Borough of Harrow Annual Report of the MEDICAL OFFICER OF HEALTH for the year 1957 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW KING AND HUTCHINGS, LTD., PRINTERS, HARROWWAND UXBRIDGE Borough of Harrow Annual Report of the MEDICAL OFFICER OF HEALTH for the year 1957 CARYL THOMAS, M.D., B.Sc., D.P.H. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 10 Deaths from Accidents 14 Cancer of the Lung 17 Coronary Thrombosis 20 General Health Services: Hospitals 23 Nursing Homes 24 Establishments for Massage and Special Treatment 25 Nursing, etc., in the Home 25 General Medical Services 26 Day Nurseries 26 Clinics and Treatment Centres 26 Provision for Special Classes of Person 29 The Aged 31 Laboratory Facilities 34 Ambulances 34 Legislation 35 Sanitary Circumstances 36 Water 36 Fluoridation 37 Drainage 38 Public Cleansing 41 Public Conveniences 42 Disposal of the Dead 43 Sanitary Inspection 44 Housing 47 Factories 58 Shops' Acts 60 Atmospheric Pollution 62 Inspection and Supervision of Food 70 Hygiene of Food 76 Health Education 77 Infectious and Other Diseases: Prevention and Control 79 Poliomyelitis 87 Tuberculosis 94 Mass X-Ray 97 B.C.G 99 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, 1 beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1957. At intervals this report deals in detail with the local services and sometimes the Minister asks for special reference to be made to certain subjects. The report which gave these full particulars was that of 1954. This report is of an interim character, detailed reference being made only to those subjects which were of special interest during the year. 1957 was in general a healthy year. The two complaints which these days fluctuate so much in incidence were not very serious, the incidence of poliomyelitis being relatively light and the outbreak of influenza which occurred towards the end of the year was mild. On top of that the weather in the colder months of the year was not particularly harsh. The 39 infant deaths yielded an infant mortality rate of only 14 0, a figure so very much less than the national rate of 23 even though this was the lowest rate ever recorded for the country as a whole. What is so striking about those infant deaths is that of the 27 deaths amongst those who failed to reach one month of age only three occurred amongst babies who had been born in the district. All the others died in the institutions outside the district in which their mothers had been confined. Once more measles and whooping cough caused no deaths. The incidence of scarlet fever was light and there were again no fatalities amongst the sufferers. There were no cases of diphtheria, this being the seventh consecutive year the district has been free from this. Once more it is possible to record a fall in the number of notifications of persons suffering from tuberculosis, a fall in the number of deaths from this disease and for the very first time a fall in the numbers of those on the tuberculosis register. The fourth chapter starting on page 44 deals especially with the work ot the Public Health Inspectors. Although the pattern of this work is changing and these days they spend less of their time in bringing about an alleviation of unsatisfactory conditions, a very important part of their duties still is to keep an eye on those matters which without such attention are liable to deteriorate. In this last year, during which there has been a shortage of staff, there have been indications of a lowering of the standard at some premises. That there should have been this deterioration in the condition of the yards of shops and even at some food establishments only emphasises the importance of the inspectors' routine work, work which is carried out unspectacularly and probably without the knowledge ot most ratepayers. As long as there is this difficulty of getting through [ns work, it is not possible to break fresh ground in such matters as e clean air campaign, at least until there is a falling off in the volume o work in connection with the issue of certificates of disrepair under the Rent Act. 6 Much of the report still deals with the communicable diseases, although these are now responsible for so very much less real illness and for fewer fatalities than even a few years ago. They cannot be ignored though, and it is inadvisable to begin to think of them as of no consequence. Scarlet fever is a disease which to-day is perhaps being treated too lightly; although to-day a complaint which is innocuous, there is always the possibility of the streptococcus which causes it reverting to a toxic strain. The position in regard to tuberculosis has steadily improved, but it is far from being completely controlled. The setback during the war years is a reminder of this. Then there is always the possibility of the appearance of what are in effect new diseases, or of major changes in already established diseases such as the invasiveness of acute poliomyelitis which occurred in 1947 and which completely altered the pattern of incidence of the disease in subsequent years. Even such a childish complaint as german measles, which had been looked on as a nuisance but little more, has been shown to be so damaging a complaint when occurring in the expectant mother. For such reasons as these, an appreciation of the communicable diseases must always be an important part of any consideration of the health services of a district. For the improvement in the position in regard to some of these infections, local authorities can claim some credit. Although part of the improvement in the position in regard to tuberculosis might be due to the fact that we are on the decline of a long-term wave of incidence, what local authorities have done to improve environmental conditions and especially housing, has undoubtedly made its contribution. Part of the post-war improvement is due to chemotherapy, but the position was improving even before the war when we had not the advantage of these preparations. For the decline of some, local authorities can claim credit as a result of a more direct attack. The outstanding instance of course is diphtheria. The exact effect of vaccination against smallpox in removing this scourge in the last century is still debated, but between improved hygiene and vaccination smallpox has been controlled. The parents in this district have responded very well to the invitation to have their 13-year-old children given B.C.G. vaccination against tuberculosis. For the high acceptance rate and the smooth running of the actual arrangements, credit is due to the head teachers of the schools who were most helpful in this as in all the other activities of the school health staff. This country was slow to embark on national arrangements for the immunising of any general body of the public, and it was only after the results of extensive trials were known that general approval was given. It has yet to be decided which is the best age to treat children. Those in favour of a younger age point to the occurrence of cases amongst those who have not reached 13. Against lowering the age is the uncertainty as yet of the duration of its protective powers. The aim is to offer this protection to those who are about to be exposed tor the first time to special risks on going out to work. Whooping cough is no longer the serious complaint of childhood it was only a short time ago. How much the active immunising of children is responsible tor this happy position is not known, but undoubtedly it has played its par Another disease in which it is hoped active immunisation will do muc to control is acute poliomyelitis. Had it not been for the altered pattern 7 of incidence of this complaint which started in 1947, and which has been seen since, perhaps little advantage would have been taken by those in this country of any facilities for immunising children against this disease, even had it been decided that they should be offered. When the disease became nation-wide in prevalence, public concern rose to a level out of all proportion to the importance of this complaint as compared with other illnesses or conditions causing deaths or disabilities. The arrangements made for immunising children against this disease have been a chapter of mis-handling and misfortune which has caused so much inconvenience to the general medical practitioners who are helping to get the population treated. Part of the report deals with some matters which are this year of special local interest. One of these is clean air. This district is fortunate in that there are few industries producing smoke, and in many houses smokeless fuel is already being consumed. It is, therefore, comparatively free from atmospheric pollution. This fact should be an incentive to action to remove what pollution there is. Many authorities have already taken steps to designate parts of their district as smoke control areas, so Harrow seems backward as it has not been in a position to do anything on these lines. This is because of shortage of staff, the result of the difficulty in filling vacancies which has been caused partly by the effect of the introduction of the new salary scales in September of last year. The surveys which are necessary to provide the information before any part of the district can be designated as a smoke control area cannot be carried out. Fortunately other measures, such as the education of the public on the general question of clean air, are not held up. A step forward in the slum clearance scheme was taken during the year when the enquiry was held into the Northolt Road clearance area proposals. Although the Minister did not confirm the Council's proposals made with a view to the redevelopment of the area, he confirmed most of the Orders involving the condemnation of the unfit houses in the locality. Apart from this large group of houses, many others have been dealt with in small groups, and by the end of the year action had been started on quite a number of houses listed in the Council's slum clearance proposals. These proposals will have to be revised, as the owners of quite numbers of houses are now deciding that it is worth their while carrying out the works necessary to make them fit for habitation. A number of subjects are mentioned, not because they are of more interest or importance here than elsewhere, nor because it is possible to do anything much about them, but because they are amongst the greatest killers, and the time must surely come when our knowledge will point to some preventive action being taken. In the case of cancer of the lung, this is partly a matter of atmospheric pollution but much more so one of cigarette smoking. The question of education of the public on cancer, not merely of cancer of the lung, is something about which a decision must soon be taken. Coronary thrombosis, that complaint which kills °ff so many in their prime and maims many more, is a subject on which much work is being done, though as yet not enough is known of its stiology to warrant advice being given suggesting marked changes in the hvmg habits of the population. The Windscale accident emphasised the 8 fact that local authorities must surely come into the picture in regard to the hazards from nuclear radiation. Consideration of the future of Local Government was taken a step forward by the issue in May, 1957, of the Government White Paper, "Functions of County Councils and County District Councils in England and Wales " (Cmd. 161), which followed the White Paper of 1956 on "Areas and Status of Local Authorities in England and Wales." The report concerned itself with certain functions, including domiciliary and certain other health and welfare services and education. In the main it was proposed that in future a population of 100,000 should normally be required for promotion to county borough status; and that the larger boroughs and urban district councils should be entrusted with the main responsibility for many of these services. But while it suggested that responsibility for some of these might be conferred outright on the district councils, some should be delegated. About delegation the report says: "It is the system which applies at present and the Government believes that it works satisfactorily where the district councils are given a large measure of independence and where they are themselves of a size and character to exercise the responsibility for the services effectively." However, none of the proposals in the main White Paper applies to the structure of government within the County of London, and it was appreciated that Middlesex presented its own difficulties. Consideration of the conditions in these districts has been referred to the Royal Commission on Local Government in Greater London with the following terms of reference: "To examine the present system and working of Local Government in the Greater London area, to recommend whether any and if so what changes in the Local Government structure and the distribution of local authority functions in the area or any part of it would better secure effective and convenient Local Government." For these purposes the area has been extended outside the Metropolitan Police District to include on the north the Borough of Watford, the Urban Districts of Chorley Wood and Rickmansworth and the Parish of Watford Rural in the Watford Rural District. Although to-day those in the Public Health Department have little direct association with the provision of such basic health services as water supply, drainage and sewage, collection and disposal of house refuse and street cleansing, much of the environmental health services is still so closely allied to these that perhaps few would contemplate their being provided by any body other than to-day's local sanitary authorities. Some of these services, though, impinge so closely on some facets of the personal health services that there is every advantage in the same body having this responsibility for providing both sets of services. There are some who, seeing the disadvantages of the tripartite arrangements for the administration ot the health services, would favour these personal services becoming the responsibility either of the hospital authorities or even of the executive councils who are responsible for the general medical practitioner services. Either method would bring those working in two out of the three divisions of these services closer together. As the remit of the Royal Commission is local government, it is unlikely that any step will be taken to move the personal health services away from being the responsibility of some local 9 authority. Whatever the White Paper might say about the Government being satisfied that delegation works satisfactorily, the position remains that an authority responsible for finance is naturally reluctant to loosen its hold on the administrative arrangements so that whatever delegation is granted is likely to be anything but unfettered. This results both in remote control and in a lessening of the responsibilities and therefore of the interests of those engaged in local administration. The authorities who are given the responsibility for maintaining these personal services should therefore be granted them as of right and not by delegation. A unit of administration to be economic and effective, must be of a minimum size. All this points, in regard to the administration of the personal health services, to the granting of powers to areas perhaps of the size of the areas into which the county of Middlesex has been divided or something smaller, with the amalgamation of certain of the existing county districts into these larger areas as fresh Local Government units. These could then become multi-purpose authorities. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Kynaston Court, Harrow Weald. 3 rdMay, 1958. 10 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population, mid-year 1957 215,000 Rateable Value (1st April, 1957) £3,881,510 Sum represented by a penny rate (1st April, 1957) £15,802 Total number of occupied houses and flats 63,912 Extracts from Vital Statistics for the Year Live Births:— Total Male Female Legitimate 2,665 1,371 1,294 Birth rate per 1,000 Illegitimate 118 59 59 population 12-9 Total 2,783 1,430 1,353 Stillbirths:— Legitimate 59 37 22 Rate per 1,000 births Illegitimate 2 1 1 21-9 Total 61 38 23 Deaths 1,937 981 956 Rate per 1,000 population 9 0 Deaths of infants under one year of age 39.0 Infant mortality rate 14.0 Legitimate infant mortality rate 14.3 Illegitimate infant mortality rate 8.5 Deaths from pregnancy and childbirth: 1 Rate per 1.000 total births 0.3 Deaths from Cancer 415 „ „ Measles 0 „ „ Whooping Cough 0 „ „ Tuberculosis 14 Population The mid-year population of the district was estimated to be 215,000. 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 mid-year 1957 figure of 215,000 being a fall of 1,200 on that of 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 846. 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. A continuation of this annual decline in the population might result in its reaching as low a figure as 200,000, one which it might perhaps have been better had it never been exceeded. For it to fall now to this level will not bring about a return to the position that would have obtained 11 had it never exceeded that figure in the first place, as so much of the then unbuilt-on land has now been developed. The following is the age distribution of the population of England and Wales in 1956 per 1,000: 0-4, 74; 5-14, 153; 15-24, 134; 25-34, 139; 35-44,142; 45-54, 143; 55-64, 110; 65-75, 74; 75-85, 35; 85 and over, 6. Births The total number of live births registered during the year was 2,783 (1,430 male and 1,353 female). Of these 118 were illegitimate, being a percentage of total births of 4-2. The numbers of live births registered in the four years from 1954 onwards were 2,721, 2,747, 2.755 and 2,791. 844 births occurred in the district (839 live, 5 stillbirths). Of this number 87 were to residents of other districts. 2,121 (2,066 live and 55 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 12-9. The local comparability factor for births is 102. The corrected birth rate was therefore 13-2; that for the country as a whole was 16-1, the highest rate since 1949. Deaths The Registrar-General arranges that the information about those who have died outside the district in which they normally reside is transferred to the Health Office of those districts. These numbers are added to the deaths of those districts, corresponding deductions being made from the deaths allocated to any district in respect of those who died in those districts, but who normally resided elsewhere. Certain types of institutions are not regarded in ordinary circumstsnces 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. 1,046 persons died in this district in 1957. This figure includes those members of the armed forces stationed here. Of these 173 were of persons who were not resident in the area. 78 deaths took place in the various hospitals and 25 in the private nursing homes. . Of the 864 deaths of the local residents which occurred outside the district, most took place in institutions, 316 being at the Edgware General Hospital. 137 deaths took place in hospitals just outside the district, including 3 in nearby isolation hospitals, and 154 in various London hospitals. 7 deaths were of infants born in hospitals outside the district. The total number of deaths was 1,937. The figure for 1955 was 1,945 and for 1956 was 1,903. The 2,094 of 1951 was the largest number of caths recorded for this district. The death rate was 8-9 per thousand population. The rates for the ast five years were 8-9, 8-7, 8-8, 8-2 and 8-8. The rate for the country as a whole was 11-5, the same as that of the two previous years. 12 Liability to death varies at different ages. Any changes in the agedistribution of a population then affect the death rate; similarly, the death rates of the sexes are not the same. To offset the effects of these variations and so produce a rate which can be compared with that of other districts, or that of the same district at other times, the Registrar-General calculates a comparative mortality index 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 1-20; the adjusted rate is 10-5, 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 11 1 Hypertension 24 33 Other tuberculosis 2 0 Other heart disease 76 175 Syphilitic disease 3 2 Other circulatory disease. 51 62 Diphtheria 0 0 Influenza 12 9 Whooping cough 0 0 Pneumonia 41 46 Meningococcal infections. 0 1 Bronchitis 59 21 Acute poliomyelitis 0 0 Other respiratory disease 10 6 Measles 0 0 Peptic ulcer 11 5 Other infective diseases 0 1 Gastritis, Enteritis 5 I 5 Cancer of stomach 26 19 Nephritis 12 Cancer of lung 80 17 Hyperplasia of prostate . 14 0 Cancer of breast 0 31 Pregnancy, etc 0 1 Cancer of uterus 0 12 Congenital malformation. 7 10 Cancer of other sites 127 113 Other diseases 56 67 Leukaemia 6 10 Motor vehicle accidents . 18 5 Diabetes 7 12 Other accidents 14 13 Vascular diseases of nervous system 90 148 Suicide 10 14 Homicide 0 2 Coronary disease 208 116 1,341 deaths were due to diseases of the circulatory system, vascular diseases of the central nervous system and to cancer, a percentage of 69 of the total deaths. The following are the numbers of persons who were of different ages at the time of death: under one year 39, over one but under five years 5, five to fourteen years 4, fifteen to twenty-four years 15, twenty-five to forty-four years 79, forty-five to sixty-four years 533, sixty-five to seventyfour years 469, seventy-five years and over 794. Of these local deaths, 59 per cent, of those of males were persons of 65 or over, 32 per cent, of 75 and over, and 85 and over 9 per cent. The corresponding figures for females were 71, 50 and 17. Of the loca residents who died last year, 46 per cent, had reached the age of 75 an 13 had reached the age of 85. There has in this century been a remarkable increase in the expectation of life. Compared with figures in 1901 to 1910 of 49 for men and 52 toi women, those for the country in 1956 were 68 and 73. This increase is largely the result of the saving of infant deaths and does not mean t a people these days are living all that much longer; in fact the expectatio of life of those of 65 has in this period increased for males by one yea only and for females by three years. 13 Infant Mortality The infant mortality rate is the ratio of the number of infant deaths under one year of age per thousand born in the year. It has for long been accepted as an index of the healthiness of a community, being influenced by so many of the factors which affect the health of the population. The marked fall in this rate, a fall from a figure of about 150 in the early years of the century to about 23 in 1957 in the country as a whole, the lowest yet reached, has been largely the result of a reduction in those deaths which occurred in those who have survived one month or even one week, a fall brought about by an improvement in environmental conditions. With the elimination of so many of these deaths, the rate is no longer the index that it was, though it is probably still true that the rates are higher in those districts where environmental conditions are not satisfactory. Most of the infant deaths were amongst those born in hospitals who had never left them. Last year 39 infants living in this district or born to mothers ordinarily resident here died under one year of age. In the same year 2,783 infants were born. The infant mortality rate therefore was 14-0. The rate for the country as a whole was 23, the lowest ever recorded. The numbers of these deaths have fallen, not steadily but in jumps. The figures for 1947 and 1948 were 92 and 93. Those in the next four years were 64, 39, 62 and 62. Then followed three years with figures of 46,46 and 49. In 1956 it rose to 59; this was due primarily to an increased number who did not survive one week, and in fact most had not left the hospitals in which they had been born. This year's figure nearly equals the lowest that had been recorded for this district, which was in 1950. But whereas in that year this was recognised as being a flash in the pan, it can be expected that this year's smaller figure is an indication of a gradual general improvement. Of these 39 deaths, 27 occurred in infants under one month old. The neo-natal rate therefore was 9-7, comprising 70 per cent, of the infant mortality rate. The mothers of all but three of these infants were confined in institutions. Ten of these babies failed to survive 24 hours. A further 11 died before they were a week old. Six of the deaths occurred in those who had survived one week but failed to reach one month of age. Three of these babies were born in hospital. The other three were the only infants amongst those who failed to reach one month of age whose mothers were confined in their own homes. All three of these deaths were the result of congenital developmental abnormalities. Of the 27 neo-natal deaths, prematurity was a factor in 12, in four of them twin pregnancies. Six fatalities were the result of congenital developmental abnormality. The number of infants who survived one month but failed to survive twelve months was 12. Of these nine failed to reach the age of three months. At this age the effect of prematurity and congenital defects is essening (only one death from developmental abnormalities), but the 1 ections (one death) are starting, and chest complaints (seven deaths) are mounting. 14 Stillbirths 61 stillbirths were registered last year. This was a rate per thousand population of 0-28 and a rate per thousand live and stillbirths of 21-4. The rate per thousand births for the country as a whole was 22-4. Of the 56 stillbirths about which particulars are known, all but five were to mothers confined in hospital. Of these five, labour was premature in two, the result of maternal toxaemia. Of the other fatalities one was due to congenital abnormalities, one to a birth injury. Of those where the mother was confined in an institution, many were premature. In six, there was no apparent cause for the premature onset of labour; in five there was premature separation of the placenta. In two, labour was prematurely induced in the interests of the mother, and in another an early caesarian section was carried out. In eleven, the infant had died before the onset of labour, the cause in six being maternal toxaemia of pregnancy, in another four some other disease of the mother, and in one the infant had some developmental abnormality. Four were one or both of twins. Three of the mothers gave a history of repeated miscarriages. A number of stillbirths were of infants who were born full time and who were alive just before the mother went into labour. In 13 there was some complication of labour, including three where the infant was post-mature, and four instances of the cord being round the neck. In three cases the mother suffered from toxaemia of pregnancy and in another from diabetes. Death 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. Four survived their first but did not reach their fifth birthdays. Of these, two were in their second, one in his fourth and one in his fifth year. One of the deaths was due to a respiratory complaint, two to congenital abnormalities and one was due to a disease. 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 the last year only one death which resulted from pregnancy or delivery, the maternal mortality rate being 0-3. This was a single girl whose death was caused by " septicaemia due to septic abortion using an instrument with intent to procure a miscarriage." Deaths from Accidents Apart from the deaths on the roads and deaths in the home, there were only ten other deaths due to accidents. These were from a variety of causes, including two from accidents on the railway and two murders. 15 Road Accidents. Despite the efforts of those concerned with road safety, the numbers of deaths due to motor vehicle accidents in England and Wales rose from 4,117 in 1952 to 4,375, 4,589, 4,923 and reached 5,036 in 1956. The local figures are too small to show any trend, those for the corresponding years being 15, 10, 15, 16 and 15, and for 1957, 23. For each of these years most of the fatalities were the result of accidents not in the district. Four of the five persons killed in the district were elderly pedestrians who were knocked down by motor vehicles. The 383 accidents on the roads in the district last year were a fall on the figure of 446 in the previous year. Of these, 268 occurred on the main roads and 115 on other roads, monthly averages of 22 and 10. Of those on the other-than-main roads, the figure was higher than the average in the three months May, June and July and also in December. Those on the main roads showed this excess from June to October and again in December. While the proportion of the less seriously injured on the two classes of road was much the same as the proportion of accidents on the two sets of roads, there was a distinctly higher proportion of serious accidents on the main roads. The person who was injured in the accident was most commonly a pedal cyclist (24-5 per cent.), next a motor cyclist (22-3 per cent.) and then a pedestrian (19 per cent.). Car passengers comprised 11-5 per cent, and car drivers 10 per cent.; pillion passengers and those on or about to board a bus were each just over 3 per cent. Accidents in the Home. The following table taken from the Annual Report of the Chief Medical Officer of the Ministry of Health for 1956 gives the age and sex distribution of the 6,908 persons who died as a result of a fatal domestic accident:— Male Female Total 0-4 374 314 688 5-14 49 59 108 15-44 219 140 359 45-64 335 379 714 65-74 401 652 1,053 75+ 1,138 2,848 3,986 2,516 4,392 6,908 More than four-fifths of these fatalities occurred at the two extremes of life, nearly 60 per cent, of them affecting persons of 75 and over, With the increase in the numbers of the elderly, the number of fatalities amongst them will increase. On the other hand there has in recent years been a gradual decline in the number of fatal accidents in children fider five years of age. Most of the local fatalities from accidents in the home were the esult of falls of the elderly which caused the deaths of three men and se!en women, a marked fall on the figures of the previous year. , he next most frequent cause was coal gas poisoning amongst the which caused the deaths of five men and of three women, more 16 than double the number of cases in 1956. To make them aware of the conditions which subject them to risk, talks are given to members of old people's clubs. It is difficult though to get into touch with the large numbers who cannot be reached by these means. Only two other accidental deaths took place at home: one was an infant of two months who died from inhalation of vomit, and another was that of a man of 60 who died as a result of burns. Increasing attention is being focussed on the way in which accidents from burns can be avoided, much research being carried out into rendering clothing material and fabrics non-inflammable. The Public Health Inspectors paid visits to premises retailing heating appliances, carrying out tests to ensure that fireguards fitted to gas fires, electric radiators and oil heaters are efficient as required by the Heating Appliance (Fireguards) Act, 1952, and the Regulations of 1953. They find that goods now in production comply with the requirements, but some of the older types of electric or gas fire do not. Some 15 defective appliances were found on the premises of second-hand dealers. In some cases the appliance was destroyed; to others guards were fitted. Circular 13/57 of the Ministry of Housing and Local Government issued 25th February, 1957, reminded local authorities of the importance of providing suitable fixtures for fireguards in Council houses. It appears that up to then few local authorities had installed such fixtures in Council houses, although surveys had shown that at least fifty per cent, of burning accidents are caused by unprotected fires. Many local authorities had taken the view that the wide variety of fireguards made it impracticable to provide fixtures; but the British Standards Institution had recently produced a specification for fireguards, incorporating fixing hooks for open fires. There is no Home Safety Committee in the Borough. For the time being the Public Health Committee has assumed responsibility for any functions of the Council in the matter. A borough which is not a health authority cannot itself set up such a committee; but it can make a grant to assist the work of an independent Home Safety Committee. The Council wished to become a registered member of the Home Safety Section of the Royal Society for the Prevention of Accidents; for a payment ot £2 2s. Od. they would have been entitled to receive helpful literature and to attend meetings on the subject. The Minister of Housing and Local Government, however, was unable to give his consent to this payment. Deaths from Suicide The 35 deaths from suicide in 1956 were exceptional, and this years figure of 24 (10 men and 14 women) is nearer the annual average of Coal gas was far and away the most common method used, being chosen by five men and six women. Poisoning was favoured more by women than by men, four as against one. On the other hand both the deaths from hanging and the one from shooting were of men. Strangely enough, the one cut-throat was of a woman. The only months in which there were no suicides were August a September, the same months of the year as in 1956; January, with four had the largest number of cases. 