advantages to be obtained in health, convenience and economy from a clear atmosphere. This problem, with all that is involved in a real attack on the menace of air pollution, is one which must be faced. We now propose to embark upon the detailed study of the practical difficulties which we have 45 indicated in this interim report. But we feel bound to point out that such work will be merely of academic interest and can lead to no material improvement unless there is general acceptance of the fact that the cure will require heavy expenditure and full co-operation of all persons and all interests." Smoke arises almost entirely from the inefficient and wasteful combustion of bituminous coal. Smoke elimination in the industrial usages of coal is largely a matter of installing proper equipment for efficient combustion. The domestic chimney is the hard core of the smoke abatement problem. Bituminous coal cannot be burnt without smoke in domestic appliances. The problem of eliminating domestic smoke is essentially the replacement of bituminous coal by solid smokeless fuel supplemented by gas and electricity for summer water and space heating. The Ridley Committee in their report last year stated:— "(2) One heavy social cost to the community is the smoke pollution usually produced when raw coal is burnt inefficiently. It is impossible to measure all this cost in money. Estimates have been cited from time to time for parts of it. In real terms it is certainly enormous, as every-day observation in our large towns and cities shows—most clearly to those who know conditions abroad, where less coal is burnt raw in inefficient conditions. Among the social costs are the loss of sunlight and the harm to the health of the citizens, the reduction in the amenities of town life, the damage to buildings and textile fabrics, the extra costs of painting, washing and laundry, and the loss of food production which results from the smoke deposit in the countryside around the towns. These are only some of the main losses which the community endures through smoke. "(3) But apart from the losses which the community suffers from smoke pollution, there is the inefficiency of which smoke is the visible symptom. "(4) The main sources of smoke pollution in the United Kingdom are:— (i) The millions of households which use raw coal burnt in old- fashioned open grates as the main source of heat comfort. There are perhaps 12 million such open fires in regular use— and producing a million tons of smoke. Thus the townsman pays heavily for smoke, both directly as a coal consumer, and indirectly as a citizen living in dirty air. (ii) Smaller industrial boilers and furnaces burning raw coal. (iii) Steam railway locomotives." The Committee expressed the view that the more general adoption of smoke abatement bye-laws by local authorities and the establishment of more smokeless zones depends on having enough smokeless fuels and suitable appliances and went on to say that as they became available there was a good case for more widespread declaration of smokeless zones in the causes both of reducing the social costs of smoke pollution and of improving fuel inefficiency. The Housing Committee at their meeting on the 18th December considered on the recommendation of the Public Health Committee, the 46 following suggestions contained in resolutions adopted by the Executive Council of the National Smoke Abatement Society:— "1. That sufficient space should be provided for the storage of fuel at dwelling houses to enable an adequate quantity of lighter solid smokeless fuels to be stored and kept separate from bituminous coal. "2. That local authorities should be urged to improve their arrangements to ensure that tenants of municipal houses with the modern appliances are advised and persistently encouraged to burn solid smokeless fuel." The Surveyor reported that the suggestions are already being implemented as far as possible on Council housing estates, and the local Fuel Officer was invited to furnish his observations on the continued difficulties confronting some householders in obtaining adequate supplies of solid smokeless fuels. 26 complaints were received during the year about smoke. Most of these were of smoke from the chimneys at three factories. As a result of the investigations made consultants were called in by the management of one factory and a number of alterations were made. This brought about an improvement and further trials and tests are proceeding. During the year a grit-arresting plant was installed at another factory; and at two others alterations to the works destructor are being considered. Infestation by Insects and Pests During 1952, in order to help householders and traders in the district who experience trouble with household insects and similar pests all specimens brought to the notice of the department were collected and retained. With the help of the Department of Entomology of the Natural History Museum, the Infestation Branch of the Ministry of Agriculture and Fisheries, and a number of other sources, a most useful collection has been built up. It now contains between 70 and 80 specimens of different species, and is shown at the talks given by the sanitary inspectors on such subjects as food hygiene, environmental hygiene and on the work of the Health Department. Many additions were made to the collection during the year. Among them was the Seaweed Fly, which received much publicity because of its prevalence along the South coast toward the end of the year. The fly was first reported in Harrow on the 31st October, when many invaded a factory in Honeypot Lane. As the fly appeared to have been attracted to the factory by some of the chemicals used, other premises in the district using similar chemicals were visited and three other infestations were found. With the co-operation of the management of the factories concerned, the infestations were dealt with and no further trouble has been experienced. The following Table gives details of the 1,333 complaints that were received during the year about rats and mice:— 47  Council Property Rats Mice Private Dwellings Rats Mice Business Premises Rats Mice Agricultural Property Rats Mice Total No. of premises inspected (a) on notification 7 2 949 95 106 44 – – 1,203 (b) otherwise 4 1 91 18 14 2 – – 130 Total 11 3 1,040 113 120 46 – – 1,333 No. of premises where no infestation found 2 — 55 — 12 — – – 69 No. of infestations 9 3 985 113 108 46 – – 1,264 During April and May 551 manholes (10 per cent.) on the Council's surface water and soil sewers were test-baited. Only six showed any evidence of infestation by rats. These manholes were treated, together with 61 others where evidence of infestation had been found during previous tests. In only 7 of these was evidence of any active infestation found. Licensed Premises There are 54 licensed premises in the district. All were inspected during the year and during October a report on the conditions found was submitted to the Licensing Justices. Most of the work the brewers were asked to carry out involved cleansing and redecorating. Cinemas and places licensed for music and dancing were also inspected and a report on the conditions found was submitted to the Middlesex County Council. Keeping of Pet Animals During 1953, two applications were received for licences under this Act. The premises were inspected, found to be satisfactory and the licences were issued. The number of licensed pet shops in the district is now 15. 60 inspections of these premises were made during the year. In ten cases it was necessary to ask for defects or omissions to be made good. One defect was outstanding at the end of the year, but the others were remedied without statutory action being necessary. Of the 15 shops, seven sell raw meat as animal food, four having started doing so during 1953. The owners of these have complied with the requirements of the department which included the taking of steps to ensure the hygienic handling and storage of meat. Rag Flock Of the five premises registered when this Act came into force, one has now closed and has been removed from the register, and one has ceased to make new articles, but the occupier wishes the premises to 48 remain on the register. There are now, therefore, four premises in the district registered under Section 2 of the Rag Flock and Other Filling Materials Act. There are no licensed premises in the district. During the year eight visits were made to the registered premises. All manufacturers continue to use materials carrying the certificate of the British Standards Institution, and on no occasion were any dirty filling materials to be found in use on the premises. Statutory records were inspected and in no cases were any contraventions of the Act found. Many visits were made to other upholstery workshops in the district to ensure that no work was being carried on which would necessitate their applying for registration under the Act. One complaint was received about the condition of the filling material in a pillow purchased in the district. This was investigated, and a warning was given. The makers of the pillow have now ceased to manufacture pillows filled with flock. Caravans For some years there have been a number of caravans at North Lodge, Stonegrove, Edgware. Apart from the unsuitability of some of the structures for permanent occupation by families, the arrangement of the site is unsatisfactory. Section 345 of the Middlesex County Council Act, 1944, prohibits movable dwellings being placed or kept on any land in the district without the previous consent of the Council and "it shall not be lawful for any person without the previous consent of the Council to let or permit to be used any land for occupation by any movable dwellings unless the surface of such land is covered with concrete or other suitable material and unless such land is provided with sufficient roads, sanitary accommodation, drains and sewers and is furnished with a separate supply of water to the satisfaction of the Council." The Planning Committee has been taking steps to secure discontinuation of the use of the site for the parking of caravans. While anxious to secure improvement in the state of affairs on the site, the Public Health Committee were reluctant to insist on the taking of steps which might prejudice the efforts of the Planning Committee. Even more caravans came on the site so that at the end of the year there were 15 caravans there, none of them on a hard standing, the roadway being unmade. Water was obtained from a tap at a nearby garage. Sanitary arrangements consisted of Elsan closets and one water closet, also used by the garage employees; the contents of the closets are emptied down a manhole of a nearby sewer. In July, five caravans were placed on a field adjoining the Watford by-pass. Numbers rose steadily, reaching 32 by December. The road to the site is in a deplorable state. There is a water supply but there is no water carriage system or drainage, each caravan having its own Elsan closet, the contents of which are disposed of by emptying into pits, an arrangement which might well give rise to a serious nuisance. 