AC 439(1) HARROW Gckd HARR 25 BOROUGH OF HARROW Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1958 CARYL THOMAS, M.D., B.Sc., D.PH. BARRISTER-AT-LAW Gckd 21/8/5 BOROUGH OF HARROW Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1958 CARYL THOMAS, M.D., B.Sc., D.PH. BARRISTER-AT-LAW TABLE OF CONTENTS page General Statistics 9 Deaths from Accidents 14 Cancer of the Lung 16 General Health Services: Hospitals 23 Nursing Homes 24 Establishments for Massage and Special Treatment 25 Nursing, etc., in the Home 25 General Medical Services 27 Day Nurseries 28 Clinics and Treatment Centres 28 Provision for Special Classes of Person 31 The Aged 34 Laboratory Facilities 39 Ambulances 40 Legislation 41 Sanitary Circumstances 42 Water 42 Fluoridation 43 Drainage 43 Public Cleansing 48 Public Conveniences 50 Disposal of the Dead 51 Sanitary Inspection 52 Housing 55 Factories 64 Shops Acts 64 Atmospheric Pollution 66 Hazards of Radiation 67 Inspection and Supervision of Food 76 Hygiene of Food 81 Health Education 82 Infectious and Other Diseases: Prevention and Control 83 Poliomyelitis 93 Tuberculosis 97 B.C.G 102 Another Five Years of Figures 104 5 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH To His Worship the Mayor, Aldermen and Councillors of the Borough of Harrow. Mr. Mayor, Ladies and Gentlemen, I beg to submit the Annual Report on the Health and Sanitary Circumstances of the District for the year 1958. This Report is interim in character only, though an extra chapter has been included which brings up to date the vital statistics of the district for the last five years. This last year was again in general, a healthy one. These days two infections in particular might be prevalent. Of these, the incidence of poliomyelitis was especially light, there being only three cases in the course of the year. While the poor weather might have been an important factor in restraining the rise of incidence in the Summer and Autumn, the extent to which immunisation has been carried out must have been a contributory factor. The other infection liable at times to explosive incidence is influenza. This year was not one of high prevalence. The weather conditions were not those which especially favoured fog or smog so that there was freedom from the respiratory complications of these phenomena. The number of infant deaths is now relatively so small that wide fluctuations can occur without these being of any special significance, fluctuations which cause correspondingly large changes in the infant mortality rate. The local rate of 17.0, though higher than that of the previous year, is still well below the national rate of 22.5, even though this was the lowest recorded for this country. Though not to the same extent as had been the case in the previous year, most of these infant deaths occurred amongst those who had been born in hospital. Neither measles nor whooping cough was prevalent. It is quite unusual these days to have to record a death from either complaint which so recently were the scourges of early childhood. One occurred this year from measles in a mongol who had a congenital defect of the heart. Scarlet fever remained of low prevalence, what few cases there were being mild in character. The district was free for another year from diphtheria, this being the eighth consecutive year. The position in regard to tuberculosis continues to improve. There was a further fall in the number of deaths due to this complaint, a large drop in the number of new cases notified, and for the second time it is possible to record a fall not only in the numbers of those on the tuberculosis register but a fall in each sex both for respiratory and non-respiratory complaints. The credit for this satisfactory state of affairs must be shared by many. Much is due to the fact that this district is in the part of the country where it is rather than in the harsher north, a lot to the fact that much of it is of recent development so that in general housing is good and the district well planned of low density. Some of it is due to the general standard of living, part of it to the district's freedom from heavy industry which in less favoured districts pollutes the atmosphere. Much of the 6 credit must go to those who provide the basic essential environmental services, the adequate supply of pure wholesome water, the efficient drainage of the district, the cleansing service including removal of house refuse and street sweeping. Given all these favourable factors though, trouble might still arise through lapses in hygienic standards through thoughtlessness, lack of consideration or ignorance. It is here that the work of the Public Health Inspectors carried out under the Chief Public Health Inspector, Mr. S. N. King, is of such importance. The emphasis on their work is changing. Inspectors passed from the designation of Inspectors of Nuisances who were concerned so much with drainage defects, housing faults and control of nuisances to the Sanitary Inspector whose time was still so much taken up with similar problems. Then on to today's Public Health Inspectors who are spending even less of their time on such physical conditions and steadily more on health education in different ways. Remedying the defects in the conditions under which people live still looms too much in their work, but even with the slum clearance programme the volume of this work is lessening. Although there were no spectacular advances in this last year on this campaign, steady progress was made and by the end of the year a further number of houses had been dealt with. As in so many of these the demolition was not carried out until 1959, the figures do not give a true indication of the extent to which the housing conditions of the occupants of those properties have improved. If not the result of, at least subsequent to, the Rent Act, there was a marked move by owners to carry out work on many houses which it had been considered at one time would have to be dealt with under the Council's slum clearance programme. Sufficient work has been done in a number of these houses to remove them from having to be considered in the five-year programme. The standard of accommodation at these often enough is not very high, but the work done to improve them certainly warrants their being retained as housing units for a further term of years. The improvement in the staffing position came too late to enable much leeway to be overtaken, with the result that it was not possible to make any definite advance in regard to the delineation of a smoke control area. The decline in the importance of some of the infections is one of the most striking changes in recent years. Even as recently as 1934 measles caused the death of twelve children in this district, whooping cough three, scarlet fever nine and diphtheria eight. In that year, even in a population not much more than half today's, there were 163 new cases of tuberculosis, a disease which caused the deaths of seventy-seven people. As a contrast, in this last year there were no deaths from scarlet fever, diphtheria and whooping cough and only one from measles. Only eight people died from tuberculosis, there being only 118 new cases. Against that, food poisoning and food infections have become more common, though fortunately not causing many fatalities, and poliomyelitis has been a matter of concern for the last twelve years. With tuberculosis apparenty now well on the way to being controlled, poliomyelitis possibly also, and there being hope in regard to the control of the spread of influenza, infections look like becoming of relatively slight public health signincanc. Housing conditions are improving and there cannot be any relaxation of 7 effort until all families are suitably housed, not only living in accommodation which is structurally sound but having enough of that so that there is no overcrowding. At long last the drive for the purification of the atmosphere is really on even though in some areas there would appear to be little enthusiasm for it. The improvement in all these different ways serves only to emphasize those conditions which today are causing so much disability and premature decease. To replace the past epidemics of infectious ailments, there are what some describe as the modern epidemics—coronary thrombosis, peptic ulceration, certain forms of cancer, chronic rheumatism, diabetes mellitus, asthma, eczema and the psychoneuroses. Of these, special reference is made in this report to cancer of the lung. The change in outlook of those in the public health service is stressed by the reference to the subject of hazards of radiation. It will perhaps never be the responsibility of local authorities to set up any system of monitoring the air, water or foodstuffs and it will probably always remain a matter of responsibility of a Government Department to ensure the whole country is protected against major risks of accidents or from the disposal of waste products. But it must surely become the responsibility of the local authority to take the first steps of setting in train the machinery in the event of an accident such as the loss of some radio-active material. They cannot do that unless they have been made aware of the amounts and the locations of potentially dangerous products in their areas. Until they know of these, they cannot be in a position to anticipate trouble or to plan what should be done in the event of an incident. Another subject dealt with at length is that of the care of the aged. District councils were divested in 1948 of all responsibilities in regard to the personal services. Nevertheless, they have certain statutory powers to deal with the aged. It is the Medical Officer of Health of the district who applies to the Court for an order under Section 47 of the National Assistance Act for the compulsory removal to hospital or welfare home of certain classes of person. It is the local authority which can arrange for the burial or cremation when no other person or body is making these arrangements. It is the local authority too which can act under Section 84 of the Public Health Act 1936 to provide a limited laundry service in certain circumstances. Beyond this the local authority as such cannot go, directly. Indirectly though, by supporting such a voluntary body as the Old People's Welfare Committee, it can provide quite an extensive service for those people who it would seem are not the responsibility of the Welfare Department of the County Council. That there should have been this development in recent years suggests that the wholesale transfer of personal services from local authorities to local health authorities, administratively tidy as this arrangement might have been, was not the wisest of steps. This last year saw the tenth anniversary of the coming into operation of the National Health Service Act, an Act which amongst other things deprived this district and others like it of the privilege of providing certain personal services which it had up to this maintained efficiently and economically. There was much uneasiness about the change. The fears of those who were despondent have been realised. In July, 1956 the 8 Government published a White Paper on Areas and Status of Local Authorities in England and Wales. It was stated they were also considering the question of some distribution of certain functions between the County Councils and County District Councils. In May, 1957 the Government issued a White Paper on the functions of County Councils and County District Councils in England and Wales. In the main White Paper it was said that it would be right that the larger borough and urban district Councils, those with populations of 60,000 or more, should be entrusted with the domiciliary and certain other health and welfare services (under Part III of the National Health Service Act, 1946 and Part III of the National Assistance Act, 1948)—education, employment of children, classified roads and bridges thereon, town and country planning, shops, theatres and cinemas, food and drugs, milk and dairies, libraries, weights and measures, fertilizers and feeding stuffs, diseases of animals, licensing of waste food boiling plants and smallholdings. In regard to whether responsibility should be conferred outright or be delegated, the White Paper said "the Government's conclusion is that the delegation method, essential for some services, is the more appropriate generally. In their opinion, however, the larger Boroughs and Urban Districts should have an unquestioned right to exercise the powers to be delegated." The White Paper pointed out that Middlesex presented its own difficulties. It was proposed that "the two-tier structure should be retained throughout Middlesex and no promotion to County Borough status should be made. Clearly the larger Middlesex district councils, some of which are very large indeed, should be entitled to exercise the responsibilities which it is envisaged should normally be exercised for the rest of the country by Boroughs and Urban Districts with a population of 60,000 or more." Middlesex is to be considered with other authorities in Greater London, the position being referred to a Royal Commission. This Commission was appointed in November, 1957. A statement was submitted to the Commission by the Council in June, and in September the Chairman of the Commission and the Secretary visited the district. I have the honour to be, Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Kynaston Court, Harrow Weald. 25th May, 1959. 9 STATISTICAL AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population, mid-year 1958 214,300 Rateable Value (1st April, 1958) £3,723,475 Sum represented by a penny rate (1st April, 1958) £15,151 Total number of occupied houses and flats 64,083 Extracts from Vital Statistics for the Year Live Births:— Male Female Total Legitimate 1,425 1,313 2,738 Illegitimate 56 36 92 Total 1,481 1,349 2,830 Live birth rate per 1,000 population 13.2 Illegitimate live births per cent. of total live births 3.2 Stillbirths:— Male Female Total Legitimate 22 24 46 Illegitimate 1 - 1 Total 23 24 47 Stillbirth rate per 1,000 live and stillbirths 16.3 Total live and stillbirths 2,877 Deaths:— Number 1,992 Death rate per 1,000 population 9.3 Deaths of infants under one year of age 48 Infant mortality rate 17.0 Legitimate infant mortality rate per 1,000 live births 16.4 Illegitimate infant mortality rate per 1,000 live births 32.5 Neonatal mortality rate per 1,000 live births 13.5 Maternal deaths (including abortions) 2 Maternal mortality rate per 1,000 live and stillbirths 0.70 Death from Cancer 414 Measles 1 Whooping cough - Tuberculosis 8 Population The mid-year population of the district was estimated to be 214,300. 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 1958 figure being 214,300, a fall of 700 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 746. Some at least of the fall is to be explained by the movement of some families out of the district to new and to expended towns. Quite apart from these transfers though there is a steady movement of population in and out of such district as this. 10 The following is the age distribution of the population of England and Wales in 1956: 0-4, 74; 5-14, 153; 15-24, 134; 25-34, 139; 34-44, 142; 45-54, 143; 55-64, 110; 65-75, 74; 75-85, 53; 85 and over 6. Births The total number of live births registered during the year was 2,830 (1,481 male and 1,349 female). Of these ninety-two were illegitimate, being a percentage of total births of 3·2. The numbers of live births registered in the five years from 1954 onwards were: 2,721, 2,747, 2,755, 2,791 and 2,783. 894 births occurred in the district (889 live, 5 stillbirths). Of this number seventy-two were to residents of other districts. 2,125 (2,082 live and forty-three 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 13·2. The local comparability factor for births is 1·02. The corrected birth rate was therefore 13·5; that for the country as a whole was 16·4, 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 circumstances as the usual residence of those living there. These include general, maternity and special hospitals, maternity homes, nursing homes, sanatoria, convalescent homes, homes for unmarried mothers, hotels, boarding houses, etc. On the other hand, there are many institutions which are regarded as the usual residence of their inmates. These include accommodation provided under Parts III and IV of the National Assistance Act, 1948, boarding schools, convents, nursing homes for the aged and chronic sick, nursing homes (mental) and residential nurseries. According to the Registrar-General's Circular G.R.O. Circ. (L.H. No. 2/58) from January 1st, 1958, a death in a chronic sick or mental hospital will be assigned to the area of occurrence only if the deceased had been there for six months or more. 1,247 persons died in this district in 1958. This figure includes those numbers of the armed forces stationed here. Of these, 185 were of persons who were not resident in the area. 180 deaths took place in the various hospitals, eighty-four in Roxbourne, seventeen in Oxhey Grove and thirty-seven persons died in non-transferable institutions. Of the 921 deaths of the local residents which occurred outside the district, most took place in institutions, 400 being at the Edgware General Hospital. 204 deaths took place in hospitals just outside the district 11 including seven in nearby isolation hospitals, and 210 in various London hospitals. Six deaths were of infants born in hospitals outside the district. The total number of deaths was 1,992. The figure for 1957 was 1,937 and for 1956 was 1,903. The 2,094 of 1951 was the largest number of deaths recorded for this district. The death rate was 9·2 per thousand population. The rates for the last five years were 8·7, 8·8, 8·2, 8·8 and 8·9. The rate for the country as a whole was 11·7, a slight rise on the figure of the two previous years. 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 1·19; the adjusted rate is 11·1, a figure well below that of 11·7 for the country as a whole. The following is the Registrar-General's abridged list of causes of death in this district:— Male Female Male Female Resp. tuberculosis 1 1 Hypertension 23 29 Other tuberculosis 0 0 Other heart disease 79 144 Syphilitic disease 4 1 Other circulatory disease 41 87 Diphtheria 0 0 Influenza 4 4 Whooping Cough 0 0 Pneumonia 33 45 Meningococcal infections 0 0 Bronchitis 68 39 Acute poliomyelitis 0 0 Other respiratory disease 12 4 Measles 1 0 Peptic ulcer 14 13 Other infective diseases 1 1 Gastritis, Enteritis 3 6 Cancer of stomach 37 17 Nephritis 9 4 Cancer of lung 71 11 Hyperplasia of prostate 8 — Cancer of breast 0 53 Pregnancy, etc. 0 2 Cancer of uterus 0 18 Congenital malformation 6 7 Cancer of other sites 106 101 Other diseases 67 71 Leukaemia 8 11 Motor vehicle accidents 19 7 Diabetes 1 10 Other accidents 13 12 ascular diseases of nervous system 122 171 Suicide 8 10 Homicide 0 0 Coronary disease 214 134 979 1,013 1,445 deaths were due to diseases of the circulatory system, vascular diseases of the central nervous system and to cancer, a percentage of seventy-two of the total deaths. The following are the numbers of persons who were of different ages at the time of death: under one year, 48; over one but under five years, 5; live to fourteen years, 5; fifteen to twenty-four years, 20; twenty-five to forty-four years, 68; forty-five to sixty-four years, 534, sixty-five to seventy-four years, 488; seventy-five years and over, 851. 12 Of these local deaths, 58 per cent. of those males were persons of sixty-five or over, 32 per cent. of seventy-five and over, and eighty-five and over 7 per cent. The corresponding figures for females were 74, 52 and 16. Of the local residents who died last year, 42 per cent. had reached the age of 75 and 12 had reached the age of 85. In recent years there has been an extraordinary increase in the expectation of life. For males, compared with a figure of 40 of 100 years ago, today's figure is 68. For females the figure of 44 has jumped to today's 74. It is a popular misconception that this means that we are living that much longer. That is not the position. Most of the increase in the expectation of life is due to the saving in the previous large numbers of infant deaths. These were so many that while the expectation of life at birth of boys in 1871 was forty-one. the expectation of life at one year of age was forty-eight. With the diminution in these infant deaths, the expectation of life of those at one year of age is now very little different from those at birth, the actual figures for boys being sixty-nine and sixty-eight. The effect of this saving of infant births was more marked in the earlier years of the century when the rate was falling rapidly. The expectation of life for boys which in the years 1910 to 1912 was fifty-two had reached fifty-nine by 1930/1932 and sixty-seven by 1953. Since then however, the figure has remained much the same, being sixty-eight for each of the years 1953 to 1957. At the same time, the expectation of life of boys of one year of age has steadily approximated to the figure of expectation of life at birth, the difference of six in the years 1910 to 1912 becoming narrowed to a difference of one by 1957. This stabilising of the figure of the expectation of life, whether at birth or at one year of age, indicates that the separate units of the population are not living to much greater ages than before. Considering the expectation of life of those aged sixty-five, there is between the expectation for males in 1957 and the years in the first decade of the century only one years' difference, and for females only three years difference. Infant Mortality The infant mortality rate is the ratio of the number of infant deaths under one year per thousand born in the year. Although higher rates are still found where environmental conditions are not satisfactory, this rate is not these days the index it used to be of the general healthiness of the district. This is because the marked saving in the infant deaths which has been seen in this century, has been largely the result of the saving of those deaths occurring after the first week, and more so after the first month of age, and which were due to environmental factors. Most ot the infant deaths which now occur take place within the first days or even the first hours of birth and are now more related to conditions operating at birth. The local rates have constantly been below the national rates; with the rapid fall in the rates for the country as a whole, this gap is narrowing. The improvement in local rates has not been a steady one year by year but has been in a series of jumps. In 1947 there were ninety-two infant 13 deaths, in 1948, ninety-three. The figures for the next four years were an average of 56, for the next five an average of 48. In 1957, 39 deaths gave an infant mortality rate of 14·0, one appreciably below the figure of 23·0 for the country as a whole, even though that figure was the lowest up to this recorded in this country. With a diminution in numbers, wide variations can occur without their being of any material significance. For instance, in 1950 the number of infant deaths was 30, a low figure sandwiched between those of 64 and 62 for the years 1949 and 1951; in the opposite direction, the figure of 59 in 1956 came between figures of 49 and 39. Last year, 48 infants living in the district or born to mothers ordinarily resident here, died under one year of age. In the same year, 2,830 infants were born. The infant mortality rate therefore was 17·0. The rate for the country as a whole was 22·5, a reduction of 0·6 on the figure for the previous year, and the lowest hitherto experienced in this country. Of these 48 deaths, 39 occurred in infants under one month old. The neonatal rate therefore was 13·5, comprising 81 per cent. of the infant mortality rate. Of the twenty-four infants who failed to survive twenty-four hours, only two had been born at home. One of these was born ten weeks premature; the other was one of twins born prematurely to a mother suffering from toxaemia of pregnancy. Of the deaths of those born in hospital, four were due to birth injuries, four to developmental abnormalities and eleven due to prematurity, in seven of which the cause of this prematurity was not known. Of the eight infants who survived twenty-four hours, but failed to live one week, one was born at home; this baby was found dead in a rot on the second day. The causes of death of those who died in hospital were of much the same distribution as those who had died under twentyfour hours. Seven infants lived one week but failed to reach one month of age. Two of these were born at home. Three suffered from congenital developmental abnormalities. Of those who attained one month but failed to reach the age of one year, four died between one and three months, of which three suffered from developmental abnormalities. Two survived three but not six months, one six but not nine months and one nine but not twelve months. Of these, two suffered from severe developmental abnormalities ; the other died during delivery. Stillbirths Forty-seven stillbirths were registered last year. This was a rate per thousand population of 0·29, and a rate per thousand live and stillbirths of 16·3. The rate per thousand births for the country as a whole was 21·6. Of the forty stillbirths about which particulars are known, all but were to mothers confined in hospital. Of those where the mother was confined in an institution, many were premature. In five there was no apparent cause for the early onset of labour In three there was premature separation of the placenta with 14 haemorrhage. Maternal toxaemia was present in three instances; in one early labour was induced because of it. Two suffered from developmental abnormalities. A number of stillbirths were of infants who were born full-time and who were alive just before the onset of labour. In seven of these there was no obvious reason for the death. In another seven, labour was difficult, in two of these labour being overdue. Three infants were in each case one of twins; in two of these instances delivery was by breech. Maternal toxaemia caused death before delivery in three instances. 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. Five survived their first but did not reach their fifth birthdays. Of these, three were in their third and two in their fourth years. Two of the deaths were due to congenital abnormalities, and two to 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 were in the last year two deaths which resulted from pregnancy or delivery, the maternal mortality rate being 0·75. One death occurred in a hospital outside the district; the death certificate read—1 (a) Cardiac arrest; (b) post operative caesarean section. The other death was that of a married woman, the result of "an air embolism due to the introduction of a frothy fluid into a pregnant uterus." Deaths from Accidents The three main causes of deaths from accidents are those which occur on the road in which a motor vehicle is mostly involved, a variety of deaths occurring in the home, and falls. There were apart from those falling into one of these three categories six deaths the result of accidents; four of them were the result of drowning, one of a railway accident and another of an aircraft accident. Death from Falls. Of the sixteen deaths from falls, all but five were the result of falls in elderly persons occurring in their homes or institutions in which they were living, including one which resulted from a fall downstairs. Road Accidents. The numbers of deaths from road accidents in England and Wales has increased each year from the figure of 4,117 in 1952 to 5,036 in 1956. In 1957 there was a slight fall to 4,898. 15 The local figures over the last few years have ranged from 10 to 23; this last year it was 26. Of these, fifteen, all of males, occurred outside the district. Of the eleven deaths which occurred in the district, eight (three males and five females) were of pedestrians of over seventy years of age who were knocked down by a motor vehicle. Although there were no fatal road accidents amongst children in this district, other districts did not enjoy the same freedom. In England and Wales as a whole, road accidents account for one-third of the total accidental deaths amongst children not injured or deformed at birth. For every death, some fifty children are injured. During 1958, 717 children under fifteen were killed in road accidents in Great Britain, this being 88 more than in 1957. In addition, 49,196 were injured, over 4,000 more than in the previous year. The pre-school child is relatively heavily involved, the accident often occurring when a vehicle engaged in local deliveries is stationary for a while and is then driven off. The age of four is one of risk because the child is starting to act independently of his parents. Amongst juveniles, cyclists are a particularly vulnerable group. Accidents in the Home. The local deaths from accidents in the home this last year included eleven of persons who died as the result of a fall when in their homes or institutions where they were living. Ten of these were persons of over seventy years of age. Five persons died as the result of falls elsewhere, only one of these being over seventy years of age. Two persons died from consuming poisons and two from coal gas poisoning. Early in the year, the Ministry of Health issued circular 6/58 with a memorandum on burns and scalds from which the following notes have been taken:— Each year more than 6,000 persons die in England and Wales as a result of accidents in the home. Of these 700 are due to burns and scalds. It is estimated that every year 50,000 persons need hospital treatment for burns and scalds caused by domestic accidents. "There can be little doubt that the majority of the burning and scalding accidents could be avoided if adequate care were given to the construction, location and handling of the causative agents." Most of the deaths are of children under five or of old people. Eighty per cent. of the deaths resulting from extensive burns are due to ignition of clothing. Most of these are due to the clothing coming into contact with a heating element or frame of an unguarded or inadequately guarded fire. The type of fire was open 66, electric 24 and gas 5. There are other causes of burning accidents ; but the chief preventive measure is guarding the fire. A second line of defence is the choice of safer garments for women and children. It had up to this been thought that some fabrics were dangerously flammable while others were relatively safe. It seems, however, that this is not so as virtually all fabrics in common use for clothing are flammable within fairly narrow limits. This makes it important to choose sensible garments. Nightdresses account for a substantial proportion of accidents and pyjamas are much safer, particularly for 16 children. Fullskirted party dresses and loose flimsy garments require special caution. Industry and science are co-operating in research at processes which impregnate fabrics to render them flame resistant. They cost more than the untreated material but increased demand might reduce this. In some cases too they alter the texture of the material. Whatever might be achieved on these lines however, must not be at the expense of concentrating on the adequate guarding of fires. On the prevention of scalding accidents, the summary reads, "Although in some cases scalding accidents may be precipitated by the shape, design and use made of the kitchen or by the form of domestic equipment, it is nevertheless clear that the majority of incidents are due to carelessness." Deaths from Suicide About twenty persons living in this district commit suicide each year. This last year the figure was 18, eight men and ten women. Coal gas poisoning was again far and away the most common method used, being chosen by three men and six women. Poisoning came next, being the method chosen by two men and three women. One man and one woman used the railway. Drowning was the method chosen by one woman, and hanging by one man. There were only three occurrences in the first five months of the year. The months with most cases were October and December. All but one of the men were between forty and fifty-one. Eight of the women were between forty and seventy; the youngest was twenty-seven and the oldest eighty. Deaths from Cancer Of the 1,992 deaths of residents in this district, 414 were due to cancer, this causing 22 per cent. of the deaths of males and 20 per cent. of the deaths of females. Of the 214 deaths from this cause amongst males, in 71 the site was the lung, in 37 the stomach. Of the 200 deaths amongst females, the breast was the site in 53, the stomach in 17, lungs in 11 and the uterus in 18. The 414 deaths from cancer this year were much the same as the number of the previous year (415). Some little time ago it seemed that the numbers of deaths from cancer were growing. Compared with the 1938 figures as a unit base, the comparative mortality index for the first decade of this century was 0.85, for the second 0·92, and for the third 0·98. The question was whether t this increase was real or only statistical. This latter could come about for more than one reason. It could be that because of the saving of lives at earlier ages more persons were surviving to reach the age at which cancer became a factor of importance. Another reason could be that because more children were born in the years at the end of the last century and the beginning of this than before then or since, apart from the saving of lives in the earlier years, there were more people to reach the susceptible 17 ages. These factors could, of course, all be allowed for by the statisticians, and the conclusion arrived at that there was a real increase. Another aspect of the problem was how much of this increase was due to improved diagnosis. That, of course, could account for an increase in incidence of disease in the deep-seated organs, but would not be a factor of importance in superficial cancers which could readily be diagnosed. As an instance, it could be that in the earlier years deaths of patients might have been erroneously attributed to pulmonary tuberculosis whereas the true cause was cancer of the bronchus. The conclusion reached on this