Borough of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1955 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW AND HUTCHINGS, LTD., PRINTERS, HARROW AND UXBRIDOE Borough of Harrow Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1955 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 8 General Health Services: Hospitals 15 Nursing Homes 15 Establishments for Massage and Special Treatment 15 Nursing, etc., in the Home 15 Day Nurseries 16 Clinics and Treatment Centres 17 Provision for Special Classes of Person19 Laboratory Facilities 23 Ambulances 23 Sanitary Circumstances 25 Sanitary Inspection : Housing 31 Smoke 39 Inspection and Supervision of Food 43 Infectious and Other Diseases : Prevention and Control 46 Tuberculosis 59 5 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH To His Worship the Mayor, Aldermen and Councillors of the Borough of Harrow. Mr. Mayor, Ladies and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1955. As contrasted with the report for the year 1954 which referred in detail to the various services, this year's report is of an interim character, detailed reference being made only to those subjects which were of special interest during the year. It is becoming commonplace to refer to the satisfactory vital statistics. There was a sharp increase in the number of deaths which was reflected in a rise in the death rate to 8-9 compared with the figure of 8-2 in the previous year; but the significance of the increase is appreciated when it is recalled that it was the 1954 figure which was exceptionally low, the death rate for the preceding years having been 8.8, 8.7 and 9.5. The number of births was almost exactly the same as that in the previous year; the slightly smaller population than last year resulted in a slight increase in the birth rate. The stillbirth rate showed a further fall. The number of deaths from tuberculosis was markedly less than the number in 1954, 14 as against 32. On the other hand deaths from cancer including cancer of the lung were up, as also were those from leukaemia. Although there were four deaths from poliomyelitis there were none from diphtheria, scarlet fever, measles, or whooping cough. Of the infections it is possible to record yet another year free from diphtheria, this being the fifth consecutive year of freedom. The 128 cases of scarlet fever was the smallest number of notifications received in the combined district; the incidence of this infection in the country as a whole was light during this last year. Only in 1947 was the country more heavily attacked by poliomyelitis that it was last year. Harrow had its proportion of cases, though the first of the summer invasion was not until July. As contrasted with the usual rather steady fall after the summer and autumn increases, in this last year the falling off in the weekly notifications was gradual, and in the country as a whole numbers of notifications were being received even in the last weeks of the year. The curve of incidence of measles too was peculiar last year; not only did the wave develop rather later than usual, but its fall was erratic, the curve rising to another peak later in the year before then falling to virtual extinction. Rather fewer new cases of tuberculosis were learned of during the year. The improvement was not as striking as the fall in the number of deaths. There was at one time the fear that the reduction in the number of deaths not accompanied by a fall in the number of new cases would, by increasing the number of spreaders in the population, add to the risk of the spread of the disease. Fortunately the new weapons in the hands of the chest physicians such as P.A.S. and streptomycin can make even the chronic Patients non-infective and so reduce this risk. It is disappointing though mat new cases still crop up. In such a district as this in which a rising 6 proportion of the population remain tuberculin-negative, it can be anticipated that the attention given to discovering the source of infection of those who succumb will bring to light the origin and so remove the risk to others. The essential health services are still the environmental services of the last century. However efficient the personal services provided by the local health authorities might be and however energetic the various bodies responsible for providing under the National Health Service Act services for those who are ailing might be, unless the basic health services are sound it is improbable that the health of the district can be good. It is in this respect that the district is fortunate. It has an adequate supply of pure wholesome water; at times there may be criticisms of its hardness, but that hardness has no direct bearing on health or illhealth. The district is adequately drained and sewered. In spite of staffing difficulties house refuse is removed regularly and in general the streets are kept swept. No part of the district is congested; there are no obstructive buildings and no back to back dwellings. The atmosphere is relatively pure though things could be better; householders could do more themselves to avoid polluting the air, while there has over the past year been a regrettable amount of black smoke from certain premises. Housing in general is good. There are relatively small numbers of houses which are considered to be unfit for human habitation and incapable of repair at a reasonable cost. There are very small numbers of houses which are substantially overcrowded, while the generous allocation by the Council ol houses to families with a member suffering from tuberculosis has resulted in very few such families now living in conditions in which it is felt that there is much risk of spread of infection to others in the house. For most of these services the corporation is responsible. Important as are the hospital services and the Part III services provided by local health authorities, most of these are for the benefit of those who have succumbed to some condition. The high standard of these health services provided by the corporation must do much to keep these numbers down. The Government's new slum clearance drive necessitated a survey to determine which houses might have to be considered for demolition, and within what period. This survey showed that there were about 600 such houses. The Council decided that they ought to be able to carry out their programme within the five years so that it was not necessary to consider deferred demolition procedure. The difficulty facing them as is the case with so many authorities is that of obtaining sites on which to build. At their periodic review of the housing situation, it has seemed each time that progress has fallen short of expectation, and now little land is available on which to build any more houses than are already allocated. The only clearance site which can be expected to yield a surplus of housing units is that at Northolt Road. This scheme is developing very slowly. In the meantime houses are being bun and are being allocated, with the result that there is a diminishing number which can be made available for those living in those houses to be condemned. The Council's decision to acquire condemned property by negotiation rather than by the use of the compulsory purchase provisions of the Housing Act causes much delay; and in the meantime families are 7 living in houses that the Public Health Committee had decided were unfit for human habitation. Not only is it improper that these families should have to remain living in these conditions, but the delay in their being rehoused means that there must be fewer houses in time in which to rehouse other families similarly placed. Much of the work of the Public Health Department is preventive in nature. To an increasing extent the inspectors are becoming instructors and demonstrators and they can feel that their lessons will result in a diminution in some annoyances and nuisances. At times a more direct preventive action can be taken. Two years ago two sisters in the district suffered from paratyphoid fever. Laboratory investigation showed that some other people in adjoining districts suffered from the same illness and had probably been attacked by the same organism. This led to the recognition of a bakery as a source of the trouble and in that bakery suspicion fell on Chinese egg albumen. Later infections proved conclusively that the preparation was liable to contamination. Measures have since been taken to remove this risk so that there should be no more cases of paratyphoid fever from thise source in this country. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Kynaston Court, Harrow Weald, If June, 1956. 8 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population mid-year 1955 217,100 Rateable Value (1st April, 1955) £2,313,467 Sum represented by a penny rate (1st April, 1955) £9,555 Total number of occupied houses 54,819 Total number of occupied flats 8,753 Extracts from Vital Statistics for the Year Live Births:— Total Male Female Legitimate 2,645 1,354 1,291 Birth rate per 1,000 population 12.7 Illegitimate 110 54 56 Total 2,755 1,408 1,347 Stillbirths:— Legitimate 48 30 18 Rate per 1,000 births 17.8 Illegitimate 2 1 1 Total 50 31 19 Deaths 1,945 961 984 Rate per 1,000 population 8.9 Deaths of infants under one year of age 47 Infant mortality rate 17.6 Legitimate infant mortality rate16.6 Illegitimate infant mortality rate 27.3 Deaths from pregnancy and childbirth: 1 Rate per 1,000 total births 0.35 Deaths from Cancer 403 „ „ Measles 0 „ „ Whooping Cough 0 „ „ Tuberculosis 14 Population The mid-year population of the district was estimated to be 217,100 This includes members of the armed forces stationed in the district. In each of the post-war years the population of the district increased to reach the highest figure of 222,300 in 1950. From that time there has been a slight fall each year in the estimated population, the figure for mid-year 1955 being 217,100, a fall of 600 on the figure for the previous year. This fall took place in spite of the natural increase in population which is the excess of births over deaths and which last year was 610. Some at least of the fall is to be explained by the movement of some families out of the district to new and to expanded towns. Quite apart from these transfers though there is a steady movement of population in and out of such districts as this. 9 Births The total number of live births registered during the year was 2,755 (1,408 male and 1,347 female). Of these 110 were illegitimate, being a percentage of total births of 4-0. The numbers of live births registered in the three years from 1952 onwards were 2,855, 2,721 and 2,747. 842 births occurred in the district (833 live, 9 stillbirths). Of this number 102 were to residents of other districts. 2,142 (2,100 live and 42 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 12.7. The local comparability factor for births is 1.02. The corrected birth rate was therefore 12.9; that for the country as a whole was 15.0. Deaths The Register-General arranges that the information about those who have died outside the district in which they normally reside is Iransferred to the Health Office of those districts. These numbers are added to the deaths of those districts, corresponding deductions being made from the deaths allocated to any districts in respect of those who died in ".hose districts, but who normally resided elsewhere. Certain types of institutions are not regarded in ordinary circumstances as the usual residence of those living there. These include general, maternity and special hospitals, maternity homes, nursing homes, sanatoria, convalescent homes, homes for unmarried mothers, hotels, boarding houses, etc. On the other hand, there are many institutions which are regarded as the usual residence of their inmates. These include accommodation provided under Parts III and IV of the National Assistance Act, 1948, boarding schools, convents, nursing homes for the aged and chronic sick, nursing homes (mental) and residential nurseries. During the year the Convent of Our Lady of Lourdes was added to the local list of this class of institution. 1,299 persons died in this district in 1955. This figure includes those members of the Armed Forces stationed here. Of these 150 were °f persons who were not resident in the area. 79 deaths took place in the various hospitals and 38 in private nursing homes. Of the 815 deaths of the local residents which occurred outside the district, most took place in institutions, 356 being at the Edgware General Hospital. 194 deaths took place in hospitals just outside the district, including 12 in nearby isolation hospitals, and 181 in various London hospitals. Seven deaths were of infants born in hospitals outside the district. The total number of deaths was 1,945. The figure for 1954 was 1,790 and for 1953 was 1,925. The 2,094 of 1951 was the largest number of deaths recorded for this district. The death rate was 8.9 per thousand population. The rates for the last three years were 8.7, 8.8 and 8.2. Lability to death varies at different ages. Any changes in the agedistribution of a population then affect the death rate; similarly, the 10 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 RegistrarGeneral calculates a comparative mortality index based on the 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 1951. The index figure is 1.14; the adjusted rate is 10.1, a figure well below that of 11.7 for the country as a whole. The following is the Registrar-General's abridged list of causes of death in this district:— Male. Female Male. Female Resp. tuberculosis 8 5 Hypertension 22 29 Other tuberculosis 0 1 Other heart disease 88 153 Syphilitic disease 2 0 Other circulatory disease 56 64 Diphtheria 0 0 Influenza 5 4 Whooping cough 0 0 Pneumonia 36 51 Meningococcal infections 1 1 Bronchitis 69 31 Acute poliomyelitis 1 3 Other respiratory disease 9 6 Measles 0 0 Peptic ulcer 11 9 Other infective diseases 2 1 Gastritis, Enteritis 1 4 Cancer of stomach 23 31 Nephritis 4 7 Cancer of lung 79 17 Hyperplasia of prostate 9 0 Cancer of breast 0 43 Pregnancy, etc. 0 1 Cancer of uterus 0 10 Congenital malformation 14 6 Cancer of other sites 110 100 Other diseases 74 80 Leukaemia 8 5 Motor vehicle accidents 13 3 Diabetes 2 4 Other accidents 10 11 Vascular diseases of nervous system 89 156 Suicide 14 8 Homicide 2 0 Coronary disease 199 140 1,399 deaths were due to diseases of the circulatory system, vascular diseases of the central nervous system and to cancer, a percentage of 72 of the total deaths. The following table shows for each sex the percentage of deaths in different age groups of those in this district for last year and for the country as a whole for 1954. Local, 1954 England and Wales, 1954 M. F. M. F. Under 1 3.3 1.5 3.7 3.0 1— 4 0.6 0.7 0.5 0.4 4—15 0.6 0.4 0.6 0.4 15—25 1.2 0.7 1.0 0.6 25—35 1.4 1.1 1.6 1.4 35—45 2.6 2.9 3.1 2.8 45—55 11.4 7.1 9.1 6.3 55—65 21.4 12.2 17.7 12.5 65—75 27.5 21.1 28.3 25.6 75—85 22.1 34.1 27.0 33.3 Over 85 8.2 17.5 7.4 12.7 11 It will be noticed that of the local deaths 57.8 per cent of those of males were persons of 65 and over; of 75 and over 30.3 and in fact of 85 or over 8.2. The corresponding figures for females were 72.7, 57.6 and 17.2. Of local residents who died last year 31 per cent, had reached the age of 75, and 12 per cent, had reached the age of 85. Infant Mortality The infant mortality rate is the number of infants dying under one year of age per thousand born. It is one of the vital statistics of special interest because it has for long been accepted as an index ot the healthiness of the community, being influenced by so many of the factors which affect the health of the population. The infant mortality rate for the country as a whole was about 150 in the early years of the century. The local rates have for many years been very satisfactory. The figure has not been over 25 since 1948. Last year 47 infants living in this district or born to mothers ordinarily resident in this district died under one year of age. In the same year 2,755 infants were born. The infant mortality rate was therefore 17.6. The rate for the country as a whole was 24.9. Of these 47 deaths, 33 occurred in infants under one month old. The neo-natal rate was therefore 12-0, comprising 70 per cent, of the infant mortality rate. The mothers of only four of these infants had been confined in their own homes, all the others being delivered in hospitals. Of the hospital cases, deaths were due to birth injury in 8, to prematurity in 9, to asphyxia in 1, atelectasis 1 and congenital defect 10. The deaths of those who died at home were due to congenital defects. Although four of the 14 deaths of those survived one month but who failed to survive twelve months were due to development abnormalities, the increasing extent to which environmental factors play their part in causing fatalities is shown by the fact that broncho-pneumonia, enteritis and other infections caused seven deaths. Stillbirths 50 stillbirths were registered last year. This was a rate per thousand Population of 0.28 and a rate per thousand live and stillbirths of 17-8. The rate per thousand births for the country as a whole was 23.1. Of the 44 stillbirths about which particulars are known, 38 were to mothers confined in hospital, two in nursing homes and four to mothers delivered in their own homes. In a number of instances some state of 'he mother brought about the death of the foetus usually before term. In 9 cases the mother suffered from toxaemia of pregnancy and in 5 she had ante-partum hæmorrhage. In 3 other instances the foetus died before labour. 10 of the losses were associated with a difficult labour. In seven others the infant was alive at the beginning of an apparently normal labour. Stillbirths occurred to three mothers who had had previous miscarriages, and one stillbirth was of a twin. In four cases the infant suffered from congenital abnormalities, and in the remaining two deliveries took place prematurely, the reason for the onset not being known. 12 Of the three stillbirths lost to mothers confined in their own homes in whom the labour was at term, in one there was no difficulty; in another labour was prolonged, but in the third it was particularly rapid. The fourth case was one in which labour occurred at the twenty eighth week of pregnancy. In only four out of these 44 cases was delivery at home. Of the 31 infants who died before reaching the age of one month, only four were to mothers confined in their own homes and in each of these cases the cause of death was some congenital abnormality. A recent report of an enquiry in prematurity carried out in Newcastle says—"The greatest loss of infant life occurs before or during birth, or in the first seven days afterwards and is then associated with premature birth,congenital abnormalities and birth injuries.... In at least fifty per cent, of cases there is no obvious medical reason for the premature onset of labour, though it is affected by social gradients and is therefore probably an environment factor." Deaths of Infants 1 to 5 Years of Age A child who survives the first year of life enters a period when the probability of dying is very small. Some survive their first birthday in spite of suffering from congenital abnormalities which later become responsible for, or contribute to death. Weaker children, especially in the earlier years, might succumb to infections which older children can throw off. Accidents too early start to exert their toll. Eleven children survived their first but did not reach their fifth birthdays. Of these one was in her second year, four were in the third, three in the fourth and three in their fifth years. Of these deaths, six were due to respiratory complaints or to infections. No deaths were due to accidents. Maternal Mortality The total maternal mortality rate includes all deaths of women primarily due to, or associated with pregnancy or childbirth expressed as a rate per thousand live and stillbirths registered in the year. There was in this last year only one death as a result of pregnancy or delivery, the maternal mortality rate being 0.35. The fatality occurred in one who suffered from a congenital malformation of the heart and on whom a caesarian section was performed. Deaths from accidents Thirteen males and three females living in this district were killed on the roads in 1955. In each of these accidents a motor vehicle was involved. The victim was in a motor car in one instance, was on a motor cycle in six, was a pedestrian in six; was a cyclist on one occasion and two victims were drivers of lorries. Eight of the deaths were due to accidents s which occurred in this district. There were 21 deaths from other accidents, a marked reduction on the 41 deaths in 1954. 