49 INSPECTION AND SUPERVISION OF FOOD (A) MILK Legislation The 1949 Milk and Dairies Regulations required every local authority to keep a register of persons carrying on the trade of distributor in their district. A distributor is defined as a person trading as a dairyman elsewhere than at or from premises in relation to which he is registered as a dairy farmer. The 1953 Amendment Regulations modify this definition and a distributor now means a person trading as a dairyman elsewhere than at or from premises in relation to which he is registered as a dairy farmer under these regulations, but does not include the purveyor of cream in hermetically sealed containers in which it is delivered to his premises provided that such a purveyor is not otherwise a purveyor of milk. The Milk (Special Designations) (Pasteurised and Sterilised Milk) (Amendment) Regulations, 1953 :— (a) allow milk to be sterilised in cans or other suitable containers as well as in bottles ; and (b) appoint October 1st, 1954, as the date from which it shall be compulsory to use overlapping caps on containers of pasteurised milk. Production There are seven farms in the district at which milk is produced. Of these six are producing tuberculin tested milk and one raw milk. This last is sold wholesale. Production ceased at one farm where for a number of years accredited milk had- been produced. Processing and Distribution (1) Number of premises licensed to pasteurise milk (Licences granted by M.C.C.) 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 16 (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 88 visits were made to cowsheds and dairies. It was found a satisfactory standard was being maintained. D 50 Sampling 48 samples were taken during the year. 46 were satisfactory. In two adverse reports were received. On investigation these were found to be associated with a plant breakdown. Follow-up samples proved satisfactory. Complaints Nine complaints about foreign matter in milk and eight about the dirty condition of milk bottles were received and investigated. Four of the complaints related to the presence of glass and five were about paper or cardboard. In all cases the paper and cardboard had instructions to the milk roundsman written on it. The public could assist in reducing the number of such cases by placing instructions around the bottle holding the paper in place by the aid of an elastic band or by using adhesive paper on to the outside of the bottle. Paper and cardboard when forced through the narrow neck of a bottle is most difficult to remove. Special Designated Milk During the year two dealer/pasteurisers of milk were licensed by the County Council. The premises of each were inspected regularly. In all, 104 samples were procured and submitted to examination to ensure that they complied with the standard for pasteurised milk. Each sample passed both the phosphatase and the methylene blue test. (B) MEAT Only two slaughter houses were used during 1953, and these very infrequently. The number of animals slaughtered in the district during the year was 90. Of these 87 were pigs, two were calves and the other a goat. Very little disease was found, only one set of lungs and three heads having to be condemned. Five slaughtermen renewed their licences to slaughter. Since the early days of the year no regular slaughtering has taken place in the district, and to-day local slaughtering is but a fraction of what was done before the war. The figures above may be compared with those of the killings in 1938, which were 205 beasts, 1,561 pigs, 1,601 sheep, 314 calves, a total of 3,681 animals. More slaughtering is likely to take place in the near future. Meat Unfit For Human Consumption. Since August 1st, 1953, all meat and offal in slaughterhouses occupied by the Ministry of Food which are unfit for human consumption have been sold by public auction. The conditions subject to which such meat and offal are sold were revised, and are referred to in circular MF.21/53 of the Ministry of Food. Condemned meat and other materials are offered for sale subject to such control as local authorities may impose. The buyer shall not sell or dispose of any condemned meat unless it has been processed, boiled or steam sterilised except to a retailer for sale by him for animal feeding, to a processor or to owners of zoos, etc., for use by them in such businesses and not for re-sale. When meat is being sold to such persons, the seller 51 before doing so must notify the Medical Officer of Health of the district to which the condemned meat is being consigned of the names and addresses of the consignees. Condemned meat and other material shall be stained green in accordance with the provisions of the Livestock (Restriction on Slaughtering) Order, 1947, before delivery to the buyer. When an officer of a local authority has inspected any meat or offal belonging to the Minister and has found it to be unfit for human consumption, the local authority may dispose of such meat or offal as it thinks fit. (C) OTHER FOODS Food Condemned The following is a summary of all foods condemned in Harrow as unsound or unfit for human consumption during 1951, 1952 and 1953. 1951 1952 1953 lbs. lbs. lbs. Groceries, Miscellaneous 3,478 7,543 3,942 Fish 1,327 1,475 849 Vegetables 1,479 4,579 968 Fruit 2,246 3,131 5,319 Meat, Meat Products 8,693 8,338 8,269 Total 17,223 25,067 19,319 Eggs No. No. No. 3,517 449 1,365 These figures show a decrease in 1953 of nearly 25 per cent. on those of 1952 and a slight increase on those of 1951. The amount of groceries condemned in 1952 was exceptionally high, partly because of damage by the flood, and during 1953 fell to a weight only slightly above the 1951 figures. There has been a substantial decrease in the amount of fish condemned partly perhaps because of more careful and more speedy handling, but also because of the comparatively cool summer weather. The 1952 increase in the condemnation of tinned fruit has continued through 1953. Tinned plums accounted for 60% of the fruit found unfit, the remainder being made up of 24 other types of fruit. Although the amount of home-killed meat condemned has risen mainly because of increased supplies, this has been offset by a decrease in the amount of imported meat found unfit, so the total is much the same as in 1952. Many more eggs were condemned, 1,365 as against 449 in 1952, though this is still lower than any other year since the war. Disposal of Unsound Food. The method of disposal of unsound food varies with the nature of the food and the circumstances giving rise to its surrender or condemnation. 52 Meat seized and laid before a Magistrate is disposed of by burning. As there is no refuse destructor in Harrow, such meat is taken to the destructor of the Corporation of Wembley. Diseased meat is disposed of in the same way. Meat surrendered because of contamination during during transit or because of bruising is disposed of by burying on a controlled tip. Other foodstuff is dealt with in the same way. Before disposal all foodstuffs were rendered unsaleable, meat by the use of a dye and disinfectant, tinned goods being punctured. The food was collected from shops by a member of the staff of the Public Health Department ; and meat diseased or to be disposed of on a Magistrate's Order was taken and seen into the destructor by a member of the Public Health Department. Ice Cream During the year five manufacturers ceased to make ice cream so the number on the register is now eight. No new premises were registered during the year. Two of the manufacturers retail ice cream from closed-in vehicles of of modern design and from shop premises ; the other six retail from shop premises only. At the end of the year there were 355 premises registered for the retailing of ice cream, 21 of these being added during the year. The number of samples taken during 1953 was 94. 20 were from local manufacturers; 13 of these samples were Grade I and the remainder Grade II. Of the 74 samples of ice cream taken from local retailers but manufactured outside the district 51 were Grade I and 11 Grade II. 10 of the remaining samples were Grade III, and two Grade IV. In the case of the Grade III and Grade IV samples enquiries were made and follow-up samples taken. Preserved and Pickled Food 164 premises are registered for the manufacture of sausages and preserved and pickled food. Most of these are butchers' shops, and are registered in respect of the manufacture of sausages. The registration of premises where sausages or preserved or pickled food are prepared or manufactured is required under Section 14 of the Food and Drugs Act, 1938. All the premises were inspected during routine visits to food shops and were found satisfactory. Registration of Hawkers At the beginning of the year 58 hawkers were registered under the Middlesex County Council Act and were trading from registered storage premises within the district. Two were registered during the year, both trading in greengrocery. 53 The registrations were cancelled of 29 hawkers who ceased to trade. The number on the register at the end of the year with storage premises in Harrow was 31. The coming into operation during October, 1952, of an Order made under the Town Police Clauses Act, 1847, was probably the reason many of the hawkers ceased to trade in the district. Most who now trade are registered for the retailing of greengrocery and operate on regular days of the week on established rounds. There are also 31 traders registered to trade in the district from storage premises outside. During the year a number of warnings were given to persons found contravening the Street Trading Order and two hawkers were summoned. In both cases fines were imposed. (D) ADULTERATION OF FOOD The following information has kindly been provided by the Chief Officer of the Public Control Department of the Middlesex County Council:— "Food and Drugs enforcement is treated as a unified County problem. So far as milk is concerned, half the samples which are taken are of new milk delivered to depots in the County and the distribution of samples in these cases depends upon the situation of the depots and has no regard to equal dispersion between County districts. The other half of the samples, however, mainly of bottled milk sold retail but including, particularly during 1952 and 1953, the procuring of samples of hot milk from cafes and restaurants throughout the County, are taken in each district, on the whole, in proportion to its population. Similarly miscellaneous food samples and drugs samples are, on the whole, taken throughout the County and co-related in number with the distribution of the population, variety being equally striven for. One of the most important factors arising from County control is the elimination of duplicate sampling of widely distributed goods. This is of great significance to-day when the vast majority of foodstuffs is pre-packed and distributed over the whole County or large parts of the County. When a sample is taken of the County of a particular brand of food an embargo is placed upon its sampling for a certain period of time in any other part of the County. Uniformity of policy of enforcement prevails throughout the County. A particular obnoxious trade practice discovered in any one part is pursued thereafter in all parts. We have found it economical and successful to set up small laboratories for simple examinations and analyses of certain food stuffs and we also found it economical and much more efficient and expeditious to train our sampling officers as experts in the examination of various natural products, for example fish, certain fruits, certain meats, livers and the like. Another quite vital factor is the accurate and expert techniques in sample taking. These are complicated and the practices which are used to discover infringements and to procure different sorts of samples are many and varied." 