point though was still the disturbing one that there was a real increase in the incidence of cancer. Since then the over-all picture has improved. There was in fact, an actual fall to 0·99 in the early 1940's and a further fall to 0·98 by 1946. This decline though has been followed by a gradual rise to 1·00 in 1947, 1·01 in 1950 and 1·02 in 1955. The figures remained the same in 1956, and then fell to 1·01 in 1957. As these figures relate to fatalities, part of the improvement which has occurred might have been due to improved means of diagnosis and therefore earlier diagnosis, and also to an improvement in means of treatment. To what extent these factors have operated in accounting for a fall in the numbers of deaths for the earlier years, they would presumably also be acting to hold back a larger increase than has taken place from occurring. A breakdown in the figures for the sexes shows that amongst females the situation is steadily improving. Since the figure of 0·6 in 1947, each year has seen either a repetition of the figure of the previous year or something less, with a result that the figure for 1957 was only 0·90. The position with regard to males is just the reverse. Each year since 1946 when the figure was 1·03 has seen either a repetition of the previous year's figure or an increase, with a result that the figure for 1957 had reached 1·18. This deterioration in the position regarding deaths from cancer amongst males is almost wholly due to an increase in the number of deaths from cancer of the lung. The only other site showing an increase is the bladder. The other disturbing increase is in leukaemia. In spite of all the work that has been done on the subject, the cause of cancer still remains unknown. It is, of course, known that those exposed to certain irritants are more likely to have cancer of certain sites ; but not all those exposed to these irritants develop cancer. Before the discovery of micro-organisms, much stress was laid on the aetiological factors which contribute to any disease. In the case of some such as tuberculosis, it was thought that there was an ingrained pre-disposition to the disease. The person was said to have a tuberculous diathesis. With the discovery of the organisms responsible for different infections, less stress was laid on this aetiological factor. An illness such as diphtheria for example, was considered to result from the reaction of the host to the Presence of the particular bacillus. Later it was appreciated that the Position was not nearly as simple as this. It began to be recognised that some of the organisms like those capable of causing diphtheria could not in fact cause the disease. There was a difference in the virulence of the organism. On the other hand, it came to be recognised that exposure of Person even to a virulent organism did not necessarily result in illness. If the person had a resistance, being said to be immune to attack, he did not 18 become ill. Later again it was appreciated that even when a person, proved to be susceptible, was exposed to a virulent organism, he even then did not necessarily succumb; there was some other factor which could operate in certain conditions and which apparently could cause a person who had resisted infection many times previously to succumb on some occasion. This change could cause the Superintendent of an isolation hospital who had been in and out of the wards in which there were infectious patients day after day for years, on one day to fall ill with scarlet fever. It is something of this sort which probably accounted for the not really explained increase in the incidence of tuberculosis during the war years. It may be that just as some succumb to any infections going, others subjected to the same exposures remain free. In the same way, it may be that the population can be divided into those likely to and the other group not likely to contract cancer. In the group liable to contract it, it can be assumed that something else is needed to trigger-off the condition—that without this inherent susceptibility, perhaps cancer does not develop, but the triggering is needed, and this will decide not only that cancer will develop but also where it will occur. That there is something in the general make-up of an individual which might affect the liability to develop cancer would seem to be the view of Ogilvie who claimed that the happy man never got cancer. That there is something in the physical make-up is suggested by the correlation of the incidence of cancer of the stomach and the 'A' blood group. Some have suggested a familial predisposition, because of the occurrence of an unusual number of cases in a family. These however, are probably coincidental occurrences. An environmental factor was suggested when it was seen that the incidence might be heavier than average amongst those living near some rivers. The only instance of diet having any relationship would seem to be the high incidence of stomach cancer amongst those living in North Wales; any association there could be more the result of the irritant effect of certain foodstuffs on the stomach wall than of any general effect of diet. In these cases it would perhaps be only those who have their predisposition in whom the disease would develop. Many a woman who has developed cancer of the breast has attributed its origin to a blow. Usually this explanation has been brushed-off with a comment that it was the blow which led to the recognition of the existence of the growth and not to its origin. That explanation though would not account for instances of malignant growths developing following an injury to the nose or a fracture of a bone. Examples of chronic irritation which have led to cancer are those of the old clay pipe smoker, the chewer of betel nut and the chimney sweep. Cancer occurring in those working in certain industries might be due to a specific irritant such as chrome or spindle-oil The man with a gastric ulcer is more prone than the man free from it to develop cancer of the stomach. Some irritants then are non-specific; others are more specific substances. Those liable to be followed by cancer are classed as carcinogens. Cancer and Education of the Public. There are different varieties of malignant growth. Some are so slow growing as to be almost innocent; about some nothing can be done because their spread is so rapid or because of the inherent malignancy of the type. There is a wide range in the rate 19 of progress even of the same type of cancerous growth, one growing in the breast of a young woman being more rapidly growing than the same type growing in the elderly. This means that although diagnosed in the early stages, there is no assurance that a growth is removable or the patient curable. On the other hand, slowly developing, almost non-malignant growths, can be excised years after their origin. Nevertheless, it can be accepted that the chances of eradicating a particular growth are that much greater the earlier the treatment is started. Unfortunately, in so many people, the growth has reached such a stage by the time treatment is first started that cure cannot be achieved. In so very many instances the patient had known of the existence of the growth for some time before having it seen to, and in many of these cases it seems that the delay in seeking treatment was the very fear of the sufferer of being told that the growth was in fact cancer; this is largely because to so many cancer is a complaint which is incurable and which inevitably continues its course. That once was the position, but is not so today. That this is so should be more generally made known because the removal of the fear of the inevitable progress will result in sufferers going for treatment at an earlier stage in what in many cases might be in a recoverable stage. The following table is part of one which appeared in the Annual Report of the Chief Medical Officer of the Ministry of Health for 1957 and refers to the commoner cancers. The table is of the percentage of cases of cancer (age corrected) surviving to five years after diagnosis by stage of disease and kind of treatment given, with the proportion of localised and radically treated cases:— Site Radically treated cases All cases treated or not Percentage of localised and radically treated cases Localised Regional spread Stomach 30 16 5 8 Intestine (except rectum). 44 29 15 21 Rectum 50 29 16 22 Lung 11 5 2 5 Breast (female) 66 34 35 25 Cervix uteri 51 30 35 44 Bladder 47 27 21 29 Skin 87 55 75 73 In all cases there is a marked difference between the percentage of survivors for five years in those in whom the disease was localised at the time of treatment and those where there was regional spread. The figures show that whereas in cancers of some sites there is a good chance of survival for five years, there is little enough in the case of cancer of the lung. This only emphasises the need that what might be done should be to arrest the steady annual increase of these cases. Cancer of the Lung. The increase in cancer of the lung amongst males is one of the most disturbing phenomena in the public health field in recent years and this for two reasons. The first is that the numbers are already very high. 19,000 men in this country died in 1957 from cancer of the lung. This means that in this country one person is dying from cancer 20 of the lung every half an hour. This complaint is already causing oneeighteenth of the deaths of all males, one-ninth of the deaths of males in the ages forty-five to sixty-four. It is said that one in eight of those men who are smoking twenty cigarettes a day will develop cancer of the lung, a marked contrast to the one in 300 of non-smokers. The other reason is that, serious as are these figures today, they are steadily rising. In 1951 something over 13,000 people in this country died from cancer of the lung; in 1952 over 14,000, in 1953 over 15,000, in 1954 16,000, in 1955 17,000, in 1956 over 18,000 and in 1957 over 19,000. It is predicted that this figure will rise in this country to 25,000; and that is the picture wherever cigarettes are being smoked. Each year, half a million people die in this country. Of these, nearly 50,000 die from cancer; and of these, one-third of these deaths in men are due to cancer of the lung. This condition is now causing each year more than four times as many deaths as tuberculosis and four times the number of deaths on the road. 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 falling on such carcinogens as benzpyrene or arsenic present in the air in 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 of the same ages living in urban as compared with rural communities, and could account for the higher incidence amongst those living on the northeastern side of London as compared with those living in the south-west, those on the lee-side breathing air which has been contaminated in its passage over London But in general the atmosphere is less polluted than it was, and yet cancer of the lung is commoner. Atmospheric pollution, then, is not the explanation, and is suspected of being responsible perhaps at the outside for twenty per cent. of the cases. If it were a very important factor, non-smokers and women would not be so relatively immune. Those in certain occupations are exposed to increased risks of contracting cancer of the lung. Certain coal mines have high levels of radio-activity. 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 said: "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." When two series of figures run in parallel, they may be associated. Such association might be one of cause and effect, or it might be that though the two series are independent of each other they are both due to some common factor. In many series of parallel figures though there might 21 be no association either direct or indirect, the apparent relationship being purely coincidental. Of the enquiries in this country on the relationship of smoking and the incidence of cancer of the lung, 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 that 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 to smoke than in those who gave it up. When the findings are broken down to the degree that they are in this report and still retain their correlation, they can point only to smoking being a factor. As the report of the Medical Research Council in 1957 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." There are those who will not accept this conclusion. They point out on the one hand that many, even the great majority, of heavy smokers, reach an advanced age without developing this complaint and on the other, that non-smokers have suffered from it; that investigations have not shown any increased incidence amongst smokers who inhale as compared with those who do not, and that in spite of the increase in cigarette consumption by women the incidence of lung cancer in them is very low. In regard to the point about only a small proportion even of heavy smokers suffering, the explanation could be the general question of predisposition. In those non-smokers who contract the infection the triggering presumably was by some other carcinogen, possibly something in the polluted atmosphere. That those who inhale are not greater sufferers than those who do not, is indeed a weakness in the case incriminating the cigarette as it can only be presumed that if cigarette smoking is the direct cause, any carcinogens are that much more liable to start the trouble in those who inhale than in the other group. Today's relative freedom of women from the complaint, in spite of their growing practice of smoking, is not a point against the conclusion; it can only be feared that when enough women have smoked heavily enough for long enough, when they have reached the years of susceptible age range, they too will suffer heavily. There are those who claim that the attention being focussed on the subject is merely a fad of the statisticians—that whatever the figures may Point to, there is no proof that cigarette smoking is in fact really the cause of the trouble. Such actual proof is, of course, virtually impossible to obtain. It is accepted that there are at least five chemical substances in tobacco smoke known to be capable of causing cancer in animals. It is known too that the local application of tobacco tar to the skin of mice can cause cancer. As to what might be the damaging factor, opinions vary. Some suggest that the paper of the cigarette is of importance, and that it is this that accounts for the higher incidence in those smoking cigarettes than pipes. Others see the actual temperature as a factor of importance, while other again would incriminate the tar condensate. Either of these latter two factors might be felt to account for the relatively higher incidence of 22 this trouble in this country than in the United States of America where the average length of the cigarette stub is 30·9 millimetres compared with 18·7 in Britain. The hypothesis that the heavy smoking of cigarettes is the direct cause of the increase in lung cancer, while it is accepted by many as an explanation of the position, is not accepted by all and it certainly does not account for all the facts. Some see in the correlation not the position of cause and effect, but one arising from the fact that something in the makeup of the individual which predisposes him to lung cancer either itself or with other causes makes him a heavy smoker. Smoking seems to be directly related not only to lung cancer but to other conditions. There is a clear relation in men of twenty-five to sixtyfour between smoking and persistent cough and sputum. Smokers have more chest illness, wheezing, breathlessness and chronic bronchitis. There is too a clear relationship between smokers and disease of the coronary arteries. The general death rate is higher within each quinquennial group in regular cigarette smokers than in non-smokers; this relationship is not seen in cigar or pipe smokers. Of the eight commonest diseases in men over sixty, three—bronchitis, peptic ulcer and hypertension were constantly associated with smoking habits. The incidence of bronchitis and peptic ulcer was higher in men smoking cigarettes than in pipe smokers or non-smokers; on the other hand, hypertension was commoner in men who do not smoke. Another condition which might be worsened by smoking is tuberculosis of the lungs; here smoking can reactivate a quiescent disease. While there is this quite severe indictment of smoking, it is probable that this applies only to heavy smoking. In the relationship of smoking and lung cancer the limiting amount seemed to be about twenty cigarettes a day. Except in those with a special idiosyncrasy, it is very doubtful it light smoking causes damage in any of these ways. On the other hand, the heavy smoker in whom this smoking causes these troubles is really an addict and needs help for the treatment of what leads to his addiction as much as, or perhaps even more than, to wean him away from his heavy smoking. What causes people to smoke at all is a very complicated matter, and is perhaps quite distinct from the question of what causes a person to become a heavy smoker. Deaths from Infectious Diseases These were eight from tuberculosis, eight from influenza and one from measles. 23 HEALTH SERVICES OF THE AREA HOSPITALS Particulars of the Hospital services for the Area were set out in the Annual Report of 1954. General Hospital Service. Although in his announcement in 1955 the Minister of Health indicated that the first stage of the erection of the Charing Cross Hospital at Northwick Park was in the 1957/58 programme, it was decided in 1957 that the new Charing Cross Hospital was to be built on the site of the Fulham hospital. This decision caused concern locally, more especially as from any discussion about these arrangements there was no assurance that any other hospital was to be built on the Northwick Park site. The Council instructed that representations be made to the Minister of Health with a view to early provision of additional hospital beds. In August, a letter was received from the North West Metropolitan Regional Hospital Board which stated that "discussions had been held with the Ministry who now seem to share the Board's view that the most satisfactory way of meeting the deficiency in hospital provision in the Harrow/Wembley area (if Charing Cross Hospital is not to be rebuilt on the Northwick Park site) would be for the Board to build a new hospital of 250 beds on the site." In a written reply to a question in the House on 18th December, 1958, the Minister of Health, referring to capital developments in the hospital service for the year 1960/61, said—"The major projects now selected include in new building, the first phases of new general hospitals for north Tees-side and at Northwick Park for the Wembley/Harrow area." A later communication from the Minister informed the Council that while he has not been able to accept the building of the whole of a new hospital for inclusion in the Government's centrally financed programme at this stage, he had decided to include a first phase, providing this can be done at a cost not exceeding £1,000,000, and he had therefore asked the Regional Hospital Board to try to complete the planning of this scheme by 1960/61. The Minister's communication also informed the Council that he had accepted a proposal made by the Regional Hospital Board, to group the Harrow and the Wembley Hospitals with the Harefield and Northwood Group Hospital Management Committee as from the 1st April, 1959. 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 (60 beds), or to the Bushey 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 24 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 240 beds (threequarters of these for women) 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, 38 are in the Edgware General Hospital. There are 51 at the Roxbourne Hospital (the Harrow Isolation Hospital), 35 at Oxhey Grove Hospital, 14 at the Stanmore Cottage Hospital and 23 at Orme Lodge. Arrangements for admission are made by the Geriatric Officer of the Edgware General Hospital. The patients are accepted from their homes direct only to the Edgware General Hospital and to Roxbourne Hospital where there are adequate facilities for their assessment, initial treatment and investigation. NURSING HOMES These are private establishments which provide accommodation for varying types of patients. Section 187 of the Public Health Act, 1936 requires that these homes shall be registered with the local health authority. The responsibility for registering and supervising them rests with the Health Committee of the County Council. Applications for registration should be made to the Clerk of the County Council. There has been a marked change in the services offered at these homes since before the war. In 1938 there were 24 homes in this district, providing a total of 187 beds, of which 100 could be used for maternity cases. The impact of the National Health Service Act made fewer prepared to meet the cost of private nursing homes for services which they coulu obtain free by other means ; and the difficulties in running these homes, partly the difficulty of obtaining staff and partly the greater cost of what staff can be engaged, have resulted in the closing of a number of them. The greatest loss has been of maternity beds. There has been an increase in the number of beds available for chronic patients, some homes accepting only this type. There is a very great need for such accommodation, somewhere which offers perhaps only temporarily somewhat the same as what is available in the Part III accommodation of the Welfare Service. At one time many beds were available here for such persons, a number being provided by trained nurses no longer engaging in private practice but who were prepared to accept two or three elderly people in the homes. Those accepted would not be bedridden, but they needed looking after, and when they were ill that need was of nursing. The standard of accommodation and of the staff of homes providing for such people could be made appreciably lower than that in those homes dealing with maternity cases or with acute surgical conditions. During the year, Maitlands Home closed. It had been registered for 8 maternity and 2 medical cases. At the beginning of the year, there were 14 homes registered for beds, of which 13 were for maternity cases. At the end of the year 13 registered homes had 174 beds of which 5 were for maternity cases. 25 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. The control exercised by the Authority is in regard to the premises. The Authority has to be satisfied about the general suitability of the premises for the work to be done, and also about equipment. There are also requirements about the exhibition of scales of fees. The licence is in force for one year only, and a further visit of inspection is paid before the application for the renewal of the licence comes before the Committee. In default of the receipt of any complaints, this is the limit of the supervision exercised. There is, of course, no supervision of the work of the practitioners, nor any real control of their qualifications. Those who carry out treatment similar to what is done at these establishments but in the homes of the patients do not need to be licenced. At the beginning of the year, 31 establishments were licenced. Three were licensed during the year, the same number were discontinued so the number at the end of the year was 31. In addition, certificates were lodged by five registered members of the Chartered Society of Physiotherapy. NURSING, MIDWIFERY, ETC., IN THE HOME General Nursing The National Health Service Act made local health authorities responsible for providing a home nursing service, either engaging their own staff or using the services of existing district nursing associations who had up to this done this work. Although this area was served by local nursing associations, the County Council decided not "to make arrangements with voluntary organisations for the employment of home nurses." Whereas the largest of the local associations—the Great arrow District Nursing Association—which covered most of the area, relied largely on nurses resident in one of the two nurses homes, these Were in time closed, the nurses from then on working from their own homes. At the end of year, there were some 21 whole-time nurses and 8 part-time nurses who worked mostly in the mornings, an equivalent of 25 whole-time staff. During the year they paid in all 59,028 visits. The service is essentially a day-time one. The general medical Practitioners get into touch with the nurses either directly or through the office. 26 The administration of the home nursing service is one of the functions for which the local Area Committee is responsible. The superintendent of the home nurses is Mrs. R. Bromley, who works from the Area Health Office at "Kynaston Court." Nursing Equipment: The County Council in exercising its powers to make available nursing equipment on loan to patients being nursed at home have used the services of the Middlesex Branch of the British Red Cross Society. The Red Cross depot in this area is at 9 Peterborough Road. Midwifery and Maternity Nursing The local midwifery service provided by the Harrow Council under the Midwives Act, 1936, passed in 1948 into the hands of the Middlesex County Council. This is one of the services administered locally by the local Area Committee. Before the war, of the 3,000 births each year to Harrow mothers, about 1,000 were attended by the local authority midwives acting either as midwives or as maternity nurses. Partly because of the fall in the number of births and also because of the greater proportion of confinements now taking place in institutions, the number of home confinements in any year is appreciably less. The number of midwives needed for this service then is less, and the establishment has been reduced to eleven. This is based on the accepted standard that a midwife working on her own can attend 55 patients and one who has a pupil 75. While in ordinary conditions this provision is adequate and allows for a certain amount of absence for illness and for holiday absence, there is no reserve when one or more of the midwives is absent for long periods through illness. Added to that is the greater difficulty when, as is now the case, there is a long interval between the resignation of one midwife and the engagement ot her successor. The administration of the service then becomes very difficult and it is a trial to the reduced number of midwives actually on duty. Most of the midwives live in their own homes and the districts which they cover is as far as possible based on those points as centres. The work of the midwives is co-ordinated by the non-medical supervisor of midwives, Mrs. R. Bromley of 213 Exeter Road, South Harrow (Telephone No.: PINNER 5723). Last year the midwives attended the confinements of 745 women in their homes, being present in 629 instances as midwives and in 116 as maternity nurses. Of these mothers confined in their own homes, 556 had the advantage of gas and air analgesia, 273 of pethidine and 200 of trilene. Home Helps This service had its beginnings as part of the Maternity and Child Welfare arrangements by which help was sent in to those households where a mother was being confined at home. During the war, because the special difficulties which followed on women being engaged war work and being therefore not available to look after those suffering from relatively minor illnesses, who in ordinary circumstances could be nursed 27 at home, the scheme was extended to provide help in a much wider range of circumstances. The arrangement under the National Health Service Act is intended essentially as an emergency service by which help is sent in to a household faced with some emergency, often enough the result of the mother herself succumbing to some illness. In practice though this service has gradually become one of providing help to the aged and those suffering from some long-standing illness. The help which can be given to these people is of the greatest assistance, as even moderate help enables some of them to continue to live at home who without that help could not have managed and would have had to have been admitted to an institution, either a Part III welfare accommodation or even a hospital. Many people, especially those living alone, either temporarily or permanently, need help more of a nursing character than can be accepted as falling within the range of duties of a home help, yet falling very short of necessitating the skilled help of trained nurses. It would be helpful if especially proficient and selected home helps could be recognised as being able to carry out these extended duties and be permitted to, being appropriately remunerated. Although at no time has it been possible to recruit sufficient home helps to meet the full demands, and particularly to give more help at such times as epidemic illness, the staff engaged are able to meet promptly most of the requests. Additional staff would enable more help to be given in certain cases where the present limitation of numbers permits giving only of a minimum service. The average number of home helps was one full-time and 54 part-time, being an equivalent of 33 full-time home helps. They gave assistance in 1,027 households; in 247 of these the patient helped was a maternity case, in 23 was one suffering from tuberculosis, in 246 was one suffering from an acute condition and in 511 was a long term case. 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 142 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 March 1959. 127 doctors were taking part in Harrow in the general medical service under the National Health Service Act. 88 of these also take part in the maternity services provided under the Act. An indication of the sufficiency or otherwise of the number of general medical practitioners practising in the area is obtained from the decision of the Medical Practices Committee. They class as "restricted" an area in which they feel the number of doctors is adequate, as "designated" an area where there is a smaller proportion, and as "intermediate" an area to which admission is decided in the light of medical man-power or other circumstances Prevailing at time of application. In the middle of 1956, although most of the area was classed as intermediate, one small Part was classed as restricted and another as designated. The position on the 1st January, 1959 was that the whole of Harrow was classed as an intermediate area. 28 DAY NURSERIES The same two day nurseries provided for the admission of children whose mothers needed to go out to work, Headstone Drive Nursery with its 50 places and the Walton Avenue, South Harrow, Nursery with its 60. CLINICS AND TREATMENT CENTRES The following is a list of the clinics and treatment centres in, or serving the district:— Infant Welfare Centres The Clinic, Alexandra Avenue, South Harrow Mon. and Fri. p.m. Broadway Clinic, The Broadway, Wealdstone Wed. a.m. and p.m. The Pavilion, Chandos Rec. Ground, Edgware Thur. and Fri. p.m. Elmwood Clinic, Elmwood Avenue, Kenton Mon. and Wed. p.m. The Rectory, Elstree 1st and 3rd Mon. p.m. Greenwood Hall, Rickmansworth Road, Pinner Wed. p.m. Memorial Hall, High Road, Harrow Weald Thu. p.m. The Clinic, Honeypot Lane, Stanmore Mon. and Wed. p.m. The Clinic, Kenmore Road, Kenton Wed. a.m. and p.m. Methodist Church Hall, Love Lane, Pinner Fri. p.m. Methodist Ch. Hall, Walton Av., S. Harrow Thu. p.m. St. Alban's Church Hall, Harrow Thu. a.m. St. Anselm's Hall, Hatch End Thu. p.m. St. George's Hall, Pinner View, Harrow Tue. and Fri. p.m. St. Hilda's Hall, Northolt Road, South Harrow Tue. and Thu. p.m. Spiritualist Ch. Hall, Vaughan Rd., Harrow Wed. p.m. Stanmore Park (R.A.F.) Station Thu. p.m. The Clinic, Whittlesea Road, Harrow Weald Wed. p.m. Ante-Natal Clinics The Clinic, Alexandra Avenue, South Harrow Wed. p.m. Broadway Clinic, The Broadway, Wealdstone Tue.a.m. and Thu.p.m. The Pavilion, Chandos Rec. Ground, Edgware Fri. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. The Rectory, Elstree 1st and 3rd Mon. p.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. The Clinic, Honeypot Lane, Stanmore Tue. p.m. The Clinic, Kenmore Road, Kenton Fri. p.m. 76 Marlborough Hill, Wealdstone 2nd and 4th Mon. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. 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. 29 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. Family Planning Association Clinic The help given by those at the Birth Control Clinic which has been held over the years, had to to be restricted to advising those in whose case further pregnancy would be detrimental to their health. The clinics provided by the Family Planning Association are free from this limitation. When the Family Planning Association opened a clinic in this area, the question was whether the local authority clinic would be needed. On the Committee's being satisfied that those who would have benefitted by attending their clinics could be helped in exactly the same way at the Family Planning Association clinic, they decided there was no point in continuing to hold it so the last session was held on the 9th May, 1958. The Family Planning Association clinic proved so popular that additional sessions had to be held, so the clinic is now open at Elmwood Avenue on Monday evenings and on Thursday afternoons. Many of the services which are today provided by local authorities or even by the State had their origin in voluntary efforts. These bodies are free from the restrictions inherent in the arrangements made by local or central authorities, and can experiment more freely. So often, once the need for the services has been proved by the trial and experiment of voluntary agencies, the local authorities have taken over the services. What has happened here in regard to this clinic is the unusual course of a clinic successfully run for over twenty years by the Authority but run within the framework of the powers granted by the Ministry, being handed over to the management and responsibility of a voluntary body. The Marriage Guidance Council now have their offices at 7 Lyon road, Harrow. (HAR. 8694). 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. 