10 of these were of males, 11 were of females The commonest cause again was a fall of the elderly; this accounted for the deaths of three men and five women; in all instances the fall occurrred indoors. A fall in an elderly person is especially serious because so commonly it results in a fractured thigh with the risk of subsequent 13 hypostatic pneumonia. There seems to be a very great risk of the elderly person tripping over an object which causes no inconvenience to younger persons. Other falls accounted for four deaths, three of children. Poisoning caused the deaths of four adult females and of a boy of six. Coal gas poisoning caused two male deaths. One child died from burns. There were no deaths this year from drowning. In all, accidents caused the deaths of five children under ten years of age. Three of these were the result of falls, one of poisoning and one of burns. Two boys of nine and two years of age were murdered. The Heating Appliances (Fireguards) Act, 1952 and the 1953 Regulations require that efficient fireguards be fitted to gas fires, electric radiators and oil heaters before they are sold. Guards must be constructed of substantial material and must be able to withstand three tests: the weight test, the probe test and the scorch test. At their meeting in January, 1955 the Public Health Committee agreed that the sanitary inspectors should be the authorised officers to carry out the inspection of heating appliances under this Act. During the year 69 visits were made to premises retailing heating appliances and 87 tests were carried out. These showed that 48 radiators did not conform to the standard. The appliances were either fitted with new guards or were destroyed. Deaths from Suicide 14 men and 8 women committed suicide during 1955. Six of the men and the same number of women chose poisoning by coal gas. No person chose a form of poisoning other than by coal gas. Two, one of each sex, drowned themselves. This year some more violent means were chosen: two men and one woman hanged themselves, three men threw themselves under trains and one man shot himself. There seems to be no set pattern of distribution of these occurrences. In some years the incidence is fairly even throughout the year. This year five took place in June, four in July and three each in January and October. The only two months free from such occurrences were August and September. Six of those who chose to end their lives were between 60 and 70 years of age. Three were in their twenties and one was 86. Deaths from Cancer Of the 1945 deaths of residents in this district, 414 were due to cancer, thi' causing 22 per cent, of the deaths of males and twenty per cent, of the deaths of females. Of the 212 deaths from this cause amongst males, in 79 the site was the lung, in 23 the stomach. Of the 202 deaths amongst females, the breast was the site in 43, the stomach in 32, lungs in 17 and the uterus in ten. This year's figures of deaths from malignant disease are a sharp increase on those of last year, the 212 deaths in males contrasting with a Eure of 196, the 202 for women being much higher then the 165 of 1954. fortunately the increase in the incidence of cancer of the lung in men as judged by these mortality figures has not been arrested as there were 79 deaths from this cause in 1955 compared with 71 in 1954. There was also a grater number of deaths from cancer of the stomach. Part of the increase in the numbers of deaths from cancer in women was due 14 to an increase in the same condition, 32 deaths compared with 23 in the previous year. Although the number of deaths amongst women from cancer of the lung is a fraction of that amongst men, nevertheless it is disturbing that there has been an increase in the number from this cause, the 17 deaths in 1955 being five more than in the previous year. Although some forms of malignant disease can cause the death of the relatively young or even of the very young, it is not until the age of 45 is reached that these conditions account for much of the mortality of the population. After the age of 75 it again accounts for only a small proportion of the deaths. Deaths from Infectious Diseases Infections accounted for a greater number of deaths last year than in 1954. There were eight from influenza, largely due to the invasion in February and March. There were four deaths from acute poliomyelitis and two from meningococcal infection. There were however none from scarlet fever, diphtheria, measles or whooping cough. 15 HEALTH SERVICES OF THE AREA HOSPITALS There were during the year no changes in the arrangements of the general or special hospital services in this area, details of which were set out in the report for 1954. The Minister of Health in February 1955 gave particulars of the new hospital building programme to be spread over the years 1956-7 and 1957-8. The first stage of the erection of the Charing Cross Hospital at Northwick Park appeared in the 1957-8 list. The special need in this as probably in most districts is for additional accommodation for the aged. With the 23 beds provided for this purpose atOrme Lodge, Stanmore and the 24 at Glebe House, Hadley Common, Barnet, the number of beds available for the geriatric service in this area at the beginning of the year was 209, these beds serving an area of nearly half a million population. The beds at the Edgware General Hospital (18) and at Roxbourne Hospital (51) are reserved for patients in need of active treatment. NURSING HOMES There were few changes during the year in the nursing homes in the district registered by the County Council under the provisions of Section 187 of the Public Health Act, 1936. At the beginning of the year there were 16 registered homes with 198 beds, 16 maternity and 182 for other patients. The College Hill Nursing Home with its 11 beds for medical and chronic cases closed. The Convent of the Little Company of Mary which changed its name to the Calvery Nursing Home was registered for 40 instead of 35 medical and chronic beds, and The Hall, Harrow Weald was registered for 11 chronic instead of for 10 borderline mental cases. At the end of the year then there were 15 registered homes with a total of 193 beds, of which 16 were for maternity cases. ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT At the beginning of the year 31 establishments in the district were licensed for the carrying on of massage and special treatment. The application for one of these was in the name of two persons. On the other hand one practitioner had two surgeries so that these establishments were licensed in the names of 31 persons. During the year three more establishments were licensed. One practitioner changed his surgery, and the use of two premises for this purpose was discontinued. The nett result was that at the end of the year 32 premises were licensed. NURSING, MIDWIFERY, ETC., IN THE HOME General Nursing Full particulars of the local arrangements for nursing in the home were set out in the report for 1954. It has been possible to recruit up to full establishment of home nurses and with this number of staff it has for most of the time been possible to meet demands and provide the day-time service. An increasing proportion of the time of the nurses is taken up by attention to the 16 elderly, and many of their visits are paid for the giving of such injections as penicillin and insulin. As far as possible someone in the household is encouraged to give the patients the help needed. In most cases there is someone, and most diabetics do not need their insulin to be given them by one of the nurses. Were this not the position the accepted number of home nurses would not be sufficient to enable them to meet the demands already made on their services. In those households where there is no-one who can carry out these duties, there is no alternative to the nurse continuing to attend. Difficulties of another nature arise at some households where the nurse has to call to carry out some definite nursing duty but the patient needs other help which is not of a nursing character, and there is no-one to provide this. Yet another problem arises at many households during the night where the patient needs not a nurse to carry out the duties of a nurse, but someone to attend her or sometimes merely someone to keep her company. The cases of this nature of special difficulty are those patients who are failing, but who cannot be admitted to hospital or other institution. At the end of the year there were 20 whole-time nurses and 8 parttime nurses who help mostly in the mornings. During the year they paid in all 64,949 visits. Midwifery and Maternity Nursing The only change in the arrangements of the domiciliary midwifery service was that Mrs. Lundy left on the 8th September, 1955. She was on the 26th September, 1955 replaced by Miss C. Clyne of 20 Southbourne Close, Pinner (Tel. No. Pinner 6278). Last year the midwives attended the confinements of 588 women in their own homes, being present in 479 instances as midwives and in 109 as maternity nurses. In recent years midwives have been allowed to do something to relieve the pain of mothers in child birth. Of these mothers confined in their own homes 546 had the advantage of gas and air analgesia, 213 of pethidene and 18 of trilene. Home Helps The Home Help Service continued last year on much the same lines as in previous years. Although essentially an emergency service or at least one in which it is intended that help shall be provided for short periods only, an increasing proportion of the time of the helps is being given to long term, including tuberculosis, cases. The average number of home helps was 2.5 full-time and 47.5 parttime, being an equivalent of 32.5 whole time helps for the year. They gave help in 927 households. In 265 of these the patient helped was a maternity case, in 46 was one suffering from tuberculosis, in 226 was one suffering from some acute condition and in 390 the case was a long-term one. DAY NURSERIES The same two day nurseries provided for the admission of children whose mothers needed to go out to work, Headstone Drive Nursery with its 50 places and the Walton Avenue, South Harrow Nursery with its 60 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, 17 these being at Tyneholme, at Rayners Lane and Buckingham Road. Older children can attend the nursery classes attached to some schools. CLINICS AND TREATMENT CENTRES The following is a list of the clinics and treatment centres in, or serving the district:— Infant Welfare Centres The Clinic, Alexandra Avenue, South Harrow Mon. and Fri. p.m. Broadway Clinic, The Broadway, Wealdstone Wed. a.m. and p.m. The Pavilion, Chandos Recreation Ground, Edg- ware Thur. and Fri. p.m. Elmwood Clinic, Elmwood Avenue, Kenton Mon. and Wed. p.m. The Rectory, Elstree Mon. p.m. Greenwood Hall, Rickmansworth Road, Pinner Wed. p.m. Memorial Hall, High Road, Harrow Weald Thu. p.m. The Clinic, Honeypot Lane, Stanmore Mon. and Wed. p.m. The Clinic, Kenmore Road, Kenton Wed. a.m. and p.m. Methodist Church Hall, Love Lane, Pinner ... Fri. p.m. Methodist Church Hall, Walton Avenue, S. Harrow Thu. p.m. St. Alban's Church Hall, North Harrow Thu. a.m. St. Anselm's Hall, Hatch End ... ... ... Thu. p.m. St. George's Hall, Pinner View, Harrow ... ... Tue. and Fri. p.m. St. Hilda's Hall, Northolt Road, South Harrow... Tue. and Thu. p.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. p.m. Stanmore Park (R.A.F.) Station ... ... ... Thu. p.m. The Clinic, Whittlesea Road, Harrow Weald ... Wed. p.m. Ante-Natal Clinics The Clinic, Alexandra Avenue, South Harrow Wed. p.m. Broadway Clinic, The Broadway, Wealdstone Tue. a.m. and Thu. p.m. The Pavilion, Chandos Recreation Ground, Edg- ware Fri. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. The Rectory, Elstree Mon. p.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. The Clinic, Honeypot Lane, Stanmore Tue. p.m. The Clinic, Kenmore Road, Kenton Fri. p.m. 76, Marlborough Hill, Wealdstone Mon. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. Methodist Church Hall, Walton Avenue, S. Harrow Thu. a.m. St. Alban's Church Hall, North Harrow Tue. a.m. St- Hilda's Hall, Northolt Road, South Harrow Tue. a.m. St. Anselm's Hall, Hatch End Thu. a.m. Spiritualist Church Hall, Vaughan Road, Harrow Wed. a.m. The Clinic, Whittlesea Road, Harrow Weald Fri. p.m. Toddler's Clinics The Clinic, Alexandra Avenue, South Harrow Mon. a.m. he Pavilion, Chandos Recreation Ground, Edg- Ware Thu. a.m. B 18 Elmwood Clinic, Elmwood Avenue, Kenton Fri. a.m. St. George's Hall, Pinner View, Harrow 1st and 2nd Tue. a.m. The Clinic, Honeypot Lane, Stanmore Mon. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Clinic, Kenmore Road, Kenton Thu. a.m. Spiritualist Hall, Vaughan Road, Harrow 1st Mon. a.m. The Clinic, Whittlesea Road, Harrow Weald Wed. 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 cases it is considered further pregnancy would be detrimental to their helath. School Minor Ailment Clinic Sessions are held at a number of premises in the district:— The Clinic, Alexandra Avenue, South Harrow Mon., Fri. and Sat, a.m. Broadway Clinic, The Broadway, Wealdstone Mon., Thu. and Sat. a.m. The Pavilion, Chandos Recreation Ground, Edg- ware Thu. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Fri. a.m. The Clinic, Honeypot Lane, Stanmore Mon. and Sat. a.m. Methodist Church Hall, Love Lane, Pinner Mon. a.m. The Clinic, Kenmore Road, Kenton Thu. a.m. The Clinic, Whittlesea Road, Harrow Weald Wed. a.m. Children attend at the request of the parents or of the teachers, or they are referred by school medical officers. Not only are those who need treatment for minor ailments seen at the clinics, but children are kept under observation for such conditions as cervical glands, cardiac murmurs, etc. Any children needing special examination, especially it these are likely to be prolonged, are referred to these clinics. Ophthalmic Clinics Sessions are held at the Marlborough Hill clinic on Tuesday afternoons and Friday mornings, and at the Alexandra Avenue clinic on Thursday mornings. The prescription is taken to an optician wtw provides the spectacles. _ ,, Arrangements are made to keep those children provided win spectacles under observation. The ophthalmic surgeons at the clinic are now on the staff or Regional Hospital Board. The deflection of a squinting eye can sometimes be straightened by exercises. Mrs. Barrett, an orthoptist, treats children in this way at the Marlborough Hill clinic. 19 Child Guidance Centre At the County Council's Child Guidance Centre at 2 St. John's Road, Harrow the full-time psychiatrist, Dr. Margaret Saul, is helped by psychologists and psychiatric social workers. Speech Clinic A speech clinic is held at the Marlborough Hill clinic where two whole-time speech therapists are engaged. Those attending are mainly pupils of maintained schools who have been referred for treatment either by the school medical officers or by the teachers. Sessions are now being held at some of the peripheral clinics. Dental Treatment Dental treatment, apart from that provided under the National Health Service Act, is available for 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 six premises: 76 Marlborough Hill, Elmwood Avenue clinic, Alexandra Avenue clinic, Roxeth clinic, Honeypot Lane clinic and Whittlesea Road clinic. Apart from the sessions when the dental officers are examining children in the schools, treatment sessions are held every week-day, morning and afternoon. The school children treated there are those found, at the routine dental inspection of children at the schools, to need treatment. Only those who attend by appointment can be seen, except those referred by the head teachers of the schools for urgent or emergency treatment. Children under five, expectant and nursing mothers are referred by the medical officers at the clinics which they attend. Expectant mothers are also referred by their own doctors. An orthodontic surgeon works at the Marlborough Hill clinic. Care of the Feet A limited chiropody service is provided by the local health authority for children attending maintained schools, for nursing and expectant mothers, and for children under school age. Appointments are made at sessions held at the various permanent clinic buildings in the district. Chest Clinic The Chest Clinic serving most of this district is that at 199 Station Road, Harrow (Tel. No. Harrow 1075). The physician in charge is Dr. Grenville Mathers. Serving part of the district on the eastern side is the chest Clinic at the Edgware General Hospital (Tel. No. Edgware 4467). The physician in charge is Dr. Trenchard. PROVISION FOR SPECIAL CLASSES OF PERSONS The Deprived Child By the Children's Act, 1948, every local authority (major authority) was required to establish a Children's Committee and to appoint a 20 Children's Officer. One duty of the authority is to accept into care the child under seventeen who has neither parent nor guardian, or has been and remains abandoned by his parent or guardian, or is lost; whose parent or guardian is for the time being, or permanently, prevented by reason of mental or bodily disease, or infirmity, or other incapacity, or any other circumstances from providing for his proper accommodation, maintenance and upbringing, and the intervention of the local authority is necessary in the interests of the welfare of the child. These children are placed in residential homes, or are boarded out. In certain circumstances a local authority may assume parental rights with respect to any child in their care. It is also the duty of the authority to act as a fit person under the Children and Young Persons Act, 1953 when the court commits a child to their care. The responsibility for the supervision of children under the Children's Acts relating to child life protection has also passed to the Children's Department. These provisions relate to children who are maintained apart from their parents for reward; such children are now being supervised up to the age of eighteen years. The Children's Department has further responsibilities in regard to children who are about to be adopted. The Children's Officer of the Middlesex County Council is Miss J Rowell, of 10 Great George Street, S.W.I. (Tel. No. Trafalgar 7799) In this area the work is carried out by the Area Children's Officer Miss Susan Boag, at Kynaston Court. The Mentally III and the Mentally Defective 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 need to be dealt with under the Lunacy and Mental Treatments Acts, and for the ascertainment and community care of mental defectives. The Health Committee of the County Council is responsible for the mental health functions of the Authority. Harrow is part of the central division of the county which is served by Shenley Hospital. The Mental Welfare Officer, Mr. W. Jand other officers, work at 249 Willesden Lane, N.W.2. (Tel. No. Willesden 6181). Some children of school age or of even below school age are tound to be ineducable. The responsibility for dealing with these rests with the Mental Health service of the County Council. Some attend the occupation centre. Persons in Need of Care and Attention . Part III of the National Assistance Act imposed certain duties on the County Council: 1. To provide residential accommodation for persons who by reason of age, infirmity or other circumstances are in need of care and attention not otherwise available to them. 2. To provide temporary accommodation for persons who are in urgent need thereof. 