54 The following is a list of the samples procured in the District during the year. Articles Total Samples Procured Unsatisfactory Milk (various) 128 5 Milk, new 258 17 Aspic Jelly 1 — Baking Powder 1 — Butter 2 — Cakes 18 — Chicken Cutlet 1 — Chops 3 — Coffee 2 — Condensed Milk 5 — Cooked Meats 66 — Cream 11 — Desiccated Coconut 1 — Dripping 2 — Drugs (various) 26 1 Fish (various) 22 2 Fish Cake 1 — Fish Paste 1 — Fish Roe 2 — Fruit Juices 2 — Fruit Squash 5 — Glucose 1 — Ground Almonds 2 — Honey 1 — Ice Cream 6 — Jam 4 — Jelly, Table 4 — Lamb 1 — Macaroon Paste 1 — Meat Pie 14 — Meat Paste 6 — Minced Meat 23 — Mincemeat 3 — Marmalade 1 — Orange Curd 1 — Powdered Milk 1 — Prawns 2 — Raisins 1 — Salt 1 — Sausages 119 1 Sausage Meat 26 — Stewed Steak 5 — Sweets (various) 15 — Carried Forward 796 26 55 Articles Brought Forward Total Samples Procured Unsatisfactory 796 26 Tripe 2 — Turkey 1 — Victoria Plums 1 — Vinegar 51 6 Wines and Spirits 22 — Xmas Pudding 1 — Totals 874 32 "With regard to samples found unsatisfactory, the following action was taken :— "Milk—Various. Four of the five samples noted were of hot milk, two from each of two cafes. Each was prosecuted in respect of one sample containing added water ; in each case fines were imposed. The fifth sample was of bottled milk sold by retail which had a slight deficiency in solids-not-fat but no added water and no further action was taken. "Milk—New. These were all samples taken of raw farmers' milk on delivery to milk depots in your district. The 17 unsatisfactory samples were in 13 cases deficient in fat and in four cases had slight excesses of water. In the 13 cases the majority of fat deficiencies were small. Five farmers were involved. "Drugs. The one sample of drugs which was unsatisfactory was a ' Cherry Cough Syrup,' the label upon which did not correctly state the ingredients. An official caution was given. "Fish. The two samples of unsatisfactory fish were cases of the sale of smoked cod for smoked haddock at each of two shops. In one case an official caution was given and in the other case the fishmonger was prosecuted and fined. "Sausages. The unsatisfactory sausage sample was a case of pork sausages containing sulphur dioxide not declared on sale. The firm was cautioned. "Vinegar. Six samples of vinegar were unsatisfactory. These were procured from four sellers and were sales of what was purported to be loose vinegar. In one case the sample was genuine but slightly deficient in acetic acid. Subsequent sample was genuine and no further action was taken. In each of two cases (two samples each) retailers sold non-brewed condiment as vinegar. Each was prosecuted and fined." (E) HYGIENE OF FOOD The activities of local authorities in their campaigns for the cleaner handling of food have followed no uniform pattern. In this district the campaign has been on three fronts. The first two concern essentially those handling food at any stage and concentrate on the one hand on the 56 condition of premises and on the other on the technique involved. To encourage those who handle food, the Council issued certificates which can be earned only if both requirements are met, that is the standard of fitness and care of the premises and the handling of the food stuffs at all stages. After the first rush of applications only small numbers have since been received. Although the campaign started in 1948, it was not until 1950 that any certificates were issued ; by the end of that year they had been granted to nearly one quarter of the establishments in this district dealing with the preparation or the sale of food. By the end of 1953 certificates had been issued to 256 out of the 984 traders in the district. This does not mean that only these numbers of premises are satisfactory, and that the others either do not come up to the desired standard or that there are short-comings in the handling of the food by the staff. On the contrary there are many places for which certificates would undoubtedly be issued were application made. There are, of course, a few of the older premises that cannot be put into a really satisfactory state, though even here there may be no real risk to infection, because in spite of the difficulties the standard of the handlins of the food is high. The following is an analysis of the various types of establishments and the numbers of these to which certificates have been issued : Trade Number in District Number Holding Certificate Bakers 63 13 Butchers 133 51 Caterers 102 28 Confectioners 164 34 Fishmongers 64 11 Greengrocers 143 10 Grocers 228 105 Ice Cream Manufacturers 8 4 These figures do not include large departmental stores. The third front in the campaign is the education of the consumer. In this regard much progress has been made in the last year. Talks are now being given regularly at the schools, including some voluntary schools, and many talks have been given to various bodies and organisations. It is hoped that in time not only will those who are future housewives and food handlers maintain a high standard in their own handling of food, but being aware of what is necessary will help to raise the standard of care by those from whom they purchase food. This side of the campaign is a long-term one which is not likely to bring about any benefits for some considerable time. In some districts most effort is concentrated on dealing with the persons handling the food. Where the response to those approached is good, it is probable that efforts on these lines will more speedily bring about results and will sooner be reflected in a reduction in the numbers of cases of food poisoning. More diffused education cannot be expected to bring this about. In fact, much of the work of many of the food hygiene campaigns 57 probably has little direct effect on the incidence of food poisoning. What is aimed at, that is a high standard of food hygiene, is desirable in itself whether or not it helps in reducing illness ; and the campaign of the education of the consumers and future consumers is well worth while if it will lead to a reduction in some revolting practices of some of those who handle food stuffs. At the same time, it is just not known what proportion of the minor illnesses so many suffer from in the course of their lives is due to some degree of food poisoning, which poisoning might be reduced if all handlers of food can be educated to decent aesthetic standards. But for the reduction of the more dramatic explosive outbreaks of food poisoning probably more attention should be concentrated on meat manufacturers and catering managers, so that the individual factories and kitchens are designed and adapted to make hygienic handling of food and the cleansing of the kitchen ware as easy as possible, and those working there made fully aware of the reasons that certain practices are asked for and others discouraged. " Processed and made-up meat dishes accounted for little over half of the food poisoning in which the vehicle of infection was ascertained Immediate and substantial reductions in the incidence of food poisoning would occur if processed and made-up dishes were rendered safe." Commenting on the Food and Drugs Amendment Bill, the British Medical Journal says : " The provisions of the Bill can be no more than the ground work on which to base a campaign for safe and clean food, and it is to be hoped that local authorities will take their responsibilities more seriously than many of them have done in the past. But in the long run the success of the plans to make dirty food a thing of the past will depend on the public. The ' education ' of food manufacturers and handlers will be painfully slow if the public remain apathetic about the purity and cleanliness of the food they buy in shops, kitchens, cafes or restaurants. How many people complain when they see their butcher digging his hands into a bowl of mince, or their confectioner using her fingers to pick the chocolates out of a box ? " Hygiene in Hospitals Catering Establishments. In June the Ministry of Health issued a circular to Hospital Boards and Committees reminding them of the dangers of food poisoning and suggesting that at each hospital a medical officer should be responsible for advising the hospital authority and the catering officer on hygiene in the catering department and for arranging lectures in hygiene to the catering staff; and attention was also drawn to the need for adequate washing facilities in and near kitchens. The circular reminded hospital authorities that the Medical Officer of Health of each borough and district and his staff have considerable experience of inspecting catering departments, and the Minister urges Boards and Committees to enlist their help as freely as possible in order to ensure that inspection of hospital catering hygiene is fully and effectively carried out. 58 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis) Disease Und. l 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 — 38 130 30 8 3 — 3 — — — — 212 Diphtheria — — — — — — — — — — — — — Pneumonia 1 5 9 5 5 2 3 15 24 20 41 — 130 Erysipelas — — — 1 — — 1 6 7 7 6 — 28 Cerebrospinal fever 1 1 — — 1 — — — 1 — — — 4 Puerperal pyrexia — — — — 1 3 7 2 — — — — 13 Ophthalmia neonatorum 1 — — — — — — — — — — — 1 Poliomyelitis— paralytic — 1 4 — 1 — 2 2 — — — — 10 non-paralytic — — 2 3 1 — 1 1 — — — — 8 Encephalitis, infective — 1 — — — — — — — — — — 1 Measles 50 1116 1229 34 11 2 10 6 2 1 1 — 2462 Whooping cough 28 209 242 7 1 1 1 2 — 2 1 — 494 Paratyphoid fever — — — — — — 1 — — — — — 1 Typhoid fever — — 1 — — — — 1 — — — — 2 Food poisoning — 3 1 1 1 — 1 — — 1 — — 8 Dysentery — 1 4 — 1 — 1 — — — — — 8 CONTROL OF INFECTIOUS DISEASES Notification The Public Health (Infectious Diseases) Regulations, 1953, came into force on April 1st and superseded the 1927 regulations. They called for the notification of the same diseases as did the former regulations, namely malaria, dysentery, acute primary pneumonia and acute influenzal pneumonia. The 1927 regulations enabled local authorities to take action to limit the spread of enteric fever and dysentery. These powers are now extended to typhoid fever, paratyphoid fever and other salmonella infections, dysentery and staphylococcal infections likely to cause food poisoning. Under the earlier regulations only persons suffering from the disease could be prohibited from continuing in an occupation connected with the preparation or the handling of food. The new regulations apply not only to sufferers, but also to carriers. Before, the sufferer could be prevented from continuing to work in the occupation ; now the person can be prevented from entering such occupations. Under the 1927 regulations the prescribed steps could not be taken until the Medical Officer of Health had reported the case to the local authority. The new regulations empower the local authority to give the Medical Officer of Health such authorisation as will permit him to take action if this is necessary to prevent the spread of infection. The Public Health Committee at their meeting on the 31st March, 1953, resolved that the Medical Officer of Health be hereby authorised to take 59 such action as may be necessary from time to time to prevent the spread of infection as indicated in the Public Health (Infectious Diseases) Regulations, 1953, on the understanding that he shall report such action to the committee at its next following meeting. Aids to Diagnosis (1) Laboratory service (see page 24). (2) Services of a consultant— (a) Ordinary infections : Dr. Livingstone, of the Hendon