30 Children attend at the request of the parents or of the teachers, or they are referred by school medical officers. Not only are those who need treatment for minor ailments seen at the clinics, but children are kept under observation for such conditions as cervical glands, cardiac murmurs, etc. Any children needing special examination, especially if these are likely to be prolonged, are referred to these clinics. Ophthalmic Clinics Sessions are held at the Honeypot Lane Clinic on Tuesday mornings, Marlborough Hill clinic on Thursday afternoons and Friday mornings, and 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 82 Gayton 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 referre the head teachers of the schools for urgent or emergency treatment. 31 Children under five, expectant and nursing mothers are referred by the medical officers at the clinics which they attend. Expectant mothers are also referred by their own doctors. An orthodontic surgeon works at the Marlborough Hill clinic. Care of the Feet A limited chiropody service is provided by the local health authority for children attending maintained schools, for nursing and expectant mothers, and for children under school age. Appointments are made at sessions held at the various permanent clinic buildings in the district. Chest Clinic The Chest Clinic serving most of this district is that at 199 Station Road, Harrow (Tel. No. Harrow 1075). The physician in charge is Dr. Grenville Mathers. Serving part of the district on the eastern side is the Chest Clinic at the Edgware General Hospital (Tel. No. Edgware 4467). The physician in charge is Dr. Trenchard. PROVISION FOR SPECIAL CLASSES OF 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.I (Tel. No. Trafalgar 7799). In this area the work is carried out by the Area Children's Officer, Miss Susan Boag, at Kynaston Court. The Mentally III and the Mentally Defective The mental health services are integrated with the other health services established under the National Health Service Act. The duties of the local health authority include responsibility for the initial care and conveyance to hospital of patients who need to be dealt with under the Lunacy and Mental Treatments Acts, and for the ascertainment and community care of mental defectives. The Health Committee of the County Council is responsible for the mental health functions of the Authority. Harrow is part of the central division of the County which is served by shenly Hospital. The Mental Welfare Officer, Mr. W. J. Pedel, and other officers, work at 249 Willesden Lane, N.W.2 (Tel. No. Willesden 32 6181). Attached to this office are two psychiatric social workers who advise and help people suffering from mental illness aggravated by social conditions. The services of a Mental Welfare Officer needed out of office hours can be obtained by telephoning Ambulance Headquarters (Wembley 1121) asking for County Control who will arrange for the message to be passed on to the Mental Welfare Officer who is on call. A recent development is the holding of a consulting clinic on the mornings of the fourth Wednesday in each month at the clinic, Elmwood Avenue, Kenton. This is attended by Dr. Bennett or by Dr. Fidler of the Mental Health Section of the Health Service of the County Council. This is particularly useful for helping parents who have only just learnt that their baby is mentally abnormal in some way. Children who are mentally retarded but are nevertheless educable, are admitted to the Shaftesbury School for the educationally subnormal. Those more retarded and who are considered ineducable might be helped by attending the Special Training School at Rayners Lane, at which in the earlier stages emphasis is placed on habit training in order to teach the children to become socially adapted. The Harrow Society for Mentally Handicapped Children which is affiliated to the National Society, works to promote the better appreciation and the welfare of all mentally handicapped children in the district. The Mental Treatment Act of 1930 brought about a complete re-orientation in outlook about the mentally ill. In contrast with what was the position before, since that time the mentally ill have been accepted as being persons suffering from an illness from which they might make complete recovery. It permitted admission to hospitals on a voluntary basis and provided for out-patient treatment. The tremendous advances in therapy have only emphasised this point of view, and have brought about such a revolutionary change that today the vast majority of admissions to hospitals for the mentally ill are on a voluntary basis, and after comparatively short periods of stay many go home cured. Since that time progress has been rapid and knowledge has so grown that a further advance is due. This has led to the Mental Health Bill, to become in time the Mental Health Act. Persons in Need of Care and Attention The Welfare Department of the County Council has three distinct duties. Its first is to provide living accommodation for persons who y reason of age, infirmity or other circumstances, are in need of care an attention not otherwise available to them. The next is to provide temporary accommodation for persons who are in urgent need of it. The third is to provide for the welfare of persons who are blind, or deaf and dumb, or of other persons who are substantially or permanently handicapped by illness, injury, congenital deformity or such other disability as may prescribed by the Minister of Health. For this last group the scheme of the local authority may provide for: 1. Informing persons to whom the arrangements relate of the services available to them; 2. Giving such persons instruction in their homes; 3. Providing workshops where they may be engaged in suitable work and hospitals where those engaged 33 the workshops may live; 4. Providing them with suitable work in their own homes or elsewhere; 5. Helping them to dispose of the produce of their work; 6. Providing them with recreational facilities in their own homes or elsewhere; 7. Compiling and maintaining classified registers of such persons. Those persons in need of care and attention falling to be dealt with by the Welfare Department are distinguished from the other group who need medical or nursing care and attention and who are the responsibility of the hospital authorities. A rough line of demarcation is whether or not the person is bed-ridden. The duty of the Welfare Authority in regard to those needing care and attention, not medical or nursing care and attention, is to provide accommodation. Their duties do not extend to making for such people arrangements comparable to those it is their duty to make for the blind, the deaf and dumb or physically handicapped. This is so much the case that it would seem that the position is that the Welfare Officer has no strict duties in regard to a person deemed to be in need of care and attention but who is not prepared to go to a welfare home. In the same way the Welfare Officer has no well-defined duties in regard to people who really are not managing too well by themselves but who he feels have not reached the stage of being classed as needing care and attention and therefore admission to a welfare home. For the administration of the Welfare Service the County is divided 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 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 County Council now has some 2,600 beds, most of them in about fifty old people's homes, in and around the County; the only one of these homes in this district is that at 79 Bessborough Road. In addition the County Council pays for about 1,100 beds in homes run by voluntary organisations. Although the Health Department of the District Council is often approached by those concerned that people apparently not fit to be living alone are not being helped, it would seem that a District Council as such has no direct powers or responsibilities in the matter unless circumstances are sufficiently bad to warrant action under Section 47 of the National Assistance Act, to obtain the removal of the person to a welfare home or hospital. That District Councils are not directly involved is understandable in that what needs to be done is essentially a personal service, and District Councils were divested of those personal services for which they were responsible in 1948. Indirectly a District Council can help by using powers under two cts, powers perhaps which were never intended to be used in this way at the time the acts were passed. The one is Section 4 of the Physical Training and recreation Act 1937 which refers to clubs, etc. having athletic, social and educational objects. The other is Section 31 of the National Assistance act, 1948 under which a local authority may make contributions to the funds of any voluntary organisation whose activities consist in or include the provision of recreation or meals for old people. 34 The Aged At the time of the 1951 census, out of a local population of 217,700 there were 7,290 men over sixty-five years of age, 11,926 women over sixty-five and 17,348 women over sixty. Fortunately the vast majority of all these are in no need of help of any sort. A small proportion of them are in need of care and attention. Those needing just simply care and attention and not medical or nursing care and attention, are the responsibility of the Welfare Department of the County Council who find them accommodation in one of the County Council's welfare homes. Those in need of medical or nursing care and attention are the responsibility of the hospital service. Most from this district who need to be admitted to hospitals are dealt with by the staff of the Edgware General Hospital where there is a Geriatric Officer, Dr. F. A. Binks, whose prime concern is for these people. He has beds at the parent hospital and also at a number of other establishments, including in this district Roxbourne Hospital, Stanmore Cottage Hospital and Orme Lodge. The procedure for obtaining admission is that the patient's own doctor makes direct approach to the Geriatric Officer. The number of beds available is far short of what is needed. To make the best use of what is available different methods have been tried out, one being that a patient is admitted to hospital for a period of six weeks, returning home for a similar length of time. To give the relatives a rest from a very onerous burden, patients can be accepted at the hospitals for periods of two or three weeks. Enforced Removal. Sometimes the person in need of care and attention should really be in an institution or hospital but declines to go there. In certain circumstances the District Council can act under the provisions of Section 47 of the National Assistance Act 1948 which refers to the removal to suitable premises of persons who (a) are suffering from grave chronic disease or being aged, infirm or physically incapacitated are living in insanitary conditions, and (b) are unable to devote to themselves and are not receiving from others proper care and attention. The procedure under Section 47 was that if the Medical Officer of Health could certify to the local authority that he was satisfied that in the interests of such person or for preventing injury to the health or serious nuisance of other persons, it was necessary to remove him from the premises in which he was residing, the local authority could apply to a court of summary jurisdiction for an order. The machinery, involving as it did serving of a 7-days notice on the person managing the premises to which it was intended to remove the person, proved cumbersome. in 1951 an Amending Act was passed which aimed at dealing with cases more expeditiously. Under this the Authority can give a general authority to the Medical Officer of Health to make application for an order for removal. This authority was in fact given by the Public Health Committee at their meeting on the 6th January, 1959 when they resolved" that the Medical Officer of Health be hereby authorised to make application for an Order pursuant to Section 47 of the National Assistance Act, 1948 as amended by the Act of 1951 authorising the removal to suitable premises of persons in need of care and attention in all cases where he considers this necessary and desirable." The procedure now is that if the Medical Officer of Health and another registered medical practitioner certify it is 35 necessary for a person to be removed without delay from the place in which he is living, an application for a removal order may be made to the Court or of a single justice. An order made under this Section is valid for three weeks only, an application for an extension being made under Section 47 of the original Act. The first case in which action had to be taken under these powers was in December. Because of the insanitary state arising from the man's grave illness and his refusal to agree to go to hospital, a Court Order was applied for and granted, and the man removed to hospital. Laundry Service. The burdens of those looking after the debilitated elderly or chronic sick are immensely added to when that person is incontinent, and more especially doubly incontinent. There is no information about how common this condition is as most households manage somehow or other to get over their difficulties. In some though, no suitable arrangements can be made, and it is in such cases that the Council uses its very limited powers under Section 84 of the Public Health Act, 1936 which empowers authorities to arrange for articles to be cleansed in certain circumstances. The local arrangements started in 1954 when the Hendon Group Hospital Management Committee agreed to arrange for the actual work of treating the articles of clothing and bedding to be done if the District Council would meet the cost. In no year have any very large numbers of persons been helped at any one time. At the beginning of last year, 10 persons were being helped. During the year, there were requests to help a further 12 cases. Because of death or removal from the district, the number provided with help at the end of the year was only 9. The period any patient had to be helped has ranged from two weeks to three years though one person has been helped since the arrangements started in 1954. A person once helped might not need the help to be continued, either because he has been admitted to hospital or has died. The average cost per week for each person being helped was about 3/-. Towards the end of the year, the Hospital Management Committee had, because of rises in wages and in cost of materials to raise the charge made for each article dealt with from 4id. to 6¼d. The limitation of the powers of the Council to help, coupled with the fact that the ordinary laundries will not accept such soiled articles, results in many households having to carry out this cleansing in their own homes >n circumstances which in many cases must make this a more unpleasant task than is faced by those who can do much of the work by machinery in a laundry. But although what can be done to help in this way must reduce the demands for admission of persons to hospitals and so is to 'he benefit of the hospital service, they can hardly be expected to assume responsibility in any way for persons who are neither in hospital nor attending as out-patients. The third Authority who might have responsibilities for such persons is the Welfare Service. They again, at the m°ment, have no responsibility and presumably no powers to help in such cases. At present then it would appear that no Authority has powers to help more than the District Council whose powers in this connection are so very limited. 36 Special laundry facilities are available to Old Age Pensioners at the Belmont Circle Laundrette and the Harrow Weald Laundrette. Pensioners can take advantage of a reduced charge of l/6d. for a 91b. load of washing on selected days once a fortnight. Tickets entitling the holder to this service are obtainable at Harrow Weald Lodge. Those needing care and attention whether from the hospital or from the welfare service are only a small proportion of the old people in the population. Were there more ample accommodation, there would be more who could with advantage be helped by one of these two services. Those who desirably should be in an institution of some sort but who cannot be accepted are a real problem and a burden to those who have to look after them. At the other end of the scale are the very many who, though definitely elderly, are healthy and independent, and who are able to look after themselves, being no problem to anyone. In between are a group who are just bordering on the first group and who at any time might fail socially or medically. This is the group that so much needs help, but for whom it would seem no local authority has any direct responsibility. Many of them could perhaps be kept in that group with help of different sorts, but failing that help are found suddenly to be in the group urgently needing care and attention. It is this group which needs to be discovered and helped in some way, so as to postpone as long as possible their transfer into the first group. There is perhaps a later problem of doing something to prevent the second and largest group of those who are healthy and independent from reaching the intermediate stage. The position as to responsibility is not very well defined. Many of these people are far from needing the arrangements for care and attention which can be provided by the Welfare Service. District Councils have no direct powers or responsibilities, and it would seem that all that could be done by them, if it can be done by an Authority, can be provided only indirectly by the Council through such agencies as the Old Peoples Welfare Committee. The Old People's Welfare Committee established in this district is comprised of representatives from all the organisations in the district, including the Council, which are concerned in any way with the problems of the elderly. It has two sub-committees, one concerned with meals, the other with home visits. It co-ordinates the activities of the various local organisations which provide services of different kinds for the elderlyThe Council contributes to the funds of the Committee and at their meeting in June they authorised, under Section 31 of the National Assistance Act, 1948: 1. The contribution of£l,000 per annum in respect of the cost of the operation by the Harrow Old People's Welfare Committee of a kitchen and restaurant for meals for old people at North Harrow an Belmont Assembly Halls, including the provision of meals for service to infirm old people through the W.V.S. "Meals on Wheels" service; 2. A grant of £230 per annum in respect of the costs of running, maintaining and garaging the mobile canteen presented to the Council by the Greate Harrow District Nurses Association Trust which is used in connection with the "Meals on Wheels" service for infirm old people; 3. A grant 37 of £35 in respect of small administrative expenses to be incurred by the Harrow Old People's Welfare Committee. The needs of the elderly vary and small numbers in the district can be helped in one way or another. Housing. The Council for some time has provided an increasing proportion of housing accommodation of a type which is suitable for the special needs of the elderly. This arrangement is not only a kindness to those for whom these houses are intended, but is also a contribution to the relief of the housing problem as the larger accommodation in which they live is released for occupation by a larger number of people. The particular problem of the rent charged to the elderly has been under consideration for some time and a report of the special SubCommittee for rent reads:— "For some time your Committee have felt that the Council Rent Scheme does not make adequate provision for the assessment of rents of dwellings occupied by old age pensioners because in the majority of such cases the tenant's income is much less than that laid down in the Scheme for a minimum rent. The Committee decided to recommend 'that a special Old People's Rent Scheme, whereby each tenant qualifying thereunder shall pay a net weekly rent of 10% of weekly gross income or the minimum rent for the property occupied, as calculated under the Council's main Rent Scheme, whichever is the smaller sum, be approved and adopted with effect from the 1st June, 1959." The recommendation accepted by the Council at its meeting on the 30th January, 1959. The Harrow Housing Society provides accommodation for a number of elderly persons at Pinner House, Church Lane, Pinner. Feeding. There are two arrangements by which some of the elderly can obtain a mid-day meal. The one is at one of the Luncheon Clubs held at the Assembly Halls in North Harrow and at Belmont. The other is by Meals on Wheels" service organised by the W.V.S. by which meals are taken to some elderly persons confined to their homes. Companionship. This is what so many of the elderly need. Some obtain it by becoming members of one of the six Evergreen Clubs run by the British Red Cross Society or one of the five Darby and Joan Clubs provided by the W.V.S. or one of the Over-Sixties Clubs. These clubs meet for a half-day once a week or once a fortnight. Another method is by the home visiting service arranged by the Co-ordinating Officer of the Harrow Old People's Welfare Committee. Chiropody. The Harrow Branch of the British Red Cross Society ave for some time provided a chiropody service for the members of their Evergreen Clubs. More recently they have extended that service to needy old people in the borough who are not club members. The council authorised the making under Section 31 of the National Assistance act of a contribution of £100 per annum towards the expenses of the Harrow Old People's Welfare Committee in providing this service. The Divisional Director of the Harrow British Red Cross Society reported 38 that during the year ending 30th June, 1958 397 people had received treatment, 291 at the clinics and 106 in their own homes., A Clinic for the Aged. The clinic which the County Council agreed should be held as an experiment for preventive medicine was opened at Twickenham early in the year. In other districts other activities have been carried out in the interests of the elderly. Some of these help to keep the mobile and the fit from moving into the group from which all too easily they can pass to needing care and attention. Others do much to save those in the second group from failing socially or medically and so becoming in need of a bed in a home or hospital. Amongst the former range of activities is the club, open for long periods and desirably providing facilities not only for recreation but for occupation. Some expressly directed to this latter purpose are the workshops. In connection with the clubs, though not always limited to those who are members are the arrangements for holidays, day excursions, visits to the theatre, etc. For those who are largely confined to their homes are the visits by the home visitors. In some districts arrangements are made for exhibition of a card in the window which draws the attention of the passers-by to the occurrence of some emergency in the home. Perhaps one of the most important steps to be taken to ensure that those who are in any way concerned with the problem whether as helpers or as those to be helped know of what facilities are available. Another very important step is to discover those who have already passed into the stage from which they might so easily become in need of care and attention. Some form of registration has been carried out in some places. There are many difficulties about the compilation of such a register. In the first place, sheer age in itself is not a factor of importance in determining whether or not the person has reached that stage. If a list were compiled, and in this district according to the 1951 census, there were 11,751 persons over seventy years of age (7,589 of them women) and even 6,283 (4,163 women) over seventy-five years of age, having discovered who these are and where they live, the value of the list on any day is short-lived as even a mild illness or a fall or perhaps even bad news could quickly convert that person into one needing care and attention. The completion of a list of such people with particulars of their nearest relatives, their closest friends, their doctors, would, of course, be useful when such persons had passed into the stage of needing care and attention. It could also ensure that each of these people was linked to some organisation providing some form of help. In some districts such lists have been compiled and the information kept up to date by a visit every six months. Without sending anyone out to discover in each road these people, it is possible to compile a working list of all those who already are taking advantage of whatever special facilities for the elderly that there are, and of those who are in need of various services such as those provided by home nurses and home helps; but at the moment it is not the responsibility 39 of anyone to undertake this task, though presumably it is one which could be undertaken by someone working for the Old People's Welfare Committee. There is room too for someone with responsibility for ensuring that those who need help can be put into the way of obtaining it. Neighbours of those in difficulties quite naturally get through to the Health Department when they wish to express their concern about the behaviour of a person or at his being left without anyone looking to his needs, or possibly about the condition of the premises. Unless these prove to be Section 47 cases, they cannot really be helped by those in the Public Health Department of the local authority. An assessment of the position can often be better made by the health visitor who can then see about medical or nursing attention or home helps or meals, but often much more needs to be done. If their situation was just that slight degree worse, these people would be the responsibility of the Welfare Officer. As however, they fall short of this stage, he has no responsibility; and yet someone is needed to get into touch with the relatives, to see that the person has home comforts and meals, and generally to see that somehow or other he comes back away from the stage of so nearly needing care and attention. In some areas health visitors are spending much of their time on the needs of the elderly. For this sort of work though the trained health visitor is not needed and even though there were enough health visitors available, it would be a waste of their skill for them to do work of this sort which can be carried out by people who have not had the training and experience of the health visitor. For the blind and the physically handicapped the welfare authorities have made full arrangements for their registration, for their supervision, for their occupation. For these elderly people there should be a comparable scheme. If the duties of the Welfare Officer cannot be extended to cover these responsibilities, and presumably as they have not these duties at the moment, legislation would be needed to impose them on them, then it would seem to be something which could be undertaken only by an officer engaged by the Old People's Welfare Committee. 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). The routine work of the Service is essentially bacteriological and virological. Except for certain tests closely associated with bacteriological and virological investigations, chemical and bio-chemical tests and histological examinations are not performed. The Service normally does not undertake work that is rightly within the province of the hospital or clinical pathologist, but is ready to offer help when facilities for such work are not otherwise available. 40 The routine specimens examined fall under two main heads—(a) medical specimens from general medical practitioners, hospitals and local authorities and (b) sanitary specimens from local or food authorities or by arrangement from private firms General practitioners, Medical Officers of Health, School Health Officers and others are offered a comprehensive bacteriological service for the diagnosis, treatment and prevention of bacterial, virus and mycotic infections. The Sanitary work includes the routine bacteriological examination of water, milk and cream, of foods such as ice cream, artificial cream and shellfish, and of sewage. The epidemiological work of the Service includes not only the investigation of outbreaks of infectious disease, but also a study of the distribution and behaviour of various infectious agents throughout the country." 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 98: faeces 179 ; sputum 5, and miscellaneous 12. Another service provided by the laboratory is the issue of certain preparations. "The following are available at the Colindale Laboratory: smallpox vaccine, gamma globulin for the protection of susceptible contacts of measles, rubella and poliomyelitis, diphtheria prophylactics, anti-rabies vaccine and serum, and anti-typhus vaccine. The Service does not issue therapeutic sera or anti-toxins, or T.A.B. or cholera vaccine, or Schick test re-agents. Therapeutic sera and antitoxins may be obtained from certain hospitals. T.A.B. and other vaccines may be obtained from commercial firms through chemists' shops. Yellow Fever vaccination is done only at centres designated by the Ministry ot Health." 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 an 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. 41 The County Council development plan provides for the building of ten ambulance depots at various places throughout the county. All ambulances and sitting-case vehicles are to be housed in these depots which will cater for the needs of the surrounding districts. They would also assist in accident work in emergency. One of these buildings is in this district at Imperial Drive (Tel. No. Pinner 8900). The hospital car service, operated jointly by the British Red Cross Society, the St. John Ambulance Association and the Women's Voluntary Services, provides cars and drivers, who give their services voluntarily, and by arrangement with the County Council takes many patients to and from hospitals and clinics. On the 30th October, 1958 the County Council submitted to the Minister of Health for his approval, a modification of their existing proposals under Section 27 of the National Health Service Act, 1946 relating to the Ambulance Service. This proposes that as from 1st April, 1959 the County Council will operate the Ambulance Service separately from the Fire Service. LEGISLATION Litter Act, 1958. This Act which came into force on 7th August makes it an offence for anyone to deposit or leave anything so as to cause defacement by litter in any place in the open-air to which the public have access without payment. Action against offenders can be taken by local authorities, private individuals or the police. Slaughterhouses Act, 1958. See page 76. 42 SANITARY CIRCUMSTANCES OF THE AREA WATER Supply Almost the whole of the area obtains its water from the 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. The Minister of Housing and Local Government issued a report by one of their Engineering Inspectors on the results of a supply survey of Hertfordshire and adjoining areas. The survey included the areas of supply of the Colne Valley Water Company and the Rickmanworth and Uxbridge Valley Water Company. The report presented a favourable position as regards present and future water supplies in the area under review. 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 results 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 January (parts per million):— Appearance: Bright with a few particles. Colour: nil. Turbidity: less than 3. Odour: nil. pH.:7.3. Free Carbon Dioxide: 10. Electric conductivity: 600. Total Solids: 400. Chlorine present as chloride: 42. Alkalinity as calcium carbonate: 215. Hardness: Total 275. Carbonate 215. Non-carbonate 60. Nitrate nitrogen: 5.1. Nitrite nitrogen : absent. Ammoniacal nitrogen: 0.000. Oxygen absorbed: 0.20. Albuminoid nitrogen: 0.013. Residual chlorine: absent. Metals: Iron: absent. Zinc: absent. Copper: 0.14. Lead: absent. "This sample is practically clear and bright in appearance, neutral in reaction and free from metals apart from a minute trace of copper. The water is hard in character but not to an excessive degree ; it contains no excess of salinity or mineral constituents in solution and it is of very satisfactory organic quality. From the aspect of the chemical analysis these results are indicative of a pure and wholesome water, suitable drinking and domestic purposes". 43 The following, a copy of a bacteriological examination of a sample submitted for analysis in September, is typical of other reports:— Probable number of coliform bacilli: MacConkey 2 days 37°: nil per 100 ml. Probable number of faecal coli: nil per 100 ml. Fluoridation. In spite of the unanimity of the findings in all areas in which fluorides in small doses have been added to the public water supplies that the teeth of children are appreciably less carious, the schemes have run into difficulties in different parts of the world. In this country, trials were limited to four districts: Andover, part of Anglesey, Kilmarnock and Watford. In Andover, as in some small towns in New Zealand, fluoridation became a political issue and Andover decided to discontinue the practice. It seems that some of the places in America where fluoridation had been introduced abandoned the practice, though in some of these districts the arrangements were in'roduced again. All evidence points to the desirability of something being done on these lines. The considered opinion of an international group of experts was given in a report published during the year from the W.H.O. on the Value of Fluoridation of Public Water Supplies for the Prevention of Dental Caries. The Committee had no doubt about the efficacy, safety and practicability of fluoridation. It drew attention to the mass of evidence that concentrations of one part per million of fluorides artificially or naturally present in drinking water do no harm to health and go far to prevent decay of the teeth. Although the reports from different parts of the world all point to this reduction in the incidence of caries and the safety of the practice, it is improbable that there will be any extension in this country of the arrangements already started, unless a limited extension as part of the trial, until the results of the consumption of treated water on teeth of children in those districts have been assessed, and for that it is necessary to wait for some years. 