17 Two persons were in their thirties, seven in their forties, nine in their fifties and two each in each of the next three decades. The peak age for women in the country as a whole is 25 to 34; for men there are two peaks, 35 to 44 and 55 to 64. The commonest method used is an overdose of drugs. Deaths from Cancer Of the 1,937 deaths of residents in this district, 415 were due to cancer, this causing 24 per cent, of the deaths of males and 20 per cent, of the deaths of females. Of the 233 deaths from this cause amongst males, in 80 the site was the lung, in 26 the stomach. Of the 192 deaths amongst females, the breast was the site in 31, the stomach in 19, lungs in 17 and the uterus in 22. The 415 deaths from cancer this year were much the same as the number (420) of the previous year. Cancer of the Lung. The number of deaths from cancer of the lung is rising each year. In 1951 something over 13,000 people in this country died from it; in 1952 over 14,000, in 1953 over 15,000, in 1954 over 16,000, in 1955 over 17,000 and in 1956 it was responsible for the deaths of something over 18,000 persons. It is predicted that this figure will reach 25,000; and this is the picture wherever cigarettes are being smoked. In this country cancer of the lung causes one death every half-hour. Each year about half a million persons die in this country. Of these nearly 50,000 are due to cancer, and in about one third of these deaths in men, the site is the lung. As contrasted with the 19,118 deaths in England and Wales from this complaint in 1957, there were only 4,250 from respiratory tuberculosis. Cancer of the lung is now causing each year more than four times as many deaths as tuberculosis, and four times the number of deaths on the roads. The attention that is being paid to this subject is not merely a fad °f the statisticians. This complaint is causing the deaths of a substantial proportion of the population; and it is not a pleasant form of death. On top of that is the fact that each year the figures are rising. It has been suspected for some time that the condition of the air we breathe is one of the factors in the aetiology of the disease, suspicion tailing on such carcirogens as benzpyrene or arsenic, present in the air •n urban communities and which have their origin in the smoke from the industrial and the domestic chimney. This atmospheric pollution could account for the higher incidence of the complaint amongst those o' the same ages living in urban as compared with rural communities, and could account for the higher incidence amongst those living on the "orth-eastern side of London as compared with those living in the southwest, those on the lee-side breathing air which has been contaminated in 's passage over London. But in general the atmosphere is less polluted an it was, and yet cancer of the lung is commoner. Atmospheric Pollution, then, is not the explanation, and is suspected of being respon^ 'e perhaps at the outside for twenty per cent, of the cases. If it were very important factor, non-smokers and women would not be so relatively immune. 18 Those in certain occupations are exposed to increased risks of contracting cancer of the lung. Certain coal mines have high levels of radioactivity. Those exposed to lubricating oils and to metallic dusts and fumes and those working with tars and oils obtained by the destructive distillation of coal are more at risk. But all these comprise small numbers, and most people are not exposed in this way. While important to the individual, then, they are not of concern to the general body of the population. For some years now in other countries and in this, attention has been focussed on smoking as a factor. Many statistical enquiries have been carried out and much research into the recognition of carcinogens and the presence of carcinogens in various substances. In 1954 a Ministry of Health report indicated that: " It must be recorded as established that there is a relationship between smoking and cancer of the lung; but though there is a strong presumption that the relationship is causal, it is not a simple one." There is the complication of the effect of atmospheric pollution. There is also the higher incidence amongst those engaged in certain occupations. Then, too, there is the well-known fact that some of those who suffer from cancer of the lung have never smoked, while many heavy smokers have lived to great ages without suffering from this complaint. Of the enquiries in this country, perhaps the best known is that of Professor Bradford Hill and Dr. Doll based on the information of the smoking habits of members of the medical profession and correlated with the findings of the causes of their deaths. This enquiry showed there was a higher mortality in smokers than in non-smokers, a higher mortality in heavy smokers than in light smokers, a higher mortality in cigarette smokers than in pipe smokers, and a higher mortality in those who continued smoking than in those who gave it up. Two series of figures might run parallel, but without there necessarily being any relationship between them, either directly or indirectly. On the other hand, while there may be no direct relationship, there can be some common cause. But when the findings are broken down to the detail that they were in this report and still retain their correlation, they can only point to smoking being a factor. As the report of the Medical Research Council issued last year says: " In the opinion of the Council the most reasonable interpretation of this evidence is that the relationship is one of direct cause and effect." Those who, while not disputing the correlation of the figures, are not prepared to accept that that is the position, suggest the explanation might be either that both smoking and cancer of the lung are due to some common factor, or perhaps that the tendency to cancer of the lung might be responsible for the individual smoking. But this is not merely a matter of statistics. Recent reports are that there are at least five chemical substances in tobacco smoke known to be capable ot cancer in animals, and local application of tobacco tar can result in skin cancer in mice. Although so many people have given up smoking, there is no reduction in the consumption of tobacco. It is said that one in eight o those men who are smoking 20 cigarettes a day will develop cancel o the lung, as contrasted with a ratio of one in three hundred of nonsmokers. Without any further increase in prevalence, cancer of the lung 19 is causing one-eighteenth of the deaths of all males, one-ninth of males of 45 to 64. As yet it accounts for only one per cent, of the deaths of females. What each person will do, of course, is something for him alone to decide. The responsibility of an authority is to ensure that everyone is made aware that those who have studied the matter are satisfied that there is this relationship. Before deciding what action to take on the suggestions contained in administrative memorandum No. 55, the Public Health Committee sought information about what the County Council proposed to do. In a report to the Health Committee on the 9th July on Smoking and Cancer of the Lung, the County Medical Officer recommended:— "1.A further approach be made to youth leaders in the county offering the services of appropriate staff to attend discussion groups, etc. "2. The Education Committee be asked to appoint representatives to discuss with representatives of the Health Committee what further action can be taken in schools to prevent children smoking. "3. Other Local Health Authorities in the London Transport area be asked to consider the advisability of a joint approach being made to the London Transport Executive with a view to securing an increase in the number of non-smoking carriages in trains. "4. The Entertainments Licensing Committee be asked to appoint representatives to discuss with representatives of the Health Committee the desirability of appropriate action being taken to prohibit smoking in cinemas and theatres." The Health Committee adopted the first two recommendations but, while not dissenting from the principles underlining them, decided it would not be opportune to take action on the last two. In regard to the first recommendation, youth leaders in the county nad been approached, and arrangements were made to distribute through the schools a leaflet on smoking. As the County Council was concentrating essentially on the child and the adolescent, the Public Health Committee decided to attempt to inform the adult members of the population. To this end they arranged to exhibit posters and also arranged for the distribution of book marks at each of the local branches of the Middlesex County Council libraries. Cancer and Education of the Public. There are many varieties malignant disease. Of these some characteristically are especially malignant, running a rapidly progressive course. Then similar types of cancer of the same sites show different degrees of malignancy according 0 the age of the sufferer. It is such factors as these that upset the figures w uch in general seem to show that better results are obtained when reatment is started early rather than later. About any particular sufferer, it can be felt that the chances of being cured are diminished with each day's delay in treatment being started. While this is probably the opinion most people, yet the position is that many of those who seek medical 20 advice have to admit that they have known of the condition some time before going, and have suspected the nature of their lesion. In many cases it seems that it is this very suspicion and fear that has kept them from seeking advice. For many years now the question of the education of the public on this subject has been debated, on whether it is desirable that something should be done or whether more harm than good might result from it. If it is agreed that something should be done, the next question is what line should be followed. In January, 1957, the Central Council for Health Education helped to focus attention on the subject by arranging a one day's conference in London on " Cancer and the Education of the Public." Commenting on the fact that one of the reasons there was so little cancer education at present was that so many medical men suffer from cancer apprehension, fearing that if they spoke about cancer the public would become alarmed, one speaker said: " We must cure the doctors of this fear of frightening people." Saying that for many years the official view of the Ministry was that cancer education should not be carried out for fear of creating cancerphobia in the public, another speaker said they had not met this fear of fear in the public, and submitted that " we must create an optimistic climate of public opinion which would support cancer control as a long-term project for the public health services." The following are the views of another speaker who is engaged on cancer education, particularly on the value of disseminating information about early signs and symptoms of the disease and the need to educate people to the fact that cancer can be cured: " The impression that all one need to do to alter the public reaction to cancer was to make reliable information available and that by correcting mistaken beliefs and dispelling ignorance one might banish unreasonable fear and henceforth expect rational behaviour was not borne out by experience. An investigation amongst women in the Manchester area showed that most women who found a lump in their breast were acutely aware of the possible significance but they still delayed. There was no sign of urgency when cancer was so generally believed incurable. The dissemination of information about symptoms might have no other effect than to make people better informed but less willing to seek treatment because their deep-rooted fear of cancer remained unaffected. It resided on a deep emotional level and any claim to alleviate fear might try to influence this primitive level of thinking. It would help to promote general confidence on the value of treatment if those who were cured knew what they were cured of and could tell others about it. Statistics about cure rates offered little help, but personal testimony was helpful and impressive. Another vital requirement was to get people used to the idea of discussing cancer as freely as other serious diseases and in a manner that did not frighten so much as enlighten." Coronary Thrombosis Of the half-million deaths which occurred in 1956 in those living in England and Wales, nearly 75,000 were ascribed to the group " coronary disease, angina." This cause has accounted for steadily increasing numbers of deaths from nearly 38,000 in 1947, to nearly 55,000 in 1950, 21 to nearly 61,000 in 1953 and 74,790 in 1956. Although the local figures do not show this steady rise, remaining for most years at just under 300, the subject is one of great importance if only because, whether rising locally or not, it is accounting for one death in six. Little definite is known of its aetiology. The actual condition of acute myocardial infarction is caused by a blood clot in part of the coronary artery. The factors involved here could be the result of changes in the blood which favour clotting, or changes in the vessel walls. Up to this, most attention has been paid to the aetiology of the pathological changes occurring in the tissue walls. These days it is felt that the important factors are those which govern the thrombosis. This lesion occurs to any extent, of course, only in those who have reached a certain age; but it is now generally agreed that arterio-sclerosis is not naturally or inevitably a concomitant of ageing. It is a pathological process; and the incidence of the disease increases with age probably because the development of the lesions is slow and because such factors as hypercholesterolaemia, obesity and hypertension become more prominent with increasing age. One school of thought lays special emphasis on the importance of diet as an Etiological factor, another on the lack of exercise; a third favours stress, though this is now a diminishing number. But even where there appears to be a correlation of the incidence and sedentary occupation, this association is not necessarily one of cause and effect. It may be that both are due to some unknown third factor. Again, any association might be accounted for by genetic characteristics, the same sorts and conditions of men not seeking employment in the same kinds of jobs. Many feel that diet is important. The dietary fat is by some considered to be the most important factor, especially diets containing saturated fatty acids which lead to a greater accumulation of cholesterol in the blood than would be caused by a corresponding amount of unsaturated fats. Unprocessed vegetable fats contain more unsaturated fatty acids than most animal fats. Some see in this question of the proportion of unsaturated to saturated fatty acids a factor of importance not only in the aetiology of coronary thrombosis, but of leukaemia and cancer of the lung as well, all conditions which are increasing in incidence. Present pointers indicate that this complaint is one which arises from our eating too much, probably too much in general rather than too much of any particular food substance. A recent report of the American Nutrition Committee said: "There is not enough evidence available to permit a ngid stand on what the relationship is between nutrition, particularly the [at content of the diet, and athero-sclerosis and coronary heart disease." Existing evidence does not justify drastic changes in the amount or type of fats eaten by the general public on the premise that heart disease will be prevented thereby. (This, of course, does not apply to any particular individual.) Existing evidence is sufficient to warrant an immediate and comprehensive investigation of diet as one factor in the development of athero-sclerosis. (Others may be hereditary, sex, the anatomy of the Wood vessel wall, arterial blood pressure.) " Deaths from Infectious Diseases Infections once more accounted for few of the deaths in 1957. There were again no deaths from measles or from whooping cough, diseases 22 which in quite recent years caused so many fatalities in children; or from poliomyelitis. There were no cases of diphtheria to provide any fatalities, and scarlet fever for some years now has been of to-day's very mild variety with virtually no case mortality. The outbreak of influenza caused 21 deaths, all but seven being in persons over 65 years of age. There was a further fall in the number of deaths from tuberculosis which this year was only 14. 23 HEALTH SERVICES OF THE AREA HOSPITALS Particulars of the hospital services of the area, including details of out-patient facilities, were set out in the Annual Report of 1954. General Hospital Service. The only general hospital in the district is the Harrow Hospital at Roxeth Hill, Harrow-on-the-Hill, with some 120 beds. The hospital which serves most of the area is the Edgware General Hospital which is just outside the district on the Edgware Road. This was opened in 1927 as the Redhill Hospital, being intended to be the prototype of municipal hospitals that the legislation which was to be introduced was expected to bring into being. The hospital was taken over by the Middlesex County Council in 1930 as the Redhill County Hospital of about 200 beds. Most of the extensions planned as part of the County Council's hospital programme in 1936 were completed in 1938 and further additions were made in 1939. The County Council's planning of hospitals throughout the county did not provide for a new hospital in Harrow, but it was assumed that the large new hospital to be built in the locality to the south-west of Harrow would serve the needs of those in part of the area and would relieve the demand on some of the existing hospitals. But before that hospital was put up, the National Health Service Act had come into operation, with the result that nearly all hospitals throughout the county passed into the hands of the Minister of Health, most of them to be parcelled out amongst the fourteen Regional Hospital Boards, with other arrangements made for the administration of the teaching hospitals. Under these arrangements the Redhill County Hospital once more changed its name, becoming the Edgware General Hospital and was the largest hospital in the Hendon Group under the administration of the Hendon Group Hospital Management Committee under the North West Metropolitan Regional Hospital Board. In the meantime Charing Cross Hospital had acquired a site at Northwick Park on which was to be erected the new hospital and medical school. In anticipation of this large new hospital coming here, the Harrow Hospital and also the Wembley Hospital and the Kingsbury Maternity Hospital became contributory hospitals of the Charing Cross Hospital. The Minister of Health in 1955 made a pronouncement about future hospital developments from which it was learned that the first stage of the erection of the Charing Cross Hospital at Northwick Park was in the 1957/58 programme. Difficulties were being encountered though in progress being made because more than one authority was concerned, the Minister of Health being responsible for the hospital; but the medical school is an incorporated school of the University of London, and the policy of the University and the University Grants Committee did not favour the building of a medical school on the Northwick Park site because the site was too far from central London. The Board of Governors, anxious as they were that a start should be made on the new hospital, felt: " There can be no question of starting the new hospital until it is certain that the school will be rebuilt, if not simultaneously, then within a short space of taie after the hospital." In August it was learned that the Board of Governors of the Charing Cross Hospital had accepted in principle a 24 proposal by the Minister of Health that the hospital and its medical school should be rebuilt on the site of Fulham Hospital. The Minister of Health's proposals are that as from April 1st, 1958, Fulham General Hospital and Fulham Maternity Hospital together with the West London Hospital shall be administered by the Charing Cross Hospital Board of Governors, and that eventually Charing Cross Hospital and medical school shall be rebuilt on the Fulham Hospital site. There was no suggestion about how the additional beds for this district's needs are to be provided. Another result of this decision is that the Harrow Hospital will no longer be one of the contributory hospitals of the Charing Cross Hospital group, but will pass to the North West Metropolitan Regional Hospital Board to be one of the hospitals of the Hendon Group. The Council at its meeting in November " authorised immediate representation being made to the Minister of Health with a view to the early provision of additional hospital beds in the Borough consequent on the change in hospital policy in regard to the abandonment of the proposal that the new Charing Cross Hospital should be built at Northwick Park; and the Minister be invited to meet representatives of the Council at an early date in order fully to discuss the matter in all its aspects." From the Minister's reply it would appear that he will look to the North West Metropolitan Regional Hospital Board to provide the additional beds in place of those of which the district has been deprived. Isolation Hospital. Infectious cases are admitted to the Hendon Isolation Hospital (112 beds) in Goldhawk Avenue, Hendon. With the lessening demand for hospital beds for the infectious sick, 20 of these beds are now used for general medical patients, and another 20 for those with gynaecological conditions. Maternity Hospitals. Most of the mothers who wish to be confined in hospital are admitted to the maternity ward of the Edgware General Hospital (60 beds); or to theBushey Maternity Hospital (36 lying-in and 14 ante-natal beds) which lies just outside the northern boundary of the district and which is an annexe to the Edgware General Hospital. Just over the boundary in another direction in Wembley is the Kingsbury Maternity Hospital (56 beds) associated with the Charing Cross Group of Hospitals. Accommodation for the Aged. There are about 200 beds at the disposal of those in charge of the Geriatric Unit of the Edgware General Hospital, disposed in groups ranging from 4 to 52 in ten different places. Of these, 18 are in the Edgware General Hospital. There are 52 at the Roxbourne Hospital (the old Harrow Isolation Hospital), 35 at Oxhey Grove Hospital, 14 at the Stanmore Cottage Hospital and 23 at Orme Lodge. NURSING HOMES These are private establishments which provide accommodation for varying types of patients. Section 187 of the Public Health Act requires that these homes shall be registered. At the beginning of the year there were 15 of these homes in this district. They had a total of 193 beds, of which 16 were for maternity 25 cases. One closed in June and one had its registration amended. The number of beds at the end of year was 184, of which 13 were for maternity cases. ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT Section 355 of the Middlesex County Council Act, 1944, prohibits any person carrying on in this district an establishment for massage and special treatment without a licence from the District Council authorising him to do so. There is a saving clause for registered members of the Chartered Society of Physiotherapy and for members of the medical profession. There were 33 of these establishments at the beginning of the year. One was licensed during the year, but three discontinued. At the end of the year 31 premises were licensed. NURSING, MIDWIFERY, ETC., IN THE HOME General Nursing This is essentially a day-time service provided by a number of nurses, some whole-time, some part-time, working under the Superintendent, Mrs. Bromley. General medical practitioners get directly into touch with the nurses about the treatment of their patients. At the end of the year there were 20 whole-time nurses and 8 part-time nurses who worked mostly in the mornings, an equivalent of 25 wholetime staff. During the year they paid in all 60,268 visits. Midwifery and Maternity Nursing There are 11 midwives living in their own homes in different parts of the district whose practices are largely round their homes. The NonMedical Supervisor of the midwives is Mrs. Bromley (Tel. No. Pinner Last year the midwives attended the confinements of 659 women in their own homes, being present in 557 instances as midwives and in 102 as maternity nurses. Of these mothers confined in their own homes, 539 had the advantage of gas and air analgesia, 246 of pethidene and 120 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 should be provided for short Periods only, an increasing proportion of the time of home helps is being given to long term, including tuberculosis, cases. The average number of home helps was 2 full-time and 49 part-time, being an equivalent of 31 full-time helps. They gave help in 1,007 useholds. In 286 of these the patient helped was a maternity case, in 34 was one suffering from tuberculosis, in 446 was one suffering from an acute condition and in 241 was a long-term case. 26 GENERAL MEDICAL SERVICES The number of general medical practitioners whose practice extends to the Borough of Harrow is learned of from notifications of infectious diseases or of births. This number of 155 includes some who live outside the district though visiting homes in this area and in some cases having surgeries here. According to the return of the Middlesex Executive Council in July, 1956, 130 doctors were taking part in Harrow in the general medical service under the National Health Service Act. 87 of these also take part in the maternity services provided under the Act. DAY NURSERIES, ETC. 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. 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 Broadway Clinic, The Broadway, Wealdstone The Pavilion, Chandos Rec. Ground, Edgware Elmwood Clinic, Elmwood Avenue, Kenton The Rectory, Elstree Greenwood Hall, Rickmansworth Road, Pinner Memorial Hall, High Road, Harrow Weald The Clinic, Honeypot Lane, Stanmore The Clinic, Kenmore Road, Kenton Methodist Church Hall, Love Lane, Pinner Methodist Ch. Hall, Walton Av., S. Harrow St. Alban's Church Hall, Harrow St. Anselm's Hall, Hatch End St. George's Hall, Pinner View, Harrow St. Hilda's Hall, Northolt Road, South Harrow Spiritualist Ch. Hall, Vaughan Rd., Harrow Stanmore Park (R.A.F.) Station The Clinic, Whittlesea Road, Harrow Weald Mon. and Fri. p.m. Wed. a.m. and p.m. Thur. and Fri. p.m. Mon. and Wed. p.m. 1st and 3rd Mon. p.m. Wed. p.m. Thu. p.m. Mon. and Wed. p.m. Wed. a.m. and p.m. Fri. p.m. Thu. p.m. Thu. a.m. Thu. p.m. Tue. and Fri. p.m. Tue. and Thu. p.m. Wed. p.m. Thu. p.m. Wed. p.m. Ante-Natal Clinics The Clinic, Alexandra Avenue, South Harrow Broadway Clinic, The Broadway, Wealdstone The Pavilion, Chandos Rec. Ground, Edgware Elmwood Clinic, Elmwood Avenue, Kenton The Rectory, Elstree Memorial Hall, High Road, Harrow Weald The Clinic, Honeypot Lane, Stanmore The Clinic, Kenmore Road, Kenton 76, Marlborough Hill, Wealdstone Methodist Church Hall, Love Lane, Pinner Wed. p.m. Tue. a.m. and Thu. p.m. Fri. a.m. Tue. p.m. 1st and 3rd Mon. p.m. Tue. p.m. Tue. p.m. Fri. p.m. 2nd and 4th Mon. p.m. Mon. p.m. 27 Methodist Ch. Hall, Walton Av., 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 Alternate Thu. a.m. Spiritualist Ch. Hall, Vaughan Rd., Harrow Wed. a.m. The Clinic, Whittlesea Road, Harrow Weald Fri. p.m. Toddlers' Clinics The Clinic, Alexandra Avenue, South Harrow Mon. a.m. The Pavilion, Chandos Rec. Ground, Edgware Thu. a.m. 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 Ch. Hall, Vaughan Rd., 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 health. Since January the Family Planning Association have held a session at the Elmwood Clinic on Monday evenings, and since October a second weekly session, held on Thursday afternoons. 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 Rec. Ground, Edgware 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 hey are referred by school medical officers. Not only are those who need treatment for minor ailments seen at the clinics, but children are kept under observation for such conditions as cervical glands, cardiac murmurs, etc. Any children needing special examination, especially if these are likely to be prolonged, are referred to these clinics. Ophthalmic Clinics Sessions are held at the Honeypot Lane Clinic on Tuesday mornings, borough Hill clinic on Tuesday afternoons and Friday mornings, and 28 at the Alexandra Avenue clinic on Thursday mornings. The prescription is taken to an optician who provides the spectacles. Arrangements are made to keep those children provided with spectacles under observation. The ophthalmic surgeons at the clinic are now on the staff of the Regional Hospital Board. The deflection of a squinting eye can sometimes be straightened by exercises. An orthoptist treats children in this way at the Marlborough Hill clinic. 