Isolation Hospital. (Tel. No. : Colindale 8182.) (b) Smallpox and typhus fever : The patient's doctor can be put into touch with one of the Ministry of Health's panel of consultants by means of the Public Health Office, or the Hendon Isolation Hospital. (c) Tuberculosis : Physicians at the Chest Clinics. Isolation in Hospital (a) The usual infectious diseases : Most patients removed to hospital are admitted to the Hendon Isolation Hospital, Goldsmith Avenue, Hendon. When there is no accommodation here patients may be admitted to one of a number of isolation hospitals around London, arrangements being made either by the staff of the Hendon Isolation Hospital or by the patient's doctor applying to the Emergency Bed Service. (b) Smallpox or Typhus Fever : Patients suffering or suspected to be suffering from these complaints are admitted to special hospitals. (c) Tuberculosis : Arrangements for admission are made by the staff of the Tuberculosis Service, mostly to special but sometimes to general hospitals. Exclusion of Contacts The practice regarding the exclusion from day schools of contacts of those suffering from infectious diseases is that recommended in the Memorandum of Closure of and Exclusion from School issued jointly by the Ministry of Health and the Ministry of Education. Contacts of those suffering from German measles, mumps and chicken pox are not excluded. Contacts of those suffering from scarlet fever or diphtheria are excluded for seven days after the removal of the patient to hospital or the beginning of his isolation at home. Infant contacts of measles who have not had the disease are excluded for fourteen days from the date of the appearance of the rash in the last case in the house. Other contacts are not excluded. Infant contacts of whooping cough who have not had the disease are excluded for twenty-one days from date of onset of the disease in the last case in the house. 60 Spread of Infection in Hospitals Although Sanitary Authorities are concerned about infections wherever they may occur in their districts, the position of hospitals in relation to the responsibilities of the authorities has not been very clear and perhaps became even more confused in 1948 when most hospitals became Government establishments. It seems to some that an outbreak of an infectious disease in a hospital was regarded solely as a matter of concern to the hospital itself. In a circular in 1952 the Minister had reminded hospitals of the importance of sending early information to the Medical Officer of Health of the district in which the hospital is situated in the event of the occurrence of an infectious disease. In April, 1953, the Minister issued a further circular to hospital authorities on the matter. This refers to instances in which hospitals either failed to inform the Medical Officer of Health of the occurrence of an infectious disease, or had done so only after a considerable lapse of time. The circular said : "Hospital authorities are asked to keep the Medical Officer of Health fully informed of outbreaks of communicable diseases in hospital. The Medical Officer of Health and his staff can give valuable help in maintaining the highest standard of hygiene in hospitals and Boards and Committees are recommended to take advantage of this." At the same time the staff of hospital and clinical laboratories were asked to help the Medical Officer of Health by ensuring that all information of epidemiological importance reaches him, this being information not merely about the notifiable diseases, but also about gastro-enteritis in infants and young children, brucellosis, leptospirosis, infectious mononucleosis, etc., in which there are public health aspects to be considered. Disinfection Steam disinfection of articles is carried out at the Washington Lyon plant which was at the Hendon Rural Isolation Hospital, together with the laundry. As steam was being raised each day for the laundry it was available any time for use for the disinfecting plant. Even though work on behalf of other bodies was being undertaken at the laundry, the volume being treated had been reduced to such an extent that the Council decided to discontinue running the laundry. This was done in the summer. The effect, of course, is that the steam needed for the disinfecting plant now has to be raised for this purpose alone, which makes the process much more costly. The question of the future arrangements for disinfection was still being looked into at the end of the year. DIPHTHERIA Five persons suspected to be suffering from diphtheria were removed to hospital. In none of the cases was the diagnosis confirmed, the illness in four instances being glandular fever. The district then has been free from this disease for three years. During the six years since the end of 1947 there have been two cases only, one a nasal, the other a faucial infection. Although it can be accepted that the freedom of this district from diphtheria is only partly due to the extent to which the population has 61 been immunised, it is quite certain that a high immunisation rate is an important factor in controlling any spread ; and of course immunisation is the only active measure which can be practised to prevent infection whether of the individual or of the community. The very success of the campaign helping to bring the virtual elimination of the disease sows the seeds of failure to continue to establish an immunised population because in the absence of the disease there is less incentive for those who have not known it to have their children treated. That the disease is one which cannot be ignored is emphasised by such outbreaks as that which occurred in 1952 in one part of the country where an infection by the gravis type of organism gave a population of something less than that of this district 13% of the corrected notifications in that year of the whole country. Then, too, in the country as a whole in 1952 the case fatality rate of the disease of those who had not been immunised was 9.9%. This figure is a marked contrast to the 11 case fatality rate amongst those who had been immunised. But the effect of immunisation is much greater than is indicated by the contrast between these two figures as the figure of 1.1 is the fatality rate amongst those who succumbed to the infection, whereas the rate of infection is very much smaller amongst the immunised than amongst those who had not been treated. The probability is that those who had been immunised but who had suffered from an attack had been treated in infancy and had not received further boosting doses. The position is that while in some immunisation in infancy remains effective, there is no assurance with any individual it does so. That is why it is so necessary that whatever is done in infancy should be looked upon only as the first stage of a course of treatment and that further boosting doses are necessary, more especially at the time the child is starting to mix with his fellows. During the year, 2,225 children were treated for the first time, 1,177 by general medical practitioners, 1,046 at infant welfare centres and two at day nurseries. The number of births notified during the year was 2,721. It is estimated that at the end of the year 62% of children under five years of age were protected and 85 per cent of children aged 5 to 15 years. SCARLET FEVER 215 cases were notified in the district in 1953. In three the diagnosis was changed. The corrected figure of 212 was an incidence rate of 1.0 per thousand population, a figure to be compared with 1.39 for the country as a whole. The distribution was a weekly average of 6.5 for the first quarter, 4.5 for the second, 10 for the third and 4.5 for the last. Only 16 cases were notified in the third quarter ; there were no cases at all in each of three weeks and only one in each of five weeks. 55 patients were removed to isolation hospitals, mostly to the Hendon Isolation Hospital, but seven to others. The numbers removed are slightly higher than the 51 removed last year although the incidence of disease was lighter ; even then though only 25 % were removed. 62 There are 12 households in which secondary cases occurred, only one in each of 11, two in the other. In three instances, the primary case was missed. In four instances the interval separating the onset of illness of the primary home treated case and of the secondary case was three days or less so that removal of the primary case to hospital would not have averted onset of illness in the other case. In four instances, though, the intervals between onsets were over four days (two being six days, one seven and one 19) and in these instances it might be considered that had the first case been removed to hospital, the second would not have contracted the infection. In the one instance in which a secondary case occurred when the primary case was removed to hospital, the removal was carried out on the second day of illness of the primary case which was the day of onset of illness in the other. Apart from these cases there were two instances in which two members of a family succumbed at the same time, each presumably on each occasion having contracted the infection together and not from the other. There were no return cases this year. In one instance a child developed scarlet fever shortly after having had his tonsils removed. Attendance at school seemed to have played little part in the spread of infection in this district in the last year. There were a few groupings of cases which were suggestive ; for instance over a period of two weeks in February where there were seven cases of scarlet fever amongst the pupils of Stag Lane Infants' School, and in three weeks in May five cases amongst those at the Belmont Infants' School. Then in December there were three cases of infection amongst the pupils of a small private preparatory school. SMALLPOX There were no occasions in 1953 on which persons in the district had been suspected of being contacts of patients suffering from smallpox. In this district last year 1,836 persons were vaccinated for the first time. Of these 1,283 were under one year of age and 154 were over one but under two years of age. 559 persons were re-vaccinated. 