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. The work which the Council had authorised in 1955 for the Pinner Relief Soil Sewer Scheme, designed to relieve the main sewers serving Pinner which had become overloaded because of the development which had taken place in this locality since the war, was completed during the year, coming into operation on the 14th March, 1958. In 1957, 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. In 1944, a 21 in. diameter sewer was laid to cater for the Cullington 44 Close development. This was to be the first section of the Relief Sewer Scheme. The next step is to provide a 21 in. sewer from the head of the existing sewer in the allotments at the Council's Depot, Elmgrove, along the eastern end of Masons Avenue, Byron Road, Oxford Road and Palmerston Road, then to run as an 18in. pipe from the High Street along Headstone Drive to Harrow View. All flow from Harrow View, north of Headstone Drive, including some of the effluent from the Kodak factories, will be diverted into the new sewer, the existing sewer at Headstone Drive continuing to serve domestic properties and discharging into the relief sewer at the High Street. A 9in. sewer in Gordon Avenue, which for much of its length is crushed and in need of major reconstruction, receives foul drainage from the Service Establishments at Bentley Priory, from Aylmer Drive, part of Uxbridge Road, The Chase, Kenneth Gardens and Chartley Avenue. For most of the day it is full, while the sewer of The Chase surcharges. The approval of the Minister of Housing and Local Government was received to a proposal to construct a 12in. soil sewer in Gordon Avenue from The Chase, some 540 yards in length in an easterly direction. The sewage pumping station at South Vale pumps into two rising mains. Of these, one laid about sixty years ago is disintegrating. Tenders were accepted for replacing 363 yards of 6in. diam. rising main from South Vale to South Hill Avenue. Properties Not Connected to the Main Drainage System. Amongst the forty-two units of accommodation not connected to the general sewerage system were four properties adjoining The Grove. Stanmore. At one time The Grove and three of these houses were drained by private drains to septic tanks north of the Grove, thence by an overflow drain to a lake, discharging eventually to the River Colne. When The Grove was put to its present use, the drainage for it and other buildings in the ground was diverted to a new pumphouse and rising main. The satisfactory arrangement would be for the houses to be connected to The Grove drainage system which discharges via a rising main to the public sewer on Stanmore Common. The difficulty to this solution was the reluctance of the owners of these properties to surrender their rights to permanent drainage to the septic tanks in return for what might prove to be a temporary form of main drainage. The difficulty could be got over it the Council would agree to assuming responsibility for the pumping station at The Grove and the rising main running from it to the main sewer, and to grant to the owners of the houses the right to use the main for the conveyance of their domestic sewage. The Public Health Committee were concerned both because of their desire to see the end of the use of some septic tanks, and indirectly because of the effect on river pollution. The toilets at the Headstone Lane Station discharge into a cess-pool which from time to time has given rise to a nuisance. The British Transport Commission were anxious to obtain a connection to a main drainage system. This would have necessitated obtaining an easement over private property, involving the consent of several owners of property who are jointly responsible for the maintenance and repair of the sewer. The 45 Transport Commission offered to bear the cost of the work, subject to the Council's agreeing to adopting the sewer. This they did. Soiling of Railway Tracks. More especially because of the large numbers of railway lines running through, the question of the disposal of sewage from trains is a matter of concern to those in this district. The following is an abstract from the Annual Report for 1957 of the Coordinating Committee of the Royal Society of Health on the problems of Public Health Engineering. From this it would seem that the British Transport Commission still have this matter under consideration:— "The request to consider this problem was received from the London District Committee of the Plumbing Trades Union. Through the Society of Medical Officers of Health, the Committee sought the views of medical officers of health of large towns, which were railway centres or terminals, regarding the effect on public health of the present method employed by British Railways for disposing of faecal wastes. The Committee informed the British Transport Commission that they had this matter under consideration and asked whether British Railways contemplated any new development in the method of disposal. In their reply, the Commission stated that a team of medical and research officers had recently studied the problem on their behalf but that there could be no assurance, at the moment, that a solution would be found, or that there could be any change in the present arrangements in the foreseeable future. The Committee were of the opinion that although the present method of disposal employed by British Railways was aesthetically objectionable, there was no evidence that this resulted in any increase in the incidence of disease, and they were unable to obtain any definite evidence that there was any danger to health." Flooding. Certain parts of the district suffer in times of sudden heavy rainfall from the surcharge of the surface water sewers. This causes sections of some roads to be under water ; exceptionally adjoining properties are affected. More serious from the public health point of view and as a nuisance to those more especially affected, is the effect of the larger volume of surface water pushing back the contents of the soil sewers, resulting in fouling of the roads and pavements and in parts private gardens. One of the heaviest falls of rain in this district in recent years was on 19th October, 1955, when there was heavy prolonged rainfall between 2.0 a.m. and 8.30 p.m. during which there were nearly 2½ inches of rain, nearly one inch of this falling in one hour. The design of the local sewers is on a rainfall of 0.5 inches in a sixty-minute storm. This rainfall was followed by the surcharging of many surface water sewers, drains and water courses. Surcharging of the soil sewers was caused with resulting flooding and pollution. On the 6th August, 1952 exceptionally heavy rain fell in North West london causing widespread flooding of roads and houses. In Harrow the heavy rain began to fall at 7.30 p.m. continuing to 8.15 p.m., during which time 2.62 inches of rain were recorded. The rain from this storm was some five times that for which the sewers are normally designed. In these 46 circumstances both foul and storm water were running at full bore and were unable to deal with the excess water falling in this area. Some flooding from the foul sewers occurred. On 16th July last there was a heavy fall of rain, some 0.9 inches falling in about two hours between 4 and 6 p.m. This was followed by the surcharging of some of the surface water sewers, with the result that certain roads were waterlogged. More serious though was the fact that again surcharging of some foul sewers occurred, with resultant flooding with sewage, in some cases of roads and pavements, in others of the gardens of houses. Four places about which complaints by the Public Health Department were received were The Chase, Stanmore, 7 Sweetmans Avenue, Pinner, Weald Lane and Byron Court. The Pinner Relief Soil Sewer Scheme was expected to reduce such trouble in that area, but not to eliminate it entirely ; on the other hand, other remedial measures could not be undertaken before these works had been completed. The trouble to which The Chase and nearby roads have been subjected can be expected to be relieved when the Gordon Avenue relief soil sewer has been constructed. The construction of the Wealdstone relief soil sewer can be expected to lead to a diminution in the flooding which has occurred at Harrow View, View Close and Brook Drive. There was a further heavy fall of rain on the night of December 13th/14th, 0.9 inches falling in six hours. Hatch End and Pinner were mostly affected, particularly shops in the Hatch End Broadway. The trouble was the heavy rainfall coupled with the collection of debris in an open length of water course which flows through private property and under private carriage crossings where the debris lodged. This is one example of the flooding to which parts of the district have been subjected, the direct result of an obstruction in a water course or ditch or in a culverted section of a water course or ditch. Generally, the blockage consists of debris or refuse which can rarely have found its way into the water course without having been deliberately placed or thrown there by some person or persons. The Highways and Cleansing Committee asked that local organisations be approached to help in drawing the attention of the public to the nuisance being caused by certain persons. The Head Teachers of the schools were circularised, asking them to draw the attention of their pupils to the flooding which occurs at intervals as a direct result of debris being thrown deliberately into water courses, ditches and culverted sections. The water courses in the Borough fall into one of three categories • 1. Those under the administration of the Thames Conservancy Drainage Board, being the water courses of the Thames above Teddington Lock. in this district is the Pinn and its tributaries ; 2. Those under the administration of the Middlesex County Council. These comprise most of the water courses in the Borough ; 3. Those higher reaches of the water courses and the tributaries and various lengths of water course or ditch which pass through private land. The powers of the Thames Conservancy and of the County Council are the same, being to prevent pollution, keep free from obstruction, to maintain in a state of efficiency and improve and straighten. In each case the powers are permissive, so t 47 each authority can decide over what lengths of watercourse it will exercise jurisdiction. The Thames Conservancy operate over the main stream of the River Pinn down-stream from where it emerges under the railway line between Hatch End and Headstone Lane Station, and the Woodridings brook downstream from Nugents Park. The County Council exercise their powers over the main stream of the Yeading brook downstream from the Broadway, North Harrow, the Roxbourne brook downstream from Malvern Avenue, the Wealdstone brook downstream from Becmead Avenue, and the Edgware brook downstream from the junction of Whitchurch Lane and Honeypot Lane. In regard to the other water courses, neither the Thames Conservators nor the County Council will exercise their permissive powers. In regard to the watercourses not the responsibility of the conservators or the County Council, the powers of the Corporation are contained in Section 269 of the Public Health Act, 1936 which refer to any ditch or water course which is found in such a state as to be prejudicial to health or a nuisance and any part of 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 Section makes it an offence to throw or deposit or other matter likely to cause annoyance in any river, stream or water course. The weakness of the procedure for abating the nuisance is the difficulty of finding the person by whose act, default or suffering the nuisance arises or continues. If that person cannot be found, notice may be served on the owner; and if the nuisance does not arise by the act, default or sufferance of the owner or occupier, the local authority may themselves do what they consider necessary to abate the nuisance and to prevent a recurrence. Local proceedings were instituted against a person for throwing verminous bones, tins and other rubbish into the River Pinn. The following are examples of what is happening:—"An almost complete blockage which occurred in a 72-inch diameter culvert in the Borough, caused by debris which could only have been deliberately cast mto the open section of the watercourse. The removal of the articles occupied a whole day, and they included the following items: Two motor-car tyres; A perambulator; A roll of chain link fencing; Piece of Timber, 4in. x 2in. x 4ft. long; Two broken chairs; Two bicycle frames; Two bicycle wheels. Serious Pollution also occurred recently in the watercourse between alkeith Grove and the Seven Acre Lake, which was caused by the umping of a cardboard container full of diesel oil. Other common causes of blockage are hedge and grass cuttings, mattresses, water tanks and cisterns, and milk crates." Where the Corporation or the County Council are the riparian owners of one or both banks, Corporation employees remove debris from time to time and give necessary attention to the maintenance of the banks. In other cases though, the powers of the Corporation are limited to taking proceedings in appropriate cases. The River Authorities have intimated that they are not prepared to extend the limits over which they will exercise their permissive powers. The County Council then has been 48 asked to include a clause in the next Middlesex County Council General Powers Bill to give added powers to the County Districts in Middlesex to deal with water courses. The ditch at the back of some houses in Cavendish Avenue, Sudbury Hill which receives surface water from the surrounding roads, houses, shops, etc. both in Harrow and Wembley, was giving rise to a nuisance. The ditch is on land owned by the British Transport Commission. The Highways and Cleansing Committee agreed to the necessary work being done if the Transport Commission as riparian owners and the owner of Hill House agreed each to contribute one-third of the cost. 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 forty 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. When there were refuse disposal plants in the district, those wishing to dispose of collections of household material which was not of the character of that usually placed in the house refuse bin, could have this collected by the Council's refuse service at a small charge, or could themselves arrange for it to be taken to the disposal plant. A similar arrangement was in force for dealing with trade refuse. Since the time that all the refuse from the district has been disposed of at Harefield. matters have been much more difficult. Admittedly, the Council is prepared to collect and remove these materials on request; this thoug is at a charge, one which many householders are not prepared to meet. They then find their own solution to their problem, one which frequently enough results in the depositing of the material somewhere in the district. Any such accumulations become in their turn an invitation to others with matter to dispose of to deal with it in the same way. Not only then does this practice soon lead to an unsightly accumulation, but to one which can so easily become a sanitary nuisance. Putrescible material is added and the deposit becomes a breeding ground for flies and rats. Once such a stage has been reached, the Public Health Department can arrange for the removal of a deposit at a charge to the Committee ; but short of such a state of affairs, this accumulation is an eye-sore and detracts from the amenities of the neighbourhood, whether this deposit is made at the back of shops in accommodation roads, on parcels of undevelope land or in the open spaces and commons. The Public Health Committee has at times been especially concerned with the problem, and they asked the 49 Highways and Cleansing Committee if they could not give a more generous interpretation to the term "house refuse." The provision of such an extended service would be an added charge to the Council; but the Council is already having to meet the cost of moving some accumulations and is suffering still further when deposits cause flooding of the watercourses. Support to such arrangements being made should come from those who are concerned with the obstruction to local watercourses caused by dumping and which leads to flooding. The Highways and Cleansing Committee at their meeting in October agreed to give publicity to this question by way of a letter to all local organisations asking such organisations in their turn to give publicity to the matter in their journals, etc. Five local organisations suggested that if arrangements were made for the collection by the Council free of charge, of such things as old furniture, mattresses, water tanks, etc. this would do much to prevent the dumping of such rubbish in watercourses. Feeling that the service provided by the Council for the special collection on payment of the appropriate charge of items not regarded as house refuse might not be as widely known in the Borough as could be desired, the Committee agreed to give publicity to this service. The present arrangements for the collection of salvage are that paper and cardboard from all shops and business premises is collected free of charge, provided it is kept separate from the normal refuse; the Corporation provide sacks for this. At ordinary collections, salvageable material is collected in sacks carried at the back of the vehicles. Refuse at Royal National Orthopaedic Hospital. This hospital has had difficulty in disposing of refuse and had asked for an estimate of various services. An agreement was reached with the hospital that: (1) there should be a collection of twelve standard bins weekly, these being mostly kitchen refuse; (2) the rest of the refuse, being ward dressings, discarded plaster casts and other rubbish after being burned and rendered innocuous shall be put in four large 1½ cubic yard containers within the hospital grounds; (3) A special bin trolley and bin lifting attachment shall be fitted to one of the Council's dual-tipping vehicles, and the four large containers were to be emptied twice weekly. It was agreed that the Council should bear the cost of providing the containers, trolley and lifting attachment, the hospital to re-imburse the council over seven years. The whole cost of the additional service was to be borne by the hospital. Secondary Access Roads. A number of unadopted roads give rise to nuisances, particularly the result of dumping rubbish in them. The solution to this problem is bound-up with the larger issue of the making UP of private streets. Fouling of Footpaths by Dogs. The Public Health Committee had asked the General Purposes Committee to consider giving further publicity of the Council's Good Rule and Government By-law with regard to fouling of footpaths by dogs. In the meantime, the Highways and Cleansmg Committee had been considering making an Order under 50 Section 15 of the Road Traffic Act, 1956 for the control of dogs on designated highways. The question was whether the enforcement of the Council's by-law about the fouling of footpaths could be associated with the operation of any Order made. The purpose of the order is a matter which is bound up with the volume of traffic on the road, so would apply primarily to the roads carrying much traffic. These are not the roads on which the greatest annoyance is being experienced as a result of the fouling of the pavement. The position at the end of the year was that the draft order which was required was being submitted to the Ministry of Transport and Civil Aviation. PUBLIC CONVENIENCES One of the services provided by every local authority in urban areas is the provision of public conveniences. These are usually sited at places where there are large gatherings of the public, such as at shopping centres, or in places such as parks and open spaces where people may be for a long time. The public conveniences at Havelock Place, Harrow; Station Road, North Harrow; Peel Road, Wealdstone; High Road, Harrow Weald and Whitchurch Lane, Edgware are for both sexes. They are open and staffed from 7 a.m. to 11 p.m. on week-days and from 8 a.m. to 10 p.m. on Sundays. Washing facilities with paper towels and liquid soap are provided free, or a towel and tablet of soap is issued for 3d. The net expenditure on these for the year 1957/58 was £16,024. The convenience at the Car Park, Station Road, Harrow, which is available for both sexes, is open for the same hours as the others. There are no washing facilities there. Except for a one-stall urinal at Northolt Road, South Harrow, the other public convenience in the district are on recreation grounds or other open spaces maintained by the Corporation. Although it has the benefit of quite a number of these conveniences, the needs of the district are far from being met. Over the years there have been two places with especially urgent need—the Kenton and the Pinner shopping districts. The position at Pinner looked like being resolved because agreement was reached about the site of a new public convenience which would see the end of the present unsatisfactory arrangement. Unfortunately the credit squeeze held up that scheme and that was the position at the end of the year. The position of Kenton does not look like being settled at as early a date as no agreement can be reached about a site. The most recent proposal led to the holding of a public enquiry at which local opposition was sufficiently marked to lead to the Council s proposals not being accepted. A similar difficulty is being met about the convenience proposed in the busy Hatch End shopping area where some provision of this sort is so necessary. Towards the end of the year, the Minister approved of the Queensbury propiosal in principle, and authorised the invitation of tenders; and details of the scheme of the proposed convenience at Belmont Circle were being prepared. 51 The standard of the conveniences varies. No criticism can be levelled at those at which there are attendants; at these too, there are facilities for washing, a service which is free to those who wish to take advantage of it. The standard of some of the others though is not so satisfactory, and at none of those at which there is no attendant are there facilities for washing. Unfortunately, the establishments at which there are no attendants are open to abuse and to the wilful damage by hooligans. This sort of thing goes on even at the conveniences at some of the parks such as Alexandra Park where there is someone in the grounds. It is so regrettable that this sort of thing should happen, that there should be this wilful damage in spite of the precautions which are taken and the provision of stout fittings. It ought to be possible to provide many of the smaller establishments which ought not to need the care of a full-time attendant. Conveniences with attendants are very costly services, the total cost for the district being nearly £18,000 a year. 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 Because of the difficulties arising from the legal construction of the word "crematorium," the Council decided to take no further action in regard to the proposed use of the Old Vicarage site. A number of other sites were considered, including one at The Warren House estate, two in the northern part of Pinner Park Farm, one in the southern part of the some farm, and also land at Carpenders Park. The Sub-Committee, while favouring the site at Warren House, instructed that planning permission be sought in respect of all schemes. 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 there was only one. 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 423 bodies were received in the mortuary, 140 of these being from Wembley. Post-mortem examinations were carried out on all but four of the bodies admitted. Inquests were held on fifty-four. 52 SANITARY INSPECTION OF THE DISTRICT AND THE INSPECTION AND SUPERVISION OF FOOD The activities of the sanitary inspectors may be divided into four main categories, viz., housing inspection; inspection and supervision of other premises; the inspection and supervision of food ; and measures to control certain infections. The following tables summarise the visits paid and the action taken. STATISTICAL SUMMARY PART I Inspections Made and Conditions Found HOUSING Visits (i) On complaint of dampness or other housing defects 1,028 (ii) On complaint of other nuisances 503 (iii) Routine inspections 1,117 (iv) Revisits arising from defects found 3,899 (v) Surveys under S. 157 Housing Act, 1936 180 Conditions Found (i) Number of dwellings or other premises where defects were found 1,462 (ii) Number of cases of overcrowding revealed 26 PUBLIC HEALTH Visits (i) On complaint or request 168 (ii) Routine inspections of premises 811 (iii) Revisits arising from defects found 920 (iv) Surveys arising from Rat and Mice complaints 1,336 (v) Inspection of Factories 261 (vi) Inspection of Workplaces 68 (vii) Inspection of Outworkers' Premises 271 (viii) Inspection of Cinemas and Places of Entertainment 71 (ix) Inspection of Licensed Premises 59 (x) Visits under Shops Act 1,591 (xi) Evening observations under Shops Acts 9 (xii) Sunday observations—Shops Acts 48 (xiii) Observations made for Smoke Nuisances 48 53 Conditions Found (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 801 (ii) Number of premises where action was taken by Rodent Operatives to deal with rats or mice 1,191 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 50 (iv) Number of Cinemas and/or Licensed Premises where defects were found 25 (v) Contraventions of Shops Acts— (a) Failure to observe closing hours 5 (b) Other contraventions (failure to exhibit notices, etc.) 401 FOOD HYGIENE Visits (i) Slaughterhouses 789 (ii) Butchers' shops 285 (iii) Cowsheds 8 (iv) Dairies 30 (v) Fish Shops 53 (vi) Bakehouses 82 (vii) Cafes and Restaurants 158 (viii) Ice Cream Premises 98 (ix) Provision Merchants 324 (x) Greengrocers 238 (xi) Other Food Premises 98 COMPLAINTS RECEIVED Summary Accumulations of Refuse 75 Animals causing a nuisance 36 Dampness and Housing defects 342 Drains and sewers—choked 71 —defective 77 Dustbins defective 15 Flooding—Gardens 37 Vermin 30 Insect infestations 101 Overcrowding, alleged 38 Smoke nuisances 35 Watercourse 15 Other complaints (wasps' nests, defective fences) 136 Food unfit (excluding requests received from shops to visit and inspect food) 53 54 NOTICES SERVED Under Housing Acts, 1936-1957 Statutory Notices served under S. 9 requiring execution of repair work — Dwellings reported under SS. 16/17 of Housing Act, 1957, as being unfit for human habitation 14 Dwellings reported under S. 18 (closing orders) Informal notices served under S. 9 6 Under Public Health Act, 1936 Statutory Notices under— (i) S. 24—work to a public sewer 56 (ii) S. 39—repair or renewal of drains 14 (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 14 (vi) S. 93—abatement of a nuisance 38 (vii) Informal notices served 1,410 ACTION TAKEN Following Housing Act Notices (i) S. 9 Housing Act, 1936—dwelling rendered fit— (a) By owners - (b) By local authority in default of owners — (ii) S. 16/17 Housing Act, 1957, Demolition order made 7 (iii) S. 18 Housing Act, 1957, Closing order made 4 (iv) Dwellings rendered fit by owners after receipt of informal notice 4 Following Public Health Act Notices (i) S. 24—Public sewers repaired 53 (ii) S. 39- (a) By Owners 53 (b) By local authority in default of owners 5 (iii) S. 45— (a) By owners 2 (b) By local authority in default of owners - (iv) S. 56— (a) By owners 9 (b) By local authority in default of owners - (v) S. 75- (a) By owners 9 (b) By local authority in default of owners 1 (c) By occupier 4 (vi) S. 93—Nuisances abated 40 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,311 55 HOUSING Inspection of Houses Although the Housing Act requires local authorities to carry out systematic inspections of houses, this routine work 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. Repair of Houses Improvement Grants. The provisions of the Housing Acts 1949/54 as to improvement grants were superseded by Sections 30-38 of the Housing (Financial Provisions) Act, 1958 which came into force on 23rd October, 1958. Twenty-eight applications were received in 1958. This was much the same number as in the previous year. Of these, eighteen were granted, all to owner occupiers. Up to the end of 1958, 128 applications had been received. Of these, sixty-eight had been approved, the vast majority of them being applications from owner-occupiers. Slum Clearance Programme The Council's proposals submitted to the Minister in August, 1955, for dealing with unfit houses in the district referred to 577 properties. It was expected that the clearing and replacement of these houses would be carried out in five years. At the time the survey was completed in April, 1955 the 577 houses included twenty-nine which were already the subject of confirmed Clearance Orders, thirty-nine the subject of confirmed Demolition Orders and 115 about which action had already been started. This 115 included the ninety-one houses in the Northolt Road area, four in Pinner Hill Road, ten 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. The position at the end of 1958 was that of the twenty-nine properties in Clearance Areas, fourteen had been demolished. Of the others five were vacant. Of all these 183 houses, by the end of 1958 fifty-two had been demolished and twenty-eight were vacant ; ninety-one of them are in the Northolt Road proposals. Of the remaining 394 unfit houses included in the clearance proposals, 130 have been the subject of some action. At the end of the year twenty-one had been demolished, forty were the subject of an order, thirty-two were the subject of action and seventeen had been reconditioned. 56 To the balance of 264 must be added seventeen others which were not included in the original returns. Of these, one has been demolished, one has been reconditioned and nine are vacant. It is quite possible that a number of the 264 houses will be reconditioned and it will then be possible to remove them at least temporarily, from the list of those properties due for demolition. Demolition of Houses There were at the end of the year, many houses which, although they had been the subject of orders condemning them as being unfit for human habitation, were still occupied. Some of the houses were included in orders made as long ago as 1939. These included two of the houses in 2-40 Headstone Drive and all of Nos. 1-5 Brewery Cottages. 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 1 Albert Cottages and 8-9 Albert Place 1956 1 15, 17, 19 Crown Street 1956 3 Northolt Road No. 1 Area 8 „ „ No. 2 Area 9 „ „ No. 3 Area 20 „ „ No. 4 Area 12 The following properties, while suitable to be the subject of Clearance Orders, were not officially represented, but negotiations were entered into with a 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:— West Street No. 17 (1956); 45 (1955); 51 (1955); 30a (1957). Wordsworth Road No. 12 (1955). Milton Road : in 1953 Nos. 40 and 58 ; 1954 Nos. 34, 38, 42, 44. 48; 1955 Nos. 32 and 46. Shelley Road : Nos. 3, 13, 15, 17, 19, 27, 29, 31, 33 (all in 1955). 153, 155, 157 Masons Avenue (1957). 1 and 2 Sunny Cottages (1957). 3 and 4 Marsh Cottages (1957). 38a St. Anns Road. 57 Victoria Terrace: No. 3 (1955). St. Anns Road: Nos. 1, 3, 5, 7, 9, 23, 25 (1957). Stanmore Hill: No. 2 (1955), No. 32 (1957). Marlborough Hill: No. 23 (G.F.) (1957). High Street, Edgware: Nos. 59, 61 (1956). Kingsfield Terrace: No. 12. Pinner Road: No. 279 (1953). Cecil Road: No. 108, 110 (1957). Crown Street: Nos. 1, 3, 5, 7, 9 (1953). Of these, eleven were occupied at the end of the year, namely 45 West Street, 279 Pinner Road, 13 Shelley Road, 12 Wordsworth Road, 1,3, 5, 9 Crown Street, 3 Marsh Cottages, 108, 110 Cecil Road. The Alma Road and Alma Crescent area, the fourth of the areas under the Northolt Road Clearance Order proposals comprise in the "pink" area sixteen houses being the odd numbers 1-31 Alma Road and the eleven properties in Alma Crescent. Most unexpectedly a number of these were excluded by the Minister from the Order, namely the odd numbers No. 1-11 Alma Crescent and numbers 15-31 Alma Road. Many complaints have since been received from the occupiers of the properties Nos. 15-31 Alma Road relating particularly to dampness and general housing defects. Negotiations were entered into for the purchase of these properties by the Council. If these prove successful, this should get round the difficult situation which arises in these houses which are suffering from serious defects but the owners of which are not willing to do the work necessary to make them fit, though the Minister decided they could be. New Demolition or Closing Orders. During the year, Demolition or Closing Orders were made in respect of the following properties: 56 Francis Road; 1 and 2 Camden Row; 33 West Street; 18 Little Common; 49 and 51 Pinner Road; 7 Frognal Avenue (ground-floor flat); 78 Station Road, Harrow ; and 104 and 106 Cecil Road. The Closing Order in operation in respect of 12 Roxborough Road was changed to a Demolition Order. Demolition. The following were demolished during the year: 1-7 Kmgsfield Terrace (1939); 58-60 Crown Street (1955); 283 and 285 nnner Road (1953); Remenham House (1958); 15 Roxeth Hill; 2 to 28 (even numbers) Headstone Drive (1939); 12 Roxborough Road. The dates indicate how very long it takes to bring about the demolition of properties which have been condemned. Admittedly in a number of instances the accommodation has not been occupied for quite a time before it is demolished so that the real object of the demolition procedure has been achieved, namely, to ensure that people are not being condemned to live in unfit houses. Even in these cases though there is the real disadvantage in there being this time lag before actual demolition has taken Place as always there is the risk of squatters moving in. In addition, an empty house steadily deteriorating is an eye-sore and detracts from the amenities of the district, while as well there is the risk of the gardens being used for the dumping of rubbish. 