21 3. To make arrangements for promoting the welfare of persons who are blind, deaf or dumb and other persons who are substantially and permanently handicapped by illness, injury, congenital deformity or such other disabilities as may be prescribed by the Minister of Health. These duties are the concern of the Welfare Department. For administrative purposes the county is divided into the same ten areas as for the County Council functions under Part III of the National Health Service Act. Acting under the supervision of the Chief Welfare Officer for the county there is a Welfare Officer in each area. The one for this district is Mr. H. G. Plummer, Kynaston Court, Boxtree Road, Harrow Weald. Enforced Removal. Apart from the powers possessed by the hospital boards or by the local health authorities to help persons in need of care and attention, the local sanitary authority has been given powers to deal with those persons who, because they cannot look after themselves are causing injury or nuisance to those living near. These powers are contained in Section 47 of the National Assistance Act, 1948, which sets out the arrangements for the removal to suitable premises of persons who (a) are suffering from grave chronic disease, or being aged infirm or physically incapacitated, are living in insanitary conditions, and (b) are unable to devote to themselves and are not receiving from other persons proper care and attention. The machinery proved to be cumbersome. By the 1951 Amendment Act, if the Medical Officer of Health and another registered medical practitioner certifies that it is necessary that a person shall be removed without delay from the place he is living in, an application for a Removal Order may be made to the Court or to a single justice. Up to this, no action has been taken in this district under the powers given by this section. A number of persons throughout the county have been admitted to County Council homes under such orders. In most cases they have been content to remain in the homes without the orders being renewed. Laundry Service. One of the problems arising from those whose admission to hospital or institution is desirable but cannot be arranged, 15 the soiling of the bedding and the clothing of the incontinent. This Problem occurs more particularly in the aged. Local Sanitary Authorities iQVe clrta'n 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 ealth 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." The Hendon roup Hospital Management Committee were prepared to arrange 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 agrred to this within the limit of their powers as to the type of case to be helped. 22 The arrangement which started in 1954 has worked smoothly. At the beginning of the year 11 persons were being helped. There were during the year seven new cases; because of death or removal from the district, the number being provided with help at the end of the year was only six. The period any patient had the help ranged from one month to a full year. A person who is being helped might not need that help to be continued either because he has been admitted to hospital, or has died. The cost of the service is not high, the average cost per week per person being about 3s. The powers of the Council to provide this form of help are restricted, so that only a few can be assisted; but to those who can be helped, the assistance is of very real benefit both to the patients and to those who are looking after them. It may so relieve the burden of those who have to care for any patient that the pressure on hospital beds might be relieved While the Council bears the cost of the service, the real burden of it falls on the staff of the Edgware General Hospital who man the laundry and thanks are due to the Hendon Group Hospital Management Committee for making these arrangements. The Aged The needs of the aged who require help vary. There is the hospital group, the group of those needing permanent medical and nursing attention; these are the responsibility of the Regional Hospital Boards. The local Edgware General Hospital, has set up a special geriatric department, with its specialist officers with their primary responsibility of seeing to the interests of those aged who are ailing. A geriatric out-patients' department and follow-up clinic has been established at the hospital where patients can be seen by appointment. Another group is those who while not needing the special nursing or medical care of the first group, nevertheless require care and attention which is not otherwise available to them. These are helped by the Welfare Department of the County Council (Area Welfare Officer. Kynaston Court, Harrow Weald) which arranges admissions to residential homes. The third group is that of those old people who are living as ordinary members of the community but who, nevertheless, are not really ordinary members because many have their own special needs. There is no official authority responsible for them, though many agencies, especial!) voluntary, help in different ways. As a housing authority, the Council has built a number of houses especially designed for the aged. The Harrow Housing Society Limited (the Secretary, Miss D. Walding.Manor Road, Harrow, Tel. No. Harrow 1418), provides accommodation for a number of elderly persons at Pinner House, Church Lane, Pinner. A number of aged are helped to obtain meals. There is a luncheon club at the Assembly Hall, North Harrow, where some 80 old people^ served with meals at a charge of 1/- a meal, and another at Bclm0'1 Assembly Hall, Kenton Lane. Applications to join these clubs should l made to the Secretary, Harrow Old People's Welfare Committee, Harrow Weald Lodge. In addition, the Women's Voluntary Service maintains J " Meals on Wheels " service, taking meals to some old people confine 23 to their homes. Enquiries should be made to the Harrow Administrator W.V.S., Bradstowe House, Headstone Road. There are a number of old people's clubs in this area, including six " Evergreen " Clubs run by the British Red Cross Society (Organiser, Mrs. Mash, 9, Peterborough Road, Harrow) and four " Darby and Joan " Clubs run by the Women's Voluntary Service (enquiries to the Harrow Administrator W.V.S., Mrs. M. E. Kingett, Bradstowe House, Headstone Road.) The Harrow Old People's Welfare Committee, on which are representatives of the many agencies in the district helping the aged in any way, helps to link up the work of these organisations. The Committee engage a co-ordinating officer, who is at the Council Offices, Peel Road, Wealdstone (Tel. No. Harrow 2974) on Tuesdays, 10 a.m. to 12 noon, Thursdays 2 to 5 p.m. A home visiting service has been set up under which arrangements are made to recruit visitors who will keep in touch more especially with lonely old people. LABORATORY SERVICE The examination of clinical material of public health significance is carried out free of cost to the patient and to the doctor at the Central Public Health Laboratory, Colindale Avenue, London, N.W.9 (Tel. No. Colindale 6041 and 4081). Many of the samples submitted are throat swabs which are examined for the presence of organisms of diphtheria or of the haemolytic strepto coccus. Another group of samples is of dejecta for the presence of organisms of the typhoid fever, dysentery or food poisoning group. Specimens of sputa are submitted for examination for the presence of tubercle bacillus. Blood serum is sent for examination of the reaction indicating the infection of the body by the typhoid group. Cough plates are examined for the presence of the organisms of whooping cough. In general the examination is carried out of material which will oe of aid in the early diagnosis of infectious conditions, one purpose of the laboratory being to carry out investigations of public health significance. The laboratory also carries out the routine bacteriological examination of such foods as milk or ice-cream, and examines other loodstuff considered possibly to have been the source of a food poisoning, ne staff of the laboratory also carry out investigations in the field in •lie case of various forms of outbreak, however spread. Another service provided by the laboratory is the issue of certain P'eparations such as lymph for vaccination against smallpox, and antigens or the immunisation of the population against diphtheria. The clinical material is collected each day by a van from the laboratory rafing about mid-day at the Harrow Hospital, " Kynaston Court," the Central Fire Station, Pinner. I. ' he following is a summary of the examinations of material from is district, carried out during the year: nose and throat swabs 163, eces 254, sputum 27, miscellaneous 11. AMBULANCE SERVICE Although the County Council decided that the Fire and Ambulance vice should be run as one combined service, the combination of the 24 two services is limited to organisation and administration. Fire appliances are manned by firemen especially 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." The County Council development plan provides for the building of ten ambulance depots at various places throughout the county. All ambulances and sitting case vehicles are to be housed in these depots which will cater for the needs of the surrounding districts. They would also assist in accident work in an emergency. One of these buildings is in this district at Imperial Drive (Tel. No. Pinner 8900). 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. 25 SANITARY CIRCUMSTANCES OF THE AREA WATER Full particulars of the origin and the purification of water supplies to this district were set out in the Annual Report for 1954. So that the Authority may comply with the obligation imposed by Section 111 of the Public Health Act, 1936 to ascertain the wholesomeness of the water supplies in the district, samples are submitted periodically for chemical and bacteriological analysis. In addition reports are received each week from the Chief Chemist of the Colne Valley Water Company on the results of the examination of samples collected at different premises in the district. The following is a summary of a typical chemical analysis (Chemical Results in Parts per Million). Appearance: Bright with a few mineral particles Colour: nil. Turbidity: less than 3. Odour: nil. pH: 7.3. Free Carbon Dioxide: 18 Electric conductivity: 690. Total Solids: 480. Chlorine present as chloride: 45. Alkalinity as Calcium Carbonate: 255. Hardness: Total 290. Carbonate 255, Non-carbonate 35. Nitrate Nitrogen: 4.0. Nitrate Nitrogen: less than 0.01. Ammoniacal Nitrogen: 0.021. Oxygen absorbed: 0.35. Albuminoid Nitrogen: 0.000. Residual Chlorine: absent. Metals: Iron 0.03, other metals absent. "This sample is practically clear and bright in appearance, neutral in reaction and free from metals apart from a negligible trace of iron. The water is hard in character but its hardness and its content of mineral and saline constituents in solution are not excessive. Its organic quality is of a high standard. These results are indicative of a water which is pure and wholesome in character and suitable for drinking and domestic purposes." The following, a copy of a bacteriological examination of a sample submitted for analysis in August, is typical of other reports: Plate count. Yeastrel agar 2 days anaerotically: 1 per ml. Probable number of coliform bacilli: MacCoukey 2 days 37°C: not found. Probable number of faecal coli: not found. A local resident drew attention to the possibility of copper being present in water as drawn off in the house. Suspicion arose from the green discolouration of the fur inside a new enamel kettle. Analysis of the fur showed the presence of copper. The water was supplied through into the house in copper pipes. Although there was no apprehension that even though copper were taken up by the water there was any risk to health especially as copper as contrasted with lead is not cumulative poison, the opinion of the chief chemist of the Colne Valley Water Company was sought. The company carried out very thorough tests from which it was found that although the water supplied by the company is free from copper, traces of copper were present as drawn off in this house. On heating the water, the copper precipitated. When this occurs in an aluminium kettle, electrolytic action takes place which in time might lead to perforation of the kettle. When copper pipes are used then it is advisable that kettles of copper, or enamel and not of aluminium be used. A reduction in the action of the copper can be 26 achieved by running off any water which has stood for any length of time. This slight solvent action by water on copper pipes is fairly common. DRAINAGE AND SEWAGE DISPOSAL The Report for 1954 set out the details of the arrangements for the disposal and treatment of sewage in this district, the drainage, particulars of the lakes of the area and of the wells. At their meeting in February, the Highways and Cleansing Committee accepted a tender for carrying out the work of extending the soil sewer in Oxhey Lane; and at their meeting in August authorised the invitation of tenders for the inclusion of the works involved in the Pinner soil sewer relief scheme. On the 19th October heavy and prolonged rain fall occurred in the north-west of London. Between 2.0 a.m. and 8.30 p.m. 2.47 in. of rain fall were recorded at the gauge at Cottesmore. Of this 215 in. fell between 6.30 a.m. and 3.30 p.m. including 0.8 in. between 11.0 a.m. and 12 noon. Many surface water sewers, drains and water courses were surcharged with resulting flooding which in many cases escaped into the soil sewers, causing there surcharging and flooding. The design of the local sewers is based on an allowance of rain fall of 0.5 in. in a sixty minute storm. PUBLIC CLEANSING Particulars of the local arrangements for refuse collection, refuse disposal and street cleansing were set out in the Annual Report for 1954 There were no changes in these during 1955. The contract with the Uxbridge Council for the disposal of refuse on a site in Hillingdon runs to the 31st March, 1957. Provision of dustbins: On Peterborough Corporation appealing against a decision of the justices, it was held that once it had been established that a dustbin should be provided, the justices are required to make an order either on the occupier or on the owner to provide a dustbin. PUBLIC CONVENIENCES Particulars of the public conveniences in the district were set out in the Annual Report for 1954. The Highways and Cleansing Committee during the year had under consideration the question of the erection of conveniences at Queensbury, Kenton and Pinner. DISPOSAL OF THE DEAD Burial Grounds There were no changes during the year in the provisions for the burial of the dead, particulars of which were set out in the Annual Report for 1954. Cremation The Open Spaces Committee at their June meeting agreed in principle to proposals for the erection of a crematorium and garden of rest on the site of the Old Vicarage, Harrow Weald. At their September 27 meeting they were informed that the Minister of Housing and Local Government felt, in the light of the statement of the Chancellor of the Exchequer on the need to restrict capital expenditure, that the scheme should be deferred for the time being. The Committee were later informed that the Minister saw no objection to the preparation of preliminary drawings. The practice of cremation is growing rapidly. Whereas in 1941 less than five per cent. of bodies were disposed of in this way, the figure had reached 10 by 1947, over 20 by 1953 and nearly 25 last year when there were 82 crematoria. 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 has been found dead in their area if no other suitable arrangements are being made. Each year there has been a small number of requests for these arrangements for burial to be made. In this last year the number was only four. Mortuary The district is served by the one mortuary at Peel Road, which is under the care of a full-time mortuary attendant, Mr. C. Russell, of 30 Lome Road, Wealdstone. At their June meeting the Public Health Committee agreed as a temporary arrangement that bodies from the Wembley area should be received in the Corporation mortuary at a charge of £2 each pending the provision of a new mortuary in Wembley. It was not expected that in any one week more than four bodies would be admitted under these arrangements. During the year 378 bodies were received in the mortuary, 81 of these being from Wembley, the first of which was admitted on April 7th. Post-mortem examinations were carried out on all but two bodies from Harrow admitted for storage. 28 SANITARY INSPECTON OF THE DISTRICT AND THE INSPECTION AND SUPERVISION OF FOOD STATISTICAL SUMMARY PART I Inspections made and Conditions Found HOUSING Inspection of Houses Visits (i) On complaint of dampness or other housing defects 925 (ii) On complaint of other nuisances 602 (iii) Routine inspections 837 (iv) Revisits arising from defects found 5,983 (v) Surveys under S. 157. Housing Act, 1936 451 Conditions Found „ (i) Number of dwellings or other premises where defects were found l,613 (ii) Number of cases of overcrowding revealed 40 PUBLIC HEALTH Inspection of Other Premises Visits (i) On complaint or request 224 (ii) Routine inspections of premises 601 (iii) Revisits arising from defects found 984 (iv) Surveys arising from Rat and Mice complaints 2,181 (v) Inspection of Factories 399 (vi) Inspection of Workplaces 64 (vii) Inspection of Outworkers'Premises 349 (viii) Inspection of Cinemas and Places of Entertainment 73 (ix) Inspection of Licensed Premises 116 (x) Visits under Shops Acts 1,645 (xi) Evening observations under Shops Acts 39 (xii) Sunday observations—Shops Acts 17 (xiii) Observations made for Smoke Nuisances 77 29 Conditions Found (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 692 (ii) Number of premises where action was taken by Rodent Operatives to deal with rats or mice 1,429 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 72 (iv) Number of Cinemas and/or Licensed Premises where defects were found 51 (v) Contravention of Shops Acts— (a) Failure to observe closing hours 4 (b) Other contraventions (failure to exhibit notices, etc.) 313 FOOD HYGIENE Inspection of Food: Food Shops, and Food Preparing Places Visits (i) Slaughterhouses 436 (ii) Butchers' shops 448 (iii) Cowsheds 20 (iv) Dairies 81 (v) Fish Shops 194 (vi) Bakehouses 122 (vii) Cafes and Restaurants 329 (viii) Ice Cream Premises 303 (ix) Provision Merchants 659 (x) Greengrocers 397 (xi) Other Food Premises 383 PART II COMPLAINTS RECEIVED Summary Accumulations of refuse 116 Animals causing a nuisance 30 Dampness and Housing defects 527 Drains and Sewers—choked 70 —defective 126 Dustbins defective 100 Flooding—Gardens 23 Vermin 49 Insect infestations 129 Overcrowding, alleged 62 Smoke nuisances 37 Water course 3 Other complaints (wasps'nests, defective fences) 177 Food unfit (excluding requests received from shops to visit and inspect unfit food) 47 30 PART III NOTICES SERVED Under Housing Act, 1936 Statutory Notices served under S.9 requiring execution of repair work 37 Dwellings reported under S.11 and S.11 as amended by S. 10 L.G. Act, 1953, as being unfit for human habitation 29 Dwellings reported under S. 12 and closing orders made Informal notices served under S. 9 86 Under Public Health Act, 1936 Statutory Notices under:— (i) S.24—work to a public sewer 162 (ii) S.39—repair or renewal of drains 25 (iii) S.45—repair or renewal of defective water closets (iv) S.56—undrained or badly drained yard area I (v) S.75—renewal of a dustbin 28 (vi) S.93—abatement of a nuisance 52 (vii) Informal notices served 1,596 ACTION TAKEN Following Housing Act Notices (i) S. 9—dwelling rendered fit:— (a) By owners In four cases the notices were served during 1954 (b) By local authority in default of owners Nil (ii) S.11 and S.11 as amended by S.10 L.G. Act, 1953—demolition order made 23 (iii) S.12—Closing order made 7 (These orders relate to properties reported in 1954) (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 18 (b) By local authority in default of owners (iii) S.45— (a) By owners 2 (b) By local authority in default of owners 1 (iv) S.56— (a) By owners 2 (b) By local authority in default of owners Nil (v) S.75 (a) By owners 16 (b) By local authority in default of owners 5 (c) By occupier 6 (vi) S. 93—Nuisances abated (8 outstanding from 1954) 43 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,491 31 SUMMARY PROCEEDINGS It was necessary on three occasions to apply to the Courts for an Abatement Order. In two cases Orders were made by the Magistrates; in the third case, the work was completed before the date of the Hearing. It was also necessary to apply to the Courts for the imposition of a penalty following the failure of an owner to comply with a nuisance abatement order, made by the Magistrates during 1954; a daily penalty was imposed; the nuisance was later abated. During the year there were six summonses relating to offences under the Shops Acts, and one under the Food and Drugs Act 1938 relating to glass in a bottle of milk. HOUSING Inspection of Houses Much of the work of the sanitary inspectors arises out of complaints. Many of these are about the houses the complainants live in. In many cases some structural work is necessary to remedy the nuisance and the owner carries out the work on being approached. Failing this the Committee authorises the service of a statutory notice. Some houses are found to need so much work to be done that the cost is prohibitive. More especially this is the case because of controlled rents and the owner can recoup himself only if he can obtain possession of the house and sells it. In these ways houses are brought to the notice of the Public