2,614 babies were born. The number of vaccinations of those under one year of age were therefore 49% of the births. This figure compares with that of 30.7 of the country as a whole in 1952, a figure which was an improvement on those of 23.8 and 29.6 for the years 1950 and 1951. Of the vaccinations of those under one year of age, 293 were performed at the local infant welfare centre sessions. Although in the campaign in favour of vaccination against smallpox, most emphasis should be laid on the desirability of all children being vaccinated in infancy, because the protection given to so many wanes, it is most desirable that the importance of re-vaccination should be stressed. Smallpox inevitably will be introduced into this country. Those who come into contact with such patients who are themselves inadequately protected by vaccination against the risk of contracting the infection are liable to succumb ; each such person is then a further source of infection to others. If on the other hand, those who come into contact 63 with the patient are fully protected there is no spread ; but this is likely only if substantial proportions of the population are not only vaccinated, but re-vaccinated. It is most desirable then that re-vaccination should be carried out as routine practice, such as on the entry of a child to school and again on his leaving. ENTERIC FEVER There were three cases of enteric fever in this district in 1953. The first case was that of a boy of seven who fell ill on January 1st with what clinically was an attack of typhoid fever. Laboratory results were negative, but this may be because even before the eruption of the typical rash he had been given chloramphenicol. The second case was an adult woman who fell ill on January 29th. Laboratory findings in this case confirmed the diagnosis. The third patient, an adult male, fell ill on March 9th with paratyphoid fever. This is the usual history of this infection in this district, a small number of cases occurring each year, apparently not connected in any way one with another, and in most instances no association with other cases being found and the source of infection not being discovered. DYSENTERY 13 persons were notified during the year to be suffering from dysentery. The diagnosis was not confirmed in three instances. On each occasion when the organism was recovered it proved to be of the Sonne type. That the notifications received are no true indication of the extent of the infection is suggested by the fact that enquiries at the households of the patients notified brought to light others in the family who had suffered from a similar condition ; for instance, enquiries at the home of an adult woman who had been admitted to hospital and the Sonne organisms recovered showed that a number of children in the house had been ill before their mother succumbed ; similarly enquiries into the origin of illness in a girl of 15 elicited the fact that her father had previously had diarrhoea for several days. Infection by the Sonne organism is probably very common. It will be only a proportion of those attacked who react clinically, only some of those who do react will go to their doctors, and only a proportion of those who attend will be notified. FOOD POISONING Only seven persons of those living in the district were notified last year as suffering from food poisoning. The first was a child who was suspected to be suffering from dysentery, but on laboratory findings the diagnosis was changed to food poisoning. The second case was an adult woman ; enquiries following her notification led to the department learning that she was a member of the kitchen staff of a local hospital at which nine patients and two other members of the staff had fallen ill at about the same time, all suffering from diarrhoea and vomiting; all recovered after a short illness. In the third patient it seems that the diagnosis of food poisoning was made as the result of the bacteriological 64 examination of the stools carried out as part of the investigation into other symptoms of which the patient was suffering. The number of notifications of food poisoning again bears no relationship to the true incidence of the complaint. Food poisoning is a subject which has received much attention in recent years, especially as part of the activities of local authorities to raise the standard of the handling of food. In spite of these activities though it is doubtful if the incidence of food poisoning is in fact falling. The food implicated in 1,281 outbreaks and family outbreaks since 1949 in the country as a whole has been ascertained. In 827 or 65 % it was meat and meat products. Of these 81 % were processed or made-up meat, so that something more than one half of these outbreaks were the result of the consumption of processed and made-up meat. To bring about a reduction of such food poisonings, special attention should be paid to the education of those dealing with these products and the provision of adequate coldstorage accommodation ensured. The clean food campaign is most desirable and it can be expected that raising the standards of the handling of food at all stages will result in a diminution of infection ; but apart from the carrying out of the diffused educative campaign special attention has to be concentrated on these particular food stuffs to bring about a reduction in the incidence of food poisoning. ERYSIPELAS 28 notifications of persons suffering from erysipelas were received during the year. 17 of the sufferers were females. In all but seven the face was the site affected. 10 of the cases occurred in the first three months of the year, 13 in the last four months. Six persons were admitted to Isolation Hospitals for treatment. MENINGOCOCCAL INFECTION In only four of the 11 persons suspected to be suffering from cerebrospinal fever was the diagnosis confirmed. These patients fell ill at different times throughout the year. All were removed to hospital for treatment ; all recovered. ACUTE ANTERIOR POLIOMYELITIS In common with the rest of the country this district was rather more heavily attacked by poliomyelitis in 1953 than in the previous year. Although 48 persons were suspected to be suffering from this infection the diagnosis was confirmed in only 18. The first of the cases occurred in the week ending June 6th, the last in the week ending November 21st. The cases were spread out over this period of six months and on no occasions were more than two cases notified in any one week. In a number of weeks, of course, there was none, there being a period of freedom for three weeks in September and again in October. Males were much more affected than females, 13 against five cases. Of the males 6 were paralytic cases, five non-paralytic and two abortive. Of the females, 4 were paralytic and one non-paralytic. One case was fatal, this being a man of 43. 65 Seven of the cases were of children of ten years of age or under, six were adults of 20 years of age or over. MEASLES From a weekly incidence of 200 in the first two months of the year, the attack rate fell to a weekly notification rate of only eight in May and then almost complete freedom in the second half of the year. In all 2,462 notifications were received. The disease was generally mild in character. There was only one death. 32 patients were removed to hospital. In the earlier weeks of the year when the infection was so prevalent almost all schools were attacked though none outstandingly. WHOOPING COUGH Some cases of whooping cough were notified in every week of the past year. In all 494 notifications were received. The weekly average for the first quarter was nine, for the second ten ; it rose to 13 in the third, but fell to four in the last quarter. 10 patients were removed to hospital. This infection this year caused no deaths of those living in the district. Few schools escaped infection entirely, but no one was heavily attacked. During the year, 1,944 children were immunised against pertussis for the first time, 942 by medical practitioners, and 1,000 at the infant welfare centres. Those treated at the clinics received the combined antigen which protects them against diphtheria and against pertussis. Although it is now generally accepted that the preparations used to induce a state of immunity to pertussis are quite effective, the County Council has not yet made arrangements for offering these facilities to the public in all areas on lines similar to those for diphtheria. Many medical practitioners, however, are treating their child patients. The figure of 942 of those children known to have been treated by their own doctors is probably not a true indication at all of the degree to which the practice is carried out. PUERPERAL PYREXIA Of the 13 cases of puerperal pyrexia received during the year, seven related to women who have been confined in London hospitals and one to one who had been delivered in a nearby hospital out of the district, and who was notified after she had returned home. Of the five who had been delivered in the district, in not one did the raised temperature appear to be due to an infection of the uterine tract. OPHTHALMIA NEONATORUM Only one notification of this condition was received this year, this being a child whose mother was confined at home. The condition was mild. The child was treated at home and recovered with no injury to the eyes and no impairment of vision. NON-NOTIFIABLE INFECTIONS These infections are not notifiable and information of the prevalence of most of them is obtained from the intimations received from the E 66 Head Teachers about children absent from school as sufferers or as contacts of such infections. Chickenpox The district was much less heavily affected this last year than in 1952, only 524 intimations being received, these being mostly from Longfield School in the Spring term, from Pinner Park School in the Summer term and a very heavy infection of Cannon Lane School in the third term of the year. Apart from these heavier invasions of these schools, small numbers of cases were reported from most schools in the Spring term and rather fewer in the other terms. Mumps There was very little of this infection in the district in 1953, only 82 intimations having been received. Of these, 25 were from one school. German Measles The district was also free from this complaint this last year, only 100 intimations being received. As contrasted with the ordinary form of measles which was prevalent in the Spring term and quiet for the rest, although there were a few cases of German measles in the Spring term most of the infection was in the Summer term. Influenza In December, 1952, the number of persons in England and Wales notified to be suffering from pneumonia rose very rapidly, a rise which continued into January, 1953, and then into February. In January the number of deaths from influenza rose, reaching a maximum in February, after which there was a sharp fall. Although there were localised outbreaks in the north, it was not until January that influenza spread to London and the surrounding towns, to a rather less extent in the southern half of England. It was not until the end of January that there was any marked rise in the number of deaths occurring in the Great Towns and in London, deaths which occurred mostly amongst older persons. Attacks were caused mostly by the Scandinavian A virus, though in some places invasion was due to virus B. By the middle of February there had been a marked fall in the prevalence in and around London, though the northern parts of the country were still being attacked and it was not until March that the decline became general. Most of the 28 deaths of local residents ascribed to influenza occurred during February. Pneumonia deaths were steady throughout January and February ; they persisted in the succeeding weeks, some cases occurring as late as the middle of May. 60% of the deaths ascribed to influenza in this district were amongst those over 75 years of age. Psittacosis In January, 1952, the Parrots (Prohibition of Import) Regulations, 1930, were revoked, and the import trade of parrots and other similar birds was again permitted. Regulations reintroducing the ban on imported parrots were made in February, 1953, by the Ministry of 67 culture and Fisheries as a precaution against the spread of psittacosis, ornithosis and foul pest amongst poultry. In August a patient was admitted to hospital suffering from psittacosis. Although the diagnosis was confirmed by laboratory findings, neither the patient nor those living in the house had had any contact with parrots or with any other birds liable to convey this infection. Weil's Disease Weil's disease or leptospiral jaundice is a complaint which results from an infection by an organism which is common in rats, being harboured in their kidneys and excreted in the urine. Infection of the human most commonly results from contact of the skin, usually abraded or mucous membrane with water polluted with the urine of infected rats. The disease then shows a selection for certain groups of worker which includes those working in sewers, agricultural workers and miners. A case of this infection was learned of this year. Although the patient was engaged in work on the maintenance of streams, these were in fact not rat infested. TUBERCULOSIS Notification The following table sets out the age and sex distribution of the patients who were notified in this district for the first time in 1953. Primary Notification Brought to notice other than on a Form "A" Pulmonary Nonpulmonary Pulmonary Nonpulmonary M F M F M F M F Under 1 3 — — — — — — — 1- 4 — 2 1 3 — — — — 5-9 4 4 3 2 — — — — 10-14 2 2 2 — — — — — 15-19 9 19 — 2 — 1 — — 20-24 18 26 — 1 3 4 1 1 25-34 33 43 2 2 14 6 1 1 35-44 18 20 2 2 2 7 — — 45-54 32 10 3 1 1 — — — 55-64 16 4 2 1 2 1 — — 65 and over 11 1 — 1 2 1 1 1 Totals 146 131 15 15 24 20 3 3 The total number of new cases learned of during the year was 357. The notifications for the four years 1949 onwards were 439, 370, 358 and 271. Of the 321 pulmonary cases 75 were known to be suffering from the disease before they moved into the district. Four men and one woman were recognised to be suffering from the disease while they were serving in the Forces. 