58 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: 18 Byron Hill Road; 48-50 High Street, Harrow-on-the-Hill, and 10 Grange Road; 8,10 and 12 Roxeth Hill; 1 and 2 Springvilla Road, Edgware. Certificates of Disrepair The following is a summary of the applications received for the issue of certificates of Disrepair under the Rent Act: Number of Certificates granted 226 Number of applications not granted 9 Number of Undertakings accepted from owners 27 Number of Certificates cancelled upon application 20 Number of applications for a Certificate as to the remedying of defects 148 Number of applications by Owners for Cancellation of Certificates not granted 6 Overcrowding The annual review of the state of overcrowding in the district shows that once more there has been an improvement As compared with the seventy-two cases known on 1st January, the number on 31st December was only fifty-five. The net reduction of seventeen is the difference between the forty-three cases in which the overcrowding was abated and the twenty-six new cases. In eighteen instances the abatement of the overcrowding was brought about by the families being rehoused in council houses. Of the twenty-six new cases, the overcrowding was caused by the increase in the size of the family, by the ageing of the children, or by the marriage of one of the children. Of the fifty-five cases which were overcrowded at the end of the year, fifteen were overcrowded by half a unit and twenty-two by one unit. Seven families were living in premises overcrowded by 1| units, five in premises overcrowded by two units and six in accommodation overcrowded by 2½ units or more. It is only when the overcrowding is by more than one unit that the Council have up to this been able to entertain an application for re-housing which is based solely on the grounds of overcrowding. The greatest sufferers are some of the families living in one or two rooms. Of the fifty-five overcrowded families, six occupy one room an twenty-two two rooms. Of these latter, five families with an equivalent number of 3½ units and thirteen families with an equivalent number 59 4 units, occupy accommodation with a permitted number of three. These families up to this could not be helped by the Council. There is a greater chance of their being assisted under the new arrangements decided upon by the Council for assessing needs according to bedroom deficiency. New Housing The total number of new dwellings provided in this district from the end of the war up to the 31st December, 1958, was 5,505. Of these, '.,595 were new permanent Council dwellings and 200 were new temporary dwellings. 2,087 permanent dwellings have been provided by private enterprise. 3,338 dwellings destroyed by enemy action were rebuilt, and 334 existing houses were converted. At the end of the previous year the number of permanent Council dwellings provided was 2,482, and the number of buildings provided by private enterprise 1,885. In addition 954 family dwelling units were provided in requisitioned premises. Of these, by the end of the year 774 had been released and sixty-two had been reduced from two to one unit dwellings, the number of properties held being 118., Further use has been made of the arrangements for the removal of Harrow families to the New and Expanded Towns. 217 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 1,637. Of these, 600 were from the normal waiting list. Most of these removals were to the New 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. In March, the number of new dwellings it was anticipated might be erected was 327, comprising 72 houses (all at Bushey), 29 bungalows (at Stonegrove and Woodlands Estate) and 226 flats. The sites for the flats were Kenton Lane (24), Shaftesbury Circle (16), Lower Road (12), Bushey (76), Kingsfield Terrace (6), Edgware Golf Course (6), Durham House (7), Harrow Weald Park (36), Woodlands Estate (11), Brookside Estate (20) and the Marsh Lane/Rayners Lane site (12). A conference of the Boroughs and Districts convened by the Middlesex County Council in March agreed that the County Council should write to the Minister of Housing and Local Government supporting the Provision of a New Town in Middlesex under the New Towns Act, 1946. from the Minister's reply though it was learned that it was not the Government's intention that the machinery of the New Towns Act should be invoked to create further New Towns in England and Wales ; and if a local authority felt a New Town was needed to provide for over-spill of its population, they should consider building one themselves Under Section 3 (3) (e) of the Housing Subsidies Act, 1956. Allocation of New Houses Waiting List. In the early part of 1958 the Housing Officer reviewed the housing list which on the 31st January, 1958 numbered 1,356 applicants, A cheek against the current register of electors disclosed some 477 families were not living at the addresses they were at when they applied to 60 be housed. Of the remainder, some forty-two were husband and wife families only, and as such were no longer eligible for housing. Eighty-six had acquired their own houses, sixty-four had become the principal tenants of whole houses and a further thirty-nine had moved to some other address. The general housing list therefore was then some 571 applicants. Other families had applied to have their names put on the housing waiting list but had not up to then qualified for housing, but their additional points due to the increased length of residence and also because of other children in the family possibly made them eligible. The New and Expanded Towns list which was opened in September, 1952 contained some 1,318 names. Health Considerations in allocation. The following is a copy of a report of the Medical Officer of Health submitted to the Housing Management Sub-Committee at their meeting to consider future policy in regard to the letting of Corporation houses:— 1. The three groups of families about which the Public Health Committee or the Public Health Department makes recommendations for rehousing are those living in condemned houses, those with a member suffering from pulmonary tuberculosis, and those living in overcrowded conditions. 2. The return sent by the Council to the Ministry of Housing and Local Government in the summer of 1955 as their slum clearance programme referred to 577 houses. There are seventy-four families in unfit houses which are the subject of Demolition, Closing or Clearance Orders. There are a further twenty-three families in houses where an Order is pending or where action which will bring about the same result is being taken. In addition there are the ninety-nine "pink" houses in the Northolt Road clearance proposals; although not all of these houses were approved by the Minister for demolition, all of them will have to be dealt with at much the same time. These amount to 196 families. Of the original 577 houses action has yet to be started on 356. Since the time of the survey for the preparation of the return of the slum clearance programme, there has been a big movement by the owners to improve many of these smaller properties. So much is being done on these lines these days that it could be that up to half of the houses not yet dealt with might be saved. If this should prove to be the case, instead of the 356 houses needing to be dealt with, the number may be only 178. To house the occupants of these, 188 houses will be wanted. On this basis, the total number of families to be rehoused from unfit houses is 196 plus 188, that is 384. 3. The Council has for some time been able to consider for rehousing on the grounds of overcrowding only those families where the overcrowding is by more than one unit, and more recently have been able to help only those where the overcrowding has been brought about by the natural increase in the size of the family or by the ageing of the childrenMany overcrowded families have of course been rehoused by the Counci on grounds other than of overcrowding. The number of cases of overcrowding has fallen steadily from 229 in 1952 to eighty-six at the beginning of last year, to seventy-two at the end of last year. Of this seventy-two in only twenty-two was the overcrowding by more than one unit. 61 corresponding figure for 1956 was twenty-four and for 1955 twenty-nine. The Committee has each year provisionally allotted a number of houses for the rehousing of overcrowded families. In 1954 the number was twenty and in the succeeding years eighteen, ten and six. With so many families in restricted accommodation, there will each year be some who become overcrowded by more than one unit by the natural increase in the family and by the ageing of the children. The worst conditions of overcrowding probably are not those in which a family living in a house with a permitted number of say seven and a half, is perhaps 1½ units overcrowded as the smaller family occupying a room with a permitted number of two which is overcrowded by half a unit. The number of houses to be allocated for the relief of overcrowding should not fall below the figure of six granted last year. 4. Particularly when many houses were being built, the Council's allocation of one sixth of those that became available for the rehousing of families with a member suffering from pulmonary tuberculosis proved sufficiently generous that the worst cases were rehoused in a few years. Because of the increasing claims to what houses become available, the Committee had to reduce the fraction to one tenth. Even the reduced fraction of the smaller number of houses which came along proved sufficient to meet the needs. The allocation in the last three years was thirteen, eleven and ten. Because of the smaller number of houses to be expected in the future, it might be as well to alter the basis of allocation, discontinuing the practice of allotting a fraction of what becomes available and instead allotting a fixed number. If that were done then that number should be not less than the ten of last year. The report of the Housing Officer indicated that to fulfil outstanding commitments 270 houses would be needed. The Committee felt that outstanding points scheme cases, being those of persons who had only qualified by residence after the general waiting list was closed in 1952, could no longer be specially provided for, but that any special cases could be considered on their merits as hardship cases. The Committee felt too it was no longer possible to continue the special allocation for dealing with the balance of seventy-two dwellings originally associated with the Poets Corner area, nor the allocation of twenty-four houses reserved to facilitate the phasing of the original Northolt Road Clearance cheme, the balance for which had had to be modified in the light of the Minister's modification of the Council's Compulsory Purchase Order. A special allocation of ten dwellings was necessary to enable the balance of the fifteen "permitted" families of caravan dwellers to be rehoused from the North Lodge caravan site, and a further special allocation of three dwelhngs to facilitate the rehousing of the remaining families at Newton Buildings. Apart from these factors, the Committee followed the same broad principals adopted in previous reviews in reaching the following Provisional allocation:- 62 (i) Tuberculosis cases 6 (ii) Overcrowded families 3 (iii) Hardship cases (to include any outstanding "points" scheme cases to be considered on hardship grounds) 35 (iv) Licensees from requisitioned premises 23 (v) Families to be re-housed from insanitary dwellings— (a) Privately owned 27 (b) Corporation owned 9 (vi) Remaining families to be re-housed from Newton Buildings 3 (vii) Balance of "permitted" caravan dwellers from the North Lodge Site 10 116 Altered Basis of Admission to Waiting List. At their meeting on the 10th October, the Council adopted the following recommendation of the Housing Committee as the new policy in regard to housing applications:— (i) Applicants must prove residence in the Borough for a minimum continuous period of five years up to the date of application: in cases concerning husband and wife, it shall suffice if either spouse possesses that qualification (ii) An application shall normally be considered from a person whose income, or the household income, does not exceed £1,000 per annum. (iii) That a general and financial hardship, as well as housing need. shall be taken into account when assessing the degree of priority to be accorded to a particular case. (iv) Housing need shall no longer be related to the standards of statutory overcrowding as specified in the Housing Acts, but shall be determined by bedroom deficiency, after allowing a family one living room for that purpose only, and taking into account the ages and sex of an applicant's children, as defined in the table appended hereto : the size of the living room shall comply with the standards laid down in the Housing Manual and the limiting ages of children of opposite sexes shall be basically ten years. (v) All housing applications shall be considered individually according to their priority as determined by paragraph (iv) above by the Housing Management Special Sub-Committee' but the present procedure shall continue whereby cases involving health considerations and/or special circumstances other than, or in addition to, housing need, shall continue to be submitted to the Housing Management Special SubCommittee for individual consideration. 63 For determining bedroom deficiency, the following formula was adopted:— Reasonable bedroom accommodation where each bedroom has a floor area of 110 sq. ft. or more). Husband, wife and one child at any age 2 bedrooms „ „ „ two children of same sex at any age 2 „ „ „ two children of opposite sex (both under ten) 2 „ „ „ two children of opposite sex one or both over ten 3 „ „ „ three children of same sex all under ten 2 „ „ „ three children of same sex one or more over ten 3 „ „ „ three children of opposite sex all under ten 2 „ „ „ three children of opposite sex one or more over ten 3 „ „ „ four children of same or opposite sex at any age 3 „ „ „ five children of same or opposite sex all under ten .. 3 „ „ „ five or more children of opposite sex one or more over ten 4 Where bedrooms have less than 110 sq. ft. in floor area, the following shall apply, viz.:— 1. A bedroom having a floor area between 90 and 110 sq. ft. should not accommodate, for sleeping purposes, more than:— Two children of the same sex, one under ten, or Two of opposite sex both under ten. A bedroom having a floor area between 70 and 90 sq. ft. should not accommodate, for sleeping purposes, more than two children of the same sex both under ten. 3. A bedroom having a floor area between 50 and 70 sq. ft. should not accommodate, for sleeping purposes, more than one child. Boxrooms having a floor area of less than 50 sq. ft. shall not be counted as bedroom accommodation. SUPERVISION OF OTHER PREMISES Routine visits are paid by the public health inspectors to such Premises as factories, licensed premises, cinemas and other buildings. 64 Factories There are 541 factories in the district. To these premises 393 visits were made and 50 contraventions were found. Of these seventeen were due to want of cleanliness, 18 were in respect of sanitary conveniences and 15 involved records. Information was passed on to the Inspector of Factories about matters with which he is concerned and he drew the attention of the Local Authority to points he has found which concern them. Local Authorities are required to keep a register of outworkers and to take action if people are employed in unwholesome premises. There are 178 outworkers premises in the district. At 110 of these wearing apparel is dealt with, being either made or cleaned; at 47 Christmas crackers or stockings were made. 271 visits of inspection were made and in all cases the premises were found satisfactory. Shops There are 2,357 shops on the register, an increase of eleven on the previous year. During the year 1,591 visits were made for the purpose of administering the Shops Act The following is a summary of the contraventions noted:— Heating, insufficient or absence there of 17 Water closet, accommodation insufficient 5 Seating for females not provided 2 Assistants employed on weekly half-holiday 13 Young person employed after the specified hours 1 Shops open on half-holiday without displaying prescribed notices 24 Shops open on half-holiday selling non-exempted articles 8 Sundays. Shops open for selling non-exempted articles 3 „ Failing to keep record of assistants employment 11 „ Failing to allow compensatory holiday for Sunday employment 2 „ Keeping shop open without prescribed notices 6 Shops failing to close at Closing Hour 5 309 warnings were sent in respect of these items. During the normal inspection of shops the following defects were noted: Washbasins defective, 3; Ascot heaters defective, 8; Redecoration necessary, 16; W.C's. needing repair, 13; W.C's. needing redecoration, 11; W.C. without artificial lighting, 4; Choked drains, 3 , Yards untidy, 4; Hairdresser's basement without sufficient ventilation, There were no prosecutions during the year. Three infringement were reported to the Public Health Committee, one for serving no exempted articles on Sunday, one for serving cigarettes after General closing hour, and another for failing to observe the Weekly half-holiday closing. In each case the Committee instructed a warning be sent. 65 Trading from Mobile Vans. The Edgware and District Chamber of Commerce submitted a resolution that they viewed with considerable apprehension the increase in trade from mobile shops after closing hours and on Sundays, by persons who have no shop premises. They felt that steps should be taken by way of amending legislation with a view to such mobile shops being brought within the meaning of the Shops Acts as regards closing hours. A High Court judgement had been given that a mobile shop was not a shop on Sunday. From replies to questions in the House on this matter, it appears that it is accepted that legislation is necessary, and that it would be introduced as soon as practicable. Places of Entertainment At the end of the year there were as last year 75 premises in the district licensed for public entertainment. These include 10 cinemas, 14 public houses, 13 church halls, 4 local authority assembly halls, 21 schools, 13 dance and other assembly halls, clubs, etc. To these, 71 visits of inspection were made. The premises on the whole were found to be kept in a clean condition, but in a few cases redecoration was necessary; on approach being made to the owners, the work was put in hand. During the year the district lost its only theatre. Licensed Premises There are 58 licensed premises in the district. Most are modern buildings with satisfactory sanitary conveniences. At a few, however, the standards were not satisfactory. Two premises are old and need modernising. 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 number of licensed pet shops in the district is 13. All were inspected during the year. They were found to be satisfactory at all but one where the premises were dirty. Rag Flock The four premises in the district registered under this Act were visited during the year. They were found to be kept in a clean condition. In no case was any dirty filling material found on the premises. Marine Stores Two persons are registered with this Authority under the Old Metal dealers Act, 1861 as they deal in old metal. No complaint of any nuisance at these premises was received during the year. Hairdressers' and Barbers' Premises The Council has made byelaws under Section 282 of the Middlesex ounty 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 66 byelaws. These establishments are subject to the provisions of the Shops Acts which ensure that 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, 1956 (Appointed Day) Order, 1958 fixed 1st June, 1958 is the date of coming into operation of all those provisions of the Clean Air Act which were not already in operation. It then became the duty of every furnace owner to minimise the emission of grit and dust. To this end some will need to instal grit-extracting appliances. Any smoke other than that from dwellings which is a nuisance to the neighbourhood is deemed to be a statutory nuisance under the Public Health Act; and the emission of dark smoke by anyone anywhere is illegal. Dark smoke is defined as smoke as dark as, or darker than, shade 2 on the Ringelmann chart. The shade card is graduated from 0 (no smoke) which is white, to 1 (light grey), 2 (dark grey), 3 (very dark grey), 4 (black) and 5 (dense black). Dark smoke though is unlikely to be produced in a domestic chimney, the chief offenders being industrial plants, locomotive sheds and at times, large institutions like hospitals. These industrial offenders may plead such reasons as inability to get suitable fuel; and there are certain exemptions until 1963 before the full provisions of these sections become operative, these being in establishments where the emission is due to the nature of the building or its equipment and not to any maintenance failure, or when it has not been practicable to alter or equip the building so as to enable it to be used without a likehhood of emitting dark smoke. Certain defences are permitted under the Act in the event of proceedings being taken. They include the submission that the contravention was solely due to the lighting up of a furnace which was cold and tha all practicable steps had been taken to prevent or minimise the emission of dark smoke ; that it was solely due to some failure of apparatus which could not have been foreseen, or, if foreseen, could not reasonably have been provided against; that the contravention was solely due to the use of unsuitable fuel, that suitable fuel was unobtainable, the least unsuitable fuel available was used, and all practicable steps were takan to prevent or minimise the emission ; that the contravention was due to a combination of two or more of these causes. 67 The following Building byelaw came into operation on 1st August, 1958:— (1) There shall be provided in a new building (except in so far as heating is provided by furnaces to which section 3 of the Clean Air Act, 1956, applies) only such appliances for heating or cooking as are suitably designed for burning any of the following fuels, namely: (a) gas; (b) electricity; (c) coke or anthracite; or are appliances of a description exempted conditionally or unconditionally from the provisions of section 11 of the Clean Air Act, 1956 (which relates to smoke control areas), by any Order for the time being in force under subsection (4) of that section. (2) This byelaw shall not apply in relation to a building begun before the date on which the byelaw comes into operation, or begun after that date in pursuance of plans deposited in accordance with byelaws before that date. (3) Nothing in the foregoing provisions of these byelaws shall be taken to apply this byelaw when an alteration or extension is made to a building. Smoke Control Area. It is disappointing to have to report that it has not been possible, owing to staffing difficulties to take any definite steps to declare any part of the district a smoke control area. Much preparatory work was done, but not any specific enough to enable any particular part of the district to be even considered for delineation as a smoke control area. Smoke Nuisance. In general, the district is largely free from any smoke nuisance from industrial premises. During the year though many complaints were received about Westerdicks where trouble is experienced at times. In July, the apparatus controlling the flow of oil to one of the boilers at Kodaks failed, with the result that for a short time there was a heavy emission of smoke. This was followed by many complaints about oily smuts in nearby houses and on the vegetation. Hazards of Radiation Types of Radiation. The electro-magnetic spectrum ranges from the long radio waves at one end, through heat radiation, infra-red radiation, visible light, ultra-violet light, x-rays and on to the short wavelength gamma rays at the other end of the range. All these radiations have some properties in common, such as their rate of travel. On the other hand, they differ markedly in their ability to penetrate, the longer wavelength rays possessing almost no power of penetration, the short ones much. The resistance to the passage of the penetrable rays depends on the density of the material through which they are passing. It was the different density of the bone compared with that of the structure of the hand that led to Rontgen's x-raying of the hands and to today's use of x-rays in radiography. On their absorption by the tissues the effect of low energy radiation appears only as in heat. The high energy radiation of x-rays or gamma rays can disrupt the electronic structure of atoms and molecules, removing an electron and leaving a positively charged residue or ion (Which is why these are called ionising radiations). These ejected electrons 68 and ions give rise to biological effects. The damage to the cells caused the burns of the earlier workers in x-rays, and the sterility which follows damage to the reproductive cells. It is also the basis of the ray therapy of malignant disease as by introducing the rays on to the structure to be destroyed by different paths, the cells of the structure itself might be killed while no harm is done to the normal tissues through which the rays pass. The source of these harmful rays is usually outside the body ; but it may be inside, having been deposited there by inhalation, ingestion or by penetration of the skin through wounds. Radioactivity. An atom is accepted as comprising a positively charged heavy nucleus surrounded by a cloud of neutrons just sufficient to balance the nuclear charge. Except in the case of hydrogen where the nucleus is a single proton, the nuclei of all types of element are built up of protons and neutrons, particles of roughly equal mass and differing only in that the proton carries a positive charge. The number of protons in any nucleus determines the chemical nature of the element, and the neutrons supply additional mass. Heavier elements tend to have more neutrons than protons. Most nuclei are stable in ordinary circumstances; but a few of the heavier elements are inherently unstable. Sooner or later a violent re-arrangement occurs in the nucleus, a charged particle is ejected, leaving the nucleus differently charged and therefore being a different element. This is the phenomenon of radio-activity. The atom of uranium is unstable; sooner or later it disintegrates, emitting a helium nucleus. The uranium then becomes thorium. This is unstable and breaks down to radium, which in turn becomes radon, passing through polonium and other unstable intermediaries to reach stable lead. Some of these changes are very slow, some almost instanstaneous, each type of nucleus having its own characteristic half-life which is the period over which one half of the atoms disappear. In addition to these radiations are the alpha and beta particle emissions. The beta emission is the commoner, being released from most unstable nuclei with the result that neutron is converted into a negative proton, resulting in a daughter nucleus with an atomic number one greater than the parent. Beta emission from a radio-active source is usually associated with gamma rays. Alpha and beta rays present a special problem from the aspect of internal harm right inside the body. Nature of Isotopes. The nuclei of some elements contain more neutrons than is usual for that element. As neutrons determine the mass, these nuclei are heavier ; but as the proton which determines the nature of the element is the same, chemically these elements are the same as those carrying the usual number of neutrons. These unusual nuclei are known as isotopes. They are usually unstable, and are radio-active. Sources of Radiation. We are exposed to radiation from many sources. There is that from outer space, from the surface of the earth from the food, water and air we take in, and from the radio-active elements in our own bodies. This is the background radiation about which nothing can be done. On top of that we have for some years now been subjected to man-made additions. 69 The first of the man-made additions were from the machines for the production of X-rays. They were closely followed by the extraction of naturally active nuclides, radium and thorium from uranium ores (these provide mainly gamma rays). There has been the fall-out from detonated bombs (which have added less than 1% to the inescapable dose). With the construction of the reactors came not only the isotopes (over 1,000 of them), but also organic compounds tagged with radio-active elements. Incidental to the production of nuclear fuel came an accumulation of mixed fission products, and with them the problem of disposal of waste. Of the hazards, that of greatest potential is from the reactors. In 1956 the Medical Research Council issued a report on the Hazards to Man of Nuclear and Allied Radiations. About the dangers of the different sources of radiation this said : "If the dose of radiation from natural sources to the gonads of the general population is expressed as 100, then the following percentage figures show the additional estimated doses that may be expected from artificial sources: diagnostic radiology, at least 22; radiotherapy, unkown; shoe-fitting, 0.1; luminous watches and clocks, 10; television sets, much less than 1.0; high-altitude flying, insignificant; occupational exposure to radiology, at least 1.6; Atomic Energy Authority, 0.1; fall-out from test explosions, less than X-Rays. This is considered to be the greatest contribution to radiation hazard at present. In regard to the risks from X-rays, the report said—"We consider that the time has come for a review of present practice in diagnostic radiology, and of certain uses of radiation in the treatment of non-malignant conditions, particularly in children. Among the less important sources of radiation, we hope that the use of x-rays in shoe-fitting will be abandoned except when prescribed for orthopaedic reasons ; that watches and clocks with radioactively luminous dials will be confined to necessary uses ; and that the x-ray hazard from television tubes, at present negligible, will be borne in mind if special types of high-voltage equipment come to be widely used." Particularly because of the risk to children whose mothers have been exposed to x-rays, especially of the pelvic organs during pregnancy, X-ray exposures are being more carefully controlled, and greater precautions are being taken to ensure that x-ray apparatus is properly shielded. Legislation has recently been introduced for the control of pedoscopes. Isotopes. Up to ten years ago, the main source of radiation was argely confined to hospitals, physics departments of universities and some heavy industry establishments. Today, the situation is very different, There is widespread employment not only of closed sources but of nuclides (naturally and artificially produced elements for distributive employment in solution). Nuclear reactors are the main sources of deliberately Produced radio-isotopes whether they are the result of nuclei fission or nuclear bombardment whereby the nuclei of very heavy elements such as uranium, plutonium or thorium are struck by neutrons and are disrupted, Isotopes are generally used only in minute amounts. Some are used in ustry (cobalt, caesium, iridium, tantalium 182, thulium, strontium 90). 70 Some are used for radio-therapy, e.g. radium, cobalt 60, caesium 137, gold 198, iodine 131, phosphorus 32. One of the risks these substances give rise to is that from exposure. In hospitals, regulations lay down the arrangements about storage, the use and movement of the materials and the disposal of waste. A second risk is in regard to the disposal of waste from wherever these materials are used. These special problems are covered by the Radio-active Substances Act, 1948. Nuclear Reactors. In ordinary circumstances the operations at the nuclear reactors which are covered by the Atomic Energy Acts, are no risk. There are risks though both to those working at the reactors and those living in the neighbourhood, when an accident such as that of Windscale on the 10th October, 1957 occurs. There is too the ever present problem of disposing of large quantities of radio-active waste. The methods include storage, disposal on ocean beds, and land burial. All— whether solid, liquid or gas—call for rigid control of their transport and of their final resting place. A great hazard from the release of radioactivity into the air is contamination of human food. This may be by the short chain (air, plants, grazing animals, milk and man) or the long chain. There are two fission products above all others which are a special hazard : iodine and strontium, the one accumulating in the thyroid, the other in bones. Iodine with its shorter half-life and its being in greater amounts is the greater risk shortly after the release. The contaminated grass is consumed by cows and radioactive iodine appears in the milk. This risk led to the decision to destroy much of the milk produced near the Windscale plant following the accident there. The transfer of iodine from diet to milk is very rapid. The hazard is much less if the milk is used for making butter or cheese or other manufacture. The next most serious risk is leaf vegetables; but this is small compared with that of milk. Strontium 90 with its longer half-life of twenty years becomes a factor of importance later by its being absorbed by the soil, passing to plants, grazing animals and human beings. It finds its way to bones where it is an internal source of radiation. Examination of the bones of sheep in some localities has shown an increase in the proportion of strontium. Fears have been expressed at the presence of strontium in wheat grown in areas contaminated by fall-out. Other foodstuffs which may be contaminated by fission products include fish which can selectively accumulate certain radio-nuclides in bones and tissues, watercress and sea-weed used to make laver bread. Another risk is of the radiation causing leukaemia. An enquiry about a number of deaths from leukaemia in Heywood, Lancashire, led to an official denial of there being any association of the increased number of cases and the Winscale accident. The fall-out from Winscale was mostly radio-iodine, whereas the agent causing leukaemia is strontium 90 which occurs in test explosions. Exposure of the gonads can result in mutations, the result of in genes. Exposure might cause an immediate effect on the in dividual, or the remote and possibly more marked effect on successive generations. Any radiation dose however small, can cause mutaion. 