Health Committee for steps to be taken to see that they are no longer to be lived in. The procedure in the case of an individual unfit house may be by way of Demolition Order or Closing Order; or of more than one house, by way of clearance procedure. Following on these complaints then, while most houses are rendered fit, some have to be demolished and recently sufficient have had to be dealt with in this way to enable the Committee to keep up to the proportion of its slum clearance scheme Proposals. Although then it is the duty of the authority to cause inspections to be made from time to time with a view to ascertaining whether any dwelling house is in a state so dangerous or injurious to health as to be unfit for human habitation, in point of fact no such routine inspections are being carried out, and the only houses inspected other than those about which a complaint has been made are those which are thought probably to be so similar to those about which complaints have been received that they are inspected to determine whether action should be taken in regard to the house complained of by way of Demolition Order or clearance procedure. A. survey of the district carried out to ascertain the number of houses Which would probably have to be dealt with in the Council's slum clearance Proposals showed— (a) Estimated total number of properties unfit for human habitation within the meaning of section 9 of the Housing Repairs and Rents Act, 1954: (i) to be dealt with as single units 23 (ii) capable of inclusion in clearance areas 371 394 32 (b) Number of properties already comprised in declared clearance areas: (i) post-war 115 (ii) Confirmed (pre-war) Clearance Orders 29 (c) Properties the subject of operative Demolition Orders 39 Proposals for Dealing with Unfit Houses The Housing Repairs and Rents Act, 1954 required each authority to submit to the Minister of Housing and Local Government proposals for dealing with unfit houses in the district. The number of unfit houses to be demolished in this district was estimated to be 577. The Clearance and Re-Development Sub-Committee was of the opinion that the problem of clearing and replacing the unfit houses could be solved within five years. Although then the Housing Repairs and Rents Act contains provision for the temporary repair of slum houses to enable them to be kept in service for a period, the Committee did not feel it would be necessary to use such powers. The following is a copy of the return submitted to the Minister on the specified form:— Part 1. The Total Problem (i) Estimated number of houses unfit for human habitation within the meaning of S. 9 of the Housing Repairs and Rents Act, 1954 and suitable for action under S. 11 or S. 25 of the Housing Act, 1936 577 (ii) Period in years which the Council think necessary for securing the demolition of all the houses in (i) 5yrs. Part 2. Orders already made, etc. (iii) Number of houses in (i) in clearance areas and already covered by operative clearance or compulsory purchase orders or owned by the local authority 29 (iv) Number of houses which are already in clearance areas and for which clearance or compulsory purchase orders have been submitted to the Minister but have not yet become operative 115 Part 3. Action in the first five years (v) Number of houses which are already in clearance areas and for which clearance or compulsory purchase orders are to be made or which are to be purchased by agreement within the five years - (vi) Number of houses which are to be included in clearance areas still to be declared and which, within the five years, will be owned by the local authority, or will have been included in a clearance order or a compulsory purchase order submitted to the Minister 371 (vii) Number of houses under (iii), (iv), (v) and (vi) to be patched (if necessary) and retained within the five years under section 2 of the Housing Repairs and Rents Act, 1954 for temporary accommodation - (viii) Number of houses under (iii), (iv), (v) and (vi) to be demolished in the five years 515 33 (ix) Number of houses (including those already comprised in operative demolition orders) to be demolished in the five years as a result of action under section 11 of the Housing Act, 1936 62 Demolition of Houses During the year 27 Clearance or Demolition Orders were made relating to— Demolition Orders: Burnt Oak Cottage 3, Shelley Road. 27, 29, 31, 33, Shelley Road. 33, 35, 37, Love Lane, Pinner. 58 and 60, Crown Street. Closing Orders: 32, Milton Road. 13, 15, 17, 19, Shelley Road. 3, Victoria Terrace. 51, West Street. 2, Stanmore Hill. 33, 36, 37, Byron Hill Road. 3a, 3b, Alma Road. la Alma Road, 45, 45a, West Street. 12 Wordsworth Road. An official representation was submitted for the clearance of numbers 34,36, 38, 40 and 42 Palmerston Road. The following groups of houses that were the subject of Clearance Orders were occupied wholly or in part at the end of the year: Address Date of Order Number still occupied 2-40, Headstone Drive 1939 9 Brewery Cottages 1939 5 High Street, Stanmore (No. 4) 1939 2 The following groups of houses were included in Clearance Orders Address Date of Order Number still occupied 3, 5, 7, Pinner Hill Road 1953 4 2-12 Palmerston Road 1953 6 29-34 Little Common 1953 6 31, 33, 35, 37, Crown Street area 1954 4 Date of Order Number still occupied Northolt Road No. 1 area 1954 8 Alma Road and Crescent area 1954 54 Northolt Road No. 2 area 1954 9 Northolt Road No. 3 area 1954 20 c 34 The following houses which had been the subject of Closing Orders or Demolition Orders were demolished during the year: 4 and 6, Shelley Road. Dower House Cottage, Stanmore Hill. Nos. 277 and 281 Pinner Road had been the subject of Closing Orders. On their being reconditioned the Orders were revoked. Repair of Houses When a house is found to be in any respect unfit for human habitation and the owner on being approached will not carry out the work, the Public Health Committee serves a notice under Section 9 of the Housing Act calling for the carrying out of the necessary work if that can be done at a reasonable expense. If the owner fails to do so, the authority can do the work and recover the cost from him. The Housing Repairs and Rents Act 1954 amended the provisions of the 1949 Housing Act by which grants could be made to the owners to modernise their houses by improvement or conversion. It appears that throughout the country little advantage has been taken of these additional powers, and very few applications have been received in respect of houses in this district. Improvement Grants. During the year 34 applications for Improvement Grants were referred to the Department by the Borough Engineer and Surveyor. Inspections were carried out to determine whether the accommodation was suitable for reconditioning and improvement; the proposed improvements would render the house in all respects fit for habitation; and whether, in those cases where disrepair existed, the owners proposals included dealing with the defects. Most of the applications received were from owner/occupiers who wished to improve the properties in which they lived; only eight related to properties where landlords wished to improve conditions for the benefit of the tenants. Overcrowding The annual review of the state of overcrowding in the district shows that there has again been an improvement. As compared with the 139 cases known on the 1st January, the number on December 31st was 109. The nett reduction of 30 is the difference between the 70 cases in which the overcrowding was abated and the 40 new cases. In 19 instances the abatement of the overcrowding was brought about by the families being rehoused in Council houses. The new cases of overcrowding are largely the result either of an increase in the size of the family, or of the ageing of existing members. Many houses are occupied so nearly to the full that a child reaching the age of one year or of ten years is sufficient to tip the scale and make the premises statutorily overcrowded. New cases of overcrowding brought about by these means can be expected to continue year by year. Of the 109 premises which were overcrowded, in 80 overcrowding was by not more than one unit. 10 families were living in premises overcrowded by H units, 14 in premises overcrowded by 2 units and five in 35 accommodation overcrowded by 2½ units or more. All the cases in which the overcrowding was by more than one unit were brought to the notice of the Committee. New Housing The total number of new dwellings provided in this district from the end of the war up to the 31st December, 1955 was 4,660. Of these, 2,301 were new permanent Council dwellings and 200 were new temporary dwellings. 1,488 permanent dwellings have been provided by private enterprise. 338 dwellings destroyed by enemy action were rebuilt, and 333 existing houses were completed. At the end of the previous year the number of permanent Council dwellings provided was 2,093, and the number of buildings provided by private enterprise 1,166. In addition 954 family dwelling units were provided in requisitioned premises. Of these by the end of the year 480 had been released and 60 had been reduced from two to one unit dwellings, 414 dwellings in all being held at the end of the year. Further use has been made of the arrangements for the removal of Harrow families to the new and expanded towns. By the end of 1954, 654 families had been housed in one of these towns. By the end of last year the number was 895. Of these families 529 were from the normal waiting list. Council House Rents. The following is an extract from a report of the Housing Committee of the 28th March, 1955: "Your Committee are of opinion that the basic purpose of Exchequer and Rate subsidies is to enable local authorities to let houses at rents within the means of those for whom they were provided; that the aim should be to satisfy the principle that subsidies should not be extended to those who do not need them, and that no one in genuine need of a Council dwelling should be obliged to pay more rent for it than he can really afford. This result can be achieved by assessing the full economic" rent (or non-subsidised rent) of all houses according to their respective accommodation and amenities in such a way that the total expenditure on the Housing Revenue Account is balanced by total rent income, excluding subsidies. The subsidies could then be utilised to grant rebates to tenants who establish a need for such an allowance to be made from the full rent of their dwellings." On the 6th June, 1955 the new differential rents scheme came into rce for determining the rents for all Council owned dwellings. Allocation of New Housing. A further review of the Council's ousing situation was carried out by the Housing Management Subcommittee in May. At that date it was anticipated that apart from the one bedroom or bed sitter dwellings for the aged, the 72 houses originally earmarked to accommodate "overspill" families from the redeveloped Poet's Corner area and the 244 needed to meet existing commitments, there would be only 131 new dwellings. The Committee recommended the following allocation— (i) Tuberculous cases. (one-tenth allocation) 13 (ii) Eviction cases 5 (iii) Overcrowded families 10 36 (iv) Families to be rehoused from insanitary dwellings 20 (v) Hardship cases 5 (vi) Licensees from requisitioned properties 50 (vii) Existing housing list cases becoming eligible under " the points scheme " by reason of changed domestic circumstances 28 SUPERVISION OF OTHER PREMISES Routine visits are paid by the sanitary inspectors to such premises as factories, licensed premises, cinemas and other buildings. Factories Sanitation. Earlier legislation was largely repealed by and to a certain extent re-enacted in the Factories Act, 1937. Under this a distinction is drawn between those factories in which mechanical power is used and those where it is not. The District Council has responsibilities in regard to the cleanliness, overcrowding, temperature, ventilation and drainage of floors of those factories where mechanical power is not used. In all factories, whether or not mechanical power is used, the District Council is concerned to see that sufficient and suitable sanitary conveniences are provided, maintained and kept clean. The standard of adequacy is set out in the Sanitary Accommodation Order, 1903. District Councils are also concerned with fire escapes at factories and with basement bakehouses. The Factories Act also lays a duty on District Councils about home workers. Lists of out-workers of those engaged in certain trades have to be kept and action taken if the persons are employed in unwholesome premises. Supervision of conditions of work. The conditions of work at factories are supervised by the department of the Ministry of Labour and National Service. Under central direction the country is divided into areas for each of which a factory inspector is appointed. The office of the local inspector is 38/39 York Terrace, Regents Park, N.W.I. In each district there is the appointed factory doctor, previously known as the factory surgeon. He is usually a part-time general medical practitioner. Amongst his duties are the examination of young persons under the age of eighteen within fourteen days of their first employment to determine whether they are fit for work or fit only for some kinds of work, or fit for work only under certain conditions. He also investigates causes of notifiable industrial diseases and gassing cases, and carries out the periodical medical examination of workers engaged in the dangerous trades. The surgeon for most of this district is Dr. D.V. Morgan-Jones, 7 Welbeck Road, West Harrow; for Edgware, Stanmore and Kingsbury he is Dr. E. E. Stephens, 3 Sefton Avenue, N.W.7. At most of the factories in the district fewer than 50 persons are engaged. Of the 24 larger factories there are eleven at which over 50 but under 100 are employed, eight at which there are between 100 and 200, two engage between 200 and 500, and at three over 500 are employed. There are 525 factories or premises which are supervised by the sanitary inspectors of the district. At 74 of these mechanical power is not used and these are therefore supervised not only as regards sanittary 37 conveniences but also as to the general health provisions. To these premises 403 visits were made, with the result that 17 notices were served. 72 defects were found; of these 31 were due to want of cleanliness, 13 were in respect of sanitary conveniences (12 unsuitable or defective). Information is passed on to the local inspector of factories about matters found at these premises with which he is concerned. In the same way he draws the attention of the inspectors to points he has found which concern them. There are 252 outworkers' premises in the district. At 148 of these wearing apparel is dealt with, being either made or cleaned; at 77 Christmas crackers and Christmas stockings were made. Shops' Acts Local authorities are concerned with shops in different ways. The earliest of the Shops' Acts related more especially to the hours the shops could remain open. Later legislation dealt mainly with the hours of employment of young persons. As a sanitary authority, the Council is concerned about such matters as the ventilation and temprature of shops and the satisfactoriness of the sanitary accommodation. As an authority responsible for administering the Shops' Acts, the Council has further responsibilities about lighting, about facilities for washing and for the taking of meals. There were at the end of the year 2,353 shops in the district, an increase of five in the number at the end of the previous year. During the year 1,645 visits were paid. Most of the contraventions found were in respect of the keeping of records or of the failure to exhibit the notices required by the Shops' Acts. 413 warnings were given to traders about these contraventions. It was necessary to take summary proceedings about six offences. In each case a conviction was recorded. Such proceedings are taken only if at least two warnings have been given and ignored. It was reported last year that there had since the war been no marked tendency to return to the pre-war practice of shops being kept open late in the evenings. The introduction of commercial television has led to a number of radio/television shops keeping open after the general shops closing hour for television demonstrations. The following is an extract from a report presented to the Public Health Committee at their December meeting: "Prior to the war, with the exception of departmental stores and the small general shop found in the side road off a shopping centre, or those isolated shops remote from such centres, shops could be classified without difficulty according to the nature of the business carried on. To-day, however, shopkeepers appear to have less regard to the wellbeing of their fellow traders and will retail any line for which there is a demand. Hence the classification of shops by trades is becoming increasingly difficult. It is, for example, now possible to obtain from the dairy which at one time retailed only dairy produce such articles as biscuits, all manner of tinned goods, cakes, soft drinks and frozen vegetables and many of these commodities are also sold by the milk roundsman. The hardware store is another type of shop where tinned foodstuffs can be purchased. Toys are 38 favoured by many tobacconists and confectioners while some include in their stock popular lines of detergents and fruit. Eggs and tinned foodstuffs are found to be popular with many greengrocers while prepacked icecream can be obtained at all manner of shops. It is not suggested that this incursion of one trader into what was accepted as the province of another is wrong, but often lack of storage space for the additional stock that has to be carried creates problems and the resulting congestion tends in some cases to lower the general standard of the premises. Another change of recent years is the self-service shop and there is no doubt it has come to stay. For the customer such shops are time saving while the prepacked and wrapped form in which articles are displayed is of particular appeal to the increasing number of hygiene conscious customers." Places of Public Entertainment The Minister of Health many years ago suggested that the Sanitary Authority should arrange for all theatres, music halls, and other places of public entertainment to be visited periodically with regard to their sanitary condition. The Secretary of State also suggested that when considering an application for the grant or renewal of a licence of any theatre or other place of public entertainment, the licensing authority should require a certificate from the sanitary inspector that the condition of the building is satisfactory in sanitary and other respects. There are 76 premises in the district licensed for public entertainment. These include the Coliseum Theatre, 10 cinemas, 14 public houses, 14 church halls, 3 local authority assembly halls, 21 schools and 12 private dance and other assembly halls, clubs etc. In addition to the attention of those responsible for the maintenance of these premises being drawn to any unsatisfactory condition, reports on their state and especially that of the sanitary accommodation are forwarded each year to the Clerk of the County Council. Licensed Premises There are 56 licensed premises in the district. Although at most ot them the state and adequacy of the sanitary conveniences are quite satisfactory, at some there is room for improvement. With the easing of the difficulties arising out of the shortage of labour and materials, most of these shortcomings are being overcome. A report about the state of these premises is sent to the Clerk of the Justices each year just before the Brewster session. Keeping of Pet Animals The Pet Animals Act, 1951, requires any person keeping a shop for the sale of pet animals to be licensed with the local authority. Before granting the licence, the local authority must be satisfied that the animals will be kept in accommodation that is suitable as to size, temperature. lighting, ventilation and cleanliness; that the animals will be adequately supplied with food and drink; that they will not be sold at too early an age; that all reasonable precautions will be taken to prevent the sprea 39 among the animals of infectious disease, and that appropriate steps will be taken in the case of fire or other emergency. The number of licensed pet shops in the district is 14. All of them were inspected during the year; in every case the conditions were found to be satisfactory. Rag Flock The Rag Flock and Other