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. On August 1st the Ancillary Dental Workers Regulations came into force. These established a class of ancillary dental workers to be called dental hygienists who will be permitted to carry out certain dental work under the direction of a registered dentist. The General Dental Council will keep a roll of dental hygienists. Care of the Feet A limited chiropody service is provided by the local health authority for children attending maintained schools, for nursing and expectant 29 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 PERSON The Deprived Child The County Council as the local authority under the Children's Act has a duty to take into care children under the age of seventeen who are without parents or have been lost, or abandoned by, or are living away from their parents or when their parents are unable to take care of them, and the intervention of the 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 the authority may assume parental rights of a child. It may also act as a fit person under the Children and Young Persons Act, 1953, when the Court commits a child to their care. It has a further responsibility for the supervision of children who are maintained apart from their parents for reward. The Children's Officer of the Middlesex County Council is Miss J. Rowell, of 10, Great George Street, S.W.1 (Tel. No. Trafalgar 7799). In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at Kynaston Court. The Mentally Ill 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 Treatment 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. J. Pedel, and other officers, work at 249, Willesden Lane, N.W.2 (Tel No. Willesden 6181). Persons in Need of Care and Attention The Welfare Department of the County Council deals with three distinct classes of person. It has a duty to provide living accommodation for persons who by reason of age, infirmity or other circumstances are in need of care and attention not otherwise available to them. Those in this group are distinguished from those others needing care and attention, but who are the responsibility of the hospital authority by their not 30 requiring medical or nursing care or attention. They are mostly elderly persons who are not suffering from any physical ailment or disability but who cannot manage by themselves in their own homes. The welfare authority helps such persons by arranging their admission to some of their homes. The County Council has over the years acquired premises for this use. Recently they have had to call a halt to expansion. Enforced Removal. The sanitary authorities have powers under Section 47 of the National Assistance Act, 1948, to move to suitable premises persons who (a) are suffering from grave chronic diseases 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 others proper care and attention. 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. Laundry Service. One of the big problems arising from the care of some who ought really to be in hospital or in an institution but who cannot be admitted there and therefore have to remain at home is the soiling of the bedding and the clothing of the incontinent. This is more particularly a problem of the aged but is not confined to them. There are difficulties in such persons being helped. Local sanitary authorities have very limited powers given them by Section 84 of the Public Health Act, 1936, which authorises authorities to cause articles to be cleansed in certain circumstances. The Hendon Group Hospital Management Committee agreed to arrange for the actual work of treating the articles of clothing to be done if the sanitary authority would meet the cost. The Harrow Council agreed to this within the limit of their powers as to the type of case to be helped. For the few who can be helped in this way, the help is really substantial. The arrangements which started in 1954 have worked smoothly. At the beginning of the year 8 persons were being helped. There were during the year 12 new cases. Because of death or removal from the district the number provided with help at the end of the year was 10. The period any patient had the help ranged from two weeks to three years. A person once helped might not need that help to be continued because he has been admitted to hospital or has died. The average cost per week of each person being helped is about 3s. The Welfare Department has two other main responsibilities apart from that of providing residential accommodation for some classes or person. One is to provide temporary accommodation for persons who are in urgent need of it. The other is to provide for the welfare of persons who are blind, deaf and dumb and of other persons who are substantially or permanently handicapped by illness, injury, congenital deformity or other such disability as may be prescribed by the Minister of Health. For the administration of the welfare service, the county is divide into the same ten areas as for the County Council's functions under Part III of the National Health Service Act. Acting under the supervision 31 of the Chief Welfare Officer for the county, there is in each area a Welfare Officer. The one for this district is Mr. H. G. Plummer, Kynaston Court, Boxtree Road, Harrow Weald. The Aged In the fifteen years 1896-1910 there was an association of a relatively high birth rate and a large population which gave a large number of births for each of those years, something over 900,000 annually. It is the survivors of these large numbers of babies born who are now swelling the numbers of the elderly and will continue to do so for a number of years. It is, of course, only a small proportion of these elderly persons who need to be helped. Even of those needing any kind of assistance, most can with some form of help manage in their own homes. There is a proportion, though, who need care and attention. Of those in this group, those who are merely frail can be distinguished from those needing medical or nursing care and attention. The latter are the responsibility of the hospital boards and in this district most whose needs cannot be met at home are dealt with by the staff of the Edgware General Hospital, where there is a Geriatric Officer (Dr. Raphael, Tel. No. Edgware 2381) whose prime concern is for these people. The procedure is that the patient's own doctor gets into touch with the hospital about admission. The patients may be admitted for longer or shorter periods to beds in the Edgware General Hospital or to such establishments as the Roxbourne Hospital. It is the responsibility of the Welfare Department of the County Council to look after the interests of those who, while not needing medical or nursing care and attention, nevertheless need care and attention because they cannot look after themselves, or have no one to look after them. Those needing this sort of help are admitted to one of the various homes provided by the Welfare Department of the County Council. Whichever of these two categories an elderly person falls into, he can be helped only by admission to an institution. The difficulty in helping them is that neither side has sufficient beds to meet the demands. There has, it seems, at times been a difficulty in deciding where the responsibility lies for helping a person. The Minister of Health has carried out a survey of the facilities available to the chronic sick, particularly the aged chronic sick and infirm, and he has issued circular 14/57 to local health authorities about local authority services for the chronic sick and infirm, and circular H.M.(57)86 to hospital authorities on the geriatric services and the care of the chronic sick. The circular to the hospital authorities sets out the division of responsibility:— "Responsibility for the care of the chronic sick and the elderly is shared by a number of statutory authorities: "(a) the hospital authorities, who are responsible for providing outpatient and in-patient hospital and specialist services and, where necessary, consultations with specialists in the patient's own home; {b) the local authorities, who, in their health capacity, provide home nursing, domestic help, health visitors and other domiciliary services; and in their welfare capacity, provide residential 32 accommodation and certain domiciliary services under the National Assistance Act; and "(c) the Executive Councils, who are responsible for the general practitioner service." A circular to local health authorities defines their responsibilities:— "Apart from the active elderly person who is in need of residential care and who is clearly the responsibility of the welfare authority, the latter's responsibility also extends to the following: "(i) Care of the otherwise active resident in the welfare home during minor illnesses which may well involve a short period in bed. "(ii) Care of the infirm (including the senile) who may need help in dressing, toilet, etc., and may need to live on the ground floor because they cannot manage stairs, and may spend part of the day in bed (or longer periods in bad weather). "(iii) Care of those elderly persons in a welfare home who have to take to bed and are not expected to live more than a few weeks (or exceptionally months) and who would, if in their own homes, stay there because they cannot benefit from treatment or nursing care beyond what can be given at home and whose removal to hospital away from their familiar surroundings and attendants would be felt to be inhumane. "All these are persons for whom any necessary nursing care would be given by relatives, etc., with the help or advice of the home nurse if they were living in their own homes. In welfare homes, that care should be given by attendants, assisted or advised by the visiting home nurse in the small welfare home, or by a small staff with nursing qualifications or experience in the larger homes." The responsibility of the hospital authorities is set out:— "Apart from the acute sick and others needing active treatment, who are clearly the responsibility of the hospital authority, the latter's responsibility also extends to the following: "(i) Care of the chronic bedfast who may need little or no medical treatment but do require prolonged nursing care over months or years. "(ii) Convalescent care of the elderly sick who have completed active treatment but are not yet ready for discharge to their own homes or to welfare homes. "(iii) Care of the senile confused or disturbed patient who is, owing to his mental condition, unfit to live a normal community life in a welfare home. It is not regarded as the responsibility of the hospital authority to give all the medical or nursing care needed by an old person, however minor the illness or however short the stay in bed; nor to admit all those who need nursing care because they are entering upon the last stage o their lives." This circular then says: "The Minister has no doubt that provide it is recognised by local authorities and hospital authorities alike that one 33 or other of them must accept the responsibility and that the paramount consideration in deciding this must be the interests of the person requiring the service, they will be able between them to settle the occasional case of difficulty." Apart from the small numbers who need special help in these ways, there are larger numbers with some special need. This may be housing or feeding or the need for companionship. Housing. An increasing proportion of housing accommodation of a type suitable for their special needs is being made available for the elderly. This is not only a kindness to those for whom they are intended, but is a contribution to the relief of the housing problem as the larger accommodation in which they live becomes available for some other family. The Harrow Housing Society provides accommodation for a number of elderly at Pinner House, Church Lane, Pinner. Feeding. Some people can be assured of a satisfactory meal on at least some days of the week in one of two ways. The one is the Luncheon Club held at the Assembly Hall in North Harrow and at Belmont. The other is the Meals on Wheels Service organised by the W.V.S. by which meals are taken to some elderly persons confined to their homes. During the year the London Area Mobile Physiotherapy Service Ltd., which benefited from the funds of the Greater Harrow District Nursing Association, gave a van to the Harrow Old People's Welfare Committee to be used for this purpose so greater numbers can now benefit from these arrangements. Companionship. This is what so many of the elderly need. Some obtain it by becoming members of the Evergreen Clubs run by the British Red Cross Society or of the Darby and Joan Clubs provided by the W.V.S. Another method is by the Home Visiting service arranged by the Co-ordinating Officer of the Harrow Old People's Welfare Committee. Chiropody. In 1956 the Council sought permission of the Minister of Housing and Local Government to make a grant under Section 136 of the Local Government Act, 1948, of £100 per annum to the Harrow Old People's Welfare Committee for the provision, in co-operation with the Harrow branch of the British Red Cross Society, of a chiropody service for needy old people in the borough. Although the Minister could not see his way to give permission to this grant being made, it could be provided under Section 31 of the National Assistance Act, 1948, and at their meeting in June the Council authorised such a grant being made. A Clinic for the Aged. In November the County Council submitted to the Minister of Health an application to modify their existing proposals under Section 28 of the National Health Service Act, 1946, relating to the prevention of illness, care and after-care by the addition of the following new proposal regarding special clinics for the elderly: The County Council will provide for one year as an experiment in Preventive medicine a special clinic for the elderly at which they can be medically examined and be given general health education, particularly in regard to diet, and if proved satisfactory will provide such clinics where considered necessary." 34 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 hæmolytic streptococcus. 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 be 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 foodstuff considered possibly to have been the source of food poisoning. The staff of the laboratory also carry out investigations in the field in various outbreaks, however spread. Another service provided by the laboratory is the issue of certain preparations such as lymph for vaccination against smallpox, and antigens for the immunisation of the population against diphtheria. The clinical material is collected each day by a van from the laboratory calling about mid-day at the Harrow Hospital, "Kynaston Court," and the Central Fire Station, Pinner. The following is a summary of the examinations of material from this district, carried out during the year: nose and throat swabs 119, faeces 337, sputum 10, miscellaneous 4. AMBULANCE SERVICE Although the County Council decided that the Fire and Ambulance Service should be run as one combined service, the combination of the two services is limited to organisation and administration. Fire appliances are manned by firemen 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, made by dialling 999. The County Council development plan provides for the building often 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). 35 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. LEGISLATION Housing Act, 1957. The Housing Act, 1957, which came into force in September, consolidated the provisions relating to the Housing Act, 1936, the Housing (Financial and Miscellaneous Provisions) Act, 1946, the Housing Act, 1949, the Housing Act, 1952, the Local Government (Miscellaneous Provisions) Act, 1953, the Housing Repairs and Rents Act, 1954, and the Slum Clearance (Compensation) Act, 1956. See page 47. Rent Act, 1957. See page 49. Agricultural (Safety, Health and Welfare Provisions) Act, 1956. This Act is based on the recommendations of the Gower Committee on health, welfare and safety in non-industrial employment. The only responsibility imposed on local authorities is to ensure compliance with the requirement that workers employed on an agricultural unit must be provided with suitable and sufficient sanitary conveniences. Thermal Insulation (Industrial Building) Act, 1957. The object of this Act which came into force in July is to secure greater efficiency in the use of fuel; it provides for the compulsory insulation of new factories and extensions to existing factories begun on January 1st, 1959. 36 SANITARY CIRCUMSTANCES OF THE AREA WATER Supply. Almost the whole of the area obtains its water from Colne Valley Water Company, coming from wells supplied by gathering grounds in the Chilterns. Full particulars of the places at which the water is collected and details of the purification processes carried out were set out in the Annual Report for 1954. Safety. Responsibility for the wholesomeness of the water supply rests with the Water Company. Following the outbreak of typhoid fever in Croydon some years before the war, the result of pollution of the town's water supply, responsibility for ascertaining the wholesomeness of the water supplies in their districts was placed on District Councils by Section 111 of the Public Health Act, 1936. To this end the Council instructed that samples of water be submitted periodically for chemical and bacteriological analysis. Apart from these routine analyses, samples are submitted for analysis of water collected from houses in which there are persons suffering from complaints which might have been Water borne. Particulars of these cases are passed by the Public Health Department to the Water Company. The following is a summary of the chemical analysis of a sample submitted in April (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. Nitrite Nitrogen: less than 0.01. Ammoniacal Nitrogen: 0.021. Oxygen absorbed: 0.35. Albuminoid Nitrogen: nil. 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 December, is typical of other reports:— Plate count. Yeastrel agar 2 days anaerobically: under 1 per ml. Probable number of coliform bacilli: MacConkey 2 days 37°: not found. Probable number of fæcal coli: not found. Water Company's Bye-Laws. The Colne Valley Water Company during the year modified their bye-laws which deal with the measures tor preventing waste, mis-use or contamination of water, etc., to ensure the greater protection of water fittings from the effects of frost. The new bye-law reads: That so far as reasonably practicable, every water fitting inside a building shall be so placed as not to render it liable to damage by frost; and where a fitting, either inside or outside a building, is placed 37 so as to render it liable to damage by frost, it shall be reasonably protected from such damage. Fluoridation of Water Supplies. Most of the earlier work on this subject was carried out in America where quite a proportion of the water supplies now have fluoride added to them. The United Kingdom Commission reported their findings of what was being done there in 1953. More recently the practice has become widespread. Whenever an enquiry is held into the subject, the findings are that fluoridation, while diminishing the incidence of caries in those taking the treated water, causes no illeffects and has no disadvantages. On evidence based on hundreds of controlled programmes in seventeen countries, some of which have been in progress for more than twelve years, the decision of the Committee on Water Fluoridation called together by the World Health Organisation in 1957, was that "the effectiveness, safety and practicability of fluoridation as a means of preventing dental caries, one of the most prevalent and widespread diseases of the world, is now established. The prevalence of dental caries in the permanent teeth decreased by 60 per cent., in the milk teeth by 50-60 per cent.; and in adults the prevalence of caries was only one-third as much as in similar groups in fluoride-free areas. (This effect on the teeth of adults would be due to exposure to fluoride during the time of tooth formation.) The results demonstrated that the use of drinking water containing one part per million fluoride produced identical dental and general effects whether the fluoride occurs naturally or is added by mechanical means." Last year the Commission of Inquiry on the Fluoridation of Public Water Supplies in New Zealand published its report. Their findings, too, point to the advantages of the process in reducing the incidence of dental caries, and is also reassuring about the absence of ill-effects. Part of the opposition to the process is based on the alleged interference with the rights of the individual. On this point the report says: " The issue concerning rights of individuals has practical importance only after a decision is made—(1) that fluoridation is a desirable process, (2) that the benefits of fluoridation cannot effectively be made available by alternative means, and (3) that it is completely safe. Since it accepted these three postulates as proved, it was unable to find itself in favour of any of the objections based on 'threat to freedom,' and its general conclusion was ' that no question of personal liberty arises in regard to fluoridation.' " The present trials in the country are limited to four districts, Andover, a part of Anglesey, Kilmarnock and Watford. For each of these fluoridation areas, there is a control area. If the intention is that nothing further shall be done until these trials have shown that those in this country can benefit from the drinking water being treated in this way just as have those in some countries abroad, it may be that public opinion will make itself felt before this. The dosage usually recommended is one part per million. The natural content of the water distributed in this district by the Colne Valley Water Company varies. That sent into supply from the Company's Ruislip Common pumping station contains 0.6 to 0.8 p.p.m. That from the arrow pumping station at Bessborough Road contains about 1.0 p.p.m.; 38 but this station is seldom used. Water supplied from the Company's other pumping stations contains only a trace of fluorides, a concentration of the order of 0.1 p.p.m. Analysis of samples collected in different parts of the district showed that in one part six out of twenty samples had a fluoride content of 0.4 to 0.7 p.p.m. In another area two samples out of seventeen had 0.3 p.p.m. In all others, as in every sample from the Harrow part of the district, fluoride could not be detected. Occasionally the Company takes water in bulk from another Water Company, but this water contains either no fluoride at all or only the smallest traces of under 0.1 p.p.m. DRAINAGE AND SEWAGE DISPOSAL The soil sewage from this district flows to the West Middlesex Drainage Works at Mogden. Surface water finds its way out of the district by the various water courses. The Annual Report for 1954 set out the arrangements for the disposal and treatment of the sewage of the district and the drainage. Soil Drainage. In August, 1955, the Council authorised the invitation of tenders for the execution of the works involved in the Pinner relief soil sewer scheme designed to relieve the main sewers serving Pinner which have become overloaded because of the development which has taken place in the district since the war. The work started in May, 1956; the contract period is two years. The new sewer which will be two miles long starts in Paines Lane, runs along Barrowpoint Avenue, Avenue Road and Love Lane, through Bridge Street and Marsh Road, then along Eastcote Road and Cannon Lane to discharge into the existing trunk sewer south of the old sewage farm. The sewer varies in diameter from 27 in. in Paines Lane to the 42 in. in Cannon Lane. When this work is completed, it is anticipated the pollution of the River Pinn will be lessened, and also the flooding in certain parts of Pinner. The Minister of Housing and Local Government intimated he would be prepared to consider a scheme for the construction of a new deep soil sewer to relieve the present overloaded Wealdstone sewerage system. Properties not connected to the Main Drainage System. Of the 64,000 units of accommodation in the Borough, the drains of all but 42 are connected to the general sewerage system. Those not so connected discharge either into cess-pools or to small treatment plants. Nearly all of these are in the northern part of the district. Since the war there has been some reduction in the number of these properties. The unsatisfactory conditions caused by the overflowing of cess-pools and inefficient disposal plants of a group of properties, including The City Cottages at Old Redding, led to some properties being connected to the sewer. Other properties were drained into the soil sewer when it was extended along Oxhey Lane. Sewage Disposal at the Coast. The problem which a district such as this is not faced with, but which is of concern to many districts bordering or near the sea, is that of pollution of the sea water by sewage. This is a matter which is raised periodically more particularly because of the 39 risk of bathers contracting infection from water containing typhoid organisms. This last summer a larger and more general agitation was aroused because it was being appreciated that the virus of poliomyelitis was excreted in the stools not merely of patients but of apparently healthy people. The suggestion was submitted that this source of infection peculiar to these coast towns might account for the increased incidence of poliomyelitis which occurs in the late summer and early autumn months at such places. The official attitude on the matter is set out in a reply given by the Minister of Housing and Local Government to a question about what steps were being taken to reduce the pollution of beaches round the coast by sewage: " Providing that the siting and design of the outfalls were such as to ensure that the sewage was carried out to the open sea and not along the coast, the discharge of sewage into the sea was not necessarily objectionable and indeed was often an efficient and economical method of disposal. Where nuisance was caused, as had happened with some of the older outfalls, it was for the local authorities concerned to provide a remedy. They were well aware of their responsibilities in the matter and a number of schemes in coastal areas had been carried out in recent years or were in preparation to improve outfalls or to provide preliminary treatment or both." Soiling of Railway Tracks. A related subject and one in which this district, because of its many railway lines, is more immediately interested and one which is raised at intervals is the discharge of effluent from railway trains on to the tracks. In a reply to a question on what extent discharge from trains was contributing to the spread of poliomyelitis or other infections, the Minister of Health said he was advised that study of the location and environmental circumstances of notified cases of poliomyelitis afforded no support for the view that effluents from railway trains was a determining factor in the incidence or transmission of the disease, and that there was no evidence of other infections being attributable to this cause. On another occasion the Minister of Transport and Civil Aviation replied that an expert committee set up by the British Transport Commission confirmed the view taken by the European and American Railway Administration that there is no practical alternative to the present method of disposal. Blocked Drains. Section 38 (1) of the Middlesex County Council Act, 1956, provides that a notice may be served by the Medical Officer of Health or a Public Health Inspector upon the owner or occupier of any premises at which a drain, private sewer, water closet or soil pipe is stopped up, requiring him to remedy the defect within 48 hours. Section 38 (2) gives powers to the authority to do the work themselves in default. The Public Health Committee at their February meeting authorised "the Chairman, if he should see fit, to approve the carrying out of work under Section 38 of the Middlesex County Council Act, 1956, in urgent cases, any such action to be reported to the Committee at their next meeting for confirmation." Flooding. The development of Paines Close was followed by complaints of flooding received from those in Paines Lane and adjoining 40 properties. The remedy was the construction of 70 yards of surface water sewer and a new manhole in Paines Lane. The River Pinn. Particularly during hot weather, complaints are received from those living nearby of the condition of the river and of smells. The Pinn is the natural drainage channel for much of Pinner and Hatch End. For most of its length it lies within the catchment area of the River Thames above Teddington Lock. By an order made in 1937, under the Land Drainage Act, 1930, the Thames Conservancy Board exercises their powers in regard only to certain parts of the river; they have not assumed control for the culverted sections. Under the Thames Conservancy Act, 1932, as amended in 1950, the Conservancy Board were charged with the conservancy, preservation and regulation of the Thames above the landward limit of the Port of London. Their powers and duties include the conservancy, navigation and regulation of water, including the power to carry out works, and the prevention of pollution. This latter includes the power to prosecute those who deposit rubbish, etc., into the watercourse. Under the 1930 Act, the Conservators have power to cleanse, repair or otherwise maintain efficiently any existing watercourse and to deepen, widen, straighten or otherwise improve any existing watercourse or remove obstruction to watercourses. The Thames Conservancy has, in fact, from time to time carried out works to remove obstructions from the Pinn to ensure the purity of the flow. It is understood that they have no proposals for extensive improvement works. The Council is concerned about the condition of the Pinn for a number of reasons. One is that at times sewage overflow enters the river. This comes about because when the foul sewer was laid in Pinner about 1870, provision was made at intervals for storm water overflows to discharge foul water above a certain degree of dilution into the Pinn. Because of the recent large building development, the dry water flow has increasingly approached the volume at which an overflow into the river occurs, so that in recent years this overflow has not been sufficiently diluted. The erosion of the banks has left exposed tree roots when the river is running high, and foul matter collects at these points. It was partly to reduce this problem that the Pinner relief foul water sewer scheme was put in hand. When the works are completed, all the storm water overflows will be stopped-up, and there should be no further pollution of the river by Council sewers. Then for short lengths the Council is itself the owner of property which borders part of the river and has some responsibility for keeping down any trouble which might arise in those places. Apart from these aspects, the Council is concerned when any body of persons is subjected to a nuisance or annoyance. Section 259 of the Public Health Act includes among statutory nuisances "a watercourse which is so foul or in such a state as to be prejudicial to health or a nuisance, and a watercourse which is so choked or silted-up as to obstruct or impede the proper flow of water and thereby cause a nuisance or give rise to conditions prejudicial to health." The same section makes it an offence to throw or deposit cinders, etc., or other matter likely to cause annoyance into or in any river, stream or watercourse. Quite apart from what might follow on the introductiion of sewage into the river, trouble arises from obstruction to the flow. Soil 41 from the banks, augmented by the silt washed