68 Of the 104 who contracted pulmonary tuberculosis while living in the district, 23 gave a family history of infection, a percentage of 22. The corresponding figures for females were 84, 23 and 27. Of the 36 persons notified to be suffering from non-pulmonary tuberculosis, only four were known to have contracted the infection before coming to live here. Of those who were living here at the time they were recognised to be suffering and presumably contracted infection here, only three gave a history of a pulmonary case living in the house. The cases notified during any one year are those which are recognised for the first time in that district during that year ; they also include the names of those who have during that period come to live in that district, even though they had contracted the infection elsewhere. The number, then, depends on a variety of factors. The first and most important is the actual number of cases in the population. Ideally all cases would be recognised immediately ; in the case of an acute infection with obvious physical signs this probably occurs, but in a disease like pulmonary tuberculosis with its insidious onset and indefinite symptoms, at least in the early stages there are not many in whom a stage can be recognised which the patient passes through definitely from the phase of not suffering to the one in which he is suffering. When the disease is recognised, it has probably been progressing for months, if not years. During that time there might have been nothing to send the patient to the doctor. But when comparing the figures of a district in one year with those of another, these factors are comparable unless there is any special effort in any one year to try to discover the affected members of the population, such as by the examination of the population by mass radiography. The notification figures can then change not because of any change in the incidence of the disease amongst the population, but by changes in the efficiency of the machinery for detecting what disease there may be amongst the various members of the population. There is yet another factor, namely the thoroughness in which cases are notified once they have been recognised. Although it is an obligation of medical practitioners attending patients who are recognised to be suffering from tuberculosis to notify the disease, this obligation is not always fulfilled. The greatest offenders are the hospitals. In some cases, of course, the diagnosis has not been made until a post-mortem examination had been carried out. In other cases the patient had rapidly succumbed to some acute manifestation such as meningitis. When the hospitals are situated in the area in which the patients live, not much harm is done by the failure to notify as distinct from the delay in the making of the diagnosis because the Medical Officer of Health soon learns from the death returns of the infection and not much time is lost in arranging for the necessary steps to be taken for the following up of members of the household who may have been exposed to the infection, or may even have been the cause of it. The position is different though when the patient dies in a hospital not in the same area as the patient lived in, because then the Medical Officer of Health does not learn of the case for some weeks or months because it takes that time for the transferred death certificates to reach him. In a district such as this where there is still much movement of the population, some patients not learned of are those who had transferred here from 69 other districts suffering from the disease. For the country as a whole the proportion of deaths from respiratory tuberculosis in 1952 which were not notified as cases during life was 19.4, a figure twice that of the 8.5 for 1938. The non-notified deaths from non-respiratory tuberculosis were 33.8%. Altogether in 1952, 21 out of every 100 deaths from tuberculosis were of persons who had not been statutorily notified. The corresponding figures for this district were much lower ; but the position in this last year was most unsatisfactory. 44 persons died on whose certificates reference was made to tuberculosis even though this was not always the cause of death. Of these, four were due to non-pulmonary disease. Of the 40 deaths where pulmonary disease was mentioned. 11 of the patients had not been notified. Of the four non-pulmonary cases, one had not been notified. Seven of these death certificates related to persons who had died in hospitals not in this district. The disease in the patients whose death certificates had been signed by local medical practitioners was old standing, in most instances the patients having been recognised to be suffering from tuberculosis before the doctors who signed the death certificates had taken over their present practices. Register Under the 1952 regulations the official register is now that kept by the Chest Physicians. But whereas the register kept by the Medical Officer of Health included all cases notified and the names of those learned of by means other than by official notification, those kept by the Chest Physicians were the working registers of the clinics and would, therefore, not include the names of those who had not at any time attended the clinic and possibly not of those who having attended at one time had discontinued attending. For these reasons the numbers on the registers at the Chest Clinics must be less than those on the registers kept in the Public Health Department. The Minister, although making these changes about the official registers, urged that Medical Officers of Health would keep records for their own purposes. This is done in this district. It is not possible to compare the numbers of those on the two registers because both the Chest Clinics which serve the population of this district accept patients from other districts. 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, 1953 1,134 927 127 153 No. of new cases added 146 131 15 15 No. of cases other than on a Form " A " 24 20 3 3 No. of cases restored to the register 3 6 — — No. of cases removed 110 84 9 9 No. on register, December 31st, 1953 1,197 1,000 136 162 Of the deductions, 115 (108 pulmonary) were of persons who had left the district, 46 (42 pulmonary) were of persons who had died, 37 70 (33 pulmonary) were of persons who had recovered, 2 (1 pulmonary) were of persons in respect of whom the diagnosis had been withdrawn and 12 (10 pulmonary) were of persons who had been lost sight of. The net increase in the number of cases on the register is 154, of which 136 were of pulmonary cases and 18 of non-pulmonary cases. This figure compares with those of 160 in 1950 and 153 in 1951. Deaths 26 persons (16 male and 10 female) died from pulmonary tuberculosis during the year and four (3 male and 1 female) from non-pulmonary tuberculosis. The number of deaths from tuberculosis in 1952 was 38. This infection, then, accounted for a death rate per thousand population of 0.14, and for 1.5 per cent. of the total deaths. These figures are a marked contrast to those of 0.57 and 71 for 1934, and even of those of 0.42 and 4.9 for 1948. Preventive Measures In the years 1851-60 tuberculosis killed each year 70,000 people in this country out of a population of nineteen million. Although there was such an improvement that by the turn of the century in spite of the population having grown to thirty-three million, the number of deaths was less than 30,000 each year ; nevertheless, that did mean that the disease was killing something over 1,100 people each week and was responsible for more than 10% of the deaths from all causes. This century has seen a further marked improvement. For the years 1926-28 the average annual number of deaths was 30,000, for 1936-38 23,000, and for 1946-48 19,500. Even since 1948 the number has been halved, there being only 9,335 deaths in 1952 compared with 17,779 in 1949. On the other hand, the number of new cases diagnosed each year remains steady at something over 40,000. That there should be this constant addition of new cases with the fall in the mortality from the disease brought about probably by improved treatment means that there are many more patients in the population and so, though not to the same extent, many more infective foci. Great as the improvements have been in the way of early recognition of the disease, operative treatment and chemotherapy, the disease is still killing 200 persons every week and those persons in the best years of their lives. Early Detection. The incubation period for tuberculosis from the primary infection to the development of the declared disease of pulmonary tuberculosis with cavities may be anything from months to many years. During that period, in many the infection is symptomless. Various methods have been tried of discovering these persons in this symptomless stage. (a) Examination of the contacts of those already diagnosed could be expected to bring to light either those infected by the patient or one who had infected him. In the country as a whole 6,841 cases were discovered by this means, or 4.6%. At the Edgware Chest Clinic in 1949-52, 16,589 contact attendances were recorded; these persons had an incidence of tuberculosis of six per thousand. 