Filling Materials Act, 1951, makes it necessary for any premises using filling materials to which the Act applies to be registered with the local authority. There are four premises in the district registered under this Act. The persons concerned use materials carrying the Certificate of the British Standards Institution. In no case was any dirty filling material found at the premises which were all inspected during the year. Marine Stores In 1953 the Public Health Committee became responsible for the registration of marine store dealers. This term includes the dealer in old metal which under the Old Dealers' Metal Act of 1861 includes any person dealing in, buying, and selling old metal, scrap metal, broken metal or partly manufactured metal goods or defaced or old metal goods. At the end of the year four persons were registered with the Authority. Hairdressers' and Barbers' Premises Section 282 of the Middlesex County Council Act, 1944, enables a local authority to make byelaws for the purpose of securing the cleanliness of any premises in their district used for the purpose of carrying on the business of a hairdresser or barber and of the instruments, towels, equipment and materials used in the premises. Every person using any such premises shall keep exhibited in a suitable place a copy of the byelaws. There are in the district 126 such establishments. They are visited periodically to see that the requirements of the byelaws are being complied with; at most establishments a very high standard of cleanliness is maintained. CONTROL OF NUISANCES The Sanitary Inspectors keep under supervision various buildings, water courses and parcels of land so as to be in a position to take action to prevent unsatisfactory conditions arising. Atmospheric Pollution The stimulation to the campaign for a reduction in atmospheric Pollution given by the four thousand deaths from the fog in and about London in December, 1952 has resulted in a Clean Air Bill being submitted. This bill which describes itself as a bill for making provision for abating pollution of the air follows very closely recommendations of the Beaver Report. It has four main purposes. (i) to prohibit the emission of dark smoke from chimneys, railway engines and vessels; (ii) to prohibit the installation of new industrial furnaces unless they are capable, so far as practicable, of being operated without emitting smoke; 40 (iii) to require that the emission of grit and dust from existing industrial furnaces shall be minimized, and that new industrial furnaces burning pulverized fuels or large quantities of other solid fuel shall be provided with gritarresting equipment; (iv) to empower local authorities to declare " smoke-control areas," in which the emission of smoke from chimneys will constitute an offence. It also provides for the payment of grants by the Exchequer and local authorities towards the cost of converting appliances in private dwellings in smoke control areas. The Public Health Committee when considering the Beaver Report expressed concern at the apparent shortage of high quality smokeless fuel and at the apparent lack of smokeless fuel and of coke in the North Western Metropolitan Region. The Minister of Fuel and Power stated that delays in deliveries of coke were mainly due to distribution difficulties following demands during the recent cold weather, that supplies of the privately manufactured product are insufficient to meet the requirements although arrangements are being made to increase production and that other smokeless fuels distributed by the National Coal Board are in great demand and are not sufficient for householders who prefer this fuel to coke. The Housing Committee at their meeting in January, having considered the report of the Government Committee on Air Pollution, with particular regard to certain passages in it to which attention had been drawn by the Public Health Committee relating to new Corporation dwellings resolved: that provision be made in future housing schemes for the installation of smokeless fuel appliances in Council dwellings. Rats and Mice The following is a copy of a report submitted to the Public Health Committee at their meeting in December— The Committee will know that the Council employs a number ol rodent operatives who spend their time dealing with complaints about infestation of rats and mice. Over the years the number of complaints has varied quite markedly. At times they have fallen so much that on one occasion on the resignation of one of the rodent operatives it was not felt necessary just then for his place to be filled. Any district has a number of places of special risk, being places where there is food supply and harbourage. In this district such places include those localities where house refuse has been dumped, sewers, water courses, railway lines and some blocks of properties such as shops where conditions were favourable to the rat. One by one these areas were dealt with and the point had been reached that it was hoped that rat infestation would cease to be a problem. But this happy state has never materialised. While there are now no places of major infestation (and periodically all these places of special risk are examined), the general situation remains much the same. As with the rabbit and with some pathogenic organisms it is probably too much to hope for complete eradication, but it had been hoped that it could be felt that the general level could be lowered and 41 could be kept down. Possible reasons for failure to attain this state are discussed in the following report from Mr. L. P. Watson who is the sanitary inspector concerned with the general overall control ot this infestation in this district. "Are there more rats in Harrow to-day than there were in 1943 ? The increase in the number of complaints would indicate that there are, but do statistics reveal the true position. This is difficult to answer because of the changes since 1943. When in 1943 the Council became responsible for dealing with rodents action was taken to deal with a number of large infestations: to-day there are no known reservoirs ot rats in the district, but ratepayers are invited and pressed to notify the presence of rats. In 1943 most people dealt with their own rat problems without reference to the Local Authority. Now few people attempt to deal with rats as it is widely known that the Corporation's service is free to private householders. It has been so since August 1948. A further point, though it is not suggested that it has had any marked effect upon the number of complaints is that the Prevention of Damage by Pests Act, 1949, laid a duty on persons to notify the Local Authority of the presence of rats. This point has been well publicised and it is believed that people are more rat conscious to-day than in 1943, and generally report the first signs of any infestation. Nearly all infestations to-day are small and localised and these are evenly distributed throughout the district. Rarely are colonies of more than six rats found and infestations generally are due to conditions created by householders in the vicinity. Likewise complaints from shopkeepers though not numerous are generally the result of carelessness. Accumulations of trade and garden waste and food scraps put out for birds are the main cause of these infestations. From 1943 to the end of the war many infestations were associated with backyard poultry-keeping which increased over this period as a result of rationing. Since the end of food rationing backyard-poultry keeping has decreased but unfortunately the return of food supplies to almost pre-war level has brought about a careless attitude towards food waste. The Corporation's collection of this for pig food has ceased and food is fed to domestic animals and wild birds by many householders in a most thoughtless manner. Dogs and cats are often provided with food on the paved areas immediately adjoining the backs of houses, and often near coal bunkers and garden sheds. All too infrequently is this paving swept or washed down after the meal. Wild birds are given food of all descriptions from bread crumbs to half loaves of bread, from bacon rinds to large pieces of animal fat. This is placed on the ground, on coal stores, or the roofs of sheds, etc., and in nine cases out of ten the food is just accessible to rats as it is to birds. Food waste is also apparently a popular form of compost to the amateur gardener and again sorts of food finds its way to an untidy heap hidden away at the end of the garden. In 1943 almost any form of scrap material was collected either by the Council or by the "Rag and Bone Man." Now old iron, tanks and bedsteads, car and cycle tyres, mattresses, metal containers, etc., have 42 to be disposed of in other ways. The Corporation make a charge to collect anything too large for the dustbin and the "Rag and Bone Man" is not interested in ferrous metals and often what he does take away is dumped by the wayside because there is no means of disposal through the trade. These unwanted articles together with rubbish collected by jobbing builders (this too has increased since the war with the gradual relaxation of control) finds its way together with large quantities of garden refuse onto pieces of waste land, railway embankments, unpaved secondary accesses, roadside verges and ditches, and heaps at the ends of gardens. These dumps, often in close proximity to dwellings, provide excellent harbourage for rats but cannot be dealt with under Public Health law until they actually become rat infested." Either because of a complaint from the occupier or because it was thought that the premises might be infested, visits were made to 1,676 premises during the year. 1,429 were found to be infested, though in each case infestation was found to be small and localised. Of the premises where rats were present 1,155 were private dwellings, 14 were Corporation properties and 85 were other premises. Of those at which mice were present, 126 were private dwellings and 49 other premises. In all 11,918 visits were paid by the rodent operatives. In June soil and surface-water sewers were test baited, baits being laid in 517 man holes. Baits were taken in eight. Poison was then laid down in these and in other man holes known to be infested. A second treatment carried out in November showed that 14 man-holes needed further treatment. Wasps The rodent operatives dealt with 345 nests during the year. Although the figure is much greater than the 114 of 1953 and the 278 of 1954, the wasps did not seem to have invaded kitchens to the extent they had in previous years. 43 INSPECTION AND SUPERVISION OF FOOD (A) MILK Production The number of farms in the district, nine, is the same as for the year 1954. Two of the farms produce ungraded milk which is sold wholesale; at the other seven, tuberculin tested milk is produced. Distribution and Licensing Two dairies in the district are equipped with pasteurising plants and are licensed by the Middlesex County Council. The following are particulars of the numbers of various types of licenses issued:— (1) The number of premises from which pasteurised milk was sold 49 (2) The number of premises outside Harrow from which pasteurised milk was retailed in the district 21 (3) The number of premises from which T.T. milk was sold 47 (4) The number of premises outside Harrow from which T.T. milk was retailed in the district 21 (5) The number of premises from which sterilised milk was sold 48 (6) The number of premises outside Harrow from which sterilised milk was retailed in the district 20 Supervision During the year 101 visits were paid by Sanitary Inspectors to dairies and cowsheds in the district. Sampling 51 samples of milk were taken and submitted to the Colindale Laboratory for analysis. All but one were satisfactory. The unsatisfactory sample was of milk from a tuberculin-tested herd; the cause was discovered and later samples proved satisfactory. Complaints Twelve complaints were received during the year about the condition of milk bottles. Three were about the presence of glass; six about foreign matter; and three about the dirty condition of the bottle. Summary proceedings were taken in one of the cases in which the glass was Present; warning letters were sent about the rest. Many millions of bottles circulate in the district each year; the small number of complaints received testifies to the efforts of the Dairy Companies and the co-operation they receive from those householders who play their part by rinsing the milk bottles before returning them. (B) MEAT Slaughtering During the year the slaughterhouse at the back of No. 7 Northolt Road was reconstructed. There are now four slaughterhouses in the district. At these 4,569 animals were slaughtered. Although this last slaughterhouse was brought into use only towards the end of the year, 44 the volume of killing in this district last year was greater than that carried out in the eight licensed slaughterhouses before the war. All the 4,569 animals were inspected. The entire carcasses of three out of the 794 cattle, of one of the 581 calves, of two of the 2,065 sheep and of six of the 1,129 pigs were condemend. Carcasses, parts of which were condemned numbered 129 (percentage 16) 1 (0.2), 332 (16) and 81 (7) The carcase of one animal was condemned because of tuberculosis. Some parts or organs of 50 cattle (percentage 6) were condemned for the same reason; and of 20 pigs (percentage 2). No parts or organs were condemned because of cysticercosis. Although the Slaughtering of Animals Act requires that animals must be stunned before slaughter by a mechanically operated instrument, this provision does not apply to animals slaughtered for Jewish or Mohammedan consumption. The Committee of Justice to Animals and Humane Slaughtering asked the Corporation if it would supports Bill proposed to remove this exemption. At their meeting in January the Public Health Committee had from the public health point of view no observations to offer. (C) OTHER FOODS Condemned Food During the year 9,036 lbs of food were found to be unfit and had to be destroyed. This was only about three-quarters of the amount dealt with in the previous year. The improvement was most marked in the case of fruit, fish and groceries. Complaints There were 30 complaints during the year about foreign matter in food, a reduction of 12 on the number received during 1954. 12 of the complaints related to bread, five to tinned or packet goods, five to cakes, two to sweets, two to fish, two to meat products and two to groceries. In no case was the cause of the trouble found to be due to gross negligence or failure to maintain conditions satisfactory to the preparation of food. Ice Cream The number of persons manufacturing ice cream in the district, seven, was the same as last year. At the end of the year 361 premises were registered for the retailing of ice cream, an increase of 11 on the number on the register at the 31st December, 1954. 86 samples were taken. Grades I and II are considered satisfactory, grades III and IV are not, and if repeated indicate faults in practice 15 samples were taken from local manufacturers; of these 13 were grade. and two grade II. Of the remaining 71, 62 were either grades I or II and of the nine unsatisfactory samples, only one was grade IV. When unsatisfactory reports are received, enquiries are made with a view to the cause of the trouble being ascertained and subsequent samples are taken. Preserved and Pickled Foods The Food and Drugs Act, 1938, requires premises where sausages or preserved or pickled foods are prepared or manufactured to be registered 45 by the local authority. Three applications for registration were received during the year. The number of premises now registered is 122. Registration of Hawkers The Middlesex County Council Act 1950 requires that any person not being a shopkeeper retailing any food from a cart, barrow, basket or any other receptacle shall be registered by the local authority, and that the storage premises used by him should also be registered. During the year 15 hawkers ceased to trade and their names were removed from the register; over the same period there were two new registrations. The number registered as trading in the district at the end of the year was 53. Of these 20 were trading from storage premises in Harrow and 33 from premises outside the district. (D) ADULTERATION OF FOOD The view of the Middlesex Local Government Conference Committee on the administration of the Food and Drugs Act was that it was not practicable at the present time for the County Council to delegate such functions to County District Councils; but they did request the County Council to send more frequent reports of action which they had taken under the Food and Drugs Act to County District Councils for their information. Neither the Public Health Committee nor the General Purposes Committee decided to submit any observations on this ruling. (E) HYGIENE OF FOOD Although there was no increase in the number of applications from those responsible for premises in which food is handled for the issue of the authority's certificates, this year has seen steady progress in the clean food campaign. It has all along been felt that the first requirement was for there to be a general awareness by the public that there was a problem of food hygiene and a need for action of some kind. It is on these lines that it is felt that progress is being made. During the year 73 talks were given at schools and clinics and to local associations, and a further 30 were given in the office. In addition on 13 occasions film strip demonstrations were given to those attending the ante-natal clinics. While at most of these talks and demonstrations the main topic dealt with is one of the various aspects of food hygiene or food poisoning and its prevention, the range of the talks has steadily widened and now embraces a wider field of subjects on environmental health conditions. At the annual delegate conference a health exhibition was prepared in which again special emphasis was laid on this subject. The exhibit was later shown at six local branch libraries and was seen by very large audiences. By the kindness of the management of some of the local cinemas oioured slides on food hygiene were seen by large audiences. A trial approach to school children was made when Dr. Emrys Davies of the Central Council of Health Education gave a recorded talk on the "Poison Trail " at one of the local cinemas on a Saturday morning, illustrating talk with lightning sketches. Some of these were photographed and have been made into slides which with a sound recording of the talk have been shown at many schools. 46 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease Und. lyr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 & over Total Scarlet Fever — 28 73 13 7 1 1 1 1 — — 125 Diphtheria — — — — — — — — . — — — — Pneumonia 2 5 16 3 4 2 10 10 23 13 22 110 Dysentery — 6 14 3 1 1 1 3 1 — — 30 Erysipelas — — — — — — 2 6 3 7 1 19 Meningococcal Infection 1 — — — — — — — — — — 1 Puerperal Pyrexia — — — — — — 1 — — — — 1 Ophthalmia Neonatorum — — — — — — — — — — — — Poliomyelitis, paralytic — 8 5 5 — — 4 — 2 — 1 25 Poliomyelitis, Non-paralytic — 3 6 3 — 1 5 1 — — — 19 Encephalitis, Post-infective — — — 1 — — — — — — — 1 Measles 49 1223 1790 42 9 1 5 5 — — — 3124 Whooping Cough 12 90 132 10 — — 1 1 — — — 246 Paratyphoid Fever — 2 2 1 1 — — — — — — 6 Typhoid Fever — — — — — 1 1 — — — — 2 57 Food Poisoning — 2 3 5 4 2 3 8 5 11 14 Malaria — — — — — 1 — — — — — 1 CONTROL OF INFECTIOUS DISEASES Particulars of the various steps taken to limit the spread of the infections were set out in the Annual Report for 1954. These measures include: the notification of a number of diseases; investigations made at the homes of the patients and the advice given to the mother over the precautions to be taken; the various ways in which help is given in early diagnosis of an infectious disease; the isolation of the patient, whether in hospital or at home; the exclusion from work of the contacts of patients who might be carriers; and the arrangements for disinfection both of the premises and of articles. The only change during the year in regard to notification was that by the Puerperal Pyrexia (Amendment) Regulations 1954 which came into force on the 1st March, a new form of notification was prescribed requiring the cause of the disease, if known, to be stated by the certifying practitioner. The object is to distinguish those cases in which epidemiological action might be taken. In December, 1954, the Public Health Committee agreed to provide a new disinfector and steam raising plant to be installed near the mortuary at Peel Road. At their meeting in January, 1955, the Committee decided that the best method of raising the steam would be by gas, and recommended the provision of a new disinfector and steam raising plant at an estimated cost of £3,316. DIPHTHERIA Incidence Two persons suspected to be suffering from diphtheria were remove to hospital. In neither of the cases was the diagnosis confirmed. The district has now been free from the disease for five consecutive years There had been a number of years when very few cases had Occured but it was not until 1948 that it was possible to record a year with no notifictions. Since the end of 1947 there has been two cases only, one a nasal, the other a faucial infection. 