off the surface of the roads, collects at points in the river, forming banks of mud; on such deposits further debris collects. Added to this is further rubbish which people deposit in the river. The Thames Conservators can prosecute those who deposit rubbish into the watercourse; their difficulty, of course, is to discover the culprits. The Council is faced with the same difficulty. In the ultimate "the local authority may themselves do forthwith what they consider necessary to abate the nuisance and to prevent a recurrence thereof." An impediment to speedy action being taken is that, before carrying out any work, the Authority is obliged to consult the Thames Conservators. The position at the end of the year was that on the completion of the Pinner relief foul water sewer scheme, the Thames Conservators are to be approached with a view to there being a general discussion on the matter. PUBLIC CLEANSING Much the same arrangements for the collection of refuse, its disposal and for street cleansing were continued last year as were described in the Annual Report for 1954. Each week some 960 tons of refuse are collected by the 40 mechanical vehicles from some 70,000 premises in the district. Other arrangements are made for the collection of waste paper from shops and business premises. For the last few years house refuse from this district has been taken to a tip at Harefield some five miles from the western boundary of the district. The present agreement with the Uxbridge Corporation runs to the 31st March, 1964. The Urban District Council had contemplated erecting plants for the disposal of refuse at sites at Newton Farm and at the Great Stanmore Sewage Farm. A scheme for the construction of a new separation and incineration plant at Newton Farm was submitted to the Minister in 1952, and an enquiry was held. No sanction, however, was received to this proposal, the Minister apparently favouring controlled tipping. The Surveyor was asked to report on the question of the provision of a refuse destructor. In regard to this, he pointed out that tipping space would still have to be found for some 25 to 30 thousand tons of clinker and tailing. The Highways and Cleansing Committee decided to defer consideration of the matter for a further twelve months. In the meantime, the Engineer was to look into the possibility of obtaining an option on the use of dry pits, and alternatively to consider joint action by neighbouring authorities in the matter of refuse disposal. Trade Waste. When house refuse was treated at disposal works in the district, traders could get rid of their refuse at low cost if it was delivered to the site. With the present methods of disposal by which all refuse has to be carted outside the district, these facilities are no longer aviable. One effect is the increase in the volume of smoke because, not only do traders get rid of some of their waste by burning, but some large factories have to do the same. The absence of facilities for removing the wastes at shops leads to accumulations in the yards. These accumulations 42 all too readily provide cover for rats and, where there is putrescible material, a breeding ground for flies. The householder, too, has material to get rid of, including such things as bedsteads and perambulators. Having no other simple means of disposing of them, some dump them in different places in the district. The Public Health Committee has at various times urged that a more generous interpretation be given to the term "house refuse" so that all these goods can be removed by the cleansing service, and so avoid this dumping which is not only an eyesore but which might encourage the breeding of rats and flies. Fouling of Footpaths by Dogs. This is a real nuisance in some parts of the district, more especially in the quieter roads near shopping centres where the occupants of flats above the shops have dogs. The Good Rule and Government Byelaw reads: "No person being in charge of a dog shall allow the dog to foul the foot-way of any street or public place by depositing its excrement thereon." Occasionally action is taken against one who offends under this byelaw. To control this nuisance, the first step should be to make the people aware that this is a punishable offence. To this end, posters drawing the attention of the public to prosecutions for these offences have been displayed on the Council's notice boards. Some residents have suggested that some more prominent type of notice might be displayed. The General Purposes Committee considered the means of publicising and enforcing the byelaw. Nothing further had been done by the end of the year, as the Highways and Cleansing Committee proposes to make byelaws under Section 15 of the Road Traffic Act, 1956, for the control of dogs on designated highways. For action to be taken under the byelaw it would appear it is necessary to rely on those members of the public who are sufficiently public spirited to be prepared to remonstrate with an offender. There are such people; and their task should be made that much easier by their being able to draw the offender's attention to his action being an infringement of the law. This help could be given by there being notices, exhibited possibly on the lamposts, especially in those roads where the owners of dogs make a regular practice of exercising them. PUBLIC CONVENIENCES The Council has under consideration proposals for providing a number of public conveniences in different parts of the district. The one which had reached the most advanced stage was the proposal for Chapel Lane, Pinner. This is held up because of the " credit squeeze." The Minister's approval is being sought for the appropriation of a small parcel of land inside the grounds of the former isolation hospital at Honeypot Lane for a convenience at Queensbury. The Council also approved the scheme for the erection of a convenience at Woodridings Close, Hatch End. The Minister of Housing and Local Governmen approved the appropriation of certain housing land in Kenton Lane for a convenience in Belmont. Proposals were considered for the erection of conveniences in Kenton and at Rayners Lane; but it was decided that no further action be taken at present relating to that proposed for Clamp Hill. 43 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 By Section 5 of the Cremation Act, 1902, no crematorium buildings, chapels and parts of grounds set aside for the disposal of ashes may be constructed nearer to any dwelling house than two hundred yards, except with the consent of the owner, lessee or occupier of such house, nor within fifty yards of any public highway, nor in the consecrated part of burial grounds. The construction placed by the Minister of Housing and Local Government on the word " crematorium " is making it difficult to use the Harrow Weald site for this purpose. 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 two. 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. The arrangement by which 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 was continued. During the year 424 bodies were received in the mortuary, 164 of these being from Wembley. Post-mortem examinations were carried out on all the bodies admitted. Inquests were held on 80. 44 SANITARY INSPECTION OF THE DISTRICT AND THE INSPECTION AND SUPERVISION OF FOOD STATISTICAL SUMMARY PART I Inspections Made and Conditions Found HOUSING Inspection of Houses Visits (i) On complaint of dampness or other housing defects 831 (ii) On complaint of other nuisances 574 (iii) Routine inspections 861 (iv) Revisits arising from defects found 4,240 (v) Surveys under S. 157 Housing Act, 1936 170 Conditions Found (i) Number of dwellings or other premises where defects were found 1,281 (ii) Number of cases of overcrowding revealed 23 PUBLIC HEALTH Inspection of Other Premises Visits (i) On complaint or request 198 (ii) Routine inspections of premises 769 (iii) Revisits arising from defects found 854 (iv) Surveys arising from Rat and Mice complaints 1,429 (v) Inspection of Factories 326 (vi) Inspection of Workplaces 53 (vii) Inspection of Outworkers' Premises 323 (viii) Inspection of Cinemas and Places of Entertainment 79 (ix) Inspection of Licensed Premises 94 (x) Visits under Shops Acts 1,612 (xi) Evening observations under Shops Acts 19 (xii) Sunday observations—Shops Acts 16 (xiii) Observations made for Smoke Nuisances 63 45 Conditions Found (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 772 (ii) Number of premises where action was taken by Rodent Operatives to deal with rats or mice 1,296 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 70 (iv) Number of Cinemas and/or Licensed Premises where defects were found 28 (v) Contraventions of Shops Acts— (a) Failure to observe closing hours 4 (b) Other contraventions (failure to exhibit notices, etc.) 364 FOOD HYGIENE Inspection of Food: Food Shops, and Food Preparing Places Visits (i) Slaughterhouses 925 (ii) Butchers' shops 302 (iii) Cowsheds 8 (iv) Dairies 26 (v) Fish Shops 116 (vi) Bakehouses 83 (vii) Cafes and Restaurants 189 (viii) Ice Cream Premises 76 (ix) Provision Merchants 429 (x) Greengrocers 244 (xi) Other Food Premises 161 PART II COMPLAINTS RECEIVED summary Accumulations of refuse 88 Animals causing a nuisance 19 Dampness and Housing defects 365 Drains and sewers—choked 78 defective 93 Dustbins defective 32 Flooding—Gardens 25 Vermin 39 Insect infestations 115 Overcrowding, alleged 28 Smoke nuisances 50 Watercourse 18 Other complaints (wasps' nests, defective fences) 179 rood unfit (excluding requests received from shops to visit and inspect unfit food) 45 46 PART III NOTICES SERVED Under Housing Acts, 1936-1957 Statutory Notices served under S. 9 requiring execution of repair work 2 Dwellings reported under SS. 16/17 of Housing Act, 1957, as being unfit for human habitation 29 Dwellings reported under S. 12 and closing orders made 2 Dwellings reported under S. 18 and closing orders made 3 Informal notices served under S. 9 22 Under Public Health Act, 1936 Statutory Notices under— (i) S. 24—work to a public sewer 117 (ii) S. 39—repair or renewal of drains 11 (iii) S. 45—repair or renewal of defective water closets 2 (iv) S. 56—undrained or badly drained yard area — (v) S. 75—renewal of a dustbin 8 (vi) S. 93—abatement of a nuisance 27 (vii) Informal notices served 1,549 ACTION TAKEN Following Housing Act Notices (i) S. 9 Housing Act, 1936—dwelling rendered fit— (a) By owners 2 The notices were served during 1956 (b) By local authority in default of owners — . (ii) S. 11 Housing Act, 1936, and S. 16/17 Housing Act, 1957—Demolition order made 27 (iii) S. 12 Housing Act, 1936, and S. 18 Housing Act, 1957— Closing order made 3 (iv) Dwellings rendered fit by owners after receipt of informal notice 10 Following Public Health Act Notices 26 (i) S. 24—Public sewers repaired (ii) S. 39— (a) By owners 8 (b) By local authority in default of owners 2 (iii) S. 45— (a) By owners 1 (b) By local authority in default of owners — (iv) S. 56— (a) By owners — (b) By local authority in default of owners — 47 (v) S. 75— (a) By owners 5 (b) By local authority in default of owners 1 (c) By occupier 2 (vi) S. 93—Nuisances abated (11 outstanding from 1956) 37 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,585 SUMMARY PROCEEDINGS During October the Magistrates at Hendon Court heard cases involving 25 summonses taken out under a Middlesex County Council Act in respect of an unauthorised caravan site at Edgware which failed to comply with the requirements of the Act. The case was proved and fines which totalled £50 were imposed. At the same Court during November the Magistrates heard an application for an Abatement Order in respect of a nuisance arising from the leaking state of the roofs of two blocks of flats in Honeypot Lane. The Order was granted, fines totalling £11 were imposed and costs amounting to 25 guineas were awarded. HOUSING Legislation Housing Act, 1957: Section 3 of the consolidating Housing Act, 1957 renews the previous provisions making it the duty of local authorities to inspect their districts from time to time to ascertain whether any houses are unfit for human habitation. The standard of fitness is set out in paragraph 4. A house is deemed to be unfit for human habitation if it is so far defective in any one or more of the following matters and is not reasonably suitable for occupation, viz., (a) repair; (b) suitability; (c) freedom from damp; (d) natural lighting; (e) ventilation; (f) water supply; (g) drainage and sanitary conditions; (h) facilities for storage, preparation and cooking of food, and for the disposal of waste water. It is an implied condition of a contract of tenancy on the letting of a small house that the house was fit for human habitation at the commencement of the tenancy and will be kept so fit by the landlord. In wis district this applies to houses let before the 6th July, 1957, at a rent not exceeding £26 or let after that date at a rent not exceeding £52. Section 9 is the same as Section 9 of the 1936 Act. Where a local authority are satisfied that a house is unfit for human habitation but that it can be made fit at a reasonable expense, they may serve notice on the Person having control of the house requiring him to execute works Within a reasonable time. This section applies to a hut, tent, caravan or other temporary or moveable shelter which is used for human habitation and has been in the same enclosure for two years. In default of the owner doing the work, the local authority might carry out the work and recover the expense. 48 Section 16 replaces Section 11 of the 1936 Act. Where a local authority are satisfied that a house is unfit for human habitation and cannot be made so fit at reasonable expense, they shall serve notice on the person having control, the owner and other mortgagee of the house, of the time and place at which they will consider the condition of the house and any offer to carry out works, or as to the future of the house. The person on whom notice is served might give an undertaking either to carry out specified works which will render the house fit, or not use the house for human habitation until the authority cancel the undertaking on the house being rendered fit. By Section 17, which replaces the Section 11 of the 1936 Act, where no undertaking is accepted it is the duty of the local authority to make a Demolition or a Closing Order or to purchase the house. A Demolition Order must require that the premises shall be vacated within a specified period being not less than 28 days from the date of the operation of the Order and shall be demolished within a further six weeks. It is an offence to enter or permit entry into occupation of a building after the date on which the Demolition Order requires it to be vacated. In default of the owner demolishing the building, the local authority shall do so and recover the cost. Section 24 authorises permission being given for the reconstruction of a condemned house. The effect of a Closing Order is to prohibit the use of the premises for any purpose other than a purpose approved by the local authority. The local authority must determine the Order on being satisfied that the premises have been made fit for human habitation. Section 30 deals with payments in respect of condemned houses which have been well maintained. A local authority may make allowances towards the removal expenses and the loss incurred in a trade or business of any person required to vacate a house as a result of a Demolition or a Closing Order or purchase of the house by the local authority. Part III of the Act deals with the declaring of clearance areas which must include only houses which are unfit for human habitation or houses or other buildings which are by reason of their bad arrangement, narrowness or bad arrangement of the streets dangerous or injurious to the health of the inhabitants of the area. (S. 42.) Having declared an area a clearance area, the authority may proceed to secure the demolition of the buildings either by making a Clearance Order or by purchasing the land and undertaking the demolition themselves. A Clearance Order must be submitted to and confirmed by the Minister. The Minister may direct the local authority to make the authorised payments for a wellmaintained house. Any owner of a house may submit a list of proposed works to the local authority with a request to be informed if the execution of the works will make a house fit for human habitation, and that with reasonable care and maintenance it will remain so fit for at least five years. (S. 69.) Local authorities have been given powers to make a Demolition Order on any obstructive building, i.e., a building which by reason of its contact with or proximity to other buildings, is dangerous or injurious to health. 49 Part IV of the Act deals with overcrowding. It is the duty of a local authority to inspect and make reports and proposals as to overcrowding. (S. 70.) A dwelling is overcrowded if the number of persons sleeping in it is (a) such that two or more such persons of ten years of age or older of opposite sexes, not being persons living together as husband and wife, must sleep in the same room; or (b) more than the permitted number defined in the sixth schedule. The permitted number of persons is defined as the smaller number of two, the one calculated on the number of rooms, the' other the aggregate of all the rooms, each room being calculated according to its floor area. In the first calculation when a house consists of one room, the permitted number is two, of two rooms 3, of three rooms 5, of four rooms 7½ and five rooms 10. In calculating on the second basis, the permitted number of a room with a floor area of 110 sq. ft. or more is two, 90-110 sq. ft. one and a half, 70-90 one, and 50-70 half. On each basis, no regard shall be had to a room with a floor space of less than 50 sq. ft. It is an offence for the occupier or the landlord of a dwelling to cause or permit it to be overcrowded. The landlord or his agent must notify the local authority of the existence of overcrowding within seven days of his knowing of it. In relation to all houses and dwellings in respect of which a local authority are required to keep a Housing Revenue Account, an authority shall secure that reasonable preference in the granting of tenancies is given to persons who are occupying insanitary or overcrowded houses, have large families or are living in insanitary housing conditions. (S. 113.) The Medical Officer of Health shall make an official representation in writing whenever he is of the opinion that a house is unfit for human habitation, or that an area should be a clearance area. (S. 157.) Rent Act, 1957. The objectives of this Act which came into force in July are "enabling rented houses and flats to be put and kept in repair, of increasing the total stock of rented accommodation, of securing a better use of existing housing accommodation, and of making a beginning on the restoration of a free market in rented houses "(Ministry of Housing and Local Government Circular 32/57). The Act freed from control houses in the Metropolitan Police district with a rateable value in November. 1956, of over £40, all owneroccupied houses and all other privately owned houses when let to new tenants, except to a widow or other member of the family succeeding to a statutory tenancy. On the 31st March, 1957, of the 63,912 houses and flats in the district, 33,519 were of rateable value of £40 or under. The landlord can neither increase the rent nor gain possession of a decontrolled house until 6th October, 1958. The Act also allows limited increases in the rent of houses still under rent control. The rent to be paid will depend on the state of the house and on the extent of the landlord's responsibility for repairs. If the landlord is 50 responsible for repairs, other than internal decorations, the highest rent is twice the gross value; if he is responsible for internal decorations as well, it is two and a third times the gross value; but where the tenant is responsible for all repairs, the factor is one and a third. Where the landlord is increasing the rent he gives three months notice. If the house needs repair, the tenant can prevent a rent increase. The procedure is set out on page 54. Repair of Houses Improvement Grants Little use was made of the powers contained in the Housing Act, 1949, to make grants to owners to modernise their houses either by improvement or conversion. Rather more use was made of the powers contained in the Housing Repairs and Rents Act, 1954. The circular issued to explain the provisions of these Acts said: "An important contribution can be made by the improvement or conversion of existing houses or other buildings. With the best possible progress in the building of new houses, the great majority of families in this country must for some considerable time occupy houses which were built many years ago and which, though they may be soundly constructed and in good general repair, lack the amenities and convenience which have come to be regarded as an essential to a decent and healthy life." Any house which needs modernising is eligible for a grant if, when the work is done, it will provide a satisfactory dwelling for at least fifteen years. Up to the end of 1957, 102 applications had been received, of which 50 had been approved. 25 of these applications were received in 1957; during the year 12 grants were made, all to owner-occupiers. Inspection of Houses Although the Housing Act requires local authorities to carry out systematic inspections of houses, this routine inspection has not been started since the end of the war because there is sufficient work to be done arising from the complaints received from tenants about the state of the houses they occupy, and the present numbers of recommendations by the Public Health Committee for the rehousing of occupants of houses on which Demolition Orders or Closing Orders are being made are sufficient embarrassment to the Housing Committee. If the house complained of is one of a number where it is thought the conditions might be much the same, then, although no complaints had been received from the occupiers of the other houses, all the houses in the block would be inspected. That is about the limit of attention to houses to which the Inspectors had not been called in by the tenants. Slum Clearance Programme The Council's proposals submitted to the Ministry in August, 1955, for dealing with unfit houses in the district referred to 577 properties. 51 It was expected that the clearing and replacing the unfit houses would be carried out in five years. At the time the survey was completed in April, 1955, the 577 houses included 29 which were already the subject of confirmed Clearance Orders, 39 the subject of confirmed Demolition Orders and 115 about which action had already been started. This 115 included the 91 houses in the Northolt Road area, four in Pinner Hill Road, 10 in Palmerston Road, four in Crown Street and six at Little Common. In April, 1955, then, 183 of the 577 houses were the subject of some action. By the end of 1956, some steps had been taken in respect of a further 84. The Clearance and Re-Development Committee had decided that activities in the first year of the Council's slum clearance programme should be limited to the clearance and redevelopment of the unfit houses in the Northolt Road clearance area. The Council submitted proposals for confirmation Orders of four separate groups of properties, some of these classed "pink," the unfit properties, and some classed "grey," being properties not unfit but whose acquisition was necessary to obtain a satisfactory area for redevelopment. The public local enquiry took place on the 2nd July, 1957. The Minister's decision was:— "1. Northolt Road No. 1 Area—8 houses, being the odd numbers 31-45, Northolt Road, classed as 'pink,' and two adjacent houses, 25 and 29, Northolt Road, classed as ' grey,' Order confirmed. "2. Northolt Road No. 2 Area—9 houses (odd numbers 115-121, Northolt Road) classed as 'Pink' and six adjoining shop properties classed as 'grey.' The Order was confirmed in respect of 'pink' properties, but the ' grey ' properties were excluded. "3. Northolt Road No. 3 Area—20 houses (odd numbers 137-175, Northolt Road) all classed as ' pink.' Order confirmed, apart from No. 165 being classed as ' grey.' "4. Alma Road and Alma Crescent. The 'pink' area comprised 16 houses, being the odd numbers 1-31, Alma Road, and all the 11 properties in Alma Crescent. The 'grey' properties comprised 64 properties, including some shops. The Minister excluded all the 'grey' land, and also the 'pink' properties 1-11 (odd numbers), Alma Crescent and 15-31, Alma Road. The decision about the 'pink' properties was unexpected as most of them are in much the same condition as the other Properties in Alma Road and Alma Crescent. Apart from these steps taken in regard to these Northolt Road area Properties, a number of other houses were the subject of some other action during the year. A few of the houses included in the original Programme had been rendered fit by the owners. On the other hand, a few houses had to be considered which were not included in the original list. in the meantime, some houses of the original 577 had been demolished preliminary actions of different sorts, whether to proceed by way of Demolition Order and Clearance Order or to acquire by agreement, were being taken in respect of many houses. 52 The following is a summary of the position at the end of the year: Number in original survey 577 Number added since 13 590 Number the subject of Orders 156 Number purchased by Local Authority 33 Number demolished 35 Action started in respect of 60 Number reconditioned 25 309 Number to be dealt with 281 Demolition of Houses At the end of the year some of the following groups of houses which were the subject of Clearance Orders confirmed in 1939 were still occupied: Address Date of Order No. still occupied 2-40, Headstone Drive 1939 4 1-5, Brewery Cottages 1939 5 High Street, Stanmore No. 4 1939 4 Some of the following groups of properties which had been officially represented since the war were still occupied at the end of the year. In all cases the Council decided to acquire by agreement: Address Date of Official Representation No. still occupied 2-12, Palmerston Road 1953 2 29-34, Little Common 1953 5 31, 33, 35, 37, Crown Street 1954 1 1, 3, 5, 7, 9, Waldron Road, 1956 1 3 1, Albert Cottages and 8-9, Albert Place, 1956 15, 17, 19, Crown Street 1956 3 The following properties, while suitable to be the subject of Clearance Orders, were not officially represented, but negotiations were entered into with the view to their being acquired by the Council by agreement. 101-9, Bessborough Road 44-60, Greenford Road 34-42, Palmerston Road. The following houses which were the subject of earlier Closing or Demolition orders were still standing at the end of the year:— 1-7, Kingsfield Terrace (1939). 40, Milton Road (1953) 45, West Street (1955) 46, Milton Road (1955) 58-60, Crown Street (1955) 32, Milton Road (1955) 53 3, Victoria Terrace (1955) 42, Milton Road (1954) 51, West Street (1955). 38, Milton Road (1954). 2, Stanmore Hill (1955). 44, Milton Road (1954) 59&61. High Street, Edgware (1956) 3, Shelley Road (1955). 279,283 & 285, Pinner Road (1953) 27, 29, 31 & 33, Shelley Road (1955) 17, West Street (1956) 34, Milton Road (1954). 58, Milton Road (1953). 15, Shelley Road (1955). 13, Shelley Road (1955). 48, Milton Road, (1954). 12, Wordsworth Road (1955). 17 & 19, Shelley Road (1955). Of these, 45, West Street, 60, Crown Street, 279, Pinner Road, 13, Shelley Road, and 12, Wordsworth Road, were occupied at the end of the year. During the year Demolition or Closing Orders were made in respect of the following properties: 1, 2, 3, Remenham House and 23, Wellington Road; 1, 3, 5, 7. and 9, St. Ann's Road; 153, 155 and 157, Masons Avenue; 30a, West Street; 1, 3, 5, 7 and 9, Crown Street; 12, Kingsfield Road; 1 and 2, Sunny Cottages; 12, Roxborough Road; 3 and 4, Marsh Cottages; 18, Byron Hill Road; 108 and 110, Cecil Road; 23 and 25, Shelley Road; 10, Grange Road; 82, Stanmore Hill; 38a, St. Ann's Road; 23, Marlborough Road. The following were demolished during the year: 33, 35 and 37, Byron Hill Road; 6 and 7, Marsh Cottages, Pinner; 2 and 10, Boxtree Road; Burnt Oak Cottage, Oxhey Lane; 1, 3. 5 and 7, Pinner Hill Road; 13 and 14, Chapel Lane; Engadine, Devonshire Road; 23, 25, 27 and 29, Milton Road; 40, 42, 44, 46, Marlborough Road. Reconditioning of Houses. If after a Closing Order has been made and even where the family which were then living in the house had been rehoused by the Council, the owners do the work needed to make the house fit for habitation, the local authority has to cancel the Closing Order. A number of houses have been saved in this way. In some cases at the time the Order was made, it was known what the owner's intention was, but it was still necessary to make the Order so that the family could be rehoused as the work which was required could not be done while the house was occupied. The following houses which were the subject of Orders have been or are to be reconditioned: 8, 10 and 12, Roxeth Hill; 1 and 2, Spring Villa Road; 48 and 50, High Street, Harrow; 11, West Street; 4a and 6a, High Street, Pinner; 1, Green Lane; 1 and 2, Ohio Cottages. Poet's Corner. For some years before the war, many of the bouses in Poet's Corner were felt to be unfit for further occupation. Although the houses had been erected at much the same time, there were big differences in the way they had been maintained. The result was bat although so many were considered to be unfit for human habitation, there were some, particularly some owner-occupied, which were in much better state. Nevertheless, it was felt that the best way of dealing with these properties was by clearance. Accordingly they were represented, as Were also some other houses in the adjoining Marlborough Road which were associated with shops. An enquiry was held in the summer The findings of the enquiry were that only some five were to 54 be dealt with as unfit houses. It was felt that this decision had regard to the fact that because of the international situation, all houses which could be should be retained. Complaints from the occupants started to come in immediately after the enquiry, and at intervals the owners of the various houses decided they could not continue to maintain them. In addition, some were destroyed by enemy action. After the war, some groups of houses were made the subject of Demolition Orders, while others have been cleared by the Council by agreement. Where groups have been closed, it has been possible to demolish them. The position at the end of last year was this:— Shelley Road—even numbers all demolished. Of the odd numbers, one has been demolished. Numbers 3, 13, 15, 17, 19, 23, 25, 27, 29,31 and 33 are the subject of Closing Orders. Of these 8 are vacant. Of the remainder, five have been purchased by the Council, leaving one property on which action has to be taken; of these six houses, one is vacant. Milton Road—of the odd numbers, all except Nos. 17 and 19 have been demolished. Of the even numbers, 32, 34, 38, 40, 42, 44, 46, 48 and 58 are the subject of demolition or closing orders; of these nine are vacant. Ten of the remaining 25 were reconditioned some years ago and have since been well maintained. There are 15 on which action has yet to be taken. Wordsworth Road—There are 19 dwellings in this road. Of these, No. 12 is the subject of a Closing Order; eight were reconditioned some years ago and three have been reconditioned during recent years. It is possible all the seven outstanding will be found to be capable of repair. Burns Road—Eleven properties originally stood in this road. Five (Nos. 7, 8, 9, 10 and 11) were demolished some years ago, and the remaining six have been reconditioned. Marlborough Road—Nine dwelling houses and nine shops in this road were included in the compulsory purchase orders associated with the 1939 Inquiry. Of these, eight dwellings have been demolished and the ninth has been reconditioned. No action has been taken over the nine shops, some of which have been improved and reconditioned by the owners. Marlborough Hill—Eight properties in this road were included in the 1939 Inquiry. Four of these, 6, 16, 18 and 20, have been demolished, and there are four on which action remains to be taken. Certificates of Disrepair When the landlord proposes to increase the rent under the Rent Act he gives three months' notice. If the house needs repair, the tenan can prevent a rent increase. "The standard of repair is to be such as will secure the remedying of defects which ought reasonably to be remedied having due regard to the age, character and locality of the dwelling" The first step is for the tenant to serve on the owner on a form G a notice of defects. The owner can then give the tenant an undertaking to do the work in three months. If he fails to give the undertaking, the tenant can apply to the local authority for a certificate of disrepair. Before issuing the certificate, the authority first gives the owner three. 