71 (b) Examination of class or school contacts of pupils recognised to be suffering from pulmonary tuberculosis. At a number of schools in this district all the pupils have been examined following the discovery that one pupil was suffering from the disease. As the findings were negative, recent investigations have been limited to the immediate class contacts. Although a number of such examinations have been undertaken here, no cases have been discovered by this means. It might be more profitable for efforts to be concentrated on the examination of the teachers or other adult members of the staff. (c) Positive tuberculin reactions indicate previous exposure to the tubercle bacillus. A positive reaction in a young child might then be the result of a home infection so that the routine tuberculin testing of young children followed up by the examination of the home contacts of the positive reactors might lead to the detection of unrecognised cases. Where tuberculisation is high, such enquiries might not be worth while, and in such circumstances the following-up of the contacts of a child whose reactions have recently changed might be more fruitful. (d) Examination by mass radiography. Throughout the country mass radiography units examine 5,000 persons each week. Since the first unit started work in 1943 ten million people have been examined and previously unsuspected tuberculosis has been found in 3.3%. This proportion is falling slowly. The unit which serves this district visited Harrow this last year. Ten sessions were held at the Victoria Hall, Station Road, Harrow, between September 1st and 11th, and ten sessions at Grant Road School, Wealdstone, between September 29th and October 5th. 6,770 persons attended at Victoria Hall, of whom 5,383 were members of the general public, the others being employees of local firms or bodies. Of these 85 were referred for further investigation out of 245 who had been recalled for the taking of large films. 2,010 attended the Grant Road School. Of these 1,480 were members of the general public, 110 were teachers and 420 were employees of local firms. 124 were recalled for the taking of large films, 64 of these being referred for further examination. The unit also visited the Ministry of Education Building, Honeypot Lane. 956 attended, of whom 667 were civil servants and 289 employees of local firms. 40 were recalled for large films, of whom 19 were referred for further investigation. At the Ministry of Food, Stanmore, 1,050 were examined. 50 were recalled for large films, 11 were referred for further examination. The unit visited three other places to examine the employees. Of 1,084 examined, 31 were recalled for large films, of whom 11 were referred for further examination. (e) The group which yields the highest proportion of sufferers on examination is that of persons referred to the Chest Clinics by their doctors. During the years 1949-52, 12,665 new patients were referred for examination by their doctors. Of these 27 per thousand were found to be suffering from tuberculosis. The following is an analysis of the new cases notified at the Harrow Chest Clinic in 1953. Of the 20 non-pulmonary cases, seven were diagnosed at the clinic and 13 were diagnosed elsewhere, that is to say 72 the patient had not primarily been referred to the clinic by the private doctor, the diagnosis being made as the result of investigation for some other purpose. Of the 193 pulmonary cases, 32 had been diagnosed elsewhere, 24 by the mass X-ray unit and 27 were contact cases (that is contacts of a case in the family or elsewhere), 11 were recognised because of the taking of routine X-ray films including four of ante-natal mothers. 99 cases were diagnosed amongst the 4,868 persons referred by doctors or attending the open X-ray session. This session is discovering 25 cases in every thousand men and 22 cases in every thousand women examined, and seems to bring to light a higher proportion of cases amongst those examined than other means. Preventive Inoculation. Although in some countries much use is being made of B.C.G. vaccination, little progress has been made in this country. There is, of course, as yet no scientific evidence of the true value of B.C.G. An enquiry by the Medical Research Council is even now being undertaken. Even though the trial shows the practice to be sound, there would be no case for the immunising of the general population, and anything done will probably be limited to such groups as those who are close contacts of infection, or those of ages who are especially prone to develop the disease, or those whose occupation renders them especially liable to infection. One group which it is generally felt would benefit are school leavers as it is desirable to protect them before they enter on the special hazards facing them when they will perhaps be more exposed to infection than they had been. The Ministry of Health has now authorised local authorities to arrange to offer B.C.G. vaccination to older school children. Years 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 Population 132049 144280 160300 174800 183500 190200 188710 195480 195100 191660 185090 191710 210890 215930 218700 220300 222300 220000 219000 217900 Houses and flats 38024 41265 46325 52681 54460 56500 58230 58362 58103 58220 — — 58984 58660 59670 60859 61173 61532 62111 62520 Births 2267 2523 2873 3098 3292 3321 3011 2751 3268 3500 3473 3068 3934 3828 3226 3083 2848 2895 2855 2721 Birth rate 16.4 17.5 17.8 17.7 17.9 17.5 16.7 14.7 16.6 18.2 18.7 160 180 17.7 14.7 13.9 12.8 131 13.1 12.5 Stillbirths 71 79 106 95 106 107 84 79 81 101 121 92 122 91 69 66 63 77 53 71 Per 1,000 total births 31.7 31.5 35.3 29.1 31.2 31.3 27.2 27.8 24.1 28.0 33.6 29.1 30.0 23.2 20.9 20.9 21.6 23.9 18.2 25.4 Deaths 1076 1108 1240 1348 1311 1408 1725 1774 1818 1749 1732 1732 1816 1834 1837 1890 1999 2094 1920 1925 Death rate 81 7.7 7.7 7.7 7.1 7.4 9.1 9.1 9.3 9.1 9.3 9.0 8.6 8.5 8.4 8.5 8.9 9.5 8.7 8.8 Infant deaths 102 108 129 110 126 128 150 151 103 133 121 100 129 92 93 64 39 62 62 46 Infant mortality 470 42.1 44.9 35.5 38.3 38.5 50.0 55.6 31.5 38.0 34.8 32.2 31.0 240 28.8 20.7 13.6 22.1 21.7 16.9 Diarrhæa 12 12 13 5 25 12 21 28 8 20 12 9 9 6 9 2 1 3 3 2 Maternal deaths 13 9 12 13 12 8 2 9 5 9 2 4 3 4 2 5 4 3 4 1 Mortality rate 5.80 3.46 4.02 4.07 3.52 2.33 0.62 3.18 1.50 2.57 0.56 1.26 0.75 1.00 0.60 1.60 1.30 100 1.30 0.30 Cancer 156 145 170 226 212 240 254 288 301 278 320 324 350 333 359 344 422 389 386 362 Suicide 23 20 17 18 25 14 11 12 10 12 17 14 13 19 15 14 21 18 24 14 Violence — 35 46 55 37 57 126 79 67 45 103 61 45 53 45 53 45 45 95 40 Scarlet Fever-Notifications 621 501 423 416 500 317 217 331 630 707 387 278 265 179 181 351 255 181 246 212 Deaths 9 3 0 2 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 Diphtheria—Notifications 80 85 30 95 63 54 78 39 51 40 16 29 17 6 0 1 1 0 0 0 Deaths 8 2 0 4 8 9 3 0 3 1 2 4 1 0 0 0 0 0 0 0 Measles—Notifications — — — — — 3 2285 1275 2509 1516 573 2184 1605 1252 1181 2038 1005 2548 1417 2462 Deaths 12 0 5 1 2 0 4 2 2 1 1 2 2 1 1 0 3 1 0 1 Whooping Cough— Notifications — — — — — 8 296 1259 468 393 682 220 441 521 626 191 772 780 424 494 Deaths 3 5 4 7 2 3 1 8 2 3 3 2 0 4 4 2 0 2 1 0 Tuberculosis—Notifications 163 180 190 212 231 210 226 349 318 261 289 261 308 342 383 439 370 358 271 357 Deaths 77 72 86 89 96 78 93 120 109 107 97 78 90 76 91 57 40 48 38 30 Erysipelas 32 38 31 32 47 46 37 40 48 52 47 37 35 38 29 26 22 25 29 28 Puerperal pyrexia 21 23 26 34 34 19 9 9 23 18 18 22 20 17 6 5 6 13 8 13 Poliomyelitis 0 1 5 4 6 6 0 4 4 0 1 3 5 57 14 23 30 8 18 18 Ophthalmia neonatorum 5 9 6 14 9 4 5 7 5 2 1 5 2 3 0 1 0 2 0 1 Cerebrospinal fever 1 2 1 7 4 4 37 24 15 17 7 9 11 13 3 1 9 5 5 4 Enteric fever 7 5 5 2 2 7 2 18 2 4 4 4 4 21 2 2 5 6 5 3 Dysentery 1 3 3 24 12 4 2 11 21 15 13 38 32 7 10 11 5 45 12 8 Food poisoning — — — — — — 0 4 1 1 5 1 0 0 0 4 5 4 4 8 74 TWENTY YEARS OF FIGURES During the late nineteen-twenties many houses were built in the districts which later became the Urban District of Harrow, with a result that the population of about fifty thousand in 1921 became ninety-seven thousand by 1931. In the early nineteen-thirties building activity was still very marked, and in 1934 4,331 houses were put up here, most of these being in the Hendon Rural District. There was some slowing down in the rate of new building until its arrest as a result of the beginning of the War in 1939. These new houses meant new families coming here and the population increased by nearly fifty per cent, from the 132,000 in 1934 to the 190,000 in 1939. Although in some districts even before the war it seemed inevitable that the time was coming when local authorities would be looked to to be responsible for the housing of the so-called working classes, there was little indication that that would be the position in this district. For many of the years just before the war the housing situation here, as judged by the number of notice boards outside houses indicating that they were for sale or were to be let, was easy. The Council which took over some houses from the constituent authorities prepared a modest building programme ; while the London County Council acquired the land on which after the war they built the houses of the Headstone estate. At one time when building was proceeding apace, there seemed to be only the two considerations ; the one that the accepted density should not be exceeded, the other that industry should not be encouraged. With the experience later acquired perhaps to neither of these aspects would so much attention again be paid. While low density development is desirable, it is very doubtful if the best method of achieving this is by a uniform sprawl, under which each house has its own garden, all building plots being of the same size. Then, too, with the freedom from nuisance of much of to-day's light industry, there might by this have been more of the civic consciousness so often hoped for if more of the residents worked locally and if the district were less of a dormitory. But to one point little enough attention seemed to have been paid and that was the limit of development. Too little land was left. To-day it would have been much better for 200,000 of the people in the district if houses for the other 20,000 had not been put up. The increase in population is reflected in an annual increase in the number of births. But at the same time the birth rate was higher than that for the country as a whole. This would come about because the population moving into the district consisted more of the younger parents With their small children. This resulted in an unbalanced age composition of the population, containing an undue proportion of those ages likely to have more children. With the passing years the birth rate fell, even to levels below that of the country as a whole. Another effect of this unbalanced age composition was that because there would be in the number of persons living in the district at any time a smaller proportion of those of higher ages (to balance the higher proportion of those in the younger age groups) there was each year a smaller number of deaths than would have occurred in a population of the same size, but of normal age 75 composition, with a result that the death rate for the district was low. To offset the effects on such rates as are brought about by changes in the age and sex distribution of the population, the Registrar General compiles a figure which when multiplied by the ordinary rate gives the corrected rate, that is, the one that would have occurred had the age and sex composition of the population been normal. The corrected death rate worked out in this way is still appreciably below that of the country as a whole. As the population becomes of more normal age distribution, the death rate can be expected to rise. In fact, if there were no movement of the population the rate would rise perhaps to above that of the country as a whole, when in time the excess population, at one time an excess of young adults, passes as a wave through the age groups to become in time an excess of the older age groups. There was a sharp rise in the number of deaths in the war years. That, coupled with the fact that the younger members of the population were away from home and perhaps too because of movements into the district of numbers of elderly persons, caused the death rates for these years to be high. Although the numbers of deaths each year since the war have