47 For the years 1916 to 1925 there were in each year some 50,000 cases of diphtheria in England and Wales, over 4,000 of these being fatal. The average incidence for the ten years 1932 to 1942 was about 55,000, of which 2,800 cases were fatal. There has been a steady fall each year since 1943 by which time the immunisation campaign was well under way. The number of deaths in any one year was below 100 for the first time in 1949; and the number of cases under a thousand for the first time in 1950. In 1954 the number of deaths attributed to diphtheria for the first time reached a single figure. Immunisation While thoughout the whole year those in touch with the parents of small children urge the advantage of protecting the child against the risk of contracting diphtheria, it has for some time been felt that the best results would be obtained by carrying out a specially intensive campaign extending over a few weeks, so that parents of small children for this period would be receiving constant urging. This campaign is now held each year in the spring so that the benefits of it can be obtained before the rising incidence of poliomyelitis in the summer months might make it desirable temporarily to discontinue the practice of immunisation. A.P.T. continues to be the preparation most used, though P.T.A.P. which is reported to be quite as effective and perhaps to be free from some of the disadvantages of A.P.T., is now available. Many of the children treated at the clinics are protected by the one preparation both against diphtheria and against whooping cough. Because the County Council has not yet adopted the principle of making arrangements available for the immunising of children against whooping cough on the same lines as they have in regard to diphtheria, it is not possible for the general medical practitioners to obtain from the Public Health Laboratories free issues of the combined preparations in the way they obtain supplies of diphtheria antigen. In spite of this, large numbers of children are being protected by their doctors by the injection of the one preparation both against diphtheria and against whooping cough. In fact it is very probable that it is the mother's fear of whooping cough and her desire to protect her child from this which results in the still large numbers of children being 8 protected against diphtheria. The very success of the diphtheria immunisation campaign in virtually eradicating the disease has, by removing the terror of the mother of this illness which she has not seen, made it the more difficult to persuade her to have the child protected, is most probable, if the single preparation did not protect against both diseases.that the proportion of those who had been treated against iphtheria would by this have fallen to an alarmingly low level. During the year 2,312 children were treated for the first time, 1,115 general medical practitioners, and 1,197 at infant welfare centres. number of births notified during the year was 2,755. It is estimated that the end of the year 59.4 per cent. of children under five years reprotected and 88 per cent. of children aged 5 to 15 years. SCARLET FEVER Today a very mild complaint, scarlet fever is one of the infections witch has shown marked variations in virulence. In the earlier part of 48 the last century, in this country it was mild in character. It then, however, passed into a phase when it had a high mortality; this lasted to towards the end of the century. This century has seen it becoming mild so that today it has a case fatality rate of 0.01. But its history in this country in the last century, its virulence in parts of Europe as recently as the nineteenthirties and the occasional limited outbreaks of very virulent nature, suggest that there is no assurance that the severe type will not return. The incidence of the disease varies markedly from one year to another. in the last twenty years the figures for this district in one year were as high as 707, in another as low as 179. Usually these variations have been in conformity to the national rates. During the last year 125 cases were notified, the smallest number in any year for the combined district. This was a rate per thousand population of 0.58; the corresponding rate for the country as a whole was 0.75. In no week in this year were more than eight notifications received. In several weeks there were none, and for three consecutive weeks from October 1st there were no notifications. The weekly notifications of cases in the first quarter were 3.5, in the second 1.8, in the third 1.5, and in the last 2.6. There were no deaths from this complaint in this last year. Although single deaths of those resident in this district were attributed to this disease in 1940 and 1949, the illness was in fact in neither of these cases contracted in this area, and it is necessary to go back to 1937 for the record of a case of scarlet fever contracted locally proving fatal. Although when infectious disease hospitals were put up, their object was the reduction in the risk of spread of some of the infectious diseases of which at that time scarlet fever was the commonest, so that half the hospital accommodation was allocated to those suffering from this disease, in point of fact in this purpose the hospitals largely failed. With the passage of time though instead of being institutions to which infectious persons were removed for isolation, they become hospitals providing the skilled medical and nursing care that those admitted needed. As scarlet fever has for so long been a mild disease, not calling for that high standard of attention that only a hospital could give, there has been a diminishing need for those suffering from scarlet fever to be removed to hospital, and in fact the position should be, and probably is becoming, that it is the only exceptional case for which admission to hospital is sought; rarely is it now required on clinical grounds. At times it necessary because the retention of the patient at home would necessitate the absence from work of a wage earner. Occasionally it is desirable because the degree of crowding in the household prevents satisfactory isolation being arranged. During the year of the 125 notified cases on 30 were removed to hospital. In all but three of these, removal was to the Hendon Isolation Hospital. There were six instances of secondary infection. In one of these the primary case was removed to hospital on the second day of but that did not prevent the onset of illness in her sister on the fourth day from the onset of the primary case and the third day from removal of that patient to hospital. In two other cases (in one of which the illness the two children was recognised at the same time) the intervals between onsets of illness were four days; in one instance, it was five days, an in 49 another six. It is probable that removal to hospital of the primary case in none of these instances would have prevented the second case succumbing. The position is different though in the remaining instance in which the primary case was nursed at home and there was an interval of 19 days before the onset of illness of the secondary case. There was one instance of simultaneous onset of two sisters. There were no return cases this year. Each year groupings of cases occur amongst the pupils of a school, sometimes in the same department and occasionally even in the same class. So very often enquiries fail to lead to the recognition of one who might be a carrier, and in due course the cases cease to occur. In the spring term 10 cases occured over a period of six weeks amongst the pupils of Harrow Weald School. In the autumn term five cases occurred amongst the pupils of Roxeth Manor Infants' School; after a period of three weeks clear of cases another case occurred in that department, followed after another clear week by another case. The occurrence of three cases in one week in the pupils of Chantry Junior School was followed in the next week by one in the infants' department, and in the following week each department had one case. SMALLPOX There are for most of the time no cases of smallpox in this country. Occasionally there are outbreaks which can be explained only by the spread from a case infected by some inanimate object. Most importations, however, are from unrecognised cases which come into the country from places abroad. Before the days of the aeroplane and because the countries in which the infection had been contracted were many days sailing away, the patient would be recognised to be suffering before he landed. Today the situation is different as air travel can result in a person who has entered the country being only in the earliest days of incubating the disease. There is then the ever present risk of the introduction of a case into the country. The extent to which this might spread depends almost entirely on the degree to which those who have been in contact with him are liable to contract the infection. This in its turn means the degree to which they are protected by vaccination carried out recently, or remotely. Although at one time it was held that vaccination carried out within a few days of exposure to infection would protect the contact against an attack, this is not the position today. Admittedly early vaccination after exposure will greatly reduce the risk and in most may avert an attack, but not necessarily in all. There is the further danger that the modified attack in a person Partially protected may be so atypical that it is not recognised in the early page, and by the time it has been recognised the contact will have been so long exposed that at that stage vaccination can do nothing to influence the development of the disease. The only measures which can give protection against the growing risk to which everyone is liable to be exposed is vaccination; and because the effects of vaccination are liable to wane, re-vaccination is desirable on at least one occasion other than the Protection given in infancy. The position about vaccination in the country as a whole is not satisfactory as only about one third of the infants are being vaccinated. In this district the position is rather more satisfactory. In 1955 1,930 D 50 persons were vaccinated against smallpox for the first time. Of these 1,499 were under one year of age and 101 were over one but under two years of age. 665 persons were re-vaccinated. 2,755 babies were born in that year. The number of vaccinations of those under one year of age was, therefore 54 per cent. of the births. Of those under one year of age who were vaccinated 623 were treated at the infant welfare centres. A boat on which there had been a person suffering from smallpox arrived at London on the 21st February. Of those on board six came to addresses in this district. They had all taken advantage of the offer to be vaccinated, and none of them had succumbed to any illness by the end of the incubation period of the disease from the time that they were last possible contacts of the patients. On another occasion a resident returned home from a stay in a part of France in which smallpox was prevalent. MALARIA Although at one time endemic in large areas in this country today malaria is endemic only in limited localities. Most of the cases notified are those who are suffering from a relapse of an infection acquired a road The one case notified this year was such an instance. ENTERIC FEVER Each year small numbers of notifications of cases of enteric infection amongst those living in this district are received. Very rarely the disease is typhoid fever; the vast majority of the cases are of paratyphoid fever, the organism nearly always being the para B type. The following are particulars of those of the district who were notified during the year to be suffering from enteric fever:— Sex Age Onset T/P.T. 1 M 3 26/2 Paratyphoid B 2 F 3 7/3 Paratyphoid B 3 F 18 18/6 Paratyphoid B Contracted out of district 4 F 22 20/6 Typhoid 5 F 7 15/6 Paratyphoid B 6 M 33 8/9 Typhoid Contracted in Spain 7 M 7 23/9 Paratyphoid 8 M 13 28/11 Paratyphoid No cases were associated with any of the others. In most, the origin of the infection was not traced. DYSENTERY The clinical diagnosis of this complaint is made on a combination of signs and symptoms of diarrhoea, fever, tenesmus and in some cases blood and mucus in the stools. It may be the result of infection by one of a variety of organisms, some of which set up a serious illness, others only a mild one. The vast majority of cases classed as dysentery which occur in this country are,the result of an infection by the sonne organism which results in a mild illness only. The main difficulty in the control of this infection is this mildness of illness in so many because some sufferers are not inconvenienced and take no special precautions although 51 they could be carriers, while many who have been infected and can infect others might have had no symptoms at all. Most of the communicable diseases with gastro-intestinal symptoms are contracted by the consumption of infected food or drink. It is probable that most of the cases of dysentery are contracted in this way,—But not all illnesses of a gastrointestinal nature are spread by this means. At times the prominent feature of influenza is gastro-enteritis, and in this case there is no reason for assuming that the infection is spread in any other than the usual way. The spread of some of these dysenteric complaints would seem to be understandable only on the assumption that the infective element passes by these means and not solely by means of food and drink. There was a sharp rise this year in the number of cases of dysentery, though again as is usually the case these figures cannot be accepted as indicating the true incidence of the complaint. In all during the year 30 notifications were received. The first three cases were two members on the staff of a day nursery, not in this district, at which there were cases of Sonne dysentery; and the younger brother of one of these, presumably infected by his older sister as were other members of the family who were not notified. On the 27th April a boy of five was notified to be suffering from Sonne dysentery. Within the next fortnight four other members of his family succumbed. On the 5th May another boy of five attending the same school fell ill. Within two weeks two other members of his family succumbed. This was the beginning of an invasion of the Cedars school which lasted throughout May and well into June. Many pupils were attacked and in many cases other members of their families succumbed. That the illnesses were associated with school attendance was supported by the fact that this school has a group of pupils from another part of the district some four miles away and some of these children were affected, but as far as is known no others in that area, except later some home contacts of the pupils of the school. On the other hand the view that the school meals probably were not responsible for the spread was supported by the fact that although many sufferers had their meals at school, large numbers did not do so and yet succumbed to the illness. Over these few weeks 24 notifications of dysentery were received relating to pupils at this school, or home contacts of these pupils where these pupils lived in the district immediately round the school, or in the other part of the area from which pupils at the school were drawn. During this same period from the same population a number of notifications of food poisoning were received. The remaining four cases occured in September, scattered in different parts of the district, in most of them salmonella organisms being recovered from the stools. On the spread of dysentery the Chief Medical Officer of the Ministry says—"The experience is that the infection is rarely conveyed by food, and that direct or indirect personal contact is mainly responsible. The danger of spread of the infections is much enhanced by the large numbers of symptomless excreters often associated with the clinical cases, not only within day nurseries, schools and elsewhere in which outbreaks occur but also in homes. This means that the home conditions as well E 52 as conditions in institutions attended by children from these homes require full attention. Good personal and environmental hygiene and in particular hand washing immediately after a visit to the toilet are of outstanding importance." FOOD POISONING There was a sharp rise in the number of notifications received this last year. The increase was contributed to by an outbreak amongst the staff and patients of two homes for old people in the district. At one. 12 patients and seven staff were affected, at the other five patients and two staff. Both establishments were associated with a general hospital from which they obtained the main meals. The infected foodstuff was meat which had been contaminated by a pickling process before it was delivered to these homes. Cl.Welchii was recovered from the faeces of some of those affected and from the pickling material. Many of the other 32 patients notified apparently contracted their infection outside the district. In January two notifications were received of members of the staff of a London hospital where there was an outbreak of food poisoning. In August a notification was received about the member of the staff of another London hospital who was similarly affected. One of the notifications in May related to a person who probably contracted the complaint in France, another in this country, In July a husband and wife were notified; infection in these cases had probably been contracted in Austria. Another couple in the same month had probably been infected while on holiday in this country, and another two had just returned from France. A child ordinarily resident in a school for the blind had been admitted to hospital for investigation of some long standing symptoms and was in June notified to be suffering from food poisoning. Another child notified in July had probably been infected while living temporarily in another part of the country. The remaining 22 cases infected presumably in this district, occurred irregularly throughout the year. In the one case in January the causative organism was S. typhimurium, as it was in the two cases in April and the one in May. One case was notified in June; in this household three other members of the family were suffering from similar symptoms, but were not notified. In July two members of the one family were notified. Three cases were notified in August. In the case of one, other members of the family were suffering from colitis. The second was a girl of 16 who had many meals outside; the infection in this case was by S. typhimurium; the third was a man of 85 infected by the same organism; this case proved fatal. The one case notified in October, also due to S. typhimurium, was possibly the result of the consumption of an infected duck egg; all other members of the family had similar symptoms although they were not notified. One case was notified in November and another in December; in this last case all other members of the family fell ill with similar symptoms at the same time. Although the number of notifications of cases of food poisoning shows no signs of falling, the fact that enquiries made at the households of the sufferers show that there are others affected who have not been notified, indicates that the number of cases actually notified is not an indication of the true incidence of the complaint. If the people in the house 53 containing a person who had been notified are not notified, it is highly probable that medical practitioners fail to notify many other cases to which they have been summoned. In addition are the many other cases there must be where the symptoms have been so slight or so evanescent that no doctor is called in. Apart from the infections at the institutions and those occurring amongst the staffs at two London hospitals, it is probable that most