55 weeks' notice of their intention. If in those three weeks the owner has not given an undertaking to the tenant to do the work within six months, the authority issues a certificate of disrepair. On receiving this, the tenant is entitled to withhold the rent increase. The landlord can claim on certain grounds that the certificate ought not to have been issued; this is a matter for the county court to decide. The tenant has a similar right of appeal against the authority's refusal to issue a certificate. The authority cancels the certificate when the work has been done; the tenant has a right of appeal against this, too. The Act is essentially one for the tenant and the landlord, and local authorities and their staff are not involved in most cases. Even the original list of defects is prepared by the tenant. This has disadvantages in that many do not appreciate what they are entitled to ask to have done, while a lack of definition creates difficulties when the authority has in turn to transcribe an item in the list as something which can be set out in the notice which the authority serves on the owner before issuing a certificate of disrepair. A special problem facing the Inspectors is whether or not to be satisfied that work which has been done does remedy a defect. What the Act is achieving in this district is difficult to determine. Most of the applications for certificates of disrepair have come from the tenants of flats built in the 1930's, properties which are well designed and have been provided with all amenities. On the other hand, no applications have been received in respect of the older houses in South Harrow, Stanmore and in Edgware, and only the occasional one in respect of houses in Wealdstone. The Act, then, has not been used to bring about a general improvement in these older types of properties. On the other hand, many owners have carried out repairs and improvements without there having been any question of the issue of a certificate of disrepair. About these the authority would not know. The procedure in this district is that the tenant is asked to supply with his application for a certificate of disrepair a copy of the form G notice and also the notice of rent increase. These are dealt with by the Town Clerk, and the case is referred to the Public Health Department 'i the rent increase demand is in order. By the end of the year 278 applications had been received by the department. The following is a summary of the cases considered by the Committee: Number of Applications considered and Committee approval given for service of notice to landlord of proposal to issue a Certificate of Disrepair 184 Number of applications cancelled, withdrawn or deferred 5 Number of applications considered by Committee and further action not approved 3 Number of Undertakings by landlords to remedy defects proposed to be included in Certificate of Disrepair 37 Overcrowding The annual review of the state of overcrowding in the district shows at once more there has been an improvement. As compared with the cases known on January 1st, the number on December 31st was only 56 72. The net reduction of 14 is the difference between the 37 cases in which the overcrowding was abated and the 23 new cases. In 14 instances the abatement of the overcrowding was brought about by the families being rehoused in council houses. Of the 23 new cases, the overcrowding was caused in 11 by the increase in the size of the family or by the ageing of the children, and in 7 by the marriage of one of the children. Of the 72 cases which were overcrowded at the end of the year, 19 were overcrowded by half a unit and 31 by one unit. Eleven families were living in premises overcrowded by 1| units, 6 in premises overcrowded by 2 units and 5 in accommodation overcrowded by 2\ units or more. It is only when the overcrowding is by more than one unit that the Council can entertain an application for re-housing which is based solely on the grounds of overcrowding. Although it is satisfactory to be able to report that there are only these comparatively small numbers of families living in overcrowded conditions, there are two less favourable aspects. The one is that these figures do not necessarily indicate the size of the problem, as no complete survey has been carried out since the one and only survey carried out specifically for this purpose throughout the country in 1936. Nevertheless, if only because they hope that the Council might be able to do something to help them, it is probable that most of those living in overcrowded conditions get in touch with the Public Health Department. While, then, it is not claimed to be an exact figure, it can be accepted as being one very close to the true size of the problem. The other aspect is the standard of crowding permitted statutorily. Unfortunately, the standard of the 1936 Act which was applicable generally throughout the whole country, could not be made very high because of the appalling conditions obtaining in many towns. It was probably intended merely as a first stage target, the standard to be raised when the worst of the conditions had been improved. Unfortunately, the war came before much could be achieved in this way in much of the country, so that the same standards still apply to-day. Where there are many rooms, a family of the permitted number of units might manage; but a family in one room, and especially when that family contains children, might be living in impossible conditions without being statutorily overcrowded. The worst conditions are met in a family with young children, especially children under ten, and more especially with babies of under one year of age, who do not rank even as half a unit when calculating the permitted number. Such a family with only half a unit of overcrowding can be much worse placed than one with perhaps 1½ units of overcrowding occupying three rooms, and yet that family cannot be helped by the Council who have had to limit their help to those overcrowded by not less than one unit. New Housing The total number of new dwellings provided in this district from the end of the war up to the 31st December, 1957, was 5,229. Of these, 2,482 were new permanent Council dwellings and 200 were new temporary dwellings. 1,885 permanent dwellings have been provided by private 57 enterprise. 338 dwellings destroyed by enemy action were rebuilt, and 333 existing houses were converted. At the end of the previous year the number of permanent Council dwellings provided was 2,399, and the number of buildings provided by private enterprise 1,659. In addition 954 family dwelling units were provided in requisitioned premises. Of these, by the end of the year 720 had been released and 62 had been reduced from two to one unit dwellings, 172 in all being held at the end of the year, the number of properties held being 157. Further use has been made of the arrangements for the removal of Harrow families to the new and expanded towns. 277 Harrow families were housed in one of the new or expanded towns during the year. By the end of the year the total number housed was 1,420. Of these, 593 were from the normal waiting list. Most of these removals were to the news towns of Hemel Hempstead, Stevenage and Harlow and the expanded towns of Bletchley and Swindon. Smaller numbers went to Welwyn, Hatfield, Basildon, Bracknell and Aylesbury. Allocation of New Houses Waiting List.-—Towards the end of the year the normal housing waiting list (applications received before the 12th September, 1952) was 1,584. Of these, 33 were within the qualifying points range for possible housing. Registrations after the 12th September, 1952, constitute the new towns list and number 1,445. There are over 500 applicants for the housing provided for the aged. Allocation. When the Housing Management Sub-committee carried out their annual review of the Council's housing position, of the 304 dwellings it was anticipated would be made available, 84 were for aged persons. Of the remaining 220, 118 were already committed. Of these, 24 were earmarked as the balance of the 72 dwellings originally associated with the Poet's Corner area, 24 were reserved to facilitate the phasing of the redevelopment of the Northolt Road Clearance Area, while 70 were needed to meet commitments brought forward from the 1956 review. The remaining 102 were allocated:— 1. Tuberculosis cases 10 2. Eviction cases Nil 3. Overcrowded families 6 4. Families to be rehoused from individual insanitary ings (other than those in Poet's Corner) 20 5. Hardship cases 20 6. Licensees from requisitioned premises 20 7. Housing list cases becoming eligible under the "points" scheme 22 8. Miscellaneous 4 While it is a statutory obligation on the Council to rehouse those families living in houses which have been condemned as a result of clearance procedure, there has not been the same statutory requirement to rehouse those living in single dwellings which have been the subject of demolition or Closing Orders. Nevertheless the Council over the 58 years has rehoused the occupants of such houses. A few years ago the Minister in a circular urged authorities to take this line, having regard to the difficult position in which these families were placed. Because of their difficulties in meeting the many demands, the Housing Committee came to the opinion that, "generally speaking, where the occupants of an insanitary dwelling are a man and wife only and of under pensionable age, they should be expected to find their own alternative accommodation, at any rate as a first step." The Public Health Committee at their September meeting passed the following resolution: "This Committee is increasingly alarmed at the number of families displaced from houses condemned as unfit for human habitation and thus making it the moral responsibility of the Council to rehouse these people." Rehousing of Tuberculous Families. In their annual review of the Council's housing position, the Housing Committee have generously treated those families with a member suffering from pulmonary tuberculosis. At one time, one in six of the houses that became available were allotted for this purpose, quite a substantial number when large numbers of houses were coming along. After a few years the worst of the cases had been rehoused. Having regard to the improvement in the position and to their increasing difficulties in meeting claims for rehousing, the Committee then changed the factor to one in ten. This smaller factor yielded sufficient houses even on the reduced number of houses which became available, and the really urgent claims have been met even on this smaller allocation. There is, though, a minimum number which will be needed annually to meet the claims of those which will of necessity be made. In this last year 10 houses were allotted to families with a member suffering from pulmonary tuberculosis. The rehousing of these families is essentially a preventive measure, to reduce the risk of spread of infection from the patient to his home contacts. It is not a step which is taken primarily in the interests of the patient himself. Two factors above all others are taken into account in assessing his risk of spreading infection. These are his infectiousness and the degree of overcrowding of the premises. In regard to the first point, the opinion of the chest physician is obtained. With the various drugs now available to reduce the infectiousness of patients, and the fall in the number of new cases, the demands of this group will diminish, but probably it will be long enough before they fall below the small numbers these days considered necessary. 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 59 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. 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, usually a parttime general medical practitioner. Amongst his duties are the examination of young persons. 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 529 factories or premises which are supervised by the public health inspectors of the district. At 54 of these mechanical power is not used and these are therefore supervised not only as regards sanitary conveniences but also as to the general health provisions. To these premises 388 visits were made, with the result that 17 notices were served. 70 defects were found; of these 10 were due to want of cleanliness, 42 were in respect of sanitary conveniences (39 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. Local authorities are required to keep a register of out-workers and to take action if people are employed in unwholesome premises. There are 212 out-workers' premises in the district. At 128 of these wearing apparel is dealt with, being either made or cleaned; at 55 Christmas crackers and Christmas stockings were made. 322 visits of inspection were made. In all cases the premises were found to be satisfactory. Occupational Health. The Dale Committee of Inquiry on Industrial Health Services came to the conclusion seven years ago that such services are in many ways complementary to the National Health Service and should be expanded. The Committee thought that eventually there should be some comprehensive provision for an occupational health service covering not only the industrial establishments of all kinds and sizes, but also non-industrial occupations. They felt that surveys and experiments would be necessary before such a service could be established. The Minister of Labour re-established the Industrial Health Advisory Committee in 1955. This set on foot two surveys. One was to examine what needs to be done in the many and varied factories in Halifax, the other to make a similar survey of one industry, the potteries being selected. The findings of these surveys might take matters a step forward, though 60 it has not yet been accepted by all that a comprehensive service is desirable. Others question whether the needs of the smallest firms would justify the expense and effort involved. Then those who agree that the services should be co-ordinated under one authority cannot agree about which that authority should be. 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 temperature 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 2,346 shops in the district, a reduction of 11 in the number at the end of the previous year. During the year 1,611 visits were paid. Over 350 contraventions were found. These ranged from failing to keep records as prescribed by the Act to selling non-exempted articles on a Sunday. Evening visits brought to light only four cases of shops failing to close at the time required by the Acts. There were ten instances of shops failing to close on the weekly half-holiday, and five where no compensatory holidays were being given instead of Sunday employment. Final warnings were given in a number of cases but in no case were proceedings instituted. The Shops Act, 1950, is a complicated piece of legislation and decisions of the Courts have not always helped to solve problems or the difficult points associated with it. It was a disappointment, then, to learn that Parliament abandoned the Bill which it was hoped would effectively deal with the difficulties and the weaknesses of the existing legislation. 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 75 premises in the district licensed for public entertainment. These include 10 cinemas, 14 public houses, 13 church halls, 3 local authority assembly halls, 21 schools and 14 private dance and other assembly halls, clubs, etc. 79 visits of inspection were made to these premises. Only occasionally was anything found needing to be remedied In addition to the attention of those responsible for the maintenance of these premises being drawn to any unsatisfactory condition, reports on 61 their state and especially that of the sanitary accommodation are forwarded each year to the Clerk of the County Council. Licensed Premises There are 58 licensed premises in the district. Although at most of them the state and adequacy of the sanitary conveniences are quite satisfactory, at a few there is room for improvement. 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 spread 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 13. All of them were inspected during the year; the conditions were found to be satisfactory in all but two which were dirty at the time. The Committee considered a suggestion from the Royal Society for the Prevention of Cruelty to Animals that, to avoid unnecessary distress to animals sold in pet shops as the result of ignorance of the purchasers, the proprietors should be compelled by a suitable regulation endorsed on their licences to issue suitable leaflets about the feeding, general care and management of the animals. The Committee resolved that when licences are granted or renewed, the licensees be informed that it is the wish of the Committee that an appropriate leaflet be supplied by licensees each time a pet animal is sold. 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 Metal Dealers 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 two persons were registered with the Authority. 62 Hairdressers' and Barbers' Premises The Council has made byelaws under Section 282 of the Middlesex County Council Act, 1944 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. These establishments are subject to the provisions of the Shops Acts which ensure there shall be a sufficient number of sanitary conveniences for the staff employed, and that the premises shall be properly heated and ventilated. The same Act regulates the early closing days, the assistants' half holidays and the arrangements for the health and comfort of the assistants. There are in the district 125 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 Public Health Inspectors keep under supervision various buildings, watercourses and parcels of land so as to be in a position to take action to prevent unsatisfactory conditions arising. Atmospheric Pollution Legislation. The Clean Air Act of 1956 had four 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 of being operated without emitting smoke; (iii) to require that the emission of grit and dust from existing industrial furnaces shall be minimised and that new industrial furnaces burning pulverised fuel or large quantities of other solid fuel shall be provided with grit-arresting equipment; (iv) to empower local authorities to declare "smoke-control areas," in which the emission of smoke from chimneys will constitute an offence. Because of the need to give industry sufficient notice of proposals which would involve changing boilers, furnaces, etc. to enable the new legal requirements to be satisfied, the provisions of the Act relating to industrial premises do not come into force until 1958. Other provisions, however, came into operation on December 31st, 1956. These relate to smoke from furnaces, smoke control areas and the extension of the Alkali etc. Works Regulation Act to cover the emission of smoke, grit and dust from premises controlled or to be controlled under the Act, colliery spoil banks, and the constitution of the Clean Air Council. Section 11 of the Act makes it an offence to emit smoke from any building in a declared smoke control area, unless the emission was not caused by the use of a fuel other than an authorised fuel. The Smoke 63 Control Areas (Authorised Fuels) Regulation, 1956, declared the following to be authorised fuels for the purposes of the Act: anthracite, briquetted fuels carbonised in the process of manufacture, coke, electricity, gas, low temperature carbonisation fuels and low volatile steam coals. The Smoke Control Areas (Exempted Fireplaces) Order, 1957, provides that fireplaces especially designed or adapted for combustion of liquid fuel shall, provided they are so installed, maintained and operated as to minimise emission of smoke, be exempt from the provision of Section 11 of the Act which relates to smoke control areas. Smoke Control Areas. There are powers in the Clean Air Act which, even if nothing else were done, will prevent the situation deteriorating. The domestic chimney was excluded from the effects of Section 104 (2) of the Public Health Act, 1956, which enabled building byelaws to require the provision in new buildings of such arrangements for heating or cooking as are calculated to prevent or reduce the emission of smoke. Section 24 of the Clean Air Act enables local authorities to make building byelaws to extend this requirement to private houses. The Minister prepared model byelaws which were adopted by tue Council at their meeting on March 15th. As to industrial smoke. Section 3 of the Act requires all new furnaces (except domestic) to be capable of being operated continuously without emitting smoke when burning fuel of a type for which they were designed. Section 10 enables authorities to control the height of chimneys (not of residences, shops or offices) so as to prevent smoke, grit and dust and gases from being prejudicial to health or a nuisance. The chief provisions of the Act of which use will be made in this district are those relating to the designation of smoke control areas. These will be areas in which it would be a punishable offence to allow the emission of smoke (subject to the defence that the emission followed the use of an authorised fuel). The intention is that certain parts of the area shall be so established, later to be linked-up with others, in time to cover much of the district. In making such an order, the authority may limit its operation to specified classes of building, and may exempt specified fireplaces or classes of fireplace. An early step in the procedure is full publicity and the Minister holds a public enquiry. Those living in an area which is the subject of an order, are entitled to financial assistance towards the cost of converting the grates to types which will consume smokeless fuel, owners or occupiers of private dwelhngs qualifying for payments up to 7/10ths of the approved expenditure (hut not in respect of houses built after the 5th July, 1956, when the Act was passed). A number of authorities have already taken action to establish smoke control areas. Many have chosen areas which are about to be developed. In this district it was thought that a start might have been made on the area to be developed on the site covered by the Northolt Road clearance scheme. As, however, there will be no large development here for some years, a start will probably be made in some other already built-up area, his could with advantage be one of the residential parts of the south ttest of the district. The high proportion of coke used for domestic 64 purposes in Harrow suggests that many houses already satisfy the requirements of properties in a smoke control area. However, before any proposals can be started, it is necessary to have a survey of some properties. Unfortunately, at present the shortage of staff prevents even these first steps being taken. In the meantime, though, every opportunity is being taken to make the public aware of this question of smoke prevention. If all of the many people who change their grates or cookers in their homes would install appliances suitable for the consumption of smokeless fuel and would then use them for burning smokeless fuel, improvement would come about even before the designation of any smoke control areas. This is something which will come about only when the householder realises the need for such action. This is where the education of the public is so important. The Public Health Committee supported in different ways the meeting and exhibition on Clean Air arranged in May at the Baptist Church Hall, College Road, by the Harrow Branch of the Women's Gas Federation. The meetings were very useful in giving indications of the points about which the public needs to be reassured. Many, of course, will take some convincing that it really is necessary that something should be done. While they accept the damage to health of such a fog as that which occurred in London in 1952, they are not prepared to see that they have any responsibility for taking action to reduce the risk of such occurrences. Many of them no doubt will have the added reason for deciding to do nothing because they are satisfied that from no other form of heating can they derive the comfort they have from their coal fires. Some seem to go further and feel that other forms of heating might even injure their health in some way. Not all those who agree in general that efforts could be made to reduce atmospheric pollution are satisfied that anything needs to be done in Harrow itself, or in their particular part of Harrow. So many continue to see the problem as one to be dealt with by the industralist, and have not appreciated how much it is the responsibility of the householder. Those who are satisfied that the householder can play a big part still need satisfying on a number of points. First perhaps they need to be convinced that other forms of heating a room can be just as satisfying and as comfortable. They need, too, to be satisfied that alternative means are not more costly; there is the cost of conversion and the continuing cost of the different fuel. Fortunately, about this they can be assured: because of the greater efficiency of the heating units which can replace the existing ones, the bill for fuel consumption will be so much reduced that they would soon save what they have to pay out as their contribution to the cost of the conversion. Then quite a lot is heard about the difficulty of obtaining suitable fuel. Many of the complaints about this are probably because, to many, smokeless fuel means one of the special proprietary fuels and does not include coke. Those who presumably are in the best position to know, are reassuring about the availability of this fuel, and it is doubtful if progress throughout the country in converting heating appliances which will increase the demands for smokeless fuel will be sufficiently rapid that supplies cannot be increased at the same rate. The case for an attempt to reduce the amount of smoke in the area is based on the damage it does in so many different ways, some of it due 65 to the smoke, some to such gases as the oxides of sulphur. The damage to buildings is notorious. Not only does smoke damage fabrics, clothes, curtains and carpets, but by dirtying them causes them to need more frequent cleansing. Vegetation is injured directly by the action of smoke on the leaves and indirectly by the action of acids on the soil. Pollution of the air means more artificial lighting. But smoke has, as well, its most damaging effect on health. Apart from the dramatic effects of such fogs as that in London in December, 1952, which caused 4,000 deaths, there is the persistent and insidious damage from the constant emission of polluting matter. It was probably the screening of the sun's rays that accounted for the higher incidence of rickets in industrial areas. It is an important factor in causing bronchitis, which is one of the plagues of those living in this country. The acute attack kills 30,000 people a year and causes the loss of work of 15 or 16 million days. The chronic variety, unpleasant in itself, is a forerunner of other diseases of the lung. 20,000 people die each year from pneumonia; many of these had previous chest trouble. Death from pneumonia affecting a previously healthy lung is rare; the previous damage in these cases often enough was the result of atmospheric pollution. Then, while it is accepted that cigarette smoking is so very important a factor in causing cancer of the lung, of the other factors, the most important is atmospheric pollution. The case for the householder doing her share is that while most of the grit and the sulphur oxides come from the industrial chimney, more smoke is produced when coal is consumed in the domestic grate than when it is burned in other places. Not only is more produced by the domestic chimney but, as contrasted with that from the factory chimney, it is let into the air at low levels, so that its effect is soon felt by those in the immediate surroundings. In industrial areas, the volume of dark smoke from some industrial chimneys, and especially where there are many of them, might suggest that the problem is wholly one of the factory. But even in those districts that is not the case, and there is much for the householder to do to improve matters; still less is that the position in an area such as this with its limited industry. When fires are lighted at about the same time in some 60,000 nouses, quite a lot of smoke is produced, and it is only the householder who can prevent this. Industrial Smoke. During the year a survey was made of 45 industrial and other establishments in the district. The eight incinerators and the 123 boilers and furnaces were inspected. In 40 of the furnaces coal is used, 50 are fired on coke and 33 are oil fired. In the following summary these boilers and furnaces have been grouped according to both me and the type of fuel consumed:— Industrial Steam Raising Boilers Type and No. of Boilers Type of fuel burnt Total Coal Coke Oil Water tube 3 5 8 Shell—horizontal 20* 4* 1 25 Shell—vertical 2 5* 1 8 Total 25 9 7 41 * Includes boilers using waste as additional fuel. 66 2. Industrial Incinerators Type of refuse Total Wood waste 1 Mixed refuse 1 8 3. Industrial Furnaces Type of fuel burnt Total Coke Oil Glass making and metal casting 7 9 16 4. Other Steam Raising Boilers Type and No. of Boilers Type of fuel burnt Total Coke Oil Shell—vertical 6 1 1 Shell—horizontal 1 1 Total 7 1 8 5. Central Heating Boilers Type of fuel burnt Total Coal Coke Oil 15 27 16 58 Of the 41 boilers in Group 1, only two of the 25 using coal are handtired. There are five boilers in this group where in addition to coke or coal, wood waste is consumed. Among these, with some in Group 2, are the most troublesome industrial chimneys in the district. All the 15 central heating boilers burning coal (Group 5) are mechanically fired; the fuel used is either washed or graded. The figures relating to central heating boilers do not include those at the schools that are controlled by the County Council; at only one of these is coal consumed, and in this case the boiler is fitted with a mechanical stoker to which the coal is automatically fed. There are, however, some schools where open coal fires are still in use. During the year boilers at three establishments changed from solid fuel to oil; among these was one of the hand-fired coal-burning plants. Towards the end of the year at one other large industrial establishment, work of this nature was in hand. London and Home Counties Smoke Abatement Advisory CouncilThe main functions of this body are of an advisory and consultative nature regarding the elimination or reduction of atmospheric pollution. The Borough Council decided to join the Advisory Council. Complaints. A number of factories and premises are now experiencing difficulty in getting rid of their trade waste because these days they are deprived of the facilities previously at their disposal in getting rid of them at a refuse tip or disposal plant. This has resulted in their burning the waste, with consequent smoke nuisance. Hazards of Radiation. Although it has been apparent for some years that local authorities would in time become affected by the growing use of nuclear energy in one form or another, and although people who are worried about the possibility of food having been contaminated look to those in the health department for information and reassurance, no indication has been given that either the local sanitary authorities or the local health authorities have any responsibilities in the matter. The 67 present division of responsibility was indicated in a reply to the following question in the House of Commons on the 31st October, 1957:— "What measures were proposed to ensure that the level of strontium 90 and other radio active substances in various parts of Britain were ascertained at frequent intervals ? " "The Agricultural Research Council had accepted responsibility for monitoring soil, herbage, farm animals and milk and other foodstuffs, while the Atomic Energy Research Establishment would remain responsible for monitoring air and rainwater and for analysing the radioactivity present in samples of human bone." The following, however, is an extract from a report of the Atomic Energy Authority on the Windscale accident (Cmd. 342). " Quite apart from the rapidly extending demand for operational health and safety staff, there is an urgent need for education in radiological problems over a wide field of industry and the public service. Medical Officers of Health and their senior medical staff must understand radiological hazards and methods of detecting whether any contamination or exposure has occurred. Inspectors of factories, sanitary and water engineers will require similar knowledge. Industrial nurses, health visitors and the police should be given basic instruction. These are but examples to illustrate the size of the problem." Rats and Mice The rodent operatives found rats or mice at 1,296 of the 1,429 premises they visited. Each of the infestations was small and localised. Most complaints were from private dwelling houses, 1,003 of these being in respect of rats, 107 of mice. Forty-one infestations of rats and four of mice were at Corporation properties, 85 and 56 at other premises. The number of visits made by the rodent operatives to these properties was 11,064. The figure of 1,296 for 1957 compares with 1,192 in 1956 and 1,429 in 1955. There was an increase over last year's figures of the rat infestations on Corporation property and on private premises. The figures for mice and rats in other premises were much the same in the two previous years. The greater number of treatments on Corporation property was possible as the services of four rodent operatives were available for almost all of the year, and they were able to give more frequent attention to the watercourses and land owned by the Corporation. Two factors may have a bearing on the increase in the number of infestations in private dwellings: 1957 did not have the periods of extreme wet and cold weather of 1956; but of perhaps more importance is that of the practice of feeding animals and wild birds in the gardens of private houses which is on the increase. This results in a great deal of the cereal-type foodstuffs which is Particularly attractive to rats being made available to them. The normal biennial treatment of the sewers known to be infested with rats was carried out. In addition a ten per cent test on the whole syestem in the district was undertaken. During this test, involving 662 manholes, was taken from only 13. This suggests that the rat Population in the sewers of the district is small. 