been higher because of the increase in the size of the population, the death rate has fallen, though these rates are now that much higher each year than they were in the years before the war. The fall in the infant mortality rate is often referred to as one of the dramas of preventive medicine. From a figure of 150 at the turn of the century (a figure which means that out of every six babies born one died before reaching the age of one year) the fall has been most marked. About 1920 a rate of 40 was referred to as the irreducible minimum. The rate of 47 in 1944 then was quite satisfactory. Lower figures were recorded, though, in some of the years before the war. The earlier of the war years saw a very sharp and disturbing rise. For the latter years of the war, though, the rate fell to figures in the thirties. These were succeeded for some years by figures in the twenties, apart from the extraordinary figure of 13.6 in 1950. At the same time there has been a gratifying fall in the stillbirth rate which for many of the years since the war has been only just over 20 per thousand total births. In the nineteen-thirties the maternal mortality rate for the country as a whole remained constantly about four per thousand births. Since the war this rate has just as constantly been about one per thousand, probably the result of chemotherapy. Local figures, though somewhat erratic, followed the same trend. Deaths from cancer for over this period increased more than proportionately to the increase in population. This can be expected because of the general ageing of the population with more reaching the ages at which the disease develops. The figures for suicide have not increased. There was a striking fall during the war years and in general to-day's figures are much the same as those in the earlier years of this period in spite of the fact that the population is now about 50 per cent, greater than it was for most of those years. 76 The figures of incidence of scarlet fever show a range from the minimum of 181 to the highest figure of 707. These prevalences were much those of the country as a whole. The numbers of deaths show how this disease has passed into a phase of absence of malignancy. After all these years of freedom from deaths from illness contracted in this district, the figures are reminders that not so long ago scarlet fever was a killing disease ; though the nine deaths out of the 621 cases in 1934 themselves indicate the marked change from the type of disease prevalent in the latter part of the last century which had a case mortality of 15%. That it is even now not a spent force is shown by the single deaths in 1940 and in 1949. In neither of these cases was the illness contracted in this district. The 1940 death was that of a boy of eleven months who had shortly before been evacuated from the district ; he was apparently quite well when he left here. The 1949 case similarly was a child who for some time had lived out of the district, though his parents' home was here. Although there is an active preventive against scarlet fever, it is not used much. The illness for most is mild ; not only does it not kill, but it rarely leads to complications or sequelae. As long as the disease remains of to-day's mild clinical variety there is little point in using to-day's rather cumbersome preventives to ward off possible infection. In the Report for 1939 the paragraph about diphtheria starts : " There were only 85 cases of diphtheria notified during the year. This is the sixth consecutive year in which a low incidence has been recorded." The incidence since has been low and was so before any substantial proportion of the population had been immunised against the infection. Immunisation was started here in 1936, but it was not until the campaign was launched by the Ministry towards the end of 1940 that large proportions of the population were treated. The incidence, though so much below that of the general rate for the country, had been erratic from year to year ; in fact the notifications for 1936 were below those of 1942 and 1943, by which time many children had been immunised. But while the incidence in the district had been low before this could be attributed to immunisation, there is no doubt that the virtual extinction of the disease must be attributable to the effects of the immunisation campaign. 1948 was the first year when there was no case of diphtheria in the district. It is quite possible that this district can claim to be the first in this country of one of a population of 200,000 being free from this disease in any one year. The only cases of the disease here in the last six years have been a nasal infection in 1949, and a mild faucial infection in 1950. The incidence of measles and whooping cough in the earlier years of this period are not known as these diseases were not notifiable in this district until the latter part of 1939. The annual notification figures for measles do not bring out the fact that measles in urban districts is essentially a biennial infection. It starts towards the end of one year, building up to a peak in the Spring of the next. The notification figures, then, though showing a beat, to-day do not indicate that the wave of incidence is then followed by a long period of freedom from infection until the start of the rise of the curve of the next outbreak. In point of fact this area has not yet developed this characteristic biennial beat. The numbers of deaths show that even over this period measles is becoming less of a 77 killing disease. Here part of the improvement may be due to the improved treatment being able to ward off complications or rendering such complications as occur less dangerous. Though less prevalent than measles, whooping cough accounts for more deaths and is the most damaging of the notifiable infectious diseases in childhood. As contrasted with measles for which there is no active preventive, there is one for whooping cough, though probably it is not nearly as effective as that against diphtheria. It is too early to say yet whether the use of this preparation is having any marked effect in protecting the child population against having this serious complaint. Whilst killing only a few, it results in serious damage to so very many of those who recover. The figures for poliomyelitis are typical of those of the country as a whole. Up to recent years all parts of the country would be free from the disease until well into the summer. The number of cases notified each week would steadily increase to reach a peak in late September or October, after which there would be a fall to extinction by the end of the year or by the beginning of the next. That was the position until 1947, when the country as a whole was invaded for the first time. The extent of this invasion made it very likely that the country would not return to the previous pattern of attack. The local figures reflect the fact that the country has been invaded each year since 1947. In fact, as contrasted with the position before 1947, the country since that date has never been entirely free from attack as although the curve of incidence falls in the earlier months of the year it never falls to zero, and after reaching a minimum of some 20 notifications each week in March, the incidence starts to rise again. The incidence of cerebrospinal fever which was low each year, rose sharply in the earlier part of the war years. The local figures support previous findings of the association of this disease and war because the increase did not occur until after the war had started. The national figures though show that the rise had in fact started before the war, so that although perhaps in the absence of war conditions the incidence would not have reached the heights it did, there would have been in those years a prevalence of something more than had occurred in the early nineteenthirties. The figures for enteric fever are fairly steady, most relating to cases of paratyphoid infection, but a few to typhoid fever. Apart from the occurrence of two cases in one house in two instances, all the 18 cases that occurred in 1941 appeared to have no connection one with the other. Of the 21 cases which occurred in 1947, all but four were children or staff at a children's home in the district. The figures for dysentery and food poisoning in all probability bore no relationship to the true incidence of these complaints. It is likely that the higher figures of recent years are not so much the result of an increased prevalence as to more cases being recognised because of the greater attention being paid to the subject of the clean handling of food and of food poisoning. The war years saw a sharp rise in the number of cases of tuberculosis notified and in the number of deaths recorded as being due to the disease. This is similar to what is occurring throughout the country as a whole 78 and which was thought to be the result of war conditions ; but it was never decided what the conditions were that did in fact produce these results. But what was much more disturbing was that after the war, although the numbers of deaths from disease fell year by year, there was no corresponding fall in the numbers of notifications. For the country as a whole they are not rising, but they are certainly not falling. Even in a district such as this where the general housing conditions can be considered to be satisfactory, where there must be as little statutory overcrowding as in any other district of its size and where the general standard of living of the population as a whole must be considered satisfactory, in spite of all these favourable factors new cases are being learned of at the rate of 5, 6 and 7 a week as contrasted with the figures of before the war of 3, 4 and 5. Not so many years ago ophthalmia neonatorum caused much blindness amongst children. The cases which are now being notified in diminishing numbers have been of mild character ; in all, recovery has been complete with no resulting scarring of the cornea or blindness. The variations in the numbers of persons notified as suffering from puerperal pyrexia cannot be accepted as an indication of the variation of the incidence of this complaint. Because puerperal fever which was notifiable under the Public Health Act was not satisfactorily being notified, puerperal pyrexia was made notifiable by regulation. This called for notification whenever a certain temperature was reached in a puerperal woman, whatever the cause of the rise in temperature. Whereas the cases notified as puerperal fever were mostly those in which there had been infection of the genital tract, the raised temperature in persons notified as suffering from puerperal pyrexia might be, or would be, due to conditions not associated in any way with the recent confinement. But as the condition which was notifiable was the raised temperature, when this temperature was kept down by drugs, notification was not called for. The definition of the condition which was notifiable was therefore altered by the 1951 regulations. The fall in the numbers of cases notified in the nineteen-forties, then, might reflect not a fall in the incidence of illness in puerperal women, but a fall in the numbers of cases i n which the temperature reached the specified point, or remained high for the specified period as set out in the previous regulations. Chemotherapy might then account for these altered figures, just as it has undoubtedly had its effect in saving the lives of some who have suffered from puerperal infection. JRZ/68