of these infections which were contracted in this district were the result of some failure in the standard of hygiene in the domestic kitchen. The Chief Medical Officer of the Ministry of Health in his Annual Report for 1954 refers to the measures which might be taken for the prevention of food poisoning. " Prevention of salmonella food poisoning depends on knowing more of potential sources of contamination and is a long-term problem. But in staphylococcal food poisoning and food poisoning due to Cl .Welchii enough is known to apply methods of food handling and food preparation which would immediately and substantially reduce the incidence. Rapid cooling, followed by proper refrigeration, of meat, including stews, gravies and meat pies, would almost eliminate food poisoning due to Cl.Welchii. Dealing promptly with cuts and sores, septic or other, on the hands of food handlers, and the application of a "no-touch" technique in the handling of dishes such as brawn, tongue, cold ham and boiled bacon, which favour the multiplication of staphylococci, would almost eliminate staphylococcal food poisoning. These remedies are simple and can be readily applied. From the continued high incidence of food poisoning, however, it is evident that certain caterers still find difficulty in applying them. It will be noticed that whenever an organism has been recovered from the faeces of a patient, this was S. typhimurium. This conforms to what occurs throughout the country. In 1954 out of the 3,694 instances in which the cause was found, this was salmonella infection in 3,508. In the same year processed and made-up meat (meat pies, re-heated meat, pressed beef, brawn, stews, cold meat, sausages and sandwiches) we mentioned in 68 per cent. of outbreaks traced to a single dish, These salmonellae have various origins. Duck eggs are often contaminated; the organism has been recovered from liquid and from frozen egg. It might be introduced into a butcher's shop in offal. Food Handlers who are excretors might transmit the organisms. Prevention must aim at keeping the organisms out; appreciating the difficulty of achieving absolute success in this, other measures are directed to provide conditions for the contaminated material unfavourable to the multiPlication of the organisms. In the single outbreak (where there was more than one case) in which organisms were recovered, this was Cl.Welchii (25 cases). In all 10 of the single cases where organism was recovered, this was S. typhiminimum. ERYSIPELAS Erysipelas is a disease which, although notifiable, has now little Public health significance. It no longer causes the dreaded outbreaks In institutions especially amongst patients in the surgical wards, while 54 today's methods of treatment have reduced the mortality rates of those attacked. There are, however, still some circumstances in which the disease may be dangerous, and so although for most little needs to be done, enquiries are still made at the homes of the notified cases. The most important of these conditions, perhaps, is that of an expectant mother nearing the time of her confinement being in the same house as a patient suffering from erysipelas. Each year, from 1934, the number of cases of erysipelas notified has ranged from 31 to 48. In 1955 only 19 cases were notified; in the same year the smallest number of cases of scarlet fever was notified. The cases were fairly evenly distributed over the year. Nine were females. In all but three the face was affected the site. Three of the patients were admitted to hospital. MENINGOCOCCAL INFECTION Each year a number of sporadic cases of cerebro-spinal fever occurs. In the post-war years the average figure was four. Last year the only case notified in which the diagnosis was confirmed was that of a boy of eleven weeks who fell ill in March. The transfer death returns contained particulars of two fatalities where the diagnosis of meningococcal septicaemia was made on the findings of the coroner's post-mortem examination. The first was a male of 54 who fell ill in April; the other a girl of eight months who succumbed in May. ACUTE ANTERIOR POLIOMYELITIS Although occasionally in this century there were localised outbreaks of poliomyelitis in this country, there had not before 1947 been a nationwide attack. Since the year the country has never been completely free from the infection, cases occurring even during the periods of lowest prevalence. The extent of the rise in the summer and autumn months has varied markedly. There are many who in spite of the conclusions of the statisticians feel that the prevalence of poliomyelitis is related in some way to weather conditions. It would not be a surprise to those to learn that in the year of the very fine summer that the country enjoyed, once the good weather had arrived, the incidence of poliomyelitis rose. The number of notifications in the country as a whole was 7,305. In 1947, the year of highest prevalence there were 7,766 cases. In the following year there were only 1,848, a figure which has proved to be the lowest of the years following 1947. The attack rate last year in the country as a whole was 0.16 per thousand population. The corrected figure of 44 notifications in this district last year had been exceeded only by the 57 notified in 1947. The attack rate was 0.21 per thousand population. In the country as a whole the rise in the number of cases was very much the same, except for undue prevalence in Barnsley, in the earlier part as the rise in 1954, a year of low prevalence. There was a sharp rise though in the week ending July 2nd which was perhaps associated with the beginning of the real summer weather. The peak figure(458) of notifications was reached in the week ending September 10th. From 55 then on there was almost week by week a slight fall. By contrast with other years though, there was no sudden drop in the late autumn. In fact there was as many as 259 notifications in the first week in November and it was not until the middle of December that the weekly notification figures fell to below 100. Locally the incidence was light to start with. There were no notifications at all until the first week in July. The weekly figures from then onwards were 2, 0, 2, 2, 1, 0, 3, 2, 3, 0, 1,4, 1, 1, and 2 in the week ending October, 22nd. Then at the period when it is usual for the incidence to fall, the attack rate in this district rose. In the week ending October 29th there were five notifications. In the succeeding weeks there were 3, 1 and 5 and then one in every week for the rest of the year, except that the week ending December, 24th was free. Of the notifications 25 related to paralytic and 19 to non-paralytic cases. There were 4 fatalities. The cases occurred in all parts of the district and none seemed to be associated with any other. There was no suggestion of school attendance or attendance at a nursery school having played any part in the transmission of the infection. Although it was not until 1947 that this country was attacked by a nation wide outbreak of poliomyelitis, other countries had already suffered devastating attacks. The incidence in the United States has for long been uniformly high. This would be an added reason for this country paying so much attention to efforts to prevent the complaint, endeavours which go back many years. By 1935 they had a vaccine which it was hoped would afford protection. Unfortunately, however, the use of the vaccine resulted in disaster and its further use was forbidden. Work continued to be carried out. Vaccines can be divided into the groups of the living though modified, or attenuated organisms, the other dead organisms or material from organisms. The latter type has the advantage of safety and it is on this type that most work has been done. Salk in America made a pure-culture vaccine, killed by formalin, which was free from the dangers of the older preparation. American experiments showed that it was safe and because it gave rise to the formation of the same protective substances as are found in those who have withstood a natural attack of the disease, it was considered that it would afford protection. Controlled trials in the United States and in other countries showed that the vaccine was 80 to 90 per cent. effective in preventing paralytic poliomyelitis amongst children. The National Foundation for Infantile Paralysis made sufficient vaccine available to inoculate nine million school children, the actual manufacture being carried out by a number of firms. The trial started in the early part of 1955. Unfortunately the use of the vaccine prepared at one laboratory was followed by inoculation paralysis in a number of those treated. It had been intended that a trial of the Salk vaccine should have been made in this country in 1955. In view of this occurrence in America this trial was cancelled. While it can be accepted that the vaccine will afford protection, nothing as yet is known of the duration of its effect, and it might be found that it will be necessary for repeated inoculations to be given if 56 the state of the immunity of the population is to be maintained. On the other hand even the temporary protection of large numbers of the susceptibles of the population might so lower the incidence of the infection in the summer and autumn months that the lowered prevalence would be followed by a period of absolute freedom from the disease in the winter; that is to say, large scale inoculation might bring back this country to the same state as it was in before 1947 when in the winter months there were no cases at all. In that event perhaps the pattern of incidence would revert to that of the years before 1947 in which at the most localised outbreaks occurred. Against such a reduced risk there would perhaps then not be the need to carry on with the protective measures. MEASLES Measles is an infection which characteristically in an urban community has a biennial beat. Cases build up towards the end of one year to reach a peak in the early months of the next year. From this high level maintained for a few weeks, notifications fall to virtual extinction in the early part, or the middle, of the summer. From then on the district is relatively free until the building up again towards the end of the next year. Although there is this long period of freedom from infection, this does not come out clearly in the figures of notifications, though usually the larger figures of one year contrast sharply with the smaller figures of the succeeding year. In point of fact this district has not yet acquired this typical pattern of distribution. 1954 was a year of very light incidence so that it could be expected that the district would be invaded in 1955. But the latter part of 1954 showed none of the building-up of the cases which are the usual prelude to an attack in the next year, and in fact conditions were quiet throughout January when in all there were only 34 cases. The incidence rose though in February, but more speedily in March, in the last week there being 210 notifications. There was the same number in the next week, but the highest number was the 249 in the week ending April, 16th this being the greatest number of notifications of measles in this district ever received. A sharp fall to the middle of May suggested the outbreak was over; but there was another rise to the end of the month. The same pattern was followed again, cases falling to a low level in the middle of June, but rising to 165 notifications in the week ending July, 16th. From then the fall continued to the extinction of the disease, but there was some smouldering again of cases in the autumn. Altogether the distribution throughout the district in this year was most atypical. The figures for the country as a whole were much the same—a peak in early April, a second peak a fortnight later, a fall and then a smaller peak at the end of June. In all 3,124 cases were notified. Measles now is not the dread disease it was not so long ago, Not only does it seem to be more mild in itself, but therapeutic agents are available to deal with those complications vyhich do arise, complication which at one time caused so much trouble. The fact that only three sufferers were removed to hospital is an indication of its more benign character, and also that there were no deaths from the complaint. There is no agent which can be used to bring about an active immunity and so protect a child from an attack from which most sutfer at 57 some stage of their lives. An attack can be avoided or modified by the use of gamma globulin which is obtainable from the Public Health Laboratories. Because of the limited supplies, the use of this preparation should be restricted to infants under six months of age who are exposed to the disease and whose mothers have never had measles, and to children under two years exposed to the disease who are weakly, suffering from some other illness, or are living under adverse conditions. WHOOPING COUGH Apart from three months August to October, cases of whooping cough occurred throughout the year; they were never however on any large scale. In all 246 cases were notified. The weekly notification rate for the first quarter was 10, for the second 5 and for the last quarter 1.5. This is a disease which now causes much less harm and is responsible for fewer deaths than it was up to quite recently. No patients were admitted to hospital and there were no deaths. Although there are no official arrangements for offering facilities to the public for children to be immunised against whooping cough by their own doctors in the way they are for diphtheria, many local medical practitioners have for years treated children by inoculating them with the one preparation which is aimed at protecting them against whooping cough and against diphtheria. It is known 970 children were in this way inoculated against whooping cough. This figure is probably much smaller than the actual number treated. At the infant welfare centres 1,147 children are treated with the combined preparation, so that during the year not less than 2,117 children received protective inoculations against whooping cough. The preparation used to ward off whooping cough has not the high standard of efficiency of that used against diphtheria. It is this lower efficiency which accounts for hesitancy in introducing official arrangements for protecting the children against the risk of contracting whooping cough on the same lines as those for diphtheria prevention because any relative failure might result in a loss of confidence of the public in all officially sponsored schemes and so damage the smooth-working arrangements for protecting the population against diphtheria. Some children who have been inoculated against whooping cough would seem to be given partial but not complete protection. The result is that on exposure such a child develops an atypical attack, never having the characteristic whoop, but apparently suffering from an infective attack. For that child, this attenuation of the attack is all to the good as the child is not much inconvenienced and there is no serious illness or severe complications; but from the point of view of the rest of the population the position is not so satisfactory because this child is infective and, not being incapacitated, goes about mixing with other children while suffering from what is not recognised as being an attack of whooping cough. Unless then those in the child's surroundings are protected, the complaint might well spread to a much greater extent than if that child had not received any protective inoculations. In the early stages of the diphtheria immunisation campaign it was feared that unless a substantial Proportion of the susceptibles were protected, the increased carrier rate might result in the greater spread of infection among those liable to it. 58 In point of fact nothing of that sort occurred. In the case of smallpox though there is an analogous occurrence. When a person vaccinated in infancy loses some, but not all, of his protection and is exposed to infection, he might acquire an atypical and not easily recognisable attack, one which perhaps does not make him sufficiently ill to limit his movements so that he spreads the infection. But what risk there is in the case of whooping cough is worth the taking, partly because of the very substantial proportion of children who are being inoculated and so acquire partial, if not total protection, but also because it is felt that so many mothers are having their children inoculated against whooping cough and at the same time against diphtheria which helps to prevent the proportion protected against diphtheria from falling to what might be a disturbingly low level. Two-thirds of the deaths from whooping cough occur in those under one year of age in which age group there is a fatality of 1.0 per cent. In those of one to three it is 0.1 and in those over three 0.01. These figures point to the desirability of any protection being given to those of the youngest ages. Unfortunately though it may prove that in the very young antibody response is not aroused by the present vaccine. In spite of this, large scale inoculation might be expected to bring about a fall in the incidence even amongst these babies indirectly. This is because the babies almost invariably contract their infection from an older child in the house; if this older child is rendered immune, he does not introduce infection into the home so the infant is not exposed. The highest incidence of whooping cough occurs in those of from two to four years of age, only ten per cent, of the cases occurring in those who have not reached their first birthday. PUERPERAL INFECTION The only notification of puerperal pyrexia received in 1955 related to a woman who had had a miscarriage in a hopital not in the district. On her return home she developed a raised temperature. OPHTHALMIA NEONATORUM There was no notification in 1955 of ophthalmia neonatorum amongst infants born in this district. PEMPHIGUS NEONATORUM In 1955 no cases of pemphigus neonatorum were notified in this area. NON-NOTIFIABLE INFECTIONS Knowledge of the prevalence of some of the infections which are not notifiable in this district is obtained from intimations received from the head teachers about the absence of children from school. Chicken Pox 999 intimations of chicken pox were received from the schools during the year. The greatest incidence was in the spring term, though in a number of schools infection continued in the early part of the summer term. A few schools, including even some of those affected in the spring term, were attacked again in the last term. 59 Mumps Many schools were affected by mumps in the spring term, though not heavily. In a few schools there were further cases in the summer term. During the last term of the year though, only two schools were affected, neither of which had been involved in the earlier part of the year. In all 379 intimations were received. German Measles Only 29 intimations of cases of german measles were received in the course of the year. These were almost invariably pupils at schools which the earlier ordinary type of measles was attacking. Influenza In the latter part of 1954 influenza due to Virus B prevailed in various parts of the country in the north and the west, attacking mostly school children with a mild illness which lasted a few days only. The wave passed through the country to reach London, the south east and the south by January. By then adults were being affected. This area was attacked in the latter part of January and in February. There was at this time much ill-defined illness and by the middle of February quite a number of influenzal pneumonia notifications were being received. The outbreak, however, never became serious. In all 37 notifications of influenzal pneumonia were received. 