68 Wasps There are marked variations in the prevalence of wasps and in the requests for help to deal with their nests. In 1956 there were only 213 such requests as compared with 345 in the previous year. The number last year was 265. The Corporation's charge of five shillings was recovered in all except three cases where the nests were on parcels of land of which the occupiers were unknown. Charges. Up to 1949 those who approached the department for help in dealing with wasps' nests were put in touch with one of the staff who did the work privately outside normal hours. Because of the large number of requests in 1949, the matter was considered by the Public Health Committee who decided that the work should be done by any of the rodent operatives prepared to do it. This arrangement was on the understanding that those doing the work should be remunerated for approved overtime, and that no charge should be made to the householder. The matter was considered again in 1954 in view of the rising cost of the service, and the feeling in some instances that the operatives were being asked to do work which might reasonably have been carried out by the householder. The Committee decided the service should be continued on the same lines. The District Auditor, however, raised the question of the legality of this free service as there appeared to be no specific statutory authority authorising it. The Council at their meeting in July then resolved to make "a charge of five shillings in each case for the service of the rodent operative in respect of the destruction of wasps' nests in the borough on the understanding that sympathetic consideration would be given in case of hardship." Caravan Site The conditions at the caravan site at North Lodge steadily deteriorated, more especially as larger numbers of caravans had been admitted to the site. The story of the efforts to bring about improvement goes back quite a long way. Any action which the Public Health Committee could take could only be to improve the condition of this site, with the possibility of its being used indefinitely for this purpose. As general opinion did not favour this, the Committee held its hand, in the hope that the Planning Committee could find a solution to the problem The enforcement proceedings taken under the Town and Country Planning Act initiated by the Planning Committee in 1951 were finally abandoned in 1954, the owner having been able virtually to establish an existing user right of the land as a caravan site. No other action was taken while there were prospects of a solution to the difficulties being found on these lines. Although the land at North Lodge is designated in the Country Development Planning for compulsory acquisition by the County Council for welfare purposes, the County Council did not feel able to take action in advance of the Minister's approval of the County Development Plan. In February the Public Health Committee decided that 15 caravans was the maximum number to be permitted on the site; each occupier was told it would be necessary for him to submit an application for consent for him to retain his caravan there. 69 The next line of action was to try to bring about an improvement of the site by insisting on the carrying out of works which could be called for under Section 345 of the Middlesex County Council Act, 1954. Legal proceedings instituted against the owner under this Section were heard in February, 1957, but were adjourned as the owner expressed her willingness to carry out the works required. Summonses were later taken out against the owner of the site, the case being heard in October when the owner was fined £2 on each of 25 summonses. Later the Committee were told the owner's surveyor was preparing plans to provide on the site an access road, hard standings, water supply points, and sanitary accommodation for 15 caravans. To make progress, the Council passed the following resolution: "That in view of the bad conditions known to exist at the North Lodge caravan site, the Council resolved to ask a joint meeting of the Public Health and Housing Committee to give immediate consideration to the future of this site and to lay down a long-term policy in relation to it." The joint meeting suggested the following course of action:— (1) That, subject to the concurrence of the Planning Committee and of the Middlesex County Council, action be taken by the Council, pursuant to Section 26 of the Town and Country Planning Act, 1947, to extinguish the existing user rights of land at North Lodge, Edgware, as a caravan site. (2) That the agreement of the Middlesex County Council be sought to the site being redesignated in the County Development Plan for residential purposes, and to its acquisition by the Borough Council, for Part V housing purposes, by the exercise of compulsory powers, if necessary. (3) That any restriction as to the number of caravans to be permitted on the site as a result of the Court hearing on 26th September, 1957, shall be enforced, by means of an injunction if necessary, at any time in the future. (4) That, subject to action being taken in accordance with paragraphs 1, 2 and 3 above, the Council be recommended to assume a moral responsibility for rehousing up to fifteen families of caravan dwellers on this site. 70 INSPECTION AND SUPERVISION OF FOOD (A) MILK Production During the year milk production ceased at one of the nine farms in the district and at two others only store cattle are now kept. Tuberculin Tested milk is produced at five of the remainder and at the other ungraded milk, which is sold wholesale. 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 licences issued under the Milk (Special Designation) Regulations, 1949-54. to 35 persons or companies:— (1) The number of premises from which pasteurised milk was sold 50 (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 49 (6) The number of premises outside Harrow from which sterilised milk was retailed in the district 21 Supervision During the year 74 visits were paid by the Public Health Inspectors to dairies and cowsheds in the district. Sampling 40 samples of milk were taken and submitted to the Colindale Laboratory for analysis. All were satisfactory. This sampling is independent of that carried out by the County Council. Complaints 22 complaints were received during the year about the condition of milk bottles. 11 were about the presence of foreign matter, and 11 about the dirty condition of the bottle. Summary proceedings taken in one of the cases; warning letters were sent about the rest. Many millions of bottles circulate in the district each year; the snia number of complaints received testifies to the efforts of the Dairy Companies and the co-operation they receive from those householders w play their part by rinsing the milk bottles before returning them. Monday is a difficult day for milk roundsmen, as householders do not put out bottles to be collected on Sundays. This leads to the practice of crates of empty bottles being stacked on the highway. 71 Milk and Tuberculosis Almost up to the time of the last war one to two per cent. of cows in the British Isles suffered from tuberculous udders, and forty per cent. of the cows reacted to the tuberculin test. Five to fifteen per cent. of samples of raw milk were found to be infected with living tubercle bacilli and the same organisms could be recovered from cream, butter and cheese. It was largely the harm done to children by the consumption of this infected milk that encouraged the growing practice of heat treatment of milk, a step which rendered the milk safe, not only from the risk of conveying tuberculosis but also the other milk-borne diseases such as undulant fever, epidemic sore throat and scarlet fever. While the Tuberculosis Order encouraged the slaughter of diseased animals, this of itself could bring about improvement only very slowly. An alternative line of action was the active immunisation of cattle. In some places abroad, reliance was placed on the building up of tuberculin-free herds. The first step on these lines in this country was the plan to build up accredited individual herds which were subjected to frequent tuberculin tests, with the removal from the herds of positive reactors. Following the building up of accredited herds would be the formation of accredited areas. These arrangements gave way to those of attested herds, these to be developed later into eradication areas and these in turn to Attested Areas. With the declaration of an Attested Area, the control by licence of cattle moving within the area is relaxed, but prohibition of movement of cattle into the area except under licence continues. The marked improvement in the position in recent years is indicated by there being at the end of 1957 7½ million cattle in attested herds and in Attested Areas in Great Britain as against 3.4 million five years ago and 1.1 million ten years ago. Over three-quarters of the cattle in the country are now attested. The Minister of Agriculture, Fisheries and Food intends to extend the free tuberculin-testing of cattle in the remaining parts of the country, and on March 31st, 1961, to declare the two final areas of England and Wales as Tuberculosis Eradication Areas. There are good prospects that the whole of Great Britain will be an attested area by 1961. This is an extraordinary change from the very gloomy outlook shortly before the war. The incidence of non-pulmonary tuberculosis in children had already fallen markedly before this. Improvement had come about principally because of the growing practice of the heat treatment of milk; and even though still greater success is achieved in eradicating tuberculosis from cows, this heat treatment will still be necessary to render the milk safe, out apart from other considerations, this progress in eradicating bovine tuberculosis is to be welcomed if only because the supervision necessary to ensure the maintenance of this satisfactory state should help to keep down other diseases of cattle communicable to man. (B) MEAT Meat Inspection Legislation as to Slaughterhouses : In May 1956 a White Paper (Cmd. 9761) was published which indicated that minimum standards would be prescribed for the construction, layout and equipment of 72 slaughterhouses. A number of regulations were formulated to supplement the Slaughter of Animals (Prevention of Cruelty) Regulations of 1954, and to improve the arrangements for handling and inspecting animals and meat in slaughterhouses. These were set out in the White Paper (Cmd. 243). The main provision in regard to securing humane slaughtering is that relating to stunning pens which should reduce the handling of adult animals. The second part of the White Paper deals with the conditions which would be imposed under the new Slaughterhouses (Hygienic Construction) Regulations which are to be introduced and which will be enforceable by local authorities in England and Wales. Pending the coming into force of the regulations, it is helpful to have these standards which have been brought to the notice of the owners of local slaughterhouses. Circular F.S.H. 6/57 of the Ministry of Agriculture, Fisheries and Food pointed out the regulations prescribing and applying the standards set out cannot be made until enabling legislation has been passed. Exchequer Grant towards the Cost of Meat Inspection: Not all the meat inspected at the slaughterhouses in any area is for local consumption. Where the bulk of it is not, the authority has an unduly heavy burden imposed on it. Arrangements have now been made by which there will be an exchequer grant towards the cost of the work which it is estimated is carried out over and above that of inspecting meat sufficient for the needs of its own population. The arrangement is referred to in Circular F.S.H. 2/57 of the Ministry of Agriculture, Fisheries and Food. Although the volume of work done at the slaughterhouse at Waldron's Yard has increased, this district does not qualify for any of the grant. Meat Inspection: The total number of animals slaughtered last year at the four slaughterhouses in the district was only 9,020. The fall from the 11,963 in 1956 was due to a virtual cessation of pig killing at the principal pig-killing centre which resulted in 3,900 fewer pigs being killed. On the other hand, the number of cattle slaughtered increased by nearly 400 more, and sheep nearly 600. The incidence of tuberculosis (1956 figures in brackets) in cattle other than cows, 5.85 per cent. (6.2 per cent.), was much the same as in the previous year, as was also the case in cows at 15.25 per cent. (13.6 per cent.); but the incidence in pigs fell to 1.4 per cent. (2 per cent.). A growing problem is that of Cysticercus bovis in cattle, diagnosed in 27. The consumption of infected meat causes tape worm in man. It infection is not generalised, detection necessitates freezing the carcase ot a suspected animal for 21 days; this results in spoilage of prime homekilled beef, with considerable loss in value. One case of swine fever was diagnosed. The incidence of other diseases and conditions, in all some 27 categories, ranging from parasites to "struck by lightning," remains almos the same, being 24.7 per cent. (24.7) in beasts, 34.3 per cent. (33.5) in cows, 17 per cent. (18.2) in pigs, 6 per cent. (6.8) in sheep, and 1.1 Per cent. (0.5) in calves. 73 The principal causes of condemnation in cattle and sheep were parasitic diseases; in pigs, it was virus pneumonia. The total weight of meat condemned at slaughterhouses was 19,883 lbs. (23,266 lbs.). All of this was destroyed by incineration at the Wembley destructor. The following is a copy of the return asked for by the Ministry about the post-mortem inspection of animals at slaughterhouses:— Carcases and Offal Inspected and Condemned in whole or in part. Cattle Excluding Cows Cows Calves Sheep and Lambs Pigs Horses Number killed 1,931 236 741 3,933 2,177 — Number inspected 1,931 236 741 3,933 2,177 — All diseases except Tuberculosis and Cysticerci Whole carcases condemned 1 2 1 3 8 - Carcases of which some part or organ was condemned 475 79 7 234 388 - Percentage of the number inspected affected with disease other than tuberculosis and cysticerci 24.7 34.3 11 60 18.2 Tuberculosis only Whole carcases condemned 6 - - 1 - Carcases of which some part or organ was condemned 107 36 1 - 30 - Percentage of the number inspected affected with tuberculosis 5.85 15.25 0.1 - 1.4 - Cysticercosis Carcases of which some Part or organ was condemned 25 2 - - - - Carcases submitted to treatment by refrigeration 24 1 - - - - Generalised and totally condemned — — - — - - 74 (C) OTHER FOODS Food Premises There were at the end of the year in the district 234 grocers shops, 143 fruiterers and greengrocers, 137 butchers, 54 fish shops, 35 dairies and 154 confectionery/cafes. Condemned Food During the year 9,596 lbs. of food were found to be unfit and had to be destroyed. This was nearly ten per cent. less than the amount dealt with in the previous year. About half was of meat and meat products, though the figure does not include the meat found unfit at the slaughterhouses. Complaints There were 31 complaints during the year about foreign matter in food. Nine of the complaints related to bread, seven to meat pies, and ten to tinned or packet goods. Warning letters were sent to those responsible. Ice Cream At the end of the year 369 premises were registered for the retailing of ice cream, an increase of four on the number on the register at the end of 1956. Of these seven are registered for the purpose of manufacture but at only three was ice cream made. 47 samples were taken. Grades I and II are considered satisfactory; grades III and IV are not, and if repeated indicate faults in practice. All 11 samples from local manufacturers were grade I. Of the others, three were grades III or IV and were from a trader who ceased to deal in ice cream. When unsatisfactory reports are received, enquiries are made with a view to the cause of the trouble being ascertained, and subsequent samples are taken. 27 of the 35 samples of ice lollies examined were satisfactory. 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 by the local authority. The number of premises now registered is 125, an increase of one over the previous year. 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. The number registered as trading in the district at the end of the year was 57, an increase of one during the year. Of these, 22 were trading from storage premises in Harrow and 35 from premises outside the district. 75 (D) ADULTERATION OF FOOD The following information about the operation of the Food and Drugs Act has been taken from the Annual Report of the Chief Officer of the Public Control Department of the Middlesex County Council for the year 1956/57:— "Of the 1,517 samples analysed by the public analyst, 223 were incorrect. Of all these samples 524 were milk (124 incorrect), 95 foods other than milk (94 incorrect) and 86 drugs of which only one was incorrect. The corresponding figures of samples examined or tested in the department were 7,140 (402), 2,933 (329), 4,186 (29) and 291 (4). Most of the unsatisfactory milk samples were taken from churns of milk despatched by firms. Most were not adulterated by the addition of water, but were below the presumed standard of the Sale of Milk Regulations, 1939, in respect of either fat or of solids-not-fat. Usually, when there is an offence, it is by a farmer who sends his milk to Middlesex collecting depots. Of the three cases prosecuted this year, only one was of that nature. One was a retailer who supplied milk with added water to a works canteen. The third was a wholesaler; in this case one of the many churns of milk he supplied to a retailer had added water in it, apparently the result of a fault developing in the washing apparatus. 346 samples of milk were submitted for examination of the tubercle bacillus. Three were found to be infected; four cows were slaughtered. 1,159 samples of milk were tested to check the adequacy of the pasteurising or sterilisation process to which the milk had been subjected. Eleven of these samples failed to pass the test. 298 visits of inspection were made to the 30 licensed processing premises." The report deals with the measures taken in regard to a variety of subjects not falling to the County Council as a Food and Drugs Authority, such as their duties under the Weights and Measures Act, the Motor Vehicle (Construction and Use) Regulations Act made under the Road Traffic Act which deals with the maximum weight to be transmitted to the road surface, the Explosives Acts which control the storage, sale and transport of explosives, Employment Agencies, the control under the Nurses Act, 1943, of the Agencies for the Employment of Nurses, and the Theatrical Employers Registration Acts. Some two years ago, particularly from one school, complaints were received about the presence of pieces of glass in the bottles delivered to schools. It was realised, of course, that not all of these occurrences were reported to the Public Health Department; on the other hand, the fact that this had happened once at a school led to the reporting of each case which occurred subsequently at that school. To obtain a correct picture of what was happening, the head teachers of the school were invited to report all such occurrences over a period. These enquiries led to nothing, and the occurrences remained something of a mystery. This district, then, has particular interest in an item in the report on this subject of glass in school milk, the results of a survey carried out from the 1st April, 1956, to the end of the year. It is based on a monthly average distribution of milk bottles of nearly six million. In the whole period there were 104 complaints of glass in milk. What was of interest was the larger numbers of complaints, 24 and 41, made in the first and second months. This 76 suggested that the action taken in connection with the investigation resulted in a marked and steady reduction in the bad bottles distributed. The 104 cases fell into one of two categories. In the first, comprising 16 instances, minute pieces of glass were in a bottle which itself was in a sound condition. The other group comprised those where the bottle was broken in such a way as to be a potential danger, and by the time of consumption some fragments had got into the milk. In 74 of these bottles the rims were broken or damaged. In the case of the 16 bottles where the glass was found to be perfectly sound, the presumption is that the fragments had been introduced before the bottles were capped. In the other cases it was not possible to prove that the damage had not occurred at the school after delivery by the dairy roundsman, though there were many cases where the nature of the damage strongly suggested that it had occurred while the bottle was being handled by the bottler or in distribution. In 12 of the 16 cases in which sound bottles contained glass in milk, prosecutions for selling milk not of the standard demanded were instituted. Three of these cases were dismissed, but in the other nine cases convictions were recorded. (E) HYGIENE OF FOOD Ten years ago the Public Health Committee started its clean food campaign and appointed a Food Hygiene Sub-Committee. The aim was, with the help of members of the public, shopkeepers and all engaged in the handling of food, to achieve higher standards of cleanliness in food shops, restaurants and in other places where food was handled or prepared. The sub-committee later gave way to the Food Hygiene Advisory Council, to which members of the various food trades and members of different organisations are elected. Much progress has been made. This has come about partly by what has been done by the traders themselves in such matters as the prepackaging of foodstuffs, in refrigeration, in the use of plastic-type materials and in modern shop design and layout. These improvements are the result of a concerted effort in which shopper and customer, shop assistant and food handler, shopkeeper and restaurateur, together with local authorities, laboratory workers and Ministries have played a part. Much, however, remains to be done, for even to-day still can be found the shopper who feels that the notice appealing to the public not to take dogs into food shops could not possibly be intended for his or her special poodle, the shopper who smokes and allows ash to fall over food, the shop assistant who has yet to learn the washing of hands and the covering of sores is important, the shopkeeper who has one standard for the front of his premises which is seen by the customer, and a different one at the back which probably would be very different if it was seen by the public; the wholesaler in whose delivery vehicles there is a risk of food being contaminated; and even the local authority whose own premises do no meet the requirements of the Food Hygiene Regulations. The progress that has been made suggests that the basis of the programme is sound and that in time higher standards will be reached. 