71 What counts is not the rate of exposure, but the total accumulated dose to the reproductive cells of the individual from the beginning of life to the time the child is conceived. Supervision and control. This varies with the material at risk. Waste. The Ministry of Housing and Local Government is responsible for a continuous watch being kept on the levels of radio-activity in the atmosphere, soil, water, herbage, milk and other foodstuffs. The monitoring arrangements are very complex, and it is felt officially that measures are not necessary in every county to obtain an appreciation of the overall situation. "In view of the watch kept by Central Government, it is not considered necessary for every local authority to ascertain radiation levels in its area." Atomic Energy Establishments do the monitoring of air and rain water and analyse the radio-activity present in samples of human bone. The responsibility for measuring activity in food and agricultural products lies with the Agricultural Research Council. An organisation has been set up to obtain information on a national scale about the radio-active contents of a number of food stuffs, and country-wide surveys are being carried out from which the Government expert advisors can assess the levels of radio-activity in the national diet. Responsibility for advising the Government on its significance rests with the Agricultural and the Medical Research Councils who are satisfied that the extensive monitoring surveys are adequate to ensure that a close and continuous watch is maintained over the levels of food in the country. The Ministry of Housing and Local Government accept responsibility for ensuring that no hazard arises from the disposal of radio-active waste. They receive details of all deliveries by the Atomic Energy Authority. Particulars of all deliveries are passed to the Ministry of Labour and National Service who take similar action with regard to handling and use of radio-active sources in factories and workships. Most radio-active wastes in the country are produced by the Atomic Energy Authority which by the Atomic Energy Act, 1943 needs an authorisation from the Ministry of Agriculture, Fisheries and Food and the Ministry of Housing and Local Government, before discharging radio-active waste—whether liquid, solid or gaseous. These provisions are to be extended to other nuclear installations to be made subject to the Nuclear Installation (Licensing and Insurance) Act. No significant discharges are expected at present from the nuclear power stations to be erected by the Central Electricity Authority. The quantities of radio-active wastes discharged by users of radioisotopes (hospitals, factories and research establishments) are small, and are generally governed by the laws controlling the disposal of ordinary waters—The Rivers (Prevention of Pollution) Act, 1951 and the Public Health (Drainage of Trade Premises) Act 1937. "A continuous watch was kept on deliveries of radio-isotopes to hospitals, factories and other users and the department does not consider that any danger to the public arises from the disposal of the amounts at present delivered." (Annual Report, 1957 Ministry of Housing and Local Government). 72 In June, 1956 the Radio-active Substances Advisory Committee appointed an expert panel to ascertain the nature and quantity of radioactive waste likely to arise in the foreseeable future, to advise on the best methods of securing that the waste is disposed of safely, and to advise whether any new legal provisions or amendments to existing legislation are necessary to ensure safe disposal ; and if so, to advise on the form which the new provisions or amendments should take. An interim report said—"We can say that no hazard from radio-activity arises from, for example, sewage or sewage effluent, anywhere in this country." Until recently, gaseous effluents have not given cause for anxiety. Stacks are monitored and the air entering and leaving the stack is filtered. The whole area of the site and the country for many miles around is regularly monitored. The Atomic Energy Research Establishment at Harwell published results of preliminary investigations which show how radio-active isotopes have penetrated into public water supplies. The amounts varied with the type of the source of water. Storage had some effect in reducing the quantity. Radio-Therapy. The Health Department of the Ministry have appointed a Committee under Lord Adrian to review the present practice in the field of radio-therapy and radiology. The Home Office have agreed with manufacturers and users a safety code governing the use of shoe-fitting fluoroscopy. Fall-out. The Government have a full programme for the measurement of fall-out deposited in this country in consequence of nuclear weapon tests. Isotopes. The transport of active fuel products by road is controlled by the Authority and by the Police. The primary responsibility in regard to factories rests with the Ministry of Labour. New regulations have been published or are under consideration. Position of Local Authorities. Local authorities as yet, have not been brought into the picture. The Minister of Housing and Loca Government feels that it is not necessary for authorities to make arrangements for monitoring. On the other hand, it is said that authorities canno be furnished with information about the distribution of isotopes to places in their districts as this is a commercial matter. The question of the training of Public Health staff is being considered by the Ministry of Health Committee. (Chairman, Sir Douglas Veale). Many members of the public are apprehensive about the present position, and still more about the future. According to some authorities the fall-out from the thermo-nuclear explosions which have alrady taken place must inevitably result in the development of cancer in a largn number of people. The concern of others is the risk of contamination of foodstuffs, more especially the milk which is to be consumed by the younger members of the population. Others see the risk of exposuse to isotopes which are to be so freely used, some of which by human frailty 73 will escape the precautionary nets. To those expressing their fears or those who turn to the Local Authorities hoping for reassurance, all that can be told is that the various Government departments have accepted responsibility for taking the necessary precautionary steps. They cannot be told even of monitoring arrangements, nor how near to the district analyses of air, soil and water or foodstuffs which can be considered comparable to those in this district are being made, and they cannot be told that the health authorities have any clear idea of what isotopes are in the area. Rats and Mice The rodent operatives found rats or mice at 1,191 of the 1,336 premises they visited. Each of the infestations was small and localised. Most complaints were from private dwelling houses, 958 of these being in respect of rats, 70 of mice. Twenty-four infestations of rats and eight of mice were at Corporation properties, 92 and 42 at other premises. The number of visits made by the rodent operatives to these properties was 10,210. The figure of 1,191 for 1958 compares with figures of 1,296, 1,192 and 1,429 for the three previous years. Vermin infestation is encouraged by the widespread practice of people feeding pets and wild birds in the back gardens of their houses without taking even elementary precautions against providing an attractive food supply for rodents. The small number of sewers known to be infested with rats were treated twice during the year. The results of the treatment do not suggest any increase in the rat population. Periodical surveys of watercourses and land owned by the Corporation were made and treatments carried out where necessary. Wasps There are marked variations in the prevalence of wasps and in the requests for help to deal with their nests. Only 111 nests were detroyed by the department during 1958. This ngure is much lower than that recorded in previous years, 345 in 1955, 213 in 1956, and 265 in 1957. The Corporation's charge of five shillings was recovered in all cases. Caravan Site In 1957, the Council decided that action be taken to extinguish the existing user rights of land at North Lodge, Edgware as a caravan site ; at agreement with 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 Council for housing purposes ; that any restrictions as to the number of caravans to be permitted on the site be enforced; and that the Council be recommended to assume a moral responsibility for rehousing up to 15 families of caravan dwellers on this site. The County Council tried to negotiate with the owner the purchase of that part of the site designated in the County Development 74 Plan for acquisition upon which to build an old people's home. Upon the owner's failure to open negotiations the County Council decided to make a Compulsory Purchase Order, subject to the Corporation's undertaking to rehouse 15 permitted families from the site. This undertaking was given and by May, 5 of the families had been rehoused and provision of 10 dwellings was made in the revised allocation of Council dwellings adopted by the Council in April. The families to be considered for rehousing were:— (a) Any family (other than those comprising husband and wife only) who are living in a caravan at the North Lodge site and have done so continuously since before the 12th September, 1952. (b) Any other such family (other than husband and wife only) who although having a shorter residence period than stipulated above, are living in such conditions as warrant special consideration being given on individual hardship grounds. Notices were served under Section 345 of the Middlesex County Council Act, 1944 on the occupants of three caravans who entered upon the site in June, July and October, 1957, two being given not less than six and not more than twelve months in which to move elsewhere. On appeal, the magistrate dismissed one and adjourned the other case sine die, the applicants being warned to obtain alternative accommodation as soon as possible. At the end of the year there were 15 caravans on the site. Nuisance from Pigeons Pigeons have been becoming a growing nuisance in certain parts of the district. Large numbers congregate in certain localities, particularly South Harrow, where perhaps the nuisance is greatest. Apart from the fouling of the pavements, complaints are received from shopkeepers of the fouling of the clothing of customers, and also of the entrances to food shops. The trouble is added to by the practice of some persons feeding the birds near shops. The Public Health Committee at their meeting in April authorised action being taken. The greatest congregations of birds were at the Gas Works in Northolt Road and the nearby railway arches which seem to be the principal sites of roosting and brooding. Large numbers of birds were removed from these two places. This procedure will probably have to be carried out at regular intervals until such time, if ever, as these places are protected with netting or in some such way to deprive the birds of their ledges. Smaller numbers of pigeons frequent some other buildings in the district, especially some of the churches. The Public Health (London) Act, 1936 contains a clause under which action can be taken to abate or mitigate any n uisance caused by the congregati°n of house doves or pigeons. The Council decided to ask the Association of Municipal Corporations to press for the inclusion in the pending Public Health (Miscellaneous Provisions) Bill of a clause to extend to authorities outside the County of London the powers contained in this Section 121 of the Public Health (London) Act which reads: For the purpose of abating 75 or mitigating any nuisance, annoyance or damage caused by the congregation, at any place in the city or a borough, of house doves or pigeons having, or believed by the sanitary authority to have, no owner, or of preventing or minimising any such nuisance, annoyance or damage which might, in the opinion of the sanitary authority, be so caused, the sanitary authority may seize and destroy, or sell or otherwise dispose of, or cause to be seized and destroyed or sold or otherwise disposed of, any such house doves or pigeons in excess of such number as the sanitary authority consider reasonable, and take such other steps as they think necessary for any purpose: Provided that a sanitary authority shall not in the exercise of the powers conferred by this section: (a) enter upon any premises (other than a public highway) without the consent of the occupier or the person having the exclusive control and management of the premises; (b) execute or do any work or thing affecting the structure of any building or the use of any land without the consent of the person in whom the building or land is vested. Spitting in Streets This question was raised at a meeting of the Public Health Committee. Byelaw 29 of the Council's Good Rule and Government Byelaws reads:— "no person shall spit on the floor, side or wall of any public carriage or of any public hall, public waiting room or place of public entertainment whether admission thereto be obtained upon payment or not." The Home Office were approached on the question of whether a byelaw prohibited spitting in streets had been confirmed and if not, would the Secretary of State give favourable consideration to a byelaw in the following terms: "No person shall spit on the paved footway of any street or public place." Because of the possibility of argument about the word "paved", it was suggested that word might be omitted. The difficulty was got over by defining the word so the byelaw as approved by the Council early in 1959 reads:—Spitting on Public Footways: No person shall spit on the paved footway or any street or public place. In this byelaw the expression "paved" includes concrete, asphalt or other made-up surface. Any person offending against this byelaw shall be liable on summary conviction to a fine not exceeding £5. 76 INSPECTION AND SUPERVISION OF FOOD (A) MILK Production Milk is produced at only six farms in the district; at two others only store cattle are now kept. Tuberculin-tested milk is produced at five; 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 37 persons or companies:— (1) The number of premises from which pasteurised milk was sold 52 (2) The number of premises outside Harrow from which pasteurised milk was retailed in the district 21 (3) The number of premises from which T.T. milk was sold 47 (4) The number of premises outside Harrow from which T.T. milk was retailed in the district 21 (5) The number of premises from which sterilised milk was sold 48 (6) The number of premises outside Harrow from which sterilised milk was retailed in the district 20 Supervision During the year 38 visits were paid by Public Health Inspectors to dairies and cow sheds in the district. Sampling Forty-four 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 During the year fifteen complaints were received about milk bottlesTen were about the dirty or damaged state of the bottles and the other five about the presence of foreign matter. (B) MEAT Meat Inspection Legislation as to Slaughterhouses. The Slaughterhouses Act, 1958, which received Royal Assent on 1st August and came into effect forthwith, amends certain of the provisions of the Food and Drugs Act, 1955 relating to slaughterhouses, and also of the Slaughter of Animals Acts, 1933 to 1954. The principle change is that the Act for the first time provides for minimum standards for the construction and equipment of 77 slaughterhouses. These standards applied immediately to all new slaughterhouses. Existing premises are to be brought up to these standards as soon as possible, but without reducing the facilities available in an area below the required minimum. The Act preserves the existing system for the licensing of private slaughter-houses by local authorities, and the provision by authorities of public slaughterhouses. Existing slaughterhouses which do not reach the minimum standards are to be dealt with in two stages. In the first phase, which will cover some two years, traders will be free to establish slaughterhouses where they like, subject to standards and to Town Planning requirements. In the next phase, some measure of control will be exercised over the granting of licenses. In due course each authority will have to review and report to the Minister on the existing and probable future requirements of their districts of slaughterhouse facilities, and facilities which are, or are likely to become, available to meet these requirements. When reporting, the Council will recommend a date on which the Minister might apply to existing slaughterhouses the new standards of construction for hygiene and for the prevention of cruelty to animals. Exchequer Grant towards the Cost of Meat Inspection: The Act also provides for arrangements being made for grants to be paid to local authorities who have to meet unduly heavy expenses in carrying out their functions with respect to the inspection of meat at slaughterhouses. The Slaughterhouses (Meat Inspection Grant) Regulations, 1958 prescribe the conditions under which Exchequer Grants towards the cost of meat inspection would be made, and the methods by which the grants would be calculated. These provisions are intended to benefit districts, particularly those low-rated, where much killing takes place, little of it being for local consumption. This district cannot benefit from them. Circular F.S.H. 3/58 of the 31st March, 1958, drew attention to the need for particular care when sheep are stunned by electricity to avoid the infliction of unnecessary suffering. Certain precautions were suggested. The Slaughtering of Pigs (Anaesthesia) Regulations, 1958 which came into operation on the 1st December, permit the use of a process of anaesthesia by carbon-dioxide in connection with the slaughter Pigs. The regulations lay down requirements that must be observed in the design and operation of an installation. No installation may be used unless the local authority have given a certificate of approval. The Slaughterhouses (Hygiene) Regulations, 1958 and the Slaughtering of Animals (Prevention of Cruelty) Regulations, 1958 which are designed to secure the observance of sanitary and cleanly conditions in connection with the construction and operation of slaughterhouses and the handling of meat therein, did not come into operation until 1st January, 1959. Inspection of Meat. In 1938 there were some 12,000 slaughterhouses he country. During the war, killing was restricted to about 500 premises. At the time when the control of meat ended there were in use 78 119 public slaughterhouses, 357 private ones and the seven new government abbatoirs. The de-control brought about by the operation of the Slaughterhouses Act, 1954, led to some 4,200 slaughterhouses coming into use. The greater the number of premises, the greater is the difficulty of ensuring that all meat is inspected. A recent analysis of the Ministry of Agriculture, Fisheries and Food of information submitted by every local authority with a slaughterhouse in its district, showed that something like 90 per cent of all meat now receives some degree of inspection by an officer of a local authority. Of the meat not inspected, some 70 per cent was pig meat, most of this being produced at bacon factory slaughterhouses. About 160 local authorities did not achieve 100 per cent inspection. In about half of these areas, Sunday slaughtering took place regularly and in a further 1 per cent occasionally. In 14% of the areas, slaughtering was sometimes carried on at very late or very early hours. The difficulties of ensuring the inspection of meat which comes about from this killing being carried out at inconvenient times have been considerably added to by shortages of staff and of course, more particularly in rural districts, by the scattered location of the slaughterhouses. A big step towards ensuring that all meat is inspected would be to keep down the number of premises at which killing takes place. Another step would be the tightening-up of the conditions which under present legislation permit of killing taking place at hours which make supervision difficult and even impossible where there is limited staff and killing takes place at the same time at widely distant premises. The total number of animals slaughtered last year at the four slaughterhouses in the district was 7,654, a fall on the figure of 9,020 in 1957. This is due to the virtual cessation in the killing of smalls at the most modern and best equipped slaughterhouse. The amount killed at the other three centres, none of which were designed for wholesale business, showed an increase. The incidence of tuberculosis (1957 figures in brackets) in cattle other than cows was 5T4 per cent (5.85 per cent); in cows 19.3 per cent (15.25 per cent); and pigs 2.34 per cent (1.4 per cent). All cases diagnosed were localised, there being no cases of generalised tuberculosis, as compared with six cattle and one pig last year. The most common site of infection is the respiratory system of cattle and cows, and the head of pigs. Cysticercus bovis, a cause of tape worm in man, again increased, being found in 32 cattle and cows (27). These animals are infected at drinking points and on pasture land which have been contaminated by the faeces of a human carrier of the tape worm. There was one outbreak of swine fever. The incidence of other diseases showed a slight increase, possibly the effect of the abnormally wet weather over the year, being 27.9 per cent (24.7), in beasts; 35.3 per cent (34.3 per cent) in cows; 22.7 per cent (18.2 per cent) in pigs; and 9.8 per cent (6 per cent) in sheep. The total weight of meat condemned at slaughterhouses was 15,405 pounds. (19,883). All was destroyed by incineration at the Wembey destructor. 79 The following is a copy of the return asked for by the Ministry about the post-mortem inspection of animals at slaughterhouses, and relates to carcases and offal inspected and condemned in whole or in part:— Cattle Excluding Cows Cows Calves Sheep and Lambs Pigs Horses Number killed 1,807 150 460 3,526 1,711 — Number inspected 1,807 150 456 3,519 1,711 — All diseases except Tuberculosis and Cysticerci Whole carcases condemned — 1 — — 9 — Carcases of which some part or organ was condemned 504 53 1 346 389 - Percentage of the number inspected affected with disease other than tuberculosis and cysticerci 27.9 35.3 0.2 9.8 22.7 - Tuberculosis only Whole carcases condemned — — - — — — Carcases of which some part or organ was condemned 93 29 1 - 40 - Percentage of the number inspected affected with tuberculosis 5.14 19.3 .2 - 2.34 - Cysticercosis Carcases of which some part or organ was condemned 28 4 - - - - Carcases submitted to treatment by refrigeration 22 2 - - - - Generalised and totally condemned - - - - - - (C) OTHER FOODS Food Premises There were at the end of the year 233 grocers shops, 144 fruiterers and greengrocers, 137 butchers, 53 fish shops, 35 dairies, 152 confectioners/ cafes. 80 Food Condemned During the year 14,668 lbs. of food were found to be unfit and had to be destroyed. Fruit and vegetables accounted for 9,243 lbs. of this, meat and meat products for 4,858 lbs., fish for 369 lbs., and groceries the remaining 198 lbs. These figures do not include over 1,500 lbs. in weight of groceries and provisions damaged by the flooding that occurred in the Hatch End district. Complaints 44 complaints were received about foreign matter in foodstuffs. 33 of these related to bread, cakes and confectionery, 6 to meat pies, and 5 to tinned or packed food. Ice Ceam At the end of the year 384 premises were registered for the retailing of ice cream, an increase of 15 on the number on the register at the end of 1957. Of these 8 were registered for the purpose of manufacture, but at only two was ice cream made. 62 samples were taken, 16 from the manufacturers in the district and 46 from retailers of prepacked or loose ice cream. Grades I and 11 are considered satisfactory; grades III and IV are not, and if repeated indicate faults in practice. Of the 16 samples from local manufacturers, four were Grade IV, and therefore not satisfactory, the remainder being Grades I and II. Of the remaining 46, five samples of loose or prepacked ice cream were Grade III, three Grade IV, the remaining 38 being in Grades I or II. 33 of the 35 samples of ice lollies examined were satisfactory, the remaining two being in Grade IV. 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, the same as 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 with the Local Authority, and that the storage premises used by him shall also be registered. The number registered as trading in the district at the end of the year was 61, an increase of 4 during the year. Of these 24 were trading from storage premises in Harrow, and 37 from premises outside the district. (D) ADULTERATION OF FOOD The following particulars have been taken from the Annual Report of the Chief Officer of the Public Control Department of the County Council for the year 1957/58. Of the 1,567 samples examined by the Public Analyst, only 140 were found to be incorrect. This was an improvement on the position of the previous year when out of 1,517 samples, 223 were incorrect. Most of the improvement was due to a fall from 128 to 24 in the number of incorrect samples of milk, an improvement which is partly offset by an increase from 95 to 116 in the samples other-than-milk. 81 The 23 incorrect samples of new milk were taken from six consignments sent by six different farmers to milk depots in the County. The slight deficiency of fat in the milk of one sample was the result of unsatisfactory bulking of the yield of a mixed herd; in the others, although there was a deficiency either in fat or in solids-not-fat, the milk was the natural product of the herds. Of the 987 samples examined in the department, 108 were incorrect. These were mostly natural foods which are examined to determine whether there has been a substitution of a different food. The proportion of unsatisfactory samples is very high, but this is because most of this work is selective, many of the samples having been procured only because of a suspicion that the position was not satisfactory. In connection with the 248 unsatisfactory samples, 84 proceedings were instituted; official cautions were sent in respect of 90 further offences. During the year, 347 samples of milk were taken and submitted for examination by inoculation for the presence of tubercle bacillus. Four samples were found to be infected. In each, examination of the herd was made by the Veterinary Officers of the Ministry of Agriculture; as a result, one cow was slaughtered. 1,185 samples of processed milk were tested to determine whether the milk had been properly subjected to the relevant heat-treatment process. Three failed to pass the phosphatase test for heat treatment, three the methylene blue test for keeping quality and one failed both tests. The percentage of failures of samples procured each year has fallen from a figure of 8.9 in 1950 when the County Council became responsible for the supervision of heat-treated milk, to 0.6 for last year. 280 visits were paid to the licensees' premises to see that all relevant regulations are being complied with. (E) HYGIENE OF FOOD In general, there has been an improvement in the handling of food. More are appreciating the significance of the measures stressed to make food safe, and many who are dealing in foodstuffs realise the appeal to the public of the special provisions they make to avoid the foodstuffs being contaminated either by those serving the food, by customers or by flies or other insects. Too often though, there are patent lapses from the desirable standards, not all of these being on the part of those serving the oodstuffs. It is regrettable that persons are selected for this important work who do not seem to have been brought up to reasonable standards. these are not ingrained, there is the much greater risk of lapses. This aspect of the work of the Inspectors is one which has suffered as a result of shortages of staff, and no specific effort directed primarily to this subect was made this last year, though of course, the Public Health Inspectors continued their routine inspections of premises. The attention of the Public Health Committee at their meeting in September was drawn to the dirty and unhygienic condition of a bakehouse and flour loft. Previously, following a number of warnings, the Committee had found it necessary to take proceedings under the Food and Drugs Act. Similar action was taken on this occasion. 82 A van containing unsound food when on the way to South Harrow was stopped in South London. The food was being brought into the Borough to be prepared for feeding greyhounds. It appears that the Ministry of Agriculture, Fisheries and Food had drafted regulations about the staining and sterilization of unsound meat, but these are still under consideration. The Association of Municipal Corporations are in touch with the Ministry on the matter. Food Hygiene (Amendment) Regulations, 1957. Section 7 of the 1955 Regulations restricted the giving out of food for preparation or packing in domestic premises. The 1957 Regulations removed this restriction in regard to shrimps, prawns and onions. These Amendment Regulations which came into force on the 31st December, 1957 provided that as from 1st June, 1958, the prohibition will apply to the preparation of shrimps, prawns and onions unless the outworkers premises are registered with the local authority, under Section 16 of the Food and Drugs Act, 1955 for the preparation of the food and certain other requirements are complied with. Health Education. This work which started as the educational side of the Clean Food Campaign has steadily developed each year and Mr. E. G. Montford, one of the Public Health Inspectors, who is especially concerned with the subject, devotes almost the whole of his time to it. The public is approached in different ways. Talks, many of them with the exhibition of film strips, are given to audiences at schools and local associations. Thirty-seven talks on environmental health or food hygiene were given during the year, and twenty-one talks on home safety were given, mostly to audiences at the clinics. A lot of material of different sorts has been collected in the Public Health office which is suitable for showing to audiences. Nineteen parties of student health visitors, overseas health students, local traders, etc. have attended demonstrations. As is now customary, the Public Health department has a large exhibit at Kodak Hall for the week-end the Delegate Conference is held. Similar exhibits have been shown at the clinics and branch libraries, totalling 109. These reach large numbers of people. The Harrow Observer is very generous in its support of the Council > efforts on health education and hardly a week passes without their including some notes on this subject. Other ways of reaching the public are the posters displayed at clinics libraries and schools and outside notice boards. Some 500 were exhibted last year. In addition, the Public Health Committee sponsored a health education brochure authorising the printing of 5,000 copies. These give those interested an account of the health education programme of the Public Health Committee and tell readers whom to approach if they want lecturers, etc. Film strips are shown at many of these talks and additions are constantly being made to the already large library, with a result that there is now a very large number from which to select slides appropriate to the lecture and to the audience. 83 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. 