8 deaths were attributed to influenza, mostly amongst those over 55 years of age. TUBERCULOSIS Notifications Any patient notified as suffering from one of the acute notifiable conditions probably has contracted the infection about that time. Because of the very indefinite onset of the illness, this is not the case in tuberculosis; a patient recognised today to be suffering from the infection may in fact have contracted it some considerable time earlier. For this reason the notifications received in any one year do not necessarily indicate the number of persons who in fact succumbed to the disease in that year. A complication arises in the case of those who move into the district suffering from an attack which has already been recognised, the patient having in fact been notified in the other district. The notification regulations require a doctor to notify any patient suffering from a notifiable disease to the Medical Officer of Health of the district in which the patient is residing. When such a patient then moves into a new district, the doctor under whose care he comes should notify the case. This notification is new to the new district and is therefore added to the number of cases notified. Each Medical Officer of Health is required to send to the Registrar-General every week figures of the notifications received in that week. For some little time now the figures of the cases of tuberculosis notified have been included in these weekly returns. The RegistrarGeneral has asked that the numbers included in these returns should in future relate only to those cases notified for the first time. This figure for any district is that of the notifications received in that district in 60 respect of patients who are being notified for the first time not merely in that district but anywhere. Only these are now counted as the notified cases. At the same time, as all these notified persons who have been transferred from elsewhere are now living in the district, their names must be added to the register of cases which, even though it is not now accepted as an official register, is still being kept. The following table sets out the age and sex distribution of the cases notified, divided into the one group of those notified for the first time during the year and the other group of those who had previously been notified but of whom this authority became aware for the first time during the year: 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 2 - - - 1 - - - 1- 4 2 1 1 - - 1 - — 5-9 3 2 1 1 1 2 - — 10-14 2 1 - 1 1 - — 15-19 9 8 1 — 1 4 - — 20-24 15 14 2 1 7 6 - — 25-34 17 11 4 2 22 25 - — 35-44 21 9 1 — 14 4 - 1 45-54 13 7 1 - 4 2 - - 55-64 10 3 - 1 2 - - — 65 and over 10 6 — — 1 4 - 1 Totals 104 62 11 6 53 49 - 2 The combined figure of 287 compares with that of 278 for the previous year. These figures mean that every week throughout the year an average of three persons living in this district were stricken down with this complaint. It is, of course, known that tuberculosis is that much commoner amongst those living in a house where there is already a sufferer than amongst others. In fact quite a large number of new cases are found by the routine examination of the contacts of those recognised as being sufferers. When there is already a sufferer in the house whose history of illness dates back to before that of the next case occurring in the house, there is a strong suspicion that the original case was the source of infection to the other. Out of the 187 patients who apparently contracted their infection while living in this district 28 (18 males and 10 females) gave a family history of tuberculosis. In a number of cases, although the home address of the patient was in the district, it is probable that the infection was contracted outside. or that it was the condition of living outside the district that enabled a previous infection to gain the upper hand. Each year a varying number 61 of notifications is received about those in the services and also amongst those engaged in nursing. Actually this year there were only four cases. There are some trades or places of work which have an unenviable record as the employees are considered to be very liable to contract tuberculosis. Only two of the sufferers could be put in any of these categories. Poor housing conditions are thought to be an important factor the aetiology of this disease. How important it is is very difficult to assess. It can be accepted that the overcrowding of a household in which there is an infective case is a highly important factor. It was this belief, of course, that has determined the Council's policy in the generous provision it makes for the rehousing of those families which there is a member suffering from pulmonary tuberculosis. Overcrowding itself, even without there being a recognised infectious person present, may be important, as also may insanitation and poor structural conditions. What makes the importance of these factors so difficult to assess is that poor health might lead to poverty, and this in its turn can lead to bad housing; and where all these factors are present, the chief one in predisposing to tuberculosis might be not so much the poor housing as the poor health of the individual. In few of the cases notified in this district could the housing conditions be felt to be the important factor. Sometimes predisposing states seem to play an important partIn children an attack of measles or of whooping cough might be followed by the disease; in adults an attack of influenza or pneumonia. Sometimes the stress of pregnancy seems to upset the balance and allows the organism to gain the upper hand. Those suffering from diseases such as diabetes seem to be more prone than others to attack. There were few enough occasions in this year when these causes seemed to play any real part. The position would seem to be then that as a bolt from the blue in some three persons every week the disease is recognised amongst those who have not been especially exposed to infection in their homes, who are not engaged on any employment in which the risk of contracting tuberculosis is especially marked, who are not living in poor surroundings and who are not themselves poor and in whom there has been no precipitating cause just before the illness. It is known, of course, that everyone is exposed to infection, that in most this very exposure builds up a resistance to further average infection, that in many probably the organisms are dormant and might re-awaken their activity if the condition of the host is adversely affected. What is it that determines the onset in all these apparently healthy people, many living apparently healthy lives? There must, of course, be many sufferers from the disease in whom it has not been detected, and of these some will be infective. It may be that some of those in whom the disease has become manifest have succumbed because of exposure to massive infection. The various steps which are now being taken to pick out the sufferers in those who are apparently healthy, such as by the examination by the mass radiography units, should result in a decline in cases originating in that way; but n many, perhaps in most of these cases, they would not appear to have een especially heavily exposed to infection. In these it must be presumed 62 that the manifestation of the disease is the result not of especial activity or invasion by the organism, but of a decline in the resistance of the host. What this might be due to often enough is not clear. The incidence of tuberculosis fell steadily for years before the introduction of the tuberculosis service with its special measures aimed at controlling this disease. These improvements then might have followed on the general raising of the standard of living or of the hygiene of those in this country. The introduction of the specific measures aimed at the disease was followed by an accelerating fall. The position reached just before the recent war was most hopeful. The war years, however, saw a reversal in the trend, the number of notifications mounting rapidly. The cause of this rise again is not known, as in many cases those affected did not seem to have been under more stress than most of the rest of the population. Although in most the early infection of the individual is overcome so that he never succumbs to an attack or suffer from the disease, presumably many must be in a state of near balance, and while many of these never succumb, in others the disease develops because of some preceding illness. In others again perhaps there is something about their general state, inclusive mental state or condition of living which tips the scale at some stage and allows the organism to get the upper hand. Register Tuberculosis was first made notifiable by the Public Health Tuberculosis Regulations of 1912. These and those of 1921 and of 1924 were consolidated in the 1930 Regulations which governed the practice of notification and the keeping of the register until 1952. The provisions as to the register were set out in the following subparagraphs of paragraph 10 of the 1930 regulations:— (2) Every medical officer of health shall cause to be entered in a register to be kept by him for that purpose all the particulars contained in every notification received by him under these Regulations and relating to a person whose place of residence or place of destination is situate within the district for which he is medical officer of health. He shall also enter in the register particulars of any person previously notified as suffering from tuberculosis who removes into the district of which he is medical officer of health and of whose removal to that district he is informed by the medical officer of health of another district, who shall supply him with the necessary particulars for the purpose; and of any person who normally resided in the district and whose death from tuberculosis has come to his knowledge but who has not been notified to him as suffering from tuberculosis. (5) Every medical officer of health shall from time to time, but not less frequently than once in every quarter, revise the register kept by him by removing from the register— (i) the entries therein relating to notifications which have been withdrawn by or with the consent of the notifying medical practitioner on the ground that the original notification was incorrectly made; 63 (ii) the entries relating to persons who are certified by the medical practitioner in attendance to have recovered; and (iii) the entries relating to persons who to his knowledge have died, have ceased to reside permanently in the district or who, after adequate search, cannot be found resident in the district. (6) Every medical officer of health, on becoming aware that a person who has been resident in his district and who is suffering from tuberculosis has permanently changed his place of residence into some other district, shall forthwith notify the medical officer of health of that district of the case and of all relevant particulars thereof which are contained in the register of notifications kept by him. The register built up over the years in each district contained particulars of every person in that district who had been notified to the medical officer of health of that district, and particulars too of others about whom intimation had been received from the medical officers of health of other districts of the removal of those in these districts. There were two ways in which the register became inaccurate. It could be inflated by names still being on the register although the persons had removed from the district. In this area the procedure for ensuring that the register was not greatly inflated in this way, was that in October all notifications were studied. Those persons about whom any information had been received during the year, such as an intimation that they had been admitted to, or discharged from a hospital, or a report had been received from those at the chest clinic, were assumed to be still in the district, and failing any other information being received about them by the end of the year they were assumed to be in the district at the end of the year. In regard to those about whom nothing had been received during the year, enquiries were made from those at the chest clinics. In most of these cases reports would have been received that the persons were still here. Enquiries about those about whom nothing was known determined whether the names were still to remain on the register, or whether particulars were to be forwarded to other areas. The other shortcoming of the register is that it might not contain the names of those who had been notified in other districts before they came to live in a new one. If on coming to the new district the patient attended the chest clinic, or went to his doctor, the case would be made known to the medical officer of health of the new district. Also, of course, if the patient had told those at the chest clinic before removing of his intention to transfer, particulars would be forwarded. Any patient who did not inform the chest clinic, perhaps because he did not attend there and who did not go to the chest clinic in the new district, or to his doctor, might be in the new district for a long time without any intimation of this being received by the local health office, with the result that his name would not be on the tuberculosis register. With the considerable amount of movement of population now taking place, in total this could cause quite a considerable error, one which could be kept in bounds only by each area undertaking to see that its own register was correct, because checking 64 the register of one area leads to those in other districts becoming more correct. For some years it had seemed that less attention was being paid by the medical officer of health to his obligations about the tuberculosis register. The practice appeared to have been growing of those at the chest clinics passing on the clinical records of the patients to those at the clinics of the districts to which the patients were going, and this practice seemed to be replacing the intimation that the medical officer of health of the district was obliged to send to the medical officer of health of the new district of the change of residence of a patient. This was in spite of the very clear wording of sub-paragraph 6 as to the procedure. That the medical officer of health of the district to which the patient removed might ultimately obtain the necessary information from the physician at the chest clinic serving those in his area, did not excuse the non-compliance by the medical officer of health of the district from which the patient was going with the provisions of this section. The 1930 regulations were revoked by those of 1952. These say nothing about the medical officer of health keeping a register. In regard to this though Circular 6/52 accompanying the regulations says—"The new regulations no longer require a medical officer of health to keep a register of tuberculosis notifications. In the Minister's view he may naturally be expected to do so—and the Minister would urge that he should —in the same way that he keeps a record, for his own purposes and without any legal requirement, of notifications of other diseases. The provisions on this point in the 1930 regulations were necessary at that time because of the correlated requirement about supplying certain particulars to the County Medical Officer. These particulars have in practice come to be derived, for some years past, from the registers maintained at chest clinics. These remain the essential " tuberculosis registers." The register serves two purposes. Firstly it is a compilation of the known cases of the disease, something which is of importance in epidemiological enquiries. Secondly it gives a figure which can be used for statistical purposes as indicating the prevalence of the disease in the district. It has been seen that there were shortcomings in the previous register. Is the new register more satisfactory, or has it too its own shortcomings? In regard to the register being a list of names of those in the district who have been notified by interchange of information between the health offices and the clinics, the registers should be the same for the areas common to both. This proviso is added because not all of an area is necessarily served by the one clinic, while many clinics serve those living in more than one sanitary district; but even to this extent the registers will be the same only if the same rules of admissions to and removals from are complied with. Now before 1952 the registers that were kept at the chest clinics would in most cases be the working registers of clinics. Although most of those living in the areas served by the clinics would be urged to attend the clinics, or to take advantage of the home visits of the clinics staffs, there would be many who for one reason or another did not do so. It was the practice then at many chest clinics to remove from the registers the names of those persons. If nothing has been done 65 to see that this practice has been discontinued, then what is referred to as the "essential tuberculosis register" cannot be accepted as a substitute for the register kept by the medical officer of health of the sanitary district. If the totals of these figures are used as an intimation of the number of persons whose names should be on the registers according to the old standards of removal, the figures today cannot fairly be compared with those of before 1952. The figure is of still less use as an intimation of local incidence because the areas served by the clinics are not co-terminous with the sanitary 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, 1955 1,236 1,017 143 157 No. of new cases added 104 62 11 6 No. of cases other than on a Form "A" 53 49 - 2 No. of cases restored to the register 8 5 - - No. of cases removed 126 103 12 11 No. on register, December 31st, 1955 1,275 1,030 142 154 On the 252 deductions, 141 (128 pulmonary) were of persons who had left the district, 34 (33 pulmonary) were of persons who had died, 65(57 pulmonary) were of persons who had recovered, 2 (both pulmonary) were of persons in respect of whom the diagnosis had been withdrawn, and 10 (9 pulmonary) were of persons who had been lost sight of. The net increase in the number of cases on the register is 48, there being 52 more pulmonary cases and 4 fewer non-pulmonary cases. This figure compares with those of 68, 154, 160 and 183 for the four preceding years. Deaths 13 persons (8 male and 5 female) died from pulmonary tuberculosis during the year and one, a female from non-pulmonary tuberculosis. The number of deaths from tuberculosis in 1954 was 28. This infection, then, accounted for a death rate per thousand population of 0-06, and for 0-7 per cent, of the total deaths. These figures are a marked contrast to those of 0-57 and 7-1 for 1934, of those of 0-42 and 4-9 for 1948, and those of 0-15 and 1-7 for last year. Preventive Measures The specific preventive measures include those which result in the early detection of the disease in the sufferers and those which raise the resistance of the individual to give them protection against the exposure to which all are subject. Examination by the mass radiography unit is one of the means of I detection. The machine serving this district visits about once in every three years. There was no visit last year. 66 When the disease is recognised in a pupil at a school, it may be worth while examining the other pupils of the school, or of the class and possibly the teaching staff with the object of perhaps detecting amongst those contacts the source of infection, or possibly detecting in those contacts some who have contracted the infection though they are in the earliest symptomless stages. Although many such investigations have been made in the district, no case has yet been discovered by this means. Last year there was no occasion on which it was felt that there was any point in carrying out the investigation in the school attended by a child who was notified to be suffering from tuberculosis, because in this year all such children were considered to have been infective by a known source outside the school; and as they were not themselves in an infective state, they had been of no risk to their fellow pupils. A further trial of the tuberculin testing of school entrants at some of the schools was continued. Although amongst the small numbers tested the examination did result in recognition of the disease in one pupil, it did not lead to the recognition of any cases amongst the home contacts of the positive reactors. As a small child whose tuberculin reaction shows he has been exposed to infection by the tubercle bacillus has most probably been exposed to that infection in his own home, the failure to discover infectious patients amongst the home contacts does not necessarily indicate that this tuberculin testing of school entrants for this purpose has no value. On the contrary it suggests that the tests applied to those contacts who attend for examination are not sufficiently delicate. Of the active preventive measures that might be taken to raise the resistance, that most commonly used is inoculation with B.C.G. Although the Ministry of Health had previously given permission to local authorities to arrange for older school children to be treated, most authorities probably decided to wait on the findings of the Medical Research Council's enquiry into the efficacy of the practice.