77 The campaign for clean food in this last year followed on much the same lines as that in the previous year. The Public Health Inspectors continued to devote special attention to the premises at which food is dealt with and to the techniques of those engaged in the work at these places. The educational side of this campaign has expanded, talks being given this last year to many local organisations, and at schools. Food Hygiene Regulations, 1957. These Regulations amend Section 7 of the 1955 Regulations which restrict the giving out of food for preparation or packing in domestic premises. The operation of the original Regulation 7 in relation to shrimps, prawns and onions has been postponed. The new regulation permits the giving out of shrimps, prawns and onions for peeling on domestic premises, if the premises are registered for the preparation of food by the local authority under Section 16 of the Food and Drugs Act, 1955, and certain other requirements are complied with. Health Education. Starting primarily as the educative side of the Clean Food Campaign, each year has seen a steady development of these activities and a widening of the range of subjects on which talks are given or demonstrations based. From the beginning of the Clean Food Campaign, the Council has had the help of the Food Hygiene Advisory Council. It is felt that this help was especially valuable in establishing good relations with the traders, more particularly before the additional powers granted by the Food Hygiene Regulations were available. Because its members come from such a variety of organisations, the views of the Committee are particularly helpful about such matters as methods of approach to bodies or on publicity. On the other hand, one of the early features of the campaign—the certificate issued to the traders—has probably ceased to be really useful. It had been hoped that all who were eligible would apply for this certificate, and that those whose standards were not sufficiently high to warrant their receiving it would improve their premises or raise their standards of work so as to qualify. As never more than about one third applied, this object has not been achieved, and, especially in view of the strengthened statutory powers in regard to standards, they have probably outlived their usefulness. This function of the Advisory Council, then, has virtually ceased. Then, too, the campaign, as something on which special attention is being focussed, has really come to an end, because all the activities arising out of it have become part of the routine of the establishment. This diminution in the functions of the Committee occurring at the same time as there were other activities of the Public Health Committee about which the public needed to be informed led to the question being raised of whether the scope of the Food Hygiene Advisory Council should not be widened so that, while continuing to be interested in the question of clean food, it would embrace other subjects. One it was felt was particularly appropriate was the campaign for clean air, as the first steps to implement the provisions of the Clean Air Act must be the advising of the public of what is involved, how it is in the interests both of their health and of their pockets, and exactly what part each person and particularly the householder has to Play in the matter. Another subject to which increasing attention is being 78 paid and must continue to a growing extent to be paid is the prevention of accidents in the home. This again is a subject which is essentially one of education and enlightenment of the public. The first step must be to make everyone aware of the facts of the situation, that there is something which needs to be put right, and then to help those who are most affected to play their part, especially in reducing the risks of accidents in their own homes. It was felt that the Food Hygiene Advisory Council, strengthened perhaps by some who had a particular interest or had special knowledge in one or more of these special subjects, might be able to help the Public Health Committee in their endeavours on these lines in the way they had been able to in the clean food campaign. It appeared, however, that some members of the Food Hygiene Advisory Council feared that the widening of the range of activities of the Council might suggest to some that the Borough Council's interest in clean food was waning. Had that been the case, it would have been most unfortunate, so no steps were taken on the lines of widening the remit of the Advisory Council. The following table summarises the work done in this last year on environmental health education:— Subject Audience No. of Talks Environmental Health and the P.H.D. Schools, Guilds and local associations 14 Food Hygiene Schools, Guilds, and local associations 26 Home Safety Mainly in clinics 24 Clean Air Women's Gas Federation meetings 2 Demonstration in Health Office Student Health Visitors 21 Overseas Health Students Traders, Etc. Lectures and Conferences outside Harrow 13 No. of exhibits Health Education of the Public exhibit Delegate Conference 1 Health Education of the Public exhibit Clinics 19 Health Education of the Public exhibit Branch Libraries 12 Health Education of the Public exhibit Education Office 2 Clean Air exhibit Women's Gas Federation 1 Home Safety exhibit British Red Cross 1 Films, Film Strips, Photos and Poster Display Food Hygiene Advisory Council 5 Press Publicity General Public (Harrow and District) 47 items Poster Displays Schools, Clinics and General Public 400 posters exhibited Morropaque Slides For general use at talks 30 slides 79 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis). Disease Under 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 + Unknown Total Scarlet Fever 1 19 49 3 2 2 — 76 Pneumonia, primary — 2 3 2 — 2 4 2 7 9 15 — 46 Pneumonia, influenzal 1 2 2 3 3 3 2 2 4 3 7 1 33 Diptheria - - - - - - - - — — — - - Dysentery — 1 7 3 — 2 — 2 2 — — — 17 Erysipelas - - - - - - - 1 5 5 3 — 14 Meningococcal Infection 1 3 1 — — — 1 — — — — — 6 Puerperal Pyrexia - - - - - - 1 - - - - - 1 Ophthalmia Neonatorum - - - - - - - - - - - - - Poliomyelitis, Paralytic 1 2 3 3 — — 4 1 — — — — 14 Poliomyelitis, Non-paralytic — 1 4 3 2 1 1 2 1 — — — 15 Encephalitis — — — — — — — — — — — — — Measles 37 721 944 48 9 7 4 4 1 — — 8 1,783 Whooping Cough 25 103 106 16 — 1 1 2 1 1 — — 256 Paratyphoid Fever - - - - - 1 - - - - - - 1 Typhoid Fever - - - 1 - - - - - - - - 1 Food Poisoning 2 6 6 6 1 3 13 10 9 4 5 — 65 Malaria - - - - - - - - - - - - - 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 about the 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. Disinfection The proposal for the erection of a new disinfector had again to be deferred because of the restriction on capital expenditure. This is unfortunate for many reasons. One is that, because the boiler used to raise steam for the disinfecting plant is of the size which was necessary to provide steam for the laundry for which it was intended, every time the plant has to be used it entails a heavy consumption of fuel which makes the disinfecting a costly matter. Another disadvantage is the cost of maintaining premises in which the disinfecting plant is housed, but which occupies only a small part of the building. The continued use of this plant means that the building and the grounds cannot be put to other use. The Public Health Committee, towards the end of the year, instructed that further representations should be made to the Minister of Housing and Local Government pressing for early and favourable consideration of the Council's proposals. Cleansing Section 42 of the Middlesex County Council Act 1956 lays down that When it appears to the Medical Officer of Health or a Public Health 80 Inspector of a local authority that the cleansing, purifying or destruction of any articles under Section 84 of the Public Health Act, 1936 (Cleansing or destruction of filthy or verminous articles) is urgently required, he may, subject to any direction of the local authority, himself cause such articles to be cleansed, purified, disinfected or destroyed at the expense of the local authority and, if necessary, be removed from the premises. The Public Health Committee at their February meeting " authorised the Medical Officer of Health to carry out the cleansing etc. of articles mentioned pursuant to Section 42 of the Middlesex County Council Act, 1956, and to report any action taken to the next ordinary meeting of the Committee for confirmation." DIPHTHERIA Incidence In none of the patients thought to be suffering from diphtheria was the diagnosis confirmed. The district has therefore now been free from diphtheria for seven years; the last fatal case in this district was 1946. There were in the whole country in 1956 only 56 cases, with eight deaths. This was the first year when notifications were fewer than 100. Immunisation The fall in the incidence of the disease must largely be attributed to the practice of immunisation. While the fact that there are only small numbers of cases in the whole country at any one time means that the likelihood of any child being infected is reduced, the position still remains that the child who has not been protected is liable to contract the disease on exposure to infection, and that infection is not necessarily from a recognised case of illness. As there are so few cases, many parents have not had any knowledge of the disease; this, unfortunately, leads to the risk of some parents becoming too complacent. With the growing number of diseases against which protection can be given by inoculation, some might start weighing one against the other. The likelihood of this is lessened when it is possible to give protection against more than one infection by the same series of inoculations, and it is possible that many children were being protected against diphtheria because the same preparation was used to protect them against both whooping cough and diphtheria. This combination was particularly fortunate, as the presence of the second antigen in the mixture enhanced the effect of the first, with the result that, because whooping cough antigen was present, the diphtheria component was more effective than if it had been given alone; and the same enhancing of the effect of the whooping cough antigen was brought about by the presence of the diphtheria component. However, when tetanus toxoid was added, giving a mixture of all three antigens, this seemed to lead to some reduction in the effect of the other two components. No doubt this is something which can be got over, and there are hopes that a preparation will be available which will protect against the four diseases—diphtheria, whooping cough, tetanus and poliomyelitis. But there would still be the question of the timing of the doses because, while it is desirable that protection against whooping cough should be given to 81 babies in early infancy, perhaps at this stage the body tissues would not react to some of the other antigens. When these multiple preparations are available, it is unlikely that many parents will not have their children protected. In the meantime the steady campaign for inoculation against diphtheria has run into difficulties. A few years ago it was recognised in this country and in Australia that there was a higher rate of paralytic poliomyelitis amongst those who had recently been inoculated to protect them against certain diseases than amongst others in the population. While this association was higher amongst those who had been given whooping cough vaccine, it was also present to some extent in those inoculated against diphtheria. A Committee of the Medical Research Council investigated the matter, and found that the risk was substantially greater when A.P.T. or a combined vaccine was used than when Formol Toxoid was given. Because of this the use of A.P.T. and the combined vaccine has been discontinued as a routine practice at the clinics. This decision means that children will need to be given many more inoculations if they are to be protected against these two complaints. Not all feel that this step was necessary. If the decision merely resulted in the children having a bigger number of injections, then no doubt it is the correct one; but if it means that, because of the larger number of injections necessary to protect children against whooping cough and against diphtheria, parents decide against having the protection against both, this could result in a substantial number being left unprotected against one of the two diseases; if so, it would be more likely that this would be diphtheria. If this should be the position, then more is lost than is gained by this precautionary measure. However, as vaccine for protecting against the risk of contracting poliomyelitis is available, it may be that the parents of large numbers of infants will elect to have them protected so that to them at least there would be little risk of provocation poliomyelitis and they could be given the combined vaccine. As a child is now not liable to be exposed to the diphtheria organism, one who has been protected against diphtheria in infancy does not have the repeated subliminal doses of infection required to keep up his protection to the necessary level. It was customary then to advise that children should have booster doses at different ages. It is now felt that it is probably sufficient if a child has a booster dose just before he reaches The age of five so that his protection is raised in time for him to meet the added risk to which he is subject on going to school. During the year 2,136 children were treated for the first time, 1,174 by general practitioners and 962 at the infant welfare centres. The number of births notified during the year was 2,853. The aim should be that as many children should be treated for the first time during the year as there Were births. It is estimated that there were at the end of the year 62 per of children under five years of age protected and 94 per cent, of children aged 5 to 15 years. Booster doses were given to 926 children, 544 by general medical practitioners and 382 at the clinics. SCARLET FEVER 76 cases of scarlet fever were notified in 1957. The rate per thousand Population was 0.35; the corresponding rate for the country as a whole 82 was 0.65. This was the smallest number of cases for any one year for the combined district, the previous lowest being 125 in 1955. The incidence over the years ranged from this figure of 125 to the highest, 707. Although there is a preventive against scarlet fever, it is not used to any extent, and the fall in the number of cases of this disease cannot be ascribed to such measures as active immunisation. As contrasted with diphtheria, where the fall in the country as a whole had been steady, the incidence of scarlet fever is most erratic and cannot be foreseen. Fortunately, although there have been the variations in the invasiveness of the streptococcus which causes scarlet fever, variations which have accounted for the altered prevalence of the disease, there has not over recent years in this country been any marked variation in its toxicity, so that whether the incidence of the disease has been high or low it has not caused much serious damage. Nevertheless, just as there have been these changes in the invasiveness of the organism, there must always be the possibility of a variation in toxicity, with the risk of the strain becoming toxic and then causing a severe type of disease. The 76 cases were fairly evenly distributed throughout the year, the average weekly notifications for the four quarters being 2.0, 1.3,1.4 and 1.4. The prevailing type continues to be mild, and there were very few deaths in the whole country from it. The last fatal contracted case in this district was in 1937. It is becoming quite exceptional for a patient suffering from scarlet fever to be removed to hospital. Of the 76 notified cases, only four were removed to hospital, all but one being to the Hendon Isolation Hospital. Although there were so few cases of scarlet fever this year, there were five households in which there were secondary cases, in each the primary case being nursed at home. The interval from the onset of the infecting case where there was only one secondary case was five days in two instances, six days in one and in the other 21 days. In one household there were two secondary cases who fell ill on two consecutive days. This led to the recognition that a third child had had an attack ten days before and by the time the illness was recognised in the other two, the patient was in fact peeling. There were no return cases this year. There was only one occasion when it seemed that school attendance might have accounted for the illness in some children. A case in an infants department one week was followed by another case in the same department in the following week; after a week with no cases, there were then three cases in that same department. This organism was especially invasive; apart from causing the disease to spread in a school (or possibly by contact of the children outside the school), it was responsible for the secondary cases in two households, including the one in which there were two in the one household. SMALLPOX Although it is now rare for there to be a case of smallpox in the country, each year much work has to be done in following up the contacts of cases who have come into the country by aeroplane or less common by boat. Any such contacts are visited up to sixteen days from the a 83 of their last known contact or possible contact, a length of time which covers the incubation period. In April a number of passengers arrived in England in an aeroplane on which they had been in contact with a person who was later discovered to be suffering from smallpox; one of these passengers came to an address in this district. This district was only slightly involved in the incident which affected a number of districts in Greater London in the summer. Towards the end of June, a boy admitted to a hospital in Tottenham was recognised to be suffering from smallpox. He had apparently been infected by his grandmother and in turn probably infected his aunt. This district was involved at that time only because one of the staff at that hospital in Tottenham was a person who lived here, and who came home for a short time a few days after the illness of the boy was diagnosed. The infection in the grandmother was probably associated with an unrecognised case of smallpox in a man who lived in Wembley. He had been infected while on a visit to West Africa and in turn infected his daughter and also his brother. The original case was atypical, probably because the effect of the vaccination carried out in infancy had waned sufficiently to permit an infection, but was nevertheless present in sufficient strength to modify the attack which was therefore atypical. The virus was sufficiently virulent to cause the deaths of two patients. This incident once more points to the desirability of all being vaccinated against smallpox, and for those who are likely to be especially exposed to infection to be re-vaccinated. Vaccination. The arrangements for the vaccination of the general population under the Vaccination Acts came to an end when the National Health Service Act came into force. Since then there has been no Vaccination Officer with a duty to see that infants are vaccinated by the time they are six months old unless their parents had obtained an exemption to this being done. In spite of there being this legal obligation, so many were exempted that in general only about one child in three was being treated. From 1948 the arrangements for vaccination against smallpox have been the same as those by which children are inoculated against diphtheria by the general medical practitioners. Whereas, however, there was a high acceptance rate for inoculation against diphtheria, only about the same proportion as before were being protected against smallpox. When the County Council agreed to arrangements being made by which those infants who attend the infant welfare centres might be vaccinated at the clinics, there was a marked rise in the numbers treated. During the year 2,578 persons living in the district were vaccinated against smallpox for the first time. Of these, 1,709 were under one year of age, and 185 were over one but under two years of age; 1,214 persons re-vaccinated. 2,853 babies were born in that year. The number of vaccinations of those under one year of age was therefore sixty per cent. the births. Of those under one year of age who were vaccinated, 768 were treated at the infant welfare centres. Anyone in this country might contract smallpox either by his being a contact of a case which has been contracted abroad, or secondary to contact case, or by him himself being affected whilst abroad. What might happen here, then, depends so very much on what happens abroad, especially in those countries where smallpox is still prevalent. To control 84 the infection, vaccination of the susceptibles is a very powerful weapon and particularly with some populations the extent to which this is done depends on the ease with which vaccination can be done. There are hopes that the recently prepared freeze-dried vaccine which retains its potency at ordinary temperatures longer than the usual preparation might result in smallpox abroad being more readily controlled, with resulting benefit to those in this country. ENTERIC FEVER Of the five patients who were notified to be suffering from typhoid fever, one was a carrier and in two the diagnosis was not confirmed. Of the other two, one was a person who lived out of the district and the notification of paratyphoid fever was made to the local authority here only because the patient at the time of diagnosis was in a hospital in this district. The remaining case was that of a girl of 11 who would seem to have contracted her infection of typhoid fever because of her fondness for cockles. She fell ill while at home on the 23rd August. She had, however, spent her holidays from the 4th to the 15th August at a seaside resort where she consumed quantities of cockles. DYSENTERY The numbers of notifications of dysentery probably do no more than give an indication of the prevalence of this condition. It is not uncommon when enquiries are being made about a case that has been notified for it to be learned that other members of the family are suffering from a similar condition, but have not been notified. On the other hand, in some cases notified on clinical grounds, the diagnosis is not confirmed on bacteriological examination. This year 17 notifications were received. Five of them related to children in a children's home who succumbed to a Sonne infection on the same day. The notification that a man of 46 was suffering from Sonne infection led to the recognition that infection had probably been introduced into the house two weeks before by a boy of seven; at the time of the visit the grandmother was suffering from diarrhoea and two persons who had visited the week before had gastro-intestinal symptoms. The illness in a girl of 11 due to a Sonne infection was followed four days later by her sister and her mother being similarly attacked. Six of those notified were the only members of the family to be affected; in none of these did laboratory examination confirm the diagnosis. When a dysenteric organism is recovered, it is almost invariably the Sonne variety. This year an adult woman suffered from an attack to a Flexner organism. She probably contracted the infection from her boy of seven who had been admitted to hospital the previous week with gastro-intestinal symptoms. 11 of the notifications were received in March. Of the others, the onset of one was in April, the next in June, and the remainder one in each month from September. At one time a disease introduced by food, dysentery as now seen in this country has changed its pattern, being brought in more by personal 85 contact. Typically it is now a complaint of the winter months and has its heaviest incidence amongst pupils at primary schools. FOOD POISONING Just as is the case with dysentery, the numbers of notifications of this complaint probably give no true indication of its incidence. Reports about the position in the country as a whole which show the frequency of trouble in schools, hospitals and works canteens suggest that the greater number of incidents at these establishments is partly due to outbreaks there being reported more than similar occurrences at restaurants and cooked-food shops. Enquiries about a notified case reveal that other members of the household have had similar symptoms but have not been notified. On the other hand, many notifications are received of isolated cases in which it remains uncertain what the origin of the trouble was. In many of these cases the sufferer had had meals out, and if the trouble was the result of consuming infected food it is presumed that it must have been some foodstuff consumed only by himself and not by the members of his family who remained unaffected. In some of these cases it seemed probable that the reaction was a personal idiosyncrasy to some foodstuff which although consumed by others did not upset them. In only a few of the cases were bacteriological examinations carried out. Where they had been and where organisms had been found, they were mostly Salmonella typhimurium. Of the 65 notifications received, 24 related to persons who were the only members of the household attacked, six related to persons who were the only ones notified but where there were others in the household who had had similar symptoms but were not notified, 35 related to persons in 14 households where others in the household were attacked and notified. One of the cases in which it was felt that the infection had been contracted outside the district was that of a child who fell ill the same evening as she returned from holiday; another, a service man, was ill within a very short time of arriving home on leave. In two households which were affected, the remaining members of the family succumbed some days after the onset of the illness amongst those who had had meals at works canteens; in one of these cases, illness amongst others at the works was reported. Another instance was that of a husband and wife who both suffered some hours after they had had a meal out. Another adult fell ill shortly after having had a meal from a mobile snack bar. The foodstuffs suspected varied. An adult lady suspected lamb's liver because, although she was the only one of the family who was ill, her dogs who ate it were also ill. In another family of four, the three who had luncheon meat succumbed but the fourth who did not eat it escaped. A mother and child who both had cream buns became ill, while the father who did not, escaped. Two members of a family of six who were the only ones to eat over-ripe tomatoes were ill, while the others remained well. A husband and wife fell ill at the same time after a cheese dish; another couple after a meal containing salami. Of the 17 cases where more than one member of the family was affected, onsets were simultaneous in only seven cases. This points to 86 faults in hygiene. In three cases, the first case was the father; in only one was it the mother. Most often one of the children was first affected, in which case the mother was the adult most likely to have the secondary attack. The secondary case was most often another child, though sometimes it was one of the parents. In none of these cases was the diagnosis confirmed by the laboratory examination, and it may be that some were not true cases of food poisoning. Salmonella typhimurium was recovered in a few instances, Salmonella cholerae suis in one. CI. Welchii was responsible for two incidents. In one of these, four notifications were received relating to some patients in a nursing home. All had diarrhoea and vomiting in the early hours of a Tuesday morning. The joint of lamb which was the main dish of the midday meal on the Sunday was kept overnight in a larder at room temperature and was eaten cold midday on Monday. The other incident due to this organism in which no cases were notified was that at a boys' school. Between midnight and 5 a.m. on the 23rd January 16 masters and 207 boys at the school had diarrhoea, some with and some without abdominal pain. The midday meal on the 22nd was silverside which had been steamed for 2\ hours on the 21st and was put in the larder. The joint was carved and warmed up just before dishing up. CI. Welchii was recovered from the meat and from the feces of some of the sufferers. In each of the last few years there has been a Welchii infection in this district. In 1954 seven persons in a household were affected by a stew. In the next year, the staff and patients at two homes for old people were involved. In 1956 many of those employed at a factory in the district were affected following consumption of a steak and kidney pie prepared at the works canteen. The number of households affected was greatest in the summer months, 24 out of 46 incidents occurring in the four months June to September. The following is a copy of a report made to the Ministry about tne organisms responsible for the individual and for family outbreaks:— I st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total 20 23 18 1 62 Outbreaks due to identified agents: Total outbreaks Total cases Nil Nil Outbreaks of undiscovered causes: Total outbreaks 13 Total cases Single cases: 31 Agent identified: Salmonella typhimurium 1 Salmonella Cholerae Suis 1 Unknown cause 29 The Monthly Bulletin of the Ministry of Health and Public Healt Laboratory Service for December, 1957, gives a summary of food Poison ing in England and Wales in 1956. "As in previous years, processed and 87 made-up meats were the vehicles of infection in over two-thirds of the outbreaks traced to a specific food. " The problem of food poisoning is becoming chiefly a problem of salmonella infection. Egg products, certain types of meat, some animal foodstuffs and fertilisers have frequently been found contaminated. The search for sources of contamination must continue and when found must be rigidly controlled. " There still remain, however, a large proportion (41 per cent.) of outbreaks and cases of food poisoning in which none of the known food-poisoning organisms can be demonstrated. This is doubtless due in some measure to imperfect investigation, but the possibility that other organisms play a part in the genesis of food poisoning must not be overlooked." As to the origin of the organisms, some are already on the meat while it is in the abattoir itself; for instance, CI. Welchii was found in raw meat in the abattoir in twenty-four per cent, of samples of meat, in twenty per cent, of pork and in fourteen per cent, of veal. 5. typhimurium occurs in animals, especially in pigs, and has been recovered after slaughter in the liver, spleen and mesenteric glands. There is always the risk of cross infection in slaughterhouses. One report says: " The moral of this part of the report is that the control of food poisoning caused by meat does not rest entirely in the kitchen but should begin in the abattoir and on the farm." ERYSIPELAS This disease although now of very little public health significance is still notifiable. The last year was again one of light incidence, there being only 14 cases, only two being of males. In all but four of the patients, the face was the affected site. The cases were evenly distributed throughout the year. Two of the patients were admitted to hospital. None of the cases was fatal. MENINGOCOCCAL INFECTION Six persons were notified in this last year to be suffering from meningococcal infection, an adult male in March, two girls in April, a baby in May, a boy of two in October and another of the same age in December. Infection in the fatal case was not contracted locally. ENCEPHALITIS This condition might occur primarily, but more often occurs as a complication to a number of infections such as measles, mumps and chicken pox. During the year six cases of the post-infective condition were diagnosed in those admitted to hospital, all secondary to mumps. ACUTE ANTERIOR POLIOMYELITIS 1957 proved to be a year of low prevalence of poliomyelitis in the Wntry as a whole. In the earlier part of the summer the notifications were at a somewhat higher level than usual, largely due to groupings of 88 cases, some in Essex and some in Hertfordshire. Later, some towns were especially attacked. The curve of incidence flattened out, though, and the peak figure of 367 was reached in the week ended August 27th. From then the fall was rapid for a few weeks, so that by the week ended October 12th fewer than 100 cases were notified in a week. The total number of cases notified was 3,440, a rate per thousand population of 0.08. The figure for 1955, a year of light incidence, was 3,900; that for 1947, a year of greatest attack, was 7,305. The usual curve of incidence is a rise to a maximum about September, followed by a fall to a minimum in March. This means that many of the notifications in any one year are of cases which are the fading out of the previous year's increased prevalence. This has meant that in this district there have usually been one or two notifications in January or February not related to the higher incidence later in the year. This year, however, there were no such cases and this district escaped until the first week in June when there was one case. Then followed two clear weeks, followed by three each with a single case. The numbers of notifications in the succeeding weeks were 0, 1, 1,0 and 1, so that by the week ended August 10th there had been only seven cases; in the next week, though, there were seven cases and in the succeeding weeks 3, 3, 2, 3, 2, 1 and 1, the last case being in the week ended October 5th. Of the 29 cases, 14 were paralytic and 15 non-paralytic. The first paralytic case did not occur until the week ended August 10th, being the seventh case notified. In the series of eight cases from the week ended August 24th to the week ended September 9th, six were paralytic cases. The sexes were nearly equally affected, 15 male and 14 female, the 14 paralytic cases being distributed 8 and 6. Four of the notified cases (three of which were paralytic) were in children under 5 years of age, seven (three paralytic) children between 5 and 10, six (three paralytic) in children 10 to 15. Only two adolescents were affected, both with non-paralytic attacks. Of the ten male adults affected, five had paralytic attacks. It was at one time quite exceptional for more than one case to occur in a family. It is now, however, not an uncommon event and there were two such instances. The first was when what proved to be a paralytic attack in the mother was followed after an interval of seven days by her boy of 7 having a non-paralytic attack; the diagnosis in the mother was not made until the boy was ill, both patients being removed to hospital together. The other instance was one of simultaneous onset in a father and his girl of 7 years of age, both non-paralytic attacks. Inoculation against Poliomyelitis. Although it had been expected that supplies of vaccine would be available from the beginning of the year, it was not until the middle of March that the first supplies of that year came to hand. The Minister had decided in 1956 that the arrangements for vaccinating children against poliomyelitis should be discontinued in the months when poliomyelitis might be expected to be particularly prevalent. There was no corresponding decision in 1957, and as there was no period of sufficiently high prevalence to raise the question of temporarily discontinuing the practice, inoculations were carried on throughout the year as vaccine became available. 