45-65 yrs. 65+ yrs. Unknown Total Scarlet Fever - 22 89 16 4 1 1 1 - - - - 134 Pneumonia, primary 1 — 1 - - - 6 3 9 3 7 1 31 Pneumonia, influenzal - 3 3 1 - - 1 2 6 1 2 1 20 Diphtheria - - - - - - - - - - - - - Dysentery 2 8 25 9 2 1 8 2 1 — - - 58 Erysipelas - - - 1 - - - 3 3 3 6 - 16 Meningococcal infection 1 - - - - - - - - - - - 1 Puerperal pyrexia - - - - 1 5 5 2 - - - 1 14 Ophthalmia neonatorum - - - - - - - - - - - - - Poliomyelitis, paralytic - - - 1 - - 1 1 - - - - 3 Poliomyelitis, non-paralytic - - - - - - - - - - - - - Encephalitis, infective - - - - - 1 - - - - - - 1 Measles 14 489 771 41 3 3 4 2 - - - 9 1,336 Whooping cough 5 9 18 6 - - - 1 - - - 1 40 Paratyphoid fever - - - - - - - - - - - - - Typhoid fever - - - - - - - - - - - - - Food poisoning 2 9 9 1 1 1 7 8 3 - 1 - 44 Malaria — - - - — - - - 1 — — 1 CONTROL OF INFECTIOUS DISEASES The benefits of the improvement in the hygienic conditions which were brought about towards the end of the last century were reflected in the reduced incidence of a number of infections which had up to that wrought such havoc. When the infectious diseases hospitals were erected from 1880 onwards, they were not so much hospitals at which the infectious sick obtained treatment, as places to which infective persons were removed to avoid their spreading infection to others. At the time and for many years, the three diseases from which those removed to these hospitals were suffering were scarlet fever, diphtheria and enteric fever. All three diseases were very prevalent and most lethal. From the 1920's sufferers from other infections have been admitted. This wider range of cases necessitated changes in the lay-out of these hospitals with many of the beds provided in single-bedded or four-bedded cubicles. Enteric fever became less common, largely the result of a safer water supply. Scarlet fever became mild in character even though so very prevalent at times; 2nd then from the beginning of the national campaign for immunisation against diphtheria in the early days of the war, there has been a steady reduction in the number of these cases. These then so very recently dread diseases now provide very small numbers of admissions to the isolation hospitals. In the meantime, measles has waned in severity, quite apart from the efficacy of therapeutic agents for cutting short the damage due to secondary infection when this occurs. Concurrently, and perhaps largely due to the increasing amount of vaccinating of infants against Whooping cough, there has been a fall in the severity of this infection, so recently such a menace to the life and health of the infant. The importance 84 then of these infections which even in the early days of the century were so damaging, has so declined that they no longer loom as public health dangers. Instead, as the infection which receives most publicity and perhaps possibly for that reason is the most feared, is acute poliomyelitis, an infection which occurred on a national scale for the first time as recently as 1947. Influenza is always in mind because so little can be done to limit its spread and its attack rate may be so high, causing disruption to the life of the community, even when its fatality rate is not high. Smallpox too is an ever present fear, even though the spread of the major type can be so speedily controlled. Apart from such incidents then, the infections do not occupy the same important position they used to, and it may be that many of them are now being treated too lightly. This is reflected in the growing laxity of general medical practitioners to notify such diseases as scarlet fever. Today this is a very mild complaint; nevertheless, it is not one to be ignored and people ought to be protected against the risks of contracting it. There are no longer many restrictions placed on the contacts of those suffering from various infections, but some contacts even of an illness as mild as today's scarlet fever should be excluded from certain occupations. The true incidence of food poisoning and of dysentery is just not known; the actual number of notifications is very short of the number of persons affected, and yet it is so very necessary that all cases should be known, not only so that steps might be taken to prevent further infection occurring from the source which gives rise to the first case, but so that preventive measures can be taken to reduce the risk of similar lapses in hygienic standards leading to similar trouble. While then the great killers are not exacting their toll, much time still has to be devoted to other infections which while not causing dramatic numbers of deaths are nevertheless accounting for much illness, pain and suffering, and loss of earning capacity not only that of the patient himself but of those who have to look after him. The control of infections then continues to be a most important part of the duties of those in the Public Health Services. The measures which can be taken vary with the different diseases and include:— Notification. The list of conditions which are notifiable includes certain infections listed in the Public Health Act, 1936 which list is largely a repetition of those diseases notifiable under the original Infectious Diseases Notification Act, and certain other conditions which have been made notifiable by regulation. The receipt of a notification sets in tram the various steps taken by those in the Public Health Department to ascertain the source of infection and so possibly prevent others contracting infection from that same source, and to discover the contacts with a view to limiting further spread of infection. Some conditions such as measles were made notifiable largely for statistical and epidemiological purposes. Some diseases such as erysipelas, once of serious significance, are now of little public health importance. Scarlet fever is an instance of an infection once so lethal but which has now become one of little public health significance. With these changes in the infections themselves, the 85 question constantly comes up of whether there is any point in continuing to have some of these diseases notifiable, or whether it might not be more profitable to remove some of them from the list to which can then be added other conditions about whose incidence there is no certain indication. G.R.O. Circular (M.O.H.) No. 1/1958 of 1st January, 1958 deals with the steps to be taken to avoid duplicate notifications. There are special provisions for London. Isolation. By contrast with the position when the isolation hospitals were first erected and all the beds were occupied by patients suffering from scarlet fever, diphtheria or enteric fever and at which time a very high proportion of those suffering from these infections would be admitted to hospitals, today these infections account for only a small proportion of the admissions to isolation hospitals. Today there are not those numbers of cases of diphtheria and enteric fever to be admitted. In the case of scarlet fever, the reduction is due to the fall in the number of severe cases because whether the disease is highly or only slightly prevalent, only very few of the patients are seriously ill. Today then those admitted to the isolation hospitals are mostly those suffering from the conditions which have become notifiable by regulation, and in general far fewer beds are occupied by the infectious sick than was the case before the war. While the mild case of scarlet fever does not need to be admitted to hospital to enable him to receive any special medical or nursing care, it is still necessary that he should be isolated. These days it would seem that many are losing their fear of scarlet fever, and for that reason perhaps fail to appreciate the need to prevent the spread of infection to others in the family. The result is that patients often enough are allowed to be up after too short a period, something which is not in their own interests or in those with whom they are permitted to come into contact. Exclusion of Contacts. At one time quite stringent precautions were taken to control the spread of infection from persons suffering from the various infections By degrees these rules have been relaxed first in the case of adults and more recently in the case of children, so that now it is quite exceptional for an adult contact to have to refrain from going to work, and the school child who is a contact of those suffering from various infections is allowed in most cases to go to school. Disinfection. At one time carried out as a routine practice after a number of infections, it has largely been abandoned as routine measure and is carried out only after certain infections. In this district it is limited virutally to the fumigation of rooms and the steam treatment of the bedding and Nothing of those suffering from smallpox, the bedding of typhoid Patients and the rooms occupied by those suffering from open tuberculosis. No progress could be made during the year about the erection of the new disinfecting plant, although towards the end of the year it was learned that it might not be very long before sanction to proceed was received. In addition to these measures of course, there is the active immunisation which can be carried out to ward off a growing number of diseases. 86 DIPHTHERIA Incidence In none of the patients thought to be suffering from diphtheria was the diagnosis confirmed. The district has now been free from the disease since 1950, a period of eight years. The last fatal case was in 1946. The number of cases notified in the country as a whole fell in 1957 to a new low level record of 37 cases, of which 6 proved fatal. Immunisation The change in the material used at the clinics for inoculating children against diphtheria, a change brought about because of the greater risk of some preparations causing provocation poliomyelitis, has resulted in a fall of the number of children inoculated against diphtheria. It is hoped that the campaign for inoculation against poliomyelitis will soon result in such a decline in incidence that it will be possible to revert to the use of the combined prophylactics against diphtheria and whooping cough which were becoming so generally accepted by mothers. Failing this, perhaps infants can be given their protection against poliomyelitis sufficiently early to allow the use of the combined preparation to those who have had two doses of the anti-poliomyelitis vaccine. During the year 1934 children were treated for the first time, 1,128 by general practitioners and 806 at the infant welfare centres. The corresponding figures in 1957 were 2,136, 1,174 and 962, and in 1956 2,336, 1,109 and 1,227. The number of births notified during the year was 2,910. The aim should be that during any year as many children should be treated for the first time against diphtheria as the number of births. It is estimated that at the end of the year 60 per cent of children under five years of age were protected and 96 per cent of children aged five to fifteen years. Booster doses were given to 901 children, 491 by general practitioners and 410 at the clinics. SCARLET FEVER 134 cases of scarlet fever were notified in 1958. The rate per thousand population was 0.62. The corresponding rate for the country as a whole was 0.86. Although the number of notifications was nearly double that of the previous year, the incidence of the infection was almost the lowest experienced in this district. On only two previous occasions, including 1957 had there been fewer cases. The incidence of scarlet fever is subject to violent fluctuation, the number of cases in this district in any one year being as low as 76 in 1957 and as high as 707 in 1943. These variations occur not on a smooth wave but quite spasmodically and without apparent cause, and are the result presumably of changes in the organism which causes the infection. There is a preventive against scarlet fever; but with today's mild type of illness, it is not worth while its being used for the protection of the general public, though possibly worth while to protect those who are subject to a special risk of contracting the intection. 87 The weekly notification rates over the four quarters were 2.3, 3.1, 18 and 3.4. The type of illness remains mild and this infection now causes very few deaths. The last fatal case contracted in this district was in 1937. Very small numbers of sufferers are now removed to hospital, there being only 3 last year. Although secondary infection so rarely occurs, even in those households where precautionary measures to prevent the spread of infection fall short of what might be desired, there were this year 9 households in which some members of the family succumbed. In two of these there were two secondary cases, in the others one each. In all instances the primary case was nursed at home. In three of these the infection had already been passed on to the other child by the time the illness in the first was recognised, as in two instances the period separating the onset of illness was only about twenty-four hours, and in the third instance the illness of the first was not diagnosed until the other child fell ill some three weeks later. In the other households though, including both where there were two secondary cases, having regard to the interval separating the onsets of illness of the primary and of the secondary cases, it is probable that had the first case in each household been removed to hospital, the other children in the houses would not have suffered an attack. There were no return cases this year. Although it is now quite exceptional for there to be a real outbreak of scarlet fever amongst pupils at a school in which it is thought the infection had been contracted at the school, groupings of cases keep cropping up which suggest that school attendance might have been responsible for some at least of the cases. In July, seven pupils at Vaughan Road Junior School went down with scarlet fever over a period of three weeks, though in fact these cases were distributed over four classes. There were similar though smaller groupings at four other schools. SMALLPOX Although it is quite exceptional these days for anyone in this country to be suffering from smallpox, most local authorities in every year have a certain amount of work to do in arranging for the surveillance of persons who have come into the country by air or sea and who are still in the incubation period of the infection. Vaccination. During the year, 2,321 persons living in the district were vaccinated against smallpox for the first time. Of these, 1,720 were under one year of age, and 183 were over one but under two years of age. 747 persons were re-vaccinated. 2,910 babies were born during the year, The number of vaccinatons of those under one year of age was therefore 59 per cent of the births. Of those under one year of age who were vaccinated, 755 were treated at the infant welfare centres. 88 ENTERIC FEVER Although notifications of typhoid fever are becoming unusual, a number of persons suffer during each year from paratyphoid fever. This last year has been exceptional in that no notifications have been received of persons suffering from typhoid or paratyphoid fever. DYSENTERY The 58 notifications of dysentery received this year was the highest number recorded for this district. It was largely the result of two outbreaks. The first occurred amongst those, principally children, at a Council housing estate and an extension from there to a school in another part of the district but attended by children from this housing estate. The outbreak which started early in February and lasted until well into April involved altogether some 26 cases. The Sonne organism was recovered from most. There were 15 home infected cases and a further 6 at the school. The earlier phase seemed to be associated with contact at home, the affected children being of school age and of under school age. From the middle of March there were fewer from this locality, and from then on most of the notifications related to pupils at the school who lived in the same area as the other children or to the home contacts of those pupils. In May and June an Infants department of another school was attacked, 12 pupils being affected, and the parents of another pupil. The whole family of yet another pupil were affected, but only one, a child of under school age, was notified. Another grouping of cases involved two pupils of a private school and three home contacts of one of the pupils. Infection by the Sonne organism was introduced into a household by a child of three years of age in March, four days later the mother succumbed and a few days later two other children in the house. In some of the other cases it is known that some other members of the family had previously suffered from an attack, but the source of the original infection was not detected, For instance, a boy of 7 notified m February probably contracted his infection from his brother aged four who had had diarrhoea lasting one day a few days previously, but the source of his infection was not known. Another child was a pupil at a school outside the district at which a number of children were affected. A husband and wife succumbed simultaneously to a Sonne infection. Apart from these instances, there were those cases where there was only the single case with apparently no contact with any other. In September, an early October, five persons were notified who had probably contracte their infections while on holiday in different places abroad. In spite of the figure of 58 being the largest number of notifications of dysentery received in this district, it is probably still very far short of being a true indication of all cases. So commonly on enquiries being made about a case it is learnt that others of the household who have not been notified have had some illness which is probably of the same nature. 89 There must be many other people who have had symptoms not sufficiently serious for them to summon a doctor who were really suffering from this complaint and who were infective. On top of that are the many symptomless excreters who, being symptomless, are not recognised as such. That children are affected so commonly accounts for the facility of passage to other children. On this the Chief Medical Officer of the Ministry of Health in one of his Annual Reports says:—"The experience is that the infection is rarely conveyed by food, and that direct or indirect personal contact is mainly responsible. The danger of spread of the infections is much enhanced by the large numbers of symptomless excreters often associated with the clinical cases, not only within day nurseries, schools and elsewhere in which outbreaks occur but also in homes. This means that the home conditions as well as conditions in institutions attended by children from these homes require full attention. Good personal and environmental hygiene and in particular hand washing immediately after a visit to the toilet are of outstanding importance." FOOD POISONING The number of notifications of cases of food poisoning gives only a rough approximation of the incidence of this complaint. On the one hand is the large number of cases not notified. In this district no single one of those who suffered from the largest of the local outbreaks of food poisoning was notified. There must be many other instances of a single case or of family or larger groupings which are not notified. On the other hand, many notifications are received of persons suffering from food poisoning in which it is very doubtful if that was the real cause of the trouble. In a number of cases laboratory investigation leads to the detection of the Sonne organism in some of these cases. During the year, allowing for the withdrawal of some of the notifications, the number of cases notified was 44. The distribution was 9 in the first quarter, 12, 16 and 7 in the remaining quarters. 17 were the only persons in the home notified, though the notified case was not always the only person in the house suffering from similar symptoms. In 5 instances Salmonella typhimurium was recovered. In one of these cases infection had probably been contracted at the place of work where there were other sufferers. In some of the other cases no organisms suggestive of food poisoning or of food infection were recovered from the stools. In a number of these cases it is questionable whether the patient did in fact suffer from tood poisoning. One of the notifications related to a person in whose family six others were suffering from gastro-intestinal symptoms, but none of the others was notified as suffering from food poisoning; the course of the passage of the illness through the family was not typical of a food poisoning, resembling more that of a food infection., Of the other cases, two members of a family were affected in two instances; three members in three and four members in another three instances. One of the cases of triple infection was due to salmonella typhimurium. Another of the triple infections was due to a coagulasePositive staphylococcus probably present in a macaroni pudding which was consumed by the three members of the family who fell ill, but was 90 not eaten by the other two who remained free from symptoms. In one of the instances where two members of the family were affected, the patients were the husband and wife of a family of four; the two sufferers had eaten oysters while the other two in the family who were not affected had not. Although this was a case in which the illness seemed to be related to the consumption of a definite foodstuff, from neither patient was it possible to recover food poisoning organisms. At another home the mother, father and two children all succumbed to a gastro-intestinal illness on the same day; in no instance though was it possible to recover from the patients either food poisoning or dysenteric organisms. The occurrence of some of these cases which seem to be definite cases of food poisoning but from which no food poisoning organisms can be recovered, raises the question of whether all the various organisms which can cause food poisoning have been recognised or are being detected. The other groupings of cases were more suggestive of food infection than food poisoning. Two children attending a school at which other pupils were suffering from dysentery had symptoms of this infection; there was too an interval of forty-eight hours between the onsets of illness in these cases. About the same time three other children of the one family living in the same area suffered from diarrhoea with blood and mucus in the stools. Also in much the same area, four children in a family including one attending the school at which there were pupils suffering from dysentery succumbed, the school child first, the others at intervals of two, four and five days. In another case where four in the family were affected, the three adults succumbed about the same time; they had all eaten some fish which a daughter did not have and she escaped; on the other hand, some eighteen hours after the onset of illness of the mother, her breast-fed baby of three months of age had similar symptoms. The largest outbreak of food poisoning—and one from which none of the sufferers was notified—was that which occurred at a boys' school. Some of the pupils from a nearby girls' school have their mid-day meals at the canteen of this school. Of the 57 girls who had their meal there on a Wednesday, 31 suffered from gastro-intestinal symptoms that night or the next day. All the 57 girls had the same meat dish; but none of the boys, nor any members of the staff. This was stewed steak. A quantity of steak was delivered to the school on the Monday. About three-quarters of this was cut-up and cooked on the Monday, kept in the refrigerator overnight and was made up into steak pies for the Tuesday's mid-day meat. The consumption of this was not followed by any illness. The remaining quarter was not heated on the Monday; but after it had been cooked on the Tuesday, was kept overnight in the refrigerator and alter warming, was served-up as steak pies on the Wednesday. Of the fifty-seven girls who had the meat nine developed symptoms during the night and a further twenty-two during the daytime on Thursday. Although not a who had this meat dish suffered from symptoms, none who did not have it suffered. No foodstuffs were available for examination. From the faeces of some of the sufferers CI. Welchii was recovered. The presumption is that the original meat was infected, and that during the cooling after the heating of the meat on the Tuesday the organisms multiplied sufficiently to cause the meat to become toxic. 91 Bacteriology. The organism responsible for one family outbreak of three cases was Salmonella typhimurium, for another family outbreak of three cases the coagulase—positive staphylococcus, and of a school canteen outbreak of thirty-one cases CI. Welchii. The agent was not discovered in six outbreaks involving in all 19 cases. Salmonella typhimurium was recovered in five of the 19 instances of single cases of food poisoning. The Position Nationally. The following information has been abstracted from a report of the Public Health Laboratory Service on Food Poisoning in England and Wales in 1957:— 1. The number of incidents, 7,071 was a reduction of 8% on the figure for 1956 and of 21% on that of 1955. The reduction was mostly in incidents due to S. typhi-murium and in those where no cause was found. Incidents due to staphylococci and to CI. Welchii were much the same in number. Incidents due to Salmonellae other than S. Typhi-murium increased; this is a continuation of an increase seen each year since 1954 and is seen in family outbreaks and sporadic cases but not in the general outbreaks. 2. The 7,071 incidents comprised 473 general outbreaks, 501 family outbreaks and 6,097 sporadic cases. Over 15,100 persons were reported as cases in these incidents, some 6,000 more than the number of cases of food poisoning reported by the Registrar General. 3. Salmonellae were responsible for 59% of all incidents and for 95% of incidents due to recognised pathogens. 4. The maximum incidence was in the summer months, reflecting the close relation between atmospheric temperature and the growth of bacteria in food. 5. 69% of outbreaks in which contaminated food was mentioned were associated with processed and made-up meats. 6. In the general outbreaks for which information was available the canteen holds first place, followed by hospitals and then restaurants. The canteen outbreaks in which a pathogenic microbe was identified were nearly all due to CI. Welchii; but in hospitals most outbreaks were associated with salmonellae, an indication of cross-infection rather than spread of infection via contaminated food. 7. The most reasonable explanation of the rise and fall of different types of salmonellae organisms is changes in the types contaminating the widely distributed food The control of egg and egg products is therefore likely to make a substantial reduction in human salmonellosis. Processed and made-up meats were mentioned as the vehicles of infection in about half the outbreaks of salmonellosis traced to a specific item of food. Analysis of the foods over the past four years shows that nearly two-thirds of the incriminating processed and re-heated meat dishes were pork pies, brawn, sausages and cold pork. Sausages and brawn are frequently made from pig meat. Pig meat therefore remains, as in the Past, a frequent source of salmonellae. Galton, etc. found that infected Pigs detained at an abattoir might infect 90% of the pigs with which they 92 were in contact in the pre-slaughter pens, and that once infection was introduced in the abattoir it spreads to all parts, including the cutting-up rooms and sausage making rooms. The types of salmonellae from the pigs were the same as those from human beings in the same area. Hobbs and others are continuing to find salmonellae in boned beef and veal from a number of countries. Walker found 40% of samples of fertilizers contaminated with salmonellae belonging to types common in cases of man. The raw material for some of these fertilizers—fish meal, bone and dried blood—is often used for the preparation of animal food stuffs The control of meatborne salmonellosis therefore may lie in great part in control of foodstuffs. It is difficult to define the importance of the human case or excreter in the spread of salmonellosis. In the general community, cases in contacts are not very common, though it is usual to find a number of excreters in family contacts of a case. In hospitals cross-infection is all too common. Spread from person to person via fomites or dust or utensils does therefore occur in hospitals. How often it occurs in the general population is not known. It is evident that the control of salmonellosis must include Reporting of human cases, so that they and their contacts may be prevented from spreading disease; education of caterers and food handlers in a high standard of kitchen and personal hygiene; extension of proper refrigeration of foods; hygienic production and pasteurization of egg products—but in addition abattoir practices need careful investigation, as does the importance of contamination of feeding stuffs and fertilizers. 8. About half the cases of staphylococci food poisoning were associated with processed and made-up meals, more commonly cold ham and bacon or brawn. In a number of instances the source of infection was one or more food handlers. The fact that the source of infection in 8 of the 15 outbreaks is the apparently normal nose, throat or hand of the food handler, shows that good hygiene and the exclusion from food handling of persons with septic lesions of their skins will not by themselves ensure the safety of such frequently implicated foods as brawn, pressed meats and ham and bacon. The additional necessary measure is refrigeration. 9. Welchii accounted for 93 incidents. Of these, 80 were general or family outbreaks; 59 of these were traced to the consumption of specific foods. Fifty-four of the foods were processed and made-up meat. As in previous years the foods most frequently at fault were re-heated meat an meat pies. 10. Discussion. This report shows that the outstanding problem in food poisoning is control of the spread of salmonellae. To this end studies of eggs and egg products, meat and meat products, and feeding stuffs and fertilizers are being made here and in other countries and are yielding information of interest and value. It is too early yet to define the importance of these products, but it is probable that, if they could be protected from contamination with salmonellae in the first place or if all products likely to be contaminated with salmonellae could be adequately heat-treated, the incidence of food poisoning would fall considerably. 93 ERYSIPELAS Sixteen persons last year were notified to be suffering from erysipelas, 9 men and 7 women. In ten cases the face was the affected site, in four the leg and in two the arm. Two of the patients were admitted to hospital. None of the cases was fatal. MENINGOCOCCAL INFECTION Although five persons were removed to hospital suspected to be suffering from meningococcal meningitis, in only one instance, a boy of nine months, was the diagnosis confirmed. ACUTE ANTERIOR POLIOMYELITIS Most of the 15 people who were suspected to be suffering from acute poliomyelitis were removed to hospital. The diagnosis was confirmed in only three of the cases. The first was a boy of fourteen who fell ill in March; the next an adult woman whose onset was in July, and the third an adult male who fell ill in September. All three suffered from paralytic attacks. 1958 proved to be a year of low incidence in the country as a whole. The usual rise of cases in the summer was at a slow rate. The curve rose to a low maximum of 86 notifications in the week ending 11th August, after which there was a decline. The incidence was irregular in the succeeding weeks with a result that the highest number of notifications 113, were received in the week ending 11th October. After a sharp fall in the next week, figures showed no marked tendency to fall, with a result that the numbers of notifications in some weeks in 1958 were actually higher than those of the corresponding weeks of the previous year, although in general, the incidence had been that much higher in 1957. The total number of notifications in the country as a whole was 1,997, a rate per thousand population of 0.04, a figure which compared with that of 0.08 in the previous year. The lighter incidence of 1958 could be ascribed in part to the weather conditions, in part to the effect of inoculations. In regard to the effect of the latter, it is significant that the figures were low in the earlier weeks of the year, that is at a time when no substantial proportion of the population had been inoculated. Inoculation. When the arrangements for inoculation against Poliomyelitis started in this country in the Spring of 1956, those eligible were children born in the years 1947 to 1954. Those of these ages who registered at that time were the priority class to be treated before any others. Because of the difficulties in supplying vaccine, it was not until the end of 1957 that all these could in fact be treated. In the Summer of 1957 those children born in the years 1955 and 1956 became eligible for treatment. Many of these were given their first doses before the end of 1957. 94 Following the decision to import vaccine from Canada and the United States, the Minister of Health made other groups eligible for registration. These included children of six months of age, children up to fifteen years of age, expectant mothers, general medical practitioners and their families and those working with infectious poliomyelitis patients in hospitals and their families. The parents could, if they wished, now have their children treated by their own doctors. They could also if they wished, insist on British vaccine being used, though this, of course, would for many entail delay in the treatment being carried out. Unfortunately difficulties of production even of the American and Canadian vaccine brought all arrangements for inoculation against poliomyelitis to a halt late in February, 1958. The Canadian and the American vaccine that had been introduced and used in this country had been subjected to safety tests here as well as in the country of origin. In April the position was that there was no prospect of the production of British vaccine being stepped-up sufficiently to meet the demand, nor were there to be available any American or Canadian supplies which had passed the safety tests in this country. Because it was so desirable that those prepared to be inoculated should be treated before the end of June, that is by some time well ahead of the time that the wave of poliomyelitis incidence could be expected to rise, on 1st May the Government decided to import vaccine which had not been subjected to safety tests in this country, this as a temporary measure to supplement supplies of British vaccine. These supplies came through steadily, and from that time onward there have been available adequate supplies of this type of vaccine. There were about 1,000 children whose parents had indicated their wish for them to receive British vaccine. In view of the continued difficulties those preparing British vaccine were experiencing resulting in a delay far longer probably than those parents had anticipated, all these parents were approached to find out whether in the circumstances they wished their children to be treated with an American or Canadian product or whether they still preferred to wait until their children could be treated with the British vaccine. All but 300 elected to have the American or Canadian vaccine. It was not until the very end of the year that sufficient British vaccine was received to enable even those reduced numbers to be treated. Ample supplies of vaccine having been made available, efforts were concentrated on inoculating as early as possible, the children who had registered. In fact most of them were given appointments which would have enabled each of them to have received their two doses of vaccine by the end of June, and all of them by the middle of July. Although in most other countries where arrangements were made for inoculation against poliomyelitis the accepted course of treatment was three doses, the first two being given at three or four weeks interval, the third dose some seven to nine months later, the decision in this country was to concentrate on as many as possible having two doses. In September, the Government decided that those who had had two doses should be given an opportunity of having a third dose. At the same time, the scheme was extended to make all those under the age of twenty-six eligible for treatment. 95 By the end of the year, all those who had been treated in 1956 and in 1957 and who wished still to be treated at the clinics were given appointments for their third doses, as were also most of those who had received their second doses not later than April, 1958. At the same time, the cards of all those in the same groups who wished to be treated by their own doctors had been sent to the various general medical practitioners. Only relatively small numbers of those in the extended age range to twenty-six have registered for treatment at the clinics. Those who elected to and who could be done in time received their first doses before the end of the year. The following is a summary of the work done during the year: Two inoculations had been given to 24,766 children born in the years 1943-1958, 837 to young persons born in the years 1933-1942, 951 expectant mothers, 93 general medical practitioners and their families, 15 ambulance staff and 8 hospital staff. Third injections were given to 4,038 persons. 421 persons had received only their first injections by the end of the year. Protection of Susceptible Contacts. Limited supplies of gamma globulin are held at the Colindale Laboratory for administration to (1) Nurses and medical students who are to be closely associated with the care of early cases and who so far as is known, have not been in contact with the infection previously; (2) Babies in a hospital or maternity home exposed to infection soon after birth; (3) Children in a hospital ward in which a case develops, especially children who have recently undergone tonsillectomy. MEASLES Measles was present to a greater or less extent throughout the whole year, there being only one week when no cases were notified. The average of 7 cases a week for the first quarter rose to a long low wave from June to early August, resulting in a weekly notification rate of 14 in the second quarter and 19 in the third. Notifications rose from early October, not steadily but erratically, with the highest figure of 118 in the week ending 13th December, the average weekly notifications for the last quarter being 59. This rise as a prelude to an outbreak in the following year started earlier than usual. Altogether 1,336 cases were notified. The prevailing pattern was mild and only 13 patients were removed to hospital. The only fatality was that of a boy of eight who suffered from mongolism and congenital defect of the heart. The passage of this complaint through the district is indicated by its incidence in the various schools. In the Spring term only the infants department of Stag Lane school was affected to any extent; in the Summer term Belmont, Harrow Weald and Stanburn. All these schools were free in the Autumn term when first Bridge and Roxeth and Roxeth Grange were affected and then later in the term Greenhill, Vaughan Road, Welldon Park, Roxeth Manor and Cannon Lane schools which had not been affected in the earlier term. 96 Protection of Susceptible Contacts. Limited supplies of gamma globulin are held at the Colindale Laboratory for (1) The control of hospital and institution outbreaks. (2) Persons suffering from intercurrent illness or living in a poor environment for whom an attack of measles would be dangerous. (3) Children under three years of age. WHOOPING COUGH The district was almost free from whooping cough in 1958, only 40 notifications being received, these cases being spread throughout the year. It is not possible to say to what extent the favourable state is the result of many of the children having been inoculated. The incidence of this and of other infections fluctuates for reasons quite unconnected with the state of relative immunity of the population. That so few cases should have occurred suggests that the district benefitted from some change in the organism; had the small number of cases been the effect of inoculation, such a high protection would not have been expected as although the efficacy of the vaccine has improved, it is not claimed for the vaccine even now being used that it is anything like as effective a preventative as that used for instance against diphtheria. While most effective in modifying an attack, it is not so successful in completely warding-off that attack so that the inoculated child can still suffer a mild but still communicable attack. No persons suffering from whooping cough were removed to hospital and there were no fatalities. Inoculation. During the year 1,921 children were inoculated, 1,047 by general medical practitioners and 874 at the clinics. PUERPERAL PYREXIA The condition which is notifiable as puerperal pyrexia is a fever of up to 100-4° occuring within fourteen days of a woman having given birth to a child or having had a miscarriage. A rise of temperature then from whatever cause such as influenza or even a cold is strictly notifiable when that occurs in a woman who has recently been confined. Of the 14 persons notified during the year as suffering from puerperal pyrexia, two had colds, two had cystitis and five engorged breasts. In the remaining cases the rise of temperature was apparently due to retained products. Four of the sufferers were removed to hospital for treatment. OPHTHALMIA NEONATORUM No notifications of ophthalmia neonatorum were received during last year. NON-NOTIFIABLE INFECTIONS Knowledge of the prevalence of some of the infections which are not notifiable in the district is obtained from intimations received from Head Teachers about the absence of children from school. 97 Chicken Pox 529 intimations of children absent from chicken pox were received from the schools during the year. Only two schools were really heavily attacked. The first was Roxeth Manor with 129 cases in the Spring term. Towards the end of the term Stag Lane was affected; the infection carried on into the next term and continued throughout that term with a total of 71 cases. Two other schools had a number of cases in the last weeks of this term but did not carry over into the next term when the whole district was almost clear of this infection. Mumps Many schools had occasional cases occurring throughout the year, but only one was heavily attacked. The invasion at Welldon Park School in the early weeks of the year accounted for 108 of the 152 intimations. German Measles Cases of german measles were reported at some time during the year from nearly all the schools in the district, in all 163 intimations being received. Although a few of the cases occurred at the time that other pupils in the school were suffering from the more usual type of measles, most of the cases occurred when there were no such sufferers at the school. The vast majority of the cases occurred in the Summer term, there being only small numbers in the other two terms. Protection of Susceptible Contacts: Limited supplies of gamma globulin are available at the Colindale Laboratory for administration to women exposed to infection in the first four months of pregnancy. Influenza Influenza caused the deaths of 9 persons during the year. Most of these were in the first few weeks of the year and were of persons over sixty-five years of age. TUBERCULOSIS The favourable trend of recent years in regard to tuberculosis continued, with the result that the numbers of new notifications in the country as a whole for 1957 was 8% fewer than those in 1956 and the number of deaths 11% fewer. Compared with the figures of five years Wore, the fall in deaths from all forms of tuberculosis was 46% and of notifications 33%. Notification Most of the infections which are notifiable have relatively short incubation periods and sudden onsets. In most instances then it can be assumed that the infection has been contracted by the individual while living in the district in which the notification was made. This is not necessarily the case in tuberculosis. In the first place, the period which in the case of the other infections is called the incubation period, is so long and signs and symptoms might be so indefinite that it is often quite impossible to give an approximate date of the onset of illness. In the meantime, during this period the individual might have moved from one district to another and by the time the disease is diagnosable and is notified, the patient might not be living in the same district as he was when he in fact developed his illness, and is no longer subjected to the same conditions which resulted in the breakdown of his resistance. Many a Primary notification then namely, a notification relating to a patient 98 notified for the first time, is in respect of a patient whose tuberculosis was not contracted in that area. Apart from the primary notifications are the other notifications of persons removing to another district. This sort of thing is only likely to happen in the case of a disease which can run into a chronic and long-continued phase. When a person suffering from tuberculosis moves to a new district he usually comes under the care of a new doctor and that doctor is required to notify the case to the Medical Officer of Health of the new district. Such notifications though relate to persons already notified to the Medical Officer of Health of some other district in the country, and these are not counted as primary notifications. On the other hand, in some persons who are notified and particularly when this occurs very soon after their removal into a district, it is apparent from the history that they must in fact have been developing the disease before they moved, even though they had not been recognised at that time to be suffering from it and the patient had not been notified. Although in such cases the disease must have been present before removal, because the case had not been notified in the district from which the patient came, the notification to the Medical Officer of Health of the new district of the patient counts as a primary notification. Not all primary notifications then are of patients whose breakdown in resistance occurred while they were living in the district which accepts the primary notification. This district is taking part in the general improvement seen in the country as a whole. The number of primary notifications in 1958 was only 118, compared with figures of 141, 160 and 183 for the years 1957, 1956 and 1955. The combined figures of those who were notified here for the first time during the year and those who came into the district during the year already suffering from tuberculosis was 199. The corresponding figure in 1957 was 214, in 1956 264 and in 1955 287. The following table gives the age and sex distribution both of the persons resident in the district who were learned of for the first time to be suffering from tuberculosis; and of those who moved into the district already suffering from the disease:— Primary Notification Brought to notice other than on a Form "A" Pulmonary NonPulmonary Pulmonary Non- Pulmonary M F M F M F M F Under 1 - - - - - - — - 1-4 - - - - - — — 5-9 - - - - - - - - 10-14 — 1 — — 1 — — - 15-19 6 3 1 1 1 1 — - 20-24 3 9 2 — 2 5 1 - 25-34 8 9 1 2 20 23 1 - 35-44 5 7 1 1 11 3 — - 45-54 19 5 — 2 3 4 — - 55-64 16 6 1 — 2 — — 1 65 and over 8 — — 1 1 1 - - Totals 65 40 6 7 41 37 2 1 99 A history of close contact with someone suffering from pulmonary tuberculosis, usually a member of a household, was obtained much less commonly this year. In the case of men it was obtained in only ten per cent, of cases in women twenty-five per cent. The history was obtained in all in only 13 instances out of 87, as compared with a figure of 27 out of 87 in the previous year. There were seven instances again this year of persons being notified who were engaged in occupations in which in general the incidence is higher amongst those so employed than it is in the general population. Some illnesses or other states predispose to the onset of tuberculosis. There was only one instance of that this year. Four of the women who were notified were pregnant when the disease was diagnosed, or they had only recently been confined, While there are in numbers of these cases factors which it is considered might have an important bearing on the development of the disease in these patients, in the vast majority no such factors can be detected, and the illness strikes almost out of the blue, some who apparently are living in comfortable healthy conditions. 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 nonpulmonary 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, 1st January, 1958 1,310 1,029 135 148 No. of new cases added (primary notification) 65 40 6 7 No. of cases other than primary notifications 41 37 2 1 no. of cases restored to Register 8 10 - - No. of cases removed 118 97 14 12 No. on register, 31st December, 1958 1,306 1,019 129 144 On the 241 deductions, 117 (109 pulmonary) were of persons who had left the district, 23 (20 pulmonary) were of persons who had died, 73 2 pulmonary) were of persons who had recovered and 27 (23 pulmonary) were of persons who had been lost sight of. One had been denotified. The net decrease in the number of cases on the register is 24, there being 14 fewer pulmonary cases and 10 fewer non-pulmonary cases. 100 This is the second year that it has been possible to record a fall not only in the numbers of those on the register but in the numbers for each sex for both types of disease. The increase which had occurred in the previous two years had been smaller than those occurring hitherto. All this suggests that the fall now occurring will continue. Deaths Only eight persons (7 male and 1 female) in this district died from tuberculosis last year, all of the pulmonary type. This is a continuation of the decline which started a few years ago. Today's figures are a marked contrast to the 78 deaths which occurred in 1939 and still more to the 97 in 1944. Even as recently as 1949 the figure was 57. This last year this infection accounted for a death rate per thousand population of 0 04 and for 0.4 of the total deaths. In 1934 the corresponding figures were 0.57 and 7.1, and even in 1948 were 0.42 and 4.9. Sometimes the first intimation that a person has had tuberculosis is received from a certificate of death. This means that the preventive services have been handicapped in starting those investigations and precautionary measures which might lead to the detection of the origin of the infection in that patient or in the recognition of others who might have been infected by him. In some instances, particularly when the diagnosis had only been made as a result of a post-mortem examination, no one could be held to be at fault. In other cases, the failure to notify would seem to be the result of an oversight of those whose duty it was to notify. This most often is a member of a hospital staff. Little can be done about this by those in such a district as this where there is no hospital with beds specifically for tuberculosis patients. Fortunately in this last year there were no such instances. Preventive Measures The incidence of the disease and the numbers of deaths from tuberculosis started to fall long before the special measures making a specific attack on this disease were started. This fall was part of the general improvement in the health of the population which was reflected in the decline in the incidence of many of the infections and in the fall in the death rate. Better housing conditions, improvement of the conditions at work, better food have all made their contribution to the improved healthiness of the population. These factors are still improving, and in regard to housing the special allocation that the Housing Committee has made over the years for the rehousing of those families with members suffering from tuberculosis must have helped and the beneficial effects must be continuing. The special attack which was directed on this disease with inauguration of the tuberculosis dispensaries (today's chest clinics) an special accommodation is still continued. One of the chief aims of those at these clinics was to secure the examination of the immediate contacts of a person found to be suffering from pulmonary tuberculosis. This was with the double object of trying to discover the source of the infection of the patient, and also to discover in the earliest stages those who might 101 have been infected by him. This still remains one of the chief activities at a chest clinic, and the examination of these contacts is one of the main ways in which new patients are discovered. Those at these clinics possess in the x-ray machines aids which were not available to their predecessors. There is too today, the mass x-ray unit, though this is run as part of the hospital service and is not based on the chest clinic. The mass x-ray unit which visits this district comes here once every three years. The last visit was in the Summer of 1956. The local school medical and nursing staff play their part in the control of this infection. The school medical officers at some schools carry out the routine tuberculin testing of school entrants. The purpose here is to detect the positive reactor. Because it is assumed that a child of that age who reacts positively and has therefore been exposed to infection is most likely to have had that exposure in his own home, the presumption is that there is in the home of the tuberculin positive entrant an infective person. The adult contacts of these positive reactors then are invited to attend the chest clinic for examination. During the year, 311 children were tested; of these only 3 reacted positively. No home contacts were in fact discovered in this way. Then whenever a pupil or an adult worker at a school is found to be suffering from pulmonary tuberculosis, the question of carrying out an investigation at this school is considered. The extent of the investigation will depend on a number of factors, such as the infectiousness of the patient, and the opportunities he had to infect others. In some cases no examinations of contacts are considered necessary. In most, the procedure is to tuberculin-test the class contacts. Those who react positively are X-rayed and if necessary, subjected to further examination. In other cases it may be necessary to examine not only all the pupils at the school but members of the staff. The clinical work is carried out by the staffs of the local chest clinics. During the year, a teacher at one school, a caretaker at another and pupils of six other schools were recognised to be suffering from pulmonary tuberculosis. In three instances it was not considered necessary to carry out any investigations. In two the class contacts were examined; in neither was the proportion of positive reactors high, and further examination of those reacting positively did not point to any of them having active disease. At one school the tuberculin testing of the thirteen-yearolds as a preliminary to B.C.G. inoculation showed a very high proportion of positive reactors. On this all the teaching staff were examined; all were found to be negative. On the occurrence of the disease in an adolescent girl pupil about the same time that an adolescent boy who had been away from school for many months was then recognised to be suffering from pulmonary tuberculosis, all at the school were examined, including the non-teaching staff. Although two persons were being kept under observation, by the end of the year no infectious person had been etected. Two of the pupil sufferers at other schools were recognised only at the end of the year so that the investigations at those schools were earned out in 1959. On the other hand, early in 1958 investigations were earned out of contacts of a pupil notified in December, 1957; the results 102 again were not of an unusually high proportion of positive reactors, and the x-ray examinations of the chest of those who reacted positively were clear. B.C.G. Inoculation. Another contribution made by the School Health staff is by B.C.G. inoculation. The groups selected for treatment are children of thirteen years of age. This entails a separate examination as this is not an age group at which a routine medical examination is carried out. As those who have already been exposed to infection do not need the injection, the procedure is first to carry out a tuberculin test. Those who react negatively are given an injection. Those reacting positively are referred to the chest clinic for examination. It has proved possible to carry out these tests on the relevant children at all schools in the course of the year, the pupils at the Secondary Modern schools being dealt with in the Spring term, those at the Grammar schools in the Summer and those at the Independent schools in the Autumn term. The following is a summary of the work carried out in 1958:— Type of School No. of Pupils Eligible No. of Acceptances Negative Reactors Positive Reactors Secondary Modern 3,016 1,798 1,496 140 Secondary Grammar 1,172 762 660 60 Special 27 16 12 - Independent 781 563 480 54 4,996 3,139 2,648 254 (3,537) (2,513) (2,011) (286) The corresponding figures for 1957 are shown in brackets. Of the negative reactors, 2,511 were given B.C.G. Many were not inoculated at the time of testing mainly because of recent poliomyelitis injections. The surprisingly high proportion of acceptances to these arrangements is presumably an indication of the public's dread of this disease. The benefit to the public as a whole of such a procedure depends on a number of factors, such as the incidence of the infection and the opportunities for spread. The Ministry authorised these facilities being offered to this group of children following the receipt of the report of the field investigation carried out by the Medical Research Council and published in 1956. This trial showed that inoculations resulted in a marked reduction in the incidence of tuberculosis amongst the vaccinated children as compared with what they might have been expected to have had if they had not been vaccinated. It showed too that the protection conferred by vaccine was evident soon after it had been given and was still substantial after two to two and a half years. Later information suggested that the protection was maintained up to four years. As children are being inoculated when they are thirteen years old, this report was not offering the hope of protection to those who had reached the age of eighteen. At the time the report was written it could of course refer only to that period of years, and it can be hoped that the beneficial effect would continue for longer. The following is an analysis of the notifications relating to 103 those who presumably contracted their infection while in this district and at the time were between fourteen and twenty-four years of age. Those with a family history of exposure to infection would probably be tuberculin-positive and would not in the ordinary way be inoculated. Age Pulmonary Non-Pulmonary M F M F F.H. o. F.H. O. F.H. O. F.H. O. 14 15 16 1 — 17 2 18 1 1 1 2 — — — 19 1 1 1 20 — — 1 — .— — — 21.. — 1 1 22 3 — 3 — 1 — — 23 — 2 24 — — — — 1 — — 104 ANOTHER FIVE YEARS OF FIGURES The Annual Report for 1953 contained a table of figures of the various vital statistics for the district in each year since the creation of the new district in 1934. This further table adds another five years to that and for purposes of comparison, the figures for certain years have been included. The earlier figures show that the district is in many ways reaching stability. The population which reached a peak figure of 222,300 in 1950 is now showing a slight fall each year, something which is all to the good. The births over these years have been remarkably uniform and as the population has not changed much, the birth rate is more or less stable at a figure appreciably below those in the earlier years of the Council's life when the erection of large numbers of houses resulted in many new young families coming to live here. The post war years also show a rise in the number of births resulting in a high birth rate ; but in and since 1953, the birth rate has been between 12 0 and 13 0. In most of the recent years, the number of deaths in any one year has been between 1,900 and 2,000. This, of course, is a marked contrast with the numbers of the pre-war years, even those in which the population figure was not so very much smaller than that today. The smaller number of deaths in those years were of course, due to the same cause as the larger number of births—namely, that the many houses which were being erected were being occupied by young families, those with a very low death rate. It could, of course, only be a matter of time before this population in turn began to reach the age at which death more commonly occurs and the general age structure of the population approximate more to that of the country as a whole. Until that position has been reached, it can be expected that the trend will be towards bigger numbers of deaths and a higher death rate. The Registrar-General assesses the abnormality of these age-structures and allocates to each district a comparability mortality index. That for this district last year was 119. As long as it continues to be above unity, it can be expected that the number of deaths will increase. The infant mortality rate, except for a recession during some of the war years, has fallen more or less steadily all the time, maintaining its favourable position as compared with the rate for the country as a whole. It is now based on such a comparatively small number of deaths that considerable fluctuations can occur from year to year without these being of any special significance. Except for rising to 211 in 1956, the infant mortality rate has been below 20 since 1953. For many years, the maternal mortality rate of the country at a figure of about 4 per thousand births was a reproach to the Heart Services. For a number of years now the figure has been about 1 thousand. Only once since 1951 has the local figure exceeded this, such a low level, one or two additional deaths can cause a large rise in local rate. 105 The figures of the deaths from cancer are now consistently higher than they were before the war. This again is a reflection of the changing age structure of the population. While malignant growths can occur at almost all ages, cancer typically attacks the middle-aged. A population with a disproportionate amount of young people would have relatively fewer persons who had reached these susceptible ages. That was the position in this district before the war. With a local population now of more usual age distribution, the number of deaths from cancer can be expected to rise—and to increase above the present figures. In 1957, the cancer death rate per thousand population in the country as a whole was 21. For this district in 1958 it was 2-0. Neither the figures for suicide nor deaths from violence call for comment, as although they fluctuate, they show no significant trend up or down. The story of most of the infections in the last five years merely continues that of the previous twenty. Scarlet fever has in these years been on the whole of low incidence, the highest number of notifications being 209 in 1954. On no occasion in this period has there been any indication of a trend to the development of such a high incidence as the 621 cases in 1934 or the 707 in 1943. At the same time, it has continued to remain typically a mild complaint, so that over these five years it has not been a factor of public health significance. On the contrary, measles which up to this has never established its biennial beat in this district as it has in other urban areas was in one of the last five years at its greatest incidence with 3,024 notifications in 1955. Against this has been the continuing mildness in character of the complaint ; coupled with improved therapeusis the result is that even from the large number of cases there have been very few fatalities. Whooping cough, possibly because of the extent to which the child population has been inoculated, has in none of the last five years been very prevalent, and has been sufficiently mild to have caused no deaths. The setback to the position in regard to tuberculosis in the country as a whole during the war years was continued into the years after the war. The improvement which later came about was seen first in the reduced number of deaths. Another few years were to pass before the improvement was reflected in the diminishing numbers of notifications of new cases. That position has now been reached and a steady fall can be looked forward to. In regard to deaths, the average number of 13 for the last four years is a marked contrast to the figures of over 100 during the war years and of 96 even in 1938. These last few years have seen the introduction of B.C.G. which, added in post war years to the other weapons to attack this complaint, mass radiography and chemotherapy, should do much to remove this disease from being °ne of importance to those in the health services. The local position in regard to poliomyelitis is each year a reflection 0 what occurs in the country as a whole. Since 1947 when it was first subjected to a nation wide attack, the country has never been wholly ,ree 'rom the infection. The incidence of any one year seems to be largely ependent on the weather in the Summer months, the summers with the 106 best weather giving the highest number of cases. For a while, no really effective steps could be taken to avoid spread of infection. This position changed here with the introduction in 1956 of arrangements for inoculating certain sections of the population against it to acquire active immunity. The smaller number of cases which occurred in 1958 offer hope that the vaccine is having its effect in reducing the general incidence. In regard to those infections due to food, there has been no real improvement. To what extent the increased number of notifications received is due to a real increase in prevalence or to a rise in the number of those notified it is not possible to say. The improved laboratory facilities and the greater attention being paid to these infections would lead to the detection and notification of many cases which before would not have been recognised. It is quite certain that the numbers notified are only a proportion of the true incidence. One reason for a real increase would be the continuation after the war of the habits of communal feeding which started during the war. In these circumstances, a lapse in hygiene could result in many persons being infected ; a similar lapse in a household by that same cook would affect only one or two. The enteric cases are mostly those due to paratyphoid infection. Most of these have been contracted abroad. The dramatic increase in the notification of cases of dysentery in 1958 was almost wholly due to a school infection which smouldered for weeks. Much of the trouble from this infection is spread at schools, being taken home by the pupils. Food poisoning is a different matter. With the many and varied sources of the food poisoning organisms, it will need much more and continuing effort to educate those dealing with food stuffs to bring to an end this complaint. Any risk from the lowering of standards or a lapse in technique could be immensely reduced by the provision of adequate cold storage facilities. The figures for these five years which probably compare very favourably with those of any district in the country of comparable size, are partly the result of those in the laboratories who have prepared preparations to ward-off complaints, partly the result of the success of other technicians who give the doctors additional weapons in treatment or earlier diagnosis, partly the chance that in some of the years the weather conditions in the summers were sufficiently bad to prevent the spread of poliomyelitis and were such that conditions were not favourable in the winter to the SDread of the virus of influenza or for promoting fog and smog. On top of all that though, for this district must be added the work done to keep high the environmental state of the district and the educational work to enlist the help of those who have their own contribution to make, whether it is by having their children inoculated or by themselves avoiding polluting the atmosphere. 107 Years 1934 1939 1944 1949 1954 1955 1956 1957 1958 Population 132,049 190,200 185,090 220,300 217,700 217,100 216,200 215.000 214.300 Houses and flats 38,024 56,500 57,736 60,859 62,987 63,572 64,060 63,912 64.083 Births 2,267 2,523 3,473 3,083 2,747 2,755 2,791 2,783 2,830 Birth rate 16.4 17.5 18.7 13.9 12.6 12.7 12.9 12.9 13.2 Stillbirths 71 107 121 66 56 50 58 61 47 Per 1,000 total births 31.7 31.3 33.6 20.9 20.0 17.8 20.4 21.9 16.3 Deaths 1,076 1,408 1,732 1,890 1,790 1,945 1,903 1,937 1,992 Death rate 8.1 7.4 9.3 8.5 8.2 8.9 8.8 90 9.3 Infant deaths 101 128 121 64 46 47 59 39 48 Infant mortality 47.0 38.5 34.8 20.7 16.7 17.6 21.1 14.0 17.0 Diarrhoea under two 12 12 12 2 10 5 7 6 - Maternal deaths 13 8 2 5 2 1 2 1 2 Mortality rate 5.80 2.33 1.56 1.60 0.7 0.35 0.7 0.3 0.7 Cancer 156 240 320 344 361 403 420 415 414 Suicide 23 14 17 14 21 22 35 24 18 Violence 35 57 103 53 57 39 48 52 51 Scarlet Fever— Notifications 621 317 387 351 209 125 128 76 134 Diphtheria— Notifications 80 54 16 1 - - - - - Measles. Notifications - 3 573 2,038 41 3.124 610 1.783 1,336 Deaths 12 - 1 - - - - - - Whooping Cough— Notifications - 8 682 191 211 246 88 256 40 Deaths 3 3 3 2 - - - - - Tuberculosis— Notifications 163 210 289 439 278 287 264 214 118 Deaths 77 78 97 57 32 14 16 14 8 Erysipelas 32 46 47 26 20 19 14 14 15 Puerperal pyrexia 21 19 18 5 16 1 1 1 14 Poliomyelitis - 6 23 6 43 14 29 3 Deaths 1 4 Ophthalmia neonatorum . 5 4 1 1 3 - 1 - - Cerebrospinal fever 1 4 7 1 3 1 5 6 1 Enteric Fever 7 7 4 2 2 8 2 2 - Dysentery 1 4 13 11 14 30 17 17 58 Food poisoning - — 5 4 37 57 77 65 44 Arthur Gaunt & Sons (Printers) Ltd. Market Place . Heanor . Derbyshire