89 Under the 1956 arrangements, all vaccine was distributed to local health authorities to be given by their medical staffs. From early in 1957 parents who elected to do so could have their children treated by their family doctors. Although the extent to which the work was done by general medical practitioners varied from one part of the district to another, in general about half the children were treated by their own doctors, the other half at the clinics. In the summer there was increasing pressure on the Minister to agree to the importation of vaccine from America to supplement the home supplies, supplies which were not coming through sufficiently quickly for there to be any hope that the children who had been registered for treatment in the spring of 1956 would be treated by the time of the peak incidence of 1957. The suggestion did not find favour, apparently on the grounds that the preparations had not passed the rigid safety tests imposed on the home products and partly because the vaccine, being made from virus prevalent in America and not here, would not be as potent a preventive to those in this country as to those given it in America. On the point of safety, it seemed there should have been no difficulty in arranging for the American vaccine to be subjected to the same safety tests as the home manufactured products. In regard to the second point, even if it were that much less potent to those in this country, many parents would doubtless have been glad to have availed themselves of the opportunity of having their children given this partial protection until such time as they could have the British product. In the summer, children born in the years 1955 and 1956 could be registered, and also those who were born in the years 1947 to 1954 but who had not registered in 1956 were given another opportunity of being registered. Those children of those ages who registered in the spring of 1956 remained the priority group who were to be treated before any other groups. In point of fact, nearly all these children were treated before the end of the year, there being outstanding only a certain number of children who needed their second doses; and in the meantime a start had been made on the second priority group, those born in 1955 and in 1956. In the autumn the Government reversed its previous decision and decided to import vaccine from America. In anticipation of these larger supplies coming along, a wider range of people became eligible for treatment. These included children over the age of 6 months, expectant mothers, general medical practitioners and their families, ambulance personnel and those treating poliomyelitis patients in hospital and their families. None of these extra supplies had come through by the end of the year; nor had any arrangements been made by then for the registration of those in these groups. 1956 was a year of low prevalence of poliomyelitis in this country, this was not favourable to an assessment of the value of the vaccine as a preventive. In America there had been an 80 per cent, reduction of Paralytic poliomyelitis over the last two years, this sharp drop being attributed to the use of the Salk vaccine. There is, as yet, no definite information about how long the effect of the vaccine lasts. A report issued towards the end of the year indicated that, after the lapse of a few months, the anti-body level which had been 90 raised by the two inoculations fell; on the other hand, it could be raised again by a booster dose. It is probable that it was similar experience in America which led them to decide that a course of inoculations should be two doses spaced at three to five weeks, followed in some nine months by another dose; what happens after that is not known. It may be that the actual level of anti-body is not the important point, but that the effect of the inoculation of the dead vaccine will result, on the exposure to infection, in an immediate increase in the state of immunity. Although there is as yet no question of the use of an attenuated live vaccine being given orally, preliminary trials did not point to any harmful effects, either on the persons vaccinated or upon members of their families. It is hoped that such a vaccine can bring about a lasting immunity and result in the elimination of virulent strains of virus at present in circulation, something that the present killed vaccine is not able to bring about. During the year 13,756 doses of vaccine were received. The number of persons known to have received two injections during the year was 5,147. A further 1,397 received one injection. MEASLES 1957 was not a year of heavy incidence of measles, in all only 1,783 being notified. Starting with a weekly average of only eight in January, the number of notifications rose to its height in April with a weekly average of 80. A fall then set in, but the upward trend was resumed in July when the weekly average reached 66. In August there was a further decline, and for the rest of the year there were only occasional notifications. Although the attack rate of schools varied and some were affected in the spring term while others which had escaped then were involved in the summer term, the disease appeared in schools throughout the entire district. Clinically the illness remains of the mild variety, only four patients suffering from it having to be admitted to hospital. There were again no deaths from measles. The fall in the fatality rate from 0.03 in 1955 to 0.02 deaths per 100 notifications in 1956 for the country as a whole suggests that measles is losing its killing power. WHOOPING COUGH 256 cases of whooping cough were notified. Most of them occurred in the first five months of the year when in many weeks as many as ten cases were notified, but in only two weeks were there more than 20. The weekly average of notifications for this period was 11. In the next three months the average weekly notifications were just over two, and in the last four months there were in all only nine cases. No sufferers were removed to hospital, and once more the infection caused no deaths amongst those in this district. It is accepted that to-day's vaccine against whooping cough is most useful. So far from it being claimed that it affords full protection in all cases, it is accepted it does not do so. On the other hand, it does seem that those who have been treated but who nevertheless contract the infection suffer from only a mild attack, so vaccination does much to remove the danger and also much of the distress of this complaint. That full protection might not be afforded has the disadvantage that an atypical 91 attack develops, one in which there is no whoop, and this might not be recognised for some days, with the result that the child is up and about and can spread the infection to others. This risk points to the added desirability of all children being given this vaccination. Because infants of the youngest ages are susceptible to attack on exposure, and because it is such a serious complaint when it occurs in the very young, it is most desirable that babies even of the tenderest ages should receive this projection. The treatment of the older child does something to protect the infant because in a proportion of those treated absolute protection is given at least for a while, so that they, even though exposed to infection, will not take the disease into the house and give it to the younger children. However, because only a proportion are given this absolute protection and so many develop only partial resistance, it is as well for infants to be inoculated against whooping cough at a very early age. Those attending the clinics can be treated. For much of the year they had been given the combined preparation to protect them against whooping cough and against diphtheria. During the year 2,026 children were treated, 1,083 by general medical practitioners and 943 at the clinics. The fall in the number treated compared with 2,184 of the previous year, is probably due to the introduction during the year of the arrangements by which combined preparations were not used. PUERPERAL INFECTION Only one person delivered in the district was notified as suffering from puerperal infection, a woman who, delivered in a nursing home, developed phlebitis. OPHTHALMIA NEONATORIUM No cases of ophthalmia neonatorium were notified relating to infants in this district in 1957. 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 495 intimations of chicken pox were received during the year. Most of these related to children from two schools in the first term of the year, and five schools in the last term. The schools attacked in the first term leaped later in the year. Almost all schools had some cases, but most only very few. Mumps 1,084 intimations were received of children attending the primary schools suffering from mumps. These were almost limited to the first half of the year, March being the month when most were affected. Almost every school had some cases; one had more than 100 and seven had between 50 and 100 cases. 92 German Measles This complaint, which is something quite distinct from the ordinary type of measles, most often appears when ordinary measles is prevalent, but sometimes it appears by itself. Of the 135 cases learned of, one-half were from one school. In none of the schools at which there were these cases was the ordinary type of measles prevalent at that time. Tetanus The organism which causes tetanus is one whose natural habitat is the alimentary tract of horses, cows etc. Infection occurs by the introduction of the organism through a wound in the skin. The special risk is when the wound contains soil from land which has been contaminated by the organism, but the risk is there from many injuries, especially deep ones, because the organism is an anaerobe. As a protective against the infection there is a toxoid which can be given to a normal person to produce active immunisation, or the serum which can be given to ward off the attack in one with injuries. Those in the Army are given this toxoid which protects them for many years; in addition those wounded receive anti-serum. This was given as a routine to those injured in the raids in the last war even though the wounds were clean. There are not many cases in this country; the exact number is not known, as the complaint is not notifiable; perhaps it is about 200 annually, of which forty per cent, are fatal. For the years 1945 to 1953 there were between 60 and 80 deaths each year, but for each of the next three years the numbers were between 30 and 40. These are deaths ascribed to the complaint. The exact number of deaths, though, is not known because the assignation of a fatality which is the result of an injury in which tetanus has occurred depends on the severity of the injury. If it is trivial, then the death is ascribed to tetanus, whereas if it is severe the death is ascribed to the injury. Whatever the number, though, most of these deaths could have been avoided had the person previously been actively immunised. This is a more practicable procedure than relying on the giving of serum to those who have been injured, because inevitably there will be the large numbers of minor injuries which are not treated by doctors and where no anti-serum will be given. Up to this, the question has not been one of public health interest; but now it has become one, because of the incorporation of tetanus toxoid with the toxoids of diphtheria and whooping cough in a single vaccine. As this entails giving no more injections than the procedure to give protection against the other two infections, it would seem that there is little point in not using the combined preparation. But about one point further assurance is needed. In the case of diphtheria and whooping cough, it was found that each toxoid enhanced the effect of the other when they were given together; but when tetanus toxoid is added, it may be that some of the potency of the others is lost. If this should be the case, then, the gain of acquiring protection against the remote chance of infection by tetanus would be at the expense of the efficacy of the preparation against the other two complaints. Another point is that for the time being many are reluctant to use the combine vaccine against whooping cough and diphtheria because of the risk of provocation poliomyelitis. Until this difficulty has been got over, it is 93 improbable that the use of vaccine containing tetanus toxoid added to one or both of the others will become accepted practice. Influenza Influenza as such is not notifiable though influenzal pneumonia is. The numbers of these, however, do not give any real idea of the prevalence in influenza, because in most outbreaks only a small proportion of the sufferers develop pneumonia. In the earlier weeks of the year, which is the commonest time for influenza to be present, the only notable outbreaks in the country as a whole were in the service units, some at least of them due to Virus A. There was little of it in this district and only one person here died from influenza at this time of the year. This district was invaded, as was the rest of the country, by the Asian influenza later in the year. 1957 Influenza Pandemic. This outbreak started in China in the early spring, the virus being first isolated in March. The spread in the subsequent months was very rapid, the complaint reaching Australia in May. By July it had reached South Africa and Chile, and during August was spreading in the Argentine, South Brazil and New Zealand, by which time it had appeared in every continent. The northern counties of this country were attacked early in August, and by the end of the month the midlands were involved. By September those in the southern counties were affected by a similar complaint. The peak incidence, as reflected by new claims for sickness benefit was reached in Yorkshire by September 24th, north and north-western regions and Wales by October 1st, the Midlands by October 8th, London and the southern, eastern and southwest regions by October 15th. The entry to countries was largely the result of cases having developed in persons on ships, those in ports being first attacked and then those in adjoining districts. The organism, which has been designated as A/Asian/57, although belonging to the A virus group, is the most aberrant type reported since the discovery of the influenza virus in 1933. Antigenic variants of the A virus have appeared in previous outbreaks, but in recent years these variations have been fairly slight. Since most of the population have never been in contact with this particular strain, they have not acquired immunity to it, and this probably is the explanation of the rapidity of the spread of this outbreak. There were two features which distinguished this outbreak of influenza from previous attacks. One was this very great invasiveness, the illness affecting more particularly those in closed or semi-closed communities such as schools and service establishments. The attack rate ranged from 10 to 30 per cent, of those exposed, possibly 25 per cent. for the country as a whole, a much higher rate than the 5 to 10 per cent. for the attacks in 1951, 1953 and 1955. Children of ages 5 to 10 were most affected, and teenagers. The other feature was the relatively mild clinical type with low rate of complications. Although in general clinical manifestations were mild, many patients suffered from pneumonia, a proportion of these cases proving fatal. Possibly 5,000 persons died of it one death to every 2,000 or 3,000 cases. Those attacked in this way 94 were of no particular age group, nor were there any recognisable predisposing causes, many of the deaths being in those of under 45 years of age. The first intimation of anything occurring locally was in the week ended September 21st when notice was received of an illness attacking many pupils in one of the local schools. At the same time a general practitioner reported that two of his adult patients were suffering from an illness similar in character to that which had been reported in the northern counties. The patients suffered from a raised temperature and headache; a high proportion had sore throats, some vomited and a small proportion had other gastro-intestinal disturbances. In due course the laboratory reported that Virus A had been recovered from the throat swabs of some of these patients. Later results were that it was of the Asian strain. In the meantime pupils at many other schools suffered from a similar illness. The number of absentees in each of these schools soon rose to a maximum, most often in the second week, followed by a fall to more normal attendances in a further three to four weeks. The wave had passed through the district by the middle of November. Experiments in influenza vaccination have been carried out for the last 20 years. Although it cannot be claimed that a pandemic can be stopped by vaccinating persons against influenza, the results obtained up to this have been sufficiently encouraging to justify the hope that a high death rate might be prevented, and also excessive absenteeism which might disorganise the public services. Unfortunately, the vaccine prepared against this virus seems to stimulate little antibody reponse, so presumably could not be expected to give much protection. This is perhaps because so few of the population have had previous experience of this virus, so that the first injection would be acting merely as a primary stimulus. The vaccine which became available was issued to members of hospital staffs and then for the use of those members of local health authority staff whose duties took them to homes and more especially to homes where there were sufferers, these including midwives and home nurses. By the time that the vaccine was available to others, the outbreak had spent itself. A report of the Medical Research Council's Committee on Influenza and Other Respiratory Virus Infections issued early in 1958 based on volunteers in public schools, teachers' training colleges and other centres showed that inoculation with one dose of Asian influenza vaccine had a very definite protective effect from four days later. TUBERCULOSIS The setback in the general improvement of the position regarding tuberculosis, one of the outcomes of the second world war, has now been overtaken, and each year is seeing a steady improvement in the situation. The number of deaths from tuberculosis in the country as a whole fell first, the figure in 1956 being 5,375 compared with 23,551 in 1947. the 1956 figure being a decline of seventeen per cent, even on that of 1955 Notifications started to fall much later, but they too are now diminishing steadily. During the five-year period from 1952, the notifications fell from 48,993 to 35,504 in 1956, a fall of twenty-six per cent. This fall is 95 continuing and was seven per cent, in the last year. Amongst the age group 20-24, the death rate in 1954 was only one-sixth of that in 1938; the reduction in those of middle ages was two-thirds. Whereas just before the war the new cases were 92 per 100,000 and after the war rose to 103, by 1955 the rate was only 71, the lowest national rate recorded. There is, however, still some way to go before it can be claimed that the disease is really on the run. Seven hundred new cases are being discovered each week and the disease is causing the deaths of nearly 100 persons every week. The number of cases on the tuberculosis register is increasing by 11,000 each year. In addition to the 300,000 recognised cases, it is thought there are some 75,000 undetected cases. Of this total of 375,000 persons, 45,000 are sputum-positive, and are therefore a danger to others. Notification The following table gives the age and sex distribution of the persons resident in the district who were learned of for the first time to be suffering from tuberculosis:— Primary Notification Other Intimations Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F Under 1 2 - - 1-4 - - 1 - - - - 5-9 1 1 1 - - - 1 1 10-14 - 2 1 - - - - - 15-19 4 7 1 1 - 2 - 1 20-24 8 11 - - 3 3 - - 25-34 15 15 - 2 17 18 - - 35-44 12 6 - - 7 4 1 1 45-54 15 7 - - 8 2 - - 55-64 18 4 - 1 3 1 - 65 and over 5 - - - - - - - Totals 80 53 3 5 38 30 2 3 Primary notifications relate to persons who had not previously been notified as suffering from the disease and who presumably contracted their infection while living here. It is this figure which is sent to the Registrargeneral. The other intimations relate to people who had been notified in other districts before coming to live here. The combined figure is the number of cases new to the district. In 1957 it was 214, compared with 264 in 1956 and 287 in 1955. The number of primary notifications was 141; the number in 1956 was 160 and in 1955 183. The fall in these sets of figures shows that the district is taking part in the improvement in the situation seen in the country as a whole. Although in general the primary notifications are accepted as relating to persons who have contracted their infection while living here in that they have not been notified elsewhere, in fact some relate to persons who probably were already suffering when they moved into the district even though the case had not been recognised. This is presumed to be the 96 case when a person is notified here within a matter of weeks of his coming to live here. There were 11 of these cases. A history of close contact with someone suffering from pulmonary tuberculosis, usually a member of the household, was obtained in twentynine per cent, of the cases of men and thirty-five per cent, of the women; or 27 out of the 87 cases in which a history was obtained. Tuberculosis is rather more common in those engaged in certain occupations than in the general population. There was seven instances of that this year. Some illness or other state predisposes to the onset of tuberculosis to such an extent that it is possible that in some cases had there not been that predisposing cause the patient would not have suffered from a clinical attack. There was, however, only one such case this year. Quite a number of notifications are received in respect of some who fall ill while they are serving in the Forces. There was only one such case this year. Assuming that these conditions were in fact responsible for the breakdown in these cases, they numbered only 47 out of 141. About the remainder, it is not known what caused the lowering of their resistance and enabled the organisms to get the upper hand. Register The tuberculosis register is a compilation of the names of those persons in the district who are suffering from the disease or have recently suffered from it. The names of those newly notified are added to it, and entries are made of those persons who have moved into the district suffering from tuberculosis. Names are deleted on the removal of persons from the district or on death or recovery, an accepted standard of recovery being a lapse of five years in the pulmonary cases and three years in non-pulmonary cases from the date the disease was arrested. 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, 1957 1,313 1,047 139 156 No. of new cases added (primary notification) 80 53 3 5 No. of cases other than primary notifications 38 30 2 3 No. of cases restored to register 8 5 — 2 No of cases removed 129 106 9 18 No. on register, December 31st, 1957 1,310 1,029 135 148 On the 260 deductions, 115 (110 pulmonary) were of persons who had left the district, 31 (28 pulmonary) were of persons who had died 86 (72 pulmonary) were of persons who had recovered and 28 (28 pulmonary) were of persons who had been lost sight of. Two had been denotified. The net decrease in the number of cases on the register is 33, there being 21 fewer pulmonary cases and 12 fewer non-pulmonary cases. 97 This is the first time it has been possible to record a fall in the number of cases on the register. The reduction was in the numbers of both types of disease and in each case in each sex. The increase in each of the previous two years had been very much smaller than in the preceding year. This suggests that the fall will continue. Deaths Twelve persons (11 male and 1 female) died from pulmonary tuberculosis during the year and two (both male) from non-pulmonary tuberculosis. The number of deaths from tuberculosis in 1956 was 16. This infection, then, accounted for a death rate per thousand population of 0.065 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 and even of those of 0.42 and 4.9 for 1948. Preventive Measures As tuberculosis is a communicable disease, its early recognition is one of the most important of the preventive measures, as not only is the sufferer able to take precautionary measures that much earlier, but early detection followed by treatment might either prevent his reaching an infective stage or reduce the risk of his becoming that much more infective. There are different ways in which this can be done, apart from the routine examination of home contacts at the chest clinics. They include the use of the mass X-ray unit, the examination of contacts of those recognised to be suffering from the disease, the examination of young persons who give positive tuberculin reactions and also of their contacts. Tuberculosis is now one of a growing group of diseases in which the resistance of the individual can be raised by inoculation. Mass X-ray Unit. This unit visits the area about once every three years. It came in the summer months of 1956. Sessions were arranged for the examination of the general public and also of organised groups, these taking place mostly at the places of employment. Twelve of these premises were visited, at which 7,815 persons were examined. Public sessions were held at a number of premises. This year, the unit, besides being at Grant Road school and Victoria Hall, went to a number of premises in different parts of the district for the first time, with encouraging results, especially as many of those who attended these sessions would probably not have attended anywhere before. Of the 8,862 who attended these public sessions 3,221 were men and 5,641 women. Out of all those examined, 229 persons were referred to the chest clinics for further investigation. Out of the 131 who attended, 29 were found to be suffering from active tuberculosis. The surveys carried out by the mass X-ray unit are detecting smaller numbers of cases, and the question is raised as to what now is their most profitable use. There must come a time when it is relatively unprofitable to re-examine the same groups of the population, and better returns will be obtained by more selective use of the apparatus. On this and in regard to one group, a memorandum of the Ministry of Health to the Regional Hospital Boards says: " Radiography of school children yielded so poor a return that it is justifiable only for contacts or those found to 98 be tuberculin positive. The need for more services is largely a need for more static units which are best sited at hospitals. Mobile units should direct most of their attention to people in whom the prevalence of tuberculosis is likely to be high or the risk of spread great; e.g., those in poor, overcrowded areas, older men, teachers and others dealing with children, food handlers, vagrants and tuberculin positive children." In 1956 in the country as a whole twenty-one per cent, of new cases were detected by these means. Examination of Contacts. Home contacts of those recognised to be suffering from tuberculosis are encouraged to attend the chest clinic for examination, not only with a view to detecting in the earlier stages the disease which the primary case might have passed on to those contacts, but also to detect the person who might have given the disease to the first patient recognised. Apart from these arrangements which are part of the routine procedure at chest clinics, special attention is paid to the school child in one of two ways: 1. The first is the examination of the contacts of a recognised case when a school child or a teacher is found to be suffering from pulmonary tuberculosis. The question is gone into of whether it is advisable for the class contacts to be examined either with the object of detecting the disease in those who might have been infected, or to detect some other person who might have caused the infection in the first case. During the year one school child and two teachers were notified. It was felt desirable that investigations should be carried out. In addition, investigations were carried out of the contacts of two other school children who had been notified late in 1956. The procedure these days is that those in the class alone are dealt with, these children being tuberculin tested and the positive reactors referred to the chest clinic. The following is a summary of the findings:— (i) A school child notified in December, 1956: 34 class contacts were tuberculin tested, of whom eight were positive; two of these were kept under further observation. (ii) A school child notified in November, 1956: Of 22 class contacts examined, four were positive; one was kept under observation. (iii) A school child who moved from one school to another: 199 pupils were tested; 27 reacted positively, six were kept under observation. (iv) A teacher: A class of 34 were tuberculin tested, all being found to be negative. (v) A teacher: A class of 31 were tuberculin tested. Of the three positive reactors, two had previously had B.C.G.; the other had probably been infected at home. 2. The other is the tuberculin-testing of school entrants. The arrangements by which the entrants at some of the schools were given the opportunity of being tuberculin tested were continued. The purpose behind this testing is that a positive reaction in a child of this age probably means that the child has been exposed to infection at his home. The positive reactors then are referred to the chest clinic, where they themselves are examined and their contacts encouraged to attend for examination. 99 During the year 146 were tested, of whom only one reacted positively. The positive reactor who attended the chest clinic was found to be free from disease. B.C.G. Inoculation. The County Council authorised arrangements being made to enable school children between their thirteenth and fourteenth birthdays to be offered protection against tuberculosis by means of B.C.G. inoculation. As those who have already been exposed to infection do not need the injection, the procedure is first to carry out a tuberculin test. The negative reactors are given the injection. The positive reactors are referred to the chest clinic for examination. A beginning was made in February in the secondary modern schools. Then came the turn of those at the grammar schools, and last the pupils at the independent schools. By dealing with two schools in one week for a few weeks, it was possible to complete the testing of pupils of these ages at all the schools before the end of the year. Of the 1,734 in the secondary modern schools eligible for testing, 1,226 accepted. Of those who were tested and read, 1,023 reacted negatively and 124 positively. The corresponding figures for the pupils at the grammar schools were 872, 648, 504. and 63; and of those in the independent schools 931, 639, 484 and 99. The total figures were: numbers eligible. 3,537; number of acceptances, 2,513; number who reacted negatively, 2,011 and positively, 286.